Diseases of the pelvic organs. Pregnancy and pelvic inflammatory disease

Pelvic inflammatory disease (PID) is a group of infectious diseases of the female reproductive system. Infection occurs when bacteria from the vagina enters other reproductive organs, such as the uterus, fallopian tubes, and ovaries. As a rule, these are bacteria that are sexually transmitted. Although PIDs can be almost asymptomatic, they often cause female infertility. The symptoms of PID can be relieved with a variety of home remedies. However, to prevent the development of complications such as infertility and chronic pelvic pain, it is important to undergo a course of medical treatment.

Attention: this article is for informational purposes only. Before using prescriptions, consult your doctor.

Steps

Part 1

PID treatment at home

It is important to notice the symptoms of PID in time. Very often, early PIDs are asymptomatic, especially if the causative agent of the infection is chlamydia. Symptoms of pelvic inflammatory disease may include pain in the lower abdomen or pelvis, lower back pain, vaginal discharge with an unpleasant odor irregular menstruation, chronic fatigue, pain during intercourse and urination, and a slight increase in body temperature.

Take a warm Epsom salt bath. If you have pain in your lower abdomen or pelvis, a warm Epsom salt bath can help reduce cramping, pain, and swelling. IN Epsom salt contains a large amount of magnesium, which is good for relaxing muscles, eliminating spasm and tension caused by PID. Fill up with warm water, add a few glasses of Epsom salts, and take a sitz bath. Within 15-20 minutes you should feel an improvement.

Do not use very hot water or sit in the bath for more than 30 minutes. Hot salt water can cause dry skin.
To eliminate spasm of the abdominal or pelvic muscles, you can use moist heat. Use special herbal pouches, best with those herbs that have a relaxing effect on the muscles. For example, lavender has this property.

Try using natural antibiotics. Given that PID is a bacterial infection of the genital organs, it is worth trying to cure it with the help of herbal antibacterial agents. For example, garlic has the strongest bactericidal and antibiotic properties, and also restores the normal microflora of the vagina. Chop a few fresh garlic cloves and squeeze the oil out of them. Apply some oil to a clean cotton swab. Insert a tampon into the vagina and lubricate its inner walls with oil. Leave the oil to soak into the vaginal mucosa for several hours and then wash it off. Do this every day until you feel improvement. The downside of this treatment is the smell of garlic and strong tingling for several minutes after applying the oil.

Part 2

Medical treatment of PID

Consult your doctor. If you have any of the symptoms of PID listed above, see your gynecologist or family doctor as soon as possible. Your doctor will likely do a pelvic exam, take a vaginal swab, and order blood tests to help identify inflammation. They may also order an ultrasound, CT scan, or MRI to confirm or rule out a diagnosis of PID.

Discuss with your doctor which antibiotics are best for you. Antibacterial therapy is the main treatment for PID. The most effective is the simultaneous treatment with several antibacterial drugs. Your doctor may prescribe doxycycline plus metronidazole, ofloxacin plus metronidazole, or a cephalosporin plus doxycycline. If you have severe PID, you may need to be hospitalized to receive intravenous (injection into a vein in your arm) antibiotics. Antibiotics can help prevent complications from PID. If serious disorders have already occurred in the body, antibiotics will not be able to eliminate them.

If PID is caused by an STD (sexually transmitted disease), such as gonorrhea or chlamydia, your sexual partner must also take antibiotics or other drugs prescribed by the doctor.
While taking antibiotics, symptoms may disappear before the infection is completely cured. Therefore, it is important to follow the doctor's recommendations exactly and complete the course of antibiotic therapy to the end.

It is important not to miss the development of complications of the infection. In most cases, antibiotics help to completely cure PID. It is much more difficult to cure a disease that occurs in a severe or chronic form, or with the ineffectiveness of drug therapy. In such cases, it is important not to miss the development of such serious complications as infertility (inability to become pregnant), the formation of scar tissue around the fallopian tubes, which can lead to tubal obstruction, ovarian abscesses, ectopic pregnancy, chronic pain in the lower abdomen or pelvis. In addition, recent studies have shown that women with PID are more at risk of having a heart attack.

Part 3

Prevention of PID

The main prevention of PID is safe sex. As a rule, it is during the exchange biological fluids body during sexual intercourse, infection occurs that leads to PID. The most common cause of PID is gonorrhea or chlamydia. Therefore, it is important to be aware of your partner's sexually transmitted diseases and to use a condom as a barrier. contraceptive. A condom reduces the risk of contracting sexually transmitted infections, although not 100%.

Remember that unprotected intercourse is a potential threat of contracting STDs. During menstruation, the risk of contracting and developing an infection becomes much higher.
Your partner should always use a new latex or polyurethane condom, no matter what type of sex you have.
The causative agents of chlamydia and gonorrhea will not be able to enter your body through the protective layer of latex or polyurethane. However, a condom provides reliable protection only when used correctly, and it can also break during intercourse. That is why a condom is not 100% protection against STDs.

Always follow the rules of personal hygiene. Genital hygiene, especially after going to the toilet, is just as important in the prevention of inflammatory diseases as safe sex and consideration of possible risk factors. Wash regularly and dry yourself from front to back after urinating or having a bowel movement to keep bacteria from your rectum from entering your vagina. Feces contain E. coli, which, along with the bacteria that cause STDs, can cause PID.

Strengthen your immune system. In order to prevent the development of a bacterial, viral or fungal infection in the body, a healthy and strong immune system is needed. The immune system is made up of specialized white blood cells that recognize and then destroy disease-causing bacteria and other microorganisms. If the immune system is weakened or does not function properly, bacteria can multiply uncontrollably and be carried through the blood to other reproductive organs. Therefore, one of important aspects prevention of PID is to strengthen immune system.

If you have been diagnosed with PID, it is essential that your sexual partner be tested and treated (if they have an infection).
Smoking increases the risk of developing PID, so you should stop this habit.
If you have been diagnosed with PID, do not take iron supplements without a doctor's prescription. Excess iron in the body can

encourage the growth of pathogenic bacteria.

Warnings

If a woman has been repeatedly diagnosed with PID, with each subsequent case of the disease, the likelihood of her developing infertility increases. One out of ten women who have had PID becomes infertile.
Untreated, PID can cause permanent damage to women's reproductive organs.

Pelvic inflammatory disease is a spectrum inflammatory processes in the upper reproductive tract in women and may include any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis.

ICD-10 code

N74* Inflammatory diseases of the female pelvic organs in diseases classified elsewhere

Causes of pelvic inflammatory disease

In most cases, sexually transmitted microorganisms are involved in the development of the disease, especially N. gonorrhoeae and C. trachomatis; however, pelvic inflammatory disease may be caused by microorganisms that are part of the vaginal microflora, such as anaerobes, G. vaginalis, H. influenzae, gram-negative enterobacteria, and Streptococcus agalactiae. Some experts also believe that M. hominis and U. urealyticum may be the causative agents of pelvic inflammatory disease.

These diseases are caused by gonococci, chlamydia, streptococci, staphylococci, mycoplasmas, Escherichia coli, enterococci, and Proteus. Anaerobic pathogens (bacteroids) play a large role in their occurrence. As a rule, inflammatory processes are caused by a mixed microflora.

The causative agents of inflammatory diseases are most often introduced from outside ( exogenous infection); processes are less often observed, the origin of which is associated with the penetration of microbes from the intestines or other foci of infection in the body of a woman (endogenous infection). Inflammatory diseases of septic etiology occur when the integrity of tissues is violated (the entrance gate of infection).

Forms

Inflammatory diseases of the upper genital organs or inflammatory diseases of the pelvic organs include inflammation of the endometrium (myometrium), fallopian tubes, ovaries, and pelvic peritoneum. Isolated inflammation of these organs of the genital tract is rare in clinical practice, since they all represent a single functional system.

According to the clinical course of the disease and on the basis of pathomorphological studies, two clinical forms purulent inflammatory diseases of the internal genital organs: uncomplicated and complicated, which ultimately determines the choice of management tactics.

Complications and consequences

Any of the forms of inflammatory diseases of the upper part of the female genital organs can be complicated by the development of an acute purulent process.

Diagnosis of inflammatory diseases of the pelvic organs

The diagnosis is established on the basis of the patient's complaints, the history of life and disease, the results of a general examination and gynecological examination. Consider character morphological changes internal genital organs (salpingoophoritis, endometritis, endomyometritis, tubo-ovarian abscess, pyosalpinx, inflammatory tubo-ovarian formation, pelvioperitonitis, peritonitis), the course of the inflammatory process (acute, subacute, chronic). The diagnosis must reflect the presence of concomitant gynecological and extragenital diseases.

During the examination, all patients should examine the discharge from the urethra, vagina, cervical canal (if necessary, washings from the rectum) in order to determine the flora and sensitivity of the isolated pathogen to antibiotics, as well as discharge from the fallopian tubes, the contents abdominal cavity(effusion) obtained by laparoscopy or abdominal surgery.

To determine the degree of microcirculation disorders, it is advisable to determine the number of erythrocytes, aggregation of erythrocytes, hematocrit, the number of platelets and their aggregation. From the indicators of nonspecific protection, the phagocytic activity of leukocytes should be determined.

To establish the specific etiology of the disease, serological and enzyme immunoassay methods are used. If tuberculosis is suspected, tuberculin reactions should be performed.

From additional instrumental methods use ultrasonography, computed tomography of small organs, laparoscopy. In the absence of the possibility of performing laparoscopy, the abdominal cavity is punctured through the posterior fornix of the vagina.

Diagnostic notes

In connection with wide range symptoms and signs Diagnosis of acute inflammatory diseases of the pelvic organs in women presents significant difficulties. Many women with pelvic inflammatory disease have mild or moderate symptoms that are not always recognized as inflammatory diseases pelvic organs. Therefore, delay in diagnosis and delay in appropriate treatment leads to inflammatory complications in the upper reproductive tract. To obtain a more accurate diagnosis of salpingitis and for a more complete bacteriological diagnosis, laparoscopy can be used. However, this diagnostic technique often not available in either acute cases or in milder cases where symptoms are mild or vague. Moreover, laparoscopy is unsuitable for detecting endometritis and mild inflammation. fallopian tubes. Therefore, as a rule, the diagnosis of inflammatory diseases of the pelvic organs is carried out on the basis of clinical signs.

Clinical diagnosis of acute inflammatory diseases of the pelvic organs is also not sufficiently accurate. The data show that in the clinical diagnosis of symptomatic pelvic inflammatory disease, positive predictive values (PPV) for salpingitis are 65-90% compared with laparoscopy as standard. PPP for clinical diagnostics acute pelvic inflammatory diseases vary depending on the epidemiological characteristics and type medical institution; they are higher for sexually active young women (especially adolescents), for patients attending STD clinics, or living in areas with a high prevalence of gonorrhea and chlamydia. However, there is no single history, physical, or laboratory criterion that has the same sensitivity and specificity for diagnosing an acute episode of pelvic inflammatory disease (i.e., a criterion that can be used to detect all cases of PID and to exclude all women without pelvic inflammatory disease). pelvis). With a combination of diagnostic techniques that improve either sensitivity (to identify more women with PID) or specificity (exclude more women who do not have PID), it only happens one at the expense of the other. For example, requiring two or more criteria excludes more women without pelvic inflammatory disease, but also reduces the number of identified women with PID.

A large number of episodes of pelvic inflammatory disease remain unrecognized. While some women experience PID asymptomatically, others go undiagnosed because a healthcare provider may not correctly interpret mild or nonspecific symptoms and signs such as unusual bleeding, dyspareunia, or vaginal discharge ("atypical PID"). Due to the difficulty in diagnosing and the possibility of reproductive health women, even with mild or atypical pelvic inflammatory disease, experts recommend that healthcare professionals use for PID " low threshold diagnostics. Even under such circumstances, the impact early treatment women with asymptomatic or atypical PID clinical outcome unknown. The presented guidelines for diagnosing pelvic inflammatory disease are needed to help healthcare professionals suspect the possibility of pelvic inflammatory disease and have Additional information for a correct diagnosis. These recommendations are based in part on the fact that the diagnosis and management of other common cases of lower abdominal pain (eg, ectopic pregnancy, acute appendicitis, and functional pain) is unlikely to be worsened if a healthcare provider initiates empiric antimicrobial treatment for pelvic inflammatory disease.

Minimum Criteria

Empiric treatment of pelvic inflammatory disease should be considered in sexually active young women and others at risk STD, if all of the following criteria are met and if there is no other cause of the patient's disease:

Pain on palpation in the lower abdomen
Pain in the appendages, and
Painful traction of the cervix.

Additional Criteria

Overdiagnosis is often justified, as misdiagnosis and treatment can lead to serious consequences. These additional criteria can be used to increase the specificity of the diagnosis.

The following are additional criteria that support the diagnosis of pelvic inflammatory disease:

Temperature above 38.3°C,
Pathological discharge from the cervix or vagina,
elevated ESR,
Enhanced Level C-reactive protein,
Laboratory confirmation of N. gonorrhoeae or C. trachomatis cervical infection.

Below are the defining criteria for the diagnosis of inflammatory diseases of the pelvic organs, which prove the selected cases of diseases:

Histopathological finding of endometritis on endometrial biopsy,
Ultrasound with a transvaginal probe (or using other technologies) showing thickened, fluid-filled fallopian tubes with or without free fluid in the abdominal cavity or the presence of a tubo-ovarian mass,
Abnormalities found during laparoscopy consistent with PID.

Although the decision to initiate treatment may be made before a bacteriological diagnosis of N. gonorrhoeae or C. trachomatis infections is made, confirmation of the diagnosis emphasizes the need to treat sexual partners.

Treatment of pelvic inflammatory disease

If acute inflammation is detected, the patient should be hospitalized in a hospital, where she is provided with a therapeutic and protective regimen with strict observance physical and emotional peace. Assign bed rest, ice on the hypogastric region (2 hours with breaks of 30 minutes - 1 hour for 1-2 days), sparing diet. Carefully monitor the activity of the intestines, if necessary, prescribe warm cleansing enemas. Patients benefit from bromine preparations, valerian, sedatives.

Etiopathogenetic treatment of patients with inflammatory diseases of the pelvic organs involves the use of both conservative therapy and timely surgical treatment.

Conservative treatment of acute inflammatory diseases of the upper genital organs is carried out in a complex manner and includes:

antibacterial therapy;
detoxification therapy and correction of metabolic disorders;
anticoagulant therapy;
immunotherapy;
symptomatic therapy.

Antibacterial therapy

Since the microbial factor plays a decisive role in acute stage inflammation, which determines during this period of the disease is antibiotic therapy. On the first day of the patient's stay in the hospital, when there are still no laboratory data on the nature of the pathogen and its sensitivity to a particular antibiotic, the presumptive etiology of the disease is taken into account when prescribing drugs.

Behind last years the effectiveness of treatment of severe forms of purulent-inflammatory complications increased with the use of beta-lactam antibiotics (augmentin, meronem, thienam). The "gold" standard is the use of clindamycin with gentamicin. It is recommended to change antibiotics after 7-10 days with repeated determination of antibiograms. In connection with the possible development of local and generalized candidiasis during antibiotic therapy, it is necessary to study hemo- and urocultures, as well as prescribe antifungal drugs.

If oligoanuria occurs, an immediate review of the doses of antibiotics used is indicated, taking into account their half-life.

Treatment regimens for pelvic inflammatory disease should provide empirical elimination of a wide range of possible pathogenic microorganisms, including N. gonorrhoeae, C. trachomatis, gram-negative facultative bacteria, anaerobes and streptococci. Although some antimicrobial regimens have been shown to be effective in achieving clinical and microbiological cure in a clinical randomized trial with short-term follow-up, there are few studies evaluating and comparing the elimination of endometrial and fallopian tube infection or the incidence of long-term complications such as tubal infertility and ectopic pregnancy.

All regimens should be effective against N. gonorrhoeae and C. trachomatis, as negative tests for these infections in the endocervix do not rule out infection in the upper reproductive tract. While the need for anaerobic eradication in women with PID is still controversial, there is evidence that it may be important. Anaerobic bacteria isolated from the upper reproductive tract of women with PID and those obtained in vitro clearly show that anaerobes such as B. fragilis can cause tubal and epithelial destruction. In addition, many women with PID are also diagnosed with bacterial vaginosis. In order to prevent complications, the recommended regimens should include drugs that act on anaerobes. Treatment should be started as soon as a preliminary diagnosis is established, as prevention long-term effects is directly related to the timing of the appointment of appropriate antibiotics. When choosing a treatment regimen, the physician should consider its availability, cost, patient acceptability, and sensitivity of pathogens to antibiotics.

In the past, many experts have recommended that all patients with PID be hospitalized so that parenteral antibiotic treatment can be administered under medical supervision under bed rest. However, hospitalization is no longer synonymous with parenteral therapy. There are currently no data available that would show the comparative efficacy of parenteral and oral treatment, or inpatient or outpatient treatment. Until data from ongoing studies comparing parenteral inpatient versus oral outpatient treatment in women with PID become available, clinical observational data should be considered. The doctor makes a decision on the need for hospitalization based on the following recommendations, based on observational data and theoretical developments:

Conditions that require urgent surgical intervention such as appendicitis,
The patient is pregnant
Unsuccessful treatment with oral antimicrobials,
Inability to comply with or tolerate outpatient oral regimen,
Severe illness, nausea and vomiting, or high fever.
tubo-ovarian abscess
The presence of immunodeficiency (HIV infection with a low CD4 count, immunosuppressive therapy or other diseases).

Most clinicians conduct at least 24 hours of direct observation in the hospital of patients with tubo-ovarian abscesses, after which adequate parenteral treatment should be given at home.

There are no convincing data comparing parenteral and oral regimens. A lot of experience has been accumulated in the application of the following schemes. Also, there are multiple randomized trials demonstrating the effectiveness of each regimen. Although most of the studies used parenteral treatment for at least 48 hours after the patient showed significant clinical improvement, this regimen was administered arbitrarily. Clinical experience should guide the decision to switch to oral treatment, which can be made within 24 hours of the onset of clinical improvement.

Scheme A for parenteral treatment

Cefotetan 2 g IV every 12 hours
or Cefoxitin 2 g IV every 6 hours
plus doxycycline 100 mg IV or po q 12 hours.

NOTE. Considering that infusion administration of drugs is associated with painful sensations, oral doxycycline should be given whenever possible, even if the patient is in the hospital. oral and intravenous treatment doxycycline has the same bioavailability. If intravenous administration is required, the use of lidocaine or other fast-acting local anesthetics, heparin, or steroids, or prolongation of the infusion time may reduce infusion complications. Parenteral treatment may be discontinued 24 hours after the patient is clinically improved, and oral doxycycline 100 mg twice daily should be continued for up to 14 days. In the presence of a tubo-ovarian abscess, many physicians use clindamycin or metronidazole with doxycycline to continue treatment, rather than doxycycline alone, as this contributes to a more effective overlap of the entire spectrum of pathogens, including anaerobes.

Clinical data on second- or third-generation cephalosporins (eg, ceftizoxime, cefotaxime, or ceftriaxone) that can replace cefoxitin or cefotetan are limited, although many authors believe that they are also effective in PID. However, they are less active against anaerobic bacteria than cefoxitin or cefotetan.

Scheme B for parenteral treatment

Clindamycin 900 mg IV every 8 hours
plus Gentamicin - loading dose IV or IM (2 mg/kg body weight) followed by a maintenance dose (1.5 mg/kg) every 8 hours.

NOTE. Although the use of a single dose of gentamicin has not been studied in the treatment of pelvic inflammatory disease, its effectiveness in other similar situations is well established. Parenteral treatment may be interrupted 24 hours after the patient has clinical improvement, and then switched to oral treatment with doxycycline 100 mg 2 times a day or clindamycin 450 mg orally 4 times a day. The total duration of treatment should be 14 days.

For tubo-ovarian abscess, many health care providers use clindamycin rather than doxycycline to continue treatment because it is more effective against anaerobic organisms.

Alternative parenteral regimens

There is limited data on the use of another parenteral regimen, but the following three regimens have been in at least one clinical trial and shown to be effective against a wide range microorganisms.

Ofloxacin 400 mg IV every 12 hours
or Ampicillin/sulbactam 3 g IV every 6 hours
or Ciprofloxacin 200 mg IV every 12 hours
plus doxycycline 100 mg orally or IV every 12 hours.
plus Metronidazole 500 mg IV every 8 hours.

The ampicillin/sulbactam with doxycycline regimen was effective against N. gonorrhoeae, C. trachomatis, and anaerobes and was effective in patients with tubo-ovarian abscess. Both intravenous drugs, ofloxacin and ciprofloxacin, have been studied as monotherapy drugs. Given the data obtained on the ineffective effect of ciprofloxacin on C. trachomatis, it is recommended to routinely add doxycycline to treatment. Since these quinolones are active only against a subset of anaerobes, metronidazole should be added to each regimen.

oral treatment

There are few data on the immediate and long-term outcomes of treatment, both in the parenteral regimen and in the outpatient regimen. The use of the following schemes provides antimicrobial action against the most common causative agents of PID, but clinical trial data on their use are very limited. Patients who do not improve with oral treatment within 72 hours should be re-evaluated to confirm the diagnosis and given parenteral treatment in outpatient or stationary conditions.

Scheme A

Ofloxacin 400 mg twice daily for 14 days
plus Metronidazole 500 mg orally twice a day for 14 days

Oral ofloxacin, used as monotherapy, has been studied in two well-designed clinical trials and has been shown to be effective against N. gonorrhoeae and C. trachomatis. However, given that ofloxacin is still not sufficiently effective against anaerobes, the addition of metronidazole is necessary.

Scheme B

Ceftriaxone 250 mg IM once
or Cefoxitin 2 g IM plus Probenecid 1 g orally once at a time
or Other third-generation parenteral cephalosporin (eg, ceftizoxime, cefotaxime),
plus doxycycline 100 mg orally twice a day for 14 days. (Use this circuit with one of the above circuits)

The optimal choice of cephalosporin for this regimen has not been determined; while cefoxitin is active against more types of anaerobes, ceftriaxone has more high efficiency against N. gonorrhoeae. Clinical trials have shown that a single dose of cefoxitin is effective in obtaining a rapid clinical response in women with PID, however, theoretical data indicate the need to add metronidazole. Metronidazole will also effectively treat bacterial vaginosis, which is often associated with PID. No data have been published on the use of oral cephalosporins for the treatment of PID.

Alternative outpatient regimens

Information on the use of other outpatient regimens is limited, but one regimen has received at least one clinical trial showing efficacy against a wide range of pathogens in pelvic inflammatory disease. When amoxicillin/clavulanic acid was combined with doxycycline, a rapid clinical effect was obtained, however, many patients were forced to interrupt the course of treatment due to undesirable symptoms from the gastrointestinal tract. Several studies have evaluated azithromycin in the treatment of upper reproductive tract infections, however, these data are not sufficient to recommend this drug for the treatment of pelvic inflammatory disease.

Detoxification therapy and correction of metabolic disorders

This is one of the most important components of treatment aimed at breaking the pathological circle of cause-and-effect relationships that occur in purulent-inflammatory diseases. It is known that these diseases are accompanied by a violation of all types of metabolism, excretion a large number liquids; there is an imbalance of electrolytes, metabolic acidosis, renal and hepatic insufficiency. Adequate correction of the identified violations is carried out jointly with resuscitators. When carrying out detoxification and correction of water-electrolyte metabolism, two extreme conditions should be avoided: insufficient fluid intake and overhydration of the body.

In order to eliminate these errors, it is necessary to control the amount of fluid introduced from the outside (drink, food, medicinal solutions) and excreted in the urine and other ways. The calculation of the introduced risk should be individual, taking into account the indicated parameters and the patient's condition. Correct infusion therapy in the treatment of acute inflammatory and purulent-inflammatory diseases is no less important than the appointment of antibiotics. Clinical experience shows that a patient with stable hemodynamics with adequate replenishment of BCC is less susceptible to the development of circulatory disorders and the occurrence of septic shock.

Main clinical signs restoration of BCC, elimination of hypovolemia are indicators of CVP (60-100 mm of water column), diuresis (more than 30 ml / h without the use of diuretics), improvement of microcirculation (skin color, etc.).

Pelvioperitonitis is observed quite often with the development of inflammatory diseases of the pelvic organs. Because peritoneal inflammation increases extrarenal fluid and electrolyte losses, the basic principles of fluid and protein replacement must be considered. According to modern ideas both colloidal solutions (plasma, albumin, low molecular weight dextrans) and crystalloid solutions (0.9% sodium chloride solution) should be administered per 1 kg of the patient's body weight.

From crystalloid solutions, isotonic sodium chloride solution, 10% and 5% glucose solution, Ringer-Locke solution, polyionic solutions are used. From colloidal solutions, low molecular weight dextrans are used. It should be emphasized that the total amount of dextrans should not exceed 800-1200 ml / day, since their excessive administration can contribute to the development of hemorrhagic diathesis.

Patients with septic complications of community-acquired abortion lose a significant amount of electrolytes along with fluid. In the process of treatment, it becomes necessary to quantify the introduction of the main electrolytes - sodium, potassium, calcium and chlorine. When introducing corrective doses of electrolyte solutions, the following should be observed:

Compensation for electrolyte deficiency should be done slowly, drip method, avoiding the use of concentrated solutions.
Periodic monitoring of the acid-base state and electrolytes of blood serum is indicated, since corrective doses are calculated only for extracellular fluid.
You should not strive to bring their performance to the absolute norm.
After reaching a stable normal level of serum electrolytes, only their maintenance dose is administered.
With deterioration of kidney function, it is necessary to reduce the amount of fluid administered, reduce the amount of sodium administered, and completely eliminate the introduction of potassium. For detoxification therapy, the method of fractional forced diuresis is widely used with the production of 3000-4000 ml of urine per day.

Since hypoproteinemia is always observed in septic conditions due to impaired protein synthesis, as well as due to increased protein breakdown and blood loss, the administration of protein preparations is mandatory (plasma, albumin, protein).

Anticoagulant therapy

With widespread inflammatory processes, pelvioperitone, peritonitis, thromboembolic complications are possible in patients, as well as the development of disseminated intravascular coagulation (DIC).

Currently, one of the first signs of DIC is thrombocytopenia. Reducing the number of platelets to 150 x 10 3 /l is the minimum that does not lead to hypocoagulable bleeding.

In practice, the determination of the prothrombin index, platelet count, fibrinogen level, fibrin monomers, and blood clotting time is sufficient to timely diagnosis ICE. For the prevention of DIC and with a slight change in these tests, heparin is prescribed at 5000 IU every 6 hours under the control of blood clotting time within 8-12 minutes (according to Lee White). The duration of heparin therapy depends on the speed of improvement of laboratory data and is usually 3-5 days. Heparin should be given before clotting factors are significantly reduced. Treatment of DIC, especially in severe cases, is extremely difficult.

Immunotherapy

Along with antibacterial therapy in conditions of low sensitivity of pathogens to antibiotics, agents that increase the general and specific reactivity of the patient's body are of particular importance, since generalization of infection is accompanied by a decrease in cellular and humoral immunity. Based on this, complex therapy includes substances that increase immunological reactivity: antistaphylococcal gamma globulin and hyperimmune antistaphylococcal plasma. Gamma globulin is used to increase nonspecific reactivity. An increase in cellular immunity is facilitated by drugs such as levamisole, taktivin, thymogen, cycloferon. In order to stimulate the immune system, efferent therapy methods (plasmapheresis, ultraviolet and laser blood irradiation) are also used.

Symptomatic treatment

An essential condition for the treatment of patients with inflammatory diseases of the upper genital organs is effective pain relief using both analgesics and antispasmodics, and inhibitors of prostaglandin synthesis.

It is mandatory to introduce vitamins based on the daily requirement: thiamine bromide - 10 mg, riboflavin - 10 mg, pyridoxine - 50 mg, nicotinic acid - 100 mg, cyanocobalamin - 4 mg, ascorbic acid - 300 mg, retinol acetate - 5000 units.

Appointment shown antihistamines(suprastin, tavegil, diphenhydramine, etc.).

Rehabilitation of patients with inflammatory diseases of the upper genital organs

Treatment of inflammatory diseases of the genital organs in a woman necessarily includes a complex rehabilitation activities aimed at restoring the specific functions of the female body.

For normalization menstrual function after acute inflammation, medications are prescribed, the action of which is aimed at preventing the development of algomenorrhea (antispasmodics, non-steroidal anti-inflammatory drugs). The most acceptable form of administration of these medicines are rectal suppositories. Restoration of the ovarian cycle is carried out by the appointment of combined oral contraceptives.

Physiotherapeutic methods in the treatment of inflammatory diseases of the pelvic organs are prescribed differentially, depending on the stage of the process, the duration of the disease and the effectiveness of the previous treatment, the presence of concomitant extragenital pathology, the state of the central and autonomic nervous system and age features sick. The use of hormonal contraception is recommended.

In the acute stage of the disease, at a body temperature below 38 ° C, UHF is prescribed for the hypogastric region and the lumbosacral plexus according to the transverse method in a non-thermal dosage. With a pronounced edematous component, combined exposure to ultraviolet light on the panty zone in 4 fields is prescribed.

With a subacute onset of the disease, the appointment of a microwave electromagnetic field is preferable.

When the disease passes into the stage of residual phenomena, the task of physiotherapy is to normalize the trophism of suffering organs by changing vascular tone, the final relief of edematous phenomena and pain syndrome. For this purpose, reflex methods of exposure to currents of supratonal frequency are used. D "Arsonval, ultrasound therapy.

When the disease passes into the remission stage, heat and mud therapy procedures (paraffin, ozocerite) are prescribed for the area of the panty zone, balneotherapy, aerotherapy, helio- and thalassotherapy.

In the presence of chronic inflammation of the uterus and its appendages in the period of remission, it is necessary to prescribe resolving therapy using biogenic stimulants and proteolytic enzymes. The duration of rehabilitation measures after acute inflammation of the internal genital organs is usually 2-3 menstrual cycles. A pronounced positive effect and a decrease in the number of exacerbations of chronic inflammatory processes are observed after spa treatment.

Surgical treatment of purulent-inflammatory diseases of the internal genital organs

Indications for surgical treatment of purulent-inflammatory diseases of the female genital organs are currently:

Lack of effect during conservative complex therapy for 24-48 hours.
Deterioration of the patient's condition during a conservative course, which can be caused by perforation of a purulent formation into the abdominal cavity with the development of diffuse peritonitis.
Development of symptoms of bacterial toxic shock. The volume of surgical intervention in patients with inflammatory diseases of the uterine appendages depends on the following main points:
1. the nature of the process;
2. concomitant pathology genital organs;
3. the age of the patients.

It is the young age of patients that is one of the main points that determine the adherence of gynecologists to sparing operations. In the presence of concomitant acute pelvioperitonitis With purulent lesions of the uterine appendages, the uterus is extirpated, since only such an operation can ensure the complete elimination of the infection and good drainage. One of important points surgical treatment of purulent inflammatory diseases of the uterine appendages is the complete restoration of normal anatomical relationships between the organs of the small pelvis, abdominal cavity and surrounding tissues. It is necessary to make an audit of the abdominal cavity, determine the condition of the appendix and exclude interintestinal abscesses with a purulent nature of the inflammatory process in the uterine appendages.

In all cases, when performing an operation for inflammatory diseases of the uterine appendages, especially when purulent process, one of the main ones should be the principle of mandatory complete removal of the focus of destruction, i.e., inflammatory formation. No matter how gentle the operation is, it is always necessary to completely remove all tissues of the inflammatory formation. Preservation of even a small portion of the capsule often leads to severe complications in the postoperative period, recurrence of the inflammatory process, and the formation of fistulas. During surgical intervention, drainage of the abdominal cavity (colyutomy) is mandatory.

The condition for reconstructive surgery with preservation of the uterus is primarily the absence of purulent endomyometritis or panmetritis, multiple extragenital purulent foci in the pelvis and abdominal cavity, as well as concomitant severe genital pathology (adenomyosis, fibroids) established before or during surgery.

Among women reproductive age in the presence of conditions, it is necessary to extirpate the uterus with the preservation, if possible, of at least part of the unchanged ovary.

In the postoperative period, complex conservative therapy continues.

Follow-up

In patients receiving oral or parenteral treatment, significant clinical improvement (eg, reduction in temperature, reduction in abdominal wall muscle tension, reduction in pain on palpation during examination of the uterus, appendages, and cervix) should be observed within 3 days from the start of treatment. Patients in whom such improvement is not observed require clarification of the diagnosis or surgical intervention.

If the clinician has opted for outpatient oral or parenteral treatment, follow-up and evaluation of the patient should be carried out within 72 hours using the above criteria for clinical improvement. Some experts also recommend repeat screening for C. trachomatis and N. gonorrhoeae 4–6 weeks after completion of therapy. If PCR or LCR is used to control cure, then a second study should be carried out one month after the end of treatment.

Management of sexual partners

Examination and treatment of sexual partners (who were in contact in the previous 60 days before the onset of symptoms) of women with PID is necessary because of the risk of reinfection and the high probability of detecting gonococcal or chlamydial urethritis in them. Male sexual partners of women with PID caused by gonorrhea or chlamydia often do not have symptoms.

Sexual partners should be treated empirically according to the treatment regimen for both infections, regardless of whether the causative agent for pelvic inflammatory disease has been identified.

Even in clinics where only women are seen, health care providers should ensure that men who are sexual partners of women with PID are treated. If this is not possible, the health worker treating a woman with PID needs to be sure that her partners have received appropriate treatment.

Special remarks

Pregnancy. Given the high risk poor outcome pregnancy, pregnant women with suspected PID should be hospitalized and treated with parenteral antibiotics.

HIV infection. Differences in the clinical manifestations of PID in HIV-infected and uninfected women are not described in detail. Based on early observational data, it was assumed that HIV-infected women with PID were more likely to need surgery. Subsequent, more comprehensive review studies of HIV-infected women with PID noted that even with more severe symptoms than HIV-negative women, parenteral antibiotic treatment of these patients was successful. In another trial, microbiological findings in HIV-infected and uninfected women were similar, except for a higher incidence of comorbidity. chlamydial infection and HPV infections, as well as cellular changes caused by HPV. HIV-infected women immunocompromised patients with PID require more extensive therapy using one of the parenteral antimicrobial regimens described in this guide.

Inflammation of the pelvic organs in women is the most serious complication of infectious diseases that are sexually transmitted. Symptoms of inflammation are usually the result of infection. The categories of women who are subject to it, unfortunately, are very extensive. timely treatment of pelvic inflammatory disease help prevent infertility problems.

Symptoms of pelvic inflammatory disease

Inflammation of the pelvic organs very often leads to irreversible damage to the ovaries, uterus, fallopian tubes. Female infertility is one of the consequences of such a phenomenon.

Symptoms of inflammation in different cases may vary, but usually these are:

seizures dull pain and slight soreness in the lower abdomen, as well as in the right iliac region,

discharge of yellow, yellow-green leucorrhoea, having unpleasant and unusual odors,

painful and irregular menstruation

cramping pains,

fever and chills,

vomiting and nausea,

unpleasant pain during intercourse.

If you have symptoms of inflammation, you need to be examined by a gynecologist. Inflammation of the pelvic organs is also indicated by pain during probing the uterus and appendages.

Symptoms of pelvic inflammatory disease in endometritis

Endometritis is a disease characterized by an inflammatory process localized in the mucous membrane of the uterus. The clinical picture of inflammation of this type begins with the appearance of leucorrhea, which at the initial stage have a normal white color, and then acquire a yellowish-green color. The discharge may have an unpleasant odor, especially when it becomes purulent, the smell becomes more offensive.

Acute inflammation of the pelvic organs is characterized by high temperature, pain in the lower abdomen, which can radiate to the sacrum.

Symptoms of inflammation of the pelvic organs with perimetritis

Perimetritis includes the inflammatory process of the peritoneal part of the uterus. The peritoneum covers the uterus front and back. In the presence of an inflammatory process in the uterus, it is able to pass to the peritoneal parts, as well as appendages. Inflammation of the pelvic organs at the initial stage has characteristic signs:

pain in the abdomen,
on palpation of the abdomen, its swelling and tension are noted,
frequent urges to urination, which are accompanied sharp pains,
pulse quickens,
the temperature rises.

Treatment of pelvic inflammatory disease

With inflammation, broad-spectrum antibiotics should be used.

You also need to complete the full course of treatment, otherwise the bacterium will remain in the body and develop resistance to this species antibiotics.

Both partners should be treated for pelvic inflammatory disease to prevent re-inflammation.

During treatment, you need to protect yourself with condoms.

To avoid intestinal dysbacteriosis, you need to take lacto - and bifidus bacteria a week before the start of treatment and two weeks after it ends.

Treatment of inflammation of the pelvic organs with simultaneous administration alcoholic beverages leads to increased side effects.

Causes of inflammation in women

Most often, this disease occurs in young women. In addition, this inflammation of the pelvic organs does not have pronounced symptoms, which causes a protracted nature of the disease, and also leads to the need for treatment in a hospital. At the beginning of the disease, the vagina and cervix are filled with conditionally pathogenic flora. This process in the pelvis can be asymptomatic and continue for several months or even years. When these bacteria find themselves in the uterine cavity and in the lumen of the fallopian tubes, inflammation of the pelvic organs occurs.

This is always the most common reason for referrals to narrowly focused women's specialists. In a normal state, the cervix is an insurmountable obstacle for all kinds of bacteria that enter the vagina and does not allow bacteria to penetrate higher.

Pelvic inflammatory disease can be caused by:

staphylococci,
mushrooms,
coli,
chlamydia,
viruses,
gardnerella,
gonococcus,
Trichomonas.

Mycoplasma and ureoplasma can cause complications during pregnancy: vaginitis (inflammation of the vagina), cervititis (inflammation of the cervix), as well as inflammation of the mucous membrane of the uterus, ovaries, peritoneum and pelvic tissue.

If the cervix is susceptible to venereal disease pathogens such as gonorrhea and chlamydia, it may lose its ability to be a protective barrier and no longer protect internal important organs from the penetration of microorganisms. If pathogens nevertheless penetrated through the cervix into the upper genital organs, then inflammation of the pelvic organs begins. Approximately 90% of all cases of the disease are due to untreated chlamydia and gonorrhea. Other causes of infection of the genital organs are childbirth, abortion, surgical and research procedures in the pelvic area.

Factors that cause pelvic inflammatory disease

Any intrauterine interventions, such as abortion surgery or the introduction of intrauterine devices, can lead to inflammation.

Sex without using barrier means contraception.

promiscuous sex life possible reason inflammation.

Hypothermia.

Transferred in the past inflammation of the genital organs.

Non-observance of personal hygiene.

Risk groups for the diagnosis of pelvic inflammatory disease

Women who are carriers of sexually transmitted diseases, patients with these diseases. Especially if they suffer from gonorrhea and chlamydia;

women who already had inflammation before are also at risk of relapse;

adolescent girls who are sexually active are much more susceptible to this disease than older women;

women who constantly have many sexual partners are also at high risk of "earning" inflammation, which is sexually transmitted.

Endometritis and perimetritis as a cause of inflammation in women

Endometritis and perimetritis - can be caused by a wide variety of microorganisms, most often they are streptococci, gonococci, E. coli, staphylococci, viruses and fungi. Getting into the vagina sexually or if proper rules of feminine hygiene are not observed, microorganisms are able to move along the genital tract to various organs.

Inflammation of the pelvic organs with endometritis and perimetritis can be triggered by a violation of the integrity of the cover of a particular genital organ. The appearance of wounds and scratches can occur when

wearing uncomfortable and rough clothes,
underwear,
can also appear during rough sexual intercourse.
In addition, inflammation contributes to being in the genitals for a long time. foreign bodies such as spirals, contraceptive caps and others.
Surgical interventions that were performed on the genitals with non-compliance with all disinfection standards can also lead to inflammatory processes.

According to statistics, most women with pelvic inflammatory disease are in their childbearing period.

Pelvic inflammatory disease (PID) includes inflammation of the uterus, its tubes, ovaries, parametrium, and pelvic peritoneum. Isolated inflammation of these formations in clinical practice is extremely rare due to their anatomical proximity and functional unity.

SYNONYMS

In the English literature, these diseases are referred to as pelvic inflammatory disease. In the domestic literature, the most commonly used term for PID is "salpingitis" or "salpingoophoritis".

ICD-10 CODE
N70 Salpingitis and oophoritis (including abscess of the fallopian tube, tubo-ovarian, ovary, pyosalpinx, salpingo-oophoritis, tubo-ovarian inflammatory disease).
N71 Inflammatory diseases of the uterus, except for the cervix (including uterine abscess, metritis, myometritis, pyometra, endo(myo-)metritis).
N72 Inflammatory diseases of the cervix (erosion and ectropion of the cervix without cervicitis are excluded).
N73 Other inflammatory diseases of female pelvic organs.
N74 Inflammatory diseases of the female pelvic organs in diseases classified elsewhere.

EPIDEMIOLOGY

Inflammatory diseases are the most common pathology of the internal genitalia in childhood. They make up from 1 to 5% of all acute surgical diseases of the abdominal organs in children, ranking third in frequency after acute appendicitis and intestinal obstruction. There are several age peaks in the incidence of PID:
at 3-5, 11-13 and 18-20 years old. The first two coincide with the age maxima of the disease with appendicitis, the last - with the debut of sexual activity. In connection with the frequent combination of inflammation of the appendix and OVZPM, appendicular-genital syndrome is distinguished.

According to domestic and foreign scientists, girls aged 15–19 are most at risk of inflammation. At this age immature stratified epithelium the cervix is more susceptible to the action of infectious, cocarcinogenic and carcinogenic agents. The current situation is due to the freedom of sexual behavior, frequent change of sexual partners, ignorance or unwillingness to use barrier contraception, addiction.

Every year, 4% of women aged 15 to 44 have medical abortions worldwide. Endometritis develops in 12.25-56% of patients after artificial termination of pregnancy.

In Russia in 2002, 1,782 million abortions were registered. Of these, 10.3% were teenagers and girls aged 15–19.

SCREENING

Carried out when contacting gynecologists and pediatricians, during preventive examinations.

CLASSIFICATION

According to the topography of the lesion of the macroorganism, inflammatory diseases of the lower urogenital tract and ascending infection can be distinguished. Lesions of the lower urogenital tract include urethritis, paraurethritis, bartholinitis, colpitis and endocervicitis.

Inflammatory processes by duration are divided into acute and chronic. Inflammatory processes lasting up to 4–6 weeks are considered acute; in most cases, acute inflammation ends within 1.5–2 weeks. In clinical practice, it is customary to distinguish between acute, subacute and chronic PID. By acute inflammation is meant a first-time disease that has a vivid clinical picture.

Currently, according to the proposal of G. Monif (1983), there are four stages of an acute inflammatory process:

Stage I - acute endometritis and salpingitis without signs of inflammation of the pelvic peritoneum;
Stage II - acute endometritis and salpingitis with signs of peritoneal irritation;
Stage III - acute salpingo-oophoritis with occlusion of the fallopian tubes and the development of tubo-ovarian formation;
Stage IV - rupture of the tubo-ovarian formation.

IN AND. Krasnopolsky (2002) identifies the following forms of PID:

uncomplicated forms (salpingitis, oophoritis, salpingo-oophoritis);
complicated forms (pyosalpinx, ovarian abscess (pyovar), purulent tubo-ovarian formation);
severe purulent-septic diseases (panmetritis, parametritis, interintestinal, subdiaphragmatic abscesses,
genital fistulas, purulent infiltrative omentitis, diffuse peritonitis, sepsis).

ETIOLOGY

As a rule, PID is characterized by a polymicrobial etiology. Almost all microorganisms present in the vagina (with the exception of lactobacilli and bifidobacteria) can take part in the inflammatory process. However, the leading role belongs to the most virulent microorganisms: representatives of the Enterobacteriaceae family (primarily Escherichia coli) and staphylococcus aureus. The role of anaerobes as copathogens is generally recognized, but it should not be overestimated.

With PID, staphylococci, streptococci, enterococci, anaerobes, chlamydia, mycoplasmas, and ureaplasmas are most often found. In recent years, great importance has been attached to opportunistic infection, which refers to predominantly endogenous microorganisms that exhibit pathogenic properties mainly against the background of a violation of the mechanisms of anti-infective defense of the body. The development of opportunistic infections is facilitated by: irrational use of broad-spectrum antibiotics, hormonal drugs; surgical interventions; various invasive medical procedures; violation of the integrity of tissues and local immunity of the vagina as a result of primary infection, etc.

PATHOGENESIS

Infection of the internal genital organs can occur:

lymphogenous in appendicitis, cholecystitis, perihepatitis, pleurisy, with the development of pelvioperitonitis and further lymphogenous spread to the peritoneum of the subdiaphragmatic region ( abdominal syndrome Fitz-Hugh-Curtis);
hematogenous, as evidenced by extragenital complications (for example, damage to the articular bags in chlamydia);
canalicularly (through the cervical canal, uterine cavity, fallopian tubes to the peritoneum and abdominal organs).

CLINICAL PICTURE

Clinical manifestations of acute inflammation of the internal genital organs: high body temperature, pain in the lower abdomen, there may be nausea, vomiting, violation general condition, severe intoxication, changes in the blood (leukocytosis, increased ESR, the appearance of C reactive protein).

Subacute inflammation is a first-time process with less pronounced symptoms than with acute inflammation of the internal genital organs: subfebrile body temperature, the absence of severe intoxication, a slight pain reaction, low leukocytosis and moderate elevated ESR in blood. This process is characterized by a protracted course. Obviously, this division is conditional, since the assessment of the manifestations of the inflammatory process is very subjective.

Chronic PID may be the result of acute inflammation that has not been fully cured, and may also be primarily chronic. Chronic PID often flow in waves with alternating periods of exacerbation and remission.

It is customary to distinguish between chronic salpingo-oophoritis in the acute stage, primary chronic salpingo-oophoritis and residual effects (cicatricial adhesions) of chronic salpingo-oophoritis.

The infection can spread upward or downward. It is necessary to distinguish between primary and secondary salpingitis. In primary salpingitis, the infection rises from the lower genital tract by spreading cervical or perianal flora on the fallopian tubes (diagnostic and therapeutic procedures). With secondary salpingitis, inflammation develops due to the penetration of the pathogen from nearby organs, in particular from the affected appendix.

DIAGNOSTICS

ANAMNESIS

When studying the anamnesis, it is necessary to pay attention to the presence of extragenital (appendicitis, cholecystitis, perihepatitis, tonsillitis, etc.) and genital (vulvitis) foci of chronic infection.

PHYSICAL EXAMINATION

Bimanual recto-abdominal examination reveals in the area of the uterine appendages soreness, their slight increase. In the formation of a tubo-ovarian tumor of inflammatory origin the formation in the area of the uterine appendages is determined, which can reach large sizes. In the presence of a pelvic ganglioneuritis note soreness in the area of the exit of the pelvic nerves and the absence of anatomical changes internal genital organs.

LABORATORY RESEARCH

If PID is suspected, a clinical blood test is performed (pay attention to leukocytosis, changes in leukocyte formula, an increase in ESR, the appearance of a C-reactive protein in the blood), microscopic and microbiological examination of discharged contents from the genital tract, urethra. Also doing research by PCR for the presence of chlamydial and gonococcal infections.

When viewing the results of ultrasound of the pelvic organs, in some cases, free fluid is found in the cavity of the small pelvis. Sensitivity this method- 32-42%, specificity - 58-97%, which allows it to be attributed to helper methods diagnosis in PID. Ultrasound should be performed if there is a suspicion of tubo-ovarian formations. In the same situation, MRI of the pelvic organs is desirable.

DIFFERENTIAL DIAGNOSIS

Inflammatory diseases of the internal genitalia often occur under the guise of SARS, acute abdominal pathology (most often acute appendicitis), which often requires diagnostic laparoscopy to clarify conditions of the appendix and uterine appendages. PID must be differentiated from uterine and ectopic pregnancy in sexually active adolescents or suspected sexual abuse. In this case, carry out ultrasound, determine hCG levelβ in blood serum. In addition, a similar clinical and laboratory picture with PID have ovulatory syndrome, ovarian apoplexy and adnexal torsion.

When PID in children, consultation with specialists is necessary therapeutic profile on suspicion of infection or inflammatory diseases of the urinary tract, by a surgeon - to exclude acute surgical pathology of the abdominal organs, a phthisiatrician - to exclude the inflammatory process of tuberculous etiology.

EXAMPLE FORMULATION OF THE DIAGNOSIS

Acute right-sided salpingo-oophoritis.

TREATMENT OF PELVIC INFLAMMATORY IN GIRLS

GOALS OF TREATMENT

Prevention of further development of the inflammatory process, prevention of reproductive dysfunction.

INDICATIONS FOR HOSPITALIZATION.

1. Body temperature above 38 °C.
2. Severe intoxication.
3. Complicated forms of PID (the presence of an inflammatory conglomerate - tubo-ovarian formation).
4. Pregnancy.
5. The presence of an IUD.
6. An unidentified or doubtful diagnosis, the presence of symptoms of peritoneal irritation.
7. Intolerance to drugs for oral administration.
8. Lack of improvement on the background of ongoing therapy after 48 hours.

NON-DRUG TREATMENT

In acute salpingoophoritis, physiotherapy is carried out only in combination with adequate antibacterial, detox and more drug therapy. You can start treatment immediately after the diagnosis is made.

Contraindications for use physical factors consist of general for physiotherapy and special for pathology genitals. In acute salpingitis, oophoritis, low-frequency magnetic therapy is indicated, therapy with constant magnetic field; with subacute inflammation of the appendages, microwave therapy is performed with decimeter waves, magneto-laser therapy, laser therapy, LS electrophoresis with impulse currents.

During the period of stable remission, it is possible to use preformed physical factors: TNF and ultrasound therapy, therapy with a low-frequency electrostatic field, electropulse therapy using hardware and software "AndroGin" complex, laser therapy, non-specific electrothermotherapy, interference therapy, LS electrophoresis impulse currents. Optimal time start of physiotherapy - 5-7th day of the menstrual cycle.

In a chronic inflammatory process in the uterine appendages, especially in combination with chronic extragenital inflammatory diseases, plasmapheresis is pathogenetically justified, because during the procedure, not only elimination of toxic substances, Ag, AT, immune complexes, immunocompetent cells, but also deblocking own detoxification systems, immune system. Plasmapheresis is most effective when conducting it in the first phase of the menstrual cycle (immediately after the cessation of menstrual bleeding).

MEDICAL TREATMENT

TREATMENT OF ACUTE PID

The dosage of drugs is selected taking into account the age, body weight of the child and the severity of the clinical picture. diseases.

Antibacterial drugs or their combination are selected taking into account the pathogen and its sensitivity to antimicrobials.

At mild form diseases basic therapy consists of antibacterial drugs, derivatives nitroimidazole, antifungal and antihistamine drugs. Additionally, NSAIDs are used immunomodulators.

With chlamydial and mycoplasmal etiology of PID, it is preferable to use antibiotics capable of accumulation in affected cells and blocking of intracellular protein synthesis. Such drugs include tetracyclines (doxycycline, tetracycline), macrolides (azithromycin, josamycin, clarithromycin, midecamycin, oleandomycin, roxithromycin, spiramycin, erythromycin) and fluoroquinolones (lomefloxacin, norfloxacin, ofloxacin, pefloxacin, ciprofloxacin, sparfloxacin).

In modern therapy of acute uncomplicated chlamydial or mycoplasmal salpingo-oophoritis, the following antibiotics:

azithromycin;
doxycycline.

With salpingo-oophoritis caused by gonococci, "protected" penicillins are used - a combination of an antibiotic with substances that destroy β-lactamase, given that 80% of gonococcus strains due to the production of β-lactamase resistant to penicillin preparations. No less effective drugs of the cephalosporin group, especially III-IV generation (ceftriaxone, cefotaxime, etc.), and fluoroquinolones.

In modern therapy of acute uncomplicated gonococcal salpingo-oophoritis, the following antibiotics are used:

ceftriaxone;
amoxicillin + clavulanic acid;
cefotaxime;
fluoroquinolones (lomefloxacin, norfloxacin, ofloxacin, pefloxacin, ciprofloxacin, sparfloxacin);
spectinomycin.

In the acute stage of the inflammatory process, in the absence of a technical or clinical possibility of taking material and determining the type of pathogens ex juvantibus use a combination of several antibacterial broad-spectrum drugs for 7-10 days.

Schemes of possible combinations antimicrobials:

amoxicillin + clavulanic acid and doxycycline;
doxycycline and metronidazole;
fluoroquinolone and lincosamide;
fluoroquinolone and metronidazole;
macrolide and metronidazole.

In severe cases, the presence of pelvioperitonitis and septic condition, purulent formations in girls recommend the following modes antibiotic therapy:

III-IV generation cephalosporin + doxycycline;
ticarcillin + clavulanic acid (or piperacillin + tazobactam) and doxycycline (or macrolide);
fluoroquinolone and metronidazole (or lincosamide);
carbapenem and doxycycline (or macrolide);
gentamicin and lincosamide.

If therapeutic and diagnostic laparoscopy is necessary, antibiotic therapy can be started 30 minutes before or during the time of induction of anesthesia or immediately after surgical treatment. Preferred for severe disease parenteral route of drug administration.

Mandatory inclusion of synthetic (azoles) or natural (polyenes) antifungal drugs in treatment regimens for systemic, and if necessary, local use. Of the systemic azoles, fluconazole and itraconazole, ketoconazole due to high toxicity are practically not used. Antifungals follows from Use with caution in patients with severe hepatic impairment. No usage observations itraconazole in children under 14 years of age. Prophylactic use of polyene antimycotics nystatin and levorin ineffective, currently natamycin is more commonly used among polyene preparations. With candida salpingoophoritis use the same antifungal drugs, combining local and general therapy.

Of the antimycotics, fluconazole is most often used (for children under 12 years of age and weighing less than 50 kg, the dose of the drug is 3-12 mg / kg of body weight, for children over 12 years old and weighing more than 50 kg - 150 mg once in the 2nd and last day of taking antibacterial drugs); itraconazole (for children over 14 years of age, 100 mg or 5 mg/kg of body weight (with weight less than 50 kg) 2 times a day for 3 days 5 days before the end of antibiotic use) or natamycin (according to 100 mg 2-4 times a day while taking antibiotics).

Antibacterial therapy can be carried out in combination with plasmapheresis with a small volume of plasma exfusion. It is also possible to conduct a course of plasmapheresis sequentially after the end of antibiotic therapy. For extracorporeal detoxification, in addition to plasmapheresis, autoblood is also irradiated with ultraviolet, laser, ozone therapy.

The use of PG synthesis blockers - nimesulide is shown (for children over 12 years of age, they are prescribed single dose 1.5 mg/kg body weight, but not more than 100 mg, 2 times a day, the maximum daily dose of 5 mg / kg) or diclofenac (for children 6-15 years use only enteric-coated tablets at a dose of 0.5–2 mg/kg body weight divided by 2–3 reception; adolescents over 16 years of age can be prescribed 50 mg 2 times a day orally or in suppositories rectally for 7 days).

Other NSAIDs may also be used. Diclofenac should be used with caution in patients with diseases of the liver, kidneys and gastrointestinal tract, and indomethacin - to patients with diseases of the liver, kidneys and erosive and ulcerative gastrointestinal lesions.

Among antihistamines, it is preferable to prescribe clemastine, hifenadine, mebhydrolin, chloropyramine, loratadine, ketotifen.

It is advisable to include IFN preparations, IFN inducers, and immunoactivators into the therapeutic complex. Viferon © is prescribed rectally (in children under 7 years old, Viferon 1 suppositories are used ©, older than 7 years and adults - Viferon2© - 2 times a day for 10 days), cycloferon © orally or intramuscularly (0.25 g each on the 1st, 2nd, 4th, 6th, 11th, 14th, 17th, 20th, 23rd, 26th th, 29th day of treatment). It is possible to use kipferon © rectally, 1 suppository 2-3 times a day for 5-7 days.

To normalize the intestinal microflora (especially after antibiotic treatment), such drugs like bactisubtil © (for children over 3 years old, 3-6 capsules per day for 7-10 days, over 3 years old, including adults - 4-8 capsules per day orally one hour before meals), hilak forte © (for infants, 15–30 drops 3 times a day day, older children age group 20-40 drops 3 times a day orally in a small amount of liquid).

Along with this, it is advisable to use antioxidants, vitamin preparations, adaptogens (saparal©, extract eleutherococcus, aralia tincture, pantocrine©, lemongrass tincture, ginseng tincture, etc.) and eubiotics. From eubiotics pre-pubertal girls should be prescribed bifido drugs (bifidumbacterin©, bifiform © etc.). Girls older people are prescribed biological products containing both bifidus and lactobacilli.

Alternative Method

Antihomotoxic drugs are used as additional therapy. For the prevention of side effects effects of antibiotics, as well as to achieve anti-inflammatory, desensitizing, immunocorrective effect against the background of taking antibacterial drugs, the following can be recommended LS complex:

hepel
gynocochel

Reception of the complex is stopped along with the intake of antibacterial drugs.

Then for 20 days they take gynacochel © 10 drops 2 times a day (preferably at 8 am and 4 pm), mucosa compositum © 2.2 ml 1 time in 5 days / m - 5 injections per course, hepel © 1 tablet 3 times a day except for days taking mucosa compositum ©. To prevent the development of adhesions and exacerbations of the inflammatory process recommend a course of antihomotoxic therapy for 3 months:

TREATMENT OF CHRONIC PID

During chronic salpingo-oophoritis, phases of exacerbation and remission are distinguished. An illness in the acute stage run through two different options: with one, a true exacerbation of inflammation develops, i.e. increased ESR, predominate pain in the appendages, leukocytosis, hyperthermia, exudative process in the uterine appendages.

In another, more frequent variant, acute phase shifts in clinical picture and the blood formula is not expressed, there is a deterioration in well-being, an unstable mood, neurotic reactions are observed, symptoms are noted neuralgia of the pelvic nerves.

Therapy of exacerbation proceeding according to the first variant is carried out similarly to the treatment of acute salpingo-oophoritis (For drug classes and dosages, see Treatment of Acute PID.)

Enzyme preparations (wobenzym©, phlogenzym ©, trypsin ©, chymotrypsin © and others) play an important role in the pathogenetic PID therapy. Wobenzym © prescribe 3 tablets 3 times a day for children under 12 years old and 5 tablets 3 times a day for children over 12 years inside 40 minutes before meals with plenty of liquid (250 ml). This drug with caution prescribed to patients with a high risk of bleeding and severe renal dysfunction and liver.

With exacerbation of salpingo-oophoritis, proceeding according to the second variant, antibacterial drugs are rarely used, only with increased signs of the inflammatory process. In complex therapy, factors of physical effects, drugs that activate blood circulation, enzyme and vitamin preparations.

Alternative Method

Antihomotoxic therapy in the complex therapy of subacute and first, infectious-toxic variant exacerbation of chronic salpingo-oophoritis includes:

Antihomotoxic therapy in the complex of rehabilitation measures for PID on the days of menstruation for 3 cycles includes:

For the prevention of adhesions for 3 cycles (with the exception of menstruation) apply:

Antihomotoxic therapy in the complex of therapy for the second variant of exacerbation of chronic salpingo-oophoritis includes the following drugs:

In case of menstrual irregularities (meager bleeding), in combination with atrophic endometrium according to according to ultrasound and / or data of histological examination, sequential estrogen preparations are prescribed (fixed combination):

in phase I, estrogen (estradiol) is taken;
in the II phase - estrogen in combination with a gestagen:

Estradiol + estradiol and dydrogesterone (femoston 1/5 ©);
- conjugated estrogens + medroxyprogesterone (premella cycle ©) daily 1 tablet without interruption for 3–6 months;
-estradiol + medroxyprogesterone (divina©);
-estradiol / estradiol + levonorgestrel (klimonorm ©);
-estradiol / estradiol + cyproterone (klymen©);
-estradiol / estradiol + norgestrel (cycloprogynova ©) 1 tablet daily for 21 days, then a break of 7 days and a new cycle for 3–6 cycles.

In these cases, estrogens are also used for 21 days:

estradiol (in transdermal form: estrogel© gels 0.06% and divigel© 0.1% - 0.5–1.0 g / day, Klimara © patches 1 time
per week, in the form of octodiol © nasal spray, in tablet form Estrimax ©, Estrofem © 1 tablet per day,
proginova © 1 tablet per day);
conjugated estrogens (K.E.S. ©, Premarin © 1 tablet per day);
in combination with gestagens in the II phase of the cycle from the 12th to the 21st day:
dydrogesterone (1 tablet 2-3 times a day);
progesterone (1 tablet 2-3 times a day, in transdermal form - the gel is applied to the skin 1 time per day).

Alternative Method

Antihomotoxic drugs:

gynecoheel © 10 drops 5-7 times a day for the first 3 days until the condition improves, then 10 drops 3 times a day
day;

During remission, to prevent unwanted pregnancy, sexually active adolescents are prescribed monophasic COCs.

SURGERY

Surgical treatment is carried out with the ineffectiveness of conservative therapy, as a rule, in the case of the formation tubo-ovarian purulent formations.

Acute salpingo-oophoritis, accompanied by peritonitis, is also an indication for surgical treatment, laparoscopic approach is preferable, while organ-preserving operations should be sought.

INDICATIONS FOR CONSULTATION OF OTHER SPECIALISTS

In PID in children, consultation with a therapeutic specialist is necessary if you suspect infection or inflammatory diseases of the urinary tract, consulting a surgeon - to exclude acute surgical pathology organs of the abdominal cavity (most often appendicitis), a phthisiatrician - to exclude inflammatory process of tuberculous etiology.

APPROXIMATE TIMES OF INABILITY TO WORK

The period of disability in acute PID or during an exacerbation of a chronic inflammatory process is 7-14 days.

FURTHER MANAGEMENT

After the end of therapy on an outpatient or inpatient basis, the underlying disease is corrected biocenosis of the intestines and genital organs, restoration of the menstrual cycle. In sexually active adolescents conduct correction of sexual behavior (the use of COCs in combination with barrier methods for a period of at least 3 months). In the absence of signs of an inflammatory process, examination and examination of clinical and biochemical blood parameters are carried out after 1, 3, 6, 9, 12 months in the first year, then 1 time in 6 months for 2 years.

INFORMATION FOR THE PATIENT

Girls with PID (and their parents) should be informed that if their general condition worsens, pain in the lower abdomen, fever, discharge from the genital tract with an unpleasant odor you need to see a doctor. In the presence of foci of chronic infection (chronic inflammatory diseases oropharynx, urinary system, Gastrointestinal tract) should be monitored by specialists of the appropriate profile. After transferred acute PID or with a formed chronic inflammation internal genitalia needed regular preventive examinations by a pediatric gynecologist.

FORECAST

With adequate treatment and rehabilitation, the prognosis is favorable.

PREVENTION

Prevention of PID in young girls is non-specific and consists in the rehabilitation of foci of chronic infection. In addition, it is possible to reduce the incidence in sexually active adolescents through the use of mechanical contraception, a reduction in the number of sexual partners, the fight against drug addiction, and a reduction in the intake of alcoholic beverages. It is also necessary to regularly test for the presence of STIs.

BIBLIOGRAPHY
Bohman Ya.V. Guide to oncogynecology. - St. Petersburg: Folio, 2002. - S. 195–229.
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According to statistics, inflammatory diseases of the pelvic organs (PID), as well as inflammation of the female genital organs in general, occupy the first place in gynecological pathology. In terms of seeking help from a doctor, infections and diseases of the pelvic organs account for 65% of all cases. In 60% of cases, PID is caused by sexually transmitted infections or sexually transmitted infections (STIs). According to the WHO, chlamydia and gonorrhea are noted in 65–70% of all cases of PID.

Accepted in gynecology classification according to the location of the inflammatory process in the pelvic regions.

Diseases of the lower genital organs:

vulvitis (inflammation in the external female genital organs);
bartholinitis (inflammation of the gland of the vestibule of the vagina);
colpitis (inflammatory process of the vaginal mucosa);
endocervicitis and cervicitis chronic and acute (inflammation of the uterus and its cervical canal);

Inflammation of the pelvic organs located in the upper sections:

Pelvioperitonitis (inflammation of the small pelvis in the peritoneum);
Unilateral and bilateral salpingo-oophoritis (a combination of inflammation in the tubes and ovaries);
Endomiometritis (inflammation covers the mucous and muscular layers of the uterus);
Parametritis (peripheral tissue is affected).

Another dividing sign of inflammatory processes is the course of the disease. There are acute forms of the disease, subacute and chronic.

The criterion that determines the tactics of treating such diseases is the type of pathogen that caused the infection of the pelvic organs.

The cause of inflammation of the uterus and appendages are various microorganisms that penetrate the genital tract: viruses, fungi, protozoa and bacteria.

As a rule, inflammation of the uterus and appendages occurs in young age, taking a severe course in 60-80% of patients. Often the onset of the disease coincides with the onset of sexual activity.

Risk factors for inflammation of the uterus and appendages:

The presence of a woman a large number sexual partners;

The presence of a large number of sexual partners in a sexual partner;

Usage intrauterine contraceptives(spirals);

Douching (contribute to the “washing out” of the normal microflora from the vagina and replacing it with a conditionally pathogenic one);

Past inflammation of the uterus and appendages or sexually transmitted diseases;

Violation of the protective mechanisms caused by the mucous plug of the cervical canal (contains antibacterial substances), in particular, with endocervicitis;

Ectropion (eversion of the mucous membrane) of the cervix is a condition that occurs as a result of unnoticed ruptures of the cervix during childbirth.

Besides, contribute to the development of inflammation of the uterus and appendages common diseases; great physical exertion and mental strain, stressful situations; endocrine disorders; allergic factors; the presence of a dormant (latent) infection in the body.

Symptoms of inflammation of the uterus and appendages:

Redness, swelling, itching of the mucous membrane of the vulva and vagina;
Pressure and pain in the lower abdomen, in the pelvic region;
Pain during intercourse (dyspareunia)
Pain in the lower back;
Abundant mucous or mucopurulent discharge from the vagina with an unpleasant odor and a yellowish tint;
Discharge with an unpleasant odor, yellowish, cloudy with gas bubbles;
Curdled discharge accompanied by itching or burning;
Bloody discharge, mucopurulent discharge with pain in the lower abdomen;
irregular menstruation;
high fever, tiredness, diarrhea or vomiting;
Painful or difficult urination.

When to see a doctor?

Do you need urgent medical care if you have:

Intense pain in the lower abdomen;
Vomit;
Signs of shock such as fainting;
Fever, temperature above 38.3°C

What are the complications of PID

Early diagnosis and adequate treatment can prevent the complications of PID. If left untreated, PID can cause damage to a woman's reproductive organs:

Tubal infertility occurs in 15-20% of women with PID;
Ectopic pregnancy develops in 12-15% of women with PID;
Chronic pelvic pain occurs in 18% of women with PID;
Tubo-ovarian abscess is one of the causes of death in women from PID;
Pelvioperitonitis - inflammation of the pelvic peritoneum. It is a formidable complication of PID, often leading to sepsis. It develops for the second time when the uterus, fallopian tubes and ovaries are affected by the penetration of pathogenic microorganisms from them by contact, hematogenous and lymphogenous routes.

Repeated episodes of PID increase the chances of developing these complications.

Diagnosis of inflammatory diseases of the pelvic organs

PID is often difficult to diagnose because symptoms can be subtle. However, the diagnosis is based on clinical examination. For accurate diagnosis, it is necessary to study the cervical smear (smear from the cervix) for infections by PCR and bacteriological culture. If an infection (such as chlamydia or gonorrhea) is detected, specific treatment is needed. However, a negative result for infection does not yet mean the absence of PID.

Ultrasound examination of the pelvic organs is a very informative procedure. Ultrasound allows you to see an increase in the fallopian tubes, as well as to establish the presence of purulent cavities.

In some cases, laparoscopy becomes necessary. Laparoscopy is a minor surgical procedure in which a thin, flexible tube (laparoscope) is inserted through a small incision in the lower abdomen. The doctor has the opportunity to examine the pelvic organs and even take tissue sections for examination, if necessary. Laparoscopy is considered the most reliable diagnostic method, but it is rarely resorted to when other studies are unsuccessful.

Treatment of the disease

The main components of the treatment of inflammation of the pelvic organs:

antibiotics (ORCIPOL - a combined antibacterial drug consisting of 2 components: ciprofloxacin - a broad-spectrum antibiotic of the 2nd generation fluoroquinolone group and ornidazole - an antibacterial drug that affects the anaerobic microflora and protozoa. It is used only as directed by a doctor. Available in tablets of 10 pieces , applied 2 times a day, so the package is enough for a course of treatment of 5 days.The drug is combined, so you do not need to use ciprofloxacin and / or ornidazole separately a doctor when it is necessary to influence anaerobic, atypical microflora and protozoa);
anti-inflammatory drugs;
antihistamines and antifungals (FLUZAMED - fluconazole, a systemic antifungal drug in the form of a 150 mg capsule. It is dispensed from a pharmacy without a prescription. For prophylactic purposes, a single dose of the drug is sufficient);
painkillers;
local procedures - washing, douching, preparations with intravaginal release forms (LIMENDA - vaginal suppositories, which include 2 components: metronidazole + miconazole. Used in the complex therapy of bacterial vaginosis with tablet forms of metronidazole, tinidazole, ornidazole, secnidazole and is used as prescribed by a doctor, BIOSELAC - vaginal capsules containing a standardized strain of Lactobacilli, which are the normal microflora of a woman's vagina. The package contains 10 capsules, 1-2 capsules per day are used for 7-10 days. Better first 2-3 days, use 2 capsules per day, and then switch to a single dose, 1 capsule at night);
general tonic (GOLD RAY - a natural preparation based on bee royal jelly, wheat germ oil, garlic powder.

GOLD RAY is intended to strengthen the body after a course of antibiotic therapy, as well as in the complex treatment of diseases of the genital area in women (algomenorrhea, climacteric syndrome, premenstrual syndrome, inflammatory diseases of the female genital organs, infertility).

The duration and effectiveness of treatment depends on the stage of the disease and the neglect of the process.

Hospitalization indicated:

pronounced signs of the disease (pain, nausea, vomiting, fever);
PID during pregnancy;
lack of effect from oral antibiotics or the need for their intravenous administration;

purulent inflammation of the tubes or ovaries, if the inflammation continues or the abscesses do not go away, the treatment is carried out by surgery.