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Lecture notes, cheat sheets
Obstetrics and gynecology. Inflammatory diseases of the uterus and periuterine tissue (lecture notes)
Directory / Lecture notes, cheat sheets Table of contents (expand) Lecture 22 1. Endometritis Endometritis is an inflammation of the lining of the uterus (endometrium). Most often occurs after complicated childbirth, abortion, less often - after diagnostic curettage of the uterine cavity, probing and other intrauterine manipulations. An acute inflammatory process can be caused by a bacterial, viral, fungal, parasitic, mycoplasmal, protozoal and spirochetal infection. It is most often caused by a mixed aerobic-anaerobic association of several microorganisms. Rarely, an isolated lesion of the mucous membrane is observed, most often the muscular membrane of the uterus is also involved in the inflammatory process with the development of myoendometritis. Endometritis Clinic. Signs of the disease usually appear on the 3-4th day after infection. General symptoms of infection are observed: increased body temperature to 38-39 ° C, malaise, weakness, headache, neutrophilic leukocytosis with a shift to the left, increased ESR. Local symptoms appear: pain in the lower abdomen, profuse liquid serous-purulent or bloody-purulent discharge. On vaginal examination, a painful enlarged uterus of dense consistency is revealed. The acute stage of endometritis lasts 8-10 days, and with timely and adequate treatment, recovery is complete. If therapy was prescribed untimely and inadequately, then a transition to a chronic form is possible. Chronic endometritis is characterized by focal inflammatory infiltrates in the uterine mucosa, located around the glands and blood vessels, leading to structural changes in the endometrium - its atrophy, hypertrophy or the formation of small cysts. The ability of the endometrium to perceive hormonal stimulation is impaired, which leads to disruption of cyclic processes and menstrual function. The most pronounced clinical symptom is menstrual irregularity with the development of menorrhagia (hypermenorrhea, polymenorrhea) or metrorrhagia. Premenstrual and intermenstrual bleeding is less common. With chronic endometritis, infertility or recurrent miscarriage often develops, since implantation of the fertilized egg into the altered endometrium is extremely difficult. Clinical symptoms of chronic endometritis are mild. The temperature is usually normal, the patient notes scant mucopurulent discharge, aching pain in the lower abdomen and lower back. On vaginal examination, slight thickening and an increase in the size of the uterus are observed. Diagnosis of chronic endometritis is based on data from the anamnesis, clinic and histological examination of endometrial scraping. Diagnostic curettage is performed on the 8-10th day of the menstrual cycle. Treatment of endometritis. In the acute stage of endometritis, etiotropic therapy is carried out. Antibacterial drugs are prescribed taking into account the sensitivity of the pathogen to them; broad-spectrum antibiotics are most often prescribed. The dosage and duration of antibacterial therapy are determined individually, taking into account the severity of the patient’s condition. In order to suppress anaerobic flora, Trichopolum (Flagyl, Klion) is included in the treatment complex. Depending on the severity of the condition, infusion, desensitizing and restorative therapy is prescribed. Treatment of chronic endometritis is complex, including medications, physiotherapeutic methods of treatment and sanatorium-resort treatment. Postpartum endometritis - inflammation of the mucous membrane of the uterus that occurs after childbirth. With the spread of the inflammatory process to the muscular layer of the uterus, endomyometritis develops. Postpartum endometritis is a type of wound infection, since the inner surface of the uterus after separation of the placenta is an extensive wound surface. Epithelialization and regeneration of the endometrium ends 5-6 weeks after birth. Postpartum endometritis clinic. Clinical manifestations of a mild form of postpartum endometritis appear on the 5-10th day after birth. Body temperature rises to 38-39 °C, mild chills are observed, tachycardia is detected up to 80-100 beats/min. In the blood there is neutrophilic leukocytosis with a shift to the left, an increase in ESR. The general health of the postpartum mother is relatively satisfactory. On palpation, tenderness of the uterus is noted, which persists for several days. The uterus is slightly enlarged, and the discharge of bloody contents continues for a long time. Manifestations of a severe form of postpartum endometritis begin on the 2-4th day after birth. Very often, this complication develops against the background of chorioamnionitis, after a complicated birth or intrauterine intervention. Body temperature rises to 39 °C and above, accompanied by severe chills. The postpartum woman complains of headache, weakness, pain in the lower abdomen. There are sleep disturbances, loss of appetite, and tachycardia up to 90-120 beats/min. Upon examination, subinvolution of the uterus is revealed, and it is painful on palpation. From the 3-4th day, discharge from the uterus becomes cloudy, bloody-purulent, and sometimes becomes foul-smelling. There may be a delay in discharge (lochiometer) as a result of insufficient contraction of the uterus. Treatment of postpartum endometritis. A comprehensive anti-inflammatory treatment is carried out, aimed at localizing the inflammatory process, detoxification, activating the body's defenses and normalizing homeostasis. Before starting treatment, a culture of discharge from the uterine cavity and vagina is performed to determine pathogens and their sensitivity to antibiotics. Sometimes, in the process of treating postpartum endometritis, surgical treatment of the uterine cavity is performed, which includes hysteroscopy, vacuum aspiration of the contents of the uterus, and washing its cavity with chilled antiseptic solutions. The effectiveness of complex intensive therapy for postpartum endometritis is assessed 7 days after the start of treatment. If there is no effect from the therapy, even against the background of a satisfactory condition of the postpartum mother, but with persistent clinical and laboratory signs of inflammation, the issue of removing the uterus is decided. 2. Pelvioperitonitis Inflammation of the peritoneum limited to the pelvic cavity. It develops as a result of the spread of the inflammatory process in the pelvic organs (salpingoophoritis, pyovaritis, torsion of the leg of the ovarian tumor, necrosis of the myomatous node, perforation of the uterus). Pelvioperitonitis is most often a complication after an abortion, childbirth, surgery on the uterus or its appendages. Along the course, acute and chronic pelvioperitonitis are distinguished. In acute pelvioperitonitis, the process is localized in the small pelvis, however, the peritoneum of the upper abdominal cavity also reacts to the inflammatory process. The patient notes sharp pains in the lower abdomen, body temperature rises, dyspeptic symptoms occur: nausea, vomiting, bloating, stool and gas retention, painful urination. There are pronounced signs of intoxication: tachycardia 100-120 bpm, dry furred tongue, sharpened facial features. There are signs of irritation of the peritoneum, the abdominal wall is not involved in the act of breathing, its tension, pain and a positive Shchetkin-Blumberg symptom are noted. All these symptoms are more pronounced in the lower abdomen, weaker - in its upper sections. Dullness of percussion sound is determined in the sloping places of the lower abdomen, associated with the presence of effusion in the abdominal cavity. Intestinal peristalsis is sluggish, gases go badly. Vaginal examination determines the overhang of the posterior fornix, pain on palpation and displacement of the cervix. The uterus with appendages is palpated with difficulty due to severe pain and tension of the anterior abdominal wall. In the blood, neutrophilic leukocytosis with a shift to the left, toxic granularity of neutrophils, increased ESR are detected. With a favorable course of the inflammatory process, after 1-2 days, its delimitation is noted due to the formation of adhesions to the pelvic organs, the omentum and intestinal loops are soldered. If delimitation does not occur, diffuse peritonitis develops with more pronounced clinical symptoms, an increase in intoxication phenomena. When conducting active adequate anti-inflammatory therapy, the process gradually subsides, the exudate is absorbed, the general condition improves, the temperature normalizes, the pain weakens and disappears. However, sometimes the inflammatory process can be complicated by the formation of an encysted abscess in the recto-uterine cavity, which requires surgical treatment. The diagnosis is established on the basis of the clinical picture. It is important to clarify whether there is pelvioperitonitis or diffuse peritonitis. The general condition with pelvioperitonitis is more satisfactory, the symptoms of intoxication are less pronounced than with diffuse peritonitis. Symptoms of peritoneal irritation are more pronounced in the lower sections. During dynamic observation of the patient, a tendency to the spread or localization of the inflammatory process is revealed. In unclear cases, diagnostic laparoscopy is performed. In the process of diagnosis, a mandatory bacterioscopy of the vaginal discharge is carried out to determine the type of pathogen. Sometimes, in order to determine the presence and nature of the existing effusion in the abdominal cavity, they resort to puncturing the abdominal cavity through the posterior fornix. Therapy of pelvioperitonitis is carried out according to the general rules for the treatment of inflammatory diseases, taking into account the specifics of the process. Antibacterial, infusion, detoxification, desensitizing and restorative therapy is carried out. If the causes of pelvioperitonitis were rupture of the pyosalpinx, perforation of the uterus, necrosis of the tumor of the uterus or ovary, then urgent surgical intervention is indicated. 3. Parametric Inflammation of the peritoneal tissue. The reason for the development of parametritis is most often previous intrauterine interventions: childbirth, abortion, supravaginal amputation of the uterus, removal of appendages, diathermocoagulation. Postpartum parametritis most often occurs with ruptures of the cervix and the upper third of the vagina. Infection with parametritis spreads through the lymphogenous route. Diagnosis of parametritis is based on bimanual examination data. The mucous membrane of the vagina during palpation and examination of the vaults is motionless due to infiltration. Due to the existing anatomical features of the parametric fiber (on the one hand it is limited by the uterus, on the other hand by the pelvic wall, from below by the vault of the vagina), the cervix, the uterus itself and the vaginal vault are immobile with parametritis. These features relate to bilateral parametritis. With unilateral parametritis, the cervix is deviated in the opposite direction from the pathological process. The infiltration has a dense, painful, motionless texture, fanning out from the side wall of the uterus to the walls of the pelvis along the anterior or posterior surface. In a severe infection, inflammation can move to neighboring sections of the pelvic tissue. If the inflammation extends to the perivesical tissue, the infiltrate can be located on the posterior surface; when the inflammation passes to the abdominal wall, it takes the form of a triangle with the apex facing the navel. The most common is lateral parametritis. Differential diagnosis is carried out with pyovar, tubo-ovarian abscess, acute salpingo-oophoritis, ectopic pregnancy, torsion of the tumor stem. Therapy of parametritis is carried out according to the general rules for the treatment of inflammatory diseases, taking into account the specifics of the process. Includes antibacterial, desensitizing and restorative therapy. In case of suppuration of the infiltrate, drainage is performed. Author: Ilyin A.A. << Back: Inflammatory diseases of the female genital organs (Bacterial vaginosis. Chlamydial infection. Viral infections. Candidal colpitis. Human papillomavirus infection. Specific infections) >> Forward: Menstrual irregularities
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