Septic shock in obstetrics

One of the most serious complications of is purulent-septic processes of any localisation is the septic or is bacteriemic-toxic shock. The septic shock represents the special reaction of an organism expressed in development serious system disorders, bound to disturbance of adequate perfusion of the tissues, coming in reply to introduction of microorganisms or their toxins. On frequency of occurrence the is bacteriemic-toxic shock costs on the third place after hemorrhagic and cardial, and on a lethality - on the first. At a septic shock perish from 20 to 80 % of patients. In akushersko-gynecologic practice the septic shock complicates after abortal infectious diseases, a chorioamnionitis in sorts, a pyelonephritis of pregnant women, purulent mastites.

Etiology

The septic shock complicates flow of the is purulent-infectious processes caused by Gram-negative flora more often: an intestinal rod, a Proteus, a Klebsiella, a pyocyanic rod. At destruction these bacteria excrete an endotoxin including a releaser of development of a septic shock. The septic process caused by Gram-positive flora (an enterococcus, a staphilococcus, a streptococcus), is less often accompanied by a shock. The active beginning at the given kind of an infection contamination is the ectotoxin developed by alive microorganisms. The cause of development of a shock can be not only aerobic bacterial flora, but also anaerobes, (first of all Clostridia perfringens), and also Rickettsias (pl Rickettsiae), viruses, the elementary viruses and mushrooms.

For shock occurrence, except an infection contamination, presence of two more factors is necessary: depression of the general resistance of an organism of the patient and presence of possibility for massive penetration of the originator or its toxins into blood. At pregnant women, parturient women and women in childbirth similar conditions arise quite often. Shock development in a similar situation is promoted by some factors:

• A uterus which is entrance collars for an infection contamination
• Clots and the residual of foetal egg serving by a fine nutrient medium for microorganisms
• Features of a circulation of the pregnant uterus, promoting easy entering of bacterial flora in a vascular bed of the woman
• Change of a hormonal homeostasis (first of all estrogenic and gestagenic)
• The lipidemia of pregnant women facilitating development of a shock
• An allergization of women pregnancy

Pathogenesis

Being based on data of the literature of last years, a septic shock pathogenesis it is possible to present as follows. The toxins of microorganisms arriving in a vascular bed, actuate vasoactive materials: kinins, Histaminum, a serotonin, catecholamins, a renin.

Primary disorders at a septic shock concern a peripheric circulation. Vasoactive materials of a type of kinins, Histaminum and a serotonin cause an angioparesis in capillary system that leads to sharp depression of a peripheric resistance. There comes BP depression. The hyperdynamic phase of a septic shock at which in spite of the fact that the peripheric blood stream is high enough, capillary perfusion is lowered educes. Metabolic processes in tissues with formation sub - the oxidised products are broken. Proceeding damaging action of bacterial toxins leads to aggravation of circulatory disorders. The selective spastic stricture of venules in a combination with advance of syndrome DIC promotes a blood sequestration in microcirculation system. Rising of permeability of sides of pots conducts to a leakage of a liquid part of blood, and then and formulated elements in intersticial space. These pathophysiological changes promote appreciable reduction BV. There comes a hypovolemia, nonperishable depression of a BP. The hypodynamic phase of a septic shock educes. In this phase of a shock progressing disturbance of histic perfusion leads to the further aggravation of a tissue acidosis against a sharp hypoxia, that, in a combination to toxic action of a contagium, quickly leads to disturbance of functions of separate fields of tissues and organs, and then and to their  destruction. This process not the long. Necrotic changes can come in 6-8 hours from the beginning of functional disturbances. At a septic shock lungs, a liver, nephroses, a brain, a gastrointestinal tract, a skin are subject to the greatest damaging action of toxins.

Clinic

The clinical picture of a septic shock is happy is typical. The septic shock comes acutely, more often after operations or any manipulations in the locus of the infection contamination, framing conditions for "break" of microorganisms or their toxins in a vascular bed. Shock development is preceded by a hyperthermia. The body temperature raises to 39-41 degrees, is accompanied by repeated cold fits, 1-3 days keep, then critically drops on 2-4 degrees to subfebrile or subnormal digits.

As the basic sign of a septic shock consider falling of a BP without a previous blood loss or mismatching it. At a hyperdynamic or "warm" phase of a shock the systolic BP decreases and keeps not for long: from 15-30 minutes till 2 o'clock. Therefore doctors sometimes look through a hyperdynamic phase. Hyperdynamic, or the "cold" phase of a septic shock is characterised by sharper and long falling of a BP (sometimes below critical digits). At some patients there can come short-term remissions. Such condition lasts from several o'clock about several days. Along with BP falling, the expressed tachycardia to 120-140 impacts in a minute educes.

The hyperemia and dryness of integuments quickly replace pallor, a cold snap with sticky cold then. The majority of women is noted by pains of changeable character and various localisation: in epigastric range, in the inferior parts of a gaste, in extremities, in a loin, a thorax, a headache. Almost half of patients has a vomiting. At advance of a shock it gets character of "a coffee ground" in connection with a necrosis and hemorrhages in fields of a mucosa of a stomach.

Symptoms of acute renal insufficiency, acute respiratory insufficiency, and also bleeding often accumulate on a clinical picture of a septic shock owing to advance of syndrome DIC.

The septic shock represents danger of death for sick, timely diagnostics therefore is important. The diagnosis put, mainly, on the basis of following clinical implications:

• Presence of the septic locus in an organism
• A high fever with the frequent cold fits, replaced by sharp depression of a body temperature
• The falling of a BP mismatching a hemorrhage
• A tachycardia
• A tachypnea
• Consciousness disorder
• Abdominal pains, a thorax, extremities, a loin, a headache
• Depression of a diuresis up to an anuria
• A petechial eruption, a necrosis of fields of a skin
• A disproportion between insignificant aboriginal changes in the locus of an infection contamination and gravity of the general condition of the patient

Main principles of rendering of acute management

Septic shock intensive care carry out the accoucheur-gynecologist in common and the resuscitator. Actions for struggle against a shock should be concentrated to restoration of a histic blood flow, on correction of metabolic disturbances and on maintenance of adequate gas exchange. The two first problems solve by carrying out of infusional therapy which is necessary for beginning as soon as possible and to carry out long time. As infusional mediums at the first stages of treatment it is more preferable to use dextran derivatives (on 400-800 ml Rheopolyglucin and-or Polyglucinum) and a polyvinylpyrolidone (Haemodesum in number of 400 ml).

Rate and quantity of poured in fluid depend on reaction of the patient to spent therapy. The fluid total in the first days, as a rule, compounds 3000-4500 ml, but can reach 6000 ml.

Against restore BV and enriching of rheologic properties of blood for correction of a hemodynamic and restoration of a histic blood flow obligatory application of warm and vasoactive agents is necessary.

Along with hemodynamic normalisation, the purpose of infusional therapy at a septic shock there should be a correction of the acid-basic and electrolytic homeostasis. At a septic shock the metabolic acidosis which can be compensated at the beginning by a respiratory alkalosis quickly enough educes. For acidosis correction it is necessary to include in structure of infusional therapy 500 ml lactasolum, 500 ml of ringer-Sodium lactatum or 150-200 ml of 4-5 % of solution of Sodium hydrogenum.

Along with restoration of hemodynamic disorders and corrections of metabolic disturbances the great value has maintenance of adequate oxygenation. Oxygen introduction is necessary for beginning with the first minutes of treatment, to use for this purpose all available agents up to artificial ventilation of the lungs.

Together with antishock actions the integral part of an intensive care of a septic shock is compounded by struggle against an infection contamination. Antibacterial therapy at a septic shock is emergency. Thus the wide circulation is found by semisynthetic Penicillinums. Methicillinum sodium salt each 4 hour and ampicillin introduces on 1-2 gramme sodium salt (Pentrexylum) - on 1,5-2 gramme each 4 hours or on 2 grammes each 6 hours intramusculary or intravenously (the maximum dose of 8 gramme). Cefamezin prescribe on 1 gramme each 6-8 hours, intravenously or intramusculary, the maximum daily dose of 4 grammes.

Besides, struggle against a shock includes liquidation of the locus of an infection contamination. Experience of akushersko-gynecologic practice shows, that the approach to liquidation of the locus of an infection contamination at a septic shock should be especially individual. The most radical mean of struggle is uterus excision. For reception of desirable effect a surgical intervention should carry out in due time. According to the majority of domestic and foreign authors, to operation it is necessary to resort at unsuccessfulness of the intensive conservative therapy spent within 6 hours. Choice operation is the hysterectomy with excision of uterine tubes, a drainage of parametriums and an abdominal lumen. On occasion at the patients who are in extremely grave condition, in the absence of macroscopical changes of a tissue of a uterus effecting of supravaginal ablation of a uterus is admissible. In these cases. Excision of uterine tubes and a drainage of an abdominal lumen is obligatory.

Treatment of a serotinal stage of a septic shock with the advent of a hemorrhagic syndrome, including a uterine bleeding, demands the differential approach. Depending on coagulogram indicators spend replaceable therapy ("warm" donor blood, cool-dehumidified plasma, dry, native and fresh-frozen plasma, a fibrinogen) and-or introduce antifibrinolitic preparations (Trasylolum, Сontrykal, Gordoxum).