Obstetric peritonitis

The peritoneum inflammation - a peritonitis - is the most dangerous complication of acute diseases of organs of an abdominal lumen. In the domestic and foreign literature the peritonitis problem is shined widely and versatily. At the same time, it is possible to pay attention that practical doctors at times have difficulties in diagnostics of this complication, leading to inopportuneness of surgical treatment.

Complexity of diagnostics of an obstetric peritonitis is caused by a number of factors:

• Features of neuroendocrinal rearrangement, character of humoral and cellular immunodefence of pregnant women and women in childbirth
• Presence of the complicated flow of pregnancy and sorts
• Enlarged frequency of an operative delivery
• Concomitant diseases
• Presence of associations of bacteria, as aerobic, and not the sporogenous anaerobic

Increase of cases of an obstetric peritonitis is bound to the general increase all over the world numbers of pyoinflammatory diseases.

Peritonitis development in a puerperal period is caused more often:

• An endomyometritis, a metrothrombophlebitis, a parametritis with the subsequent generalisation of an infection contamination, and also the infected apostatis of seams on a uterus after operation cesarean sections
• Diseases of appendages of a uterus (pyosalpinx punching, a breakage of a capsule of a cystoma of an ovary or a torsion of its leg)
• Was rarely meeting extragenital diseases (an acute appendicitis, to damages of a side of an intestine or a bladder, an endogenous infection contamination)

More often use peritonitis classification in which dynamics of process is reflected: 1 phase - a reactive, 2 phase - a toxic, 3 phase - terminal.

At a reactive phase compensatory mechanisms are kept, there are no disturbances of a cellular metabolism, there are no hypoxia signs. The general condition rather satisfactory. The moderate paresis of an intestine is noted. Blood indicators: a leukocytosis, moderate alteration of the formula to the left. Acid phosphatase (ACP) and an alkaline phosphatase (ALP) lysosomes of polymorphocellular leucocytes essential do not vary.

The toxic phase is bound to an accruing intoxication. The general condition of the patient suffers, metabolic processes are broken, the electrolytic balance variates, the hypoproteinemia educes, activity of enzymatic system is broken - considerably raises ACP and ALP lysosomes of polymorphocellular leucocytes. The leukocytosis accrues.

At a terminal phase of change have deeper character. Symptoms of a lesion a CNS, the general condition serious, patients flaccid, adynamic prevail. Motor function of an intestine is broken. Symptoms of a boring of a peritoneum are expressed rather weakly. Intestinal hums do not listen. There is an oppression of activity of enzymes.

The peritonitis after cesarean sections on clinical flow can show in several variants, depending on a becoming infected path.

1st variant: operation has been effected against an available infection contamination, more often in the form of a chorioamnionitis. Pathological symptoms educe early, already to the extremity of the first days or in the beginning of the second. Note a fervescence (38-39), the expressed tachycardia (120-140 ud./minutes), an abdominal distention. The reactive phase is expressed insufficiently. The toxic phase quickly educes. The general condition worsens, the intestine paresis has nonperishable character. Tongue dry. Vomiting with an admixing of a considerable quantity of green masses keeps, then it becomes hemorrhagic. The protective strain of muscles of an abdominal wall can be absent. The septic shock educes, cardiopulmonary and renal insufficiency accrues.

2nd variant arises when the peritoneum becoming infected is bound to endometritis development in the postoperative season. The condition of patients after operation can remain rather satisfactory. The body temperature within 37,4-37,6, a moderate tachycardia (90-100 ud./minutes), early appears an intestine paresis. Abdominal pains are not present. Periodically there is a nausea and vomiting. The gaste remains soft, there are no symptoms of a boring of a peritoneum. The most typical is the reflexivity of symptoms. At process advance, despite spent conservative therapy, about 3-4 days the condition of the patient worsens, intoxication symptoms accrue. It is necessary to underline, that the differential diagnosis between a usual postoperative paresis of an intestine and an educing peritonitis is not simple.

3rd variant - peritonitis development at an incompetence of seams on a uterus. More often it happens is bound to an infection contamination, is rarer - with a technical error of suture. At an irregular sealing of angles of a wound where there can be a flaking of muscles, abjections from a uterus start to arrive in retroperitoneal space and in an abdominal lumen. Clinical symptoms usually show early. From first days peritonitis signs accrue. The condition of the patient worsens, disturb pains in the inferior parts of a gaste on the right or at the left. Attracts attention scarcity of abjections from a uterus. The tachycardia, vomiting, an abdominal distention with firmness keep. At a percussion define an exsudate in the abdominal lumen which quantity accrues. The intoxication comes quickly.

Treatment

Having diagnosed, it is necessary to start operative treatment in a combination to the complex therapy referred on restoration of functions of the vital organs and all systems of an organism.

Preoperative preparation spend within 2-2,5 hours, its volume depends on gravity of a condition of the patient. Spend correction BV, water electrolytic disturbances, power deficiency, introduce cardiacs.

Under the general anaesthesia (the intubation, the PULMONARY ventilation) perform operation. An abdominal section do longitudinal, that is important for the subsequent sanation of an abdominal lumen and a drainage. An exsudate at once take for sowing and sensitivity definition to antibiotics. Effect a hysterectomy with uterine tubes. In the presence of purulent formations of appendages or a cystoma of ovaries effect a uterus adnexectomy.

The abdominal dialysis in toxic and terminal phases can be effected a flow or fractional mean. The patient is in intensive care chamber. Its position in bed with the raised thoracal part, feet are a little incurvated in patellar and hip joints.

The intensive care develops of many components. Her spend under the control of a diuresis and biochemical blood analysises (electrolytes, squirrels, albuminous fractions, urea, a creatinine, Saccharum, bilirubin, PLAITS, etc.).

Correction of water-electrolytic disturbances carry out introduction of preparations of a potassium, calcium. From albuminous preparations introduce albumin solution, a protein, plasma, albuminous hydrolysates and amino-acid admixtures. Totally pour in to 3 l of fluid a day against diuretics.

To struggle against an infection contamination apply antibiotics of a various spectrum and the action mechanism. Widely use for introduction in an abdominal lumen Kanamycinum on 1 gramme 2 times a day. For intravenous and subsequent intramuscular application prefer antibiotics of a wide action spectrum.

Against antibacterial therapy apply hormonal preparations. One of the central places in peritonitis treatment normalisation evacuate-motor occupies stomach and intestine functions. With that end in view apply nasogastric sounding, peridural blockage, intravenous introduction of Cerucalum on 2 ml 3 times a day, a contained stomach promoting evacuation in a small bowel.

Thus, only the complex therapy of a peritonitis referred on various mechanisms of its development, can lead to a congenial outcome.