Acute Diffuse Puerperal Peritonitis
It may occur after natural way of delivery, after obstetrical operations (application of forceps, etc), and after cesarean section.
After natural way of delivery peritonitis develops due to spread of infection from the uterine cavity by lymphatic vessels and through fallopian tubes.
The disease occurs a few days after delivery, but it may also appear on the 1-2nd day of puerperal period.
Clinical features. The following stages of obstetric peritonitis are usually distinguished:
- a reactive phase
- a toxic phase
- a terminal phase
The first phase (first 24 hours) is manifested by absence of metabolic failure; general condition is not bad but enteroparesis just starts. Signs of inflammation may be found in blood tests.
A toxic phase (24-72 hours) is manifested by elevated intoxication, worsening of general condition, development of severe metabolic changes, increase of enteroparesis.
A terminal phase (>72 hours) is manifested by deep changes in the central nervous system, very severe general condition, the function of abdominal organs being deeply changed.
The typical clinical signs are increased body temperature up to 39-40˚C, shivering, hyperemia of the face, a dry, coated tongue. In severe cases, due to decreased immune reactivity of maternal organism the body temperature may be normal. One should pay attention to the difference between axillary and rectal temperature (in the rectum the temperature is 1.5-3˚C higher than in axillary cavity). The pulse rate is elevated but often there is no correspondence with the elevation of temperature (“scissors” symptom-Vreden’s symptom). The pulse is rapid, weak and soft on palpation, arrhythmia is not rare. The arterial blood pressure decreases. Respiration is quickened (tachypnea). At the beginning the upper abdomen takes part in respiration, then discontinues. Nausea, vomiting, tympanism appear.
It is of significance that Shchotkin-Blumberg symptom and muscle tension (defance musculorum) are not typical of diffuse obstetric peritonitis, because of overdistension of abdominal muscles due to pregnancy. The intestinal peristalsis is slowed at first, and then it stops at all. Passage of gases is arrested; stool retention is typical of these patients. There is moderate tympanitis in the upper parts of the abdomen, and weakening of percussion sound in the lower abdomen on percussion.
On vaginal examination one can find protrusion of posterior vaginal fornix, flattening of lateral fornices, the cervical canal gapes, discharges are bloodish. Vaginal examination is painful. In puncture of Duglas pouch a serous effusion may be taken.
Significance: at intensive therapy the clinical course of peritonitis may be wave-like. A temporary effect of treatment may be evaluated as a good result, and if the treatment is discontinued, the recurrent worsening of general condition happens. Intensification of intoxication, suppression of host defenses will increase probability of maternal death.
But usually in obstetrical practice peritonitis is masked by atypical clinical course that makes this disease more dangerous.
As to peritonitis after cesarean section, it may develop in three forms:
1. The first form – an early form. It develops at the end of the 1st or at the beginning of the 2nd day after the operation. It means that the peritoneum was infected during the operation.
2. The second form is middle depending on the term of development. This form occurs in term of 3-4 days after cesarean section. Usually it develops because of enteroparesis in post-operative period.
3. The third form is late – it occurs in term of 7-9 days after the operation; usually the main reason of this form is incompetent surgical suture.
Treatment. Treatment of diffuse peritonitis is surgical. The earlier diagnostics and surgical treatment are – the better prognosis and outcome are. Sometimes it is necessary to administer a conservative treatment for 6-7 hours to prepare the patient for operation. This treatment includes antibiotics, anti-inflammatory, anti-histamine therapy, infusion therapy, which can lead to stabilization of the heart condition, arterial blood pressure, to prevention of maternal death during the operation. The volume of operation is extirpation of the uterus, treatment and drainage of the abdominal cavity.
A bacteriological examination of the cervcal discharge and a secret, contained in the Douglas pouch (which is obtained by puncture the posterior fornix of the vagina or during the surgical operation) is indicated for patients with acute pelvic peritonitis. The culture of the pathogens and sensitivity to antibiotics would be determined. The data obtained in this case is the background for the choice of effective antibiotic therapy of the patient. Antibiotic therapy usually should be started before the operation, continued during and after operation.
An intensive therapy of diffused inflammation should be continued in post-operative period.
Common principles of choice of antibacterial medications are:
1. Pathogen is unclear - use gentamicin + metronidazole, which is effective for E. coli and anaerobic bacteria.
2. When the bacterial culture and drug susceptibility test results are detected - the choice should be based on drug sensitivity test results.
3. Against the backround of the first choice of antibiotics - determine whether antibiotic to be replaced. If the general effect is good - do not replace; if medication is not effective - it should be replaced dependant on results of sensitivity test, use the stronger medication with higher doses
Date added: 2022-12-25; views: 236;