Application-sorption method of prophylaxis of septic complications in mothers of high-risk groups in the implementation of infection after cesarean section

 

(57) Abstract:

The invention relates to medicine, namely to gynecology. Proposed intrauterine intraoperatively to enter sorption drainage-swab, made of nylon membrane with the value of dialysis then from 1.5 to 3.0 nm, filled with carbonaceous mineral sorbent SUMS-1 adsorbed thereon metronidazole in a dose of 3 mg/ml Method allows to quickly arrest the inflammatory process, to prevent or quickly reduce the overall toxicity, reduce the risk of generalization of infection and to reduce the time of stay of mothers in the maternity facility. 6 table.

The invention relates to medicine, namely to the prevention of generalized purulent-septic inflammatory complications from childbirth, from the group of high infection risk after cesarean section in obstetric-gynecological clinic.

Successful prevention implementation and / or generalization of purulent-inflammatory complications is impossible without reliable sanitation primary focus of infection. Currently, prevention of inflammatory diseases after abdominal delivery to the birth of high infectious ripta, Dimexidum, antibiotics, used actively-washing draining.

Closest to the proposed method is APD - aspirazione-washing draining the uterus (Krasnopolsky C. I. et al. Surgical aspects of abdominal delivery. Methodical recommendations. - 1993. - S. 15) used for the prevention and treatment of MetroEthernet after spontaneous birth after cesarean sections, which consists in uninterrupted forced the evacuation of the uterine cavity, debridement, reduction of intoxication in the presence of the inflammatory process and thereby creating favorable conditions for tissue repair. The ADF of the uterine cavity is used as in the continuous mode of evacuation, and in conjunction with sessions of the irrigation of the uterine cavity solutions of antibiotics or antiseptics.

The disadvantages of this method are:

1. The relatively low availability of the method for most obstetric facilities, as conducting the ADF of the uterine cavity requires the use of special medical equipment, namely, surgical suction device OP-1, constructed in the research Institute of electromechanics, precise degree of vacuum from 0 to 120 cm water column and automatically save preset mode rarefaction in a long time.

2. The need to flush the uterine cavity with a mixture solution of furacin 1: 5000, which itself can serve as a nutrient medium for microorganisms. Lavage of the uterus dangerous incursion into the fallopian tubes and peritoneal cavity and symptoms of peritoneal irritation when injected solution into the abdominal cavity.

3. Having an antiseptic effect due furacin, which has a limited range of actions (he has almost no effect on gram-negative microflora and anaerobes), APD does not reduce the absorption of the decay products of fabrics, Exo - and endotoxins, thereby reduces the toxic load on the uterine tissue, regional lymph system and the entire body.

We offer application-sorption way to prevent septic complications from childbirth, from the group of high infection risk after abdominal delivery is in intrauterine intraoperative introduction sorption drainage-swab, nylon representing the container with the value of dialysis then from 1.5 to 3.0 nm, filled with carbonaceous mineral sorbent SUMS-1 adsorbed thereon metronidazole.

Sorption properties of the sorbent SUMS-Sibirsk) created carbonaceous mineral sorbent SUMS-1 (rachkovskaya L. N. and others, 1982; register MOH N 93/174/7), which is a black shiny granules with a size of 0.4 to 1.0 mm Sorbing surface preparation 150-200 sq m/year SMS-1 combines good strength characteristics developed meso - and macroporous structure. The volume of medium and large pore is 0.3 to 0.4 CC/g, the Amount of transport then reaches micron values. Chemically surface SUM-1 is characterized by the presence of polar and non-polar sites, which leads to their adsorption properties. The presence of medium and large transport pores, especially the chemical nature of the surface provide good adsorption characteristics of the adsorbent SUMS-1 in relation to medium-and high-molecular toxins and microbial cells.

Microbial cell contains protein - protein a, which is in the outer layers of the cell wall of a microbe. Protein has a complex structure, containing in its composition of hydrophilic and hydrophobic groups forming salt hydrogen bonds, stabilizing the protein. Under the influence of environmental conditions, the role of which performs a chemical surface SUM-1, is the destruction stabilizing protein relations, the structure of the protein is similar to denatured. On the th nature of adsorption.

The efficiency of carbonaceous mineral sorbent SUMS-1 against anaerobic microflora insignificant, but when adsorbed on metronidazole, SUMS-1 successfully acts as aerobic and anaerobic microflora with maintaining the effectiveness of the drug within 2 days. To the free activity of metronidazole and possible reabsorption necessary concentration of 2 mg/ml (lubarsky M. C. , 1989). Metronidazole adsorbed on the sorbent SUMS-1, has antimicrobial activity against most gram-positive and gram-negative bacteria, including anaerobic microflora (Lomachenko I. I., Tarasov A. A., 1988; Zubarev b.p. and others, 1990; Brousil L., 1985; Mehta R. B. et al., 1986), which is observed in 44-76% of mothers of high infectious risk (Kulakov Century. And. and others, 1987; Gurtovoy B. L., Emelyanov A. I., 1989; C. I. Krasnopolsky, 1993; Fortunato, S. J., Dobson, 1988; M. G. Ketting E. , 1993). In addition, metronidazole restores the phagocytic activity of white blood cells and has anti-inflammatory action (Kropacheva E. I., 1986; Kozlov, C. A. and others, 1987).

Adsorption of the drug "metronidazole" SMS-1 as follows: sterile drainage-swab is placed in a sterile container filled with metronidazole (concentration 500 mg/100 ml). the -1 with adsorbed thereon metronidazole is entered once intraoperatively in the uterus just before wound closure for two days.

Thus, the use of carbonaceous mineral sorbent SUMS-1 with immobilized thereon metronidazole is etiotropic therapy of purulent-septic complications after abdominal delivery. This method allows to provide adequate local detoxification, significantly affect the course of the wound process uterus walls, and thereby to accelerate healing processes in the body.

These clinical applications application sorption way to prevent septic complications from childbirth, from the group of high infection risk after cesarean section

Under our observation were 143 women. In the main (1st) group consisted of 80 mothers of high infectious risk for the implementation of purulent-septic complications after cesarean section, which along with the traditional integrated management of the postoperative period with the use of infusion, antibacterial, anti-inflammatory and uterotonic therapy was performed intraoperative intrauterine introduction drainage-swab SUMS-1 adsorbed on the metronidazole. The control group (2-I) was 63 postpartum women and adolescent girls from high infectious ri is the SPE treatment using aspirazione-irrigation and drainage (APD) of the uterus.

Under the high-risk groups, we meant the women's 3, 4 and 5 the degree of infection risk based on the classification of C. I. Krasnopolsky et al. (1993), namely:

3 degrees - woman operated on an emergency basis during the duration of childbirth up to 15 hours and a dry period of less than 6 hours;

4 degree - pregnant operated in a planned manner, with exacerbations of chronic infectious diseases or acute infectious processes of any localization;

5 degree - woman operated on an emergency basis during the duration of childbirth more than 15 hours and a dry period of more than 6 hours.

The wound in the uterus in all cases recovered separate 2-row anchor kemptville seams. Drainage-swab was introduced with the purpose of preventive maintenance once in 2 days. The pregnancy and the level of disclosure uterine throat in both groups did not differ significantly. Intraoperative total blood loss in the comparison of the 1st and 2nd groups were 644,426,3 and 673,339,9 ml or 0,830,02 and 0,940,05% of body weight, respectively, p>0,05.

Normalization temperature came quickly from childbirth, both groups (table. 1), however, noted a clear trend towards a more rapid normalization of body temperature by unidata.

More clearly the advantages of our proposed method of prevention in mothers of high infection risk were observed during the study duration "acute treatment" (PL. 2). Under "cupping therapy" we understand the pain syndrome and signs of intoxication.

Analysis of the data table. 2 shows that the duration of acute treatment is not the same. So, if in the 1st group, its duration was within 5 days the vast majority of postpartum 69 of 80 (86,29,1%), second - by this time was marked by a strong tendency towards the reduction process and the normalization condition, only 39 out of 63 mothers of high infectious risk (61,96,1%) - p<0,001. Statistically significant difference is detected and when considering therapeutic effect among parturients 1 and 2 groups (p<0.05) in the next 6-9 days or more of treatment.

These data suggest certainly higher efficiency of our proposed method intraoperative injection of drainage-swab SUMS-1 adsorbed on the metronidazole for the prevention of septic complications from childbirth, from the group of high infection risk compared with group adeleye night doing the postoperative period the proposed complex at 59 (73,7%) parturients main group there was an improvement in the General condition. They became more active, less complain of anything. Skin and visible mucous membranes were normal coloration. The tongue was moist, but was imposed, it was noted early appearance of peristalsis. On the background of the location of the drainage-swab deep night sleep occurred in 64 (80%) mothers.

Already on the second day of the postoperative period there was a significant decrease in pain in hypogastrium, 53 (66.2 per cent) of them decreased tenderness of the anterior abdominal wall.

5-6 day postoperative period, all the puerperium 1st group (the principal) was cancelled antibacterial therapy. Complaints women did not show, everyone was in a satisfactory condition, felt cheerful, said good night's sleep with a feeling of relaxation after him in a good mood.

The favorable impact of local debridement of postpartum uterine drainage swab was noted in the postoperative period and the improvement of some hematological and biochemical parameters. No statistically significant changes compared with the 2nd group we observed only when the hemoglobin, erythrocyte, leukocyte and erythrocyte sedimentation rate. All other indicators p is traslacoon and cytological control of aspirates of the uterine cavity (see table. 3, 4, 5, 6).

At vaginal examination during this period postoperative period 59 (73,7%) parturients 1st group found statistically significant reduction of postoperative uterine confirmed ultrasound data.

On 8-9 day postoperative period state 69 (86.2 per cent) mothers group 1 was satisfactory, complaints, they were not charged and were healthy.

With regard to the postoperative period in puerperas control group, our analysis showed a statistically significant gap in terms of normalization of peripheral blood counts involution of the uterus and data cytological observations in comparison with the main group.

The maximum therapeutic effect was obtained in puerperas 1-th group. According to our observations, clinical recovery (full recovery + significant improvement) when used in the treatment of postoperative period intraoperative local readjustment of the uterus drainage swab SUMS-1 adsorbed thereon metronidazole occurred in 100% of cases, while in puerperas control group - 82,54,78%.

Despite ongoing therapy, 11 (17,5%) parturients 2nd group (cont From childbirth, the 1st group of inflammatory complications were noted. Only 6.2% of patients (5) prophylactic intraoperative introduction drainage-swab SUMS-1 adsorbed thereon metronidazole with concomitant interstice-subserous fibroid of the womb after 9 days was observed subinvolution of the uterus compared with the calm of blood and aspiration biopsies of the uterine cavity.

The average duration of treatment of parturient women in the 1 and 2 groups was not the same (9,330,59 and 11,70,47 and, respectively, (p<0,001). Therefore, postpartum women and adolescent girls from high infectious risk in preventive application sorption drainage of the uterus sorbent SUMS-1 adsorbed on the metronidazole was discharged from the hospital with a 100% clinical recovery (full recovery 8010,7% + significant improvement 2010,7%) more than 2 days faster than with usual care.

Clinical example, here is the extract from the birth history N 133: pregnant B., 28 years old, was admitted in the Department of pathology of pregnant regional maternity hospital, Novosibirsk 01.02.1995, Clinical diagnosis: pregnancy I was 38 weeks, ORD, secondary infertility. Combined late OCG-gestosis of moderate severity on the background of the alimentary obesity mild. Pure agogical burdened by obesity, mild nutritional origin, gynecological - XP. left salpingitis, periovarian, acute serous colpitis. Thus, belonging to the group of high risk of occurrence of septic complications in the postoperative period.

05.02.1995, due to premature rupture of amniotic fluid on the complex relative readings in the interests of the fetus produced emergency operation isthmic caesarean section. Intraoperative maternity held applicative sorption drainage of the uterine cavity carbonaceous mineral sorbent SUMS-1 adsorbed on the metronidazole. Drainage-swab SUMS-1 adsorbed on the metronidazole had been in the uterus for 2 days after surgery. Complications in the early postoperative period, we have not recorded.

Examination: blood from 05.02.1995, leukocytes to 18.6 thousand (eosinophils 0%, stab 1%, segment-nuclear 79%, lymphocytes 14%, monocytes 6%), erythrocyte sedimentation rate of 24 mm/h; LII - 4,05; GPI - 10,206. The content of total protein in the blood 72 g/l, albumin - 55%; globulins: alfa-1 to 5.7%, alfa-2 - 8,6%, betta - 16,8%, gamma - 13,9%, A/G coefficient. - 1,22, SLO 2. In a smear and bacteriological culture for aerobic-anaerobic flora of the cervical canal from 04.02.1995, N 13 selected Streptococus anhemolyticus study of discharge from the urethra from 04.02.1995, identified Gr-sticks in moderation, chlamydia, urine analysis without pathological changes.

The results of ultrasound examination on the 3rd day after surgery 08.02.1995, the body of the uterus in the midline with indistinct contours 102 x 78 x 89 mm M-echo - 7 mm, homogeneous. The ovaries on both sides without pathological changes. In the back dupacova pocket free liquid is not rendered.

The results of the study aspiration biopsy of the uterine cavity from 08.02.1995, N 10 - large accumulations segment-nuclear leukocytes are all in sight, many segments with signs of destruction; the shadow of cytolysis; the red blood cells in large numbers. Segment-nuclear neutrophils - 95%, lymphocytes - 5%.

In the postoperative period in the background of the application sorption intraoperative drainage body temperature returned to normal by the end of 1 day. In Exodus 3 days stopped the pain in the lower abdomen and has greatly improved the condition of the patient.

In the treatment of puerperal from the group of high infection risk was examined again in the dynamics. In the analysis of blood from 11.02.1995, leukocytes 9.7 thousand (eosinophils 0%, stab 4%, segment-nuclear 65%, lymphocytes 30%, mo alfa-2 - 8,9%, betta - 8,7%, gamma - 13,5%, A/G ratio is 1.7, SLO - 0. In a smear and bacteriological culture for aerobic-anaerobic flora of the cervical canal from 11.02.1995, N 27 selected E. coli, sensitive to most antibiotics.

The results of ultrasound examination from 11.02.1995, the body of the uterus in the midline with a clear unde circuits 94 x 62 x 89 mm M-echo - 6 mm, without expressed echogenic inclusions. The right ovary 23 x 19 x 24 mm with a homogeneous internal structure, the left ovary 17 x 22 x 25 mm with liquid inclusion in diameter up to 11 mm Free fluid in the rear dupacova pocket is not revealed.

The results of the study aspiration biopsy of the uterine cavity from 11.02.1995, N 5: unmodified cells to 8-10 in the field of view, macrophages 0-1 in the field of view; a single red blood cells; segment-nuclear neutrophils 66%, lymphocytes 32%, monocytes - 2%.

Seams with skin removed on the 7th day - healing by primary intention. Discharged home with your child in a satisfactory condition 14.02.1995, Duration of hospital stay after surgery was 9 days.

The way to prevent septic complications in mothers of high-risk groups in the implementation of infection after OPE is peracino enter sorption drainage-tampon made of nylon membrane with the value of dialysis then from 1.5 to 3.0 nm, with carbonaceous mineral sorbent SUMS-1 adsorbed thereon metronidazole in a dose of 3 mg/ml

 

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