Clinical features
After cesarean section, classical symptoms of peritoneal irritation are often masked. Physicians focus on early markers:
- Pronounced intestinal paresis.
- Dryness of the tongue.
- Tachycardia outpacing the temperature reaction.
As intoxication progresses, vomiting and loose stools develop, and the Blumberg sign becomes clearly positive.
Diagnostic algorithm
A combination of methods is used to establish the diagnosis:
- Laboratory tests: leukocytosis with a shift to the left, increased procalcitonin, hypoproteinemia.
- Ultrasound: visualization of free fluid, assessment of the uterine suture condition and peristalsis.
- Radiography: detection of «Koil's gas-fluid levels» in dynamic intestinal obstruction.
- Microbiology: cultures for selecting targeted antibiotic therapy.
Treatment stages
Therapy is carried out strictly in stages:
- Preparation: stabilization of the patient's condition.
- Surgery: elimination of the purulent focus (sanation, drainage, or removal of the uterus).
- Intensive care: infusion support, electrolyte correction, antibacterial, and metabolic therapy.
To combat intestinal paresis, a combination of neostigmine with potassium solution and epidural anesthesia is used.
Briefly: answers to topical questions
What laboratory markers and blood test changes indicate the development of postpartum peritonitis?
The development of postpartum peritonitis is indicated by specific changes in complete blood count and biochemical blood tests. The main laboratory markers include:
- Leukocytosis — accompanied by a left shift in the leukocyte formula (an increase in the number of band neutrophils).
- Procalcitonin — an increase in its blood level is noted.
- Hypoproteinemia — a decrease in total protein, primarily due to albumin.
- Electrolyte disturbances — a decrease in potassium (K⁺) levels is detected.
What methods and drugs are used for the conservative treatment of intestinal paresis in peritonitis?
For the conservative treatment of intestinal paresis, drug stimulation of motor function and additional methods are used. Complex therapy includes:
- Drug therapy — intravenous administration of 0.1% neostigmine methylsulfate solution (1 ml) and 4% potassium solution (60 ml) in 400 ml of 5% dextrose (glucose) solution up to twice a day.
- Additional methods — cleansing enemas, as well as epidural anesthesia with a prolonged block.
What are the absolute indications for hysterectomy in the surgical treatment of postpartum peritonitis?
An absolute indication for hysterectomy with fallopian tubes in postpartum peritonitis is the absence of conditions for organ preservation. Radical surgery is performed when uterine suture failure (e.g., after cesarean section) is combined with the clinical picture of peritonitis, making organ-sparing tactics impossible. Indications also include situations where the uterus acts as the source of inflammation, with the development of diffuse peritonitis and the formation of multiple abdominal abscesses.
Which microorganisms are most often the causative agents of postpartum peritonitis?
Postpartum peritonitis is most frequently caused by gram-negative bacteria and non-spore-forming anaerobes, usually presenting as a mixed infection. The main microorganisms include:
- Gram-negative flora — bacteria of the Enterobacteriaceae family (Escherichia coli, Proteus spp., Klebsiella spp., Enterobacter spp.) and the genus Pseudomonas.
- Anaerobes — non-spore-forming bacteria, especially Bacteroides.
- Gram-positive flora — streptococci, staphylococci, and enterococci (found in approximately one-third of patients).
What stages (phases) is postpartum peritonitis divided into according to its clinical course?
According to its clinical course, peritonitis is divided into three stages of development. The provided materials describe the first two in detail:
- Reactive stage — lasts about one day, characterized by hyperemia, peritoneal edema, exudation with fibrin formation, initial intoxication, and pronounced pain syndrome.
- Toxic stage — lasts about two days, manifested by increasing symptoms of intoxication (patients become lethargic, adynamic) against the background of decreasing local manifestations, as well as the development of pronounced intestinal paresis.
Information about the third stage is absent in the sources.
The «THREE S» rule: Dryness (of the tongue), Speed (of the pulse), Stimulation (of the intestine).
Class and exam questions
Why might peritoneal irritation signs be absent?
After a cesarean section, the clinical picture is often masked by the postoperative state; therefore, general signs of intoxication and intestinal paresis come to the forefront.
When is hysterectomy indicated?
Radical surgery is performed for uterine suture failure if conditions for organ preservation are absent.
What is the difference between sepsis and septic shock?
Sepsis is a systemic reaction to infection with organ dysfunction, and septic shock is a critical condition with hypotension unresponsive to fluid resuscitation.
What else to study on this topic
- Differential diagnosis of postpartum peritonitis and endometritis.
- Features of managing patients with septic shock in obstetrics.
- Infusion therapy protocols in hypoproteinemia.
- The role of nasogastric decompression in the postoperative period.
- Risk factors associated with premature rupture of membranes.
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