METROTHROMBOFLEBITIS: CLASSIFICATION AND TREATMENT.
Metrothrombophlebitis is a disease in which the uterine veins become inflamed and thrombose.
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Pathology refers to complications of endometritis that occurs in the postpartum or postoperative periods.
Clinically, the disease is manifested by fever, abundant and prolonged blood discharge from the vagina, abdominal pain of a aching or pulling character, palpitations and general weakness. The diagnosis of metrothrombophlebitis is confirmed by a gynecological examination, a blood test for coagulation and an ultrasound of the pelvic organs. Treatment of pathology requires hospitalization, the appointment of antibiotics, anti-inflammatory drugs, anticoagulants and antiplatelet agents. With a significant worsening of the condition (massive bleeding, septicopyemia), a hysterectomy is performed.
MORE ABOUT PATHOLOGY
Metrotrombophlebitis got its name from the Greek words uterus and inflammation of the veins, which together means thrombosis of the inflamed veins of the uterus. Occurs after childbirth or after surgery on the fetus. The penetration of infectious agents into the venous network of an organ is accompanied by inflammation of the walls of blood vessels and the surrounding tissues, which is called periphlebitis. The inflammatory process in the uterine veins creates optimal conditions for the formation of blood clots. The disease is characterized by local and general manifestations, with generalization of the infection, septic and thromboembolic complications develop (pulmonary embolism, suppuration of blood clots, heart attack pneumonia, exfoliating metritis until sepsis occurs).
WHAT CAUSES AND RISK FACTORS
The background for the occurrence of the disease is almost always metroendometritis, which developed after undergoing surgical interventions on the pelvic organs or complicated delivery.
The etiological factors of metrothrombophlebitis are gram-negative microorganisms (E. coli, Klebsiella) and anaerobic bacteria that do not form spores (peptococci, bacteroids). But more often the development of pathology is due to associations of microbes. In the mechanism of the development of the disease, the leading role is played by an increase in blood coagulability due to the activation of platelet and procoagulant components of hemostasis and the suppression of immunity.
The occurrence of pathology is predisposed by gestosis, abnormalities of labor (weakness, discoordination), anhydrous interval of 12 hours or more, massive blood loss in childbirth (postpartum hemorrhage, bleeding in the subsequent period). Also, the risk of developing metrothrombophlebitis significantly increases after obstetric operations and benefits (cesarean section, manual removal of the placenta, suturing tears of cervix grade 3, uterine massage on the fist).
Much less often, the disease occurs after gynecological surgery (removal of myomatous nodes, excision of endometriotic foci in the uterus, reconstructive plastic surgery on the uterus). It is noted that patients with a history of metrotrombophlebitis have indications of thrombophlebitis in the past, excision of varicose veins of the lower extremities.
Clinically expressed manifestations of metrothrombophlebitis are determined on the 6th-9th day after childbirth, as a rule, after discharge of the puerpera from the hospital. A woman notes an increase in temperature to subfebrile digits, lochia remain abundant without a tendency to decrease, the general condition worsens, sleep is disturbed, weakness with lethargy and aching abdominal pain occur. A characteristic sign of pathology is the increase in heart rate to 120 beats per minute, which does not correspond to temperature. When conducting anti-inflammatory treatment of endometritis, the clinical picture of the developed metrothrombophlebitis is erased, but there are postpartum subinvolution of the uterus with tachycardia, prolonged blood discharge from the genital tract.
Metrothrombophlebitis, which occurred in the postoperative period, is manifested by pains in the lower abdomen and in the depth of the pelvis, urination and defecation disorders, and fever. Peritoneal symptoms may occur. With the progression of the disease, blood clots in the uterine veins suppurate, which is accompanied by a significant worsening of the condition, the appearance of chills and a sharp increase in temperature to 40 – 41 degrees. Timely diagnosis and adequate treatment is accompanied by normalization of temperature after 2 – 3 chills. Progression of the process leads to the development of thrombophlebitis of the pelvic veins.
An unfavorable form of thrombophlebitis is exfoliating metritis, which is characterized by myometrial necrosis as a result of thrombosis of blood and lymph vessels.
Exfoliating metritis occurs 3 to 4 weeks after birth and is accompanied by rejection and release of necrotic areas of the myometrium. The disease is characterized by severe course, fever and headaches. The uterus does not contract, the bottom of the organ is at the level of the first day of the postpartum period. Allocations are first plentiful, bloody, then acquire a putrefactive smell and brown color, later become purulent. A sharp reduction in secretions from the genital tract is observed a day or two after the dead pieces exit from the uterine cavity. The persistence of the abundance of discharge after the sequestration has passed indicates the presence in the uterine cavity of non-secreted areas of necrotic tissue.
DIAGNOSTICS OF METROTHROMBOPHLEBITIS
You can suspect a disease after collecting an anamnesis and elucidating factors predisposing metrothrombophlebitis. The pronounced clinical picture and gynecological examination allow a preliminary diagnosis to be made. With bimanual palpation of the abdomen, a painful and enlarged uterus is determined, its size does not correspond to the days of the postpartum period, the consistency of the organ is soft. The maximum soreness is detected in the region of the sides of the organ, there dense convoluted veins are sometimes felt there. Typically, the opening of the cervical canal to 1 finger on 8 – 10 days of the postpartum period. Due to the expansion and compaction of the veins of the uterus by thrombi, its surface during palpation is defined as uneven or faceted. When pelvic vein thrombophlebitis occurs, painful infiltrates are felt in the parametria. The diagnosis is confirmed by ultrasound scanning of the uterus and appendages.
In a general blood test, low hemoglobin, accelerated ESR and moderate leukocytosis are detected. A blood coagulation test shows a shorter coagulation time, decreased fibrinolytic activity, increased prothrombin index and fibrinogen level, signs of hypercoagulation.
A gynecological examination for metrothrombophlebitis should be carried out with caution so as not to cause a blood clot to break off and subsequent embolism, as well as to prevent generalization of the infection.
Differential diagnosis is carried out with a placental polyp postpartum and postoperative endometritis.
TREATMENT OF METROTHROMBOPHLEBITIS
All patients with metrothrombophlebitis are hospitalized in the gynecological department. The basis of treatment is the appointment of a gentle regimen (limiting physical activity, but not strict bed rest to avoid blood circulation disorders and the formation of new blood clots) and a diet that excludes spicy, fried, fatty foods, strong tea and coffee. In order to suppress the inflammatory process, antibiotics and sulfonamides are prescribed. Pain is relieved by prescribing antispasmodics and non-steroidal anti-inflammatory drugs (Diclofenac). Also shown is the use of antihistamines and antiplatelet agents (Curantil, Aspirin, nicotinic acid preparations). For blood thinning, anticoagulants (Heparin, Phenilin) and intravenous infusions of rheological action solutions (Reopoliglyukin, Dextran) are prescribed. Anticoagulant therapy is carried out under the control of the prothrombin index and OAM every 3 to 4 days. A decrease in IPT and the appearance of hematuria require a decrease in the dose of anticoagulants or their withdrawal (signs of drug accumulation in the body). In the chronic course of the disease, physiotherapy is indicated: treatment with mud, paraffin, hydrogen sulfide baths. Suppuration of blood clots or massive bleeding against a background of exfoliating metritis is an indication for removal of the uterus.
COMPLICATIONS OF METROTHROMBOFLEBITIS
With the development of metrothrombophlebitis, infection with a blood flow into the venous network of the pelvis and lower extremities is possible. A blood clot can cause pulmonary embolism or heart attack pneumonia. The severe course of the disease is fraught with suppuration of blood clots, necrosis of the walls of the fertility, exfoliating metritis, profuse bleeding and sepsis. Untimely treatment of pathology can result in a partial or complete gangrene of the uterus and the formation of abscesses in the walls of the organ.
FORECAST AND PREVENTION
Timely and adequate treatment, including anticoagulant, antiplatelet and antibacterial therapy, avoids the development of thromboembolic and septic complications. With the late start of therapy, suppuration of blood clots and the occurrence of thromboembolic complications, the prognosis is dubious.
The rational management of childbirth, the postoperative and postpartum periods, the prevention of bleeding and the adequate restoration of blood loss, adherence to aseptic techniques during abortion, gynecological and obstetric surgery can prevent the development of severe pathology – metrothrombophlebitis.