Horioamnionit — the infectious inflammation of fetal covers and amniotic liquid caused by polymicrobic associations. It is shown by a hyperthermia, pain in a uterus, purulent or sanious allocations from a vagina. Perhaps subclinical course of a disease with the minimum symptomatology. Ultrasonography of a small pelvis is diagnosed by means of gynecologic survey, KTG of a fruit, laboratory researches. Tactics of maintaining the pregnant woman assumes an urgent rodorazresheniye in natural patrimonial ways or by Cesarean section with simultaneous purpose of intensive antibacterial, anti-inflammatory, infusional therapy.
Horioamnionit (an intraamniotichesky infection, an amniotic infectious syndrome) arises in the II trimester more often and, according to different authors, comes to light at 0,9-10,5% of pregnant women. Development of a disease in the III trimester is usually connected with the long waterless period after premature an izlitiya of waters. Pathology is found more often in the women having chronic genital and ekstragenitalny infections. Relevance of timely diagnostics and treatment of antenatalny infection is caused by what horioamnionit is one of the most common causes of premature termination of pregnancy, increases probability of emergence of life-endangering complications for a fruit and the woman.
Reasons of a horioamnionit
Inflammation of the covers surrounding a fruit — the polymicrobic infectious disease caused by association from two and more pathogenic or opportunistic microorganisms. Streptococci of group B, a peptostreptokokka, staphylococcus, colibacilli, mycoplasmas, ureaplasmas, enterokokk, hlamidiya, trichomonads, gonokokk, gardnerella, Candida, a bakteroida, a virus of simple herpes, a cytomegalovirus, etc. can become direct activators of a horioamnionit. To start inflammatory process the combination of several contributing conditions, as a rule, is required, are basic of which:
- Existence of the infectious center. Infection of amniotic covers usually happens in the ascending way. The risk of development of a horioamnionit increases in the presence of a bacterial vaginosis, a vulvovaginit, a colpitis, an endotservitsit, an endometritis. The descending infection is possible at salpingita, ooforita, adneksita. The hematogenic drift of microorganisms is not excluded from the existing ekstragenitalny centers of a chronic infection.
- Access to a uterus and fetal bubble. In 98% of cases of physiological pregnancy amniotic liquid is sterile. From infection it is protected by fetal covers and the slime closing the channel of a neck of a uterus. Operation of these protective mechanisms is weakened at istmiko-tservikalny insufficiency, dribble of amniotic waters, a rupture of a fetal bubble. The probability of an inflammation especially increases in labor with a waterless interval more than 24 hours.
- Invasive diagnostic and medical manipulations. In certain cases at the complicated course of pregnancy, suspicion on anomaly of development or a disease of a fruit carry out researches with penetration into a cavity of a uterus and a fetal bubble. In the development plan for a horioamnionit the amnioskopiya, amniocentesis, , are the most dangerous. Infection is also possible during an amnioinfuziya and pre-natal blood transfusion.
- Decrease in immunity. More active reproduction of opportunistic and pathogenic microorganisms happens when weakening protective forces of an organism. Catarrhal diseases, exacerbations of ekstragenitalny pathology, long or intensive physical and mental activities, reception of medicines with direct or secondary immunosupressorny effect become provocative factors of immune insufficiency.
The risk of emergence of a horioamnionit also increases from the beginning of natural childbirth, especially if in their course manual vaginal researches after opening of fetal covers are repeatedly conducted or the internal kardiotokografiya of a fruit for obtaining objective data on its state and characteristics of sokratitelny activity of a uterus is carried out.
At the normal course of pregnancy development of inflammatory changes in the horiyena and other fetal covers is interfered by the natural placentary mechanisms of protection presented by several types of Toll-like receptors which define presence of ligands of a microorganism and initiate protective reaction in response to damage of an epithelium. Allocation of defenzin, sekretorny leykotsitarny inhibitors of proteinases, elafin promotes lysis of bacteria and an inactivation of their damaging factors. The massive ascending, descending or hematogenic arrival of infectious agents provokes failure of local immunity, and the proteases produced by them destroy fibers of the collagen which is a part of fetal covers, have the direct damaging effect on a placenta.
The mediated effects promoting development of inflammatory process at a horioamnionita are connected with allocation of cytotoxic tsitokin and matriksny metalproteases, apoptosis. The increased concentration of microbic phospholipases in amniotic liquid promotes the strengthened synthesis of prostaglandins from fabric phospholipids that is followed by the premature beginning of patrimonial activity. Swallowing the infected amniotic liquid, the fruit vnutriutrobno catches. More than in 80% of cases the fetoplatsentarny complex suffers – the inflammation extends to interfleecy space, vessels of a basal detsidualny cover trombirutsya.
At systematization of clinical forms of a horioamnionit consider the course of pathological process — the speed of its development and expressiveness of clinical manifestations. The morphological changes happening in fabrics of amniotic covers and probability of emergence of complications are directly connected with sharpness of an inflammation. Experts in the sphere of obstetrics and gynecology, distinguish two types of a horioamnionit:
- Sharp. The most common form of a disease. The inflammation develops quickly, is shown by the expressed symptomatology. In the covers surrounding a fruit leykotsitarny infiltrates are formed, are usually involved in process a placenta, , , an umbilical cord. Defeat of vessels in the form of horionalny vaskulit, a funikulit is characteristic.
- Chronic. It is observed extremely seldom, mainly at patients with herpes, syphilis, toxoplasmosis. It is combined with arterial hypertension, diabetes, the Rh-conflict. Is determined by existence of complications. Morphologically lymphocytic infiltration of extra placentary covers is found and chronic villit.
Symptoms of a horioamnionit
At the sharp course of a disease the pregnant woman has pains of various intensity in the lower part of a stomach. It can irradiate to the inguinal area, a sacrum, to amplify when probing a uterus through a forward belly wall. Body temperature is often increased to 38 °C and above, the patient has an expressed fever, pulse becomes frequent to 100 reductions a minute and above. The general health of the woman worsens, she tests weakness, bystry fatigue. Pathological vaginal allocations with an unpleasant smell — gray-green (purulent) or with blood impurity can be observed. In some cases horioamnionit proceeds asymptomatically and it is diagnosed after suddenly interrupted pregnancy or on existence of characteristic complications of the postnatal period.
The most serious complications of a horioamnionit are fetoplatsentarny insufficiency, a premature rupture of fetal covers, peeling of normally located placenta, early childbirth in 2-3 trimesters. Such pregnant women have a bacteremia, weakness of patrimonial activity, atonichesky postnatal bleedings, a thrombembolia, postnatal endometritises, obstetric peritonitises, pelvic abscesses, infectious complications of the traumatic wounds got in labor more often. Koagulopatiya, septic shock, a respiratory distress syndrome are possible. Violation of normal functioning of a fetoplatsentarny complex at a horioamnionita can provoke a fruit arrest of development. At newborns the risk of getting injured in labor, development of congenital neonatal infections (pneumonia, sepsis, meningitis), a cerebral palsy and death is increased.
As horioamnionit poses a serious threat to the further course of pregnancy, at suspicion on development of a disease all inspections are carried out in the emergency order. Diagnostic search is directed to identification of signs of a local inflammation of amniotic covers, assessment of a condition of a fruit and definition of possible activators. Are most informative for diagnosis:
- Survey on a chair. The Bimanualny vaginal research allows to find morbidity of a uterine wall, expansion of the tservikalny channel. At the expense of hypostasis of fabrics the sizes of a pregnant uterus can be more gestational term. At survey in mirrors characteristic allocations are noticeable.
- Kardiotokografiya of a fruit. A sign of violation of work of a fetoplatsentarny complex and possible pre-natal infection of the child at a horioamnionita compensatory tachycardia is considered. Fruit heart rate at an inflammation of covers exceeds 160 beats per minute.
- Laboratory analyses. Typical laboratory signs of frustration are over 15109/l and acceleration of SOE in the general blood test. All-inflammatory changes are also demonstrated by shift of a leykotsitarny formula to the left. Level of C-jet protein exceeds 5,0 mg/l.
- Ultrasonography of a uterus and fruit. OUSE criterion of a horioamnionit is included by a thickening of placentary fabric, expansion of interfleecy and subkhorialny spaces. Horialny plate usually gipoekhogenna. Signs of premature maturing of a placenta come to light, the quantity and quality of amniotic waters is changed.
- Bacteriological researches. The microscopy and bacterial crops of vaginal dab give the chance to define possible activators of infectious and inflammatory process. According to indications microbiological analyses supplement with special methods of detection of infections (RIF, IFA, PTsR).
Falling of level of an estriol, increase in maintenance of a horionichesky gonadotrophin, strengthening of a tromboagregation in combination with violations of a plasma link of a hemostasis are additional signs of inflammatory defeat of fetal covers. After the delivery existence of an inflammation is found at a histologic research of fetal covers. Differential diagnostics is carried out with an endometritis, other inflammatory diseases of reproductive organs, sharp surgical pathology of an abdominal cavity. If necessary appoint consultations of the surgeon, the infectiologist, the urologist, a neonatolog.
Treatment of a horioamnionit
The inflammation of covers of a fruit is the indication for the emergency hospitalization of the pregnant woman and her transfer to a bed rest. Tactics of maintaining the patient assumes as much as possible bystry rodorazresheniye (stimulated childbirth or Cesarean section) with purpose of massive antibacterial and symptomatic therapy which proceed in the postnatal period. The choice of a method of a rodorazresheniye depends on expressiveness of inflammatory changes, term of the waterless period (at premature izlitiya of amniotic waters), conditions of the woman and a fruit. The scheme of drug treatment is directed to the solution of such therapeutic tasks as:
- Fight against infectious agents. Usually at a horioamnionita even before obtaining results of an antibiotikogramma apply the antibiotics of a broad spectrum of activity influencing including on hlamidiya and mycoplasmas. In the subsequent correction of appointments depending on sensitivity of flora is possible.
- Prevention of complications of antibiotic treatment. Taking into account farkoterapevtichesky and pharmakodinamichesky characteristics of antibacterial means protivogistaminny, protivokandidozny medicines can be recommended to the patient. For restoration of normal microflora use eubiotik.
- Infusional therapy. At the expressed violations of haemo dynamics, symptoms of the general intoxication appoint dezintoksikatsionny, colloidal and salt solutions. According to indications perhaps drop introduction of the medicines improving warm activity, peripheral microcirculation, hemostasis indicators.
- Impact on inflammatory processes. Use of nonsteroid resolvents allows to reduce secretion of mediators of an inflammation, to reduce body temperature at a considerable hyperthermia. NPVS are also capable to weaken pain due to increase in a threshold of painful sensitivity of receptors.
Appointment to patients with horioamnionity vitamin and mineral complexes, immunoexcitants accelerates process of recovery and reduces probability of complications. During the recovery period physiotherapeutic treatment with use of UVCh-therapy, infrared laser therapy, electropulse therapy is shown.
Forecast and prevention
At timely diagnosis the forecast of a horioamnionit for the pregnant woman favorable. The probability of a positive outcome for a fruit increases in process of increase in gestational term on which there was a disease. Preventive actions assume early registration in antenatal clinic for identification and treatment of genital infections, ekstragenitalny pathology. Reasonable approach to purpose of invasive prenatal diagnostics, the emergency hospitalization and the choice of optimum tactics of conducting pregnancy and childbirth at a premature otkhozhdeniye of amniotic waters are recommended.