CC BY
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11. Wojcieszek AM, Shepherd E, Middleton P, Lassi ZS, Wilson T, Murphy MM, Heazell AE, Ellwood DA, Silver RM, Flenady V.Care prior to and during subsequent pregnancies following stillbirth for improving outcomes. Cochrane Database Syst Rev. 2018; 12:CD012203. doi: 10.1002/14651858.CD012203.pub2.
I i(|к iMIII
ПЕРИНАТАЛЬШ НАСЛ1ДКИ ПОРУШЕННЯ АДАПТАЦП ПРИ ОБТЯЖЕНОМУ АКУШЕРСЬКОМУ АНАМНЕЗ1 Жданович О.1., Воробей Л.1., Аношина Т.М., Коломiйченко Т. В.
Пережитий стрес на тлi перинатальних втрат (ПВ) може негативно впливати на перебЬ наступно! вагiтностi. Проведено дослщження варiабельностi серцевого ритму плода шляхом кардюштервалографп (К1Г) плода жiнок з обтяженим акушерським анамнезом (ПВ в анамнезi ) у 32-34 тижш вагiтностi Обстежено 200 вагiтних з ПВ та 100 ваптних без ПВ в анамнеза Порiвняння результата кардiотокографii та допплерометрii з даними К1Г плода показало, що при зривi адаптацii регуляторних систем плода його дистрес дiагностовано у 90,0 % жшок, при вираженому напруженш регуляторних систем плода - у 27,3 %, тобто результати К1Г плода пiсля 32 тижнiв ваптност можуть бути дiагностичними маркерами його дистресу. Переважна бшьшють (76,1 %) дiтей вiд матерiв з ПВ в анамнезi пiсля перенесеного внутршньоутробно дистресу народжуються у станi асфжсп, що обумовлюе високу частоту синдромiв дизадаптацii, найчастiшими з яких порушення ЦНС (73,9 %) та дизадаптоз серцево-судинно! системи (41,3 %).
Ключовi слова: перинатальнi втрати, кадiоiнтервалографiя, адаптацiя, дистрес плода, новонароджений
Стаття надшшла 19.04.2019 р.
ПЕРИНАТАЛЬНЫЕ ПОСЛЕДСТВИЯ НАРУШЕНИЯ АДАПТАЦИИ ПРИ ОТЯГОЩЕННОМ АКУШЕРСКОМ АНАМНЕЗЕ Жданович А.И., Воробей Л.И., Аношина Т.Н.,
Коломийченко Т. В. Пережитый стресс на фоне перинатальных потерь (НИ) может негативно влиять на течение последующих беременностей. Проведено исследование вариабельности сердечного ритма (ВСР) плода путем кардиоинтервалографии (КИГ) плода женщин с отягощенным акушерским анамнезом (ИВ в анамнезе) в 3234 недели беременности. Обследованы 200 беременных с НИ и 100 беременных без НИ в анамнезе. Сравнение результатов кардиотокографии и допплерометрии с данными КИГ плода показало, что при срыве адаптации регуляторных систем плода его дистресс диагностирован у 90,0% женщин, при выраженном напряжении регуляторных систем плода - у 27,3%, то есть результаты КИГ плода после 32 недель беременности могут быть диагностическими маркерами его дистресса. Подавляющее большинство (76,1%) детей от матерей с НИ в анамнезе после перенесенного внутриутробно дистресс рождаются в состоянии асфиксии, обусловливает высокую частоту синдромов дизадаптации, частыми из которых нарушения ЦНС (73,9%) и дизадаптоз сердечно-сосудистой системы (41,3%).
Ключевые слова: перинатальные потери, кадиоинтервалография, адаптация, дистресс плода, новорожденный
Рецензент Иохилько В.1.
DOI 10.26724/2079-8334-2020-1-71-49-53 UDC 618.1-089-06-084
\.M. /.;i|>iini/h;in. I./. Glmlcliiik. N.M. Ro/likovska. A.G. Volyniiskn. O.I. Shevclieiiko. II.Yii. kushnir Odesa National Medical I niversily. Odesa
PREVENTION OF PURULENT-SEPTIC COMPLICATIONS DURING LAPAROSCOPIC SURGERIES ON PELVIC ORGANS WITH THE RISK OF VAGINAL MICROBIOTA
CONTAMINATION
e-mail: [email protected]
The efficacy analysis of the purulent-septic complications prevention at 115 "clean-contaminated" laparoscopic surgeries on the pelvic organs (laparoscopic hysterectomy, conservative myomectomy with the node resection via colpotomy incision) was performed. In the experimental group of patients (n = 60), 0.02% decamethoxin solution was administered intravaginally. The control group (n = 55) received traditional systemic perioperative antibiotic prevention using cephalosporins. It was shown that the early postoperative period dynamics, as well as indicators of systemic inflammatory response and the number of complications did not show significant differences between the studied groups, and in the experimental group there was an increase in the lactobacilli number and 87.3% decrease in the opportunistic pathogens content, which indicated the feasibility of preventive intraoperative topical decamethoxin application.
Key words: laparoscopy, purulent-septic complications, prevention, decamethoxin.
The study is a fragment of the research project "Improving methods ofprevention, diagnosis and treatment of diseases of the reproductive system of women using the latest medical and molecular genetic technologies", state registration No. 0117U007494.
Endoscopic surgery has a clear place in modern surgical gynecology. Due to the minimal invasiveness, high precision and operative endoscopic technique improvement, the incidence of postoperative purulent-septic complications (PSC) in endoscopic gynecological operations does not exceed 3.5% and depends on the complexity, surgery duration, the presence of risk factors, including vaginal microbiota contamination [1].
© V.M. Zaporozhan, I.Z. Gladchuk, 2020
Most gynecological surgeries performed by laparoscopic approach are "clean-contaminated", requiring the prophylactic administration of antibacterial drugs in order to counterbalance the benefits of this minimally invasive surgical method [1-3, 5]. The drug choice for the infectious-inflammatory complications prevention should be based on its clinical and pharmacoeconomic efficacy, taking into account the increased opportunistic pathogens virulence and the spread of antibiotic resistance [6, 8, 10]. The emergence of antibiotic-resistant microflora and the widespread of pan-resistant microorganisms significantly reduce the effectiveness of antibacterial prevention and increase the purulent-septic complications incidence [1, 4, 8].
Despite improving knowledge about pathogenesis of early purulent-septic complications and therapeutic technologies development, PSC incidence does not tend to decrease, especially in patients with extragenital and combined gynecological pathology, obesity, impaired neuroendocrine regulation, immune suppression, which often develops against the background of the frequent and uncontrolled application of antibacterial drugs [4, 9].
The results of numerous clinical studies on the application of antibacterial agents in the PSC prevention are quite controversial [7-9]. Difficulties in vaginal microbiome correction are usually attributed to the formation of biofilms by opportunistic pathogens, which matrix prevent the proper penetration of systemic antibacterial drugs and leads to increased resistance of microorganisms to antibiotics [1, 6, 10].
Therefore, it is important to find a rational way to prevent infectious complications in "clean-contaminated" surgeries on the pelvic organs with the risk of vaginal microbiota contamination.
The purpose of the study was to evaluate the effectiveness of topical application of decamethoxin for the purulent-septic complications prevention in "clean-contaminated" laparoscopic operations on the pelvic organs with the risk of the vaginal microbiota contamination.
Materials and methods. The study was performed at the Clinical Trial Centre of the Department of Obstetrics and Gynecology No. 1 at the Multidisciplinary Medical Center of Odesa National Medical University for the period of January 2017 to March 2019. 115 women with low risk of PSC, who underwent "clean-contaminated" laparoscopic surgeries (laparoscopic hysterectomy, myomectomy with wide opening of the posterior vaginal vault) were examined. The exclusion criteria were: intraperitoneal bleeding, presence of urogenital infections, acute or chronic pelvic inflammatory diseases, systemic diseases (diabetes, immunodeficiency, obesity), allergic diseases, the history of laparotomy surgeries.
Depending on the method of antimicrobial prevention of PSC, patients were randomly assigned to two groups by random sampling. Experimental group (Group 1, n = 60) included patients who underwent surgery without systemic perioperative antibiotic prophylaxis (ABP), but with topical use of a disinfectant; the control group (Group 2, n = 55) included patients who underwent systemic perioperative ABP according to the traditional scheme (cephalosporins of II-III generation for 1 g intravenously with the beginning of anesthesia and again 1 g intravenously after 6-12 hours).
30 minutes before surgery, patients of the Group 1 were given intravaginally a swab, irrigated with 40.0-55.0 ml of 0.02% antiseptic solution, the active substance of which is decamethylenedimethylmethoxycarbonylmethylammonium dichloride (decamethoxin). Decamethoxin is a broad-spectrum antiseptic agent with bactericidal, fungicidal, virucidal and sporicidal activity, which has vaginal dysbiosis correction properties, contributes to the destruction of the bacterial biofilm matrix. Removal of this swab was performed during the emptying uterus or myomatous node from the abdominal cavity through the colpotomy incision.
To determine the degree of exo- and endogenous intoxication, a leukocyte index of intoxication (LII), which is an indicator of acute-phase inflammatory reactions according to Ya.Ya. Kalf-Kalif in the modification of B.A. Reys [6] was used.
The study of vaginal biotope before and after surgery included bacterioscopic and bacteriological studies [6, 8, 10]. In bacterioscopic examination, the preparations were stained by the Gram-Syniov, Romanovskyi-Giemsa method, methylene blue, and microscopic at immersion; bacterial forms of microbiota were identified by the Berge method. The analysis of the vaginal bacterial spectrum and the recording of results were carried out in accordance with the Order of the Ministry of Health of Ukraine No. 234 of 2007. The number of bacteria in 1.0 ml of secretions was determined by the number of colonies that grew with the degree of the inoculum dilution. 104-105 CFU/ml indicators were evaluated as the average degree of microbial genital contamination, at 106 or more - as a high degree [4, 10].
Laparoscopic surgery was performed according to the standard procedure under general endotracheal anesthesia, using special sets of equipment and instruments produced by "Karl Storz".
The study was performed in accordance with the ethical principles of the Helsinki Declaration on Bioethics and obtaining the written consent of patients to participate in the study.
Statistical processing of the results was performed using Microsoft Excel 2019.
Results of the study and their discussion. A study of 115 women aged 20-55 found that patients in both groups had complaints of abdominal or lumbar pain - 86 (74.8%) menstrual disorders - 57 (49.8%), weakness - 43 (37.4%), increased fatigue - 37 (32.2%), sexual disorders - 10 (8.7%). In 33 (28.7%) women, iron deficiency anemia of the first degree of severity was detected. There were no significant differences between the study groups (table 1).
Table 1
Clinical characteristics of patients in the examined groups
Clinical symptoms In general Group 1 Group 2 P
Abdominal or lumbar pain 86 (74.8%) 44 (73.3%) 42 (76.4%) 0.375
Menstrual disorders 57 (49.6%) 28 (46.7%) 29 (52.7%) 0.234
Overall weakness 43 (37.4%) 23 (38.3%) 20 (36.4%) 0.453
Increased fatigue 37 (32.2%) 18 (30%) 19 (34.5%) 0.305
Sexual Function Disorders 10 (8.7%) 4 (6.7%) 6 (10.9%) 0.197
Iron deficiency anemia of the first degree of severity 33 (28.7%) 16 (26.7%) 17 (30.9%) 0.316
Prevention of PSC in postoperative patients consisted of pre-operative, intra-and post-operative measures. Preoperative measures included a meticulous clinical and laboratory examination to exclude risk factors for postoperative inflammatory complications (subcompensated extragenital pathology, subclinical inflammatory processes, examination for sexually transmitted infections), and the vagina rehabilitation 35 days before surgery. Intraoperative PSC prevention consisted of the surgery technique with scrupulous hemostasis, minimal electrocoagulation, limited suture application, application of synthetic absorbable filaments, antibiotic prophylaxis before the anesthesia administration and again after 6-12 hours, drainage of the pelvic cavity.
Indicators of Complete Blood Count before surgery had no significant differences: hemoglobin level in the Group 1 was equal to 120.2±0.1 g/l, in the Group 2 - 121.1±11.1 g/l, White Blood Cell content was, respectively, in the Group 1 7.9±0.5*109/l, in the Group 2 - 8.10±0.4*109/l. Prior to surgery, mild leukocytosis and ESR increasing were noted in 17 (14.8%) cases, and LII before surgery was within the normal range in both study groups.
The study of the bacterial spectrum of the vagina in the examined patients showed that 44 (38.3%) had biotope disorders. Along with lactobacilli that have antimicrobial activity against opportunistic pathogens, associations of opportunistic microorganisms have been found in clinically significant concentrations. Most often, E. coli, Enterococcus faecalis, Candida albicans, Bacillus, Corynebacterium spp., Staphylococcus aureus, Klebsiella were sown.
The vaginal biotope state before surgery had no significant differences: I degree of vagina cleanliness was diagnosed in 61.7% of patients in Group 1 and in 61.8% in Group 2 (p = 1), II degree of vagina cleanliness, respectively, in 38.6 and 37.9% of patients (Fisher's exact test p = 1). Therefore, in examined patients were found endogenous ways of infection: the presence of a significant content of opportunistic bacteria and their associations.
All surgeries were planned and performed by laparoscopic approach: laparoscopic hysterectomy -in 67 (58.3%) patients, conservative myomectomy with posterior colpotomy - in 48 (41.7%) patients.
The duration of surgeries in both groups of patients did not differ (p=0.962): in the experimental group it was 79.5±19.1 minutes, in the control group - 80.5±7.4 minutes. The mean volume of intraoperative blood loss in both groups was not significantly different and amounted to 130.5±40.5 ml.
Post-operative measures consisted of early motor activity of patients, physical therapy, monitoring of heart rate, body temperature, diuresis, as well as the LII monitoring, which characterizes the inflammation severity of cellular and plasma origin and is important for treatment monitoring and prognosis for the PSC development.
The vaginal biotope state before surgery had no significant differences: I degree of vagina cleanliness was diagnosed in 61.7% of patients in Group 1 and in 61.8% in Group 2 (p = 1), II degree of vagina cleanliness, respectively, in 38.6 and 37.9% of patients (Fisher's exact test p = 1).
In the postoperative period, an average hemoglobin content in the patients of both groups also did not differ; in both groups there was mild leukocytosis and ESR increasing; but in patients of Group 1 LII was within the normal range of 1.20±0.02 units, and in the Group 2 it was increased to 1.80±0.04 units (table 2).
In the study of vaginal biotope in the post-surgery period, in the Group 1 was found an increase in lactobacilli number and a decrease of 87.3% in the opportunistic microflora number (Fig. 1). Thus, the pathogenic flora number in the experimental group of patients decreased from 5.1±0.1 lg10 (CFU/ml) to 3.4±0.1 lg10 (CFU/ml), or by 87.3% (p <0.001), while in Group 2, this indicator had no significant changes (table 2).
Table 2
Dynamics of clinical and laboratory parameters in the examined patients
Indices Group 1 (Experimental, n=60) Group 2 (Control, n=55)
Before treatment After treatment Before treatment After treatment
White blood cells * 109/l 7.9±0.5 9.2±0.5 8.1±0.4 9.3±0.3
LII, units 1.50±0.05 1.20±0.02* 1.50±0.05 1.80±0.04*
Number of opportunistic bacteria, lg10 (CFU/ml) 5.1±0.1 3.4±0.1* 5.1±0.1 4.9±0.1
Note: * difference between pre- and post-surgery values, p <0.001
In the control group, lactobacilli decreased in 27 (49.1%) patients in the vaginal biotope and in 17 (30.9%) the Candida fungi growth was observed, which indicated dysbiotic disorders.
As a result of antiseptic administration for complex PSC prevention in patients of the experimental group in "clean-contaminated" laparoscopic surgeries in the postoperative period, LII decreased from 1.50±0.05 units to 1.20±0.02 units, and in the vaginal biotope significantly decreased the content of opportunistic microflora (p <0.01); while in the control group the LII indicator had a significant increase from 1.50±0.05 units to 1.80±0.04 units (p <0.01) and there were noted manifestations of dysbiosis (table 2).
The duration of the anesthesia period was 3.4±1.3 days versus 3.5±1.5 days, the period of intestinal function recovery was 3.5±1.5 days versus 2.4±0.9 days and the mean hospital stay of 3.0±0.4 days versus 3.2±0.3 days had no significant differences in the compared groups (table 3).
Table 3
Features of the post-surgery period course
Indices Group 1 Group 2 p
Duration of anesthesia period, days 3.4±1.3 3.5±1.5 0.960
Intestinal function recovery, days 3.5±1.5 2.4±0.9 0.934
Post-surgery bed day, days 3.0±0.4 3.2±0.3 0.690
In the analysis of early postoperative complications, the PSC incidence was similar in both groups (table 4). There were no severe complications (subphrenic abscess, subhepatic abscess, pelvic cavity abscesses, intestinal abscesses, peritonitis).
In our opinion, the absence of severe forms of infectious-inflammatory complications in the examined groups is associated with careful patients selection without significant risk factors for PSC development (metabolic and endocrine disorders, urogenital infections, immunodeficiency states, allergic reactions, severe anemia, bleeding).
Table 4
Frequency of postoperative complications in studied groups
Indices Group 1 Group 2 p
Fever >37.5 °C for more than 3 days 1 (1.7%) 1 (1.8 %) 0.496
Periculitis, inflammatory infiltrate of a colpotomy wound 1 (1.7%) 1 (1.8 %) 0.496
Signs of intestinal dysbiosis 1 (1.7%) 3 (5.5%) 0.131
The data obtained correlate with the results of studies by Ierano C. et al. (2017), which have shown that topical application of antiseptic agents for high-risk wounds causes a reduction in the infectious complications incidence [9]. Antibiotic prophylaxis should not be used as a temporary measure in the absence of timely application of antiseptics. Proper preoperative preparation and risk assessment are critical to preventing purulent-septic complications in the surgical site [6, 9].
Thus, the effectiveness of topical application of decamethoxin antiseptic solution, as well as the absence of negative factors inherent in systemic antibiotic prophylaxis (increase in the treatment cost, the risk of side effects; the risk of developing polyresistant bacterial strains; difficulty in diagnosis, the clinical picture "vague" of infectious complication), allows to recommend this method for optimization of PSC prevention at "clean-contaminated" laparoscopic surgeries on the pelvic organs with the risk of vaginal microbiota contamination.
8
■ Before ■ After
7
1 6 3"
H 5
Fig. 1. Changes in vaginal biotope after antiseptic administration in the experimental group.
The study showed that intravaginal application of decamethoxin in "clean-contaminated" gynecological surgeries contributes to the vaginal microbiome correction, 87.3% reduction in the content of opportunistic flora and the inflammatory processes intensity at the postoperative stage of treatment. The proposed method of treatment is effective and comparable to traditional antibiotic prophylaxis of complications (subject to careful selection of patients, adherence to scrupulous surgical technique and minimization of tissue injury).
Prospects for further research are to study the long-term results of treatment, as well as the cost-effectiveness of the proposed method ofprevention of infectious-inflammatory complications in operations on the pelvic organs.
1. Vdovychenko YuP, Voloshyn OA. Diahnostyka i profilaktyka uskladnen pry laparoskopichnykh hinekolohichnykh operatsiyakh. Zdorovye zhenshchyny. 2015; 4 (100): 72-74. [in Ukrainian]
2. Henyk NI, Lasytchuk OM, Pakharenko LV, Kinash NM, Orishchak IK. Profilaktyka pislyaoperatsiynykh hniyno-zapalnykh uskladnen u hinekolohiyi. Aktualni pytannya pediatriyi, akusherstva ta hinekolohiyi. 2016; 2:52-54. [in Ukrainian]
3. Kaminskyi IV, Kosenko OV, Herbali OYu. Prohnozuvannya ta profilaktyka pislyaoperatsiynykh hniyno-septychnykh uskladnen v abdominalniy khirurhiyi. Shpytalna khirurhiya. 2013; 2: 35-38. [in Ukrainian]
4. Letiayeva OI, Dolgushin II. Kliniko-mikrobiologicheskoye obosnovaniye kompleksnoy terapii vospalitelnykh zabolevaniy urogenitalnogo trakta negonokokkovoy etiologii u zhenshchin reproduktivnogo vozrasta. Akusherstvo i ginekologiya. 2013; 6:6064. [in Russian]
5. Mayorov MV, Voroshchuk SV, Zhuperkova YeA, Zhuchenko SI, Chernyak OL. Vaginalnyy biotsenoz i genitalnyye infektsii: osobennosti mestnogo lecheniya. Meditsinskiye aspekty zdorovya zhenshchiny. 2018; 7-8 (120-121): 25-32. [in Russian]
6. Ostrovskiy VK, Makarov SV, Yangolenko DV, Rodionov PN, Kochetkov LN. Pokazateli krovi i leykotsitarnyi indeks intoksikatsii pri otsenke tyazhesti techeniya i opredelenii prognoza vospalitelnykh, gnoynykh i gnoyno-destruktivnykh zabolevaniy organov bryushnoy polosti i legkikh. Ulyanovskiy mediko-biologicheskiy zhurnal. 2011; 1: 73-78. [in Russian]
7. Anderson DJ, Marathe J, Pudney J The structure of the human vaginal stratum corneum and its role in immune defense. Am. J. Reprod. Immunol. 2014; 71:618-623. doi: 10.1111 / aji.12230. Epub 2014 .
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Conclusion
Реферат
ПРОФ1ЛАКТИКА ГН1ЙНО-СЕПТИЧНИХ УСКЛАДНЕНЬ ПРИ ЛАПАРОСКОП1ЧНИХ ОПЕРАЦ1ЯХ НА ОРГАНАХ МАЛОГО ТАЗА З РИЗИКОМ КОНТАМ1НАЦП' ВАПНАЛЬНО1
М1КРОБ1ОТИ Запорожан В.М., Гладчук 1.З, Рожковська Н.М., Волянська А.Г., Шевченко О.1., Кушшр Г.Ю.
Проведений аналiз ефективност профшактики гншно-септичних ускладнень при 115 "умовно чистих" лапароскотчних операщях на органах малого таза (лапароскотчна riстеректомiя, консервативна мiомектомiя з видаленням вузла через кольпотомний розтин). В основнш грут хворих (п = 60) штравагшально застосували 0,02 % розчин декаметоксину. Контрольна група (п = 55) одержувала традицшну системну периоперацшну антибюткопрофшактику з
використанням цефалоспоритв. Показано, що як за динамкою перебку раннього тсляоперацшного перюду, так i показниками системно! запально! вщповвд i кшьюстю ускладнень достовiрних вщмшностей мiж дослщжуваними групами не було. В основнш грут мало мюце збшьшення кшькост лактобацил i зменшення на 87,3% вмюту умовно-патогенно! мкрофлори, що свщчило про доцшьшсть профшактичного штраоперацшного мюцевого застосування
декаметоксину.
Ключовi слова: лапароскотя, гншно-септичт ускладнення, профшактика, декаметоксин.
Стаття надшшла 28.04.2019 р.
ПРОФИЛАКТИКА ГНОЙНО-СЕПТИЧЕСКИХ ОСЛОЖНЕНИЙ ПРИ ЛАПАРОСКОПИЧЕСКИХ
ОПЕРАЦИЯХ НА ОРГАНАХ МАЛОГО ТАЗА С РИСКОМ КОНТАМИНАЦИИ ВАГИНАЛЬНОЙ МИКРОБИОТЫ Запорожан В.Н., Гладчук И.З., Рожковская Н.Н., Волянская А. Г., Шевченко О.И., Кушнир Г.Ю. Проведен анализ эффективности профилактики гнойно-септических осложнений при 115 "условно чистых" лапароскопических операциях на органах малого таза (лапароскопическая гистерэктомия, консервативная миомектомия с удалением узла через кольпотомный разрез). В основной группе больных (п = 60) интравагинально применяли 0,02% раствор декаметоксина. Контрольная группа (п = 55) получала традиционную системную периоперационную антибиотикопрофилактику с использованием цефалоспоринов. Показано, что как по динамике течения раннего послеоперационного периода, так и по показателями системного воспалительного ответа и количеством осложнений достоверных различий между исследуемыми группами не было. В основной группе имело место снижение степени эндогенной интоксикации, уменьшение на 87,3% содержания условно-патогенной микрофлоры, нормализация микробиоценоза, что свидетельствовало о целесообразности профилактического интраоперационного местного применения декаметоксина.
Ключевые слова: лапароскопия, гнойно-септические осложнения, профилактика, декаметоксин.
Рецензент Лiхачов В.К.
