Медицина/1. Акушерство и гинекология

Izimbergenov N.I., Tusupkaliyev A. B., Karimova B. Zh.

West Kazakhstan State Medical University after Marat Ospanov,

Aktobe, Kazakhstan.

OUR EXPIRIENCE IN ORGAN-PRESERVING OPERATIONS DURING UTERINE SCAR DEHISCENCE MANAGEMENT AFTER THE CESAREAN SECTION

Frequency of operative delivery in Russia and Kazakhstan composes in average 10%. Frequency of cesarean section in Aktobe was 17% - in Regional Perinatal center, 27% - in delivery room of Regional emergency hospital. The rise of gravity of cesarean section normally involves the increase of frequency of postoperative infectious complication, the rate of which varies from 13,3 up to 54,3% and in women with high infection risk they may rich 91% (Sidorova I. S. and others, 2006).

Uterine scar dehiscence is a severe lesion affecting the reproductive system of women and revealed in almost every case of peritonitis accompanied with systemic inflammatory response syndrome (SIRS) following obstetric operations (A. N. Strizhakov et al. 2004). Absolute majority of such patients have been undergone the radical operation represented in a form of uterus extirpation. According to Kostyuchenko, all of the patients (120 women) with peritonitis following obstetric operation were undergone a supravaginal amputation or uterus extirpation. The mortality rate in those cases was about 4% in consequence of progressive peritonitis (V.V. Abramchenko et al. 2005).

In obstetric practice postoperative uterus extirpation with uterus tubes is being performed at present in cases of purulent inflammatory complications after cesarean section such as uterine scar dehiscence during endomyometritis, peritonitis. Modern new technologies have wide opportunities in treating purulent septic complications in obstetrician’s practice and allow to improve their results, that open new perspectives in development of organ serving direction in obstetrics during uterine scar dehiscence (Krasnopolsky V.I. and others, 2001, Izimbergenov N. I. and others, 2009).

With the aim to improve the organisation of surgical service to pregnant and puerperant women the Regional Centre for Surgical Aid to Pregnant and Puerperant women was established in 2009 on a basis of clinic of Advanced Surgery Department. For the period of centre’s operation from 2009 to 2013 we observed 29 patients with diffuse peritonitis following caesarean section operation. The causes of peritonitis were: uterine scar dehiscence in 23 patients, paralytic ileus – in 3, iatrogenic lesion of ureter with retroperitoneal hematoma after repeated laparotomy, uterus extirpation because of bleeding – in 2 cases, and lesion of transverse colon – in 1 patient. 11 patient (38%) have been undergone an organ-preserving operation – excision of uterus wound edges and repeated suturing of uterus. The average age of patients was 22,5±0,3 years.

During the postoperative period subfebrile temperature, the decrease of intestinal peristalsis were noted in 8 women during the first 24 hours. 3 women had no abnormalities from normal puerperium. Due to the protocols all the puerperal were made ultrasound examination on the 3^rd -4^th day that allowed to diagnose uterine scar dehiscence at early dates, even in unclear clinical picture of developing complication and this by all means influenced on the results of treatment.

The range of surgical intervention included relaparotomy, during which due to limited inflammatory changes, young age of women and wish to preserve reproductive organ, we performed organ preserving surgical treatment: excision of necrotic tissues of the uterine wall, curettage of uterine wall, ozone sanation and draining of the abdominal cavity, restoration of the abdominal wall. During the postoperative period antibacterial treatment was performed to all the patients. All the operations were successful, there were no any complications connected with uterus preservation. Thus in present cases timely diagnosis, general satisfactory organism condition, absents of peritonitis presence of possibilities for technical fulfillment of operations, the use of modern technologies provided favorable results. Tactics and indices to organ preserving operations must be determined individually in each definite case. Certainly in severe patients with APACHE II more then 10-12 points, with generalization of SIRS IV and more process with marked clinical-endoscopic signs of metroendometritis the effectuation of organ serving operations will be risky and unjustified.

Two patients in 11 months and 1,5 years after secondary suture were undergone cesarean section according to the plan in full-term pregnancy. Postoperative period was smooth, babies were discharged on the 5^th and 7^th days.

REFERENCES:

1. I. S. Sidorova, I. O. Makarov, S. A. Levakov Postpartum purulent-inflammatory diseases, Moscow OOO “MIA” 2006 – p. 128

2. A. N. Strizhakov, O. R. Bayev, M. V. Rybin Physiology and pathology of postpartum, Moscow 2004 – p. 120

3. V. V. Abramchenko, D. F. Kostyuchek, E. D. Khadzhiyeva Purulent-septic infection in obstetrics and gynaecology, Saint-Petersburg “SpetsLit” 2005 – p. 459

4. N. I. Izimbergenov, B. Zh. Karimova Diagnosis and treatment of peritonitis after caesarean section. Practical guidance, Aktobe 2010 – p. 28

5. A. N. Strizhakov, O. P. Bayev et al. Organ-preserving surgical treatment of uterine scar dehiscence and peritonitis following caesarean section, Issues of gynaecology, obstetrics and perinatology 2 (7) 2008 – pp. 5-10