METROENDOMETRITIS (metroendometritis; grech, metra uterus + lat. endometrium an endometria + - itis) — an inflammation of a body of the womb.
The inflammatory process which is limited only to a mucous membrane of a uterus is called an endometritis, however more often inflammatory changes develop in a muscular layer that is defined by the terms «metritis», «myometritis» or «endomyometritis» (the endometritis usually precedes a metritis).
The etiology and a pathogeny
M. can be infectious and aseptic character. Most often M. are caused by staphylococcus, a streptococcus, colibacillus, proteas, a pyocyanic stick, anaerobic bacilli, mycoplasmas, and also gonokokk, a treponema, mycobacteria of tuberculosis, a diphtheritic stick, actinomycetes. Microbic associations are found in many patients at M.
The m usually develops at decrease in resistance of an organism, in connection with patol, process (the long anhydrous period in labor, blood loss, overcooling, a congestive plethora at the wrong provisions of a uterus, a tumor in cavities of a small pelvis, etc.). Microorganisms, as a rule, get into a cavity of the uterus from a neck and a vagina owing to expansion of the channel of a neck of uterus, absence in it a mucous stopper (during periods, at abortion, childbirth). The m can develop at use of intrauterine contraceptives, distribution of the contagiums from a worm-shaped shoot affected with tuberculosis of uterine tubes, and also a hematogenous way, napr from almonds, etc. Entering of contagiums into a uterus at disturbance of an asepsis and antiseptics during execution of diagnostic is possible and to lay down. procedures.
The m of aseptic character can arise because of an injury at a bruise, medical and diagnostic procedures, damages (at use of cryotherapy, introduction to a uterus of the pharmaceuticals rendering irritant action); contagiums are implemented into the damaged fabrics in most cases for the second time. At hron, the course of process the microbic factor loses the leading role.
Distinguish acute and hron. M. Inflammatory process in a uterus begins in an endometria. The acute current is characterized by a thickening, a loosening, puffiness, a hyperemia of the endometria which is becoming covered is purulent - a mucous plaque. The plethora, hypostasis, infiltration is microscopically observed by segmentoyaderny leukocytes, to a lesser extent lymphocytes. Infiltrates are located in a stroma perivaskulyarno and periglandulyarno, hemorrhages in a cavity of uterine glands sometimes are found; cells of glands at the same time are exposed to dystrophic changes, are exfoliated. Destruction and exfoliating of a plethoric epithelium of glands leads to formation of superficial ulcerations of an endometria, sometimes with growth of granulyatsionny fabric on border with healthy fabric.
Postabortion M. arises in a zone of the remains of fetal egg more often; in such cases of a vorsina of chorion, a decidual (deciduous) cover infiltrirutsya by segmentoyaderny leukocytes and lymphocytes, then are exposed to a hyalinosis, a necrosis, substitution by connecting fabric. However postabortion M.'s development and after full removal of fetal egg is possible. At postabortion and puerperal M. inflammatory process on a wound surface of a decidua more often quickly extends to a muscular layer; in a deciduous cover the phenomena of a necrosis are noted, distribution of contagiums on a vascular bed is possible, fibrinferments circulatory and limf, vessels are found (see. Metrotromboflebit ). The myometrium becomes edematous, infiltrirovan segmentoyaderny leukocytes, lymphocytes; the inflammation can sometimes take purulent and even gangrenous form (see. Inflammation ) with rejection of nekrotizirovanny sites of a myometrium (metritis dissecans); in the started cases the serous cover of a uterus with the subsequent development of a perimitritis and peritonitis can be involved in an inflammation. Acute M. sometimes passes in hron, a form.
At hron. M in inflammatory infiltrate begin to prevail lymphatic, and then plasmocytes; the hyperemia and hypostasis decrease. In a stroma there is a fibroplastic transformation of connecting fabric, hemorrhages, melkoochagovy deposits of hemosiderin, in spiral arteries — sclerous changes are found, at a long current hron. M appear ksantomny cells; at enough in blood of progesterone and a histamine lozhnodetsidualny cells are found: these cells are formed in a basal layer of a mucous membrane of a uterus; they have the polygonal form, their cytoplasm light, kernels with moderate amount of chromatin. Lozhnodetsidualny cells differ from true, revealed at pregnancy, a little smaller maintenance of a glycogen. Thickness of an endometria becomes uneven, with the phenomena of a hyperplasia of sites of a basal layer. Glands are sharply deformed, located unevenly; their epithelium dystrophic changes, decreases the content of RNA. Even at preservation of a normal menstrual cycle secretory changes in an endometria happen insufficiently expressed or completely are absent, the quantity of a glycogen is reduced. At patients with an anovulatory cycle in a mucous membrane of a uterus proliferative changes are observed. The inner surface of a uterus becomes uneven, polypostural growths are formed, the muscular layer is thickened at the expense of connecting fabric (tsvetn. fig. 3).
As a result of hard proceeding M. the phenomena of a mucosal atrophy with the expressed hyalinosis of blood vessels, the termination of cyclic changes and anovulation develop. It is connected with a hypo-ovaria owing to disturbance of the receptor device of a uterus. Sometimes glands of an endometria grow into a muscular coat, internal is formed endometriosis (see).
In cases of distribution of causative agents of gonorrhea from a neck of uterus on a mucous membrane of a body of the womb the gonorrheal endometritis develops; afterwards process can extend to a muscular coat, and also to uterine tubes (see. Gonorrhoea ). Gonokokk causes in a mucous membrane of a uterus inflammatory process (an endometritis gonorrheal). Reproduction of gonokokk happens preferential on a mucosal surface of a cover to their penetration into epithelial and subepithelial layers and formation of leukocytic infiltrates.
Tubercular M. proceeds more often in the form of a productive form with formation of the specific hillocks consisting of epithelial and colossal cells in a mucous membrane of a uterus. Miliary tuberculosis of an endometria is characterized by hematogenous damage of all mucous membrane in the form of the tubercular hillocks which are at the same stage of development. These hillocks can merge and be exposed to caseous disintegration (a caseous endometritis), at the same time the muscular layer of a uterus is usually involved in inflammatory process; owing to caseous disintegration on an inner surface of a uterus ulcers can be formed. It is long the proceeding process is followed by fibrous changes, formation of synechias (intrauterine unions), deformation of a cavity of the uterus. However thanks to rejection of a mucous membrane at periods the tubercular endometritis samoizlechivatsya sometimes.
The clinical picture
Acute M. is characterized by the fervescence, deterioration in the general state, an indisposition which are unsharply expressed by pains in the bottom of a stomach, to-rye can irradiate to the area of a sacrum. The uterus at a palpation is a little increased, painful, a soft consistence, allocation from a uterus considerable, purulent character.
Postnatal and postabortion M. is shown by fervescence to 38,0 — 39,0 °, usually with 3 — the 4th day of the puerperal (postabortion) period; pulse is speeded up. The patient feels weakness, a headache, deterioration in the general state, heavy feeling in the bottom of a stomach. The palpation of a uterus is painful, its involution is slowed down. Allocations from a genital tract contain impurity of pus, can become purulent, sometimes get a putrefactive smell. At puerperal M. the delay of allocations (lokhiya) owing to insufficient reduction of a uterus, obstruction of the channel of a neck of uterus clots, an excess of a body of the womb is possible; such state is called a lohia serosa (see. Puerperal diseases ); in hard cases generalization inf is possible. process. In cases when at M. there is an obstacle for outflow of allocations from a uterus (at cancer, cicatricial processes, atrophic changes of the channel of a neck of uterus), the accumulation of pus in a cavity of the uterus (pyometra) bringing to heavier a wedge, to manifestations is possible.
At hron. M are observed light serous, is more rare with impurity of pus bleach (see). The uterus is usually increased unsharply, condensed, painless. It is most characteristic for hron. M disturbance of menstrual function in a look uterine bleedings (see), and sometimes and intermenstrual bloody allocations. At nek-ry patients are observed anovulatory cycles (see), it is frequent — decrease in oestrogenic function of ovaries, shortening of the second phase of a cycle. Hron. The m often accompanies hron, an inflammation of appendages of a uterus (see. Adnexitis ), rubtsovospayechny changes in a small basin, secondary neuralgia of pelvic nerves. Sometimes intrauterine unions develop, genital function is broken.
acute M.'s Diagnosis does not present great difficulties. In the anamnesis the factors able usually come to light to cause inflammatory process in a uterus (abortion, childbirth, administration of contraceptive or other intrauterine interventions, the sexual intercourses during periods, etc.). Confirm acute M. the morbidity at a palpation and increase in a uterus, availability of pus in allocations, fervescence, a leukocytosis, a deviation to the left accelerated by ROE. Displays of intoxication, positive tuberkulinovy tests are typical for tubercular process; at a caseous necrosis of an endometria — curdled allocations from a uterus. For establishment of the activator M. carry out bacterial, a research on identification of causative agents of a specific infection. So, in gonorrheal puerperal M.'s cases of a gonokokka are found in allocations on 3 — the 4th day after the delivery. Mycobacteria of tuberculosis even at use of special methods of a research seldom manage to be revealed.
In diagnosis hron. M identification of the previous acute inflammatory process in a uterus is important; complaints to heavy feeling in the bottom of a stomach, in a waist and a sacrum, disorder of menstrual function in a look meno-and metrorrhagias; in the anamnesis — infertility, spontaneous, usual abortions. At nek-ry patients (apprx. 22%) monophase basal temperature comes to light that testifies to anovulatory cycles. At a bimanual research and survey of a vagina the increased, dense uterus comes to light, liquid bleach, inflammatory changes of appendages, necks of uterus. In scrapings of a mucous membrane of a cavity of the uterus, to-rye sometimes make in connection with meno-or a metrorrhagia, find infiltration by plasmocytes, increase in amount of connecting fabric, a sclerosis of spiral arteries, insufficiency or lack of secretory changes in the second phase of a cycle.
Patients with acute M. shall be on a bed rest. Appoint cold to a bottom of a stomach, pharmaceuticals (Praegnantolum, Pituitrinum, oxytocin) reducing a uterus. From antibiotics semi-synthetic Penicillin, drugs of a broad spectrum of activity, cephalosporins, further (after the research of sensitivity of microflora) the corresponding antibiotics are most reasonable. In nek-ry cases reasonablly combined treatment by several antibiotics, streptocides, furadoniny, antifungal means. At the increased coagulability of blood anticoagulants are shown, at pains — candles with a belladonna or pantopon, pyramidon. If after elimination of the acute phenomena of puerperal or postabortion M. the bloody allocations and other symptoms testimonial of a delay in a uterus of parts of fetal egg are found, then against the background of antibacterial therapy vacuum aspiration is made (see. Vacuum ekskokhleation ) or a scraping of a uterus (see. Scraping of a mucous membrane of a uterus ). At tubercular M. appoint the specific therapy including antibiotics and other drugs (see. Tuberculosis ).
It is necessary to wash external genitals disinfecting solutions not less than two times a day, to monitor regular function of intestines and bladder, good nutrition, vitamin-rich.
At hron. The physical therapy is shown to m: an electrophoresis of magnesium (at a pain syndrome), iodine and zinc (at commissural, cicatricial changes). It is reasonable to carry out an electrophoresis by impulse currents of low frequency. In childbearing age at a hypo-ovaria performing microwave therapy, ultrasound in pulsed operation, a diathermy, parafino-and an ozoceritotherapy, mud cure, hydrosulphuric bathtubs and vulval irrigations is recommended. At dysfunction of ovaries, frustration of a menstrual cycle in the form of bleedings appoint hormonal therapy (see. Dysfunctional uterine bleedings , Uterine bleedings ).
At formation of a pyometra expansion of the channel of a neck of uterus for removal of pus from a cavity, washing is shown by solution of Furacilin. If there is a suspicion of a malignant tumor, after the termination of the acute phenomena under protection of an antibioticotherapia make a diagnostic fractional scraping.
Acute M. at most of patients comes to the end with recovery. However in nek-ry cases generalization of an infection is possible that it depends on virulence of activators and reactivity of an organism; at acute postabortion and puerperal M. in cases of insufficient treatment process can extend to the next bodies and be complicated by development of metrothrombophlebitis, sepsis (see).
The forecast for life upon acute M.'s transition in chronic with a long current favorable, however an absolute recovery comes seldom: aggravations, disturbance of menstrual, genital functions are observed (premature abortion, pathology of an implantation of placenta, weakness of patrimonial activity, subinvolution of a uterus after the delivery).
Prevention consists in the prevention of inflammatory diseases of female generative organs, prevention of hit of contagiums in a cavity of the uterus, rational conducting childbirth.
See also Uterus, pathology .
Bibliography: Bodyazhina V. I. Chronic nonspecific inflammatory diseases of female generative organs, M., 1978; Bodyazhina V. I. and m of joint stock company and K. N. Ginekologiya's N, page 155, M., 1977; Zheleznov B. I. and Loginova H. E. Structural changes of a mucous membrane of a uterus and function of ovaries at a chronic endometritis, Akush, and ginek., No. 4, page 3, 1977; L about and N about in an an.a. and With t r at and c to and y V. M. Treatment of a chronic nonspecific endometritis, in the same place, No. 4, page 17, 1976; With about l -
with to and y Ya. P. and And in and N yu t and L. I. Inflammatory diseases of female generative organs, Kiev, 1975; Humphrey M. D. Post-partum infection, Med. J. ‘Aust., V. 2, p. 657, 1972; N o-vak E. R. a. Woodruff J. D. Novak’s gynecologic and obstetric pathology, Philadelphia, 1974; Obstetric and perinatal infections, ed. by D. Charles a. M. Finland, Philadelphia, 1973.
V. I. Grishchenko.