EVIDENCE-BASED MEDICINE PRINCIPLES IN THE DIAGNOSIS AND PREVENTION OF PYOINFLAMMATORY THROMBOEMBOLIC EVENTS IN PUERPERAS: RESULTS OF INTRODUCTION OF NEW PROTOCOLS

Postpartum pyoinflammatory and thromboembolic events continue to remain important causes of maternal morbidity and mortality in developed countries. A search for effective treatments in surgical patients has led to the elaboration of the multimodal program Fast track surgery (FTS) or Enhanced Recovery After Surgery» (ERAS), that has been recently used in obstetrics and gynecology. Objective. To evaluate the clinical efficiency of postpartum and postoperative management protocols based on the current FTS and evidence-based medicine principles. Subject and methods. The specific features of pregnancy, labor, and postpartum period were traced in 5614 women retro- and prospectively followed up and delivered at the V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia, in May 1, 2011 to April 30, 2013. Of them, 2631 women delivered before introduction of the protocols (May 1, 2011 to April 30, 2012): Group 1a (n = 1196) delivered via cesarean delivery; Group 1b (n = 1435) had spontaneous delivery. After introduction of the protocols (May 1, 2012 to April 30, 2013), 2983 pregnant women delivered, of them 1252 women (Group 2a) did via cesarean section; 1731 (Group 2b) had spontaneous delivery. The frequency of postpartum and postoperative complications, including thromboembolic, infectious and inflammatory, and postinfection ones, was analyzed. Statistical data processing was done using the mass market Winpepi 10.7 software. The odds ratio (OR) was given with 95% confidence interval (CI). Results. This trial showed considerably reduced antibiotic therapy after protocol introduction: from 72.4 to 23.6% (OR 8.02 (95% CI, 1.9 to 2.2)) after surgical delivery (p = 0.05) and from 9.6% to 0.5% (OR 20.1 (95% CI, 9.8 to 47.7)) after spontaneous delivery (p = 0.05). Revision of criteria for the uterine subinvolution diagnosis caused a decrease in its rate (from 9.2 to 1.6% (OR 29.1 (95% CI, 17.2 to 52.9)) after spontaneous delivery (p = 0.05), from 20.3 to 0.87% (OR 6.3 (95% CI, 3.9 to 10.8)) after cesarean section (p = 0.05); from 4.4 to 0.6% (OR 6.3 (95% CI, 3.3 to 13.3)) prior to and following protocol introduction, respectively and, hence, vacuum aspiration of the uterine cavity contents after spontaneous delivery (p = 0.05); from 3.3 to 1.4% (OR 2.8 (95% CI, 1.5 to 5.3)) after cesarean section (p = 0.05). The introduction of the FTS program could reduce the frequency of postoperative complications: enteroparesis by 3.5 times from 0.8 to 0.2% (OR 3.5 (95% CI, 0.89 to 19.82)) and urinary tract infection by 6 times from 2.4 to 0.4%, [OR 6.6 (95% CI, 2.53 to 21.96)). Prevention of pyoinflammatory and thromboembolic events, by using the scale of risk factors for thrombotic events could reduce their frequencies, the unreasonable use of low molecular-weight heparins, and hemostasiogram examinations. Conclusion. Decreased unreasonable antibiotic therapy during surgical intervention, optimization of thrombus prevention, use of current postoperative management principles reduced postpartum and postoperative complications.

postpartum period, infectious and inflammatory complications, fast track surgery, thromboembolic events