Terzhinan in pregnant women with genital pathology

Microflora of a woman during pregnancy

During pregnancy, hormonal levels change, and the balance of bacteria in the vagina, cervix and urethra can be disrupted.

The vaginal microflora, or microbiocenosis, consists of 95–98% of permanent protective lactobacilli and 3–5% of transient, non-permanent microorganisms. In the acidic environment of the vagina, it is lactobacilli that inhibit the growth of pathogenic microorganisms and protect the sterile fetus from infection, tirelessly producing lactic acid, bactericides and hydrogen peroxide.

In a gynecologically healthy woman, more than 40 species of microorganisms peacefully coexist in the vaginal microbiocenosis, of which only lactobacilli of aerobic and anaerobic origin number more than 9 species.

Normal microflora consists of 85–90% lactobacilli and 5–9% bifidobacteria.
If this balance is disturbed, a woman begins to be bothered by:

• itchy, bursting sensations in the labia area;
• pain when urinating and during sexual intercourse;
• discharge of an uncharacteristic color, sometimes mixed with pus;
• repulsive odor in the perineal area.

For any combination of these signs, the gynecologist will assess the condition of the mucous membranes of the internal genital organs, the cervix and will collect biomaterial for research:

• flora smear - to determine the concentrations of microorganisms inhabiting the genital organs, including pathological ones, counting red blood cells and leukocytes in the field of view of the microscope;
• bacterial culture - to select an effective medicine against identified pathogens from pathogenic microflora.

Table: smear microscopy indicators are normal and with imbalance

When choosing the optimal treatment option for a pregnant woman, doctors usually lean toward combined topical antimicrobial agents, which locally combat the pathogen and do not penetrate the systemic bloodstream, and therefore are not capable of harming the fetus. One of these vaginal drugs is Terzhinan. Its manufacturers claim that it is impossible to find an identical drug with a set of effective active ingredients.

Terzhinan in pregnant women with genital pathology

prof. N.V. Anastasieva Department of Obstetrics and Gynecology, Novosibirsk Medical Institute

Currently, the problem of genital infection can be the cause of various disorders of pregnancy and postpartum complications: chorioamnionitis, premature birth, postpartum endometritis.

Despite the use of new medications, the incidence of inflammatory diseases does not tend to decrease. The presence of a genital infection can cause various disorders during pregnancy and postpartum complications:

• chorioamnionitis;
• premature birth;
• postpartum endometritis.

We studied the effectiveness of the drug terzhinan

in pregnant women with genital infection. The studies were carried out on the basis of the second gynecological hospital.

Of the 50 drug standards we received for testing, 40 patients received a full course of treatment; an analysis of the results is presented to your attention today; the rest are in the process of treatment.

Terzhinan

presented as the drug of first choice for the treatment of bacterial, fungal, parasitic vaginitis and colpitis. It includes:

• ternidazole (200 mg);
• neomycin sulfate (100 thousand units);
• nystatin (100 thousand units);
• prednisolone (3 mg).

Ternidazole has a suppressive effect on anaerobic infection and Gardnerella vaginalis, neomycin sulfate - on coliform bacteria (Escherichia coli, Proteus, Pseudomonas aeruginosa), nystatin - on fungi, prednisolone - has an antiallergic effect.

Pregnancy is not a contraindication to the drug. During the treatment process, we strongly recommended that women have sexual rest or use a barrier method as a prevention of reinfection. Since sexual activity is not recommended after 36-38 weeks, it is planned to conduct a second course of treatment, which will prevent infection from entering the uterus and infecting the fetus and newborn.

When deciding on the treatment of women, we gave preference to the intravaginal method, because The stratified squamous epithelium of the vagina has minimal absorption capacity and there is no damaging effect of the drug on the fetus due to the lower therapeutic dose.

In studies of the American Center for Genetic Research 1 gr. 100% doses of metronidazole per os were found in the blood, while per vagina - only 2%.

Terzhinan

is especially effective in pregnant women with a history of allergies, because vulvovaginitis, having an allergic nature, responds well to prednisolone.

The following studies were performed on all women registered:

• OAK, LII, GPI;
• bacterioscopic examination of vaginal discharge and cervical canal;
• determining the reaction of vaginal discharge using a set of litmus papers;
• amino test is whiter.

During the bacterioscopic examination, we paid attention to the number of leukocytes and desquamated epithelium, the presence of signs of leukocyte activity, calculated the leukocyte formula in the discharge from the cervical canal, the presence of lactobacilli, and opportunistic microflora.

Signs of leukocyte activity:

• unclear cell boundaries,
• big sizes,
• nuclear hyperfragmentation,
• vacuolization of the cytoplasm,
• phagocytosis.

SURVEY RESULTS

Group I:

27 pregnant women (67%) diagnosed with pregnancy 5-6 weeks. USV vaginosaginitis. The picture of microscopic examination of smears taken from the urethra (y), vagina (v) and cervical canal (c) corresponded to 4 degrees of purity.

In strokes from "B":

• leukocytes up to 30 p./sp.;
• desquamated epithelium in large quantities;
• Gram-negative bacteria predominated.

In strokes from “C”:

• leukocytes up to 15 per view, desquamated epithelium in large numbers of gram-negative bacteria.

The diagnosis was made on the basis of copious, foamy discharge with an unpleasant odor.

In smears from the cervical canal it was noted:

• presence of active leukocytes: s/i - 85%, macrophages -15%, total 100% active cells.
• pH-5.6-6.0;
• amino test - positive;
• presence of key cells.

Group II:

5 pregnant women (13%) diagnosed with pregnancy 5-6 weeks. USV Vaginosaginitis. Genital candidiasis.

In strokes: from “B”:

• leukocytes up to 40 per view;
• desquamated epithelium in large quantities,
• Gram-negative bacteria predominated;
• fungi of the genus Candida.

In strokes from “C”:

• leukocytes up to 15 per view;
• epithelium in large quantities;
• gram-negative bacteria.
• active leukocytes: s/i - 95%, macrophages - 5% (total 100% active cells);
• pH 5.0-6.0;
• amino test - positive;
• presence of key cells.

Ill group:

8 pregnant women (20%) diagnosed with pregnancy 9-10 weeks. USV. Colpitis of nonspecific etiology.

In strokes: from “B”:

• leukocytes up to 40 per view,
• squamous epithelium 4-5 in p/zr,
• gram-negative bacteria in small numbers,

In strokes from “C”:

• leukocytes up to 20 in p/zr,
• squamous epithelium 4-5 in p/zr,
• gram-negative bacteria.
• active leukocytes: s/i - 90%, macrophages - 10% (total 100% active cells),
• pH - 5.0.

Please note that the drug terzhinan

used in women with a gestational age of up to 9-10 weeks, when there may be an infection and damage to the ovum with subsequent malformation and fetal growth retardation syndrome.

METHOD OF APPLICATION OF TERZHINAN

1 vaginal tablet at night.

The course of treatment is 10 days.

Evaluation of the clinical effectiveness of local use of the drug terzhinan

was carried out 2-3 days after completion of the course of treatment using a bacterioscopic examination, which took into account the nature of the vaginal microflora, its composition, quantity, as well as the presence of signs of leukocyte activity.

RESULTS OF TREATMENT

In group I: in 11 pregnant women (40%)

• pathological leucorrhoea disappeared,
• feeling of discomfort in the genitourinary system,
• itching and discomfort in the vagina,
• the pH of vaginal secretions was normalized,
• amino test - negative.

In strokes:

• leukocytes up to 5 in p/zr,
• single squamous epithelium in the n/zr,
• reduction of rod and coccal flora,
• absence of key cells,
• There are no signs of leukocyte activity.

In 16 pregnant women (60%), as a result of the treatment, the following results were clinically noted:

• reduction of leucorrhoea,
• no feeling of discomfort and burning in the vagina.

In strokes:

• leukocytes up to 5 in p/zr,
• squamous epithelium in large quantities,
• the presence of gram-negative bacteria, coccal flora,
• pH-5.0.

Therefore, treatment of bacterial vaginosis was continued using the following methods:

• Tinidazole - course dose 6.0 g. per os
• Metronidazole - course dose 7.0 g. per os or
• Dalacin is a 2% cream for intravaginal use.

At the end of the course of treatment, the vaginal microbiocenosis was restored for 7-10 days using tampons with the following preparations:

• Bifidobacterin,
• Lactobacterin,
• Narine.

In group II: in 5 pregnant women (13%), as a result of treatment with bacterioscopic control, the following results were obtained:

• single leukocytes in the field of view,
• squamous epithelium in small quantities,
• reduction of rod and coccal flora,
• absence of key cells, but fungi of the genus Candida predominated,
• there were signs of leukocyte activity,
• pH-5.0.

Treatment of genital candidiasis was continued with dafnedzhin suppositories - a course of treatment of 6 days.

The use of imidazole drugs leads to the activation of fungi. This is not a complication of treatment. In Terzhinan

There is also nystatin, but because The course dose is 1 million, then in persistent cases (16%) dafnegin was used to treat genital candidiasis.

After completing the course of treatment, the vaginal microcenosis was restored for 7-10 days.

In group III

: in 8 pregnant women (20%) the results of the treatment:

• disappearance of inflammatory changes in the external genitalia and vagina;
• disappearance of hyperemia and swelling of tissues;
• normalization of local temperature;
• normalization of the pH of vaginal discharge;
• typical character of leucorrhoea.

Bacterioscopic picture:

• leukocytes up to 2-3 per view;
• squamous epithelium 4-5 in p/z;
• gram-negative bacteria in small numbers;
• -pH4.5.

IMMEDIATE RESULTS OF TREATMENT. RESTORATION OF VAGINA MICROCENOSIS

• recovery: 19 people (47.5%);
• improvement: 21 people (52.5%);
• no changes: 0 people (0%)
• deterioration: 0 people (0%).

The results obtained indicate the high effectiveness of the drug terzhinan in

general complex of treatment of patients with mixed genital infection, bacterial vaginosis.

The use of the drug leads to the suppression of pathogenic and conditionally pathogenic microflora of the genitals, helps to eliminate the infectious and inflammatory process in the vagina, which prevents the penetration of infection into the uterus in pregnant women, thereby preventing the possibility of damage to the ovum.

When using terzhinan

no allergic reactions were observed. Considering the above, the drug can be recommended for the treatment of patients with acute and subacute inflammatory diseases of the vagina of nonspecific etiology, with mandatory rehabilitation therapy aimed at restoring the vaginal microcenosis.

Control of cure was carried out 2-3 days after completion of the course of treatment. However, all pregnant women continue to remain under our supervision. In the future, we will study the course of pregnancy and birth outcomes for the mother and fetus, and also analyze the frequency of postpartum inflammatory diseases.

Terzhinan: composition and release form of the drug

Terzhinan is not just an antibiotic for thrush. Its therapeutic effect is large-scale and confirmed in the treatment of many diseases. Gently penetrating the tissues of the mucous membranes, the drug does not damage them or disturb the pH level of the vagina, but has a local anti-inflammatory effect, while destroying bacteria, protozoa and fungi in its path.

The composition of the drug includes:

• ternidazole is a component for the destruction of fungi, trichomonas, gardnerella. But it also strengthens the cell membranes of the affected mucous membranes of the genital tract;
• neomycin sulfate is an antibiotic that is inactive for endotoxic streptococci, but is destructive for the following types of pathogens: gram-positive - staphylococci, pneumococci, corynebacteria, listeria, Staphylococcus aureus;
• gram-negative - Escherichia coli, Pseudomonas aeruginosa, Proteus, four types of rod-shaped bacteria of the genus Shigella.

Also added to the drug are auxiliary components:

• wheat starch;
• lactose monohydrate;
• colloidal silicon dioxide;
• magnesium stearate;
• sodium carboxymethyl starch.

The universal formula of the product helps to destroy the microbial film formed on the mucous membranes and carry out bactericidal cleaning to prevent the spread of the disease.

Terzhinan is widely available in pharmacies in the form of vaginal tablets, packaged in packs of 6 and 10 pieces. Each tablet is sealed separately in foil packaging.

Terzhinan in a package of six pieces is most often prescribed for prevention, and in a package of ten - for treatment

Indications for prescribing Terzhinan to expectant mothers

Regardless of the pathogen, any inflammation in the vaginal mucosa must be treated, even if its manifestations are minor.

The action of the drug is aimed primarily at extinguishing inflammation caused by the vigorous activity of microorganisms:

• bacterial vaginitis: specific, in particular, vaginal trichomoniasis;
• nonspecific due to the proliferation of opportunistic vaginal microflora, namely: yeast-like fungi of the genus Candida;
• Proteus, staphylococcus, streptococcus, Escherichia coli, Gardnerella, Pseudomonas aeruginosa;
• mixed vaginitis with any combination of pathogenic microorganisms, for example, bacterial vaginosis and urogenital candidiasis;

But even with ideal tests, Terzhinan can be prescribed as a prophylactic before childbirth and any gynecological manipulations to prevent infection of the fetus with chronic asymptomatic urogenital infections and inflammations.

The vaginal tablet of the drug Terzhinan has an oval, flattened shape with a logo in the form of the letter T

Doctors' opinion about the effectiveness of the drug

Terzhinan

Terzhinan (ternidazole + neomycin + nystatin + prednisolone) is an original combined gynecological drug from the French Bouchard-Recordati Laboratory. Used topically, release form: vaginal tablets. It has an antibacterial, antiprotozoal (directed against protozoan organisms), anti-inflammatory effect. Designed to maintain the constancy of the acid-base balance in the vagina and the integrity of the mucous membrane lining it. Each component of the drug deserves a separate discussion. Ternidazole is responsible for the antimycotic action of Terzhinan. Inhibits the formation of a key element of the cell membrane of fungi - ergosterol, causing radical structural changes in the membrane, leading to the death of parasitic fungi. Active against Trichomonas and Gardnerella. Neomycin is an aminoglycoside with a broad damaging ability. Destroys Staphylococcus, Streptococcus pneumoniae, Shigella boydii, Shigella dysenteriae, Shigella flexneri, Shigella sonnei, Proteus spp., Escherichia coli. For Streptococcus spp. practically no effect. Bacterial resistance to this antibiotic develops slowly and insignificantly. Nystatin is a polyene antibiotic, which, along with ternidazole, exhibits antimycotic properties. In the sphere of its action is the “vaginal thunderstorm” - the yeast-like fungus Candida. And the last (in order, but not least) component of Terzhinan is the glucocorticosteroid prednisolone.

It has an anti-inflammatory and anti-allergic effect, suppresses exudation at the site of inflammation.

Terzhinan has proven itself in the treatment of vaginal dysbiosis. Thanks to a thoughtful combination of components, the drug is active against the opportunistic microflora most characteristic of the vagina and prevents the growth and reproduction of candida. The presence of prednisolone, a powerful anti-inflammatory agent, determines the effectiveness of the drug for bacterial or yeast vulvovaginitis. Associated infections are another specialty of Terzhinan. As a rule, in patients of a dermatovenerologist who have applied for a specific infection, several more associated ones are identified. In such situations, it is not recommended to prescribe only systemic antibiotic therapy: medications that have a local effect on the vaginal microflora are also needed. And Terzhinan comes in handy with its anti-inflammatory and antibacterial properties. The drug is also used during preoperative preparation before cryodestruction, excision of the cervix, conization, cauterization of erosion - it is prescribed for 10 days before the upcoming procedure. This is done to suppress the inflammatory process accompanying the underlying disease in order to prevent morphological changes in the epithelium of the cervix and vaginal mucosa.

Contraindications and side effects of the drug

According to the instructions, the only absolute contraindication is an allergy to the composition of the medicine. An additional limitation is the occurrence of undesirable consequences from use. If they do not go away within three days, the drug must be replaced. Side effects include:

• local allergic reactions in the form of intolerable burning, itching and irritation of the mucous membrane;
• any painful or unpleasant sensations at the injection site.

A possible reaction to prednisolone is considered to be a slowdown in the healing processes of wounds and cracks, as well as atrophic processes in the mucous membrane.

Features of the use of the drug Terzhinan

The drug is effective when used correctly.

Method of administration of the vaginal tablet:

1. After thoroughly toileting the genitals and washing hands with soap, the vaginal tablet is removed from the package.
2. The tablet is placed in a glass of water for 30 seconds to facilitate administration.
3. You need to lie on your back and pull your knees towards your chest as much as possible due to your enlarged belly.
4. The softened tablet is inserted as deep as possible into the vagina using the index finger.
5. Immediately after administration, you must lie down for at least 10–15 minutes so that the drug begins to dissolve inside under the influence of body temperature and does not leak onto your underwear. It is ideal to use the drug before bed so that it can be completely absorbed inside overnight.

Before administering the tablet, do not forget to wash your hands with soap.
General recommendations for using the drug:

• tablets are intended only for vaginal use, other methods are not acceptable;
• The dosage depends on the cause of the disease and is determined by the attending physician depending on the results of smears and culture, as well as the clinical symptoms of the disease. Usually, one tablet is prescribed before bedtime;
• the safety of the dosage specified in the instructions is beyond doubt, unless allergic reactions to the action of the drug occur;
• The duration of the course of treatment is also individual due to the variety of pathogenic microorganisms. On average, the terms are as follows: for bacterial infections - 10 days;
• for fungal infections - 20 days, repeating the course if necessary;
• for prophylaxis before childbirth - 6 days.

Important points:

• any effect on the body of a pregnant woman must be agreed upon with the gynecologist observing her. You can’t just take and prescribe a drug for yourself; it is important to monitor the condition of the fetus during therapy;
• after administration of the tablet, an increased separation of a yellowish mass is possible within a few hours. Usually, the next morning, a colored yellowish-white spot appears on the underwear after the first urination, which is normal due to incomplete dissolution of the drug inside the vagina;
• in the case of treatment of inflammatory processes and trichomoniasis, it is important to treat not only the woman, but also her sexual partner.

Due to its negligible penetration into the bloodstream, Terzhinan does not affect the action of other drugs.

Features of prescribing Terzhinan for pregnant women

Prescribing Terzhinan in the first trimester is possible only in extreme cases. Doctors are wary of even minimal interventions during this important period for the formation of internal organs. The drug is approved for use in the 2nd and 3rd trimesters of pregnancy when indications for its use arise.

As a guarantee of the drug’s effectiveness in the treatment and prevention of urogenital infections, the manufacturer of Terzhinan provides the results of three different European studies of the drug’s effect on 191 pregnant women.

In Russia, obstetricians and gynecologists published data on the use of Terzhinan in 452 pregnant women at different stages for the treatment and prevention of urogenital infections from 1997 to 2004. Terzhinan is also included in Russian recommendations for the treatment of pregnant women.

In the first trimester of pregnancy, the main organs and systems of the baby develop

Instructions for use TERGYNAN

Prednisolone related

Undesirable combinations

Acetylsalicylic acid:

increased risk of bleeding. Combination with anti-inflammatory doses of acetylsalicylic acid ≥1 g per single dose and/or ≥3 g/day is undesirable.

Combinations requiring precautions during use

Anticonvulsants are isoenzyme inducers:

decrease in the level and effectiveness of corticosteroids in the blood due to an increase in their metabolism in the liver by the inducer. In patients with Addison's disease taking hydrocortisone and those undergoing transplantation, the effects are particularly significant. Clinical and biological monitoring is recommended, and the dose of corticosteroids should be adjusted during treatment with an isoenzyme inducer and after its cessation.

Isoniazid:

reducing the level of isoniazid in the blood by increasing its metabolism in the liver and reducing the metabolism of glucocorticoids in the liver.

Rifampicin:

decrease in the level and effectiveness of corticosteroids in the blood due to an increase in their metabolism in the liver after interaction with rifampicin. In patients with Addison's disease taking hydrocortisone and those undergoing transplantation, the effects are particularly significant. Clinical and biological monitoring is recommended, and the dose of corticosteroids should be adjusted during treatment with rifampicin and after its cessation.

Other hypokalemic drugs:

increased risk of hypokalemia. It is recommended to monitor potassium levels in the blood and make adjustments if necessary.

Foxglove preparations.

The toxic effects of digitalis contribute to hypokalemia. It is recommended to correct hypokalemia and monitor the patient's clinical condition, electrolytes and ECG.

Drugs that can cause Torsades de pointes (polymorphic ventricular tachycardia):

increased risk of ventricular arrhythmia, especially polymorphic ventricular tachycardia. It is recommended to correct hypokalemia and monitor the patient's clinical condition, electrolyte levels and ECG before administering the drug.

Combinations to consider

Cyclosporine:

increased effects of prednisolone, including Cushing's syndrome, decreased glucose tolerance (decreased clearance of prednisolone).

Acetylsalicylic acid:

increased risk of bleeding when used in combination with acetylsalicylic acid in doses that have an analgesic or antipyretic effect, ≥500 mg per single administration and/or <3 g/day.

NSAIDs:

increased risk of peptic ulcers and gastrointestinal bleeding.

Fluoroquinolones:
increased risk of tendon disease, and in exceptional cases tendon rupture, especially in patients receiving long-term corticosteroid therapy.

Structural and functional analogues allowed during pregnancy

If, after starting therapy with the drug, during the first three days of administration, discomfort at the injection site does not go away, but only intensifies, the drug must be replaced with an analogue. But even without allergic reactions, not everyone is satisfied with the price of the drug, which reaches about 500 rubles. Moreover, now, with all the variety of choices, choosing an analogue is not difficult.

The closest structural analogue is the drug Giterna, with a similar composition, only ternidazole is replaced by metronidazole, and the other three active ingredients are identical.

There is no identical analogue on the Russian market, but there are drugs with the same spectrum of effects on the lesion. According to their pharmacotherapeutic group, analogue drugs are divided into types:

• antifungal - Pimafucin, Clotrimazole;
• antimicrobial combination agents - Giterna, Neo-Penotran, Macmiror complex, Klion-D, Hexicon, Polygynax;
• antiseptics - Hexicon D, Fluomizin;
• antimicrobial and antiseptic agents - Neotrizol.

Table: drug analogues by therapeutic effect

Photo gallery: functional analogues of the drug Terzhinan

For many years, inflammatory processes in the uterus and its appendages occupy one of the first places in the structure of gynecological diseases. The presence of persistent pain syndrome, menstrual dysfunction, and infertility is a consequence of chronic inflammatory diseases of the uterus and its appendages and determines the relevance of this problem [2].

From the perspective of modern pathophysiology, the development of an inflammatory disease, the features of its course and the outcome of the infectious process are determined by three components: a microorganism, a macroorganism and environmental conditions [2, 3]. One of the reasons for failures in the treatment of patients with inflammatory diseases of the genital organs is the peculiarities of the relationship between a macroorganism with altered reactivity (the most important component of which is immune homeostasis) and a microorganism that has acquired new biological properties in new environmental conditions [5].

The trigger mechanism in the development of pelvic inflammatory diseases (PID) is the impact of microbial factors. Currently, the structure of causative agents of inflammatory diseases of the pelvic organs is dominated by polymicrobial flora, including both pathogenic and opportunistic microorganisms [4, 5]. Pathogenic microorganisms, the isolation of which is clearly interpreted as identifying the etiological agent, include Treponema pallidum, Neisseria gonorrhoeae, Haemophilus ducreyi, Chlamydia trachomatis, Trichomonas vaginalis

[5].

Currently, most authors note the increasing role of opportunistic pathogens, which are present in small quantities in the human body without causing disease, and only under certain conditions can become truly pathogenic [6]. Such potentially pathogenic pathogens of nonspecific PID include aerobic gram-positive bacteria of the genera: Streptococcus, Staphylococcus, Enterococcus, Corynebacterium

and aerobic gram-negative rods of the
Enterobacteriaceae family: Escherichia coli, Enterobacter
spp.,
Proteus
spp.,
Klebsiella
spp.,
Pseudomonas
spp.
Among anaerobic bacteria, gram-negative non-spore-forming bacteria of the genera Bacteroides, Fusobacterium, Prevotella
and gram-positive bacteria of the genera
Clostridium
spp.,
Peptostreptococcus, Peptococcus
[2].

As for mycoplasmas and ureaplasmas, which are opportunistic pathogens, their role in the development of the inflammatory process has not been fully determined, although most practitioners, despite the dubious etiological role of these microorganisms, recommend the use of antibacterial drugs aimed at eradicating mycoplasmas and ureaplasmas in the case of their detection in the discharge from the cervical canal.

The routes of infection into the internal genital organs are different, but the main mechanism of infection of the internal genital organs is ascending. Less commonly, a lymphogenous route from nearby pelvic organs is possible. The possibility of infection being introduced into the genital organs from distant foci by hematogenous route cannot be ruled out.

However, for the development of a picture of inflammation, in addition to the presence of the causative microorganism, additional conditions are necessary: ​​violation of barrier defense mechanisms (anatomical and physiological features of the structure of the external genitalia, colonization resistance, acidic environment of the vagina, its ability to self-cleanse, the presence of a mucous plug of the cervical canal), violation local and general anti-infective immunity [1, 6].

Thus, the trigger for the development of exacerbation of chronic salpingo-oophoritis is the influence of a microbial factor due to the activation of opportunistic vaginal flora or the entry of an infectious agent from the outside when barrier defense mechanisms and local anti-infective immunity are disrupted.

The main place in the treatment of inflammatory diseases of the pelvic organs belongs to antibacterial agents, selected taking into account microbiological research data. Considering the polyetiological nature of inflammatory diseases of the uterine appendages, as well as the need to start treatment as early as possible, even before laboratory identification of the pathogen, doctors widely use combinations of antibacterial drugs that can eliminate the widest range of possible pathogenic microorganisms, or broad-spectrum drugs that provide a sufficient clinical effect in the form of monotherapy [7, 8].

In addition to the use of antimicrobial chemotherapy, the complex treatment of chronic PID must include drugs that prevent excessive activation of the inflammatory reaction when it is excessive and activate it when it is insufficient, with the correction of hemostasiological, hemodynamic and metabolic disorders [9].

Treatment and subsequent rehabilitation of women should be based on pathogenetic principles, taking into account the mechanisms of infection of the internal genital organs. Long-term persistence of the pathogen in the lower genital tract with an inadequate response of the immune system contributes to the chronicity of the inflammatory process. The development of subsequent exacerbations, as a rule, is associated with a violation of anti-infective defense mechanisms and with the activation of opportunistic flora.

Therefore, along with systemic drugs for the treatment and prevention of PID, the use of local drugs aimed at normalizing the vaginal microbiocenosis is justified.

The predominance of predominantly polymicrobial associations with the dominant role of opportunistic microorganisms and bacteroid anaerobes explains the fact that currently preference is given to combination drugs capable of eliminating the widest range of possible pathogenic microorganisms. One of these drugs is terzhinan, which is a combination drug containing components necessary for the treatment of bacterial (neomycin sulfate), fungal (nystatin), parasitic and mixed (ternidazole) vaginitis and colpitis. Prednisolone, which is part of it, reduces capillary permeability, helps normalize microcirculation in the vaginal mucosa, thereby improving the flow of anti-inflammatory defense components to the site of inflammation, reducing exudation phenomena, and facilitating the penetration of antibacterial drugs into tissues. Thus, the anti-inflammatory effect of prednisolone is realized, clinically manifested by the rapid disappearance of the main manifestations of the inflammatory reaction: pain, hyperemia, itching, burning. The absence of a systemic effect on the body and the need for additional use of antifungal agents to prevent candidiasis, as well as the absence of an inhibitory effect on the vaginal lactoflora, allows the use of terzhinan for the treatment of mixed infections of the lower genital tract.

The purpose of the study was to evaluate the clinical effectiveness of the drug terzhinan in the complex treatment of chronic nonspecific PID: chronic metroendometritis, chronic salpingoophoritis in combination with nonspecific colpitis, endocervicitis, bacterial vaginosis.

Material and research methods

During the work, a clinical and laboratory examination was carried out on 60 women aged 15 to 50 years with exacerbation of chronic nonspecific PID: chronic salpingoophoritis and chronic metroendometritis. In all patients, inflammatory diseases of the upper reproductive tract were combined with inflammatory processes in its lower section (with nonspecific colpitis, endocervicitis, bacterial vaginosis). The examination of patients included a medical history, general clinical laboratory research methods (general blood and urine analysis, biochemical tests), as well as bacteriological (examination of cultures from the cervical canal for flora), bacterioscopic (examination of smears of vaginal contents, urethra, anus) and instrumental (colposcopy , Ultrasound of the pelvic organs) methods.

During the study, all patients were divided into 2 groups: group 1 included 40 women who used the combined drug terzhinan (1 tablet in the vagina at night for 10 days) in the complex treatment of PID for the purpose of vaginal sanitation (1 tablet in the vagina at night for 10 days); The third group consisted of 20 women who used a topical drug containing metronidazole and miconazole nitrate.

Research results and discussion

The average age of the patients was 26.78±0.78 years. When analyzing social and everyday factors, it was revealed that 61% of women were unmarried; by professional affiliation, 34% of women were housewives, 29% were students.

The frequency of concomitant extragenital pathology was 69.00±4.65%. Noteworthy is the high percentage of concomitant diseases of an infectious and inflammatory nature: acute respiratory viral infection (65.00±7.54%) and influenza (20.00±6.32%) in the anamnesis, chronic tonsillitis (30.00±7.24% ), chronic pyelonephritis (22.50±6.60%), chronic bronchitis and pneumonia (22.50±6.60%).

Analysis of gynecological pathology showed that 65.00±4.77% of patients had a history of episodes of chronic salpingoophoritis. Disturbances of the ovarian-menstrual cycle took second place in the structure of gynecological pathology and amounted to 31.00±4.62%, manifested mainly as algodismenorrhea and oligoopsomenorea. These patients often had a history of other diseases of the genital organs of inflammatory origin: metroendometritis (13.00±1.71%), bartholinitis (2.00±1.40%) and endocervicosis (11.00±3.14%).

When studying the characteristics of reproductive function, each woman had 1.42±0.21 pregnancies (38 ended in childbirth, 23 in medical abortion, 25 in spontaneous abortion).

A history of chronic urogenital infection and vaginal dysbiosis was identified in 42 (63.41±5.35%) patients. Urogenital candidiasis was most often diagnosed (17.07±4.15%), which may be due to both a decrease in general immunological resistance and the use of antibacterial drugs during previous exacerbations. Every sixth woman was treated for bacterial vaginosis (15.00±5.64%), which is a recognized risk factor for PID. Chlamydial infection took third place and amounted to 9.76±3.28%, a history of trichomoniasis was detected in 4.88±2.38% of cases.

When analyzing complaints, patients most often noted pelvic pain of varying severity: from periodic pulling to sharp, “cutting” pain. The average temperature was 37±0.04 °C. Pathological discharge from the genital tract occurred in every second patient with inflammatory diseases of the uterus and its appendages and amounted to 74%. In addition, patients noted itching, burning in the vagina (6%), painful urination (5%).

In 20 patients, during a gynecological examination, the inflammatory process in the internal genital organs was combined with pathology of the cervix. Colposcopy revealed signs of severe focal and diffuse cervicitis in all cases.

Ultrasound signs of inflammatory diseases of the uterus and its appendages were enlarged, cystic-changed ovaries (46%), increased in diameter and length of the fallopian tubes with a thickened hyperechoic wall, which were in most cases soldered to the uterus (63%), increased size uterus, the presence of hyperechoic contents with suspension in its cavity (50%), the presence of reactive effusion in the pelvis (17%).

According to the results of a bacterioscopic examination of a vaginal smear, in most cases (87%) the inflammatory type of smear predominated: a large number of leukocytes and coccal microflora.

In 13.00±4.16% of cases, bacterial vaginosis was detected, which is one of the most common infectious diseases of the lower reproductive tract and, according to various authors, accounts for 20 to 60% of cases in women of reproductive age. Bacterial vaginosis is not accompanied by symptoms of severe inflammation and is characterized by a sharp decrease or absence of lactoflora and its replacement by polymicrobial associations of obligate and facultative anaerobic opportunistic microorganisms.

It is noteworthy that in every third woman, nonspecific colpitis and bacterial vaginosis were associated with urogenital candidiasis. According to statistics, over the past 10 years the number of vaginal candidiasis has almost doubled. At a certain stage of life, 75% of women have at least one episode of vaginal candidiasis; in 5% of women, candidiasis constantly recurs. This determines the choice of therapy, including the simultaneous administration of antibacterial and antifungal drugs.

We identified microflora in cultures from the cervical canal in 5.00±7.97% of patients; in the remaining patients there was no growth of microflora under aerobic conditions. The predominant microorganisms were Staphylococcus

spp.
(15.00 ± 5.65%), fungi of the genus Candida
(20.00 ± 6.32%), as well as
Streptococcus
spp.
(5.00±3.45%), Gardnerella vaginalis
(7.50±4.16%),
E. coli
(2.50±2.455), associations (5.00±3.45%).

Complex treatment included antibacterial monotherapy with broad-spectrum drugs (inhibitor-protected aminopenicillins, second-third generation cephalosporins) or a combination of antibacterial agents (amoxicillin/clavulanate + doxycycline; clindamycin + gentamicin, second-third generation cephalosporins - cefuroxime, cefotaxime, ceftriaxone with doxycycline or macroles ladies and metronidazole).

In addition, the components of the complex treatment included non-steroidal anti-inflammatory drugs, immunomodulators, drugs that improve the rheological properties of blood, and desensitizing agents.

In order to reduce the toxic effect of antibacterial drugs and improve treatment results, patients were prescribed multienzyme drugs and probiotics.

During the acute period of the disease, the patients received physiotherapeutic procedures such as magnetic therapy and low-frequency electrotherapy. At the second stage of treatment, the use of ultrasound and low-pulse laser effects, which have a fibrolytic effect, was practiced.

The dominance of polymicrobial associations, including both aerobic, obligate and facultative anaerobic opportunistic microorganisms, and yeast fungi of the genus Candida

, dictates the need to prescribe, along with systemic antibacterial therapy, complex local agents, of which terzhinan is a representative.

According to a clinical and laboratory study, the effectiveness of terzhinan therapy was 87.7%, which was manifested by normalization of the degree of purity of vaginal contents, subjective and objective improvement, which was characterized by the disappearance or reduction of discharge from the genital tract, and in 12.3% of cases these indicators significantly improved compared with those before treatment (see table).

The dynamics of clinical symptoms when using Terzhinan included the disappearance of vulvar itching on average on the 5th day of treatment, relief of pain in the area of ​​the vaginal vestibule - on the 2nd, normalization of the nature of discharge - on the 6th day. By the end of the course of treatment (on the 10th day), all patients had no complaints. Of the 40 patients with nonspecific colpitis, according to a microbiological study, cure was found in 34. In addition, all patients had an increase in the number of lactobacilli without additional use of eubiotics.

In group 2, the disappearance of these symptoms occurred 1-2 days later, and in some cases the pathological symptoms resumed on the 9-10th day and later (see figure).

Figure 1. Time frame for relief of the main clinical manifestations of inflammatory diseases of the lower reproductive tract during treatment in the examined groups. In 12 out of 20 patients, treatment was found to be ineffective, which required an additional anti-inflammatory course of treatment.

Side effects of terzhinan were observed in 2 patients in the form of unexpressed short-term burning sensations, and only on the 1st-2nd day after application.

Among the patients of group 1, 12 had concomitant pathology of the cervix, in group 2 - 8. According to the results of colposcopy, signs of focal and diffuse cervicitis were revealed in patients of both groups. A cytological study, allowing to assess the structure and cellular level of tissue damage, was carried out after anti-inflammatory treatment.

In the group where terzhinan was used, there was no questionable cytological evidence of the presence of intraepithelial neoplasia; In no case was additional anti-inflammatory treatment required. In group 2, 5 out of 8 patients, due to incomplete relief of the inflammatory process in the cervical tissues, had difficulties with the differential diagnosis of intraepithelial neoplasia and inflammatory changes, which required an additional course of vaginal sanitation.

Thus, a decrease in local immunological resistance of the lower genital tract, characteristic of the chronic course of the inflammatory process, contributes to the disruption of normal colonization resistance of the vagina, serves as a source of ascending infection of the internal genital organs and is the main factor in the development of exacerbation. Antibacterial therapy, which is an integral part in the treatment of exacerbation of infectious processes in the internal genital organs, in turn, is accompanied by the development of dysbiosis of the vaginal flora. Thus, one of the vicious circles in the pathogenesis of exacerbation of PID is closed. Local use in complex treatment of a broad-spectrum antibiotic, a metronidazole component that affects anaerobic flora, and an antifungal drug not only promotes vaginal sanitation, but also prevents the development of bacterial vaginosis. The role of prednisolone as one of the components of terginan is significant, which allows normalizing microcirculation in the vaginal mucosa, promotes the influx of anti-inflammatory defense components, optimizes the delivery of drugs to the site of inflammation, and ensures the maintenance of normal flora in the vagina.

conclusions

The combined local drug terzhinan, along with systemic antibacterial chemotherapy drugs, immunomodulators, drugs aimed at combating hemodynamic and metabolic disorders, as well as degenerative processes in the tissues of the uterus and its appendages, is the drug of choice in the complex treatment of inflammatory diseases of the pelvic organs.

Reviews from women

Terzhinan has saved me more than once. During pregnancy, it eliminated the itching that tormented me and gave me no rest due to the onset of thrush. And in the later stages I easily coped with bacterial vaginosis, when I was bothered by a fishy smell and sticky copious discharge. And so yes, I highly recommend it too. Despite the high price, it is worth the money spent on it.

Ignoring unpleasant sensations in the genital area is not necessary, and sometimes dangerous. Especially for the expectant mother, who is responsible not only for her intimate health, but also for the child developing inside her. After all, there are drugs with local antimicrobial combined action that quickly and thoroughly cope with inflammation or infection, such as Terzhinan, for example.

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