Placenta accreta is one of the most severe anomalies of attachment, due to the high risk of massive bleeding. At present, the paradigm of organ-preserving delivery is laid. The implementation of this tactic is possible in the context of the introduction into the obstetric practice of patient blood management (PBM).Objective:to evaluate the effectiveness of blood preservation methods in the management and delivery of pregnant women with placenta placenta accrete.Materials and methods:The study group consisted of 59 pregnant women with placenta accreta in age from 20 to 40 years old (32,43 ± 5,05), who were examined in «Scientific Medical Research Center of Obstetrics”. Clinical, special (ultrasound and magnetic pelvic magnetic resonance imaging) and laboratory methods were used. A program of preparation for delivery was developed using the principles of the PBM: treating anemia at the preoperative stage; a multidisciplinary operating team was prepared (two obstetricians, a surgeon, anesthesiologist and resuscitator, anesthetist, transfusionist, physician, who provides work for Cell Saver, laboratory assistant). Operational tactics included a bottom cesarean section using one of the methods of surgical prevention and arrest of bleeding - bilateral ligation of the internal iliac arteries (1st group) (19 women), temporary stop of blood flow in common iliac artery by means of vascular clamps Satinsky (18 patients – 2ndgroup); bilateral overlay of turnstile harnesses on the base of the wide ligaments and the cervical-neck area, supplemented by a controlled balloon tamponade of the uterus (22 patients – 3rd d group). The operation was carried out under conditions of intraoperative reinfusion of autoerythrocytes on the apparatus “Cell-Saver 5”, donor FFP and erythrocyte component, tranexam preparations, rFVIIa (KoagilVII) were administered. In 80% of women, operations were performed under combined spinal-epidural anesthesia.Results:the lowest blood loss was detected in the 3rd group with compression complex hemostasis: 1286 ± 510 ml. Accordingly, the volumes of infusion and transfusion therapy were also the smallest in this group. The volume of reinfused autoerythrocytes ranged from 260 ml to 1420 ml and averaged 801,7 ± 414,18 ml with a hematocrit of 55-60%. Donor erythrocytes were transfused to only 27 patients in an average volume of 785,1 ± 134,2 ml. rFVIIa (Koagil) was administered to four patients: three from the first group and one from the second group: a significant decrease in the speed and volume of bleeding was noted, and he performed an organ-sparing operation. Hysterectomy was performed on five women (8,77%). In the postoperative period was carried out antianemic therapy. The hospital stay averaged 7,9 ± 1,8 days.Conclusion:The special role in the management and delivery of pregnant with placenta accreta plays the use of various PBM techniques , which include rational therapy of preoperative and postoperative anemia with modern iron preparations, rational surgical tactics, red blood cell autotransfusion, use of modern hemostatic agents and blood substitutes. A comprehensive multidisciplinary approach to this problem allows reducing blood loss, minimizing the volume of donor blood components and implementing organ-preserving tactics in a significant number of women.
Background: At the moment, an urgent and unresolved problem is the search for a diagnostic method for disorders of the hemostasis system in patients against the background of the course of a new coronavirus infection. Presumably, integral tests, in particular, the thrombodynamics test, will make it possible to monitor changes in blood clotting, predict the course of the disease in patients with COVID-19. Aims: to comparative assessment of plasma hemostasis parameters and thrombodynamics test in patients with COVID-19 viral infection of varying severity. Methods: The study included 96 patients with a confirmed diagnosis of COVID-19, hospitalized in an infectious diseases hospital on the basis of National Medical Research Center for Obstetrics, Gynecology and Perinatology named after V.I. Kulakov in the period from 04.23.2020 to 06.20.2020 and discharged at the end of treatment. SARS-CoV-2 was identified by PCR. Patients were stratified by severity into 3 groups: mild course (n = 25), moderate course (n = 54), severe course (n = 17). Diagnostics and treatment of patients was carried out in accordance with the Temporary Methodological Recommendations of the Ministry of Health of the Russian Federation for the prevention, diagnosis and treatment of new coronavirus infection, versions 5, 6, 7. In the dynamics of treatment, patients were assessed APTT, prothrombin %, prothrombin time and thrombin time, fibrinogen, D-dimer, platelet count and thrombodynamic test (V / Vi / Vst, Tlag, Cs, D). Results: It was found that significant differences before admission and a week after the start of hospital treatment were observed for the thrombin time, D-dimer, platelet count, and thrombodynamic parameters: V / Vst, Cs, D. PT, APTT, TD (Tlag, D)) with the duration of hospital stay. There was a positive relationship between the content of fibrinogen and D (r = 0.6307, p 0.0001) and a strong positive relationship between PT and Tlag (r = 0.7499, p 0.0001). Conclusions: The thrombodynamics test can be recommended as a potential tool for a personalized approach to monitoring the hemostasis system and treating patients with COVID-19.
The aim of the work was to determine frequency of lupus anticoagulant (LA) detection in patients at various degrees of COVID-19 severity as well as duration of LA circulation after the infectious disease. The study included 103 patients with COVID-19. The patients were observed during the hospital care and in ambulance, if required. The patients were admitted to the departments of infectious diseases arranged at the V.I.Kulakov National Medical Research Center for Obstetrics, Gynecology, and F.I. Inozemtsev City Clinical Hospital. Treatment schedules and stratification of the patients by clinical severity was carried out in accordance with Interim Guidelines issued by the Ministry of Health of the Russian Federation for the prevention, diagnosis and treatment of new coronavirus infection (version 9). The following groups were formed: mild (n = 27), moderate (n = 55) and severe (n = 20). The patients were tested for LA positivity in the course of disease: on the day of starting medical care (with outpatient observation), or on the day of hospitalization; repeated tests were made before discharge (inpatients), and later, 1-2 months and 7 months after recovery. Lupus anticoagulant was determined by two independent tests (dRVVT and SCT), i.e., as a screening test and a confirmation test. At initial examination, LA was found in 50 patients (49%). The effect of LA in 98% of cases was observed with dRVVT test, as an increase of normalized ratio (NR). The maximum median value of NR was 1.54 (0.97: 2.1) was revealed in patients with severe course of COVID-19 (p 0.0001) compared with other groups and correlated with severity of the infectious process (r = 0.491, p 0.0001). In mild cases of COVID-19, LA was detected less often (4 cases, 14.8%) than in moderate severity cases (27, 49.1%), and severe patients (19, 95%) (p 0.05). Re-examinations of the patients before discharge from the hospital and 1-2 months later revealed high frequency of LA (p 0.05). However, no LA-positive test was found 7 months after discharge. In patients with COVID-19, high frequency of circulating LA was registered, depending on severity of the infectious process. In addition, we have first shown that persistence of the circulating LA over post-infectious period does not exceed 7 months.
Introduction. About 30 to 50% of women with endometriosis complain of infertility. The incidence of infertility in all localizations of endometriosis is about 3-4 times higher than that in the general population.Objective of the study: estimate the hormonal profile of patients with deep infiltrative endometriosis (DIE) based on the study of the level of AMH, FSH, LH, progesterone, estradiol, prolactin in the serum of peripheral blood, conduct a comparative analysis of the level of these hormones between groups of patients with DIE and tuboperitoneal infertility.Materials and methods: the main study group consisted of 99 patients of reproductive age (from 18 to 40 years) with DIE, the comparison group consisted of 18 patients with tuboperitoneal infertility. The patients of the main group were divided into 2 subgroups: subgroup IA - DIE with colorectal endometriosis (n = 63), subgroup IB - DIE without colorectal endometriosis (n = 36). AH patients underwent determination of the level of AMH, LH, FSH, progesterone, estradiol, prolactin in the serum of peripheral blood before surgery.Results and discussion: a significant decrease in AMH level was revealed in patients with DIE. The level of AMH in the main and comparison groups was 1.80 and 3.28 ng/ml, respectively (p = 0.01). At the same time, subgroup IA has a more decreased AMH level (1.37 ng/ml) than in the comparison group (p = 0.003). In subgroup IB (the median AMH level - 2.50 ng/ml) were no significant differences with the comparison group (p = 0.14). It was also noted that in the group of patients with colorectal endometriosis (subgroup IA) the percentage of patients with reduced ovarian reserve (AMH 0.01 - 1.0 ng / ml) was significantly higher than in the comparison group (30.2% versus 5, 6%, p = 0.03), there were no significant differences between the subgroups. There were no significant differences in the level of LH, FSH, E2, prolactin in serum between the groups (p> 0.05).Assessment of the level of anti-mullerian hormone, as the most accurate marker of ovarian reserve, revealed a significant decrease in AMH levels in patients with DIE, more decreased in the group of patients with colorectal endometriosis. Every 3rd patient with DIE had an AMH level of less than 1, which is a risk factor for a “poor” response to ovarian stimulation according to the Bologna criteria.Conclusion. A significant decrease in the level of serum AMH, along with a high percentage of previous surgeries for endometriosis, including ovarian resections, may be one of the factors in a decrease in the reproductive potential of patients with DIE.
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