Plasmapheresis in the treatment of pathological states in obstetrics. Plasmapheresis is an indication and contraindication before blood purification.

In case of early toxicosis of the vagina, which is characterized by bagatorasis vomits with waste body mass and acetonuria, the course of membrane plasmapheresis was brought up to significant polypsennia. I'll become a stalker. Nudity and vomitting pripinalis, zayavlya appetite, body weight was restored, the ratio of average molecules was reduced by 77%. In the ears of the woman, it was possible to save the vaginess. Additive treatment of such an active approach to the treatment of early toxicosis is evidence that toxicosis develops in 88.5% of women with impaired uteroplacental circulation in the first trimester.

At the canopy booth im. Snegirova (St. Petersburg) in 123 patients with toxicosis and vicarious membrane plasmapheresis. 3-5 sessions were carried out from intervals up to 30% of the BCP with intervals of 2-3 days. Air blowing was carried out in the izovolemic regime with crystal-lined roses. After plasmapheresis of the vagitis, polypsynia of self-perception was indicated, head pain was stopped, swelling changed, diuresis increased, the level of arterial hypertension decreased by 20%. Bilirubin and ALT levels were normalized, plasma factors and coagulation decreased, although they were left with increased adhesive-aggregation power of platelets, but at the same time, bleeding was not observed for half an hour.

Stable clinical effect of indications in 39 patients with mild stage preeclampsia. Usі voni gave birth at once that was written at home with children. In a group of 84 women with an important pre-eclampsia, the clinical effect was less stable - 60% of women were born prestrokovo and in 40% of cases, the weight of the fetus was born up to 1500 rubles. There were no proteo perinatal care for the children. All the stench dressed up and were written home after the rehab and rehabilitation in the children's hospitals of the city.

Boinov B.A.

І Інші materials on the topic "Plasmapheresis"

STATE OF PLASMA HERESIS IN LIKUVANNI PATHOLOGICAL STATIONS IN OBSTETRICS

Fedorova T. A., Serov V. N., Sidelnikova V. M.
NTs Agip RAMS, director - acad. RAMN, prof. V.I. Kulakov, m. Moscow

Obstetric bleeding, gestosis and other complication of vaginess, purulent inflammation of the disease are filled with urgent problems of modern obstetrics, gynecology and neonatology. Regardless of the significant success achieved in the fight against bleeding, gestosis and infection, stench, like before, may be succumbing to the mother's veil in the structure of maternal illness and mortality.
Цьому сприяє низка факторів, що становлять особливості сучасної медицини, до яких відносяться зміна контингенту вагітних і породіль, значне збільшення частоти абдомінального розродження, не завжди достатньо обґрунтоване застосування з профілактичною та лікувальною метою антибіотиків широкого спектру дії, що призводить до накопичення в клініках антибіотикоустойчів. , Vykoristannya of modern invasive methods of obstezhennia medicinal preparations, including corticosteroids, which may be immunosuppressive.
Autoimmune disorders play an important role among the causes of ovarian innocence, including the antiphospholipid syndrome, the frequency of which is 27-42%. Without adequate therapy, the death of the embryo (fetus) is expected in 90-95% of women.
In addition, in the etiology of autoimmune processes, a great role is played by infectious factors, such as genital herpes, cytomegalovirus. According to the data of the WHO, the figure is up to 10%, which can lead to mimicry, pregnancy, intrauterine death of the fetus and disability of the child.
Іsnuyuchi methods of therapy for pathologies that are always effective. High doses of glucocorticoids are toxic to the mother of the fetus, anticoagulants can lead to the development of iatrogenic complications - heparin-induced thrombosis, osteoporosis, stagnation of immunoglobulin - to the development of anaphylactic reactions.
In 1992, the SC AG&P RAMS was the first in Russia to create gravitational blood surgery, to the functions of which included not only blood preparation and її components, but also the development of extracorporeal methods in obstetrics and necology.
One of the methods, which I know at the moment has its own place in the obstetric clinic, is plasmapheresis. The essence of this method is based on distant parts of the plasma and substituted with plasma-smelting variances, or freshly frozen donor plasma, as a deposit for indications and purposes.
Inclusion of plasmapheresis to the complex of leaching is indicated in pathological states that are accompanied by intoxication, hypercoagulability, impaired function of natural detoxification systems, tissue diarrhea, autoimmune aggression. Mechanisms of different methods of hemopheresis, plasmapheresis zocrema, can be represented as follows:

1. On par with the body:
   1. Increased compensatory-adherent reactions.
   2. Normalization of hormones in the hypothalamic-pituitary-superior-ovarian system.
2. On the client's level:
   1. Normalization of acid metabolism.
   2. Normalization of metabolic directing.
   3. Normalization of immunoregulatory disorders.
3. On the organ level:
   1. Polypshenya microcirculation of vital organs.
   2. Normalization of systemic hemodynamics.
4. On the level of biomembranes:
   1. Antihypoxic effect. Protection against end products of lipid peroxidation and products of intoxication.
      Based on the results of the investigations carried out in our patient, plasmapheresis (PA) can be performed in obstetrics, gynecology and neonatology in advanced pathological states:
      1. In prevention and treatment of early and late toxicosis of the vagina.
      2. Prevention of Rh-conflict between mothers and fetuses.
      3. In case of non-vinoculation vaginess, associated with chronic DIC, antiphospholipid syndrome.
      4. With placental insufficiency.
      5. With the treatment of cytomegalovirus and herpetic infections, including in women.
      6. In cupped ovarian hyperstimulation syndrome.
      7. In the treatment of premenstrual and menopausal syndromes.
      8. With vagity, aggravation of circulatory diabetes, bronchial asthma, chronic pneumonia, pyelonephritis, hepatitis, Gaucher's syndrome, neurodermatitis, hepatosis and other extragenital ailments.
      9. In case of impaired reproductive function of a woman, which is caused by chronic inflammatory diseases of the state organs.
      10. With an aggravated transition of the post-abortion and post-abortion periods.
      11. In the system of rehabilitation visits after reconstructive plastic surgery on the pelvic organs.
      12. With prophylaxis and therapy of bleeding.
      13. With prophylaxis and treatment of multiple organ failure.
          Other contraindications for plasmapheresis:
          1. Anemia (Hb - less than 90 g / l, Ht - less than 30%).
          2. Hypoproteinemia (hard protein less than 60 g/l).

Positive results were obtained in the treatment of moderate and severe forms of preeclampsia. Among the causes of maternal mortality, preeclampsia is stable in other places. According to the materials of the All-World Organization for the Protection of Health, preeclampsia is the main cause of perinatal illness and mortality.
Severe forms of preeclampsia in this hour are characterized by an early onset (24-27 days), progressive rupture against the background of extragenital pathology, resistance to chronic therapy, mild forms with rapt-sharp aggravation of the vagitic organ, non-perfectly warmed up.
In important forms of preeclampsia, there is an increase in the middle arterial pressure in 20% of women, the development of mild azotemia - in 60%, an exudative hyperbility in 20%, an increase in the level of transaminases - 30%; thrombocytopenia is suspected in 65% of pregnant women, which dictates the need for clinical and laboratory monitoring with the method of revealing a timely adequate assessment of the pathological process and the appointment of obstetric tactics.
Нами в комплексну інтенсивну терапію гестозу впроваджено нову методику, що складається з застосування лікувального плазмаферезу та представників нового класу плазмозамінників – розчинів на основі гідроксиетильованого крохмалю, які на сучасному етапі розглядаються як ідеальні інфузійні середовища для корекції гіповолемії, гемореології.
About 200 women are afraid that the complex of therapy included plasmapheresis, 50% of which reduced the form of preeclampsia. After the treatment, the normalization of the parameters of the hemostasis system, the improvement of the antioxidant potential, the improvement of systemic and regional hemodynamics, the normalization of the functional state of the "mother - placenta - plaid" complex were revealed.
In complex intensive therapy of important forms of gestosis, there were at least two sessions of plasmapheresis with an interval of 3-4 deb. The volume of plasma exfusion becomes 30-40% of the volume of circulating plasma in one session.
After plasmapheresis, continue infusion therapy with hydroxyethyl starch-based infusions at a dose of 10 ml/kg of body weight, followed by concentrations of carbohydrates at a dose of 5 ml/kg of body weight and magnesia therapy (if necessary).
We have established that the stagnation of discrete plasmapheresis in the case of HECs should be carried out until the establishment of systemic hemodynamics, so I will become the “mother - placenta - plyd” system, which confirms an increase in the titer of trophoblastic beta-1-globulin by 46%, a decrease in mariary alpha -1-microglobulin by 17%, a change in the middle mass molecules by 34.5%, a change in low important biochemical indicators (a decrease in the level of sechin by 57.3%, creatinine - by 35.8%, cholesterol - by 33.6%, bilirubin - by 16%), correction of indications in the hemostasis system.
When treating moderate forms of preeclampsia, plasmapheresis causes a decrease in the coagulation potential of blood by 20% for the plasma and platelet counts with unchanged activity of laryngeal inhibitors, fibrinolysis and fibrinolytic potential; the activity of intravascular blood clotting is reduced in two. It was revealed an increase in indicators of the volumetric transport of acid by 14% and normalization of the transport of acid for the circulatory and hemic type, which indicates the transition of the organism of the vaginal from preeclampsia from the state of hypoxia to the state of normoxia.
Vikoristannya plasmapheresis allows to improve the fetal body: the frequency of damage to the utero-placental and fetoplacental blood flow was reduced by 1.5 times, the indicator of the fetal state, following the results of cardiotocography, was reduced by 1.7 times.
Indications for carrying out licuvial plasmapheresis in vaginal patients with important forms of preeclampsia are: the absence of an effect in drug therapy, the recurrence of the clinical picture of preeclampsia (high hypertension, expressions of bloating syndrome, proteinuria, no drug therapy).
Notable contraindications: uncorrected hypoproteinemia (hypoalbuminemia), lack of venous access, anemia (hemoglobin less than 70 g/l), thrombocytopenia (platelets less than 100 10 9 /l).
In case of ineffectiveness of therapy (according to our data, in 12% of women), it is necessary in due time (for a period of 1-3 days) to review nutrition about pre-stroke birth.
Propionation of complex treatment of preeclampsia allowed:

• increase the efficiency of vaginal lubrication by 1.8 times,
• to prolong the vagity with important forms of preeclampsia in the middle by 3 strokes, with moderate forms - by 4 strokes and more,
• reduce perinatal mortality by 2.4 times,
• reduce perinatal morbidity by 2.8 times,
• change the trivality of parenting at the hospital by 1.5 times.

Methods of hemopheresis have known their place in the exuberant festering conditions, which are blamed for post-operative periods. Purulent-flammable disease (PI) continues to be one of the most pressing problems in obstetrics and gynecology. The frequency of purulent-septic conditions in obstetrics and gynecology ranges from 15 to 26%. For the frequency of vindication, septic shock is ranked third after hemorrhagic and cardiogenic, and for lethality - at first.
На підставі отриманих даних при обстеженні та лікуванні хворих з ГВЗ встановлено, що в структурі акушерського сепсису перше місце займає постабортний сепсис (40%), що супроводжується високою летальністю, що пов'язано з використанням несучасних методів штучного переривання вагітності в пізні терміни (інтраамніальне введення , glucose, infusion of aseptic sepsis) followed by septic sepsis (32%), and the remaining space is occupied by septic aggravation after abdominal sepsis (28%).
The severity of the provision of adequate therapy for HL is based on the fact that given pathology accompanied by impaired microcirculation, multiple organ failure, and profound metabolic disorders.
We have carried out treatment of 100 ailments for reproductive age with purulent-septic complications, which were followed by abortions or both, with inclusions to complex infusion-transfusion therapy sessions of repeated double-stage plasmapheresis.
At the first stage of therapy, plasmapheresis was carried out in 1-2 dobu manifestations of purulent-septic condition. operational jubilation purulent middle with plasma exfusion not less than 50% of the VCP. plasma, which is seen, was replaced with fresh-frozen plasma, 10% albumin, 6% hydroxyethyl starch, crystalline. The amount of blood, which was administered, increased, but sometimes it exceeded (by 15–20%) the amount of plasma that was seen. At another stage, plasmapheresis was carried out in the early post-operative period in the plasma exchange mode (obtaining 70% of the VCP), so that all the exfused plasma was replaced by donor fresh frozen plasma.
Carrying out a two-stage discrete plasmapheresis in 1-2 dobu from the moment of manifestation of sepsis to lead to correction of the hemocoagulative potential of blood (increase in the number of platelets from 102.5±24.1x10 9 /l to 170.5±18.4x10). index by 15%, AT-III - by 18%), a decrease in the function of natural detoxification systems of the body (a decrease in the concentration of bilirubin by 32%, sechovin - by 7.3%, creatinine - by 12% at p<0,05), стабилизации КОС и газов крови независимо от исходной формы (метаболический алкалоз или ацидоз), нормализации общего количества лейкоцитов и лейкоцитарной формулы.
On the basis of clinical and laboratory analysis, a corrective action of two-stage plasmapheresis was established on the parameters of hemocoagulation, CBS and hemodynamic indications in the process of complex intensive care of ailments and septic conditions, which allows a radical surgeon to carry out the sanation of the mind of an ulcer. Використання плазмаферезу в комплексній терапії генералізованих форм ГВЗ у хворих без вираженої поліорганної недостатності призводить до зниження летальності в 4 рази, сприяє зменшенню обсягу та тривалості проведення інфузійно-трансфузійної терапії та скорочення койкодней в 2 рази і дозволяє суттєво знизити материнську летальність з 4 %.
Carrying out plasmapheresis on aphids caused by the syndrome of multiple organ failure, however, leads to an increase in mortality up to 83%. In these cases, it is necessary to carry out hemophilization or hemodialysis.
In this way, the simultaneous conduction of licuvial plasmapheresis in ailments with HVD in complex infusion-transfusion therapy can significantly improve the number of ailments, reduce mortality and may have a great economic effect.
In the rest of the years, plasmapheresis zastosovuetsya in clinics of innocence of vaginess, which is a complex political problem of modern obstetrics. Among the reasons for sonic innocence, otherwise, as it is customary in worldly literature, spying in vagity, autoimmune damage plays a great role. Among the autoimmune disorders that lead to the death of the embryo/fetus, the most common is the antiphospholipid syndrome (APS). Use the embryo/fetus in different gestational terms as one of the criteria for diagnosing APS, in order of having a history of venous or arterial thrombosis, thrombocytopenia and the presence of autoantibodies to phospholipids. The role of antiphospholipid autoantibodies in the development of such obstetric complications, such as preeclampsia, obstruction of fetal development, placental insufficiency, antenatal fetal death in the 2nd and 3rd trimesters of pregnancy, is shown.
The development of a chronic form of DIC-syndrome with early terms of pregnancy disrupts the normal processes of implantation, placentation, growth and development of the embryo. The literature discusses the possibility of a direct auricular fibrillation of autoantibodies to syncytiotrophoblast. APS infections represent a risk group for the development of such complications, such as placental rupture, thrombosis of various localizations, thromboembolism (mostly in the postnatal period).
In clinics of innocence of vagility, plasmapheresis is vicorated for preparation to vagility and induction of vagility in women with primary innocence of autoimmune genesis and in later autoimmune disorders and persistent viral and bacterial infections In Usyi, 259 women with APS were cued.
Exhausted women with APS posture showed that stench may cause changes in the immune system, hemostasis indicators, parameters of endogenous intoxication, the activity of coagulation tests was expressed. Changes in the hemostasis system should be noted: hyperfunction of platelets, hypercoagulability, the presence of markers in the chronic form of DVZ in 25% of patients with vagalgia.
In connection with the obviousness of the hypothesis about the trigger role of infection in the development of autoimmune processes, we carried out bacteriological and virological exacerbation of women with APS.
Coxsackie virus infection was detected in 98% of women, herpes simplex virus in 56.9%, cytomegalovirus infection in 60.8% of women. The manifestation of dysbiotic changes was revealed in 94% of women, vaginal candidiasis - in 14% of patients. Normocinosis of pichwi was detected only in 54.2% of patients.
In this way, in patients with APS, the posture of vagitis and the temple is manifested by bacterial and viral infections, which, perhaps, was wised up by the camp of the medical lanka of immunity, when there is no elimination of infection.
Лікування запальних змін геніталій та нормалізація мікрофлори піхви до вагітності у хворих з АФС є головним завданням раціональної підготовки до вагітності, оскільки терапія аутоімунних порушень під час вагітності вимагає призначення кортикостероїдів, що може призвести до активації інфекції, що персистує.
A follow-up of coagulation tests in patients with APS after an antibacterial and immunomodulatory test showed that the test results were positive, which is typical for immune antiphospholipid antibodies.
After correcting hemostasis, carrying out protizapal and immunomodulatory treatments, recognizing the biocenosis of the psychiatric patients with APS, it was allowed to be pregnant with recommendations for taking corticosteroids at a dose of 5–10 mg in the II phase of the menstrual cycle.
The group of patients with APS to vaccinated was held three sessions of licuval plasmapheresis with an interval of 1-2 decibels in the first phase of the menstrual cycle. Indications for PA were: pronounced activity of the autoimmune process, manifestation of chronic DIC, allergic reactions to antiplatelet agents and anticoagulants, activation of bacterial and viral infections, rupture of the duct and 12-colon, in case of impossibility.
As studies have shown, already after the first sessions of PA, the number of strongly positive reactions to VA changed 6 times and decreased by 5.6%, and after the third session and 4 times after the end, there was no sharply positive result. The frequency of positive reactions to VA changed by 8 times, and only in 5.6% of patients with high activity of VA after PA after a month a slightly positive reaction to VA was noted.
In the 1st trimester of vaginess in women, when PA was taken away, the frequency of vaping to the chorion was higher, lower in the group of women, yakі took away more than medication preparation, in the second and later, the threat of vaccination was indicated (30.4 and 66.7% in dpovіno). Doses of glucocorticoids were minimal, and heparin was not needed.
In this way, the stagnation of the likuvalny PA posture of vagity is more favorable to the transition of the early stage of vaginess to the aphids of less drug stress, which is vignatkovo important for the first hour of embryogenesis.
Conducted studies have shown that under the diagnosis of PA in women, the normalization of hemostasis indicators to a value that corresponds to the gestational term is normalized. There was no evidence of a sharp decrease in the burning potential of the blood, which indicates an adequate supply of plasma exfusion and adequate plasma replacement. The richness of the infusion of licuvial PA is associated not only with plasma exfusion, but also with various infusions on the blood cells. We did not determine the number of erythrocytes, thrombocytes, hemoglobins.
After the conducted PA, there was a significant decrease in the level of bilirubin, creatinine, sechovin, pudendal phosphatase, which reduces the burden on the body's natural detoxification systems. Vidsutnіst zminіn elektrolitnogo depot plasma, instead of zagalnoe protein, glucose to indicate a slight influx of PA on qi indications.
After the PA was carried out, the partial pressure of sourness was significantly improved, instead of sourness and saturation, all indicators of the acid-base state were normalized.
Follow-up of the fetoplacental complex by ultrasound, Doppler, CTG showed that after the PA, a reduction in all parameters was indicated, which became the basis for the selection of PA for the treatment of placental insufficiency.
The analysis of the results of vaccinity showed that with all the therapy options, up to the term of the timely peaks, it was possible to prolong the vaccinity in 97.4% of patients, who took PA, and in 90%, they took drug therapy. Front canopies became more pronounced in 6.7 and 10% of women.
Such a disease, and most of all in this contingent of ailments, was reduced, like the removal of the placenta, it was considered to be two or more of the group, PA was eliminated.
In the post-slyapological period in ailments, yakі otrimuly PA, it was not noted that there was a regular pattern of thrombotic complications. In women, yakі otrimuvali medicamentous therapy, after a gradual venous thrombophlebitis was detected in 4.8% of patients, ileofemoral thrombosis was revealed in 3.2%, which required prompt treatment and staging of the cava filter.
The frequency of purulent inflammation in patients who took PA was 2.7%, and in the group with drug therapy - 9.5%.
When analyzing the early neonatal period, it was found that the frequency of intrauterine infection in patients with PA was 6.8%, and for drug treatment - 14.3%.
In this way, the inclusion of PA, which can have detoxification reo-, coagulo-, immunocorrigible effects, in the complex therapy of ailments with APS is pathogenetically primed and potentiates the positive effect of medicinal preparations.
Наведений досвід застосування плазмаферезу в комплексному лікуванні деяких патологічних станів в акушерській клініці свідчить про досить високу його ефективність, що сприяє зниженню материнської та дитячої захворюваності та смертності, та необхідність подальших досліджень з впровадження методів гемоферезу в акушерсько-гінекологічну практику.