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Estimation of haemocoagulation state in dynamics and risk factors of thrombotic complications at women with uterine...
5. BarttR. E. The Neurology of AIDS.//JAMA. - 2006. - Vol. 295. - 331 p.
6. Sacktor N., Lyles R. H., Skolasky R. HIV-associated neurologic disease incidence changes: Multicenter AIDS Cohort Study, 1990-1998//Neurology. - 2001. - Vol. 56. - P. 257-60.
Mamadjanova Nodira Nosirjonovna, Republican specialized scientific-practice medical center of obstetrics and gynecology, Tashkent, Uzbekistan, junior scientific explorer E-mail: [email protected]
Estimation of haemocoagulation state in dynamics and risk factors of thrombotic complications at women with uterine myoma exposed to the surgical treatment
Abstract: In purpose on to estimate of influence of the operative treatment to the haemocoagulation and to the risk of developing of thrombosis at women with uterine myoma we have carried out retrospective research of case histories of woman operated concerning a uterine myoma. The received results shown, that the surgical trauma directly influences increases of coagulation and thrombogen potential ofblood aggravating a condition ofhemostasis at women on the post operative period. Postoperative period complicated with deep vein thrombosis at 2 women from group II on the 27th day after discharging from hospital, and at 3 there is occurred secondary adhesion of postoperative wound. Women are elderly after 40 years are believe in thrombotic dangerous, carrying out of the expanded operative interventions allows to note them high group of the risk of development of thrombotic complications, demanding corresponding specific thromboprophylaxis. Thus, preventive maintenance with UFH at the present contingent patients does not allow to the result of coagulation potential in initial level, which at them were before operation.
Keywords: uterine myoma, hemostasis, thromboembolia.
Introduction. Treatment of myoma at all stages of development of medicine caused multiple discussions. The basic method of treatment of uterine myoma is the combination of conservative and surgical interventions. However, despite productive enough conservative methods, frequency of radical operations remains is high and makes 80 % [4]. Also it is more increases frequency of postoperative thrombotic complications among patients with uterine myoma. As a testifying this, dates received by Ozolini L. A. after retrospective research of case histories of patients with uterine myoma show, that thrombotic complication after vaginal hysterectomy originated in 7 % and after abdominal hysterectomy in 13 % cases [3; 4]. At the present, there are no doubts that fact, that at performing operative intervention there is a role of influence of complex stress factors including not only traumatic component, but also humoral reactions. It has established that operative intervention increases of the risk of thrombogenesis on 10 times [4; 5; 9], especially if it lasts more than 45 mines, expanded, and it is accompanied with massive hemorrhages. The urgency of the present position takes place is that in the majority cases (80 %) postoperative deep veins thromboses proceeds unsymptomatically, and moreover it will appearance clinically on the 27th day after discharging from hospital [3; 6; 8].
Purpouse. To estimate of hemocoagulation state, to study of influence of operative intervention to the impairing of coagulation system and developing of postoperative
thrombotic complications at woman with uterine myoma exposed to the surgical treatment.
Materials and methods. We have carried out a retrospective research of116 case histories ofwomen with the diagnosis of uterine myoma, which have performed uterine extirpation with its appendages or without them at the Department of operative gynecology of the Republican specialized scientific-practice medical centre of obstetrics and gynecology (RSSPMC O&G) during 2005-2008 years. Average age ofpatients was 45 ± 8 years old. In the general number of investigated patients 76 of them were women aged after 40 (group I), 40 were below 40 years old (group II) which have not being treated with hormonal therapy before due to myoma. All patients have admitted to the RSSPMC O&G for the operative treatment with the diagnosis of symptomatic uterine myoma, which further confirmed by histologically. In maj ority cases they have been spent spinal anesthesia, in those cases, at revealing of the contra-indications, that patients have been spent the general anesthesia. Besides antithrombotic nonspecific methods (elastic bandaging of lower limbs, early mobilization, abundant drink), all patient received pharmacological prophylaxis with unfractionated heparin (UFH) in dosage of 2500 ID subcutaneously each 8 hours prior to and of the postoperative period.
For comparison of haemostasiological pattern there is also studied haemostasis system of 20 rather somatically healthy women at the reproductive age without gynecologic diseases (control group).
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Estimation of the hemostasis condition is carried out in dynamics prior to and on 1st, 3rd, 7th days of the postoperative period at the hemostasiological laboratory of RSSPMC O&G with usage of reactants firms Barnaul (Russia) which included in itself definition: activated partial thromboplastin time (APTT), prothrombin time (PT), prothrombin ratio (PR), the international normalised ratio (INR), concentration soluble fibrin-monomer complexes (SFMC) and fibrinogen, amount of platelets. Definition of PR and INR were realized by using following formulas:
PR = PT of patient/PT of control serum. (1)
PT of control serum is equal on 15 in haemostasiological laboratory of RSSPMC of O&G.
INR = PRAISI. (2)
IS I — the international sensitivity index for different thromboplastin it is intended differently. In laboratory RSSPMC O&G there is used thromboplastin named Teh-plastin (Technology-standard, Russia), received of a brain of the person, and it’s ISI equal to 1.1-1.2.
Results. The average size of a uterus together with myomatous node was 12 ± 4 weeks (min. 7 weeks; max. 24 weeks). In the structure of somatic pathologies cardiovascular disease (40 %), obesity (20 %), anemia (30 %), varicose veins of lower limbs (14.8 %), gastrointestinal tract diseases (14.8 %) were predominant. At the majority of patients there are revealed some accompanying diseases: the combination obesity, arterial hypertension, anemia and varicose veins of lower limbs.
Table 1. - Volume, duration of operative performance and anesthesia, amount of intra operative hemorrhage and infusion
Parameters Group I (n = 76) Group II (n = 40)
Operative performance: Uterine extirpation (total hysterectomy) 58 (76.2 %) 9 (22.5 %)
Uterine amputation (hysterectomy) 13 (17.2 %) 3 (7.5 %)
Conservative myomectomy (Laparotomy) 1 (1.3 %) 14(35 %)
Conservative myomectomy (Laparoscopy) 4 (5.3 %) 14(35 %)
Duration of operative performance: Up to 45 min. 13 (17 %) 12 (30 %)
From 45 up to 60 min. 22 (29 %) 13 (32.5 %)
More than 60 min. 41 (54 %) 15 (37.5 %)
Interoperation blood loss volume: Up to 100 ml. 12 (15.8 %) 21 (52.5 %)
Up to 200 ml. 33 (43.2 %) 14(35 %)
Up to 300 ml. 21 (27.6 %) 3 (7.5 %)
Up to 400 ml. 5 (6.6 %) 2 (5 %)
Up to 500 ml. 5 (6.6 %) 0
Anesthesia: SBA 62 (82 %) 21 (52.5 %)
ОКА 7 (9 %) 15 (37.5 %)
Endotracheal anesthesia 7 (9 %) 4(10 %)
Interoperation infusion volume: Up to 1600 ml. 64 (84.2 %) 27 (67.5 %)
More than 1600 ml. 12 (15.8 %) 3 (7.5 %)
Frozen plasma 6 (7.9 %) 1 (2.5 %)
Duration of operation almost were analogical (averaged 60 min.) in both group, however average volume of intraoperative hemorrhage in difference from I, in patients of group II did not exceed above 200 ml. (table 1).
According to the received dates of coagulogram, conducted in dynamics, pre- and postoperative parameters of screening tests of haemostasis at women from group I essentially differed from parameters of group II (table 2). At the postoperative period, we have noted the tendency to the increasing of hypercoagulation, despite on spent thromboprophylaxis with UFH. About this testified statistically significant (p < 0.05) changes of parameters of the haemostasis. At the group I average initial meanings of SFMC (4.1 mg. %) on admitting
to the hospital in comparison with control (2.8 ± 1.3 mg. %) was on 42.8 % more (p < 0.05). Dynamics analysis coagulogram at women from retrospective research (group II) on the 7th day of the postoperative period has shown, that at women with uterus myoma aged after 40 years, on performing uterine extirpation with its appendages or without of them against spent thromboprophylaxis with UFH improvements haemostasiological parameters did not occur or they had negative dynamics. It was accompanied by increasing of fibrinogen concentration on 53.5 % (4.3 ± 0.7 g/l), SFMC on 82.5 % (7.5 ± 0.6 mg %), with simultaneous shortening of ATTP on 15.6 % (31.8 ± 6.3 sec.) in comparison with initial level which was before operation (2.8 ± 0.6 g/l, 4.1 ± 1.1 mg. %, 37.7 ± 5.2 sec. accordingly).
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Estimation of haemocoagulation state in dynamics and risk factors of thrombotic complications at women with uterine...
In difference from group I, at group II patients, initial meaning of SFMC on admitting was increased insignificantly in comparison with control group. The highest meaning of SFMC were observed on the 3rd day (5.7 mg. %), which have decreased by 7th day (4.7 mg. %) at the postoperative period and in comparison with its initial level (3.8 mg. %) was on 50 % and in comparison
with control it was on 2.03 times more. As, in this group patients postoperative increasing of fibrinogen concentration not observed, although on 7th days of the postoperative period it’s noted shortening ofAPPT (31.8 ± 6.3) on 19.3 % less in comparison with its initial level (38.7 ± 3.1 sec.). Other indicators of a haemostasis were within norm.
Table 2. - Haemostasis state indices at women with uterine myoma in dynamics before and after hysterectomy against administering of UFH (M ± m)
Parameters Prior to 1st day 3rd day 7th day
1st group (n = 76)
Fibrinogen (g/l) 2.8 ± 0.6 3.0 ± 0.6 3.7 ± 0.7 4.3 ± 0.7
APTT (sec.) 37.7 ± 5.2 37.4 ± 5.2 35.3 ± 4.4 31.8 ± 6.3
PT (sec.) 15.6 ± 1.2 15.9 ± 1.2 15.9 ± 0.9 15.9 ± 1.0
PR (IU) 1.0 ± 0.1 1.1 ± 0.1 1.1 ± 0.1 1.1 ± 0.1
INR 1.0 ± 0.1 1.1 ± 0.1 1.1 ± 0.1 1.1 ± 0.1
SFMC (mg. %) 4.1 ± 1.1 5.3 ± 1.4 6.5 ± 1.6 7.5 ± 0.6
Т (10 9/l) 210.7 ± 44.5 202.3 ± 27.4 229.7 ± 76.7 215.0 ± 35.4
2nd group (n = 40)
Fibrinogen (g/l) 2.7 ± 0.6 3.0 ± 0.6 3.5 ± 0.6 3.9 ± 0.7**
APTT (sec.) 37.9 ± 3.9 37.8 ± 6.0 36.0 ± 5.2 31.2 ± 3.4**
PT (sec.) 15.7 ± 0.9 15.9 ± 1.4 15.8 ± 1.0 16.1 ± 1.5
PR (IU) 1.1 ± 0.1 1.1 ± 0.1 1.1 ± 0.2 1.1 ± 0.2
INR 1.1 ± 0.1 1.1 ± 0.1 1.1 ± 0.2 1.1 ± 0.2
SFMC (mg. %) 3.1 ± 1.8 5.0 ± 1.1** 4.5 ± 0.9** 4.7 ± 1.3**
Т (10 9/l) 218.4 ± 41.5 202.0 ± 29.3 196.3 ± 31.5 171.0
Control group (n = 20)
Parameters Meanings Parameters Meanings
Fibrinogen (2-4 g/l) 2.3 ± 0.5 PR 1.02 ± 0.3
APTT (32-42 sec.) 37.7 ± 3.1 INR 1.2
PT (14-17 sec.) 15.3 ± 0.7 SFMC (up to 3.5mg %) 2.8 ± 1.3
Note: ** — significant in comparision with initial dates (p > 0.05)
Postoperative period complicated with deep vein thrombosis at 2 women from group II on the 27th day after discharging from hospital, and at 3 there is occurred secondary adhesion of postoperative wound.
Discussion. The problem a genesis of haemostasis system changes at performance of surgical interventions, it is necessary to allocate two basic moments. First — importance of operative intervention as combination of the general (nonspecific) and local (specific, depending on a zone of operation and its character) pathophysiologic answer to programmed extreme influence of special type, which is the surgical stress [2; 8]. After operative interventions, performing on pelvic as response to trauma of tissues and vessels there are significant amount of thromboplastin substances will thrown in bloodstream, than at operations which performed in abdominal cavity. As organs in pelvic and the lower part of peritoneum are the most powerful sources of the thromboplastin after brain, lungs and kidney. The uterus and its appendages except thromboplastin substances contain in significant amount of anti-heparin factor, and also stimulators and inhibitors of fibrinolysis. Any operative intervention, or trauma, inflammatory processes lead to activation and ejection in blood of these substances in consequence occur infringement in curtailing system up to deep changes
towards hypercoagulation [1;7; 9]. As more expanded and dilated operative intervention in gynecologic patients, as more deeply it influences to the coagulation state.
The second moment this initial condition of systems and organs, integrated criterion, which character of system nonspecific mechanisms of adaptation is. This criterion in many respects defines predisposition and limited changes of haemostasis system during operation and at the early postoperative period [2; 11]. It is possible to suggest, that features adaptable and desadaptable changes in haemostasis system as response to developed haemodynamic and coagulation changes, caused with the existing disease, cause the initial parameters revealed by us at women aged after 40 years in coagulation part of haemostasis in the presence of myoma. Dominating point of view at the present according to which in an organism ofwomen in presence of myoma, it has created defined conditions to curling strengthening. At development in a uterine myoma throm-boplastic activity of its tissue increases, at the time there is decrease fibrinolytic activity of myomatous tissue at the expense of low concentration of the plazminogen activator. At the same time decrease of fibrinolytic activity in myomatous tissue to the amount of low concentration of the activator plazminogen established, that may be connected with low vascularization
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of tumor tissue [3; 4; 8]. However it is necessary to notice, that not always at women with a uterus myoma the thromboses, fortunately available in an organism a number of compensator mechanisms will develop. This results from the fact that on any pathological changes initially the organism answers with compensator the reactions, directed on protection of an organism from thrombogenesis. In process of progressing of pathological processes or against joining of concomitant factors (for example, age after 40 years, operative intervention, extragenital disease and i. e.) compensator mechanisms pass to decompensate mechanisms which are shown with chronic form disseminated intravascular coagulation (DIC). As show our dates, the preoperative haemostasis system is characterized with expressed changes of chronic form of DIC, which have noted at patients aged after 40 years. Despite on spent thromboprophylaxis with UFH, operative intervention at women from group I aggravated available complex infringements of haemostasis, which at them it has been revealed on
admitting, increasing of danger of development thrombotic complications in the postoperative period. Although, size of uterine myoma, volume, duration of operative performance were similar in both groups
Conclusion. Thus, as show our dates, the preoperative haemostasis system is characterizing with chronic form of DIC. Especially, these changes more significantly noted at patients aged after 40 years. Followingly, women elderly after 40 years are believe in thrombotic dangerous, carrying out of the expanded operative interventions allows to note them high group of the risk of development of thrombotic complications, demanding corresponding specific thromboprophylaxis. Thus, preventive maintenance with UFH at the present contingent patients does not allow to the result of coagulation potential in initial level, which at them were before operation. Hence, it is necessary to apply other methods of pharmacological preventive maintenance, for example low-molecular heparin.
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2. Jeffrey I. Weitz Unanswered questions in venous thromboembolism.//Thrombosis Research. - 2009. - S. 123., V. 4. - P. S2-S10.
3. Lee A. D., Stephen E., Agarwal S., Premkuma P. Venous Thrombo-embolism in Indiar.//Eur J Vasc Endovasc Surg. -2009. - V. 37. - P. 482-485.
4. Falcone Marco, Serra Pietro. Massive pulmonary embolism in a woman with leiomyomatous uterus causing pelvic deep venous thrombosis.//Ann Ital Med Int. - 2013. - V 20. - P. 104-107.
5. Nao S., Norihito Y., Tatsuru O., Noriyuki Y. Risk factors for perioperative venous thromboembolism: A retrospective study in Japanese women with gynecologic diseases.//Thrombosis Journal. - 2012. - V 43. - P. 8-17.
6. Nao S., Fumio K., Atsushi H., Takeshi H., Sachiko E. Intermittent pneumatic compression for prevention of pulmonary thromboembolism after gynecologic surgery.//Thrombosis Journal. - 2013. - V 45. - P. 3:18.
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Rakhimov Bakhodir, Tashkent Medical Academy, assistant, the department of hygiene of children and adolescents and hygiene of nutrition E-mail: [email protected]; [email protected]
Identification of risk factors for obesity in children and adolescents living in Tashkent city
Abstract: This article analyzes the identification of risk factors for obesity in children and adolescents living in Tashkent city in order to form the following prophylactic measures to prevent obesity in children and adolescents at an early age.
Keywords: children and adolescents, body mass index, obesity, risk factors, relative risk.
Obesity is a major public health problem in the twenty-first century. The use of integral approach to solving this problem will allow to take into account all its aspects — malnutrition, physical activity, as well as socio-economic and socio-political factors in this area [1, 12-44; 2, 32-36]. Considering them in terms of epidemic spread of obesity as a problem that goes beyond time and national borders,
in particular, an alarming increase in the frequency of obesity among children and adolescents, we can assume that the problem is a threat to the health and well-being of future generations [7, 29-33; 8, 277-284].
An important specificity of the last decade is the increase in the number and change in the balance of risk factors affecting the health of children and adolescents, the effective
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