RU2418595C1 - Method of preventing inflammatory and thromboembolic complications after cesarean section operation in women from high risk group - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to obstetrics and gynecology and can be used for prevention of thromboembolic and inflammatory complications after Cesarean section operation in women from high risk group. For this purpose, intraoperationally 12 and 24 hours after delivery antibiotics are introduced. In addition, 12 hours after operative delivery under skin of anterior abdominal wall introduced are 40 mg of enoxaparin sodium. After that, 24 and 48 hours after introduction of the first dose also subcutaneously in area of anterior abdominal wall introduced are another 40 mg of enoxaparin sodium. Totally 3 injections during 3 days. ^ EFFECT: method makes it possible to reduce frequency of thromboembolic and inflammatory complications in women from high risk group after Cesarean section operation with minimal course of treatment. ^ 3 ex, 6 tbl

Description

The invention relates to medicine, in particular to obstetrics.

Delivery by cesarean section (CS) in high-risk patients helps to reduce perinatal and maternal mortality, but it is associated with a higher risk of developing inflammatory and thromboembolic complications.

It is a well-known method for the prevention of inflammatory complications after cesarean section surgery by the use of antibacterial drugs. The widespread use of antibiotics at one time led to a decrease in the frequency of severe forms of infectious postpartum diseases. However, official statistics only consider severe forms of endometritis. The peculiarity of the course of postpartum endometritis at present, according to most domestic and foreign authors, is the erased clinical manifestations of the inflammatory process, which do not correspond to the depth of morphological changes and do not reflect the severity of the state of the puerpera. Other forms of the pathological course of the postpartum period are recorded under the diagnoses of subinvolution of the uterus, hematometer, lochiometer, pathological lactostasis, infiltration of sutures of the anterior abdominal wall.

This requires obstetricians to use drugs in the postoperative period that would minimize inflammatory and thromboembolic complications, while avoiding polypharmacy.

Recent studies have shown that the processes of hemocoagulation and inflammation are closely related and play a key role in the development of many diseases. Activation of the blood coagulation system in response to inflammation serves as a protective mechanism aimed at limiting the site of tissue damage and preventing the further spread of the pathogenic factor in the body. Thrombus formation can be an impetus for an inflammatory response and, conversely, inflammation leads to a pronounced activation of blood coagulation processes. Therefore, the impact on the hemostatic system can, on the one hand, prevent thrombosis, and on the other hand, reduce or even prevent the development of an inflammatory reaction.

It should be noted that the use of low molecular weight heparins (LMWH), which include enoxaparin sodium, has recently been quite widespread in obstetric and surgical practice, mainly for the prevention of thromboembolic complications. In particular, in the postpartum period, the duration of the administration of enoxaparin sodium is at least 7-10 days and depends on the degree of risk of venous thrombosis and the method of delivery. After physiological birth, the duration of the enoxaparin sodium course is on average 7 days, 20-40 mg once a day. After the use of obstetric operations (cesarean section, obstetric forceps, manual examination of the walls of the postpartum uterus), due to the increased risk of thrombotic complications in the postpartum period, enoxaparin sodium was prescribed for 7-10 days at 40 mg once a day (S. B. Kerchelaeva , L.A. Ozolin. Problems of pregnancy. 2002, No. 5).

In cancer patients, long-term (at least 1-3 months) prevention of deep vein thrombosis with enoxaparin is effective, since the thrombophilic state after surgery lasts longer, which is associated not only with the release of a large number of thromboplastic substances into the blood during surgery, but also with the nature underlying disease (A.D. Makatsaria, V.O. Bitsadze and others. Russian Medical Journal, 2008, Volume 13, No. 17).

The objective of the invention is to minimize inflammatory and thromboembolic complications in the postpartum period after cesarean section in women at high risk.

The problem is achieved by the use in the postoperative period of 40 mg of enoxaparin sodium 1 time per day for 3 days.

In practice, the method is as follows: after 12 hours after surgical delivery, 40 mg of enoxaparin sodium is administered under the skin of the anterior abdominal wall. Then, 24 and 48 hours after the administration of the first dose of enoxaparin sodium, another 40 mg of enoxaparin sodium is also administered subcutaneously in the region of the anterior abdominal wall. Total 3 injections over 3 days.

The following examples demonstrate the proposed method:

Example 1: puerpera F., 35 years old, history of childbirth No. 1176.

From the anamnesis: the mother has hypertension, thrombophlebitis, thromboembolism. In childhood, chickenpox, moderate myopia, laser retinal coagulation in 2007, pneumonia, and concussion. Gynecological diseases: acute salpingoophoritis, ureaplasmosis, fibrocystic mastopathy. Generative function: I pregnancy - medical abortion in the period of 5-6 weeks., II - this, came on its own. Clinical diagnosis: Pregnancy 38-39 weeks. Pelvic presentation. Myopia is moderate. Peripheral chorionopathy, retinal dystrophy. Condition after laser coagulation of the retina. Moderate oligohydramnios. Heterozygous form of PAI mutation. Birthright at 35 years old.

05/14/09 - the operation was performed in the planned order: transverse suprapubic laparotomy, cesarean section in the lower uterine segment by transverse section. A girl weighing 3330 was recovered. There were no complications during the operation. Total blood loss was 600 ml.

12 hours after surgical delivery, 40 mg of enoxaparin sodium was administered under the skin of the anterior abdominal wall. Then, 24 and 48 hours after the first dose was administered, another 40 mg of enoxaparin sodium was also injected subcutaneously into the region of the anterior abdominal wall. Total 3 injections over 3 days.

General blood analysis: Indicator 1 day after CS (05/15/09) 3 days after the COP (05/18/09) Normative values Erythrocytes, 10 ¹² / l; 4.03 3.8 3.8-5.1 White blood cells, 10 ⁹ / l; 18.7 9.3 4,5-11,0 Platelets, 10 ⁹ / L; 142 181 150-400 ESR, mm / h; 17 27 0-20

Hemostasiogram: Indicator 1 day after CS (05/15/09) 3 days after the COP (05/18/09) Normative values The concentration of fibrinogen, g / l; 5.5 4.9 1.8-6.0 APTT, sec; 36 32 20-40 Prothrombin index,%; 116 117 80-125 Thromboelastogram: r + k, mm 16 + 8/24 12 + 6/18 19-27 mA, mm; 49 43 48-52 ITP, mustache units; 12 10.5 6-12

On the 5th day after surgical delivery, an ultrasound examination of the pelvic organs was performed: The uterine cavity is slightly expanded due to blood clots. No placental tissue remains. The suture area on the uterus and on the anterior abdominal wall is without features.

The postpartum woman was discharged home on the 7th day after surgery in a satisfactory condition.

Example 2: puerpera P., 30 years old, history of childbirth No. 202.

From the anamnesis: in childhood chickenpox, measles. Varicose veins of the lower extremities from 18 years. Gynecological diseases denied. This pregnancy is the first, it came on its own.

Clinical diagnosis: Pregnancy 38-39 weeks. Head presentation. Heterozygous form of PAI mutation. Varicose veins. Obesity II degree. Birthright 30 years.

04/02/09 - the operation was performed in the planned order: transverse suprapubic laparotomy, cesarean section in the lower uterine segment by transverse section. Autoerythrocyte reinfusion. A boy weighing 3305 was recovered. There were no complications during the operation. Total blood loss was 600 ml.

12 hours after surgical delivery, 40 mg of enoxaparin sodium was administered under the skin of the anterior abdominal wall. Then, 24 and 48 hours after the first dose was administered, another 40 mg of enoxaparin sodium was also injected subcutaneously into the region of the anterior abdominal wall. Total 3 injections over 3 days.

General blood analysis: Indicator 1 day after the COP (04/02/09) 4 days after the COP (04/06/09) Normative values Erythrocytes, 10 ¹² / l; 4.16 4.08 3.8-5.1 White blood cells, 10 ⁹ / l; 17,2 15.3 4,5-11,0 Platelets, 10 ⁹ / L; 267 329 150-400 ESR, mm / h; 31 25 0-20

Hemostasiogram: Indicator 1 day after the COP (04/02/09) 3 days after the COP (04/06/09) Normative values The concentration of fibrinogen, g / l; 5.7 5.5 1.8-6.0 APTT, sec; 32 32 20-40 Prothrombin index,%; 108 104 80-125 Thromboelastogram: r + k, mm; 14 + 8/22 12 + 6/18 19-27 mA, mm; 48 45 48-52 ITP, mustache units; 12.5 10,2 6-12

On the 5th day after surgical delivery, an ultrasound examination of the pelvic organs was performed: The uterine cavity is not expanded. No placental tissue remains. The suture area on the uterus and on the anterior abdominal wall is without features.

The postpartum woman was discharged home on the 7th day after surgery in a satisfactory condition.

Example 3: puerpera K., 38 years old, history of childbirth No. 1165.

From the anamnesis: In childhood, chickenpox, rubella, varicose veins of the lower extremities from the age of 30. Gynecological diseases: cervical ectopia - cryodestruction in 2005. Generative function: I pregnancy in 1995 - timely spontaneous delivery without any special features, II pregnancy - nurse-abortion - without complications, this pregnancy III - came on its own.

Clinical diagnosis: Pregnancy 38-39 weeks. Head presentation. Edema of pregnant women. Chronic venous insufficiency. Varicose veins of the legs, perineum and vagina. Rh-negative blood without sensitization. Heterozygous form of the MTHFR mutation and homozygous PAI. Complicated obstetric and gynecological history.

05/19/09 - the operation was performed as planned: transverse suprapubic laparotomy, cesarean section in the lower uterine segment by transverse section. A girl weighing 2620 was recovered. There were no complications during the operation. Total blood loss was 700 ml.

12 hours after surgical delivery, 40 mg of enoxaparin sodium was administered under the skin of the anterior abdominal wall. Then, 24 and 48 hours after the first dose was administered, another 40 mg of enoxaparin sodium was also injected subcutaneously into the region of the anterior abdominal wall. Total 3 injections over 3 days.

General blood analysis: Indicator 1 day after CS (05/20/09) 3 days after the COP (05/22/09) Normative values Erythrocytes, 10 ¹² / l; 3.24 3.19 3.8-5.1 White blood cells, 10 ⁹ / l; 12,43 9.26 4,5-11,0 Platelets, 10 ⁹ / L; 180 226 150-400 ESR, mm / h; 40 26 0-20

Hemostasiogram: Indicator 1 day after CS (05/20/09) 3 days after the COP (05/22/09) Normative values The concentration of fibrinogen, g / l; 5,0 4.8 1.8-6.0 APTT, sec; thirty thirty 20-40 Prothrombin index,%; 111 119 80-125 Thromboelastogram: r + k, mm; 10 + 5/15 15 + 8/23 19-27 mA, mm; fifty 45 48-52 ITP, mustache units; 20,0 10,2 6-12

On the 5th day after surgical delivery, an ultrasound examination of the pelvic organs was performed: the uterine cavity was expanded slightly due to blood clots. No placental tissue remains. The suture area on the uterus and on the anterior abdominal wall is without features.

The postpartum woman was discharged home on the 7th day after surgery in a satisfactory condition.

Under our supervision, there were 15 puerperas of the main group who underwent cesarean section surgery with subsequent administration of enoxaparin sodium in the postoperative period and 20 puerperas of the comparative group who underwent cesarean section surgery without subsequent administration of enoxaparin sodium in the postoperative period. Among the risk factors for thromboembolic complications are hereditary thrombophilia, varicose veins, arterial hypertension. A risk factor for the occurrence of inflammatory diseases for both groups was a caesarean section.

All postpartum women of both groups received a short intravenous prophylactic course with antibiotics, which were administered intraoperatively and 12 and 24 hours after delivery. In the postoperative period, puerperas were prescribed NMH-enoxaparin sodium in the main group to prevent thromboembolic complications. Women in the comparative group did not receive LMWH. Clinically, such indicators as the level of platelets in women of the main group on 3-4 days after surgery was 280.5 ± 13.27 · 10 ⁹ / l, in women of the comparative group - 230.6 ± 10.54 · 10 ⁹ / l, ITP - 11.6 ± 0.45 whiskers units and 14.5 ± 0.34 whiskers units, respectively, the appearance of fibrin degradation products (PDF) is 56.5 ± 1.8 μg / L and 175.2 ± 6.1 μg / L, respectively. There were no complications during the course of prophylaxis with enoxaparin sodium.

Comparing the effectiveness of enoxaparin sodium in the postoperative period, it should be noted that its use is pathogenetically justified in connection with the presence of antithrombotic and anti-inflammatory properties in the drug.

Claims (1)

A method for the prevention of thromboembolic and inflammatory complications after cesarean section in women at high risk, characterized in that antibiotics are administered intraoperatively 12 and 24 hours after delivery, in addition, 40 mg of enoxaparin sodium are injected under the skin of the anterior abdominal wall 12 hours after surgical delivery then, after 24 and 48 hours after the first dose, an additional 40 mg of enoxaparin sodium is also injected subcutaneously into the anterior abdominal wall, for a total of 3 injections over 3 days.