The use of neuroaxial blockades in obstetric practice for thrombocytopenia

Thrombocytopenia is the second most frequent hematological complication of pregnancy after anemia. Among all thrombocytopenia during pregnancy, the most common is gestational thrombocytopenia. Gestational thrombocytopenia is not accompanied by coagulation disorders, has a minimal risk of bleeding, for both a mother and her fetus. Nevertheless, according to modern concepts, thrombocytopenia is a contraindication for performing obstetric neuroaxial blockades only on the basis of quantitative count of platelets, without taking into account coagulation status. These contraindications are derived from the general surgery and traumatology practice due to the high risk of developing epidural hematoma, but do not take into account the features, including physiological hypercoagulation, of pregnant patients. Refusal of the patient to perform a neuroaxial blockade during delivery on the basis of only counting the number of platelets often leads to an unreasonable increase in the risk / benefit ratio for both the mother and the fetus. Analysis of the research results indicates a change in attitude towards this problem towards a more loyal approach, taking into account the assessment of the coagulative status of a particular patient

Lexical combinability of adjectives and nouns expressing elements of appraisal

The present article aims to examine and analyze the nature of lexical combinability in the English language, namely collocates expressing elements of appraisal found in authentic online news article

Retrobulbar blockade during eyeball enucleation surgery in children with retinoblastoma

Retinoblastoma (RB) is a malignant tumor of the embryonic nerve retina.Purpose. To determine the effectiveness of retrobulbar blockade (RbB) with ropivacaine 0.5% for intra- and postoperative analgesia, as well as for the prevention of oculocardial reflex (OCR), postoperative nausea and vomiting (PONV) during enucleation.Material and methods. A prospective randomized controlled clinical trial was performed. Eighty patients aged 0 to 10 years were included, who were randomly assigned to the RbB group (retrobulbar blockade with ropivacaine 0.5% with general anesthesia) (n=40) and the GA control group (general anesthesia) (n=40).Results. There were no complications in the RbB group caused by the methodology. In the intraoperative period, the average dose of fentanyl in the RbB group was 4.7±0.7 μg/kg, which is significantly lower than in the OA group of 10.1±1.9 μg/kg (p<0.05). OCR in the RbB group was observed in 5% of cases versus 100% in the GA group (p=0.002). The average VAS score was 1.8 vs. 3.7 60 minutes after surgery (p<0.001). For the first time 12 hours after surgery, PONV was not observed in the RBB group, and in the control group it was observed in 45% of patients.Conclusion. The study revealed that intraoperative retrobulbar blockade with 0.5% ropivacaine solution in children with RB is effective and safe. Provides stable intraoperative hemodynamics and reduces the need for opioids. Promotes the prevention of OCD and PONV, as well as the improvement of postoperative analgesia during the operation of enucleation of the eyeball i n pediatric

Возможности тромбоэластографии при оценке безопасности нейроаксиальных блокад при гестационной тромбоцитопении (клиническое исследование)

Gestational thrombocytopenia (GT) is the most common type of thrombocytopenia during pregnancy. Unlike other types of thrombocytopenia, it is not accompanied by dysfunction of the cellular component of hemostasis. Currently, a quantitative decrease in platelets in GT is a contraindication to neuraxial blockades (NAB), which significantly reduces the quality of care in childbirth.The aim of the study is to determine the possibility of safe use of neuraxial blockades in gestational thrombocytopenia. A retrospective prospective study involved 70 patients who were performed delivery, depending on obstetric indications, either conservatively or surgically. The patients were divided into two groups. The main group (group No. 1) included 35 patients with gestational thrombocytopenia. The comparison group (group No. 2) consisted of 35 patients with a platelet content above 150×109/l. A comparative intergroup analysis of indicators of a general blood test, coagulogram, thromboelastography with a test for functional fibrinogen before childbirth and 2 days after delivery. The change in platelet content and its effect on the coagulation status of patients during pregnancy were retrospectively analyzed. A comparative assessment of the volume of blood loss during childbirth and the early postpartum period and the risk of complications of neuraxial blockade in patients with and without gestational thrombocytopenia was carried out.It was found that during gestational thrombocytopenia in the perinatal period, there is no decrease in coagulation potential, assessed by the results of coagulography and thromboelastography at a platelet level above 49×109/l. The investigated indicators of hemostasis did not have significant intergroup differences during pregnancy and childbirth. In the group of patients with gestational thrombocytopenia, the volume of blood loss during labor and the postpartum period did not differ from the group without thrombocytopenia, regardless of the method of delivery. The median blood loss after vaginal delivery in group 1 was 225 ml, in group 2 – 250 ml, with abdominal delivery – 572 ml and 386 ml – respectively. In this study, no complications of neuraxial blockade were observed in any of the groups.The results obtained suggest that in patients with gestational thrombocytopenia, even with a significant decrease in platelet content, it is possible to perform neuraxial blockades during labor, taking into account the clinical picture and the absence of coagulation disorders confirmed by thromboelastography.ВВЕДЕНИЕ Гестационная тромбоцитопения (ГТ) является наиболее распространенным видом тромбоцитопении во время беременности. В отличие от других видов тромбоцитопении она не сопровождается нарушением функции клеточного звена гемостаза. В настоящее время количественное снижение тромбоцитов при ГТ является противопоказанием к проведению нейроаксиальных блокад (НАБ), что значительно снижает качество оказания помощи в родах.ЦЕЛЬ ИССЛЕДОВАНИЯ Определить возможности безопасного применения НАБ при ГТ.МАТЕРИАЛ И МЕТОДЫ В ретроспективно-проспективном исследовании приняли участие 70 пациенток, родоразрешенных в зависимости от акушерских показаний консервативным или оперативным путем. Пациентки были разделены на две группы. В основную группу (группа № 1) вошли 35 пациенток с ГТ. Группу сравнения (группа № 2) составили 35 пациенток с содержанием тромбоцитов в крови выше 150×109/л. Проведен сравнительный межгрупповой анализ показателей общего анализа крови, коагулограммы, тромбоэластографии с выполнением теста на функциональный фибриноген перед родами и через 2 дня после родоразрешения. Ретроспективно проанализированы изменение содержания тромбоцитов и его влияние на коагуляционный статус пациенток в течение беременности. Проведена сравнительная оценка объемов кровопотери в родах и раннем послеродовом периоде и риска развития осложнений НАБ у пациенток с ГТ и без нее. Выявлено, что при ГТ в перинатальном периоде не происходит снижения коагуляционного потенциала, оцениваемого по результатам коагулографии и тромбоэластографии при уровне тромбоцитов выше 49×109/л. Исследованные показатели гемостаза не имели значимых межгрупповых различий в течение беременности и родов. В группе пациенток с ГТ объем кровопотери в родах и послеродовом периоде не отличался от группы без тромбоцитопении независимо от метода родоразрешения. Медиана кровопотери после родов через естественные родовые пути в группе № 1 составила 225 мл, в группе № 2 — 250 мл, при абдоминальном родоразрешении — 572 мл и 386 мл соответственно. В проведенном исследовании не зафиксировано каких-либо осложнений НАБ ни в одной из групп.ЗАКЛЮЧЕНИЕ Полученные результаты позволяют предположить, что у пациенток с ГТ даже при значительном снижении содержания тромбоцитов возможно выполнение НАБ в родах с учетом клинической картины и отсутствия нарушений коагуляции, подтвержденных тромбоэластографией

Blood saving possibilities in delivering patients with placenta increta

According to the results of systematic reviews of WHO, maternal mortality associated with massive bleeding almost reached 30% and has no tendency to decrease. Among the causes of massive obstetric hemorrhage, the most challenging ones are uterine hypotension and morbidity adherence placenta. Most severe complication for placentation is placenta increta in the uterine wall. Over the past 50 years, the number of cases with morbidity adherence placenta has increased tenfold. By all indications, this pathology has taken on the character of an epidemic and is one of the main causes for massive blood loss and blood transfusion, as well as peripartum hysterectomy. For surgical hemostasis in this pathology we apply X-ray vascular methods (temporary balloon occlusion of large vessels, vascular embolization), ligation of the iliac, uterine, ovarian arteries, various versions of distal hemostasis, including the use of uterine turnstiles, intrauterine and vaginal cylinders, compression sutures. However, data confirming the advantage of any specified methods are not enough. The risk of massive bleeding is high while using any of these methods. The article analyzes the blood saving methods existing at the present stage and possibility of these methods usage in obstetrics. Besides, we describe efficacy and safety of their use in massive blood loss, including the surgical treatment of morbidity adherence placenta

Выбор анестезиологического пособия при органосохраняющих операциях по поводу врастания плаценты

Abstract Placenta accreta (PAS-disorders) is one of the most serious complications of pregnancy, associated with the risk of massive uterine bleeding, massive hemotransfusion and maternal mortality. Peripartum hysterectomy is a common treatment strategy for patients with placenta accreta. Currently, there is a clear trend of changing surgical tactics in favor of organ-saving operations, but there are no studies devoted to anesthesiological support of such operations.The aim of the study is to substantiate an effective and safe method of anaesthesia in organ-saving operations for placenta accreta spectrum disorders.Materia l and methods The study involved 80 patients with a diagnosis of placenta accreta spectrum disorders, confirmed intraoperatively, who underwent organ-saving operations. The patients were randomized depending on the method of anesthesia into 3 groups: general anesthesia, spinal anesthesia with planned conversion to general after fetal extraction and epidural anesthesia with planned conversion to general also after fetal extraction. The comparison of intraoperative hemodynamics, efficiency of tissue perfusion, efficiency of antinociceptive protection at the stages of surgery was performed. A comparative analysis of the volume of blood loss and blood transfusion, time of patients activation in the postoperative period, severity of pain on the first day after surgery, duration of hospital stay before discharge and comparison of the assessment of the newborn according to Apgar score at first and fifth minute after extraction.Conclusion The study shows that the optimal method of anesthesia in organ-saving operations for placenta accreta spectrum disorders is epidural anesthesia with its planned conversion to general anesthesia with an artificial lung ventilation after fetal extraction. Such an approach to anesthesia allows to maintain stable hemodynamic profile with minimal vasopressor support, sufficient heart performance, providing effective tissue perfusion and a high level of antinociceptive protection at the intraoperative stage and reduce the volume of intraoperative blood loss and hemotransfusion. In the current study there were no differences in neonatal outcomes and duration of hospitalization depending on the method of anesthesia. The advantage of epidural anesthesia with its conversion to general anesthesia was earlier activation after surgery and lower intensity of postoperative pain syndrome.Резюме Врастание плаценты (placenta accreta, PAS-disorders) - одно из наиболее серьезных осложнений беременности, сопряженное с риском массивного маточного кровотечения, массивной гемотрансфузии и материнской смертности. Общепринятой стратегией лечения пациенток с врастанием плаценты является перипартальная гистерэктомия. В настоящее время отмечается отчетливая тенденция изменения хирургической тактики в пользу органосохраняющих операций, но исследований, посвященных анестезиологическому обеспечению таких операций, нет.Цель исследования Обоснование эффективного и безопасного способа анестезиологического пособия при органосохраняющих операциях по поводу врастания плаценты.Материал и методы В исследовании приняли участие 80 пациенток с диагнозом врастания плаценты, который был подтвержден интраоперационно. Всем пациенткам выполнены органосохраняющие операции. В зависимости от способа анестезиологического пособия были сформированы три группы: общей анестезии, субарахноидальной анестезии с плановой конверсией в общую после извлечения плода и эпидуральной анестезии с плановым переходом в общую также после извлечения плода. Выполнено сравнение интраоперационной гемодинамики, показателей эффективности тканевой перфузии, эффективности антиноцицептивной защиты на этапах операции. Проведен сравнительный анализ объемов кровопотери и гемотрансфузии, времени активизации пациенток в послеоперационном периоде, оценки выраженности болевого синдрома в 1-е сутки после операции, длительности пребывания в стационаре до выписки и сравнение оценки новорожденных по шкале Апгар на 1-й и 5-й минутах после извлечения.Зак лючение В исследовании показано, что оптимальным способом анестезиологического пособия при органосохраняющих операциях по поводу врастания плаценты является эпидуральная анестезия с ее плановой конверсией в общую анестезию с искусственной вентиляцией легких после извлечения плода. Подобный подход к анестезии позволяет поддерживать стабильность гемодинамического профиля и минимизировать вазопрессорную поддержку, сохранить достаточную производительность сердца и перфузию тканей. Антиноцицептивный эффект сочетания эпидуральной и общей анестезии был выше как на интраоперационном этапе, так и в послеоперационном периоде. Преимуществом эпидуральной анестезии с ее переходом в общую явилось снижение объемов интраоперационной кровопотери и гемотрансфузии. В проведенном исследовании не выявлено различий в неонатальных исходах и сроках госпитализации в стационаре в зависимости от способа анестезиологического пособия

Assessment of the quality of life in elderly and senile age patients with chronic heart failure

The present study aimed to compare the QOL in patients with heart failure with mid-range ejection fraction (HFmrEF) in different age groups, taking into account gender difference

Bilateral anterior ischemic optical neuropathy against the background of newly diagnosed antiphospholipid syndrome in a young patient

Objective – to present a clinical case of bilateral anterior ischemic opticoneuropathy against the background of newly diagnosed antiphospholipid syndrome in a young patient.Цель работы – представить клинический случай двусторонней передней ишемической оптиконейропатии на фоне впервые выявленного антифосфолипидного синдрома у молодой пациентки

Comparative morphological characteristics of the uteroplacental area in abnormal placentation

The aim. To carry out a comparative morphological characteristic of the uteroplacental area with abnormal placentation – pl. accreta, pl. increta, pl. percreta. Materials and methods. The study included 47 patients with atypical placentation; the comparison group included 10 healthy pregnant women with uterine scar after a previous caesarean section. A histological study of uteroplacental area samples was performed with hematoxylin and eosin, methylene blue staining. An immunohistochemical study with primary antibodies to cytokeratin 7 (CK7), Hif2a, vascular endothelial growth factor, α-SMA was carried out. The differences between the compared values were considered to be statistically significant at p < 0.05. The results of the study. Pl. accreta was determined in 12 (25.5 %), pl. increta – in 30 (63.9 %), pl. percreta – in 5 (10.6 %) patients. In all patients of the main group, the decidua was completely or partially absent in the area of abnormal placentation or was replaced by an uneven layer of fetal fibrinoid. Cases when placental villi unevenly penetrated into the thickness of myometrium in the form of “tongues” or “coves” bordered by fetal fibrinoid and often located intermuscularly were defined as pl. increta (n = 26). Cases with the placental villi ingrowth to the serous membrane were considered as pl.  percreta (n  =  5). In cases with deep variants of  ingrowth (pl. increta and pl. percreta) (n = 31), the villi were visualized in the lumen of the vessels and the thinning of the lower uterine segment with the presence of stretched muscle bundles was revealed. Aseptic necrosis of  the myometrium was  found: in 2 (16.7 %) of 12 women with pl. accreta, in 26 (86.7 %) of 30 women with pl. increta and in 5 (100 %) women with pl. percreta. There were no areas of necrosis in the myometrium of the women of comparison group. Conclusion. The appearance and increase of myometrial necrosis zones in response to an increase in the depth of placental villus ingrowth were detected. Myometrial necrosis zones could be the cause of activation of angiogenic factors and an important stimulus for the development of abnormal vascularization in placenta accreta spectrum

Современные представления о возможности применения антиангиогенных препаратов в качестве адъювантной терапии при неоваскулярной глаукоме

The article analyzes literature data on the use of modern antiangiogenic drugs in the treatment of neovascular glaucoma (NVG) presenting information on the mechanisms of action of inhibitors of vascular endothelial growth factor (VEGF) as adjuvant therapy in NVG, as well as the clinical effectiveness of these drugs in modulating the activity of ocular tissue healing processes after surgical treatment of glaucoma.The article also considers the results of studies on the use of VEGF inhibitors bevacizumab, ranibizumab, and aflibercept by different routes of administration. Usage of these drugs is indicated to require taking into account the contraindications, as well as the possibility of side effects associated with the intravitreal route of drug administration. The effects of anti-VEGF drugs in the treatment of NVG have been noted to be temporary and last 4–6 weeks, so the result of using a combination of these drugs and standard methods of treating the disease is assumed to be more pronounced and lasting.Выполнен анализ данных литературы о применении современных антиангиогенных лекарственных средств в лечении неоваскулярной глаукомы (НВГ). Приведены сведения о механизмах действия ингибиторов сосудистого фактора роста эндотелия сосудов (VEGF) в качестве адъювантной терапии при НВГ, а также клинической эффективности этих препаратов в отношении модулирования активности процессов заживления тканей глаза после хирургического лечения глаукомы.Рассмотрены результаты исследований применения ингибиторов VEGF: бевацизумаба, ранибизумаба и афлиберцепта при разных путях введения. Указано, что при использовании этих препаратов следует учитывать противопоказания к их применению, а также возможность возникновения побочных эффектов, связанных с интравитреальным путем введения. Отмечено, что эффекты анти-VEGF препаратов в лечении НВГ носят временный характер и длятся обычно 4–6 недель, в связи с этим предполагается, что более выраженным и длительным может быть результат использования комбинации этих лекарственных средств и стандартных методов лечения заболевания