RU2704464C1 - Method for correction of blood loss in operative resolution of pregnant women with ingrown placenta - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to obstetrics and gynecology, anaesthesiology-resuscitation, transfusiology, and can be used for correction of blood loss in surgical resolution of a pregnant woman with ingrown placenta. Autoplazmodonorship is carried out with an autoplasma blank by plasmapheresis during pregnancy and its transfusion by a pregnant woman during operative delivery. Billet of autoplasma is performed by single-needle membrane plasmapheresis procedure, carrying out 3 procedures in terms of 24 to 30 weeks of pregnancy with interval of not less than 7 days between them. Each procedure is used to prepare 450–550 ml of autoplasma by 8–10 cycles per minute. One cycle involves taking 10 ml of blood, which is passed through a plasma filter with a membrane having a pore diameter of not more than 0.4 mcm, returning the blood cell elements back into the blood stream and obtaining 3–3.5 ml of blood plasma filtrate. After receiving 100 ml of autoplasma 100 ml of the balanced solution of electrolytes are introduced into the pregnant woman. During operative delivery at the stage of massive blood loss transfusion of prepared autoplasma is carried out simultaneously with collection, washing and reinfusion of auto-erythrocytes, Tranexam 1,000 mg is introduced.

EFFECT: method provides improved results of operative delivery of patients with ingrown placenta due to timely, adequate and safe autologous plasma and erythrocytes.

1 cl, 6 tbl, 2 ex

Description

The invention relates to medicine, namely to obstetrics and gynecology, anesthesiology-resuscitation, transfusiology, can be used in organ-preserving operations in patients with placental ingrowth to reduce the risk of donor blood transfusions and improve treatment outcomes for this patient population.

Bleeding is currently one of the leading causes of maternal mortality. According to a WHO systematic review published in 2014, about 73% of all maternal deaths between 2003 and 2009 were due to obstetric causes, of which 27.1% were bleeding [Global causes of maternal death: a WHO systematic analysis / Lale Say, Doris Chou, Alison Gemmill et al. // Lancet Glob Health. - 2014. - T. 2, No. 6. - P. 323-333. DOI: 10.1016 / S2214-109X (14) 70227-X]. In the last decade, there has been an increase in the number of placentation disorders, including placental growths, leading to massive postpartum hemorrhage and blood transfusion [Clinical Analysis of Postpartum Hemorrhage Requiring Massive Transfusions at a Tertiary Center. / Hu J, Yu ZP, Wang P et al. // Chin Med Journal. - 2017. - No. 130. - P. 581-585. DOI: 10.4103 / 0366-6999.200545].

According to published data, the volume of intraoperative blood loss during operations for placenta ingrowth varies from 2000.0 ml to 7800.0 ml, depending on the depth of invasion [Silver R.M. Placenta accreta spectrum: accreta, increta, and percreta. / R.M. Silver, K.D. Barbour // Obstet Gynecol Clin North Am. 2015 Jun; 42 (2): 381-402. DOI: 10.1016 / j.ogc.2015.01.01.014].

An analysis of the use of donor blood components in a group of patients with varying degrees of placenta invasion during and after cesarean section shows that transfusion of blood products is performed in more than 73% of cases [Perioperative and transfusion outcomes in women undergoing cesarean hysterectomy for abnormal placentation / K.F. Brookfield, L.T. Goodnough, D.J. Lyell et al // Transfusion. - 2014 Jun; 54 (6): 1530-1536. DOI: 10.1111 / trf.12483]. However, massive allogeneic blood transfusions increase the length of stay in a resuscitation and hospital bed, morbidity and mortality due to complications that develop at different times after blood transfusion [Clinical Management Guidelines for Obstetrician-Gynecologists. Postpartum Hemorrhage / Practice bullet // American College of Obstetricians and Gynecologists (ACOG) - 2017; 183: 168-178].

The issues of immunological and infectious safety of donor media remain unresolved today. Despite significant progress in laboratory screening of donated blood for markers of blood-borne infections, the risk of transmission of these infections remains in both developed and developing countries [Zhiburt EB "New" blood-borne infections and their prevention, - Vestnik "MEDSI", - 2016: 16; 33-39].

According to the United States Food and Drug Administration for 2012-2016. in 34%, the cause of fatal complications associated with transfusion of blood and its components was the development of TRALI (Transfusion Related Acute Lung Injury) syndrome. Hemolytic (non-AB0) complications accounted for 10% of deaths, hemolytic (AB0) - 8%. In 10% of cases, death occurred as a result of bacterial infection, in 30% - as a result of circulatory overload. Anaphylaxis as a cause of death was recorded in 6% and in 2% of cases the cause of death was shock, not associated with anaphylaxis.

In connection with the foregoing, the most promising methods of substitution transfusion therapy for predicted massive blood loss can be considered preoperative autoplasma donation and intraoperative reinfusion of washed red blood cells.

Currently, the use of autoplasm donation is regulated by the Federal Clinical Recommendations "Autoplasm donation in obstetrics" of the Russian Society of Obstetricians and Gynecologists, FSBI "Scientific Center of Obstetrics, Gynecology and Perinatology" of the Ministry of Health of the Russian Federation from 2013. In accordance with these recommendations, a patient with possible massive blood loss within 32-37 weeks is autoplasma harvested by intermittent or hardware plasmapheresis once or twice with a break of a week. Both methods involve the simultaneous collection of up to 500 ml of blood, followed by its separation into plasma and erythrocyte mass with replacement of the volume of exfused blood with a colloidal plasma-replacing solution (6% HES) in a volume of 500 ml.

However, simultaneous sampling of 500 ml of blood in a pregnant patient for a period of 32-37 weeks leads to a decrease in BCC, systemic hemodynamic disorders, which can adversely affect the uteroplacental and fetal blood flow. The recommended replacement of exfused blood with a 6% hydroxyethyl starch solution contradicts current recommendations for the use of this drug. Currently, in connection with the identified serious complications, the only indication for the use of a 6% hydroxyethyl starch solution is acute massive blood loss in the case of ineffective crystalloid solutions. The use of 6% HES during pregnancy is possible only in situations where the potential benefit of using the drug in the mother outweighs the possible risk to the fetus [Letter of Roszdravnadzor of the Ministry of Health of the Russian Federation No. 01i-373/19 of 02/12/2019 “On new data on the safety of the drug Refortan HES 6%, containing hydroxyethyl starch as an active ingredient "].

A known method of using autoplasmodorrhea and acute normovolemic hemodilution in abdominal delivery (RU 2410129, C1), which we have chosen as a prototype. Its essence is as follows. Before surgical delivery, hemodilution is performed by exfusion of whole autologous blood. An autoplasma prepared by the method of intermittent plasmapheresis with a gestation period of 32 to 38 weeks is used as a volume-replacing component. Additionally, 6% HES 500 ml is used as a volume-replacing drug. Then, upon achievement of surgical hemostasis, reinfusion of harvested whole blood is carried out in an amount of 5-10 ml / kg body weight. The method allows for adequate replenishment of operational blood loss by stabilizing the coagulation potential of the blood and restoring the red blood cell population in the vascular bed, which prevents the risk of complications from predicted blood loss during delivery due to the observance of the sequence of measures taken.

The disadvantages of this method, limiting its use for blood preservation during surgical treatment of patients with placental ingrowth, include the following:

1. Due to the physiological increase in plasma volume in relation to the erythrocyte pool by the end of pregnancy, the woman is already in a state of hemodilution and a relative decrease in hemoglobin concentration. Conducting acute preoperative hemodilution can lead to an even greater decrease in hemoglobin concentration, the development or aggravation of anemia, a decrease in the oxygen-transporting function of the blood, and a deterioration in the condition of the mother and fetus due to the development of circulatory and metabolic disorders.

2. The permissible volume of exfused autologous blood cannot cover the need for blood components in case of massive blood loss, typical for surgical treatment of placental ingrowth.

3. According to the order of the Ministry of Health of the Russian Federation No. 183 "On the approval of the rules for the clinical use of donated blood and (or) its components", acute preoperative hemodilution is impossible at a hemoglobin concentration of less than 110 g / l, hematocrit below 33%, which also limits the application of this method , since by the end of pregnancy, in most patients, hemoglobin is below 110 g / l.

4. In accordance with the Letter of Roszdravnadzor of the Ministry of Health of the Russian Federation No. 01i-373/19 dated 12.02.2019 “On new safety data for the drug Reftan HES 6% containing hydroxyethyl starch as the active substance”, the current use of 6% HES as a replacement solution for acute hemodilution in pregnant women is not allowed.

5. When using intermittent centrifugal plasmapheresis used in the prototype method, most of the platelets and leukocytes fall into the harvested plasma and die during subsequent freezing.

The objective of the invention is to develop the most effective and safest method of blood saving during delivery of patients with placental implantation, which allows to reduce the volume of donor blood transfusions, the risk of post-transfusion complications and improve the outcome of surgical treatment.

The task is achieved by combining the original methods of autoplasma donation and intraoperative hardware reinfusion of washed red blood cells.

The medical-technical result achieved by the implementation of the invention is

- improving the results of surgical delivery of patients with placental growth by timely, adequate and safe replenishment of blood loss through a combination of original methods of plasma donation and red blood cells;

- reducing the number of post-transfusion complications by reducing or eliminating the number of donor blood transfusions, as well as the introduction of the drug Reftan HES 6%;

- prevention of the development of circulatory and metabolic disorders in the mother and fetus by maintaining the hemoglobin concentration, oxygen-transporting function of the blood, eliminating anemia in the pregnant woman using the original scheme of preoperative blood saving during autoplasma donation in combination with intraoperative hardware reinfusion of washed red blood cells.

The invention consists in the following.

To correct blood loss with the operative resolution of a pregnant woman with placental ingrowth, autoplasma donation is used with autoplasma harvesting by plasmapheresis during pregnancy and transfusion of the pregnant woman during surgical delivery. In this case, autoplasma harvesting is carried out by the method of single-needle membrane plasmapheresis, performing 3 procedures in the period from 24 to 30 weeks of pregnancy with an interval of at least 7 days between them.

Moreover, 450-550 ml of autoplasma is harvested for each procedure, for which 8-10 cycles per minute are performed. In one cycle, 10 ml of blood is taken, which is passed through a plasma filter with a membrane having a pore diameter of not more than 0.4 μm, the blood cell elements are returned back to the bloodstream and 3-3.5 ml of blood plasma filtrate is obtained.

After receiving every 100 ml of autoplasma, 100 ml of a balanced electrolyte solution is administered to the pregnant woman.

During surgical delivery at the stage of massive blood loss, transfused autoplasma is transfused simultaneously with the collection, washing and reinfusion of autoerythrocytes, 1000 mg of Tranexam is administered.

The method is as follows.

Autoplasma harvesting is carried out after the second screening (18-22 weeks of pregnancy) in the case of confirmation of the ultrasound diagnosis of "placental ingrowth" in order to prepare for delivery, which may be accompanied by massive blood loss.

After 22-23 weeks, the patient enters the hospital. A set of diagnostic measures is carried out: a general blood test, a biochemical blood test, a coagulogram, an ECG, dopplerography of the uteroplacental and fetal blood flow. In the period from 24 to 30 weeks, three consecutive autoplasma harvesting procedures are performed using the single-needle membrane plasmapheresis method with an interval of at least 7 days between the procedures.

Before the start of the plasmapheresis procedure, continuous monitoring of blood pressure, heart rate, ECG, SpO2 (saturation of hemoglobin with oxygen) of the patient is established.

If the procedure is performed after 28 weeks of pregnancy (auto-preparation No. 3), fetal cardiotocography (CTG of the fetus) is performed throughout the procedure.

The process of instrumental membrane plasmapheresis occurs cyclically, approximately 8-10 cycles per minute. Blood flow - 10 ml per cycle passes through a porous dacron membrane with a pore diameter of not more than 0.4 μm, which can pass the liquid part of the blood and does not pass the shaped elements (for example, the ROSA plasma filter).

A chamber pump of the "ventricular" type with inlet and outlet valves cyclically pumps blood and directs it into the plasma filter, and then returns cell elements that have not passed through the pores back into the bloodstream. The plasma filtrate in this case is 3-3.5 ml, it enters a special bag for collecting plasma.

To prevent thrombosis of the plasma filter, a blood preservative 4% sodium citrate solution is used in a volume of 0.5 ml per cycle. After separation of every 100 ml of autoplasma in order to prevent hemodynamic disturbances, 100 ml of a balanced solution of electrolytes is introduced in a total dose equivalent to the dose of exfused autoplasma. The volume of autoplasma harvested in one session is 450-550 ml.

Harvested autoplasma is subjected to shock freezing at a temperature of -60 degrees Celsius and subsequently stored at a temperature of -30-35 degrees Celsius.

On the next day after the plasmapheresis procedure, the patient undergoes dopplerography of the uteroplacental and fetal blood flow. Three days after the plasmapheresis procedure, a control analysis of the coagulogram, the concentration of total protein, hemoglobin, and red blood cells is performed.

Autoplasma is prepared for transfusion before surgery. At the stage of metroplasty (the stage of massive blood loss), the collection, washing and reinfusion of autoerythrocytes begin. At the same time, transfusion of harvested autoplasma is started in order to maintain bcc and concentration of blood coagulation factors. To prevent the activation of fibrinolysis, tranexamic acid (Tranexam) 1000 mg is administered.

In contrast to the existing methods of blood saving during delivery of patients at high risk of developing massive blood loss, the proposed method provides a safer autoplasma harvesting mode, which allows to prepare up to 450-550 ml in one session and up to 1350-1650 ml of autoplasma in three sessions without dangerous for the pregnant patient and fetal changes in bcc and hemodynamic disturbances.

A cyclic blood sampling of 10 ml with a return to the bloodstream after plasma separation up to 6.5-7 ml through one vascular access with the replacement of every 100 ml of autoplasma with an equivalent amount of a balanced electrolyte solution allows the body to gradually adapt the volume of the vascular bed to the changing volume of circulating blood.

As a result, the application of the proposed method allows not only to reduce the volume of replacement infusion therapy, but also to completely abandon currently prohibited colloidal blood substitutes, such as 6% hydroxyethyl starch, an obligatory component of the previously proposed blood-saving methods in obstetric practice.

The positive side of the proposed method is the preservation in the bloodstream of the patient of all shaped elements (platelets, white blood cells) and, as a result, the absence of a significant effect on platelet hemostasis and the immune status of the pregnant woman, since the filtering membrane has a pore diameter significantly smaller than the size of all shaped elements .

In addition, single-needle membrane plasmapheresis is a completely enclosed extracorporeal circuit that excludes microbial contamination and “cross" return of the patient red blood cells to another donor, in contrast to previously proposed methods using intermittent centrifugal plasmapheresis.

Thus, autoplasma harvested begins to be administered simultaneously with the administration of washed red blood cells when massive blood loss begins, fully replenishing red blood cells, blood coagulation factors and the volume of circulating blood.

At the same time, volume overload of the cardiovascular system is excluded (it can be if plasma transfusion is started before the onset of blood loss). In addition, if plasma transfusion begins later than red blood cell reinfusion, coagulopathy may develop, since there are no coagulation factors in the washed red blood cells.

The trigger for the start of the introduction of autoplasma is the beginning of the collection, washing and reinfusion of autoerythrocytes - these media are introduced simultaneously.

To confirm the feasibility of implementing the stated purpose and achieving the specified medical and technical result, we present the following data.

Example 1

Patient N., 39 years old. Height 168 cm, weight 83 kg, BMI 29.4.

Diagnosis: Second pregnancy in head presentation. The threat of premature birth. Placenta previa. Postoperative uterine scar, the growth of the placenta in the scar. Gestational arterial hypertension. Mild anemia.

The diagnosis was established at 22 weeks of gestation according to the results of ultrasound. At the 24th, 26th, 28th weeks of gestation, 3 autoplasma blanks were performed in a total volume of 1600.0 ml (550 ml, 500 ml, 550 ml) (18% bcc). When plasmapheresis was carried out, 10 cycles per minute were carried out, 10 ml of blood was taken in one cycle, which was passed through a plasma filter with a membrane having a pore diameter of not more than 0.4 μm, the blood cell elements were returned back to the bloodstream and 3 ml of blood plasma filtrate was obtained.

Emergency delivery in the period 33-34 weeks due to the appearance of bloody discharge from the genital tract.

Anesthesiological aid: combined endotracheal anesthesia.

Scope of operation: laparotomy in the lower midline with a bypass of the navel. Caesarean section. Excision of uterine aneurysm. Metroplasty. Sterilization. Intraoperative hardware blood reinfusion.

At the stage of excision of uterine aneurysm and metroplasty in connection with the development of massive bleeding, intraoperative collection, washing and reinfusion of autoerythrocytes with simultaneous transfusion of autoplasma were started, tranexam was administered 1000 mg.

The volume of intraoperative blood loss amounted to 3300.0 ml (41% of bcc). The total volume of infusion-transfusion therapy is 4580.0 ml, including intraoperative reinfusion of washed autoerythrocytes 980.0 with hematocrit 60%, autoplasm transfusion 1600.0, crystalloids 2000.0. The duration of the operation is 2.5 hours. Intraoperative diuresis 200.0 ml.

The effectiveness of the intraoperative infusion-transfusion therapy is confirmed by hemodynamic parameters and laboratory data (table No. 1).

Coagulation disorders at the intraoperative stage and in the early postoperative period were not detected (table No. 2).

2 hours after the operation, enteral nutrition and activation of the patient are started. After 12 hours, the patient was transferred from the intensive care unit to the postpartum unit. Discharged on the 5th day in a satisfactory condition, laboratory data on the 3rd postoperative day and at discharge are presented in table No. 3.

The postoperative period was uneventful. Additional blood transfusions in the postoperative period were not required. Given the presence of post-hemorrhagic clinically insignificant anemia of moderate severity, the patient received iron preparations. Thus, the application of the proposed method of blood saving allowed to avoid donor blood transfusions, despite the massive (41% of BCC) blood loss. In the absence of donor blood transfusions, immunosuppression that inhibits erythropoiesis does not develop. Intraoperative reinfusion of one's own erythrocytes ensures their maximum viability and, unlike canned donor erythrocytes, more effectively support oxygen transport function. Harvesting of 1600.0 autoplasma before surgery ensures its rapid availability in a critical situation and fully covers the need for plasma with massive blood loss reaching 40-50% of bcc.

Example No. 2.

Patient N., 40 years old. Height 160 cm, weight 73 kg, BMI 28.52.

Diagnosis: 5th pregnancy. Complete placenta previa. Insufficient scar on the uterus after two operations, cesarean section. The growth of the placenta in the scar. Mild anemia.

The diagnosis was made at 22 weeks of gestation according to ultrasound. At the 24th, 27th and 30th weeks of gestation, 3 autoplasis blanks were performed in a total volume of 1,400 ml (500 ml, 450 ml, 450 ml) (20.6% of the bcc). When plasmapheresis was carried out, 8 cycles per minute were carried out, while 10 ml of blood was taken in one cycle, which was passed through a plasma filter with a membrane having a pore diameter of not more than 0.4 μm, blood cell elements were returned back to the bloodstream and 3.5 ml was obtained blood plasma filtrate.

The dynamics of the indicators of red blood, the level of total protein and the indicators of the coagulogram before and after harvesting autoplasma No. 3 in a volume of 450.0 ml, carried out at 30 weeks of gestation, are presented in table No. 4.

The data presented in table No. 4 indicate the absence of plasma exfusion in a volume of 450.0 ml by the method of single-needle membrane plasmapheresis on the blood cell composition, the concentration of total protein and fibrinogen, and coagulation indices. The following table No. 5 demonstrates the absence of the influence of the applied plasmapheresis method on hemodynamic parameters during the procedure.

During the plasmapheresis procedure, cardiotocography of the fetus was carried out in a continuous mode - there were no deviations from the norm. According to the results of dopplerometry performed the next day after plasmapheresis, there were no signs of a violation of placental and fetal circulation.

Delivery was carried out as planned with a gestational age of 37-38 weeks.

Anesthesiological aid: combined anesthesia: epidural anesthesia with the transition after extraction of the fetus to combined endotracheal anesthesia.

The child is removed at 8 minutes. Apgar score 7/7 points.

Scope of operation: Median laparotomy with bypass of the navel. Caesarean section. Ligation of the internal iliac artery on the right. Excision of uterine aneurysm. Metroplasty. Sterilization. Intraoperative hardware blood reinfusion.

At the stage of excision of uterine aneurysm and metroplasty, massive bleeding developed. The collection, washing and reinfusion of autoerythrocytes with the simultaneous introduction of autoplasma prepared before the operation began. After reaching a blood loss of one liter, 1000 mg of tranex was administered.

The total volume of intraoperative blood loss amounted to 4600.0 ml (63% of bcc). The volume of infusion-transfusion therapy is 5230.0 ml, of which reinfusion of autoerythrocytes 1530.0 ml, autoplasma 1400.0, donor erythrocyte suspension 300.0 ml, balanced electrolyte solution 2000.0 ml.

The duration of the operation is 2.5 hours. Diuresis was 300 ml.

In the postoperative period, complications were not registered. Repeated blood transfusions of donor blood components were not required. The patient was discharged on the 5th day in satisfactory condition. The dynamics of laboratory parameters in the perioperative period are presented in table No. 6.

This example demonstrates the safety of single-needle membrane plasmapheresis at the autoplasma harvesting stage: the stability of hemodynamic parameters, the absence of changes in laboratory parameters, and negative effects on the condition of the fetus.

The combination of intraoperative reinfusion of washed red blood cells and transfusion of harvested autoplasm in a volume of not less than 20% of BCC by single-needle membrane plasmapheresis can minimize donor blood transfusions, avoid coagulation disorders and severe posthemorrhagic anemia.

The proposed method was used in preparation for surgical treatment of 54 patients with a diagnosis of placental ingrowth, established in the second trimester of pregnancy according to ultrasound, MRI. The average volume of plasma collected before surgery was 23% of the bcc (18.1-27%). In order to compare the effectiveness and safety of the proposed method, a control group of 14 patients was diagnosed with placental ingrowth, which was not preoperative autoplasma harvesting. Patients of both groups did not differ in age (p = 0.366) and BMI (p = 0.368), delivery time (p = 0.386), and urgency of the operation (p = 0.304).

The volume of blood loss in the autoplasmic harvested group was 2947.0 (1083.0; 4650.0) and did not significantly differ from the volume of blood loss in the control group - 2750.0 (2061.0; 4000.0), p = 0.942. But in the group with autoplasma harvesting, the volume of transfusion of donor plasma significantly decreased (p = 0.02). In the control group, the volume of transfusion of donor plasma was 993.0 (600.0-1462.0) ml, all patients in this group required transfusion of allogeneic plasma, while out of 54 patients in the main group only 18 needed transfusion of one dose of donor plasma and four - two doses. The volume of transfusion of donor plasma in this group was 0.0 (0.0; 576.0) ml.

Reducing the volume of donor transfusions or refusing them contributes to a more rapid recovery of red blood counts after massive blood loss, significantly reduces the volume of postoperative transfusions of donor erythrocyte suspension and reduces the length of stay in a resuscitation bed.

In the early postoperative period, for the correction of clinically significant severe posthemorrhagic anemia in the control group, 50% of cases (7 patients) required transfusion of one or two doses of erythrocyte donor suspension. In the preoperative autoplasma harvesting group, additional transfusions of donor erythrocyte suspension were required for 3 patients, which amounted to 5.5%. Two of the 14 patients in the control group in the early postoperative period showed coagulation disorders requiring transfusion of donor plasma, while in the autoplasma donation group there were no coagulation disorders in the postoperative period.

The application of the proposed method avoided post-transfusion complications in the autoplasma harvesting group. In the control group, one serious complication of massive transfusion of donor plasma in the form of TRALI syndrome was recorded, in four cases of reaction to transfusion of donor plasma in the form of urticaria. The average hospital bed day in the group of patients who underwent autoplasma harvesting before surgery was 5 days, while in the control group it was 7 days.

Claims (4)

A method for correcting hemorrhage during operative resolution of a pregnant woman with placental growth, including autoplasma donation with autoplasma harvesting using plasmapheresis during pregnancy and transfusion of a pregnant woman during surgical delivery, characterized in that autoplasma harvesting is carried out using single-needle membrane plasmapheresis, performing 3 procedures in a period of 24 30 weeks of gestation with an interval of at least 7 days between them; and for each procedure, 450-550 ml of autoplasma is harvested; why spend 8-10 cycles per minute, while in one cycle 10 ml of blood is taken, which is passed through a plasma filter with a membrane having a pore diameter of not more than 0.4 μm, the cellular elements of blood are returned back to the bloodstream and get 3-3.5 ml of blood plasma filtrate; after receiving every 100 ml of autoplasma, 100 ml of a balanced electrolyte solution is administered to the pregnant woman; during surgical delivery at the stage of massive blood loss, transfused autoplasma is transfused simultaneously with the collection, washing and reinfusion of autoerythrocytes, 1000 mg of Tranexam is administered.