RU2709819C1 - Method for reducing blood loss in operative delivery in obstetric patients of high risk groups - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to obstetrics, and can be used to reduce blood loss in operative delivery in obstetric patients of high risk groups. For this purpose, intraoperatively immediately after the umbilical cord is crossed before the placenta is separated, Terlipressin preparation 0.4 mg is added with addition of 0.9 % sodium chloride solution and bringing the administered volume to 10 ml into the muscular tissue of the uterus through a uterine incision in equal doses of 0.2 mg into uterus incision angles.

EFFECT: method enables reducing blood loss in the obstetric patients of the high obstetric risk group in a combination with normalizing such cardiovascular parameters as cardiac output, systemic vascular resistance, cardiac index, arterial pressure in the absence of complications specific for the intravenous introduction.

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Description

The invention relates to medicine, namely to obstetrics, and can be used to reduce blood loss during surgical delivery.

With surgical abdominal delivery, one inevitably has to solve the problem of reducing the amount of blood loss. Massive bleeding requires more highly skilled care, the prognosis for the mother and newborn in these cases is usually poor. Caesarean section is an operation accompanied by significant blood loss, 1.5-2 times greater than the permissible volume and 2-3 times that during physiological births [I.F. Fatkullin, I.A. Milova Principles and methods for reducing blood loss and preventing bleeding during cesarean section // Medical practice, 2010 http://mfvt.ru/principy-i-metody-umensheniya-krovopoteri-i-profilaktiki-krovotechenij-pri-operacii-kesareva-secheniya /].

It is known that the range of blood loss during abdominal delivery is from 300 ml to 2600 ml. The average blood loss is about 650 ml. [Kulakov V.N., Chernukha EA, Komissarova L.M. Cesarean section. M., 1998. - S. 140]

The well-known drug Terlipressin (Terlipressin) [Russian drug register https://www.rlsnet.ru/mnn_index_id_1153.htm#puti-vvedeniya]. According to the manufacturer's instructions, the drug increases the tone of the smooth muscles of the vascular wall, causes a narrowing of arterioles, veins and venules, reduces blood flow in the smooth muscle organs and liver, and lowers pressure in the portal system.

The drug is indicated in obstetrics and gynecology during childbirth and abortion, metrorrhagia of various origins, intraoperatively for abdominal interventions and topically for gynecological bleeding. The instructions indicate the intramuscular, intravenous para- and intracervical routes of administration. The preferred route of administration of the drug is intravenous, in exceptional cases, intramuscular administration is possible.

Local administration during gynecological operations according to the scheme: salt solution is added to 0.4 mg of the drug and the volume is adjusted to 10 ml, injected into the cervix or paracervically.

The route of administration of Terlipressin into the myometrium is described [Burbello A.T., Shabrov, Denisenko P.P. Modern medicines Moscow, 2016. found on the Internet https://books.google.ru/books?id]. The authors indicate that the dose depends on the speed and volume of blood loss, on the duration of bleeding. A single dose is 200-800 mg. If necessary, the introduction is repeated every 6-8 hours, until the bleeding stops. The duration of the drug can be up to 7 days. However, the reference book does not indicate the optimal localization of the administration of Terlipressin to the myometrium, the timing of administration of the drug in relation to the time of the onset of bleeding: before the alleged blood loss begins as a preventive measure or during the development of obstetric or gynecological blood loss.

The following symptoms accompanying intravenous administration are indicated by the manufacturers as disadvantages when using the drug: pallor, shortness of breath, increased blood pressure, bradycardia, heart failure, myocardial infarction, abdominal pain, nausea, vomiting, necrosis at the site of intramuscular injection. The results of the use of the drug in practice confirm the high incidence of the above side effects.

It is known to use the drug Terlipressin to reduce the volume of obstetric bleeding in women of high obstetric risk [Ways to reduce obstetric bleeding with premature detachment and placenta previa / Yu.P. Vdovichenko, N.P. Goncharuk, S.Yu. Vdovichenko // Zhinochiy Likar, 2011. No. -4. S. 28-31; https://z-l.com.ua/upload/journals/36/block36site4.pdf]. Patients underwent cesarean section surgery due to premature detachment of a normally located placenta. A comparison was made of the treatment regimens of patients in the subgroups: the first - receiving oxytocin (10 units) for the prevention of obstetric hemorrhage and the second - receiving carbetocin (100 μg) and terlipressin (0.2 mg). The drugs were administered intravenously immediately after separation of the placenta and isolation of the placenta.

The authors confirmed that the combined use of Carbetocin and Terlipressin reduced the frequency of ligation of the great vessels by 3 times and completely eliminated the need for obstetric hysterectomy.

It is known that Terlipressin is used to minimize blood loss during elective cesarean section surgery with conservative myomectomy [Prevention of bleeding with a combination of cesarean section and conservative myomectomy / O. V. Golyanovsky, A. V. Titov, S. O. Radkevich, M. A. Bachinskaya // Tauride Medical and Biological Bulletin, 2013, Volume 16, No. 2, Part 2 (62). - S. 155-158]. After partial uterine devascularization, the authors injected 0.4 mg Terlipressin solution per 20.0 ml of isotonic NaCl solution into the myometrium along the periphery of the leiomyomatous node. The use of Terlipressin in complex treatment has made it possible to minimize intraoperative blood loss, reduce the risk of uncontrolled bleeding during conservative myomectomy during cesarean section.

In the cited works, the effects of the drug Terlipressin during surgical delivery in women at high risk by means of intraoperative introduction into the myometrium were not investigated.

The technical result is a reduction in blood loss in women of high obstetric risk group in combination with the normalization of such parameters of the cardiovascular system as cardiac output, systemic vascular resistance, cardiac index, blood pressure.

The technical result was achieved by analyzing the kinetic observations of patients with high obstetric risk during surgical delivery with an assessment of the main factor - the amount of blood loss in patients, as well as the parameters of the cardiovascular system.

The control group treated according to the standard method [Order of the Ministry of Health of Russia dated 06.11.2012 N 583н “On the approval of the standard of specialized medical care for delivery through cesarean section” (Registered in the Ministry of Justice of Russia on 05.03.2013 N 27475)] consisted of 43 patients operated on for pathology pregnancy with high obstetric risk. Terlipressin was not used in this group. The second group consisted of 58 patients who, along with standard treatment intraoperatively, immediately after the umbilical cord was crossed, before extraction of the placenta, locally in the myometrium, Terlipressin was administered.

The scheme of drug administration is as follows. Patients were intraoperatively immediately after crossing the umbilical cord before separation of the placenta, Terlipressin was injected into the muscle tissue of the uterus through the incision on the uterus. For uniform distribution of the drug Terlipressin, its administration is carried out in equal doses of 0.2 mg to the angles of the incision on the uterus. This scheme provides a decrease in blood flow in the injection region due to the pronounced vasoconstrictor effect at the site of surgical intervention on the uterus. Provides earlier hemostasis and eliminates additional organ trauma. An injection solution is prepared in the standard way: 0.9% sodium chloride solution is added to the dose of Terlipressin, the volume is adjusted to 10 ml in order to exclude the development of general disorders and disorders at the injection site.

The following indicators of the cardiovascular system were evaluated and compared in the observation groups: cardiac output, systemic vascular resistance, left ventricular function, cardiac index, stroke volume, systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate, SpO2, ECG, body temperature, diuresis. The volume of blood loss was determined by the gravimetric method.

It was established that there are no statistically significant differences between the groups according to age, the number of previous pregnancies, childbirth, complications of the current pregnancy and labor;

The results of the observations are presented in the table.

Table.

The results of the examination of patients with high obstetric risk treated with standard and proposed methods

Indicator Standard technique
(control group) n = 43 The developed method
(group using Terlipressin) n = 58 Before surgery After operation Before surgery After operation Systolic blood pressure 125.89 ± 4.28 148.75 ± 5.24 # 129.6 ± 3.71 131.10 ± 5.29 * Diastolic blood pressure 80 ± 7.24 110 ± 8.28 # 83 ± 8.63 86 ± 6.11 * systemic vascular resistance 1395.72 ± 17.4 1527.16 ± 12.9 # 1234.18 ± 15.6 1282.22 ± 16.8 * Red blood cells 3.93 ± 0.34 3.47 ± 0.28 3.99 ± 0.48 3.76 ± 0.43 Fibrinogen 3.7 ± 0.17 4.2 ± 0.26 # 3.7 ± 0.35 3.6 ± 0.76 * Pallor of the skin - 93.0% - - Nausea, vomiting - 62.8% - - Absolute blood loss (ml) 960.35 ± 71.43 500.35 ± 64.29 * Blood loss relative to circulating blood volumes (%) 13.15 ± 2.57 6.54 ± 1.62 *

Note: * indicates statistically significant differences in indicators between study groups; the sign # - statistically significant differences in the indicators within the group before and after the operation.

In our observation, a statistically significant decrease in blood loss was proved, the method allows to stabilize the condition of patients during surgery. Stable indicators of cardiac output, systemic vascular resistance, left ventricular function, cardiac index, stroke volume, systolic blood pressure, diastolic blood pressure, medium blood pressure, heart rate, SpO2, diuresis

The proposed regimen of Terlipressin allows surgeons to work on a bloodless surgical field.

In the group using the drug Terlipressin, an improvement in the postoperative state of patients, a decrease in the activation time of patients was noted.

The proposed method of administration during surgical delivery is effective to reduce systemic toxicity. Effects: complete elimination of disorders of the cardiovascular system, chest pains - 100%; peripheral vascular spasm - 100%. The absence of changes in the ECG, supraventricular tachycardia, atrial fibrillation, angina pectoris, lengthening of the QT interval, polymorphic ventricular tachycardia of the pirouette type, ventricular fibrillation, shortness of breath, bronchospasm, hyponatremia, hypokalemia. There were no pains in the intestines, vomiting, colic, headache.

Clinical examples:

Patient M.O.S., 37 years old, weight 103, height 158 cm, BMI 41.3, weight gain 26 kg.

Diagnosis: Pregnancy 38 weeks, double-operated uterus, edema of pregnant women, obesity, chronic pyelonephritis.

Caesarean section 06/26/2018 After a uterine incision, the fetus is removed, the placenta is separated. The uterus is sutured, the abdominal cavity is sutured. Intraoperative blood loss of 850 ml (8.3%).

Patient P.N.V., 32 years old, weight 100kg, height 161 cm, BMI 38.6, weight gain 5.3 kg.

Diagnosis: Pregnancy 39 weeks, double-operated uterus, thinning of the scar, chronic renal failure, chronic toxaplasmosis, obesity.

Caesarean section 03/14/2018 After the uterine incision, the fetus was removed. Before removing the placenta, Terlipressin in equal doses of 0.4 mg in a 1/25 dilution with 1/25 isotonic sodium chloride solution was introduced into the muscle tissue at the corners of the incision, the volume was brought up to 10 ml

The placenta is separated. The uterus is sutured, the abdominal cavity is sutured. Intraoperative blood loss of 470 ml (4.7%).

Thus, we have developed a new regimen for the administration of Terlipressin for pregnant women at high risk of bleeding during cesarean section, which significantly reduced the amount of intraoperative blood loss while eliminating complications characteristic of the intravenous route of administration.

Claims (1)

A method of reducing blood loss during surgical delivery in high-risk women in labor with the use of the drug Terlipressin in a dose of 0.4 mg with the addition of 0.9% sodium chloride solution and bringing the injected volume to 10 ml, characterized in that the drug is administered intraoperatively immediately after crossing the umbilical cord to separation of the placenta into the muscle tissue of the uterus through the incision on the uterus in equal doses of 0.2 mg to the corners of the incision on the uterus.