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It is known that human health is laid even in the period of its intrauterine development. Many works point to the connection of various diseases in children, especially such as allergies (including neurodermatitis, bronchial asthma), chronic bronchitis, kidney disease, with disorders in the course of pregnancy of their mothers. Moreover, there are direct links between the complicated course of pregnancy and the level of perinatal mortality.
Toxicosis of pregnant women, or preeclampsia - a severe complication of pregnancy, is one of the leading causes of maternal and perinatal morbidity and mortality. In most cases, gestosis is secondary or combined, developing against the background of other types of extragenital pathology - kidney disease (pyelonephritis, glomerulonephritis), obesity, hypertension, diabetes mellitus. In any case, the pathological processes are based on the accumulation of toxic products leading to toxic edema of the interstitium. The result is hypoxia of organs and tissues with secondary violations of their functions. In severe cases, eclampsia occurs against the background of multiple organ failure - loss of consciousness, convulsions (cerebral edema), severe parenchymal respiratory failure (toxic pulmonary edema - RDS), anuria, liver failure, arterial hypertension with microcirculation disorders, and often retinal detachment, develops DIC syndrome with the risk of severe bleeding during childbirth.
Prolonged exposure of the fetus in conditions of such toxemia disrupts all processes of development of its organs and systems, up to its intrauterine death. Born children, as a rule, suffer from encephalopathy with mental retardation, pneumopathy with a syndrome of respiratory disorders, hepatonephropathy with the formation of chronic hepatitis and even early cirrhosis of the liver with portal bleeding during the first year of life, chronic pyelonephritis, lag behind in physical development.
Preeclampsia or toxicosis of pregnant women - this can be said to be the only disease whose name includes the concept of "toxicosis", but the statement of this fact does not yet mean that detoxification is the main therapeutic measure. Instead of measures for the purposeful removal of pathological products from the body of a pregnant woman, she is prescribed many different medications, often far from being indifferent to the fetus.
On the other hand, it is obvious that instead of introducing some additional substances, one should, on the contrary, remove pathological products and this can be best done only with the help of efferent therapy.
The development of the fetus is threatened by another danger - intrauterine infection if the pregnant woman has a syndrome of latent urogenital infections - chlamydia, mycoplasmosis, gardenellosis, lesions by herpes viruses and cytomegalovirus. During the life of women before pregnancy, these infections may not cause significant disorders and manifest themselves as periodic exacerbations of cystitis, adnexitis, colpitis. However, during pregnancy, the main danger threatens the fetus, causing malformations and violations of its development, up to early termination of pregnancy (i.e., infertility in fact), premature birth, and even intrauterine death of the fetus. However, even if born alive, the child has signs of serious violations of the functions of the brain, liver, kidneys, and lungs.
The main reason for the development and chronicity of these infections, and to some extent even conditionally pathogenic ones, is considered to be the weakening of the body's defenses in women. Therefore, the most pathogenetically substantiated approach to the treatment of these chronic infections is efferent therapy aimed at removing those pathological products that contributed to secondary immunosuppression, as well as quantum methods of immunostimulation. It is necessary to force the body to cope with these pathogens on its own. Indeed, plasmapheresis has proven effective in the treatment of miscarriage due to cytomegalovirus and herpes infections.
Efferent therapy is able to remove these pathological products of exogenous origin, incorporated both in the process of labor, activity in hazardous industries, and so on. and as a result of living in contaminated areas. In cases of infertility caused by gonadotropic substances, coupled treatment is also indicated. If there were indications of the possibility of ingestion of embryotoxic and teratogenic compounds, then efferent therapy should be carried out for women even before gestation, since it is known that both the laying of the main organs and systems and their developmental defects are formed already in the first trimester of pregnancy.
Plasmapheresis helps to timely and effectively remove antibodies from the body of a pregnant woman in case of Rhesus conflict.
Among the causes of miscarriage, in addition to those described above, autoimmune diseases play a role, mainly antiphospholipid syndrome, in the treatment of which plasmapheresis shows the best results.
All these cited facts emphasize the relevance of preventive detoxification both before and during pregnancy in cases where a complicated course and fetal pathologies can be expected. These measures are of particular importance when indicating an unfavorable course or outcome of a previous pregnancy. .
Eclampsia. The increase in the severity of late toxicosis before childbirth dictates in some cases the need for an urgent termination of pregnancy in order to save the mother, regardless of the fate of the baby, since eclampsia, as the apotheosis of preeclampsia, threatens with toxic cerebral edema (coma, convulsions, retinal detachment), toxic edema and hepatization of the lungs with severe parenchymal respiratory failure, nephropathy up to anuria, liver failure. Each of these complications, not to mention their simultaneous combination, threatens the life of the woman in labor and requires the most urgent intensive care measures. At the same time, detoxification and efferent therapy seem to be the most pathogenetically justified.
Our own experience in carrying out these activities shows that detoxification contributes to a much faster restoration of the functions of the affected organs than the traditional therapy - drug, infusion, artificial ventilation, and even hyperbaric oxygenation. In particular, diuresis, even against the background of complete anuria, can be restored already during plasmapheresis as the “toxic pressure” is eliminated from the kidneys, and in the next few hours consciousness and airiness of the lung parenchyma are restored. Delayed detoxification shows a slower reverse dynamics of organ damage.
As noted above, preeclampsia, accompanied by the same fetal toxemia aggravated by its intrauterine hypoxia, the consequences of exacerbations of chronic urogenital infection and Rh-conflicts between mother and fetus, lead to severe complications in the pre-, intra- and postnatal periods.
These complications are the main causes of intrauterine fetal death. They contribute premature birth, in which, even if born alive, the newborn is in an extremely serious condition with a complex of multiple organ disorders that cannot be corrected either with the help of artificial or assisted ventilation of the lungs with oxygen or a pressure chamber, or antibiotics or any other medicines.
This happens because in the circulation, interstitium and cells of the child's body there are huge amounts of various toxic products that make it impossible to restore the normal metabolism of organs and tissues with the development of a number of vicious circles. The toxic pressure does not make it possible to establish the normal function of hepatocytes, alveolocytes, neurons, kidney parenchyma, which inhibits the restoration of the natural processes of detoxification, excretion and gas exchange. an allegedly recovered child is doomed from childhood to remain chronically ill, suffering from liver diseases up to cirrhosis, kidneys, lungs, brain, various manifestations of allergies and immune shifts that differ little from acquired immunodeficiency syndrome, i.e. actually AIDS.
The developed method of syringe membrane plasmapheresis made it possible to carry out efferent therapy even for newborns, including preterm infants with a body weight of 700 g or more. Indications in such cases are complicated intrauterine infection, septic complications, the consequences of severe asphyxia, hyperbilirubinemia due to hemolytic disease of the newborn. Mortality in these groups decreased by 35.3%. The period of stay of children on mechanical ventilation, the need for infusions of cardiosympathomimetics, and the start of enteral nutrition also decreased.
Among the methods of efferent therapy in obstetrics, the safest and most effective is membrane plasmapheresis, which is successfully used not only in large specialized centers, but also in any medical institutions of the municipal level, including maternity hospitals.
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In the treatment of gynecological patients, one or another surgical intervention is often resorted to.
The outcome of each operation depends not only on how it is technically performed, but to a greater extent on the general condition of the body, on the state and function of the central nervous system. Therefore, each patient must be properly prepared for surgery.
General preparation for surgery
The patient is greatly influenced by the behavior of the patients around her, as well as caring and attendant personnel. It is necessary to be attentive to the patient. It is necessary to create for her that therapeutic and protective regimen, which has already been mentioned.
In most patients, the thought of the upcoming operation causes excitement, sometimes even depression. All this, as established by numerous studies, negatively affects the activity of the cerebral cortex. In this regard, from the moment the patient enters the gynecological department, all necessary measures must be taken to create a calm, cheerful mood in her; the patient must be sure of a favorable outcome of the operation.
Some patients are prescribed medication before surgery to improve the activity of the cardiovascular system. Patients with a low percentage of hemoglobin in the blood undergo a blood transfusion.
Gynecological operations on the vagina and on the cervix are performed through the vagina. Operations on the uterus and its appendages are done mainly by abdominal surgery.
Depending on the nature of the upcoming operation, 1-2 days before it, the patient is directly prepared for the operation.
Hair from the external genital organs and surrounding areas are shaved off. The patient takes a shower. Underwear and bed linen are changed.
On the eve of the operation, a laxative is given. On the day of the operation, an enema is given early in the morning, after which the patient is thoroughly washed away. Sometimes a laxative is not given on the eve of the operation, but an enema is given instead.
On the eve of the operation, the patient receives the usual breakfast and lunch, and in the evening sweet tea and a little white bread. It is necessary to ensure that the patient does not eat much, and also does not eat any of the unauthorized foods. With a full stomach, there may be vomiting during anesthesia and bloating after surgery. On the day of the operation in the morning 2-3 hours before it, the patient can be given sweet tea, but without bread.
If a vaginal operation is to be performed, then sometimes douching with disinfectant solutions is performed before the operation.
Some operations require special preparation. So, when sewing up large perineal injuries, especially if the integrity of the sphincter of the anus is broken, 2-3 days before the operation, the patient should receive only liquid food, and daily during this period she should be given an enema. For good healing of the surgical wound, it is necessary that these patients do not have bowel action for 5-6 days after the operation; for this, it must be well cleaned in advance. During surgery for cervical cancer, although it is performed by abdominal dissection, the vagina is also prepared in advance, and a gauze swab is inserted into it before the operation.
Half an hour before the operation, the patient is injected with 1-1.5 ml of a 1% solution of morphine, immediately before the operation, she must urinate.
In the preoperative room, the patient is put on a sterile shirt and stockings; the head must be covered with a scarf that completely covers the hair. If an operation is to be performed under general anesthesia, then it is desirable that it be started in the preoperative room, and not in the operating room itself, since the patient is worried about the appearance of the operating table, instruments and the whole environment of the operating room.
In gynecological operations, various methods of anesthesia are used. Their choice depends on the condition of the patient, her age and the nature of the upcoming operation.
Most often, one of the following types of anesthesia is used: 1) ether anesthesia, 2) local anesthesia with a 0.25% solution of novocaine, 3) spinal anesthesia, 4) intravenous anesthesia (hexenal, pentothal sodium, etc.).
Technique for all listed species anesthesia is no different from that used in surgical operations.
Sterilization of instruments, material, suture material, as well as the preparation of the surgeon and his assistants (assistants) are carried out in the same way as is customary in general surgery.
When the ball is laid on the operating table, it is given the position that is necessary for the upcoming operation, then they begin to prepare the operating field.
Vaginal operations
During vaginal surgery, the patient's legs are bent in hip joints, put on leg holders attached to the operating table, and tied to them. The patient's pelvis should be at the very edge of the operating table.
In the absence of leg holders, a sheet can be used, as shown in fig. 134.
The preparation of the surgical field is carried out either by the surgeon himself or by one of his assistants.
The vagina is opened with mirrors. A gauze ball is taken with a forceps, it is abundantly moistened with alcohol and the cervix and the entire vagina are wiped with it. Then this is done again with a new ball, after which the excess of alcohol is removed with dry gauze. With a new gauze ball, the cervix and the entire vagina are treated with 5% tincture of iodine. The mirrors are taken out and put aside, as they are already contaminated and cannot be used in the future during the operation. At the end of the treatment of the vagina, they proceed to the preparation of the external genital organs and nearby skin areas. Their treatment also consists in wiping twice with alcohol and lubricating with 5% tincture of iodine.
When the operating field is prepared, the patient is covered with sterile sheets and towels so that only the external genitalia remain open. Linen is fixed to the skin with the help of special clips (caps) or hemmed with silk.
During a vaginal operation, in addition to the surgeon, there are also assistants (doctor, nurse), anesthetist and an operating sister. During the operation, a nurse who knows the work of the operating room must be constantly present.
About some operations performed by the vaginal route, it has already been provided earlier (biopsy, puncture of the posterior fornix, curettage of the uterine cavity, artificial miscarriage).
Other operations often include the following.
Removal of a Bartholin gland cyst.
The operation consists in cutting the skin covering the cyst, after which the tumor is peeled out of its bed and the wound is sutured.
Removal of a cervical polyp. After the neck is exposed with mirrors, the polyp is cut off at its base. Bleeding during surgery almost never occurs, so stitches are usually not applied.
plastic surgery on the crotch. These operations are performed to restore the integrity of the perineum and pelvic floor after their former rupture. The scar tissue at the site of the former rupture is excised. The bundles of dispersed muscles are connected with sutures, after which the vaginal wound is sutured with catgut sutures, and the skin with silk sutures. The seams are treated with 5% tincture of iodine and a gauze pad is placed on the perineum.
In addition to these operations by the vaginal route, other operations are also performed, such as restoring the integrity of the cervix after its ruptures, amputation of the vaginal part of the cervix. Sometimes, though rarely, more complex operations are performed vaginally, for example, removal of the uterus and its appendages, suturing fistulas, etc.
Abdominal operations
For the production of the operation by the abdominal wall (abdominal dissection), the patient is placed on the operating table on her back. The foot part of the table is lowered so that the patient's legs are bent at the knee joints. The shins and thighs should be well tied to the table with wide towels. All this is done in order to be able to give the patient an inclined position. The head end of the operating table is lowered and, as a result, the patient lying on it assumes an inclined position (Fig. 192). In this position, the patient's intestines move upward and the pelvic organs become clearly visible and accessible for surgical intervention.
The preparation of the operating field is carried out by the operating assistant. The skin of the abdomen, pubis and inguinal folds are rubbed twice with gauze balls, abundantly moistened with alcohol, then dried and treated with 5% tincture of iodine. The patient is covered with sterile linen, leaving only the site of the intended incision open.
The abdominal cavity is opened either by a longitudinal incision along the midline of the abdomen below the navel, or by a transverse incision in the lower abdomen slightly above the pubic joint.
Of the operations performed by cerebrosection, the caesarean section has already been mentioned above. Of the gynecological operations, the following are most often performed:
Amputation of the body of the uterus. This operation is performed with fibromyomas, with damage to the uterus (criminal abortion, uterine rupture) and for some other indications. First, the tubes and round ligaments are cut off from the uterus. Then the body of the uterus is cut off from the cervix near the peritoneum in the pelvic area and sutured. After that, the abdominal wall is sutured in layers. Silk sutures or staples are applied to the skin of the abdomen and a sterile bandage is applied.
Removal of the entire uterus. The difference from the previous operation is that not only the body of the uterus is removed, but also the cervix; which is cut off from the vagina.
Rice. 192. The position of the patient during gynecological surgery
(abdominal).
Removal of the uterus with appendages. To remove the appendages, it is necessary to cut them off from the ligaments going from the tubes and ovaries to the walls of the pelvis, also cut off the round ligaments. After that, the entire uterus or only its body is removed, and the cervix is left. Removal of the uterus with appendages is done for various diseases, including cancer. In this case, all periuterine tissue is also removed. Lymph nodes located in it are often affected by cancer.
Pipe removal. This operation is performed mainly in ectopic pregnancy. It consists in cutting off the tube from the broad ligament and from the uterus.
Oophorectomy. The operation is performed most often for ovarian tumors. The leg of the tumor is bandaged and cut. Sometimes the ovary is removed along with the tube.
A significant number of other operations are performed by abdominal surgery, such as suturing round ligaments, exfoliation of tumors from the body of the uterus, tubal ligation, etc.
In addition to the surgeon, one or two assistants (doctors), an anaesthetist and an operating nurse take part in operations performed by abdominal surgery.
There must be a nurse in the operating room at all times.
Tissues and organs removed during gynecological operations are not thrown away. They are placed in glassware, filled with 10% formalin solution and sent along with an accompanying note to the laboratory for microscopic examination.
Indicative list tools for operations performed by abdominal dissections
Abdominal mirrors 2
Sliding belly mirrors... 1
Hooks for wounds ............................................... ............ 2
Straight scissors 2
Curved scissors .................................................. .... 2
Scalpels .................................................. ................. 2
Tweezers long 4
Anatomical tweezers............................................... 4
Surgical tweezers............................................... 4
Kocher clamps .................................................. ............ 6
Kocher clamps are long. 12
Pean Clamps .................................................. ........... 12
Mikulich clamps .................................................. ..... 10
Korntsangi .................................................. ................ 6
Muzo forceps .............................................. ............. 4
Bullet tongs .................................................. .......... 6
Intestinal sphincter .............................................................. ......... 2
Corkscrew uterine 1
Curettes ................................................. ............. 2
Ovarian forceps .............................................. 2
Uterine probe ................................................................ .... one
Grooved probe ........................................ ....... ...... one
Spatulas .................................................. ............ 2
Needle holders ................................................................ ... 4
Needles various sizes. . . . 12
Intestinal needles .................................................. ... 6
Deschamps needles .................................................. .... 2
Parentheses................................................. ... . twenty
Tweezers for applying brackets. 2
Caps .............................................................. ................ 6
Male catheter .................................................. . one
For vaginal operations, the same set of instruments is needed, but instead of abdominal mirrors, 6 vaginal mirrors are needed. - front, rear and side.
Female catheter .................................................. . one
Pregnant women are considered one of the most vulnerable categories of patients who are prone not only to infectious and respiratory diseases, but also to various disorders in the functioning of internal organs. Pregnant women may experience complications from the nervous, vascular and digestive systems, as well as endocrine disorders that develop against the background of hormonal changes. Negative changes can also occur in the hematopoietic system, as well as hemostasis - a biological system that ensures the vital activity of the body, maintains the liquid state of the blood and contributes to the rapid recovery of the skin and mucous membranes after injury.
A fairly common pathology of hemostasis during pregnancy is DIC. This is the process of active leaching of thromboplastin (an external stimulator of the coagulation process) from tissues and organs, which leads to impaired blood clotting. In medical practice, this condition is called "disseminated intravascular coagulation." The syndrome is dangerous with an asymptomatic course and the rapid development of systemic coagulopathy, so all pregnant women should be observed by a gynecologist or obstetrician-gynecologist at the place of residence during the entire period of pregnancy.
Minor disorders of hemostasis, accompanying signs of disseminated intravascular coagulation, can be explained by physiological processes occurring in a woman's body during pregnancy, but in the vast majority of cases (more than 94%), such symptoms are the result of certain pathologies.
Fetal death
One of the causes of acute DIC at any gestational age is intrauterine fetal death and fading of pregnancy. This can happen for a number of reasons, but the most common ones are:
- mother taking toxic drugs and potent drugs;
- amniotic fluid embolism (amniotic fluid entering the pulmonary arteries and their branches);
- placenta previa or abruption;
- acute alcohol or drug intoxication of the fetus;
- tumors of the outer cell layer of the placenta (trophoblast).
One of the causes of pathology is the death of the fetus.
Pregnancy fading can occur at any time, but disseminated intravascular coagulation syndrome manifests itself only 4-6 weeks after antenatal fetal death. Pathology is complicated by acute intoxication and a high risk of toxic products entering the systemic circulation, which can lead to the development of sepsis and inflammation of the bone marrow.
It is possible to determine a frozen pregnancy at an early stage only with the help of ultrasound, as well as a blood test for the level of chorionic gonadotropin, which will be significantly lower than the gestational norm. After 20-22 weeks, fetal death can be suspected by the absence of movements and palpitations.
Important! DIC of the 4th degree can lead to the death of a woman, therefore, with any signs indicating a possible termination of pregnancy, you should immediately contact the pregnancy pathology department at the district maternity hospital.
Preeclampsia and early signs of preeclampsia
Preeclampsia ("late toxicosis") is the most common pathology of pregnant women, which is experienced by almost 60% of women. Preeclampsia has three main features that allow diagnosing pathology at an early stage:
- stable increase in blood pressure with a weak response to ongoing drug correction;
- detection of protein or its traces in the urine;
- swelling on the face and extremities, most often having a generalized form.
Women with diagnosed preeclampsia should be under the constant supervision of specialists, since progressive forms of pathology can cause the development of preeclampsia - cerebrovascular accident against the background of late toxicosis of the second half of pregnancy. Another danger of preeclampsia is damage to endothelial cells (single-layer flat cells covering the surface of the heart cavity, lymphatic and blood vessels). If the integrity of the endothelium is compromised, DIC may develop, requiring close monitoring and timely emergency care.
Other reasons
The causes of DIC may be infectious. Infection of amniotic waters, prolonged bacterial infections of the internal organs of the mother, which increase the risk of bacteria and their toxins entering the bloodstream - all this can cause clotting disorders and systemic coagulopathy, so it is important to treat any diseases of an infectious nature in time and follow all doctor's prescriptions. Some women refuse to take antibiotics, believing that they can harm the unborn child, but it has long been proven that the consequences of using antimicrobial drugs are much easier compared to the possible complications if the infection gets to the fetus.
Other causes of acute disseminated intravascular coagulation may include:
- surgical operations performed during pregnancy with blood or plasma transfusion (the risk increases if blood was used for transfusion that is not compatible with the group or Rh factors);
- damage to the cells of the erythrocyte or platelet mass;
- prolonged uterine bleeding leading to the development of hemorrhagic shock;
- uterine rupture;
- atony of the muscles of the uterus (decrease in muscle tone);
- medical massage of the uterus.
Infectious diseases, burns, injuries skin, shock conditions of various origins, placental pathologies can also cause coagulopathy, so it is important for a pregnant woman to undergo the examinations prescribed by the doctor on time and take the necessary tests.
Symptoms: when should you see a doctor?
The danger of DIC lies in its almost asymptomatic course.. In most cases, it is possible to determine the pathology only after laboratory diagnostics, which can determine hematological disorders (changes in blood chemical parameters). With the syndrome of disseminated intravascular coagulation of degrees 3 and 4, a woman may experience specific symptoms, the main of which is a hemorrhagic rash. It looks like a small pink or light red spot, localized on the surface of the epidermis and appears as a result of rupture of small blood vessels and hemorrhage under the skin.
Other signs that may indicate the need to seek medical attention include:
- frequent bleeding from the nose in the absence of injuries and other injuries;
- bleeding gums (provided that the woman does not suffer from inflammatory periodontal and periodontal diseases, as well as gingivitis);
- bruises that form on various parts of the body without exposure to any damaging factors;
- uterine bleeding and spotting;
- poor wound healing;
- bleeding at injection sites.
A woman may also feel constant weakness, her performance is impaired, and increased drowsiness appears. With frequent bleeding, persistent headaches, dizziness, a feeling of squeezing in the temporal and occipital zone are noted. All these signs are the reason for carrying out diagnostic measures, therefore, if they occur, you should immediately consult a doctor in charge of the pregnancy.
Symptoms of pathology depending on the stage
In total, there are 4 stages of DIC, each of which has its own clinical features. For a more accurate diagnosis and determination of the pathogenesis of existing disorders, the doctor needs to collect a complete history and conduct laboratory diagnostics.
Table. Stages of disseminated intravascular coagulation syndrome and their signs.
Important! Thrombohemorrhagic syndrome of the 4th degree can lead to massive internal bleeding and death of a woman, so if you need inpatient treatment, you should not refuse hospitalization.
Treatment: principles of therapy, drugs used
The main factor in the treatment of DIC is the elimination of the causes that provoked it. If coagulopathy occurs against the background of intrauterine fetal death, the woman is prescribed curettage / vacuum aspiration (depending on the gestational age). The choice of method depends on the general condition of the woman, the stage of existing disorders and other factors. To artificially stimulate labor, Oxytocin is administered intravenously, causing uterine contractions and labor pains. After the fetus is removed from the uterus, the woman is prescribed a course of antibacterial and anti-inflammatory drugs (Metronidazole, Ciprolet, Tetracycline), as well as hematological control for 6 months.
With gestosis, taking drugs to normalize blood pressure is indicated. The drug of choice during pregnancy is "Dopegit" (analogue - "Methyldopa"). It is a central adrenergic receptor stimulant with a pronounced therapeutic effect in essential and secondary hypertension, including hypertension in pregnancy. The therapeutic dose is 250 mg, which should be taken 2-3 times a day. The duration of treatment is determined individually.
To combat edema, herbal preparations, for example, Brusniver, can be used. This is a diuretic of plant origin, which includes rose hips, succession, St. John's wort and lingonberry leaf. The collection has a mild diuretic effect and helps to cope with mild edema. You need to take it 2 times a day for 2-3 weeks (in a glass of boiling water, brew one sachet of the collection).
In severe edema, the doctor may prescribe Furosemide. This is a fairly toxic diuretic, so you can not take it without a doctor's prescription. To normalize the functioning of the kidneys and urinary tract during pregnancy, "Canephron" is used - an antiseptic of plant origin in the form of a dragee and a solution.
First aid for DIC
As emergency care for acute disseminated coagulation syndrome, intravenous administration of "Heparin" is indicated. It can be administered by stream or used for infusion infusion (using a dropper). The initial dose is 5000 IU. Maintenance therapy involves the use of an infusion pump. Dosage - 1000-2000 IU / hour.
To normalize the condition, therapy can be supplemented with protease inhibitors ("Trasilol", "Kontrykal", "Gordox"), but you can use the funds of this group only as directed by a doctor.
5
0
8484 0
Efferent (or extracorporeal) treatments (EML) are currently widely used in various fields of medicine, primarily to restore disturbed homeostasis. Homeostasis is a dynamic constancy of the internal environment - an indispensable condition for the functioning of organs and systems of the body. It persists despite changes in environment and changes that occur in the life of the organism.
Of particular importance in ensuring the functioning of organs and systems is the constancy of the composition of the liquid base of the body - tissue fluid and blood. This constancy is ensured by the function of many organs that are able to remove metabolic products from the body and produce the necessary biologically active substances in the proper quantity and ratio. Violation of the functions of individual organs, their insufficiency inevitably entails changes in the composition of the liquid base of the body and disruption of the physiological processes of other organs and systems.
EML is based on four main processes: diffusion, filtration (convection), sorption, gravity-centrifugation.
At the same time, each of the methods for restoring homeostasis, based on the removal of metabolic products and toxic substances from the body, has its own ability to remove substances of a certain molecular weight, its own advantages and disadvantages. Thus, hemodialysis (HD) and peritoneal dialysis (PD) are able to effectively remove substances with a low molecular weight, hemosorption (HS) and plasma sorption (PS) - mainly substances with an average molecular weight (from 500 to 5000 daltons), plasmapheresis (PA) is able to remove the entire blood plasma, cascade plasma filtration (CPF) - only part of the plasma with a high molecular weight, including low density lipoproteins and immunoglobulins, immunosorption (IS) is able to selectively extract substances with different molecular weights. Cytapheresis (CF) extracts various blood cells.
Treatment methods based on the diffusion process
The high efficiency of the use of HD is currently due to the high permeability and clearance of the dialysis membrane for creatinine and urea, the early onset of dialysis and its combination with the use of Recormon, etc., which allows maintaining sufficient good quality patients live for decades.Hemodiafiltration is a combination of diffusion and high volume hemofiltration, making it more effective at high blood flow in excess of 350 ml/min. Sequential ultrafiltration with HD made it possible to separate the processes of HD and ultrafiltration in patients with unstable hemodynamics who tolerate ultrafiltration during HD due to a decrease in blood osmolarity.
PD- a promising method for the treatment of renal failure, especially widespread abroad. The advantages of the method are ease of use, the possibility of using it at home and in patients with vascular pathology.
Treatment methods based on the filtration process (convection)
Since the 1970s, isolated ultrafiltration (IUF) and hemofiltration (HF) methods have been used in practical medicine. These methods have been successfully used in patients with renal insufficiency, in the treatment of heart failure and in coronary disease heart, congenital and acquired heart defects, cardiomyopathies, resistance to diuretics to eliminate hyperhydration, in the treatment of nephrotic syndrome, hyperosmolar coma, in severe exogenous intoxications, in purulent-septic complications.The mechanism of action of IUF and HF is the convection release of blood from water and substances dissolved in it by creating an increased positive hydrostatic pressure from the blood or rarefaction from the outside of the semipermeable membrane. Excess fluid (hyperhydration) leads to serious consequences for the patient. Appear heart failure, ascites, hydrothorax, pulmonary edema, cerebral edema. The action of diuretics in this case, especially in heart failure, is not always effective, it is difficult to predict and can cause electrolyte disturbances, which is especially unfavorable for cardiac arrhythmias.
IUF allows you to immediately start removing fluid, remove it at a given rate, in the right amount and, if necessary, stop it, leading to the elimination of overhydration, relief of pulmonary and brain edema, etc. The good tolerability of IUV is due to the stable electrolyte composition and plasma osmolarity, and an increase in plasma oncotic pressure. This ensures an adequate inflow of interstitial fluid into the vascular bed.
The GF method is most often used for renal and hepatic insufficiency, poisoning and malignant hypertension.
The volume of excreted fluid during HF is usually significantly greater than that during IUF (10-20 times) and can be 20-80 liters, which is comparable to the total volume of body water, and sometimes even exceeds it. Thus, the replacement of a significant part of the water releases the body by convection from a large number of compounds dissolved in water (urea, creatinine, compounds with an average molecular weight).
The clearance of urea and creatinine in HF with the replacement of 40-50 liters of fluid is somewhat less than that in hemodialysis, and the clearance of "medium" molecules is much higher. Precise replacement of fluid losses avoids complications even at a high fluid exchange rate due to the maintenance of a stable osmolarity of the body's internal media. IUV and HF procedures are performed by perfusion of the patient's heparinized blood through a filter or dialyzer with a large area semipermeable membrane (0.7–2.0 m2).
Taking into account the mechanism of action, the use of IUF and HF is promising in the treatment of pregnant women with circulatory failure, toxicosis in the first and second half of pregnancy, especially against the background of liver and kidney pathology, in patients with purulent-septic diseases and complications.
Plasma filtration (PF)— a new section of gravitational blood surgery. The first publications on plasma filtration appeared in the late 80s, when fiber filters were used in the treatment of familial hypercholesterolemia, cryoglobulinemia, Sjögren's disease, rheumatic vasculitis, and polyneuropathy.
In PF, after blood separation on the device, the erythromass is immediately returned to the patient, and the separated plasma passes through a fiber filter before returning, which retains high molecular weight proteins (IgM, immune complexes, low density lipoproteins). At the same time, the albumin fraction of plasma proteins almost completely passes through the filter and is returned to the patient. IgG (55%), IgA (40%), high density lipoproteins partially return. The advantages of this method are obvious: no plasma replacement is required, which eliminates the potential risk of allergic reactions to protein preparations, colloidal solutions, there is no risk of transfer viral infections with foreign plasma.
PF can also be used in the treatment of pregnant women with preeclampsia, hypertension, diabetes mellitus, myasthenia gravis, septic conditions after gynecological and obstetric operations, acute and chronic inflammation of the internal genital organs in women. The method of cascade plasma filtration makes it possible to remove only the high-molecular part of the plasma, which in most cases does not require replacement of the removed volume with proteins.
Treatment methods based on the sorption process
The simplest and most widely used in our country method of treatment from this group is hemosorption (HS), which allows you to significantly change the hemostatic potentials of peripheral blood by removing coagulation and anticoagulation factors from it, stimulate the cellular link of immunity, regulate the level of hematocrit, circulating blood volume, and platelet count. , microcirculation.As a sorbent, activated carbon of various brands is used, which is produced by the industry in standard sealed bottles. They are sterile, apyrogenic, have the ability to absorb a number of toxic products due to the porous structure.
The most selective and high-tech method is hemosorption using various immunosorbents that can specifically remove various antibodies, proteinases, immunoglobulins, low-density lipoproteins, lipoprotein (a), etc. from blood plasma. healing effect and prevents toxicity. The effect of GS is due not only to the simple extraction of toxic metabolites from the blood, but also to the normalization of a wide range of oxidative enzymes.
GS has found wide application in the treatment of allergic and autoimmune diseases, allowing a significant reduction in doses of glucocorticoid drugs and other medications. HS is increasingly used as a method of intensive care for patients with liver disease, viral and chronic hepatitis, meningococcal infection, leptospirosis. It is possible to use GS in the complex treatment of rheumatic diseases, in septic conditions, and hypertension.
In recent years, there have been works on the use of GS in obstetric and gynecological practice, in particular in the treatment of late toxicosis of pregnant women. The researchers suggest starting HS in pregnant women with toxicosis as early as possible, which allows to achieve a pronounced clinical effect. Normalization of the main clinical and laboratory parameters in patients begins already in the process of HS. N.N. Rasstrigin et al. (1989), as a result of the treatment of women with toxicosis, showed that GS should be used in liver and kidney failure. GS is also used in the treatment of immunological conflict during pregnancy, hemolytic disease of the fetus and newborn. After HS, the antibody titer is significantly reduced, the general condition of pregnant women, the function of the liver and kidneys improves. HS should be started as early as possible if the woman has a high antibody titer and the fetus has signs of hemolytic disease on ultrasound.
A pronounced clinical effect was also obtained with the use of GS in the complex therapy of septic conditions in obstetric and gynecological practice. After HS, there is an improvement in the general condition, improvement in blood counts, kidney and liver function, respiratory function, signs of encephalopathy decrease. There is also an increase in the number and functional activity of T-lymphocytes, an increase in Ig M and Ig G in the blood serum.
The outcomes of the treatment of septic conditions in obstetric and gynecological patients indicate favorable results of the use of GS, especially in combination with other methods of exposure, in particular with ultraviolet blood irradiation, hemodialysis, plasmapheresis and plasmasorption.
Methods of treatment based on the process of gravity or centrifugation
In clinical practice, the use of plasma and cytopheresis is continuously expanding. Plasmapheresis (PA) is the extraction of plasma through the process of apheresis. At first, this term denoted the extraction of plasma from healthy donors. Today, the term is used to refer to the process of extracting plasma as a medical procedure. PA was introduced into clinical practice in the 1960s.Plasma and cytapheresis have found wide application in various fields of medicine, in particular in the blood service; in clinical medicine with intoxications of endo- and exogenous origin for the removal of pathological ingredients from the circulating blood in diseases of various etiologies.
The therapeutic effect of PA is due to many mechanisms: removal of toxic substances, autoantibodies, immune complexes (antigen-antibody), metabolic products, components of destroyed tissues and cells from the bloodstream; deplasmation of cellular "cleansing" systems and blood cells; an increase in functional activity and a change in the vital activity of hematopoietic, stromal, immunocompetent cells; deblocking the natural organs of "purification" and the phagocytic system; elimination of the phenomenon of optical turbidity of plasma; improvement of microcirculation, extracorporeal effect on reinfused blood cells.
Due to the above effects of action, in recent years, plasmapheresis has also been used in obstetric and gynecological practice in the treatment of various pathological conditions. The need to use PA in obstetrics and gynecology is dictated by the fact that many pathological conditions in women occur against the background of pronounced changes in the system of regulation of the aggregate state of the blood, the circulation of vasoactive substances, and toxic substrates. These changes often prevent the compensation of central, organ and peripheral hemodynamics, and the therapeutic effect of PA is due to the impact on these factors.
As shown by previous studies, plasmapheresis is very effective in the treatment of pregnant women with early and late preeclampsia. After a course of therapeutic PA, patients have an increase in diuresis, a decrease in blood pressure, improved blood rheological properties, normalization of the acid-base state and gas composition of the blood, an improvement in biochemical parameters and fetal cardiotocogram data, a decrease in total peripheral vascular resistance, an increase in stroke and minute volume. blood. These changes in hemodynamic parameters, contributing to the normalization of organ and systemic blood flow, entail an improvement in the functional state of the kidneys.
At the same time, many issues of the use of PA in the treatment of pregnant women with preeclampsia remain unclear, PA regimens and volumes of plasma removed have not been developed, and the mechanisms of the therapeutic action of PA are unclear.
The issue of plasma compensation is also very important. During each PA procedure, it is advisable to administer an albumin solution, solutions of essential amino acids: alvesin, neframin, etc. Reopoliglyukin is also the drug of choice for plasma replacement in gestosis. It is attracted by its ability to reduce blood viscosity, restore blood flow in small capillaries, and prevent aggregation of blood cells. Reogluman has similar properties. It is acceptable to use hemodez, which promotes the elimination of toxic substances, which has diuretic activity.
Some authors advocate a selective approach in the treatment of patients with preeclampsia: with ineffective therapy for severe forms of the disease, hemosorption should be used, and for mild and moderate forms of the disease, more gentle methods of treatment should be used - plasmapheresis and plasmafiltration.
The inclusion of plasmapheresis in the treatment of pregnant women with immunoconflict between the mother and fetus can reduce or completely eliminate the effect of mother's isoantibodies on fetal erythrocytes and thereby reduce or prevent the development of hemolytic disease of the fetus and newborn. Plasmapheresis performed at various stages of pregnancy in women with Rh conflict, in combination with the introduction of immunoglobulin, has a significant positive effect on the outcome of pregnancy, reducing the likelihood of giving birth to children with edematous form of hemolytic disease of the newborn. Skachilova N.N. et al. revealed that PA is most effective in women who develop hemolytic disease of the fetus in the third trimester of pregnancy (after 24 weeks). PA reduces the titer of antibodies in the blood of a woman, which leads to a decrease in their content in the amniotic fluid and blood of the fetus.
Therapeutic plasmapheresis is used in the treatment of pregnant women suffering from pyelonephritis. With the use of PA in the complex treatment of pyelonephritis in pregnant women, clinical and laboratory signs of pyelonephritis disappeared faster, while the doses of antibacterial drugs were 1.5-2 times lower. Also, PA contributed to the elimination of the deficiency of the cellular link of immunity.
In recent years, plasmapheresis has been used in the clinic of miscarriage in women with chronic DIC, with lupus anticoagulant, which makes it possible to reduce the titer of lupus anticoagulant in blood plasma, reduce the doses of corticosteroid drugs and drugs that reduce platelet hyperaggregation.
Positive results were obtained in the treatment of pregnant women with genital herpes, cytomegalovirus infection. As a result of PA, the antibody titer decreased by 2–2.5 times.
Quite widely, plasmapheresis is used in obstetric and gynecological practice in the treatment of patients with peritonitis that occurred after gynecological operations, cesarean section, after septic abortion. In the absence of the effect of medications, plasmapheresis can be used in the treatment of acute and chronic inflammatory diseases of the internal genital organs. In recent years, the use of plasmapheresis has begun in the treatment of patients with ovarian hyperstimulation syndrome, with severe menopausal and post-castration syndromes. But many problems related to indications and contraindications for this type of therapy in patients with the above syndromes, the volume of plasma exfusion, the quality and volume of plasma replacement, possible complications and methods for their relief, remain not fully resolved, which requires further research using modern diagnostic, laboratory tests.
Efferent methods also began to occupy a significant place in the complex therapy of multiple organ failure syndrome (MODS), which develops as a result of massive bleeding. The use of plasmapheresis, hemofiltration has significantly reduced mortality in this pathology. Plasmapheresis in such patients is indicated for acute liver failure and the initial stages of acute renal failure, with replenishment of the exfused volume with an adequate amount of donor fresh frozen plasma, protein preparations.
With the formed acute renal failure, plasmapheresis is no longer advisable, since the replacement of the exfused volume with protein preparations will inevitably lead to an increase in azotemia. In this situation, it is advisable to carry out hemofiltration as the most gentle method. Further development of methods for the prevention and treatment of MODS in obstetric patients using the possibilities of extracorporeal detoxification methods seems to be very relevant and promising.
Effects of efferent methods on body systems
The accumulation of knowledge about the etiology and pathogenesis of diseases gives us reference points for explaining some of the effects of efferent therapies (EML). But since the process of cognition is endless, our ideas about the mechanisms of action of these methods will be constantly subject to adjustment. In view of the fact that the impact is carried out on such a multicomponent system as blood, the effects that arise in this case have a wide spectrum, many parts of which are still to be investigated.It should be borne in mind that a change in the concentration of substances that make up the blood causes their active diffusion from the interstitial fluid, which, in turn, can affect the intracellular concentration of these substances. Thus, the deficiency of proteins that occurs during PA stimulates their synthesis, involving various body systems in this process.
All effects of extracorporeal therapy methods are divided into three groups:
a) specific;
b) non-specific;
c) additional.
Among the specific effects, researchers distinguish the following main types of effects: detoxification, rheological correction and immunocorrection, increased sensitivity to endogenous and medicinal substances. The specific effects of extracorporeal hemocorrection are presented below:
1. Detox.
Elimination of toxic substances Extracorporeal biotransformation of toxic substances. "Unblocking" natural detoxification systems.
2. Reocorrection.
Decrease in blood viscosity. Decreased total peripheral resistance. Increased deformability of blood cells. Decreased aggregation characteristics of blood cells.
3. Immunocorrection.
Elimination of antigens, antibodies, CEC, immunocompetent cells. Unblocking the immune system. Change in the "direction" of the immune response.
4. Increased sensitivity to endogenous and drug substances.
Detoxification is achieved by extracorporeal elimination of exogenous and endogenous toxic substances. Exotoxins include substances that enter the body from the outside, disrupting the processes of information exchange at any level, from the expression and transcription of the genetic code to the disruption of the activity of organs and systems that determine the course of metabolic processes in the body and the maintenance of homeostasis.
When choosing a method of efferent therapy for the purpose of extracorporeal detoxification, in each case it is necessary to imagine with sufficient certainty the removal of which toxic substances will really break the vicious circles formed during the development of intoxication syndrome and endotoxicosis. At the same time, when using extracorporeal hemocorrection, a significant amount of substances that give bioregulatory effects are removed. The content of these substances, as a rule, is increased in acute and chronic endotoxicosis. Obviously, an excess of regulatory substances leads to a decrease and then to suppression of the sensitivity of the detoxification system to neuroendocrine regulation and determines a perverted response to drug therapy in these conditions. With a decrease in the amount of these regulatory substances below the critical level during the implementation of hemocorrection methods, the authors associate the so-called deblocking effect in relation to the detoxification system.
Extracorporeal methods also have an antioxidant effect. Elimination of free radical oxidation products from the body leads to an increase in the activity of antioxidant protection factors. In the manifestation of the antioxidant effect when applying the methods of extracorporeal hemocorrection, a certain injury of blood cells in the extracorporeal circuit also plays a significant role, since the main antioxidants are concentrated mainly intracellularly.
Authors who used extracorporeal methods of influence (PA, GS) in the complex treatment of surgical toxicosis associated with purulent-septic complications of organs abdominal cavity, septic conditions after gynecological operations, link the success of therapy with the removal of toxic substances, antibodies, CEC, bacteria and their toxins, vasoactive substances. In addition, it improves the rheological properties of blood, normalizes the function of the sympathoadrenal system, improves intestinal motility, increases diuresis, and normalizes cellular and humoral immunity.
In the treatment of chronic pyelonephritis in pregnant women and urosepsis, a positive effect was also achieved not only due to the elimination of intoxication products, but also the elimination of DIC, the removal of circulating immune complexes (CIC), fibrinogen, activation of the macrophage system due to the effect of "deplasmation", improvement antitoxic and protein-forming functions of the liver.
Thus, from these works it follows that another specific effect of efferent therapy is rheocorrective. This effect is realized through several mechanisms. First, the plasma and part of the formed elements are removed. Secondly, part of the plasma coagulation factors is excreted from the body or deposited on the elements of the extracorporeal circuit and module, including coarse proteins, the presence of which largely determines the level of blood plasma viscosity.
Also, on the elements of the extracorporeal system, a certain amount of mostly low-plastic blood cells is deposited, as a result of which its viscosity decreases and fluidity increases. Studies have shown that extracorporeal methods of therapy improve the elasticity of uniform elements. Also, the functional state of cell membranes changes, which, during chronic intoxication, absorb toxic substances on themselves. On the other hand, accelerated removal of platelets with low activity and a change in the functional state of their membranes can provide their pool with better functioning in the form of reverse aggregation and more complete disaggregation under the influence of targeted drugs and infusion agents. The change in the system of regulation of the aggregate state of the blood is especially clearly manifested during hemocorrection against the background of the syndrome of intravascular coagulation, which is part of the pathogenesis of many pathological conditions, including chronic recurrent salpingo-oophoritis.
The rheocorrective effect can also be caused by a change in the state of vascular tone and the microcirculation system due to a change in the ratio of vasoactive substances in the blood plasma during efferent methods of exposure.
The use of antiplatelet agents, anticoagulants and infusion therapy for the purpose of hemodilution can enhance the rheocorrective orientation of procedures.
Due to the combined action of all these mechanisms, there is a decrease in blood viscosity, an increase in the deformability of erythrocytes, which is realized in the improvement of microcirculation, an increase in the transcapillary regime, optimization of the oxygen regime, and normalization of altered tissue metabolism.
Vorobyov P.A., emphasizing the importance of using PA in the treatment of DIC, noted that during PA, plasma is purified from coarse components of tissue decay, vessels infiltrated by immune complexes are released, tissues are drained, aggregation and platelet activating factors are removed, and fibrinolysis is activated. , the activity of the macrophage system increases, the anticoagulant function of the endothelium is restored.
The next specific effect of hemapheresis methods is immunocorrection. It is implemented through several mechanisms. First, the mechanical removal of antigens, including autoantigens, from the bloodstream, which unloads for some time the specific immune mechanisms of their elimination, ensures an increase in the reliability of the functioning of these systems. The researchers noted that adequate functioning of the immune system typically continued for several months after extracorporeal unloading. Probably, the body "uses" the period of reduced antigenic load to restructure the activity of antigen elimination systems. The intimate mechanisms of this process are not yet fully understood, however, a similar clinical and laboratory effect has been described in many pathological conditions using efferent methods of therapy.
Also, a significant amount of antibodies (including autoantibodies) and products of their interaction with antigens (CEC) are removed from the patient's bloodstream, which, accumulating in excess, exacerbate violations of the body's natural detoxification systems.
Thus, in Rhesus sensitized pregnant women, sessions of extracorporeal hemocorrection (plasmapheresis, plasma sorption, plasma filtration) help to reduce the growth of antibody titer, which significantly increases the percentage of live births without severe forms of hemolytic disease. After PA, in patients with rheumatoid arthritis, in women with miscarriage and lupus anticoagulant, there was a significant decrease in the CEC level, and this decrease was greater than the expected calculated level, which the authors attribute to the unblocking of the system of phagocytic mononuclear cells.
The third mechanism of immunocorrection, the authors consider the change in the functioning of the elements of the monocyte-macrophage system. This mechanism is implemented through a change in the functional properties of the cell membranes of immunocompetent cells due to nonspecific activation upon contact with foreign surfaces of extracorporeal highways, plastic bags, etc. Researchers have shown that the components of the monocyte-macrophage system change their properties when the overall balance of lipid peroxidation processes and system factors antioxidant protection, which is rebuilt when using methods of extracorporeal hemocorrection.
To date, the mechanisms of influence of extracorporeal methods on the system of cellular immunity remain unclear. Thus, the intermittent method of plasmapheresis, yielding to the continuous method in execution speed, turns out to be a much more convenient model from a scientific point of view for studying the mechanism of action of plasmapheresis. It is possible to evaluate the contribution of the components of the procedure (removal of part of the blood from the bloodstream, its centrifugation, deplasmation of the obtained blood cells, their resuspension in saline, return to the bloodstream) in the overall clinical effect obtained.
Thus, this advantage of intermittent plasmapheresis was used in a study that showed the role of PA in restoring the functional activity of segmentonuclear neutrophils, reduced in patients with non-healing gastroduodenal ulcers. It was found that the restoration of the ability of cells to phagocytosis occurs due to leukocytes remaining in the bloodstream during plasmapheresis, as a reaction to the removal of part of the blood (usually 500 ml, which are temporarily switched off from circulation during PA). At the same time, leukocytes that underwent centrifugation retained low functional activity.
Functional and homeostatic reactions associated with the use of efferent therapy methods (additional effects) are mainly determined by the influence of a blood stabilizer, most often heparin, the administration of infusion, transfusion and targeted drugs and the use of substitution therapy, the possibilities of which are significantly expanded against the background of efferent therapy. Due to special transfusion and drug programs, it is possible, on the one hand, to significantly potentiate the specific actions of EML, and on the other hand, to neutralize or reduce their negative effects.
Postnikov A.A. (78) also singled out the diffusion mechanism of action of PA to explain the effectiveness of therapy in cases of treatment of patients with high levels of cholesterol, bilirubin, which, infiltrating tissues and organs, lead to atherosclerotic vascular damage, xanthomatosis, jaundice, and itching. Removal of plasma from the bloodstream leads to a decrease in serum levels of these metabolites, facilitating their diffusion from tissues and organs. This leads to regression of xanthomas, atherosclerotic vascular lesions, jaundice, and itching.
Nonspecific effects of extracorporeal circulation and blood processing are determined primarily by its contact with the surfaces of highways and bags. This initiates the reaction of those body systems that usually react to the introduction of immunoalien substances into the internal environment, despite the desire of technologists to maximize the biological compatibility of materials chosen for the production of extracorporeal highways, bags and other equipment. Nonspecific effects are manifested by hemodynamic reactions, redistribution of blood cells, activation of the endocrine system, catabolic reactions.
A number of authors include in the nonspecific mechanisms of EML a change in the activity of regulatory neurohumoral systems, which is included in the definition of "stress". Moreover, stress reactions can be divided into technological, associated with the use of one or another extracorporeal technology, and psycho-emotional, caused by excitement and expectation of the procedure, getting into an unusual environment of the procedural, pain during puncture or catheterization of a vein.
Thus, from the considered effects of EML exposure on the patient's body, it follows that their use can be accompanied by multidirectional and numerous specific and nonspecific effects. In this case, the overall effect will be the result of an ambiguous interaction and interference of mechanisms. Mechanisms for implementing the impact can significantly change depending on the initial state of the patient, the intensity of use and the type of EML, plasma-substituting therapy and concomitant basic treatment.
When using methods of efferent therapy in obstetric and gynecological clinics, it is necessary in each case, from a pathogenetic position, relying on known mechanisms of action on the body, to clearly formulate the purpose of their use, to analyze the indications and contraindications for this method of treatment. This will allow you to choose the optimal method, its mode of use, determine the necessary changes in basic therapy to improve the clinical effect of efferent methods and to prevent their possible complications.
V.N. Kulakov, V.N. Serov, A.M. Abubakirova, T.A. Fedorova
