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It is known that human health is laid even during the period of its intrauterine development. Many works indicate the connection of various diseases in children, especially such as allergies (including neurodermatitis, bronchial asthma), chronic bronchitis, kidney disease, with impaired pregnancy in their mothers. Moreover, there are direct links between the complicated course of pregnancy and the level of perinatal mortality.
Pregnancy toxicosis, or preeclampsia, is a severe complication of pregnancy, and 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 disorders 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 DIC syndrome with the risk of severe bleeding during childbirth.
Long-term presence of the fetus in conditions of such toxemia disrupts all the processes of development of its organs and systems, up to its intrauterine death. Newborn children, as a rule, suffer from encephalopathy with mental retardation, pneumopathy with a syndrome of respiratory disorders, hepato-nephropathy with the formation of chronic hepatitis and even early cirrhosis of the liver with portal bleeding during the first year of life, chronic pyelonephritis, and lagging behind in physical development.
Gestosis or toxicosis of pregnant women - this can be said to be the only disease in the name of which the concept of "toxicosis" is included, but the statement of this fact does not mean that detoxification is the main therapeutic measure. Instead of measures for the targeted removal of pathological products from the body of a pregnant woman, she is prescribed many different medications, often far from indifferent to the fetus.
On the other hand, it is obvious that instead of introducing some additional substances, on the contrary, pathological products should be removed and this can be done in the best way only with the help of efferent therapy.
Another danger threatens the development of the fetus - intrauterine infection if a pregnant woman has a syndrome of latent urogenital infections - chlamydia, mycoplasmosis, gardenellosis, lesions of 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., virtually infertility), premature birth and even intrauterine fetal death. However, even a child born alive has signs of serious disorders 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, is considered to be the weakening of the defenses of the body of women. Therefore, the most pathogenetically grounded 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 proved to be effective in the treatment of miscarriage caused by cytomegalovirus and herpes infection.
Efferent therapy is able to remove these pathological products of exogenous origin, incorporated both in the process of labor, activities in hazardous industries, and so. and as a result of living in contaminated areas. In cases of infertility caused by gonadotropic substances, paired 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 to women even before gestation, since it is known that both the laying of the main organs and systems and their malformations are formed already in the first trimester of pregnancy.
Plasmapheresis helps to promptly and effectively remove antibodies from the body of a pregnant woman in case of Rh-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 underline the relevance of preventive detoxification both before and during pregnancy in those cases when a complicated course and fetal pathologies can be expected. These measures are of particular importance when there are indications of an unfavorable course or outcome of a previous pregnancy. ...
Eclampsia. The increasing 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 gestosis, threatens with toxic cerebral edema (coma, convulsions, retinal detachment), toxic edema and hepatitis 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 a 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 recovery of the functions of the affected organs than the traditional therapy - medication, 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 press" from the kidneys is eliminated, and in the next few hours, the consciousness and airiness of the pulmonary parenchyma are restored. Delayed detoxification shows a slower reverse dynamics of organ damage.
As noted above, gestosis, accompanied by the same fetal toxemia, aggravated by intrauterine hypoxia, the consequences of exacerbations of chronic urogenital infection and Rh-conflicts between the mother and the fetus, lead to severe complications of the pre-, intra- and postnatal periods.
These complications are the main causes of intrauterine fetal death. They contribute to premature birth, in which, even when born alive, a 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 medications.
This is because in the circulation, interstitium and cells of the child's body there are huge quantities of various toxic products that do not give the opportunity to restore the normal metabolism of organs and tissues with the development of a number of vicious circles. Toxic press does not make it possible to establish the normal function of hepatocytes, alveolocytes, neurons, and renal parenchyma, which inhibits the restoration of natural processes of detoxification, excretion and gas exchange. Breaking these vicious circles without removing toxic products from the body is almost impossible, which explains the significant frequency of early neonatal mortality, and the 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, which 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 to newborns, including premature babies with a body weight of 700 g. The indications in such cases are complicated intrauterine infection, septic complications, the consequences of severe asphyxia, hyperbilirubinemia due to hemolytic disease of newborns. The mortality rate in these groups decreased by 35.3%. The time spent by children on mechanical ventilation, the need for infusion of cardiosympathomimetics, and the initiation 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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When treating gynecological patients, they often resort to one or another surgical intervention.
The outcome of each operation depends not only on how it is technically performed, but to a greater extent on the general state of the body, on the state and function of the central nervous system. Therefore, each patient must be properly prepared for the operation.
General preparation for surgery
The patient is greatly influenced by the behavior of the patients around her, as well as the nursing and service personnel. It is necessary to be attentive to the patient. It is necessary to create for her that medical and protective regime, which has already been mentioned.
In most patients, the thought of an 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 the 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 medications before surgery to improve the activity of the cardiovascular system. Patients with a low percentage of blood hemoglobin receive 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 performed mainly by celiac disease.
Depending on the nature of the upcoming operation, 1-2 days before it, the patient is directly prepared for the operation.
Hair from the vulva and surrounding areas is shaved off. The patient takes a shower. Underwear and bed linen are replaced.
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. 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 some white bread. It is necessary to ensure that the patient does not eat a lot, and also does not eat anything from the unauthorized foods. If the stomach is full, 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, sometimes douching with disinfectant solutions is performed before the operation.
Some operations require special preparation. So, when suturing large injuries of the perineum, 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 every day during this period she should be given an enema. For good healing of the surgical wound, it is necessary that these patients have no bowel action within 5-6 days after the operation; for this, it must be well cleaned in advance. In an operation for cervical cancer, although it is performed by gastrointestinal surgery, the vagina is 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 1% morphine solution, immediately before the operation, she must urinate.
In the preoperative room, a sterile shirt and stockings are put on the patient; the head should be covered with a headscarf that completely covers the hair. If an operation is to be performed under general anesthesia, it is desirable that it be started in the preoperative room, and not in the operating room itself, since the type of the operating table, instruments and the whole environment of the operating room worries the patient.
Various methods of pain relief are used in gynecological operations. Their choice depends on the patient's condition, 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 0.25% novocaine solution, 3) spinal anesthesia, 4) intravenous anesthesia (hexenal, pentothal sodium, etc.).
The technique for carrying out all the listed types of anesthesia is no different from that used in surgical operations.
Sterilization of instruments, material, suture material, as well as training 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 the preparation of the operating field is started.
Vaginal surgery
During vaginal surgery, the patient's legs are bent at the hip joints, placed 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 supports, a sheet can be used, as shown in fig. 134.
The preparation of the operating field is carried out either by the surgeon himself or by one of his assistants.
The vagina is opened with mirrors. Kornzang take a gauze ball, moisten it abundantly with alcohol and rub the cervix and the entire vagina with it. Then this is done again with a new ball, after which the excess alcohol is removed with dry gauze. With a new gauze ball, the cervix and the entire vagina are treated with 5% iodine tincture. The mirrors are taken out and put aside, since they are already dirty 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 processing 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 genitals remain open. The linen is fixed to the skin using special clamps (pins) or hemmed with silk.
In addition to the surgeon, during a vaginal operation, assistants (doctor, nurse), an anesthetic and an operating nurse are also involved. During the operation, a nurse who is well aware of the operation of the operating room must always be present.
Some of the operations performed by the vaginal route have already been provided earlier (biopsy, puncture of the posterior fornix, curettage of the uterine cavity, artificial miscarriage).
Of the other operations, the following are often performed.
Removal of the Bartholin gland cyst.
The operation consists in the fact that the skin covering the cyst is cut, after which the tumor is removed from its bed and the wound is sutured.
Removal of the cervical polyp. After exposing the neck with mirrors, the polyp is cut off at its base. Bleeding almost never occurs during surgery, so sutures are usually not applied.
Plastic surgery on the perineum. 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 wound of the vagina is sutured with catgut sutures, and the skin with silk sutures. The seams are treated with 5% iodine tincture and a gauze pad is placed on the perineum.
In addition to these operations by the vaginal route, other operations are performed, such as restoration of the integrity of the cervix after its rupture, amputation of the vaginal part of the cervix. Sometimes, although rarely, more complex operations are performed by the vaginal route, for example, removal of the uterus and its appendages, suturing of fistulas, etc.
Abdominal operations
For the production of the operation by the abdominal way (gluttony), the patient is placed on the operating table on his back. The leg 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 takes an inclined position (Fig. 192). In this position, the patient's intestines are displaced upward and the pelvic organs become clearly visible and accessible for surgery.
The operating field is prepared by the operating assistant. The skin of the abdomen, pubis and the area of the groin folds are wiped 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 with a longitudinal incision along the midline of the abdomen below the navel, or with a transverse incision in the lower abdomen slightly above the pubic articulation.
Of the operations performed by gastrointestinal surgery, a cesarean section has already been indicated above. Of gynecological operations, the following are most often performed:
Amputation of the body of the uterus. This operation is performed with fibroids, with damage to the uterus (criminal abortion, rupture of the uterus) and for some other indications. First, tubes and round ligaments are cut off from the uterus. Then the body of the uterus is cut off from the cervix and the peritoneum in the pelvic area is sutured. After that, the abdominal wall is sutured in layers. Silk stitches or braces are applied to the abdominal skin 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
(gluttony).
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, and the round ligaments are also cut off. After that, the entire uterus is removed or only its body, and the cervix is left. Removal of the uterus with appendages is done for various diseases, including cancer. In this case, all peri-uterine tissue is also removed. The lymph nodes in it are often affected by cancer.
Removing the pipe. This operation is performed mainly for ectopic pregnancies. It consists of 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 tied up and cut. Sometimes the ovary is removed along with the tube.
A significant number of other operations are performed by gastrointestinal surgery, such as suturing round ligaments, exfoliation of tumors from the body of the uterus, ligation of tubes, etc.
In addition to the surgeon, one or two assistants (doctors), an anesthetist and an operating nurse take part in operations performed by gastrointestinal surgery.
A nurse must be in the operating room all the time.
Tissues and organs removed during gynecological operations are not thrown away. They are placed in glassware, poured with 10% formalin solution and sent along with an accompanying note to the laboratory for microscopic examination.
An indicative list of instruments for operations performed by gluttony
Abdominal mirrors 2
Abdominal flap mirrors ... 1
Hooks for wounds ............................................... ............ 2
Straight scissors 2
Curved scissors ................................................ .... 2
Scalpels ................................................. ................. 2
Long tweezers 4
Anatomical forceps .............................................. 4
Surgical tweezers .............................................. 4
Kocher clamps ................................................ ............ 6
Kocher clamps are long. 12
Pean Clamps ................................................ ........... 12
Mikulich's clamps ................................................ ..... 10
Kornzangi ................................................. ................ 6
Musot Forceps ................................................ ............. 4
Bullet forceps ................................................ .......... 6
Intestinal pulp ................................................ ......... 2
Uterine corkscrew 1
Curettes ................................................. ............. 2
Ovarian forceps ........................................... 2
Uterine probe ................................................ .... one
Probe grooved ......................................... ....... ...... one
Spatulas ................................................. ............ 2
Needle Holders ................................................. ... 4
Needles in various sizes. ... ... ... 12
Intestinal needles ................................................ ... 6
Deschamps needles ................................................ .... 2
Parentheses................................................. .... twenty
Tweezers for applying staples. 2
Pins ................................................. ................ 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, back and side.
Female catheter ................................................ . one
Pregnant women are considered one of the most vulnerable categories of patients who are susceptible not only to infectious and respiratory diseases, but also to various disorders in the work 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 changes in hormonal levels. 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 restoration of the skin and mucous membranes after damage.
DIC syndrome is a fairly common pathology of hemostasis during pregnancy. This is the process of active leaching of thromboplastin (an external stimulator of the coagulation process) from tissues and organs, which leads to a violation of blood clotting. In medical practice, this condition is called "disseminated intravascular coagulation." The syndrome is dangerous for the asymptomatic course and the rapid development of systemic coagulopathy, therefore, 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 the physiological processes occurring in a woman's body during pregnancy, but in the overwhelming majority of cases (more than 94%), such symptoms are the result of certain pathologies.
Fetal death
One of the causes of acute disseminated intravascular coagulation at any gestational age is intrauterine fetal death and pregnancy fading... This can happen for a number of reasons, but the most common ones are:
- the mother is taking toxic drugs and strong drugs;
- amniotic fluid embolism (the ingress of amniotic fluid into the pulmonary arteries and their branches);
- presentation or placental abruption;
- acute alcoholic or drug intoxication of the fetus;
- tumors of the outer cell layer of the placenta (trophoblast).
One of the causes of pathology is fetal death
Fading of pregnancy can occur at any time, but disseminated intravascular coagulation syndrome appears only 4-6 weeks after antenatal fetal death. The 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 an ultrasound scan, 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 syndrome of 4 degrees can lead to the death of a woman, therefore, for any signs indicating a possible termination of pregnancy, it is necessary to immediately contact the department of pregnancy pathology at the district maternity hospital.
Preeclampsia and the initial signs of preeclampsia
Gestosis ("late toxicosis") is the most common pathology of pregnant women, which is faced by almost 60% of women. Gestosis has three main features that make it possible to diagnose pathology at an early stage:
- a stable increase in blood pressure with a weak response to ongoing drug correction;
- detection of protein or its traces in urine;
- edema on the face and limbs, most often having a generalized form.
Women with diagnosed preeclampsia should be under constant supervision of specialists, since progressive forms of pathology can cause the development of preeclampsia - cerebrovascular accident against the background of late toxicosis in the second half of pregnancy. Another danger of gestosis is damage to endothelial cells (single-layer flat cells that cover the surface of the heart cavity, lymphatic and blood vessels). If the integrity of the endothelium is compromised, disseminated intravascular coagulation (DIC) may develop, requiring close monitoring and timely emergency care.
Other reasons
The causes of disseminated intravascular coagulation can be of infectious origin. Infection of amniotic waters, lingering bacterial infections of internal organs in the mother, increasing the risk of bacteria and their toxins entering the bloodstream - all this can cause clotting disorders and systemic coagulopathy, therefore it is important to treat any diseases of an infectious nature on 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 reaches the fetus.
Other causes of acute disseminated intravascular coagulation can be:
- surgical operations performed during pregnancy with blood or plasma transfusions (the risk increases if blood that is not compatible with the group or Rh factors was used for the transfusion);
- damage to cells of the erythrocyte or platelet mass;
- prolonged uterine bleeding, leading to the development of hemorrhagic shock;
- rupture of the uterus;
- atony of the muscles of the uterus (decreased muscle tone);
- medical massage of the uterus.
Infectious diseases, burns, skin injuries, shock conditions of various origins, pathologies of the placenta can also cause coagulopathy, so it is important for a pregnant woman to undergo the examinations prescribed by the doctor and take the necessary tests on time.
Symptoms: when should you see a doctor?
The danger of disseminated intravascular coagulation syndrome lies in its almost asymptomatic course.... In most cases, pathology can be determined only after laboratory diagnostics, which can determine hematological disorders (changes in blood chemical parameters). With disseminated intravascular coagulation syndrome of grade 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, is 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 injury or other damage;
- bleeding gums (provided that the woman does not suffer from inflammatory periodontal and periodontal disease, as well as gingivitis);
- bruising that forms on various parts of the body without exposure to any damaging factors;
- uterine bleeding and bleeding;
- poor wound healing;
- the release of blood at the injection sites.
A woman may also feel constant weakness, her performance is impaired, and increased drowsiness appears. With frequent bleeding, there are constant headaches, dizziness, a feeling of squeezing in the temporal and occipital zones. All these signs are the reason for carrying out diagnostic measures, therefore, if they occur, you should immediately consult a doctor leading a pregnancy.
Symptoms of pathology depending on the stage
In total, there are 4 stages of DIC syndrome, 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 the syndrome of disseminated intravascular coagulation and their signs.
Important! Grade 4 thrombohemorrhagic syndrome 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 therapy 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 duration of pregnancy). The choice of the method depends on the general condition of the woman, the stage of the existing disorders and other factors. For artificial stimulation of labor activity, "Oxytocin" is injected intravenously, causing uterine contractions and labor pains. After removing the fetus from the uterus, the woman is prescribed a course of antibacterial and anti-inflammatory drugs (Metronidazole, Tsiprolet, Tetracycline), as well as hematological control for 6 months.
With gestosis, the administration of drugs to normalize blood pressure is indicated. The drug of choice during pregnancy is Dopegit (analogue - Methyldopa). It is a stimulant of central adrenergic receptors with a pronounced therapeutic effect in essential and secondary hypertension, including hypertension of pregnancy. The therapeutic dose is 250 mg, which must 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. It is a herbal diuretic, 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 (brew one collection bag per glass of boiling water).
For severe edema, the doctor may prescribe Furosemide. This is a fairly toxic diuretic, so you cannot take it without a doctor's prescription. To normalize the functioning of the kidneys and urinary tract during pregnancy, "Kanefron" is used - an antiseptic of plant origin in the form of pills and solution.
First aid for disseminated intravascular coagulation
Intravenous administration of "Heparin" is indicated as an emergency aid in acute disseminated coagulation syndrome. It can be given as a stream or used for infusion (using a dropper). The starting dose is 5000 IU. Supportive therapy involves the use of an infusion pump. The dosage is 1000-2000 IU / hour.
To normalize the condition, therapy can be supplemented with protease inhibitors (Trasilol, Kontrikal, Gordox), but the drugs of this group can only be used as directed by a doctor.
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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 the environment and shifts occurring 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 body's liquid base - tissue fluid and blood. This constancy is provided 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 amount and ratio. Dysfunctions of individual organs, their insufficiency inevitably entail changes in the composition of the body's fluid base and disruption of the physiological processes of other organs and systems.
EML are based on four main processes: diffusion, filtration (convection), sorption, gravity-centrifugation.
Moreover, each of the methods for restoring homeostasis, based on the elimination of metabolic products and toxic substances from the body, has its own capabilities for removing substances of a certain molecular weight, its advantages and disadvantages. So, hemodialysis (HD) and peritoneal dialysis (PD) are able to effectively remove substances with low molecular weight, hemosorption (HS) and plasmasorption (PS) - mainly substances with an average molecular weight (from 500 to 5000 daltons), plasmapheresis (PA) is able to remove all blood plasma, cascade plasma filtration (CPF) - only part of plasma with high molecular weight, including low density lipoproteins and immunoglobulins, immunosorption (IP) is able to selectively extract substances with different molecular weights. Cytapheresis (CF) removes various blood cells.
Diffusion-based treatment methods
The high efficiency of HD use is currently due to the high permeability and clearance of the dialysis membrane for creatinine and urea, early onset of dialysis and its combination with the use of Recormon, etc., which allows patients to maintain a fairly good quality of life for decades.Hemodiafiltration is a combination of diffusion and high volume hemofiltration, which makes it more effective for 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 can easily endure 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 70s, the methods of isolated ultrafiltration (IUF) and hemofiltration (GF) have been used in practical medicine. These methods are successfully used in patients with renal failure, in the treatment of heart failure and in ischemic heart disease, congenital and acquired heart defects, cardiomyopathies, diuretic resistance to eliminate overhydration, in the treatment of nephrotic syndrome, hyperosmolar coma, with severe exogenous intoxication, with purulent - septic complications.The mechanism of action of IFU and GF consists in the convective release of blood from water and substances dissolved in it by creating an increased positive hydrostatic pressure from the blood side or rarefaction from the outer side of a semipermeable membrane. Excess fluid (overhydration) leads to serious consequences for the patient. Heart failure, ascites, hydrothorax, pulmonary edema, cerebral edema appear. 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 in heart rhythm disturbances.
IUF allows you to immediately start removing fluid, remove it at a given rate, in the required volume and, if necessary, stop it, leading to the elimination of overhydration, relief of pulmonary edema, brain, etc. The good tolerance of IUF is due to the stable electrolyte composition and osmolarity of the plasma, and an increase in the oncotic pressure of the plasma. This ensures an adequate flow 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 with HF is usually much greater than that with 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, replacing a significant part of the water frees 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 GF with the replacement of 40-50 l of fluid is slightly less than that in hemodialysis, and the clearance of "medium" molecules is much higher. Accurate replacement of fluid losses avoids complications even at a high rate of fluid exchange due to the maintenance of a stable osmolality of the internal media of the body. FTI and GF 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).
Considering the mechanism of action, the use of IFU and GF 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, Sjogren's disease, rheumatic vasculitis, and polyneuropathy.
With PF, after blood separation on the apparatus, the erythromass is immediately returned to the patient, and the separated plasma, before returning, passes through a fiber filter that retains proteins with high molecular weight (IgM, immune complexes, low density lipoproteins). At the same time, the albumin fraction of plasma proteins almost completely passes through the filter and returns to the patient. Partially return IgG (55%), IgA (40%), high density lipoproteins. The advantages of this method are obvious: no plasma substitution is required, which eliminates the potential risk of allergic reactions to protein preparations, colloidal solutions, there is no danger of transmission of viral infections with foreign plasma.
PF can also be used in the treatment of pregnant women with gestosis, hypertension, diabetes mellitus, myasthenia gravis, in septic conditions after gynecological and obstetric operations, in acute and chronic inflammation of the internal genital organs in women. The method of cascade plasma filtration allows removing only the high-molecular part of the plasma, which in most observations does not require replacement of the removed volume with proteins.
Sorption-based treatment methods
The simplest and most widely used method of treatment from this group in our country is hemosorption (HS), which makes it possible 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, the volume of circulating blood, the number of platelets. , microhemocirculation.As a sorbent, activated carbon of various brands is used, which is produced by the industry in standard sealed vials. They are sterile, pyrogen-free, and have the ability to absorb a number of toxic products due to their porous structure.
The most selective and high-tech method is hemosorption using various immunosorbents capable of specifically removing various antibodies, proteinases, immunoglobulins, low-density lipoproteins, lipoprotein (a), etc. from blood plasma. Selective HS increases the therapeutic effect and prevents intoxication. 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 to significantly reduce the dose of glucocorticoid drugs and other medications. HS is increasingly used as a method of intensive therapy for patients with liver diseases, viral and chronic hepatitis, meningococcal infection, and leptospirosis. It is possible to use HS in the complex treatment of rheumatic diseases, septic conditions, hypertension.
In recent years, works have appeared on the use of HS in obstetric and gynecological practice, in particular in the treatment of late toxicosis of pregnant women. Researchers suggest starting HS in pregnant women with toxicosis as early as possible, which allows a pronounced clinical effect to be achieved. 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 HS should be used for hepatic and renal insufficiency. HS is also used in the treatment of immunological conflict during pregnancy, hemolytic disease of the fetus and newborn. After HS, the antibody titer significantly decreases, the general condition of pregnant women, liver and kidney function improves. HS should be started as early as possible if the woman has a high titer of antibodies and the fetus has signs of hemolytic disease according to ultrasound.
A pronounced clinical effect was also obtained with the use of HS in the complex therapy of septic conditions in obstetric and gynecological practice. After HS, there is an improvement in the general condition, an improvement in blood counts, kidney and liver function, respiratory function, and 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 the favorable results of the use of HS, especially in combination with other methods of exposure, in particular with ultraviolet irradiation of blood, hemodialysis, plasmapheresis and plasma absorption.
Therapies based on gravity or centrifugation
In clinical practice, the use of plasma and cytapheresis is constantly expanding. Plasmapheresis (PA) is the extraction of plasma using the apheresis process. At first, this term was used to denote the extraction of plasma from healthy donors. Today the term is used to refer to the plasma extraction process as a therapeutic procedure. PA was introduced into clinical practice in the 60s.Plasma and cytapheresis are widely used in various fields of medicine, in particular in the blood service; in clinical medicine for intoxication 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; deplasmization of cellular "cleansing" systems and blood cells; an increase in functional activity and a change in the vital activity of hematopoietic, stromal, immunocompetent cells; unblocking of natural organs of "cleansing" and phagocytic system; elimination of the phenomenon of plasma optical turbidity; improvement of microcirculation, extracorporeal effect on reinfused blood cells.
Due to the above effects of action, in recent years, plasmapheresis has begun to be 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 blood, circulation of vasoactive substances, and toxic substrates. These changes often impede the compensation of central, organ and peripheral hemodynamics, and the therapeutic effect of PA is due to the effect on these factors.
Previous studies have shown that plasmapheresis is very effective in the treatment of pregnant women with early and late gestosis. After a course of therapeutic PA in patients, there is an increase in diuresis, a decrease in blood pressure, the rheological properties of blood improve, the acid-base state and gas composition of the blood normalize, there is 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 questions of the use of PA in the treatment of pregnant women with preeclampsia remain unclear, PA regimens, the volume of plasma removed, are unclear, the mechanisms of PA therapeutic action are unclear.
The issue of plasma displacement is also very important. During each PA procedure, it is advisable to introduce a solution of albumin, solutions of essential amino acids: alvezin, nephramine, etc. Rheopolyglucin 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 the aggregation of blood corpuscles. Reogluman has similar properties. It is permissible to use hemodesis, which promotes the elimination of toxic substances and has diuretic activity.
Some authors advocate a selective approach in the treatment of patients with gestosis: 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 plasma filtration.
The inclusion of plasmapheresis in the treatment of pregnant women with immunoconflict between the mother and the fetus makes it possible to reduce or completely eliminate the effect of maternal 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 administration of immunoglobulin, has a significant positive effect on the outcome of pregnancy, reducing the likelihood of having children with edematous hemolytic disease of newborns. Skachilova N.N. et al. revealed that PA is most effective in women in whom hemolytic disease of the fetus develops 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 the blood of the fetus.
Therapeutic plasmapheresis is used in the treatment of pregnant women suffering from pyelonephritis. When using PA in the complex treatment of pyelonephritis in pregnant women, the clinical and laboratory signs of pyelonephritis disappeared faster, while the doses of antibacterial drugs were 1.5-2 times lower. PA also 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 disseminated intravascular coagulation syndrome, with lupus anticoagulant, which makes it possible to reduce the titer of lupus anticoagulant in the blood plasma, to reduce the dose 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 2-2.5 times.
Plasmapheresis is widely used in obstetric and gynecological practice in the treatment of patients with peritonitis arising after gynecological operations, caesarean section, after septic abortion. In the absence of the effect of drugs, 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 climacteric and post-castration syndromes. But many problems concerning the 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 of 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 (SPD), which develops as a result of massive bleeding. The use of plasmapheresis and hemofiltration made it possible to significantly reduce mortality in this pathology. Plasmapheresis in such patients is indicated for acute liver failure and the initial stages of acute renal failure, with replacement 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 of prevention and therapy of SPON in obstetric patients using the capabilities of methods of extracorporeal detoxification seems to be very relevant and promising.
Effects of the influence of efferent methods on body systems
The accumulation of knowledge about the etiology and pathogenesis of diseases provides us with anchor points for explaining some of the effects of efferent therapies (EMT). But since the process of cognition is endless, then our ideas about the mechanisms of action of these methods will be constantly subject to correction. In view of the fact that the effect is carried out on such a multicomponent system as blood, the effects arising 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 making 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 arising in PA stimulates their synthesis, involving various systems of the body in this process.
All the 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 drug substances. The specific effects of extracorporeal hemocorrection are presented below:
1. Detoxification.
Elimination of toxic substances Extracorporeal biotransformation of toxic substances. "Unblocking" of natural detoxification systems.
2. Re-correction.
Decreased blood viscosity. Decrease in total peripheral resistance. Increased deformability of blood cells. Decrease in the 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 medicinal substances.
Detoxification is achieved by extracorporeal elimination of exogenous and endogenous toxic substances. Exotoxins include substances that have entered 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 understand with sufficient certainty the removal of which toxic substances will actually 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 a suppression of the sensitivity of the detoxification system to neuroendocrine regulation and determines a perverse response to drug therapy in these conditions. The authors associate the so-called unblocking effect on the detoxification system with a decrease in the amount of these regulatory substances below the critical level when carrying out hemocorrection methods.
Extracorporeal methods also have antioxidant effects. Elimination of free radical oxidation products from the body leads to an increase in the activity of antioxidant defense factors. In the manifestation of the antioxidant effect when using the methods of extracorporeal hemocorrection, a certain trauma of blood corpuscles in the extracorporeal circuit also plays a significant role, since the main antioxidants are concentrated mainly intracellularly.
The authors who used extracorporeal methods of exposure (PA, GS) in the complex treatment of surgical toxicosis associated with purulent-septic complications of the abdominal organs, septic conditions after gynecological operations, associate the success of therapy with the removal of toxic substances, antibodies, CIC, 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 urine output, 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, removal of circulating immune complexes (CIC), fibrinogen, activation of the macrophage system in connection with the effect of "deplasma", improvement antitoxic and protein-forming function of the liver.
Thus, it follows from these works that another specific effect of efferent therapy is re-correction. This effect is realized through several mechanisms. First, the plasma and some of the corpuscles are removed. Secondly, some of the plasma coagulation factors are removed 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 mainly low-plastic blood cells settles, as a result of which its viscosity decreases and its fluidity increases. Studies have shown that with extracorporeal methods of therapy, the indicators of the elasticity of the shaped elements improve. At the same time, the functional state of cell membranes changes, which, during chronic intoxication, absorb toxic substances on themselves. On the other hand, the accelerated removal of low-activity platelets 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 blood is especially clearly manifested during hemocorrection against the background of intravascular coagulation syndrome, which is part of the pathogenesis of many pathological conditions, including chronic recurrent salpingo-oophoritis.
The re-correcting effect can also be caused by a change in the state of the 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 be used to enhance the re-corrective 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.
Vorobiev P.A., emphasizing the importance of the use of PA in the treatment of disseminated intravascular coagulation syndrome, noted that during PA, plasma is purified from coarse components of tissue decay, vessels infiltrated by immune complexes are released, tissues are drained, factors of aggregation and activation of platelets are removed, 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 from the bloodstream, including autoantigens, which unloads the specific immune mechanisms of their elimination for some time, provides an increase in the reliability of the functioning of these systems. The researchers noted that adequate functioning of the immune system usually continues for several months after extracorporeal discharge. Probably, the body “uses” the period of low 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 the products of their interaction with antigens - CECs - are removed from the patient's bloodstream, which, accumulating in excess amounts, aggravate the disruption of the body's natural detoxification systems.
Thus, in Rh sensitized pregnant women, extracorporeal hemocorrection sessions (plasmapheresis, plasmasorption, plasma filtration) help to reduce the increase in 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, a significant decrease in the level of CEC was noted, and this decrease turned out to be more significant than the expected calculated level, which the authors associate with unblocking the system of phagocytic mononuclear cells.
The authors consider the change in the functioning of the elements of the monocytic-macrophage system as the third mechanism of immunocorrection. This mechanism is realized 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. antioxidant protection, which is rebuilt when using methods of extracorporeal hemocorrection.
To date, the mechanisms of the effect of extracorporeal methods on the cellular immunity system remain unclear. Thus, the intermittent method of plasmapheresis, yielding to the continuous method in the speed of execution, turns out from a scientific point of view to be a much more convenient model for studying the mechanism of action of plasmapheresis. It is possible to assess the contribution of the components of the procedure (removal of a part of the blood from the bed, its centrifugation, deplasmization of the obtained blood cells, their resuspension in saline, return to the bloodstream) to the resulting total clinical effect.
Thus, this advantage of intermittent plasmapheresis was used in a study that showed the role of PA in restoring the functional activity of segmented nuclear neutrophils, which is 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 a part of the blood (usually 500 ml, which are temporarily turned off from circulation during PA). At the same time, the 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 introduction of infusion, transfusion and targeted drugs and the use of substitution therapy, the possibilities of which significantly expand 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, to neutralize or reduce their negative effects.
A.A. Postnikov (78) also identified the diffusion mechanism of PA action to explain the effectiveness of therapy in the treatment of patients with high cholesterol and bilirubin levels, which, infiltrating tissues and organs, lead to atherosclerotic vascular lesions, xanthomatosis, jaundice, and itching. Removal of plasma from the bloodstream leads to a decrease in the level of these metabolites in the serum, facilitating their diffusion from tissues and organs. This leads to regression of xanthomas, atherosclerotic vascular lesions, jaundice, itching.
The nonspecific effects of extracorporeal circulation and blood processing are determined primarily by its contact with the surfaces of highways and sacs. At the same time, the reaction of those body systems is initiated, which usually respond to the introduction of immune-alien substances into the internal environment, despite the desire of technologists to maximize the biological compatibility of materials selected for the production of extracorporeal lines, 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 changes in the activity of regulatory neurohumoral systems in the nonspecific mechanisms of EML, which are included in the definition of "stress". Moreover, stress reactions can be divided into technological, associated with the use of a particular extracorporeal technology, and psychoemotional, caused by excitement and expectation of the procedure, getting into an unusual procedural environment, painful sensations during puncture or catheterization of a vein.
Thus, from the considered effects of EML 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 ambiguous interaction and interference of mechanisms. The mechanisms for the implementation of the effect can significantly change depending on the initial state of the patient, the intensity of use and the type of EML, plasma replacement therapy and concomitant basic treatment.
When using the methods of efferent therapy in obstetric and gynecological clinics, it is necessary in each specific case from a pathogenetic point of view, relying on the known mechanisms of influence on the body, to clearly formulate the purpose of their application, to analyze the indications and contraindications to this method of treatment. This will allow you to choose the optimal method, its mode of use, to determine the necessary changes in the 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
