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A.B. TUSSUPKALIYEV, S.S. ZHUMAGULOVA, A.N. GAIDAY, L.K. SARSEMBAYEVA, L.K. AYAZBAYEVA
DIAGNOSTICS OF HYPERTENSIVE DISORDERS IN PREGNANCY
West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
Department of obstetrics and gynecology №2
A.B. Tussupkaliyev-Candidate of Medical Sciences, Head of Department;
S.S. Zhumagulova- Candidate of Medical Sciences, Head of laboratory of RPC;
A.N. Gaiday- PhD student, phone: 8 775 645 94 95, e-mail: [email protected];
L.K. Sarsembayeva - Assistant;
L.K. Ayazbayeva - Resident student.
Abstract. The article is devoted to the study of the state of platelet hemostasis in patients with hypertensive states during pregnancy. The determination is devoted to the study on the absolute number of platelets (PLT) and platelet indices - the average size of platelets (MPV), heterogeneity of platelets (PDW), thrombocrit (PCT), and the degree of platelet aggregation. The prospective observational cohort study is conducted. The characteristics of platelets in uncomplicated pregnancy, hypertension during pregnancy, mild and severe preeclampsia are studied. Data analysis shows statistically significant indicators of platelet dysfunction in mild and severe preeclampsia. Based on these results of the authors propose the need to identify platelet dysfunction in the diagnosis of pre-eclampsia.
Key words: pregnancy, hypertension, preeclampsia, diagnostics, platelets.
^ solution to this dissatisfaction may reduce ^ monitoring costs by reducing unnecessary ^ hospitalizations and improve maternal ^ and perinatal outcomes associated with ^ the use of treatment on the background ^ of overdiagnostics [8]. ^ Today for the diagnosis of pre-eclampsia use only terms of absolute ^ number of platelets (PLT), although, it is important to determine the degree of ^ platelet dysfunction.
Materials and methods.
The work was performed under ^ the scientific and technical program ^ "Development of new technologies of ^ child health with reproductive health".
I
Study design:
prospective
^ observational cohort study.
Relevance. Hypertensive ^ and symptoms, proteinuria and other ^
complications observed in 12-22% ^laboratory changes [1,5]. of all pregnancies and are one of the Modern principles of management diagnostic criteria-
The term hypertensive status during pregnancy included the following hypertension
I
main factors of maternal and neonatal of pregnant women with risk factors
^ (mild) - systolic blood pressure >140
morbidity and mortality [1]. According to ^ for hypertension during pregnancy do ^
^ mm of mercury.St. and/or diastolic
the world health organization, maternal | not provide adequate reduction in the | pressure mm of mercury.St. two
mortality in hypertensive complications | frequency and quality of diagnosis, | measurements with an interval of at least
. . , r ^ f« 30 minutes; severe hypertension diastolic
during pregnancy occurs in 16% in therefore, further improvement of S;
industrialized countries [2] and to 25% in | diagnostic methods based on identified | blood pressure -110 mm Hg.St two developing countries [3], although most | risk factors [6]. Currently, the "gold | measurements with an interval of at least deaths due to preeclampsia and eclampsia | standard" for the diagnostics of pre-| 30 minutes; or systolic pressure S16° mm
can be avoided by timely diagnosis and | eclampsia is used in the measurement | Hg.St two measurements with an interval
r « , ,, , jji-^ r of at least 30 minutes; Proteinuria is > 0.3
treatment. Outcomes of pregnancy S; of blood pressure and determination of S;
complicated by hypertension, in most | protein in urine. However, because of | g/day or 03 g/l twice urine sample taken
^ ^ after 4 hours
cases not cause any major concerns, but ^ its syndromal nature and the different ^
I
sometimes these complications can have clinical trag [4].
picture, the specificity and ^
Chronic
hypertension is
tragic consequences for mother and child ^ reliability of these assessments to predict ^ hypertenslon diagnosed before
% , i , i % pregnancy or before 20 weeks of
S; the development of preeclampsia or S;
by I eclampsia is to assess the degree of | pregnancy. Hypertension caused by
Complicated pregnancy _______,____ „ ______ ....__0...
j- j ■ i j « u i ■ ■ ri- cfc pregnancy (gestational) is hypertension
hypertensive disorders includes a hemolysis, increase of liver enzymes, ^ ° ' '
spectrum of clinical manifestations from | and low platelet count [7]. However, | arising after 20 weeks of pregnancy. Mild
mild to severe forms, the classification | there remains significant dissatisfaction | preeclampsia - mild hypertension and
of which depends on the severity of | with practitioners in short-term reliable I proteinuria not more than 3G/l, with mild
hypertension, presence of clinical signs | diagnosis in suspected pre-eclampsia. The | to moderate edema, with or without.
Severe preeclampsia is a severe arterial
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hypertension with proteinuria with generalized or rapidly progressive, with or without oedema or hypertension of any severity with proteinuria attach one of the symptoms: severe headache, blurred vision, swelling of optic disc, epigastric pain and/or nausea, vomiting, convulsive, generalized edema, oliguria (less than 30 ml/hour or less than 500 ml of urine in 24 hours), tenderness to palpation of the liver, platelet count below 100x10/6 g/l, elevated liver enzymes, HELLP-syndrome [9,10]. Measurement of systolic and diastolic blood pressure performed in sitting or half-sitting sphygmomanometer with calibrated according to standards. Determination of the level of proteinuria underwent standard quantitative method.
All of the investigated blood sampling was carried out in conventional manner, upon admission to the hospital, after voluntary informed and written consent for participation in the study. From the study excluded cases of pre-hospital treatment and prevention of hypertensive states, including the use of antiplatelet agents and anticoagulants, to avoid impact on the hemostatic system in the form of side effects.
Morphometric determination of the platelets was carried out on automated Hematology analyzer MEK 7222 (Japan). Characteristics of the platelets was determined by the following parameters: platelet count (RLT), total platelets (PST), the average volume of platelets (MPV), the index of anisocytosis PDW. Platelet aggregation was determined by Agresin - test (Russia). Statistical analysis of the data conducted by the Department of Biostatistics" SCHMO named after M. Ospanov, a program for statistical data processing STATISTICA 10. To determine the type of distribution was applied the method of Shapir-Wilk. For data with normal distribution, parametric methods are applied: 95% CI, student's
^ t-test applied to test the hypothesis, the ^ ^ coefficient of correlation was determined ^ ^ by Pearson correlation method. ^
^ The purpose of the study: ^
^ to assess the state of platelet ^ ^ dysfunction in hypertension during ^ ^ pregnancy.
¡^ piegnancy. ¡^
^ Objectives of the study: ^
^ to determine quantitative and ^ ^ qualitative characteristics of platelets of ^ ^ healthy pregnant women and in groups ^ ^ with hypertensive states; ^
^ to reveal the relationship of platelet ^ ^ dysfunction in relation to hypertensive ^ states;
based on the study of basic units ^ of platelet dysfunction in hypertension ^ ^ to develop effective methods of early ^ ^ diagnosis of this complication of ^ ^ pregnancy. ^
^ Results. ^
^ The study was conducted from ^ ^ March 2014 to June 2015, 96 women with ^ ^ clinical manifestations of the hypertensive ^ ^ syndrome and healthy pregnant women ^ were surveyed. All studied were divided into 4 groups depending on the type and severity of hypertension.
» The first group consisted of 26 ¡S
studied with uncomplicated pregnancy
without hypertension.
The II group included 23
^ pregnant women with chronic arterial ^
hypertension, the III group included 24 pregnant women with preeclampsia mild and severe preeclampsia 23 pregnant women were included in the IV group.
The average age of the studied groups were: group I 26±1.3 years, group II 28±1.5 years, group III 29±1.2 years, group IV 30±2.2 years. Clinical characteristics of the groups are presented in tables 1,2.
The study of morphological and functional properties of thrombocytes in the group of healthy pregnant women showed that the total number of platelets in the blood match (214,2±11,6x109/l, 95% CI) and was significantly higher compared to pregnant women in the group with hypertensive states. In pregnant women at risk, as well as with increasing severity of preeclampsia a number of platelets decreased significantly (r=- 0,84) (table 3). The most significant was the change MPV and PDW (r=0.8; 0,87). MRV was a significant increase in pre-eclampsia defined mild and severe (8,6 ± 0,2 to 9,3 ± 0,24fl 95% CI) and PDW with 18.89 ± 0.75 and 19.9 ± 0.84% respectively (CI 95%; r = 0,8). The rate of platelet aggregation in a group of pregnant women with physiological course was 79.2±3.1 percent. In groups of pregnant women with chronic hypertension and preeclampsia mild, this
Table 1. Analysis of the parity test.
Group Parity group Group I (n=26) Group II (n=23) Group III (n=24) Group IV (n=23)
Primigravida 50%(13) 39,2%(9) 41,7%(10), 30,4%(7)
Repeatedly pregnant 15,4%(4) 13,0%(3) 20,8%(5), 8,7%(2)
Multipara 36,6%(9) 47,8%(11) 37,5%(9); 60,9%(14)
Table 2. Analysis of the gestational period under study.
^^ Group Gestation^^^»^^ Group I (n=26) Group II (n=23) Group III (n=24) Group IV (n=23)
34 - 37 weeks 19,3% (5) 26% (6) 33,3% (8) 30,4% (7)
37 - 41 weeks 61,4% (16) 65,2% (15) 58,4% (14) 65,2% (15)
> 41 weeks 19,3% (5) 8,8% (2) 8,3% (2) 4,4% (1)
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Table 3. The research results of hemostasis of pregnant women peripheral blood (platelet part).
Indicators Group I (n=26) Group II (n=23) Group III (n=24) Group IV (n=23)
The number of platelets (PLT) x109l 214,2±11,6 178,1±8,8* 162,1±10,3** 148,14±9,4***
The average volume (MPV) fl 7,8±0,3 8,2±0,5 8,64±0,2* 9,3±0,24**
degree of anisocytosis (PDW) % 14,8±0,60 16,5±0,44* 18,89±0,75** 19,9± 0,84***
The rate of platelet aggregation % 79,2±3,1 88,4±2,9** 108,2±4,1*** 68,6±3,5**
Note: significant differences in comparison with the I group : * - p<0.05; ** - р<0,01; ***- р<0,001.
Conclusion.
figure was significantly higher than in the control group, in group II this figure was
1
6. A.
Tussupkaliyev, S. S. N. Gaiday et al.
.4±2.9%, and in pre-eclampsia mild §i reduction in the number of platelets, the §i The Pathogenesis and diagnosis of
1. In hypertension it is noted reliable 5s Zhumagulova, A.
108,2±4,1% (p<0.05; r=-0,18). However, ^ degree of reduction correlated with the ^ hypertensive disorders in pregnancy. The
the decrease of the aggregation ability of ^severity of hypertensive condition. ^ role of platelets associated endothelial
platelets in pregnant women with severe Sfc
»
2. Quality parameters of platelets, ^ dysfunction. XXIV European congress of preeclampsia compared to the control ^ the MPV and PDW have a statistically ^ perinatal medicine 2014 pp. 130. group (p<0.05, r= - 0,26), which indicates ^ reliable increase in performance with ^ 7. Steegers EA, von Dadelszen P, the occurrence of decompensation of ^ correlation dependence with the severity ^ Duvekot JJ, Pijnenborg R: Pre-eclampsia. hemostasis system due to the transition ^ of hypertensive condition. ^ Lancet 2010, 376:631-644.
I
3. Reliable data on the change in ^ 8. Scazzocchio E, Figueras
adaptive mechanisms in the regulation of
pathological. (Table 3). ^ the aggregation properties of platelets in ^ F: Contemporary prediction of
Discussion. thrombocytopenia ^ hypertension were not obtained. ^ preeclampsia. Curr Opin Obstet Gynecol
occurs in 7-10% of pregnant women ^ References: ^ 2011, 23:65-71.
4 times more often than nonpregnant ^ 1. Tussupkaliyev A.B. etc. of Platelet- ^ 9. WHO recommendations for women. There are several possible ^ endothelial dysfunction as a method ^ prevention and treatment of pre-causes of thrombocytopenia during ^ for diagnosis of hypertensive States of ^ eclampsia and eclampsia 2014. 10. pregnancy. The most common are: ^ pregnant women. Oncology of the XXI ^ The clinical Protocol of diagnosis and
§
r
gestational thrombocytopenia (GE) century. Materials of XX international treatment of Hypertensive state during
(60-75%), preeclampsia (PE) and HELLP scientific conference "Oncology of the XXI ^¡pregnancy". Approved by the Expert
(hemolysis, increased liver enzymes, low century". 1-7 may 2016.
Committee on development of health of
platelets) syndrome (21%) and idiopathic ^
àj the Ministry of health of the Republic of
Dogomys, Russia. P. 187-190.
immune thrombocytopenia (ITP) (3 -10%) ^ 2. Khan KS, Wojdyla D, Say L, ^Kazakhstan (minutes No. 10, 2014.
^ Gulmoznglu am Van look pf who ^ 11. Jodkowska A, Martynowicz
[11]. The use of low-dose aspirin is one ^ Gulmezoglu AM, Van Look PF: WHO
of the effective methods of prevention ^ analysis of causes of maternal death: ^ H, Kaczmarek-Wdowiak B, Mazur G.
of hypertensive disorders in pregnancy a systematic review. Lancet 2006, Thrombocytopenia in pregnancy -
[12], which explains the probability of ^ 367:1066-1074. ^ pathogenesis and diagnostic approach. platelet dysfunction in hypertension. ^ 3. Steegers EA, von Dadelszen P, ^ Progress Hig Med Dosw (Online). 2015 However, there is evidence of the lack of ^ Duvekot JJ, Pijnenborg R: Pre-eclampsia. ^ Nov 12; 69(0):1215-21. prognostic data of platelet dysfunction in ^ Lancet 2010, 376:631-644. ^
^ 4. Tussupkaliyev A.B. etc., Markers ^
12. Campos A The Role of Aspirin in
the development of preeclampsia [13]. ^ 4. Tussupkaliyev A.B. etc., Markers ^ Preeclampsia Prevention: State of the Art Analysis of the data shows a ^ of dysfunction of hemostasis of pregnant ^ Acta Med Port. 2015 Jul-Aug 28(4):517-significant decrease in the number of ^ women with arterial hypertension. ^24. Epub 2015 Aug 31. platelets and changes in their degree ^ Medical journal of Western Kazakhstan. ^ 13. Dogan K, Guraslan H, Senturk of variation (from small to larger) with 2(46)2015. P. 131-134. MB et al. Can Platelet Count and Platelet
increasing severity of hypertension and ^ 5. Report of the National High ^Indices Predict the Risk and the Prognosis pre-eclampsia confirms the involvement ^ Blood Pressure Education Program ^ of Preeclampsia. Hypertens Pregnancy. of platelet link of hemostasis in the Working Group on High Blood Pressure 2015 Nov;34(4):434-442. Epub 2015 Sep development of this disease. ^ in Pregnancy. Am J Obstet Gynecol. 2000 ^ 11.
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ТYИIН
А.Б. ТУОПКАЛИЕВ, С.С. ЖУМАГУЛОВА, А.Н. ГАЙДАЙ, Л.К. САРСЕМБАЕВА, Л.К. АЯЗБАЕВА
ЖУКТ1Л1К КЕЗ1НДЕГ1 ГИПЕРТЕНЗИВТ1 ЖАГДАЙДЬЩ ДИАГНОСТИКАСЫ
Марат Оспанов атында^ Батыс Казакстан мемлекетпк медицина университетi, Актебе, Казахстан
Бул макала жYктiлiк кезiндегi гипертензия жаедайында гемостаздын тромбоцитарлык жYЙесiн зерттеуге арналfан. Зерттеу жумысы тромбоциттердщ абсолютпк санын (PLT), тромбоцитарлык индекс, тромбоциттердщ орташа келемiн (MPV), тромбоциттердщ гетерогендтн (PDW), тромбокрит (РСТ), тромбоциттердiн агрегация дэрежесш анык,тауfа баfытталfан. Проспективтi обсервациялык когорттык зерттеу жумысы жYPгiзiлдi. Аск,ынбаfан жYктiлiк, жYктiлiк кезiндегi артериалды гипертензия, жент жэне ауыр преэклампсия кезшдеп тромбоциттердiн сипаттамасы зерттелдi. Зерттеу мэлiметтерi женiл жэне ауыр преэклампсия кезшдеп тромбоцитарлык дисфункциясынын статистикалык сенiмдi керсеткштерш керсетедi. Алынfан мэлiметтер негiзiнде макала авторлары преэклампсия диагностикасында тромбоцитарлык дисфункцияны аныктауды кажет деп усынады.
Нег'зг'! свздер: жYктiлiк, артериалды гипертензия, преэклампсия, диагностика, тромбоциттер.
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РЕЗЮМЕ
А.Б. ТУСУПКАЛИЕВ, С.С. ЖУМАГУЛОВА, А.Н. ГАЙДАЙ, Л.К. САРСЕМБАЕВА, Л.К. АЯЗБАЕВА
ДИАГНОСТИКА ГИПЕРТЕНЗИВНЫХ СОСТОЯНИИ ВО ВРЕМЯ БЕРЕМЕННОСТИ
Западно-Казахстанский Государственный медицинский университет имени Марата Оспанова, Актобе, Казахстан
Данная статья посвящена изучению состояния тромбоцитарного звена гемостаза при гипертензивных состояниях во время беременности. Исследование посвящено изучению абсолютного количества тромбоцитов (Р^Г) и тромбоцитарных индексов - средний объем тромбоцитов (MPV), гетерогенности тромбоцитов (PDW), тромбокрита (РСТ), степени агрегации тромбоцитов. Проведено проспективное обсервационное когортное исследование. Изучены характеристики тромбоцитов при неосложненной беременности, при артериальной гипертензии во время беременности, легкой и тяжелой преэклампсии. Анализ данных показывает статистически достоверные показатели тромбоцитарной дисфункции при легкой и тяжелой преэклампсии. На основании полученных результатов авторами предлагается необходимость определения тромбоцитарной дисфункции в диагностике преэклампсии.
Ключевые слова: беременность, артериальная гипертензия, преэклампсия, диагностика, тромбоциты.
УДК: 618.3
А.Н. ГАЙДАЙ, А.Б. ТУСУПКАЛИЕВ, С.С. ЖУМАГУЛОВА
ГИПЕРГОМОЦИСТЕИНЕМИЯ ПРИ ГИПЕРТЕНЗИВНЫХ СОСТОЯНИЯХ В ДОНОШЕННОМ СРОКЕ БЕРЕМЕННОСТИ
Западно-Казахстанский Государственный медицинский университет имени Марата Оспанова. Актобе, Казахстан
Кафедра акушерства и гинекологии №2
Гайдай А.Н. - докторант PhD; тел.: 8 775 645 94 95, e-mail: [email protected];
Тусупкалиев А.Б. - к.м.н., руководитель кафедры;
Жумагулова С.С. - к.м.н., ассистент кафедры акушерства и гинекологии, e-mail:
sagira+[email protected]
Аннотация. Гипертензивные состояния, по-прежнему, занимают одно из ведущих мест среди материнской и перинатальной заболеваемости и смертности. Исследование посвящено определению уровня гомоцистеина при нормально протекающей беременности, а также, при гипертензивных
Актуальность. Гипертензивные
^ осложнения наблюдаются в 12-22%
всех беременностей и являются одним
из главных факторов материнской и неонатальной заболеваемости и смертности [1]. По данным Всемирной
организации материнская
здравоохранения смертность при
гипертензивных осложнениях во
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