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Thus, with high professionalism and experiences ofoperators, as well as highly skilled anesthetic and intensive care provision simultaneous surgery in gynecology and surgery through the classic and
combined accesses can take its rightful place in department practice, as far as they don't represent a great danger for patients and positively perceived by them while adhering above-mentioned conditions.
References:
1. Aleksandrov L. S., Ishchenko A. I., Vedernikov N. V. Co-operation in gynecology//Akusha. and gin. - M., 2003. - № 4. - S. 4-11.
2. Ganiev F. I., Negmadzhanov B. B., Narzullaev H. B., Azimov S. A. Laparoscopy in gynecology and surgery//Proceedings of the VII Congress of Obstetricians and Gynecologists of Uzbekistan. - Tashkent, 2013. - P. 245-246.
3. Tanks V. S. Simultaneous laparoscopic surgery combined with diseases of the abdomen and pelvis. Abstract. diss. cand. honey. nauk. -Ryazan, 2000. - 24 s.
4. Emelyanov S., Protasov A. V., Rutenburg G. M. Endosurgery inguinal and femoral hernias. - SPb., 2000.
5. Zaporozhtsev D. A., Lutsevich O. E., Gordeev S. A., Prokhorov Yuri. New in operative laparoscopy in the treatment ofpelvic disease in combination with cholelithiasis//Endoscopic hirurgiya. - M., 2001. - № 6. - S. 10-14.
6. Puchkov K. V., Tanks V. S., Ivanov V. V. Simultaneous laparoscopic surgery in surgery and gynecology. - M., 2005.
Zakirova Feruza Akildjanovna, Candidate of Medical Sciences, Doctoral Candidate of theRepublican Specialized Center of Cardiology E-mail: [email protected] Bekbulatova Indira Renatovna, Candidate of Medical Sciences, Scientific Secretary of the Republican Specialized Center of Cardiology E-mail: [email protected] Eliseyeva Marietta Rafaelevna, Doctor of Medical Sciences, Professor, Chief Editor of the journal "International Journal of Biomedicine" E-mail: [email protected]
Hemodynamic performance and tolerance to physical activity in women with rheumatic heart diseases
Abstract: We have studied the parameters of central hemodynamics in relation to the physical activity tolerance in women with rheumatic heart disease. The increase of the depth and severity of the valve apparatus lesions is associated with an increase of functional class of heart failure. In pregnant women with rheumatic heart diseases, the heart failure signs develop on the background of minimal changes of linear and volumetric parameters of the myocardium, which does not exceed the normal limits.
Keywords: pregnancy, rheumatic heart disease, heart failure, functional class, functional state of the cardiovascular system.
During many years, the rheumatic diseases were frequent extra genital pathology in pregnant women [5]. But in recent decades, due to the successful prophylaxis of fever, the incidence of the current disease in pregnant women has slightly decreased [2]. Recently, it was observed that there has been an increase in the number ofpreg-nant women and mothers suffering from heart diseases, which is explained by a number of reasons: the early diagnosis of such diseases; the opportunity to save the pregnancy in cases, which were previously impossible; the increase in the number of women under gone the heart surgery; and the number of seriously ill women, who make a decision to continue the pregnancy with the permission of doctors or on their own, being confident in the success of medical science and practice. The exacerbation of rheumatoid process has also an adverse effect on fetal development, it increases the risk of developing of complications from the mother's side during the pregnancy, the childbirth and the postpartum period. This is explained by the fact, that pregnancy increases the load on the cardiovascular system (CVS), even in healthy women; while at a risk of hemodynamic changes due to existing defects, the load increase many times [3; 4]. An increase in the frequency of premature births, incidence of pathological blood loss during delivery and perinatal
mortality is observed depending on the severity of heart failure (HF) [6]. In this regard, it is important to consider the assessment of physical performance as an indicator of myocardial reserve capacity. According to ESC, it is recommended to use the exercise testing for the objective evaluation of the functional activity of the pregnant woman [1]. But in the available literature, we have not found an answer to: what kind of exercise testing exactly is advisable to apply for pregnant women? So, the assessment of physical performance and capacity, in our view, is preferably to carry out with the most physiological method, namely, a six-minute walking test in order to evaluate the risk of cardiovascular complications.
Objective
To estimate the parameters of central hemodynamics in relation to exercise tolerance in women with rheumatic heart disease.
Methods and materials of investigation
The study involved 70 pregnant women at the age of 19-35 years, with rheumatic heart disease in the 2nd and 3rd trimester of gestation. Along with the considering and evaluating the complaints and anamnestic data, a physical examination was also fulfilled during pregnancy. The evaluation of the functional state of the cardiovascular system was carried out comprehensively, taking into account electrocardiographic
Hemodynamic performance and tolerance to physical activity in women with rheumatic heart diseases
and hemodynamic parameters. The ECG was conducted in 12 standard leads. The assessment of hemodynamic parameters included: the analysis of heart rate frequencies (HRF); blood pressure (BP) level, measured by the standard method of Korotkov. For the purpose of studying the intra cardiachemodynamics, the echocardiography method was used on "SONOLINE VERZA PRO" device ("SIEMENS", Germany), in accordance with the recommendations of the American Association of Echocardiography in M and B modes. Laboratory blood tests included complete blood count (CBC), and the identification of rheumo test (RT). The exercise tolerance test in the form of a 6-minute walk was applied to all surveyed patients. The test was conducted in the hospital corridor with a length of40 meters. Before fulfilling the test, the initial state of women: BP control, heart rate and electrocardiogram was evaluated. Then pregnant women were offered to walk for 6 minutes in individually adjusted maximum rate, which does not cause the further discomfort or manifestations of HF symptoms (breathlessness, weakness, tiredness or heaviness in the legs). In case of appearance ofHF symptoms during the performance of physical activity, the women had to slow down or stop walking until their state stabilized, and then continue walking. Thus, the duration of test remained the same, and the rest timeMwas included into 6-minutes period. The 6-minute test result sallow us to determine the functional class of HF. For this purpose we used the HF classification, proposed by New York Heart Association (NYHA) in 1964. Depending on the passed distance, all surveyed pregnant women were divided into 3 groups: Groupl (n = 12) — women with functional class (FC) I of HF, Group 2 (n = 24) — pregnant with FC II of HF, and Group 3 (n = 34) — pregnant with FC III of HF. The research results were subjected to statistical processing based on BIOSTAT program for Windows (version 4.03). The sample average (X) and the sample standard deviation (SD) were determined. The reliability of inter group differences was assessed by Student's T-test. For all types of analysis, p < 0.05 value was considered statistically significant.
The research results
The average age of the patients, gestation period, the parity number in groups did not differ. The systolic blood pressure BP (SBP) level and diastolic BP (DBP) in groups were also comparable. In pregnant women in FC III of HF the HRF (heart rate frequency) was higher in comparison to the pregnant in FC I of HF, respectively 102.63 ± 10.94 beats/min, vs. 94.25 ± 10.87 beats/min (p = 0.028) in group 1; 98.79 ± 14.59 beats/min in group 2.
According to ECG data, higher parameters ofHRF (heart rate frequency) were marked in Group 3, compared to Group 1, amounting
to 93.86 ± 14.6 beats/min in Group 3, and 85.73 ± 9.48 beats/min in Group 1 (p = 0.02). In Group 2 the HRF (heart rate frequency) did not differ significantly from Groups 1 and 3, amounting to 90.89 ± 11.57 beats/min. Lower atrial rhythm was observed in 2 pregnant women (5.9 %) in Group 3. The blockade of the right bundle branch block was observed in 4 pregnant women (11.8 %) and 1 pregnant (2.9 %) of Group 3. In 16 pregnant women (47 %) of Group 3 there was revealed cardiac arrhythmias in the form of ventricular premature beats (PVCs), whereas it was observed only in 1 pregnant (8.3 %) in Groups 1 and 2 (x2=4.168, p = 0.041). Supraventricular arrhythmias (SVES) was detected in 3 surveyed patients of Group 3, and 2 pregnant in Group 1. In the 3rd group it was observed the slowing of the pulses on the cardiac conduction system, extending the PQ, QRS, QT intervals.
According to the echocardiography data; in Group I, the1st type mitral regurgitation (MR) is detected in 4 pregnant women (33.3 %), 2nd type in 8 pregnant women (66.7 %). The1st degree of tricuspid regurgitation (TR) was revealed in 1 patient (8.3 %), and 2nd degree TR in 1 pregnant (8.3 %) also. In group 2: 1st type MP was detected in 11 (52.3 %), and 2nd type MP — in 7 (29.2 %) pregnant women. 1st type aortic regurgitation (AR) was detected in 3 (12.5 %), and 2nd type AP in 4 (16.7 %) pregnant women. The1st type TP was detected in 6 (25 %), and 2nd type TP in 1 (4.2 %) pregnant. In 2 (8.3 %) patients it was revealed stenosis of the mitral orifice and in 1 (4.2 %) patient stenosis of the aortic orifice of moderate severity. In Group 3: 1st type MP was detected in 14 (41.1 %), 2nd type MP — in 13 (38.2 %), and 3rd type MP in 2 pregnant women.1st type AP was detected in 5, 2nd type AP in 3, and 3rd type AP in 1 (2.9 %) pregnant. The 1st degree TP was seen in 6 (17.6 %), 2nd degree TP in 2 (5.9 %) pregnant women. In 2 (5.9 %) of pregnant women it was diagnosed mitral stenosis holes and in 1 (2.9 %) patient stenosis of the aortic orifice of moderate severity. In other words, the increase in the depth and severity ofvalve apparatus lesions is associated with an increase in FC of HF. The study of central hemodynamic parameters showed that in pregnant women with FC III of HF, despite the persistence of average standard indicators of the group, there is a significant trend towards an increase in heart size (mostly left chambers), the frequency of occurrence of separation sheets of pericardium, as a marker of pericardial effusion, as well as decrease in the contractility of the left ventricle myocardium (Table 1). What is more, the differences in myocardial contractility is fairly significant between all analyzed groups.
Table 1. - Indicators of echocardiography in pregnant women with rheumatic heart diseases depending on FC of HF
Parametres Group 1 (n = 12) P1 Group 2 (n = 24) P2 Group 3 (n = 34)
LA (mm.) 30.42 ± 3.9 > 0.05 33.96 ± 6.02 0.016 34.05 ± 4.43
LVEDD (mm.) 50.42 ± 2.15 > 0.05 50.39 ± 4.74 0.035 53.33 ± 4.37
LVESD (mm.) 30.83 ± 1.95 > 0.05 31 ± 3.53 0.028 33.57 ± 3.98
IVS (mm.) 8.08 ± 0.97 > 0.05 8.1 ± 0.65 > 0.05 8.17 ± 0.71
PW (mm.) 7.35 ± 0.89 > 0.05 7.37 ± 0.62 > 0.05 7.42 ± 0.65
RV (mm.) 20.86 ± 3.0 > 0.05 21.3 ± 3.95 > 0.05 22.45 ± 3.64
LV mass (g.) 129.83 ± 23.9 > 0.05 132.06 ± 28.79 > 0.05 144.45 ± 27.74
EDV (ml.) 115.7 ± 17.11 > 0.05 122.5 ± 25.6 0.015 137.58 ± 27.98
ESV (ml.) 35.2 ± 5.91 > 0.05 43.1 ± 19.98 0.002 47.69 ± 12.94
EF ( %) 68.3 ± 4.04 0.000 61.3 ± 5.16 0.000 60.7 ± 5.6
E/A 1.57 ± 0.36 > 0.05 1.99 ± 2.63 > 0.05 1.44 ± 0.37
The fluid in the pericardial cavity (amount) 1 (8.3 %) > 0.05 5 (20.8 %) 0.044 12 (35.3 %)
Note: P1 — the reliability of differences between groups 1 and 2; P2 — reliability of differences between groups 1 and 3.
Table 2. - Indicators of exercise testing in pregnant women with rheumatic heart diseases according to FC of CH
Parameters Group 1 (n = 12) P1 Group 2 (n = 24) P2 Group 3 (n = 34)
Passed distance in meters 474.17 ± 25.33 0.000 371.04 ± 30.24 0.000 261.03 ± 52.73
SBP before (mm Hg) 102.08 ± 11.17 > 0.05 100.42 ± 8.59 > 0.05 100.71 ± 7.87
SBP after (mm Hg) 123.75 ± 11.5 0.000 109.79 ± 8.29 0.000 108.86 ± 11.51
DBP before (mm Hg) 65 ± 6.74 > 0.05 64.37 ± 6.96 > 0.05 62 ± 6.66
SBP after (mm Hg) 70.83 ± 9.0 > 0.05 70.83 ± 8.29 > 0.05 69.71 ± 8.31
HRF before (beats/min) 92.4 ± 7.98 > 0.05 99.04 ± 15.47 0.025 102.2 ± 13.8
HRF after (beats/min) 122.5 ± 9.2 > 0.05 129.79 ± 13.3 0.021 132.4 ± 13.2
Breathlessness 7 (58.3 %) > 0.05 18 (75 %) X2 = 6.2; p = 0.01 32 (94.1 %)
Heartbeats 5 (41.7 %) > 0.05 11 (45.8 %) X2 = 5.3; p = 0.02 28 (82.3 %)
Tiredness 4 (33.3 %) > 0.05 10 (41.7 %) X2 = 5.6; p = 0.02 26 (76.5 %)
Note: P1 — the reliability of differences between groups 1 and 2; P2
During the test with a 6-minute walk, the distance covered was significantly greater in Group 1 compared to Groups 2 and 3. Thus, in Group 2 and 3 of there was a less marked increase in SBP levels, in response to physical strain compared with Group 1, in spite of the initial lack of these differences. Before the physical activity, the HRF was higher in Group 3 compared to Groups 1 and 2. The increase of HRF related to physical activity prevailed in Group 3. In this case, it is typical that a subjective exercise tolerance in Group 1 was better than in Group 3 of pregnant women (see table 2).
The analysis of hemogramindicated the prevalence of inflammatory blood indices in Group 3 compared to Group 1, so, the level ofleu-cocytes in Group 3 was 9.2 ± 2.22 -10 9/L, 7.34 ± 1.87 -109/L (p = 0.013) in Group 1, and 9.4 ± 3.84 -10 9/l in Group 2. Erythrocyte sedimentation rate (ESR) was also higher in Group 3: 4.28 ± 0.23 mm/h, 22.5 ± 7.37 mm/h in Group 1 (P = 0.034) and 24.33 ± 10.28 mm/h in Group 2. Blood hemoglobin levelinall groups was comparable. According to the results of rheumotest higher indicators of CRP and ASO was revealedin a group of pregnant women with FC III of HF, compared with the group ofpregnant women with FC I of HF. Thus, the CRP in
- reliability of differences between groups 1 and 3. Group 3 was 12.64 ± 16.64 mg/L, in Group 1 — 6.04 ± 2.58 mg/L (p = 0.008), and in Group 2—9.53 ± 7.22 mg/liter. ASO in Group 1 was 251.6 ± 139.53 IU/ml, in Group 3 — 347.2 ± 134.28 IU/ml (p = 0.041), and in Group 2 — 268.48 ± 118.5 IU/ml. The level of rheumatoid factor (RF) in subgroups did not differ: in Group 1 — 10 ± 0.94 IU/ml, in Group 2 — 10.2 ± 0.77 IU/ml, and in Group 3 — 10.88 ± 2.36 IU/ml.
The obtained data indicate that in pregnant women with rheumatic heart diseases the signs of heart failure, defined by exercise tolerance with a standard six-minute test, develop on the background of minimal changes of linear and volumetric parameters of the myocardium, which does not exceed the normal limits. However, in this case, a significant difference is observed between these parameters in groups of women with FCI and FC III. Reduction of myocardial contractility has reliably significant character as the increasing of physical activity of HF. Along with this, the hemodynamic parameters and their correlation with the PAT (physical activity tolerance) testify that the signs of inflammation, with comparable values of hemoglobin, have a significant impact on increase in HF.
References:
1. Baumgartner H., Bonhoeffer P., De Groot N. M. et all. ECS Guidelines for the management of grown-up congenital heart disease (new version 2010)//Eur Heart J. - 2010. - 31: 2915-2957.
2. Khairy P., Ionescu-Ittu R., Maskie A. S. et all. Changing mortality on congenital heart disease//J Am. Coll. Cardiol. - 2010. - 56:1149-1157.
3. Robson S. C., Dunlop W., Moore M. Et all. Combined Doppler end echocardiography measurement of cardiac output: theory and application in pregnancy//Br. J ObstetGynaecol. - 1987. - 94: 1014-1027.
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5. Stangl V. et all. Maternal heart disease and pregnancy outcome: a single-centre experience//Eur J Heart Fail. - 2008. - 10: 855-860.
6. Weiss B. M., von Segesser L. K., Seifert B., Turina M. I. Outcome of cardiovascular surgery and pregnancy: a systemic review of the period 1984-1996//Am J ObstetGynecol. - 1998. - 179: 1643-1653.
Indiaminov Sayit,
Samarkand State Medical Institute, doctor degree in medicine,
department of forensic medicine E-mail: [email protected]
Changes of the brain microcirculatory bed in different types of the blood loss and hemorrhagic shock
Abstract: The aim of the research was to determine thanatogenetic significance of blood filling degree of MCB vessels in the brain sections in different types of blood loss and in hemorrhagic shock. By means of by-stage method comparing the number of blood-filled vessels of microcirculatory bed in large hemispheres and in the brain trunk their different content has been estimated in acute, massive blood loss and hemorrhagic shock.
Keywords: premotor cortex, brain, neuroglia, blood loss, hemorrhagic shock.
