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Low molecular weight heparin on prevention of postoperative thromboembolic complications...
Mamadjanova Nodira Nosirjonovna, Republican specialized scientific-practice medical center of obstetrics and gynecology, Tashkent, Uzbekistan, junior scientific explorer, E-mail: [email protected]
Low molecular weight heparin on prevention of postoperative thromboembolic complications at women with uterine myoma concerned to high risk
Abstract: In purpose of to evaluate of low-molecular weight heparin (LMWH) efficiency on prevention ofpost-operative thrombotic complications at women with uterine myoma concerning to the high risk 60 women aged above 40 years with uterine myoma, which admitted for the operative treatment, have been underwent to the studying. . All operated women have been administered LMWH Clexan in a daily dosage of 0,4 ml once a day subcutaneously in the field of abdomen till 10 days.
Keywords: uterine myoma, a haemostasis, deep veins thrombosis, low-molecular weight heparin.
Introduction. The problem of prevention of thrombo- tive function of women of the given contingent of patients
embolic complications of operative gynecology is a rather actual one. Frequency of deep veins thrombosis (BME) after various gynecologic operations varies within 11-37%, and pulmonary thromboembolism (PTE) developed due to DVT is one of the reasons of postoperative lethal outcomes in 18-22% cases [3, 5, 6, 7]. Venous thromboembolism (VTE) is an important and potentially preventable complication of major gynecologic surgery, and the common frequency of postoperative thromboembolic complications with rates of DVT, PTE, and fatal PTE (19-20%) are comparable to those seen after general surgical procedures [1; 2; 3; 4; 5; 8].
Despite the quality which has increased during last two decades period of the operative gynecologic care, DVT of lower limbs and PTE generated by it take a leading place among postoperative complications in gynecologic patients and it's still recognized as an important problem of operative gynecology.
All gynecologic patients who are especially undergoing the operative treatment, to some extent, are thrombotically dangerous, as in majority of them hypercoagulation alterations in haemostasis system are indicated and venous circulation failure in the lower limbs and a pelvic can be observed (Ozolini L. A., 1999, Russia).
The purpose of the present study is to evaluate of low-molecular weight heparin (LMWH) Clexan efficiency in prevention of postoperative thrombotic complications at women with uterine.
Materials and methods. 60 women (group I) aged above 40 years old (average age was 45±4 years) with uterine myoma who admitted for the operative treatment Republican specialized scientific-practice medical center of obstetrics and gynecology (RSSPMC of O&G) have been examined. All patients have undergone the total hysterectomy. The average size of both uterus and fibroid were 12 weeks (min. 8 weeks; max. 24 weeks). At 7 (37%) of surveyed women there is revealed a fast-growing uterine myoma. Prominent features of reproduc-
has shown, that 7 (35%) among of them were multiparas, and 11 (55%) were multigravidas, hence, recurrent artificial abortions are revealed at 6 (30%), spontaneous abortions at 7 (35%) women. In the structure of extragenital diseases there are most often observed pathologies had appeared cardiovascular disease in 12 (60%), obesity in 4 (20%), anemia in 6 (30%), varicose veins of the lower limbs at in (15%), a gastrointestinal tract disease in 3 (15%) patients with uterine myoma.
In majority patients there are most often revealed some concurrent diseases such as obesity, hypertension, anemia and varicose veins of lower limbs. Most often occurring accompanied gynecologic pathologies at investigated patients with uterine myoma were ovarian cysts and cystomas, cervical erosion, endocervicitis, endoservicosis, ovuli naboti which because of all patients were exposed to the operative intervention in volume of extirpation of uterus with its appendages and without of them.
For comparison of LMWH efficiency there were conducted a retrospective studying of 158 case histories of patients (II group) at the similar age with investigated group, which undergone to the abdominal hysterectomy due to uterine myoma at Department of operative gynecology of RSSPMC of O&G of Uzbekistan during the period from 2005 up to 2008 years.
All patients from the retrospective analysis on purpose preventing of postoperative thrombotic complications had been administered unfractionated heparin (UFH) subcutaneously in dosage on 5000 IE 3 times a day. The results of analyzing a reproductive function, the structure of accompanied extragenital and gynecological diseases, clinical-anamnesis dates in both investigated group were almost similar. For the comparison of haemostasiological results there was studied haemostasis system of 20 rather somatically healthy women (control group) at the reproductive age without any accompanied gynecologic diseases.
Section 7. Medical science
The estimation of haemostasis state was conducted in dynamics prior to and on 1st, 3rd, 7th days on the postoperative period at haemostasiological laboratory of RSSPMC O&G. And there were used a reactants of firm Barnaul (Russia) which included in itself definition of: activated partial thromplastine time (APTT), prothrombin time (PT), prothrombin ratio (PR), the International normalized ratio (INR), amount of soluble fibrin — monomer complexes (SFMC), and fibrinogen, platelets count (PLC). Definition of PR and INR were realized by using following formulas:
PR=PT of patient/PT of control serum (l) PT of control serum is equal on 15 in haemostasiological laboratory of RSSPMC of O&G.
INR=PRAISI (2)
ISI — international sensibility index, for the thromboplastin which we have used it was equal to 1,2.
Results and discussion. We have included all women to high degrees of risk for the prophylactic of postoperative thromboembolic complications. Group I has been administered LMWH Clexan in a daily dosage of 0,4 ml once a day subcutaneously in the area of abdomen up to 10 days. On the applying the spinal anesthesia preoperative dose of Clexan has been injected before 12 hours and at the general anesthesia 2 hours prior to operation. The subsequent doses have been started at once after 8 hours of the performed intervention. After the full mobilization of patients as a preparation of system enzyme therapy — Wobenzim (Mucous farm, Germany), in a daily dosage by 3 tablets three times a day before meals up to four weeks have been prescribed to them.
Results of the analysis a coagulogram which had being carried in dynamics at group II of patients were distinctly dif-
fered from I, and results of comparison with I and control groups were statistically accurate (p<0,05). At patients of group II on the 3rd and 7th days of the postoperative period the concentration of fibrinogen had statistically accurately increased, results of SFMC analysis was characterized by the progressing the reliable increase in the amount of the latter on the 1st, 3rd, 7th days (Table 3). In contrast to group II, at patients from group II against underground of the carried complex preventive measures carried on the 3rd, 7th days of the postoperative period any significant hypercoagulation changes were have not revealed (Table 2).
As it is shown in Table 3, the analysis of the conducted haemostasiological study results is at women from group II characterized with increasing in quantity of SFMC and fibrinogen in comparison with control group and its initial level before operation. At these patients on admission to the hospital initial average level ofSFMC (N up to 3,5mg%) was 4,0±1,0 mg%, in comparison with control group (2,8±1,3 mg%) was to 42,8% more (on the reliability p<0,05); on the1st, 3rd, 7th days of postoperative period there was detected increase of its quantity (5,3±1,3 mg of%, 6,3±1,6 mg%, 7,3±0,8 mg% accordingly), the highest average curve occurred on 7-day (7,5±0,6 mg%) and in comparison with its initial level was authentically increased to 82,5% (p<0,05), and against the control group it was on 2,7 times more. Fibrinogen concentration has begun to increase about on 3rd day (3,7±0,7 g\l) and the highest average curve were observed on 7th day (4,3±0,7 g\l) after hysterectomy. As increase SFMC at these patients confirmed about thrombinemia, joining increased amount of fibrinogen (N 2-4 g\l) in the 7-day confirms intensifying coagulation of investigated patients in the postoperative period (Table 3).
Table 1. - Haemostasis state indices in women from control group (n=20)
Parameters Meanings Parameters Meanings
Fibrinogen (2-4-g/l) 2,3±0,5 PR 1,02±0,3
APTT (32-42 sec) 37,7±3,1 INR 1,2
PT (14-17 sec) 15,3±0,7 SFMC (up to 3,5mg%) 2,8±1,3
Table 2. - Haemostasis state indices in women with uterine myoma before and after hysterectomy received LMWH Clexan (I group n=60)
Parameters Prior to 1st day 3rd day 7th day
Fibrinogen (g/l) 2,5±0,5 2,6±0,6 2,7±0,6 2,8±0,7
APTT (sec) 35,3±2,1 36,5±2,4 37,5±2,8 37,2±3,1
PT (sec) 15,4±0,9 16,2±0,8 16,8±1,4 16,6±1,4
PR (IU) 1,03±0,07 1,07±0,06 1,05±0,05 1,05±0,05
INR 1,0±0,1 1,1±0,2 1,1±0,2 1,1±0,2
SFMC (mg%) 3,8±0,6 2,6±2,1 3,4±2,9 3,3±2,8
T (10 9/l) 218,2±33,6 217,2±32,7 227,2±33,8 220±30,5
Table 3. - Haemostasis state indices in women with uterine myoma before and after hysterectomy received UFH (II group n=158)
Parameters Prior to 1st day 3rd day 7th day
1 2 3 4 5
Fibrinogen (g/l) 2,8±0,6 3,0±0,6 3,7±0,7 4,3±0,7*
APTT (sec) 37,7±5,2 37,4±5,2 35,3±4,4 31,8±6,3*
PT sec 15,6±1,2 15,9±1,2 15,9±0,9 15,9±1,0
Low molecular weight heparin on prevention of postoperative thromboembolic complications.
1 2 3 4 5
PR IU 1,0±0,1 1,1±0,1 1,1±0,1 1,1±0,1
INR 1,0±0,1 1,1±0,1 1,1±0,1 1,1±0,1
SFMC mg% 4,1±1,1 5,3±1,4 6,5±1,6 7,5±0,6*
T 10 9/l 210,7±44,5 202,3±27,4 229,7±76,7 215,0±35,4
The analysis of results APTT which conducted in dynamics has demonstrated, that as distinctly from patients administered LMWH, in patients from group II on 7th day was detected shortening of its meaning (on the average 33,8±6,3 sec) which testified to alteration of blood coagulation towards hy-percoagulation. Despite on conducting thromboprofylaxion with UFH on the 7th day of postoperative period there were observed an activation of initial mechanisms of the internal cascade of haemostasis in these patients.
The analysis of dynamics of laboratory parameters on the 7th day of postoperative period at patients of group II concerning to the high risk has shown, at these patients in comparison with patients concerning to the high risk of thromboembolic complications development under exposing abdominal hysterectomy against carrying out thromboprophylaxis with UFH haemostasiological pattern characterized of prethrom-botic state which demands carrying out an optimal complex thromboprophylaxis. This is accompanied with synchronic increasing of SFMC and fibrinogen concentration with simultaneously shortening a time of APTT.
On the contrary, at carrying out thromboprophylaxis with LMWH there was demonstrated another haemosta-siological pattern at control laboratory analysis which conducted in dynamics (Table 2). In comparison from patients of the retrospective analysis (group II), increasing amount of SFMC was insignificant, and it's the highest average curve in patients of group I was detected on 3rd day (3,4±2,9 mg%) in the postoperative period, in comparison with initial level was reduced on 10,5% (prior to operation 3,8±0,6 mg%). Significant increase of SFMC in the postoperative period during the studying of haemostasiogram analyses in patients from retro-
spective studying have detected especially in those patients who had accompanying extragenital pathologies, such as arterial hypertension, obesity, moderate anemia, varicose veins disease. Have especially been expressed at what had some accompanying pathologies.
Postoperative decrease of PLC was detected in patients from group II in the 3rd day of postoperative period (229,0±66,7x10 9/l), which explaining by heparin induced thrombocytopenia causing with administering of UFH, however LMWH does not influence of amount of platelets. Other parameters were within the limits of norm at all patients from I and II investigated groups (Table 1).
Conclusion.
1. Received dates from studying have demonstrated, that traditional preventive maintenance of thromboembolic complications with administering UFH does not allow to result coagulation potential of patients with uterine myoma concerning to the high risk of development of thromboembolic complication at carrying out of abdominal hysterectomy even in an initial level which at them was before operative treatment.
2. Receiving LMWH simultaneously with complex measures for preventive maintenance postoperative thromboembolic complications with the account of degree of risk allows to decrease a little of thrombotic complications in women with uterine leyomyoma. Thus, administrating ofWobenzim as a desagregate therapy simultaneously with LMWH leads to the improvement ofhaemostasiological conditions, also, prevents and reduces not only developing of post operative thromboembolic complications, but reduces haemorragic complications caused by administering of antithrombotic therapy.
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