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Bazarova Zarina Zafarovna, resident graduate, Department of Obstetrics and Gynecology Samarkand State Medical Institute E-mail: [email protected] Sobirova Sayyora Ergashevna, candidate of medical sciences, Samarkand State Medical Institute assistant of the Department of Obstetrics and Gynecology Todjiyeva Nigina Iskandarovna, assistant of the Department of Obstetrics and Gynecology Samarkand State Medical Institute Xudayarova Dildora Raximovna, doctor of medical sciences, Head of the Department of Obstetrics and Gynecology Samarkand State Medical Institute
QUALITY OF LIFE OF WOMEN UNDERGOING OBSTETRIC HYSTERECTOMY
Abstract: The issues of the long-term effects of surgical menopause remain little studied, since the long-term after surgery in most cases women develop a kind of pathological symptom complex, leading to a significant reduction in their quality of life.
Keywords: quality of life, surgical menopause, obstetric complications, postpartum hemorrhage.
The relevance of research: The consequences of the removal of the uterus in recent years have been actively discussed in the literature [6, 252]. Of particular interest are data on the development of the so-called post-hysterectomy condition in women at reproductive age after hysterectomy, with or without preservation of ovarian tissue [7, 28-33]. In the literature there is no consensus about the reasons for its appearance. According to some authors, the posthyster-ectomy condition while preserving the ovaries is due to the intersection of the ovarian branches of the uterine arteries during the operation, which reduces the blood supply to the ovaries, leading to a decrease in steroidogenesis and the formation of hypoestrogenism [1, 860-9]. Others believe that the removal of the uterus has a damaging effect on the hypo-thalamic-pituitary system, leading to a decrease in the level of compensatory processes in a woman's body [4, 3829-38]. It is believed that the uterus as a target organ naturally affects the neuroendocrine regulation of ovarian function through a central mechanism, or local regulation [2, 109-50]. In this regard, the preservation of the uterus with various obstetric complications remains an urgent and debatable problem. Questions about the health status of women who have undergone various obstetric complications are actively discussed in modern literature. One of the leading places among obstetric complications belongs bleeding. Bleeding is the leading cause of maternal mortality in the world; they
kill 127.000 women annually, accounting for 25% of all maternal deaths. The tendency to reduce the frequency of this complication is not observed. The evolution of therapies for postpartum hemorrhage suggests that the most common mistake in the treatment of obstetric hemorrhages is a delay with the operation of hysterectomy [5, 1-17]. Serov V. N. (2008) recommends that in cases of massive obstetric hemorrhages, the operation should be carried out in 3 stages: in the first stage, an urgent celiac section is performed on the background of infusion-transfusion therapy, temporary hemostasis; at the second stage, surgical manipulations are stopped, intensive therapy is continued until hypovolemia is reduced, and blood coagulation is improved; in the third stage of the operation, the uterus is extirpated. The same recommendations are given in the Clinical guidelines for the management of patients with bleeding during labor and the postpartum period, Ministry of Health of the Republic of Uzbekistan. And despite the fact that some authors today hysterectomy and amputation of the uterus to stop bleeding is called "operation of despair", when other ways of preserving a woman's life have already shown their futility, hysterectomy for many ordinary obstetric institutions that do not own modern technological capabilities remains a life saving operation for patients with bleeding [3, 1236-12].
Purpose of the study: To study the quality of life of women undergoing obstetric hysterectomy at reproductive
QUALITY OF LIFE OF WOMEN UNDERGOING OBSTETRIC HYSTERECTOMY
age; analyze the risk factors that led to the need to remove the uterus at this age.
Material and research methods: We carried out a retrospective analysis of 63 stories of childbirth of women, which due to various obstetric complications made hysterectomy, for the period from 2013 to 2017. This work was carried out in the maternity complex of the clinic SamMI number 1, the regional Perinatal Center and the maternity complex number 2 of the city of Samarkand. The following were studied: social level, history, the presence of extragenital diseases, pregnancy, type of delivery, complications of childbirth, the amount of blood loss, the amount of surgical intervention, the postoperative and postnatal period; Objective and clinical laboratory data on discharge and recommendations. Questionnaires for assessing the quality of life - SF36, PISQ and a questionnaire to identify signs of vegetative changes - were used to assess the quality of life of female patients.
Results and discussion: When analyzing the age composition of puerperas, all 63 patients included in the study were in active reproductive age - from 20 to 37 years. The average age was 27.8 ± 1.6 years. Housewives predominated in the social structure (71.4%), the remaining 28.6% were students and office workers. The residents of the city were 35(55.6%), and the rural area was 28(44.4%). Analysis of the menstrual function showed that the average age of menarche was 13.2 ± 1.4 years, which corresponds to that in the population. The duration of the menstrual cycle ranged from 25 to 35 days. Menstrual bleeding lasted from 3 to 7 days. When analyzing the reproductive function, attention is drawn to the fact of a large number of pregnancies, childbirth, abortions and miscarriages in the examined women. Infertility suffered 4 women (6.3%) of the main group. But at the same time, 10(15.9%) patients were first-pregnant and primipa-rous.
The study of anamnestic data showed that 10(15.9%) patients used hormonal contraception, 22(34.9%) patients received intrauterine contraception, and in 6 of them the intrauterine device was in the uterus for more than 3 years; barrier contraception was used by 7(11.1%) patients. The remaining 24(38%) patients did not use any means, or were protected by interrupted sexual intercourse, ofwhich 4(6.3%) were not protected due to primary and secondary infertility.
In the structure of extragenital diseases, iron deficiency anemia occupies the leading place - 76.2%, in the second place, diseases of the urogenital system - 22.2%, in third place, diseases of the cardiovascular system - 9.5%, etc.
In the structure of concomitant genital pathology, inflammatory diseases of the uterus and appendages (19%), second place are vaginosis and vaginitis (17.5%) and third place of the uterus and cervical ectopia (7.9%).
According to our data, the risk factor in patients under study should be referred to - high parity - in 29(46%), multiple pregnancy in 8(12.7%), scar on the uterus after cesarean section - in 25(39.7%), large size of the fetus - in 12(19%), uterine myoma - in 4(6.3%). Weakness of labor activity and excessive strong labor activity was a risk factor for bleeding in 6(9.5%) patients.
According to the method of delivery in the majority of patients - 65% - the pregnancy ended in timely delivery, but 20 (31.7%) deliveries were premature, which is almost the second higher than in the population. Delayed delivery occurred in 2 (3.2%) patients, in 88.9% of patients, delivery ended with a cesarean section, and only 11.1% through the birth canal.
In our study, in a planned manner, the operation was performed in 25(39.7%) women, in an emergency - in 31(49.2%) women. In 9 (14.3%) fetus weight was more than 4000 g. Indications for 25 planned operations were: in 14 (56%) - uterine scar after cesarean section inferior according to ultrasound, in 2(8%) - multiple pregnancy, 6(10.7%) - eclampsia and severe pre-eclampsia, 3(5.4%) - large fruit. The main indications for emergency operative delivery were weakness of labor activity - in 3(9.7%), threatening uterine rupture of the scar in 6(19.4%) patients, placenta previa -3(4.8%), and in 2 patients there was a combination of placenta previa with a scar on the uterus after cesarean section.
The volume of blood loss in patients was determined by the gravidary method. In assessing the response of the body to massive blood loss were taken during attention such clinical signs as: blood pressure, peripheral vein tone, skin color and conjunctiva, the presence of dyspnea, a decrease hourly diuresis, symptom of collapse or shock. The degree of blood loss was determined by the classification of Shifman E. M.: I degree - blood loss 650-1000 ml, II degree - 1001-1500 ml, III degree - 1501-2000 ml, IV degree - 2001 ml and more. III degree of blood loss was determined in 11(17.5%) patients, III degree - in 30(47.6%), IV - in 22(34.9%).
The postoperative period in 7(11.1%) women was complicated by postoperative wound suppuration and suture mismatch, in three women (4.8%) postoperative focal pneumonia developed and in one - deep vein thrombophlebitis of the lower extremities.
All women were recommended supervision in the women's consultation at the place of residence. The analysis of the quality of life of women after hysterectomy was carried out by us by interviewing them during personal contact using a specially designed questionnaire.
According to the results of testing, it was revealed that 57% of women had their first complaints in the first 6 months after surgery. The main complaints were: a sharp decrease in physical activity, a feeling of anxiety or nervousness, a dull, depressive
state, weakening of memory, as well as pain in the lower abdomen and back. Among those surveyed by doctors of medical institutions, no one sought medical help. 32% of respondents were engaged in self-medication, by using sedatives, as well as drugs made from medicinal plants (valerian, motherwort).
In 27% of women, the first complaints after surgery appeared within 1 year. They complained mainly of a decrease in physical activity, a feeling of anxiety and depression, a weakening of memory and a sleep disorder. Among this group, 10% of women took sedative herbal preparations and antidepressants.
During the second year after hysterectomy, the first complaints appeared in 17% of women. The most pronounced symptoms were nervousness and anxiety, weakening of memory, sleep disturbance, changes in the function of urination in the form of pollakiuria. Of these, 18% of women engaged in self-treatment.
Conclusion: Of the 63 women who underwent hysterectomy at reproductive age, 35(57%) women had their first complaints during the first 6 months, 17(27%) women had their first year, and 11(17%) women had their first complaints during the second years after surgery. All women had a decrease in physical activity, anxiety and depression. Over 44% of women reported memory loss and sleep disturbance. Symptoms of night and daytime pollakiuria were observed in 17% of women. The general condition of women was assessed as satisfactory. Thus, studies of the quality of life of women undergoing hysterectomy at reproductive age have shown that they need a long and adequate rehabilitation, in a rational selection of hormone replacement therapy to improve the quality of life.
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