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9Выводы
Оптимизация организации управлением учреждения родовспоможения первого уровня с укреплением материально-технической базы позволяет улучшить показатели качества оказания перинатальной помощи. Так по данным за период с 2013 по 2016 год отмечено снижение показателей младенческой смертности за счет всех ее компонентов: ранняя и поздняя неонатальная летальность, летальность детей с возрастом от 1 месяца до конца первого года жизни. Однако на сегодняшний день существуют нерешенные проблемы. Резервом снижения показателей перинатальной летальности могут явиться: дальнейшая модернизация поликлинического акушерско-гинекологического звена для обеспечения адекватной прегравидарной подготовки и повышения доступности своевременной лабораторной, инструментальной и ультразвуковой диагностики, улучшение материально-технического оснащения и оптимизация межведомственного взаимодействия учреждений акушерско-гине-кологической помощи и вспомогательных служб.
Литература
1. Совершенствование трехуровневой системы оказания медицинской помощи женщинам в период беременности, родов и в послеродовом периоде. Методическое письмо. - М., 2014. - 27 с.
2. Арцыбашева Л.Р. Необходимость оптимизации перинатальной помощи в системе ФМБА России на современном этапе / Л.Р. Арцыбашева, С.Ф. Торубаров // Материалы III Международной научно-практической конференции «Достижения и перспективы естественных и технических наук». Ставрополь, 2013г. - С. 43-45.
3. Суханова Л.П. Медико-организационные факторы в обеспечении репродуктивного процесса в России Л.П. Суханова, М.С. Скляр, Т.В. Кузнецова // Проблемы репродукции. Тенологии XXI века в гинекологии, М., 2008. - С. 22-23.
4. Brown S. Geographical information systems (GIS) mapping indicates access to tertiary care perinatal centers / S. Brown, M. Richards, W. Rayburn // Am. J. Obstet. Gynecol. 2012. V. 206. - P. 304.
5. Neto M.T. Perinatal care in Portugal: effects of 15 years of a regionalized system / M.T. Neto // Acta Paediatr. - 2006. -V. 95 (11). - P.1349-1352.
6. Pilkington H. Impact of maternity unit closures on access to obstetrical care: the French experience between 1998 and 2003 / H. Pilkington, B. Blondel, M. Carayol, G. Breart, J. Zeitlin // Soc Sci Med. - 2008. - V. 67(10). - P.1521.
7. Ohara M. Safety and usefulness of emergency maternal transport using helicopter / M. Ohara, Y. Shimizu, H. Satoh, T. Kasai, S. Takano, R. Fujiwara // J. Obstet Gynaecol Res. - 2008. V. 34(2) -P. 189.
8. Ravelli A.C. Travel time from home to hospital and adverse perinatal outcomes in women at term in the Netherlands / A.C. Ravelli, K.J. Jager, M.H. de Groot, J.J. Erwich, G.C. Rijninks-van Driel , M. Tromp, M. Eskes, F. Abu-Hanna // BJOG. - 2011. -V.118(4). - P. 457.
9. Maternity services in England. Report by the Comptroller and Auditor General. November 2013. -47 p.
10. Плутницкий А.Н. Медико-демографические аспекты оценки состояния здоровья населения сельского муниципального образования в современных условиях / А.Н. Плутницкий, В.И. Филли-пова // Сб. науч. тр. «Актуальные проблемы управления здоровьем населения». - Нижний новгород. -2013. - Вып.6. - С. 149-151.
SYMPTOMS OF ORGANIC BRAIN DAMAGE IN PRIMARY
HYPOTHYROIDISM
Pavlovych L.B.
Bilous I.I.
MD,PhD;
Department of Nervous Diseases, Psychiatry and Medical Psychology «Higher State Educational Establishment» Bukovinian State Medical University ", Chernivtsi, Ukraine
ABSTRACT
The purpose of the work is to identify the clinical features of the peripheral nervous system in patients with subclinical and clinically expressed hypothyroidism against the background of autoimmune thyroiditis and postoperative hypothyroidism. The study involved 56 patients with hypothyroidism as a result of AIT (autoimmune thyroiditis) and 20 patients with postoperative hypothyroidism. 18 patients had subclinical hypothyroidism. We used clinical-neurological and electrophysiological examination of patients. The affection of the peripheral nervous system manifested itself by sensitive polyneuropathy (86,8%) in combination with tunnel neuropathies (62,5%), and supplemented by myotonic phenomenon (21,1%) and myopathic syndrome (18,4%). In patients with autoimmune thyroiditis with thyroid hypofunction, polyneuropathy and tunnel neuropathies were prevalent. In patients with postoperative hypothyroidism, myopathic changes predominated. Sensory polyneuropathy and multiple tunnel syndromes, especially in combination with mild myopathic syndrome suggests hypothyroidism in the thyroid gland and determines the need for further endocrinological examination for justification of differentiated tactics for the management of these patients.
Keywords: autoimmune thyroiditis, subclinical hypothyroidism
Introduction. The nervous and endocrine system is the main regulatory systems in the processes of maintenance of homeostasis. Interaction and interpenetration of the two systems occurs not only on the functional, but also on the structural levels. Thus, a number of cells of the hypothalamus synthesize and secrete hormonal substances (releasing factors) that regulate the activity of the endocrine system in the blood stream, and some hormonal substances (endorphins, monoamines) act as neurotransmitters in the nervous system.
The close relationship between the two systems causes not only their interaction in physiological conditions, but also their simultaneous involvement in pathological processes. However, the processes of the relationship between systems in clinical practice are not given sufficient attention.
Neurological disorders are a component of the clinical picture of virtually every endocrine disorder, in some cases they form the syndromic core of the disease, the basis for its diagnosis. In other cases, the impression of the nervous system is initially almost imperceptible, but gradually, eventually manifested. It should be noted that a stable and transient violation of the function of a particular gland of the inner secretion is sometimes manifested by various neurological disorders.
Among the whole mass of neurological disorders in endocrine pathology can be identified acute and chronic conditions. Acute disorders arise, as a rule, against the background of a progressive course of the underlying disease or a sharp deterioration in its course (for example, a coma in a patient with diabetes melli-tus). Chronic disorders develop both against the background of progression, and the smooth course of the disease and even remission (for example, distal polyneuropathy in patients with diabetes mellitus, progressively overcoming with full compensation of the underlying disease).
The aim of the study. To identify the clinical features of the peripheral nervous system in patients with subclinical and clinically expressed hypothyroidism against the background of autoimmune thyroiditis and postoperative hypothyroidism.
Materials and methods. The study involved 56 patients with hypothyroidism as a result of AIT (autoimmune thyroiditis) and 20 patients with postoperative hypothyroidism. The control group consisted of 20 practically healthy persons. 58 (76,3%) of patients were on substitution therapy using synthetic derivatives of L-thyroxin, and 18 (23,7%) patients had subclinical hypothyroidism. We used clinical-neurological and electrophysiological examination of patients.
Research results discussion. The most common syndrome of the peripheral nervous system affection in patients with primary hypothyroidism is polyneuropa-thy. It was found in 66 (86,8%) patients under examination. Polyneuropathy was mild in 32 (48,5%) cases, moderate in 34 (51,5%); no severe polyneuropathy was found, which is consistent with the literature data [57]. The clinical picture included complaints of non-intense and moderate intensity of pain and paresthesia in the distal parts of the extremities, hypesthesia by the type of "gloves and socks". Motor disorders are represented by a decrease in tendon and periosteal reflexes, and
only in 7 (10,6%) individuals the hand strength decreased to 4 points. There were no expressed paresis and paralysis or muscular hypotrophy. Vegetative disorders were also slightly expressed and manifested themselves mainly by dry skin and feet, non-coarse acrohyperhidrosis and acrocyanosis. All of these symptoms were more pronounced in the upper limbs. It should be noted that there is no correlation between the severity of the disorder and the age of the patient.
In the group of patients with hypothyroidism secondary to AIT, polyneuropathy was practically obligate syndrome and occurred in 52 (92,8%) cases. In patients with postoperative hypothyroidism, polyneuropathy was observed less frequently - 15 (75%) cases. In addition, polyneuropathy against the background of AIT was more pronounced. The nature of polyneuropathy did not depend on the severity of the thyroid gland function. In patients with subclinical hypothyroidism, polyneuropathy was diagnosed in 16 (88,9%) cases, in those with clinical hypothyroidism - in 53 (91,4%) cases.
Therefore, the feature of the clinical picture of pol-yneuropathy in patients with primary hypothyroidism was mainly its sensitiveness, mild and moderate manifestations, more pronounced in the arms. The onset of this syndrome was influenced by the actual cause of hypothyroidism of the thyroid gland: in patients with hy-pothyroidism secondary to AIT polyneuropathy occurred more frequently and was more pronounced. In patients with varying severity of hypothyroidism, the incidence and severity of polyneuropathy were almost the same.
Another type of affection of the peripheral nervous system with primary hypothyroidism is tunnel neuropathies. Tunnel neuropathies can be a mask of hypothy-roidism [7]. They develop as a result of pinching the peripheral nerves in the osteoarticular channels and under the muscle tendons against the background of soft tissue edema [2,3,5]. Mucopolysaccharides accumulate in the synovial membranes of the muscles and tendons, as well as in the shells of the peripheral nerve itself, which leads to the formation of a tunnel syndrome [6,7].
The syndromes of the carpal canal, the Guyon's canal, the cubital and tarsal canals are most frequently diagnosed. The clinical picture of this pathology included complaints of patients about morning and night paresthesia, as well as positive tests on tunnel neuropathy. In some cases, a decreased sensitivity in the area of the affected nerve was identified. There were no motor disorders associated with tunnel neuropathy. One of the features of tunnel neuropathies in primary hypothyroidism was their multiple nature. Among the patients with primary hypothyroidism clinical signs of tunnel neuropathy were diagnosed in 49 (64,5%) patients.
Among patients with hypothyroidism secondary to AIT tunnel neuropathies were diagnosed in 35 (62,5%) of cases. In patients with postoperative one the signs of this pathology were less common and accounted for 11 (55%). Like in case of polyneuropathy, the severity of tunnel neuropathy was reliably higher in patients with AIT. Patients with primary hypothyroid-ism were more frequently diagnosed with carpal tunnel
syndrome. Its clinical manifestations were noted in 40 (52,63%) of cases. The Guyon's canal syndrome is the second most common one. In all patients who were examined this syndrome occured in 36 (47,3%) of cases. The cubital canal syndrome occupied the third place among tunnel neuropathies in patients with primary hypothyroidism. This syndrome was observed in 33 (43,4%) of patients. The syndrome of the tarsal channel was the least common 17 (22,4%).
The syndromes of the carpal canal and the Guyon's canal were more common and were more pronounced in patients with hypothyroidism against the background of AIT. Tunnel neuropathies were found in 10 (55,6%) of patients with subclinical hypothyroidism and in 40 (68,9%) of patients with clinical hypothyroid-ism.
Therefore, tunnel neuropathies were a frequent syndrome of peripheral nervous system damage in primary hypothyroidism. They were multiple and mainly involved the nerves of the upper extremities in the pathological process. Sensitive disorders prevailed in the clinical picture. The severity and incidence of tunnel syndromes depended on the cause of primary hypo-thyroidism and prevailed in patients with hypothyroid-ism against the background of AIT and did not depend on its severity.
Neuromuscular disorders are caused by oppression of all types of metabolism. Reducing the utilization of oxygen by tissues, increasing the protein degradation products in skeletal muscles, and excessive deposition of glycosaminoglycans change the structure of tissues, increasing their hydrophilicity, making it difficult for lymphatic drainage [7,8]. The microscopic examination of cross-striated muscles in patients with hy-pothyroidism finds changes in normal striation in combination with degenerative foci and basophilic infiltrates [5,6,7]. Disurbing mitochondrial oxidation processes leads to greater acidification of the intercellular space in the process of muscular contraction compared to the muscle that works properly [3,5,7], in addition, the hypothyroid rhabdomyopathy is characterized by the transformation of type 2 fast twitch muscle fibers into type lslow twitch muscle fibers [2,4,6].
According to the literature, clear clinical manifestations of myopathy syndrome are rare, but its obliterated and mild forms are observed in 4.4-80% cases. In our study, the manifestations of hypothyroid myopathy were mostly mild and obliterated, and occurred mainly in the muscles of the legs. Almost all patients did not complain of weakness in the proximal parts of the limbs on their own. Only being actively questioned, the patients noted that they felt weakness in the muscles of the thighs when walking upstairs or when walking up, which they did not experience before. The examination found a decrease in strength by 1-2 points in the proximal parts of the limbs (mostly in the legs), while there were not atrophies or muscle hypertrophies. Only one patient with clinical hypothyroidism secondary to AIT noted a pronounced decrease in strength in the proximal parts of the limbs, which changed the pace and made her movement hard.
Signs of hypothyroid myopathy were found in 14 (18,4%) of patients with primary hypothyroidism. In
patients with hypothyroidism against the background of AIT, hypothyroid myopathy was observed in 8 (14,3%) of cases, and in patients with postoperative hypothy-roidism - 6 (30%).
Signs of hypothyroid myopathy in patients with clinical hypothyroidism were observed in 11 (18,9%) of cases, and in patients with subclinical hypothyroid-ism in 1 (5,5%) the clinical picture of myopathy was more pronounced. Thus, the myopathic syndrome in patients with primary hypothyroidism was mild. Features of hypothyroid myopathy were associated both with the cause of primary hypothyroidism, and with its severity.
Like in the case of hypothyroid myopathy, there were no expressed myotonic phenomena in the examined patients. None of the patients had such symptoms as propblems with breathing while staring to move or a significant increase in mechanical excitability of the muscles - " cushion " with percussion, described in the literature [2,5]. There only was a visible extension of the time of the tendon reflexes (Achilles and / or carpo-radial ones). This phenomenon was observed in 16 (21,4%) of patients with primary hypothyroidism. The combination of delayed reflexes with myopathy was noted in 3 (18,75%) of patients with myotonic phenomenon. In patients with hypothyroidism secondary to AIT, this syndrome was noted in 13 (23,2%) of the subjects. In patients with clinical hypothyroidism, delayed reflex abnormalities were noted in 11 (18,9%) of cases, and in patients with subclinical hypothyroidism - 4 (22,2%). The cause of the myotonic phenomenon is a disorder of muscle relaxation. This is due to impaired SERCA in the sarcoplasmic reticulum, which is provided by Ca2+ ATPase [5,6]. Decreasing activity of this enzyme in the muscles is due to the presence of a T3-sensitive element [3,5]. EMG examination does not detect any characteristic myotonic phenomena [7,8].
The severity of the peripheral nervous system affection also primarily depended on the immune status of the patients and did not depend on their age and the severity of hypothyroidism. Polyneuropathy and tunnel syndromes were prevalent in patients with AIT with elevated levels of anti-thyroid antibodies.
The findings are indicative of a great role of autoimmune mechanisms in affecting the nervous system in patients with primary hypothyroidism.
Therefore, the affection of the nervous system in the primary hypothyroidism was almost obligatory. The main clinical feature of neurological syndromes in primary hypothyroidism was their "mild" course, which most often did not lead to gross social maladaptation and disability of patients.
The conducted research showed the features of the nervous system affection in hypothyroidism under current conditions and allowed to outline a number of possible causes of this variable clinical picture in patients with seemingly identical pathology.
Conclusions
1. The affection of the peripheral nervous system manifested itself by sensitive polyneuropathy (86,8%) in combination with tunnel neuropathies (62,5%), and supplemented by myotonic phenomenon (21,1%) and myopathic syndrome (18,4%).
2. In patients with autoimmune thyroiditis with thyroid hypofunction, polyneuropathy and tunnel neuropathies were prevalent. In patients with postoperative hypothyroidism, myopathic changes predominated.
3. Sensory polyneuropathy and multiple tunnel syndromes, especially in combination with mild myo-pathic syndrome suggests hypothyroidism in the thyroid gland and determines the need for further endo-crinological examination with mandatory determination of the level of antibodies to peroxidase tyrocytes and antibodies to thyroglobulin for justification of differentiated tactics for the management of these patients.
References
16. Lee KW, Kim SH, Kim KJ, Kim SH, Kim HY, Kim BJ, et al. A Rare Manifestation of Hypothyroid Myopathy: Hoffmann's Syndrome. Endocrinol Metab (Seoul). 2015;30(4):626-30. doi: 10.3803/EnM.2015.30.4.626
17. Chung J, Ahn KS, Kang CH, Hong SJ, Kim BH. Hoffmann's disease: MR imaging of hypothyroid myopathy. Skeletal Radiol. 2015;44(11):1701-4. doi: 10.1007/s00256-015-2226-1
18. Samy DM, Ismail CA, Nassra RA. Circulating irisin concentrations in rat models of thyroid dysfunction - effect of exercise. Metabolism. 2015;64(7):804-13. doi: 10.1016/j.metabol.2015.01.001
19. Jbara Y, Bricker D. Rhabdomyolysis in the setting of induced hypothyroidism and statin therapy: a case report. Eur Thyroid J. 2015;4(1):62-4. doi: 10.1159/000371548
20. Villar J, Finol HJ, Torres SH, Roschman-Gon-zalez A. Myopathy in patients with Hashimoto's disease. Invest Clin. 2015;56(1):33-46..
21. Mangaraj S, Sethy G. Hoffman's syndrome -A rare facet of hypothyroid myopathy. J Neurosci Rural Pract. 2014;5(4):447-8. doi: 10.4103/09763147.140025
22. Sharma V, Borah P, Basumatary LJ, Das M, Goswami M, Kayal AK. Myopathies of endocrine disorders: A prospective clinical and biochemical study. Ann Indian Acad Neurol. 2014;17(3):298-302. doi: 10.4103/0972-2327.138505
ОСОБЕННОСТИ КОНСЕРВАТИВНОМ ТЕРАПИИ ЛЕИОМИОМЫ МАТКИ, СОВРЕМЕННЫЙ ВЗГЛЯ
Цветкова Т. П.
Ведущий гинеколог-эндокринолог высшей категории ООО Иммуно-реабилитационный Центр
г. Хабаровска
FEATURES OF CONSERVATIVE THERAPY OF UTERINE LEIOMYOMA, MODERN LOOK
TsvetcovaT.P.
Leading gynecologist-endocrinologist highest category Company Immuno-Rehabilitation Center
in Khabarovsk
АННОТАЦИЯ
Выявленные корригирующие возможности препаратов ИндинолФорто позволяют рекомендовать его в качестве обоснованной альтернативной терапии лейомиомы матки ABSTRACT
The revealed corrective capabilities of IndinolForto products make it possible to recommend it as a justified alternative therapy for uterine leiomyoma
Ключевые слова: лейомиома матки, модуляторы рецепторов прогестерона, индуктор роста Keywords: uterine leiomyoma, progesterone receptor modulators, growth inducer
Принимая во внимание, что точная природа возникновения миомы матки по-прежнему неизвестна, определенная роль в развитии этого заболевания отводится эстрогенам и различным изофор-мам прогестерона в сочетании с повышенным содержанием митогенных факторов роста, цитокинов хемокинов и компонентов внеклеточного матрикса, которые стимулируют рост миоматозных узлов, гормональная терапия занимает ведущее место в консервативном лечении этого заболевания. Несмотря на это, ни один из существующих на сегодняшний день методов медикаментозной терапии
не способен полностью излечить больных, страдающих миомой матки, т.е. не происходит ликвидации анатомического субстрата, он лишь подвергается регрессии. При выборе тактики ведения необходимо выделять симптомное и бессимптомное течение этого заболевания.
Миома матки встречается у 77% женщин репродуктивного возраста, при этом разнообразные симптомы, сопряженные с этим заболеванием отмечены только в 25%. К первой линии терапии симптомных миом относится медикаментозная терапия.
