Atypical hemolytic-uremic syndrome as one of the causes of acute kidney injury in pregnant women.

AIM: Analysis of clinical manifestations, course and outcomes of obstetric aHUS. MATERIALS AND METHODS: 45 patients with aHUS development during pregnancy or immediately after childbirth were observed between 2011 and 2017, age from 16 to 42 years. RESULTS: All patients had AKI (serum creatinine 521,5±388,0 µmol/l, oliguria or anuria that required initiation of hemodialysis). 93.3% pts had extrarenal manifestations of TMA with the development of multiple organ failure (MOF). The mean number of damage organs was 3,7±1,2. In all patients, the development of aHUS was preceded by obstetric complications, surgery, infection, etc. In the outcome: 53.4% women showed complete recovery of renal function, 11.1% developed CKD 4-5 stages, 35.5% had dialysis-dependent end-stage renal failure (ESDR). Maternal mortality was 23.9%. Perinatal mortality was 32.6%. The early start of eculizumab treatment (within 1-2 weeks from the onset of aHUS), compared with therapy start after 3 weeks, increased the chances of favorable outcome for mother in 5.33 times, and the chances for normalization of renal function in 48.7 times. CONCLUSION: Obstetric aHUS is characterized by the development of AKI in 100% of cases. In most patients, the obstetric aHUS occurs with the development of MOF. Timely diagnosis of aHUS and immediate treatment by eculizumab allows not only to save the life of patients, but also completely restore their health.

ANESTHETIC MANAGEMENT OF DELIVERY IN PATIENTS WITH COMPLEMENT-ASSOCIATED DISORDERS. CLINICAL OBSERVATION OF A PREGNANT WOMAN WITH PAROXYSMAL NOCTURNAL HEMOGLOBINURIA.

There was a case in MRRIOG (Moscow Regional Research Institute of Obstetrics and Gynecology) in 2015 when pregnant patient with paroxysmal nocturnal hemoglobinuria(PNH) has successfully passed through a delivery process. This paper analyzes the medical history, clinical, laboratory and instrumental examination, particularly anesthesia tactics for the patients with complement-associated diseases during delivery. The presented clinical case demonstrates the need for and the importance of early diagnosis of PNH in pregnant women. Of course, women with PNH are one of the most complex contingent ofpregnant women, threatened by the development of obstetric and anesthetic complications, and it requires constant monitoring of clinical and laboratory parameters of their condition, the joint hematologist, obstetri- cian and anesthesiologist observationand delivery in hospitals of III and IV levels.

[OBESITY AS A RISK FACTOR FOR MASSIVE POSTPARTUM HEMORRHAGE.]

INTRODUCTION: No mat analysis devoted to the study of obstetric hemorrhage due to obesity has not yet been carried out. Publications of the results of major studies on the subject have appeared recently. Only the multivariate analysis will make a reasonable conclusion about the causes that affect the outcome and assess the extent of the simultaneous influence on him of often interrelated reasons. THE AIM: To estimate the signficance of obesity as an independent risk factor for serious obstetric haemorrhage. MATERIALS AND METHODS: A retrospective cohort study ofpregnancy and childbirth outcomes of 24634 women in childbirth. Depending on the initial body mass index (BM) of the patients were allocated two groups: basic - 2140 obese women with control - 17937 patients with an initial BW of 18.5 to 24.9 kg / m2. In order to determine the significance of obesity as a riskfactor of massive blood loss midwife performed multivariate statistical analysis, including cluster analysis, multiple correlation, linear and non-linear regression, statistical quality control using control charts. RESULTS: Hypotension uterus has been a major factor in the development of massive blood loss. For the implementation of hypotonic uterine bleeding was necessary set of conditions, interacting with other causal factors affecting the outcome. The minimum combination of these factors is the combination of "obesity" + "somatic pathology" + "induction of labor," in which the OR of postpartum hemorrhage was 8,57 [CI 95% 6,13-36,28], p < 0.001. It is also significant risk factors were fetal macrosomia, multiple pregnancy, abdominal method of delivery, the degree of obesity, the method of anesthesia and duration of the operation. OR to define obesity as an isolated risk factor for the implementation of massive blood loss was 1.18 [95% CI: 0,78-1,27], p > 0.05. DISCUSSION: The impact of obesity as an isolated causes massive obstetric hemorrhage was minimal, but is powerful potentiating factor in the outcome. CONCLUSION: Analysis of the causes of complications in childbirth did not confirm the possibility of considering obesity as an independent risk factor for massive blood loss.

[CONTROVERSIAL ISSUES OF THE ANESTHESIOLOGICAL MAINTENANCE OF DELIVERY IN OBESE PATIENTS].

The review represents debatable issues of the anesthesia management of the surgical delivery and postoperative period in patients with obese: the choice of anesthesia methods, anesthesia as a risk factor of maternal and perinatal morbidity and mortality and methods of intraoperative pain management. Authors made an attempt to reveal preventable risk factors of complications in obese patients: professional skills, technical equipment, standards compliance, period of time from the decision till delivery itself selection of an adequate dose of local anesthetic during spinal anesthesia, necessity of monitoring and correction of intra-abdominal hypertension. The article discusses the variety of problems, and in case offurther researches they will help to decrease frequency of the anesthetic complications, that determine obstetric and perinatal outcomes in obese patients.

[Effect of preoperative infusion volume on frequency of intraoperative nausea and vomiting as complications of spinal anaesthesia in pregnant women during caesarian operation (pilot study)].

Purpose of the study was to define a prophylactic effect of different preload volumes on the rate of intraoperative nausea and vomiting (IONV) as a complication due to spinal anaesthesia (SA) during caesarian operation (SO) in parturient. Data for analysis was collected during clinical observational multi-center research included several medical centers. Statistics involved originally developed method allowed to analyze relative risk changing along the entire interval of all applied preload volumes. The results suppose that preload is effective method of IONV prophylactics in parturient during SO under SA if only infused preload volumes do not break specially determined limits of effective interval. If preload volume value is out of this range then preinfusion may lead to increasing risk of IONV occurrence.

[Correction of local anesthetic dosage in spinal anesthesia in pregnant women with obesity].

INTRODUCTION: Intra-abdomninal pressure (IAP) is one of the reasons for reducing the volume of the subarachnoid space, the cerebrospinal fluid of pregnant iwomnen with obesity and as a result, a high spinal block in spinal anesthesia (SA), clinical manifestation of which is marked arterial hypotension. OBJECTIVE: To decrease the frequency and severity of arterial hypotension related to the conduct of SA due to the correction dose of local anesthetic with the level of intra-abdomninal pressure and timing of operative delivery MATERIAL AND METHODS: The study involved 252 women. To determine the physiological level of IAP at different stages of gestation used to study the level of IAP in 118 pregnant women with normal body weight. To explore the relationship of frequency of hypotension in the SA and the development of methodology for calculating the dose of local anesthetic in pregnant women examined 92 patients, 62 of whom were obese. To assess the adequacy of the developed technique further examined 42 obese women. RESULTS: it was determined that the gestation 38-40 weeks, the mean physiological IAP corresponds to 20 mm Hg, at the term of 35-37 weeks - 18 mm Hg at 32-34 weeks of pregnancy - 16 mnm Hg. Studies have shown that an adequate dose of local anesthetic for spinal anesthesia for operative delivery in pregnant women with obesity depends on the level of IAP The required dosage is determined by the percentage reduction for the difference between the actual level of IAP and the predicted IAP The required dosage 5.5% per mm Hg IAP is higher than the physiological norm. CONCLUSION: The developed method of calculating the dose of local anesthetic with the levels of IAP and gestational age prevents development of arterial hypertension, the optimum level of sensory block during SA for operative delivery obese women.

[Oxidative stress in perioperative period of cesarean section].

OBJECTIVE: To assess a pro- and antioxidant status in pregnant women at the system level in the perioperative period of cesarean section under regional and general anaesthesia. MATERIAL AND METHODS: 62 pregnant women aged 21 to 37 years (30,9 ± 6,2 y,ears) undergone delivery by cesarean section under general (n = 33) and regional (29) anaesthesia (1-2 class ASA (American Society ofAnesthesiologists). Blood samples were collected immediately after placing patients on an operating table (T1), immediately after suturing the surgical wound (T2), and 12 (T3) and 24 (T4) hours after taking the first sample. We studied following parameters: superoxide dismutase (SOD), glutathione peroxidase (GP). reduced glutathione (RG), total antioxidant activity, active products that react with thiobarbituric acid (TBA-ap). RESULTS: In general anaesthesia cesarean critical period activation ofprooxidant and antlioxidant activity is the period T2. Activation prooxidant activity (TBA-ap) was stored at 12 and 24 hours after surgery. Increased antioxidant activity (SOD, GP) was observed in the period T2. which wass replaced by its inhibition to 24 hours. Reduced glutathione content (RG) was reduced during T2 remains at low values up to 24 hours. Regional anaesthesia did not change observed prooxidant (poorly marked increase antioxidant activity (SOD, GP), which persists up to 24 hours). Reduced glutathione content (RG) was reduced in the period T3. but recovered after 24 hours. CONCLUSION: The use of regional imnaesthesia and spontaneous breathing with atmospheric air during an elective caesarean section helps to avoid induction and manifestations of oxidative stress in pregnant women in the perioperative period and to fully implement the program early activation parturients after cesarean section.

[Concept, definition and classification of intra-abdominal hypertension in pregnancy].

The article stresses methodological aspects of intaabdominal hypertension at pregnancy. Formal-logical analysis of conceptual framework and available classifications of intaabdominal hypertension was carried out. The article presents new definition and classification of intaabdominal hypertension.

[Anesthetic aspects of the problem of morbid obesity in pregnancy].

The prevalence of morbid obesity has been grown at a very heart rate in developed countries during the last decades. Over-weight pregnant women make up a group of risk of such serious complications as gestational hypertension, preeclampsia, gestational diabetes, increased frequency of Cesarean sections, and uterine inertia. Morbid obesity creates problems in anesthetic support. Obesity is associated with many physiological changes that compromise the adaptive ability in pregnant and delivering women. This review describes clinical and functional peculiarities of pregnancy, labor, and perioperative period in women with morbid obesity. Main physiological changes in these patients are described. Clinical aspects of the problem of practical significance for obstetricians/anesthetists are discussed.

[Role of intra-abdominal hypertension in the development and outcome of ovarian hyperstimulation syndrome].

OBJECTIVE: To evaluate the role of intraabdominal hypertension in the development and outcome of ovarian hyperstimulation syndrome. MATERIAL AND METHODS: 60 patients with varying degrees of ovarian hyperstimulation syndrome (OHSS) due to ongoing pregnancy were involved in the study. Intraabdominal pressure (IAP) was measured in the bladder. Performance of abdominal perfusion pressure, filtration gradient, extensibility and compliance of the anterior abdominal wall were evaluated. A size of the ovaries, chorionic condition and ascites were determined by ultrasonic method. Relation of pregnancy outcome and IAP was analyzed. RESULTS: The mean value of IAP in patients with light form of ovarian hyperstimulation syndrome was 7.05 +/- 1.76 mm Hg, 13.65 +/- 1.92 mm Hg in patients with moderate form, and 20.60 +/- 2.52 mm Hg in patients with severe form of OHSS. The leading factors in the development and progression of intraabdominal hypertension (IAH) are the volume of the ovaries, ascites, and extensibility of the abdominal wall. The comparison of pregnancy outcome and severity of IAP revealed a strong positive correlation--r = 0.726, p < 0.001. CONCLUSION: Evaluation of the severity of intra-abdominal hypertension in patients with ovarian hyperstimulation syndrome with considering the clinical data and results of laboratory and instrumental studies allow clarifying the severity of condition and predict the potential complications and pregnancy outcomes.

[Anticoagulant therapy in pregnant women with mechanical prosthetic heart valves. Review of international clinical guidelines].

Recently thromboembolic and hemorrhagic complications are main causes of maternal morbidity and mortality. Normal pregnancy is associated with ahypercoagulation. This condition is complicated if the patient has a mechanical prosthetic heart valve. Therefore an anticoagulant therapy in these patients is a challenging task. Effects of anticoagulant drugs on the fetus, pregnancy and delivery must also be taken into consideration. The review deals with international clinical guidelines. Diagrams of anticoagulant therapy in pregnant women with mechanical prosthetic heart valves using direct (unfractionated and low-molecular-weight heparins) and indirect (warfarin) anticoagulants are presented in the review.

[Relationship between uteroplacental blood flow and of intra-abdominal hypertension in pregnant women].

UNLABELLED: RESEARCH AND OBJECTIVE: Identification of relationship between intra-abdominal pressure and uteroplacental blood flow MATERIALS AND METHODS: 90 second trimester women (20-24 weeks) were examined. An assessment of intra-abdominal pressure (IAP) was carried out by "Unometerabdopressure" system through a bladder. Doppler imaging with resistance index in uterine arteries (RIUA) and umbilical cord arteries (UCA) assessment was carried out to evaluate uteroplacental blood flow. We calculated indicator (1) that characterize extent uteroplacental blood flow compensation degree. Pregnancy course and birth results were studied. RESULTS: It is established that uteroplacental blood flow disturbances during 2nd trimester of pregnancy are closely connected with IAP level. RIUA and I data are assessment criteria of chronic intra-abdominal hypertension compensation degree in pregnant women. Obstetric and perinatal complications frequency is closely connected with IAP value. IAP and uteroplacental blood flow data are important parameters which can be received with use of noninvasive techniques.

[Heart function changes during pregnancy].

The aim of the study was to assess the left ventricle (LV) systolic and diastolic functions during normal pregnancy. Patients were divided in 2 groups: women with normal pregnancy (30-40 weeks) and a control group--healthy non-pregnant women. Echocardiography and tissue Doppler imaging (TDI) were registered in both groups. Women age, height and weight were additionally registered. Static handling included correlation analysis with calculation of Pearson and Spirmen pair factors correlation. Obtained data showed that stroke volume during pregnancy plays a key role not only in minute volume increase, but also in its regulation in general. Preload and stroke volume increase during constant heart rate is in need of systolic and diastolic LV walls movement speed and myocardium contractility function increase. Results of our research explain imperfection of pregnant women adaptable mechanisms to hypertransfusions and heavy hypovolemia.

[Correction of anaemia in HIV-positive pregnant women receiving antiretroviral therapy].

The analysis of 162 surgical deliveries cases in HIV-infected pregnant women was carried out. Anaemia type identification was based on blood analysis data and erythrocytes morphology. Ways of disease correction were defined. Recommendations for anemia prevention and treatment in HIV-infected patients receiving anti-retroviral drugs are presented.

[Haemostasis disorders and ways of its correction in HIV-positive pregnant women receiving chemopreventive antiretroviral therapy].

The analysis of 162 surgical deliveries cases in HIV-positive patients with antiretroviral therapy--induced haemostasis disturbances and thrombocytopenia was carried out. The article gives the perioperative management during surgical delivery.

[Angiogenic growth factors in the ceresbropinal liquid of pregnant women during planned cesarean section under combined spinal - epidural anaesthesia].

The content of soluble angiogenic growth factors in cerebrospinal liquid and blood serum in 33 pregnant women aged from 21 to 37 years (30.9 +/- 6.2 years) before spinal - epidural anaesthesia during Cesarean section was studied in observative, prospective, stratificative research. All patients without somatic pathology were divided into 2 groups -control and main. 12 pregnant women with high degree myopia as a main indication for Cesarean section were included in the 1st control group. 21 pregnant women were included in the 2nd main group. This group was divided into 2 subgroups: group 2a--with eukinetic haemodynamics type (12 patients), group 2b--with hyperkinetic haemodynamics type and moderate hypoxemia (9 patients). The indications for planned Cesarean section in patients of the 2nd group were uterine scar and/or pelvis bones pathology. The analysis of angiogenic growth factors content in cerebrospinal liquid revealed differences between group 2b and group 2a. Results of angiogenic growth factors content in cerebrospinal liquid testify hidden intracerebral hypoxemia and can be used for its assessment before anaesthesia and for the testifying of the haemodynamics status and system hypoxemia relationship.