For the Obstetrician
Membrane plasmapheresis for patients with climacteric syndrome (CS).
(In accordance with the methodological recommendations of Kharkiv State Medical University and Maternity Hospital No. 3 of the Kyivskyi district of the city of Kharkiv, Kharkiv, 2007).
The problem of human aging has attracted the attention of the outstanding thinkers of mankind since ancient times. In the 21st century, in connection with the clear trend toward an increase in the life expectancy of the population, this problem has acquired particular relevance. The process of aging in a woman's body begins with the reproductive sphere.
The climacteric is a transitional period from the reproductive phase of life to aging.
This is the time when reproductive and menstrual functions cease. The climacteric period occurs in a woman at the age of 48 - 50 years and coincides with the period of her most active social and professional activity. During this period the body of the woman undergoes age-related changes, which in turn leads to a restructuring of general homeostasis and to psycho-emotional stress. The nervous, cardiovascular, skeletal and neuroendocrine systems undergo marked changes. In 35 - 70% of women, under the influence of unfavorable factors, a pathological climacteric may arise, which is manifested in endocrine and metabolic, vegetative and vascular and neuropsychiatric disturbances
Plasmapheresis in Rh conflict during pregnancy
Membrane plasmapheresis is performed with the aim of reducing the titer of Rh antibodies in pregnant women to a safe level.
Indications for membrane plasmapheresis:
1. The presence and increase of the level of antibodies during pregnancy.
2. The presence of Rh antibodies during the period of preparation for pregnancy, especially in cases of Rh conflict in a previous pregnancy.
Relative contraindications:
1. Acute respiratory infections (febrile state)
2. Threatened miscarriage or premature labor.
Technique of the procedure
A course of membrane plasmapheresis (MP) in the pregestational period consists of 3-5 sessions with the removal of 25-30% of the CPV and replacement with crystalloid solutions. During pregnancy, MP is performed after an increase in the titer of Rh antibodies to a level above 1:16 - 1:32 at any stage of pregnancy. From 25 to 50% of the CPV is removed in one session. In the latter case, especially against a background of pre-existing hypoproteinemia, albumin and fresh frozen plasma may be added as a plasma-substituting medium. The initial course consists of 3-5 sessions of membrane plasmapheresis; however, if the level of Rh antibodies rises again, repeat sessions may be performed at intervals of up to a week under monitoring of the total protein content in the blood.
Efficacy criteria: A decrease in Rh antibodies to a level below 1:16.
Autodonor plasmapheresis in preparation for elective cesarean section.
Autodonor plasmapheresis is used to procure autoplasma to compensate for blood loss in elective abdominal delivery. This reduces the risk of transmissible diseases and other post-transfusion complications, and the factors of the coagulation and anticoagulation systems of the blood are replenished during the surgical intervention.
Indications:
1. The third trimester of pregnancy during preparation for elective cesarean section.
Contraindications:
1. Congenital and acquired disorders of hemostasis.
2. Severe neurological, vascular or cardiac pathology.
3. Endocrinological pathology where replacement therapy is required.
4. Anemia (with Hb below 100 g/l).
5. Weight less than 50 kg before pregnancy.
Technique of the procedure
When standard blood loss is planned for, 2 doses of autoplasma are procured at an interval of no less than 48 hours, and also no less than 48 hours before the planned surgical intervention. Isotonic sodium chloride solution is used as the plasma-substituting fluid.
Features of the method: the position of the pregnant woman during plasmapheresis must be "on her side" in order to prevent "inferior vena cava" syndrome.
The efficacy criteria are:
1. Normalization of hemocoagulation values.
2. Normalization of hemodynamics, or a reduction in the dose of inotropic drugs.
3. Absence of the formation of multiple organ failure.
Plasmapheresis in the treatment of recurrent miscarriage
Membrane plasmapheresis is used in the combined treatment of recurrent miscarriage. MP is used with the aim of normalizing microcirculation and blood rheology; removing middle-molecular-weight toxins, immune and fibrin-monomer complexes and inhibitors of erythropoiesis from the blood; stimulating antithrombin activity and fibrinolysis; normalizing the circulation in the mother-placenta-fetus system; prolonging pregnancy; preparing for delivery; eliminating multiple organ disturbances; and preventing the development of severe placental insufficiency and fetal hypotrophy.
Indications:
1. Autoimmune disorders (APS, anti-hCG, etc.).
2. Hypercoagulation syndrome, chronic DIC.
3. Lack of effect from therapy.
4. Carriage of HSV, CMV infection.
4. Long-standing infectious pathology in the history.
Absolute contraindications:
1. Marked organic changes in the cardiovascular and nervous systems.
2. Anemia (Hb < 90 g/l).
3. Hypoproteinemia (total protein level <60 g/l).
4. Thrombocytopenia (platelets < 100 x 10⁹/l).
5. Hypocoagulation.
Relative contraindications:
1. Absence of venous access.
2. Phlebitis of the peripheral veins in the acute stage.
3. Allergic reactions to anticoagulants and to colloid and protein preparations.
Technique of the procedure
A course of MP consists of 3 procedures at an interval of 1 day. It may be carried out by the discontinuous method - centrifugation at 3800 revolutions for 6 minutes - or by the instrumental method. From 20 to 40% of the CPV is removed per procedure. Membrane plasmapheresis is performed in an isovolemic regimen. Plasma replacement is carried out with 6% and 10% solutions of hydroxyethyl starch (Infucol HES, Refortan, etc.) in combination with physiological saline. In cases of initial hypoproteinemia (total protein <60 g/l), an infusion of 10 ml of 10% albumin solution is performed at the end of each procedure. In the event of a relapse of the disease or an insufficient clinical effect, a repeat course of MP is carried out.
The dose of heparin per procedure is 5 thousand IU.
Efficacy criteria:
1. Normalization of hemodynamic values.
2. Normalization of hemostasiogram values.
3. A decrease in the level of antiphospholipids.
4. Normalization or improvement of the values of fetoplacental blood flow.
5. Normalization or improvement of the intrauterine condition of the fetus.
Plasmapheresis in ovarian hyperstimulation syndrome
Membrane plasmapheresis (MP) is used in the combined treatment of moderate and severe forms of ovarian hyperstimulation syndrome, which develops in patients with infertility during an in vitro fertilization program. It is used for the treatment of generalized edema syndrome, for detoxification, and in hemoconcentration and DIC syndrome.
Indications:
1. Ovarian hyperstimulation syndrome of moderate and severe degree.
2. An increase in abdominal circumference and in the size of the ovaries.
3. Marked edema syndrome, the presence of ascites and hydrothorax.
4. Hypercoagulation, hemoconcentration.
5. Intoxication (nausea, vomiting, diarrhea, etc.).
Relative contraindications:
1. Absence of venous access.
2. Phlebitis in the acute stage.
3. Allergic reactions to anticoagulants and to colloid and protein preparations;
Absolute:
1. Marked organic changes in the cardiovascular and nervous systems.
2. Anemia (Hb less than 90g/l).
3. Hypoproteinemia (total protein below 60 g/l).
4. Hypocoagulation.
Technique of the procedure
The course of treatment consists of 3-4 procedures at an interval of 1-2 days. The volumes of plasma removed amount to 20-30% of the CPV per session. Plasma replacement in percentage terms: 45% colloid, 45% crystalloid and 10% protein solutions. The ratio of plasma-substituting solutions to the removed plasma is 1,5-2: 1,0. The dose of heparin per procedure is 5-10 thousand IU.
Criteria for the efficacy of treatment:
1. Improvement of clinical and laboratory values.
2. Normalization of hemostasiogram values.
3. A decrease in or disappearance of the phenomena of intoxication.
4. Disappearance of generalized edema syndrome, a decrease in the amount of ascitic fluid.
5. A decrease in the size of the ovaries, disappearance of the pain syndrome.
Plasmapheresis in gestosis of pregnancy
Plasmapheresis is used in the combined treatment of gestosis. Plasmapheresis is used with the aim of normalizing microcirculation and blood rheology; removing middle-molecular-weight toxins, immune and fibrin-monomer complexes and inhibitors of erythropoiesis from the blood; stimulating antithrombin activity and fibrinolysis; normalizing the permeability of the basement membrane of the renal glomeruli and thereby reducing proteinuria and normalizing the proteinogram; prolonging pregnancy; preparing for delivery; eliminating multiple organ disturbances; and preventing the development of severe gestosis.
Indications:
1. Lack of effect from therapy.
2. Recurrence of the clinical picture of gestosis.
3. Extragenital pathology (hypertensive disease, diseases of the liver, kidneys and other internal organs.)
4. Disturbance of fat metabolism.
5. Autoimmune disorders (APS, anti-hCG, etc.).
6. Long-standing infectious pathology in the history.
Absolute contraindications:
1. Marked organic changes in the cardiovascular and nervous systems.
2. Anemia (Hb < 90 g/l).
3. Hypoproteinemia (total protein level <60 g/l).
4. Thrombocytopenia (platelets < 100 x 10⁹/l).
5. Hypocoagulation.
Threatened miscarriage or premature labor.
Relative:
1. Absence of venous access.
2. Phlebitis of the peripheral veins in the acute stage,
3. Allergic reactions to anticoagulants and to colloid and protein preparations.
Technique of the procedure
A course of PA consists of 3 procedures at an interval of 1 day. PA may be carried out by the discontinuous method - centrifugation - or, preferably, by the instrumental, atraumatic method of Membrane plasmapheresis (MP) on the "HEMOFENIX" apparatus. From 20 to 40% of the CPV is removed per procedure
Plasmapheresis is performed in an isovolemic regimen. Plasma replacement is carried out with 6% and 10% solutions of hydroxyethyl starch (Infucol HES, Refortan, etc.) in combination with physiological saline. In cases of initial hypoproteinemia (total protein <60 g/l), an infusion of 100 ml of 10% albumin solution is performed at the end of each procedure. In the event of recurrence of the disease or an insufficient clinical effect, a repeat course of PA is carried out. The dose of heparin per procedure is 5 thousand IU.
Efficacy criteria:
1. Normalization of hemodynamic values.
2. A reduction in edema.
3. Normalization of the level of total protein and albumin in the blood plasma.
4. Absence of proteinuria.
