MODERN APPROACH TO EARLY DIAGNOSIS OF THROMBOHEMORRHAGIC DISORDERS IN PATIENTS WITH ELEVATED BODY MASS INDEX IN THE PERIOPERATIVE PERIOD OF LAPAROSCOPIC MYOMECTOMY

Abstract

According to various authors from 32 to 70%, uterine fibroids is one of the most common diseases in gynaecological practice. In 80% of cases, fibroids are observed in women of reproductive age. 80 – 90% of women with uterine fibroids are treated surgically. Laparoscopic myomectomy is one of the main methods of surgical treatment of uterine fibroids in women of reproductive age. Changes in the haemostatic system in uterine fibroids are often the cause of thrombohemorrhagic complications in the perioperative stage of treatment. Traditional screening tests do not always answer the main issues that need to be asked when assessing the state of the haemostatic system in the perioperative period of laparoscopic myomectomy: the rate and intensity of platelet aggregation, assessment of clot density, coagulation potential, and the intensity of clot lysis. The use of screening tests in emergencies is not appropriate due to the long study time. Besides, deviations of the results from the control values do not predict intraoperative thrombohemorrhagic complications and postoperative thrombohemorrhagic complications (Craig J., Aguiar-Ibanez R., Bhattacharya S. et al., 2012; Doran, C.M., Woolley T., Midwinter, M.J., 2010). Based on these tests, it is impossible to make the most correct selection of the dose and discreteness of drugs for the prevention and treatment of thrombohemorrhagic complications (Tiutrin, I.I.). The goal of the research. Early diagnosis of thrombohemorrhagic disorders, the appointment of an adequate scheme of their complex correction, which is carried out to improve the results of surgical treatment in this group of patients, using a global system of haemostasis as low-frequency piezoelectric haemoviscosimetry. Materials and methods. The results of surgical treatment of 60 patients with uterine fibroids who underwent laparoscopic myomectomy at the Mother and Child medical centre, NEOMED 2007 LLC in Kyiv in 2019-2020 were studied. Patients were divided into 3 groups depending on the value of the Body Mass Index (BMI) and the choice of thromboprophylaxis method (Table 1). Group 1 (16 patients) included patients with BMI < 30 kg/m2, who were not treated with drug thromboprophylaxis. Group 2 (18 patients) included patients with a BMI > 30 kg/m2 who used Enoxaparin for thromboprophylaxis. Group 3 (26 patients) included patients with a BMI > 30 kg/m2 who used Enoxaparin and Pentoxifylline for thromboprophylaxis. The state of the haemostatic system before surgery, as well as on Day 1 and Day 5 after surgery, was monitored by standard biochemical tests, as well as by an instrumental method for assessing the functional state of the components of the haemostatic and fibrinolysis system as a Low-Frequency Vibration Piezoelectric Haemoviscosimeter (NFVPH). Results. After evaluating standard biochemical tests for assessing haemostasis before surgery, on Day 1 and Day 5 after surgery, no existing or significant pathological changes were detected in all groups of patients. When assessing the functional status of the components of the haemostasis and fibrinolysis system with Mednord LFVPH before surgery in Group 1 (Control Group of Patients), there were no significant differences within normal limits. According to Low-Frequency Piezoelectric Thromboelastographic (LFPT) data, statistically significant (p < 0.05) deviations from the reference values of the haemostasiogram in the direction of structural and chronometric hypercoagulation were found in Group 2 and Group 3 of patients. On the first day after surgery, changes in the haemostasis system were observed in all groups of patients, but they were multidirectional. In Group 2 and Group 3, there is a significant increase (compared to preoperative indicators) in such chronometric indicators as T1, T3, T5; a decrease in the structural indicator of MA (Maximum Amplitude), as well as a significant decrease in CTA (Constant of Thrombin Activity), ICD (Intensity of Coagulation Drive) on the first day after surgery, which confirms the effectiveness of antithrombotic therapy. However, in Group 2, there is an increased activity of the vascularplatelet link of haemostasis, compared with the Control Group and Group 3. At the stage of formation of CLF (Cross-Linked Fibrin) significant differences in the haemostasiogram between Group 2 and Group 3 were not detected. On Day 5 after surgery, a normocoagulation tendency of haemostatic potential was observed in all groups of patients. Evaluating the fibrinolytic activity of blood in all groups of patients, it should be noted that one day after surgery, against the background of antithrombotic therapy, the lytic activity of blood normalizes. No thrombohemorrhagic complications were observed in Group 1 of patients during the study period. In Group 2, there was 1 episode of Deep Vein Thrombosis (DVT) of the lower extremities on Day 10 after surgery. Group 3 had massive bleeding in the first 24 hours after surgery. Conclusions. The use of traditional screening tests for the diagnosis of the haemostatic system is not sufficient for adequate assessment and early diagnosis of thrombohemorrhagic disorders in patients with an increased body mass index in the perioperative period of laparoscopic myomectomy at the present stage of surgical treatment. Low-frequency piezoelectric hemoviscosimetry allows you to quickly and accurately assess the kinetics of thrombosis from the initial viscosity and aggregation of platelets to the formation of fibrin-platelet structure and lysis of the clot; viscoelastic properties of the primary clot and the density of the fibrin-platelet structure. With the help of low-frequency piezoelectric hemoviscosimetry, the existing thrombosis at the perioperative stage of laparoscopic myomectomy was revealed in patients with an increased body mass index at the earliest stages of haemocoagulation disorders, as evidenced by significantly significant (p < 0.05) changes in the main indicators of the method. Low-frequency piezoelectric hemoviscosimetry allows for the most correct selection of the dose and discreteness of drugs for the prevention and treatment of thrombohemorrhagic complications in this group of patients, thereby significantly reducing the risk of their occurrence.