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OBSTETRICS AND GYNECOLOGY

INVENTION
Patent of the Russian Federation RU2151543

METHOD OF ADMINISTRATION OF RODS IN RHEUMATIC HEART DISEASES

METHOD OF ADMINISTRATION OF RODS IN RHEUMATIC HEART DISEASES

The name of the inventor: Turkov Oleg Nikolaevich
The name of the patent holder: Turkov Oleg Nikolaevich
Address for correspondence: 123631, Moscow, ul.Isakovskogo 28, building 2, ap.505, Turkov ON
Date of commencement of the patent: 1996.11.20

The invention relates to medicine, to obstetrics. Women with rheumatic heart defects are diagnosed with cardiac arrhythmias, increased heart chambers, rheumatic process activity, and circulatory changes. Each of the diagnostic signs is assigned a certain number of points - from 1 to 26. The management of births is carried out in accordance with the total number of points. Depending on this indicator, without switching off or turning off attempts, by cesarean section or by the operation of applying obstetric obstetrical forceps during pregnancy, the accuracy in assessing the risk level, choosing the optimal strategy and treatment tactics in the conditions of antenatal clinic and non-specialized obstetric hospital for heart defects in Dynamics of pregnancy in heart diseases.

DESCRIPTION OF THE INVENTION

The invention relates to medicine, namely obstetrics.

The purpose of the invention is to determine the method of delivery in women with rheumatic heart diseases, taking into account the presence of cardiac rhythm disturbances, enlargement of the heart chambers, activity of the rheumatic process and changes in blood circulation, by concretizing the heart disease form and all the above risk factors, after which each of the diagnostic features is assigned A certain number of points, and the method of conducting childbirth is determined in accordance with the number of points, so when the number of points from 1 to 13, the birth is conducted without turning off attempts, from 14 to 17 points - attempts are turned off by applying cavity obstetric forceps, from 18 to 27 points - give birth By operation of caesarean section, from 28 points or more - the delivery is performed during the period of stabilization of hemodynamics by the operation of applying cavitary obstetric forceps, and in case of left ventricular failure only by caesarean section, each diagnostic attribute being assigned a quantitative score according to the qualimetry method.

The prototype of the invention is "the risk of pregnancy and childbirth in the combination of pregnancy with heart defects," according to which 1 degree of risk corresponds to pregnancy in a heart disease without significant signs of heart failure and exacerbation of the rheumatic process; 2 degrees of risk - pregnancy in a heart disease with initial symptoms of heart failure (dyspnea, tachycardia) and signs of the active phase of rheumatism (A1 stage according to AI Nesterov); 3 degree of risk - pregnancy with decompensated heart disease with predominance of right ventricular failure, in the active phase of rheumatism (A2 stage according to AI Nesterov), with newly developed atrial fibrillation, pulmonary hypertension (2nd stage according to I.K. Rabkin) and 4 degree Risk - pregnancy in decompensated heart disease with signs of left ventricular or total heart failure, in the active phase of rheumatism (A3 by AI Nesterov), atriomegaly or cardiomegaly, long-term atrial fibrillation with thromboembolic manifestations, pulmonary hypertension (stage III Rabkina).

Continuation of pregnancy can be considered acceptable at 1 and 2 degrees of risk in conditions of outpatient observation and inpatient treatment of a patient in an obstetric (better specialized) institution throughout the pregnancy, and with appropriate management of pregnancy and childbirth. At 2 degrees of risk in the second stage of labor, the operation of superimposing obstetric forceps is shown in order to turn off attempts. At 3 and 4 risk levels, pregnancy is contraindicated. - L.V. Vanina - "Pregnancy and cardiovascular pathology" -M., M., 1991, 79-80.

However, the application of the prototype method - the "risk of pregnancy and childbirth", in practical medicine, and even more so in the network of obstetric institutions that are not specialized in heart diseases, is difficult and ineffective due to the undifferentiated approach to the form of heart disease and other diagnostic features introduced into the "scheme" , And as a result - frequent overdiagnosis and, in the end - an incorrect decision on the way of management of pregnancy and childbirth.

This is due to the fact that the adoption of management decisions involves the analysis of the situation, the identification of its critical values, and the causes of the emergence of critical situations in the simulated system (in the specific case - pregnancy complicated by heart disease), in accordance with the goal (for example, Pregnancy and childbirth with rheumatic heart disease). In this system, at least two functional complexes should be present that characterize both qualitative (in the form of a symptom complex) and quantitative criteria (normative values ​​or scales).

Therefore, in order to improve the reliability of recognition of the risk level, its improvement and increase in the accuracy of determining the risk levels of pregnancy and childbirth in rheumatic heart diseases, it is necessary to assign a quantitative coefficient to each diagnostic characteristic and increase the number of diagnostic signs to the minimum extent necessary.

In connection with this, a mathematical method for solving this problem was developed. When choosing the characteristics, the possibility of receiving them was taken into account in the conditions of a non-specialized obstetric institution and a women's consultation. In the same way, the number of features simulating (describing) the situation was minimized. All selected diagnostic features have a high correlation coefficient (r = 0.72) with indices of central hemodynamics, external respiration functions, ECG and FCG data and ultrasound of the heart. In other words, a group of diagnostic parameters was replaced by one with high mutual correlation by the method of correlation analysis (qualimetry) and by assigning to it a diagnostic coefficient in scores.

The following mathematical model was used as the main (decisive) diagnostic algorithm.

Let the statistical sample be represented by the parameters Pnq, where

N O N is the parameter index,

Q is the sample index.

The algorithm includes the following steps:

1. for the selection of parameters Pnq, the level of a statistically reliable criterion r is determined;

2. the matrix Rij (i, j O N) of the mutual correlation of the parameters is formed;

3. The matrix Rij is transformed into a discrete correlation matrix according to the rule - Dij = 1 / Rij>> r,

Dij = 0 / Rij <r;

4. Diagnostic coefficient Bm in points is determined -

;

Where Dmj is the sum of the coefficients of the elements of the matrix with respect to j,

Bm = [score].

It should be noted that the significance of the correlation coefficient was determined in the joint practical experience of obstetrics in rheumatic heart diseases of the Department of Obstetrics and Gynecology of the Sanitary and Hygienic Faculty. IM Sechenov (head of the department of Prof. LV Vanin) and cardiac obstetric hospital of the City Clinical Hospital No. 67 in Moscow (deputy head of the physician for obstetric obstetrics, Dr. A. Beilin) ​​- (3, 4, 5, 7, 8, 9, 11, 13, 15, 16) - by retrospective analysis of the case histories of 1110 pregnant women with rheumatic heart disease, with a known outcome of pregnancy and childbirth. At the same time, diagnostic signs that were relevant only to the cardiovascular pathology, independent of obstetric and other complications were taken into account.

The significance level of the diagnostic criterion (attribute) was adopted as

R = 2,

Which corresponds to a correlation coefficient of 0.5 (50%).

5. The most informative parameter is defined as

Dm = max Bm,

M O N;

6. Parameters with index j are included in the group M under the condition Dmj = 1;

7. The rows and columns of the matrix Dij with the index j are zeroed and are taken out of consideration, because Only one of all these strongly correlated parameters is sufficient;

8. Then a new group of parameters is formed (statistical sampling of the parameters - see item 1), starting with the definition of the most informative parameter;

9. In the formed groups, the functional dependence of one most informative parameter with the others is established and the group parameters are replaced by this one.

This method of correlation analysis (qualimetry) is computer-adapted and calculations by this method were carried out on the M 700 computer in the NGO Kvant (executor AI Sushko, under the supervision of the head of the department - the actual member of the Academy of Sciences of the Russian Federation, N.S. Lidorenko) in 1992.

- Tables -

In accordance with the above, 48 out of 238 diagnostic signs (criteria for rheumatic heart disease) were allocated with the corresponding coefficients assigned to them - see Table. 1. In the table, all diagnostic features are distributed in 6 independent groups, and the claimed method involves the use of at least 3-4 signs - see Table. 4.

For a comparative assessment of the accuracy of the determination of the risk levels by the proposed method (see Table 2) and the prototype method, an analysis was made of the medical decision in 2213 pregnancies and the determination of the degree of risk for them (analysis of the case histories of the Maternity Hospital No. 67 for 1971-1992) .

Simultaneously, a comparison was made of recommendations on prenatal preparation, the timing and mode of delivery - see Table. 3.

A high comparability between the adoption of a practical decision, the determination of the risk of pregnancy by midwives profiled in the heart defects of the maternity hospital and the results obtained with the use of the proposed method is established. Determination of the risk of pregnancy and childbirth in rheumatic heart diseases by the method of the prototype, especially when determining the II degree of risk, is ineffective, because. It is in this degree of risk that conclusions are drawn on the way of giving births from spontaneous without switching off attempts to delivery by cesarean section, therapeutic measures are conducted as differently - from the preventive introduction of cardiotonic drugs in childbirth to mandatory systematic complex treatment. The determination of the degree of risk by the method of the prototype has a tendency to overdiagnosis.

Table 4 shows the specificity indicators of the diagnostic signs of the risk levels of the proposed method in the control group (2,213 disease histories) to determine the degree of risk. Specificity was calculated by the method used in the development of diagnostic criteria (criteria) of the degree of risk.

As can be seen, the presence of two diagnostic signs of the degree of risk is characterized by high specificity (65.0%), the presence of 3 signs allows us to make a conclusion about the "probable" degree of risk (92.5%). The presence of 4 or 5 - to make a conclusion about the "certain" degree of risk (94.9 - 98.8%). The presence of 6 diagnostic signs allows us to make a conclusion about a "convincing" degree of risk (100%).

The presence of the 6 diagnostic signs in determining the degree of risk by the prototype method allows to make a conclusion about the "certain" degree of risk, and only the presence of 8 diagnostic features of the proposed method allows to make a conclusion about a "convincing" degree of risk. The presence of 13 diagnostic signs and more in determining the degree of risk by the method of the prototype is impossible and it can be concluded that the diagnosis is incorrect. The same can be said about the proposed method in the case of the presence of 9 or more diagnostic signs (criteria).

Particular attention should be paid to the fact that, despite the decision of the All-Union Cardiological Conference (Yerevan, 1977), devoted to the issues of the nomenclature of acquired defects, the terminology and rules for the formulation of a clinical diagnosis to date in practical medicine remain unordered.

Therefore, the most used terms in practical work, which characterize the clinical picture of the diagnosis, are listed in the table of diagnostic signs.

Terms of use of the table 1.

I. Depending on the formulated clinical diagnosis of heart disease, the diagnostic coefficients that make up this diagnostic diagnosis are summed.

II. When a combination of several valvular defects (for example - mitral-aortic-tricuspid heart disease), all the predominant diagnostic signs of valvular lesion are summarized.

III. In simple forms of heart disease (mitral or aortic), the diagnostic features of this lesion are also summarized. And when referring to the prevailing valvular lesion, only this one diagnostic feature is taken into account.

IV. The diagnostic coefficients NN 13, 14, and 15 are never combined together.

V. Diagnostic coefficient N 1 is not combined with the diagnostic coefficients NN 46, 47, 48, when the diagnosis of the form of heart disease.

For clarity, we give a sequence of actions for working with tables. All clinical examples are taken from the monograph of L.V. Vanina "Pregnancy and cardiovascular pathology", M., M., 1991, 84-85.

Example 1

The final (stage) diagnosis: primigenerous 20 years. Pregnancy is 29-30 weeks. Mitral valve insufficiency without significant clinical symptoms of heart failure. Preclinical stage of heart failure (2nd group of tolerance to physical activity). Rheumatism of the AI ​​stage. Degree of risk I-II.

Conclusion. The appointment of cardiac glycosides, drugs that improve metabolic processes (cocarboxylase, vitamin B6), panangin, potassium orotate, antirheumatic drugs (brufen, prednisolone), exercise therapy, sanitation of the throat (on the recommendation of an otolaryngologist).

You can allow births through the natural birth canal with an anesthetic aid, which ensures the stability of hemodynamics.

In this example, the following diagnostic features have a diagnostic coefficient:

1. Mitral valve insufficiency.

This sign can be regarded as: a / mitral insufficiency II Art. (Moderately expressed) - 6 points, or b / mitral defect with a prevalence of insufficiency - 6.5 points, or in / mitral insufficiency of the I degree - 1 point.

2. Without severe symptoms of heart failure. This sign can be regarded as a violation of blood circulation - I st. - 1 point.

3. Rheumatism AI - 1 point.

4. Tolerance to physical activity is not included in the proposed method (this feature is available in the computer forecasting system and has numerous and unequal links with many features).

Thus: the sum of points = 8-8.5 points (see Table 1). With this amount - according to Table. 2 determine the I degree of risk, and according to Table. 5, 6 determine the strategy and tactics of pregnancy management in the pregnancy period presented in the example.

Example 2

The final diagnosis: a 36-year-old. Pregnancy second, 27-28 weeks. (The first birth 10 years ago, the child died). Aortic insufficiency. Insufficiency of blood circulation of IIB degree. Rheumatism, active phase. AII stage. 2 group of exercise tolerance. Level of risk III.

Conclusion. Pregnancy is contraindicated, has come against the background of heart failure and stimulates the further development of the defect (as a result of not only hemodynamic loads, but also the active course of rheumatism). The patient was offered an early termination of pregnancy, from which she and her immediate relatives (husband, mother) categorically refused. In connection with the period of pregnancy and the patient's persistent desire to have a child, it is necessary to continue treatment in the hospital for the remainder of the term. It is expedient to give birth by abdominal route at a time close to birth in a planned manner. Patient consult with a cardiac surgeon for surgical correction of the heart in the future (1-2 years after childbirth). Regardless of the results of the consultation, the patient should be offered tubal sterilization simultaneously with cesarean delivery.

In this example, the following diagnostic features have a diagnostic coefficient:

1. Aortic insufficiency.

This sign can be regarded as: a / aortic insufficiency, in which the diastolic pressure is not less than 25 mm Hg. - 13 points; B / aortic insufficiency, in which the diastolic pressure is below 25 mm Hg. Art. - 25 points.

2. Insufficiency of blood circulation of IIB degree - 3 points.

3. Rheumatism AII stage - 2 points.

Thus: there is a sum of 18 to 30 points, with insufficient information on the size of the heart chambers, pulseometry. In this case, the risk of pregnancy corresponds - II - IV degree. When referring to Table. 5, 6 find out the tactics of managing a pregnant woman.

Example 3

The final diagnosis: primipara is 27 years old. Pregnancy first, 38-39 weeks. (Came amenorrhea). Mitral stenosis, stage IV defect, circulatory failure of IIB degree. Rheumatism, active phase. AII stage. Pulmonary hypertension II degree. Atrial fibrillation (during the year). Cardiac cachexia. Fetal hypotrophy. Level of risk III.

Conclusion: Pregnancy is dangerous due to the possibility of pulmonary edema, thromboembolism. Intensive therapy is indicated.

Taking into account the primary burden on the right heart for this defect, the presence of pulmonary hypertension and atrial fibrillation, the most gentle way of delivery is the delivery of births through the natural birth canal with the exclusion of attempts in the second stage of labor with the operation of superimposing obstetric forceps.

In this example, the following diagnostic features have a diagnostic coefficient.

1. Mitral stenosis, IV stage - 26 points.

2. Insufficiency of blood circulation IIB degree - 3 points.

3. Rheumatism, AII stage - 2 points.

4. Pulmonary hypertension II degree - 4 points.

5. Atrial fibrillation - 7 points.

Thus: the sum of points = 42 points, which corresponds to the IV degree of risk. Then, according to Tables 5 and 6, the method of delivery, management of pregnancy and the postpartum period is determined.

In this example, there is a complete description of the state of the cardiovascular system, which allows you to more specifically choose the strategy and tactics of managing a pregnant woman with rheumatic heart disease.

The use of the proposed method of delivery in rheumatic heart diseases in the dynamics of pregnancy progression will increase the accuracy in assessing the risk level, choosing the optimal strategy and treatment tactics in the conditions of antenatal clinic and non-specialized obstetric hospital by 45%, and increase the efficiency of the method by 33%.

BIBLIOGRAPHY

1. Bakulev AN, Damir EA // Indications for surgery in patients with mitral stenosis / Therapeutic archive, 1955, 27, 4, 29-37.

2. Vasilenko V.X. // Classification of circulatory failure / Proceedings of the cardiological session, Odessa, 1936, 42-45.

3. Vanina L.V. // Actual questions of pathology of pregnancy / Ed. L. S. Persianinova - M., 1978, p.71-80.

4. Vanina L.V. // Pregnancy and cardiovascular pathology / M., M., 1991.

5. Vanina LV, Olkhovskaya NA, Shilova GA, Korenevskaya IL // Akush. And gin. / 10, 1985, pp. 31-34.

6. Generalov SI // Predicting the outcome of pregnancy and childbirth in women with rheumatic heart defects and late toxicosis of pregnancy / Abstract. Diss. Kand .... - Kharkov, 1983.

7. Eliseev, OM. // Cardiovascular diseases in pregnant women / M., M., 1963, P.52-82.

8. VF Kuzin, E. Chudnivtsev, M. Shekhtman, V. Solyanik-Shileiko. // Akush. And gin. / 10, 1985, P.28-31.

9. Kuzin VF, Gurin E.N. / Interactive multi-terminal system for predicting the course and outcome of pregnancy and childbirth in women with a high risk of parinatal pathology / PROGNOZ. Central Information Fund of Gos.FAP N 50870000724, 1986.

10. Nesterov A.I. / Rheumatism / M., M., 1973, 391.

11. Persianinov LS, Bykhovsky MA, Selezneva ND And others. // Cybernetic systems and computers in obstetrics and gynecology / M., M., 1980, P. 168-180.

12. Rabkin I.Kh. / X-ray semeniotics of pulmonary hypertension / M., M., 1967.

13. Serov VN, Manukhin IB, Levina OE // Akush. And gin. / 12, 1986, pp. 33-34.

14. Sokolov B.P. // Clinico-anatomical comparisons in the stenosis of the aortic estuary / Clinical Medicine, 1963, 1, 38-43.

15. Chudnyadtsev E.L. // Predicting the outcome of pregnancy and childbirth with rheumatic heart defects with the help of a computer. / Author's abstract. Diss. Cand. Odessa, 1983.

16. Shekhtman M. M., Barhatova TP // Diseases of internal organs and pregnancy., M., 1982, P.30-57.

CLAIM

The method of conducting labor in rheumatic heart diseases, including the determination of cardiac arrhythmia, enlargement of the heart chambers, activity of the rheumatic process, characterized by the fact that the form of the heart defect and the violation of the heart rhythm are further specified, after which each diagnostic attribute is assigned a certain number of points calculated by the method Qualimetry - from 1 to 26, and the method of conducting labor is determined in accordance with the total number of points, so with the number of points from 1 to 13 - births are through the natural birth canal without turning off attempts, from 14 to 17 points - attempts are turned off by applying cavity obstetric From 18 to 27 points - delivery is given by cesarean section, from 28 points or more - the delivery is performed during the period of stabilization of hemodynamics by the operation of applying cavitary obstetric forceps, and in case of left ventricular failure only by cesarean section.

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Date of publication 27.03.2007gg