INVENTION
Russian Federation Patent RU2216275

METHOD prediction of wound healing uterus after cesarean section

METHOD prediction of wound healing uterus after cesarean section

Name of the inventor: Kramarskiy VA .; Raevskaya L.YU .; Dudakov VN
The name of the patentee: Irkutsk State Institute of Advanced Medical
Address for correspondence: 664079, Irkutsk, District Jubilee, 100, and / I 70, IGIUV, patent
Starting date of the patent: 2001.07.26

The invention relates to medicine, namely to obstetrics. The process is as follows: during a cesarean operation conducted biopsy sampling of the myometrium, which is determined by such factors as the number of capillaries, the degree of endothelial cell proliferation, the presence and severity of edema of the myometrium, the presence of inflammatory infiltration. On the basis of these parameters set the value of the morphological index (MI) and at values ​​<7 predict the physiological nature of the wound, and a value of MI 7 - secondary nature of the healing wounds on the uterus. The method improves the accuracy of the forecast.

DESCRIPTION OF THE INVENTION

The invention relates to medicine, namely to obstetrics, and can be used to predict the nature of the wound healing in the uterus after cesarean section and prediction method of delivery of women with a uterine scar during subsequent pregnancies.

There is a method of forecasting the nature of the wound healing in the womb through an ultrasound scan. Ultrasound examination of postoperative sutures on the uterus is well visualized infiltration of the joints, the presence of hematoma, fibrinous overlay, gas as an indirect sign of infection (Mareeva LS Levashova II and others. Informative and predictive value of PSM uterine scar after cesarean section in spontaneous delivery:. in the book Problems of Obstetrics and gynecology MONIIAG, 1995, S.42-45).

However, this process is subjective and requires special equipment and specialists with research methodology and interpretation of the information obtained. Reflecting the indirect signs of local inflammation, tissue injury caused by a (incision on the uterus), and the possible presence of infection, ultrasound does not reflect the nature of the healing process. In this method, the study inflammation in joints and uterine holds only 41.6% of its true manifestation (Strizhakov AI, Baev O. P .// Akusha. And gin. 1999, 9, S.21-27 ).

The closest to the technical nature of the proposed is a method for predicting the healing of the joint nature of the uterus after cesarean section surgery by dynamic research cytology smears of the aspirate from the cavity of the uterus, reflecting the wound healing phase (Worlds IM Forecasting, early detection, treatment and prevention of purulent -vospalitelnyh diseases after birth and cesarean section: Abstract dis Dr. medical sciences, Moscow, 1996).....

The disadvantages of the known method include the low prediction accuracy phases of wound healing in the uterus, which can be disrupted when changing the immunological parameters and status of the organism when expressed in the virulence of the infection of the wound surface. This method largely reflects the presence or absence of inflammation, its degree, and not the nature of the healing, since in primary (physiologic) healing occurs layering phases of wound healing, one to another, so it is very difficult to observe the sequence of stages of healing. It is known that inflammation phase - the local inflammatory changes are permitted to 3-5 days, and the healing - phase inflammatory and regenerative completed in 8-10 days, and in those days only outlines the regeneration phase of the scar (Kuzin MI, Kostyuchenok BN Wounds and wound infection: a Guide for physicians - M., 1990, pp 34-38)...

In addition, the known method requires repeated sampling of material from the uterine cavity, which increases the risk of re-infection of the uterus (Worlds IM Forecasting, early detection, treatment and prevention of chronic inflammatory diseases after birth and cesarean section: Abstract dis d.. -ra honey. Sciences. Moscow, 1996).

The objective of the claimed invention is to provide a method for the prediction mode of delivery in women with a uterine scar during subsequent pregnancies.

The technical result of this proposal is to increase the accuracy of the healing nature of the wounds on the uterus forecast by taking into account the source of morphological status of the myometrium.

The technical result is achieved in that a method for predicting uterine wound healing of character after surgery cesarean section includes cytology of uterine tissue.

The difference method is that during the operation carried out sampling biopsy of the myometrium, which determine the number of capillaries, the degree of endothelial cell proliferation, the presence and severity of edema of the myometrium, the presence of inflammatory infiltration, in terms of which set the morphological index according to the formula: MH = A + B + C + D, where MI - morphological index

And - the number of cross-sections of the capillaries:

A = 0 to 10 capillaries,

A = 1 to 15 capillaries,

A = 2 to about 20 capillaries,

A = 3, more than 20 of the capillaries;

In - the degree of endothelial cell proliferation:

B = 0 - the endothelium of the capillaries single row,

B = 1 - Multi-row endothelium in individual capillaries,

B = 2 - 1/3 Pseudostratified endothelium of the capillaries, the emergence of single capillary "glomeruli"

B = 3 - endothelial Pseudostratified more than 1/2 of the capillaries;

C - the presence and severity of edema of the myometrium:

C = 0 - predominantly perivascular edema,

C = 1 - interstitial and perivascular edema,

C = 2 - perivascular and interstitial edema, early vacuolization of the cytoplasm of myocytes,

C = 3 - marked vacuolization of cytoplasm, including perinuclear vacuoles;

D - the presence of inflammatory infiltration:

D = 0 - isolated perivascular white blood cells, mainly lymphocytes,

D = 1 - perivascular white blood cells in the capillaries around 1/4 of the fields studied,

D = 2 - appearance exudates neutrophils,

D = 3 - migration of leukocytes into the space intermediates.

If the value of the morphological index <7 predict physiological nature of wound healing, leading to the formation of postoperative scar with a predominance of muscle tissue.

If the value of the morphological index 7 predict secondary to healing wounds on the uterus, leading to the subsequent formation of connective tissue scar.

Matching analysis with the prototype showed that the proposed technical solution is different from the well-known fact that the patient once during the operation, under aseptic conditions, conduct a fence material for cytological study determined baseline number of histological parameters, the sum of which is set the value of the morphological index, the indicator which is the predictor of the nature of the uterine wound healing after cesarean section.

Thus, the proposed technical solution meets the criterion of invention "novelty."

The analysis of the patent and technical literature has shown that this method differs from the prototype is not only, but also other technical solutions in this and related fields. Thus, the authors found the nature of forecasting methods of wound healing after surgery on the uterus Caesarean section, which would have included histological examination of uterine tissue and the determination of morphological index.

For the first time on the characteristics of the original morphostructural myometrium state using a mathematical expression predicted the nature of healing the wounds of the uterus. Proof of this are the complex investigations: the PSM data (echo-positive zone, hematoma, retractions, edema, etc.), the rate of protein ratio greater than 2 and aspirate cytology data from the uterus.

The proposed process parameters enable us achieve a technical result - increase the accuracy of the healing nature of the forecast wounds on the uterus after cesarean section that, in turn, allows to predict the mode of delivery in a subsequent pregnancy. For physiological wound healing leads to the formation of postoperative scar with a predominance of muscle tissue and allows to predict the possibility of conducting labor in a subsequent pregnancy vaginal and secondary wound healing, leading to the subsequent formation of connective tissue scar, predicts a high probability of developing signs of insolvency rumen during subsequent pregnancies.

This method is simple, accessible, accurate.

Thus, the method for predicting the nature of the wound healing after surgery on the uterus Caesarean section meets the criterion of "inventive step".

Method constituting claimed invention is intended for use in health care. This method can be used in maternity hospitals any level. The possibility of its implementation verified methods and means described in the application, therefore, the proposed solution meets the criterion of the invention of "industrial applicability".

The proposed prediction method is performed as follows: pieces of myometrium obtained during cesarean section were fixed in 10% neutral formalin. Paraffin sections were stained with 5.4 mm thick hematoxylin and eosin and examined for light microscope binocular "Olimpus CHT-213E". When studying the myometrium quantify capillary endothelial proliferation degree, presence and severity of swelling of the myometrium, the presence of the inflammatory infiltration, which is set in terms of morphological index according to the formula: MI = A + B + C + D, where:

MI - morphological index

And - the number of capillaries in the three fields at × 100:

- A = 0 - 10 cross sections in the field of view,

- A = 1 - up to 15 slices in sight,

- A = 2 - 20 slices in the field of view,

- A = 3 - more than 20 sections in the field of view;

In - the degree of endothelial cell proliferation in three fields at X400:

- B = 0 - the endothelium of the capillaries single row,

- B = 1 - Multi-row endothelium in individual capillaries,

- B = 2 - 1/3 Pseudostratified endothelium of the capillaries, the emergence of single capillary "glomeruli"

- V 3 - Multi-row endothelium in more than 1/2 of the capillaries;

C - the presence and severity of edema of the myometrium in the three fields at · 400:

- C = 0 - predominantly perivascular edema,

- C = 1 - interstitial and perivascular edema,

- C = 2 - perivascular and interstitial edema, early vacuolization of the cytoplasm of myocytes,

- C = 3 - marked vacuolization of cytoplasm, including perinuclear vacuoles;

D - the presence of inflammatory infiltration in the three fields at · 400:

- D = 0 - isolated perivascular white blood cells (mainly lymphocytes)

- D = 1 - perivascular white blood cells in the capillaries around 1/4 of the fields studied,

- D = 2 - the appearance of neutrophils in the exudate,

- D = 3 - migration of leukocytes into the space intermediates.

When MI <7 predict wound healing as a physiological, leading to the formation of postoperative scar with a predominance of muscle tissue and allows to predict the possibility of conducting labor in a subsequent pregnancy vaginally, and the morphological index 7 predict wound healing as a secondary, leading to the subsequent formation of connective tissue scar, and predicted a high probability of insolvency signs of scar during subsequent pregnancies.

The proposed method is explained in an example of embodiment.

example 1

Kolbaeva TE, age 20 years, the history of childbirth in 2684, 1 pregnancy, childbirth 1. The first half of pregnancy proceeded with the phenomena of interruption threat, the second - without features. I received in kind. home with a diagnosis of pregnancy 39 weeks. Breech presentation. Large fruit? pelvis Dimensions: 27-29-32-21. The estimated fetal weight of 4000 grams. According to the CTG and fetal PSM satisfactory. Given the breech presentation and estimated fetal weight is above average, relatively high risk of perinatal lesions of the fetus, the woman decided rodorazreshit cesarean section in a planned manner. Produced by Pfannenstiel laparotomy, caesarean section on Gusakov. Checked boy weighing 3950 g, length 54 cm, with a score Apgar score 8-9. The incision on the uterus stitched double-row suture obvivnym kaproagom. 55 minutes Duration of surgery, anesthesia - 60 minutes. Total blood loss was 600 mL. Postoperatively received antibiotic therapy for 3 days and physiotherapy. On day 5, the size of the uterus on ultrasound length - 121 mm, width - 64 mm, front-back - 101 mm, length 85 mm joints, width of 35 mm. Doppler velocimetry of uterine arteries: the right of resistance index of 0.66, 0.64 left. The cavity is closed. On day 7, the size of the uterine length - 95 mm, width - 55 mm, front-back - 85 mm, 45 stitches 18 mm. Leukocyte index of intoxication on day 5 was 2.7, on the 7th day - 2.37; blood immunoglobulins G = 9,5, IgA = 1,5, IgM = 1,6. According to the histological examination of biopsy of the myometrium, taken during surgery: single perivascular white blood cells, swelling one, the development of the capillary network moderate 2, proliferation of endothelial 0.

Thus, the morphometric index was 3. The patient was discharged on the 7th day in a satisfactory condition. After 6 months, the incision on the uterus is not determined by ultrasound scanning.

example 2

Long AP, age 24, history of births in 2660, 3 pregnancy, childbirth 2. Received race. home with a diagnosis of pregnancy to 40 weeks. Breech presentation. Chronic intrauterine fetal hypoxia. Without complications during pregnancy. Dimensions of the pelvis 25-28-30-21 mm. Estimated fetal weight 3800-3900 grams. According to the CTG - mild fetal hypoxia (6 points Fischer). Given the breech presentation and estimated fetal weight is above average, relatively high risk of perinatal lesions of the fetus, the woman decided rodorazreshit cesarean section in a planned manner. Produced by Pfannenstiel laparotomy, caesarean section on Gusakov. Fetched girl weighing 3750 g, 50 cm long, with a score Apgar score 8-9. The incision on the uterus stitched double-row suture obvivnym kaproagom. 65 minutes Duration of surgery, anesthesia - 70 minutes. Total blood loss was 700 mL in the postoperative period received antibiotic therapy and physiotherapy. On day 5, the size of the uterus on ultrasound length - 112 mm, width - 74 mm, front-back - 103 mm, length 68 mm joints, width - 30 mm. When Doppler uterine artery resistance index was 0.58 right, 0.51 left. In the area of ​​seams and infiltrates mikrogematomy. The cavity is closed. On day 7, the size of the uterine length - 102 mm, width - 60 mm, front-back - 90mm, the seams 65 · 28, nonuniform. Leukocyte toxicity index was 4.26 at day 5, day 7 - 8.1, the blood immunoglobulins G-9,0, IgA = 1,0, IgM = 2,4. According to the histological examination of biopsy of the myometrium, taken during the operation: perivascular leukocyte infiltration +2 +3 pronounced swelling, moderate development of the capillary network 2, the proliferation of endothelial expressed +3. Therefore, morphometric index was 10. The patient was discharged on the 8th day in a satisfactory condition. After 6 months in the area of ​​the incision on the uterus by ultrasound scanning is determined by echo-positive area (scar) size of 46 · 21 mm.

The proposed method for predicting uterine wound healing character used in 120 postpartum women. Accuracy evaluation method is 93%. Its accuracy is confirmed by research complex: ultrasound, hysteroscopic and cytological methods, indicator protein ratio greater than 2, and histological examination of the area of ​​the scar tissue with repeated cesarean section (in some cases).

The use of this method does not require any additional material costs. This method can be used in medical institutions at all levels. The widespread use of the proposed method will allow more objectively assess the nature of healing and, therefore, to build a forecast of subsequent delivery methods. Using the proposed method will undoubtedly affect the rate of vaginal birth in women with a uterine scar after cesarean section that will bring significant economic benefits, due to the cost of the operation cesarean section and nursing women in childbirth.

CLAIM

that during the operation carried out sampling biopsy of the myometrium, which determine the number of capillaries, the degree of endothelial cell proliferation, the presence and severity of edema of the myometrium, the presence of inflammatory infiltration, by method of predicting uterine wound healing of character after cesarean section includes cytology of uterine tissue, wherein parameters which establish the morphological index (MI) by the formula

MI = A + B + C + D,

where A - number of cross-sections of the capillaries: A = 0-10 capillaries, A = 1-15 capillaries, A = 2-20 capillaries, A = 3 - more than 20 of the capillaries;

In - the degree of endothelial cell proliferation: B = 0 - the endothelium of the capillaries single row, B = 1 - endothelial Pseudostratified in single capillaries, B = 2 - 1/3 Pseudostratified endothelium of the capillaries, the emergence of single capillary glomeruli, B = 3 - Multi-row endothelial over 1/2 of the capillaries;

C - the presence and severity of edema of the myometrium: C = 0 - predominantly perivascular edema, C = 1 - perivascular and interstitial edema, C = 2 - perivascular and interstitial edema, early vacuolization of the cytoplasm of myocytes, C = 3 - pronounced vacuolization of cytoplasm in the tons. h perinuclear vacuoles.;

The D - presence of inflammatory infiltration: D = 0 - isolated perivascular white blood cells, mainly lymphocytes, D = 1 - perivascular white blood cells in the capillaries around 1/4 of the fields studied, D = 2 - the appearance of neutrophils in the exudate, D = 3 - the migration of leukocytes into the intermediates space

and at values ​​<7 predict the physiological nature of the wound, and a value of MI 7 - secondary nature of the healing wounds on the uterus.

print version
Publication date 07.01.2007gg