#1
|
||||
|
||||
ÑÒÎÏ èññëåäîâàíèÿì ãåìîñòàçà (Ä-äèìåðà) ïðè íîðìàëüíî ïðîòåêàþùåé áåðåìåííîñòè!
Ïîâûøåíèå Ä-äèìåðà âî âðåìÿ áåðåìåííîñòè - íîðìàëüíûé ôèçèîëîãè÷åñêèé ïðîöåññ, îòðàæàþùèé àêòèâàöèþ ñèñòåìû ãåìîñòàçà ïðè áåðåìåííîñòè, íàïðàâëåííûé íà áûñòðîå ïðåêðàùåíèå ïîñëåðîäîâîãî êðîâîòå÷åíèÿ, è ó çäîðîâûõ áåðåìåííûõ óðîâåíü Ä-äèìåðà ìîæåò äîñòèãàòü 1400-1700 íã/ìë íà ñðîêå äî 28 íåäåëü è äî 3000 íã/ìë ìåæäó 29-42 íåäåëÿìè áåðåìåííîñòè. Ïîýòîìó, åñëè áåðåìåííîñòü ïðîòåêàåò íîðìàëüíî, Ä-äèìåð áåññìûñëåííî ìåðÿòü âî âðåìÿ áåðåìåííîñòè (à ðàâíî ÐÊÌÔ è äð. ïîêàçàòåëè êîàãóëîãðàììû) è òåì áîëåå ïûòàòüñÿ êîððåêòèðîâàòü åãî óêîëàìè ôðàêñèïàðèíà èëè äð. ÍÌÃ, ñóëîäåêñèäîì, àñïèðèíîì, êóðàíòèëîì, âîáåíçèìîì è äð. òàáëåòêàìè.
îòðûâêè èç íèæåïðèâåäåííîé ñòàòüè ïîêàçûâàþò, ÷òî íàçíà÷åíèå íèçêîìîëåêóëÿðíîãî ãåïàðèíà ó áåðåìåííûõ æåíùèí ñ òðîìáîôèëèåé íå ïðåïÿòñòâóåò ðîñòó Ä-äèìåðà è äð. ïîêàçàòåëåé àêòèâàöèè ñâåðòûâàíèÿ ïî ñðàâíåíèþ ñ êîíòðîëåì: ...patients at high risk of pregnancy complications with confirmed thrombophilia are randomized to receive either dalteparin (5,000 units/day until 20 weeks then 5,000 units q12h until 37 weeks or onset of labor) or no treatment... dalteparin had no significant effects on the levels of thrombin-antithrombin complexes (TAT), prothrombin fragments 1 + 2 and D-dimer throughout pregnancy in thrombophilic women. The effect of dalteparin on coagulation activation during pregnancy in women with thrombophilia. A randomized trial. Abou-Nassar K, Kovacs MJ, Kahn SR, Wells P, Doucette S, Ramsay T, Clement AM, Khurana R, Mackinnon K, Blostein M, Solymoss S, Kingdom J, Sermer M, Rey E, Rodger M; TIPPS investigators. Thromb Haemost. 2007 Jul;98(1):163-71.
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#2
|
||||
|
||||
Íîðìû êîàãóëÿöèîííûõ ïàðàìåòðîâ ó áåðåìåííûõ
"×àñòî âîçíèêàåò âîïðîñ – ïî÷åìó íåëüçÿ ïîëüçîâàòüñÿ ó áåðåìåííûõ ïàðàìåòðàìè êîàãóëîãðàììû äëÿ íåáåðåìåííûõ æåíùèí?
Áåðåìåííîñòü ñîïðîâîæäàåòñÿ âûðàæåííûìè èçìåíåíèÿìè â ïîêàçàòåëÿõ ãåìîñòàçà. Ïðè íîðìàëüíîé áåðåìåííîñòè ñîäåðæàíèå ôèáðèíîãåíà ïîâûøàåòñÿ âäâîå, êîíöåíòðàöèÿ ðÿäà ôàêòîðîâ ñâåðòûâàíèÿ, òàêèõ êàê VII, VIII, IX, X, è XII ïîâûøàåòñÿ íà 200-1000% îò èñõîäíûõ çíà÷åíèé. Òàêæå îòìå÷àåòñÿ çíà÷èòåëüíîå ïîâûøåíèÿ óðîâíÿ ðàñòâîðèìûõ êîìïëåêñîâ ôèáðèíà è Ä-äèìåðà, ïðè÷åì ó 25% çäîðîâûõ áåðåìåííûõ òàêîå ïîâûøåíèå ìîæåò èìåòü ìåñòî óæå â ïåðâîì òðèìåñòðå.  òîæå âðåìÿ, åñòåñòâåííàÿ àíòèêîàãóëÿíòíàÿ àêòèâíîñòü ñíèæàåòñÿ, òàê óðîâåíü ïðîòåèíà S ìîæåò ñíèæàòüñÿ â òðè ðàçà îò èñõîäíûõ ïîêàçàòåëåé." http://www.forums.rusmedserv.com/sho...21&postcount=3
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#3
|
||||
|
||||
Ðåòðîñïåêòèâíûé àíàëèç èç Õåëüñèíêè ïîêàçûâàåò, ÷òî íàçíà÷åíèå íèçêîìîëåêóëÿðíûõ ãåïàðèíîâ (ôðàêñèïàðèíà è òï.) âî âðåìÿ áåðåìåííîñòè íå óìåíüøàåò íè ðèñê ïðåæäåâðåìåííûõ ðîäîâ, íè ìåðòâîðîæäåíèÿ, íè çàäåðæêè âíóòðèóòðîáíîãî ðàçâèòèÿ, íè ïðåýêëàìïñèè, â ïîëòîðà ðàçà ïîâûøàåò ÷àñòîòó àíòåíàòàëüíîãî êðîâîòå÷åíèÿ - ïîýòîìó äàííûå ïðåïàðàòû äîëæíû íàçíà÷àòüñÿ òîëüêî ïî ïîêàçàíèÿì (ëå÷åíèå-ïðîôèëàêòèêà òðîìáîçà, ïðèâû÷íîå íåâûíàøèâàíèå ïðè ÀÔÑ), à íå äëÿ óëó÷øåíèÿ êðîâîòîêà â ïëàöåíòå, ðàçæèæåíèÿ ãóñòîé êðîâè ïðè áåðåìåííîñòè, ñíèæåíèÿ Ä-äèìåðà, ÐÊÌÔ è òï.
648 pregnancies exposed to LMWH were compared with 626 unexposed pregnancies. The incidence rates of various pregnancy complications did not differ between the groups (LMWH group vs control group): 1.56% vs 1.1% for thrombocytopenia, 8.7% vs 6.5% for preterm delivery, 0.7% vs 0.3% for stillbirth, 1.4% vs 1.0% for severe pre-eclampsia, 2.7% vs 2.2% for foetal growth restriction, and 10.7% vs 7.8% for antenatal bleeding. --- Galambosi PJ, Kaaja RJ, Stefanovic V, Ulander VM. Safety of low-molecular-weight heparin during pregnancy: a retrospective controlled cohort study. Eur J Obstet Gynecol Reprod Biol. 2012 Aug;163(2):154-9.
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#4
|
||||
|
||||
Ïîâûøåíèå Ä-äèìåðà âî âðåìÿ íîðìàëüíîé áåðåìåííîñòè áîëåå âûðàæåíî ïðè ìíîãîïëîäíîé áåðåìåííîñòè:
The d-dimer levels (μg/ml, mean±SD [number of specimens]) determined at the 1st trimester did not differ significantly (0.81±0.82 [102] for singleton vs. 1.20±0.77 [7] for multifetal), but those at the 2nd (1.61±1.45 [216] vs. 2.62±2.26 [59]) and 3rd (2.37±2.22 [659] vs. 4.02±2.14 [46]) trimesters were significantly higher in women with multifetal than singleton pregnancies. --- Thromb Res. 2013 Jun;131(6):493-6. Difference in the D-dimer rise between women with singleton and multifetal pregnancies.
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#5
|
||||
|
||||
 Ìàêåäîíèè òîæå ëåä òðîíóëñÿ:
260 pregnant women were admitted in Outpatient department in the first 3 months in 2012 year. The values of D-D show those results: In the first trimester in 34 women values of D-D was until 1316 ng/mL. In second trimester 107 women had D-D values until 2369 ng/mL. In last trimester in 167 women values was until 3122 ng/mL. All those women have born healthy child. Summary/Conclusions: Range of D-D not correlates with pregnancy problems. D-Dimers and pregnancy. J Thromb Haemost. 2013; 11 (Suppl 2):1102.
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#6
|
||||
|
||||
Íîðìàëüíûé óðîâåíü Ä-äèìåðà íàáëþäàåòñÿ ó æåíùèí äî ÝÊÎ âíå çàâèñèìîñòè îò èñõîäà è ïîâûøàåòñÿ ó âñåõ îäèíàêîâî ïîñëå ñòèìóëÿöèè - íåò ñìûñëà åãî ìåðÿòü è åãî "ëå÷èòü" âî âðåìÿ äàííîé ïðîöåäóðû:
J Ovarian Res. 2014 May 22;7:58. Plasma concentrations of D-dimer and outcome of in vitro fertilization. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#7
|
||||
|
||||
Åùå îäíà ïóáëèêàöèÿ, ïîêàçûâàþùàÿ ÷òî íè ïðîôèëàêòè÷åñêàÿ, íè ëå÷åáíàÿ äîçà êëåêñàíà íå ïðåäîòâðàùàþò ïîâûøåíèå Ä-äèìåðà âî âðåìÿ áåðåìåííîñòè, íî âñå ñàìî ïðèõîäèò â íîðìó ÷åðåç 2 ìåñ. ïîñëå ðîäîâ:
Despite being prescribed prophylactic LMWH, substantial activation of coagulation was seen during pregnancy in this study, i.e. the prophylactic doses of LMWH did not dampen down the increase in D-dimers one might expect to observe. òàáëèöà ñ öèôðàìè äëÿ ñðàâíåíèÿ: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] ïîëíûé òåêñò: [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#8
|
||||
|
||||
Åùå îäíî èññëåäîâàíèå ïîêàçàëî, ÷òî ó æåíùèí ñ 2 ïîäðÿä ðàííèìè èëè 1 ïîçäíèì íåâûíàøèâàíèÿìè íàçíà÷åíèå ÍÌà (äàëüòåïàðèíà ñ 5-8 íåäåëü è äî 24 íåäåëü) ÍÅ óëó÷øàåò âûíàøèâàíèå: è íà ÍÌà è áåç íåãî æåíùèíû äîíàøèâàþò è ðîæàþò â 86-87%, òàê ÷òî óòâåðæäåíèÿ âðà÷åé èç æåíñêèõ êîíñóëüòàöèé è ïðî÷èõ îòå÷åñòâåííûõ ËÏÓ, ÷òî íàçíà÷åíèå ÍÌà ðàçæèæàåò êðîâü, óëó÷øàåò êðîâîñíàáæåíèå ïëîäà è òåì ñàìûì 100% ãàðàíòèðóåò âûíàøèâàíèå - ìÿãêî ãîâîðÿ, íå ñîîòâåòñòâóþò äåéñòâèòåëüíîñòè:
449 women with at least 2 consecutive early miscarriages or 1 late miscarriage were included during 5 to 8 weeks' gestation after a viable pregnancy was confirmed by ultrasonography. Women in the control group received multivitamin pills, and the intervention group received vitamins and 5000 IU of dalteparin-sodium for up to 24 weeks' gestation. At 24 weeks' gestation, 191 of 220 pregnancies (86.8%) and 188 of 214 pregnancies (87.9%) were intact in the intervention and control groups, respectively (absolute difference, -1.1 percentage points [95% CI, -7.4 to 5.3 percentage points]). The live-birth rates were 86.0% (185 of 215 women) and 86.7% (183 of 211 women) in the intervention and control groups, respectively (absolute difference, -0.7 percentage point [CI, -7.3 to 5.9 percentage points]). Ann Intern Med. 2015 May 5;162(9):601-9. Low-molecular-weight heparin for women with unexplained recurrent pregnancy loss: a multicenter trial with a minimization randomization scheme.[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#9
|
||||
|
||||
×åì âûøå Ä-äèìåð, òåì áîëüøå îáüåì ïëàöåíòû ïî ÓÇÈ, ÷òî âåðíî êàê äëÿ íîðìàëüíîé áåðåìåííîñòè, òàê è ïðîáëåìíîé áåðåìåííîñòè (ýêëàìïñèÿ, âíóòðèóòðîáíàÿ çàäåðæêà ðàçâèòèÿ ïëîäà):
Relationship between Plasma D-Dimer Concentration and Three-Dimensional Ultrasound Placental Volume in Women at Risk for Placental Vascular Diseases [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#10
|
||||
|
||||
Large D-Dimer Fluctuation in Normal Pregnancy:
A Longitudinal Cohort Study of 4,117 Samples from 714 Healthy Danish Women [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ]
__________________
Èñêðåííå, Âàäèì Âàëåðüåâè÷. |