The Short-term Effects Of Coagulation And Fibrinolytic System In Gynecologic

Background and objectiveGynecological operation is in the pelvic. Operation trauma cause series of changes to postoperative coagulation and fibrinolytic system. If the balance of coagulation and fibrinolysis system is destroyed, the emergence of high coagulation state will lead to venous thromboembolic disease (VTE). Deep venous thrombotic disease after operation which is most common in the lower extremity (LEDVT), is one of the most serious complication after gynecologic operation. Due to the posture, laparoscopy operation and the pneumoperitoneum pressure etc, thrombotic diseases are often reported in gynecological operation. If not treated timely, pulmonary embolism(PE) will happen and lead to sudden death. The statistical data of the western countries on the deep venous thrombosis were mostly from the year 70,80, about 2 millions of people suffering from deep venous thrombosis (DVT) in USA,600000 of them suffering from pulmonary embolism, and about 1/3 death. The high incidence and mortality rate of has caught high attention to DVT. In recent years, many American clinical medical associations have held special meetings on venous thrombotic diseases and develop guidelines for diagnosis and treatment of the DVT. Due to foreign reports, the incidence of VTE after any operation was 2.83%, after gynecologic operation, the incidence is 2.0%. In the retrospective analysis of domestic reports, the incidence of VTE was 0.27% after gynecologic operation. Among the gynecologic operations, the incidence of VTE was 1.59% after malignant tumors operation, while it’s 0.02% to the benign diseases.The incidence in malignant tumors operation was obviously higher than that in benign diseases. The malignant tumor patient easily complicated with thrombosis. The earliest report of relationship between malignant tumor and thrombus was in 1865 by Armand Trousseau, he found that the thrombus is often one of the recessive clinical manifestations of malignant tumor,thrombosis is one of the complications of malignant tumor. In course of disease,thrombosis occurs in about 10%～20% of the malignant tumor patiants which is 5-6 times to the benign diseases; it’s higher in the autopsy, about 50% of the patients had thrombosis.Though many studies are promoted, the mechanism related to thrombosis is still not completely elucidated. In 1946, Vichow summarized three factors of deep venous thrombosis:a injury in wall of vein, slow blood flow and hypercoagulable state of blood, their final result is the emergence of venous thrombosis in blood vessel. In recent years, study found that thrombosis is occurred by comprehensive effect as changes in platelet, endothelial cells, blood coagulation system, anticoagulation system, fibrinolytic system, the occurrence rheology of the blood, but before thrombosis occurs they began to change different degree. Therefore, based on the detection of specific molecular markers such as activated partial thromboplastin time(APTT), prothrombin time(PT), thrombin time (TT),D-dimer (D-D), fibrinogen (FIB) and platelet count (PLT) in prothrombotic state (PTS) enable us to recognize prothrombotic state after a operation, which has important significance for prevention of deep venous thrombosis.Most of the domestic study about the occurrence of deep venous thrombosis after operation is retrospectively study rather than prospective study. In this study we observe the patients with gynecological operation,detect the indexes such as activated partial thromboplastin time (APTT), prothrombin time (PT),thrombin time (TT), D-dimer (D-D), fibrinogen (FIB), platelet count(PLT), and color ultrasonography in lower extremity venous.We take a prospective study of dynamic changes in indexes of blood coagulation system, fibrinolysis system before and after operation and whether there is a deep venous thrombosis of lower limbs, we also assess the risk of deep venous thrombosis in peri operation period and discuss the method of preventing thrombosis in gynecologic operation.Materials and methodsl.The research object:Choose patients who planned to have operation between 2014 June to 2014 September to take prospectively study,including 70 patients divided into the benign disease group and malignant tumor group. Benign disease group has 42 cases, the average age is (39.9±11.2) years old; there are 28 cases in malignant tumor group, the average age is (42.5±10.6) years old. Benign disease group including 13 cases of uterine myoma,5 cases of uterine myoma with adenomyosis,3 cases of uterineprolapse,16 cases of benign ovarian tumor,1 cases of congenital absence of vagina,4 cases of infertility. Malignant tumor group included 3 cases of endometrial carcinoma,9 cases of ovarian cancer,15 cases of cervical cancer,1 cases of squamous cell carcinoma of vulva. Malignant tumor group were all pathologically diagnosed patients before operation.2.The inclusion criteria:All patients with no previous history of deep vein thrombosis or pulmonary embolism history, without lower limb operation history in 6 months, body mass index<30kg/m2, no coagulation dysfunction or hemorrhagic disease, no serious liver disease, no history of myocardial infarction and cerebral infarction. Patients haven’t take estrogen or contraceptive drugs within 6 months. All patients haven’t take any drugs affecting platelet number or coagulation in peri operation period.3.Operation mode:In the 70 cases,20 cases is abdominal operation,including 4 cases of extensive hysterectomy and pelvic lymph node dissection,9 cases of ovarian tumor cytoreductive surgery,4 cases of subtotal hysterectomy,3 cases of uterine fibroids.46 cases of laparoscopic operation, including 11 cases of extensive hysterectomy and pelviclymph node dissection,3 cases of endometrial carcinoma radical resection of uterine,1 case of vaginal anterior sacral fixation,4 cases of total hysterectomy,7 cases of uterine fibroids,16 cases of accessory resection or ystectomy,4 cases of laparoscopy combined syntheticexploration,3 case of Transvaginal operation, including 2 cases of the trans vaginal hysterectomy,1 case of congenital absence of vaginavaginal plastic operation,1 case of Vulva cancer for extensive vulvaresection and laparoscopic inguinal lymph node dissection.4.The preoperative, intraoperative and postoperative treatment:all surgical operation patients, intraoperative and postoperative medication, postoperative activity and diet were routinely. During and after the operation, the routine use of hemostatic drug does not affect the function of blood coagulation:Carbazochrome Sodium Sulfonate Injection.5.Two groups of patients collect venous blood before and after surgery,1 daysand 3 days at the same time, send to Laboratory of evacuation after pretreatment.Detecting activated partial thromboplastin time (APTT), prothrombin time (PT),thrombin time (TT), two D- dimer (D-D), fibrinogen (FIB) and platelet count (PLT). Take lower extremity venousultrasound examination, measure femoral vein flow velocity at the same time of 3-7 days inpreoperative and postoperative. Using Philips IE33 color Doppler ultrasound to detect left femoral vein blood flow velocity femoral vein blood flow velocity of flow. Using rench’s STAGO company automatic coagulation analyzer to detect PT, APTT, TT, D-D, FIB,related reagent kit were purchased from STAGO company of France, operated according to kit instructions. Using Japanese SYS-MEX automatic blood cell analyzer to detect platelet number as PLT.6.The follow-up:Follow-up Patients for one month after discharge from hospital in referral form, observe whether a deep venous thrombosis of lower limbs with symptoms or signs occurred.7.Statistical methods:All the results obtained was made data table and data figure, use SPSS17.0 statistical software to take significant processing of data. The expression of data is mean value±standard deviation, data of benign and malignant compared by independent samples t test;data before and after operation were compared using analysis of variance, with P< 0.05 as significant difference.Result1.Compare each index of benign disease group before and after operation:there were no significant differences between the value of APTT before and after surgery, P values, respectively (0.626,0.821,0.795). The value of PT 1 day after is different with preoperatively (P=0.000),3 days after is different with preoperatively (P =0.000),3 days after is different with 1 days after operation (P=0.048). The value of TT 1 day after is different with preoperatively (P=0.000),3 days after is different with preoperatively (P=0.000),3 days after is different with 1 days after operation (P=0.021). The value of D-D 1 day after is different with preoperatively (P=0.000),3 days after is different with preoperatively (P= 0.000),3 days after is different with 1 days after operation (P=0.000). The value of FIB 1 day after is different with preoperatively (P=0.001),3 days after is different with preoperatively (P=0.000),3 days after is different with 1 days after operation (P= 0.000). The value of PLT 1 day after is different with preoperatively (P=0.003),3 days after is different with preoperatively (P=0.000),3 days after is not different with 1 days after operation (P=0.314).2.Compare each index of benign disease group before and after operation:The value of APTT 1 day after is different with preoperatively (P=0.014),3 days after is not different with preoperatively (P= 0.272),3 days after is not different with 1 days after operation (P=0.174). The value of PT 1 day after is different with preoperatively (P=0.000),3 days after is different with preoperatively (P=0.000), 3 days after is different with 1 days after operation (P=0.009). The value of TT 1 day after is different with preoperatively (P=0.000),3 days after is different with preoperatively (P=0.000),3 days after is not different with 1 days after operation (P= 0.284). The value of D-D 1 day after is different with preoperatively (P=0.000),3 days after is different with preoperatively (P=0.000),3 days after is different with 1 days after operation (P=0.000). The value of FIB 1 day after is different with preoperatively (P=0.000),3 days after is different with preoperatively (P=0.05), 3 days after is different with 1 days after operation (P=0.000). The value of PLT 1 day after is different with preoperatively (P=0.027),3 days after is different with preoperatively (P=0.001),3 days after is not different with 1 days after operation (P=0.244).).3.Compare benign disease group and malignant tumor group contrast at each time points:(1) the APTT value is different when comparing preoperative data (P= 0.008);no significant difference is found with data 1 day after operation (P=0.613); no significant difference is found with data 3day after operation (P=1.636). (2) the PT value is different when comparing before surgery,1 days,3 days after operation (all of three have P<0.001). (3) the TT value is different when comparing preoperative data (P<0.001);no significant difference is found with data 1 day after operation(P=0.622); no significant difference is found with data 3day after operation (P=0.754). (4) the D-D value is different when comparing before surgery,1 days,3 days after operation (P<0.001,P=0.011, P<0.001).(5) the FIB value is different when comparing before surgery,1 days,3 days after operation (Pvaluesere<0.001,<0.001, 0.0014). (6) the PLT value is different when comparing before surgery,1 days,3 days after operation (P values were<0.001,<0.001,<0.001).4、Thrombus formation:two groups of patients were followed up in one month, there were no thrombosis.Conclusion1.The research on operation treatment effects to coagulation and fibrinolysis system within gynecological malignant tumors and benign disease patient, the APTT and TT value of two groups of patient decreased after operation,D-D level increased, and the consumption of PLT and blood coagulation factor in operation caused PT prolonged, FIB and PLT decreased after surgery,which indicates that surgery trauma enactives the inner and the extrinsic coagulation system, the body occours a series of coagulation react, while fibrinolysis system is in secondary hyperparathyroidism, after operation patients are in hypercoagulable state which is more obvious within malignant tumor patients.2.Compare the patients with malignant tumor with benign disease patients APTT,PT,FIB,TT extented,FIB,D-D and PLT increased, the femoral venous velocity slowed down, indicating that before operation the obvious abnormality of coagulation and fibrinolysis function had already existed in patients with malignant tumor, peformed as high coagulation state.Detection and lower extremity venous ultrasound.3.The examination of blood coagulation, fibrinolysis indexes and ultrasound color Doppler to lower extremity venous in peri operation period has positive significance for thromboembolic disease prevention and early diagnosis.