RU2266704C2 - Method for diagnosing the cases of chronic fetal hypoxia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out cardiotocographic examination taking into account day rhythmostasis and following data analysis. Diagnostically significant cardiotocographic characteristics like basal rhythm, accelerations, acceleration durations, motor fetus activity and integral fetus state characteristic are determined. Non-conjugated estriol/progesterone coefficient is calculated with day rhythmostasis taken into account. Maternal and fetal blood circulation hemodynamic values synchronization coefficient is determined. Diagnostically significant characteristics values typical for fetus hypoxia are determined. When carrying out cardiotocographic examination, basal rhythm (strokes/min) is equal to 156±2.9 at 12 o'clock and 159±3.7 at 20 o'clock; accelerations (strokes/min) 3.0±0.2 at 12 o'clock and 2.2±0.3 at 20 o'clock; acceleration durations (s) 14.2±0.7 at 12 o'clock and 13.6±1.2 at 20 o'clock; motor fetus activity (during 10 min) 2.0±0.4 at 12 o'clock and 1.7±0.3 at 20 o'clock; integral fetus state characteristic 1.25±0.15 at 12 o'clock and 1.37±0.22 at 20 o'clock. When determining noncojugated estriol/progesterone coefficient: 0.57±0.05 at 8 o'clock and 0.67±0.06 at 20 o'clock. When determining maternal and fetal blood circulation hemodynamic values synchronization coefficient: 2.35±0.19 before 37 pregnancy weeks date and 2.78±0.18 after 37 pregnancy weeks date. The values corresponding to the above referenced ones, functional fetus state change and chronic fetal hypoxia are to be diagnosed.

EFFECT: high accuracy of diagnosis.

Description

The invention relates to medicine, namely to obstetrics and gynecology, and relates to a method for the diagnosis of chronic intrauterine hypoxia of the fetus.

The experience of clinical and experimental obstetrics today confirms the value of a dynamic approach in determining the functional state of fetal life support systems, since any physiological indicators have a temporal scatter due to the evolution of living matter and astronomical reasons (Komarov F.I. Chronobiology and Chronomedicine. Moscow, Medicine, 2000 ) Currently, data have been obtained indicating that in the diagnosis of fetal hypoxia, a comprehensive assessment of the results of various research methods is necessary, and their analysis in the last trimester of pregnancy should be carried out taking into account the fetal sleep-wake cycle and the characteristics of the biological rhythms of the mother-placenta-functional system the fetus "is normal and pathological (Khloponina A.V. Daily rhythms of functional indicators of the system" mother-placenta-fetus "with uncomplicated pregnancy and its menacing termination taking into account morpho -functional asymmetries of the female reproductive system. Rostov-on-Don, 2000).

One of the effective approaches to solving the problem of monitoring the intrauterine state of the fetus during pregnancy and childbirth is to study the spatio-temporal variations in the levels of hormones that are adaptive to pregnancy (estriol, progesterone), and indicators of the reactivity of the fetal cardiovascular system (frequency, rhythm, heart rate variability) ), blood flow velocities in the uteroplacental and placental-fetal channels (in the vessels of the fetus, umbilical cord, uterine arteries), which allows you to get the most complete picture of those enii gestation (Botasheva TL Hronofiziologichesky stereofunktsionalnye and features of the system "mother-placenta-fetus" in normal and complicated pregnancy. Rostov-on-Don, 1999).

The concept of a chronobiological norm, which reflects the totality of morphological and functional indicators of maternal and fetal organisms, characterizing the state as a whole and individual systems on the basis of data on the dynamics of biorhythms of their integral indicators and determining the average periodic values of these indicators, is gaining importance in the obstetric clinic.

A known method for diagnosing the condition of the fetus by recording its cardiac activity using cardiotocography (Chernukha EA, Birth block. Moscow, Medicine, 2002).

In the known method for the diagnosis of fetal hypoxia, the diagnostically significant characteristics of the cardiotocogram (basal rhythm, acceleration) are determined and deviations from the norm are used to judge the presence of a fetal condition.

The disadvantage of this method is the low accuracy of diagnosis of fetal hypoxia in the third trimester of pregnancy due to lack of information when using only estimated indicators of the cardiotocogram.

Closest to the claimed is a method for diagnosing the condition of the fetus by recording its cardiac activity, taking into account the biological rhythms of the functional system "mother-placenta-fetus" (Rykov S.V., Lipatov I.S., Tezikov Yu.V., Gordeeva E.V. ., Gogel L.Yu. Biorhythmological principles for assessing the functional state of the fetus. A collection of theses and articles of the XXXVI final scientific and practical conference of the scientific and pedagogical staff of the Samara Military Medical Institute. - Samara, 2003. - P.128-129).

In this method of diagnosing fetal hypoxia, the diagnostically significant characteristics of the cardiotocogram are determined taking into account their daily rhythm, namely at 12 hours and 20 hours - the time of the largest and smallest deviations of the parameters, and abnormalities of the fetus are judged by deviations from the norm.

The disadvantage of this closest to the claimed method is the low accuracy of diagnosis of fetal hypoxia in the third trimester of pregnancy due to lack of information when using only one test.

The problem solved by the invention is the diagnosis of chronic fetal hypoxia.

The technical result is to increase the accuracy of diagnosis. The specified technical result is achieved by the fact that in the method for diagnosing chronic intrauterine hypoxia of the fetus by rhythmometry of diagnostically significant indicators of cardiotocography, additionally the rhythmometry of the coefficient of unconjugated estriol / progesterone (NE / P) and the determination of the synchronization coefficient (Sf) of the hemodynamic indicators of maternal and fetal blood flow and by changing these parameters in comparison with the norm diagnose violations of the functional state of the fetus, indicating the presence of chronic hypoxia.

A method for diagnosing chronic fetal hypoxia is as follows.

The pregnant woman and the fetus are examined taking into account the daily rhythmostasis of the levels of fetoplacental hormones, cardiotocography (CTG) and hemodynamics of maternal and fetal blood flow (SPG) revealed at physiological and hypoxic fetal course of pregnancy: at 12.00 and 20.00 - CTG and ultrasound; at 8.00 hours and 20.00 hours - blood sampling to determine the level of hormones.

The survey is carried out by determining

- indicators of the cardiotocogram of the mother and fetus;

- rhythmometry of unconjugated estriol and progesterone with the calculation of their ratio (NE / P);

- systolic-diastolic coefficient (Vs / Vd) of blood flow in the uterine arteries and umbilical cord vessels with the calculation of the synchronization coefficient of uterine and fetal blood flow (Sf).

With physiological and complicated fetal hypoxia, the above parameters have the following meanings.

The CTG indicators, when determined on a fully automated computer cardiotocograph AUSP-1 (Unikos company), normally in the third trimester of pregnancy, have the following quantitative characteristics:

- basal rhythm (beats / min) at 12.00 hours 132 ± 3.2 and at 20.00 hours 139 ± 4.1;

- acceleration (bpm) at 12.00 hours 8.3 ± 0.1 and at 20.00 hours 8.9 ± 0.2;

- the duration of acceleration (sec) at 12.00 hours 20.1 ± 0.5 and at 20.00 hours 23.2 ± 0.6;

- motor activity of the fetus (for 10 min) at 12.00 hours 3.8 ± 0.6 and at 20.00 hours 4.2 ± 0.5;

- an integral indicator of the state of the fetus (PSP <1.0 corresponds to the state of “healthy fetus”) at 12.00 hours 0.52 ± 0.03 and at 20.00 hours 0.74 ± 0.04.

For chronic fetal hypoxia, the following CTG indicators are characteristic:

- basal rhythm (beats / min) at 12.00 hours 156 ± 2.9 and at 20.00 hours 159 ± 3.7;

- acceleration (bpm) at 12.00 hours 3.0 ± 0.2 and at 20.00 hours 2.2 ± 0.3;

- the duration of acceleration (sec) at 12.00 hours 14.2 ± 0.7 and at 20.00 hours 13.6 ± 1.2;

- motor activity of the fetus (for 10 minutes) at 12.00 hours 2.0 ± 0.4 and at 20.00 hours 1.7 ± 0.3;

- an integral indicator of the state of the fetus (1.0 <PSP <2.0 corresponds to the state of "initial violations of the state of the fetus; 2.0 <PSP <3.0 -" expressed violations of the state of the fetus "; PSP> 3.0 -" pronounced violations of the state of the fetus ") at 12.00 hours 1, 25 ± 0.15 and at 20.00 hours 1.37 ± 0.22.

The level of steroid hormones in the blood serum (unconjugated estriol, progesterone) was determined by the radioimmunological method. Unification and standardization of research is achieved by using special kits (Kit), in which all the preparatory stages of the technological process of research are carried out by the factory (Artamoshkina L.V. Hormonal-immunological relationships in the system "mother-placenta-fetus" during postponement. Kiev, 1998) . When comparing the data of rhythmometry of the coefficient of unconjugated estriol / progesterone, the largest difference in the indicator during physiological gestation and complicated fetal hypoxia was noted at 8.00 hours and 20.00 hours while maintaining the daily rhythm. Normally, the indicator (NE / P) corresponds to the following values:

at 8.00 hours - NE / P 1.52 ± 0.2;

at 20.00 hours - NE / P 1.5 ± 0.1.

With fetal hypoxia: at 8.00 hours - NE / P 0.57 ± 0.05;

at 20.00 hours - NE / P 0.67 ± 0.06.

The synchronization coefficient of hemodynamic parameters (Vs / Vd) of maternal and fetal blood flow was calculated by the formula Sf = 1 / V, where V is the coefficient of variability of the ratio of modulating frequencies T1 / T2, where T is the length of the longest period in the spectrum (Halberg P., Katinas GS, Chronobiologic glossary of the international society for the study of biological rhythms. Ind. J. ChronobioL, 1993, No. 1).

When evaluating interfunctional relationships, 3 types of synchronization are distinguished (LI Agulova. Biorhythmological patterns of the formation of compensatory-adaptive reactions in the context of the clinical stress model. Tomsk, 1999): hypersynchronous (GS) - with a synchronization coefficient Sf> 3.5; synchronous (CX) - Sf corresponds to 3.0-3.5; asynchronous (AC) - Sf <3.0.

The synchronization coefficient during physiological gestation up to 37 weeks of pregnancy is 3.24 ± 0.16; in this period, all examined pregnant women showed a synchronous type of connection between maternal and fetal blood flow. After 37 weeks, Sf corresponds to 4.08 ± 0.24, a hypersynchronous type of interfunctional bonds is noted.

In chronic fetal hypoxia in the third trimester of pregnancy, regardless of gestational age, an asynchronous type of connection between maternal and fetal blood flows takes place. The synchronization coefficient up to 37 weeks of pregnancy corresponds to 2.35 ± 0.19, after 37 weeks of pregnancy - 2.78 ± 0.18.

EXAMPLE 1. Pregnant M., 26 years old, registered at the place of residence in the antenatal clinic of the city clinic with a diagnosis of Pregnancy 1, 9-10 weeks. Of the past diseases, SARS, mumps, and chickenpox in childhood are noted. Extragenital diseases - chronic pyelonephritis, last exacerbation 3 years ago. Menstrual function without features. Gynecological diseases - pseudo-erosion of the cervix. The husband is healthy. In the obstetric-therapeutic-pediatric complex was observed regularly. At 22 weeks, clinical and instrumental signs of the threat of abortion, for which reason she was hospitalized for 15 days in the Department of Pregnancy Pathology, City Clinical Hospital No. 2 named after N.A.Semashko. Therapy included tocolytics, antiplatelet agents, calcium antagonists, antioxidants, electrophoresis with magnesium sulfate on the uterus. Examination data (ultrasound - fetometry, ultrasound dopplerography (USG), α-fetoprotein, tetrapolar rheovasography, conjunctival biomicroscopy, standing height of the uterine fundus in dynamics, general analysis of blood, urine, biochemical blood test) before discharge corresponded to the "pregnancy rate". Discharged in satisfactory condition for further treatment and follow-up in a antenatal clinic. At 29 wk. pregnancy, a comprehensive examination was carried out in the conditions of a screening hospital GKB No. 2 named after N.A.Semashko: ultrasound - fetometry, ultrasound of uterine and fetal blood flow, CTG of the mother and fetus, conjunctival biomicroscopy, regional and integral rheovasography, determination of unconjugated estriol, progesterone, general analysis and biochemical blood tests, urine tests.

Results: total weight gain during pregnancy - 4 kg; photometric data correspond to 28-29 weeks. pregnancy microcirculatory disorders in the vessels of the conjunctiva of 1 degree; violations of regional and central hemodynamics were not detected, eukinetic type of hemodynamics; blood and urine tests - without features; CTG - at 12.00 and 20.00 hours - basal rhythm - 130 and 134 beats / min, respectively, acceleration - 8 and 7.7 beats / min, duration of accelerations - 18 and 20 s, motor activity of the fetus - 3 movements per 10 min, PSP - 0.65 and 0.71; rhythmometry of the coefficient of unconjugated estriol / progesterone (8.00 hours and 20.00 hours) - 1.32 and 1.41, respectively; coefficient of synchronization of hemodynamic indicators of maternal and fetal blood flow - 3.06, type of synchronization - synchronous.

Clinical diagnosis:

Pregnancy 1, 29 weeks. Head presentation of the fetus.

Chronic pyelonephritis in remission. Pseudo-erosion of the cervix.

Recommended vitamin-mineral complex for pregnant women "Materna".

At 34 weeks at a reception at a local obstetrician-gynecologist, a pregnant woman complains of pulling pains in the lower abdomen, lower back.

Objectively: the uterus during palpation comes in tone, the height of the bottom of the uterus, the abdominal circumference correspond to 33-34 weeks. pregnancy. With a diagnosis of Pregnancy 1, 34 weeks. Head presentation of the fetus. The threat of premature birth. Chronic pyelonephritis in remission. Pseudo-erosion of the cervix, is sent for inpatient treatment at the Department of Pregnancy Pathology, City Clinical Hospital No 2 N.A.Semashko, where a comprehensive examination and treatment of the threat of premature birth is carried out. The survey results in 34-35 weeks. pregnancy: ultrasound - fetometry - the fetus according to photometric data corresponds to 34-35 weeks of pregnancy; UZDG - impaired blood flow 1A degree (in the uterine arteries); conjunctival biomicroscopy - a violation of microcirculation of 1 degree; general analysis of blood and urine - without pathology; urine according to Nechiporenko is the norm; biochemical blood test - the norm; CTG at 12.00 and 20.00, respectively - the basal rhythm is 154 and 158 beats / min, the acceleration is 3.2 and 2.5 beats / min, the duration of the accelerations is 14.8 and 13.9 s, the motor activity of the fetus is 2.5 movements and 2 movements in 10 minutes, PSP - 1.28 and 1.41; the ratio of unconjugated estriol / progesterone at 8.00 hours and 20.00 hours - respectively 0.62 and 0.71; Sf maternal and fetal blood flow - 2.55, asynchronous type of synchronization. In addition to the diagnosis: chronic fetoplacental insufficiency (CKDF), chronic fetal hypoxia. During the week, therapy is carried out aimed at correcting CKDF, chronic fetal hypoxia - sigetin, actovegin, trental, antioxidants, antihypoxants, unitiol, ginipral, oxygen therapy. Control examination in 35-36 weeks. - indicators of USDG, CTG, rhythmometry of the coefficient of unconjugated estriol / progesterone, Sf - stable. Continued conservative treatment of CKDF with daily monitoring of CTG. Examination results at 37 weeks - there is a positive trend (basal rhythm, acceleration, fetal movement test, PSP (0.85) - within normal limits; NE / P at 8.00 - 1.23; Sf-2.9). It was decided to conduct induced childbirth using hormonal energy background, amniotomy. Delivery at 37 weeks was uneventful. A live full-term boy was born with a body weight of 3000 g, a length of 50 cm, with an Apgar score of 1 min - 6 points, 5 min - 7 points (mild asphyxiation), without signs of morphofunctional immaturity. In the period of early adaptation and during the entire stay in the neonatal ward, the child was in a satisfactory condition. The postpartum period in the mother proceeded without complications, the puerpera and the newborn were discharged home on the 7th day after delivery in a satisfactory condition. The results of a histological examination of the placenta: subcompensated placental insufficiency.

EXAMPLE 2. Pregnant N., 34 years old, was registered in the antenatal clinic of the Regional Perinatal Center with a diagnosis of:

Pregnancy 3, 11-12 weeks.

Nulliparous older.

A burdened obstetric history (2 medical abortions in terms of 7-8 weeks, 9-10 weeks without complications).

From the anamnesis: every 2-3 years of acute respiratory viral infection, children do not remember infections, appendectomy at 14 years. Extragenital diseases - varicose veins of the lower extremities. Gynecological diseases - chronic salpingoophoritis. The husband is healthy. In the first half of pregnancy, early mild toxicosis occurred (outpatient treatment). At 28-29 weeks. - the threat of premature birth, for which he was treated for 3 weeks in the Department of Miscarriage of the Regional Perinatal Center. At 34 weeks, edema appeared, blood pressure 140/90 and 145/90 mm Hg, urine protein 0.066 g / l, a total increase in body weight of 14 kg. With a diagnosis of Pregnancy 3, 34 weeks. Combined gestosis against varicose veins of the lower extremities. Nulliparous older. A burdened obstetric history, was hospitalized in the Department of Pregnancy Pathology, City Clinical Hospital No. 2 named after N.A.Semashko. Treatment is being carried out, including antihypertensive therapy, herbal medicine, antiplatelet agents, antioxidants, metabolites, electrophoresis with reopoliglyukin to the uterine fundus. At 36 weeks in the course of clinical and laboratory-instrumental examination revealed: blood pressure 120/80 and 125/85 mm Hg, pasty legs, daily diuresis positive; Ultrasound fetometry - without features; Ultrasound placentography - ultrasonic signs of gestosis; UZDG - impaired blood flow 1A degree (in the uterine vessels); conjunctival biomicroscopy - disorders of microcirculation of 1 degree; fundus - without pathology; integral rheovasography - hypokinetic type of hemodynamics; general analysis and biochemical blood test - without pronounced changes (total protein - 62 g / l without dysproteinemia); urine is the norm; CTG at 12.00 hours and 20.00 hours, respectively - the basal rhythm is 155 and 158 beats / min, the acceleration is 3.0 and 2.5 beats / min, the duration of the accelerations is 13.6 and 12.8 s, the fetal movement test is 2 movements and 1.5 movements in 10 minutes, PSP - 1.39 and 1.57; the coefficient NE \ P at 8.00 hours and 20.00 hours, respectively, 0.53 and 0.61; Sf-2.39, asynchronous type. Diagnosed with Pregnancy 3, 36 weeks. Combined mild gestosis against varicose veins of the lower extremities. HFPN. Chronic fetal hypoxia. Nulliparous older. OAA

Taking into account the revealed signs of chronic intrauterine hypoxia of the fetus (according to CTG, NE / P, Sf rhythmometry), it was decided to strengthen the treatment of CKDF and repeat the examination after 24-48 hours. 48 hours after therapy, including intravenous drip of actovegin, riboxin, pentoxifylline, sigetin, piracetam, a control examination was performed: the rhythmometry indicators of CTG, NE / P, Sf - worsened (basal rhythm 156-159 beats / min, acceleration - 2.8 -2.0 beats / min, the duration of the acceleration is 13.5-12.4 s, the fetal movement test is 1.7 and 1.4 movements per 10 minutes, PSP is 1.45 and 1.59; NE / P - 0.5-0.6; Sf-2.2, asynchronous type). Given the lack of effect from the treatment of CKDF, the progression of chronic fetal hypoxia, it was decided to urgently deliver the pregnant woman by cesarean section, the consent of the woman to the operation was obtained. The operation went without special features; a neonatologist-resuscitator was invited to the operating room. A live premature girl was born weighing 2450 g, length 45 cm, in asphyxiation of moderate severity (Apgar score after 1 minute - 5 points, after 5 minutes - 5 points), with signs of morphofunctional immaturity. In the period of early adaptation and during the observation of the newborn in the department for newborns, the condition was from moderate to satisfactory. The postpartum period of the mother went smoothly. On the 10th day, the child in satisfactory condition was transferred to the department of premature babies of the Children's City Clinical Hospital No. 1 for further nursing and further examination. Histological examination of the placenta: decompensated chronic placental insufficiency. After 1 year, the development of the child corresponded to the age norm.

Thus, the rhythmometry of the functional indicators of fetal life support (cardiac activity, hormones adaptive to pregnancy, synchronization of hemodynamics of maternal and fetal blood flows), in contrast to single studies without taking into account biorhythms in the mother-placenta-fetus system, allows you to effectively monitor the intrauterine state of the fetus and in a timely manner diagnose chronic fetal hypoxia.

A change in the indicators proposed to characterize the state of the fetoplacental complex indicates a failure of the adaptive capabilities of the fetus and the need for their intensive correction up to early delivery.

The outcomes for the fetus from the standpoint of evidence-based medicine were determined sensitivity, specificity, accuracy, prognostic value of the positive and negative results of this method for the diagnosis of chronic fetal hypoxia during pregnancy, which are respectively 95.3%, 98.8%, 98.3%, 91% and 98%, which indicates a high information content and reliability of the proposed diagnostic method.

The positive effect of the proposed diagnostic method is a fundamentally new opportunity for timely diagnosis of fetal hypoxia due to the assessment of previously unused parameters. The method is non-invasive, safe for the health of the pregnant woman and the fetus, widely available for modern obstetric institutions.

On the filing date, the applicant did not find a diagnostic method with the claimed combination of features, as a result of which we conclude that the claimed technical solution meets the criteria of the invention of “novelty”.

According to the results of the comparative analysis, the totality of the features of the proposed diagnostic method provides it with new properties in the form of increasing the accuracy of diagnosis, that is, according to the applicant, the proposed method meets the criterion of "inventive step".

The criteria of the invention "industrial applicability is confirmed by the fact that the inventive diagnostic method can be successfully applied in mass prophylactic examinations of pregnant women and their fetuses as screening with the detection of accurate and early signs of fetal hypoxia.

Claims (3)

A method for diagnosing chronic fetal hypoxia, including cardiotocography taking into account daily rhythmostasis followed by data analysis, characterized in that it determines the diagnostically significant indicators of cardiotocography: basal rhythm, acceleration, duration of acceleration, fetal motor activity, an integral indicator of the fetal condition; the coefficient of unconjugated estriol / progesterone (NE / P) is calculated taking into account the daily rhythmostasis and the synchronization coefficient of hemodynamic indicators of maternal and fetal blood flow is determined and the value of diagnostically significant indicators of cardiotocography: basal rhythm (beats / min) at 12.00 hours 156 ± 2.9 and at 20.00 hours 159 ± 3.7; acceleration (bpm) at 12.00 hours 3.0 ± 0.2 and at 20.00 hours 2.2 ± 0.3; the duration of acceleration (s) at 12.00 hours 14.2 ± 0.7 and at 20.00 hours 13.6 ± 1.2; fetal motor activity (for 10 min) at 12.00 hours 2.0 ± 0.4 and at 20.00 hours 1.7 ± 0.3; the integral indicator of the fetus at 12.00 hours 1.25 ± 0.15 and at 20.00 hours 1.37 ± 0.22; NE / P ratio: 8.00 hours - NE / P 0.57 ± 0.05; 20.00 hours - NE / P 0.67 ± 0.06 and the synchronization coefficient of hemodynamic indicators of maternal and fetal blood flow: up to 37 weeks of pregnancy from 2.35 ± 0.19, after 37 weeks of pregnancy 2.78 ± 0.18; detect a change in the functional state of the fetus and diagnose chronic fetal hypoxia.