RU2377569C1 - Method for predicting clinical effectiveness in severe gestoses - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to obstetrics and can be used in the 3^rd trimester of pregnancy for predicting clinical effectiveness in severe gestosis. Substance of the invention consists in that starting from 28 weeks of pregnancy peripheral venous blood of a woman suffering from severe gestosis is analysed for the content of CD16+CD3-cells. If the related values are less than 9%, conventional therapy of severe gestosis is predicted as efficient, while the value 9% or more show the absence of clinical effectiveness in gestosis.

EFFECT: application of the method allows predicting effectiveness of conventional therapy in severe gestosis from 28 weeks of pregnancy with high accuracy, sensitivity and specificity that enable to determine approach to further prenatal care and delivery, to reduce risk of fetal pathology, maternal and perinatal mortality.

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Description

The invention relates to medicine, namely to obstetrics, and can be used to predict the effectiveness of standard therapy for severe gestosis in the 3rd trimester of pregnancy.

The relevance of the development of the method is determined by the high risk of maternal and perinatal mortality in severe gestosis. This necessitates the search for objective methods for predicting the effectiveness of standard therapy for severe gestosis to develop adequate management tactics and determine the timing of delivery of pregnant women with severe gestosis.

Currently, there are methods to predict the effectiveness of the treatment of diseases using complex mathematical calculations. There is a method for predicting the effectiveness of methods of treating diseases by analyzing the nth number of private diagnostic indicators during the diagnostic procedures and calculated generalized coefficients of predicted effectiveness before, after the first and second treatment procedures (Patent No. 2303955. A method for predicting the effectiveness of methods of treating diseases / C.E. .Golevenkov, OG Ovechkin, A.G. Kozlov and others // Inventions. Utility models. - 2007. - No. 22). The efficiency prediction coefficient is determined by the formula including the parameter Xi (t _j ), which is a complex coefficient calculated by the formula in which the relative particular diagnostic indicators obtained during repeated diagnostic procedures are compared with the parameter values corresponding to the initial and critical stages diseases and indicators of a healthy person.

This method has several disadvantages:

- to determine the coefficient of prognosis of effectiveness, an extremely complex mathematical formula is used, including more than 12 parameters, which in turn should also be calculated using two formulas, which greatly complicates the use of the method and makes it inapplicable in practical public health;

- the method requires a 3-fold study of diagnostic parameters in the dynamics of treatment of the patient.

Another analogue is a method for comprehensively assessing the prognosis of the treatment of diffuse diseases of connective tissue with low molecular weight anticoagulants, including measuring the reaction time of citrated blood under conditions of low-contact activation with the creation of a deficit in the final concentration of ionized calcium by thromboelastographic method and determining the level of immunoglobulin G in blood serum before and after treatment (Patent No. 2195676. A method for a comprehensive assessment of the prognosis of the effectiveness of treatment of diffuse diseases of linen tissue with low molecular weight anticoagulants / T.L. Nakryzhskaya, P.A. Sarapultsev, T.A. Popova and others // Inventions. Utility models. - 2002. - No. 36. - P.327). Then, using the linear regression analysis method with the introduction of 3 coefficients, the model is used to construct a model of dependence on indicators before treatment, and if the coefficient exceeds 0.8, then treatment is predicted to be ineffective. This method allows to predict the effectiveness of the treatment of diffuse diseases of the connective tissue, but does not allow to predict the effectiveness of the standard therapy of gestosis.

This method has several disadvantages:

- the application of the method requires the determination of 2 diagnostic parameters (before and after treatment);

- to determine the reaction time of citrated blood, special reaction conditions are necessary with the creation of a deficit in the final concentration of ionized calcium;

- the complexity of calculating the formula for predicting the effectiveness of treatment.

Closest to the claimed method according to the technical solution is a method for predicting the effectiveness of atenolol in the treatment of gestosis in 32-38 weeks of pregnancy (Shekhtman M.M., Elokhina TB, Petrova SB, Sokolova M.Yu. Antihypertensive effectiveness β -blockers for gestosis in pregnant women with various types of central hemodynamics // Gynecology. - 2001. - T.3, No. 2. - P.68-70). To do this, at 32-38 weeks of pregnancy, echocardiography is used to study the parameters of the final diastolic volume of the left ventricle (BWW), stroke volume (UO), ejection fraction (EF), the rate of shortening of the myocardial circulatory fibers (V _cf ) and predict the effectiveness of atenolol in treatment preeclampsia. The effectiveness of atenolol at a dose of 50 mg / day is predicted in pregnant women with gestosis, the indicators of which differ from the normative increase in BWW, UO and PV, at a dose of 25 mg / day - in pregnant women with gestosis, in which the indicators BWW, UO, PV and V _cf do not differ from regulatory values. The use of atenolol in complex therapy in pregnant women with preeclampsia and reduced rates of UO, PV and V _cf compared with the standard values is predicted inappropriate.

The specified method is selected as a prototype.

The disadvantages of the prototype method are:

- the lack of normative and critical values of the BWW, UO, PV and V _cf parameters, allowing them to be compared with the patient's indicators;

- the method allows to evaluate the effectiveness of only one of the drugs included in the standard therapy of gestosis;

- the text does not provide data on the accuracy, sensitivity and specificity of this method of evaluating the effectiveness of the treatment of gestosis.

These disadvantages are proposed to eliminate in the present method.

The technical result is to predict the effectiveness of the standard therapy of severe gestosis from 28 weeks of pregnancy with an accuracy of 90.60%.

The claimed technical result is achieved by the fact that in the 3rd trimester of pregnancy in the peripheral venous blood of women with severe gestosis, the relative content of CD16 + CD3 cells is determined and, with a value of less than 9%, the effectiveness of the standard treatment of severe gestosis is predicted.

The novelty of the proposed method lies in the fact that for the first time it is proposed to predict the effectiveness of the use of traditional therapy for severe gestosis by determining the relative content of CD16 + CD3 cells in the peripheral blood of a pregnant woman. Previously, this indicator was examined in the peripheral blood of pregnant women and revealed an increase in the content of CD16 + CD3 cells with the development of gestosis (Skripkina I.Yu. Participation of various subpopulations of T-helper cells, natural killer cells and cathepsin D in the mechanism of development of gestosis // Abstract of Cand. Medical Sciences. - Ivanovo, 2004 .-- 23 p.). Our studies have found that in women with severe preeclampsia, the content of CD16 + CD3 cells in the peripheral blood in the 3rd trimester of pregnancy did not have significant differences compared to women with a physiological pregnancy (Sotnikova N.Yu., Antsiferova Yu.S., Kudryashova A.V. et al. Immunological riddle of pregnancy. - Ivanovo: Publishing House MIK. - 2005. - 272 p).

The population of natural killer CD16 + has a high level of cytotoxic activity (Khaitov PM, Ignatieva GA, Sidorovich IG Immunology: Textbook. - M .: Medicine, 2000. - P.143) and is able to carry out the lysis of endothelial cells indirectly through the reaction antibody-dependent cellular cytotoxicity (ADCC) by binding to circulating immune complexes fixed on the endothelium. Damage to the endothelium of the vessels of the kidneys can contribute to the progressive penetration of activated ECs into the glomeruli, leading to the development of proteinuria. In addition, the CD16 + population of natural killers is capable of synthesizing interferon-γ, which directly stimulates the expression of angiotensin II receptors in the blood vessel wall, which can provoke the development of hypertension (Horiuchi M., Hayashida W., Akishita M., E.a. Interferon -gamma induces AT (2) receptor expression in fibroblasts by Jak / STAT pathway and interferon regulatory factor-1 // Circ. Res. - 2000.- Vol.48. - No. 2. - P.233-240). Thus, an increase in the level of the CD16 + CD3 population of natural killers may indicate a deep damage to the endothelium of blood vessels, tissues of various organs and impaired functioning of the renin-angiotensin system, which are irreversible and do not respond to standard therapy.

The method is as follows.

1) Blood sampling for the study is carried out from the ulnar vein in a volume of 1 ml into a heparinized tube (at the rate of 25 units of heparin per 1 ml of blood).

2) Isolation of lymphocytes from peripheral venous blood is carried out according to standard methods (Boyum A. Isolation of mononuclear cell and granulocytes from human blood and bone marrow // Scand.J. Clin. Lab. Invest. - 1968. -v.21. - No. 97. - P.77.).

3) 100 μl of isolated lymphocytes at a concentration of 1 · 10 ⁶ cells / ml are incubated with 20 μl of monoclonal anti-CD16 labeled with FITC and 20 μl of monoclonal anti-CD3 labeled with PE for 30 minutes at room temperature in the dark, after whereby the cells are washed 1 time with 1 ml of physiological saline by centrifugation at 1500 rpm for 2 minutes. Cells are resuspended in 500 μl of saline. The reaction is recorded on a flow cytometer, determining the content of CD16 + CD3 cells in the lymphocyte gate. The result is read in percent (%).

Using the proposed method allows with high accuracy of 90.60% to predict the effectiveness of traditional therapy for severe gestosis in the 3rd trimester of pregnancy.

Distinctive features of the method are:

- the method is used in the period of 28-38 weeks of pregnancy;

- a prognostic parameter has been established for the relative content of CD16 + CD3 cells in the peripheral venous blood, with a content of less than 9%, the standard therapy for severe gestosis is predicted, and with a value of 9% or more, the treatment is not effective.

The essence of the proposed method is illustrated by the following examples.

Example 1. Pregnant Ch., 27 years. Re-pregnant, primiparous woman. From extragenital pathology - anemia of 1 degree. Registered in the antenatal clinic is from 8-9 weeks of pregnancy. The initial blood pressure of 120/80 mm RT. Art., the initial weight is 72.8 kg. During the observation in the antenatal clinic, blood pressure is 120/80 mm Hg. Art., from 30 weeks of pregnancy marked pathological weight gain, swelling of the legs, increased blood pressure to 130 / 80-140 / 90 mm RT. Art., proteinuria up to 0.132 g / l. At 35 weeks of pregnancy she was admitted to the hospital. Upon receipt, the state of moderate severity. Complaints of severe swelling, decreased urine output. Blood pressure upon receipt of 160 / 100-150 / 90 mm RT. Art., severe swelling of the legs, anterior abdominal wall, puffiness of the face, in the urine proteinuria - 1.32 g / l. According to ultrasound, the syndrome of delayed fetal development, with Doppler examination, hemodynamic impairment 1A degree.

Diagnosed with a pregnancy of 35 weeks. Severe gestosis: hypertension with significant proteinuria caused by pregnancy. Anemia of the 1st degree. Fetoplacental insufficiency. Fetal development retardation syndrome.

In hospital conditions, severe gestosis therapy has been started according to the standard of medical care for patients with this pathology: tranquilizers, antihypertensive drugs, drugs that affect the blood coagulation system, antispasmodics, solutions and plasma substitutes (colloids and crystalloids).

The results of the examination according to the claimed method: in the peripheral blood was determined by the content of CD16 + CD3 cells, which amounted to 8.7%. The effectiveness of the treatment of gestosis is predicted.

During therapy, a decrease in blood pressure to 140/85 mm RT. Art., according to the daily monitoring of blood pressure - hypertension of 1 degree, the daily rhythm is not broken (an adequate decrease at night). In the daily amount of urine, a decrease in the level of proteinuria to 0.66 g / l, a decrease in edema, according to Doppler examination, is a hemodynamic disorder of 1A degree. During therapy, pregnancy was prolonged to 38 weeks of gestation.

Pregnancy ended in timely delivery at 38 weeks of gestation. A full-term girl with a weight of 3000 g and a height of 52 cm was born with an Apgar score of 7/8 points.

Conclusion: predicting the effect of therapy for severe gestosis by the present method was confirmed.

Example 2. Pregnant K., 27 years old. The primordial, primogenous woman. From extragenital pathology - obesity 2 degrees. Registered in the antenatal clinic is from 7 weeks of pregnancy. The initial blood pressure of 120/80 mm RT. Art., the initial weight is 97.7 kg. At 28-29 weeks of pregnancy at the doctor’s appointment in the antenatal clinic, blood pressure is 160 / 105-170 / 110 mm Hg. Art., pathological weight gain - +2.5 kg in 2 weeks, swelling of the lower extremities, anterior abdominal wall. The patient was hospitalized in a hospital. Upon receipt, the state of moderate severity. Complaints of nasal congestion, severe swelling. Blood pressure upon receipt of 160 / 110-170 / 110 mm RT. Art., swelling of the legs, anterior abdominal wall, proteinuria in the urine - 1.32 g / l. According to ultrasound, the syndrome of delayed fetal development, with a Doppler examination - hemodynamic impairment of 2 degrees.

Diagnosed with pregnancy 28-29 weeks. Severe gestosis: hypertension with significant proteinuria caused by pregnancy. Obesity 2 degrees. Placental insufficiency. Fetal development retardation syndrome.

In a hospital, the treatment of severe gestosis has been started according to the standard of medical care for patients with this pathology: tranquilizers, antihypertensive drugs, drugs that affect the blood coagulation system, antispasmodics, solutions and plasma substitutes (colloids and crystalloids).

The results of the examination according to the claimed method: in the peripheral blood was determined by the content of CD16 + CD3 cells, which amounted to 10.8%, which is higher than the claimed level. The lack of effect of the therapy is predicted.

Against the background of intensive therapy, severe arterial hypertension up to 160 / 100-170 / 110 mm Hg remained for 4 days. Art., according to daily monitoring of blood pressure - severe arterial hypertension with no adequate reduction at night. In the peripheral blood - a decrease in platelet count, in the daily amount of urine proteinuria - 1.32 g / l, there was an increase in edema, according to the Doppler examination - a hemodynamic disorder of 3 degrees. Given the lack of effect of ongoing gestosis therapy, deterioration in the condition of the fetus, further prolongation of pregnancy was impractical.

Pregnancy ended in preterm birth at 29 weeks of gestation. A male child was born weighing 1300 g, height 37 cm, with an Apgar score of 4-6 points.

Conclusion: predicting the lack of effect of therapy for severe gestosis by the present method was confirmed.

Example 3. Pregnant V., 29 years old. The primordial, primogenous woman. From extragenital pathology - chronic pyelonephritis, varicose veins. Registered in the antenatal clinic is from 9-10 weeks of pregnancy. The initial blood pressure of 120/70 mm RT. Art., the initial weight - 68 kg, in the analysis of urine protein was not. From the 31st week, an increase in edema was noted, in the 33th week of pregnancy, a referral was given for inpatient treatment for gestosis, the patient refused to be hospitalized. Against the background of deterioration, she was admitted to the hospital at 35 weeks of gestation. Upon admission to the hospital blood pressure 160 / 105-170 / 110 mm RT. Art., weight gain - +12.7 kg, pronounced edema of the lower extremities, anterior abdominal wall, puffiness of the face. Upon receipt, the state of moderate severity. Complaints: severe swelling within a month. Blood pressure upon receipt of 160 / 110-160 / 120 mm RT. Art., swelling of the legs, anterior abdominal wall, proteinuria in the urine - 3.3 g / l. According to ultrasound, the fetus corresponds to the gestational age, with Doppler examination - hemodynamic impairment 1A degree.

Diagnosed with a pregnancy of 35 weeks. Severe gestosis: hypertension with significant proteinuria caused by pregnancy. Chronic pyelonephritis.

In a hospital, the treatment of severe gestosis has been started according to the standard of medical care for patients with this pathology: tranquilizers, antihypertensive drugs, drugs that affect the blood coagulation system, antispasmodics, solutions and plasma substitutes (colloids and crystalloids).

The results of the survey according to the claimed method: in the peripheral blood was determined by the content of CD16 + CD3 cells, which amounted to 9.0%, which is higher than the claimed level. The lack of effect of the therapy is predicted.

On the background of intensive therapy, arterial hypertension up to 150 / 100-160 / 100 mm Hg remained for 3 days. Art., according to daily monitoring of blood pressure - severe arterial hypertension with no adequate reduction at night. In peripheral blood - a decrease in platelet count, in the daily amount of urine proteinuria - 3.3 g / l, there was an increase in edema, according to the Doppler examination - hemodynamic impairment of 2 degrees. Given the lack of effect of ongoing gestosis therapy, deterioration in the condition of the fetus, further prolongation of pregnancy was impractical.

Pregnancy ended in preterm birth at 35-36 weeks of gestation. A 2300 g female child was born, 46 cm tall, with an Apgar score of 7-8 points.

Conclusion: predicting the lack of effect of therapy for severe gestosis by the present method was confirmed.

This method examined 32 women in the 3rd trimester of pregnancy with severe gestosis, the research data are shown in table 1.

Table 1

Indicator The number of examined Total women 32 True positive result fifteen False positive one True negative result fourteen False negative result 2

Total:

the accuracy of the proposed method is 90.60%,

the sensitivity of the proposed method is 88.20%,

the specificity of the proposed method is 93.00%.

The advantages of the proposed method:

1. a study of the content of CD16 + CD3 cells in peripheral blood allows predicting the effectiveness of standard therapy for severe gestosis before treatment, which allows you to determine the tactics of further management and delivery of the patient, reduce the risk of maternal and perinatal mortality;

2. The ability to predict the effectiveness of standard therapy for severe gestosis from 28 weeks of gestation;

3. predicting the effectiveness of the use of complex preparations of standard therapy for severe gestosis;

4. high accuracy - 90.60%, sensitivity - 88.20%, specificity - 93.00%;

5. simplicity and accessibility of the methodology.

Claims (1)

A method for predicting the effectiveness of the treatment of severe gestosis by examining a pregnant woman in the 3rd trimester, characterized in that from 28 weeks of gestation in the peripheral venous blood an indicator of the relative content of CD16 + CD3-cells is determined and if it is less than 9%, the effectiveness of standard therapy is predicted, and when a value equal to or more than 9%, predict the lack of effectiveness of therapy.