RU2517374C2 - Method for choosing management of pregnant women with placental insufficiency and foetal growth inhibition syndrome - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: blood is examined for angiogenic factors, namely soluble fms-like tyrosine kinase (sFlt-1) and placental growth factor (PIGF). An angiogenic factor (Ka) is calculated by formula: Ka=sFlt-1/PlGF×10. If Ka is 10 or less, the pregnant woman is stated to require no admission to hospital, no case follow-up; doctor's appointments are scheduled. If Ka falls within the range of 10 to 50, the pregnant woman is admitted to hospital, wherein foetal monitoring, Doppler monitoring are performed; an amniotic fluid index (AFI) is calculated; a therapy aiming at the uterine-placental blood flow improvement is prescribed for 10 days. The amount of infusion makes 400 ml a day. The prescribed preparations are Actovegin, Trental, Instenon, Carnitini chloridum. Control ultrasonography, Doppler monitoring, foetal monitoring, AFI and Ka measurements are performed 2 weeks later. The pregnant woman is discharged from hospital if observing no negative trends. If Ka falls within the range of 50 to 100, the pregnant woman is admitted to hospital, wherein foetal monitoring, Doppler monitoring are performed, and AFI is measured; a therapy aiming at the uterine-placental blood flow improvement is prescribed for 14 days The amount of infusion makes 800 ml a day. The prescribed preparations are Actovegin, Trental, Instenon, Carnitini chloridum. Control Doppler monitoring and foetal monitoring are performed every 3 days; 2 weeks later control Ka is measured. If the trend is positive, the pregnant woman may be discharged from hospital, while no positive trend requires another 2 weeks of the therapy. If Ka is 100 or more, but less than 150, the pregnant woman is admitted to hospital, wherein foetal monitoring, Doppler monitoring are performed, and AFI is measured; a therapy aiming at the uterine-placental blood flow improvement is prescribed for 14 days. The amount of infusion makes not less than 800 ml a day with the same preparations prescribed. Those are added with the preparations for homeostasis correction, including Fraxiparine, Fragmin, Clexane optionally. Control Doppler monitoring and foetal monitoring are daily. Hypamnion also requires measuring control AFI. If a gestational age is less than 34 weeks, respiratory distress syndrome (RDS) should be prevented by administering the preparation Dexon 24 mg according to the schedule: 6 mg every 12 hours 4 times. Control Ka is necessarily measured after 2 weeks of the treatment. If the trend is positive, the pregnant woman may be discharged from hospital, while no positive trend requires another 2 weeks of the therapy. If Ka is 150 or more, and the gestational age is more than 34 weeks, the therapeutic approach is the same, as for Ka being within 100 to 150, control Doppler monitoring, foetal monitoring are performed twice a day, as well as measuring AFI. If observing no foetal weight gain for 2 weeks of the therapy or the functional state of the foetus deteriorates, a Cesarean section is performed. If the gestational age is 34-36 weeks, the therapeutic approach and follow-up are the same as for the gestational age of 34 weeks, except for the prevention of foetal RDS. However, if observing the deterioration of a foetal movement pattern or the functional status of the foetus, a Cesarean section is performed according to the foetal monitoring and Doppler monitoring findings. If the gestational age is more than 36 weeks, and Ka is 150 or more, pre-mature delivery is applied.EFFECT: optimal selection of the therapeutic approach ensured by determining the values reflecting the severity of the cardiovascular disorder directly in the uterine-placental complex and mother's and foetus's compensatory capacities.5 ex

Description

The invention relates to medicine, namely to obstetrics, and is intended to choose the tactics of managing pregnant women with placental insufficiency and fetal growth retardation syndrome (PN and SZRP).

To date, the problem of placental insufficiency in obstetrics occupies one of the central places. However, there is no unified theory regarding the etiology and pathogenesis of PN, which greatly complicates the prediction, assessment of severity and, accordingly, the implementation of preventive measures for this type of pathology. Thus, among the many problems associated with the development of PN, forecasting occupies one of the most important places and is of great importance in prevention and in the choice of obstetric tactics.

It is known that with PN, the transport, trophic, endocrine, metabolic, antioxidant functions of the placenta are disturbed, which leads to pathology of the fetus and newborn. Often, placental insufficiency is identified with fetal growth retardation syndrome, which is the end result of complex morphofunctional changes in the mother-placenta-fetus system that occur when PN occurs (Battaglia FC, Regnault TR Placental transport and metabolism of amino acids. Placenta 2001; 22: 2-3: 145-161. Butler EL, Dashe JS, Ramus RM Association between maternal serum alpha-fetoprotein and adverse outcomes in pregnancies with placenta previa. Obstet Gynec 2001; 97: 1: 35-38).

Currently, the main diagnostic methods for PN are based on the use of ultrasound. But the variety of functions of the placenta dictates the need to use not only ultrasonic methods, but also laboratory ones.

The methods used to assess the condition of the fetus and the entire placental system as a whole reflect various aspects of its functioning, and therefore should be used in combination, given that their information content in various conditions is not always the same.

At the same time, since the manifestation of PN is, in addition to SZRP, fetal hypoxia or its death, the search for clear criteria for determining the PN, on the basis of which it would be possible to formulate tactics for further management of a pregnant woman with PN and SZRP, is very relevant.

To date, in the prior art there are no uniform criteria by which it is possible to unambiguously determine the tactics of conducting pregnancy in women with PN. There are ways to determine management tactics in identifying violations of the various functions of the placenta.

So, there is a method for determining pregnancy management tactics for violations of the trophic function of the placenta, which manifests itself in the formation of SZRP. The ultrasound diagnosis of SZRP is based on a comparison of fetometry data with normative indicators for a given gestational age. The basic fetometric parameters (biparietal size of the head, average diameter of the abdomen and length of the femur) and the parameters of the mass-growth ratio are determined. The diagnosis of SZRP is established when fetometry parameters are detected below the 10th percentile. With I degree of severity of SZRP there is a lag of 2 weeks, with II - within 3-4, and with III degree more than 4 weeks. With the diagnosis of SZRP I-II degree, dynamic observation and conservative treatment are indicated. A third-degree srpd is an indication for delivery by cesarean section.

The disadvantage of this method is the reduced accuracy, lack of information about the constitutional features of the fetus and the compensatory capabilities of the mother's body. The proposed tactics for patients with SZRP I-II degree is also ambiguous and raises questions.

There is a method of determining pregnancy management tactics by dopplerometry in the vessels of the utero-placental and fetal-placental complexes (Sidorova I.S., Makarov I.O. Research methods during pregnancy and childbirth. Standard and new technologies: Textbook. - M .: MED press - inform, 2005. - p76). If blood flow disorders are detected in the mother-placenta-fetus system, a diagnosis of PN is established and therapy aimed at improving the uteroplacental blood flow is prescribed. In case of severe violations according to Dopplerometry and critical figures, tactics are decided in favor of early delivery by cesarean section, if there are no conditions for a quick and gentle delivery through the natural birth canal.

The disadvantage of this method is the reduced accuracy and complexity in interpreting the results, predicting the further development of violations. This method does not provide information about the prognosis of the fetus and the compensatory capabilities of the uteroplacental bed and fetus, but only reflects hemocirculatory disorders.

There is a method of determining the tactics of managing patients with PN according to the results of measuring the amniotic fluid index (IAI), since it reflects violations of the excretory function of the placenta. With severe oligohydramnios and critical index numbers (IAI <5), early delivery is indicated.

The disadvantage of this method is also low information content. Since the IAI is a variable variable, reflecting only the excretory function of the placenta. And with a long-lasting fluctuation of the IAI, either towards normovodia, or toward low water, there is a risk of missing the decompensation of the fetus.

A known method for determining tactics of pregnancy in women with PN according to the results of cardiotocography.

The disadvantage of this method is the low sensitivity of the reaction of the cardiovascular system of the fetus to the changes. In most cases, according to CTG, cases of deterioration of the functional state of the fetus with severe decompensation are recorded, which ultimately leads to high perinatal morbidity and mortality.

The objective of the invention was to develop a simple, affordable method for determining the severity of ST and SZRP, which allows you to clearly determine not only the severity itself, but also the tactics of managing patients, depending on the parameters established as a result of the method.

The technical result of our proposed method is the ability to clearly identify those cases where the intervention during pregnancy is impractical or, conversely, requires the adoption of various measures, as well as the opportunity to determine which intervention is necessary according to the values of the method.

The technical result of the proposed method is the ability to choose pregnancy management tactics for patients with PN and SZRP based on the values of the coefficient we have determined, which is determined by the formula we developed, i.e. the possibility of deciding on the need for delivery or the possibility of prolonging pregnancy without danger to the life of the woman and the fetus.

Thus, the technical result consists in determining an additional diagnostic criterion in identifying at least one of the signs of PN, namely the angiogenic coefficient, which reflects the severity and depth of vascular disorders directly in the uteroplacental complex and determines the compensatory capabilities of the mother's body. Based on the results of this coefficient, pregnancy management tactics are built in patients with PN and SZRP.

The indicated technical result can be achieved due to the determination of angiogenic factors sFlt-1 — soluble fms-like tyrosine kinase and PIGF — placental growth factor in the blood plasma of pregnant women in patients with PN and SZRP, and the calculation of the Ka coefficient, which is the ratio of sFlt-1 to PIGF.

The placental soluble fms-like tyrosine kinase sFlt-1 (soluble fms-like tyrozine kinase) is an anti-angiogenic protein that binds pro-angiogenic proteins, vascular endothelial growth factor VEGF, and placental growth factor PIGF (placental growth factor), who are responsible for successful implantation and placentation. With an excess of sFlt-1, pro-angiogenic proteins cannot bind to endothelial cell receptors. This causes endothelial placental dysfunction by affecting the uterine spiral artery remodeling, which is necessary for normal placentation and gestation.

Despite the widespread popularity of the relationship between the factors themselves, indicating the presence of endothelial dysfunction in women, with the development of various pregnancy complications in these women, the analysis of the prior art did not reveal the popularity of the relationship between the numerical values of these factors and how they should be interpreted in the clinic, i.e. what pregnancy management tactics should be chosen if women find one or another indicator value indicating endothelial dysfunction.

At the same time, the issue of managing pregnant women who are diagnosed with PN and SZRP at the present time seems to be the most difficult. So, on the one hand, in obstetric practice there is an established opinion that “one day spent by the fetus in the mother’s womb is equal to 1 week of the child’s life outside the womb,” which indicates the need to prolong pregnancy for the maximum possible period in order to ensure the formation and maturation of all organs and systems of the fetus. On the other hand, in certain situations, prolonging pregnancy can be dangerous both for a woman’s life and for the fetus.

Our observations (including a retrospective analysis of case histories) made it possible to establish that in practice pregnant women with an established diagnosis of PN of a similar severity can be divided into several groups: women whose condition allowed the pregnancy to be prolonged, which led to the birth of a healthy fetus; women whose condition allowed the pregnancy to be prolonged, but the newborn had functional and organic changes typical of placental insufficiency; women whose prolonged pregnancy may lead to antenatal and intranatal fetal death. At the same time, at the time of diagnosis of PN and SZRP, these groups of pregnant women showed similar or close clinical and laboratory pictures.

This fact required the search for additional criteria for determining pregnancy management tactics in patients with PN and SZRP; criteria, the determination of which would allow us to conclude about the need for delivery or about the possibility of prolonging pregnancy without danger to the life of the woman and the fetus.

As such a criterion, we proposed an angiogenic coefficient (Ka).

The method is as follows:

If at least one standard PN criterion is identified:

- lag in size according to ultrasound fetometry from the proper values;

- identification of violations according to dopplerometry;

- identification of water shortage;

- the detection of changes according to cardiotocography (CTG) is determined by the concentration of vascular growth factors in the peripheral plasma of a pregnant woman - sFlt-1 and PIGF and the values of the angiogenic coefficient (Ka), calculated by the formula Ka = sFlt-1 / PlGFx10, determine the tactics of further pregnancy .

So if

Ka is less than or equal to 10

A pregnant woman should not be diagnosed with PN and SZRP, as she has no signs of endothelial dysfunction.

The patient does not require hospitalization and there is no need for dynamic monitoring of the functional state of the fetus. Doctor visits to the antenatal clinic according to plan.

Ka is greater than or equal to 10 but less than 50

The patient needs hospitalization in a hospital. A compulsory examination should include CTG: (with a gestational age of more than 30 weeks), dopplerometry, determination of IAI), treatment is carried out aimed at improving the uteroplacental blood flow, for 10 days with drugs such as actovegin, trental, instenon, carnitine chloride - to choose from.

The volume of infusion is 400 ml per day.

After 2 weeks, the control of ultrasound, Doppler, CTG, IAH, control of the angiogenic coefficient.

In the absence of negative dynamics, an extract is possible.

Ka is greater than or equal to 50 but less than 100

The patient needs hospitalization in the hospital or continued treatment.

CTG should be included in the mandatory examination: (with a gestational age of more than 30 weeks), dopplerometry, determination of IAH). Treatment is being carried out aimed at improving the utero-placental blood flow, for 14 days with drugs such as actovegin, trental, instenon, carnitine chloride - to choose from.

The volume of infusion is 800 ml per day.

Mandatory control of dopplerometry and CTG 1 time in 3 days.

After 2 weeks, control of the angiogenic coefficient.

With positive dynamics, discharge is possible, in the absence of dynamics - continued treatment for 2 weeks.

Ka is greater than or equal to 100 but less than 150

The patient needs hospitalization in the hospital or continued treatment.

The mandatory examination should include: CTG (with a gestational age of more than 30 weeks), dopplerometry, determination of IAH). Treatment is carried out aimed at improving the utero-placental blood flow, within 14 days (Actovegin, Trental, Instenon - to choose from), if necessary - correction of hemostasis (fraksiparin, fragmentin, clexane).

The volume of infusion is at least 800 ml per day.

Mandatory control of Doppler and CTG daily, with oligohydramnios and IAH.

Prevention of fetal RDS up to 34 weeks. (Dexon 24 mg on a 6 mg schedule every 12 hours No. 4).

After 2 weeks, control of the angiogenic coefficient.

With positive dynamics, discharge is possible, in the absence of dynamics - continued treatment for 2 weeks.

Ka is greater than or equal to 150

With a gestational age of up to 34 weeks: the tactics are the same as with Ka from 100 to 150, but the risk of antenatal and intranatal death of the fetus rises sharply, therefore mandatory monitoring of dopplerometry and CTG, IAH 2 times a day, prevention of RDS of the fetus by dexon according to the scheme.

In the absence of positive dynamics in the increase in fetal weight within 2 weeks of treatment or a deterioration in the functional state of the fetus, caesarean section.

With a gestational age of 34-36 weeks - treatment, as with Ka from 100 to 150, 2 times a day control of CTG, dopplerometry. With a deterioration in the nature of fetal movements or a deterioration in the functional state of the fetus according to CTG or Dopplerometry, a cesarean section.

With a gestational age of more than 36 weeks, delivery is indicated (preferably by cesarean section, but delivery through the natural birth canal is possible in the presence of biological maturity of the cervix).

The method has been tested by us in clinical practice for several years and has shown good results.

The following are clinical examples of the implementation of the proposed method:

Example 1

Pregnant P., 32 years old, was admitted to the department of pregnancy pathology with a diagnosis of:

Pregnancy is 31-32 weeks. Head presentation. The threat of premature birth.

During the examination, the following data were obtained: mismatch of fetometry data to gestational age for 2 weeks. According to Dopplerometry - a violation of the uteroplacental blood flow IA degree. IAI within normal limits. CTG is within normal limits.

Ka = 4.2.

Based on the results of the examination, the following clinical diagnosis was made:

Pregnancy is 31-32 weeks. Head presentation. The threat of premature birth. Chronic placental insufficiency. SZRP 1 degree.

He was prescribed therapy aimed at treating the threat of preterm birth and therapy aimed at improving the utero-placental blood flow, which the patient refused and insisted on discharge on receipt. Delivery at 39-40 weeks, proceeded without complications. A live full-term boy was born, weights 3100, height 50 cm. The Apgar score is 8/9 points. Statement for 4 days in satisfactory condition with the child.

This example demonstrates that despite the fact that fetometry and Dopplerometry were diagnosed with PN and SZRP, there were no vascular disorders in the feto-placental complex, as evidenced by low Ka values. In this case, PN therapy was not required.

Example 2

Pregnant M., 24 years old, enters the Department of Pregnancy Pathology with a direct diagnosis:

Pregnancy 34 weeks. Pelvic presentation. Chronic placental insufficiency.

The survey revealed a discrepancy between the data of ultrasound fetometry gestational age - a delay of 3 weeks. According to Dopplerometry: a violation of the uteroplacental blood flow of the II degree, a violation of the fetal-placental blood flow of the IB degree. IAI = 10.2 (normative). CTG is within normal limits. Laboratory data within acceptable limits.

Ka = 47.

Based on the results of the examination, the following clinical diagnosis was made:

Pregnancy 34 weeks. Pelvic presentation. Chronic placental insufficiency. SZRP 2 degrees.

The treatment was prescribed according to the proposed method (with Ka greater than 10, but less than 50), aimed at improving the rheological properties of blood and increasing blood flow. After 2 weeks, a follow-up examination using fetometry revealed a lag from the proper values for a gestational period of 2 weeks. According to Dopplerometry: violation of the utero-placental blood flow of the IB degree, violations of the fetal-placental blood flow were not detected. IAI = 12 (normative). CTG is within normal limits. The patient is discharged home.

Delivery in the period 38-39 weeks. A live full-term girl was born, weighing 2440, growing 48 cm. The Apgar score is 8/8 points. Extract for 5 days in satisfactory condition with the child. In this example, the values Ka = 47 reflect the initial stage of vascular disorders and a mild degree of endothelial dysfunction and dictate the need to monitor the state of the uteroplacental complex by Doppler and CTG.

The prognosis for timely treatment according to the proposed method (with Ka is greater than 10, but less than 50), aimed at improving the rheological properties of blood and increasing blood flow, is favorable for life and health of the fetus.

Example 3

Pregnant J., 21 years old, enters the Department of Pregnancy Pathology with a direct diagnosis:

Pregnancy 36 weeks. Head presentation. Chronic placental insufficiency. SZRP 2 degrees.

The survey revealed a discrepancy between the data of ultrasound fetometry gestational age of 3 weeks. According to Dopplerometry: a violation of the uteroplacental blood flow of the II degree, a violation of the fetal-placental blood flow of the IIA degree. IAI = 8 (low water). CTG is within normal limits.

Ka = 83.

A clinical diagnosis is made:

Pregnancy 36 weeks. Head presentation. Chronic placental insufficiency. SZRP 2 degrees. Moderate oligohydramnios.

Assigned treatment and follow-up according to the proposed method with Ka more than 50, but less than 100.

In the period of 37-38 weeks, during follow-up examination:

ultrasound fetometry data: lag for 2 weeks. According to Dopplerometry: violation of the utero-placental blood flow of the IA degree, violations of the fetal-placental blood flow of the IB degree. IAI = 12.4 (normative). CTG is within normal limits. Ka = 64. The patient is offered an extract.

Ka = 83 reflects the average degree of endothelial dysfunction, a decrease in compensatory-adaptive mechanisms and dictates alertness and the need for dynamic observation to prevent the transition of placental insufficiency to a more severe form and the occurrence of perinatal complications.

Example 4

Pregnant A., 37 years old, enters the department of pregnancy pathology with complaints of worsening fetal movements.

The survey revealed a discrepancy between ultrasound fetometry data to gestational age - a delay of 2-3 weeks. According to Dopplerometry: a violation of the uteroplacental blood flow of the II degree, a violation of the fetal-placental blood flow of the IA degree. IAI = 13.5 (normative). CTG is within normal limits. Laboratory data within acceptable limits.

Ka = 147, which indicates deep vascular disorders and severe endothelial dysfunction. Compensatory-adaptive mechanisms are on the verge of decompensation, therefore, daily monitoring of the status of the feto-placental complex is necessary.

Based on the results of the examination, the following clinical diagnosis was made:

Pregnancy 33 weeks. Pelvic presentation. Chronic placental insufficiency. SZRP 2 degrees.

Assigned treatment and follow-up according to the proposed method (with Ka more than 100, but less than 150). Prevention of RDS of the fetus with dexon according to the scheme was carried out.

In a period of 33-34 weeks According to Dopplerometry: a violation of the uteroplacental blood flow of the III degree, a violation of the fetal-placental blood flow of the IIB degree. CTG - 2 type. IAJ - 8 cm.

Control Ka = 171, which reflects deep vascular disorders in a state of decompensation and the failure of compensatory mechanisms. An active tactic is being developed that requires early delivery after the prevention of RDS or preparation of the birth canal under close monitoring of the functional state of the fetus. The patient made K / S urgently.

A living premature girl, weighing 1850, and a height of 45 cm with signs of morphofunctional immaturity was recovered. The Apgar score is 6/8 points. Amniotic fluid - meconium (++), pronounced water shortage. The newborn was delivered to the intensive care unit, on the 5th day of life was transferred to the children's department. Discharged on the 15th day of life in satisfactory condition.

Example 5

Pregnant J., 23 years old, enters the department of pregnancy pathology with complaints of worsening fetal movements.

The survey revealed a discrepancy between the data of U3-fetometry and gestational age - a delay of 2-3 weeks. According to Dopplerometry: violation of the uteroplacental blood flow II degree, violations of the fetal-placental blood flow 1A degree. IAI = 9 (moderate oligohydramnios). CTG is within normal limits. Laboratory data within acceptable limits.

Ka = 172.

A clinical diagnosis is made:

Pregnancy 33-34 weeks. Head presentation. Chronic placental insufficiency. SZRP 2 degrees, symmetrical shape. Moderate oligohydramnios. The patient undergoes prophylaxis of RDS of the fetus with dexon according to the scheme and early delivery is offered, which the patient categorically refused. Against the background of active treatment and dynamic observation on the 2nd day, antenatal fetal death was recorded.

This example demonstrates the need to strictly follow the proposed pregnancy management tactics.

Claims (1)

A method for choosing the management tactics for pregnant women with placental insufficiency (PN) and fetal growth retardation syndrome (FPS), which includes determining the angiogenic factors sFlt-1, a soluble fms-like tyrosine kinase and PIGF, a placental growth factor, in the blood of a pregnant woman with PN and FSR, calculating the angiogenic coefficient (Ka) according to the formula: Ka = sFlt-1 / PlGF × 10 and the choice of tactics for further pregnancy management by the value of the angiogenic coefficient; at the same time, if Ka is less than or equal to 10, the pregnant woman does not need hospitalization, does not require dynamic monitoring, visits to the doctor of the antenatal clinic are carried out according to the plan; in the event that more than 10, but less than 50, the pregnant woman is hospitalized in a hospital; conduct cardiotocography (CTG), dopplerometry, determination of the amniotic fluid index (IAI); carry out treatment aimed at improving the uteroplacental blood flow within 10 days, while the infusion volume is 400 ml per day, the drugs of choice are actovegin, trental, instenon, carnitine chloride; after 2 weeks, control ultrasound, Doppler examination, CTG, IAH, control of the angiogenic coefficient are carried out; in the absence of negative dynamics, a pregnant woman is prescribed; in the event that Ka is greater than or equal to 50, but less than 100, the pregnant woman is hospitalized in a hospital, CTG, dopplerometry, IAH are performed; carry out treatment aimed at improving the uteroplacental blood flow within 14 days, while the infusion volume is 800 ml per day, the drugs of choice are actovegin, trental, instenon, carnitine chloride; carry out control dopplerometry and CTG once every 3 days, after 2 weeks - control Ka; with positive dynamics, discharge is possible, in the absence of dynamics - continued treatment for 2 weeks; in the event that Ka is greater than or equal to 100, but less than 150, the pregnant woman is hospitalized in a hospital, CTG, dopplerometry, IAH are performed; carry out treatment aimed at improving the uteroplacental blood flow within 14 days, the amount of infusion is at least 800 ml per day, the drugs of choice are the same; additionally injected drugs aimed at correcting hemostasis - fraksiparin, fragmentin, clexane to choose from; Dopplerometry and CTG monitoring daily, with oligohydramnios daily IAI control; up to 34 weeks, prophylaxis of fetal RDS is performed - Dexon 24 mg according to the scheme: 6 mg every 12 hours No. 4; after 2 weeks of treatment - mandatory control of Ka; with positive dynamics, discharge is possible, in the absence of dynamics - continued treatment for 2 weeks; in the event that Ka is greater than or equal to 150 - with a gestational age of up to 34 weeks, the treatment tactics are the same as with Ka from 100 to 150, but control Dopplerometry, CTG, IAH 2 times a day; in the absence of dynamics of fetal weight gain within 2 weeks of treatment or with a deterioration in the functional state of the fetus, caesarean section; with a gestational age of 34-36 weeks - the treatment and observation tactics are the same as with a term of up to 34 weeks, except for the prevention of fetal RDS, but with a deterioration in the nature of fetal movements or a deterioration in the functional state of the fetus according to CTG or dopplerometry - cesarean section; with a gestational age of more than 36 weeks and Ka values greater than or equal to 150 - early delivery.