RU2550939C1 - Method of predicting shoulder dystocia in case of foetus macrosomia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: direct size between the most distant points of a presenting segment of the foetus head at the level of the sagittal plane, large transverse size of the foetus head between the most distant points of the parietal tubers, transverse size of the shoulders between the most distant points of the acromial processes and the anteroposterior size of the foetus chest at the level of VII thoracic vertebra and the base of the xiphoid process are determined. A probability coefficient of the foetus shoulder dystocia is calculated by a mathematic formula. Development of the foetus shoulder dystocia is made on the basis of the obtained coefficient value.

EFFECT: method makes it possible to predict the development of the foetus shoulder dystocia due to the evaluation of the significant ultrasonic indices in the foetus.

1 tbl, 4 ex

Description

The invention relates to medicine, namely to obstetrics, and can be used to predict dystocia of the shoulders with macrosomia of the fetus.

For the period from 2000-2010. in Russia, the frequency of birth of a large fetus has significantly increased from 8% to 12%. The rational management of labor in pregnant women with macrosomia of the fetus is one of the most difficult sections of practical obstetrics, since clinical mismatch and dystocia of the shoulders remain the leading causes of birth injuries of the mother and fetus, as well as perinatal mortality and child disability [2]. The prevalence of shoulder dystocia ranges from 0.15 to 1.61% [9]. The frequency of dystocia of the shoulders increases with increasing fetal mass at birth. In the structure of labor by a large fetus, the prevalence of shoulder dystocia is 6.5% [6].

Cases of dystocia of the shoulders are accompanied by increased mortality and a significant number of complications, primarily injuries of the newborn (damage to the brachial plexus - 4-16% of all cases, fractures of the clavicle, humerus, asphyxia) and mother (bleeding, severe rupture of the perineum) [1, 4 ]. Perinatal mortality due to dystocia of the shoulders is 0.5%, the incidence of fetal injuries is 0.42% [7].

A known method for predicting shoulder dystocia proposed by B.Q. Li et al. [12], according to which, with a high duration of the latent phase and active period of labor, a decrease in the rate of cervical dilatation and advancement of the pre-existing part of the fetus, dystocia of the fetal shoulders is predicted. The method has the following disadvantages: insufficient accuracy of the method due to the subjectivity of the assessment, the absence of instrumental criteria for the occurrence of dystocia of the fetal shoulders, the role of the anatomical and physiological characteristics of the mother and the size of the fetus are not taken into account.

A known method for predicting shoulder dystocia proposed by J.L. Kitzmiller [11], according to which computed tomography is performed in women on the eve of childbirth and the width of the shoulders of the fetus is determined. With a shoulder width of more than 14 cm, the occurrence of dystocia of the shoulders of the fetus is predicted. The method has the following disadvantages: insufficient accuracy due to the fact that the size of the fetal head [10], which has passed through the birth canal, is not taken into account, the possibility of displacement of the axis of the shoulders due to mobility in the sternoclavicular joint [3] is not taken into account.

A known method for predicting shoulder dystocia proposed by EA Chernukha et al. [6], taken as a prototype, consisting in the fact that on the eve of childbirth, the direct dimensions of the small pelvis are straightened by X-ray pelvic geometry, the size of the circumference of the fetal chest with the handles is determined by ultrasound, after which the result corresponding to the direct size of the woman's pelvis and chest circumference with handles, compared with statistically verified data and predict on the basis of this the likelihood of dystocia of the fetal shoulders.

However, the method has the following disadvantages:

1. The complexity of the method due to the need for x-ray and ultrasound.

2. The lack of accuracy of the method due to the lack of clear criteria for predicting dystocia of the fetal shoulders and comparing the results of the study exclusively with statistical data.

, где ПР - прямой размер предлежащего сегмента головки, БПР - большой поперечный размер головки, ПЗРГ - передне-задний размер груди плода, ПРП - поперечный размер плечиков, и при коэффициенте вероятности дистоции плечиков плода D менее 0,58 прогнозируют возникновение дистоции плечиков плода.To simplify and improve the accuracy of the method for predicting shoulder dystocia during fetal macrosomia on the eve of childbirth, an ultrasound examination of the fetus is performed [8], which includes the following fetometric indicators: the direct size of the pre-existing segment of the fetal head, the large transverse size of the fetal head, the transverse size of the shoulders and the anteroposterior breast size the fetus, calculate the probability coefficient of dystocia of the shoulders of the fetus D according to the formula:

where PR is the direct size of the pre-present segment of the head, BDP is the large transverse size of the head, PZRG is the anteroposterior size of the fetal chest, PRP is the transverse size of the shoulders, and with a probability of dystocia of the fetal shoulders D less than 0.58, fetal shoulder dystonia is predicted.

The selection of ultrasonic criteria for evaluation was carried out on the basis of an analysis of the significance of ultrasonic features in the occurrence of shoulder dystocia in childbirth according to the construction of a mathematical model [5] and based on regression analysis methods [13].

, где ПР - прямой размер предлежащего сегмента головки, БПР - большой поперечный размер головки, ПЗРГ - передне-задний размер груди плода, ПРП - поперечный размер плечиков, и при коэффициенте вероятности дистоции плечиков плода D менее 0,58 прогнозируют возникновение дистоции плечиков плода.The method is as follows: when a pregnant woman enters a prenatal hospitalization, an ultrasound examination of the fetus is carried out, the direct size between the most distant points of the preceding segment of the fetal head at the sagittal plane is determined, the large transverse size of the fetal head between the most distant points of the parietal tubercles, the transverse size of the shoulders between the most distant points of the acromial processes and the anteroposterior size of the fetal chest at the level of the VII thoracic vertebra and base I of the xiphoid process, calculate the probability coefficient of dystocia of the shoulders of the fetus D according to the formula:

where PR is the direct size of the pre-present segment of the head, BDP is the large transverse size of the head, PZRG is the anteroposterior size of the fetal chest, PRP is the transverse size of the shoulders, and with a probability of dystocia of the fetal shoulders D less than 0.58, fetal shoulder dystonia is predicted.

Example 1. Pregnant Z., 21 years old, primogenous, was admitted on 09.24.13 to the Department of Pregnancy Pathology with a diagnosis of:

Pregnancy 39 weeks. Burdened Obstetric History (OAA). Large fruit. Alimentary-constitutional obesity (AKO) I Art. Endemic nodular goiter of the 1st century, euthyroidism. Neurocirculatory dystonia (NDC) by the hypertonic type. H ₀ .

An ultrasound scan was performed in a pregnant woman at the pregnancy pathology department, the following fetometric parameters were determined: the direct size of the pre-existing segment of the fetal head = 10 cm, the large transverse size of the fetal head = 10 cm, the transverse size of the shoulders = 13 cm, the anteroposterior size of the fetal chest = 10.5 cm. The probability coefficient of dystocia of the fetal shoulders

.

.

Conclusion: at the birth of the shoulder girdle of the fetus, complications are not predicted.

09/27/13, through a natural birth canal a lively full-term boy was born, without visible injuries and deformities, weighing 4050 g, height 52 cm, with an Apgar scale rating of 10-10 points.

The diagnosis is final:

Childbirth in the period of 39-40 weeks of pregnancy with a large fetus. OAA AKO I Art. Endemic nodular goiter of the 1st Art. Euthyroidism. NDC according to the hypertonic type. H ₀ .

Premature discharge of amniotic fluid.

Episiotomy, episiorography.

Example 2. Pregnant G., 28 years old, repetitive was admitted on 12.02.14 to the Department of Pregnancy Pathology with a diagnosis of:

Edema of a pregnant woman at a gestation period of 39-40 weeks. Large fruit. Chronic pyelonephritis, in the stage of latent inflammation. CKD ₀ . Gestational diabetes mellitus, target HbA1c level less than 6%. Nonspecific vaginitis.

An ultrasound scan was performed in a pregnant woman at the pregnancy pathology department, the following fetometric parameters were determined: the direct size of the pre-present segment of the fetal head = 11 cm, the large transverse size of the fetal head = 10 cm, the transverse size of the shoulders = 14 cm, the anteroposterior size of the fetal chest = 11.0 cm. The probability coefficient of dystocia of the fetal shoulders

.

.

Conclusion: at the birth of the shoulder girdle of the fetus, complications are not predicted.

02.16.14, a natural full-term girl was born through the natural birth canal, without visible injuries and deformities, with signs of diabetic fetopathy, weighing 4310 g, 54 cm tall, with an Apgar score of 8-9 points.

The diagnosis is final:

Delivery at 40 weeks of gestation with a large fetus. Chronic placental insufficiency, compensated form. Diabetic fetopathy. Edema of the pregnant. Chronic pyelonephritis, in the stage of latent inflammation. CKD ₀ . Gestational diabetes mellitus, target HbA1c level less than 6%.

Nonspecific vaginitis.

Flat fetal bladder. Amniotomy.

Example 3. Pregnant K., 25 years old, repetitive was admitted on April 22, 2014 to the Department of Pregnancy Pathology with a diagnosis of:

Chronic placental insufficiency, subcompensated form at 39 weeks of gestation. HVUGP. Large fruit. Mild gestational anemia. AKO I degree. Chronic gastritis, remission. Chronic stoneless cholecystitis, remission.

A pregnant woman in the pregnancy pathology department underwent a routine ultrasound examination, the following fetometric parameters were determined: the direct size of the pre-present segment of the fetal head = 9.5 cm, the large transverse size of the fetal head = 9.5 cm, the transverse size of the shoulders = 14.5 cm, front - the posterior size of the fetal breast = 11.0 cm. The probability coefficient of dystocia of the fetal shoulders

.

.

Conclusion: the occurrence of dystocia of the shoulders of the fetus in childbirth is predicted.

04/29/14, through a natural birth canal, a live full-term boy was born, weighing 4340 g, height 55 cm, with an Apgar score of 7-8 points. After the birth of the head, dystonia of the fetal shoulders was diagnosed. To correct dystocia of the shoulders, manual aids were performed. After birth, the baby was diagnosed with a fracture of the right clavicle, moderate neurological symptoms were observed.

The diagnosis is final:

Delivery at 40 weeks of gestation with a large fetus. Chronic placental insufficiency, subcompensated form. HVUGP. Mild gestational anemia. AKO I degree. Chronic gastritis, remission. Chronic stoneless cholecystitis, remission.

The distance of the shoulders of the fetus.

Manual benefit for dystocia of the shoulders of the fetus.

Example 4. Pregnant A., 30 years old, repetitive was admitted 12.12.13, the Department of pathology of pregnancy with a diagnosis of:

Chronic placental insufficiency, subcompensated form at a period of 40-41 weeks of pregnancy. HVUGP. Low water. Large fruit. Chronic pyelonephritis, in the stage of latent inflammation. CKD ₀ .

An ultrasound scan was performed in a pregnant woman at the pregnancy pathology department, the following fetometric parameters were determined: the direct size of the pre-present segment of the fetal head = 9.5 cm, the large transverse size of the fetal head = 9.5 cm, the transverse size of the shoulders = 14.0 cm, anterior - the posterior size of the fetal breast = 11.0 cm. The probability coefficient of dystocia of the fetal shoulders

Conclusion: at the birth of the shoulder girdle of the fetus, complications are not predicted.

12/15/13, through the birth canal, a girl was born, without injuries and deformities, weighing 4400 g, height 56 cm, with an Apgar score of 8-9 points. At the birth of the head, dystonia of the fetal shoulders was diagnosed. To correct dystocia of the shoulders, manual aids were performed.

The diagnosis is final:

Childbirth at 41 weeks of gestation with a large fetus. Chronic placental insufficiency, subcompensated form. HVUGP. Chronic oligohydramnios. Large fruit. Chronic pyelonephritis, in the stage of latent inflammation. CKD _I.

The distance of the shoulders of the fetus.

Amniotomy. Episiotomy, episiorography. Manual benefit for dystocia of the shoulders of the fetus.

This method was used in predicting shoulder dystocia in childbirth in 100 women with fetal macrosomia. The results are presented in the table.

Bibliography

1. Barashnev Yu.I. Key problems of perinatal neurology / Yu.I. Barashnev // Obstetrics and gynecology. - 2007. - No. 5. - S. 51-54.

2. Vlasyuk V.V. Birth injury and perinatal cerebrovascular accident. - St. Petersburg: Nestor-Istoriya, 2009 .-- 252 p.

3. The possibilities of magnetic resonance imaging when choosing a delivery method / A.P. Myagkov, KS. Lutsenko et al. // Materials of the III Russian Forum “Mother and Child” - M. - 2001.

4. Gulchenko OV, Nikiforovsky NK, Pokusaeva V.N., Stas L.I. Obstetric and perinatal outcomes with a large fetus // Russian Bulletin of the Obstetrician-Gynecologist. - 2010. - T. 10. - No. 1. - S. 55-58.

5. Fleman M. Bible Delphi / M. Fleman - St. Petersburg: BHV-Petersburg, 2011. - 686 p.

6. Chernukha EA Anatomically and clinically narrow pelvis / E.A. Chernukha, A.I. Volobuev, T.K. Puchko - M .: Triad-X, 2005 .-- 186 p.

7. Chernukha EA The birth block. - M .: Triad-X, 1999 .-- 533 p.

8. Eberhard Merz. Ultrasound diagnostics in obstetrics and gynecology. In 2 volumes. Volume 1: Obstetrics: Per. from English / Merz Eberhard; under the editorship of A.I. Gus. - M.: MEDpress-inform, 2011 .-- 720 p.

9. Bocken J.A. Shoulder dystocia - malpractice or acceptable risk? // Acta Obstet Gynecol, 2000 .-- P. 750-756.

10. Houchang D, Modanlou HD, Komatsu G, et al. Large for gestational age neonates: Anthropometric reasons for shoulder dystocia // Obstet Gynecol, 1982. - Vol. 60. - P. 417.

11. Kitzmiller J. L., Mall J. C., Gin G. D., et al. Masurement of fetal shoulder width with computed tomography in diabetic women // Obstet Gynecol, 1987. - Vol. 70. - P. 941.

12. Li B.Q., Cong K.J. Abnormal partograph in primipara with vertex presentation. // Chung. Hua. Fu. Chan. Ko. Tsa. Clin., 1994 .-- Vol. 29, N 12. - P. 717-719.

13. Ohman E.M., Granger C. B., Harrington R. A. et al. // JAMA. 2000. - Vol. 284. - P. 876-878.

Claims (1)

A method for predicting dystocia of the shoulders during fetal macrosomia, which involves ultrasound fetometry, characterized in that the direct size of the pre-present segment of the fetal head, the large transverse size of the fetal head, the lateral size of the shoulders and the anteroposterior size of the fetal chest are calculated, and the probability coefficient of dystocia of the fetal shoulders D is calculated by the formula:

where PR is the direct size of the pre-present segment of the head, BDP is the large transverse size of the head, PZRG is the anteroposterior size of the fetal chest, PRP is the transverse size of the shoulders, and with a probability of dystocia of the fetal shoulders D less than 0.58, fetal shoulder dystonia is predicted.