RU2565655C1 - Method for prediction of clinical disproportion in delivery of macrosomic infants - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: gestational age is determined just before the delivery. An ultrasound examination is conducted to measure a foetus's occipitofrontal head circumference, major transverse head diameter, head extension angle between the spine and the occipital lobe, conjugate and transverse diameter of the pelvic inlet. A cephalopelvic disproportion coefficient N is calculated by formula: $$N=\frac{\mathrm{0,1}GA\times (MTD+OFC\times \frac{(180°-HEA)}{100°}\times \frac{(220°-HEA)}{100°})}{(FDEr+TDEr+FDWP+TDWP+FDNP+TDNP+FDEx+TDEx)},$$

wherein OFC is the foetus's occipitofrontal head circumference, MTD is the major transverse head diameter, HEA is the head extension angle between the spine and the occipital lobe, GA is the gestational age, FDEr is the conjugate diameter of the pelvic inlet, TDEr is the transverse diameter of the pelvic inlet, FDWP is the conjugate diameter of the pelvic plane of the greatest dimensions, TDWP is the transverse diameter of the pelvic plane of the greatest dimensions, FDNP is the conjugate diameter of the pelvic plane of the least dimensions, TDNP is the transverse diameter of the pelvic plane of the least dimensions, FDEx is the conjugate diameter of the pelvic outlet, TDEx is the transverse diameter of the pelvic outlet. If the cephalopelvic disproportion coefficient N is 1.0 and more, clinical disproportion is predicted.

EFFECT: method enables providing the more accurate prediction of the clinical disproportion in the delivery of a macrosomic infant by taking into account the gestational age, as well as by using the considerable ultrasonic signs of the above pathology.

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Description

The invention relates to medicine, namely to obstetrics, and can be used to predict clinical mismatch during childbirth with a large fetus.

The rational management of labor in pregnant women with a large fetus is one of the most difficult sections of practical obstetrics, since clinical discrepancy remains the leading cause of birth injuries of the mother and fetus, as well as perinatal mortality and child disability [2]. The prevalence of a clinically narrow pelvis is 1.3-1.7%, which is associated with an increase in the birth rate of a large fetus, as well as the appearance of “erased” forms of an anatomically narrow pelvis [3]. The true frequency of the clinically narrow pelvis is much higher, since this complication is diagnosed only if there are significant degrees of mismatch between the size of the fetal head and the pelvis of the mother, which requires surgical delivery. With the I degree of clinical mismatch, delivery through the natural birth canal is possible. However, in such a case, two factors have a direct damaging effect on the fetus: mechanical, caused by an obstruction from the mother’s pelvis, and intrapartum hypoxia, associated with local and systemic circulatory disorders [1]. In the context of modern obstetric care, hypoxic lesions occurring as a result of a local disturbance in cerebral hemodynamics, due to the nature and degree of fetal configuration, come to the fore [8]. An excessively pronounced configuration of the fetal head leads to compression of the main venous collector of the brain - the sagittal sinus and venous trunks of the cerebral hemispheres [3]. This is accompanied by difficulty or blockage of the venous outflow, progressive intracranial hypertension, hypoxia and cerebral ischemia [2]. Thus, the prediction of clinical mismatch during childbirth by a large fetus determines the probability of not only birth injury, but also intranatal damage to the central nervous system of the fetus [9].

A known method for predicting clinical inconsistencies proposed by V.A. Kramarsky [4], according to which, in order to predict a possible imbalance between the mother’s pelvis and the fetal head, the pelvic cranial index is determined, calculated as the ratio of the biparietal size of the fetal head to half the sum of the direct dimensions of the wide part of the pelvic cavity and exit. With index values less than 0.8, the prognosis of childbirth is favorable, with 0.8-0.83 - borderline, more than 0.83 - there is a high probability of functional inferiority of the pelvis. The method has the following disadvantages: insufficient accuracy of the method due to the fact that only the direct dimensions of two planes of the small pelvis are taken into account, other head sizes and the degree of bending, gestational age are not taken into account.

A known method for predicting clinical inconsistency proposed by Ch.M. Steer [11], according to which the imbalance diagram is determined based on the data of X-ray pelvic and ultrasound. The degree of mismatch is expressed as the difference between the diameter of the circle, which corresponds to the plane of the pelvis, and the diameter of the fetal head. The method has the following disadvantages: insufficient accuracy of the method due to the use of diagnostics by methods with various instrumental errors, the lack of consideration for gestational age.

A known method for predicting imbalances between the pelvis of the mother and the fetal head, proposed by EA Chernukha et al. [7], taken as a prototype, which consists in the fact that on the eve of childbirth, the ratio of the areas of the planes of the small pelvis to the cross-sectional area of the insertion segment of the fetal head (input - K _{1 of the} wide part of the cavity - K ₂ , the narrow part of the cavity - is determined by X-ray pelvic geometry) To ₃ , exit - To ₄ ). With values of Κ ₁ <1.29, K ₂ <1.32, K ₃ <0.66, K ₄ <0.85, a clinically narrow pelvis is predicted.

However, the method has the following disadvantages:

The lack of accuracy of the method due to the lack of consideration for gestational age, since with increasing gestational age, the ability of the configuration of the fetal head gradually decreases [5].

, где ЛЗР - лобно-затылочный размер головки плода, БПР - большой поперечный размер головки, УРГ - угол разгибания головки между позвоночником и затылочной костью плода, СГ - срок беременности, FDEr - прямой размер плоскости входа, TDEr - поперечный размер плоскости входа, FDWP - прямой размер широкой части, TDWP - поперечный размер широкой части, FDNP - прямой размер узкой части, TDNP - поперечный размер узкой части, FDEx - прямой размер плоскости выхода, TDEx - поперечный размер плоскости выхода малого таза, и при коэффициенте плодово-тазовой диспропорции N, равном 1,0 и более, прогнозируют клиническое несоответствие.To improve the accuracy of the method for predicting clinical inconsistencies in childbirth by a large fetus on the eve of childbirth, the gestational age is determined, an ultrasound examination of the fetus is performed [9], which includes the following fetometric indicators: the fronto-occipital size between the epigastric and the occipital tubercle of the fetal head at the level of the visual tubercles, large transverse size the head of the fetus between the most distant points of the parietal tubercles, the angle of extension of the head between the spine and the occipital bone of the fetus, by ultrasound new pelviometry determine the direct size of the entrance plane from the sacrum to the upper inner surface of the symphysis, the direct size of the plane of the wide part of the pelvic cavity from the junction of the vertebrae S2 and S3 to the middle of the inner surface of the symphysis, the direct size of the plane of the narrow part of the pelvic cavity from the top of the sacrum to the lower edge of the symphysis , the direct size of the exit plane of the small pelvis, the transverse size of the entrance plane between the most distant points of the anonymous lines of the pelvic bones, the transverse size of the plane of the wide part of m between the thin plates of the acetabulum, the transverse size of the narrow part between the tops of the sciatic bones, the transverse size of the exit plane of the small pelvis between the sciatic tubercles, calculate the coefficient of fruit-pelvic imbalance N by the formula:

where LZR is the fronto-occipital size of the fetal head, BPR is the large transverse size of the head, URG is the angle of extension of the head between the spine and the occipital bone of the fetus, SG is the gestational age, FDEr is the direct size of the entrance plane, TDEr is the transverse size of the entrance plane, FDWP - the direct size of the wide part, TDWP - the transverse size of the wide part, FDNP - the direct size of the narrow part, TDNP - the transverse size of the narrow part, FDEx - the direct size of the exit plane, TDEx - the transverse size of the exit plane of the small pelvis, and with the coefficient of fruit-pelvic imbalance N equal to 1 , 0 or more, predict clinical mismatch.

The selection of ultrasound criteria for evaluation was carried out on the basis of the analysis of the significance of ultrasound traits in the occurrence of clinical mismatch during childbirth by a large fetus according to the construction of a mathematical model [6] based on regression analysis methods [10].

, где ЛЗР - лобно-затылочный размер головки плода, БПР - большой поперечный размер головки, УРГ - угол разгибания головки между позвоночником и затылочной костью плода, СГ - срок беременности, FDEr - прямой размер плоскости входа, TDEr - поперечный размер плоскости входа, FDWP - прямой размер широкой части, TDWP - поперечный размер широкой части, FDNP - прямой размер узкой части, TDNP - поперечный размер узкой части, FDEx - прямой размер плоскости выхода, TDEx - поперечный размер плоскости выхода малого таза, и при коэффициенте плодово-тазовой диспропорции N, равном 1,0 и более, прогнозируют клиническое несоответствие.The method is as follows: when a pregnant woman enters a prenatal hospitalization, the gestational age is determined, an ultrasound examination of the fetus is performed, the fronto-occipital size between the epigastric and the occipital tubercle of the fetal head is determined at the level of the visual tubercles, the large transverse size of the fetal head is between the most distant points of the parietal tubercles, the angle of extension of the head between the spine and the occipital bone of the fetus, by means of ultrasonic pelviometry determine the direct size of the plane in ode from the cape of the sacrum to the upper inner surface of the symphysis, the direct size of the plane of the wide part of the pelvic cavity from the joint of the vertebrae S2 and S3 to the middle of the inner surface of the symphysis, the direct size of the plane of the narrow part of the cavity of the small pelvis from the top of the sacrum to the lower edge of the symphysis the pelvis, the transverse size of the plane of entry between the most distant points of the anonymous lines of the pelvic bones, the transverse size of the plane of the wide part between the thin plates of the acetabulums, the transverse p the size of the narrow part between the tops of the sciatic bones, the transverse size of the plane of the exit of the small pelvis between the sciatic tubercles, calculate the coefficient of the fruit-pelvic imbalance N by the formula:

where LZR is the fronto-occipital size of the fetal head, BPR is the large transverse size of the head, URG is the angle of extension of the head between the spine and the occipital bone of the fetus, SG is the gestational age, FDEr is the direct size of the entrance plane, TDEr is the transverse size of the entrance plane, FDWP - the direct size of the wide part, TDWP - the transverse size of the wide part, FDNP - the direct size of the narrow part, TDNP - the transverse size of the narrow part, FDEx - the direct size of the exit plane, TDEx - the transverse size of the exit plane of the small pelvis, and with the coefficient of fruit-pelvic imbalance N equal to 1 , 0 or more, predict clinical mismatch.

Example 1. Pregnant N., 29 years old, multiparous, was admitted on July 12, 2014 to the Department of Pregnancy Pathology with a diagnosis of:

Pregnancy 41 weeks. Burdened Obstetric History (OAA). Chronic placental insufficiency, subcompensated form. Chronic intrauterine hypoxia of the fetus. Large fruit. Mixed neurocirculatory dystonia (NCD). H0. Mild gestational anemia. Bacterial vaginosis.

Pregnant when admitted to the hospital, the gestational age is determined = 41 weeks, an ultrasound scan was performed, the following fetometric parameters were determined: fronto-occipital size = 12.5 cm, large transverse size of the fetal head = 10 cm, extension angle of the head between the spine and the occipital bone of the fetus = 110 °, by ultrasonic pelviometry, the following were determined: direct dimension of the inlet plane = 11.0 cm, direct dimension of the plane of the wide part of the pelvic cavity = 12.5 cm, direct dimension of the plane of the narrow part of the pelvic cavity = 11.0 cm, straight the second dimension of the exit plane of the small pelvis = 9.5 cm, the transverse dimension of the plane of entry = 13.5 cm, the transverse dimension of the plane of the wide part = 12.5 cm, the transverse dimension of the narrow part = 10.5 cm, the transverse dimension of the exit plane of the pelvis between = 11.0 cm, the coefficient of fruit-pelvic imbalance N is calculated by the formula:

The coefficient of fruit-pelvic imbalance N is less than 1.0.

Conclusion: Clinical mismatch is not predicted.

07/13/14, a boy was born through the natural birth canal, without injuries and deformities, weighing 4090 g, height 52 cm, with an Apgar score of 8-9 points.

The diagnosis is final:

Delivery at term (at 41 weeks of gestation) by a large fetus. OAA Chronic placental insufficiency, subcompensated form. Chronic intrauterine hypoxia of the fetus. Large fruit. Mixed type NDC. H0. Mild gestational anemia. Bacterial vaginosis.

Flat fetal bladder.

Amniotomy.

Example 2. Pregnant Ch., 25 years old, nulliparous, was admitted on 06/26/14 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. Gestational pyelonephritis, in the stage of latent inflammation. Gestational diabetes mellitus, target HbAlc level less than 6%. Alimentary-constitutional obesity I degree. Hypertension of the I stage, 1 degree, risk 2. CHF ₀ .

Pregnant when admitted to the hospital, the gestational age is determined = 39-40 weeks, an ultrasound scan was performed, the following fetometric parameters were determined: fronto-occipital size = 13.0 cm, large transverse size of the fetal head = 10.5 cm, extension angle of the head between the spine and the occipital bone of the fetus = 100 °, by ultrasound pelviometry determined: the direct size of the entrance plane = 10.5 cm, the direct size of the plane of the wide part of the pelvic cavity = 11.8 cm, the direct size of the plane of the narrow part of the pelvic cavity = 10.6 cm, P pit size of the exit plane of the small pelvis = 8.5 cm, transverse dimension of the inlet plane = 12.9 cm, transverse dimension of the plane of the wide part = 12.2 cm, transverse size of the narrow part = 10.1 cm, transverse dimension of the exit plane of the small pelvis between = 10.0 cm, the coefficient of fruit-pelvic imbalance N is calculated by the formula:

The coefficient of fruit-pelvic imbalance N is more than 1.0.

Conclusion: Clinical mismatch is predicted.

06/29/14, a woman entered into labor, when a uterine pharynx of 8.0 cm was revealed, a clinical narrow pelvis was diagnosed, it was decided to deliver the woman by cesarean section.

06/29/14, through the operation of Caesarean section, a boy was born, without injuries and deformities, weighing 4300 g, height 54 cm, with an Apgar score of 7-8 points.

The diagnosis is final:

Surgical delivery on time (at 40 weeks of gestation) with a large fetus. Edema of the pregnant. Gestational pyelonephritis, in the stage of latent inflammation. Gestational diabetes mellitus, target HbAlc level less than 6%. AKO I degree. Hypertension of the I stage, 1 degree, risk 2. CHF ₀ .

Premature discharge of amniotic fluid. Clinically narrow basin. Papannenstiel laparotomy. Caesarean section in the lower segment of the uterus.

Example 3. Pregnant E., 36 years old, multiparous, was admitted on 02.08.14 to the Department of Pregnancy Pathology with a diagnosis of:

Chronic placental insufficiency, compensated form at 39 weeks of gestation. Low water. Large fruit. Mild gestational anemia. AKO I degree. Chronic gastritis, remission. Chronic pyelonephritis, in the stage of latent inflammation. ΧΒΠ _I.

Pregnant when admitted to the hospital, the gestational age is determined = 39 weeks, an ultrasound scan was performed, the following fetometric parameters were determined: fronto-occipital size = 12.5 cm, large transverse size of the fetal head = 10.5 cm, extension angle of the head between the spine and occipital bone fetus = 105 °, by ultrasound pelviometry determined: the direct size of the inlet plane = 10.5 cm, the direct size of the plane of the wide part of the pelvic cavity = 12.0 cm, the direct size of the plane of the narrow part of the pelvic cavity = 10.9 cm, straight my size of the plane of exit of the small pelvis = 10.5 cm, the transverse size of the plane of entry = 13.0 cm, the transverse size of the plane of the wide part = 12.0 cm, the transverse size of the narrow part = 10.7 cm, the transverse size of the plane of exit of the small pelvis between = 10.8 cm, the coefficient of fruit-pelvic imbalance N is calculated by the formula:

The coefficient of fruit-pelvic imbalance N is less than 1.0.

Conclusion: Clinical mismatch is not predicted.

08/07/14, through a natural birth canal, a girl was born, without injuries and deformities, weighing 4260 g, height 55 cm, with an Apgar score of 9-9 points.

The diagnosis is final:

Delivery at term (at 39-40 weeks of gestation) by a large fetus. Chronic placental insufficiency, compensated form. Low water. Mild gestational anemia. AKO I degree. Chronic gastritis, remission. Chronic pyelonephritis, in the stage of latent inflammation. ΧΒΠ _I.

Primary labor weakness.

Amniotomy. Honey. rhodostimulation with oxytocin.

Example 4. Pregnant B., 21 years old, primogenous was admitted on July 27, 2014 to the Department of Pregnancy Pathology with a diagnosis of:

Pregnancy 40-41 weeks. Chronic placental insufficiency, compensated form. Chronic polyhydramnios. Large fruit. Chronic pyelonephritis, in the stage of latent inflammation. CKD ₀ .

Pregnant when admitted to the hospital, the gestational age is determined = 40-41 weeks, an ultrasound scan was performed, the following fetometric parameters were determined: fronto-occipital size = 12.0 cm, large transverse size of the fetal head = 10.5 cm, extension angle of the head between the spine and the occipital bone of the fetus = 100 °, by ultrasound pelviometry determined: the direct size of the entrance plane = 10.5 cm, the direct size of the plane of the wide part of the pelvic cavity = 12.0 cm, the direct size of the plane of the narrow part of the pelvic cavity = 10.8 cm, P pit size of the exit plane of the small pelvis = 9.0 cm, transverse dimension of the inlet plane = 11.0 cm, transverse dimension of the plane of the wide part = 12.5 cm, transverse size of the narrow part = 11.0 cm, transverse size of the exit plane of the small pelvis between = 10.8 cm, the coefficient of fruit-pelvic imbalance N is calculated by the formula:

The coefficient of fruit-pelvic imbalance N is more than 1.0.

Conclusion: Clinical mismatch is predicted.

07/30/14, through a natural birth canal, a girl was born, without visible injuries and deformities, weighing 4140 g, height 55 cm, with an Apgar score of 7-7 points. The newborn had mild asphyxiation.

The diagnosis is final:

Delivery at term (at 41 weeks of gestation) large fetus. Chronic placental insufficiency, subcompensated form. Chronic polyhydramnios. Chronic intrauterine hypoxia of the fetus. Chronic pyelonephritis, in the stage of latent inflammation. CKD ₀ .

Secondary patrimonial weakness.

Amniotomy. Honey. rhodostimulation with oxytocin. Episiotomy, episiorography.

This method was used in predicting clinical mismatch in childbirth with large fetus in 30 women. The results are presented in the table.

Bibliography

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Claims (1)

A method for predicting clinical mismatch in childbirth with a large fetus, involving pelviometry and fetometry, characterized in that they determine the gestational age, using ultrasound to determine the fronto-occipital and large transverse size of the fetal head, the angle of extension of the head between the spine and the occipital bone of the fetus, straight and the transverse dimensions of the planes of the pelvis, calculate the coefficient of fruit-pelvic imbalance N by the formula:

where LZR is the fronto-occipital size of the fetal head, BPR is the large transverse size of the head, URG is the angle of extension of the head between the spine and the occipital bone of the fetus, SG is the gestational age, FDEr is the direct size of the entrance plane, TDEr is the transverse size of the entrance plane, FDWP - the direct size of the wide part, TDWP - the transverse size of the wide part, FDNP - the direct size of the narrow part, TDNP - the transverse size of the narrow part, FDEx - the direct size of the exit plane, TDEx - the transverse size of the exit plane of the small pelvis, and with the coefficient of fruit-pelvic imbalance N equal to 1 , 0 or more, predict clinical mismatch.