RU2741730C1 - Method for prediction of the risk of developing severe complications of preeclampsia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to obstetrics, gynecology and clinical laboratory diagnostics, and can be used for prediction of risk of developing severe complications of preeclampsia by means of laboratory blood analysis. Blood serum of the pregnant woman with hypertensive disorders is examined for the neurotrophic cerebral factor (BDNF) concentration. If its value is equal to or higher than 11.1 ng/ml, a high risk of a severe complication of preeclampsia - HELLP-syndrome is predicted. If the value is less than 11.1 ng / ml, a low risk of developing HELLP syndrome.

EFFECT: method provides higher sensitivity and specificity of predicting the development of HELLP syndrome, reduced labor input, availability for conducting in any laboratory by determining concentration of BDNF, which reflects the characteristics of the process of compensating the nervous system and vasa nervorum endothelium in response to the injury, besides, the balance of the neurotrophin / receptor / vascular growth factor system has a high prognostic significance with respect to the HELLP syndrome determination.

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Description

The invention relates to medicine, namely to obstetrics and gynecology, clinical laboratory diagnostics, and can be used for timely prediction of the risk of developing severe complications of preeclampsia during pregnancy, namely HELLP syndrome.

Preeclampsia is a multisystem pathological condition that occurs in the second half of pregnancy (after the 20th week), characterized by arterial hypertension in combination with proteinuria (> 0.3 g / L in daily urine), often, edema, and manifestations of multiple organ (polysystem dysfunction) failure. Preeclampsia occurs in 4-8% of pregnant women and is one of the leading causes of maternal mortality worldwide [Amin S.V., 2014, Anderson U.D., 2015]. More often, preeclampsia is observed in the third trimester of pregnancy [Makarov OV, Tkacheva ON, Volkova EV, 2010]. In addition, due to the severity of preeclampsia and the associated frequent early delivery, there is an increased morbidity in newborns [Jillian T. Henderson, 2017].

Severe complications of preeclampsia include HELLP syndrome (Hemolysis - free hemoglobin in serum and urine, Elevated Liverenzimes - an increase in the level of ACT, ALT, Low Platelets - thrombocytopenia), accompanied by a syndrome of multiple organ failure, which is manifested by acute renal failure, pulmonary edema, acute cerebrovascular accident circulation, myocardial infarction, disseminated intravascular coagulation syndrome.

In routine practice, clinical laboratory methods are used to diagnose preeclampsia and its complications: general clinical blood test, biochemical blood test, general urinalysis. Disadvantages of these methods: they allow to identify changes in indicators only when complications occur, the methods are not specific and prognostic.

Late verification of the diagnosis leads to the inevitable progression of the disease, an increased risk of developing severe lesions of internal organs with the formation of persistent disability and disability, as well as a high risk of intrauterine fetal death.

All this necessitates the development of publicly available methods for the timely forecasting of the development of severe complications of preeclampsia.

There are methods for preclinical diagnosis of gestosis (preeclampsia). These include an immunological method that allows you to determine the cytotoxicity index of endothelial antibodies and the activity of paired glycolytic enzymes in peripheral blood monocytes. Their increase in the second and third trimesters of pregnancy by 2-3 times in relation to physiological occurs 1-2 weeks before the clinical manifestations of severe gestosis [V.A. Melnikov et al. New criteria for early diagnosis and prediction of severe forms of gestosis. Topical issues of obstetrics and gynecology. T1] No. 1, 2002, p. 53]. Disadvantages: the complexity of the implementation of the technique, the need to examine patients in dynamics, the method does not take into account the genesis of other hypertensive disorders during pregnancy.

A known method for predicting severe forms of gestosis (preeclampsia) by studying the state of cell membranes. In pregnant women with high rates of Na + -L + -protivotransport (more than 500 μM Li per hour), the risk of developing such forms of gestosis increases 2.5 times [I.F. Fatkullin et al. The functional state of cell membranes as a predictor of the development of preeclampsia. Obstetrics and Gynecology No. 4, 2007, p. 19-23]. Disadvantages of the method: laboriousness, high cost, duration in terms of execution time, specificity and sensitivity are unknown.

A known method for predicting preeclampsia in the second trimester of pregnancy by determining the activity of acidic and neutral proteinases in the blood serum of women at 7-8 weeks of pregnancy [Pogorelova T.N., Linde V.A., Gunko V.O., Krukier I.I., Selyutina S.N., Drukker N.A. Method for predicting preeclampsia in the second trimester of pregnancy, RF Patent 2552931 dated 06/10/2015]. Disadvantages: the method is not specific for hypertensive complications of the third trimester, which occur 4-5 times more often.

There is a method for predicting the development of preeclampsia (preeclampsia), based on the determination of the level of neurospecific enolase and gliofibrillar acidic protein in blood serum by ELISA method from 22 weeks of gestation. With the value of neurospecific enolase above 12.4 ng / ml and gliofibrillar acidic protein above 4 ng / ml, the development of gestosis is predicted. The authors also predict severe preeclampsia (severe preeclampsia) with a neurospecific enolase value of 19 ng / ml and above and a glyofibrillar acidic protein of 10 ng / ml and above [Sidorova I.S., Dmitrieva T.B., Turina O.I., Galinova I. .L. Method for predicting the development of preeclampsia, RF Patent 2304783 dated 20.08.2007]. Disadvantages of the method: the specificity and sensitivity of the methods are not known, the high cost of carrying out, since two expensive laboratory reagents are used to obtain the results.

As a prototype, we used a method for predicting the development of preeclampsia in late pregnancy, based on the determination of the concentration of biochemical markers metalloproteinase 12 (ADAM 12), and retinol-binding protein 4 (RBP4) in the serum of women at 12-13 weeks of gestation by ELISA [Dubrovin CO. , Mutsalkhanova Yu.S., Pligina E.V. A method for predicting the development of preeclampsia in late pregnancy, patent for invention RU 2691114 dated 06/11/2019]. With RBP4 levels above 87.90 μg / ml and ADAM 12 levels above 2.33 ng / ml, moderate preeclampsia is predicted in the third trimester of pregnancy. The prognosis of preeclampsia with this method is carried out with a sensitivity of 87.5% and a specificity of 85%. The disadvantages of this method include: laboriousness, high cost of the method, determination of preeclampsia only of moderate severity, the impossibility of predicting other hypertensive disorders.

EFFECT: increased sensitivity and specificity of the method for predicting the development of severe complications of preeclampsia, reduced labor intensity, availability for carrying out in any laboratory.

This result is achieved by the fact that the concentration of brain neurotrophic factor (BDNF) is determined in the blood serum of a pregnant woman, and if its value is equal to or higher than 11.1 ng / ml, a high risk of developing severe complications of preeclampsia, namely HELLP syndrome, is predicted, and if the value is below 11.1 ng / ml - a low risk of developing severe complications of preeclampsia.

This method reflects both qualitative and quantitative characteristics of the process of compensation of the nervous system and endothelium of the vasa nervorum in response to damage, due to which it has high sensitivity and specificity. The balance of the neurotrophin / receptor / vascular growth factor system has a high prognostic value in determining severe complications of preeclampsia.

The method is carried out as follows: in a pregnant woman with hypertensive disorders on an empty stomach, venous blood is taken into a standard vacuum tube without coagulant, the sample is defended for 20 minutes at room temperature, centrifuged for 15 minutes at a speed of 3000 rpm, the resulting serum is distributed among the tubes Eppendorf. If necessary, the samples are stored for a long period at a temperature of -30 ° C. An enzyme-linked immunosorbent assay (ELISA) of the "sandwich" type is carried out using test systems for the quantitative calculation of brain neurotrophic factor (SEA011Hu ELISA Kit for Brain Derived Neurotrophic Factor) in peripheral blood serum [Instructionmanual, 1th Edition, July, 2013. Cloud-CloneCorp .USA]. The microplate in the standard kit is adsorbed with biotin-conjugated antibodies specific for BDNF, Trk-B, VEGF. Samples are added to specific wells of the plate. Then avidin conjugated with horseradish peroxidase is added to each well of the plate, incubation is carried out. After adding the enzymatic substrate, the color changes only in the wells containing BDNF, antibodies with biotin and avidin with horseradish peroxidase. The enzymatic reaction is terminated by the addition of a sulfuric acid solution. Optical density is measured photometrically at a wavelength of 450 ± 10 nm. The BDNF concentration in the samples is calculated according to a standard (calibration) curve constructed from the results of analysis with a series of standards. The quantitative BDNF content obtained is expressed in ng / ml.

This method was tested in a study of 78 people with various forms of hypertensive disorders. The comparison group consisted of 11 healthy pregnant women. With the development of severe preeclampsia, HELLP-syndrome, the index of the quantitative content of BDNF in the blood serum is equal or higher than 11.1 ng / ml. The sensitivity of the method was 85%, the specificity was 90% at a significance level of P - 0.03.

Examples of specific applications

Example 1

Pregnant T., 37 years old. Registered about pregnancy at 5-6 weeks. History of rare acute respiratory viral infections. This pregnancy is the third. The first is frozen at 7-8 weeks; the second - urgent delivery at 39 weeks. Gynecological history: multiple myoma of the uterus, ovarian apoplexy on the left. From an early stage, she took folic acid 400 mg, morning 200 mg. BMI 38 kg / m ² ; BP initial 110/80 mm Hg When examining in the first trimester in the general blood count of leukocytes - 3.6 × 109 / l, Hb - 107 g / l, Tr - 320 thousand. took chime. At 37 weeks, intrahepatic cholestasis of pregnant women.

She was admitted for childbirth at 38-39 weeks at the Shurovnya obstetric hospital with a diagnosis of I period of II labor. Hepatosis of pregnant women. Diet-corrected gestational diabetes mellitus. Polyhydramnios. Large fruit. Polymorphism of hemostasis genes. Myoma of the uterus. Delivery by cesarean section. A live full-term girl weighing 4 kg 360 g and a length of 54 cm was born, Apgar score 8/9. The total blood loss was 400 ml. The maximum increase in blood pressure during labor (intraoperatively) is 150/100 mm Hg. Art., protein in urine - 0.74 g / l. Hemoglobin 107 g / l; platelets 320 × 109 / l; ALAT - 78-200 U / l; AsAT-46 - 126 U / l; ALT - 470-510, creatinine 70-101 μmol / l; urea 2.2-4.5 mmol / l. Postpartum HELLP syndrome was diagnosed, hourly magnesia therapy was started, and a course of dexamethasone was started.

Final diagnosis: second delivery urgent. OGA. Severe preeclampsia. HELLP syndrome. Diet-corrected gestational diabetes mellitus. Intrahepatic cholestasis. Polymorphism of hemostasis genes. Myopic astigmatism. PVCRD. Obesity grade 2. Weakness of labor. The release of meconium into the amniotic fluid. Polyhydramnios. Large fruit. Joel-Cohen laparotomy. Emergency cesarean section in the lower segment.

The study of the quantitative content of BDNF in the blood serum of the patient was 30.1 ng / ml, which indicates a high risk of developing a severe complication of preeclampsia - HELLP-syndrome.

Example 2

Pregnant K., 25 years old. Registered about pregnancy at 10 weeks This is the first pregnancy. Somatic pathology: neg. Gynecological diseases: cervical erosion. BMI - 21 kg / m2. Pregnancy: 12 weeks - nonspecific vaginitis (sanitized). 22 weeks - asymptomatic bacteriuria (Kanephron), 25 weeks. - ARVI (mild course, without temperature rise). She was admitted to childbirth at 38-39 weeks in an obstetric hospital of the III level with a diagnosis: I period I urgent delivery. Birth through the natural birth canal. A live full-term girl weighing 2 kg 910 g and a length of 49 cm was born, according to Apgar 7/9 points. The total blood loss was 200 ml. The postpartum period is without complications. The postpartum woman was discharged from the hospital in satisfactory condition.

The final diagnosis: the first delivery is urgent. Episiotomy. Seams.

The study of the quantitative content of BDNF in the blood serum of the patient was 3.7 ng / ml, which indicates that there is no risk of developing a severe complication of preeclampsia - HELLP syndrome, i.e. about the normal course of pregnancy and childbirth.

Example 3

Pregnant K., 25 years old. Registered about pregnancy at 10-11 weeks. This is the first pregnancy. Gynecological history: polycystic ovary syndrome, infertility. Somatic pathology: AIT. Myopia 2 degrees. From an early stage she took folic acid 400 mg, morning 200 mg, potassium iodide. BMI 38 kg / m; BP initial 110/70 mm Hg. Art. Pregnancy: 16-17 weeks - UTI, Candidiasis (pimafucin).

At 32-33 weeks, an obstetric hospital of the III level was admitted with a diagnosis: Pregnancy 32-33 weeks. Proteinuria due to pregnancy. Fetal growth retardation syndrome. Myopia 2 degrees. AIT. Euthyroidism. Blood pressure on admission 120/80 mm Hg. After 2 days, there were complaints of pain in the epigastric region, vomiting. BP 155/100 mm Hg. Art. Protein in urine - 1.97 g / l. Hemoglobin 125 g / l; platelets 104 × 109 / l; ALAT - 59-580 U / l; AsAT - 53-893 U / l; LDH - 470-2176. creatinine 56-86 μmol / l; urea 2-3 mmol / l. Diagnosed with HELLP syndrome, started hourly magnesium therapy, a course of dexamethasone. Delivery by cesarean section. A live premature girl was born, weighing 1 kg 965 g and length 46 cm, according to Apgar 7/8 points. Total blood loss was 400 ml

Final diagnosis: First birth, premature at 33 weeks. OGA. Severe preeclampsia. HELLP syndrome. Myopia 2 degrees. AIT. Euthyroidism. Joel-Cohen laparotomy. Emergency cesarean section in the lower segment.

The study of the quantitative content of BDNF in the blood serum of the patient was 21.6 ng / ml, which indicates a high risk of developing a severe complication of preeclampsia - HELLP-syndrome.

Example 4

Pregnant C, 25 years old. Registered about pregnancy at 8-9 weeks. This is the first pregnancy. Gynecological history: cervical erosion. Somatic pathology: Anemia, diffuse goiter. Euthyroidism. From an early age, she took dyufaston, folic acid, potassium iodide. BMI 33 kg / m; BP initial 110/70 mm Hg. The course of pregnancy: normal. At 39 weeks. The rise in blood pressure to 150/100 mm Hg, was hospitalized in an obstetric hospital of the III level with a diagnosis of Pregnancy 39 weeks. Moderate gestational arterial hypertension. Blood pressure on admission 155/100 mm Hg. Protein in urine 0.11 g / l. After 10 days, spontaneous childbirth. A live full-term boy was born, weighing 3 kg 740 g, length 52 cm, Apgar score 8/9. The total blood loss was 200 ml.

Final diagnosis: First delivery is urgent. OGA. Moderate gestational arterial hypertension.

Prenatal effusion of o / fetal waters (anhydrous period 14 hours). Weakness of labor. Rupture of the vagina, perineum 1 tbsp. Oxytocin reinforcement. EDA. Seams.

The study of the quantitative content of BDNF in blood serum in the patient was 10.9 ng / ml, which indicates that there is no risk of developing a severe complication of preeclampsia - HELLP syndrome.

Example 5

Pregnant 3., 29 years old. Registered about pregnancy at 8 weeks. This pregnancy is the second, the second birth is coming. Gynecological history: endometriosis. Somatic pathology: denies. From an early date she took iodomarin, folic acid, ascorutin. BMI ref. 18 kg / m2 (underweight); BP initial 90/60 mm Hg. Pregnancy: 10 weeks - acute otitis media, nazonex, suprastin was prescribed. 32 weeks - edema of the lower extremities, a rise in blood pressure to 135/90 mm Hg, the diagnosis was made: gestational arterial hypertension, kanephron was prescribed. At 32 weeks. hospitalized in an obstetric hospital of the III level with a diagnosis of Pregnancy 32 weeks. Severe preeclampsia. Acute gastritis? Complaints about vomiting food, loose stools, swelling of the face. Blood pressure on admission is 150/100 mm Hg. Protein in urine 8.3 g / l. Delivery by cesarean section the next day, due to deterioration. Diagnosed with HELLP syndrome. BP 135/85 mm Hg Protein in urine - 4.7 g / l. Hemoglobin 110 g / l; platelets 77-100-84 × 109 / l; ALAT - 53-90-102 U / l; AsAT - 72-106-118 U / l; LDG - 1114-1153. creatinine 87 μmol / l; urea 4-5 mmol / l. A live premature girl was born, weighing 1776 g, 43 cm long, according to Apgar 7/8 points. The total blood loss was 400 ml. Transfer to RANO.

Final diagnosis: Childbirth 2 premature at 32 weeks. OGA. Severe preeclampsia. HELLP syndrome. Joel-Cohen laparotomy. Emergency cesarean section in the lower segment.

The study of the quantitative content of BDNF in blood serum in the patient was 11.1 ng / ml, which indicates a high risk of developing a severe complication of preeclampsia - HELLP-syndrome.

Thus, the use of the proposed method makes it possible to predict the development of severe complications of preeclampsia, namely HELLP-syndrome, in order to carry out timely preventive and therapeutic measures aimed at preserving the health of the mother and child.

Claims (1)

A method for predicting the risk of developing severe complications of preeclampsia using a laboratory blood test, characterized in that the concentration of brain neurotrophic factor (BDNF) is determined in the blood serum of a pregnant woman with hypertensive disorders, and when its value is equal to or higher than 11.1 ng / ml, a high the risk of developing a severe complication of preeclampsia - HELLP-syndrome, and with a value below 11.1 ng / ml - a low risk of developing HELLP-syndrome.