Article Type : Research Article
Authors : Aslonova MJ
Keywords : Fetal growth restriction syndrome; Dopplerometry; Middle cerebral artery; Umbilical artery
The
article presents the effectiveness of doppler imaging for assessing blood flow
in large vessels, including the umbilical, uterine artery and middle cerebral
artery. 90 women were examined in the second trimester, and 45 women showed
signs of fetoplacental insufficiency, such as fetal growth restriction syndrome
at 28-34 weeks. The study of utero-placental-fetal
blood flow allows timely detection of early signs of a violation in the
fetoplacental system and its timely correction.
Today, fetal growth restriction syndrome (FGRS) is one
of the most important problems of modern obstetrics, which plays an important
role in the manifestation of perinatal diseases andfatal outcomes. Fetal growth
restriction syndrome occurs with a frequency of 5 to 22% among full-term
infants and 18 to 24% among premature infants. According to the World Health
Organization, "...the incidence of fetal growth retardation syndrome in
Central Asia is 31.1%, in the USA - 10-15%, in Russia - 2.4-17%...” It is often
believed that non???????????-gestation and fetal growth restriction syndrome
are associated with the presence of common pathogenetic mechanisms in
development). [1-13]. A number of studies are being conducted around the world
regarding forecasting issues, to identify its causes and the consequences that
come from it, as well. Aspects for identifying the causes of FGRS –rearly
detection of them, using highly sensitive laboratory tests for both diagnosis,
and screening. Therefore, early diagnosis and treatment of fetal growth
restriction syndrome, especially the development of prevention methods for
specialists in this field, remains poorly understood and controversial [14,15].
Fetal growth restriction syndrome is an important risk factor for neonatal and
post-neonatal death. The mortality rate of children with this pathology is 3-10
times higher than in new-borns with normal development, which increases the
risk of stillbirth in young children by 8 times. Epidemiological studies
confirm that a number of changes in the blood coagulation system, such as
maternal thrombophilia in 40-75% of cases, lead to the development of
pathogenetic mechanisms of pregnancy aggravation, including fetal loss syndrome
in 39.1% of cases?????, 11, 5 %, retrochorial hematoma in 11.5 %, premature
detachment of the normally located placenta in 13.6%, complications in the form
of thromboembolism during pregnancy and the postpartum period) [16,17].
To develop criteria for predicting the
development of fetal growth restriction syndrome based on the determination of
ultrasound and Doppler markers.
In order to solve the identified problems, 120
pregnant women with a gestation period of 24-36 weeks were examined. All
examined women were divided into 2 groups: the main group, 90 pregnant women,
with FGRS, the control group consisted of, and 30 pregnant women with a
physiological course of the antenatal period. During the study, on the basis of
the research department of the Bukhara State Medical Institute, the Bukhara
Regional Screening Centre, the Department of Obstetrics and Gynaecology and the
research was conducted in the Bukhara city maternity complex. Melody (ultrasound and Doppler) in the
regional screening centre, as well as maternity hospitals and private clinics
in Bukhara.
The average age of pregnant women in the main group was 26.78 ± 0.63 years, in the control group-26.20 ± 0.9 years (ranged from 19 to 37 years) (p < 0.05). Analysis of the obtained data on the place of residence of pregnant women showed that 46 patients (51.1%) of the main group live in cities (mainly urban), 44 (48.9%) - in rural areas. In the control group, data close to the above were obtained: 16 women lived in the city (53.3%); in rural areas – 14 (46.7%). The reproductive function of pregnant women included in the study was evaluated taking into account the number of pregnancies in the anamnesis and their outcome. When analysing the ratio of pregnancies with FGRS during pregnancy, it was found that this pathology significantly develops in women who had multiple pregnancy (16% vs. 1% in the control group, p<0.05). In the study of obstetric history of women with a history of FGRS, miscarriage (10% vs. 1% in the control group, p<0.05), preterm birth (11.6% vs. 3.3% in the control group, p <0.05) and FGRS (22% vs. 1% in the control group, p<0.05) previous pregnancies were reliably recorded.
Table
1: Comparison
of fetometric parameters (mm) in the examined women.
Pregnancy period |
Indicator |
Main group |
Control group, n = 30 |
||
I degree, n = 34 |
II degree, n = 42 |
III degree, n = 14 |
|||
28 |
BPR |
69,75±0,1,8767,5,1,87? |
±2,3461,75? |
±0,05** |
70,85±3,06 |
CH |
256,75±4,72? |
243,1,15±2,14*** |
236,8383±0,04** * |
264.05±5.13 |
|
CA |
226,0±2,05*** |
219,0±2,24*** |
209,6,6±0,6*** |
236,95±1,07 |
|
LF |
52,6,6±1,3951,0? |
±0,53* |
48,3,3±0,3*** |
53,65±1,22 |
|
32 |
BPR |
79,21±2,77? |
77,21±1,474? |
75,45,45±0,7,78* |
80.20±2.08 |
CH |
GAS
293,00±5,829? |
290,12,12±2,5,592? |
288,23,23±3,02297,45? |
±3,62 |
|
CA |
level
261,65,65±3,2727*** |
259,21±3,92*** |
251,06,06±4,14*** |
278,40±1,84 |
|
LF |
62,15,15±1,6760,68,67? |
±1,0958,68? |
58±1,5* |
63,00±1,26 |
|
36 |
BPR |
85.90±1.49849? |
82.14,14±1,3535*** |
81,75,75±1,29*** |
87,61±0,8585 |
CH |
318,0±2,493? |
309,9,9±3,84*** |
301,11±2,2*** |
320,48±1,2 |
|
CA |
level
297,21±2,12*** |
289,13,13±2,86** |
281,61,61±3,83*** |
319,70±2,31 |
|
LF |
67.58±1.226? |
66,1,18±0,64*** |
65,12,12±0,64*** |
69,87±0,7979 |
|
Note:
- P0. 05; *- P0. 05; **-P0. 01; ***-P0. 001; significance of differences in
indicators in patients of the compared group with the control group |
Table
2:
Ultrasound markers in the study groups.
? |
Indicator no |
Main group |
Control group, n = 30 |
||||||||
I degree, n = 34 |
II degree, n = 42 |
III degree, n = 14 |
|||||||||
Abs. |
% |
Abs. |
% |
Abs. |
% |
Abs. |
% |
||||
1. |
Buccal
index <10 mm |
8 |
23,5% |
30 |
71,4% |
14 |
100% |
0 |
0 |
||
2. |
Cephalic
Index <71% |
1 |
2,9% |
5 |
12% |
3 |
21,4% |
1 |
3,3% |
||
3. |
Cephalic
Index> 87% |
1 |
2,9% |
4 |
9,5% |
4 |
28,5% |
2 |
6,7% |
||
Table
3:
Doppler parameters in the middle cerebral artery of the fetus in the main and
control groups.
Pregnancy period |
Indicator |
Patient group |
|
Control group
|
Main group |
||
28 |
SDR |
6.57±0.42 |
5.06±0.3232* * |
IR |
0.84±0.03 |
0.80±0.03PI? |
|
PI |
2.0±0.15,15 |
1.54±0.0707** |
|
32 |
SDR |
7.81±0.2323 |
4.68±0.2828*** |
IR |
0.85±0.01 |
0.78±0.03* |
|
PI |
2.07±0.0909 |
1.68±0.0909* * |
|
36 |
SDR |
5.33±0.2424 |
4.87±0.22IR |
IR |
0.79±0.02 |
0.78±0.02PI |
|
PI |
1.76±0.07 |
1.70±0.0808? |
|
Note: - P0. 05; *- P0. 05; **-P0. 01;
***-P0. 001; significance of differences in indicators in patients of the
compared group with the control group |
Table
4:
Clinical and laboratory data of pregnant women with SORP.
Indicator |
Main group (n = 90) |
Control group (n = 30) |
Ppothrombin
index, % |
76,2±4,4** |
95,6±1,88 |
Fibrinogen value , g / l |
5.2±0.12,12** |
3.1±0.0909 |
Activated partial thromboplastin time (APTT) |
22.1±3.2* |
25.8±1.11 |
D-dimer,
ng/ ml |
1170.2±58.4** |
639.5±23 |
Ferritin,
ng/ ml |
66.6±5.84** |
87.6±2.02 |
S-reagent protein, mg / l |
12.1±0.6** |
5.7±0.72 |
Note: *- P0. 05; **- P0. 001;
significance of differences in indicators in patients of the compared group
with the control group |
The study groups were similar in other indicators of
obstetric history. Analysis of the structure of gynecological diseases in the
examined women showed that in the main group, pelvic and genital inflammatory
diseases (endometritis, colitis)were common respectively, in 34 (37.8%) and
uterine fibroids in 14 (15.5%) women. The medical history of the examined women
showed the presence of various somatic diseases. Somatic diseases such as
anaemia (95%), varicose veins (30%), urinary tract infections (4%), and chronic
arterial hypertension (13%) were detected more frequently in the main group
than in the control group (p<0.05). Thus, when studying the medical history
of the examined patients, the most important risk factors for the development
of FGRS in pregnant women are a burdened history of obstetrics and gynecology,
as well as a high frequency of somatic pathology. Ultrasound examination was
mainly performed in 90 pregnant women of the main group, who were divided into
3 subgroups depending on the level of FGRS. Using ultrasound fetometry, we
observed the development of the fetus and determined its size in 4 weeks from
the 28th week. The data obtained during fetometryare shown in (Table 1). As can be seen from Table 1, significant
differences were found between the values of abdominal circumference (CA) and
femoral bone length (LF) in fetal women of the main and control groups during
the entire third trimester of pregnancy. Thus, the value of CA in the fetus of
the main group of pregnant women was 5.5% lower than in the fetus of the
control group at 28 weeks, by 7% - at 32 weeks and by 11% - at 36 weeks. -legal
age. LF values in fetuses of the main group of pregnant women were 5% lower
than in fetuses of the 28-week control group, 4 % — in 32-week — olds, and 3%-in
36-week-olds. Then we compared the estimated fetal weight in pregnant women of
the main and control groups, which was calculated on the basis of ultrasound
fetometry data. This analysis showed that 63 (70%) out of 90 patients in the
main group had fetal hypotrophy detected by ultrasound fetometry: 29 (32%) had
a symmetrical shape, and 61 (68%) had an asymmetric shape. To optimize the
antenatal diagnosis of FGRS in the fetus, we developed ultrasound markers, and
then evaluated their effectiveness in the diagnosis of: The frequency of detection by ultrasound markers in
the clinical groups was as follows (Table 2). A head index <71% indicated a
dolichocephalic shape of the fetal head and was found in 9 (10%) cases in the
main groups, while a head index >87% was found only in 9 (10%) cases in the
main groups. brachycephalic shape of the fetal head. Therefore, these indicators are not effective
for FGRS. In addition, in the control group, more than 87% were detected in 2
(6.7%) cases and less than 71% in 1 (3.3%) case, which can be explained by the
constitutional specifics of the skull configuration in fetuses. The main groups
showed an increase in the number of ultrasound markers with an increase in the
severity of FGRS, as well as an increase in the number of pregnant women with
different ultrasound markers. This is largely due to the fact that the buccal
index is less than 10 mm (in pregnant women with grade I FGRS - 8 (23.5%),
grade II - 30 (71.4%), and in the group with grade III FGRS - 100% of pregnant women).
A decrease in the buccal index is associated with immaturity of subcutaneous
fat in fetuses with FGRS, and placental hypoplasia is associated with placental
insufficiency. Ultrasound specificity of the placenta in the analyzed small
groups is shown in (Figures 1-3).
Figure 1: Pregnant N. (birth history No. 1890). Diagnosis: Pregnancy II 33.4 weeks. FGRSII II degree. Circulatory? blood circulation disorders of the fetoplacental system are 2b degrees. The buccal coefficient is 8 mm.
Figure 2: Data of ultrasound placentography in examined pregnant women.
Lack of water was detected in 3 (8.8%)
pregnant women with grade I, 10 (23.8%) pregnant women with grade II, and 6
(42.8%) pregnant women with grade III. The amniotic fluid index (AFI) was
moderate: from 5 to 8 cm in grade I, from 2 to 5 cm in grade II, and less than
2 cm in grade III. In group I, it was moderate from 5 to 8 cm, in group II from
2 to 5 cm, in group III it was less than 2 cm. In the main groups, placental
calcifications were observed in 32 pregnant women (35.6%). At the same time,
the level of placental maturation was corresponding in all pregnant women with
FGRS of the first degree, in pregnant women with FGRS of the third degree-in
half of all cases, it’s premature "aging" was noted, and in pregnant
women with FGRS of the second degree - 14 (33.4%) did not meet the deadline,
and in 11 (78.6%) there were cases of premature "aging" and in 3
(21.4%) cases - morph functional insufficiency. In most cases, a combination of
several exographic features was observed. In the individual analysis, changes
in placental thickness, placental cysts, premature maturation and
"aging" were observed in 10 cases (71.4%) in a small group with grade
III FGRS. as well as a combination of exographic signs such as calcification.
Of 42 women with grade II FGRS, 36 pregnant women (85.7%) were characterized by
a combination of symptoms such as premature maturation and "aging",
calcification, low and placental density. However, the most important
echographic marker of grade II-III FGRS was placental thickness. Thus, placental
hypoplasia was 1.4 times more common in patients with severe FGRS than in
subgroups I and II.
Figure 3: Hemodynamic disorders of the fetoplacental complex (UA, PA) on Doppler analysis.
On the contrary, the placental size
thickening was 2.3-2.5 times greater in grade II–III FGRS than in group I and
control. This may be due to the peculiarities of the formation of placental
compensatory mechanisms. Simultaneously with fetometry in pregnancy dynamics,
all patients underwent Doppler studies of blood flow in the main arteries of
the mother-placenta-fetus functional system (uterine artery, umbilical artery
and fetal midbrain), as well as Doppler evaluation. In the main group of women,
we analyzed their occurrence due to the fact that hemodynamic disorders in the
arteries of the functional mother-placenta-fetus system were observed at
different levels. Of the 39 pregnant women of the main group, 12 (13.3%) had no
hemodynamic disorders of placental circulation at the time of the study, but
according to ultrasound fetometry, hypotrophy was noted in the fetuses of these
patients. Grade me hemodynamic disorders were observed in 34 (43.6%) patients,
including fetal hypotrophy in 11 (32.4%) patients. Grade II hemodynamic
disorders were detected in 21 (26.9%), of which fetal hypotrophy was noted in
10 (47.6%), grade III hemodynamic disorders were detected in 11 (14.1%), of
which fetal hypotrophy was detected in 8 (72.7%), acute circulatory
disorders-in 12 (15.4%), of which 10 (83.3%) patients had atrophy (Fig. 4). We started
our analysis of the results of a placental blood flow Doppler study by
comparing vascular resistance indicators in the main arteries. According to the
results of a Doppler study of blood flow in the uterine arteries in pregnant
women examined in the third trimester, the values of systole of diastolic ratio
(SDR), resistance index (IR), pulsation index (PI) in the uterine arteries of
the main group of patients in all the studied periods were significantly higher
compared to these values in pregnant women of the control group. In the main
group, 6 pregnant women had severe violations of fetal blood flow in the period
from 32 to 36 weeks of gestation. In these disorders, the SDR in the umbilical
artery has no mathematical significance, and since the IR is always equal, only
PI is shown. In the main group, the average PI of the umbilical artery was 2.16
± 0.15 (p < 0.05) in patients with acute fetal blood flow disorders.
According to Doppler measurements in the umbilical arteries of patients in the
main group, SDR was 42-61%, IR - 16-39%, and PI - 33-98% higher than in
pregnant women in the control group. Doppler blood flow in the middle cerebral
artery in the fetus of the examined pregnant women showed a significant
decrease in these indicators compared to the control group in the main group of
women (Table 3). To identify signs of
centralization of fetal-placental blood flow, we calculated the
cerebral-placental ratio (CPR), which is a division of the resistance index
values in the fetal midbrain artery and the umbilical artery. CPR = RI (middle
cerebral artery) / RI (umbilical artery) CPR values differed at all time
periods calculated based on the results of the study of fetal-placental
circulation in the main group of patients and in the control group of patients.
So, at 32 weeks in the fetus of the main group of patients, its decrease was
revealed by 13%, at 36 weeks-by 15%. Thus, different indicators of placental
circulation-from the first to the acute level-were observed with the same
frequency in fetuses of the main group of pregnant women. In the main group of
pregnant women, the indicators of vascular resistance in the uterine arteries
and umbilical cord arteries were higher compared to pregnant women in the
control group. Doppler parameters of blood flow in the middle cerebral artery
in the fetus of pregnant women in the main group were lower than in the control
group. The results of the hemastasiogram are presented in Table 4, which
clearly shows a significant increase in the main indicators such as fibrinogen
a, D-dimer, APTT (Table 4). With elevated fibrinogen and APTT values, we
decided to assess the degree of D-dimer hemostasis disorder, which is the most
reliable indicator. D-dimer was also high in women with FGRS, especially in
those who had a complicated course -hypertensive disorders, preeclampsia of
varying degrees, and exacerbation of extra genital pathology, with varicose
veins of various localization. Out of 90pregnant cats, we tested the D-dimer
with a double analysis of fibrinogen over 5 g/l, and the results did not always
show violations in the last marker. From this, it should be noted that with low
rates offibrinosis not with SORP, we still recommend that the degree of
hemostasis disturbance should be evaluated with a D-dimer, which is the most
sensitive and specific for such complications. Thus, the study of the
hemostatic system revealed some deviations: pregnant women with FGRS had a
violation of the blood clotting process. Changes in the hemostatic system were
significantly higher (P<0.05). An increase in the level of fibrinogen, C -
reactive protein has a clinical effect. In severe cases, the level of D dimer
increases significantly, which is a potential risk factor and grounds for an
unfavorable prognosis.