Method for evaluating fetal state and predicting the state in neonatals in case of maternal diabetes mellitus according to circulation values during dopplerometric survey

FIELD: medicine, obstetrics, gynecology.

SUBSTANCE: one should study circulation in one of fetal renal arteries during the second half of third trimester of pregnancy. At increased resistance index from 0.81 and higher and, correspondingly, systolodiastolic ratio - from 5.1 and higher - one should fix the presence of fetal hypoxia and the necessity for urgent correction of this state. The suggested method increases the number diagnostic preparations and enables to increase the significance of predicting the state of neonatals.

EFFECT: higher accuracy of evaluation and prediction.

5 dwg, 5 ex, 1 tbl

 

The present invention relates to obstetrics-gynecology, in particular to the assessment of fetal status in diabetes mellitus mother.

It is known that diabetes is a disease that increases the risk of placental insufficiency, which usually leads to violation of the condition of the fetus and as one of the leading factors that determine the state of the system mother-placental are flowing in her hemodynamic processes, their estimation performed using ultrasound abnormal Doppler waveforms, is of particular importance (R.J. Bradley, Nicolaides K.H., Brudenell J.M., Campbell S. Early diagnosis of chronic fetal hypoxia in a diabetic pregnancy // Brit. Med. J. 1988. V.296. No. 9. P. 94-95).

It is also known that the conduct diplomaticheskogo research in the arteries of the umbilical cord with the definition of the indices of vascular resistance allows you to objectively judge the condition of the fetus at the Board of Directors of the mother (M.V. Fedorov, V. Krasnopolsky, Vladimir Petrukhin VA diabetes, pregnancy and diabetic fetopathy. M: Med., 2001. c.288.).

It was considered that the use of diplomaticheskii assess blood flow in the renal artery is not possible to reliably diagnose hypoxia (P. Sieroszewski, Sabatowska M, Karowicz-Bilinska A., Suzin J. Prognostic Doppler ultrasound examination of fetal arteries blood flow // Ginekol l. 2002. v. 73. No. 8 p. 677-84).

The aim of the invention is to determine the status of the fetus and the prediction condition is a newborn pregnant, suffering from diabetes.

This goal is achieved by the fact that examine the blood flow in one renal artery of the fetus in the second half of the third trimester of pregnancy and at higher index of resistance from 0.81 and more and, accordingly, systolicdiastolic relationship between 5.1 and more - record the presence of hypoxia in the fetus and the need for urgent correction of this condition, and changes in tactics pregnant until its emergency delivery in the interests of the fetus.

Figure 1 presents dopplergram normal blood flow in the renal artery of the fetus in healthy pregnant N.; figure 2 - dopplergram normal blood flow in the renal artery of the fetus in pregnant Century, suffering from diabetes mellitus type I; figure 3 - dopplergram altered blood flow in the renal artery of the fetus in pregnant K., suffering from diabetes mellitus type I; figure 4 - dopplergram altered blood flow in the renal artery of the fetus in pregnant A., suffering from diabetes mellitus type I; figure 5 - dopplergram altered blood flow in the renal artery of the fetus in the pregnant C., suffering from gestational diabetes mellitus.

The claimed invention is illustrated by the following clinical examples.

Example 1.

Pregnant N., 28 years. Before pregnancy somatic pathology, the patient was not identified. This pregnant the spine first, was uneventful. The results of the clinical examination, including laboratory studies (clinical and biochemical blood tests, urinalysis, microscopy research detachable urethra, the canal of the cervix and vagina), is within the physiological norm. At 39 weeks of pregnancy, with the aim of clarifying the status of the foetus, as outpatients at the Department of ultrasound diagnostics CCH no.1. After N.I. Pirogov, Moscow, the patient was given a comprehensive ultrasound examination, including dopplerometrical assessment of arterial blood flow in the system mother-placenta-fetus. Along with the conventional way of assessing fetal status during diplomaticheskii study on indicators of blood flow in the umbilical artery was also conducted assessment of blood flow in one renal artery of the fetus in transverse scanning his body. To assess blood flow in the test vessels was selected index of resistance, as the most commonly used and allows you to accurately judge the changes in hemodynamics. Search fruit of the vessels was carried out using color Doppler mapping. The resistance index in the umbilical artery was 0,54, and in the renal artery of the fetus is 0.71 (see figure 1), indicating a satisfactory condition of the fetus. 40 week berame the activities the patient had spontaneous labor occurred. Born live, full-term girl, in a satisfactory condition, body weight 3550 grams, length 51 cm Estimation on Apgar scale in the first minute of extrauterine life was 9 points.

Thus, the absence of changes in blood flow in the renal artery of the fetus, as well as in the umbilical artery, the result diplomaticheskii assessment indicated a lack of fetal hypoxia, which was confirmed by the subsequent condition of the newborn.

Example 2.

Pregnant Century, 27 years old, is ill with diabetes mellitus type I within 5 years. Before pregnancy for the underlying disease was stable, no complications. This first pregnancy. Diabetes during pregnancy has also been stable. The amount of glycated hemoglobin in its entirety is not exceeded 6.0%. At 38 weeks of pregnancy to clarify the status of the fetus and determine the tactics of pregnant we conducted another comprehensive ultrasound examination, including dopplerometrical assessment in terms of blood flow in the umbilical artery (a common way of assessing the status of the fetus) and in one of his renal arteries. The resistance index in the umbilical artery was 0.73, indicating a fetal suffering of the fetus. However, the resistance index in the renal artery of the fetus amounted to 0.75 (see figure 2)that the light of what was Edelstahl its satisfactory condition. At 38-39 weeks of gestation occurred a spontaneous birth. Born live, full-term girl, in a satisfactory condition, body weight 3320 g, length 50 cm Estimation on Apgar scale in the first minute of extrauterine life was 8 points.

Thus, the absence of changes in blood flow in the renal artery of the fetus, testified to the absence of hypoxia and allowed to predict its satisfactory condition at birth, whereas indicators of blood flow in the umbilical artery indicated fetal suffering of the fetus.

Example 3.

Pregnant K., 20 years old, is ill with diabetes mellitus type I in the last 10 years. Before the pregnancy for the underlying disease was stable, no complications. This first pregnancy. Until the mid-third trimester pregnancy proceeded without features. The amount of glycated hemoglobin did not exceed 6.5 percent. At 34 weeks of pregnancy was marked decompensation of diabetes that was the reason for hospitalization in the Department of pathology of pregnancy clinical hospital №1 named after. N.I.Pirogov for treatment and determine further tactics of treatment of the patient. In the hospital she was held comprehensive ultrasound examination, including dopplerometrical assessment of the fetus in terms of blood flow in the umbilical artery (generally accepted method of assessment PLO is a) and in one of his renal arteries. The resistance index in the umbilical artery was 0.6, the renal artery of the fetus - 0,78. Both indicators testified satisfactory condition of the fetus. The Department was pregnant conducted correction doses of insulin. In the subsequent dynamic diplomaticheskii monitor the condition of the fetus the resistance index in the umbilical artery amounted to 0.62, indicating that its satisfactory condition. The resistance index in the renal artery of the fetus was 0,81 (see figure 3), on the basis of which he concluded that the presence of a hypoxia. Despite therapy aimed at normalizing condition Feto-placental complex, improve the parameters of blood flow in the renal arteries of the fetus has not happened and at 36-37 weeks of gestation in the interests of the fetus was resolved the issue in favor of preterm delivery pregnant. Born alive premature-old girl in serious condition, body weight 3500 g, length 49 see At the birth of the child were reversed signs transferred in utero hypoxia. Estimation on Apgar scale in the first minute of life was 6 points.

This observation illustrates how dynamic dopplerometrical the study of blood flow in the renal artery of the fetus possible to diagnose him hypoxia, whereas indicators of blood flow in the umbilical artery showed his UD is vetorial.net condition.

Example 4.

Pregnant A., 24 years old, is ill with diabetes mellitus type I for 22 years. For the underlying disease before pregnancy was relatively stable. From complications of diabetes revealed - diabetic retinopathy and diabetic nephropathy. This first pregnancy. In the early stages proceeded with the phenomena threat of abortion. For diabetes during pregnancy was labile. The pregnancy 35 weeks due to decompensation of diabetes, the patient was hospitalized in the Department of pathology of pregnancy clinical hospital No. 1, where the background of therapy for diabetes stabilized. During the next comprehensive ultrasound examination performed at 35-36 weeks of gestation, was held diplomaticheskaja assessment of the fetus in terms of blood flow in the umbilical artery (a common way of assessing the status of the fetus) and one renal artery of the fetus. The resistance index in the umbilical artery amounted to 0.62, indicating satisfactory condition of the fetus. The resistance index in the renal artery of the fetus was 0.82 (see figure 4), on the basis of which he concluded that the presence of fetal hypoxia. Treatment aimed at normalizing the status of the fetus, the effect is not given. In this regard, the issue was resolved in favor of early ro is about. Born alive prematurely boy in serious condition, body weight 2890 g, length 48 see At birth were noted signs of chronic intrauterine hypoxia. Estimation on Apgar scale in the first minute of life was 6 points.

Presents observation demonstrates the benefits diplomaticheskii evaluation of blood flow in one renal artery of the fetus in the assessment and forecasting of a condition of the newborn in diabetes mellitus of mother, compared with the assessment of blood flow in the umbilical artery.

Example 5.

Pregnant With., 20 years. Before pregnancy somatic pathology, the patient was not identified. This first pregnancy, up to 25 weeks passed without features. At 25 weeks of pregnancy, if regular clinical examination in the antenatal clinic was diagnosed gestational diabetes mellitus and treatment. On the background diet was achieved normalization of carbohydrate metabolism. For the first time a pregnant woman was admitted to the Department of pregnancy pathology clinical hospital No. 1, Moscow 38 weeks of pregnancy to determine further tactics of reference. Conducted comprehensive ultrasound examination, including dopplerometrical assessment of the fetus in terms of blood flow in the umbilical artery (a common way of assessing the status of the fetus) and one renal artery of the fetus. Index resisted the values in the umbilical artery was 0.68, on the basis of what was stated in the violation of the condition of the fetus. The resistance index in the renal artery of the fetus was 1.0 (see figure 5), on the basis of which he concluded that the presence of fetal hypoxia.

Given the gestation (pregnancy full-term), in the interests of the fetus, the issue was resolved in favor of the emergency operative delivery of the patient. This resulted in the birth of live full-term boy in serious condition, body weight 4250 g, length 52 see At birth were noted signs of chronic intrauterine hypoxia. Estimation on Apgar scale in the first minute of life was 5 points.

Thus, the violations of the blood flow in one renal artery of the fetus, as well as in the umbilical artery was allowed to diagnose hypoxia, which was confirmed by subsequent condition of the newborn, and in the interests of the fetus, to resolve the issue in favor of the emergency operative delivery pregnant with gestational diabetes.

Just in our clinic with this method surveyed 233 pregnant women, of whom 113 were diabetics - studied group. Of these, 70 (of 61.95%) with diabetes mellitus (type I) and 43 (38,05%) with gestational diabetes. In 39 (55,71%) pregnant women with diabetes mellitus type I revealed vascular complications. The control group consisted of 120 healthy pregnant women. All pregnant women with diabetes is diabetes were hospitalized in the Department of pathology of pregnancy clinical hospital №1 named after. After N.I. Pirogov, Moscow. 2 pregnant women to be tested against the background of deterioration of utero-placental and fetal circulation due to degenerative changes in the placenta (37 and 38 weeks of gestation) occurred antenatal loss of the fruit. Other pregnant treatment group took delivery in the presence of a living fetus. 46 (41,44%) births were timely, 65 (58,56%) were premature. Premature delivery was due, as a rule, the deterioration of the functional status of the fetus, as well as the labile diabetes. Among live births in the study group - 19 (17,12%) were born in a satisfactory condition, as assessed by the Apgar scale in the first minute of extrauterine life 8 points, 71 (63,96%) in the state of moderate severity rating scale Apgar score of 7, 21 (18,92%) was in a serious condition, and 20 (18,02%) score on a scale of Apgar scores in the first minute after birth was 5-6 points, and 1 (0,9%) - 3-4 points. All the families of the pregnant control group were timely. All children were born in a satisfactory condition, as assessed by the Apgar scale in the first minute of extrauterine life 8-9.

When using the previously known method for the assessment of fetal status in diabetes mellitus of mother and indicators of blood flow in the umbilical artery diagnostic accuracy of his suffering in our investigated and was 38,10% (sensitivity) and the lack thereof in 92,92% of cases (specificity). Use demonstration of criteria for the assessment of fetal possible to diagnose his suffering in 80,95% of cases and to ensure that no one in 79,72% of cases. Thus, when using the claimed method for the assessment of fetal status and forecasting newborn diabetes mothers significantly increased the rate of detection of fetuses in a state of hypoxia (table 1)that have contributed to the development of rational tactics of pregnancy and delivery in pregnant women with diabetes. Therefore, the claimed method was required during the examination of pregnant women in our clinic.

Table 1.

The sensitivity of different methods for diagnosing hypoxia in diabetic patients mother.
 Methods of assessment of fetal status in DM mother when diplomaticheskii study on indicators of blood flow
in umbilical arteryin the renal artery of the fetus
% identified fetuses with signs of hypoxia (sensitivity)38,10%80,95%

The claimed invention is not obvious to a person skilled operating in this field.

As noted above, the most significant for the evaluation comprising the Oia fruit and forecasting the state of the newborn, pregnant, diabetes is when blood flow in the umbilical artery. Published data indicate that, despite the ability to measure blood flow in the renal artery of the fetus, the use of diplomaticheskii its evaluation is not possible to reliably diagnose hypoxia.

Our study was performed over 2 years, on a representative number of the examined healthy volunteers and patients with diabetes mellitus pregnant women, using the appropriate methods of statistical analysis and assess the validity of our findings.

We first established that diplomaticheskaja assessment of blood flow in one renal artery of the fetus in the second half of the third trimester of pregnancy, you can detect hypoxia in the fetus in 80,95% of cases, which is significantly more than when using diplomaticheskii assess blood flow in the umbilical artery.

We first worked out the criteria for evaluation: with the increase of the resistance index from 0.81 and more and, accordingly, systolicdiastolic relationship between 5.1 and more than one renal artery of the fetus when diplomaticheskii the study of blood flow, record the presence of fetal hypoxia and the need for urgent correction of this condition, and changes in tactics pregnant until its emergency delivery online is for the sake of the fruit.

The claimed method is of great scientific and practical importance, as it determines the tactics of pregnancy and delivery in pregnant women with diabetes type I diabetes and gestational diabetes.

The method is safe and does not require new equipment, can be performed without additional equipment, without permission of the regulatory authorities.

The method can be used in antenatal and obstetric hospital directly on this description.

Method of assessment of fetal status in diabetes mellitus of mother, including the definition of indicators of blood flow in diplomaticheskii study, characterized in that the blood flow indices examined in one renal artery of the fetus in the second half of the third trimester of pregnancy and at higher index of resistance from 0.81 and more and, accordingly, systolicdiastolic relationship between 5.1 and more - record the presence of hypoxia in the fetus.



 

Same patents:

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EFFECT: higher accuracy of evaluation.

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4 ex, 1 tbl

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1 ex, 1 tbl

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1 ex, 1 tbl

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4 ex, 1 tbl

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EFFECT: high accuracy in estimating patient health state.

4 tbl

FIELD: medicine, hepatology.

SUBSTANCE: one should detect splenic length in mm (X1) and circulation in portal vein, moreover, additionally, on should detect volumetric circulation in splenic vein in cu. cm/min. (X2), the index for the ratio of volumetric circulation in splenic vein to the area of longitudinal splenic section (X3), circulatory direction in left-hand gastric vein (X4) by establishing its direction towards the liver to be 1, from the liver to be 2, diameter of splenic artery in cm (X5) and transhepatic portal volumetric circulation in cu. cm/min. (X6), then one should calculate discriminant function Z = 15.9850 - 0.0187X1 + 0.2006X3 - 1.9025X4 - 19.0493X5 - 0.0025X6, where Z - the criterion for predicting "healthy-sick" state; then it is necessary to detect the group with hepatic diseases by the value of Z ≤ 1.621 to calculate for them discriminant function Y = 9.7396 - 0.0279X1 - 0.0018X2 + 0.1873X3 - 4.9174X4, where Y - the criterion to predict "patients with chronic hepatitis - patients with cirrhosis" state and at Y > 1.239 one should diagnose chronic hepatitis, at Y ≤ 1.239 - cirrhosis.

EFFECT: higher efficiency of diagnostics.

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SUBSTANCE: one should detect informational-valuable signs of patient's state, such as either the presence or absence of hypertonic disease and uterine extirpation together with adnexa, the value of body weight index, predominance of disorders according to modified menopausal index (MMI)such as autonomic, metabolic-endocrine or psycho-emotional ones, the type of metabolic structures of blood serum, moreover, it is necessary to echocardiographically detect stroke volume, cardiac index and systemic vascular resistance (SVR), at ultrasound testing one should detect maximal linear rate of circulation (LRC max) by medial cerebral artery and thyroid alterations, rheovasographically one should detect specific circulation (SC) of shins, at testing laser doppler flowmetry one should detect microcirculation index, biochemically it is necessary to detect the value of beta-adrenoreactivity, cholesterol level and that of B-lipoproteides, crystallographically - the presence of serotonin and dopamine crystals, due to immunoenzymatic assay on should detect the values by Table 1 and then after obtaining the values of diagnostic coefficients of every parameter it is necessary to summarize them and obtain diagnostic index (DI), at its value being below 10 one should state no alteration, at its value 10-10 - undetermined state, at its value being 21-30 - the 2nd severity degree of disorders, and at DI value being above 31 one should state the 3d severity degree of disorders available.

EFFECT: higher accuracy of evaluation.

5 ex, 2 tbl

FIELD: medicine, obstetrics, gynecology.

SUBSTANCE: one should study circulation in one of fetal renal arteries during the second half of third trimester of pregnancy. At increased resistance index from 0.81 and higher and, correspondingly, systolodiastolic ratio - from 5.1 and higher - one should fix the presence of fetal hypoxia and the necessity for urgent correction of this state. The suggested method increases the number diagnostic preparations and enables to increase the significance of predicting the state of neonatals.

EFFECT: higher accuracy of evaluation and prediction.

5 dwg, 5 ex, 1 tbl

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