Method for predicting clinical effectiveness in severe gestoses

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to obstetrics and can be used in the 3rd trimester of pregnancy for predicting clinical effectiveness in severe gestosis. Substance of the invention consists in that starting from 28 weeks of pregnancy peripheral venous blood of a woman suffering from severe gestosis is analysed for the content of CD16+CD3-cells. If the related values are less than 9%, conventional therapy of severe gestosis is predicted as efficient, while the value 9% or more show the absence of clinical effectiveness in gestosis.

EFFECT: application of the method allows predicting effectiveness of conventional therapy in severe gestosis from 28 weeks of pregnancy with high accuracy, sensitivity and specificity that enable to determine approach to further prenatal care and delivery, to reduce risk of fetal pathology, maternal and perinatal mortality.

1 tbl, 3 ex

 

The invention relates to medicine, namely to obstetrics, and can be used to predict the effectiveness of standard therapy of preeclampsia severe in the 3rd trimester of pregnancy.

The relevance of the method development is determined by a high risk of maternal and perinatal mortality in severe preeclampsia. This calls for a search for objective methods for predicting the effectiveness of standard therapy severe preeclampsia to develop adequate tactics and timing of delivery of pregnant women with preeclampsia severe.

Currently, there are methods to predict the efficacy of treatment with the use of complex mathematical calculations. There is a way of predicting the effectiveness of methods of treatment of diseases by analyzing the n-th individual diagnostic indicators in the process of diagnostic procedures and calculate the generalized coefficients predicted efficiency before, after the first and second sessions of treatment (Patent No. 2303955. A method for predicting the effectiveness of treatment methods for diseases / Chelovekov, Ogievetsky, Achkasov etc. // Invention. The utility model. - 2007. No. 22). The coefficient of the prediction efficiency is determined by the formula, including the parameter X i(tjrepresenting with the th complex coefficient, calculated according to the following formula, in which the relative private diagnostic parameters obtained during repeated diagnostic procedures are compared with parameter values corresponding to the initial and critical stage of disease, and indicators of a healthy person.

This method has several disadvantages:

- to determine the coefficient of performance estimates used are extremely complex mathematical formula that includes more than 12 parameters, which in turn also rely on two formulas, which greatly complicates the use of the method and makes it not applicable in practical health;

the method requires a 3-fold study of diagnostic parameters in the dynamics of treatment.

Another similar method is a comprehensive evaluation of the prognosis of the effectiveness of treatment of diffuse connective tissue diseases molecular anticoagulants, including the measurement of reaction times citrate blood in conditions nizkochastotnoi activation deficiency creation final concentration of ionized calcium thromboelastographic method and determination of the level of immunoglobulin G in the serum before and after treatment (Patent No. 2195676. The method of complex assessment of the prognosis of the effectiveness of treatment of diffuse diseases soedinitel the Noah fabric low-molecular anticoagulants / Tlachtga, Pasarela, Taupou etc. // Invention. The utility model. - 2002. No. 36. - S). Then use the method of linear regression analysis with the introduction of the 3 coefficients according to the formula models are built based on the performance indicators before treatment, and if the ratio exceeds 0.8, then predict treatment as ineffective. This method allows to predict the effectiveness of treatment of diffuse diseases of connective tissue, but does not allow to predict the efficacy of standard therapy of preeclampsia.

This method has several disadvantages:

- the application of the method requires determination of the 2 diagnostic parameters (before and after treatment);

- to determine the response time of citrate blood requires special reaction conditions, creating a deficit final concentration of ionized calcium;

- the complexity of a formula factor predicting the effectiveness of treatment.

Closest to the claimed method according to technical solution is the method of predicting the efficacy of atenolol in the treatment of preeclampsia at 32-38 weeks gestation (Schechtman M.M., Elokhin T.B., Smith S. B., Sokolova M. Antihypertensive efficacy of β-blockers in preeclampsia in pregnant women with different types of Central hemodynamics // Gynaecology. - 2001. - V.3, №2. - S-70). To do this, at 32-38 weeks gestation method echocardiog is the her survey parameters end-diastolic volume of the left ventricle (BWW) stroke volume (PP), ejection fraction (EF), the rate of shortening of circulatory fibers of the myocardium (Vcfand predict the efficacy of atenolol in the treatment of preeclampsia. Efficacy of atenolol dose of 50 mg/day predicted in pregnant women with preeclampsia, the properties of which differ from the normative increase in BWW, PP and PE, at a dose of 25 mg/day in pregnant women with preeclampsia, in which the performance of MLC, PP, PV, and Vcfnot differ from normative values. The use of atenolol in complex therapy in pregnant women with preeclampsia and low for PP, PV, and Vcfcompared with normative values predicted impractical.

This method is chosen as the prototype.

The disadvantages of the prototype method is:

- the absence of normative and critical parameter values BWW, PP, PV, and Vcfthat allows you to compare them with the figures of the patient;

the method allows to evaluate the performance of only one of the drugs included in the standard therapy of preeclampsia;

- in the text no reference is made to the accuracy, sensitivity and specificity of this method of evaluating the effectiveness of treatment of preeclampsia.

These drawbacks are proposed to be eliminated in the present method.

The technical result is the prediction of efficiency of application of the standard is therapy severe preeclampsia with 28 weeks of pregnancy with precision 90,60%.

The claimed technical result is achieved by the fact that in the 3rd trimester of pregnancy in the peripheral venous blood of women with severe preeclampsia determine the indicator of the relative content of CD16+CD3-cells and if the value of this indicator is less than 9% predict the efficacy of standard therapy of preeclampsia severe.

The novelty of the proposed method lies in the fact that for the first time proposed to predict the effectiveness of traditional therapy severe preeclampsia by definition in the peripheral blood of a pregnant woman in the relative content of CD16+CD3-cells. Previously, this figure was examined in the peripheral blood of pregnant women and found increased levels of CD16+CD3-cells in the development of preeclampsia (Skripkin IU Participation of different subpopulations of T-helper cells, natural killer cells and cathepsin D in the mechanism of development of preeclampsia // abstract. dis. Kida. the honey. Sciences. Ivanovo, 2004. - 23 C.). Our research found that women with severe preeclampsia content CD16+CD3-cells in the peripheral blood in the 3rd trimester of pregnancy had no significant differences compared with the rate in women with physiological pregnancy (Sotnikova POSTGRADUATE, Antsiferov US, Kudryashov A.V. and other Immunological mystery of pregnancy.- Ivanovo: Publisher MICK. - 2005. - 272).

The population of CD16+ natural is the result of the killers has a high level of cytotoxic activity (Khaitov R.M P.M., Ignatiev GA, Sidorovich I.G. Immunology: a Textbook. - M.: Medicine, 2000. - P.143), and is capable of lysis of endothelial cells indirectly through the reaction of antibody-dependent cellular cytotoxicity (ADCC), contacting fixed on the endothelium of circulating immune complexes. Damage to the vascular endothelium of the kidney may contribute to the progressive penetration of activated EC in glomeruli, leading to the development of proteinuria. In addition, the population of CD16+ natural killer cells capable of synthesis of interferon-γ, which directly stimulates the expression of receptors for angiotensin II in the wall of blood vessels, which may provoke the development of hypertension (Horiuchi M, Hayashida W, Akishita M, EA. Interferon-gamma dosage at(2) receptor expression in fibroblasts by Jak / STAT pathway and interferon regulatory factor-1 // Circ. Res. - 2000.- Vol.48. No. .2. - P.233-240). Thus, raising the level of CD16+CD3-population of natural killer cells may indicate a deep lesion of the endothelium of blood vessels, tissues of various organs and functioning of the renin-angiotensin system, the irrevocable nature and not amenable to standard therapy.

The method is as follows.

1) blood Sampling to conduct research from the cubital vein in a volume of 1 ml heparinised tube (case of 25 units of heparin per 1 ml of blood).

2) Allocation of lymph is itov from peripheral venous blood is carried out according to standard methods (Boyum A. Isolation of mononuclear cell and granulocytes from human blood and bone marrow // Scand.J. Clin. Lab. Invest. - 1968. -v.21. No. 97. - P.77.).

3) 100 μl of selected lymphocytes at a concentration of 1·106cells/ml are incubated with 20 μl of monoclonal anti-D16 labeled with FITC, and 20 μl of monoclonal anti-D3, labeled D, for 30 minutes at room temperature in the dark, after which the cells washed 1 time with 1 ml of saline by centrifugation at 1500 rpm for 2 minutes. Cells resuspended in 500 μl of saline. The reaction accounting is performed on a flow cytometer, determining the content of CD16+CD3-cells in the lymphocyte gate. The result is read in percent (%).

The use of the proposed method with high accuracy 90,60% to predict the effectiveness of traditional therapy severe preeclampsia in the 3rd trimester of pregnancy.

Distinctive features of the method are:

the method is applied in terms 28-38 weeks gestation;

- established prognostic parameter of the relative content of CD16+CD3 - cells in peripheral venous blood, when the content is less than 9% predict the effectiveness of standard therapy for severe preeclampsia, and when it is equal to 9% or more, the lack of effectiveness of treatment.

The essence of the proposed method is illustrated by the following examples.

Example 1. Pregnant'clock, 27 years. Avtomobilnaya, the first is odawa woman. From extragenital pathology - anaemia 1 degree. Registered in female consultations consists of 8-9 weeks of pregnancy. Initial blood pressure of 120/80 mm RT. century, the original weight was 72.8 kg During surveillance in antenatal clinic blood pressure of 120/80 mm RT. Art., with 30 weeks of pregnancy marked pathological weight gain, swelling of the legs, increased blood pressure to 130/80-140/90 mm RT. Art., proteinuria to 0,132 g/l At 35 weeks of gestation was admitted to the hospital. When you receive a state of moderate severity. Complaints expressed edema, decreased urine output. Blood pressure at admission 160/100-150/90 mm RT. senior, pronounced swelling of the lower legs, anterior abdominal wall, puffiness of the face, in the urine proteinuria - 1,32 g/L. According to the U.S. syndrome of delayed fetal development, when the Doppler examination is a violation of hemodynamics 1A class.

Diagnosis: pregnancy 35 weeks. The severe preeclampsia: hypertension with significant proteinuria caused by pregnancy. Anemia of 1 degree. Placental insufficiency. The syndrome of delayed fetal development.

The patient started therapy severe forms of preeclampsia according to the standard of care for patients with this pathology: tranquilizers, antihypertensives, means affecting the blood clotting system, antispasmodic with whom estva, solutions and plasma substitutes (colloids and crystalloids).

The survey results by the present method: peripheral blood was determined the content of CD16+CD3-cells, which amounted to 8.7%. The projected effectiveness of the treatment of preeclampsia.

During therapy, a marked decrease in blood pressure up to 140/85 mm RT. century, according to the daily monitoring of blood pressure - hypertension 1 degree, the circadian rhythm is not disturbed (adequate reduction in night hours). In the daily amount of urine a decrease in proteinuria to 0.66 g/l, reduction of swelling, according to the Doppler examination is a violation of hemodynamics 1A degree. therapy was able to prolong the pregnancy to 38 weeks of gestation.

The pregnancy ended with timely delivery at 38 weeks of pregnancy. She was born full-term girl weighing 3000 grams and height 52 cm with estimation on Apgar scale 7/8 points.

Conclusion: prediction of the effect of treatment of severe forms of preeclampsia according to the claimed method was confirmed.

Example 2. Pregnant K., 27 years. Parvovirinae, perforada woman. From extragenital pathology - obesity 2 degrees. Registered in female consultations consists of 7 weeks of pregnancy. Initial blood pressure of 120/80 mm RT. century, the original weight of 97.7 kg At 28-29 weeks of gestation on the appointment in the women's consultats and blood pressure 160/105-170/110 mm RT. Art., abnormal weight gain - +2.5 kg for 2 weeks, edema of the lower extremities, anterior abdominal wall. The patient admitted to hospital. When you receive a state of moderate severity. Complaints stuffy nose, pronounced swelling. Blood pressure at admission 160/110-170/110 mm RT. Art., swelling of legs, anterior abdominal wall, in the urine proteinuria - 1,32 g/L. According to the U.S. syndrome of delayed fetal development, when Doppler examination is a violation of the hemodynamics of 2 degrees.

Diagnosis: pregnancy 28-29 weeks. A severe form of preeclampsia: hypertension with significant proteinuria caused by pregnancy. Obesity 2 degrees. Placental insufficiency. The syndrome of delayed fetal development.

The patient started therapy severe forms of preeclampsia according to the standard of care for patients with this pathology: tranquilizers, antihypertensives, means affecting the blood clotting system, antispasmodic, solutions and plasma substitutes (colloids and crystalloids).

The survey results by the present method: peripheral blood was determined the content of CD16+CD3-cells, which was 10.8%, which is higher than the proposed level. Predicted no effect of therapy.

On the background of intensive care for 4 days remained expressed Arte the territorial hypertension to 160/100-170/110 mm RT. century, according to the daily monitoring of blood pressure - severe hypertension lack of adequate reduction in night hours. In the peripheral blood - reduced level of platelets in the daily amount of urine proteinuria - 1,32 g/l, there was an increase in swelling, according to the Doppler examination is a violation of the hemodynamics of 3 degrees. Given the lack of effect of therapy of preeclampsia, the deterioration in the condition of the fetus, further prolongation of pregnancy was not appropriate.

The pregnancy ended in preterm labor at 29 weeks of gestation. Born male child weight 1300 grams and height 37 cm, with rating on a scale of Apgar 4-6 points.

Conclusion: prediction of absence of effect from treatment of severe forms of preeclampsia according to the claimed method was confirmed.

Example 3. Pregnant Century, 29 years. Parvovirinae, perforada woman. From extragenital pathology - chronic pyelonephritis, varicose disease. Registered in female consultations consists of 9-10 weeks of pregnancy. Initial blood pressure 120/70 mm RT. century, the original weight is 68 kg, urine protein was not. 31 weeks marks the increase of swelling, at 33 weeks of pregnancy the referral to inpatient treatment for preeclampsia, a patient from the hospital refused. On the background of the deterioration of the village is opila in the hospital at 35 weeks of pregnancy. When admitted to hospital, blood pressure 160/105-170/110 mm RT. Art., weight gain - +12,7 kg, pronounced swelling of the lower extremities, abdominal wall, puffiness of the face. When you receive a state of moderate severity. Complaints: pronounced swelling in the month. Blood pressure at admission 160/110-160/120 mm RT. Art., swelling of legs, anterior abdominal wall, in the urine proteinuria and 3.3 g/L. According to the ultrasound, the fetus corresponds to the gestational age at ultrasound examination is a violation of hemodynamics 1A class.

Diagnosis: pregnancy 35 weeks. A severe form of preeclampsia: hypertension with significant proteinuria caused by pregnancy. Chronic pyelonephritis.

The patient started therapy severe forms of preeclampsia according to the standard of care for patients with this pathology: tranquilizers, antihypertensives, means affecting the blood clotting system, antispasmodic, solutions and plasma substitutes (colloids and crystalloids).

The survey results by the present method: peripheral blood was determined the content of CD16+CD3-cells, which amounted to 9.0%, which is higher than the proposed level. Predicted no effect of therapy.

On the background of intensive care for 3 days was preserved arterial hypertension to 150/100-160/100 mm R is. century, according to the daily monitoring of blood pressure - severe hypertension lack of adequate reduction in night hours. In the peripheral blood - reduced level of platelets in the daily amount of urine proteinuria and 3.3 g/l, there was an increase in swelling, according to the Doppler examination is a violation of the hemodynamics of 2 degrees. Given the lack of effect of therapy of preeclampsia, the deterioration in the condition of the fetus, further prolongation of pregnancy was not appropriate.

The pregnancy ended in a premature birth at 35-36 weeks of gestation. Born a female child weight 2300 g, a height of 46 cm, with rating on a scale of Apgar 7-8 points.

Conclusion: prediction of absence of effect from treatment of severe forms of preeclampsia according to the claimed method was confirmed.

In this way 32 women in the 3rd trimester of pregnancy with severe preeclampsia, these studies are shown in table 1.

Table 1

IndexThe number of the examined
Total female32
True-positive result15
False-positive rez is ltat 1
A true-negative result14
A false-negative result2

Total:

the accuracy of the proposed method is 90,60%,

the sensitivity of the proposed method is 88,20%,

the specificity of the proposed method is 93,00%.

The advantages of the proposed method:

1. study the content of CD16+CD3-cells in the peripheral blood allows the prediction of the effectiveness of standard therapy for severe preeclampsia before treatment, which allows to determine the strategy for the conduct and delivery of the patient to reduce the risk of maternal and perinatal mortality;

2. the possibility to forecast the effectiveness of standard therapy of severe preeclampsia with 28 weeks of pregnancy;

3. predicting the effectiveness of complex drugs standard therapy of severe gestosis;

4. high accuracy - 90,60%, sensitivity - 88,20%, specificity 93,00%;

5. the simplicity of execution methods.

A method for predicting the effectiveness of treatment of severe preeclampsia through examination of a pregnant woman in the 3rd trimester, characterized in that from 28 weeks of pregnancy in the peripheral venous blood define the indicator otnositelnoj the content CD16+CD3 - cells and when it is less than 9% predict the efficacy of standard therapy, a value equal to or more than 9%, predicted the lack of effectiveness of therapy.



 

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