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https://doi.org/10.29013/ESR-20-1.2-26-29
Deinichenko Olena, postgraduate student, Department of Obstetrics and Gynecology, Zaporizhzhia State Medical University
E-mail: agol0309@gmail.com.
Krut Yuriy,
MD, Professor, Head of the Department of Obstetrics and Gynecology, Zaporizhzhia State Medical University
E-mail: yuriy.krut@ukr.net.
PROGNOSTIC SIGNIFICANCE OF RISK FACTORS FOR FETAL GROWTH RETARDATION IN PREGNANT WOMEN WITH CHRONIC HYPERTENSION
Abstract. The role of risk factors for fetal growth retardation during pregnancy in patients with hypertension has not been sufficiently studied and their interaction in such patients has not yet been fully understood. To determine the prognostic significance of risk factors for fetal growth retardation in pregnant women with chronic arterial hypertension, depending on their number, is the primary purpose of this work. Analyzing the results of the clinical course of pregnancy and childbirth and treatment of pregnant women with chronic arterial hypertension 1 and 2, we can draw the following conclusions: in the presence of both risk factors together (chronic arterial hypertension 2 degrees and the presence disorders of uterine placental circulation) fetal growth retardation will develop.
Keywords: fetal growth retardation, pregnancy, arterial hypertension.
Arterial hypertension (AH) is a leading among According to the case-control study [8], the cardiovascular diseases. AH promotes the develop- following risk factors for FGR are identified: the ment of long-term vascular and metabolic disor- mother's age is less than 18 years and the father's ders [1, 2]. Arterial hypertension causes a number age is over 40; the birth of a mother in the autumn; of pathological changes in the body of a pregnant poor socio-economic conditions; carrier of TORCH woman, in particular, increases the risk of developing infections; presence of extragenital pathology; stillfetal growth retardation (FGR) [4-6]. births in history; gestational complications and con-
Nowadays, different fetal developmental criteria genital malformations of the fetus. do not allow the diagnosis of FGR in early pregnan- In pregnant women with FGR have identified cy. This leads to late medical and preventative mea- increases in blood markers of protein peroxidation, sures. Thus, there is a need to improve the methods lipids, and decreased activity of synthesis of nitric of diagnosis of FGR. oxide, L-arginine and thiol compounds, indicating
There is also ambiguity in the assessment of prog- that the FGR is accompanied by a disorder of regula-nostic criteria for FGR in pregnant women. Thus, tory and adaptive processes [3]. in [7], the risk factors for FGR were determined by It should be noted that the increase in blood pres-arterial hypertension, nicotine dependence during sure during pregnancy in most cases is accompanied pregnancy, acute respiratory infection, anemia, fe- by a normal course of pregnancy, and moderate pres-toplacental insufficiency, and chronic fetal hypoxia. sure increase can be considered as an element of the
general process of adaptation of a woman's body to pregnancy and preparation for childbirth, as well as a physiological mechanism for maintaining the required level of feto-placental blood [10].
The incidence of hypertension of pregnant women ranges from 5-30% [10]. AH is a condition in which systolic blood pressure (SBP) rises above 140 mm Hg and diastolic blood pressure (DBP) exceeds 90 mm Hg as a result of repeated blood pressure measurements. According to the classification ofAH there are the following types: AH that existed before pregnancy, or during the first 20 weeks; gestational hypertension, which is induced by pregnancy and is not accompanied by proteinuria; gestational hypertension, which is accompanied by significant proteinuria (more than 300 mg / l), considered as preeclampsia; Hypertension diagnosed before pregnancy in conjunction with gestational hypertension and proteinuria; unclassified hypertension with or without systemic manifestations, which is diagnosed after 20 weeks of pregnancy, if previous values of blood pressure were unknown [10; 11].
Even moderate chronic or gestational hypertension presents an increased risk of cerebrovascular and normal pregnancy [10].
The literature proposes models for prediction of occurrence FGR and preeclampsia in pregnant women with mild hypertension. Thus, in order to predict such complications in the first trimester of pregnancy, it is necessary to determine the degree of nocturnal reduction in DBT, left ventricular myocardial mass, time index of day DBT and malonic dialdehyde concentration; in order to predict them in the second trimester, it is necessary to determine the degree of nocturnal decrease in DBT and concentration of malondialdehyde [11].
In pregnant women with hypertension due to changes in the functioning of the cardiovascular system, there is a decrease in placental circulation. This includes a number of compensatory mechanisms aimed at restoring placental perfusion. The placenta begins to produce a number of pressor factors that
can damage it. These factors include vasoactive hormones of the endothelium: nitric oxide and prostacyclin (vasodilators) and endothelin, thromboxane, fibronectin (vasoconstrictors). Disruption of the normal relationship between these factors in hypertension is accompanied by dysregulation ofvascular tone and leads to placental insufficiency.
Changes in fetal and uterine-placental complexes with violation of the adaptive-compensatory mechanisms at the molecular, cellular and tissue levels are at the heart of the feto-placental insufficiency. Which leads to disorders of transport, trophic, endocrine, metabolic and antitoxic function of the placenta, and subsequently - to the pathology ofthe fetus and newborn.
As a prognostic factor for possible FGR in pregnant women with hypertension, it is suggested to determine in the blood plasma the intermediate metabolite of methionine - homocysteine [9]. Hy-perhomocysteinemia promotes the development of oxidative stress and the prothrombotic state of hemostasis. Thus, in women with hypertension, the levels of this metabolite were increased compared to pregnant women without hypertension. And the highest levels of homocysteine reached in pregnant women, who were subsequently defined by the FGR.
Given the established value of factors of an-giogenesis and hormones of the placenta in the pathogenesis of FGR, it is promising to establish disturbances of their balance in combination with Doppler data of blood flow of the functional system of mother-placenta-fetus (circulation in uterine arteries, umbilical cord arteries) factors in early pregnancy in women with hypertension. To date, only isolated works have been found in the literature to study these indices in complex and / or in women with hypertension.
Aim. To determine the prognostic significance of risk factors for fetal growth retardation in pregnant women with chronic hypertension.
Materials and methods. A retrospective analysis of 117 case histories of pregnant patients with hypertension undergoing treatment at the Zaporizhzhia
Perinatal Center in 2017-2018 was conducted. A case-control study was performed. Criteria for inclusion in the study: pregnancy, chronic arterial hypertension (CAH) 1-2 stages. Exclusion criteria: stage 3 CAH, diabetes mellitus, multiple pregnancy, chromosomal and genetic disorders, thrombophilia, perinatal infections, systemic connective tissue diseases. Women were observed at 26-36 weeks of gestation. Pregnant women were divided into 2 groups. Group 1 included 14 pregnant women with hypertension who were diagnosed with fetal growth retardation. Group 2 (comparison group) included 103 women with arterial hypertension who did not determine fetal growth retardation. The CAH and the FGR were diagnosed according to current clinical protocols. Disturbances of uterine-placental circulation were established by means of the ultrasonic device "MyLabClassC-Esaote". Pregnant women were treated according to current clinical protocols. Statistical analysis was performed using the pro-
gram "STATISTICA® for Windows 6.0" (Stat Soft Inc., No. AXXR712D833214FAN5). The statistical significance of the differences between the groups was determined using qualitative Fischer criteria and quantitatively using the Student's T-test.
Results and Discussion. Risk factors of fetal developmental delay: 2 degree CAH, excess of blood pressure exceeding 140 and 90 mmHg, presence of disorders of uterine placental circulation of 2 and 3 stages were analyzed using anamnestic and standard clinical and instrumental indicators. There were no statistically significant differences between the groups according to the structure of comorbidi-ties, p > 0.05
Thus, analyzing the risk factors for fetal growth retardation revealed the prognostic significance of the risk factors for FGR (grade 2 CAH, grade 2-3 disorders of uterine placental circulation (DUPC)) in pregnant women with CAH depending on their number (Table 1).
Table 1. - Analysis of the prognostic significance of the risk factors for FGR in pregnant women with CAH
Number of risk factors 1 group, n=14 2 group, n=103 P
Abs. % Abs. %
no factor 0 0 50 48.5 < 0.01
only one factor 4 28.6 43 41.7 > 0.05
2 factors together 10 71.4 8 7.8 < 0.001
In the absence of risk factors, no cases of FGR in pregnant women with CAH were reported, p < 0.01. While about half of CAH patients who did not have a FGR had at least 1 risk factor (51.5%), only 1/3 of pregnant 1 group had 1 factor (28.6%), p > 0.05.
Only 8 women in group 2 had both risk factors, whereas 71.4% of pregnant women in group 1 had stage 2 CAH and 2-3 stage DUPC, p < 0.001.
Conclusions. Thus, analyzing the results of the clinical course of pregnancy and childbirth and treatment of pregnant women with CAH 1 and 2 stages, we can draw the following conclusions: in the absence of risk factors (in women with CAH1 degree and in the absence of stage 1 or stage 1), it is most
likely that pregnant women will not develop FGR. In the presence of both risk factors together (grade 2 CAH and 2-3 grade DUPC), the most likely will be a FGR. In the presence of at least one risk factor (either HAG 2 degree and the absence of DUPC or DUPC1 degree, or CAH 1 degree and the presence of DUPC2-3 stages), it is impossible to predict the development of FGR in pregnant women.
Prospects for further research. In-depth study of methods of prognosis and prevention of FGR in pregnant women with CAH. We plane to find features of angiogenesis factors and placental hormones changes in patients with arterial hypertension with fetal growth retardation and detect
early indicators of such complication of placental insufficiency.
Conflict of interests. The authors declare no conflict of interest.
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