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Radjabova Zulola Abdukhakimovna, Postgraduate student, Department of Obstetrics and Gynecology No. 2, Tashkent Institute of postgraduate medical education E-mail: [email protected]
The investigation of biophysical profile of the fetus in pregnant women with herpes infection
Abstract: In recent years there has been a tendency to a predominantly asymptomatic flow of herpesvirus diseases. Therefore application of biophysical profiling in fetus condition evaluation, and development of prognostic criteria of perinatal
outcomes, with herpes infection can help in differential diagnosis of placental insufficiency prior to childbirth. Keywords: herpes, pregnancy, fetoplacental insufficiency, fetus, placenta.
Currently, there is a significant increase in the population incidence of viral infections, including those of women during pregnancy. Separate delivery of women with herpesvirus infection complicates the postnatal adaptation of the newborns and their state, which suffered during childbirth additional burden by transvaginal infection, with long process of childbirth. The risk of death or serious neurologic consequences among infected infants, given birth by mothers with primary form of genital herpes (HSV2), is estimated to 51 %. The growing role of intrauterine infections among the causes of adverse perinatal outcomes determine the relevance of a comprehensive study of the problem.
Objective: The abovementioned defined the following objective of the current study: to develop prognostic criteria of perinatal outcomes, with herpes infection in mother, to reduce perinatal complications and perinatal losses.
Materials and methods
Fetal biophysical profile in 131 pregnant women with a core group of recurrent herpes infection was studied in order to perform
functional fetal assessment. The comparison group consisted of 126 pregnant women with herpes infection in remission, the control group consisted of 60 pregnant women with full-term uncomplicated pregnancy.
In normal and satisfactory BFN study was conducted only once, when doubtful and pathological — doubly at intervals of 24 hours. The study of fetal biophysical profile began by holding a general ultrasound. In all cases the fetal position was longitudinal.
These ultrasound showed the accordance of fetus biometric indicators to gestational age in the main group 72.5 %, in the control group 89.3 %, and all pregnant women in the control group (Table 1).
Biparietal head size (BHS) of the fetus at 35-38 weeks in the comparison groups averaged 89.9 ± 0.07 mm. The stomach diameter (SD) on the measurement level of the standard section plane averaged 102.4 ± 0.73 mm. Femur length (FL) of the longitudinal section averaged 68.44 ± 0.2 mm. BHS of the fetus at 39-41 weeks in the comparison group averaged 95.1 ± 0.2 mm., SD averaged 106.3 ± 0.4 mm. and FL averaged 76.63 ± 0.4 mm.
The investigation of biophysical profile of the fetus in pregnant women with herpes infection
Table 1. - Biometrical indices of the fetus
Biometrie indicators I-main group n = 131 II-main group n = 126 Control group n = 60
abs. % abs. % abs. %
Accordance 95 72.5 ± 3.2 113 89.3 ± 3.5 60 100 ± 1.2
Symmetrical malnutrition 21 15.9 ± 2.8 12 9.3 ± 2.1 - -
Asymmetric malnutrition 15 11.6 ± 1.3 2 1.4 ± 1.7 - -
Symmetrical malnutrition of the fetus at term revealed 11 (15.9 %) of pregnant women of the main group, 7 (9.3 %) pregnant of the comparison group. In symmetrical malnutrition of the fetus at 35-38 weeks — BHS in the main group averaged 84.5 ± 1.03 mm., in the comparison group 85.2 ± 2.13 mm.; FL in the main group averaged 64.73 ± 1.03 mm., and in the comparison group 65.21 ± 2.14mm., SD in the main group averaged 87.38 ± 0.27 mm., and 88.71 ± 0.64 mm. in the comparison group.
Asymmetrical shape of malnutrition of the fetus at 35-38 weeks was determined 8 (11.6 %) in the main group, and 1 (1.4 %) in the comparison group. Average BHS was 88.3 ± 3.21 mm. in the main group and 87.1 ± 1.14 mm. in the comparison group; average FL were 64.8 ± 1.23 mm., and 66.2 ± 1.84 mm. accordingly in the groups. Average SD were 86.21 ± 0.22 mm. and 101.3 ± 1.04 mm. in each group consequently.
The placenta thickness measurement in the control group showed no significant change, thus biometrical indices at 35-38 weeks was 33.67 ± 0.3 mm. However, placentography of 47 (68.1 %) pregnant women in the main group with biometrical indices averaged 51.23 ± 2.04 mm. and identified signs ofplacental insufficiency, characterized by a thickening of the placenta edema, the appearance of cysts, calcification sites in the placenta and premature aging of the placenta. Biometrical indices at 39-41 weeks of 22 (31.8 %) pregnant in the main group averaged 23.01 ± 1.2 mm., thinning of the placenta and immature placenta signs were observed.
Average rating of the fetus biophysical profile in the main group was 6.80 ± 0.31 points, which is 1.3 times less than that of in the comparison group, and 1.5 times less than that in the control group.
Difference in the tone of the fetus was also determined. So, it was normal in 10 (28.5 %) of surveyed in the main group and in 38 (76 %) in the comparison group. Moderate decline occurred 2 times more in the main group, and hypotonus occurred 7.8 times more often.
A similar pattern occurred in the evaluation of its motor activity, so almost all fetuses with reduced tone had reduced motor activity.
The surveyed groups were differed by quality and quantity of amniotic fluid. So, on herpes virus infection, oligohydramnios with the inclusion of fine suspension was significantly more often detected in 20 (37.1 %) pregnant women of the main group, in 11 (14.7 %) of the comparison group, polyhydramnios was found in 27 pregnant women of the main group (39.2 %), in 17 (22.7 %) of the comparison group and in 2 (3.4 %) pregnant women of the control group.
During clinical and functional comparison, it was revealed that these patients had a history of cervicitis, metritis, long treatment for infertility, and threat of present pregnancy interruption.
In structural terms and the degree of placental maturity the surveyed groups were characterized as follows: in the main group ofpreg-nant women detected so-called "immature" the placenta in the main group 32 (46.4 %) cases, in 7 (9.4 %) in the comparison group that is at a stage ofpregnancy 37-38 weeks — the first — second degree ofpla-centa maturity, at term of34-35 weeks of pregnancy "overripe" placenta was detected with areas ofcalcification, cystic rebirth in 28 (40.6 %) in the main group and 11 (14.7 %) in the comparison group. Edematous placenta was detected in 18 (26.1 %) of pregnant women in the main group and in 10 (13.4 %) in the comparison group. Placental thickness in the main group was 2.79 ± 0.07 cm., and in the comparison group with control group 3.37 ± 0.03 cm. and 3.51 ± 0.02 cm., respectively (p < 0.05). Such difference in placental thickness constitutes violation of its function, so as thinning or swelling of the placenta is a predictor of the placental insufficiency development. Our research confirmed the literature data about reduction of placental thickness during placental insufficiency of infectious genesis [2].
Dynamic observation of pregnant women helped to reveal enlargement of the lateral ventricles of the fetus brain. Such pathology was detected in 7 (10.2 %) patients of the main group and in 1 (1.4 %) of the comparison group.
Pneumatosis offetal bowel was detected in 23 (33.4 %) cases in the main group and 8 (10.7 %) in the comparison group. And this pathology in 73.1 % cases, combined with oligohydramnios, cloudy amniotic fluid and lowering the tone of the fetus.
Fetal intestinal pneumatosis was detected on 10 (10.7 %) of surveyed in the comparison group, though in pregnant women with polyhydramnios and which have borne during this pregnancy recurrent herpes infection.
Thus, for pregnant women infected with herpes virus infection intrauterine infection of the fetus were typical symptoms, corresponding to the presence of chronic long-term current intrauterine infection. Such as: water scarcity and murky amniotic fluid, asymmetric fetal malnutrition, decreased fetal tone and motor activity, as well as the discrepancy degree of maturity of the placenta to gestational age.
CTG method in the study of HCT determined parameters: basal rhythm variability, the presence and nature of the acceleration and decelerations.
As shown by the results of research, reactive (normal) CTG — NST was detected in 38 (50.6 %) of the main group and in 58 (96.7 %) of the control group. Questionable test — in 38 (55.1 %) of the main group, in 29 (38.7 %) of the comparison group and in 2 (3.4 %) cases in the control group, unresponsiveness in 31 (44.9 %) of the main group and in 7 (9.4 %) of the comparison group.
Table 2. - CTG data in the research groups
main group comparison group control group
CTG n = 131 n = 126 n = 60
abs. % abs. % abs. %
Reactive - - 64 50.6 58 96.7
Doubtful 72 55.1 49 38.7 2 3.4
Unresponsiveness 59 44.9 12 9.4 - -
Note: * — The difference was statistically significant between the I and IIgroup ^ < 0.001).
Thus, when infected with herpes infection with reliable frequency the signs of intrauterine infection of the fetus was determined, which manifested the presence of symmetric and asymmetric fetal malnutrition, decreased motor activity, and its tone, as well as the presence of abnormal respiratory movements as hiccups shaped. This is often revealed oligohydramnios and lagging degree of maturity of the placenta of gestational age. Suffering intrauter-ine infection with herpes virus infection was confirmed during the HCT-CTG CTG data showed that the herpes virus infection with recurrent fetal condition suffers much more than the herpes virus infection in remission, which is confirmed by the literature [3; 4; 5].
The results of these studies indicate violations of the fetus state in pregnant women of the first main group. Antenatal fetal hypoxia occurred in almost all cases. The total number of early signs of hypoxia in the surveyed group was observed 2 times more often than that in the comparison group and severe hypoxia was observed 4 times more frequently in the comparison group. Also in the comparison group of surveyed group worsening of antenatal fetal hypoxia in childbirth were detected significantly more frequently. Contractions in childbirth causing a reduction of uterine-placental blood flow and reduced oxygen supply to the fetus. In full-term fetuses without initial antenatal hypoxia there is no pathological reaction to short-term hypoxia-induced vascular spasm during the fight. Infected fetus, considering existing antenatal fetal hypoxia and infection of CNS structures, even short-term decrease in the supply of oxygen at the time of the bout is worsening hypoxia is the cause ofperinatal complications. Thus, the data suggest quite informative cardiotocography in assessing the status of the fetus in the III trimester of pregnancy in patients with herpes infection.
The I-main group questionable BFN (6-7 points) was observed in 26 (37.6 %) of pregnant. Among them in 26 (37.6 %) cases motor activity decrease was diagnosed, in 11 (42.1 %) — decrease of reactivity of cardiac activity, in 17 (65.3 %) cases, there was oligohydramnios, in 7 (26.9 %) observations — a decrease of the respiratory activity of the fetus. Unsatisfactory (pathological) fetal biophysical profile was observed only in the main group in 27 (39.1 %) cases. In 100 % of the violation of biophysical characteristics except fetal tone was stated. In this group in 16 (23.1 %) infants were born in the severe asphyxia. Satisfactory BFN evaluation (8-9) was observed in 18 (26.1 %) pregnant. In this group, a decrease points in 38.7 % of the cases observed by reducing the amount of amniotic fluid, in 10.8 % of pregnant decrease respiratory movements and in 27.8 % reduction of motor activity.
In the comparison group, satisfactory BFN (8-9 points) was observed in 41 (54.7 %) cases. Reduced points 28 (37.3 %) was observed due to low water, in 19 (25.4 %) patients by reducing heart rate reactivity, 8 (9.3 %) were due to changes in respiratory activity. Doubtful assessment BFN (6-7) score was diagnosed in 17 (22.7 %) cases. In this group, a decrease of 22 points (29.3 %) cases were observed by reducing the amount of amniotic fluid, in 13 (17.4 %) ofpregnant decrease respiratory movements. Normal BFN (10-12 points) was observed 17 (22.6 %).
From the table above it is clear that the majority of perinatal complications observed in detecting abnormal fetal biophysical profile. Asphyxia and hypoxic-ischemic encephalopathy, severe only occur in pathological assessment of BFN. Hyperexcitability
syndrome with pathological BFN occurs 2.5 times more frequently than in dubious.
In the control group total score BFN was 10.74 ± 0.13. Normal evaluation of BFN (10-12 points) were 58 (96.7 %) of newborns. Satisfactory evaluation BFN (9 points) was diagnosed in 2 (3.4 %) cases. The diagnosis of oligohydramnios was not present, but in the determination of fetal biophysical profile in one of the vertical pockets volume of water was less than 2 cm.
In the main group there was no any fetus with normal FFT score of 10-12 points revealed, while unsatisfactory fetal biophysical profile (5-4 points) was observed only in the main group. Questionable score BFN (7-6 points) in the main group met 2.5 times more frequently than in the control group (p < 0.001).
Studies have shown that during detection of abnormal fetal biophysical profile in 100 % birth by pregnant women with herpes infection relapsing.
Thus, in the main group BFN score of fetus ranged from 5 to 9 points, while the largest group made of pregnant women with doubtful and pathological results of BFN. All infants with abnormal result with 5 points were born in the severe asphyxia, were demanded in resuscitation, treatment in the neonatal period and were transferred to Stage II of nursing.
In the first main group operative delivery was performed in 32 (46.3 %), among them in 15 (21.8 %) — with an emergency. The main indication for an emergency cesarean section was the aggravation of fetal hypoxia in childbirth, so called fetal distress. These results suggest that in pregnant women with herpes infection in remission stage the fetus is less susceptible to the influence ofvarious pathological factors and its adaptive capabilities better than that in fetuses of pregnant women with herpes infection relapsing.
Performed research shown that in the main group violation of biophysical fetal activity occurred more than in 50 % of cases. Newborns of the main group 2.5 times more susceptible to hypoxia and harder tolerates the stress of childbirth. In asphyxia with varying degrees of severity newborns in the main group are born 4-5 times more often than in the control group. Pregnancy with recurrent herpes infection is characterized by an increase in the passage of the frequency of adverse perinatal outcomes, which are exacerbated by the detection of antenatal signs of fetal suffering: (infringement of the biophysical characteristics of the fetus, the symptoms of chronic hypoxia in the CTG-research, abuse of dopplerometric flow indicators).
In identifying dubious and, moreover, the pathological results in the study of fetal BFN it is necessary to predict the adverse condition of the newborn at birth and in a timely manner to resolve the issue of the date and method of delivery.
The results of the biophysical profile of the fetus and its comparison with the state of the newborn at birth and in the early neonatal period shows a high diagnostic value of this method in the evaluation of fetal condition. Thus, biophysical profile of the fetus is an objective criterion of fetal condition evaluation, characterized the severity of the of the fetus state and its compensation stage of placental insufficiency and is a predictor of perinatal outcomes. Also, considering identified differences in research of fetal biophysical profile in the main group and in the comparison group, it is possible to use such method for differential diagnosis of placental insufficiency prior to childbirth.
References:
1. Radjabova Z. A., Karimov F. D. Neurologic complications in infants born by mothers with herpes infection. The collection of materials of the Congress of Neurologists of Uzbekistan. - Tashkent, May 22-23, 2014. - P. 142.
2. Karimov A. K. Doppler examination with physiological pregnancy//Zh. Patologiya. - 2004. - № 3. - P. 37-38.
Application of the injector at implantation IOL RSP-III during phacoemulsification of cataract through a small self-sealing incision
3. Krasnopolskiy V. I. Monitoring of pregnant women with family of herpes viral infections: medical technology/V. I. Krasnopolsky and others. - Ministry of Health of the Russian Federation Ministry of Health and Ministry of Defense. - M., 2006. - P. 38.
4. Radjabova Z. A., Karimov F. D. Fetoplacental system at pregnant women with herpes infection. - Association of Physicians of Uzbekistan, 2013.
5. Mwanyumba F. Placental inflammation and perinatal transmission of HVS-I/F. Mwanyumba et al.//J. Acquir. Immune Defic. Syndr. -2002. - Vol. 29. - P. 262-269.
6. Radjabova Z.A. Features of histomorphology placental tissue with herpes virus infection//Medical Journal of West Kazakhstan. -2014. - № 1(41). - P. 134-136.
7. Newton E. R. Diagnosis or perinatal TORCH infections//Clin. Obstet. Gynaecol. - 2004. - Vol. 42, № 1. - P. 59-70, 174-175.
8. Alanen A. Herpes simplex virus DNA in amniotic fluid without neonatal infection/A. Alanen, V. Hukkanen.//Clin. Infect. Dis. -2000. - Vol. 30, № 2. - P. 363-367.
Rozukulov Vahid Ubaydullaevich, Republican Specialized Center of Eye Microsurgery, MD, PhD, Deputy Director for Clinical Work, Tashkent, Uzbekistan E-mail: [email protected]
Application of the injector at implantation IOL RSP-III during phacoemulsification of cataract through a small self-sealing incision
Abstract: Implantation of intraocular lens RSP-III at using the injector at rupture of the posterior capsule during the performance of phacoemulsification cataract allows stable position intraocular lens in the early and relatively distant observation periods, high levels of visual acuity with minimum values of corneal astigmatism.
Keywords: phacoemulsification, posterior capsule rupture, implantation of intraocular lens RSP-III through the injector.
Relevance
"The gold standard" of cataract surgery is ultrasound phacoemulsification cataract through a small self-sealing tunnel incision with intracapsular fixation flexible intraocular lens (IOL) [9, 345]. Application of this technology allows to achieve the minimization of injury to the eye structures. The virtual absence of postoperative corneal astigmatism due to the implementation of small self-sealing corneal incision (2.5 mm.), allows to reach high functional results early after surgery. An important factor to achieve the desired result is the initial state structures of the eye. It is obvious that the dominant factor is the safety and strength of the ligaments of the lens unit. According to the literature it is known that at outpatient screening for the level of 5-15 % of patients with cataract are breach of its integrit. According to the classification of N. P. Pashtaev on this group of patients is dominated by the first degree lens subluxation [4, 25-28; 5, 82]. It should be noted that 20 % of patients violations ligament of the lens unit is intraoperative finding that ophthalmic already preparing a flexible implant posterior chamber intraocular lens, which represents a considerable risk and it is likely luxcation of intraocular lens into the vitreous body [1, 22-23; 9, 345]. Atypical for phacoemulsification cataract can significantly increase the risk of damage to the capsular bag, provoke loss of the vitreous body, which leads to the abandonment of posterior chamber implantation intraocular lens [4, 25-28; 6, 290-293; 7, 192-195; 8, 100-102]. An this situation, the implantation technique intracapsular rings is most commonly used. Intracapsular rings spreading the capsular bag and creates tension in the areas of defects Zinn ligaments. In spite of this, this method does not solve the problem of weak ligaments, because in the future lysis of ligaments progresses and increases the risk of dislocation of the complex "capsular bag — intraocular lens — intracapsular rings". All kinds of suturing an intraocular lens or a set of "capsular bag — intraocular lens" to the iris or sclera can lead to hemorrhagic complications.
It must be remembered that in 5-7 years possible eruption of yarn or its biodegradation in the long term, which significantly increases the risk of intraocular lens dislocation into the vitreous body. Equally important is the constant mechanical pressure of the intraocular lens haptics to the ciliary body and the iris, leading to chronic cyclites and impaired hydrodynamics eye [3, 27-29]. Using a variety of techniques or implants pupil anterior chamber intraocular lens model with a wide access (5.0-6.0 mm.) traumatic, increases the possibility of the development of intra- and postoperative complications (vitreous loss, expulsive hemorrhage, endophthalmitis, a high degree of post-operative astigmatism, development of epithelial — endo-telialnoy corneal dystrophy, cystic maculopathy), with consequent whole set of problems [2, 9-11]. The postoperative astigmatism is characterized by the fact that the shape and contours of the obj ect are distorted and become fuzzy and uneven, the eyes often hurt, blush, sometimes a burning sensation is felt in eyes. Increased load on the eyes (reading, computer work) can lead to impaired vision — can seeing double, it becomes difficult to determine the distance between the objects. In addition to fatigue the eye, astigmatism can cause constant headaches. Furthermore, during the execution ofphacoemulsi-fication 0.05-1.2 % of posterior capsule rupture occurs.
In view of the above, the development of methods of selecting an intraocular lens implantation during cataract phacoemulsification with intraoperative posterior capsule rupture emerged, and in the eyes of the weakness ofligament of the lens unit is relevant, because of its solution depends on improving the quality of functional rehabilitation of patients.
Objective: to study the possibility of implantation of intraocular lens RSP-III using the injector during cataract phacoemulsification through a small self-sealing incision.
Material and methods. The object of the study were the results of phacoemulsification of 16 patients (16 eyes) with complicated cataract, at intraoperative posterior lens capsule rupture.
