Pregravid preparation and obstetric tactics in women with a history of antenatal foetal death
The objective. Finding risk factors for repeated reproductive losses, development of a differential approach to the tactics of management of pregnancy based on complex clinical, echographic and laboratory examination of the state of the foetoplacental system for decreasing perinatal morbidity and mortality among women with antenatal losses in a previous pregnancy. Patients and methods. The study included 110 women. The study was performed in 2 stages: stage 1 - complex pregravid laboratory-instrumental examination of 45 women with a history of foetal losses (prospective group) and 30 women with a noncomplicated obstetric-gynaecological history (control group) for detection of risk factors of repeated foetal losses. Stage 2 - analysis of the course of pregnancy, childbirth and perinatal outcomes in 95 women from 3 groups. The basic group - 35 women of the prospective group, who became pregnant during the period of study, went through complex laboratory-instrumental examination and careful follow-up during gestation. The reference group - 30 pregnant women with antenatal foetal loss (AFL) in medical histories who underwent standard follow-up and examination in a maternity outpatient clinic. The control group - 30 pregnant women with a physiological course of single-foetus pregnancy examined at the 1 st stage. Results. Complex pregravid examination for subsequent pregnancy in women with a history of AFL permitted to find risk factors of repeated reproductive losses: in 64.4% - urogenital infections; in 9% - structural changes of the myometrium; in 13.3% -disorders of uterine haemodynamics and/or central brain haemodynamics (CBH); in 18% -circulation of antiphospholipid antibodies (APA), in 46.7% - excessive activity of vascular-thrombocyte and/or plasma haemostasis. Complex echographic examination of pregnant women at early terms of gestation that began after AFL found the factors conditioning impairment of the processes of physiological placentation in 25.7% of women: retrochorionic haematoma (8.6%); a hypokynetic type of CBH (14.3%) and increased uterine arteries (UA) resistance (11.4%) revealed at the state of pregravid examination. Disorders of uterine and systemic haemodynamic revealed at pregravid examination determined the development of placental insufficiency (PI) and gestosis. During pregnancy that occurred after AFL, in 45% of women who did not have disorders of haemostasis before gestation pathological activation of intravascular blood coagulation at terms 10-18 wks was found. In 12.5% of pregnant women, who received therapy for disorders of haemostasis during gestation, repeated disorders of blood coagulation at terms 28-29 wks were found. A differential approach to management of subsequent pregnancy in women with a history of AFL permitted to decrease the incidence of complications of gestation as compared with the reference group: of threatened miscarriage - by 1.63 times, PI - by 1.33 times (40 vs. 53.3%), gestosis was found by 1.2 times more rarely and by 2 more frequently took a milder course (85.7% of mild forms in the basic group vs. 43% in the reference group), chronic foetal hypoxia was absent. Medication prevention of PI from early terms of gestation permitted to avoid progression and development of severe forms of PI. In the basic group, only compensated PI was found (40%), in 57% represented by isolated haemodynamic disorders grade 1, in 43% - in combination with intrauterine growth restriction syndrome (IUGR) grade 1, oligoamniosis and early placental maturation. Conclusion. Pregravid preparation, laboratory-instrumental examination, medication prevention of placental insufficiency from early terms of gestation, development of an individual obstetric tactics in women with a history of AFL contribute to a decrease of the incidence and severity of gestational complications, improvement of perinatal outcomes and decrease of perinatal morbidity.