RU2294136C2 - Method for predicting fetal state during parturition - Google Patents

Abstract

FIELD: medicine, obstetrics.

SUBSTANCE: the present innovation deals with detecting the time for parturition. One should simultaneously register fetal cardiotocography (CTG) and its direct ECG. At registering pathological CTG along with its ECG being without deviations one should diagnose the necessity for urgent parturition within 1.5-2 h. At registering pathological CTG and ECG with deviations against the norm one should diagnose the necessity for immediate parturition. The innovation enables to achieve decreased fetal hypoxia at different abnormalities of parturition.

EFFECT: higher accuracy and efficiency of diagnostics.

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Description

The invention relates to medicine, to obstetrics.

It is known that to diagnose the condition of the fetus with anomalies of labor, external cardiotocography is used with simultaneous recording of its direct electrocardiogram in childbirth.

Modern obstetrics, although it has a number of methods for assessing the status of the fetus in childbirth with impaired labor, however, the use of external cardiotocography alone leads to a significant percentage of errors in the diagnosis of fetal hypoxia in childbirth. It is known that to study the condition of the fetus, simultaneous recording of a direct ECG and external cardiotocography / CTG / are used (Amer. - Uelin et al., Lancet, 2002, 358, p. 544), but we did not find information on dynamic signs in the literature.

The purpose of the invention is the reduction of fetal hypoxia during childbirth with anomalies of labor.

1. The essence of the proposed method for diagnosing the condition of the fetus, including continuous simultaneous registration of direct electrocardiography of the fetus and its external CTG and ECG: in the case of registration of abnormal CTG and simultaneous ECG without significant deviations from the norm, they diagnose the need for urgent delivery within 1.5-2 hours, and in case of registration of abnormal CTG with ECG with abnormalities, the need for immediate delivery is diagnosed.

2. The method is as follows. Upon admission to the maternity ward, all women in labor must undergo cardiomonitorial monitoring of the condition of the fetus using fetal monitors “Fetalgard-3000” with computerized processing of CT data in points according to V. M. Fisher. The technique allows you to simultaneously assess the condition of the fetus and contractile activity of the uterus. Recording is carried out at a tape speed of 1 or 2 cm / min for at least one hour. At the same time, in the absence of a fetal bladder or after an amniotomy, when the uterine pharynx is opened 3-4 cm, a special scalp electrode is attached to the fetal head, which is connected to an apparatus that allows you to record a direct ECG of the fetus in childbirth, in particular using BMT 9141 / Germany /, which has highly insulated inputs for branching the fruit electrocardiogram. The screw electrode wire is inserted into the conductor and reaches the preceding part of the fetus, is easily pressed and attached to the fetus by 1/2 to 3/4 turn of the handle in the clockwise direction. On the special screen of the video block and on paper, the ECG is simultaneously visible. The BMT monitor allows you to simultaneously record the intrauterine pressure and fetal ECG. Monitoring the condition of the fetus allows real-time assessment of the condition of the fetus during childbirth (first and second stage of labor). The combined use of external cardiotocography with direct electrocardiography of the fetus allows for timely diagnosis of fetal hypoxia during childbirth.

The claimed method for the diagnosis of fetal hypoxia in childbirth can be demonstrated by the following examples.

Example 1

Multiparous B. E. S., 30 years old, birth history number 4811 from 2002 was admitted to the State Research Institute of Obstetrics and Gynecology named after D.O. OTTO RAMP 3.12.02

Diagnosis: childbirth 2 urgent. Early outflow of water. Fetoplacental insufficiency. Hypotrophy of the fetus. Chronic tonsillitis. Chronic pyelonephritis. Stomach ulcer. Mitral valve prolapse. Pneumonia during pregnancy. Uterus scar after conservative myomectomy.

Upon admission to the maternity ward, leakage of light waters is noted. An internal study noted that the cervix is smoothed, the edges of the pharynx are of medium thickness, the opening of the uterine pharynx is 3 cm, and there is no fetal bladder. The head is pressed to the entrance to the pelvis. Cape is not reachable.

Given the complicated course of pregnancy and childbirth, antioxidants and antihypoxants were used prophylactically. Conducted at 13.30 min simultaneous registration of the fetal cardiac activity and its motor activity by methods of external cardiotocography and direct fetal ECG. The parameters of the external cardiotocography of the fetus and direct ECG in childbirth: basal frequency of 130 beats / min, oscillations of 6-8 per minute, motor-cardial reflex of 15 beats / min. At the end of the first period of childbirth - the beginning of the second period of childbirth, pathological abnormalities of CTG with decelerations up to 90 beats / min were noted. Diagnosis: delivery by obstetric forceps. After the birth of the fetus, it was found that these decelerations were due to the presence of a true umbilical cord node. At 2:30 p.m., a live full-term boy was born, weighing 3160.0 g and growing 51 cm, with an Apgar score of 8 points. It is attached to the breast in the delivery room, the minimum weight is noted on the day, the weight is restored on the 6th day, the umbilical cord is dropped on the 3rd day. Mild neurological symptoms were noted due to impaired spinal circulation at the level of C2-C7. The postpartum period was complicated by subinvolution of the uterus, and therefore the postpartum was discharged on the 10th day home in satisfactory condition with the child.

Example 2

Multiparous Sh. O.D., 28 years old, birth history number 3032 dated 06/19/2002, was admitted to the maternity department of the Research Institute of Obstetrics and Gynecology named after DO Otto RAMS with a diagnosis of childbirth 2 urgent. Early outflow of water. Scar on the uterus after cesarean section. The onset of fetal hypoxia. Thrombocytopenia. Shortening 2 periods of childbirth. Perioneemiotomy Manual examination of the uterine cavity. A woman has a history of 1 urgent delivery, due to the presence of pelvic presentation, a cesarean section was performed. Regular labor activity was established from 9 a.m. 06/19/02. At 9 a.m. 45 pours, green colored meconium spilled water. During vaginal examination, the cervix is 11 cm long, soft, centered, the cervical canal is 3 cm long. There is no fetal bladder, the head is lying, pressed to the entrance to the pelvis. Cape is not reachable. Water stained with meconium is leaking. At 13 00 min, due to the onset of fetal hypoxia, a simultaneous external CTG and direct fetal ECG were performed to identify the severity of hypoxia and choose a delivery tactic. Measures were taken to treat fetal hypoxia with antioxidants and antihypoxants. According to external CTG, its parameters are within normal limits, according to direct ECG, a moderate increase in the ST segment is observed within normal limits. Monitoring of the fetus continues, it was decided to conduct childbirth conservatively through the natural birth canal. Clan activities developed at a good pace and childbirth began on 06/19/02 at 14 h 05 min. A boy was born with a mass of 3320.0 and a height of 50 cm, with an Apgar score of 8 points. Sanitation of the upper respiratory tract was carried out with suction of meconium. The condition after birth is satisfactory. In connection with the onset of fetal hypoxia, the second period of labor was shortened. The condition of the child before discharge from the hospital is quite satisfactory. The minimum weight was noted on the 3rd day, restored on the 5th day, the umbilical cord was dropped on the 4th day. The postpartum woman and her child were discharged on the 6th day in a satisfactory condition.

Example 3

Patient E.O.Yu., 24 years old, birth history number 2053 was received on 04.28.2003 in the maternity ward with a diagnosis of Childbirth I, urgent. Nephropathy I degree. Hypotrophy of the fetus II degree. Chronic pyelonephritis in remission. The onset of fetal hypoxia. Fetoplacental insufficiency. Rhesus negative blood without antibodies. Chronic gastritis. Biliary dyskinesia. Amniotomy. Caesarean section operation.

The start of contractions was preceded by a pathological preliminary period from 13 h 40 min. In connection with the availability of data for fetal hypotrophy / ultrasound /, trental was introduced at a dose of 5 ml No. 4 in the antenatal ward; upon admission to the maternity ward due to the presence of a pathological preliminary period, a ginipral beta-mimetic was prescribed in a 5 μg position intravenously, drip and for prevention fetal hypoxia prescribed antioxidants in combination with antihypoxants / solution of unitiol and mildronate /. According to internal research, the cervix is shortened to 1.5 cm, deflected posteriorly, the cervical canal passes for 1.5 fingers beyond the internal pharynx. CTG data at this time is within normal limits: basal frequency 145 beats / min, intra-minute fluctuations of 8-10 strokes motor-cardial reflex 15-17-20 beats / min. Ginipral infusion continues.

After 4 hours, fetal heart rate abnormalities / 18 h 26 min / are noted: basal heart rate of 170 beats / min, oscillations - 9-12 strokes, motor-cardial reflex is absent. After 1 hour, an amniotomy was performed - meconium was found in the amniotic fluid and oligohydramnios. A direct ECG of the fetus was put, and antioxidant preparations (unitiol in combination with mildronate) were reintroduced. According to the direct ECG, the basal frequency is 170/180 bpm, there is a further decrease in oscillations to 7-9-11 and the absence of a motor-cardial reflex. Repeated data of internal research: the neck is smoothed, the edges of the pharynx are of medium thickness, the opening of the uterine pharynx is 4 cm, the head is pressed to the entrance to the small pelvis. The cape is not reachable / 20 h 45 min /.

Given the increase in symptoms of hypoxia according to the external and direct ECG of the fetus, at 21 h 10 min, a Caesarean section was performed. A live full-term girl with a mass of 2990.0 and a height of 50 cm was extracted with an Apgar score of 7 points in the first minute and 7 points in 5 minutes.

From birth, the condition of the child was regarded as moderate due to mild respiratory disorders and neurological symptoms of the type of central nervous system depression syndrome. The diagnosis was established: cerebrovascular accident I degree of hypoxic origin, fetal malnutrition II degree, risk group II.

The child on the 3rd day was already attached to the mother’s chest, was discharged on the 9th day with his mother / cesarean section /.

Example 4

Patient G. G.A. 20 years old, birth history number 370 dated 01/21/2003, was admitted to the maternity ward with a diagnosis of Childbirth I urgent. Ureaplasmosis. Premature discharge of water. Weak labor. The onset of fetal hypoxia. Rear view of the occipital presentation. Nephropathy I degree. Cesarean section. Asphyxia of the newborn mild / enlivened /. On January 22, an internal examination was performed in the maternity ward: the cervix is shortened to 1.5 cm, deflected toward the sacrum, moderately softened, tightened in the region of the internal pharynx, the cervical canal passes for the I transverse finger. There is no fetal bladder, bright water is leaking, there is a head, slightly pressed to the entrance to the pelvis. Cape is not reachable.

Given the night time / 1 h 00 min /, the patient was given medication sleep-rest / promedol in combination with no-shpa and diphenhydramine, relanium /. Cardiotocography data at the upper limit of the norm are heart rate-150 beats / min, oscillations 5-10-15 min, motor-cardial reflex 30 beats / min. At 7 hours and 30 minutes, it was prescribed due to the lack of labor - a site library of 25 mcg 3 times with an interval of 3 hours.

Repeated CTG data are the same. After 2 hours, CTG recording indicates a pathological curve - heart rate-155 beats / min, oscillations 4-7, motor-cardiac reflex 25 beats / min. Appeared in the amniotic fluid of meconium. In connection with changes in the CTG and direct EVH symptoms of fetal hypoxia, fetal hypoxia was treated. After another 3 hours, according to the external and internal CTGs, variable decelerations of 70 beats / min appeared and at the opening of the uterine pharynx 7 cm. In the absence of conditions for rapid delivery, an emergency cesarean section was performed. On January 22, at 13 h, 26 min, a boy was weighed out, weighing 3,760.0, and a height of 51 cm, with a slight degree of asphyxiation (animated). The Apgar score on the 1st minute is 6 points, on the 5th minute 7 points.

The condition of the child at birth was regarded as moderate, there was a moderate neurological symptomatology, but the condition quickly improved, the tone and reflexes from 4 days are satisfactory, applied to the mother’s chest, was discharged with the mother on the 9th day (cesarean section).

Thus, the proposed new method for diagnosing fetal hypoxia during childbirth can be recommended for use in obstetric hospitals for timely diagnosis of fetal hypoxia, assessing the effectiveness of the therapy and choosing a delivery method in the interests of the fetus.

Continuous monitoring of fetal cardiac activity by external CTG in combination with a direct ECG of the fetus reduces the frequency of severe asphyxiation (1-4 points on the Apgar scale) by 3 times from 4.68 to 1.54% of 194 women in labor.

Continuous monitoring allows timely diagnosis of fetal hypoxia and timely cesarean section, in which there is a decrease in the frequency of birth of children in severe asphyxia by 3.7 times. In conditions of combined monitoring of fetal cardiac activity, a 2-fold decrease in the number of newborns admitted to the intensive care unit and intensive care unit was noted (37.1 versus 71.7% in the control).

The presence of persistent bradycardia with the absence of CTG curve variability, regardless of the ST-segment indices, requires immediate operative delivery.

The presence of a pathological CTG curve with tachycardia over 160 beats / min, reduced variability (less than 5 beats / min) or a sinusoidal rhythm in combination with a biphasic type 2, when the ST segment components cross the isoline, indicates the need for delivery within 1-1.5 hours .

Claims (1)

A method for determining delivery time, including the simultaneous registration of cardiotocography (CTG) of the fetus and direct registration of its ECG, characterized in that when registering a pathological CTG and at the same time an ECG without deviations, the need for urgent delivery for 1.5-2 hours is diagnosed when registering a pathological CTG and ECGs with abnormalities diagnose the need for immediate delivery.