RU2477079C2 - Method of antenatal correcting gymnastics in case of fetus neck entanglement by umbilical cord - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine: prenatal ultrasonic diagnostics and obstetrics. Ultrasonic examination is performed in order to specify fetus position and umbilical cord trajectory before pregnant patient does correcting gymnastics, daily ultrasonic control is carried out daily after it. Correcting gymnastics includes four successive 90-degree turns from position "lying on back" with 10 minute interval: to the right or to the left in direction, opposite to direction of umbilical cord. Fetus is released from umbilical cord loop by making successive turn in amnionic fluid under impact of its own force of gravity as a result of a kind of "untwining".

EFFECT: method makes it possible for fetuses to get free from entanglement in 60-70% of cases, in 71,5% of cases - to move from pelvic to cephalic presentation independently or after administration of traditional correcting gymnastics in connection with pelvic presentation or by means of external rotation by Arkhangelskiy.

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Description

The claimed invention relates to medicine, namely to prenatal ultrasound diagnostics and obstetrics, and may find application for the correction of entanglement of the umbilical cord around the fetal neck in the third trimester of pregnancy in order to prevent possible threatening fetal conditions and complications during childbirth, including when the fetus is in the pelvic presentation, reduce the frequency of surgical interventions.

The proposed method is used to correct the entanglement of the umbilical cord around the neck of the fetus, located in the head or pelvic presentation with the longitudinal position of the fetus in the uterine cavity.

Umbilical cord entanglement around the fetal neck is quite common - on average, in 14-20% of cases of all births [1]. In 74-82% of cases, it happens once. In other cases, the frequency of entanglement can vary from 2 or more. The entanglement can be tight and weak. The frequency of tight entanglement ranges from 26.1 to 35% of the total number of this pathology [2]. In the later stages, according to the research results of prof. V.N.Demidova [2], during the last week before delivery, only about 1 out of 10 fetuses is independently released from the umbilical cord around his neck as a result of rotational movements.

According to some researchers, umbilical cord entanglement in 21-65% of cases is the direct cause of acute fetal hypoxia and in 2.4-6.9% of cases, the cause of intra- and postnatal mortality [2].

The most common type of cord entanglement is an isolated single, not tight entanglement around the neck of the fetus, which, as a rule, is not dangerous for him.

Dangerous can be mainly double or multiple tight tight entanglement of the umbilical cord. With this entanglement, signs of fetal hypoxia are already recorded during pregnancy. With tight entanglement and the occurrence of relative shortening of the umbilical cord in the second stage of labor, tension arises, narrowing of the lumen of the vessels, leading to a sharp decrease in blood supply to the baby’s tissues (acute hypoxia and asphyxiation).

The entanglement of the umbilical cord around the fetal neck with pelvic presentation is also dangerous. At the same time, it also causes the fetus to be in the wrong position in the uterine cavity if the entanglement occurs immediately after the umbilical cord leaves the placenta. This can be diagnosed with ultrasound (Fig. 1). This situation can lead not only to fetal hypoxia and abnormalities of labor, but also in the case of a relative shortness, can cause tension of the umbilical cord and placental abruption and fetal asphyxiation in labor.

Therefore, for a period after 37 weeks in the presence of such an entanglement of the umbilical cord, a planned cesarean section is most often produced.

In this regard, the proposed method can become another independent method or the basis for the subsequent appointment of other methods used to turn the fetus from the pelvic presentation to the head, when the fetus is placed incorrectly around the umbilical cord around its neck.

Several methods of non-invasive antenatal correction of the pelvic position of the fetus are known [3]. These include the method of I.F. Dikan, the methods of V.V.Fomicheva, E.V. Bryukhina, I.I. Grishchenko and A.E. Shuleshova. Known techniques are a set of exercises designed to transfer from the pelvic presentation of the fetus to the head.

The disadvantage of the known methods is, first of all, the lack of visual control using sonography the next day, i.e. the pregnant woman may not feel that the child has rolled over, and will continue gymnastics for a week until the next admission to the antenatal clinic. And, by the way, it is not always possible to palpate accurately even the physician with a long history of work to accurately determine the pre-existing part of the fetus (this is the head or the pelvic end). In addition, the known methods do not contain exercises for "removing" the umbilical cord from the fetal neck. Many corrective gymnastics complexes must be performed only with the consent of the attending physician, preferably under the guidance of an instructor in a school for pregnant women, provided that the patient does not have a whole range of contraindications:

- the threat of abortion;

- the presence of a scar on the uterus;

- malformations of the fetus;

- history of infertility and miscarriage;

- pregnancy toxicosis;

- placenta previa;

- low or high water;

- multiple pregnancy;

- severe extragenital diseases;

- Anomalies in the development of the uterus.

Closest to the claimed method of antenatal corrective gymnastics in the pelvic position of the fetus is the method of I.F. Dikan. This method is used for high uterine tone and gestational age of 29-37 weeks. Pregnant, lying on the bed, 3-4 times rotates alternately on the left or right side and lies on each of them for 10 minutes. Such classes are carried out 3-4 times a day for 7-10 days. Dikan gymnastics has no contraindications and is absolutely safe. The rotation of the fetus usually occurs during the first week.

However, the disadvantage of this method is the lack of visual control using ultrasound the next day and the absence of exercises to "remove" the umbilical cord from the fetal neck.

The effectiveness of known exercises, according to various estimates, is about 75%. In our case, a positive result is also achieved in 70-80% of cases. However, in this case, in contrast to the known methods, the basis of our proposed method is a less complex set of exercises. These are the usual, but targeted changes in the location of the body that the pregnant woman takes during the day, resting, or when she is unloading the kidneys during hydronephrotic transformation of the latter, standing on all fours or in the knee-elbow position.

Sometimes gymnastic exercises do not give any result. In this case, we can recommend a preventive external obstetric preventive rotation of the fetus on the head with pelvic presentation according to B.A. Arkhangelsky.

It is carried out at a gestational age of 34-37 weeks in an obstetric hospital. Before turning, funds are introduced to relax the uterus. The rotation is carried out under the supervision of ultrasound. This is a difficult procedure, and it is not suitable for every pregnant woman. There are quite a few contraindications to an external turn, here are some of them:

- scar on the uterus;

- the threat of abortion;

- obesity;

- The age of primiparas is more than 30 years;

- a history of infertility or miscarriage;

- gestosis (toxicosis);

- placenta previa;

- Anomalies in the development of the uterus;

- entanglement of the umbilical cord;

- low water or high water;

- narrow basin;

- severe extragenital diseases of the mother;

- pregnancy that has occurred with the help of assisted reproductive technologies.

External rotation is an unsafe procedure for both the mother and the child, fraught with a number of complications, including placental abruption, premature birth, deterioration and fetal death, and the development of immunological conflicts between the mother and the fetus.

External rotation is effective only in about 65% of cases; after a successful external rotation, almost all births occur through the natural birth canal. But in general, due to a large number of contraindications and possible complications, an external turn is rather rare [6].

The application of the proposed method ultimately reduces by one third the frequency of use of this technique.

The objective of the invention is the correction of the entanglement of the umbilical cord around the neck of the fetus in the third trimester of pregnancy in order to remove the obstacle and create the basis for its subsequent rotation into the head presentation for the prevention of possible threatening fetal conditions and complications in childbirth associated with this pathology, and to reduce the frequency of surgical interventions.

The problem is solved by ultrasound examination to clarify the path of the umbilical cord from the placenta to the umbilical ring; the appointment of corrective gymnastics to the pregnant patient, determining the latter in which direction she needs to make four consecutive turns of 90 degrees from the “lying on her back” position (general circular rotation of 360 degrees) at intervals of 10 minutes: to the right or left so that “Tell” the fetus a similar direction of rotation inside the amniotic cavity after the mother to exit the loop. The pregnant woman independently conducts corrective gymnastics taking into account the recommendations received. A daily echographic control is carried out until a positive result is achieved. The proposed method is applicable for the rotation of the fetus from the pelvic presentation to the head, when the cause of the incorrect position is the entanglement of the umbilical cord around the neck of the fetus immediately after it leaves the placenta. The method is used to remove the loop around the neck of the fetus also in the longitudinal position and head presentation of the fetus.

The method is as follows. With the help of ultrasound, the position of the fetus, the trajectory of the umbilical cord from the placenta to the umbilical ring, is clarified. The direction of rotation is selected. The patient assumes the initial position of "lying on his back." He then spends four consecutive 90-degree turns, making a total of 360-degree circular turns at 10-minute intervals. The final position of the pregnant woman after the turn is “lying on her back”. When performing a coup, a pregnant woman takes a knee-elbow or palmar-elbow position. The next day, an ultrasound scan is performed. Gymnastics is carried out until a positive result is obtained.

The main positions of the pregnant patient during corrective gymnastics are presented in the figures, where:

Fig.2 - the initial and final position of the pregnant woman before and after the turn: in the "lying on his back" position.

Fig. 3 - position on the left side (depending on the direction of the chosen turn);

Fig. 4 - position on the right side;

Fig. 5 - knee-elbow or palmar-elbow position.

As a result of the corrective gymnastics of the proposed method from 65 (100%) in 39 (60%) cases, it was possible to "remove" the umbilical cord from the fetal neck.

For 1 day of gymnastics, entanglement disappeared in 17 (43.58%), in 2 days - in 6 (15.38%), in 3 days - in 7 (17.95%), in 5 days - in 2 (5 , 13%), in 6 days - in 2 (5.13%), in 7 or more days - in 5 (12.8%) fruits out of 39 (100%) fruits.

Of the 7 (100%) observations when the cause of the pelvic presentation of the fetus was the entanglement of the umbilical cord around his neck immediately after it left the placenta, in 2 (28.5%) cases it was possible to remove the loop of the umbilical cord, but the fetus never passed into the head for pure gluteal previa and oligohydramnios, which prevent bending of the legs in the knee joints to create support and the subsequent basis for making an independent turn on the head. In 2 (28.5%) cases, the day after the appointment of the gymnastics, the fruits, having gotten rid of the entanglement, independently switched from mixed gluteal to head presentation. In 3 (43%) other cases, the external obstetric preventive rotation of the fetus onto the head was successfully performed according to B.A. Arkhangelsky after ascertaining the absence of cord entanglement around the neck of the fetus, with its anterior view and mixed gluteal presentation.

Example 1. Pregnant patient C, 23 years old. Pregnancy 33 weeks. The fruit is in a longitudinal position and mixed gluteal previa. A 2-fold entanglement around the fetal neck with an umbilical cord immediately after it leaves the placenta. On the 3rd day during the control ultrasound examination, no entanglement was found. The fetus was transferred to the head presentation by means of an external obstetric preventive turn according to B.A. Arkhangelsky. An urgent delivery through the natural birth canal occurred at 39 weeks with an Apgar score of 9-10 points.

Example 2. Pregnant patient K., 27 years old. Pregnancy 34 weeks. The fetus is in a longitudinal position and pelvic presentation. 1-fold entanglement around the fetal neck with the umbilical cord immediately after it leaves the placenta. The day after the appointment of corrective gymnastics, the fetus independently transferred to the head presentation, which was ascertained during the control ultrasound examination. There was no entanglement. The baby was born at 40 weeks as a result of an urgent birth through the natural birth canal with an Apgar score of 8-10 points.

Example 3. Pregnant patient D., 31 years old. Pregnancy 32 weeks. The fetus is in a longitudinal position and head presentation with a 2-fold circular complete entanglement of the umbilical cord around the neck. On the second day after the appointment of corrective gymnastics in the course of the control echography, a 1-fold incomplete entanglement of the type of muffler was ascertained. After another 2 days, no entanglement was found. The baby was born on time through the natural birth canal without entanglement with an Apgar score of 9-10 points.

Note: all of the above examples took place in the department of prenatal diagnostics of the Perinatal Center in the city of Yoshkar-Ola of the Republic of Mari El.

Information sources

1. Yudina E.V., Volkov A.E., Medvedev M.V. Ultrasound examination of the placenta, umbilical cord and amniotic fluid // Prenatal Ultrasound / Ed. Medvedeva M.V. M .: Realnoe Vremya, 2005.

2. Demidov V.N. The use of dopplerography for the diagnosis of umbilical cord entrapment // Prenatal diagnosis. 2005.V.4. No. 1. S.10-13.

3. Aristov A.A. Early diagnosis of threatening fetal conditions: Diss ... cand. honey. sciences. M., 1975. 112 s .;

4.http: //materinstvo.ru/art/953/:

5.Http: //www.pregnancvcalendar.ru/biblioteka/vse_о_beremennosti/gimnastika_рri_tazovom/:

6. http://www.9months.ru/press/11/11/;

Claims (3)

1. The method of antenatal corrective gymnastics in the case of entwining the umbilical cord around the neck of the fetus, including corrective gymnastics and ultrasound, characterized in that the ultrasound examination is performed to clarify the position of the fetus and the trajectory of the umbilical cord before the pregnant patient performs corrective gymnastics and daily ultrasound monitoring after it, when this corrective gymnastics includes four consecutive turns of 90 ° from the position of "lying on your back" with an interval of 10 minutes: on the left or in the opposite direction to the cord, to release the fruit from it by committing successive turning them in the amniotic fluid under the action of gravity as a result a kind of "unwinding". 2. The method according to claim 1, characterized in that the corrective gymnastics is performed to remove the umbilical cord from the fetal neck with its pelvic presentation. 3. The method according to claim 1, characterized in that the corrective gymnastics is performed to remove the umbilical cord from the fetal neck with its head presentation.

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