Placental insufficiency and intrauterine growth retardation

Placental insufficiency (PN) is a clinical syndrome caused by morphofunctional changes in the placenta and violations of compensatory and adaptive mechanisms that ensure normal growth and development of the fetus, as well as adaptation of the woman's organism to pregnancy. Placental insufficiency is the result of a complex reaction of the fetus and placenta to various pathological conditions of the maternal organism and is manifested in a complex of transport, trophic, endocrine and metabolic functions of the placenta underlying the pathology of the fetus and the newborn. Clinical manifestations of it - the syndrome of fetal growth retardation and / or fetal hypoxia.

Placental insufficiency is a pathophysiologic phenomenon consisting of a complex of disorders of the trophic, endocrine and metabolic functions of the placenta, leading to the inability to maintain adequate and sufficient exchange between the mother and fetus organisms. The placental insufficiency syndrome has a multifactorial nature. Now it is established that this pathological phenomenon accompanies almost all complications of pregnancy. Usual miscarriage is complicated by placental insufficiency, according to the literature, in 47.6-77.3% of observations. There is an unfavorable background for pregnancy due to hormonal insufficiency, functional and structural infertility of the endometrium, chronic endometritis, malformations of the uterus, autoimmune and other reproductive system disorders that often lead to fetal development not only of delayed development but also severe chronic hypoxia .

Fetal growth retardation syndrome (FGR), intrauterine fetal growth retardation; fetus, small for the duration of pregnancy and fetus with a low birth weight - terms describing the fetus that has not reached its growth potential due to genetic or environmental factors. A generally accepted criterion is a decrease in body weight <10 percentile for gestational age.

ICD-10

• P00 Fetus and newborn affected by maternal condition not associated with present pregnancy
• P01 Fetus and newborn affected by complications of pregnancy in the mother
• P02 Fetus and newborn affected by complications from the placenta, umbilical cord and membranes
• P05 Slow growth and malnutrition of the fetus
• P20 Intrauterine hypoxia.

Epidemiology

Epidemiology of placental insufficiency

Placental insufficiency is often noted in obstetric and extragenital pathology in pregnant women and is 22.4-30.6%. Thus, in case of termination of pregnancy, placental insufficiency is diagnosed in more than 85% of women, in gestosis - in 30.3%, in arterial hypertension - in 45%, in anemia and isoserological incompatibility of blood of the mother and fetus - up to 32.2% with uterine myoma - in 46%, with diabetes - in 55%, with violations of fat metabolism - in 24% of pregnant women. Perinatal mortality in placental insufficiency reaches 40%, perinatal morbidity - 738-802 ‰. In this case, the proportion of hypoxic-ischemic lesions of the central nervous system is 49.9%, which is 4.8 times higher than in uncomplicated pregnancy; respiratory disorders and aspiration syndrome are noted in 11% of newborns, and resuscitation should be carried out in 15.2%. The incidence of FGRS varies in the population from 10 to 23% of full-term newborns in developed and developing countries, respectively. The frequency of FGRS increases with decreasing gestational age. Presence of congenital malformations, intrauterine hypoxia, transient cardiorespiratory disorders, chromosomal aberrations, intrauterine infections, and prematurity significantly (up to 60%) increase the risk of perinatal losses.

Thus, among full-term newborns with a body weight of 1500-2500 g perinatal mortality is 5-30 times higher, in children with body weight less than 1500 g - 70-100 times higher than in newborns with a normal body weight.

70% of the fetuses and newborns whose body weight is no higher than 10 percentile for the gestation period are small due to constitutional factors (female gender, maternal affiliation to certain ethnic groups, maternity parity, mass growth characteristics of the mother), but among these children, perinatal mortality rates are not differ from those in children with a normal body weight for a period.

The moderate and severe delay in fetal growth is determined by body weight from 3 to 10 percentiles and <3 percentiles, respectively.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Forms

Classification of placental insufficiency

There is no generally accepted classification of placental insufficiency in connection with its multifactorial etiology. Depending on the structural units in which pathological processes occur, three forms of placental insufficiency are distinguished:

1. Hemodynamic, manifested in the utero-placental and fruit-placental pools;
2. placental-membrane, characterized by a decrease in the ability of the placental membrane to transport metabolites;
3. cell-parenchymal, associated with a violation of the cellular activity of trophoblast and placenta.

There are also primary fetoplacental insufficiency, which appeared before the 16th week of pregnancy, and secondary, developing in later terms.

Placental insufficiency - Classification

[12], [13], [14], [15], [16], [17], [18], [19]

Diagnostics of the placental insufficiency and intrauterine growth retardation syndrome

Diagnosis of placental insufficiency

Currently, various methods are used to diagnose placental insufficiency. Clinical methods include the detection of anamnestic risk factors, an objective examination of the pregnant and fetus by measuring the circumference of the abdomen and the height of the standing of the uterine fundus, determining the tone of the myometrium, the position of the fetus, and calculating its estimated weight. It is known that the lag of the height of the standing of the uterus bottom by 2 cm or more in comparison with the proper value for a specific gestation period or the absence of an increase within 2-3 weeks indicates the probability of the development of the FGR. Clinical evaluation of the state of his cardiovascular system is carried out by auscultation. For female counseling, a ballistic system for determining the risk of placental insufficiency, developed by O.G. Frolova and E.N. Nikolaeva (1976, 1980).

Important information in childbirth about the functional reserves of the fetus is the evaluation of the quality of amniotic fluid. At present, prognostic criteria for a severe complication of placental insufficiency are found - meconial aspiration of fetus and newborn (by the nature of amniotic fluid in combination with data on its cardiac activity and respiratory activity). A scoring scale is created that takes into account the color of the water, the consistency of meconium, the duration of pregnancy and the presence of signs of hypoxia according to the evaluation of cardiac activity of the fetus. At 12 points the probability of meconial aspiration in a fetus is 50%, 15 and more - 100%. However, the individual variability of the size of the abdomen and uterus of a pregnant woman, depending on the anthropometric features, the severity of the subcutaneous fat layer, the amount of amniotic fluid, the position and the number of fruits, are considered to be a significant limitation of clinical diagnostic methods.

Placental insufficiency - Diagnosis

[20], [21], [22], [23], [24], [25], [26], [27], [28]

Treatment of the placental insufficiency and intrauterine growth retardation syndrome

Treatment of placental insufficiency

Objectives of treatment of placental insufficiency and intrauterine growth retardation

Therapy should be aimed at improving uteroplacental and placental blood flow, intensification of gas exchange, correction of rheological and coagulation properties of blood, elimination of hypovolemia and hypoproteinemia, normalization of vascular tone and contractile activity of the uterus, enhanced antioxidant protection, and optimization of metabolic and metabolic processes.

Indications for hospitalization for placental insufficiency and intrauterine growth retardation

Subcompensated and decompensated placental insufficiency, a combination of placental insufficiency and FGRS with extragenital pathology, gestosis, threatening premature birth.

Placental insufficiency - Treatment

Prevention

Prevention of placental insufficiency

• treatment of extragenital diseases before pregnancy;
• correction of metabolic disorders and blood pressure from early gestation;
• adherence to a rational diet and the regimen of a pregnant woman;
• According to the indications, the appointment of antiplatelet agents (acetylsalicylic acid 100 mg / day, dipyridamole 75 mg / day and pentoxifylline 300 mg / day) and anticoagulants (calcium supraparin, dalteparin sodium);
• according to the indications, the use of deproteinized hemoderivate from the blood of dairy calves (Actovegin) 200 mg 3 times a day, for 21-30 days;
• use of gestagens (dydrogesterone, microionized progesterone) in pregnant women with a habitual loss of pregnancy from early gestation;
• the appointment of multivitamin complexes.