Placental insufficiency - Treatment

Therapy should be aimed at improving uteroplacental and fetoplacental blood flow, intensifying gas exchange, correcting rheological and coagulation properties of the blood, eliminating hypovolemia and hypoproteinemia, normalizing vascular tone and contractile activity of the uterus, enhancing antioxidant protection, and optimizing metabolic and exchange processes.

Indications for hospitalization in case of placental insufficiency and intrauterine growth retardation syndrome

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

Drug treatment of placental insufficiency and intrauterine growth retardation syndrome

Considering that the damaging effects of chemical agents, unbalanced nutrition, extragenital and infectious diseases, gestosis, long-term threat of miscarriage and other pregnancy complications are of great importance among the causes of placental insufficiency, it is methodically correct to begin treatment with the elimination of the unfavorable effects of these etiologic factors. Normalization of the diet in a group of pregnant women with a low quality of life by increasing the content of protein and essential minerals while reducing the proportion of fats and carbohydrates to a balanced content allows us to reduce the incidence of IUGR by 19%.

Great importance in the treatment of placental insufficiency is given to the normalization of the uterine tone, since its increase contributes to the disruption of blood circulation in the intervillous space due to a decrease in venous outflow. For this purpose, drugs with an antispasmodic effect and tocolytics (fenoterol and hexoprenaline) are used. As our studies have shown, with adequate treatment of placental insufficiency against the background of the threat of termination of pregnancy, a positive effect can be achieved in 90% of cases. The effectiveness of therapy for compensated and subcompensated forms of placental insufficiency against the background of anemia in pregnant women approaches 100%. Also quite effective is the treatment of placental insufficiency using antibacterial drugs in case of intrauterine infection (positive effect in 71.4% of cases). At the same time, in pregnant women with gestosis, treatment of placental insufficiency is effective only in 28.1% of cases with initial circulatory disorders in the mother-placenta-fetus system, which is probably associated with morphological disorders in the process of placenta formation.

The most common medications used to treat placental insufficiency include antiplatelet agents and anticoagulants. The following are commonly used from this group of drugs: acetylsalicylic acid, dipyridamole (curantil), pentoxifylline (trental), nikoshpan, xanthinol nicotinate, and sodium heparin. Reduction in the manifestations of placental insufficiency during treatment with antiplatelet agents and anticoagulants is due to increased activity of the peripheral cytotrophoblast, decreased volume of intervillous fibrinoid, adherent villi, intervillous hemorrhages, and placental infarctions. The use of antiplatelet agents is most effective in cases of excessive activation of the vascular-platelet link of the hemostasis system; in more severe disorders, including pathological enhancement of the plasma link, it is advisable to supplement treatment with heparin. This drug has an antihypoxic effect and is involved in the regulation of tissue hemostasis and enzymatic processes. Heparin does not penetrate the placental barrier and does not have a damaging effect on the fetus. In recent years, low-molecular heparins have been used to treat placental insufficiency, which have a more pronounced antithrombotic activity and produce fewer side effects (calcium nadroparin, sodium dalteparin).

Given the relationship between the uteroplacental blood flow indices and the activity of blood enzymes in pregnant women with a high risk of perinatal pathology, it is advisable to carry out metabolic therapy using ATP, inosine, cocarboxylase, vitamins and antioxidants, as well as hyperbaric oxygenation for the prevention and treatment of fetal hypoxia. Metabolic therapy is considered an essential component in the treatment of placental insufficiency. In order to reduce the intensity of lipid peroxidation, stabilize the structural and functional properties of cell membranes, and improve fetal trophism, membrane stabilizers are used - vitamin E and phospholipids + multivitamins (Essentiale). Currently, metabolic therapy for placental insufficiency in both outpatient and inpatient settings includes the use of actovegin (a highly purified hemoderivative from calf blood with low-molecular peptides and nucleic acid derivatives). The basis of the pharmacological action of actovegin is the influence on the processes of intracellular metabolism, improvement of glucose transport and oxygen absorption in tissues. The inclusion of a large amount of oxygen in the cell leads to the activation of aerobic glycolysis processes, an increase in the energy potential of the cell. In the treatment of PN, actovegin activates cellular metabolism by increasing the transport, accumulation and enhancement of intracellular utilization of glucose and oxygen. These processes lead to the acceleration of ATP metabolism and an increase in the energy resources of the cell. Actovegin also enhances blood supply. The basis of the anti-ischemic action of actovegin is also considered to be the antioxidant effect (activation of the enzyme superoxide dismutase). Actovegin is used in the form of intravenous infusions of 80-200 mg (2-5 ml) in 200 ml of 5% dextrose solution (No. 10) or in dragees (1 dragee 3 times a day for 3 weeks). The neuroprotective effect of actovegin on the fetal brain under hypoxic conditions has been proven. It also has an anabolic effect, which plays a positive role in IUGR.

In subcompensated and decompensated forms of placental insufficiency, it is also possible to combine actovegin and hexobendin + etamivin + etofillin (instenon), a combination drug that combines nootropic, vascular and neurotonic components.

Sufficient oxygen supply to the fetus plays a major role in its life support. In this regard, oxygen therapy is indicated in case of placental insufficiency.

However, it is necessary to take into account the development of protective reactions when inhaling excess 100% oxygen. Therefore, 30-60-minute inhalations of a gas mixture with an oxygen concentration of no more than 50% are used.

An important component of the treatment of placental insufficiency against the background of extragenital pathology and pregnancy complications is infusion therapy. One of the most important components of the complex of therapeutic measures for placental insufficiency is ensuring the energy needs of the fetus by administering dextrose in the form of intravenous infusions in combination with an adequate amount of insulin.

Infusion of glucose-novocaine mixture has not lost its therapeutic value as a means of reducing vascular spasm, improving microcirculation and blood flow in the arterial vessels of the placenta. Intravenous administration of ozonized isotonic sodium chloride solution helps to normalize the condition of the fetus in the presence of laboratory and instrumental signs of hypoxia.

In order to correct hypovolemia, improve the rheological properties of blood and microcirculation in the placenta, the introduction of dextran [average molecular weight 30,000–40,000] and solutions based on hydroxyethyl starch is effective. Infusions of 10% hydroxyethyl starch solution in the treatment of placental insufficiency against the background of gestosis allow achieving a reliable decrease in vascular resistance in the uterine arteries, and perinatal mortality decreases from 14 to 4‰. If hypoproteinemia is detected in pregnant women, as well as the presence of disorders in the plasma link of the hemostasis system, infusions of fresh frozen plasma are carried out in an amount of 100–200 ml 2–3 times a week. In case of protein deficiency, severe loss or increased need for proteins, in particular in case of IUGR, it is possible to use infusion therapy with preparations containing amino acid solution (aminosol, aminosteril KE 10% carbohydrate-free, infezol 40). At the same time, it should be taken into account that an increase in the concentration of amino acids in the mother's blood does not always lead to an increase in their content in the fetus.

Non-drug treatment of placental insufficiency and intrauterine growth retardation syndrome

In the treatment of placental insufficiency, physical methods of influence (electrorelaxation of the uterus, magnesium electrophoresis, the use of thermal procedures in the perirenal region) are of great importance, relaxing the myometrium and leading to vasodilation.

A new method in the treatment of pregnant women with placental insufficiency is conducting sessions of therapeutic plasmapheresis. The use of discrete plasmapheresis in the absence of an effect from the treatment of placental insufficiency with medications allows improving the metabolic, hormone-producing functions of the placenta and promotes the normalization of feto- and uteroplacental blood flow.

Treatment of placental insufficiency is effective if the first course begins before 26 weeks of pregnancy, and the second one at 32–34 weeks. Treatment at later stages improves the condition of the fetus and increases resistance to hypoxia, but does not normalize its condition and ensure adequate growth. The high frequency of unfavorable perinatal outcomes in IUGR is largely due to the need for early delivery at a time when the newborn is poorly adapted to the external environment (on average, 31–33 weeks). When deciding on early delivery, glucocorticoids are included in the complex of preparation for childbirth to prevent complications in the neonatal period [44]. These drugs not only accelerate the maturation of the fetal lungs, but also reduce the frequency of some complications. According to the American National Institutes of Health (1995), the frequency of intraventricular hemorrhages and enterocolitis in newborns with IUGR is lower in observations of prenatal administration of glucocorticoids. Dexamethasone is administered orally at a dose of 8–12–16 mg for 3 days or intramuscularly at 4 mg every 12 hours 4 times.

Patient education

It is essential to explain to the woman the need to maintain a rational diet, sleep and rest during pregnancy. The patient should be taught to monitor her body weight and blood pressure. To diagnose hypoxia, the woman should be taught to count fetal movements throughout the day and discuss situations in which she should immediately seek medical help.

Further management of placental insufficiency and intrauterine growth retardation syndrome

Compensated placental insufficiency is characterized by favorable perinatal outcomes. In this case, spontaneous births through the natural birth canal occur in 75.82% of cases, without complications - in 69.57%. Most often, the course of labor in compensated placental insufficiency is complicated by a pathological preliminary period, progression of chronic intrauterine hypoxia of the fetus, untimely rupture of amniotic fluid, weakness and discoordination of labor. The occurrence of these pregnancy complications is an indication for emergency delivery by surgery in 38.1% of cases. Indications for planned cesarean section in most cases: complicated obstetric and gynecological history (including a uterine scar after a previous cesarean section, infertility, pregnancy loss syndrome) in combination with compensated placental insufficiency, as well as complicated pregnancy, as well as the presence of signs of fetal distress (IUGR grade I, hemodynamic disorders in the mother-placenta-fetus system grade IA or Istrong, initial signs of fetal hypoxia) in older women with post-term pregnancy. As the severity of placental insufficiency worsens, the frequency of favorable outcomes of spontaneous labor decreases, and therefore, in case of subcompensated placental insufficiency, the method of choice is considered to be planned delivery by cesarean section at a time close to full-term.

Subcompensated placental insufficiency

Indications for planned delivery by cesarean section:

• moderate fetal hypoxia (reduced variability of the basal rhythm, the number of accelerations, their amplitude and duration);
• hemodynamic disturbances in the mother-placenta-fetus system of the second degree in the presence of bilateral changes and dicrotic notch in the uterine arteries;
• combination with other obstetric pathology;
• IUGR combined with gestosis or post-term pregnancy. Criteria for prolongation of pregnancy:
  • IUGR grades I–II in the presence of adequate growth of fetometric parameters during control ultrasound examinations at intervals of 7 days;
  • Stage III IUGR without increasing lag in fetometric parameters against the background of non-progressive disorders of fetoplacental circulation and/or initial signs of blood flow centralization (SDO in the fetal aorta is more than 8.0 with a SDO value in the MCA of 2.8–9.0 at 33–37 weeks);
  • absence of pronounced disturbances of uteroplacental blood flow (unilateral, without disturbance of the blood flow spectrum in the uterine arteries, SDO more than 2.4) in case of moderate gestosis;
  • absence of clinical progression of combined gestosis;
  • initial signs of hypoxia according to cardiotocography data in the absence or initial centralization of arterial fetal circulation, normal indicators of organ (renal) fetal blood flow (SDO no more than 5.2 at up to 32 weeks, and no more than 4.5 at 33–37 weeks);
  • eukinetic and hyperkinetic type of central hemodynamics of the fetus in the absence of intracardiac hemodynamic disorders. A comprehensive study of fetal hemodynamics and analysis of perinatal outcomes in placental insufficiency made it possible to develop indications for urgent delivery by cesarean section in this pathology. These include:
• cardiotocographic signs of severe fetal hypoxia (spontaneous decelerations against the background of a monotonous rhythm and low variability, late decelerations during the oxytocin test);
• critical state of fetal-placental blood flow at a pregnancy term of more than 34 weeks;
• severe disturbances of blood flow in the venous duct and inferior vena cava.

Indications for emergency delivery are the onset of labor in pregnant women with subcompensated placental insufficiency, as well as premature rupture of membranes. Indications for transferring a newborn to the intensive care unit are prematurity, hypoxic-ischemic damage to the central nervous system of varying severity.

Decompensated placental insufficiency

Indications for urgent delivery by cesarean section:

• Severe IUGR with signs of pronounced centralization of fetal arterial blood flow with disturbances in intracardiac blood flow and with signs of moderate fetal hypoxia according to CTG data;
• progression of gestosis against the background of complex therapy with severe disturbances of uteroplacental blood flow (bilateral disturbances with a dicrotic notch on the spectrum);
• the pregnancy period in the presence of signs of decompensated placental insufficiency is more than 36 weeks.

Indications for emergency delivery:

• disturbances of venous blood flow in the fetus (retrograde blood flow in the venous duct, increased reverse blood flow in the inferior vena cava of the fetus), the presence of pulsations in the umbilical vein;
• preeclampsia and eclampsia.

In case of premature pregnancy (32–36 weeks) and absence of zero and retrograde values of blood flow in the venous duct during atrial systole and pulsatility index up to 0.74, with percentage of reverse blood flow in the inferior vena cava up to 43.2% at 32 weeks and up to 34.1% at 32–37 weeks), pregnancy should be prolonged. At the same time, complex treatment of placental insufficiency is carried out with mandatory intravenous administration of hexobendine + etamivin + etofillin solution with daily Doppler and cardiotocographic monitoring. Glucocorticoids are included in the treatment complex to accelerate maturation of the fetal lungs.

Delivery is performed by cesarean section when signs of progression of venous blood flow disorders or spontaneous decelerations, hypokinetic type of hemodynamics and "adult" type of transvalvular blood flow of the fetus appear. The duration of pregnancy prolongation ranged from 4 (at 35-36 weeks) to 16 days (at 32-34 weeks).

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