Advances in Clinical and Experimental Medicine

Title abbreviation: Adv Clin Exp Med
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ISSN 1899–5276 (print)
ISSN 2451-2680 (online)
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Advances in Clinical and Experimental Medicine

2009, vol. 18, nr 5, September-October, p. 481–486

Publication type: original article

Language: English

Doppler Parameters Predicting Fetal Heart Rate Abnormalities in Diabetic Pregnancies

Parametry badania dopplerowskiego pozwalające przewidywać zaburzenia w akcji serca płodu u ciężarnych chorych na cukrzycę

Małgorzata Pawelec1,, Andrzej Karmowski1,, Joanna Krzemieniewska1,, Marek Kaniak1,, Mikołaj Karmowski1,

1 First Clinic of Gynecology and Obstetrics, Wroclaw Medical University, Poland

Abstract

Background. Uteroplacental insufficiency is reflected by an increased pulsatility index in the umbilical artery (Umb PI). This leads to a redistribution of blood in the fetus (brain sparing), which is reflected by an increased middle cerebral artery PI (MCA PI) to Umb PI ratio (AI – acidemic index) and may cause a reduction in blood flow. An abnormally low AI is connected with unfavorable pregnancy outcome.
Objectives. The primary purpose of this study was to determine diabetes mellitus and circulatory variables that could relate to low arterial pH in the umbilical cord measured immediately after birth.
Material and Methods. The study group comprised 64 diabetic women with class B, C, D, or F diabetes and at least 26 weeks pregnant. Umb PI and MCA PI were measured every two days from admission to delivery. Doppler MCA PI, Umb PI, and AI were compared with fetal heart traces (NST) and pH from the umbilical artery measured immediately after birth.
Results. During the study about 34% of the fetuses of the diabetic mothers showed flow redistribution and nearly 22% abnormal NSTs. Abnormal AI was associated with abnormal NST in nearly 19% of cases. Doppler velocimetry is in itself good in confirming acidosis, detecting 90% of all acidemias (pH < 7.1). Abnormal Doppler velocimetry predicted fetal heart rate abnormalities in patients with B, C, D, or F diabetes about 8 days before they occurred.
Conclusion. No cardiotocographic parameter alone was found to be a good predictor of umbilical acidemia. An abnormal NST in diabetic pregnancies should be verified by the AI. Both methods are noninvasive and safe. Abnormal cardiotocographic changes were usually preceded by abnormal MCA PI, Umb PI, and AI which occurred on average about 8 days earlier. Using both methods together, a predictive and a predisposal value of umbilical acidemia of 91.7 and 95% were obtained.

Streszczenie

Wprowadzenie. Około 40% noworodków rodzących się w naszej klinice z ciąż matek chorych na cukrzycę klasy B, C, D, F według klasyfikacji White, ma bezpośrednio po porodzie kwasicę (pH < 7,1).
Cel pracy. Celem pracy było zidentyfikowanie wskaźników świadczących o zagrożeniu kwasicą płodów matek chorych na cukrzycę B–D oraz F wg White.
Materiał i metody. Wykonując u ciężarnych chorych na cukrzycę B–F wg klasyfikacji White badania KTG oraz USG w ciągu ponad 2 lat, autorzy stwierdzili, że u ok. 34% płodów wystąpiły w badaniu dopplerowskim cechy redystrybucji, na podstawie pomiarów PI (pulsatility index) w tętnicy pępowinowej i tętnicy środkowej mózgu.
Wyniki. U około 22% ciężarnych wystąpiły patologiczne zapisy kardiotograficzne. Nieprawidłowy wskaźnik kwasicy (acidemic index), będący stosunkiem MCA PI do Umb PI (z punktem odcięcia 1.1) towarzyszył patologicznym zapisom KTG w ok. 19%. Indeks kwasicy (acidemic index) pozwala dobrze zidentyfikować te noworodki, które nie będą miały kwasicy (pH < 7,1) bezpośrednio po porodzie (95,2%). Około 81% noworodków z nieprawidłowymi wynikami badań dopplerowskich, opisanych w pracy, będzie miało kwasicę (pH < 7,1), jeśli obydwa wskaźniki, tj. KTG i AI, będą nieprawidłowe, to dla kwasicy PPV wynosi 91,7%, a NPV 95%.
Wnioski. Badanie dopplerowskie jest samo w sobie dobrym wskaźnikiem kwasicy. Pozwala na wychwycenie 90% wszystkich kwasic wykrytych w krwi pępowinowej bezpośrednio po porodzie. Nieprawidłowe wartości wskaźników badania dopplerowskiego wyprzedzały średnio o 8 dni patologiczne zmiany w KTG. Oba sposoby przewidywania kwasicy po porodzie są metodami bezpiecznymi i nieinwazyjnymi i pozwalają zrezygnować z konieczności stosowania kordocentezy oraz pozwalają zmniejszyć liczbę cięć cesarskich wykonywanych z powodu nieprawidłowych zapisów KTG u ciężarnych chorych na cukrzycę.

Key words

NST (non−stress test), CTG (cardiotocography), PI (pulsatility index), BCDF diabetes mellitus, AI (acidemic index), FHR (fetal heart rate)

Słowa kluczowe

test niestresowy, kardiotokografia, cukrzyca ciężarnych klasy B, C, D, F, wskaźnik kwasicy, akcja serca płodu

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