Uteroplacental blood flow in normal and pathological conditions. Violation of the uteroplacental blood flow

08.08.2019

Blood flow disorders in the uterine arteries, umbilical cord, placenta during pregnancy (NMPK)

Currently, the assessment of uteroplacental blood flow is a mandatory study in the generally accepted standards for the management of pregnant women. Thanks to triple ultrasound screening, which is performed on expert-class devices, obstetrician-gynecologists are able to recognize the degree of uteroplacental blood flow disorder (UTPC) in time, and, most importantly, choose the necessary tactics for managing the patient.

How is the circulatory system between mother and fetus arranged?

Many people mistakenly think that only the placenta is responsible for blood flow in the mother-fetus system. In fact, this is too superficial a judgment, because everything is much more complicated.

The uteroplacental blood flow system is an anatomically complex complex of the placenta, as well as the blood vessels of the mother and fetus.

Levels of the uteroplacental system:

The main vessels that bring blood to the placental complex are the terminal branches of the uterine arteries. An interesting fact is that before pregnancy, these arteries are called "spiral", since they contain muscle cells that can contract and close the lumen of the vessel. This is necessary during menstruation in order to quickly stop uterine bleeding. But what happens during pregnancy? Starting from 4-5 weeks of gestation, the walls of the spiral arteries undergo changes, namely, the muscle layer disappears in them. Thanks to these processes, a full blood flow to the placenta is maintained. It has been proven that already by the 16th week of pregnancy, the spiral arteries are completely transformed. However, it is precisely for this reason that obstetric bleeding is so massive, and it is so difficult to stop them, because the terminal branches of the uterine arteries no longer spasm.
The placenta is the central link in the uteroplacental system. It is here that the most complex processes of blood transfer from mother to child take place. Everyone has long known the postulate that maternal and fetal blood do not mix. But how does it happen? All this is achieved due to the complex anatomical structure. The placenta is very firmly attached to the inner wall of the uterus with the help of the so-called villi. These "outgrowths" of placental tissue are, as it were, immersed in the thickness of the uterine mucosa. Placental villi penetrate into the walls of the uterine vessels and are practically "washed" by maternal blood. It is here, at the cellular level, that complex processes of diffusion of maternal and fetal blood take place, separated from each other by only a few layers of cells. This is called the "blood-placental barrier", which literally means "the barrier between the mother's blood and the placenta." In addition, it is in the placenta that two blood flows “meet”: from mother to child and vice versa. Such a complex and fragile system cannot but cause admiration!
The umbilical cord vessels are the third layer in the complex system of blood flow between mother and child. The umbilical cord contains three vessels: two arteries and one vein. The hemodynamics (blood circulation) of the fetus is arranged in such a way that the arteries bring blood to the organs and tissues of the baby, and the vein, on the contrary, performs the function of returning blood to the placenta. Violation of blood flow at this level is called "fetal-placental", it is the most severe option for the fetus in terms of prognosis.

Video: Fetal Circulation Lecture Series

Causes that can lead to impaired blood flow in the mother-placenta-fetus system

in a pregnant woman. The decrease leads to an acceleration of blood flow in all vessels, including the uterine arteries. This happens for one simple reason: with anemia, the body tries to increase the delivery of oxygen to the tissues by increasing the speed of circulating blood. This is a compensatory response. The same thing happens in the utero-placental system.
Pathology of placental attachment(low placentation, presentation) is characterized by reduced blood flow, since in the lower segment of the uterus the muscle layer is much thinner than in other areas. A similar situation develops when the placenta is attached to the scar on the uterus (usually after a previous caesarean section). The thinned area of the scar cannot fully provide blood flow, so the amount of blood that enters the fetus may not be enough for the normal functioning of the developing organism.
(late toxicosis) is one of the most common causes of impaired blood supply to the uteroplacental system, since with this obstetric complication, small vessels are damaged.
Various infectious diseases transferred during pregnancy. Some microorganisms infect the placenta and cause pathological changes in its tissue, which can cause placental insufficiency.

Why is NMPK dangerous for the fetus?

- one of the main consequences of NMPK

Reduced blood supply to the fetus can cause the following obstetric complications:

Decreased weight and size (syndrome of intrauterine growth retardation);
Violation, in addition to tachycardia (rapid rhythm) and bradycardia (slow rhythm), arrhythmia can also develop as a result of a violation of the electrolyte composition of the blood;
Violation of the acid-base balance in the body of the fetus (change);
Pathological functioning of the hormonal system of the child;
A pronounced decrease in fat depots, which is also manifested by a low body weight of the fetus;
The threat of termination of pregnancy;
A critical violation of blood flow can cause intrauterine death of the fetus.

Degrees of violation of uteroplacental circulation

Changes can occur at each of the levels of the system, which is the basis of the classification:

1 A - characterized by changes in blood flow in one of the uterine arteries, while the rest of the parameters of the system are normal.
1 B - blood circulation is disturbed at the fetal-placental level (vessels of the umbilical cord), while the indicators in the uterine arteries are within the normal range.
2 - violation at the level of the uterine and umbilical vessels.
3 - characterized by critical indicators, up to reverse (reverse) blood flow in the arteries.

This classification is extremely convenient for physicians, as it accurately reflects the level at which changes have occurred. In addition, the degree of violation of the uteroplacental circulation also affects the tactics of managing the patient.

At grade 1 (A and B), pregnancy can be maintained and treated with conservative methods, grade 2 is borderline, and at grade 3, emergency surgical delivery may be required.

Diagnostic methods

The "gold standard" of blood flow disorders in the mother-placenta-fetus system at the moment in obstetrics is. This method opens up opportunities for recognizing even the smallest changes, as it has high sensitivity and information content.

Doppler is a type of ultrasound that uses the Doppler effect. The essence of the study is to measure the frequency of an ultrasonic wave reflected from moving objects. In the study of blood vessels, the moving particles are blood cells, in particular, erythrocytes, as the most numerous cells. Registration of the received data and their comparison with the norm is called dopplerography.

What are the benefits of doppler sonography?

Modern ultrasound machines make it possible to examine the direction, speed of blood flow in the uterine arteries, and even intraplacental blood flow.
Thanks to color mapping, it is possible to study the blood flow in vessels with different blood flow (arteries and veins) separately. The direction of arterial blood on the device is reflected in red, and venous - in blue.
It has been proven that the use of this method during pregnancy does not adversely affect the development of the fetus.
A unique feature of the method is the prediction of the development of pregnancy. What does this mean? Many studies have shown that disturbances in the blood flow of the uterine-placental system appear a little earlier than any clinical manifestations of fetal suffering appear (weight loss, changes in heart rhythm, etc.). And this means that with the timely diagnosis of fetal circulatory disorders, the doctor has a small amount of time to make the right decision. An example of this is the detection of a change in blood flow, which is called "dicrotic notch" in 90% of cases before the development of clinical manifestations of preeclampsia (edema, increased blood pressure, the appearance of protein in the urine). Dopplerography is widely used in obstetric practice, as it opens up the opportunity for doctors not only to recognize blood flow disorders in time, but even to prevent the development of certain pregnancy complications.

Recently, the results of the use of Doppler ultrasound are being published more and more often, not only during pregnancy, but during childbirth. The conducted studies prove that the effectiveness of contractions can be assessed by measuring the diastolic blood flow velocity in the uterine arteries. Thus, this research method can even predict weakness or incoordination of labor activity already at the beginning of the first stage of labor.

case from practice

The non-standard situation that occurred in the maternity ward made obstetrician-gynecologists think about the use of Doppler ultrasound during childbirth.

A 25-year-old woman without any concomitant pathology was admitted to the genus. house with regular contractions every 3-5 minutes. Childbirth the first, urgent.

According to the anamnesis: the pregnancy proceeded without complications, no pathology was found on the part of the fetus, all ultrasound protocols with Doppler ultrasound were within the normal range.

The first stage of labor proceeded physiologically, with the full opening of the cervix, the woman in labor was transferred to the delivery room.

However, during the attempts, at first glance, inexplicable phenomena began to occur: the fetal heartbeat during the attempts was restored, and in the intervals between the attempts it slowed down significantly. Although, as a rule, everything happens the other way around. In this regard, it was decided to perform an ultrasound with a study of blood flow in the vessels during childbirth. The result of the study surprised everyone: in the intervals between contractions, the fetus clamped the umbilical cord with a pen, as a result of which the blood flow was significantly disturbed. As hypoxia increased in the child's body, his arms weakened, and he let go of the umbilical cord, meanwhile the blood flow was restored. Given the picture obtained, it was decided to force the management of the second stage of labor with the use of auxiliary aids. So, thanks to dopplerometry, doctors managed to avoid serious complications.

Secondary diagnostic methods

In addition to dopplerography, there are other research methods that indirectly indicate a violation of blood flow:

Collection of complaints. In case of circulatory disorders, the fetus experiences hypoxia, which is manifested by an increase in the baby's motor activity. Usually pregnant women complain about the active movement of the fetus.
Listening to the heartbeat with a stethoscope can also help in the diagnosis. Deceleration or acceleration of the rhythm, which goes beyond the physiological norm, may also indicate hypoxia.
. Registration of CTG within 40-60 minutes may be enough to diagnose signs of intrauterine fetal hypoxia.
Some ultrasound indicators (premature aging of the placenta, biophysical profile study) can fix the unfavorable condition of the fetus.

Important! A slight decrease in the estimated fetal body weight on ultrasound does not necessarily indicate a developmental delay and impaired blood flow. An isolated measurement of fetal weight is not very informative, since this indicator is also largely influenced by genetic factors. Therefore, it is necessary to take into account the anthropometric indicators of the parents (height, weight) and their weight at birth. Only a combination of a decrease in fetal weight and impaired blood flow during Doppler sonography gives grounds for making a diagnosis of intrauterine growth retardation syndrome.

Treatment of uteroplacental blood flow disorders

In order to improve the blood supply to the fetus, it is necessary to influence several links of pathogenesis at once:

Improvement of microcirculation. The following drugs have this property: "Pentoxifylline", "Actovegin".
Maintaining normal blood flow in the vessels, eliminating low blood pressure is achieved through the use of drugs based on hydroxyethyl starch: "Stabizol", "Infukol", "Voluven", "ReoHES", "Venofundin". These drugs are an osmotic solution of starches that are able to retain fluid in the lumen of blood vessels. Their appointment is especially effective for preeclampsia, when it is necessary to transfer fluid from the intercellular to the lumen of the vessel. Thus, two goals are achieved at once: normalization of blood flow and a decrease in the severity of edema.
Vasodilator drugs help to eliminate spasm of arteries and arterioles (smaller vessels). Particularly effective use "Eufillina", "No-shpy", "Magnesia" in the form of injections.
A decrease in uterine tone also helps eliminate vasospasm, hypoxia, and also maintain pregnancy in the event of a threat of premature birth. In this situation, appoint "Magnesia", "Ginipral", "Magne B6".
Antioxidant drugs help to cope with the undesirable consequences of hypoxia. Usually prescribed "Tocopherol", "Ascorbic acid", "Hofitol".
Useful intravenous administration 5% glucose solution which has detoxifying properties.
The drug has a protective effect on the placenta "Essentiale", which saturates placental tissue with phospholipids. This medicine is especially useful in placental insufficiency.
When blood flow is disturbed, it is very effective to prescribe drugs that lead to the processes of activation of cellular respiration, for example "Cocarboxylases".
With a combination of uterine fibroids and blood flow disorders, the drug showed a good result. "Curantil", it is able to improve blood circulation in the vessels, and also prevents the formation of microclots. Many studies have shown that taking "Kurantil" with a large myoma prevents the development of secondary, inflammatory changes in the myomatous nodes, due to the improvement of blood flow in them and the uteroplacental system.

Conclusion

The study of uteroplacental blood flow using dopplerography is a mandatory study during pregnancy. Practice shows that the use of this method has a positive effect on the prevention and treatment of many obstetric complications. However, do not forget that in order to obtain reliable and informative results, blood flow research should be carried out on expert-class devices by highly qualified specialists.

Video: about fetal hypoxia - a consequence of NMPK

Placenta - formed in the uterus after pregnancy. It is necessary for binding the body of mother and child with one blood circulation. With the help of the placenta, the fetus is supplied with oxygen, nutrients necessary for the development and formation of organs. In the opposite direction, unnecessary substances formed as a result of biochemical processes are removed.

Impaired uteroplacental blood flow causes a condition called placental insufficiency. This leads to the death of the fetus, miscarriage.

For 36 weeks, three mandatory ultrasound examinations are performed. It allows you to timely identify the violation, develop a plan for the management of pregnancy and childbirth, prescribe treatment, prevent the death and abnormal development of the child.

Modern requirements of obstetrician-gynecologists are aimed at examining pregnant women using safe methods in order to assess uteroplacental blood flow by volume.

How does blood flow between mother and fetus work?

The mother-fetus circulatory system is based on such anatomical formations as the placenta, umbilical arteries, and veins.

Blood flows to the placenta through the uterine arteries. The structure of their walls is characterized by the presence of a muscle layer that can contract and block the lumen. Before pregnancy, this mechanism helps to reduce blood loss during menstruation.

At 4–5 weeks of fixation of a fertilized egg (gestation process), the muscle layer disappears. Blood flow to the placenta is no longer dependent on vascular contraction. And by the sixteenth week, the arteries are transformed for constant blood supply. This is dangerous when bleeding occurs, since it is impossible to stop it by reducing the lumen of the vessels.

Under normal conditions, the placenta is fixed on the inner surface of the uterus with the help of villi that penetrate deep into the thickness of the mucosa. They grow into the walls of blood vessels and directly contact with maternal blood.

Here at the cellular level is happening:

exchange between the maternal organism and the fetal blood flow;
two oppositely directed streams meet;
necessary substances are transferred (diffusion).

Another part of the general blood circulation is provided by the vessels of the umbilical cord (normally there are 2 arteries and a vein). The main volume of blood flows to the fetus through the arteries, flows through the vein towards the placenta.

With the growth of the uterus, the arteries expand, form anastomoses

Violation of the fetal-placental blood flow is most difficult for a developing child. It creates conditions for an unsatisfactory forecast of the construction of internal organs and systems, the birth of a healthy baby.

What causes can break the flow of blood between the mother, placenta and fetus?

Causes of violations of the circulatory system between the mother's body and the fetus (fetoplacental insufficiency) are well understood. Some of the factors are formed only against the background of pregnancy. Another - depends on the general health of the woman.

Pathologies of pregnancy include:

Low attachment of the placenta (obstetricians say - presentation, "placentation") - the lower sections of the uterus are distinguished by a thinner muscle layer. Not enough blood flows through it to the fetus. A similar situation develops in the case of presentation in the area of the postoperative scar (for example, from a caesarean section).
Late toxicosis - accompanied by damage to the small vessels of the uterus, a complication is the most common violation of blood flow.
Anemia - a low level of hemoglobin causes a compensatory acceleration of the heartbeat, blood flow through the uterine arteries increases in order to compensate for the lack of oxygen. The circulation in the utero-placental circle also changes.
Incompatibility between the blood of the mother and the fetus according to Rhesus - an immune conflict arises with the development of a hemolytic disease of the child, anemia. The same situation is possible when transfusing blood of different groups from a donor.
The burden on the kidneys due to toxicosis can cause an increase in blood pressure. This contributes to the change in blood flow.
Rarely, pathology of the umbilical arteries is detected. If there is only one umbilical artery, then the blood flow is insufficient for the fetus.
Multiple pregnancy - the placenta is enlarged and requires enhanced nutrition. Sometimes blood flow passes from one fetus to another.

It turns out that the first child is a constant donor for the twin, develops worse, because he transfers blood to his brother, and he himself is “malnourished”

Such changes are called fetotransfusion syndrome. The donor has a smaller body weight. And the recipient has an increased load on the developing heart. Both babies have problems.

Of the diseases of women, the most dangerous are:

Acute infections during pregnancy - pathogens can penetrate the placental barrier and destroy the vasculature.
Malformations of the uterus - the most significant is the "two-horned" uterus. Inside the cavity there is a partition dividing it into 2 parts. Pregnancy is possible only in one of them. The main violation is not the compression factor (the cavity has the ability to stretch enough), but the lack of communication between the uterine arteries, insufficient development of the vascular network, placental hypoxia.
Endometriosis - changes in the inner lining of the uterus, occur after inflammatory diseases (including genital infections), frequent abortions, diagnostic curettage. One reason is smoking and alcohol.
Tumor of the uterus - if a woman has even a small fibroid (benign tumor), then pregnancy stimulates the growth of nodes. They take over part of the blood supply, and the blood flow of the fetus is “robbed”. Deficiency directly depends on the size of the tumor.
Diabetes mellitus - affects the walls of blood vessels, often occurs in women with risk factors during pregnancy.

What threatens the fetus with insufficient placental blood supply?

All violations of both uteroplacental and fetal-placental nature lead to oxygen deficiency of the fetus (hypoxia). Complications are caused precisely by this mechanism:

the formation of the internal organs of the fetus is disrupted, there is a lack of mass, this is called "intrauterine growth retardation";
the heart reacts with rapid contractions (tachycardia) or arrhythmias, bradycardia;
the composition of electrolytes and acid-base balance are disturbed;
the functioning of the endocrine system is disrupted, the fetus has a hormonal imbalance;
fat depots are not formed.

The most severe complications are fetal death, the threat of abortion.

Myomatous nodes take part of the vascular network in the fetus for its growth

Types of blood flow disorders in the placenta

There are fetoplacental (between the fetus and the placenta) insufficiency and uteroplacental insufficiency.

Fetoplacental hypoxia can proceed as:

Acute deficiency- occurs in any period of pregnancy and during labor pains. Causes premature detachment of the placenta, vascular thrombosis, heart attack in the area of the placenta, hemorrhage. Can cause the death of a child.
Chronic - occurs more often, develops from the second trimester, but manifests itself only in the third. Changes in the placenta are in the nature of premature aging, fibrin is deposited on the surface of the villi. Permeability is sharply reduced, which provokes fetal hypoxia.

Against the background of the development of chronic placental insufficiency, stages can be distinguished:

compensation - a favorable course, since the protective mechanisms of the mother's body work and compensate for the missing nutrition for the baby, the treatment is effective, the child is born on time, healthy;
subcompensation - the mother's body is not able to fully compensate for the "unprofitable" blood supply to the fetus, full treatment is necessary, the child can be born with complications, lags behind in development;
decompensation - the pathology develops rapidly, compensatory mechanisms are not enough, the activity of the heart is disturbed in the fetus, intrauterine death is possible;
critical stage- characterized by pronounced structural changes in the placenta, which violates its functions, therapy cannot change the state of the fetus, death is inevitable.

Degrees of impaired blood flow

In a joint violation of the fetoplacental and uteroplacental blood flow, 3 degrees are distinguished.

I - changes are compensated, do not threaten the fetus, they capture only the uteroplacental blood flow, the child develops normally. Depending on the level of change, there are:

degree Ia - violation of uteroplacental blood flow is limited to one of the arteries of the uterus, all hemodynamic parameters are stable, within normal limits;
degree Ib - the blood flow is disturbed at the level of communication between the fetus and the placenta due to the vessels of the umbilical cord, enough blood flows through the uterine arteries.

If small changes in the first stage were not detected and the woman did not receive treatment, then after 3-4 weeks, violations of the second degree occur.

II - the blood flow in the uterine and umbilical arteries changes.

III - indicators are critical, reverse blood flow in the arteries is possible.

How is the diagnosis carried out?

The Doppler ultrasound method helps to make the correct diagnosis and identify the level of impaired blood flow most accurately. The method is highly sensitive and very informative. Shows even small changes in the first stage to clinical manifestations. An important advantage is safety for the fetus and the expectant mother.

With the help of dopplerography, it is possible to examine the blood flow through the arteries and veins, obtain a color graphic image, and measure the hemodynamic parameters of the fetus.

This plays a significant role in predicting the course of pregnancy, creates conditions for making decisions on therapeutic measures.

Indirect diagnostic methods include:

computed tomography,

Methods allow you to identify the lack of fetal weight, the placenta is not well. These signs may be evidence of the development of hypoxia.

What does the mother feel and the doctor determines during the examination?

Hypoxia stimulates the motor activity of the fetus.

At an appointment with an obstetrician-gynecologist, the doctor listens, draws attention to a high frequency, arrhythmia or bradycardia. This necessitates referral for Doppler examination.

A pregnant woman pays attention to the increase in movements, tremors

Treatment of disorders

Establishing the degree of impaired uteroplacental blood flow is necessary for choosing the tactics of pregnancy management.

It is believed that it is possible to maintain pregnancy in the first degree (a and b), treatment will still help.
The second degree is considered as borderline, requiring constant monitoring, the effectiveness of treatment is unlikely.
In the third degree, urgent delivery by surgical methods is required.

The possibilities of therapy are aimed at all parts of the pathology:

to improve microcirculation, Pentoxifylline, Actovegin are used;
Stabizol, Venofundin, Infucol are used as support for low blood flow velocity and pressure in the vessels (synthesized on the basis of a starch solution, capable of retaining fluid in the vessels);
vasodilating drugs such as Eufillin, No-shpy eliminate spasm of medium and small arteries;
by reducing the tone of the uterus, it is possible to influence vasospasm, reduce the degree of hypoxia, use magnesium sulfate, Magne B6, Ginipral;
antioxidants eliminate the effects of hypoxia, destroy decay products, prescribe Tocopherol, combinations of vitamin E and ascorbic acid, Hofitol;
Essentiale has a protective effect by increasing the level of useful phospholipids in the blood, improving liver function;
Curantyl is prescribed during pregnancy against the background of uterine fibroids, a positive effect on microcirculation and prevention of thrombosis has been established.

In the practice of obstetricians continue to use Cocarboxylase, which was abandoned by cardiologists. But gynecologists consider the drug effective for restoring tissue respiration.

For the treatment of newborns and care for them, according to indications, incubators are used

Forecast and consequences

For statistical studies, such an indicator as "perinatal mortality" is used. It includes all deaths in the fetus from the 22nd week of pregnancy and among newborns in the first week of life. It is believed that it fully reflects the influence of the factor of pregnancy and childbirth. The calculation is based on 1000 born children.

Currently, 13.3% of children die from the second degree of violation of the uteroplacental circulation, in the third - up to 47%. Timely caesarean section can reduce mortality.

Need intensive care for:

35.5% of newborns with the first degree;
45.5% - from the second;
88.2% - from the third.

The consequences of preserving and treating children born under conditions of pathological hypoxia are unclear. Pediatricians and psychiatrists point to its unconditional influence on physical and mental development.

Only experienced specialists can diagnose and treat conditions associated with a violation of the uteroplacental barrier. You can not take medications on your own or use the advice of poorly educated people. The situation can become critical not only for the fetus, but also for the woman.

The placenta is responsible for transferring nutrition and oxygen from the mother to the fetus. Thanks to her, two complex vascular systems are combined. One of them connects the placenta with the uterine arteries, and the other with the umbilical cord. In this case, the placenta serves as a barrier that protects the baby from viruses and harmful substances. It happens that during ultrasound, there is a violation of blood flow during pregnancy, which can affect the development of the baby.

Doppler

Such an unusual name has a diagnostic procedure that reveals any pathology of blood flow in the arteries and veins. As a result, a Dopplerogram is built on specialized equipment, which displays the frequency difference between the sent and reflected signals. The study is carried out in a standard mode or with color mapping, that is, the movement of blood through the arteries is displayed in color. The latter option allows you to quickly and accurately detect even a slight violation of the uteroplacental blood flow.

Dopplerometry is carried out lying on your back or side. At the same time, a more truthful result can be obtained on the side, since many pregnant women begin to tone on the back, which provokes various pathologies. The specialist covers the area to be examined with gel and begins to drive the sensor over it.

This study is prescribed to all pregnant women along with the first (18-22 weeks) and second (32-34 weeks) screening. It can be carried out at intermediate dates if there are indications.

Causes of impaired blood flow

To identify a failure in the blood flow system, experts conduct ultrasound with Doppler ultrasound for women. This allows you to see defects in the vessels, track the amount of oxygen and nutrients that enter the fetus.

Very often, expectant mothers are interested in why there is a violation of blood flow during pregnancy. The main reasons for this condition:

The age of the woman (too early or, conversely, late).
Small interval between births.
Gestosis (late toxicosis during pregnancy).
Neoplasms in the uterus (for example, fibroids), pathologies of the myometrium, endometriosis.
Diabetes.
Hypertension.
Kidney problems.
Intrauterine infection due to viral diseases of a woman.
Numerous abortions or miscarriages.
Anemia (lack of iron).
Placenta previa.
Rhesus conflict.
Problems with blood clotting leading to the formation of blood clots.

Degrees of blood flow disturbance

At the moment, there are three degrees of pathology. The first degree is divided into two subspecies: 1A (impaired uteroplacental blood flow) and 1B (problems with blood circulation between the fetus and the placenta). In the second degree, there are problems with both systems ("uterus - placenta" and "placenta - fetus"). The third degree is given to those women who have serious complications with blood circulation.

The first stage of the disease can be corrected with drugs, and as a result, a healthy child is born. In other cases, there is a risk of perinatal death.

Types of placental insufficiency

If, when carrying a baby, a violation of blood flow is detected, then doctors usually make a diagnosis. During pregnancy, such a pathology occurs quite often and can be acute or chronic. The acute form can appear suddenly, at any moment, as a result, the fetus experiences hypoxia and may die. This is possible with premature detachment of the placenta, placental infarction, the formation of blood clots.

The chronic form is much more common than the acute form. It usually occurs after 13 weeks, and manifests itself in the third trimester. As a result, premature aging of the placenta occurs. Depending on the severity, the disease can be compensated, decompensated, subcompensated, critical.

At the compensated stage, the baby continues to develop normally, since these changes are eliminated by the protective mechanisms of the female body. With decompensated pathology, it ceases to cope with problems, as a result of which the fetus experiences growth retardation and the subcompensated stage of the disease leads to a delay in the development of the baby, as well as to its possible death. The most difficult form is considered to be critical placental insufficiency. It does not occur very often, but its onset leads to the inevitable death of the child.

The main symptoms of the disease

Depending on the type of blood flow disorder, various symptoms may appear. Compensated placental does not manifest itself in any way, so they learn about it only during an ultrasound scan. In the acute and decompensated form, changes appear in the movements of the baby: he moves either too much, or very little. In this case, it is important to monitor this indicator (the fetus should move at least 10 times per day).

As additional signs, there may be slow growth of the abdomen, a lack or excess of amniotic fluid. You won’t be able to monitor this on your own, so you need to visit a doctor so that he tracks changes in measurements. It happens that a violation of blood flow accompanies preeclampsia - late toxicosis during pregnancy. To the existing symptoms, an increase in pressure, a sharp weight gain, swelling, and the excretion of protein in the urine can be added.

The most dangerous sign of placental insufficiency is the appearance of blood from the birth canal associated with placental abruption. In such a situation, only an ambulance of specialists will help.

Treatment of pathology

If a woman has an increased or tendency to thrombosis, most often she has a violation of blood flow. During pregnancy, treatment is prescribed only by a doctor, because you will have to take serious drugs. Most often prescribed drugs such as Curantil, Trental and Hofitol. They thin the blood and improve its movement through the arteries.

Most often, pregnant women are prescribed "Kurantil", which has been used in obstetrics for more than 15 years. The drug does an excellent job with its tasks - it normalizes blood circulation due to its thinning, prevents blood clots from forming, helps to form new vessels, and improves immunity.

Also in demand is Trental, a drug that is similar in action to Curantil. However, it has serious advantages: the drug does not dilate the vessels of the heart and continuously releases the active substance for 12 hours.

It happens that a woman has a slight violation of blood flow during pregnancy. Treatment in this case is carried out by "Hofitol" - a preparation with mineral and plant components (for example, juice of field artichoke leaves). It has a slight diuretic effect and does not harm the liver.

Methods of treatment for different degrees of pathology

The first degree of the disease involves taking drugs that improve blood circulation. Doctors will also perform dopplerometry and cardiotocography in dynamics. Research should be carried out 1-2 times in 7 days. With positive dynamics, the woman will continue to bear the baby until his birth. If the indicators worsen, it is necessary to conduct daily studies in order to prevent irreversible changes and to conduct an emergency caesarean section on time. With the normal development of the fetus, childbirth can occur naturally.

Violation of the blood flow of the 2nd degree during pregnancy is also treatable. Usually the same drugs are used as in the first case, however, the woman will be offered hospitalization. Doctors will monitor changes in the body and, if necessary, will carry out early delivery.

The third degree is not treated in any way, since irreversible consequences begin to appear. In this case, the specialists do not risk the life of the child and prescribe an emergency operation.

Prevention

Any woman can make sure that the baby develops and grows without complications. To do this, she will have to monitor her diet: it should contain a lot of vitamins, trace elements, proteins and other important substances. If a pregnant woman does not suffer from edema, then she must drink at least 1 liter of fluid daily (preferably water).

It is very important to control your weight - an increase in carrying a baby can be a maximum of 10 kg. Some women need medication to improve blood circulation between mother and fetus. It will prevent blood flow disorders during pregnancy. It should be remembered that the life of the child will help to maintain the correct method of conducting childbirth and the timely connection of drugs.

Most women do not know about such a study as Doppler until the onset of the third trimester, and from that moment on, Doppler for pregnant women becomes quite a familiar procedure.

Doppler- this is one of the ultrasound diagnostic methods that allows you to assess the intensity of blood flow in various vessels, for example, in the vessels of the uterus and umbilical cord. It is most informative after 30 weeks, but in case of deviations during pregnancy (for example, if the fetus is lagging behind in development), Doppler ultrasound can be prescribed earlier - starting from 20 weeks.

Doppler indications

Adequate placental blood flow ensures the normal course of pregnancy. Violation of blood flow can lead to intrauterine growth retardation (IUGR), so the main reason for prescribing dopplerometry during pregnancy is precisely the discrepancy between the size of the body and / or organs of the baby.

Not necessarily with impaired blood flow, the child will lag behind in development, just the risk of an unfavorable course of pregnancy increases significantly. And vice versa, if there is a suspicion of a fetal lag in development, but the blood flow is not disturbed, then in most cases this indicates that the woman is carrying a small but healthy child.

Dopplerometry is also prescribed for:

premature maturation of the placenta;
severe oligohydramnios or polyhydramnios;
umbilical cord anomalies;
Rhesus conflict;
gestosis (late toxicosis, complicated by vomiting, severe swelling and increased pressure in a pregnant woman);
the future mother has kidney disease, hypertension, diabetes mellitus;
suspected chromosomal pathology;
non-immune dropsy of the fetus;
uneven development of babies during multiple pregnancy (when there is a difference in their body weights of more than 10%).

If the fetus has heart problems, Doppler is performed together with CTG, the so-called Doppler echocardiography.

With fetoplacental insufficiency, dopplerometry is carried out systematically every 2-3 weeks.

Also, with the development of complications during the previous gestation of the fetus, a Doppler ultrasound may be prescribed during a subsequent pregnancy.

Preparation for the study and how it is carried out

Dopplerometry in pregnant women is carried out according to indications, and is not a mandatory examination during the normal course of pregnancy. But more and more often in antenatal clinics, all women, without exception, undergo Doppler ultrasound at 30-34 weeks as an assessment of the condition of the fetus.

This procedure is painless and harmless to both mother and fetus. The principle of Doppler ultrasound is the same as conventional ultrasound during pregnancy: a special Doppler sensor is driven across the abdomen, which is equipped with every modern ultrasound diagnostic device. Therefore, this type of research does not require special preparation.

Doppler- this is a visual assessment of blood flow (when a color and graphic image of curves of blood flow velocities is observed from the monitor screen).

dopplerography- this is the same dopplerometry, only the indications are additionally recorded on the tape in order to track the change (improvement / deterioration) in blood flow after the treatment.

Interpretation of dopplerometry indicators

Uterine arteries (a. uterina dextra - right and a. uterina sinistra - left uterine arteries, respectively). The uzist must determine the nature of the blood flow both in the left and in the right uterine artery, because with gestosis it can be disturbed in only one artery. Thus, assessing the blood flow in only one artery, you can give a false conclusion, which will negatively affect the health of the baby and the expectant mother.

There is such a scientific theory that if blood flow is disturbed in only one (mainly in the right) uterine artery, a woman has a high risk of late toxicosis (preeclampsia) with all the negative consequences.

With gestosis, the blood flow in the uterine artery is first disturbed, and when the situation worsens, the blood flow in the umbilical cord arteries worsens. Therefore, in case of violation of blood flow in the uterine arteries, it is necessary to periodically re-doppler to control the situation.

To assess blood flow in the uterine arteries, the resistance index (IR or RI) is calculated.

Often, pregnancy-induced hypertension develops due to impaired uterine blood flow. The body of the expectant mother independently increases blood pressure to increase blood flow to the intervillous space. So mom, without realizing it, helps the baby. Thus, it is necessary to improve blood flow and hypertension will disappear on its own.

Violation of blood flow in the uterine arteries is when the value of IR, PI or LMS is greater than normal.

The pulsation index (PI) of the uterine arteries should be within the following limits.

Indicators in the right and left uterine artery may differ slightly from each other. If both indicators are within the normal range, then such a picture is not considered a negative phenomenon.

Deviation of blood flow parameters from the norm in two uterine arteries at once indicates a violation of the uteroplacental circulation. This situation requires specific treatment - move more (regularly go for swimming or gymnastics for pregnant women).

Violation of blood flow in only one uterine artery indicates asymmetry of the uteroplacental blood flow. If the pregnancy proceeds normally, and the baby develops in accordance with the term, then the placenta is performing its functions.

You should be aware that at 18-21 weeks there may be a temporary violation of blood flow in the uterine arteries. This phenomenon is explained by the fact that the adaptive physiological process of cytotrophoblast invasion has not yet been finally completed. Therefore, if abnormalities in the uterine arteries are detected, a second Doppler ultrasound should be performed after 2-3 weeks, i.e. observe blood flow in dynamics.

The systolic-diastolic ratio (SDO) in the uterine arteries should be:

Umbilical cord arteries (a. umbilicalis). To obtain true results, the study should be carried out only at a time when the baby is at rest, and only when his heart rate is in the range of 120-160 beats per minute. Indeed, physiologically it is so laid down that with an increase in heart rate, there is a decrease in IR in the umbilical artery, and vice versa, with a decrease in heart rate, an increase in IR occurs.

Measurement of blood flow in the umbilical arteries should be carried out when the pregnant woman is lying on her back! An assessment of the severity of umbilical cord blood flow disorders cannot be objective when the future mother is located “on the left side”.

The umbilical cord must have two arteries and one vein. If there is an anomaly (the only artery of the umbilical cord), then the fetus may suffer from a lack of oxygen and nutrients, due to which there is a lag in its mass and growth. But it happens that the fetus adapts to such an existence and does not experience a deficiency of the necessary substances. Such children are born with low weight, but absolutely viable. Therefore, if there is one umbilical artery and the blood flow in it is not disturbed, then there is no cause for concern. But if the blood flow in a single artery is disturbed, inpatient treatment should be carried out to improve blood flow and, if necessary, early delivery (if the fetus is far behind in development).

The most widely used in assessing the nature of blood flow in the arteries of the umbilical cord was the resistance index. The readings in both umbilical cord arteries should be almost the same.

A blood flow disorder in the umbilical cord is when the value of IR, PI or LMS in the umbilical cord arteries is higher than normal.

The pulsation index (PI or PI) of the umbilical arteries must comply with the following standards:

Pathological is the registration of zero and reverse values of diastolic blood flow. This means that the fetus is in critical condition.

Only 2-3 days remain from the moment the permanent reverse values appear to the death of the fetus, therefore, it is necessary to carry out a caesarean section as soon as possible in order to save the life of the baby. This is possible only from the 28th week, when the baby is viable.

Systolic-diastolic ratio (SDO) in the umbilical arteries:

If the blood flow in the umbilical cord is disturbed, then, as a rule, there is a delay in the development of the fetus. If now there is no developmental delay, and the blood flow in the umbilical cord is disturbed, then later, without treatment, a fetal developmental lag may be observed.

Middle cerebral artery of the fetus (a. cerebri media). When the fetus suffers, there is increase in the values of PI, SDO and speed in SMA.

Maximum speed (aka V max) in the fetal middle cerebral artery:

Systolic-diastolic ratio (SDO) for the middle cerebral artery:

fetal aorta. It leaves the left ventricle of the heart, goes along the spine and ends in the lower abdomen, where the aorta divides into two iliac arteries, which provide blood supply to the human legs.

Deviations in the blood flow of the aorta can be detected only after 22-24 weeks of pregnancy.

The disruption of blood flow is increasing the values of IR, PI and SDO. Critical (talking about the death of the fetus) is considered registration of extremely low values up to their complete disappearance.

Changes in the aorta characterize the severity of intrauterine fetal hypoxia.

Systolic-diastolic ratio (SDR) for the fetal aorta:

Venous duct (VP). It is studied in the extended Doppler assessment of blood flow.

During the study, it is necessary not to take into account episodes of hiccup-like respiratory movements of the child and active movement.

Indexes are not used to assess the venous duct.

The diagnostic criterion for the pathological condition of the fetus is the presence of negative or zero blood flow values in the phase of atrial contraction. Zero or reverse values are recorded with fetal malnutrition, congenital malformations of the right heart, non-immune dropsy of the fetus.

Even with critical blood flow in the arteries of the umbilical cord, but with preserved blood flow in the venous duct in the phase of atrial contraction, it is possible to extend gestation to the optimal time for childbirth.

Description of blood flow disorders and their treatment

1 degree

1 A degree- violation of blood flow in the uterine arteries, while in the umbilical cord the blood flow remains normal.

This degree of blood flow disturbance is not dangerous for the fetus.

Medical treatment of this condition is ineffective. Doctors still prescribe therapy with Actovegin and Curantil. Do not see on occasion!
In fact, if blood flow in the uterine arteries is disturbed, it is more expedient to simply walk in the fresh air more often (breathing deeply) + eat right + move more (hiking, special exercises for pregnant women, morning exercises, yoga, swimming). And do not sit for hours at the computer! That's all treatment.

1 B degree- violation of blood flow in the arteries of the umbilical cord, and in the uterine arteries hemodynamics is normal.

This degree of blood flow disturbance requires the use of blood-thinning drugs to avoid developmental delay and fetal hypoxia.

In this case, a treatment is prescribed aimed at improving blood circulation (Placenta compositum, Curantil or Trental). Actovegin is prescribed as an antihypoxant, which improves the supply of oxygen to the fetus.
A blood test for coagulation ability (coagulogram) is also prescribed. With increased blood clotting, it is necessary to take stronger blood-thinning drugs than Curantil (for example, heparin or an agent that includes acetylsalicylic acid).

I degree of violation does not lead to the death of the fetus. There is a systematic monitoring of the nature of the blood flow (every 2 weeks) "plus" the control of fetal CTG (after 28 weeks of pregnancy). In addition, be sure to monitor blood pressure in a pregnant woman.

2 degree- simultaneous violation of blood flow in the uterine arteries and in the umbilical cord, which does not reach critical values (when the blood flow is preserved in the venous duct).

In this condition, medical treatment is mandatory in a hospital, where round-the-clock monitoring of the fetal condition is provided. It is also necessary to monitor the state of blood flow by conducting Doppler + CTG every 2 days.

In degree II hemodynamic disturbances are rare, but there may be cases of intrauterine death.

3 degree- critical disorders of blood flow in the umbilical cord with intact or impaired blood flow in the uterine arteries. A critical violation is understood as the registration of reverse diastolic blood flow or its absence at all.

III degree of violation poses a danger to the health of the child, because in half of the cases, intrauterine death of the baby occurs. Therefore, when a 3rd degree of blood flow disturbance is detected, it is necessary to urgently perform a caesarean section in order to save the life of the baby, because at this stage of the disorder, treatment is not effective.

Conservative (natural) childbirth at grade 3 can lead to perinatal death of the child.

The cost of a doppler ultrasound in a private clinic is about 1,200 rubles.

The placenta in the body of a future mother plays not only the well-known role of a transport channel for supplying the fetus with nutrients. Its functionality extends much more widely - up to ensuring the complete protection of the child from the effects of negative substances and that may be present in the feeding maternal environment. Violation of blood flow during pregnancy is a direct threat of intrauterine death of the fetus due to poor blood circulation in the complex communicating apparatus of two closed vascular systems.

The blood of the fetus and mother should not mix at any stage of the complex multi-level movement. The barrier functions are provided by the first mechanism of the blood circulation of the mother-fetus - the hematoplacental barrier, which is a kind of unique filter that works in only one direction: by removing waste substances from the fetus along with the blood flow.

The movement of blood in the reverse order, from mother to child, is carried out through the arteries, which are fully formed by the 16th week of pregnancy. This is the second mechanism of the system. Due to the high tone of the arteries, starting from this period, the risk of fetal loss also increases.

The vessels of the uteroplacental circle, isolated by the umbilical trunk, are the third important mechanism of blood circulation between two organisms - feeding and feeding. Violation of blood flow during pregnancy at this stage, has the most serious and irreversible consequences for the fetus.

Causes

The causes of impaired blood flow during pregnancy can be found in the following pathological conditions:

Anemia (anemia) of the expectant mother. cause high blood flow. This occurs due to compensation for the lack of oxygen and cannot but affect the processes in the development of the fetus and the quality of blood exchange;
The position of the placenta. If presentation is diagnosed, which can be justified by a cesarean section, then the blood supply will be clearly reduced due to the thinning of the uterus at the site of the scar;
Late toxicosis causing pathological changes in the work of small vessels. This is one of the most common signs of blood flow disorders during pregnancy;
Viruses and infections present in the mother's body during the period of gestation. Some of them can cause damage to the placental tissue and contribute to the development of placental insufficiency;
- may be complicated by the anemic condition of the fetus;
Defects of the uterus. The most significant of them, capable of changing the course of fetal development for the worse, is the two-cavity structure of the uterine sac. The uterine space, divided into two parts, in itself is not an obstacle to the normal growth and formation of the child. However, the blood supply system does not adequately supply such a two-chamber cavity;
Serious quantitative or configurational umbilical cord;
Damage to the inner wall of the uterus obtained as a result of surgical interventions, or as a result of bad habits;
Tumors such as fibroids, especially dangerous in women who have not given birth before after thirty-five years. This also applies to uterine fibroids, which are abundantly saturated with blood during perinatation. Against the background of an increase in size and the formation of a myomatous node, a persistent lack of blood flow to the placenta is formed;
, which do not allow maintaining the uniformity of the blood flow rate;
Pregnancy complicated by multiple pregnancy. Since the placenta is forced to adapt to the maintenance of several feeding organisms in proper conditions at once, such errors in the blood supply as the donor position of one of the fetuses are not excluded. Often at the same time, there is an underdevelopment of the feeding fetus, a significant lack of weight and physiological normal signs. A child who unwittingly acts as a recipient also suffers seriously from, on the contrary, too abundant blood supply;
Mother's disease, sometimes developing precisely against the background of pregnancy, loosens the walls of blood vessels, which affects blood circulation in a bad way.

The degrees of violation of the uteroplacental circulation during pregnancy, in which significant changes in the development of the fetus are likely, formed the basis of the following classification list:

Violation of blood flow during pregnancy 1A - all diagnostic indicators of the uteroplacental apparatus are normal, except for an insignificant change in blood flow in any of the uterine arteries;
Violation of blood flow during pregnancy 1B - there are violations of blood circulation in the vessels of the umbilical cord, despite the fact that the state of the vessels of the uterus is unchanged;
2 - a comprehensive violation of both uterine and umbilical vessels;
3 - changes at the global level, characterized by the most extreme rates of deviation.

Degrees of blood circulation 1 (A and B) allow you to keep the pregnancy and give birth to a healthy baby, subject to the prescribed treatment and all the doctor's recommendations. Grade 2 allows for fetal preservation, but this will require hospitalization. Grade 3 requires immediate surgical removal of the fetus to save the life and health of the mother.

The main diagnosis of blood flow disorders during pregnancy, at the moment, is. The most insignificant, at first glance, changes at one of the early stages of disorders are clearly visible on the screen, since Doppler provides a picture in color and has a high degree of resolution in terms of the clarity of the picture.

The very analysis of the frequency of ultrasonic waves reflected from objects in motion makes it possible to determine the speed of blood flow through the arteries, in the umbilical vessels, as well as the blood circulation inside the placenta. Then the indicators taken during the survey are compared with the table of normative data and the result is recorded.

The biggest plus of dopplerography, in addition to the safety of the study, is the accurate prediction of any form of abnormality, detecting them at the stage when it is still possible to save the fetus and not harm the mother's body.

In addition, classical measures to confirm or refute the pathology are mandatory used:

Analysis of the activity of the fetus, based on the words of the mother;
Stethoscopic listening to the baby's heartbeat in the womb;

Treatment

It is impossible to treat disorders of the uteroplacental blood flow, acting only in one direction, or eliminating problems as they arise.

A complete cure necessarily includes a set of measures aimed at:

Increased blood microcirculation;
Achievement of optimal blood pressure;
Vasodilation with spasmodic manifestations in the arteries;
Reduction of uterine tone due to the relaxation of blood vessels;
Prevention of the consequences of oxygen starvation (hypoxia);
Saturation of the placental tissue with the phospholipids it needs.

Consequences

Depending on the degree and nature of circulatory disorders during pregnancy, there are also difficulties in the development of the fetus, in rare cases leading to the death of the child.

The consequences of impaired blood flow during pregnancy are characterized by such nuances as:

Inhibition of fetal development at some of the stages, or significant delays in its intrauterine formation;
Critical indicators of weight and size;
Rapid, slow, or intermittent heartbeat;
Floating blood pH;
Improper course of hormonal processes;
Risk of miscarriage.

It must be remembered that only a cumulative assessment of the development of the baby, and not the results of one study, can provide complete information about compliance with standard indicators, or lagging behind them. At the moment, the Doppler ultrasound procedure, which is the basis of examinations of the perinatal period, in no way detracts from the need for tried and tested methods of the old school of medicine.