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Modern methods for assessing the condition of the fetus. Assessment of the condition of the fetus

In the physiological course of pregnancy, the condition of the fetus is assessed on the basis of:

The results of comparing the size of the uterus and the fetus with the gestational age;

Auscultation of fetal heart sounds at each visit to a pregnant antenatal clinic:

Motor activity of the fetus;

The results of an ultrasound scan, which is carried out at a gestational age of 18-22 weeks, 32-33 weeks and before childbirth (to identify the correspondence of the biophysical profile of the fetus and the degree of maturity of the placenta to the gestational age).

In case of a complicated course of pregnancy, an assessment of the condition of the fetus is included in the complex of inpatient examination of a pregnant woman, aimed at diagnosing her pathology, fetal hypoxia and determining the degree of its severity.

To diagnose fetal hypoxia, you need:

Assessment of fetal cardiac activity:

Assessment of fetal motor activity;

Amnioscopy;

Ultrasound of the fetus and placenta.

Fetal cardiac activity is assessed based on the results of auscultation of fetal heart sounds and cardiotocography (CTG). Auscultation of fetal heart sounds is performed at each examination of a pregnant woman, in the first stage of labor - every 15-30 minutes and outside the contraction, in the second stage of labor - after each contraction. The frequency, rhythm and sonority of the fetal heart sounds are assessed. Tachy or bradycardia, arrhythmia, deaf or muffled heartbeat of the fetus are clinical signs of hypoxia.

Ante- and intrapartum cardiotocography makes it possible to assess the fetal heart rate against the background of uterine contractile activity and fetal motor activity. Changes in basal rate, heart rate variability, acceleration and deceleration reflect the condition of the fetus and may be signs of hypoxia.

Fetal motor activity is assessed by counting the number of fetal movements in 30 minutes in the morning and in the evening. Normally, 5 or more fetal movements are recorded in 30 minutes. By the evening, in healthy pregnant women, the motor activity of the fetus increases. With the onset of fetal hypoxia, there is an increase and increase in movements, with progressive hypoxia - weakening and decreasing, followed by cessation of fetal movements. With chronic fetal hypoxia, there is an excessive increase or a sharp decrease in the difference between the number of movements in the morning and the number of movements in the evening.

The reaction of the fetal heartbeat to its motor activity can be objectively recorded with CTG (myocardial reflex).

Amnioscopy (transcervical examination of the lower pole of the fetal bladder) is performed using an amnioscope in the absence of contraindications (placenta previa, colpitis, endocervicitis) but during pregnancy (after 37 weeks) and in the first stage of labor. Normally, there is a sufficient amount of light, clear amniotic fluid, with fetal hypoxia - a small amount of greenish water and lumps of meconium.

Ultrasound examination reveals fetal growth retardation syndrome, placental insufficiency, on the basis of which chronic intrauterine fetal hypoxia can be established.

To clarify the severity of fetal hypoxia, it is necessary to use:

CTG with functional (stress) tests;

Doppler ultrasound;

Determination of the biophysical profile of the fetus, ultrasound placentography;

Amniocentesis;

Biochemical studies of placental enzymes and indicators of fetal acid-base balance;

Studies of hormone levels.

CTG with functional (stress) tests is performed in order to timely identify the compensatory capabilities of the fetus. It is possible to carry out tests with holding the breath on inhalation and exhalation, with physical exertion (step test), thermal tests and the identification of the fetal response to ultrasound. The change in the CTG curve against the background of functional (non-stress) tests allows diagnosing fetal hypoxia and its severity. The oxytocin stress test is rarely used due to possible complications for the mother and fetus.

Ultrasound with Doppler ultrasound makes it possible to examine the blood flow in the aorta and umbilical cord of the fetus and in the uterine arteries, obtaining curves of blood flow velocities on the monitor screen. Normally, in the third trimester of pregnancy, there is a gradual increase in volumetric blood flow due to a decrease in peripheral vascular resistance. When fetoplacental circulation is impaired, diastolic blood flow in the umbilical artery and the fetal aorta decreases. Decompensated placental insufficiency has zero and negative diastolic blood flow.

The biophysical profile of the fetus is a cumulative score in points of five parameters: the results of a non-stress test according to CTG data and four indicators of fetal ultrasound. Respiratory movements of the fetus, the motor activity and tone of the fetus, the volume of amniotic fluid, taking into account the degree of "maturity" of the placenta, are assessed. The score indicates the severity of fetal hypoxia.

Ultrasound placentography involves determining the location, size and structure of the placenta. In the normal course of pregnancy, the placenta "matures" and its thickness and area progressively increase by the time of delivery. With placental insufficiency, there is a thinning or thickening of the placenta, an increase or decrease in its area, as well as premature maturation and pathological changes in its structure (cysts, calcification, heart attacks and hemorrhages).

Amniocentesis - the study of amniotic fluid obtained by transabdominal (less often - transcervical) puncture of the amniotic cavity under ultrasound control, allows you to conduct a cytological and biochemical study of fetal cells, determine its gender, chromosomal pathology, metabolic diseases, malformations (in the period of pregnancy 16-18 weeks ).

During pregnancy more than 34 weeks, it is determined:

PH, pCO2, pO2, the content of electrolytes, urea, protein in the amniotic fluid (to diagnose the severity of fetal hypoxia;

The level of hormones (placental lactogen, estriol), enzymes (alkaline phosphatase, β-glucuronidase, hyaluronidase, etc.) (to exclude placental insufficiency and fetal malnutrition);

Optical density of bilirubin, fetal blood group, titer of Rh or group antibodies (to diagnose the severity of fetal hemolytic disease);

Cytological and biochemical (creatinine, phospholipids) indicators (to assess the degree of maturity of the fetus).

Biochemical studies of the level of specific enzymes (oxytocinase and thermostable alkaline phosphatase) of the placenta in the dynamics of the II and III trimesters of pregnancy make it possible to identify the functional state of the placenta.

The study of indicators of the acid-base state (CBS) of the fetus (pH, pCO2 and pO2) is carried out by cordocentesis (puncture of the umbilical cord of the fetus during amniocentesis) during pregnancy or puncture of the presenting part of the fetus during childbirth (Zaling's test). For research, you can also use amniotic fluid. Indicators of CBS in comparison with the results of clinical and instrumental studies (CTG, ultrasound) allow to objectively establish the severity of hypoxia.

Determination of the level of hormones (progesterone, placental lactogen, estrogens) formed in the placenta and organs of the fetus is carried out in the II and III trimester of pregnancy. Normally, the content of all hormones is constantly increasing towards the end of pregnancy. With placental insufficiency, there is a decrease in the level of progesterone and placental lactogen. An indicator of fetal suffering is a decrease in the amount of estriol (produced mainly in the fetus). In chronic placental insufficiency with impaired fetal trophism, a decrease in the concentration of all hormones is revealed.

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Methods for assessing the condition of the fetus 1. Feature assessment
anatomical development of the fetus.
2. Study of its functional
states.
To assess the condition of the fetus during
pregnancy and childbirth are used
clinical,
biochemical and biophysical
research methods

Clinical methods

auscultation
definition
frequency of movements
fetus
determination of the growth rate of the uterus
definition
character
staining
amniotic
liquids
(at
amnioscopy,
amniocentesis,
outpouring
amniotic fluid)

Amnioscopy

Lower pole inspection
fetal egg (fetal
shell,
amniotic
water and presenting part
fetus)
at
help
amnioscope.

The normal color of amniotic fluid is
transparent or straw yellow
Pathological coloration:
Green - stained with meconium, a sign
fetal hypoxia
Bright yellow (golden) - Rh
conflict
Red - premature detachment
placenta
Brown (dark brown) -
intrauterine fetal death

Amniocentesis

Puncture of the amniotic membrane
in order to obtain amniotic
waters
for
subsequent
laboratory research, or
introduction
v
amniotic
cavity of medicines.

Biochemical methods

study
hormonal
profile:
chorionic gonadotropin, placental
lactogen, estrogens (estriol), progesterone,
prolactin,
thyroid
hormones,
corticosteroids;
determination of the degree of maturity of the fetus on
the basis
cytological
research
amniotic
waters
and
concentration
phospholipids (lycetin and sphingomyelin) in
amniotic
waters,
received
by way
amniocentesis;
examination of fetal blood obtained by
intrauterine puncture - cordocentesis;
chorionic villus sampling for karyotyping
fetal and determination of chromosomal and gene
anomalies.

Biophysical Methods

electrocardiography
phonocardiography
echography
cardiotocography

Electrocardiography
determine the heart rate, the nature of the rhythm,
size, shape and
duration
ventricular complex.
Phonocardiography
represented by oscillations,
reflecting I and II cardiac
tones.

Echography (ultrasound)

Dynamic fetometry
Assessment of general and respiratory movements
fetus
Assessment of fetal cardiac activity
Measurement of thickness and area
placenta
Determination of the volume of the amniotic
liquids
Measuring the speed of the uterine
blood circulation (dopplerometry)

Cardiotocography (CTG)

continuous
synchronous
registration of heart rate
contractions (heart rate) of the fetus and
uterine tone with graphic
image
signals
on
calibration tape.

registration
Heart rate
produced by ultrasonic
sensor based effect
Doppler.
Registration of uterine tone
carried out
tensometric
sensors.

Cardiotocogram

Parameters of CTG

basal heart rate
variability of the basal rhythm:
oscillation frequency and amplitude
amplitude and duration
accelerations and decelerations
fetal heart rate in response
for fights
fetal movement
functional tests

Basal rhythm
this is a long-term change in heart rate
160
beats
10 min.
120
beats
Physiological basal rhythm - 120-160 beats / min.
During pregnancy - 140-150 beats / min.
The first stage of labor is 140-145 beats / min.
The second stage of labor is 134-137 beats / min.

Amplitude
145
max
min
135
1 minute.
Amplitude, or recording width,
is calculated between the maximum and
minimum deviations of heart rate within 1 min.

The following types of oscillations are distinguished by amplitude.

"dumb" or monotonous type -

are 5 or less strokes per minute
"slightly undulating" - 5-9 beats / min
"undulating" (uneven,
intermittent) type - deviations
from the basal level 10-25 beats / min
"saltator" (jumping) type -
deviations from the basal level
more than 25 beats / min).

Oscillation classification
140
0-5 bpm
100
140
"Dumb"
type of
5-9
bpm
Slightly
undulate
type of

140
10-25 bpm
Undulate
type
180
140
100
25 and bpm
Saltator
type

Oscillation frequency
determined by the number of line crossings,
drawn through the midpoints of the oscillations in 1 min
160
139
1 minute.
Low - less than 3 oscillations per minute
Moderate - 3 to 6 oscillations per minute
High - over 6 oscillations per minute

ACCELERATION
160
Deceleration
120
Acceleration - increase in heart rate by 15 beats / min in
for at least 15 sec.
Deceleration - slowing down the heart rate by 15 beats / min in
for 10 sec. and more

Criteria for normal CTG

Basal rhythm within 120-160
beats / min
Amplitude of variability
basal rate - 5-25 beats / min
Oscillation frequency 6 or more per min
There are no decelerations or
sporadic
shallow and very short
2 accelerations are registered and
more over 10 min recording

Fisher scale

8 - 10 points is the norm.
6-7 points - pre-pathological
type of,
necessary
repeated
examination.
Less than 6 points - pathological
type, signs of intrauterine
hypoxia
fetus,
requires
immediate hospitalization or
urgent delivery.

Ultrasound Screening

The main method of monitoring the baby's condition is ultrasound. Thanks to its use, it is possible to detect the embryo itself, starting from the earliest dates - from 2-3 weeks. Already during this period, with the help of ultrasound, the fetal heartbeat is determined, which confirms its correct development.

An ultrasound scan is performed several times during pregnancy. At 10-14 weeks, the first screening is performed, aimed at detecting chromosomal abnormalities in the fetus. At the same time, the following are evaluated:

1.thickness of the collar space (TVP); this is the area between the inner surface of the fetal skin and the outer surface of its soft tissues, covering the cervical spine, in which fluid can accumulate; normally, in terms of 11-14 weeks, it is 2-2.8 mm; TVP is a marker of fetal chromosomal abnormalities, primarily Down's syndrome;

2. the presence and length of the nasal bone (NK); normally for a period of 12-13 weeks is 3 mm; her absence is suspicious of Down syndrome.

Together with the first ultrasound screening, maternal serum markers ("double test") are determined: free human chorionic gonadotropin (b-hCG) and pregnancy-associated plasma protein A (PAPP-A), the level of which changes with fetal chromosomal abnormalities: Down's syndrome ( trisomy 21 chromosome), Edwards syndrome (18) and Patau syndrome (13).

The second ultrasound screening is carried out at 20-22 weeks, so that if a genetic pathology is detected, the woman has the opportunity to terminate the pregnancy up to 24 weeks, that is, until the time when the fetus is considered viable. Second trimester biochemical screening ("triple test") is currently canceled due to the large number of false results.

When prolonging pregnancy, the next ultrasound is recommended to be performed at 32-34 weeks and before childbirth. If necessary, the number of studies is increased.

Feto- and placentometry

During an ultrasound, fetometry is performed - measuring the size of the fetus. At the same time, such parameters of the fetus as:

Biparietal size (BPR),
- head circumference (OG),
-abdominal circumference (coolant),
- thigh length (DB),
- the size of the liver and spleen,
- estimated mass (PMP).

With ultrasound, it is possible to assess the size of the placenta, its condition, the degree of maturity and the amount of amniotic fluid, the parameters of which may change with some pathology of the fetus.

Also, ultrasound allows you to determine the muscle tone of the fetus in real time, to identify increased ("boxer posture") or decreased tone (symptom of an "open handle" - unclenched hand and extended fingers), to study the respiratory movements of the fetus (FDP), which are contractions of the respiratory muscles and diaphragm ...

Normally, at 35-40 weeks of gestation, the fetal respiratory rate can reach 50 per minute, combined with periods of apnea (lack of breathing). Changes in fetal respiratory movements at the end of pregnancy, especially of the type of shortness of breath, are considered an unfavorable prognostic sign and require special treatment.

Dopplerometry

Today, ultrasound data makes it possible not only to assess the size of body parts, organs and the fetus itself. With the help of a modern modification of ultrasound - dopplerometry, which studies the blood flow in various vessels, it is possible to assess the composition of the fetal blood non-invasively, that is, without using operational methods for taking the baby's umbilical cord blood.

So, by the speed of blood flow in the middle cerebral artery of the fetus, one can judge the level of its hemoglobin (oxygen carrier), as well as the presence and severity of anemia (decrease in erythrocytes and hemoglobin) and hypoxia (lack of oxygen).

Assessment of the parameters of blood flow in the middle cerebral artery allows to determine the management tactics for multiple pregnancies and hemolytic disease of the fetus. If signs of anemia are detected, an intervention is performed - intrauterine blood transfusion (MIC) to the fetus to replenish the circulating blood volume (up to 32-33 weeks of gestation) or delivery (after 32-33 weeks).

Cardiotocography

To assess the condition of the baby, all pregnant women undergo cardiotocography - registration of the fetal heart rate depending on its activity (movements), uterine contractions and various external factors.

CTG is performed from 32 weeks of gestation. The study is performed with the pregnant woman on her back, on her left side, or sitting in a comfortable position. In this case, the sensor is placed in the area of ​​stable recording of the fetal heart rate. The research is carried out within 50-60 minutes.

Fetal cardiograms are interpreted taking into account 5 indicators of cardiac activity: heart rate (HR), amplitude and frequency of oscillations (oscillations), the presence of accelerations (deceleration of heart rate) and decelerations (acceleration of heart rate).

Each of these parameters is assessed in points (from 0 to 2), the condition of the fetus - by the total amount of points. With 8-10 points, the fetus is considered good, with 6-7 points, it requires intensive therapy, less than 5 - emergency delivery.

CTG has no contraindications and is absolutely safe. Using the method allows you to monitor the condition of the fetus for a long time, if necessary - daily. However, it should be understood that the conclusion of CTG is not a diagnosis, but only represents some information along with the results of other research methods.

Amniocentesis

Often, for the examination of the fetus, invasive (with the introduction into the body) procedures are required, which include amniocentesis - obtaining amniotic fluid through a puncture in the fruit membranes.

The procedure is performed on an outpatient basis in the II and III trimesters under ultrasound guidance. For puncture, the most convenient place is chosen depending on the location of the placenta and small parts of the fetus. For the intervention, a special puncture needle is used, which, after puncturing the anterior abdominal wall, uterus and fruit membranes, enters the amniotic bladder. 10-15 ml of amniotic fluid is taken from it.

In the future, a laboratory study of the obtained waters is carried out. In this case, the following indicators can be determined:

Signs of intrauterine infection;
- fetal blood group;
- the optical density of bilirubin (OPB) - a sign of hemolytic disease of the fetus;
- fetal karyotype (genetic testing of the sample); it is used to diagnose chromosomal abnormalities (Down's syndrome, etc.) and hereditary diseases (cystic fibrosis, etc.);
- the degree of maturity of the lungs according to a special foam test.

Also, through amniocentesis, a number of therapeutic manipulations are performed during pregnancy: the introduction of drugs into the amniotic cavity, treatment of complications of multiple pregnancies.

You should be aware that amniocentesis is performed only if there are certain indications, since complications are possible in the postoperative period. Here are the main ones:

Leakage of water;
-infection;
- premature birth.

Cordocentesis

In some critical situations, a more in-depth examination of the fetus is required - the study of the umbilical cord blood. This is possible due to the use of cordocentesis - puncture (puncture) of the umbilical cord vein.

Cordocentesis is performed if there is a suspicion of chromosomal fetal abnormalities, severe forms of fetal hemolytic disease, fetal anemia with multiple pregnancies, etc. Contraindications to cordocentesis are: the threat of termination of pregnancy and severe disorders of the mother's blood coagulation system.

The study is carried out under ultrasound control. At the first stage, amniocentesis is performed. Then, through the lumen of the first needle, a second needle is inserted into the amniotic cavity, brought to the umbilical cord vein and punctured. Next, a syringe is connected and 2 ml of fetal blood is removed, after which the needles are slowly removed from the uterine cavity.

At the same time, the work of a surgeon can be compared with jewelry, because the size of the umbilical cord vein is extremely small, which leads to the risk of complications (thrombosis of the umbilical vein, the addition of a bacterial infection, fetal death). In the obtained blood sample from the umbilical cord vein, the following indicators are assessed:

Blood type, Rh-affiliation,
-values ​​of hematocrit, hemoglobin, leukocytes, platelets;
- levels of liver enzymes, bilirubin;
- indicators of iron metabolism;
-gas composition of blood;
- acid-alkaline state.

Cordocentesis is performed not only for diagnostic, but also for therapeutic purposes. If, according to the examination, the fetus has anemia (decreased hemoglobin), then the intervention is carried out - intrauterine blood transfusion (MIC) to the fetus to replenish the circulating blood volume, which fully justifies the risk of the intervention. Indeed, without the MIC, the fetus could die.

Modern diagnostic technologies make it possible to identify any abnormality in the development of the fetus from the earliest stages of pregnancy. The main thing is to pass all the necessary examinations in a timely manner and follow the recommendations of specialists.

Always with you,

The widespread introduction into clinical practice of various methods for assessing the state of the fetus contributes to a significant decrease in perinatal mortality, which is one of the main indicators of the level of development of medical care. Diagnostics is carried out in two directions: 1 - assessment of the features of the anatomical development of the fetus, 2 - the study of its functional state.

Clinical, biochemical and biophysical research methods are used to assess the condition of the fetus during pregnancy and childbirth.

To clinical diagnostic methods relate:

Auscultation,

Determination of the frequency of movement of the fetus,

Determination of the rate of growth of the uterus,

· Determination of the nature of the staining of the amniotic fluid (with amnioscopy, amniocentesis, amniotic fluid outflow).

In daily practice, the obstetrician is widely used auscultation with a stethoscope , the rhythm and heart rate, clarity of heart sounds are assessed. The normal fetal heart rate is 120 to 160 beats per minute. However, auscultation of the fetal heart rate is not always important for assessing the condition of the fetus or for diagnosing its hypoxia. It allows you to identify only gross changes in the heart rate (HR) - tachycardia, bradycardia and severe arrhythmia, which occur more often with acute hypoxia. In chronic hypoxia, in most cases, it is not possible to detect changes in cardiac activity by auscultation. Fetal heart rate auscultation is of great value in determining fetal health when used as a test to assess fetal reactivity. For this purpose, the fetal heartbeat is listened to before and after its movements. An increased fetal heart rate in response to movement is a clear indicator of good fetal health. The absence of a heart rate response or the appearance of only a slight increase in heart rate may indicate fetal hypoxia and requires additional research methods.

An indicator of the condition of the fetus is its physical activity , which in healthy pregnant women reaches a maximum by 32 weeks, after which the number of fetal movements decreases. The appearance of fetal movements (FF) indicates its good condition. If the mother feels DP without their decrease or decrease in activity, then the fetus is healthy and there is no threat to its condition. Conversely, if the mother notes a certain decrease in LTP, then he may be in danger. At the initial stages of intrauterine fetal hypoxia, the restless behavior of the fetus is observed, which is expressed in the increase and increase in its activity. With progressive hypoxia, there is a weakening and cessation of movements.

To assess the motor activity of the fetus, special forms are offered in which a pregnant woman marks each DP from 9:00 to 21:00, that is, 12 hours in advance . Number of DP more than 10 indicates a satisfactory condition of the fetus. If a woman notes less than 10 movements, especially two days in a row, then this condition is regarded as threatening the fetus. Consequently, the obstetrician receives information about the intrauterine state of the fetus from the pregnant woman herself. The registration methodology does not deprive women of their normal daily activities. If negative results are obtained, the doctor should send the pregnant woman to a hospital for examination.


In stationary conditions, in addition to additional research methods, it is possible to use the second method for registering DP to assess its intrauterine state. Pregnant DP is recorded lying on its side for 30 minutes. four times a day (9:00, 12:00, 16:00 and 20:00) and entered into special cards. When evaluating the results, it is important to pay attention not only to a certain number of movements (if the fetus is in a satisfactory condition, it should be not less than 4 in 2 hours), but also on the change in their number over the course of several days. The suffering of the fetus is indicated by the complete disappearance of physical activity or a decrease in the number of DPs by 50% per day. If in the following days DP returns to the previous level, then there is no danger to the fetus at the moment.

Of particular value in the diagnosis of fetal hypoxia is the combined registration of its cardiac activity and motor activity.

A significant amount of information about the condition of the fetus can be obtained by measuring the height of the fundus of the uterus. Measurement data is commonly used between 20 and 36 weeks pregnancy. To determine the rate of growth and development of the fetus, it is necessary in dynamics (every 2 weeks) measure the height of the fundus of the uterus above the pubic articulation and the circumference of the abdomen. Comparison of the sizes obtained with the gestational age allows us to identify a lag in the growth of the fetus. Lagging behind the height of the fundus of the uterus on 2 cm and more compared to the norm or the absence of its growth within 2-3 weeks . with dynamic monitoring of a pregnant woman indicates fetal growth retardation , which requires further evaluation. There are many factors that make it difficult to assess the growth of the fetus (violation of the measurement method, violations of fat metabolism in the mother, excess or reduced amount of amniotic fluid, multiple pregnancies, abnormal position and presentation of the fetus). However, these measurements of the standing height of the uterine fundus remain a good clinical indicator of normal, accelerated or reduced fetal growth.

Amniotic fluid staining during pregnancy can be detected by amnioscopy or amniocentesis, as well as with premature rupture of the membranes.

Amnioscopy- transcervical examination of the lower pole of the fetal bladder. Availability impurities of meconium indicates chronic fetal hypoxia or the former acute short-term, and the fetus, in the absence of new disturbances in its oxygen supply, can be born without asphyxia. The presence of a small admixture of meconium in the amniotic fluid (yellow or greenish color) in premature pregnancy is not an absolute sign of fetal hypoxia. If meconium in the amniotic fluid is found in large quantities (dark green or black), especially in high-risk pregnant women (late gestosis, Rh isoimmunization, chorioamnionitis, etc.), then this is regarded as a threatening condition of the fetus. Turbid staining amniotic fluid indicates a post-term pregnancy, yellow - about GBP or rhesus incompatibility.

Biochemical methods for diagnosing the condition of the fetus:

· Study of the hormonal profile: chorionic gonadotropin, placental lactogen, estrogens (estriol), progesterone, prolactin, thyroid hormones, corticosteroids;

· Determination of the degree of fetal maturity on the basis of a cytological study of amniotic fluid and the concentration of phospholipids (lycetin and sphingomyelin) in amniotic fluid obtained by amniocentesis;

· Examination of fetal blood obtained by intrauterine puncture - cordocentesis;

· Chorionic villus sampling for fetal karyotyping and determination of chromosomal and gene abnormalities.

To assess the condition of the fetus during pregnancy, they also examine hormonal activity of the fetoplacental system , which to a certain extent depends on the physiological activity of the fetus and to a large extent on the functional activity of the placenta. Among biochemical methods studies have found the most widespread application in practice to determine the concentration of estriol and placental lactogen in the mother's body.

In non-pregnant estriol is the main metabolite of the main estrogen - estradiol. During pregnancy, the fetus and placenta are responsible for most of the production of estriol. The average daily amount of hormone excreted in the urine is 30-40mg... Highlighting less than 12 mg / day indicates a decrease in the activity of the fetoplacental complex. Decrease in estriol content up to 5 mg / day indicates the suffering of the fetus. Decrease in estriol excretion below 5 mg / day threatens the life of the fetus. Since the level of estriol in the mother's body is influenced by many factors (the state of liver and kidney function, the difficulty of collecting daily urine, the intake of medicinal substances, a wide range of research results, etc.), the information obtained when determining the level of estriol is valuable if it coincides with other clinical and biophysical parameters. It is generally accepted that estriol levels reliably reflect the state of the fetus in case of pregnancy complicated by late gestosis, fetal growth retardation, maternal diabetes mellitus, that is, in the group of pregnant women with a high risk of fetal hypoxia.

Placental lactogen (PL) synthesized by the placenta and can be determined in maternal serum. The concentration of PL in the mother's blood is in direct proportion to the mass of the functioning placenta. Consequently, in the normal course of pregnancy, serum PL values ​​increase as the placenta grows. In the presence of a pathologically small placenta, PL levels in maternal blood are low. Determination of PL can play a significant role in assessing the condition of the fetus in women who have a fibrous placenta with infarctions of small sizes, especially when pregnancy is complicated by late gestosis or in the presence of intrauterine fetal growth retardation. During physiological pregnancy, the PL content in the mother's blood gradually increases and during full-term pregnancy is from 6 to 15 μg / ml, then the decrease in PL in women after 30 weeks. pregnancy to the level less than 4 μg / ml is threatening to the fetus. A few weeks before the death of the fetus, the level of PL drops sharply. With insufficient function of the placenta, a moderate decrease in the level of PL in the blood is observed. The results of determining the PL content, obviously, cannot be used as the only diagnostic criterion for fetal hypoxia.

However, in modern clinical practice, the determination of the level of estriol in the blood and its excretion in the urine has not found widespread use, especially since the determination of estriol gives about 80% of false-positive results. The determination of the level of placental lactogen has the same low value. Currently, they have been replaced by methods of ultrasound examination and electronic monitoring of the fetus.

Most informative are considered biophysical methods for assessing the condition of the fetus . These include: electro- and phonocardiography, echography and cardiotocography, which are widely used in the daily work of an obstetrician.

Methods for the study of fetal cardiac activity are also indirect (from the abdominal wall of the uterus) electrocardiography and fetal phonography. When analyzing antenatal ECG determine Heart rate, the nature of the rhythm, the size, shape and duration of the ventricular complex. With fetal hypoxia, violations of the conduction of the heart are detected, a change in the amplitude and an increase in the duration of heart sounds, their splitting. The occurrence of murmurs, especially systolic, during chronic fetal hypoxia indicates its serious condition.

FCG presented oscillations reflecting I and II heart sounds. The pathology of the umbilical cord is characterized by the appearance of a systolic murmur on the PCG and an uneven amplitude of heart sounds.

Ultrasound procedure is the most reliable and accurate method of antenatal diagnosis of fetal health.

The method allows:

To carry out dynamic fetometry,

Evaluate the general and respiratory movements of the fetus,

Cardiac activity of the fetus,

The thickness and area of ​​the placenta,

Amniotic fluid volume

· To measure the rate of fetal-uterine blood circulation.

First of all, they define biparietal size of the fetal head (BPD), mean diameters of the chest (DG) and abdomen (DW). A reliable sign of fetal growth retardation is a discrepancy of 2 weeks. and more BPD of the fetal head to the actual gestational age, as well as disturbances in the relationship between the size of the fetal head and trunk. Comprehensive ultrasound assessment of fetal growth rates allows early diagnosis and an objective assessment of the condition of the fetus.

Is of great importance the study of the respiratory movements of the fetus... To analyze the respiratory activity of the fetus, the following indicators are used: the index of respiratory movements of the fetus (the percentage of the time of respiratory movements to the total duration of the study); fetal respiratory rate (number of breaths per minute); the average duration of episodes of respiratory movements; the average number of breaths per episode. The duration of the study should be at least 30 minutes. In the absence of fetal respiratory movements, the study is repeated the next day. The absence of respiratory movements during 2-3 studies is regarded as a poor prognostic sign. Signs of fetal suffering are changes in the nature of respiratory activity in the form of a sharp decrease or increase. With severe fetal hypoxia, the nature of fetal movements changes. Respiratory movements appear in the form of hiccups or intermittent breathing with prolonged episodes of apnea.

The most accessible, reliable and accurate method for assessing the condition of the fetus during the last trimester of pregnancy is fetal cardiotocography (CTG). The cardiotocograph is designed in such a way that it simultaneously records the fetal heart rate, uterine contractions and fetal movement. Modern cardiotocographs meet all the requirements put forward for monitoring the fetal heartbeat and uterine contractile activity both during pregnancy and during childbirth. Currently, it is generally accepted to conduct screening control of the condition of the fetus both on an outpatient basis and in a hospital. In risk groups for perinatal losses, screening control is carried out over time. Usually, the registration of the fetal heart rate is applied from 30 weeks. pregnancy on a tape moving at a speed of 10 to 30 mm / min, for 30 minutes.

To characterize the condition of the fetus using CTG, the following indicators are used: basal heart rate, variability of basal rhythm, frequency and amplitude of oscillations, amplitude and duration of accelerations and decelerations, fetal heart rate in response to contractions, fetal movements and functional tests.

Under basal rhythm (BR) understand the long-term change in heart rate. A decrease in it below 120 beats / min is classified as bradycardia, and an increase over 160 beats / min is classified as tachycardia. Therefore, a long-term heart rate in the range of 120-160 beats / min is regarded as a normal area. Tachycardia is distinguished by severity: mild (160-170 beats / min) and severe (more than 170 beats / min). Bradycardia is also divided into mild (120-100 beats / min) and severe (less than 100 beats / min) severity. If bradycardia manifests itself in a time interval of no more than 3 minutes, and then it returns to the original BR, then it is called deceleration.

At the present stage of development of medicine, prevention and timely diagnosis of possible disorders in the life of the fetus are quite important. The main task of modern obstetrics is to reduce perinatal morbidity and mortality. For this, an assessment of the intrauterine state of the fetus is used throughout the pregnancy.

Features of the assessment of the intrauterine state of the fetus in pregnant women

At the moment, it is possible to diagnose not only disorders that occur during pregnancy in the fetus, but also the presence of chromosomal hereditary diseases, delayed development of the fetus or individual organs and systems, and much more.

The state of the fetus can be judged by the presence or absence of certain substances in the waters. For example, a decrease in the level of estriol in them indicates a violation of important functions of the fetus, the presence of creatinine, glucose, protein, etc. in the waters is also important in this.

Sometimes, with the pathological course of the birth act, it becomes necessary to study the fetal blood for oxygen starvation, acidosis and other disorders. For this, blood is taken very carefully with a special instrument from the presenting part of the fetus.

Often there is a need to investigate the function of the placenta. To do this, determine the content of hormones produced by it in the blood or their excretion in the urine. Chorionic gonadotropin, progesterone (in the blood), pregnadiol (in the urine), estradiol, etc. are determined.

It is also important in some cases to record and analyze the contractile activity of the uterus. For this, electrohysterography and mechanography are used. And if it is necessary to obtain information about the intrauterine pressure, radio telemetry is used. In some institutions, thermography is used, which allows you to clarify the placenta attachment, establish a prolonged pregnancy, the presence of twins, etc.

The program for assessing the intrauterine state of the fetus at different stages of pregnancy

There are certain programs for examining pregnant women at various stages of pregnancy, the organization of which is provided by the women's consultation, where the woman is registered.

Assessment of the intrauterine state of the fetus in the 1st trimester of pregnancy

Starting from the first trimester of pregnancy, with a period of 10 weeks of pregnancy, it is possible to carry out the following studies to assess the intrauterine state of the fetus. Assessment of the intrauterine state of the fetus:

Ultrasound examination at 10-14 weeks, which is necessary to diagnose malformations, the presence of chromosomal abnormalities.

Mother's blood test for serum markers at 10–11 weeks, at the same time highlighted groups of risk for chromosomal pathology.

Chorionic villus aspiration biopsy at 9–12 weeks can also diagnose chromosomal abnormalities.

Assessment of the condition of the fetus in the 2nd trimester of pregnancy

The second trimester of pregnancy allows you to expand the used research methods.

Maternal blood test for serum markers at 16–20 weeks - AFP, hCG.

Ultrasound examination at 20-24 weeks diagnoses malformations.

Doppler study of uteroplacental-fetal blood flow at 16–20 weeks is performed to predict the development of preeclampsia in the second half of pregnancy and placental insufficiency (FPI).

Invasive prenatal diagnosis from 16 weeks is carried out strictly if indicated. You can perform amniocentesis, placentocentesis, cordocentesis - these methods are diagnosed with chromosomal and gene abnormalities.

Assessment of the intrauterine state of the fetus during the 3rd trimester of pregnancy

In the third trimester of pregnancy, all studies, as a rule, are aimed at diagnosing placental insufficiency. Assessment of the intrauterine state of the fetus:

Ultrasound examination at 32–34 weeks diagnoses malformations with late appearance, FGRP (fetal growth retardation syndrome).

Doppler study of uteroplacental-fetal blood flow assesses the functional state of the fetus.

Cardiotocographic examination assesses the functional state of the fetus.

When considering in more detail the individual research methods, all methods used to assess the intrauterine state of the fetus can be divided into non-invasive and invasive.