Antenatal Death Research Articles

Pathomorphological Changes of the Placenta in Antenatal Asphyxia of the Fetus Associated with the Coronavirus Disease (COVID-19) in Pregnant Women

Сoronavirus disease (COVID 19) in a pregnant woman remains a risk factor for perinatal losses despite the barrier function of the placenta. This prompted us to do some research. Objective — to determine the pathomorphological changes of the placenta and fetus during antenatal asphyxia in the acute period of COVID-19 in a pregnant woman. Materials and methods. We studied placentas and fetuses in case of antenatal asphyxia (n = 16) in the acute period of the COVID-19 in a pregnant woman, confirmed by a positive PCR test (determination of SARS-CoV-2 RNA). The duration of the post-COVID interval (time from the diagnosis of COVID-19 to delivery) was 1—3 weeks. Results and discussion. Intrauterine death of the fetus occurred at different gestational period: from 26 to 38 weeks (median 33). At the same time, the woman fell ill with COVID-19 between 18 and 35 weeks of gestation (median 31). Hemorrhages in the right atrium and auricle of the heart were observed in fetuses — 93.8 % (95 % CI: 75.4—100); dark blood clots in the chambers of the heart; hemorrhages under the periosteum of the bones of the skull, stasis in the veins of the brain — 81.3 % (95 % CI: 57.1—96.7), hemorrhages in the scrotum, spermatic cord — 6.3 % (95 % CI: 0.0—24.6) and kidney hemorrhages — 62.5 % (95 % CI: 36.2—85.4). When examined macroscopically, the placenta was characterized by a flabby or dense consistency; diffuse hemorrhages or local blood clots in numerous cysts; areas of abruption, thrombosis of umbilical cord vessels. Microscopic examination of the placenta revealed chorioamnionitis — 81.3 % (95 % CI: 57.1—96.7 %), intervillositis — 93.8 % (95 % CI: 75.4—100), acute villitis — 56.3 % (95 % CI: 30.2—80.6). Basal deciduitis was detected in all observations in 100 % (95 % CI: 88.8—100). Disorders of blood circulation were found in the placentas: stasis, thrombosis, hemorrhages; and necrosis of the arteriole endothelium — 100 % (95 % CI: 88.8—100 %). Conclusions. COVID-19 in a pregnant woman from 18 to 35 weeks of gestation (median 31) is a risk factor for perinatal losses. No significant differences were found between the severity of the course of COVID-19 in the mother and the morphological changes of the placenta. Pathognomonic changes in the fetus with COVID-19 in the mother in the acute period: «porphyry lung», hemorrhages in the right atrium, under the periosteum of the bones of the skull, spermatic cord, kidneys, blood clots in the chambers of the heart. The cause of antenatal death of the fetus in the acute period of COVID-19 in a pregnant woman is acute placental insufficiency associated with disorder of placental-fetal blood circulation, due to manifestations of the exudative phase of inflammation: placentitis (focal chorioamnionitis, acute villitis, intervilositis, basal deciduitis) and disorder of blood rheology, which was manifested by thrombosis, hemorrhages in the intervillous space, detachment of the placenta.

The spectrum of infections identified in pregnant women with different types of fetal growth restriction

BACKGROUND: Bacterial, viral and protozoal infections can cause miscarriage, antenatal death, congenital organ abnormalities or other limited consequences depending on the pathogen. The role of infection processes identified during pregnancy on placental pathology and fetal growth restriction. AIM: The aim of this study was to conduct a comparative analysis of infections identified in pregnant women with different types of fetal growth restriction, as well as to assess a potential impact of identified infections on the outcomes of fetal growth restriction in newborns in the same groups. MATERIALS AND METHODS: We performed a retrospective analysis of outcomes for 394 pregnant women with an established diagnosis of fetal growth restriction, who had given birth from 2018 to 2022 in the Perinatal Center of the Arkhangelsk Regional Clinical Hospital. Maternal and neonatal case histories were obtained using a continuous sampling method. Considering the transition to new criteria for establishing the diagnosis of fetal growth restriction in Russia, we formed four study groups, of which only 139 cases met the Delphi criteria of clinical guidelines by Russian Society of Obstetricians and Gynecologists, 2021. In the selected groups, we analyzed the results of microscopic and microbiological tests of various localizations in mothers during antepartum examination, as well as postpartum examination of the placenta and culture tests in newborns in their relation to adverse outcomes. RESULTS: A high prevalence (25–70.4%) of positive bacteriological findings was revealed in all of the study groups. The frequency was highest in the group of pregnant women with fetal growth restriction before 32 weeks (90–92%). Combined infections (two or more localizations) were noted in 59.2% of pregnant women in groups with early fetal growth restriction compared to 23.3% in late fetal growth restriction groups. In all cases, we observed a direct relationship between the severity of fetal growth restriction and the prevalence of infections. The range of infections identified during routine examination of pregnant women is quite limited; Candida spp. (from 40.8% in the control group to 75% in the comparison group), Escherichia coli (from 22.9 to 33.3%, respectively), and Chlamydia trachomatis (from 4.5 to 23.5%, respectively) being identified most commonly. In a morphological study of the placenta, infectious and inflammatory lesions were the most significant and ranged from 100 to 81.4% of cases in groups with early and late fetal growth restriction, respectively, with signs of hematogenous transmission prevailed. When analyzing infectious lesions in fetuses, we have found the presence of three and more localizations of the infectious process in 90 to 45% of cases with a fatal outcome for early and late fetal growth restriction, respectively. In the control groups, similar rates were 40 and 15.8%. When assessing the distribution of various types of infectious process in newborns, Candida spp., Escherichia coli, and Enterococcus faecalis also took the lead in all cases. However, the percentage of the same etiology of maternal and neonatal infections turned out to be very low (from 0 to 31% for individual pathogens), which makes it difficult to apply preventive treatment during pregnancy. CONCLUSIONS: Authors identified indirect but numerous signs of significant involvement of infectious processes in the development of fetal growth restriction, especially its early type, as well as the influence of infections on the outcomes for such newborns. In most cases, infectious processes during pregnancy are subclinical. Current screening of pregnant women is insufficient to identify high-risk groups. Examination of pregnant women for infections carried out by culture tests provide low-component and, most likely, incomplete information.

FEATURES FUNCTIONING OF THE DETOXIFICATION SYSTEM AT THE THREAT TERMINATION OF PREGNANCY AS A CONSEQUENCE OF ACCUMULATION OF 137CS

To date, there is no consensus on the pathogenesis of miscarriage. In modern life, human health is signifi cantly infl uenced by environmental factors. In this regard, 37 years after the accident at the Chornobyl nuclear power plant, the question of remote cytogenetic and hereditary eff ects in the off spring of parents aff ected by radiation remains relevant. Ecosystems contaminated with radioactive substances are a source of exposure for humans. Internal irradiation is the cause of reproductive losses. Radiation stress aff ects the course of redox processes in the body. Biochemical indicators are markers of the infl uence of environmental factors on a person. The study is dedicated to determining the state of peroxide hemostasis in the case of miscarriage. Aim: to determine the peculiarities of the functioning of the detoxification system in case of miscarriage due to the accumulation of 137Cs.Material and methods. The fi rst (research) group included women with reproductive losses in anamnesis and signs oftermination of the current pregnancy; the second (control) group included women with an uncomplicated history and course of pregnancy. Additionally, the fi rst group was divided into subgroups according to pregnancy outcomes: А – 38 women who gave birth at 37-40 weeks, despite the complicated course of the current pregnancy, В – 13 women who gave birth at 28-36 weeks + 6 days, С – 9 women who birth at 22-27 weeks + 6 days. The state of peroxide hemostasis in women was studied using biochemical studies. Accumulation of 137Cs with diff erent activity was detected in the placentas of the examined women of both groups using β-spectrometry. Morphological examination of placentas was performed according to the protocol. The severity of placental damage was studied by Olympus BX51 and Axioskop 40 microscopes. Analyzing the results revealed a relationship between biochemical indicators, the activity of 137Cs, and pregnancy scenarios. Statistical data analysis was performed using Microsoft Excel (2016) and Fisher angular transformation. The diff erence between comparative values was considered signifi cant at p < 0.05 (probability index greater than 95 %). Permission to conduct research was obtained from the Medical Ethics Committee of the SI «Institute of Pediatrics, Obstetrics, and Gynecology named academic Elena M. Lukyanova of the National Аcademy of Мedical Sciences of Ukraine» (protocol No 3 of 07.06.2017).Scientifi c research work is to «Develop the latest and improve existing technologies for diagnosis, prevention, and treatmentof premature termination of pregnancy in women with miscarriage taking into account the passport of the placenta» (2018-2020). Code VN.20.00.02.18, state registration number 0118U000039, KPKV 6561040.Results. It has been confi rmed that the state of the environment plays a decisive role in the pathogenesis of miscarriage. Ithas been proven that placental dysfunction caused by abnormal oxidative stress due to the action of incorporated 137Cs leads to pregnancy termination. As a result of the depletion of the antioxidant reserve, the compensatory capabilities of the placenta decrease. It was established that activity in the placenta up to 1.0 Bq/kg of 137Cs does not aff ect the course of gestation. The compensatory capacity of the placenta remains preserved even with the accumulation of 1.1 to 4.4 Bq/kg of 137Cs. At the same time, it is possible to prolong the pregnancy until the term of timely delivery. Internal irradiation with an activity of 4.5-10.4 Bq/kg of 137Cs causes damage to the stroma of the maternal surface of the placenta and premature birth at 28-36 weeks + 6 days. At the same time, newborns are viable due to the preservation of compensatory reactions in the placenta. Accumulation of more than 10.4 Bq/kg of 137Cs causes antenatal death of the fetus and early premature birth due to damage to maternal and fetal structures of the placenta. An increase in the content of malondialdehyde and a decrease in the activity of superoxide dismutase in the blood indicate the severity of radiation damage.Conclusions. Internal exposure to 137Cs disrupts the architecture and functional capacity of the placenta. Extreme eff ectsdepend on the activity of 137Cs, the compensatory capabilities of the placenta, and the pregnant woman’s body. Activation of lipid peroxidation acts as a biochemical amplifi er of radiation exposure. An increase in the blood of malondialdehyde, diene conjugates, and free SH groups is associated with the severity of radiation damage. An early marker of primary placental dysfunction, premature birth, and antenatal fetal loss is an increase in MDA content in the blood by 12.0 % and a decrease in SOD by 6.5 % relative to permissible values. An early marker of exhaustion of the compensatory reserve is an increase in the content of MDA in the blood by 23.3 % and a decrease in SOD by more than 18.2 % relative to the permissible values. Decompensation of adaptation mechanisms in the system «mother- placenta-fetus» leads to antenatal losses.

Congenital malformations of the neural tube spina bifida in the Republic of Tajikistan

Objective. Determine the prevalence of the congenital neural tube defect, Spina bifida.Materials and methods. This study utilized data from epidemiological monitoring of statistical registration forms, the National Register of Congenital Malformations F32, and the Report on Medical Assistance provided to Pregnant Women, Postpartum Women, and Newborns from 2016 to 2021.Results. Throughout the study duration, a total of 1,442,030 newborns were recorded in the republic. Of these, 11,320 had congenital malformations of the CNS, with 9,682 being born alive. Neural tube defects were diagnosed in 1,447 (14.9%) of these children: 102 (7.0%) had anencephaly (Q00), 112 (7.7%) had encephalocele (Q01), and 667 (46.0%) had Spina bifida (Q05). Notably, in the post-COVID years of 2020 and 2021, births of children with Spina bifida decreased by almost half compared to prior years, a statistically significant difference (P<0.001). Concurrently, there was a rise in antenatal death rates for these children, reaching 15.5% and 18.3% for the two respective years.Conclusion. Spina bifida has a multifactorial etiology. Its population prevalence does not exceed 1.5‰, majority of lethal outcome occurs in early neonatal period in the first 168 hours of life accounting for 96.5%.

FAKTOR YANG BERPENGARUH TERHADAP KEJADIAN ASFIKSIA NEONATORUM DI RSUD BATARA GURU BELOPA

Asphyxia is an emergency event in the form of spontaneous breathing failure immediately after birth. It is very risky for death when the fetus does not breathe spontaneously and regularly so that it can reduce oxygen and increase carbon dioxide, which has bad consequences for continuing life. The cause of early neonatal death at Batara Guru Belopa Hospital is Asphyxia. Factors related to the incidence of asphyxia neonatorum at Batara Guru Belopa Hospital in 2021 This study uses a descriptive correlational method with a cross-sectional time approach. Sampling using the Slovin formula amounted to 62 respondents. Data collection tools using medical records Bivariate data analysis using the Chi-Square test shows that the incidence of asphyxia neonatorum is 52 infants, and infants who do not experience asphyxia neonatorum are 10 infants. There is a relationship between maternal age and neonatal asphyxia (p = 0.008), there is a relationship between parity and neonatal asphyxia (p = 0.000), there is a relationship between low birth weight (LBW) and neonatal asphyxia (p = 0.013), and there is a relationship between premature rupture (PROM) of membranes and neonatal asphyxia (p = 0.021). For institutions, it is hoped that the results of this study can be useful input for students, especially in preventing Neonatal Asphyxia so that it does not cause antenatal and neonatal deaths.
 Keywords: Asphyxia, maternal age, parity, LBW, PROM

57 Butterflies and Ribbons: The Positive Impact of Educational Strategies to Optimize Communication with Parents after the Perinatal Loss of a Co-twin

Abstract Background In neonatology, multiples pregnancies are common: 50% of twins and 95% of triplets are admitted to the NICU. Unfortunately, it is not rare for one baby to die. When this happens, parents are in a unique situation: they need to mourn their baby, while continuing to visit their other baby(ies) in the NICU. Communication with parents in these circumstances has been demonstrated to be sub-optimal, sometimes because clinicians are unaware and ask harmful questions (e.g., “Do you have any other kids?”) or because their education on how to deal with such issues was limited (despite available evidence). These gaps often lead to parental distress. Objectives To assess the impact of two different teaching strategies for clinicians dealing with the perinatal loss of a co-twin or triplet. Design/Methods Two different programs aimed at educating clinicians dealing with perinatal loss of co-twins or triplets were evaluated in 2022: 1) an open online 4-hour course with theory and practical points (the Butterfly project); and 2) a one hour in-person (workshop) or online course offered to NICU clinicians (free of charge) in a large academic NICU. The second course became the “Ribbon project” because bereaved parent partners had recommended the symbol of a ribbon rather than the butterfly as better reflecting perinatal loss. In both courses, essential topics were covered. For example: identifying the status of a surviving twin (including name of the deceased one); moving the surviving baby to another room after the death, knowing when and how to speak with bereaved parents, and identifying the surviving twin status at discharge. Participants in both groups were surveyed to ask whether they were satisfied with the course, their knowledge of care for perinatal loss was evaluated pre- and -post course, as well as when and how they used their training. Clinical impacts of the Ribbon project were also evaluated. Results In the butterfly project, all participants (n=734) reported that training exceeded or met their expectations, while 97% reported they learned new skills, and 48% reported already applying them. Many participants were grateful for the course, answering positively to open-ended questions: e.g., “I found this course incredibly useful for my future practice,” and “I feel a lot more confident in supporting parents.” For the ribbon project (n= 174), 97% were satisfied or very satisfied with the training, and 97% reported feeling more comfortable talking to bereaved parents. Knowledge improved with training. In clinical audits that occurred between 2020 and 2022, 100% of cases were identified (28/28; 23 twins and 5 triplets surviving; 8 antenatal deaths) on the incubator and the baby(ies)’ admission card. Also, 100% of the surviving twins or triplets kept their identification (#1, 2, or 3) after speaking with parents, all changed rooms after the death of their co-twin or triplet, and all had the name of their co-twin or triplet on the discharge summary. All clinicians (55) knew what the ribbon symbol meant when asked during surprise audits at the bedside; 38/55 (71%) felt comfortable dealing with parents in this situation and for those who did not, they knew who to ask for help. Conclusion Different educational strategies to optimize communication with families after the perinatal loss of a co-twin/triplet are appreciated and have a positive impact. One hour of teaching specifically for NICU personnel is enough to make a difference.

A case of observing cardiac twins

Introduction. Reverse twin arterial perfusions, also known as cardiac malformation, is a uniquely rare complication of monochorionic multiple pregnancy due to the presence of a large arterio-arterial anastomosis, the formation of a rudimentary heart or its absence in one of the fetuses. The heart of a morphologically normal twin (fetus-pump, fetus-donor) provides blood circulation for both fetuses.The aim of the work was to determine a possible way to reduce perinatal mortality using the clinical example of monochorionic multiple pregnancy with the presence of cardiac twins.Materials and methods. Materials for clinical case analysis were the exchangenotification card of the pregnant and parenting woman, labor history, the results of functional and laboratory tests. Methods: analysis of anamnesis, results of functional and laboratory tests, peculiarities of pregnancy and delivery.Results. The analysis successfully demonstrates the possibility of improving perinatal outcomes in monochorionic twins complicated by the presence of acardia syndrome in the case of timely diagnosis of the complication, close dynamic monitoring of pregnancy and timely delivery in the case of functionally confirmed deterioration of the living fetus.Discussion. Monochorial type of placentation is recognized as a high risk factor for adverse perinatal outcomes (fetal-fetal hemotransfusion syndrome, the formation of discordant growth andfetal growth retardation, cardiac twins, increase frequency of preterm birth, perinatal morbidity and death). The presence of cardiac twins is the highest risk factor for antenatal death of a second fetus in the absence of timely surgical treatment and delivery. The presented clinical case demonstrates the possibility of improving perinatal outcomes by prolonging a multiple pregnancy complicated by cardiac malformation up to 33 weeks of gestation and delivery at decompensation of the placental complex.Conclusion. In the vector of reducing the incidence of perinatal mortality, individual management of pregnant women with monochorionic multiple pregnancy is necessary to enable timely diagnosis of its complicated course by cardiac malformation of one of the fetuses, dynamic functional examination of the placental complex, determination of indications for surgical correction and choice of term of delivery.

Analysis of the causes of antenatal death of premature fetuses in the Chelyabinsk region

Introduction. The stillbirth rate is steadily increasing accounting for about 80 per cent of perinatal mortality in Russia. There is currently no uniform international classification for coding the causes of perinatal death.The aim of the study was a comparative analysis of the causes of antenatal death of full-term fetuses in the Chelyabinsk region on the basis of various classifications of perinatal mortality to determine possible reserves for reducing the stillbirth rate.Materials and methods A retrospective case-control study based on the analysis of medical documentation of all cases of antenatal death of full-term fetuses during the period of pregnancy 37 weeks 0 days - 41 weeks 6 days held in the Chelyabinsk region from 2019 to 2021. We use the MedCalc software package (Version 20.110, Belgium, 2022) for statistical analysis.Results Based on the ICD-10 classification applied to perinatal deaths (ICD-PM), the leading cause of antenatal death of full-term fetuses is acute antenatal complication. In this case, disorders related to duration of pregnancy and growth of the fetus are the main concomitant pathology. There has also been an increase in the proportion of maternal conditions that have a direct impact on antenatal fetal death (placental and umbilical cord pathology) and other diseases or pathological conditions of the mother (hypertensive disorders and infectious and parasitic diseases). According to the Scandinavian-Baltic Classification, most cases fall into category III and are considered preventable. The distribution of full-term fetal death by CODAC showed that antenatal hypoxia of the fetus is rarely the primary and only cause. First comes the pathology of the placenta and umbilical cord.Discussion The ICD-PM classification allows to lead the most detailed analysis of the causes of antenatal death, considering the pathological conditions of the fetus and the mother, which have a direct influence on the occurrence of the adverse outcome. However, a comparison of the distribution of the cases studied by other classifications showed that the pathology of the placenta and umbilical cord could be considered as the main cause of antenatal death of full-term fetuses, rather than a concomitant cause.Conclusion The main cause of antenatal death of full-term fetuses in Chelyabinsk region is antenatal hypoxia of the fetus. At the same time, all cases of antenatal fetal death relate to preventable losses, which determines the urgent need to identify predictors of this unfavorable outcome in order to reduce the stillbirth rate.

Stillbirths and neonatal mortality in LMICs: A community-based mother-infant cohort study.

The exact timing, causes, and circumstances of stillbirth and neonatal mortality in low- and middle-income countries (LMICs) remain poorly described, especially for antenatal stillbirths and deaths occurring at home. We aimed to provide reliable estimates of the incidence of stillbirth and neonatal death in three LMICs (Madagascar, Cambodia and Senegal) and to identify their main causes and associated risk factors. This study is based on data from an international, multicentric, prospective, longitudinal, community-based mother-infant cohort. We included pregnant mothers and prospectively followed up their children in the community. Stillbirths and deaths were systematically reported; information across healthcare settings was collected and verbal autopsies were performed to document the circumstances and timing of death. Among the 4436 pregnancies and 4334 live births, the peripartum period and the first day of life were the key periods of mortality. The estimated incidence of stillbirth was 11 per 1000 total births in Cambodia, 15 per 1000 in Madagascar, and 12 per 1000 in Senegal. We estimated neonatal mortality at 18 per 1000 live births in Cambodia, 24 per 1000 in Madagascar, and 23 per 1000 in Senegal. Based on ultrasound biometric data, 16.1% of infants in Madagascar were born prematurely, where 42% of deliveries and 33% of deaths occurred outside healthcare facilities. Risk factors associated with neonatal death were mainly related to delivery or to events that newborns faced during the first week of life. These findings underscore the immediate need to improve care for and monitoring of children at birth and during early life to decrease infant mortality. Surveillance of stillbirth and neonatal mortality and their causes should be improved to mitigate this burden in LMICs.

Management of a pregnancy with Crigler-Najjar syndrome type 2: a case report

Objective: To report a case with Crigler-Najjar syndrome type 2 of elevated bilirubin levels who was treated with triple therapy. Case(s): Crigler-Najjar syndrome is a rare congenital disorder that causes non-obstructive non-hemolytic unconjugated jaundice. The syndrome is divided into two groups according to the severity and the clinical presentation of the disease. In these cases, there is an elevated risk of antenatal death or permanent neurological impairment of the fetus due to fetal kernicterus caused by excessively increased unconjugated bilirubin levels. Phototherapy, phenobarbital and plasmapheresis can be useful in reducing serum total bilirubin concentrations, thus adverse maternal and neonatal risks. Conclusion: At her 37 weeks of gestation, the patient delivered a healthy girl. No pathological neurological findings were found and the baby had normal growth with intact neurological development.

Management of orofacial clefts in Africa, insufficient management centers, and workforce.

Management of orofacial clefts in Africa, insufficient management centers, and workforce.

PECULIARITIES OF THE FORMATION OF THE FUNCTIONAL SYSTEM "MOTHER- PLACENTA-FETUS" BY THE INFLUENCE OF SMALL DOSES OF RADIATION

Introduction. 137Cs ecosystem pollution is a source of radiation for humans. Undifferentiated cells capable of rapid division are the most vulnerable to ionizing radiation. Therefore, the fetoplacental and immune systems should be expected powerful responce to ionizing radiation. The functional capacity of the placenta determines pregnancy scenarios.Aim: to study the features of the formation of the fetoplacental system under the influence of low doses of radiation. Materials and methods. Pregnant women were in two groups, according to the design. The main (1) group included 60 women with reproductive losses in their history and a threat of termination to the current pregnancy, control (2) group consisted of 30 women with a physiological course of pregnancy and an uncomplicated anamnesis. The found incorporation of 137Cs in the placentas of the women of the studied groups was on β-spectrometry. The nature of placental damage was studied using the pathomorphological examination. The expressions of vimentin and CEA were studied in the structures of the placenta using immunohistochemistry. The effects of radiation on the functional system "mother-placenta-fetus" was determined in immunological, hormonal, biochemical, and bacteriological studies.The study was approved by the Medical Ethics Commission of the State Institution "Institute of Pediatrics, Obstetrics and Gynecology named after Academician O. M. Lukyanova of the National Academy of Medical Sciences of Ukraine" (Protocol No. 3 of 07.06.2017). The results were statistically processed on a PC using Microsoft Excel-2016 using Fisher's angular transformation criterion. Differences in comparative values are considered probable if p < 0.05 (probability index more than 95%).The research was carried out as a fragment of the research work of the State Institution "Institute of Pediatrics, Obstetrics and Gynecology named after Academician O.M. Lukyanova of the National Academy of Medical Sciences of Ukraine" "To develop the latest and improve existing technologies for the diagnosis, prevention and treatment of premature abortion in women with miscarriage, taking into account the placenta passport" (2018-2020). Code ВН.20.00.02.18, state registration number 0118U000039, КПКВ 6561040.Research results. According to the results, chronic radiation stress plays a decisive role in the multifactorial nature of placental dysfunction and antenatal losses. Activity up to 1.0 Bq/kg of 137Cs does not affect the course of gestation. The compensatory capacity of the placenta remains preserved at the accumulation of 1.1 to 4.4 Bq / kg of 137Cs. It is possible to prolong the pregnancy until term delivery. As a result of exposure to 4.5-10.4 Bq/kg of 137Cs, the stroma of the maternal surface of the placentas is damaged. At the same time, the pregnancy is terminated prematurely, at 28-36 weeks + 6 days, but thanks to the preservation of compensatory reactions in the placenta, the children are born alive. Accumulation in placentas of more than 10.4 Bq/kg of 137Cs is a probable factor in antenatal death of the fetus and early premature birth, as both maternal and fetal structures of the placenta are damaged.Conclusions. Internal irradiation by incorporated 137Cs damages the architecture of the placenta, which complicates the course of gestation. Extreme effects depend on the volumetric activity incorporating 137Cs and compensatory placental properties. The placental accumulation of 4.5 to10.4 Bq / kg of 137Cs triggers premature labor. Accumulation in the placenta of more than 10.4 Bq / kg 137Cs is a probable factor in antenatal fetal death and premature birth. An imbalance of steroid hormones and peroxide hemostasis system are predictors of placental dysfunction and termination of pregnancy. Expression of vimentin is a marker of placental destruction by internal exposure to radionuclides. Expression of CEA is a marker of premature birth and the antenatal death of the fetus.

Features of the prognosis and outcomes of pregnancy with massive subchorionic thrombosis. A literature review

Massive subchorionic thrombohematoma, also termed in the literature as Breus mole, is a rare condition in which a large maternal blood clot separates the chorionic plate from the chorionic villi. The etiology and pathogenesis of this condition are yet unclear, and the very concept of massive subchorionic thrombohematoma remains vague due to the singularity of clinical cases and the necessity to distinguish it from other types of hematomas. The lack of a unified view on the pathology and clear-cut clinical, laboratory and ultrasound criteria can lead to insufficient attention of doctors and untimely or even incorrect establishing diagnosis, which significantly worsens the prognosis of pregnancy and increases the risk of potential complications. Patients with massive subchorionic thrombohematoma require increased attention due to the high rate of such manifestations as antenatal death, fetal growth retardation, late miscarriage, and preeclampsia. Each case should be carefully analyzed in order to find predictors of thrombohematomas and methods of their prevention.

Клинико-анамнестические факторы риска антенатальной смерти доношенного плода

Introduction. Current clinical and laboratory methods for assessing the intrauterine growth of a fetus are indirect and often have a low prognostic significance. Meanwhile, the determination of risk factors of antenatal death of a full-term fetus with the assessment of their prognostic significance and the possible preventability of adverse perinatal outcome will identify ways to reduce the stillbirth rate. Aim. Determine the clinical and anamnestic risk factors for antenatal death of a full-term fetus in the Chelyabinsk region. Materials and methods. A retrospective analysis of the medical records of all cases with antenatal fetal death at 37 weeks 0 days – 41 weeks 6 days of pregnancy, registered in the territory of the Chelyabinsk region from 2019 to 2021, was carried out. Two groups were assigned: group 1 – women with antenatal death of the full-term fetus (158 patients), group 2 – women with live full-term births (50 patients). Results. Women with antenatal death of the full-term fetus statistically significantly more often lived in the city of Chelyabinsk and big cities of the Chelyabinsk region, had secondary vocational education and used to smoke tobacco; they had first or second pregnancy and first delivery. Among these women, female pelvic inflammatory diseases, hypertension, endocrine system diseases and specific infectious diseases (HIV infection, hepatitis C and tuberculosis) were statistically more common. These women had statistically more pregnancy-related complications such as hypertension without significant proteinuria; diabetes mellitus arising in pregnancy; gestational edema; false labour up to 37 full weeks of pregnancy; placental disorders; maternal care for poor fetal growth; acute respiratory infections. The following factors have a direct impact on antenatal death at full-term pregnancy: a history of hypertension, moderate pre-eclampsia, placental disorders, and fetal growth retardation. Conclusion. In the presence of risk factors directly affecting the occurrence of antenatal death of a full-term fetus, we consider it appropriate to deliver at 37 weeks 0 days – 38 weeks 0 days of pregnancy in order to reduce the risk of an adverse outcome of pregnancy.

Sexuality and affectivity after a grieving process for an antenatal death: a qualitative study of fathers' experiences

The loss of an infant at the prenatal stage is one of the most traumatic events parents can experience. Prenatal losses have several negative implications for parents’ physical, psychological, and social well-being, including intimacy and sexuality. Fathers who suffer from this experience have to cope not only with their grief, but also with the physical and emotional suffering of their partners. The social context gives the father a masculine role of strength, insensitivity, and protection of the mother, with the result that his pain and grief become invisible. The objective of this study is to understand fathers’ experience of affective-sexual relationships after a grieving process for an antenatal death; A qualitative study based on interviews with 11 fathers in Spain who have experienced an antenatal death was conducted. Data were analyzed with the help of ATLAS.ti software to discover emerging themes. 6 sub-themes were developed from the analysis, grouped into two main themes: the invisibility of grieving fathers and the relationships between the grieving parents are influenced by the death of their infants. The sexuality of fathers who suffer an antenatal death is altered. Gender stereotypes and the lack of social and professional awareness make their grief invisible. Fathers need to express their emotions to cope with their own grief and break the stereotypical gendered bereavement. In most cases, the couple’s relationship is altered, from a close union to a more distant relationship, in addition to a decrease in sexual desire and arousal. However, other fathers experienced greater closeness and intimacy in the couple. A communication based on sincerity, exposing their own grief, feelings, emotions and needs could help the couple’s relationship.

The combination of type 1 diabetes and eating disorder during pregnancy

The problem of eating disorders currently holds a special place in clinical practice. Bulimia nervosa is one of the main forms of eating disorders, characterized by the difficulty in its treatment and a long, recurrent course. Eating disorders are common in patients with type 1 diabetes mellitus (T1D), especially in adolescent girls.In this article, we present a clinical case of a patient with T1D and bulimia nervosa, which developed before the manifestation of T1D and progressed against its background. The patient is overly concerned with controlling body weight, specifically restricted the intake of carbohydrates, forcibly caused vomiting. During pregnancy fasting ketonuria («low-carb ketone») was repeatedly detected. The minimum weight was 37 kg (BMI 15.2 kg/m2). Particular interest of this case is the course of pregnancy, which ended in the antenatal death. The possible cause could be the restriction on carbohydrate food and prolonged stay in ketosis, that might lead to the development of pregnancy pathology. Additional examination also revealed multiple complications of diabetes and recurrent depressive disorder, which requires conjoint monitoring by an endocrinologist and a psychiatrist.Combination of T1D and eating disorder in a pregnant patient should be considered as an atypical course of the disease.

Risk factors for birth asphyxia

Introduction. Intrauterine hypoxia and asphyxia during childbirth are the leading causes of infant mortality in the structure of certain conditions arising in the perinatal period.Purpose. To study the involvement of negative events for the fetus in the ante- and intranatal periods in the occurrence of perinatal asphyxia in newborns and identify the main modifiable risk factors that will allow formulating preventive strategies in the development of child hypoxia.Materials and methods. A retrospective assessment of the course of the ante- and intranatal period was carried out according to 50 case histories. Nominal data are presented with indication of absolute and relative values. Sets of quantitative indicators are described by the values of the median (Me) and the lower and upper quartiles (Q1–Q3). The χ2 test was used to compare unrelated samples. Differences were considered statistically significant at p < 0.05. Statistical data processing was carried out using the Microsoft Office 2021 software package.Results: In the group of children with moderate and severe asphyxia at birth, the median gestational age was 36 and 33 weeks. The main ante- and intranatal risk factors for asphyxia of newborns were established in the following percentage: fetoplacental insufficiency – 32%; premature rupture of membranes and medical abortions in history, 30% each; first pregnancy, anemia, obesity, hypertension, smoking, maternal age > 35 years, 18% each; isthmic-cervical insufficiency – 16%; history of antenatal death, threatened miscarriage, vaginitis, 14% each; acute respiratory infections during pregnancy, assisted reproductive technologies (IVF), uterine fibroids – 12% each; oligohydramnios – 8%; polyhydramnios – 6%.Conclusion. The structure of factors that can contribute to the development of asphyxia in newborns is diverse. Understanding the involvement of modifiable risk factors determines the need to build a strategy and tactics to reduce their impact on the development of the pathology under consideration.

Perinatal outcomes of pregnancy and childbirth in moderate to severe COVID-19 patients

BACKGROUND: The presence of COVID-19 caused by SARS-CoV-2 during pregnancy increases the incidence of adverse perinatal outcomes, which are manifested in more frequent spontaneous miscarriages, premature births, antenatal fetal deaths, and fetal growth retardation, as well as in the development of intraamniotic infection and respiratory distress syndrome of the newborn. The most likely cause of premature birth can be considered severe respiratory failure of the mother with hypoxemia, which leads to circulatory disorders in the hemodynamic system of the mother-placenta-fetus. Currently, there is no single expert opinion on pregnancy prolongation tactics, as well as the timing and methods of delivery in patients with COVID-19, which is decided individually by an interdisciplinary consultation of the experts, taking into account the severity of the patients condition, gestational age and fetal condition.
 AIM: The aim of this study was to analyze perinatal outcomes of pregnancy and childbirth in the presence of moderate and severe COVID-19.
 MATERIALS AND METHODS: We carried out a retrospective analysis of perinatal outcomes in patients with the novel coronavirus infection in a specialized level III infectious hospital in St. Petersburg, Russia in 20202021 (from the first to the fourth wave of COVID-19) based on the birth histories of 50 patients with moderate (n = 31) and severe (n = 19) forms of the disease.
 RESULTS: Most of the patients suffered from chronic somatic diseases, with the course of pregnancy and childbirth complicated by premature rupture of amniotic fluid and progressive fetal hypoxia (fetal distress). In severe COVID-19, preterm labor prevailed and the proportion of operative abdominal delivery more than doubled that of vaginal delivery. The course of the postpartum period was determined by the COVID-19 positive dynamics. The majority of patients in the study groups showed significant changes in laboratory parameters such as anemia, an increase in the level of neutrophilic leukocytes with a subsequent decrease in their count, lymphopenia followed by lymphocytosis, and an increase in the levels of C-reactive protein and the activities of lactate dehydrogenase, alanine aminotransferase and aspartate aminotransferase. The study of the relationship between the most characteristic laboratory parameters in the disease dynamics showed the presence of statistically significant correlations between inflammation markers and metabolic markers, which allowed for assessing the severity of the patients condition.
 Antenatal diagnosis of the fetal functional status based on cardiotocography, ultrasound and Doppler sonography data revealed a predominantly compensated fetal condition in the study groups. The condition of newborns in all patients with moderate COVID-19 and in most of patients with the severe form of the disease was satisfactory. In severe COVID-19, the birth of children with moderate asphyxia was due to prematurity and antenatal hypoxia resulted from decompensation of chronic placental insufficiency. The histopathological patterns of the afterbirth in the study groups were represented by inflammatory changes and chronic placental insufficiency.
 CONCLUSIONS: The data obtained suggest that the basis for favorable perinatal outcomes is an adequate assessment of the condition of the pregnant woman and the fetus with timely delivery before the onset of irreversible organ damage.

ВОЗРАСТНЫЕ АСПЕКТЫ АНТЕНАТАЛЬНЫХ, ИНТРАНАТАЛЬНЫХ И РАННИХ НЕОНАТАЛЬНЫХ ПОТЕРЬ

Abstract. Unfavorable demographic trends, combined with the aging of the population, make it possible to consider the reduction and prevention of perinatal losses as a potential demographic reserve. The reduction in the number of women of active reproductive age, the increase in the birth rate among women over 35 years of age and the lack of a unified scientific opinion regarding the age of mothers unfavorable for the perinatal period indicate the need for research and consideration of age-related aspects in the prediction and prevention of perinatal losses. Objective of the study: to study the role of women's age as a risk factor for antenatal and intrapartum fetal death, early neonatal death of a newborn. Materials and research methods. A retrospective study was conducted with the participation of patients with antenatal (n=134) and intrapartum (n=41) fetal death, early neonatal death of a newborn (n=61) and a favorable perinatal outcome (n=50) as a control. We studied the age of women, conducted a comparative analysis of the age structure of these groups, determined the prognostic weight of significant age intervals in antenatal, intrapartum fetal death and early neonatal death of a newborn. We used the program "Statistica 10.0" for statistical processing of the obtained data and the Bayes model of prediction with analysis by A. Wald, method of E.V. Gubler and the criterion of S. Kullback. Results. We found that there was a statistically significant difference in the age of patients between the groups of antenatal risk and control (p=0.01), as well as antenatal and early neonatal risk (p=0.003). A comparative analysis of the age structure of the groups showed that patients aged 15-19 years were significantly more likely, in comparison with the control, to occur in the early neonatal risk group (p=0.003), and women aged 30 and over ‒ in the antenatal (p=0.002) and intranatal (p= 0.01) risk groups. We have calculated prognostic coefficients and indicators of informativeness of the most significant age intervals in the blood serum of pregnant women with antenatal fetal death, intrapartum fetal death and early neonatal death of a newborn. We have determined age intervals that worsen and improve the perinatal prognosis. Conclusion. The conducted study allows us to consider certain age categories of women as factors of differentiated risk of antenatal, intrapartum and early neonatal losses. The obtained results clearly demonstrate the prognostic role of women's age and indicate the need to include this factor in the systems for assessing the condition of the fetus and newborn at each stage of the perinatal period.

Assessment of the fetoplacental complex and hemostasis system status in perinatal care of pregnant women with fetal congenital malformations

Research objective: to assess the morpho-functional status of the fetoplacental complex and hemostasis system in pregnant women with congenital malformations in the fetus to prevent antenatal fetal death and determine further tactics of management and delivery.Materials and methods. The state of fetoplacental circulation was studied in 120 pregnant women with fetal congenital malformations in the third trimester by Doppler assessment of blood flow in the umbilical artery (UA) and middle cerebral artery (MCA) in the fetus, with resistance index, pulse index and maximum systolic and terminal diastolic velocities ratio. The functional activity of the hemostasis system was assessed by low-frequency piezoelectric thromboelastography. Morphological examination of the placenta was performed. The control group included 25 pregnant women without fetal congenital malformations.Results. In case of Doppler flow disturbances in UA and combination of these disturbances with hypercoagulability, the probability of antenatal fetal death if there were congenital malformations ranged from 2–3 to 7–14 days (r = 0.51 and r = 0.55, respectively). A high risk of antenatal fetal death occurred with blood flow disorders in the UA and MCA (r = 0.70), as well as with blood flow disorders in the UA in combination with hypercoagulation and inhibition of fibrinolysis (r = 0.78). The highest risk of antenatal death occurred in case of impaired blood flow in the MCA with hypercoagulation and inhibition of fibrinolysis (r = +0.99).An urgent delivery within a day is indicated when there are blood flow disorders in the UA or MCA, combined with hypercoagulation and inhibition of fibrinolysis. The respiratory distress syndrome is treated by administering a surfactant at gestational ages up to 34 weeks. Delivery within 2–3 days is indicated in case of impaired blood flow in the UA and hypercoagulation, this allows preventing of respiratory distress syndrome with corticosteroids if the gestational age is less than 34 weeks. Conclusions. In pregnant women with fetal congenital malformations, significant disturbances in blood flow in the UA (increased resistance index and maximum systolic and final diastolic velocities ratio) and decreased pulse index in the MCA were revealed, which indicates intrauterine hypoxia and centralization of blood flow. The functional activity of the hemostasis system was characterized by an increase in the blood coagulation potential in the vascular-platelet, a coagulation unit, which was accompanied by morphological and functional changes in the placenta in response to hypoxia.Implementation of the proposed algorithm for perinatal support of pregnant women with fetal congenital malformations and placental dysfunction helps to optimize pregnancy management and delivery, reduce perinatal morbidity and mortality.