Hemodynamic changes in the mother–placenta–fetus system depending on the infertility factor and the management of pregnant women after the use of reproductive technologies

During pregnancy the most significant changes are observed in the cardiovascular system, which is the most important in the process of life support. These changes are necessary to achieve an accurate correspondence of the level of functioning of physiological systems to the growing energy and plastic needs of the pregnant woman and the fetus.The main method of assessing the state of uterine placental circulation and fetal hemodynamics is Doppler ultrasonography. Most of the researches devoted to the study of blood flow in the uterine arteries using Doppler have demonstrated the wide possibilities of this method for predicting pregnancy complications, such as gestosis, fetal growth retardation, premature birth, as well as negative perinatal outcomes.The objective: to study the features of hemodynamics in pregnant women depending on the factor of infertility in the anamnesis in the dynamics of the second trimester of pregnancy and to determine the effectiveness of the proposed treatment and prevention complex during the correction of hemodynamic disorders of the mother-placenta-fetus system in the dynamics of pregnancy in women after the use of assisted reproductive technologies (ART) to improve the management of antenatal care and prevention of obstetric and perinatal complications.Materials and methods. A prospective clinical examination of 299 pregnant women was conducted. The main group included 249 women whose pregnancy occurred as a result of the use of ART; the control group included 50 pregnant women with spontaneous pregnancy.At the first stage of the study, depending on the cause of infertility the women in the main group were divided into subgroups: I subgroup – 94 pregnant women with a tubal infertility, II subgroup – 87 pregnant women with a history of endocrine type of infertility, III subgroup – 68 pregnant women with a history of male factor infertility. At the second stage, depending on the prescribed therapy, women were divided into subgroups: letter A – women received the proposed therapeutic and prophylactic and psycho-emotional correction complexes; letter B – pregnant women were observed in accordance with generally accepted standards of obstetric care. So: subgroup IA – 49 pregnant women, subgroup IB – 45, subgroup IIA – 48, subgroup IIB – 39, subgroup IIIA – 36 and subgroup IIIB – 32 pregnant women.All women underwent ultrasound examination with determination of blood flow velocity (systolic/diastolic (SR) ratio) in the main vessels using Doppler ultrasonography at 16–17, 24–25 and 27–28 weeks of gestation. The recommended therapeutic-preventive complex (RCTPC) for pregnant women after ART is: progesterone support, magnesium saturation, folic acid, L-arginine aspartate, omega-3 polyunsaturated fatty acids, long-term psychological correction.Results. Given the blood flow disorders in the main arteries of the fetoplacental complex identified in the previous stage of the study, a repeated examination was performed in the dynamics of treatment at 27–28 weeks of pregnancy.The average value of blood flow intensity in the right uterine artery in women of subgroups IA and IIA was significantly lower (IA subgroup – 1.6, IB subgroup – 2.3, p < 0.05; subgroup IIA – 1.7, subgroup IIB – 2.4; p < 0.05), as well as in the left uterine artery (subgroup IA – 1.7, subgroup IB – 2.5, p < 0.05; subgroup IIA – 1.6, subgroup IIB – 2.3; p < 0.05) and corresponded to the values of pregnant women from subgroup III and the control group.To assess the effectiveness of treatment of RCTPC in all pregnant women of the main groups at 34–35 weeks of pregnancy, a comprehensive ultrasound examination was performed: fetometry, placentography and determination of the amount of amniotic fluid. The results showed that the sizes of the fetuses corresponded to the gestational age, and the frequency of cases of symmetric fetal growth retardation in pregnant women of subgroups IA and IIA significantly decreased (subgroup IA – 2 (4.1%), subgroup IB – 7 (15.5%); subgroup IIA – 2 (4.2%), subgroup IIB – 6 (15.4%), p < 0.05). Newborns in women of subgroups IA and IIA were born at the expected term of delivery, which had a positive effect on perinatal outcomes. Among women receiving standard therapy (subgroups IIA, IIB and IIIA), one case of fetal growth retardation was determined in each subgroup. When using RCTPC in pregnant women of subgroups IA and IIA, a significant decrease in the incidence of placental dysfunction was found (subgroup IA – 7 (14.3%), subgroup IB – 14 (31.1%); subgroup IIA – 6 (12.5%), subgroup IIB – 11 (28.2%); p < 0.05), which was accompanied by normalization of placental thickness, although without statistically significant differences (subgroup IA – 37.1±0.3 mm, subgroup IB – 40.2±0.3 mm; p > 0.05, subgroup IIA – 37.3±0.5 mm, subgroup IIB – 39.7±0.3 mm; p > 0.05).Conclusions. When conducting Doppler ultrasonography in women after the use of ART at 16–17 weeks of gestation, the absence of two main criteria was revealed - stability and identity of fetoplacental blood flow indicators, in particular in the middle cerebral artery (MCA), as the final link of hemodynamic changes.Thus, in women with male factor infertility, the S/D ratio was comparable – 3.2 (3.1–3.3) compared to spontaneous pregnancy, where this indicator was 3.4 (3.4–3.5). In patients with endocrine infertility, a significant increase in blood flow in the MCA was observed – 2.8 (2.7–2.9), as well as an increased indicators in the umbilical artery. In fetuses of women with tubal factor, the lowest peripheral resistance in the MCA was observed – 4.4 (4.3–4.5).The obtained results of determining the S/D ratio in the main arteries of the uterus and fetoplacental complex at 27–28 weeks, fetometry and amniometry at 34–35 weeks demonstrate the effectiveness of the proposed complex of measures (progesterone support, magnesium saturation, folic acid, L-arginine aspartate, omega-3 polyunsaturated fatty acids, long-term psychological correction) in eliminating hemodynamic disorders in pregnant women after the use of ART.The S/D ratio indicators in the uterine arteries in the subgroup with the proposed complex of measures were 1.4 times lower than in women who used standard pregnancy management, and approached those in women in whom pregnancy occurred spontaneously; the frequency of placental dysfunction in pregnant women with tubal infertility factor decreased due to the use of the recommended complex by 2.2 times and with endocrine one – by 1.4 times; The frequency of abnormal amount of amniotic fluid in pregnant women with tubal infertility factor decreased by 2.1 times when using the recommended complex, and with endocrine infertility – by 1.7 times.