Echographic markers of reproductive potential formation of adolescent girls with gynecological pathology born small to gestational weight

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Kharkiv National Medical University

Echographic markers of reproductive potential formation of adolescent girls with gynecological pathology born small to gestational weight

Pylypenko N.S.

Introduction

In Ukraine, in recent decades, the conditions for the reproduction of labor resources, their quantitative and qualitative characteristics, the ability to self-reproduction have deteriorated. This is due to the unfavorable situation both quantitatively (population decline, ultra-high mortality with low birth rates) and qualitatively (low life expectancy, demographic aging). According to the Institute of Demography of the National Academy of Sciences of Ukraine, in 2026 the total population will decrease to 36 million, and in 2050 - to 34.8 million people[8,5].

Given the projected further decline in the number of Ukrainians, the most important problem of demographic policy is the reproduction of the population based on fertility, maintaining reproductive health as a socio-biological factor of its reproduction, increasing reproductive potential (RP) and preserving the health of the nascent generation.

RP is the level of physical and mental condition of an individual (a complex individual indicator that reflects the unity of biological and social status of the individual), which optimally allows when reaching social maturity to reproduce healthy offspring and ensure reproductive health.

The optimal case is the minimal negative impact of medical and social risk factors with high biological reserves of the body. RP has a complex structure, the main components of which are the birth rate, reproductive health and reproductive behavior of the population -components of the threat of reproduction. The following indicators are considered in the analysis of different aspects of RP as a component of population reproduction: fertility, infertility, morbidity of women that occurred during pregnancy or in the previous period; prevalence of abortions, levels of maternal, perinatal, infant mortality. The principal feature of RP and reproductive losses is in particular their obvious demographic significance, dependence on medical and organizational factors and social features of life. Realizing the potential of sexual and reproductive health is provided for in the Sexual and Reproductive Health Action Plan to support the implementation of the 2030 Agenda for Sustainable Development in Europe - Nobody to Be Disregarded (WHO, 2016)[1,8].

Our study was performed within the research area of the Department of Obstetrics, Gynecology and Pediatric Gynecology, Kharkiv National Medical University "Clinical and pathogenetic features and ways to correct pathological conditions of the reproductive system of women at different ages" state registration number 0116U004978.

We aim to find prognostic criteria for identifying risk groups to reduce the reproductive potential of young people, namely among adolescent girls born small to gestational weight(SGW).

The birth of girls with SGW is based on the formation of fetal growth retardation syndrome. According to modern ideas, the concept of intrauterine growth retardation is associated with the concept of compliance with anthropometric indicators of the fetus at a certain gestational age. Intrauterine Growth Retardation or Intrauterine Growth Restriction (IUGR) is diagnosed in children who are underweight and /or short; birth in relation to gestational age. That is when the body weight is below 10% of the percentile at a given gestational age 1 (or) morphological index of maturity, lags behind by 2 or more weeks from the true gestational age. To date, there is no generally accepted definition of IUGR; therefore, in the literature, this condition has several names at the same time: "small for gestational age", (SGA), "intrauterine growth retardation", "prenatal growth retardation", "fetal growth retardation syndrome", "intrauterine growth retardation", "syndrome" , which is the result of a complex polycausal reaction of the fetus and placenta, which occurs in various pathological conditions of the maternal body. International Classification of Diseases X revision (1996); IUGR; refers to the class of diseases XI "Certain conditions that occur in the perinatal period" and is interpreted as slow growth and malnutrition of the fetus: low-weight fetus for gestational age. (P 05.0), the minimum size of the fetus for gestational age (P 05.1). d) x 100 / (body length, cm) 3. Depending on body weight and MRI, it is proposed to classify IUGR as follows[11,4].

The first type is classic, characterized by almost normal growth of the skeleton and head, but reduced subcutaneous fat and decreased muscle mass. This variant is also described in the literature as Clifford's syndrome, as a disproportionate, asymmetric growth retardation; subacute variant of IUGR. In domestic literature, often as a synonym: used; the term "malnutrition". The second is called chronic and is characterized by a simultaneous violation of the growth of soft tissues and skeleton. It is called-proportional or symmetrical and domesticauthors to characterize this variant of violation of IUGR uses the term "hypoplastic version"[4].

II degree: reduction: both body weight and length by 2-3 standard deviations (10-3 centiles). In 75% of children it is noted. a similar reduction in head circumference. These newborns look proportionate to young children. They have no clinical manifestations of malnutrition, but stigmas of dysembryogenesis are much more common.

III degree: the most severe, characterized by a significant reduction in all parameters of physical development (3 or more standard deviations, or <3rd centile), the presence of disproportions in the physique, trophic disorders of the skin, stigma of dysembryogenesis.

Currently, it is customary to distinguish the following stages of IUGR:

1. IUGR without hemodynamic changes. This is the most initial form of lag: fetal growth, when: no changes were observed: Doppler blood flow in any vessel of the fetus.

2. IUGR with defeat of an arterial segment of blood circulation of a fruit. At this stage, the first sign is an increase in vascular resistance of the placenta is an increase in pulsation index only in the umbilical artery as placental insufficiency progresses, there are signs of signs of centralization of blood circulation called brainsparing effect (brain-protecting effect). It is manifested by redistribution of flow; blood to, the most vital organs (heart and brain), decreased cerebral vascular tone and decreased pulsation index in the middle cerebral artery. Typically, these changes; accompanied by a decrease in heart rate reactivity. The disappearance of spontaneous respiratory movements is the next stage of hypoxic damage to the fetal CNS. After; this reduces the volume of amniotic fluid, followed by inhibition of motor activity and decreased muscle tone. This phase coincides in time with the third stage of IUGR[10].

3. IUGR with defeat of a venous segment of circulation. This stage is characterized by the appearance of obvious signs of heart failure. These include: dilatation of the heart chambers and the development of atrioventricular valve insufficiency (regurgitation of blood flow, primarily through the tricuspid valve). This is manifested by Doppler pulsation in the venous duct and inferior vena cava, and is an indication for emergency delivery. We can safely say that the pathophysiology of IUGR at the stage of explicit clinical development is quite well studied. There is a known sequence of changes in the main parameters of hemodynamics, which can not be said about the initial phase of placental insufficiency - IUGR without hemodynamic disorders. In this phase, due to the violation of transplacental transfer of nutrients, and especially amino acids, begins to slow the growth of organs and bodies of the fetus. Is it really not accompanied by any changes in hemodynamics or simply our ability to assess this change is still insufficient to detect early and subtle changes. Such research has been conducted and continues to deepen and expand. In the pathogenesis of primary placental insufficiency the most important are disorders of chorionic villi formation due to anomalies of gamete division and pathology of chromosomal composition of the trophoblast, as well as insufficiency of the corpus luteum, which causes structural and functional insufficiency of decidual tissue. , maturation of chorionic villi, incorrect anatomical structure of the placenta, anomalies in the location and attachment of the placenta, as well as involuntary termination of pregnancy in the first trimester - components of clinical and morphological symptom complex of primary placental insufficiency[2,3].

Presenting main material

We supervised 20 adolescent girls from 2018 to 2020, who were hospitalized in the clinical base of the Department of Obstetrics, Gynecology and Pediatric Gynecology of Kharkiv National Medical University - in KNP CHO "Regional Children's Clinical Hospital G1", and formed the main group. The control group included 24 girls of the same age without gynecological pathology, who underwent annual examinations in the outpatient department of the Regional Children's Clinical Hospital №1. The main group was with the following nosology: volume formation of uterine appendages, menstrual disorders (abnormal uterine bleeding - AUB, oligoopsomenorrhea, dysmenorrhea), genital injuries, breast pathology, pelvic inflammatory disease and genital abnormalities.

Inclusion criteria: voluntary informed consent of patients and their parents to the study, accurate information on body weight at birth, birth at 37-41 weeks of gestation, the presence of gynecological pathology in the absence of abnormal development of the genitals. Patients born less than 37 weeks or more than 41 weeks of multiple pregnancies were excluded from the study.

The main group (1) included girls born weighing less than 2499.0 grams (n = 20) and had gynecological pathology. The control group (2) consisted of 24 girls with a birth weight of 2500.0 - 3699.0 grams and without gynecological pathology.

To verify the diagnosis, a detailed collection of complaints and anamnesis, clinical analysis of menstrual function, ultrasound examination of the pelvic organs, assessment of sexual development, determination of levels of gonadotropic and sex hormones. All girls were assessed for gynecological status through recto - abdominal and vaginal examinations depending on sexual experience.

With the help of line diagrams developed by the Academy of Medical Sciences of Ukraine, the nature of physical development of adolescent girls was determined[9]. Body mass index (BMI) was measured, which is closely correlated with the total body fat content: BMI = weight, kg/height, m.2 According to the WHO classification, BMI less than 18.5 kg/m2 corresponds to insufficient, 18.5 - 24.9 kg/m2 - normal, greater than or equal to 25.0 - overweight, more than 30.0 kg/m2 - obesity.

Sexual development was studied on the basis of the sequence of occurrence and severity of secondary sexual characteristics. The degree of sexual development of girls was assessed by the formula 1.2xMa + 0.3xP + 0.4xAx + 2.1xMe, which includes the following indicators: development of the mammary glands - Ma, pubic hair - P, axillary hair - Ah and age of menarche - Me[7]. Patients were examined by related specialists, especially a neurologist, to detect extragenital pathology. demographic gynecological pathology fertility

Itrasound scanning was performed in real time with an ultrasound scanner Medison 6000 CMT (Korea) in pulsed mode using a transabdominal transducer through the anterior abdominal wall with pre-prepared intestines and filled bladder, and in transgender girls having sex. .

In the gray-scale mode, the size of the uterine cavity, the presence of its deformation, the nature of the contours of the endometrium, the magnitude of the M-echo were assessed.

The volume of the ovaries was calculated according to the standard formula: V = 0.5236xLxWxT, where L is longitudinal, W is anterior-posterior, T is the transverse size of the ovary. The volume of the ovaries was considered increased if it exceeded 8 cm3. The average echogenicity of the stroma, compared with the echogenicity of the myometrium, was considered normal.

Statistical data processing was performed using the software package Statistica 6.0 and Microsoft Excel Office 10. Test hypotheses about the equality of the two means was performed using the Student's t-test. Measurements were considered reliable at p <0.05. In the absence of normal distribution in the studied samples, nonparametric methods were used to compare groups. The Wilcoxon-Mann-Whitney U test was used to compare the two independent samples. The statistical significance of differences between qualitative characteristics was assessed using the criterion X2. The nature and severity of the relationships between the various indicators were determined using simple and rank correlations by Spearman. Differences were considered statistically significant at p <0.05.

Gynecological pathology was verified in all girls of the main group included in the study. The mean age of the subjects was 14.8 ± 1.8 years. It was found that girls with low birth weight were lower than their peers born with normal body weight. Mean body weight and BMI in the study groups did not differ significantly.

However, girls in group 1 had a tendency to lose weight. The average score of sexual development in girls of group 1 was lower among those surveyed.

Statistical analysis revealed a significant correlation between the presence of volumetric formations of the uterine appendages of adolescent girls in group 1 compared with patients in the control group (p<0.05). The criterion %2 was %21-3 = 7,136, ie we can predict that almost every 7th girl with a body weight at birth less than 2500 grams may develop cystic formations of the uterine appendages at puberty.

Next, we investigated the nature of the menstrual cycle in adolescent girls with gynecological pathology born with low body weight. Normoponation was found significantly more often among 1 group. The duration of menstruation less than 21 days was also significantly higher among girls born with low body weight (25% and 6% for groups 1 and 2, p<0.05).

When studying the nature of menstrual discharge in the examined groups, we found that scanty discharge was significantly more common among girls in group 1 (51%, p<0.05). In analyzing the duration of menstrual bleeding, we investigated the following patterns. Bleeding less than three days is typical for low-birth adolescent girls (37%, p<0.05). Analysis of the structure of menstrual dysfunction among the examined groups revealed that dysmenorrhea was more common among group 1 (82%, p<0.05).

The number of women of childbearing age in Ukraine is declining every year, so the health of every girl is an important aspect of preserving the nation's reproductive potential. Our data suggest significant differences in the formation and functioning of the reproductive system in girls depending on body weight.

The analysis of ultrasound parameters revealed changes in indicators that were associated not only with the nature of gynecological disorders, but also with body weight at birth.

The analysis of ultrasound of the pelvic organs of adolescent girls aged 10-14 years with gynecological pathology revealed the following changes. The body length of the uterus was significantly lower in girls of group 1 - 2,893 ± 0,258 cm compared with the control group - 3,85 ± 0,208 cm. The width of the uterine body in group 1 - 1,87 ± 0,29 cm, respectively, p <0,05 ; - in the control group - 3.56 ± 0.34 cm). Anterior-posterior uterine size was found: 2.28 ± 0.27 and 2.49 ± 0.39 cm in the main and control groups, respectively.

The lag in ovarian size was in girls of group 1 relative to the control group. Yes, the volume of the left ovary was lower in all groups than the size of the right ovary. In group 1, the volume of the left ovary was 2.82 ± 0.003 cm3, the right - 3.22 ± 0.0009 cm3, and in the control group - 3.86 ± 0.003 cm3 and 4.78 ± 0.002 cm3, respectively.

Ultrasound parameters of the pelvic organs of adolescent girls 15 - 18 years with gynecological pathology had the following indicators: uterine body length was found in girls of group 1 - 3.55 ± 0.27 cm compared with the control group - 4.41 ± 0.35 cm.

The width of the uterine body by the age of 16 in girls of group 1 was significantly lower than in the control group (3.37 ± 0.31 cm vs. 4.35 ± 0.41 cm). Anterior- posterior uterine size was 2.73 ± 0.29 cm 3.41 ± 0.26 cm in the main and control groups, respectively. The volume of the right ovary was higher in all groups than the size of the left ovary. In group 1, the volume of the left ovary was 3.18 ± 0.003 cm3, the volume of the right ovary was 3.95 ± 0.003 cm3, and in the control group it was 4.97 ± 0.004 cm3 and 7.45 ± 0.003 cm3, respectively.

The value of M-echo in patients in group 1 aged 10 -14 years ranged from 4.075 mm to 4.565 mm, and in the age group 15 -18 years from 5.14 mm to 5.84 mm. The length of the cervix in these adolescent girls ranged from 1.95 cm to 2.31 cm, and in 15 -18 years - from 2.21 cm to 2.67 cm.

Echosonographic parameters of the control group were as follows: M-echo in girls 10-14 years: from 5.31 mm to 6.23 mm, and in the age group 15-18 years - from 6.9 mm to 7.8 mm, respectively. The length of the cervix of adolescent girls aged 10 - 14 years ranged from 2.12 cm to 2.73 cm, and at 15 -18 years from 2.29 cm to 3.34 cm.

Statistical data revealed a significant relationship between the presence of three-dimensional formations of the uterine appendages of adolescent girls in the main group compared with the control group, p<0.05. The criterion %2 was %21-3 = 7,136, and we can predict that almost every 7th girl with a body weight at birth less than 2500 grams may develop cystic formations of the uterine appendages at puberty. Figure 1 shows a clinical case of cystic formation of the right ovary, born with a body weight of2780.0 grams.

Patient V., 14 years old. Diagnosis: Cyst of the right ovary

Conclusions

The syndrome of fetal growth retardation leads to delayed physical development, menstrual dysfunction is formed, which leads to hypomenstrual syndrome.

Ultrasound parameters of the uterus and ovaries in adolescent girls with gynecological pathology depending on body weight at birth were determined. The relationship between pelvic changes on ultrasound scan and gestational weight in adolescent girls born with low body weight has been demonstrated.

In the presence of the syndrome of intrauterine growth retardation in the postnatal period in the process of pubertogenesis develops a lag in the ultrasound of the pelvic organs.

The identified features allow for further research to timely optimize the formation of risk groups at childbearing age. Gradual monitoring and prognostic models of formation and preservation of ovarian reserve of this cohort will allow to implement differentiated pre-pregnancy training at an early reproductive age.

References

1. Wennerstrom, E. C., Simonsen, J., & Melbye, M. (2015). Long-term survival of individuals born small and large for gestational age. PLoS ONE, 10(9), e0138594. DOI: 10.1371/journal.pone.0138594. PMID: 26390219. PMCID: PMC4577072.

2. Vikstrom, J., Hammar, M., Josefsson, A., Bladh, M., & Sydsjo, G. (2014). Birth characteristics in a clinical sample of women seeking infertility treatment: a case-control study. BMJ Open, 4(3), e004197. DOI: 10.1136/bmjopen-2013-004197, PMID: 24613821, PMCID:PMC3963097.

3. Garces, A., Perez, W., Harrison, M. S., Hwang, K. S., Nolen, T. L., Goldenberg, R. L. et al. (2020). Association of parity with birthweight and neonatal death in five sites: The Global Network's Maternal Newborn Health Registry study. Reprod. Health, 17(3), Article 182. DOI: 10.1186/s12978-020-01025-3, PMID: 33334362, PMCID: PMC7745358.

4. Ma, R., Luo, Y., Wang, J., Zhou, Y., Sun, H., Ren, X. et al. (2020). Ten-year time trends in preterm birth during a sociodemographic transition period: a retrospective cohort study in Shenzhen, China. BMJ Open, 10(10), e037266. DOI: 10.1136/bmjopen-2020-037266, PMID: 33082182. PMCID: PMC7577040.

5. Huraseva, A. B. (2010). Reproduktivnoie zdorovie zhenshchin, rodivshikhsia s poliarnymi znacheniiami massy tela [Reproductive health of women born with polar body weights]. Extended abstract of Doctor's thesis. Volgograd (40 p.). [in Russian].

6. Nazarenko, L. G., & Nestertsova, N. S. (2016). Aspekty reproduktivnoho zdoroviia u zhenshchin s nizkoi i izbytochnoi massoi tela pri rozhdenii [Aspects of reproductive health in women with small and large for gestational age birth weight]. Zdoroviie zhenshchiny - Woman's Health, 10 (116), 53-55. Retrieved from: http://nbuv.gov.ua/UJRN/Zdzh_2016_10_12 [in Russian].

7. Bogdanova, E. A. (2011). Prakticheskaia hinekolohiia molodykh [Practical gynecology of young people]. Moscow: Meditsinskaia kniha (238 p.). [in Russian].

8. Sait Derzhavnoi ustanovy «Instytut okhorony zdorovia ditei ta pidlitkiv Natsionalnoi akademii medychnykh nauk Ukrainy». (2012). Ranneie i pozdneie poiavleniie pervoi menstruatsii (menarhe) u devochek [Early and late appearance of the first menstruation (menarche) in girls]. Retrieved from: http://iozdp.org.ua/index.php/2012-09-03-08-35-35 [in Russian].

9. Tuchkina, I. A., Dobrovolskaya, L. A., & Tuchkina, M. Yu. (2016). Kliniko-diahnosticheskiie aspekty pervichnoi dismenorei v podrostkovom vozraste [Clinical and diagnostic aspects of primary dysmenorrhea in adolescence]. Medicine (Almaty), 6(168), 51-56 [in Russian].

10. Tuchkina, I. O., Dobrovolska, L. A., Vyhivska, L. A., & Tuchkina, M. Yu. (2015). Patent na korysnu model No.94513U Ukraina. Sposib likuvannia dysmenorei u divchat-pidlitkiv [Utility model patent No.94513U Ukraine. A method of treating dysmenorrhea in adolescent girls]. Applicant and patent holder Kharkiv National Medical University. No. application u201408487; stated July 25, 2014; published on November 10, 2015, valid from November 10, 2015 [in Ukrainian].

11. Tuchkina, I. O., Vyhivska, L. A., Maltsev, H. V., Blahoveshchenskyi, Ye. V., Demidenko, O. D., Rohachova, N. Sh., et al. (Compilers). (2018). Zatrymka rostuvnutrishnoutrobnoho ploda: metodychni vkazivky dlia likariv-interniv, likariv akusherivhinekolohiv, dytiachykh hinekolohiv, pediatriv, simeinykh likariv [Intrauterine growth retardation: guidelines for interns, obstetricians and gynecologists, pediatric gynecologists, pediatricians, family physicians]. Kharkiv: KhNMU, 40 p. [in Ukrainian]

Аннотация

Эхографические маркеры формирования репродуктивного потенциала девочек-подростков с гинекологической патологией, родившихся с малой массой тела при гестации

В Украине за последние десятилетия ухудшились условия для воспроизводства трудовых ресурсов, их количественные и качественные характеристики, способность к самовоспроизводству. Это связано с неблагоприятной ситуацией как в количественном отношении (сокращение численности населения, сверхвысокая смертность при низкой рождаемости), так и в качественном (низкая продолжительность жизни, демографическое старение). По данным Института демографии Национальной академии наук Украины, в 2026 году общая численность населения сократится до 36 миллионов, а в 2050 году - до 34,8 миллиона человек[8,5].

Учитывая прогнозируемое дальнейшее сокращение численности украинцев, важнейшей проблемой демографической политики является воспроизводство населения на основе фертильности, поддержание репродуктивного здоровья как социально-биологического фактора его воспроизводства, повышение репродуктивного потенциала (РП) и сохранение здоровья подрастающего поколения.

РП - это уровень физического и психического состояния индивида (комплексный индивидуальный показатель, отражающий единство биологического и социального статуса индивида), который оптимально позволяет при достижении социальной зрелости воспроизводить здоровое потомство и обеспечивать репродуктивное здоровье. Оптимальным вариантом является минимальное негативное воздействие медицинских и социальных факторов риска при высоких биологических резервах организма. РП имеет сложную структуру, основными составляющими которой являются рождаемость, репродуктивное здоровье и репродуктивное поведение населения -компоненты угрозы размножения.

При анализе различных аспектов РП как компонента воспроизводства населения учитываются следующие показатели: фертильность, бесплодие, заболеваемость женщин, возникшая во время беременности или в предшествующий период; распространенность абортов, уровни материнской, перинатальной, младенческой смертности.

Принципиальной особенностью РП и репродуктивных потерь является, в частности, их очевидная демографическая значимость, зависимость от медицинских и организационных факторов, а также социальных особенностей жизни.

Реализация потенциала сексуального и репродуктивного здоровья предусмотрена Планом действий в области сексуального и репродуктивного здоровья в поддержку реализации Повестки дня в области устойчивого развития в Европе на период до 2030 года "Никто не должен быть оставлен без внимания" (ВОЗ, 2016)[1,8].

Наше исследование проводилось в рамках научно-исследовательского направления кафедры акушерства, гинекологии и детской гинекологии Харьковского национального медицинского университета "Клинико-патогенетические особенности и пути коррекции патологических состояний репродуктивной системы женщин разного возраста", государственный регистрационный номер 0116U004978.

Наша цель - найти прогностические критерии для выявления групп риска снижения репродуктивного потенциала молодых людей, а именно среди девочек-подростков, родившихся с малой массой тела при беременности.

Выводы. Синдром задержки роста плода приводит к задержке физического развития, формируется нарушение менструального цикла, что приводит к гипоменструальному синдрому.

Определены ультразвуковые показатели матки и яичников у девочек-подростков с гинекологической патологией в зависимости от массы тела при рождении. Была продемонстрирована взаимосвязь между изменениями органов малого таза при ультразвуковом исследовании и массой тела во время беременности у девочек-подростков, родившихся с низкой массой тела.

При наличии синдрома задержки внутриутробного развития в послеродовом периоде в процессе пубертогенеза развивается отставание при ультразвуковом исследовании органов малого таза.

Выявленные особенности позволяют проводить дальнейшие исследования для своевременной оптимизации формирования групп риска в детородном возрасте. Постепенный мониторинг и прогностические модели формирования и сохранения овариального резерва этой когорты позволят осуществлять дифференцированную подготовку к беременности в раннем репродуктивном возрасте.

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