FEATURES OF CHILDBIRTH IN WOMEN WHO HAVE GIVEN BIRTH TO A LARGE FETUS FOR THE FIRST AND AGAIN

ABSTRACT

It is known that 50% of the development of fetal macrosomy is made up of women who have a history of large fetuses and who have a short intergravity break, and also occurs in mothers who have had three or more children.

The fetal mortality rate of 4500-5000g is 2 deaths per 1000 births in non-diabetic women, and about 8 deaths per 1000 births in diabetic women.

Therefore, we present data on the complications, course, features of childbirth in pregnant women who have undergone repeated and first childbirth in our clinical practice.

АННОТАЦИЯ

Известно, что 50% случаев развития макросомии плода приходится на женщин, у которых в анамнезе были крупные плоды и у которых был короткий межгравитационный перерыв, а также встречается у матерей, родивших троих или более детей.

Уровень внутриутробной смертности в 4500-5000 г составляет 2 смерти на 1000 родов у женщин, не страдающих диабетом, и около 8 смертей на 1000 родов у женщин, страдающих диабетом.

Поэтому мы приводим данные об осложнениях, течении, особенностях родов у беременных женщин, перенесших повторные и первые роды в нашей клинической практике.

Keywords: large fetus, pregnancy, first and second childbirth, childbirth, macrosomy, extragenital diseases.

Ключевые слова: крупный плод, беременность, первая и повторная роды, роды, макросомия, экстрагенитальные заболевания.

Introduction. Macrosomia are a term used for babies born with a weight of 4000 g or more [1]. Among the factors leading to macrosomia, the excess weight of the mother and the associated methobolic disorders are located in the first place [2].

The presence of these factors in a woman of reproductive age increases the frequency of developing gestational diabetes during pregnancy. Its distribution is found from 1 to 14%, which is equivalent to an average of 7% [2].

According to the literature, the incidence of macrosomy during GDM is from 5.3 to 35% [3, 4]. During childbirth with macrosomy, it is characterized by deviations of the birth apparatus, inconsistency of the size of the child's head, the size of the female pelvis and an increase in the frequency of using operations for cutting, vacuum extraction, insertion of obstetric forceps [5].        

The most serious complication that occurs with macrosomy is shoulder dystocia, which occurs at 5-24%, and as the fetal weight increases, the frequency of its occurrence increases: if the child weighs 4000.0-4500.0-by 5-6%, if the fetal weight is 4500.0 or higher, by 12-19% [6]. Due to the presence of a large fetus, due to the fact that the uterine wall is too stretched, there is often hypotonic bleeding in the early stages of childbirth and postpartum [7].

Arm: Description of the main problems in women with a large fetal pregnancy in our practice

Materials and methods: In our research work, from May to June 2023, we conducted a retrospective clinical and statistical analysis of the medical history of n=67 pregnant women who gave birth with a diagnosis of a "large fetus" baby on the basis of Maternity Hospital №5 in Almaty.

Criteria for inclusion in the study: pregnant women who have given birth to a large fetus. The exclusion criteria are: pregnant women who have given birth prematurely, the birth of a stillborn baby, and HIV detected. 

Together with clinical data of pregnant women, data on anthropometric parameters (body weight, height, body mass index), age, parity of childbirth in the first and re-delivery, method of delivery, fetal weight, assessment on the Apgar scale in the 1st and 5th minutes, conclusions of laboratory studies and comorbidities were collected.

Statistical methods were used that made it possible to verify the analyzed data, the accuracy of the differences between the average values (М±m), the arithmetic mean values were evaluated by the T – criterion of Studenten. the difference at the level of р˂0,05 was considered statistically reliable. Statistical edits were collected in the electronic application Microsoft Office Excel.

Results and discussion: Of all the examined, there were: women who gave birth for the first – n=23 (34.3%), women who gave birth again – n=44 (65.67%). The mean age of pregnant women in the study was 35.83±4.11 years, with a frequency of 3.09±0.14 at pregnancy parity (р˂0,05). The birth of a large fetus by the weight of the baby was 4263.91±152.09 g. According to the study carried out, in the process of calculating the estimated fetal weight according to the Giordani formula, a discrepancy was found - 263.09±98.14 g (р˂0,05). This discrepancy can increase complications during and after childbirth.

Body mass index was normal in n=29 (43.28%), overweight – in n=22 (32.83%), obesity – in 16 (23.88%) women. Weight gain during pregnancy ranged from 2 to 26.3 kg (р˂0,05).

Among pregnancy complications, anemia was most common – in n=43 (64.17%), premature rupture of the fetal membranes – in n=23 (34.32%), the threat of termination of pregnancy – in n=9 (13.43%), late gestosis – in n=11 (16.41%), polyhydramnios – at n=19 (28.35%) (р˂0,05).

A study of the female reproductive system found that 26.28% had large fetuses in previous births. 26.8% of women had a complicated obstetric and gynecological history, they had: spontaneous abortions at different periods of pregnancy, underdeveloped pregnancy, infertility, ectopic pregnancy. In 49.18% of pregnant women, various extragenital pathologies were detected, of which the most common are auras of the respiratory (17.43%) and urinary (16.2%) systems. In addition, depending on the frequency of meetings: diseases of the gastrointestinal system (9.31%), thyroid gland (6.32%) and cardiovascular system (3.77%) were detected.

In 16.41% of women tested for fetal macrosomy, childbirth occurred by caesarean section, including: planned - 57.94%, emergency – 42.06%. Indications for operative delivery: estimated fetal weight – 4500.0 or more, or the presence of obstetric pathology in combination with the diagnosis of a large fetus: pregnancy with the help of additional reproductive technologies, lying on the pelvis, scar on the uterus. Emergency caesarean section was performed in the following cases: premature discharge of water and unpreparedness of the birth canal, weakness of labor, discrepancy in the size of the baby's head, female pelvis, threat to the position of the fetus at the first stage of labor.

Normal labor through the birth canal is 83.59%, of which induced labor is 15.63%. The duration of labor of stage I, on average, is 10-12 hours, Stage II-60-80 minutes. The first women in Labor had a higher total blood loss, on average – 316.34±43.82 ml (р˂0,05).

The total duration of labor carried out through the natural birth canal in primiparous was from 6 h 43 min to 8 h 35 min, in repeat births - from 3 h 45 min to 6 h 55 min. In n=9 (13.43%) women, perineotomy was performed due to the threat of perineal dilation. In one case, a grade 1 cervical rupture was diagnosed. Pathological blood loss caused by uterine hypotension occurred in n=2 (2.98%) cases. Clavicle fracture was diagnosed in n=1 (1.49%) cases, cephalohematoma - in n=2 (2.98%), asphyxia – in n=1 (1.49%), impaired adaptation by cerebral type - in n=1 (14.9%). The remaining complications were not related to fetal weight.

Conclusion: Thus, macrosomia is more common in pregnant women who are going to give birth again. In women with a large fetus, deviations during childbirth occur 2 times more often. According to the above study, the question of large-scale fetal delivery remains relevant.

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