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Metode de evaluare a riscului de natere prematur

Rezumat Naterea nainte de termen constituie n zilele noastre principala cauz de morbiditate i mortalitate a nou-nscutului, aceasta din urm putnd depi 75%(1). La aceasta se adaug numeroase sechele neurologice i psihice precum i costuri ridicate impuse de ngrijirea unui astfel de nou-nscut. Pn n prezent nu au fost puse la punct metode eficiente de predicie a naterii premature. Totui exist cteva metode de evaluare a factorilor de risc, metode cu ajutorul crora naterea prematur poate fi mai precoce i mai corect evaluat, astfel nct tratamentul ar putea fi efectuat la timp. Cuvinte cheie: natere prematur, factori de risc, metode de predicie a naterii premature. Abstract Preterm birth represents the main cause of morbidity and mortality of the newborn, mortality frequently exceeding 75%. Beyond this there are a lot of neurologic and psychiatric disorders caused by prematurity and very high financial costs. There are no very efficient methods of predicting preterm birth. Some methods have been introduced so far in order to evaluate the risk of preterm birth so that a treatment could be performed in time. n arsenalul medicului obstetrician exist o serie de metode de evaluare a riscului The arsenal of the obstretician contains a series of methods of evaluatios of rhe risc de natere prematur. Aceste metode sunt reprezentate de o serie de factori of preterm birth. This methods are represented of a series of

biochimici i biofizici pe baza crora se poate calcula un risc de natere prematur biochemical and biophysical factors based on which we can calculate the risc of preterm birth att la pacientele cu elemente clinice de iminen de natere prematur ct mai ales la so to the patients with clinical evidence of imminent preterm birth, but mostly pacientele nc asimptomatice. Aceste elemente de predicie au aprut din necesitatea to the patients still asymptomatic. These predictions elements developed from the necessity evalurii ct mai precoce a elementelor care sunt implicate n etiopatogenia naterii to evaluate how early of the factors that are involved in etiopatogenie. premature. Un asemenea moment precoce de depistare a gravidelor cu risc ar permite o Also since early detection of pregnancies at risk would allow intervenie terapeutic cu rezultate mult mai bune. therapeutic intervention with improved results 1. Evaluarea ecografic a lungimii colului uterin.Exist numeroase studii care Ultrasound evaluation of cervix length. There are numerous studies that demonstreaz legtura ntre scurtarea colului uterin evaluat ecografic i naterea demonstrate the link between the shortening of the cervix ultrasound assessed and the preterm birth, prematur(2,3), ecografia transvaginal fiind superioar fa de cea transabdominal n transvaginal ultrasound being superior to the transabdominal one in this sense. acest sens(4).Ultrasonografia cervical este o metod utilizat pentru evaluarea gravidelor Cervical ultrasonography is a method used to assess cu risc redus dar i a celor cu risc crescut de natere prematur(5). low-risk pregnancies as well as those with increased risk of premature birth. pozitiv de 20% i o valoare predictiv negativ de 96% n identificarea naterilor by 20% positive and a negative predictive value of 96% in identifying preterm birth premature la vrste gestaionale sub 34 sptmni. the gestational age below 34 weeks. premature birth

La gravidele cu un avort de trimestru II n antecedente lungimea cervical a fost In pregnant women with a history of abortion for quarter II cervical length was cel mai bun parametru pentru predicia riscului de natere prematur. Lungimea cervical the best parameter for predicting the risk for premature. The cervix length de asemenea a evaluat mai fidel riscul de natere prematur sub 28 30 de sptmni also more accurately assessed the risk of premature birth in 28 to 30 weeks than for. dect pentru 32 34 sptmni. De asemenea a fost evideniat faptul c incidena ruperii 32 to 34 weeks. It also was revealed that the incidence of fracture premature a membranelor amniotice a fost de 39% n cazul n care lungimea colului a premature of amniotic membranes was 39% for the cervix length fost de sub 25 mm n intervalul 14 24 sptmni. was less than 25 mm within 14 to 24 weeks. 2. Fibronectina fetal din secreia vaginal i naterea prematur Fetal Fibronectina of vaginal discharge and premature birth. Fibronectina fetal este o glicoprotein ce constituie un component major al matricei Fetal Fibronectina is a glycoprotein which is a major component of the extracelulare a jonciunii corio-deciduale. Un test pozitiv este dat de prezena extracellular matrix junction corio-deciduale. A positive test is given by the fibronectinei fetale n secreia vaginal sau cervical ca rezultat al separrii corionului de fibronectin fetal presence in vaginal or cervical secretion as a result of the chorionic stratul decidual cu eliberarea componentelor corionice ale matricei extracelulare, intacte separation of decidual layer with the release of extracellular matrix components, intact. sau degradate. Un test pozitiv n trimestrele II i III este predictiv intens pentru natere or degraded. A positive test in the second and third trimesters is highly predictive for prematur att la pacientele cu ameninate de natere prematur ct i la gravidele preterm birth bouth in patients with threatened premature delivery and the asimptomatice. Se apreciaz c prezena fibronectinei fetale nainte de 20 de sptmni asymptomatic pregnant. It is estimated that the presence of fetal fibronectin before 20 weeks de gestaie se datoreaz fuzionrii incomplete a membranelor fetale cu decidua. ns of gestation is due to incomplete merger of fetal membranes with decidua. But

concentraii mari de fibronectin chiar n intervalul 13 20 de sptmni constituie un high concentrations of fibronectin even within 13 to 20 weeks is a factor de risc pentru naterea prematur(6). risk factor for premature birth. Testul pozitiv reprezint un factor de predicie pentru naterea prematur nainte Positive test is a predictive factor for premature birth de 34 de sptmni la gravidele asimptomatice i simptomatice, iar pentru before 34 weeks in asymptomatic and symptomatic pregnant and gravidele cu ameninare de natere prematur este un factor de risc pentru natere for pregnant with the threat of preterm birth is a risk factor for the n intervalul de timp de 7 10 zile de la pozitivarea testului. Un test negativ are valoare birth within 7 to 10 days from the positive test. A negative test is n identificarea gravidelor cu un risc redus pentru natere prematur. valuable in identifying pregnant women with a reduced risk of premature birth. 3. Vaginoza bacterian, ntlnit la aproximativ 15 20% dintre femeile gravide, Vaginoza bacterial encountered about 15 to 20% of pregnant women, search este unul dintre principalii factori de risc pentru natere prematur. Se manifest printr-o is a leading risk factors for premature birth. modificare a florei vaginale, cu reducerea numrului de lactobacili i proliferarea mai There is a change in vaginal flora, to reduce the number of lactobacili and proliferation multor specii bacteriene anaerobe i facultativ anaerobe (Mobilunculus, Prevotella, of several anaerobic bacterial species and optionally anaerobic (Mobilunculus, Prevotella, Gardnerella, Mycoplasma i Ureaplasma). Gardnerella, Mycoplasma and Ureaplasma). Principala metod de diagnostic a vaginozei bacteriene o reprezint coloraia Primary method of diagnosis of a bacterial vaginoza is represented by Gram a frotiului cervico-vaginal, flora anormal fiind apreciat ca prezent la un scor de Gram coloration of cervico-vaginal smear, abnormal flora are considered to be present at a score 4 10. Datele obinute pn n prezent evideniaz faptul c vaginoza bacterian of 4 to 10. The data obtained so far show that bacterial vaginoza reprezint un factor de risc pentru naterea prematur, fiind asociat cu infecia intraamniotic. Au fost is a risk factor for premature birth, being associated with intraamniotic infection.

propuse protocoale de tratament, cu utilizarea metronidazolului i clindamicinei, ns Treatment protocols have been proposed, using metronidazole and clindamycin, but tratamentul profilactic la acest grup de gravide nu a ameliorat incidena naterii premature. prophylaxis treatment in this group of pregnant has not improved the incidence of preterm birth. 4. Corticotropin Releasing Hormone (CRH) i riscul de natere prematur. Corticotropin releasing hormone(CRH) and the risk of preterm birht. Asocierea ntre aceste dou elemente s-a datorat constatrilor conform crora The association between these two elements was due to findings that gravidele care au nscut prematur au prezentat concentraii de CRH mult mai mari dect pregnant women who gave birth prematurely had higher CRH concentrations than gravidele care au nscut la termen. De asemenea, gravidele cu stress cronic, situaie pregnant women who gave bitrh at term. Also, pregnant women with chronic stress intens predispozant la natere prematur, prezint niveluri mai ridicate de CRH. mostly predisposing situation to premature birth, have higher levels of CRH. Gravidele care au nscut la termen prezint concentraii mai mici de CRH. Pregnant women who gave birth at term, have lower concentrations of CRH. 5. Estriolul salivar i riscul de natere prematur. Estriolul salivar n Salivary estriol and the risk of premature birth. Salivary estradiol concentraii mari reprezint un element predictiv pentru naterea prematur, dar datorit in high concentrations is a predictive factor for premature birth, but valorii predictiv pozitive reduse (o valoare prag de 2,1 ng/ml are o sensibilitate de 57%, due to low positive predictive value (threshold value of 2.1 ng / ml has a sensitivity of 57%, specificitate de 78%, valoare predictiv pozitiv de 9% i o valoare predictiv negativ de specificity 78%, positive predictive value of 9% and a negative predictive value 98%) nu s-a impus ca metod de screening a evalurii riscului de natere prematur. 98%) was not imposed as a method of screening of premature birth. the evaluation of risk of

6. Generarea de trombin i riscul naterii premature. Sarcina reprezint o stare Generation of thrombin and the risk of preterm birth. Pregnancy is a n care echilibrul coagulrii este modificat n sensul unei hipercoagulabiliti. n condition in which the balance of coagulation is amended to a hipercoagulability. sarcina cu risc de natere prematur au fost puse n eviden un numr crescut de In pregnancy with risk of premature delivery were highlighted an increased number complexe TAT (trombin-antitrombin), o concentraie plasmatic a comlexelor TAT of complex TAT (thrombin-antithrombin), a plasma concentration of TAT comlex mai mare de 6,3 ng/ml are o sensibilitate de 75%, o specificitate de 73%, o valoare more than 6.3 ng / ml has a sensitivity of 75%, a specificity of 73 %, a positive. predictiv pozitiv de 67% i o valoare predictiv negativ de 73% pentru predicia predictive value of 67% and a negative predictive value of 73% for the prediction of naterii premature n urmtoarele 3 sptmni. premature birth in the next 3 weeks. 8. Biomarkerii din secreia cervico-vaginal, ultrasonografia cervical i riscul Biomarkers of cervico-vaginal secretion, cervical ultrasonography and risk of de natere prematur. S-a remarcat o cretere a puterii de predicie a riscului de natere premature birth. There was an increase in the predictive power of assessing the risk prematur evalund concomitent aceti factori. Prezena n fluidul vaginal a unor of premature birth while these factors. Presence in vaginal fluid of concentraii crescute de IL-6 i IL-8 i scurtarea colului uterin obiectivat prin ecografie increased levels of IL-6 and IL-8 and shortened cervix objectified by transvaginal transvaginal sunt asociate cu culturi amniotice pozitive i cu corioamniotit. ultrasound are associated with positive amniotic cultures and corioamniotic. n concluzie se poate afirma c naterea prematur reprezint unul dintre In conclusion we can say that preterm birth represents one of elementele de grea ncercare n practica obstetrical a crui rezolvare nc rmne un the difficult elements in obstetric practice whose solution still remains a obiectiv de atins. goal to reach.

Bibliografie: 1. Stretean A, Obstetrica patologic, Ed Univ L. Blaga, Sibiu, 1997, pp 350-67. 2. Iams JD, Goldenberg RL, Meis P Jet al: The lenght of the cervix and the risk of spontaneous delivery: New England Journal of Medicine, 1996, 224; pp 567-572. 3. Heath VCF, Southal TR, Souka Ap, Elliseou A & Nicolaides KH: Cervical length at 23 weeks of gestation: prediction of spontaneous preterm delivery: Ultrasound in Obstetrics and Gynecology, 1998, 12; pp 312-317. 4. To MS, Skentou C, Cicero S & Nicolaides KH: Cervical assesment at the routine 23 weeks scan: problems with transabdominal sonography: Ultrasound in Obstetrics and Gynecology, 2000, 15, pp 292-296. 5. Ple L i colab: Evaluarea sonografic transvaginal a lungimii colului uterin , Info Medica, 2007, Nr 4, 142. 6. Natere prematur, Profilaxie: www.natereprematur.ro