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International Journal of Medical Sciences And Clinical Research
(ISSN
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VOLUME
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AGES
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ABSTRACT
The article is devoted to the problems associated with connective tissue dysplasia (CTD), predominantly
undifferentiated forms of the disease (nDST). The topic's relevance is due to the high prevalence of this pathological
condition. The generalized nature of connective tissue damage with the involvement of the reproductive system in
the pathological process significantly affects the course of pregnancy and Birth. Complications that may be associated
with pregnancy, childbirth, and the postpartum period in women with nDST and which cause a high need for surgical
aids: amnio-, episio- and perineotomy, and cesarean section are presented. Particular attention is paid to magnesium,
which plays one of the determining roles in the complex biosynthesis of the extracellular matrix in the formation of
connective tissue and the morphofunctional state of fibroblasts. The methods used to detect connective tissue
metabolism disorders (determination of the level of oxyproline and fibronectin in blood serum, pyrinx D and
glucosaminoglycans in urine, etc.) are described. Given the lack of reliable diagnostic (biochemical and genetic) criteria
for nDST, special attention is paid to the need for an integrated approach to assessing the condition of patients using
anamnesis data, the results of clinical, instrumental, and laboratory examinations.
Research Article
FEATURES OF THE COURSE OF GESTATION IN WOMEN WITH MITRAL
VALVE PROLAPSE AGAINST THE BACKGROUND OF UNDIFFERENTIATED
CONNECTIVE TISSUE DYSPLASIA
Submission Date:
October 20, 2024,
Accepted Date:
October 25, 2024,
Published Date:
October 30, 2024
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume04Issue10-15
Khudoyarova Dildora Rakhimovna
Professor, Samarkand State medical university, Samarkand, Uzbekistan
Shodikulova Gulandon Zikiryayevna
Professor, Samarkand State medical university, Samarkand, Uzbekistan
Yunusova Zarnigor Maksadovna
Assistant, Samarkand State medical university, Samarkand, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 04 Issue 10-2024
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International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
VOLUME
04
ISSUE
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P
AGES
:
91-100
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
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KEYWORDS
Connective tissue dysplasia, hemostasis, complications of pregnancy and childbirth, magnesium deficiency,
endothelial dysfunction, markers of collagen breakdown, genital prolapse.
INTRODUCTION
In recent years, much attention has been paid to the
problem of connective tissue dysplasia, which is
associated with the high prevalence of its
manifestations in the population from 26 to 80% [2].
Mitral valve prolapse (MVP) is a minor abnormality in
the development of the heart, considered one of the
common abnormalities of the valvular apparatus of the
heart and the most common visceral marker of
connective tissue dysplasia [2]. MVP occurs in 60.8% of
the population, 17
–
38% of women of reproductive age,
and 8% to 32.9% of pregnant women [4, 5]. The
combination
of
mitral
valve
prolapse
and
undifferentiated connective tissue dysplasia (NCSTD)
increases the incidence of complications of the
gestational period, both in the somatic state of a
woman's health and in the course of pregnancy [1, 3,
4]. In this regard, it is worth paying attention to the
study of the features of reproductive and somatic
health, the course of pregnancy and childbirth, and
perinatal outcomes in women against the background
of the incompetence of connective tissue structures.
The study aimed
to examine the features of the
gestational course in women with mitral valve prolapse
against the background of undifferentiated connective
tissue dysplasia.
METHODS
In 2023
–
2024, we followed 190 pregnant women with
voluntary informed consent per WHO international
ethical requirements. The observation group consisted
of 124 pregnant women with mitral valve prolapse
against the background of undifferentiated connective
tissue dysplasia of mild severity, the comparison group
consisted of 66 practically healthy pregnant women.
The criteria for inclusion in the observation group were
the presence of mitral valve prolapse and mild
undifferentiated connective tissue dysplasia.
Exclusion criteria: differentiated forms of connective
tissue dysplasia; endocrine diseases; chronic somatic
pathology at the stage of decompensation; congenital
or acquired heart defects; operated heart defects;
infectious diseases; pregnancy after the use of assisted
reproductive technologies; history of infertility and/or
miscarriage; multiple pregnancies. The groups were
formed according to the principle of continuous
selection for the period: 2021
–
2024 using random and
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typological sampling
–
by the method of balanced
groups identically in terms of age, parity of
pregnancies, social, educational and family status. The
age range of the examined patients ranged from 17 to
41 years. In the observation group, the mean age was
28.6±4.6 years, in the comparison group 27.7±5.2 years
(p>0.05).
Women of both groups were observed in the dynamics
of gestation under the procedure for providing care in
the profile "obstetrics and gynecology (except for the
use of assisted reproductive technologies)", approved
by the order of the Ministry of Health of the Republic
of Uzbekistan No. 572n dated 01.11.2021.
The diagnosis of MVP and the stage of heart failure was
made in conjunction with cardiologists by the
International Classification of Diseases, tenth revision:
I34.1 Mitral valve prolapse.
RESULTS
MVP was diagnosed before pregnancy in 108 (87.1%)
and during the present pregnancy in 16 (12.9%) women
in the observation group. Mitral valve regurgitation of
the 1st degree has been established in all pregnant
women. Anterior leaflet MVP was diagnosed in 70.2% of
cases. Of these, 95.4% of the 1st degree and 4.6% of the
2nd degree. MVP of the posterior leaflet was detected
in 29.8% of cases. Myxomatous degeneration of the
mitral valve leaflets of the 1st degree was only in 8.9%.
Chronic heart failure of the first degree of severity
occurred in 12 (9.7%) women in the observation group.
The diagnosis of undifferentiated connective tissue
dysplasia in the observation group was made before
the onset of real pregnancy in 35 (28.2%) women, in real
pregnancy
–
in 89 (71.8%) pregnant women. All patients
were diagnosed with a mild degree of undifferentiated
connective tissue dysplasia.
It draws attention to the fact that each group of
pregnant women accounted for an average of 4.8
somatic diseases, which is 3 times higher than the
comparison group. In the structure of extragenital
morbidity, diseases of the circulatory system were in
the first place in the observation group (p<0.001).
Among them, rhythm and conduction disorders
(p<0.001), minor cardiac anomalies (p<0.001),
neurocirculatory dystonia (p<0.001) were in the lead,
mainly of the hypotonic type [6]. Thus, pregnant
women with MVP are 1.7 times more likely to have
cardiovascular diseases. In terms of the frequency of
occurrence, the second place was taken by previous
infectious diseases, which are significantly more
common in women in the observation group (p<0.001).
Women were significantly more likely to suffer from
influenza and childhood infections, especially
chickenpox. The third place was occupied by blood
diseases significantly different from the comparison
group in the observation group (p<0.001). Every third
pregnant woman with MVP was diagnosed with iron
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deficiency anemia (p<0.001). Thrombocytopenia was
diagnosed only in pregnant women in the observation
group. It should be noted that diseases of the skin and
musculoskeletal system were detected only in the
women of the observation group (p<0.001).
Prior to the onset of real pregnancy, complaints about
the underlying disease bothered mainly women in the
observation group, the main of which were
palpitations and heart failures, pain in the heart area of
an aching and stabbing nature, shortness of breath
during physical exertion, headaches, dizziness. It
should be noted that 38 pregnant women with MVP
(30.6%) did not complain in the dynamics of gestation.
Attention is drawn to the fact that the clinical
manifestations of palpitations and interruptions in the
work of the heart, pain in the heart area, disorders of
thermoregulation and heat transfer, asthenia, vascular
syndrome tended to increase by the second trimester
and decrease by the time of delivery. Respiratory
syndrome, on the other hand, tended to increase
depending on the gestational age due to increasing
complaints of shortness of breath and poor tolerance
to stuffy rooms. Thus, for women with MVP due to
NCSTD in the first and third trimesters of pregnancy,
the most common complaints are from the
cardiovascular system, which may be due to
physiological stress.
When assessing gynecological morbidity, it was
revealed that there were 1.3 gynecological diseases for
each patient of the observation group, and 0.6 for each
patient of the comparison group, which is 2 times more
often. Among gynecological diseases, women in the
observation group were significantly more likely to
suffer from chronic pelvic inflammatory diseases
(p<0.001) in combination with endocervicitis (p<0.01),
and cervical diseases (p<0.05). Bacterial vaginosis was
also significantly more common in the observation
group compared to the comparison group (p<0.05).
Thus, women in the observation group were 5 times
more likely to have a history of gynecological diseases
than practically healthy pregnant women. Clinical
examination revealed that almost every pregnant
woman had a history of sexually transmitted
infections. It should be noted that 34 (27.4±4.0 per 100
examined) pregnant women in the observation group
suffered from ureaplasma infection, 28 (22.6±3.8)
suffered from candidiasis, and 16 (12.9±3.0) suffered
from chlamydial infection (p>0.05). It should be noted
that during the examination for perinatally significant
infections in the 1st trimester, it was revealed that
women in the observation group were more often
carriers of cytomegalovirus infection 20.2±3.6 per 100
examined (p<0.05) and herpes simplex virus type II
21.8±3.7 (p<0.001).
The analysis of menstrual function revealed that
women in the observation group were significantly
more likely to observe various disorders compared to
practically healthy women (p<0.01). In the observation
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group, 23 (18.5±3.5%) patients had significantly more
algodysmenorrhea compared to the comparison group
–
3 (4.5±2.6%) (p<0.01), as well as hypermenorrhea,
respectively, 16 (12.9±1.3) and 4 (6.1±2.9) (p<0.05).
Women in the observation group were taken for
dispensary observation for pregnancy in the antenatal
clinic at an average period of 8.1±0.3 weeks of
pregnancy and in the comparison group at 9.7±0.4
(p>0.05) in antenatal clinics at the place of medical care
or district hospitals. It should be noted that in the
antenatal clinic specialized in the management of
women with cardiovascular diseases at the Republican
Clinical Diagnostic Center of the Udmurt Republic,
every third (31.5%) woman with NCST was observed.
The number of visits by a pregnant woman to the
antenatal clinic did not differ in the groups (p>0.05).
The analysis of morphoanthropometric data revealed
that the average height and div weight of pregnant
women in the observation group did not differ from
the average height of pregnant women in the
comparison group (p>0.05). The average weight gain
in the patients of the observation group of 17.8±6.4 kg
was higher than that of the comparison group
–
11.5±6.9 kg, but no significant differences were
revealed (p>0.05).
Pelvimetry of pregnant women with MVP against the
background of NCST revealed an anatomically narrow
pelvis 4.5 times more often (69.4±4.1 out of 100
examined) than in practically healthy pregnant women
(28.8±5.6). When assessing the forms of pelvic
constriction, it should be noted that in pregnant
women with MVP against the background of NCST, the
first rank is occupied by the transversely narrowed
pelvis, the second by the flat pelvis, and the third by the
generally uniformly narrowed pelvis. At the same time,
in practically healthy pregnant women, the generally
uniformly narrowed pelvis is in the lead, followed by a
flat and transversely narrowed pelvis. In terms of the
degree of pelvic narrowing, the groups were
comparable.
Analysis of the course of pregnancy revealed that in
the observation group, 93 (75.0±3.9 per 100 examined)
various pregnancy complications were diagnosed
significantly more often in the first trimester than in
the comparison group
–
31 (47.0±6.1 per 100) (p<0.001).
It should be noted that toxicosis in the first half of
pregnancy was significantly more common in pregnant
women with MVP against the background of NCST
(p<0.01), as well as diseases of the urinary system and
acute respiratory diseases (p<0.05). Thus, pregnant
women with MVP in combination with NCDT in the first
trimester of pregnancy are 3 times more likely to have
obstetric and somatic complications compared to
healthy pregnant women. In the second trimester,
among the obstetric complications in women with
MVP on the background of NCDT, disorders of
uterofetal-placental circulation and fetal growth
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retardation appeared as signs of formed placental
insufficiency. Among the extragenital pathology in the
second trimester about practically healthy pregnant
women, women with MVP against the background of
NCST were 4 times more likely to have somatic
pathology. Blood diseases were detected significantly
more often 46.8±4.5 per 100 examined (p<0.01),
including anemia and thrombocytopenia (p<0.05), as
well as diseases of the urinary system (p<0.01). In the
third trimester, pregnant women with MVP against the
background of NCST were significantly more likely to
have chronic intrauterine fetal hypoxia (11.3±2.8)
(p<0.01), fetal growth retardation (11.3±2.8) (p<0.01),
impaired uterofetal-placental circulation (12.9±3.0)
(p<0.01) and chronic placental insufficiency (12.9±3.0)
(p<0.001). The threat of preterm birth and
preeclampsia were also significantly more common in
pregnant women with MVP on the background of
NCST, respectively (p<0.05) and (p<0.001).
Thus, the mutual influence and aggravation of
pregnancy and MVP, especially in the setting of NCST,
led to a higher incidence of pregnancy complications.
He draws attention to the fact that every tenth of them
was treated in an inpatient setting 2-3 times.
According to the data of the study, in the anamnesis of
pregnant women in the observation group, 42
(17.6±2.5%) pathological births were 4 times more
often than in the comparison group
–
3 (4.5±2.6;
p<0.001). Most women gave birth at term on average,
at an average of 38.5±1.4 weeks of pregnancy in the
observation group and at 38.3±1.2 weeks in the
comparison group (p>0.05). In the observation group,
115 (92.7%) pregnant women had an urgent birth and,
accordingly, 64 (97.0%) in the comparison group. The
incidence of preterm birth was higher in the
observation group, but no significant differences were
found (p>0.05). It should be noted that in all cases of
the women we examined, premature birth occurred at
gestational age from 32 to 35 weeks, in the observation
group at the mean gestation period
–
33.8±0.5 weeks,
and in the comparison group
–
34.5±0.5 weeks of
pregnancy (p>0.05).
Labor in puerperas in the observation group was
longer (p<0.01). This may be due to the high incidence
of abnormalities in labor, particularly in labor
weakness. The anhydrous interval was 7.8±1.2 hours in
pregnant women in the observation group and 6.1±0.9
hours in pregnant women in the comparison group
(p>0.05). Timely rupture of amniotic fluid was
observed in 69 (55.6±4.5%) women in the observation
group and 42 (63.7±5.9%) in the comparison group.
Premature effusion was 2 times more frequent in 25
(20.2±3.6%) and 8 (12.1±4.0%), respectively. Early
effusion was diagnosed in 30 (24.2±3.8%) women in the
observation group and 16 (24.2±5.3%) in the
comparison group. Thus, the most common
complication of childbirth in patients was untimely
discharge of amniotic fluid. According to our data, 83
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(66.9±4.2) women in the observation group and 59
(89.4±3.8) in the comparison group had normal births.
The results of the analysis of the course of labor
showed that pregnant women with MVP against the
background of NCST significantly more often had such
complications of labor as abnormalities of labor in the
form of its weakness (p<0.01), and hypotonic bleeding
(p<0.05).
In this regard, women with MVP were significantly
more likely to undergo amniotomy (42.7±4.4 compared
to the comparison group 25.8±5.4 (p<0.05), induction
of labor using prepidil gel, 8.9±2.6 and 1.5±1.4 (p<0.05),
induction of labor (20.2±3.6 and 6.1±2.9 (p<0.01),
respectively. It draws attention to the fact that women
in the observation group more often required
induction and stimulation of labor due to labor
abnormalities, which had a significant difference to the
comparison group (p<0.001).
Blood loss during childbirth did not differ in the groups
and amounted to an average of 347.7±42.1 ml in the
observation group and 329.0±27.5 ml (p>0.05) in the
comparison group. Hypotonic bleeding in the third
stage of labor was present only in 3 (2.4%) women in
the observation group, for which therapeutic
measures were taken.
The prevalence of birth canal injuries in puerpera in the
observation group was more common in 51 (41.1±4.4
per 100) women, compared to 14 (21.2±5.0 per 100)
women (p<0.01). Birth injuries are associated with the
failure of the mechanical properties of the connective
tissue fibers of the birth canal and abnormalities of
labor activity [2, 6]. Cervical rupture and labia fissures
(p<0.01) were significantly more common in women in
labor with MVP on the background of NCST compared
to the comparison group. Various complications have
led to a higher need for operational aids. Operative
delivery was performed in 31 (25.0±3.9 per 100) women
in the observation group and 13 (19.7±4.9 per 100)
women in the comparison group (p>0.05). The main
indications for cesarean section were: the presence of
an untenable scar on the uterus, maca cervical
dystocia, and fetal growth retardation. In the
postpartum period, women in the observation group
had a higher incidence of pregnancy complications
such as uterine subinvolution and hypogalactia
(p<0.05). In 3 (1.3±0.7 per 100) parturient women in the
observation group, perineal sutures were inadequate
after episiotomy.
The results obtained confirmed the opinion of some
authors that pregnant women with MVP, especially
against the background of NCST, have a significantly
higher incidence of complicated pregnancy and
childbirth compared to healthy women, and the tactics
of delivery in this category of women are determined
individually, taking into account the general condition
of the patient, complications of pregnancy and the
obstetric situation.
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The average weight of babies born in patients suffering
from MVP was 3085.7±554.2 grams, but there were no
significant differences from the comparison group
–
3644.6±587.1 grams (p>0.05). In the Apgar assessment
of newborns at the first and fifth minutes, lower scores
were also found in the group of children of mothers
with MVP than in the children of mothers of the
comparison group (p<0.001). The condition of
puerperal infants with MVP against the background of
NCSTD at birth was worse than that of infants of
healthy women and 5 minutes after birth did not reach
the indicators of the comparison group, which
indicates the presence of the most pronounced
pathological changes of a hypoxic nature in newborns
of this group.
Intrauterine growth retardation occupies an important
place in the structure of neonatal pathology. It draws
attention to the fact that premature babies were born
4.5 times more often in the observation group. In the
observation group, the number of children with grade
I hypotrophy was 4.6 times more common in 9 (7.3±2.3
per 100 examined) than in the comparison group
(3.0±2.1), and only this subgroup included newborns
with grade II hypotrophy. The rate of perinatal
morbidity in newborns born to women with MVP for
NCDT is higher than in the comparison group. The
course of pregnancy in patients with MVP in
combination with NCDT against the background of
chronic hypoxia and metabolic disorders in the
placenta led to a significantly more frequent perinatal
lesion of the central nervous system and conjugation
jaundice in children relative to the comparison group
(p<0.001), respiratory distress syndrome (p<0.01), and
intrauterine infection (p<0.001). It should be noted
that only in the observation group, small heart
anomalies were diagnosed in 15 (12.1±2.9) newborns in
the form of an open foramen ovale, a false chord in the
left ventricle, and an atrial septal defect.
CONCLUSION
Thus, the presence of extragenital disease
–
MVP
during pregnancy, the progression of circulatory
disorders due to the interaction of pregnancy and
MVP, along a complicated gestational period, were of
particular importance in the prognosis of adverse
outcomes of pregnancy and childbirth in patients with
MVP against the background of NCDT. The presented
data convincingly show that patients with MVP,
especially against the background of NCST, have a
higher incidence of pre-and postnatal pathology. The
health status of newborns from mothers with MVP was
determined by fetal suffering due to placental
insufficiency and several obstetric complications,
depending on the presence of NCST in the mother, the
course of pregnancy, the weight of the newborn, and
the timing and method of delivery.
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