Extragenital pathology contributes to an increase in complications during pregnancy and childbirth, infant and maternal mortality and equally concerns both the health of the mother and the child. The development and formation of the placenta, the laying of the embryo, ensuring the vital activity of the fetus occur against the background of existing diseases with their complications and specific course. Gestational diabetes mellitus (GDM) and iron deficiency anemia (IDA), being extragenital pathologies, occupy one of the leading places in the structure of causes of maternal morbidity and mortality and represent the most urgent problem of public health worldwide [1-4]. Any physiological pregnancy itself is a diabetogenic factor. When it occurs, metabolic processes change significantly. This is due to the formation and active functioning of a new organ - the placenta, which determines the development of the fetus and the health of the future child. The role of the fetoplacental complex is difficult to overestimate. Throughout pregnancy, the placenta is in a state of continuous development with alternating periods of branched angiogenesis, unbranched angiogenesis, trophoblast differentiation and syncytium formation [5]. With the onset of the second trimester of pregnancy, the consumption of high-energy substrates (glucose) and micronutrients (iron) by the placenta and fetus increases. The uteroplacental and fetoplacental blood flows perform an important function in the delivery and removal of metabolic products. After 28 weeks of pregnancy, metabolic changes worsen, reaching a maximum by 32 weeks of pregnancy. During pregnancy, it is very important to correctly assess the condition of the fetus, promptly diagnose pathological changes and conduct adequate therapy in order to reduce complications and obtain a viable child. The aim of the study was to study the relationship between perinatal outcomes and the state of the fetoplacental complex during pregnancy complicated by gestational diabetes mellitus combined with anemia.

Material and methods of the study

The prospective study included 75 pregnant women, among them, the main group consisted of 38 patients with GDM combined with anemia, and the comparison group included 37 practically healthy pregnant women. In order to study the state of the fetoplacental complex, the study groups were conducted using the methods of gravidogram, ultrasound fetometry and Doppler blood flow in the mother-placenta-fetus system. In order to identify the compliance of the fetus size for the specified gestational age, starting from 20 weeks of pregnancy at the antenatal level, pregnant women in all study groups filled out a gravidogram. Ultrasound examination was performed on the Sonomed-500 (C) device with an installed Doppler (PW / CF / PD) block. Ultrasound fetometry (US) was performed to assess the state of the fetoplacental complex. Doppler study was conducted at 28-32 weeks of pregnancy in the umbilical artery, aorta and uterine artery. During the study, such indicators as uteroplacental blood flow, fetal-placental blood flow and blood flow in the umbilical vessels were assessed. Statistical analysis was performed using the software packages Statistica 10.0 (StatSoft Inc, USA) and SPSS Statistics 23 (IBM, USA). The null hypothesis of all variance analysis methods was rejected at p <0.05.

Study Results

Of the 38 pregnant women diagnosed with GDM in combination with anemia, according to the gravidogram results, a large fetus was noted in 13.6% (5 cases) of the subjects, however, when compared with the data on the weight of newborns after birth, fetal macrosomia was confirmed in 3 (60.0%) cases out of 5 diagnosed women.

It should be noted that the combination of GDM with anemia was more often observed in the birth of children with intrauterine growth retardation (IUGR), which indicates a possibly more unfavorable effect of anemia on perinatal outcomes in women with GDM in combination with anemia in a region with a high incidence of anemia and fertility.

The most pronounced changes in all fetometric parameters at 28-32 weeks of pregnancy were noted in patients with GDM combined with anemia than in the comparison group. An insignificant predominance of the biparietal size and fronto-occipital size parameters was noted in the group with GDM combined with anemia 82.2±8.9 and 94.0±9.5 mm from such parameters in the comparison group 79.6±8.3 and 92.2±9.4 mm (p>0.05). The most significant predominance of the femur length (FL) parameter was noted in the group of GDM combined with anemia 62.1±8.6 mm than in the comparison group 58.6±7.6 mm (p<0.05). A comparative analysis of the results of placental thickness in the group of GDM in combination with anemia was 36.8 ±7.1 versus 31.8 ±4.4 in the comparative group.

According to the ultrasound examination data, the tendency to fetal acceleration was established in 2 cases (5.4%) in the comparison group and in 3 cases (7.9%) in the GDM in combination with anemia group. The diagnosis of IUGR was made in 5 cases (13.5%) in the comparison group and in 4 cases (10.5%) in the GDM in combination with anemia group. Violation of fetoplacental blood flow of varying severity was diagnosed in 11 cases (28.9%) from the GDM in combination with anemia group against five cases (13.5%) in the comparison group. Of the 11 cases, 5 were due to impaired blood flow in the uterine artery, 6 cases - in the umbilical artery. It should be noted that when comparing Doppler data and perinatal outcomes taking into account blood flow disorders in the mother-placenta-fetus system in subjects in the GDM group combined with anemia, a comparative analysis showed that newborns with impaired blood flow had lower height-weight indicators, a lower score on the Apgar scale at the 1st and 5th minutes, and were also more likely to be born with asphyxia (50.0%), IUGR (50.0%) and weighing more than 4000 g (25.0%) compared to the group without impaired blood flow.

Conclusion

Both the graviogram and ultrasound fetometry turned out to be informative methods for diagnosing a large fetus and IUGR. At the same time, discrepancies when comparing them with the body weight of newborns at birth as a large fetus are minimal, and with IUGR - none.

The results of Doppler studies of blood flow in the mother-placenta-fetus system showed blood flow disturbances mainly in the umbilical arteries of the fetus in patients with GDM combined with anemia, while the blood flow indicator in the uterine arteries was within the normal range, which probably indicates the mobilization of compensatory capabilities at 28-32 weeks of pregnancy. However, the disturbance of uteroplacental blood circulation, apparently, affected the condition of the intrauterine fetus, including in the group of GDM combined with anemia. This was subsequently confirmed by the birth of children with low birth weight, which was assessed by neonatologists as intrauterine growth retardation.