MATERNAL RISK FACTORS OF PERINATAL WOMEN COMPLICATIONS WITH THE URINARY SYSTEM DISEASES

Lidiіа Melenchuk Ph.D., Assistant Professor, Institute of Hereditary Pathology of the National Academy of Medical Sciences of Ukraine, Ukraine e-mail: Lidycja@gmail.com, orcid.org/0000-0001-5318-9992 Yevheniya Sharhorodska Ph.D., Senior Researcher, Institute of Hereditary Pathology of the National Academy of Medical Sciences of Ukraine, Ukraine e-mail: gendoctor86@gmail.com, orcid.org/0000-0003-0240-4765


Introduction
In Ukraine, studies of genetic and demographic processes conducted in recent years have shown that the socially conditioned demographic crisis observed in the country is significantly exacerbated by perinatal complications. This is manifested in an increased incidence of lost pregnancies and the birth of unhealthy children in women with extragenital pathology (Veropotvelian MP, 2016;Shestakova T. S., 2012;Mandal D., 2017).
The relevance of the study of infectious diseases of the urinary system in obstetrics is due to the high prevalence of this pathology, as well as complications that occur during pregnancy, childbirth and postpartum and pose a danger to mother and fetus (Bounds KR, 2015;Hryhorenko AP, 2014;Samigullina AE, 2016;Sharhorodska Ye.B., 2018). Nowadays, almost 60% of pregnant women have diseases of the internal organs. Abnormalities in the development of the child are observed in extragenital diseases of the mother 4 times more often than in the general population. The relationship between the severity of the clinical course of the disease in pregnant women and the degree of fetal and neonatal disorders was found (Haistruk N.A., 2017;Limanskaya A.Yu., 2016;Olshevska O.V., 2016).
The role of extragenital diseases (diseases of internal organs) in the occurrence of obstetric complications (late preeclampsia, prematurity, uterine contractile dysfunction, etc.) in the development of perinatal pathology (Tillett J., 2015;Veropotvelian P. M., 2011;Wing D. A., 2014) has been convincingly proven.
Diseases of the urinary system in pregnant women are second only to extragenital diseases. Their frequency is from 0.1 to 7 -10% and poses a serious danger to the normal development of pregnancy and fetus (Glaser A. P., 2015;Govoruha I. T., 2016;Talalaienko Yu. O., 2016). First of all, it is pyelonephritis, urolithiasis, abnormalities in the development of the kidneys and ureters, chronic cystitis, asymptomatic bacteriuria, chronic glomerulonephritis (Bahri A. El., 2015;Holubenko M. Yu., 2012). Most often there is a combination of several diseases of the urinary system (Kazemier B. M., 2015;Szweda H., 2016).
Scientific research and practical experience show that the issues of preserving reproductive health, reducing maternal and fetal losses, and especially the demographic situation go far beyond the medical field and have become a national interdisciplinary problem in Ukraine.
Improving the principles of pregnancy management and the use of optimal delivery help reduce infant mortality and morbidity. The analysis of the literature shows that not all reserves for the improvement of perinatal indicators are used. One such reserve is the improvement of measures to improve the preconceived health of the population of reproductive age. Screening of preconception perinatal risk and its active correction in women who have had negative consequences of previous pregnancies, allows to realize the positive results of the next pregnancy (Melenchuk L. M., 2019;Safonova I. M, 2015).
Therefore, the development of informative criteria for individual prediction of pregnancy and perinatal period is of great medical and social importance.
Thus, effective prevention of the pathological condition of the fetus in women with diseases of the urinary system requires a targeted study of maternal factors due to the influence of somatic pathology. Timely detection of women at risk will create a basis for the prognosis of the next pregnancy, reduce the level of perinatal pathology, which will have a significant medical and social effect. The obtained data will allow to improve the system of approaches to determining the risk groups of perinatal pathology and improve specialized care for women with diseases of the urinary system. As a result of this work, informative factors of high risk of perinatal pathology in women at risk with pathology of the urinary system will be identified.
The purpose of the research is to identify maternal factors of perinatal complications in women with kidney disease. To solve this goal, the following tasks were set: 1. To form contingents of women with pathology of the urinary system among the population of Lviv region.
2. Investigate the complications of pregnancy and childbirth in women with kidney disease.
3. Assess the condition of newborns in women with kidney disease.

Selecting a group of women with pathology of the urinary system for this research
To achieve this goal, we conducted an analysis of clinical, epidemiological, medical and statistical data of primary medical records. Selected maps of pregnant women with a clinical diagnosis of "Diseases of the urinary system" according to the International Classification of Diseases-10 (N010 -N099). The obtained indicators were compared with similar parameters of the control group: healthy women who gave birth to alive children in the maternity ward of the Regional Clinical Hospital of Lviv in 2014-2017: 100 healthy pregnant women who gave birth to children in the same period of time formed a control group. To assess the maternal factors of perinatal complications in women with diseases of the urinary system, the course of pregnancy and childbirth, gestational age at birth, assessment of the condition of children at birth were studied.
For the purpose of this study two groups of researched women were created -the main 130 pregnant women and the control 100 women (without extragenital pathology). The main group was divided into two groups: I -pregnant women with acute pyelonephritis (GP), this group included pregnant women, who were diagnosed with acute pyelonephritis for the first time during their pregnancy. Group II included pregnant women with chronic pyelonephritis (CP) -women who had diseases of the urinary system before pregnancy.
The women in the control group had no reproductive and somatic history of diseases and were healthy.
It should be noted that in the Regional Clinical Hospital of Lviv pregnant women with extragenital pathology from all Lviv region are concentrated. Statistical processing of research results was performed using computer programs «Statistica 6.0» and Excel 5.0 «. Differences were considered significant at P <0.05.

The course of pregnancy in women with diseases of the urinary system
Analysis of archival documentation -maps of pregnant women in the obstetrics department of the Regional Clinical Hospital of Lviv for a period of (for) 4 years showed that most women in groups I and II were pregnant again, and the control group was dominated by women with the first pregnancy number (P <0.05), table 1.
According to the results of a detailed retrospective analysis, it was proved that somatic diseases were diagnosed in the majority of patients of the main group. In 10 (7.7%) women of the main group and in all 100 (100.0%) women of the control group complications of somatic anamnesis were not registered (p <0.05). Significantly more often than the control group, women with kidney disease had a combination of pathology of the urinary system and chronic infectious diseases (58-44.6%), diseases of the endocrine system (21-16.2%), a combination of cardiovascular diseases and chronic infectious diseases (17-13.1%), a combination of diseases of the cardiovascular and endocrine system (12-9.2%), diseases of the cardiovascular system (12-9.2%), a combination of pathology of the urinary system and endocrine pathology (5-3.8%) (p <0.05). Analysis of the spectrum of reproductive losses showed that 32 (24.6%) women of I and 42 (32.3%) women of group II had various complications. Thus, frozen pregnancies: in group I -9 (6.9%), in group II -17 (13.1%); ectopic pregnancy -in group I -7 (5.4%), in group II -8 (6.2%); unauthorized miscarriages -in group I -13 (10.0%), in group II -10 (7.7%); medical abortions -in I -3 (2.3%), in II -7 (5.4).
In women with acute and chronic pyelonephritis in the spectrum of reproductive losses in the first place were miscarriages -10.0% and 7.7%, respectively. In contrast to the women of the main group, in the control group -all patients -100 (100.0%) had no features of reproductive history (p <0.05).
In the sample of patients who were analyzed, a study of the peculiarities of the course of pregnancy of patients was conducted (Table 2). According to the results of the analysis of pregnancy indicators, all 130 (100.0%) women of the main group had complications. The main complications were in group I -pyelonephritis -32 (24.6%) cases (a), and in women of group II, with chronic pyelonephritis recorded 11 (8.5%) cases of anemia, 8 (6.2%) -threats of termination of the first half of pregnancy, 7 (5.4%) cases of preeclampsia in combination with anemia, 5 (3.8%) with the threat of abortion of the first and second half of pregnancy. In contrast to women in the main group, in the control group significantly more patients -90 (90.0%) did not notice pregnancy (p <0.05). And the number of complications there was significantly lower (p <0.05).

Completion of pregnancy and childbirth. Assessment of the condition of children at birth in women with diseases of the urinary system
The analysis of the results of termination of pregnancy showed that women of the main group II had significantly more frequent recurrences, as well as patients of group II in 10 (7.7%) cases -completion of childbirth by cesarean section (p <0.05) (table 3).
When studying the course of childbirth in women of both groups a significantly higher percentage of complications in women of the main group compared to the control was found. 28 (21.5%) women with pathology of the urinary system and 97 (07%) women of the control group did not show any features of childbirth (p <0.05).  Significantly more women in the main group had a weakness of labor: Group I -8 (6.2%), II -9 (6.9%) against 1 (1.6%) in the control group; manure defect -group I 8 (6.2%), II -7 (5.5%) in the absence of these complications in the control group (p <0.05). In the main group, births occurred significantly more often: Group I 6 (4.6%), ІІ -29 (22.3%) (p <0.05). It should be noted that much more often premature births were in group I of women with chronic pyelonephritis. All women in the control group had timely births (table 4). According to the results of the assessment of the condition of children at birth, it was found that the number of children of women in the main group with a score on the V. Apgar scale was: Group I satisfactory -7-10 points -53 (40.8%) children; mild and severe hypoxia 6 or less points -15 (11.5%) newborns; and in group II -satisfactory condition -7-10 points -37 (28.46%) children; mild and severe hypoxia 6 or less points -25 (19.2%) children.
A significant proportion of children from mothers with pathology of the urinary system required transfer to specialized intensive care units: 7 (5.4%) from women of group I and 13 (10.0%) -group II. In one case (0.8%) mortality was noted. All children from the mothers of the control group were discharged home in satisfactory condition (P <0.05) (table 5).
A significant proportion of children from mothers with pathology of the urinary system required transfer to specialized intensive care units: 7 (5.4%) from women of group I and 13 (10.0%) -group II. In one case (0.8%) mortality was noted. All children from the mothers of the control group were discharged home in satisfactory condition (P <0.05) (table 5). Therefore, after conducting a comparative analysis of reproductive losses, somatic history in women with pathology of the urinary system and studying the results of the course and completion of pregnancy, as well as complications of childbirth in such women living in Lviv region, we can draw the following conclusions.
It has been proved that women with pathology of the urinary system are at risk of obstetric complications. Significant differences were found in the comparison of pregnancy parity in women of the main and control groups (P <0.05): most women in both surveyed groups were pregnant again: 74 (56.9%) in the main group, and 22 (73.3%)in the control group with most women pregnant for the first time. There were significant differences in the rates of termination of pregnancy and complications during childbirth: women in the main group were significantly more likely to have premature births (15.4% of women with GP and 46.2% of women with CP), while all women in the control group gave birth in term (P <0.05).

Conclusions
1. Significant differences were found in the comparison of the ordinal number of pregnancy in women of the main and control groups: a significant number of women in the main group were pregnant again: 74 (56.9%), and the control group was dominated by first-born 22 (73.3%), (P <0.05). The majority of patients in the main group (120 -92.3%) had somatic diseases. The most common was the combination of pathology of the urinary system and chronic infectious diseases (58-44.6%). All women in the control group were healthy (p <0.05).
3. Analysis of the course of pregnancy in the studied women showed a much higher percentage of complications in pregnant women of the main group. The main complications were in group I -pyelonephritis -32 (24.6%) cases. Significantly more often women of group II had chronic pyelonephritis, anemia -11 (8.5%), the threat of termination of the first half of pregnancy -8 (6.2%), preeclampsia in combination with anemia -7 (5.4%) and the threat of termination of the first and second half of pregnancy 5 (3.8%). In the control group, 90 (90.0%) women did not note the peculiarities of pregnancy (p <0.05).
4. There were significant differences in the rates of termination of pregnancy and complications during childbirth: women in the main group were significantly more likely to have premature births (15.4% of women with acute pyelonephritis and 46.2% of women with chronic pyelonephritis), while all women in the control group gave birth on time (P <0.05). Significantly more women in the main group had a weakness of labor: Group I 8 (6.2%), Group 9 (6.9%) against 1 (1.6%) in the control group; defect of manure I group 8 (6.2%), II 7 (5.5%) in the absence of these complications in the control group (p <0.05).
5. Pregnancy termination in the vast majority of women in the main group was physiological: in 65 (50.0%) women of group I and in 52 (40.0%) women of group II (P <0.05). Respectively, cesarean delivery was completed in 3 (2.3%) women from groups I and 10 (7.7%) from group 2. All women in the control group had timely, physiological births.
6. The obtained results indicate that the condition of newborns from mothers with pathology of the urinary system, was often disturbed and was differed from similar indicators in almost healthy newborns. Estimate on the V. Apgar scale was the following: in group I 6 or less points had 15 (11.5%) newborns; and in group II -6 or less points -25 (19.2%) children. A significant proportion of children from the main group (I -5.4%, II -10.0%) needed immediate resuscitation measures at birth and their transfer to specialized departments for further treatment.
Prospects for further research The solutions proposed in the paper are promising in terms of further possibility to determine the informative range of risk factors for perinatal pathology in women with diseases of the urinary system to improve the comprehensive prevention of this pathology.