The Effect of Omega 3 on Pregnancy Complicated by asymmetrical IUGR

INTRODUCTION

An estimated fetal weight (EFW) or abdominal circumference (AC) below the tenth percentile is defined as an IUGR, whereas an EFW or AC below the third percentile is considered a severe IUGR. It is estimated that 10–15% of women who are pregnant are affected by IUGR. Obstetricians and perinatologists must notice growth-restricted foetuses since they are linked to a high rate of perinatal morbidity and death. ¹

Antenatal diagnosis of IUGR decreases the fetal morbidity and mortality which complicate IUGR. Accurate dating is the most important step. Other important steps are identification of the risk factors, monitoring of the EFW and symphysis to fundus distance (SF). ²

IUGR has early complications as increase rate of preterm labor, intrauterine fetal death, still birth, respiratory distress syndrome and entero-colitis. The late complications include increase the risk for hypertension, type 2 diabetes mellitus, neurodevelopmental disorders and renal diseases. ³

Polyunsaturated fatty acids containing a double bond at the third carbon atom from the end of the carbon chain make up Omega 3. The carboxylic acid end that is regarded as the "start" of the chain, so "alpha," and the methyl end that is regarded as the "tail" of the chain, hence "omega," are the two ends of fatty acids. Omega-3 has two mechanisms for improving fetal health: First, during gestation and lactation, maternal and docosahexaenoic acid supplements normalize IUGR-induced alterations in adipose deposit and expression of visceral peroxisome proliferator activated receptor (PPAR). Second, maternal docosahexaenoic acid supplements raise serum adiponectin and also adiponectin and adiponectin receptor expression in adipose tissue. New research shows that maternal docosahexaenoic acid supplements normalize adipose malfunction and enhance adiponectin-induced enhancements in metabolic functioning in IUGR. ⁴

We can diagnose with two dimensional (2 D) ultrasound and choose the best for management by Doppler ultrasound. Three dimensional (3D) ultrasound also used for anomaly scan. In our study we used 2 D ultrasound to diagnose IUGR and for follow up the EFW. ⁵ We also used Doppler to follow up the blood flow in the umbilical and uterine arteries. ⁶ Following diagnosis of IUGR, evaluation of the fetal wellbeing is the next step in its management which includes: fetal movement, Non stress test (NST), biophysical profile (BPP) and Doppler indices. ⁷

Researchers mentioned many drugs which can be used in IUGR treatment as acetyl salicylic acid (ASA), heparin, sildenafil and others. Other researchers used vitamins and minerals as omega 3 fatty acid, zinc, magnesium, folic acid, iron, vit A and vit B. ⁸

Our study is the first RCT, to our knowledge, using the combination of omega-3 fatty acid and aspirin in the management of IUGR.

PATIENTS AND METHODS

The research compared the effects of low dosage aspirin and low molecular weight heparin and low dosage aspirin and low molecular weight heparin plus omega-3 on asymmetrical IUGR fetuses in a registered, single-center, open-randomized, parallel treatment clinical trial. Patient recruitment was performed at Obstetrics and Gynecology Department Al- Hussein University hospital & Obstetrics and Gynecology Department Bolak Eldakror General Hospital in Giza, Egypt. Both treatment arms were followed up from the time or recruitment till delivery.

This is an open, parallel, randomized controlled trial that has been clinically registered and included 100 women who were pregnant (28–32 weeks) with IUGR at the Obstetrics and Gynecology Department of Al-Hussein University Hospital and the Obstetrics and Gynecology Department of Bolak Eldakror General Hospital in Giza, Egypt. They have been randomly assigned to one of two groups: aspirin and low molecular weight heparin or aspirin and low molecular weight heparin plus omega 3. Doppler blood flow variations in the uterine and umbilical arteries, birth weight, timing and manner of birth, and neonatal intensive care unit (NICU) admissions were among the outcomes. The paired and unpaired t-tests have been utilized to analyze the outcome factors.

Inclusion Criteria: Age: between 20 and 35 years old, pregnant between 28 and 32 weeks, singleton gestation, asymmetrical IUGR, and normal uterine and umbilical Doppler indicators at the recruitment time.

Exclusion Criteria: Women with hypertension, multiple gestations, early membrane rupture, abnormal Doppler indices in the shape of Doppler blood flow indices > 2 standard deviation, absent diastolic flow, and finally, reversed flow, congenital fetal deformity, gestation accompanied by antepartum bleeding, and marked reduction in the volume of amniotic fluid.

Primary Outcome Measures: Estimated fetal weight (gm).

Secondary Outcome Measures:  Changes in Doppler blood flow indicators in both arteries of the uterus. The changes in Doppler blood flow indices in umbilical artery.  Weight of the fetus at the time of birth (gm). The total number of newborns admitted to the NICU.

Statistical analysis: 

To code, process, and analyze the obtained data, IBM SPSS (Statistical Package for Social Sciences) version 22 for Windows® was used (IBM SPSS Inc, Chicago, IL, USA).The Shapiro-Walk test has been performed to determine if the data has a normal distribution. Frequencies and relative percentages have been employed to represent qualitative data. To compare two or more groups of qualitative data, employ the Chi square test (χ2). The mean ± SD (standard deviation) has been employed to express quantitative data. An independent samples t-test has been performed to compare two independent groups of normally distributed data (parametric data). P values of < 0.05 have been considered significant.

RESULTS

Table 1: The study population's age and previous abortion distribution

A total of 100 patients have been chosen for the tests. The average age was 27.2 years old, the lowest age was 20 years old and the highest age was 35 years old for groups treated with Aspirin, and in the case of groups treated with Aspirin plus omega 3 fatty acid, the average age was 27.5 years old, the lowest age was 20 years old and the highest age was 35 years old. The distribution of age groups shows no any statistically significant, Previous abortion show almost the same between treated groups with no any statistically significant as shown in table (1).

Table 2: Relation between (Estimated weight) before and after with different treated groups

The Estimated weight after treatment high increase in weight for patients used aspirin + low molecular weight heparin plus omega 3 fatty acid with about 250 gm than patients treated with Aspirin, the distribution of weight groups shows no any statistically significant before treatment and shows highly statistically significant after treatment of data as shown in table (2).

Table 3: Relation between (Blood flow in umbilical arteries) before and following with different treated groups

The Blood flow in umbilical arteries following therapy show significant different in RI for patients used aspirin + low molecular weight heparin than women managed with aspirin + low molecular weight heparin plus omega 3 fatty acid, the distribution of Blood flow in umbilical arteries shows no any statistically significant after and before treatment only in case of  RI after treatment shows highly statistically significant of data as shown in table (3).

Table 4: Relation between (Blood flow in uterine arteries) before and after with different treated groups

The Blood flow in uterine arteries after treatment significant different in all parameter and S\D before treatment for patients used aspirin + low molecular weight heparin than patients managed with aspirin + low molecular weight heparin plus omega3 fatty acid, the distribution of Blood flow in uterine  arteries shows no any statistically significant before treatment in (RI and PI) in case of after treatment and S\D before treatment shows highly statistically significant of data as shown in table (4).

Table 5: Relation between aspirin + low molecular weight heparin treated group before and after treatment

The Estimated weight show significant different with increase with about 750 gm,The Blood flow in umbilical arteries show significant decrease in all parameter after treatment, The Blood flow in uterine arteries after treatment show significant decrease in PIafter treatment as shown in table (5).

Table 6: Relation between aspirin + low molecular weight heparin plus omega3 fatty acid treated group before and after treatment.

The Estimated weight show significant different with increase with about 1000 gm. The blood flow in the arteries of the umbilical shows a significant decrease in all parameters after treatment. The blood flow in the arteries of the uterine after treatment shows a significant decrease in PI after treatment as shown in table (6).