Obstetrics and Gynecology

Peer-review scientific medical journal

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“Akusherstvo i Ginekologiya” (Obstetrics and Gynecology) is included in the list of peer-reviewed scientific journals recommended for publication of principal scientific results of dissertations competing for scientific degrees of Candidate of Science and Doctor of Science.

“Akusherstvo i Ginekologiya” (Obstetrics and Gynecology) member of COPE (JM13971), WAME, is included in the list of peer-reviewed scientific journals recommended for publication of principal scientific results of dissertations competing for scientific degrees of Candidate of Science and Doctor of Science.

The journal is presented in the following international databases: Russian Science Citation Index; Google Scholar; WorldCat; Scopus; EBSCO; Emerging Sources Citation Index WoS; Russian Citation Science Index WoS; Abstract of Bulgarian Scientific Medical Literature; Experta Medica; Ulrich’s International Periodicals Directory


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No 4 (2023)

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Reviews

Cardiovascular consequences of great obstetrical syndromes
Akhmadeyev N.R., Fatkullin I.F., Fatkullina L.S.
Abstract

The great obstetrical syndromes (GOS) are a term that summarizes major obstetric complications from a pathogenesis perspective. It includes preterm labor, pre-labor rupture of membranes, pre-eclampsia, fetus small for gestational age (low birth weight), and other conditions. The pathogenesis of GOS includes immune and vascular elements, which, among others, determine its effects on the cardiovascular system. Preeclampsia is the most studied complication of pregnancy in terms of the development of cardiovascular complications, including arterial hypertension, impaired cardiac function, risk of cardiovascular events, and mortality. Fetal growth restriction and preterm birth are not accompanied by the development of critical organ dysfunction; however, the common pathogenesis determines the risk of future cardiovascular events. The cardiovascular risk in patients with obstetric complications is elevated even before pregnancy; therefore, the development of GOS may trigger the development of complications. Despite the existence of some evidence base on the consequences of GOS, patient follow-up is not organized, and a regulatory framework has not been developed. The Russian Federation has no regulatory framework for the inclusion of such patients in outpatient medical supervision. Early diagnosis and appropriate rehabilitation can minimize the risk of long-term sequelae.

Conclusion: The data presented in this review indicate a high incidence of cardiovascular events following obstetric complications. The development of a methodology, forms of implementation, and recommendations for rehabilitation based on interdisciplinary interaction and continuity can become a new direction for scientific research and organizational solutions to this important problem.

Obstetrics and Gynecology. 2023;(4):5-11
pages 5-11 views
Prospects of treating infertility in women over 40 using assisted reproductive technology with autologous oocytes
Khachatryan L.V., Makarova N.P., Kalinin A.P., Smolnikova V.Y.
Abstract

Today, childbearing in women of late reproductive age is not only a pressing clinical problem but also a social one. In couples in this age group, the pathogenesis of infertility is extremely complex, representing a combination of several factors that often require tailored treatment for individual patients.

This review presents data on the role of genetic factors and oxidative stress signaling pathways in the pathogenetic mechanisms underlying ovarian aging. The authors summarized various controlled ovarian stimulation protocols and approaches for the optimization of assisted reproductive technology in patients of late reproductive age. This article provides information about experimental studies that will expand our understanding of the prospects for treating infertility in patients of this age category.

Conclusion: The study of pathogenetic mechanisms of ovarian aging is one of the key directions for the optimization of infertility treatment in women of late reproductive age using ART with autologous oocytes and is of scientific interest for the future development of innovative therapeutic approaches for this cohort of patients.

Obstetrics and Gynecology. 2023;(4):12-19
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Genetic determinants of adenomyosis
Malysheva O.V., Yarmolinskaya M.I.
Abstract

Adenomyosis is defined as the presence of endometrial-like tissue within the myometrium. It is a multifactorial disease with possible genetic predisposition. This article presents the results of the studies carried out within the framework of three approaches: association analysis, gene expression study and somatic mutation study. According to the classical concepts, the genetic predisposition to multifactorial diseases (including adenomyosis) depends on the presence of a certain set of polymorphic gene variants in a person. Such investigations are very few in adenomyosis; most of the studies are devoted to the analysis of gene variants whose products are involved in the synthesis and metabolism of estrogens, neoangiogenesis and remodeling of the extracellular matrix. Moreover, epigenetic mechanisms of adenomyosis can cause long-term changes in the expression of individual genes or entire blocks of genes due to DNA methylation, changes in the structure of chromatin, and non-coding RNAs. The article highlights a new area of research devoted to the study of the role of somatic mutations in adenomyosis. In comparison with other tissues, the endometrial glands of healthy women carry a particularly large number of somatic mutations, while stromal cells mostly remain intact. Somatic mutations in epithelial cells are also found in the ectopic endometrium of patients with adenomyosis and extragenital endometriosis. The spectra of somatic mutations detected in the ectopic endometrium in extragenital endometriosis and adenomyosis have their own characteristics and they are different in these two diseases.

Conclusion: The above genetic aspects of pathogenic mechanisms of adenomyosis indicate that this disease has a polyetiological origin. The presence of unfavorable alleles that impair the functioning of gene networks associated with the pathogenesis of the disease, long-term changes in gene expression followed by disorders in tissue homeostasis in target organs, and appearance of somatic mutations in the cells of the glands of the ectopic and eutopic endometrium are the factors that together can lead to the development of this pathology.

Obstetrics and Gynecology. 2023;(4):20-27
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The role of dynamic magnetic resonance imaging in the diagnosis of pelvic organ prolapse
Gilyadova A.V., Ishchenko A.A., Reshetov I.V., Ishchenko A.I., Apolikhina I.A., Saidova A.S., Puchkova E.N., Petrovichev V.S., Mershina E.A., Novruzalieva M.F.
Abstract

Dynamic magnetic resonance imaging (dMRI) of the pelvic floor is a valuable tool for diagnosing pelvic organ prolapse. It provides a comprehensive assessment of all anatomical and functional characteristics of the pelvic walls and pelvic organs. Despite the advantages of dMRI, there remains much debate regarding its diagnostic accuracy and correlation with clinical findings. This review presents an analysis of the literature on the capabilities and limitations of dMRI in the diagnosis of pelvic organ prolapse. The etiology, pathogenesis, clinical presentation, and diagnosis of this pathology were reviewed. Dynamic pelvic floor MRI provides a comprehensive assessment of the anatomical and functional characteristics of the pelvis, while being free of ionizing radiation. This method makes it possible to assess the evacuatory function of the visualized structures in dynamics. Simultaneous visualization of all three parts of the pelvic floor using dMRI enables the assessment of multicompartmental disorders, allowing surgical correction in approximately 67% of the cases. Image interpretation is discussed, beginning with viewing three orthogonal T2-weighted sequences acquired at rest to assess baseline anatomy and pelvic organ positioning. Dynamic images were then studied to assess the position of the pelvic organs in relation to the pelvic bones during different phases of straining and gel evacuation from the intestine and vagina.

Conclusion: dMRI is characterized by a high resolution and reproducibility. It allows the identification of the pathology of organs and supporting structures of all pelvic areas. dMRI is characterized by a high correlation between acquired findings and clinical data, which is important for patients with a complicated medical history or ambiguous clinical findings, as well as for multicompartment disorders.

Obstetrics and Gynecology. 2023;(4):28-39
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Impact of hormone therapy on the overall and relapse-free survival of patients receiving treatment for ovarian cancer
Babaeva N.А., Yureneva S.V., Aleshikova O.I., Yakushevskaya O.V., Ashrafyan L.A.
Abstract

Objective: To analyze the literature data on the possibility of using different variants of hormone therapy in patients who previously underwent treatment for ovarian malignancies, oncofertility and the effect of hormone therapy on the overall and relapse-free survival of patients with different morphological variants of ovarian malignancies. The review includes the data from foreign and Russian publications in PubMed on this issue over the past ten years. This was an analysis of the possibilities and contraindications to the use of hormone therapy, as well as menopausal hormone therapy in women with different morphological variants of ovarian malignancies. It was concluded that hormone therapy can be used in patients with a history of ovarian cancer, non-epithelial malignant tumors and borderline ovarian tumors.

Conclusion: The correlation between the use of hormone therapy and the risk of recurrence of neoplasms in women treated for ovarian cancer has been clearly established only for granulocellular ovarian tumors and serous tumors of low malignant potential. In case of other morphological variants of ovarian malignancies, menopausal hormone therapy should be prescribed very carefully. Before making a decision on the use of hormone therapy for each patient, it is necessary to conduct a thorough examination and consult an interdisciplinary group of specialists in order to individualize the hormone therapy plan based on the assessment of the potential risks and benefits of the treatment.

Obstetrics and Gynecology. 2023;(4):40-48
pages 40-48 views

Original Articles

Retrospective analysis of telemedicine consultations conducted in pregnant and puerperal women with novel coronavirus infection COVID-19
Shabanova N.E., Pyregov A.V., Nikolaeva A.V., Bembeeva B.O., Skorobogaty A.V., Chubarov V.V., Denisov P.A., Klimov V.A., Pekarev O.G., Polibin R.V., Priputnevich T.V.
Abstract

Objective: To evaluate the incidence of prescribing antibacterial agents (ABA) and the results of microbiological examination in pregnant and puerperal women with COVID-19 by analyzing the electronic records of telemedicine consultations (TMC) in patients from different regions of the Russian Federation.

Materials and methods: A retrospective analysis was done on 2500 pregnant and puerperal women from the database of patients with COVID-19 who received TMC between January and July 2021. The analysis included age, gestational age, medical history, chest computed tomography (chest CT), respiratory support, laboratory test results, frequency of microbiological studies, and ABA administration.

Results: This analysis revealed that 78.8%, 49.6%, and 55.8% of pregnant and puerperal COVID-19 patients were prescribed antibiotics, antifungals, and glucocorticoids, respectively. In microbiological testing, Candida albicans was the most frequently isolated microorganism (30.4 %). The most common gram-positive microorganisms were Staphylococcus spp. (18.8%), and Streptococcus spp. (15.9%), and Acinetobacter spp. among the gram-negative (14,5%). Acinetobacter baumannii accounted for 10.1% of the isolates. Klebsiella pneumoniae accounted for 11.6% of the cases.

Conclusion: The retrospective analysis showed that although microbiological testing was important, it was performed in only 4% of the cases. ABA were used in 78.8% of the cases, and broad-spectrum and reserve drugs were the most common choice. Antifungals were used in 49.6% of patients. Prescribing occurred immediately upon admission to the hospital without confirmation of a bacterial or fungal infection.

Obstetrics and Gynecology. 2023;(4):50-57
pages 50-57 views
Novel coronavirus infection in the third trimester of pregnancy: perinatal and maternal outcomes
Malgina G.B., Dyakova M.M., Bychkova S.V., Grishkina A.A., Melkozerova O.A., Bashmakova N.V., Pepelyaeva N.A., Olkov S.S.
Abstract

Objective: To investigate the characteristic features of the course of pregnancy, labor, and perinatal outcomes in women who had novel coronavirus disease 2019 (COVID-19) in the third trimester of pregnancy and gave birth after COVID-19.

Materials and methods: The study group included 313 patients divided into subgroups 1 (n=90), 2 (n=154), and 3 (n=69) who had COVID-19 at 28–32, 32.1–36.6 and ≥37 weeks of gestation, respectively. The comparison group included 216 women who gave birth before the COVID-19 pandemic (2019). Histological examination of the placenta was performed in the study (n=87) and comparison (n=20) groups.

Results: COVID-19 at 28–32 weeks increases the risk of fetal growth restriction (relative risk (RR)=5.6; 95% CI 2.4; 13.0; p<0.001), preterm birth (RR=2.7; 95% CI 1.2; 5.8; p=0.01), placental abruption (RR=5.2; 95% CI 1.6; 16.4; p=0.002), fetal distress (RR=4.9; 95% CI 1.7; 13.6; p=0.001), and emergency caesarean section (RR=4.0; 95% CI 1.8; 9.1; p=0.001). The newborns had significantly smaller chest circumferences and lower Apgar scores. The placentas showed marked signs of maternal and fetal vascular malperfusion. COVID-19 at 32.1–36.6 weeks gestation increased the risk of uteroplacental circulation disorders (UPCD) (RR=4.3; 95% CI 1.1; 16.1; p=0.02), preterm birth (RR=2.8; 95% CI 1.4; 5.6; p<0.001), fetal distress (RR=3.9; 95% CI 1.5; 10.3; p=0.003), and emergency caesarean section (RR=3.4; 95% CI 1.6; 7.3, p=0.001). Newborns had a significantly smaller chest circumference and lower Apgar scores. COVID-19 after 37 weeks increased the risk of UPCD (RR=8.0; 95% CI 2.0; 31.9, p=0.001). Vascular abnormalities were most pronounced in the placentas of patients in group 1.

Conclusion: COVID-19 in the early and middle third trimesters is associated with the most adverse perinatal outcomes.

Obstetrics and Gynecology. 2023;(4):58-66
pages 58-66 views
Impact of menopausal hormone therapy on immune system parameters
Averyanova M.V., Yureneva S.V., Kiseleva V.V., Yakushevskaya O.V., Iskusnykh M.E., Elchaninov A.V., Fatkhudinov T.K., Vishnyakova P.A.
Abstract

The decline in sex hormone levels with age is known to affect the functioning of the immune system in both men and women. Immunological aging is a consequence of age-related changes in the function of immune cells and the composition of their subpopulations. Taking menopausal hormone therapy has been shown to neutralize these changes. The route of estrogen administration in postmenopausal women may play a crucial role in these processes.

Objective: To investigate the effect of combined menopausal hormone therapy (MHT), including transdermal estradiol gel combined with micronized intravaginal progesterone, on blood immune parameters.

Materials and methods: The subpopulation composition of leukocytes was assessed in 23 peri- and postmenopausal women aged 44–57 years who were referred to the Gynecological Endocrinology Department of the V.I. Kulakov NMRC for OG&P, Ministry of Health of Russia. The treatment duration was 3 months. Clinical and laboratory examinations were performed before therapy and three months after MHT.

Results: After 3 months of MHT, the patients were found to have a significant reduction in the severity of vasomotor (by 4 times), physical (by 3 times), and psychoemotional and sexual symptoms (by 2 times) (p<0.05). The use of MHT significantly reduced the incidence of sleep disturbances by a factor of 1.6, from 82.6 to 52.2% (p=0.020), muscle and joint pain by a factor of 1.4, from 73.9 to 52.2% (p=0.026), hot flashes by a factor of 2.7, from 82.6 to 30.4% (p<0.001), and night sweats by a factor of 1.8, from 73.9 to 39.1% (p=0.012). The effect of MHT on immune system parameters was manifested by a significant increase in the percentage of T-helper cells (CD45+CD3+CD4+) and changes in the expression of CD163, CD206, and CX3CR1 markers in subpopulations of classical, intermediate, and non-classical blood monocytes.

Conclusion: Our findings suggest that combined MHT including transdermal estradiol in combination with intravaginal micronized progesterone influences patients' blood immune parameters. It affects both lymphocytes and monocytes, with changes in the monocyte phenotype in different subpopulations that are likely to contribute to the immunopotentiating properties of MHT.

Obstetrics and Gynecology. 2023;(4):68-77
pages 68-77 views
Comparing the effectiveness of ultrasound and mri in assessing cesarean uterine scar defects
Sukhareva T.A., Martynov S.A., Adamyan L.V., Kulabukhova E.A., Uchevatkina P.V., Letunovskaya A.B., Boykova Y.V.
Abstract

Objective: To improve the effectiveness of uterine cesarean scar defect assessment using ultrasonography and magnetic resonance imaging (MRI).

Materials and methods: This comparative study included 61 patients with uterine scar dehiscence after cesarean section (CS), who were interested in having another pregnancy. All patients underwent expert pelvic ultrasonography (eUS) and MRI at V.I. Kulakov NMRC for OG&P; 30 patients underwent echo-hysterosalpingography (eHSG). Each examination (eUS and MRI) was performed by two independent specialists. Scar parameters were measured using the standardized Delphi technique, irrespective of the examination method used. Measurements of uterine scar parameters obtained using eUS, MRI, and eHSG in the same patients were compared, and the consistency of measurements between specialists was assessed.

Results: A comparative analysis showed a statistically significant difference in the minimum scar thickness (mST) between eUS [2.19(0.77) mm] and MRI [1.93 (0.7) mm] (p<0.05). A comparative analysis of MRI and eHSG data also revealed statistically significant differences in niche depth measurements of 3.29 (1.48) and 7.01 (2.97) mm, respectively (p<0.05); mST was significantly lower when measured by eHSG than MRI, 1.5 (0.4) mm and 1.81 (0.6) mm, respectively (p=0.03). There was no statistically significant difference between the eUS and MRI measurements taken by two independent specialists. However, according to the Bland–Altman analysis, MRI and eHSG showed less variability than eUS, indicating higher reproducibility.

Conclusion: If a uterine scar is detected on ultrasound, MRI or eHSG is recommended to confirm the diagnosis and decide whether surgical treatment is necessary, as these methods are highly reproducible and reduce the risk of diagnostic errors. eHSG should be considered as the "gold standard" for diagnosing uterine scar defects after CS, due to its advantages of filling the uterine cavity with contrast and the possibility of detecting perforating scar defects.

Obstetrics and Gynecology. 2023;(4):78-86
pages 78-86 views
Principles of early diagnosis of endometriosis based on the assessment of comorbidity and clinical manifestations
Pronina V.A., Dumanovskaya M.R., Chernukha G.E.
Abstract

Objective: To analyze the clinical characteristics and concomitant diseases in patients with endometriosis.

Materials and methods: The cross-sectional study was conducted at the National Medical Research Center for Obstetrics, Gynecology and Perinatology in Moscow, Russia in the period from 2021 to 2022. The main group included 110 patients (mean age 29 (25; 36) years) with extragenital endometriosis confirmed by ultrasound and MRI assessment; the control group consisted of 110 women who were comparable in age to the patients of the main group (mean age 27 (26; 32) years) without echographic signs of endometriosis. The patients of both study groups were interviewed and surveyed for a comprehensive analysis of clinical and anamnestic data; the presence of comorbid conditions was determined on the basis of laboratory and instrumental studies which were carried out in accordance with the clinical recommendations of the Ministry of Health of the Russian Federation.

Results: Not only the severity of dysmenorrhea, dyspareunia and chronic pelvic pain, assessed by the visual analog scale (VAS), are significant, but also the combination of the symptoms is of importance, as it demonstrates a two-fold increase in the risk of endometriosis. It was found that lower body mass index (BMI) is characteristic of the patients of the main group (p=0.001). Every fifth patient with endometriosis had a body weight deficit (BMI<18.5 kg/m2), every second patient had a BMI<21 kg/m2. The patients with endometriosis, in comparison with the patients of the control group, had a higher incidence of acne (39.5 and 13.6%), fibrocystic disease (29.5 and 12%), human papillomavirus (41.7% and 22.7%), endometrial polyps (20.9 and 5.5%), uterine fibroids (23.6 and 8.2%, respectively). The presence of recurrent functional cysts (OR 2.11, 95% CI 1.66–2.69) and ovarian apoplexy (OR 1.99, 95% CI 1.62–2.45) had the greatest diagnostic significance. The combination of several comorbid conditions greatly increased the likelihood of endometriosis.

Conclusion: At the initial stage of the examination of a patient with suspected endometriosis, it is advisable to listen to the patient’s complaints and also to conduct a cumulative assessment of their severity counting the points according to the VAS score. Thus, precise anamnesis and clinical examination can be considered effective and available methods of identifying women at risk for the development of endometriosis.

Obstetrics and Gynecology. 2023;(4):87-96
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Clinical and molecular aspects of autologous embryo-cumulus cells co-culture in ifv programs
Asfarova G.R., Smolnikova V.Y., Makarova N.P., Bobrov M.Y., Eldarov C.M., Zingerenko B.V., Kalinina E.A.
Abstract

Objective: To assess the effectiveness of autologous embryo-cumulus cells co-culture in assisted reproductive technology (ART) programs for infertility treatment, as well as to analyze metabolic profile of culture media after culturing cumulus cells.

Materials and methods: 127 married couples who underwent infertility treatment using ART were tested. Embryological indicators and treatment effectiveness were assessed. The prospective study of metabolome in cumulus cells and culture media after cumulus cells co-culture was performed by high performance liquid chromatography and mass spectrometry using 90 samples of culture media after culturing cumulus cells, 90 samples of cumulus cells, as well as 10 control samples of culture media without cumulus cells.

Results: The prospective study of the influence of embryo-cumulus cells co-culture on the morphology of blastocysts and possibility of their implantation versus standard-based method using conventional culture media was performed. The study showed that autologous embryo-cumulus cells co-culture reduces the chances of implantation in women of late reproductive age by 1.2 times, and is not advisable for young patients. At the same time, co-culture significantly increases the number of high-quality blastocysts suitable for cryopreservation in the general cohort. This results in a greater likelihood of having a child with the use of a single ovarian stimulation protocol. Assessment of metabolism of cumulus cells showed that in culture media, co-cultivation increases the concentration of some amino acids (leucine, valine, serine) and amino-acid containing dipeptides. The obtained data suggest that cumulus cells are involved in lipid metabolism, initiating fatty acid oxidation, which is essential for normal embryonic development.

Conclusion: The results obtained in this study suggest that it is reasonable to refuse embryo-cumulus cells co-culture in women aged over 36 years, who had multiple IVF failures in anamnesis. Autologous embryo-cumulus cells co-culture significantly increases the number of high-quality embryos in young women.

Obstetrics and Gynecology. 2023;(4):97-110
pages 97-110 views
Excess adipose tissue and chronic subclinical inflammation in patients with polycystic ovary syndrome
Kirillova E.D., Krechetova L.V., Vtorushina V.V., Ivanets T.Y., Chernukha G.E.
Abstract

Objective: To analyze the serum levels of proinflammatory markers in patients with polycystic ovary syndrome (PCOS) and assess their association with body composition and metabolic parameters.

Materials and methods: This single-center cross-sectional study included 148 women with PCOS (mean age 25.1 (5.5) years). Of these, 118 had PCOS (mean age 25.1 (5.5) years), 14 were overweight and obese without PCOS (mean age 26.1 (7.4) years) and 16 were somatically healthy women (mean age 25.3 (5.1) years). All participants underwent comprehensive clinical, laboratory, and instrumental examination.

Results: Patients with PCOS had significantly higher levels of IL-6, TNF-α, and CRP than those in the control group; however, there were no statistically significant differences in the levels of IL-1, leptin, and adiponectin. PCOS patients had signs of chronic subclinical inflammation in the form of elevated IL-6 and CRP levels in 39% and 37% of the cases, respectively. Hidden obesity was diagnosed in 65.0% of PCOS patients with a normal BMI, manifesting as excess visceral adipose tissue in 46.2% of cases. This group was seven times more likely to have elevated CRP levels and nearly four times more likely to be insulin resistant than patients with normal total body fat percentage.

Conclusion: It is appropriate to recommend adipose tissue densitometry and assessment of levels of proinflammatory markers to identify risk groups for pregnancy complications, cardiovascular disease, and type 2 diabetes mellitus in patients with PCOS with normal BMI and for further correction of modifiable risk factors by lifestyle changes, drug therapy, and pre-pregnancy care.

Obstetrics and Gynecology. 2023;(4):111-119
pages 111-119 views

Experience Exchange

Personnel management in a medical organization: modern tools and technologies
Avdeeva O.V., Minakova E.N., Goloshubov P.A., Verkhovtsev A.A., Kaverina E.V., Nikolaeva A.V.
Abstract

Relevance: A loyal, engaged and satisfied employee is more productive and influences positively the overall productivity and success of the organization.

Objective: To study the characteristics of employees that directly affect labor productivity using three evaluation indicators (loyalty, engagement and satisfaction); information technology use is taken as an example.

Materials and methods: The research process was modeled using an empirical method. During the observation, an experiment with the use of information technologies was carried out.

Results: Corporate survey with the use of information technologies allowed us to computerize and correctly evaluate 1009 respondents. The analysis of qualitative and quantitative indicators followed the survey which helped us to understand the characteristics of the personnel, their productivity, attitude and loyalty to the organization.

Conclusion: The above methodology makes it possible to evaluate personnel in the shortest possible time, change the content of questionnaires for specific goals and objectives of the organization, create a database of the most productive employees or identify negative factors, evaluate the behavior of an employee in real situations in the future. This technique helps to remove numerous routine tasks from human resources managers, make their time free for solving other issues, thereby allowing them to be closer to employees, react faster to changes in the team, analyze data and manage human resources more successfully.

Obstetrics and Gynecology. 2023;(4):120-131
pages 120-131 views
Course and outcomes of pregnancy in patients with chronic endometritis and impaired reproductive function after receiving complex treatment with drug Superlymph: randomized control trial in parallel groups “Tulip”
Dikke G.B., Sukhanov A.A., Ostromensky V.V., Kukarskaya I.I.
Abstract

The prevalence of chronic endometritis (CE) in the general population varies from 14.1 to 24.4%. CE is potentially associated with poor reproductive outcomes.

Objective: To increase the effectiveness of complex treatment in the preconception period of patients with CE and impaired reproductive function using a complex of exogenous natural antimicrobial peptides and cytokines and to evaluate the effect of the treatment on the pregnancy rate, course and outcomes.

Materials and methods: This was an open prospective randomized controlled trial in parallel groups which included 2252 patients with CE and infertility. The patients were divided into two groups (1126 people in each): antibacterial (AB) therapy and a complex of exogenous natural antimicrobial peptides and cytokines (Superlymph) were administered in group I, and only AB therapy was used in group II. Two subgroups were identified: the patients received progestogens as part of complex therapy in groups IA and IIA, and they did not receive progestogens in groups IB and IIB.

Results: The overall pregnancy rate within 6 months after treatment was 44.9% versus 26.1% in groups I and II, respectively, p=0.0001. The use of Superlymph and AB increased the chances of pregnancy by 1.5 times (RR=1.58, 95% CI 1.40–1.78) compared with AB therapy, regardless of progesterone intake. After taking Superlymph/progesterone/AB, pregnancy rate increased almost 3-fold in patients with infertility for five years or more, compared with those who received only progesterone/AB, 19.6 vs. 11.2%, p<0.001 (RR=2.91, 95% CI 1.55–5.47). Spontaneous pregnancy was observed in 33.7% of patients in group I, and in 17.4% in group II, p=0.0001 (RR=1.93, 95% CI 1.66–2.25); after IVF it was in 11.2% and 8.5%, p=0.04 (RR=1.31, 95% CI 1.02–1.69), respectively. The live birth rate was 37.3 and 21.1%, respectively, p<0.001 (RR=1.77, 95% CI 1.55–2.03). The Superlymph/progesterone/AB complex reduced the risk of early miscarriage by 6.3 times compared with AB alone (RR=0.16, 95% CI 0.08–0.33, p<0.001) and 4.5 times compared with progesterone and AB (RR=0.22, 95% CI 0.11–0.44, p<0.001). None of the treatment options had a statistically significant effect on late miscarriage rate. The overall incidence of preterm birth in groups I and II was 11.3 vs. 16.7%, respectively, p=0.04; the risk of having a premature baby was decreased almost twice (RR=0.56, 95% CI 0.38–0.81). The Superlymph/progesterone/AB complex reduced the risk of preterm birth by 2.5 times compared with AB alone (RR=0.39, 95% CI 0.23–0.66, p<0.001) and also reduced the risk of preeclampsia (RR=0.51, 95% CI 0.28–0.93, p=0.004), hypoxia (RR=0.49, 95% CI 0.25–0.96, p=0.05) and fetal growth retardation (RR=0.43, 95% CI 0.21–0.88, p=0.03) by two times.

Conclusion: The treatment of CE with Superlymph at a dose of 25 IU for 20 days simultaneously with antibiotics and progesterone in the second phase of the cycle in the preconception period has high clinical efficacy and increases the chances of pregnancy with improved outcomes; it decreases the risk of preeclampsia, hypoxia and fetal growth retardation, spontaneous miscarriages in early terms, preterm birth and it increases the frequency of live births compared with patients who received only AB therapy.

Obstetrics and Gynecology. 2023;(4):132-144
pages 132-144 views
Hysteroscopy for infertile women: experience of using anti-adhesion barriers
Kozachenko I.F., Adamyan L.V.
Abstract

Objective: To evaluate the effectiveness of the anti-adhesion intrauterine barrier Antiadhesin during hysteroscopic surgery in infertile patients.

Materials and methods: We examined and performed surgical treatment of 331 patients with infertility and intrauterine pathology, including patients with submucous uterine fibroids (n=100), with intrauterine septum (n=152) and intrauterine synechiae (n=79). Intrauterine barrier Antiadhesin was used in 114 cases after surgical interventions. Ultrasound assessment of the uterine cavity was carried out for the presence or absence of intrauterine synechiae after three months, and the patients were allowed to plan pregnancy. The patients included in the study were treated for infertility using the IVF/ICSI protocol with controlled ovarian stimulation and transfer of fresh embryos into the uterine cavity or cryoprotocol. The reproductive function was evaluated within 12 months after the operation.

Results: Antiadhesin was introduced in 27 cases after hysteroresectoscopy (type II myoma, with 4 or more nodes, the size of the nodes exceeding 3 cm), in 54 cases after dissection of the intrauterine septum, and in 33 cases after dissection of intrauterine synechiae of II–III degree. There were no complications after the use of anti-adhesive gel. The control ultrasound assessment which was performed three months after the operation revealed the presence of synechiae in 5 (18.5%) out of 27 patients after myomectomy, in 19 (35.2%) out of 54 patients after dissection of the intrauterine septum and in 14 (42%) out of 33 patients after dissection of intrauterine synechiae. The reproductive function restoration was evaluated within one year after the complex treatment with assisted reproductive techniques. Pregnancy was observed in 167 (50.4%) women.

Conclusion: Infertile patients especially those after ineffective IVF programs should undergo hysteroscopy during their examination, as intrauterine pathology can be timely diagnosed and eliminated, and effectiveness of infertility treatment can be improved. Currently, we have obtained the preliminary results on the safety and effectiveness of intrauterine use of the anti-adhesion barrier Antiadhesin. In order to accumulate a larger number of clinical observations and obtain data on the reproductive function restoration, it is necessary to conduct further studies.

Obstetrics and Gynecology. 2023;(4):147-152
pages 147-152 views
Conservative treatment of atypical hyperplasia and endometrial carcinoma: immunohistochemical aspects
Pashov A.I., Sivova E.N., Volkova L.V., Rachkovskaya V.V.
Abstract

Objective: To test the algorithms of conservative hormonal therapy using buserelin depot and levonorgestrel releasing intrauterine system in women with identified atypical endometrial hyperplasia and/or adenocarcinoma of the uterine body and unrealized fertility.

Materials and methods: The results of the treatment with hormonal drugs were retrospectively evaluated in 52 reproductive-aged patients diagnosed with atypical endometrial hyperplasia ICD-O code 8380/2 (n=40, 77.1%) and well-differentiated (grade 1) endometrioid adenocarcinoma of the uterine body ICD-O code 8380/3 (n=12, 22.9%). The expression of immunohistochemical markers, namely ER, PR, Ki-67, Bcl-2, and E-cadherin, was studied in endometrial samples before and after the treatment.

Results: A complete response to the treatment was noted in 100% of cases. The spontaneous pregnancy occurred in 22 cases (40.4%). The recurrence of the disease was not detected in the patients participating in the study for 15 years, the five-year survival rate was 100%. The study of immunohistochemical markers revealed differences in their expression in endometrial samples of the patients with atypical endometrial hyperplasia and endometrioid adenocarcinoma of the uterine body.

Conclusion: The complex use of gonadotropin-releasing hormone agonists (buserelin depot) with the subsequent insertion of levonorgestrel releasing intrauterine device is an effective method of treating atypical endometrial hyperplasia and stage IA well-differentiated endometrioid adenocarcinoma without invasion into the myometrium in reproductive-aged women with unrealized fertility.

Obstetrics and Gynecology. 2023;(4):155-160
pages 155-160 views
Effectiveness of early start of menopausal hormone therapy in the menopausal transition: comparative analysis of therapy
Gasparyan S.A., Chotchaeva A.M., Karpov S.M.
Abstract

Objective: To optimize preventive and therapeutic measures aimed at reducing the severity of menopausal symptoms as well as preserving cognitive function to improve the quality of life in perimenopausal women.

Materials and methods: The study included 120 women aged 40–50 years with signs of primary hypoestrogenism. There were the following study groups: group 1 included patients who received systemic menopausal hormone therapy (MHT) in the form of a combination of 1 mg of estradiol/ 10 mg of dydrogesterone orally (n=30); group 2 consisted of patients receiving a combination of 1 mg of estradiol/10 mg of dydrogesterone orally and intramuscular injections of polypeptides of the pineal gland of cattle (10 mg, lyophilizate for intravenous administration) (n=30); group 3 included those who received 17-β estradiol transdermally in the form of a 0.06% gel in combination with 52 mg of LNG-IUD (n=30); group 4 consisted of patients who did not receive treatment (n=30). The duration of the study was 12 months. Baseline indicators were evaluated using the Greene climacteric scale, Beck Depression Inventory, Montreal Cognitive Assessment test and laboratory levels of nerve growth factor followed by dynamic control of these indicators on days 180 (6 months) and 360 (12 months).

Results: The frequency and severity of vasomotor symptoms in the group 1 were 0.79±0.68 and were reduced by 88.3% for 12 months in comparison with the baseline. Group 2 showed a decrease by 76.8%. Groups 1 and 2 showed a comparable decrease in overall menopausal indicators over 12 months; the decrease in vasomotor symptoms was less severe in group 3. According to the severity of depressive symptoms, the results of the follow-up showed a decrease by 49.9% (7.80±2.01 vs. 15.57±4.27) and 65.9% (5.90±2.08 vs. 17.30±5.85) respectively, in groups 1 and 2. In group 3 the decrease was less severe and amounted to 15.3% (11.86±4.01 vs. 14.00±4.31). Improvements were noted only in groups 1 and 2 in patients receiving fixed combined MHT. Groups 1 and 2 demonstrated an improvement in rheological properties of blood. There was positive dynamics of clotting parameters in both study groups.

Conclusion: Early initiation of cyclic combined MHT (1 mg of estradiol, 10 mg of dydrogesterone) contributed to the decrease of menopausal symptoms and restored cognitive function, however, this was not observed in the group of patients receiving transdermal therapy of 17-β estradiol in the form of a gel in combination with LNG-IUD or in the absence of therapy. Moreover, there was a positive dynamics of hemostasis indicators in patients receiving MHT with dydrogesterone. The obtained data make it possible to improve preventive and therapeutic measures, to personalize therapy for perimenopausal women.

Obstetrics and Gynecology. 2023;(4):162-169
pages 162-169 views
Latent iron deficiency and iron-deficiency anemia in women with heavy menstruations
Sokolova T.M., Marinkin I.O., Makarov K.Y., Kuleshov V.M.
Abstract

Latent iron deficiency (LID) and iron-deficiency anemia (IDA) are wide spread in the female population. Heavy menstrual bleeding is considered to be the most common cause of LID and IDA in reproductive-aged women.

Objective: to present the authors’ own experience with Ferretab comp. used to treat IDA and iron-deficiency states in patients with profuse uterine bleeding.

Materials and methods: Thirty-four reproductive-aged (18- and 45-year-old) women with profuse uterine bleeding (PUB) during their menstruations were examined and treated at the Clinical Base of the Department of Obstetrics and Gynecology, Medical Consulting Center, Novosibirsk State Medical University, Ministry of Health of Russia, in 2020–2022. The patients were divided into 2 groups: Group 1 consisted of 22 female patients with mild IDA (hemoglobin was below 120 g/l and above 99 g/l); Group 2 included 12 patients with LID (the serum ferritin level was below 30 µg/l).

To treat iron deficiency, the physicians used the oral agent containing 163.56 mg of iron (II) furamate in one capsule equivalent to 50 mg of iron and 500 µg of folic acid. A treatment regimen was chosen according to the diagnosis of IDA (the daily dose was 2 capsules) and LID (the daily dose was 1 capsule). The efficiency of therapy was evaluated after 8 weeks from the time course of changes in the levels of hemoglobin and serum ferritin, as well as from the health status of the female patients, and their complaints associated with iron deficiency.

Results: The analysis of therapy results has shown an increase in the level of hemoglobin from 110 g/l to 122 g/l in Group 1 and from 124 g/l to 132 g/l in Group 2 and a rise in the level of ferritin from 12.5 µg/l to 27 µg/l in group 1 and from 21 µg/l to 32.6 µg/l in Group 2.

Conclusion: By taking into account the high incidence of iron-deficiency states in PUB, the need for consulting women by outpatient physicians is beyond question. When profuse menstrual bleeding is detected, it is advisable for the patients to have full blood count, ferritin test, and to timely use iron agents.

Obstetrics and Gynecology. 2023;(4):171-176
pages 171-176 views

Help for the Practicing Physician

Predictors of infertility
Barinova E.K., Aryutin D.G.
Abstract

Infertility is a disease characterized by the failure to establish a clinical pregnancy after 12 months of regular unprotected sexual life. Infertility tends to become another pandemic of the modern world. According to some estimates, the frequency of infertile marriages ranges 10–25% (from 48 to 180 million). Such couples face adverse consequences for physical and mental health, financial difficulties, a serious social stigma, an increased risk of domestic violence, and instability in marriage. The evaluation of the female factor infertility has been traditionally the driving force in the examination of infertility.

Although men and women are equally susceptible to infertility; however, women bear a greater social burden, especially in the societies where identity and social value are closely related to the ability to give birth to babies. The age-related decline in female fertility is of serious concern; moreover, the decision about pregnancy is frequently made at a later age. Therefore, the study of the causes of infertility development is extremely important and a review of the current studies on this topic seems relevant. This review considers the most common causes of infertility, such as ovulatory dysfunctions, male infertility, tubal diseases, lifestyle (smoking, obesity), environmental factors, abnormalities of the uterus and cervix uteri, as well as endometriosis.

Conclusion: Infertility is a multifactorial disease that requires further investigation and solution of this problem to achieve the main result – to overcome infertility. Despite advances in the modern diagnosis and treatment of infertility, the number of infertile couples is growing every year. Therefore, female patients of any age need a personalized treatment approach. It should be noted that modern trends in medicine are aimed at the prediction and prevention of diseases that can lead to menacing complications, including infertility.

Obstetrics and Gynecology. 2023;(4):178-183
pages 178-183 views

Notes from Practice

Diffuse ectopic peritoneal deciduosis
Misnik V.V., Oleneva M.A., Raksha A.P., Chernotalova N.S., Semenov Z.S., Ilyichev A.A., Lebedev I.S.
Abstract

Relevance: Ectopic deciduosis rarely presents with definite symptoms and complications, and regresses soon after delivery. However, rare cases have been reported, in which the condition may present a different clinical picture. We present a clinical case of diffuse ectopic deciduosis in a 37-year-old patient who presented with an acute abdomen with peritonitis that simulated peritoneal carcinomatosis. During the long-term follow-up, she developed right-sided ureterohydronephrosis, which led to obstruction of urine outflow.

Case report: On the second day after delivery, the patient developed a clinical picture of an acute abdomen and underwent diagnostic laparoscopy, which revealed multiple miliary lesions in the parietal and visceral peritoneum. Histological examination of the laparoscopic biomaterial showed changes consistent with diffuse ectopic decidualization.

Conclusion: Ectopic deciduosis can be masked by various pathological conditions. Our case demonstrates the importance of using histological and immunohistochemical studies to make a diagnosis and guide appropriate patient management strategy.

Obstetrics and Gynecology. 2023;(4):184-190
pages 184-190 views

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