No 1 (2024)

Placenta accreta spectrum refers to a form of abnormal placentation and its severity depends on the depth of trophoblast invasion. This abnormality leads to a partial or complete delay in the separation of the placenta in the third stage of labor. The incidence of placental attachment disorders has increased by more than 9 times over the past 20 years. The etiological factors of the abnormality include placenta previa, the presence of postoperative uterine scar, the history of intrauterine interventions, pelvic inflammatory diseases, etc. Placenta previa and uterine scar after cesarean section (CS) are the most common causes of placenta accreta; moreover, the risk of placenta accreta after one CS increases by 7 times, and it increases by 56 times after two or more CS.

Currently, the main theory on the pathogenesis of placenta accreta consists in an impaired decidualization of the endometrium, which leads to uncontrolled invasion of the trophoblast. It is the decidua basalis that regulates proper invasion of the trophoblast by producing pro- and anti-invasive factors. This review presents the evolution of placenta accreta classifications. The main methods of antenatal diagnosis of placenta accreta are ultrasound assessment and magnetic resonance imaging, but none of them has 100% sensitivity and specificity; therefore, laboratory studies are currently conducted to search for biomarkers associated with the depth of trophoblast invasion.

Conclusion: The tactics of managing patients with placenta accreta depends on the depth of invasion, the amount of blood loss and the experience of surgeons, as well as the woman’s desire to preserve her fertility. There are conservative or organ-preserving methods of surgical treatment and non-conservative ones which include hysterectomy. The conservative methods include leaving the placenta in situ, one-stage surgical management, and the Triple-P procedure. The traditional technique involving CS followed by hysterectomy is characterized by a high maternal morbidity due to the development of intra- and postoperative complications.

Antenatal expression refers to the expression of colostrum before the onset of labor. Colostrum is a valuable concentrate of various substances which have a huge impact on the child’s health. The objective of antenatal colostrum expression is to obtain a safe alternative to formula milk in the case of indications for complementary feeding of the baby in the early neonatal period. Hormonal changes that occur in the body of a pregnant woman make it possible to receive colostrum even before childbirth. The composition of colostrum expressed before childbirth has its own characteristics that reflect its energy and immune value. Antenatal expression accelerates the transition to the second phase of lactogenesis, reduces postpartum breast engorgement, helps to avoid formula milk feeding, stabilizes glucose levels in the blood plasma of children who are at risk of hypoglycemia, and also it supports exclusive breastfeeding up to 6 months after birth. The issue of safety for the pregnant woman and fetus during antenatal expression is an important aspect. Different studies have shown that there are no risks for the mother and the fetus as well.

Conclusion: It is impossible to overestimate the importance of breastfeeding. However, the practical aspects and benefits of antenatal expression have not been completely described so far; there are no approved schemes for the beginning, duration and frequency of antenatal expression, and there is no approved list of contraindications to it. There are no articles in the Russian Federation on the practical use of antenatal expression. Therefore, this issue requires a more detailed study.

Uterine fibroids are the most common benign tumors in women. However, despite the high incidence of uterine fibroids among reproductive-aged women, its negative impact on a woman’s quality of life, and health care costs for the treatment of patients with uterine tumors, there is currently no unified understanding of the etiopathogenesis of this disease. The modern data on the causes and mechanisms of uterine fibroids development are considered in the article. Uterine fibroids have a complex, multifactorial nature. Genetic, epigenetic factors, dysregulation of key signaling pathways involved in cell proliferation, apoptosis, extracellular matrix proliferation, as well as reactions to steroid hormones play an important role in the development and growth of myoma nodes.

Conclusion: Modern views on the etiopathogenesis of uterine fibroids indicate that this disease has a complex, multifactorial nature. The development of this disease involves genetic and epigenetic mechanisms, reactions to steroid hormones, dysregulation of key signaling pathways, etc. However, in spite of significant progress in understanding of uterine fibroids pathophysiology, today there are still more questions than answers.

Objective: This study aimed to analyze the surgical approaches and effectiveness of various methods for managing and preventing bleeding in patients with placenta accreta spectrum disorders in the Russian Federation (RF).

Materials and methods: This retrospective multicenter study analyzed clinical and anamnestic data as well as surgical delivery outcomes of 2297 patients with placenta accreta spectrum who were treated in tertiary-level hospitals over the past 6 years. Data were collected from 33 regions of the Russian Federation, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Ministry of Health of Russia and the Mother and Child Group of Companies.

Results: From 2017 to 2023, 2297 patients with placenta accreta spectrum were operated on by multidisciplinary teams of doctors in 33 regions of the Russian Federation. The mean gestational age at delivery was 35.3 (3.3) weeks. Organ-removing surgery was performed in 342 (14.9%) patients, including one surgical delivery at 18 weeks of gestation due to missed miscarriage. Abdominal access techniques included lower midline laparotomy (LML), which was performed in 1954 (85.1%) patients, and transverse suprapubic incision (TSI), which was performed in 343 (14.9%) patients. A fundal uterine incision was used in 1327 (57.7%) patients. Lower uterine segment incision and corporal cesarean sections were performed in 685 (29.9 %) and 284 (12.4%) patients, respectively. The methods used to prevent and stop bleeding included complex compression hemostasis in 1196 (52.1%) patients, temporary balloon occlusion of the common iliac arteries in 280 (12.2%) patients, and other methods in 589 (25.6%) patients.

Conclusion: This pilot multicenter study analyzed the surgical approaches for managing placenta accreta spectrum in various regions of the Russian Federation. The study found that three main methods were used to reduce blood flow in the uterine blood supply system: complex compression hemostasis, ballooning of vessels (internal or common iliac arteries, and aorta), and other methods (ligation of vessels, installation of a vaginal module, and application of compression sutures). Further multicenter prospective studies are necessary to evaluate the factors influencing the development of early and long-term complications and feasibility of subsequent reproductive function.

In this article, we report a unique case of simultaneous occurrence of trisomy X and incontinentia pigmenti (IP) in a prematurely born girl with extremely low birth weight, a scenario that has not been documented in literature worldwide.

Understanding fetal growth restriction (FGR) is of paramount importance, as it is a major cause of stillbirth, neonatal morbidity, and mortality. Recent studies have reported the efficacy of noninvasive prenatal screening (NIPS) for fetal aneuploidies through maternal blood sampling as a valuable tool in the management of high-risk pregnancies. This method enables the detection of major fetal aneuploidies, including numerical abnormalities in the sex chromosomes.

In our clinical observation, based on the results of early combined screening, the patient was identified as at high risk for preeclampsia and FGR, both of which, despite preventive measures, occurred at the end of the second trimester of pregnancy. From the first days of life, the newborn girl developed characteristic skin lesions associated

with IP, inherited in an X-linked manner. Subsequent chromosomal analysis revealed abnormal 47,ХХХ karyotype in the child.

Conclusion: This clinical observation demonstrates the effectiveness of contemporary ante- and postnatal diagnostic methods for identifying rare combined genetic pathologies associated with FGR.

Objective: To evaluate the efficacy of antenatal prevention of neonatal respiratory distress syndrome (RDS) at 34/0–36/6 weeks of gestation at preterm delivery in patients with abnormally invasive placenta and to determine the optimal timing and frequency of maternal antenatal corticosteroid (AC) administration in pregnant women with abnormally invasive placenta.

Materials and methods: This study included 226 late preterm neonates born to mothers with abnormally invasive placenta. The patients were divided into Group 1 (study group, n=80), which comprised children whose mothers received a full course of RDS prevention within 7 days before delivery, and Group 2 (control group, n=146), which consisted of children born to mothers who received antenatal RDS prevention for > 7 days before delivery. Furthermore, the children were divided into four subgroups: subgroup 1A (n=42) included children whose mothers received a single course of RDS prevention no more than seven days before delivery; subgroup 1B (n=35) included children whose mothers received two courses of RDS prevention, one of which was no more than seven days before delivery. Subgroups 2A (n=97) and 2B (n=45) represented children whose mothers had received RDS prevention more than seven days before delivery once and twice, respectively. The analyzed parameters included gestational age (GA) of the newborns, birth weight and length, sex, Apgar score at 1 and 5 minutes, frequency and duration of neonatal respiratory therapy (non-invasive respiratory support, invasive mechanical ventilation (IMV), high-frequency oscillatory ventilation (HFOV), maximum required mean airway pressure, frequency and duration of supplemental oxygen delivery, frequency of surfactant therapy and neonatal hypoglycemia, length of stay in the NICU, and total length of infant hospitalization.

Results: Infants born to mothers with abnormally invasive placentas who were given RDS prevention seven days before birth were 1.6 times less likely to require intubation and invasive respiratory therapy (RR [95%CI] 0.62 [0.39; 0.96]), 1.8 times less likely to require HFOV (RR [95%CI] 0.57 [0.35;0.93]), and 1.7 times less likely to require supplemental oxygen (RR [95%CI] 0.59 [0.39;0.87]). The required oxygen concentration in this group was significantly lower, and there was a significantly shorter total duration of respiratory support and a shorter length of stay in the NICU. When comparing cases with single and double courses of RDS prevention, considering the time of administration in relation to labor, no significant benefits of increasing the frequency of courses were found.

Conclusion: Antenatal RDS prevention during the latest 7 days before delivery is effective in reducing the severity of respiratory disorders in late preterm infants of 34/0-36/6 gestational age born to mothers with abnormally invasive placenta. The course of RDS prevention in the earlier stages of pregnancy is not decisive, and in patients with abnormally invasive placenta, an additional course is required during the week before the planned delivery.

Objective: Determination of expression levels of molecular genetic markers to improve the diagnosis of ovarian endometriosis (OE) and define prognostic criteria for recurrence and possible malignant transformation.

Materials and methods: Expression levels of lncRNAs in 30 and 25 cases of ovarian endometriotic cysts and ovarian adenocarcinomas, respectively, as well as in 25 cases in the control group, were studied using molecular genetic testing.

Results: Persistent increase in lncRNA MALAT1 expression level was found with the disease progression, and consistent increase and reduction of Linc-ROR expression level in the control group and in the group of patients with adenocarcinoma. For differential diagnosis of normal condition and OE, OE and adenocarcinoma, ROC curves for lncRNA expression levels were constructed, and important rule was derived to determine the histological status of the surgical material.

Conclusion: According to the results of expression levels of lncRNA markers MALAT1 and Linc-ROR in the groups of patients with endometriosis, adenocarcinoma and in the control group, the assessment of their potential possibility for predicting these conditions was suggested. Further targeted research in this area is necessary to develop new prognostic markers for endometriosis-associated ovarian cancer and search for additional therapeutic targets.

Objective: To evaluate the efficacy and safety of Alive Collagen in postmenopausal women with genitourinary menopausal syndrome (GMS).

Materials and methods: This was a single-center, uncontrolled before-after study. Twenty-five women aged 50–68 years (mean age is 59.44±5.39 years) diagnosed with postmenopausal atrophic vaginitis were examined at the Family Clinic from April to June 2023. The efficacy of taking Alive Collagen at a dosage of 15 g/day for 12 weeks was evaluated. The analysis was carried out using a questionnaire with calculation of the Female Sexual Function Index (FSFI) and visual analog scale developed by R. Nappi.

Results: The postmenopausal period lasted 7±2.40 years, the duration of GMS symptoms ranged from 2 to 10 years (mean period is 5.44±2.63 years). In 12 weeks after taking Alive Collagen, the women noticed a decrease in the symptoms of GMS, namely, itching, burning, and vaginal dryness; a decrease in the severity of dyspareunia was also revealed. FSFI increased from 15.36±4.33 before therapy to 21.58±3.94 after collagen supplementation for 12 weeks. No adverse side effects were detected.

Conclusion: The patients suffering from various symptoms of GMS and having contraindications to menopausal hormone therapy can have a possible alternative to improve their quality of life by taking Alive Collagen supplement at a dose of 15 g/day 30 minutes before meals for 12 weeks.

Abnormal uterine bleeding (AUB) is one of the most common symptoms in gynecological practice. AUB is nearly always a condition that reduces the quality of life and requires medical care.

Objective: To highlight modern approaches to the diagnosis and treatment of AUB, to develop an algorithm for the management of patients from various groups.

Materials and methods: The databases and information resources, namely eLibrary and PubMed, have been searched for publications, systematic reviews and meta-analyses using the words “abnormal uterine bleeding” and “profuse menstrual bleeding” for the period 2017–2023.

Results: Approaches to diagnosis and treatment directly depend on the nature of AUB, the cause of bleeding and its effect on hemodynamics. In case of acute AUB, the main task is to stop bleeding and stabilize the patient’s condition. In chronic bleeding, surgery is performed in addition to medical treatment. According to the Cochrane review and network meta-analysis, levonorgestrel-releasing IUD, antifibrinolytics, and progestogens in prolonged cyclic mode can be used as first-line therapy that effectively reduces blood loss. When prescribing hormonal therapy, it is recommended to explain the importance of following the instructions and consistency of taking the medications during the entire period of treatment. The effectiveness of progestogen therapy, which can contribute to the restoration of the physiological menstrual cycle, is of particular interest. Among the progestogens, dydrogesterone takes a special place as it is possible to personalize the treatment of patients due to high selectivity and good safety profile of dydrogesterone.

Conclusion: Progestogens remain some of the main medications for the treatment and prevention of AUB. When consulting patients, it is necessary to clarify their reproductive plans or the need for contraception as this information can help to personalize treatment. In prolonged cyclic mode, dydrogesterone can help normalize the menstrual cycle, including in patients planning pregnancy.

Relevance: Ovarian stimulation and hormone therapy in assisted reproductive technology (ART) programs are accompanied by procoagulant changes in the hemostasis system. The changes in patients with thrombophilia may be more severe and lead to thrombosis, as well as possibly reduce the frequency of embryo implantation and have a negative impact on the course of pregnancy, resulting in spontaneous miscarriages, preeclampsia, and fetal growth retardation.

Case report: A 40-year-old patient with a bad obstetric history was admitted to the Department of Assisted Reproductive Technologies in the Treatment of Infertility of the National Medical Research Centre for Obstetrics, Gynecology and Perinatology, Moscow. Her history included 5 miscarriages in early pregnancy; she also experienced a combined form of thrombophilia: heterozygous factor V Leiden mutation, antiphospholipid syndrome, and JAK2-positive essential thrombocythemia. After providing preconception care, ART treatment, and combined therapy for hemostatic disorders in the pregnancy planning stage and during pregnancy, it was possible to deliver a live full-term baby.

Conclusion: Timely and complete examination, administration of proper complex therapy to women with recurrent miscarriage and thrombophilia may increase the effectiveness of ART treatment and improve reproductive outcomes. Thrombophilia as a risk factor for thromboembolic complications in ART treatment, as well as reproductive losses, is a subject of further study and discussion due to the ambiguous data on the safety and effectiveness of modern therapeutic approaches to this issue.

25 апреля 2023 г. состоялся экспертный совет, посвященный оптимизации методов поддержки лютеиновой фазы в программах вспомогательных репродуктивных технологий (ВРТ) в условиях импортозамещения.