Nº 12 (2024)

Severe postpartum hemorrhage is responsible for significant maternal mortality and morbidity worldwide. The traditional use of uterotonics (oxytocin, prostaglandins) and medications for maintaining coagulation (fibrinogen and tranexamic acid) is not always effective and may not be sufficient to control life-threatening postpartum hemorrhage. Severe postpartum hemorrhage leads to an increased need for blood transfusion and the use of invasive techniques such as intrauterine balloon tamponade, compression sutures and artery ligation, which are important steps in treatment. In extreme cases, hysterectomy may be required to avoid possible maternal death. Intrauterine tamponade with chitosan-covered gauze is a novel technique in the arsenal of the obstetric team, especially when resources for surgical intervention and other invasive methods may be limited.

The modified gauze was initially developed for the management of acute bleeding in military medicine. It combines the physiological anti-hemorrhagic effect of modified chitosan with compression tamponade and is used to treat acute wound bleeding. The first description of the use of gauze with chitosan in obstetrics dates back to 2012; it showed that tamponade with chitosan-covered gauze is an effective means of controlling postpartum hemorrhage that is resistant to conventional therapy. Further research has demonstrated a reduction in the rates of hysterectomy and blood transfusion. However, this technique is not sufficiently presented in the literature and is not commonly used yet.

Conclusion: Intrauterine tamponade with chitosan-covered gauze is a novel adjunctive method in the management of severe uterine hemorrhage, especially in places where resources for advanced surgical techniques and other invasive therapies may be limited. In order to put this technique into practice, it is necessary to conduct a prospective, multicenter, randomized, placebo-controlled study to determine the effectiveness of tamponade with chitosan-covered gauze in severe obstetric hemorrhage.

Cervical intraepithelial neoplasia (CIN) is one of the most important issues in gynecology and gynecologic oncology. Despite the efficacy of excisional treatment for CIN2+ patients, there is a risk of CIN2+ recurrence and late diagnosis of cervical cancer. The risk of developing cervical cancer after excisional treatment has been shown to triple compared to the general population. CIN2+/HSIL recurrence after excisional treatment occurs in 4.8–14.4% of cases. HPV persistence, in particular high-risk HPV (HR-HPV), is one of the main predictors of CIN2+ recurrence, regardless of the type of excisional treatment. Given the significance of HR-HPV in the development of recurrence, HPV vaccination is recommended as a method of modern prevention of HSIL recurrence. The benefit of postexcision immunization with HPV vaccine for the prevention of CIN2+, regardless of the specific HR-HPV genotype, has been demonstrated in studies published since 2011. Bivalent and quadrivalent HPV vaccines given on the day of conization or within one year after surgical excision can reduce the risk of CIN2+ recurrence by 67–85% during a follow-up period of up to 6 years. Evidence suggests that HSIL is reduced in vaccinated patients following treatment, despite the time when vaccination was initiated. It is noteworthy that the incidence of CIN2+ recurrence was reduced by 90% in patients who received 9vHPV vaccine compared to those who underwent only excision.

Conclusion: HR-HPV persistence has a prognostic value for the development of CIN2+ recurrence after excisional treatment, which explains the need for HPV testing in the follow-up dynamics. Postexcision HPV vaccination proves highly effective in reducing the risk of recurrence of CIN2+ associated with HR-HPV.

Background: The most common indication for intrauterine surgery is the fetoscopic laser coagulation (FLC) of placental anastomoses in twin-twin transfusion syndrome (TTTS). TTTS is a complication of monochorionic multiple pregnancy characterized by high perinatal and neonatal morbidity and mortality caused in most cases by preterm birth. FLC has been shown to be more beneficial than amnioreduction and is therefore the current standard of care for the treatment of TTTS. Fetoscopic coagulation is characterized by a postoperative survival rate of both fetuses of almost 90% and is associated with a high incidence of premature rupture of membranes and subsequent termination of pregnancy.

Objective: To analyze the association of preoperative cervical length shortening and its correction with termination of pregnancy in women with monochorionic twins after intrauterine TTTS surgical treatment.

Materials and methods: This was a retrospective cohort study with the analysis of postoperative termination of pregnancy and preterm labor in patients with monochorionic twins complicated by TTTS. The study included 450 pregnant women with monochorionic diamniotic twins. All of them underwent FLC for TTTS at the National Medical Research Centre for Obstetrics, Gynecology and Perinatology in Moscow from January 2013 to January 2024. Group I (n=345) consisted of patients with preoperative cervical length ≥3 cm, group II (n=104) included patients with cervical length <3 cm, one patient was excluded from the study. Depending on the methods of cervical shortening correction, group II was divided into subgroups: subgroup 1 (n=53) had pessary, subgroup 2 (n=51) had cervical cerclage. FLC was performed in 440 cases, namely, in patients with I-IV stages of TTTS. Nine pregnant women received intrauterine treatment of TTTS stage V as transabdominal cordocentesis, intrauterine transfusion of erythrocyte mass to the surviving fetus with severe anemia.

Results: No statistically significant increase in the frequency of pregnancy loss was found in patients with correction of cervical shortening. Spontaneous pregnancy loss within seven days after surgery occurred in 17 (4.9%) patients of group I and in 6 (5.8%) patients of group II. The median term of delivery was 31.8 and 32 weeks in the study groups (p=0.281 and p=0.330, respectively). In the group of patients with cervical shortening, premature rupture of membranes was statistically significantly more frequent (p<0.05), regardless of the correction method.

Conclusion: No correlation between cervical length shortening, methods of correction and adverse pregnancy outcomes was found in our study.

Background: Current obstetric and gynecological practice is characterized by increased caesarean section (CS) rates and CS-related prenatal and perinatal complications. The uterine scar is a potential risk factor for preterm birth, uterine rupture at the site of previous SC scar, preterm placental abruption, increased risk of placental insufficiency and other placenta-associated complications.

Objective: Given the fact that vasoactive intestinal polypeptide (VIP) plays an important role in regulation of myometrial contractility and uteroplacental blood flow, the aim of the study was to investigate correlation between VIP expression in the myometrium and prenatal complications in women with repeat CSs.

Materials and methods: The study was carried out in the Obstetric Emergency Hospital in Kursk. Complex medical examination of 21 women after repeat СS at 37–41 weeks of pregnancy was performed including general and obstetric anamnesis; obstetric examination; ultrasound and Doppler ultrasound; immunohistochemical staining of biopsy material of uterine tissues, using polyclonal antibodies that recognize VIP; pathomorphological examination of the placenta; analysis of сomplete blood count and calculation of the Garkavi index.

Results: Negative correlation was found between VIP expression in the myometrium and the concentration of leukocytes (p=0.012), and positive correlation was found between VIP expression in the myometrium and the percentage of lymphocytes and the Garkavi index (p=0.031). In women with low expression of VIP, decreased placental mass (p = 0.0009), abnormal placental function, calcium deposits, foci of fibrosis and pseudo-infarction that manifested placental insufficiency, were found.

Conclusion: Low expression of VIP in the myometrium is associated with pelvic inflammatory disease, increased concentration of leukocytes, reduced level of lymphocytes and high rate of placental insufficiency, possibly due to immunological disorders associated with VIP deficiency. High expression of VIP in the myometrium is associated with preeclampsia and is considered to be a compensatory mechanism that can improve uterine and placental blood flows.

Background: Modifications of infertility treatment protocols in assisted reproductive technology (ART) programs based on the clinical and laboratory history of couples still have limitations in predicting their effectiveness. The search for minimally invasive markers of gamete quality and markers of the effectiveness of ART treatment is a relevant area at this stage of development of reproductive medicine.

Objective: To create a model for predicting pregnancy on the basis of the lipid profile of blood plasma and follicular fluid in patients undergoing ART treatment by means of liquid chromatography and mass spectrometry.

Materials and methods: The present study analyzed the clinical and anamnestic characteristics, as well as the lipid profile, of couples undergoing infertility treatment with standard ovarian stimulation in the ART department. Follicular fluid and blood plasma sampling followed by cryopreservation was performed on the day of puncture. The lipid composition of biological fluids was studied using liquid chromatography with tandem mass spectrometry. The lipid profile of the samples underwent analysis to develop OPLS-DA models.

Results: The study revealed statistically significant differences in the composition of follicular fluid and blood plasma depending on the outcome of the treatment in patients who had assisted reproduction. ROC curve analysis of the developed models showed that the model based on plasma lipid composition was more effective than the model based on follicular fluid (AUC=0.97, AUC=0.91, respectively).

Conclusion: The data of the present study are consistent with the results of world studies and confirm the potential of using the lipid composition of follicular fluid and blood plasma as markers of the effectiveness of ART programs.

Background: Ovarian reserve denotes the functional potential of the ovaries, which determines the ability of the ovaries for development of healthy follicles and eggs and the adequate response to ovarian stimulation. Mature cystic teratomas account for 15–20% of all ovarian tumors. These ovarian neoplasms require timely surgical treatment, as a rule, laparoscopic surgery with organ-sparing approach, that allows to preserve reproductive function in patients.

Objective: To assess the ovarian reserve in patients of reproductive age, who have mature cystic teratomas of the ovaries before and after surgical treatment.

Materials and methods: The retrospective analysis of 267 medical histories of patients, who were admitted to the Gynecological Department of the Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Ministry of Health of Russia, with diagnosis of ovarian teratomas from 2016 to 2022. All patients underwent routine medical examination according to the standard algorithm – clinical and laboratory examination, the CA-125 and anti-Müllerian hormone (AMH) blood tests, pelvic ultrasound, and when necessary, MRI of the pelvis before and after surgery. Laparoscopic surgery was performed with maximum preservation of healthy ovarian tissue.

Results: The mean age of patients was 35.0 (6,5) years (aged 18–45 years). The age of most patients – 114/267 (43%) was 32–38 years; 19/267 (7%) were aged 18–23 years; 67/267 (25%) were aged 24–31 years, 32/267 (12%) were aged 39–42 years and 35/267(13%) were aged 43 years and over. In 259/267 (97%) of women, neoplasms were unilateral. Bilateral teratomas were in 8/267 cases (3%). The size of mature cystic teratomas ranged from 1.0 to 17.0 cm. The average antral follicle count (AFC) before surgical treatment was 4.0 (2.4) follicles; AMH level was 2.6 (2.0) ng/mL. AMH levels (р<0.001) and AFC (р<0.001) reduced 3 months after surgery. The average AMH level was 1.7 (1.5) ng/mL, and AFC was 3.0 (1.8).

Conclusion: Standard methods of surgical hemostasis are not always applicable in patients with low ovarian reserve. For this reason, it is necessary to continue searching for new methods that can minimize ovarian tissue damage with purpose of preservation of the ovarian reserve to realize reproductive function.

Dysmenorrhea is the most common pathology among adolescent girls, affecting between 41.7% and 95%, depending on the diagnostic criteria and calculation method used. The multicomponent clinical manifestations, significant impact on quality of life, and potential modifiability of this condition make it not only a medical issue, but also a socially important problem.

Objective: To investigate the prevalence of dysmenorrhea among adolescent girls aged 15–19 years, as well as its symptoms, menstrual function characteristics, and impact on behavioral characteristics, physical activity, and quality of life, depending on the severity of the pain syndrome.

Materials and methods: A cross-sectional study was conducted at outpatient healthcare facilities in Arkhangelsk by surveying 585 healthy teenage girls aged 15–19 years who met the inclusion criteria, followed by a comparative statistical analysis.

Results: The prevalence of dysmenorrhea in our study was 97%. Clinical parameters of menstrual function were comparable between girls with painless and painful menstruation, suggesting that menstrual cycle characteristics alone are insufficient to fully assess dysmenorrhea. More than half of the teenage girls (52.9%) rated the severity of the pain as moderate, while approximately a quarter (24.9%) rated it as severe. Severe forms of dysmenorrhea were characterized by more widespread localization of pain. Dysmenorrhea included a wide range of “non-gynecological” symptoms, the frequency and severity of which correlated with the intensity of pain. It also had a significant negative impact on various aspects of life for the vast majority (up to 79.7%) of adolescent girls, including decreased academic performance, difficulties with homework, absenteeism, concentration problems, and limited social and physical activity. These findings are consistent with data from similar studies, and emphasize the importance of an integrated diagnostic approach for this condition.

Conclusion: The wide prevalence of dysmenorrhea and the lack of other symptoms in standard gynecological evaluations can normalize the condition and hinder a realistic assessment, potentially worsening both the medical and social prognosis. Given the specificity of the condition and the subjectivity of its clinical manifestations, careful development of objective tools for assessing the severity of dysmenorrhea is essential.

The early diagnosis of ovarian cancer (OC) represents an important step in reducing the number of fatal outcomes associated with the disease. Timely treatment initiation, minimizing the risk of recurrence and side effects of therapy, largely depend on early diagnosis.

Objective: To create stable panels of blood metabolites for differentiating healthy patients, patients with early-stage high-grade OC from other ovarian tumors.

Materials and methods. A search for markers for clustering of blood samples obtained from patients with verified stage I–II high-grade OC (n=10) and other proliferative processes (cystadenoma (n=30), endometrioid cyst (n=56), teratoma (n=21), borderline tumor (n=28), low-grade OC (n=16), stage III–IV high-grade (n=49)) and control volunteers (n=19) was performed. The study was carried out at the V.I. Kulakov National Medical Research Centre for Obstetrics, Gynecology and Perinatology, Moscow, Russia. The data were analyzed using recursive variable removal from the support vector machine and other statistical tools. There was a search for markers of malignant neoplasms (MNPs), followed by the analysis of their involvement in metabolic pathways. Models based on neural networks were built.

Results: The panels of metabolite-markers of early stages of MNPs were identified. The overlap of the obtained panels with metabolic pathway databases was studied. Artificial neural network models were developed to differentiate blood samples from I–II stage OC from controls with sensitivity and specificity of 90% and 89%, and from I–II stage OC from other ovarian neoplasms with sensitivity and specificity of 80% and 71%, respectively.

Conclusion: The introduction of post-genomic research has the potential to increase the diagnostic value of the methods used to detect ovarian MNPs at an earlier stage and also to expand the available data on the processes of carcinogenesis in the ovaries.

Objective: To develop and validate a radiomic model for predicting tumor response to neoadjuvant chemotherapy (NACT) in patients with locally advanced cervical cancer (LACC) based on MR imaging.

Materials and methods: A total of 182 patients aged 27 to 49 years with disease stages IB3-IIB and IIIC1 (two patients with metastatic pelvic lymph node involvement) according to FIGO 2018 were retrospectively enrolled in the study. The patients underwent treatment at the Academician Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow from 2018 to 2023. Radiomic parameters were extracted from T2-weighted (T2-WI) and diffusion-weighted (DWI) MR images. The most statistically significant characteristics were selected using LASSO (Least Absolute Shrinkage and Selection Operator) linear regression. The construction of the prediction model was based on a combination of radiomic signs and clinical data. In order to assess the prognostic effectiveness and clinical benefit of the developed model, ROC and decision curve analysis were used.

Results: Two models for predicting response to NACT were developed in the study. The first model included isolated radiomic signs and demonstrated a sensitivity of 79.6% in the main and 85.7% in the test group, specificity 80.6% and 72.1%, respectively. AUC was 0.90 in the main group and 0.83 in the validation group. In order to improve the quality of the model, clinical data (maximum linear size and degree of tumor differentiation, age of the patients, presence of metastatic lymphatic nodes) were included in the nomogram in addition to radiomic parameters. Radiomic nomogram showed sensitivity of 87.8% and 71.4%; specificity of 88.8% and 97.7% in the main and test groups, respectively. AUC was 0.96 and 0.94.

Conclusion: The constructed radiomic model is effective in predicting the therapeutic response of NACT in cervical cancer.

The article examines the patient’s informed consent for medical intervention as one of the fundamental legal principles of modern health care. The issues of providing information and obtaining patient’s informed consent for medical intervention in the routine practice of obstetrician-gynecologists are discussed. However, the proper level of information and consent for medical interventions is not always achieved and as a result, disagreements arise between patients and medical professionals, sometimes leading to the initiation of legal proceedings. Current legislation does not provide uniform requirements for the amount and format of information that an obstetrician-gynecologist must provide to a patient when performing a medical intervention. The development and adoption of universal standard forms of informed consent for medical interventions appear to be a necessary solution to this problem.

Conclusion: The development of the standard form can balance the rights of citizens to be informed when seeking medical assistance and protect doctors legally from patient claims by providing comprehensive and intelligible information. This is particularly important given that doctors may be held legally in case of violation of the informed consent rule. It should be noted that the acknowledgment of the potential risks associated with substandard medical care, as outlined in the informed consent for medical intervention, does not absolve the physician of legal responsibility.

Objective: To evaluate the efficacy and safety of Gynestril, 50 mg tablet, in patients with symptomatic uterine fibroids in routine clinical practice.

Materials and methods: This was an open, multicenter, non-interventional, prospective study conducted on the basis of seven Russian clinical centers between 2022 and 2023 in order to investigate the therapeutic efficacy and safety of Gynestril in patients with symptomatic uterine fibroids in routine clinical practice (GYNNEO). All patients (n=234) were administered the drug orally, in the form of a single tablet, once a day on days 1-3 of the menstrual cycle for a period of three months (one course of treatment). The efficacy and safety of the treatment were evaluated during the patients’ visits to the centers: before the drug was prescribed, immediately after completing the treatment with its course for three months and three months after completing the treatment. Efficacy was assessed by changes in the volume and largest linear size of the dominant myomatous node and nodes 2 and 3, which were considered to be the second and third nodes in diameter after the dominant node (provided that their initial diameter was less than 1.5 cm), uterine volume, number of visualized nodes, endometrial thickness, resistance index (RI) and blood flow velocity in the nodes, hemoglobin level, dynamics of symptom severity according to the 5-point Likert scale, etc. The incidence and characteristics of adverse and serious events were considered in the safety assessment.

Results: According to the ultrasound data, the volume of the dominant myomatous node decreased by 33% after three months of therapy with Gynestril and by 59.5% after three months of follow-up compared to baseline (pre-treatment) level. A number of other efficacy endpoints also showed positive trends during the study. They included decreases in volume of nodes 2 and 3, uterine volume, maximum linear size of the nodes, increased RI, and decreased blood flow velocity in the nodes. The severity of the symptoms associated with the disease (pain, dyspareunia, and symptoms of compression) was found to decrease with the complete elimination of moderate and severe symptoms after three months of therapy. Half of the patients had amenorrhea after the treatment and it persisted in 101/234 (43%) patients for three months after completing the treatment with Gynestril. During the study, there were 26/226 (11%) adverse events related to treatment.

Conclusion: The study demonstrates that treatment with Gynestril results in a statistically significant decrease in the volume of myomatous nodes after three months of therapy (immediately after the course) and this effect persists for three months following the completion of the course of therapy. Therapy with Gynestril controls and reduces the severity of symptoms of the disease and the amount of menstrual blood loss. The drug is generally well tolerated by patients.

The article presents a comprehensive analysis of the scientific literature on antimicrobial therapy for pelvic inflammatory diseases (PID). This is a literature review of the data obtained from the world sources in PubMed (the National Library of Medicine), Cochrane Library, Medline, and scientific citation databases (Scopus, Web of Science) for the period from 2005 to 2024.

Sexually transmitted infections are the primary cause of PID, but recent publications point to anaerobic microorganisms as a significant etiologic factor. PID represents a significant clinical and public health issue due to its potential to cause infertility. Broad-spectrum antibiotics are the principal drugs used in the treatment of PID. Antibacterial therapy regimens for PID follow certain principles and are aimed at eliminating the main pathogens, namely Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium. The polymicrobial nature of PID is also taken into account in the current recommendations for its treatment. One antibacterial drug that meets all the principles of the prescribed therapy and is included in almost all treatment regimens for PID is doxycycline. The novel form of the well-known and widely used antibiotic, Doxycycline EXPRESS, is the bioequivalent of the original drug, doxycycline monohydrate, in the form of dispersible tablets.

Conclusion: Currently, antibiotic resistance in the treatment of women with PID remains a complex medical problem. Doxycycline has an advantage in antimicrobial activity against intracellular pathogens including Chlamydia trachomatis and Mycoplasma genitalium. Doxycycline monohydrate demonstrates improved tolerability and eliminates the development of a number of side effects associated with tetracycline-type drugs. Due to the rapid release and even distribution of the active ingredient in the blood when taking the dispersible tablet (Doxycycline EXPRESS), higher concentrations are achieved in the area of the infectious lesion that help to overcome antibiotic resistance.

The issue of female intimate hygiene is a delicate matter that is frequently neglected in the communication between patients and primary care physicians. From a pragmatic perspective, there is an extensive range of feminine hygiene products available that women can use as part of their daily hygiene routine. However, there is a lack of research and recommendations related to the care of the female genitalia. Consequently, the present review concentrates on the issue of female hygiene, as it has been the subject of comparatively little research.

This article considers the role and place of proper intimate hygiene in the prevention of vulvovaginitis and bacterial vaginosis in women. The authors analyze the basic principles and rules of intimate hygiene that help maintain vaginal health and prevent the development of these diseases.

The relevance of the issue is due to the high prevalence of vulvovaginitis and bacterial vaginosis among women of different age groups. The authors also consider factors that contribute to vulvovaginitis and bacterial vaginosis, such as improper use of hygiene products, wearing synthetic underwear, frequent spaying, etc.

The vaginal microflora has a unique balanced environment during the reproductive period of a healthy woman’s life. This environment may change under the influence of external factors, but it returns to normal due to the mechanism of self-purification. The acid-base balance of the vaginal environment varies between 3.8 and 4.5. It can vary during the menstrual cycle, during pregnancy, and it depends on the sexual activity of the woman.

During the reproductive years, the vaginal microbiota of healthy women is characterized by the presence of various microorganisms, including aerobic and anaerobic, Gram-positive and Gram-negative bacteria. Lactobacillus spp. and Corynebacterium spp. predominate over other bacteria such as Streptococcus spp., Bacteroides spp., Staphylococcus spp. and Peptostreptococcus spp. The bacteria of the Lactobacillus spp. and Corynebacterium spp. produce lactic and acetic acid from glycogen, maintaining an acidic environment (low pH) in the vagina. This results in colonization resistance and inhibition of the multiplication of pathogenic flora in the vagina. If colonization resistance is compromised, opportunistic bacteria can cause vulvovaginitis.

The article presents the findings of the analytical study of several clinical cases on the treatment of bacterial vaginosis and vulvovaginal candidiasis and modification of intimate hygiene with the use of the Saforelle product for intimate hygiene.

Conclusion: The results showed that the use of a comprehensive approach, including antibacterial therapy and the Saforelle product for intimate hygiene, contributes to the rapid and effective elimination of symptoms of bacterial vaginosis and vulvovaginal candidiasis.