No 8-2 (2012)

The study of the rate of preterm births and their outcomes at 22-37 weeks gestation provided an update on the diagnosis, treatment of threatened premature labor, pregnancy management in case of isthmico-cervical insuff iciency and premature amniorrhea. It was performed using the records of Moscow maternity hospitals and the Center for Family Planning and Reproduction, Moscow Healthcare Department. The short cervix uteri detected by transvaginal ultrasound was shown to be the most accurate criterion for threatened premature labor at 22-34 weeks gestation. Patients with a cervical length of below 26 mm and extended internal os are a group at risk for preterm birth. What delivery procedures should be used in case of spontaneous preterm birth, particularly at less than 28 weeks gestation, remains debated. Due to the fact that preterm birth is one of the central problems in modern obstetrics, it is reasonable to conduct multicenter trials of the prevention, diagnosis, and treatment of threatened premature delivery, by attracting leading specialists. It is necessary to prepare issues relating to the analysis of perinatal outcomes of preterm birth at 22-28 and 29-37 weeks gestation depending on the procedures of delivery, to accumulate experience in improving cesarean section techniques for preterm delivery and, among other processes, to give an objective assessment of how to extract babies in the whole fetal bladder.

The literature review discusses the contribution of the phenomenon of premature luteinization (PL) to the effectiveness of in vitro fertilization protocols using gonadotropin-releasing hormone analogues: the specific features of used terminology, the mechanism for development of PL, its influence on the values of folliculogenesis, oogenesis, embryogenesis, and endometrial receptivity, as well as measures for its prevention.

Objective. To improve the outcomes of treatment for obstetric peritonitis following cesarean delivery, by performing organ-saving treatment andpathogenetically warranted intensive therapy in the postpartum period. Subjects and methods. Twenty-two clinical cases with peritonitis underwent organ-saving surgery with metroplasty and application of secondary sutures to the uterus. Results. The authors discuss management tactics for puerperas with obstetric peritonitis developing in the presence of inconsistent uterine sutures and current criteria for the examination and treatment of these patients. They show the needfor using procalcitonin, leukocyte index of intoxication, and integral scales of organ dysfunctions in the algorithm of examination of puerperas with obstetric peritonitis. Conclusion. The current approaches to surgical treatment and starting antibacterial therapy with ultrabroad-spectrum antibiotics in combination with early intensive therapy in an intensive care unit make it possible to avoid removal of the uterus as a primary focus.

Objective. To study endometrial receptivity in infertile women with uterine myoma (UM) without endometrial pathology. Subjects and methods. Ninety-one patients, whose mean age was 33.8±4.4 years, with UM were examined. Their clinical and anamnestic features were studied and their reproductive function was evaluated. Group 1 (n=50) comprised infertile patients with UM. The group was divided into 2 subgroups: A) women with UM and primary infertility (n=32) and B) those with UM and secondary infertility (n=18). Group 2 (n=41) included fertile patients with UM who had a history of pregnancy in the presence of UM. Specimens from 26 patients were immunohistochemically investigated. Results. The study enrolled patients without endometrial pathology, as evidenced by clinical, laboratory, and histological examinations. Their endometrium corresponded to the mid-secretory phase. The number of pinopodia on the endometrial surface did not exceed 20%. Immunohistochemical study of biopsy specimens from the infertile patients with UM showed an imbalance between steroid hormone receptors in the endometrium, by increasing the level of progesterone receptors and decreasing that of estrogen receptors, and hence by disturbing the progesterone/ estrogen receptor ratio index and reducing leukemia inhibitory factor expression. Conclusion. The high progesterone receptor levels in the UM endometrium and tissue give rise to both impaired endometrial receptivity and myoma nodular growth, which may suggest that the mechanisms of pathogenesis of these diseases are common.

The problem of urinary incontinence (UI) in women has been recently more and more relevant, stress UI (SUI) being 51—77%. Conservative treatments for SUI and pharmacological agents are now ineffective while surgery may give rise serious complications. Due to the development of cell technologies and regenerative medicine, new approaches to treating SUI, which are based on the transplantation of stem/progenitor cells (SPCs) and tissue-engineering designs (TED), are being developed. Analysis of the scientific literature has demonstrated that many unsolved problems still remain in this f ield of regenerative medicine. In particular, there is no consensus of opinion on which type of cells should be chosen for transplantation, as before. The question of the mechanisms for therapeutic activity of cell transplantation in SUI remains debatable. However, this area shows just now a quite evident trend in the use of cells as carrier matrices, i.e. TEDs, rather than as suspension.

Objective. To show a relationship between autoimmune reactions against spermatozoa, their functional characteristics, and real fertility. Subjects and methods. Clinical and laboratory examination was made in 425 men from infertile couples aged 18—45 years, the fertile men, the wives of whom were 8—16 weeks pregnant, formed a control group (n=82). Their sperm was examined in accordance with the WHO requirements; computer-aided sperm analysis was used. Antisperm antibodies (ASA) were determined in the sperm by MAR test and flow cytofluorometry and in the serum by ELISA. Spontaneous and ionophore A23187-induced acrosome reactions were examined by the double fluorescence sperm staining method using fluorescin isothiocyonate-labelled P. sativum lectin and tetramethyl rodamine isothiocyanate-labelled A. hypogaea lectin. Oxidative stress was assessed by luminol-dependent chemiluminescence assay. Chromosome damage was evaluated from DNA fragmentation by the chromatin dispersion test of sperm in inert agarose gel, with visual microscopic estimation of halo formation after acid denaturation of DNA and lysis of nuclear proteins. Results. The decline in real fertility is proportional to the percentage of MAR-positive spermatozoa. Autoimmune reactions against spermatozoa are accompanied by hyperproduction of reactive oxygen species. There is a positive correlation between MAR test results and track velocity of spermatozoa, amplitude of their head oscillation, percentage of spermatozoa with a premature or none acrosome reaction, and their proportion with DNA fragmentation and its degree. Conclusion. The leading factors reducing fertility in men with ASA are sperm dysfunction: premature hyperactivation, an increased and/or none acrosome reaction, and enhanced DNA fragmentation. The pathogenesis of pathospermia in immune infertility is associated with oxidative stress.

The fact that the fetal safety of antihypertensive agents has been little studied limits their choice to treat arterial hypertension in pregnant women. In the Russian Federation, this problem is more acute than in other countries of Europe and the United States because labetalol is commercially unavailable. The results of small clinical trials that have indicated the efficacy and no negative effects of the highly selective metabolically neutral beta-blocker bisoprolol show that it is promising to further investigate its gestational safety in retrospective and prospective studies.

Objective. To establish echographic signs characteristic of different types of complicated fetal ovarian cysts and to choose the most rational management tactics for pregnant women and neonatal infants, by taking into account the found abnormality. Material and methods. Sixteen cases of ultrasound diagnosis of complicated fetal ovarian cysts revealed at 33—38 weeks gestation were examined. There was in utero torsion of an ovarian cyst in 10 cases, ovarian apoplexy in 1, a ruptured or hemorrhagic ovarian cyst in 1 and 4 cases, respectively. When fetal space-occupying lesion was found, its site and size were estimated and its internal structure was determined. Dynamic fetal ultrasound monitoring was also done to assess mass dimensional and structural changes throughout the remaining period of gestation and after birth. Results. The echographic signs of this abnormality were described. Emergency delivery at 33 weeks gestation was required in 1 case of ovarian apoplexy and intraabdominal hemorrhage; full-term births occurred in the other 15 cases. Post-birth surgery was performed in 11 (in utero torsion of an ovarian cyst) and 5 (rupture or hemorrhage of a cyst) cases — the abnormal mass spontaneously disappeared. Neonatal survival was 100%. Conclusion. Echography is a valuable technique the use of which makes it possible to establish an in utero diagnosis of a complex abnormality, such as complicatedfetal ovarian cysts, and, relying on the findings, to decide which of the most rational pregnancy management tactics and treatment options for the newborn should be chosen.

Objective. To present a clinical case of management in a pregnant woman with idiopathic pulmonary hypertension (PH) Case: Patient K. aged 31 years was transferred to the V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology from her domicile perinatal center with for new-onset PH to decide further management tactics and delivery time. Progressive edema and leg edemas were noted at 20 weeks gestation. Worse health could be caused by the fact that the woman with chronic autoimmune thyroiditis and hypothyroidism stopped taking thyroxine at 14 weeks gestation. The diagnosis was established at her local polyclinic at 29—30 weeks gestation. On admission, the patient’s condition was severe, which was induced by significant respiratory failure. The data of her examination and laboratory and instrumental studies could diagnose that she was 33—34 weeks pregnant and had fetal cephalic presentation, severe pulmonary hypertension, NYHA FC IV. The patient underwent emergency surgical delivery. In the postpartum period, she was treated with fraxiparine 0.6 ml/day, furosemide 40 mg/day under control of diuresis and blood electrolytes, and amlodipine 1.25 g b.i.d., which was then titrated up or down in 1.25 g increments every 7 days. A calcium antagonist was used without performing a vasoreactive test as right heart catherization was possible only after achieving thyroid compensation. For this, the patient was given euthyrox 200ig/day. Results. A premature baby was born with a weight of 1955g and the signs of pneumonia, jaundice, and transient hypothyroxinemia, which required special care, massive drug therapy, and long-term follow-up. The woman’s postpartum condition remained stable. On day 3 of delivery, the patient was transferred to her domicile perinatal center and recommended to continue the started treatment and to replace low-molecular-weight heparin by warfarin under control INR. She was recommended be examined by a cardiologist at the A.L. Myasnikov Research Institute of Clinical Cardiology 6-8 weeks later. Conclusion. Thus, PH is a pathological condition incompatible with pregnancy. The signs of severe cardiac and respiratory failure in HP, a high risk for death and cardiovascular and thromboembolic events, and a need for active medicinal intervention require that pregnancy should be terminated in any period. The multidisciplinary approach to pregnancy management and clinical alertness allow timely diagnosis and prevention of maternal and fetal complications.

Galactosemia is a hereditary metabolic disease, the pathogenetic treatment of which is based on dietary therapy. The early diagnosis and timely therapy of the disease determines its prognosis and course. The paper describes a case of classical galactosemia in a neonatal infant and shows that its early diagnosis and adequate choice of etiopathogenetic dietary therapy could achieve compensation for congenital galactose metabolic defect and optimize the further development of the infant.