No 5 (2013)

This paper gives the current data available in the world and Russian literature on preeclampsia, one of the severest pregnancy complications. It presents the basic concepts of its pathogenesis, the summarized data of recent Cochrane systematic reviews, the recommendations of the American College of Obstetricians and Gynecologists (2002), the Society of Obstetricians and Gynecologists of Canada (2008), the European Society of Hypertension and European Society of Cardiology (2003, 2007), and the Society of Obstetric Medicine of Australia and New Zealand (2008) on the terminology, classification, treatment, and prevention of preeclampsia, and the choice of tactics for management and delivery for patients with this condition.

The paper deals with the determination, systematization, and study of the effects of maternal magnesia therapy (MT) for preeclampsia on the newborn. Objective. To determine, systematize, and study the effects of maternal magnesia therapy (MT) for preeclampsia on the newborn. Subject and methods. Analytical studies involved a meta-analysis and systematic reviews on the problems set. Results. MT used in preeclamptic women during labor results in fetal and neonatal hypermagnesemia. Blood magnesium concentrations in preterm neonates and newborn babies with birth asphyxia are higher than those in full-term and healthy babies. Decreased muscle tone in the newborn infants may be associated with hypermagnesemia. The blood concentrations of calcium and ionized calcium are above the normal values in the neonates with hypermagnesemia, which may be due to the release of calcium from the bone tissue into the blood. The full-term neonates and fetuses from the mothers receiving MT do not differ significantly from the control group in plasma calcium levels. The high fetal and neonatal blood concentrations of magnesium (and possibly calcium) can suppress parathyroid function in the neonatal period. Obviously, the placenta has a protective function in modulating the effects of altered maternal magnesium and calcium homeostasis on the fetal and neonatal concentrations of these minerals. Even when the magnesium level is greater than the normal physiological value, the organism attempts to regulate a bioactive ionized magnesium fraction. The investigation revealed no association between the poor outcomes in the neonatal infants and the total dose of magnesium, the duration of MT, the maternal plasma level of magnesium before childbirth and its fetal plasma level. Conclusion. An earlier meta-analysis and the results of this review may argue that maternal MT for preeclampsia caused no adverse poor physiological and clinical effects on full-term healthy newborn babies. However, MT in preterm neonates, newborn babies with intrauterine growth restriction or asphyxia may have adverse physiological and clinical effects and give rise to severe complications, which calls for further investigations.

Objective. To estimate the plasma concentration of endothelin-1 and sICAM-1 in pregnant women with gestational diabetes mellitus (GDM). Subjects and methods. The study included 83 pregnant women who formed four comparison groups: 1) 25 patients with GDM on diet therapy (dGDM); 2) 25 with GDM on insulin therapy (iGDM); 3) 12 apparently healthy pregnant women without carbohydrate metabolic disturbance (a control group); 4) 21 with preeclampsia without carbohydrate metabolic disturbance (a comparison group). The diagnosis of GDM was established on the basis of a glucose tolerance test. The levels of endothelin-1 and sICAM-1 were determined using the standard test systems. Results. The highest values of endothelin-1 were found in the pregnant women with dGDM (3.36 fmol/ml (CI 3.09-3.63)), iGDM (3.82 fmol/ml (CI 3.53-4.11)) and the lowest ones were in the control group (2.54 fmol/ ml (CI 2.32-2.77)) (p<0.001). There was a positive correlation between ET-1 and glucose levels (r=0.45-0.57; p<0.05). Estimation of the level of sICAM-1 in the pregnant women from the study groups showed the highest values in those with carbohydrate metabolic disturbance and the lowest ones in those with preeclampsia. However, there were no significant intergroup differences in the levels of intercellular adhesion molecules. Conclusion. The pregnant women with GDM have higher plasma endothelin-1 levels. This level depends on the degree of diabetes compensation and takes the highest values in the patients with iGDM. In this connection, this contingent of women is at high risk for preeclampsia, HELLP syndrome, and fetal hypoxia. Timely detection of GDM, pathogenetic prevention, and therapy for preeclampsia will aid in reducing poor perinatal outcomes.

Objective. To evaluate the clinical symptoms of bowel endometriosis and to identify a group at risk for this disease. Subject and methods. Complaints, medical history, and clinical features were analyzed in 93 patients with the verified diagnosis of bowel endometriosis. Results. The clinical forms of bowel endometriosis were identif ied as follows: 1. An aggressive form. This was typical for young women aged 18 to 25 years who had not been treated for endometriosis. In this group, the disease manifested with obvious «intestinal» symptoms (cyclic rectal bleeding, impaired passage of the intestinal contents). 2. A subtle form. This was typical for patients aged 25 to 34 years with meager clinical manifestations, in whom the clinical symptoms of bowel endometriosis were found only during an accentuated survey. This patient group showed a preponderance of complaints of infertility. Patients who had complaints associated with bowel dysfunction were not of particular concern due to their minor impact on quality of life. 3. A stenotic form. This was typical for patients aged 35 to 45 years with a long disease history who had previously received combination (medical and surgical) treatment for endometriosis. The effect of treatment was transient in all the patients. The patients commonly complained of chronic constipation, had to be on a strict diet and to constantly take laxatives, and had a complete lack of defecation and flatus during menstruation. Conclusion. The bowel endometriosis risk group comprises young patients with characteristic clinical symptoms and women with a long disease history who had been previously reoperated on for endometriosis and received ineffective medical treatment. In these patients, a directed search for bowel endometriosis should be carried out using a set of current examination techniques: ultrasonography, magnetic resonance imaging, colonoscopy, and biopsy.

Objective. To evaluate the impact of intraoperative reinfusion of autoerythrocytes (IRA) on the morphological state of peripheral red blood cells in patients at myomectomy. Subject and methods. A study group consisted of 179 patients operated on for multiple myoma (myomectomy and hysterectomy). IRA was carried out using a Autotransfusion System (ATS) in 94 patients (a study group). Donor red blood cells were transfused in 85 patients (a comparative group). Blood loss averaged 1012.6±511.3 ml. In Group 1, the volume of reinfused autoerythrocytes averaged 579.3±227.4 ml. In Group 2, that of allogeneic blood averaged 598.9±198.4 ml. A control group included 20 healthy female blood donors. The morphological parameters of peripheral red blood cells were examined using intravital blood cell computed phasometry (CPM). Microelectrophoresis (MEP) was used to evaluate the electrokinetic properties of red blood cells. Results. Preoperatively, the peripheral blood of patients with uterine myoma showed increases in the mean diameter, perimeter, and area of circulating red blood cells with a reduction in the mean phasic cell height. Analysis of the morphological structure of red blood cells from healthy donors indicated that the content of diskocytes, echinocytes, and spherocytes amounted to 73.5, 16.1, and 10.4 %, respectively. In the uterine myoma group, the ratio of the morphological cell types was different: 63.9, 19.5, and 16.6%, respectively. In this group, the ratio of the number of all transformed red blood cells to the absolute number of diskocytes (transformation index) was much higher (0.56) than that in the healthy donors (0.36), which quantitatively characterizes poikylocytosis. Analysis of the electrokinetic properties of red blood cells revealed that the patients had preoperatively the mean count of treatment-suitable cells of as many as 165.87±72.65; the mean fluctuation amplitude for red blood cells was 5.62±1.78 μm; the proportion of immobile red blood cells was 29.21±7.92%. Postoperatively, the patients undergoing IRA were found to have better electrokinetic parameters of peripheral red blood cells: the treatment-suitable cells increased and accounted for 331.25±98.0; the mean fluctuation amplitude for red blood cells was 6.12±3.46 μm; the proportion of immobile red blood cells was 36.23±6.92%. In Group 2 patients, the parameters were significantly lower: the treatment-suitable cells increased and amounted to 229.33±12.4; the mean fluctuation amplitude for red blood cells was only 4.66±0.99 μm; the proportion of immobile red blood cells was 46.62±8.81%. Conclusion. The findings suggest that IRA is effective and should be used at myomectomy, which ensures rapid stabilization in the morphometric and electrokinetic properties of circulating red blood cells unlike in those obtained at transfusion of donor red blood cells. Transfusion of autoerythrocytes contributes to the recovery of blood rheological properties in patients.

Objective. To improve and optimize the postpartum period in puerperas with soft tissue injuries in the generative passage via a differentiated approach, by taking into account the infection risk and by using the current highly effective means for suture care. Subject and methods. Birth history data over five years (2008-2012) from the records of three Volgograd maternity hospitals were retrospectively analyzed to specify the incidence of birth injury in the population. The long-term consequences of birth injuries were studied and their impact on the reproductive health and quality of life was evaluated in the women, by analyzing the birth histories of patients admitted to hospital to be surgically treated for cicatricial deformity of the perineum and varying descent of the vaginal wall, as well as for genital prolapses requiring surgical treatment. Clinical investigations were designed as an open-label randomized controlled trial. The puerperas were randomized into two groups: 1) 48 with soft tissues injuries in the parturient canal who had received conventional suture care (a comparison group); 2) 73 patients had been managed by the improved procedure (a study group). The degree of risk for parturient infectious complications and the pattern of suture healing were assessed in all the purperas. Results. The retrospective analysis of the birth history data has shown that every three (31%) births are accompanied by rupture of the vaginal walls or vulvar lips; the rupture rates for the cervix uteri and peritoneum were 8.7 and 9%, respectively; however, with consideration for episeo- and perineotomies, peritoneal injury was observed in every three (36.4%) parturients. The other component of this problem is the peculiarities of tissue healing. The postpartum period and puerperal ulcer healing patterns were analyzed in the puerparas of the compared groups during the clinical investigation. All the puerparas receiving depantol suppositories in combination with vaginal treatment with hexicon showed primary intention healing; all the puerperas of this group and their newborn infants were discharged on days 6-7 postpartum. Conclusion. The retrospective analysis of maternity hospital birth history data over 5 years suggest that the rate of birth trauma remains high and has no declining tendency, which has an extremely negative impact on the reproductive potential and quality of life in the women. This problem must be solved in two directions: on the one hand, a reduction in the rate of soft tissue injuries in the generative passage should be achieved and, on the other, postpartum management optimization is required in puerperas with these injuries; in this connection it is proposed to identify three degrees of infection risk and to implement remedial measures differentially, by applying the current highly effective means for suture care. The clinical investigation of depantol used to manage puerperas with soft tissue injuries in the generative passage suggests its higher efficacy due to rapid regeneration than conventional suture care methods. The use of depantol is promising in managing puerperas with soft tissue injuries in the postpartum units of the maternity hospitals.

Objective. To ascertain via what mechanisms for thyroid dysfunction the impact of iodine deficiency on the occurrence and progression of benign tumors of the cervix uteri (CU) is shown. Subjects and methods. 100 fertile-aged women, including 50 women who lived in an iodine-deficient area (Transcarpathian Region) and had benign CU diseases (Group 1 (a study group)) and 50 who resided in a non-iodine-deficient area (Poltava Region) and had no CU pathology (Group 2 (a comparison group)), were examined. Clinical, microbiological, hormonal, and instrumental studies and determination of daily urine iodine excretion the cerium-arsenite method were made. Results. The correlation between ioduria and the serum levels of sex, gonadotropic, and thyroid hormones was analyzed in women with background cervical diseases, who lived in the region with natural iodine deficiency. The specific features of reproductive disorders were shown depending on the nosological entity of background CU diseases. Conclusion. The most marked iodine deficiency was found in CU polyps (100%) and cylindrical epithelial ectopia (93%). In grades I and II goiter, thyroid functional impairments (38%) were presented with subclinical and clinical hypothyroidism, respectively. Diminished pituitary-ovarian function was detected in women with background diseases of CU, which appeared as relative hyperestrogenism and hypoprogesteronemia worsening depending on the degree of iodine deficiency.

Chronic pelvic pain syndrome is one of the urgent problems of modern gynecology and therapy for the pain syndrome should be based on its pathogenetic features, which in full measure holds true for gynecological practice. According to the published European guidelines, the management of chronic pelvic pain should be approached in a comprehensive manner; moreover, the basic stage of its therapy is the use of nonsteroidal anti-inflammatory drugs (NSAIDs) just on the first days of pain. NSAID is an effective agent for the pathogenetic therapy of acute or chronic pain and cyclooxygenase-2 inhibitors are novel promising therapeutic targets. Analysis of trials calls for their incorporation into a package of measures taken to treat patients with pelvic pain symptoms.

The paper describes the world’s seventh case of spontaneous hysterorrhexis during full-term pregnancy in a nulliparous patient who had no risk factors for uterine rupture. The patient was admitted to hospital with the clinical presentation of hemorrhagic shock and intra-abdominal bleeding. There was a 20-cm incomplete posterior uterine rupture without penetrating the uterine cavity. Laparotomy, cesarean section, and hysterorrhexis closure were performed.

Ovarian hyperstimulation syndrome (OHSS) is a complication of ovarian stimulation in the programs aimed to achieve pregnancy: in anovulation for natural conception, during intrauterine insemination, and in IVF programs. The authors of this paper attempted to summarize the data available in the literature and the results of their investigations pertaining to the development of severe OHSS, by modifying the tactics for management of an induced cycle.