No 10 (2013)

Despite numerous investigations demonstrating the high rate of spontaneous delivery after previous cesarean section and the relative low risk of hysterorrhexis, the number of repeated operations in women with uterine scars is constantly growing. Evaluation of the lower uterine segment raises a number of questions: in what postpartum period examinations should be performed, what methods are most effective in diagnosing the state of a scar, and what evaluation criteria should be used. Ultrasonography is now considered to be a basic method for visualizing anatomic structures in obstetrics. Hysterosalpyngography, echohysterography, hysteroscopy, computed tomography, and magnetic resonance imaging are also used to detect myometrial defects. The above methods for assessing the state of a surgical area are of informative value in the diagnosis of space-occupying lesions or uterine wall defects. Scar defects can be identified by hysterography, echohysterography, and transvaginal echography in 58, 59, and 37% of cases, respectively. At the same time, the information provided by the above techniques does not contain significant criteria characterizing the qualitative properties of a scar, which fails to predict its functional state.

Objective. To develop a differentiated approach to determining the risk of obstetric and perinatal complications in relation to the results of examination for the inherited and acquired forms of thrombophilia in pregnant women with preeclampsia.

Objective. To assess the relationship of genetic and acquired risk factors and hemostatic status to complicated pregnancy in different forms of hypertension. Design. A prospective cohort study. Methods. Clinical, coagulation, molecular genetic, immunological, and statistical studies. Subject. These included 106 women with chronic hypertension, 21 with chronic hypertension concurrent with preeclampsia, 63 with gestational hypertension, 10 with preeclampsia, and 100 nonhypertensive women who had no family history of obstetric/gynecological and/or thrombotic diseases. Results. Overweight, obesity, and smoking were most common in the pregnant women with all forms of hypertension and the women with chronic hypertension and preeclampsia had also more frequently a family history of hypertension and venous and arterial thrombosis than the nonhypertensive pregnant women. Pregnancy was more often complicated by chronic placental insufficiency and fetal growth restriction in the women with all forms of hypertension. The outcomes of pregnancy were characterized by higher preterm birth rates and lower neonatal weight for height indicators in the chronic hypertension + preeclampsia group than in the nonhypertension one. Evaluation of hemostatic status in the women with hypertension concurrent with preeclampsia showed excessive activation of the platelet and coagulation components of hemostasis throughout their pregnancy as compared to the nonhypertensive women. The women with chronic hypertension were found to have a higher frequency of the D allele and DD genotype in the angiotensin-converting enzyme gene, the C allele in the angiotensinogen II type-1 receptor gene, the T allele and CT genotype in the MTHFR gene, as well as the T allele and TC genotype in the NO synthase gene than the nonhypertensive women. The pregnant women with preeclampsia were observed to have a higher frequency of the M allele and MM genotype in the angiotensinogen T174M gene. The factors independently associated with hypertension during pregnancy were an increased Quetelet index (>25 kg/m 2), TM genotype in the angiotensin-II gene, and the AC genotype in the angiotensin II type-1 receptor gene. Conclusion. Identification of genetic and clinical predictors makes it possible to improve the prediction of different forms of hypertension during pregnancy and to timely form risk groups to prevent hypertension-associated gestational complications.

Objective. To conduct a comprehensive immunomorphological study of the endometrium to substantiate pregestational preparation steps in women with reproductive disorders. Subject and methods. Two hundred patients with reproductive disorders, including 100 women with tuboperitoneal infertility and 100 with miscarriage, were examined. A control group consisted of 83 healthy women. Immunohistochemical study was used to determine the expression of CD20 +, CD138 +, estrogen and progesterone receptors in the glandular and stromal epithelium. Results. Endometrial morphofunctional examination using routine staining revealed the clinical picture of chronic endometritis in 17.0% of the patients with tuboperitoneal infertility and in 66.0% of those with miscarriage. Immunohistochemical study showed a higher CD20 + immunocyte density of 3.02±0.6 per mm 2 of the stroma in the women with miscarriage, with predominant arrangement close to the basement membrane of the endometrial glands. CD138 +-positive plasma cells were detected only in women with reproductive losses and had also a higher endometrial stromal numerical density of 2.91±1.2 in the miscarriage group, by showing a diffuse distribution, which suggested that the activity of immunological processes occurring in the endometrium was high. Conclusion. The comprehensive immunomorphological evaluation of the endometrium is of decisive importance in making the steps of pregestational preparations in patients with reproductive disorders. Evaluation of humoral immunity raises the question as to whether it is necessary to use repeated courses of empirical antibacterial therapy. Analysis of the level of estrogen and progesterone receptor expression makes it possible to substantiate hormonal therapy under echographic guidance.

Objective. To comparatively assess diagnostic methods and endometrial changes by ultrasonography (USG) and hysteroscopy in postmenopausal patients taking tamoxifen. Subject and methods. One hundred tamoxifen-treated women with breast cancer who had the endometrium more than 5 mm thick were examined using USG. All the examinees were postmenopausal. The study evaluated the sensitivity, specificity, accuracy, and diagnostic efficiency of USG and hysteroscopy. Results. Ultrasound scanning revealed the following abnormalities: 38 cases of endometrial polyps, 11 cases of endometrial polyps concurrent with endometrial hyperplasia, and 51 cases of endometrial hyperplasia. Endometrial polyps were the most common diagnosis (in 59 cases of the 100 cases). Conclusion. The sensitivity and specificity of USG were 89.3 and 66.6%, respectively. Hysteroscopy had a very high sensitivity (96.97%) and specificity (91.2%).

Background. Increased sperm chromosome aneuploidy may negatively affect the probability of conception in couples with different spermatogenic disorders. Objective. To study the efficiency of assisted reproductive technology (ART) programs in couples with different types of pathozoospermia (PZ) in relation to the rate of sperm chromosome aneuploidy. Subject and methods. The prospective cohort study enrolled 86 married couples treated for infertility in the ART programs, who were divided into three groups: 1) 26 patients with teratozoospermia (TZ); 2) 35 with asthenozoospermia and/or oligizoospermia; 3) 25 with normozoospermia (NZ). The number of sperm chromosomes X, Y, and 18 was estimated by fluorescence in situ hybridization. Ovarian function was stimulated using the uniform short protocol. The primary endpoint was an adjusted odds ratio (OR adj) of conception in relation to the rate of sperm chromosome aneuploidy. The secondary endpoints were the mean rate of sperm chromosome aneuploidy; the mean rate fertilization in the compared patient groups; the threshold level of aneuploidy in the sperm nuclei; a correlation between different spermogram parameters, as well as the rate of fertilization and that of sperm chromosome aneuploidy. Results. Sperm aneuploidy rates statistically significantly differed in the patient groups and were 0.93±0.61% in Group 1, 0.74±0.78% in Group 2, and 0.34±0.12% in Group 3 (p=0.0003). Negative correlations were found between the normal shapes of spermatozoa and the rate of aneuploidy (r=-0.21; p=0.047) and between the rate of sperm aneuploidy and that of fertilization (r=-0.31; p = 0.0035). The ART protocols showed the same number of embryos in the 3 patient groups. Two embryos of equal quality were transferred in each cycle. Twenty-four pregnancies were clinically diagnosed: 4 (15.4%) in Group 1, 8 (22.8%) in Group 2, and 12 (48%) in Group 3 (p=0.0237). OR adj was 4.51 (95% CI=1.09; 18.68). Analysis of the ROC curve of 0.63 determined the threshold value of aneuploidy in the sperm nuclei in relation to the efficiency of ART program, which was 0.7%. Conclusion. Male PZ, TZ in particular, contributes to the increased risk of failures of ART programs. One of these outcomes may be elevated sperm chromosome aneuploidy. Molecular cytogenetic study of ejaculates from men with PZ should be recommended for married couples treated using the in vitro fertilization (IVF)/intracytoplasmic sperm injection technique to make a decision on preimplantation genetic diagnosis of embryos or sperm donation, which may improve the outcomes of IVF programs.

Analgesia in very low and extremely low birth weight (VLBW, ELBW) infants is an urgent problem. Both drug and non-drug analgesic modes are used. Every method has its advantages and disadvantages. In addition, changing the glycemic status during painful procedures may lead to sequels unfavorable for the baby. Objective. To evaluate the glycemic status in VLBW and ELBW infants during painful maneuvers (finger pricking) and the efficiency of nondrug anesthetic modes. Subject and methods. Forty-three neonatal infants, including 22 ELBW and 21 VLBW infants, treated in the intensive care unit, V.I. Kulakov Research Center of Obstetrics, Gynecology and Perinatology, were examined. All the infants were divided into three groups: 1) 11 babies who were anesthetized with glucose solution; 2) 14 neonates who were given a pacifier for pain relief. These infants were compared with a control group of 18 babies who were not anesthetized. Results. Skin conduction examination of the infants when pricking the finger showed differences in peak/sec values between the control and 20% glucose solution groups (Me = 0.31 [0.2-0.43] Hz and Me = 0.125 [0.05-0.215] Hz, respectively; p = 0.026; Mann Whitney U-test) and between the control and pacifier groups (Me = 0.31 [0.2 0.43] Hz and 0.07 [0.05-0.1] Hz, respectively; р = 0.001; Mann Whitney U-test). In both groups, blood glucose levels remained within the normal range. Both before and 30 minutes after the painful maneuver, the blood glucose levels in Group 1 were 5.2±1.5 and 5.3±2.2 mmol/l, respectively; and these were 5.6±1.6 and 5.5±1.1 mmol/l in Group 2 and 5,4±1.1 and 5.6±1.1 mmol/l in the control group. Conclusion. Pacifier-sucking or 20% glucose solution use was clinically effective and safe in pain relief when finger capillary blood was sampled in premature neonatal infants. The use of glucose solution for pain relief was not followed by the development of hyperglycemia in extremely premature babies during painful maneuvers. This pain assessment method using an algesimeter is probably most accurate than subjective pain assessment (with a pain rating scale).

Objective. To improve the prevention of inflammatory and thrombotic events with low molecular-weight heparins (LMWH) after cesarean section in puerperas with moderate risk factors for thrombosis. Subject and methods. Fifty-one puerperas who prophylactically received LMWH (a study group) and 60 puerperas who did not take LMWH (a comparison group) were examined. All the patients underwent physical and hemostasiological examinations, determination of the serum concentrations of pro- and anti-inflammatory cytokines and endotoxin, and Doppler sound of postpartum uterine vessels. Results. The preventive use of LMWH after abdominal delivery in women at moderate risk for thrombotic events contributes to the normalization of their hemostatic and inflammatory blood potential. Conclusion. The preventive use of LMWH after abdominal delivery in women at moderate risk for thrombotic events promotes the favorable puerperium.

Background. The widespread use of antibacterial drugs in modern medicine, self-treatment, and sexual promiscuity promote the formation of a large cohort of women with vaginal discomfort complaints caused by impaired microbiocenosis, including the lactoflora. The predominance of lactobacterial strains with a low peroxide-forming potential, which occurs after inadequate courses of antibiotics, antiseptic solutions, decreases the efficiency of their regulating anaerobic exposure and enhances the risk of bacterial vaginosis. Objective. To evaluate the efficiency of local use of gynoflor E in patients with vaginal discharge and discomfort complaints caused by the impaired quantitative and qualitative composition of the normal flora. Subject and methods. Forty patients complaining of vaginal discharge and discomfort were followed up. Their comprehensive examination was made, which involved vaginal discharge pH-metry, amine test with 10% KOH, microscopic and molecular genetic studies with a florocenosis test system. The patients were given gynoflor E tablets vaginally at bedtime once a day for 12 days. Results. Examination of vaginal discharges revealed that the amount of lactobacilli was decreased in all the women regardless of the day of a menstrual cycle. The administration of gynoflor E eliminated subjective and objective symptoms in 95% of the patients. Conclusion. Polymerase chain reaction-based quantification of the flora (florocenosis) convincingly showed that the use of gynoflor E promoted recovery of the lactoflora in 95% of the women.