No 1 (2017)

Objective. To carry out a systematic analysis of the data available in modern literature on the immunological aspects of repeated implantation failures in an IVF program, as well as on current personalized immunotherapies to overcome repeated implantation failures. Material and methods. The review includes the data of foreign and Russian papers published in 2010-2016 and found in Pubmed on this topic. These articles have become the basis for this review; however, for better understanding of the topic, the authors have expanded the search and included older articles that are widely cited. Conclusion. There is substantial evidence that the impaired expression of nonclassical HLA molecules, cytokine imbalance, and changes in the number and activity of NK cells may contribute to reproductive dysfunction. A more complete understanding of hormonal modulation of the immune microenvironment of the endometrium will be able to elaborate new personalized therapeutic approaches to preventing repeated implantation failures.

In the last decades various methods to terminate pregnancy have been widely introduced in the Kyrgyz Republic, but little attention has been paid to their impact on the psychological status of a woman. Objective. To determine the rate of depressive disorders and to compare psychological outcomes in women before and after termination of early-stage non-developing pregnancy. Subjects and methods. This was a non-blinded randomized cohort trial. A sample consisted of633 women at less than 12 weeks+6days of gestation; of these, 399 women had non-developedpregnancy. Testing was carried out using the Tsungpre-diagnosis depression scale. Results. The pre-abortion rate of psychological disorders was 30.3%. There were 72.9% of mild depression cases in the structure of depressive disorders. The post-abortion rate of depression was increased by 6.0%. Following medical abortion with mefipristone in combination with misoprostol, the rate of mild depressive disorders (36.4%) was, with high statistical significance, greater than that with misoprostol alone (22.3 %) (φетr 2.598; P < 0.01) and surgical abortion (20.2%) (φemr 2.872; P < 0.001). Conclusion. The high level of depressive disorders in women with early pregnancy suggests that there is a need to elaborate programs for the early detection of psychological disorders and the choice of an abortion method.

Objective. To study an ovarian response in ART programs for tubal infertility in patients before and after age 35 years. Subjects and methods. 128 patients with tubal infertility underwent bilateral salpingectomy (SE) (n =80; Group 1) or fallopian tube occlusion (n =48; Group 2). A control included apparently healthy women (n =15). Superovulation was induced according to a protocol with gonadotropin-releasing hormone antagonists. Results. Age limits ovarian reserve: there is a decrease in anti-Müllerian hormone (AMH) (p =0.004), an increase in the rate of a poor response (p =0.003) regardless of SE, and a reduction in ovarian volume (V) (p =0.016) after SE. In the women with tubal infertility who are less than 35 years of age, follicle-stimulating hormone (FSH) is higher than that in the controls (p =0.038) no matter whether SE is done; inhibin B (p < 0.001) and estradiol (p =0.001) are lower only after SE. AMH, AFC, and ovarian volume do not differ from those in the controls. Estradiol relatively increases (p =0.018) and ovarian volume decreases (p =0.037) in the women over 35 years who have undergone SE as compared to those after occlusion. The duration of stimulation does not depend on age (p =0.218) and salpingectomy (p =0.566). The course doses of gonadotropins for women aged 35-45years are one-third higher than those for women 21-35 years of age (p < 0.001). The starting dose of FSH after SE is lower than that after occlusion (p =0.045); the total dose eliminates this effect (p =0.751). The number of retrieved oocytes depends on the age above 21-35years (p < 0.001). The contribution of salpingectomy is insignificant (p =0.255). Conclusion. The limited ovarian reserve after SE suggests that the ovarian response wll become poorer in the long term.

Objective. To estimate the value of anti-Müllerian hormone (AMH) for the diagnosis of polycystic ovary syndrome (PCOS) and the possible characteristics of its secretion in various phenotypes of the syndrome. Subjects and methods. The investigation enrolled 502 reproductive-aged women, including 250 patients aged 25.4±4.2 years (body mass index (BMI), 24.2±5.6 kg/m2) with PCOS and 252 women (aged 25,2±3,8years; BMI, 24.2±5.6 kg/m2) without reproductive dysfunction. Four phenotypes of the syndrome were identified using the Rotterdam criteria. Phenotypes A, B, C, and D were detected in 58, 10.4, 6.4, and 25.2% of the women, respectively. The investigators made complex clinical and laboratory examinations, including small pelvic ultrasound and a study of the androgen profile, AMH, luteinizing hormone, follicle-stimulating hormone, prolactin, and thyroid-stimulating hormone. Results. The mean serum AMH level in the healthy women and women with PCOS was 3.3±1.9 and15.8±10.2ng/ml, respectively (p < 0.05). The highest AMH level (17.9±11.6 ng/ml) was found in the women with phenotype A as compared with other phenotypes of the syndrome (p < 0.05). ROC analysis revealed that the threshold level of AMH for the diagnosis of PCOS was 5.2 ng/ml (an AUC of 0.97, a sensitivity of 95%, a specificity of 92%, and a confidence interval (CI)) of 95%). Conclusion. The AMH level exceeding 5.2 ng/ml can be considered as a threshold in the diagnosis of PCOS regardless of the phenotype of the syndrome. The elevated serum level of AMH is a more specific and sensitive diagnostic criterion for PCOS than enlarged ovaries.

Objective. To evaluate the autonomic status and adaptation in neonates born with intrauterine growth retardation (IUGR) through different delivery modes in pregnant women. Subjects and methods. There were 55 and 17babies born with and without IUGR, respectively; and 25 apparently healthy children. Clinicoanamnestic, physical, electrophysiological, and statistical studies were applied. Results. Fetal growth retardation was not a criterion for selecting a delivery mode in pregnant women. Surgical delivery was needed by women with a more compromised somatic (especially hypertension and hypothyroidism) and obstetric/gynecological (abortions, threatened miscarriage, and rhesus-immunization) histories, while their childbirth was more frequently complicated by heart rate changes (by 3.24 times) and meconium discharge in amniotic fluid (by 3.24 times), which was suggestive of experienced intranatal hypoxia; and the newborns were more often diagnosed as having grades I-II grade cerebral ischemia (by 1.52 times), an Apgar score of 7-8 (by 2.16 times), ventricular dilatation (by 1.58 times), maximum weight loss in the first 1-2 days of life (by 1.3 times), hemorrhagic syndrome (by 2.16 times), jaundice (by 1.57 times), hypoglycemia (by 1.23 times), autonomic dysfunction (by 1.41 times), even more depletion of the sympathetic segment and adaptation reserves; but at one month of life, there was their greater stress, which was accompanied by more severe clinical manifestations of autonomic dysfunction. Conclusion. The natural delivery of pregnant women who had growth retardation in their fetus at 37-42 weeks’ gestation is more adequate.

Objective. To investigate the course of the neonatal period and the development of pathological conditions at birth and in the first year of life among late preterm neonates. Material and methods. A total of 568 case histories of babies born at 340/7 to 366/7 weeks’ gestation in the period from 01.10.2013 to 31.12.2015 were retrospectively analyzed and 60 late preterm infants were selectively followed up for their development during the first year of life at the Academician V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia. Results. The investigation showed that 28.9% of the late preterm babies needed treatment in an intensive care unit (ICU). 51.4% required treatment in a pathology unit for neonates and premature babies (PUNPB). 45.9% of the late premature infants were discharged home from the neonatal unit (NU). The mean length of hospital stay in ICU, PUNPB, and NU was 5.4±4.2, 0.8±4.7, and 5.2±1.8 days, respectively. The severity of prematurity-related complications in the followed-up infants was proportional to gestational age (p < 0.005). The follow-up of the late preterm infants revealed that their vast majority caught up with their full-term peers in terms of physical and psychomotor development during the first six months of life. Conclusion. The investigation confirms the need for increased attention, differentiated approaches to nursing, feeding, and management of infants born at 34-36 weeks’ gestation.

Objective. To investigate the efficiency and antirecurrent activity of adjuvant therapy with Multi-Gyn actigel for bacterial vaginosis (BV) in reproductive-aged women. Subjects and methods. The investigation covered 50 female patients, whose mean age was 18 to 45 years (29.6±4.5 years), with a clinical diagnosis of BV confirmed by real-time polymerase chain reaction (Femoflor-16 real-time PCR). The patients were randomized into two equal groups of 25 subjects in each. Group 1 received one-dose vaginal clindamycin cream overnight for 10 days and, as therapy stage 2, the actigel 2 mg twice daily for 10 days. Group 2 used one-dose vaginal clindamycin cream overnight for 10 days and, as therapy stage 2, a drug containing Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 for 14 days. Results. The therapeutic effectiveness was 92% (n = 46) in both groups. However, the more sustained remission rates were 88% (n = 22) in the group of patients receiving adjuvant therapy with Multi-Gyn actigel and 64% (n = 16) in the comparison group (p < 0.5). Conclusion. Long-term adjuvant Multi- Gyn actigel therapy in conjunction with etiotropic therapy was associated with a longer recurrent BV-free interval. Addition of Multi-Gyn actigel considerably improved treatment results. Drugs that contain probiotic Lactobacilli are also effective in the combination therapy of BV; however, their efficacy is based on their longer use.

Background. Despite the fact that maternal mortality associated with HELLP syndrome has declined considerably during the last decades, now it remains rather high and ranges from 0 to 24%; perinatal mortality is very high, amounting to 8 to 60%. The HELLP syndrome is very often subtle, without manifestations of a classic symptom triad. In this case, clinicians always raise a question as to whether this diagnosis is justifiable. There is the greatest difficulty in the differential diagnosis of HELLP syndrome and atypical hemolytic uremic syndrome (aHUS) due to their very similar clinical and laboratory manifestations and to the lack of clear clinical and laboratory markers used to conf irm or exclude these syndromes. The paper describes a case of HELLP syndrome or aHUS, which has caused substantial difficulties in their differential diagnosis. Case report. Patient O. aged 33years was admitted to the V.I. Kulakov Research Center of Obstetrics, Gynecology, and Perinatology on January 19, 2016. Two previous pregnancies were uneventful and ended favorably; this was her third pregnancy. The patient had episodes of high blood pressure (BP) in the second trimester and received therapy. Edema in the hands appeared at 36 weeks’ gestation. Her total weight gain was 24 kg. On January 20, the patient gave birth to a full-term live girl with an Apgar score of 7/8. The patient had a total blood loss of650 ml. In the early postpartum period, she developed hypotension and tachypnea; brown-red urine was taken using a urinary catheter; the results of her analyses were as follows: leukocytes, 18.28 x 109/l; hemoglobin, 70 g/l; red blood cells, 2.24 x 1012/l; and platelets, 62 x 109/l. She was transferred to an intensive care unit and started intensive therapy. On the first day of her stay there, the patient had oligoanuria, she underwent a hemodiafiltration session; the subsequent urine output rate remained normal. She also had three plasma exchange sessions and one plasmapheresis session. Despite positive changes in the levels of platelets, lactate dehydrogenase, and aspartate aminotransferase, there was a continuing rise in creatinine and urea with the normal urine output rate. This fact could put in doubt the diagnosis of HELLP syndrome and think about the diagnosis of aHUS; however, the values of creatinine and urea began to normalize after the fourth plasmapheresis session and a week later the levels of these indicators were 1583 μmol/l and 6.9 mmol/l, respectively. Conclusion. The paper reviews the literature on the simulators for HELLP syndrome and a variant of differential diagnosis if a pregnant woman is found to have thrombocytopenia.