No 10 (2017)

Objective. To carry out a systematic analysis of the data available in the current literature on the role of a systemic inflammatory response in the development of gestational complications in obese women. Material and methods. The review presents the data of foreign and Russian articles published in the past 15 years and found in Pubmed on this topic. Results. The paper describes the mechanism of the pathogenesis of insulin resistance, endothelial dysfunction that underlies the development of placental insufficiency, preeclampsia, and thrombophilia in the presence of a chronic inflammatory response in obese women. Conclusion. There is a need for further investigations of the mechanisms of a relationship of systemic inflammation in obesity to the development of gestational complications. The investigation of markers of systemic inflammation in pregnant women with obesity is of considerable interest and enhances an understanding of the pathogenesis of gestational complications will be able to make an efficient pregravid preparation, timely prevention, and correction of possible complications in this category of women.

Objective. To comprehensively analyze the data available in the current literature on a pathogenetic relationship between obesity and thrombophilia in the development of obstetric and thrombotic events in female patients with metabolic syndrome (MS). Material and methods. The review included the data of foreign and Russian articles published in the past 10 years and found in PubMed and e-Library on this topic. Results. The paper clearly shows possible mechanisms and a pathogenetic relationship between endocrine, proinflammatory, and prothrombotic statuses observed in patients with MS in the development of obstetric and thrombotic events. Conclusion. Despite a significant number of investigations of the risk factors and pathogenetic mechanisms for the development of thromboembolic events in MS patients, the problem of identifying the causes and ways of correcting the abnormalities has not been fully resolved and requires further study. Moreover, the annually increasing percent of persons with obesity and metabolic syndrome among reproductive-aged women poses new challenges of optimizing their preparation for pregnancy and preventing thrombohemorrhagic complications during pregnancy, delivery, and the postpartum period.

Excision of the cervix uteri with a large volume of lost tissue is a risk factor for preterm birth (PB). Today, the role of a main mechanism is given to the reduced barrier function of the cervix rather than to its decreased mechanical support. Objective. To establish the role of abnormal vaginal microbiota was a risk factor for PB in pregnant women after excision of the cervix. Subjects and methods. A total of 314 pregnant women having a history of cervical excision were examined. All they underwent ultrasonic cervicometry and vaginal microbiota examination. Pregnancy outcomes (PB <37 weeks’ gestation) were assessed. Results. Abnormal vaginal microbiota (lactobacillary grades IIb and III) in pregnant women with a history of cervical excision was associated with a lower rate of PB (14%) than that in pregnant women without episodes of microbiota disorders during gestation (5.8%). The relative risk ((RR) of PB was significantly higher than that in pregnant women with cervical excision, but with the normal microbiota: RR, 2.4 (95% CI, 1.1-5.4). Conclusion. Abnormal vaginal microbiota in pregnant women with a history of cervical excision is a substantial risk factor for PB.

Objective. To evaluate the efficacy of metformin in the androgen and non-androgen phenotypes of polycystic ovary syndrome (PCOS). Subject and methods. The investigation included 143 women (mean age, 26.4±4.6years; mean body mass index, 23.8±4.8 kg/m2) with PCOS. A comprehensive examination, Including a pelvic ultrasound, was made; serum androgens, anti-Müllerian hormone (AMH), luteinizing hormone (LH), and follicle-stimulating hormone levels were determined; and two-hour glucose tolerance test was carried out to estimate the levels of glucose and insulin at baseline and after 6 months of therapy. The patients were divided into two groups: 1) 101 women with the androgen phenotypes of PCOS; 2) 42 women with its non-androgen phenotype. All the patients were treated with metformin 1500 mg/day for 6 months. Results. The mean levels of AMH and LH were higher in the androgen phenotype group (p < 0.05). There were no differences in the frequency of metabolic disorders; the mean level of fasting insulin was higher in women with hyperandrogenism. After 6 months of metformin therapy, there were decreases in the level of LH, androgens, and insulin in Group 1 (p < 0.05) and in that of AMH in both groups. Regardless of the phenotype of PCOS, the menstrual cycle was regulated in every two patients; pregnancy occurred in every three patients. Conclusion. Therapy with metformin at a dose of 1500 mg daily can be considered as an effective approach to correcting ovulatory dysfunction irrespective of the phenotype of the syndrome.

Objective. To evaluate the clinical and laboratory characteristics and efficiency of assisted reproductive technology (ART) programs in patients with HIV infection. Subjects and methods. A prospective case-control study was conducted in 94patients who had consulted a doctor about ART programs. A study group included 38 women with HIV infection; a control group consisted of 56 HIV-seronegative patients. The study group underwent 74 in vitro fertilization (IVF) cycles, including 44 therapy cycles and 30 cryo ones. The control group had 59 and 30 cycles, respectively. The patients’ HIV infection status was assessed on the basis of the stage and phase of the disease, the level of viral load, CD3+,CD4+, and CD8+ lymphocytes, immunoreactive index, and the duration of antiretroviral treatment (ARVT). Results. The duration of HIV infection was 10 years (median (interquartile range) 6-13 years); its subclinical stage 3 was dominant (68.4 %). All the patients received combined ARVT. The median duration of drug use was 4 years (2-6.2 years). No blood viral load was detectable in 100% of cases. The patients in both groups were matched for age (median 34 and 32 years; p = 0.160) and infertility duration (5 and 5years; p = 0.430). Tuboperitoneal (39.5 and 30.4%, p = 0.467) and combined (23.6and 21.4%;p = 0.540) infertility factors were equally common in both groups. Anti-Müllerian hormone concentrations in HIV-infected women were significantly lower than those in HIV-seronegative patients (1.86 and 3.2 ng/ml; p = 0.024). Analysis of the stimulated cycle parameters revealed no significant difference in the starting and total doses of gonadotropins and in the duration of stimulation in both groups. Nevertheless, smaller numbers of oocytes (8.86±1.1 and 12.9±0.8; p = 0.001), mature oocytes (7.45±0.9 and 10.1±0.6;p = 0.003), zygotes (5.88±0.7and 8.4±0.001;p = 0.001), cleavage-stage embryos (5.55±0.6and 8.1±0.4;p = 0.001), as well as blastocysts (2.68±0.5and 4.4±0.4;p = 0.009) were obtained from HIV-infected patients than from control subjects. Selective single embryo transfer was performed on day 3 or 5 of cultivation in both groups. HIV-infected patients were found to have lower incidence rates of biochemical and clinical pregnancy than HIV-seronegative women in both the therapy cycles of ART(17.2and 44.2%, p = 0.015; 13.8% and 40.4%, p = 0,014) and cryo cycles (30 and 55.2%, p = 0.049; 20 and 53.6%; p = 0.008). Conclusion. HIV-infected women receiving an IVF program were noted to have a higher frequency of cycle cancellation, fewer obtained oocytes, and the lowest pregnancy rate. Further investigations are needed to understand the specific effects of HIV and/or ARVT on an ovarian response, oocyte quality, and outcomes of ART programs.

Objective. To determine the efficacy and safety of Er:YAG laser in the treatment of genitourinary disorders, such as stress urinary incontinence, mixed urinary incontinence, vaginal relaxation syndrome, grade I-II pelvic organ prolapse, and vulvovaginal atrophy. Subjects and methods. The investigation included 65 patients with varying degrees of genitourinary disorders. Their mean age was 44±4.1 years. During the investigation, the patients were surveyed using the specialized questionnaires: the Pelvic Floor Distress Disorders Inventory (PFDI-20) and the Female Sexual Function Index (FSFI) before treatment and at each treatment session. At each visit, the strength of pelvic floor muscles was measured using the PMTx system with biological feedback. The Q-tip test was used to assess the mobility of the urethra and bladder neck. The patients underwent ultrasound examination of the vaginal walls and sonoelas tography before and after treatment. All the patients in the study group received erbium laser IncontiLase and IntimaLase treatments using the Fotona Smooth technology on the SP Spectro unit (Fotona, Slovenia) according to the sequence patented by the manufacturer: 4 sessions of laser radiation at an interval of 28 days. Results. Statistical data processing revealed a statistically significant (Wilcoxon t-test; p < 0.05) reduction in the severity of symptoms of genitourinary disorders and an improvement in quality of life in the patients. In the study group, the incidence of stress urinary incontinence symptoms decreased by 52%. The patients of the study group showed a 36% increase in muscle power as compared to that before treatment. The Q-tip angle reduced by 10.1° at Visit 2, by 12.8° at Visit 3, and by 20.7°at Visit 4 as compared with that at Visit 1. Assessing the changes in PFDI-20scores showed that the median score was 62.5[41.7; 85.9] and 22.9[12.5; 40.6] before and after treatment, respectively. Sonoelastography revealed higher vaginal wall stiffness in 54 (83%) of the 65 patients after treatment. The latter resulted in an improvement in 60 (92%) of the 65 patients. Conclusion. Based on the data of the clinical study, it can be argued that IncontiLase and IntimaLase procedures using the Fotona Smooth technology are a highly effective and safe treatment for patients with genitourinary disorders.

Objective. To analyze the 25-year work of the nonprof it professional organization of the Kemerovo, namely the regional public organization “Association of Obstetricians and Gynecologists” (Association) in contributing to the protection of a physician’s rights. Material and methods. The Association’s twenty-five-year work aimed at improving the quality of obstetric/ gynecological care and at contributing to the protection of a physician’s rights was analyzed. Results. Currently, the physicians understand the need of consolidation, the number of members is steadily increasing, the members of the Association are 99% of the obstetricians/gynecologists from 32 towns and districts of the Kemerovo region, as well as those from other regions of the Siberian Federal District. The paper describes the Association’s experience in contributing to the increase of professional levels, the elaboration of clinical guidelines, the support of certification, the arrangement of conflict cases at the pre-trial stage, and public defense in court. Conclusion. Thus, the professional consolidation of obstetricians and gynecologists is particularly necessary and the regional nonprofit professional organizations can play a signif icant role in contributing to the protection of a physician’s rights at the present stage of national health care reform in Russia.

Objective. To estimate the overall prevalence, age structure, leading syndrome of pelvic floor dysfunction (PFD) among obstetricians/gynecologists and to identify factors influencing the choice of therapeutic approaches. Material and methods. 428 questionnaires anonymously completed by obstetricians/gynecologists were analyzed. Results. The frequency of PFD in the examined cohort was about 58% and depended on age. The symptoms of prolapse were observed in 34.1% of the respondents, colorectal and urinary symptoms were seen in 33.6 and 34.6%, respectively; the symptoms of sexual dysfunction were in 41.6%. Moreover, only 12.5% of the respondents had objective information about PFD revealed by examinations. The physicians who took part in the survey regarded medical methods as f irst-line therapy, while choosing more often pelvic floor muscle training and, to a lesser extent, pessaries. 2.1% preferred surgical tactics. 46.4% ignored the early, but obvious signs of illness, by selecting none of the management options proposed in the questionnaire. Conclusion. More than half of the physicians pay undue regard to their health, which requires that the medical opinion leaders and general public should draw attention to the discussed problem and that the knowledge and skills of obstetricians/gynecologists in the early diagnosis of PFD and its medical treatment should be enhanced in the continuing medical education system.

Background. Tuberculosis (TB) is difficult to diagnose in pregnant women; pregnancy management in patients with TB also poses certain challenges. The incidence of TB in pregnant women was 1.3 times higher than that in the general population. Description. The paper describes a case of recurrent multidrug-resistant pulmonary TB in a 24-year-old woman. The patient decided to maintain her current pregnancy, despite the use of anti-TB drugs and X-ray examination. The pregnancy was hard; the baby was born with birth defects. The second case reflects a good maternal immunity because TB of the placenta was detected only after normal delivery and spontaneously cured TB of the uterine appendages was identified in three more months. Conclusion. Pregnancy and TB are a negative concurrence for a woman; the patient should be oriented towards the prevention of an unplanned pregnancy.

Background. Placental hemangioma belongs to the group of nontrophoblastic tumors. Case report. The paper gives a case of giant placental hemangioma detected at 32 weeks’ gestation. It also describes the course of labor at 35 weeks of pregnancy. There are computed tomographic, histological, and immunohistochemical data on the born placenta. There are also literature data on histological characteristics of the structure of placental hemangiomas, as well as possible pregnancy and labor complications. It is noted that the obstetric tactics for hemangioma mainly depends on its size and the status of the fetus. Conclusion. An observation of giant placental hemangioma is of interest due to its relative rarity and little knowledge of such tumors concerning their importance for fetal development and possible pregnancy complications. The choice of optimum obstetric tactics of management and delivery for pregnant women with placental hemangioma is of importance.