No 8 (2019)

The literature review is devoted to fast-track surgical technologies, accelerated recovery programs after surgical treatment. The key positions of fast-track surgery are aimed at optimizing a human stress response and regulating metabolic changes in response to surgical aggression, which significantly reduce the duration of inpatient treatment and the incidence of postoperative complications.

This review analyzes a literature database including systematic reviews and randomized clinical trials devoted to current ideas on the pathogenesis of genital endometriosis-associated infertility. The 2012-2019publications available in the databases PubMed, MedLine, and Crossref underwent analysis. Endometriosis is considered as a multifactorial disease, the pathogenesis of which involves both genetic and environmental factors. This review demonstrates the role of genetic and epigenetic influences in the development of endometriosis and its associated infertility. It presents recent studies of the impact of oxidative stress accompanying endometriosis on fertility.

More than 10 years of global experience with prophylactic human papillomavirus (HPV) vaccines suggest that the latter are safe and highly effective. There is convincing evidence that in countries where HPV vaccination programs are implemented, the incidence of genital warts and the incidence of cervical precancerous lesions have substantially decreased in the respective populations and in 2018 there was the first evidence for the effectiveness of vaccination against invasive HPV-associated cancers. It is predicted that cervical cancer will become an extremely rare disease over the next few decades and can be completely eradicated by the end of the century in developed countries where a high vaccination and screening coverage remains.

Objective. To identify clinical and anamnestic risk factors in pregnant women with preterm premature rupture of membranes Subjects and methods. Examinations were made in 150 women aged 18 to 40 years, who were divided into 3 groups: 1) 50 pregnant women with premature rupture of membranes (PROM); 2) 50 pregnant women with intact membranes, who delivered at 22-36 weeks’ gestation; 3) 50 pregnant women who delivered spontaneously at term (at 5 37 weeks). The age indicators, the history of somatic and gynecological diseases, the outcomes of previous pregnancies, the features of the course of this pregnancy, childbirth and neonatal outcomes were studied in detail. Results. The risk of PROM significantly more often occurred at the most active reproductive age (25-30 years) in primigravida primiparous women who were somatically burdened with frequent respiratory and odontogenic inflammatory diseases. Pregnant women with PROM had several risk factors that occurred during this pregnancy. Cervical diseases and uterine fibroid were statistically significantly more common. The gestational age for PROM varied within 22-36 weeks’ gestation, and the statistically significantly more common method of delivery was cesarean section. In the same group of women, the newborn infants had a birth weight of less than 2500g, which affected neonatal outcomes. Conclusion. The etiology of PROM during preterm pregnancy is multifactorial; there is a need for timely detection, the correction of one or another condition not only during, but also before pregnancy, and the elaboration of strategies for improving the outcomes, by predicting, preventing, and treating this situation.

The incidence of premature rupture of membranes (PROM) during full-term and preterm pregnancy is 10 and 40%, respectively. To clarify the diagnosis of PROM in clinical practice, tests are used, which have a high frequency of false-positive results, being accompanied by unreasonable economic costs. At the same time, new biochemical markers of high accuracy have been developed. Objective: to compare the clinical and economic efficacy of traditional clinical examination and a placental alpha-microglobulin-1 (PAMG-1) test in patients with a presumptive diagnosis of PROM. Subjects and methods. The investigation enrolled 114 women with a presumptive diagnosis of PROM. A decisionmaking model was developed and the cost-effectiveness of traditional tactics and the PAMG-1 test were compared. Results. The cost of a case with the traditional survey strategy was 16,700 rubles. That of the PAMG-1 test was 3,000 rubles. The average cost of a case when using the latter was 3,060 rubles. The average cost saving per patient was 13,640 rubles. Conclusion. Compared with the traditional approach to diagnosing PROM, the use of the PAMG-1 test is more effective and cost-effective.

Objective. To evaluate the clinical sensitivity and specificity of a care system for human papillomavirus (HPV) for the identification of its DNA in an organized screening program versus conventional cytology in the remote areas of the Sverdlovsk Region. Subjects and methods. A total of 857 women underwent cervical screening by the hybrid capture HPV DNA test using the careHPV testing system, with a parallel cytological examination by the conventional method, followed by a colposcopic, pathomorphological study in patients with a positive HPV test and/or altered cytological patterns. Results. A high-titer high-risk HPV (hr-HPV) positive test using the careHPV diagnostic system was seen in 84 patients: 35 (41.67%) hrHPV-positive women were found to have cervical precancer and cancer, while 16 (2.07%) hrHPV-negative patients with the visually altered cervix had cervical intraepithelial neoplasia 1 (CIN 1). Virological screening was ascertained to have a signif icantly higher sensitivity in high-grade CIN and cervical cancer (CC), which demonstrates the feasibility of using this method during CC screening in the remote areas. Conclusion. This investigation and calculations of screening methods demonstrated that the hybrid capture test using the careHPV diagnostic system versus conventional cytology had a significantly higher sensitivity in identifying high-grade CIN and CC, but cytology had a higher specificity.

Objective. To determine the characteristics of the proliferative and antiproliferative activities of the cells of the endometrium in its hyperplasia concurrent with chronic endometritis (CE), by analyzing the expression level of Ki-67 and p16INK4a proteins in the uterine mucosa. Subjects and methods. Ninety patients were examined. Group 1 consisted of 29 women, in whom histological examination of endometrial biopsy specimens revealed endometrial hyperplasia (EH) without atypia concurrent with CE; Group 2 included 21 patients with EH without atypia (Comparison Group 1); Group 3 comprised 20 women with CE (Comparison Group 2); Group 4 consisted of 20 gynecologically healthy women (a control group). A comprehensive morphological and immunohistochemical study of endometrial samples was carried out according to the generally accepted criteria. Results. Evaluation of the proliferative activity of endometrial cells in patients with EH concurrent with CE indicates that there is a high proliferative potential of the epithelial cells of endometrial glands and stroma. The higher expression of p16INK4a in Group 1 suggests that viruses may be involved in the development of the hyperplastic process. A comparison of the expression levels of Ki-67 and p16INK4a in the uterine mucosa of the women in Groups 1 and 2 showed that the expression level of p16INK4a was directly proportional to that of Ki-67. Discussion. The endometrial cells with EH concurrent with CE are characterized by both the enhanced proliferative and antiproliferative activities. The observed coexpression of Ki-67 and p16INK4a in EH concurrent with CE may be a signal of cell cycle damage and requires a search for factors determining the simultaneous expression of these markers in this pathology. Evidence for the maximum expression levels of Ki-67 and p16INK4a in the endometrial samples of patients with a recurrent endometrial hyperplastic process can be the basis for the development of a program to assess the risk of recurrent EH.

Objective. To optimize the diagnosis of vulvar condyloma acuminatum (CA), by expanding the possibilities of using the polymerase chain reaction (PCR) in clinical practice. Subjects and methods. Ninety patients with vulvar CA were examined. All the examined women underwent vulvoscopy with a vinegar test, high-frequency ultrasound of the skin and vulvar mucosa, human papillomavirus (HPV) typing in the samples of the cervical canal epithelium, scrapes from CA, and its biopsy specimens. Biopsies (n = 90) were performed in AC measuring more than 3 mm in diameter. Result. Analyzing the identification of HPV types revealed that HPV 6 and HPV 44 were statistically significantly more common in the biopsy specimens of CA than in those of the cervical canal and in the CA scrapes; HPV 11 was found statistically significantly more frequently in the scrapes from CA than in those from the cervical canal and in the biopsy specimens. High-risk HPV types were also detected in the CA biopsy specimens, while the viral load was more often found to be statistically significantly higher in the samples of the cervical canal epithelium. The viral load in the scrapes from CA on the vulvar mucosa turned out to be statistically significantly higher than that in those on the vulvar skin. Conclusion. CAs on the vulvar mucosa, even with small sizes, are a reservoir of HPV infection and have a more pronounced viral potential than those located on the skin, therefore CAs absolutely require timely and effective treatment.

Objective. To provide a pathogenetic rationale for and to evaluate the clinical efficiency of improved combination treatment in patients with acute pelvic inflammatory diseases (PID), by using some physical factors on the basis of a study of the vascular endothelial status. Subjects and methods. A total of 164 patients with acute PIDs were examined. All the patients received antiinflammatory drug therapy in an inpatient setting. A study group of 84patients were exposed to laser and magnets via vaginal access on 2 days of treatment. The clinical course and the endothelial functional markers: a sample with postocclusal vasodilation (POVD), the number of desquamated endothelial cells (DEC), NO, iNOS, and ET-1 were assessed. Results. All patients with acute inflammation were observed to have obvious endothelial dysfunction as a 4-fold decrease in POVD, a 5-fold increase in DEC, and a 2.5-fold rise in NO, iNOS, and ET-1 compared with healthy women. The influence of preformed factors in combination with medications contributed to a reduction in the duration of pain and intoxication syndromes, by eliminating vascular endothelial dysfunction. Conclusion. The early use of vaginal laser and magnetic therapy contributes to the elimination of vascular disorders, the relief of clinical symptoms, and the reduction of the risk of chronic inflammation.

Objective. To evaluate the diagnostic signif icance of determining extracellular fetal DNA in the plasma of pregnant women with preeclampsia and fetal growth restriction. Subjects and methods. Plasma samples from 55 women were investigated during the study. The pregnant women were divided into groups: 1) 17 pregnant women with preeclampsia and fetal growth restriction; 2) 19patients with a conf irmed diagnosis of preeclampsia without fetal growth restriction; 3) 19 women with physiological pregnancy. Quantitative PCR analysis was used in all the patients to measure the plasma level of extracellular fetal DNA, by determining the concentration of the hypermethylated RASSF1A gene. Results. The pregnant women with preeclampsia and growth restriction were found to have a significantly higher level of extracellular fetal DNA (284 GE/ml for impaired fetoplacental blood flow by Doppler ultrasound; 339 GE/ ml for the absence of impaired fetoplacental blood flow) than those with preeclampsia (79 GE/ml) and apparently healthy pregnant women (25 GE/ml). The level of extracellular fetal DNA in pregnant women with preeclampsia and fetal growth restriction without impaired fetoplacental blood flow was shown to be an indicator of fetal growth restriction at a threshold of 201 GE/ml with a sensitivity of 80% and a specificity of 89%. Conclusion. The findings indicate that quantitative determination of the plasma level of extracellular fetal DNA can be used to identify groups at risk for fetal growth restriction in pregnant women with preeclampsia. Quantification of the level of extracellular fetal DNA in combination with other methods for fetal assessment can assist in choosing the optimal timing and methods of delivery to improve perinatal outcomes.

Objective. To evaluate the pelvic floor microvascular bed using laser Doppler flowmetry (LDF) in reproductive-aged women. Subjects and methods. All examinees were divided into 5 groups: 1) women after vaginal delivery (VD); 2) those who had undergone cesarean section (CS); 3) those who had a history of one spontaneous miscarriage at less than 12 weeks’ gestation; 4) those who had a history of two pregnancy losses before 12 weeks’ gestation. LDF readings were once recorded for 30 seconds from 2 points, from the anterior and posterior vaginal walls. To determine normal LDF values, Group 5 (a control group) of apparently healthy women having no history of pregnancies was made up. Results. The LDF values for anterior vaginal wall blood flow were lower. A substantial decrease in blood flow was recorded in the women after VD and CS. There were no microcirculatory disorders in Group 3. The women with recurrent miscarriage had significantly lower blood flow values. Conclusion. LDF is a non-invasive technique that can be used to diagnose pelvic floor microcirculatory disorders. A significant blood flow decrease was recorded in women who had undergone BP and CS, which necessitates more detailed monitoring of these patient groups and inclusion of medical methods for pelvic floor restoration into a postpartum rehabilitation program. Women with recurrent miscarriage have significantly lower blood flow values and require that rehabilitation programs that include pharmacological agents and physiotherapeutic procedures aimed at improving pelvic floor microcirculation should be drawn up.

Background. McArdle’s disease (glycogen storage disease type V) is metabolic myopathy caused by homozygous or compound heterozygous mutations in the PYGM gene. It is characterized by skeletal muscle glycogen phosphorylase deficiency. The absence of this enzyme worsens glycogenolysis. In clinical practice, there is hypodiagnosis of this condition, which does not exclude the rarity of its definition. Description. The paper presents a clinical case of anesthetic management during operative delivery in a female patient with McArdle’s disease. Patients with McArdle’s disease who undergo surgery and anesthesia have a potential risk for perioperative complications, such as hypoglycemia, rhabdomyolysis, myoglobinuria, acute renal injury, postoperative fatigue, and, possibly, malignant hyperthermia. Conclusion. Regional anesthesia is safe and effective for operative delivery in female patients with McArdle’s disease.