No 1 (2020)

The data available in the world literature on studies of infection and inflammation as a factor that leads to premature birth have been sought and analyzed. Premature birth is the central problem of modern obstetrics, the leading cause of perinatal and infant morbidity and mortality. New potential methods for the diagnosis of spontaneous premature birth and preterm amniorrhea, as well as the basic stages of the pathogenesis of this process have been analyzed in detail. Diagnostic transabdominal ultrasound-guided amniocentesis should be considered as an important element in the diagnostic verification of threatening and imminent preterm births with subsequent correction of their obstetric management according to the findings.

The paper reviews international researches in the role of various gene networks in the development of obstetric pathology. It considers not only the most studied hemostatic system and folate metabolism genes, but also renin-angiotensin-aldosterone system, detoxification system, and immune response ones and genes that regulate the function of the endothelium. In addition, an update on genome-wide studies investigating a genetic predisposition to pregnancy complications is analyzed.

The relevance of studying the role of microRNAs in the pathogenesis of diseases of organs and systems is beyond question. The reproductive system is no exception. Since the early 2000s, many studies have been conducted to identify microRNAs in the ovaries. A literature review demonstrates the important role of microRNAs in folliculogenesis, including as regulators of apoptosis of granulosa cells, ovulation, and luteinization. It is established that microRNAs can be important regulatory molecules directly involved in premature ovarian insufficiency and polycystic ovary syndrome. MicroRNAs can become biological markers of ovarian reserve, which is of great importance in reproductology.

Micronutrient supplementation is a key factor for physiological pregnancy and directly correlates with positive maternal outcomes, has a direct impact on neonatal health and subsequent development. A relationship was found between the insuff icient supply of mothers with nutrients and preeclampsia, fetal growth restriction, neural tube defects, skeletal deformities, and low birth weight. Multicomponent vitamin and mineral complexes intended to use in the pregravid period, during pregnancy, and lactation allow the entry of essential micronutrients, such as iron, folates and other B vitamins, iodine, zinc, and antioxidants, into the body at the physiological daily requirements. This review presents current evidence regarding the needs for macronutrients and micronutrients during pregnancy, the risks and consequences of their deficiency, and the impact of additional exogenous intake on pregnancy outcomes.

Objective. To assess the risks of pregnancy complications in patients with false-positive results (FPRs) of screening for fetal chromosomal abnormalities. Subjects and methods. Combined screening was carried out to determine the risk of fetal chromosomal abnormalities in 2500 patients. The course of pregnancy and its outcomes were analyzed in 1618 cases without fetal chromosomal and structural abnormalities. Results. In accordance with the screening results, the investigators identified 2 groups: 1) FPRs of screening (n = 55); 2) its low-risk results (n = 1563). Groups 1 and 2 displayed a statistically significant difference in the incidence of the following complications: spontaneous abortions before 22 weeks of gestation (9.1% and 0.7%) (Relative risk (RR), 12.9); preterm birth (23.6% and 3.97%) (RR 5.9); birth of a low-weight fetus (16.36% and 3.67%) (RR 4.1);perinatal death (3.6% and 0.06%) (RR 113.7), respectively. Conclusion. Patients with FPRs of screening are a high-risk group for pregnancy complications.

Objective. To evaluate the effectiveness of an integrated approach using intravaginal peloid therapy and oral dydrogesterone to improve an outcome in subsequent pregnancy in women with unexplained sporadic loss of early pregnancy. Subjects and methods. A prospective, open-label, randomized study. Randomization was conducted using the envelope technique. The study enrolled 40 reproductive-aged women after sporadic pregnancy loss at less than 12 weeks of gestation. Group 1 consisted of 20 patients who, after spontaneous abortion, received peloid therapy using a gel based on Dead Sea mud. In the third menstrual cycle after abortion, the patients were prescribed 60 ml administered as a single intravaginal injection over 60 minutes for 12 days on days 7-8 of the menstrual cycle. If the period was delayed, a pregnancy test was carried out and when its results were positive, dydrogesterone was prescribed in a daily dose of 20 mg up to 20 weeks’ gestation. After spontaneous abortion, 20 patients in Group 2 underwent traditional rehabilitation, including physiotherapy and vitamin-mineral complexes. Primary and secondary outcomes were evaluated. The primary outcomes were the levels of estradiol (E2) and progesterone (PG), the frequency of ovulatory cycles, and that of recording the full secretory phase (histological examination of the endometrium on day 24 of the fourth menstrual period). The secondary outcomes were the rate of pregnancy during a year after completing rehabilitation, the frequency of recording heartbeats at 12 weeks of gestation, and the rate of live birth.All the patients underwent general clinical and special gynecological examinations. Enzyme immunoassay was used to measure the level of E2 on days 2-5 of the menstrual period and that of PG on days 21-22 of the second and fourth menstrual ones. A test was carried out to detect ovulation. All the patients underwent endometrial biopsy, followed by histological examination, on days 23-24 of the fourth menstrual period. Results. All the patients enrolled in the study completed the planned protocol. The obtained results showed that there were no statistically significant differences in the levels of E2 and PG in the patients of the comparable groups (p>0.05). In the first menstrual period after a miscarriage, anovulation occurred in 15% and 42% of women, respectively; and the inadequate luteal phase (ILP) was observed in 55% and 42% (p=0.003). Three months after a miscarriage, anovulatory cycles were recorded in only the patients (39%) in Group 2 (p=0.008). Pipelle endometrial biopsy showed the presence of a full secretory phase and the correspondence of the endometrium to the phase of the cycle in 55.5% and 16.7% of patients, respectively (p=0.035); ILP in 38.9% and 61.1% and chronic endometritis in 16.7% and 55.5% (p=0.035). During a year after completion of rehabilitation, the occurrence of pregnancy was recorded in 17(85%) women in Group 1 and in 8 (40%) patients in Group 2 (p=0.008). Fetal heart activity was recorded in all these women at 12 weeks’ gestation. There were 16 (80%) and 7 (35%) live births, respectively (p=0.01). The absolute benefit increase (ABI) when applying the integrated approach was 45%. The relative benefit increase (RBI) was 113%. That is, to achieve pregnancy in one woman with sporadic unexplained pregnancy loss within one year, it is necessary to treat two patients in this way. The odds ratio of the probability of obtaining a positive result in the use of peloid therapy versus traditional treatment was 8.50 [1.88-38.47]. Conclusion. Thus, the comprehensive approach including intravaginal peloid therapy at the preconceptional stage and administration of dydrogesterone, when pregnancies of less than 20 weeks’ gestation is recorded, is more effective than the traditional approach and can improve outcomes of subsequent pregnancy in patients with sporadic unexplained pregnancy loss. The combined use of peloid therapy and dydrogesterone contributes to the restoration of the biphasic cycle in patients with a history of early reproductive losses, to the creation of the full secretory phase, to the lower incidence of chronic endometritis, and allows a greater than twofold increase in live birth rates.

Objective. To study and compare the parameters of the activity-dormancy cycle in fetuses having various degrees of growth restriction in the presence and absence of disorders of placental circulation in the third trimester of pregnancy. Subjects and methods. The presence and components of the activity-dormancy cycle were assessed in the fetuses of 43 women with singleton pregnancy at 34/35 weeks and at fetometric values below the 10th percentile. All the women underwent great artery Doppler studies in the mother-placenta-fetus functional system. According to the presence and absence of impaired placental hemodynamics, the pregnant women were divided into 2 groups. Groups 1 and 2 contained 33 and 10 fetuses, respectively. The newborn infants were divided according to the severity of hypotrophy, by using the tables proposed by G.M. Dementieva et al. (1984). Results. The activity-dormancy cycle was formed only in 33% of the fetuses in Group 1 and in 40% of those in Group 2. Half of these fetuses were found to have grades 2 and 3 hypotrophy; the remaining fetuses had grade 1 hypotrophy. The duration of dormancy in the cycle was reduced equally by 40%, and the amplitude of the heart rate and motor-cardiac reflex decreased by 50% and 19% in the fetuses of Groups 1 and 2 women, respectively, as compared with in the fetuses of healthy women during physiological pregnancy. There was an inverse correlation between the duration of dormancy in the activity-dormancy cycle and the severity of neonatal hypotrophy (r = -0.35; p = 0.05). It was found that the more severe disorders of placental circulation were observed, the less frequently the fetal activity-dormancy cycle was formed (r = -0.39; p = 0.021). Conclusion. The activity-dormancy cycle and its parameters can serve as qualitative and quantitative criteria for growth restriction and developmental delay in fetuses having prenatal fetometric values between the 5th and 10th percentiles. The integrated approach to prenatal diagnosis of growth restriction and developmental delay will be able to adequately assess fetal adaptive capabilities when planning the timing and mode of delivery.

Aim. To identify the contemporary features of the development and progression of the most severe forms of PE and its complications, specify medical errors and management flaws in obstetric care associated with maternai deaths (both in the outpatient and hospital settings), and conduct the next stage of the confidential audit of maternai mortality due to PE and eclampsia in the regions of the Russian Federation in 2017-2018. Materials and methods. The audit was based on a retrospective analysis of primary medical documentation of 25 cases of maternai deaths from preeclampsia, eclampsia, and their complications in 2017-2018 in the Russian Federation. The data sources included outpatient medical records, maternity records, protocols of clinical examinations, inpatient medical records, and anatomic pathology reports. The documentation was provided by the Department of Child’s Care and Maternity Services of Minzdrav of Russia. Results. In 2017, according to Minzdrav of Russia, 80.9% of maternal deaths were avoidable (preventable and amenable). Analysis of our findings and literature showed that main complications of PE and eclampsia accounting for the majority of maternal deaths included cerebral edema with brainstem dislocation, multiple organ failure, massive coagulopathic hemorrhage, and, most notably, increasing incidence of stroke. We also report the most common medical errors and management flaws in obstetric care during pregnancy, delivery, and postpartum associated with maternal deaths. Conclusion. A thorough analysis of all cases of maternal deaths made it possible to formulate and substantiate several recommendations aimed at reducing maternal mortality due to PE, eclampsia, and their complications.

Objective. To analyze trends in the incidence of corpus uteri cancer (CUC) in the Omsk Region in 2002-2018 to prioritize cancer prevention in patients with endometrial hyperplasia (EH). Material and methods. A continuous descriptive observational retrospective epidemiological study of CUC incidence rates was conducted using official statistics. Results. There was a moderate tendency for higher CUC incidence rates in the region (Growth rate (Gr) = +1.8%; p < 0.001) and in the Russian Federation (Gr = +1.7%; p <0.001). The highest proportion was 32.3% of women aged 60-69 years. There was a moderate tendency for increased CUC incidence rates among 30 to 39 year olds and a marked tendency for higher ones in women aged 35-39 years (Gr = +5.6%; p <0.05). A rationale was provided for an integrated approach to managing patients with EH in the context of prevention of the recurrent disease. Conclusion. It was established that the Omsk Region showed a rise in CUC incidence and a tendency for patients with th is disease to become younger. One of the measures to reduce the risk of HE recurrence and progression is the need for a preventive therapy cycle, by taking into account endometrial morphological control.

Objective. To investigate the features of the course of pregnancy and labor and the health status of newborn babies born to HPV-positive mothers and women who had undergone vaccination against papillomavirus infection (PVI) in adolescence. Subjects and methods. A survey was conducted in 440 women aged 18 to 36 years, who were divided into 2 groups: 1) HPV-negative patients, who undergone vaccination against PVI mainly in adolescence, as well as at reproductive age; 2) HPV-positive patients who had not been vaccinated or treated for PVI. The course of pregnancy, its complications, as well as outcomes and neonatal health status were studied in the comparison groups. Results. Gestational and postnatal complications were found to have much less common in the group of women who had undergone quarivalent HPV vaccination than in that of HPV-positive patients who had not been vaccinated and treated for PVI during pregnancy. Conclusion. The findings showed that HPV vaccination itself had a pronounced effect on the onset of pregnancy, its course and outcome in the mother and fetus, as well as safety. These investigations require further consideration and studies of a number of issues related to the follow-up of an infant and his/her immunity, as well as confirm the need for urgent inclusion of vaccination in Russia’s immunization schedule for teenagers.

Objective. To investigate the pattern of prehospital obstetric and gynecological care defects, claims for which have not been settled within the healthcare system and have resulted in legal proceedings. Material and methods. During the investigation, the author studied 152 clinical cases associated with the provision of obstetric and gynecological care. In the pattern of these cases, there were 70 adverse outcomes of obstetric care, 69 disputes on gynecological care quality, and 13 cases related exclusively to outpatient care in the pre- and postpartum periods. The materials were anonymized in the open-access databases. Forensic medical expert opinions were reviewed. The inclusion criteria were clinical cases that had led to a judicial dispute between the healthcare facility (HCF) and the female patient, her relatives, and representatives. Results. In the presence of unfavorable obstetric care outcomes, medical care defects were identified in 59/70 (84.3%) cases. These defects were arbitrarily divided into 7 groups. The relationship of defects to an unfavorable obstetric care outcome was assessed. The leading factors were incorrect delivery tactics generally due to the underestimation of an obstetric risk and the inadequate follow-up of the maternal and infant health status, as well as prehospital obstetric care defects. The nature of a direct or indirect relationship between the defect and the outcome affected the responsibility of a healthcare facility. The direct relationship between the outcome and the outpatient care defect was established if the pathology caused by severe birth defects was undetected. The pattern of defects in the outpatient management of pregnant women was as follows: inappropriate examination and follow-up (ultrasound diagnosis, CT scanning, screening, etc.) in 15 (63%) patients, incomplete history in 10 (41%), non-observance of the schedule for visits to physicians in 8 (33%), no perinatal conference in the three-level healthcare facility in 8 (33%), untimely hospitalization in 5 (21%), and pathology overdiagnosis in 1 (4%). A complex of defects generally took place. In gynecological practice, defects in the outpatient phase accounted for almost three quarters of trials. Conclusion. Outpatient medical care defects in the pattern of obstetric cases with adverse obstetric care outcomes have a high frequency. A significant number of unresolved conflicts within the healthcare system are caused by the communication deficits between the woman and the physician (the midwife).

Background. Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) or Herlyn-Werner-Wunderlich (HWW) syndrome is an associative genitourinary tract malformation: uterus didelphys and unilateral aplasia of its lower two-thirds and the kidney. Despite the fact that the defect occurs in 0.16-10% of women with genital tract malformation from the detection of renal aplasia to the identification of genital malformation, is present throughout childhood and pre-puberty; that is, an average of 10-12 years. Moreover, lack of awareness about the possible association between genital and urinary tract defects causes girls to frequently undergo wrong surgical interventions. As a result, the common outcome of these interventions is the formation of strictures, fistulas, and suppurations of the closed vagina and cicatricial deformities of the adequate second vagina in every three patients. Case report. The paper describes three clinical cases of girls with HWW syndrome that was timely unestablished, which resulted in various complications. Conclusion. Detection of urinary tract malformation in a girl at any age requires that a pediatric and adolescent gynecologist should mandatorily examine in order to timely diagnose associated developmental abnormalities. Patients with genitourinary tract defects should be assisted at third-level specialized hospitals, which will be able to minimize the risk of subsequent complications.