No 1 (2022)

Infertility of unclear genesis is diagnosed in a married couple with no obvious defects in the reproductive system. A number of cases with infertility of unclear genesis are found to have impaired processes of fertilization and early embryogenesis through in vitro fertilization (IVF) programs. This may suggest that infertility of unclear genesis may be due, inter alia, to gamete defects. The sources of world literature have been reviewed in the databases Scopus, Web of Science, MedLine, Cochrane CENTRAL, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE), EMBASE, Global Health, CyberLeninka, and Russian Science Citation Index (RSCI) for a comprehensive study of the contribution of the oocyte factor to infertility. Diminished oocyte quality in most women is associated with their natural aging. However, some young women have low rates of fertilization and embryo development during IVF, which indirectly indicates the irregularly low quality of their oocytes and may be a manifestation of accelerated aging processes. In another portion of women, the low quality of oocytes is probably due to mutations in the genes encoding proteins involved in the processes of oocyte development. The low quality of oocytes may be associated with mutations in the PATL2, TUBB8, WEE2, and PAD16 genes, the change in expression of which leads to impaired oocyte maturation at metaphase of meiosis II (MII), to decreased oocyte ability for full fertilization and embryo formation, and to early embryonic development arrest, respectively. It is difficult to develop screening tests to identify these mutations, as they often occur sporadically and are not Inherited due to infertility. Conclusion: Genetic diagnosis is necessary to optimize treatment policy for patients with infertility, including that of unclear genesis, and to reduce the time before making a decision, for example, on the use of donor oocytes.

It is generally accepted that the priority in the choice of treatment belongs to drug therapy, since an adequately and timely selected regimen can prevent the need for surgery. To date, there is no universal approach to medical treatment for endometriosis. However, given that drugs control, but do not cure the disease, long-term pharmacological treatment may be required until pregnancy or, sometimes, physiological menopause occurs. This review presents the current state of the problem of medical treatment for endometriosis and the available clinical guidelines on this topic, including in the treatment of early reproductive-aged patients. It summarizes currently available information on approaches to treating endometriosis. The review discusses the drug groups that show the highest efficacy in treating endometriosis and dysmenorrhea associated with endometriosis (gestagens, combined oral contraceptives, gonadotropin-releasing hormone agonists), as well as the promising drugs that go through clinical trials (selective progesterone and estrogen receptor modulators, metformin, statins, cabergoline, etc.). Particular attention is paid to the mechanisms of anti-endometrioid action of gestagens, which is associated not only with the induction of endometrial decidualization, but also with anti-inflammatory and immunomodulatory effects, the decrease in the transcription of neuro- and angiogenic factors, and the suppression of the proliferative activity of foci and trophism to the latter, by inhibiting the growth of blood vessels and nerves. Conclusion: The available treatment regimens for endometriosis combine symptomatic and pathogenic effects that determine the long-term efficacy, safety profile, and rationale, starting from the diagnosis at an early reproductive age.

Objective: To determine the impact of physical activity on the pelvic floor muscles in women. Materials and methods: The review provides scientific evidence over the past 5 years regarding the impact of physical activity on stress urinary incontinence. Results: Sports and fitness are associated with stress urinary incontinence in women. Stress urinary incontinence is most common during aerobic exercise associated with shock to the lower extremities: volleyball, running, and trampolining. The pathophysiology of this problem is associated with two key factors: an increase in intraabdominal pressure and a failure of the pelvic floor muscles, which is common in women involved in sports. Unlike specialized exercises, general exercise is not only inappropriate for strengthening the pelvic floor muscles, but it also increases the likelihood of pelvic floor prolapse. Conclusion: The benefits of an active lifestyle for women, such as prevention of many diseases and improvement of health and quality of life, substantially tackle the problem caused by stress urinary incontinence. Strategies are being actively developed to reduce the incidence of stress urinary incontinence in women involved in sports.

Objective: To investigate the predictive value of angiogenesis-related serum markers in the third trimester of pregnancy to assess the likelihood of placenta accreta spectrum (PAS) and the prognosis of emergency delivery in patients with placenta previa. Materials and methods: This case-control study included women in the third trimester of pregnancy (2638 weeks) with (group I, n=46) and without PAS (group 2, n=42) managed at the Perinatal Center of Krasnodar Regional Clinical Hospital No. 2. All participants were tested for serum vascular endothelial growth factor (VEGF), placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), determined by enzyme-linked immunosorbent assay. PAS was verified intraoperatively during delivery and by histological examination of the surgical specimens. The correlation between biomarker levels of and the depth of placental implantation was analyzed. The predictive value of biomarkers was assessed using multivariate logistic regression and ROC analysis. Results: With an increase in gestational age, patients with PAS group had significantly higher levels PlGF and lower sFlt-1/PlGF ratio than patients without PAS with a difference between groups at ≥37+0 weeks gestation [Me (IQR) : 778 (751-1057) versus 190 (171-369) pg/ml, p=0.005 and 1.1 (0.8-1.4) versus 8.0 (2.8-20.3), p=0.003, respectively]. The ratio of sFlt-1/PlGF <2.5 predicts PAS with sensitivity (Se) of 65.2% (49.8-78.6%), specificity (Sp) of 59.5%, (43.3-74, 4%), positive predictive value (PPV) of 63.8% (53.6-72.9%), negative predictive value (NPV) of61.0% (45.9-71.4%), area under ROC-curve (AUC) of0.624 (0.514-0.725), p=0.018. The inclusion of maternal age and a history of caesarean section in the predictive model increases the predictive accuracy: Se = 87.0% (73.7-95.1%), Sp = 78.6% (63.2-89.7%), PPV = 81.6% (71.1-89.9%), NPV = 84.6% (72.0-92.1%), aUc=0.886 (0.800-0.944), p<0.001. The PIGFlevel (pg/ml) statistically significantly correlates with the PAS depth (Spearman's rho=0.292; p<0.01). The sFlt-1/PlGF ratio <2.5, combined with maternal age and a history of cesarean section predicts the likelihood of emergency delivery with placenta previa with Se=40.0% (21.1-61.3%), Sp=92, 1% (82.4-97.4%), PPV=66.7% (38.4-88.2%), NPV=79.5% (68.480.0%), AUC=0.789(0.689-0.869), p<0.001. Conclusion: Increased levels of angiogenesis-related serum markers in the third trimester can be used to predict PAS and emergency delivery in pregnant women with placenta previa.

Objective: To investigate the clinical characteristics of patients with peripartum cardiomyopathy (PPCM) and the indications, timing, and mode of delivery. Materials and methods: This study retrospectively analyzed medical records of 16 patients diagnosed with PPCM from 2012 to 2021, who were divided into those who developed PPCM before (n=10) and after (n=6) delivery. Results: PPCM manifested before delivery at 26-37 weeks in 62.5% of patients and 6 cases (37.5%) on days 1-9 postpartum. All patients with PPCM had left ventricular heart failure (HF) symptoms with an acute onset manifesting as NYHA functional class III/IV in 37.5% (n=6). Left ventricular ejection fraction (LVEF) at the onset of PPCM ranged from 19 to 45%, with a median of 38.5% (24.75%; 40%). Among the patients with PPCM onset before delivery (n=10), 100% were delivered by cesarean section. Of these, 70% had cardiovascular indications, and three patients (30%) underwent early delivery due to a significant decrease in LVEF with decompensated HF. Ten and 60% of the patients required emergency and urgent Cesarean section, respectively, and 30% had elective surgical delivery due to stable hemodynamics against the background of decreased LVEF. Two patients (12.5%) required mechanical circulatory support systems, and one (6.25%) required heart transplantation. In 87.5% of patients, LVEF was restored to > 45%; mortality was 6.25%. Conclusion: Based on the analysis of PPCM clinical cases managed at the Almazov NMRC, indications for delivery were evaluated. Cardiovascular indications were identified in 70% of patients who had decompensated HF despite the ongoing therapy. Management of pregnancy and childbirth of women with PPCM is determined on a case-by-case basis; therefore, a generalization of the experience, based on the clinical cases of 16 patients, is of great importance for the further development of obstetric clinical protocols.

Objective: To improve intrauterine adhesions (IUA) diagnosis accuracy and integrate three-dimensional echography into the algorithm for examining patients with IUA. Materials and methods: The study comprised 79 patients with suspected IUA. We analyzed various functions and modes of three-dimensional echography, including multiplanar reconstruction mode, Vocal, OmniView mode, frontal section (using HI, SRI CRI functions or Render Mode automatic versions, surface scanning mode with a combination of minimum/maximum intensity), ultrasound tomography mode. The examination was performed on the Canon Aplio 500 ultrasound system to assess the degree of obliteration and septal architectonics. The role of three-dimensional hydrohysteroscopy in navigation during endoscopic adhesiolysis was determined. Results: Echographic criteria for assessing uterine cavity obliteration by three-dimensional echography were developed. Echographic features of the three-dimensional uterine model, including "muscular invagination" (frontal section, OmniView mode, ultrasound imaging), hourglass and discontinuous M-echo character (frontal section, OmniView mode), allowed for a detailed evaluation of uterine cavity obliteration, its architectonics, and determine the intraoperative strategy for IUA destruction. Conclusion: The developed three-dimensional criteria enabled developing a unified strategy to guide pre-surgical planning, reduce the risk of intraoperative complications and disease recurrence. To reduce the risk of uterine perforation and surgical trauma in patients with IUA, it was suggested to form a surgical team consisting of an endoscopy specialist and a diagnostic medical sonographer.

Objective: To study data on the development of online health resources to provide obstetric and gynecological care in Moscow healthcare facilities. To present the possibilities of the developed online resource as a tool for preventive measures to provide medical care for women during the COVID-19 pandemic. Materials and methods: The investigators analyzed online health resources to develop the online resources of Moscow healthcare facilities providing obstetric and gynecological care. They developed an online resource that provided an opportunity to be on air with the participation of specialists from the women’s health clinics of the S.I. Spasokukotsky City Clinical Hospital, Moscow Healthcare Department. Results: The development of online health resources is aimed at creating the healthcare facility’s competitive image and, to a lesser extent, at doing information work with the population; therefore, the creation of highly professional Internet resources is relevant, especially during the COVID-19 pandemic. The study showed an insufficient amount of information about the existing online resources in the social network Instagram and the time when the patient visited his/her physician for preventive work in the healthcare facilities providing primary specialized medical care. The statistics of visits to the created resource "Academy of Reproductive Health" suggests that the patients need to have high-quality information and there is an increase in its availability on the issues of reproductive health. Online communication for physicians contributes to the expansion of professional competencies, which contributes to the provision of affordable and high-quality medical care to women, and the healthcare facility is a tool to implement preventive measures. Conclusion: The COVID-19 pandemic, insufficient information on the existing online resources, and the time for preventive work in healthcare facilities providing specialized medical care, require the development of online resources containing information on obstetrics and gynecology, contributes to the development of patient information literacy, provides an opportunity for online communication with a physician, which will be able to improve the availability and quality of obstetric and gynecological care.

Objective: To present the authors’ own experience with monotherapy for bacterial vaginosis with vaginal gel (Vapigel) in reproductive-aged patients. Materials and methods: The efficiency and compliance of monotherapy for bacterial vaginosis with intravaginal gel (Vapigel) were evaluated in 30 patients on the basis of the time course of changes in clinical symptoms, vaginal fluid pH-metry, the quantitative characteristics of representatives of the vaginal microbiota, and treatment adherence. Results: Vaginal gel (Vapigel) monotherapy for bacterial vaginosis eliminates subjective complaints and clinical symptoms of the disease in 29/30 (96.7%) patients, determines the detection rate for Lactobacillus spp. at a concentration of107 CFU/ml in 26/30(86.6%), and restores the physiological vaginal discharge pH level in 28/30 (93.3%). Adherence to the use of Vapigel was noted in 25/30 (83.3%) patients; no adverse events were observed in 30/30 (100.0%) patients. Conclusion: Clinical efficacy, acceptability, absence of adverse events, and treatment refusals determine the advisability of using Vapigel as a monotherapy for bacterial vaginosis in reproductive-aged women as an important component in the implementation of measures to reduce the prescription of antimicrobial drugs in clinical practice.

Background: A decreased glomerular filtration rate in patients with chronic kidney diseases with the development of renal failure leads not only to infertility and amenorrhea, but also to a high risk for the unfavorable course and outcomes of pregnancy. More than half of babies whose mothers require renal replacement therapy are born prematurely and are underweight. An increasing number of hemodialysis hours minimize the risk of antenatal fetal death because of the improved monitoring of urea nitrogen clearance. Case report: This clinical observation gives the history data of a 34-year-old patient with the absence of both kidneys after bilateral nephrectomy as part of a one-stage donor kidney transplantation and then transplantatectomy for end-stage renal failure in the presence of rapidly progressive glomerulonephritis and allograft rejection, as well as the features of the course of her pregnancy and perinatal outcomes. The patient received renal replacement therapy for a year before and throughout the pregnancy. Conclusion: Timely correction of hemodialysis parameters and metabolic disorders could prolong pregnancy to the period that was prognostically favorable from the perinatal points of view.

Background: Malformations of internal genital organs have various clinical manifestations. Anatomical structural abnormalities of the genitals can cause serious complications in obstetric practice. Case report: The paper describes a case of necrosis of the right horn of a bicornuate uterus, which results from ligation of the ascending branch of the right uterine artery. It depicts the clinical presentations and presents the data of additional studies. Particular emphasis is placed on the causes of delayed diagnosis of complications. A brief review of the literature on this problem is given. Conclusion: The cause of uterine necrosis was the ligation of the ascending branch of the right uterine artery, which was the only source of blood supply to the right uterine horn of the abnormally formed uterus. Uterine necrosis can be timely diagnosed, by comparing its clinical presentation with additional diagnostic test data (the absence of the normal uterine architectonics, the presence of gas bubbles in the myometrium, and its avascularization). Congenital malformations of the internal genital organs are accompanied not only by a change in their anatomical shape, but also by their impaired blood vessel formations, which should be taken into account when examining and delivering patients with this pathology.