No 10 (2020)

Aim. To improve the accuracy of prenatal diagnosis of placenta accreta and compliance of the research protocols with international requirements by using standardized ultrasound criteria. Materials and methods. The review includes scientific articles and meta-analyses of various approaches to ultrasound and radiologic imaging of placenta accreta over the past 5 years. Results. Based on the generalized results of the analyzed scientific information, the standardized ultrasound criteria for placenta accreta were proposed, which contribute to the improvement of prenatal diagnosis of the condition, minimization of diagnostic errors and formulation of a standard examination protocol. Conclusion. In accordance with the recommendations of expert working groups of the most signif icant international professional communities, the primary role of echography in prenatal diagnosis and screening of placenta accreta was determined, as well as the need to use a standard protocol with registration of each ultrasound sign.

Functional assessment of the fetal cardiovascular system is an important method for monitoring its condition in health and disease. The myocardial performance index (MPI) based on the principles of heart cycle phase analysis is a new information indicator for the systolic and diastolic functions of the fetal heart. Since the introduction of MPI, its correct definition makes significant demands for a procedure to record cardiac time intervals and their reproducibility and to develop standard indicators. Application of MPI shows early and significant changes in fetal cardiac function in diseases, such as fetal growth retardation, maternal diabetes, severe heart defects, and fetofetal transfusion in monochorionic twins. Conclusion. Further studies of the sensitivity of MPI to cardiac loading conditions, its correlation with the results of tissue Doppler imaging and automated calculation will be able to use this index as an effective diagnostic tool in studying the fetal cardiovascular system in different types of obstetric pathology.

Premature ovarian insufficiency (POI) is a multifactorial disease with a significant contribution of genetic factors; one of the leading socially significant complaints in this disease is persistent infertility with a high resistance to standard treatment methods. The method for activating follicular growth, which was first described by K. Kawamura, A. Hsueh and co-authors, turned out to be effective and it was confirmed clinically and by molecular genetic research data. Currently, it has been used in various modifications in more than 6 countries around the world. In Russia, the first operation based on surgical activation of ovarian function was performed by academician of the Russian Academy of Sciences L.V. Adamyan on March 06, 2019. For the first time in Russia, a 32-year-old patient suffering from premature ovarian insufficiency with dichorionic diamniotic twins underwent planned operative delivery by caesarean section at 37 weeks and 4 days of gestation. The operation was performed at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia, on October 01, 2020. The patient became pregnant spontaneously 1.5 months after undergoing surgical treatment aimed at restoring reproductive potential. A one-stage surgical procedure for activation of ovarian function was performed by academician L.V. Adamyan on December 13, 2019. Conclusion. This clinical case of a spontaneous pregnancy and delivery in the patient with POI demonstrates that this operation is appropriate to be performed in patients with a noticeable decrease in the ovarian reserve, and it can be considered as an alternative to oocyte donation.

Aim. To identify the percentiles of the cerebral-placental-uterine ratio (CPUR) and investigate the likelihood of giving birth to low birth weight infants in patients with reduced CPUR. Materials and methods. The study retrospectively analyzed pregnancy outcomes and f indings of 1780 Doppler studies performed in 1215 patients at 24-40 weeks of gestation. The Doppler study included measurement of pulsatility index in the fetal middle cerebral artery, umbilical cord arteries, and uterine arteries. CPUR was calculated as sequential divisions of the above parameters. Results. The study group included 79 (6.5%) newborns with birth weight <10th percentile; 1136 (93.5%) newborns with birth weight >10h percentile were assigned to the control group. The results of 1639 Doppler studies of the control group formed the basis of the CPUR percentile intervals. A decrease in CPUR <5th percentile statistically significantly increased the odds of giving birth to low birth weight infants [OR 5.0 (95%CI; 3.1-8.1) (p <0.0001)]. Conclusion. CPUR is a combined measure that is statistically significantly associated with increased odds of delivering low birth weight babies. These pilot values can be used for further prospective studies.

Objective. To study the course and outcomes of twin pregnancy following assisted reproductive technology (ART). Materials and methods. A total of 669 pregnant women with dichorionic diamniotic twins were examined. The patients were divided into two groups: group I included 266 (39.8%) patients who became pregnant after ART and group II consisted of 403 (60.2%) patients who became pregnant spontaneously. All pregnant women had a comprehensive examination, including fetometry, determining the length of the cervix, Doppler assessment, and treatment of all complications. The course and outcomes of pregnancy were evaluated in patients of both groups. Results. Group I (ART) compared to group II (spontaneous twin pregnancy) demonstrated a higher incidence of pregnancy complications, namely anemia in the 1st trimester (29.3 and 19.1%, respectively, р<0.001), miscarriage (3.4 and 0.5%;р<0.001), cervical incompetence (17.1 and 5.2%;р<0.001), preterm birth (59.5and 40.9%; р<0.05), fetal growth restriction (46.2 and 38.4%; р=0.04), oligohydramnios (6.6 and 2.7%; р<0.001), gestational diabetes mellitus (13.6 and 8.5%; р=0.01). Perinatal death also was 2.8 times higher in group I than in group II: 6.6% vs. 2.4% (р=0.01). Prematurity was found to determine most of the adverse perinatal outcomes in twin pregnancies in the ART group. Conclusion. Multiple pregnancy following ART in comparison with spontaneously conceived pregnancy is in the highest risk group due to the incidence of multiple gestational complications, therefore, the number of transferred embryos should be limited to one.

Aim. To improve the intrauterine diagnosis of fetal lymphangiomas at various locations and assess postnatal outcomes. Materials and methods. Between 2006 and 2019, 54fetal lymphangiomas were diagnosed. The most common were lymphangiomas of the neck (51.8%), abdomen (11.1%), mediastinum (11.1%), axillary region (9.3%), and thigh and lower leg (9.3%). Less common were lymphangiomas of the chest and anterior abdominal wall (5.6%) and multiple lymphangiomas (1.9%). Results. Ultrasound visualization of lymphangiomas showed masses of various sizes with multiple septations filled with fluid and without vascularization zones. The pregnancy resulted in a live birth in 50 cases; 49 infants were referred to the neonatal surgery for further treatment, and in one fetus the tumor disappeared before birth. Three patients underwent termination of pregnancy. There was one intrapartum fetal death. Thirty-three infants underwent surgery with favorable outcomes. Conclusion. Ultrasound imaging is useful for the in utero diagnosis of such a rare pathology as fetal lymphangioma. In the absence of concomitant pathology, the prognosis for the newborn is favorable.

Objective. To study the state and time of thinning of uterine scars after cesarean section (CS) in pregnant women using ultrasound monitoring. Materials and methods. The study included 148 pregnant women at periods of 6-12, 13-20, 21-29, 30-36 and 37-40 weeks gestation; the patients were divided into groups based on the initial thickness of the residual myometrium in the scar area; pregnancy outcomes were studied. Results. Patients in group A whose residual myometrium was more than 3 mm had a late (by 37 weeks) and gradual (on average, 1 mm per trimester) thinning of the scar. The outcomes were a full-term pregnancy in 89.1% of patients, and preterm delivery at 30-36 weeks in 10.9% of cases (vaginal delivery in 17.2%, CS in 82% of cases). Patients of group B whose residual myometrium was 2-3 mm had a full-term pregnancy in 84.6% of cases, preterm delivery at 30-36 weeks in 15.4% (CS in 92.3%; CS and hysterectomy in 7.3% of cases). Pregnant women in group C had residual myometrium less than 2 mm, and its thickness was less than 1 mm in 45.7% of them at 26 weeks of gestation. Patients in this group had a high incidence of placenta previa and placenta increta (11.3%) and adverse outcomes (full-term pregnancy in 31.4%, preterm delivery at 30-36 weeks in 31.4%, preterm delivery at 22-29 weeks in 11.4% of cases). CS was performed in 57.7%, CS and metroplasty were done in 8.5%, CS and hysterectomy were performed in 5.65% of cases. Preterm delivery at 22 weeks was noted in 28.1% of cases (metroplasty - 22.5%, hysterectomy - 5.65%). Conclusion. Pregnant women whose residual myometrium is 1 mm thick or less in the period up to 26 weeks gestation are an extremely high-risk group and require special monitoring (it is recommended to perform ultrasonography at 12, 18, 22, and 26 weeks gestation).

Objective. To determine the diagnostic value of two-dimensional shear wave elastography in patients with cervical cancer. Materials and methods. Two-dimensional shear wave elastography was performed in the control group (in 20 women) and in 18 patients with confirmed cervical cancer. The study was performed using the Aixplorer ultrasound system (SSI, France). Results. There was a statistically significant (p<0.001) increase in the stiffness (Me=66.6 kPa (51; 88.7)) of cervical tissues affected by cancer, compared to the control group (Me=21.1 kPa (20; 23.5). ROC analysis showed that when using a 32 kPa cut-off value, the sensitivity, specificity, and prognostic value of the positive and negative results were 96%, 89%, 86%, and 95%, respectively. AUROC for this threshold reaches 0.97. Conclusion. Two-dimensional share wave elastography may be a new objective method for diagnosing cervical cancer.

Objective. To determine the possibilities and advantages of various modes of three-dimensional echography and echohysterography (3DEG/3DEHG) in the diagnosis of Mullerian duct anomalies (MDAs). Materials and methods. The authors examined 450patients of reproductive age (from 15 to 45years) with various malformations of the pelvic organs. The study inclusion criteria were suspected MDAs according to previous ultrasound imaging; abnormal uterine bleeding; infertility; and recurrent miscarriage. It should be noted that in 23% of the examinees, the revealed defect was unaccompanied by any clinical manifestations and was a routine ultrasound finding during screening. 3DEG/3DEHG was done on a Canon Aplio MX device using a threedimensional transvaginal probe (6. 5 MHz). Ultrasound was performed on the day of the first patient visit to a physician and again on the 5th-7th day of the menstrual cycle. To obtain informative echograms, the authors used different available three-dimensional echography modes, such as multiplanar reconstruction, Omni-view, image inversion, Glass body vascular mode, and tomographic ultrasound imaging. 3DEHG was performed according to the authors’ standard procedure using catheter balloons, sterile saline that was delivered through an automated Hamou Endomatpump (KarlStorz, Germany). Results. The results of elastography were compared with those of MRI, hysteroscopy, laparoscopy, and laparotomy in 70, 92, 23, and 8.5% of cases, respectively. Based on the studies mentioned above, the authors identified an arcuate uterus (Class U0) in 60patients; a T-shaped uterus and accessory and cavitated uterine masses (ACUM) (Class U1) in 4 and 2 patients, respectively; incomplete and complete intrauterine septa (Class U2a/b) in 78 and 85 examinees, respectively; a bicornuate uterus (Class U3a) in 92; dimetria (Class U3b) in 91, a septate uterus (Class U3c) in 7; and a unicornuate uterus (Class U4a/b) in 31. The construction and interpretation of a three-dimensional echogram of the defect are not routine and require a specialist having sufficient qualif ications, must be performed according to the regulations and be analyzed taking into account the tasks set out below. The parameters of the uterus and parametrial area, such as the shape of the uterine corpus and its size, external myometrial contour; uterine cavity shape and volume; additional anatomical structures as two reflections from the endometrium or/and endocervix, as well as additional masses in the parametrial projection, which are connected to the corpus uteri, should be consistently assessed. The authors developed clear echographic patterns of each nosological entity, which made it possible not only to diagnose the presence of a malformation, but also to classify it, as well as to obtain additional unique defect characteristics that are relevant to determine further management tactics. Conclusion. Thus, three-dimensional echography proposes a qualitatively new method for ultrasound diagnosis of Mullerian duct anomalies, which is similar to MRI and makes it possible to get an echogram as a virtual display of real anatomy. A combination of various modes will be able to yield additional information on vascular architectonics, to predict possible pregnancy complications, to form clear indications for defect correction, and to navigate during intrauterine surgery. 3DEHG is an additional highly specif ic method used for differential diagnosis or in case of the difficult-to-interpret altered anatomy associated with other endometrial and myometrial diseases.

Objective. To improve the effectiveness of antenatal echographic and molecular genetic diagnosis of tuberous sclerosis. Materials and methods. The authors analyzed 13 cases of antenatal detection of cardiac rhabdomyoma at 20 to 36 weeks’ gestation in pregnant women who had undergone perinatal consultation at the Academician V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology in October 2017 to March 2020. All the fetuses had undergone neurosonography in order to detect brain diseases associated with tuberous sclerosis. Clinical data on the condition of the babies born and the results of a molecular genetic study to detect mutations in the TSC1 and TSC2 genes were obtained in 9 cases. Results. Primary echographic imaging of rhabdomyoma was observed in 69% of cases in the third trimester. Echography detected multiple subcortical tubers in the brain in half (5/10) of the fetuses with multiple cardiac rhabdomyomas. Follow-up analysis revealed subcortical and subependymal tubers, as well as mutations in the TSC1 and TSC2 genes in 6 infants with multiple cardiac rhabdomyomas. Conclusion. Echographic detection of tubers in the brain of fetuses with multiple cardiac rhabdomyomas substantially increases the risk of tuberous sclerosis. For early tuberous sclerosis diagnosis, it is necessary to search for new echographic markers, including brain diseases before the beginning of sulcation processes.

Objective. To provide a multiparametric ultrasound assessment of the pelvic floor in patients with genital prolapse after biofeedback (BFB) therapy and electrical pulse stimulation (EPS). Subjects and methods. The investigation enrolled 134 women with signs of Pelvic Organ Prolapse Quantification (POP-Q) Stages I-II genital prolapse. A follow-up program was implemented in 107 patients: lifestyle modification was recommended for the patients of a control group; BFB therapy and EIS were for those of a study group. Pelvic floor ultrasound multiparametric examination findings were assessed at baseline and 6 months and 1 year after the follow-up and rehabilitation program. Results. The authors provided an ultrasound multiparametric assessment of the pelvic floor after BFB therapy and EPS for grades I and IIgenital prolapse as its levelled signs in 47 (53.3%) patients and as transformation of Stage II genital prolapse into Stage I in 35(46.7%). Multiparametric ultrasound assessment confirmed the positive effect of physiotherapeutic rehabilitation for failure of the anatomical and functional structures of the pelvic floor. Endoanal ultrasound was shown to have a diagnostic advantage in analyzing the echostructure of pelvic floor elements and in detecting the pathologies that could not be scanned by using endovaginal and transperineal approaches. Conclusion. Multiparametric ultrasound for grades I and II genital prolapse has confirmed that BFB therapy and EPS are more effective than standard lifestyle modification. Endoanal ultrasound is essential for the examination of gynecological patients. The patient adherence in the follow-up and rehabilitation program is 79.9%.

Objective. To improve the effectiveness of diagnosing metastatic parasternal lymph nodes. Materials and methods. The study included 55 women diagnosed with breast cancer during the period from 2017 to 2019. Results. The patients were divided into two groups: 24 patients with metastatic lesions and 31 patients with lymphoid hyperplasia. The average shear wave velocity in the lymph node was 2.14 (0.77) cm/s in patients with lymphoid hyperplasia, it was 3.13 (1.09) cm/s in case of metastatic lesions and 2.26 (0.71) cm/s in the surrounding tissues. Shear wave velocity in metastasis was higher (p<0.0001) than one in the lymph node hyperplasia and in the surrounding tissues. The optimal threshold value was 2.385 m/s. Elastometry was informative with the following indicators: sensitivity - 77.4%; specificity - 66.7%; positive prognostic value - 75.0%; negative prognostic value - 69.6%. Elastography showed that hard consistency was characteristic of 23 (95.8%) metastatic lymph nodes, and soft consistency was in one (4.2%) case. Elastometry showed hard consistency of hyperplasia in 7 (28.0%) cases, and soft consistency in 18 (72.0%) cases. Elastography was informative with the following indicators: sensitivity - 77.3%, specificity - 69.7%, positive prognostic value - 63.0%, negative prognostic value - 82.1%. Conclusion. Comprehensive ultrasound examination of the lymph nodes, including shear wave elastography and elastometry can increase informative value of the standard ultrasound examination.

The author has carried out a systematic analysis of the data available in the literature on the use of phytoestrogens to improve quality of life and to preserve health in women during the menopausal transition and postmenopause. For the analysis, she has conducted a search for foreign and Russian publications over the past 15 years in the international citation system PubMed. The paper considers the clinical aspects of the pathological course of peri-and postmenopause. It determines the possible mechanisms of action of phytoestrogens on menopausal symptoms. There are data on the efficacy of phytoestrogens and other biologically active substances in alleviating climacteric symptoms. The results of clinical trials demonstrating the possibility of using phytoestrogens in the prevention of chronic diseases associated with aging are analyzed. Additional abilities of complex remedies to relieve climacteric symptoms are indicated. The place of phytoestrogens in the comprehensive strategy for maintaining a good quality of life and health in the ageing female population is shown. Conclusion. The given data make it possible to substantiate the use of complexes with phytoestrogens to correct moderate vasomotor symptoms and psychosomatic disorders.

The paper deals with female urinary incontinence that is a serious social and medical problem with a substantial negative impact on the physical, social, economic, and psychological well-being of women. Urinary incontinence is quite common in patients, although not all seek medical care for this problem despite the fact that there are many effective treatment options today. The paper describes different urinary incontinence types that can occur in different periods of a woman’s life. It depicts diagnostic features and possible treatment options according to the type of urinary incontinence, the degree of its severity, and the efficiency of one or other therapeutic methods. It should be noted that many of the studies described in the paper indicate that the use of antimuscarinic agents, trospium chloride in particular, in the treatment of overactive bladder, as well as in the elderly, is safe and effective in improving the well-being and quality of life of patients. Conclusion. The optimal therapeutic approach to treating overactive bladder symptoms should include drug and behavioral therapies in addition to lifestyle advice.

Objective. To present an update on the prenatal diagnosis of aortopulmonary window (APW), by using twodimensional fetal echocardiography. Materials and methods. The review includes data from foreign articles that have been published over the past 10 years and are available in PubMed on this topic. It describes two clinical cases of APW, a rare congenital heart defect. Results. The review describes the main diagnostic ultrasound projections that are informative for prenatal diagnosis of this defect and presents data from postnatal computed tomography scans of the newborn. It also shows the outcomes of surgery for this defect. Conclusion. Prenatal diagnosis of APW can be made. The connection between the aorta and the pulmonary artery can be determined using a standard three-vessel section and be suspected during routine second-trimester screening.

Studying the features of ultrasound criteria used in the differential diagnosis of primary and metastatic ovarian tumors in patients with cancer of corpus uteri cancer (CUC) is an urgent problem of modern medicine. Case report. This paper analyzes the results of examinations in 4 patients diagnosed with CUC who were suspected to have ovarian metastases during initial ultrasound examination. Histological examination diagnosed pathological masses in both ovaries in all the 4 patients: metastatic CUC in one ovary and an independent ovarian tumor in the other. Ultrasound examination revealed masses in both ovaries in all the 4 patients. In case of synchronous cancer of the corpus uteri and ovaries, the ovarian tumor structure is more frequently solid cystic with uneven clear contours, the sizes of the ovaries exceed 6.0 cm; elastography shows that the ovaries are mapped mainly as type 4 elastogram. In case of metastatic lesions, ovarian tumors are more often represented by solid masses with clear even contours; the sizes of the ovaries fail to exceed 6.0 cm or do not differ from those of intact ones, while elastography demonstrates that solid masses in the ovarian structure are mapped mainly as type 5 elastogram. Conclusion. Studying different semiotic variants of ovarian tumors in patients with CUC is necessary to improve their visualization. Timely diagnosis of ovarian neoplasms (regardless of their morphological nature) in patients with CUC is of fundamental importance, since it affects the volume of surgery and the prognosis of the disease.