No 9 (2020)

The place of extraperitoneal cesarean section (EPCS) in modern operative obstetrics is undeservedly forgotten. It is especially relevant to use this procedure in patients at high risks for pyoseptic complications, which reduces postoperative infectious complications and the need for prolonged antibiotic therapy, and also promotes early postoperative recovery. EPCS cannot completely replace cesarean section. Currently, it is possible to choose the optimal procedure for EPCS. With sufficient surgical skills, EPCS does not differ in complexity from the classical peritoneal cesarean section. Even in the era of antibacterial drugs, the EPCS procedure should be used by practitioners. Conclusion. EPCS has its own indications and contraindications and should be performed when it is more appropriate than the traditional cesarean section.

This review analyzes the current literature data on the radiodiagnosis of ovarian masses (OM), the problems of ovarian cancer screening, and modern classification methods in terms of the main characteristics and risks of OM malignancy. Ultrasound (US) is the first step in diagnostic imaging today. Many different systems have been developed to assess OM characteristics based on ultrasound indicators. One of the most promising current systems is the standardized scale to assess US results - Ovarian-Adnexal Reporting and Data System (O-RADS) that aims to improve interdisciplinary interactions between specialists and to increase diagnostic accuracy. Based on the existing O-RADS, an algorithm was presented in 2020 to assess the results and to stratify the risks of OM malignancy detected by Ovarian-Adnexal Reporting and Data System Magnetic Resonance Imaging (O-RADS MRI). This algorithm makes it possible to stratify the risk of OM malignancy, by evaluating the MRI pattern based on five formulated categories. Conclusion. According to the conducted studies, including external validation ones, O-RADS MRI demonstrates not only the accuracy of the scoring system and high efficiency, but also ease of use, which makes it possible to recommend the O-RADS MRI scale as a routine system for assessing MR images to differentiate and stratify the risks of OM malignancy in case of the uncertain degree of the latter, as evidenced by US.

Objective. To provide the current classification of spontaneous uterine ruptures, which is based on the features of their etiopathogenesis and clinical presentations, and to prove the feasibility of organ-sparing surgery for uterine injury. Materials and methods. A total of 281 histories of labor complicated by uterine rupture were retrospectively analyzed. Births occurred in the obstetric facilities of the Moscow Healthcare Department in 1997 to 2018. Results. In accordance with the proposed classification, the investigators identified patients with violent (n = 6) and spontaneous (n = 275) uterine rupture; among the latter, there were patients with mechanical rupture (n = 35), histopathic rupture along the scar (n = 169), histopathic rupture of the unoperated uterus (n = 59), and mechanohistopathic rupture (n = 12). Conclusion. The leading cause of rupture is a uterine scar after cesarean section and endoscopic myomectomy. The rupture of the operated uterus has clear step-by-step symptoms that a physician of any specialty should know in order to timely save the fetus’s life and to promote the mother’s health. In case of uterine rupture of any etiology, organ-sparing surgery is shown to be expedient during instrumental autoerythrocyte suspension reinfusion that makes it possible not only to reduce operative blood loss, but also to preserve a woman's reproductive function.

Objective. To investigate pro- and antioxidant system parameters in early- and late-onset fetal growth restriction. Materials and methods. The study included 82patients: the main group consisted of 41 women whose pregnancies were complicated by fetal growth restriction and the control group included 41 women without fetal growth restriction. The main group was divided into two subgroups. Subgroup Ia consisted of 20 pregnant women with early-onset fetal growth restriction (manifested before 34 weeks’ gestation), subgroup Ib included 21 patients with late-onset fetal growth restriction (manifested after 34 weeks’ gestation). Maternal plasma pro- and antioxidant system markers were evaluated using spectrophotometry, polarography and Western blot analysis. Results. A significant increase in oxidative stress level was observed in early-onset fetal growth restriction subgroup, whereas there was a decrease in late-onset fetal growth restriction subgroup compared to the controls. Logistic regression model was developed to differentiate early- and late-onset fetal growth restriction using maternal plasma pro- and antioxidant system parameters. Conclusion. Maternal plasma pro- and antioxidant system markers can be used in differential diagnosis of early-and late-onset fetal growth restriction after 34 weeks’ gestation.

Relevance. Twin-to-twin transfusion syndrome (TTTS) is associated with fetal cardiovascular disorders carrying the risk of antenatal death and congenital heart disease. Aim. To investigate the effect of TTTS on the fetal cardiovascular system. Materials and methods. The study included 145 pregnant women with monochorionic diamniotic twin pregnancies complicated by TTTS. The participants were divided into two groups based on the Quintero staging: stage I-II (group I, n=100) and stage III-IV (group II, n=45). Myocardial hypertrophy, cardiomegaly, the state of the heart valves, and venous hemodynamics were examined by expert echocardiography. Results. In the whole study cohort, 54.2% of recipient twins had cardiomyopathy. Women with Quintero stage III and IV TTTS were more likely (100%) to have twins with myocardial hypertrophy than those with stage I and II TTTS (73.8%), p=0.001. Recipient twins with cardiomyopathy had a high antenatal mortality rate (19.3%), p=0.01. Cardiomyopathy persisted in 25.4% of newborns from pregnancies affected by TTTS. Conclusion. Cardiomyopathy of the recipient twin is a TTTS complication, which increases in frequency as the disease progresses. The presence of cardiomyopathy increases the risk of antenatal death of the recipient. Surgical correction of TTTS aimed to reverse hemodynamic imbalance may improve fetal cardiac function, which illustrates the adaptability of the developing heart. However, a quarter of surviving recipient twins has cardiomyopathy and remains at risk for pulmonary stenosis.

Objective. To determine intrauterine pathologies in infertile women preparing for IVF and to evaluate the significance of minimally invasive intrauterine interventions in relation to the effectiveness of subsequent IVF programs. Materials and methods. Hysteroscopy and morphological examination of the endometrium were performed in 600 infertile patients of reproductive age. The analysis of clinical data and the results of restoration of reproductive function were conducted in 351 patients, who were divided into the following groups: group 1 (n=140) included patients with chronic endometritis, group 2 (n=116) consisted of women with endometrial hyperplastic processes, group 3 (n=95) included patients with intrauterine pathology (fibroids, septum, synechiae, adenomyosis). Results. Normal morphological structure of the endometrium was detected in 36% of the examined patients, benign endometrial pathology in 42.7%, atypical hyperplasia and endometrial cancer in 5.5%, and intrauterine pathology in 15.9% of patients. The average duration of infertility was 5.8 (0.6) years. All patients had a history of intrauterine interventions: one intrauterine intervention was in 27.8%, two intrauterine interventions were in 46.6%, and three or more intrauterine interventions were in 25.6% of cases. The results of restoration of reproductive function were evaluated within one year after undergoing complex treatment of assisted reproductive technology (ART) cycles. Pregnancy occurred in 62% of women. Pregnancy resulted in childbirth in 51% of cases. Conclusion. Intrauterine pathology was observed in 58.5% of infertile women. Surgical and subsequent conservative treatment of intrauterine pathology contributed to a reduction in pregnancy losses, as well as an increase in the frequency of pregnancies that ended in childbirth. The risk factors for repeated ART failures in patients with intrauterine pathology are the maternal age over 35 years, the presence of chronic salpingoophoritis, endometriosis and chronic endometritis, as well as the previous history of three or more different intrauterine interventions.

Objective. To determine the most common types of human papillomavirus (HPV) involved in the neoplastic transformation of the cervical epithelium in HPV vaccinated women of reproductive age. Materials and methods. The study included 3 groups with 141 patients. Group 1 (HPV vaccinated) included 62 patients (average age of 31 years). This group was divided into 2 subgroups: patients vaccinated before sexual activity (n=26, 41.9%) were enrolled in subgroup 1a and women vaccinated after sexual activity (n=36, 58.06%) were in subgroup 1b. Group 2 included patients with the cytological diagnosis of high-grade squamous intraepithelial lesions (HSIL) (n=42), group 3 included patients negative for intraepithelial lesion or malignancy (NILM) (controlgroup, n=37). A comprehensive clinical and laboratory examination was carried out, including HPV typing, cytological examination. Results. Among them, 76 (53.9%) patients were HPV-positive: 100% in the HSIL group, 54% in the NILMgroup and 22.5% in the vaccinated group (38.8% in subgroup 1b and 0% in subgroup 1a). HPV vaccine types were statistically significantly less identified in group 1 (vaccinated) - 6.4%, compared to group 2 (HSIL) (29.7%) (p<0.05). In group 1 the most common type of HPV was HPV 56 (4.2%), in groups 2 and 3, HPV type 16 was the most common one with 21.9% and 4.96%, respectively. Conclusion. HPV of group 1 (carcinogenic) A9 and A7 were significantly less common in patients of group 1 compared to unvaccinated patients of groups 2 and 3.

Aim. To investigate the impact of patient immune status on the severity of COVID-19. Materials and methods. The prospective study included 63 employees of the V.I. Kulakov NMRC for OG&P of Minzdrav of Russia with confirmed COVID-19. The patients were stratified into three groups based on the disease severity, including asymptomatic (group 1, n=17), mild (group 2, n=29), and moderate (group 3, n=17) form of COVID-19. On days 3-7 from the onset of the disease, peripheral venous blood samples were collected from the study subjects and tested for serum levels of anti-SARS-CoV-2 IgG antibodies and immune profile by ELISA. After day 20+, testing for serum levels of anti-SARS- CoV-2 IgG antibodies was repeated using ELISA. Results. Patients who had a higher BMI, blood group A(II), lower leukocyte and lymphocyte counts, higher relative monocyte count, changes in the immune profile in the form of a lower number of CD3+, CD3+CD8+, CD19+, CD19+CD5+, and phagocytic activity of neutrophils, developed more severe forms of COVID-19. They had severe clinical manifestations of the disease, and 100% of them developed antiviral immunity. Conclusion. This study identified several clinical, laboratory, and immune profile features that may be considered as predictive factors of severe COVID-19 and can be used in clinical practice to predict the clinical course of the disease.

Appropriate use of statistical analysis and research methodology is essential for obtaining objective and reliable results in medical studies. Studies with poor methodological quality and poor statistics cannot prove or disprove the study hypothesis with certainty. This review evaluates the reporting of the statistics and methodological quality in articles submitted to the journal Obstetrics and Gynecology between 2018 and 2020. The analysis showed that large proportions of these articles contained errors in the application, analysis, interpretation, reporting of statistics, or in the design of research. Conclusion. The review concludes that authors of biomedical papers should be responsible for maintaining an integrated statistical presentation because valuable articles are in danger of being wasted through the misuse of statistics and poor methodological quality.

Objective. To compare the effect of various vaginal lubricant compositions used during sexual intercourse on the vaginal mucosa, acid-base status, and vaginal microbiome composition in reproductive-aged women. Materials and methods. The vaginal epithelium, pH values in the vaginal environment, and the vaginal microbiome were assessed according to the additive contained in the lubricant regularly used by women of reproductive age (27.3±4.9 years) during sexual intercourse for three months. Sixty study participants were divided into 4 groups of 15 women in each according to the type of a lubricant (an indifferent lubricant, lubricants containing colloidal silver, lactose, or lactic acid). The investigators used the following assessment methods: visual inspection to assess the color and moisture of the mucosa, its folds, the nature of leucorrhoea, and the existence of injury to the vaginal mucosa; Kolpo-test pH indicator test strips; as well as a real time polymerase chain reaction (PCR) assay using the Femoflor-4 system. Results. The regular use of the studied lubricants by reproductive-aged women was found to keep the vaginal mucosa in its normal state, not to negatively affect the acid-base balance of the vaginal environment and the composition of the vaginal microbiome. Conclusion. The use of a lubricant with an additive of colloidal silver and a prebiotic can significantly improve the status of the vaginal mucosa (p=0.032).

Objective. To present the experience with intravaginal Gaynomax in the complex preoperative preparation of patients with cicatricial deformity of the cervix uteri. Materials and methods. Fifty patients with old ruptures of the cervix uteri were examined and treated. The patients’ mean age was 32.5±5.6 years. Before surgery, the patients underwent an analysis of the vaginal microbiome by real-time PCR diagnosis using Femoflor 16 test systems and bacterial culture from the cervical canal. As preparation for elective surgery, the patients with an abnormal vaginal microbiome received a short 3-day regimen with the intravaginal administration of a combination of thioconazole and tinidazole. All the patients underwent Emmet's operation. Results. Exploring the composition of the vaginal microbiota revealed that 30 patients had the following dysbiotic conditions: Gardnerella vaginalis 105 in 8 (40%) women; Escherichia coli 105 in 5 (25%), which totaled 65%; at the same time 7 (35%) of them had vaginal dysbiosis associated with a combination of several pathogens: Gardnerella vaginalis, Enterobacterium spp., Streptococcus spp., Klebsiella pneumonia, and Candida albicans. No specific infections were detected in the patients. The control examination made within 2 weeks after surgical treatment showed suture competences and no signs of inflammation in the study group. Conclusion. A wide antimicrobial spectrum and the efficiency of short exposure to a combination of thioconazole and tinidazole allow it to be recommended for use while preparing for elective surgery to restore the integrity of the cervix uteri with old ruptures.

The data available in the world literature on the use of therapeutic radiofrequency exposure in gynecology are analyzed. The review includes the results of recent studies on this topic and considers the physical foundations and mechanisms of radiofrequency exposure to biological tissues. Radiofrequency currents affect mainly the dermis that is known to be composed of cells and a matrix containing 60-70% water. Modern literature includes various data on the minimally required frequency and multiplicity of exposure of the dynamic quadripolar radiofrequency to vulvovaginal tissues, which provides relief of the symptoms of genitourinary syndrome of menopause, vaginalrelaxation syndrome andpelvic organ prolapse, the stress and mixed types of mild urinary incontinence, and sexual dysfunction. Conclusion. Taking into account the high efficiency and promise of this technique, the data analyzed and the experience presented are scanty and require further investigation in this area.

The review presents the data of experts from the World Health Organization on the medical, ethical, and socioeconomic aspects of pregnancy planning. It reflects the principles of contemporary counseling of patients when choosing a method for preventing unwanted pregnancy, as well as the urgency of the problem for Russia. The review gives the results of studying the advantages of a monthly regimen of the contraceptive vaginal ring NuvaRing versus a daily regimen of combined oral contraceptives: the higher contraceptive effectiveness in real clinical practice; optimal cycle control; fewer side effects, such as nausea/vomiting, mastalgia. The authors notice the minimal systemic effect of NuvaRing on the body, as well as the metabolic neutrality of the drug. The review presents the study data on the absence of a negative effect of the contraceptive ring on vaginal microbiocenosis, cervical mucosa, and sexual life. There is information on the availability of the NuvaRing applicator to ease the insert of the ring into the vagina. The paper gives the study results on an about fourfold increase in the number of women who have chosen the vaginal contraceptive ring after structured counseling, compared to the initial desire to use combined oral contraceptives. Conclusion. Contemporary structured counseling expands the possibilities of choosing a contraceptive method. The informed choice of vaginal hormonal contraception is optimal for women who are interested in the advantages of the monthly regimen of the contraceptive ring NuvaRing.

Objective. To study the impact of immunostimulating therapy on changes in the indicators of local cytokine status and autoimmunity in female patients with latent forms of human papillomavirus infection (PVI). Materials and methods. Clinical and laboratory examinations were made in 96 patients aged 18 to 45 years with the latent forms of PVI. A study group consisted of 48patients who underwent follow-up and a differentiated approach to using the immunostimulating and antiviral drug Inosine pronabex 1000 mg thrice daily for 28 days. A comparison group included 48 women who underwent co-testing at 12 months after the start of the follow-up. Results. Analyzing the outcomes of latent forms of PVI following 12 months showed that in the study group, there was a complete elimination of human papillomavirus (HPV) and a clinically insignificant viral load in 95.8% of cases, which was 1.5 times more often than in the comparison group. Moreover, in the latter group, every three (35.5%) patients had a "significant" high-risk HPV concentration. Conclusion. Immunostimulating and antiviral therapy with Groprinosin-Richter in patients with latent forms of PVI leads to elimination of the initial imbalance of cytokines and to normalization of autoantibody levels, which suggests that the local inflammatory changes in the cervical epithelium are eliminated, and, as a result, the reproductive potential is preserved.

Background. Recently, the vast majority of patients with uterine myoma seek to preserve the organ, regardless of age. Since the introduction of laparoscopic morcellation, there have been reports on the occurrence of parasitic smooth muscle tumors frequently of uncertain malignant potential. They are two types: iatrogenic parasitic myoma and iatrogenic adenomyoma that is more common. Case report. The paper describes a clinical case of parasitic myomas and adenomyomas 8 years after laparoscopic myomectomy and morcellation for cell leiomyoma of large sizes, which were performed in 2011. Two years after surgery, a spontaneous pregnancy occurred, which ended successfully with abdominal delivery of a full-term baby in 2014. Pelvic organ ultrasound in 2019 revealed multiple uterine myoma and myomatous nodules of atypical location. Physicians performed laparotomy and removed multiple myomatous nodules in the uterus and large parasitic myomas and adenomyomas of the peritoneum and pelvic organs. Conclusion. This case demonstrates the typical growth pattern of parasitic myoma several years after morcellation with its characteristic histological features and typical clinical manifestations.

Background. Today, open fetal surgery is a rare intervention, the main goal of which is to correct intrauterine fetal malformations. Studies have provided evidence that intrauterine correction of spina bifida reduces the incidence and severity of neurological disorders, compared with the standard surgical treatment for newborns. Anesthetic management of open fetal surgery is complex and differs from the standard anesthesia management during pregnancy. Case report. The paper describes two clinical cases of anesthesia of an open fetal surgical intervention for congenital malformation - myelomeningocele (spina bifida). The surgery was performed in the second trimester of pregnancy. Pregnant women underwent combined anesthesia with high doses of an inhalation anesthetic. This clinical case demonstrates the features of anesthesia and the approach to choosing the tactics for anesthetic management of open fetal surgery. It shows that such operations cannot be performed without well-coordinated work of a large multidisciplinary team of professionals. Conclusion. Fetal surgery is a rapidly growing field of medicine. Anesthetic management of fetal surgery is developing together with progress in surgical techniques. Anesthetic management is based on knowledge of the physiology and pathophysiology of the mother and fetus. Open fetal surgery cannot be performed without the multidisciplinary teamwork of professionals, who include obstetricians/gynecologists, neurosurgeons, anesthesiologists/resuscitators, neonatologists, fetal medicine specialists, operating nurses, anesthetic nurses, and midwives; operating rooms prepared with appropriate equipment are also needed.