№ 10 (2016)

Objective. To discuss the controversial issues associated with the use of immunomodulatory therapy for recurrent abortion of alloimmune genesis. Material and methods. The review included the data of foreign and Russian papers published in the past 10 years and found on this topic. Results. Despite long-term clinical experience, there are no ideas on the mechanisms of immunomodulatory effects of immunocytotherapy, its clear indications, or uniform recommendations for the frequency of its procedures and for the dosage and routes of administration of a partner’s allogeneic cells. Conclusion. The review reveals the reasons for conflicting opinions concerning the efficiency of immunocytotherapy for recurrent abortion of alloimmune genesis and provides evidence for the need to continue investigations in this area.

Objective. To substantiate approaches to diagnosing and managing patients with human papillomavirus (HPV-associated cervical diseases. Material and methods. The review included the data of foreign and Russian articles published in the past 10 years and found in electronic citation systems on this topic. Results. It has been pointed out that each of the diagnostic techniques, such as cytology, HPV test, and colposcopy, has advantages and disadvantages, which should be considered by a modern specialist. The tactics in the management of patients with LSIL and HSIL is determined by the type of a transformation area and by age. One of the approaches to managing patients with HPV can be antiviral/immunomodulatory therapy in combination with physiosurgical techniques. Conclusion. The review will allow a practitioner to find a rational approach to managing patients with HPV-associated genital diseases.

Background. The specific features of the endocrine system in the antenatal period predetermine not only neonatal adaptive capacities, but they can underlie endocrine diseases in children and adults and also affect the nature of metabolic processes, the magnitude of an immune response, the properties of oncogenesis, and lifespan. Objective. To determine the fetal endocrine status in complicated pregnancy and placental insufficiency to develop varying degrees of intrauterine growth restriction (IUGR). Subjects and methods. A comprehensive (clinical, echographic, Doppler, and hormonal) examination was made in 135 pregnant women with uncomplicated pregnancy and in 320 with varying degrees of placental insufficiency. The investigators studied the ultrasound morphology (fraction sizes, circumference, echostructure, and echogenicity) and the specif ic features of formation of blood flow in the thyroid, adrenal glands, and pancreas of the fetus during uncomplicated pregnancy and in varying degrees of IUGR. Results. In varying degrees of IUGR, there is a reduction in all sizes of the fetal thyroid, adrenal glands, and pancreas as compared to the reference values in the given gestational period, most pronounced at an average fetal age (28-33 weeks’ gestation) (p < 0.05 for Grade I IUGR; p < 0.001 for Grade III IUGR). In pregnancy complicated by the development of IUGR, there is also a decrease in all indicators of vascular resistance in the thyroid, adrenal, superior mesenteric, and splenic arteries as compared to the reference values. There is a significant hormonal imbalance in the newborn babies with IUGR, which determines impaired adaptation and high perinatal morbidity (67-86%). Conclusion. The above data will assist in elaborating protocols for managing the infant in terms of a high risk for socially important metabolic and endocrine disorders (impaired growth and dwarfism, hypothyroidism, autoimmune thyroiditis, metabolic syndrome and diabetes mellitus, gastrointestinal tract dysfunction, chronic pancreatitis, gastroduodenitis, etc.).

Objective. To define the possibility and expediency of organ-sparing surgery in patients with massive obstetric hemorrhage of various etiologies. Subjects and methods. The data of histories of labor and delivery accompanied by bleeding were analyzed in 444 patients, including 112 with hypotonic uterine hemorrhage, 111 with placenta previa growing into a uterine scar after cesarean section, 214 with uterine rupture, and 7 with premature detachment of the normally situated placenta accompanied by the Couvelaire uterus. To stop bleeding, all the patients underwent surgery or angiosurgical hemostasis. Results. Organ-sparing surgery using up-to-date technologies (instrumental reinfusion of autoerythrocyte suspension, uterine artery embolization, and temporary balloon occlusion of the common iliac arteries) proved to be effective in treating hypotonic uterine hemorrhage in 94.6% of the patients, placenta previa growing into the uterine scar after cesarean section in 85.6%, uterine rupture in 94.4%, and the Couvelaire uterus due to premature detachment of the normally situated placenta in 100%. Conclusion. When the above technologies are used in third-level hospitals, organ-sparing surgery can be recommended for obstetric complications accompanied by massive blood loss.

Objective. To search for molecular genetic markers associated with chromosomal abnormalities in embryos in order to optimize the selection of transferred embryos to enhance the efficiency of infertility treatment using assisted reproductive technologies. Subjects and methods. 42 cumulus cell samples from 11 patients who had undergone an in vitro fertilization (IVF) (intracytoplasmic sperm injection, ICSI) + preimplantation genetic screening (PGS) program were analyzed during the conducted study. The obtained embryos were divided into 4 groups according to the presence of their chromosomal abnormalities: 1) embryos without chromosomal abnormalities (20 samples); 2) those with sex chromosomal aneuploidies (n = 3); 3) those with somatic chromosomal aneuploidies (n =15); 4) heteroploid embryos (n = 4). A real-time RT-PCR assay was used to examine the cumulus cell mRNA expression in 10genes: hyaluronan synthase 2 (HAS2), prostaglandin synthase 2 (PTFS2), gremlin 1 (GREM1), versican (VCAN), inositol-triphosphate 3 kinase A (ITPKA), activated leukocyte cell adhesion molecules (ALCAM or CD 166), syndecan 4 (SDC4), calmodulin 2 (CALM2), SPRY domain-containing suppressor of cytokine signaling box protein 2 (SPSB2), and tumor protein 5313 (TP5313). Results. There was a relationship between the mRNA expression level in the СD166 (ALCAM), SDC4, VCAN and CALM2 genes and the presence of chromosomal abnormalities of the embryo (p = 0.004, p = 0.009, p = 0.042, p = 0.054, respectively). Discriminant analysis showed that the mRNA expression level in the CALM2 gene is the most informative marker for chromosomal abnormalities in the embryos in IVF programs. The study revealed that the poor embryo quality group showed chromosomal abnormalities in 78.6% of cases (OR = 5.7 (1.4 to 23.9);p = 0.023). There were no statistically significant differences between the mRNA expression level in the studied genes and the quality of developing embryos (p > 0.05). Conclusion. The mRNA expression level in the CALM2 gene is the most informative marker for chromosomal abnormalities in the embryos in IVF programs. However, there is a need for further investigation of the gene expression profile to search for potential biomarkers in the cumulus cells in order to create a prognostic model that can highly accurately predict the probability of chromosomal abnormalities in the embryos. This mathematical model will be able to further optimize the selection of transferred embryos, thereby enhancing the effectiveness of IVF programs as a whole.

Objective. To analyze recurrences of uterine myoma and the state of a postoperative scar in reproductive-aged patients after robot-assisted laparoscopic myomectomy. Subjects and methods. 44 patients underwent planned da Vnci Si myomectomy. Results. Recurrent uterine myoma was detected in 17 patients, including 4 after 6 months, 8 after one year, and 5 after 2 years. A solitary growing nodule was observed in 13 patients and multiple uterine myoma was seen in 4. Correlation analysis revealed a moderate positive relationship between the risk of recurrent uterine myoma and a patient’s age, as well as the number of removed nodules. Pregnancy occurred in 11 patients. One patient had a normal spontaneous delivery at time. Four patients delivered via cesarean section. Intraoperatively, the myometrium was not thinned at the scar site. Currently, two patients are 22 and 24 weeks pregnant. Second-trimester ultrasonography showed that the post-myomectomy scar was competent. Conclusion. Robot-assisted laparoscopic myomectomy should be regarded as an effective organ-sparing reconstructive plastic treatment for uterine myoma in reproductive-aged patients who plan to implement their generative function in the future.

Background. The symptoms of vulvovaginal atrophy (VVA), such as vaginal dryness, itching, burning, and dyspareunia, are observed in 40-57% of postmenopausal women. Vulvovaginal symptoms can also affect the aspects of women’s lives beyond physical health and subjective feelings. A number of studies have shown that VVA negatively affects the quality of life and sexual health of women. Local menopausal hormone therapy (MHT) is the gold standard treatment for the symptoms of VVA. There is now a trend towards low-dose local estrogen therapy in European countries. Objective. To investigate the efficiency of low-dose local estriol MHT in postmenopausal patients with VVA, by using subjective and objective criteria. Subjects and methods. Initially, the study enrolled 136 women aged 40 to 75years, whose menopause duration was 1 to 20 years. All the patients underwent cytological examination for VVA. The latter was diagnosed in 84 patients. Of them, 44 patients formed a treatment group. The follow-up lasted 3 months. Block randomization was used to divide the study participants into 2 groups of 22 people each. Group 1 used a drug composed of estriol 0.5 mg (Ovipal Clio); Group 2 had an agent containing the freeze-dried culture of Lactobacillus casei L. rhamnosus Doderleini 341 mg, estriol 0.2 mg, and progesterone 2.0 mg (Trioginal). Treatment regimens with the equal cycle estriol dose amounting to 9.8 mg were developed for both patient groups (Group 1 received estriol 0.5 mg every other day for 3 weeks, then 0.5 mg once weekly for 9 weeks; Group 2 had the freeze-dried culture of Lactobacillus casei L. rhamnosus Doderleini 341 mg, estriol 0.2 mg, and progesterone 2.0 mg daily for 2 weeks, then every other day for 10 weeks). The studies encompassed questionnaire surveys, cytological examination of the vaginal wall, followed by the estimation of the vaginal epithelium maturation index (VEPI), vaginal pH, and vaginal health index (VHI). Results. The full treatment cycle was completed by 91% of the women in Group 1 and by 95.5% in Group 2. After the therapy, the patients of both groups reported alleviation or relief of vaginal atrophy symptoms. Conclusion. Low-dose local estriol therapy contributed to the restoration of the vaginal epithelium, as confirmed by statistically significant increases in VEPI and VHI and a reduction in pH values. Low-dose local MHT led to a gradual reduction in the symptoms of vaginal atrophy, which had a positive impact on menopausal patients’ sexual function and quality of life.

Objective. To improve the results of treatment for small pelvic varicose veins (SPVV) in women and to prevent a recurrence of the disease. Subjects and methods. 67 patients, in whom spectral Doppler revealed varicose transformation of veins in the small pelvic, were divided into 3 groups according to the grade of dilation of the ovarian varicose vein: grade I (n = 35), grade II (n = 23), and grade III (n = 9). The treatment of SPVV depended on the degree of phlebectasia. The patients with grades I and II SPVV (Group 1 (n = 58)) received conventional therapy that included vasoprotective (phlebodia and antistax) and antiplatelet (trental, curantil) agents for 2 months twice a year. Those with grade III SPVV (Group 2 (n = 9)) underwent bilateral ovarian vein sclerosurgery using Fibro-Vein 30 mg/ml under laparoscopic guidance. To explore the pathogenetic mechanisms of SPVV, the investigators studied the indicators of lipid peroxidation (LPO) and antioxidant defense, as well as the immune system of patients with this disease. Results. Over the 3-year follow-up period, 18 of the 58 women in Group 1 were observed to have SPVVprogression accompanied by increased dilatation of the ovarian vein (>10 mm). In Group 2, SPVV progression was found in 5 cases (the ovarian vein diameter was 13-15 mm). The findings were indicative of intensified LPO, reduced antioxidant reserves, and an activated nonspecific immune response. The found laboratory changes suggest that the etiopathogenetic mechanisms for the development of SPVV are polyvalent, which must be considered when treating the disease, by complementing its conventional treatment regimen with antioxidants and immunoprotectors. Conclusion. To prevent recurrent SPVV, in addition to conventional therapy for varicose veins, the package of therapeutic measures should include drugs that correct oxidative stress and secondary immunodeficiency. Recurrent SPVV after scleroobliteration of the ovarian veins is caused by their recanalization or incomplete obliteration of the appendages, the treatment of which is achieved by compression sclerotherapy under intraoperative quality control using functional tests.

Objective. To identify the factors influencing the prevalence of contraception, the additional requirements of women for its noncontraceptive benefits and their realization possibility in case of hyperandrogenic dermopathy. Materials and methods. The mixed method is a counseling procedure based on the ability to offer the wide range of contraceptive methods and devices, from which a user can choose one and further switch to another that best meets her needs during her sexual life. Results. The idea of the mixed method can be used in the combined oral contraceptives line (COCs) under the single umbrella brand Modelle. The additional needs of women suffering from hyperandrogenic dermopathy can be met when using an agent containing ethinyl estradiol (EE) 35 ßg and cyproterone acetate (CPA) 2 mg (35ЕЕ/ CPA- Modelle PURE), which can provide the maximum noncontraceptive (therapeutic) benefit. Conclusion. 35EE/CPA is the most suitable contraceptive for women with androgen-dependent skin diseases.

Objective. To carry out a systems analysis of the data available in the current literature on the antimineralocorticoid and antiandrogenic effects of a combined oral contraceptive (COC) pill containing 20 ßg ethinyl estradiol (EE) and 3 mg drospirenone (DRSP) in a 24/4 regimen. Material and methods. The review includes the foreign and Russian publications available in the Pubmed database on this topic. The search depth was 15 years. Results. The paper describes the mechanisms of the antimineralocorticoid and antiandrogenic effects of the combination of 20 μg EE and 3 mg DRSP and presents data on its efficacy in patients with premenstrual syndrome and premenstrual dysphoric disorder PMS/PMDD, as well as with androgen excess-related diseases and acne. Conclusion. The combination of 20 μg EE and 3 mg DRSP, that of the low-dose estrogen and the highly selective progestogen with antimineralocorticoid and antiandrogenic properties, at a short hormone-free interval is optimal for patients with hyperandrogenism, acne, and PMS/PMDD.