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No 6 (2023)
Reviews
Modern instrumental methods for the diagnosis of placental pathological invasion
Abstract
Background: Over the past few decades, the placental pathological invasion-associated morbidity significantly increased, which is associated with an increase in the proportion of cesarean section. To prevent severe complications and to choose the optimal obstetric tactics, it is necessary to diagnose placental pathological invasion in time.
Objective: To study modern instrumental capacities in the diagnosis of placental pathological invasion.
Materials and methods: By using the keywords: “placental pathological invasion, “placental ingrowth”, “placenta accreta”, “placenta increta”, “placenta percreta”, “uterine scar”, “ultrasound study”, “magnetic resonance imaging (MRI)”, “elastography”, the authors analyzed the Russian and foreign literature databases: eLibrary, Medline/PubMed, Embase, Crossref, and the Russian Science Citation Index (RSCI). In accordance with the goal set, a total of 72 references were selected.
Results: The early ultrasound criteria may include отнести: visualization of the ovum in the uterine scar niche, in which the most part of the ovum is embedded in the myometrium and does not cross the endometrial zone, the ovum crosses the conventional serous line. The characteristic predictors for the second trimester are the presence of placental lacunae, the loss of the retroplacental hypoechoic zone, hypervascularizaton of the uterovesicular or retroplacental space, the spread of placental tissue into the myometrium or bladder, placental bridging vessels. The MRI criteria are dark intraplacental bands on the T2-weighted image, loss of a low-intensity retroplacental signal line on T2-weighted image, thinning/rupture of myometrial visualization, discontinuity of the contours of the bladder wall, focal exophytic placental mass, and the abnormal vascular network of the placental bed.
Conclusion: This review presents the significant diagnostic parameters of placental pathological invasion in different gestational periods, which have been identified by the modern visualization methods: ultrasound study and MRI. The prospects of elastography used in the diagnosis of placental pathological invasion require further investigations.
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Long-term consequences of the effect of alcohol on the fetus
Abstract
High alcohol consumption is a social problem in our country and the world. The paper analyzes Russian and foreign literary sources for studying fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorders (FASDs). By now, there have been a certain amount of studies on female alcohol use during pregnancy. FAS is observed for 1000 live newborns. There is no standard accounting system for the diagnosis of FAS/FASDs in any country of the world. A historical reference is given regarding the nature of alcohol effect on the fetus; however, the problem of the effects of alcohol metabolites at the biochemical and molecular levels requires further investigation. The babies who were born with the signs of FAS are noted to have phenotypic changes in the cerebral cranium and viscerocranium, morphological changes in brain tissue, mental disorders, and behavioral, neurological disorders. To prevent the occurrence of FAS/FASDs in children, it is necessary to enhance the role of medical workers in educating young people about the risk factors of these diseases.
Conclusion: the dissemination of modern information and the transfer of knowledge to pregnant women and reproductive-aged women by physicians, psychologists, social pedagog-ists, and social workers about the irreparable harm of their alcohol use done to the child are extremely important to prevent FAS and FASDs.
It is necessary to fix the attention of the society on the problem of FAS, to popularize a healthy lifestyle, to foster the alcohol use culture, as the ubiquitous availability of alcoholic beverages and the lack of self-discipline lead to harmful consequences.
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Fetal cardiotocography in childbirth
Abstract
The fetal status during childbirth may be assessed analyzing the patterns of fetal cardiac rhythm. Despite the wide use of the method, interpretation of cardiotocography (CTG) remains controversial due to the absence of significant differences in the number of cerebral palsy diagnoses, infant deaths, and other standard assessments of neonatal well-being as compared to periodic auscultation. The paper considers modern ideas on the pathophysiological processes determining the main patterns of CTG and a new concept CTG assessment in childbirth.
Conclusion: Changing ideas on the pathophysiological mechanism underlying in the interpretation of CTG will be able to formulate a new approach that is more sensitive to the degree of fetal hypoxic changes and will increase its informative value.
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New approaches to studying the regulation of preimplantation embryonic development
Abstract
Only 40% of embryos obtained in ART programs are known to develop to the blastocyst stage; the remaining embryos stop developing at different division stages. The genetic and epigenetic factors of both the very embryo itself and the oocyte, which play a key role in the early preimplantation embryonic development, are of great importance in the genesis of infertility.
This review discusses new approaches to studying the regulation of preimplantation embryo development, analyzes the impact of the genetic and epigenetic status of oocytes on the quality of obtained embryos and the rate of pregnancy. It gives the data of investigations in this area and promises of their use in clinical practice. On the strength of thee available data, the authors consider the possibility of overcoming severe infertility forms associated with a small number of obtained embryos and their poor quality; that of overcoming a condition, such as infertility of unclear genesis; they also discuss the possibility of searching for new methods for assessing the quality of oocytes and embryos to improve IVF programs. The review underlines the need for expanding and intensifying the investigations determining the epigenetic status of an embryo and the corresponding oocyte, those studying the processes of epigenetic regulation in the early embryo development.
The paper analyzes the data of researches in the epigenetic regulation of preimplantation embryonic development, characterizes the main epigenetic modifications affecting the quality of obtained oocytes and embryos, and identifies the possibility of clinical application of the available data.
Conclusion: At the present stage, the methods for assessing the quality of obtained embryos are based on morphological criteria. However, the morphological assessment grounded mainly on the visual determination of the degree of their competence does not correlate with the capability of embryos for implantation and development of high-quality pregnancy to a sufficient extent. In this connection, it is expedient to study the molecular genetic characteristics of embryos during the period of early embryonic development to devise clinical and pathogenetic methods to enhance the efficiency of infertility treatment in the IVF programs.
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Extracellular vesicles in follicular fluid: clinical aspects and molecular biology
Abstract
Recently, extracellular vesicles (EVs), membrane vesicles secreted into the extracellular medium by various cell types of reproductive tissues, have been discovered in human follicular fluid (FF). It was originally thought that EV secretion might be a mechanism used by cells to eliminate intracellular 'debris', but subsequent studies have shown that EVs are used to deliver specific molecular information encapsulated in a double-layered lipid membrane from the donor cell to the recipient cell. EVs contain bioactive molecules, such as mRNA, microRNA, proteins, and lipids, that enable communication and interaction between different cells and tissues, including between the oocyte and somatic cells of the growing follicle. EVs in follicular fluid play an important role in the biological processes of folliculogenesis, oogenesis, and early embryogenesis.
Conclusion: The reviewed studies provide an opportunity to increase our understanding of the complex mechanisms of reproductive biology and improve the potential for the use of EVs to optimize the embryological stage of in vitro oocyte and embryo culture in assisted reproductive technology programs.
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Impact of systemic menopausal hormone therapy on symptoms of urinary incontinence in postmenopausal women
Abstract
Urinary incontinence (UI) is one of the common symptoms in postmenopausal women. There is estrogen deficiency at the heart of the development of this disorder, as well as other signs of genitourinary syndrome of menopause (GSM), which makes menopausal hormone therapy (MHT) pathogenetically justified.
The review includes the data of foreign and foreign publications found in the PubMed on this topic for the period from 2016 to 2022. The data available in the modern literature on the impact of systemic MHT on the symptoms of UI in postmenopausal women were systematically analyzed to improve approaches and to optimize patient management tactics.
Conclusion: Parodoxically, systemic MHT causes deterioration or development of UI, which may be associated with the effects of systemic estrogens on collagen metabolism in the perurethral tissues. Further study of the effect of estradiol-containing therapy on the genitourinary tract of postmenopausal women is relevant for the improvement of approaches and for the optimization of patient management tactics.
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Original Articles
Platelet function and blood clotting during normal pregnancy
Abstract
Objective: To investigate the changes in hemostasis during healthy pregnancy.
Materials and methods: Platelet contractile function assessed as a degree of blood clot contraction was studied in 38 healthy pregnant women, in relation to the markers of platelet activation, hemogram, hemostatic tests, and analysis of prothrombotic genetic polymorphisms.
Results: From the first week of normal pregnancy to delivery, there was moderate but statistically significant progressive impairment of blood clot contraction. A decrease in the ability of blood clots to shrink may be associated with physiological thrombocytopenia as well as partial continuous activation and exhaustion of platelets against a background of hypercoagulability and hyperfibrinogenemia. In 23/28 (82%) pregnant women, a transient reduction in the degree of clot contraction below the reference values was observed between 18 and 24 weeks of pregnancy. This reduction corresponds to the timing of placentation, suggesting local intraplacental mechanisms of platelet involvement during normal pregnancy.
Conclusion: The findings demonstrate the value of laboratory evaluation of platelet hemostasis, including platelet contractile function, during pregnancy.
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Postcovid syndrome in pregnant women
Abstract
Objective: To assess the prevalence and characteristics of postcovid syndrome (PCS) in pregnant women who have not concomitant comorbid pathology.
Materials and methods: To assess the independent impact of the novel coronavirus infection on the development of PCS, the investigation involved women who had no known risk factors: those who are younger than 35 years, are without overweight/obesity, diabetes mellitus, chronic hypertension, and other somatic and chronic infectious diseases, who experienced COVID-19 in July to October 2021.
A study group consisted of patients without uncomplicated pregnancy (n=111); a comparison group included non-pregnant women (n=181). SARS-CoV-2 was identified by a polymerase chain reaction assay in the nasopharyngeal material in all cases. The symptoms of PCS were considered to be the clinical manifestations that were absent before COVID-19 and appeared not earlier than 4 weeks from the onset of the disease and lasted at least 2 months, which could not be explained by alternative diagnoses. The statistical database had been formed on the basis of primary medical documentation and an interview of the patients according to a special questionaire with an assessment of the existing symptoms on a 10-score scale.
Results: The pregnant women were 2.0 and 6.6 times more likely to have been ill with moderate and severe COVID infection, respectively, as compared with non-pregnant women (χ2=16.42; p<0.001; OR=2.99 (95% CI, 1.68; 5.35); p<0.001), which caused the increased risk of their hospitalization (OR=3.59 (95% CI, 2.06; 6.25); p<0.001). The incidence of PCS had no differences and amounted to 93.7 and 97.2%, respectively (p>0.05). PCS in the pregnant women was more frequently manifested by the development of dyspnea (37.8% vs 26.5%) (χ2=4.13; p=0.043; OR=1.69 (95% CI, 1.02; 2.80); p<0.05); moreover, the severity of the symptom did not differ in the comparison groups. Coughing and frequent urination occurred with same frequency in the pregnant and non-pregnant women, but their intensity prevailed in the maternal group. The pregnant women were less likely to have hair loss (46.8% vs 60.8% (χ2=5.4; p=0.021) with the symptom severity in the groups. Headache occurred less frequently in the pregnant women (30.6% vs 43.1% (χ2=4.52; p=0.034) and was less intensive (3.0 (2.6; 5.2) vs 5.0 (5.0; 5.9) scores (p=0.047). Other PCS symptoms (fatigue/easy fatigability, myalgia, weight loss, chest pain, palpitation, memory impairment, sleep disorders, depression, etc.) were recorded with the same frequency and severity.
Conclusion: Our investigation has demonstrated the widespread prevalence of PCS in young initially somatically healthy pregnant and non-pregnant women. The obtained facts regarding the symptoms identified in the pregnant women can be partly explained by physiological gestational changes in the mother’s body. However, further large-scale and longer-term investigations are needed to elucidate the pathophysiological mechanisms of the development of PCS and its possible consequences in pregnant women.
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Hyperandrogenism as a risk factor for isthmic-cervical insufficiency
Abstract
Objective: To assess the association of isthmic-cervical insufficiency (ICI) with hyperandrogenism (HA).
Materials and methods: A prospective cohort controlled study was performed (the study period was 2014–2019). The clinical base was Maternity Hospital One, Branch, L.A. Vorokhobov City Clinical Hospital Sixty-Seven (Moscow). The study involved 98 women, including 63 with ICI (a study group) and 35 without ICI (a control group). HA was evaluated by high-performance liquid chromatography according to the steroid profile and quantitative determination of urinary steroids. The data were statistically analyzed using the programs of Microsoft Excel 2007, Statistica 12.0. The association of HA with ICI was assessed.
Results: Regardless of the presence of HA, ICI is associated with the factors of a compromised reproductive history (the number of pregnancies, р=0.00008; the term of premature birth (р=0.04); with the frequency of miscarriage (р<0.001); with the experience in using cerclage (р=0.49); with the pregestational weight exceeding the norm (OR=4.16; 95% CI, 1.32–13.31)). ICI is associated with HA (OR=3.48; 95% CI, 1.37–8.84). HA in the women with ICI is associated with an earlier age at menarche (р=0.01) and an older age during the current pregnancy (p=0.002).
The gestational risk factors of HA-associated ICI are shown to be the absence of progesterone therapy in the preconception period/the first trimester of pregnancy (ОR=10.23; 95% CI. 1.12–93.35); the greater frequency of threatening spontaneous abortion (SA) (OR=5.38; 95% CI 1.83–15.79); that of imminent SA (p=0.01); the length of the cervix is 10 mm or less; ICI totals more than 6 scores; the significantly earlier gestational period in the diagnosis of ICI (19 weeks or less).
Conclusion: The asymptomatic onset of ICI cannot implement modern prevention, limits the possibilities of medical management. Prescribing progesterones to woman with HA in the preconceptional period/the first trimester of pregnancy should be considered as a measure for the prevention of ICI.
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Sacrococcygeal fetal teratoma
Abstract
Relevance: Fetal sacrococcygeal teratoma (SCT) is a serious malformation, and predicting its outcome remains an unsolved problem. SCT is associated with postnatal and antenatal complications. A review of the literature has identified the risk factors for adverse outcomes in fetal SCT; when present, fetal surgery is performed.
Objective: To investigate SCT outcomes and identify and analyze the main factors influencing perinatal outcomes.
Materials and methods: The study included 59 pregnant women with fetal SCT who received perinatal consultation in the V.I. Kulakov NMRC for OG&P over 5 years. The analyzed data included medical history, fetal ultrasound (size, structure, and degree of SCT vascularization, Altman type, tumor volume/fetal weight ratio, and fetal complications), and pregnancy outcomes. In the final part of the study, prenatal factors that could be considered as predictors of disease outcomes were analyzed.
Results: The median gestational age at SCT diagnosis was 19 weeks. There was a predominance of female fetuses (3.5:1). The most common type was type II (56.9%) according to the Altman classification, and the rarest was type III (10.3%). Most SCTs had a predominant solid component (54.2%). Non-immune hydrops fetalis (NIHF) was detected in eight (13.6%), cardiomegaly in 16 (27.6%), and polyhydramnios in 23 (39%) cases. In 38 (64.4%) cases, live births occurred, including 29 (76.3%) by caesarean section and 9 (23.7%) by vaginal delivery. Adverse prenatal risk factors included solid SCT structure and pronounced tumor vascularization, which led to the development of NIHF and cardiomegaly (p<0.005). Tumor volume/fetal weight ratio >0.12 was more than three times more common in the adverse outcome group (76.9% vs. 21.4%).
Conclusion: Early detection of SCT, predominance of the solid component and abundant vascularization of SCT, and tumor volume/fetal weight ratio >0.12 before 24 weeks of gestation, can be considered as predictors of poor outcome.
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Experience with a modified molded sorbent in the treatment of postpartum endometritis
Abstract
Objective: To investigate the potential detoxifying effect of an application form of a polyvinylpyrrolidone-modified sorbent in the treatment of postpartum endometritis (PE).
Materials and methods: This retrospective study included 124 post-cesarean section patients with PE. The study group (n=63) received combined treatment including antibiotic therapy in combination with intrauterine administration of an applicative form of a polyvinylpyrrolidone-modified sorbent (VNIITU-1(PVP)). The control group (n=61) received standard antibacterial treatment.
Results: In patients with PE, predominantly cocci were isolated from the uterine cavity, including Enterococcus faecalis (26.6%) and Staphylococcus spp. (21.0%), and Enterococcus faecium (14.5%). Antibiotic resistance of the pathogens reached 53.6–68.3%. Atomic force microscopy and electron microscopy of sorbent rods extracted from the uterine cavity confirmed the high sorption capacity of VNIITU-1(PVP) against microorganisms, regardless of their antibiotic resistance. IR spectroscopy showed the high sorption capacity of the molded sorbent VNIITU-1 (PVP) against proteins and microbial toxins. Following treatment, uterine microflora growth was significantly reduced in the treated group, and the concentrations of IL-1β and TNF-α in the uterine aspirate decreased. The risk of hysterectomy in the study group was 14.5 times lower than in the control group (relative risk 0.069 (95% CI 0.009–0.51)).
Conclusion: Intrauterine use of VNITU-1 (PVP) molded sorbent in the complex therapy of PE improves treatment results and reduces the risk of hysterectomy by 14.5 times.
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Influence of ovulation inducing drugs and the woman’s age on the results of infertility treatment using assisted reproductive technologies with sperm selection by oocyte-cumulus complexes
Abstract
Objective: To investigate the effect of ovulation-inducing drugs and woman’s age on the outcomes of infertility treatment using ART with spermatozoa selection by cumulus cells.
Materials and methods: This study included 267 couples undergoing ART for infertility treatment. Clinical and embryological parameters of the ART cycle were assessed. The study group included 130 patients (CC group) with spermatozoa selected by CC and subsequent ICSI procedures. The control group consisted of 137 patients who underwent a standard ICSI procedure with spermatozoa selection based on morphological characteristics (ICSI group). Each group was divided into women under the age of 35 years and those aged 36 years and above. To assess the effect of ovarian stimulation, groups of women were categorized according to the type of trigger for final follicle maturation: human chorionic gonadotropin (hCG) (n=182) and gonadotropin-releasing hormone agonist (GnRH agonist) (n=52). Some women did not undergo embryo transfer (n=33). VitroLife medium (Sweden) was used during the embryological stage. Only one embryo was transferred to the uterine cavity. Statistical analysis was performed using SPSS Statistics software (USA), and included both parametric and non-parametric methods.
Results: Among women aged < 35 years, the absolute number of blastocysts obtained on the 5th day of culture was significantly higher in the CC group than that in the ICSI group (Me 2 (1; 3) and 3 (1; 5), p=0.02). Patients of late reproductive age (≥ 36 years) also showed a significantly higher number of blastocysts on the 5th day of culture when spermatozoa were selected using CC (p=0.03). When evaluating the effect of the trigger of the final follicle maturation, it was found that the embryo implantation rate was significantly higher when hCG was used and sperm were selected by CC (CC 44.9%, ICSI 17.9%, p=0.01); however, the birth rate did not differ significantly, regardless of the age of the woman.
Conclusion: This study shows that the technology of spermatozoa selection using CC in infertility treatment with ART can be successfully implemented in different age groups of women, which will increase the number of embryos at the blastocyst stage suitable for transfer to the uterine cavity and cryopreservation. At the same time, the implantation rate can only be increased in women in whom exogenous hCG is used to trigger the final maturation of oocytes. The data obtained in this study provide hope for the development of more advanced in vitro sperm selection methods that would mimic the physiological conditions in the female reproductive tract.
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Sexual functioning, psycho-emotional status and quality of life in patients with extragenital endometriosis and insomnia
Abstract
Цель: Оценка особенностей сексуального функционирования, психоэмоционального статуса и качества жизни (КЖ) пациенток с наружным генитальным эндометриозом (НГЭ) и инсомнией.
Материалы и методы: В сравнительном одномоментном исследовании приняли участие 323 пациентки в возрасте от 18 до 45 лет: 165 – с НГЭ и инсомнией и 158 – с НГЭ без инсомнии. У всех пациенток оценивали качество сна с помощью Питтсбургского опросника качества сна (Pittsburgh Sleep Quality Index, PSQI), выраженность инсомнии с помощью опросника для оценки тяжести инсомнии (Insomnia Severity Index, ISI). Изучали сексуальное здоровье с помощью опросника индекса женской сексуальной функции (Female Sexual Function Index, FSFI) и психоэмоциональный статус с помощью шкал оценки тревоги и депрессии Гамильтона (Hamilton Anxiety Rating Scale, HARS; Hamilton Rating Scale for Depression, HDRS). Мониторировали КЖ пациенток с использованием опросника оценки КЖ (Medical Outcomes Study Short Form-36, MOS SF-36).
Результаты: У пациенток с НГЭ и инсомнией по сравнению с пациентками с НГЭ без инсомнии наблюдаются более выраженное снижение качества сексуальной жизни, более высокая распространенность расстройств тревожно-депрессивного спектра (ТДС), более высокий уровень депрессии и более низкий уровень КЖ. Установлен обратный характер корреляции интегрального значения ISI с итоговыми показателями FSFI и SF-36, прямой – с итоговым показателем HARS.
Заключение: Наличие взаимосвязи НГЭ и инсомнии диктует необходимость проведения рутинной диагностики инсомнических расстройств у данной категории пациентов. У пациенток с НГЭ присоединение инсомнии приводит к нарушению сексуального функционирования, расстройств ТДС и значительно снижает КЖ. Наличие взаимосвязи НГЭ и инсомнии диктует необходимость проведения рутинной диагностики инсомнических расстройств у данной категории пациентов. Своевременная целенаправленная коррекция инсомнии может способствовать повышению эффективности лечения НГЭ.
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Exchange of Experience
Correction of an iron-deficiency state in women during pregnancy
Abstract
Objective: To estimate the level and rate of an iron deficiency state in pregnant women in the initial gestation period and to analyze the therapeutic efficacy of the use and clinical tolerability of the iron agent ferrous protein succinylate/folinic acid in the patients of this group.
Materials and methods: A total of 524 women who were registered for pregnancy in the VitroClinic were examined. All the patients underwent serum ferritin concentration determinations in addition to general clinical blood testing. During their therapy, 221 pregnant women with identified iron deficiency were divided into two groups. The study group patients (n=112) took ferrous protein succinylate in combination with folinic acid; the comparison group patients (n=109) received other agents based on inorganic iron (II) salts.
Results: According to our data, at the beginning of the gestation, iron deficiency was identified in 67.2% of the pregnant women; moreover, half of them had latent iron deficiency detectable by the ferritin concentration. The pregnant women’s use of the drug Ferlatum Fol based on a combination of ferrous protein succinylate and folinic acid demonstrated a more significant therapeutic effect; as a result of two-month intake of the drugs; the average increase in ferritin levels was 110.5%, relatively 61.0% in the women who received other iron agents, that in hemoglobin was 12.6% and 5.1% and in packed cell volume was 9.1% and 6.1%, respectively (p<0.001). Adverse reactions were detected in 7/112 (6.3%) pregnant women taking Ferlatum Fol and in 12/109 (11.1%) patients taking iron (II) salts.
Conclusion: Ferlatum Fol is highly effective in rapidly correcting hyposiderosis in the patients in the gestation period, has a high safety profile and an extremely low rate of side effects.
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The prevalence of breastfeeding up to 18 months of life in relation to the use of prelactation feeding with a formula in the perinatal center
Abstract
Currently, the importance of increasing the prevalence of breastfeeding (BF) is well known as the health-saving the national strategy based on medicine-evidence data.
Objective: To analyze the prevalence of BF in relation to the feeding method in a maternity hospital after its discharge.
Materials and methods: The investigation involved 37 mother-baby dyads, in which the babies received supplementary feeding with expressed colostrum and/or a formula. A control group included 24 mother-baby dyads, in which the babies were exclusively on BF. The prevalence of the latter in the first year was revealed during a telephone interview at 1, 3, 6, 12, and 18 months. All the women were consulted by specialists from the Breastfeeding Support Department, Institute of Neonatology and Pediatrics, V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology, and Perinatology, Ministry of Health of Russia. According to the supplement feeding method, the study group was divided into 2 subgroups. Subgroup 1 consisted of 18 babies who took supplementary feeding with colostrum/milk and partially with a formula in an alternative way (digital syringe feeding). In this subgroup, the investigators used a novel convenient accessory, such as a syringe nozzle invented by Doctor M.G. Shneiderman. Subgroup 2 included 18 babies who received supplementary bottle feeding with a formula. In Subgroup 2, the mothers consciously made the choice of bottle feeding as more convenient for them, which served as a criterion for dividing into subgroups.
Results: The number of mother and baby dyads on BF in all age periods predictably prevailed in the control group versus the subgroups that received supplementary feeding. However, the statistically significant differences were only compared to those in Subgroup 2 at 3 and 6 months, respectively. Moreover, the risk of BF loss at the age of 6 months 6 times higher if prelactation supplementary feeding with a bottle formula was used as compared with the group on exclusively BF in the maternity hospital (RR=5.6; 95% CI, 1,34–22.5; p<0.05).
Conclusion: Exclusively BF in the maternity hospital contributes to an increase in the duration of BF in the further. Exclusively BF in the maternity hospital depends on the women’s BF motivation (the lactation dominant formed before childbirth) and professional BF support allowing one to overcome the difficulties that arise at the beginning of BF, by avoiding prelactation supplementary feeding with a formula without medical indications.
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Intrauterine synechiae after myomectomy
Abstract
Objective: To study the incidence of intrauterine synechiae in patients after myomectomy, to evaluate the effect of the antiadhesive enzyme bovhyaluronidase azoximer on their formation.
Materials and methods: A total of 160 patients with uterine fibroids who had been operated on in the Department of Operative Gynecology and Gynecological Oncology, and in the day hospital, Moscow Regional Research Institute of Obstetrics and Gynecology, were studied. This was a two-stage study (Stage 1 was a retrospective study of 80 patients after myomectomy; Stage 2 was an open-label prospective controlled study of 80 patients).
Results: The submucous localization of the nodes of uterine fibroids (0–2 types) is clinically unfavorable; its main manifestations are abnormal uterine bleeding (95%), pains (27.5%), infertility (45%), and anemia (60%). One of the causes of continuing infertility after myomectomy are intrauterine synechiae (46.1%) that are twice more often observed in patients after myomectomy of the nodes of 0–2 types (56.3%) than those of 3–7 types (30%). A prospective study, office hysteroscopy during the first two months after myomectomy) reveal that 18.5% the patients were found to have intrauterine synechiae. The main cause of their formation is dissection of the uterine cavity and damage to the endometrium when removing nodes of 0–2 types. In this period of time, all synechiae have a loose, delicate structure (organization type 1) and are easily destroyed by hydrodissection. The use of the enzyme bovhyaluronidase azoximer in the postoperative rehabilitation program after myomectomy can reduce the frequency of formation of intrauterine synechiae from 23.1 to 3.8% (p=0.03771).
Conclusion: Intrauterine synechiae form in every 5 patients after myomectomy of nodes of 0–2 types via through uterine cavity dissection of the uterine cavity after myomectomy of nodes of 0–2 types, by dissecting the uterine cavity, therefore it is expedient to include office hysteroscopy into the postoperative rehabilitation program for the patients (after 2 months). It is also advisable to incorporate long-acting hyaluronidase that reduces the frequency of formation of intrauterine synechiae into the postoperative rehabilitation program for reproductive-aged patients planning pregnancy after myomectomy of nodes of 0–2 types.
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Guidelines for the Practitioner
The clinical role of anatomical abnormality of the hymen
Abstract
Hymen atresia is a congenital anomaly of the female genital organs, which occurs in 1 per 1000–2,000 newborn girls.
In the paper, based on the data of modern medical literature, the authors carry out a critical analysis of the theories of vaginal embryogenesis, detailed the key stages of development of the female genital system as a whole and show the relationship of formation of the urinary and genital systems. Also, based on the cases presented in the literature, they indicate that due to the nonspecific symptoms, the detection of hymen atresia is often delayed, which leads not only to female reproductive dysfunction, but also to cardiovascular, urinary, nervous, digestive, and locomotor complications, and to unjustified surgical interventions.
Conclusion: In this connection, the authors believe that for the timely diagnosis of hymen atresia, concomitant anomalies, and complications, for the prevention of unjustified surgical interventions, it is important that practitioners should have a certain clinical alertness and a clear idea of different types of symptomatic manifestations of this congenital malformation.
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Clinical Notes
Pregnancy in a patient with the repaired common arterial trunk
Abstract
Background: The common arterial trunk is a congenital cardiac defect (CCD), in which the only main vessel carrying mixed blood into the greater and lesser circulations originates from the heart. CCD refers to a cyanotic heart disease. The incidence of this pathology is 0.043 per 1,000 live births. As much as 75% of the infants with the common arterial trunk die in the first year of life; 65% of them do within the first six years. The cause of death is cardiac failure and blood overflow of the pulmonary vessels. The treatment is surgical. Hereafter, the patients with the common arterial trunk need to be followed up by a cardiologist and a cardiosurgeon throughout their life. During pregnancy, the maternal and fetal risks are determined by the existing CCDs and the severity of right ventricular outflow tract obstruction, arrhythmias, and cardiac failure. Maternal death during pregnancy in the presence of heart diseases is 0–1%, while cardiac failure complicates the course of pregnancy in 11% of cases. There are single reports on pregnancy and delivery in women with the repaired common arterial trunk.
Case report: A 32-year-old primigravida with the repaired common arterial trunk and repeated surgical interventions on the heart was for the first time admitted to an obstetric hospital at 30 weeks’ gestation for treating threatened premature birth and developing the tactics of management of pregnancy and delivery. Pregnancy occurred as a result of the first VF attempt. Heart function was evaluated over time on the basis of EchoCG data. Despite the increase in systolic pressure in the pulmonary artery (PA) to 55 mm Hg; the patient’s status was satisfactory: it corresponded to functional Class I according to the New York Heart Association (NYHA) Functional Classification and to functional maternal WHO (mWHO) according to the NYHA classification, it corresponded to Functional Class II–III according to the maternal WHO (mWHO) Risk Classification of Cardiovascular Complications during Pregnancy. She delivered via cesarean section at 34–35 weeks’ gestation due to the appearance of signs of fetal distress (a slow increase in fetometric indicators, oligohydramnios, and signs of central fetal blood flow).
Conclusion: Pregnancy is not contraindicated for women with the repaired common arterial trunk in the compensation for their status and in the absence of significant hemodynamic disorders and may progress without cardiological and obstetric complications. Multidisciplinary decision on the possibility of pregnancy, the tactics of its management and delivery depends on cardiac hemodynamic parameters, on the presence of obstetric complications and is taken on the basis of joint conclusions by a cardiologist, an obstetrician, and an аnesthetist. There are no strictly defined recommendations for pregnancy management for this or that cardiac defect, since the type of a defect and the stages of its surgical treatment make each case unique.
149-154
A successful outcome of in vitro fertilization in absolute teratozoospermia after spermatozoon selection by the zeta potential
Abstract
Modern sperm selection methods have not been widely applied in embryological practice, which is primarily associated with the insufficient volume of the documentary basis on their effectiveness. Sperm selection by the zeta potential is one of few methods, the clinical results of which have been published in the world literature.
Case report: This paper describes a clinical case of the in vitro fertilization protocol with sperm selection by the zeta potential in a couple with a history of few unsuccessful attempts to use assisted reproductive technologies (ART). The main cause of infertility in the couple was absolute teratozoospermia (0% of morphologically intact spermatozoa by Kruger’s strict criteria). After intracytoplasmatic injection of the sperm selected by the zeta potential into the oocytes, seven normal zygotes formed; three embryos developed; two embryos were cryo-preserved, and one embryo was transferred into the uterine cavity with the subsequent onset of pregnancy that resulted in the birth of a baby.
Conclusion: Sperm selection by the zeta potential and other studied methods for selecting male gametes deserve more active use in the ART protocols, especially in couples with repeated implantation failures. The experience gained in this way will be able to choose the most effective methods, to formulate indications for each of them, and provide a rationale their application in the context of evidence-based medicine.
155-159
Prenatal diagnosis of Siamese twins after in vitro fertilization with preimplantation genetic diagnosis
Abstract
Background: Siamese or undivided twins are one of the most formidable complications of monozygotic twins. This pathology has an extremely poor prognosis and, as a rule. Pregnancy in this case results in premature termination.
Case report: The paper describes a case of the earliest prenatal diagnosis of Siamese twins in the Russian Federation. The case can be considered unique, as the pregnancy has occurred in a woman having a history of unsuccessful pregnancy with a fetus with multiple malformations. It has been considered that this pathology cannot practically occur after in vitro fertilization (IVF); however, the review of foreign and Russian literature says the opposite and the probable cause may be an injury of the pellucid zone of the blastocyst. The pregnancy described in the paper resulted from IVF with preimplantation genetic diagnosis. This method of genetic diagnosis allows one to select genetically healthy embryos with a normal number of chromosomes, but it is incapable of excluding this pathology. In the Perinatal Cardiology Center, the patient at 8 weeks and 2 days’ gestation was diagnosed with congenital anomalies in embryos. Short tandem repeat (STR) markers were analyzed using the quantitative fluorescence polymerase chain reaction (QF PCR) assay that did not reveal aneuploidies of chromosomes 7, 13, 15, 16, 18, 21, 22, Х, and Y.
Conclusion: The earliest diagnosis of this pathology is as relevant as possible, since it allows a reduction of both the risks of postoperative complications and the patient’s psychological trauma associated with unviable pregnancy termination, since it happens during the first trimester even before the onset of the fetal period.
160-164