Nº 12 (2023)

Background: Placenta accreta spectrum (PAS) poses a serious threat to the life of the mother and fetus. Untimely diagnosis of PAS resulting in delayed treatment may be one of the key causes of serious adverse pregnancy outcomes. Recent studies have increasingly focused attention on various biomolecules that have the potential to diagnose PAS in due time.

Objective: To compare the effectiveness of various molecular biological markers in the antenatal diagnosis of abnormally invasive placenta.

Materials and methods: The analysis of the Russian and foreign research literature databases, namely eLibrary, Medline, PubMed, Embase, Crossref, RSCI, was carried out with the keywords “abnormally invasive placenta”, “placenta accreta spectrum”, “biomarkers”, “antenatal diagnosis”, “epithelial-mesenchymal transition”, “biomolecules”. According to the above goal, 68 literature sources were selected for the analysis.

Results: The significant biomarkers of abnormally invasive placenta and their dynamic change at different gestation periods were described and compared in this review. Biomolecules involved in the pathogenesis of abnormally invasive placenta can be conventionally divided into several groups. These are growth factors, interleukins, signaling molecules, oxidative stress products, microRNA, DNA, and circulating cells. Their content in biological fluids and placenta reflects the activity of pathophysiological processes involved in the formation of abnormally invasive placenta.

Conclusion: Studying the spectrum and concentration of biomarkers of abnormally invasive placenta can contribute to the antenatal confirmation of the diagnosis and severity of this pathology and it can be crucial for improving maternal and perinatal outcomes.

The experience of the COVID-19 pandemic has shown that pregnant women are at high risk of severe disease and mortality due to physiological changes in the body aimed at maintaining pregnancy. According to WHO experts, the risk of new epidemic outbreaks in the world remains; at the same time, the number of indications for vaccination of the population has reduced. Therefore, it is necessary to search for additional methods of anti-infective protection. It is believed that vitamin D deficiency, which often occurs during pregnancy, also leads to increased susceptibility to the SARS-CoV-2 virus.

Objective: To analyze the sources of modern literature on the effect of vitamin D on the course of COVID-19 in pregnant women.

Materials and methods: The databases and services, namely PubMed, PubMed Central, Scopus, MEDLINE, ScienceDirect, Cochrane Library, eLibrary, have been searched for publications of the Russian and foreign authors for the period from 2015 to the present.

Results: During epidemics and pandemics, it is advisable to control and/or correct the level of vitamin D in the patients in the preconception period (especially in the risk group), as this vitamin plays a significant role starting from the moment of conception to delivery. Vitamin D deficiency in mothers causes a high risk of COVID-19 infection as well as its severe course which often leads to adverse obstetric and perinatal outcomes.

Conclusion: It is reasonable to maintain optimal level of vitamin D during the whole pregnancy in order to reduce the likelihood of COVID-19 disease, the development of obstetric and infectious complications.

Objective: To summarize the current data on the combination of endometrial cancer and pregnancy, including risk factors, pathogenetic mechanisms and management options for patients.

Materials and methods: The databases and services, namely PubMed, Wiley, Scopus and Google scholar have been searched for the articles on the association of pregnancy and endometrial cancer over the past 12 years.

Results: The article presents the analysis of the modern literature on the incidence, possible mechanisms of pathogenesis and characteristics of the clinical course of endometrial cancer associated with pregnancy. The main risk factors typical for this pathology which were highlighted in various studies are presented. The studies of foreign scientists reviewing the molecular genetic and transcriptional profiles of endometrial malignancies during pregnancy are analyzed. The role of chorionic gonadotropin in the pathogenesis of endometrial cancer is also identified. Since this pathology affects the organ necessary for pregnancy and actually reduces a woman’s reproductive potential, it becomes obvious that cancer of the uterine body is not only an important medical problem, but it is also a social issue in the modern world. The combination of endometrial cancer and pregnancy is a rare case, its incidence is 1% and it is characterized by a favorable course and prognosis.

Conclusion: Endometrial cancer associated with pregnancy is rather a rare pathology and it is characterized by a favorable course and prognosis. There are no cases of cancer progression during pregnancy in the literature. However, the mechanisms of the protective effect of this physiological condition have not been studied enough, thus, it is necessary to continue research in this direction.

This article describes the international experience of prevention of group B streptococcal (GBS) infections and screening programs for the prevention of GBS infection in obstetrics and neonatology. Two key national strategies have been identified: risk factor assessment and screening. Since 1996, when the first clinical guidelines for the prevention of GBS infections were first developed, risk factor assessment has been used and a number of countries, such as the United Kingdom and the Netherlands, have followed this strategy to date. Screening programs are used in the United States of America, Canada, Italy, France, Germany and, since 2020, in the Russian Federation. The national clinical guidelines specify the main stages of the algorithm for diagnosing patients to identify the carrier of group B streptococcus and prevention of mother-to-fetus transmission of the microorganism. Despite the effectiveness of the screening program, there are several limitations and inaccuracies in the national regulatory documentation, including those related to patient routing, the preanalytical stage of diagnosis and management of patients with multiple pregnancies.

The recommendations for the improvement of the national screening program were offered after the analysis of the national legal documentation regulating the prevention of GBS infections in obstetrics and neonatology.

Our analysis of the international experience and national regulatory documentation was taken into account in making updated versions of clinical recommendations and preparing practical recommendations for laboratory medicine specialists.

Conclusion: In order to resist GBS infections in obstetrics and neonatology effectively, it is necessary to develop clinical recommendations that will specify all the stages and aspects of the prevention of group B streptococcal infections in detail to reduce neonatal morbidity, disability and mortality, and increase demographic indicators.

Objective: To determine the etiology of non-immune hydrops fetalis (NIHF) in order to improve prenatal care and provide timely counseling to parents regarding the prognosis and risk of recurrent births of children with NIHF.

Materials and methods: Two clinical observations related to rare lysosomal storage diseases (LSDs), a leading cause of prenatally diagnosed NIHF, were presented. Pregnant women with NIHF were examined using the algorithm developed at V.I. Kulakov NMRC for OG&P. DNA samples from fetuses and parents were analyzed using chromosomal microarray analysis and special examination methods, including whole-exome sequencing and Sanger sequencing for pathogenicity analysis. A joint analysis of data from whole exome sequencing of the fetus and parents (trio-whole exome sequencing) was also performed.

Results: Mucopolysaccharidosis type VII and galactosialidosis, both belonging to the LSD group, were prenatally identified. Whole exome sequencing data revealed that in two clinical cases, two probable pathogenic variants were detected in the GUSB and CTSA genes, respectively, in a compound heterozygous state. The progression of pregnancies was analyzed, and the mode of inheritance of these diseases was determined. It was found that both parents in each observation were carriers of probable pathogenic variants in the GUSB and CTSA genes associated with autosomal recessive diseases. Genetic counseling was provided to the parents, informing them about the high risk of recurrence of this pathology in subsequent pregnancies (25% adverse outcomes) and the possibility of preimplantation or prenatal diagnosis.

Conclusion: The proposed examination enables optimization of pregnancy management strategies, prediction of the risk of identified pathology in subsequent pregnancies, and expands the possibilities of genetic counseling.

Relevance: Selective fetal growth restriction (sFGR) and twin-to-twin transfusion syndrome (TTTS) are the most common complications of monochorionic multiple pregnancies (10–35%) and are characterized by high perinatal mortality and a wide range of neonatal complications. The main etiological factor in the development of TTTS and sFGR is placental dysfunction, which is primarily associated with vasculogenic and angiogenic factors during monochorionic pregnancy.

Objective: This study aimed to investigate the role of vascular endothelial growth factors in perinatal outcomes, neonatal morbidity, and mortality in complicated monochorionic twin pregnancies.

Materials and methods: This was a prospective study with comparative analysis of the relationship between vasculogenic and angiogenic factors and perinatal outcomes, neonatal morbidity, and mortality in monochorionic multiple pregnancies complicated by sFGR and TTTS. The study included 84 pregnant women with monochorionic diamniotic twins and 152 newborns. An analysis of the course of pregnancy and childbirth, perinatal outcomes, and neonatal morbidity was also performed. The study also analyzed vasculogenic and angiogenic factors in the second trimester of pregnancy depending on the development of specific complications.

Results: Antenatal losses occurred in 6.45% (n=2) of patients in the TTTS group (p=0.249). Early neonatal mortality was observed in 14.3% (n=4) of the TTTS group and in 5% (n=1) of the sFGR group (p=0.272). The gestational age at delivery was significantly different in the complicated pregnancy groups (32.2–32.4 weeks) compared to the control group (36.2 weeks); (p<0.001). A study of vasculogenic and angiogenic factors in the second trimester of pregnancy showed an increase in maternal blood VEGF-C to 0.66 ng/ml and HIF-1a to 0.69 ng/ml, a decrease in VEGF-R1 to 0.73 ng/ml with neonatal mortality. In case of stillbirth, a high concentration of HIF-1a was observed (0.69 ng/ml). Changes in maternal blood concentrations of VEGF-R1 (0.787 ng/ml) and ANGPT2 (8255.91 pg/ml) were associated with the risk of fetal growth restriction. Analysis of the early neonatal period showed high respiratory, cardiovascular, and gastrointestinal morbidity in neonates from the TTTS and sFGR groups associated with prematurity and intrauterine deficits.

Conclusion: An association was found between changes in vasculogenic and angiogenic factors in the blood of pregnant women and high neonatal morbidity and mortality in complicated monochorionic twins. Specifically, the concentrations of VEGF-C and HIF-1a increased while VEGF-R1 decreased. The data obtained make it possible to predict antenatal and neonatal risks, improve perinatal outcomes, and minimize the risk of severe neonatal complications.

Relevance: Currently there is no trend toward reduction in postpartum purulent-inflammatory diseases (PPID), and they account for 5–26% of all postpartum complications. Postpartum endometritis (PE) ranks first in the structure of PPID, and is diagnosed in more than 40% of all cases of postpartum complications.

Objective: To explore the clinical and anamnestic characteristics in women with PPID according to the data in Krasnoyarsk and in the Krasnoyarsk region.

Materials and methods: A retrospective assessment and statistical analysis of clinical and anamnestic data of 387 patients with various complications in late postpartum period and 446 puerperant women with PE in the period 2017–2022 was conducted.

Results: In the structure of postpartum complications, the rate of postoperative wound to the anterior abdominal wall is very high and reaches in general 64.2% (248/387), the rate of endometritis is 36.7% (142/387), and the rate of suppurating perineal wound is 11.1% (43/387). Manifestation of the clinical picture of preeclampsia is blurred in most cases – in 36.8% (164/446)) of women, and only one third of patients have classical clinical symptoms of the disease. On average, the debut of clinical symptoms is on day 11 of the postpartum period. At the same time, the symptoms in women after cesarean section occur one day earlier (10,5 days) in comparison to the vaginal delivery (11.2 days).

Conclusion: Thus, there is no trend toward reduction in the rate of PPID. At the same time, it is noteworthy that predominantly blurred clinical picture of PPID does not correlate with the severity of destructive processes in the site of inflammation, and therefore, delays timely diagnosis, leading to critical delayed consequences up to sepsis. The obtained results are of scientific and practical interest and are aimed at development of novel, most effective methods of diagnosis and treatment of PPID.

Objective: This study aimed to evaluate the clinical and anamnestic data of patients with different forms of extragenital endometriosis (EGE), considering previous surgical interventions.

Materials and methods: A cross-sectional study was conducted at the V.I. Kulakov NMRC for OG&P from 2021 to 2023. The study involved 200 patients (mean age: 32.03 (7.15) years) with EGE, diagnosed using pelvic ultrasound (US) and magnetic resonance imaging (MRI). Patients were categorized into 3 groups based on the form of endometriosis: peritoneal endometriosis (PE), endometrioid cysts (EC), and deep endometriosis (DE). In cases of combined pathology, inclusion in a specific group was determined based on the most severe form of EGE. Women’s complaints were obtained through interviews, questionnaires, and comprehensive analysis of clinical and anamnestic data, including previous surgical and drug treatments.

Results: The study revealed that one in every three patients had complaints not typically associated with endometriosis. In every third case, the EC was incidentally identified using ultrasonography. When specifically questioned, 23.4% of patients with EC did not experience the characteristic pelvic pain associated with endometriosis, compared to 10.0% in the PE group and only 2.7% in the DE group. One in every three patients had undergone at least one previous surgical intervention, with 30.2% of them not receiving suppressive hormone therapy and 39.7% receiving short courses. Subsequently, the recurrence rate was 94.7% among patients who did not receive hormone therapy and 92% among those who received a short course of suppressive hormone therapy, irrespective of hormone therapy type. After previous surgical treatment for PE and EC, 48.7% of patients were subsequently diagnosed with DE. Among patients with previous surgery for EC, 41.9% experienced EC recurrence and 54.8% progressed to DE, whereas DE recurred to the same form of EGE in 85.7% of cases.

Conclusion: In one in every three cases, patients with EGE presented with complaints that were not typical of endometriosis. A targeted collection of complaints and medical history can aid in suspecting endometriosis as early as the initial outpatient visit, thereby reducing the time before diagnosis and treatment. Short courses of suppressive hormone therapy, regardless of type, do not prevent recurrence or progression of endometriosis after surgical treatment.

Objective: To optimize the therapy of overactive bladder in peri- and postmenopausal women.

Materials and methods: The study included 70 patients (mean age 57 years) with an average period after menopause of 6.3 years; the patients’ complaints were vaginal dryness, itching, burning, frequent urination during the day and/or at night, and urgent desire to urinate with or without incontinence. The women were divided into two groups: group 1 included 35 women who received estriol 0.5 mg (one dose of Ovestin intravaginally for 21 days daily, then one dose twice a week); group 2 included 35 patients who received a combination of the β₃-adrenergic receptor agonist mirabegron (Betmiga 50 mg per day) and estriol 0.5 mg using the same scheme. The effectiveness of therapy was assessed with the help of filled questionnaires and diaries of urination, the findings of the examination and comprehensive urodynamic examination, G. Bachman score for the assessment of urogenital atrophy.

Results: Both groups showed a decrease in the incidence of pollakiuria, nocturia, urgency and urgent urinary incontinence after three months of treatment. The improvements were significantly more remarkable in the combination therapy group. There was a decrease in the severity of symptoms of genitourinary syndrome of menopause, including manifestations of vulvovaginal atrophy, in both groups.

Conclusion: Combination therapy with a β₃-adrenergic receptor agonist (mirabegron 50 mg) together with local estrogens (estriol 0.5 mg intravaginally) is more effective against all symptoms of overactive bladder than monotherapy with intravaginal estriol. An important advantage of combination therapy is a two-fold decrease in the frequency of relapses. Local therapy with estriol is effective against the symptoms of vulvovaginal atrophy, both in the form of monotherapy and in combination treatment.

The World Congress of the International Federation of Gynaecology and Obstetrics (FIGO) which took place in Paris from October 9 to 12, 2023, brought together representatives from more than 130 countries. The Congress presented new methods for the detection and treatment of cervical cancer, recommendations on strategies for its screening and prevention, the relationship of hormonal contraception with cancer, new data on the human microbiome and reproductive function, male and female contraception, extreme conditions in obstetric and gynaecological practice, as well as aesthetic gynaecology. The issue of the microbiome of the genital tract was of considerable importance in many sections. The unique data from the Isala project and the International Research on Microbiota were presented: they demonstrated the importance of informing both doctors and women about the health state and microbiota of the vagina and vulva. As part of the project, a map of the female microbiome was made, and the importance of lactobacilli in the diagnosis and treatment of various diseases was revealed. The influence of lifestyle and environment on the composition of the vaginal microbiota was also determined. The research aims to raise awareness about the microbiome and overcome taboos in women’s health. The obtained results became the basis for further research and development of methods for the prevention of disorders of the vaginal microbiota. There was a discussion of important aspects of female intimate hygiene including the prevention of vulvovaginal infections. The line of Saforel products for intimate hygiene was presented at the congress exhibition; these products were shown to be effective and safe for maintaining healthy intimate hygiene due to the properties of burdock, which is a component of the products.

Conclusion: Most women with diseases and symptoms of discomfort in the vulva (for example, contact dermatitis, vulvovaginitis) need advice on vulvar skin care and how to avoid contact irritants. The role of an obstetrician-gynecologist and dermatologist-venereologist is important in providing information on the principles of proper intimate hygiene and the basics of preserving and maintaining the microbiota of the vulva and vagina in balance. The clinical experience of using the new line of Saforel products has demonstrated optimal properties and safety for female intimate hygiene, as well as for vulvar dermatoses.

This article presents up-to-date information on the use of vaginal dilators in gynecology, taking into account the indications for their use and effectiveness.

The findings of 36 articles found in the databases Medline, Scopus, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Google Scholar, eLibrary were analyzed over the period 2014–2023 using keywords.

The results of the analysis showed that there are the following indications for the use of vaginal dilators: condition after radiation therapy for cancer of the vulva, cervix, uterus, anogenital area (high risk of vaginal stenosis); scars/stenosis after episiotomy or perineal rupture during childbirth, vaginoplasty surgery (neovagina, vaginal hypoplasia/agenesis, or Mayer–Rokitansky–Küster–Hauser syndrome); dyspareunia, vaginismus, vulvodynia, sclerosing complications of skin diseases of the external genitalia (sclerotic lichen, lichen planus). The use of vaginal dilators is effective in 75–81% of patients for the prevention of vaginal stenosis after radiation therapy for cancer of the genitalia and anogenital area; it is effective in the treatment of hypoplasia/agenesis of the vagina in 75%, and is also effective in stenosis caused by sclerotic lichen and lichen planus. The success of therapy depends on informing and educating patients.

Conclusion: The analysis of studies published over the past 10 years has shown the possibility of using vaginal dilators for various diseases, in particular for the prevention of vaginal stenosis after radiation therapy in patients treated for gynecological cancer, postpartum injuries, after gynecological operations on the vulva and vagina, as well as for stenosis caused by sclerotic lichen and lichen planus. Informing and educating patients influence the success of therapy. The use of vaginal dilators should become more widespread in clinical practice.

Relevance: Placental mesenchymal dysplasia (PMD) is a rare morphological anomaly that can resemble a partial hydatidiform mole caused by the mosaicism of genes inherited from the father or both parents. PMD is rather often associated with severe complications in the fetus and/or mother. It is difficult to diagnose this condition and manage pregnancy due to the variety of clinical and laboratory manifestations of PMD.

Case report: This is a clinical observation of a case with of PMD which was misdiagnosed and treated as partial hydatidiform mole due to the similarity of their clinical and ultrasound signs. The clinical case had a favorable outcome: on the one hand, the erroneous diagnosis of partial hydatidiform mole did not result in termination of pregnancy, and on the other hand, PMD, fortunately, did not have severe antenatal and postnatal disorders in the offspring.

Conclusion: In order to identify the tactics of pregnancy management, the specialists of prenatal diagnostics should be cautious and carry out thorough antenatal differential diagnosis of partial hydatidiform mole and PMD. To stratify the risks to the mother and fetus, it is necessary to apply a multidisciplinary approach to the detailed comparison of ultrasound images, clinical and laboratory data during the whole pregnancy in each case of suspected partial hydatidiform mole on ultrasound examination.

Relevance: Uterine artery pseudoaneurysm is a rare and potentially life-threatening pathology of the arterial system. It can occur due to the damage to tissues during complicated vaginal delivery or cesarean section, uterine surgery, adnexal surgery (myomectomy, hysterectomy, metroplasty, cervicoplasty, perforation of the uterus during curettage or during diagnostic manipulations, removal of various tumors in the pelvic area, and others). This may be a rare cause of delayed postpartum hemorrhage in 3–6 cases per 1000 births.

Case report: A 25-year-old primigravida underwent an emergency cesarean section in the lower uterine segment due to an acute intrauterine fetal hypoxia at 40–41 weeks gestation. On the 4th day after surgery, she complained of an increase in body temperature to 37.5°C, nagging pains in the left iliac region. Doppler ultrasound imaging of the pelvic area to the left of the uterus revealed a pathological vascular formation in the parametrium. An emergency angiography of the pelvic vessels was performed, it was followed by embolization with two coils of the branches of the uterine artery feeding the pseudoaneurysm. Seven years after the operative delivery and embolization, the patient became pregnant and had a planned cesarean section at 40 weeks gestation without complications.

Conclusion: The first diagnostic method in an emergency situation is Doppler sonography. The method of choice in the treatment of uterine artery pseudoaneurysm is embolization of the feeding artery (provided there are conditions for such an operation).