Obstetrics and Gynecology

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“Akusherstvo i Ginekologiya” (Obstetrics and Gynecology) is included in the list of peer-reviewed scientific journals recommended for publication of principal scientific results of dissertations competing for scientific degrees of Candidate of Science and Doctor of Science.

“Akusherstvo i Ginekologiya” (Obstetrics and Gynecology) member of COPE (JM13971), WAME, is included in the list of peer-reviewed scientific journals recommended for publication of principal scientific results of dissertations competing for scientific degrees of Candidate of Science and Doctor of Science.

The journal is presented in the following international databases: Russian Science Citation Index; Google Scholar; WorldCat; Scopus; EBSCO; Emerging Sources Citation Index WoS; Russian Citation Science Index WoS; Abstract of Bulgarian Scientific Medical Literature; Experta Medica; Ulrich’s International Periodicals Directory


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No 12 (2023)

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Reviews

Spectrum of significant serum biomolecules and genetic predictors in antenatal diagnosis of placenta accreta spectrum
Kayumova A.V., Melkozerova O.A., Bashmakova N.V., Malgina G.B., Chistyakova G.N., Tretyakova T.B., Grishkina A.A.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):5-15
pages 5-15 views
Methods of compression hemostasis in the management of postpartum hemorrhage
Artymuk N.V., Marochko T.Y., Apresyan S.V., Artymuk D.A.
Abstract

The incidence of postpartum hemorrhage (PPH) in the world is currently about 5% and has no tendency to decrease. Most maternal deaths associated with PPH are preventable. The patients respond appropriately to first-line treatments for PPH, which include uterotonics, uterine massage, and tranexamic acid; however, 10–20% of these patients remain refractory and require the use of second-line interventions. In case of severe refractory PPH, the patient often undergoes an emergency hysterectomy, which leads to loss of reproductive and menstrual functions, but to date it remains an urgent surgical intervention aimed at saving the life of a mother with uncontrolled bleeding.

The article presents the historical aspects of the problem and overview of the current data on the management of refractory PPH with the use of compression methods, including compression measures (compression of the aorta or bimanual compression of the uterus), intrauterine balloon tamponade, endovascular methods (temporary balloon occlusion and embolization), ligation and temporary vascular occlusion using tourniquet hemostasis. Each of the methods has indications, contraindications, conditions, limitations, complications and effectiveness. The choice of the hemostasis method is known to depend on the preferences of the surgeon and the equipment of the clinics. Each of these methods can be used alone or in combination with other methods. However, conservative measures for preserving the uterus are acceptable only in a situation of hemodynamic stability of the patient when there is no life-threatening bleeding.

Conclusion: The problem of management of refractory PPH continues to be relevant at the present time. Various methods of compression hemostasis have been approved and they are successfully used alone or in combination with each other. However, there is a lack of data on their most rational sequence, combination with each other and with other methods. It is necessary to continue research in this direction.

Obstetrics and Gynecology. 2023;(12):16-24
pages 16-24 views
Vitamin D and COVID-19 in pregnant women
Belokrinitskaya T.E., Malko D.V., Mudrov V.A., Shametova E.A.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):25-31
pages 25-31 views
Placental hemangioma
Frolova E.A., Tumanova U.N., Shchegolev A.I.
Abstract

The article presents the analysis of the literature data on the role of placental hemangioma. Hemangioma refers to rare benign non-trophoblastic tumors of the placenta and it can have several synonyms. According to the literature, the diagnosis and risk of complications depend on the size of the tumor. The diagnosis is made prenatally on the basis of ultrasound imaging of a round-shaped hypoechoic formation with relatively clear boundaries of a homogeneous or heterogeneous structure located on the fetal surface of the placenta. The use of color Doppler ultrasonography makes it possible to visualize the feeding vessels included in this formation and peri-tumor diffuse vascularization. The variability of the histological structure and immunohistochemical characteristics of the tumor are noted. Complications include the development of uteroplacental insufficiency, polyhydramnios, preeclampsia, fetal distress, placental abruption, preterm birth, fetal death or artificial termination of pregnancy. Large and giant hemangiomas (more than 4–5 cm) may require medical interventions aimed at tumor devascularization.

Conclusion: Though placental hemangioma occurs rarely, it is characterized by an increased risk of complications and adverse outcomes for both the mother and the fetus.

Obstetrics and Gynecology. 2023;(12):32-38
pages 32-38 views
Endometrial cancer and pregnancy
Chernyakov A.A., Chernyshova A.L., Kolomiets L.A., Trushuk Y.M., Dil O.S., Krasilnikov S.E., Antipov V.A., Shumeikina A.O., Chernyshova A.E.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):40-46
pages 40-46 views
Magnetic resonance imaging in the planning and monitoring of the treatment of cervical cancer
Solopova A.E., Bendzhenova B.B.
Abstract

Cervical cancer remains one of the leading causes of cancer morbidity and mortality among the female population worldwide. The prognosis as well as the choice of therapy depends on the initial assessment of the extent of the tumor spread. The latter is mainly determined with the use of methods of radiologic diagnostics: magnetic resonance imaging (MRI), positron emission tomography and multispiral computed tomography. These methods also play one of the leading roles in assessing the treatment response. The updated classification of the International Federation of Gynecology and Obstetrics (FIGO, 2018) recognizes the value of imaging in cervical cancer, in particular MRI, before, during and after antitumor treatment. The development of medical imaging and the search for new biomarkers will increase the prognostic value in assessing the response to therapy, identifying residual tumors and relapse of the disease.

This review presents the relevant information on the possibilities and limitations, the place of MRI in the complex diagnostic algorithm at the stage of primary assessment of the tumor process, the choice of tactics and analysis of the effectiveness of cervical cancer treatment. Different data bases, including PubMed/MEDLINE, eLibrary, Scopus, NCCN, ESUR, ACR, were searched. We analyzed the studies results on the use of noninvasive imaging techniques at the stage of primary diagnosis, assessing the effectiveness of treatment and its prognosis in patients with cervical cancer. The diagnostic opportunities and limitations of MRI in the cervical cancer diagnosis are summarized in our review. Due to the high soft tissue contrast, MRI is the method of choice in assessing the response to therapy, predicting treatment and further monitoring.

Conclusion: Noninvasive imaging plays a leading role in the primary diagnosis of cervical cancer. Further research is needed to overcome the difficulties of staging, monitoring the response to therapy and detecting relapse of the disease.

Obstetrics and Gynecology. 2023;(12):47-58
pages 47-58 views
Creating an effective system for the prevention of group B streptococcal infections in obstetrics and neonatology
Grigorian I.E., Priputnevich T.V., Dolgushina N.V., Kan N.E., Nikolaeva A.V., Shabanova N.E.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):59-67
pages 59-67 views
Application of fluorescent in situ hybridization in the diagnosis of bacterial vaginosis
Savicheva A.M., Krysanova A.A., Shalepo K.V., Spasibova E.V., Budilovskaya O.V., Khusnutdinova T.A., Tapilskaya N.I., Kogan I.Y., Swidsinski A.V., Swidsinski S.
Abstract

Bacterial vaginosis (BV) is a polymicrobial biofilm vaginal syndrome characterized by a high prevalence, recurrence rate and associated complications, including preterm birth, infertility and a higher risk of sexually transmitted infections. Traditional diagnostic methods used to detect the disease do not provide complete information on the morphology, number, and spatial arrangement of microorganisms associated with BV. Fluorescence in situ hybridization (FISH) combines the accuracy of molecular genetics with the informative power of microscopy to visualize the relationships between bacteria in their natural microhabitat, such as the biofilm in BV. The persistence of biofilm composed of BV-associated microorganisms is one of the most likely pathways for recurrence and is an important diagnostic marker for the disease. The review of the literature presents the history of the use of FISH, outlines its basic principles and demonstrates its advantages in the diagnosis of bacterial vaginosis, especially its recurrent forms.

Conclusion: The use of the FISH method may not only change the understanding of BV pathogenesis, but it can also identify the etiological agent in each particular case, diagnose biofilm/non-biofilm vaginosis by determining the spatial relationship of bacteria to each other and to epithelial cells, predict the recurrence of the disease and choose the appropriate therapy.

Obstetrics and Gynecology. 2023;(12):68-77
pages 68-77 views

Original Articles

Lysosomal storage diseases as a cause of non-immune hydrops fetalis
Lyushnina D.G., Tetruashvili N.K., Shubina J., Zaretskaya N.V., Tolmacheva E.R., Svirepova K.A., Bolshakova A.S., Pak V.S., Bokeriya E.L., Trofimov D.Y.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):78-86
pages 78-86 views
Post-COVID syndrome in pregnant women with a history of mild and moderate COVID-19
Malgina G.B., Dyakova M.M., Bychkova S.V., Shikhova E.P., Klimova L.E.
Abstract

Objective: This study aimed to investigate the characteristic features of the course of post-COVID syndrome in women with a history of mild and moderate forms of novel coronavirus infection (NCVI) at different gestational ages.

Materials and methods: The study group (n=200) was divided into three subgroups: subgroup 1 (n=22) with NCVI in the 1st trimester, subgroup 2 (n=76) with NCVI in the 2nd trimester, and subgroup 3 (n=102) with NCVI in the third trimester. The control group (n=99) included women without a history of acute respiratory viral infections (ARVI) during pregnancy. The mean gestational age at the time of the study was 38.3 weeks (37.0–40.2) in the study group and 38.2 weeks (37.1–40.2) in the control group (p=0.1). The time between the disease and the study was more than 20 weeks in subgroup 1 (mean 31.3 (1.1) weeks), 13–20 weeks in subgroup 2 (17.6 (1.1) weeks), and 4–12 weeks in subgroup 3 (6.9 (1.0) weeks). An online survey and psychological research were conducted.

Results: Symptoms not explained by an alternative diagnosis were detected in 93.0% of the pregnant women in the study group and in 38.4% of the women in the control group (p<0.001). The most common symptoms in pregnant women of the study and control groups included cognitive impairment (78.0% vs. 19.2%), distortion of smell and taste (47.5% vs. 0.0%), dry mouth (27.5% vs. 9.1%), fatigue when performing household work (27.0% vs. 9.1%), and weakness (26.0% vs. 8.1%). In the study group, 90.0% and 59.6% of the women in the control group had psychological disorders. Pregnant women with NCVI in the first trimester were significantly more likely to be at risk of developing post-COVID disorders that persisted until full-term pregnancy. A correlation was established between the number of symptoms of post-COVID syndrome and the Hamilton Depression Scale score (r=0.58; 95% CI 0.81–0.89, p<0.001).

Conclusion: The data obtained allowed us to substantiate the need for rehabilitation measures in pregnant women after NCVI, depending on the severity and duration of post-COVID symptoms.

Obstetrics and Gynecology. 2023;(12):87-94
pages 87-94 views
The role of vasculogenic and angiogenic factors in perinatal outcomes, neonatal morbidity, and mortality in complicated monochorionic multiple pregnancies
Gladkova K.A., Khodzhaeva Z.S., Sakalo V.A., Frolova E.R., Shakaya M.N., Kirtbaya А.R.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):95-103
pages 95-103 views
Paradigm shift in pharmacotherapy for late-onset preeclampsia: advantages of two-component antihypertensive therapy compared to monotherapy based on analysis of vasoactive status data in pregnant women
Ziganshina M.M., Muminova K.T., Khodzhaeva Z.S., Оshkhunova M.S., Baranov I.I.
Abstract

An important aspect of the effectiveness of antihypertensive therapy is its effect on the production of vasoactive factors that control blood pressure (BP). The most commonly used drugs, methyldopa (Dopegyt) and nifedipine (Cordaflex), have different mechanisms for reducing BP; however, their impact on the production of vasoactive factors in pregnant women with preeclampsia (PE) has not been studied.

Objective: To characterize the vasoactive status of pregnant women with late-onset PE who received different antihypertensive therapy regimens: monotherapy with Dopegyt and two-component therapy with Dopegyt and Cordaflex.

Materials and methods: The study included 47 pregnant women with a gestational age > 34 weeks. The control group comprised 18 patients with healthy pregnancies, while the study group included 29 pregnant women with PE; 15 received antihypertensive monotherapy (Dopegyt) (Group 1), and 14 received two-component therapy (Dopegyt+Cordaflex) (Group 2). Clinical assessments included the following: 1) hemodynamic status based on 24-hour ambulatory blood pressure monitoring, considering parameters characterizing changes in central aortic pressure, intracardiac hemodynamics, and arterial stiffness; 2) hemodynamic status in the fetoplacental system based on Doppler findings; and 3) factors regulating vascular tone, thrombosis, and markers of cardiovascular insufficiency in peripheral blood based on the results of the immunoassay analysis.

Results: A balance was established between vasoconstrictors and vasodilators in pregnant women with late-onset PE who received both antihypertensive regimens. Pregnant women receiving two-component therapy exhibited a more compensated hemodynamic status. An increase in antithrombin levels in the blood of pregnant women who received both regimens was noted, presumably owing to the effects of Dopegyt.

Conclusion: In late-onset PE, antihypertensive therapy provides control of the humoral regulation of vascular tone and promotes a balance between vasoconstrictors and vasodilators. The use of two antihypertensive drugs with different mechanisms of action favorably influences the cardiovascular system of pregnant women and adequately regulates the synthetic function of endothelial cells.

Obstetrics and Gynecology. 2023;(12):104-113
pages 104-113 views
Regional clinical and anamnestic characteristics of the course of the postpartum period in women according to the data in Krasnoyarsk and the Krasnoyarsk region
Galkina D.E., Makarenko T.A., Bochanova E.N., Shageeva G.A., Ulyanova I.O.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):114-124
pages 114-124 views
The potential of magnetic resonance imaging in the diagnosis of placenta accreta
Ralnikova A.Y., Arakelyan B.V., Bezhenar V.F., Morozov A.N., Voydak I.V.
Abstract

Placenta accreta spectrum (PAS) is one of the most serious complications of pregnancy and the postpartum period. Despite this, a considerable number of PAS cases remain undetected in the prehospital stage. Ultrasonography (US) and magnetic resonance imaging (MRI) are commonly used for PAS diagnosis. A correct prenatal diagnosis is necessary to reduce maternal and fetal complications associated with this pathology. This article provides an analysis of the MRI parameters used to identify PAS.

Objective: This study aimed to investigate the potential of magnetic resonance imaging (MRI) in optimizing the surgical treatment strategy in patients with placenta accreta spectrum.

Materials and methods: This study retrospectively analyzed the medical records of 87 patients who gave birth at the obstetrics and gynecology clinic of Pavlov First St. Petersburg State Medical University, Ministry of Health of Russia. Pregnant women with placenta accreta (n=45, 52%) were divided into two groups based on the outcome of surgical delivery. Group 1 included 30 (66.7%) patients who underwent cesarean section and metroplasty, whereas Group 2 comprised 15 patients (33.3%) who had to undergo hysterectomy. The diagnosis was confirmed postoperatively in all the patients through histopathological examination. The control group included 42 pregnant women (48 %) with no placental pathology.

Results: The study found that the most common MRI marker of placenta accreta, present in 82.2% of cases, was an abnormal structure of the uteroplacental interface. The second most common marker was the presence of hypointense stripes in placental tissues, observed in 73.3% of cases. When analyzing the sensitivity (Se) and specificity (Sp) indicators, the following results were obtained: disruption of the structure of the uteroplacental interface: Se 82.2%, Sp 76.2%; deformation of the bladder wall: Se 85.7%, Sp 81.6%; the presence of wide hypointense bands in the placenta: Se 73.3%, Sp 100%; changes in the structure of placental tissue and thinning of the myometrium in the area of the lower segment: Se 64.4%, Sp 66.7%; intramural and parametric hypervascularization: Se 62.2%, Sp 83.3%. Significantly, in forms of placenta accreta characterized by the deepest invasion into the cervix and underlying structures, such as the parametrium, the MRI marker «naked vessel» was encountered more frequently. In all cases of this sign during MRI studies in our sample of pregnant women, surgical delivery had to be completed with hysterectomy.

Conclusion: MRI is an adjunct to the diagnosis of placenta accreta. Initially, all at-risk patients should undergo US of the uterus and placenta. However, when it is necessary to assess pathological changes in the uterine blood supply and topography of placental invasion, MRI is of greater interest than ultrasound diagnostics.

Obstetrics and Gynecology. 2023;(12):125-132
pages 125-132 views
Clinical manifestations and recurrence rates of various forms of extragenital endometriosis
Pronina V.A., Sokolova A.V., Chernukha G.E.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):134-142
pages 134-142 views

Exchange of Experience

Management and treatment of postmenopausal women with overactive bladder in genitourinary syndrome of menopause
Tikhomirova E.V., Balan V.E., Titchenko J.P.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):143-151
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Preparation of patients with chronic endometritis for the procedure of assisted reproductive technologies
Karakhalis L.Y., Zhigalenko A.R., Dotsenko S.V., Voronkova V.V.
Abstract

Objective: To evaluate the ability of L. paracasei CNCM I-1572 in Enterolactis Duo to influence the course of chronic endometritis (CE) and the level of cholecalciferol in patients undergoing ART.

Materials and methods: A total of 68 patients with CE were examined. Group 1 (n=40) received standard therapy for CE, cholecalciferol and Enterolactis Duo; group 2 (n=28) received standard therapy for CE and cholecalciferol. A general clinical study was conducted before and after the end of therapy. The study included physical examination, complete blood count and urine tests, measurement of the level of thyroid-stimulating hormone, vitamin D, Femoflor 16, ultrasound examination of the uterus and thyroid gland, measurement of CD-138.

Results: Before administration of therapy, there were no significant differences in vitamin D levels: 24.4 (15–38) ng/ml in group 1 and 25.6 (16–41) ng/ml in group 2. Dysbiosis was diagnosed in 19/40 (47.5%) patients of group 1 and in 1/28 (3.6%) patient of group 2; moderate anaerobic dysbiosis was revealed only in patients of group 1 (4/40 (10%), and anaerobic dysbiosis was found only in group 2 (11/28 (39.3%)). Ultrasound signs of CE were detected in 30/40 (75.0%) patients of group 1 and in 19/28 (67.9%) patients of group 2. Histological verification of CE was performed in the first phase of the menstrual cycle in all patients; the marker of chronic endometritis, namely plasma cell membrane protein CD-138, was detected in 100% of cases in both groups. The level of vitamin D significantly differed between the groups in 12 weeks after the beginning of therapy: it was 34.4 ng/ml in group 1 and 28.4 ng/ml in group 2. After treatment, normocenosis was observed in 26/40 (65.0%) and absolute normocenosis was in 14/40 (35.0%) patients in group 1. Among patients of group 2, there were 2/28 (7.1%) patients with anaerobic dysbiosis, normocenosis was observed in 26/28 (92.9%) women. Ultrasound signs of CE were absent in 29/40 (72.5%) patients of group 1 and in 13/28 (46.4%) patients of group 2. According to the results of histological verification of CE, CD-138 was absent in group 1 and remained in 1/28 (3.6%) patient in group 2.

Conclusion: The use of Enterolactis Duo synbiotic which was administered together with standard therapy of CE contributes to the normalization of vaginal biocenosis. The patients of both groups took vitamin D, but in group 1 using the Enterolactis Duo synbiotic, vitamin D levels increased significantly more compared to the group 2; this allowed us to conclude that the absorption of oral vitamin D increased when the patients received Enterolactis Duo. Besides, the histological and ultrasound findings of the study showed the ability of L. paracasei CNCM I-1572 in Enterolactis Duo to have a beneficial effect on the course of CE.

Obstetrics and Gynecology. 2023;(12):152-157
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Guidelines for the Practitioner

Women’s and men’s health through the prism of the International Federation of Gynaecology and Obstetrics 2023 recommendations. A new insight into the microbiome and intimate hygiene
Apolikhina I.A., Teterina T.A., Tarnaeva L.A., Bartous K.A.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):158-166
pages 158-166 views
The use of a subcutaneous contraceptive implant in women with chronic viral infections
Samarina A.V., Mozaleva O.L., Martirosian M.M., Skryabneva T.S., Shamaeva N.S., Filatova M.P.
Abstract

The proportion of women with HIV continues to grow due to the prevalence of sexual transmission route of the infection. Most of the patients are reproductive-aged women who are not always interested in pregnancy and need counseling on family planning issues. The frequency of unwanted pregnancies and obstetric complications in HIV-infected patients is higher than frequency in the population, thus the risks of maternal and infant mortality in this group of patients are increased. Unwanted and unplanned pregnancy in women with HIV is a predictor of low commitment to monitoring and receiving prevention of perinatal HIV transmission. The task of a practitioner working with this group of patients is to conduct detailed family planning counseling. During the choice of contraception, it is necessary to assess the safety and effectiveness of the chosen method, taking into account high comorbidity and drug interactions, in particular interaction with antiretroviral therapy (ART). There was a study of 41 women with HIV who used a contraceptive radiopaque implant containing 68 mg of etonogestrel (ETG). The study was conducted at the Center for the Prevention and Control of AIDS and Infectious Diseases, St. Peterburg. When the patients used the implant with ETG, there were no significant changes in the number of CD4 lymphocytes, hemoglobin levels, ALT and AST, body weight, as well as serious adverse events; these findings confirm the safety of using this contraception method in HIV-infected women and patients with HIV coinfection and chronic hepatitis C (HCV). There was a decrease in the average level of HIV RNA in dynamics which could be connected with an increase in patients receiving ART; their percentage increased from 85% to 100% during the study period.

Conclusion: Before administering hormonal contraception or starting ART/changing the ART regimen in patients with HIV, it is necessary to evaluate possible drug interactions. It is important to integrate family planning services in the treatment of women with chronic viral infections and provide them with contraceptives via regional HIV prevention programs.

Obstetrics and Gynecology. 2023;(12):169-179
pages 169-179 views
Vaginal dilaters in the prevention and treatment of stenosis and vaginal pain syndromes
Dikke G.B., Ostromenskiy V.V., Shcherbatykh E.Y.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):181-188
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Intimate hygiene in patients with genital itching and dryness
Chernova N.I., Zadorozhnaya I.S., Proskurina M.I.
Abstract

The article presents the data which are available in the modern literature on the possibilities for patients with itching and dryness of the vulva to use cleansers. Washing the skin without special products is not effective enough as most biological contaminants are poorly soluble in water. The type, concentration, combination of surfactant with other components, its washability and pH can significantly affect the epidermal barrier and lead to transdermal water loss, dryness, skin irritation in healthy people and worsening of symptoms in patients with skin problems. Therefore, it is extremely important to understand these differences in order to determine the most appropriate cleanser for each situation. There are two most common types of cleansers: natural soaps and synthetic detergents (syndets). According to scientific studies, syndets can effectively maintain the natural structure, function and integrity of the skin, whereas natural soaps tend to negatively affect the skin and cause an impairment of the protective epidermal barrier, dissolution of lipids and pH changes, which can lead to dryness, itching and imbalance of microbial composition. The article covers the advantages and disadvantages of soap-based products and synthetic cleansers.

Conclusion: In order to preserve the health of the vulva and eliminate and/or reduce existing complaints and symptoms in patients with pathological conditions, it is important to use specialized detergents that are soft in nature, highly effective, and have minimal effect on the stratum corneum. The products of Ginocomfort® line have such properties and are able to restore the hydro-lipid layer of the epidermis, reduce itching, dryness and inflammation; they can moisturize, saturate and retain fatty components.

Obstetrics and Gynecology. 2023;(12):190-196
pages 190-196 views

Clinical Notes

Management of pregnancy with placental mesenchymal dysplasia
Frolova N.I., Belokrinitskaya T.E., Batoyeva V.V., Garyashina E.A., Zolotukhina A.O., Makarova M.I.
Abstract

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.

Obstetrics and Gynecology. 2023;(12):198-204
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Monozygotic twins discordant for multiple congenital anomalies
Bolshakova A.S., Yarygina T.A., Sakalo V.A., Gladkova K.A., Barkov I.Y., Sadelov I.O., Khodzhaeva Z.S.
Abstract

Relevance: The management of a monochorionic multiple pregnancy with abnormal development of one of the fetuses is a clinical and ethical dilemma, since, there is a risk of preterm birth and perinatal death of the second twin regardless of the chosen tactics. Modern molecular genetic methods assist in optimizing the management of pregnant women and newborns in such cases.

We present a case report on the management of multiple pregnancy: discordant monozygotic twins with multiple developmental anomalies.

Case report: A 40-year-old multigravida presented at 17 weeks gestation to the National Medical Research Centre for Obstetrics, Gynecology and Perinatology, Moscow, to determine the tactics of managing monochorionic twins with large omphalocele and spinal deformity in one of the fetuses.

At the first stage of the examination, the patient underwent a separate amniocentesis; normal female molecular karyotype arr(1-22,X)x2 was detected in both fetuses. Impairments in methylation of IC1 (H19) and IC2 (KCNQ1OT1) sites of the critical region of chromosome 11 associated with Beckwith–Wiedemann syndrome were excluded on the basis of DNA of the amniotic fluid in both fetuses. Monozygosity was confirmed by matching samples of the first and second fetuses for five SNP markers on each of 22 pairs of autosomes. Given the normal result of the genetic examination of both fetuses and the potential risks of perinatal complications during intrauterine intervention, the patient refused selective fetocide.

An operative delivery was performed at 33 weeks and 5 days due to the repeated increase in polyhydramnios and zero diastolic blood flow in the umbilical cord arteries, according to the ultrasound Doppler assessment. The first healthy girl was born with a body weight of 2140 g, an Apgar score of 7-8 points, and was discharged home in satisfactory condition at the age of 12 days of life. The second girl with multiple developmental anomalies was born with a body weight of 1760 g, an Apgar score of 5-6 points, and died at the age of 2 days 2 hours due to multiple organ failure.

Both children had a normal female karyotype (46,XX) which was revealed postnatally, and a whole-exome sequencing of pathogenic and likely pathogenic variants associated with the phenotype was performed. Monozygosity of the twins was confirmed, no accidental findings were detected.

Conclusion: The above case demonstrates the principles of modern ante- and perinatal multidisciplinary tactics for multiple pregnancies discordant for structural fetal malformations.

Obstetrics and Gynecology. 2023;(12):205-212
pages 205-212 views
Emergency embolization of uterine artery pseudoaneurysm after cesarean section
Kondrashin S.A., Koblikov V.V., Kovalev M.I.
Abstract

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).

Obstetrics and Gynecology. 2023;(12):213-218
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Jubilee

To the jubilee of Professor V.N. Prilepskaya
Editorial B.
Obstetrics and Gynecology. 2023;(12):219-220
pages 219-220 views

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