Vol 69, No 2 (2020)

Original Researches
Clinical value of c-reactive protein level in predicting the development of postpartum endometritis
Batrakova T.V., Zazerskaya I.E., Vavilova T.V., Kustarov V.N.
Abstract

Hypothesis/aims of study. In the Russian Federation, postpartum septic complications are third among the causes of maternal mortality, along with obstetric bleeding and preeclampsia. A wide range of methods for predicting postpartum endometritis has been proposed. However, none of these methods has sufficient clinical efficacy. The lack of information and the lack of clear criteria highlight the difficulties in the early diagnosis and prognosis of postpartum endometritis. The aim of this study was to evaluate the role of C-reactive protein (CRP) in the prediction of postpartum endometritis in puerperas with a high risk of developing septic complications.

Study design, materials and methods. The study included 135 puerperas, who were retrospectively divided into two groups. The main group consisted of women with developed postpartum endometritis (n = 72), and the comparison group comprised individuals with physiological course of the postpartum period (n = 63). Serum CRP levels were determined for all puerperas on days 1 and 3 of the postpartum period using the immunoturbodimetric method.

Results. On day 1 of the postpartum period, the diagnostic threshold value for CRP levels was 69 mg / ml. The sensitivity and specificity of the method were low: 62% (95% CI 50–74) and 65% (95% CI 51–76), respectively. The predictability at a CRP level above 69 mg / ml was 67% (95% CI 54–77). Thus, in puerperas on day 1 of the postpartum period at a CRP level above 69 mg / ml, the probability of developing postpartum endometritis was 67%, the chances of developing postpartum endometritis being extremely low, increasing by 1.76 times. There were no statistically significant differences when comparing CRP levels in the study groups of puerperas on day 1 of the postpartum period. On day 3 of the postpartum period, CRP level was significantly higher in the main group of puerperas — 148 mg / ml (95% CI 126–171), and in the comparison group — 43 mg / ml (95% CI 38–49) (p = 6 × 10–14). On the 3rd day of the postpartum period, the diagnostic threshold value for CRP levels was 60 mg / ml. The sensitivity of the method was moderate — 79% (95% CI 68–86), the specificity of the method being high — 93% (95% CI 85–98). The predictability at a CRP level above 60 mg / ml was 93% (95% CI 84–96). Thus, in postpartum women on day 3 of the postpartum period at a CRP level above 60 mg / ml, the probability of developing postpartum endometritis was 93%, with the chances of developing postpartum endometritis increased by 10 times (95% CI 5–30). In addition, determining CRP level on day 3 of the postpartum period is clinically informative, as evidenced by the standardized effect size (SES) equal to 1.4 (p = 6 × 10–14). This is confirmed by the ROC analysis data: the clinical significance value (AUC indicator) was 0.89 (CI 0.81–0.93), according to which CRP determination is evaluated as a method with high clinical informativity.

Conclusion. The determination of CRP on day 3 of the postpartum period is a clinically informative method. An increase in CRP level above 60 mg / ml is a predictor of postpartum endometritis with a sensitivity of 79% and a high probability (93%).

Journal of obstetrics and women's diseases. 2020;69(2):5-14
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Current issues of effectiveness and safety of uterine artery embolization in patients with uterine leiomyoma
Korobova P.G., Sulima A.N., Mkrtchyan A.A., Rumyantseva Z.S., Korobov S.A.
Abstract

Uterine artery embolization (UAE) is a highly effective minimally invasive method for treating patients with symptomatic uterine leiomyoma, which becomes more popular between those refusing hysterectomy and conservative myomectomy for a number of reasons, including unrealized fertility. Some issues of UAE effectiveness and safety are still being investigated: optimization of method in order to guarantee radiation safety, extension of indications for UAE, recurrence risk prediction, choice of tactics according to individual anatomy of local blood supply, fertility impact assessment. The results of investigations demonstrate safety and high efficacy of UAE in the treatment of symptomatic uterine leiomyoma on condition that modern techniques of procedure optimization and an individualized approach to the selection and treatment of patients are used.

Journal of obstetrics and women's diseases. 2020;69(2):15-22
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Features of the medical history and pregnancy outcomes in women with antiphospholipid syndrome depending on correction methods
Kravchenko E.N., Goncharova A.A., Kuklina L.V.
Abstract

Hypothesis/aims of study. The aim of this study was to evaluate the features of the medical history and pregnancy outcomes in women with miscarriage and antiphospholipid syndrome depending on the methods of its correction.

Study design, materials and methods. A prospective cohort study was conducted, in which a total of 137 pregnant women with a history of abortion and antiphospholipid syndrome were examined. The women were divided into two groups according to the principle of the presence or absence of plasmapheresis procedures in the scheme of miscarriage therapy at the pregravid stage. Group I (main) consisted of individuals (n = 73), who were treated with the inclusion of plasmapheresis at the pregravid stage; group II (comparison) included women (n = 64), who were not given efferent therapy.

Results. Antiphospholipid syndrome was more common in patients with a complicated obstetric and gynecological history. As a result of persistent infection, chronic endometritis and salpingo-ooparitis were more often observed in patients with TORCH infection. The titer of antiphospholipid antibodies, regardless of the presence or absence of TORCH infection, decreased after plasmapheresis, such positive dynamics being observed only in patients with a history of gestational losses of less than four.

Conclusion. The level of reduction of antiphospholipid antibodies in relation to the initial values was 60–95%, which indicates the optimal choice of the characteristics of plasmapheresis therapy and its duration.

Journal of obstetrics and women's diseases. 2020;69(2):23-32
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Operative vaginal delivery: outcomes for mothers and newborns
Leonova M.D., Aganezova N.V., Aganezov S.S., Frederiks E.V., Dymarskaya Y.R.
Abstract

Hypothesis/aims of study. The frequency of surgical abdominal delivery in Russia, as in the world, continues to grow, reaching 29.3% in 2017. Operative vaginal delivery is an alternative to abdominal delivery in the second stage of labor. This study was aimed at analyzing the outcome of labor for mothers and newborns using different operative vaginal delivery methods.

Study design, materials and methods. We studied 293 cases of childbirth in the period from 2015 to 2018. Three groups were distinguished: (I) the main group consisting of 172 women delivered by the operation of applying obstetric forceps (OF); (II) the comparison group including 85 patients delivered by the operation of vacuum extraction (VE) with the fetal head being near the pelvic floor; and (III) the control group comprising 34 cases of vaginal birth without use of instrumental delivery. In group I, 114 patients were delivered by the low forceps operation (subgroup IA), and 60 individuals by the mid forceps operation (subgroup IB).

Results. Vaginal lacerations were found in 21.3% of cases in group I, less often less often in groups II (10.6%, p < 0.05) and III (2.9%, p < 0.05). Vaginal hematoma occurred in one patient of group III (2.9%) and three women of group I (1.7%, p > 0.05). There were no cases of damage to the anal sphincter. The greatest blood loss was recorded in subgroup IB (554 ± 44.9 ml), when compared to subgroup IA (473 ± 20.7 ml; p < 0.05), group II (418 ± 24.9 ml; p < 0.05), and group III (347 ± 33.4 ml; p < 0.05). There were no differences in blood loss between the outlet OF and VE groups (p > 0.05). Most newborns were born in good condition (84.5%, 77.6%, and 88.2% of cases in groups I, II, and III, respectively). Cephalohematoma in newborns was more common after VE (32.9%) than after OF (9.2%, p < 0.01) and in control (5.9%, p < 0.01). No retinal hemorrhage was recorded in newborns. There were no significant differences in the frequency of children being transferred to the children’s hospital (7.5%, 9.4%, and 8.8% of cases in groups I, II, and III, respectively; p > 0.05).

Conclusion. The use of OF is an effective and safe method of vaginal operative delivery. It does not increase the fetal injury rate, the frequency of newborn cephalohematoma being 3.5 times less than with VE. Complications of OF and VE (except for a greater number of vaginal lacerations in cases of OF), blood loss, and the course and duration of the postpartum stay in the maternity ward are comparable.

Journal of obstetrics and women's diseases. 2020;69(2):33-42
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Ultrasound examination of pregnant women in diagnosing fetal cardiac pathology
Lim V.A.
Abstract

Hypothesis/aims of study. Fetal heart defects are the most common malformations causing infant mortality. The task of the obstetric care service is to make a timely diagnosis, which includes high-quality ultrasound screening and, if necessary, fetal echocardiography. This study aimed to compare fetal echocardiography with postpartum echocardiography.

Study design, materials and methods. 101 pregnant women with both isolated fetal heart defects and combined pathology were examined for the period 2017–2019.

Results. The greatest number of heart defects was detected at 23–31 weeks of gestation. The structure of the malformations is diverse, the most common one being a complete form of the atrioventricular canal defect. In multiple pregnancies, complex heart defects were often combined with abnormalities in other organ systems.

Conclusion. It is recommended to describe the heart structure in detail from 21–22 weeks of pregnancy. If cardiac pathology is detected in utero, it is mandatory to conduct an examination of other fetal organs.

Journal of obstetrics and women's diseases. 2020;69(2):43-50
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Hysteroscopic and morphological assessment of intrauterine pathology in different age periods
Sulima A.N., Kolesnikova I.O., Davydova A.A., Kriventsov M.A.
Abstract

The pathology of the endo- and myometrium takes the main place in the structure of gynecological diseases. The introduction of endoscopic technologies has expanded the diagnostic capabilities of the study of intrauterine pathology. The morphological method is the gold standard in diagnosing the uterine cavity pathology. A retrospective analysis of 100 video protocols of hysteroscopy and morphological data obtained in Vash Doctor Clinic Ltd., Simferopol over the year 2018 was performed. During a retrospective analysis of hysteroscopic pictures and pathomorphological findings, all patients were divided into three age groups: (I) 25–35 years old (35 women); (II) 36–45 years old (35 women); and (III) 46–55 years old (30 women). In the early reproductive period, endometrial hyperplasia without atypia prevailed, chronic endometritis prevailing in the late reproductive period, and polyps of the uterus in the period of the menopausal transition and postmenopause.

Journal of obstetrics and women's diseases. 2020;69(2):51-58
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Reviews
Modern methods for radiological diagnosis of endometriosis
Rusina E.I., Yarmolinskaya M.I., Ivanova A.O.
Abstract

Endometriosis is a widespread gynecological disease, which affects reproductive-aged women. An accurate diagnosis is critical to develop a more comprehensive treatment strategy for endometriosis than is currently available. This article provides an overview of current data on the value of radiation techniques for the diagnosis of external genital and extragenital endometriosis, deep infiltrating endometriosis, and adenomyosis. The necessity of using a systematic approach to examine the pelvis in women with suspected endometriosis is shown, modern terms and methods of measurement being given to describe ultrasound picture of endometriosis.

Journal of obstetrics and women's diseases. 2020;69(2):59-72
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Obesity represents a strong pathogenetic link with the pathology of pregnancy and childbirth
Seryogina D.S., Nikolayenkov I.P., Kuzminykh T.U.
Abstract

Obesity is a significant health and social problem that is the scale of the growing worldwide epidemic. Over the past 10 years, the number of obese pregnant women has doubled. There are multiple risk factors associated with obesity, which includes poor nutrition, foods that are high in easily digestible carbohydrates and fats, frequent snacks, and widespread fast food consumption. Metabolic changes, especially in women with the genetic predisposition, are manifested by insulin resistance, hyperinsulinemia, arterial hypertension, and hypercoagulation syndrome. The course of pregnancy and childbirth in obese women is associated with a series of successive pathological conditions, such as miscarriage, the occurrence of gestational diabetes mellitus, preeclampsia and eclampsia, infectious complications, prolonged pregnancy, the occurrence of bleeding and much more. We have analyzed modern ideas about women’s reproductive health and the course of pregnancy and childbirth in obesity.

Journal of obstetrics and women's diseases. 2020;69(2):73-82
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Theory and Practice
Complete asymptomatic fundal rupture of the uterus in the first stage of labor
Mochalova M.N., Kuzmina L.A., Mironenko A.Y., Likhanov I.B., Mudrov V.A.
Abstract

A clinical case of a complete fundal rupture of the uterus at the first stage of labor of a woman with a uterine scar from a previous cesarean section in the lower uterine segment is addressed in this article. During clinical observation, the patient did not have hemorrhagic and pain syndromes. Operative delivery was performed due to primary uterine inertia. A newborn did not show any signs of asphyxia. During the operation, a rounded defect of 4 × 5 cm in size, penetrating the uterine cavity, was detected in the uterine fundus. It was sutured with a triple-row suture. The area of the lower segment was thinned to 2 mm, with deformation and defects not detected. In the postpartum period, subinvolution of the uterus was noted. The patient was discharged from hospital in satisfactory condition on the 10th day of the postpartum period.

Journal of obstetrics and women's diseases. 2020;69(2):83-88
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Articles
Complete uterus didelphia and stage 3 genital prolapse during the labor of a woman at 35–36 weeks of pregnancy while using intrauterine device
Mochalova M.N., Kuzmina l.A., Mironenko A.Y., Mudrov V.A.
Abstract

A clinical case of operative delivery of a woman with stage 3 genital prolapse, which was diagnosed at 35–36 weeks of gestation, is addressed in this article. The woman became pregnant while using intrauterine device. During cesarean section, the patient was diagnosed with complete uterus didelphia. In the abdominal cavity, between the two uteruses, a T-shaped intrauterine device was detected, with no signs of uterus perforation revealed.

Journal of obstetrics and women's diseases. 2020;69(2):89-92
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Public Health Organization
Analysis of perinatal losses in Saint Petersburg and the Leningrad region in 2006–2018
Bezhenar V.F., Ivanova L.A., Korshunov M.Y.
Abstract

Hypothesis/aims of study. Prevention of the most common causes of perinatal mortality provides an opportunity to reduce perinatal losses. It is customary to distinguish between maternal, fetal and placental factors, dividing them into preventable and unavoidable subfactors. Of all nosologies, intrauterine hypoxia and asphyxia of the newborn, infectious (viral and / or microbial) damage to the placenta and fetus / newborn, and placental insufficiency (acute and chronic) are most important. The aim of this study was to analyze perinatal losses most often diagnosed in Saint Petersburg and the Leningrad Region in order to assess the possibility of developing a set of measures to reduce perinatal mortality.

Study design, materials and methods. The analysis of perinatal losses in Saint Petersburg and the Leningrad Region in 2006–2018 is based on the official reports of the Saint Petersburg State Budgetary Healthcare Institution “Medical Information and Analytical Center” and the Leningrad Regional State Budgetary Healthcare Institution “Medical Information and Analytical Center,” as well as the reports of the Leningrad Regional Pathological and Anatomical Bureau (LRP&AB).

Results. The main causes of perinatal losses in Saint Petersburg and the Leningrad Region for 2006–2018 were: fetal hypoxia (acute and chronic), intrauterine infections, respiratory distress syndrome (for premature babies), congenital malformations, and chromosomal abnormalities. Throughout the period, intrauterine hypoxia and asphyxia of the newborn (which are the pathology manifestation, not etiology) were indicated as leading diagnoses in the conclusions of perinatal death. Moreover, according to the LRP&AB pathomorphological findings, intrauterine infections were the leading (over 60% of cases) cause of perinatal losses over the years. During the analyzed period in Saint Petersburg and the Leningrad Region, a high frequency of “individual states arising in the perinatal period” remained unchanged without determination of a specific diagnosis, which significantly complicates our analysis.

Conclusion. For an adequate diagnosis of the etiological mechanisms of perinatal losses, it is necessary to improve histological examination of the afterbirth and pathomorphological examination of the fetus / newborn using virological and immunological tests. It is also necessary to change the structure of statistical reports, obliging medical institutions to indicate the exact cause of perinatal death, excluding whenever possible the diagnoses of intrauterine hypoxia and asphyxia in labor that indicate no etiological diagnosis explaining the occurrence of hypoxia / asphyxia.

Journal of obstetrics and women's diseases. 2020;69(2):93-102
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