Vol 70, No 3 (2021)

Notable an obstetrician-gynecologist, urologist, Doctor of Medical Sciences, Professor Alexander Mazhbits made a great contribution to the history of medicine of the USSR and the annals of the Arkhangelsk state medical Institute (ASMI, now – the North-State Medical University (NSMU)), where he headed the Department in 1953-1958. Being the author of over 120 scientific works and 7 books, many scientific inventions and publications on obstetric and gynecological urology and its history, he was a creator of the textbook “Operative urogynecology”, inventor and prominent scientist. Each operation for a particular urogynecological disease the author described in detail and step by step with the attachment of original visual drawings, photos or radiographs, diagrams of practical activities. Alexander Moiseevich was the first who proposed a new direction for the creation of urogynecology. Not specific urologists, surgeons or obstetricians-gynecologists should deal with this activities, but urogynecologists who consider the female pelvis as a whole. A.M. Mazhbits wrote: “Obstetrics-gynecology and female urology are daughter cells of general pelvic surgery, they are twins of different ages, so closely related to each other genetically, clinically and practically that the boundaries between them are often smoothed out.”

BACKGROUND: The increase in the incidence of type 2 diabetes mellitus worldwide and the improvement in the quality of diabetic and obstetric care lead to an increase in the number of pregnant women with type 2 diabetes mellitus. The incidence of obstetric and perinatal adverse outcomes in women with type 2 diabetes mellitus is often higher than in women with type 1 diabetes. In the world literature, there are few works on the effect of pregnancy planning on the course and outcome of pregnancy in women with type 2 diabetes mellitus.

AIM: The aim of this study was to evaluate the role of pregnancy planning in patients with type 2 diabetes mellitus in improvement of pregnancy and birth outcomes.

MATERIALS AND METHODS: We retro- and prospectively analyzed the course and outcome of pregnancy in 124 women with type 2 diabetes mellitus, who were observed in the Diabetes Mellitus and Pregnancy Center of the Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott for the period from 2010 to 2019. The study included 34 women with type 2 diabetes mellitus at the stage of pregnancy planning and 90 women during pregnancy. All patients underwent a general clinical examination, carbohydrate metabolism correction, training at the School of Diabetes Mellitus in the principles of rational nutrition, self-control of glycemia and insulin therapy. Diabetes compensation was assessed by the level of glycated hemoglobin, determined using a method certified in accordance with the National Glycogemoglobin Standartization Program and standardized in accordance with the reference values adopted in the Diabetes Control and Complications Trial, as well as by the level of glycemia (self-control at least four times a day). We also assessed the severity of vascular complications of type 2 diabetes mellitus before and during pregnancy, and identified and treated comorbidities. To assess the degree of obesity, the criteria of the World Health Organization and the pregravid body mass index calculated by the Quetelet formula were used. The severity of preeclampsia was assessed in accordance with federal clinical guidelines. Ultrasound examination of the fetus with Doppler blood flow in the vessels of the fetoplacental complex was performed using a Voluson E6 ultrasound system (GE Healthcare, USA). For the timely diagnosis of diabetic fetopathy and fetal cardiomyopathy, dynamic fetometry and echocardiography were conducted. In addition, cardiotocography was performed for antenatal assessment of the fetus from the 30th week of pregnancy. After delivery, a neonatologist assessed the condition of the newborn using the Apgar scale at the first and fifth minutes of life, and then the assessment was carried out in the early neonatal period.

RESULTS: In the group of women who received pregravid training, the course and outcomes of pregnancy were significantly better: the frequency of preeclampsia was lower (14.7%) compared to the group of women with an unplanned pregnancy (40.0%); there was no severe preeclampsia compared to the same women (13.3%). The number of preterm births was significantly lower (14.7%) in the group of women with planned pregnancy compared to the group of women without pregravid preparation (37.8%). In addition, in the group of women planning pregnancy, there were no fetal congenital malformations, neonatal hypoglycemic conditions, hypertrophic cardiomyopathy; in the group of women with an unplanned pregnancy, these parameters being found to amount to 6.7%, 24.4% and 6.7%, respectively. There was no perinatal mortality in the group of women with a planned pregnancy; however, this parameter was shown to be 3.3% in the group of women with an unplanned pregnancy.

CONCLUSIONS: Pregnancy planning in patients with type 2 diabetes mellitus can significantly improve the course of pregnancy and childbirth outcomes.

BACKGROUND: Uterine leiomyoma and endometriosis are the most common gynecological diseases in women of reproductive age. A number of data indicate that there are common elements in the pathogenesis of these hyperproliferative conditions. This article is devoted to comparative analysis of the role of the WNT4, HOXA10 and TWIST1 genes in the development of uterine leiomyoma and external genital endometriosis.

AIM: The aim of this study was to evaluate the frequency of polymorphic variants rs7521902 (WNT4) and rs4721745 (TWIST1) in patients with uterine leiomyoma, external genital endometriosis and in the comparison group; to determine the frequency of rare allelic variants of the HOXA10 gene in patients with external genital endometriosis; and to study the expression of these genes in the endometrium in patients with uterine leiomyoma, EGE and in the comparison group.

MATERIALS AND METHODS: The polymorphic variants of the WNT4 and TWIST1 genes were studied by real-time PCR in patients with external genital endometriosis, uterine leiomyoma and in the comparison group. In patients with EGE and women in the comparison group, the second exon of the HOXA10 gene was sequenced. Real-time PCR with reverse transcription analysis of the expression of the WNT4, TWIST1 and HOXA10 genes in endometrial samples from the patients of the study groups was performed.

RESULTS: The frequencies of polymorphic variants rs7521902 (WNT4) and rs4721745 (TWIST1) in patients with uterine leiomyoma, external genital endometriosis and in the comparison group did not differ significantly. Minor alleles of the HOXA10 gene were not identified in patients with external genital endometriosis. Expression of the WNT4 gene in the endometrium of patients with external genital endometriosis was independent of menstrual cycle phase and was reduced by 1.9 times compared to the endometrium of women with uterine leiomyoma. Expression of the HOXA10 gene in the endometrium of endometriosis patients on days 20-23 of the menstrual cycle was significantly reduced compared to the women in the comparison group. Expression of the TWIST1 gene was not altered in the endometrium of patients with uterine leiomyoma and external genital endometriosis.

CONCLUSIONS: We did not identify associations of the studied polymorphic variants of the WNT4 and TWIST genes and minor variants of the HOXA10 gene with uterine leiomyoma and external genital endometriosis. The expression of the WNT4 and HOXA10 genes is reduced in the endometrium in patients with external genital endometriosis, but not in women with uterine leiomyoma. Changes in expression patterns of the studied genes in the endometrium differ significantly in these two diseases.

BACKGROUND: The imbalance of vascular endothelial cell metabolism determines the clinical manifestations of preeclampsia; however, the molecular mechanisms underlying the vessel destabilization are not fully understood. In recent years, researchers have focused on clarifying the role of dysmetabolic disorders in patients with obstetric pathology, including preeclampsia. This is due to the fact that pregnancy is accompanied by metabolic restructuring aimed at switching the energy supply of the pregnant woman’s body from the carbohydrate to the fat component in order to maintain an effective energoplastic supply of the developing fetus. Impairment of this evolutionary adaptation mechanism realized during pregnancy requires additional in-depth study.

AIM: This study was aimed to identify and compare pathogenetic patterns that characterize early and late preeclampsia at the preclinical stage, based on dynamic clinical and laboratory examination of high-risk pregnant women.

MATERIALS AND METHODS: A prospective clinical and laboratory examination of 180 pregnant women with independent factors of high risk of developing preeclampsia was carried out. Comparison groups were identified retrospectively, depending on the period of preeclampsia manifestation: Group I consisted of 31 pregnant women with early preeclampsia; Group II comprised 58 pregnant women with late preeclampsia; and Group III (control) included 30 healthy pregnant women with uncomplicated gestation. Pregnant women were examined twice at the preclinical stage of preeclampsia (11-14 and 18-21 weeks of gestation) and once at clinical manifestation of the disease (28-36 weeks of gestation). The markers of metabolic, hormonal, hemocirculatory, hemostasiological and placental disorders were evaluated.

RESULTS: We found similar pathophysiological changes in pregnant women with both early and late PE, from early gestation periods. Those were characterized by pathological insulin resistance and hyperinsulinemia, as well as associated atherogenic changes in the lipid profile, hyperleptinemia, hyperuricemia, hypersympathicotonia, visceral fat deposition, and contra-insular hormonal deviations. The observed alterations reflected a single hormonal and metabolic pattern of the preclinical stage of preeclampsia. During pregnancy, there was shown an increase in clustering diabetogenic and atherogenic abnormalities and hormonal changes, which were supplemented by associated endothelial and hemostasiological dysfunction and, in early preeclampsia, placental dysfunction, thus accelerating the time of clinical implementation of preeclampsia.

CONCLUSIONS: From the pathogenetic point of view, preeclampsia of various periods of manifestation is an indivisible category with a common basic developmental mechanism characterized by a hormone metabolic pattern from the early stages of pregnancy. These stable changes are the result of the pathologically transformed phylogenetic mechanism of energoplastic supply of the fetus. This transformation is realized via physiological insulin resistance and compensatory hyperinsulinemia development due to the contra-insular activity of placental hormones. The added structural and functional disorders of the embryo (feto) placental system potentiate basic mechanisms (pathological insulin resistance and hyperinsulinemia) and determine the period of preeclampsia clinical manifestation in each particular woman.

Premature ovarian insufficiency is a syndrome characterized by hypergonadotropic ovarian insufficiency and the reduction of ovarian function before age 40. This leads to reproductive failures, metabolic changes, and a decrease in quality of life. Currently, occult and initial forms of premature ovarian insufficiency, which have their own diagnostic features and management tactics, can be figured out. The frequency of this syndrome is between 1.1 and 3.7% and the tendency for incidence to increase can be seen. This article is a literature review of the data available in the PubMed database (2005–2020), with international clinical guidelines taken into consideration. The genetic causes of premature ovarian insufficiency, clinical signs of this pathology and treatments options for such patients are included into the review. In addition, some features of assisted reproductive technology within this group are described.

HIV-infected women have a higher risk of complications during pregnancy and delivery (chronic placental insufficiency, anemia, placental abruption, preterm birth) compared with HIV-negative women, especially in case of opportunistic infections, immunodeficiency and a high viral load in the blood. The obstetrical pathologies are hard to study in these women because the above conditions are associated with a range of confounding factors that are not directly related to HIV infection but are often present, such as drug addiction, weight deficit, and chronic viral hepatitis coinfection. The literature review provides data from domestic and international studies on the correlation between HIV infection and the frequency of complications during pregnancy, delivery and the postpartum period, as well as the effect of the infection on the condition of newborns. The article cites current recommendations on the choice of delivery types for HIV-infected women.

The prevalence of genital endometriosis and adenomyosis, in particular, is tending to increase. The lack of a complete understanding of the pathogenetic mechanisms and multifactorial causes of adenomyosis, the low effectiveness of existing drug therapy, and the importance of preserving reproductive function make it necessary to further study the pathogenesis of the disease, search for new non-invasive highly informative diagnostic methods and develop a new strategy for pathogenically based drug therapy. The review presents current data on the role of signaling pathways in the pathogenesis of the development of adenomyosis based on domestic and foreign literature sources retrieved from the electronic databases PubMed, CyberLeninka, and Google Scholar in the period from 1999 to 2020. Considerable emphasis is placed on the discussion of the research results in recent years. Based on the analysis, the role of transforming growth factor â (TGFβ), vascular endothelial growth factor (VEGF), dual-specificity protein phosphatase (PTEN), Notch receptors, and eukaryotic translation initiation factors (eIFs) in the signaling of adenomyosis is presented. Further advanced study of signaling pathways in the pathogenesis of adenomyosis will allow developing highly specific and highly sensitive markers for non-invasive diagnostics, as well as new directions for drug treatment of the disease.

Insufficient diagnosis of ovarian tumors during pregnancy and decreased oncological alertness constitute huge problems that can subsequently have an unfavorable outcome for both the pregnant woman and the fetus. The difficulties of diagnosing and treating ovarian cancer during pregnancy were demonstrated on the following clinical case example. In pregnant patient A. at 19-20 weeks of pregnancy, a lesion was found in the area of the right appendages (100.9 × 55.4 × 93.4 mm, V = 273 cm³), with many tissue partitions and parietal tissue inclusions. The growth of the neoplasm was noted (CA-125 884 U / ml) and the pain syndrome occurred in the patient at 23-24 weeks of pregnancy. Magnetic resonance imaging revealed a solid-cystic neoplasm of the right ovary (cystadenoma?) and surgery was performed in November 2019. Based on the results of histological examination, a high-grade serous ovarian cancer was diagnosed without signs of microsatellite instability MSI-H/dMMR (in the right ovary, in the biopsy of the left fallopian tube). The patient. received two cycles of polychemotherapy (TC scheme). The treatment was tolerated satisfactorily (CA-125 287.3 U / ml). At a gestational age of 34 6/7 weeks (January 2020), a simultaneous operation was performed, including a lower midline laparotomy, a lower uterine segment caesarean section, extirpation of the uterus with appendages, and an omentectomy. A boy was born (weight 2280 g, height 44 cm) with the Apgar score of 7/7 points, with no complications noticed in the postpartum period. Postoperative histological examination showed metastasis of carcinoma in the left ovary with signs of therapeutic pathomorphosis. The treatment was completed in March 2020 after six cycles of polychemotherapy.

BACKGROUND: Perinatal death is the death of the fetus, starting from 22 weeks of pregnancy and in childbirth, as well as the death of a newborn in the first seven days of life. Despite the fact that reducing perinatal losses is one of the most important tasks of contemporary medicine, the level of perinatal mortality in Russia in recent years has been about 7.5 ‰.

AIM: The aim of this study was to analyze documentation related to the legal aspects of perinatal loss.

MATERIALS AND METHODS: The article analyzes the main federal laws, agency regulations, orders, methodological letters, recommendations, and materials on the Internet concerning the main aspects and questions that most often arise among doctors, as well as postpartum women who have undergone perinatal loss and their family members.

RESULTS: The article provides data on:

– the medical criteria for birth, basic documentation issued in case of stillbirth, the birth of a live child who died in the perinatal period, and the rules for their issuance;

– the rules and procedure for notifying state bodies in case of perinatal death, the rules for registering a stillborn and a child who died in the first 168 hours of extrauterine life;

– the types of perinatal death certificate;

– the rules for conducting a pathological autopsy and the possibility of refusing it;

– the issues of burial of children who died perinatally;

– the rules for handling material obtained during termination of pregnancy up to 22 weeks.

CONCLUSIONS: The legislative framework was analyzed and answers were given to the most frequently asked questions regarding the legal aspects of perinatal loss.