Vol 73, No 5 (2024)

BACKGROUND: The infectious factor during pregnancy remains the leading cause not only of maternal mortality, but also of premature pregnancy loss and subsequent reproductive function impairment. Patients with infected miscarriage represent a special cohort in terms of complexity of clinical decision-making, while the choice of antimicrobial chemotherapy is particularly difficult in conditions of accumulation of scientific knowledge about the main microbial agents. For adequate treatment, it is essential to use all modern methods of microbiota diagnosis and conduct regular monitoring of microorganism resistance in order to update empirical schemes of antibacterial therapy.

AIM: The aim of this study was to evaluate the correlation relationship between antimicrobial resistance genes and identified microbial agents in patients with infected miscarriage in order to optimize empirical antimicrobial chemotherapy.

MATERIALS AND METHODS: We prospectively studied 42 samples of genital tract discharge in patients with infected miscarriage. The classical culture method was used to determine microorganism sensitivity to standard antibacterial drugs by the disc diffusion test. A molecular genetic study of the species composition of clinically significant microbial agents and genes of resistance to β-lactam and glycopeptide antibiotics was performed using Femoflor Screen and BakRezista GLA test systems (“DNA-Technology” LLC., Russia), respectively.

RESULTS: In the cultural study, one microbial agent was identified in 59.5% of cases, two in 40.0% of cases, and three in 7.1% of cases. The following microorganisms were most frequently identified: Enterococcus spp. in 25.0% of cases, Esherichia coli in 16.7% of cases, and Candida spp. in 11.7% of cases. During the molecular genetic study, Lactobacillus spp. were identified in 64.3% of the samples, the microorganisms associated with bacterial vaginosis in 45.3% of the samples, Candida spp. in 23.8% of the samples, and Herpesviridae family viruses in 14.3% of the samples. In 45.2% of the samples, one to 14 genes of resistance to β-lactam and glycopeptide antibiotics were identified, while Tem (19.0%), Oxa-40-like (19.0%), Stx-M1 (14.3%), Ges (14.3%), Oxa-51-like (11.9%), and Van A/B (9.5%) were most frequently determined in the samples positive for resistance genes. Comparison between phenotypic susceptibility testing and genetic prediction for antibiotics resistance demonstrated that the specificity varied from 96.4 to 100%, and the sensitivity from 40.0 to 85.7%.

CONCLUSIONS: The use of molecular genetic diagnostic methods allows for the identification of clinically significant urogenital tract infections and the detection of markers of their resistance to β-lactam antibiotics and glycopeptides in the shortest possible time. The data obtained make it possible to optimize the initial antimicrobial chemotherapy.

BACKGROUND: Uterine fibroids are the most common cause of surgical treatment in women and total hysterectomy is performed in most cases to radically solve this problem. The organ-preserving approach aims to preserve fertility and the ability to reproduce in patients of reproductive age. The atypical location of leiomyomas complicates the possibility of performing an organ-preserving myomectomy.

AIM: The aim of this study was to assess the possibility of performing myomectomy for atypical leiomyoma using laparoscopic access in routine practice to preserve fertility and implement reproductive plans.

MATERIALS AND METHODS: This study included 213 patients of reproductive age with uterine fibroids. Myomectomy for typical or atypical leiomyomas was performed by laparoscopic access. A comparative analysis of surgical treatment and perioperative management of patients with atypically located fibroids and fibroids of other localization was carried out. The results of the achievement by the patients of their reproductive goals were evaluated. The duration of follow-up was 24 months.

RESULTS: Atypical node location was noted in 65 (30.5%) cases. When comparing the duration of surgical treatment, volume of blood loss, need for analgesics, presence of intraoperative and postoperative complications, duration of hospitalization and recovery period in patients with atypical leiomyoma, these parameters did not differ from those in the surgical treatment of patients with typical leiomyoma. Anatomical and functional results of surgical treatment were analyzed after one, three, six, 12, and 24 months. Of the 70 patients planning pregnancy, 26 (37%) women became pregnant on average 8.3 months after surgery. The location of the removed fibroids was atypical in ten cases.

CONCLUSIONS: The atypical location of leiomyoma does not affect the course of the surgical and postoperative periods and long-term results of surgical treatment. The possibility of routine organ-preserving treatment by laparoscopic access in patients with atypical fibroids leaves prospects for the implementation of the woman’s reproductive plans.

BACKGROUND: Need for early diagnosis of intravascular activation of coagulation in obstetric patients at risk of preeclampsia.

AIM: The aim of this study was to assess the diagnostic value of the thrombodynamics test in patients at risk of developing preeclampsia and during its manifestation.

MATERIALS AND METHODS: Dynamic thrombophotometry was performed in 56 pregnant women using a domestic “T2 Thrombodynamics Recorder” device (GemaKor Ltd., Russia). The first study group consisted of patients in the second to early third trimester of pregnancy (n = 45), who, due to hypercoagulability, according to the conventional coagulogram, received low-molecular-weight heparin therapy (calcium nadroparin 0.3 ml or enoxaparin sodium 0.4 ml subcutaneously). The thrombodynamics test was performed to evaluate the efficacy of anticoagulant therapy. The second study group involved patients with moderate (n = 11) and severe (n = 8) preeclampsia.

RESULTS: The test was effective in monitoring the state of the hemostasis system in pregnant women receiving anticoagulant therapy — despite normal coagulogram test parameters, the increased rate of fibrin clot formation and / or spontaneous clots indicated increased anticoagulant therapy in 37.8% of patients. Among patients with extragenital pathology, the incidence of spontaneous clots, which should not form during normal coagulation, was observed in all pregnant women with chronic arterial hypertension combined with obesity (χ² = 6.11; p < 0.02), which characterizes the tendency to activate intravascular coagulation in such patients. Subsequently, moderate PE developed in 15.6% of pregnant women with predisposing extragenital pathology, there being no cases of severe preeclampsia. A comparison of thrombodynamics test parameters in patients with moderate and severe preeclampsia showed that in severe preeclampsia, there is a tendency to a higher rate of fibrin clot formation and a higher frequency of spontaneous clot formation (χ² = 12.7; p < 0.01). The test demonstrated high sensitivity (81.8%) and specificity (97.4%) of signaling the presence of severe preeclampsia.

CONCLUSIONS: Demonstration of a clinical case of HELLP syndrome in a pregnant woman showed that confirmation of consumption thrombocytopenia due to activation of intravascular coagulation using the thrombodynamics test, in contrast to the global thromboelastography test and the conventional coagulogram test, allowed timely initiation of anticoagulant therapy and avoided the development of irreversible secondary microangiopathy.

BACKGROUND: Uterine fibroids are a benign monoclonal tumor arising from myometrial smooth muscle cells and fibroblasts with the deposition of extracellular matrix components in response to vascular injury. Diagnosis of uterine fibroids is steadily growing every year due to the introduction of new and accessible research methods. At the moment, the preferred organ-preserving surgical method for treating uterine fibroids is laparoscopic myomectomy, which allows preserving reproductive function. Considering the high risk of intra- and postoperative bleeding during surgery, the development and use of blood-saving technologies remains relevant. This article contains results of the effectiveness of the surgical technique without performing the stage of vessel clipping, which involves assessing the volume of intraoperative blood loss and the duration of the operation.

AIM: The aim of this study was to analyze the effectiveness of using a standardized technique of laparoscopic myomectomy without uterine artery clipping.

MATERIALS AND METHODS: This study included 77 patients with symptomatic uterine fibroids who underwent surgical treatment in Gynecological Department I with Operating Unit, The Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott (St. Petersburg, Russia). Implying an assessment of the volume of intraoperative blood loss and the duration of the operation.

RESULTS: The average number of removed myomatous nodes was 2.2 ± 1.2 (from 1 to 11). The size of the removed fibroids averaged 5.1 ± 1.8 cm in diameter. At the same time, the minimum size of the remote node was 1.5 cm, and the maximum size was 15 cm. Intramural [International Federation of Gynecology and Obstetrics (FIGO) types 3 and 4] localization of myomatous nodes was found in 30 (17.6%) cases, intramural subserosal (FIGO type 5) in 45 (26.4%) cases, subserosal (FIGO type 6) in 54 (31.7%) cases, subserosal pedunculated (FIGO type 7) in 30 (17.6%) cases, and intramural submucosal and submucosal forms (FIGO types 0–2) in ten (5.8 %) cases. The average intraoperative blood loss was 187.7 ± 16.71 ml, average hemoglobin level in the postoperative period was 117.1 ± 13.15 g/l, with an initial level of 126 ± 12.1 g/l. The average duration of the operation was 95 ± 30.3 minutes, and the average bed-day was 8 ± 1.5.

CONCLUSIONS: The data obtained allow for drawing a reasonable conclusion about the effectiveness and safety of the standardized technique of laparoscopic myomectomy, developed in Gynecological Department I with Operating Unit, The Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott (Saint Petersburg, Russia), and for recommending its widespread use.

BACKGROUND: Human leukocyte antigen, isotype DR (HLA-DR) expression is associated with inflammatory and autoimmune diseases. It is also found on the surface of tumor cells. The role of HLA-DR in endometrial pathology has not been sufficiently studied.

AIM: The aim of this study was to determine HLA-DR expression features in the endometrium under normal and pathological conditions.

MATERIALS AND METHODS: We performed immunohistochemical examination of endometrial biopsy specimens, namely, 18 cases of endometrioid carcinomas, 139 cases of chronic endometritis, and 37 cases of endometrial polyps. The control group included 50 cases of the endometrium without pathology. Positive HLA-DR expression was detected as brown staining of varying intensity of immune cells of the cytogenic stroma, as well as the cytoplasm and membranes of endometrial epithelial cells. The average number of positively stained stromal cells in ten visual fields was counted. HLA-DR expression in the cytoplasm and on the membrane of endometrial epithelial cells was assessed semi-quantitatively as weak (low) (with staining up to 50% of the glands) or pronounced (high) (with staining more than 50% of the glands).

RESULTS: HLA-DRim expression was detected on immune cells of the cytogenic stroma of the endometrium in all of the study groups. HLA-DR expression in the endometrial epithelium was characterized by two main immunophenotypes — negative and positive. Negative HLA-DR expression was found in 55.6% of endometrial cancer cases, in 25.2% of chronic endometritis cases, in 27.7% of endometrial polyp cases, and in all cases of the normal endometrium. The positive HLA-DR (high) immunophenotype was found in 21.6% of chronic endometritis cases, in 28.6% of endometrial polyp cases, and in 16.7% of endometrial cancer cases. Pronounced HLA-DR expression in the epithelium was associated with a high HLA-DR level in the cytogenic stroma and a significantly frequent detection of HLA-DR+ lymphoid follicles in endometrial cancer. The positive HLA-DR (low) immunophenotype was established in 51.8% of chronic endometritis cases and in 27.8% of endometrial polyp cases, and in 27.7% of endometrial cancer cases, and was associated with low HLA-DR levels in the stroma.

CONCLUSIONS: The revealed heterogeneity of HLA-DR expression in chronic inflammation and endometrial cancer allows for distinguishing two main immunophenotypes of endometrial cancer, namely, with negative and positive HLA-DR expression. HLA-DR may be an early predictor of adverse background endometrium and endometrial cancer. The positive HLA-DR immunophenotype of endometrial cancer probably indicates a specific mechanism of carcinogenesis associated with chronic inflammation and requires further comprehensive clinical, morphological and molecular genetic research.

Considering the universally high rates of obesity among the population, including women of reproductive age, and the negative impact of obesity on female fertility, the interest in this problem in the modern world becomes understandable. Many researchers have confirmed the pattern of ovulatory dysfunction development because of metabolic disorders in obese women. The exact mechanism for the development of anovulation and infertility in women with obesity has not been established, however, many pathogenetic factors that affect reproductive function are already known. Obese women have a high risk of developing ovulatory dysfunction due to insulin resistance, hyperandrogenism, as well as subclinical inflammation, lipotoxicity, and disruption of adipokines due to excess adipose tissue, which generally leads to impaired steroidogenesis and regulation in the hypothalamic – pituitary – gonadal axis. Due to the high prevalence of obesity in women of reproductive age, the objective of this review was to examine the pathogenetic mechanisms of the impact of obesity on female fertility, as well as the impact of high body mass index on the results of assisted reproductive technology (ART) cycles. We carried out a literature search in the PubMed database for the entire period of publications using phrases such as “ovarian function + obesity,” “pathogenesis of ovarian dysfunction in obesity,” “ART + obesity,” and “perinatal outcomes + bariatric surgery”. The most relevant studies being selected, with domestic and foreign clinical recommendations used in preparing the manuscript.

The article provides an overview of the modern literature covering the role of the fallopian tubes in reproduction.

The understanding of the anatomy and functions of the fallopian tubes has changed several times over the centuries. There is still no generally accepted opinion regarding some of the features of their structure. The normal functioning of the fallopian tubes is possible only due to the complex interaction of physical and biochemical processes occurring therein. In recent years, many discoveries have been made regarding the fallopian tubes that showed that we still do not know all the details of how this organ works. There are several basic methods for assessing the functions of the fallopian tubes, but all of them have their drawbacks and are of limited use, which is why it can sometimes be quite difficult to get a complete picture of the organ’s functioning. Modern discoveries and the introduction of new techniques into practical work can significantly expand the doctor’s capabilities in treating infertility associated with the tubal factor.

The current knowledge about the anatomical, functional and morphological features of the fallopian tubes emphasizes the importance of this organ in the implementation of the woman’s reproductive function. It is generally believed that the role of the fallopian tubes in conception is secondary and unimportant in comparison with the tasks performed by the uterus and ovaries. The importance of the fallopian tubes is most often mentioned in the literature in no more than a few paragraphs, where it is said only that the egg moves through them to the uterine cavity. However, modern research proves that complex processes and interactions occur in the organ that maintain homeostasis therein. After all, only the totality of the preserved function of each of the organs of the female reproductive system can ensure the onset and prolongation of future pregnancy.

This article describes a clinical case of pregnancy management in a patient after surgical treatment of low-grade squamous intraepithelial lesions (LSIL) of the cervix and endometrial cancer. In the structure of female oncological morbidity, precancerous conditions and malignant diseases of the female genital organs occupy leading positions and require the most sparing treatment in women who have not realized reproductive function. The frequency of miscarriage in early pregnancy associated with a history of endometrial cancer, requiring repeated invasive manipulations to assess the effectiveness of treatment, reaches 36–40%, depending on the age of the woman. After surgical interventions on the cervix, regardless of the method of exposure, the frequency of miscarriage significantly increases due to the formation of an organic form of isthmic-cervical insufficiency, which dictates the need for preventive cervical circumcision in a regulated time. In addition, the results of numerous studies also indicate an infectious cause as the main etiological factor in the development and progression of isthmic-cervical insufficiency. Management tactics, obstetric risks, as well as the possibilities of choosing a treatment method are discussed on the basis of the presented clinical case.

A system analysis of the results of modern scientific research has shown the most complex organization of the parturition, during which the unfolding and activation of the genetic birth program initially embedded in the mother and child occurs. 2–3 weeks before birth, desympatization and formation of an acupuncture network begin in the uterus. Along these acupuncture channels the wave flows of biologically active substances with both contractile and inhibitory properties move. These substances are delivered to the uterus by the bloodstream and blood cells. Some of them also have psychotropic properties, thereby enhancing the effect on the brain and causing a state of altered consciousness in the woman and her child. As labor approaches, the prenate revealed activation of the locus on chromosome 2, which allowed the researchers to assert that the prenate is initiator of the birth beginning. The totality of the data presented in the article served as a prerequisite for the formulation of a scientifically substantiated Theory of the parturition, according to which childbirth is a genetic-psychosomatic phenomenon, free of pain.