卷 69, 编号 2 (2020)

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%).

目的是评估有流产和抗磷脂综合征的妇女的回顾和妊娠结局的特征，根据其纠正方法。

材料与方法。进行了前瞻性队列研究。对137名有流产史和抗磷脂综合征的孕妇进行了检查。根据孕前期流产治疗方案中是否有血浆置换的原则，将孕妇分为两组。第一组(主要)是在妊娠期接受包括血浆置换(传出疗法)的复杂治疗的女性(n = 73)，而第二组(比较，n = 64)没有进行传出疗法。

结果。抗磷脂综合征常发生在有复杂妇产科病史的患者身上。在持续性TORCH感染的患者中，慢性子宫内膜炎和输卵管-卵巢炎的发生率明显更高。无论是否有TORCH感染，抗磷脂抗体的效价在血浆置换后都降低了，同时，这种积极的动态只在四次或少于四次妊娠损失的患者中观察到。

结论。抗磷脂抗体含量相对于初始值的下降水平为60-95%，表明血浆分离治疗的特点和持续时间的最佳选择。

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.

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.

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 10^th day of the postpartum period.

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.

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.