卷 69, 编号 5 (2020)

本文介绍了有关子宫畸形类型诊断特征的文献资料。本文的主要内容是三维超声在子宫纵隔鉴别诊断中的作用和有效性。

研究现实性。多囊卵巢综合征是一种常见的疾病。根据诊断标准，10-20%的育龄妇女可见此病，
占所有形式的高雄激素症综合征的70-80%。多囊卵巢综合征是一种具有多因素病因的异质性疾病，
以多种临床、内分泌和代谢紊乱为特征。在这方面，阐明甾体激素的生物合成和代谢特征、甾体生成酶的活性、寻找新的实验室标准以早期诊断和及时开始治疗是有意义的。

目的：根据气相色谱-质谱分析研究正常体重肥胖多囊卵巢综合征女性的雄激素、黄体酮和糖皮质激素的代谢组学。

研究材料和方法。本文对53例多囊卵巢综合征育龄妇女进行了检查。第一组包括30名体重正常、
年龄在22至29岁的女性。第二组包括23例肥胖患者，年龄为25-33岁，平均体重指数为35.3 ± 0.4 kg/m2。对照组包括25例健康女性，年龄为26 ± 0.6岁，体重指数正常，无高雄激素血症临床及生化体征。采用血清免疫测定方法测定促黄体激素、促卵泡激素、游离睾酮、17-羟孕甾酮和性激素结合球蛋白的水平。采75g的口服葡萄糖耐量试验测定葡萄糖负荷前后的血糖和胰岛
素水平。采用气相色谱-质谱分析对尿液中的类固醇成分进行了分析，并对样品制备规则进行了优化。
统计数据处理使用STATISTICA软件系统为WINDOWS（10版本）。患者的主要定量特征以中位数（Me）、
第25百分位和第75百分位（Q25-Q75）的形式表示。为了比较研究组的结果，使用非参数Mann-Whitney U检验。置信标准p < 0.05认为有统计学意义。

研究成果。本文对多囊卵巢综合征妇女的雄激素、糖皮质激素和孕激素代谢组学进行分析，并与
对照组相应指标进行比较。无肥胖的多囊卵巢综合征患者尿中雄烯二酮、脱氢表雄酮及其代谢
产物、17-羟基孕烯醇酮、孕三醇、5-en-孕烷的排泄量增加，而多囊卵巢综合征和肥胖的女性中，
尿中雄酮和脱氢表雄酮代谢产物（16-oxo-雄烯二醇和17β-雄烯二醇）的排泄量较对照组增加。无肥胖
的多囊卵巢综合征患者皮质醇和可的松四氢衍生物与11-oxo-孕三醇、孕三醇和17-羟基孕烯醇酮的比值较对照组降低，这是21-羟化酶功能不足的迹象。在患有多囊卵巢综合征和肥胖的女性中，
有四种迹象表明5α-还原酶酵酶活性增加，而在体重指数正常的多囊卵巢综合征患者中，这三个指标表明多囊卵巢综合征患者5α-还原酶活性不同程度，这取决于体重指数。

结果。气相色谱-质谱分析同时定量测定尿液中类固醇检测中雄激素代谢产物、黄体酮、雄烯二酮和糖皮质激素的5α和5β代谢产物，为多囊卵巢综合征的诊断开辟了新的机遇。

Hypothesis/aims of study. The search for early predictors of preeclampsia currently remains relevant. There is still a need to study maternal factors affecting the development of preeclampsia such as intergenic interactions in a pregnant woman with single nucleotide polymorphisms (SNPs) in genes associated with hemostasis system and folate cycle, as well as predictors. The aim of this study was to assess the role of comorbid pathology and gene polymorphism associated with the hemostasis system and folate cycle in predicting preeclampsia in a pregnant woman.

Study design, materials and methods. We examined 158 pregnant women in two study groups, including 92 women with preeclampsia and 66 healthy subjects. Somatic anamnesis of the patients was studied, with the course and outcomes of pregnancy analyzed. The carriage of SNPs in genes involved in hemostasis and the folate cycle was studied once by the method of polymerase chain reaction in real time with amplification of polymorphic loci and restriction analysis using specific endonucleases. The analysis of intergenic interactions was performed using the MDR 3.0.2 program.

Results. Seven genes involved in hemostasis and three genes involved in the folate cycle were studied. The highest entropy of the case-control status for preeclampsia is associated with the locus of coagulation factor F7 10976G>A — 9.49% and that of methylenetetrahydrofolate reductase MTHFR 677C>T (A223V) — 5.35%. The combination of loci of the tissue plasminogen activator inhibitor-1 gene SERPINE1 (PAI-1) and the platelet glycoprotein integrin 1α-2 gene ITGA2 (SERPINE1 (PAI-1) (5G>4G) + ITGA2 (807C> T)) account for 18.28%, and SERPINE1 (PAI1) (5G>4G) + MTHFR (677C>T) 14.26% of results. A three-locus synergy model SERPINE1 (PAI-1) (5G>4G) + MTHFR (677C>T) + ITGA2 (807C>T) responsible for the development of preeclampsia was obtained, which has a reproducibility of 10/10 and an accuracy of predictions of 84.3%.

Conclusion. Our data indicate a high contribution of the ITGA2, SERPINE1 (PAI-1), and MTHFR mutations combination to the prediction of preeclampsia.

Hypothesis/aims of study. Overcoming infertility and miscarriage in adenomyosis is a complex practical problem in obstetrics and gynecology. It is likely that one of the signs of the disease is a thickening of the transitional zone between the endometrium and the myometrium (J-zone), which can be visualized using magnetic resonance imaging (MRI). The data on the influence of the biometric characteristics of the J-zone on the course and outcome of pregnancy in patients with adenomyosis is ambiguous. This study was aimed to assess the effect of J-zone thickness on pregnancy outcomes in patients with adenomyosis.

Study design, materials and methods. This is a prospective study, which included 102 patients aged 22-39 years with ultrasound signs of adenomyosis who were going to conceive. The patients were divided into two groups: Group 1 (n = 58) consisted of nulliparous patients with no history of previous intrauterine interventions; Group 2 (n = 58) comprised multiparous women with any of those, such as curettage of the uterine cavity for a non-developing or unwanted pregnancy and separate diagnostic curettage for a reason not related to pregnancy. Using MRI, J-zone maximum thickness was measured at the thickest part. We evaluated the relationship between J-zone thickness and pregnancy outcomes, while estimating J-zone thresholds for subfertility outcomes in the both groups.

Results. The average value of J-zone maximum thickness in Group 2 was significantly higher than that in Group 1 and amounted to 12.1 ± 4.2 mm and 10.3 ± 3.9 mm, respectively (p < 0.05). The pregnancy rate in the both groups did not differ significantly and amounted to 43.1% in Group 1 and 38.6% in Group 2 (p > 0.05). The frequency of retrochorial hematoma was diagnosed in 13.8% and 22.7% of cases, respectively, and did not differ significantly in the both groups (p > 0.05). The frequency of spontaneous miscarriage in Group 1 and Group 2 did not differ, either (6.9% and 6.8%, p > 0.05). The J-zone thresholds for unfavorable pregnancy outcomes were determined with a probability of 60% in Group 1 (9.1 mm) and Group 2 (10.0 mm).

Conclusion. J-zone thickness may be used as a prognostic marker of pregnancy outcome in patients with adenomyosis.

最近的一些研究表明，与标准的腹会阴联合切除术相比，肛提肌外腹会阴联合切除术能提高远端直肠癌的肿瘤学效果。作为肛提肌的切开的结果，会阴形成广泛的缺陷，这需要阴道会阴成形术。在进行肛提肌外腹会阴联合切除术的过程中，形成盆腔隔膜受到影响，因此，经过这种干预，女性有较高的盆腔器官脱垂的风险。这严重影响了生活质量，并导致后续手术治疗的需要。尽管盆腔器官脱垂是手术治疗的结果，肿瘤学家并不认为它是术后长期的并发症。这样的病人不转诊给手术妇科医生。目前对这一问题了解甚少，因此这类患者的盆腔器官脱垂手术治疗尚无标准化的方法。

The presence of antibodies to thyroid peroxidase and thyroglobulin of the thyroid gland in women with infertility is more common than in the population. Some studies describe the negative effect of autoantibodies on reproductive function and the results of assisted reproductive technology (ART) programs even in the absence of impaired thyroid function. This article presents a review of literature data on the possible mechanisms of this negative influence. To date, there are no data on a significant decrease in the quality of oocytes, embryos and pregnancy rates in ART cycles in such patients. The negative effect of autoantibodies on the frequency of live births can be realized through such complications of pregnancy as miscarriage and premature birth. Currently, the possibilities for preventing these complications are poorly understood. According to recent meta-analyses, the use of levothyroxine in euthyroid patients with autoantibodies who are treated for infertility using ART methods does not result in a decrease in the frequency of miscarriage and premature birth.

Uterine fibroids are one of the most common benign tumors of the female reproductive system, originating from smooth muscle cells of the cervix or uterine body. The controversial issues of the pathogenesis of the disease make equal the various theories of its development and approaches to therapy. To date, there is no single and unambiguous opinion on the causes of the onset and recurrence of uterine fibroids, but thanks to the modern level of molecular medicine, much progress has been made in the study of hormonal and molecular genetic mechanisms of the initiation, formation and growth of the myoma node. The aim of this work was to review the modern aspects of the pathogenesis of uterine fibroids. We analyzed book chapters, original and review articles deposited in the PubMed database and related to the study of the pathogenesis of uterine fibroids from 2000 to 2019. This review presents modern data on the role of sex steroid hormones and their enzyme regulation, as well as growth factors and vitamin D in the pathogenesis of the disease. Particular attention was paid to signaling pathways involved in the regulation of basic cellular processes, in the onset and progression of the disease. It was noted that the activation of signaling pathways such as Wnt / β-catenin, MAPK / ERK, and TGF-β / SMAD plays a significant role in the development of uterine fibroids. Further study of the pathogenesis of the disease is needed for new strategies to design targeted therapy of uterine leiomyoma.

This article presents a clinical case of pregnancy and preterm labor at 31-32 weeks of pregnancy in a woman with stage III genital prolapse. This pregnancy occurred spontaneously within three years after a seven-year period of taking combined oral contraceptives. The birth was complicated by premature outpouring of amniotic fluid and ended with the birth of premature fetus.