卷 70, 编号 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.”

论证。世界范围内2型糖尿病发病率的增加、糖尿病和产科护理质量的提高导致2型糖尿病孕妇人数的增加。2型糖尿病妇女的产科和围产期不良结局的频率往往高于1型糖尿病。在世界文献中，很少有关于2型糖尿病患者孕前准备对妊娠过程和结局的影响的研究。

目的是评价妊娠前准备治疗2型糖尿病的有效性。

材料与方法。对124例2型糖尿病患者的妊娠过程和结局进行了回顾性和前瞻性分析。从2010年到2019年，患者在The Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott的联邦州预算科学机构的“糖尿病与怀孕”中心进行了观察。在妊娠前准备阶段，研究包括34名患有2型糖尿病的妇女，以及90名怀孕期间的妇女。所有患者均接受临床一般检查，纠正碳水化合物代谢，并在糖尿病学校进行培训，即学习合理营养原则、血糖控制原则、胰岛素治疗原则。采用国家糖化血红蛋白标准化方案认证的方法（源自英语National Glycogemoglobin Standartization Program），以糖化血红蛋白水平评估糖尿病代偿性。该方法根据DCCT研究（源自英语Diabetes Control and Complications Trial）中采用的参考值和血糖水平（每天至少自我监测四次）进行标准化。同时也考虑了妊娠前、妊娠中糖尿病血管并发症的严重程度，以及伴随病理的发现和治疗。根据世界卫生组织的标准，并考虑到根据Quetelet公式计算的孕前体重指数，对肥胖程度进行评估。子痫前期的严重程度是根据联邦临床指南确定的。使用Voluson E6设备（GE Healthcare，美国）对胎儿进行超声检查，用多普勒测量胎儿胎盘复合体血管内的血流。为及时诊断糖尿病胎儿病和胎儿心肌病，采用动态胎儿测量和超声心动图。为了产前评估胎儿状况，从怀孕30周开始进行心脏造影。分娩后，新生儿专家在新生儿出生的第一分钟和第五分钟用阿普加量表评估新生儿的状况，然后观察新生儿早期的病程。

结果。在接受孕前训练的妇女中，妊娠过程和结果都有显著改善：子痫前期的发生率（14.7%）低于计划外怀孕组（40%）的指标，无发现严重的先兆子痫（13.3%非计划怀孕的妇女组）。与未接受孕前训练的妇女（37.8%）相比，计划怀孕妇女组的早产数（14.7%）显著降低。计划怀孕组无胎儿先天性畸形、新生儿低血糖、肥厚性心肌病（在非计划怀孕妇女组，这些指标为6.7；24.4；分别为6.7%）。计划妊娠组无围产期死亡率，计划外妊娠组为3.3%。

结论。2型糖尿病患者妊娠前准备可显著改善妊娠过程和分娩结果。

论证。子宫肌瘤和子宫内膜异位症是育龄妇女最常见的妇科疾病。许多数据表明，存在共同因素的发病机制，这些过度增殖条件。本研究旨在比较分析WNT4、HOXA10、TWIST1基因在子宫肌瘤及生殖器外子宫内膜异位症发生发展中的作用。

目的是评估子宫肌瘤、生殖器外子宫内膜异位症患者和对照组中多态变异rs7521902（WNT4基因） 和rs4721745（TWIST1基因）的频率；确定生殖器外子宫内膜异位症患者中HOXA10基因罕见等位变异的频率；研究这些基因在子宫肌瘤、生殖器外子宫内膜异位症及对照组子宫内膜中的表达特点。

材料与方法。采用实时聚合酶链反应方法研究WNT4和TWIST1基因在生殖器外子宫内膜异位症、子宫肌瘤和对照组中的多态性变异。对生殖器外子宫内膜异位症患者和对照组妇女进行了HOXА10二代基因外显子的测序。采用实时反转录聚合酶链反应方法分析WNT4、TWIST1、HOXA10基因在实验组患者子宫内膜标本中的表达情况。

结果。子宫肌瘤、生殖器外子宫内膜异位症患者和对照组中多态变异rs7521902（WNT4基因） 和rs4721745（TWIST1基因）的频率无显著性差异。在生殖器外子宫内膜异位症患者中未检测到少量HOXA10等位基因。WNT4基因在生殖器外子宫内膜异位症患者子宫内膜中的表达不受月经周期分期的影响，并与子宫肌瘤患者相比，WNT4基因在子宫内膜中的表达减少1.9倍。生殖器外子宫内膜异位症患者月经周期20-23天子宫内膜中HOXA10基因的表达较对照组显著降低。子宫肌瘤和生殖器外子宫内膜异位症患者子宫内膜中TWIST1基因的表达无变化。

结论。我们没有发现WNT4和TWIST基因的多态变异和HOXA10基因的少量变异与子宫肌瘤和生殖器外子宫内膜异位症之间的关联。WNT4和HOXA10基因在生殖器外子宫内膜异位症患者的子宫内膜中表达减少，而在子宫肌瘤患者中不表达。在这两种疾病中，所研究的基因在子宫内膜表达性质的变化显著不同。

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.

与未感染艾滋病毒的孕妇相比，感染艾滋病毒的妇女发生妊娠和分娩并发症的风险（慢性胎盘功能不全，孕妇贫血，正常位置的胎盘脱落，早产）要高得多，特别是随着机会性感染的增加，免疫缺陷的存在和血液中的高病毒载量。这组患者的产科病理研究的复杂性是由于广泛的加重因素，与艾滋病毒感染没有直接关系，但经常伴随感染：积极服用麻醉药品，体重不足，并发慢性病毒性肝炎。文献综述提供了来自俄罗斯和国际上关于艾滋病毒感染对妊娠、分娩、产后期和新生儿状况并发症发生率影响的研究数据。对感染艾滋病毒的妇女选择分娩方法提出了现代建议。

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.