卷 70, 编号 5 (2021)

Maternal mortality is the most important indicator of women’s health, but its level is still high. In 2018, 146 cases of maternal death were registered in the Russian Federation. Its main causes were extragenital diseases, bleeding, preeclampsia and eclampsia, amniotic fluid embolism, clinical narrow pelvis, and unsafe abortion. The aim of this study was to assess the structure of maternal mortality in recent years and to evaluate possible ways to reduce it. This was achieved by using an analytical method including carrying out a detailed systematic analysis of modern domestic and foreign literature on the maternal mortality issue. The study used databases such as eLIBRARY.RU, Scopus, PubMed, MEDLINE, ScienceDirect, and Cochrane Library from the creation until July 2021. The measures adopted so far do not allow for counting on a further decrease in maternal mortality rate, therefore the coming decade requires the introduction of artificial intelligence technologies.

BACKGROUND: Obstetric and neonatal infections caused by Steptococcus agalactiae are among the most significant perinatal infections. To date, intrapartum antibiotic prophylaxis is used to prevent the transmission of the pathogen to the child, however, the growth of antibiotic resistance and ineffectiveness of therapy against late-onset neonatal infection are its limitations. Vaccination is considered to be the most effective method for preventing diseases caused by S. agalactiae in both pregnant women and newborn babies. To identify promising vaccine targets and to develop alternative prevention approaches, it is necessary to study the virulence factors of S. agalactiae strains and their variability in the population.

AIM: The aim of this study was to evaluate the variability of virulence and pathogenicity factors (capsular polysaccharides, pili, hypervirulent sequence type ST-17, biofilm-forming ability, antibiotic resistance) of S. agalactiae isolated from pregnant women and newborn infants in St. Petersburg, Russia.

MATERIALS AND METHODS: We studied isolates of S. agalactiae out of clinical material samples obtained from pregnant women and newborns at the D.O. Ott Research Institute of Obstetrics, Gynecology, and Reproductology in 2018-2020. The PCR method was used to determine the types of capsular polysaccharides, pili, and strain affiliation with the hypervirulent sequencing type ST-17. Biofilm-forming ability was determined by the Christensen method. The antibiotic sensitivity was determined by disc diffusion.

RESULTS: We examined 60 clinical isolates of S. agalactiae. The most common S. agalactiae serotypes were Ia, Ib, II, III, IV, and V; in total, these six serotypes accounted for 95.1% of all strains. The most common pili genotype was PI-1 + PI-2a (60%). Resistance to erythromycin was found in 36.7% of the strains, and a similar number of the strains were resistant to clindamycin. The ability to form biofilms was detected in 68% of the strains, and the increased ability was associated with the PI-2b pili allele.

CONCLUSIONS: A hexavalent vaccine based on capsular polysaccharides of types Ia, Ib, II, III, IV, and V would have a 95% efficacy in this region. Stable distribution of different pili types is an important factor when using pili as vaccine targets. The high level of resistance of S. agalactiae strains to erythromycin and clindamycin indicates that isolates should be tested for sensitivity to these antibiotics before their use, and regular regional monitoring of antibiotic resistance of the pathogen to update clinical guidelines should be performed.

BACKGROUND: Modern achievements of pharmacology, surgery and reproductive medicine have determined an increase in the implementation of reproductive function in endometriosis of various localization. The onset of pregnancy in presence of impaired endometrial receptivity and progesterone resistance, pro-inflammatory and pro-thrombotic status, abnormal functioning of the immune system, structural changes in the reproductive organs leads to impaired formation of the embryo (feto) placental system, early reproductive losses, complicated pregnancy and adverse perinatal outcomes. In this regard, the “endometriosis and pregnancy” issue requires close study and specific proposals to optimize pregnancy management.

AIM: The aim of this study was to develop predictive (PIs) and diagnostic (DIs) indices of placenta-associated fetal pathology in pregnant women with endometriosis, to determine their prognostically and diagnostically significant parameters.

MATERIALS AND METHODS: This prospective study in the dynamics of gestation included a comprehensive clinical and laboratory examination of 175 pregnant women with endometriosis (100 subjects with adenomyosis and 75 subjects with ovarian endometriosis). To develop PIs and DIs, two comparison groups with fetal pathology due to placental insufficiency were retrospectively identified, depending on the location of endometriosis. Group I consisted of 49 pregnant women with adenomyosis and placental insufficiency isolated from other pregnancy complications, accompanied by growth retardation and/or chronic fetal hypoxia; Group II comprised 29 pregnant women with ovarian endometriosis and placental insufficiency isolated from other pregnancy complications, accompanied by growth retardation and/or chronic fetal hypoxia. The control group (Group III) included 30 healthy pregnant women with a normal course of gestation. The examination was performed at 10-14 weeks, 20-24 weeks, and 28-34 weeks of gestation and included an assessment of placental insufficiency markers such as placental growth factor (PlGF), placental α-1-microglobulin (PAMG-1), tumor necrosis factor (TNFα), lymphocytes with membrane receptor FasR (L CD95⁺), C-reactive protein, placental alkaline phosphatase (PAPh), and fetal hemoglobin (HbF). The information value of individual parameters and indices was determined by ROC analysis, odds ratio, and clinical epidemiology tests.

RESULTS: Pregnancy in presence of endometriosis in 100% of cases was complicated by placental insufficiency of varying severity (with fetal pathology in 81.5% of cases), the frequency of which had statistically significant differences between the groups of pregnant women with adenomyosis and ovarian endometriosis (χ² = 4.06, p = 0.04). To predict growth retardation and / or chronic fetal hypoxia, we have developed PI I (PlGF / TNFα × 100) and PI II (PAMG-1 / PlGF × 100), which characterize the state of placental angio-and vasculogenesis depending on systemic inflammatory response level. For early diagnosis of fetal pathology, we have proposed DI I (CRP / PAPh × 100), DI II (HbF / PlGF × 100) and DI III (L CD95⁺ / PAPh × 100), which allow for diagnosing placental alterations with impaired placental energy supply due to an increase in inflammatory status. Evaluation of prognostic and diagnostic significance of PIs and DIs showed that the most informative tools are PI I (Se = 86.1%, Sp = 80.5%) and DI I (Se = 88.3%, Sp = 83.7%).

CONCLUSIONS: The use of PIs allows for risk stratification of pregnant women from the 1^st trimester of gestation to address the issue of the prevention method. The clinical capabilities of DIs optimize obstetric tactics for the timely prescription of therapy for placental insufficiency and targeted diagnosis of fetal pathology. Pregnant women with endometriosis should be classified as a high perinatal risk group, and therefore the proposed PIs and DIs should be included in the dynamic examination complex.

BACKGROUND: Abnormal labor is the most common complication of labor. It occurs in 10-15% cases of labor and is an indication for operative delivery in a third of all cases. Until now, there are no effective ways to predict abnormal labor. Meanwhile, the use of high-tech forecasting methods is not available for a wide range of obstetric institutions in the Russian Federation.

AIM: The aim of this study was to create a technology for predicting abnormal labor, based on generally available methods of laboratory and instrumental research.

MATERIALS AND METHODS: Based on the data collected in the Regional Clinical Hospital Perinatal Center, Chita, Russia in 2018-2021, the retrospective analysis of 200 cases of labor was carried out. The total sample was divided into four study groups: 100 women with normal labor activity (group 1), 30 women with uterine inertia (group 2), 30 women with incoordinate uterine activity (group 3), and 50 women with excessive uterine activity (group 4). The groups were comparable in terms of age, anthropometric parameters and extragenital pathology. All women on the eve of labor (1-2 days) underwent general clinical and ultrasound examination. Statistical processing of the results was carried out using the IBM SPSS Statistics version 25.0 software.

RESULTS: The technology for predicting abnormal labor is implemented based on a multilayer perceptron, with the percentage of incorrect predictions being 21.3%. The structure of the trained neural network included nine input neurons: labor parity, gestational age, leukocyte count, erythrocyte sedimentation rate, total protein concentration, amniotic fluid index, biparietal size, as well as fetal head and abdomen circumference.

CONCLUSIONS: An integrated approach based on generally available laboratory and instrumental research methods, such as complete blood count and biochemical blood test, as well as ultrasound examination, on the eve of labor allows for predicting the abnormal labor development with an accuracy of up to 70%. The use of this technology in clinical practice will help, in the future, not only to prevent abnormal labor, but also to reduce the incidence of adverse obstetric and perinatal outcomes.

本研究的目的是分析子宫肌瘤切除术后妇女的生殖功能，怀孕和分娩的过程，在妇女与非手术肌瘤。

材料与方法。主要组为60例有子宫瘢痕的患者，采用腹腔镜入路行肌瘤切除术。入选标准： 年龄为25—46岁，足月妊娠，腹腔镜肌瘤切除术后子宫瘢痕，子宫浆膜下或壁内肌瘤，大小3—10厘米， 肌瘤结节1—3个。对照组包括30例，年龄为25—46岁，未行手术治疗，子宫浆膜下或壁内肌瘤，大小3—10 cm，肌瘤结节1—3个，足月妊娠。主要组的所有患者采用腹腔镜入路行子宫肌瘤切除术。在所有病例中，肌瘤淋巴结被囊内切除，留下平滑肌瘤假性包膜，假性包膜位于跨壁肌瘤淋巴结的深部，可以避免打开子宫腔；对肌瘤淋巴结进行分切。由于平滑肌瘤的壁内位置较深，肌层缺损被分层缝合，并植入几排内膜鞘。

结果。子宫肌瘤切除术后6个月，患者接受磁共振成像骨盆器官对比。在95%的病例中， 子宫瘢痕在解剖学上是健全的。在评估记忆时，注意到在主要组的女性中，妇科疾病的发病率是两倍：22例（36.7%）患者妊娠的发病采取辅助生殖技术的使用，而对照组患者中只有两个—6.7%（χ2 = 12.8；p<0.001）。在主要组中，中度子痫前期和妊娠期糖尿病的发生率为两倍。主要组均为剖宫产，其中83.3%为计划分娩，16.7%为紧急分娩。对照组73.3%的患者经阴道分娩，26.7%的患者经剖宫产（χ2 = 149；p<0.0001）。最易发生产科并发症和手术分娩的不良体征为多淋巴结[机会比率 5.96（1.09—32.72）；p<0.05]，子宫底淋巴结或瘢痕位置[机会比率2.52（1.00—6.33）；p<0.05]，与体外受精联合[机会比率9.09（2.42—34.07）；p<0.01]。

结论。95%的妇女肌瘤切除术后的疤痕是一致的，但所有这些孕妇都是通过手术分娩的，主要是为了综合适应证。尽管如此，他们还是安全地忍受了怀孕，对胎儿的结果很好。子宫肌瘤患者保守治疗后加重的妇科病史及产科并发症发生率较低，73.3%的患者经阴道产道分娩。尽管剖腹产的风险增加，即使较大的子宫肌瘤（超过4 cm）也不应该被认为是阴道分娩的禁忌症。

2—8%的妊娠合并子痫前期。根据文献，子痫前期与产妇和围产期发病率和死亡率的增加有关，也预示着慢性疾病在遥远的未来的发展，这是一个重要的医学和社会问题。尤其值得关注的是子痫前期的发病机制和危险因素的分子机制，目前对其研究和认识尚不充分，这就要求对这一可怕的妊娠并发症进行进一步的研究。本文介绍子痫前期的病因、发病机制及危险因素的现代认识。

The relevance of this study is due to the high prevalence of stress urinary incontinence in women of different age groups and the search for effective conservative treatment methods.

The aim of this study was to present scientific data based on modern evidence on the effectiveness of conservative treatment methods and their safety in the treatment of stress urinary incontinence in women.

A review of the literature (original articles, systematic reviews) on the use of conservative therapy for the treatment of stress urinary incontinence in women was carried out.

Depending on the severity of stress urinary incontinence in women, their age and concomitant diseases, the options for the proposed treatment may vary. For the conservative treatment of the disease, along with lifestyle modification and the use of hygiene products, it is possible to use training and electromyostimulation of the pelvic floor muscles, innovative laser technologies, and drug therapy. The first line therapy is to train one’s pelvic floor muscles. The best effect of the training is observed in younger patients with mild to moderate severity of the disease using stationary biofeedback simulators under the supervision of medical staff. An alternative to this type of treatment is to conduct training of the pelvic floor muscles in the biofeedback mode with portable simulators remotely under the supervision of specially trained personnel. In connection with the coronavirus pandemic, this therapy is gaining wide popularity, as every patient should be offered acceptable and effective treatment options.

This article presents an unusual case of rupture of the scarred uterus at 36-37 weeks of gestation. The patient presented with pain in the pubic and hip joint area, growing stronger while her walking, seated and changing position. No clinical manifestations of hemorrhagic shock were observed. External obstetric examination revealed a normotonic uterus and satisfactory fetus condition. Provocation tests were conducted to exclude subluxation of the pubic joint. Pubic symphysis diastasis palpation, long dorsal sacroiliac ligament palpation, P4 test, Patrick’s test, and the modified Trendelenburg test were negative. Pelvic examination revealed sharp pain in lower uterus segment. Ultrasound scan revealed deformation and thinning of the scar up to 1 mm, and no abnormalities in pubic symphysis. A threatening uterine rupture was diagnosed, and emergency cesarean section was performed. Intraoperative examination showed that the scar located in the lower segment consisted of connective tissue. In addition, there was a 4 × 5 cm scar defect with the overlying amniotic sac, no hemorrhage being noted. After removing the fetus, scar excision was performed. The uterine defect was repaired with a double layer running-locking suture. The patient was discharged from hospital on day 5 of postpartum period. The infant was exposed in the neonatal intensive care unit to provide an early developmental care.

BACKGROUND: Laparoscopic myomectomy is becoming the leading method of surgical treatment of uterine fibroids while preserving reproductive and menstrual functions. Increasingly, ultrasound energy is used to dissect the myometrium. Meanwhile, the mode and direction of the ultrasound energy supply to minimize damage to the underlying tissues have not been specified.

AIM: The aim of this study was to perform a comparative analysis of the myometrium and the fibroid pseudocapsule in the projection of the myoma nodule after dissection using ultrasound energy with different initial characteristics of the surgical instrument.

MATERIALS AND METHODS: For comparison, we selected two instruments with a longitudinal ultrasound energy supply with an output frequency of 80 MHz ... 2.5 GHz and 47 kHz at intermittent operating mode of 5/10 sec and one torsion instrument with a transverse ultrasound energy supply with an output frequency of 36 kHz at intermittent operating mode of 3/30 sec.

RESULTS: Our study has shown that the smallest zone of irreversible changes is formed when using ultrasound energy with an output frequency of 36 kHz at intermittent operating mode of 3/30 sec with its transverse feed at 90 degrees to the blade, and the largest zone of irreversible changes is formed when using ultrasound energy with an output frequency of 47 kHz at intermittent operating mode of 5/10 sec with its longitudinal feed.

CONCLUSIONS: Morphometric studies with an analysis of the depth of necrotic and necrobiotic changes in the myometrial tissue showed that from the standpoint of reproductive surgery, it is preferable to use USE with an output frequency of 36 kHz at intermittent operating mode of 3/30 sec with its transverse feed.