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No 6 (2024)
Reviews
Role of maternal hemodynamics in choosing antihypertensive therapy: concept shift
Abstract
Antihypertensive drugs used in pregnancy can reduce blood pressure (BP) by different mechanisms; however, none of these drugs has an advantage over the other. Due to the comparable efficacy and safety profile as outlined in national and international guidelines, the choice of antihypertensive drug in pregnancy is ultimately dependent on the doctor’s expertise, consideration of potential side effects and contraindications, availability, and cost. The risk for hypertension in pregnancy is determined by a woman’s baseline hemodynamic profile. Thus, as a rule, there is a decrease in cardiac output and increased peripheral vascular resistance in patients with preeclampsia even before pregnancy. Numerous hemodynamic studies with promising results suggest a new, phenotype-based approach to the selection of antihypertensive therapy used in pregnancy. The choice of hypotensive therapy is based on hemodynamic changes in a woman rather than on BP readings. It is recommended to prescribe a beta-blocker if cardiac output is increased (usually it is accompanied by decreased vascular resistance), but if vascular resistance is increased (usually it is accompanied by decreased cardiac output), it is recommended to prescribe a vasodilator. It is possible to correct the prescribed therapy during dynamic monitoring of its effectiveness if hemodynamic parameters normalize. This innovative concept has been shown to lead to better pregnancy outcomes, namely, faster achievement of target BP, lower incidence of severe hypertension, decreased rates of iatrogenic preterm labor and low birth weight babies.
Conclusion: Further large-scale studies are necessary to determine the optimal BP in pregnancy, as currently, there is no general consensus regarding this issue. Additionally, there is a need to investigate the efficacy of hemodynamically-based therapy for hypertension in pregnancy. This will facilitate the development of individualized therapeutic approaches.
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Missed opportunities for improving the effectiveness of in vitro fertilization programs in patients with diminished ovarian reserve
Abstract
Improving the effectiveness of in vitro fertilization (IVF) programs in patients with diminished ovarian reserve is an essential issue for modern reproductive medicine. One of the options to achieve better treatment results is to determine the most favorable period for the beginning of ovarian stimulation, to modify the protocol of gonadotropin administration and the choice of the day for follicle puncture, taking into account the characteristics of the reproductive system of a woman with diminished ovarian reserve, short follicular phase, and early ovulation. The analysis of literature data shows that the attention of researchers is mainly focused on modification of ovarian stimulation protocols in patients with diminished ovarian reserve and poor response to gonadotropin administration, however, it is necessary to study further the size of the dominant follicle on the day of injecting the ovulation trigger for final oocyte maturation. It is presumed that choosing the most favorable period for ovarian stimulation may be crucial for patients with diminished ovarian reserve. It is useful to define the prognostic criteria for more or less successful IVF cycles, which may include hormonal and ultrasound characteristics of ovarian reserve and their combined effect at the beginning of the follicular phase.
Conclusion: The hidden reserve of increasing the effectiveness of IVF programs in patients with diminished ovarian reserve, poor response to ovarian stimulation and low pregnancy rate may include adaptation of trigger for oocyte maturation to the size of the dominant follicle, which is smaller than usual, as well as a prediction of a more successful IVF cycle on the basis of reliable markers.
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The effect of nursing mothers’ diet on breast milk composition
Abstract
Грудное молоко (ГМ) является наиболее сбалансированным продуктом питания для детей раннего возраста. ГМ содержит все необходимые питательные вещества, биологически активные соединения, защитные антитела, которые должен получать ребенок в первые годы жизни. Развитие ребенка напрямую зависит от молока матери, качество которого обусловлено здоровьем матери и качеством ее питания.
Целью данной статьи является популяризация информации о преимуществах ГМ, подтверждение или опровержение корреляционных связей между составом ГМ и рационом питания кормящей женщины.
В статье обсуждаются результаты исследований, проведенных для определения влияния различных компонентов рациона кормящей женщины на содержание жирных кислот, белков, углеводов, витаминов и минералов в ГМ. Кроме того, обсуждаются практические рекомендации по оптимизации питания кормящих женщин, чтобы улучшить качество грудного молока, обогащая его необходимыми питательными веществами и антителами для обеспечения наилучшего старта в жизни для новорожденных. Исследование подчеркивает необходимость информационной поддержки кормящих матерей со стороны медицинских и социальных служб, а также значимость продолжения научных исследований в этой области для дальнейшего развития и улучшения рекомендаций по питанию.
Заключение: Обогащенный и сбалансированный рацион не только способствует улучшению общего состояния здоровья матери, но и значительно влияет на качество ГМ, увеличивая содержание в нем жизненно необходимых витаминов и микронутриентов. Это особенно важно для развития и роста ребенка, обеспечения его потребностей в этих веществах на первых этапах жизни. Употребление разнообразных продуктов, богатых необходимыми витаминами и микроэлементами, должно быть в приоритете для кормящих женщин. Кроме того, при необходимости возможно применение витаминно-минеральных комплексов по рекомендации врача, что позволит обогатить ГМ всеми необходимыми питательными веществами, поддерживая здоровье и гармоничное развитие ребенка.
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Original Articles
Intrauterine correction of open forms of spina bifida: comparative analysis of the results of V.I. Kulakov NMRC for OG&P of Minzdrav of Russia and the MOMS multicenter randomized trial
Abstract
Objective: This study aimed to evaluate the results of intrauterine correction of open forms of spina bifida performed at V.I. Kulakov NMRC for OG&P of Minzdrav of Russia and compare them with the results of the MOMS trial.
Materials and methods: This study included 30 patients with a confirmed diagnosis of meningomyelocele or fetal rachischisis who underwent intrauterine treatment at the center. The inclusion criteria were completion of a perinatal consultation at the center, maternal age over 18 years, singleton pregnancy, normal fetal karyotype, gestational age between 19 and 25+6 weeks, presence of Arnold–Chiari malformation type II, cervical length >20 mm, absence of fetal kyphosis >30°, and signed informed consent for surgical intervention. Comparisons were made with 78 women from the MOMS trial whose fetuses underwent intrauterine meningomyelocele repair. Statistical analysis was performed using the StatTech v 3.1.10 (Stattech LLC, Russia) and Prism v. software. 8.0.1 (GraphPad Software, USA).
Results: The most common complication of intrauterine correction for open forms of spina bifida was preterm birth. The mean gestational age at delivery was 33.3 weeks. Premature placental abruption and premature rupture of membranes were observed in 13.3% and 30% of cases, respectively. Delivery was performed via cesarean section in all cases. Correction of Arnold–Chiari II malformation was observed in 100% of the cases, and CSF shunt surgery was performed in one case for intraventricular hemorrhage. Obstetric and neurological outcomes were comparable to those of the MOMS randomized multicenter trial.
Conclusion: Timely diagnosis and careful selection of fetuses for intrauterine correction of open forms of spina bifida lead to regression of Arnold–Chiari II syndrome with subsequent improvements in neurological outcomes in children managed with an integrated multidisciplinary approach.
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Changes in the composition of intestinal microbiota and their association with cortisol, melatonin, tumor necrosis factor-α, and interleukin-17 levels in women with idiopathic recurrent miscarriage
Abstract
Objective: This study aimed to evaluate changes in the taxonomic composition of the intestinal microbiota and examine their relationship with serum levels of cortisol, melatonin, tumor necrosis factor-α (TNF-α), and interleukin-17 (IL-17) in women with idiopathic recurrent miscarriage (IRM).
Materials and methods: This study included 55 women with IRM and 60 women with healthy pregnancies. The taxonomic composition of the gut microbiota and the serum concentrations of cortisol, melatonin, TNF-α, and IL-17 were analyzed.
Results: The study found that women with IRM exhibited changes in the taxonomic composition of intestinal microbiota, characterized by a significant decrease in α-diversity of the bacterial community (Chao1 index p=0.014) and a decrease in the abundance of Bifidobacterium (p<0.001), Lachnospira (p=0.032), Roseburia (p=0.003), and Coprococcus (p=0.012). Additionally, there was an increase in the abundance of Ruminococcus (p<0.001) and Klebsiella (p=0.002). Significant correlations were observed between cortisol levels and the presence of Lachnospira bacteria (r=-0.51; p=0.002) and between melatonin and the presence of Coprococcus bacteria (r=-0.49; p=0.012). Correlations were also identified between TNF-α and IL-17 concentrations and the Chao1 index (r=-0.51, p=0.002; r=-0.54, p=0.001, respectively), TNF-α and the abundance of Ruminococcus bacteria (r=0.51; p=0.002), and IL-17 and the abundance of Bifidobacterium (r=-0.52; p=0.001).
Conclusion: Potential modifications to the gut microbiota may have preventive and therapeutic implications in women with IRM.
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The role of pathological hemostasis in formation of perinatal complications of the novel coronavirus infection
Abstract
Objective: To investigate relationship between maternal and fetal complications after novel coronavirus (nCoV) infection (COVID-19 infection) in the presence of polymorphism of gene encoding proteins of the hemostasis system.
Materials and methods: A comparative study of 270 cases of pregnancy and delivery was carried out. Among them, 170 women were infected with novel coronavirus, and 100 women had no COVID-19 with a proven absence of antibodies to SARS-CoV-2 in the blood. Real-time PCR was used for detection of gene polymorphism of F2, F5, F7, F13, FGB, ITGA2, ITGB3, SERPINE1 in the peripheral blood samples. The enzyme-linked immunosorbent assay (ELISA) was used to quantify specific proteins – soluble fms-like tyrosine kinase 1; placental growth factor; tissue plasminogen activator (t-PA); plasminogen activator inhibitor-type 1 (PAI-1).
Results: Gene polymorphism of the hemostasis system influences the course of novel coronavirus infection, the concentration of the major regulatory proteins and determines formation of perinatal complications. Maternal carriage of the plasminogen activator inhibitor-type 1 (675 4G/4G) allele during pregnancy is associated with mild course of COVID-19 infection. At the same time, homozygous carriage of PAI-1(675) 4G/4G determines the development of severe preeclampsia. Carriage of F13(103) T allele is associated with increased risk of infection and clinical significance of the disease with circulation of the most aggressive SARS-CoV-2 Beta variant and increased concentration of t-PA and PlGF in the blood. Moreover, the novel coronavirus infection leads additionally to increased concentration of these proteins at delivery. Homozygous carriage of F13(103) T/T increases the risk of premature placental abruption.
Conclusion: The mechanisms of gestational complications after nCoV infection are mediated by accumulation of supraphysiological concentrations of proangiogenic factors and fibrinolysis activators at delivery, and their action is modulated by the presence of genetic risk factors associated with hereditary thrombophilia.
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Potential of ultrasound diagnostics in an experimental model of fetal growth restriction
Abstract
Objective: This study aimed to evaluate the effectiveness of an experimental model of fetal growth restriction (FGR) during the intrauterine stage, using ultrasound tracking of fetal biometric parameters and Doppler measurements in Oryctolagus cuniculus rabbits.
Materials and methods: The study included 16 female Oryctolagus cuniculus rabbits (eight for modeling early-onset FGR and eight for late-onset FGR). Ultrasound examinations were conducted on days 20th and 27th days of gestation, with assessment of the head circumference (HC), abdominal circumference (AC), femur length (FL), and pulsatility index (PI) of the umbilical cord artery.
Results: On the 20th day of gestation, the early-onset FGR experimental group exhibited the lowest values of HC (41.0 [IQR 39.5–42.1] mm), AC (48.8 [IQR 46.7–49.7] mm), and FL (4.7 [IQR 4.68–4.82] mm) compared to the control group (p<0.001). Additionally, fetuses from the experimental FGR group displayed an increase in PI in the umbilical cord artery compared with the control group (1.87 versus 1.56, respectively, p<0.001). A similar trend was observed on the 27th day of gestation. All fetal biometric parameters (HC, AC, and FL) were significantly reduced in early-onset FGR fetuses compared to both the control and late-onset FGR groups. Moreover, there was an increase in cord artery PI in early-onset FGR fetuses (both experimental (2.48, IQR 2.15–2.75) and control groups (2.44, IQR 2.30–2.56)) when compared to the late-onset FGR model (p<0.001). When modeling late-onset FGR, an increase in PI in the umbilical cord artery was observed in the experimental group compared to that in the control group (1.83 versus 1.57, respectively, p<0.001).
Conclusion: Selective ligation of uteroplacental vessels is an effective method for modeling FGR in rabbits, and ultrasound examination during the prenatal stage confirms the success of the operation and the presence of severe placental insufficiency.
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Comparative analysis of the reliability of data on the molecular karyotype of the embryo obtained by whole-genome amplification methods based on NGS technology of trophectoderm of individual cells
Abstract
Aneuploidies in human embryos play a significant role in the development of implantation failures and early reproductive losses in assisted reproductive technology (ART) programs. Preimplantation genetic testing for aneuploidy (PGT-A) is the most commonly used method for assessing embryo ploidy. The introduction of PGT-A into clinical practice has greatly reduced the chances of transferring aneuploid embryos to the uterus and has increased the effectiveness of ART programs.
Different PGT-A methods and sampling techniques have advantages and disadvantages, and there are various reasons for potential false-positive and false-negative PGT-A results. Since only a few cells are used for the study, the uniformity of DNA amplification is crucial for obtaining reliable analysis results. Therefore, the most important stage of PGT-A is whole-genome amplification (WGA).
This article presents an analysis of the current literature regarding the effectiveness and reliability of methods for amplifying small quantities of DNA. The results of our study, which compares different methods of whole-genome amplification of individual trophectoderm cells, are presented in order to obtain reliable data on the molecular karyotype of embryos using NGS. The effectiveness of using domestic WGA kits has been demonstrated.
Conclusion: Comparing PGT-A results using various kits has shown that the "hybrid" protocol we developed, which allows for the use of both foreign and domestic WGA kits, is applicable. This approach has demonstrated the high reliability of WGA kits with SD polymerase for preparing materials for PGT of human embryos, and can also be applied in other areas of biomedicine and forensic research where high reliability and accuracy in amplifying extremely small quantities of DNA is required.
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Analysis of pathomorphological characteristics of the placental structure in cases of prenatally diagnosed fetal congenital heart disease
Abstract
Objective: The purpose of the study was to determine placental pathologic changes associated with live-born premature and small-for-gestational-age (SGA) infants in cases of prenatally diagnosed fetal congenital heart disease (CHD).
Materials and methods: A comparative retrospective analysis of the results of pathologic examination of placentas was carried out in the cohort of 115 cases with fetal CHD, that was formed prenatally and divided into groups depending on the gestational age at delivery and birth weight of newborns. Group 1 consisted of 15 cases with premature and/or SGA infants. Group 2 consisted of 100 newborns with birth weight ≥ the 10th percentile.
Results: Examination of placentas in the general cohort showed small for gestational age in 59.1% of cases, abnormal shape in 53%, infarctions in 15.6%, delayed maturation of the vascular tree in 13.3%, meconium staining of the membranes in 8 .7%, massive fibrin deposition in 7.8%, multiple calcifications in 2.6% of cases. There were differences in the placental weight between the groups: the values less that the 3rd percentile and the 10th percentile were in 80% vs 40%, 93.3% vs 54%, in group 1 and group 2, respectively (p<0.01). It was found that the odds ratio for giving birth to premature and/or SGA babies with CHD, when placental weight was less that the 3rd and the 10th percentile, was 6.0 and 11.9, respectively.
Conclusion: According to the results of the pathologic examination of the placenta in cases of congenital heart disease, multiple macro- and microscopic signs of pathological changes were found in the fetus. A significant association between small placental weight and the birth of SGA or premature infant with cardiac pathology indicates the need to expand the scope of prenatal ultrasound examination for searching the markers of placental dysfunction in the diagnosis of fetal cardiac anomalies.
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Balance of serum cytokines regulating inflammatory activity in patients with leiomyoma
Abstract
Objective: To analyze the concentrations and balance of serum cytokines that activate (IL-1β, IL-6) and inhibit (IL-4, IL-10) inflammation in healthy individuals and in patients with leiomyoma in general, with and without endometrial lesions.
Materials and methods: The study included 109 women aged 23 to 61 years with uterine fibroids and 92 women of similar age (22–61 years) without uterine fibroids. All women had general clinical, standard instrumental and laboratory examinations. The concentrations of pro-inflammatory and anti-inflammatory cytokines were determined by enzyme-linked immunosorbent assay (ELISA) for ELx800 Plates (BioTek, Taiwan) using Vector-Best (Russia) kits. Descriptive statistical analysis and nonparametric statistical methods were used.
Results: The course of the tumor process in uterine fibroids is accompanied by a fivefold increase in pro-inflammatory cytokines IL-1β and IL-6 in the serum of female patients in comparison with healthy individuals (p<0.001); the concentrations of cytokines with anti-inflammatory activity, namely IL-4, are not so remarkable, but they are also higher (4.09(2.36-6.94) versus 2.42(0.97-5.86) in healthy individuals, p<0.001). Significant increase in IL-6 concentration in all patients with uterine fibroids (8.93(4.95-14.11), p<0.001) was found to be maximal among women with endometrial pathology (9.67(5.22-14.60), p<0.05).
Conclusion: Proliferation of tumor myocytes and development of microcirculatory channel components in patients with uterine fibroids are accompanied by the prevalence of pro-inflammatory activity of the cytokine network and a shift in the balance of its functional state towards dysregulation of control over the processes of myometrial remodeling.
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Endothelial functional activity in women of reproductive age and menopausal women with metabolic syndrome
Abstract
Objective: This study aimed to investigate the functional state of the endothelium in patients with metabolic syndrome (MS) during the late reproductive age and early postmenopausal period.
Materials and methods: The study included 85 women with MS, of whom 35 patients (group 1) were of late reproductive age (mean age 44.3 (5.8) years) and 46 women (group 2) were of early postmenopausal age (mean age 51.5 (3.4) years). The control group consisted of 29 healthy women with a mean age of 41.4 (11.3) years. Biometric and metabolic parameters, lipid spectrum, follicle-stimulating hormone (FSH), and estradiol levels were measured. Laboratory markers of endothelial dysfunction (ED) including exfoliated endothelial cells (EEC), endothelin-1, vascular endothelial growth factor (VEGF), and von Willebrand factor activity were also assessed. The functional state of the endothelium was evaluated using local skin thermometry using a Microtest device (Russia).
Results: Laboratory signs of MS were more pronounced in postmenopausal patients in both groups. Hormonal status assessment revealed a significant increase in FSH and a decrease in estradiol levels in menopausal women with MS compared to menstruating patients with MS. The number of laboratory markers of ED in both subgroups of women with MS was significantly higher than that of the control group. Additionally, the activity of von Willebrand factor, which indicates thrombogenic potential and degree of endothelial damage, and the blood level of the vasoconstrictor endothelin-1 in patients with menopausal MS exceeded those in fertile women (p = 0.041 and p = 0.031, respectively).
Conclusion: Late reproductive age and early postmenopausal period in women with MS are accompanied by the development of dyslipidemia and significant changes in the vascular system, resulting in ED with increased levels of endothelin-1, EEC, VEGF, and von Willebrand factor activity, as well as impaired physiological vasodilation in response to local heating. As estrogen levels decrease, the severity of MS components and dyslipidemia increases, and ED progresses in the form of persistent vasoconstriction.
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Activation of ovarian function in patients with diminished ovarian reserve through administration of extracellular vesicles
Abstract
Relevance: Poor response to ovarian stimulation during an IVF program is a pressing issue that limits the effectiveness of assisted reproductive technology (ART). Currently, there are no verified and effective methods in routine clinical practice to improve the success rates of treatment in patients with a poor ovarian response. The use of cell-free therapy as a preparation for IVF/ICSI programs offers a promising alternative to donor oocytes, allowing this group of patients to have genetically related children.
Case report: This article presents three clinical observations that demonstrate the effectiveness of a technique involving the activation of ovarian function through intraovarian administration of mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) in patients with a history of multiple IVF failures and poor response to ovarian stimulation.
Conclusion: The presented information on the efficacy of MSC-EVs, based on clinical cases of complex and challenging patients with significantly diminished ovarian function, provides hope for the development of a new direction in reproductive medicine based on the use of cellular technologies. Further research is needed to study the intraovarian regulation of folliculogenesis and the mechanisms by which extracellular vesicles influence these processes.
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Effect of preconceptional cervical electroconizationon the course of pregnancy and childbirth
Abstract
Objective: This study aimed to investigate the impact of preconceptional cervical electroconization on the course of pregnancy and childbirth.
Materials and methods: This study compared the pregnancy course and birth outcomes of women who underwent preconceptional electroconization (n=50) with those without cervical pathology (n=48). Statistical analysis was performed using descriptive statistics in an Excel spreadsheet, and comparative analysis was conducted using Fisher's exact test.
Results: Among the pregnant women with a history of cervical electroconization, 34% had cardiovascular disease, 32% had gastrointestinal disease, 14% had neurological disease, 6% had Rh-negative blood, 14% had myomas, 10% were infertile, and 4% had congenital genital malformations. Women with a history of cervical electroconization were more likely to experience isthmic cervical insufficiency (10%) during pregnancy. The percentage of preterm births was higher in women with a history of cervical electroconization than in those without. Labor induction was performed in 22% of the cases, and labor augmentation with oxytocin was performed 7% less frequently than in women without a history of electroconization.
Conclusion: A history of cervical electroconization was associated with a higher prevalence of somatic and gynecological pathologies. However, it did not increase the frequency of cesarean sections or labor induction with oxytocin. No negative effects on the fetus were observed.
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New possibilities for assessing the magnetic resonance characteristics of endometrioid ovarian cysts and their response to dienogest therapy
Abstract
Objective: To evaluate the dynamics of changes in the size of ovarian endometriomas (OMA) in patients receiving the dienogest (DNG) therapy and determine the significant parameters of magnetic resonance imaging (MRI) that affect their reduction.
Materials and methods: This was a prospective study which was conducted at the Academician V.I. Kulakov National Medical Research Centre for Obstetrics, Gynecology and Perinatology, Moscow, in the period from 2021 to 2023. The study included 24 patients with 37 OMA (average age is 33.54 (7.08) years). The patients received DNG (drug "Zafrilla") at daily dosage 2 mg in a continuous mode. Before the start of therapy and after 6 months of its administration, an MRI of the pelvic organs was conducted with a simultaneous calculation of a number of parameters: the size and volume of cysts with the calculation of the reduction coefficient, the measured diffusion coefficient (MDC), the ratio between the maximum and minimum values of MDC, signal intensity on T2-weighted images. The initial and subsequent levels of AMH and CA-125 were determined in the blood serum.
Results: The analysis of the data showed that DNG therapy leads to a decrease in the volume of OMA by 50% or more in 73% of cases, by 75% or more in every 2nd case of the disease. The full effect of the therapy was noted in every 10th case (100%). The reduction coefficient was significantly influenced by the initial MDC values (r=0.559, p=0.068), the degree of uniformity of the cyst contents (r=0.5491, p=0.0081), the time until its detection (r=-0.4432, p=0.0077), as well as its initial dimensions (<2 cm in diameter, p=0.0015). The higher the initial MDC values correlated with more pronounced effect of therapy. It was shown that at an MDC value of ≥0.792, a decrease in OMA volume by 75% or more with a sensitivity of 90.0% and a specificity of 78.57% can be expected (AUC 0.814 (0.093) [95% CI 0.604;0.942], p=0.0007).
Conclusion: DNG suppressive hormone therapy helps to reduce the volume of OMA by an average of 78.91%. MRI of the pelvic organs is not only a method of diagnosing OMA, but it is also a tool for evaluating the effectiveness of therapy with MDC. MDC value of ≥0.792 may indicate a potential decrease in the volume of OMA by 75% or more, which is important for making a decision about the patient’s management tactics.
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Exchange of Experience
Possibilities of the biologically active complex of phytopreparations in the correction of menopausal disorders
Abstract
Objective: To conduct a comparative assessment of the effectiveness of a biologically active complex of phytopreparations and menopausal hormone therapy (MHT) in the treatment of the climacteric syndrome (CS).
Materials and methods: This was a prospective analysis of the effectiveness of using the biologically active complex of phytopreparations NOW Menopause Support 560 mg and MHT in the treatment of CS in women 6 months after receiving therapy. Group 1 included 50 women with CS who received a phytopreparation made on the basis of soy isoflavonoids, cimicifuga rhizome, and red clover isoflavones. Group 2 included 42 patients who received systemic MHT.
Results: According to the Greene Climacteric Scale, the emotional state significantly improved (10.0 (8.0; 14.0) scores) in the group receiving systemic MHT after 6 months from the beginning of therapy, but it was worse than in the other group (p=0.044). The somatic condition effectively improved in the group receiving MHT (3.0 (3.0; 6.0) scores), however it was not different from the condition of women in the group receiving phytopreparations after 6 months of therapy (3.0 (3.0; 6.0) scores), p=0.233. Vasomotor symptom status significantly improved (p<0.001) in both groups after 6 months of treatment. It was assessed as 3.0 (2.0; 5.0) scores in the group of patients after taking MHT and it differed from the group receiving phytopreparations which was 1.0 (1.0; 3.0) scores (p=0.032); it was associated with the presence of milder forms of vasomotor manifestations of CS in the group receiving phytopreparations.
Conclusion: The treatment of CS with phytopreparations and systemic MHT showed high effectiveness. The phytopreparation made on the basis of soy isoflavonoids, cimicifuga rhizome, red clover isoflavone shows positive results in the treatment of the whole spectrum of menopausal disorders, but it can be used with greater benefit for women with moderate severity of symptoms, where the dominant symptoms are somatic and emotional manifestations.
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Guidelines for the Practitioner
Economic aspects of introducing tests for early diagnosis of preeclampsia into the routine practice of managing pregnancy
Abstract
Preeclampsia is one of the most serious pregnancy complications affecting 2-8% of pregnancies. In the last decade, it has become possible to detect preeclampsia early by determining the ratio of angiogenic factors sFlt-1/PlGF; thus, the incidence of maternal and perinatal complications may be reduced.
Objective: To assess the impact of introducing the sFlt-1/PlGF ratio for early diagnosis of preeclampsia into the routine practice of managing pregnancy on clinical outcomes and health care system costs in the Russian Federation.
Materials and methods: The study was based on a mathematical model to determine the ratio of angiogenic factors sFlt-1/PlGF in all pregnant women at high risk of preeclampsia; these factors were determined by first trimester screening. The initial data for building the model were the results of the PROGNOSIS clinical trial, statistical materials and a survey of experts. The early detection of preeclampsia was expected to contribute to the improvement of pregnancy management tactics and reduce the health care costs, including preventive care, emergency and planned hospitalizations, and treatment of pregnancy complications. The developed model was tested in the Moscow region, the Samara region and the Republic of Bashkortostan.
Results: The introduction of testing into the routine practice of managing pregnancy may reduce the incidence of life-threatening complications for the pregnant woman (severe preeclampsia, HELLP syndrome) and fetus/newborn (stillbirth, perinatal mortality, respiratory distress syndrome, periventricular leukomalacia). Due to the decrease in the number of cases of providing medical care for patients who do not develop preeclampsia (misdiagnosed without a test), as well as the decrease in the number of emergency hospitalizations and deliveries for patients who have preeclampsia outside the hospital (in the absence of timely diagnosis), the total costs of the Obligatory Medical Insurance system will not increase if the average number of tests is 1.45 or less per pregnant woman with a high risk of developing preeclampsia.
Conclusion: The introduction of the sFlt-1/PlGF ratio into the routine practice of managing patients at high risk for preeclampsia has the potential to reduce adverse pregnancy outcomes and the cost of managing pregnancy.
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Chronic endometritis
Abstract
Chronic endometritis is a chronic infectious inflammatory disease that leads to morphofunctional disorders of the endometrium. Chronic endometritis unlike acute one is almost asymptomatic and is rarely accompanied by specific clinical manifestations like pelvic pain, abnormal uterine bleeding, dyspareunia and leukorrhea. The incidence of chronic endometritis in infertile women ranges from 0.2 to 46%. Percent difference in the data is due to the lack of clear diagnostic criteria to verify the diagnosis. Morphologic examination is the diagnostic gold standard. Such pathomorphological signs as superficial edema, increased stromal density, unsynchronized differentiation between endometrial epithelium and stroma, and infiltration of the endometrium by stromal plasmacytes are the most informative. The simultaneous use of CD138 and MUM1 immunohistochemistry could potentially compensate for the weaknesses of the method in the histopathologic diagnosis of chronic endometritis. Overdiagnosis leads to unnecessary prescription of antibiotics. Antibiotic resistance has increased by 8.27 times in the last 5 years; therefore, it is necessary to search for additional alternative therapies. The study of efficacy of bovhyaluronidase azoximer in the therapy of patients who experienced chronic endometritis and had implantation failures showed that remodeling of connective tissue by bovhyaluronidase azoximer promotes improvement of reparative processes, normalization of blood circulation and receptor apparatus in the uterine cavity.
Conclusion: The absence of clear diagnostic criteria for verifying the diagnosis leads to overdiagnosis of chronic endometritis and unjustified prescription of antibacterial agents. Identifying the connection between the microbiome, chronic inflammation and the immune status of the body in the future can solve the problem of many reproductive failures, and miscarriage in particular.
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Experience of using a combined melatonin-containing drug in the correction of sleep disorders in women
Abstract
A review of existing research suggests that women are more likely to experience sleep disorders than men. Chronic sleep deprivation results in the activation of the hypothalamic-pituitary system and sympathetic nervous system, which increases the risk of menstrual disorders, ovarian dysfunction, spontaneous abortion, decreased ovarian reserve in women over 35 years of age, and low effectiveness of in vitro fertilization in women with infertility. Sleep disorders such as hypersomnia and insomnia associated with premenstrual syndrome and premenstrual dysphoric disorder have been described. Sleep disorders in women with polycystic ovary syndrome are almost twice as common as in healthy women of the same age. Insomnia is a common complaint in menopausal transition period and in postmenopause in more than half of women.
The results of numerous studies emphasize the importance of diagnostics and treatment of sleep disorders for effective correction of the underlying disease that leads to reproductive impairment and reduced quality of life in women.
The first-line drug choice in the treatment of insomnia are herbal sedatives and melatonin. Melatonin is a pleiotropic hormone, produced by the epiphysis, that regulates the circadian and seasonal rhythms of physiological functions of the body. It affects not only sleep-wake cycles, but also neuronal development, metabolic processes, protection and regulation of the immune, endocrine and reproductive systems.
SonNorm Duo is a combined drug containing melatonin, peppermint leaf oil and motherwort herb extract, which has adaptogenic and sedative effect, helps to reduce the nervous system excitability, reduce anxiety and excitement, improve sleep quality; it also normalizes circadian rhythms, including the sleep-wakefulness cycle and adaptation of weather-sensitive people to weather changes. Due to the gradual release of its components, SonNorm Duo has a higher clinical efficacy relative to mono-melatonin-containing drugs, as well as a high safety profile, and can be used with hormone therapy.
Conclusion: The use of the combined drug SonNorm Duo in clinical practice confirms its efficacy and safety in women of reproductive and menopausal age.
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Clinical Notes
Stress-induced cardiomyopathy (takotsubo syndrome) complicated by cardiogenic shock in a pregnancy with cesarean delivery
Abstract
Актуальность: Стресс-индуцированная кардиомиопатия (синдром такоцубо) – редкий вид неишемической кардиомиопатии, характеризующийся острым началом и относительно быстрым обратным развитием левожелудочковой систолической дисфункции при отсутствии атеросклеротического поражения коронарных артерий. К ранним осложнениям этой патологии относят остановку сердца, тахи- и брадиаритмии, острую сердечную недостаточность, шок, верхушечное тромбообразование, инсульт, разрыв межжелудочковой перегородки и свободной стенки левого желудочка. Смертность пациентов со стресс-индуцированной кардиомиопатией (синдромом такоцубо) достигает 5,6%.
Описание: Описан редкий случай стресс-индуцированной кардиомиопатии (синдрома такоцубо), осложненной острой сердечно-сосудистой недостаточностью и кардиогенным отеком легких, развившейся в момент оперативного абдоминального родоразрешения в плановом порядке при доношенной беременности, потребовавший участия специалистов мультидисциплинарного профиля для оказания экстренной помощи (акушеров-гинекологов, анестезиологов-реаниматологов, кардиологов, неонатологов, подготовленного среднего медицинского персонала), что способствовало успешному исходу представленного наблюдения.
Заключение: Необходимо помнить о вероятности стрессового повреждения миокарда у пациентов любого профиля, в том числе у беременных женщин, особенно при повышенной тревожности пациентки, предстоящем оперативном вмешательстве.
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Clinical case of hemorrhagic stroke in a pregnant woman
Abstract
Relevance: Stroke is a potentially life-threatening condition for the patient. Hemorrhagic stroke due to the rupture of an arteriovenous malformation in pregnant women is a rare pathology, and its description is of practical interest.
Case report: A 26-year-old female patient N., primipara, at 30 weeks gestation, was transported by air ambulance with signs of haemorrhagic stroke. According to the case conference, the patient underwent the skull trepanation on the left side and ventriculostomy taking into account intraventricular haemorrhage with the development of ventricular tamponade, cerebral edema confirmed by CT scan; the next day the patient had bifrontal decompressive skull trepanation, excision of arteriovenous malformation, removal of hematomas of the right, left lateral and third ventricles. The pregnancy was complicated by chronic fetal hypoxia, with a tendency to progression, stage 2 placental disorder, low water supply, stage 2 anemia; the pregnancy ended at 32 weeks with operative delivery and birth of a live female child, weight 2140 g, height 46 cm with a score of 6–7 according to the Apgar scale. The postoperative period was uneventful. The patient was treated subsequently in accordance with the underlying disease and recommendations of narrow specialists regarding the persisting neurologic deficit and liquorodynamic disorders.
Conclusion: Hemorrhagic stroke due to the rupture of an arteriovenous malformation in a primigravida at 30 weeks is an extremely rare condition with a high risk of death but can be treated in case of timely diagnosis and emergency medical care. Timely neurosurgical treatment and subsequent operative delivery resulted in a favourable pregnancy outcome.
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Consensus statement of the Russian Society of Obstetricians and Gynecologists and the Russian Association of Mammologists on the effect of combined oral contraceptives on breast tissue
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