Nº 11 (2024)

This review presents the main aspects of a rare localization of ectopic pregnancy, namely cervical and cesarean scar pregnancy. It should be noted that the incidence of this type of ectopic pregnancy is increasing in the modern world. In addition to the well-known risk factors for ectopic pregnancy, the increasing prevalence of abdominal-pelvic surgery, assisted reproductive technologies (ART), and operative abdominal delivery are discussed as potential contributing factors. This paper considers the pathogenetic mechanisms of ectopic pregnancy that may occur in the cesarean scar and in the cervix, as well as the classification of pregnancy variants and the diagnostic methods that may be used to identify these variants. The article presents an overview of the various tactical approaches to surgical and non-surgical treatment, combinations of different techniques aimed at preserving the organ and reproductive potential.

Conclusion: Due to the unique nature of this pathology, there is no single algorithm for diagnosis and treatment, and various therapeutic approaches are used. Therefore, further studies are required to improve the management of ectopic pregnancies with rare localization. 

Endometriosis is a chronic inflammatory disease characterized by the presence of endometriosis-like tissue outside the uterus. Every ninth woman is diagnosed with this pathology, and most women experience dysmenorrhea, non-menstrual pelvic pain, asthenia and infertility. According to its location, endometriosis is divided into extragenital and genital endometriosis, which in turn is subdivided into external and internal one. The present review focuses on the genital form in particular. Endometriosis should be considered as a systemic, not only gynecological disease, therefore it is important to study the psychosocial mechanisms of its development. Endometriosis is currently known to be accompanied by significant psychosomatic and social discomfort. Further research is required to identify the complex of psychosomatic factors affecting women with this disease, to determine how these factors interact with one another, and how they contribute to the pathogenesis of the disease. The article presents the current data of the world literature on the psychoemotional status of patients with endometriosis. The paper considers a wide range of relevant psychosomatic issues of endometriosis, including the pathogenesis of chronic pelvic pain in terms of psychoemotional disorders, the interrelationship between psychoemotional factors such as body image, self-compassion, catastrophizing of pain, perception of illness, as well as problems of stigmatization and sexual dysfunction.

Conclusion: The literature review demonstrates that endometriosis is a complex disease where the psychological factors of emotional distress and cognition play an important role. This emphasizes the need to identify psychosomatic factors affecting patients with endometriosis and common links in pathogenesis. It is necessary to further investigate psychological symptoms and determine possible prevention and treatment approaches aimed at eliminating these predictors and improving the quality of women’s lives.

There is a need for greater awareness of the use of modern contraceptive methods in today’s medical practice. This can be due to the low level of public knowledge about contraceptive methods and to the fact that contraception remains within the scope of obstetricians and gynecologists, who consult on the choice of contraceptive method, prescribe a contraceptive and then carry out routine follow-up. However, there are a number of chronic somatic diseases in which an unplanned pregnancy is a threat to the life and health of both the woman and her future child. The issue of contraceptive use and the assessment of drug interactions may be overlooked when patients with a variety of chronic conditions are referred to other specialists and prescribed treatment for their primary diagnosis. The panel discusses the potential use of the subcutaneous contraceptive implant releasing etonogestrel in patients with a variety of chronic diseases, including cardiovascular, pulmonary and endocrine pathologies, immune-mediated and orphan diseases, chronic viral infections and tuberculosis. The etonogestrel implant is a highly effective long-acting reversible hormonal contraceptive option and is the method of choice for women with chronic medical conditions that may limit the use of the estrogen component.

Conclusion: Interdisciplinary collaboration between obstetricians and gynecologists and other specialists is necessary for choosing the best contraceptive method for patients with chronic diseases. Interdisciplinary documents (methodological and/or clinical guidelines) on the use of contraception in specific groups of patients with contraindications to pregnancy could be developed in addition to the current National Medical Eligibility Criteria for Contraceptive Use (2023) and the draft clinical guidelines ‘Contraception. Contraceptive Surveillance’ (2024), which would expand relevant information on contraception for various medical specialists (including cardiologists, endocrinologists, pulmonologists, rheumatologists, infectious disease specialists, and others).

Colorectal neoplasms and endometriosis are significant pathologies that require the attention of specialists from different fields of medicine. Colorectal cancer (CRC) is one of the most common types of cancer, taking the third place by number of cases in the world and the second place in Russia. Most colorectal neoplasms are benign polyps and adenomas, but their potential for malignancy requires mandatory removal and histological examination. The key method for diagnosing colorectal neoplasms is forceps biopsy performed during colonoscopy. Early detection and removal of such masses significantly reduces the risk of cancer.

Endometriosis is an important interdisciplinary issue attracting the attention of both gynecologists and surgeons. The extragenital forms affecting the colon require differential diagnosis with oncological diseases, due to the similarity of clinical manifestations. To achieve an accurate diagnosis, the following methods are used: transvaginal ultrasound, magnetic resonance imaging (MRI) and laparoscopy. The latter provides the most accurate assessment of the extent of the pathological process.

Surgical intervention represents the standard treatment for both colorectal neoplasms and endometriosis. Various techniques, including shaving, discoid and segmental resection, are used to treat endometriosis. Minimally invasive techniques such as endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and transanal endoscopic microsurgery (TEM) are used for colorectal neoplasms. These techniques can result in good outcomes with minimal risk of complications, improving the quality of patients’ lives.

Conclusion: The analyses of the overall benefits and risks of minimally invasive surgery in the short and long terms have shown that there are still controversial issues to be addressed. There is a need for joint projects between clinicians, engineers and health care organizers to develop and test technologically advanced, minimally invasive devices and instruments for implementation in practice.

Objective: To study variants of gene regulatory regions and identify potential markers of fetal growth restriction.

Materials and methods: This study involved the genetic analysis of polymorphic loci of genes associated with thrombophilia, prothrombotic states, folate cycle enzyme disorders, matrix metalloproteinases and their tissue inhibitors, interleukin-1 and-10, as well as laminin and estrogen receptor genes (F2, F5, F7, F13, FGB, ITGA2, ITGB3, PAI-1, MTHFR, MTR, MTRR, MMP9, MMP2, TIMP2, TIMP3, IL10, IL1B, LAMC1, and ESR1) in 110 pregnant women with fetal growth restriction and 272 control patients (without fetal growth restriction). Polymerase chain reaction was used to genotype single nucleotide polymorphisms. The functional effects of polymorphic loci were assessed using HaploReg (for epigenetic effects) and GTEx Portal (for association with gene expression) software.

Results: In the group with fetal growth restriction, the T allele of the polymorphic locus -1296 C>T [rs5749511] of TIMP3 was found to be significantly associated (OR=3.14 (95% CI 1.08–9.13), p=0.03), as was the G allele of the polymorphic locus MTR: 2756 A>G (Asp919Gly) (OR=2.18 (95% CI 1.15–4.13), p=0.02) compared to the control group. A rare allele of the F7 polymorphic locus, 10976 G>A (Arg353Gln), was found to be protective against the development of fetal growth restriction (OR=0.46 (95% CI 0.21–1.01), p=0.05). In the group with fetal growth restriction, accumulation of the rare G allele of the MTRR polymorphic locus: 66 A>G (Ile22Met) was observed; however, the differences with the control group did not reach statistical significance. A statistically significant association was found between the 4G variant of the -675 5G>4G polymorphic locus of the SERPINE1 (PAI-1) gene and early onset fetal growth restriction.

Conclusion: The results of this study suggest that polymorphisms in the regulatory regions of TIMP3, MTR, MTRR, and PAI-1 can be considered potential markers of the risk of fetal growth restriction.

Objective: To investigate the incidence and types of fetal congenital anomalies (FCA) detected during first-trimester screening in pregnant women from various risk groups.

Materials and methods: This retrospective study included 10,044 patients who underwent first-trimester screening at 11–14 weeks of pregnancy at V.I. Kulakov NMRC for OG&P of the Ministry of Health of Russia from 2018 to 2023. Based on baseline medical history and established recommendations, patients were categorized into low- and high-risk groups for fetal pathology. The incidence and types of FCA were analyzed for each group. Pregnancy outcomes including diagnostic verification were assessed using archived electronic patient records. Ultrasound examinations were performed by expert physicians of the Ultrasound and Functional Diagnostics Department with appropriate qualifications. Statistical analysis was conducted using the generalized D'Agostino–Pearson test, Mann–Whitney U test, and Kruskal–Wallis test, with differences considered significant at p<0.05.

Results: Of the study population, 61.6% were in the low-risk group, and 38.3% were in the high-risk group. The mean age of high-risk patients was 37.6 (3.5) years, compared to 29.7 (3.2) years for low-risk patients (p<0.001). Although the median body mass index (BMI) did not differ significantly between the groups, obesity (BMI>30 kg/m²) was more common in the high-risk group (8.7%) than in the low-risk group (4.8%). Additionally, assisted reproductive technologies (ART) were used more frequently in the high-risk group (19.2%) than in the low-risk group (8.4%; p<0.01). In the low-risk group, most women were primigravidae (64.6%) and primiparae (63.2%), whereas in the high-risk group, 41.5% were primigravidae and 44% were primiparae. The overall incidence of FCA in the cohort was 4.3%, with fetal defects occurring in 1.9% of the low-risk patients and 8.1% of the high-risk patients (p<0.01). Combined fetal defects were the most common, accounting for 55% of all the detected anomalies. The most frequently isolated FCAs were congenital heart, limb anomalies, genitourinary, anterior abdominal wall, and gastrointestinal tract defects. Statistically significant differences in isolated FCA incidences were observed between the groups, specifically for facial, chest, and genitourinary pathologies in low-risk patients (p<0.05). Of the 194 isolated defects, anomalies consistently detected before 14 weeks of pregnancy accounted for 35%, those sometimes detected constituted 58.3%, and those practically not detected made up 6.7%.

Conclusion: Prenatal ultrasound diagnostics enables the detection of a significant proportion of fetal anomalies at 11–14 weeks of gestation. The higher incidence of FCA in the high-risk group than in the low-risk group supports the efficacy of risk-based stratification in prenatal screening.

Introduction: Obstetric care that respects a woman’s autonomy during childbirth is a basic component of quality care that every woman needs and deserves during childbirth.

Objective: To determine the degree of respect for a woman’s autonomy during childbirth and providing respectful care as well as their interrelationship.

Materials and methods: A quantitative cross-sectional study design was chosen. The study sample included 453 women (mean age is 29.8 (4.6) years) after spontaneous vaginal delivery from 0 to 1 year. The tool for data collection was the MADM questionnaire supplemented with self-constructed questions. Descriptive and inductive statistics (Student’s t-test) were used for analysis.

Results: The mean MADM scale score was 24.9 (10.33) which represents the borderline between the low and adequate degrees of parturient woman’s autonomy. In the assessment of respectful care, the lowest scores were obtained for questions related to the possibility of choosing a position, the woman’s feeling that she could refuse any routine procedure or examination, and the possibility of moving freely in the delivery room. A statistically significant association was demonstrated between the degree of women’s autonomy during childbirth and all variables of respectful care.

Conclusion: Health care providers should make every effort to actively support a woman’s autonomy during childbirth in all available ways to ensure that respectful care becomes the norm.

Endometriosis is a chronic inflammatory disease that affects women of reproductive age and is characterized by the presence of a wide range of autoantibodies, including those directed against steroid hormones. Of particular scientific interest is the detection of autoantibodies to steroidogenic enzymes, which have been identified as a risk factor for premature ovarian insufficiency (POI).

Objective: To study the profile of autoantibodies to steroid and gonadotropic hormones, and steroidogenic enzymes, in women with endometriosis.

Materials and methods: Using enzyme immunoassay, serum antibodies to estradiol, progesterone, follicle-stimulating hormone, and steroidogenic enzymes (21-hydroxylase, aromatase, cholesterol side-chain cleavage enzyme) were determined in patients with ovarian and deep infiltrating endometriosis (n=45) and in women without endometriosis (n=20).

Results: In patients with endometriosis, in addition to the predominant antibodies to estradiol and progesterone (60% and 55.6%, respectively), antibodies (M and G) to steroidogenic enzymes were detected. The detection rate and odds of detecting these antibodies were higher (33.3%, OR=9.5) than those in the control group (5%). Combinations of several antibodies against enzymes were observed in patients with severe endometriosis.

Conclusion: In addition to the high prevalence of autoantibodies to steroid hormones, patients with endometriosis are highly likely to have antibodies to steroidogenic enzymes. The latter may contribute to the development of autoimmune POI and infertility. The study will continue with a larger sample size and broader range of laboratory and instrumental parameters.

Objective: To evaluate the effect of chronic endometritis treatment including cytokine therapy on uterine artery and endometrial blood flows.

Materials and methods: The retrospective analysis of 298 women of reproductive age with a verified diagnosis of chronic endometritis was performed. The main group consisted of 140 patients. The patients received standard anti-inflammatory therapy and cytokine therapy (the drug Superlymph). The comparison group included 158 patients who received similar treatment, but without cytokine therapy. Doppler sonography assessment of uterine artery blood flow and calculation of arterial perfusion index (PI), as well as VI, FI and VFI was performed.

Results: After therapy in combination with treatment with cytokines, there was redistribution of arteriovenous blood flow and restoration of balanced microcirculation, so that the blood volume of the arterial bed was in compliance with venous blood volume. This was evidenced by a significantly decreased uterine artery and endometrial VI, FI and VFI, and relatively stable arterial PI. Hypervascularization of the uterus and endometrium during the inflammatory process was caused by venous outflow obstruction, but not by increased arterial inflow.

Conclusion: The effectiveness of anti-inflammatory therapy for chronic endometritis in combination with treatment with exogenous cytokines improves the hemodynamics of the uterus and endometrium by restoring venous outflow.

Background: Patient-centered medical care is one of the most promising areas in the development of digital healthcare, including remote monitoring of pregnant women’s health, since it meets the demand for improved access and quality of medical services.

Objective: To analyze the experience of using a system of remote monitoring and control of pregnancy, including the possibility of monitoring high-risk pregnancies, to evaluate the use of remote monitoring of pregnant women’s health using a cloud-based digital platform and to assess the potential for its future implementation based on prospective follow-up in Orenburg.

Materials and methods: The remote monitoring system for pregnancy health is a cloud-based digital platform, web application, and symptom-based surveillance scripts. The qualitative study was based on prospective follow-up of 2,488 pregnant women and 489 women who gave birth. A total of 18,206 questions asked by pregnant women to their attending physicians and 4,013 notifications (‘alarms’) were studied. The notifications were generated using the parameters entered by pregnant women on the Medsenger.AI remote monitoring platform, provided by AyPat LLC, in collaboration with the Orenburg Clinical Perinatal Centre and seven antenatal clinics in Orenburg. The data cover the period from 17 October 2023 to 20 May 2024.

Results: The system for remote monitoring of pregnant women’s health has received high marks from users. Professionals who were introduced to the system appreciated its usefulness in existing routine work. The study demonstrated the importance, convenience and accessibility to the patients. The time spent by the physician on participating in remote monitoring was assessed. There was a high demand for remote monitoring among pregnant women: 81% of participants used the platform, 86% of those who used it indicated that it was useful and convenient. The participant feedback score was 4.82 (out of 5).

Conclusion: A comprehensive scenario for remote monitoring of pregnant women has demonstrated that both patients and physicians are receptive to its integration into routine practice. The proposed tool can be used in the management of pregnancy at the primary specialist health care level.

Background: The search for informative methods to determine the readiness of the endometrium for embryo implantation in patients with infertility caused by chronic endometritis (CE) represents a significant issue in the field of reproductive medicine.

Objective: To evaluate the possibility of using the technology of Laser Conversion Testing (LCT) performed with the PHOTON-BIO spectrometer for diagnosing the functional state of endometrium and determining its readiness for embryo implantation in patients with uterine infertility caused by CE.

Materials and methods: The study was conducted in two stages. Stage I involved the evaluation of the LCT method for the diagnosis of CE and the functional activity of the endometrium (n=40). Stage II aimed to verify the performance of the LCT method among patients with CE and infertility during preconception preparation prior to IVF (n=300). The following methods were used: pelvic ultrasound, Dopplerometry, histological and immunohistochemical studies of endometrial biopsy specimens, and LCT with the PHOTON-BIO spectrometer.

Results: The LCT method was evaluated for reproducibility (Cohen’s kappa coefficient – from 0.59 to 1.0), precision (variability) of results, analytical (diagnostic) characteristics (sensitivity 61.4–81.2%, specificity 76.8–89.7%, positive predictive value 50–59.8%, negative predictive value 53.9–97.8%) and accuracy (63.3–69.7%). The results showed its feasibility and scientific validity for solving a specific problem, namely, improving reproductive outcomes by preventing failed embryo transfers in assisted reproductive technology programs. The use of LCT for this purpose makes it possible to significantly improve the results of IVF and achieve pregnancy in 83.8% and live birth in 72.1% of cases among the patients who underwent several courses of treatment with a complex of antimicrobial peptides and cytokines; the amount of these substances was determined individually using this method.

Conclusion: The LCT medical technology meets the objectives of diagnosing the functional state of the endometrium in patients with CE and is effective in determining the readiness of the endometrium for embryo implantation.

Placenta percreta is a serious obstetric complication, arising from the pathological attachment of the placenta. It is characterized by the invasion of the trophoblast beyond the basal lamina of the endometrium, into the myometrium, reaching as far as the bladder. Women with placenta percreta often experience profuse bleeding during childbirth, which leads to massive blood loss and a significant increase in the number of hysterectomies. The condition also adversely affects women’s reproductive function and poses a risk of maternal mortality. Every year, the number of cases of this pathology grows with the increasing number of caesarean sections. Timely diagnosis and competent management of pregnancy in the presence of placental percreta is critical to reduce both maternal and perinatal morbidity. The choice of appropriate obstetric tactics, from the outpatient phase to hospital discharge, can significantly improve patient outcomes.

This algorithm addresses key issues related to hospitalization, examination, treatment and medical tactics, which depend on the depth of invasion and the intraoperative period. Special attention is given to postnatal care for women with diagnosis of placenta percreta. It is important to note that a comprehensive approach to the diagnosis and treatment of this pathology, effective organization of medical care and constant monitoring of women’s condition not only reduces the risk of complications, but also improves the quality of life of patients in the future.

Conclusion: Placenta percreta is a serious life-threating condition that requires a careful and comprehensive approach to diagnosis and treatment. Effective obstetric tactics, from antenatal to postnatal care, can significantly reduce the risk of complications and improve reproductive outcomes. Continuous medical follow-up and a personalized approach are key factors in reducing maternal mortality.

The article presents the current data on the pathogenetic validity of the use of gonadotropin-releasing hormone (GnRH) agonists in the therapy of severe forms of endometriosis. Endometriosis is a multifactorial, hormone-dependent disease that is common in women of reproductive age and results in a significant reduction in quality of life and impaired reproductive function. In most cases, the treatment of endometriosis requires a comprehensive approach, including not only surgical treatment but also postoperative adjuvant hormonal therapy to reduce the recurrence rate. The analysis of the literature demonstrated the efficacy of the Russian drug Buserelin-depo in the management of pain, the treatment of abnormal uterine bleeding, the reduction of uterine size in adenomyosis, as well as in the preparation of patients with endometriosis for surgical treatment and in postoperative adjuvant therapy. The postoperative cyclic administration of Buserelin-depo effectively reduces the recurrence rate of endometriosis, normalises the volume of menstrual blood loss and reduces the risk of repeated ovarian surgery.

Conclusion: The treatment of endometriosis with hormonal therapy is a complex process that requires an individualised approach, taking into account the patient’s age, reproductive plans and somatic status. The combination of surgical treatment with GnRH agonists has been demonstrated to provide rapid relief of clinical symptoms, restoration of quality of life, reduction in the risk of pathology recurrence, and improvement in reproductive outcomes. The use of GnRH agonists promotes organ-preserving surgeries, reducing the risk of postoperative complications and recurrences.

Background: McCune–Albright syndrome (MAS) is a rare genetic disease characterized by a triad of symptoms: fibrous bone dysplasia, the presence of pigmented skin lesions café-au-lait macules and hyperfunctioning endocrinopathies. This disease is caused by activating somatic mutations of the imprinted GNAS gene (guanine-binding nucleotide-polypeptide with alpha-stimulating activity), which encodes the alpha subunit of G proteins. Patients with this condition are common in clinical practice, especially in pediatric gynecology, since this pathology is frequently diagnosed in connection with premature puberty.

Case report: The article presents a clinical observation of a 22-year-old patient with MAS who came for an outpatient appointment. The diagnosis of MAS was made at the age of 4.5 years due to the presence of menstrual-like bloody discharge from the genital tract, breast engorgement, hormone-producing cyst of the right ovary, multinodular thyrotoxic goiter. The patient was treated with fulvestrant and thiamazole. Thyroidectomy was performed and thyroid hormone therapy prescribed at the age of 8.8 years due to progression of thyrotoxicosis. A pathological fracture of the neck of the right femur required osteosynthesis at the age of 10.5 years. A regular menstrual cycle started at the age of 11. Due to an enlarged cyst in the right ovary, she had the cyst enucleated at the age of 13, but there was a relapse and the menstrual cycle became irregular. The patient was treated symptomatically with progestogens and combined oral contraceptives. Worldwide experience in treating this syndrome was analyzed.

Conclusion: MAS syndrome is a complex orphan genetic disorder with underlying endocrinopathy and osteodystrophy associated with a somatic mutation in the GNAS gene. To date, no specific prophylaxis or therapy for this disease has been developed on a global scale. All treatment is basically limited to the prescription of symptomatic, substitution and antihormonal therapies that impact the pathogenic mechanisms underlying the disease process.

The use of terlipressin to reduce blood loss during surgical procedures is due to its pronounced vasoconstrictor effect on the microcirculatory system of abdominal organs and tissues, the rapid onset of the effect, the absence of systemic effects in local application, and the rare occurrence of adverse reactions. Terlipressin has several advantages over vasopressin because of its selectivity for V1α receptors. In gynecological practice, the drug is usually given intravenously, paracervically or intramyometrically. Terlipressin can be used both in planned surgical procedures (laparoscopic myomectomy, hysteroresectoscopy, cervical conization) and in emergency gynecological care (ectopic pregnancy, abdominal pregnancy, bleeding during endometrial scraping after miscarriage).

Case report: The article presents two clinical cases of successful use of combined administration of terlipressin in urgent situations. The drug was administered off-label after the patients signed an informed consent. In the first case, a 34-year-old woman with abnormal uterine bleeding (AUB) that occurred after taking anticoagulants following a recent iliofemoral thrombosis and pulmonary embolism was given a simultaneous paracervical and intravenous injection of terlipressin due to contraindications to all known recommended methods for arresting AUB; the patient’s bleeding decreased dramatically after 10 minutes and stopped completely after 2 hours. In the second case, a 47-year-old woman was admitted with hemorrhage due to a submucosal myomatous node in a bad condition, with severe post-hemorrhagic anemia (Hb 61 g/L) that required a hemotransfusion of a red blood cell mass. Terlipressin was administered simultaneously paracervically and intravenously prior to removal of the node, which stopped bleeding after 12 minutes and allowed virtually bloodless removal of the node using a twisting technique without the need for hysterectomy. No side effects or complications were observed in either of the two patients.

Conclusion: The presented cases demonstrate the successful use of combined administration of terlipressin in urgent gynecology to stop uterine bleeding of various etiologies in the absence or contraindication of other recommended methods.