Vol 23, No 4 (2021)

XXVII All-Russian Congress with international participation "Outpatient and polyclinic care at the epicenter of women's health from menarche to menopause", held in Moscow on April 21-23, 2021, chaired by Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor G.T. Sukhikh and Doctor of Medical Sciences, Professor V.N. Prilepskaya, was dedicated to the memory of Corresponding Member of the Russian Academy of Sciences, Professor E.M. Vikhlyaeva - an amazing person, an excellent doctor, a great scientist. The presented material is a tribute to a woman whose life is an example of selfless service to people, medical science, her teachers and students.

Microbiota – a set of human microorganisms that exist with him in normal and pathological conditions, are involved in physiological and pathophysiological reactions, metabolism. The classic manifestation of a violation of the vaginal microbiota is a clinical non-inflammatory syndrome – bacterial vaginosis (BV), characterized by certain changes in the composition of the vaginal microbiota and excessive reproduction of microorganisms, which are normally present in small quantities. To date, literature data emphasize that the issues of the etiology, pathogenesis of BV, the reasons for the recurrence of the process are not fully understood, the reasons for the lack of long-term effectiveness of BV therapy are unknown. Further research in this area should be aimed at studying predictors and prognostic signs of recurrence and persistence of the process, differences in vaginal microbiota in patients with recurrent and persistent BV.

The review considers features of iron and folic acid (FA) pharmacokinetics, which affect the effective micronutrient support: molecular mechanisms of absorption and distribution, homeostatic processes of maintaining plasma vitamin and mineral levels by the feedback mechanism, including by regulating the deposition. An important characteristic of ferrokinetics is the presence of unique iron exporter ferroportin which is controlled by a family of iron regulatory proteins. Systemic ferrotherapy and oral rout of iron delivery are distinguished. In general, parenteral iron preparation complexes consist of Fe(III) oxide/hydroxide core stabilized by a carbohydrate polymer shell. Once entering the bloodstream, iron complexes are absorbed by resident macrophages of the reticuloendothelial system of the liver, spleen and bone marrow. Systemic Fe(III) preparations are prodrugs, the active part of which, i.e. iron is released in the lysosomal matrix of phagocytes. Oral iron preparations are divided into those containing bivalent (ferrous) and trivalent (ferric) iron. The article discusses factors determining the differences in the absorption of oral ferrous and ferric iron preparation, the spectrum of side effects, as well as key pharmaceutical approaches to increase the tolerance and adherence of ferrotherapy. These include using preparations containing Fe(II) organic compounds that have a lower dissociation rate than inorganic iron salts as well as slowing down the release of the active Fe(II) pharmaceutical substance from the drug. The review pays special attention to folates as iron synergists and examines the features of FA pharmacokinetics, the molecular basis of synergism, and substantiates the use of combined iron and FA preparations.

Aim. To analyze the recurrence of endometriosis after surgical treatment of patients with deep endometriosis.

Materials and methods. The case histories of 90 patients aged 19 to 45 years were retrospectively analyzed. The study group consisted of 70 endometriosis patients: 20 with peritoneal endometriosis and 50 with deep infiltrative endometriosis (DIЕ). The comparison group included 20 women without endometriosis. There was an in-depth study of anamnestic data in the cohort of patients under study. The results of preoperative laboratory tests, including serum levels of the CA-125 and CA 19-9 oncomarkers, were processed.

Results. Analysis of the obtained data showed that about half of the DIE patients (54%) in the main group had a history of surgical interventions for endometriosis. The number of operations was significantly higher in patients compared to the peritoneal endometriosis group (68% vs 20%, respectively; р=0.0012). Two subgroups were formed from the group of women with DIE: patients who had no history of previous surgical treatment for endometriosis and those hospitalized for repeated surgical treatment of endometriosis (patients with recurrent endometriosis). Patients with recurrent endometriosis had a significantly higher incidence of heavy menstruation, pregnancy terminations (abortions), and a high proportion of gastrointestinal diseases. Analysis of the hormonal therapy received in patients with DIE showed that every second patient with relapses (18/53%) after surgical treatment and every third patient without a prior history of surgery (5/31%) received hormonal therapy. Examination of the preoperative serum levels of CA-125 and CA 19-9 serum markers in patients with DIE showed an increase in their serum levels and a correlation with the frequency of endometriosis recurrence and the size of DIE foci.

Conclusion. Despite the conservative and surgical treatment of DIE patients, the recurrence rate is still high. At present, there is no satisfactory therapy for all endometriosis patients. Therefore, the development of therapy for the conservative treatment of the disease remains an urgent task.

Aim. To assess the perinatal outcomes of monochorionic diamniotic (MCDA) pregnancy after fetoscopic laser coagulation of anastomoses (FLCA) performed for twin-to-twin transfusion syndrome (TTTS), accompanied by induced or unintentional septostomy, and to identify the factors leading to septostomy.

Materials and methods. The retrospective study included 231 cases of FLCA performed in pregnant women with TTTS: in 19 cases septostomy was performed, and in 212 cases intertwin membrane remained intact.

Results. The incidence of septostomy during FLCA for TTTS was 8.2%. In 47.3% the rupture of the intertwin membrane occurred during trocar insertion (unintentional septostomy); in 42.1% septostomy was needed to perform laser coagulation of anastomoses located on the placental surface in the donor's amnion (forced septostomy). The placenta was located on the anterior uterine wall in 78.9% in the septostomy group and in 47.6% with an intact intertwin membrane (p=0.01). Anastomoses were located on the “donor” half of the placenta significantly more often when septostomy was needed to perform selective coagulation of anastomoses located far from the intertwin membrane and obstructed by the body of the donor fetus (42.1%). In 15.8% of patients with septostomy and 2.4% with intact intertwin membrane, umbilical cords of the donor and the recipient fetus were attached closer than 2 cm to each other (p=0.003). In the septostomy group premature rupture of membranes was more frequent (42.1% vs 18.4%, p=0.03) and a delivery time was shorter [26.3 (18.0, 37.0) vs 34.4 (20.3, 40.0) weeks, respectively, p=0.01] than in patients with an intact intertwin membrane. The survival rate after FLCA was lower after septostomy compared to intact intertwin membrane: at least one of the twins survived in 47.4% vs 80.7%, respectively (p=0.002), both fetuses survived in 36.8% vs 75.0%, respectively (p=0.001). Logistic regression analysis showed increased risk of septostomy in patients with the anastomoses located on the “donor” half of the placenta and when the donor and the recipient umbilical cords are attached close to each other, regardless of the localization of the placenta, gestational age and the stage of TTTS.

Conclusion. Lower incidence of unintentional septostomy during FLCA achieved by using modern equipment and surgical techniques will lead to better perinatal outcomes in patients with MCDA twins with TTTS.

Background. Ovarian cancer is the first fatal malignancy of the female reproductive system. Early detection is associated with better outcomes, but is significantly difficult because of asymptomatic or low-symptomatic course.

Aim. To study the possibility of detecting of OC in early stages (Ia–Ic) by the lipid profile of blood serum obtained using high-performance liquid chromatography with mass spectrometric (MS) detection.

Materials and methods. An observational "case-control" study was conducted in period November 2019 – July 2020 in the Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology. 41 patients were included: group 1 (main) – 28 patients with histologically verified high grade serous ovarian cancer of I–IV FIGO stage, group 2 (control) – 13 conditionally healthy women. Venous blood samples were collected immediately before the operation. Extracts of serum lipids were obtained in accordance with the modified Folch method. The composition of the samples was analyzed by electrospray ionization MS. Using the method of discriminant analysis and orthogonal projections to latent structures (OPLS-DA) were building OPLS-models based on profile of significant lipids. The comparison based on the non-parametric Mann–Whitney test.

Results. The presence of 128 lipids in blood serum samples makes a major contribution to the OPLS-models, that are different for patients with I–IV OC stage and controls. The OPLS-model parameters are: R²=0.87 and Q²=0.80, the area under the ROC curve reached 1, sensitivity and specificity of the model – 100%. The second OPLS-model was developed to assign patients to 13 blood serum samples of the control group or to 5 blood samples of patients with I-II stages of OC: 108 lipids made the main contribution to this model (R²=0.97, Q²=0.86). The third OPLS-model was constructed to distinguish patients with earlier (Ia–Ia stages; n=5) and advanced (IIa–IVa; n=23) stages: R²=0.96 and Q²=1.00, AUC=0.99. Diglycerides, triglycerides, phosphatidylcholines, ethanolamines, sphingomyelins, ceramides, phosphatidylserines, phosphoinositols and prostaglandins significantly differ in the blood serum samples of patients with Ia–Ic stages of OC and patients with II–IV stages and controls, that indicates the diagnostic value.

Conclusion. It is possible to distinguish a healthy person from patient with Ia–Ic or II–IV stages of OC. Serum oncolipids profile obtained by high-performance liquid chromatography with MS detection can be used as markers of early stages of OC, that are associated with better prognosis.

Aim. To study a stress-protective efficacy of micronized progesterone (MP) in pregnant women with anxiety disorders after in vitro fertilisation (IVF).

Materials and methods. We conducted a prospective, comparative open-label randomized trial in two IVF-clinics. A total of 98 pregnant women after IVF with anxiety disorders were recruited at the 9th week of pregnancy. Progesterone supplementation after IVF for luteal phase support was administered out until 9 weeks gestation. Then, after randomization, group 1 (n=35) received 400 mg per day of MP vaginally, group 2 (n=33) received 400 mg of MP orally, group 3 (n=30) was comparative for the other groups. The duration of progesterone treatment was 12 weeks. The Spielberger State Trait Anxiety Inventory (STAI), the Montgomery–Åsberg depression rating scale (MADRS), Hospital Anxiety and Depression Scale (HADS), and the Epworth Sleepiness Questionnaires (ESQ) were used to compare maternal mood at 9 weeks (day of randomization) after delivery and at 28±3, 56±5, 84±7 days after randomization.

Results. The mean STAI sumscore in MP-groups was significantly lower than in group 3 starting from day 56±5 and continued until the end of the study. There were no significant differences between vaginal and oral administration of progesterone. There were no significant differences between the mean sumscores when questioning on the HADS, MADRS and ESQ.

Conclusion. Prolonged use of MP in pregnant women with anxiety disorders led to the prevention of manifestations of an increase in anxiety and depression. The stress-protective and neuromodulating properties of MP can determine additional indications for its prolonged administration in women with anxiety disorders and/or premorbid history.

Summary: to evaluate the efficacy and safety of dienogest therapy for 24 weeks in patients with endometriosis-associated pelvic pain resistant to surgical treatment.Material and methods. The study included 126 patients aged 33-40 years with external genital endometriosis confirmed by laparoscopy and morphological examination (NGE; ICD-10-N80. 1, 80.2, 80.3, 80.4) and with pelvic pain that occurred 3-6 months after surgical treatment of NGE (ICD-10 — N94.8 "Pain and other conditions associated with female genital organs and menstrual cycle"). The participants were stratified into three groups depending on the severity of the pain syndrome according to the verbal rating scale (VAS; Verbal Analog Scale). Group 1 included patients with a VAS pain score of 10-40 mm, group 2-41-70 mm, and group 3 — more than 71 mm. Patients of all three groups were prescribed the drug Zafrilla (dienogest 2 mg/day) for a course of 24 weeks (according to the current instructions

Due to the introduction of modern methods of contraception in Europe and, in particular, in Russia, the abortion rate has decreased significantly. This is largely due to the use of such a progressive method as hormonal contraception. However, the level of use of modern methods of contraception in Russia remains low, which is often due to fear of side effects and existing myths, especially in relation to hormonal contraception. Combined oral contraceptives are well studied, have a favorable profile of efficacy and safety, the risks of taking them are minimal and are reflected in the instructions for use. When properly prescribed, hormonal contraception is a reliable method of protection against unwanted pregnancy, which also has additional benefits, including therapeutic effects.