Vol 24, No 2 (2022)


Predictable benefits of folate-containing combined oral contraceptives after abortion in women: review

Maltseva L.I., Garifullova J.V.


Despite all prevention and education campaigns, the rate of unintended pregnancies is 40% of the more than 200 million pregnancies occurring worldwide. About half of them end in abortion. Women in the 20–30 age group, where abortions peak, have not yet fulfilled their reproductive plans. The lack of competent post-abortion rehabilitation for women, including contraception counselling, results in one in three choosing a less effective method, and one in four not using any contraceptive methods at all. According to the The World Health Organization Guidelines for Safe Abortion, all women should use hormonal contraception after spontaneous or induced abortion. Combined oral contraceptives (OCs) with 30 mcg ethinyl estradiol in combination with drospirenone, which has strong antigonadotropic activity, can effectively suppress hypothalamic-pituitary-ovarian axis excitability after abortion. OCs can be used to prevent neural tube defects in the case of pregnancy after withdrawal of OCs. The use of folate-containing OCs is a sensible means of folate supplementation in women of reproductive age that may guarantee a future healthy pregnancy and overall health.

Gynecology. 2022;24(2):72-79
pages 72-79 views


The differential diagnosis algorithm of ovarian tumors in reproductive patients: a prospective study

Podzolkova N.M., Osadchev V.В., Babkov K.V., Safonova N.E.


Aim. The aim of the study was to evaluate the efficiency of different methods of preoperative diagnostics and to develop an algorithm for examining patients of reproductive age with ovarian tumors.

Materials and methods. The study included 100 patients operated in the gynecological and oncogynecological departments of Pletnev State Clinical Hospital (Moscow) in the period from Sep 2019 to Dec 2020. The inclusion criteria were reproductive age (18–40 years); unilateral/bilateral nature of ovarian lesion; ovarian tumor existing for at least 3 months and confirmed by the data of instrumental research methods; the size of the pathological formation of the ovary according to instrumental examination ≥30 mm; normal/elevated level of biochemical markers and diagnostic calculation indices: Carbohydrate Antigen 125 (СА 125), Carbohydrate Antigen 19-9, Carcinoembryonic Antigen, Human Epididymis protein 4 (HE4), Risk of Ovarian Malignancy Algorithm (ROMA), Risk of Malignancy Index (RMI). All patients underwent determination of the level of cancer markers CA 125 and HE4, followed by calculation of the RMI and ROMA indices for premenopause, gray scale ultrasound examination with Doppler blood flow assessment was performed. Next, a contrast-enhanced ultrasound examination (CEUS) was performed.

Results. Sensitivity (Se) of the Ovarian-Adnexal Imaging-Reporting-Data System (O-RADS) in predicting tumor malignancy was 84.8% (95% confidence interval – 95% CI 80–88), specificity (Sp) – 88.1% (95% CI 85–91), accuracy (Acc) – 0.86 (95% CI 0.82–0.90), odds ratio (OR) – 41.18 (95% CI 21.0–80.7), area under the curve (AUC) 0.744. Se of CEUS in predicting malignancy was 90.9% (95% CI 85–95), Sp – 92.5% (95% CI 89–97), Acc – 0.92 (95% CI 0.88–0.96), OR – 150.0 (95% CI 76.5–294.0), AUC 0.895.

Conclusion. Patients with O-RADS 2 are shown to be monitored by a gynecologist for 6 months with a control ultrasound examination once every 3 months. When O-RADS 3 criteria are identified, it is recommended to include the determination of cancer markers and surgical treatment in a gynecological hospital with subsequent morphological examination of the obtained material as a preoperative diagnosis. The identification of O-RADS 4 and O-RADS 5 criteria requires additional examination methods, such as the study of cancer markers (CA 125, HE4, ROMA, RMI), contrast-enhanced ultrasound (CEUS) and magnetic resonance imaging. CEUS showed high diagnostic efficiency in the presence of O-RADS 4 criteria, which made it possible to determine the necessary management tactics for patients with «complex» tumors. If the characteristics of the tumor are unclear, it is necessary to consider the possibility of surgical treatment in an oncological hospital.

Gynecology. 2022;24(2):80-87
pages 80-87 views

The prevalence of chronic endometritis in patients with secondary infertility associated with a caesarean scar niche

Kurtser M.A., Egikian N.M., Savelyeva N.A., Sinitsyna O.V., Shestakova L.A.


Background. The trend towards an increase in the number of caesarean sections (CS) has led to the fact that many women are more likely to plan a second pregnancy with a caesarean scar niche. According to current data, planning pregnancy with a niche may be associated with a decrease in the likelihood of successful implantation, which is a consequence of the uterine form of secondary infertility. In the context of studying the effect of stagnant contents in the projection of the niche on fertility, it is important to assess the prevalence of chronic endometritis (CE) and use new knowledge to personalize patient management schemes in achieving reproductive goals.

Aim. To study the prevalence of CE according to various laboratory diagnostic methods in a group of patients with secondary infertility associated with stagnant contents in the niche projection, compared with a group of fertile patients without stagnant contents in the niche projection; to evaluate the possibilities of the cytological and immunocytochemical (ICC) method for studying the endometrium in the diagnosis of CE in comparison with the histological and immunohistochemical (IHC) method.

Materials and methods. The prospective study included 38 patients of reproductive age with a caesarean scar niche, who met the inclusion criteria. After excluding other known factors of secondary infertility, performing ultrasound and/or magnetic resonance imaging of the pelvic organs on the 5th–8th day of the menstrual cycle, where the presence/absence of stagnant contents in the projection of the niche was assessed, the patients were divided into 2 groups: group 1 (n=30) – patients with secondary infertility in combination with stagnant contents in the niche projection (main group), group 2 (n=8) – patients without clinical complaints, without stagnant contents in the projection of a clinically insignificant niche (control group). All patients (n=38) underwent an aspiration pipel biopsy of the endometrium (and, in the presence of stagnant contents in the projection of the niche) under ultrasound control on the 7th–10th day of the menstrual cycle. Then a cytological, ICC study (using the CD138 marker), a histological, IHC study of the endometrium (using the CD138 marker) was performed. The statistical study was carried out using the IBM SPSS Statistica v22 program (IBM Corp., USA).

Results. In the 1st group (n=30), the prevalence of CE according to cytological and ICC studies was 90% (n=27/30), a normal cytological picture was recorded in 10% (n=3/30); the prevalence of CE according to histological and IHC studies was 80% (n=24/30), of which 37.5% (n=9/24) were diagnosed with an incomplete morphological picture of CE, and 62.5% (n=15/24) a complete morphological picture of CE was revealed, a normal morphological picture was recorded in 20% (n=6/30) of cases. In the 2nd group (n=8), the prevalence of CE according to cytological and ICC studies was 12.5% (n=1/8), a normal cytological picture was recorded in 87.5% (n=7/8); according to histological and IHC studies, CE was not diagnosed, a normal morphological picture was recorded in 100% (n=8/8) of cases. A high degree of consistency of laboratory data was revealed for 2 groups (n=38), p=0.0001. The sensitivity of the cytological method compared with the histological method was 95.83% (95% CI 79.76–99.26%), specificity – 64.29% (95% CI 38.76–83.66%), positive predictive value – 82.14% (95% CI 64.41–92.12%), negative predictive value – 90% (95% CI 59.58–98.21%), the accuracy of the cytological method compared to the histological one was 84, 21% (95% CI 68.06–93.03%).

Conclusion. Secondary infertility in patients with stagnant contents in the projection of caesarean scar niche may be associated with CE. Cytological examination of the endometrium in combination with ICC seems to be a promising method for the laboratory evaluation of CE, given the high correlation with histological and IHC data.

Gynecology. 2022;24(2):88-94
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Predicting recurrence of uterine myoma after carrying out a selective uterine arteries embolization

Timchenko M.A., Kuznetsova T.A., Morozova T.I., Nikolaeva M.G.


Aim. To establish clinic and anamnestic predictors for recurrence of uterine myomas growth after carrying out a selective uterine arteries embolization (s-UAE).

Materials and methods. The one-center longitudinal retrospective cohort study including 366 women with symptomatic uterine myoma, after carrying out s-UAE at 2013–2017. The Control group – 315 patients after s-UAE with absolute reduction of blood-circulation and strong remission for 3 years. The main group – 51 cases of restoration of clinical symptoms and blood-groove after ultrasonography registered absolute reduction and knocking over of clinical symptoms more than two years period. The median of age of control group patients has made 40 years (95% confidence interval – 95% CI 39.0–41.1), the main – 42 years (95% CI 39.0–43.0). In group of comparison it is carried out the analysis of 103 potential risk factors for uterine myomas relapse after s-EMA. For the correlation between uterine myomas relapse and subset quantitative and qualitative signs the model of the logistic regressions was used with a step-by-step elimination of a sign.

Results. Statistically significant risk factors for recurrence of uterine myomas after s-EMA are established: body mass index (BMI) <22,3 (odds ratio – OR 4.03); previous plentiful menstrual bleedings (OR 3.56); the previous hormonal therapy (OR 3.06); hypertension (OR 2.58); chronic cystitis (OR 2.18); dyspareunia (OR 2.22); the conglomerate including 2–3 uterine myomas (OR 1.79); an edge localization of uterine myomas (OR 2.24). Use a logit-models, with inclusion of these specific signs allows to predict uterine myomas growth recurrence after s-EMA in 78.8% cases (95% Cl 0.76–0.83; р<0.0001).

Conclusion. At preoperative consultation stage to patients with symptomatic uterine myoma establishment a combination of criteria "body mass index" (BMI)<22.3, previous plentiful menstrual bleedings and previous hormonal therapy, assumes to refuse carrying out s-EMA in advantage alternative method of treatment.

Gynecology. 2022;24(2):95-100
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Clinical effect of the combination of myoinositol and D-chiroinositol in the ratio 5:1 with manganese and folic acid on female reproductive function in patients with anovulatory infertility in patients with abnormal menstrual cycles and obesity

Tapilskaya N.I., Sazhina I.N., Andreeva M.D., Sorokina O.V.


Aim. Effect of daily use of the combination of myoinositol and D-chiroinositol with manganese and folic acid (Dikirogen®) on the onset of a regular menstrual cycle, ovulation, pregnancy, tolerance and satisfaction of the study participants.

Materials and methods. The study involved 60 women aged 40 years and younger, the average age was 30,93±3,79 years. Duration of taking Dikirogen was 170±3 days, participants observation was 180±3 days. Body mass index, waist circumference (WC), ultrasound of the pelvic organs and ovaries, assessment of hirsutism (Ferryman-Gallway scale), acne severity (Cook questionnaire), depressive symptoms (Hamilton scale), quality of life (SF36 questionnaire) were performed during the study.

Results. The pregnancy rate at the end of the study was 31.7%. During the daily using of the Dikirogen®, there was a decrease in WC (p=0,007), the severity of acne (p=0,002) and the number of points on the Hamilton scale (p=0,04). Also there was a increase in the number of points on the SF36 questionnaire (p=0,0001). 93.33% of the woman has been reported that the Dikirogen® was well tolerated.

Conclusion. Dikirogen® is an optimal doses chemical composition, selected taking into account the synergism of the components and the daily requirement, and it is effective in treatment for women with anovulatory infertility.

Gynecology. 2022;24(2):101-107
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Obstetric and gynecological history and arterial stiffness in women of different age groups

Ivanova O.S., Maychuk E.Y., Yureneva S.V., Voevodina I.V.


Aim. To study the correlation between the features of obstetric and gynecological anamnesis with indicators of arterial stiffness in women of different age groups to assess additional risk factors for the development of cardiovascular diseases.

Materials and methods. The single centre study involved women aged 18 to 65 years. The surveyed 161 women were divided into three groups: 1st group – 52 young women from 18 to 30 years old; 2nd group – 54 women from 31 years old to the onset of menopause; 3rd group – 55 postmenopausal women. The 1 and 2nd groups included women with preserved reproductive function. All women underwent a questionnaire survey, clinical examination, determination of anthropometric data, measurement of cfPWV, determination of arterial stiffness by volume sphygmography, 24-hour blood pressure monitoring with assessment of aortic stiffness and characteristics of the central pulse wave.

Results. In group 1, the early age of menarche was associated with an increase in the rate of morning rise in SBP (r=-0.46, p=0.002) and a decrease in SEVR (r=0.33, p=0.03); the use of combined oral contraceptives correlates with an increase in the Weissler coefficient PEP/ET (R=0.3, p=0.03) and amplification of pulse pressure PPA (R=0.29, p=0.04). A history of 1 or 2 pregnancies is associated with a decrease in arterial stiffness. At the same time, 3 or more pregnancies in the anamnesis create the prerequisites for the formation of arterial stiffness. The early onset of pregnancy pathologies, namely, starting from the 1st or 2nd trimester of pregnancy, is associated with a violation of the characteristics of the reflected wave at a young age and the formation of arterial stiffness in the menopausal period. History of abortions was associated with PWVao (R=0.45, p=0.002), ASI (R=0.43, p=0.002) in group 2. History of miscarriages is associated with SEVR (R=0.52, p=0.00005) and SEVR to HR75 (R=0.27, p=0.04) in the menopausal period.

Conclusion. Pathology of pregnancy, three or more pregnancies in history, early age of menarche, taking combined oral contraceptives, abortions and miscarriages in history are associated with an increase in arterial stiffness in the future, which predisposes women to the development of CVD and should be taken into account for preventive purposes.

Gynecology. 2022;24(2):108-113
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Prophylactic efficacy of recombinant interferon alfa-2b in pregnant women during their stay in the family with SARS-CoV-2 infection: prospective study

Sinchikhin S.P., Stepanyan L.V., Proskurina E.V., Nasri O., Sinchikhina E.S.


Background. The high contagiousness and susceptibility of a pregnant woman's body to a new coronavirus infection requires study not only of etiopathogenesis, but also of developing methods to prevent the development of this disease.

Aim. To evaluate the preventive effectiveness of the use of a drug containing recombinant interferon alfa-2b (IFN-a2b) and an antioxidant complex in pregnant women during their stay in the family focus of a new coronavirus infection.

Materials and methods. 75 pregnant women were under observation, in whose family there were patients infected with the virus that causes a new coronavirus infection. Treatment of sick relatives was carried out at home, as the disease in them proceeded in an uncomplicated form. The main group was formed by 37 pregnant women who treated the nasal mucosa with a preparation containing recombinant IFN-a2b in the amount of 5000 IU and an antioxidant complex (alpha-tocopherol acetate, citric and benzoic acids). The comparison group was formed by 38 pregnant women who did not use any drugs for prophylactic purposes. All patients observed generally accepted rules of personal hygiene and behavior. The duration of prophylactic use of the indicated medicinal product depended on obtaining a negative result for the causative agent of a new coronavirus disease, an infected family member. A smear from the nasopharynx and oropharynx was examined to detect SARS-CoV-2 RNA by PCR once every 5–7 days.

Results. COVID-19 vaccination did not exclude infection with the SARS-CoV-2. Preventive treatment of the nasal mucosa with an IFN-a2b containing drug reduced the risk of infection with this viral agent in vaccinated patients who were in household contact with a patient with COVID-19 by 6 times. Asymptomatic and mild course of a new coronavirus infection was observed in 3 (25%) and 7 (58.3%) patients of 12 infected women from the main group and in 8 (22.9%) and 18 (51.4%) patients of 35 infected women from the comparison group, respectively. Further local use of the drug containing recombinant IFN-a2b and an antioxidant complex contributed to a decrease in the duration of infection and the course of the disease. Progression of COVID-19 was observed in unvaccinated patients with concomitant somatic pathology (diabetes mellitus, iron deficiency anemia, cardiovascular diseases, etc.): 2 (16.7%) and 9 (25.7%) people in groups, respectively.

Conclusion. The use of recombinant IFN-a2b with an antioxidant complex in pregnant women with a family focus of new coronavirus infection is clinically appropriate and highly effective.

Gynecology. 2022;24(2):114-119
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Predictors of Mental health in Pregnant Women: Application of the theory of planned behavior

Jalambadani Z., Hosseini Z.


Aim. The purpose of this study was to predictors of mental health in pregnant women based on theory of planned behavior referred to Iran health centers during the COVID-19 in 2021.

Materials and methods. This study was cross-sectional study thatwas conducted on 250 pregnant women. Pregnant women completed General Health Questionnaire (GHQ) and theory of planned behavior questionnaire. The data were analyzed with SPSS software version 20 (SPSS Inc., Chicago, IL, USA) through running Pearson Correlation statistical tests, descriptive statistics methods including frequency, percentage, mean, standard deviation scores. The Kruskal-Wallis test was used for normally distributed variable. The significance level of the tests was considered to be 0.05.

Results. There was a significant correlation between mental health disorders and some personal and socioeconomic factors. The findings showed that all structures attitude (r=0.69, p<0.001), subjective norms (r=0.58, p<0.001) and perceived behavioral control (r=0.56, p<0.001) and intention (r=0.51, p<0.001) had significant correlations with mental health. Among the variables entered into the regression model, attitude, subjective norms and perceived behavioral control were able to predict 65 percent of variance of mental health among the participants (F=60.75, R=0.66, R2=0.65).

Conclusion. It is necessary to plan for appropriate care in order to prevent the occurrence of mental disorders among this vulnerable group.

Gynecology. 2022;24(2):120-125
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Risk factors for the threat of termination of pregnancy in women with recurrent miscarriage: a suvey-based study

Malyshkina A.I., Grigushkina E.V., Talanova I.E.


Background. Habitual miscarriage remains an urgent problem of modern obstetrics and does not tend to decrease.

Aim. To identify risk factors for the threat of abortion in the first trimester in women with recurrent miscarriage.

Materials and methods. A survey of 353 pregnant women at a gestational age of 5–12 weeks was carried out. The main group consisted of 111 women with signs of the threat of termination at the time of examination and recurrent miscarriage. The control group consisted of 242 women with uncomplicated pregnancy without recurrent miscarriage. Each patient was monitored throughout pregnancy and the postpartum period, the condition of the newborn was assessed according to the medical documentation of the pediatric departments. Statistical data processing was carried out using standard licensed programs Microsoft Excel 2007, the calculation of the odds ratio of risk factors was carried out using the OpenEpi system.

Results. We identified the following risk factors for termination of pregnancy in women with recurrent miscarriage: the age of women over 30; alimentary factors – insufficient consumption of meat, eggs, while more frequent use of alcoholic beverages; burdened obstetric and gynecological history: acute/chronic endometritis, endometriosis; the presence of surgical interventions on the pelvic organs in the history of infertility, ectopic pregnancy, anomalies in the development of the genital organs; the presence of extragenital diseases and their combinations, in particular, thyroid disease.

Conclusion. With the timely identification of significant risk factors, it becomes possible to carry out measures aimed at correcting controllable factors, careful pregravid preparation in order to improve the perinatal outcomes of future pregnancy.

Gynecology. 2022;24(2):126-131
pages 126-131 views

Evaluation of results of combined treatment in patients with disseminated ovarian cancer

Iurova M.V., Khabas G.N., Pavlovich S.V.


Background. According to the modern concept of surgical treatment of ovarian cancer (OC) it is necessary to perform cytoreductive surgery (CRS) without residual tumor in order to achieve more favorable oncological prognoses. However, the possibilities of achieving it with a disseminated process (stages III–IV) are limited, and therefore, for some patients, neoadjuvant chemotherapy (NACT) is the optimal initial treatment.

Aim. To compare the duration of progression-free survival (PFS) of patients with advanced OC after treatment, as well as to assess the value of the prognostic nutritional index (PNI) in predicting this outcome.

Materials and methods. We conducted a retrospective cohort study of 78 patients with stages III–IV OC, who received combined treatment between January 2016 and March 2020 (54 patients after primary CRS (PCRS)+platinum-based chemotherapy (CT), 24 patients after NACT+interval CRS (ICRS)+postoperative CT. The predictive value of the PNI was calculated.

Results. The complete PCRS is associated with increased PFS: after complete PCRS – 32±11.21 months (95% confidence interval – CI 10.09–53.97); after optimal PCRS – 22±3.46 months (95% CI 15.21–28.79); after suboptimal PCRS – 14±7 months (95% CI 0.28–27.72). Performing a complete ICRS is associated with decreased PFS compared to PCRS, even if the complete CRS is achieved: after complete ICRS – 14±3.34 months (95% CI 7.46–20.54); after optimal ICRS – 17±2.16 months (95% CI 12.77–21.23); after suboptimal ICRS – 7 months. PNI≥27.86 correlates with an increased probability of complete PCRS in patients with advanced PCR (AUC 94.3, sensitivity – 80%, specificity – 91.7%; p<0.001).

Conclusion. Achieving complete PCRS in patients with disseminated OC leads to an improvement in the oncological outcome. The prognostic value of pre-treatment calculation of PNI has been revealed: an increased PNI is associated with more favorable perioperative outcomes. Objective criteria should be developed for a strictly reasoned refusal to carry out the first stage of surgical treatment due to the obviously less favorable prognosis of the tactics of "NACT+ICRS+CT".

Gynecology. 2022;24(2):132-139
pages 132-139 views


Bacterial vaginosis as a risk factor for lower urinary tract infection in women: case report

Tevlin K.P., Khanaliev B.V., Tevlina E.V.


Conservative therapy of acute (exacerbation of chronic) cystitis in women in combination with bacterial vaginosis is a task that often causes difficulties for a practicing doctor. Escherichia coli is still the main causative agent of urinary tract infection due to the presence of virulence factors that not only affect the affinity of the pathogen to the urothelium, but also hinder the development of an immune response. At the same time, bacterial vaginosis is a factor that often accompanies and supports inflammation of the lower urinary tract in women. Simultaneous occurrence of the above conditions is a frequent clinical situation. A differential approach is needed to prescribe antimicrobials to patients with urinary tract infection and bacterial vaginosis, as well as the use of safe natural medicines (biologically active additives) in their complex therapy.

Gynecology. 2022;24(2):140-143
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Intrauterine synechiae and chronic endometritis – is there a causal relationship?

Orazov M.R., Mikhaleva L.M., Ismayilzade S.Y., Bezuglova T.V., Lagutina E.V.


Both in our country and around the world, childless marriages currently remain an important medical and social problem, the frequency of which remains high and has no tendency to decrease. One of the main roles in the structure of this condition is the uterine factor of infertility. In the structure of the uterine factor, a separate place belongs to intrauterine synechiae associated with chronic endometritis. The high prevalence, unclear mechanisms of pathogenesis and the lack of a unified approach to therapy determines not only the relevance of the chosen topic, but also the need for an integrated approach to the management of patients suffering from uterine infertility. The article presents modern ideas about the tactics of treatment of patients with infertility of uterine genesis associated with chronic endometritis and intrauterine synechiae, according to domestic and foreign literature.

Gynecology. 2022;24(2):144-149
pages 144-149 views

Personalized tactics in cervical intraepithelial neoplasia of the cervix of varying severity

Pestrikova T.Y., Ismaylova A.F., Yurasova E.A., Tulvinskaya O.S.


Purpose. To study the effectiveness of the drug diindolylmethane for the elimination of human papillomavirus (HPV) of high oncogenic risk in women with cervical intraepithelial neoplasia (CIN) of varying severity.

Materials and methods. Conducted a comprehensive examination of 150 women, aged 20 to 49 years, with the presence of CIN. Verification of the diagnosis was carried out on the basis of data from clinical, cytological, colposcopic, and histological studies. HPV typing was carried out using the PCR (Kvant 21 test).

Results. The obtained results emphasize the feasibility of using complex therapy for CIN of varying severity, including etiotropic correction of chronic cervicitis, with the parallel use of the drug diindolylmethane for 6 months, as well as destruction of the cervix in patients with CIN II–III. The use of the drug diindolylmethane allows, with a statistical degree of certainty, to eliminate HPV of high oncogenic risk in patients with CIN of I–II.

Conclusion. Despite the fact that we did not receive results indicating that it accelerates the elimination of HPV in patients with CIN III (p>0.05), nevertheless, the use of diindolylmethane in patients with CIN III reduces the number of cases (p<0.001) requiring expansion of surgical intervention (amputation of the cervix, extirpation of the uterus), which is important for patients of reproductive age.

Gynecology. 2022;24(2):150-156
pages 150-156 views

Abnormal uterine bleeding. Hemostatic therapy: hematologist point of view

Vinogradova M.A.


Abnormal uterine bleeding (AUB) is a common pathology at the confluence of different specialties, mainly occurring in women of reproductive age. There are two main groups of AUB causes: the structural pathology of the female reproductive system and the functional changes, which include the pathology of the hemostatic system, among other things. Regardless of the severity of manifestations, for the efficacy of the treatment, it is important to establish the certain cause of AUB and to choose the precision therapeutic strategy. However, there are universal therapeutic approaches to provide the hemostatic effect, regardless of the etiology of the process. Fibrinolysis inhibitors, in particular, tranexamic acid, are the basis of this approach.

Gynecology. 2022;24(2):157-162
pages 157-162 views

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