Vol 24, No 4 (2022)

EDITORIAL

"The memory that warms the hearts" Academician Vladimir I. Kulakov (on his 85th birthday)

Prilepskaya V.N.

Abstract

Уважаемые коллеги!

Вот уже пятнадцать лет с нами нет академика Владимира Ивановича Кулакова. Мне выпала большая честь неоднократно посвящать свои выступления Владимиру Ивановичу: и в его звездные, и в его траурные дни. То, как его провожали в последний путь, какой скорбью утраты был наполнен наш Центр, трудно передать словами. Мне кажется, что аура его присутствия до сих пор сохраняется в аудиториях, в благодарных сердцах коллег, учеников, пациентов, а с 2008 г. и в названии Центра.

Gynecology. 2022;24(4):236-239
pages 236-239 views

REVIEW

Vulvovaginal atrophy: issues of treatment and rehabilitation: A review

Ampilogova D.M., Solopova A.G., Blinov D.V., Achkasov E.E., Petrenko D.A., Korabelnikov D.I.

Abstract

The review presents data on the management tactics of women with vulvovaginal atrophy in patients of reproductive age and menopause. The influence of vulvovaginal atrophy on the psycho-emotional and sexual spheres, modern methods of diagnosis and therapy of this pathology are considered. Special attention is paid to the role of rehabilitation and an integrated interdisciplinary approach to patients with symptoms of atrophic changes in the urogenital tract: the experience of rehabilitation measures is highlighted on the example of foreign and local studies, the effectiveness of "prerehabilitation" at the stage of the period from diagnosis to treatment is indicated. There is still a need for further studies of complex rehabilitation and its implementation in clinical recommendations.

Gynecology. 2022;24(4):240-245
pages 240-245 views

Pathogenesis mechanisms of endometrial polyps in women of reproductive age: a literature review

Orazov M.R., Mikhaleva L.M., Poymanova O.F., Mullina I.A.

Abstract

Endometrial polyp (EP) is a frequent incidental finding during hysteroscopy in asymptomatic patients. To date, the pathogenesis of EPs has not been fully disclosed, which challenges the primary and secondary prevention of EPs and their targeted therapy. It determined the focus of our work. We searched for scientific publications in Cochrane Library, ScienceDirect, PubMed (MEDLINE), eLIBRARY using the keywords "polyps", "endometrial polyps", "pathogenesis", "reproductive age", "recidive" for 2012–2022. Analysis of the literature data allowed us to conclude that ES pathogenesis most likely involves several mechanisms, both estrogen-mediated (hyperestrogenism, including related to impaired progesterone reception and deficiency) and non-hormonal (inflammatory, immune, genetic factors, neoangiogenesis). Hormonal and non-hormonal factors disturb normal cyclic changes of the endometrium during the menstrual cycle, alter the balance and dynamics of proliferation and apoptosis, and initiate neoangiogenesis that serves as a resolving mechanism of polyposis formation, persistence of ES, and their recurrence after surgical removal. The objective of our study was to analyze and summarize the scientific data available on the mechanisms of ES pathogenesis in women of reproductive age.

Gynecology. 2022;24(4):246-250
pages 246-250 views

Prolonged hormonal contraception: current research and practice: A review

Aganezova N.V., Aganezov S.S.

Abstract

This review presents information on demographic processes in Russia and the relevance of highly effective contraception for the prevention of artificial abortion. We present data on the etonogestrel implant (68 mg), an innovative single-stranded subcutaneous implant, a long-acting reversible contraceptive option with high efficacy (Pearl index 0.05) with optimal and typical use of the product. We analyzed the results of the studies that showed a favorable safety profile of the etonogestrel implant with no significant effect on the risks of thrombotic events, metabolic processes, depression incidence, bone mineral density, and characteristics of reproductive function after discontinuation of the drug. The article presents data on possible side effects in the form of changes in the characteristics of menstrual bleeding and a slight increase in body weight, which is comparable with the natural gain in an adult with age. The importance of qualified counseling of patients before and during the use of etonogestrel implants is emphasized.

Gynecology. 2022;24(4):252-260
pages 252-260 views

Prospects of exogenous inositols in maintaining of skin, hair and nails condition: A review

Gromova O.A., Torshin I.Y., Tetruashvili N.K.

Abstract

Myoinositol (MI) and D-chiroinositol (DCI), used in the therapy of menstrual disorders, polycystic ovarian syndrome (PCOS), hirsutism, acne, gestational diabetes, and other diseases, are required for intracellular signal transduction from insulin and other hormone receptors. Clinical practice shows that, for instance, MI and DCI in the treatment of PCOS improve the condition of skin, hair, and nails. These effects of MI and DCI are related to the normalization of insulin signaling and support of differentiation and growth of various skin cell types (keratinocytes, fibroblasts, epitheliocytes, etc.). The effects of MI and DCI on the skin and its appendages, including in wound healing, can be enhanced by manganese, which provides an antioxidant effect and improves the connective tissue matrix of the skin, and folic acid, which is involved in amino acid metabolism, proliferation, and differentiation of dividing cells.

Gynecology. 2022;24(4):261-270
pages 261-270 views

Short courses of antimicrobial therapy for bacterial vaginosis: the possibilities of modern pharmacology: A review

Shikh E.V., Lazareva N.B., Ponomarenko T.M.

Abstract

Bacterial vaginosis is associated with severe infectious and inflammatory diseases and reduces the quality of life in women of reproductive age. Its worldwide prevalence is up to 80%. Thus, the development of new effective and safe methods of antimicrobial therapy becomes an urgent problem.

This article provides a review of current antimicrobial therapies for bacterial vaginosis and evaluates the safety and efficacy of short courses of antimicrobial therapy using combined agents for intravaginal use.

Gynecology. 2022;24(4):271-276
pages 271-276 views

ORIGINAL ARTICLE

The reproductive function of patients with prior atypical endometrial hyperplasia and endometrial cancer treatment: cohort study

Dzhanashvili L.G., Khachatryan N.A., Nazarenko T.A., Biriukova A.M., Dmitrieva I.E.

Abstract

Aim. To define the management of realization of reproductive function implementation in patients experienced atypical endometrial hyperplasia and endometrial cancer IA stage.

Materials and methods. 150 patients aged 21–42 years were included. Among them 78 patients with atypical endometrial hyperplasia (group 1) and 72 – with endometrial cancer IA stage (group 2). General clinical, anamnestic and laboratory examination and follow-up with monitoring of gonadotropins and steroid hormones, as well as pelvic ultrasound supplemented with outcomes of reproductive function and in vitro fertilization (IVF) programs.

Results. It was shown a possibility of spontaneous pregnancy in young patients with regular cycles without other infertility factors with pathomorfosis 2–3 stages and the endometrial receptivity. The practicability of IVF-programs with frozen oocytes and embryo transfer in young women with a lower ovarian reserve and high-risk cancer relapse was demonstrated when their reproductive plan was uncertain.

Conclusion. The reproductive function in patients who experienced atypical endometrial hyperplasia and endometrial cancer IA stage might be realized through a personified approach using assisted reproductive technologies and modified IVF-programs with frozen oocytes and embryo transfer.

Gynecology. 2022;24(4):277-282
pages 277-282 views

Endometrial receptivity during hormonal therapy in women of reproductive age with abnormal uterine bleeding due to ovulatory disorders

Ten A.R., Oboskalova T.A., Vorontsova A.V.

Abstract

Background. After an episode of abnormal uterine bleeding, it is of critical importance to restore endometrial receptivity to prevent the recurrence of abnormal uterine bleeding and implement reproductive plans.

Aim. To study endometrial steroid receptor expression in women of reproductive age after an episode of abnormal uterine bleeding due to ovulatory dysfunction during micronized progesterone or combined oral contraceptive therapy with bioidentical estrogen and dienogest.

Materials and methods. A cohort prospective study was conducted. The study included 70 females aged 18–40 years who were observed with abnormal uterine bleeding due to ovulatory dysfunction at the Department of Obstetrics and Gynecology of Ural State Medical University based at the Yekaterinburg Municipal Hospital №40 from 2016 to 2018. After a bleeding episode, the patients received a combined oral contraceptive with bioidentical estrogen and dienogest or micronized progesterone.

Results. During therapy, variable changes in the expression of estrogen and progesterone receptors in the stromal and glandular components of the endometrium during the 6-month follow-up were observed.

Discussion. Changes in steroid receptor expression and endometrial receptivity during hormone therapy are similar, although certain trends are identified which can guide the choice of hormone therapy.

Conclusion. Due to the lack of complete recovery of steroid receptor expression and endometrial receptivity, even 6 months after hormonal treatment, short courses of hormonal rehabilitation after abnormal uterine bleeding due to ovulatory dysfunction are not sufficient, and permanent hormonal contraception or periodic courses of progestogens are required to prevent a relapse of the endometrial proliferation.

Gynecology. 2022;24(4):283-288
pages 283-288 views

Association of VEGF cytokine levels and single nucleotide polymorphisms of the VEGF-A gene with the genital endometriosis in the female population of the Northwestern Federal District of Russia

Kulikova N.V., Litvinova L.S., Shperling N.V., Ivanov A.V.

Abstract

Aim. To study the association of neoangiogenesis VEGF-A gene polymorphisms C(-460)T (rs833061), C(+936)T (rs3025039) with the risk of genital endometriosis in the population of the Northwestern Federal District; to examine the relationship of polymorphic variants of the VEGF-A neoangiogenesis gene C(-460)T (rs833061), C(+936)T (rs3025039) with the concentration of VEGF-A factor in the blood of females with genital endometriosis.

Materials and methods. Eighty-five female volunteers aged from 19 to 44 (mean age 32.9 (5.8) years) with a histologically confirmed diagnosis of genital endometriosis were included in the stud; also, 79 females without endometriosis according to diagnostic laparoscopy for infertility or ectopic pregnancy, aged 20 to 42 (mean age 32.5 (7.2) years, p=0.71) were included in the study. The obtained data were analyzed using SPSS 20.0 statistical software package; χ2 value and p value were estimated.

Results. In our study, we found an association between the C allele and the CC genotype of the C(+936)T (rs3025039) polymorphism of the VEGF-A gene with genital endometriosis: odds ratio (OR) 2.35, 95% confidence interval (CI) 1.03–4.61, p=0.023; OR 1.89, 95% CI 1.03–4.61, p=0.048, respectively. The TT genotype of the C(-460)T (rs833061) polymorphisms and the TT genotype and the C(+936)T (rs3025039) allele of the VEGF-A gene were less common in patients with genital endometriosis: OR 0.43, 95% CI 0.14–1.29, p=0.023; OR 0.06, 95% CI 0.04–3.18, p=0.001; OR 0.43, 95% CI 0.23–1.29, p=0.023 respectively. The blood concentration of VEGF-A cytokine was lower in patients with genital endometriosis at all genotypes of C(-460)T (rs833061) locus of VEGF-A gene than that in females without endometriosis. The analysis of genotype frequency distribution of polymorphic site C(+936)T of the VEGF-A gene showed that the VEGF-A cytokine level was 1.5 times higher in the comparison group with heterozygous ST genotype versus that in homozygous genotypes. Enzyme immunoassay in the examined females showed a 2.5-fold decrease in the level of the VEGF-A angiogenic cytokine in blood serum in patients with endometriosis compared to those without endometriosis.

Conclusion. To better understand the pathogenetic features of the endometriosis course and to make an individual prognosis of the course and therapy efficacy, an additional analysis of the associations between the polymorphisms of the listed genes and the angiogenesis factor level is required.

Gynecology. 2022;24(4):289-293
pages 289-293 views

Early diagnosis and prevention of pelvic and urodynamic dysfunctions in women after delivery

Mikhelson A.A., Malgina G.B., Lukianova K.D., Lazukina M.V., Lugovykh E.V., Varaksin A.N., Lukach M.A., Nesterova E.A.

Abstract

Background. According to various researchers, obstetric perineal injury is the most commOn complication in childbirth, the frequency of which can vary from 13 to 85%. Currently, vaginal delivery and birth trauma are recognized as the leading risk factors for the development of pelvic, urodynamic and sexual dysfunctions. Urinary and fecal incontinence, pelvic organ prolapse, sexual health disorders, chronic pelvic pain and the presence of cosmetic defects in the perineum are the reasons for a significant decrease in the quality of life of women after delivery. Recently, there has been a tendency to "rejuvenate" dysfunctions of the ligamentous apparatus and muscles of the pelvic floor, which support the pelvic organs in a normal position in women after the first birth. In the absence of timely diagnosis and treatment, anatomical changes and clinical symptoms will rapidly progress, forming persistent dysfunctions of the pelvic organs.

Aim. To evaluate pelvic and urodynamic dysfunctions in women after per vias naturales delivery with concomitant perineal trauma.

Materials and methods. A prospective cohort comparative study was conducted, which included 55 women of reproductive age after delivery per vias naturales of the fetus in cephalic presentation. The main group consisted of 30 women who had a perineal injury during childbirth, the control group included 25 women with uncomplicated straining period. All patients 3–4 months after delivery underwent a gynecological examination with perineometry, ultrasound examination of the pelvic organs, as well as a comprehensive urodynamic study.

Results. Women with a perineal injury during childbirth were significantly more likely to complain of frequent urination and urinary incontinence during physical exertion than women in the control group – 70.0% versus 40.0% and 76.7% versus 40.0% of cases respectively (p<0.05). According to the ultrasound data, the patients of the main group had a significantly more pronounced deviation of the angle α and the angle β during straining in comparison with the control group – 4.67±2.6º versus 2.65±1.1º and 11.93±7.1º versus 7.10±4.7º respectively (p<0.05). Statistically significant differences were also obtained when measuring the strength of the pelvic floor muscles in patients with perineal injury in comparison with the control group – 68.17±5.8 mmHg versus 76.80±5.3 mmHg (p<0.05). According to urofluometry, the patients of the main group showed a statistically significant decrease in the rate of average and maximum urine flow than in the women of the control group – 11.69±3.8 ml/sec versus 17.90±2.1 ml/sec and 20.61±7.0 ml/s versus 25.22±3.1 ml/s respectively (p<0.05).

Conclusion. The results obtained indicate the occurrence of urodynamic and pelvic disorders in women during the first 4 months after childbirth, complicated by perineal trauma. In women who have experienced birth trauma, such pelvic and urodynamic dysfunctions as hypermobility of the urethrovesical segment in 86% of cases, a decrease in the strength of the pelvic floor muscles in 54% of cases, and a decrease in the average urine flow rate in 25% of cases were revealed. These disorders can be diagnosed using available non-invasive instrumental examination methods, such as ultrasound, perineometry and uroflowmetry. Thus, there is a need for early detection of pelvic floor dysfunctions for the purpose of subsequent treatment after childbirth, which in turn will help prevent the progression of genital prolapse and urinary incontinence, prevent their severe forms, reduce the need for surgical interventions and preserve the quality of life of women.

Gynecology. 2022;24(4):295-301
pages 295-301 views

Analysis of risk factors for pelvic organ prolapse in females after hysterectomy

Soloveva O.V., Volkov V.G.

Abstract

Aim. To identify risk factors for pelvic organ prolapse in females after hysterectomy.

Materials and methods. A cross-sectional study from August 2019 to October 2021 in women after hysterectomy for benign neoplasms (n=91) analyzed history, outpatient medical record data, and clinical examination findings. Pelvic organ prolapse was assessed using the POP-Q (Pelvic Organ Prolapse Quantification) international classification. All patients were divided into two groups: Group 1 (n=61) included patients with the pelvic organ prolapse; Group 2 (n=30) included patients without the pelvic organ prolapse.

Results. Post-hysterectomy pelvic organ prolapse was observed in 67% (61/91) patients, including grade 1 in 49.2% (30/61), grade 2 in 36.0% (22/61), and grade 3 in 14.8% (9/61). The significant risk factors include obstetric trauma (41 – 83.7%; odds ratio – OR 5.6, 95% confidence interval – CI 2.1–14.8; p=0.00034), age (49 – 84.5%; OR 19.7, 95% CI 0.599–0.831; p=0.00001) and lifestyle associated with weight lifting (32 – 72.1%; OR 9.8, 95% CI 0.6–3.9; p=0,00267). No statistically significant differences were observed when comparing the prolapse rate with the presence of connective tissue dysplasia and somatic disorders. Analysis of cumulative risk factors showed significant differences; in Group 1, the mean number of risk factors was 4.6±1.6 (95% CI 3.2–6.1), and in Group 2, 2.7±1.8 (95% CI 2.5–3.8), t-test value was 6.76, p<0.001.

Conclusion. Genital prolapse occurs in more than 1/2 of females after hysterectomy. The most significant risk factors are obstetric trauma, age, and a lifestyle associated with weight lifting. The incidence of pelvic organ prolapse increases when several risk factors are combined.

Gynecology. 2022;24(4):302-305
pages 302-305 views

Change of angiogenesis in the nodular form of benign mammary dysplasia during treatment with alkaloids, flavonoids and glycosides

Pokul' L.V., Chugunova N.A., Lebedeva M.G., Sorokivskii I.M., Uriupina A.P., Solov'eva E.A., Utkina A.M.

Abstract

Introduction. The formation of new blood vessels is called angiogenesis. As the tumor grows, the oxygen and nutrient requirements of the abnormal cells continuously increase, and new blood vessels are formed. These processes are disrupted by angiogenesis inhibitors. Therefore, it is warranted to investigate ways to enhance the capabilities of angiogenesis inhibitors – alkaloids, flavonoids, and glycosides.

Aim. To justify the extension of clinical use of alkaloids, flavonoids and glycosides (Conium maculatum and Hydrastis canadensis, Thuja occidentalis), being a part of the complex medical product Mastopol®, taking into account the obtained data on the angiogenic balance in the nodular form of benign mammary dysplasia (BMD).

Materials and methods. The study included 69 volunteers divided into two groups: Group 1 included 27 patients with medical history of surgery for nodular BMD who received antiproliferative preoperative therapy with Mastopol® for 12 weeks. Group 2 (comparison group), n=42, also included patients with medical history of surgery for nodular BMD but without preoperative therapy with the herbal medicine Mastopol®. We studied angiogenesis markers (VEGF-A [vascular endothelial growth factor] and pVEGF-1) and immunohistochemical marker CD34 (cluster of differentiation – CD).

Results. We found a significantly higher (p<0.001) rate of CD34 detection on medium and small caliber vessels in the comparison group, i.e., in the patients who were not treated preoperatively with alkaloids, flavonoids, and glycosides (Mastopol®), while blood supply to the nodules by the medium and small vessels was 1.4 and 1.8 times lower in the Group 1, respectively. Analysis of VEGF expression shows an increase of angiogenic promoters VEGF-A and pVEGF-1 in serum before treatment with biologically active herbal components of Mastopol® in both groups. There were no statistically significant differences in vascular markers. However, a statistically significant decrease in VEGF-A and pVEGF-1 (p<0.001) was noted in Group 1 after Mastopol® therapy. Note the presence of a moderate direct correlation (rs=0.49) of CD34 expression with VEGF-A expression in Group 1 and rs=0.41 in Group 2, which indicated a direct relationship between angiogenesis and proangiogenic factors.

Conclusion. In addition to the proven antiproliferative, anti-inflammatory, cytokine stabilizing, analgesic, and anti-edema properties of Mastopol®, the study also showed the antiangiogenic effect of the herbal drug components. Considering the decreased vascular growth in fibroadenomas during Mastopol® treatment, the indications for its use in patients with fibroadenomas before the surgery can be extended. Specific immunological test to measure VEGF can be proposed as a noninvasive screening method to evaluate the effectiveness of conservative treatment in general clinical practice.

Gynecology. 2022;24(4):306-310
pages 306-310 views

Influence of pregravid preparation on the structural reorganization of the endometrium in women with chronic endometritis in infertility

Smirnova D.V., Gerasimov A.M., Kulida L.V., Verteletskaya T.V., Malyshkina A.I.

Abstract

Aim. To reveal the peculiarities of structural reorganization of the endometrium in various variants of pregravid preparation in women with chronic endometritis (CE) and infertility.

Materials and methods. We examined 90 women aged 18–40 who were treated for CE. For all patients, examination with microbiological (cultural) examination of the cervical canal to be separated for aerobic and facultative anaerobic microorganisms with the determination of sensitivity to antibiotics, ultrasound examination (ultrasound) of the pelvic organs and morphological examination of endometrial biopsy samples before and after treatment. All women of the study group were divided into 2 subgroups. Patients of the 1st subgroup (n=30) received standard treatment for CE – antibacterial and non-steroidal anti-inflammatory drugs; in the 2nd (n=60) – an additional course of immunostimulating therapy with a bacterial lipopolysaccharide preparation was prescribed.

Results. According to the cultural method, repeated cultures from the cervical canal after treatment turned out to be sterile more often in women of the 2nd subgroup. Ultrasound diffuse-focal changes in the subendometrial zone of the myometrium occurred in all patients before and after treatment. In the 2nd subgroup, after treatment, significant changes in the endometrium were noted in the form of an increase in its thickness and a 4-fold decrease in the number of hyperechoic inclusions in the basal layer, as well as the disappearance of the irregularity of the endometrial closure line. In the endometrial biopsies of women of the 2nd subgroup, a significant decrease in the specific area of the inflammatory infiltrate, the absence of foci of fibrosis, and an increase in the thickness of the vessel wall were noted.

Conclusion. The addition of a bacterial lipopolysaccharide to the standard CE treatment regimen not only improves the microbiological environment of the female genital tract, but also significantly affects the morphofunctional state of the endometrium.

Gynecology. 2022;24(4):311-318
pages 311-318 views

IN AID OF THE CLINICIAN

Myo-inositol in the treatment of male factor infertility

Shikh E.V., Grebenshikova L.Y., Zhukova O.V., Bagdasaryan A.A.

Abstract

About 187 million couples worldwide suffer from infertility, with the male factor being diagnosed in 20–70% of cases. The main cause of idiopathic infertility has been recognized as the adverse effects of reactive oxygen species. On the one hand, the cellular antioxidant defense is a highly efficient multilevel system; therefore, the pharmacological targets may vary. On the other hand, antioxidant enzymes (superoxide dismutase, catalase, peroxidase) have high activity and specificity, which limits the pharmacological capabilities of direct antioxidants. Indirect methods, such as the normalization of mitochondrial function, are more promising. Mitochondria play a key role in providing energy for sperm motility (one of the main factors of male fertility). Myo-inositol (MI) derivatives involved in cell signaling regulate intracellular Ca2+ ion levels affecting mitochondrial oxidative metabolism and adenosine triphosphate production. Thus, mitochondrial antioxidants are of particular interest for therapeutic strategies. Currently, various routes and regimens of MI use in the treatment of males with oligo-astheno-teratozoospermia (OAT) are being considered in clinical practice. MI-based oral nutraceutical complexes for the treatment of male factor infertility contain both direct and indirect antioxidants. In vitro studies revealed damage to mitochondrial cristae in the sperm intermediate tract in patients with OAT. Experimental studies have demonstrated that mitochondrial structure is restored when sperm are incubated in an MI-containing medium. Clinical studies confirmed that sperm incubation in such an environment leads to increased sperm motility and viability in patients with OAT. Intravaginal administration of MI showed increased total sperm motility and an increased proportion of progressively motile sperm. It is the progressive motility that is considered the best marker for identifying quality and healthy sperm. This type of sperm is usually used for in vitro fertilization techniques. In addition, intravaginal MI administration improved the quality of cervical mucus and reduced its viscosity and crystallization. The effect of intravaginal MI on cervical mucus can be considered as an additional independent factor in increasing fertility.

Gynecology. 2022;24(4):319-326
pages 319-326 views

Effectiveness of alternative GSM therapies: "twist of fate" or natural evolution?

Orazov M.R., Radzinsky V.E., Dolgov E.D.

Abstract

The study and development of new therapies for genitourinary syndrome of menopause (GSM) remain an area of focus in modern gynecology. The relevance and need for scientific research in this area are undeniable due to the significant negative impact of GSM on patients' quality of life. At this point, however, a great deal of controversy is arising as the knowledge of the treatment of GSM-associated disorders deepens. Local hormonal therapy remains the "gold standard" for vulvovaginal atrophy treatment, but alternative therapies for GSM are launching in the pharmaceutical market. Have we got more answers? Yes. Have we got more questions? Sure. So why does the very fact of studying GMS require us to be so pedantic and focus the attention of the entire global medical community? Let's get to the bottom of this.

Gynecology. 2022;24(4):327-333
pages 327-333 views

CLINICAL CASE

Pregnancy outcome in uterus didelphys: case report

Chechulina O.V., Davliatshina L.R.

Abstract

Most malformations of the female reproductive organs, depending on their features, have a serious impact on reproductive function and the condition of pregnant women. Therefore, all women with uterine and vaginal malformations require counseling in preparation for pregnancy, follow-up during the pregnancy from the early stages, taking into account possible complications, adequate pregnancy management and prevention of complications, as well as fetal monitoring according to gestational age and planning the term and method of delivery.

Gynecology. 2022;24(4):334-337
pages 334-337 views


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