Vol 24, No 5 (2022)

Aim. To optimize preoperative diagnosis of infiltrative forms of genital endometriosis.

Materials and methods. We analyzed the results of the preoperative examination and surgical treatment of 667 patients from 22 to 49 years old (31.4 [27.3; 34.2]) with external endometriosis presented with pelvic pain, dysmenorrhea, dyspareunia (n=580), and primary or secondary infertility (n=215). The duration of the disease ranged from 1 to 16 years. Seventy-eight (11.69%) patients had a history of surgery for external endometriosis. The serum concentration of the CA-125 tumor marker was measured by immunochemiluminescence assay. Colonoscopy was performed in 655 cases, and cystoscopy in 66 cases. In addition, pelvic ultrasound was performed for all patients. Pelvic magnetic resonance imaging (MRI) was performed with an intravenous bolus injection of a contrast agent.

Results. Patients with endometrioid ovarian cysts (n=564) and "minor" forms of endometriosis (n=44) predominated. Endometrioid infiltrates occurred in 59 (8.84%) patients. In the group of patients with infiltrates, 18.64% had a history of surgery for endometriosis; 5.7% had a recurrence. Patients with retrocervical endometriosis and endometriosis of uterosacral ligaments predominated among females with infiltrative forms. No statistically significant differences in CA-125 concentration between patients with and without infiltrates were observed. The infiltrate was revealed, and its topography was described in 49 (83.05%) patients using ultrasound and 56 (94.81%) patients using MRI. All patients with dysuria had ultrasound, MRI, colonoscopy and cystoscopy.

Conclusion. The combined use of pelvic ultrasound and MRI provides high accuracy in diagnosing infiltrative endometriosis.

Aim.To prove the safety and efficacy of using the ultrasonic cavitation of saline to restore the endometrial receptivity, local immune balance, and antioxidant status in females with chronic endometritis (CE) and a history of reproductive losses.

Materials and methods. Fifty females aged 29.95±7.65 years (range 23–38 years) with histologically and immunohistochemically confirmed CE were examined. The control group included 45 female patients aged 28.98±9.9 years (range 23–38 years) with infertility of tubal-peritoneal genesis without histochemical studies confirming CE and with no history of reproductive losses. Transvaginal pelvic ultrasound was used in the study. All the patients had histological, immunohistochemical examination of endometrial scrapings, including quantification of CD138⁺, CD20⁺, CD56⁺, progesterone receptors (PR), and estrogen receptors (ER) in the stroma and glands. The following cytokines were measured in protein-free fractions of uterine cavity contents by ELISA: interleukin (IL)-2, IL-10, IL-8, tumor necrosis factor-α, IL-1β, interferon-γ, interferon-α. The activity of lipoperoxidation factors and antioxidant system enzymes (catalase, superoxide dismutase, glutathione peroxidase) was detected by spectrophotometry. As a part of the treatment, irrigation of the uterine cavity with sonicated 0.9% sodium chloride solution was applied twice in 6 sessions consecutively within three months.

Results. According to transvaginal pelvic ultrasound, the endometrial thickness before treatment was 6.54±1.2 mm. An increase in endometrial thickness up to 9.02 (7.62–10.42) mm in the luteal phase of the next cycle and up to 9.34 (8.12–10.56) mm in the two subsequent luteal phases was observed within three months after irrigation of the uterine cavity with sonicated normal saline. The normalization of the ЕR/PR ratio and decrease in CD138⁺, CD20⁺, and CD56⁺ cells in the endometrial stroma and glands were noted. Mature pinopods were revealed in 71.25 (67.29–74.46)% of patients, which is 2.95 times more than the respect value before the treatment, 24.55 (21.43–27.75)%. After treatment, a recovery of cytokine production was noted: IL-2, IL-10, tumor necrosis factor-α, IL-8, IL-1β, interferon-γ, interferon-α; concentration of primary, secondary and tertiary products of lipoperoxidation decreased; superoxide dismutase enzyme activity increased by 36.98 (32.88–41.18)%, catalase by 15.32 (14.13–16.51)%, glutathione peroxidase by 12.32 (11.12–14.2)%; р<0,005. Reduced colonization rate of Streptococcus spp, Enterococcus faecalis, Escherichia coli, elimination of Mycoplasma genitalium, Ureaplasma urealyticum, and increased of Lactobacillus spp. were reported.

Conclusion. Using the cavitated normal saline restores the endometrium structure, normalizes the ЕR/PR ratio, reduces the colonization by opportunistic and pathogenic microorganisms in the uterine cavity and normalizes the cytokine balance and the content of pro-oxidative and anti-oxidative factors. High clinical and immunological efficacy supports cavitated solutions in the complex treatment of infertility in females with CE.

Aim. To perform a comparative evaluation of different methods for preventing functional constipation in pregnant women.

Materials and methods. The study included 150 pregnant women aged 18 to 42 years, 22 to 36 weeks of gestation, with functional constipation. Group 1 included 50 patients who received dietary fiber OptiFibre in addition to diet therapy; group 2 included 50 patients who received diet therapy in combination with lactulose; group 3, the control group, included 50 pregnant women who received corrective diet therapy only. The outcomes were evaluated on day 14 of observation.

Results. A diet only was not sufficiently effective in normalizing stools in pregnant women with a gestational age of 22–36 weeks. By day 14, stool frequency was restored in groups 1 and 2 patients. However, during lactulose use, gastrointestinal discomfort persisted more frequently; not all patients reported normal stools at the medium recommended dose, which required an increase of the dose. However, there were episodes of loose stool, which required discontinuation of the medicine. The best results were achieved with the combination of diet and partially hydrolyzed OptiFibre dietary fibers, both in terms of restoration of stool regularity, relief of associated gastrointestinal symptoms, and tolerance of the dietary fibers.

Conclusion. Soluble dietary fiber OptiFibre, combined with diet therapy, restores regular stools and resolves constipation in pregnant women. It is well tolerated and safe to use in obstetric practice. The findings suggest using OptiFibre for constipation in pregnant women.

Aim. To evaluate the hormonal parameters and embryological outcomes of an ovarian stimulation protocol using dydrogesterone to prevent the premature LH surge in IVF/ICSI programmes.

Materials and methods. A prospective study randomised, including 79 women with normal ovarian reserve undergoing ovarian stimulation for IVF/ICSI with recombinant FSH (rFSH) from Day 2 or 3 of the menstrual cycle. To prevent the premature LH surge, participants in Group 1 (n=38) received oral dydrogesterone 20 mg/day from the start of ovarian stimulation until the day of ovulation trigger administration. Participants in Group 2 (n=41) received a GnRH antagonist. We evaluated the starting and total dose of gonadotropins, duration of stimulation, serum levels of LH, oestradiol and progesterone on Day 1 and 6 of stimulation and the day of trigger administration, number of retrieved and mature oocytes, fertilization rate, and the number of blastocysts and cryopreserved embryos.

Results. There were no significant differences in most hormonal parameters, characteristics of the ovarian stimulation and embryological outcomes between the two groups. Serum levels of progesterone in the dydrogesterone arm were higher than in the GnRH antagonist arm (2.3 nmol/l [2.0–3.4] vs 1.5 [1.0–2.4] nmol/l; p=0.026), but without any impact on the embryological outcomes.

Conclusion. Prevention of premature LH surge in ovarian stimulation cycles using oral dydrogesterone may represent a convenient alternative to the conventional use of GnRH antagonists, reducing the number of required injections and potentially increasing the convenience in patients who are not planning a fresh embryo transfer.

Aim. To investigate the associations of matrix metalloproteinase (MMP) MMP3 (rs679620), MMP8 (rs1940475), and MMP9 (rs17576 and rs3787268) gene polymorphisms with different biological subtypes of breast cancer (BC).

Materials and methods. The study sample consisted of 285 patients with BC of various biological subtypes (luminal A and B [n=153], triple negative [n=108], and HER2 positive [HER2+, n=24]) and 746 females in the control group. Genotyping of four polymorphic sites of MMP3 (rs679620), MMP8 (rs1940475), and MMP9 (rs17576 and rs3787268) genes was performed in the study groups.

Results. The role of MMP gene polymorphisms in the BC development of various biological subtypes differs. The c.836 A>G MMP9 polymorphism (rs17576, the odds ratio is 0.67–0.71 for the G allele) has a protective effect on the development of luminal A- and B-subtypes of BC; susceptibility to triple-negative BC is associated with the polymorphic site c.1331-163 G>A MMP9 (rs3787268, OR 4.51 for genotype AA), and two polymorphisms of the MMP3 (c.133 T>C, rs679620, OR 0.46–0.49 for T allele) and MMP8 (c.259 T>C, rs1940475, OR 0.37–0.48 for T allele) genes are associated with HER2+ BC development. According to the in silico data, the above polymorphisms have pronounced functional effects in organs and tissues that are pathogenetically significant for the disease, including the target organ, the breast.

Conclusion. The c.836 A>G MMP9 (rs17576) polymorphism is associated with luminal A- and B-subtype of BC; c.1331-163 G>A MMP9 (rs3787268) is associated with triple negative BC, and c.133 T>C MMP3 (rs679620) and c.259 T>C MMP8 (rs1940475) are involved in HER2+ BC development.

Chronic endometritis remains one of the most controversial issues of modern gynecology. The high relevance of research in this area is confirmed not only by the high prevalence but also by the extremely negative impact of this disease on the reproductive potential of patients. The complexity of the pathogenesis mechanism of the chronic inflammatory process of the endometrium stimulates the genuine interest of the world gynecological community to study the main patterns of endometrial receptor disorder, including implantation status and repeated reproductive failures. In this regard, it is essential to summarize the accumulated results of worldwide research to find the most optimal and effective diagnostic and therapeutic approaches.

The problem of extrapulmonary tuberculosis (EPT) remains urgent since, along with a decrease in the incidence of the disease, there is an increase in the number of neglected, late diagnosed cases. Female genital tuberculosis (FGT) is a relatively rare disease difficult to diagnose, occurring on average in 0.5–2.0 cases per 100,000 population; in recent years, an increase of EPT in this localization has been observed. Tuberculosis can affect any organ of the female genital system, either single or in combination. The most frequently involved are the tubes (95–100%), endometrium (50–60%), ovaries (20–30%), cervix (5–15%), myometrium (2.5%) and vagina/vulva (1%). The most common symptom of FGT that makes patients seek medical advice is infertility. Other symptoms of FGT include menstrual irregularities (oligo-, hypo-, dis-, amenorrhoea as well as meno- and metrorrhagia), pelvic pain, and abnormal vaginal discharge. In postmenopausal women, FGT is characterized by symptoms resembling endometrial malignancy, such as postmenopausal bleeding, persistent leukorrhea, and pyometra. The diagnosis is based on a thorough history, clinical examination, and proper examination of the sample material obtained by endoscopy. Tuberculin test with intradermal injection of 2 TU of tuberculin (Mantoux test) was positive in 42.6% of patients with genital tuberculosis. Hysterosalpingography is an important method for diagnosing FGT, which assesses the internal structure of the female reproductive tract and the patency of the fallopian tubes. On ultrasound, the fallopian tubes may appear dilated, thickened, or filled with serous discharge (hydrosalpinx) or caseous mass (pyosalpinx). Laparoscopy and dye hydrotubation are reliable tools for the diagnosis of genital tuberculosis, especially for the involvement of the fallopian tubes, ovaries, and peritoneum. Microbiological examination of sampled material in FGT using solid media is low-informative; polymerase chain reaction and other molecular diagnostic methods should be used. It should be acknowledged that FGT is not a rare condition, but it is often overlooked. The two main reasons for late diagnosis are vague clinical signs and low alertness. Since infertility is a frequent complication of FGT, all infertile women should be screened for tuberculosis: tuberculin, ultrasound, hysterosalpingography, and in complicated cases, diagnostic laparoscopy with obligatory tissue sampling for pathomorphological and microbiological studies.

Background. A "Method of cervical incompetence treatment in pregnant women" (RF patent for invention №2746437, priority dated December 25, 2019) is presented. Method details are described.

Aim. To evaluate the efficacy and safety of the novel cervical incompetence (CI) treatment method in pregnant women.

Materials and methods. The study included 150 pregnant women divided into three groups, with 50 subjects in each group. Group 1 included pregnant women with CI who received the novel treatment method (narrowing of the dilated cervical canal with a flexible tape with a fixation lock); Group 2 included pregnant women who underwent surgical correction of CI (U-shaped sutures to the cervix); Group 3 included pregnant women with the initial stage of CI, in whom obstetric pessaries were used. Patients in the groups were comparable in age, reproductive behavior, somatic diseases, and obstetric and gynecological history.

Results. After CI correction, different early complications were observed in 20, 66, and 34% of pregnant women by groups, respectively. The novel method of narrowing the dilated cervical canal with a flexible loop with a fixation lock is technically a simpler manipulation than surgical suturing of the cervix with a prolapsed amniotic sac. Clinical signs of threatening miscarriage in subsequent gestational periods occurred in 22% of patients in Group 1, 64% of Group 2, and 28% of Group 3. Full-term delivery was reported in 88, 68, and 84%, respectively.

Conclusion. The novel method of CI correction is technically simple, clinically- and cost-effective. Furthermore, this method does not involve using medications that can affect the pregnant woman and the fetus.

The article summarizes the published data on the prevalence, pathogenesis, features of clinical presentation, and treatment of myasthenia gravis and myasthenic crises. Particular attention is paid to the anesthesia method choice and perioperative management of patients with myasthenia gravis. A clinical case of successful combined spinal-epidural anesthesia for complete repeat cytoreductive surgery in a patient with moderate myasthenia gravis is presented.