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Vol 11, No 4 (2024)

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Reviews

Fertility potential in patients with ovarian cancer

Dobrokhotova Y.E., Matevosyan T.A., Ilyina I.Y., Narimanova M.R.

Abstract

Malignant neoplasms of the reproductive system are the most common form of oncological morbidity in women, accounting for over 30% of all cancer cases. Most antineoplastic agents act by inducing DNA damage in highly proliferating cancer cells, resulting in oocyte death. Ovarian toxicity is the most common side effect of cancer treatment in young women. Both chemotherapy and radiotherapy have been shown to be toxic to the ovaries, increasing the risk of premature ovarian failure, early menopause, endocrine disorders, and infertility. Patients who have undergone cancer treatment have severe follicular atresia, even if they have a regular menstrual cycle.

Currently, the most effective methods of preserving fertility in cancer patients include cryopreservation of oocytes and embryos after ovarian hyperstimulation. Other fertility preservation methods include ovarian tissue cryopreservation, follicle or embryo maturation in vitro, ovarian transposition, ovarian suppression, and adjuvant therapy.

Despite promising fertility prospects, iatrogenic infertility is one of the most undesirable adverse effects of cancer therapy for young women. Timely referral to a gynecologist prior to chemotherapy or radiation therapy is key to successful fertility preservation. Women should be aware of the available opportunities of assisted reproductive technologies, along with potential risks and failures with regard to their age, stage of disease, and treatment method. At this stage, it is necessary to develop well-defined and effective algorithms for oncologists, obstetrician-gynecologists, fertility specialists, and embryologists.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):385-394
pages 385-394 views

Uterine scar after caesarean section: principles of healing and evaluation criteria

Gulyaeva M.A., Zhilkina A.A., Bokieva D.S., Panina O.B.

Abstract

Caesarean delivery results in the formation of a uterine scar. Inadequate scar healing and subsequent formation of an incompetent uterine scar tissue are common complications that may lead to the abnormal uterine bleeding, painful menstrual periods, and secondary infertility. In pregnant women, an incompetent scar may cause life-threatening complications, such as uterine rupture at any gestational age or placenta increta at the scar level.

Given the potential dangers of uterine scars, numerous recent studies have focused on identifying risk factors and understanding the pathophysiology of incompetent scar formation, as well as developing diagnostic methods. Early diagnosis is essential in maintaining women’s health and well-being and preventing complications in subsequent pregnancies. Unfortunately, there is currently neither exact understanding of the pathophysiological mechanism of uterine scar formation, nor unambiguous guidelines on some aspects of its diagnosis after caesarean section.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):395-405
pages 395-405 views

Bacterial vaginosis biofilms: a target for therapeutic innovation

Rossolovskaya K.A., Trifonova N.S., Gadaeva I.V., Spivak L.G.

Abstract

Bacterial vaginosis (BV) is one of the most common vaginal microbiome abnormalities worldwide and a risk factor for various obstetric and gynecological complications.

Despite years of exploration, existing and quickly emerging clinical, laboratory and instrumental diagnostic methods, and progressive development of science in general, the etiology and pathogenesis of BV remain poorly understood. This is evidenced by the high incidence of chronic and/or recurrent course. There are standard therapeutic approaches aimed to eradicating the causative agent, but the level of efficacy remains questionable due to recurrent episodes. Therefore, further studies of this problem are warranted. Actually, it is evident that G. vaginalis forms polymicrobial biofilms on urogenital tract mucosa.

Biofilms represent associations of microorganisms that are adhered to the surface of the epithelium and connected together in the polymer matrix. Biofilms change the properties of the microorganisms involved into their structural frame and provide beneficial conditions for their interactions. This results in the increase of the existing pathogenic properties of bacteria associated with BV, as well as in the appearance of new features. Thus, the microorganisms become less susceptible to previously effective antibiotics and to aggressive media. Finally, this contributes to the recurrent course of the disease.

In most cases, treatment of BV is based on the immediate effect on the microorganisms, but in patients with confirmed biofilm-associated BV this strategy is not effective and is associated with BV recurrences. Thus, currently relevant issues include exploration of the causes of recurrent BV, development of anti-biofilm agents able to disrupt their matrix and release bacteria from their carcass, and introduction of these agents into clinical practice. This will increase the effectiveness of treatment.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):406-415
pages 406-415 views

Current challenges in diagnosing gestational breast cancer

Sadrtdinova R.F., Malikova E.V., Ponomarev A.V., Agzamova A.A., Kireev D.I., Ramazanova D.S., Amirova J.V., Tadzhibova Z.I., Ibragimov I.I., Akhmetova E.A., Kagramanyan V.R., Zeinalova N.A., Khashegulgova M.M.

Abstract

Gestational (pregnancy-associated) breast cancer is diagnosed during pregnancy, within the first postpartum year, or while breastfeeding. Delayed diagnosis and treatment, often due to low physician awareness and the complexities in interpreting diagnostic data to assess the severity of disease, contribute to the poor prognosis of this condition. Russian literature concerning the diagnosis of gestational breast cancer is very limited. Therefore, further exploration of this issue is relevant. The aim of this review is to analyze existing literature on diagnosing gestational breast cancer. A search of PubMed, eLibrary, and Google Scholar was conducted using keywords such as “гестационный рак молочной железы,” “рак молочной железы,” “рак молочной железы, ассоциированный с беременностью,” “беременность,” “кормление грудью,” “лактация,” “МРТ,” “КТ,” “маммография,” “УЗИ,” “биопсия,” “диагностика,” and their English correlates “gestational breast cancer,” “breast cancer,” “pregnancy-associated breast cancer,” “pregnancy,” “breastfeeding,” “lactation,” “MRI,” “CT,” “mammography,” “ultrasound,” “biopsy,” and “diagnosis.” Gestational breast cancer remains a serious challenge for modern medicine. Various methods are employed in diagnosing and treating this disease, including needle aspiration biopsy, fine-needle biopsy, and surgical biopsy. Ultrasound plays a crucial role in monitoring the response to neoadjuvant chemotherapy and assessing regional lymph nodes. Advanced imaging techniques, such as ultrasound elastography, contrast-enhanced ultrasound, and the hybrid PET/MRI technique, may enhance the diagnosis and management of gestational breast cancer. The use of non-contrast diffusion MRI in pregnant and breastfeeding patients is an intriguing area for future research.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):416-429
pages 416-429 views

Original study articles

Modern approaches in combined surgical treatment of complex forms of genital prolapse

Bryunin D.V., Ishchenko A.I., Pyatkina A.N., Chushkov Y.V.

Abstract

BACKGROUND: Despite the existence of a considerable number of techniques for surgical correction of genital prolapse, patients and doctors cannot be always sure regarding the efficacy of surgical treatment in achieving satisfactory results. As was the case many years ago, the issues of improving the efficacy, reliability and safety of surgical treatment of genital prolapse, as well as the intent to generate individual treatment approach, taking into account the type of prolapse and medical condition of women, remain pertinent.

AIM: The objective of this study is to develop surgical techniques for patients with complex types of pelvic organ prolapse, including women with unfavourable general medical condition.

MATERIAL AND METHODS: A comprehensive clinical examination and surgical treatment of 20 patients with II–IV stage pelvic organ prolapse according to the POP-Q classification, who exhibited similar nosological forms of prolapse but disparate comorbidity status, was conducted. Group 1 included 11 patients with complex pelvic organ prolapse who underwent combined laparoscopic pectopexy. Due to the presence of decubitus changes of the cervix and adverse general status, a two-staged strategy was chosen for nine patients of the Group 2, i.e. laparoscopic correction of apical prolapse — uterine suspension with the use of titanium tapes — at the first stage, and modified Manchester (Moscow) operation with the use of titanium tape, colpoperineorrhaphy with levator ani muscles plication — at the second stage.

RESULTS: The results of the questionnaire indicated that all patients reported a notable improvement in their quality of life and social integration. In all patients, the symptoms of pelvic organ prolapse significantly improved, and no signs of disease recurrence were present.

CONCLUSION: The findings suggest that the proposed surgical techniques for treating pelvic organ prolapse are a viable, efficacious and secure option. They offer swift recuperation and reliable rehabilitation. These techniques have the potential to improve both the physical and social well-being of patients. The described surgical techniques help to restore the normal anatomical position and functions of the organs.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):430-439
pages 430-439 views

Treatment strategies in different phenotypic forms of bacterial vaginosis

Dobrokhotova Y.E., Kazantseva V.D., Ozolinya L.A., Savchenko T.N.

Abstract

BACKGROUND: Bacterial vaginosis represents the most prevalent non-inflammatory syndrome affecting the lower genital tract in women. It is associated with significant complications in obstetric and gynecological practice. At present, the only recommended treatment regimens for bacterial vaginosis include antibiotics (metronidazole and clindamycin), which have been observed to have only short-term effects. Recurrence of bacterial vaginosis occurs in 50–80% of cases within a year of completing treatment. This may be attributed to the distinctive characteristics of the vaginal microbiome and the fact that following antibiotic treatment, beneficial strains of Lactobacillus spp., such as L. crispatus, are unable to recolonize the vagina. In the absence of an efficacious and long-term treatment, clinicians and scientists are investigating alternative approaches to the management and prevention of this syndrome. This has led to a rapid evolution in the understanding of the etiology of bacterial vaginosis and of the best patient care. Current research in this field is focused on the use of antiseptics, probiotics, prebiotics, transplantation of the vaginal microbiome, pH modulation and biofilm disruption as potential treatments for bacterial vaginosis.

AIM: The objective is to identify the species of vaginal Lactobacillus and the genotypes of Gardnerella vaginalis in women before treatment of bacterial vaginosis and after administration of a one-step antibacterial regimen in comparison to a two-step therapy with suppositories containing at least 10⁷ live Lactobacillus acidophilus or a lactic acid-glycogen complex.

MATERIAL AND METHODS: A prospective, comparative, randomized study was conducted in 90 women aged 18 to 45 years old diagnosed with bacterial vaginosis based on the molecular genetic characteristics of the vaginal microbiota. The patients were randomized to one of three groups, with 30 subjects in each. Group 1 received only antibiotic therapy, Group 2 received antibiotic therapy concomitantly with a suppository containing ≥107 live Lactobacillus acidophilus, and Group 3 received antibiotic therapy concomitantly with lactic acid and glycogen. Clinical and laboratory efficacy of the treatment was assessed at the end of Week 4.

RESULTS: The results showed that four weeks after treatment, all study groups experienced favorable changes in the symptoms and signs, normalization of vaginal pH, and improvements in molecular genetic testing. These effects were more pronounced in Group 2 patients.

CONCLUSION: The combination of antibiotic therapy with lactic acid and glycogen demonstrated high clinical efficacy and good tolerability. However, further studies are needed to assess the long-term results of this treatment approach.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):440-448
pages 440-448 views

Use of titanium implants in the surgical treatment of complete uterine or vaginal prolapse in elderly and senile patients after hysterectomy

Ishchenko A.I., Chushkov Y.V., Ishchenko A.A., Khokhlova I.D., Dzhibladze T.A., Komarova A.D., Tevlina E.V., Moskvicheva A.P., Koryagina A.D., Baburin D.V.

Abstract

BACKGROUND: With increasing life expectancy, the need to improve the quality of life in elderly and senile women has become more urgent. Pelvic organ prolapse is a significant concern, particularly because this pathology tends to progress in the postmenopausal period. Surgical treatment of pelvic organ prolapse using only the patient’s own tissues often results in recurrence of the disease. This highlights the need for developing new surgical techniques that utilize durable and biologically inert materials, such as titanium implants.

AIM: The objective of this study is to analyze the effectiveness and reliability of surgical correction of complete uterine or vaginal prolapse after hysterectomy in elderly and senile women.

MATERIAL AND METHODS: A total of 65 women, aged between 65 and 86 years old, were examined and underwent surgery using two newly developed original surgical techniques. Group I (31 patients) underwent surgery with the use of a titanium mesh implant, while Group II (34 patients) underwent surgery with the use of a combination of the aforementioned mesh implant with two non-absorbable ligatures.

RESULTS: The outpatient follow-up was carried out on Months 1, 6, 12, 24, 36 and 48 after surgery. The comprehensive examination, comprising questionnaires, gynecological examination and transperineal post-surgery ultrasound, demonstrated that the surgical treatment was satisfactory, as evidenced by an improvement in the women's quality of life. During Month 1 after the surgery, 32 patients (49.2%) reported intermittent perineal pain and/or aches in the area of the inguinal folds, while 15 patients (65.0%) experienced frequent attempts to urinate. These symptoms abated with time. No recurrences of the disease or mesh-associated complications were recorded during the follow-up period.

CONCLUSION: The study demonstrates the efficacy and reliability of newly developed surgical techniques for treating complete uterine and vaginal prolapse after hysterectomy in elderly and senile women. The accumulated clinical experience attests to the fact that severe pelvic organ prolapse in elderly patients with concomitant somatic diseases can be successfully treated via surgical intervention. This has the potential to relieve women from the range of symptoms associated with the disease and normalize the functioning of pelvic organs. The introduction of such surgeries into clinical practice will improve the quality of life of elderly and senile patients.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):449-459
pages 449-459 views

Correlation between inflammatory biomarkers in biological fluids in patients with ovarian endometriosis

Mangileva Y.A., Kudryavtseva E.V., Polushina L.G., Shakiryanova E.I., Potapov N.N., Kovalev V.V.

Abstract

BACKGROUND: To date, there are no available screening techniques allowing to distinguish groups of women with the risk of endometriosis. Therefore, many researchers are searching for meaningful biomarkers for non-invasive diagnosis. The peritoneal fluid is subject to multidirectional changes in patients with external genital endometriosis, although its sampling requires invasive procedure. Testing of the inflammatory markers in saliva is a simple and safe method of particular interest, given that its sampling is non-invasive.

AIM: To assess the correlations between the level of inflammatory biomarkers in the peritoneal fluid and saliva in patients with ovarian endometriosis.

MATERIAL AND METHODS: A prospective cohort comparative study of 46 women with ovarian endometriosis was carried out. Inclusion criteria: confirmed diagnosis of ovarian endometriosis; age between 18 and 40 years; written informed consent for surgical intervention and for participation in the study; no prior hormonal treatment. Non-inclusion criteria: patient's refusal to participate in the study; age below 18 and above 40 years; contraindications for surgical treatment; oral inflammatory diseases. Patients were excluded if the diagnosis could not be visually confirmed during surgery or if there were histological discrepancies. All patients underwent laparoscopic cystectomy. Peritoneal fluid samples were collected during surgery. Mixed unstimulated saliva was collected before surgery in the morning, on an empty stomach. The levels of interleukins and of vascular endothelial growth factor were assessed in biological fluids.

RESULTS: The mean age of the study subjects was 32,4±6,1 years. Correlation analysis showed a direct statistically significant moderate relationship between the levels of IL-6 (r=0.548; p=0.001) and IL-8 (r=0.360; p=0.026) in the peritoneal fluid and saliva, respectively.

CONCLUSION: These data suggest that the onset and progression of endometriosis are associated with the increase of inflammatory cytokine levels both in the peritoneal fluid and in saliva. This may serve a potential tool for diagnosis and assessment of the severity of endometriosis. Evaluation of IL-6 and IL-8 levels in saliva may be useful in clinical practice in patients with external genital endometriosis.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):460-469
pages 460-469 views

Long-term pharmacotherapy in patients with uterine myoma: assessment of effectiveness

Sinchikhin S.P., Magakyan O.G., Sinchikhina E.S.

Abstract

BACKGROUND: Uterine myoma is one of the most prevalent gynecological diseases. Data concerning the effects of the medicinal agents used in patients with uterine leyomyomas, are both scientifically and practically important.

AIM: This study aims to assess the clinical, laboratory, and instrumental effectiveness of 5-year use of micronized oral contraceptive containing estrogen and progestogen, intrauterine levonorgestrel-releasing system and progesterone receptor modulator in patients with uterine myoma.

MATERIAL AND METHODS: Patients aged from 21 to 40 years old were assigned to 3 arms in accordance with the treatment regimen. Group 1 included 42 women with myomas ≤2 cm in diameter. These patients received combined oral contraceptive pills containing ethinylestradiol 20 mcg and desogestrel 150 mg according to the conventional contraceptive regimen, i.e. one pill daily, 21-day courses with following 7-day pauses. Group 2 included 34 women with uterine myoma and concomitant uterine endometriosis. In this group, the intrauterine devices containing levonorgestrel were inserted. Group 3 included 33 patients treated with the progesterone receptor modulator in order to reduce the diameter of uterine myomas. They received oral mifepristone at a dose of 50 mg daily for three months, followed by a 3-month pause and subsequent 3-month course of treatment. During the year, two cycles that included 3-month treatment course and 3-month treatment-free period, were repeated. All patients underwent standard clinical, laboratory and instrumental gynecological examination. Statistical processing was performed in the basis of Statistica 12.0 software.

RESULTS: In Group 1, 80.9% of patients exhibited unchanged mean diameters of uterine myomas all over the course of treatment with contraceptive drugs, 16.7% of patients demonstrated growth of myoma (by 15%), while in 2.4% of patients myoma reduction (by 5%) was observed. In Group 2, the increase in the diameter of leiomyoma ranged from 20 to 30 percent was observed following the insertion of intrauterine levonorgestrel-releasing system in 58.8 percent of patients. In contrast, 35.3 percent of patients exhibited no change in myoma size, while a decrease by 15 percent was observed in only 5.9 percent of patients. In Group 3, 10 intermittent 3-month courses of mifepristone (50 mg) resulted in the reduction of uterine myoma by 40%–50% of the baseline diameter in 97.0% of patients. In general, the study drugs demonstrated beneficial effects and safety in patients with leiomyoma.

CONCLUSION: The long-term use of low-dose oral contraceptives generally leads in the stabilization of the size of uterine myomas, while intrauterine levonergestrel-releasing system prevents their intensive growth. Nevertheless, the use of a drug belonging to the progesterone receptor modulator class, has proven to be the most effective approach to reducing the size of myomas.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):470-479
pages 470-479 views

Risk factors for the onset of cervical intraepithelial neoplasia

Anisimova M.A., Shcherbakova L.N., Bugerenko A.E., Jain M., Kirillova K.I., Samokhodskaya L.M., Panina O.B.

Abstract

BACKGROUND: Persistent human papillomavirus (HPV) infection is a well-established cause of cervical intraepithelial neoplasia (CIN). Epidemiological studies show that while HPV infection is common, it is far more prevalent than CIN itself. Consequently, HPV testing exhibits moderate specificity and positive predictive value for detecting high-grade CIN. Currently, there is no optimal strategy for identifying HPV-positive women at high risk of CIN.

AIM: This study aims to assess the socioeconomic, behavioral, and comorbidity factors associated with an increased risk of developing cervical intraepithelial neoplasia.

MATERIAL AND METHODS: The study included 121 women who presented to the Medical Research and Education Center of Moscow State University in the period from 2022 to 2023. Pap-smear revealed normal data in 66 women (Group 1, NILM), mild cervical intraepithelial neoplasia in 27 (Group 2, LSIL), and severe cervical intraepithelial neoplasia in 28 (Group 3, HSIL). A comparative analysis of clinical data and medical history, data of liquid cytology and HPV typing was performed in all patients. Statistical analysis was performed using the MedCalc software package.

RESULTS: The analysis showed that the risk of severe cervical intraepithelial neoplasia increased 5.4-fold in patients aged >30 years, 3.4-fold in smokers, 9.9-fold in patients who had been sexually active for more than 10 years, 6.3-fold in patients who had ≥4 sexual partners, 4.1-fold in patients who used withdrawal method of contraception (coitus interruptus), 7.0-fold in patients who had ≥3 pregnancies, 4.7-fold in patients with HPV infection (in particular, 4.3-fold in women infected with HPV 16). Patients with cervical intraepithelial neoplasia had significantly greater probability to be infected with high-risk HPV types (88.9% in patients with LSIL and 85.7% in patients with HSIL vs. 56.1% in NILM women), in particular, HPV 16 was detected in more than half of patients with HSIL.

CONCLUSION: In this study sample, the risk of cervical intraepithelial neoplasia was associated with age over 30 years, smoking, duration of the sexual activity >10 years, number of sexual partners (>4), lack of barrier contraception, number of past pregnancies (>3), and persisting high-risk HPV infection, especially HPV 16.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):480-489
pages 480-489 views

Clinical case reports

Pregnancy vomiting obscuring other disease: a clinical case of Wernicke encephalopathy

Sinayskaya E.A., Zemlina N.S., Murashko A.V., Zinovieva O.E., Prokhorov D.E.

Abstract

The article presents a clinical case of Wernicke encephalopathy occurring as complication of excessive pregnancy-related vomiting (hyperemesis gravidarum). This disorder has developed due to thiamine (vitamin B1) deficiency. The correct diagnosis is challenging due to the similarity of clinical manifestations with several other disorders. Timely diagnosis and early treatment reduce the risk of severe course and irreversible complications that can lead to the potentially adverse outcome. This case is remarkable due to the appearance of the disease in a 32-year-old pregnant woman with excessive vomiting. The patient demonstrated the classic symptom triad found in only 16% of patients with Wernicke encephalopathy. Primarily ataxia and nystagmus appeared, and later memory impairment with confabulations was recorded. Magnetic resonance imaging of the brain revealed bilateral symmetrical areas with increased MR signal intensity in T2 (SE and FLAIR) sequences in the mediodorsal nucleus (MD) of thalamus, subependymal microglia of the III ventricle, and periaqueductal gray. The treatment of Wernicke encephalopathy was immediately initiated with the use of intravenous thiamine 200 mg 3 times daily. The beneficial treatment effect was reported. Further pregnancy proceeded unremarkably and resulted in the birth of a live term girl. During the postpartum period, the patient reported persisting instability when walking, which increased with closed eyes, and non-systemic dizziness.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):490-498
pages 490-498 views

Simultaneous tumors: ovarian cancer in a patient with multiple myeloma

Gadaev I.Y., Gadaeva I.V., Rossolovskaya K.A., Bochkarnikova O.V., Sokolova I.Y.

Abstract

Multiple myeloma is the second most common hematological malignancy, accounting for approximately 1% and 10–15% of malignant tumors of the hematopoietic and lymphoid systems, respectively. Until recently, the diagnosis of multiple myeloma was inherently associated with unfavorable prognosis of overall survival. On the one hand, advanced diagnosis techniques and the development of new treatment approaches have led to the improved life expectancy and significant reduction of mortality of patients with multiple myeloma. On the other hand, the medical and research communities have encountered a previously unknown issue: the combination of multiple myeloma with other types of cancer. This combination sets a task of multidisciplinary approach in the diagnosis and requires development of patient management strategy and prognostic parameters of the outcome. Some researchers adhere to the theory of independent tumor appearance in patients suffering from multiple myeloma, while other authors suppose that multiple myeloma and secondary cancer virtually represent multiple primary malignant neoplasms. This article presents a clinical case of postmortem verification of ovarian cancer in a patient with recurrent multiple myeloma.

V.F.Snegirev Archives of Obstetrics and Gynecology. 2024;11(4):499-506
pages 499-506 views