Clinical and pharmacological rationale for principles of therapy for bacterial vaginosis

Metronidazole and clindamycin have been the main medications for the treatment of bacterial vaginosis (BV) for 60 years. Despite the available arsenal of therapeutic agents, the frequency of disease recurrence remains high, and therefore the search for new therapeutic approaches remains relevant. In 2017, the FDA (Food and Drug Administration, USA) approved the use of secnidazole for the treatment of BV. As a member of the 5-nitroimidazole group, secnidazole differs structurally from metronidazole and tinidazole by radical groups attached to the annular nitrogen next to the nitro group. Structural differences may explain physicochemical and biochemical differences (e.g., tissue distribution, metabolic pathways) between these agents within the same pharmacological class of 5-nitroimidazoles. Secnidazole has the longest half-life compared to other medications in this group, which can significantly increase adherence to treatment, due to the possibility of achieving a clinical effect after a single use and a low incidence of adverse drug reactions, comparable to placebo. Key words: bacterial vaginosis, gardnerella vaginalis, lactobacilli, metronidazole, secnidazole

Diagnosis and surgical correction of isthmocele after caesarean section

Objective. To compare the efficacy of different methods of surgical correction of isthmocele after caesarean section. Patients and methods. The study included 56 patients aged 29–41 years, who were divided into three groups: group 1 (n = 16) – patients who underwent surgical laparoscopy with suturing the uterine wound with single-row separate muscularmuscular sutures; group 2 (n = 23) – patients after repair of the uterus with a double-row continuous seromuscular and muscular-muscular suture performed by laparoscopy; group 3 (n = 17) consisted of patients who underwent laparotomy and suturing the uterine wound with a double-row continuous suture. Results. We developed a three-stage plastic and reconstructive surgical laparotomic and laparoscopic program in case of the uterine scar incompetence, which improved the quality of life in all patients. Pregnancy occurred 9–14 months after plastic and reconstructive surgery on the uterus and resulted in timely surgical delivery in 4 (25%) patients in group 1, in 7 (30.4%) patients in group 2 and in 3 (17.6%) patients in group 3. Two (12.5%) patients in group 1 and three (13.04%) patients in group 2 were observed during pregnancy with a period of 10–28 weeks. Conclusion. The use of laparoscopy ensured better visualization of anatomical structures (vessels, nerves, ureters, bladder), which led to a decrease in intraoperative blood loss, in the risk of damage to adjacent organs and in the development of adhesions, and to accelerated postoperative rehabilitation of patients. Key words: double-row suture, istmocele, laparoscopy, metroplasty

Evaluation of tubal patency using hysterosalpingo-contrast sonography (HyCoSy) following salpingostomy and medical treatment of tubal pregnancy

Objective. Ectopic pregnancy adversely affects the patency of the fallopian tube and consequently the future pregnancy. There are different options of conservative treatment of tubal pregnancy such as methotrexate and salpingostomy [1]. There is little information on the success rate of maintaining tubal patency after methotrexate and salpingostomy [2]. Therefore, the aim of this study is to evaluate the ipsilateral tubal patency using HyCoSy after treatment of tubal pregnancy with methotrexate therapy versus salpingostomy. Patients and methods. This was a case-series study conducted in Ain Shams and Al-Azhar University Maternity Hospitals to evaluate the ipsilateral tubal patency using hysterosalpingo-contrast sonography (HyC0Sy) following salpingostomy and medical treatment of tubal pregnancy. This study included patients who were admitted to Ain Shams and Al-Azhar University Maternity Hospitals for having tubal pregnancy and were treated either with methotrexate or salpingostomy over a 4-year period between January 2017 and December 2020. The patients seeking fertility were re-evaluated for fallopian tubes patency by hysterosalpingogram 3 months after discharge. The study included 2 groups of women: group I (n = 200): women who were treated with methotrexate, and group II (n = 140): women who underwent salpingostomy. Results. HSG was performed in 200 cases of patients with tubal pregnancy who were treated with methotrexate and 140 cases of patients who underwent salpingostomy. The patency of the ipsilateral tube was 85% after methotrexate treatment and 84.2% after salpingostomy. There was no statistically significant difference between the two groups. Conclusion. The findings suggest similar success rate in maintaining the patency of the fallopian tube with either methotrexate or salpingostomy. Key words: ectopic pregnancy, hysterosalpingography, methotrexate, infertility, salpingostomy

Surgical treatment of patients with deep infiltrating endometriosis of the rectovaginal septum

Objective. To optimize the tactics of surgical treatment of deep infiltrating endometriosis of the rectovaginal septum, including with bowel involvement. Patients and methods. The study included 122 patients diagnosed with deep infiltrating endometriosis of the rectovaginal septum, who underwent surgical interventions of different volumes using laparoscopy. The patients were divided into a main group and a comparison group. The main group consisted of 92 patients with deep infiltrating endometriosis of the rectovaginal septum who underwent surgical treatment using the original technique of systematic approach; the comparison group consisted of 30 patients who were operated using the generally accepted technique. Results. There was a statistically significant decrease in the operation duration, intraoperative blood loss, as well as more effective relief of dysmenorrhea and chronic pelvic pain syndrome, less complications and relapses in the main group compared to the comparison group. In addition, it was found that the combination of three symptoms such as dysmenorrhea, dyspareunia and chronic pelvic pain increase the likelihood of deep infiltrating endometriosis up to 93%. Conclusion. Based on the results obtained, the proposed method of surgical treatment of deep infiltrating endometriosis is more efficient and safer in comparison with the generally accepted technique, which can be considered as a valid reason for its wide introduction into clinical practice. Key words: deep infiltrating endometriosis, bowel endometriosis, surgical treatment of endometriosis, treatment algorithm

Chronic endometritis: prevention and treatment options

This article is a review of publications devoted to the treatment of chronic endometritis and methods of its prevention. Methods of empiric therapy, standards of antibacterial therapy, and modern guidelines for treatment under development (colonystimulating factor, immunotherapy, amplipulse therapy) are presented. Key words: infertility, miscarriage, colony-stimulating factor, chronic endometritis, cytokine therapy

Monitoring of patients with cervical intraepithelial neoplasia after excisional treatment

Cervical intraepithelial neoplasia (CIN) refers to precancerous changes in the cervix. After surgical treatment, a certain proportion of patients remain at risk of disease reccurence. Therefore, monitoring of patients after CIN surgery is an important and necessary part of their management tactics. Objective. Review of world literature on modern approaches to patients monitoring after using excisional methods of CIN treatment. Materials and methods. The information material includes data from scientific articles on the subject available in Pubmed and published over the past 20 years. Results. The analysis of data contained in modern literature on the frequency and risk factors for the development of reccurent CIN after excisional methods of treatment, diagnostic methods, the timing of follow-up examinations during post-operative monitoring, the main approaches to monitoring in different countries and the effectiveness of the proposed strategies for postoperative follow-up of patients after treatment was conducted. It was established that the approaches to the observation of this category of patients differ in various countries. Almost everywhere, the priority tool for monitoring of patients with CIN after treatment is a combined test, which involves a joint use of cytology and human papillomavirus tests. The main difference between countries is the timing of the first post-treatment follow-up visit. In some countries a follow-up visit is recommended within 24 months, while in others it is suggested to return to routine screening if the primary combined test is negative. Conclusion. Despite existing disagreements, the proposed post-operative monitoring strategies for CIN patients provide a fairly high percentage of “healing” and return to routine screening. Key words: human papillomavirus, monitoring, cervical cancer, cervical intraepithelial neoplasia, excisional treatment

Morphological features of dichorionic triamniotic triplet pregnancy complicated by intrauterine death of two fetuses in the surrogacy program

A clinical case of management of a pregnant woman (surrogacy) with dichorionic triamniotic triplets, self-reduction of one fetus from triplets in the gestation period of 13 weeks, intrauterine death of the second fetus at week 20 of pregnancy and delivery of the third live fetus in full-term pregnancy. Key words: surrogacy, triplets, multiple pregnancy, intrauterine fetal death, immunological tolerance

Epidemiology of omphalocele: data analysis of regional congenital malformation registers in the Russian Federation

Omphalocele is a congenital malformation belonging to the group of abdominal wall defects. Objective. To determine the incidence of omphalocele and analyze its dynamics for the period 2011–2018 in the regions of the Russian Federation according to monitoring data of congenital anomalies. Materials and methods. Statistical analysis of omphalocele cases among newborns and fetuses with malformations for the period 2011–2018 in 22 regions of the Russian Federation was carried out. The incidence of malformations was calculated per 10,000 births. Results. A total of 1,073 cases of omphalocele were reported from 2011 to 2018, of which 69.34% were in fetuses eliminated due to the prenatal detection of malformation, 27.03% – in liveborn fetuses, and 3.63% – in stillborn fetuses. The male to female ratio was 1.56:1. The overall incidence of omphalocele was 2.95 (95% CI 2.77– 3.13) and the incidence among newborns excluding fetuses was 0.9 per 10,000 (95% CI 0.81– 1.01). There was a statistically significant positive time trend in the dynamics of the overall incidence of omphalocele between 2011 and 2018. Conclusion. The evaluation of the incidence of severe malformation – omphalocele – was obtained in different regions of the Russian Federation for the first time. The incidence of this malformation tended to increase over the study period. Male gender and maternal age over 35 years can be considered as risk factors. These results can be used in planning preventive measures. Key words: congenital malformation, monitoring, newborns, omphalocele, fetuses, incidence, epidemiology

Role of the audit of delivery methods for optimizing the indications for cesarean section and reducing its frequency in clinical practice

Objective. To analyze the frequency of indications for cesarean section (CS) and optimize obstetric tactics on the example of a level 3 perinatal center. Materials and methods. We performed retrospective analysis of 7,672 deliveries. Results. The indications for CS included abnormal labour (150; 6.3%), fetal distress (120; 5%), placental abruption (60; 3%), and narrow pelvis (34; 1.4%). Most often (23%) CS was performed in patients with CS scars. Conclusion. The most important step towards reducing the proportion of CS is the change of the approaches to the use of labour induction methods and assessment of the fetus condition. It is extremely important to develop a comprehensive strategy for choosing an optimal delivery method in women with post-CS scars, as well as to perform thorough analysis of the indications for planned and emergency CS. Key words: caesarean section, Robson classification, efficiency coefficient

Fetal growth restriction: unresolved issues of risk stratification, early diagnosis, and obstetric management

Fetal growth restriction (FGR) refers to pregnancy complications associated with an increased risk of perinatal morbidity and mortality and is defined in the Russian-language literature as the fetal size and weight retardation in relation to the norm for a given gestational age, and in the English-language literature – as the inability of the fetus to realize its genetically determined growth potential. FGR is the cause of 43% of stillbirths of unspecified etiology, and some cases remain undiagnosed even in high-risk populations due to the lack of universal diagnostic standards for this pathology. The review presents a critical analysis of the existing definitions of FGR, the latest data on risk factors, an assessment of diagnostic methods for its early and late forms, the prospects of using biomarkers and instrumental methods of examination in predicting adverse perinatal outcomes, and an algorithm for the management of pregnancy complicated by FGR. For a more complete coverage of the literature and deeper understanding of the nosology, attention is focused on FGR that is not accompanied by preeclampsia and other hypertensive disorders, which occur in about 30% of cases. Key words: placental insufficiency, fetometry, percentile, pulsatility index, fetal growth restriction For citation: Podzolkova N.M., Denisova Yu.V., Skvortsova M.Yu., Denisova T.V., Shovgenova D.S. Fetal growth restriction: unresolved issues of risk stratification, early diagnosis, and obstetric management. Vopr. ginekol. akus. perinatol. (Gynecology, Obstetrics and Perinatology). 2021; 20(5): 76–86. (In Russian). DOI: 10.20953/1726-1678-2021-5-76-86