Ukrainian Journal «Health of Woman»

Selection of the surgical intervention in rare cases of ectopic pregnancy: clinical cases

Wed, 20 Nov 2024 00:00:00 +0200

Ectopic pregnancy is a significant problem of modern gynecology. Recently, a new variant of ectopic pregnancy with localization in the area of the surgical scar after cesarean section has appeared. The etiology of cervical pregnancy is still unknown. Both types have a high threat to a woman's life and health. There is certain treatment strategies aimed at preserving fertility. However, the urgency of the situation affects the choice of method and volume of operative treatment.

The aim of the work was to substantiate the adequacy of access and the extent of surgical intervention in patients with ectopic pregnancy according to the clinical situation.

Clinical cases. This article demonstrates 2 cases of ectopic pregnancy that required hysterectomy. In the first case, an emergency hysteroresectoscopy was performed on a patient with vaginal bleeding due to an ectopic pregnancy in the area of the cesarean scar. However, it was not possible to stop the bleeding via coagulation of the vessels due to significant thinning and hypervascularization of the niche area. Therefore, the intervention was expanded to laparoscopy, hysterectomy. The second patient with a cervical pregnancy confirmed via ultrasonography was attended in a severe status due to a hemorrhagic shock clinic. She has been performed a laparotomy and hysterectomy.

The described clinical cases demonstrate that the bleeding and hemodynamic instability of the patient affect the choice of the volume of intervention in rare cases of ectopic pregnancy.

The study was conducted in accordance with the principles of the Helsinki Declaration. Informed consent was obtained from all patients.

The author declares no conflict of interest.

Modern approaches to diagnosis, treatment and prevention of postpartum hemorrhage (literature review)

O.V. Golyanovskiy, R.M. Vorona, I.M. Holenia, D.S. Fedorenko — Wed, 20 Nov 2024 00:00:00 +0200

Postpartum hemorrhage (PPH) remains one of the main causes of maternal morbidity and mortality worldwide, despite the progress of medical science and the introduction of new methods of diagnosis and therapy of hemorrhagic complications during pregnancy, childbirth and the postpartum period.

Aim - to familiarize the general public with the latest recommendations of the International Federation of Gynecology and Obstetrics (FIGO, 2022) and our own experience regarding the most effective and evidence-based methods of diagnosis, therapy and prevention of PPH.

Postpartum hemorrhage is classified into primary (early), which occurs when more than 500 ml of blood is lost during the first 24 hours after childbirth, and secondary (late), which occurs after 24 hours and up to 6 weeks after childbirth. The initial examination of the patient should include a rapid clinical assessment and analysis of risk factors. In order to objectify the volume of blood loss according to FIGO recommendations, the shock index (SI) should be used. Treatment should be directed at the specific cause of PPH (uterine atony, genital trauma, retained placenta and/or coagulopathy), and therapeutic steps should move from a less invasive method to a more complex and radical approach. In the case of refractory PPH, it is necessary to use the most effective modern methods of surgical hemostasis: ligation of the main uterine vessels, compression sutures on the uterus, bilateral ligation of the internal iliac arteries, methods of remodeling the lower uterine segment (LUS-1,2). The paradigm of infusion-transfusion therapy for massive PPH has changed, which is based on the concept of damage control resuscitation (DCR), which is based on warming the parturient, limited use of crystalloids, permissive hypotension tactics, early initiation of blood product transfusion, use of massive blood transfusion protocols, and targeted correction of coagulopathy. PPH prevention strategies include prenatal identification of risk factors, correction of anemia during pregnancy, active management of the third stage of labor, and intravenous administration of tranexamic acid.

Conclusions. The implementation of the latest FIGO recommendations for the prevention, diagnosis, and treatment of PPH in the practice of obstetric facilities in the country will contribute to reducing maternal morbidity and mortality.

The authors declare no conflict of interest.

Modern understanding of the role of vitamin D in the genesis of premature birth (literature review)

I.V. Poladych, D.O. Govsieiev — Wed, 20 Nov 2024 00:00:00 +0200

Preterm births remain one of the most pressing challenges in modern obstetrics, accounting for approximately 70% of perinatal mortality cases among preterm infants. Even those who survive face an increased risk of chronic lung diseases, hearing and vision impairments, and cognitive dysfunctions. The pathophysiology of preterm births is complex and remains insufficiently understood. One of the potential factors influencing preterm birth is maternal vitamin D levels during pregnancy. According to biological assumptions, adequate levels of vitamin D may reduce the risk of preterm births due to its immunomodulatory properties. However, large-scale, well-designed randomized studies are needed to confirm this and to elucidate the mechanisms of vitamin D action.

Aim - to assess the relationship between maternal vitamin D levels during pregnancy and the risk of preterm birth.

The analysis involved a search of scientific publications in databases such as "PubMed," "Google Scholar," "PMC," "Web of Science," and other reputable sources. The review included randomized controlled trials, cohort studies, case-control studies, and review articles. Key search terms included: "preterm birth," "vitamin D," "immunomodulation," and "vitamin D and immune system". Evidence suggests that vitamin D plays a role in regulating the innate and adaptive immune systems. Both "sterile" and "infectious" inflammation are triggers of preterm births, and low levels of vitamin D may exacerbate these processes. Specifically, studies have shown that higher doses of vitamin D reduce the risk of preterm births.

Conclusions. Current research highlights the role of vitamin D in regulating immune functions in reproductive tissues and its impact on pregnancy outcomes. However, the existing evidence is insufficient to determine the optimal vitamin D levels required for positive immune modulation. Additional well-designed clinical studies are needed to establish a causal relationship between vitamin D deficiency, immune system modulation, and improved reproductive outcomes through vitamin D supplementation.

The authors declare no conflict of interest.

Cervical immune changes in women with infertility and post-traumatic stress disorder in the dynamics of treatment

O.O. Karlova, F.E. Blali — Wed, 20 Nov 2024 00:00:00 +0200

More than 48 million couples in the world suffer from infertility, which, in addition to numerous social consequences, also has a psychological impact.

Aim - to study the peculiarities of the cervical local immune status in patients with PTSD and infertility in order to improve the treatment of fertility disorders.

Materials and methods. Cervical concentrations of IL-6, IL-8, lactoferrin and secretory leukocyte proteinase inhibitor were studied, as well as their dynamics during treatment in 112 women with infertility, divided into 3 groups. The Group I - 36 women who had the criteria of post-traumatic stress disorder syndrome, which developed after the diagnosis of infertility, the Group II - 31 women with infertility that arose against the background of post-traumatic stress disorder, Group III - 45 patients with infertility without criteria for post-traumatic stress disorder. For control, 50 healthy women were examined. Groups of infertility were divided into 2 subgroups each. 18 women of subgroup IA and 15 of IIA were treated for infertility according to its cause, 18 women of subgroup IV and 16 of IIV additionally received trauma-based psychotherapy sessions.

Results. All patients with infertility showed an increased content of all studied pro-inflammatory cytokines. After 3 months, patients of subgroups IA and IIA retained an increased content of pro-inflammatory cytokines. The content of IL-8 and lactoferrin after 3 months reached normal values in subgroups IV and IIV, and SILP - only in patients of subgroup IIV.

Conclusions. In patients of all examined groups, the level of IL-6 and IL-8, SILP and lactoferrin in cervical mucus was significantly increased compared to similar values in the control group, which indicates the activation of the anti-inflammatory link of the immunoinflammatory reaction. The highest value of IL-6 and SILP is characteristic of women of group I, lactoferrin - of women of group II. The use of trauma-oriented psychotherapy in the complex treatment of patients with infertility on the background of PTSD allows achieving a more pronounced decrease in IL-8 levels in women of subgroup IA. A decrease in cervical IL-6 and SILP concentrations on the background of psychotherapy was obtained only in women of subgroup IIV, which has a beneficial effect on the implementation of reproductive function.

The study was conducted in accordance with the principles of the Declaration of Helsinki. The study protocol was approved by the local ethics committee of the participating institution. Informed consent of the patients was obtained for the study.

The authors declare the absence of a conflict of interest.

HPV-associated cervical intraepithelial neoplasia: treatment and rehabilitation in perimenopausal women

T.G. Laskava, T.R. Nykoniuk, T.V. Kovaliuk — Wed, 20 Nov 2024 00:00:00 +0200

Optimization of postoperative rehabilitation of women with recurrent of cervical intraepithelial neoplasia (CIN) II contributes to a decrease in the frequency of postoperative complications and an increase in the efficiency of cervical epithelialization.

The aim is to reduce the frequency of complications after destructive treatment of recurrent CIN in perimenopausal women.

Materials and methods. 60 HPV-positive perimenopausal women with verified recurrent CIN II were examined. After radiowave conization, vaginal suppositories with extracts of centella asiatica seeds, calendula officinalis, aloe, tea tree essential oil; hyaluronic acid were prescribed in the Group I (n=30); vaginal suppositories with methyluracil - in the Group II (n=30). The effectiveness was assessed based on complaints, clinical manifestations, degree and duration of cervical epithelialization and complications at 6 weeks and 3 months after treatment.

Results. The high level of subjective comfort feeling at the 6th after operation in the Group I was 86.7% versus 63,4% in the Group II; at the 3rd month - 100% versus 83.3%, respectively. Pain, bloody vaginal discharge, lymphorrhea during the first 1-3 days of the postoperative period and during scab rejection on the 10-15th day were observed in 3-6% of women (Group I) versus 23-26.7% (Group II). A high degree of cervical epithelialization in the Group I occurred on 33.4±1.9 days versus 44.5±3.1 days in the Group II.

Conclusions. Radiowave conization in combination with a blend of herbal extracts for local application proves the high effectiveness of rehabilitation of women with recurrent CIN II compared to traditional management tactics.

The study was conducted in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the local ethics committee of the participating institution. Informed consent was obtained from all patients.

No conflict of interests was declared by the authors.

Evaluation of exocrine pancreatic function in pregnant women with gestational diabetes

L.M. Kupchik, T.V. Tsapenko — Wed, 20 Nov 2024 00:00:00 +0200

Gestational diabetes (GD) is a consequence of physiologically determined insulin resistance in pregnant women aimed for adequate fetal growth maintenance. The frequency of GD has no tendency to decrease. Endocrine and exocrine parts of the pancreas are in anatomical and functional interaction, therefore, investigation of not only pancreatic islet but also acinar complex functioning in women with GD is becoming an urgent issue in modern pregnancy management.

Aim - to investigate the state of pancreatic exocrine function in pregnant women with GD.

Materials and methods. 104 women took part in our research. Serum levels of pancreatic lipase and amylase together with fecal elastase-1 (FE-1) concentration were evaluated. Statistically significant difference between groups was confirmed at the Student's test criterion value p≤0.05.

Results. Pregnant women with GD had significantly lower levels of serum pancreatic enzymes amylase (25.9±7.5 U/l compared to 35.1±6.8 U/l in the control group) and lipase (40.6±9.8 U/l compared to 61.9±10.5 U/l in the control group), as well as FE-1 levels (294.4±64.3 μmol/l compared to 368.1±62.1 μmol/l in the control group). A positive correlation between the level of pancreatic enzymes and the level of FE-1 was established, as well as a negative relationship between the level of FE-1 and pregnancy term.

Conclusions. GD is characterized by a decrease in pancreatic exocrine function, which worsens with increasing gestational term and can be diagnosed by measuring serum levels of amylase and lipase, as well as FE-1.

No conflict of interests was declared by the authors.

Course of the first trimester and the condition of the immune system in pregnant women after application of the assisted reproductive technologies

V.O. Beniuk, L.M. Vygivska — Wed, 20 Nov 2024 00:00:00 +0200

Pregnancy, which is a consequence of the assisted reproductive technologies (ART) application, takes place in specific conditions and is accompanied by numerous complications. One of the factors’ causing infertility is disorders in the immune system (IC), which lead to a pregnancy complication.

Aim - to evaluate the course of the first trimester of pregnancy and determine the state of the immune system in women with tubal-peritoneal infertility whose pregnancy occurred application of the ART.

Materials and methods. 94 women with tubo-peritoneal type of infertility, whose pregnancy occurred as a result ART application, who formed the main group and 50 pregnant women with spontaneous onset and physiological course of pregnancy, who formed the control group, were examined. In addition, determination of the immunological link of homeostasis in all women was performed.

Results. In the first trimester of pregnancy in the main group women took place changes in the T-cell IC link, which was reflected in an increase in the number of CD3+ cells and a decrease in the number of CD8+ cells, which indicated the first degree of immune disorders. Examination of the humoral link in the main group pregnant women revealed a decrease in CD22⁺ cells, an increase in their absolute number together with an increase in the concentration of IgM and decrease in the concentration of IgG.

Conclusions. When analyzing the immune system in pregnant women with tubo-peritoneal type of infertility, a tendency to the formation of immune disorders in both the cellular and humoral links of the immune system due to an increase in the absolute and relative number of T-lymphocytes and a decrease in B-lymphocytes, an increase in the concentration of IgM and a decrease in the concentration of IgG, was established. confirms the activation of cellular and humoral links of the immune system.

No conflict of interests was declared by the authors.

Analysis of modern markers of spontaneous preterm birth

E.V. Petrenko, Yu.O. Dubossarska — Wed, 20 Nov 2024 00:00:00 +0200

Preterm birth (PВ) is an important problem of modern obstetrics and the main cause of morbidity and mortality among newborns worldwide.

Aim - to evaluate the clinical and anamnestic status of women with spontaneous preterm birth and to determine the role of certain haematological parameters and melatonin as prognostic markers of PB, development of pregnancy and delivery complications in such patients.

Materials and methods. The main study group included 57 women whose pregnancy ended in PB at 24-36 weeks of gestation. The control group consisted of 30 patients who had term labour. We studied the obstetric, gynaecological and somatic anamnesis of patients, including the history of pregnancy, childbirth and the postpartum period, clinical and laboratory parameters, including melatonin levels.

Results. Significant differences were found in the frequency of preterm birth in the history, which was reported by 14.0% of women in the main group and none of the patients in the control group. The percentage of women in the main group with a history of 3 or more abortions (artificial and spontaneous) was 4.8 times higher than in the control group. The overall incidence of pregnancy complications in the main group was twice as high as in the control group. The activation of the inflammatory process was confirmed by significantly increased levels of leukocytes (1.3 times) and C-reactive protein (4.9 times) in the blood serum of women in the main group. A 3.5-fold decrease in melatonin in the saliva of women with PB was found compared to the control group.

Conclusions. Among the main risk factors for spontaneous PB were the presence of a history of preterm birth, 3 or more abortions and miscarriages, concomitant gynaecological pathology, as well as a complicated course of pregnancy with cases of threatened abortion in the first and second trimesters and anaemia in the second trimester. The risk of PB was directly associated with increased levels of C-reactive protein, leukocytes, neutrophil/lymphocyte ratio, mean platelet volume and platelet distribution width, and inversely with melatonin production and magnesium levels. This allows us to consider these indicators as possible markers of preterm birth prediction.

The study was conducted in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the local ethics committee. Informed consent was obtained from the patients.

The authors declare no conflict of interest.

Perinatal complications of membrane premature rupture depending on laboratory markers of amniotic fluid

K.V. Tymoshchuk, O.S. Zahorodnia — Wed, 20 Nov 2024 00:00:00 +0200

Premature rupture of membranes complicates up to 10% of all births, but in the case of premature pregnancy it is the cause of one third of premature births.

Aim - to investigate the influence of low glucose concentration and increased creatinine content in amniotic fluid on the course of labor in case of premature rupture of membranes for improvement of management.

Materials and methods. The course of pregnancy in 200 women with premature rupture of membranes was analyzed. The Group 1 consisted of 50 pregnant with preretm gestation and glucose content >0.5 mmol/l, the Group 2 - 50 pregnant with preterm gestation and glucose content <0.5 mmol/l, the Group 3 - 50 pregnant in term and glucose content >0.5 mmol/l and the Group 4 – 50 pregnant in term and glucose content <0.5 mmol/l. Each group, depending on the creatinine content, was divided into subgroups A and B, the subgroup A included women with creatinine <200 mmol/l, and B - >200 mmol/l. In all pregnant women, the frequency of hyperthermia before the onset of labor and during labor, fetal distress and the need for operative delivery were analyzed.

Results. Patients with low glucose levels in amniotic fluid are more likely than those with normal glucose levels to have hyperthermia before labor begins (40% vs. 6% in preterm pregnancy, 64% vs. 10% in term pregnancy). Also noteworthy is the higher frequency of hyperthermia within 12 hours - 26% vs. 4% in preterm pregnancy, 44% vs. 6% in term pregnancy. An increase in creatinine levels against the background of low glucose levels in amniotic fluid in 35.7% is accompanied by fetal distress during labor (in women with normal creatinine levels - no more than 8.3%).

Conclusions. In women with premature rupture of membranes, reduced amniotic glucose concentration increases the risk of hyperthermia before the onset of labor and during labor, as well as other criteria for chorioamnionitis in both full-term and preterm pregnancies. Pregnant women with amniotic creatinine concentration greater than 200 mmol/l and low glucose levels have a higher rate of complications, such as fetal distress and meconium staining of the fluid.

The authors declare no conflict of interest.

Coagulation and hemodynamic parameters in premature and growth restricted fetuses

S.S. Leush, A.G. Ter-Tumasova — Wed, 20 Nov 2024 00:00:00 +0200

Premature birth and fetal growth retardation complicate 20% of pregnancies. Intraventricular hemorrhages cause up to 35% of neonatal losses. There is no complete understanding of the mechanisms of development and ways to prevent these complications.

Aim - to compare the indicators of newborns blood coagulation and fibrinolysis with growth retardation and prematurity, taking into account their hemodynamic prenatal characteristics for differential diagnostic of hemostasis disorders.

Materials and methods. 86 newborns and their mothers were examined. The indicators of pH, fibrinogen and D-dimer in mothers and newborns at 28-34 weeks of gestation after moderate premature birth (MPB group) and with growth restriction (FGR group) and after full-term childbirth (FT) were compared. On the eve of childbirth, hemodynamics of the uterine, umbilical cord and middle cerebral arteries were measured.

Results. The fibrinogen concentration in newborns is 2.29, 2.47 and 2.15 times lower than maternal ones respectively. The ratio of fibrinogen/D-dimer in mothers of the MPB group is 1.02x10³ vs 6.7×10³ and 6.5×10³ of other groups. The ratio of fibrinogen/D-dimer of newborns is 2.0×10³; 1.9×10³ and 3.5×10³ respectively. That is, in the FGR group, fibrinolysis is slowed down by 75-84% compared to MPB and FT. The peak blood flow velocity is higher in the MPB group (pulsatility index 1.99±0.204) with reduced vascular resistance (resistance index 0.87±0.048). The indicators are within the normal range in the FT group (1.17±0.062 and 1.54±0.101, respectively). Vascular resistance in the FGR group is reduced - 0.64±0.062.

Conclusions. The newborns fibrinogen content is up to 2.5 times lower than the mother's, on the contrary, the D-dimer content is 1.5-2 times higher, except for growth restricted newborns. There is a decrease in the D-dimer content in fetuses with growth retardation against the background of slow blood circulation, which indicates a decrease in fibrinolysis.

No conflict of interests was declared by the authors.

Evaluation of the state of glutathione antiperoxidant system of oral fluid in adolescent smoking girls

I.S. Lisetska, V.A. Solohub — Wed, 20 Nov 2024 00:00:00 +0200

The powerful glutathione antiperoxidant system, which is involved in three of the four lines of defence, plays a leading role in providing antioxidant protection in the human body. It is represented by reduced glutathione and enzymes of its metabolism: glutathione peroxidase, glutathione transferase and glutathione reductase.

Aim - to study the state of the glutathione antiperoxidant system of the oral fluid in adolescent smoking girls.

Materials and methods. The study of indicators of the glutathione antiperoxidant system of oral fluid in 137 adolescent girls aged 18 to 24 years was conducted. The level of reduced glutathione was determined by the method of Travina O.V. (1955). The state of the system of glutathione-dependent enzymes was assessed by the activity of glutathione peroxidase - by the method of Vlasova SN et al. (1990); glutathione transferase activity - by the method of Vlasova SN et al. (1990); glutathione reductase activity - by the methods of biochemical studies edited by M.I. Prokhorova (1982).

Results. In adolescent girls who smoke traditional cigarettes, the most pronounced decrease in reduced glutathione activity was observed, which was 2.1 times less than in non-smokers. In participants who regularly smoked electronic cigarettes (vapes), the average activity of reduced glutathione in oral fluid was 3.75±0.02 mlmol/l, and in people who regularly smoked tobacco heating devices (IQOS) - 3.67±0.02 mlmol/l, which was 1.5 times less compared to non-smokers. Changes in the functioning of glutathione-dependent enzymes in the oral fluid of the study participants were also found depending on the presence of a bad habit and type of smoking. The glutathione-dependent enzymes of the oral fluid were characterised by activation of glutathione peroxidase and significant deficiency of glutathione transferase and glutathione reductase.

Conclusions. Thus, the changes in reduced glutathione and the system of glutathione-dependent enzymes of oral fluid in adolescent girls, which occur under the influence of smoking, depend on the type of smoking and are characterised by a decrease in the activity of reduced glutathione, glutathione transferase and glutathione reductase enzymes, as well as activation of the glutathione peroxidase enzyme.

No conflict of interests was declared by the authors.