Intrauterine Intervention Research Articles

A UTERINE RUPTURE NOT TO OVERLOOK IN THE CONTEXT OF RETROPLACENTAL HEMATOMA

Objective: To report a rare case of uterine rupture in the context of a Couvelaire uterus in a patient with no history of uterine surgery or manipulation and to discuss the clinical challenges and management strategies for such cases. Case Summary: A 34-year-old multiparous woman presented at 34 weeks gestation with intrauterine fetal death (IUFD) and preeclampsia. Despite an unremarkable history with no prior cesarean deliveries or intrauterine interventions, she developed sudden hemodynamic instability and was diagnosed with uterine rupture during an emergency laparotomy. Intraoperatively, a large posterior uterine rupture was identified and repaired. Postoperatively, the patient experienced uterine atony and significant hemorrhage, necessitating additional surgical interventions including Tsirulnikov ligation and the B-Lynch uterine compression technique. The patient recovered well following intensive care management. Discussion: Uterine rupture in an unscarred uterus is an exceedingly rare event, particularly in the absence of classic risk factors. This case occurred in the context of a Couvelaire uterus, where extensive intramyometrial hemorrhage due to placental abruption may have weakened the uterine wall. The nonspecific clinical presentation, including the absence of abdominal pain or vaginal bleeding, poses diagnostic challenges. Immediate surgical intervention is crucial, especially in low-resource settings where advanced treatment options may be limited. This case underscores the importance of maintaining a high index of suspicion for uterine rupture, even in patients without typical risk factors, and highlights the need for adaptable management strategies. Conclusion: Uterine rupture should be considered in the differential diagnosis of acute abdomen in pregnancy, regardless of the patients obstetric history. Early recognition, prompt surgical management, and flexible treatment strategies are essential for optimizing outcomes in such rare but potentially life-threatening situations. Further studies are needed to improve understanding and management of this rare complication.

Challenges of Diagnosis and Management of Congenital Chylothorax in a Low-Resource Setting: A Case Report

Chylothorax is a form of pleural effusion. In the neonate, it may be diagnosed in the antenatal or postnatal period. Congenital forms of chylothorax are due to abnormal development or obstruction of the lymphatic system and may be associated with hydrops foetalis; it may also be idiopathic or associated with chromosomal anomalies. The diagnosis is usually based on biochemical analysis of pleural aspirate, and the interpretation of the biochemical parameters depends on whether the baby is feeding. The treatment involves dietary modification, the use of different types of drugs, chest tube drainage, pleurodesis or some other surgical intervention. There are no clinical trials to document the most effective treatment modality. Intrauterine interventions have been reported in some cases. We report a case of neonatal chylothorax to document the diagnostic challenges and management outcomes in a resource-limited setting.

The effectiveness of pulsed magnetic therapy, high-intensity magnetic stimulation of the pelvic floor muscles and intrauterine plasma therapy to restore endometrial receptivity after intrauterine interventions in patients of different age

Abstract. Objectives. Advanced age is the cause of female infertility. Restoring endometrial receptivity, especially after intrauterine interventions in women of different reproductive ages, is an unsolved problem of modern rehabilitation. The aim of the study was to evaluate the effectiveness of non-drug methods for restoring endometrial receptivity after intrauterine interventions in women of different reproductive ages. Material and methods. A prospective study was conducted with the participation of 120 women planning pregnancy and undergoing various surgical interventions for endometrial diseases. All patients were randomly divided into three equal groups according to the method of exposure: group 1 — patients received combined pulsed magnetic therapy and intrauterine plasma therapy of the endometrium; group 2 — patients underwent high-intensity magnetic stimulation of the pelvic floor muscles andintrauterine plasma therapy of the endometrium; group 3 — patients underwent pulsed magnetic therapy. Subsequently, in eachgroup, the patients were divided by age into two subgroups: up to 34 years and over 35 years. Results. According to the medical history, patients in the advanced age group were characterized by a significantly greater amount of pathology and a less active lifestyle. The pregnancy rate is twice higher in patients under 34 years of age. Normalization of the menstrual cycle and the rate of increase in blood flow through the uterine arteries occurred twice as fast in younger patients than in older ones. Endometrial thickness and normalization of pipell biopsy data after a course of treatment with high-intensity magnetic stimulation of the pelvic floor muscles and intrauterine plasma therapy were statistically significantly higher in the group of patients under 34 years of age. An increase in the speed of blood flow through the uterine arteries in patients over 35 years of age occurs more effectively with the help of pulsed magnetic therapy and intrauterine plasma therapy of the endometrium. Conclusion. Endometrial receptivity restoration in patients underwent intrauterine interventions using combined non-pharmacological methods is safe and effective. In patients under 34 years of age, the technique of choice may be high-intensity magnetic stimulation of the pelvic floor muscles with intrauterine plasma therapy. In patients over 35 years of age, the method of pulsed magnetic therapy with intrauterine plasma therapy of the endometrium is more effective.

Optimization of intrauterine interventions in spontaneous abortion

Introduction. Retained products of conception (RPOC) are detected in 15 % of women after spontaneous or medical abortion. RPOC blind removal from the uterine cavity remains the "gold standard" of surgical treatment, which, however, may be associated with a high risk of certain complications that pose a serious threat to female reproductive function and quality of life. An alternative method for eliminating RPOC proposed by operative hysteroscopy demonstrating the visual control advantages.Aim: to evaluate clinical effectiveness and safety of RPOC removal in incomplete spontaneous abortion using hysteroscopic morcellation.Materials and Methods. The prospective comparative study included 135 women with incomplete spontaneous abortion aged 18 to 40 years, divided into 3 groups: group 1 – 42 patients after RPOC electromechanical vacuum aspiration (EVA); group 2 – 44 patients after RPOC manual vacuum aspiration (MVA); group 3 – 49 patients after RPOC hysteroscopic morcellation (HM). In all patients, the level of total endotoxin was measured, metroaspirate cytokine profile was analyzed, the indicator of endometrial microcirculation was assessed before surgical treatment and on day 1 afterwards, and genital ultrasound examination was performed on day 3–5 post-surgery.Results. In the post-surgical vs. pre-treatment period, the EVA and MVA groups revealed significantly increased levels of total endotoxin and interleukin (IL) IL-1β (p < 0.05). In contrast, these parameters in the HM group changed insignificantly (p > 0.05). In all groups, IL-8 and tumor necrosis factor alpha (TNF-α) levels after surgery were significantly elevated (p = 0.001). In the EVA and MVA groups, levels of anti-inflammatory cytokines IL-4 and IL-10 were markedly decreased (p = 0.001), which did not change in the HM group (p > 0.05). A significantly accelerated microcirculation rate was noted in the EVA and MVA groups while comparing it at pre-surgery level (p = 0.001), but not in the HM group (p = 0.415). Incomplete RPOC removal was reported for 4.5 % MVA patients, all EVA and HM patients had total RPOC elimination. Intraoperative bleeding, uterine perforation were not reported in any examined patient.Conclusion. The early-stage treatment results showed that RPOC removal by the HM is an effective and safe approach. Limited inflammatory response and stable endometrial microcirculation upon using the HM evidence about a minimal impact on the endometrium that lowers probability of postoperative adhesion.

Exploring the Prospects of Antenatal Microcoil Embolization of Giant Placental Chorioangioma: Case Report and Review of Literature

AbstractGiant placental chorioangiomas, which measure more than 4 cm, are associated with adverse maternal, fetal, and neonatal outcomes, with an estimated perinatal mortality of 30 to 40%. Early diagnosis, close prenatal surveillance, intrauterine intervention, and timely delivery would play a vital role in improving pregnancy outcomes. Using conventional treatment options like amniodrainage to reduce intrauterine pressure and intrauterine blood transfusion to correct fetal anemia fails to tackle the underlying pathophysiology. Interventions aimed at devascularizing the tumor, such as injection of alcohol or surgical glue, use of bipolar cautery, placement of vascular clips, interstitial laser, and radiofrequency ablation, have had mixed results due to their invasive nature and associated complications. In this case report, we discuss a minimally invasive, percutaneous, extraamniotic method of focal occlusion accomplished by microcoil embolization of the feeding vessel. The combination of slow blood flow and endothelial vessel damage due to the presence of coils stimulates thrombogenic mechanisms, contributing to the formation of a clot and leading to the cessation of blood flow to the chorioangioma, thereby treating the primary pathology.

Comparative analysis of endometrium after using levonorgestrel-releasing intrauterine system and copper intrauterine device

BACKGROUND: To date, the risks of pelvic inflammatory diseases, including chronic endometritis, associated with the use of various intrauterine contraceptives, have remained debatable. AIM: The aim of this study was to conduct a comparative analysis of the endometrial status in women of reproductive age after the use of copper- or levonorgestrel-releasing intrauterine device. MATERIALS AND METHODS: Morphological and immunohistochemical studies of endometrial biopsies obtained by aspiration Pipelle biopsy were performed after intrauterine device extraction in 18 patients who used a copper-containing intrauterine device and in 12 women who used the levonorgestrel-releasing intrauterine device Mirena. Monoclonal mouse antibodies to CD20, CD138, and α-smooth muscle actin (DAKO, Denmark) were used. Criteria for inclusion of patients in the study are reproductive age, use of an intrauterine device for five years, absence of complications associated with the intrauterine device during its use. Exclusion criteria are a history of pelvic inflammatory diseases, sexually transmitted infections, habitual miscarriage, two or more intrauterine interventions. RESULTS: After using a copper-containing intrauterine device, signs of chronic inflammation were found in the endometrium such as cytogenic stroma fibrosis with pronounced infiltration by inflammatory cells, positive expression of CD138 (33.3% of observations), CD20 (88.9% of observations with an average number of 27.4 ± 5.7), α-smooth muscle actin (up to 70% of the cytogenic stroma area), and the presence of lymphatic follicles consisting of B lymphocytes (33.3% of observations). During the use of the levonorgestrel-releasing intrauterine device, decidual transformation of cytogenic stroma cells, as well as secretion and atrophy of the glandular epithelium, were found in the endometrium. CD20-positive cells were detected in five out of 12 cases (41.6% of observations with an average number of 12.8 ± 4.6). Expression of CD138 and α-smooth muscle actin was not detected in any of the cases. CONCLUSIONS: The use of a copper-containing intrauterine device is associated with a high risk of developing chronic endometritis. The absence of signs of chronic inflammation in the endometrium after the use of a levonorgestrel-releasing intrauterine device is probably due to the protective effect of levonorgestrel on the uterine mucosa. Thus, levonorgestrel-releasing intrauterine devices, in comparison with copper-containing intrauterine devices, have a favorable safety profile relative to the endometrium and can be recommended for women of reproductive age, including those who have not given birth.

Perinatal Outcomes of Intrauterine Interventions for Fetal Sacrococcygeal Teratoma Based on Different Surgical Techniques-A Systematic Review.

Background: This study aims to evaluate the outcomes of fetal sacrococcygeal teratoma (SCT) submitted to prenatal interventions. Methods: We performed a systematic literature review of fetal SCT patients and compared the outcomes between open fetal surgery and percutaneous intervention. In addition, we also compared the results of SCT fetuses who did not undergo any surgical intervention (NI). Results: We identified 16 cases of open fetal surgery (OS), 48 cases of percutaneous fetal intervention (PI), and 93 NI patients. The survival rate was 56.2% in OS, 45.8% in PI (p = 0.568), and 71.0% in NI patients. The gestational age at delivery was earlier in cases where there was no survival compared to cases where the fetuses did survive across all evaluated cohorts (OS: p = 0.033, PI: p < 0.001, NI: p < 0.001). The gestational weeks at delivery in OS and PI fetuses were more similar; however, OS tended to be performed later on in pregnancy, and the affected fetuses had more severe presented findings. In our evaluation, we determined that the presence of fetal hydrops and cardiac failure had no significant impact on survival in SCT cases. In NI patients, polyhydramnios was much higher in fetuses who did not survive compared to their surviving cohorts (p < 0.001). Conclusions: In conclusion, gestational age at delivery can affect the short-term prognosis of fetuses affected with sacrococcygeal teratomas. Regardless of the mode of delivery or the necessity for intervention during the fetal period, monitoring for complications, including polyhydramnios, can prevent premature delivery.

Examination of Risk of Depression and Perception of Social Support in Pregnant Women Undergoing Intrauterine Intervention.

Interventions during pregnancy might increase the risk of depression becausethey may cause anxiety and stress in the mother. In these cases, it is important to provide social support to pregnant women. This study aimed to determine the relationship between the risk of depression and the perception of social support in pregnant women who had undergone intrauterine intervention (IUI). The population of this descriptive study consisted of all pregnant women (n = 267) who attended a state hospital in Izmir between March and September 2022 and who had undergone IUI. Data were obtained using a sociodemographic data form, the Beck Depression Inventory (BDI), and the Multidimensional Scale of Perceived Social Support (MSPSS). Descriptive statistics and the Chi-square test were used in the study. In this study, of the women, 42.7% had ≥3 pregnancies; the gestational week of 93.6% of the pregnant women was between 13-24 weeks. The mean scores of the pregnant women were 11.12 ± 8.04 on the BDI and 61.06 ± 19.84 on the MSPSS. According to the results of the correlation analysis, there was a weak (<0.05) negative reverse correlation between the scales. In the results of this study, it has been determined that as perceived social support increases in pregnant women, symptoms of depression are less likely to occur. This result is important in terms of indicating the need for providing social support to pregnant women. Women should be able to identify depression risk factors during this process to receive appropriate care and support.

Intrauterine interventions options for preventing recurrence after hysteroscopic adhesiolysis: a systematic review and network meta-analysis of randomized controlled trials.

Recurrence of adhesions after hysteroscopic adhesiolysis is a challenging clinical problem without a unified management approach. Therefore, we conducted a network meta-analysis that considered both direct and indirect comparisons between interventions to identify optimal strategies for preventing recurrence. We searched for research trials published up to July 2023 from PubMed, Embase and the Cochrane Database. We selected randomized controlled trials comparing the use of different interventions for the prevention of adhesion recurrence, with no language or regional restrictions. We used random-effects models to assess odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CI). Adverse events associated with the interventions were also assessed. This study was registered on PROSPERO, CRD42023449068. Data from 21 randomized controlled trials involving 2406 patients were synthesized, including interventions with balloon, amnion, platelet-rich plasma (PRP), intrauterine device (IUD), hyaluronic acid (HA), platelet-rich fibrin (PRF), and granulocyte colony-stimulating factor (G-CSF). The top 5 interventions for change in AFS scores were: PRP + Balloon (MD = 5.44; 95% CI, 2.63-8.25), Amnion + Balloon (MD = 5.08; 95% CI, 2.71-7.44), IUD + Balloon (MD = 4.89; 95% CI, 2.49-7.30), HA + Balloon (MD = 3.80; 95% CI, 1.78-5.82), and G-CSF + Balloon (MD = 3.84; 95% CI, 1.05-6.63). There were no statistically significant differences between interventions in the recurrence rate of moderate-to-severe uterine adhesions and the clinical pregnancy rate. Most interventions were safe. To our knowledge, this is the most comprehensive network meta-analysis to date of interventions for preventing postoperative intrauterine adhesion recurrence. Our results indicate that PRP + Balloon seems to be the most effective approach.

The role of CD138 immunohistochemical marker in the diagnosis of chronic endometritis: causes of female infertility

This article focused on “The role of CD138 immunohistochemical marker in the diagnosis of chronic endometritis: causes of female infertility”. Aims: The aim of the study was to assess the diagnostic efficacy of CD138 in identifying chronic endometritis among infertile patients with endometrial pathology and to examine the association between CE and various factors related to infertility. Methodology: A cross-sectional observational study exploring the utility of the CD138 immunohistochemical marker in diagnosing chronic endometritis and its association with infertility in a sample of 63 couples. The t-test, chi-square test and logistic regression was applied using SPSS 26. Results: The study examined infertility characteristics and chronic endometritis in 63 infertile woman with pathology of endometrium. Results also established a significant association between CE and CD 138 presence, suggesting CD 138 as a potential diagnostic marker for CE. Additionally, the age was identified as a notable factor linked to CE. Factors such as abortion history, intrauterine interventions, delivery experiences, and cervical pathology, mycoplasma infections were found to have a significant correlation with CE. The logistic regression indicated a lower likelihood of CE in certain infertility types. It also identified a significant association between increased CE odds and longer fertility duration, while specific causes of fertility had a modest impact. Overall, CD 138 demonstrated its diagnostic potential for CE, age was associated with CE, and certain factors correlated with CE, emphasising the complexity of CE etiology in infertility patients with endometrial patology. Scientific Novelty: A Gateway to Understanding Female Infertility Conclusion: In conclusion, the research findings underscored the significance of CD 138 as a diagnostic marker for chronic endometritis in infertility patients. The age emerged as a notable factor associated with CE, while specific qualitative factors like delivery history exhibited a correlations with CE status, warranting further investigation

A systematic review of early intrauterine intervention at 12 + 0 to 16 + 6 weeks in twin reversed arterial perfusion sequence

There is some evidence that in twin reversed arterial perfusion sequence, intervention at early gestational age could prevent a spontaneous death of the pump twin, achieving a better global survival. ObjectiveTo review the perinatal outcomes of early intervention in pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence. Study designA comprehensive search from inception to December 2022 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported intervention in twin or triplet pregnancy complicated with TRAP sequence at 12 + 0 to 16 + 6 weeks of gestation were eligible. A descriptive and bivariate analysis was performed. ResultsOut of the 222 full-text articles, 44 studies reporting 108 cases of early intervention in TRAP sequence were included. A successful procedure was achieved in 105 (95.5 %) interventions: 89 (94.7 %) among twin pregnancies and 16(100 %) among triplet pregnancies. An overall livebirth rate was achieved in 75 patients (70.8 %): intrafetal laser group 55 (73.3 %), radiofrequency 10 (76.9 %) and endoscopic laser 3 (75.0 %). The median gestational age at delivery was 38 + 0 (37 + 4 – 39 + 4) weeks. The median treatment–delivery interval was 23 + 2 (IQR, 21 + 0–25 + 6) weeks. The most frequent adverse outcomes reported were preterm labor in 7 (13.7 %) patients. There were no severe adverse maternal outcomes. ConclusionEarly intervention with intrafetal laser and radiofrequency in TRAP sequence achieves a livebirth rate of the pump twin of about 75 %.

Efficacy of pulsed magnetic therapy, high-intensity magnetic stimulation of the pelvic floor muscles and intrauterine plasma therapy to restore endometrial receptivity after intrauterine interventions: a randomized trial

Surgical interventions on the pelvic organs lead to damage to the basal layer of the endometrium, which disrupts embryo implantation. Restoring endometrial receptivity helps improve fertility. Purpose of the study. Evaluation of the effectiveness of non-drug methods for restoring endometrial receptivity after intrauterine interventions in women of reproductive age. Material and methods. The prospective randomized study included 120 patients aged 18–45 years who had undergone intrauterine surgery and were planning pregnancy. The patients were divided into three equal groups: group 1 — 40 patients who received combined pulsed magnetic therapy and intrauterine plasma therapy of the endometrium; group 2 — 40 patients who underwent high-intensity magnetic stimulation of the pelvic floor muscles and intrauterine plasma therapy of the endometrium; group 3 — 40 patients who underwent pulsed magnetic therapy. Anamnesis data, as well as clinical, laboratory, and instrumental data of the patients were analyzed, an ultrasound assessment of endometrial thickness and blood flow velocity in the uterine arteries was performed, and the pregnancy rate was assessed 1, 2, and 3 months after treatment. Results. The probability of pregnancy in group 1 was significantly higher than in group 3 (p = 0.014), but it did not reach statistically significant differences from the first group. The treatment method in group 2 increased the likelihood of pregnancy most effectively (by 70 %) (risk ratio 2.37 (95 % confidence interval 1.10–5.11), p = 0.027). Taking vitamins increased the chance of getting pregnant by 72 %, absence of chronic diseases — by 81 %, younger age — by 49 %, and normal body mass index — by 48 %. Based on the data obtained, the predictors of a favorable treatment outcome and a high probability of pregnancy are as follows: endometrial thickness more than 7.5 mm after 1 month, more than 9.5 mm after 2 months, more than 10.5 mm after 3 months; blood flow velocity more than 11.5 mm/s after 2 months and more than 13.5 mm after 3 months. Conclusion. The highest probability of restoration of endometrial receptivity after intrauterine interventions and pregnancy occurs when using a rehabilitation complex, including the combined use of high-intensity magnetic stimulation of the pelvic floor muscles and intrauterine plasma therapy. Predictors of a favorable outcome of treatment and pregnancy are the thickness of the endometrium and the blood flow velocity in the uterine arteries during the course of therapy.

Radiofrequency thermal ablation of giant placental chorioangioma complicated with fetal hydrops: a case report and successful outcome

Abstract Objectives Chorioangiomas are the most frequently occurring type of benign tumour of the placenta. However, large chorioangiomas greater than 4 cm are rare and can be more frequently associated with serious complications such as: polyhydramnios, hydrops fetalis, fetal anaemia, intrauterine growth restriction, preterm birth, and an increased risk of perinatal mortality. Importantly timely prenatal diagnosis with close surveillance alongside potential intrauterine intervention can prove impactful on pregnancy outcome and fetal survival. Case presentation We present a case of a 36-year-old female referred to our tertiary fetal medicine unit at 28 weeks’ gestation with a large chorioangioma measuring 9.4×8.8×5.5 cm and ultrasonographic evidence of severe fetal anaemia and fetal hydrops. The patient underwent an intrauterine transfusion and in utero surgical therapy with radiofrequency ablation (RFA). Immediately following the procedure, the fetus sustained a period of bradycardia, followed by asystole. Delivery was expedited via emergency caesarean section. Careful planning and rapid delivery after fetal intervention within the most appropriate surgical setting mitigated risks for the baby and resulted in a positive outcome. The baby was discharged from the neonatal unit on day 84 of life. Conclusions Large placental chorioangiomas are a rare occurrence, however, when associated with fetal complications present a high incidence of adverse perinatal outcomes. In utero interventions require careful planning and surgical expertise to ensure improved fetal and neonatal outcomes. To the best of our knowledge this case is the first recorded instance of a successful postnatal outcome following RFA for a large placental chorioangioma, whereby the fetus was complicated by fetal hydrops.

#311 : Intrauterine Administration of Human Chorionic Gonadotropin in Women Undergoing IVF– An Individual Participant Data Meta-Analysis

Background and Aims: Human chorionic gonadotropin (hCG) has been proposed as an intrauterine intervention around embryo transfer period due to its potential to enhance endometrium receptivity and implantation. Existing randomised controlled trials (RCTs) showed inconsistent findings and multiple meta-analyses on this topic showed high unexplained heterogeneity. Individual participant data meta-analysis (IPDMA) is considered the “gold standard” synthesis method due to its ability to standardise and harmonise the data reporting and analysis. In this IPDMA, we aimed to investigate the effectiveness and safety of intrauterine hCG before embryo transfer. Method: We searched Cochrane Gynaecology and Fertility Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PsycINFO without language restrictions up to November 2022. We included RCTs comparing intrauterine administration of hCG before embryo transfer versus placebo or no intervention in women undergoing IVF. The outcomes were live birth, clinical pregnancy and other fertility outcomes. We invited trial authors to share the de-identified IPD and established the IHABT collaboration. We performed a one-stage IPDMA as the main analysis. Results: Eight RCTs including IPD of 2338 participants were included. These RCTs were conducted in 6 different countries, with a dosage of intrauterine hCG between 500 IU and 1000 IU. In women undergoing IVF, compared to the control group, intrauterine administration of hCG before embryo transfer does not improve live birth rates (7 RCTs, 2245 participants, odds ratio [OR] 0.98, 95% confidence interval [CI] 0.82–1.17) or clinical pregnancy rates (8 RCTs, 2338 participants, OR 1.13, 95%CI 0.89–1.43). There was insufficient evidence of a difference between the two groups on any of the other fertility outcomes. Conclusion: Intrauterine administration of hCG does not improve live birth or clinical pregnancy rates in women undergoing IVF. Therefore, it should not be offered as an IVF add-on in clinical practice.

СОВРЕМЕННЫЕ ИНСТРУМЕНТАЛЬНЫЕ ИCСЛЕДОВАНИЯ ПРИ ГИПЕРПЛАСТИЧЕСКИХ ПРОЦЕССАХ ЭНДОМЕТРИЯ

The data concerning the issues of diagnosing endometrial hyperplastic processes in terms of diagnostic accuracy, accessibility and minimal invasiveness are considered. The necessity of transition in most intrauterine interventions to Pipelle-biopsy instead of diagnostic curettage and hysteroscopy has been substantiated and confirmed. Pipelle biopsy is an effective, low-traumatic, affordable and cost-effective method. Particular attention is paid to the advantages and features of using various types of aspiration probes for Pipelle biopsy.

Study of the cervical and vaginal microbiota in women with intrauterine pathology and infertility

The widespread introduction of hysteroscopy into clinical practice has significantly expanded the possibilities of diagnosis the causes of infertility. Almost 25% of patients with infertility are diagnosed with intrauterine pathology during hysteroscopy, which is not always identified during ultrasonography and/or hysterosalpingography. The World Health Organization recommends the use of office hysteroscopy in all cases of suspected intrauterine pathology. Among all complications of hysteroscopy, the frequency of which ranges from 0.4 to 6.0%, infectious and inflammatory complications occur most often (0.6-2.5%). Intrauterine interventions disturb the “cervical” protective barrier, which, in the presence of dysbiotic or inflammatory processes of the genital tract, increases the risk of complications. In view of the increase in the frequency of intrauterine pathology, and, accordingly, the frequency of diagnostic and operative intrauterine interventions in women of reproductive age, the development of algorithms for the prevention of infectious and inflammatory complications is relevant.The objective: to investigate the state of the cervical and vaginal microbiota of women of reproductive age with intrauterine pathology and infertility who are preparing for hysteroscopy.Materials and methods. 45 women aged 26 to 45 years (main group) and 30 women of the same age without gynecological pathology (comparison group) were examined before hysteroscopy. A comprehensive study of the state of the cervical and vaginal microbiota, diagnosis of infection with sexually transmitted pathogens, included pH-metry of vaginal contents, bacterioscopic examination of vaginal smears, and polymerase chain reaction (PCR).Results. Indications for hysteroscopy were chronic abnormal uterine bleeding (13.3%), endometrial hyperplasia (8.9%); suspicion of endometrial polyps (8.9%), submucosal myoma (8.9%) or uterine malformations (17.8%); infertility of unclear origin (42.2%). In patients of the main group, inflammatory and dysbiotic processes of the lower part of the genital organs in the anamnesis occurred 5.6 times more often. In 22.2% of the patients of the main group, the normal vaginal pH level was determined (3.8–4.5) versus 60.0% of the women of the comparison group (p&lt;0.05). According to bacterioscopy, normocenosis was found in 28.9% of women in the main group and 43.3% – in the comparison group, while according to PCR normocenosis was determined in 35.6% and 63.3% of cases, respectively. A significant frequency of the intermediate state of the microbiota was estimated (37.8% in the main group and 23.3% – in the comparison group), which correlated with changes in the pH of the vagina (r=0.567). Of the 18 patients in the main group, bacterial vaginosis was diagnosed in 22.2% of cases, vulvovaginal candidiasis – in 4.4%, and chlamydia – in 8.9%.Conclusions. A significant frequency of diseases of the lower part of the genital tract in the anamnesis is typical for patients with infertility and intrauterine pathology. In 77.8% of patients with infertility and intrauterine pathology, a shift in vaginal pH to the alkaline side (&gt; 4.5) is found, which creates conditions for the reproduction of opportunistic and pathogenic microflora. This is confirmed by the low frequency (35.6%) of normocenosis of the cervical and vaginal microbiota at 63.3% in patients without gynecological pathology and correlates with the frequency of intermediate microbiota state. Taking into account the risk of ascending infection during intrauterine interventions, the use of diagnostic methods with high sensitivity and specificity (PCR) is revealed for adequate diagnosis of the state of the cervical and vaginal microbiota, which at the same time will avoid unfounded medical measures.

The Construction of an Intrauterine Diagnosis and Treatment System and Comprehensive Lifecycle Health Service of Congenital Heart Disease: Xinhua Hospital Model

With the growing influence of slow population growth and population aging, China has established the birth policy and issued a series of documents to promote maternal and fetal health and improve the birth rate. With the increase in prevalence of birth defects, timely diagnosis and intervention in utero provide possibilities to reduce unnecessary abortions and offer better prognosis. Congenital heart disease (CHD), as one of the most common congenital birth defects, is the leading cause of mortality in patients aged &lt;5 years, and brings a heavy burden to both the affected families and society. Fetuses with CHD are associated with an increased risk of pregnancy-related complications and premature birth, and children with CHD typically face growth and developmental problems even after the correction of malformation. Therefore, management including diagnosis, treatment, and rehabilitation throughout the fetal period into childhood and even adulthood is essential for children with CHD. Based on the rapid advances in intrauterine and perinatal medicine and an in-depth collaboration among obstetrics and pediatrics, a novel diagnosis and treatment system has been established for the management of CHD in the past 2 decades in Shanghai Xinhua Hospital. This Intrauterine Diagnosis and Treatment System and Comprehensive Lifecycle Health Service of Congenital Heart Disease model provides prenatal diagnosis, intrauterine intervention, delivery room service and neonatal therapies, and postintrauterine rehabilitation for children with CHD. We have developed a four-dimensional spatiotemporal image correlation echocardiography and a three-dimensional cardiac virtual endoscopy system for the intrauterine diagnosis of CHD, dramatically raising the diagnostic utility. Our innovative and independent newborn-intervention technique has effectively reduced the re-intervention rate in patients with pulmonary atresia with intact ventricular septum and critical pulmonary stenosis. In 2018, Xinhua Hospital independently performed the case of fetal aortic valvuloplasty in Asia through a multidepartment collaborative effort. All children treated in this system achieved biventricular circulation and a better long-term postoperative outcome. We also have conducted postoperative rehabilitation therapy to promote the development and health of children with CHD. The practice of Xinhua model has reduced unnecessary abortion of CHD fetuses, reduced the mortality rate associated with critical CHD, and improved the mid- and long-term prognosis in CHD, which is essential to promote the fertility level and children’s health. Furthermore, translational medicine platform and the birth cohort Early Life Plan was constructed to explore the origins of major developmental diseases and establish an early intervention model in CHD. This practice of assessment of the intrauterine system has been expanded to other congenital defects in Xinhua Hospital, and sequential treatment of more than 2,000 cases has been completed to date. Based on practice in intrauterine management of CHD and other diseases, the concept of Intrauterine Pediatrics was proposed as a first to emphasize early prevention and intervention of childhood diseases and promote a comprehensive lifecycle service for children. The development and evolution of this system requires further attention not only from researchers but also from the government and global medical communities.

Fetal pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum: a single-center clinical experience.

Fetal pulmonary valvuloplasty for pulmonary atresia with intact ventricular septum: a single-center clinical experience.

Применение временной баллонной окклюзии внутренних подвздошных артерий при родоразрешении беременных с плацентарной адгезивно-инвазивной патологией

Study Objective: to evaluate the effects of temporary bilateral balloon occlusion of the internal iliac arteries on the volume of blood loss during operative delivery of pregnant women with placental adhesive-invasive pathology to internal cervical os and complete placenta previa. Study Design: randomized study. Materials and Methods. We analyzed 37 histories of patients with placental adhesive-invasive pathology to internal cervical os and complete placenta previa, who had operative delivery during 2018–2019. All examined women were divided into two clinical groups. The fact of using X-ray endovascular methods during delivery by caesarean section was the main principle of dividing the study participants. Group I is represented by women (n = 18) who underwent temporary balloon occlusion of the internal iliac arteries, group II (n = 19) is represented by women who delivered without X-ray endovascular methods. Study Results. Among the risk factors for placental adhesive-invasive pathology, the following can be distinguished: in the main group, 7 women (38.9%) had miscarriage in early pregnancy, 3 women (16.7%) had genital tract infection, 2 patients (11.1%) had endometriosis, myomectomy — in 1 case (5.5%), intrauterine interventions in 5 cases (27.8%), in the comparison group: 8 (42.1%), 5 (26.3%), 3 (15.8%), 1 (5.3%),2 (10.5%) respectively. In the main group, 7 patients (38.9%) had one operative delivery in history, 5 pregnant women (27.7%) had two cesarean sections, 3 women (16, 7%) had a scar on the uterus after 3 cesarean sections, and 3 women (16,7%) had a scar on the uterus after 4 caesarean sections, in the comparison group — 4 (21.05%), 8 (42.1%), 3 (15.8%), 4 (21.05%) respectively. In both groups, in 100% of cases, the operations were organ-preserving. In the main group, the volume of intraoperative blood loss, taking into account the volume of blood collected by the CellSaver device and by the gravimetric method, was 650.0 [500.0; 800.0] ml versus 866.0 [750.0; 1400.0] ml in the comparison group and was significantly lower (p &lt; 0.05). 7 (36.8%) patients from the comparison group required transfusion of fresh frozen blood plasma to replace the deficiency of coagulation factors. Assessment of newborns on the Apgar scale at 1/5 minutes did not show significant differences in the study groups. Conclusion. Endovascular temporary bilateral balloon occlusion of the internal iliac arteries is becoming an extremely necessary procedure to ensure the elimination of blood flow in the system of internal iliac arteries, reduce the collateral blood supply to the uterus and reduce intraoperative blood loss. This technique can reduce the amount of intraoperative blood loss by 33–43% in case of patients having placental adhesive-invasive pathology to internal cervical os and placenta previa. Keywords: placenta previa, pregnancy, placental adhesive-invasive pathology, temporary balloon occlusion of the internal iliac arteries.

Разработка экспериментальной модели патологии эндометрия (синдрома Ашермана)

Introduction. One of the most challenging problems faced in gynecology is Asherman’s syndrome (AS), characterized by the formation of intrauterine adhesions, partial or complete obliteration of the uterine cavity with scar tissue, and the loss of the functional layer of the endometrium following intrauterine interventions. Treatments for AS are not always effective. This indicates a need to search and evaluate the effectiveness of new approaches to the prevention of fibrosis and stimulation of endometrial regeneration. According to ethical principles, this is possible only when simulating AS on laboratory animals. The aim of the work is to develop an etiologically adequate model of AS in Sprague Dawley rats. Materials and methods. We simulated AS in 18 female Sprague Dawley rats that were divided into 3 groups (6 rats in each). Operations were performed in the estrus phase. We made longitudinal incision of the right uterine horns, and the endometrium was scraped out to the inner layer of the myometrium with the scalpel. Groups 1 and 2 underwent only endometrial scraping. In group 3 abdominal cavities were opened on day 7 after curettage and intrauterine adhesions were destroyed with a needle inserted into the horn. Then, the standard procedure for suturing surgical wound was performed. The animals were removed from the experiment on days 7 (group 1) and 15 (groups 2 and 3) after the surgery with an overdose of ether anesthesia. The tissue samples of the operated and non-operated uterine horns were fixed with 10% buffered formalin and embedded in paraffin; the sections were stained with hematoxylin and eosin. Results. Macroscopic examination on day 7 after the surgery showed that all females had a compaction and contraction of the operated area of the uterine horn and uterine cavity fluid. On day 15, fluid collection was more pronounced. After the destruction of the uterine adhesions in rats from group 3, there was no fluid collection or it was less voluminous than in females of other groups. Histological examination showed that on days 7 and 15 after endometrial curettage, the uterine cavity and the luminal epithelium covering it were absent due to complete replacement by connective tissue. Uterine glands were not detected or were individual. On day 7 after the destruction of the adhesions and on day 15 after endometrial scraping the subjects developed a small stenosed uterine cavity lined with luminal epithelium or a larger uterine cavity containing single or multiple adhesions covered with epithelium. The number of glands was significantly smaller than in the non-operated horn. Conclusion. To simulate Asherman’s syndrome, female Sprague Dawley rats in the estrus phase were scraped out of the endometrial layer of the right uterine horn. On days 7 and 15 after surgery, the uterine cavity and luminal epithelium were absent due to complete replacement with connective tissue, which proves the formation of intrauterine adhesions and the adequacy of the obtained model. A significant difference of the original model was the destruction of the adhesions on day 7 after endometrial damage to remove excess fluid in the uterine cavity and restore uterine patency, which led to the formation of the uterine cavity and re-epithelialization on day 15. The developed model of Asherman’s syndrome can be used to develop new approaches to the prevention of adhesive process and the restoration of endometrial structure and functionality. Keywords: Asherman’s syndrome, experimental model, rat uterus, endometrial curettage, intrauterine adhesions