Оценка медицинских технологий в акушерстве: преимущества индивидуального консервативного ведения монохориальной беременности, осложненной синдромом обратной артериальной перфузии, перед хирургическим вмешательством

Introduction. Twin reversed arterial perfusion (TRAP) syndrome is one of the types of complications of monochorial twins (MT) with a frequency of occurrence of 1:35000 births. It is characterized by the presence of the main vessel instead of a normal 4 chambers heart and intrauterine developmental abnormalities. This pregnancy requires monitoring using dynamic ultrasound diagnostics every 7 days, in accordance with current recommendations. The treatment is intrauterine laser coagulation of blood vessels of the “acardial fetus” (AP) in order to prevent the development of a threatening condition for the “fetal pump” (PP). Aim: to demonstrate the possibilities of comprehensive conservative management of monochorial pregnancy complicated by TRAP.Materials and methods. An ultrasound examinations were performed on a weekly basis in monochorionic pregnancy, complicated by TRAP within the period 12-38 weeks. Serum concentrations of biochemical markers PAPP-A (pregnancy-associated plasma protein-A) and β-hGC (β-subunit of human chorionic gonadotropin) were studied in the first trimester to predict adverse perinatal outcomes.Results. The possibility of prolonging a pregnancy complicated by TRAP without performing intrauterine surgical intervention, during which quite serious complications can occur in this category of pregnancies, has been demonstrated. In a patient with monochorionic twins complicated by TRAP, totally 27 ultrasound examinations were performed within the period 12-38 weeks. This approach made it possible to dynamically monitor the condition of a pregnant and healthy fetus and to prolong pregnancy without surgery until the full term.Conclusions. Following the existing guidelines, without tailoring for individual risk, may lead to an unreasonable increase in surgical interventions. In turn, surgery is not only accompanied by a high risk of complications (up to 15%), but also constitute a certain financial burden on the budget, determined by the state on the level of 208,000 rubles. Performing routine ultrasound examinations according to the examination protocol for monochorionic pregnancy will contribute to avoiding the complications associated with surgery and better selection for surgery as well as reducing the government costs. Введение. Синдром обратной артериальной перфузии (СОАП) – один из видов осложнений монохориальной двойни (МХ) с частотой встречаемости 1:35000 родов, характеризующийся наличием магистрального сосуда вместо полноценного сердца у одного близнеца (акардиальный плод) и нарушениями внутриутробного развития разной степени. Данная беременность требует наблюдения с динамикой ультразвукового исследования (УЗИ) каждые 7 дней, что определено практическими рекомендациями. Операцией выбора является внутриутробная лазерная коагуляция сосудов, питающих акардиальный плод (АП) с целью не допустить развития угрожающих состояний для плода-помпы (ПП).Цель – продемонстрировать возможности успешного консервативного ведения монохориальной беременности, осложненной СОАП.Материалы и методы. УЗИ при монохориальной беременности двойней проводилось еженедельно, в течение 12-38 недель беременности. В первом триместре выполнялось исследование сывороточных концентраций биохимических маркеров PAPP-A (англ. – pregnancy-associated plasma protein-A, ассоциированный с беременностью протеин-А плазмы) и β-ХГЧ (свободная бета-субъединица хорионического гонадотропина человека) с целью прогнозирования неблагоприятных перинатальных исходов.Результаты. Продемонстрирована возможность пролонгации беременности, осложненной СОАП, без выполнения внутриутробного хирургического вмешательства (ВХ), в ходе которого в данной категории беременностей могут иметь место достаточно серьезные осложнения. У пациентки с монохориальной двойней, осложненной развитием СОАП, было выполнено 27 УЗИ в период 12-38 недель. Такой подход позволил динамически наблюдать за состоянием беременной и здорового плода и пролонгировать беременность без проведения хирургической операции до доношенного срока.Заключение. Следование регламентированным практическим рекомендациям к проведению ВХ, без учета индивидуальных особенностей каждого отдельного случая, может потенциально приводить к необоснованному увеличению оперативных вмешательств, повышая прямые затраты. ВХ не только сопровождаются высоким риском осложнений (до 15%), но и накладывают высокую финансовую нагрузку на бюджет, определенный государством на сегодняшний день квотой 208000 рублей. Выполнение рутинного УЗИ, согласно протоколу обследования для МХ, может способствовать снижению риска осложнений, ассоциированных с ВХ, более качественному отбору потенциальных кандидатов для ВХ, а также связанному с этим снижению бюджетных затрат на оказание медицинской помощи

ROLE OF INOSINE PRANOBEX IN MANAGEMENT OF HPV-ASSOCIATED DISEASES: PROBLEMS AND PROSPECTIVE

The prevalence of HPV in Russia and the world is quite high, although epidemiological data are limited because morbidity rate of papillomatosis, particularly genital warts, are not clear. The most effective method of preventing infection is vaccination against HPV infection. One of the most effective preventive measure to reduce the risk of death from HPV-related cancer diseases is a regular screening. None of the treatments of HPV infection will not totally effective and will not prevent disease transmission. In most cases, treatment is aimed at getting rid of symptoms but not cure infection. Immunomodulators for management of HPV-associated diseases could not have evidence base. Clinically proven treatment with inosine pranobex eliminates HPV to 98% cases and 3 times reduce frequency of relapses in combined therapy. Correct and complete counseling, aimed at informing the patient about the connection of HPV infection and cancer, as well as the possibility of preventing infection by timely vaccination and proper compliance are issue at present time. Isoprinosine saves a woman from the HPV, reducing the possibility of recurrence and malignancy, only when patient has complete course of therapy

DIAGNOSTICS OF HEMOSTASIS DISORDERS IN INFANTS

This clinical lecture is dedicated to the diagnostic approaches of blood coagulation disorders in newborns. The work presents a clinical substantiation of different diagnostic methods of hemostasis disorders with description of routine standard methods of research and special techniques

NEW DIDACTIC MEANS СREATION OF A MEDICAL HIGHER SCHOOL TEACHER AS FACTOR OF HIS PROFESSIONAL-PEDAGOGICAL COMPETENCIES DEVELOPMENT

The article considers the problem of professional-pedagogical competencies development of the Higher Medical School teacher. It is revealed dependence of improving quality of students’ professional training from the level of the teacher’s psychological-pedagogical and methodical competence. The article describes the process of teacher’s developing of the new didactic means – «Student’s Study-book» and «Student’s Collection of reference tables and reference cards» as the index of teacher’s professional-pedagogical competencies development

Errors of antithrombotic therapy in management of pregnancy and childbirth after in vitro fertilization and transfer of two embryos

Thrombophilia might be the essential pathogenetic mechanism of thromboembolism associated with pregnancy. Venous thromboembolism during or after assisted reproductive technologies is predicted to emerge due to increased number of women undergoing this technique. Low molecular weight heparins was effective for preventing recurrent thromboembolism and severe obstetric complications. Women with personal or family history of thromboembolism or with history of obstetric complications should be screened for thrombophilia

HORMONAL CONTRACEPTION AND MAGNESIUM DEFICIENCY: A SUBANALYSIS OF THE MAGYN STUDY

The use of estrogen-containing hormonal drugs facilitates excretion of magnesium ions. It is therefore important to characterize women who use hormonal contraceptives, and to test correlation between the use of hormonal contraception -(HC) and the magnesium deficiency (MgD).Objectives. To create a profile of HC-using women who enrolled in the MAGYN study.Materials and Methods. The study included the disease registry (MgD in women with hormone-dependent diseases) and the data on safety and effectiveness of magnesium supplementation with a combination of magnesium citrate and pyridoxine. The standard questionnaire and biochemical determination of serum magnesium were used to diagnose MgD. The severity of MgD symptoms was evaluated using a 10-point visual analogue scale; the quality of life was assessed using the WHOQOL-BREF questionnaire after four weeks of therapy.Results. Among the total of 9168 women in the MAGYN study, hormonal contraceptives were used by 1528 women (16.7%). Of these women, combined estrogen-progestin single-phase contraceptives were used in 66.2% cases, a vaginal ring with a combination of estrogen and progestogen – 11.7%, and oral combined estrogen-gestagenic two-phase medications – 10.9%. The most common complaints among the women on hormonal contraception were "fatigue", "nervousness", "irritability", "state of chronic stress"; those symptoms were significantly more frequent in women with confirmed MgD. The prevalence of MgD in the group of women receiving hormonal contraception was 67%.Conclusion. The present study demonstrates high prevalence of MgD in women using hormonal contraception. Correcting MgD significantly improves the women’s health and their quality of life. Since the nutrition profile, behavior patterns, quality of life and social preferences of women may depend on urban population size, larger studies are warranted in cities with a population of >250 thousand to obtain the data relevant to the entire country

THE BASIC POINTS OF SAFE MANAGEMENT OF PREGNANCY AND DELIVERY IN PATIENTS WITH MARFAN SYNDROME

Marfan syndrome is dominantly inherited connective tissue diseases, associated with microfibrillar fiber connective tissue deficiency in vascular walls, heart valves, joints, dural membrane,  bones, and other organs. Diagnosis may be confirmed by clinical  criteria and molecular tests. Pregnancy bears a risk of fatal complications,  including aortic dissection, aortic root dilation, mitral valve insufficiency.  Women must be followed and managed in a high risk pregnancy unit by a team from obstetricians, cardiologists, anesthetists, pediatricians, neonatologists  and cardiac surgeons who are skilled in high risk pregnancies. This approach allows to avoid the serious maternal and fetal complications. Caesarean section should be offered for such patients, because it minimizes the hemodynamic changes, associated with vaginal delivery. Some authors recommend to perform post-cesarean hysterectomy, because of the high incidence of massive hemorrhage in postpartum