Modern possibilities for the diagnosis of adenomyosis

Maria A. Shalina
In: Journal of obstetrics and women's diseases · 2021 · doi:10.17816/jowd18983 · W4206648384
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This article reviews modern diagnostic approaches and pathogenetic mechanisms for adenomyosis, including genetic and immunological factors, and highlights informative non-invasive diagnostic markers.

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Abstract

The article presents modern data on the diagnosis and pathogenetic mechanisms of the development of adenomyosis. Various classifications of the disease are highlighted. The role of genetic and immunological factors in the development of internal endometriosis is reflected. The results of domestic and foreign studies are presented and the most informative non-invasive markers for the diagnosis of adenomyosis are described.
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Abstract

Background: Cardiological pathologies, including heart defects, remain a leading cause of maternal mortality. Patients with congenital heart defects (CHD) have an increased risk of developing gestational complications and dysbiotic disorders due to hypoxemia caused by reduced cardiac output. However, there are only a few studies on the vaginal microbiota in pregnant women with CHD. Aim: The aim of the study was to evaluate clinical changes during pregnancy and assess the species composition of the vaginal microbiota in pregnant women with CHD, depending on hemodynamic manifestations.

Methods

This retrospective study included 276 pregnant women, who were divided into 2 groups. The main group consisted of pregnant women with CHD (n = 149), and the comparison group comprised healthy pregnant women (n = 127). The group of pregnant women with CHD was divided into 2 subgroups: the first consisted of pregnant women with CHD and manifestations of chronic heart failure (CHF) (n = 47), and the second comprised pregnant women with CHD without CHF (n = 102). The course of pregnancy and laboratory parameters were assessed using maternity health records. A cardiologist established diagnoses of CHD and CHF based on clinical and instrumental examination in accordance with approved diagnostic criteria.

Results

Vaginal microbiota disorders more often complicate pregnancy in patients with CHD, with the frequency of bacterial vaginosis positively correlating with the presence of CHF. In pregnant women with CHD, regardless of the presence of CHF, Staphylococcus spp., Candida spp., Enterococcus faecalis, and Escherichia coli were predominant in the vaginal microbiota. Candida spp. and E. coli were more common in pregnant women with CHD and CHF, leading to a higher miscarriage rate and urinary tract infections in this category of pregnant women.

Conclusion

In pregnant women with CHD and CHF, Candida spp. and E. coli predominate in the vaginal biotope, while Lactobacillus spp. colonization decreases, leading to the development of gestational complications associated with infection. CHD combined with CHF in pregnant women is a risk factor for bacterial vaginosis. Experience with vaginal natural orifice transluminal endoscopic surgery in obese women

Abstract

Background: Despite the development of minimally invasive technologies, the optimal approach for hysterectomy in obese patients remains a subject of debate. The comparative effectiveness of the new vaginal natural orifice transluminal endoscopic surgery (vNOTES) method and robot-assisted surgery in this patient group has been insufficiently studied. Aim: The aim of this study was to compare the effectiveness of hysterectomy using the vNOTES method and robot-assisted hysterectomy in obese patients with gynecological diseases.

Methods

This prospective study included patients with a body mass index (BMI) > 30 kg/m2 who underwent hysterectomy for benign conditions. In group 1 (n = 45), hysterectomy was performed using the vNOTES method with prior traditional ligation of the cardinal and uterosacral ligaments. In group 2 (n = 45), hysterectomy was performed using the vNOTES method with the LigaSure device for transecting the cardinal and uterosacral ligaments. In group 3 (n = 80), robot-assisted hysterectomy was performed. Surgery duration and blood loss volume were assessed. Statistical analysis was performed using the Kruskal–Wallis, Mann–Whitney, and Fisher’s exact tests.

Results

The mean age of the patients was 57±8.5 years. BMI was highest in the robot-assisted surgery group (36.9±6.7 kg/m2). The median surgery duration was shortest in the vNOTES with LigaSure group — 90 [75; 110] min, which was shorter than in the traditional vNOTES group — 110 [95; 125] min and robot-assisted access group — 115 [90; 150] min, p < 0.009. The lowest blood loss was recorded in the robot-assisted hysterectomy group — a median of 70 [50; 100] ml, which was lower than the values for vNOTES with LigaSure — 150 [100; 180] ml and traditional vNOTES — 180 [150; 250] ml, p < 0.0001.

Conclusion

The conducted analysis demonstrates that vNOTES hysterectomy using the LigaSure device ensures the shortest operative time, while robot-assisted hysterectomy results in minimal blood loss. The choice of the optimal method in obese patients should be made individually, taking into account the clinical situation and technology availability. Maternal attitude and mental health during pregnancy and after childbirth as factors of postpartum depression

Abstract

Background: The prevalence of postpartum depressive experiences and their negative impact on mother–child dyad interactions in the short and long term necessitates an examination of pre- and postnatal factors of postpartum depression. Aim: The aim of this study was to examine maternal mental health characteristics and attitudes toward the child during pregnancy and after childbirth as predictors of postpartum depressive experiences.

Methods

This longitudinal study included 430 pregnant women, 105 of whom were interviewed 4–8 months after childbirth. The following instruments were used: the Achenbach System of Empirically Based Assessment (ASEBA); the Pregnant Women’s Attitude Test; the Maternal Attitude Test; the Maternal Antenatal and Postnatal Attachment Scales; and the socio-demographic questionnaire.

Results

18.1% of pregnant women showed signs of depressive disorders (11.3% were at risk, 6.8% had clinical manifestations). The severity of depression was higher in women in unregistered marriages (p = 0.026), in cases of unplanned pregnancy (p = 0.000), and in women who had been raised in a single-parent family (p = 0.013). In the postnatal period, 15.4% of women were at risk, and 3.9% had a clinical level of depressive disorder. Regression analysis revealed a significant combined effect (R2 = 0.426) of depressive disorder (β = 0.419, p < 0.01) and avoidance disorders (β = 0.337, p < 0.05) during pregnancy on the severity of maternal depressive experiences in the first year of the child’s life. In the postnatal period, depression was predicted by withdrawal syndrome (R2 = 0.54; β = 0.735, p < 0.001), depressive attitudes towards motherhood and child (β = 0.413, p < 0.001), and the quality of postnatal attachment (β = –0.320, p < 0.01).

Conclusion

The prevalence and identified pre- and postnatal predictors of postpartum depressive disorders confirm the importance of joint monitoring of women by physicians and psychologists from the very moment of pregnancy, the significance of developing a social support network, and a positive attitude towards motherhood and child. Analysis of perinatal outcomes in the presence of maternal asthma

Abstract

Background: Asthma is traditionally considered as a risk factor for obstetric and perinatal complications, such as preterm birth (PB), fetal growth restriction, small for gestational age and low birth weight (LBW) infants. The safety of asthma drug therapy during pregnancy is not fully established. Contradictions in the literature, the breadth of the medical and social significance of the issue, and the desire to improve public health prompted an analysis of perinatal outcomes in pregnant women with asthma in St. Petersburg, Russia. Aim: The aim of this study was to analyze perinatal outcomes of pregnancies complicated by maternal asthma, depending on the severity of the disease, the presence of exacerbations, and the type of therapy administered.

Methods

This retrospective analysis of 2637 singleton deliveries that occurred between January 2002 and December 2024 in St. Petersburg, Russia among patients with asthma was conducted including 1047 patients with mild intermittent asthma, 893 with mild persistent asthma, 628 with moderate persistent asthma, and 69 patients with severe asthma.

Results

The average birth weight of full-term infants was inversely correlated with the severity of asthma during pregnancy (p = 0.00054). In cases of severe asthma, the relative risk (RR) of delivering full-term newborns with a birth weight in the range from 3 to 9‰ at term was 6.06 [95% confidence interval (CI) 3.3–11.2], and for LBW infants, RR was 3.76 [95% CI 2.0–6.9]. The PB rate was 3.8% and did not depend on the severity of asthma. Asthma exacerbations were observed in 47.4% of the cohort overall, and were associated with LBW — RR 1.51 [95% CI 1.05–2.2]. A total of 81.8% of pregnant women with persistent asthma received treatment with inhaled corticosteroids (ICS) combined with short-acting (SABA) or long-acting (LABA) β2-agonists. Most patients received fixed-dose combinations of ICS with LABA: budesonide / formoterol (n = 586) and fluticasone / salmeterol (n = 268). Infants whose mothers were treated with ICS+LABA had higher birth weights, both among full-term newborns (p = 0.002) and in the overall study group (p = 0.019). Treatment with ICS + LABA was not associated with an increased RR of PB, LBW infants, or infants with birth weights in the range from 3 to 9‰ and less than 3‰ at the gestational age.

Conclusion

This study confirms the necessity of regular clinical follow-up for pregnant women with asthma, prevention of asthma exacerbations, and adequate therapeutic interventions. Management of modifiable risk factors for exacerbations is crucial, including behavioral aspects such as treatment adherence, anxiety or depression. Improving patient awareness contributes to better health outcomes in children in cases of maternal asthma. Risk factors for non-alcoholic fatty liver disease in pregnant women as a basis for in-depth examination and prevention of obstetric complications

Abstract

Background: Over the past decade, the incidence of non-alcoholic fatty liver disease (NAFLD) in pregnant women has increased significantly, reaching approximately 10% of all cases; the disease being associated with an increased risk of hypertension, postpartum bleeding, and preterm birth. Pregnant women with NAFLD should be considered a high-risk group due to potential adverse perinatal and obstetric outcomes and potential impact on offspring health. Аim: The aim of this study was to identify NAFLD prevalence and risk factors in patients entering pregnancy. Мethods: This retrospective observational case-control study included data from the medical histories and outpatient records of women who were pregnant between February 2019 and December 2022 (n = 2023). The main group consisted of pregnant women with NAFLD in the first trimester (n = 104), while the remaining pregnant women without a diagnosis of liver or biliary disease were considered the control group. The patients’ blood biochemical parameters were monitored. Additionally, the following were evaluated: the age of pregnant women, the number of pregnancies, the number of fetuses, body weight, body mass index (BMI), bad habits, social status, and the number of previous births. All statistical analyses were performed using MedCalc (version 23.4), Statistica (version 13), and Excel (version 19) software with XRealStats add-ins (version 4.4.1). Statistical significance was determined as a two-sided p value <0.05. Disease prevalence was calculated using the generally accepted formula in Excel (version 19), and the significance of within-group differences was determined between the numbers of patients with or without NAFLD.

Results

NAFLD prevalence in pregnant women in the first trimester was 5.14% (p 27.1); total cholesterol levels (AUC area = 0.945, p 6.0); smoking (maximum value of the Youden index J = 0.7806, associated criterion >27.1); the number of pregnancies in the anamnesis (β = 0.3257), odds ratio ≈ 1.38.

Conclusion

At the initial visit for pregnancy follow-up, NAFLD incidence was more than 5% in our study. The identified risk factors for NAFLD were elevated BMI and total cholesterol levels, smoking, and history of multiple pregnancies. Such patients should undergo additional examination, including liver ultrasound, lipid profile, and liver function tests, to ensure timely detection and treatment of this condition and reduce the incidence of obstetric complications. The role of the junctional zone in the diagnosis and treatment of adenomyosis

Abstract

Background: Timely diagnosis of adenomyosis remains important due to the high incidence of the disease among women of reproductive age. Interest in using myometrial transition zone parameters in diagnostic algorithms has persisted since the first data on it as a marker for adenomyosis emerged. However, the role and clinical significance of the junctional zone in patients with adenomyosis currently remain a subject of scientific debate due to the inconsistency of the available data. Furthermore, the literature lacks information on its dynamics and changes under the influence of various therapies. Aim: The aim of this study was to evaluate the diagnostic significance of the junctional zone parameters in adenomyosis and their changes during the treatment of the disease.

Methods

A prospective cross-sectional, single-center study was conducted. All patients underwent ultrasound examination using an expert-class GE Voluson E10 (GE Healthcare, USA) with IC5-9-D and RIC6-12-D probes, color Doppler mapping, elastography, and volume reconstruction. To diagnose adenomyosis, we used the results of a comprehensive ultrasound examination using a patented proprietary scoring method. All patients underwent a junctional zone assessment.

Results

344 women were examined: 287 with a diagnosis of adenomyosis, of whom 273 had complaints and 14 were without complaints, and 57 patients in the control group. Significant differences were found in the assessment of the junctional zone in the main groups and the control group (p = 0.37). In 156 patients, the junctional zone was assessed before and 6 months after treatment of adenomyosis using several regimens: resveratrol 100 mg daily, dienogest 2 mg daily, and resveratrol 100 mg + dienogest 2 mg daily. During treatment, the average size of the junctional zone decreased, especially after combined treatment (p = 0.03).

Conclusion

The significance of the assessment of the junctional zone in the diagnosis of adenomyosis is currently small, due to the peculiarities of its visualization in some patients, however, the assessment of the thickness and uniformity of the junctional zone can be successfully used in the complex diagnosis of the disease. Furthermore, dynamic assessment of these parameters is a useful tool for monitoring treatment effectiveness, particularly during maintenance therapy. Comparative efficacy of regenerative medicine approaches in patients with recurrent implantation failure undergoing euploid embryo transfer

Abstract

Background: Recurrent implantation failure occupies a central place among the unresolved challenges of contemporary reproductive medicine, occurring in 15–20% of women undergoing in vitro fertilization treatment. Despite the implementation of preimplantation genetic testing for aneuploidy, which allows for the embryonic factor to be excluded, the pregnancy rate following euploid embryo transfer in patients with recurrent implantation failure remains substantially lower than in fertile women. Effective methods for correcting endometrial dysfunction in this patient population are still absent from clinical guidelines. Aim: The aim of this study was to compare, in patients with recurrent implantation failure, the efficacy of two regenerative medicine approaches (intrauterine perfusion of platelet rich plasma and subcutaneous administration of granulocyte colony stimulating factor) in frozen–thawed euploid embryo transfer cycles.

Methods

This randomized controlled trial was conducted involving patients with recurrent implantation failure and confirmed euploid embryos. Four groups of 47 patients each were formed: Group 1 received intrauterine perfusion of 1 ml of autologous platelet rich plasma on days 10–11 of the menstrual cycle; Group 2 received subcutaneous injections of 300 μg of recombinant human granulocyte colony stimulating factor (filgrastim) daily for 3 consecutive days, starting on the day of embryo transfer; Group 3 underwent standard endometrial preparation without any regenerative intervention; and the control group consisted of gestational surrogates (fertile women) who received an identical hormonal preparation protocol. The primary outcome was the clinical pregnancy rate, defined as visualization of a gestational sac on transvaginal ultrasound at 6–7 weeks. Secondary outcomes included the live birth rate, the miscarriage rate up to 12 weeks of gestation, and endometrial thickness.

Results

The clinical pregnancy rates in Groups 1, 2, 3, and the control group differed significantly: 63.8% (30/47), 48.9% (23/47), 27.7% (13/47), and 68.1% (32/47), respectively. Group 1 demonstrated a significant superiority over Groups 2 and 3 (p 0.050). The live birth rates were 55.3% (26/47) in Group 1, 40.4% (19/47) in Group 2, 21.3% (10/47) in Group 3, and 61.7% (29/47) in the control group, with significant differences identified between Group 1 and Groups 2 and 3 (p < 0.010). Factor analysis demonstrated that patient age, endometrial thickness, and the absence of chronic endometritis are independent predictors of clinical pregnancy and live birth.

Conclusion

Intrauterine perfusion of platelet rich plasma is a highly effective method for increasing the clinical pregnancy and live birth rates in patients with recurrent implantation failure, yielding outcomes comparable to those achieved in fertile women. One-stage correction of apical-rectal prolapse in reproductive-aged females

Abstract

Background: Pelvic organ prolapse is a problem faced by most women over 45 years of age. It can cause discomfort and pain, and negatively affect the quality of life. In patients of reproductive age, severe rectocele is combined with apical prolapse, and these patients require immediate simultaneous closure of rectovaginal fascia defects and correction of the uterosacral and cardinal ligament complex. Aim: The aim of this study was to evaluate the effectiveness of one-stage correction of apical-rectal prolapse by replacing the uterosacral and cardinal ligament complex with a synthetic implant and closing rectovaginal fascia defects by forming native neofascia.

Methods

The study included 107 patients of reproductive age with apical-rectal prolapse, who underwent surgical correction of pelvic organ prolapse by replacing the uterosacral and cardinal ligament complex with a synthetic implant and closing the defects by forming native neofascia. The preoperative examination included a collection of complaints, a personal medical history, a physical and gynecological examination, electromyography of the pelvic floor muscles and anal sphincter, and defecography. The impact of the disease on quality of life was assessed using the Pelvic Floor Impact Questionnaire (PFIQ-7), which was completed by patients before surgery. In the postoperative period, examinations were carried out after 3, 9 and 12 months and then annually thereafter.

Results

The average age of the patients was 38.36 ± 5.07 years, with body mass index of 27.32 ± 4.17 kg/m2. History of childbirth was 1.86 ± 0.74. The average duration of the operation was 48.4 ± 19.6 minutes, the volume of intraoperative blood loss was 50 ± 90 ml, the length of hospital stay was 4.2 ± 0.7 bed days (maximum 7). Anatomical recovery efficiency, assessed according to the Pelvic Organ Prolapse Quantification (POP-Q) System, was 91.6%. Average POP-Q values (D, C, Ap, Bp) were –8.1 ± 0.7, –7.1 ± 0.6, –2.0 ± 0.7, and –2.6 ± 0.6, respectively. An assessment of patient satisfaction with the surgical results showed that 96.0% of patients were satisfied and would recommend this intervention to their relatives and friends. According to the PFIQ-7 questionnaire, the total score decreased from 130 [100; 168] to 46 [28; 74] by 12 months (p < 0.001; Wilcoxon test).

Conclusion

Surgical reconstruction of the pelvic floor in stage III–IV apical-rectal prolapse by means of prosthetic replacement of the uterosacral and cardinal ligament complex with a synthetic implant and closure of rectovaginal fascia defects by forming native neofascia is a safe technique that provides high anatomical and functional efficiency, and improves patients’ quality of life. Cervical and serum relaxin-1 and elastin as biomarkers of cervical remodeling during pregnancy: a pilot study

Abstract

Background: Cervical remodeling during pregnancy is a multistage biological process that involves sequential changes in the extracellular matrix, hormonal regulation, and biomechanical properties of the tissue. Existing methods for assessing the risk of preterm birth mainly identify already established structural changes of the cervix, which limits the possibilities for early diagnosis. The search for biochemical markers that reflect early stages of functional remodeling is an important task of modern perinatology. Aim: The aim of this study was to assess the predictive value of cervical and serum relaxin-1 and elastin as biochemical markers of functional cervical remodeling and to evaluate their potential for early stratification of the probability of delivery.

Methods

A single-center prospective cohort study was conducted. Blood serum and cervical fluid samples were collected followed by determination of relaxin-1 and elastin concentrations using an enzyme-linked immunosorbent assay (n = 43). All patients underwent transvaginal cervicometry, compression elastography (HR, IOS, EOS, ECI), and the Actim Partus test. Spearman correlation analysis and ROC analysis were performed to evaluate predictive performance.

Results

Relaxin-1 correlated with ultrasound parameters of cervical stiffness (HR, ECI) and delivery interval. Higher serum relaxin-1 levels were associated with the mature cervical phenotype (p = 0.004) and a positive Actim Partus test (p = 0.028). Maximum relaxin-1 values in cervical fluid were observed in the maturing cervix phenotype (p = 0.001), which corresponds to the phase of active functional remodeling. Statistically significant differences in elastin levels were found only in cervical fluid (p = 0.024), with higher values observed in the immature phenotype. The combined model (HR + RLN1c + Actim Partus) demonstrated the highest predictive accuracy for delivery within 14 days (AUC = 0.982; 95% CI 0.982–1.000; sensitivity 100%; specificity 97.3%).

Conclusion

Relaxin-1 and elastin are involved in cervical remodeling during pregnancy and may be considered potential biochemical markers of functional cervical maturity. The combined use of biochemical markers and ultrasound elastography parameters improves the accuracy of delivery prediction. The data obtained require confirmation in larger cohorts with consideration of gestational age and may serve as a basis for the development of new diagnostic algorithms for assessing cervical maturity. Reviews Treatment tactics for chronic endometritis

Abstract

Chronic endometritis (CE) is a common pathology among women of reproductive age, which negatively affects health, fertility and quality of life. Clinical guidelines for its treatment have not yet been developed either abroad or in the Russian Federation, and therefore a unified algorithm for the management of patients with CE is lacking. Current literature offers a wide variety of treatment methods, including a two-stage approach. At the same time, the primary and fundamental stage of CE treatment is the use of antibacterial and anti-inflammatory therapy, as the disease is considered to be infectious. However, this approach to CE treatment, with its emphasis on antibacterial therapy, does not always resolve issues associated with reproductive failure and menstrual irregularities (MI). It has been suggested that treatment failure may be related to the ambiguity of the exclusively infectious etiology of chronic endometrial inflammation (CEI). This review article addresses the study, analysis, and generalisation of the world literature on CE treatment, utilizing publications from open electronic databases such as Google Scholar, PubMed, eLIBRARY, and CyberLeninka over the past 8 years. In overcoming the infectious factor in the genesis of implantation failure and MI, modern therapy aimed at elimination of pathogens does not always lead to the desired result (restoration of fertility and morphological characteristics of the endometrium). Such cases require extended clinical examination of patients to be consulted further by specialists of related fields to identify diseases / conditions that contribute to the development of CEI. Given the variety of factors that may contribute to this, patients who do not respond to conventional treatment (no clinical and pathomorphological effects) require more in-depth pre-treatment evaluation with the selection of personalised therapy. The search for new therapeutic methods is ongoing to improve treatment outcomes. Disorders of spermatogenesis and the effectiveness of assisted reproductive technology programs: a literature review

Abstract

Disorders of spermatogenesis represent a significant yet insufficiently studied factor that influences the outcomes of assisted reproductive technology (ART) programs and the incidence of early reproductive loss. The aim of this review was to systematize current evidence on the relationship between routine and advanced parameters used for the assessment of spermatogenesis and embryo quality, ART effectiveness, and the risk of implantation failure. The results of large retrospective and prospective studies, as well as systematic reviews and meta-analyses, addressing the role of sperm concentration, motility, morphology, and sperm DNA fragmentation in determining embryological and clinical outcomes of ART have been analyzed. It has been shown that conventional semen parameters have limited prognostic value, whereas sperm DNA fragmentation is associated with reduced clinical pregnancy rates and an increased risk of miscarriage. Special attention is given to modern methods for assessing sperm DNA integrity and their diagnostic capabilities. The review also discusses the impact of oxidative stress and the role of antioxidant therapy in the context of male preconception preparation prior to ART programs. The review highlights the importance of a comprehensive evaluation of male reproductive function and a personalized approach to patient management in order to improve ART outcomes and reduce the risk of early reproductive loss. Case reports Bartholin’s gland cancer is a rare tumor of the vulva. Four clinical cases

Abstract

The greater vestibular glands of the vagina were described in the 17th century by the Danish anatomist Caspar Bartholin the Younger. In his honor, the glands received their second name — Bartholin’s glands (BG). Obstetricians and gynecologists more often encounter retention and inflammatory lesions of the BG in their routine clinical practice. Furthermore, different types of BG epithelium can be a source of malignant tumors characterized by varying clinical courses. The following malignant BG tumors have been described in the literature: transitional cell carcinoma, neuroendocrine carcinoma, adenocarcinoma, adenosquamous carcinoma, adenoid cystic carcinoma, leiomyosarcoma, and epithelial-myoepithelial carcinoma. The diagnostic criteria for primary BG carcinoma were proposed in 1972 by Dikran L. Chamlian and Herbert B. Taylor and remain valid today: the tumor is located in the BG region and originates from cellular elements characteristic of the region; areas of clear transition from normal vulvar tissue to tumor elements are identified; there are no signs that the tumor is a metastasis from a primary tumor in another location. Malignant vulvar tumors, according to available literature, account for 3% to 5% of all vulvar carcinomas. Despite the rarity of malignant BG diseases, they constitute the majority of vulvar adenocarcinomas. Data on malignant BG tumors in the literature are presented very sparingly, mainly in the form of case reports or small series. This article describes four clinical cases of primary malignant BG tumors. All four patients were treated in the Department of Gynecologic Oncology, the N.N. Petrov National Medical Research Center of Oncology from 2019 to 2025. Two cases of HPV-associated squamous cell carcinoma, one of adenocarcinoma, and one of myoepithelial adenocarcinoma are reported. The authors present the signs and symptoms, clinical course, treatment outcomes, and recurrences of the malignant BG tumors with varying histopathologies. Malignant BG tumors can be cured with a high probability in case of early diagnosis and adequate combined treatment, including surgical removal of the tumor, radiation therapy, and polychemotherapy.

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