[Placental mesenchymal dysplasia]. / Mezenkhimal'naia displaziia platsenty.

OBJECTIVE: To carry out a clinical and morphological analysis of 6 cases of placental mesenchymal dysplasia (PMD) that is not associated with Beckwith-Wiedemann syndrome. MATERIAL AND METHODS: Medical records, placental macroscopic and microscopic changes, histochemical (MSB staining) and immunohistochemical studies of placental tissue with antibodies against p57, CD34, smooth muscle actin, desmin, and Ki-67 were analyzed. RESULTS: Vascular anomalies in the chorionic plate and stem villi, the increased size and edema of the stem villi during normal formation of the terminal branches of the villous tree, the lack of proliferation of villous trophoblast were the typical signs of PMD and were noted in all cases. Comparison of the results of ultrasonography with the morphological pattern of the disease suggested that there were ultrasound signs that were typical of PMD. The characteristics of the course and outcomes of pregnancy in PMD were given. The features of morphological changes in the presence of PMD concurrent with preeclampsia were found. Significant variability in p57 expression in PMD was shown and variants of changes given. There were no substantial features of the expression of desmin and smooth muscle actin in PMD. CONCLUSION: MDP has typical morphological and ultrasound signs. The significant variability in the levels of chorionic gonadotropin and alpha-fetoprotein and in the expression of p57 does not allow their use in the differential diagnosis of PMD. The high incidence of thrombotic events in the intervillous space and fetal vessels, as well as intrauterine growth restriction, intrauterine hypoxia, and an impaired neonatal adaptation period in PMD should be taken into account when determining the management tactics for female patients and newborns.

[Features of the pathogenesis of the placenta growing in the scar after cesarean section]. / Osobennosti patogeneza vrastaniia platsenty v rubets posle kesareva secheniia.

OBJECTIVE: to investigate the structural and pathogenetic features of pathological placental attachment in the scar after cesarean section. MATERIAL AND METHODS: The investigators explored 12 uteri; 11 of which were removed with placentas at 9 to 38 weeks' gestation (one in the first trimester, three at 18-22 weeks, two at 32-35 weeks, and five at 37-38 weeks); one uterus was removed after an artificial abortion at 12 weeks' gestation in the scar, as well as the scars excised in the first trimester in non-developing (n=4) and progressive (n=2) pregnancies. For histological examination, fragments of the full-thickness uterine wall were taken from the placental bed in different areas. The sections were stained for fibrin with hematoxylin and eosin, van Gieson stain, and the Martius scarlet/blue (MSB) technique. Decidual tissue, trophoblast, vascular component, and smooth muscle tissue were identified by an immunohistochemical assay using antibodies to vimentin, pan-cytokeratin, vascular endothelium (СD31), and smooth muscle actin. RESULTS: In most cases, placental localization in the scar after cesarean section was accompanied by abnormal placental attachment: almost always placenta accreta, less frequently in combination with its ingrowth (placenta accreta/increta). The morphological substrate of placenta increta was a change in the content and ratio of normal histological components in the uterine wall, such as the mucosa, smooth muscle tissue, and vessels (the absence or thinning of decidual tissue and the myometrium, as well as its cicatricial changes). The structural criterion for placenta increta was necrosis of the walls of the large veins in the myometrium due to the replacement of their intermediate trophoblast and fibrin and to the destruction of vessel walls, leading to prolapse of the chorionic villi into the veins. CONCLUSION: In most cases, placental localization in the scar after cesarean section is accompanied by abnormal placental attachment: placenta accreta, less frequently in combination with its ingrowth (placenta accreta/increta).

[The mother-placenta-fetus system in diffuse toxic goiter: Morphopathological aspects].

OBJECTIVE: to compare the clinical and morphological parallels of the mother-placenta-fetus system in diffuse toxic goiter (DTG) through current morphological examinations. SUBJECTS AND METHODS: Sixty-five women whose pregnancy occurred with DTG were examined using both clinical and morphological studies (light, scanning electron, and atomic-force microscopies and macro- and microelement analysis); the placenta and uterus were investigated. RESULTS: Destructive changes and microrelief impairment, resulting from circulatory disorders (ischemia) and hemic hypoxia, were observed in the presence of DTG during pregnancy. Abnormal placental immaturity developed; the number of terminal villi decreased; sclerosis occurred. The magnitude of changes showed up to a greater extent in the myometrium, umbilical cord, and placenta of women, whose pregnancy occurred with DTG, and in patients with disease recurrence. In preeclampsia, plethora, stasis, and thrombosis were added to circulatory disorders. CONCLUSION: Not only the diagnosis itself of DTG, but also the type of its course and the pattern of obstetric disease, primarily preeclampsia, affect the state of structural components of the uteroplacental unit.

[Gestational diabetes mellitus: yesterday, today, tomorrow].

Gestational diabetes mellitus (GDM) is hyperglycemia that is first detected during pregnancy and does not meet the criteria for manifest diabetes. The incidence of GDM worldwide varies from 1 to 14% and that in Russia is as high as 4%. Hyperglycemia during pregnancy is associated with the development of preeclampsia, the birth of a big baby, emergency cesarean section, birth trauma, and neonatal hypoglycemia. The fact that there is no well-organized screening for GDM in our country leads to that the diagnosis of this condition is delayed for 4--20 weeks in 50-60% of cases. The risk group distribution of pregnant women leads ,to the diagnosis of GDM only in 50% of cases. At the same time, pregnancy is accompanied by physiological insulin resistance so the latter itself is a clinically important risk factor for carbohydrate metabolic disturbances. The Hyperglycemia and Adverse Pregnancy Outcomes (HYPO) study has indicated that the previously used diagnostic criteria for GDM require reconsideration. There is a need for uniform standards for the diagnosis and treatment of carbohydrate metabolic disturbances during pregnancy. The concepts (diabetes mellitus (DM)W and (manifest (new-onset DM during pregnancy( and directly UGDM( require clear clinical and laboratory definitions. Furthermore, GDM is a risk factor for obesity, type 2 DM and cardiovascular diseases in the mother and her offspring in future.

[Blood rheological characteristics of uteroplacental blood flow in severe gestosis].

OBJECTIVE: To investigate the clinical and morphological features of uteroplacental blood flow during pregnancy in severe gestosis. SUBJECTS AND METHODS: One hundred and twenty-five patients with severe gestosis were examined. Scanning probe and electron microscopy with macro- and microelement analysis and transmission microscopy were used to study their placentas, umbilical cords, endometrium, myometrium, and maternal blood in severe gestosis. RESULTS: It is shown that circulatory disorders in the structural components of the examined tissues and organs, as well as changes in cytoarchitectonics and red blood cell functional properties may be a component of the trigger of disseminated intravascular coagulation, followed by impaired maternal and fetal vital activity. CONCLUSION: The investigation of the pathomorphological features of the microcirculatory bed in the mother-placenta-fetus system in gestosis has shown that possible methods of their correction should be further sought.

[Surgical treatment of pregnant women with benign ovarian tumors].

The article describes the features of surgery in tumors and tumor-like formations of the ovaries in pregnant women. The influence of surgery on the course and outcome of pregnancy and childbirth is presented. It is showed high efficiency of laparoscopic surgery during I and II trimesters of pregnancy.

[Placental alterations in pregnant women with autoimmune polyglandular endocrinopathy].

The paper gives the results of a morphological study of 13 placentas from patients with rare autoimmune polyglandular syndrome and adrenal insufficiency, a disease history of 2 to 14 years, receiving corticosteroid replacement therapy. All pregnancies were full-term; labors were term surgical. The clinical and morphological associations suggest the placental alterations characteristic of diabetes mellitus, autoimmune diseases, uteroplacental and placentofetal ischemia.

[Peculiarities of pregnancy management after multiple stenting of coronary arteries].

This paper describes the strategy for pregnancy and labour management in women with the history of myocardial infarction after multiple stenting of coronary arteries using stents with cytostatic coating. The authors discuss a broad range of diseases underlying coronary lesions in young pregnant women receiving antiaggregation therapy. Neither multiple stenting nor intake of aspirin and ticlopid provoked teratogenic effect.

[The mother-placenta-fetus system in maternal thyroid diseases].

In maternal thyroid diseases, the placenta shows an increase in complications during pregnancy. There are signs of lesions as alterations, focal sclerosis, and fibrinoid necrosis. There is also a circulatory disorder as plethora and thrombosis. Progression in these changes correlates with the cases of miscarriage and other pathology in the obstetric history. The concurrence of obstetric and endocrine diseases increases the risk of pregnancy, labor, and delivery complications in different maternal thyroid diseases.

[Use of scanning microscopic techniques in the study of uteroplacental relationships in hypothyroidism].

Uteroplacental relationships were studied in women with and without hypothyroidism, by applying electron, atomic force, and scanning electron microscopies, which enables one to gain more insight into morphometric characteristics. Moreover, not only fixed, but also native materials were used, which brings the studies to a live object and opens up new avenues for rapid diagnosis. The use of gross and trace analysis allows the biochemical parameters of the structure of uterine and placental tissues to be studied for an additional diagnosis and development of treatment options.

[Functional morphology of maternal placental circulation in severe gestosis].

One hundred and twenty-five women with incomplete pregnancy in the presence of severe gestosis were examined. The placenta of women receiving 6% hydroxyethyl starch showed a compensatory plethora of villous chorion, stabilization of wall structures in the capillaries and red blood cell membranes, which contributed to the normalization of fetal oxygen homeostasis. In the female myometrium, the capillary lumen displayed starch fibers that stabilized the capillary wall, promoting the stabilization of the shape of vessels, and better circulation as a plethora.

[Pregnancy in women with heart defects: outlook on the problem].

Modern approach to management of pregnancy and delivery in women with heart defects is presented in this paper. The 3-level system of observation of this contingent of patients is based on stratification of risk of development of cardiological complications which allows to form an algorithm of physicians actions, and to optimize tactics of ambulatory and hospital stages of treatment. Stratification of risk is supplemented with quantitative echocardiographic parameters which reflect hemodynamic overload of the myocardium and facilitate work of a practical physician. Special consideration is given to pregnant women subjected to palliative cardiac surgery. If contractile function is preserved these women have good prognosis relative to prolongation of pregnancy and unassisted delivery.

[A newly diagnosed intraventricular septal defect in a pregnant woman presenting with pulmonary hypertension].

This clinical description of pregnancy follow-up and labour management in women with severe pulmonary hypertension caused by an interventricular septum defect is intended to familiarize practicing physicians with the methods for maintaining pregnancy and ensuring spontaneous delivery despite the said pathology. Indispensable conditions for the attainment of these goals include thorough clinical and laboratory control, comprehensive analysis of possible complications, efficacious epidural anesthesia, and correct choice of medicines.

[Diabetic fetopathy in gravida with autoimmune hemolytic anemia complicated by steroid diabetes].

The authors made a clinicoanatomic analysis of fetal death in a 32-year-old diabetic gravida at 34-35 weeks gestational age. Fetal autopsy identified the characteristic signs of fetopathy: macrosomy, cardiomegaly, hepatomegaly, and brain weight reduction. Histological analysis revealed minute foci of leukomalacia with glial proliferation in the cerebral hemispheres; adipose and hyaline drop degeneration of cardiomyocytes in the heart, that of hepatocytes in the liver, the proximal renal tubular epithelial cells; hemorrhages in the respiratory portions of the lung. The pancreas displayed inflammation foci, hypertrophy and hyperplasia of the islets of Langerhans. Immunohistochemical studies identified cells with enlarged nuclei among the beta and alpha-cells. The placenta showed a large mass with pronounced changes. It has been demonstrated that steroid diabetes may lead to the development of diabetic fetopathy and placental changes, which are typical of maternal diabetes.

[The course of the diabetes type I in pregnants with different levels of antibodies to insulin].

The course of the diabetes type I at pregnants (n=120) with different levels of idiotypic (ABI) and antiidiotypic (AB2) antibodies to insulin was investigated. It is known that AB2 to insulin can interact with insulin receptor. It was shown that changes of levels AB1 and AB2 to insulin are often observed at pregnants suffered from diabetes type I. Isolated high levels of AB1 to insulin is relatively good prognostic sign of the course of the diabetes type I at pregnants. On the contrary, isolated high levels of AB2 to insulin lead to decompensation of the diabetes type I and deep glycohemia. High levels of AB1 and AB2 to insulin together lead to unstable course of the diabetes type I. The same situation is observed in case of abnormal low levels AB1 and AB2 to insulin, taking into consideration that serum of health people contains the certain level of autoantibodies (AB1 and AB2) to insulin. The conclusion about significance of detection AB1 and AB2 to insulin during pregnancy of patients with diabetes type I was made.

[Pregnancy management and spontaneous labor in heart diseases: present-day solution to the dilemma].

AIM: to study cardiac rhythm variability (CRV), to optimize pregnancy management tactics and to choose a delivery procedure. SUBJECTS AND METHODS: Ninety-six 19-to-37 year-old (mean age 28.3 +/- 9.4 years) women at 35-39 weeks gestational age were examined. All the women were diagnosed as having congenital or acquired (rheumatic) heart disease. Their hemodynamics and CRV were analyzed according to the type of hemodynamic overload, for which purpose three patient groups were formed: 1) volume overload; 2) pressure overload; and 3) combined overload. A control group comprised 40 healthy pregnant women. Before and 2-3 days after delivery, all the women underwent 24-hour Holter cardiac rhythm monitoring with the estimation of the temporary and spectral parameters of CRV. RESULTS: In antepartum heart diseases accompanied by volume overload, there was a tendency for total CRV (SDNN 95.4 +/- 15.8 msec versus 125.5 +/- 17.8 msec in the controls) to decrease and for sympathetic activity to significantly increase (SDANN 65.7 +/- 13.7 and 109.9 +/- 14.7 msec, respectively; p < 0.05). When pressure overload (a moderate gradient) developed, the temporary parameters of total CRV, sympathetic and parasympathetic activities did not differ from those in the control group. Heart diseases attended by pressure overload and a high gradient were characterized by a significant reduction in total CRV (100.5 +/- 24.6 msec; p < 0.05) as compared with those in patients having a moderate pressure gradient, with a declining trend for total spectrum power, Group 3 patients showed a reduction in all the indices reflecting the temporary and spectral characteristics, suggesting a considerable rise in sympathetic activity and a decrease in total autonomic spectrum power. CONCLUSION: Based on SRV studies, indications for prolonged pregnancy and spontaneous or, in some cases, surgical delivery can be assessed in pregnant women with heart diseases.

[Heart disease and pregnancy: grounds for confidence in the safe outcome].

Indications for prolongation of pregnancy and spontaneous delivery in women with congenital and acquired heart disease are proposed based on original observations and literature data. Special attention is given to risk factors of an undesirable outcome of pregnancy for mothers with high functional class cardiac insufficiency, high blood pressure gradient, and severe pulmonary hypertension with mitral valve and aortic stenosis.

[Optimization of antihypertensive therapy in pregnant women using 24-hour arterial pressure monitoring].

The purpose of the investigation was to study peculiarities in the parameters of 24-hour arterial pressure monitoring (APM) in pregnant women with various extragenital and obstetric pathologies to define indications to administration and optimization of hypotensive therapy. The results of 24-hour APM of 558 pregnant women with a suspected arterial hypertension (AH) of different origins were matched with peculiarities of pregnancy and its outcome (gestosis, an abortion due to AH complications, serious obstetric complications such as intrauterine fetal death or detachment of placenta). The control group consisted of 41 women without cardiovascular diseases or any complications during pregnancy. The analysis of the results made it possible to offer a classification of 24-hour curves of systolic and diastolic arterial pressure and heart rate based on relations between these parameters. This classification is convenient for clinical application and makes it possible not only to define indications to hypotensive therapy, but also to recommend certain pharmacological group of hypotensive preparations in each particular case. Prognostication of the development of severe gestosis or serious obstetric complications.

[Placental morphology in pregnancy complicated with iron-deficiency anemia].

Iron-deficiency anemia in pregnant females negatively affects pregnancy, delivery, neonatal infants. Anemia-caused placental changes found during pregnancy are characterized by imbalance between the processes of adaptation and dysadaptation in response to the developed hypoxia in the pregnant-placenta-fetus system and placental tissue ischemia. When iron-deficiency anemia had developed before pregnancy, placental morphological changes show the signs of chronic placental insufficiency. The developed therapy for anaemia with Ferro-Folgama corrects all the elements of the pregnant-placenta-fetus system.

[Supraventricular paroxysmal tachycardias during pregnancy: the therapeutic tactics and prognosis].

The paper contains recommendations on treatment of supraventricular paroxysmal tachycardias (SVPT) during pregnancy. The recommendations are based on contemporary literature data and authors" own data. SVPT in postural syndrome are shown to be benign and to demand no continuous antiarrhythmic therapy, while tachycardiac attacks are terminated by vagal tests and adenosine application. Relapsing and steady forms of SVPT with a high heart rate are accompanied by subjective symptoms and require preventive antiarrhythmic therapy, which should be conducted considering risk/benefit ratio. According to the authors, sotalol is the most effective and safe pharmaceutical.