akusherstvoObstetrics, Gynecology and ReproductionАкушерство, Гинекология и Репродукция2313-73472500-3194IRBIS LLC10.17749/2313-7347/ob.gyn.rep.2024.522akusherstvo-2101Research ArticleОRIGINAL ARTICLESОРИГИНАЛЬНЫЕ СТАТЬИOptimization of intrauterine interventions in spontaneous abortionОптимизация внутриматочных вмешательств при самопроизвольном абортеhttps://orcid.org/0000-0002-0729-9995СаловИ. А.SalovI. A.

Салов Игорь Аркадьевич – д.м.н., профессор, заслуженный врач Российской Федерации, зав. кафедрой акушерства и гинекологии лечебного факультета, директор Университетской клиники акушерства и гинекологии

Scopus Author ID: 6602843316.

Author ID: 428263

410012 Саратов, ул. Большая Казачья, д. 112

Igor A. Salov – MD, Dr Sci Med, Professor, Honored Doctor of the Russian Federation, Head of the Department of Obstetrics and Gynecology, Faculty of General Medicine, Director of the University Clinic of Obstetrics and Gynecology

112 Bolshaya Kazachya Str., Saratov 410012

https://orcid.org/0000-0002-4220-1236НаумоваЮ. В.NaumovaI. V.

Наумова Юлия Владимировна – к.м.н., доцент кафедры акушерства и гинекологии лечебного факультета 

410012 Саратов, ул. Большая Казачья, д. 112

Iuliia V. Naumova – MD, PhD, Associate Professor, Department of Obstetrics and Gynecology, Faculty of General Medicine

112 Bolshaya Kazachya Str., Saratov 410012

jvnaumova@list.ruhttps://orcid.org/0009-0003-4036-6162ЛомовицкаяМ. В.LomovitskayaM. V.

Ломовицкая Марина Владимировна – ординатор кафедры акушерства и гинекологии лечебного факультета 

410012 Саратов, ул. Большая Казачья, д. 112

Marina V. Lomovitskaya – MD, Clinical Resident, Department of Obstetrics and Gynecology, Faculty of General Medicine

112 Bolshaya Kazachya Str., Saratov 410012

ФГБОУ ВО «Саратовский государственный медицинский университет имени В.И. Разумовского» Министерства здравоохранения Российской ФедерацииРоссияRazumovsky Saratov State Medical UniversityRussian Federation202404072024183352364Copyright © Salov I.A., Naumova I.V., Lomovitskaya M.V., 20242024Салов И.А., Наумова Ю.В., Ломовицкая М.В.Salov I.A., Naumova I.V., Lomovitskaya M.V.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.gynecology.su/jour/article/view/2101Introduction

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

Aim: to evaluate clinical effectiveness and safety of RPOC removal in incomplete spontaneous abortion using hysteroscopic morcellation.

Materials and Methods

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

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

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.

Введение

Введение. Остатки плодного яйца (ОПЯ) выявляются у 15 % женщин после самопроизвольного или медицинского аборта. Слепое удаление ОПЯ из полости матки до сих является «золотым стандартом» хирургического лечения, однако оно может быть связано с высоким риском ряда осложнений, создающих серьезную угрозу репродуктивной функции и качеству жизни женщины. Альтернативным методом элиминации ОПЯ является оперативная гистероскопия, демонстрирующая преимущества визуального контроля.

Цель

Цель: оценить клиническую эффективность и безопасность удаления ОПЯ при неполном самопроизвольном аборте с помощью гистероскопической морцелляции.

Материалы и методы

Материалы и методы. В проспективное сравнительное исследование включены 135 женщин с неполным самопроизвольным абортом в возрасте от 18 до 40 лет, среди которых выделены 3 группы: группа 1 – 42 пациентки, которым выполнялась электромеханическая вакуум-аспирация (ЭВА) ОПЯ; группа 2 – 44 пациентки, которым проводилась мануальная вакуум-аспирация (МВА) ОПЯ; группа 3 – 49 пациенток, которым проводилась гистероскопическая морцелляция (ГМ) ОПЯ. У всех пациенток измеряли уровень общего эндотоксина, определяли цитокиновый профиль метроаспиратов, показатель микроциркуляции в эндометрии до и в 1-е сутки после оперативного лечения, выполняли ультразвуковое исследование (УЗИ) гениталий на 3–5-е сутки после операции.

Результаты

Результаты. В послеоперационном периоде в группах ЭВА и МВА определен значительный рост концентраций общего эндотоксина и интерлейкина (англ. interleukin, IL) IL-1β по сравнению с показателями до лечения (р < 0,05); в группе ГМ их значения после операции достоверно не изменились (р > 0,05). Рост содержания IL-8 и фактора некроза опухоли альфа (англ. tumor necrosis factor alpha, TNF-α) после операции был статистически значимым во всех группах (p = 0,001). В группах ЭВА и МВА выявлено снижение уровней противовоспалительных цитокинов IL-4 и IL-10 (p = 0,001), а в группе ГМ их значения существенно не менялись (p > 0,05). Значимое увеличение скорости микрокровотока при сравнении с показателями до лечения обнаружено в группах ЭВА и МВА (p = 0,001); в группе ГМ скорость микрокровотока значимо не отличалась от исходной (р = 0,415). Неполное удаление ОПЯ установлено у 4,5 % пациенток группы МВА, у всех пациенток групп ЭВА и ГМ диагностирована полная элиминация ОПЯ. Интраоперационного кровотечения, перфорации матки не было ни у одной пациентки.

Заключение

Заключение. Ближайшие результаты лечения показали, что удаление ОПЯ посредством ГМ является эффективным и безопасным методом лечения. Ограниченный воспалительный ответ и стабильная микроциркуляция в эндометрии при использовании ГМ свидетельствуют о минимальном воздействии на эндометрий, что снижает вероятность послеоперационной адгезии.

остатки плодного яйцаОПЯцитокиновый профильвакуум-аспирацияоперативная гистероскопиягистероскопическая морцелляцияГМretained products of conceptionRPOCcytokine profilevacuum aspirationoperative hysteroscopyhysteroscopic morcellationHMReferencesGuarino A., Di Benedetto L., Assorgi C. et al. Conservative and timely treatment in retained products of conception: a case report of placenta accreta ritention. Int J Clin Exp Pathol. 2015;8(10):13625–9.Guarino A., Di Benedetto L., Assorgi C. et al. Conservative and timely treatment in retained products of conception: a case report of placenta accreta ritention. Int J Clin Exp Pathol. 2015;8(10):13625–9. 2Sharma D.P., Choudhary D.V., Rahariya D.P. Overview of retained products of conception and its management. IOSR Journal of Dental and Medical Sciences. 2017;16(4):70–5. https://doi.org/10.9790/0853-1604087075.. Sharma D.P., Choudhary D.V., Rahariya D.P. Overview of retained products of conception and its management. IOSR Journal of Dental and Medical Sciences. 2017;16(4):70–5. https://doi.org/10.9790/0853-1604087075.Smorgick N., Barel O., Fuchs N. et al. Hysteroscopic management of retained products of conception: meta-analysis and literature review. Eur J Obstet Gynecol Reprod Biol. 2014;173:19–22. https://doi.org/10.1016/j.ejogrb.2013.11.020.Smorgick N., Barel O., Fuchs N. et al. Hysteroscopic management of retained products of conception: meta-analysis and literature review. Eur J Obstet Gynecol Reprod Biol. 2014;173:19–22. https://doi.org/10.1016/j.ejogrb.2013.11.020.Sutherland N.S.V., Rajesh H. The intrauterine Bigatti Shaver System: an alternative option for focal retained products of conception. Case Rep Obstet Gynecol. 2018;2018:1536801. https://doi.org/10.1155/2018/1536801.Sutherland N.S.V., Rajesh H. The intrauterine Bigatti Shaver System: an alternative option for focal retained products of conception. Case Rep Obstet Gynecol. 2018;2018:1536801. https://doi.org/10.1155/2018/1536801.Foreste V., Gallo A., Manzi A. et al. Hysteroscopy and retained products of conception: an update. Gynecol Minim Invasive Ther. 2021;10(4):203–9. https://doi.org/10.4103/GMIT.GMIT_125_20.Foreste V., Gallo A., Manzi A. et al. Hysteroscopy and retained products of conception: an update. Gynecol Minim Invasive Ther. 2021;10(4):203–9. https://doi.org/10.4103/GMIT.GMIT_125_20.Munros J., Gracia M., Nonell R. et al. Delayed hysteroscopic removal of retained products of conception is associated with spontaneous expulsion. SRL Reprod Med Gynecol. 2017;3(1):024–028.Munros J., Gracia M., Nonell R. et al. Delayed hysteroscopic removal of retained products of conception is associated with spontaneous expulsion. SRL Reprod Med Gynecol. 2017;3(1):024–028.Hooker A.B., Thurkow A. Asherman’s syndrome after removal of placenta remnants: a serious clinical problem. Gynecol Surg. 2011;8(4):449–53. https://doi.org/10.1007/s10397-011-0677-5.Hooker A.B., Thurkow A. Asherman’s syndrome after removal of placenta remnants: a serious clinical problem. Gynecol Surg. 2011;8(4):449–53. https://doi.org/10.1007/s10397-011-0677-5.Nanda K., Lopez L.M., Grimes D.A. et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2012;(3):CD003518. https://doi.org/10.1002/14651858.CD003518.pub3.Nanda K., Lopez L.M., Grimes D.A. et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2012;(3):CD003518. https://doi.org/10.1002/14651858.CD003518.pub3.Klement A.H., Frederic M., Bentov Y. et al. Oral contraceptive pills as an option for non-surgical management of retained products of conception – a preliminary study. Gynecol Endocrinol. 2018;34(7):609–11. https://doi.org/10.1080/09513590.2018.1427714.Klement A.H., Frederic M., Bentov Y. et al. Oral contraceptive pills as an option for non-surgical management of retained products of conception – a preliminary study. Gynecol Endocrinol. 2018;34(7):609–11. https://doi.org/10.1080/09513590.2018.1427714.Stewart K.T., Lee J.S., Pan K. et al. Outcome of using vaginal misoprostol for treatment of retained products of conception after first trimester miscarriage: a retrospective cohort study. Eur J Contracept Reprod Health Care. 2020;25(6):474–9. https://doi.org/10.1080/13625187.2020.1807498.Stewart K.T., Lee J.S., Pan K. et al. Outcome of using vaginal misoprostol for treatment of retained products of conception after first trimester miscarriage: a retrospective cohort study. Eur J Contracept Reprod Health Care. 2020;25(6):474–9. https://doi.org/10.1080/13625187.2020.1807498.Alonso L., Nieto L., Carugno J. Hysteroscopic removal of retained products of conception implanted over a focal area of adenomyosis: a case report. J Minim Invasive Gynecol. 2018;25(3):382–3. https://doi.org/10.1016/j.jmig.2017.09.010.Alonso L., Nieto L., Carugno J. Hysteroscopic removal of retained products of conception implanted over a focal area of adenomyosis: a case report. J Minim Invasive Gynecol. 2018;25(3):382–3. https://doi.org/10.1016/j.jmig.2017.09.010.Hamerlynck T.W., Blikkendaal M.D., Schoot B.C. et al. An alternative approach for removal of placental remnants: hysteroscopic morcellation. J Minim Invasive Gynecol. 2013;20(6):796–802. https://doi.org/10.1016/j.jmig.2013.04.024.Hamerlynck T.W., Blikkendaal M.D., Schoot B.C. et al. An alternative approach for removal of placental remnants: hysteroscopic morcellation. J Minim Invasive Gynecol. 2013;20(6):796–802. https://doi.org/10.1016/j.jmig.2013.04.024.Ben-Ami I., Melcer Y., Smorgick N. et al. A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception. Int J Gynaecol Obstet. 2014;127(1):86–9. https://doi.org/10.1016/j.ijgo.2014.05.003.Ben-Ami I., Melcer Y., Smorgick N. et al. A comparison of reproductive outcomes following hysteroscopic management versus dilatation and curettage of retained products of conception. Int J Gynaecol Obstet. 2014;127(1):86–9. https://doi.org/10.1016/j.ijgo.2014.05.003.Capmas P., Lobersztajn A., Duminil L. et al. Operative hysteroscopy for retained products of conception: efficacy and subsequent fertility. J Gynecol Obstet Hum Reprod. 2019;48(3):151–4. https://doi.org/10.1016/j.jogoh.2018.12.005.Capmas P., Lobersztajn A., Duminil L. et al. Operative hysteroscopy for retained products of conception: efficacy and subsequent fertility. J Gynecol Obstet Hum Reprod. 2019;48(3):151–4. https://doi.org/10.1016/j.jogoh.2018.12.005.Jansen F.W., Vredevoogd C.B., van Ulzen K. et al. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000;96(2):266–70. https://doi.org/10.1016/s0029-7844(00)00865-6.Jansen F.W., Vredevoogd C.B., van Ulzen K. et al. Complications of hysteroscopy: a prospective, multicenter study. Obstet Gynecol. 2000;96(2):266–70. https://doi.org/10.1016/s0029-7844(00)00865-6.Gambadauro P., Gudmundsson J., Torrejón R. Intrauterine adhesions following conservative treatment of uterine fibroids. Obstet Gynecol Int. 2012;2012:853269. https://doi.org/10.1155/2012/853269.Gambadauro P., Gudmundsson J., Torrejón R. Intrauterine adhesions following conservative treatment of uterine fibroids. Obstet Gynecol Int. 2012;2012:853269. https://doi.org/10.1155/2012/853269.Mallick R., Middleton B. The use of hysteroscopic morcellation in the outpatient management of retained products of conception. Res Rep Gynaecol Obstet. 2017;1(1):15–7. https://doi.org/10.13140/RG.2.2.27125.17128.Mallick R., Middleton B. The use of hysteroscopic morcellation in the outpatient management of retained products of conception. Res Rep Gynaecol Obstet. 2017;1(1):15–7. https://doi.org/10.13140/RG.2.2.27125.17128.Hamerlynck T.W., van Vliet H.A., Beerens A.S. et al. Hysteroscopic morcellation versus lLoop resection for removal of placental remnants: a randomized trial. J Minim Invasive Gynecol. 2016;23(7):1172–80. https://doi.org/10.1016/j.jmig.2016.08.828.Hamerlynck T.W., van Vliet H.A., Beerens A.S. et al. Hysteroscopic morcellation versus lLoop resection for removal of placental remnants: a randomized trial. J Minim Invasive Gynecol. 2016;23(7):1172–80. https://doi.org/10.1016/j.jmig.2016.08.828.Клинические рекомендации – Выкидыш (самопроизвольный аборт) – 2021-2022-2023 (19.01.2023). М.: Министерство здравоохранения Российской Федерации, 2023. 25 с. Режим доступа: http://disuria.ru/_ld/12/1232_kr21O02O05MZ.pdf. [Дата обращения: 31.03.2024].Clinical guidelines – Miscarriage (spontaneous abortion) – 2021-2022- 2023 (19.01.2023). [Klinicheskie rekomendacii – Vykidysh (samoproizvol'nyj abort) – 2021-2022-2023 (19.01.2023)]. Moscow: Ministerstvo zdravoohraneniya Rossijskoj Federacii, 2023. 25 p. (In Russ.). Available at: http://disuria.ru/_ld/12/1232_kr21O02O05MZ.pdf. [Accessed: 31.03.2024].Warembourg S., Huberlant S., Garric X. et al. Prevention and treatment of intra-uterine synechiae: review of the literature. J Gynecol Obstet Biol Reprod (Paris). 2015;44(4):366–79. (In French). https://doi.org/10.1016/j.jgyn.2014.10.014.Warembourg S., Huberlant S., Garric X. et al. Prevention and treatment of intra-uterine synechiae: review of the literature. J Gynecol Obstet Biol Reprod (Paris). 2015;44(4):366–79. (In French). https://doi.org/10.1016/j.jgyn.2014.10.014.Thiruchelvam U., Dransfield I., Saunders P.T., Critchley H.O. The importance of the macrophage within the human endometrium. J Leukoc Biol. 2013;93(2):217–25. https://doi.org/10.1189/jlb.0712327.Thiruchelvam U., Dransfield I., Saunders P.T., Critchley H.O. The importance of the macrophage within the human endometrium. J Leukoc Biol. 2013;93(2):217–25. https://doi.org/10.1189/jlb.0712327.Ge Y., Huang M., Zhu X.M., Yao Y.M. Biological functions and clinical implications of interleukin-34 in inflammatory diseases. Adv Protein Chem Struct Biol. 2020;119:39–3. https://doi.org/10.1016/bs.apcsb.2019.02.003.Ge Y., Huang M., Zhu X.M., Yao Y.M. Biological functions and clinical implications of interleukin-34 in inflammatory diseases. Adv Protein Chem Struct Biol. 2020;119:39–3. https://doi.org/10.1016/bs.apcsb.2019.02.003.Wang J., Li D., Pan Y. et al. Interleukin-34 accelerates intrauterine adhesions progress related to CX3CR1+ monocytes/macrophages. Eur J Immunol. 2021;51(10):2501–12. https://doi.org/10.1002/eji.202149174.Wang J., Li D., Pan Y. et al. Interleukin-34 accelerates intrauterine adhesions progress related to CX3CR1+ monocytes/macrophages. Eur J Immunol. 2021;51(10):2501–12. https://doi.org/10.1002/eji.202149174.Wang Z.N., Wang M.S., Xi X. Clinical evidence of positive correlation between intrauterine adhesions and chronic endometritis: a retrospective study. Eur Rev Med Pharmacol Sci. 2023;27(10):4601–7. https://doi.org/10.26355/eurrev_202305_32467.Wang Z.N., Wang M.S., Xi X. Clinical evidence of positive correlation between intrauterine adhesions and chronic endometritis: a retrospective study. Eur Rev Med Pharmacol Sci. 2023;27(10):4601–7. https://doi.org/10.26355/eurrev_202305_32467.Hooker A.B., Aydin H., Brölmann H.A.M., Huirne J.A.F. Long-term complications and reproductive outcome after the management of retained products of conception: a systematic review. Fertil Steril. 2016;105(1):156– 64e1–2. https://doi.org/10.1016/j.fertnstert.2015.09.021.Hooker A.B., Aydin H., Brölmann H.A.M., Huirne J.A.F. Long-term complications and reproductive outcome after the management of retained products of conception: a systematic review. Fertil Steril. 2016;105(1):156–64e1–2. https://doi.org/10.1016/j.fertnstert.2015.09.021.Tam T., Estes S.J. Hysteroscopic morcellator used in the diagnosis and evacuation of retained products of conception. J Gynecol Surg. 2013;29(6):332–5. https://doi.org/10.1089/gyn.2013.0038.Tam T., Estes S.J. Hysteroscopic morcellator used in the diagnosis and evacuation of retained products of conception. J Gynecol Surg. 2013;29(6):332–5. https://doi.org/10.1089/gyn.2013.0038.Petrozza J. Removal of retained products of conception using a hysteroscopic morcellator: a safer alternative. J Minim Invasive Gynecol. 2015;22(6):S1–S235. https://doi.org/10.1016/j.jmig.2015.08.489.Petrozza J. Removal of retained products of conception using a hysteroscopic morcellator: a safer alternative. J Minim Invasive Gynecol. 2015;22(6):S1–S235. https://doi.org/10.1016/j.jmig.2015.08.489.Ansari S.H., Bigatti G., Aghssa M.M. Operative hysteroscopy with the Bigatti shaver (IBS®) for the removal of placental remnants. Facts Views Vis Obgyn. 2018;10(3):153–9.Ansari S.H., Bigatti G., Aghssa M.M. Operative hysteroscopy with the Bigatti shaver (IBS®) for the removal of placental remnants. Facts Views Vis Obgyn. 2018;10(3):153–9.

The authors declare that there are no conflicts of interest present.