Aim. А determination of predictors of early placental abruption (up to 34 weeks of pregnancy). Design. Multicenter retrospective cohort study. Materials and methods. The total number of cases of placental abruption — 1594, data from 22 medical centers in 16 constituent entities of the Russian Federation. The main group (n = 618) — patients with placental abruption at a gestation period of less than 34 weeks, comparison group (n = 976) — pregnant women with placental abruption at 34 weeks or more. Results. Multivariate analysis carried out using the logistic regression method revealed a statistically significant effect of smoking, pregnancy number, the presence of a scar on the uterine abnormalities of its structure on the occurrence of early placental abruption. Conclusion. Disentangling placental abruption into early and late phenotypes may provide insight into the causes of this obstetric condition and improve maternal and neonatal outcomes. Keywords: placental abruption, predictor, risk factors, phenotype.

Aim. Placental abruption is a severe complication of pregnancy, which is often accompanied by pre-eclampsia and early delivery. Here we aimed to study maternal and neonatal outcomes in patients with placental abruption depending on the severity of pre-eclampsia. Materials and Methods. The study included 509 patients with placental abruption and pre-eclampsia from 22 medical centers in 16 regions of the Russian Federation, which were divided into two groups: patients with placental abruption and severe pre-eclampsia (n = 369) and patients with placental abruption and moderate pre-eclampsia (n = 140). Results. Regardless of the severity of pre-eclampsia, average term of placental abruption was 34 weeks of pregnancy. Among the adverse maternal outcomes in patients with placental abruption and severe pre-eclampsia were coagulopathy (OR = 5.01; 95% CI = 1.17–21.46) and near miss proportion (OR = 2.95; 95% CI =1.22 –7.08) which were significantly more common as compared to a moderate pre-eclampsia. Neonatal outcomes were accompanied by a high perinatal mortality (12.8%) and neonatal morbidity due to a high prevalence of premature birth (65%), asphyxia (64%), and small for gestational age (40%). Groups with severe and moderate pre-eclampsia had no statistically significant differences in neonatal outcomes, excepting congenital malformations which were found less frequently (OR = 0.32; 95% CI 0.13–0.79) in severe pre-eclampsia. Conclusion. Severity of pre-eclampsia did not affect neonatal outcomes in women with placental abruption. Maternal outcomes were significantly worse in patients with severe pre-eclampsia in comparison with those with moderate pre-eclampsia.

Placental abruption is a rare complication of pregnancy with a high risk of maternal and neonatal morbidity and mortality. Preeclampsia (PE) is often mentioned among the possible causes of placental abruption. However, the combined effect of PE and placental abruption on maternal and neonatal outcomes has been little studied. Objective. To conduct a comparative analysis of somatic and obstetric histories, pregnancy course, maternal and neonatal outcomes in placental abruption in pregnant women with and without PE. Patients and methods. A total of 1594 cases of placental abruption collected from 22 medical centers in 16 regions of the Russian Federation were included in the study. The number of patients with PE was 509 (31.9% out of the total sample). The study group comprised 509 pregnant women with placental abruption and PE, the control group – 1085 pregnant women with placental abruption without PE. Results. Overweight and obesity (OR = 2.03; 95% CI: 1.64–2.52), chronic arterial hypertension (OR = 6.90; 95% CI: 4.78–9.95), chronic kidney disease (OR = 1.55; 95% CI: 1.07–2.25) and chronic anemia (OR = 1.33; 95% CI: 1.07–1.66) were statistically significantly more common in the group of patients with PE. An association between obstetric and gynecological history and risk of PE was established only for parity of 2 or less (OR = 1.37; 95% CI: 1.11–1.70) and PE in a previous pregnancy (OR = 4.83; 95% CI: 2.59–9.01). During the current pregnancy, patients in the study group were almost 4 times more likely to be diagnosed with intrahepatic cholestasis (OR = 3.88; 95% CI: 1.89–7.95) and about 2 times more likely to have fetal growth restriction (OR = 1.85; 95% CI: 1.48–2.31), low birth weight (OR = 1.72; 95% CI: 1.19–2.48), and anemia of pregnancy (OR = 1.77; 95% CI: 1.43–2.19) compared to patients without PE. The study group was about twice as likely to have severe maternal morbidity (OR = 2.12; 95% CI: 1.41–3.17) and require hysterectomy (OR = 1.82; 95% CI: 1.01–3.29) despite the same mean blood loss (800 mL) in both groups. Patients with PE were almost 3 times more likely to be diagnosed with intrauterine fetal demise (OR = 2.80; 95% CI: 1.92–4.08) and about twice as likely to have hypotrophy (OR = 1.81; 95% CI: 1.45–2.26) and asphyxia (OR = 1.81; 95% CI: 1.44–2.26) compared to controls. Conclusion. It was demonstrated that patients with PE and placental abruption had statistically and clinically significant differences compared to the control group. Key words: placental abruption, pre-eclampsia, maternal outcomes, neonatal outcomes

BACKGROUND: Death is a leading factor in post-traumatic stress disorder development. The adequacy of medical and psychological support for childbirth with a dead fetus plays a key role in severe psychological disorder prevention. MATERIALS AND METHODS: The authors have developed a questionnaire to assess the quality of obstetric, anesthesiological, and psychological assistance to females with death. The questionnaires of 173 respondents were analyzed. The duty factor or completeness of answers was 0.96. Of the cases, 55% of childbirth with a dead fetus occurred after 34 weeks of gestation, whereas the time interval from the moment of delivery to the questionnaire did not exceed 2 years in 60% of cases. RESULTS: The heavy emotional state was rated by 70% of females. Psychological assistance was recognized as unsatisfactory in 52% of cases. Most females (63%) wanted to be conscious at the time of the birth of a child and contact with him. This issue was not discussed with females in labor in 51% of cases. Neuroaxial methods of analgesia were used in 36% of cases in vaginal childbirth, whereas anesthesia was not performed in 40% of patients. Sedative therapy was needed by 76% of females in the postpartum period, which was prescribed only in 25% of cases. A third of respondents rated unsatisfactory medical care provided, and 94% of females believe that special training and seminars on communication with patients who have had a stillbirth are necessary for medical workers. CONCLUSION: The analysis of questionnaires filled out by women with stillbirth revealed several problems in the quality of medical care provided to them, wherein the most significant was the insufficient realization of the patients desire for contact with a dead child, insufficient anesthesia in childbirth, and sedation in the postpartum period, as well as unsatisfactory psychological care provided by doctors of an interdisciplinary team and a clinical psychologist, according to respondents.

Introduction. The Russian Federation’s stillbirth rate is almost twice that of the United States and Europe, while domestic treatment protocols are still lacking. Objectives. To analyze the results of a survey of obstetricians-gynecologists and intensivists on the problems of providing medical care to patients with stillbirth. Materials and methods. We have developed a questionnaire, which consisted of 23 questions in Russian. A total of 369 Russian-speaking doctors, intensivists and obstetricians-gynecologists took part in the survey. Results. The need to turn off the mother’s consciousness at the time of giving birth to a dead fetus caused great disagreement between the related specialists (p = 0.0001). 56 % of intensivists and 35 % of obstetricians-gynecologists were in favor of turning off the mother’s consciousness. According to 23 % of obstetricians-gynecologists and only 9 % of intensivists, visual and tactile contact of a mother and her dead fetus has a positive impact on the psychoemotional state of the woman (p = 0.002). Respondents from both specialties preferred epidural analgesia in more than half of the cases. Conclusions. A list of issues for which the greatest differences in ratings were obtained has been identified, which will further help to identify priority issues for discussion and points of application for creating agreed documents on the best management of pregnant women with stillbirth.

Актуальность. В Российской Федерации показатель мертворождаемости практически в два раза превышает данный показатель в США и Европе, при этом отечественные клинические рекомендации до сих пор отсутствуют. Цель исследования. Проведение анализа результатов опроса специалистов акушеров-гинекологов и анестезиологов-реаниматологов по проблемам оказания медицинской помощи пациенткам с мертворождением. Материалы и методы. Был разработан опросник, состоящий из 23 вопросов на русском языке. Всего в опросе приняли участие 369 русскоязычных врачей анестезиологов-реаниматологов и акушеров-гинекологов. Результаты. Необходимость выключения сознания матери в момент рождения мертвого плода вызвала большие разногласия между смежными специалистами (p = 0,0001). За выключение сознания матери выступили 56 % анестезиологов-реаниматологов и 35 % акушеров-гинекологов. Визуальный и тактильный контакт матери с мертвым плодом оказывает положительную роль на психоэмоциональное состояние женщины, по мнению 23 % акушеров-гинекологов и лишь 9 % анестезиологов-реаниматологов (р = 0,002). Респонденты обеих специальностей отдают предпочтение эпидуральной анальгезии более чем в половине случаев. Заключение. Определен список вопросов, по которым получены наибольшие различия рейтингов, что в дальнейшем поможет определить первоочередные проблемы для обсуждения и точки приложения для создания согласованных документов по оптимальному ведению беременных с мертворождением.

Background. The effects of perioperative low-dose ketamine in caesarean section are not well understood. Objective. To evaluate the clinical effects of various subanesthetic doses and regimens of intravenous ketamine in early postoperative period after caesarean section. Material and methods. Searching in the PubMed, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials ( CENTRAL) databases was performed until December 31, 2019. Heterogeneity of samples was assessed using chi-square test. I2 index was used to assess heterogeneity. Both fixed-effect model and random-effect model were applied to assess the cumulative effect. Continuous results are presented as weighted differences between the means of two groups with 95% confidence intervals (95% CI). Differences in dichotomous variables are represented as relative risk (RR) and 95% CI. Анестезиология и реаниматология 2021, No2, с. 19-35 https://doi.org/10.17116/anaesthesiology202102119 Russian Journal of Anaesthesiology and Reanimatology 2021, No. 2, pp. 19-35 https://doi.org/10.17116/anaesthesiology202102119

Актуальность. За последнее десятилетие отмечается повышенное внимание к кетамину, что связано с выявлением его новых эффектов при использование низких (менее 1 мг/кг при болюсном введении и менее 20 мкг/кг/мин при продленной инфузии) доз препарата. У беременных женщин изменяется фармакокинетика большинства лекарственных препаратов, поэтому результаты исследований низких доз кетамина, полученные на других категориях пациентов, могут быть не воспроизведены в акушерской популяции. Цель систематического обзора. Оценка клинических эффектов различных доз и схем введения кетамина в пределах субанестетического диапазона в периоперационном периоде кесарева сечения. Материалы и методы. Поиск публикаций производился в электронных базах данных PubMed, MEDLINE, EMBASE и Cochrane Central Register of Controlled Trials (CENTRAL) четырьмя рецензентами независимо друг от друга. Дата последнего поискового запроса — 30 декабря 2019 г. Результаты. Всего в обзор было включено 18 рандомизированных контролируемых исследований с участием 2703 пациенток. Результаты настоящего систематического обзора показали, что введение низких доз кетамина (в диапазоне 0,15–0,5 мг/кг) в периоперационном периоде кесарева сечения, выполняемого в условиях спинальной анестезии, способно снижать интенсивность боли и потребность в анальгетиках в послеоперационном периоде. Использование низких доз кетамина при этих условиях также может быть полезным для уменьшения выраженности озноба, зуда, профилактики возникновения послеоперационной тошноты и рвоты, постпункционной головной боли и послеродовой депрессии. Дозы менее 0,5 мг/кг представляются более безопасными и сопоставимо эффективными в профилактике вышеописанных осложнений. Однако малое количество и высокая гетерогенность исследований не позволяют сделать однозначные выводы. Эффективность низких доз кетамина в профилактике указанных осложнений при проведении операции в условиях общей анестезии также остается неясной. Выводы. Необходимы дальнейшие исследования и проведение метаанализа данных для получения окончательных выводов.

In the Russian Federation, the stillbirth rate in 2018 was 5.51 per 1000 live and dead births, which is almost twice the figure in the United States and Europe. This study aimed to conduct a rating analysis separately for each factor that influences the selection of techniques for the management of labor and the postpartum period in women with stillbirth. Material and methods. A questionnaire was developed, which consisted 23 questions in Russian. A total of 402 Russian-speaking medical workers took part in the survey. Results. In this study, 49.7% of the respondents seldom encounter patients with stillbirth. Moreover, 59.5% of the respondents find it easy to create a supportive communication with these patients, 70% believed that contact between the mother and her stillborn child has a negative influence on her psychoemotional state both at the time of delivery and in the long term, and only 27.7% found that mothers wanted to spend time with the child. As the optimal method of analgesia, 57.2% of the respondents chose epidural analgesia for stillbirth delivery. Furthermore, 57.7% believed that patients with stillbirth were satisfied with the quality of medical care, and 74.1% gave a positive assessment of the quality of medical care provided to patients with stillbirth in their medical institutions. Moreover, medical professionals (89.3%) consider it necessary to develop clinical recommendations on this problem. Conclusions. The results indicate that a unified technique of managing the peripartum period with stillbirth is still not established. Clinical guidelines on this problem are necessary.

Introduction. Over the past decade, there has been increased attention to ketamine, which is associated with the identification of its new effects when using low (less than 1 mg/kg for bolus administration and less than 20 μg/kg/min for prolonged infusion) doses of the drug. In pregnant women, the pharmacokinetics of most drugs change, so the results of studies of low doses of ketamine obtained in other categories of patients may not be reproduced in the obstetric population. Objectives. Assessment of the clinical effects of various doses and regimens of ketamine administration, within the subanesthetic range, in the perioperative period of cesarean section. Material and Methods. Publications were searched in the electronic databases PubMed, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) by four reviewers independently. The date of the last search query was December 31, 2019. Results. A total of 18 randomized controlled trials (RCTs) involving 2703 patients were included in the review. The results of this systematic review showed that the administration of low doses of ketamine (in the range of 0.15-0.5 mg/kg) in the perioperative period of cesarean section performed under spinal anesthesia can reduce the intensity of pain and the need for analgesics in the postoperative period. The use of low doses of ketamine under these conditions can also be useful to reduce the severity of chills, itching, and the prevention of postoperative nausea and vomiting, post-puncture headache, and postpartum depression. Doses of less than 0.5 mg/kg appear to be safer and comparatively effective in the prevention of the above complications. However, the small number and high heterogeneity of research does not allow us to draw unambiguous conclusions. The effectiveness of low doses of ketamine in the prevention of these complications with general anesthesia also remains unclear. Conclusion. Further research and a meta-analysis of the data are necessary to obtain final conclusions.

В статье отражены основные положения клинических рекомендаций по профилактике, анестезии и интенсивной терапии при послеродовых кровотечениях. Последовательно представлены основные факторы риска, возможные осложнения, принципы клинической и лабораторной диагностики при данной патологии. Особое внимание уделено вопросам инфузионной, трансфузионной терапии и коррекции коагулопатических нарушений. Обсуждены проблемы оценки величины кровопотери, диагностики нарушений системы гемостаза, регуляции гемодинамики при геморрагическом шоке. Обосновано применение рекомбинантных факторов свертывания крови при коагулопатии на фоне массивной кровопотери.

To analyze the management of severe ovarian hyperstimulation syndrome based on aspects of its etiology and pathogenesis a systematic review of the literature was done. An evaluation of clinical trials, meta-analysis, case-reports and reviews assessing the management of different conditions related to ovarian hyperstimulation syndrome was made using the following data sources: MEDLINE Pubmed (from 1966 to July 2018) and the Cochrane Controlled Clinical Trials Register, Embase (up to July 2018). The role of intra-abdominal hypertension in the development of the severe forms of ovarian hyperstimulation syndrome and its complicated outcomes was assessed. The pathophysiology and clinic of intra-abdominal hypertension syndrome are almost identical to moderate and severe forms of ovarian hyperstimulation syndrome and associated organ dysfunction. The classic triad (respiratory disorders, reduction in venous return, and restriction of perfusion in internal organs) is present in severe ovarian hyperstimulation syndrome as well as in intra-abdominal hypertension syndrome. This review provides recommendations for the management of ovarian hyperstimulation syndrome and insight into the different medical complaints of this syndrome. The principles of therapy for intra-abdominal hypertension syndrome might be considered in the treatment of severe forms of ovarian hyperstimulation syndrome.

The article observes the main provisions of the clinical recommendations for prevention, anesthesia and intensive care for postpartum hemorrhage. The main risk factors, possible complications, principles of clinical and laboratory diagnosis in this pathology are consistently presented. Particular attention is paid to issues of infusion, transfusion therapy and correction of coagulopathic disorders. The problems of estimating the amount of blood loss, diagnosing disorders of the hemostatic system, regulation of hemodynamics in hemorrhagic shock are discussed. The use of recombinant coagulation factors in coagulopathy on the background of massive blood loss has been substantiated.

To study the dependence of the wound infection rate after cesarean section and the level of postoperative intra-abdominal pressure (IAP) in obese patients. A study was conducted, involving 313 patients delivered by cesarean section. All patients were divided into 4 groups: control group 90, with degree I obesity 137, with II 49 and III 37 patients. The frequency of development of wound postoperative complications was determined, bacteriological studies of amniotic fluid, placenta, lousy and discharge wound of the anterior abdominal wall were carried out. Postoperative dynamics of IAP was investigated. IAP research was carried out using vesical indirect method. Wound postoperative complications were diagnosed in 17,9% of the puerperas, 8,6% of them had a discrepancy and suppuration of the sutures in the anterior abdominal wall. The incidence of wound complications increased with increasing severity of obesity. In patients with severe obesity, in the sowing of septic purulent wounds, microorganisms of the genus Escherichia coli, Enterococcus spp. prevailed. Analysis of postoperative dynamics of IAP showed that in obese patients its values exceeded those in the control group at all stages of the study. The correlation analysis showed the presence of a positive average force of communication between the postoperative intestinal paresis and the development of wound infection, r = 0,500 (p < 0,01). The relationship between wound infection and postoperative dynamics of IAP was approaching a strong-r ratio of 0,654 (p<0,001). Representatives of the intestinal microbioma are leading in patients with obesity in infection of the postoperative wound. In the contamination of the intestinal microflora, intra-abdominal hypertension (IAH) is one of the main triggers. Long-term persistent IAH in the postoperative period is a significant risk factor for the development of postoperative infectious complications.

Introduction: Given in the literature, there is a possible link between perinatal pathology and intra-abdominal pressure (IAP) in pregnant women.Since intra-abdominal hypertension (IAH) is the companion of obesity, we can assume that there is a casual relation of perinatal complications of high frequency which obese patients with a level of IAP have. Methods:A pilot study involving 407 patients: 135 of those were patients with the spontaneous labor, 273 were patients with the abdominal delivery.Patients, depending on their body mass index (BMI) were divided into four groups: group I -control (n=117), group II -patients with I degree of obesity (n=158), group III -with II degree of obesity (n=84), group IV -with III degree of obesity (n=48).The groups were divided into subgroups according to the neurological status of a newborn.IAP research was carried out using the indirect method through the bladder.The assessment of mental status of the newborn was performed with the help of NACS scale. Results:The frequency and severity of the neurological deficit in newborns depended on the level of IAP before delivery and IAP in delivery.The correlational analysis of the degree of asphyxia and neonatal neurologic status is the presence of an average bond strength (r=-0.66,p<0.001).In subgroups where the epidural analgesia was introduced during labor, the overall score on NACS scale was significantly higher (p<0.001).In the groups of patients with severe obesity, the total score on the NACS scale was significantly lower (p<0.05)compared with other methods of anesthesia. Conclusion:The results of the limited pilot study indicate the impact of the level of IAP of parturient women with obesity on the severity of asphyxia and the neurological status of the newborn in the early neonatal period.