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According to modern scholarly data, decidual macrophages play a significant role both in the physiological and pathological course of pregnancy due to their plasticity and immunosuppressive properties, participation in the remodeling of tissues and vessels, and the ability to form a local adaptive immunity. The normal course of pregnancy is characterized as a condition of moderate systemic inflammatory process because of activation of the immune system components, in the first place, the innate immunity and vascular endothelium. The development of preeclampsia is characterized by the impairment of placental processes and production of pathologically altered placenta, an excess of proinflammatory cytokines that contribute to the development of a systemic inflammatory response. However, there is still not enough data on the peculiarities of cytokine levels, the nature of phenotypic and morphofunctional macrophage changes, the ratio of subpopulations of decidual macrophages in the physiological and pathological course of pregnancy, which limits the understanding of the pathogenetic role of M1 and M2 decidual macrophages in preeclampsia. It is only probable, but not proven, that the development of preeclampsia is associated with an imbalance of decidual macrophages during the late phase of the first trimester and the early phase of the second trimester of pregnancy, with the predominance of macrophages of the M1 phenotype and subsequent inadequate remodeling of the uterine spiral arteries. The effectiveness of preventing preeclampsia by stimulating the differentiation of decidual macrophages in the direction of the M2 phenotype has not been studied. The obtained results determine the expediency and relevance of further studying the etiopathogenesis of preeclampsia, improving the knowledge of the immunological mechanisms of this obstetric pathology development (taking into account the peculiarities of differentiation in subpopulations of decidual macrophages with the formation of M1 and M2 phenotypes) and determine the need for the development of new methods for the early formation of high-risk groups for preeclampsia, ways of secondary prevention of the disease, which would enable us to develop effective tactics for the management of pregnant women with preeclampsia, specifically aimed at reducing maternal and perinatal morbidity and mortality.

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According to the literature, inappropriate polarization of decidual macrophages is associated with abnormal pregnancy conditions such as spontaneous abortion, premature childbirth, preeclampsia, foetal growth retardation, etc.; therefore, studying the relationship between subpopulations of decidual macrophages and factors promoting their production in women with preeclampsia is of great clinical relevance. The purpose of this study was to identify the features of differentiation in subpopulations M1 and M2 of decidual macrophages in pregnant women with preeclampsia and to assess the impact of factors promoting their induction. Materials and methods. The concentrations of pro- and anti-inflammatory cytokines (TNF-α, INF-γ, IL-10) and the activity of iNOS and arginase in cervical mucus in pregnant women with preeclampsia were studied in comparison with the corresponding indicators in healthy pregnant women, with subsequent comparison of these indicators with the number of decidual macrophages M1 and M2 in the placentas of the examined women. We determined the concentration of cytokines by using immunoassay. NO synthase activity was determined by the difference in nitrite concentration before and after cervical mucus incubation. The total arginase activity was assessed by the difference in the concentration of L-ornithine before and after incubation in phosphate buffered saline, which contained L-arginine. Immunohistochemical study of macrophages M1 and M2 in placental tissue was carried out in the pathomorphological laboratory "CSD Health Care" (Kiev). A total of 62 pregnant women were examined: the control group included 30 healthy pregnant women who did not have risk factors for preeclampsia and unimpaired circulation in the uterine spiral arteries in the area of ​​the placental site at 18-20 + 6 weeks of gestation. The study group included 32 pregnant women at high risk to develop preeclampsia, with impaired circulation in the uterine spiral arteries in the area of ​​the placental site at 18-20 + 6 weeks of gestation; 14 of them then developed preeclampsia. Results. In pregnant women with preeclampsia, the balance of pro- and anti-inflammatory cytokines is impaired in favour of TNF-α and INF-γ with a decrease in IL-10 content that results in an imbalance in the activity of enzymes regulating the L-arginine metabolism with the following increase in iNOS activity. The activity of arginine is significantly reduced. In the placentas of women with preeclampsia, the content of decidual macrophages M1 phenotype is 1.7 times higher than their number in healthy women, while the content of macrophages M2 phenotype, on the contrary, goes down in 1.5 times. The study has shown that the predominance of decidual M1 macrophages in women with preeclampsia occurs due to the stimulating effect of INF-γ and the activation of inducible NO-synthase. This imbalance of decidual macrophages in favour of the M1 subpopulation is likely to cause the progression of endothelial dysfunction, manifestation of preeclampsia, and dysfunction of the placenta in the second trimester and in the early phase of the third trimester of gestation.

Between 2015 and 2020, the incidence of abdominal delivery in Ukraine increased annually and reached 26.7% of the total number of births in 2021. In Poltava Region, in 2022, the rate of caesarean delivery reached an all-time high of 28.7%. To outline the tendencies in providing quality obstetric care and to identify ways to reduce the frequency of abdominal delivery in the Poltava region, there has been conducted a statistical analysis of the annual reports for the period from 2017 to 2022 obtained from the perinatal centre of the M.V. Sklifosovskyi Poltava Regional Clinical Hospital and reports on medical care for pregnant women, women in labour, newborns and children in the first year of life (forms No. 21 and No. 21-a) from the Health Department of the Poltava Regional State Administration. The data show a notable rise in the percentage of abdominal deliveries in 2022 in hospitals of the first and second levels of perinatal care, with a 4% decrease in the share of caesarean deliveries at the third level hospitals, which primarily deal with patients having severe obstetric and extragenital pathologies. For instance, in 2022, more than one out of four women (25.7%) was reported as having caesarean delivery at the Municipal Clinical Maternity Hospital of Poltava, and one in three women (33.6%) was reported to have surgical delivery at the Kremenchuk Perinatal Centre of the second level. Since 2018, the average rate of caesarean sections performed as the level I obstetric hospitals in Poltava Oblast has been progressively rising and in 2022 reached 23.9% of all surgical interventions in the region. Conversely, in the perinatal centre of the M.V. Sklifosovskyi Poltava Regional Clinical Hospital, the number of abdominal deliveries has been decreasing annually, and in 2022 this figure was 35.8%. Notably, this decrease in abdominal delivery coincided with a reduction in the perinatal mortality rate, which declined from 22.06‰ in 2018 to 14.51‰ in 2022. Thus, the key strategy for reducing the rate of caesarean deliveries in the Poltava region lies in the adherence to regional peculiarities and requirements of perinatal care that entail timely referral of pregnant women at high risk of maternal and infant complications to the third level settings of perinatal care, where the decision regarding caesarean delivery can be appropriately assessed, ensuring a balanced approach that minimizes both the overall incidence of abdominal deliveries and perinatal mortality.