Postmortem radiology studies in global and national healthcare: literature analysis and perspectives of Russian specialists

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Abstract

Despite the significant importance of autopsies for determining the cause of death and the evaluating the effectiveness of treatments, there is a progressive decrease in their number across all countries. At the same time, there is an active introduction of postmortem radiological studies to analyze the bodies of deceased patients.

The article presents literature analysis summarizing the results of surveys from foreign specialists, as well as the opinions of Russian specialists, regarding the possibilities and features of postmortem radiological studies, mainly focusing on deceased newborns and infants. It is noted that postmortem radiological studies are carried out as part of both pathoanatomical autopsy and forensic medical examination. Postmortem computed tomography in cases of violent death and postmortem magnetic resonance imaging in cases of death from diseases were performed more often. General clinical equipment located in clinical radiology departments was more frequently used than those located in the mortuary, pathology department, or forensic facility. The analysis of the results of postmortem radiological examinations was predominantly carried out by radiologists, with a joint analysis involving a radiologist and a pathologist being less common. It is emphasized that in the Russian Federation, postmortem radiological studies are mostly of a single nature. According to Russian researchers, in the current era of advancing personalized medicine, radiation techniques, and information technologies, there arises a need to use postmortem radiological studies to objectify and improve the accuracy of traditional autopsies. Postmortem radiological studies, which are objective operator-independent methods of examining the bodies of dead people, should be considered as a highly effective stage of pathology and, especially, forensic autopsy.

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INTRODUCTION

A conclusion about the cause of death is made by autopsy pathology specialists performing an autopsy of a deceased patient to confirm a clinical diagnosis or reveal a diagnostic error, establish the course of a disease and components of the dying process (thanatogenesis), evaluate the effectiveness of diagnostic and therapeutic measures, and generate mortality statistics [1]. Autopsies play a vital role in perinatal examinations, identification of hereditary and congenital diseases, and evaluation of subsequent pregnancy risk [2]. However, since the 1950s, in all countries where the consent of relatives is required for an autopsy, the number of these procedures has been progressively decreasing, mainly due to religious reasons, a long delay between death and burial, and the unwillingness of treating physicians to obtain information that may discredit their treatment strategy [3, 4].

In addition, the development of new medical equipment and diagnostic techniques allowed the ability to perform radiological examinations of people after death. Postmortem radiology was primarily used in forensic medicine. Therefore, in the 1990s, the Institute of Forensic Medicine at the University of Bern (Switzerland) began actively using 3D optical technologies for scanning corpses to better document external injuries and compare them with the suspected weapon of infliction. Then, postmortem computed tomography (CT) and magnetic resonance imaging (MRI) were introduced and compared with traditional autopsy [5]. In the United States, the Office of the Armed Forces Medical Examiner provided postmortem multispiral CT of dead members of the Armed Forces before autopsy to better assess combat injuries [6, 7]. Postmortem multispiral CT of people who died in the January 2020 earthquake in Haiti enabled rational body sorting for adequate subsequent autopsy [8].

Postmortem radiology is now used in many countries as part of a forensic medical examination and an autopsy, as reflected in the progressively increased number of publications [9, 10]. However, there is still no consensus on the objects (age group of patients and nature of abnormalities), type of apparatus, location, specialty, and qualifications of specialists performing postmortem radiology and analyzing results.

This information is undeniably important, particularly for those who intend to implement and perform such examinations in their institutions, cities, or regions. Because of its multinational and multireligious population, postmortem radiology is essential in the Russian Federation. Despite the relatively high level of radiology equipment in healthcare organizations, postmortem radiology is only used episodically in some institutions.

This paper aims to analyze the experience, recommendations, and proposals of foreign and Russian experts in postmortem radiology, considering potential opportunities and special aspects.

POSTMORTEM RADIOLOGY IN GLOBAL AND RUSSIAN HEALTHCARE

Conditions and stages of the study

The study is based on four surveys of members of the European Society of Pediatric Radiology (ESPR) and the International Society of Forensic Radiology and Imaging (ISFRI) from 2013 to 2021, postmortem radiology literature from eLibrary and National Center for Biotechnology Information databases (PubMed and PubMed Central), and opinions of Russian round table participants “Thanatoradiology: Real opportunities for organization and practical use in the healthcare system,” which was held on October 8, 2022, in Moscow as a part of II Scientific and Practical Conference of the Interregional Thanatoradiology Society “Diagnostic radiology in pathology and forensic medicine: From antemortem to postmortem.”

Due to the lack of consistent and generally accepted international guidelines on organizing and using postmortem radiology, the study analyzed literature data on surveys of foreign experts performing such examinations [11–14]. However, it should be noted that these surveys only included perinatal and pediatric medical institutions.

In the first survey (2013), questionnaires were distributed to 244 ESPR members [11]. The study included 66 questionnaires from 66 corresponding institutions, with postmortem radiological examinations performed in 47 (71%) institutions in 17 countries: Australia, Austria, Brazil, Great Britain, Hungary, Germany, Israel, Ireland, Canada, the Netherlands, New Zealand, Norway, USA, Finland, France, Switzerland, and Sweden. The largest number of responses and institutions were from the United Kingdom (11), the United States (9), and the Netherlands (5).

Three subsequent surveys included members of the ESPR and ISFRI. As a result, in the second survey (2016–2017), questionnaires were distributed to members of the aforementioned societies from 25 institutions [12]. Responses from 20 institutions in 11 countries were analyzed: Great Britain, Australia, USA, and Poland (three each); the Netherlands (2); Denmark, Italy, Switzerland, New Zealand, Canada, and Japan (one each).

In the third survey (2018–2019), questionnaires were distributed to all 14 members of the ESPR Postmortem Imaging Working Group and 17 members of the ISFRI Working Group, representing 25 different institutions [13]. The analysis included responses from 11 institutions in seven countries where postmortem radiology was used in the perinatal and pediatric practice: Australia (3), Great Britain (2), the Netherlands (2), Belgium (1), Switzerland (1), New Zealand (1), and Canada (1).

A fourth survey was conducted in 2021, with emails sent to 22 members of the ESPR Postmortem Imaging Working Group from 26 institutions. The analysis included 18 responses from 18 institutions in nine countries: Great Britain (6), Australia (3), Germany (2), the Netherlands (2), Austria (1), Belgium (1), Hungary (1), New Zealand (1), and Canada (1). Results were published by Chambers et al. [14].

Some questions were repeated in the above four surveys (questionnaires), whereas others were different. The first questions referred to objects of postmortem radiology.

Analysis of survey results

According to the first survey [11], all stillborn children were examined in 32% (15 out of 47) of institutions, whereas 26% (12/47) and 17% (8/47) examined all deceased newborns and infants, respectively. Only some stillborn children (45%), deceased newborns (49%), and infants (49%) were examined in most institutions.

According to the second survey [12], only one-third (35%) of institutions used postmortem radiology for all cases of fetal and pediatric death. In the third study [13], no institutions used postmortem radiology for all the deceased patients. According to the fourth survey [14], all institutions performed examinations on a case-by-case basis, with the majority (92.9%) performed for dead newborns (age 0–28 days), infants (1–12 months), and children (1–12 yr), followed by adolescents (age 13–18 yr; 85.7%) and fetuses (42.9%). Postmortem radiological examinations of deceased newborns and infants, children, and adolescents were less common in cases of nonviolent death: 82.4%, 58.5%, and 52.9%, respectively. However, fetal examinations were more common (76.5%) [14].

Since 2004, the Robert Kilpatrick Clinical Sciences Building Leicester Royal Infirmary in Leicester, UK, has regularly performed postmortem radiological examinations for deceased newborns and children in the radiology departments (24/7) [15].

As for the location of postmortem radiology equipment, in the first two surveys, general clinical equipment was used more frequently than in the mortuary, pathology department, or forensic institution (55% vs. 45%) [12]. According to the third survey [13], all specialists performed postmortem MRI using equipment in clinical radiology departments, and none of the centers surveyed had a special MRI scanner exclusively for postmortem imaging or a scanner located in the morgue or pathology department.

Controversial data on postmortem radiology procedures (and equipment) were obtained. The most common response in the first [11] and fourth [14] surveys was radiography (81% and 100% of cases, respectively), followed by CT (51% and 88.9%, respectively), MRI (38% and 61.1%), and ultrasound (8.5% and 27.8%). In most fatal cases, two or more different scanners (techniques) were used for radiological examination of corpses, but ultrasound was performed in all cases with radiological examination. However, in the third survey, all participants reported only postmortem MRI [13]. There are ongoing debates regarding who should conduct postmortem radiological examinations and, more importantly, who will evaluate their results. According to the second survey, radiological examinations were performed in most cases (65%) by a radiologist or a radiographer at a radiology department, considerably less frequently (15%) by morgue staff or a pathologist, and only in one institution by a forensic medical examiner [12]. According to the third survey, such examinations were performed in 90.9% of institutions by a radiologist or X-ray technician and 9.1% by an MRI specialist [13].

In terms of specialists analyzing postmortem radiology results, the first survey mentioned a radiologist in most cases (89%), including a pediatric radiologist (64%); in significantly fewer cases (17%), such an analysis was performed collaboratively by a radiologist and pathologist [11]. According to the second survey, 45% and 40% of responses mentioned radiologists and pathologists, respectively [12].

Shelmerdine et al. [12] should be cited in global literature data. This study was noteworthy because it presented a consensus protocol for postmortem CT. An important objective of Chambers et al. [14] was to evaluate funding and payment systems for postmortem radiology examinations. These aspects are undeniably important and should be the subject of separate publications on the characteristics of healthcare funding systems in different countries. However, according to most participants of the fourth survey [14], the main barrier to the widespread implementation of postmortem radiology was the lack of a special, nationally centralized (whenever possible) funding source. Therefore, in 2004, the UK Department of Health and Social Care initiated postmortem radiology of corpses, mainly deceased fetuses and newborns, as well as adults, to address the issue of possible autopsies being replaced by radiological examinations [16]. Since 2010, postmortem CT has been available in all cases of child death in the Netherlands if parents decide to perform an autopsy [17].

In our country, postmortem radiology is used episodically [18–20]. However, Academician V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology, and Perinatology has conducted its research since 2011 to study and implement thanatoradiology (CT and MRI) into the practice of pathological examinations of stillborn and deceased newborns [21, 22]. Some cases of postmortem CT use in forensic medical examination have been reported in the Moscow region since 2018 [23, 24].

II SCIENTIFIC AND PRACTICAL CONFERENCE OF THE INTERREGIONAL THANATORADIOLOGY SOCIETY “DIAGNOSTIC RADIOLOGY IN PATHOLOGY AND FORENSIC MEDICINE: FROM ANTEMORTEM TO POSTMORTEM”: KEY POINTS OF THE ROUND TABLE

Opportunities for organization and practical use of thanatoradiology

Due to the importance of postmortem radiology in the Russian Federation, in October 2022, a round table discussion was held as a part of II Scientific and Practical Conference of the Interregional Thanatoradiology Society “Diagnostic Radiology in Pathology and Forensic Medicine: From antemortem to postmortem” on the topic “Thanatoradiology: Real opportunities for organization and practical use in the healthcare system” [25]. The meeting was moderated by Yu. A. Vasiliev, director of the State Budgetary Institution “Research and Practical Clinical Center for Diagnostics and Telemedicine Technologies” of the Moscow Department of Health, chief freelance consultant in Radiology and Investigations of the Moscow Department of Health.

All participants noted that in the Russian Federation, in accordance with Federal Law No. 323-FZ dated November 21, 2011 (Article 67),1 all deceased persons are subjected to a pathological autopsy, including a mandatory autopsy (despite the refusal) of stillborn children and children who died up to 28 days of life. A forensic autopsy is required if a violent death is present or suspected. Accordingly, a pathological autopsy (Article 67, paragraph 1) aims to obtain data on the cause of death and the diagnosis, and a forensic medical examination (Article 62, paragraph 1) establishes the circumstances as evidence for a specific case.

According to valid Order No. 346n of the Ministry of Health and Social Development of the Russian Federation dated May 12, 2010,2 the type, nature, and scope of the examination are determined by the head of the forensic institution. It also determines specialists responsible for performing such an examination and involved staff of expert, scientific, educational, and other institutions. An expert should use medical technologies approved for use in the Russian Federation, primarily technologies and techniques not associated with modification, destruction, or destruction of examined objects. Moreover, paragraph 47.8 states that radiography is first performed (wherever technically possible) during an external examination of a corpse to clarify the nature and characteristics of damage or painful changes in skeletal bones. In other words, postmortem radiography is even recommended during a forensic examination; however, in accordance with the above order, only for bones. Simultaneously, according to Appendix 2 to Order No. 364n, the standard equipment for state forensic medical institutions includes an X-ray machine and a digital mobile X-ray system.

Selection of the most informative method of postmortem examination

A pathological autopsy is performed by a pathologist in accordance with Order No. 354n of the Ministry of Health of the Russian Federation dated June 6,3 2010, whereas histological, biochemical, microbiological, and other necessary methods of examining individual organs and tissues of the deceased people are considered an integral part of the pathological autopsy. Biological material is transferred to an appropriate structural unit of a healthcare organization to be examined. Radiology may be one of the procedures used for such mandatory examinations.

In 1969, a Soviet pathologist, I.I. Medvedev wrote about the important role of radiology, particularly X-ray, examination of a corps in guidelines for hospital anatomists Fundamentals of pathological and anatomical technique (Osnovy patologoanatomicheskoy tekhniki), “the X-ray method is rarely used by pathologists, although for a long time there are many reasons for its wide use, (...) therefore, it can be strongly recommended to install X-ray machines in dissecting rooms” [26]. Medvedev emphasized that X-ray examination allows the detection of even small changes in bone structure, bone tumors, osteochondropathies, calcification sites, and foreign bodies. Moreover, he stated that “the use of the X-ray method in pathology can play a great role in the development of X-ray diagnostics” [26].

Congenital abnormalities of the skeleton, which can be an independent defect or a manifestation of a syndrome, can include abnormalities of the facial skull, spine, and upper and lower extremities. In such cases, postmortem CT is the most effective and objective tool for postmortem identification of congenital abnormalities of bones, particularly small and facial bones, in stillborn and deceased newborns because of its superiority over traditional pathological autopsy [27, 28]. Accordingly, when discussing the advantages of various radiology methods, forensic experts named CT as a method of first choice because it provides the best visualization of injuries and fractures of bones, the degree of displacement of fragments, the course of the wound canal, hemorrhages, and foreign bodies, including bullets [29, 30]. CT also has other important advantages in forensic medicine, such as short examination duration and, accordingly, high throughput of the scanner, which is particularly important for examining bodies in cases of mass death (transport and natural disasters, military operations, or terrorist acts), as well as the availability of mobile CT modules to perform examination even directly at the place of the incident. Postmortem MRI is less popular among medical examiners than CT, although it better visualizes soft tissues and parenchymal organs.

We believe that the choice of an examination method should be based on the feasibility of obtaining maximum information in each specific case. This opinion is supported by literature data. Thus, Roberts et al. [31] found that CT is more accurate than CT in determining a cause of death in adult patients. Authors considered CT to have advantages, such as better visualization of coronary artery calcifications, hemorrhage areas, and fractures. MRI was more sensitive in acute myocardial infarction and soft tissue pathology [31]. According to Wijetunga et al. [32], a comprehensive postmortem CT and autopsy revealed more lesions in trauma deaths than either method alone, whereas Proisy et al. [33] found strong agreement between postmortem CT and autopsy data, with significant discrepancies detected primarily in lung diseases. Sieswerda-Hoogendoorn et al. [34] found a strong correlation between postmortem CT and autopsy data in cases of violent death, with no correlation in cases of natural death, and complete agreement between CT with autopsy data when the cause of death could not be determined initially. According to Krentz et al. [35], an autopsy is often superior to postmortem CT for detecting soft tissue and vascular changes, although CT is more effective for visualizing skeletal injuries.

When comparing the capabilities of postmortem CT and MRI, Arthurs et al. [36] found that MRI has higher diagnostic accuracy than CT in examining fetuses of less than 24 weeks of gestation and similar accuracy for older fetuses and newborns. Authors recommend postmortem MRI to visualize dead fetuses and children because it is the most effective method for determining brain, heart, and kidney diseases. Indeed, postmortem MRI allows one to determine the degree of brain maturity and visualize congenital abnormalities and abnormal changes [37, 38], assess the condition of lung tissue to identify those who were live-born and children with congenital pneumonia, assess the degree of pulmonary hypoplasia as a component of thanatogenesis [39–41], and determine the severity of anasarca and the volume of free fluid accumulated in serous cavities without opening cavities and tissue incisions [42, 43]. Thayyil et al. [44] reported in a large prospective study that the accuracy of postmortem MRI corresponds to the results of autopsies of dead fetuses, newborns, and infants and is lower when examining children over 1 yr of age.

To summarize, postmortem CT is the most informative method to visualize:

  • traumatic, primarily mechanical, injuries, and wound channels, particularly in areas that are technically difficult for traditional dissection (bones and tissues of the facial skeleton, skull base, distal limbs, and spine);
  • hemorrhages and fluid accumulations in organs, tissues, and cavities;
  • air and gas accumulations in tissues, organs, lumen of blood vessels, and cavities;
  • distinguishing dentition, including personal identification; and
  • foreign bodies, including medical probes and catheters.

Postmortem CT is adequate for examining frozen, burned, and putrefied bodies and corpses in mummification and saponification. Limitations for postmortem CT include the low efficiency of unenhanced visualization of injuries and diseases of soft tissues, parenchymal and hollow organs, and spinal cord lesions. To assess vessels and cavities of the heart, including those with congenital abnormalities and injuries, contrast-enhanced CT should be performed [45, 46].

Postmortem MRI allows the identification of injuries and diseases of soft tissues and parenchymal organs and the examination of the brain and spinal cord, bone bruises, and hemorrhages. Compared with CT, postmortem MRI is more effective for examining dead fetuses, stillborns, and deceased newborns.

Limitations of postmortem MRI include insufficient visualization of respiratory system injuries and diseases in adult patients, as well as hollow organs, the gastrointestinal tract, and long bones. MRI images are challenging to interpret due to artifacts caused by metal elements present in the body.

Unfortunately, CT and MRI do not allow for microscopic, biochemical, toxicological, microbiological, virological, and genetic examinations of tissue and organ specimens, which are required to determine the histological picture and nature of the tumor, causative agent of the infectious process, impaired metabolic pathways, and poisonous substance. To perform this, a minimally invasive autopsy is recommended, which includes postmortem radiological examination and needle biopsy of tissue and organ specimens for the abovementioned examinations [47, 48]. This method has proven effective for postmortem diagnostics and protecting dissection staff from SARS-CoV-2 infection during autopsies of COVID-19 patients [49, 50]. Moreover, organ or tissue lesion visualization effectiveness also depends on age, body weight, and tissue condition [51].

Based on our own thanatoradiology experience [52–54], we believe that comprehensive postmortem radiology, including CT for accurate visualization of skeletal abnormalities and gas accumulations, MRI for tissue and organ assessment, and contrast-enhanced CT for assessment of blood vessels and the heart, should be used for a complete examination of stillborn and deceased newborns. However, radiological procedures are currently selected due to the availability of the corresponding equipment or the possibility of conducting such an examination.

Selecting an institution for postmortem examination

According to Order No. 346n of the Ministry of Health and Social Development dated May 12, 2010,4 the standard equipment of state forensic medical institutions includes an X-ray machine and a digital mobile X-ray system so such institutions can perform radiological examinations.

CT and MRI require particular premises and appropriate equipment. As for large forensic medical examination institutions that examine living persons and dead bodies, the optimal strategy would be creating a radiology office with a CT and/or MRI scanner based on such an institution. Indeed, in Switzerland, joint activities of the Institute of Forensic Medicine and the Institute of Diagnostic Radiology at the University of Bern led to conducting such postmortem CT examinations since 2000 [5]. At the Department of Forensic Medicine at the University of Copenhagen (Denmark) since 2002 and the Victorian Institute of Forensic Medicine in Melbourne (Australia) since 2005, all incoming corpses are subject to postmortem CT before autopsy [16, 55]. An interesting solution is to use mobile scanners, which are tomographs mounted on special vehicles that can be driven to the location of a corpse [56].

In Russia, any X-ray examinations are regulated by state sanitary and epidemiological rules and regulations, such as SanPiN 2.6.1.1192-03, which has been in effect since May 1, 2003.5 These rules establish basic requirements and standards for ensuring the radiation safety of personnel, patients, and the general public when conducting diagnostic, preventive, therapeutic, or research X-ray procedures. There are no procedures to receive additional approval from Roszdravnadzor authorities for postmortem X-ray examinations. This was probably one reason pathologists participating in the above round table spoke about the need to conduct such studies in radiology departments of those healthcare institutions with pathology departments. Some proposals were made regarding using a separate room with its entrance and equipment. The above analysis of four surveys with foreign specialists shows that the same equipment is commonly used in clinical practice for living patients. However, in most of these institutions, postmortem examinations are conducted in the morning, in the evening, or at specially designated times when there are no appointments with living patients; hence, the principle of separating these flows was complied with.

Even though bodies are delivered and subjected to postmortem radiological examination in sealed plastic bags, SanPiN 2.6.1.1192-03 provides for mandatory wet cleaning of walls, washing floors, and thorough disinfection of elements and accessories of the X-ray machine, as well as monthly full-scale cleaning by wiping surfaces of the room, equipment, and accessories with a 1%–2% acetic acid.

Selecting a specialist for conducting a postmortem examination and analyzing the results obtained

As for those who should directly perform postmortem radiological examinations, all round table participants name radiologists, X-ray technicians, or radiotherapists. However, the type and extent of postmortem radiological examination before autopsy should be determined by a joint decision of a radiologist and a dissector. Because a pathological autopsy is performed after evaluating the medical history, which includes clarification of the clinical course and treatment of disease and antemortem laboratory tests and investigations, a radiologist should also be provided with available clinical information before conducting a radiological examination. This is confirmed by Fernandes et al. [57], who showed that awareness about clinical information improved the diagnostic accuracy of traditional autopsy by 8% and minimally invasive autopsy (including postmortem imaging and tissue sampling) by 12%.

In forensic medicine, the algorithm for postmortem radiological examination should be designed collaboratively based on the examination statement or decision, considering information on death circumstances, the postmortem period, and an external examination of the corpse. However, in 2010, the Republican Bureau of Forensic Medicine of the Ministry of Health of the Republic of Tatarstan began to provide special training in diagnostic radiology for internists and medical examiners [58].

During the round table, Russian experts agreed that a radiologist should also analyze and post-process images, including 3D modeling. From a legal point of view, additional certificates are not required for such activities, but a radiologist should have special knowledge of patterns of nonspecific postmortem changes in internal organs and associated radiological signs [59, 60]. When introducing postmortem radiology, a radiologist, pathologist, or medical examiner should analyze images and prepare a report [61].

Some additional questions occurred when discussing special aspects of introducing postmortem radiology in the Russian Federation. For example, how much postmortem radiology data (i.e., full description or a summary conclusion) should be presented in a pathological or forensic autopsy report and whether particular combined protocols are required. Most participants agreed that a separate complete thanatoradiology report with a conclusion should be prepared even in case of discrepancies with the macroscopic and microscopic examination of a corpse. However, as with clinical guidelines, postmortem radiology reports should be unified, containing technical parameters of equipment and scanning modes.

A separate discussion is required to determine whether results of postmortem radiological examinations may or should be provided to relatives upon their request and to what extent.

CONCLUSION

Therefore, literature data and opinions of Russian specialists indicate the feasibility and urgent need to use postmortem radiology to make traditional autopsy more objective and accurate. Such examination should be considered the first stage of a pathological and forensic autopsy.

The key to effective thanatoradiological examination is close cooperation between radiologists, pathologists, or medical examiners. The collaboration of specialists and available equipment makes it possible to determine practical aspects of postmortem radiological examinations to obtain the most informative results in each case.

When determining the best place to install CT and/or MRI equipment, factual circumstances of the regional medical care and the availability of equipment and radiologists in healthcare institutions should be considered. However, for comprehensive implementation of postmortem radiology into pathological and forensic practice, a centralized solution is required for some organizational issues.

ADDITIONAL INFORMATION

Funding source. This article was not supported by any external sources of funding.

Competing interests. The authors declare that they have no competing interests.

Authors’ contribution. All authors made a substantial contribution to the conception of the work, acquisition, analysis, interpretation of data for the work, drafting and revising the work, final approval of the version to be published and agree to be accountable for all aspects of the work. A.I. Shchegolev, U.N. Tumanova — concept and design of the article, data collection and analysis, drafting and revising the work, approval of the final version of the article.

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About the authors

Alexander I. Shchegolev

Research Center for Obstetrics, Gynecology and Perinatology

Author for correspondence.
Email: ashegolev@oparina4.ru
ORCID iD: 0000-0002-2111-1530
SPIN-code: 9061-5983

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Ulyana N. Tumanova

Research Center for Obstetrics, Gynecology and Perinatology

Email: ashegolev@oparina4.ru
ORCID iD: 0000-0002-0924-6555
SPIN-code: 7555-0987

MD, Dr. Sci. (Med.)

Russian Federation, Moscow

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