акушерство и гинекология

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41
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300
200
40
37,9
36,5
600
400
34
29,3
31,9
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537
503
479
587
572
1999
2000
02
538
469
529
463
352
27,5
25,4
370
30
26,2
24,2 22,6
22
20,7 20
23,6
354
350
354
493
440
404
387
389
387
2001
2002
2003
()
2004
2005
2006
2007
2008
10
100
0
()
100 000 ()
100 000 ()
03
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M
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25%
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2008
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2007
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We must not let technology

dehumanize us: we must
humanize technology
D.Gibb, S.Arulkumaran, 2008
1)
2)

!!!
3)
03
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:
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3. 150-180 /.
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22
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:

. 2 " "
2008
Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in
Pregnancy. Am J Obstet Gynecol. 2000;183:S1S22.
Podymow ., August Ph. Update on the Use of Antihypertensive Drugs in Pregnancy. Hypertension 2008;51:960969.
American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk.
Pediatrics 2001;108:776789.
Hypertension Guideline Committee and approved by the Executive and Council of the Society of Obstetricians and
Gynaecologists of Canada. Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy. J
Obstet Gynaecol Can 2008; V30(3):1-48.
Lowe S.A., Brown M.A., Dekker G., et al. Guidelines for the management of hypertensive disorders of pregnancy.
Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) 2008; 31.
ESC Expert Consensus Document on Management of Cardiovascular Diseases during Pregnancy. European Heart
Journal 2003; 24(8):761-781.
Roberts J.M., Pearson G., Cutler J., Lindheimer M. Summary of the NHLBI Working Group on Research on
Hypertension During Pregnancy . Hypertension 2003.
(ESH)
(ESC) 2007
2008; 1-2: 51-53.
Diagnostik und therapie hypertensiver schwangerschaftserkrankungen Deutsche Gesellschaft furGynakologie und
Geburtshilfe (DGGG), Arbeitsgemeinschaft Schwangerschaftshochdruck/Gestose 2008; 24.
02

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Gestational hypertension
Pre-existing hypertension plus superimposed gestational
hypertension with proteinuria
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ESK Guidelines on the management of cardiovascular diseases during
pregnancy, 2011
26
3./
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09

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Vintzileos AM et al., Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation: a meta-analysis,1995
Alfirevic Z. et al., Cochrane Database of Systematic Reviews, 2008
97%
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Vintzileos AM et al., Comparison of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation in detecting fetal acidemia at birth, 1995
15
Recommendations on EFM and record-keeping
In order to ensure accurate record-keeping regarding EFM:
The date and time clocks on the EFM machine should be correctly set.
Traces should be labelled with the mothers name, date and hospital
number.
Any intrapartum events that may affect the FHR should be noted at the time
on the FHR trace, which should be signed and the date and time noted (for
example, vaginal examination, FBS or siting of an epidural).
Any member of staff who is asked to provide an opinion on a trace should
note their findings
on both the trace and the womans medical records along with the date, time
and signature.
Following birth, the healthcare professional should sign and note the date,
time and mode of birth on the FHR trace.
The FHR trace should be stored securely with the womans medical records
at the end of the monitoring process.
Intrapartum care 2007 guideline ROCG 13.5 Interpretation
of FHR traces
16
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Chen Han-Yang et al. Electronic fetal heart rate monitoring and its relationship to
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ACOG Practice Bulletin No. 116, 2010
Vintzileos A.M. Does Electronic Fetal Monitoring Reduce Perinatal or Infant Mortality?, Birth, Chicago, 2011
21

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Cynthia A.Wong
Department of Anesthesiology,
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Chicago, Il, USA
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16.06.2006, , ,
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- ( + + ), N012666/01,
11.08.2006, ., , Woerwag
Pharma GmbH & Co.KG, Germany.
( (III) ),
100 N011981/03, 02.06.2006, ()
., , Vifor (International) Inc., Switzerland.
( (III) + ),
N011982/01, 02.06.2006, () .,
, Vifor (International) Inc., Switzerland.
( ) (Tothema),
( ) 10
N015590 / 01, 21.04.2004,
, ,
, Laboratoire Innotech International, manufactured by
Innothera Chouzy, France.
75
:

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2530
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03
04
GUIDELINE TITLE
Uncomplicated urinary tract infections
()

.
(, )
(, , ).

6%.

12,5% .

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,
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B. ,
C. Made,
Uncomplicated urinary tract infections in adult. In: Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, ek M, Lobel B, Naber KG, Palou J, Tenke P,
Wagenlehner F. Guidelines on urological infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 11-38. [152
references]
o
05
06
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09

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19
20
Cochrane Pregnancy and Childbirth Group.
Practice Guidelines
ACOG Releases Bulletin on Managing Cervical Insufficiency,
2004

?

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( () 0,08; 95%
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WHO
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J Obstet Gynaecol Can 2009;31(9):863867 J Obstet Gynaecol 2009; 31 (9) :863-867

JOGC Septembre 2009
27
28
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<15 (A-1b)

(A-1b)
Su LL, .: Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD006770. DOI: 0.1002/14651858.CD006770.pub2.
Da Fonseca EB .: Prophylactic administration of progesterone by vaginal suppository to reduce the incidence of sponta-neous preterm birth in
women at increased risk: a randomized placebo-controlled double-blind study. Am J Obstet Gynecol. 2003
126
16

Effect of 17--Hydroxyprogesterone Caproate on Glucose Intolerance in Pregnance/

Watters TP . Obstet Genecol, 2009; 114:45-54 ;
The effect of 17-alfa hydroprogesterone caproate on the risk of gestational diabetes in
singleton or twin pregnancies Gyamfi C. . Amer J OG, 2009; 201:392
:
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.

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17
Vaginal progesterone reduces the rate of
preterm birth in women with a sonographic
short cervix: a multicenter, randomized,
double-blind, placebo-controlled trial
Sonia S. Hassan, Roberto Romero, D.Vidyadhari, S.Fusey, J.Baxter,
M.Khandelwal, J.Vijayaraghavan, Y.Trivedi, P.Soma-Pillay, P.Sambarey, A.

Dayal, V.Potapov, J.O'Brien, V.Astakhov, Ol.Yuzko, W.Kinzler, B.Dattel,
H.Sehdev, L.Mazheika, D.Manchulenko, M.- .Gervasi, L.Sullivan, A.CondeAgudelo, J.A. Phillips, G. W. Creasy
Ultrasound in Obstetrics &Gynecology 2011, 2011 Jul;38(1):18-31
RESULTS: Of 465 women randomized, seven were lost to follow-up and 458 (vaginal
progesterone gel, n=235; placebo, n=223) were included in the analysis. Women
allocated to receive vaginal progesterone had a lower rate of preterm birth before 33
weeks than did those allocated to placebo (8.9% (n=21) vs 16.1% (n=36); relative risk
(RR), 0.55; 95% CI, 0.33-0.92; P=0.02). The effect remained significant after adjustment
for covariables (adjusted RR, 0.52; 95% CI, 0.31-0.91; P=0.02). Vaginal progesterone
was also associated with a significant reduction in the rate of preterm birth before 28
weeks (5.1% vs 10.3%; RR, 0.50; 95% CI, 0.25-0.97; P=0.04) and 35 weeks (14.5% vs
23.3%; RR, 0.62; 95% CI, 0.42-0.92; P=0.02), respiratory distress syndrome (3.0% vs
7.6%; RR, 0.39; 95% CI, 0.17-0.92; P=0.03), any neonatal morbidity or mortality event
(7.7% vs 13.5%; RR, 0.57; 95% CI, 0.33-0.99; P=0.04) and birth weight < 1500 g (6.4%
(15/234) vs 13.6% (30/220); RR, 0.47; 95% CI, 0.26-0.85; P=0.01). There were no
differences in the incidence of treatment-related adverse events between the groups.
CONCLUSIONS:
The administration of vaginal progesterone gel to women with a sonographic short cervix
in the mid-trimester is associated with a 45% reduction in the rate of preterm birth before
33 weeks of gestation and with improved neonatal outcome.
18
:

(40-50%)

- (~50%)
,
:

( )
19

:
.
,
(A-1b)
Alfirevic Z., Heath V.C., et al. Cervical cerclage for prevention of preterm delivery in women with short
cervix: randomised controlled trial. //Lancet 2004; 363; 18491853.
Berghella V., Odibo A., To M.S., Rust O., Althuisius S.M.Cerclage for short cervix on ultrasonog-raphy;
meta-analysis of trials using individual patient data. //Obstet. Gynecol. 2005; 106; 181189.
15

(A-1b)
Fonseca E.B., Celik E., Parra M., Singh M., Nicolaides K.H.; Fetal Medicine Foundation Second
Trimester Screening Group.Progesterone and the risk of preterm birth among women with a short
cervix. //N. Engl. J. Med. 2007; 357; 46269.
20

, ,
(B-3a)
Berghella V., Odibo A., To M.S., Rust O., Althuisius S.M. Cerclage for short cervix on ultrasonog-raphy;
meta-analysis of trials using individual patient data. //Obstet. Gynecol. 2005; 106; 181189.
(33-34 ),
, .
Khodzhaeva Z. Sukhikh G. et al. Experience with cervical serclage in multiple pregnancies. //The journal
of Maternal-Fetal @ Nenatal Medicine, Vol. 21; 2009
21
.
:
,
105 / (A-1a).
(
). : 500 * 4
per os 3 ;
[ : , : 2,5 .
(1,5 ) ;
- : 2,5 . (1,5 )
1 .
22
.
:
(
) (A-1a)
Andrews W.W., Sibai B.M., Thom E.A., et al. Randomized clinical trial of
metronidazole plus erythromycin to prevent spontaneous preterm delivery in fetal
fibronectin-positive women. //Obstet Gynecol 2003; 101; 847855.
-

,
(A-1a)
McDonald H.M., Brocklehurst P., Gordon A. Antibiotics for treating bacterial vaginosis
in preg-nancy. Cochrane Database Syst. Rev. 2007; 1; CD000262.

(B-2a). :
125 400 .
127
o
23
.
:
24

McDonald H.M., Brocklehurst P., Gordon A. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst. Rev. 2007; 1: CD000262.
, ,
20 ,

Swadpanich U., Lumbiganon P., Prasertcharoensook W., Laopaiboon M. Antenatal lower genital
tract infection screening and treatment programs for preventing preterm delivery. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006178.
: 500 2 per os
7 300 2 per os
7 .
N.B. I- ,
.
.
: 1 per os 500 4
per os 7 10 .
Martin D.H., Eschenbach D.A., Cotch M.F. , et al. Double - blind placebo - controlled treatment
trial of Chlamydia trachomatis endocervical infections in pregnant women . //Inf. Dis. Obstet.
Gynecol. 1997 ; 5 ; 10 17 .

- .

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-1,
(-1) .

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(B-2a).
26

,

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,
,
,
,
, .

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27

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2. (
).
3.
,
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4.
128
28

(
):

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35 ,
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- 24
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34% ;
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,
, 1%
Goldenberg R.L., Mercer B.M., Meis P.J., Copper R.L., Das A, McNellis D. The preterm predic-tion study:
fetal fibronectin testing and spontaneous preterm birth. //Obstet. Gynecol.1996; 87: 643648.
Goldenberg R.L., Iams J.D., Mercer B.M., et al. The preterm prediction study: the value of new vs.
standard risk factors in predicting early and all spontaneous preterm births. NICHD MFMU Network.
//Am. J. Public Health 1998; 88; 233238.
o
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31
32
JDIams, Obstet. Gynecol., 2003

and JH Harger., Obstet. Gynecol., 2002
* G.Jones D. Taylor, 2001, Harcourt Publishers Ltd
33
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$10.291 ( $ 197)
Rouse (NEJM,2008, AJOG,2009):
-20 ;
--, < 31 ;
- PROM (87%), (4-8 ) (10%), (3%);
- 6 : 2/. 6 .
: < 28 , NNT=29.
Doyle
Do
le LW .
(Cochrane Database of S
Systematic
stematic Re
Reviews
ie s 2009:
2009
No.: CD004661. DOI: 10.1002/14651858.CD004661.pub3) :
:
. NNT= 63.
: 50-100 per os,

25 6 ( 48 ).
132
52
ACOG 3/2010:
<30 : 4 6 MagSO4
2-4 / 12
o
53
54
Chlamydia trachomatis, ,
Gardnerella vaginalis, Prevotella bivia
Gardnerella vaginalis, Prevotella bivia
B,
2, F2
Gardnerella vaginalis,
: (-1,-8, -6), - , -
Goldenberg RL ., NEJM, 2000 c .
55
56
. , ,
,
;

()

NN
R.R (95% CI)
Carey
2000
953/966
1.0 (0.8-1.2)
Klebanoff
1995
3283/3289
0.9 (0.6-1.3)
Hauth
1995
, +
, -
172/86
254 /104
0.6 (0.5-0.9)
0.9 (0.6-1.3)
Morales
1994
44/36
0.4 (0.2-0.8)
Eschenbach
1991
U. Urealiticum +
583/544
1.3 (1.0-1.9)
McGregor
1990
119/110
0.8 (0.3-2.1)
McCormack
1987
398/427
0.7 (0.5-1.1)
57
58

:
1.
2.
3.
4.
5.
6.
7.

?

?
, Str. . B.
?
133
o
59

/
;
, ,
,
60

G. vaginalis, U.
urealyticum, C. trachomatis,
T. vaginalis, ,
. ,

. 4
(B-2a).
:
2 /
, 1 4
1- 1 /,
6
3
/, 1,5 4 .

( )
61
62

, ,
,
.
.
( )
.
N.B. (,
40 1 ) [93, 94].
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[0,41
(95% CI 0,17-0,98)] [95].

, .
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-
(A-1b).
63

, , ,
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, .

,
32 .
134
64

.
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, ,
.

30120 (
)
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o
65
66
: , ,
1 025 093 1998 2005 .

( - )
Mode of Delivery and Neonatal Outcomes

in Preterm, Small-for-Gestational-Age
Newborns
,
25-34 6/7 .
N=31 135
Erika F. Werner, MD, MS, David A. Savitz, PhD, Teresa M.

Janevic, PhD, Robert M. Ehsanipoor, MD,
Stephen F. Thung, MD, Edmund F. Funai, MD, and Heather
S. Lipkind, MD, MS
From the Departments of Gynecology and Obstetrics, Johns Hopkins University

School of Medicine, Baltimore, Maryland, and The Ohio State University,
Columbus, Ohio; the Departments of Epidemiology and Obstetrics and Gynecology,
Brown University, Providence, Rhode Island; the Department of Epidemiology,
University of Medicine and Dentistry of New Jersey School of Public
Health, Piscataway, New Jersey; and the Department of Obstetrics, Gynecology
& Reproductive Sciences, Yale University School of Medicine, New Haven,
Connecticut.
Impact Factor:
(,

-,
500 .)
N= 7 991
N= 23 144
4.730

,
Obstetrics and Gynecology, 2012, Vol. 120, N3, September: 560-4
N= 20 259

N= 2 885

N= 1 214

N= 1 671
67

68

, N (%)
(95% )

(95% )*
280 (23.1)
515(30.8)
1.5 (1.3-1.8)
1.3 (1.1-1.6)
37 (3.1)
63 (3.8)
1.3 (0.8-1.9)
1.2 (0.8-2.0)
63 (5.2)
91 (5.5)
1.1 (0.8-1.5)
0.9 (0.6-1.4)
5 (0.4)
18 (1.1)
2.6 (1.0-7.1)
1.9 (0.6-6.2)
8 (0.7)
18 (1.1)
1.6 (0.7-3.8)
1.3 (0.5-3.4)
5-
7
82 (6.8)
156 (9.4)
1.4 (1.1-1.9)
1.4 (1.0-2.0)
47 (4.3)
58 (3.9)
0.9 (0.6-1.3)
0.7 (0.4-1.1)
* , , , ,
, ,
69
70
:
:
:
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35 .

2)

..

II

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. 32: , , ..

,
135
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71
72

23 6 .

.
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73

24-27 6
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24-27 6
:
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28 - 33 6
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34-36 5 :
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136
, .

01
02
5*B/0%146-D
,

(,
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12-17%

(24,2%)
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(640-780 %) (18-30 %0).

: , ,
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03
04
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(2005)
3,6% (2005)
44,7%
.., ., .. 5 . .
2001. 3. . 15-19.
137
o
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06

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, ,
(Marin
et al., 2000).

;

(, ,
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.
07
08

*
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),
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1,9.
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400 000
1973-1982.

( )

,
( )
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S .)

I ,
(
235 ( 174) ( -
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09

,

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)
138
10

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18 35

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o
11
12

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3
,
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,
2
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(Skjrven R. et al., BMJ,
2005).
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,

(OR-1.9, CI -1,4-2,5) (Skjrven R. et
al., BMJ, 2005).

,
,
, 2
,

(Lie RT et al, BMJ,
1998).

5-7 (OBrien T.E. et al., 2003 13 1000000
)
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30 /2
(Baeten J.M. et al., 2001,
96 000 ).
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4,5 ...
13
14

II III
*
1- (3,9%)
(%)

17,1
2-
18,6
2,9
5,7
3-
4,3
5,7
15,7
9,9
1-
28,6
8,6
0
10
20
30
* Skjrven R. et al., N Engl J Med 2002;346:

33-38
15

18
,
(, 1993)
. .

..

..
<120
120-129
130-139
<80
80-84
85-89
:
1-
2-
3-
4-
140-159
160-179
180-209
>210
90-99
100-109
110-119
>120
139
16

139
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6
105 . .
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90
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o
17

140 ...
90 ...
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300
18

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6 20
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20

160/110... ,
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),
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70 /

100
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140
22
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20
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1800 ,
4000 . .

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30
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56

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;
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= ( + 2) /3

57
58
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147
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60
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61
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67
68
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02
1.
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:
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:
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1.
157
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o
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:

:
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3.
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06
1.
2.
3.
4.
0%
3.
4.
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0%
2.
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0%
3.
4.
07

:

:
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2.
3.
4.
5.
08
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3.
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3.
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4.
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09

:
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2.
3.
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2.
3.
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158
10
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3.
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0%
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0%
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11

:
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3.
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:
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3.

4.

0%
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2.
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3.
12
0%
4.
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13

:
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0%
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159
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3.
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01
02
03
04
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.
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160
o
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06
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10

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3.
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12

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3
,
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13

14

10-11
13-14
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10-11
12-14
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14
11-13
Spina bifida 12-14
15
10-11
3,
3,5
3,
3
2
1,5
10
11
12
13
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,
,

162
2,5
14
14
16
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20
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16
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8
o
17
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19
20
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IgG
IgM
Toxoplasma gondii
Rubella
Cytomegalovirus
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- Ig G
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- Ig G
Herpes simplex virus - Ig G
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IgG +
IgM
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IgG IgM -
IgG +
IgM +
IgG +
IgM +
IgG +
IgM +
21
22
()

- ,
0,5
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15-20
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163
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o
23

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24

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25
26
16-19
35

,
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27
18
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,

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-

-
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,

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164
28
- :
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o
29
30
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30%
26,7%
14,7%
15%
12,9%
7,8%
10%
8%
4%
2%
5%
6%
2,3%
0,7%
0%
3,4%
9,3%
9,1%
10%
25%
20%
( )
0,6%
1,7%
0%
31
32

,
()
( -)
- 2%
- 87,5 - 100%
33
20-24
34
100%
95,0%
90%
77,3%
80%
73,0%
64,0%
70%
60%
50%
40,0%
40%
39,3%
30%
20%
10%
0%
165
o
35
36
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20-24

/
,

,
,
,

,

37
38

1.
2.
3.
4.
5. ELISA- ( )
6. (, , )
7. (, )?
39
40
, :
, ,

,

,

16-20
6
5
95
4
3
2
1
0
16
20
22
24
166
o
41

42
,

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III

III
(32-34 )
43
44

90
70
,
III
7 ,

-

3,8
45

( >3,0)

(>8,0)

(<2,8)
167
46

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IA
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I
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II
(>2,4)
(>3,0)
III -
(
)
o
47

48

,

( , %R 29,
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49

32 (26)

((),
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)

( , ,
)

50
Macones GF et al. The National Institute of Child Health

and Human Development Working Group report on
EFM: update on definitions, interpretation, and research
guidelines. Obstet. Gynecol,,2008; 112;661-6
()
10, ,
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, ,
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10
110-160 \
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51

( 10)
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)
,

:

5 /
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25 /
168
52


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)
32 15
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10
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o
53

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30

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.
54

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30

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55

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30

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30

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.
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57


30

15 / ,
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169
58


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59

60

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61

62

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( I III)
( )
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63
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W. Fisher et al., 1973

50 - 4
/ 2 .
21%

Malder EJ et al., 2004
<100
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100-119
161-180
120-160
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III pH
.

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68
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ACOG Practice Bulletin N 106, 2009

,
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15.08 (39) 22.08.12
186

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,

I, II, V, VIII, XI, XIII

25-30 1500-2000 1200-1500

We must not let technology

> 0,3 < 5 /.

. 1/5, 0,5, 2-20 2-3

500 2000 2-3

Simkin P et all 2011

Simkin P. et all., 2011

Simkin P. et all., 2011

Simkin P. et all., 2011

Simkin P. et all., 2011

Alfirevic Z. et al., Cochrane Database of Systematic Reviews, 2008

Macones G.A. et al., 2008

RR 0,75 (95% CI 0,69-0,81)

RR 0,50 (95% CI 0,44-0,57)

ACOG Practice Bulletin No. 116, 2010

Marucci, M. et al., 2007

-2.60 (-3.82 to -1.38)

1.38, (1.24 to 1.53)

1.07, (0.93 to 1.23)

0.70, (0.44 to 1.10)

1.00, (0.89 to 1.12)

1.18 (0.92 to 1.50)

1,08 (1,01; 1.15)

0,77 (0,77; 0,85)

-0,19 (-0,27; -0,12)

0,80 (0,57; 1,12)

0,88 (0,72; 1,07)

0,97 (0,88; 1,06)

Brancato R.M. et al. 2008

0.50; CI 95% 0.43 to 0.59

0.50; CI 95% 0.39 to 0.64

0.38; CI 95% 0.32 to 0.46

-79.33; CI 95% 0.39 to 0.64

-9.77 ; CI 95% -10.00 to -9.53

1,83; CI 95% 1.51 to 2.23

12,8 13,4 13,2 12,9

* Hb, Ht, RBC ,

140/90 .. > 160/110 ..

> 0,3 < 5 /

[9, 11, 13, 21].

I 2,6% 7,1% ( 29 096 , 209

1& Jnrfp jn vtlbrfvtynjpyjq nth ,

Treponema pallidum, Neisseria

1-1,7: 1000. 100

Prophylactic antibiotic administration in pregnancy to prevent infectious morbidity and mortality

(2) 250 6 10 (IA)

J Obstet Gynaecol Can 2009;31(9):863867 J Obstet Gynaecol 2009; 31 (9) :863-867

Source: Free material from www.gapminder.org

Source: Free material from www.gapminder.org

Maternal and Child Health Care

21.11.2011 N 323- (. 25.06.2012)

1976 . March of Dimes National Foundation Toward

Survey of hospital-based newborn services in the United States, 2001 yr

IIIB, IIIC, IIID,

Standards for Maternal and Neonatal Care , WHO

"=@6:65.D6L @.8@686 </?932<0.;6L 6

0323;6L =.D63;@<8 6 ?<52.;63 .91<>6@:.

Rayburn W.F. , 2011

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