Вы находитесь на странице: 1из 186

,

..

2012


.,... ,
. .. ,
,
. ..

01


1 000

48,3

800

50

45,2

900

41

44,2

39,7

700

33,6

500

300
200

40

37,9

36,5

600

400

34
29,3

31,9

23,4
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

Mc
M

c, c /100000

,

25%

04

2008

: , , 2009 .

2007

o
05

06



/


-


(87,2%)

:
1.
2.
3. ,


4.

07

08

1000 (Radek Bukowski, Gary D.V. Hankins)


( , ,
, )




, ,

(,
)


, %

12,6

4,7

4,5

> 35

3,0

3,0

2,7

> 12

2,0

1,7

, -

1,7

1,7

1,6

1,5

09

1000 (Radek Bukowski, Gary D.V. Hankins)

:
-
-

-
:
-

-

:
-

, %
2,2
3,7
8,8
1,7
3,9

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10

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(
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13

14




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15


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16

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18


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19

20


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I, II, V, VIII, XI, XIII

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:

( 30%)



( % )

0,8

10 %

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20 %

1,3 1,4

30 %

1,5

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0,036 V

V =

Ht

24
0,86 Ht

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, 24 ,
,

31

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. (Ht . Ht .)
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-
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.. (1960) :

V =
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32


(
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1,1 1,2
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)

33

( 70 )
I


()

<750

750-1500

1500-2000

>2000


(% )

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15-30

30-40

>40

IV

<100

>100

>120

>140

(...)

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20-30

30-40

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34

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35

()

36

37

38

39

40

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( 500000 )


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70/, 0,25
30%

1000-2000
60 . . .

42



10 12
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43

44

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( 70 ) -

<750
7501000
10001500
15002000
>2000

- ()

% *
/

20%

<15
15-20

2000
10-15 1500-2000

600-800

20-30

15-20 1500-2000

800-1400

30-40

20-25 1500-2000

800-1400

100-200

25-30 1500-2000 1200-1500

200-300

.
400-600

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4-6

45



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51


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o
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54

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12

01

02

,


.

- XVII
1723.
1765.
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,

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03


1. (diameter fronto-occipitalis)
(glabella)
12 .
(circumferentia fronto-occipitalis) 34 .
2. (diameter mento-occipitalis)
13-13,5 .

(circumferentia mento-occipitalis) 38-42 .
3. (diameter suboccipito-bregmaticus)

9,5 . ,
(circumferentia suboccipito-bregmatica), 32 .
4. (diameter suboccipitio-frontalis)
10 . (circumferentia
suboccipito-frontalis) - 33 .
5. (diameter verticalis, s. trashelo-bregmaticus) ()
9,5-10 . ,
(cipcumferentia trashelo-bregmatica), 32 .
6. (diameter biparietalis) -
9,25-9,5 .
7. (diameter bitemporalis)
8 .

13

04

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07

08

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10



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2.
3.
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12

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)
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)

15



..

01

02

60%
3,8%

53%

. -
5,7%

47%

50%

12,7%

40%

28,6%

40%

39%

32%
30%

28%

20%

44%
.

15,4%

16,8%

10%

17%

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10

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..

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400-500 /.

,
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13
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.




HLA-DR

1,850,09 = 1,280,13
54,62,7

= 24,52,4%

592403990 = 228902860

CD4/CD8

1,630,09 = 1,400,11

()

1,570,09 = 1,790,14

(%)
()

4,10,6

14

12,01,7


1. , .
2. : -1 , ; ,
.
3.
. .
(),
.
4. (
)

0,950,04 = 0,780,04
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15

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16


108 (10/)

170 (10/)

III

80%

102%


20% /

9%; 6%

..

18

..

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17

18

64%



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..

,
60%
,
5-7%
..

19
-

20
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02

:

We must not let technology


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

1)

2)

!!!
3)

03

04
3.

1.

2.

21

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05

06

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36 . .

I.
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07
:
1.

2.

3.

40
.

,
10

08

:
1. 90-110 /.
2. 110-160 / .
3. 120-160 /.
4. 120-180 /.

09
:
1. 90-110 /.
2. 80-119 /.
3. 80-110 /.
4. 100-110 /.
:
1. 180 /.
2. 160-180 /.
3. 150-180 /.
4. 200 /.

22

10

o
11

12

13

14

( ):
1.

2.
10 .
3.

5-25
5
25

15

23

16

o
17

18

19

20

21
1.
2.
3.
4.

5.

6.
7.

8.

24

(180 . /)
. (,
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22

( )
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120-160

24

100

110-120

180

160-180

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25

10-25

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5-7
4

25

25



... ,

. ..

01
: , ... ..,
, ... .., , ... ..,
, ... .., ... .., ... ..,
. ... .., ... .., ... .., ... ..
:

. 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

()

.
()
> 140 ..
/
> 90 ..

03

04

, 20

1.

.
, 20 , 12


()

, , .
(

2.

() .

4./

 Pre-existing hypertension
 Gestational hypertension
 Pre-existing hypertension plus superimposed gestational
hypertension with proteinuria
 Antenatally unclassifiable hypertension
ESK Guidelines on the management of cardiovascular diseases during
pregnancy, 2011

26

3./

()

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.

18 , .

o
05

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< 80

120 - 129

80 - 84

...

...

...

06

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140 - 159

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160

130 - 139

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100 - 109

180

110

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..

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08

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20

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4

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(>25)

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11


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2.

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,
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13

14

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25


26


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140/90 ..

140/90 ..

140/90 ..

(/ ;
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130 ..
80 ..

27

28

, , ,

30

o
29

30
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()

1500 2000
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4000)

.



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.

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.

()

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,
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2,4

.
,
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.
.

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.

31

()

()

()


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,
max 480 /

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,

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,
.

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,
.

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, max 320/


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33




FDA

()

. 250 ;
500 2000 , 2-3
( 1500)

.

.

()

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.
30/40/60 ;
40-90 1-2
,
max - 120 .


.

.

. 25/50/100/200
25-100, 1-2 , max
- 200.

()

31

FDA

. 5/10;
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.

.

. 40/80, .
240 ;
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35

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36

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+ () +

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5 ,
15-30
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45
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38

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12

39


,
150/95 ..
,

40


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1-2 ( 90 )

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500 2000 2-3

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( / ,

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100-200

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32

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41
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1,49

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35

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0,90 (0,84-0,96)

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-0,58 (-0,86 -0,30)

0,93 (0,88-0,99

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. .
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.
Simkin P. et all., 2011

Hodnett ED et al. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2011

09

10
,
:

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Bailit et al. Outcomes of Women Presenting in Active Versus Latent Phase of Spontaneous Labor, 2005

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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
()

I
:
110-160 /


Macones G.A. et al., 2008

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Chen Han-Yang et al. Electronic fetal heart rate monitoring and its relationship to
neonatal and infant mortality in the United States, 2011

/
1000

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

III

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,
Northwestern University Feinberg School of Medicine
Chicago, Il, USA

49

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04.04.2007, .., , Lek d. d., Slovenia.
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Lannacher Heilmittel GmbH, Austria.
(Fenules) () N016072/01,
30.11.2004, , ,
Ranbaxy laboratories Limited, India.
( (III) ), 50 /, 001683,
16.06.2006, , ,
Ranbaxy laboratories Limited, India.
- ( + + ), 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

:


1. () 56
(
) (Hb), (RBC), (Ht),
(),
(), (),
2- Hb, RBC, Ht.
,
,
2,9 .
(. 1) : ,
, (. 2, 3).
2. (. 4).

I II
, 20
( , ,
, , ).
III ,
, 50
4 .
, 1
1
(Ladys Formula).
3. (. 4).

,
.
, 1
, 6 50
100 .
Fe2+ 50 (, , , )
Fe3+ 100 ( , , , ,
).

o
>90%.
( )

(Hb, RBC, Ht),
(. . 2).
,
( ) / (,
),

,
III .
6
(Hb, Ht, RBC) (, , ) .
.
.
. (Hb, RBC,
Ht) (, , ),
. (. 4).

( ), , 94% ,
.



.
.




( ) [Wulff M. et al., 2003],
(

76


) [Haram K. et al., 2001]. () ( 60 120
) , ,
: 2060 / [Haram K. et al., 2001]
70 / [Milman N., 2006].

. .. (2008). , Hb, Ht, RBC, C,
, ,
, ,
, .
. ..
,
,
( )

(Hb, RBC, Ht), (. . 2).
, (
, 100 /)
1,5 Hb, Ht RBC,
(p<0,05) ,
. ,
, 0,52,5 ,
(p<0,05).
, , 1,5 .


, ,
( ) 23% 9% (p<0,05).
12%
32% (p>0,05).
,

.
1
,
(7,80,1 7,30,2 ; p<0,05) [ .., 2008].
, ,

o
65% ,
94%
-

,

( 40%).

1.

b (/)

RBC
(1012/)

Ht (%)

(/)

(%)

(/)

127137

3,9

37,5

67

24

13

II

127137

3,9

37,7

40

20

13

III

122126

3,94,2

37,640,0

3751

16

13

2.

1 =

2 =

3 =

RBC (, ,
, , )

: MCV<80 .; MCH<27 ;
MCHC<30 /; RDW>14,5%

(b), /

122126

110120

90110

(RBC) x 1012/

3,94,2

3,73,85

3,33,7

(Ht), %

3740

3537

3035

(), /

3050

2030

20

16

16

<16

13,0

13,0

<12,5

(), %
(), /

3.

1 = *

2 =

3 =

b, /

120124

101119

90100

RBC, 1012/

3,94,0

3,33,9

2,83,3

Ht, %

3739

3037

2530

* Hb, Ht, RBC ,


(, )
[ . ., 2008].

77

o
4.

,
1 // (2025 )

1 /

25

50100

100120

68


Fe2+ Fe3+


/ ()

( )

1
0

2
1
0

10

1618

1 4

1 3

1 2

1 2


(, , )

1 12

1 10

1 8

1 6


,
,
2, 1, 0

()

* /
.

78




, ... .., , ... ..,
, ... .., , ... ..,
... .., ... .., ... ..,
... .., ... .., ... ..,
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. .. ,
,








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1- II













-


79


HELLP- hemolysis elevated liver enzymes and low
platelets syndrom (, )
FDA Food and Drug Administration ( )
1.
()
, ,
. 530% . , 12%,
50 .
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[1].
, , ,
.

,
[2, 3]. , ,
, ,
(), [4].

o
, , - [5].
2.

, ().
140 .. /
90 ..
,
, .

30 . . /
15 . . ,
(
1990 ).
,
[6-8].
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, 20-
, .

20- . ,
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) ( ).
/
.
,
: , , / /, .

1.
2.
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4. /

[914].
, 20 .

80

, 20
, 12 , ,
. (
).
30% .
,
. 1829 0,62% ,
3039 622,3%.
. ()
2275% [15,16].
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() . ,
,

, ,
. 9095% . 510% , , ..
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.

, - .
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.
,
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, 18 ,
[17].

, .. I II -

o

. ,
,

:
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,
20 .
. ,
12 ,

, , .
50% [18,19].
,
, .
12 .
, 20- ,
( 300
).
(, ; , ; , , , ;
; ). 314% . , ,

,
[20].
.
[9,11,12,13,21,22].

60%.
,
:
- , ,
,
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;

, , ;

81

, , , , .
, , ,
: ; ; HELLP-; ;
; , ;
; ; .

,
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:
1) 20 (0,3 ) ;
2) , 20
;
3) (, , ,
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,
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.
1

( . .)

..

< 140

< 90

140159

90109

160

110

..

: ;

o

( , , ).
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160 .. / 110 .. [23].

, ,
90% .
.
, ,
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,
, 100% 155 .. , 95,8% 160 ..
. 110 .. 12,5% , .
53% [23].
3.

5- ,
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.
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, 80% . 1213 , 3035 , ..
.

. .
, , .
I ,
V ( ). 15% V .
IV ,
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,
.


() .

82


,
,
.

.
, 1015%
1218% HELLP- [24].
, , , ,
.


, ;
;
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,
, .
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(, ).

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2
.

83

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[25-28]

[25,29]

, 100109
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[30,31]

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[32-34]

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.


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.

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.
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, ,
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84

, (
1- II).

.
150/95 .. .


,
[35].
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20 )
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, ( 2)
.

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3

140/90 .. > 160/110 ..

> 0,3 < 5 /

> 5/

> 100 /

< 20 /

<500 /

<100109/

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:
1. ,
.
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.

85

.
( ) (160/110
..). ,
, ,
.

.
( 140-159/90-109 ..)
.
, ,
, .
[35].
( 160/110 .. )

, , - .
160 .. [23].

. , ,
.
4.
4


150/95 ..

140/90 ..

140/90 ..

140/90 ..

: ,
,
,

.

o
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.
130150 ..
8095 ..


:
(160/110 ..)

/


, . ,
, .

.
.

, .
, .

. , .
[36].
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,
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. -

,
, .


, , -
. - , .
,
. [15].
5.
, .
,

(Food and Drug Administration), 5 .
, , (
), -- ,
() - ( - ),
.
, , , , .
,
II, , .
,
, 5 . ,
- [37].

86

,
10 ., .

30-45 ,
45

, ..
,
. . ,
[38,39].

[40].

0,075 0,15 .
0,075 3 , 0,15, / . 0,6
2-15

20-50 , / . 5 ,
15-30

. .

**

5-10 , / .
20 ,
20

.
,
. , ; , HELP- (,
).
[41].

15-45 , 300 , / .
3-5 ,
5

,
. ,
, , .

/ 10-20 100200 5% ,
1-2 /,
8-10 /.
1-2 .

. 100- 110
. . 4 ,
.

/ , 250 5% -

, 0,25 /
/, 5 /
/.
2-5

, /
[42].

4 .

:
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87


.
. , .

( 6).

o
6
,
.
( FDA)

. 250
2-
500 2000
() ( 1500 /),
2-3 ,

[9, 11, 13, 21].


I
[43].
[44,45] [45-49]. (242 , 7,5) [50].
[50], 22 %
(, , ) [51]. ,
- .

()

. 0,075/0,150

0,15,
0,6 .

[9]. . , , I (59
), [43]. [52].
(100 ),

[53]. [54]. (22 , 6
)
, , , , - [55].
: , , ,
, , , , .

()

. , I
( 299 )
[43]. : , , ; ; , .

()

.
20, . 30/40/60

40-90 1-2

,
120 .

88

,
[9, 11, 13, 21, 56].
, ,
[57-62].
(126 ) , , ,
, [63].
(110 , 18 ) [64].

o
( , ,
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[65-67],
( 1%) [68-70].

()

. 5/10
5-10 1

[43].
, , ,
[71]. , 11 36 ,
5 - [72].

()

, [43].
(II, III
), [73,74].

()

1650 ,
[75]

()

[43]. [76-79].

()

[43]. (3
) [80].

. 2,5/5/10
2,5-10 1 ,

20.

() . 40/80, . 240
40-480, 1-2

,
480 /.
-
(-)

89

[43].
.
, I , [43,52,81].


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[82]. - :
, , ,
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25-100, 2
.

, ,
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[84].

,
, [85-87].
(190 ), [88].

()

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25-100, 1-2
,
- 200/.


-.
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, [89].

()

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5-10 , 1 ,

20 .

, 87
(), II
[90].

()

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5-10, 1 ,

20.

(42 ) [91],
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() . 5
2,5-5, 1 ,

10.

. ,
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()

, I .
- [43].

( )

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5-30/ 2-3 ,

20,
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. - .
[43].

()

. 40
80-160/ 2-3 , 320.


( , , , -), 160
, . 23 (167 ) [43].

()


[46,47].
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()

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40-240 1 ,

320.

, I
- [43].

90

o
()


( )

.
[43].

- -
()

-
.
[9,12,21]. ,
[93]. [43,48,49,94,95].
[96]. -
[97]. [94].

--
[43]. ,
- ( -) [98,99].
()

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

[43].
[101,102].
(2008),

[102].
(2008), , [13].

()

. 1/2/4, . 4
1, - 16

[43].

[102].
1985 . 9 , 7000 , , [103].
, ,
[104]. , - , ..
. :
, , , ; .

()

. 25
12,5-25/


. , . 567 [43] I ,
(232 )
(73 ) [105].

() . 40
, 20-80/,


2

91

()

.2,5, .1,5
(
)
1

(46 I ) [43].

(28 I ) [43].

I (318 ) [43].

()

.25
50-200/ 2-4 ,
300/

.
.
, [106,107].
[108].

()

. 5

,
,
.
19 [109]. .

2-


,
[110,111].

.
7.

, ,
.
7
,

() +
-


-,

(-
) +

- + -

.
-, -
3-

+ () + -
+ +

+
+

+
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(-
) +

92

+ - +
() + - +
4-
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+ () + - +
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() + - + +

o
8.
, , I

,
( )
( 12 19-22 ) .

8
,


()
( I ;
II, III D)

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


I ) [112],
[43,52,113].
II-III
, [114]
/,
[115,116]; : ,
, (
- ); ; [116,117, 118,119]. .
. .

II ()
( I ;
II, III D)

II-III , , I [120-124].
, , , , [43,52].

(D)

,
. ,
, ( 2 , 13 )
[125]. I (13 ) [43].

(C)


[126].
, .
, I , 4 27 (15%), , 2 -
[43].

()

.
. (48 , I
) 4 , . (15 )
. 475 ,
: (7), (3), (3),
(12). , , [43].

93

o
6.

48 .
28% [127], 730% HELLP- [128].
150/95 ..
, -. 12

() .
7.


. 5

100 .. ,
, - [129].

- .
, .

1& Jnrfp jn vtlbrfvtynjpyjq nth ,


150/95 ..
.
2.
, 150/95 179/109 ..,
. , , ,
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3. ,
( / ,
180/110 , , )
.

,
.
,
. , ,
9. , ,
, ,
,
[130].

, , .
300-1200 / 1,14 / /
0,2-0,5. 3,2% .
(90 /). [43,52,131, 132]

.
5% , , 2%
. 3-4 , [43, 52,131, 133].

,
300-1200 / 0,7 / / 0,2-1,5. 0,1 / ,
0,3% . 2-3
.
. , ,
[43, 52, 131, 134, 135].

94

o
**

.
300 / 0,7 / / 0,03.
0,014% . , , [43, 52, 131, 136,137].

**

0,1% .
, , . ,
[43, 52, 131, 136,138].

.
240-360 / 0,3 / / 0,2-0,9.
1% [52].

. ,
[43],
[52].

100-200 /
0,7 / / 3.
0,1 / , 3,2% [43,52].

. 0,4% . 2-3
[43, 52, 131].

, , (80%),
. 1,5%
. [43, 52, 131, 139, 140].

. 4,6
. 5% . [43,
52, 131, 141].

. 3,3%
. [43,131,140].

***

.
50 / 0,12 /.
2,2% . [52,142,143,144].

***

[143].
100 / 0,1 / / 0,5-0,7.
1,2% . [52]
( ) ,
1
/

:
* , -. , , ,
, .
, ; .
** , , , , .
, 2- , ( ).
*** (, ) .

95

o
8.

, , , ,
-
[145-148].
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3,7
14 , 2,16 11,7 ,
1,81 10,4 , 1,49 14,5 [4].

.
, ,

, ,
, , [149-151].
, ,

, 2 [5].
, , .
, , , . -
.

-10
: ,
: , ,

, ,

10

()

, ,

10.0

, ,

10.1

, ,

10.2

,
,

10.3


( )

, ,

10.4


()

, , ,

10.9

11

12

12.0

12.1

12.2

13

()

14

()

14.0

14.1

()

14.9

15

96

15.0

15.1

15.2

15.9

16

97

,

, ... .

01

02



, ,
. ,
, , .

,
.

:
I II


()

,
, , .
37,5%
,
.

Treponema pallidum, Neisseria


gonorrhoeae,Ureaplasma urealyticum,
Mycoplasma hominis, Chlamydia
trachomatis,Trichomonas vaginalis,
Streptococcus haemoliticus,
Bacteroides spp, E coli

03

04
GUIDELINE TITLE
Uncomplicated urinary tract infections

()

.
(, )
(, , ).

6%.

12,5% .

: , ,
,
, (<2500 ).

98


, 20-40%
.
- 104 /)
(IIa).
(125-250 ) (50 )
(IbA)
-
, , aminopenicillin (IIbB).
, TMP
,
(IIbB).
Ib , ,
IIa ,
,
IIb , , -
. , 1

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

:
105 / ,
24 (37 )


+/
:
(,
, )
(10 1 )

102 / ( )
105 / ( )

,
. .
,
.
:
(, , , ,
, )
(10 1 )
104 /

28-30

.
3 1-2 .
, 250 3
1 ,


-
( ).
.
, .

. 100 4

07


(
.
+ 2 .
,
.

3 10 , 50100 1
.
14 (5 ,
per os). 4872

( ).
1030%.
(.
), 2 .

08

()
,
, 49,2% .

,
,
.

:
40,7%
33,9%
20,3%
.. . ..., , 2004
.. . ,2007;9(2):162

09

10


, , ,
,
.
.
5-35% .
20%
(4,6 40%). 20 ,
,
:
. .

, :
.
50% ,
, .


42-72%,
8%. 2/3
.

,
7
1,3 3:1000, , 7

1-1,7: 1000. 100


.
, 16-47%


.
.

13-43%.

99

o
11

12

,
( ):
, ( 7-10-15 ),
, ,
,
12-18 ( -24 ),
. ,

.

""
-
,

- .
(99%)
,
.
: , , , .
-
, .
: ,
:
) ,
, 71, 90, 61, 94%.

13

14


,
: .

, . . ,
, , , ,
-, . 10
: 1-2,0 /
1,0 4-6 .

() - ,

.

. , ,
- ,
,
,
.
.

- (1993-1994.)

(10-35% , 20%).
20-30% ,
, .
(1992.) 26
,
(4-6% ).
4-8% ,
26 .

(
6 ) .
90
(, ) .
,

.

15
B .

100

35-37
35-37
GBS :
(<37 )
> 18 ,
38.
:
GBS ,
GBS ( ) .
, .
- :
( ,
);
(
( ,
).
,
GBS

16

:

. ,
,

: ,
(-, -, ),
1- 2- ,
, .

,
().

o
17

18

()
,

(
)
.

10% . 2025%

. 2538%
. 1820%
.

(ACOG)


: .
-
, .
,

.

, , , - , ,
.


19

20
Cochrane Pregnancy and Childbirth Group.

Practice Guidelines
ACOG Releases Bulletin on Managing Cervical Insufficiency,
2004



?

,
.



.


( () 0,08; 95%
() 0,00, 1,44) ( 0,15; 0,01 CI, 2,92),
( = 45).
-
,
.

.

Prophylactic antibiotic administration in pregnancy to prevent infectious morbidity and mortality


WHO

2 , +
. 2
+ +
+.
.

21

2428 . .
1 .

.
37 . 2448
50% . (7095%)
7 .
.
.
:
12 50% ;
24 70%;
48 85%;
72 95%.

101

22

,
,
. , ,
4
.
-.
70%.

.
-
. 15-30%
.
.
.
.

o
23

24




( )
,
, .


, .
,
, .
, .
12 .
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.
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.


37

.
,
.
, - 4.
,
.

.
. , ,
.
,
.


.
.
, .
, .
( 34-35 ).
.

.
.

25

26


>34 .

.
32-34 <32 .
.
25 34 .


.
.
.
N.B. ,
.
, .

32 , , ,
(I-A)

> 32 , -

/ (IA) .

(2
:

(1) 2 / 6 250 6 48 ,
250 8 333 8
5 (IA);

(2) 250 6 10 (IA)

/ -
.
(IA) .

, ,
B ,
(II-2B)

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


JOGC Septembre 2009

27

28

, 6
.

, ,
,
( 0,32, 95% 0,14- 0,73).
(
0,48 , 95% 0,27-0,84).
. 3 6
.
- (
, , ,
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(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
:
, / 17-
!
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.
S. Hassan, R. Romero etc (2011): 17- .
17- FDA. 17-
.

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.
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,
.
4/17
,

o
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 .




- .

--

-1,

(-1) .

25

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4 20 )
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( )
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1 %.

(B-2a).

26

,

,
,
,
,

,
, .

,
, .

27

.

:
1. .
2. (
).
3.

,
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4.

128

28

(
):

:
.

-
35 ,
, 2 .
- 24
, 2426
34% ;
. ,

,
, 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

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and JH Harger., Obstet. Gynecol., 2002

* G.Jones D. Taylor, 2001, Harcourt Publishers Ltd

33

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, ;
: , ,
.
. ,
,

.

10 (1
2 ) , 10
, 5-10
0,3 /;

- 0,075 /. 430 .
500
.
/ . 0,3 / : 1 (25 )
120 , 2 (50 ) 60 ..;
: 75 (3
) 50 ;

45

( )

46
2- :
15 ;


2 0,5 (1 - 2,5 )
500 .
0,5 / (5 ),
15 .
1,52 / (1520 ).

. .

15 ;
4 ;
;
4 ;
.

N.B. (
per
os)

(A-1a) [King J.F., Flenady V.J., Papatsonis D.N.M, Dekker G.A.,


Carbonne B. Calcium channel blockers for inhibiting preterm labour. Cochrane
Database Syst. Rev. 2003; 1; CD002255 ]

131

o
47

48
II

(, )

;

140 .
80/50 ..


(16 31 ):
()
,
, .

( )

49

,

(A-1a):
;
(
,
).
N.B.
,

.
48 ,
.
N.B. (A-1a)

50
:
20 per os; 30
20 , 20 38 48
. 160 /;

10 , , , 20 10
( 40 ), 4
20 48 [82].
( ):
( );
;
, , .
:

, ;
, 30 ,
24 , 4 .

51
( 32
)
:
: , , ;
:
, .
N.B.
48 32 [85].
:
;
;
;
;
;
.

:
(RR:0,69)

NNT=52
$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].
- 9


[0,41
(95% CI 0,17-0,98)] [95].

, .
N.B.

-
(A-1b).

63


, , ,
,
, .


, .

,
32 .

134

64

.

.

.
N.B. (B-3a).

, ,
.

30120 (
)
:
, , (A-1a)

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
:

:
:
1)

35 .

2)

..


II


( )
,
-

. 32: , , ..


,

135

o
71

72

23 6 .

.
-
( ):

()

73

24-27 6
-

( ):
- , ..
(> 18*10 9/) -

. (1
1-2 ) ( ).

(, -)
:

( ).

74


24-27 6

:
( )
, ,
( )
( )
( )
( )
( )
( : ,
, -
)

75

28 - 33 6
- (
)

( )
( /)
, ,
( )
( ) ( )
( )
( : , ,
- )


34-36 5 :

( )

: / ( )

136

, .

01

02

5*B/0%146-D
,




(,
, ,
),

12-17%

(24,2%)
(18,2%), 12,9%.


(640-780 %) (18-30 %0).

: , ,
, -, ,
.

03

04

18,2%

24,2%

12,9%

-2,5%

3,9%
1,7% ( )

3-8%
(2000-2002)

-7,9%
(2005)

3,6% (2005)

44,7%

.., ., .. 5 . .
2001. 3. . 15-19.

137

o
05

06

13,6
, ,
(Marin
et al., 2000).


;

(, ,
, )

(OR-2.0) (Smith et
al., 2001)

( ):
- , ,
2- , ).


8,12 ,
(Irgenset al., 2001).

,
, ,

.

07

08

*
, ,
1,6 (
),
1,9 - -
2,8 .
,


1,9.
,
,
2,8.
* Wikstrom A. et al., 2005; BJOG
400 000
1973-1982.


( )

,
( )
( ,
S .)


I ,

(
235 ( 174) ( -
) (Samani, 1994)

09

,




( 13, )

(
)

138

10



(condom)

,




18 35


,

o
11

12



,
,
2 ,
(2,2 CI 2.0-2,4).
,

3
,
(3,0, CI -2.4-3,7).
,
,
2
(OR-2,0, CI -1,7-2,3)
(Skjrven R. et al., BMJ,
2005).

,
(OR-1.5, CI -1,3-1,7)
,


(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
)

25-29 /2
30 /2
(Baeten J.M. et al., 2001,
96 000 ).

4,5
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
.. (135 .. )
140/90 ..,
2-
6
105 . .

= (. + 2 .)/3
90
.. (85 ... )

o
17

140 ...
90 ...
20 . ,

300

18


- 140/90 159/109, 2-

6 20

- 300 /.
-
;

( 400,0 ).

19

20



160/110... ,
2-
6 20

5 /.

(<500 ),
1,2
/ (

),

>5 /


70 /

100
000
..

1,2 /
(600 / )

21

140

22
4-5 10000
20
(
, )
50%

15% 22% , 1/3 -


1/3
/


, ,

,

, ,
:
- 2%
- 9 25%
- 65%

o
23
,

24





/
,

25


, ,
,

, ,

26

,
(
, , ,
),


1800 ,
4000 . .

11012

27

II

141

(NO)

28

,
:
,
,

o
29

30

(,

,
)

(
,
, NO)

31

32

33

()

142

34

-




-


( 0.42)

o
35

36

(1010-1015)
(
)


(, )
(
)

, , ,

37

38
.




( , S, )




39

, ,

Ht, ,
, 2
2

143

40

o
35

36


24

, , ,

24


,



.

,
,
Ht, , ,

( , 2-3
)

37

38

25-27


(
).

,
,

(

).

1.
2.

34

:
bed rest
?
28-32


24

,


.

39


(
,
)
34

.

;

per vias
naturales

144

40
:


3-12 ;
3-5 ;


( , ,
);

o
41
,

42




(

25-27 )

43

44

-


( , .
,
)



, , ,

?
(,
-)

45




II



, ,
(,
)

145

46

1

( , , ,

)
,
( )

o
47

48

(, ,
, )
(
)

- ()




(, , )

49

50

, ..







-
(
)
(, ,
), ,

51

5



(, , )
(, )
(, , ,
)
()
(, )

146

52



, ..

.


,
.
,
.

o
53

54


- ,
.


- .

-
.
, ,
105 ... ,
160 ...,

?
(
).

55

56

1.

;
2.

,

;
3.

140/90 ..
> 25-30 ..

= ( + 2) /3

57

58

20
.
3-8
(

) .
8- .

:
1
:

D:

:
. ,

147

o
59

60

()
(-)

()

- (+)


(, );
- (,
.);
--
(, );
()

();
().

61

62

- !
, ,

:
, ,
, ,

:
, ,
, ,

63

148

64

o
65

66
(,
)


2-


(500 2-4 ) -

4-6

2-3

()
:
2-
(NTS),
,

67

68

: ,


(, )
( ,
)

25-50 1-2 /
() 5-10 1 /

() 5-10 1 /

69

Na ( )

149

70
(,
)
I

0,15-0,75 3
/

6-12

o
71

72

:
, --
,
: ,

:
, -
,
: ,

73


(
)



: ,

,



,

,
,

10 3 /;
20-40 2 /

40-80 3-4 /

75

76


(
)



,


(, )

150

74

1.
2.
3.

- 250 2 per os,


4 /.
, 2-3
.
(,-) - 100-200 /. 2
, 2400 .
30-90 1
; 7-14
120 /.
1 :
50-100 /. 2 ;
5-20 /. ;
100-200 /. 2 .
- (,
), , .

o
77

78

, ,
:


2-3 (

5-8 )


, ,
, ,

,

(, )


(
).

.

79

80

,
:


()

81



,

.

, ,



.

151



., ... .., ., ... ..,
... .., ... .., ... ..,
... .., ..

() ,
().
140 .. /
90 ..
, , 4 .

30 . . / 15
. . (
1990 ).

,

.

1.
2.
3. /
4. /
, 20 .

() .

, .. I II
.
- , 20 .
() -
, 20- ,
( 300 ).
. -

152

60%.

,
.
:
1) 20
(0,3 ) ;
2) , 20
;
3) 20 .
-10
: ,
: , ,

10

( )

10.0

( )

10.4

13

14

14.0

14.1

11

15

15.0

15.1

15.2

o
(
. .)

,
..

< 140

< 90

140 - 159

90 - 109

160

110

,
..

, ,

, .

160 .. / 110 ..
.


, ;
;
,
-, .
:
(), , , .
, -, , + .
, , (+
), ().
, .
:
(), , .
, , , (03.14.011).
+ , ,
(+, , , , ), +-, +
() +.


, , .

153

, - .

() ()

150/95 ..

140/90 ..

140/90 ..

140/90 ..


130-150 .. 80-95 ..

(160/110 ..)

/
, ,
:
1. ,
.
2. .

140/90
..

> 160/110
..

> 0,3 < 5 /.

> 5/.

< 20 /

> 100 /

<500 /.

<100109/

-/+

-

(),
, (
), -- , () -, -

.
, , . ,
II, ,
.

; ,

FDA

. 250 ;
500 2000 , 2-3 ( 1500)

. .

. 20,
. 30/40/60 ;
40-90 1-2
, max - 120 .


,
.

.

. 25/50/100/200
25-100, 1-2 , max
- 200.

; ,

FDA

. 5/10;
5-10 1


. .

. 40/80, . 240 ;
40-480, 1-2
,
480 /


.

, I
.

. 5/10
5-10, 1 , 20.


. .

. 0,075/0,150
0,15, 0,6 .

. 25
12,5-25/

.
,
- , .

154

. 40
20-80/

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


2-3

30-45 ,
45

.

.

10 .,

0,075 0,15 .
/ .

2-15 .

:
0,075 3 ,
0,15, 0,6

/ 10-20
100-200 5%
,
1-2 /,
8-10 /

1-2 .

.
100- 110
. . 4 ,

.

/ , 250 5%
- ,
0,25 //, 5 //

2-5 .

, , /
.

4

, .
. ,
.

.


5 .
1. ,
150/95 ..
.
2.
, 150/95 179/109 ..,
. -

155

, , ,
- .
3. ,
( / ,
180/110 , , )
.
, , ,
.

o
,

2-5%

3,2%

3,2%

0,4%

0,3%

1,5%

**

0,014%

5%

**

0,1%

3,3%

1%

***

2,2%

1%

***

1,2%

( ) , 1
* , -. , , ,
, .
, ; .
** , , , .
*** .

156

01

:


:
1.
2.
3.
4.

02

1.
2.
3.
4.

0%
1.

0%
2.

0%
3.

0%

0%

4.

1.

0%
2.

0%
3.

0%
4.

03

:
1.
2.
3.
4.


:
1.

2.
3.
4.

0%
1.

157

04

0%
2.

0%
3.

0%
4.

0%
1.

0%
2.

0%
3.

0%
4.

o
05


:



:
1.

2.
3.
4.

0%

0%

1.

0%

2.

06

1.

2.
3.
4.

0%

3.

4.

0%
1.

0%
2.

0%

0%

3.

4.

07

:


:
1.

2.

3.
4.
5.

08

1.

2.
3.
4.
0%
1.

0%

0%

2.

3.

0%

0%

4.

5.

0%
1.

0%
2.

0%

0%

3.

4.

09

:

1.

2.
3.
4.

1.

2.
3.
4.
0%
1.

158

10

0%
2.

0%
3.

0%
4.

0%
1.

0%
2.

0%
3.

0%
4.

o
11


:
1.
2.
3.
4.


:
1.
2.

3.

4.





0%

0%

1.

0%

2.

0%

3.

12

0%

4.

1.

0%
2.

13


:
1.
2.
3.
4.

5. ,

0%
1.

159

0%

0%

2.

3.

0%

0%

4.

5.

0%
3.

0%
4.



. ..
, ,
1 ...

10%

5%

16%

01

02

03

04

11%
40%

18%

/


-

,

,
;

;



;

,
,
.
, , 1989

160

o
05

06

- ,

( ,
- )

,
,
PAPP-A, , ,

07

08


-
()
-

1. 10-14
- ,

2. 10-13

,
,
,


,
, ,

3.
9-12 ( ).

09


-
1. 16-18

-
(, , )

2. 16-20
--
- ,

3. 22-24
-

4. 16
( )
-, ,

161

10


-
1. 32-34

- ,

2.

--
-

3.
-
-

o
11

12


(10-14 )

( - , )
10-11

3
,

, , , -

- 2

- - 70-80%

13

14

10-11
13-14

10-14
10-11
12-14
- 12-14
14
11-13
Spina bifida 12-14

15
10-11

3,
3,5
3,
3

2
1,5

10

11

12

13

-

-

-

- 100 /

,
,

162

2,5

14
14

16

6 2
20

- 6
16

95 190 /
8

o
17

18



-

,

10

1-3%
6-14%

19

20

TORCH

IgG / IgM
IgG
IgM

Toxoplasma gondii
Rubella
Cytomegalovirus

- Ig G
- Ig G
- Ig G
- Ig G
Herpes simplex virus - Ig G
- Ig G

IgG +
IgM

IgG - IgG +
IgM + IgM +

IgG IgM -

IgG +
IgM +

IgG +
IgM +

IgG +
IgM +

21

22
()



- ,

0,5

( -) - -

2,0


15-20

(16-18)

163

-
(, )
- (, )
- - , ,
,

o
23





: , ,

(+) +

24

/ ,
-,
,
,


,

(++) +
70-90%

25

26

16-19

35

,
-

0,2-2,1%

27

18

(fluorescence in situ hybridization)

,

-

-

-
( )

,


1-3%

164

28

- :

80-95%

o
29

30
1-14 - 25%


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
3D 4D

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
,


--
III


III
(32-34 )

43

44


90
70
,
III
7 ,

-


3,8

45





( >3,0)

(>8,0)



(<2,8)

167

46


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

o
47


48

,


( , %R 29,
)

49


32 (26)



((),
Rh-,
)

( , ,
)

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, ,
(
, ,
, 25 /).
,
2
10
110-160 \
- 160 \
- 110 \

51

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)
()
(
)
,



:

5 /
() 6-25 /
25 /

168

52

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


( 30
)
32 15
\ ,
15 , 2

32 10 \
, 10 , 2


2 , 10
10
.

o
53

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

,
,
,


30

,
,
,
.

54

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

,
,
,


30


,

,

, .

55

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

,
,
,


30



,
,
.

56

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




30

15 / ,
15 , 2
.
, ,

57

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




30


15 / ,
15 ,
2 .

, ,

169

58

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



15 / ,
2 ,
10
10
-

o
59

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

60

I
:
,
, ,
3-5
20

110-160 /


Macones G.A. et al., 2008

61

62

II

( I III)

( )

III

( )



2, 10

,
, ,

Macones G.A. et al., 2008

63
50 - 4


W. Fisher et al., 1973

50 - 4
/ 2 .

21%

Malder EJ et al., 2004

<100
>180

100-119
161-180

120-160

- \
- \

<3
<3

3-5
3-6

6-25
>6

30

,
1-4

30

Dip2,
Dip3


Dip3

Dip0, Dip1

22%

170

64

10-8
6-7 -
6

o
65


(, )

, ,
-


(
+ ,

+
)


,

. ,

, ,
, ,

()

66

, (),
, /,
/, ,
, .

,
, 29


,
,

, , ,
, ,

67

( )
= pH 7,15 Level III (Parer JT
et al., 2006)

= pH >7,0 97% Level II-3 (Williams KP et al., 2003)





III pH
.

36-50% 3-9%.
97-99%.

68
II III
ACOG Practice Bulletin N 106, 2009


,
,



, ,
,

.

,

,

69
.

171

70
.

o
71
.

72
.

73
. 1

74
. 2

75
.

172

75
.

o
77

78

0,01 1
1 /, /. 3-4 10 .
.
.
:

( )
.

80%
( ) .


29%

79


-
,


( > 0,9 32-37., >0,7 38-40.)


( 27,5-29%)

80


,
, )
II .
( >2,8; >2,4)



I-II .

( short-term )

II-III
( 3 ),
,

81

82


( 41 . )

+





short-term 5

173

I II III

2,8 - 7,0

< 2,8

2,8 7,0

< 8,0

> 8,0

< 8,0

..
. ..

01
Pregnancy is a nine months disease

02

:

Francois Mauriceau (1637-1709)

?

,

. 280
.


, ,

.
:
50
808

03


1. : -
2. :

- , , , ,
-
-

3. :

-
-
-
- , , ,

4.

, ,

174

04

. :
. :
*
:
- 32

- 24-26

,
,


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( 11-14)

o
05

06

,
:

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2.

2-

7-10 1-


(/+)

5-7

:
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-

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07

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18 35
40

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08

4





,
, .

-

, , , .



1 2
()
-

Rh 0


09

10


,


RW(3), (2),
(2)

30 37-38

18 30

175


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TORCH-
TO -toxoplasma
R - rubella
C -cytomegalovirus
H -herpes

30

( )

30 37-38

o
11

12

(11-14 )

(16-18 )

1.
2.

1. -
2.-

1.-
2.
3.

1.

30.

35

13

14

11-14
20-22
32-34
:
.
-
- /
-
.
- .

20-22 , 32-34

C 32 , ?

15

16


I. 5 10 .
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

13.
, 4
13.
14. RW, HBS, HCV, , Rh-
15. TORCH-.
II. 10 12 .
1.
2. 1
3.
III. 16 18 .
1.

2.

3.
4. 2
5.
6.
IV. 20 22
1.
2.
3.
V. 22 24
1.
2.
3.

176

VI.
26 28
1.
2.
VII.
30
1.
2.
3.
4.
5.
6. RW, HBS, HCV
7.
8.
9.
10. TORCH-.

VIII. 32
1.
2.
3.
4.
IX.
34
1.
2.
X.
36
1.
2. RW
3.
4.
6.



,


3-

2-




38

XI. 37
1.
2.

o
17
Rh 0
Rh (-)
Rh (+)

18


*
350 /
10-12 (+)

0(I)
(II), B(III), (IV)


Rh
1 2

Rh :
1. 32 1
2. 3235 2
3. 36 -

, :
, ,
, *
13%
5 **


28 Rh

*Addo V.N., 2010; **Gawade P. et al.,2011

19

20

1.
2.
3.
4.
5.

-3-

(, , .)

: , ,

21

22

-

7-10
1 28
2 28 36
7-10 37

10


30
28

177


1.

: (
.),
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3.
4.
5.
6. -
7.
8.
9.

10.
11.

o
23
36-37 :
1.
2.
3.
( ):
-
-
-
-

24


Bishop
0

<1

1-2

2-4

>4

>4

2-4

1-2

<1

-3

-2

-1/0

+1/+2

0-5 -
6-8
9 >

25


23.05(72)
02.06(86)

06.07(135)

Francois Mauriceau (1637-1709)

10.01.12
08.01.12

08.01.12
07.01.12

., 27
13 , , 6 25-90 .
1 ,

02.02.

06.04 (96)

26
Pregnancy is a nine months disease

., 25
12 5-6 30-31 , .
1 , .

04.04.

10.11.11

: 02.11.11
, 3760 , 8/9

04.11.11

27.04 (136)

28.10.11

22.06 (21 1)
23.07 (25)

03.11.11
06.11.11


,

. 280
.

27

178


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)

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179

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: ,
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100109/3

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,

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180


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(, small for date,

,
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09


,
(Hb 85-105 /)
/



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( 4500)
1
40
.
.
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.
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08

, II-III

. (
)
/

( )
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.

06

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11

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,

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.
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13
I

14

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. .
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1. : , ,
.

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0,3-0,4/ - 3-8

0,35-0,45\- 2-5

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1,5-2/ - 2-4

2-2,5/ - 2-4

35 10

0-2

5-6 14

4-5 9

18

12-14

.
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2. :



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(, , , , Rh)
(., . , , )

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: , , ,

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:

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,
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.

(, , )

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181

3.

.
..

16






,
()

4.
4.1. :
4.2. (d. spinarum, d.cristarum, d.trochanterica, c.externa)
4.3. : , , ,
4.4.
5. : , ,
, , ,
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.
6. ( 7
): , , , ,
; , , .
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o
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18

8. :
8.1. Hbs Ag Hepatitis B virus #
8.2. M,G (Ig , Ig G) Hepatitis C virus#
8.3. M,G (Ig , Ig G) Human immunodeficiency virus HIV1,
HIV2#
8.4.
8.5. -,

8.6.
8.7.
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10.
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21
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19
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(
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(
110\, 160\,
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23

24

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100-109
161-180

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50%

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90


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50%
,

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25

26

160-180

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.


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5
10

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9
.
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27

28

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.
12 3, 30 -1 2

II

( )
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), (
).
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1
.
:
2
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183

II -

( , , ,
, , ).
, 30 ,
.

. , 1 ,
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30-1 II
15 , .
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.
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29

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5 50
, 1,9 /.
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)
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31

III


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(45-600)

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)


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,
0(I) Rh
: , , ,
:
, , -, , .


.
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33

III

:


(
)
III 30

( ):



III 60
.
..

184

32

34



(
)
2 :
1. ,
20-30
2.

3. 20-30
4. 20-30

5. .
6.

7.
2
.
..

o
35





()
(-)

RH0 []
.
..

185



. ..

01

35 . . 2 . 2 .

:
1.

) 2
2., ,

3.
4. , /

5., -

02

35 . . 2 . 3 .

:
1.

) 2
2., ,

3.
4. , /

5., -

03

21 . . 1 .

:
1.
24
2.
3.

04

20.12 26.09.12

07.03 (11) 26.09.12


27.03 (14) 25.09.12
22.05(23) - 19.09.12
06.06(26) 13.09.12
15.08 (39) 22.08.12

186

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