CC BY
26
BecmHUK Kß^HJ^ №1-2019
UDC 616.12:618.3-06
iSh.A.Temirkulova, 2A.A.Yessaliyev, 3A.D. Nurmet
international Kazakh-Turkish University named after Kh.A. Yassawi 2South Kazakhstan State University named after M.O. Auezov 3South Kazakhstan Medical Academy, Shymkent city
FEATURES OF THE TREATMENT OF ARTERIAL HYPERTENSION IN PREGNANCY
(OVERVIEW)
The article reviewed the literature on the features of the treatment of hypertension in pregnant women. The goal of treating hypertension in pregnant women is the prevention of complications associated with an increase in blood pressure, the preservation of pregnancy, the normal development of the fetus and timely delivery. Before 12 weeks of gestation, a patient with hypertension before pregnancy should be examined to clarify the diagnosis, determine the functional state of the target organs, and decide on the possibility of prolonging the pregnancy. Keywords: hypertension in pregnancy, blood pressure, antihypertensive treatment, complications
Arterial hypertension [AH] is a condition in which an SBP of > 140 mmHg is recorded. and / or DBP >90 mm Hg as a result of repeated measurements of blood pressure, made at different times in a calm environment for the patient; however, the patient should not take drugs that affect blood pressure levels. To make a diagnosis of AH, it is necessary to confirm an increase in blood pressure by at least two measurements and for at least four hours [1,2,3].
Prevalence. AH during pregnancy is the most frequent extragenital pathology, it is diagnosed in 7-30% of pregnant women and serves as the main cause of deaths, perinatal mortality, significantly worsens the prognosis in the mother and in children. Complications of pregnancy with hypertension are: placental insufficiency; perinatal mortality; premature detachment of a normally located placenta; acute renal failure; acute heart failure; eclampsia, eclamptic coma; DIC syndrome; cerebral hemorrhage [4,5].
AH classification. Hypertensive conditions during pregnancy are represented by a group of diseases: - existing before pregnancy; -developed directly in connection with pregnancy. There are four main forms of hypertension: arterial hypertension before pregnancy [hypertension or symptomatic hypertension); gestational AH; AH, existing before pregnancy and combined with gestational hypertension and proteinuria; unclassifiable AH. AH in a pregnant woman in all cases contributes to the development of various complications of the mother and fetus. The greatest danger is PE [regardless of the level of blood pressure) and severe hypertension [blood pressure> 160/110 mm Hg). In these cases, the likelihood of development of detachment of a normally located placenta, rapid progression of hypertension with damage to target organs, such as the development of stroke in the mother, premature birth, or deceleration of intrauterine growth of the fetus increases dramatically. In moderate AH [140-159 / 90-109 mm Hg), clinical trials have not proven the benefit of AGT: there was no reduction in the risk of PE, perinatal mortality, premature birth,
and low birth weight babies. However, the treatment of moderate hypertension prevents the development of severe hypertension [6,7,9,10].
The goal of treating hypertension in pregnant women is the prevention of complications associated with an increase in blood pressure, the preservation of pregnancy, the normal development of the fetus and timely delivery. Before 12 weeks of gestation, a patient with hypertension before pregnancy should be examined to clarify the diagnosis, determine the functional state of the target organs, and decide on the possibility of prolonging the pregnancy. Examination can be carried out both in a hospital, and out-patient, including, in the conditions of a day hospital [3,4,5].
Non-drug treatments. Measures for non-drug reduction of blood pressure should be recommended to all patients, regardless of the severity of hypertension and drug therapy: cessation of smoking; normal balanced diet without limiting the consumption of table salt and fluids; moderate aerobic exercise [FN], sufficient 8-10 hours of sleep at night, preferably 1-2 hours of sleep; reducing BM during pregnancy is not recommended due to the risk of low birth weight babies and subsequent slowdown in their growth. However, maternal obesity can cause adverse outcomes for both the woman and the fetus, therefore, recommended ranges of weight gain during pregnancy have been proposed [8,9,10,11]. According to the recommendations of the European Society of Cardiology for the treatment of cardiovascular diseases in pregnant women [2011] in patients with normal BMI [<25 kg/m2), the recommended weight gain is 11.2-15.9 kg, in overweight women [ 25.0- 29.9 kg/m2) - 6.811.2 kg, in women with obesity [> 30 kg/m2) - <6.8 kg/m2. Drug therapy. Criteria for the onset of AHT in different variants of the course of AH in pregnant women are presented in Table 1. The general principles of medical treatment of hypertension are:
• Maximum effectiveness for the mother and safety for the fetus.
• Start treatment with minimal doses of a single drug.
Table 1 - Criteria for initiating antihypertensive therapy with different options for hypertension in pregnant women
Clinical Options of AH Blood pressure level, mm Hg
AH, before pregnancy without POM, AKS >150/95
AG, available before pregnancy with POM, AKS >140/90
Gestational hypertension >140/90
Pre-eclampsia >140/90
• Transition to another class of drugs with insufficient treatment effect [after increasing the dose of the first drug) or its poor tolerability.
• In the case of a woman taking AGP at the planning stage of pregnancy - correction of drug therapy: the abolition of angiotensin-converting enzyme inhibitors [ACE inhibitors), anigiotensin II receptor blockers and direct renin inhibitors, as well as the dose of the drug, achieving a target BP level <140/90 mm Hg.
• Use of long-acting drugs to achieve a 24-hour effect with a single dose. The use of such drugs provides a milder and more
prolonged antihypertensive effect, more intensive protection of target organs, as well as high patient adherence to treatment. Appointment during pregnancy of any drug must meet the safety requirements for the fetus, it is desirable that the drug does not have a negative effect on the physiological course of pregnancy and childbirth [11,12,13,14]. The FDA Food and Drug Administration (Food and Drug Administration) Classification of Food and Drug Administration identifies 5 categories of safety medicines for the fetus (Table 5). In accordance with the recommendations of VNOK (2010), the Working Group on the treatment of hypertension ESH, ESC (2007), as well as the recommendations of the European Society of Cardiology for the
Vestnik KazNMU №1-2019
Treatment of Cardiovascular Diseases in Pregnant Women (2011), 3 groups are currently used to treat hypertension during pregnancy AhP meeting the criteria for pharmacotherapy during pregnancy:- drugs of central action (methyldopa);- calcium antagonists (AK) of the dihydropyridine series (long-acting nifedipine); - cardioselective p-blockers ( P-AE) (metoprolol succinate, bisoprolol).
Combined therapy is carried out in case of failure of monotherapy in the maximum dose. A rational combination is
long-acting nifedipine + a-AB, with the ineffectiveness of such a combination, hydrochlorothiazide may be added in small doses (6.5-25.0 mg/day) [14,15,16].
The main drugs recommended for use during pregnancy for the treatment of hypertension are presented in Table 2. Acetylsalicylic acid in a low dose (75-100 mg /day) is used prophylactically in women with a history of early (<28 weeks) PE. Treatment begins before pregnancy or early pregnancy (up to 16 weeks of gestation) and continues until delivery [14,15,20].
Table 2 - Antihypertensive drugs recommended during pregnancy
Drug/ FDA category Dose Commentaries
Methyldopa (V) from 0.5 to 3.0 g/day. 2-3 receptions In terms of 16-20 weeks. pregnancy is not recommended due to its possible effect on fetal dopaminergic receptors. In the postpartum period, the use of methyldopa should be avoided, given the risk of developing postpartum depression.
Nifedipine (C) from 30 to 180 mg/ day. slow release of the active substance Causes tachycardia.
Cardio selective p-AB (C) (metoprolol succinate, bisoprolol) depends on the drug May reduce placental blood flow, in high doses increase the risk of neonatal hypoglycemia and myometrial tone.
Hydrochlorothiazide (C) 6.5 to 25.0 mg/day Reduced BCC and hypokalemia may develop.
In the postpartum period, even in normotensive women, a tendency to an increase in blood pressure is observed, which reaches maximum values on the 5th day after birth, which is a consequence of the physiological increase in fluid volume and its mobilization into the vascular bed. In patients with hypertension, the same trend continues. The choice of drug in the postpartum period is largely determined by breastfeeding, but it is usually recommended the same drugs that a woman received during pregnancy and after childbirth. However, it should be emphasized that diuretics (furosemide, hydrochlorothiazide, spironolactones) can reduce milk production [16,17,18]. Treatment of AH during lactation. Controlled studies assessing the neonatal effects of AGP that the mother is taking are not currently available. It is known that milk secreted by alveolar cells is a suspension of fatty drops with a high content of proteins, the pH of which is <the pH of the mother's blood plasma. Factors contributing to the penetration of the drug into breast milk are: - small amount of milk; - weak binding to plasma proteins; - high solubility in lipids; - reduced physiological pH of milk.
The effect of the drug on a child depends on the amount of milk eaten, the interval between taking the drug and feeding, the characteristics of the pharmacokinetics and pharmacodynamics of the drug, and the child's ability to eliminate it. Neonatal effects when taking methyldopa during breastfeeding is considered safe. Atenolol and metoprolol accumulate in milk in a concentration that can have a negative effect on the child, while there is no such
effect when usingpropranolol. In relation to such cardioselective P-AB, as bisoprolol, betaxolol, nebivolol, information about the neonatal effects of breastfeeding is currently not received [17,18,19]. Regarding the safety of an ACE inhibitor when breastfeeding information exists only about 2 drugs - captopril and enalapril. Currently, there are no data on the effect of ARBs on breastfeeding. Various animal tests show the negative effect of this group of drugs on the level of milk, as a result of which ARBs cannot be recommended for use during lactation. Diuretics (hydrochlorothiazide, furosemide and spironolactones) can reduce the formation of milk, but can be prescribed if necessary. AGP compatible with breastfeeding are recognized: methyldopa, nifedipine, verapamil, diltiazem, propranolol, oxprenolol, nadolol, timolol, hydralazine, hydrochlorothiazide, spironolactone, captopril, enalapril [20,21,22,23]. Tactics of management of patients with hypertensive crisis. The course of hypertension can be complicated by hypertensive crisis (CC). This is a rapid, additional, significant rise in blood pressure, which can be triggered by FN and mental stress, the intake of large amounts of salt, fluid, and the abolition of drug treatment. Increased blood pressure to 170/110 mm Hg requires urgent hospitalization and drug therapy. Emergency hospitalization of the woman is required, preferably in the intensive care unit in order to continuously monitor blood pressure and parenteral administration of AHD for a rapid decrease in blood pressure (Table 3).
Table 3 - Antihypertensive drugs for the treatment of hypertensive crisis
Drug Dose Beginning Duration Side effects Special effects
Nitroglycerin (C) 5-15 mg/h e/v 5-10 min 15-30 min, may be > 4 h Tachycardia, headache, facial flushing, phlebitis The drug for preeclampsia complicated by pulmonary edema
Nifedipine (C) 10-30 mg per os, if necessary, within 45 minutes again 5-10 min 30-45 min Tachycardia, headache, facial flushing, Can't be taken sublingually and in conjunction with magnesium sulfate
Methyldopa (V) 0.25 mg, the maximum dose of 2 g during the day. 10-15 min 4-6 hours May cause orthostatic hypotension, fluid retention, bradycardia May mask fever in infectious diseases
In the treatment of acute hypertension, intravenous medication is safer and more preferable than oral or intramuscular (intramuscular) administration, since it can prevent the development of severe hypotension by stopping the infusion. Blood pressure must be reduced by 25% from baseline during the first 2 hours and until its level is normalized in the next 2-6 hours. Gestational hypertension (GAH) treatment (after 20
weeks of gestation) is carried out in an obstetric hospital. When a good effect from treatment is obtained (normalization of blood pressure, lack of proteinuria, satisfactory condition of the mother and fetus), it can be continued on an outpatient basis, and if the therapy is insufficient, the pregnant woman is in the hospital until delivery [22,23]. Pregnant women who are observed on an outpatient basis should be hospitalized in an obstetric hospital 2-
Вестник Ка^НМУ №1-2019
3 weeks before the expected time of delivery. In the hospital, after assessing the state of the mother and fetus, the method and time of delivery are selected. At all the above stages, a dynamic
monitoring of the state of the placental complex, prevention and, if indicated, correction of the detected violations (according to the standards adopted in obstetrics) is carried out.
REFERENCES
1 Drenthen W1, Pieper PG, Roos-Hesselink JW, et al.; ZAHARA Investigators Outcome of pregnancy in women with congenital heart disease: a literature review // J Am Coll Cardiol. - 2007. - №49. - Р. 2303-2311.
2 Drife JO, Lewis G, Clutton-Brock T, Why mothers die 2000-2002; the sixth report of confidential enquiries into maternal deaths in the United Kingdom. - London: RCOG Press at the Royal College of Obstetricians and Gynaecologists, 2004. - 597 р.
3 Drenthen W, Boersma E, Balci A, et al. Predictors of pregnancy complications in women with congenital heart disease // Eur Heart J. -2010. - №31. - Р. 2124-2132.
4 Kovacs AH, Harrison JL, Colman JM, et al. Pregnancy and contraception in congenital heart disease: what women are not told // J Am Coll Cardiol. - 2008. - №52. - Р. 577-578.
5 Nishimura RA, Otto CM, Bonow RO, et al.; American College of Cardiology/American Heart Association Task Force on Practice Guidelines 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines // J Am Coll Cardiol. - 2014. - №63. - Р. 157-185.
6 Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy // Cochrane Database Syst Rev. - 2014. - №2. - Р. 52-56.
7 Committee on Obstetric Practice. Committee Opinion No. 692: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period // Obstet Gynecol. - 2017. - №129. - Р. 90-95.
8 ACOG Committee on Obstetric Practice. Diagnosis and management of preeclampsia and eclampsia. Number 33, January 2002. American College of Obstetricians and Gynecologists // Int J Gynaecol Obstet. - 2002. - №771. - Р. 67-75.
9 Peacock WF 4th, Hilleman DE, Levy PD, Rhoney DH, Varon J. A systematic review of nicardipine vs labetalol for the management of hypertensive crises // Am J Emerg Med. - 2012. - №6. - Р. 981-993.
10 Molvi SN, Mir S, Rana VS, Jabeen F, Malik AR. Role of antihypertensive therapy in mild to moderate pregnancy-induced hypertension: a prospective randomized study comparing labetalol with alpha methyldopa // Arch Gynecol Obstet. - 2012. - №285. - Р. 1553-1562.
11 Magee LA, Duley L. Oral beta-blockers for mild to moderate hypertension during pregnancy // Cochrane Database Syst Rev. - 2003. - №3.
- Р. 263-271.
12 Bateman BT, Huybrechts KF, Maeda A, et al. Calcium Channel Blocker Exposure in Late Pregnancy and the Risk of Neonatal Seizures // Obstet Gynecol. - 2015. - №126. - Р. 271-278.
13 Sibai BM. Chronic hypertension in pregnancy // Obstet Gynecol. - 2002. - №100. - Р. 369-377.
14 Magee LA, von Dadelszen P, Singer J, et al. The CHIPS Randomized Controlled Trial (Control of Hypertension in Pregnancy Study): Is Severe Hypertension Just an Elevated Blood Pressure? // Hypertension. - 2016. - №68. - Р. 1153-1159.
15 Rolnik DL, Wright D, Poon LC, et al. Aspirin versus Placebo in Pregnancies at High Risk for Preterm Preeclampsia // N Engl J Med. - 2017.
- Р. 258-266.
16 Bramham K, Parnell B, Nelson-Piercy C, Seed PT, Poston L, Chappell LC. Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis // BMJ. - 2014. - №348. - Р. 23-31.
17 Thorne S, MacGregor A, Nelson-Piercy C. Risks of contraception and pregnancy in heart disease // Heart. - 2006. - №10. - Р. 1520-1525.
18 Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease // Circulation. -2001. - №10. - Р. 515-521.
19 European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC) // Eur Heart J. - 2011. - №32. - Р. 3147-3197.
20 Shechtman M. M. Guide to extragenital pathology in pregnant women. - M.: "Triad-X", 2003. - 271 р.
21 Clinical guidelines "Hypertension during pregnancy. Treatment of hypertensive disorders during pregnancy" was approved at a meeting of the Expert Council of the Ministry of Health of the Republic of Kazakhstan (protocol No. 11 of July 06, 2012).
22 "Diagnosis and treatment of cardiovascular diseases during pregnancy", national recommendations approved by the National Congress of Cardiology in 2010.
23 Recommendations of the European Society of Cardiology for the treatment of cardiovascular diseases in pregnant women (2011).
^.3.TeMiprçY-™Ba, 2А.А.Есалиев, 3Э.Д. Нурмет
1К,ожа Ахмет Ясауи атындагы Халыцаралыц цазац-mYpiK yHueepcumemi 2М.О. Эуезов атындагы OHmycmiKЦазацстан мемлекеттiкyHueepcumemi 3Оцтустк Казахстан медицина академиясы, Шымкент цаласы
ЖУКТ1 ЭЙЕЛДЕРДЩ АРТЕРИЯЛЬЩ ГИПЕРТОНИЯСЫН ЕМДЕУ ЕРЕКШЕЛ1КТЕР1
ty^h: Ма;алада жукт эйелдердщ гипертониясын емдеу ерекшелiктерi туралы эдебиеттер ;арастырылган. Жукт эйелдердщ гипертензиясын емдеу ма;саты артерия ;ысымын жогарылатуын алдын алуы, жуктшжтщ са;талуы, уры;тыц ;алыпты дамуы жэне уа;ытында жеткiзiлуiмен байланысты ас;ынуларды болдырмау болып табылады. Жуктшжтщ алдындагы 12 аптадан бурый жуктшжке дешнп артериалды гипертониямен ауыратын нау;ас диагнозды аны;тап, ма;сатты мушелердщ функционалды; жагдайын аны;тайды жэне жуктыжт узарту мумкшдИн шешедг
ty^hîï сездер: жукт эйелдердщ гипертониясы, ;ан ;ысымы, антигипертензивтж терапия, ас;ынулар.
Vestnik KazNMU №1-2019
1Ш.А. Темиркулова, 2А.А.Есалиев, 3А.Д. Нурмет
1Международный казахско-турецкий университет им. Ходжи Ахмеда Ясави 2Южно-Казахстанский государственный университет им. М.О. Ауезова 3Южно-Казахстанская медицинская академия, г.Шымкент
ОСОБЕННОСТИ ЛЕЧЕНИЯ АРТЕРИАЛЬНОЙ ГИПЕРТОНИИ У БЕРЕМЕННЫХ
Резюме: В статье проведен обзор литературы по особенностям лечения АГ у беременных. Целью лечения гипертонии у беременных является предотвращение осложнений, связанных с повышением артериального давления, сохранением беременности, нормальным развитием плода и своевременными родами. До 12 недель беременности пациент с гипертонией до беременности должен быть обследован, чтобы уточнить диагноз, определить функциональное состояние органов-мишеней и принять решение о возможности продления беременности.
Ключевые слова: гипертония у беременных, артериальное давление, антигипертензивная терапия, осложнения
УДК 618.2-07:616.155.194
Н.М. Мамедалиева, А.М. Сапаралиева, Н.О. Мусабаева, М.Э. Эд1лова, К.Б. Сариева, А.Х. Абсалямова, А.Ш. Жаркынбекова
С.Ж. Асфендияров атындагы Цазсщ ¥лттьщ медицина университетi
ЭКСТРАКОРПОРАЛЬДЫ ¥РЬЩТАНДЫРУДАН КЕЙ1НГ1 ЖYКТIЛIКТЩ АКУШЕРЛ1К ЖЭНЕ ПЕРИНАТАЛЬДЫ АГЫМЫНЬЩ ЕРЕКШЕЛ1КТЕР1
Экстракопоральды урыктандырудан Keüi^i жyктi болган 100 эйелдщ босану тарихын pempocneKmuemi зерттеу аркылы, бедеулктщ ce6e6iH ескере отырып, жуктшктщ агымы мен нэтижеа талданды. Бедеулк ce6e6iHe к,арамастан жуктшктщ I mpuMecmpi жуктшктщ узыу каут' жогаргы жишкпен сипатталды (42%-дан 76%-га дeйiн), ал II триместр - истмико-цервикальды жетюл'казд'кпен (25%) вткенi аныкталды. Бедеулктщ эндокриндi генездi тобында III триместр жогаргы жишкте преэклампсиямен аскынды (36%). Тymiкmiк-nepumoнeальды жэне эндoкpuндi гeнeздi жуктшк топтарында кесар тыш операциясымен аякталу жuiлiгi жогары (32% жэне 71,4%). 62,3% нэресте мepзiмiнe жетп туылды, ал мepзiмiнeн ерте туылган нэрестелер 37,7% курады. Соныц iшiндe квп урыкты жуктШктщ кездесу жuiлiгiжогары (45%). Tyümöi свздер: экстракопоральды урыктандыру, жуктшк, босану, бeдeулiк
Так;ырып езекпшп: K^3ipri тацда бедеулж медициналык жэне элеуметтж -психологиялык мэселе болып табылады, ейткеш ол тек eKi жупты гана камтымай, олардыц eMip суру сапасына, жалпы мемлекеттщ демографиялык керсеткштерше де эсерш тигiзeдi [1]. 17 млн. хал;ы бар Казакстанда бедеулж баска елдермен салыстырганда аз кeздeспeйдi жэне оныц дeцгeйi 15 % курайды [2,3]. Статистикалык мэлiмeттeргe суйенсек, Казакстанда жыл сайын 160 неке ^ркеледь соныц iшiндe 20 мыц жуп бедеулжке ушырайды [3].
БYгiнгi кунде заманауи eмнiц медикаментозды жэне хирургиялык эдiстeрiн колдана отырып, табиги фертильдыж сэттi калпына келуде. Сонымен катар, эйелдердщ жартысында калаулы ЖYKтiлiк косымша рeпродуктивтi технологиялар аркылы, атап айтканда экстракорпоральды урыктандыру жэне эмбрионды тасымалдау аркылы жузеге асады. Казакстандык репродуктивт медицина Ассоциациясыныц дeрeктeрiнe суйенсек, Казакстанда 20 жылдыц iшiндe косымша репродуктивт технологияларды колдану аркылы 12200 нэресте туылды. Жылына 2000 жуык «шыны тYтiкшeдeгi » нэрестелер вмiргe келдь Косымша рeпродуктивтi технологиялар аркылы eлiмiздe 50 мыцга жуык нeкeдeгi жуптар ем кабылдады. Олардыц нэтижeлiлiгi орташа есеппен 15 %-дан 43 %-га дeйiнгi кврсeткiштi курайды. Багдарламаныц нэтижелшпн айкындайтын «take home baby» кeрсeткiшi 29 % дeцгeйiндe, ол Европалык eлдeрдiц мэлiмeттeрiмeн шамалас [3].
Сонымен катар экстракорпоральды урыктандыру багдарламасы аркылы ЖYKтiлiктiц дамуы аскынган акушерлж гинекологиялык анамнeзi бар Yлкeн репродуктивт жастагы эйелдерде ЖYргiзiлгeндiктeн, олардыц ЖYKтiлiгiнiц агымы мен нэтижeсiн зерттеу мацызды болып табылады.
Бiздщ зерттеу жумысымыздыц ма^саты - анамнезшде бeдeулiктiц тYрлi сeбeбi бар экстракорпоральды
урьщтандырудан кейiнгi эйелдердiц жуктшпнщ агымы мен нэтижесiн талкылау болып табылды.
Максатка жету барысында экстракорпоральды урыктандырудан кейiнгi 100 эйелдiц жуктшж жэне босану агымы, перинатальды нэтижеа зерттелшдь Анализ ретроспективтi зерттеу эдiсiмен Алматы каласы, 2016 жыл келемшде «Акушерия, Гинекология жэне Перинатология гылыми орталыгы» жэне «Перинатология жэне балалар кардиохирургия орталыгында» ЖYргiзiлдi. Аурулардыц жасы 21 жас пен 42 жас аралыгында болды, орташа жас мeлшерi 32,5±1,3 жасты курады. Алгаш босанушылар саны- 56, кайта босанушылар саны -44. Бедеулжтщ узактыгы 2-11 жылды камтыды (орта есебi 6,1±1,2 жыл).
Барлык аурулар бедеулiктiц себебiне байланысты топтарага бвлiндi.
1.Бiрiншi топка бедеулжтщ тYтiктi-перитонеальды факторымен 56 эйел ирдь оныц iшiнде 14 эйел тYтiктiц екi жакты болмауымен (абсолюттi бедеулж).
2.Екiншi топка бедеулiктiц эндокриндiк факторымен 25 эйел ирдь
3.Yшiншi топка бедеулжтщ ерлiк факторымен 19 эйел ирдь
I топтагы тYтiктi-перитонеальды бедеулжпен аурулар жасы 27-ден 38 жас аралыгында болды, орта есеппен 33,5±1,2 жас. Бедеулiктiц бiрiншiлiк типi 18 (32,1%) эйелде, екшшыж типi 38 (67,9 %) эйелде аныкталды. Бедеулжтщ TYтiктi-перитонеальды факторымен инфертильдiлiктiц мерзiмi 2 жылдан 9 жылга дешн аралыкты курады, орташа кврсеткiш 5,4 жыл. Бiрiншi топтагы эйелдерде бул ЖYKтiлiк экстракорпоральды урыктандырудыц 1-2 эрекетшен 36 эйелде (64,2%) пайда болды, 3-5 эрекеттен кешн 15 (26,9%) эйелде жэне 5 эйелде ЭК¥ 6 жэне одан да кеп эрекет кажет болды. Бул топтагы эйелдерде аскынган акушерлiк анамнез басым болды, соныц iшiнде дамымаган ЖYKтiлiк 9 эйелде (16 %), езд^нен тYсiк тастау 14 эйелде (25%), медициналык аборт 18 эйелде (32,1%), кесар тшп 6 эйелде (10,7 %) болды.
