ФГБУ «Уральский научно-исследовательский институт охраны материнства и младенчества» (и.о. дир.-д.м.н. Г.Б. Мальгина) Минздрава России, Екатеринбург, Россия В статье освещена важная проблема службы родовспоможения-критические акушерские состояния (near miss), организация медицинской помощи при которых определяет материнскую смертность. Представлен опыт анализа near miss в мире, России и Уральском федеральном округе с позиций дифференцированного подхода для территорий с низкой и высокой плотностью населения. Обращено внимание на необходимость разработки единых четких критериев мониторинга и оценки акушерских критических случаев с учетом совершенствования организационной модели оказания перинатальной помощи. Ключевые слова: критические состояния в акушерстве, мониторинг near miss, едва не умершие женщины.

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Aim: The aim of this research was to have a thorough study of predictors of critical states during pregnancy after assisted reproductive technologies. Materials and methods: A retrospective study of 303 patients with ''near-miss,'' out of which 37 are pregnancy cases after ART (the main group) and 265 are spontaneous pregnancy cases (the control group). Results: Pregnancy after ART constituted 12.3% of all critical states. In the main group (10.8%), severe ovarian hyperstimulation prevailed over all possible reasons for critical states within the period of up to 22 weeks of gestation, whereas bleeding predominated in the control group (57.1%). When pregnancy terms exceeded 22 weeks, the leading reason for ''near-miss'' in the main group was preeclampsia (59.5%) with underlying thrombophilia (29.7%) and gestation pancreatic diabetes (32.4%); bleeding was the main factor in the control group (36.6%). Conclusion: Women after assisted reproductive technologies constitute a high-risk group for critical obstetric states not only in the nearest time period but also long after ART.

The article presents three-year experience of organization of implementation of perinatal audit of service of delivery and childhood on territories of the Ural federal okrug and attached territories of Siberia and Far East. The primary, current and target stages of perinatal audit are marked out. On the basis of carried out studies the territories were singled out: leaders with “standard” indicators of service functioning (the Khanty-Mansi Autonomous Okrug and the Tyumenskaia oblast) and territories outsiders with high indicators on maternity mortality and feto-infant losses (Yamal-Nenets Autonomous Okrug and Tcheliabinskaia oblast). The described system of organization ofperinatal audit permits in operative mode to implement evaluation of effectiveness of functioning of service of delivery and childhood of territories and to formulate recommendations on increasing effectiveness of service functioning.

In the UFO there are different models of perinatal care (MVPN, MNPN, M), which introduced a system of monitoring of cases of maternal mortality. The study of the dependence of the frequency of critical obstetric conditions on the model of perinatal care in the UFO was not revealed, but most clearly shows its advantage of a three-level system of perinatal care in the territory of the Yamal-Nenets Autonomous district by reducing the proportion of critical obstetric conditions (from 0.8% to 0.3%) after the completion of the three-level system of perinatal care. With regard to the models of perinatal care organization, the predominance of NM share in the model of MVPN was revealed. In addition, the MVPN model was dominated by all causes of critical obstetric conditions. In this case, bleeding is the leader of the causes at any gestation period. NM monitoring allowed to assess the optimality of the organization of a three-level system of perinatal care for the prevention of critical obstetric conditions.