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Etiopatogenetichesky features and risk factors of a chronic endometritis

Prevalence of a chronic endometritis in population varies within 2,3-67,7 %, and is defined by features of sample of surveyed patients, a variety of diagnostic approaches and unresolved questions of morphological verification of the diagnosis [59,100,119,130].

Among risk factors of development of a chronic endometritis allocate medical-diagnostic manipulations in a cavity of the uterus (a currettage of a cavity of the uterus, a hysteroscopy, metroosalpingografija), infectious - inflammatory complications of pregnancy and sorts, application of endometrial contraception, inflammatory diseases of appendages and a uterus neck, disbioticheskie and inflammatory processes of a vagina, postradiation injuries endometrija [86,97,101].

The etiological structure of a chronic endometritis is defined by frequency augmentation mikstinfektsii which is presented by conditionally - pathogenic flora and viruses, and differs with high level of resistance to pharmacological preparations [68,108].

Leading originators of chronic inflammatory process in endometrii are obligatno-anaerobnye microorganisms (bakteroidy, peptostreptokokki) in association with microaerophiles (mycoplasmas, gardnerelly) and facultatively-anaerobic microorganisms (esherihii, enterococci, group streptococcuses). It is shown, that at

Patients with nevynashivaniem pregnancy the chronic endometritis in 55,1 % of observations is caused sochetannym by a virusno-bacteriemic lesion endometrija, 51,8 % – monovirusno-bacteriemic and in 12,3 % – the isolated bacteriemic becoming infected endometrija.

The risk of a becoming infected endometrija is repeatedly enlarged at disbioticheskih vagina changes. According to I.K.Kolesnikovoj (2004) implications bacteriemic vaginoza are found out in 70 % of patients with the chronic endometritis caused by conditionally - pathogenic flora and at 26,7 % of women with sterile crops endometrija. V.I.Kozlova, A.F.Puhner (2002) consider, that chronic inflammatory processes in endometrii in 40 % of cases are caused by inflammatory diseases of a neck of the uterus, caused is long persistent patogenami – S trachomatis, N. gonorrhoeae and Str. agalactiae. Nevertheless, A.V.Shurshalina (2010) specifies, that at 3-25 % of women in the cervical channel it is not possible to tap the microorganisms which are present in endometrii that confirms expediency of carrying out of microbiological research of the contained cervical channel and endometrija.

The reason of development of inflammatory diseases of organs of a small basin, and in particular, endometrija, in 15 30 % of cases is M hominis. At inspection of patients with sterility and a chronic endometritis of a mycoplasma and an ureaplasma are taped at 13 % of patients [57].

M Peuchmaur (1989) for the first time has described a HIV-assotsiirovannyj an endometritis when in monotsitarno-makrofagalnyh stroma cells endometrija it was found out replikatsija a HIV that has extreme value in a transmission of infection at heterosex contacts and through a placenta.

D. Kleiman (1994), T.F.Kowalik (1994) it is shown, that cells endometrija have high sensitivity to tsitomegalovirusnoj

Infections, long persistentsija which development of a chronic endometritis initiates. It is established, that at 55,8 % of women with nevynashivaniem pregnancy it is taped asymptomatically proceeding virusno-bacteriemic kontaminatsija endometrija with participation of viruses of herpes and a cytomegaly and at 36,3 % in endometrii is present monovirus kontaminatsija endometrija these viruses.

It is necessary to notice, that gerpeticheskoe the lesion endometrija is the leading factor nevynashivanija pregnancy that is bound to absence or atypical implications of clinical semiology at a virus lesion endometrija that predetermines diagnostic mistakes and untimely appointment of a causal treatment, frequently after repeated courses of antibiotics. The endometritis caused gerpeticheskoj by an infection, arises at patients with atypical or latent forms of genital herpes is more often. [69].

Prevalence hlamidijnoj infections at surveyed concerning sterility varies from 50 % to 75 %. At presence trubno - peritoneal forms of sterility the lesion of uterine pipes is combined by a lesion endometrija. Frequency detektsii Chlamydia trachomatis in endometrii at morfologicheski the verified chronic endometritis, according to different authors, varies from 2,3 % to 70,6 % [76,184]. Now depression of frequency of the endometritises bound with hlamidijnoj by an infection that is caused by improvement of diagnostics and pharmacotherapy of it patogena is noticed.

Often enough, on the average about 30 % of observations, at morfologicheski the verified chronic endometritis absence of growth of flora that testifies to a prevalence of conditionally - pathogenic microorganisms in development of infectious caused lesion endometrija, and-or absence of the complex approach is taped in

To diagnostics virus and hlamidijnyh infections [108,190]. Originator identification is one of the basic problems in diagnostics of a chronic endometritis – use of routine methods of inspection at inflammatory diseases of organs of a small basin in most cases does not allow to tap the etiological factor that causes complicating of clinicodiagnostic approaches and dilates possibilities of application of empirical antibacterial therapy.

Alteration endometrija conditional and absolute patogenami initiates the local inflammatory reactions accompanied by disturbance of microcirculation, a chemotaxis of leucocytes in an inflammation zone, activation of neutrophils and macrophages. The activated macrophages intensively synthesise cytokines, growth factors, active forms of oxygen, hydrogen peroxide, starting processes perekisnogo oxidations of lipids and damage of cellular membranes. The further mechanisms of development of inflammatory process are interconnected with intercellular interactions of leucocytes, cytokines and factors of growth with degradation of components of an extracellular matrix at the expense of action of proteolytic enzymes. Diffusive disturbances of microcirculation, a sladzh-syndrome, a sclerosis of walls of vessels initiate ishemicheski - gipoksicheskie disorders in tissues which aggravate processes of a neoangiogenesis and further sklerozirovanija. Long antigenic stimulation of immunocompetent cells causes attrition of kompensatorno-adaptive reactions and causes development of autoimmune mechanisms that predetermines the further damage endometrija, closing a pathological circle with wavy clinical implications of disease. It is necessary to notice, that features of a current of disease depend on an initial condition of systems of immune protection in a combination to pathogenicity of microorganisms, that

Assumes various variants of depression of effective protection of an organism and long persistentsii pathogenic microorganisms [37,14].

One of the major factors of an inflammation and reactions of cellular immunity is the transforming factor of growth TNF - α, activating a proliferation and a differentiation of neutrophils, fibroblasts, hemopoietic and endothelial cells, cells, T - and In - lymphocytes, hepatocytes; modulating a proliferation and a differentiation of cells of an inflammation; stimulating production of other proinflammatory cytokines IL-1 and IL-6; immediately operating on cells, causing their  destruction [42,84].

Fabric reactions to originator introduction are bound to sclerotic changes in tissues which are caused by development by the activated macrophages, T - and V-limfotsitami profibroticheskogo the growth factor TGF - β. This factor of growth is synthesised in the latent form which is activated by fibers of a thermal shock, liposaharidami, proteolytic enzymes of macrophages, activators of system a plazminogen-PLASMIN [155]. TGF - β even in small concentration possesses expressed mitogennym and proliferative effect, influencing on mesenchymal cells, induces synthesis of extracellular matrix proteins of which fibrous structures of a connecting tissue consist.

The vascular endothelial factor of growth VEGF is the basic regulator of an angiogenesis in the tissues, raising proliferative activity endotelijalnyh cells and permeability of vessels [41]. It is experimentally established, that steroid hormones regulate production VEGF which expression correlates with a menstrual cycle and synthesis of sexual steroids.

It is known, that morphological changes endometrija at infectious-inflammatory process, are in many respects caused by balance of processes of the programmed cellular  destruction and a proliferation of cells endometrija. In modulation of processes of an apoptosis the system bcl-2/Вах, defining sensitivity of cells to an apoptosis has defining value. Inhibiting influence has fiber bcl-2 and proapptoticheskoe – fiber Vakh [63,89]. Definition of nuclear fiber Кi-67 corresponds with activity of the proliferating cells which are in all phases of a cellular cycle, except phase G0.

The condition of the receptor apparatus endometrija is interconnected with its functional features both during a menstrual cycle, and at realisation of processes of a reproduction [85]. It is established, that during a menstrual cycle a main role the quantity of functioning receptors that defines normal development endometrija, necessary for successful implantation and pregnancy offensive plays not only concentration of steroid hormones, but, first of all.

One of prominent features of a chronic endometritis is depression of sensitivity of receptors endometrija to sexual hormones and inferiority of cyclic changes, even in case of sufficient level of estrogens and progesterone [8]. In the researches bound to sterility and habitual nevynashivaniem of pregnancy of an obscure genesis, disturbance retseptsii endometrija has leading value in formation of these pathological conditions.

Endometry contains a significant amount of the immunocompetent cells presented by population of leucocytes which share in a proliferative phase of a cycle makes about 8 % from all cells endometrija, in a secretory phase about 60 %, lymphocytes and the macrophages which are the basic sources of cytokines thanks to which reactions of intercellular interaction [11] are mediated.

Thus, development of a chronic inflammation is interconnected from an etiological component, reactions of immune protection, structural and, hence, by functional changes of endometrial cells that defines variants of clinical semiology of disease and potential possibilities of a reduction of these disturbances.

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A source: Gogsadze Lija Grigorievna. PRE-SAVIDARY PREPARATION AND FEATURES OF THE COURSE OF PREGNANCY AND BIRTH IN PATIENTS WITH CHRONIC ENDOMETRITIS. Thesis for the degree of candidate of medical sciences. Moscow –2014. 2014

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