1.anc Final

antenataluri meTvalyureoba fiziologiurad mimdinare orsulobis dros

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

klinikuri praqtikis erovnuli rekomendacia (gaidlaini) `antenataluri meTvalyureoba fiziologiurad mimdinare orsulobis dros” miRebulia klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo standartebis (protokolebi) SemuSavebis, Sefasebis da danergvis erovnuli sabWos 2007 wlis 21 martis sxdomaze da damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris #??????? brZanebiT.

2

antenataluri meTvalyureoba fiziologiurad mimdinare orsulobis dros avtorTa jgufi: ⇒ zaza boxua - mean ginekologi, saqarTvelos mean ginekologTa asociaciis generaluri mdivani, saqarTvelos Sromis, janmrTelobis da socialuri dacvis jandacvis departamentis ufrosis moadgile. ⇒ barbare brolaZe - q. Tbilisis 4 samSobiaro saxlis mean ginekologi, saqarTvelos mean ginekologTa asocoaciis wevri. ⇒ iza kurdRelaiZe - m.SaraSiZis samedicino centris qalTa konsultaciis mean ginekologi, saqarTvelos mean ginekologTa asocoaciis wevri. ⇒ jgufis xelmZRvaneli – Tengiz AasaTiani, mean ginekologi, Tssu postdiplomuri samedicino ganaTlebis da uwyveti profesionaluri ganviTarebis institutis reproduqciuli janmrTelobis departamentis xelmZRvaneli, asocirebuli profesori, saqarTvelos mean ginekologTa asociaciis prezidenti. •

saeqsperto Sefaseba: ⇒

ekaterine SeSaberiZe - kaspis raionis qvemo gomis/ambulatoriis eqimi – Terapevti, saojaxo medicinis moklevadiani rezidenturis rezidenti

⇒ veriko baziari- saqarTvelos Sromis, janmrTelobis da socialuri dacvis jandacvis departamentis dedaTa da bavSTa samarTvelos ufrosi, saqarTvelos mean ginekologTa asocoaciis wevri. ⇒ Tamar zubadalaSvili – q.Tbilisis S.p.s. £# 5 saavadmyofo-poliklinikuri gerTianebis qalTa konsultaciis gamge, saqarTvelos mean ginekologTa asocoaciis wevri ⇒ lali ruxaia – q.Tbilisis № 5 samSobiaro saxlis ambulatoriuli profilaqtikis ganyofilebis gamge ⇒ magda omiaZe – q.Tbilisis saojaxo medicinis erovnuli saswavlo centris № 5 qalTa konsultaciis direqtori, saqarTvelos mean ginekologTa asocoaciis wevri ⇒ marina turZelaZe - № 1 samkurnalo profilaqtikuri centris qalTa konsultaciis ufrosi ⇒ klinikuri rekomendaciebis zogadi mizani klinikuri rekomendaciebis mizans warmoadgens: •

antenataluri meTvalyureobis Sesaxeb meanebis, bebiaqalebis, ojaxis eqimebis, menejerebisa da sxva dainteresebuli pirebisaTvis uaxlesi samecniero informaciis miwodeba fiziologiurad mimdinare orsulobis dros;

•

antenataluri meTvalyureobis mqone orsulTa ricxvis gazrda;

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orsulebisa da gaumjobeseba.

maTi

ojaxis

wevrebis

sanitaruli

ganaTlebis

3

ganxiluli klinikuri sakiTxebi mocemuli klinikuri rekomendaciebi ar ganixilaven im garTulebebs, romlebic SeiZleba warmoiSvas orsulobis dros, aseve mSobiarobisa da mSobiarobis Semdgomi periodis marTvis Taviseburebebs. im pacientTa SesarCevad, romelTaTvisac SesaZlebelia mocemuli rekomendaciebis gamoyeneba, SemoTavazebulia SefasebiTi cxrilis gamoyeneba. (cxrili 1). visTvis aris gankuTvnili mocemuli klinikuri rekomendacia mocemuli rekomendacia SeiZleba gamoyenebuli iyos im samedicino personalis mier, romelTac exebaT orsulTa mSobiarobamdeli meTvalyureobis sakiTxebi. is agreTve SeiZleba gamoyenebuli iyos rogorc diplomamdeli, ise diplomisSemgomi samedicino ganaTlebisaTvis.

Ziebis, mtkicebulebaTa Sefasebisa da rekomendaciebis formulirebis aRwera antenataluri meTvalyureobis aqtualobasTan dakavSirebiT arsebobs meTodologiaTa sakmarisi raodenoba, romlebic Seicaven mkacri samecniero mtkicebulebze dafuZnebul rekomendaciebs. amitom mocemuli meTodologiis SemqmnelTa samuSao jgufis mier gadawyvetili iyo ukve arsebuli praqtikuli rekomendaciebiis moZieba da Sefaseba da rekomendaciebis adaptirebuli formis Seqmna, romelic erTis mxriv, upasuxebda saerTaSoriso moTxovnebs, xolo meore mxriv misaRebi iqneboda saqarTvelos jandacvis pirveli rgolis pirobebSi gamosayeneblad. samuSao jgufis mier daSvebuli iyo is SesaZlebloba, rom arsebul rekomendaciebSi ar iqneboda ganxiluli yvela klinikuri SekiTxva, da am SemTxvevaSi warmoiSveboda aucilebloba konkretul klinikur SekiTxvebTan dakavSirebiT mtkicebulebaTa damoukideblad moZiebaSi. klinikuri rekomendaciebis wyaroebi da meTodebi •

•

da

mtkicebulebebis

moZiebis

damatebiTi

klinikuri rekomendaciebis, epidemiologiuro monacemebisa da antenataluri meTvalyureobis mtkicebeulebebis Semdgomi moZieba xorcieldeboda inglisurenovani (Yahoo, AltaVista, Google, DoctorGuide da rusulenovani (Yandex, Rambler) saZiebo operatorebis meSveobiT, aseve inglisurenovani samedicino monacemebis eleqtronuli bibliografiuli monacemTa bazis, „medlainis,, (MEDLINE) meSveobiT, sakvanZo sityvebis gamoyenebiT. pirvel rigSi moZiebuli iyo (National Guidelines Clearinhouse, TRIP, SumSearch) antenataluri meTvalyureobis analogiuri rekomendaciebi, romlebic SemuSavebulia Sesabamisi profesionaluri jgufebis mier. calkeuli klinikuri sakiTxebis Sesaxeb mtkicebulebaTa moZieba da im sakiTxebis moZieba, romlebic arasrulad aris ganxiluli, warmoebuli iyo kohreinis monacemTa bazaSi The Cochrane Library 2006, Issue 3, da jandacvis msoflio organizaciis reproduqciuli janmrTelobis biblioTekaSi #9. ar iyo Catarebuli ruxi literaturis moZieba (konferenciebi, Tezisebi, gamouqveynebeli masalebi) 4

moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi Catarebuli Ziebis Sedegad miRebuli iyo ramodenime klinikuri meToduri rekomendacia antenataluri meTvalyureobis sakiTxze{Chan, 2004 165 /id;Guillermo Carroli, 2001 7 /id;National CollaboratingCentre for Women's and Children's Health, 2003 163 /id}, romlebic Seicavda jgufis miznis Sesaferis saWiro informacias. am rekomendaciebis saboloo Sefasebisas gamoyenebuli iyo formaluri Sefasebis meTodi AGREE ( Appraisal of Guidlines for Research and Evaluation ){2001 160 /id}. Sefasebis Sedegad amorCeuli iyo ramodenime rekomendacia, romlebic safuZvlad daedo Semdgom analizsa da adaptacias. am rekomendaciaSi mocemuli debulebebi Sejamebuli iyo cxrilebSi da warmodgenili iyo samuSao jgufis wevrebis mier Sefasebis mizniT. cxrilSi Sedioda debulebis originaluri versia da mtkicebulebis done wyaros mixedviT. samuSao jgufs unda Seefasa rekomendaciebis vargisianoba saqarTvelos jandacvis pirveladi rgolis pirobebSi. rekomendacia miRebuli iTvleboda, Tu mis sasargeblod xmas aZlevda SemqmnelTa samuSao jgufis umravlesoba. rekomendaciis SemuSavebisas Cven gamoviyeneT modificirebuli sqema, romelic mowodebulia SIGN (Scottish Intercollegiate Guideline Network) mier{Harbour R, 2001 161 /id}. konfliqtTa interesebis deklaracia muSaobis dawyebamde mocemuli klinikuri rekomendaciis proeqtSi, samuSao jgufis yvela wevrma Tanxmoba ganacxada, werilobiT formaSi ganecxada farmacevtul kompaniebTan finansuri kavSirebis Sesaxeb. saavtoro koleqtivis arc erT wevrs ar hqonda finansuri daintereseba an sxva interesTa konfliqti farmacevtul kompaniebTan an sxva organizaciebTan SesamuSavebel rekomendaciasTan dakavSirebiT. klinikuri rekomendaciebis Sida recenzireba Catarebuli iyo klinikuri rekomendaciebis Sida recenzireba ( sia Tan erTvis) rekomendaciebis mowodebis sizustis gamosavlenad, maTi efeqturobis da usafrTxoebis Sesafaseblad da praqtikuli gamoyenebisaTvis masalis arsebobis dasadgenad. recenziebis miRebis Semdeg ganxiluli iyo Sedegebi da samuSao jgufis mier Setanili iyo cvlilebebi klinikuri rekomendaciebis SinaarsSi. klinikuri rekomendaciis gadaxedvis vada -2009 w mtkicebulebaTa doneebisa da rekomendaciebis gradaciis sqema

yvela ZiriTadi rekomendacia Seesabameba garkveul gradacias, romelic aRiniSneba laTinuri asoebiT A-dan C-mde. (Agency for Health Care Policy and Research-1994 Sesabamisad). amasTan erTad, yovel gradacias Seesabameba monacemTa mtkicebulebis Sesabamisi done. es niSnavs, rom rekomendaciebi dafuZnebuli iyo kvlevebis monacemebze, romlebsac gaaCniaT mtkicebulebis garkveuli done. rac ufro maRalia rekomendaciis gradacia, miT ufro maRalia kvlevis mtkicebuleba, romelzedac is aris dafuZnebuli. qveviT moyvanilia sqema, romelSic aRwerilia rekomendaciebis gradaciis sxvadasxva doneebi, romlebic CarTulia am saxelmZRvaneloSi. 5

saWiroebs ZiriTadi literaturuli wyaros arsebobas, minimalurad erT

A

randomizirebul sakontrolo kvlevas, romelic Catarebulia kargi xarisxiTa da SinaarsiT, rac specifiurad Seesabameba mocemul mtkicebulebas an rekomendacias. saWiroebs maRali xarisxis klinikuri, magram ara randomizirebuli

B

kvlevis Catarebas, romelic Seesabameba rekomendaciis Sinaarss. saWiroebs mtkicebulebebis arsebobas, romlebic dafuZnebulia eqspertTa komisiis daskvnaze an maT azrze da/an dafuZnebulia

C

am dargSi cnobili avtoritetuli warmomadgenlebis azrze. miuTiTebs xarisxiani kvlevebis ar arsebobaze am sakiTxTan dakavSirebiT.

Sesavali antenataluri meTvalyureobis Tanamedrove models safuZveli Caeyara me-20 saukunis dasawyisSi da am droidan farTod gamoiyeneba msoflioSi. dRemde antenataluri vizitebis komponentebi da Sinaarsi ar iyo mecnierulad dasabuTebuli. 1972 wels arCi kohrani werda:{Cochrane A, 1972 162 /id} “samwuxarod, antenataluri meTvalyureoba ar moicavs kritikul Sefasebas, Tu romeli skrininguli procedurebia dasabuTebuli.” 1998 wels janmo/evropis perinataluri daxmarebis samuSao jgufis meore Sexvedraze{World Health Organization., 1998 1 /id} Camoyalibda perinataluri daxmarebis principebi, sadac gamocxadda, rom orsulobis dros yvela Carevas unda hqondes mkacri Cveneba da rac mTavaria, damtkicebuli dadebiTi zegavlena orsulobis gamosavalze. samwuxarod, dRemde orsulobis meTvalyureobis dros xSirad gamoiyeneba Carevebi, romlebic dafuZnebulia kerZo gamocdilebasa da STabeWdilebebze, ar efuZneba samecniero mtkicebulebebs da amrigad, ar axdens dadebiT zegavlenas dedisa da bavSvis janmrTelobaze. mocemul Lklinikur rekomendaciebSi Sejamebulia ukanaskneli mtkicebulebebi, romelTa mixedviTac unda mimdinareobdes antenataluri dakvirveba fiziologiurad mimdinare orsulobis dros. antenataluri meTvalyureobis miznebi miuxedavad imisa, rom Tanamedrove mtkicebulebebis mixedviT antenataluri meTvalyureoba ar aumjobesebs mSobiarobis gamosavals{Fiscella K., 1995 8 /id}, is exmareba qals da nayofs janmrTelobis SenarCunebaSi. antenataluri momzadeba gulisxmobs aseve orsuli qalis, misi partniorisa an ojaxis 6

daxmarebasa da mxardaWeras. es niSnavs imas, rom personali awarmoebs ara marto samedicino meTvalyureobas orsulze, aramed axorcielebs maT ganaTlebasac. samedicino personalis roli:  orsulis janmrTelobis gaumjobesebisaken mimarTuli saqmianobis daxvewa;  daavadebebis profilaqtikuri RonisZiebebis gatareba;  samkurnalo RonisZiebebis gaweva;  kavSiris uzrunvelyofa iseT samsaxurebTan, rogorebic aris orsulTa specializirebuli daxmareba, mSobelTa momzadeba da sxva;  orsulTa swavlebis uzrunvelyofa, janmrTelobasTan dakavSirebuli codnisa da unar-Cvevebis gaRrmaveba;  qalis mxardaWera, mzadyofna orsulobis, mSobiarobisa da mSobiarobis Semdgom periodTan dakavSirebul nebismier sakiTxze misi azris mosasmenad;  orsuli qalebisaTvis socialur-samarTleblivi daxmarebis aRmoCena saqarTvelos kanonmdeblobis Sesabamisad. Tu ra saxis meTvalyureoba unda gaewioT qalebs fiziologiuri orsulobiTa da meores mxriv, garTulebuli orsulobiTa da mSobiarobiT. ganisazRvreba antenatalur meTvalyureobis dros. sakiTxebi Seexeba aseve vizitebis sixSires, momsaxureobis saxes, testebsa da analizebs, romlebic SeiZleba SevTavazoT qalebs yoveli vizitis dros. aucilebelia vicodeT da gaviTviswinoT qalis azri maTi movlis Sesaxeb orsulobis nebismier vadaze. {Chalmers I, 1989 2 /id} orsulTa ayvana aRricxvaze 2005 wels saqarTveloSi Catarebuli mimoxilvis monacemebiT{2005 33 /id} 4 da meti viziti Seasrula orsulTa 75%-ma. 4 an meti vizitis Sesruleba ufro xSirad moxda TbilisSi (90%) da imereTSi (83%), sxva regionebTan SedarebiT. yvelaze dabali maCveneblebi dafiqsirda qvemo qarTlisa da kaxeTis regionebSi (56% da 59% Sesabamisad). Aantenataluri vizitebis raodenoba yvelaze maRali iyo qarTvel qalebSi, romelTa 80%-s hqonda 4 prenataluri viziti. mimoxilvis Sedegebidan gamomdinare, mSobiareTa mxolod 5%-s ar Cautarda prenataluri meTvalureoba. es maCvenebeli ufro dabali iyo qalaqis pirobebSi da Seadgenda 2%-s, TbilisSi ki am maCvenebelma Seadgina mxolod 1%. arsebobs mravali mizezi, romelTa gamo orsulebi ar mimarTaven pirveladsamedicino dawesebulebebs, magram umetes wilad ZiriTad mizezebad gvevlineba Semdegi:  vizitis Sesaxeb gadawyvetileba miRebulia ara TviTon qalis, aramed misi ojaxis wevrebis mier, romlebic ar xedaven amis aucileblobas da zogjer ar endobian samedicino personalis momsaxureobas, gansakuTrebiT soflis pirobebSi;  samedicino momsaxureobis gawevisas orsulTan urTierToba xSirad ar aris megobruli, ar aris daculi konfidencialuroba, keTdeba dausabuTebeli analizebi, Carevebi da gamokvlevebi;  arsebobs samedicino procedurebis SiSi qalis arasrulfasovani informirebis gamo;  xSir mizezs warmoadgens Sori manZili da transportis problemebi, zogierTi kulturuli Taviseburebebi da aseve socialur-ekonomiuri problemebi.

7

vin unda uzrunvelyos meTvalyureoba sistematurma mimoxilvam{Hatem M, 2004 35 /id} Seafasa antenataluri meTvalyureobis efeqturoba bebiaqalisa da ojaxis eqimis mier gaweuli daxmarebis Sedarebis gziT mean-ginekologis mier gaweul daxmarebasTan. jgufebs Soris ar gamovlenila gansxvaveba naadrevi mSobiarobis, sakeisro kveTis, anemiis, saSarde gzebis infeqciebis, mSobiarobamdeli sisxldenebisa da perinataluri sikvdilianobis ganviTarebis sixSiris TvalsazrisiT. am mimoxilvidan gamomdinare, bebiaqalebisa da ojaxis eqimebis mier aRmoCenili daxmareba dakavSirebulia orsulobasTan dakavSirebuli hipertenziisa da preeklamfsiis ganviTarebis statistikurad ufro dabal sixSiresTan ( OR 0.56, 95% CI 0.45 - 0.70), (OR 0.37, 95% CI 0.22 - 0.64) standartuli meTvalyureobis jgufTan SedarebiT. 3 kvlevis meta-analizze dayrdnobiT, romelSic monawileobda 3 041 qali, bebiaqalebisa da zogadi profilis eqimebis mier gaweuli antenataluri meTvalyureobis pirobebSi dabali riskis mqone qalebisaTvis ar izrdeboda dedisa da perinataluri gamosavalis riski. miuxedavad imisa, rom miRebuli monacemebi sarwmunod mowmoben bebiaqalebisa da ojaxis eqimebis mier gaweuli antenataluri meTvalyureobis upiratesobaze fiziologiurad mimdinare orsulobis dros, arsebuli kanonmdebloba da ojaxis eqimebisa da bebiaqalebis momzadebis done ar iZleva saSualebas mocemuli rekomendaciis danergvisaTvis. fiziologiuri orsulobis dros sakmarisia saTanadoT momzadebuli bebiaqalis an ojaxis eqimis mier ganxorcielebuli meTvalyureoba. mean-ginekologis rutinuli CarTva meTvalyureobis procesSi aseT SemTxvevebSi ar aumjobesebs perinatalur gamosavals, garda garTulebuli orsulobis SemTxvevebisa.

A

antenataluri meTvalyureoba antenataluri momzadebis kursebi xSirad gamoiyeneba momavali mSoblebisaTvis orsulobis da mSobiarobis Sesaxeb, agreTve dedobisa da mamobis sakiTxebze informaciis misawodeblad. antenataluri meTvalyureoba eyrdnoba farTo saganmanaTleblo da mxardamWer koncefcias, romelic exmareba momaval mSoblebs gaacnobieron sakuTari socialuri, emociuri, fsiqologiuri da fizikuri moTxovnilebebi orsulobis, mSobiarobisa da mSobiarobis Semdgomi periodis dros da saSualebas aZlevs maT darwmundnen sakuTar SesaZleblobebSi. kiTxvarma, romlis mizani iyo informaciis mopoveba imis Sesaxeb, Tu ra surs qals pirvel rigSi Seityos antenatalur kursebze, gamoavlina, rom es moicavs: informacias nayofis ganviTarebis, orsulobis dros fizikuri da fsiqologiuri cvlilebebis, mSobiarobis dros movlenebis ganviTarebisa da maTi moqmedebis, SesaZlo garTulebebisa da mSobiarobis Semdeg bavSvis movlis sakiTxebis Sesaxeb.

8

orsulebi unda daeswron antenataluri momzadebis kursebs da unda miewodoT werilobiTi informacia antenataluri meTvalyureobis Sesaxeb. A

A

orsulebs unda mivawodoT sarwmuno informacia maT meTvalyureobasTan dakavSirebiT (mkurnalobasTan, mkurnal eqimebTan da sxv.). gadawyvetilebebis miRebis dros mxedvelobaSi aucileblad unda iyos miRebuli qalis winadadebebi da survilebi.

C

uwveti meTvalyureoba qalis meTvalyureoba orsulobis, mSobiarobisa da mSobiarobis Semdgom periodSi xSirad xorcieldeba mravali zedamxedvelis mier. mocemuli klinikuri rekomendaciis mixedviT, uwyveti meTvalyureoba gulisxmobs meTvalyureobas erTi da imave zedamxedvelis an zedamxedvelTa jgufis mier mTeli orsulobis, mSobiarobisa da mSobiarobis Semdgom periodSi. erT sistematiur mimoxilvaSi{Hodnett ED, 1998 19 /id} Sefasda uwyveti meTvalyureobis klinikuri efeqturoba orsulobis, mSobiarobisa da postnatalur periodSi rutinul meTvalyureobasTan SedarebiT, romelsac uzrunvelyofda ramodenime zedamxedveli. ganxorcielda 1815 qalis randomizacia Semdeg jgufebSi: qalebi bebiaqalTa mcire jgufis uwyveti meTvalyureobiT, meanebisa da rutinuli (sxvadasxva zedamxedveli) meTvalyureobiT, romelsac axorcielebdnen eqimebi da bebiaqalebi. qalebs, romelTa uwyvet meTvalyureobasac axorcielebda bebiaqalTa mcire jgufi, ufro iSviaTad aReniSnebodaT Semdegi monacemebi:     

klinikaSi 15 wT-ze meti lodinis dro (OR 0.14. 95% CI 0.10 - 0.19); antenataluri hospitalizacia (OR 0.79. 95% CI 0.64 - 0.97); antenataluri klasebis gacdena (OR 0.58, 95% CI 0.41 - 0.81); orsulobasTan dakavSirebuli SekiTxvebi (OR 0.72 95% CI 0.56 - 0.92); mSobiarobisaTvis aradamakmayofilebeli momzadeba (OR 0.64. 95% CI 0.48 - 0.86).

ar gamovlinda mniSvnelovani gansxvaveba sakeisro kveTis, mSobiarobis aRZvris, naadrevi mSobiarobisa da neonataluri sikvdilianobis, aseve axalSobilTa reanimaciul ganyofilebaSi gadayvanisa da 2500 gramze mcire wonis axalSobilebis sixSireebSi. antenataluri meTvalyureoba unda ganxorcieldes meTvalyureTa mcire jgufis mier, romlebTanac orsuli komfortulad grZnobs Tavs. meTvalyureoba uwyveti unda iyos mTeli antenataluri periodis ganmavlobaSi.

A

dokumentacia antenatalur CanawerebSi informacia 2 ZiriTadi mizniT grovdeba:  administraciisaTvis;  dedisa da nayofis riskis Sefasebisa da Semdgomi marTvis dagegmvis mizniT. antenataluri meTvalyureobis Canawerebi aseve uzrunvelyofen marTvis xarisxis Sefasebas, iuridiul dokumentacias, komunikaciasa da masalas Semdgomi epidemiologiuri kvlevebisaTvis. antenataluri istoriis Sedgenis sami meTodis Sesadareblad Catarda rkk, sadac Sedarda arastruqturirebuli istoriebi, romelTac 9

qaRaldze werdnen bebiaqalebi, struqturirebuli istoriebi (qaRaldze kiTxvaris CarTviT) da interaqtiuli kompiuterizirebuli kiTxvarebi inglisis antenatalur klinikebSi.{Lilford RJ, 1992 36 /id} struqtirirebul istoriebSi Segrovda ufro meti da srulfasovani informacia arastruqturirebul istoriebTan SedarebiT. ar gamovlenila interaqtiuli kompiuterizirebuli sistemebis upiratesoba struqturirebul istoriebTan SedarebiT. orsulebis saSinao baraTebi mraval qveyanaSi orsulebs eZlevaT sakuTari baraTebi orsulobis dros Canawerebis gasakeTeblad, rac zrdis maTi pasuxismgeblobis grZnobas da amaRlebs kmayofilebas zedamxedvelobiT. Catarda 3 kvleva (n =675 qali){Brown HC, 2004 11 /id}. qalebi, romlebsac hqondaT sakuTari baraTebi, Tavs ufro kargad akontrolebdnen ((RR) 1.56, 95% CI 1.18 - 2.06). erTma kvlevam gamoavlina, rom qalebis umetesoba (66/95) ufro kmayofili iyo gaweuli meTvalyureobiT baraTebiT sargeblobis jgufSi, sakontrolo jgufTan SedarebiT (58/102) (RR 1.22, 95% CI 0.99 - 1.52); orma kvlevam ar gamoavlina gansxvaveba qalebis kmayofilebaSi (erTma kvlevam ar warmoadgina Sedegebi da erTSi gamoyenebuli iyo 17 punqtiani kmayofilebis sqema). baraTiT sargeblobis jgufSi qalTa didma raodenobam moisurva igives ganmeoreba momavali orsulobis drosac (RR 1.79, 95% CI 1.43 to 2.24). ar gamovlenila gansxvaveba mSobiarobis dros analgeziis aucileblobis, Cveuli abortebis, naadrevi mSobiarobisa da neonataluri sikvdilianobis sixSireebSi. orsulebisaTvis informaciis miwodeba antenataluri meTvalyureobeis erT-erT prioritetul sakiTxs warmoadgens orsulisaTvis sakuTar meTvalyureobasTan dakavSirebiT informirebuli gadawyvetilebebis SesaZleblobis micema: Tu vin unda ganaxorcielos misi meTvalyureoba, ra skrininguli testebi unda Cautardes da sad unda daigegmos misi mSobiaroba. am mizniT qalisaTvis xelmisawvdomi unda iyos mtkicebulebebze dafuZnebuli informacia, raTa man monawileoba miiRos zedamxedvelebTan gamarTul diskusiaSi. sinamdvileSi qalTa garkveuli raodenoba ar flobs sakmaris informacias. qalTa Sefasebam antenataluri meTvalyureobis dros informaciis miRebisa da komunikaciis TvalsazrisiT gamoavlina, rom orsulTa 32-40%-ma miiRo arasakmarisi zepiri da werilobiTi informacia orsulobis dros sxvadasxva skrininguli testebis Catarebis sargeblianobisa da riskis Sesaxeb.{Audit Commission for Local Authorities, 1997 38 /id} erT mimoxilvaSi,{Singh D, 2000 158 /id} sadac gamoikiTxa 1188 orsuli, gamovlinda, rom isini isurvebdnen damatebiT informaciis miRebas pirveli vizitis dros. maRali Sefaseba mieca werilobiTi saxiT informaciis miwodebas. Catarda rkk mtkicebulebebze dafuZnebuli bukletebis gamoyenebis efeqturobis Sesaxeb orsul qalebSi informirebuli gadawyvetilebis miRebaze{O'Cathain A, 2002 37 /id}. bukletebi SemuSavebuli iyo orsulisaTvis gasagebi eniT. ar gamovlenila mniSvnelovani gansxvaveba jgufebs Soris gadawyvetilebis miRebis TvalsazrisiT, magram kmayofileba informaciiT ufro maRali iyo im jgufSi, romelsac daurigda sainformacio bukletebi.

unda SemuSavdes mkacrad gansazRvruli referaluri programebi, raTa saWiroebis SemTxvevaSi orsuls droulad aRmovuCinoT sxva specialobis eqimis konsultacia.

С

10

garemo pirobebi, romelSic tardeba antenataluri vizitebi, unda ganawyobdes orsuls gulaxdili saubrisaTvis (mag: ojaxuri problemebi da seqsualuri Zaladoba, fsiqiuri daavadebebi da sxv.) yoveli antenataluri vizitis dros eqimebma da bebiaqalebma orsuls unda miawodon amomwuravi informacia misTvis saintereso sakiTxebze. informaciis miwodeba unda xdebodes orsulisaTvis gasagebi eniT, fizikuri da fsiqikuri naklovanebebis arsebobis SemTxvevaSi maTi gaTvaliswinebiT.

С

С

antenataluri vizitebis sixSire fiziologiurad mimdinare orsulobis dros antenataluri vizitebis raodenoba SeiZleba Semcirdes 4-mde dedisa da nayofis janmrTelobis mdgomareobisaTvis zianis miyenebis gareSe. kerZod, gamovlinda, rom 4 vizitis Catarebisas ar izrdeboda dedisa da perinataluri sikvdilianoba, preeklamfsiis, Sard-sasqeso traqtis infeqciebis sixSire da sxeulis dabali woniT dabadebul bavSvTa raodenoba (>2500 g) mtkicebulebebi adastureben im Sexedulebas, rom ganviTarebul qveynebSi, sadac kargad aris organizebuli sameano servisi, prenataluri vizitebis Semcireba dakavSirebulia iseTive karg perinatalur gamosavalTan, rogorc standartuli modelis gamoyenebisas. mosalodneli iyo, rom vizitebis raodenobis Semcirebas moyveboda ukmayofileba qalTa mxridan. ganviaTarebad qveynebSi Catarebulma orma kvlevam daamtkica igive mosazreba am sakiTxze. arsebuli mtkicebulebebis Tanaxmad 4 antenataluri vizitis sqema warmoadgens im minimums, romelic unda SevTavazoT dabali riskis jgufis orsulebs. {Marteau TM, 1992 39 /id} samedicino personals unda mieces saSualeba, saorientacio sqemaze dayrdnobiT TviTon gadawyvitos vizitebis sixSire, maT Soris mSobiarobis Semdegac. sxva sityvebiT rom vTqvaT, upiratesoba eniWeba gamosavalze orientirebul antenataluri meTvalyureobis models. antenataluri vizitebis Sinaarsi pirveli viziti pirveli viziti unda ganxorcieldes orsulobis adreul vadaze (13 kviramde). didi raodenobis informaciis miwodebis aucileblobis gamo SesaZlebelia pirveli vizitis gayofa or nawilad:  orsuls miewodos informacia da mieces SesaZlebloba dasvas SekiTxvebi da monawileoba miiRos diskusiaSi. informacia dietis, cxovrebis wesis, gamokvlevis meTodebis, orsulobis dros arsebuli momsaxureobisa da sxva aspeqtebis Sesaxeb unda iyos rogorc zepiri, aseve werilobiTi formiT  unda gamovlindes qalTa is kategoria, romelic saWiroebs damatebiT meTvalyureobas da daigegmos meTvalyureoba Semdegi kategoriis orsulebisaTvis: (cxrili 1) cxrili 1 11

sameano anamnezi  hqonda Tu ara orsuls naadrevi mSobiaroba an mkvdradSobadoba anamnezSi?  hqonda Tu ara 3 Cveuli aborti TanmimdevrobiT?  xom ar aRiniSneboda ukanaskneli mSobiarobisas axalSobilis sxeulis masa <2500gramze?  xom ar iyo ukanaskneli mSobiarobisas axalSobilis sxeulis masa >4500gramze?  hqonda Tu ara adgili ukanaskneli orsulobis dros klinikaSi hospitalizacias hipertenziis, preeklamfsiisa an eklamfsiis gamo?  iyo Tu ara Catarebuli raime operacia reproduqciuli organoebze? (miomeqtomia, tixris mocileba, biofsia, klasikuri sakeisro kveTa, saSvilosnos yelis serklaJi)

mimdinare orsuloba  xom ar iyo diagnostirebuli an eWvis qveS mravalnayofiani orsuloba?  xom ar aris asaki 16 welze naklebi?  xom ar aris asaki 40 welze meti?  xom ar aRiniSneboda rezus-izoimunizacia wina an mimdinare orsulobis dros?  xom ar aRiniSneboda sisxldena saSodan?  xom ar aris raime simsivne menjis RruSi?  xom ar aris arteriuli diastoluri wneva 90 mm/vwy/sv-ze meti?

zogadi samedicino problemebi  xom ar aRiniSneba insulin-damokidebuli Saqriani diabeti?  xom ar aRiniSneba Tirkmelebis daavadeba?  xom ar aRiniSneba gulis daavadebebi?  xom ara aqvs adgili mavne nivTierebebis alkoholis didi raodenobiT miRebas?)

moxmarebas? (maT Soris

 xom ar aRiniSneba raime sxva daavadeba?

dadebiTi pasuxi romelime zemoT aRniSnul SekiTxvaze miuTiTebs, rom mocemuli klinikuri rekomendaciebi am orsulTan mimarTebaSi ar unda iyos gamoyenebuli. I antenataluri vizitis dros:

12

 unda ganisazRvros sisxlis jgufi da rezus faqtori;  Catardes sisxlis saerTo analizi;  Catardes anemiis, aiv/Sidsis, B-hepatitis, wiTurisa da sifilisis skriningi swrafi martivi meTodiT;  wiTelas skriningi gansazRvrulia orsulis imunuri statusis dasadgenad da orsulobis Semdeg saWiroebisas acris Casatareblad; kvleva ar aris mowodebuli orsulobis dros nayofis mdgomareobis Sesafaseblad;  ganisazRvros sxeulis masis indeqsi;  gaizomos arteriuli wneva;  Catardes Sardis saerTo analizi (proteinuriisa da asimptomuri baqteriuriis gamosavlenad) test-xazebis meSveobiT, Sardis naleqis baqterioskopiiT an Sardis daTesviT;  Catardes saSos nacxis baqterioskopiuli kvleva – sarkeebSi daTvaliereba  rac SeiZleba adre Catardes ultrabgeriTi kvleva gestaciuri vadis gansazRvris mizniT Semdegi parametrebis gamoyenebiT: –10-13 kviramde Txem-kudusunis sigrZe; –14 kviris zemoT Tavis garSemowriloba da biparietaluri zoma.  pirveli vizitis dros sasurvelia Catardes Terapevtis da stomatologis konsultacia Semdgomi viziti, romelic ganixleba, rogorc pirveli vizitis gagrZeleba, analizebis miRebis Semdeg unda daigegmos Semdegi mizniT:  ganixilos da Caiweros yvela Catarebuli skrininguli testis Sedegi, moxdes antenataluri meTvalyureobis SemuSavebuli gegmis gadaxedva qalTa im kategoriis gamosavlenad, romlebic saWiroeben damatebiT meTvalyureobas;  orsuls miewodos rogorc zepiri, ise werilobiTi informacia, romelic gaRrmavdeba antenataluri mecadineobebis Catarebisas. aseve orsuls unda mieces SesaZlebloba, aqtiuri monawileoba miiRos diskusiaSi. meore viziti _ 18-20 kvira  18-20 kviraze, qalis Tanxmobis SemTxvevaSi unda Catardes ultrabgeriTi kvleva nayofis struqturuli anomaliebis gamosavlenad. im qalebs, romelTac orsulobis am vadaze daudgindebaT placentis kidiTi mimagreba, unda CautardeT ganmeorebiTi ultrabgeriTi kvleva 36 kviris vadaze  unda gaizomos saSvilosnos fuZis simaRle;  gaizomos arteriuli wneva da Catardes testi proteinuriis gamosavlenad;  wonis gansazRvra (mxolod dabali sxeulis masis indeqsis mqone orsulebSi);  meore vizitis dros unda Catardes skrininguli kvleva Tandayolil simaxinjeebze (daunis sindromi) mesame viziti 30-32 kvira am vizitis dros unda:  ganisazRvros hemoglobinis done da 10,5 g/l SemTxvevaSi dainiSnos rkinis Semcvleli preparatebi;  gaizomos arteriuli wneva;  gakeTdes Sardis analizi proteinuriis gamosavlenad;

naklebi

maCveneblis

13

 ganisazRvros saSvilosnos fuZis simaRle;  orsuls mieces laqtaciis/ kontracefciis rekomendaciebi  orsuls miewodos rogorc zepiri, aseve werilobiTi informacia, romelic gaRrmavdeba antenataluri mecadineobebis Catarebisas, mieces SesaZlebloba aqtiuri monawileoba miiRos diskusiaSi meoTxe viziti 36-38 kvira        

 

gaizomos arteriuli wneva da Catardes testi proteinuriis gamosavlenad; ganisazRvros hemoglobini sisxlSi; Catardes sifilisis diagnostika swrafi martivi meTodiT; ganisazRvros saSvilosnos fuZis simaRle; ganisazRvros nayofis pozicia; menjiT winamdebareobis SemTxvevaSi ganxorcieldes TaviT garegani mobruneba orsulis Tanxmobis SemTxvevaSi (stacionaris pirobebSi); dadasturdes placentis migracia wina ultrabgeriT kvlevebTan SedarebiT; moxdes Catarebuli Sedegebis ganxilva da dokumentireba, saWiroebis SemTxvevaSi Seicvalos orsulobis marTvis gegma da gamovlindes qalTa is kategoria, romelic saWiroebs damatebiT meTvalyureobas; orsuls mieces laqtaciis/ kontracefciis rekomendaciebi orsuls miewodos rogorc zepiri, aseve werilobiTi informacia, romelic gaRrmavdeba antenataluri mecadineobebis Catarebisas, mivceT mas SesaZlebloba, aqtiuri monawileoba miiRos diskusiaSi

MmSobiarobis Semdgomi viziti janmo-s rekomendaciiT mSobiarobis Semdgomi viziti unda Catardes mSobiarobis Semdgom erTi kviris ganmavlobaSi {Villar J, 2001 1 /id}. miuxedavad imisa, rom es viziti ar finansirdeba saxelmwifos mier, kvlevis farglebSi saqarTveloSi Catarebulma gamokiTxvam{2000 34 /id} gamoavlina, rom 38% melogine gasinjuli iyo samedicino personalis mier pirveli 6 dRis ganmavlobaSi, xolo 45% ori kviris Semdeg.

antenataluri vizitebis grafiki ganpirobebuli unda iyos vizitebis SinaarsiT. qalisaTvis pirveli fiziologiurad mimdinare orsulobis dros sakmarisia 4 viziti.

A

pirveli vizitis dros orsuls unda mivawodoT Semdegi informacia: orsulobis meTvalyureobis, cxovrebis stilis, dietisa da gamokvlevis meTodebis Sesaxeb.

C

orsulobis adreul vadebze yvela qals unda miewodos informacia antenataluri vizitebis raodenobis, droisa da Sinaarsis Sesaxeb;

С

14

yoveli antenataluri viziti unda iyos dagegmili da gaaCndes garkveuli Sinaarsi. vizitebi ufro xangrZlivi unda iyos orsulobis adreul vadebze, raTa uzrunvelyofili iyos amomwuravi informacia. antenataluri vizitis dros unda Catardes standartiT gaTvaliswinebuli testebi da gamokvlevebi, raTa Semcirdes orsulTa ganmeorebiT vizitTan dakavSirebuli diskomforti.

С

orsulis klinikuri gamokvleva mSobiarobis vadis gansazRvra orsulobisaTvis damaxasiaTebelia Semdegi niSnebi:        

SeSupeba; Tavis tkivili; gulisreva da Rebineba; sisxldena an sisxliani gamonadeni saSodan; sarZeve jirkvlebis momatebuli mgrZnobeloba; muclis Seberiloba da Sekruloba; saSodan gamonadenis raodenobis gazrda; iseTi funqciuri Civilebi, rogorebicaa uZiloba da gaRizianebadoba.

zogierTi niSnebi, romlebic miiReba fizikaluri gamokvlevis Sedegad, aseve adastureben orsulobis diagnozs. am niSanTa umravlesoba vlindeba Casaxvidan me-6-8 kviras.     

sarZeve jirkvlebis zomaSi momateba areolis hiperpigmentaciiT; saSos kedlebisa da saSvilosnos yelis cianozi da SeSupeba; saSvilosnos da saSvilosnos yelis isTmuri nawilis darbileba; saSvilosnos konsistenciisa da formis cvlilebebi; imunologiuri testebi iZleva sarwmuno Sedegebs orsulobis 6 kviris Semdeg;

orsulobis vadis gansazRvra bolo menstruaciis TariRis mixedviT damokidebulia imaze, Tu ramdenad zustad axsovs qals TariRi, aseve damokidebulia menstrualuri ciklis xangrZlivobasa da regularobaze. gestaciuri vadis gansazRvra bolo menstruaciis mixedviT ar aris zusti 11-42%-Si. arsebobs Secdomis albaToba meore da mesame trimestrebSi ultrabgeriTi kvleviT gestaciuri vadis dadgenisas, Tumca Secdomebis albaToba naklebia, bolo menstruaciis mixedviT orsulobis vadis gansazRvrasTan SedarebiT. ultrabgeriTi gamokvlevisas 10-13 kviraze gestaciuri vadis gansazRvra xdeba Txem-kudusunis zomis mixedviT. ultrabgeriT vadis gansazRvra rutinulad unda Catardes 24 kviramde. Tu ultrabgeriTi kvleviTa da bolo menstruaciiT gansazRvruli orsulobis vadebi ar emTxveva, upiratesoba eniWeba ultrabgeriT kvlevis maCveneblebs.{Backe B, 2006 41 /id;Blondel B, 2006 43 /id;Savitz DA, 2002 40 /id} sistematurma mimoxilvam, romelSic CarTuli iyo 9 kvleva, gamoavlina, rom rutinuli ultrabgeriTi kvlevis dros ufro adre vlindeboda mravalnayofiani orsuloba (26 kviramde aradiagnostirebuli tyupebi OR 0.08 CI 0.04-0.16) aseve rutinuli kvlevisas mcirdeboda vadagadacilebuli orsulobis gamo samSobiaro moqmedebis aRZvris 15

sixSire (OR 0.61, 95% CI 0.52 - 0.72). kvlevaSi ar gamovlinda gansxvaveba perinataluri sikvdilianobis maCveneblebs Soris (OR 0.86, 95% CI 0.67 - 1.12). rutinuli ultrabgeriTi gamokvleva orsulobis adreul vadebze gvaZlevs saSualebas, ufro zustad davadginoT orsulobis vada, adreulad gamovavlinoT mravalnayofiani orsuloba da nayofis anomaliebi. ar gamovlinda antenatalur periodSi Catarebuli ultasonografiis aranairi uaryofiTi zegavlena swavlisa da neiro-qceviT funqciebze SemdgomSi.{Neilson JP, 1999 44 /id} ultrabgeriTi kvleva orsulobis vadis dadgenis mizniT unda Catardes orsulobis adreul vadaze (bolo menstruaciis TariRis gansazRvris magivrad). es uzrunvelyofs orsulobis vadis zust gansazRvras da amcirebs mSobiarobis induqciis aucileblobas 41 kviris zeviT. ultrabgeriTi kvleva gestaciuri vadis gansazRvris mizniT unda Catardes 10-13 kviris orsulobis vadaze Txem-kudusunis zomis dadgeniT. 14 kviris orsulobis vadis Semdeg gestaciuri vada isazRvreba Tavis garSemowerilobis an biparietaluri zomis dadgeniT saSosmxrivi gasinjva antenatalur periodSi ar aris rekomendebuli, radganac is ar iZleva zust informacias gestaciuri vadisa an naadrevi mSobiarobis riskis Sesaxeb.

A

С

B

orsulis gamokvleva nayofis anomaliebis gamosavlenad nayofis struqturuli da qromosomuli anomaliebis gamosavlenad (nervuli Reros Ria defeqtebi da daunis sindromi) saWiroa ultrabgeriTi kvleva da orsulis Sratis gamokvleva. kvlevis mizania dadgindes:  anomaliebi, romlebic iwveven invalidobas an SeuTavsebadia sicocxlesTan;  anomaliebi, romelTa mkurnalobac SesaZlebelia orsulobis dros an mSobiarobis Semdgom periodSi; eqimma zustad unda auxsnas orsuls yoveli kvleviTi testis mizani, misi Catarebis detalebi, kvlevis dadebiTi an uaryofiTi Sedegebis mniSvneloba da mkurnalobis SesaZlo variantebi. saWiroa orsulis informirebuli Tanxmoba testebis Catarebaze. ultrabgeriTi gamokvleva struqturuli anomaliebis gamosavlenad Catarda sistemuri mimoxilva, romelic dafuZnebuli iyo 11 kvlevaze (erTi rkk, 6 retrospeqtuli kohortuli da oTxi prospeqtuli kohortuli kvleva), romelic miznad isaxavda rutinuli ultrabgeriTi gamokvlevis mniSvnelobis Seswavlas nayofis anomaliebis dadgenis mizniT.{Bricker L, 2000 45 /id} kvlevebi, romlebic moicavda 96 633 bavSvs, Catarda evropaSi, aSS-Si da koreaSi 1988-1996 ww-Si. nayofis anomaliebis saerTo gavrcelebam Seadgina 2,09% da varirebda 0,76%-dan 2,45%mde da moicavda rogorc mcire, ise did anomaliebs. anomaliebis dadgenis sixSire 24 kviris qvemoT Seadgenda 41,3%, xolo 24 kviris zemoT 18,6%. saerTo jamSi, nayofis anomaliis dadgena Seadgenda 44,7%, da varirebda 15,0%-dan 85,3%-mde. es iyo Sedegi imisa, rom zogierTi anomaliis 16

diagnostirebis sizuste maRali iyo. magaliTad, anencefaliis diagnostireba 14-22 kviraze Seadgens SemTxvevaTa 100%-s{Williamson P, 1997 46 /id} ( cxrlili 2) cxrili 2 mocemulia inglisis mean-ginekologTa samefo kolejis mier{Royal College of Obstetricians and Gynaecologists, 2000 47 /id} minimaluri ultrabgeriTi kvlevis standartebi anomaliis dasadgenad 20 kviris vadaze normaluri nayofi: • Tavis forma da zoma, aseve Sida struqturebi (naTxemi, parkuWebis zoma winagulis zomaze < 10 mm) • xerxemali: gaswvrivi da ganivi skanireba • muclis forma da Semadgenloba kuWis doneze • muclis forma da Semadgenloba Tirkmelebis da Wipis doneze • Tirkmelebis menji < 5 mm wina-ukana gazomvisas; • mucel-mkerdis gaswvrivi mdgomareoba (diafragma da Sardis buSti); • gulmkerdi oTxkameriani gulis vizualizaciisas; • mklavebi: sami Zvali da xelis mtevani (ar aris saWiro TiTebis daTvla) • fexebi: sami Zvali da terfebi (ar aris saWiro TiTebis daTvla) optimaluri standarti 20 kviraze anomaliis dasadgenad: • gulis sisxlis mimoqceva; • saxe da tuCebi. gestaciis 18-20 kviraze nayofis anomaliebis dadgenis mizniT unda Catardes ultrageriTi kvleva Sesabamisad momzadebuli specialistis mier da mowodebuli standartebiT. A

A

daunis sindromis skriningi daunis sindromi (21 trisomia) warmoadgens Tandayolil anomalias, romlisaTvisac damaxasiaTebelia damatebiTi 21 qromosomis arseboba. daunis sindromis sixSire evropis qveynebSi Seadgens 6,2/10,000 cocxlad da mkvdradSobilze. ( saqarTvelos monacemebi ver movipoved). sindromi ZiriTadad xasiaTdeba bavSvis gonebrivi CamorCenilobiT - aReniSneba daavadebul bavSvTa 80%-s. daunis sindromisaTvis damaxasiaTebelia Tandayolili simaxinjeebi, romlebic SesaZloa sikvdilis mizezi gaxdes (leikemia, farisebri jirkvlis daavadebebi, epilefsia, alcheimeris daavadeba). daunis sindromiT daavadebul bavSvTa daaxloebiT 46%-s aReniSneba gulis Tandayolili anomaliebi, romlebic saWiroebs qirurgiul Carevas. daunis sindromis Tanamedrove kvleva arsebobs mravali kvleva, romlebSic Sedarebulia daunis sindromis skrininguli testebis Semdegi kombinaciebis efeqturoba:

17

• • • • • •

kombinirebuli testi – orsulobis pirvel trimestrSi ultrasonografiuli kvleviT kisris naoWis sisqis, SratSi PAPP-A–sa ( plazma protein A ) da qorionuli gonadotropinis gansazRvra. „ormagi testi“-orsulobis 14-20 kviraze qorionuli gonadotropinisa da alfafetoproteinis gansazRvra. „sammagi testi“- qorionuli gonadotropinis, alfa-fetoproteinis da uE3 (ara konigirebuli estrioli) –is gansazRvra. “oTxmagi testi”- qorionuli gonadotropinis, alfa-fetoproteinis, uE3 –isa da inhibini-A-s gansazRvra. integrirebuli testi- orsulobis 10-12 kviraze kisris naoWis sisqisa da PAPP-A gansazRvra, SemdgomSi 14-20 kviraze qorionuli gonadotropinis, alfafetoproteinis, uE3 –isa da inhibini A gansazRvriT. Sratis integrirebuli testi - integrirebuli testi, kisris naoWis sisqis gansazRvris gareSe.

daunis sindromis kvlevis dros markerebis sxvadasxva kombinaciis gamoyenebisas miRebuli cru-dadebiTi Sedegebi da dadgenis sixSire Sejamebulia Semdeg cxrilSi:

markerebi kisris naoWis sisqe ultrabgeriti kvlevisas 9-14 kviraze* (13 kohortuli kvleva, r=170,343) kombinirebuli testi: kisris naoWis sisqe da Sratis kvleva (10 kvleva) “ormagi testi” (6 kohortuli kvleva, r=110,254) “sammagi testi” (20 kohortuli kvleva, r=194,326) riskis Sefardeba 1:200 “oTxmagi testi” (1 kohortuli kvleva, r=46,193) Sratis integrirebuli testi: (1 SemTxveva - kontrolis kvleva, r=28,434) integrirebuli testi: (1 SemTxveva - kontrolis kvleva, r=28,434)

cru-dadebiTi pasuxebis sixSire(%)

dadgenis sixSire

4,7

77

5

85-89

monacemebi ar aris**

66

4 5

67 85

2,7 1,3

85

*es monacemebi miRebulia gamoqveynebuli kohortuli kvlevebidan. SURUSS monacemebi ar aris CarTuli imis gamo, rom es iyo SemTxveva-kontrolis kvleva da arsebobda ufro maRali donis mtkicebulebebi. **praqtikaSi sxvadasxva skrininguli programebis gamoyenebis gamo. antenatalur periodSi daunis sindromis saboloo diagnozis dasma xdeba invaziuri meTodebiT nayofis ujredebis kultivirebis Semdeg. amisaTvis gamoiyeneba qorionis bususebis biofsia da amniocentezi. zemoaRniSnuli meTodebi dakavSirebulia garkveul riskTan, magaliTad amniocentezis Semdeg spontanuri abortis sixSire Seadgens daaxloebiT 1%-s..

18

qorionis bususebis biofsia keTdeba orsulobis 11-13 kviraze, xolo amniocentezi - 15 kviris zeviT. qorionuli bususebis biofsia pirvel trimestrSi xasiaTdeba uSedegobis da spontanuri abortis ufro maRal sixSiresTan meore trimestrSi Catarebul amniocentezTan SedarebiT (OR 2,86, 95%, CI 1,93 4,24); (OR 1,33,95%, CI1,17 1,52). amniocentezis gakeTeba pirvel trimestSi ar SeiZleba. qorionis bususebis biofsiasTan Sedarebisas orsulobis pirvel trimestrSi amniocentezi dakavSirebulia uSedegobis ufro maRal sixSiresTan (0,4% 2%-Tan SedarebiT; RR 0,23, 95%, CI 0,08 0,65). aqedan gamomdinare, riski yvelaze dabalia 15 kviris Semdeg amniocentezis Catarebisas da yvelaze maRalia qorionis bususebis biofsiis Catarebisas orsulobis nebismier vadaze. maRali mgrZnobelobis mqone test-sistemebiT Tanamedrove laboratoriis aRWurvisas SesaZlebelia “ormagi testis” Catareba (alfa-fetoproteini da adamianis qorionuli gonadotropini). testis dadebiTi Sedegis miRebisas orsuli unda gaigzavnos sisxlis imunofermentul analizze da informirebuli Tanxmobis Semdeg mas Cautardes invaziuri meTodebi nayofis ujredebis kultivirebaze. sxeulis masis indeqsis gansazRvra sxeulis masis indeqsis gansazRvra xdeba Oorsulis sxeulis masis (kilogramebSi) SefardebiT simaRlis (metrebSi) kvadratze. (kg/m2). Tu sxeulis masis indeqsi naklebia 18-ze an metia 35-ze, orsuls unda miewodos Sesabamisi rekomendaciebi dietasTan dakavSirebiT., radganac 30-ze meti sxeulis masis indeqsi dakavSirebulia momatebul mkvradSobadasTan (RR 3.1 95% СI 1.6 – 5.9) da neonatalur sikvdilobasTan RR 2.7 95% СI (1.2 – 6.1) normaluri sxeulis masis indeqsis mqone orsulebTan SedarebiT. orsulobis dros dedis sxeulis masis normaluri namati individualurad varirebs. arsebobs kavSiri orsulis sxeulis masasa da axalSobilis wonas Soris, Tumca mcire masis axalSobilebis skriningisaTvis am kavSiris gamoyeneba arazust informacias iZleva. dedis wonisa da simaRlis gansazRvra unda xdebodes minimum erTxel, magaliTad, pirveli vizitis dros. aqedan gamomdinare, rutinuli awonva da simaRlis gazomva orsulobis dros mizanSewonili ar aris damatebiTi diskomfortis Tavidan asacileblad. garda amisa, am procedurebs ar moaqvT aranairi sargebloba. gamonaklisi unda gakeTdes im orsulebisaTvis, romlebic arasrulfasovnad ikvebebian. retrospeqtul kvlevaSi, romelic moicavda 1092 qals, gamovlinda, rom orsulobis vada, dedis asaki, Tambaqos moweva, yovelkvireuli wonis namati da dedis wona warmoadgendnen faqtorebs, romlebic zegavlenas axdenen axalSobilis wonaze.{Dawes MG, 1991 48 /id} antenatalur periodSi orsulobis vadasTan SedarebiT mcire masis axalSobilis gamosavlenad yvelaze efeqtur markers warmoadgenda dedis sxeulis dabali wona (<51 kg-ze) (dadebiTi prognozuli Rirebuleba 20%). dedis mcire yovelkvireuli namatis (<0,20 kg) prognozuli Rirebuleba gestaciis vadasTan SedarebiT mcire masis axalSobilis gamosavlenad Seadgenda 13%-s (ufro dabali iyo, vidre dedis Tambaqos mowevis prognozuli (16%) Rirebuleba). wonis kleba an namatis ar arseboba mesame trimestrSi ori kviris ganmavlobaSi SeiniSneboda Seswavlili qalebis 46%-Si.

B

19

pirveli antenataluri vizitis dros orsuli unda aiwonos da gaizomos misi simaRle. miRebuli monacemebidan gamomdinare unda gamoiTvalos sxeulis masis indeqsi (kg/m2) ganmeorebiTi awonva normalurad mimdinare orsulobis dros ar aris aucilebeli.

C

anemiis skriningi dRemde sakamaToa hemoglobinis maCveneblis zRvari, romliTac ganisazRvreba anemia, magram kvlevebSi gamovlinda, rom orsulobis dros hemoglobinis done meryeobs 11g/l-12g/l. imis gamo, rom hemoglobinis done meryeobs orsulobis sxvadasxva vadebze, rekomendebulia hemoglobinis donis gansazRvra I, III da IV vizitebze. 12 kviris vadis Semdeg hemoglobinis done orsul qalebSi unda iyos 11 g/l-ze meti, xolo 30 kviris Semdeg 10,5 g/l-ze meti.{Ramsey M, 2006 49 /id} hemoglobinis dabali maCveneblebi (8,5-dan-10,5g/l) SesaZlebelia dakavSirebuli iyos dabali wonis axalSobilisa da naadrevi mSobiarobis momatebul riskTan{Steer P, 1995 50 /id}. Tu arsebobs eWvi rkinis deficitze, unda Catardes Sratis feritinis gansazRvra rkinis WeSmariti donis gamosavlenad. testis mgrZnobeloba Seadgens 90%-s{Breymann C, 2002 51 /id}.

anemiis gamosavlenad hemoglobinis ganxorcieldes I, III da IV vizitebis dros.

gansazRvra

unda

hemoglobinis normaluri done orsulobis dros aris 11 g/l pirveli vizitis dros da 10,5 g/l orsulobis 30 kviris Semdeg. am maCveneblebis cvlilebebis dros unda gadawydes sakiTxi rkinis Semcvleli preparatebis daniSvnis Taobaze. A

B A

arteriuli wnevis gazomva Cveulebrivad, normaluri orsulobis pirvel naxevarSi arteriuli wnevis maCveneblebi klebulobs, xolo mSobiarobis momentisaTvis ubrundeba orsulobamde arsebul maCveneblebs.{Duckitt, 2003 53 /id} qronikuli hipertenziis SemTxvevaSi gestaciis 1013 kviraze SeiZleba aRiniSnebodes arteriuli wnevis normaluri maCveneblebi. orsulobis dros hipertenziis miRebuli gansazRvreba gulisxmobs arteriul wnevas 140/90 mm/vwy/sv-s orjeradad, 4 saaTis intervalebiT gazomvisas. aseTi maCveneblebis dros matulobs perinataluri sikvdilianoba.{Friedman EA, 2006 54 /id} aRsaniSnavia, rom orsulTa 20%-s orsulobis 20 kviris Semdeg minimum erTxel mainc aReniSneba arteriuli wnevis maRali maCveneblebi. es iwvevs Carevebis ganxorcielebas orsulTa 10%-Si, Tumca preeklamfsia SeiZleba ganviTardes orsulTa mxolod 2-4%-Si. {Redman CW, 1995 55 /id} hipertenziis diagnostireba damokidebulia arteriuli wnevis gazomvis sizusteze. qvemoT moyvanili klinikuri rekomendaciebi miwodebulia amerikis gulis asociaciis mier{Frohlich ED, 1988 56 /id}, da emTxveva eqspertebis adre arsebul azrs{Petrie JC, 1986 57 /id}: 20

 wnevis gazomva orsulis mjdomare an naxevradmjdomare poziciaSi ise, rom mklavi moTavsebuli iyos gulis doneze;  Sesabamisi zomis manJetis gamoyeneba (minimum 33X15 sm zomis). naklebi Secdomebi daiSveba didi manJetis gamoyenebisas mcire manJetTan SedarebiT;  haeri nela unda iyos gamoSvebuli, daaxloebiT 2-3 mm/wm-Si, mTeli haeris gamoSvebam unda daikavos daaxloebiT 30 wami;  arteriuli wneva unda gaizomos 2mm/vwy-mde sizustiT;  diastoluri wnevis gasazomad gamoyenebuli unda iyos korotkovis V toni (gulis xmianobis gaqroba), radganac am SemTxvevaSi SeiniSneba naklebi uzustobebi korotkovis IV tonis (gulis tonebis moyrueba) gamoyenebasTan SedarebiT.  I faza: pirveli susti tonebis gamoCena, intensiobis TandaTanobiT momateba daafiqsireT sistoluri arteriuli wneva;  II faza: tonebis intensiobis Serbilebis mokle faza;  III faza: tonebis intensiobis xanmokle gaZliereba;  IV faza: wyvetili moyruebuli tonebi, rbili da „ mberavi“;  V faza: tonebis sruli gaqroba - aRniSneT diastoluri arteriuli wneva.  Tu aRiniSneba arteriuli wnevis nulamde dacema (orsulTa 15%-Si), unda Caiweros rogorc IV, aseve V fazis maCveneblebi (mag.: 148/84/0 mm/vwy).  Tu saWiroa ganmeorebiTi gazomva, gamoyenebuli unda iyos maCveneblebis saSualo ariTmetikuli da ara mxolod ufro dabali maCvenebeli. meta-analizma orsulobis dros arteriuli wnevis monitoringis mizniT{Cuckson AC, 2002 58 /id} avtomaturi mowyobilobebis gamoyenebasTan dakavSirebiT gamoavlina, rom avtomaturi mowyobilobebi iZleva arteriuli wnevis SedarebiT dabal maCveneblebs preeklamfsiis dros. gamoyenebis win mniSvnelovania avtomaturi mowyobilobebis Semowmeba da aseve am mowyobilobebiT miRebuli Sedegebis interpretireba didi sifrTxiliT.

arteriuli wnevis gazomvis sixSire ar arsebobs mtkicebulebebi imis Sesaxeb, Tu ra sixSiriT unda gaizomos arteriuli wneva. miuxedavad amisa, rkk-is mimoxilvam, romelSic Sedarebuli iyo antenataluri vizitebis Semcirebuli raodenoba standartul raodenobasTan, ar gamoavlina gansxvaveba preeklamfsiis ganviTarebis sixSireebis TvalsazrisiT. (OR 0.37, 95% CI: 0.22 to 1.64). {Villar J, 2003 59 /id} samedicino personalis yvela wevrma unda icodes arteriuli wnevis gazomvis swori teqnika, standartizirebuli aRWurvilobis gamoyeneba da orsulis swori pozicia gazomvisas

C

proteinuriis gansazRvra WeSmariti proteinuriis Sesafaseblad Zalzed mniSvnelovania Sardis swori Segroveba da urogenitaluri infeqciis gamoricxva. amisaTvis xorcieldeba Sardis Sua ulufis Segroveba sasqeso organoebis winaswari damuSavebisa da saSos steriluri tamponiT SemosazRvris Semdeg. proteinuriis donis dasadgenad ar aris saWiro

21

Sardis Segroveba kaTeteris meSveobiT, radganac es procedura SesaZlebelia garTuldes saSarde gzebis inficirebiT. proteinuriis gamosavlenad xSiria test-xazebis gamoyeneba. test-xazebi warmoadgens mxolod skriningul tests da ar SeiZleba mxolod mis Sedegebze dayrdnoba, radgan cilis niSnebis gamovlenisas cru-dadebiTi Sedegebis sixSire SemTxveviT aRebul Sardis nimuSebSi zogjer aRwevs 25%.{Murray N, 2002 60 /id}

test -xazis bolo ramodenime wuTiT Tavsdeba SardSi. test-xazis feris Secvlis Semdeg miRebul Sedegs adareben etiketze mocemul fers. Sedegebi Semdegnairad SeiZleba iyos warmodgenili: 1+ =0,3 g/l, 2+ = 1g/l, 3+ = 3 g/l. Sardis pirveli nimuSSi +1-ze meti maCveneblis miRebisas Sedegi dadasturebuli unda iyos 24 saaTian SardSi cilis an cila/kreatininis Sefardebis gansazRvriT.{Rodriguez-Thompson D, 2001 61 /id} 300 mg/24 saaTSi an kreatininis donis momateba 30 mg/mmolze meti raodenobiT ZiriTadad ganixileba, rogorc mniSvnelovani proteinuria {Ferrazzani S, 1990 62 /id} . zRvari 500mg/24 saaTSi raodenobiT ganixileba, rogorc SesaZlo cudi gamosavalis maniSnebeli.{Shennan AH, 2003 63 /id} proteinuriis arseboba dasturdeba 24 saaTian SardSi >300 mg/l cilis aRmoCeniT (+) an Sardis Sua ulufaSi >1 g (an meti ++) cilis aRmoCeniT orjeradi Semowmebisas 4saaTze meti intervaliT, Tu Sardis xvedriTi wona <1030 da 8-ze naklebi pH-is dros. pirveli vizitis dros unda Sefasdes preeklamfsiis ganviTarebis riski da SemuSavdes antenataluri vizitebis gegma. preeklamfsiis ganviTarebis riski matulobs Semdegi kategoriis orsulebSi: pirveladmSobiareebSi; 40 wlis zeviT mSobiareebSi; preeklamfsiis ojaxuri anamnezis mqone qalebSi (mag: preeklamfsia dedis an dis anamnezSi; pirveli vizitis dros 35-ze meti sxeulis masis indeqsi; mravalnayofiani orsuloba an arsebuli sisxlZarRvovani daavadeba (mag: hipertenzia an diabeti).

C

cxovrebis wesi muSaoba orsulobis dros orsuli qali informirebuli unda iyos sakuTari uflebebis Sesaxeb.

C

qalebs unda mivawodoT informacia, rom orsulobis dros umravlesobisaTvis muSaoba usafrTxoa. kvebiTi danamatebi

C

foliumis mJava sistemurma mimoxilvam{Lumley J, 2001 18 /id} gamoavlina, rom Casaxvis periodSi folatebis miReba mniSvnelovnad aqveiTebs nervuli Reros defeqtebis ganviTarebis risks. (RR 0.28, 95% CI 0.13 - 0.58) defeqtebis gavrcelebis sixSire daqveiTda rogorc wina orsulobisas janmrTeli axalSobilis arsebobisas (RR 0.07, 95% CI 0.00 - 1.32), aseve 22

wina orsulobisas daavadabuli axalSobilis an nayofis SemTxvevaSi (OR 0.31, 95% CI 0.14 - 0.66). jgufebs Soris.ar gamovlinda mniSvnelovani gansxvaveba Cveuli abortis, saSvilosnos gare orsulobisa da naadrevi mSobiarobis sixSireebSi. foliumis mJavis damatebas Casaxvis periodSi gaaCnia mniSvnelovani damcavi efeqti nervuli Reros defeqtebis ganviTarebis TvalsazrisiT. informacia foliumis mJavis Sesaxeb farTod unda iyos xelmisawvdomi janmrTelobisa da ganaTlebis sistemebis meSveobiT. qalebs, romelTa axalSobilebsa an nayofs dadgenili aqvT nervuli Reros defeqtebi, unda mivawodoT informacia ganmeorebis momatebuli riskis Sesaxeb da vurCioT foliumis mJavis uwyveti miReba.

orsul qalebsa da maT, visac dagegmili aqvs orsuloba unda mivawodoT informacia Casaxvamde da orsulobis 12 kviramde foliumis mJavis miRebis aucileblobis Sesaxeb, radganac es amcirebs nervuli Reros defeqtebis ganviTarebis albaTobas. rekomendirebuli doza Seadgens 4 mg dReSi.

A

rkina cnobili ar aris, Tu ra gavlenas axdens dedisa da axalSobilis gamosavalze rkinis rutinuli daniSvna anemiis ararsebobis dros. 20 rkk-is sistemuri mimoxilvaSi{Mahomed K, 2001 66 /id}, Sedarebuli iyo rkinis da placebos miReba orsulebSi (n=5552) hemoglobinis normaluri maCvenebliT (10 g/lze meti) 28 kviris orsulobis vadamde. rkinis rutinuli damateba zrdida an inarCunebda Sratis feritinis dones 10 mkg/l-ze maRla da mniSvnelovnad aqveiTebda im qalTa raodenobas, romelTa hemoglobinis done 10-10,5 g/l-ze naklebi iyo orsulobis gvian vadebze. rkinis seleqtiuri da rutinuli damatebis Sedarebis mizniT Catarebulma yvelaze didma kvlevam (n=2682) gamoavlina, rom sakeisro kveTisa da mSobiarobis Semdgomi sisxlis gadasxmis albaToba momatebulia, xolo perinataluri sikvdilianoba daqveiTebulia rkinis seleqtiuri damatebis SemTxvevaSi.{Hemminki E, 1991 64 /id} sxva sistemur mimoxilvaSi Seiswavlili iyo rkinis da folatebis rutinuli damatebis efeqti orsulebSi hemoglobinis normaluri maCvenebliT. 8 kvlevaSi monawileobda 5449 qali. aqedan gamomdinare, rkinisa da folatebis rutinul damatebas ar gaaCnia arc sasargeblo da arc saziano efeqti dedisa da nayofis gamosavalze.{Elbourne D, 1987 65 /id}

rkinis preparatebis rutinuli daniSvna anemiis ararsebobis dros rekomendirebuli ar aris, radgan ar aris damtkicebuli amis arc dadebiTi da arc uaryofiTi zemoqmedeba nayofsa da dedaze. SesaZlebelia, rutinulma daniSvnam gamoiwvios arasasurveli gverdiTi efeqtebi dedasa da axalSobilSi.

A

vitamini A 23

vitamin A-s maRali dones orsulobis dros SesaZlebelia, hqondes teratogenuli efeqti{Dolk HM, 1999 67 /id;Oakley GP Jr, 1995 68 /id;Rothman KJ, 1995 69 /id}. epidemiologiuri mtkicebulebebidan gamomdinare, SeuZlebelia pirveli trimestris dros vitamin-A-s saziano raodenobis doza-pasuxis mrudis an zRvaris zustad ganisazRvra. vitamin A-s 10 000 - 25 000 erTeulis raodenobiT SesaZlebelia gaaCndes teratogenuri efeqti. imis gamo, rom RviZli da RviZlis produqtebi Seicaven A-vitaminis maRal dones (10 000-38 000 mg/tipiur porciul raodenobaze 100mg) orsulobis dros sasurvelia am sakvebi produqtebisagan Tavis Sekaveba. 700 mikrogramze meti A vitaminis miReba dakavSirebulia sxvadasxva Tandayolili simaxinjeebis ganviTarebis momatebul riskTan.{Rothman KJ, 1995 69 /id} orsulebs unda mivawodoT informacia imis Sesaxeb, rom A vitaminis damatebam (700 mikrogramze meti doziT) SesaZlebelia iqonios teratogenuli efeqti nayofze da amitom misi miReba ar aris mizanSewonili. orsulebmaa unda icodnen, rom RviZli da RviZlis produqtebi Seicaven didi raodenobiT aRniSnul vitamins da amitom Tavi unda Seikavon am produqtebis miRebisagan.

C

vitamini D vitamin D-s moTxovnileba izrdeba orsulobis dros kalciumis aTvisebis gasaumjobeseblad. D vitaminis ZiriTad wyaros warmoadgens mzis sinaTle da cximiani Tevzi. mzis sxivebze yoveldRiuri yofna warmoadgens D-vitaminis naklebobis profilaqtikas. erT sistemur mimoxilvaSi{Mahomed K, 1999 70 /id} Sefasda D-vitaminis damatebis zemoqmedeba orsulobis gamosavalze. mimoxilvaSi CarTuli iyo mxolod ori mcire rkk (n=232). neonataluri hipokalcemia ufro iSviaTad aRiniSneboda vitamin D-s damatebis jgufSi (OR 0.13, 95% CI 0.02 - 0.65). ar arsebobs sakmarisi mtkicebulebebi D vitaminis miRebis efeqturobis Sesaxeb orsulobis dros. misi rutinuli miReba orsulobis dros ar aris rekomendebuli.

A

iodis damateba Catarda 3 kvleva{Mahomed K , 1997 24 /id}, romelic moicavda 1551 qals. or kvlevaSi, iodis damateba dakavSirebuli iyo axalSobilobisa da adreuli bavSvobis periodSi sikvdilianobis da(RR 0.71, 95% CI 0.56 - 0.90), epidemiuri kretinizmis gavrcelebis daqveiTebasTan 4 wlis asakisaTvis (RR 0.27, 95% CI 0.12 - 0.60), aseve gaumjobesebul fsiqo-motorul aqtivobis maCveneblebTan 4-dan 25 Tvis asakamde. iodis daniSvna orsulobamde an orsulobis dros amcirebs bavSvTa asakis sikvdilianobis 2-jer da kretinizms 2/3-iT. imisaTvis, rom iodis damatebas sasurveli efeqti hqondes, yvela reproduqciuli asakis qals orsulobamde unda hqondes SesaZlebloba, miiRos iodizirebuli marili. 24

iodis damateba im populaciaSi, sadac maRalia endemuri kretinizmis sixSire, iwvevs am daavadebis sixSiris mniSvnelovan Semcirebas gverdiTi efeqtebis gareSe

A

sakvebismieri infeqcia listeriozi listeriozi aris daavadeba, romelic gamowveulia baqteriiT Listeria monocytogenes, romelic SeiZleba gamovlindes msubuqi, gripismagvari simptomebiT. is zogjer iwvevs Cveul aborts, naadrev mSobiarobas da axalSobilis mZime daavadebebs. orsulTa populaciaSi listeriozis gavrceleba maRalia (12/100 000) saerTo populaciasTan SedarebiT 0,7/100,00){Southwick FS, 1996 71 /id}. infeqciis yvelaze gavrcelebul wyaros warmoadgens dabinZurebuli sakvebi{Southwick FS, 1996 71 /id}. ZiriTadad es aris arapasterizebuli rZe, amoyvanili rbili yveli da paSteti. L. monocytogenes gamovlenilia aseve niadagSi da Sinauri da gareuli cxovelebis fekaliebSi. orsul qals unda mivawodoT Semdegi informacia listeriozis riskis daqveiTebasTan dakavSirebiT: • miiRon mxolod pasterizebuli rZe; • Seikavon Tavi obiani rbili yvelis miRebisagan (kamamberi, bri). yvelis magari tipebi (Cederi da xaWo) ar warmoadgens saSiSroebas; • ar miirTvan naxevrad umi an umi sakvebi.

D

salmonela salmonela aris baqteria, romelic iwvevs sakvebismier infeqcias. mis wyaros ZiriTadad warmoadgens Sinauri frinveli, kvercxi, auduRari rZe da arasrulyofilad Termulad damuSavebuli xorci, aseve wyali. misi mtarebeli SeiZleba iyos ku da frinvelebi.. miuxedavad imisa, rom salmonela ar axdens zegavlenas nayofze, man SeiZleba gamoiwvios mZime diarea da Rebineba. Tanamedrove rekomendaciebiT, orsulma qalebma ar unda miiRon umi kvercxi da umi kvercxis Semcveli produqtebi. kvercxi unda moixarSos gamagrebamde. imis gamo, rom wiwilebi da umi xorci aseve warmoadgenen salmonelozis wyaros, yvelanairi sakvebi kargad unda damuSavdes Termulad, xolo um xorcTan da qaTamTan Sexebis Semdeg saWiroa xelebis saguldagulo dabana{British Nutrition Foundation.BNF Information.Diet through Life: Pregnancy.2003.Accessed 1 August 2006., 2006 72 /id}.

orsul qals unda mivawodoT informacia imis Sesaxeb, Tu rogor Seamciros salmoneloziT dainficirebis riski: Tavi Seikavos Toxlo da umi kvercxis miRebisagan da kvercxis Semcveli produqtebisagan

D 25

(mag: maionezi); aseve umi da naxevrad umi miRebisagan, gansakuTrebiT ojaxis frinvelis xorcis.

sakvebis

varjiSi orsulobis dros qalebs orsulobis fiziologiuri mimdinareobiT SeuZliaT regularuli varjiSi orsulobis dros. erT sistemur mimoxilvaSi Sefasda orsulis regularuli (kviraSi minimum 2-3 jer) varjiSis zemoqmedeba orsulobisa da mSobiarobis gamosavalze{Kramer MS., 2002 73 /id}. orsulobisaTvis damaxasiaTebeli mravali Civili, magaliTad, zogadi sisuste, venebis varikozi da kidurebis SeSupeba mcirdeba im qalebSi, romlebic varjiSoben. aqtiur qalebs aseve naklebad awuxebT Zilianoba, stresi, agzneba da depresia. arsebobs rigi mtkicebulebebisa imasTan dakavSirebiT, rom datvirTuli varjiSi mTeli orsulobis dros SesaZlebelia iwvevdes mSobiarobis xangrZlivobis Semoklebasa da aumjobesebdes orsulobis gamosavals. erT sistemur mimoxilvaSi Sedarebuli iyo saSualo intensiobis regularuli aerobika orsulobis dros Cveulebriv fizikuri aqtiurobis SenarCunebasTan preeklamfsiis prevenciis TavsazrisiT{Meher S, 2006 20 /id}. sarwmunoebis intervali didi iyo da gadakveTa uefeqtobis xazi yvela miznnobrivi gamosavalisaTvis preeklamfsiis CaTvliT (RR 0.31, 95% CIl 0.01 - 7.09). ar arsebobs sakmarisi mtkicebulebebi sarwmuno daskvnebis gasakeTeblad varjiSis zemoqmedebis Seaxeb preeklamfsiasa da mis garTulebebze.

orsuli qali informirebuli unda iyos, rom saSualo intensiobis varjiSi orsulobis dros (misi dawyeba an gagrZeleba) ar aris dakavSirebuli gverdiT efeqtebTan.

A

orsuli qali informirebuli unda iyos, rom zogierTi tipis aqtivoba SeiZleba saziano iyos orsulobis dros, magaliTad: kontaqturi da mZime sportis saxeobebi, ramac SeiZleba gamoiwvios muclis travma, dacema da zedmeti datvirTva saxsrebze. saSiSia aseve yvinTvasTan dakavSirebuli sportis saxeobebi, romlebic iwveven nayofis defeqtebs da mis dekompresias.

C

sqesobrivi aqtivoba orsulobis dros Catarda ori kohortuli kvleva 52 000 qalze, romelSic gamovlinda ukukavSiri orsulobis sxvadasxva vadebze sqesobrivi kontaqtebis sixSiresa da naadrevi mSobiarobis risks Soris. ar gamovlenila kavSiri sqesobrivi kontaqtebis sixSiresa da perinatalur sikvdilianobas Soris{Read JS, 2003 74 /id;Klebanoff MA, 1984 76 /id}. orsulebis mier mowodebuli informaciis mixedviT, sqesobrivi kontaqti orsulobis adreul vadebze ar iyo dakavSirebuli Cveuli abortis sixSiris momatebasTan. dadasturda kavSiri qalis mravlobiT sqesobriv partniorebsa da Cveul abortebs Soris{Nicole P.Yost, 2006 21 /id} 26

orsuli qali informirebuli unda iyos, rom sqesobrivi aqtivoba orsulobis dros ar aris dakavSirebuli raime uaryofiT gamosavalTan.

B

alkoholis moxmareba da Tambaqos moweva orsulobis dros alkoholi Tavisuflad gadis placentarul bariers da gadadis nayofTan, amitom arsebobs mosazreba, rom qalebma Tavi unda Seikavon misi gadaWarbebuli moxmarebisagan orsulobis dros. sabolood ar aris garkveuli, alkoholis ra done aris saziano nayofisa da dedisaTvis. arsebobs mtkicebulebebi imasTan dakavSirebiT, rom alkoholis erTi an ori erTeuli kviraSi saziano ar aris{Walpole I, 1990 78 /id} magram rekomedebulia alkoholos miRebisagan sruli TavSekaveba orsulobis dros{Kesmodel U, 2002 157 /id}. Troba da alkoholis didi raodenobiT miReba dakavSirebulia axalSobilis dabali wonasTan{Borges G, 1993 80 /id;Holzman C, 1995 81 /id} da bavSvis qceviT da inteleqtualur darRvevebTan{Aronson M, 1997 82 /id}. Tambaqos moweva warmoadgens orsulobis cudi gamosavlis mizezs. misi uaryofiTi zegavlena sabolood aris damtkicebuli. meta-analizma gamoavlina, rom arsebobs mniSvnelovani kavSiri orsulobis dros Tambaqos mowevasa da perinatalur sikvdilianobas{DiFranza JR, 1995 83 /id} , axalSobilTa uecar sikvdils{DiFranza JR, 1995 83 /id} placentis naadrev aclas{Ananth CV, 1999 84 /id} , sanayofe garsebis naadrev darRvevas{Castles A, 1999 85 /id} , eqtopiur Norsulobas{Castles A, 1999 85 /id}, placentis winamdebareobas{Castles A, 1999 85 /id}, Cveul aborts{DiFranza JR, 1995 83 /id}, naadrev mSobiarobas{Shah NR, 2000 86 /id}, axalSobilTa dabal wonas{DiFranza JR, 1995 83 /id} da axalSobilebis mglis xaxisa da kurdRlis tuCis Camoyalibebas Soris{Wyszynski DF, 1997 88 /id}. kohortulma kvlevebma gamoavlines mniSvnelovani kavSiri orsulobis dros dedis mier Tambaqos mowevasa da gestaciur vadasTan SedarebiT mcire wonis axalSobilis dabadebas {Clausson B, 1998 89 /id}, mkvdradSobadobasa{Raymond EG, 1994 91 /id} da nayofisa da axalSobilis sikvdilianobas Soris{Kleinman JC, 1998 92 /id}.

alkoholis zedmeti raodenobiT moxmareba mavne zemoqmedebas axdens nayofze.Bamitom orsulma unda Seamciros alkoholis miReba 1 standartul erTeulamde dReSi, mag.: erTi patara Wiqa Rvino an kaTxa ludi dReSi. orsuli qali unda gavafrTxiloT mowevis mavne zemoqmedebis Sesaxeb orsulobis dros (naadrevi mSobiaroba, dabali wonis axalSobili). yuradReba unda gamaxvildes orsulobis nebismier etapze mowevis Sewyvetis dadebiT efeqtze. mwevel orsulebs unda davexmaroT sxvadasxva saSualebebiT - eqimis rCeviT, jgufuri SexvedrebiT, qceviTi TerapiiT da sxva. A

C

A

TviTmfrinaviT mgzavroba orsulobis dros 27

ar arsebobs mtkicebulebebi orsulobis dros mgzavrobisas venuri Tromboemboliis riskis momatebis Sesaxeb. simptomuri venuri Tromboemboliis saerTo sixSire xangrZlivi frenis Semdeg Seadgens daaxloebiT 1/400 -1/10 000. venuri Tromboemboliis riski ZiriTadad dakavSirebulia imobilizaciasTan. profilaqtikur RonisZiebebs miekuTvneba: wvivis kunTebis izometriuli varjiSebi, seirnoba TviTmfrinavSi, didi raodenobiT siTxis miReba da alkoholisa da kofeinis miRebisagan Tavis Sekaveba{Royal College of Obstetricians and Gynaecologists., 2001 93 /id}. zogadad, gaurTulebeli erTnayofiani orsulobis dros 36 kviramde frena Sor manZilze daSvebulia eqimis an bebiaqalis janmrTelobis kargi mdgomareobis dadasturebiTa da mSobiarobis dadgenili zusti vadiT orsulobis 28 kviris Semdeg{World Health Organization., 2006 94 /id}.

orsuli informirebuli unda iyos, rom TviTmfrinaviT xangrZlivi mgzavroba dakavSirebulia venuri Trombozebis riskTan. riskis SemcirebisaTvis efeqturia specialuri kompresiuli windebis xmareba mgzavrobis dros.

B

avtomobiliT mgzavroba orsulobis dros avtomobiliT mgzavrobis dros orsuli qalisaTvis Zalian mniSvnelovania Rvedebis swori gamoyeneba. Rvedebis arasworma gamoyenebam SeiZleba gamoiwvios nayofis dazianeba sagzao SemTxvevis dros. orsuls unda miewodos Semdegi informacia Rvedebis swor gamoyenebasTan dakavSirebiT{Lewis G, 2001 95 /id}: • Rvedebi unda gakeTdes muclis zemoT an qvemoT da ara uSualod mucelze; • gamoyenebuli unda iyos 3 nawiliani Rvedebi zonaris moTavsebiT muclis qvemo areze, barZayebs Soris da diagonalurad mxris dafiqsirebiT muclis zemoT sarZeve jirkvlebs Soris; orsuli qali informirebuli unda iyos Rvedebis swor gamoyenebis Sesaxeb

B

orsuli gavafrTxiloT, rom sazRvargareT mogzaurobamde man unda gaiaros konsultacia eqimTan frenis, vaqcianaciis da mgzavrobis sxva aspeqtebis Sesaxeb. P

C

orsulobasTan dakavSirebuli ZiriTadi simptomebi gulisreva da Rebineba orsulobis dros gulisreva aris orsulobasTan dakavSirebuli yvelaze xSiri simptomi da gvxvdeba orsulobis I trimestrSi SemTxvevaTa 80-85%-Si. aris mdgomareoba, romelic viTardeba im orsulebSi, romelTac SeuCerebeli Rebinebis gamo uviTardebaT siTxeebisa da eleqtrolitebis disbalansi orsulobis adreul vadebze. es mdgomareoba iSviaTia da gvxvdeba 3,5/1000 SemTxvevaSi da ZiriTadad saWiroebs hospitalizacias77. Hyperemesis gravidarum

28

qalTa umravlesobaSi gulisreva da Rebineba aRniSneba sibolo menstruaciis Semdeg 8 kviris ganmavlobaSi (94%) da mxolod erTi mesamedi (34%) aRniSnavs simptomebs bolo menstruaciis Semdeg 4 kviris Tavze. qalTa umravlesoba (8791%) aRniSnavs simptomebis gaqrobas gestaciis 16-20 kviraze da mxolod 11-18% aRniSnavs gulisrevas da Rebinebas dilaobiT{Whitehead SA, 1992 96 /id;Gadsby R, 1993 97 /id} . gulisrevisa da Rebinebis dros receptis gareSe SesaZlebelia, koWasa an janjafilis, akupunqturisa da B-vitaminis daniSvna. receptiT gasacemi medikamentebidan SesaZlebelia antihistaminuri saSualebebisa da fenoTiazidebis gamoyeneba. antiemezuri preparatebi aqveiTeben gulisrevasa da Rebinebas orsulobis adreul vadebze. arsebobs mtkicebulebebi maTi gverdiTi efeqtebis Sesaxeb, magram rkkdan gamomdinare mtkicebulebebi nayofze maTi zemoqmedebis Sesaxeb mcirea. Tanamedrove midgomiT gulisrevis intensiobis dasaqveiTeblad gamosayenebeli samkurnalo preparebidan yvelaze efeqturia piridoqsinis gamoyeneba (vitamini B6). akupunqturis gamoyenebasTan dakavSirebuli kvlevis Sedegebi ara erTmniSvnelovania. dakvirvebiTma kvlevebma ar gamoavlina zemoT aRniSnuli intervenciebis teratogenuli efeqti.{Jewell D, 2003 30 /id} koWa (janjafili) dReSi oTxjer 250 mg-is raodenobiT, P6 akupunqtura (Neiguan) da antihistaminuri saSualebebiT mkurnaloba aqveiTebs gulisrevisa da Rebinebis sixSires. aseve efeqturia piridoqsinis (vitamin B6) gamoyenebac, Tumca arsebobs eWvebi vitamini B6-is toqsiurobasTan dakavSirebiT. ciankobalamini (vitamini 12) efeqturia gulisrevisa da Rebinebis SemsubuqebisaTvis, Tumca ar arsebobs monacemebi misi gamoyenebis usafrTxoebis Sesaxeb. gulisreva da Rebineba SemTxvevaTa umravlesobaSi TavisiT gaivlis 16-20 kviraze, orsulobaze raime uaryofiTi zegavlenis gareSe, amitom receptiT gasacemi preparatebis daniSvna ar aris mizanSewonili im SemTxvevebis garda, rodesac simptomatika Zlier aris gamoxatuli an Zalian Semawuxebelia orsulisaTvis. {2003 98 /id} orsuli informirebuli unda iyos, rom gulisreva da Rebineba ZiriTad SemTxvevebSi TavisiT gaivlis 16-20 kviris vadaze da es ar aris dakavSirebuli orsulobis cud gamosavalTan. Tu qali moiTxovs mkurnalobis Catarebas, aucileblad unda iyos gaTvaliswinebuli Semdegi: • arafarmakologiuri mkurnaloba (mag: akupunqtura);farmakologiuri saSualebebidan unda gamoviyenoT antihistaminuri saSualebebi.

A

gulZmarva orsulobis dros gulZmarva warmoadgens xSir simptoms orsulobis dros. erT did kvlevaSi, romelSic monawileobda 607 orsuli qali, gamovlinda, rom gulZmarvis sixSire izrdeboda orsulobis vadis momatebisas da Seadgenda 22%-s pirvel, 39% meore da 72% mesame trimestrSi{Marrero JM, 1992 99 /id}. mkurnaloba gulZmarvis dros moicavs cxovrebis stilis gaumjobesebas, antacidebisa da tutovani miqsturebis gamoyenebas, H2 receptorebis antagonistebs da protonuli dguSebis inhibitorebs, rac saSualebas iZleva mJavas refluqsis SemcirebiT gaumjobesdes simptomatika.

29

cxovrebis stilis gaumjobeseba moicavs sxeulis swori poziciis SenarCunebas, gansakuTrebiT sakvebis miRebis Semdeg, Zils maRal baliSze da dietis dacvas, kerZod ki kvebas mcire xSiri ulufebiT, cximiani da kuWis gamaRizianebeli sakvebisagan, magaliTad kofeinisagan Tavis Sekaveba. antacidebi, romlebic axdenen naRvlis mJavebis neitralizacias, aseve efeqturia gulZmarvis dros. Catarda rkk, romelSic antacidebiT mkurnaloba Sedarda placebomkurnalobasTan. gamovlinda, rom antacidebiT mkurnalobis dros qalTa 80%-ma aRniSna GgulZmarvasTan dakavSirebuli tkivilebis Semsubuqeba placebo jgufTan (13%) SedarebiT H2 receptorebis blokatorebi an antagonistebi, romlebic amcireben mJavis sekreciasa da moculobas, aseve efeqturad moqmedeben gulZmarvis dros da usafrTxoa dReSi orjer - dilasa da SuadRes miRebisas. {Rayburn W, 2006 101 /id;Larson JD, 1997 102 /id} meta-analizma (5 kohortuli kvleva, n=593 axalSobili), romelic Seiswavlida protonis dguSebis inhibitorebis - omeprazolis gamoyenebis usafrTxoebas, gamoavlina misi kavSiri nayofis simaxinjeebis ganviTarebasTan{Nikfar S, 2002 103 /id}. amitom, omeprazolis anotaciaSi miTiTebulia orsulobis dros misi SesaZlo toqsiurobis Sesaxeb, rac gamovlinda cxovelebze eqsperimentebSi da mocemulia rekomendacia orsulobis dros misgan Tavis Sekavebisagan, Tu arsebobs sxva alternativa.

qalebs, romelTac awuxebT gulZmarva orsulobis dros, unda mivawodoT informacia cxovrebis stilisa da dietis Secvlis Sesaxeb.

С

im qalebs, romelTac zemoT aRniSnuli RonisZiebebi ar aZlevs Svebas, unda davuniSnoT antacidebi.

A

Sekruloba Sekruloba orsulobis dros xSir Civils warmoadgens. erT kvlevaSi gamovlinda, rom orsulTa 39% aRniSnavda Sekrulobis simptomebs gestaciis 14 kviraze, 30% - 28 kviraze da 20% - 36 kviraze{Meyer LC, 1994 104 /id}. ori rkk-is sistemur mimoxilvaSi (n=215) qalebis erTi jgufis randomizacia xdeboda boWkovani damatebis jgufSi, xolo meore jgufs ar eZleoda aranairi damatebebi{Jewell DJ, 2003 105 /id}. gamovlinda xorblis an Wvavis boWkoebis damatebis efeqturoba Sekrulobis dros. (OR 0.18, 95% CI 0.05 - 0.67).

Sekrulobis dros orsulebs unda mieceT rekomendaciebi cxovrebis stilis Secvlisa da boWkovani dietis Sesaxeb A

A

hemoroiduli daavadeba (buasili)

30

mimoxilviT kvlevaSi gamovlinda, rom orsulobis bolo trimestrSi qalTa 8%-s aReniSneba hemoroiduli daavadeba {Abramowitz L, 2002 106 /id}. hemoroiduli daavadebis mkurnaloba moicavs dietis gaumjobesebas, adgilobrivi kremebis daniSvnas (mag, anusoli), per os misaReb wamlebsa da qirurgiul Carevas. qirurgiuli Careva orsulobis dros iSviaTad gamoiyeneba, radganac hemoroidulma daavadeba xSirad TavisiT gaivlis mSobiarobis Semdeg.

Tu buasilis konservatuli mkurnaloba orsulobis dros uefeqtoa, saWiroa specialuri dietis daniSvna. simptomatikis gauaresebisas saWiroa adgilobrivi kremebis daniSvna

С

venebis varikozi venebis varikozis sakiTxze Catarebuli sistemuri mimoxilva moicavda 3 rkk-s, romlebic Seiswavlida sxvadasxva mkurnalobis efeqts 115 qalSi{Young GL, 1998 31 /id}. erTi rkk Seiswavlida pnevmatur wyvetil kompresias, meore - wyalSi moTavsebas da woliT reJims qalebSi, romelTac aReniSnebodaT venebis varikozi. aseve Seswavlili iyo uSualod mkurnalobis Semdgomi efeqtebi. mesame kvlevaSi Seswavlili iyo orsulobis bolo trimestrSi 8 kviris ganmavlobaSi rutosidis kafsulebis miReba placebosTan SedarebiT da gamovlinda simptomatikis subieqturi gaumjobeseba gestaciis 36 kviraze (OR 0.30 95% CI 0.12 - 0.77). mtkicebulebebi rutosidis gamoyenebis usafrTxoebis an gverdiTi efeqtebis Sesaxeb orsulobis am vadaze ar arsebobs. orsuli informirebuli unda iyos, rom venebis varikozi warmoadgens xSir simptoms orsulobis dros da ar saWiroebs mkurnalobas. mdgomareobis gaumjobeseba SesaZlebelia specialuri elastiuri windebis tarebiT, Tumca isini ar icaven venebs progresuli gaganierebisagan. A

A

welis tkivili welis tkivilis gavrceleba orsulobis dros varirebs 35-61%-mde{Greenwood CJ, 2001 107 /id;Kristiansson P, 1996 108 /id;Ostgaard HC, 2006 109 /id;Mantle MJ, 1977 110 /id}. qalTa 47-60% tkivilis dawyebas aRniSnavda orsulobis 5-7 Tveebze, xolo misi intensioba matulobda saRamosken. welis tkivili orsulobis dros dakavSirebulia muclis simZimisa da kunTebis gadawelvis gamo simZimis centris gadanacvlebasTan. welis tkivili orsulobis dros Semawuxebelia, man SeiZleba imoqmedos qalis yoveldRiur cxovrebasa da Zilze, gansakuTrebiT mesame trimestrSi. sistemur mimoxilvaSi Sefasebuli iyo 3 rkk, romlebic Seiswavlida yvelaze efeqtur intervenciebs orsulobis dros welis tkivilis prevenciisaTvis{Young G, 2002 32 /id}. varjiSi wyalSi Sedarebuli iyo intervenciebis CautareblobasTan, ozlos baliSebi 31

Cveulebriv baliSebTan, xolo akupunqtura fizioTerapiasTan. qalebi, romlebic akeTebdnen varjiSebs wyalSi, ufro iSviaTad aRniSnavdnen welis tkivils sakontrolo jgufTan SedarebiT (OR 0.38, 95% CI 0.16 - 0.88).. meore kvlevaSi, ozlos baliSebis (budis formis) gamoyenebisas ufro iSviaTad aRiniSneboda weli tkivili orsulobis 36 kvirazee standartul baliSebTan SedarebiT (OR 0.32, 95% CI 0.18 - 0.58) (OR 0.35, 95% CI 0.20 - 0.62) mesame rkk-Si gamovlinda, rom akupunqturis aTi seansi ufro efeqturia, vidre jgufuri fizioTerapiis seansebi (OR 6.58, 95% CI 1.00 - 43.16).

orsuls unda mivawodoT informacia, rom wyalSi varjiSi dadebiTad moqmedebs welis tkivilis dros.

A

infeqciebis skriningi sakiTxi qalis infeqciebze gamokvlevis aucileblobis Sesaxeb sadavoa da yovelTvis ar Seesabameba mtkicebulebebis monacemebs. sakmaod xSirad orsulebs utardebaT ZviradRirebuli da dausabuTebeli analizebi, romelTac ar gaaCniaT praqtikuli Rirebuleba, xolo qalebi, romelTac aseTi gamokvlevebi marTlac esaWiroebaT, mxedvelobaSi miRebulni ar arian. dausabuTebeli gamokvlevebi da mkurnaloba iwvevs mniSvnelovani danaxarjebis gawevas. asimptomuri baqteriuria asimptomuri baqteriuria ganisazRvreba, rogorc saSarde gzebis persistirebadi baqteriuli kolonizacia simptomatikis gareSe. misi sixSire aSS-Si Catarebul kvlevebSi varirebs 2-10%-mde, upiratesi gavrcelebiT dabali socialur-ekonomiuri donis qalebSi{Whalley P, 1967 112 /id} {Villar J, 2000 14 /id}. orsuli qalebi asimptomuri baqteriuriiT imyofebian maRali riskis jgufSi naadrevi mSobiarobisa 2,1%-12,8%-Si da pielonefritis ganviTarebis TvalsazrisiT.{Vazquez JC, 2003 114 /id;Foley ME, 1987 116 /id} yvela orsul qals orsulobis vadis miuxedavad pirveli vizitis dros unda Cautardes testi asimptomur baqteriuriaze. moSardvamde gareTa sasqeso organoebis gamwmendi saSualebiT samjeradi dabanis Semdeg miRebuli unda iyos Sardis Sua ulufa. is rac SeiZleba male unda gaigzavnos laboratoriaSi. amis SeuZleblobis dros Sardis Senaxva unda moxdes 4°C. Tu Sardis kulturaluri gamokvleva SeuZlebelia raime, magaliTad finansuri mizezis gamo, unda Catardes Sardis naleqis mikroskopuli gamokvleva maRali simZlavris velSi >10 leikocitis gamosavlenad an gamoyenebuli iyos leikocitebis esTerazaze mgrZnobiare test-xazebi nitratebis arsebobis gamosavlenad. yvelaze adeqvatur da sasurvel meTods warmoadgens Sardis kulturaluri gamokvleva. 14 rkk-is sistematurma mimoxilvam Seadara antibiotikoTerapia placebomkurnalobasTan an mkurnalobis ararsebobasTan antenatalur periodSi. antibiotikoTerapiam Seamcira persistirebadi baqteriuriis sixSire orsulobis dros (Peto OR 0.07, 95% CI 0.05 - 0.10), naadrevi mSobiarobis riski da dabali wonis axalSobilebis dabadebis sixSire (OR 0.60, 95% CI 0.45 - 0.80), Semcirda aseve pielonefritis 32

ganviTarebis sixSire (OR 0.24, 95% CI 0.19 - 0.32, NNT 7) {Vazquez JC, 2003 114 /id;Vazquez JC, 2003 115 /id} sistemurma mimoxilvam, romelSic Sedarebuli iyo antibiotikis erTjeradi miReba antibiotikoTerapiis 4 an 7 dRian kursTan asiptomuri baqteriuriis dros, ar gamoavlina gansxvaveba naadrevi mSobiarobis (RR 0.81, 95% CI 0.26 to 2.57) an pielonefritis prevenciis TvalsazrisiT. (RR 3.09, 95% CI 0.54 to 17.55). mkurnalobis xangrZlivi kursi dakavSirebuli iyo gverdiTi efeqtebis ganviTarebis momatebul albaTobasTan. (RR 0.53, 95% CI 0.31 to 9.91) {Vazquez JC, 2003 114 /id;Milo G, 2005 113 /id}

asimptomuri baqteriuriis gamosavlenad yvela orsuls unda Cautardes Sardis Sua ulufis gamokvleva. asimptomuri baqteriuriis dadasturebisas antibiotikoTerapia aqveiTebs pielonefritisa da naadrevi mSobiarobis risks.

A

qlamidia qlamidiuri infeqciis arseboba orsulobis dros dakavSirebulia naadrevi mSobiarobis momatebul sixSiresTan (OR 1.6, 90%CI 1.01 - 2.5) da nayofis saSvilosnosSida zrdis Seferxebis sindromis ganviTarebasTan. (OR 2.5, 90%CI 1.32 - 4.18) {The JohnHopkins Study of Cervicitis and Adverse Pregnancy Outcome., 1989 117 /id} . mkurnalobis ararsebobisas asimptomuri baqteriuria dakavSirebulia axalSobilebis dabal wonasa da axalSobilTa sikvdilianobasTan{Ryan GM, 1990 118 /id}. rkk–ebis mimoxilvis Sedegebis mixedviT qlamidiis kulturis dadebiTi maCveneblebiT qalTa raodenoba 90%-iT mcirdeboda antibiotikoTerapiis Catarebis jgufSi placebosTan SedarebiT. (OR 0.06, 95% CI 0.03 - 0.12) {Stary A., 2001 119 /id}. miuxedavad amisa, ar daqveiTebula 37 kviramde mSobiarobaTa ricxvi. dRevandel dRes ubralo, iafi laboratoriuli testi qlamidiis diagnostikisaTvis ar arsebobs, xolo rac Seexeba skriningul testebs, maT Casatareblad saWiroa masalis aReba sxvadasxva anatomiuri adgilebidan{Ryan GM, 1990 118 /id}. swrafi testebi moicaven antisxeulis pirdapir fluorescenciul SeRebvas (mgrZnobeloba 50-90%), ferment-dakavSirebul imunur kvlevebs (mgrZnobeloba 75%-80%, specifiuroba 85-100%) da dnm-rnm hibridizacias (mgrZnobeloba 70-85%) pirdapiri fluorescentuli antisxeulebis SeRebva Zalian Sromatevadia da amitom meTodis gamoyeneba ar aris mizanSewonili pacientta didi raodenobis dros. mwvave qlamidiuri infeqciis dros serologiuri kvleva mizanSewonili ar aris {Vazquez JC, 2003 114 /id;Stary A., 2001 119 /id} qlamidiuri infeqciis gamosavlenad testis Catareba klinikuri simptomatikis ararsebobisas mizanSewonili ar aris, radganac ar arsebobs sakmarisi mtkicebulebebi misi efeqturobis Sesaxeb da is ZviradRirebul gamokvlevas warmoadgens.

A

citomegalovirusuli infeqcia

33

citomegalovirusi aris herpesvirusebis ojaxis warmomadgeneli. is latenturia pirveladi dainficirebis Semdeg da SeiZleba ganicados aqtivacia imunodepresiis dros. citomegalovirusuli infeqciis antenataluri skriningi mizanSewonili ar aris, radganac rTulia ganisazRvros, Tu romeli orsuloba garTuldeba nayofis dainficirebiT{Peckham CS, 1983 120 /id}. SeuZlebelia imis gansazRvra, Tu romel dainficirebul axalSobils Camouyalibdeba seriozuli garTulebebi. vaqcinebi, profilaqtikuri Terapia transmisiis prevenciisaTvis da meTodi imis gasarkvevad, Tu rodis moxda saSvilosnosSida transmisia, ar arsebobs {Bolyard EA, 1998 121 /id;Stagno S, 1985 122 /id}.

ar arsebobs sakmarisi mtkicebulebebi citomegalovirusis rutinuli skriningisaTvis, amitom misi Catareba ar aris mizanSewonili. B

B

B-hepatiti bavSvTa 85%, romlebic ibadebian (eAg) dadebiTi dedebisagan SemdgomSi xdebian qronikuli infeqciis mtareblebi, rac aRiniSneba antigen uaryofiTi dedebisagan dabadebuli bavSvebis mxolod 31%-s.(RR 2.8, 95% CI 1.69 - 4.47){Beasley RP, 1977 123 /id}. dedidan bavSvze B-hepatitis virusis transmisiis profilaqtika 95%-Sia SesaZlebelia vaqcinaciiT an bavSvis dabadebisas imunoglobulinis SeyvaniT{Sehgal A, 1992 124 /id}. HbsAg skrinings nerwyvSi gaaCnia 92% mgrZnobeloba (95% CI 84.5% - 99.5%) da 86,8% specifiuroba (95% CI 76.0% - 97.6%), Sratis analizebTan SedarebiT{Chaita TM, 1995 125 /id}. dedidan bavSvze transmisiis maRali maCveneblebis gamo prevencia unda xdebodes vaqcinaciiTa da imunizaciiT. imis gamo, rom risk-faqtorebis SefasebiT ver xerxdeba virusis mtarebelTa identifikacia, rekomendebulia orsuli qalis skriningi B-hepatitis virusze.

mSobiarobis Semdgomi aucilebelia B-hepatitis periodSi

efeqturi intervenciebis Casatareblad serologiuri gamokvleva antenatalur

A

C-hepatiti C-hepatitis virusi warmoadgens sazrunavs{Pembrey L, 2000 126 /id}.

sazogadoebrivi

janmrTelobis

mniSvnelovan

virusiT dainficireba SesaZlebeliaAdainficirebuli sisxlis transfuziis, narkomaniis, tatuirebis, sxeulis pirsingisa da vertikaluri transmisiiT. miuxedavad arsebuli 34

mtkicebulebebisa dedidan bavSvze transmisiis albaTobisa da virusis titris zrdis pirdapirproporciuli damokidebulebis Sesaxeb,{Okamoto M, 2000 127 /id;Tajiri H, 2001 128 /id}, transmisiisaTvis zRvari jer-jerobiT dadgenili ar aris. bavSvebis dainficireba ufro xSirad xdeba saSosmxrivi mSobiarobis dros sakeisro kveTasTan SedarebiT, Tumca statistikurad sarwmuno gansxvaveba gamovlinda mxolod erT kvlevaSi{Paccagnini S, 1995 129 /id}. kvlevis oqros standarts warmoadgens polimerazuli jaWvuri reaqciia, mgrZnobeloba da specifiuroba Seadgens 100% da 66%-s Sesabamisad{Lin HH, 2000 130 /id}. skriningis testis dadebiTi Sedegebis infeqcionistTan mkurnalobisaTvis.

miRebisas

qali

unda

gaigzavnos

C-hepatitis gamosavlenad ar aris mizanSewonili serologiuri gamokvlevis Catareba, radganac ar aris sakmarisi mtkicebulebebi intervenciis efeqturobis Sesaxeb da is ZviradRirebul gamokvlevas warmoadgens.

C

Sidsi adamianis imunodeficitis virusiT dainficireba iwyeba asimptomuri stadiiT, rasac SemdgomSi moyveba imunuri funqciebis etapobrivi dazianeba da SeZenili imunodeficitis sindromis Camoyalibeba (Sidsi). aiv-inficirebasa da Sidsis ganviTarebas Soris periodi mkurnalobis gareSe meryeobs ramodenime Tvidan 17 wlamde{2002 131 /id}. 2006 wels saqarTveloSi gamovlinda 217 aiv-inficirebuli qali. 1,4%- dainficirda virusis vertikalurad (dedidan bavSvze) gadacemis gziT. Tu ar Catarda Sesabamisi intervenciebi, transmisia dedidan bavSvze aRiniSneba SemTxvevaTa 25,5%-Si. zidovudiniT antiretrovirusuli mkurnalobis Semdeg{Connor EM, 1994 132 /id} es maCvenebeli Semcirda 8%-mde. intervenciebis kombinacias (antiretrovirusuli mkurnaloba, sakeisro kveTa da ZuZuTi kvebisagan Tavis Sekaveba) SeuZlia transmisiis riskis daqveiTeba 1%-mde. dRevandel dRes xelmisawvdomi aiv-testebis mgrZnobeloba da specifiuroba Seadgens 99%{Samson L, 1998 133 /id} antenatalur periodSi dedidan bavSvze vertikaluri transmisiis Sesamcireblad SemoTavazebulia antiretrovirusuli mkurnaloba, gegmiuri sakeisro kveTa da mSobiarobis Semdeg ZuZuTi kvebisagan Tavis Sekaveba. 2006 wlidan saqarTveloSi yvela orsulisaTvis antenatalur periodSi rekomendebulia aiv-testis Catareba.

orsul qals unda Cautardes gamokvleva aiv-infeqciaze/Sidsze, radganac adreuli intervenciebi antenatalur periodSi amcireben transmisiis risks.

A

35

unda arsebobdes kargad Camoyalibebuli referaluri programa aivinfeqcia/Sidsis diagnostirebis SemTxvevaSi orsulis Sesabamis specialistTan gadasagzavnad D

С

wiTela orsulobis dros wiTelas skriningis mizans warmoadgens im qalebis gamovlena, romlebsac ara aqvT antisxeulebi wiTelasadmi, rom ganxorcieldes mSobiarobis Semdgomi vaqcinacia momavali orsulobebis usafrTxoebisaTvis. wiTelas vaqcinacia orsulobis dros winaaRmdegnaCvenebia SesaZlo teratogenobis gamo. {Tookey P, 2002 134 /id}

wiTelass skriningi gansazRvrulia orsulis imunuri statusis dasadgenad da orsulobis Semdeg saWiroebisas acris Casatareblad; kvleva ar aris mowodebuli orsulobis dros nayofis mdgomareobis Sesafaseblad

B

aTaSangi aranamkurnaleb aTaSangiT daavadebul orsulebSi axalSobilTa dainficireba xdeba SemTxvevaTa 70-100%-Si, xolo axalSobilTa mesamedi umwifari ibadeba.{Ingraham NR Jr., 1951 136 /id} arsebobs aTaSangis serologiuri testebis 2 ZiriTadi klasifikacia: aratreponemuli da treponemuli. aratreponemuli testebi gamoavlens aTaSangis araspecifiur antisxeulebs da moicavs veneriuli daavadebis kvlevis laboratoriasa (VDRL) da plazmis swraf reaginis testebs. (RPR) rekomendebulia, aTaSangis skriningi ganxorcieldes pirvel da meoTxe antenatalur vizitze. yvela qali, romelic dadebiTi aRmoCndeba aTaSangze, unda gaigzavnos samkurnalod specialistTan. kvlevaSi ar dadasturda orsulobis dros aTaSangis peniciliniT mkurnalobis arasasurveli zomoqmedeba orsulobaze, rodesac moxda mkurnalobis jgufis Sedareba aranamkurnalebi seronegatiuri qalebis populiaciasTan {Walker GJA., 2001 135 /id} aTaSangis kvleva unda Cautardes yvela orsul qals, radganac adreuli mkurnaloba aumjobesebs gamosavals rogorc dedis, ise axalSobilis mxriv.

A

toqsoplazmozi pirveladi toqsoplazmozi gamowveulia parazitiT Toxoplasma gondii da xSirad asimptomurad mimdinareobs janmrTel qalebSi. dainficireba uzrunvelyos mudmiv imunitets. ar aris dadgenili saqarTvelos monacemebi toqsoplazmozis gavrcelebis 36

sixSireze, Tumca sxva qveynebSi gavrcelebis sixSire varirebs 2,4/1000 qalidan fineTSi da 16/1000 safrangeTSi. toqsoplazmoziT dainficireba SesaZlebelia moxdes oTxi gziT: • arasrulfasovnad damuSavebuli an umi sakvebiT cocxali cistebis miRebiT • oocitebis miRebiT, romelTac gamoyofen katebi, aseve dabinZurebul niadagTan da wyalTan kontaqtiT. (mag: gaurecxavi xili da bostneuli, romelic katis fekaliebiTaa dabinZurebuli); • toqsoplazmoziT daavadebuli adamianisagan organoebis an qsovilebis gadanergviT; • dedidan nayofze transmisiiT orsulobis dros pirveladi dainficirebisas. 6 evropul centrSi Catarebulma kvlevam gamoavlina, rom Termulad arasrulfasovnad damuSavebuli rZis produqtebi da dakonservebuli xorcis produqtebi warmoadgens orsulis toqsoplazmoziT dainficirebis ZiriTad faqtorebs{Cook AJ, 2000 137 /id}. niadagTan kontaqti bevrad iSviaTad iwvevda dainficirebas. rodesac T. gondii-sTan pirveli kontaqti orsulobis dros xdeba, dedidan nayofze transmisiis albaToba matulobs orsulobis vadis zrdasTan erTad{Pratlong F, 1996 138 /id;Dunn D, 1999 139 /id;Foulon W, 1999 140 /id} Tandayolili toqsoplazmozisaTvis saerTo riski Seadgens 18-44%-s, is ufro dabalia orsulobis adreul vadebze da Seadgens 6-26%-s orsulobis 7-15 kviraze da izrdeba 32-93%-mde 29-34 orsulobis vadisaTvis. imis gamo, rom toqsoplazmoziT pirveladi dainficireba usimptomod mimdinareobs, inficirebis dadgena SesaZlebelia mxolod serologiuri testirebiT. toqsoplazmozis infeqciaze antenataluri skriningi moicavs IgG da IgM M antisxeulebis skrinings. xelmisawvdomi klinikuri testebi serokonversiis dasadgenad ver avlenen, dainficireba moxda orsulobis dros Tu orsulobamde 12 TviT adre. qalebs, romlebic dainficirdnen Casaxvamde, nayofze gadacemis riski ara aReniSnebaT{Gilbert RE, 2002 141 /id} toqsoplazmozis pirveladi prevencia xdeba orsulis informirebiT dainficirebis Tavidan acilebis gzebis Sesaxeb orsulobis adreul vadebze. qalebi informirebulebi unda iyvnen Termulad arasakmarisad damuSavebuli sakvebisa da konservebis miRebis riskze, aseve katis fekaliebTan, niadagTan da gaurecxav xilsa da bostneulTan Sexebis saSiSroebis Sesaxeb. ar arsebobs mtkicebulebebi, rom antenataluri skriningi aqveiTebs transmisias dedidan nayofze, amitom toqsoplazmozis skriningis rutinulad daniSvna rekomendebuli ar aris.

orsul qals unda mivawdoT informacia imis Sesaxeb, rom toqsoplazmoziT inficirebis albaTobas orsulobis dros amcirebs Semdegi moqmedebebi: • Wamamde xelis dabana; • xilisa da bostneulis saguldagulo garecxva; • sakvebis saguldagulo Termuli damuSaveba; • miwasTan muSaobis dros xelTaTmanebis gakeTeba; • katis fekaliebTan Sexebis Tavidan acileba.

C

37

nayofis winamdebareobis dadgena Catarda kvleva nayofis winamdebareobis dadgenis mizniT muclismxrivi palpaciis leopoldis wesebis gamoyenebis Taobaze, romelmac gamoavlina, rom SemTxvevaTa 53%-Si nayofis winmdebareoba arasworad iyo dadgenili.{McFarlin BL, 1985 142 /id} es damtkicda sxva kvleviT, romelic specifiurad mimarTuli iyo menjiT winamdebareobis dasadgenad{Vause S, 1997 143 /id} leopoldis wesebis mgrZnobeloba da specifiuroba Seadgenda 28% da 94%-s Sesabamisad{Thorp JM Jr, 1991 144 /id}. erT kvlevaSi gamovlinda, rom qalebs ar siamovnebT palpaciis procesi, isini mas arakomfortulad da arainformaciulad miiCneven.{Olsen K., 1999 153 /id}

mSobiarobis gegmis SemuSavebis mizniT 36 kviris Semdeg unda Catardes nayofis muclismxrivi palpacia, xolo 36 kviramde palpaciis ganxorcieleba mizanSewonili ar aris, radganac is arasakmarisad zustia da diskomforts uqmnis orsuls.

A

nayofis araswori mdebareoba unda dadasturdes ultrabgeriTi gamokvleviT. P

С

saSvilosnos fuZis simaRlis gansazRvra simfiz-saSvilosnos fuZis simaRlis gansazRvra (santimetrebSi) dagvexmaros saSvilosnos obieqturi zomebis gansazRvraSi.

SesaZlebelia

simfiz-saSvilosnos fuZis simaRlis regularuli gazomva aadvilebs nayofis zrdis siCqaris dadgenas. zomisa da vadis Seusabamobis mizezebi Semdegia: • • • • •

gestaciuri vadisaTvis mcire zomis axalSobili; didi raodenobiT sanayofe siTxe; mravalnayofiani orsuloba; buStnamqeri; gestaciuri vadis gansazRvris uzustoba.

sistemurma mimoxilvam{Buchmann, 2006 16 /id} gamoavlina, rom ar arsebobs mtkicebulebebi saSvilosnos fuZis simaRlis rutinuli gazomvis raime sargeblianobis Sesaxeb. amis miuxedavad, xelmisawvdomi literaturis monacemebiT, rutinuli gazomva warmoadgens mgrZnobiare meTods gestaciis vadasTan SedarebiT mcire wonis axalSobilebis gamosavlenad ganviTarebad qveynebSi. amis gamo, is kvlav rekomendebulia antenataluri meTvalyureobis standartul praqtikaSi. saSvilosnos fuZis simaRlis rutinuli gazomvisaTvis saWiroa Semdegi: 1. sazomi metrebisa da antenataluri baraTebis uzrunvelyofa, rac moicavs grafaze mrudis aRniSvnas, romelic aCvenebs 10, 50 da 90 sentils; 2. treinings mocemul meTodSi; 3. gazomvis praqtikisa da xarisxis uwyvet audits;

38

yoveli antenataluri vizitis dros unda gaizomos saSvilosnos fuZis simaRle gestaciur vadasTan SedarebiT didi an mcire wonis axalSobilis gamosavlenad.

A

saSvilosnos fuZis simaRle unda gaizomos da aRiniSnos grafaze yoveli antenataluri vizitis dros.. A

С

nayofis moZraobis rutinuli monitoringi dedis SegrZneba nayofis moZraobis SemcirebasTan dakavSirebiT gamoiyeneba antenataluri meTvalyureobis dros nayofis keTildReobis dasadgenad, magram dadebiTi prognozuli Rirebuleba dedis SegrZnebebisaTvis nayofis moZraobebis SemcirebasTan dakavSirebiT dabalia da Seadgens 2-7%- {Macones GA, 1996 154 /id} mtkicebulebebi ar adastureben nayofis moZraobebis formalur daTvlas gviani sikvdilisagan Tavis asacileblad.

nayofis moZraobaTa raodenobis daTvla mogvianebiT nayofis sikvdilis Tavidan acilebis mizniT ar aris mizanSewonili.

nayofis

A

nayofis guliscemis auskultacia miuxedavad imisa, rom nayofis guliscemis mosmena adasturebs imas, rom nayofi cocxalia, mas ar gaaCnia sxva klinikuri an prognozuli Rirebuleba{Divanovic E, 1999 146 /id;Sharif K, 1993 147 /id} es imis gamo, rom iseTi detaluri informacia nayofis guliscemis Sesaxeb, rogoricaa deceleracia da variabeloba ar gamovlinda auskultaciis dros.

nayofis guliscemis auskultacia adasturebs imas, rom nayofi cocxalia, magram am gamokvlevas ara aqvs prognozuli Rirebuleba, amitom ar aris rekomendebuli. is unda Catardes im SemTxvevaSi, Tu amas orsuli moiTxovs. D

С

kardiotokografia ar arsebobs antenataluri kardiotokografiis gamoyenebis Sefasebis mtkicebulebebi normaluri orsulobis dros nayofis rutinuli SefasebisaTvis. sitemur mimoxilvam ver gamoavlina antenataluri kardiotokografiis efeqti perinatalur avadobasa da sikvdilianobaze{Pattison N, 2001 148 /id}. ar gamovlenila iseTi intervenciebis sixSiris zrda, rogorebicaa sakeisro kveTa da mSobiarobis induqcia.

39

fiziologiuri orsulobis dros antenatalur periodSi kardiotokografiis rutinuli gamoyenebis Sesaxeb ar arsebobs sakmarisi mtkicebulebebi da amitom ar aris mizanSewonili.

A

ultrabgeriTi gamokvleva mesame trimestrSi 7 rkk-is sistemur mimoxilvaSi{Bricker L, 2006 12 /id}, sadac monawileobda 25 036 orsuli 24 kviris Semdeg Seswavlili iyo rutinuli ultrabgeriTi gamokvlevis faseuloba. aRiniSna farTo variacia ultrabgeriTi gamokvlevis SedegebSi kvlevaTa Soris. ZiriTadad 6 kvlevis jgufebs Soris Sedarebuli iyo rutinuli ultrabgera 24 kviris Semdeg intervenciis Catarebis gareSe jgufTan, seleqtiur ultrabgeriT kvlevasTan 24 kviris Semdeg. ar gamovlenila gansxvaveba naadrevi mSobiarobis, nayofis mcire wonisa da perinataluri sikvdilianobis sixSireebSi. aseve ar iyo gansxvaveba antenataluri, sameano da neonataluri intervenciebis sxva gamosavalebis TvalsazrisiT{Bricker L, 2006 12 /id}

ar arsebobs sakmarisi mtkicebulebebi gestaciis 24 kviris Semdeg rutinuli ultrabgeris gamoyenebisaTvis.

A

Wipisa da saSvilosnos arteriis doplerografia 5 rkk-s sistemuri mimoxilvidan dadgenili iyo, rom Wiplaris dopleruli ultrabgeris rutinul gamoyenebas ara aqvs zegavlena sameano da neonatalur gamosavalze, perinataluri sikvdilianobis CaTvliT. Wiplaris doplerografiuli ultrabgeris rutinuli gamoyeneba zrdis sxva intervenciebis Catarebis albaTobas{Bricker L, 2006 12 /id}. 27 pirveladi dakvirvebiTi kvlevebis sistemurma mimoxilvam Seiswavla dopleruli ultrabgeris gamoyeneba preeklamfsiis, nayofis zrdisa da perinataluri sikvdilianobis Sesafasablad maRali riskis populaciebSi. prognozuli Rirebuleba dabali iyo janmrTel qalebSi da gaurTulebeli orsulobis SemTxvevaSi (anu dabali riskis populaciaSi). {Chien PF, 2000 155 /id}

Wipis arteriis rutinuli doplerografiuli nayofis zrdis Seferxebis sindromis rekomendebuli.

gamokvlevis dasadgenad

Catareba ar aris

saSvilosnos arteriis rutinuli doplerografiuli gamokvleva eklamfsiis riskis Sesafaseblad ar aris rekomendebuli.

pre-

A

A

40

menjiT winamdebareoba vadamitanili orsulobis dros. intervencias menjiT winamdebareobis dros warmoadgens Tavze garegani Semobruneba, moqsibastionis gamoyeneba (akupunkturis dros) da poziciuri mkurnaloba. 9 rkk-s 2 sistemur mimoxilvaSi Sefasda Tavze garegani mobruneba menjiT winamdebareobisas vadamitanili orsulobis dros an vadamde adre.{Hofmeyer GJ., 2005 149 /id;Hofmeyer GJ., 2006 150 /id} TaviT garegani mobruneba gestaciis 37 kviramde ar axdenda mniSvnelovan zegavlenas menjiT winamdebareobaze orsulobis dromde mitanis SemTxvevaSi. ( RR 1.02, 95% CI 0.89 - 1.17), aseve arc sakeisro kveTis sixSireze ( RR 1.10, 95% CI 0.78 1.54) {Hofmeyer GJ., 2005 149 /id}. Tavze garegani Semobruneba vadamitanili orsulobis dros amcirebda menjiT winamdebareobas 60%-iT, rodesac Sedarebuli iyo intervenciis CautareblobasTan. ( RR 0.42, 95% CI 0.35 - 0.50). sakeisro kveTis mniSvnelovani Semcireba aseve aRniSnuli iyo Tavze garegani Semobrunebis jgufSi ( RR 0.52, 95% CI 0.39 - 0.71,) {Brocks V, 1984 152 /id}. Tavze garegani mobruneba vadamitanili orsulobis dros amcirebs araswor winamdebareobas mSobiarobis momentisaTvis. uSedego mcdelobis albaTobas amcirebs proceduris dros tokolitikebis gamoyeneba. TaviT garegani mobruneba dakavSirebulia dedisa da nayofis mxriv rig gverdiT efeqtebTan, romelTa minimizacia SesaZlebelia proceduris dros nayofis monitoringis gamoyenebiT. poziciuri mkurnaloba TaviT mobrunebis mizniT moicavs relaqsacias menjis amaRlebiT. es ZiriTadad miiRweva muxl-idayvis poziciis miRebiT an zurgze woliT menjis amaRlebiT solisebri baliSis meSveobiT. dedis poziciuri teqnika ganxiluli iyo rkk-is sitemur mimoxilvaSi{Hofmeyr GJ, 2003 151 /id} ar aRiniSna poziciuri teqnikis efeqti araswori winamdebareobiT mSobiarobis sixSireze eqsperimentalur da sakontrolo jgufSi ( RR 0.95, 95% CI 0.81 - 1.11) ar gamovlinda gansxaveba sakeisro kveTis sixSireebSic ( RR 1.07, 95% CI 0.85 - 1.33). moqsibastionis gamoyeneba Seswavlili iyo erT rkk Si{Cardini F, 1998 156 /id}. eqsperimentalur jgufSi TaviT winamdebareoba mSobiarobis droisaTvis statistikurad sarwmuno meti iyo. gaurTulebeli orsulobis dros menjiT winamdebareobisas 36 kviris vadaze unda Catardes TaviT garegani mobruneba. gamonakliss warmoadgenen orsulebi, romlebic imyofebian mSobiarobaSi an aReniSnebaT nawiburi saSvilosnoze, misi malformacia, nayofis mdgomareobis gauareseba, darRveuli sanayofe buSti, sisxldena da sxvadasxva davadebebi.

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jmo-s mier rekomendirebuli gravidograma

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gamoyenebuli literatura

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