Placenta Praevia

placentis winamdebareoba da winamdebare placentis mixorceba klinikuri rekomendaciebi

Tbilisi 2006

avtorTa jgufi:

⇒ Tengiz AasaTiani, FRCOG, mean ginekologi, Tssu postdiplomuri samedicino ganaTlebis da uwyveti profesionaluri ganviTarebis institutis reproduqciuli janmrTelobis departamentis xelmZRvaneli, asocirebuli profesori, saqarTvelos mean ginekologTa asociaciis prezidenti. ⇒ zaza boxua - mean ginekologi, saqarTvelos Sromis, janmrTelobis da socialuri dacvis jandacvis departamentis ufrosis moadgile, saqarTvelos mean ginekologTa asociaciis generaluri mdivani. ⇒ Tamaz Jojua - S.p.s m.SaraSiZis samedicino centris anesTeziologi ⇒ aleqsandre TaraSvili- S.p.s m.SaraSiZis samedicino centris meanginekologi ⇒ nino abulaZe aspiranti

– Tssu reproduqciuli janmrTelobis departamentis

saeqsperto Sefaseba: ⇒ aleko goxelaSvili - anesTeziologi, #5 samSobiaro saxli ⇒ petre lomaia - mean ginekologi, medicinis mecnierebaTa kandidati, m.SaraSiZis samedicino centris sameano ganyofilebis gamge, saqarTvelos mean ginekologTa asocoaciis wevri ⇒ akaki baqraZe – £# 2 samSobiaro saxlis mean ginekologi, medicinis mecnierebaTa kandidati, saqarTvelos Sromis, janmrTelobis da socoaluri dacvis eqsperti meanoba ginekologiaSi, saqarTvelos mean ginekologTa asocoaciis gamgeobis wevri ⇒ mamuka xoStaria – mean ginekologi, sagarejo S.p.s. £# 5 saavadmyofo-poliklinikuri gerTianrbis qalTa konsultaciis gamge, saqarTvelos mean ginekologTa asocoaciis gamgeobis wevri

klinikuri rekomendaciebis zogadi mizani am rekomendaciis mizans warmoadgens

placentis

winamdebareobisa

da

winamdebare placentis mixorcebis marTvis meTodebis standartizacia dedisa da axalSobilis gamosavlis gasaumjobeseblad.

ganxiluli klinikuri sakiTxebi am rekomendaciebSi ganxilulia placentis winamdebareobisa da winamdebare placentis mixorcebis diagnostireba da am mdgomareobebis mkurnaloba rogorc antenatalur periodSi, aseve mSobiarobis dros.

visTvis aris gankuTvnili mocemuli klinikuri rekomendacia mocemuli klinikuri rekomendaciebi gankuTnilia stacionarSi momuSave meanginekologebisaTvis, aseve jandacvis pirveladi rgolisE mean-ginekologebis, bebiaqalebisa da ojaxis eqimebisaTvis, romelTac aqvT mSobiaresTan kontaqti an exebaT mSobiarobis warmarTva. rekomendacia SeiZleba gamoyenebuli iyos rogorc diplomamdeli, ise diplomisSemgomi uwyveti samedicino ganaTlebis mizniT.

Ziebis, mtkicebulebaTa Sefasebisa da rekomendaciebis formulirebis aRwera placentis winamdebareobisa da winamdebare placentis mixorcebis aqtualobis gamo

arsebobs

meTodologiaTa

sakmarisi

raodenoba,

romlebic

Seicaven

samecniero mtkicebulebebze dafuZnebul rekomendaciebs. amitom samuSao jgufis mier gadawyvetili iyo ukve arsebuli praqtikuli rekomendaciebis moZieba da Sefaseba da rekomendaciebis adaptirebuli formis Seqmna, romlebic erTis mxriv, upasuxebdnen saerTaSoriso moTxovnebs, xolo meores mxriv, misaRebi iqnebodnen saqarTvelos jandacvis pirobebSi gansaxorcieleblad. samuSao jgufis mier daSvebuli iyo is SesaZlebloba, rom arsebul rekomendaciebSi ar iqneboda ganxiluli

yvela

mtkicebulebaTa

klinikuri

sakiTxi

damoukidebeli

da

am

moZiebis

SemTxvevaSi aucilebloba

warmoiSveboda

konkretul

klinikur

sakiTxebTan dakavSirebiT. klinikuri rekomendaciebisa da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi •

klinikuri rekomendaciebis, epidemiologiuri monacemebisa da mtkicebulebebis 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) placentis winamdebareobisa da winamdebare placentis mixorcebis analogiuri rekomendaciebi, romlebic SemuSavebulia Sesabamisi profesionaluri jgufebis mier.

•

calkeuli, aseve ara srulad ganxiluli klinikuri sakiTxebis Sesaxeb mtkicebulebaTa moZieba 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).

moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi Catarebuli

Ziebis

Sedegad

miRebuli

iyo

ramodenime

klinikuri

meToduri

rekomendacia, romlebic moicavda jgufis miznis Sesaferis saWiro informacias. am rekomendaciebis saboloo Sefasebisas gamoyenebuli iyo formaluri Sefasebis meTodi

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

mtkicebulebis

mizniT.

done

cxrilSi

wyaros

Sedioda

mixedviT.

debulebis

samuSao

originaluri

jgufs

unda

versia

da

Seefasebina

rekomendaciebis vargisianoba saqarTvelos jandacvis stacionaluri daxmarebis pirobebSi.

rekomendacia

miiReboda,

Tu

mis

sasargeblod

xmas

aZlevda

SemqmnelTa samuSao jgufis umravlesoba.

konfliqtTa interesebis deklaracia muSaobis dawyebamde mocemuli klinikuri rekomendaciis proeqtSi, samuSao jgufis yvela wevrma ganacxada Tanxmoba, werilobiT formaSi gamoecxadebina farmacevtul kompaniebTan finansuri kavSirebis Sesaxeb. saavtoro koleqtivis arc erT wevrs ar hqonda finansuri daintereseba an sxva interesTa konfliqti farmacevtul kompaniebTan

da

sxva

organizaciebTan

SesamuSavebel

rekomendaciasTan

dakavSirebiT. klinikuri rekomendaciebis Sida recenzireba Catarebuli iyo klinikuri rekomendaciebis Sida recenzireba (sia Tan erTvis) rekomendaciebis

mowodebis

sizustis

gamosavlenad,

maTi

efeqturobisa

da

usafrTxoebis Sesafaseblad da praqtikuli gamoyenebis TvalsazrisiT. recenziebis miRebis Semdeg

ganxiluli iyo

Sedegebi da samuSao jgufis mier Setanili iyo

cvlilebebi klinikuri rekomendaciebis SinaarsSi. klinikuri rekomendaciis gadaxedvis vada - 2009w.

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 (AHCPR), 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. saWiroebs

A B

ZiriTadi

literaturuli

wyaros

arsebobas,

minimalurad

erT

randomizirebul sakontrolo kvlevas, romelic Catarebulia kargi xarisxiTa da SinaarsiT, rac specifiurad Seesabameba mocemul mtkicebulebas an rekomendacias, an sistematiuri mimoxilva saWiroebs maRali xarisxis klinikuri, magram ara randomizirebuli kvlevis Catarebas, romelic Seesabameba rekomendaciis Sinaarss. saWiroebs mtkicebulebebis arsebobas, romlebic dafuZnebulia eqspertTa

C

komisiis daskvnaze an maT azrze da/an dafuZnebulia am dargSi cnobili avtoritetuli warmomadgenlebis azrze. miuTiTebs xarisxiani kvlevebis ar arsebobaze am sakiTxTan dakavSirebiT.

am mimarTulebiT muSaobis erT-erT Sedegs warmoadgens mocemuli klinikuri rekomendacia. am dokumentSi asaxulia placentis winamdebareobisa da winamdebare placentis mixorcebis Tanamedrove Sexedulebebi da aRwerilia mkurnalobis ZiriTadi meTodebi.

Sesavali placentis winamdebareobisa da masTan dakavSirebuli garTulebebi mniSvnelovan ricxvs aRwevs , xolo perinataluri sikvdiloba oTxjer maRalia normalurad mimdinare orsulobasTan SedarebiT.

pacienti xSirad

saWiroebs hospitalizacias. sakeisro

kveTis Semdeg placentis

winamdebareobis gamo histereqtomiis sixSire aRwevs

5.3%. placentis winamdebareoba ewodeba mdgomareobas, rodesac placenta mTlianad an nawilobvrivad mimagrebulia saSvilosnos qveda segmentSi. Tu is srulad faravs yelis Sida pirs, am mdgomareobas ewodeba placentis sruli winamdebareoba, xolo Tu ara - arasruli winamdebareoba. tradiciuli klasifikacia dafuZnebulia imaze Tu ramdenadaa placenta miaxlovebuli saSvilosnos yelis Sida pirs (dabali, kidiTi, nawilobrivi da sruli) da ganisazRvreba ultrasonografiuli

kvlevis

SedegebiT.

placentis

winamdebareobis

dros

qalis

mkurnaloba damokidebulia klinikur da ultrasonografiul monacemebze.

skriningi da diagnozi miuxedavad imisa, rom placentis winamdebareobis diagnostikaSi didi roli eniWeba klinikur ganWvretas, am mdgomareobis umravlesobis saboloo diagnostireba xdeba

ultrasonografiuli

kvlevis

dros.

im

SemTxvevebSic

ki,

rodesac

ultrasonografiuli kvlevis monacemebi normaluria, yvela qalSi saSodan sisxldeniT an winamdebare nawilis maRla dgomiT, aseve nayofis araswori mdebareobiT unda gamoiricxos placentis winamdebareoba.

ultrasonografiuli kvleva placentis dabali mimagrebis skriningisa da placentis winamdebareobis diagnostikisaTvis Catarda

ramodenime

prospeqtuli

observaciuli

kvleva

transvaginaluri

ultrasonografiuli kvlevis Sesaxeb placentis winamdebareobis dros. gamokvlevis dros arc erTxel ar ganviTarebula hemoragiuli garTulebebi, ramac daadastura meTodis

usafrTxoeba

.

arsebobs

mxolod

erTi,

transabdominaluri

ultrasonografia

Sedarebulia

winamdebareobis

diagnostirebis

mizniT,

rkk,

romelSic

transvaginalurTan

placentis

romelSic

mcire

aseve

dadasturda

transvaginaluri meTodis usafrTxoeba. Tu meore trimestrSi saSvilosnos qveda segmenti ar aris formirebuli, mogvianebiT placentis winamdebareobis Camoyalibebis skriningi aucileblad migviyvans cru dadebiT Sedegamde transabdominaluri kvlevis Catarebisas , radganac yvela qvemoT ganlagebuli placenta ar persistirebs. transvaginaluri kvleva aumjobesebs vizualizacias.

meore

trimestrSi

transabdominaluri

ultrasonografiiT

dadgenili

placentis

dabali

mimagrebis

SemTxvevaTa

26-60%

transvaginaluri

kvleviT

diagnozi ar dasturdeba, xolo mesame trimestrSi transabdominaluri kvleviT diagnostirebuli placentis winamdebareobis 32 qalidan mxolod 12,5%-Si ar iyo dadasturebuli transvaginaluri kvlevis dros.

gamoavlinda, rom transvaginaluri

ultrasonografiis mgrZnobeloba placentis winamdebareobis diagnostirebaSi (II da III trimestrebSi) Seadgens 87,5%, specifiuroba - 98,8%, dadebiTi prognozuli Rirebuleba - 93,3%, uaryofiTi prognozuli Rirebuleba - 97,6%, cru uaryofiTi Sedegis sixSire - 2,33%. erT rkk-Si gamokvleuli iyo 38 qali, romlebSic gamovlinda transvaginaluri ultrasonografiis placentis

upiratesoba

mimagrebisas

transabdominalurTan

saSvilosnos

ukana

SedarebiT, kedelze,

gansakuTrebiT

aseve

aRiniSna

iyo

placentis

skanirebisaTvis daxarjuli drois Semcireba. magnitur

rezonansuli

winamdebareobis

dros

kvleva

im

(mrk)

gamoyenebuli

SemTxvevaSi,

rodesac

transabdominaluri

ultrasonografiuli kvlevis Sedgegebi aradamakmayofilebeli iyo. mrk Catareba mizanSewonilia imis gamo, rom is ar saWiroebs Sardis buStis avsebas da misi Catarebisas

gamoricxulia

operatoris

Secdoma.

misi

gamoyeneba

aseve

mizanSewonilia placentis ukana kedelze mimagrebisas. mrk ar iyo Sedarebuli transvaginalur ultrasonografiasTan, radganac ar iyo amis saWiroeba, garda im SemTxvevebisa, rodesac mrk gamoyenebuli iyo kvleviTi miznebisaTvis.

placentis winamdebareobis dros transvaginaluri ultrasonografia aris usafrTxo meTodi da placentis lokalizaciis dadgenis TvalsazrisiT ufro zusti, vidre transabdominaluri ultrasonografia

B

Semdgomi transvaginaluri kvleva esaWiroebaT im qalebs, romelTac aReniSnebaT placentis mimagreba saSvilosnos yelis SigniTa piris doneze (an faravs SigniTa pirs) Semdegis gaTvaliswinebiT: •

qalebi,

romelTac

aReniSnebaT

sisxldena,

gamokvleulebi

unda

iyon

individualuri gegmis mixedviT; •

placentis asimptomuri arasruli winamdebareobis dros gamokvleva SeiZleba gadaidos 36 kviramde;

•

im SemTxvevaSi, rodesac arsebobs eWvi placentis srul winamdebareobaze, ultrabgeriTi kvleva unda Catardes 32 kviraze, imisTvis, rom daigegmos Semdgomi meTvalyureobisa da mSobiarobis meTodi.

placentis migracia mimdinareobs meore da mesame trimestris dros , rasac xels uwyobs saSvilosnos qveda segmentis Camoyalibeba, magram es ufro iSviaTad xdeba, rodesac placenta ganlagebulia saSvilosnos ukana kedelze

an qals

gadatanili aqvs sakeisro kveTa . placentis winamdebareobiT 714 qalis retrospeqtulma mimoxilvam gamoavlina, rom 20-30 kviraze placentis kidiTi winamdebareobis SemTxvevaSic ki (rodesac placentis

kide

uaxlovdeboda

saSvilosnos

yelis

Sida

pirs)

placentis

winamdebareobis persistireba, romelic moiTxovda mSobiarobas bunebrivi gziT, Seadgenda 11% im SemTxvevaSi Tu saSvilosnoze ar iyo nawiburi da 50% gadatanili sakeisro kveTis Semdeg. sxva

kvlevaSi,

sadac

winamdebareobiT, sonografiiT,

monawileobda

18-23

mSobiarobis

kviraze,

55

rac

momentisaTvis

qali

placentis

diagnostirebuli mxolod

5-s

sruli iyo

an

arasruli

transvaginaluri

aReniSna

placentis

winamdebareoba da yvela SemTxvevaSi placentis kide faravda yelis Sida pirs 15 milimetriT. miuxedavad imisa, rom placentis mniSvnelovani migracia naklebad savaraudoa maSin, rodesac placenta nawilobriv faravs yelis Sida pirs (23 mm 11-14 kviraze, 25 mm-ze metad 20-30 kviraze

da 20 mm 26 kviraze ),

migracia mainc

SesaZlebelia 50% SemTxvevaSi Tu placentis sruli winamdebareoba dadgenilia 20 kviraze. am mizezebis gamo, mesame trimestrSi unda Catardes gamokvleva imisaTvis, rom daigegmos Semdgomi meTvalyureobis gegma. im SemTxvevaSi, rodesac placentis

arasruli

an

kidiTi

mimagreba

diagnostirebulia

meore

trimestrSi,

diagnozis dasadastureblad ultrabgeriTi kvleva unda ganmeordes 36 kviraze. im SemTxvevaSi, Tu arsebobs eWvi placentis srul winamdebareobaze, saWiroa dawvrilebiTi gamokvleva da analizi Semdgomi taqtikis gansazRvrisaTvis. am gegmaSi aseve unda Sediodes ganmeorebiTi ultrabgeriTi kvleva 32 kviraze. am vadaze sruli placentis winamdebareobis diagnostireba miuTiTebs imaze, rom es mdgomareoba SenarCundeba SemTxvevaTa 90%-Si antenataluri meTvalyureobis programaSi CarTuli unda iyos transvaginaluri ultrasonografiis Catareba im SemTxvevebSi, rodesac orsulobis 20-24 kviraze transabdominaluri kvlevis dros gamovlindeba placentis dabali mimagreba placentis sruli Sezrdis diagnostireba

B

qalebi placentis winamdebareobiT imyofebian maRali riskis jgufSi placentis mWidro

mimagrebisa

da

Cazrdis

TvalsazrisiT

im

SemTxvevaSi,

rodesac

winamdebare placenta ganlagebulia wina kedelze an anamnezSi aRiniSneba gadatanili sakeisro kveTa. es riski izrdeba gansakuTrebiT im SemTxvevaSi, rodesac sakeisro

kveTasa

da

Casaxvas

Soris

aRiniSneboda

mcire

drois

intervali.

antenataluri kvlevis dros SesaZlebelia am mdgomareobis diagnostireba rogorc ultrasonografiuli kvlevisas, aseve mrk-sa da doplerografiuli kvleviT. 80 qalis prospeqtul kvlevaSi placentis winamdebareobiT transabdominaluri

da

doplerografiuli gamoyenebiT placentis Cazrda mSobiarobis dros gamovlinda 17 SemTxvevaSi. doplerografiuli kvleviT placentis winamdebareobaze eWvi Setanili iyo 16 SemTxvevaSi, saidanac dadasturda 14 SemTxveva, 2 cru dadebiTi SedegiT, xolo 3 SemTxvevaSi placentis Cazrda ar iyo diagnostirebuli, ramac gamoavlina mgrZnobeloba 82,4%, xolo specifiuroba 96,8%. dadebiTi da uaryofiTi prognozuli Rirebuleba Seadgenda Sesabamisad 87,5% da 95,3%,-s. winaswari Sedegebi cxadyofs, rom samganzomilebiani feradi dopleruli kvlevis danergva SeiZleba damxmare meTodi iyos sxva teqnologiebTan erTad antenataluri meTvalyureobis dros. retrospeqtul kvlevaSi magnitur rezonansuli meTodi 13 qalSi Sedarebuli

iyo

transabdominaluri

sonografia,

dadasturebuli iyo histologiuri kvleviT. 9 qalidan

rodesac

placentis

Cazrda

mxolod 4-s daudasturda swori

diagnozi, rodesac ultrabgeriTi kvleviT gamokvleuli 13 qalidan mxolod 4-s daudasurda swori diagnozi. mgrZnobeloba, romelic Seadgenda Sesabamisad 38% da 33%-s iyo Zalian mcire klinikuri efeqturobis dasadastureblad da aqedan gamomdinare,

feradi

doplerografiuli

kvleva

aris

yvelaze

mizanSewonili

gamokvlevis meTodi manamde, sanam ar gaumjobesdeba magnitur rezonansuli kvlevis xarisxi.

antenataluri meTvalyureobis dros qalebSi, romlebSic diagnostirebulia placentis winamdebareoba da romlebic imyofebian placentis Cazrdis risk-jgufSi, unda Catardes doplerografiuli ultrasonografia. Tu es SeuZlebelia, aseTi qalebis meTvalyureoba unda gagrZeldes ise, rogorc placentis Cazrdis SemTxvevaSi, sanam ar moxdeba diagnozis dazusteba mkurnaloba antenatalur periodSi

B

orsulebi placentis sruli winamdebareobiT moiTxoven did yuradRebas radganac is mimdinareobs asimptomaturad. SesaZloa ganviTardes masiuri da sicocxlisaTvis saSiSi sisxldena, romelic moiTxovs saswrafo Carevas.

tradiciuli mkurnaloba

placentis sruli winamdebareobis dros gulisxmobda hospitalizacias mesame trimestris bolos (30-32 kviridan) qalebSi, romlebsac anamnezSi ar aReniSnebodaT sisxldena. arsebobs rigi observaciuli kvlevebisa, romlebic miznad isaxavda imis garkvevas,

Tu

ra

kategoriis

qalebSi

viTardeba

sisxldena

yvelaze

xSirad.

gamovlinda, rom alfa-fetoproteinis donis momateba 15-20 kviris vadaze, placentis iseTi mdebareoba, rodesac is faravs yelis Sida pirs, sqelia misi qveda nawili da vlindeba turbulentoba mis qveda kideze ultrasonografiuli kvlevis dros, yvelaze xSirad iyvnen dakavSirebuli mSobiarobamdel sisxlisdenasTan. Catarda 3 rkk, romelSic mTlianad CarTuli iyo 114 qali placentis winamdebareobiT: erT kvlevaSi Sedarebuli iyo saxlis pirobrbSi mkurnaloba samSobiaroSi saxlSi mkurnalobasTan; danarCen orSi gamokvleuli iyo saSvilosnos Yyelis serklaJis efeqti. kvlevaSi Sedarebuli iyo 26 qali, romelTac mkurnalobdnen saxlSi 27 qalTan, romlebic

mkurnalobdnen

gansxvavebas

stacionaris

warmoadgenda

pirobebSi.

saavadmyofoSi

erTaderT

mniSvnelovan

gatarebuli

sawol-dReebis

raodenobis Semcireba. or sxva retrospeqtul mimoxilvaSi Seswavlili iyo im 86 qalis gamosavali, romelTa mkurnaloba mimdinareobda mocdiTi taqtikiT saxlSi 90 qalTan SedarebiT, romlebsac mkurnalobdnen stacionarulad am kvlevebiT gamovlinda, rom gansxvaveba jgufebs Soris mdgomareobda mxolod hospitalizaciis dReebis raodenobasa da fasSi. aseTi mcire kvlevis SedegebiT rTulia usafrTxoebis, Tanamedrove standartis an sxva maCveneblebis Sesaxeb msjeloba. amitom placentis winamdebareoba mesame trimestris bolos warmoadgens garkveul problemas, gansakuTrebiT saqarTvelos pirobebSi, rodesac xangZlivi hospitalizacia pacientis did xarjebTan aris dakavSirebuli. saerTaSoriso azri ufro liberaluria, magaliTad, avstraliisa da axli zelandiis

meanTa da ginekologTa koleji iZleva rekomendacias, rom is qalebi

placentis

winamdebareobiT,

romlebic

arian

maRali

riski

jgufSi

sisxldenis

ganviTarebis TvalsazrisiT, orsulobis mesame trimestrSi unda imyofebodnen saavadmyofosTan axlo manZilze. retrospeqtulma mimoxilvebma aCvenes, rom placentis winamdebareobis dros gamosavali qalebisaTvis sxvadasxvagvaria da misi prognozireba antenataluri movlenebis mixedviT yovelTvis ver xerxdeba magram im qalebSi, romelTac placentis winamdebareobisas ganuviTardaT sisxldena, ufro naadrevi mSobiarobisaken.

vlindeba tendencia

orsulebi placentis winamdebareobiT, romlebsac anamnezSi aReniSnebaT sisxldenis epizodi, hospitalizirebulebi unda iyvnen gestaciis 34 kviraze. im pacientebSi, romlebsac aReniSnebaT placentis sruli winamdebareoba, magram arasodes ar hqoniaT sisxldena da ar aReniSnebaT simptomatika, unda Catardes saguldagulo konsultireba antenataluri meTvalyureobis dagegmvisaTvis. nebismieri mkurnaloba, romelic saxlis pirobebSi tardeba, unda iyos mWidrod dakavSirebuli stacionarTan informirebuli Tanxmobis safuZvelze da aseve qals gverdze unda hyavdes Tanmxlebi piri.

C

orsulebi , romlebic rCebian saxlis pirobebSi, darwmunebulebi unda iyon sakuTar usafrTxoebaSi da yovelTvis kompanionis daxmarebiT mzad unda iyvnen hospitalizaciisaTvis yoveli orsuli qali, romelic rCeba saxlSi, unda flobdes informacias, rom nebismieri saxis sisxliani gamonadenis, tkivilis an saSvilosnos SekumSvis dros maT unda mimarTon stacionars. mSobiarobis win orsuli da misi axloblebi unda gaecnon informacias SesaZlo garTulebebis, sisxldenis, sisxlis transfuziis, histereqtomiisa da ZiriTadi qirurgiuli Carevebis Sesaxeb

Catarda 2 kvleva cervikaluri serklaJis Sesaxeb, romelic moicavda aseve kohreinis mimoxilvas. mxolod erT kvlevaSi gamovlinda serkliaJis potenciuri sargeblianoba (mSobiaroba 34 kviramde da 2 kilogramamde wonis dabadebuli bavSvebis ricxvis Semcireba).

C

orsulobis prolongirebisa da sisxldenis Semcirebis TvalsazrisiT cervikaluri serklaJis mxardasaWerad mtkicebulebebi ara sakmarisia, amitom ar SeiZleba misi rekomendireba klinikuri kvlevebis farglebs gareT.

placentis winamdebareobis dros sisxldenis ganviTareba gamowveulia saSvilosnos qveda segmentis formirebiT, magram is SeiZleba aseve gamowveuli iyos saSvilosnos SekumSviTac. am situaciebSi meanTa nawili irCevs e.w. „agresiul konservatul mkurnalobas“, romelSic igulisxmeba tokolizi. es sakiTxi gamokvleulia rkk-Si, romelSic monawileobda 60 qali, romlebic stacionarSi moTavsebuli iyvnen placentis winamdebareobisas ganviTarebuli sisxldenis gamo 28-34 kviraze. Catarda tokolizi 10 mg ritodrinis gamoyenebiT

intramuskularuli inieqciiT yovel 6 saaTSi erTxel 7 dRis ganmavlobaSi, rac Sedarebuli iyo SemTxvevebTan, rodesac ar tardeboda aranairi mkurnaloba. mkurnaloba dakavSirebuli iyo orsulobis prolongirebasTan (25,33 dRe+- 17,7 dRe, 14,47 dRe+-20,33 dResTan SedarebiT, p<0,05) da axalSobilis wonis zrdasTan (2,27+-0,59kg, 1,95+-0,55 kg-Tan SedarebiT, p <0,05) ar gamovlenila gverdiTi efeqtebi dedisa da nayofis mxriv da sisxldenis momatebuli riski. SemTxvevaTa seriebis yvelaze didi raodenoba, romlebSic ganxiluli iyo placentis winamdebareobis dros ganviTarebuli sisxldenis mkurnaloba tokoliziT mesame trimestrSi

105

dan

76

qalSi,

mocemulia

retrospeqtul

mimoxilvaSi65

da

gamoavlina, rom am mkurnalobis gamoyeneba ar aris dakavSirebuli avadobisa da

sikvdilianobis

gamoyeneba

momatebasTan.

sisxldenis

amave

profilaqtikisaTvis

dros, ar

profilaqtikurad aris

terbutalinis

dakavSirebuli

aranair

sargeblianobasTan qalebSi placentis winamdebareobiT. vinaidan ar aris dadgenili Bbetamimetikebis optimaluri doza da Seyvanis rejimi da

misi

gamoyeneba

dakavSirebulia

mniSnelovan

gverdiT

efeqtebTan,

saqarTvelos pirobebSi betamimetikebis gamoyeneba placentis winamdebareobis dros ar aris naCvenebi mSobiaroba mSobiarobis gzis arCevis rekomendacia ultrasonografiuli kvlevis Sedegebze dayrdnobiT rTulia imis gamo, rom am sakiTxTan dakavSirebuli kvlevebi aris observaciuli da xSirad retrospeqtuli. Caatares transvaginaluri kvleva 127 qalSi mesame

trimestrSi,

winamdebareoba.

romelTaganac

31

SemTxvevaSi

52-s

aReniSneboda

aRiniSneboda

placentis

placentis

sruli

winamdebareoba, xolo 21 SemTxvevaSi – placentis nawilobrivi winmdebareobiT saSualo manZili saSvilosnos SigniTa piris donidan placentis kidemde iyo mniSvnelovnad gansxvavebuli im qalebSi, romelTac imSobiares sakeisro kveTis gziT imaTgan gansvavebiT, romelTac imSobiares bunebrivi

gziT.

(2sm

saSvilosnos yelamde) (p=0,0004). axlaxan Catarda prospeqtuli observaciuli kvleva, romelic moicavda 63 qals placentis winamdebareobiT. kvlevaSi gamovlinda, rom im qalebSi, romlebSic Catarda saSosmxrivi mSobiaroba, manZili placentis kidesa da saSvilosnos yelis SigniTa pirs Soris iyo 2 sm placentis ganlagebisas wina kedelze da 3 sm placentis ganlagebisas ukana kedelze.

sxva retrospeqtul kvlevaSi, romelic moicavda 121 qals, 40 qalSi, romlebSic manZili Seadgenda 0,1- 2,0sm-s

CautardaT saSosmxrivi mSobiaroba, xolo 39

qalidan 22-s, romlebSic distancia Seadgenda 2 sm-s imSobiares saSosmxrivad. am kvlevaSi ar iyo gamaxvilebuli yuradReba imaze, Tu saSvilosnos romel kedelze iyo ganlagebuli placenta. gadawyvetileba mSobiarobis gzis Sesaxeb mxedvelobaSi unda iyos miRebuli klinikuri

faqtorebis

gaTvaliswinebiT,

maT

Soris

ultrasonografiuli

Sedegebis gaTvaliswinebiT, gansakuTrebiT, rodesac nayofis

kvlevis

Tavi mcire menjis

RruSia. ultrabgeriTi kvleva am SemTxvevaSi iZleva damatebiT informacias imis Sesaxeb, Tu ra urTierTganlageba aqvs nayofis Tavsa da placentis kides. placentis sisqe aseve axdens

gavlenas mSobiarobis gzis arCevaze: rac ufro sqelia

winamdebare placentis kide, (1 sm meti) miT ufro metia mSobiarobis albaToba sakeisro kveTis gziT (p=0,02).

B

mSobiarobis gza yvela SemTxvevaSi unda efuZnebodes klinikur Sefasebas da ultrasonografiuli kvlevebis monacemebs. Tu placentis kide saSvilosnos yelis Sida piris donidan daSorebulia 2 sm-ze naklebi manZiliT, sasurvelia sakeisro kveTis Catareba, gansakuTrebiT im dros, rodesac placenta ganlagebulia saSvilosnos ukana kedelze.

gadaudebeli

operaciis

drois

gansazRvra

damokidebulia

individualur

SemTxvevaze, magram, rodesac aris amis SesaZlebloba, eleqtiuri sakeisro kveTa unda gadaidos 38 kviris vadamde imisaTvis, rom Semcirdes neonataluri avadobis sixSire.

C

mSobiarobis dros sisxli unda iyos swrafad xelmisawvdomi. sisxlis saWiro raodenoba damokidebulia individualur SemTxvevasa da adgilobriv sisxlis bankze.

C

yvela orsuls, romelic saoperacioSi xvdeba placentis winamdebareobis gamo, operacia unda Cautaros gamocdilma qirurgma . operacias unda eswrebodes gamocdili anesTeziologi. axalgazrda eqimebi ar unda marTvadnen msgavs SemTxvevebs.

qirurgiuli Careva placenta accreta, increta and percreta dros amerikis, axali zelandiisa

da avstraliis meanTa da ginekologTa kolejma

SeamuSava Sexeduleba da miiRo saerTo gadawyvetileba imis Sesaxeb, rom rodesac dagegmilia histereqtomia am paTologiis dros, unda iyos qalisagan

miRebuli informirebuli Tanxmoba amis Sesaxeb. amasTan erTad, mSobiaroba unda Catardes multidisciplinaruli gundis mier iseT adgilze, sadac swrafad aris xelmisawvdomi hemotransfuziisaTvis aucilebeli sisxlis produqtebi.

C

qalebi placentis winamdebareobiT, romlebsac anamnezSi aReniSnebaT sakeisro kveTa, imyofebian maRali riskis jgufSi placentis mWidro mimagrebis TvalsazrisiT da gamokvleulebi unda iyon antenatalur periodSi. rodesac Cndeba eWvi placenta accreta Taobaze, konsultanti meani da anesTeziologi valdebulni arian, dagegmon da marTon mSobiaroba. xelmisawvdomi unda iyos Tanamosaxele sisxli da saWiroebismebr marTvaSi CarTulebi unda iyon saWiro specialobis kolegebi.

C

placenta accreta SemTxvevaSi, sisxldenis, hemotransfuziis da histereqtomiis SesaZlebloba ganxiluli unda iyos pacientTan konsultaciis dros.

masiuri sisxldena placentas

winamdebareobisas ganviTarebuli masiuri sisxldenis dros yvela

qirurgiuli intervencia Catarebuli unda iyos gamocdili qirurgis mier. damatebiTi daxmarebis gamoZaxeba misasalmebelia. uterotonuli

saSualebebis

gamoyeneba

mizanSewonilia

raTa

gamoviwvioT

SedarebiT atoniuri saSvilosnos qveda segmentis SekumSva. sxva damxmare meTodebTan erTad bimanualuri kompresia, hidrostatiuli baloniT kaTeterizacia an saSvilosnos tamponireba, iseve rogorc aortis kompresia SesaZlebelia efeqturi iyos drois mogebis TvalsazrisiT manam, sanam ar gamocxaddeba ufrosi meani. damatebiT qirurgiul manevrebs miekuTvneba B-linCis nakeri, saSvilosnos an TeZos SigniTa arteriis ligireba an histereqtomia. aRwerilia aseve arteriis embolizaciis SemTxvevebic. (ixileT gaidlaini – msobiarobis Semdgomi sisxlisdena) .

C

yovel samSobiaro blokSi unda iyos masiuri sameano sisxldenis marTvis protokoli. masiuri sisxldenebis mkurnaloba unda xdebodes am protokolis mixedviT.

C

SemuSavebuli unda iyos gadaudebeli klinikuri scenarebi masiuri sameano sisxldenis dros da saswrafod xelmisawvdomi unda iyos sisxlis produqtebi.

auditis sakiTxebi •

iyo Tu ara gamoyenebuli transvaginaluri ultrasonografia placentis winamdebareobis diagnostikisaTvis?

• •

iyo Tu ara gaTvaliswinebuli placentis Sezrdis arsebobis SesaZlebloba? iyo Tu ara Sesabamisi antenataluri mkurnaloba da konsultireba im qalebSi, romlebSic placentis winamdebareoba persistirebda mesame trimestrSi.

•

mSobiarobis gza; Sesabamisi konsultireba da informirebuli Tanxmoba

•

anesTeziis

SerCeva;

Sesabamisi

konsultireba

da

informirebuli

Tanxmoba •

garTulebebis SesaZlebloba; Sesabamisi konsultireba da informirebuli Tanxmoba

•

sakeisro kveTis dros operatorisa da anesTeziologiis done

•

mniSvnelovani

sameno sisxldenis

protokolis mixedviT

mkurnaloba klinikaSi miRebuli