Postpartum Hemorrhage Protocol

mSobiarobis Semdgomi sisxldenis marTvis protokoli

mSobiarobis Semdgomi sisxldenis dros dedaTa sikvdilianobis yvelaze mTavar mizezebs warmoadgens : 1 mSobiarobis Semdgomi sisxldenis ganviTarebis maRali riskis pacientebis araadeqvaturi Sefaseba; 2

koloidebis da kristaloidebis gadametebuli xmareba da sisxlis danakargis arasaTanado kompensacia;

3

dsS sindromis gviani diagnostika;

4

centraluri venuri wnevis monitoringis ararseboba;

5

sisxlis da sisxlis produqtebis arasakmarisi maragi;

6

gamocdili meanebis dagvianebuli gamoZaxeba;

7

qirurgiuli manipulaciebis dagvianebuli Catareba.

mSobiarobis mesame periodis aqtiuri marTva unda ganxorcieldes yvela qalSi, radganac aseTi taqtika mniSvnelovnad (60%) amcirebs saSvilosnos hipotoniiT gamowveuli mSobiarobis Semdgomi sisxldenis albaTobas mSobiarobis III periodis aqtiuri marTvis ZiriTadi komponentebia: • uterotonuli saSualebebis Seyvana • Wiplaris kontrolirebadi traqciebi. • saSvilosnos masaJi placentis mocilebis Semdeg. uterotonuli saSualebebis gamoyeneba 1. bavSvis dabadebidan 1 wuTis ganmavlobaSi, saWiroa Catardes muclis palpacia mravalnayofiani orsulobis gamosaricxad, ris Semdegadac kunTSi Seyvanili unda iyos 10 erT oqsitocini.

oqsitocini warmoadgens arCevis

preparats imis gamo, rom misi efeqti gamovlindeba 2-3 wT-is Semdeg, gaaCnia minimaluri gverdiTi efeqtebi da misi gamoyeneba SesaZlebelia yvela qalTan. 2. Tu oqsitocini ar aris xelmisawvdomi, SesaZlebelia sxva uterotonuli saSualebebis gamoyeneba, magaliTad, ergometrini 0,2 mg kunTSi, an misoprostoli 400-600 mkg peroralurad. unda aRvniSnos, rom misoprostolis peroraluri miReba unda gadavdoT im SemTxvevisaTvis, rodesac oqsitocinis an alkaloidebis usafrTxo daniSvna an maTi inieqciuri formebis Senaxva SeuZlebelia. 3. uterotonuli saSualebebis swori Senaxvis pirobebia: • oqsitocini: Senaxuli unda iyos 15-30 gradusze, daculi iyos gayinvisagan.. • ergometrini: Senaxvis temperatura 2-8 gradusi, daculi unda iyos mzis pirdapiri sxivebis zemoqmedebisa da gayinvisagan • misoprostoli: Senaxuli unda iyos oTaxis temperaturasa da daxurul konteinerSi. 4.

saWiroa

preparatebis

gverdiTi

efeqtebis

gamovlinebisa

da

maTi

mkurnalobis codna. yuradReba! arteriuli

qalebSi

preeklamfsiiT,

wneviT

eklamfsiiTa

meTilergometrinis

da

momatebuli daniSvna

winaaRmdegnaCvenebia kontrolirebadi traqciebis Catareba 1. Wiplarze ideba momWeri SorisTan axlos (imis Semdeg, rac Sewydeba Wiplaris pulsacia) daaxloebiT 30-40 wamis Semdeg da aseTi saxiT xdeba Wiplaris xelSi daWera 2. erTi xeli Tavsdeba simfizis odnav zeviT saSvilosnoze kontr-zewolis gansaxorcieleblad 3. Wiplaris msubuqi daWimvis pirobebSi unda davelodoT saSvilosnos Zlier SekumSvas (2-3 wT-is Semdeg)

4. saSvilosnos Zlieri SekumSvis Semdeg unda vTxovoT qals, gaiWinTos, amave

dros

ganvaxorcieloT

Wiplaris

nazi

daWimva

qveviT

placentis

dabadebamde. amave dros unda ganxorcieldes kontr-zewola saSvilosnoze. 5. Tu placenta ar gamoiyo kontrolirebadi traqciebis dawyebidan 30-40 wm-is ganmavlobaSi, traqcia unda Sewydes • Wiplaris nazi daWimulobis pirobebSi saWiroa davelodoT saSvilosnos Semdeg SekumSvas • Semdegi SekumSvisas procedura unda gavimeoroT. arasodes ar ganaxorcieloT Wiplaris traqcia (daWimva qveviT) kontrzewolis ganxorcielebis gareSe simfizis zeviT kargad SekumSuli saSvilosnos pirobebSi 6. placentis dabadebis Semdeg is unda daviWiroT ori xeliT da RerZis irgvliv datrialebiT mivaRwioT garsebis dabadebas 7. garsebis defeqtis SemTxvevaSi saWiroa saSos zeda nawilis frTxili daTvaliereba steriluri xelTaTmanebiT da gamoviyenoT pinceti CarCenili garsebis gamoyofisaTvis 8.

saaWiroa

Semowmeba.

garsebis Tu

saguldagulo

aRiniSneba

daTvaliereba

garsebis

defeqti,

da

maTi

saWiroa

mTlianobis Sesabamisi

moqmedebebis ganxorcieleba. saSvilosnos masaJis ganxorcieleba 1. saSvilosnos fuZis masaJi unda gakeTdes manamde, sanam is srulad ar SeikumSeba. 2. yoveli 15 wT unda Catardes saSvilosnos palpacia

da saWiroebis

SemTxvevaSi masaJi ganmeordes mSobiarobidan 2 sT-is ganmavlobaSi. 3. saWiroa davrwmundeT, rom saSvilosno ar dundeba saSvilosnos masaJis Catarebis Semdeg yvela zemoT aRniSnuli moqmedebebis arsi unda aexsnas qals da mis axloblebs. amave dros qals unda gavuwioT moraluri daxmareba

mSobiarobis Semdgomi sisxldenis dros marTva moicavs Semdeg oTx komponents: • Sesamabisi ganyofilebebis da specialistebis informireba; • mocirkulire sisxlis moculobis aRdgena; • meTvalyureoba da gamokvleva; • mizezis gamovlena da sisxldenis SeCereba. RonisZiebebis aRwerisas igulisxmeba, rom sisxlisdena ganviTarda samedicino dawesebulebis pirobebSi, Tu sisxldena ganviTarda aseTi dawesebulebis farglebs gareT, im samedicino muSakebis roli, romlebic monawileoben reanimaciaSi

mdgomareobs

pirveladi

daxmarebis

aRmoCenasa

da

Sesabamisi donis stacionarSi swrafad transportirebaSi. 11.

Sesabamisi gamoZaxeba 2 3 ZiriTadi zomebi niSnebi)

samsaxurebisa

da

specialistebis

(sisxldena 500-1000 ml, ar aris Sokis klinikuri

4 • gamocdili meanis, anesTeziologis, bebiaqalis gamoZaxeba; •

erTi bebiaqalisa an anesTeziologiis eqTnis gamoyofa monitoringisaTvis (aw, diurezi, medikamentebis da siTxeebis Seyvana, sisxlis danakargis zusti aRricxva);

•

sisxlis gadasxmis samsaxuris Setyobineba;

•

saoperacio blokis momzadeba;

•

satransporto

momsaxureobisa

da

damatebiTi

damxmare

personalis

Setyobineba.

2.

mocirkulire

sisxlis

moculobis

aRdgena

da

sisxlis

Semadedebeli sistemis darRvevevis gamovlena •

sisxlis moculobis aRdgena unda tardebodes imis gaTvaliswinebiT, rom sisxlis danakargis aRricxva yovelTvis arazustia

•

mocirkulire sisxlis moculobis aRsadgenad saWiroa 3 l kristaloiduri xsnarebisa (ringeris laqtati, hartmani) da koloidebis swrafi gadasxma;

•

yvelaze saukeTeso preparati mocirkulire sisxlis moculobis aRsadgenad aris donoris sisxli (eriTrocitaruli masis saxiT) romelic unda gadaisxas rac SeiZleba male Cvenebis arseboboisas

•

dakarguli sisxlis raodenoba da misi aRdgenis wesi ixileT qvemoT

mocirkulire sisxlis moculobis (csm) deficitis AaRdgenis wesi*

sisxlis danakargi (ml),

cirkulirebadi sisxlis moculobisTan SefardebiT

%

10-20% (500-1000 ml)

aRdgena 75 kg masis mqone orsuli qalisaTvis

(Mcsm sNnormSi Seadgens 75 kg X 75

ramdenad saswrafo aris sisxli

ml\kg = 5625 ml) kristaloiidebi da koloidebi

eritracitaruli masa

kristaloidebi mTlianad,Lan kristaloidebi da koloidebi ( 3:1)

ara

rogorc wesi, ar aris saswrafo, sisxlis gadaxmis sadguri mzadyofnaSia

aRdgena 300% 21-30% (1000-1500

kristaloidebi da koloidebi ( 3:1) aRdgena 200%

saswrafoa (saWiroa 10,2%

2 saaTSi)

ml)

31-40% (1500–

kristaloidebi da koloidebi ( 3:1) aRdgena 180%

0,3%

3000ml)

41% da > 3000 ml

kristaloidebi da koloidebi ( 3:1)

0,5%

Zalian saswrafoa ( sisxli saWiroa 10-15 wT-Si) 1-2 erTeuli I jgufis rezus-uaryofiTi sisxli, Tanamosaxele jgufis sisxlis motanamde

aRdgena 170%

* sqema mocemulia mxolod saorientaciod. magaliTi 1: 75 kg wonis melogineSi mSobiarobis Semdgomma sixlis danakargma Seadgina 1200 ml, ramac Seadgina csm daaxlovebiT 21%. (aRniSnuli orsulis csm = 75ml/kg x 75 kg = 5600ml csm deficiti orsulSi = 1200 : 5600 = 0,21 x 100% =21%) csm aRdgenisaTvis aucilebelia vawarmooT :

kristaloidebi da koloidebi – 1200 x 200% = 2400 ml ( 1800 + 600), eritracitaruli masa 1200 x 0,2% = 240 ml magaliTi 2: 75 kg wonis melogineSi mSobiarobis Semdgomma sixlis danakargma Seadgina 2300 ml, ramac Seadgina csm daaxlovebiT 41%. csm aRdgenisaTvis aucilebelia infuzia Seadgens: kristaloidebi da koloidebi 2300ml x 170% = 3910 ml ( 3000 + 900) eritracitaruli masa – 2300 ml x 0,5% = 1150 ml

sisxlis danakargis Sefaseba procentebSi mocirkulire sisxlis moculobasTan

sisxlis danakargi

wona kg 10%

15%

21%

25%

31%

35%

41%

50

375

560

790

940

1165

1315

1540

55

415

620

865

1030

1280

1445

1690

60

450

675

945

1125

1395

1575

1845

65

490

730

1025

1220

1510

1705

2000

70

525

790

1105

1315

1630

1840

2150

75

560

845

1180

1405

1745

1970

2300

80

595

900

1260

1500

1860

2100

2460

85

630

950

1340

1595

1975

2230

2615

90

665

1010

1420

1690

2090

2360

2770

95

700

1070

1495

1780

2210

2495

2920

100

735

1125

1575

1875

2325

2625

3075

105

770

1180

1655

1970

2440

2750

3230

mwvane FFferi – aRdgena 300% kristaloidebi mTlianad,Lan kristaloidebi da

koloidebi ( 3:1) yviTeli Fferi - aRdgena 200% kristaloidebiT da koloidebiT ( 3:1), eritrocitaruli masa danakargis 20% vardis Fferi – aRdgena 180% kristaloidebiT da koloidebiT ( 3:1), eritrocitaruli masa danakargis 30%

wiTeli Fferi - aRdgena 170% kristaloidebiT da koloidebiT ( 3:1), eritrocitaruli masa danakargis 50%

1 2mocirkulire sisxlis moculobis aRdgenis ZiriTadi zomebi: 3 4sisxldena 500-1000 ml, csm danakargi ar aRemateba 20%: • gadasxmisaTvis saWiro sistemis dayeneba (1 sistema, 1 kanula zomiT 14 G) • kristaloidebis Seyvanis dawyeba (hartmanis xsnari, ringeris laqtati) sruli protokoli (masiuri sisxlis danakargi 1000 ml-ze meti an hemoragiuli Sokis suraTi –pulsi >100/wT-Si an sistoluri wneva <100 mm/vwy/sv-ze) • • • •

•

•

• •

• •

gadasxmisaTvis saWiro sistemis dayeneba (1 sistema, 2 kanula zomiT 14); pacienti unda moTavsdes horizontalur mdgomareobaSi daweuli TaviT; Jangbadis SesunTqva niRbiT 8l/wT-Si; manam, sanam xelmisawvdomi gaxdeba sisxli, ( eriTrocitaruli masa) saWiroa monacvleobiT gadaisxas (saWiro siCqariT) sawyis sistolur wnevamde kristaloiduri xsnarebi (hartmanis xsnari, ringeris laqtati)maqsimum 2 litri, koloiduri xsnarebi: maqsimum 1,5 litri; 3,0 litri koloidebisa da kristaloidebis gadasxmis Semdeg saWiroebis SemTxvevaSi sisxlis gadasxma, (gadasxmas iwyeben ZiriTadad hemoglobinis koncentraciisas <70 g/l-ze, Tumca es aris gadmwyveti faqtori) Tu ar aris xelmisawdomi Tanamosaxele jgufis sisxli saWiroa pirveli jgufis rezus uaryofiTi sisxlis gadasxma, rac unda Sewydes Tanamosaxele jgufis miRebisas; sisxlis gadasxmis sistema unda gamoicvalos yovel 12 saaTSi; Tu sisxldena grZeldeba koagulopaTiaze eWvis dros saWiroa 1 l axladgayinuli plazmis gadasxma; (krioprecipitati da Trombocitaruli masa saqarTvelos pirobebSi xelmisawvdomia SekveTidan mxolod 24 sT-is Semdeg) saWiroa yvelanairi xelmisawvdomi aRWurvilobis gamoyeneba SemTbari xsnarebis swrafi intravenuri infuziis ganxorcielebisaTvis; deqstranebis gamoyeneba dakavSirebulia riskTan da maTi gamoyeneba rekomendebuli ar aris.

3. meTvalyureoba da gamokvleva ZiriTadi zomebi

5(sisxldena 500-1000 ml, sisxldena 500-1000 ml, csm danakargi aRemateba 20%: • arteriuli wnevisa da pulsis xSiri kontroli ( yovel 15 wT-Si)

ar

1 2 sruli protokoli (masiuri sisxlis danakargi 1000 ml-ze meti an hemoragiuli Sokis suraTi –pulsi >100/wT-Si an sistoluri wneva <100 mm/vwy/sv-ze) 3 4 •

pulsis sixSiris da a.w. mudmivi monitoringi ( pulsoqsimetris, ekg da a.w. avtomaturi Camweris gamoyenebiT SesaZleblobisdagvarad); • folis kaTeteri gamoyofili Sardis raodenobis gansazRvrisaTvis; • centraluri venuri wnevis monitoringi (Tu saxezea personali, romelic flobs am meTodikas) • sisxlis aReba analizisaTvis-22 ml (10 ml eriTrocitaruli masis SeTavsebisaTvis, 2ml hemoglobinis, hematokritis, Tromocitebis gansazRvrisaTvis, 5 ml citratuli sisxli koagulaciis skrininguli testebisaTvis ( proTrombinis dro, plazmis aqtivirebuli nawilobrivi Tromboplastinuri dro). Tu aRiniSneba raime cvlilebebi, unda ganisazvros Trombinis dro, fibrinogeni, d-dimeri. 5ml Sardovanisa da eleqtrolitebis gansazRvrisaTvis. • reanimaciis ganyofilebaSi gadayvanis sakiTxis ganxilva

4. mizezis gamovlena da sisxldenis SeCereba adreuli mSobiarobis Semdgomi sisxldenis yvelaze xSir mizezs warmoadgens saSvilosnos hipotonia. magram mxedvelobaSi miRebuli unda iyos Semdegi mdgomareobebic: • • • • •

1

qsovilebis CarCena saSvilosnos RruSi (placenta, garsebi, sisxlis koltebi); saSos/saSvilosnos yelis travma, hematomis ganviTareba; saSvilosnos gaxeva; saSvilosnos farTe iogis hematoma; sisxldena, romelic ar aris dakavSirebuli sasqeso traqtTan.

2Tu sisxldenis mizezs warmoadgens saSvilosnos hipotonia, saWiroa

Semdegi zomebis miReba mocemuli TanmimdevrobiT: 3 • Sardis buStis dacla (moTavsdes da adgilze iyos datovebuli folis kaTeteri); • saSvilosnos Rrus xeliT revizia da masaJi • oqsitocini 10 erT i.v neli nakadiT Seyvana saSvilosnos Rrus xeliT reviziis dros • oqsitocinis infuzia (20-40 erT gaxsnili 1 l ringeris laqtatSi, hartmanSi an fiziologiur xsnarsi an ergometrini 0,2 mg kunTemSi yoveli 15 wuTSi – 5 dozis maqsimalur Seyvanamde) • enzaprosti ( prostaglandin F 2 alfa) 2.5 mg, kunTebSi, saWiroebis dros gaimeoreT yovel 15 wT-Si 5 dozis maqsimalur Seyvanamde)

• •

1 • • • • •

misoprostoli 1000 mkg ( 5 abi ) reqtalurad Tu konservatuli zomebi uSedego aRmoCnda an sisxldena grZeldeba, saWiroa ganxorcieldes qirurgiuli hemostazi, im wesis gaTvaliswinebiT, rom jobs “ufro adre, vidre gvian” Semdegi zomebi unda ganxorcieldes mocemuli TanmimdevrobiT: laparatomiis ganxorcielebis Semdeg saSvilosnos kunTSi Seyvanili unda iyos enzaprosti ( prostaglandini FF2 alfa) 0,5 mg ganxorcieldes saSvilosnos da sakvercxis arteriebis ormxrivi ligireba saSvilosnoze daedos B-linCis nakerebi Catardes histereqtomia* ganxorcieldes TeZos Sida arteriebis ormxrivi gadakvanZva

*rodesac vxelmZRvanelobT wesiT “jobs ufro adre, vidre gvian “ saWiroa mivmarToT hisereqtomias (gansakuTrebiT placentis winamdebareobisa da saSvilosnos gaxevis dros).