Postpartum Hemorrhage Upd

MmSobiarobis Semdgomi sisxlisdena klinikuri rekomendaciebi

Tbilisi 2006

avtorTa jgufi:

⇒ Tengiz AasaTiani, 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 mean ginekologTa asociaciis generaluri mdivani, saqarTvelos Sromis, janmrTelobis da socialuri dacvis jandacvis departamentis ufrosis moadgile. ⇒ Tamaz jojua - S.p.s m.SaraSiZis samedicino centris anesTeziologi ⇒ aleqsandre TaraSvili- S.p.s m.SaraSiZis samedicino centris meanginekologi ⇒ nino abulaZe – Tssu reproduqciuli janmrTelobis departamentis aspiranti 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 gerTianebis qalTa konsultaciis gamge, saqarTvelos mean ginekologTa asocoaciis gamgeobis wevri

klinikuri rekomendaciebis zogadi mizani am rekomendaciis mizans warmoadgens mSobiarobis Semdgomi sisxldenis marTvis standartizacia dedisa da axalSobilis gamosavlis gasaumjobeseblad.

ganxiluli klinikuri sakiTxebi mocemul

klinikur

rekomendaciebSi

ganixileba

mSobiarobis

Semdgomi

sisxlisdenebi adreul da gvian loginobis xanaSi. rekomendaciaSi ar ganixileba orsulobis dros ganviTarebuli sisxldenebi. visTvis aris gankuTvnili mocemuli klinikuri rekomendacia mocemuli klinikuri

rekomendaciebi gankuTnilia stacionarSi momuSave

mean-ginekologebisaTvis, ginekologebis,

aseve

bebiaqalebisa

da

jandacvis ojaxis

pirveladi

eqimebisaTvis,

rgolisE

mean-

romelTac

mSobiaresTan kontaqti an exebaT mSobiarobis warmarTva.

aqvT

rekomendacia

SeiZleba gamoyenebuli iyos rogorc diplomamdeli, ise diplomisSemgomi uwyveti samedicino ganaTlebis mizniT.

Ziebis, mtkicebulebaTa Sefasebisa da rekomendaciebis formulirebis aRwera mSobiarobis Semdgomi sisxldenebis 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 mxriv,

upasuxebdnen

adaptirebuli formis Seqmna, romlebic erTis

saerTaSoriso

moTxovnebs,

xolo

meores

mxriv,

misaRebi iqnebodnen saqarTvelos jandacvis pirobebSi gansaxorcieleblad. samuSao

jgufis

rekomendaciebSi SemTxvevaSi

mier

daSvebuli

iyo

is

SesaZlebloba,

rom

arsebul

ar iqneboda ganxiluli yvela klinikuri sakiTxi da am

warmoiSveboda

mtkicebulebaTa

damoukidebeli

moZiebis

aucilebloba 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,

da

DoctorGuide

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) mSobiarobis Semdgomi sisxldeis 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 AGREE (Appraisal of Guidlines for Research and Evaluation )

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.

vargisianoba

samuSao

saqarTvelos

jgufs

jandacvis

unda

Seefasebina

stacionaluri

rekomendaciebis

daxmarebis

pirobebSi.

rekomendacia miiReboda, Tu mis sasargeblod xmas aZlevda SemqmnelTa samuSao jgufis umravlesoba.

konfliqtTa interesebis deklarireba

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 Research1994 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 ZiriTadi literaturuli wyaros arsebobas, minimalurad erT ran-

A B

domizirebul sakontrolo kvlevas, romelic Catarebulia kargi xarisxiTa da SinaarsiT, rac specifiurad Seesabameba mocemul mtkicebulebas an rekomendacias an sistematiur momoxilvas 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.

sisxldena, rogorc dedis avadobisa da sikvdilianobis mizezi, xangrZlivi drois ganmavlobaSi wamyvan adgils ikavebs rogorc mTels msoflioSi, aseve saqarTveloSi. ase magaliTad, saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros samedicino statistikisa da informaciis centris statistikuri cnobaris bolo wlebis monacemebiT, sisxlis denas stabilurad ukavia wamyvani adgili (30-50%) dedis sikvdilobis mizezTa Soris am paTologiis ganviTarebis siswrafe cnobilia yvela mean-ginekologisaTvis, rac iTxovs gansakuTrebuli yuradRebis miqcevas sisxldenis umciresi niSnebis gamovlinebisadmi da gadaudebeli zomebis miRebas. miuxedavad mniSvnelovani miRwevebisa sameano sisxldenebis profilaqtikis SemuSavebisa da danergvisa, pacientis sicocxlis gadarCena da janmrTelobis SenarCuneba

damokidebulia

multidisciplinaruli

jgufis

efeqtur

da

zustad

dagegmil muSaobaze drouli da zustad organizebuli daxmarebis aRmoCenisas. mniSvnelovani roli am dros eniWeba erTiani SemuSavebuli meTodebisa da standartebis gamoyenebas samedicino daxmarebis aRmoCenisas. am mimarTulebiT muSaobis erT-erT Sedegs warmoadgens mocemuli klinikuri rekomendacia. am dokumentSi asaxulia sameano sisxldenebisadmi Tanamedrove Sexedulebebi, aRwerilia daxmarebis aRmoCenisa da profilaqtikis ZiriTadi meTodebi. Sesavali adreuli mSobiarobis Semdgomi sisxlisdenebi Seadgens yvela sameano sisxldenebis did nawils. janmos oficialuri ganmartebebis mixedviT, adreul mSobiarobis Semdgom sisxldenas miekuTvneba sisxldena sasqeso gzebidan 500 an meti ml raodenobiT mSobiarobidan 24 saaTis ganmavlobaSi, amave dros gvian mSobiarobis Sem-

dgom sisxldenas miekuTvneba paTologiuri sisxldena

sasqeso gzebidan 24

saaTidan 12 kviris ganmavlobaSi mSobiarobis Semdeg.

samwuxarod es gan-

marteba naklebad aris gamoyenebadi klinikur praqtikaSi. zogadad miRebulia, rom qalTa umravlesoba gansakuTrebuli garTulebebis gareSe umklavdeba sisxldenas 500-1000 ml-mde.

meores mxriv, rodesac

qalebSi adgili aqvs anemias an preeklamfsias, 300 ml sisxlis danakargic ki SeiZleba savalalo aRmoCndes. sxva sixlisdenis ganmarteba moicavs hematokritis Semcirebas 10%-iT an nebismier danakargs, romlis kompensireba ar xdeba fiziologurad. rogorc cnobilia, qalis gardacvaleba xSirad aris dakavSirebuli masiur sameano sisxldenebTan, amitom am mdgomareobas unda mieqces gansakuTrebuli yuradReba. masiuri sameano sisxldenis ganmarteba - sisxlis danakargi 1500 ml-ze meti, rac Seadgens mocirkulire sisxlis moculobis daaxloebiT 25%-s. samuSao gansazRvreba SeiZleba iyos sisxlis moculobis 50% dakargva 3 saaTis ganmavlobaSi an 150 ml/wT. dakarguli sisxlis raodenobis klinikuri Sefaseba ar asis saimedo da aqvs tendencia sisxlisdenis Sefasebis Semcirebisaken daaxlovebiT 30-50%

mSobiarobis Semdgomi sisxlisdenis risk-faqtorebi yvela pacientis mdgomareobis pirveladi Sefaseba da gasinjva, romlebic klinikaSi Tavsdebian sameano

daxmarebis aRmosaCenad, unda moicavdes

anamnezis detalur Sekrebas. dokumentirebas eqvemdebareba yvela saxis gadatanili koagulopaTia pacientsa an mis axloblebSi, aseve qalis mier antikoagulantebis moxmarebis faqti. srulma fizikalurma daTvalierebam SeiZleba gamoavlinos sisxlCaqcevebis an peteqiebis arseboba. am SemTxvevaSi unda Catardes laboratoriuli kvleva hemostazis sistemis mdgomareobis gamosakvlevad da ganxiluli iyos sakiTxi Sesabamisi specialistebis CarTvisa. yvela dagegmili procedura ganxiluli unda iyos pacientTan erTad. garTulebebis riski, maT Soris sisxldenis ganviTarebis riski zustad unda iyos formulirebuli

da Setanili qalis individualur istoriaSi. sisxldenis ganviTarebis riskTan dakavSirebulia zogierTi klinikuri mdgomareobebi da maTi mkurnalobis qirurgiuli meTodebi: saSvilosnos gare orsuloba, miomeqtomia, normalurad mimagrebuli placentis naadrevi acla, placentis winamdebareoba. gansakuTrebuli yuradReba unda mieqces im qalebs, romlebic uars amboben donoris sisxlis hemotransfuziaze ( am orsulebis raodenoba gaizarda bolo wlebis ganmavlobaSi) klinicistebma unda Seafason yoveli pacientis riski hemoragiuli Sokis ganviTarebis TvalsazrisiT da am Sefasebis mixedviT Caataron Sesabamisi RonisZiebebi

C

risk-faqtorebi, romlebic ganisazRvreba mSobiarobis win SansTa Tanafardobis Sefaseba mSobiarobis Semdgomi sisxldenis ganviTarebis TvalsazrisiT mocemulua cxrilSi

.

yvela moyvanil SemTxvevaSi SansTa Tanafardoba aRwevda statistikur mniSvnelobas da doneebi damrgvalebuli iyo erTamde.

B

Semdegi faqtorebi dakavSirebulia mSobiarobis Semdgomi sxlisdenis ganviTarebis maRal riskTan. maTi mSobiaroba Catardes II an III doni sameano dawesebulebaSi.

risk faqtori

siunda

SansTa Tanafardoba sameano sisxldenis ganviTarebis TvalsazrisiT.

normalurad mimagrebuli placentis dadasturebuli acla.

13

placentis diagnostirebuli winamdebareoba

12

mravalnayofiani orsuloba

5

C

orsulobiT gamowveuli preeklamfsia/hipertenzia

4

Semdegi faqtorebi aseve dakavSirebulia mniSvnelovan (Tumca ufro mcire) riskTan mSobiarobis Semdgomi sisxldenis ganviTarebis TvalsazrisiT.

risk faqtori 1• pirveladi mSobiare 1• mSobiarobis Semdgomi sisxldena anamnezSi 1• aziuri eTnikuri kuTvnileba. 1• gacximovneba

B

SansTa Tanafardoba sameano sisxldenis ganvitarebis TvalsazrisiT 3 3 2 2

risk-faqtorebi mSobiarobis dros

Semdegi risk-faqtorebi, romlebic Tavs iCens mSobiarobis dakavSirebulia mSobiarobis Semdgomi sisxldenis viTarebis maRal riskTan. maTi arseboba moiTxovs sonalis mxriv pacientisadmi zedmiwevniT dakvirvebas

risk faqtori 1• 1• 1• 1• 1• 1• 1• 1•

saswrafo sakeisro kveTa gegmiuri sakeisro kveTa placentis nawilebis CarCena epiziotomia operaciuli saSosmxrivi mSobiaroba gaxangrZlivebuli mSobiaroba (>12sT) didi nayofi (>4kg) cxeleba mSobiarobis dros

dros, gan- B per-

SansTa Tanafardoba sameano sisxldenis ganviTarebis TvalsazrisiT. 9 4 5 5 2 2 2 2

rogorc wesi sisxlis denis etiologia ganisazRvreba 4 mTavari faqtoris gaTvaliswinebiT “tonusi, qsovili, travma da trombini -koagulopaTia) tabula 1 saSvilosnos SekumSvis anomalia (tonusi) - 70%

CarCenili qsovilebi (qsovili) 10%

genitaluri traqtis tramvatizmi (tramva) 20%

etiologiuri faqtori saSvilosnos gadaWimva

klinikuri risk- faqtori  mravalwylianoba  mravalnayofiani orsuloba  didi nayofi saSvilosnos kunTebis  swrafi mSobiaroba gadaRla  gaxangZlivebuli mSobiaroba  mravali mSobiaroba anamnezSi  oqsitocinis gamoyeneba intraamnionuri infeqcia  cxeleba  xangrZlivi uwylo periodi saSvilosnos  fibromatozuli saSvifunqciuri/anatomiuri palosno Tologia  placentis winmdebareoba  saSvilosnos anomaliebi  halogenizirebuli saasaSvilosnos relaqsantebi nesTezio saSualeba  nitroglicerini CarCenili qsovilebi arasrulfasovani placentis anomaliuri placentacia dabadeba CarCenili wilaki an daoperaciebi saSvilosnoze matebiTi wili mravalnamSobiarevi qali placentis anomalia ubg-It CarCenili koltebi atonuri saSvilosno yelis, saSos an Sorisis swrafi mSobiaroba Caxevebi operaciuli mSobiaroba sakeisro kveTa nayofis araswori mdebareoba saSvilosnos gaxeva saSvilosnos gadmobruneba

operaciebi saSvilosnoze mravalnamSobiarevi qali placentis lokalizacia fuZeze

koagulopaTiebi (Trombini) -1%

hemofilia A von vilenbrandis daavadeba Trombocitopenia dsSs-is sindromi preeklamfsia mkvdari nayofi mZime infeqcia placentis naadrevi acla amnionuri siTxis embolia Terapia antikoagulantebiT

Tandayolili koagulopaTia anamnezSi RviZlis paTologia anamnezSi momatebuli wneva nayofis sikvdili cxeleba, neitrofilia an neitropenia sisxldena orsulobisas uecari kolafsi

Trombolizuri daavadeba anamnezSi

mSobiarobis Semdgomi sisxldenis profilaqtika mesame periodis aqtiuri marTva. meta-analizma, romelic Catarda mSobiarobis mesame periodis aqtiuri da mocdiTi marTvis Sesadareblad, gamoavlina, rom mSobiarobis mesame periodis aqtiuri marTva amcirebs sisxldenis ganviTarebis albaTobas 2/3-iT. amasTan erTad, aseTi taqtika dakavSirebulia mSobiarobis Semdeg gulisrevis, Rebinebis, Tavis tkivilebisa da hipertenziis ganviTarebis riskTan.

oqsitocinis

sainieqcio formebi warmoadgenen arCevanis preparats mSobiarobis Semdgomi sisxldenis profilaqtikisaTvis, magram SezRuduli resursebis pirobebSi, (preparatebis Sesaferisi Senaxva, personali) misoprostoli aris arCevis preparati mSobiarobis Semdgomi sisxldenis profilaqtikisaTvis. ukanaskneli kvlevebic adastureben misoprostolis gamoyenebis efeqturobas mSobiarobis Semdgomi sisxldenis profilaqtikisaTvis.

mSobiarobis mesame periodis aqtiuri marTva unda ganxorcieldes yvela qalSi, radganac aseTi taqtika mniSvnelovnad amcirebs saSvilosnos hipotoniiT gamowveuli mSobiarobis Semdgomi sisxldenis albaTobas

mSobiarobis III periodis aqtiuri marTva moicavs Carevebs, romlebic tardeba placentis mocilebis gaadvilebis mizniT saSvilosnos SekumSvebis stimulaciisa da mSobiarobis Semdgomi sisxldenis profilaqtikisaTvis. taqtikis ZiriTadi komponentebia: • uterotonuli saSualebebis Seyvana • Wiplaris kontrolirebadi traqciebi. • saSvilosnos masaJi placentis mocilebis Semdeg.

yovelma meanma unda icodes da flobdes Carevebs, romlebic exeba mesame periodis aqtiur marTvas da aseve icnobdes amisaTvis saWiro aRWurvilobas. 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 400600 mkg peroralurad. unda aRvniSnod, rom misoprostolis peroraluri miReba unda gadavdoT im SemTxvevisaTvis, rodesac oqsitocinis an alkaloidebis usafrTxo daniSvna an maTi ineqciuri formebis Senaxva SeuZlebelia. Mmisoporostolo

ar

aris

registrirebuli

saqarTveloSi

sameano

praqtikaSi

gamosayeneblad 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! qalebSi preeklamfsiiT, eklamfsiiTa da momatebuli arteriuli wneviT meTilergometrinis daniSvna winaaRmdegnaCvenebia kontrolirebadi traqciebis Catareba 1. Wiplarze ideba momWeri SorisTan axlos (imis Semdeg, rac Sewydeba Wiplaris pulsacia daaxloebiT 30-40 wamis Semdeg) 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 ganaxorcieloT Wiplaris traqcia (daWimva qveviT) simfizis zeviT kontr-zewolis ganxorcielebis gareSe, 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 garsebis saguldagulo daTvaliereba da maTi mTlianobis Semowmeba. Tu aRiniSneba garsebis defeqti, saWiroa 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

uterotonuli saSualebebis gamoyeneba unda xdebodes rutinulad mesame periodis marTvis dros, radganac es procedura amcirebs mSobiarobis Semdgomi sisxldenis ganviTarebis risks daaxloebiT 60%-iT

A

qalTa im kategoriisaTvis, romelTanac gadawyvetilia mxolod oqsitocinis Seyvana, preparatis sasurvel dozas warmoadgens 10 erT oqsitocini. mxedvelobaSia misaRebi, rom 10 erT oqsitocinis SeyvaA nisas 0,5 mg ergometrinTan erTad profilaqtikuri efeqti mcirdeba

mSobiarobis Semdgomi sisxlis denis diferenciuli diagnostika tipiuri simptomebi • •

sisxlis ikargeba saSodan pla- • centis dabadebis Semdeg; saSvilosnos rbili konsistencia;

SesaZlo simptomebi Sokis simptomebi

savaraudo diagnozi saSvilosnos atonia

• • •

• •

• • • • • •

saSvilosno ar ikumSeba profuzuli sisxldena saSvilos- • nodan; • mwvave tkivili muclis RruSi • sisxldena (Sinagani an • garegani) • gamoxatuli tkivilis sindromi; • • sisxldena (Sinagani an • garegani) momyolis mocilebisa da gamoyofis niSnebis ar arseboba 30 wuTis ganmavlobaSi sisxldena; • placentaruli qsovilis an garsebis defeqti momyolis daTvalierebisas garegani sisxldena; • momyolis defeqtis ar arseboba

Sokis simptomebi; saSvilosnos fuZe ar isinjeba; saSvilosnos fuZe Cans saSos karibWeSi Sokis simptomebi; muclis Seberiloba, Tavisufali siTxe muclis RruSi; dedis gamoxatuli taqikardia nayofis gulis cemis Secvla saSvilosnos mkvrivi konsistencia

saSvilosnos gadmobruneba

saSvilosnos gaxeva

momyolis mWidro mimagreba

saSvilosnos mkvrivi konsistencia;

momyolis nawilebis CarCena

saSvilosnos mkvrivi konsistencia;

rbili samSobiaro gzebis dazianeba

klinikuri suraTi da organizmis fiziologiuri pasuxi sisxlis danakargze sisxlis saerTo moculobis 10-15% danakargi Cveulebriv ar cvlis

sisxlis

wnevis maCveneblebs, magram iwvevs zomier taqikardias da posturalur hipotenzias

(msubuqi

simZimis

Soki).

adgili

aqvs

kanis

sisxlZarRvebis

Sevuwroebas, ris gamoc pacienti fermkrTali, aqvs sisuste da misi kani aris civi. rodesac sisxlis danakari miaRwevs 15-30%-s, sistoluri wneva odnav ecema, aRiniSneba taqikardia da sisustis grZnobasTan aris wyurvilis SegrZneba (saSualo Soki). sisxlis danakargis 30-40%-ze meti iwvevs sistoluri wnevis daqveiTebas 60-80mde da metad. hipotenzia iwvevs gulisa da Tavis tvinis perfuziis daqveiTebas.

sisustesa da oligurias emateba cnobierebis AaSliloba, mousvenroba da ekg-s cvlilebebi (mZime Soki). 40%-ze meti danakargi iwvevs sistoluri wnevis daqveiTebas 46-60-mde, sunTqvis ukmarisobas, ekg cvlilebebs da anurias. Tu ar moxda adeqvaturi reanimaciuli RonisZiebebis Catareba da hemostazi, izrdeba sikvdilis Sansi.

sisxlis danakargi orsulobis dros Sisxlis danarki

Aarteriuli

Simptomebi

Sokis xarisxi

wneva 10-15%( 500 -1000

normis fargleb-

ml)

Si

15-25% ( 1000-1500

umvniSnelo

ml)

daweva

25-35%(1500–2000

70-80 mm

ml)

35-45% (2000-

50-70 mm

Taqikardia

kompemsatoruli

taqikardia da wyurvilis SegrZneba

Mmsubuqi

fermkrTali kani civi ofli da hipoTermia, qoSini, oliguria (30 ml-ze naklebi Sardis gamoyofa 1 saaTSi) kollapsi, anuria

saSualo

MmZime

3000ml)

klinicistebi kargad unda icnobdnen hemoragiuli Sokis suraTs da stadiebs

mSobiarobis Semdgomi sisxlis denis efeqturi marTva gulisxmobs erTdroulad 4 mimarTulebiT moqmedebas:

1. komunikacia

C

samedicino personali unda iyos mzadyofnaSi da xelmisawvdomi. arsebuli personali unda Sedgebodes gamocdili meanebis, anesTeziologebis, eqTnebis, saoperacio personalis, hematologis, iseve rogorc masalebisa da sisxlis produqtebis gadamtani personalisagan.

2. reanimacia pacientis marTva hemoragiuli Sokis dros adreuli reanimaciuli RonisZiebebi moicavs sisxldenis SeCerebasa da mocirkulire sisxlis moculobis aRdgenas qsovilebis oqsigenaciis aRsadgenad.

SeZ-

lebisdagvarad yvela SemTxvevaSi miRebuli unda iyos zomebi sisxlis danakargis Semcirebisaken. sisxldenis swrafi SeCerebisaTvis mniSvnelovania sisxldenis wyaros dadgena, gamocdili personalis mzadyofna, panikis Tavidan acileba da sistemuri midgoma daxmarebis aRmoCenisas. multidisciplinaruli jgufis CarTva muSaobaSi (ginekologebis, anesTeziologis, saSualo samedicino personalis, SeZlebisdagvarad zogadi qirurgis, sisxlZarRvTa qirurgis, reanimatologis, hematologis) aucilebelia masiuri sisxldenisa da Sokis pirvelive niSnebis gamovlenis Taneve. aucilebelia SevatyobinoT sisxlis gadasxmis samsaxuris da laboratorias. vinidan ujredTa kvdoma warmoadgens Sokis bolo stadias, yvela moqmedeba mimarTuli unda iyos qsovilebis oqsigenaciis aRsadgenad. am miznis misaRwevad saWiroa Semdegi momentebis gaTvaliswineba: Jangbadis miwodebis uzrunvelyofa, mocirkulire sisxlis moculobis aRdgena, samkurnalwamlo Terapiis Catareba, misi efeqturobis Sefaseba, sisxldenis mizezis aRmofxvra. garda amisa, unda gvaxsovdes, rom gamosavali damokidebulia iseT faqtorebze, rogoricaa adreuli diagnostika da efeqturi Terapiis saswrafo Catareba,

gadaudebe li RonisZiebe bi

• • • • • •

specifiuri RonisZiebe bi

• • •

• • • • mizezebis gavlena da hS-Tan brZolis taqtika

•

Tavisufali samedicino personalis mobilizacia pacientis sasicocxlo parametrebis monitoringi (pulsi, arteriuli wneva, sunTqva, temperatura) pacientis moTavseba gverdze pirnaRebi masebiT aspiraciis riskis Sesamcireblad da adeqvaturi ventilaciis uzrunvelsayofad siTburi reJimis uzrunvelyofa sacicocxlo organoebis sisxliT avsebis gaumjobesebisaTvis pacientis fexebis aweva sasicocxlo organoebis sisxliT momaragebis optimizaciisaTvis intravenuri infuzia (2 venaSi) kanulis an didi zomis nemsis gamoyenebiT (#16) sisxlis aReba hemoglobinis donis, sisxlis jgufisa da rezus-faqtoris, donoris sisxlTan SeTavsebisa da Sededebis drois gansazRvrisaTvis pirveli saaTis ganmavlobaSi aucilebelia ara nakleb 3 litri kristaloidebis gadasxma, rac Cveulebriv sakmarisia Sokidan gamosayvanad saWiroa Tavidan aviciloT plazmis Semcvlelebis infuzia (hek, deqstranebi). ar arsebobs mtkicebulebebi imis Sesaxeb, rom es xsnarebi ufro efeqturia pacientebis hemoragiuli Sokidan gamosayvanad, vidre fiziologiuri xsnari hemoragiuli Soki moiTxovs infuziis moculoba iyos 2-3-jer meti sisxlis danakargis savaraudo moculobaze yovel 15 wuTSi sasicocxlo parametrebisa da sisxlis danakargis monitoringi diurezis kontroli mudmivi kaTeteriT Jangbadis sveli wesiT miwodeba niRabiT an nazaluri milidan 6-8 litri/wuTSi siCqariT aucilebelia sisxlis denis mizezisa da wyaros dadgena maTi likvidaciiT

mocirkulire sisxlis moculobis aRdgena mocirkulire sisxlis moculobis aRdgena unda daiwyos

kristaloidebis da ko-

loidebis gadasxmiT. dawyebiTi mkurnaloba moicavs 1-2l kristaloidebis Seyvanas.

mocirkulire sisxlis moculobis saswrafo aRdgenisaTvis saWiroa ganxorciel-

des midgoma erT (an ramodenime) periferiul venasTan, amave dros gamoyenebuli unda iyos didi diametris kaTeterebi (14-16G) SesaZlebelia ganxiluli iyos sakiTxi centraluri kaTeteris dayenebasTan dakavSirebiT, magram unda gaviTvaliswinoT, rom mocirkulire sisxlis moculobis swrafi aRdgenisaTvis centraluri venis kaTeterizacias ar gaaCnia aranairi upiratesoba. gaTvaliswinebuli unda iyos iseTi momentebi, rogorebicaa kvalificirebuli personalis daswrebis aucilebloba, romelsac SeuZlia kaTeterizaciis Catareba, proceduris xangrZlivoba, aseve iseTi garTulebis Tavidan acileba, rogoricaa pnevmoToraqsi. cvw-is gazomva SesaZlebelia sasargeblo aRmoCndes usafrTxo reanimaciisaTvis im SemTxvevaSi, roca aRiniSneba gul-sisxlZarRvTa sistemis an filtvebis sisxlZarRvovani sistemis dazianeba imis gaTvaliswinebiT, rom xSirad rTulia imis gaTvla, Tu siTxis ra raodenobaa saWiro qsovilebis normaluri oqsigenaciisaTvis da perfuziisaTvis, xolo siTxeebis gadaWarbebuli Seyvana dakavSirebulia filtvebis SeSupebis ganviTarebis riskTan. cvw-is monitoringi xelsayrelia multiorganuli dazianebis dros. unda gvaxsovdes, rom cvw-s normaluri maCvenebeli Seadgens 5 mm/vwy/sv-s (0-8 mm/vwy/sv-s farglebSi) cvw-is momateba aRiniSneba siTxeebiT gadatvirTvis dros, gulis marjvenamxrivi ukmarisobis dros, filtvis arteriis Tromboemboliis, gulis tamponadis, samkariani sarqvlis gamoxatuli ukmarisobis dros. cvw-is maCveneblebis daqveiTeba aRiniSneba Sokis dros (hipovolemiis Sedegad) sefsisisa da anafilaqsiis dros. kristaloiduri xsnarebi kristaloidebi warmoadgenen xsnarebs intravenuri SeyvanisaTvis da Seicaven eleqtrolitebs. kristaloidebis udavo upiratesobas warmoadgens usafrTxoeba, iafi Rirebuleba da xelmisawvdomoba. maTi gamoyenebis uaryofiT mxares warmoadgens maTi swrafi gadanacvleba Seyvanisas sisxlZarRvSida sivrcidan sisxlZarRvgareTa sivrceSi. Aase magaliTad 1 litris ringer laqtatis Sexvana Zrdis plazmis moculobas 200 ml, rac saWiroebs danakargis moculobasTan mimarTebiT 3-jer ufro meti raodenobiT gadasxmas.

sasurvelia ringeris laqtatis gadasxma, radganac natriumis qloridis

xangrZlivma gadasxmam SeiZleba gamoiwvios hiperqloremiuli acidozi. hipertonuli marilis xsnarebis gadasxma ZiriTadad rekomendebuli ar aris, radganac

am dros savaraudoa eleqtrolituri darRvevebis ganviTareba. aseve hipovolemiuri mdgomareobebis dros (hemoragiuli Soki) ar gamoiyeneba deqstrozis hipotoniuri xsnarebi. amis mizezia dadasturebuli faqti, rom glukozis Semcveli xsnarebi swrafad ganicdian metabolizms sisxlSi, romlis drosac Tavisufldeba Tavisufali wyali, romelic sisxlZarRvSida sivrcidan nawildeba

da axdens minimalur

zegavlenas mocirkulire sisxlis moculobaze. saboloo jamSi, aman SeiZleba migviyvanos wylismier intoqsikaciamde mTels organizmSi eleqtrolitebis diluciis Semdeg. koloiduri xsnarebi koloiduri xsnarebi SemuSavebulia im gaTvliT, rom Seyvanili preparati darCes sisxlZarRvovan kalapotSi. am medikamentebs miekuTvneba albumini, hidroqsieTilis saxamebeli, deqstranebi da Jelatinebi. preparatebi ufro ZviradRirebulia da naklebad xelmisawvdomi kristaloidebTan SedarebiT. unda gvaxsovdes, rom yoveli am preparatTagani atarebs gverdiTi reaqciebis ganviTarebis risks, radganac zogi maTgani ukavSirdeba kalciums, zogi arRveven imunoglobulinebis transports. amis garda, ar arsebobs mtkicebulebebi, rom koloidur xsnarebs gaaCniaT raime upiratesoba kristaloidebTan SedarebiT mocirkulire sisxlis moculobis aRdgenaSi pacientebTan hemoragiuli SokiT. sistematiur mimoxilvaSi romelSic Sedarebuli iyo mkurnaloba hemoragili Sokis dros albuminiT an plazmiT kristaloidebTan,

gamoavlina rom yovel 100 namkurnaleb pacientSi albuminis

jgufSi 6 damatebiTi sikvdili gamovlinda calke unda aRiniSnos, rom deqstranebis gamoyeneba ar aris rekomendebuli sameano praqtikaSi

es dakavSirebulia ara imasTan, rom prepar-

atebi zegavlenas axdnen laboratoriuli testebis Sedegebze da Trombocitebis funqciaze aramed imaze, rom literaturaSi arsebobs xSiri miniSnebebi deqstranebis mSobiarobis dros gamoyenebisas mZime anafilaqsiuri reaqciebis ganviTarebaze, ramac SeiZleba gamoiwvios dedis sikvdili (an nayofis sikvdili da Tavis tvinis dazianeba, rodesac deqstranebis gamoyeneba xdeboda antenatalurad). im dros, rodesac mosalodnelia sisxlis transfuzia, SesaZlebelia 2 litri kristaloidebis da 1,5 koloidebis gadasxma.

im SemTxvevaSi, rodesac srulad SeTavsebadi sisxli ar aris xelmisawvdomi 3,5 l sisxlis Semcvlelebis gadasxmis momentisaTvis, saWiroa saukeTeso alternatiuli variantis moZebna. saukeTeso varianti varirebs pacientis adgilmdebareobisa da sxva garemoebebis mixedviT. gansakuTrebiT urgentul situaciaSi SesaZlebelia da yvelaze saukeTeso variants warmoadgens pirveli jgufis uaryofiTi rezusis sisxlis gadasxma. yvela sameano ganyofileba, gansakuTrebiT mcire ganyofilebebi, sadac ar aris pirobebi sisxlis bankis adgilobrivi Seqmnisa, unda flobdnen pirveli jgufis rezus uaryofiTi sisxlis marags, imisTvis rom iyos saSualeba, aRdges sisxlis Jangbadis transportis funqcia drois garkveul monakveTSi. sisxlis minimaluri moculoba, romelic saxezea ganyofilebaSi, unda gamarTlebuli iyos Tanamosaxele jgufis sisxlis transportirebis drois TvalsazrisiT.

reanimaciuli RonisZiebebi hemoragiuli Sokis dros unda moicavdnen cvw-is aRdgenas ori didi diametris kaTeteris dayenebis gziT da kristaloidebisa da koloidebis swrafi SeyvaniT hemoragiuli Sokis SemTxvevaSi ar unda gamoviyenoT deqstrozis hipotoniuri xsnarebi ramdenad swrafad aris saWiro sisxli? sisxlis moTxovnisas samSobiaro dawesebulebis samedicino personali xvdeba rig siZneelebs (sisxlis saWiro jgufis ar arseboba, sisxlis motanis dro sisxlis gadaxsmis sadguridan da sxva). unda gamaxvildes yuradReba sisxlis produqtebis droul miwodebaze.

mocirkulire sisxlis moculobis (csm) deficitis AaRdgenis wesi*

A A

sisxlis danakargi (ml),

cirkulirebadi sisxlis moculobisTan SefardebiT %

aRdgena 75 kg masis mqone orsuli qalisaTvis (Mcsm sNnormSi Seadgens 75 kg X 75

ml\kg = 5625 ml) kristaloiidebi da koloidebi

10-20% (500-1000 ml)

ramdenad saswrafo aris sisxli

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 1-2 0,2%

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 wTSi) 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%

dRevandel dRes arsebobs sisxlisa da misi Semcvelebis mravali preparatebi, romlebic mimarTulia mocirkulire sisxlis moculobisa da koagulaciuri

faqtorebis aRdgenaze, romlebsac SeuZlia sisxlis Jangbadis transportuli funqciis aRdgena.

Kkomponenti

Cveneba

eriTrocitaruli masa

sisxlis Jangbad-satransporto funqciis aRdgena Trombocitopenia sisxldenasTan erTad dadasturebuli koagulopaTia

Trombocitebi axladgayinuli plazma Krioprecipitati

Cveulebrivi sawyisi doza 2-4 erT* i/v

koagulopaTia, fibrinogenis donis daqveiTeba

6-10** erT i/v 2-6*** erT i/v 10-20**** erT i/v

damateba: saqarTvelos pirobebSi Trombocitaruli masisa da krioprecipitatis miReba SesaZlebelia mxolod SekveTis micemidan 24 sT-Si, romelic praqtikulad gamoricxavs. mis gamoyenebas mwvave situaciaSi *eriTrocitaluri masis Cveulebrivi doza Seadgens 240-340ml, hematokritis maCvenebeli 80% **Trombocitaruli masis doza Seadgens 55X10 9 Trombocitebs, romlebic suspenzirebulia 50-55 ml plazmaSi. ***axladgayinuli plazmis moicavs 250 ml fibrinogenis normalur koncentracias da VIII da V faqtorebs ****krioprecipitatis erTi doza moicavs aranakleb 80erT MVIII faqtors da 150 mg fibrinogens, romelic ganzavebulia 5-15 ml plazmaSi

komponenturi Terapia saSualebas iZleva es preparatebi gamoyenebuli iyos specifiuri miznebisaTvis. ase magaliTad, saukeTeso preparatebs hipovolemiis aRsadgenad warmoadgenen kristaloiduri xsnarebi. hemoragiuli Sokis ganviTarebisas mocirkulire sisxlis moculobis aRsadgenad yvelaze farTod xmarebad preparats warmoadgens eriTrocitaruli masa. unda aRvniSnoT, rom janmrTel adamianebSi Jangbadis gadamtani funqcia ar irRveva manam, sanam hemoglobinis done ar daqveiTdeba 60-70 g/l-mde.

magram klinikur situaciaSi

“hemoglobinis zRvruli done” ar unda iyos gamoyenebuli. 20-25%-ze meti sisxlis danakargi an dadasturebuli/savaraudo koagulopaTia moiTxovs koagulaciuri faqtorebis gadasxmas, xolo hemostazis sistemis laboratoriuli analizi unda Catardes 5-10 erT eriTrocitaruli masis gadasxmis Semdeg.

Trombocitaruli mas-

is transfuzia SesaZlebelia saWiro gaxdes mniSvnelovani Trombocitopeniis dros

(<20000-50000 mm3) da gaxangrZlivebuli sisxlis denis dros. koagulaciuri faqtorebis koncentratebi SesaZlebelia sasargeblo aRmoCndes maTi deficitis dros, axladgayinuli plazma SeiZleba dainiSnos urgentul situaciebSi, rodesac dadasturebulia proTrombinisa da nawilobrivi Tromboplastinuri drois gaxangrZliveba. amave dros unda gvaxsovdes, rom ar arsebobs Cvenebebi Trombocitaruli masis profilaqtikuri daniSvnisaTvis, aseve plazmisa da specifiuri

komponentebis

daniSvnisaTvis

reanimaciuli

RonisZiebebis

Catarebisas hemoragiuli Sokis dros. garTulebebis albaToba sisxlis transfuziisas matulobs sisxlisa da misi komponentebis didi raodenobiT gadasxmisas. sisxlis yvela preparati Semowmebuli unda iyos SeTavsebaze da gadaisxas specialuri filtris daxmarebiT, amave dros ar unda moxdes sxva samkurnalwamlo saSualebebTan sisxlis Sereva. sisxlis transfuziis dros SesaZlebelia ganviTardes mJava-tutovani balansis darRveva. hipoTermiis Tavidan asacileblad saWiroa preparatebis SeTboba.

sisxlis preparatebis gadasxma mizanSewonilia maSin, rodesac dadasturebulia sisxlis mocirkulire moculobis deficiti da is dokumentirebulia mdgomareobis klinikuri SefasebiTa da hematologiuri kvlevebiT. oqsigenacia reanimaciis Catarebis pirvel etaps warmoadgens sasunTqi gzebis gamavlobis uzrunvelyofa da adeqvaturi oqsigenacia. SemTxvevaTa umravlesobaSi qirurgiuli Carevis dros es uzrunvelyofilia anesTeziologis mier. regionaluri anesTeziis dros aucilebelia Jangbadis damatebiTi miwodeba. im SemTxvevaSi, Tu pacienti dezorientirebulia an gadaRlilia, ganxiluli unda iyos sakiTxi traqeis intubaciis Sesaxeb. intubacia unda Catardes gadaudeblad, Tu aRiniSneba tkivilisadmi mgrZnobelobis daqveiTeba. unda gvaxsovdes, rom siTxeebis masiuri infuziis dros traqeis garkveulwilad SeSupebam SeiZleba gaarTulos intubacia, xolo filtvebis elastiurobis daqveiTebis gamo filtvebis xelovnuri ventilaciisas SeiZleba saWiro gaxdes damatebiTi dadebiTi wnevis Seqmna.

B

reanimaciuli RonisZiebebi hemoragiuli Sokis dros unda moicavdnen adeqvatur oqsigenacias

B

3. monitoringi da gamokvleva Catarebuli Terapiis efeqturobis Sefaseba imis Semdeg, rac mTlianad aRdgenilia mocirkulire sisxlis moculobis deficiti da qsovilebis oqsigenacia, saWiroa klinikuri situaciis ganmeorebiTi Sefaseba. ZiriTadi sasicocxlo niSnebi, cnobierebis mdgomareoba, gamoyofili Sardis raodenoba, kapilaruli avseba regularulad unda iyos Sefasebuli. SesaZlebelia saWiro gaxdes centraluri monitoringis Catareba, Tu Catarebuli mkurnaloba mosalodnelze nakleba defeqturia an sisxldena grZeldeba. sisxlis gamokvleva unda xdebodes eleqtrolitebis parametrebis, koagulaciuri, hematologiuri da metaboluri jaWvebis parametrebis gaTvlaliswinebiT. metabolizmis, eleqtrolituri balansis an koagulaciuri sistemis deficiti eqvemdebareba gadaudebel koreqcias. oqsigenaciis deficitis, filtvebis ventilaciis, pH balansis, siTxeebis balansis koreqcia unda Catardes laboratoriuli Sedegebis gaTvaliswinebiT. zogierT SemTxvevebSi gamovlenili darRvevebis koreqciisaTvis SeiZleba saWiro gaxdes sisxlis preparatebis damatebiTi Seyvana.

dsS SeiZleba ganviTardes rig sameano situaciaSi, romlis drosac irRveva koagulaciuri faqtorebis , Trombocitebisa da fibrinis moxmarebis cikli. specifiuri gamSvebi mdgomareobebia placentis acla, sanayofo siTxiT embolia, preeklamfsia da sefsisi, magram dsS gavrcelebis dadgena rTulia mwiri populaciuri kvlevebis da SedarebiT dabali sixSiris gamo. rTulia aseve diagnostikuri kriteriumebis miReba da simZimis xarisxis Sefaseba. SemoTavazebulia, rom dsS daiyos 3 ZiriTad safexurad. safexuri 1 – warmoadgens kompensatorul situacias sadac saxezea fibrinis degradaciis produqtebis laboratoriuli momateba, magram sakuTriv fibrinogenis done damakmayofilebelia da koagulaciuri darRvevis klinikuri gamovlena ar xdeba.

safexuri 2 – SesaZloa iyos fibrinogenis donisa da Trombocitebis daqveiTeba, aseve mdgomareobis dekompensacia, Tumca hemostatiuri darRvevebi saxeze ar aris. safexuri 3 – Trombocitebis donis da koagulaciuri faqtorebis daqveiTeba, fibrinisis degradaciis produqtebis gamoCena, hemostazis darRvevebis gamoxatuli klinikuri suraTi. masiurma sisxldenam mSobiarobis dros SesaZloa daaCqaros da gaaRrmavos dsS siTxis Canacvlebisa da transfuziis Sedegad. pacientebma, romelTac esaWiroebaT intensiuri transfuziuli Terapia, regularulad unda Caitaron sisxlis suraTis (hemostatiuri) rutinuli kvlevebi koagulopaTiis aRmoCenis mizniT. qalebi, romlebic manmade praqtikulad janmrTelebi iyvnene, saeWvoa gauCndeT Semadedebeli faqtoris deficiti, Tu ar moxda maTi sakuTari sisxlis moculobis 80%-de Canacvleba. didi raodenobiT kristaloidebisa da sufTa eriTrocituli masis an damatebiT xsnarSi ganzavebuli eriTrocitebis infuziisas, adgili aqvs koagulaciis faqtorebisa da trombocitebis Semdgom ganzavebas. Tu aqtivirebuli parcialuri tromboplastinis dro protrombinis dro normaSi ar aris , unda ganisazRvros trombinis warmoqmnisn dro, fbrinogeni, d-dimerebi. rodesac Sededebis drois gaxangZlivebas ukavSirdeba paTologiuti sisxldena da adgili aqvs sisxlis gamoJonvas lorwovani garsebidan, Wrilobebidan, ineqciis adgilebidan, axlad gayinuli plazma unda mieces sawyisi doziT 12 - 15 ml/kg. es aris 4-5 erT axalad gayinuli plazma, romlis infuzia unda moxdes swrafad. regularulad unda moxdes trombocitebis daangariSeba. rodesac xdeba 1,5 -- 2 sisxlis moculobis transfuzia mosalodnelia trombocitopenia. trombocitebi unda iyos 50.109 g/l maCvenebelze zemoT. Tu saWiroa qirurgiuli Careva maSin es maCvenebeli unda avwioT 80-100 _ 109/l-mde. rodesac masiuri sisxldenisas trombocitebis maCvenebeli ecema 50- 109/l –mde, xolo sisxldenis kontroli gaZnelebelia saWiroa 8+12 erTeuli trombocituli masis swarafi infuzia, romelsac sasurveli win uswrebdes axlad gayinuli plazmis bolusiT gadasxma.

adeqvaturi reanimaciuli RonisZiebebi saWiroeben Catarebuli mkurnalobis efeqturobis mudmiv Sefasebas klinikuri Sefasebis CaTvliT, aseve hematologiuri, bioqimiuri da metaboluri kvlevebis tarebas.

C

Ca-

4.

sisxldenis SeCereba

saSvilosnos atoniis Sedegad ganviTarebuli sisxldenis marTvis algoriTmi

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

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.

1 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 (10-20 erT gaxsnili 500 ml ringeris laqtatSi, hartmanis xsnarSi 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)

• •

• • • • •

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 ganxorcieldes TeZos Sida arteriebis ormxrivi gadakvanZva histereqtomia*

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

mkurnalobisadmi refraqteruli hemoragiuli Sokis ganviTarebis SemTxvevaTa umravlesoba meanobaSi dakavSirebulia sisxldenis gagrZelebasTan. reanimaciuli RonisZiebebis dawyebasTan erTad saWiroa aqtiuri zomebis Catarebis dawyeba sisxldenis SeCerebis mizniT. normaluri arteriuli wnevis “agresiuli“ miRweva

gamoiwvevs

sisxldanakargis

gazrdas

sisxlismidinebis

Trombebis formirebis darRvevas dazianebis adgilze.

gazrdisa

da

piriqiT, hipotenziis gark-

veuli done xels uwyobs Trombebis warmoqmnas da sisxlis danakargis Semcirebas dazianebuli sisxlZarRvebidan. sisxlis denis wyaro dadgenili unda iyos rac SeiZleba male.

pacientebSi, romlebSic aRiniSneba hemostazis gauareseba

qirurgiuli Carevidan 12 saaTze meti drois ganmavlobaSi, saWiroa eWvi mivitanoT sisxlisdenis farul retroperitonealur wyaroebze. am SemTxvevaSi sisxlis denis wyaros zusti identificireba rTuldeba. sisxldena, romelic iwyeba uSualod qirurgiuli Carevis Semdeg, saswrafod unda iyos SeCerebuli yvela sisxlmdeni sisxlZarRvis ligirebiT.

hemoragiuli Sokis dros reanimaciuli RonisZiebebis CatarebasTan Tad saWiroa sisxldenis SeCerebisaken mimarTuli aqtiuri zomebis Catareba

mSobiarobis Semdgomi sisxlis denis dros

er-

C

taqtikis gviani Secvla qirurgiuli

hemostazis sasargeblod aris ZiriTadi faqtori, romelic iwvevs gamosavalis gauaresebas sameano sisxldenebis dros

qirurgiuli Carevis gadawyvetilebis

miRebisas, misi Catarebis meTodika damokidebuli unda iyos arsebuli personalis kvalifikaciasa da gamocdilebaze. saoperacioSi

gadayvanamde

sisxlis

danakargis

Semcirebis

mendibulia ramodenime meTodi: •

saSvilosnos garegani bimanualuri kompresia

mizniT

reko-

o marcxena xeli Tavsdeba saSvilosnos fuZeze da gadaadgildeba qveviT da SeZlebisdagvarad saSvilosnos ukan; o marjvena xeli Tavsdeba muclis wina kedelze Wipsa da boqvenis simfizs •

Soris; xorcieldeba saSvilosnos tanis zewola orive xeliT erTmaneTis Semxvedri mimarTulebiT placentaruli moednis sisxlZarRvebis kompresiis mizniT

•

saSvilosnos Sinagani bimanualuri kompresiia o qirurgis xelebis damuSaveba ise, rogorc operaciuli Carevis dros; o steriluri xelTaTmanebis gamoyeneba; • marcxena xeli Tavsdeba saSvilosnos fuZeze da gadaadgildeba qveviT da SeZlebisdagvarad saSvilosnos ukan; o marjvena xelikonusiseburad Sedis saSos wina TaRSi; o xorcieldeba saSvilosnos tanis zewola orive xeliT erTmaneTis Semxvedri mimarTulebiT placentaruli moednis sisxlZarRvebis kompresiis mizniT.

•

aortis muclis nawilis xeliT kompresiia • • •

erTi xeli gamoiyeneba barZayis arteriis pulsaciis kontrolisaTvis; meore xeliT warmoebs zewola Wipis zemoT xerxemlis wina zedapiris mimarTulebiT, barZayis arteries pulsaciis gaqrobis dros – aortis xeliT kompresia iTvleba sakmarisad da sisxlis dena samSobiaro gzebidan Cerdeba.

rekomendaciebis mixedviT, romelic mocemulia am naSromSi, qirurgiuli Careva sameano sisxldenis dros unda Catardes Semdegi TanmimdevrobiT: B-linCis nakerebi, saSvilosnos arteriebis bilateraluri gadakvanZva, TeZos Sida arteriebis gadakvanZva da histereqtomia. B-linCis nakeri

am nakeris teqnika moicavs saSvilosnos irgvliv wyvili, vertikaluri nakeris dade-

bas wina da ukana kedlebis piri-pirTan misatanad saSvilosnos kompresiisaTvis. procedura tardeba zogadi anesTeziis qveS, pacientis loi-devisis poziciaSi, gaSlili fexebiT - romelic aadvilebs saSosTan midgomas da sisxlis danakargis obieqtur Sefasebas. saWiroa Sardis buStSi kaTeterizacia. muclis Rru ixsneba pfanenStilis ganakveTiT an Sua xazze. Tu sisxldena viTardeba sakeisro kveTis Semdeg, keTdeba relaparatomia. Sardis buSti CaiTiSeba qveviT, ris Semdegadac tardeba ganakveTi saSvilosnos qveda segmentSi. ixsneba saSvilosnos Rru. saSvilosnos Rru unda daTvalierdes momyolos CarCenili nawilebis evakuaciis mizniT. Semdeg xorcieldeba saSvilosnos gamotana Wrilobidan sisxlmdeni adgilebis aRmosaCenad da aRsadgenad. Tu sisxldena difuzuri xasiaTisaa, gamoiyeneba bimanualuri kompresia, raTa ganvsazRvroT efeqturi iqneba Tu ara kompresiuli nakeris dadeba. Tu sisxldena emorCileba kompresias, SeiZleba ganxorcieldes B-linCis nakeri. meTodikisaTvis gamoiyeneba 70 mm momrgvalebuli nemsi da #2 qromirebuli ketgutis an vikrilis Zafi. nakeris dadeba iwyeba 3 sm-iT qvemoT saSvilosnos ganakveTis marjvena qvemo kididan da 3 sm marjvniv lateralur sazRvridan da xorcieldeba Semdegnairad (ix. suraTi a). sixldenis SeCereba miuTiTebs proceduris warmatebul Catarebaze, sisxldenis gagrZeleba miuTiTebs qirurgiuli Carevis aucileblobaze. muclis Rrus aRdgena proceduris Catarebis Semdeg xdeba Sreebis mixedviT.

• • • • • • •

meTodis dadebiTi mxare- Tu bimanualuri kompresia iZleva dadebiT efeqts, bi-linCis kvanZebis dadeba am dros efeqturi iqneba; kvanZebi unda daidos ise, rogorc aRniSnulia ilustraciaze zemoT; gamoyenebuli unda iyos qromirebuli ketguti an vikrili; Tu sakeisro kveTa ar tardeba, saWiroa saSvilosnoze gakeTdes iseTive ganakveTi, rogorc sakeisro kveTis dros (ganivi ganakveTi saSvilosnos qveda segmentSi); asistentma unda ganaxorcielos saSvilosnos kompresia nakerebis mWidro ganlagebisaTvis unda Semowmdes, xom ar moyva nakerebSi nawlavebi, Sardis buSti an SardsawveTebi, didi sisxlZarRvebi an saSvilosnos danamatebi. Tu nakeri moisxlita saSvilosnos fuZidan, SesaZlebelia nakeris gatareba fuZeSi

saSvilosnos arteriebis ligireba saSvilosnos sisxlis momarageba 90%-iT xorcieldeba

saSvilosnos arterie-

bidan, amitom logikuria maTi ligireba sisxldenis dros. saSvilosnos arteriis ligireba teqnikurad ufro advili da usafrTxoa SigniTa TeZos arteriis ligirebasTan

SedarebiT.

ganxorcieleba

misi

Semdegnairad

xdeba. pirvel rigSi ganivad ikveTeba SardbuSt-saSvilosnos naoWi da Semdeg Sardis buSti mobilizdeba qveviT. Semdeg saSvilosno aiweva zeviT da sisxlZarRvovani

fanjara

identificirdeba

farTo iogis furclebs Soris – am nakerma

SesaZloa

ilobrivad

gaiaros

saSvilosnos

naw-

lateralur

nawilSi, rac usafrTxoa. farTo atravmuli nemsi #1 qromirebuli ketgutiT an poliglikoliT gaivlis uknidan winisaken saSvilosnos arteriis 2-3sm-iT medialurad (miometriumis nawilis CaTvliT) da arasisxlZarRvovani fanjris gavliT SardbuSt-saSvilosnos

naoWis

doneze.

daTvalierdeba

SardsawveTi

da

Sardis

buSti

SemTxveviTi dazianebis gamosaricxad. procedura meordeba mopirdapire mxaresac. menj-Zabriseburi sisxlZarRvis ligirebam sakvercxis medialurad SesaZloa SemdgomSi kidev Seamciros sisxldena fertilobaze raime saziano efeqtis gareSe.

TeZos Sida arteriebis ormxrivi ligireba TSa-s gadakvanZva SeiZleba dagvexmaros sisxldenis SesaCereblad, Tu is vaginaluri totidan gamomdinareobs.

bilateraluri TSa-s gadakvanZva 85%-Si

iwvevs pulsuri wnevis daqveiTebas gadakvanZvis qvemoT arteriebSi da aseve amcirebs sisxlis midinebas 50%-iT distalurad ganlagebul sisxlZarRvTa nawilSi. arteriuli sistemis wneva uTanabrdeba venuri sistemis wnevas, rac zrdis Trombebis warmoqmnis albaTobas. proceduris warmatebuloba Seadgens 40%-s. am periodisaTvis pacients SesaZloa hqondes mdgomareobis mniSvnelovani gauareseba, iseve rogorc koagulopaTia. procedura aseve SeiZleba garTuldes qsovilTa SeSupebiT da hematomiT, rac arTulebs anatomiur amocnobas. imisaTvis, rom ganvaxorcieloT TSa-s usafrTxo ligireba, mniSvnelovania zustad gavigoT retroperitoneluri TeZos sivrceSi

arteriisa da SardsawveTis

urTierTmdebareoba. Cveulebriv Ta-s bifurkacia Sida da gare totebad xdeba menjis SesavalSi (koncxis doneze) SardsawveTi kveTs saerTo TeZos arterias misi bifurkaciis doneze. ixsneba retroperitonealuri sivrce, keTdeba 8-10sm ganakveTi, peritoneumis lateralurad SardsawveTis paralelurad. SardsawveTi da peritonealuri nakeci xSirad medialurad aris ganlagebuli. TSa xSirad midis Tavisuflad, sanam gamoiyofa ukana toti. rodesac ukana toti gamoeyofa TSa-s mTavar Reros, es ukanaskneli midis Tavisuflad Sida TeZos venidan. marjvena kuTxis momWeris gamoyenebiT 2 ligatura Tavsdeba sisxlZarRvis garSemo. mowmdeba gareTa TeZos arteriis pulsacia raTa davrwmundeT, rom sisxlmomaragebas ar emuqreba safrTxe. procedura meordeba meore mxaresac. proceduris garTulebebs miekuTvneba: dundulosa da dundulos kunTis sisxlmomaragebis darRveva TeZos SigniTa arteriidan ukana totis gamosvlis adgilis zeviT arteriis SemTxveviTi gadakvanZvis Sedegad, menjis iSemiuri dazianeba da TeZos venis dazianeba.

histereqtomiis adreuli

Catareba

gansakuTrebiT rekomendebulia im

SemTxvevaSi,

rodesac arobis

mSobiSemdgomi

sisxldena kombinirebulia

placentis

mWidro mimagrebasTan/CazrdasTan,

saSvilosnos

gaxevasTan, aseve im SemTxvevebSi, rodesac personali srulad ceduris

flobs

pro-

Catarebis

teqnologias.. Caatarda masiuri sameano sisxldenebis qirurgiuli mkurnalobis meTodebis analizi da gaakeTda aqcenti imaze, rom histereqtomiis gadavadeba ar SeiZleba pacientis terminaluri mdgomareobis dadgomamde, ar unda daixarjos dro naklebad radikalur Carevebze, miT ufro, Tu eqims ar gaaCnia maTi Catarebis gamocdileba. am mklevarebma gamoTqves azri, rom subtotaluri histereqtomia warmoadgens arCevanis meTods mSobiarobis Semdgomi sisxldenis SemTxvevaTa umravlesobaSi, xolo saSvilosnos yelis takvis kibos ganviTarebis riski Semdgom wlebSi ver edreba risks sicocxlisaTvis saSiSi sisxldenis dros. yvela sameano dawesebulebaSi unda tardebodes regularuli saswavlo gangaSebi, raTa TiToeulma multidisciplinaruli jgufis wevrma zustad icodes Tavisi movaleobani mSobiarobis Semdgomi sisxlis denis dros

C