Protocol Hypertension In Pregnancy

mZime formis preeklampsiisa da eklampsis marTva stacionarSi protokoli

mZime preeklamfsiis klinikuri niSnebi Semdegia: • hipertenzia - arteriuli wneva=> 160/110 mm/vwy/sv; • gamoxatuli proteinuria ( 3 + an meti, an 5g /24 sT SardSi); • Zlieri Tavis tkivili; • mxedvelobis darRvevebi; • tkivili epigastriumis midamoSi da/an Rebineba; • klonuri krunCxvis niSnebi; • RviZlis gamkvriveba; • Trombocitopenia < 150 000; • RviZlis fermentebis (alaninaminotransferaza da aspartataminotransferaza) momateba; • HELLP sindromi; qronikuli hipertonuli davaadebis mqone yvela pacienti preeklampsiiT ganixileba, rogorc pacienti mZime eklampsiiT; mxedvelobaSia mimdinareobs;

misaRebi,

rom

daavadeba

zogjer

atipuri

klinikiT

mZime formis preeklampsia SeiZleba ganviTardes arteriuli wnevis umvniSnelo momatebis drosac, da Tan axldes Tirkmelebisa da RviZlis funqciis moSla da koagulopaTia.

I.

mZime formis preeklamfsiisa da eklamfsiis dros saWiroa: 1. 2. 3. 4.

dedis hospitalizacia da sasicocxlo funqciebis uwyveti kontroli; konsiliumi (meani, anesTezilogi, neonatologi); individualuri posti; dedis mdgomareobis Sefaseba: ➢ fizikaluri gamokvleva; ➢ sisxlis saerTo analizi Trombocitebis raodenobis daTvliT; ➢ koagulograma im SemTxvevaSi, Tu Trombocitebis raodenoba < 100 000 ➢ hematokritis, sisxlis jgufisa da rezusis, Sardovanis gansazRvra; ➢ RviZlis funqciebi - alaninaminotransferazis, aspartataminotransferis donis gansazRvra; ➢ Sardis saerTo analizi; ( 24 saaTiani Sardis analizi proteinuriaze); 1

sisxlis arteriuli wnevis seriuli gazomva damjdar mdgomareobaSi. 5. nayofis Sefaseba: ➢ non-stres testi; ➢ ultrabgeriTi gamokvleva. ➢

arteriuli wnevis gazomva ➢ daadeT manJeti xels, romelic mdebareobs gulis doneze, da SeaerTeT is manometrTan ➢ gaakeTeT pulsis palpireba mxris arteriaze idayvis moxris adgilas da Cqara datumbeT haeri manJetSi a.w. maCvenebelze 30 mm/vwy-iT metad, romlis drosac qreba arteriis pulsacia ➢ swrafad gamouSviT haeri manJetidan da gansazRvreT maCvenebeli, romelzec pulsi kvlav gaaisinjeba- es aris sistoluri wnevis miaxloebiTi maCvenebeli ➢ isev Cqara datumbeT haeri 30 mm/vwy-ze metad imaze, rodesac qreba pulsacia ➢ miadeT stetoskopi mxris arterias da darwmundiT kanTan mWidro kontaqtSi da maT Soris tansacmlis arsebobaSi ➢ nela, 2mm/vwy/wm-Si gamouSviT haeri manJetidan da mousmineT korotkovis tonebs

1.

➢

I faza: pirveli susti tonebis gamoCena, intensiobis TandaTanobiT momatebiTaRniSneT sistoluri arteriuli wneva

➢

II faza: tonebis intensiobis Serbilebis mikle faza

➢

III faza: tonebis intensiobis xanmokle gaZliereba

➢

IV faza: wyvetili moyruebuli tonebi, rbili da „ mberavi“

➢

V faza: tonebis sruli gaqroba- aRniSneT diastoluri arteriuli wneva

II.

pacientis marTva arteriuli wnevis kontroli

dRevandel dRes orsulobis hipertenziuli darRvevebis mkurnalobisaTvis gamoiyeneba 5 ZiriTadi jgufis preparatebi: beta-adrenoblokatorebi, kalciumis arxebis blokatorebi (kalciumis antagonistebi), centraluri simpatomometikebi, periferiuli vazodilatatorebi, kombinirebuli alfa- da beta-blokatorebi. gamoiyeneba aseve am xuTi jgufis preparatebis kombinacia. beta-adrenoblokatorebi am jgufis preparatebi propranololi (obzidani), atenololi (tenormini), metoprololis tartarati (lepresoli) iwveven gulis gadmosrolis Semcirebas, periferiuli sisxlZarRvebis adrenoreceptorebis blokirebasa da Tirkmelebis mier reninis gamomuSavebis daqveiTebas. beta- adrenoblokatorebis jgufis preparatebs gaaCniaT moqmedebis sxvadasxva xangrZlivoba da beta-receptorebis amorceviTi blokirebis gansxvavebuli potenciali (kardioseleqtiuroba). am jgufis 2

preparatebisaTvis damaxasiaTebelia gulis riTmis Seneleba (Sida simpatomimetikuri aqtivoba). yvela es Tviseba zegavlenas ar axdens betaadrenoblokatorebishipotenziur aqtivobaze, romelic daaxloebiT erTnairia am jgufis yvela preparatisaTvis. alfa-adrenoblokatorebi alfa-adrenoblokatorebis (prazozini, pratenoni) hipotenziuri mdgomareobs postsinafsuri alfa-1 receptorebis blokirebaSi, arteriolebis gafarToebas da arteriuli wnevis mdgrad daqveiTebas.

meqanizmi rac iwvevs

kalciumis arxebis blokatorebi (kalciumis antagonistebi) kalciumis antagonistebi (nifedipini, (korinfari), amlodipini (norvaski)) iwvevensisxlZarRvTa gluvkunTovan qsovilSi da kardiomiocitebSi kalciumis ionebis Semadgenlobis daqveiTebas, rac iwvevs periferiuli sisxlZarRvebis gafarToebas, maTi winaRobisa da gulis gadmosrolis Semcirebas, misi kumSvadobis Zalisa da sixSiris daqveiTebis gziT. kalciumis blokatorebi iyofa or ZiriTad qvejgufad: dihidropiridinis derivatebi (nifedipini, amlodipini) da ara dihidropiridinis derivatebi (verapamili, dilTiazemi). centraluri moqmedebis hipotenziuri saSualebebi centraluri moqmedebis hipotenziuri preparatebi axdenen centraluri alfa2receptorebisa da imidazolis receptorebis stimulacias (moqsonidini, meTildopa, klonidini, guanfacini), ris Sedegadac mcirdeba gulsa da sisxlZarRvebze simpaTikuri zemoqmedeba da qveiTdeba arteriuli wneva. simpatolitikebi da pirdapiri moqmedebis vazodilatatorebi am jgufis preparatebi (hidralazini, apresolini) iwveven nervebis simpaTikur daboloebebSi kateqolaminis raodenobis Semcirebas (rezerpini), kalciumisa da kaliumis ujredSida metabolizmis cvlilebas, sisxlZarRvebis gluvi muskulaturis kumSviTi moqmedebis daqveiTebas, arteriolebis gafarToebas (hidralazini, minoqsidili) rac iwvevs sisxlZarRvebis periferiuli winaRobis Semcirebas da arteriuli wnevis daqveiTebas.

III. mkurnaloba Tu arteriuli wneva =an >160/100 mm/vwy/sv: peroralurad Seyvanili unda iyos erT-erTi qvemoTCamoTvlili preparati an maTi kombinacia : •

nifedipini: sawyisi doza 10mg, ganmeorebiTi dozebi yovel 30 wuTSi saWiroebisamebr. Uunda mieces peroralurad,da ara enis qveS.

•

nifedipin retardi - 20 mg dRe-RameSi 1-2-jer;.

•

meTildofa: abebis saxiT (0,25g-iani). zrdasrulebSi Cveulebriv gamoiyeneba 0,25g-dan dReSi 2-3jer. aucileblobis SemTxvevaSi dRiur dozas zrdian 1-1,5g-mde. maqsimalur dRiur doza zrdasrulebSi Seadgens 3g-s. unda aRiniSnos, rom meTildofas gamoyenebisas 3

meTildofas hipotenziuri moqmedeba SedarebiT male qreba, Cveulebriv arteriuli wnevis momateba xdeba 48 saaTSi. •

labetololi: sawyisi dozaa 20mg i/v bolusiT; Tu efeqti ar miiRweva 10 wTSi SehyavT 40mg da 80mg yovel 10wT-Si ori damatebiTi dozis saxiT. maqsimaluri dozaa 220mg. Tu ar miiRweva arteriuli wnevis sasurveli maCvenblebi, maSin gamoiyeneba sxva preparati. labetololis gamoyenebas eridebian qalebSi, romelTac aqvT gulis ukmarisoba an bronqialuri asTma. • • • •

intravenurad, erT momentad, neli nakadiT 5-10 wT-is ganmavlobaSi unda gakeTdes 20 mg labetaloli. xangrZlivi intravenuri infuziis aucileblobis dros gamoyenebuli unda iyos infuzomati; ( 20 mg labetaloli ganzavdes 20 ml fiziologiur xsnarSi) unda moiniSnos sasurveli arteriuli wneva (ZiriTadad 150\90–140\80 mm/vwy/sv);

intravenuri infuziis damTavrebamde 1 sT-iT adre paciens peroralurad unda mieces 200 mg labetaloli;

Ddro

dawyeba 30 wT-is Semdeg 60 wT-is Semdeg 90wT-is Semdeg

labetalolis intravenuri Seyvana infuzomatiT doza infuzomatis siCkare

20 mg/sT-dan 40 mg/sT 80 mg/sT 160 mg/sT

4 ml/sT 8 ml/sT 16 ml/sT 32 ml/sT

•

klofelini 0,5-1,5 ml 0,01% xsnari unda gaixsnas 10-20 ml NaCl-is izotonur xsnarSi da Seyvanili iyos intravenurad, neli nakadiT 3-5 wT-is ganmavlobaSi.

•

gautkivarebisa da arteriuli wnevis daqveiTebis mizniTs HELLP sindromisa da Trombocitopeniis ararsebobis dros naCvenebia xangrZlivi periduraluri analgezia.

gaxsovdeT! arteriuli wnevis swrafma Semcirebam SeiZleba gamoiwvios nayofis distresi; mkurnalobis mizans warmoadgens wnevis daqveiTeba daaxloebiT 140\90 130/80 mm/vwy/sv-mde; arteriuli wnevis gasazomad avtomaturi xelsawyoebis gamoyenebisas SesaZlebelia araswori- maCveneblebis (gansakuTrebiT diastoluri wnevis) miReba.

4

eklampsiuri krunCxvebis prevencia/kontroli

2.

magniumis sulfati warmoadgens arCevanis preparats eklamfsiis profilaqtikisa da mkurnalobisaTvis (mwvave krunCxvebis mkurnalobis CaTvliT). is rekomendebulia agreTve mZime preeklamfsiis dros vinaidan naxevarze metad amcirebs eklamfsiis sikvdilianobasac.

ganviTarebis

risks

da

SesaZlebelia,

aqveiTebs

dedis

magniumis sulfatis intravenmuri Seyvana magneziis Seyvana kunTSi mtkivneulia da rTuldeba adgilobrivi abscesebis CamoyalibebiT 0,5%-SemTxvevebSi. ufro miznSewonilia intravenuri Seyvana. •

Spricis meSveobiT intravenurad - magniumis sulfatis 25% -5,0 ml 4 ampula – ( mSrali nifTierebis raodenoba – 5 grami -damtvirTavi doza) erTi 20 ml SpriciT an ori 10 ml SpriciT intravenurad neli nakadiT 15 - 20 wT-is ganmavlobaSi.

•

infuzomatiT meSveobiT - magniumis sulfatis 25%-iani xsnari unda gaixsnas infuzomatis 50 ml-ian SpricSi (10 xuTmililitriani an 5 aTmililitriani ampula), infuziis siCqare unda Seadgendes 64 ml/sT-Si, rac udris 4g/sT-Si, romelic unda iyos Seyvanili 15 -20 wT-is ganmavlobaSi. Semdgom infuziis siCqare unda Semcirdes 4-6 ml/sTmde, rac udris 1-2 g sT-Si.

•

magniumis sulfatis intravenuri Seyvana unda gagrZeldes krunCxvidan an mSobiarobidan 24 saaTis ganmavlobaSi;

•

saWiroa gansakuTrebuli yuradReba magneziis toqsiurobis Semdegi niSnebis gamovlinebisas: (Sratis done> 13 mg%l)

bolo

myesTa Rrma refleqsebis daTrgunva; sunTqvis sixSiris daqveiTeba < 16/wT-Si; ➢ diurezis Semcireba (naklebi 25ml saaTSi) ➢ kunTTa tonusis daqveiTeba; ➢ ➢

•

aRniSnuli simtomebis aRmoCenisas infuzia unda Sewydes. sunTqvis sixSiris daqveiTebas Seyvanili unda iqnas 10% - 10 ml kalciumis glukonati intravenurad 10 wuTis ganmavlobaSi

siTxis balansi

3. •

aucilebelia siTxis balansis uwyveti Sefaseba; ○ unda Caidgas mudmivi kaTeteri Sardis buStSi; ○ Seyvanili siTxis raodenoba ar unda aRematobes 80 ml/sT; ○ gaizomos Sardis saaTobrivi gamoyofa. 5

• • • •

4.

pacienTTa umravlesobas mSobiarobidan 6 saaTis ganmavlobaSi aReniSneba oliguria; oliguriis SemTxvevaSi unda gamoiricxos hipovolemia – gaizomos centraluri venuri wneva; hipovolemia ar aRiniSneba, Tu centraluri venuri wneva>=5 mm-ze. (gulis daavadebis ararsebobisas); saWiroa sifrTxile siTxeebis gadasxmisas– am dros unda gaizomos centraluri venuri wneva.

mSobiarobis dagegmva mSobiarobis saxis amorCeva preeklampsiis dros saWiroebs individualur midgomas, magram mSobiarobis sasurvel meTods warmoadgens bunebrivi gziT mSobiaroba. Aam SemTxvevaSi mSobiarobis III periodis aqtiuri marTva unda iyos gamoyenebeli

mZime preeklamfsiis SemTxvevaSi mSobiaroba unda gadavaddes Semdeg SemTxvevebSi: ➢ rodesac mkurnaloba aumjobesebs mdgomareobas; ➢ rodesac saxeze ar aris qronikuli hipertenzia, nayofis saSvilosnos Sida zrdis Seferxeba, tyupi nayofi, nayofis distresi, dedis mdgomareobis gauareseba ➢ naadrevi mSobiarobis dros an nayofis filtvebis umwifrobisas,Tu mSobiarobis gadavadeba 48 sT-iT usafrTxoa da SesaZlebelia dedis dauyovnebeli gadayvana maRali riskis referalur centrSi. mSobiaroba naCvenebia: ➢ ➢

➢

➢ ➢ ➢ ➢ ➢

drouli nayofis SemTxvevaSi ; umwifari nayofis SemTxvevaSi preeklamfsiis dros, rodesac saxezea qronikuli hipertenzia, nayofis saSvilosnosSida zrdis Seferxeba an distresi; eklamfsiis dros rogorc drouli, aseve umwifari nayofis SemTxvevaSi ➢ rodesac mkurnalobis Catarebis miuxedavad 6-8 saaTis ganmavlobaSi) arteriuli wneva ar qveiTdeba, SeiniSneba misi momatebis tendencia, saxezea pacientis saerTo mdgomareobis gauvareseba (Tavis tkivili, klonusi, mxedvelobis darRvevebi paTologiuri sisxldena ) gulis ukmarisoba, filtvebis SeSupeba garTulebebi Tavis tvinis mxridan - sisxlCaqcevebi (masiuri ann diseminirebuli), Trombozebi, cerbraluri hipoqsia, SeSupeba, koma Tvalis baduras SeSupeba da acla placentis naadrevi acla nayofis saSvilosnosSida hipoqsiisa niSnebis gaZliereba

eklamfsiis marTvis algoriTmi 6

eklamfsia- erTi an meti konvulsia, romelic viTardeba preeklmafsiis fonze da ar aris dakavSirebuli orsulis Tavis tvinis sxva darRvevebTan (epilefsia an insulti). konvulsiebi SeiZleba ganviTardes orsulobis, mSobiarobisa da mSobiarobis Semdgom periodSi. Tu konvulsiis gamomwvevi mizezi ar aris dadgenili, saWiroa qalis mdgomareobis marTva rogorc eklamfsiis dros, paralelurad konvulsiis realuri mizezis gamovleniT. daxmarebis gamoZaxeba - aucilebelia: individualuri posti, gamocdili bebiaqali pasuxismgebeli meani, anesTeziologi sasunTqi gzebi - niRbiT Jangbadis micema 8l/wT-Si siCqariT cirkulacia – Caidgas intravenuri kaTeteri, ganxorcieldes pulsis kontroli. BP krunCxvebis prevencia da kontroli - intravenurad 4 g magniumis sulfatis damtvirTavi doza, Semdeg 1 g/sT-Si an 10-20 mg diazepami, 1 ml/wT-Si hipertenziis kontroli- intravenurad 20 mg labetaloli neli nakadiT, Semdeg intravenurad infuzomatis meSveobiT (pirveli xazi) monitoringi/gamokvleva – sisxlis saerTo analizi, hematokriti – pulsi/arteriuli wneva – kardiopulmonaruli monitoringi – oqsimetria – folis kaTeteri- Sardis gamoyofa mSobiaroba – klinikuri situaciis da samSobiaro gzrbis momzadebis gaTvaliswinebiT – pacientis stabilizaciis Semdeg ufro mosalodnelia sakeisro kveTis Catareba, ganasakuTrebiT orsulobis 34-35 kviris vadamde. mizanSewonilia regioaluri anesteziis – periduruli an spinaluris gautkivarebis Catareba.

gaxangrZlivebuli krunCxvis mkurnaloba gaxangrZlivebuli krunCxvebis intravenurad damatebiT unda gakeTdes magneziis 2-4g 10 wT-is ganmavlobaSi; ➢ gaxangrZlivebuli krunCxvebis dros SesaZlebelia 10 mg diazepamis intravenurad Seyvana. ➢ Tu krunCxva ar eqvemdebareba magneziiT an diazepamiT mkurnalobas, SesaZlebelia, anesTeziologma intravenurad Seiyvanos 50mg Tiopentali, ganaxorcielos intubacia da Seiyvanos kunTTa relaqsanti (amis saWiroeba iSviaTia). ➢

mSobiarobis Semdgomi marTva stacionaridan gawera damokidebulia Semdegze: ➢ aRar aris magnezialuri Terapiis aucilebloba; ➢ Sardis gamoyofa > 100 ml/sT-Si 4 saaTze meti drois ganmavlobaSi diurezuli Terapiis an bolusis intravenuri Seyvanis gareSe; 7

sistoluri/diastoluri arteriuli wneva mudmivad naklebia 150/100 mm/vwy/sv-ze; ➢ laboratoriuli kvleviT Trombocitebis raodenoba >100 000; ➢ pacienti stabiluria, klinikuri mdgomareoba umjobesdeba mkurnalobisa da mSobiarobis Semdeg; ➢ preeklamfsiis SemTxvevaSi eklamfiis ganviTarebis yvelaze maRali riski aRiniSneba mSobiarobidan 24 saaTis Semdeg. ➢

8