mZime preeklamfsiis/eklampsiis marTva

klinikuri rekomendaciebi

Tbilisi 2006

avtorTa jgufi:

baCuki SublaZe – mean-ginekologi, S.p.s m.SaraSiZis klinikuri medicinis centri

aleko goxelaSvili - anesTeziologi, #5 samSobiaro saxli

Tengiz AasaTiani,

saeqsperto Sefaseba:

revaz suluxia- o.RuduSauris sax e.sc-is ginekologiuri ganyofilebis gamge

aleqsandre TaraSvili- S.p.s m.SaraSiZis samedicino centris mean-ginekologi

klinikuri rekomendaciebis zogadi mizani

am rekomendaciis mizans warmoadgens mZime preeklamfsiisa da eklamfsiis

mkurnalobis standartizacia orsulobis da mSobiarobis dros, dedisa da

axalSobilis gamosavalis gasaumjobeseblad.

ganxiluli klinikuri sakiTxebi

mocemul klinikur rekomendaciebSi ganixileba mZime preeklampsiisa da

eklampsiis marTva. rekomendaciaSi ar ganixileba hipertenziuli

darRvevebis sxva formebi orsulobis dros.

visTvis aris gankuTvnili mocemuli klinikuri rekomendacia

mocemuli klinikuri rekomendaciebi gankuTnilia stacionarSi momuSave

mean-ginekologebisaTvis, aseve jandacvis pirveladi rgolisE mean-

ginekologebis, bebiaqalebisa da ojaxis eqimebisaTvis, romelTac aqvT

orsulTan an MmSobiaresTan kontaqti, an exebaT mSobiarobis

meTvalyureoba. rekomendacia SeiZleba gamoyenebuli iyos rogorc

diplomamdeli, ise diplomisSemgomi swavlebisaTvis.

Ziebis, mtkicebulebaTa Sefasebisa da rekomendaciebis formulirebis aRwera

preeklamfsiisa da eklamfsiis sakiTxis aqtualobis gamo arsebobs

meTodologiaTa sakmarisi raodenoba, romlebic Seicaven mkacri samecniero

mtkicebulebis safuZvelze damtkicebul rekomendaciebs. amitom mocemuli

meTodologiis SemqmnelTa samuSao jgufis mier gadawyvetili iyo ukve

arsebuli praqtikuli rekomendaciebiis moZieba da Sefaseba da

rekomendaciebis adaptirebuli formis Seqmna, romlebic erTis mxriv,

upasuxebdnen saerTaSoriso moTxovnebs, xolo meore mxriv, misaRebi

iqnebodnen saqarTvelos jandacvis pirobebSi gamosayeneblad. samuSao

jgufis mier daSvebuli iyo is SesaZlebloba, rom arsebul rekomendaciebSi ar

iqneboda ganxiluli yvela klinikuri sakiTxi, da am SemTxvevaSi

warmoiSveboda mtkicebulebaTa damoukidebeli moZiebis aucilebloba

konkretul klinikur SekiTxvebTan dakavSirebiT.

klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi

klinikuri rekomendaciebis, epidemiologiuri monacemebisa da

mtkicebeulebebis Semdgomi moZieba xorcieldeboda inglisurenovani (Yahoo,

AltaVista, Google, DoctorGuide da rusulenovani (Yandex, Rambler) saZiebo

operatorebis meSveobiT, aseve inglisurenovani samedicino monacemebis

eleqtronuli bibliografiuli monacemTa bazis, „medlainis,, (MEDLINE)

meSveobiT, sakvanZo sityvebis gamoyenebiT. pirvel rigSi moZiebuli iyo

(National Guidelines Clearinhouse, TRIP, SumSearch) preeklamfsiisa da eklamfsiis

marTvis analogiuri rekomendaciebi, romlebic SemuSavebulia Sesabamisi

profesionaluri jgufebis mier.

calkeuli, aseve arasrulad ganxiluli klinikuri sakiTxebis Sesaxeb

mtkicebulebaTa moZieba warmoebuli iyo kohreinis monacemTa bazaSi The

Cochrane Library 2007, 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 Seicavda jgufis miznis Sesaferis saWiro informacias.

am rekomendaciebis saboloo Sefasebisas gamoyenebuli iyo formaluri

Sefasebis meTodi AGREE (Appraisal of Guidlines for Research and Evaluation )1.

Sefasebis Sedegad amorCeuli iyo ramodenime rekomendacia, romlebic

safuZvlad daedo Semdgom analizsa da adaptacias. am rekomendaciaSi

mocemuli debulebebi Sejamebuli iyo cxrilebSi da warmodgenili iyo samuSao

jgufis wevrebis mier Sefasebis mizniT. cxrilSi Sedioda debulebis originaluri

versia da mtkicebulebis done wyaros mixedviT. samuSao jgufs unda

Seefasebina rekomendaciebis vargisianoba saqarTvelos jandacvis pirveladi

rgolis pirobebSi. rekomendacia miRebuli iTvleboda, Tu mis sasargeblod xmas

aZlevda SemqmnelTa samuSao jgufis umravlesoba.

rekomendaciis SemuSavebisas Cven gamoviyeneT modificirebuli sqema,

romelic mowodebulia SIGN (Scottish Intercollegiate Guideline Network) mier 2.

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 efeqturobis da

usafrTxoebis Sesafaseblad da praqtikuli gamoyenebisaTvis masalis arsebobis

dasadgenad. recenziebis miRebis Semdeg ganxiluli iyo Sedegebi da samuSao

jgufis mier Setanili iyo cvlilebebi klinikuri rekomendaciebis SinaarsSi.

klinikuri rekomendaciis gadaxedvis vada -2010 w

mtkicebulebaTa doneebisa da rekomendaciebis gradaciis sqema

yvela ZiriTadi rekomendacia Seesabameba garkveul gradacias, romelic

aRiniSneba laTinuri asoebiT A-dan C-mde. (Agency for Health Care Policy and

Research-1994 Sesabamisad). amasTan erTad, yovel gradacias Seesabameba

monacemTa mtkicebulebis Sesabamisi done. es niSnavs, rom

rekomendaciebi dafuZnebuli iyo kvlevebis monacemebze, romlebsac

gaaCniaT mtkicebulebis garkveuli done. rac ufro maRalia rekomendaciis

gradacia, miT ufro maRalia kvlevis mtkicebuleba, romelzedac is aris

dafuZnebuli. qveviT moyvanilia sqema, romelSic aRwerilia rekomendaciebis

gradaciis sxvadasxva doneebi, romlebic CarTulia am saxelmZRvaneloSi.

A

saWiroebs ZiriTadi literaturuli wyaros arsebobas, minimalurad erT

randomizirebul sakontrolo kvlevas, romelic Catarebulia kargi xarisxiTa da

SinaarsiT, rac specifiurad Seesabameba mocemul mtkicebulebas an

rekomendacias an sistematiur momoxilvas

B saWiroebs maRali xarisxis klinikuri, magram ara randomizirebuli kvlevis

Catarebas, romelic Seesabameba rekomendaciis Sinaarss.

C

saWiroebs mtkicebulebebis arsebobas, romlebic dafuZnebulia eqspertTa

komisiis daskvnaze an maT azrze da/an dafuZnebulia am dargSi cnobili

avtoritetuli warmomadgenlebis azrze. miuTiTebs xarisxiani kvlevebis ar

arsebobaze am sakiTxTan dakavSirebiT.

Sesavali

orsulobis hipertenziuli darRvevebi viTardeba dedis organizmis orsulobasTan

adaptaciis procesis darRvevis gamo. hipertenziuli garTulebebi arTuleben

orsulobis normalur mimdinareobas. mocemuli mdgomareobisaTvis

damaxasiaTebelia angiospazmis, sisxlZarRvebis endoTeliumis dazianebisa da

maTi ganvladobis darRveva, rasac Tan sdevs hipovolemiis ganviTareba,

sisxlis reologiuri Tvisebebis Secvla diseminirebuli Trombebis warmoqmniT da

hemodinamikis darRveviT. es movlenebi iwvevs organuli cvlilebebis

ganviTarebas Tavis tvinSi, placentaSi, RviZlSi da sxva.

mZime formis preeklamfsia da eklamfsia aris orsulobis da mSobiarobis

mZime garTuleba. ganviTarebul qveynebSi eklamfsia gvxvdeba 1

SemTxvevaSi 2000 orsulobidan, xolo ganviTarebad qveynebSi-1/100-1/1700

mSobiarobidan. amave dros eklamfsia warmoadgens dedaTa sikvdilianobis

erT-erT wamyvan mizezs msoflioSi. 3 eklamfsiis dros qalTa 35%-s

uviTardeba mZime garTulebebi4. 1997-2005 wlis monacemebiT saqarTveloSi

dedaTa mokvdaobis maCvenebeli 100 000 cocxladSobilze Seadgenda 2.2,

rac umetes SemTxvevaSi ganpirobebuli iyo substandartuli mkurnalobiTa da

marTviT. 2004 – 2005 wlebSi q TbilisSi Cataraebulma aidutma gamoavlina

rom

klasifikacia

diagnostikuri da samkurnalo midgomis erTiani standartis Sesaqmnelad da

terminologiis swori interpretaciisaTvis am klinikur rekomendaciebSi

gamoiyeneba orsulobiT gamowveuli hipertenziis saerTaSoriso klasifikaciis

daavadebaTa Х gadaxedvis terminologia ( rubrikebi 013, 014, 015 - cxrili

1, ). da ar ganixileba daavadedebi miTiTebuli rubrikebSi 010 (adre

arsebululi hipertenziiT garTulebuli orsuloba, mSobiaroba da loginobis

xana), 011 (adre arsebuli hipertenziuli avadmyofoba TandarTuli

proteinuriiT) 012 (gestaciuri (orsulobiT gamowveuli) SeSupeba da

proteinuria hipertenziis gareSe)

cxrili 1

013 gestaciuri (orsulobiT gamowveuli) hipertenzia mniSvnelovani

proteinuriis gareSe,

msubuqi preeklampsia

014 gestaciuri (orsulobiT gamowveuli) hipertenzia mniSvnelovani

proteinuriiT

014.0 zomieri preeklamfsia

014.1 mZime preeklamfsia

014.9 preeklamfsia, dauzustebeli

015 eklamfsia

015.0 eklamfsia orsulobis dros

015.1 eklamfsia mSobiarobis dros

015.2 eklamfsia loginobis xanaSi

015.9 eklamfsia, dauzustebeli

preeklamsiis niSnebi

Hhipertenzia

hipertenziis diagnozi unda daisvas maSin, rodesac diastoluri arteriuli wneva

udris an aRemateba 110 mm/vwy/sv-s erTjeradi gazomvis dros an 90

mm/vwy/sv-s orjeradi gasinjvis dros 4 saaTiani intervaliT.

mZime hipertenzia

mZime hipertenziis dros diastoluri arteriuli wneva udris an aRemateba 120

mm/vwy/sv-s erTjeradi gazomvis dros an 110 mm/vwy/sv-s orjeradi gasinjvis

dros 4 saaTiani intervaliT.

proteinuria

Tu proteinuriis done ar udris an ar aRemateba 300 mg-s 24 saaTSi an Sardis

or sinjSi, romelic aRebulia 4 saaTiani intervaliT, is ar iTvleba paTologiurad.

proteinuriis dros saWiroa saSarde gzebis infeqciis gamoricxva. paTologiuri

proteinuria orsulobis dros warmoadgens Sinagani organoebis dazianebis

pirvel niSans.

SeSupeba

zomieri SeSupeba aReniSneba orsulTa 50-80%-s fiziologiurad mimdinare

orsulobis dros. miRebulia, rom preeklampsia, romelic mimdinareobs

SeSupebis gareSe, ufro saSiSia dedisa da nayofisaTvis, vidre preeklamfsia

SeSupebis fonze. swrafad mzardi generalizebuli SeSupeba, gansakuTrebiT

welis areSi, cud prognozul niSans warmoadgens.

msubuqi preeclampsia

diastoluri arteriuli wneva 90 udris mm/vwy/sv da sistoluri arteriuli wneva 140

mm/vwy/sv, magram naklebi vidre 160/110 mm/vwy/sv, proteinuriis gareSe

((< 0,3g. 24 saaTian SardSi an 1+ test xazis gamoyenebisas ). miuTiTebs

dedisa da nayofis mdgomareobaze saTanado meTvalyureobis aucileblobaze.

orsulobaTa umravlesoba mimdinareobs garTulebebis gareSe, rac miuTiTebs

imaze, rom garkveulwilad hipertenzia dadebiTad moqmedebs saSvilosno-

placentarul sisxlis mimoqcevaze momatebuli sisxlZarRvovani winaRobis

pirobebSi da kompensatorul meqanizms warmoadgens.

mZime preeklamfsia - diastoluri arteriuli wneva udris an aRemateba 110

mm/vwy/sv-s erTjeradi gazomvis dros an 90 mm/vwy/sv-s orjeradi gasinjvis

dros 4 saaTiani intervaliT, , xolo sistoluris 170 mm/vwy/sv orjeradi

gazomvisas, proteinuriasTan erTad (min. 1 g/l) an 2+ test xazis

gamoyenebisas. 6

mZime preeklamfsiis klinikuri niSnebi Semdegia:

hipertenzia => 170/110 mm/vwy; gamoxatuli proteinuria ( 2+, >5g /24 sT-ian SardSi); Zlieri Tavis tkivili; mxedvelobis darRvevebi; tkivili epigastriumis midamoSi da/an Rebineba; klonuri krunCxvis niSnebi; RviZlis gamkvriveba; Trombocitopenia < 150 000; RviZlis fermentebis (alaninaminotransferazisa da

aspartataminotransferazis) donis momateba; filTvebis SeSupeba nayoFis hipotrofia HELLP sindromi.

mxedvelobaSi misaRebisa isic, rom eklamsiiT daavadebul qalTa nawils

prodromuli NniSnebi ar aReniSneba. mZime preeklamfsiis seriozul

garTulebas warmoadgens HELLP sindromi, (hemolizi, RviZlis fermentebis

momateba da Trombocitopenia).

eklamfsia ganisazRvreba, rogorc preeklamfsiis fonze ganviTarebuli erTi an meti gulyra.5

Worldwide, each year, more than four million women will develop pre-eclampsia and approximately 100 000 women will have eclamptic convulsions, with over 90% occurring in developing countries. Pre-eclampsia complicates 2–3% of all pregnancies (5–7% in nulliparous women) and 2% of women with pre-eclampsia will develop eclampsia.

Pre-eclampsia is a multisystemic syndrome usually recognised by new onset hypertension and proteinuria appearing in the second half of pregnancy. Clinicians should be aware that pre-eclampsia may occasionally occur with hypertension in the absence of proteinuria (and proteinuria without hypertension) but with other features such as eclampsia, renal impairment, thrombocytopenia, liver dysfunction or fetal compromise.

Our understanding of the pre-eclampsia syndrome would be facilitated by recognition of discrete subsets of women with pre-eclampsia including early onset disease and those associated with fetal growth restriction.

Recommendations for clinical practice

1. Women with previous pre-eclampsia should be offered counselling, if possible preconceptually, and given realistic estimates of the likelihood of recurrence. Facilities for local expert counselling should be available as widely as possible. (Grade A)

2. Women with underlying medical conditions associated with an increased risk of pre-eclampsia should be offered prepregnancy counselling to explain this risk and to encourage early attendance for specialist antenatal care. (Grade A)

3. Many women with subfertility are at increased risk of pre-eclampsia. This is due to a combination of the underlying medical condition such as polycystic ovary syndrome and the risk of multiple pregnancy. This risk should be explained to the women and specialist antenatal care provided. (Grade B)

4. It should be considered that women at increased risk of pre-eclampsia requiring assisted reproduction should have only one embryo transferred. (Grade C)

5. Care pathways should be in place to provide appropriate specialist obstetric care for those identified to be at risk of pre-eclampsia. (Grade A)

6. Women with underlying medical conditions associated with an increased risk of pre-eclampsia require increased antenatal surveillance and should be managed by clinicians with expertise in the diagnosis and management of pre-eclampsia. (Grade A)

7. Women with multiple pregnancies are at increased risk of pre-eclampsia and should receive specialist antenatal care. (Grade A)

8. All women with blood pressure greater than 140/90 mmHg with or without proteinuria should be referred to a day assessment or obstetric unit. (Grade A)

9. All women with persistent proteinuria, even in the absence of hypertension, should be referred for further investigation. (Grade A)

10. All women should have access to a day assessment unit. (Grade A) 11. Although pregnancies associated with an abnormal uterine artery Doppler waveform are at

significant risk of adverse outcome (particularly severe pre-eclampsia requiring early delivery) its introduction as a screening test for all women cannot currently be recommended other than in clinical trials. (Grade B)

12. Antiplatelet therapy, in particular, low dose (< 75 mg) aspirin, reduces the risk of pre-eclampsia by around 15% for women at both low and high risk. There appears to be a similar reduction in the risk of perinatal death. Aspirin should be considered, particularly for women at high risk. In countries with a high prevalence of pre-eclampsia, more widespread use may be worthwhile. (Grade B)

13. All new interventions to prevent pre-eclampsia should be properly evaluated in large randomised trials before being introduced into clinical practice. (Grade A)

14. Data from small trials are promising that supplementation with vitamins C and E may reduce the risk of pre-eclampsia. Large trials are now underway. In the meantime, supplementation with vitamins C and E cannot be recommended for clinical care. (Grade B)

15. Automated instruments for blood pressure measurement are generally not validated for use during pregnancy and pre-eclampsia. Therefore, the use of mercury sphygmomanometers remains preferable. If used, automated instruments require the calibration to be checked regularly. (Grade B)

16. If automated devices are used for monitoring in an intensive care area, the accuracy of the devices should be confirmed with mercury sphygmomanometers on a regular basis or an intra-arterial line should be considered. (Grade A)

17. Measurement of blood pressure in pregnancy and pre-eclampsia should include the following: o instrument: mercury/aneroid sphygmomanometer or validated automated device o cuff size: it is imperative that the appropriate cuff size is used; it is better to use one that

is too big than one that is too small o setting: relaxed, quiet environment, preferably after rest o position: lying at a 45-degree angle or sitting (cuff at heart level) o arm: left or right (higher value if difference is greater than 10 mmHg) o dependent arm, if in a lateral position o Korotkoff sounds: first (systolic) and fifth (diastolic); if diastolic is persistently less than 40

mmHg use muffling or fourth sound and make a note.

(Grade A)

18. There is considerable observer error involved in dipstick urinalysis for proteinuria. This can be overcome by the use of automated dipstick readers, which significantly improve false positive and false negative rates. (Grade C)

19. The definition of gestational proteinuria is derived from studies calculating the 95th centile for an uncomplicated population. A protein loss of over 300 mg in 24 hours is associated with an increased morbidity to the mother and her baby. (Grade B)

20. There is considerable variation between laboratory assays for the quantification of proteinuria. This, combined with the unknown errors associated with 24-hour urine collection, means that new tests at point of care have potential advantages over the current gold standards. An elevated protein creatinine ratio of greater than 30 mg/mmol correlates with a 24-hour protein excretion greater than 300 mg and should be used to check for significant proteinuria. (Grade C)

21. Due to the variation in urine concentration, largely determined by hydration, all urine screening in obstetric day units should be by protein creatinine ratio. This can be by laboratory test or at point of care. (Grade C)

22. New urinalysis devices and dipsticks should be tested for accuracy and predictive values before being introduced into clinical practice. (Grade C)

23. Women with severe pre-eclampsia should have early referral to a specialist centre. A woman should not be transferred unless it is considered safe to do so and she has been stabilised. (Grade C).

24. There should be regional consensus guidelines agreed by all relevant parties. (Grade A) 25. Women with elevated blood pressure should be given antihypertensive therapy consistent with

local protocols. (Grade A) 26. Magnesium sulphate is the anticonvulsant of choice for both prevention and treatment of

eclampsia (including treatment of acute seizure). Magnesium sulphate is recommended for women with pre-eclampsia deemed at risk of seizure and for whom there is a plan for delivery. Magnesium sulphate is relatively low cost and therefore of particular relevance in developing countries. (Grade A)

27. Women with a history of severe early onset pre-eclampsia, especially if associated with growth restriction or late fetal loss, should be screened for antiphospholipid syndrome and the implications for future pregnancies should be discussed. (Grade B)

28. Women who had early severe pre-eclampsia or pre-eclampsia associated with fetal growth restriction, stillbirth or abruption, may be tested for hyperhomocysteinuria, factor V Leiden, protein

S, protein C and antithrombin (AT) deficiency but the implications for future pregnancies have yet to be determined. (Grade C)

preeklamfsia warmoadgens orsulobiT gamowveul hipertenzias,

romlisaTvisac damaxasiaTebelia proteinuria (>0,3g. 24 saaTian SardSi),

SeSupeba, (SeiZleba ar iyos). preeklamfsiis dros SeiZleba daziandes

nebismieri organo an organoTa sistema. arsebobs mZime preeklamfsiis

ramodenime gansazRvreba. miRebulia konsensusi, rom mZime hipertenzia

ganisazRvreba, rogorc diastoluri arteriuli wnevis momateba 110 mm/vwy-ze,

xolo sistoluris 170 mm/vwy/sv orjeradi gazomvisas, rac mniSvnelovan

proteinuriasTan erTad (min. 1 g/l) warmoadgens mZime preeklamfsias.

naklebad zustadaa gansazRvruli saSualo xarisxis hipertenzia, romelic sxva

simptomebTan da niSnebTan erTad aseve gvevlineba mZime preeklamfsiis

saxiT.

profilaqtika

dRevandel dRes ar aris damtkicebuli Semdegis efeqturoba:

siTxeebisa da marilis SezRudva orsulobis periodSi;

cilebisa da naxSirwylebis damateba an SezRudva orsulobis periodSi;

rkinis, foliumis mJavis, magneziis, cinkis, Tevzis qonis, E da C

vitaminebis damateba orsulobis dros (mtkicebulebis done IIa);

damtkicebulia, rom preeklamfsiis sixSiris daqveiTebas xels uwyobs

Semdegi:

orsulobis dros aspirinis mcire dozebis miReba (75- mg

yoveldRiurad) preeklamfsiis ganviTarebis maRali riskis jgufSi; (IIa);

Ca miReba sakvebi danamatebis saxiT (1g-mde dReSi)- Ca

ukmarisobis ganviTarebis maRali riskis jgufSi.

preeklamfsiisa da eklamfsiis diagnozi da Sefaseba

msubuqi preeklamfsia ar saWiroebs mkurnalobas, aucilebelia mxolod

saguldagulo dakvirveba pacientze (SesaZlebelia ambulatorulad) Semdegi

pirobebis dacviT: pacienti adeqvaturad afasebs sakuTar mdgomareobas da

SeuZlia misi damoukidebeli kontroli, aseve nebismier dros SeuZlia

samedicino daxamrebis gamoZaxeba.

qalTa konsultaciis eqimma an bebiaqalma msubuqi xarisxis preeklamfsiis

dros unda gaakeTon Semdegi:

выдать официальное освобождение от работы

Провести обучение мониторинга основных признаков развития преэелампсии

( АД, отеков, белка в моче, суточного диуреза, числа щевелений плода

Протестировать, что пацинета немежленно обратиться в стационар при появлении

головной боли, расстройства зрения, болей в ,подреберье, внезапное появдение

отеков, на лице или руках,

Убедиться что у нее есть транспортраная возможность экстренно добраться до

стационара

Периодичность наблюления ( визитов) каздые три дня

При невозможности выполения вышеуказанных условий беременная

госпитализирутся ( может быть испльзован девной стационар)

Медикаментозное левение не назначается ( диеретики, гипотензивные, седативные)

mZime xarisxis preeklamfsia hospitalizebuli unda iyos intensiuri Terapiis

palataSi II an III donis saavadmyofos samSobiaro blokSi. Tu amis saSualeba

ar aris, mdgomareobis stabilizaciis Semdeg hospitalizacia unda saswrafo

daxmarebis manqaniT specializirebuli ( reanimaciuli) brigadis TanxlebiT.

qronikuli hipertoniuli davaadebis mqone yvela pacienti preeklampsiiT

ganixileba, rogorc pacienti mZime eklampsiiT.

mZime preeklamfsiiTa da eklamfsiiT daavadebuli qalebis Sefasebasa da

mkurnalobaSi monawileoba unda miiRon meanebma, anesTeziologebma da

gamocdilma bebiaqalebma.

Tavis tkivili an muclis tkivili3 warmoadgens daavadebis damZimebis

mniSvnelovan klinikuri simptoms. saWiroa arteriuli wnevis seriuli gazomva

da Sardis analizi proteinuriis gamosavlenad. magnezialuri Terapiis

Catarebisas yuradReba unda gamaxvildes misi toqsiurobis niSnebze. puls-

oqsimetris meSveobiT saWiroa Jangbadis saturaciis uwyveti monitoringi,

radganac am dros SesaZlebelia filtvebis SeSupebis niSnebis drouli

gamovlena.

miuxedavad imisa, rom preeklamfsiisa da eklamfsiis klasifikacia dafuZnebulia sisxlis arteriuli wnevis maCveneblebsa da proteinuriis xarisxze, dedis riskis Sesafaseblad klinicistebma aseve yuradReba unda miaqcion sxva organoebis SesaZlo dazianebis niSnebs, placentis paTologiisa da nayofismxrivi simptomatikis CaTvliT.

arteriuli wnevis gazomva

arteriuli wnevis gazomva unda ganxorcieldes standartizirebuli

meTodebis meSveobiT. mniSvnelovania orsulis swori pozicia arteriuli

wnevis gazomvis dros. aucilebelia, rom manJeti iyos Sesaferisi zomis

da moTavsdes orsulis gulis doneze. diagnozis dasadastureblad

miRebuli Sedegi mravaljer unda gadamowmdes bunebrivi variaciebis

arsebobis gamo. diastoluri arteriuli wnevis gansazRvrisaTvis saWiroa

korotkovis me-5-e fazis dafiqsireba. arteriuli wnevis gasazomad

avtomaturi xelsawyoebis gamoyenebisas SesaZlebelia arteriuli wnevis

arazusti maCveneblebis (gansakuTrebiT diastoluri wnevis) miReba.7

arteriuli wnevis gasazomad sasurvelia vercxliswylis

sfigmomanometrebis gamoyeneba.8;9 Tu vercxliswylis

sfigmomanometri ar aris xelmisawvdomi, gamoyenebuli unda iyos

alternatiuli, kargad Semowmebuli mowyobiloba.

arteriuli wnevis gazomvis dros orsuli unda ijdes 45 gradusiani daxriT. wnevis gasazomi manJeti unda iyos Sesaferisi zomis da moTavsdes orsulis gulis doneze.

arteriuli wnevis avtomaturi sazomebis xmarebisas SesaZlebelia arazusti maCveneblebis miReba, amitom sasurvelia kalibrirebuli vercxliswylis sfigmomanometris gamoyeneba.

proteinuriis gansazRvra

SardSi cilis gansazRvris mizniT xSirad gamoiyeneba test-xazebi. test -

xazis bolo ramodenime wuTiT Tavsdeba SardSi. test-xazis feris Secvlis

Semdeg miRebul Sedegs adareben etiketze mocemul fers. Sedegebi

Semdegnairad SeiZleba iyos warmodgenili: 1+ =0,3 g/l, 2+ = 1g/l, 3+

= 3 g/l. am skriningul meTods gaaCnia cudi prognozuri Rirebuleba10..

testis vizualuri SefasebiT xSirad iReben rogorc cru dadebiT, aseve cru

C

C

B

uaryofiT Sedegebs.11; 12. yovelive zemoaRniSnulis gaTvaliswinebiT,

rekomendebulia 24 saaTiani Sardis laboratoriuli analizis Catareba.13

proteinuriis gansazRvris ZiriTad skriningul tests warmoadgens test-xazebis Sefaseba. proteinuriis damtkicebisaTvis unda gamovlindes maCvenebeli 2+, ris Semdegac proteinuria unda dadasturdes 24 saaTiani Sardis laboratoriuli analiziT

qalis monitoringi preeklamfsiisa da eklamfsiis dros

preeklamfsiis diagnozs adasturebs sisxlSi Sardovanis donis momateba. es

dakavSirebulia garTulebebis momatebul riskTan rogorc dedisaTvis, aseve

axalSobilisaTvis.14;15 amis miuxedavad, Sardovanas done ar unda iyos

ganmsazRvreli klinikuri gadawyvetilebis miRebisas. Tirkmlis ukmarisoba

preeklamfsiis dros Tanamedrove mkurnalobis pirobebSi iSviaTia16 misi

ganviTareba ZiriTadad dakavSirebulia HELLP sindromTan, sisxlis denasa an

sefsisTan. sisxlSi kreatininis donis momateba daavadebis adreul stadiaze

miuTiTebs Tirkmlis Tanmxleb daavadebaze da dakavSirebulia garTulebebis

momatebul riskTan.14

laboratoriulad Trombocitopeniis dadastureba miuTiTebs preeklamfsiis

damZimebaze..17 100 000-ze naklebi Trombocitebis raodenoba

dakavSirebulia koagulopaTiis ganviTarebis riskTan 18 da warmoadgens

Cvenebas mSobiarobisaTvis. aspartataminotransferazis maRali

maCveneblebi dakavSirebulia dedis momatebul avadobasTan.19 HHELLP

sindromis diagnostika SesaZlebelia laboratoriuli meTodebiT hemolizis

dadasturebiT14

qalis mdgomareobis stabilizaciamde arteriuli wneva unda gaizomos yovel 15 wT-Si erTxel da yovel 30 wT-Si erTxel gamokvlevis pirvel etapze. konservatuli mkurnalobis pirobebSi da qalis stabilizaciis Semdeg arteriuli wneva unda gaizomos 4 saaTSi erTxel

qalis gamokvleva moicavs yoveldRiurad sisxlis saerTo analizs, aseve RviZlisa da Tirkmelebis funqciebis Sefasebas

koagulograma aucilebeli ar aris, Tu Trombocitebis raodenoba aRemateba 100 000

aucilebelia siTxis balansis Sefaseba. amisaTvis SesaZlebelia Sardis buStSi folis kaTeteris Cadgma. saWiroa saaTobrivi diurezis aRricxva, gansakuTrebiT mSobiarobis Semdgom periodSi.

С

C

nayofis Sefaseba

klinikebis umravlesobaSi nayofis mdgomareobis Sefaseba xorcieldeba

kardiotokografiis meSveobiT (non-stres testi). am meTods gaaCnia

dabali prognozuli Rirebuleba. mudmivi eleqtronuli monitoringis

Catareba mizanSewonilia mSobiarobis dros20

preeklamfsiis dros orsulTa 30%-Si placentaruli ukmarisoba iwvevs

nayofis saSvilosnosSida zrdis Seferxebas. hipertenziiT daavadebul

orsulebSi nayofis zrdis Sefasebis mizniT pirveli vizitis dros unda Catardes

ultrabgeriTi kvleva. nayofis zrdis Seferxeba ZiriTadad viTardeba

asimetriulad, amitom sasurvelia muclis garSemowerilobis da saSvilosnos

FfuZis gazomva dinamikaSi ( gravidograma) .21 sanayofe siTxis

moculobis Semcirebam aseve SeiZleba gamoiwvios placentaruli

ukmarisoba da nayofis zrdis Seferxeba. amitom ultrabgeriTi kvlevis dros

orsulobis manZilze unda moxdes sanayofe siTxis moculobis seriuli

Sefaseba. randomizirebul kvlevebSi gamovlinda rom Wiplaris arteriis

doplerografiuli kvleva aumjobesebs axalSobilTa gamosavals22

hospitalizaciis dros orsulis an mSobiares pirveli Sefasebisas unda Catardes kardiotokografia. igi iZleva informacias nayofis mdgomareobis Sesaxeb mocemuli momentisaTvis.

mZime formis preeklamfsiis dros mSobiarobis dros unda Cautardes mudmivi kardiotokografia.

konservatuli mkurnalobis Catarebisas nayofis Sefaseba unda ganxorcieldes ultrabgeriTi kvleviT, Wiplaris arteriis doplerografiiT da sanayofe siTxis moculobis seriuli SefasebiT.

mZime formis preeklamfsiis mkurnaloba

mZime preeklamfsiis mkurnaloba moicavs orsulis dauyonlebliv

hospitalizacias, stabilizacias, mudmiv monitoringsa da mSobiarobas dedisa

B

B

A

da nayofisaTvis optimalur dros. mkurnaloba gulisxmobs arteriuli wnevisa da

krunCxvebis kontrols.

arteriuli wnevis kontroli

Tu arteriuli wnevis maCveneblebi metia an toli 170/110 mm/vwy/sv-sa, dedis

interesebidan gamomdinare saWiroa mkurnalobis dawyeba14 am drois

gamoiyeneba nifedipini an labetaloli. mwvave hipertenziis SemTxvevaSi

labetalolis Seyvana SesaZlebelia peroralurad da aucileblobis SemTxvevaSi

Semdgom intravenuradac. hidralazinis miReba naklebadaa mizanSewonili,

rac dadasturda erT-erT mimoxilviT kvlevaSi, Tumca ar arsebobs sakmarisi

mtkicebulebebi misi gamoyenebis akrZalvisaTvis.23 garda amisa, saqarTveloSi

Hhidralazini ar moipoveba.

Tu arteriuli wnevis maCveneblebi naklebia 160/100 mm/vwy/sv-ze, saswrafo

antihipertenziuli mkurnalobis dawyeba aucilebeli ar aris. gamonaklisi unda

gakeTdes im SemTxvevebisaTvis, rodesac mdgomareoba rTuldeba masiuri

proteinuriTa da RviZlis funqciebis darRveviT, aseve laboratoriulad vlindeba

hematologiuri darRvevebi. aseT SemTxvevebSi antihipertenziuli mkurnalobis

dawyeba gamarTlebulia arteriuli wnevis ufro dabal maCveneblebzec..24

grZeldeba debatebi im SemTxvevebTan dakavSirebiT, rodesac diastoluri

wneva varirebs 100 da 110 mm/vwy/sv-s Soris. mkurnaloba am dros

amcirebs mwvave hipertenziuli krizebis sixSires da Semdgomi

antihipertenziuli mkurnalobis Catarebis aucileblobas; Tumca aseve

SeimCneva nayofis wonis umniSvnelo Semcireba dabadebis momentisaTvis.25

Tu ar arsebobs Cveneba saswrafo mSobiarobisaTvis, antihipertenziuli

mkurnalobis dawyebiT SesaZlebelia orsulobis prolongireba saSualod 15

dRiT.26

meTildopa da labetaloli xSirad gamoiyeneba preeklamfsiisa da eklamfsiis

mkurnalobis dros23 meTildopas gamoyeneba usafTxoa nayofisaTvis, rac

damtkicda misi xangrZlivi gamoyenebiT. zogierT kvlevaSi gamovlinda

labetalolis upiratesoba27. atenololis gamoyenebisas SesaZlebelia nayofis

zrdis Seferxebis ganviTareba. angiotenzin makonvertirebeli fermentis

inhibitorebis gamoyeneba winaaRmdegnaCvenebia nayofis SesaZlo gverdTi

efeqtebis ganviTarebis gamo.

sasurvelia, eqimebma gamoiyenon is preparatebi, romelTac isini kargad

icnoben..

kortikosteroidebi gamoiyeneba HELLP sindromis dros. arsebuli

mtkicebulebebidan gamomdinare, isini aumjobeseben hematologiur da

bioqimiur maCveneblebs, Tumca ar arsebobs mtkicebulebebi imis Sesaxeb,

rom kortikosteroidebis gamoyeneba amcirebs dedaTa avadobas. 28

Tu sistoluri wneva metia 160 mm/vwy/sv-ze, an diastoluri wneva metia 110 mm.vwy/sv-ze, saWiroa antihipertenziuli mkurnalobis dawyeba. im SemTxvevaSi, Tu aRiniSneba orsulobis hipertenziuli garTulebebis sxva niSnebi, mkurnalobis dawyeba SesaZlebelia arteriuli wnevis ufro dabal mCveneblebzec

mZime formis hipertenziis saswrafo mkurnalobis dros SesaZlebelia labetalolis (rogorc oralurad, aseve intravenurad), nifedipinis (oralurad) gamoyeneba

saSualo xarisxis hipertenziis dros mkurnaloba xels uwyobs orsulobis prolongirebas. sasurvelia, eqimebma gamoiyenon is preparatebi, romlebsac isini kargad icnoben.

Tavi unda SevikavoT atenololis, angiotenzin makonvertirebeli fermentis inhibitorebisa da angiotenzinis receptorebis mablokirebeli agentebis gamoyenebisagan.

nifedipinis micema unda moxdes oralurad da ara sublingvalurad.

Tu orsuls aReniSneba asTmis niSnebi, Tavi unda SevikavoT labetalolis gamoyenebisagan.

krunCxvebis prevencia

MAGPIE kvlevam gamoavlina, rom magneziis sulfatis gamoyeneba

preeklamfsiis dros 58%-iT amcirebs eklamfsiuri krunCxvebis ganviTarebis

risks. (95% CI 40-71%).29 magneziis sulfatis infuzia unda gagrZeldes

mSobiarobidan an bolo krunCxvidan 12 - 24 saaTis ganmavlobaSi.. infuziis

dros mniSvnelovania Sardis gamoyofis, dedis refleqsebis, sunTqvis sixSiris da

Jangbadis saturaciis regularuli Sefaseba.

mZime preeklamfsiis dros eklamfsiis ganviTarebis riskis gamo saWiroa magneziis sulfatis gamoyeneba.

C

A

C

B

С

С

A

krunCxvebis kontroli

mZime formis preklamfsiisa da eklamfsiis dros aucilebelia qalTan mudmivi

postis arseboba. samSobiaro blokSi unda imyofebodnen anesTeziologebi,

ufrosi meanebi da neonatologebi. orsuli unda davawvinoT gverdze da

daviwyoT Jangbadis micema. unda Semowmdes sasunTqi gzebi, sunTqvis

sixSire, gaizomos pulsi da arteriuli wneva. amisaTvis mizanSewonilia puls-

oqsimetris gamoyeneba.30 qalis mdgomareobis stabilizaciis Semdeg unda

daigegmos mSobiaroba.

preeklamfsiisa da eklamfsiis dros diazepami da fenitoini aRar warmoadgenen

pirveli xazis preparatebs, arCevanis preparats warmoadgens magneziis

sulfati.31 magneziis intravenuri Seyvanisas gverdiT efeqtebi ufro iSviaTad

SeiniSneba. sisxlSi magneziis donis rutinuli gazomva mizanSewonili ar aris,

radganac misi toqsiuroba iSviaTad vlindeba miRebuli sqemebiT Seyvanisas.

magneziis gamoyofa ZiriTadad xdeba SardiT. saWiroa Sardis gamoyofis

mkacri kontroli da oliguriis dros (> 20 ml/sT-Si) magneziis infuzia unda

Sewydes. magneziis sulfatis toqsiuroba ZiriTadad vlindeba myesTa Rrma

refleqsebis gaqrobiT da sunTqvis sixSiris cvlilebiT.. respiratoruli depresiis

ganviTarebaze eWvis dros, saWiroa 1g kalciumis glukonatis Seyvana 10 wT-

is ganmavlobaSi.

krunCxvebis ganmeorebisas SesaZlebelia diazepamisa da Tiopentonis

gamoyeneba erTjeradi dozebiT. diazepamis xangZlivi gamoyeneba

dakavSirebulia dedis sikvdilianobis zrdasTan.32 krunCxvis gagrZelebisas

oqsigenaciis uzrunvelsayofad SesaZlebelia saWiro gaxdes intubacia. am dros

mizanSewonilia qalis gadayvana intensiuri mkurnalobis ganyofilebaSi.

krunCxvebis mkurnaloba efuZneba ventilaciis, sunTqvisa da cirkulaciis sabaziso principebis dacvas.

krunCxvebis kontrolisaTvis arCevanis preparats wamoadgens. magneziis sulfati. damtvirTavi doza 4 g. Seyvanili unda iyos infuzomatis an sainfuzio Spricis saSualebiT 15 wT-is ganmavlobaSi, SemdgomSi 1sT/1g-is SeyvaniT 24 saaTis ganmavlobaSi bolo krunCxvis Semdeg.

A

A

C

ganmeorebiTi krunCxvebis mkurnaloba unda xdebodes 2g magneziis sulfatis erTjeradi dozis SeyvaniT bolusiT SemdgomSi dozis gazrdiT 1,5-2 g/1 sT-Si.

siTxis balansi

bolo 20 wlis ganmavlobaSi, dedis sikvdilianobis mniSvnelovan mizezs

warmoadgens filtvebis SeSupeba.33 filtvebis SeSupeba xSirad aris

gamowveuli siTxeebis araswori SeyvaniT. ar arsebobs mtkicebulebebi siTxis

raodenobis gazrdis dadebiTi zegavlenis Sesaxeb34, piriqiT, Seyvanili siTxis

raodenobis SezRudva dakavSirebulia dedis ukeTes gamosavalTan.3 siTxeebis

balansis marTva gansakuTrebulad rTuldeba sisxldenis dros da aseT

SemTxvevebSi siTxeebis SezRudva mizanSewonili ar aris.

mSobiarobisa da mSobiarobis Semdgomi periodis dros sasurvelia Seyvanili siTxis raodenobis SezRudva 80 ml/sT-de anu 1 ml/kg/sT-Si.

mSobiarobis dros gansazRvra

dedis stabiluri mdgomareobis dros mSobiarobis gadavadeba ramodenime

saaTiT saSualebas iZleva neonatologiuri ganyofilebis ufro kargad

mosamzadeblad. Tu gestaciis vada aRemateba 34 kviras, mSobiaroba

rekomendebulia mxolod mdgomareobis stabilizaciis Semdeg. orsulobis 34

kviramde SesaZlebelia mSobiarobis gadavadeba 24 saaTiT, rac iZleva

saSualebas steroiduli mkurnalobis Casatareblad, romelic amcirebs

respiratorul distres sindromTan dakavSirebul sikvdilianobis risks.35 steroidebs

efeqturoba vlindeba im SemTxvevaSic ki, rodesac mSobiaroba iwyeba

Seyvanidan 24 saaTze nakleb droSi36; 37

gestaciis adreul vadebze orsulobis prolongireba aumjobesebs bavSvis

gamosavals38; 39 orma mcire randomizirebulma kvlevam gamoavlina

neonataluri garTulebebis riskis daqveiTeba mZime formis preeklamfsiis

adreuli gamovlinebisas mocdiTi taqtikis gamoyenebisas. 40 39. orsulobis

prolongireba xdeboda saSualod 7-15 dRemde, Sesabamisad gestaciis 28-34

da 28-32 kvirebze.

C

mSobiarobis gegma unda Camoyalibdes konsiliumis meSveobiT. ufro

mizanSewonilia saSosmxrivi mSobiaroba, Tumca, Tu gestaciis vada 32

kviraze naklebia, sasurvelia sakeisro kveTis Catareba. sakeisro kveTis

SemTxvevaSi upiratesoba eniWeba regioalur ( spinaluri, epiduruli)

anestezias. orsulobis 34 kviris Semdeg nayofis TaviT winamdebareobisas

sasurvelia saSosmxrivi mSobiaroba. saSosmxrivi prostaglandinebis an misi

analogebis gamoyeneba am dros zrdis warmatebis albaTobas.

antihipertenziuli mkurnaloba unda gagrZeldes gamokvlevisa da mSobiarobis

dros.

qalia mdgomareobis stabilizaciisa da konsiliumis Semdeg unda gadawydes sakiTxi mSobiarobis Sesaxeb

34 kviris orsulobis vadamde sasurvelia mSobiarobis gadavadeba kortikosteroidebis Seyvanis mizniT.

konservatuli mkurnaloba gestaciis adreul vadaze aumjobesebs perinatalur gamosavals

mSobiarobis tipi unda ganisazRvros nayofis winamdebareobis da mdgomareobis Sefasebis, mSobiarobis induqciis warmatebisa da saSvilosnos yelis Sefasebis Semdeg.

arteriuli wnevis momatebis riskis gamo ergometrinisa gamoyeneba sisxlisdenis profilaqtikis mizniT mSobiarobis Semdeg mizanSewonili ar aris. am mizniT saWiroa oqsitocinis gamoyeneba

mkurnaloba mSobiarobis Semdeg

mSobiarobis Semdgom periodSi mZime preeklamfsia an eklamfsia

viTardeba SemTxvaTa 44%-Si, gansakuTrebiT vadamitanili orsulobis dros.4

preeklamfsia unda gamoiricxos im melogineebSi, romelTac mSobiarobis

Semdeg aReniSnebaT hipertenziis an preeklamfsiis niSnebi (Tavis tkivili,

mxedvelobis darRveva, gulisreva, Rebineba an tkivili epigastriumSi)41

preeklamfsiis (an eklamfsiis) fonze mSobiarobis Semdeg melogine unda

imyofebodes mudmivi dakvirvebis qveS. sabolood ar aris garkveuli, Tu

ramdeni sawoldRe unda gaataros mSobiarobis Semdeg meloginem

saavadmyofoSi, Tumca cnobilia, rom preeklamfsiisa da eklamfsiis

A

A

C

C

C

ganviTarebis sixSire qveiTdeba mSobiarobis Semdeg meoTxe dRidan42

klinikuri simptomatikis gaumjobeseba unda dadasturdes qalis gaweramde.

antihipertenziuli mkurnaloba mSobiarobis Semdegac unda gagrZeldes.

mSobiarobis Semdeg arteriuli wnevis daqveiTebis miuxedavad, misi

maCveneblebi SeiZleba gaizardos mSobiarobidan 24 saaTis Semdeg.

antihipertenziuli mkurnalobis moxsna TandaTanobiT unda moxdes. qalis

gaweris Semdeg mkurnalobis gagrZeleba SesaZlebelia ambulatorulad.

arteriuli wnevis maCveneblebis normalizeba preeklamfsiis Semdeg 3 Tvis

ganmavlobaSi SeiZleba moxdes. am periodis ganmavlobaSi arteriuli wnevis

maCveneblebi ar unda aRematebodes 160/110mm/vwy/sv-s. dRevandel

dRes ar aris mtkicebulebebi raime garkveuli antihipertenziuli saSualebis

dasaniSnad. meZuZur dedebTan SesaZlebelia atenololis, labetalolis,

nifedipinisa da enalaprilis gamoyeneba, rogorc calke, aseve kombinaciis

saxiT.

meanebi unda acnobierebdnen gviani krunCxvebis ganviTarebis SesaZleblobas da saxlSi gaweramde darwmundnen qalis usafrTxoebaSi

antihipertenziuli mkurnaloba arteriuli wnevis maCveneblebis Sesabamisad unda gagrZeldes mSobiarobis Semdegac. SesaZloa, mkurnalobis gagrZeleba saWiro gaxdes mSobiarobidan 3 Tvis ganmavlobaSi

mdgradi hipertenziisa da proteinuriis SemTxvevaSi mSobiarobidan 6 kviris ganmavlobaSi unda gamoiricxos Tirkmelebis Tanxmlebi paTologia, rac saWiroebs Sesabamis gamokvlevas.

eklamfsiis 44% viTardeba mSobiarobis Semdgom, amitom preeklamfsiisa da eklamfsiis fonze mSobiarobis Semdeg saWiroa meloginis mdgomareobis mudmivi Sefaseba

mSobiarobis Semdgomi dakvirveba.

mtkicebulebebi mowmobs, rom preeklamfsiiT daavadebul qalTa 13%-s aReniSneba Tanmxlebi qronikuli an esenciuri hipertenzia, romelic ar gamovlinda antenatalurad. 43 44

rekomendebulia zogadi profilis eqimis mier arteriuli wnevisa da proteinuriis kontroli mSobiarobidan 6 kviris ganmavlobaSi.

C

C

C

C

C

Tu saxezea persistirebadi hipertenzia an proteinuria, saWiroa Semdgomi gamokvlevebis Catareba.

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