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 mean-
ginekologi
⇒ nino abulaZe – Tssu reproduqciuli janmrTelobis departamentis as-
piranti

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, aseve jandacvis pirveladi rgolisE mean-
ginekologebis, bebiaqalebisa da ojaxis eqimebisaTvis, romelTac aqvT
mSobiaresTan kontaqti an exebaT mSobiarobis warmarTva. rekomendacia
SeiZleba gamoyenebuli iyos rogorc diplomamdeli, ise diplomisSemgomi
uwyveti samedicino ganaTlebis mizniT.

Ziebis, mtkicebulebaTa Sefasebisa da rekomendaciebis formulirebis

aRwera
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 adaptirebuli formis Seqmna, romlebic erTis
mxriv, upasuxebdnen saerTaSoriso moTxovnebs, xolo meores mxriv,
misaRebi iqnebodnen saqarTvelos jandacvis pirobebSi gansaxorcieleblad.
samuSao jgufis mier daSvebuli iyo is SesaZlebloba, rom arsebul
rekomendaciebSi ar iqneboda ganxiluli yvela klinikuri sakiTxi da am
SemTxvevaSi 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, 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) 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. samuSao jgufs unda Seefasebina rekomendaciebis
vargisianoba saqarTvelos jandacvis stacionaluri 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 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.

saWiroebs ZiriTadi literaturuli wyaros arsebobas, minimalurad erT ran-

domizirebul sakontrolo kvlevas, romelic Catarebulia kargi xarisxiTa da Sin-
A aarsiT, rac specifiurad Seesabameba mocemul mtkicebulebas an reko-
mendacias an sistematiur momoxilvas
saWiroebs maRali xarisxis klinikuri, magram ara randomizirebuli kvlevis
B Catarebas, romelic Seesabameba rekomendaciis Sinaarss.
 saWiroebs mtkicebulebebis arsebobas, romlebic dafuZnebulia eqspertTa
komisiis daskvnaze an maT azrze da/an dafuZnebulia am dargSi cnobili
C 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 profilaqti-
kis 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 Ta-
namedrove Sexedulebebi, aRwerilia daxmarebis aRmoCenisa da profilaqtikis
ZiriTadi meTodebi.

Sesavali

adreuli mSobiarobis Semdgomi sisxlisdenebi Seadgens yvela sameano sis-

xldenebis did nawils.
janmos oficialuri ganmartebebis mixedviT, adreul mSobiarobis Semdgom sis-
xldenas 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 hema-
tokritis 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 yurad-
Reba. 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 ganmavlo-
baSi an 150 ml/wT.
dakarguli sisxlis raodenobis klinikuri Sefaseba ar asis saimedo da aqvs tenden-
cia 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 ga-
datanili koagulopaTia pacientsa an mis axloblebSi, aseve qalis mier antikoagu-
lantebis moxmarebis faqti. srulma fizikalurma daTvalierebam SeiZleba gamoa-
vlinos sisxlCaqcevebis an peteqiebis arseboba. am SemTxvevaSi unda Catardes
laboratoriuli kvleva hemostazis sistemis mdgomareobis gamosakvlevad da gan-
xiluli iyos sakiTxi Sesabamisi specialistebis CarTvisa.
yvela dagegmili procedura ganxiluli unda iyos pacientTan erTad. garTule-
bebis riski, maT Soris sisxldenis ganviTarebis riski zustad unda iyos formulirebuli
da Setanili qalis individualur istoriaSi. sisxldenis ganviTarebis riskTan dakavSire-
bulia zogierTi klinikuri mdgomareobebi da maTi mkurnalobis qirurgiuli meTode-
bi: saSvilosnos gare orsuloba, miomeqtomia, normalurad mimagrebuli placentis
naadrevi acla, placentis winamdebareoba.
gansakuTrebuli yuradReba unda mieqces im qalebs, romlebic uars ambo-
ben 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
C
Sesabamisi RonisZiebebi

risk-faqtorebi, romlebic ganisazRvreba mSobiarobis win

SansTa Tanafardobis Sefaseba mSobiarobis Semdgomi sisxldenis ganviTarebis

TvalsazrisiT mocemulua cxrilSi .

yvela moyvanil SemTxvevaSi SansTa Tanafardoba aRwevda statistikur mniSv-

nelobas da doneebi damrgvalebuli iyo erTamde.

Semdegi faqtorebi dakavSirebulia mSobiarobis Semdgomi B si-

sxlisdenis ganviTarebis maRal riskTan. maTi mSobiaroba unda
Catardes II an III doni sameano dawesebulebaSi.

SansTa Tanafardoba
sameano sisxldenis
risk faqtori
ganviTarebis
TvalsazrisiT.
normalurad mimagrebuli placentis dadasturebuli C
13
acla.
placentis diagnostirebuli winamdebareoba 12

mravalnayofiani orsuloba 5
orsulobiT gamowveuli preeklamfsia/hipertenzia 4

Semdegi faqtorebi aseve dakavSirebulia mniSvnelovan

(Tumca ufro mcire) riskTan mSobiarobis Semdgomi sisxldenis
B
ganviTarebis TvalsazrisiT.

SansTa Tanafardoba
risk faqtori sameano sisxldenis gan-
vitarebis TvalsazrisiT
1• pirveladi mSobiare 3
1• mSobiarobis Semdgomi sisxldena
3
anamnezSi
1• aziuri eTnikuri kuTvnileba. 2
1• gacximovneba 2

risk-faqtorebi mSobiarobis dros

Semdegi risk-faqtorebi, romlebic Tavs iCens mSobiarobis dros,

dakavSirebulia mSobiarobis Semdgomi sisxldenis gan- B
viTarebis maRal riskTan. maTi arseboba moiTxovs per-
sonalis mxriv pacientisadmi zedmiwevniT dakvirvebas

SansTa Tanafar-
doba sameano sis-
risk faqtori
xldenis ganviTarebis
TvalsazrisiT.
1• saswrafo sakeisro kveTa 9
1• gegmiuri sakeisro kveTa 4
1• placentis nawilebis CarCena 5
1• epiziotomia 5
1• operaciuli saSosmxrivi mSobiaroba 2
1• gaxangrZlivebuli mSobiaroba (>12sT) 2
1• didi nayofi (>4kg) 2
1• cxeleba mSobiarobis dros 2
rogorc wesi sisxlis denis etiologia ganisazRvreba 4 mTavari faqtoris gaTval-
iswinebiT “tonusi, qsovili, travma da trombini -koagulopaTia)

tabula 1

etiologiuri faqtori klinikuri risk- faqtori

saSvilosnos SekumS- saSvilosnos gadaWimva  mravalwylianoba
vis anomalia (tonusi)  mravalnayofiani or-
- 70% suloba
 didi nayofi
saSvilosnos kunTebis  swrafi mSobiaroba
gadaRla  gaxangZlivebuli
mSobiaroba
 mravali mSobiaroba
anamnezSi
 oqsitocinis
gamoyeneba
intraamnionuri infeqcia  cxeleba
 xangrZlivi uwylo pe-
riodi
saSvilosnos  fibromatozuli saSvi-
funqciuri/anatomiuri pa- losno
Tologia  placentis winmdeba-
reoba
 saSvilosnos anoma-
liebi
 halogenizirebuli saa-
saSvilosnos relaqsantebi nesTezio saSualeba
 nitroglicerini
CarCenili qsovilebi CarCenili qsovilebi arasrulfasovani placentis
(qsovili) 10% anomaliuri placentacia dabadeba
CarCenili wilaki an da- operaciebi saSvilosnoze
matebiTi wili mravalnamSobiarevi qali
placentis anomalia ubg-It
CarCenili koltebi atonuri saSvilosno
genitaluri traqtis yelis, saSos an Sorisis swrafi mSobiaroba
tramvatizmi (tramva) Caxevebi operaciuli mSobiaroba
20% sakeisro kveTa nayofis araswori mdeba-
reoba

saSvilosnos gaxeva operaciebi saSvilosnoze

saSvilosnos gadmobru- mravalnamSobiarevi qali
neba placentis lokalizacia fuZe-
ze
koagulopaTiebi hemofilia A Tandayolili koagulopaTia
(Trombini) -1% von vilenbrandis anamnezSi
daavadeba RviZlis paTologia anam-
nezSi
Trombocitopenia momatebuli wneva
dsSs-is sindromi nayofis sikvdili
preeklamfsia cxeleba, neitrofilia an nei-
mkvdari nayofi tropenia
mZime infeqcia sisxldena orsulobisas
placentis naadrevi uecari kolafsi
acla
amnionuri siTxis
embolia
Terapia antikoagulante- Trombolizuri daavadeba
biT anamnezSi

mSobiarobis Semdgomi sisxldenis profilaqtika

mesame periodis aqtiuri marTva.

meta-analizma, romelic Catarda mSobiarobis mesame periodis aqti-

uri 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, (prepar-
atebis Sesaferisi Senaxva, personali) misoprostoli aris arCevis preparati mSobi-
arobis Semdgomi sisxldenis profilaqtikisaTvis.
ukanaskneli kvlevebic adastureben misoprostolis gamoyenebis efeqturo-
bas mSobiarobis Semdgomi sisxldenis profilaqtikisaTvis.

mSobiarobis mesame periodis aqtiuri marTva unda ganxorcieldes

yvela qalSi, radganac aseTi taqtika mniSvnelovnad amcirebs saS-
vilosnos hipotoniiT gamowveuli mSobiarobis Semdgomi sisxldenis al-
baTobas
mSobiarobis III periodis aqtiuri marTva moicavs Carevebs, romlebic tardeba pla-
centis mocilebis gaadvilebis mizniT saSvilosnos SekumSvebis stimulaciisa da
mSobiarobis Semdgomi sisxldenis profilaqtikisaTvis. taqtikis ZiriTadi komponen-
tebia:
• 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 palpa-

cia 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 saSuale-

bebis gamoyeneba, magaliTad, ergometrini 0,2 mg kunTSi, an misoprostoli 400-
600 mkg peroralurad. unda aRvniSnod, rom misoprostolis peroraluri miReba
unda gadavdoT im SemTxvevisaTvis, rodesac oqsitocinis an alkaloidebis usa-
frTxo daniSvna an maTi ineqciuri formebis Senaxva SeuZlebelia. Mmiso-
porostolo 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 me-
Tilergometrinis 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 gansaxor-
cieleblad
3. Wiplaris msubuqi daWimvis pirobebSi unda davelodoT saSvilosnos Zlier Se-
kumSvas (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 ze-

viT kontr-zewolis ganxorcielebis gareSe, kargad SekumSuli saSvilosnos
pirobebSi

6. placentis dabadebis Semdeg is unda daviWiroT ori xeliT da RerZis irgvliv da-
trialebiT mivaRwioT garsebis dabadebas
7. garsebis defeqtis SemTxvevaSi saWiroa saSos zeda nawilis frTxili daTvaliere-
ba steriluri xelTaTmanebiT da gamoviyenoT pinceti CarCenili garsebis gamoyofi-
saTvis
8. saaWiroa garsebis saguldagulo daTvaliereba da maTi mTlianobis Semowme-
ba. Tu aRiniSneba garsebis defeqti, saWiroa Sesabamisi moqmedebebis ganxor-
cieleba.

saSvilosnos masaJis ganxorcieleba

1. saSvilosnos fuZis masaJi unda gakeTdes manamde, sanam is srulad ar Sei-
kumSeba.
2. yoveli 15 wT unda Catardes saSvilosnos palpacia da saWiroebis SemTxveva-
Si masaJi ganmeordes mSobiarobidan 2 sT-is ganmavlobaSi.
3. saWiroa davrwmundeT, rom saSvilosno ar dundeba saSvilosnos masaJis Cata-
rebis 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 A

mesame periodis marTvis dros, radganac es procedura amcirebs
mSobiarobis Semdgomi sisxldenis ganviTarebis risks daaxloebiT
60%-iT

qalTa im kategoriisaTvis, romelTanac gadawyvetilia mxolod oqsitocinis

Seyvana, preparatis sasurvel dozas warmoadgens 10 erT oq-
sitocini. mxedvelobaSia misaRebi, rom 10 erT oqsitocinis Seyva-
nisas 0,5 mg ergometrinTan erTad
A
profilaqtikuri efeqti mcirdeba

mSobiarobis Semdgomi sisxlis denis diferenciuli diagnostika

tipiuri simptomebi SesaZlo simptomebi savaraudo

diagnozi
• sisxlis ikargeba saSodan pla- • Sokis simptomebi
centis dabadebis Semdeg; saSvilosnos
• saSvilosnos rbili konsisten- atonia
cia;
• saSvilosno ar ikumSeba
• profuzuli sisxldena saSvilos- • Sokis simptomebi;
saSvilosnos
nodan; • saSvilosnos fuZe ar isin-
gad-
• mwvave tkivili muclis RruSi jeba;
mobruneba
• saSvilosnos fuZe Cans sa-
Sos karibWeSi
• sisxldena (Sinagani an • Sokis simptomebi;
garegani) • muclis Seberiloba, Tavisufa- saSvilosnos
• gamoxatuli tkivilis sindromi; li siTxe muclis RruSi; gaxeva
• dedis gamoxatuli taqikardia
• nayofis gulis cemis Secvla
• sisxldena (Sinagani an • saSvilosnos mkvrivi konsist-
momyolis
garegani) encia
mWidro
• momyolis mocilebisa da mimagreba
gamoyofis niSnebis ar arse-
boba 30 wuTis ganmavlobaSi
• sisxldena; • saSvilosnos mkvrivi kon- momyolis
• placentaruli qsovilis an sistencia; nawilebis Car-
garsebis defeqti momyolis Cena
daTvalierebisas
• garegani sisxldena; • saSvilosnos mkvrivi konsist- rbili samSobi-
• momyolis defeqtis ar arse- encia; aro gzebis
boba 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 60-80-
mde 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 rean-
imaciuli RonisZiebebis Catareba da hemostazi, izrdeba sikvdilis Sansi.

sisxlis danakargi orsulobis dros

Sisxlis danarki Aarteriuli Simptomebi Sokis xarisxi
wneva
10-15%( 500 -1000 normis fargleb- Taqikardia kompemsatoruli
ml) Si
15-25% ( 1000-1500 umvniSnelo taqikardia da wyur- Mmsubuqi
ml) daweva vilis SegrZneba

25-35%(1500–2000 70-80 mm fermkrTali kani civi saSualo

ofli da hipoTermia,
ml)
qoSini, oliguria (30
ml-ze naklebi Sardis
gamoyofa 1 saaTSi)
35-45% (2000- 50-70 mm kollapsi, anuria MmZime
3000ml)

klinicistebi kargad unda icnobdnen hemoragiuli Sokis suraTs da C

stadiebs

mSobiarobis Semdgomi sisxlis denis efeqturi marTva

gulisxmobs erTdroulad 4 mimarTulebiT moqmedebas:

1. komunikacia
samedicino personali unda iyos mzadyofnaSi da xelmisawvdomi. arsebuli perso-
nali unda Sedgebodes gamocdili meanebis, anesTeziologebis, eqTnebis, saope-
racio personalis, hematologis, iseve rogorc masalebisa da sisxlis produqtebis
gadamtani personalisagan.

2. reanimacia

pacientis marTva hemoragiuli Sokis dros

adreuli reanimaciuli RonisZiebebi moicavs sisxldenis SeCerebasa da mo-

cirkulire 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, SeZ-
lebisdagvarad zogadi qirurgis, sisxlZarRvTa qirurgis, reanimatologis, hematolo-
gis) aucilebelia masiuri sisxldenisa da Sokis pirvelive niSnebis gamovlenis Ta-
neve. aucilebelia SevatyobinoT sisxlis gadasxmis samsaxuris da laboratorias. vi-
nidan ujredTa kvdoma warmoadgens Sokis bolo stadias, yvela moqmedeba mi-
marTuli unda iyos qsovilebis oqsigenaciis aRsadgenad. am miznis misaRwevad
saWiroa Semdegi momentebis gaTvaliswineba: Jangbadis miwodebis uzrunvel-
yofa, 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,
 • Tavisufali samedicino personalis mobilizacia
gadaudebe • pacientis sasicocxlo parametrebis monitoringi (pulsi, arteri-
li uli wneva, sunTqva, temperatura)
RonisZiebe • pacientis moTavseba gverdze pirnaRebi masebiT aspiraciis
bi riskis Sesamcireblad da adeqvaturi ventilaciis uzrunvelsay-
ofad
• siTburi reJimis uzrunvelyofa sacicocxlo organoebis sisxliT
avsebis gaumjobesebisaTvis
• pacientis fexebis aweva sasicocxlo organoebis sisxliT mo-
maragebis optimizaciisaTvis
• intravenuri infuzia (2 venaSi) kanulis an didi zomis nemsis
gamoyenebiT (#16)
specifiuri • sisxlis aReba hemoglobinis donis, sisxlis jgufisa da rezus-fa-
RonisZiebe qtoris, donoris sisxlTan SeTavsebisa da Sededebis drois
bi gansazRvrisaTvis
• pirveli saaTis ganmavlobaSi aucilebelia ara nakleb 3 litri
kristaloidebis gadasxma, rac Cveulebriv sakmarisia Sokidan
gamosayvanad
• saWiroa Tavidan aviciloT plazmis Semcvlelebis infu-
zia (hek, deqstranebi). ar arsebobs mtkicebulebebi imis
Sesaxeb, rom es xsnarebi ufro efeqturia pacientebis hemo-
ragiuli 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 danakar-
gis monitoringi
• diurezis kontroli mudmivi kaTeteriT
• Jangbadis sveli wesiT miwodeba niRabiT an nazaluri milid-
an 6-8 litri/wuTSi siCqariT
mizezebis • aucilebelia sisxlis denis mizezisa da wyaros dadgena maTi
gavlena da likvidaciiT
hS-Tan
brZolis
taqtika

mocirkulire sisxlis moculobis aRdgena

mocirkulire sisxlis moculobis aRdgena unda daiwyos kristaloidebis da ko-

loidebis gadasxmiT. dawyebiTi mkurnaloba moicavs 1-2l kristaloidebis Seyva-
nas. mocirkulire sisxlis moculobis saswrafo aRdgenisaTvis saWiroa ganxorciel-
des midgoma erT (an ramodenime) periferiul venasTan, amave dros gamoye-
nebuli unda iyos didi diametris kaTeterebi (14-16G) SesaZlebelia ganxiluli iyos
sakiTxi centraluri kaTeteris dayenebasTan dakavSirebiT, magram unda gaviTva-
liswinoT, rom mocirkulire sisxlis moculobis swrafi aRdgenisaTvis centraluri venis
kaTeterizacias ar gaaCnia aranairi upiratesoba. gaTvaliswinebuli unda iyos iseTi
momentebi, rogorebicaa kvalificirebuli personalis daswrebis aucilebloba, romel-
sac SeuZlia kaTeterizaciis Catareba, proceduris xangrZlivoba, aseve iseTi garTu-
lebis Tavidan acileba, rogoricaa pnevmoToraqsi. cvw-is gazomva SesaZlebelia
sasargeblo aRmoCndes usafrTxo reanimaciisaTvis im SemTxvevaSi, roca aRini-
Sneba gul-sisxlZarRvTa sistemis an filtvebis sisxlZarRvovani sistemis dazianeba
imis gaTvaliswinebiT, rom xSirad rTulia imis gaTvla, Tu siTxis ra raodenobaa sa-
Wiro qsovilebis normaluri oqsigenaciisaTvis da perfuziisaTvis, xolo siTxeebis ga-
daWarbebuli 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 mar-
jvenamxrivi ukmarisobis dros, filtvis arteriis Tromboemboliis, gulis tamponadis,
samkariani sarqvlis gamoxatuli ukmarisobis dros. cvw-is maCveneblebis daq-
veiTeba 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 war-
moadgens maTi swrafi gadanacvleba Seyvanisas sisxlZarRvSida sivrcidan sis-
xlZarRvgareTa 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. hiper-
tonuli 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, hidroqsi-
eTilis 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 mocu-
lobis aRdgenaSi pacientebTan hemoragiuli SokiT. sistematiur mimoxilvaSi ro-
melSic 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 reko-
mendebuli sameano praqtikaSi es dakavSirebulia ara imasTan, rom prepar-
atebi zegavlenas axdnen laboratoriuli testebis Sedegebze da Trombocitebis fun-
qciaze aramed imaze, rom literaturaSi arsebobs xSiri miniSnebebi deqstranebis
mSobiarobis dros gamoyenebisas mZime anafilaqsiuri reaqciebis ganviTare-
baze, 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 alterna-
tiuli variantis moZebna. saukeTeso varianti varirebs pacientis adgilmdebareo-
bisa da sxva garemoebebis mixedviT. gansakuTrebiT urgentul situaciaSi
SesaZlebelia da yvelaze saukeTeso variants warmoadgens pirveli jgufis uary-
ofiTi 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 Jang-
badis transportis funqcia drois garkveul monakveTSi.
sisxlis minimaluri moculoba, romelic saxezea ganyofilebaSi, unda gamar-
Tlebuli iyos Tanamosaxele jgufis sisxlis transportirebis drois TvalsazrisiT.

reanimaciuli RonisZiebebi hemoragiuli Sokis dros unda moicavdnen

cvw-is aRdgenas ori didi diametris kaTeteris dayenebis gziT da A
kristaloidebisa da koloidebis swrafi SeyvaniT

hemoragiuli Sokis SemTxvevaSi ar unda gamoviyenoT deqstrozis hipo- A

toniuri xsnarebi

ramdenad swrafad aris saWiro sisxli?

sisxlis moTxovnisas samSobiaro dawesebulebis samedicino personali xvdeba

rig siZneelebs (sisxlis saWiro jgufis ar arseboba, sisxlis motanis dro sisxlis ga-
daxsmis sadguridan da sxva). unda gamaxvildes yuradReba sisxlis produ-
qtebis droul miwodebaze.

mocirkulire sisxlis moculobis (csm) deficitis AaRdgenis wesi*

sisxlis dana- aRdgena ramdenad saswrafo
kargi (ml), 75 kg masis mqone orsuli qalisaTvis aris sisxli
cirkulirebadi (Mcsm sNnormSi Seadgens 75 kg X 75
sisxlis mocu-
lobisTan
ml\kg = 5625 ml)
SefardebiT %
kristaloiidebi da ko- eritracitaruli masa
loidebi

10-20% kristaloidebi rogorc wesi, ar aris

mTlianad,Lan saswrafo, sisxlis
(500-1000 kristaloidebi da ko- ara gadaxmis sadguri
loidebi ( 3:1) mzadyofnaSia
ml)
ardgena 300%
21-30% kristaloidebi da ko- saswrafoa (saWiroa 1-2
loidebi ( 3:1)
0,2% saaTSi)
(1000-1500
aRdgena 200%
ml)
31-40% kristaloidebi da ko- Zalian saswrafoa ( si-
loidebi ( 3:1) sxli saWiroa 10-15 wT-
(1500– 0,3% Si)
aRdgena 180%
1-2 erTeuli I jgufis re-
3000ml) zus-uaryofiTi sisxli, Ta-
41% da > kristaloidebi da ko- namosaxele jgufis sisx-
loidebi ( 3:1) 0,5% lis motanamde
3000 ml aRdgena 170%

* sqema mocemulia mxolod saorientaciod.

magaliTi 1: 75 kg wonis melogineSi mSobiarobis Semdgomma sixlis dana-

kargma 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), eritra-
citaruli masa 1200 x 0,2% = 240 ml

magaliTi 2: 75 kg wonis melogineSi mSobiarobis Semdgomma sixlis dana-

kargma 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

wona kg sisxlis danakargi

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 ko-

loidebi ( 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 prepar-

atebi, romlebic mimarTulia mocirkulire sisxlis moculobisa da koagulaciuri
faqtorebis aRdgenaze, romlebsac SeuZlia sisxlis Jangbadis transportuli funqciis
aRdgena.

Kkomponenti Cveneba Cveulebrivi sawyisi

doza
eriTrocitaruli masa sisxlis Jangbad-satrans- 2-4 erT* i/v
porto funqciis aRdgena
Trombocitebi Trombocitopenia sisxlde- 6-10** erT i/v
nasTan erTad
axladgayinuli plazma dadasturebuli koagulopa- 2-6*** erT i/v
Tia

Krioprecipitati koagulopaTia, fibrino- 10-20**** erT i/v

genis donis daqveiTeba

damateba:
saqarTvelos pirobebSi Trombocitaruli masisa da krioprecipitatis miReba SesaZlebelia
mxolod SekveTis micemidan 24 sT-Si, romelic praqtikulad gamoricxavs. mis gamoyene-
bas 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, ro-
melic ganzavebulia 5-15 ml plazmaSi

komponenturi Terapia saSualebas iZleva es preparatebi gamoyenebuli

iyos specifiuri miznebisaTvis. ase magaliTad, saukeTeso preparatebs hipo-
volemiis aRsadgenad warmoadgenen kristaloiduri xsnarebi. hemoragiuli Sokis
ganviTarebisas mocirkulire sisxlis moculobis aRsadgenad yvelaze farTod xmare-
bad preparats warmoadgens eriTrocitaruli masa. unda aRvniSnoT, rom janmrTel
adamianebSi Jangbadis gadamtani funqcia ar irRveva manam, sanam hemo-
globinis done ar daqveiTdeba 60-70 g/l-mde. magram klinikur situaciaSi
“hemoglobinis zRvruli done” ar unda iyos gamoyenebuli. 20-25%-ze meti sisxl-
is 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 da-
dasturebulia proTrombinisa da nawilobrivi Tromboplastinuri drois gaxangrZ-
liveba. amave dros unda gvaxsovdes, rom ar arsebobs Cvenebebi Trom-
bocitaruli masis profilaqtikuri daniSvnisaTvis, aseve plazmisa da spe-
cifiuri komponentebis daniSvnisaTvis reanimaciuli RonisZiebebis
Catarebisas hemoragiuli Sokis dros. garTulebebis albaToba sisxlis trans-
fuziisas 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 pre-
paratebis SeTboba.

sisxlis preparatebis gadasxma mizanSewonilia maSin, rodesac da-

dasturebulia sisxlis mocirkulire moculobis deficiti da is dokumentire- B
bulia mdgomareobis klinikuri SefasebiTa da hematologiuri kvlevebiT.

oqsigenacia
reanimaciis Catarebis pirvel etaps warmoadgens sasunTqi gzebis gamav-
lobis uzrunvelyofa da adeqvaturi oqsigenacia. SemTxvevaTa umravlesobaSi qi-
rurgiuli Carevis dros es uzrunvelyofilia anesTeziologis mier. regionaluri anesTe-
ziis dros aucilebelia Jangbadis damatebiTi miwodeba. im SemTxvevaSi, Tu pa-
cienti dezorientirebulia an gadaRlilia, ganxiluli unda iyos sakiTxi traqeis intuba-
ciis Sesaxeb. intubacia unda Catardes gadaudeblad, Tu aRiniSneba tkivilisadmi
mgrZnobelobis daqveiTeba. unda gvaxsovdes, rom siTxeebis masiuri infuziis
dros traqeis garkveulwilad SeSupebam SeiZleba gaarTulos intubacia, xolo filtve-
bis elastiurobis daqveiTebis gamo filtvebis xelovnuri ventilaciisas SeiZleba saWi-
ro gaxdes damatebiTi dadebiTi wnevis Seqmna.
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. ZiriT-
adi sasicocxlo niSnebi, cnobierebis mdgomareoba, gamoyofili Sardis raodenoba,
kapilaruli avseba regularulad unda iyos Sefasebuli. SesaZlebelia saWiro gaxdes
centraluri monitoringis Catareba, Tu Catarebuli mkurnaloba mosalodnelze na-
kleba defeqturia an sisxldena grZeldeba. sisxlis gamokvleva unda xdebodes
eleqtrolitebis parametrebis, koagulaciuri, hematologiuri da metaboluri jaWvebis
parametrebis gaTvlaliswinebiT. metabolizmis, eleqtrolituri balansis an koagula-
ciuri sistemis deficiti eqvemdebareba gadaudebel koreqcias. oqsigenaciis defi-
citis, filtvebis ventilaciis, pH balansis, siTxeebis balansis koreqcia unda Catardes
laboratoriuli Sedegebis gaTvaliswinebiT. zogierT SemTxvevebSi gamovlenili dar-
Rvevebis 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, preeklamf-
sia da sefsisi, magram dsS gavrcelebis dadgena rTulia mwiri populaciuri kvleve-
bis da SedarebiT dabali sixSiris gamo. rTulia aseve diagnostikuri kriteriumebis
miReba da simZimis xarisxis Sefaseba. SemoTavazebulia, rom dsS daiyos 3 Ziri-
Tad safexurad.
safexuri 1 – warmoadgens kompensatorul situacias sadac saxezea fibrinis de-
gradaciis produqtebis laboratoriuli momateba, magram sakuTriv fibrinogenis
done damakmayofilebelia da koagulaciuri darRvevis klinikuri gamovlena ar xde-
ba.
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, fibrini-
sis degradaciis produqtebis gamoCena, hemostazis darRvevebis gamoxatuli kli-
nikuri suraTi. masiurma sisxldenam mSobiarobis dros SesaZloa daaCqaros da
gaaRrmavos dsS siTxis Canacvlebisa da transfuziis Sedegad.
pacientebma, romelTac esaWiroebaT intensiuri transfuziuli Terapia, regula-
rulad 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, ad-
gili aqvs koagulaciis faqtorebisa da trombocitebis Semdgom ganzavebas. Tu aq-
tivirebuli parcialuri tromboplastinis dro protrombinis dro normaSi ar aris , unda
ganisazRvros trombinis warmoqmnisn dro, fbrinogeni, d-dimerebi. rodesac Se-
dedebis 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 maCve-
nebeli ecema 50- 109/l –mde, xolo sisxldenis kontroli gaZnelebelia saWiroa
8+12 erTeuli trombocituli masis swarafi infuzia, romelsac sasurveli win uswreb-
des axlad gayinuli plazmis bolusiT gadasxma.

adeqvaturi reanimaciuli RonisZiebebi saWiroeben Catarebuli

mkurnalobis efeqturobis mudmiv Sefasebas klinikuri Sefasebis C
CaTvliT, aseve hematologiuri, bioqimiuri da metaboluri kvlevebis Ca-
tarebas.
4. sisxldenis SeCereba

saSvilosnos atoniis Sedegad ganviTarebuli sisxldenis marTvis algor-

iTmi

adreuli mSobiarobis Semdgomi sisxldenis yvelaze xSir mizezs warmoad-

gens saSvilosnos hipotonia. magram mxedvelobaSi miRebuli unda iyos
Semdegi mdgomareobebic:

• qsovilebis CarCena saSvilosnos RruSi (placenta, garsebi, sisxlis kolte-

bi);
• 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 Sem-
degi 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 revi-
ziis 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 gaimeo-
reT 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 histereqto-
mias (gansakuTrebiT placentis winamdebareobisa da saSvilosnos gaxevis dros).

mkurnalobisadmi refraqteruli hemoragiuli Sokis ganviTarebis SemTxvev-

aTa umravlesoba meanobaSi dakavSirebulia sisxldenis gagrZelebasTan. rean-
imaciuli RonisZiebebis dawyebasTan erTad saWiroa aqtiuri zomebis Catarebis
dawyeba sisxldenis SeCerebis mizniT. normaluri arteriuli wnevis “agresiuli“ miR-
weva gamoiwvevs sisxldanakargis gazrdas sisxlismidinebis gazrdisa da
Trombebis formirebis darRvevas dazianebis adgilze. piriqiT, hipotenziis gark-
veuli done xels uwyobs Trombebis warmoqmnas da sisxlis danakargis Semcire-
bas 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 mivitan-
oT 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 er-

Tad saWiroa sisxldenis SeCerebisaken mimarTuli aqtiuri zomebis C
Catareba

mSobiarobis Semdgomi sisxlis denis dros 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 mizniT reko-

mendibulia ramodenime meTodi:

• saSvilosnos garegani bimanualuri kompresia

 o marcxena xeli Tavsdeba
saSvilosnos fuZeze da
gadaadgildeba qveviT da
SeZlebisdagvarad saS-
vilosnos 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 na-
kerebi, 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, keT-
deba relaparatomia. Sardis buSti CaiTiSeba qveviT, ris Semdegadac tardeba
ganakveTi saSvilosnos qveda segmentSi. ixsneba saSvilosnos Rru. saSvilosnos
Rru unda daTvalierdes momyolos CarCenili nawilebis evakuaciis mizniT. Sem-
deg xorcieldeba saSvilosnos gamotana Wrilobidan sisxlmdeni adgilebis aRmosa-
Cenad da aRsadgenad. Tu sisxldena difuzuri xasiaTisaa, gamoiyeneba bimanua-
luri 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 Semdeg-
nairad (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 li-
gireba teqnikurad ufro advili da
usafrTxoa SigniTa TeZos arteriis li-
girebasTan SedarebiT. misi
ganxorcieleba Semdegnairad
xdeba. pirvel rigSi ganivad ik-
veTeba SardbuSt-saSvilosnos na-
oWi da Semdeg Sardis buSti mo-
bilizdeba qveviT. Semdeg saS-
vilosno aiweva zeviT da sisxlZar-
Rvovani fanjara identificirdeba
farTo iogis furclebs Soris – am na-
kerma SesaZloa gaiaros naw-
ilobrivad saSvilosnos lateralur
nawilSi, rac usafrTxoa. farTo atravmuli nemsi #1 qromirebuli ketgutiT an polig-
likoliT gaivlis uknidan winisaken saSvilosnos arteriis 2-3sm-iT medialurad (mi-
ometriumis nawilis CaTvliT) da arasisxlZarRvovani fanjris gavliT SardbuSt-saS-
vilosnos naoWis doneze. daTvalierdeba SardsawveTi da Sardis buSti
SemTxveviTi dazianebis gamosaricxad. procedura meordeba mopirdapire mx-
aresac. 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 ganak-
veTi, peritoneumis lateralurad SardsawveTis paralelurad. SardsawveTi da peri-
tonealuri nakeci xSirad medialurad aris ganlagebuli. TSa xSirad midis Tavisu-
flad, sanam gamoiyofa ukana toti. rodesac ukana toti gamoeyofa TSa-s mTavar
Reros, es ukanaskneli midis Tavisuflad Sida TeZos venidan. marjvena kuTxis mo-
mWeris 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 sis-
xlmomaragebis darRveva TeZos SigniTa arteriidan ukana totis gamosvlis adgilis
zeviT arteriis SemTxveviTi gadakvanZvis Sedegad, menjis iSemiuri dazianeba
da TeZos venis dazianeba.
 histereqtomiis ad-
reuli Catareba
gansakuTrebiT
rekomendebulia
im SemTxvevaSi,
rodesac mSobi-
arobis Semdgomi
sisxldena kombin-
irebulia placentis
mWidro mimagre-
basTan/CazrdasT-
an, saSvilosnos
gaxevasTan, aseve
im SemTxvevebSi,
rodesac personali
srulad flobs pro-
ceduris Catarebis
teqnologias..
Caatarda masiuri sameano sisxldenebis qirurgiuli mkurnalobis meTodebis analizi
da gaakeTda aqcenti imaze, rom histereqtomiis gadavadeba ar SeiZleba pa-
cientis terminaluri mdgomareobis dadgomamde, ar unda daixarjos dro nakle-
bad radikalur Carevebze, miT ufro, Tu eqims ar gaaCnia maTi Catarebis
gamocdileba. am mklevarebma gamoTqves azri, rom subtotaluri histereqtomia
warmoadgens arCevanis meTods mSobiarobis Semdgomi sisxldenis SemTxvev-
aTa umravlesobaSi, xolo saSvilosnos yelis takvis kibos ganviTarebis riski Sem-
dgom wlebSi ver edreba risks sicocxlisaTvis saSiSi sisxldenis dros.

yvela sameano dawesebulebaSi unda tardebodes regularuli saswavlo

gangaSebi, raTa TiToeulma multidisciplinaruli jgufis wevrma zustad C
icodes Tavisi movaleobani mSobiarobis Semdgomi sisxlis denis dros