antenataluri meTvalyureoba fiziologiurad mimdinare orsulobis dros

antenataluri meTvalyureobafiziologiurad mimdinareorsulobis drosklinikuri praqtikis erovnuli rekomendacia(gaidlaini)

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)`antenataluri meTvalyureoba fiziologiurad mimdinareorsulobis dros” miRebulia klinikuri praqtikis erovnulirekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifostandartebis (protokolebi) SemuSavebis, Sefasebis da danergviserovnuli sabWos 2007 wlis 21 martis #1 sxdomaze dadamtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuridacvis ministris 2007 wlis 27 agvistos # 262/o brZanebiT.2

antenataluri meTvalyureoba fiziologiuradmimdinare orsulobis drosklinikuri rekomendaciebis zogadi mizani⇒ antenataluri meTvalyureobis Sesaxeb meanebis, bebiaqalebis, ojaxiseqimebis, menejerebisa da sxva dainteresebuli pirebisaTvis uaxlesisamecniero informaciis miwodeba fiziologiurad mimdinareorsulobis dros;⇒ antenataluri meTvalyureobis mqone orsulTa ricxvis gazrda;⇒ orsulebisa da maTi ojaxis wevrebis sanitaruli ganaTlebisgaumjobeseba.ganxiluli klinikuri sakiTxebi⇒ mocemuli klinikuri rekomendaciebi ar ganixilaven im garTulebebs,romlebic SeiZleba warmoiSvas orsulobis dros, aseve mSobiarobisada mSobiarobis Semdgomi periodis marTvis Taviseburebebs. impacientTa SesarCevad, romelTaTvisac SesaZlebelia mocemulirekomendaciebis gamoyeneba, SemoTavazebulia SefasebiTi cxrilisgamoyeneba. (cxrili 1).gaidlaini gankuTvnilia:⇒ mocemuli rekomendacia SeiZleba gamoyenebuli iyos im samedicinopersonalis mier, romelTac exebaT orsulTa mSobiarobamdelimeTvalyureobis sakiTxebi.antenataluri meTvalyureobis Tanamedrove models safuZveli Caeyara me-20saukunis dasawyisSi da am droidan farTod gamoiyeneba msoflioSi. dRemdeantenataluri vizitebis komponentebi da Sinaarsi ar iyo mecnieruladdasabuTebuli. 1972 wels arCi kohrani werda: 7 “samwuxarod, antenatalurimeTvalyureoba ar moicavs kritikul Sefasebas, Tu romeli skrininguliprocedurebia dasabuTebuli.”1998 wels janmo/evropis perinataluri daxmarebis samuSao jgufis meoreSexvedraze 8 Camoyalibda perinataluri daxmarebis principebi, sadacgamocxadda, rom orsulobis dros yvela Carevas unda hqondes mkacriCveneba da rac mTavaria, damtkicebuli dadebiTi zegavlena orsulobisgamosavalze.samwuxarod, dRemde orsulobis meTvalyureobis dros xSirad gamoiyenebaCarevebi, romlebic dafuZnebulia kerZo gamocdilebasa da STabeWdilebebze,ar efuZneba samecniero mtkicebulebebs da amrigad, ar axdens dadebiTzegavlenas dedisa da bavSvis janmrTelobaze.mocemul Lklinikur rekomendaciebSi Sejamebulia ukanasknelimtkicebulebebi, romelTa mixedviTac unda mimdinareobdes antenataluridakvirveba fiziologiurad mimdinare orsulobis dros.3

antenataluri meTvalyureobis miznebimiuxedavad imisa, rom Tanamedrove mtkicebulebebis mixedviT antenatalurimeTvalyureoba ar aumjobesebs mSobiarobis gamosavals 9 , is exmareba qals danayofs janmrTelobis SenarCunebaSi. antenataluri momzadeba gulisxmobsaseve orsuli qalis, misi partniorisa an ojaxis daxmarebasa damxardaWeras. es niSnavs imas, rom personali awarmoebs ara martosamedicino meTvalyureobas orsulze, aramed axorcielebs maTganaTlebasac.samedicino personalis roli:• orsulis janmrTelobis gaumjobesebisaken mimarTuli saqmianobisdaxvewa;• daavadebebis profilaqtikuri RonisZiebebis gatareba;• samkurnalo RonisZiebebis gaweva;• kavSiris uzrunvelyofa iseT samsaxurebTan, rogorebic aris orsulTaspecializirebuli daxmareba, mSobelTa momzadeba da sxva;• orsulTa swavlebis uzrunvelyofa, janmrTelobasTan dakavSirebulicodnisa da unar-Cvevebis gaRrmaveba;• qalis mxardaWera, mzadyofna orsulobis, mSobiarobisa da mSobiarobisSemdgom periodTan dakavSirebul nebismier sakiTxze misi azrismosasmenad;• orsuli qalebisaTvis socialur-samarTleblivi daxmarebis aRmoCenasaqarTvelos kanonmdeblobis Sesabamisad.Tu ra saxis meTvalyureoba unda gaewioT qalebs fiziologiuri orsulobiTada meores mxriv, garTulebuli orsulobiTa da mSobiarobiT. ganisazRvrebaantenatalur meTvalyureobis dros. sakiTxebi Seexeba aseve vizitebissixSires, momsaxureobis saxes, testebsa da analizebs, romlebic SeiZlebaSevTavazoT qalebs yoveli vizitis dros. aucilebelia vicodeT dagaviTviswinoT qalis azri maTi movlis Sesaxeb orsulobis nebismier vadaze. 10orsulTa ayvana aRricxvaze2005 wels saqarTveloSi Catarebuli mimoxilvis monacemebiT 11 4 da metiviziti Seasrula orsulTa 75%-ma. 4 an meti vizitis Sesruleba ufro xSiradmoxda TbilisSi (90%) da imereTSi (83%), sxva regionebTan SedarebiT. yvelazedabali maCveneblebi dafiqsirda qvemo qarTlisa da kaxeTis regionebSi (56%da 59% Sesabamisad). Aantenataluri vizitebis raodenoba yvelaze maRali iyoqarTvel qalebSi, romelTa 80%-s hqonda 4 prenataluri viziti. mimoxilvisSedegebidan gamomdinare, mSobiareTa mxolod 5%-s ar Cautarda prenatalurimeTvalureoba. es maCvenebeli ufro dabali iyo qalaqis pirobebSi daSeadgenda 2%-s, TbilisSi ki am maCvenebelma Seadgina mxolod 1%.arsebobs mravali mizezi, romelTa gamo orsulebi ar mimarTaven pirveladsamedicinodawesebulebebs, magram umetes wilad ZiriTad mizezebadgvevlineba Semdegi:• vizitis Sesaxeb gadawyvetileba miRebulia ara TviTon qalis, aramed misiojaxis wevrebis mier, romlebic ar xedaven amis aucileblobas da zogjerar endobian samedicino personalis momsaxureobas, gansakuTrebiT soflispirobebSi;4

• samedicino momsaxureobis gawevisas orsulTan urTierToba xSirad ar arismegobruli, ar aris daculi konfidencialuroba, keTdeba dausabuTebelianalizebi, Carevebi da gamokvlevebi;• arsebobs samedicino procedurebis SiSi qalis arasrulfasovaniinformirebis gamo;• xSir mizezs warmoadgens Sori manZili da transportis problemebi,zogierTi kulturuli Taviseburebebi da aseve socialur-ekonomiuriproblemebi.vin unda uzrunvelyos meTvalyureobasistematurma mimoxilvam 12 Seafasa antenataluri meTvalyureobis efeqturobabebiaqalisa da ojaxis eqimis mier gaweuli daxmarebis Sedarebis gziT meanginekologismier gaweul daxmarebasTan. jgufebs Soris ar gamovlenilagansxvaveba naadrevi mSobiarobis, sakeisro kveTis, anemiis, saSarde gzebisinfeqciebis, mSobiarobamdeli sisxldenebisa da perinataluri sikvdilianobisganviTarebis sixSiris TvalsazrisiT. am mimoxilvidan gamomdinare,bebiaqalebisa da ojaxis eqimebis mier aRmoCenili daxmareba dakavSirebuliaorsulobasTan dakavSirebuli hipertenziisa da preeklamfsiis ganviTarebisstatistikurad ufro dabal sixSiresTan ( OR 0.56, 95% CI 0.45 - 0.70), (OR 0.37, 95%CI 0.22 - 0.64) standartuli meTvalyureobis jgufTan SedarebiT. 3 kvlevis metaanalizzedayrdnobiT, romelSic monawileobda 3 041 qali, bebiaqalebisa dazogadi profilis eqimebis mier gaweuli antenataluri meTvalyureobispirobebSi dabali riskis mqone qalebisaTvis ar izrdeboda dedisa daperinataluri gamosavalis riski.miuxedavad imisa, rom miRebuli monacemebi sarwmunod mowmoben bebiaqalebisada ojaxis eqimebis mier gaweuli antenataluri meTvalyureobis upiratesobazefiziologiurad mimdinare orsulobis dros, arsebuli kanonmdebloba daojaxis eqimebisa da bebiaqalebis momzadebis done ar iZleva saSualebasmocemuli rekomendaciis danergvisaTvis.fiziologiuri orsulobis dros sakmarisia saTanadoT momzadebulibebiaqalis an ojaxis eqimis mier ganxorcielebuli meTvalyureoba.mean-ginekologis rutinuli CarTva meTvalyureobis procesSi aseTSemTxvevebSi ar aumjobesebs perinatalur gamosavals, gardagarTulebuli orsulobis SemTxvevebisa.Aantenataluri meTvalyureobaantenataluri momzadebis kursebi xSirad gamoiyeneba momavali mSoblebisaTvisorsulobis da mSobiarobis Sesaxeb, agreTve dedobisa da mamobis sakiTxebzeinformaciis misawodeblad. antenataluri meTvalyureoba eyrdnoba farTosaganmanaTleblo da mxardamWer koncefcias, romelic exmareba momavalmSoblebs gaacnobieron sakuTari socialuri, emociuri, fsiqologiuri dafizikuri moTxovnilebebi orsulobis, mSobiarobisa da mSobiarobis Semdgomiperiodis dros da saSualebas aZlevs maT darwmundnen sakuTarSesaZleblobebSi. kiTxvarma, romlis mizani iyo informaciis mopoveba imis5

Sesaxeb, Tu ra surs qals pirvel rigSi Seityos antenatalur kursebze,gamoavlina, rom es moicavs: informacias nayofis ganviTarebis, orsulobisdros fizikuri da fsiqologiuri cvlilebebis, mSobiarobis dros movlenebisganviTarebisa da maTi moqmedebis, SesaZlo garTulebebisa da mSobiarobisSemdeg bavSvis movlis sakiTxebis Sesaxeb.orsulebi unda daeswron antenataluri momzadebis kursebs da undamiewodoT werilobiTi informacia antenataluri meTvalyureobisSesaxeb. Aorsulebs unda mivawodoT sarwmuno informacia maTmeTvalyureobasTan dakavSirebiT (mkurnalobasTan, mkurnal eqimebTanda sxv.). gadawyvetilebebis miRebis dros mxedvelobaSi aucilebladunda iyos miRebuli qalis winadadebebi da survilebi.ACuwveti meTvalyureobaqalis meTvalyureoba orsulobis, mSobiarobisa da mSobiarobis SemdgomperiodSi xSirad xorcieldeba mravali zedamxedvelis mier. mocemuliklinikuri rekomendaciis mixedviT, uwyveti meTvalyureoba gulisxmobsmeTvalyureobas erTi da imave zedamxedvelis an zedamxedvelTa jgufis miermTeli orsulobis, mSobiarobisa da mSobiarobis Semdgom periodSi.erT sistematiur mimoxilvaSi 13 Sefasda uwyveti meTvalyureobis klinikuriefeqturoba orsulobis, mSobiarobisa da postnatalur periodSi rutinulmeTvalyureobasTan SedarebiT, romelsac uzrunvelyofda ramodenimezedamxedveli. ganxorcielda 1815 qalis randomizacia Semdeg jgufebSi: qalebibebiaqalTa mcire jgufis uwyveti meTvalyureobiT, meanebisa da rutinuli(sxvadasxva zedamxedveli) meTvalyureobiT, romelsac axorcielebdnen eqimebida bebiaqalebi. qalebs, romelTa uwyvet meTvalyureobasac axorcielebdabebiaqalTa mcire jgufi, ufro iSviaTad aReniSnebodaT Semdegi monacemebi:• klinikaSi 15 wT-ze meti lodinis dro (OR 0.14. 95% CI 0.10 - 0.19);• antenataluri hospitalizacia (OR 0.79. 95% CI 0.64 - 0.97);• antenataluri klasebis gacdena (OR 0.58, 95% CI 0.41 - 0.81);• orsulobasTan dakavSirebuli SekiTxvebi (OR 0.72 95% CI 0.56 - 0.92);• mSobiarobisaTvis aradamakmayofilebeli momzadeba (OR 0.64. 95% CI 0.48 - 0.86).ar gamovlinda mniSvnelovani gansxvaveba sakeisro kveTis, mSobiarobis aRZvris,naadrevi mSobiarobisa da neonataluri sikvdilianobis, aseve axalSobilTareanimaciul ganyofilebaSi gadayvanisa da 2500 gramze mcire wonisaxalSobilebis sixSireebSi.antenataluri meTvalyureoba unda ganxorcieldes meTvalyureTamcire jgufis mier, romlebTanac orsuli komfortulad grZnobsTavs. meTvalyureoba uwyveti unda iyos mTeli antenataluriperiodis ganmavlobaSi.A6

dokumentaciaantenatalur CanawerebSi informacia 2 ZiriTadi mizniT grovdeba:• administraciisaTvis;• dedisa da nayofis riskis Sefasebisa da Semdgomi marTvis dagegmvis mizniT.antenataluri meTvalyureobis Canawerebi aseve uzrunvelyofen marTvisxarisxis Sefasebas, iuridiul dokumentacias, komunikaciasa da masalasSemdgomi epidemiologiuri kvlevebisaTvis. antenataluri istoriis Sedgenissami meTodis Sesadareblad Catarda rkk, sadac Sedarda arastruqturirebuliistoriebi, romelTac qaRaldze werdnen bebiaqalebi, struqturirebuliistoriebi (qaRaldze kiTxvaris CarTviT) da interaqtiulikompiuterizirebuli kiTxvarebi inglisis antenatalur klinikebSi. 14struqtirirebul istoriebSi Segrovda ufro meti da srulfasovaniinformacia arastruqturirebul istoriebTan SedarebiT. ar gamovlenilainteraqtiuli kompiuterizirebuli sistemebis upiratesoba struqturirebulistoriebTan SedarebiT.orsulebis saSinao baraTebimraval qveyanaSi orsulebs eZlevaT sakuTari baraTebi orsulobis drosCanawerebis gasakeTeblad, rac zrdis maTi pasuxismgeblobis grZnobas daamaRlebs kmayofilebas zedamxedvelobiT. Catarda 3 kvleva (n =675 qali) 15 .qalebi, romlebsac hqondaT sakuTari baraTebi, Tavs ufro kargadakontrolebdnen ((RR) 1.56, 95% CI 1.18 - 2.06). erTma kvlevam gamoavlina, romqalebis umetesoba (66/95) ufro kmayofili iyo gaweuli meTvalyureobiTbaraTebiT sargeblobis jgufSi, sakontrolo jgufTan SedarebiT (58/102) (RR1.22, 95% CI 0.99 - 1.52); orma kvlevam ar gamoavlina gansxvaveba qalebiskmayofilebaSi (erTma kvlevam ar warmoadgina Sedegebi da erTSi gamoyenebuliiyo 17 punqtiani kmayofilebis sqema). baraTiT sargeblobis jgufSi qalTadidma raodenobam moisurva igives ganmeoreba momavali orsulobis drosac (RR1.79, 95% CI 1.43 to 2.24). ar gamovlenila gansxvaveba mSobiarobis drosanalgeziis aucileblobis, Cveuli abortebis, naadrevi mSobiarobisa daneonataluri sikvdilianobis sixSireebSi.orsulebisaTvis informaciis miwodebaantenataluri meTvalyureobeis erT-erT prioritetul sakiTxs warmoadgensorsulisaTvis sakuTar meTvalyureobasTan dakavSirebiT informirebuligadawyvetilebebis SesaZleblobis micema: Tu vin unda ganaxorcielos misimeTvalyureoba, ra skrininguli testebi unda Cautardes da sad undadaigegmos misi mSobiaroba. am mizniT qalisaTvis xelmisawvdomi unda iyosmtkicebulebebze dafuZnebuli informacia, raTa man monawileoba miiRoszedamxedvelebTan gamarTul diskusiaSi. sinamdvileSi qalTa garkveuliraodenoba ar flobs sakmaris informacias. qalTa Sefasebam antenatalurimeTvalyureobis dros informaciis miRebisa da komunikaciis TvalsazrisiTgamoavlina, rom orsulTa 32-40%-ma miiRo arasakmarisi zepiri da werilobiTiinformacia orsulobis dros sxvadasxva skrininguli testebis Catarebissargeblianobisa da riskis Sesaxeb. 16 erT mimoxilvaSi, 17 sadac gamoikiTxa 1188orsuli, gamovlinda, rom isini isurvebdnen damatebiT informaciis miRebaspirveli vizitis dros. maRali Sefaseba mieca werilobiTi saxiT informaciismiwodebas.7

Catarda rkk mtkicebulebebze dafuZnebuli bukletebis gamoyenebisefeqturobis Sesaxeb orsul qalebSi informirebuli gadawyvetilebismiRebaze 18 . bukletebi SemuSavebuli iyo orsulisaTvis gasagebi eniT. argamovlenila mniSvnelovani gansxvaveba jgufebs Soris gadawyvetilebismiRebis TvalsazrisiT, magram kmayofileba informaciiT ufro maRali iyo imjgufSi, romelsac daurigda sainformacio bukletebi.unda SemuSavdes mkacrad gansazRvruli referaluri programebi,raTa saWiroebis SemTxvevaSi orsuls droulad aRmovuCinoT sxvaspecialobis eqimis konsultacia.garemo pirobebi, romelSic tardeba antenataluri vizitebi, undaganawyobdes orsuls gulaxdili saubrisaTvis (mag: ojaxuriproblemebi da seqsualuri Zaladoba, fsiqiuri daavadebebi da sxv.)yoveli antenataluri vizitis dros eqimebma da bebiaqalebma orsulsunda miawodon amomwuravi informacia misTvis sainteresosakiTxebze.informaciis miwodeba unda xdebodes orsulisaTvis gasagebi eniT,fizikuri da fsiqikuri naklovanebebis arsebobis SemTxvevaSi maTigaTvaliswinebiT.Dspspantenataluri vizitebis sixSirefiziologiurad mimdinare orsulobis dros antenataluri vizitebisraodenoba SeiZleba Semcirdes 4-mde dedisa da nayofis janmrTelobismdgomareobisaTvis zianis miyenebis gareSe. kerZod, gamovlinda, rom 4 vizitisCatarebisas ar izrdeboda dedisa da perinataluri sikvdilianoba,preeklamfsiis, Sard-sasqeso traqtis infeqciebis sixSire da sxeulis dabaliwoniT dabadebul bavSvTa raodenoba (>2500 g) mtkicebulebebi adastureben imSexedulebas, rom ganviTarebul qveynebSi, sadac kargad aris organizebulisameano servisi, prenataluri vizitebis Semcireba dakavSirebulia iseTivekarg perinatalur gamosavalTan, rogorc standartuli modelisgamoyenebisas. mosalodneli iyo, rom vizitebis raodenobis Semcirebasmoyveboda ukmayofileba qalTa mxridan. ganviaTarebad qveynebSi Catarebulmaorma kvlevam daamtkica igive mosazreba am sakiTxze.arsebuli mtkicebulebebis Tanaxmad 4 antenataluri vizitis sqemawarmoadgens im minimums, romelic unda SevTavazoT dabali riskis jgufisorsulebs. 23samedicino personals unda mieces saSualeba, saorientacio sqemazedayrdnobiT TviTon gadawyvitos vizitebis sixSire, maT Soris mSobiarobisSemdegac. sxva sityvebiT rom vTqvaT, upiratesoba eniWeba gamosavalzeorientirebul antenataluri meTvalyureobis models.8

antenataluri vizitebis Sinaarsipirveli vizitipirveli viziti unda ganxorcieldes orsulobis adreul vadaze (13 kviramde).didi raodenobis informaciis miwodebis aucileblobis gamo SesaZlebeliapirveli vizitis gayofa or nawilad:• orsuls miewodos informacia da mieces SesaZlebloba dasvas SekiTxvebida monawileoba miiRos diskusiaSi. informacia dietis, cxovrebis wesis,gamokvlevis meTodebis, orsulobis dros arsebuli momsaxureobisa dasxva aspeqtebis Sesaxeb unda iyos rogorc zepiri, aseve werilobiTiformiT• unda gamovlindes qalTa is kategoria, romelic saWiroebs damatebiTmeTvalyureobas da daigegmos meTvalyureoba Semdegi kategoriisorsulebisaTvis: (cxrili 1)cxrili 1sameano anamnezi• hqonda Tu ara orsuls naadrevi mSobiaroba an mkvdradSobadobaanamnezSi?• hqonda Tu ara 3 Cveuli aborti TanmimdevrobiT?• xom ar aRiniSneboda ukanaskneli mSobiarobisas axalSobilissxeulis masa 4500gramze?• hqonda Tu ara adgili ukanaskneli orsulobis dros klinikaSihospitalizacias hipertenziis, preeklamfsiisa an eklamfsiis gamo?• iyo Tu ara Catarebuli raime operacia reproduqciuliorganoebze? (miomeqtomia, tixris mocileba, biofsia, klasikurisakeisro kveTa, saSvilosnos yelis serklaJi)mimdinare orsuloba• xom ar iyo diagnostirebuli an eWvis qveS mravalnayofianiorsuloba?• xom ar aris asaki 16 welze naklebi?• xom ar aris asaki 40 welze meti?• xom ar aRiniSneboda rezus-izoimunizacia wina an mimdinareorsulobis dros?• xom ar aRiniSneboda sisxldena saSodan?• xom ar aris raime simsivne menjis RruSi?• xom ar aris arteriuli diastoluri wneva 90 mm/vwy/sv-ze meti?9

zogadi samedicino problemebi• xom ar aRiniSneba insulin-damokidebuli Saqriani diabeti?• xom ar aRiniSneba Tirkmelebis daavadeba?• xom ar aRiniSneba gulis daavadebebi?• xom ara aqvs adgili mavne nivTierebebis moxmarebas? (maT Sorisalkoholis didi raodenobiT miRebas?)• xom ar aRiniSneba raime sxva daavadeba?dadebiTi pasuxi romelime zemoT aRniSnul SekiTxvaze miuTiTebs, rommocemuli klinikuri rekomendaciebi am orsulTan mimarTebaSi arunda iyos gamoyenebuli.I antenataluri vizitis dros:• unda ganisazRvros sisxlis jgufi da rezus faqtori;• Catardes sisxlis saerTo analizi;• Catardes anemiis, aiv/Sidsis, B-hepatitis, wiTurisa da sifilisisskriningi swrafi martivi meTodiT;• wiTuras skriningi gansazRvrulia orsulis imunuri statusis dasadgenadda orsulobis Semdeg saWiroebisas acris Casatareblad; kvleva ar arismowodebuli orsulobis dros nayofis mdgomareobis Sesafaseblad;• ganisazRvros sxeulis masis indeqsi;• gaizomos arteriuli wneva;• Catardes Sardis saerTo analizi (proteinuriisa da asimptomuribaqteriuriis gamosavlenad) test-xazebis meSveobiT, Sardis naleqisbaqterioskopiiT an Sardis daTesviT;• Catardes saSos nacxis baqterioskopiuli kvleva – sarkeebSi daTvaliereba• rac SeiZleba adre Catardes ultrabgeriTi kvleva gestaciuri vadisgansazRvris mizniT Semdegi parametrebis gamoyenebiT:– 10-13 kviramde Txem-kudusunis sigrZe;– 14 kviris zemoT Tavis garSemowriloba da biparietaluri zoma.• pirveli vizitis dros sasurvelia Catardes Terapevtis da stomatologiskonsultaciaSemdgomi viziti, romelic ganixleba, rogorc pirveli vizitis gagrZeleba,analizebis miRebis Semdeg unda daigegmos Semdegi mizniT:• ganixilos da Caiweros yvela Catarebuli skrininguli testis Sedegi,moxdes antenataluri meTvalyureobis SemuSavebuli gegmis gadaxedvaqalTa im kategoriis gamosavlenad, romlebic saWiroeben damatebiTmeTvalyureobas;• orsuls miewodos rogorc zepiri, ise werilobiTi informacia, romelicgaRrmavdeba antenataluri mecadineobebis Catarebisas. aseve orsuls undamieces SesaZlebloba, aqtiuri monawileoba miiRos diskusiaSi.10

meore viziti _ 18-20 kvira• 18-20 kviraze, qalis Tanxmobis SemTxvevaSi unda Catardes ultrabgeriTikvleva nayofis struqturuli anomaliebis gamosavlenad. im qalebs,romelTac orsulobis am vadaze daudgindebaT placentis kidiTimimagreba, unda CautardeT ganmeorebiTi ultrabgeriTi kvleva 36 kvirisvadaze• unda gaizomos saSvilosnos fuZis simaRle;• gaizomos arteriuli wneva da Catardes testi proteinuriis gamosavlenad;• wonis gansazRvra (mxolod dabali sxeulis masis indeqsis mqoneorsulebSi);• meore vizitis dros unda Catardes skrininguli kvleva Tandayolilsimaxinjeebze. (daunis sindromi)mesame viziti 30-32 kviraam vizitis dros unda:• ganisazRvros hemoglobinis done da 10,5 g/l naklebi maCveneblisSemTxvevaSi dainiSnos rkinis Semcvleli preparatebi;• gaizomos arteriuli wneva;• gakeTdes Sardis analizi proteinuriis gamosavlenad;• ganisazRvros saSvilosnos fuZis simaRle;• orsuls mieces laqtaciis/ kontracefciis rekomendaciebi• orsuls miewodos rogorc zepiri, aseve werilobiTi informacia, romelicgaRrmavdeba antenataluri mecadineobebis Catarebisas, miecesSesaZlebloba aqtiuri monawileoba miiRos diskusiaSimeoTxe viziti 36-38 kvira• 34 kviraze antenataluri viziti unda Catardes Semdegis mizniT:• gaizomos arteriuli wneva da Catardes testi proteinuriis gamosavlenad;• ganisazRvros hemoglobini sisxlSi;• Catardes sifilisis diagnostika swrafi martivi meTodiT;• ganisazRvros saSvilosnos fuZis simaRle;• ganisazRvros nayofis pozicia;• menjiT winamdebareobis SemTxvevaSi ganxorcieldes TaviT gareganimobruneba orsulis Tanxmobis SemTxvevaSi (stacionaris pirobebSi);• dadasturdes placentis migracia wina ultrabgeriT kvlevebTanSedarebiT;• moxdes Catarebuli Sedegebis ganxilva da dokumentireba, saWiroebisSemTxvevaSi Seicvalos orsulobis marTvis gegma da gamovlindes qalTais kategoria, romelic saWiroebs damatebiT meTvalyureobas;• orsuls mieces laqtaciis/ kontracefciis rekomendaciebi• orsuls miewodos rogorc zepiri, aseve werilobiTi informacia, romelicgaRrmavdeba antenataluri mecadineobebis Catarebisas, mivceT masSesaZlebloba, aqtiuri monawileoba miiRos diskusiaSi11

MmSobiarobis Semdgomi vizitijanmo-s rekomendaciiT mSobiarobis Semdgomi viziti unda CatardesmSobiarobis Semdgom erTi kviris ganmavlobaSi22 . miuxedavad imisa, rom esviziti ar finansirdeba saxelmwifos mier, kvlevis farglebSi saqarTveloSiCatarebulma gamokiTxvam 24 gamoavlina, rom 38% melogine gasinjuli iyosamedicino personalis mier pirveli 6 dRis ganmavlobaSi, xolo 45% orikviris Semdeg.antenataluri vizitebis grafiki ganpirobebuli unda iyos vizitebisSinaarsiT. qalisaTvis pirveli fiziologiurad mimdinareorsulobis dros sakmarisia 4 viziti.pirveli vizitis dros orsuls unda mivawodoT Semdegi informacia:orsulobis meTvalyureobis, cxovrebis stilis, dietisa dagamokvlevis meTodebis Sesaxeb.orsulobis adreul vadebze yvela qals unda miewodos informaciaantenataluri vizitebis raodenobis, droisa da Sinaarsis Sesaxeb;yoveli antenataluri viziti unda iyos dagegmili da gaaCndesgarkveuli Sinaarsi. vizitebi ufro xangrZlivi unda iyosorsulobis adreul vadebze, raTa uzrunvelyofili iyos amomwuraviinformacia. antenataluri vizitis dros unda Catardes standartiTgaTvaliswinebuli testebi da gamokvlevebi, raTa SemcirdesorsulTa ganmeorebiT vizitTan dakavSirebuli diskomforti.ACDDorsulis klinikuri gamokvlevamSobiarobis vadis gansazRvraorsulobisaTvis damaxasiaTebelia Semdegi niSnebi:• SeSupeba;• Tavis tkivili;• gulisreva da Rebineba;• sisxldena an sisxliani gamonadeni saSodan;• sarZeve jirkvlebis momatebuli mgrZnobeloba;• muclis Seberiloba da Sekruloba;• saSodan gamonadenis raodenobis gazrda;• iseTi funqciuri Civilebi, rogorebicaa uZiloba da gaRizianebadoba.zogierTi niSnebi, romlebic miiReba fizikaluri gamokvlevis Sedegad, aseveadastureben orsulobis diagnozs. am niSanTa umravlesoba vlindebaCasaxvidan me-6-8 kviras.12

• sarZeve jirkvlebis zomaSi momateba areolis hiperpigmentaciiT;• saSos kedlebisa da saSvilosnos yelis cianozi da SeSupeba;• saSvilosnos da saSvilosnos yelis isTmuri nawilis darbileba;• saSvilosnos konsistenciisa da formis cvlilebebi;• imunologiuri testebi iZleva sarwmuno Sedegebs orsulobis 6 kvirisSemdeg;orsulobis vadis gansazRvra bolo menstruaciis TariRis mixedviTdamokidebulia imaze, Tu ramdenad zustad axsovs qals TariRi, asevedamokidebulia menstrualuri ciklis xangrZlivobasa da regularobaze.gestaciuri vadis gansazRvra bolo menstruaciis mixedviT ar aris zusti 11-42%-Si. arsebobs Secdomis albaToba meore da mesame trimestrebSiultrabgeriTi kvleviT gestaciuri vadis dadgenisas, Tumca SecdomebisalbaToba naklebia, bolo menstruaciis mixedviT orsulobis vadisgansazRvrasTan SedarebiT. ultrabgeriTi gamokvlevisas 10-13 kvirazegestaciuri vadis gansazRvra xdeba Txem-kudusunis zomis mixedviT.ultrabgeriT vadis gansazRvra rutinulad unda Catardes 24 kviramde. TuultrabgeriTi kvleviTa da bolo menstruaciiT gansazRvruli orsulobisvadebi ar emTxveva, upiratesoba eniWeba ultrabgeriT kvlevis maCveneblebs. 25-27sistematurma mimoxilvam, romelSic CarTuli iyo 9 kvleva, gamoavlina, romrutinuli ultrabgeriTi kvlevis dros ufro adre vlindebodamravalnayofiani orsuloba (26 kviramde aradiagnostirebuli tyupebi OR 0.08CI 0.04-0.16) aseve rutinuli kvlevisas mcirdeboda vadagadacilebuliorsulobis gamo samSobiaro moqmedebis aRZvris sixSire (OR 0.61, 95% CI 0.52 -0.72). kvlevaSi ar gamovlinda gansxvaveba perinataluri sikvdilianobismaCveneblebs Soris (OR 0.86, 95% CI 0.67 - 1.12). rutinuli ultrabgeriTigamokvleva orsulobis adreul vadebze gvaZlevs saSualebas, ufro zustaddavadginoT orsulobis vada, adreulad gamovavlinoT mravalnayofianiorsuloba da nayofis anomaliebi. ar gamovlinda antenatalur periodSiCatarebuli ultasonografiis aranairi uaryofiTi zegavlena swavlisa daneiro-qceviT funqciebze SemdgomSi. 28ultrabgeriTi kvleva orsulobis vadis dadgenis mizniT undaCatardes orsulobis adreul vadaze (bolo menstruaciis TariRisgansazRvris magivrad). es uzrunvelyofs orsulobis vadis zustgansazRvras da amcirebs mSobiarobis induqciis aucileblobas 41kviris zeviT.ultrabgeriTi kvleva gestaciuri vadis gansazRvris mizniT undaCatardes 10-13 kviris orsulobis vadaze Txem-kudusunis zomisdadgeniT. 14 kviris orsulobis vadis Semdeg gestaciuri vadaisazRvreba Tavis garSemowerilobis an biparietaluri zomisdadgeniTsaSosmxrivi gasinjva antenatalur periodSi ar aris rekomendebuli,radganac is ar iZleva zust informacias gestaciuri vadisa annaadrevi mSobiarobis riskis Sesaxeb.AspB13

orsulis gamokvleva nayofis anomaliebis gamosavlenadnayofis struqturuli da qromosomuli anomaliebis gamosavlenad (nervuliReros Ria defeqtebi da daunis sindromi) saWiroa ultrabgeriTi kvleva daorsulis Sratis gamokvleva. kvlevis mizania, dadgindes:• anomaliebi, romlebic iwveven invalidobas an SeuTavsebadiasicocxlesTan;• anomaliebi, romelTa mkurnalobac SesaZlebelia orsulobis dros anmSobiarobis Semdgom periodSi;eqimma zustad unda auxsnas orsuls yoveli kvleviTi testis mizani, misiCatarebis detalebi, kvlevis dadebiTi an uaryofiTi Sedegebis mniSvneloba damkurnalobis SesaZlo variantebi. saWiroa orsulis informirebuli Tanxmobatestebis Catarebaze.ultrabgeriTi gamokvleva struqturuli anomaliebis gamosavlenadCatarda sistemuri mimoxilva, romelic dafuZnebuli iyo 11 kvlevaze (erTirkk, 6 retrospeqtuli kohortuli da oTxi prospeqtuli kohortuli kvleva),romelic miznad isaxavda rutinuli ultrabgeriTi gamokvlevis mniSvnelobisSeswavlas nayofis anomaliebis dadgenis mizniT. 29 kvlevebi, romlebicmoicavda 96 633 bavSvs, Catarda evropaSi, aSS-Si da koreaSi 1988-1996 ww-Si.nayofis anomaliebis saerTo gavrcelebam Seadgina 2,09% da varirebda 0,76%-dan 2,45%-mde da moicavda rogorc mcire, ise did anomaliebs.anomaliebis dadgenis sixSire 24 kviris qvemoT Seadgenda 41,3%, xolo 24kviris zemoT 18,6%. saerTo jamSi, nayofis anomaliis dadgena Seadgenda 44,7%,da varirebda 15,0%-dan 85,3%-mde. es iyo Sedegi imisa, rom zogierTi anomaliisdiagnostirebis sizuste maRali iyo. magaliTad, anencefaliis diagnostireba14-22 kviraze Seadgens SemTxvevaTa 100%-s 3014

ekomendebuli minimaluri standarti 20 kviraze anomaliisdasadgenad mocemulia inglisis mean-ginekologTasamefo kolejis mier 31 (cxrili 2).cxrili 2minimaluri standartebi 20 kviraze anomaliis dasadgenad (inglisis meanginekologTasamefo kolejis monacemebi RCOG 31 )normaluri nayofi:• Tavis forma da zoma, aseve Sida struqturebi (naTxemi, parkuWebis zomawinagulis zomaze < 10 mm)• xerxemali: gaswvrivi da ganivi skanireba• muclis forma da Semadgenloba kuWis doneze• muclis forma da Semadgenloba Tirkmelebis da Wipis doneze• Tirkmelebis menji < 5 mm wina-ukana gazomvisas;• mucel-mkerdis gaswvrivi mdgomareoba (diafragma da Sardis buSti);• gulmkerdi oTxkameriani gulis vizualizaciisas;• mklavebi: sami Zvali da xelis mtevani (ar aris saWiro TiTebis daTvla)• fexebi: sami Zvali da terfebi (ar aris saWiro TiTebis daTvla)optimaluri standarti 20 kviraze anomaliis dasadgenad:• gulis sisxlis mimoqceva;• saxe da tuCebi.gestaciis 18-20 kviraze nayofis anomaliebis dadgenis mizniT undaCatardes ultrageriTi kvleva Sesabamisad momzadebulispecialistis mier da mowodebuli standartebiT. AAdaunis sindromis skriningidaunis sindromi (21 trisomia) warmoadgens Tandayolil anomalias,romlisaTvisac damaxasiaTebelia damatebiTi 21 qromosomis arseboba. daunissindromis sixSire evropis qveynebSi Seadgens 6,2/10,000 cocxlad damkvdradSobilze.( saqarTveloSi monacemebi ar arsebobs). sindromi ZiriTadadxasiaTdeba bavSvis gonebrivi CamorCenilobiT - daavadebul bavSvTa 80%-saReniSneba mZime xarisxis gonebrivi CamorCeniloba. daunis sindromisaTvisdamaxasiaTebelia Tandayolili simaxinjeebi, romlebic SesaZloa sikvdilismizezi gaxdes (leikemia, farisebri jirkvlis daavadebebi, epilefsia,alcheimeris daavadeba). daunis sindromiT daavadebul bavSvTa daaxloebiT46%-s aReniSneba gulis Tandayolili anomaliebi, romlebic saWiroebsqirurgiul Carevas.15

daunis sindromis Tanamedrove kvlevaarsebobs mravali kvleva, romlebSic Sedarebulia daunis sindromisskrininguli testebis Semdegi kombinaciebis efeqturoba:• kombinirebuli testi – orsulobis pirvel trimestrSiultrasonografiuli kvleviT kisris naoWis sisqis, SratSi PAPP-A–sada qorionuli gonadotropinis gansazRvra.• „ormagi testi“-orsulobis 14-20 kviraze qorionuli gonadotropinisa daalfa-fetoproteinis gansazRvra.• „sammagi testi“- qorionuli gonadotropinis, alfa-fetoproteinis dauE3 –is gansazRvra.• “oTxmagi testi”- qorionuli gonadotropinis, alfa-fetoproteinis, uE3 –isa da inhibini-A-s gansazRvra.• integrirebuli testi- orsulobis 10-12 kviraze kisris naoWis sisqisa daPAPP-A gansazRvra, SemdgomSi 14-20 kviraze qorionuli gonadotropinis,alfa-fetoproteinis, uE3 –isa da inhibini A gansazRvriT.• Sratis integrirebuli testi - integrirebuli testi, kisris naoWissisqis gansazRvris gareSe.daunis sindromis kvlevis dros markerebis sxvadasxva kombinaciisgamoyenebisas miRebuli cru-dadebiTi Sedegebi da dadgenis sixSireSejamebulia Semdeg cxrilSi:markerebikisris naoWis sisqe ultrabgeritikvlevisas 9-14 kviraze*(13 kohortuli kvleva, r=170,343)kombinirebuli testi: kisrisnaoWis sisqe da Sratis kvleva(10 kvleva)“ormagi testi”(6 kohortuli kvleva, r=110,254)“sammagi testi” (20 kohortuli kvleva,r=194,326)riskis Sefardeba 1:200cru-dadebiTipasuxebissixSire(%)dadgenissixSire4,7 775 85-89monacemebi araris** 664 67“oTxmagi testi”(1 kohortuli kvleva, r=46,193) 5 85Sratis integrirebuli testi:(1 SemTxveva - kontrolis kvleva, r=28,434) 2,7integrirebuli testi:(1 SemTxveva - kontrolis kvleva, r=28,434) 1,3 85*es monacemebi miRebulia gamoqveynebuli kohortuli kvlevebidan. SURUSS monacemebi araris CarTuli imis gamo, rom es iyo SemTxveva-kontrolis kvleva da arsebobda ufro maRalidonis mtkicebulebebi.**praqtikaSi sxvadasxva skrininguli programebis gamoyenebis gamo.16

antenatalur periodSi daunis sindromis saboloo diagnozis dasma xdebainvaziuri meTodebiT nayofis ujredebis kultivirebis Semdeg. amisaTvisgamoiyeneba qorionis bususebis biofsia da amniocentezi. zemoaRniSnulimeTodebi dakavSirebulia garkveul riskTan, magaliTad amniocentezis Semdegspontanuri abortis sixSire Seadgens daaxloebiT 1%-s..qorionis bususebis biofsia keTdeba orsulobis 11-13 kviraze, xoloamniocentezi - 15 kviris zeviT. qorionuli bususebis biofsia pirveltrimestrSi xasiaTdeba uSedegobis da spontanuri abortis ufro maRalsixSiresTan meore trimestrSi Catarebul amniocentezTan SedarebiT (OR 2,86,95%, CI 1,93 4,24); (OR 1,33,95%, CI1,17 1,52). amniocentezis gakeTeba pirveltrimestSi ar SeiZleba. qorionis bususebis biofsiasTan Sedarebisasorsulobis pirvel trimestrSi amniocentezi dakavSirebulia uSedegobisufro maRal sixSiresTan (0,4% 2%-Tan SedarebiT; RR 0,23, 95%, CI 0,08 0,65).aqedan gamomdinare, riski yvelaze dabalia 15 kviris Semdeg amniocentezisCatarebisas da yvelaze maRalia qorionis bususebis biofsiis Catarebisasorsulobis nebismier vadaze.maRali mgrZnobelobis mqone test-sistemebiT Tanamedrove laboratoriisaRWurvisas SesaZlebelia “ormagi testis” Catareba (alfa-fetoproteini daadamianis qorionuli gonadotropini). testis dadebiTi Sedegis miRebisasorsuli unda gaigzavnos sisxlis imunofermentul analizze dainformirebuli Tanxmobis Semdeg mas Cautardes invaziuri meTodebi nayofisujredebis kultivirebaze.sxeulis masis indeqsis gansazRvrasxeulis masis indeqsis gansazRvra xdeba Oorsulis sxeulis masis(kilogramebSi) SefardebiT simaRlis (metrebSi) kvadratze. (kg/m2). Tu sxeulismasis indeqsi naklebia 18-ze an metia 35-ze, orsuls unda miewodos Sesabamisirekomendaciebi dietasTan dakavSirebiT., radganac 30-ze meti sxeulis masisindeqsi dakavSirebulia momatebul mkvradSobadasTan (RR 3.1 95% СI 1.6 – 5.9)da neonatalur sikvdilobasTan RR 2.7 95% СI (1.2 – 6.1) normaluri sxeulismasis indeqsis mqone orsulebTan SedarebiT.orsulobis dros dedis sxeulis masis normaluri namati individualuradvarirebs. arsebobs kavSiri orsulis sxeulis masasa da axalSobilis wonasSoris, Tumca mcire masis axalSobilebis skriningisaTvis am kavSirisgamoyeneba arazust informacias iZleva. dedis wonisa da simaRlis gansazRvraunda xdebodes minimum erTxel, magaliTad, pirveli vizitis dros. aqedangamomdinare, rutinuli awonva da simaRlis gazomva orsulobis drosmizanSewonili ar aris damatebiTi diskomfortis Tavidan asacileblad. gardaamisa, am procedurebs ar moaqvT aranairi sargebloba. gamonaklisi undagakeTdes im orsulebisaTvis, romlebic arasrulfasovnad ikvebebian.retrospeqtul kvlevaSi, romelic moicavda 1092 qals, gamovlinda, romorsulobis vada, dedis asaki, Tambaqos moweva, yovelkvireuli wonis namatida dedis wona warmoadgendnen faqtorebs, romlebic zegavlenas axdenenaxalSobilis wonaze. 32 antenatalur periodSi orsulobis vadasTan SedarebiTmcire masis axalSobilis gamosavlenad yvelaze efeqtur markers17

warmoadgenda dedis sxeulis dabali wona (

orsulobis dros hipertenziis miRebuli gansazRvreba gulisxmobs arteriulwnevas 140/90 mm/vwy/sv-s orjeradad, 4 saaTis intervalebiT gazomvisas. aseTimaCveneblebis dros matulobs perinataluri sikvdilianoba. 37 aRsaniSnavia, romorsulTa 20%-s orsulobis 20 kviris Semdeg minimum erTxel mainc aReniSnebaarteriuli wnevis maRali maCveneblebi. es iwvevs Carevebis ganxorcielebasorsulTa 10%-Si, Tumca preeklamfsia SeiZleba ganviTardes orsulTa mxolod2-4%-Si. 38hipertenziis diagnostireba damokidebulia arteriuli wnevis gazomvissizusteze. qvemoT moyvanili klinikuri rekomendaciebi miwodebulia amerikisgulis asociaciis mier 39 , da emTxveva eqspertebis adre arsebul azrs 40 :‣ wnevis gazomva orsulis mjdomare an naxevradmjdomare poziciaSi ise,rom mklavi moTavsebuli iyos gulis doneze;‣ Sesabamisi zomis manJetis gamoyeneba (minimum 33X15 sm zomis). naklebiSecdomebi daiSveba didi manJetis gamoyenebisas mcire manJetTanSedarebiT;‣ haeri nela unda iyos gamoSvebuli, daaxloebiT 2-3 mm/wm-Si, mTeli haerisgamoSvebam unda daikavos daaxloebiT 30 wami;‣ arteriuli wneva unda gaizomos 2mm/vwy-mde sizustiT;‣ diastoluri wnevis gasazomad gamoyenebuli unda iyos korotkovis Vtoni (gulis xmianobis gaqroba), radganac am SemTxvevaSi SeiniSnebanaklebi uzustobebi korotkovis IV tonis (gulis tonebis moyrueba)gamoyenebasTan SedarebiT.‣ I faza: pirveli susti tonebis gamoCena, intensiobis TandaTanobiTmomateba - daafiqsireT sistoluri arteriuli wneva;‣ II faza: tonebis intensiobis Serbilebis mokle faza;‣ III faza: tonebis intensiobis xanmokle gaZliereba;‣ IV faza: wyvetili moyruebuli tonebi, rbili da „ mberavi“;‣ V faza: tonebis sruli gaqroba - aRniSneT diastoluri arteriuliwneva.‣ Tu aRiniSneba arteriuli wnevis nulamde dacema (orsulTa 15%-Si), undaCaiweros rogorc IV, aseve V fazis maCveneblebi (mag.: 148/84/0 mm/vwy).‣ Tu saWiroa ganmeorebiTi gazomva, gamoyenebuli unda iyos maCveneblebissaSualo ariTmetikuli da ara mxolod ufro dabali maCvenebeli.meta-analizma orsulobis dros arteriuli wnevis monitoringis mizniT 41avtomaturi mowyobilobebis gamoyenebasTan dakavSirebiT gamoavlina, romavtomaturi mowyobilobebi iZleva arteriuli wnevis SedarebiT dabalmaCveneblebs preeklamfsiis dros. gamoyenebis win mniSvnelovania avtomaturimowyobilobebis Semowmeba da aseve am mowyobilobebiT miRebuli Sedegebisinterpretireba didi sifrTxiliT.arteriuli wnevis gazomvis sixSirear arsebobs mtkicebulebebi imis Sesaxeb, Tu ra sixSiriT unda gaizomosarteriuli wneva. miuxedavad amisa, rkk-is mimoxilvam, romelSic Sedarebuliiyo antenataluri vizitebis Semcirebuli raodenoba standartulraodenobasTan, ar gamoavlina gansxvaveba preeklamfsiis ganviTarebissixSireebis TvalsazrisiT. (OR 0.37, 95% CI: 0.22 to 1.64). 4219

samedicino personalis yvela wevrma unda icodes arteriuli wnevisgazomvis swori teqnika, standartizirebuli aRWurvilobis gamoyenebada orsulis swori pozicia gazomvisasCproteinuriis gansazRvraWeSmariti proteinuriis Sesafaseblad Zalzed mniSvnelovania Sardis sworiSegroveba da urogenitaluri infeqciis gamoricxva. amisaTvis xorcieldebaSardis Sua ulufis Segroveba sasqeso organoebis winaswari damuSavebisa dasaSos steriluri tamponiT SemosazRvris Semdeg. proteinuriis donisdasadgenad ar aris saWiro Sardis Segroveba kaTeteris meSveobiT, radganaces procedura SesaZlebelia garTuldes saSarde gzebis inficirebiT.proteinuriis gamosavlenad xSiria test-Cxirebis gamoyeneba. test-Cxiriwarmoadgens mxolod skriningul tests da ar SeiZleba mxolod mis Sedegebzedayrdnoba, radgan cilis niSnebis gamovlenisas cru-dadebiTi SedegebissixSire SemTxveviT aRebul Sardis nimuSebSi zogjer aRwevs 25%. 43Sardis pirveli nimuSSi +1-ze meti maCveneblis miRebisas Sedegidadasturebuli unda iyos 24 saaTian SardSi cilis an cila/kreatininisSefardebis gansazRvriT. 44 300 mg/24 saaTSi an kreatininis donis momateba 30mg/mmolze meti raodenobiT ZiriTadad ganixileba, rogorc mniSvnelovaniproteinuria 45 .zRvari 500mg/24 saaTSi raodenobiT ganixileba, rogorc SesaZlo cudigamosavalis maniSnebeli. 46proteinuriis arseboba dasturdeba 24 saaTian SardSi >300 mg/l cilisaRmoCeniT (+) an Sardis Sua ulufaSi >1 g (an meti ++) cilis aRmoCeniTorjeradi Semowmebisas 4saaTze meti intervaliT, Tu Sardis xvedriTi wona

kvebiTi danamatebifoliumis mJavasistemurma mimoxilvam 47 gamoavlina, rom Casaxvis periodSi folatebis miRebamniSvnelovnad aqveiTebs nervuli Reros defeqtebis ganviTarebis risks. (RR0.28, 95% CI 0.13 - 0.58) defeqtebis gavrcelebis sixSire daqveiTda rogorc winaorsulobisas janmrTeli axalSobilis arsebobisas (RR 0.07, 95% CI 0.00 - 1.32),aseve wina orsulobisas daavadabuli axalSobilis an nayofis SemTxvevaSi (OR0.31, 95% CI 0.14 - 0.66). jgufebs Soris.ar gamovlinda mniSvnelovani gansxvavebaCveuli abortis, saSvilosnos gare orsulobisa da naadrevi mSobiarobissixSireebSi.foliumis mJavis damatebas Casaxvis periodSi gaaCnia mniSvnelovani damcaviefeqti nervuli Reros defeqtebis ganviTarebis TvalsazrisiT. informaciafoliumis mJavis Sesaxeb farTod unda iyos xelmisawvdomi janmrTelobisa daganaTlebis sistemebis meSveobiT. qalebs, romelTa axalSobilebsa an nayofsdadgenili aqvT nervuli Reros defeqtebi, unda mivawodoT informaciaganmeorebis momatebuli riskis Sesaxeb da vurCioT foliumis mJavis uwyvetimiReba.orsul qalebsa da maT, visac dagegmili aqvs orsuloba undamivawodoT informacia Casaxvamde da orsulobis 12 kviramde foliumismJavis miRebis aucileblobis Sesaxeb, radganac es amcirebs nervuliReros defeqtebis ganviTarebis albaTobas. rekomendirebuli dozaSeadgens 4 mg dReSi.Arkinacnobili ar aris, Tu ra gavlenas axdens dedisa da axalSobilisgamosavalze rkinis rutinuli daniSvna anemiis ararsebobis dros.20 rkk-is sistemuri mimoxilvaSi 48 , Sedarebuli iyo rkinis da placebos miRebaorsulebSi (n=5552) hemoglobinis normaluri maCvenebliT (10 g/l-ze meti) 28kviris orsulobis vadamde. rkinis rutinuli damateba zrdida an inarCunebdaSratis feritinis dones 10 mkg/l-ze maRla da mniSvnelovnad aqveiTebda imqalTa raodenobas, romelTa hemoglobinis done 10-10,5 g/l-ze naklebi iyoorsulobis gvian vadebze.rkinis seleqtiuri da rutinuli damatebis Sedarebis mizniT Catarebulmayvelaze didma kvlevam (n=2682) gamoavlina, rom sakeisro kveTisa damSobiarobis Semdgomi sisxlis gadasxmis albaToba momatebulia, xoloperinataluri sikvdilianoba daqveiTebulia rkinis seleqtiuri damatebisSemTxvevaSi. 49sxva sistemur mimoxilvaSi Seiswavlili iyo rkinis da folatebis rutinulidamatebis efeqti orsulebSi hemoglobinis normaluri maCvenebliT.8 kvlevaSi monawileobda 5449 qali.aqedan gamomdinare, rkinisa da folatebis rutinul damatebas ar gaaCnia arcsasargeblo da arc saziano efeqti dedisa da nayofis gamosavalze. 5021

kinis preparatebis rutinuli daniSvna anemiis ararsebobis drosrekomendirebuli ar aris, radgan ar aris damtkicebuli amis arcdadebiTi da arc uaryofiTi zemoqmedeba nayofsa da dedaze.SesaZlebelia, rutinulma daniSvnam gamoiwvios arasasurveligverdiTi efeqtebi dedasa da axalSobilSi.Avitamini Avitamin A-s maRali dones orsulobis dros SesaZlebelia, hqondesteratogenuli efeqti 51-53 . epidemiologiuri mtkicebulebebidan gamomdinare,SeuZlebelia pirveli trimestris dros vitamin-A-s saziano raodenobis dozapasuxismrudis an zRvaris zustad ganisazRvra. vitamin A-s 10 000 - 25 000erTeulis raodenobiT SesaZlebelia gaaCndes teratogenuri efeqti. imis gamo,rom RviZli da RviZlis produqtebi Seicaven A-vitaminis maRal dones (10 000-38 000 mg/tipiur porciul raodenobaze 100mg) orsulobis dros sasurvelia amsakvebi produqtebisagan Tavis Sekaveba. 700 mikrogramze meti A vitaminismiReba dakavSirebulia sxvadasxva Tandayolili simaxinjeebis ganviTarebismomatebul riskTan. 53orsulebs unda mivawodoT informacia imis Sesaxeb, rom A vitaminisdamatebam (700 mikrogramze meti doziT) SesaZlebelia iqoniosteratogenuli efeqti nayofze da amitom misi miReba ar arismizanSewonili.orsulebmaa unda icodnen, rom RviZli da RviZlis produqtebiSeicaven didi raodenobiT aRniSnul vitamins da amitom Tavi undaSeikavon am produqtebis miRebisagan.Cvitamini Dvitamin D-s moTxovnileba izrdeba orsulobis dros kalciumis aTvisebisgasaumjobeseblad. D vitaminis ZiriTad wyaros warmoadgens mzis sinaTle dacximiani Tevzi. mzis sxivebze yoveldRiuri yofna warmoadgens D-vitaminisnaklebobis profilaqtikas.erT sistemur mimoxilvaSi 54 Sefasda D-vitaminis damatebis zemoqmedebaorsulobis gamosavalze. mimoxilvaSi CarTuli iyo mxolod ori mcire rkk(n=232). neonataluri hipokalcemia ufro iSviaTad aRiniSneboda vitamin D-sdamatebis jgufSi (OR 0.13, 95% CI 0.02 - 0.65).ar arsebobs sakmarisi mtkicebulebebi D vitaminis miRebisefeqturobis Sesaxeb orsulobis dros. misi rutinuli miRebaorsulobis dros ar aris rekomendebuli.A22

iodis damatebaCatarda 3 kvleva 60 , romelic moicavda 1551 qals. or kvlevaSi, iodis damatebadakavSirebuli iyo axalSobilobisa da adreuli bavSvobis periodSisikvdilianobis da(RR 0.71, 95% CI 0.56 - 0.90), epidemiuri kretinizmisgavrcelebis daqveiTebasTan 4 wlis asakisaTvis (RR 0.27, 95% CI 0.12 - 0.60), asevegaumjobesebul fsiqo-motorul aqtivobis maCveneblebTan 4-dan 25 Tvisasakamde. iodis daniSvna orsulobamde an orsulobis dros amcirebs bavSvTaasakis sikvdilianobis 2-jer da kretinizms 2/3-iT. imisaTvis, rom iodisdamatebas sasurveli efeqti hqondes, yvela reproduqciuli asakis qalsorsulobamde unda hqondes SesaZlebloba, miiRos iodizirebuli marili.iodis damateba im populaciaSi, sadac maRalia endemuri kretinizmissixSire, iwvevs am daavadebis sixSiris mniSvnelovan SemcirebasgverdiTi efeqtebis gareSeAsakvebismieri infeqcialisteriozilisteriozi aris daavadeba, romelic gamowveulia baqteriiT Listeriamonocytogenes, romelic SeiZleba gamovlindes msubuqi, gripismagvarisimptomebiT. is zogjer iwvevs Cveul aborts, naadrev mSobiarobas daaxalSobilis mZime daavadebebs. orsulTa populaciaSi listeriozisgavrceleba maRalia (12/100 000) saerTo populaciasTan SedarebiT 0,7/100,00) 61 .infeqciis yvelaze gavrcelebul wyaros warmoadgens dabinZurebuli sakvebi 61 .ZiriTadad es aris arapasterizebuli rZe, amoyvanili rbili yveli dapaSteti. L. monocytogenes gamovlenilia aseve niadagSi da Sinauri da gareulicxovelebis fekaliebSi.orsul qals unda mivawodoT Semdegi informacia listeriozis riskisdaqveiTebasTan dakavSirebiT:• miiRon mxolod pasterizebuli rZe;• Seikavon Tavi obiani rbili yvelis miRebisagan (kamamberi, bri).yvelis magari tipebi (Cederi da xaWo) ar warmoadgenssaSiSroebas;• ar miirTvan naxevrad umi an umi sakvebi.Dsalmonelasalmonela aris baqteria, romelic iwvevs sakvebismier infeqcias. mis wyarosZiriTadad warmoadgens Sinauri frinveli, kvercxi, auduRari rZe daarasrulyofilad Termulad damuSavebuli xorci, aseve wyali. misi mtarebeliSeiZleba iyos ku da frinvelebi.. miuxedavad imisa, rom salmonela ar axdenszegavlenas nayofze, man SeiZleba gamoiwvios mZime diarea da Rebineba.23

Tanamedrove rekomendaciebiT, orsulma qalebma ar unda miiRon umi kvercxida umi kvercxis Semcveli produqtebi. kvercxi unda moixarSos gamagrebamde.imis gamo, rom wiwilebi da umi xorci aseve warmoadgenen salmoneloziswyaros, yvelanairi sakvebi kargad unda damuSavdes Termulad, xolo umxorcTan da qaTamTan Sexebis Semdeg saWiroa xelebis saguldagulo dabana 62 .orsul qals unda mivawodoT informacia imis Sesaxeb, Tu rogorSeamciros salmoneloziT dainficirebis riski: Tavi Seikavos Toxloda umi kvercxis miRebisagan da kvercxis Semcveli produqtebisagan(mag: maionezi); aseve umi da naxevrad umi sakvebis miRebisagan,gansakuTrebiT ojaxis frinvelis xorcis.DvarjiSi orsulobis drosqalebs orsulobis fiziologiuri mimdinareobiT SeuZliaT regularulivarjiSi orsulobis dros.erT sistemur mimoxilvaSi Sefasda orsulis regularuli (kviraSi minimum 2-3jer) varjiSis zemoqmedeba orsulobisa da mSobiarobis gamosavalze 63 .orsulobisaTvis damaxasiaTebeli mravali Civili, magaliTad, zogadi sisuste,venebis varikozi da kidurebis SeSupeba mcirdeba im qalebSi, romlebicvarjiSoben. aqtiur qalebs aseve naklebad awuxebT Zilianoba, stresi, agznebada depresia. arsebobs rigi mtkicebulebebisa imasTan dakavSirebiT, romdatvirTuli varjiSi mTeli orsulobis dros SesaZlebelia iwvevdesmSobiarobis xangrZlivobis Semoklebasa da aumjobesebdes orsulobisgamosavals. erT sistemur mimoxilvaSi Sedarebuli iyo saSualo intensiobisregularuli aerobika orsulobis dros Cveulebriv fizikuri aqtiurobisSenarCunebasTan preeklamfsiis prevenciis TavsazrisiT 64 . sarwmunoebisintervali didi iyo da gadakveTa uefeqtobis xazi yvela miznnobrivigamosavalisaTvis preeklamfsiis CaTvliT (RR 0.31, 95% CIl 0.01 - 7.09). ar arsebobssakmarisi mtkicebulebebi sarwmuno daskvnebis gasakeTeblad varjiSiszemoqmedebis Seaxeb preeklamfsiasa da mis garTulebebze.orsuli qali informirebuli unda iyos, rom saSualo intensiobisvarjiSi orsulobis dros (misi dawyeba an gagrZeleba) ar arisdakavSirebuli gverdiT efeqtebTan.orsuli qali informirebuli unda iyos, rom zogierTi tipis aqtivobaSeiZleba saziano iyos orsulobis dros, magaliTad: kontaqturi damZime sportis saxeobebi, ramac SeiZleba gamoiwvios muclis travma,dacema da zedmeti datvirTva saxsrebze. saSiSia aseve yvinTvasTandakavSirebuli sportis saxeobebi, romlebic iwveven nayofisdefeqtebs da mis dekompresias.AD24

sqesobrivi aqtivoba orsulobis drosCatarda ori kohortuli kvleva 52 000 qalze, romelSic gamovlindaukukavSiri orsulobis sxvadasxva vadebze sqesobrivi kontaqtebis sixSiresada naadrevi mSobiarobis risks Soris. ar gamovlenila kavSiri sqesobrivikontaqtebis sixSiresa da perinatalur sikvdilianobas Soris 65;66 .orsulebis mier mowodebuli informaciis mixedviT, sqesobrivi kontaqtiorsulobis adreul vadebze ar iyo dakavSirebuli Cveuli abortis sixSirismomatebasTan. dadasturda kavSiri qalis mravlobiT sqesobriv partniorebsada Cveul abortebs Soris 67orsuli qali informirebuli unda iyos, rom sqesobrivi aqtivobaorsulobis dros ar aris dakavSirebuli raime uaryofiTgamosavalTan.Balkoholis moxmareba da Tambaqos moweva orsulobis drosalkoholi Tavisuflad gadis placentarul bariers da gadadis nayofTan,amitom arsebobs mosazreba, rom qalebma Tavi unda Seikavon misigadaWarbebuli moxmarebisagan orsulobis dros. sabolood ar arisgarkveuli, alkoholis ra done aris saziano nayofisa da dedisaTvis.arsebobs mtkicebulebebi imasTan dakavSirebiT, rom alkoholis erTi an orierTeuli kviraSi saziano ar aris 68 magram rekomedebulia alkoholosmiRebisagan sruli TavSekaveba orsulobis dros 69 . Troba da alkoholisdidi raodenobiT miReba dakavSirebulia axalSobilis dabali wonasTan 70;71da bavSvis qceviT da inteleqtualur darRvevebTan 72 .Tambaqos moweva warmoadgens orsulobis cudi gamosavlis mizezs. misiuaryofiTi zegavlena sabolood aris damtkicebuli. meta-analizmagamoavlina, rom arsebobs mniSvnelovani kavSiri orsulobis dros Tambaqosmowevasa da perinatalur sikvdilianobas 73 , axalSobilTa uecar sikvdils 73placentis naadrev aclas 74 , sanayofe garsebis naadrev darRvevas 75 , eqtopiurNorsulobas 75 , placentis winamdebareobas 75 , Cveul aborts 73 , naadrevmSobiarobas 76 , axalSobilTa dabal wonas 73 da axalSobilebis mglis xaxisa dakurdRlis tuCis Camoyalibebas Soris 77 .kohortulma kvlevebma gamoavlines mniSvnelovani kavSiri orsulobis drosdedis mier Tambaqos mowevasa da gestaciur vadasTan SedarebiT mcire wonisaxalSobilis dabadebas 78 , mkvdradSobadobasa 79 da nayofisa da axalSobilissikvdilianobas Soris 80 .alkoholis zedmeti raodenobiT moxmareba mavne zemoqmedebas axdensnayofze.Bamitom orsulma unda Seamciros alkoholis miReba 1standartul erTeulamde dReSi, mag.: erTi patara Wiqa Rvino an kaTxaludi dReSi.C25

orsuli qali unda gavafrTxiloT mowevis mavne zemoqmedebis Sesaxeborsulobis dros (naadrevi mSobiaroba, dabali wonis axalSobili).yuradReba unda gamaxvildes orsulobis nebismier etapze mowevisSewyvetis dadebiT efeqtze. mwevel orsulebs unda davexmaroTsxvadasxva saSualebebiT - eqimis rCeviT, jgufuri SexvedrebiT,qceviTi TerapiiT da sxva. AATviTmfrinaviT mgzavroba orsulobis drosar arsebobs mtkicebulebebi orsulobis dros mgzavrobisas venuriTromboemboliis riskis momatebis Sesaxeb. simptomuri venuri TromboemboliissaerTo sixSire xangrZlivi frenis Semdeg Seadgens daaxloebiT 1/400 -1/10 000.venuri Tromboemboliis riski ZiriTadad dakavSirebulia imobilizaciasTan.profilaqtikur RonisZiebebs miekuTvneba: wvivis kunTebis izometriulivarjiSebi, seirnoba TviTmfrinavSi, didi raodenobiT siTxis miReba daalkoholisa da kofeinis miRebisagan Tavis Sekaveba 81 .zogadad, gaurTulebeli erTnayofiani orsulobis dros 36 kviramde frenaSor manZilze daSvebulia eqimis an bebiaqalis janmrTelobis kargimdgomareobis dadasturebiTa da mSobiarobis dadgenili zusti vadiTorsulobis 28 kviris Semdeg 82 .orsuli informirebuli unda iyos, rom TviTmfrinaviT xangrZlivimgzavroba dakavSirebulia venuri Trombozebis riskTan. riskisSemcirebisaTvis efeqturia specialuri kompresiuli windebis xmarebamgzavrobis dros.BavtomobiliT mgzavroba orsulobis drosavtomobiliT mgzavrobis dros orsuli qalisaTvis Zalian mniSvnelovaniaRvedebis swori gamoyeneba. Rvedebis arasworma gamoyenebam SeiZlebagamoiwvios nayofis dazianeba sagzao SemTxvevis dros. orsuls unda miewodosSemdegi informacia Rvedebis swor gamoyenebasTan dakavSirebiT 83 :• Rvedebi unda gakeTdes muclis zemoT an qvemoT da ara uSualod mucelze;• gamoyenebuli unda iyos 3 nawiliani Rvedebi zonaris moTavsebiT muclisqvemo areze, barZayebs Soris da diagonalurad mxris dafiqsirebiT mucliszemoT sarZeve jirkvlebs Soris;orsuli qali informirebuli unda iyos Rvedebis swor gamoyenebisSesaxeborsuli gavafrTxiloT, rom sazRvargareT mogzaurobamde man undagaiaros konsultacia eqimTan frenis, vaqcianaciis da mgzavrobis sxvaaspeqtebis Sesaxeb. PBpg26

orsulobasTan dakavSirebuli ZiriTadi simptomebigulisreva da Rebineba orsulobis drosgulisreva aris orsulobasTan dakavSirebuli yvelaze xSiri simptomi dagvxvdeba orsulobis I trimestrSi SemTxvevaTa 80-85%-Si.Hyperemesis gravidarum aris mdgomareoba, romelic viTardeba im orsulebSi,romelTac SeuCerebeli Rebinebis gamo uviTardebaT siTxeebisa daeleqtrolitebis disbalansi orsulobis adreul vadebze. es mdgomareobaiSviaTia da gvxvdeba 3,5/1000 SemTxvevaSi da ZiriTadad saWiroebshospitalizacias 77 .qalTa umravlesobaSi gulisreva da Rebineba aRniSneba sibolo menstruaciisSemdeg 8 kviris ganmavlobaSi (94%) da mxolod erTi mesamedi (34%) aRniSnavssimptomebs bolo menstruaciis Semdeg 4 kviris Tavze. qalTa umravlesoba (87-91%) aRniSnavs simptomebis gaqrobas gestaciis 16-20 kviraze da mxolod 11-18%aRniSnavs gulisrevas da Rebinebas dilaobiT 84;85 .gulisrevisa da Rebinebis dros receptis gareSe SesaZlebelia, koWasa anjanjafilis, akupunqturisa da B-vitaminis daniSvna. receptiT gasacemimedikamentebidan SesaZlebelia antihistaminuri saSualebebisa dafenoTiazidebis gamoyeneba.antiemezuri preparatebi aqveiTeben gulisrevasa da Rebinebas orsulobisadreul vadebze. arsebobs mtkicebulebebi maTi gverdiTi efeqtebis Sesaxeb,magram rkk-dan gamomdinare mtkicebulebebi nayofze maTi zemoqmedebis Sesaxebmcirea. Tanamedrove midgomiT gulisrevis intensiobis dasaqveiTebladgamosayenebeli samkurnalo preparebidan yvelaze efeqturia piridoqsinisgamoyeneba (vitamini B6). akupunqturis gamoyenebasTan dakavSirebuli kvlevisSedegebi ara erTmniSvnelovania. dakvirvebiTma kvlevebma ar gamoavlina zemoTaRniSnuli intervenciebis teratogenuli efeqti. 86koWa (janjafili) dReSi oTxjer 250 mg-is raodenobiT, P6 akupunqtura (Neiguan)da antihistaminuri saSualebebiT mkurnaloba aqveiTebs gulisrevisa daRebinebis sixSires. aseve efeqturia piridoqsinis (vitamin B6) gamoyenebac,Tumca arsebobs eWvebi vitamini B6-is toqsiurobasTan dakavSirebiT.ciankobalamini (vitamini 12) efeqturia gulisrevisa da RebinebisSemsubuqebisaTvis, Tumca ar arsebobs monacemebi misi gamoyenebisusafrTxoebis Sesaxeb.gulisreva da Rebineba SemTxvevaTa umravlesobaSi TavisiT gaivlis 16-20kviraze, orsulobaze raime uaryofiTi zegavlenis gareSe, amitom receptiTgasacemi preparatebis daniSvna ar aris mizanSewonili im SemTxvevebis garda,rodesac simptomatika Zlier aris gamoxatuli an Zalian SemawuxebeliaorsulisaTvis. 87orsuli informirebuli unda iyos, rom gulisreva da RebinebaZiriTad SemTxvevebSi TavisiT gaivlis 16-20 kviris vadaze da es araris dakavSirebuli orsulobis cud gamosavalTan. Tu qali moiTxovsmkurnalobis Catarebas, aucileblad unda iyos gaTvaliswinebuliSemdegi:A• arafarmakologiuri mkurnaloba (mag: akupunqtura);farmakologiurisaSualebebidan unda gamoviyenoT antihistaminuri saSualebebi.27

gulZmarva orsulobis drosgulZmarva warmoadgens xSir simptoms orsulobis dros. erT did kvlevaSi,romelSic monawileobda 607 orsuli qali, gamovlinda, rom gulZmarvissixSire izrdeboda orsulobis vadis momatebisas da Seadgenda 22%-s pirvel,39% meore da 72% mesame trimestrSi 88 .mkurnaloba gulZmarvis dros moicavs cxovrebis stilis gaumjobesebas,antacidebisa da tutovani miqsturebis gamoyenebas, H2 receptorebisantagonistebs da protonuli dguSebis inhibitorebs, rac saSualebas iZlevamJavas refluqsis SemcirebiT gaumjobesdes simptomatika.cxovrebis stilis gaumjobeseba moicavs sxeulis swori poziciisSenarCunebas, gansakuTrebiT sakvebis miRebis Semdeg, Zils maRal baliSze dadietis dacvas, kerZod ki kvebas mcire xSiri ulufebiT, cximiani da kuWisgamaRizianebeli sakvebisagan, magaliTad kofeinisagan Tavis Sekaveba.antacidebi, romlebic axdenen naRvlis mJavebis neitralizacias, aseveefeqturia gulZmarvis dros. Catarda rkk, romelSic antacidebiT mkurnalobaSedarda placebo-mkurnalobasTan. gamovlinda, rom antacidebiT mkurnalobisdros qalTa 80%-ma aRniSna GgulZmarvasTan dakavSirebuli tkivilebisSemsubuqeba placebo jgufTan (13%) SedarebiT H2 receptorebis blokatorebian antagonistebi, romlebic amcireben mJavis sekreciasa da moculobas, aseveefeqturad moqmedeben gulZmarvis dros da usafrTxoa dReSi orjer - dilasada SuadRes miRebisas. 89;90meta-analizma (5 kohortuli kvleva, n=593 axalSobili), romelic Seiswavlidaprotonis dguSebis inhibitorebis - omeprazolis gamoyenebis usafrTxoebas,gamoavlina misi kavSiri nayofis simaxinjeebis ganviTarebasTan 91 . amitom,omeprazolis anotaciaSi miTiTebulia orsulobis dros misi SesaZlotoqsiurobis Sesaxeb, rac gamovlinda cxovelebze eqsperimentebSi damocemulia rekomendacia orsulobis dros misgan Tavis Sekavebisagan, Tuarsebobs sxva alternativa.qalebs, romelTac awuxebT gulZmarva orsulobis dros, undamivawodoT informacia cxovrebis stilisa da dietis Secvlis Sesaxeb.spim qalebs, romelTac zemoT aRniSnuli RonisZiebebi ar aZlevs Svebas,unda davuniSnoT antacidebi.ASekrulobaSekruloba orsulobis dros xSir Civils warmoadgens. erT kvlevaSigamovlinda, rom orsulTa 39% aRniSnavda Sekrulobis simptomebs gestaciis14 kviraze, 30% - 28 kviraze da 20% - 36 kviraze 92 .ori rkk-is sistemur mimoxilvaSi (n=215) qalebis erTi jgufis randomizaciaxdeboda boWkovani damatebis jgufSi, xolo meore jgufs ar eZleoda28

aranairi damatebebi 93 . gamovlinda xorblis an Wvavis boWkoebis damatebisefeqturoba Sekrulobis dros. (OR 0.18, 95% CI 0.05 - 0.67).Sekrulobis dros orsulebs unda mieceT rekomendaciebi cxovrebisstilis Secvlisa da boWkovani dietis Sesaxeb AAhemoroiduli daavadeba (buasili)mimoxilviT kvlevaSi gamovlinda, rom orsulobis bolo trimestrSi qalTa8%-s aReniSneba hemoroiduli daavadeba 94 .hemoroiduli daavadebis mkurnaloba moicavs dietis gaumjobesebas,adgilobrivi kremebis daniSvnas (mag, anusoli), per os misaReb wamlebsa daqirurgiul Carevas. qirurgiuli Careva orsulobis dros iSviaTad gamoiyeneba,radganac hemoroidulma daavadeba xSirad TavisiT gaivlis mSobiarobisSemdeg.Tu buasilis konservatuli mkurnaloba orsulobis dros uefeqtoa,saWiroa specialuri dietis daniSvna. simptomatikis gauaresebisassaWiroa adgilobrivi kremebis daniSvnaspvenebis varikozivenebis varikozis sakiTxze Catarebuli sistemuri mimoxilva moicavda 3 rkk-s,romlebic Seiswavlida sxvadasxva mkurnalobis efeqts 115 qalSi 95 . erTi rkkSeiswavlida pnevmatur wyvetil kompresias, meore - wyalSi moTavsebas dawoliT reJims qalebSi, romelTac aReniSnebodaT venebis varikozi. aseveSeswavlili iyo uSualod mkurnalobis Semdgomi efeqtebi. mesame kvlevaSiSeswavlili iyo orsulobis bolo trimestrSi 8 kviris ganmavlobaSirutosidis kafsulebis miReba placebosTan SedarebiT da gamovlindasimptomatikis subieqturi gaumjobeseba gestaciis 36 kviraze (OR 0.30 95% CI 0.12- 0.77). mtkicebulebebi rutosidis gamoyenebis usafrTxoebis an gverdiTiefeqtebis Sesaxeb orsulobis am vadaze ar arsebobs.orsuli informirebuli unda iyos, rom venebis varikozi warmoadgensxSir simptoms orsulobis dros da ar saWiroebs mkurnalobas.mdgomareobis gaumjobeseba SesaZlebelia specialuri elastiuriwindebis tarebiT, Tumca isini ar icaven venebs progresuligaganierebisagan. AA29

welis tkiviliwelis tkivilis gavrceleba orsulobis dros varirebs 35-61%-mde 96-99 . qalTa 47-60% tkivilis dawyebas aRniSnavda orsulobis 5-7 Tveebze, xolo misiintensioba matulobda saRamosken.welis tkivili orsulobis dros dakavSirebulia muclis simZimisa dakunTebis gadawelvis gamo simZimis centris gadanacvlebasTan. welis tkiviliorsulobis dros Semawuxebelia, man SeiZleba imoqmedos qalis yoveldRiurcxovrebasa da Zilze, gansakuTrebiT mesame trimestrSi.sistemur mimoxilvaSi Sefasebuli iyo 3 rkk, romlebic Seiswavlida yvelazeefeqtur intervenciebs orsulobis dros welis tkivilis prevenciisaTvis 100 .varjiSi wyalSi Sedarebuli iyo intervenciebis CautareblobasTan, ozlosbaliSebi Cveulebriv baliSebTan, xolo akupunqtura fizioTerapiasTan.qalebi, romlebic akeTebdnen varjiSebs wyalSi, ufro iSviaTad aRniSnavdnenwelis tkivils sakontrolo jgufTan SedarebiT (OR 0.38, 95% CI 0.16 - 0.88)..meore kvlevaSi, ozlos baliSebis (budis formis) gamoyenebisas ufroiSviaTad aRiniSneboda weli tkivili orsulobis 36 kvirazee standartulbaliSebTan SedarebiT (OR 0.32, 95% CI 0.18 - 0.58) (OR 0.35, 95% CI 0.20 - 0.62) mesamerkk-Si gamovlinda, rom akupunqturis aTi seansi ufro efeqturia, vidrejgufuri fizioTerapiis seansebi (OR 6.58, 95% CI 1.00 - 43.16).orsuls unda mivawodoT informacia, rom wyalSi varjiSi dadebiTadmoqmedebs welis tkivilis dros.Ainfeqciebis skriningisakiTxi qalis infeqciebze gamokvlevis aucileblobis Sesaxeb sadavoa dayovelTvis ar Seesabameba mtkicebulebebis monacemebs. sakmaod xSiradorsulebs utardebaT ZviradRirebuli da dausabuTebeli analizebi, romelTacar gaaCniaT praqtikuli Rirebuleba, xolo qalebi, romelTac aseTigamokvlevebi marTlac esaWiroebaT, mxedvelobaSi miRebulni ar arian.dausabuTebeli gamokvlevebi da mkurnaloba iwvevs mniSvnelovani danaxarjebisgawevas.asimptomuri baqteriuriaasimptomuri baqteriuria ganisazRvreba, rogorc saSarde gzebispersistirebadi baqteriuli kolonizacia simptomatikis gareSe. misi sixSireaSS-Si Catarebul kvlevebSi varirebs 2-10%-mde, upiratesi gavrcelebiT dabalisocialur-ekonomiuri donis qalebSi 101 102 .orsuli qalebi asimptomuri baqteriuriiT imyofebian maRali riskis jgufSinaadrevi mSobiarobisa 2,1%-12,8%-Si da pielonefritis ganviTarebisTvalsazrisiT. 103;10430

yvela orsul qals orsulobis vadis miuxedavad pirveli vizitis dros undaCautardes testi asimptomur baqteriuriaze.moSardvamde gareTa sasqeso organoebis gamwmendi saSualebiT samjeradidabanis Semdeg miRebuli unda iyos Sardis Sua ulufa. is rac SeiZleba maleunda gaigzavnos laboratoriaSi. amis SeuZleblobis dros Sardis Senaxvaunda moxdes 4°C. Tu Sardis kulturaluri gamokvleva SeuZlebelia raime,magaliTad finansuri mizezis gamo, unda Catardes Sardis naleqismikroskopuli gamokvleva maRali simZlavris velSi >10 leikocitisgamosavlenad an gamoyenebuli iyos leikocitebis esTerazaze mgrZnobiaretest-xazebi nitratebis arsebobis gamosavlenad. yvelaze adeqvatur dasasurvel meTods warmoadgens Sardis kulturaluri gamokvleva.14 rkk-is sistematurma mimoxilvam Seadara antibiotikoTerapia placebomkurnalobasTanan mkurnalobis ararsebobasTan antenatalur periodSi.antibiotikoTerapiam Seamcira persistirebadi baqteriuriis sixSireorsulobis dros (Peto OR 0.07, 95% CI 0.05 - 0.10), naadrevi mSobiarobis riski dadabali wonis axalSobilebis dabadebis sixSire (OR 0.60, 95% CI 0.45 - 0.80),Semcirda aseve pielonefritis ganviTarebis sixSire (OR 0.24, 95% CI 0.19 - 0.32,NNT 7) 103;105sistemurma mimoxilvam, romelSic Sedarebuli iyo antibiotikis erTjeradimiReba antibiotikoTerapiis 4 an 7 dRian kursTan asiptomuri baqteriuriisdros, ar gamoavlina gansxvaveba naadrevi mSobiarobis (RR 0.81, 95% CI 0.26 to 2.57)an pielonefritis prevenciis TvalsazrisiT. (RR 3.09, 95% CI 0.54 to 17.55).mkurnalobis xangrZlivi kursi dakavSirebuli iyo gverdiTi efeqtebisganviTarebis momatebul albaTobasTan. (RR 0.53, 95% CI 0.31 to 9.91) 103;106asimptomuri baqteriuriis gamosavlenad yvela orsuls undaCautardes Sardis Sua ulufis gamokvleva. asimptomuri baqteriuriisdadasturebisas antibiotikoTerapia aqveiTebs pielonefritisa danaadrevi mSobiarobis risks.Aqlamidiaqlamidiuri infeqciis arseboba orsulobis dros dakavSirebulia naadrevimSobiarobis momatebul sixSiresTan (OR 1.6, 90%CI 1.01 - 2.5) da nayofissaSvilosnosSida zrdis Seferxebis sindromis ganviTarebasTan. (OR 2.5, 90%CI1071.32 - 4.18) . mkurnalobis ararsebobisas asimptomuri baqteriuriadakavSirebulia axalSobilebis dabal wonasa da axalSobilTasikvdilianobasTan 108 . rkk–ebis mimoxilvis Sedegebis mixedviT qlamidiiskulturis dadebiTi maCveneblebiT qalTa raodenoba 90%-iT mcirdebodaantibiotikoTerapiis Catarebis jgufSi placebosTan SedarebiT. (OR 0.06, 95% CI0.03 - 0.12) 109 . miuxedavad amisa, ar daqveiTebula 37 kviramde mSobiarobaTaricxvi. dRevandel dRes ubralo, iafi laboratoriuli testi qlamidiisdiagnostikisaTvis ar arsebobs, xolo rac Seexeba skriningul testebs, maTCasatareblad saWiroa masalis aReba sxvadasxva anatomiuri adgilebidan 108 .31

swrafi testebi moicaven antisxeulis pirdapir fluorescenciul SeRebvas(mgrZnobeloba 50-90%), ferment-dakavSirebul imunur kvlevebs (mgrZnobeloba75%-80%, specifiuroba 85-100%) da dnm-rnm hibridizacias (mgrZnobeloba 70-85%)pirdapiri fluorescentuli antisxeulebis SeRebva Zalian Sromatevadia daamitom meTodis gamoyeneba ar aris mizanSewonili pacientta didi raodenobisdros. mwvave qlamidiuri infeqciis dros serologiuri kvleva mizanSewoniliar aris 103;109qlamidiuri infeqciis gamosavlenad testis Catareba klinikurisimptomatikis ararsebobisas mizanSewonili ar aris, radganac ararsebobs sakmarisi mtkicebulebebi misi efeqturobis Sesaxeb da isZviradRirebul gamokvlevas warmoadgens.Acitomegalovirusuli infeqciacitomegalovirusi aris herpesvirusebis ojaxis warmomadgeneli. islatenturia pirveladi dainficirebis Semdeg da SeiZleba ganicados aqtivaciaimunodepresiis dros.citomegalovirusuli infeqciis antenataluri skriningi mizanSewonili araris, radganac rTulia ganisazRvros, Tu romeli orsuloba garTuldebanayofis dainficirebiT 110 . SeuZlebelia imis gansazRvra, Tu romeldainficirebul axalSobils Camouyalibdeba seriozuli garTulebebi.vaqcinebi, profilaqtikuri Terapia transmisiis prevenciisaTvis da meTodiimis gasarkvevad, Tu rodis moxda saSvilosnosSida transmisia, ar arsebobs111;112 .ar arsebobs sakmarisi mtkicebulebebi citomegalovirusis rutinuliskriningisaTvis, amitom misi Catareba ar aris mizanSewonili. BBB-hepatitibavSvTa 85%, romlebic ibadebian (eAg) dadebiTi dedebisagan SemdgomSi xdebianqronikuli infeqciis mtareblebi, rac aRiniSneba antigen uaryofiTidedebisagan dabadebuli bavSvebis mxolod 31%-s.(RR 2.8, 95% CI 1.69 - 4.47) 113 .dedidan bavSvze B-hepatitis virusis transmisiis profilaqtika 95%-SiaSesaZlebelia vaqcinaciiT an bavSvis dabadebisas imunoglobulinisSeyvaniT 114 .HbsAg skrinings nerwyvSi gaaCnia 92% mgrZnobeloba (95% CI 84.5% - 99.5%) da86,8% specifiuroba (95% CI 76.0% - 97.6%), Sratis analizebTan SedarebiT 115 .dedidan bavSvze transmisiis maRali maCveneblebis gamo prevencia undaxdebodes vaqcinaciiTa da imunizaciiT. imis gamo, rom risk-faqtorebis32

SefasebiT ver xerxdeba virusis mtarebelTa identifikacia, rekomendebuliaorsuli qalis skriningi B-hepatitis virusze.mSobiarobis Semdgomi efeqturi intervenciebis Casatarebladaucilebelia B-hepatitis serologiuri gamokvleva antenatalurperiodSiAC-hepatitiC-hepatitis virusi warmoadgens sazogadoebrivi janmrTelobis mniSvnelovansazrunavs 116 .virusiT dainficireba SesaZlebeliaAdainficirebuli sisxlis transfuziis,narkomaniis, tatuirebis, sxeulis pirsingisa da vertikaluri transmisiiT.miuxedavad arsebuli mtkicebulebebisa dedidan bavSvze transmisiisalbaTobisa da virusis titris zrdis pirdapirproporciulidamokidebulebis Sesaxeb, 117;118 , transmisiisaTvis zRvari jer-jerobiTdadgenili ar aris.bavSvebis dainficireba ufro xSirad xdeba saSosmxrivi mSobiarobis drossakeisro kveTasTan SedarebiT, Tumca statistikurad sarwmuno gansxvavebagamovlinda mxolod erT kvlevaSi 119 .kvlevis oqros standarts warmoadgens polimerazuli jaWvuri reaqciia,mgrZnobeloba da specifiuroba Seadgens 100% da 66%-s Sesabamisad 120 .skriningis testis dadebiTi Sedegebis miRebisas qali unda gaigzavnosinfeqcionistTan mkurnalobisaTvis.C-hepatitis gamosavlenad ar aris mizanSewonili serologiurigamokvlevis Catareba, radganac ar aris sakmarisi mtkicebulebebiintervenciis efeqturobis Sesaxeb da is ZviradRirebul gamokvlevaswarmoadgens.CSidsiadamianis imunodeficitis virusiT dainficireba iwyeba asimptomuri stadiiT,rasac SemdgomSi moyveba imunuri funqciebis etapobrivi dazianeba da SeZeniliimunodeficitis sindromis Camoyalibeba (Sidsi). aiv-inficirebasa da SidsisganviTarebas Soris periodi mkurnalobis gareSe meryeobs ramodenime Tvidan17 wlamde 121 .2006 wels saqarTveloSi gamovlinda 217 aiv-inficirebuli qali. 1,4%-dainficirda virusis vertikalurad (dedidan bavSvze) gadacemis gziT.Tu ar Catarda Sesabamisi intervenciebi, transmisia dedidan bavSvzeaRiniSneba SemTxvevaTa 25,5%-Si. zidovudiniT antiretrovirusulimkurnalobis Semdeg 122 es maCvenebeli Semcirda 8%-mde. intervenciebiskombinacias (antiretrovirusuli mkurnaloba, sakeisro kveTa da ZuZuTi33

kvebisagan Tavis Sekaveba) SeuZlia transmisiis riskis daqveiTeba 1%-mde.dRevandel dRes xelmisawvdomi aiv-testebis mgrZnobeloba da specifiurobaSeadgens 99% 123antenatalur periodSi dedidan bavSvze vertikaluri transmisiisSesamcireblad SemoTavazebulia antiretrovirusuli mkurnaloba, gegmiurisakeisro kveTa da mSobiarobis Semdeg ZuZuTi kvebisagan Tavis Sekaveba. 2006wlidan saqarTveloSi yvela orsulisaTvis antenatalur periodSirekomendebulia aiv-testis Catareba.orsul qals unda Cautardes gamokvleva aiv-infeqciaze/Sidsze,radganac adreuli intervenciebi antenatalur periodSi amcirebentransmisiis risks.unda arsebobdes kargad Camoyalibebuli referaluri programa aivinfeqcia/Sidsisdiagnostirebis SemTxvevaSi orsulis SesabamisspecialistTan gadasagzavnad DADwiTuraorsulobis dros wiTuras skriningis mizans warmoadgens im qalebisgamovlena, romlebsac ara aqvT antisxeulebi wiTurasadmi, romganxorcieldes mSobiarobis Semdgomi vaqcinacia momavali orsulobebisusafrTxoebisaTvis.wiTuras vaqcinacia orsulobis dros winaaRmdegnaCvenebia SesaZloteratogenobis gamo. 124wiTurass skriningi gansazRvrulia orsulis imunuri statusisdasadgenad da orsulobis Semdeg saWiroebisas acris Casatareblad;kvleva ar aris mowodebuli orsulobis dros nayofis mdgomareobisSesafasebladBaTaSangiaranamkurnaleb aTaSangiT daavadebul orsulebSi axalSobilTa dainficirebaxdeba SemTxvevaTa 70-100%-Si, xolo axalSobilTa mesamedi umwifariibadeba. 125arsebobs aTaSangis serologiuri testebis 2 ZiriTadi klasifikacia:aratreponemuli da treponemuli. aratreponemuli testebi gamoavlensaTaSangis araspecifiur antisxeulebs da moicavs veneriuli daavadebiskvlevis laboratoriasa (VDRL) da plazmis swraf reaginis testebs. (RPR)rekomendebulia, aTaSangis skriningi ganxorcieldes pirvel da meoTxeantenatalur vizitze. yvela qali, romelic dadebiTi aRmoCndeba aTaSangze,34

unda gaigzavnos samkurnalod specialistTan. kvlevaSi ar dadasturdaorsulobis dros aTaSangis peniciliniT mkurnalobis arasasurvelizomoqmedeba orsulobaze, rodesac moxda mkurnalobis jgufis Sedarebaaranamkurnalebi seronegatiuri qalebis populiaciasTan 126aTaSangis kvleva unda Cautardes yvela orsul qals, radganacadreuli mkurnaloba aumjobesebs gamosavals rogorc dedis, iseaxalSobilis mxriv.Atoqsoplazmozipirveladi toqsoplazmozi gamowveulia parazitiT Toxoplasma gondii da xSiradasimptomurad mimdinareobs janmrTel qalebSi. dainficireba uzrunvelyosmudmiv imunitets. ar aris dadgenili saqarTvelos monacemebitoqsoplazmozis gavrcelebis sixSireze, Tumca sxva qveynebSi gavrcelebissixSire varirebs 2,4/1000 qalidan fineTSi da 16/1000 safrangeTSi.toqsoplazmoziT dainficireba SesaZlebelia moxdes oTxi gziT:• arasrulfasovnad damuSavebuli an umi sakvebiT cocxali cistebismiRebiT• oocitebis miRebiT, romelTac gamoyofen katebi, aseve dabinZurebulniadagTan da wyalTan kontaqtiT. (mag: gaurecxavi xili da bostneuli,romelic katis fekaliebiTaa dabinZurebuli);• toqsoplazmoziT daavadebuli adamianisagan organoebis an qsovilebisgadanergviT;• dedidan nayofze transmisiiT orsulobis dros pirveladidainficirebisas.6 evropul centrSi Catarebulma kvlevam gamoavlina, rom Termuladarasrulfasovnad damuSavebuli rZis produqtebi da dakonservebuli xorcisproduqtebi warmoadgens orsulis toqsoplazmoziT dainficirebis ZiriTadfaqtorebs 127 . niadagTan kontaqti bevrad iSviaTad iwvevda dainficirebas.rodesac T. gondii-sTan pirveli kontaqti orsulobis dros xdeba, dedidannayofze transmisiis albaToba matulobs orsulobis vadis zrdasTan erTad 128-130 Tandayolili toqsoplazmozisaTvis saerTo riski Seadgens 18-44%-s, isufro dabalia orsulobis adreul vadebze da Seadgens 6-26%-s orsulobis 7-15 kviraze da izrdeba 32-93%-mde 29-34 orsulobis vadisaTvis. imis gamo, romtoqsoplazmoziT pirveladi dainficireba usimptomod mimdinareobs,inficirebis dadgena SesaZlebelia mxolod serologiuri testirebiT.toqsoplazmozis infeqciaze antenataluri skriningi moicavs IgG da IgM Mantisxeulebis skrinings.xelmisawvdomi klinikuri testebi serokonversiis dasadgenad ver avlenen,dainficireba moxda orsulobis dros Tu orsulobamde 12 TviT adre. qalebs,romlebic dainficirdnen Casaxvamde, nayofze gadacemis riski araaReniSnebaT 131toqsoplazmozis pirveladi prevencia xdeba orsulis informirebiTdainficirebis Tavidan acilebis gzebis Sesaxeb orsulobis adreul vadebze.qalebi informirebulebi unda iyvnen Termulad arasakmarisad damuSavebuli35

sakvebisa da konservebis miRebis riskze, aseve katis fekaliebTan, niadagTan dagaurecxav xilsa da bostneulTan Sexebis saSiSroebis Sesaxeb.ar arsebobs mtkicebulebebi, rom antenataluri skriningi aqveiTebstransmisias dedidan nayofze, amitom toqsoplazmozis skriningis rutinuladdaniSvna rekomendebuli ar aris.orsul qals unda mivawdoT informacia imis Sesaxeb, romtoqsoplazmoziT inficirebis albaTobas orsulobis dros amcirebsSemdegi moqmedebebi:• Wamamde xelis dabana;• xilisa da bostneulis saguldagulo garecxva;• sakvebis saguldagulo Termuli damuSaveba;• miwasTan muSaobis dros xelTaTmanebis gakeTeba;• katis fekaliebTan Sexebis Tavidan acileba.Cnayofis winamdebareobis dadgenaCatarda kvleva nayofis winamdebareobis dadgenis mizniT muclismxrivipalpaciis - leopoldis wesebis gamoyenebis Taobaze, romelmac gamoavlina,rom SemTxvevaTa 53%-Si nayofis winmdebareoba arasworad iyo dadgenili. 132es damtkicda sxva kvleviT, romelic specifiurad mimarTuli iyo menjiTwinamdebareobis dasadgenad 133 leopoldis wesebis mgrZnobeloba daspecifiuroba Seadgenda 28% da 94%-s Sesabamisad 134 .erT kvlevaSi gamovlinda, rom qalebs ar siamovnebT palpaciis procesi, isinimas arakomfortulad da arainformaciulad miiCneven. 135mSobiarobis gegmis SemuSavebis mizniT 36 kviris Semdeg unda Catardesnayofis muclismxrivi palpacia, xolo 36 kviramde palpaciisganxorcieleba mizanSewonili ar aris, radganac is arasakmarisadzustia da diskomforts uqmnis orsuls.nayofis araswori mdebareoba unda dadasturdes ultrabgeriTigamokvleviT. PAspsaSvilosnos fuZis simaRlis gansazRvrasimfiz-saSvilosnos fuZis simaRlis gansazRvra (santimetrebSi) SesaZlebeliadagvexmaros saSvilosnos obieqturi zomebis gansazRvraSi.simfiz-saSvilosnos fuZis simaRlis regularuli gazomva aadvilebs nayofiszrdis siCqaris dadgenas. zomisa da vadis Seusabamobis mizezebi Semdegia:36

• gestaciuri vadisaTvis mcire zomis axalSobili;• didi raodenobiT sanayofe siTxe;• mravalnayofiani orsuloba;• buStnamqeri;• gestaciuri vadis gansazRvris uzustoba.sistemurma mimoxilvam 136 gamoavlina, rom ar arsebobs mtkicebulebebisaSvilosnos fuZis simaRlis rutinuli gazomvis raime sargeblianobisSesaxeb. amis miuxedavad, xelmisawvdomi literaturis monacemebiT,rutinuli gazomva warmoadgens mgrZnobiare meTods gestaciis vadasTanSedarebiT mcire wonis axalSobilebis gamosavlenad ganviTarebad qveynebSi.amis gamo, is kvlav rekomendebulia antenataluri meTvalyureobisstandartul praqtikaSi.saSvilosnos fuZis simaRlis rutinuli gazomvisaTvis saWiroa Semdegi:1. sazomi metrebisa da antenataluri baraTebis uzrunvelyofa, racmoicavs grafaze mrudis aRniSvnas, romelic aCvenebs 10, 50 da 90sentils;2. treinings mocemul meTodSi;3. gazomvis praqtikisa da xarisxis uwyvet audits;yoveli antenataluri vizitis dros unda gaizomos saSvilosnosfuZis simaRle gestaciur vadasTan SedarebiT didi an mcire wonisaxalSobilis gamosavlenad.AsaSvilosnos fuZis simaRle unda gaizomos da aRiniSnos grafazeyoveli antenataluri vizitis dros.. Aspnayofis moZraobis rutinuli monitoringidedis SegrZneba nayofis moZraobis SemcirebasTan dakavSirebiT gamoiyenebaantenataluri meTvalyureobis dros nayofis keTildReobis dasadgenad,magram dadebiTi prognozuli Rirebuleba dedis SegrZnebebisaTvis nayofismoZraobebis SemcirebasTan dakavSirebiT dabalia da Seadgens 2-7%- 137mtkicebulebebi ar adastureben nayofis moZraobebis formalur daTvlasnayofis gviani sikvdilisagan Tavis asacileblad.nayofis moZraobaTa raodenobis daTvla mogvianebiT nayofissikvdilis Tavidan acilebis mizniT ar aris mizanSewonili.A37

nayofis guliscemis auskultaciamiuxedavad imisa, rom nayofis guliscemis mosmena adasturebs imas, romnayofi cocxalia, mas ar gaaCnia sxva klinikuri an prognozuliRirebuleba 138;139 es imis gamo, rom iseTi detaluri informacia nayofisguliscemis Sesaxeb, rogoricaa deceleracia da variabeloba ar gamovlindaauskultaciis dros.nayofis guliscemis auskultacia adasturebs imas, rom nayoficocxalia, magram am gamokvlevas ara aqvs prognozuli Rirebuleba,amitom ar aris rekomendebuli. is unda Catardes im SemTxvevaSi, Tuamas orsuli moiTxovs. DDkardiotokografiaar arsebobs antenataluri kardiotokografiis gamoyenebis Sefasebismtkicebulebebi normaluri orsulobis dros nayofis rutinuliSefasebisaTvis.sitemur mimoxilvam ver gamoavlina antenataluri kardiotokografiis efeqtiperinatalur avadobasa da sikvdilianobaze 140 . ar gamovlenila iseTiintervenciebis sixSiris zrda, rogorebicaa sakeisro kveTa da mSobiarobisinduqcia.fiziologiuri orsulobis dros antenatalur periodSikardiotokografiis rutinuli gamoyenebis Sesaxeb ar arsebobssakmarisi mtkicebulebebi da amitom ar aris mizanSewonili.AultrabgeriTi gamokvleva mesame trimestrSi7 rkk-is sistemur mimoxilvaSi 141 , sadac monawileobda 25 036 orsuli 24 kvirisSemdeg Seswavlili iyo rutinuli ultrabgeriTi gamokvlevis faseuloba.aRiniSna farTo variacia ultrabgeriTi gamokvlevis SedegebSi kvlevaTaSoris. ZiriTadad 6 kvlevis jgufebs Soris Sedarebuli iyo rutinuliultrabgera 24 kviris Semdeg intervenciis Catarebis gareSe jgufTan,seleqtiur ultrabgeriT kvlevasTan 24 kviris Semdeg. ar gamovlenilagansxvaveba naadrevi mSobiarobis, nayofis mcire wonisa da perinatalurisikvdilianobis sixSireebSi. aseve ar iyo gansxvaveba antenataluri, sameanoda neonataluri intervenciebis sxva gamosavalebis TvalsazrisiT 141ar arsebobs sakmarisi mtkicebulebebi gestaciis 24 kviris Semdegrutinuli ultrabgeris gamoyenebisaTvis.A38

Wipisa da saSvilosnos arteriis doplerografia5 rkk-s sistemuri mimoxilvidan dadgenili iyo, rom Wiplaris dopleruliultrabgeris rutinul gamoyenebas ara aqvs zegavlena sameano da neonatalurgamosavalze, perinataluri sikvdilianobis CaTvliT. Wiplarisdoplerografiuli ultrabgeris rutinuli gamoyeneba zrdis sxvaintervenciebis Catarebis albaTobas 141 .27 pirveladi dakvirvebiTi kvlevebis sistemurma mimoxilvam Seiswavladopleruli ultrabgeris gamoyeneba preeklamfsiis, nayofis zrdisa daperinataluri sikvdilianobis Sesafasablad maRali riskis populaciebSi.prognozuli Rirebuleba dabali iyo janmrTel qalebSi da gaurTulebeliorsulobis SemTxvevaSi (anu dabali riskis populaciaSi). 142Wipis arteriis rutinuli doplerografiuli gamokvlevis Catarebanayofis zrdis Seferxebis sindromis dasadgenad ar arisrekomendebuli.AsaSvilosnos arteriis rutinuli doplerografiuli gamokvleva preeklamfsiisriskis Sesafaseblad ar aris rekomendebuli.AmenjiT winamdebareoba vadamitanili orsulobis dros.intervencias menjiT winamdebareobis dros warmoadgens Tavze gareganiSemobruneba, moqsibastionis gamoyeneba (akupunkturis dros) da poziciurimkurnaloba.9 rkk-s 2 sistemur mimoxilvaSi Sefasda Tavze garegani mobruneba menjiTwinamdebareobisas vadamitanili orsulobis dros an vadamde adre. 143;144TaviT garegani mobruneba gestaciis 37 kviramde ar axdenda mniSvnelovanzegavlenas menjiT winamdebareobaze orsulobis dromde mitanis SemTxvevaSi. (RR 1.02, 95% CI 0.89 - 1.17), aseve arc sakeisro kveTis sixSireze ( RR 1.10, 95% CI0.78 - 1.54) 143 .Tavze garegani Semobruneba vadamitanili orsulobis dros amcirebda menjiTwinamdebareobas 60%-iT, rodesac Sedarebuli iyo intervenciisCautareblobasTan. ( RR 0.42, 95% CI 0.35 - 0.50).sakeisro kveTis mniSvnelovani Semcireba aseve aRniSnuli iyo Tavze gareganiSemobrunebis jgufSi ( RR 0.52, 95% CI 0.39 - 0.71,) 145 .Tavze garegani mobruneba vadamitanili orsulobis dros amcirebs arasworwinamdebareobas mSobiarobis momentisaTvis. uSedego mcdelobis albaTobasamcirebs proceduris dros tokolitikebis gamoyeneba. TaviT gareganimobruneba dakavSirebulia dedisa da nayofis mxriv rig gverdiT efeqtebTan,39

omelTa minimizacia SesaZlebelia proceduris dros nayofis monitoringisgamoyenebiT.poziciuri mkurnaloba TaviT mobrunebis mizniT moicavs relaqsacias menjisamaRlebiT. es ZiriTadad miiRweva muxl-idayvis poziciis miRebiT an zurgzewoliT menjis amaRlebiT solisebri baliSis meSveobiT. dedis poziciuriteqnika ganxiluli iyo rkk-is sitemur mimoxilvaSi 146 ar aRiniSna poziciuriteqnikis efeqti araswori winamdebareobiT mSobiarobis sixSirezeeqsperimentalur da sakontrolo jgufSi ( RR 0.95, 95% CI 0.81 - 1.11) argamovlinda gansxaveba sakeisro kveTis sixSireebSic ( RR 1.07, 95% CI 0.85 - 1.33).moqsibastionis gamoyeneba Seswavlili iyo erT rkk Si 147 . eqsperimentalurjgufSi TaviT winamdebareoba mSobiarobis droisaTvis statistikuradsarwmuno meti iyo.gaurTulebeli orsulobis dros menjiT winamdebareobisas 36 kvirisvadaze unda Catardes TaviT garegani mobruneba. gamonaklisswarmoadgenen orsulebi, romlebic imyofebian mSobiarobaSi anaReniSnebaT nawiburi saSvilosnoze, misi malformacia, nayofismdgomareobis gauareseba, darRveuli sanayofe buSti, sisxldena dasxvadasxva davadebebi.AAdanarTi 1jmo-s rekomendirebuli gravidograma40

gaidlainis gadasinjvisa da ganaxlebis vada – 3 weligaidlainis miRebis xerxi/wyarogaidlainis SemuSavebis meTodologia• mocemuli gaidlainis Semqnis procesSi samuSao jgufisgadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebulipraqtikuli rekomendaciebi. moxda arsebuli rekomendaciebisadaptirebuli variantis SemuSaveba, romelic erTis mxriv pasuxobssaerTaSoriso moTxovnebs, xolo meore mxriv iTvaliswinebssaqarTvelos samedicino dawesebulebaTa rogorc adamianur, iseteqnikur resursebs.• klinikuri rekomendaciebis, epidemiologiuri monacemebisa damtkicebeulebebis Semdgomi moZieba xorcieldeboda Yahoo, AltaVista,Google, DoctorGuide, Yandex, Rambler saZiebo operatorebis meSveobiT, asevesamedicino monacemebis eleqtronuli bibliografiuli monacemTabazis, „medlainis,, (MEDLINE) meSveobiT. pirvel rigSi moZiebuli iyo(National Guidelines Clearinhouse, TRIP, SumSearch) antenatalurimeTvalyureobis analogiuri rekomendaciebi, romlebic SemuSavebuliaSesabamisi profesionaluri jgufebis mier.• calkeuli klinikuri sakiTxebis Sesaxeb mtkicebulebaTa da imsakiTxTa moZieba, romlebic arasrulad aris ganxiluli, warmoebuliiyo kohreinis monacemTa bazaSi The Cochrane Library 2006, Issue 3, dajandacvis msoflio organizaciis reproduqciuli janmrTelobisbiblioTekaSi #9.moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analiziCatarebuli Ziebis Sedegad miRebuli iyo ramodenime klinikuri meTodurirekomendacia, romlebic Seicavda jgufis miznis Sesaferis saWiroinformacias. 1;2;3 am rekomendaciebis saboloo Sefasebisas gamoyenebuli iyoformaluri Sefasebis meTodi AGREE-s (Appraisal of Guidelines for Research andEvaluation) 5 meSveobiT. Sefasebis Sedegad amorCeuli iyo ramodenimerekomendacia, romlebic safuZvlad daedo Semdgom analizsa da maTadaptacias. am rekomendaciaSi mocemuli debulebebi Sejamebuli iyocxrilebSi da warmodgenili iyo samuSao jgufis wevrebis mier SefasebismizniT. cxrilSi Sedioda debulebis originaluri versia da mtkicebulebisdone wyaros mixedviT. samuSao jgufs unda Seefasebina rekomendaciebisvargisianoba saqarTvelos jandacvis pirveladi rgolis pirobebSi.rekomendacia miRebulad iTvleboda, Tu mas mxars uWerda SemqmnelTa samuSaojgufis umravlesoba.rekomendaciis SemuSavebisas Cven gamoviyeneT modificirebuli sqema, romelicmowodebulia SIGN (Scottish Intercollegiate Guideline Network) mier 6 .41

mtkicebulebaTa doneebisa da rekomendaciebis gradaciis sqemamocemul rekomendaciebSi gamoyenebulia Scottish Intercollegiate Guidelines Network(SIGN) mier mowodebuli rekomendaciebis mtkicebulebaTa doneebismodificirebuli sqema.yvela ZiriTad rekomendacias gaaCnia gradacia, romelic aRiniSneba laTinuriasoebiT А dan D mde. amave dros yovel gradacias Seesabameba monacemTamtkicebulebis garkveuli done. rac ufro maRalia rekomendaciis gradacia,miT ufro maRalia kvlevebis sizuste, romlebzec is aris dafuZnebulimtkicebulebis doneAB BCD DDspkvlevebis daxasiaTeba, romlebic safuZvlad daedorekomendaciasmaRali xarisxis meta-analizi, randomizirebulikontrolirebadi kvlevis meta-analizi, rkksistemuri mimoxilva an didi rkk sistematuriSecdomis Zalian dabali albaTobiT (+++), romlisSedegebic SesaZlebelia gavrceldes Sesabamispopulaciaze;kohortuli an SemTxveva-kontrolis tipiskvlevebis maRali xarisxis sistemuri mimoxilvaanmaRali xarisxis (++) kohortuli an SemTxvevakontrolistipis kvleva sistematuri SecdomisZalian dabali albaTobiT.anrkk (+) sistemuri Secdomis dabali albaTobiT,romlis Sedegebic SeiZleba gavrceldes Sesabamispopulaciaze;kohortuli an SemTxveva-kontrolis tipis kvleva ankontrolirebadi kvleva randomizaciis gareSesistematuri Secdomis dabali albaTobiT (+),romlis Sedegebic SeiZleba gavrceldes Sesabamispopulaciazeanrkk Zalian dabali (++) an dabali (+) sistematuriSecdomis albaTobiT, romlis Sedegebic arSeiZleba gavrceldes Sesabamis populaciaze;SemTxvevaTa seriebis aRweraanarakontrolirebadi kvlevaaneqspertTa azri.saukeTeso praqtika, romelic dafuZnebuliarekomendaciis SemqmnelTa gamocdilebaze.alternatiuli gaidlaini ar arsebobs42

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⇒ marina turZelaZe - №1 samkurnalo profilaqtikuri centris qalTakonsultaciis ufrosi;⇒ ekaterine SeSaberiZe - kaspis raionis qvemo gomis s/ambulatoriis eqimi– Terapevti, saojaxo medicinis moklevadiani rezidenturisrezidenti;⇒ veriko baziari – mean-ginekologi. saqarTvelos Sromis, janmrTelobisda socialuri dacvis saministro;⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuridacvis saministros janmrTelobis dacvis departamenti;⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa dasocialuri dacvis saministros janmrTelobis dacvis departamenti.49