sisxldena orsulobis I naxevarSi
moduli # 5
TBILISI STATE MEDICAL UNIVERSITY - UNICEF GEORGIA
orsulobis I naxevris sisxldena
mizezi
• TviTnebiTi aborti
• trofoblasturi daavadeba
aborti (1)
• aborti aris nayofis gamoZeveba misi
sicocxlisunarianobis miRwevamde
(orsulobis 20 kviramde) WHOMDE
aborti aris saSvilosnos Rrudan nayofis gamoZeveba orsulobis 20
kviris vadamde. jandacvis msoflio organizaciis rekomendaciiT, nayofi
sicocxlisunarianad iTvleba orsulobis 20 kviris vadidan, misi wona ki
500 grami, an metia.
rigi qveynebis monacemebiT, abortis sixSire diagnostirebul
orsulobebTan mimarTebaSi 10%-dan 15%-mde meryeobs.
abortis dros, rogorc wesi, SeimCneva sasqeso organoebidan sisxldena
da aris saSvilosnos SekumSvebi. saSodan sisxldenis mizezi 95%
SemTxvevaSi abortia.
aborti (2)
klasifikacia
• naadrevi (12 • TviTnebiTi
kvramde)
• xelovnuri
• gviani (13-22 kv.)
xelovnuri (samedicino) aborti aris orsulobis Sewyveta
medikamentozuri an qirurgiuli gziT, mkacri samedicino CvenebiT,
nayofis sicocxlisunarianobis miRwevamde.
aborti, ganviTarebuli samedicino Carevis gareSe, TviTnebiTi, anu
spontanuria.
TviTnebiTi aborti (1)
mizezebi
• dedismxrivi
• nayofismxrivi
orsulobis adreul vadaze (10 kv. vadamde) TviTnebiTi aborti
ganixileba, rogorc bunebrivi gadarCevis gamovlena. Aamas adasturebs
isic, rom am vadaze Sewyvetil orsulobaTa saaborto masalis
histomorfologiuri gamokvleviT, SemTxvevaTa 60-80%-Si
diagnostirebuli iyo embrionTa qromosomuli darRvevebi. abortis
ganviTarebaSi xSiria nayofismxrivi mizezebi, kerZod:
Canasaxis araswori ganviTareba an nayofis ganviTarebis manki;
qromosomuli aberaciebi;
trofoblastis araadekvaturi implantacia.
orsulobis 11-22 kviris vadaze abortis ganviTarebaSi xSiria
dedismxrivi mizezebi, kerZod:
zogadi daavadebebi,
saSvilosnos ganviTarebis anomaliebi;
fsiqosomaturi faqtorebi.
TviTnebiTi aborti (2)
stadiebi
• mosalodneli aborti
• aborti msvlelobaSi
• daumTavrebeli aborti
• damTavrebuli aborti
• armomxdari aborti
TviTnebiTi aborti erT-erTi ZiriTadi sameano paTologiaa. sasurvel
orsulobaTa 15-20% TviTnebiTi abortiT mTavrdeba. orsulobis
TviTnebiTi SewyvetisaTvis damaxasiaTebelia sami procesis ganviTareba:
saSvilosnos SekumSva;
sanayofo kvercxis aSreveba saSvilosnos kedlidan;
sanayofo kvercxis gamoZeveba saSvilosnos Rrudan.
aqedan gamomdinare, TviTnebiTi abortis klinikuri simptomatika da
marTvis taqtika orsulobis TviTnebiTi Sewyvetis procesis
stadiurobazea damokidebuli. TviTnebiTi abortis klinikuri
klasifikacia ki swored am stadiurobis amsaxvelia.
mosalodneli aborti (1)
mosalodneli aborti (2)
• abortus imminens et incipiens
• vaginaluri sisxlisdena, mcire an
umniSvnelo
• sxvadasxva intensivobis tkiviliT
an mis gareSe
• saSvilosnos yeli daxuruli
• saSvilosno rbili da palpaciisas
intaqturi
mosalodneli aborti iwyeba sasqeso organoebidan sisxliani
gamonadeniT saSvilosnos kumSviTi aqtivobiT, an mis gareSe. saSvilosnos
kumSviTi aqtivoba simptomurad gamoixateba boqvens zemoT da gavis areSi
SeteviTi tkiviliT, saSosmxrivi gasinjvisas ki saSvilosnos yeli
daxurulia.
mosalodneli aborti(4)
mosalodneli aborti (3) woliTi reJimi
• hormonaluri da tokolituri
mkurnaloba Sedegs ar iZleva (A)
• woliTi reJimi ar cvlis mosalodneli
abortis gamosavals (A)
mosalodneli aborti (5)
hormonaluri mkurnaloba
mtkicebiTi medicinis monacemebiT, mosalodneli abortis mkurnaloba
Sedegs ar iZleva. medikamentebi, hormonebi-progesteroni da sedaciuri
saSualebebi araefeqturia da moqmedebs, rogorc placebo. orsuloba
mosalodneli abortis SemTxvevaTa 7,8%-Si (WHO) mTavrdeba drouli
mSobiarobiT.
aborti msvlelobaSi
abortus progrediens
• Warbi sisxliani gamonadeni saSodan
• Zlieri tkivili
• saSvilosnos yelis dilatacia
• saSvilosnos zomebi Semcirebuli
abortis procesis progresirebisas Zlierdeba saSvilosnos SekumSvebi
da sisxldena sasqeso organoebidan. saSosmxrivi gasinjvisas
saSvilosnos yeli dilatirebulia. abortis ganviTarebis am etaps
ewodeba aborti msvlelobaSi da aseT SemTxvevebSi sanayofo kvercxi
nawilobriv an mTlianad gamoZevdeba.
daumTavrebeli aborti damTavrebuli anu sruli aborti
abortus incompletus
abortus completus
• saSvilosnos Rrudan sanayofo kvercxi mxolod • Canasaxi, placenta da sanayofe garsi srulad
nawilobriv gamoZevdeba gamoZevebulia saSvilosnodan
• SesaZloa gamoiwvios Zlieri sisxlisdena da/an • tkivili wydeba
infeqcia • orsulobis niSnebi ukuganviTarebas ganicdis
• warmoadgens abortTan dakavSirebul yvelaze • palpaciT saSvilosno mkveTrad SekumSulia
xSir garTulebas
• Semdgomi samedicino Carevebi saWiro araa
saSvilosnos Rrudan sanayofo kvercxis mxolod nawilobriv
gamoZevebisas laparakoben daumTavrebel abortze. aseT SemTxvevebSi
ZiriTadi simptomia sasqeso organoebidan Zlieri sisxldena.
daumTavrebeli abortis dros awarmoeben saSvilosnos Rrus kiuretaJs.
aborti damTavrebulia, Tu saSvilosnos Rrudan sanayofo kvercxi
srulad gamoZevdeba. aseT SemTxvevebSi instrumentuli Careva, rogorc
wesi, araa saWiro.
armomxdari aborti (1)
missed abortion
• sanayofo kvercxis daRupvas Tan ar sdevs
saSvilosnos Rrudan misi gamoZeveba
• embrioni ufro xSirad gestaciis 8 kviris
vadamde iRupeba
• klinikurad aRiniSneba saSodan moyavisfro
gamonadeni
• orsulobis niSnebi qreba
armomxdari aborti diagnostirdeba klinikuri dakvirvebis Sedegad,
saSvilosnos zrdis Sewyvetis safuZvelze. klinikurad SeiZleba
aRiniSnos sisxliani moyavisfro gamonadeni saSodan, qreba orsulobis
niSnebi. diagnozi zustdeba ultrabgeriTi kvlevis safuZvelze. Tu
armomxdari aborti orsulobis adreul vadaze fiqsirdeba, viTardeba
anembrionia.
armomxdari aborti (2)
mkurnaloba
• ar saWiroebs urgentul mkurnalobas
• 28 dRis ganmavlobaSi Tu ar moxda
TviTnebiTi gamoZeveba:
orsulobis 12 kviris vadamde -
saSvilosnos Rrus kiuretaJi
orsulobis 12 kviris zemoT -
medikamentozuri aborti
armomxdari abortis diagnostirebis dagvianebisas SesaZloa,
ganviTardes mZime koagulaciuri darRvevebi da saWiro gaxdes
qirurgiuli mkurnaloba. armoxdari abortis SemTxvevaSi orsulobis 12
kviris orsulobis vadamde mizanSewonilia erTmoentad saSvilosnos
Rrus gaTavisufleba sanayofo kvercxis narCenebisagan da upiratesoba
eniWeba vakuumaspiracias. orsulobis II trimestrSi daRupuli nayofis
mosacileblad unda gamoviyenoT specifikuri meTodebi: oqsitocini,
prostoglandinis i/v Seyvana, saSosmxrivi prostaglandinebi,
mifepristoni 600mg, 36 saaTis Semdeg -- mizoprostoli (300mg 2-2 sT-is
intervaliT), an prostoglandini E2 (saSos pesariebi 20mg) -- yovel 3 an 6
sT-Si. efeqturia saSvilosnos yelSi laminariis Seyvana.
septiuri aborti (2)
septiuri aborti (1) klinikuri simptomebi
• gulisreva
• cxeleba
• xelovnuri an arasruli abortis • taqikardia (120>)
yvelaze ufro xSiri garTuleba • Tavis tkivili
• WuWyiani, Cirqovani vaginaluri
• mizezi - aRmavali infeqcia gamonadeni saSodan
• menjis Rrus anTebiTi daavadebis niSnebi
• gadidebuli, mtkivneuli saSvilosno
• muclis palpatoruli mtkivneuloba
TviTnebiTi abortis dros iqmneba septiuri procesebis
ganviTarebisTvis xelSemwyobi mTeli rigi faqtorebi. 80% SemTxvevaSi
infeqcia msubuqi formisaa da lokalizebulia deciduaSi. infeqciuri
agentebi ki, umeteswilad, aris anaerobuli streptokoki, stafilokoki an
nawlavis Cxiri.
SemTxvevaTa 15%-Si infeqcia aris mZime formis da miometriumSi,
falopiusis milebSi, parametriumsa da menjis faSar SemaerTebel
qsovilSi vrceldeba.
SemTxvevaTa 5%-Si gvxvdeba generalizebuli infeqcia. inficirebuli
abortis klinikuri simptomebi slaidzea CamoTvlili.
Williams Ob. 2005
septiuri aborti (3) septiuri aborti (4)
laboratoriuli gamokvlevebi: mkurnaloba:
• saSos an saSvilosnos yelis nacxi • antibiotikoTerapia
• sisxlis kultura • saSvilosnos Rrus kiuretaJi
• sisxlis plazmis eleqtrolituri • histereqtomia
Semadgenloba
• sisxlis koagulaciuri Tvisebebis gansazRvra
septiuri abortis diagnostikisaTvis aucilebelia, pacients Cautardes
Semdegi laboratoriuli gamokvlevebi:
saSodan an saSvilosnos yelidan aRebuli nacxis baqterioskopiuli
da baqteriologiuri gamokvleva antibiotikogramiT;
sisxlis plazmaSi eleqtrolitebis gansazRvra;
sisxlis koagulaciuri Tvisebebis gansazRvra;
sisxlis analizi.
inficirebuli abortisas pacientebis mkurnaloba warmoebs:
konservatiulad – farTo speqtris antibiotikebiT;
antibiotikoTerapiis dawyebidan 12 sT-Si keTdeba saSvilosnos Rrus
kiuretaJi;
infeqciis gavrcelebis SemTxvevaSi naCvenebia operaciuli mkurnaloba
– histereqtomia.
Cveuli aborti
• Tu TviTnebiTi aborti, romelic viTardeba
zedized 3 an/da meti orsulobisas
• mkurnaloba ar aris efeqturi
• cervikaluri ukmarisobis diagnostirebisas
(20%) keTdeba saSvilosnos yelis serkliaJi
Tu TviTnebiTi aborti sami an/da meti orsulobisas zedized meordeba,
saubaria Cveul abortze (Williams Ob. 2005).
arsebobs ori Rirebuli testi Cveuli abortis diagnostirebisaTvis:
mSoblebis citogenetikuri analizi;
mgluras antikoagulanturi da antikardiolipinuri antisxeulebis
gansazRvra.
saSvilosnos yelis ukmarisobis diagnostirebisas saSvilosnos yelze
ideba cirkularuli nakeri (serkliaJi). operaciis Semdgom hormonebis,
kerZod, progesteronis da saSvilosnos relaqsantebis daniSvna
mizanSeuwonelia.
TviTnebiTi aborti
gestaciuri trofoblasturi daavadeba (2)
gestaciuri trofoblasturi daavadeba (1)
• buStnamqeri (mola hidatidosa)
• gestaciuri trofoblasturi daavadebis
dros adgili aqvs trofoblastis
paTologiur proliferacias
• gestaciuri trofoblasturi neoplazia
anu avTvisebiani gestaciuritrofo-
blasturi daavadeba (qorionepiTelioma)
gestaciuri trofoblasturi daavadeba trofoblastis paTologiuri
proliferaciaa, romlis drosac qorionis bususebis stromi Supdeba da
mtevniseburad gadagvardeba.
1983 wels jandacvis msoflio organizaciam gamoaqveyna rekomendacia
gestaciuri trofoblasturi daavadebis definiciis, klasifikaciisa da
stadiebis Sesaxeb. rekomendacia Sesworda 2004 wels da miRebuli iyo
Semdegi klasifikacia.
gestaciuri trofoblasturi daavadeba (3)
etiologia
• ZiriTadad ucnobia
• genetikuri darRvevebi
• dedis imunuri sistemis defeqti
plazmis qorionaluri gonadotrpinis maRali done ganapirobebs
sakvercxeebSi Teka-luTeinuri kistebis Camoyalibebas.
gestaciuri trofoblasturi daavadeba (4)
buStnamqeri gestaciuri trofoblasturi daavadeba (5)
• buStnamqeris ganviTarebisas
• sruli
histologiurad viTardeba:
• nawilobrivi
trofoblastis proliferacia
qorionis bususebis stromis SeSupeba
buStnamqeri SemTxvevaTa 0,25%-Si gvxvdeba. is, pirvelorsulebTan
SedarebiT, samjer ufro xSirad uviTardebaT ganmeorebiTorsulebs
(WHO).
buStnamqers axasiaTebs qorionis bususebis gadagvareba mtevnisebur
warmonaqmnad, romelic sxvadasxva diametris mqone gamWvirvale
SigTavsis buStukebisagan Sedgeba.
Tu buStnamqeri viTardeba orsulobis adreul vadebze, roca
kvercxujredis mTeli zedapiri pirveladi bususebiT aris dafaruli,
rogorc wesi, isini mTlianad gadagvardeba.
sanayofo kvercxis nawilebis an nayofis arseboba-ararseboba
gansazRvravs nawilobriv an srul buStnamqers.
sruli buStnamqeri
gestaciuri trofoblasturi daavadeba (6)
sruli buStnamqeri
• cvlilebebi viTardeba mTel qorionSi
• qorionis bususebi srulad transformirdeba
gamWvirvale SigTavsis mqone buStukebad
• qorionis bususebSi qreba sisxlZarRvebi
• nayofi, Wiplari da sanayofo garsebi ar
arsebobs
• kariotipi normaluria
• mtevniseburi warmonaqmnis buStukebis zoma
varirebs erTeuli milimetridan ramdenime
santimetramde
gestaciuri trofoblasturi daavadeba (7)
nawilobrivi buStnamqeri nawilobrivi buStnamqeri
• cvlilebebi viTardeba qorionis nawilSi
• qorionis bususebi SeSupebulia
• trofoblastis ujredebi atrofirebulia
• gadagvarebul bususebTan erTad aRiniSneba
normaluri bususebi
• nayofi, Wiplari da sanayofo garsebi
ganviTarebulia
gestaciuri trofoblasturi daavadeba (8)
buStnamqeri
klinikuri mimdinareoba:
• vaginaluri sisxlisdena
• gestaciur vadasTan SedarebiT didi
saSvilosno
• saSvilosnos comisebri konsistencia
• gulisreva, pirRebineba
• orsulobis II trimestrSi preeklamfsia
gestaciuri trofoblasturi daavadeba (10)
gestaciuri trofoblasturi daavadeba (9) buStnamqeri
buStnamqeri
mkurnaloba
diagnostika:
• saSvilosnos Rrus vakuumaspiracia
• ultraberiTi gamokvleva:
mravlobiTi eqosignalebi normaluri sanayofo • 40 wlis zemoT asakis qalebSi
kvercxis niSnebis gareSe rekomendirebulia histereqtomia
nayofis nawilebisa da guliscemis ar arseboba • profilaqtikuri qimioTerapia
Teka-luTeinuri kistebi
• sisxlis SratSi qorionaluri gonadotropinis
raodenoba >100000mMu/ml
gestaciuri trofoblasturi daavadeba (11)
buStnamqeri
Semdgomi dakvirveba:
• orsulobis prevencia minimum 6 Tve
• plazmis qorionaluri gonadotropinis
monitoringi 2 kviraSi erTxel
• qorionaluri gonadotropinis regresis
SemTxvevaSi qimioTerapia ar iniSneba
• qorionaluri gonadotropinis donis
normalizebis Semdeg yovelTviuri erTjeradi
monitoringi 6 Tve
gestaciuri trofoblasturi neoplazia(1)
invaziuri anu arametastazuri buStnamqeri,
procesi SemosazRvrulia saSvilosnoTi
qorionepiTelioma – metastazuri simsivne,
procesi scildeba saSvilosnos farglebs
invaziuri buStnamqeris ganviTarebisas gadagvarebuli qorionis
bususebi penetracias ganicdian saSvilosnos miometriumSi, arRveven
serozul garss da sxvadasxva organoSi vrceldebian.
qorionepiTelioma avTvisebiani simsivnea da metastazirebis
gansakuTrebiT maRali unariT gamoirCeva.
gestaciuri trofoblasturi neoplazia(2)
invaziuri buStnamqeri
• qorionis bususebi Rrmad Caizrdeba
miometriumSi qsovilTa daSliT
• SesaZlebelia saSvilosnos perforaciis
ganviTareba
• Zlieri sisxlisdena
gestaciuri trofoblasturi neoplazia(3)
qorionepiTelioma
• ZiriTadad uviTardebaT reproduqciuli asakis
qalebs
• buStnamqeris Semdeg misi ganviTarebis riski 38-
50%
• klinika damokidebulia metastazebis
lokalizaciaze
• kavSiri wina orsulobasTan
gestaciuri trofoblasturi neoplazia(4)
qorionepiTeliomis klinika
• sisxlisdena, rogorc garegani, aseve Sinagani
• saSvilosnos gadideba
• serozuli an Cirqovani, suniani gamonadeni
saSodan
• trofoblasturi hormonebis maRali done
• adreuli metastazireba, upiratesad filtvebSi
• metastazireba xorcieldeba Hhematogenuri
gziT
gestaciuri trofoblasturi neoplazia(5)
qorionepiTelioma
qalebs, romlebsac diagnostirebuli aqvT
keTilTvisebiani trofoblasturi daavadeba
imyofebian qorionepiTeliomis ganviTarebis
maRali riskis qveS, Tu:
• asaki 40 welze metia.
• ßhCG-is koncentracia maRalia (>1000IU ml-Si).
• diagnostirebulia 6 da >sm-is diametris Teka-
luTeinuri kistebi.
gestaciuri trofoblasturi neoplazia(6)
qorionepiTelioma
mkurnaloba warmoebs specializi-
rebul samkurnalo dawesebulebaSi
• qimioTerapia
• qirurgiuli mkurnaloba
• sxivuri Terapia
• Semdgomi dakvirveba
