1

P

saSvilosnosgare orsuloba

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

P

2

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

`saSvilosnosgare orsuloba” miRebulia klinikuri praqtikis

erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa

marTvis saxelmwifo standartebis (protokolebi) SemuSavebis,

Sefasebis da danergvis erovnuli sabWos 2007 wlis 21 martis

#1 sxdomaze da damtkicebulia saqarTvelos Sromis,

janmrTelobisa da socialuri dacvis ministris 2007 wlis 21

dekembris # 359/o brZanebiT.

3

klinikuri rekomendaciebis zogadi mizani

standartebis daweseba qalTa janmrTelobis gaumjobesebis mizniT

mocemuli instruqcia aris saSvilosnosgare orsulobis

diagnostikisa da mkurnalobis pirveli gaidlaini-saxelmZRvanelo,

romelic SemuSavebuli da gamocemulia gaeros mosaxleobis fondis

da saqarTvelos Sromis, socialuri da janmrTelobis dacvis

saministros SekveTiT, saqarTvelos ginekolog-endoskopistTa

asociaciis mier 2006 wlis seqtemberSi.

klinikuri instruqciebi warmoadgens sistematiurad SemuSavebul

monacemebs, romlebic klinikosebsa da pacientebs exmareba ama Tu im

konkretul mdgomareobaSi Sesaferis mkurnalobasTan dakavSirebuli

gadawyvetilebis miRebaSi. mocemuli rekomendaciebis mizans ar

warmoadgens mkurnalobis eqskluziuri kursis miTiTeba. isini

Sefasebuli unda iqnas pacientis individualuri saWiroebebis,

dawesebulebaSi arsebuli resursebisa da SezRudvebis, adgilobriv

mosaxleobaSi arsebuli gansxvavebebis gaTvaliswinebiT. imedia,

adgilobrivi mflobelobis es procesi xels Seuwyobs mocemuli

instruqciebis gaerTianebas yoveldRiur praqtikaSi. yuradReba

gamaxvilebulia klinikuri uzustobis im sferoebze, romlebSic

aucilebelia damatebiTi kvleva-Ziebis Catareba.

mtkicebulebaTa doneebisa da rekomendaciebis gradaciis sqema

monacemebi, romlebic am saxelmZRvaneloSi iqna gamoyenebuli,

klasificirebulia qvemoT moyvanili sqemis mixedviT, xolo

rekomendaciebi formulirebulia igive wesiT, standartuli

klasifikaciis sqemis mixedviT.

4

monacemebis xarisxis

klasifikacia

Ia randomizebuli

kontrolirebadi cdebis meta-

analizis Sedegad miRebuli

monacemebi;

Ib aranakleb erTi

randomizebuli kontrolirebadi

cdis Sedegad miRebuli

monacemebi;

IIa aranakleb erTi

kontrolirebadi cdis –

randomizaciis gareSe - Sedegad

miRebuli monacemebi;

IIb aranakleb erTi sxva tipis

kvazi-eqsperimentaluri cdis

Sedegad miRebuli monacemebi;

III iseTi kargad daproeqtebuli,

ara-eqsperimentaluri aRweriTi

cdebis Sedegad miRebuli

monacemebi, rogoricaa

SedarebiTi kvlevebi,

korelaciuri kvlevebi da

konkretuli SemTxvevebis

gamokvlevebi;

IV monacemebi, romlebic

miRebulia eqspertTa komitetis

angariSebidan an daskvnebidan

da/an Sesabamisi organoebis

klinikuri gamocdilebidan.

rekomendaciebis klasifikacia

A moiTxovs aranakleb erT

randomizebul kontrolirebad

kvlevas saerTo maRali

xarisxisa da Tanmimdevrobis

dacvis mizniT ama Tu im

konkretuli rekomendaciis

micemiT;

B moiTxovs kargad

kontrolirebad, magram ara

randomizebul klinikur

kvlevebs rekomendaciebis

saganTan dakavSirebiT

(monacemebis klasi IIa, IIb, III);

C moiTxovs monacemebs,

romlebic miRebulia eqspertTa

komitetis angariSebidan an

daskvnebidan da/an Sesabamisi

organoebis klinikuri

gamocdilebidan. miuTiTebs

pirdapir gamosayenebeli, maRali

xarisxis klinikuri kvlevebis

deficitze;

(monacemTa klasi IV);

kargi gamocdilebis punqti

rekomendirebuli mowinave

gamocdileba, romelic efuZneba

instruqciebis SemmuSavebeli

jgufis klinikur gamocdilebas.

5

saSvilosnosgare orsuloba

1. definicia, sinonimebi, klasifikacia

saSvilosnos Rrus gareT ganayofierebuli kvercxujredis implantacias

saSvilosnosgare orsuloba ewodeba. sinonimi _ eqtopiuri orsuloba.(1)

daavadebaTa saerTaSoriso klasifikaciiT (2) ganarCeven eqtopiuri

orsulobis Semdeg formebs:

1. abdominuri anu muclis Rrus orsuloba;

2. kvercxsavali milis orsuloba:

• milis mTlianobis SenarCunebiT;

• milis mTlianobis darRveviT (kvercxsavali milis

gaskdoma-rubtura);

• milis abortis tipiT mimdinare orsuloba;

3. sakvercxis orsuloba;

4. saSvilosnosgare orsulobis sxva formebi:

• saSvilosnos yelis orsuloba;

• saSvilosnos rqis orsuloba;

• iogTaSorisi orsuloba;

• nawlavis jorjlis orsuloba;

• kombinirebuli eqtopuri orsuloba;

• daudgeneli lokalizaciis orsuloba;

2. daavadebis epidemiologia

eqtopiuri orsulobis sixSire CDC –is monacemebiT Seadgens 200

orsulobidan 1-s. saSvilosnosgare orsulbisas yvelaze xSirad (98%-Si)

gvxvdeba kvercxsavali milis orsuloba, sakvercxis orsuloba

aRiniSneba 0.1-0.2%-Si, abdominaluri orsuloba – 0.4%-Si, xolo

saSvilosnos yelis orsuloba 0.7-1%-Si.

bolo 3 wlis manZilze (2002-2005) saqarTveloSi eqtopiuri orsulobis

2701 diagnozi daisva. sayuradReboa, 2002-2005 wlebSi, saqarTveloSi

eqtopiuri orsulobis Sedegad daiRupa 2 orsuli.

anamnezSi eqtopiuri orsulobis mqone qalebis 60%-Si fertiloba

SenarCunebulia, maTgan 12% kvlav saSvilosnos gareT viTardeba, xolo

saSvilosnos RruSi ganviTarebuli orsulobis 15-20% spontanuri

abortiT sruldeba.

3. etiopaTogenezi

saSvilosnosgare orsulobis ganviTarebis ZiriTadi mizezebia:

1. kvercxsavali milis gamavlobis darRveviT ganpirobebuli

kvercxujredis Senelebuli gadaadgileba kvercxsaval milSi;

2. trofoblastis proteolizuri aqtivobis darRvevebi.

6

am mizezebis ganviTarebas xels uwyoben Semdegi faqtorebi:

• sasqeso organoebis anTebiTi daavadebebi;

• saSvilosnosSida kontraceptivebis gamoyenebis fonze

ganviTarebuli orsuloba;

• kvercxsaval milebze Catarebuli rekonstruqtiul-plastikuri

operaciebi;

• eqtopiuri orsuloba anamnezSi;

• unayofoba;

• muclis Rrus organoebze warmoebuli operaciebi;

• Cveuli spontanuri aborti;

• kriminaluri aborti

• adenosalpingiti;

• sasqeso infantilizmi;

• sasqeso organoebis ganviTarebis da mdebareobis anomaliebi;

• sanayofo kvercxis migraciis darRveva;

• trofoblastis proteolizuri aqtivobis momateba;

• endokrinuli daavadebebi.

4. klinikuri simptomatika

eqtopiuri orsulobis paTognomuri simptomi ar arsebobs. am paTologiis

klinika Zalzed mravalferovania da damokidebulia daavadebis tipze.

eqtopiuri orsulobis dros SemTxvevaTa 50%-Si, ZiriTadad darRveuli

eqtopiuri orsulobis dros, gamoxatulia simptomTa klasikuri

triadidan ori simptomi mainc:

• menstruaciis gadacdena;

• vaginaluri sisxldena, aramenstrualuri genezis;

• tkivili (calmxrivi an ormxrivi, yru an mwvave, mudmivi an

SeteviTi, sxvadasxva lokalizaciis), romelic viTardeba uecrad

milis mTlianobis darRvevis mxares da iradiacias iZleva

epigastriumisken.DAD

fizikaluri kvleviT:

• palpaciiT muclis wina kedlis mcired mtkivneuloba an tkivilis

ararseboba;

• muclis wina kedlis daWimuloba;

• dadebiTi SCotkin-blumbergis simptomi;

• bimanualuri gasinjvisas saSvilosnos yelis mtkivneuloba;

• saSos ukana TaRis Camoberva da mtkivneuloba;

• danamatis areSi momkvrivo-elastiuri moculobiTi warmonaqmni.

7

5. diagnostika

saSvilosnosgare orsulobis Tanamedrove diagnostika emyareba:

klinikur gamokvlevas;

plazmaturi qoriogoninis donis gansazRvrasa;

ultrabgeriT diagnostikas.

am meTodebisgan arcerTi cal-calke, iSviaTi gamonaklisebis garda, ar

iZleva zusti diagnozis dasmis saSualebas, magram rodesac

xorcieldeba maTi monacemebis Sedareba da kompleqsuri analizi,

saSvilosnosgare orsulobis zusti diagnozis dadgenis albaToba 93-97%

aRwevs.

Tu saqme exeba saSvilosnosgare orsulobas kvercxsavali milis

gaxeTqviT, an masiuri sisxldeniT milismieri abortis dros, monacemebis

interpretacia da klinikuri gamokvleva sakmaod garTulebulia. amitom

gansakuTrebuli yuradReba unda mieqces am paTologiis gamovlenis

adreul diagnostikas.

yvelaze xSirad klinikuri gamokvlevis mizans warmoadgens ara zusti

diagnozireba, aramed gare orsulobis saeWvo simptomatikis gamovlena,

Semdgomi gamokvlevebis Catarebis mizniT.

pacientis gamokiTxvis dros yuradRebas iqcevs Semdegi simptomebi:

• amenorea (gvxvdeba 75-85 % SemTxvevebSi) _ sirTules

warmoadgens situaciebi, rodesac qali konsultaciaSi xvdeba

mosalodneli menstruaciis vadamde adre, an aRniSnavs ciklis

araregularobas, ar axsovs bolo menstruaciis TariRi.

• metroragia (gvxvdeba pacientebis 80% SemTxvevebSi). rogorc

wesi, araWarbi da araregularulia, zogjer mas SeuZlia

simulireba gaukeTos TviTnebur aborts orsulobis adreul

stadiaze (e.w. klasikuri diagnostikuri xafangi!).

• tkivilebi (85-dan 100%-mde SemTxvevebSi) _ klasikuri,

milismieri Wvalis tipis unilateraluri tkivilebi iSviaTia.

xSirad isini difuzur xasiaTs atareben, erT-erTi mxaris siWarbiT,

da varireben intensiurobis mixedviT.

anamnezis Segrovebis dros aseve yuradReba unda mieqces:

- adre gadatanil saSvilosnosgare orsulobas;

- anamnezSi kvercxsavali milis plastikur operacias; - qirurgiul Carevas, muclis Rrus gaxsniT; - Sida sasqeso organoebis infeqcias; - Tambaqos moxmarebas.

8

6. saSvilosnosgare osulobis gamokvlevebis sqema

ginekologiuri kvlevis Catarebas iwyeben saSvilosnos yelis sarkeebSi

gasinjviT. saSvilosnos yelis arxSi sekretoruli sacobis aRmoCena

(“gugis simptomi”) warmoadgens saSvilosnosgare orsulobis gamoricxvis

yvelaze swraf da iaf saSualebas gaurkveveli etiologiis menjis

tkivilebis dros. (“gugis simptomi” arasodes ar gvxvdeba

saSvilosnosgare orsulobis dros!)

orsulobis klasikuri niSani – saSvilosnos yelis cianozuri

Seferiloba – xSirad ar aris gamoxatuli, gansakuTrebiT Tu gamokvleva

adreul stadiaze tardeba.

muclis palpaciis dros saSvilosnosgare orsulobis ganviTarebis

adreul stadiebze vlindeba muclis qvemo nawilisa da boqvenzeda aris

tkivili. gamoxatuli defansi, rogorc wesi, ar aris. SesaZloa

gamovlindes peritonealuri gaRizianebis niSnebic.

im periodSi, rodesac, saSvilosnosgare orsulobaze mxolod eWvi

arsebobs, bimanualuri gamokvlevis dros SeimCneva saSos kuTxis TaRebis

gamouxatavi mtkivneuloba, xandaxan metad mwvave erTi mxidan. agreTve

xSirad mtkivneulia ukana TaRis palpaciac, rac mowmobs duglasis

sivrceSi garkveuli raodenobis sisxlis arsebobas. cxadia, rom

saSvilosnos erT-erTi mxridan moculobiTi warmonaqmnis arsebobis

gasinjva iSviaTad xerxdeba, gansakuTrebiT saSvilosnosgare orsulobis

ganviTarebis adreul periodSi.

gamokvlevis laboratorul-instrumentuli meTodebi ZiriTadad moicavs

sisxlSi plazmaturi qoriogoninis (HGG) titris gansazRvras da ubk-s (ultrabgeriTi kvleva).

HGG-s dozireba – fundamenturi analizia, romelic sutuaciaSi

orientirebisa da saeWvo simptomatikis SemTxvevebSi saSvilosnosgare

orsulobis gamoricxvis saSualebas iZleva. qoriogoninze uaryofiTi

testi saSualebas iZleva gamovricxoT, rogorc saSvilosnos Sida, aseve

eqtopiuri orsulobis arseboba.

plazmaSi qoriogoninis arseboba trofoblastis arsebobaze mowmobs,

rac gamokvlevebis gagrZelebas moiTxovs.

9

diagnostikisTvis mniSvnelovania HGG-s donis dinamika – Tu yovel 48

saaTSi hormonis done daaxloebiT orjer izrdeba, es faqti

normalurad ganlagebul da ganviTarebul orsulobaze metyvelebs.

donis stagnacia an misi neli zrda (“plato”) sanayofo kvercxis

aranormalur ganviTarebas mowmobs, rac SeimCneva rogorc

saSvilosnosgare orsulobis, aseve mosalodneli TviTneburi abortis

dros.

ubk – es iseTi gamokvlevaa, romelic HGG-s donis gamokvlevis

SedegebTan erTad Semdgom diagnostikur da Terapiul taqtikas

ganapirobebs.

saSvilosnos RruSi sanayofo kvercxis, da gansakuTrebiT embrionuli

guliscemis vizualizacia, faqtobrivad gamoricxavs saSvilosnosgare

orsulobis SesaZleblobas (saSvilosnos Sida da gare orsulobis

erTdrouli arseboba Zalze iSviaTad xdeba – 1/30000 SemTxveva).

Zalze mniSvnelovania Semdegi debulebebis gaTvaliswineba:

abdominaluri ubk-s Catarebis dros sanayofo kvercxis

vizualizacia SesaZlebelia orsulobis me-5 kviridan, an rodesac

qoriogoninis done 5000 UI-s tolia an aRemateba mas;

10

vaginaluri ubk-s dros Sida orsulobis SemCneva xerxdeba me-4

kviraze, an rodesac qoriogoninis done 1000 UI-s tolia an mas

aRemateba.

saSvilosnosgare orsulobis dafiqsireba ultrabgeriTi kvleviT

sakmaod iSviaTad xerxdeba. gamonaklis SemTxvevebSi eqtopiuri

orsulobis dros xdeba embrionaluri guliscemis vizualizacia, rac

ubk utyuar markerad SeiZleba CaiTvalos. xSirad eqimi-eqoskopisti

duglasis sivrceSi saSvilosnos ukan an gverdiT SeimCneva amorfuli

heterogenuli warmonaqmni (hematosalpinqsi), agreTve Tavisufali siTxe,

xSirad Sededebuli sisxlis koltebiT.

diferencialuri diagnozi – TviT es termini arc Tu ise jdeba

saSvilosnosgare orsulobis dianostikis koncefciaSi, radgan eqims,

romelic konsultirebas eweva, yovelTvis unda axsovdes

saSvilosnosgare orsulobis Sesaxeb, da unda gamoricxos misi areseboba

mravali ginekologiuri Tu sxva paTologiebis dros. mxolod imis

Semdeg, rac eqimi eqtopiuri orsulobis ararsebobaSi darwundeba, mas

SeuZlia pacientis Civilebis warmoSobis sxva versiebis ganxilva.

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saSvilosnosgare orsuloba unda gamoiricxos Semdegi mdgomareobebis

dros:

saSvilosnosSida orsuloba;

spontanuri aborti;

mtkivneuli ovulacia;

sakvercxis funqciuri kista, romelsac xSirad Tan erTvis amenorea

da menjis tkivilebi;

sakvercxis apopleqsia an saSvilosnos danamatebis gadagrexva

dros;

mwvave apendiciti;

mwvave gauvaloba;

Tirkmlis Wvali.

7. saSvilosnosgare orsulobis mkurnaloba

saSvilosnosgare milismieri orsulobis mkurnaloba SesaZlebelia

laparotomiis, operaciuli laparoskopiisa da zogjer medikamentebis

meSveobiT.

saSvilosnosgare orsulobis qirurgiuli mkurnaloba

falopis milismieri orsulobis qirurgiuli mkurnalobisas,

hemodinamikurad stabilur pacientSi, rekomendebulia laparoskopiuri

midgoma.

laparoskopiuri operacia Sedarebuli iqna Ria operaciasTan 228 qalSi,

sam randomizirebul, kontrols daqvemdebarebul cdaSi (RCT) (A done). xanmokle operaciebTan SedarebiT laparoskopiuri procedurebis

upiratesobaa sisxlis naklebi danakargi, xanmokle stacionaruli rejimi

da SedarebiT mcire analgetikuri moTxovnileba.4 (A done). am or

midgomas Soris milebis saerTo gamtarobis mxriv gansxvaveba ar aRiniSna

(RR 0.89, 95% CL 0.74-1.1) (A done). im qalebSi, romlebsac surdaT momavalSi

ganayofiereba (n=145), momdevno saSvilosnosSida orsulobis maCveneblebi

msgavsi iyo (RR 1.2, 95% Cl 0.88-1.15) da laparoskopiuri midgomis

gamoyenebis SemTxvevaSi dafiqsirda ganmeorebiTi eqtopiuri orsulobis

SedarebiT dabali maCveneblisaken tendencia (RR 0.43, 95% Cl 0.15-1.2). (A done)

falopis milis orsulobis mkurnaloba, hemodinamikuri

arastabilurobis dros rekomendebulia Catardes laparotomiiT.

Tu pacients aReniSneba hipovolemiuri Sokis niSnebi, saSvilosnos

milismieri orsulobis an savaraudo gare orsulobis dros

medikamenturi Terapia mizanSewonili ar aris. saSosSida

(transvaginaluri) ultrasonografia swrafad daadasturebs

hemoperitoneumis arsebobas, Tu raime saxis diagnostikur uzustobas

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aqvs adgili, magram miRebuli unda iqnas Sesabamisi reanimaciuli da

operatiuli zomebi. gamocdil operatorebs specializebul centrebSi

SeuZliaT laparoskopiuri meTodiT usafrTxod umkurnalon qalebs didi

hemoperitoneumis drosac ki, xolo umetes centrebSi aRniSnul

proceduras warmoadgens laparotomia.

janmrTeli kontralateraluri milis SemTxvevaSi salpingotomiis

gamoyenebis upiratesoba salpingeqtomiasTan SedarebiT gamoxatulad

dadasturebuli ar aris.

sistematiuri ganxilvebis mTel rigSi Seswavlili iqna is Sedegebi,

romlebic aRiniSna saSvilosnos milismieri orsulobis salpingotomiiT

an salpingeqtomiiT mkurnalobis Semdeg. es masalebi gviCvenebs, rom

Semdgomi saSvilosnos Sida orsulobis SesaZlebloba ar izrdeba

salpingotomiis Semdeg – salpingeqtomiasTan SedarebiT..10-16

saSvilosnosgare orsulobis mkurnalobisas laparoskopiul

salpingotomias upiratesoba eniWeba im SemTxvevaSi, Tu aRiniSneba

kontralateraluri milis daavadeba da Tu pacients Semdgomi

fertilurobis survili aqvs.

im qalebSi, romelTac aReniSneboda dazianebuli an amokveTili

kontralateraluri mili, salpingeqtomiis SemTxvevaSi, savaraudod,

saWiro iqneba in vitro ganayofiereba. postoperaciuli mkurnalobis

periodisa da persistentuli trofoblastis mkurnalobis aucileblobis

gamo salpingotomiis moklevadiani xarjebi salpingeqtomiasTan

SedarebiT maRalia.21 (C done) Tumca, mxedvelobaSi miRebulia gare

(damxmare) Casaxvis Semdgomi saWiroeba, saSvilosnos Sida orsulobis

maCveneblis mxolod 3%-iT zrda salpingotomias salpingeqtomiasTan

SedarebiT bevrad ufro naklebxarjians gaxdis.19 (C done)

kontralateraluri milis daavadebis SemTxvevaSi, sasurvelia SedarebiT

konservatiuli qirurgiis gamoyeneba. qalebs unda gaacnon Semdgomi

eqtopiuri orsulobis riski.

13

saSvilosnosgare orsulobis medikamenturi mkurnaloba

medikamenturi Terapiis gamoyeneba SeiZleba mxolod gansazRvrul

SemTxvevebSi. eqtopiuri orsulobis mkurnalobaSi metotreqsatis

gamoyenebisaTvis aucilebelia mkurnalobisa da Semdgomi mkurnalobis

protokolebis warmoeba.

saSosSida (transvaginaluri) ultrasonografia, romelic

kombinirebulia sisxlis SratSi hCG analizTan, qmnis eqtopiuri

orsulobis zusti diagnozirebis SesaZleblobas laparoskopiis

Catarebis gareSec.22-24 laparoskopiis gamoyeneba eqtopiuri orsulobis

dadgenis mizniT xSirad qirurgiuli Carevis gamoyenebis mTavar mizezs

warmoadgens.

arakontrolirebadi da kontrolirebadi kvlevebis ganxilvam cxadyo is,

rom stabilur pacientebSi medikamenturi mkurnalobis nairsaxeoba

iseTive efeqturia, rogorc qirurgia.25 (B done) yvelaze farTod amJamad

gamoiyeneba medikamenturi mkurnaloba kanqveS metotreqsatis daniSvnis

saxiT, romelic keTdeba erTjeradi doziT, romelic, Tavis mxriv,

gamoiTvleba pacientis sxeulis zedapiris farTobis mixedviT (50 mg/m2).

qalebis umetesobisaTvis aRniSnuli doza Seadgens 75-90 mg-s. sisxlis

SratSi hCG koncentracia mowmdeba meoTxe da meSvide dRes da Tu hCG koncentracia ar iklebs 15%-ze mets meoTxe da meSvide dReebs Soris

periodSi, keTdeba metotreqsatis kidev erTi doza.16, 27, 28 didi

arakontrolirebadi kvlevebi cxadyofs, rom qalTa daaxloebiT 14%-s

esaWiroeba metotreqsatis erTze meti doza, xolo 10%-ze naklebi,

romlebsac utardeba metotreqsatiT mkurnalobis kursi, saWiroebs

qirurgiul Carevas.25, 26 (C done). igive iqna dafiqsirebuli randomizebul

cdebSic metotreqsatis Sedarebisas laparoskopiul qirurgiasTan.27, 28 (A done).

Tu upiratesoba eniWeba medikamentur mkurnalobas, qals unda mieces

sruli informacia (sasurvelia werilobiTi formiT) Semdgomi

mkurnalobis SesaZlo aucileblobisa da mkurnalobis Semdgomi

ukureaqciebis Sesaxeb.

TiTqmis 75% mkurnalobis Semdeg ganicdis abdominalur tkivils. zogjer

qalebs SeiZleba ganuviTardes koniunqtiviti, stomatiti da

gastrointestinaluri aSliloba. tuboabdominaluri abortis Sedegad

gamowveuli e.w. “separaciis tkivilis” gansxvaveba milis mTlianobis

darRvevis Sedegad gamowveuli tkivilisagan SeiZleba rTuli aRmoCndes,

amitom qalTa garkveul nawils metotreqsatiT mkurnalobis Semdeg unda

Cautardes saSosSida ultrabgeriTi gamokvleva.25, 29 qalebs aseve unda

mieces rCeva, mkurnalobis periodSi Tavi Seikavon sqesobrivi

kavSirisagan, didi raodenobiT miiRon siTxe da saimedo Casaxvis

sawinaaRmdego saSualebebi gamoiyenon metotreqsatis miRebidan sami Tvis

ganmavlobaSi – SesaZlo teratogenuri riskis gamo.

14

qalebSi, romlebisTvisac SeiZleba metotreqsatis daniSvna, sisxlis

SratSi hCG Semcveloba ar unda aRematebodes 3000 iu/l-s; maT aseve unda

aReniSnebodeT minimaluri simptomebi.

did arakontrolirebad kvlevebSi metotreqsati gamoyenebuli iqna

qalebSi, romlebsac aReniSnebodaT sisxlis SratSi hCG donis sxvadasxva maCveneblebi, Tumca, am qalTa umetesobaSi aRniSnuli maCvenebeli ar

aRemateboda 5000 iu/l-s.15, 16 (C done). Semgdomi periodis xangrZlivoba,

metotreqsatis damatebiTi dozebis saWiroeba da qirurgiuli Carevis

albaToba izrdeba SratSi hCG koncentraciis Sesabamisad.26

miuxedavad imisa, rom medikamenturi mkurnaloba SeiZleba warmatebuli

aRmoCndes im SemTxvevaSi, rodesac sisxlis SratSi hCG koncentracia mniSvnelovnad aRemateba 3000 iu/l-s, mTeli rigi monacemebi (sococlxis

xarisxis Sefaseba) gviCvenebs, rom metotreqsatiT mkurnaloba dasaSvebia

mxolod im qalebisaTvis, romelTa hCG koncentracia sisxlis SratSi ar

aRemateba 3000 iu/l-s.30, 31

eqtopiuri orsulobis moculobis SedegebTan dakavSirebuli monacemebi

naklebad gamoxatulia, magram didi adneqsaluri wonis qalebSi milebis

mTlianobis darRvevis albaToba SedarebiT didia.26

ambulatoriuli medikamenturi mkurnaloba metotreqsatis erTjeradi

doziT asocirebulia mkurnalobis xarjebis dazogvasTan.

medikamenturi Terapiis erT-erT mniSvnelovan upiratesobas warmoadgens

mkurnalobis xarjebis sagrZnobi ekonomiis SesaZlebloba. ekonomikuri

Sefasebebi, romlebic Catarda randomizebul kvlevebTan erTad, sadac

xdeboda metotreqsatisa da laparoskopiuri qirurgiis urTierTSedareba,

gviCvenebs, rom rogorc pirdapiri, aseve arapirdapiri xarjebi

medikamenturi mkurnalobis dros im xarjebis naxevarze naklebia,

romlebic saWiroa laparoskopiisaTvis. Tumca, am orive randomizebul

kvlevaSi xarjebis dazogva ar dafiqsirda im SemTxvevebSi, rodesac

sisxlis SratSi hCG koncentracia aRemateboda 1500 iu/l-s – damatebiTi

mkurnalobis aucileblobisa da Semdgomi periodis xangrZlivobis gamo.

(A done).

mkurnalobis mocdiTi-dakvirvebiTi taqtika warmoadgens erT-erT

variants klinikurad stabiluri qalebisaTvis minimaluri simptomebiTa

da nayofis ucnobi adgilmdebareobiT.

saeWvo eqtopiuri orsulobis mkurnalobaSi yuradReba eqceva sisxlis

SratSi hCG koncentracias, romelzec, rogorc miRebulia, TiToeuli

sicocxlisunariani saSvilosnos Sida orsuloba vizualizebuli iqneba

transvaginaluri ultrabgeriTi gamokvleviT. mas uwodeben

diskriminatorul zonas.32 rodesac sisxlis SratSi hCG koncentraciebi diskriminatorul zonaze naklebia (< 1000 iu) da orsuloba (saSvilosnos

Sida Tu gare) ar Cans transvaginaluri ultrabgeris skanogramaze,

orsuloba SeiZleba aRwerili iqnas, rogorc ucnobi adgilmdebareobis.33

diskriminatoruli zonis koncefcias garkveuli zRvrebi aqvs. hCG koncentraciebi: 1000 iu/l, 1500 iu/l da 2000 iu/l gamoyenebuli iqna

15

diskriminatorul koncentraciebad.23, 24, 33 es koncentraciebi

damokidebulia ultrabgeriTi aparaturis xarisxze, sonografiis

specialistis gamocdilebaze, qalis riskisa da simptomebis winaswar

Seswavlaze da iseTi fizikuri faqtorebis arsebobaze, rogoricaa

saSvilosnos fibromebi da mravalnayofiani orsuloba. specialuri

danadgarebisaTvis, romlebiTac warmoebs maRali xarisxis vaginaluri

ultrabgeriTi gamokvleva qalis simptomebisa da hCG koncentraciis

winaswari Seswavlis pirobebSi SeiZleba gamoyenebuli iqnas 1000 iu/l diskriminatoruli zona. sxva danadgarebSi, romlebiTac warmoebs

diagnostikuri transvaginaluri skanografia winaswari klinikuri Tu

bioqimiuri gamokvlevis gareSe, misaRebia 1500 iu/l an 2000 iu/l diskriminatoruli zona.

dakvirvebaze dafuZnebuli xuTi kvlevis Sedegebma gviCvena, rom ucnobi

adgilmdebareobis orsulobis 44 - 69% wydeba TviTneburad mkurnalobis

momlodineobiTi taqtikiT.34-38 savaraudoa, rom TviTneburad Sewyvetili

orsulobebis Tu regresiuli trofoblastis35 rigi SemTxvevebi mocemul

kvlevebSi warmoadgenda mcire eqtopiur orsulobebs, romlebic

TviTneburad iqna absorbirebuli Tu Sewyvetili tuboabdominaluri

abortis Sedegad. danarCeni warmoadgenda adreul, saSvilosnos Sida

orsulobebs, romlebic Sewyvetili iqna. eqtopiuri orsuloba

diagnozirebuli iqna ucnobi adgilmdebareobis orsulobebis

SemTxvevaTa 14-28%-Si.36, 38 (C done).

sisxlis SratSi hCG 1000 – 1500 iu/l koncentraciis sawyisi zeda zRvris gamoyeneba ucnobi adgilmdebareobis orsulobis dadgenis mizniT,

minimaluri an nulovani simptomebis mqone, eqtopiuri orsulobis riskis

qalebSi unda Catardes momlodineobiTi taqtikis mkurnaloba 48 – 72

saaTis ganmavlobaSi, xolo Tu eqtopiuri orsulobis simptomebi

vlindeba, sisxlis SratSi hCG koncentracia izrdeba da aRemateba

diskriminatoruls (1000 iu/l) an koncentraciebi iwyebs dacemas, aqtiuri intervenciis SesaZlebloba unda iqnas ganxiluli.36, 38

intervencia, rogorc aRmoCnda, saWiro gaxda SemTxvevaTa 23-29%-Si34,36,

magram met gamocdilebasTan erTad, SesaZlebelia SedarebiT dabali

intervenciuli donis miRweva.37 Tu qalebs uniSnaven momlodineobiTi

taqtikis mkurnalobas, Catarebuli unda iqnas hCG analizebis cikli,

vidre aRniSnuli koncentracia ar miaRwevs 20 iu/l-ze nakleb maCvenebels.

garda amisa, im qalebs, romlebic SerCeulni iqnen ucnobi

adgilmdebareobis orsulobis momlodineobiTi taqtikis

mkurnalobisaTvis, unda mieces garkveuli informacia (sasurvelia

werilobiTi formiT) Semdgom mkurnalobis mniSvnelobis Sesaxeb.

mocdiTi-dakvirvebiTi mkurnalobis taqtika warmoadgens erT-erT

variants klinikurad stabiluri, nulovani simptomebis mqone

qalebisaTvis, romelTac ultrabgeriTi gamokvleviT dausves eqtopiuri

orsulobis diagnozi da romelTa sisxlis SratSi aRiniSneba hCG koncentraciis kleba - sawyis etapze 1000 iu/l-ze naklebamde.

mocdiTi-dakvirvebiTi mkurnalobis taqtikis rolis Semswavleli

kvlevebi erTmaneTisagan gansxvavdeba diagnostirebis meTodebis mixedviT.

16

momlodineobiTi taqtikis mkurnalobamde zogjer gamoyenebulia

eqtopiuri orsulobis laparoskopiuli identifikacia.39, 40 sxva

SemTxvevebSi ar arsebobs araviTari qirurgiuli dadastureba imisa, rom

is eqtopiuri orsulobebi, romelTa mimarT gamoyenebuli iqna mocdiTi-

dakvirvebiTi mkurnalobis taqtika, sinamdvileSi eqtopiuri

adgilmdebareobisa iyo. mocemul instruqciaSi, mxolod is kvlevebi iqna

ganxiluli, romlebSic gamoyenebuli iqna eqtopiuri gestaciis

skanograma an predominanturad myari gare sakvercxis adneqsaluri masa

an xaos ararseboba endometriul nimuSebSi. TiToeul ganxilul

kvlevaSi pacientis mimarT wamoyenebul moTxovnas warmoadgens

klinikuri stabiluroba da minimaluri simptomebi. kvlevaTa umetesobaSi

aucilebeli iyo iseTi adneqsaluri masis arseboba, romelic ar

aRemateboda 4 sm-s41, 42 an 5 sm-s44 da Tavisufali siTxe, romelic ar

aRemateboda 50 ml-s43 an 100 ml-s42. sawyisi hCG kleba 15%-ze metiT 24

saaTis ganmavlobaSi saWiro iyo erT kvlevaSi CasarTavad.43

ganxiluli iqna sami dakvirvebiTi kvleva; sul 478 qals Cautarda

momlodineobiTi mkurnaloba.39-45 (C done) momlodineobiTi mkurnalobis

taqtika warmatebuli aRmoCnda 318 qalSi (67%). dabali sawyisi hCG koncentraciis maCveneblebi TviTneburi Sewyvetis erT-erT

umniSvnelovanes winapirobas warmoadgenda.44 momlodineobiTi taqtika

SedarebiT warmatebuli aRmoCnda (88%) im SemTxvevebSi, rodesac sawyisi

hCG koncentracia naklebi iyo 1000 iu/l-ze.42 - Cohen et al.46 (C done). kvlevis

ganxilvis Sedegad dadasturebuli daskvna. garda amisa, swrafad

klebadi hCG koncentraciis maCvenebeli keTilsasurvel Sedegze

metyvelebda.42-45 (C done). identificirebadi saSvilosnos gare gestaciuri

skanogramis deficiti transvaginaluri ultrabgeriTi gamokvlevis dros

TviTneburi Sewyvetis SesaZleblobas zrdida 5.6-jer.44 (C done) Tumca, ar

aris dazustebuli, warmoadgens Tu ara eqtopiuri orsulobis sawyisi

zoma SesaZlo Sedegis winapirobas, im erTi kvlevis mixedviT, romelsac

ar daudasturebia araviTari zemoqmedeba.44 (C done). warmatebuli

SewyvetisaTvis mniSvnelovan faqtors, rogorc aRmoCnda, warmoadgenda

adneqsaluri masis saSualo diametris Semcireba meSvide dRisaTvis.45 (C done).

mocdiTi-dakvirvebiTi taqtika warmoadgens SerCeul SemTxvevebSi

eqtopiuri orsulobis mkurnalobis gamosadeg formas. Tumca, es forma

misaRebia mxolod im SemTxvevaSi, Tu igi qalisaTvis minimalur risks

moicavs. momlodineobiTi taqtika gamoyenebuli unda iqnas mxolod

usimptomo qalebSi eqtopiuri orsulobis ultrabgeriTi gamokvlevis

Sedegad dasmuli diagnoziT, duglasis sivrceSi sisxlis arsebobis

gareSe da hCG koncentraciis klebadi maCveneblebiT, romlebic ar

aRemateba 1000 iu/l-s sawyis monacemebs da duglasis sivrceSi 100 ml-ze

naklebi odenobis siTxis arsebobiT. im qalebs, romlebsac utardeba

momlodineobiTi taqtikis mkurnaloba, kviraSi orjer unda Cautardes

hCG cikluri analizi, xolo kviraSi erTxel – transvaginaluri

gamokvleva swrafad klebadi hCG koncentraciis maCveneblisa (saukeTeso

SemTxvevaSi - misi sawyisi koncentraciis 50%-iT naklebi Svidi dRis

ganmavlobaSi) da meSvide dRisaTvis adneqsaluri masis Semcirebis

uzrunvelyofis mizniT. amis Semdeg rekomendirebulia yovelkvireuli

hCG da transvaginaluri ultrabgeriTi gamokvlevis Catareba, vidre hCG

17

koncentraciis maCvenebeli 20 iu/l-ze naklebi ar aRmoCndeba, ramdenadac

calkeul SemTxvevebSi, dabali ßhCG koncentraciis maCveneblis

pirobebSi, dafiqsirebuli iqna milis mTlianobis darRveva.47 .

persistentuli trofoblasti

rodesac salpingotomia gamoiyeneba saSvilosnos milebis orsulobis

mkurnalobis mizniT, aucilebelia protokolebis warmoeba im qalTa

identifikaciisa da mkurnalobisaTvis, romlebsac aReniSneba

persistentuli trofoblasti.

persistentuli trofoblastis dadgena xdeba im SemTxvevaSi, rodesac

sisxlis SratSi hCG koncentraciis kleba ar SeiniSneba sawyisi

mkurnalobis Semdeg. aRniSnuli problema salpingotomiis – da ara

salpingeqtomiis - Semdeg iCens Tavs. miuxedavad imisa, rom

persistentuli trofoblastis arsebobis SemTxvevaSic ki hCG

koncentraciis maCveneblebi SeiZleba yovelgvari garTulebis gareSe

daubrundes normas, dafiqsirebuli iqna trofoblastiT gamowveuli

gviani sisxldenis SemTxvevebi48, es ki warmoadgens qalebis hCG cikluri

analizis Catarebisa da metotreqsatis daniSvnis safuZvels im

SemTxvevaSi, rodesac aRniSnuli koncentraciis maCveneblebi ar iklebs

im donemde, rogorc mosalodneli iyo.

kontrolirebadi da arakontrolirebadi kvlevebis ganxilvebSi,

persistentuli trofoblastis maCveneblebi monacemTa bazis mixedviT

Seadgenda 3.9-4.1%-s Ria salpingotomiis Semdeg.15, 16, 49 (B done) faqtorebi, romlebic savaraudod warmoadgenda persistentuli trofoblastis

ganviTarebis gazrdil risks, moicavs winasaoperacio periodSi sisxlis

SratSi hCG koncentraciis SedarebiT maRal maCveneblebs (> 3000 iu/l),50 swraf winasaoperacio zrdas hCG koncentraciis maCveneblebSi51 da

milebidan aqtiuri sisxldenis arsebobas.50

trofoblasturi qsovilebis sruli amokveTis Semdeg sisxlis SratSi

hCG koncentraciis maCveneblebi daecema prognozirebadi gawmendis

mrudamde49, magram im qalTa proporcia, romlebsac Cautarda mkurnaloba

persistentul trofoblastze, nawilobriv damokidebuli iqneba

postoperaciuli analizis sixSiresa da misi gansazRvrisaTvis aRebul

nimuSebze.

erT kvlevaSi persistentuli trofoblastis mkurnaloba iwyeboda im

SemTxvevaSi, Tu sisxlis SratSi hCG koncentracia 10%-ze metiT

aRemateboda preoperaciul maCvenebels qirurgiidan aTi dRis Semdeg.52

meore kvlevis mixedviT mkurnalobis dawyeba sasurvelia im SemTxvevaSi,

Tu hCG maCveneblebi sawyisTan SedarebiT 65%-iT metia qirurgiuli

Carevidan 48 saaTis Semdeg.53

50 mg/m2 dozis metotreqsati farTod gamoiyeneboda erTjeradi dozis

saxiT ganmeorebiTi qirurgiuli proceduris nacvlad, Tumca Catarebuli

ar yofila araviTari formaluri SedarebiTi kvlevebi. profilaqtikuri

metotreqsati gamoyenebuli iqna laparoskopiuri salpingotomiis

SemTxvevaSic, xolo erT-erT randomizebul cdaSi da martiv

salpingotomiasTan Sedarebisas aRiniSna mniSvnelovani kleba

18

persistentuli trofoblastis maCveneblebSi (1.9% 14%-is winaaRmdeg, RR 0.12, 95% Cl 0.02 – 0.97)54. (A done)

anti-D imunoglobulini

arasensibilizirebuli, rezus-uaryofiTma qalebma saeWvo Tu

dadasturebuli eqtopiuri orsulobis diagnozis SemTxvevaSi unda

miiRon anti-D imunoglobulini.

meanTa da ginekologTa samefo kolejis instruqcia # 22-is Sesabamisad,

rom anti-D imunoglobulini 250 iu (50 mikrogrami) doziT miRebuli unda

iqnas yvela rezus-uaryofiTi arasensibilizirebuli qalis mier,

romelsac aReniSneba eqtopiuri orsuloba.59

8. pacientebis monawileoba da informireba

qalebs, SeZlebisdagvarad, safuZvlianad unda Cautardes konsultacia

eqtopiuri orsulobis mkurnalobis mizniT gamoyenebuli TiToeuli

midgomis dadebiT da uaryofiT SedegebTan dakavSirebiT. isini

monawileobas unda iRebdnen maqsimalurad Sesaferisi mkurnalobis

meTodis SerCevaSi.

adreul etapze orsulobis Sewyvetis fsiqologiurma zemoqmedebam

SeiZleba seriozuli ziani miayenos qalTa mniSvnelovan nawils, maT

partniorebsa da ojaxebs.55 Semdgomi periodis gegmebi naTlad unda iqnas

Camoyalibebuli adreuli orsulobis klinikidan gaweris

rekomendaciebSi. qalebs unda miawodon werilobiTi informacia maTi

mkurnalobis variantebTan, Semdgom periodsa da adgilobrivi Tu qveynis

wamyvan reproduqciul centrebTan dakavSirebiT.

monacemebis mixedviT, fsiqologiur SedegebSi mciredi gansxvaveba

arsebobs eqtopiuri orsulobis mkurnalobis qirurgiuli da

medikamenturi meTodebis urTierTSedarebisas.28, 60

9. alternatiuli gaidlaini ar arsebobs. 10. gaidlainis gadasinjvisa da ganaxlebis vada – 3 weli

11. gamoyenebuli literatura:

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22. Ankum W. Laparoscopy in the diagnosis of ectopic pregnancy. In: Grudzinskas JG, O'Brien PMS, editors. Problems in Earty Pregnancy: Advances in Diagnosis and Treatment. London: RCOG Press; 1997. p. 154-9

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34. Ankum W, Van der Veen F, Hamerlynck J, Lammes F. Suspectted ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone. J Reprod Med 1999;40:525-8

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37. Hajenius P, Mol B, Ankum W, Van der Veen F, Bossuyt P, Lammes F. Suspected ectopic pregnancy: expectant management in patients with negative sonographyic findings and low serum ß-hCG concentrations. Early Pregnancy 1995;1:258-62

38. Makinen J, Kivijarvi A, Irjala K. Sucvcess of non-surgical management of ectopic pregnancy. Lancet 1990;335:1099

39. Shalev E, Peleg D, Tsabari A, Romano S, Bustan M. Spontaneous resolution of ectopic turbal pregnancy: natural history. Fertil Sterill 1995;63:15-9

40. Ylostalo P, Cacciatore B, Korhonen J, Kaariainen M, Makela P, Sjoberg J, et al. Expectant management of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 1993;49:83-4

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avtorTa jgufi:

saqarTvelos ginekolog-endoskopistTa asociacia:

arsen gvenetaZe _ medicinis mecnierebaTa doqtori, asocirebuli

profesori, Tsu-is menoba ginekologiisa da reproduqciuli

janmrTelobis departamenti, i. Jordanias sax. adamianis reproduqciis

s/k institutis qirurgiuli ganyofilebis xelmZRvaneli.

nikoloz kintraia _ medicinis mecnierebaTa doqtori, sruli

profesori, Tssu menoba ginekologiis departamentis xelmZRvaneli,

s/s akad. k. CaCavas sax. meanoba ginekologiisa da perinataluri

medicinis s/k institutis ginekologiuri seqtoris xelmZRvaneli.

eqspertebi:

⇒ paliko kintraia _ mean-ginekologi, akad. CaCavas sax. mean-

ginekologiis da perinataluri medicinis samecniero-kvleviTi

institutis direqtori, profesori;

⇒ Tengiz AasaTiani _ mean-ginekologi, Tssu postdiplomuri

samedicino ganaTlebis da uwyveti profesionaluri ganviTarebis

institutis reproduqciuli janmrTelobis departamentis

xelmZRvaneli, asocirebuli profesori, saqarTvelos mean-

ginekologTa asociaciis prezidenti;

⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros janmrTelobis dacvis

departamenti;

23

⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros janmrTelobis dacvis

departamenti.