1

hiperbilirubinemiis marTva

axalSobil bavSvebSi,

romelTa gestaciuri asaki 35 da

meti kviraa

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

2

klinikuri praqtikis erovnuli rekomendacia (gaidlaini)

`hiperbilirubinemiis marTva axalSobil bavSvebSi, romelTa

gestaciuri asaki 35 da meti kviraa~ 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 27

agvistos # 258/o brZanebiT.

3

hiperbilirubinemiis marTva axalSobil bavSvebSi,

romelTa gestaciuri asaki 35 da meti kviraa

1. daavadebis definicia, sinonimebi, klasifikacia da terminologia

axalSobilTa siyviTle axalSobilis kanis da sklerebis yviTeli

Seferilobaa, rac ganpirobebulia qsovilebSi bilirubinis CalagebiT.

hiperbilirubinemiad miCneulia sisxlis SratSi bilirubinis

Semcvelobis mateba 85 µmol/L (5 mg/dl-ze) metad1.

tranzitoruli (fiziologiuri) siyviTle msubuqi arakoniugirebuli

(arapirdapiri) bilirubinemiaa, romelic vlindeba sicocxlis 48-120 sT-Si.

mwvave bilirubinuli encefalopaTia – arapirdapiri bilirubinis

toqsiuri zemoqmedebiT ganpirobebuli cns-is darRveva, romelic vlindeba

mwvaved adreul neonatalur periodSi.

kerniqterusi _ bilirubinis toqsiurobiT ganpirobebuli qronikuli

da permanentuli xasiaTis cns-is dazianeba.

butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia

mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis

(saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT.

gaidlaini gankuTvnilia

⇒ samedicino personalisaTvis, romelic muSaobs axalSobilTan,

rogorc samSobiaro saxlSi, ise stacionarSi – neonatologi,

pediatri.

gaidlainis samizne jgufi:

⇒ 35 kviris da meti gestaciuri asakis axalSobilebi, romelTac

ganuviTardaT hiperbilirubinemia.

⇒ gaidlainSi ar aris ganxiluli 35 kviraze naklebi gestaciuri

asakis dRenaklul axalSobilTa hiperbilirubinemiis marTva

gaidlainis gacnobis Semdeg samedicino personals ecodineba, rom

aucilebelia

1. ZuZuTi kvebis propaganda da mxardaWera.

2. saeqTno protokolebis Sedgena hiperbilirubinemiis identifikaciisa

da SefasebisaTvis.

3. Ssb da tkb gansazRvra axalSobilebSi, romelTac siyviTle

gamouvlindaT dabadebidan pirvel 24 sT-Si.

4. siyviTlis xarisxis gansazRvrisTvis siyviTlis intensivobis

vizualuri SefasebasTan erTad laboratoriuli kvlevis Catareba

(mxolod vizualuri Sefasebisas xSiria daignostikuri Secdoma,

gansakuTrebiT muqkanian axalSobilebSi).

4

5. bilirubinis maCveneblis interpretacia axalSobilis asakTan

(saaTebSi) mimarTebaSi

6. hiperbilirubinemiis ganviTarebis maRali riskis gamovlena da maTi

monitoringi.

7. mZime hiperbilirubinemiis ganviTarebis riskis sistemuri Sefaseba

yvela axalSobilTan.

8. mSoblebisadmi werilobiTi da zepiri informaciis miwodeba

axalSobilTa siyviTlis Seasaxeb.

9. axalSobilis mkurnaloba Cvenebis mixedviT fotoTerapiiTa da

SenacvlebiTi transfuziiT.

10. Sesabamisi ambulatoriuli meTvalyureobis uzrunvelyofa, rac

axalSobilis gaweris drosa da riskis Sefasebas efuZneba.

gamoyenebuli Semoklebebi:

Sbs – Sratis saerTo bilirubini

tkb – transkutanuri bilirubini

b/a - bilirubinis da albuminis Sefardeba

rds – respiraciul distres sindromi

1 µmol/L = 17,1 mg/dl

2. epidemiologia1-3

tranzitoruli (fiziologiuri) siyviTle viTardeba dRenaklul

axalSobilTa umravlesobasa da droul axalSobilTa 25-50%-Si. daniis

monacemebiT mZime hiperbilirubinemiis sixSire 35 kviraze meti gestaciis

axalSobilebSi Seadgens 25-s 100 000 cocxladSobilze. janmos

monacemebiT axalSobilTa hemolizuri daavadebis sixSire Seadgens 1-s

yovel 2000-3000 axalSobilze.

saqarTveloSi zusti statistikuri monacemebi ar arsebobs, Tumca 2000

wlis maCveneblebiT yovel 1000 cocxladSobilze gamovlinda

hiperbiliribinemiis 5 SemTxveva63.

3. etiopaTogenezi1,2,4

hiperbilirubinemia SesaZlebelia mimdinareobdes arapirdapiri an

pirdapiri bilirubinis donis momatebiT. gaZlierebuli hemolizi,

bilirubinis koniugaciis unaris Semcireba iwvevs arapirdapir

bilirubinemias, xolo naRvlis eqskreciis darRveva – pirdapir

bilirubinemias.

1. tranzitoruli siyviTlis mizezebi:

• erTrocitebis da hemoglobinis maRali Semcveloba

• eriTrocitebis sicocxlis xangrZlivobis daqveiTeba

• fetaluri hemoglobinis Semcveli eriTrocitebis hemolizi

• RviZlSi bilirubinis koniugaciis unaris umwifroba

• bilirubinis gazrdili enterohepatuli cirkulacia

• RviZlis mier plazmidan bilirubinis moxmarebis Semcireba

5

2. paTologiuri siyviTlis mizezebi:

eriTrocitebis hemolizis gaZliereba:

• sisxlis jgufuri da rezus SeuTavsebloba

• Tandayolili membrano (sferocitozi da sxv.), fermentopaTia

(glukoza 6 fosfatdehidrogenazas - g6fd – ukmarisoba da sxv.) da hemoglobinopaTia (Talasemia da sxv.)

• policitemia

• kefalohematoma, sisxlCaqcevebi

• infeqcia

bilirubinis koniugaciis Semcireba

• dRenakluloba

• iSviaTi Tanadayolili daavadebebi (Jilberis, krigler-naiaris

sindromi da sxva)

• bilirubinis metabolizmis da eqskreciis darRveva (rotoris da

dubin-jonsonis sindromi)

bilirubinis reabsorbciis gazrda gastrointestinuri traqtidan

• asfiqsia

• kvebis gvian dawyeba, iSviaTi kveba

• nawlavTa obstruqcia

• mekoniumis pasaJis Seferexeba

naRvlis eqskreciis darRveva

• biliaruli atrezia

• qolestazuri sindromi

• sefsisi

• saSvilosnosSida infeqcia

• hepatiti

• cisturi fibrozi (mukoviscidozi)

siyviTle ZuZuTi kvebis dros5

• dedis rZiT ganpirobebuli (ariasis sindromi): savaraudoa dedis

rZeSi arsebuli nivTierebis (araesterificirebuli cximovani

mJavebis da hormon pregnanis) gavlena bilirubinis metabolizmze

(iTrguneba ferment glukuroniltransferazas aqtivoba da

bilirubinis koniugacia).

• ZuZuTi kvebis araswori reJimiT ganpirobebuli, iSviaTi ZuZuTi

kvebis SemTxevaSi arasakmarisi raodenobiT rZis miReba iwvevs

enterohepaturi cirkulaciis gazrdas.

siyviTle agreTve SeiZleba ganpirobebuli iyos: endokrinuli

paTologiiT (hipoTireozi da sxv.) dedasTan an bavSvTan zogierTi

medikamentis gamoyeneba (sulfanilamidebi, oqsitocini, nitrofuranebi da

sxv).

6

bilirubinis toqsiuroba - bilirubini potenciuri neirotoqsinia.

arakoniugirebulma bilirubinma, romelic ar aris dakavSirebuli

albuminTan, SeiZleba gaiaros hematoencefaluri barieri da Tavis tvinSi

gamoiwvios ujredebis sikvdili apoptoziT (ujredebis programirebuli

sikvdili) da/an nekroziT. yvelaze metad ziandeba bazaluri ganglia da

Tavis tvinis Reros okulomotoruli da auditoruli funqciebis

makontrolebeli birTvebi.

Tu droul axalSobilebSi bilirubini gadaWarbebs 428 - 513 µmol/L (25-30 mg/dl), maRalia bilirubinis toqsiuri moqmedebis ganviTarebis riski.

Ssb toqsiuroba variabeluria da damokidebulia axalSobilis

janmrTelobis mdgomareobasa da gestaciur asakze6.

mZime hiperbilirubinemiis ganviTarebis risk-faqtorebi

mZime hiperbilirubinemiis ganviTrebis riski miT ufro maRalia, rac

ufro meti riskis faqtoria gamoxatuli axalSobilTan:

maRali riski1,2

− dabadebidan pirvel 24sT-Si gamovlenili siyviTle7.

− gaweris win Ssb an tkb done butanis nomogramaze maRali riskis

zonaSi8,9

− sisxlis jgufuri SeuTavsebloba dadebiTi pirdapiri

antiglobulinuri testiT, sxva cnobili hemolizuri daavadeba

(mag.: g6fd deficiti), − gestaciuri asaki 35-36 kvira 10,11

− da-Zmas Catarebuli aqvs fotoTerapia11,12

− kefalohematoma an mniSvnelovani sisxlCaqcevebi10

− araxSiri ZuZuTi kveba, rodesac aReniSneba wonaSi mkveTri kleba

(>12%-ze meti)2,10,11

dabali riski

_ gaweris win Ssb an tkb-is done butanis nomogramaze maRali

gardamavali riskis zonaSi8,9

_ gestaciuri asaki 37-38 kvira10,11

_ da-Zmis anamnezSi siyviTle11,12

_ diabetiT daavadebuli dedis makrosomuli axalSobili

_ dedis asaki ≥ 25 welze10

_ mamrobiTi sqesi10,11

mdgomareobebi, romlis drosac mZime hiperbilirubinemiis ganviTarebis

riski Zalian dabalia:

− gestaciuri asaki ≥ 41 kviraze10, − srulyofili enteraluri kveba10,11

− gawera stacionaridan 72 sT-is Semdeg8,9,13

− Ssb butanis nomogramaze dabali riskis zonaSi8,9

7

4. klinikuri simptomatika rekomendacia - siyviTlis monitoringi unda moxdes yvela

axalSobilTan rutinulad vitaluri funqciebis Sefasebisas, ara

nakleb 8-12 sT-Si erTxel (rekomendacia D)1. siyviTlis arsebobis Sefaseba unda moxdes kargad ganaTebul oTaxSi,

umjobesia dRis Suqze fanjarasTan. siyviTle Cveulebriv pirvelad

vlindeba saxeze da Semdeg progresirebs kaudalurad sxeulsa da

kidurebze14. siyviTlis ukeT gansazRvrisaTvis tardeba kanze TiTis

zewolis testi. zewola lokalurad amcirebs kanis perfuzias da xels

uwyobs siyviTlis diagnostikas. rodesac bilirubini 68-137 µmol/L (4-8

mg/dl), Cveulebriv iqterulia saxe da sklera, Tu bilirubini >257 µmol/L (15 mg/d) siyviTle vlindeba mTel sxeulze xelis da fexisgulebis

CaTvliT. Ssb an tkb mizanSewonilia gaizomos, Tu siyviTle vlindeba

Wipis qvemoT. krameris modificirebuli sqema saSualebas iZleva siyviTlis

gavrcelebis mixedviT vivaraudoT, Tu ramdenia Sratis saerTo

bilirubinis done.

krameris modificirebuli sqema3,14 cxrili 1

zona

1 2 3 4 5

Ssb µmol/L

100

150

200

250

>250

siyviTlis xarisxis gansazRvra

siyviTlis intensivobis mxolod

vizualuri SefasebiT xSirad iwvevs

diagnostikur Secdomas, gansakuTrebiT

muqkanian axalSobilebSi. (rekomendacia

C)1,16,17.

cxrili 2 siyviTlis simZimis Sefaseba lokalizaciis mixedviT (janmo)3

asaki (dRe) siyviTlis lokalizacia daskvna

1 nebismieri*

«saSiSi» siyviTle 2 kidurebi*

≥ 3 terfebi, mtevnebi

* sicocxlis I dRes nebismier adgilas an II dRes kidurebze gamovlenili

siyviTle saWiroebs dauyovnebliv fotoTerapiis dawyebas analizis

pasuxis miRebamde.

C

D

8

axalSobilTa siyviTlisGgarTulebebi

axalSobilTa siyviTlisGgarTulebebia mwvave da qronikuli

(kerniqterusi) bilirubinuli encefalopaTia, romlebic uxSiresad

hemolizuri daavadebis dros viTardeba62.

mwvave bilirubinuli encefalopaTia1

mwvave bilirubinuli encefalopaTias axasiaTebs ganviTarebis 3 faza:

1. adreuli faza vlindeba ramdenime dReSi da axasiaTebs leTargia,

hipotonia, susti wova da sustad gamoxatuli “cerebruli kivili”.

2. gardamavali stadia viTardeba kviris bolos da axasiTebs

zomieri stupori, agznebadoba da hipertonia. axalSobils

SeiZleba aReniSnos cxeleba mkveTrad gamoxatuli “cerebruli

kivili”. hipertonia vlindeba kisris (retrokolisi) da sxeulis

(opistotonusi) ukan rkaliseburad gadaxriT.

3. bolo stadia vlindeba 1 kviris Semdeg, am dros centraluri

nervuli sistemis dazianeba Seuqcevadia, mas axasiaTebs mkveTri

retrokolisi da opistotonusi, mkveTrad gamoxatuli “cerebruli

kivili”, apnoe, cxeleba, sakvebis autanloba, Rrma stupori

komamde, zogjer krunCxvebi da sikvdili. 18;19

kerniqterusi1,47

Bmwvave bilirubinuli encefalopaTiis Semdeg gadarCenil

axalSobils sicocxlis pirveli wlis manZilze uviTardeba

bilirubinuli encefalopaTiis mZime qronikuli forma, romelic 3

ZiriTadi gamovlinebiT xasiaTdeba 18-20 motoruli darRvevebi - aTetoiduri cerebluri dambla, tremori,

qorea

mxedvelobis darRvevebi

smeniTi disfunqcia

inteleqtualuri darRvevebi SedarebiT iSviaTia.

kerniqterusis dros 70%-Si aRiniSneba nevrologiuri darRvevebi da

10%-Si sikvdiloba.

9

diferenciuli diagnozi:

axalSobilTa siyviTlis dros unda ganisazRvros siyviTle

fiziologiuria Tu paTologiuri3.

fiziologiuri siyviTle

paTologiuri siyviTle

vlindeba ara uadres 2 dRisa da

qreba me-10-14 dRisTvis

vlindeba pirvel 24 saaTSi an

7 dRis Semdeg

gavrceleba ar aRemateba krameris

1-3 zonebs

gavrceleba: krameris nebismieri

zona sicocxlis I dRes, 4 zona

sicocxlis II dRes da 5 zona

nebismier asakSi

bavSvi aqtiuria, temperatura

normaluria, wovis refleqsi kargia

zogadi mdgomareoba

damakmayofilebeli an darRveuli

Sardis da ganavlis feri ar

icvleba

SeiZleba iyos Sardis da ganavlis

feris cvlileba

RviZli da elenTa ar aris

gadidebuli

SeiZleba iyos hepatosplenomegalia

axalSobilTa fiziologiuri siyviTlis dros bilirubinis

Semcvelobis pikuri done sicocxlis III dRisTvis uxSiresad 85,5-136,8 µmol/L (5-8 mg/dl-ia), Semdeg xdeba misi donis daqveiTeba. 205,2µmol/L-mde (12 mg/dl) mateba fiziologiurad iTvleba. 35-37 kviris gestaciuri asakis

axalSobilebSi Bbilirubinis donem SeiZleba maqsimums miaRwios

dabadebidan me-7 dRes.

arakoniugirebuli hiperbilirubinemiis ufro maRali done sxvadasxva

paTologiuri mdgomareobebis dros vlindeba2.

dedis rZiT ganpirobebuli siyviTlis sadiagnostikod (samkurnalod)

SeiZleba Semdegi maCveneblebis gamoyeneba5:

• dedis rZiT ganpirobebuli siyviTle vlindeba me-4-14 dRes

• 24-48sT-is ganmavlobaSi ZuZuTi kvebis Sewyveta da alternatiul

sakvebis miwodeba iwvevs bilirubinis donis daqveiTdebas.

axalSobilTa hiperbilirubinemiis difdiagnozi ix. algormiTi 1.

10

klinikurad gamoxatuli siyviTle

hiperbilirubinemia

bilirubini ≥ 205 µmol/L da

axalSobilis asaki < 24sT

bilirubini < 205 µmol/L da

axalSobilis asaki > 24sT

kumbsis testi bilirubinis

kontroli

dadebiTi uaryofiTi

antisxeulebis

gansazRvra

Rh ABO Kell da sxva.

pirdapiri bilirubini

> 34,2 µmol/L

hematokriti

< 34,2 µmol/L

norma an dabali maRali

• policitemia

• materno-fetaluri

transfuzia

• Wiplaris gviani

gadakvanZva

hepatiti

saSvilosnosSiga

infeqcia

sanaRvle gzebis

obstruqcia

sefsisi

galaqtozemia

α-1-antitrifsinis

deficiti

mukoviscidozi

Tirozinozi

qolestazi

aTaSangi

hemoqromatozi

eriTrocitebis

morfologia

retikulocitebis

raodenoba

paTologia norma

sferocitozi

elifsocitozi

stomatocitozi

piknocitozi

ABO SeuTavsebloba

eriTrocitebis

fermentTa deficiti

α Talasemia

medikamentebi (mag.

penicilni)

sisxlZarRvTaSida

Sededebis sindromi

sisxldena

gazrdili enterohepatuli

cirkulacia

dedis rZiT ganpirobebuli

siyviTle

hipoTireozi

krigler-naiaris sindromi

diabetiani dedis axalSob.

rds

asfiqsia

infeqcia

Jilberis sindromi

medikamentebi (novobiocini)

galaqtozemia

axalSobilTa hiperbilirubinemiis diferenciuli diagnozis algoriTmi

11

5. daavadebis diagnozi:

diagnozi efuZneba klinikur gamovlinebas – kanisa da xiluli

lorwovani garsebis siyviTles, bilirubinemiuli encefalopaTiis niSnebs

da hiperbilirubinemias.

6. gamokvlevis sqema1,15

rekomendacia1:

tkb da/an Ssb unda ganesazRvros yvela axalSobils,

romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si

(rekomendacia C)7. tkb da/an Ssb unda ganesazRvros yvela axalSobils,

romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle

(rekomendacia D). bilirubinis donis Sefaseba unda moxdes axalSobilis

asakis (saaTebSi) gaTvaliswinebiT (sqema 1) (rekomendacia C).

Tu axalSobils utardeba fotoTerapia an aReniSneba

bilirubinis swrafi mateba (sqema 1 – monacemi kveTs

percentilebs), rac ar aixsneba obieqturi gamokvleviT da

anamnezuri monacemebiT, saWiroa siyviTlis SesaZlo

mizezebis dadgena (rekomendacia D). axalSobilebs romelTac aReniSnebaT pirdapiri

(koniugirebuli) bilirubinis mateba unda CautardeT Sardis

saerTo da baqteriologiuri gamokvleva.21 damatebiTi

laboratoriuli gamokvlevebi unda Catardes Tu anamneziT

da obieqturi gamokvlevebiT saeWvoa sefsisi (rekomendacia C).

Tu pirdapiri an koniugirebuli bilirubinis done

momatebulia, rekomendirebulia damatebiTi gamokvlevebi

qolestazis sadiagnostikod (rekomendacia C). avadmyof axalSobilebsa da Cvilebs, romelTac aReniSnebaT

siyviTle 3 kviris an ufro mogvianebiT asakSi, unda

ganesazRvroT saerTo da pirdapiri (koniugirebuli)

bilirubini qolestazis sadiagnostikod (cxrili 3)

(rekomendacia D). aseT axalSobilebTan mizanSewonilia

skriningi hipoTireozsa da galaqtozemiaze (rekomendacia D) glukoza-6-fosfat dehidrogenazas donis gansazRvra

saWiroa im axalSobilebTan, romelTa ojaxuri anamnezi an

eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s

deficitze da utardebaT fotoTerapia da/an

axalSobilebTan, Tu fotoTerapia uefeqtoa. (sqema 3)

(rekomendacia C).

C

D

C

D

C

C

D

D

C

12

cxrili 3: 35 da meti gestaciuri asakis axalSobilSi gamovlenili

siyviTlis laboratoriuli Sefaseba1,22

Cveneba laboratoriuli kvleva pirvel 24 sT-Si gamovlenili

siyviTle • tkb da/an Ssb gansazRvra

asakisaTvis Seusabamo mkveTri

siyviTle kanze G • tkb da/an Ssb gansazRvra

axalSobils utardeba fotoTerapia

an aReniSneba bilirubinis swrafi

mateba (namati >8.5 µmol/L/sT an 0.5 mg/dl/sT) (butanis nomogramaze

maCvenebeli kveTs percentilebs),

rac ar aixsneba obieqturi

gamokvleviT da anamnezuri

monacemebiT

• sisxlis jgufi da rezusi kumbsis testi, Tu ar aris gakeTebuli

Wiplaris sisxlSi

• sisxlis saerTo analizi, da nacxi

formiani elementebis

morfologiis Sesaswavlad

• pirdapiri (koniugirebuli)

bilirubinis gansazRvra

• Tu SesaZlebelia, isazRvreba

retikulocitebis ricxvi, g6fd

• Ssb ganmeorebiT isazRvreba 4-24

sT-Si, axalSobilis asakisa da

Ssb donis Sesabamisad

fotoTerapia uSedegoa an Ssb aRwevs

dones, romelzec naCvenebia

SenacvlebiTi transfuzia

• Tu SesaZlebelia, isazRvreba

retikulocitebis ricxvi, g6fd

• SesaZlebelia saWiro gaxdes

hematokritis da albuminis

gansazRvra

momatebulia pirdapiri

(koniugirebuli) bilirubinis done • Sardis anlizi

• Sardis kultura

• gamokvleva sefsisze, Tu misi

arseboba saeWvoa anamneziT an

obieqturi gamokvleviT

siyviTle sami kviris asakis an

avadmyof axalSobilSi

• saerTo da pirdapiri

(koniugirebuli) bilirubini

• pirdapiri bilirubinis

momatebisas tardeba kvleva

qolestazis sadiagnostikod • skriningi hipoTireozsa da

galaqtozemiaze

• axalSobilis Sefaseba

hipoTireozis simptomebis

gamosavlenad

13

sqema 1. butanis nomograma

butanis nomograma saSualebas iZleva ganisazRvros, ramdenad maRalia

mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis

(saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT.

bilirubinis gansazRvra

bilirubini isazRvreba transkutanurad da sisxlis SratSi.

transkutanuri gansazRvra gamarTlebulia, rogorc skriningis

meTodi. is isazRvreba specialuri aparatiT. aRniSnuli xelsawyos

gamoyenebiT bilirubinis gansazRvra SesaZloa 34-54µmol/L (2-3 mg/dl) variabelobiT. bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris

Canacvleba transkutanuri gansazRvriT, gansakuTrebiT maSin, roca Ssb < 257 µmol/L (15 mg/dl)23-28.

Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes

saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT

transfuziaze gadawyvetilebis miRebis dros.

14

7. mkurnalobis sqema pirveladi profilaqtika

rekomendacia1 • eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi

ZuZuTi kveba dReSi 8-12-jer (rekomendacia C)30. - arasrulyofili kaloriebis miRebam da/an dehidrataciam,

SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba31,32. • ZuZuTi kvebis SemTxevaSi, Tu axalSobils ar aReniSneba

dehidratacia, ar aris rekomedirebuli wylisa da

deqstrozis rutinulad damateba (rekomendacia: B da C). - wylis da deqstrozis damateba ar axdens

hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s

Semcirebas33.

• yvela Rh (D) negatiur orsuls an melogines mizanSewonilia

Cautardes anti D imonoglobuliniT profilaqtika

(rekomendacia A)33: − orsulobis 28 kviraze (garda im SemTxvevebisa, rodesac bavSvis

mamac Rh (D) negatiuria) − mSobiarobidan 72 sT-is gamnavlobaSi, Tu axalSobili Rh (D)

pozitiuria

− orsulobis pirvel trimestrSi ganviTarebuli abortis da

invaziuri procedurebis dros rogorica: amniocentezi, nayofis

invaziuri procedurebi.

meoradi profilaqtika

rekomendacia: klinicistma unda moaxdinos axalSobilTa

hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba

neonatalur periodSi (rekomendacia B)1. sisxlis jgufobrioba

rekomendacia1

yvela orsuli qali unda iyos gamokvleuli ABO da Rh(D) sisxlis jgufebze da hqondes Catarebuli skriningi SratSi

izoimunur antisxeulebze (rekomendacia B). Tu dedas ar Cautarebia prenatalurad sisxlis jgufis da

rezusis gamokvleva an igi Rh negatiuria, mkacrad aris

rekomendirebuli pirdapiri antisxeulebis testis (an

kumbsis testi), sisxlis jgufis da Rh (D) tipis gansazRvra axalSobilis (Wiplaris) sisxlSi. (rekomendacia B).

Tu dedas sixlis jgufi aris O, Rh(D) pozitiuri

axalSobilis sisxlis jgufis da pirdapiri antisxeulis

testis gansazRvris aucilebloba damokidebulia

meTvalyureobis xarisxze, gaweris win riskis Sefasebasa da

gaweris Semdeg meTvalyureobaze. (rekomendacia C).

C

B

A

C

B

B

B

C

15

mkurnalobis ZiriTadi principebia:

fotoTerapia

SenacvlebiTi transfuzia

mkurnaloba iwyeba fotoTerapiiT.

fotoTerapia

fotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri

bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad,

romlebic gamoiyofa SardiT da naRveliT. rekomendacia: yvela samSobiaro saxli unda iyos aRWurvili

mowyobilobiT, romelic saWiroa intensiuri fotoTerapiisaTvis

(rekomendacia D)1.

fotoTerapiis Cvenebebi

fotoTerapia iwyeba Tu bulirubinis done aRemateba 95 percentils

butanis nomogramaze (sqema 1), amave dros metad mniSvnelovania risk-

faqtorebis gaTvaliswineba, romlebic xels uwyobs mZime

hiperbiliruminemias (hemolizuri daavadeba, g6fd deficiti, asfiqsia,

mkveTrad gamoxatuli leTargia, temperaturis arastabiluroba, sefsisi,

acidozi an hipoalbuminemia <3,0 g/dl).

amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema

2), romelic axalSobilis asaksa da bilirubinis donesTan erTad

iTvaliswinebs risk-faqtorebsa da gestaciur asaks. mocemuli sqemis

mixedviT “intensiuri” fotoTerapia iwyeba, Semdegi principebiT:

dabali riskis axalSobili* (janmrTeli, risk-faqtorebis gareSe,

gestacia > 38 kvira) – Ssb >12 mg/dl (205 µmol/L) 24 sT-Si, Ssb >15

mg/dl (257 µmol/L) 48 sT-Si, Ssb >18 mg/dl (308 µmol/L) >72 sT.

saSualo riskis axalSobili (gestacia > 38 kvira da risk-faqtorebi,

an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) – Ssb > 10

mg/dl (171 µmol/L) 24 sT-Si, Ssb >13 mg/dl (222 µmol/L) 48 sT-Si, Ssb

>15 mg/dl (257 µmol/L) >72 sT. gestaciis 35 kviris axalSobilebSi

fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze.

maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) -

Ssb > 8 mg/dl (137 µmol/L) 24 sT-Si, Ssb >11 mg/dl (188 µmol/L) 48 sT-

Si, Ssb >13.5 mg/dl (231 µmol/L) >72 sT.

* Tu dabali riskis axalSobilebSi Ssb done 2-3 mg/dl-iT dabalia

moyvanil monacemebze, SesaZlebelia mkurnalobis dawyeba “Cveulebrivi”

fotoTerapiiT

• stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba

“intensiuri” fotoTerapia bilirubinis maCveneblis gansazRvramde

• “intensiuri” fotoTerapia aseve rekomendebulia hemolizuri

daavadebis dros35

D

16

sqema 2. fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis

hospitalizebul axalSobilebSi1

rekomendacia: Tu Sratis albuminis maCvenebeli naklebia 3.0

g/dl-ze, fotoTerapiis dawyeba rekomendebulis ufro dabali

maCveneblebis dros (rekomendacia D)1.

janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb

mocemulia cxrilSi 4.

cxrili 4. fotoTerapiis Cveneba Ssb mixedviT (janmo)3

asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris

mqone axalSobili*

mg/dl µmol/L mg/dl µmol/LI gamoxatuli siyviTle

II 15 260 13 220

III 18 310 16 270

IV da meti 20 340 17 290

Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis

dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba. janmos

rekomendaciiT fotoTerapia iwyeba, Tu siyviTlis lokalizaciis mixedviT

siyviTlis simZimis Sefasebisas (cxrili 1) dadginda “saSiSi siyviTle”.

fotoTerapiis ukuCveneba:

pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri

bilirubini Ssb-s 50%-ze metia)1,36 Tandayolili porfiria an porfiriis ojaxuri anamnezi1,37.

D

D

17

fotoTerapiis teqnika1

fotoTerapiis efeqturoba damokidebulia dozaze. fotoTerapiis

doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze,

sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze.

sinaTlis wyaro

fotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da

filtrze. yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba

Seicavs dRis Suqis, gril TeTr, cisfer, an “specialur cisfer”

fluorescentul naTurebs.

manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba,

sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur

manZilze, romelic miTiTebulia fotoTerapiis mowyobilobis

instruqciaSi38. halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes

axalSobilTan axlos, radgan SeiZleba gamoiwvios damwvroba.

sxeulis zedapiris farTobi

bilirubinis maRali Semcvelobisas, mniSvnelovania fotoTerapiis

dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi.

“Cveulebrivi fotoTerapia” - sinaTlis speqtris iradiacia dabalia (6-

12 µW/cm2/nm) (talRis sigrZe daaxloebiT 425-475 nm) da damokidebulia

sxvadasxva mwarmoeblis mier mowodebul fotoTerapiiis sistemis aparatis

monacemebze. saWiroa aparatis Semowmeba, Seesabameba Tu ara sinaTlis

speqtris iradiacia mwarmoeblis mier mowodebul monacemebs.

“intensiuri fotoTerapia” - lurj-mwvane speqtris iradiacia (talRis

sigrZe daaxloebiT 430-490 nm) sul cota 30 µW/cm2/nm-ia (isazRvreba

axalSobilis kanze fotoTerapiis aparatis centris qveS). gazomva xdeba im

warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis

aparatis mwarmoeblis mier39. sinaTlis talRis asareklad TeTreuli unda

iyos TeTri, inkubatori da sawolis gverdebi daifaros TeTri qsoviliT

an aluminis folgiT40.

fotoTerapiis procedura da monitoringi3

temperatura sinaTlis wyaros qveS unda iyos 28-300C. fotoTerapiis dros bavSvi unda iyos SiSveli, ecvas erTjeradi

higienuri safeni, Tvalebze unda hqondes damcavi saTvale.

yovel 3 saaTSi erTxel bavSvs unda Seucvalon pozicia.

yovel 3 saaTSi erTxel unda Sefasdes sinaTlis wyaros qveS

arsebuli temperatura da axalSobilis sxeulis temperatura. Tu

bavSvis t > 37,50C saWiroa oTaxis temperaturis daqveiTeba an

fotoTerapiis droebiT Sewyveta, sanam bavSvis temperatura ar iqneba

normis farglebSi (36,5-37,50C). fotoTerapia mimdinareobas mudmivad, igi wydeba mxolod im

procedurebis dros, romelTa warmoeba ar SeiZleba sinaTlis

wyaros qveS.

centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda

Sewydes mcire droiT

fotoTerapiis dros unda gagrZeldes bavSvis kveba:

18

⇒ axalSobilTan unda gagrZeldes ZuZuTi kveba

moTxovnilebis mixedviT (intervali kvebaTa Soris

araumetes 3 sT-isa) (rekomendacia C). ZuZuTi kvebis

dros wydeba fotoTerapia da Sesabamisad bavSvs unda

moexsnas damcavi saTvale.

⇒ Tu bavSvi ikvebeba gamowvelili rZiT, formuliT an

parenteralurad, misawodebeli sakvebis an siTxis raodenoba

izrdeba dRiuri normis 10 %-iT.

⇒ Tu bavSvi ikvebeba zondiT an parenteralurad, fotoTerapia

mimdinareobs uwyvetad.

⇒ fotoTerapiis dros axalSobils ar esaWiroeba rutinulad

damatebiT siTxis an sakvebis miwodeba. damateba naCvenebia

mxolod araefeqturi ZuZuTi kvebis, sxeulis masis

paTologiuri danakargis (>10%-ze mesame dRisTvis) da

dehidrataciis SemTxvevaSi.

fotoTerapiis dros bilirubinis daSlis produqtebi gamoiyofa

SardiT da naRveliT, adeqvaturi hidrataciis SenarCuneba da Sesabamisad

adekvaturi diurzis SenarCuneba zrdis fotoTerapiis efeqturobas.

zogierT axalSobils hiperbilirubinemiiT aReniSneba dehidratacia

da saWiroa damatebiTi siTxis miwodeba (per-os an intravenurad)

dehidrataciis koreqciisaTvis.

araefeqturi ZuZuTi kvebis SemTxvevaSi fotoTerapiis dros

axalSobils damatebiT miewodeba gamowvelili dedis rZe, donoris rZe an

xelovnuri sakvebi.

⇒ adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da

nawlavTa moqmedeba 3-4 jer/dReSi sicocxlis meoTxe dRisaTvis.

janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi

(minimaluri maCveneblebi) 41 cxrili 5

dRe nawlavTa minimaluri

moqmedeba/24sT

sveli safeni/24sT

1 1 1

2 1 2

3 1 3

4 2 yviTeli fafisebri 4

5 2YyviTeli fafisebri 5-6

⇒ dehidrataciaze miuTiTebs Semdegi niSnebis arseboba5

- masis paTologiuri kleba (>10%-ze mesame dRisTvis)

- anuria 4-6 sT

- Cacvenili Tvalebi

- Cavardnili yoflibandi

- daqveiTebuli kanis elastiuroba (kanis naoWi swordeba

nela)

- daqveiTebuli kanis kapilaruli avseba (>3 wm)

- taqikardia

- Sratis Na >145, HCO3 <17

C

19

bilirubinis monitoringi fotoTerapiis dros1

fotoTerapiis efeqturobaze miuTiTebs sawyisi bilirubinis

maCveneblis Semcireba 6-20%-iT standartuli42 da 30-40%-iT intensiuri8,43

fotoTerapiis dawyebidan 24sT-Si. fotoTerapiis dros kanis vizualuri SefasebasTan erTad

aucilebelia Sratis bilirubinis gansazRvra, radgan fotoTerapia

“aTeTrebs” kans1.

• Tu Ssb 342–428 µmol/L L (20–25 mg/d), ganmeorebiTi gansazRvra _ 3-4 sT-

Si,

• Tu Ssb <342 µmol/L L (20 mg/d), ganmeorebiTi gansazRvra xdeba 4–6 sT-Si,

Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si.

• Tu Ssb ar mcirdeba an uaxlovdeba SenacvlebiTi transfuziis

Cvenebis dones an Ssb/albuminis Sefardeba aWarbebs cxrilSi

mocemul dones (ix. cxrili 6), iwyeba SenacvlebiTi transfuzia, Tu

amis saSualeba aris an xorcieldeba referali

• intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba,

miuTiTebs hemolizze.

⇒ anemia/hemolizis Sefaseba5 SesaZlebelia sisxlis saerTo

analizis mixedviT - Hgb< 130 g/l,LHct < 40%,

retikulocitebi - > 6%

• Ssb < 13–14 mg/dL (239 µmol/L), fotoTerapia wydeba

• fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb, Tu Ssb

moimata im donemde, romelzec daiwyo fotoTerapia, fotoTerapia

ganmeorebiT iwyeba8.

fotoTerapiis garTulebebi

fotoTerapiis garTulebebi1.,2: ⇒ mwvane feris ganavali/diarea (mkurnalobas ar saWiroebs)

⇒ dehidratacia ⇒ muclis Seberva (mkurnalobas ar saWiroebs)

⇒ Tvalis SesaZlo dazianeba

yvelaze seriozuli, magram iSviaTi klinikuri garTulebaa brinjaos

axalSobilis sindromi44, romelic vlindeba qolestazuri siyviTlis

mqone axalSobilSi kanis, Sratis da Sardis muqi, nacrisfer-yavisferi

SeferilobiT45. brinjaos axalSobilis sindromi ar vlindeba qolestazis

mqone yvela axalSobilTan. axalSobilebSi, romelTac uviTardebaT

brinjaos sindromi naCvenebia SenacvlebiTi transfuzia. monacemebis

arasrulyofilebis gamo mkacri rekomendaciis gakeTeba ar SeiZleba.

mZime qolestazuri siyviTlis mqone axalSobilebSi fotoTerapiis

dros aseve SeiZleba ganviTardes:

⇒ purpura ⇒ bulozuri gamonayari

fotoTerapiis dros kanSi Calagebuli bilirubini swrafad iSleba, amitom ar aris rekomendebuli kanis ferze dayrdnobiT SratSi

bilirubinis donis Sesafaseba rogorc fotoTerapiis dros, ise misi Sewyvetidan 24 sT-is ganmavlobaSi.

20

mzis ultraiisferi sxivebiT Terapia

marTalia, mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm,

magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski

(SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar

aris1,2,46.

intravenuri imunoglobulinis gamoyeneba

rekomendacia: izoimunuri hemolizuri daavadebis dros

rekomendebulia intravenuri imunoglobulinis gamoyeneba (0,5-1

g/kg 2 sT-s ganmavlobaSi), Tu Ssb imatebs intensiuri

fotoTerapiis miuxedavad an Ssb aris 2-3 mg/dl-iT (34-51mkmol/l) naklebi SenacvlebiTi transfuziis Cvenebis doneze (sqema 3).

aucilebelobis SemTxvevaSi intravenuri imunoglobulinis doza

SeiZleba ganmeordes 12 sT-Si. (rekomendacia B)1,48. kvlevebiT dadgenilia, rom intravenuri imunoglobulini amcirebs

SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis

dros49,50. SenacvlebiTi transfuzia

rekomendacia: SenacvlebiTi transfuzia unda Caataros mxolod

gamocdilma samedicino personalma intensiuri Terapiis

ganyofilebaSi monitoringisa da srulyofili reanimaciis

SesaZleblobis pirobebSi (rekomendacia D)1.

SenacvlebiTi transfuziis Cvenebebi (rekomendacia D)1:

mwvave bilirubinuli encefalopaTia51-53 - SenacvlebiTi

transfuzia iwyeba dauyovnebliv.

intensiuri fotoTerapiis miuxedavad:

* Ssb mateba - Ssb aRemateba SenacvlebiTi transfuziis

dawyebis maCvenebls.

* ucvleli Ssb.

samSobiarodan gawerili axalSobilebis hospitalizaciis

SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi

transfuziis dawyebis maCvenebls (sqema 3). (transfuziamde iwyeba

“intensiuri” fotoTerapia da saWiroebis SemTxvevaSi

rehidratacia, Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu

adekvaturi rehidrataciisa da “intensiuri” fotoTerapiis

miuxedavad Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali

4-6 sT-is Semdeg, iwyeba SenacvlebiTi transfuzia)62.

b/a Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba,

rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis

gansazRvrisTvis53.

B

D

D

21

sqema 3. SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri

asakis hospitalizebul axalSobilebSi1

cxrili 6. bilirubinisa da albuminis Sefardeba, rodesac saWiroa

SenacvlebiTi transfuzia1

riskis kategoria

b/a Sefardeba, rodesac

saWiroa SenacvlebiTi

transfuzia

Ssb (mg/dl)/

alb (g/dl)

Ssb (µmol/L)/ alb (µmol/L)

axalSobilebi gestaciuri asaki - ≥38 kvira 8.0 0.94

janmrTeli axalSobilebi gestaciuri asakiT an

riskis jgufis axalSobilebi gestaciuri

asakiT ≥38 kvira an izoimunuri hemolizuri

daavadeba an g6fd deficiti

7.2 0.84

riskis jgufis axalSobilebi gestaciuri

asakiT 35–36 kvira an izoimunuri hemolizuri

daavadeba an g6fd deficiti

6.8 0.80

janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis

Sesaxeb mocemulia cxrilSi 7.

22

cxrili 7. SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)3

asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris

mqone axalSobili*

mg/dl µmol/L mg/dl µmol/LI 15 260 13 220

II 25 425 15 260

III 30 510 20 340

IV da meti 30 510 20 340

*Tu Ssb uaxlovdeba im dones, rodesac naCvenebia SenacvlebiTi

transfuzia:

sisxli dauyovnebliv igzavneba, raTa dadgindes jgufi da

rezusi da SeTavseba, Tu klinikaSi aris transfuziis

saSualeba

an

xorcieldeba referali.

teqnika1,4,54

• SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-), xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli. Tu saxezea orive

saxis SeuTavsebloba gamoiyeneba O(I) Rh(-) sisxli.

• sisxli gamokvleuli unda iyos Sidssa da sxva infeqciebze.

• gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas, saSualod 170-180 ml/kg. an

gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2

• SenacvlebisaTvis xdeba 2 venis an arteria da venis kaTeterizacia; iReben bavSvis 20 ml sisxls da SeyavT 20 ml donoris sisxli (3-4

wT-is ganmavlobaSi) SemTbaris 36,7-37,00C-mde. • dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi

Senacvleba xdeba 5-10 ml-iT

axalSobilis momzadeba 49

• kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSi • SeiZleba saWiro gaxdes bavSvis dabma

• SeiZleba sawovaras gamoyeneba

• Sardis Semkrebis gamoyeneba diurezis kontrolisTvis

SelacvlebiTi transfuziis Catarebamde fasdeba axlSobilis 49

• temperatura • guliscema

• sunTqva

• wneva • glukoza SratSi

• Sardis analizi

• ganavlis analizi sisxlis Semcvelobaze

• kanis feri • tonusi • qceva

23

uSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si) 49

• temperatura • guliscema (mwvervalze) (umjobesia kardiomonitoriT)

• sunTqva

• kanis feri • qceva

monitoringi transfuziis Semdeg 49

• grZeldeba fotoTerapia

• kardiomonitoringi kontroldeba

• sisxlis wneva proceduris damTavrebis Semdeg

• saaTobrivad 6 sT-is ganmavlobaSi: temperatura, guliscema

(mwvervalze), sunTqva

• glukoza SratSi yovel 3 sT-Si 24 sT-is ganmavlobaSi

• muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi,

nawlavebis peristaltikis auskultacia

• Sardis analizi

• ganavali sisxlis Semcvelobaze

• sakvebis autanlobis niSnebi: Rebineba, muclis Seberva

• Ssb 6 sT-Si erTxel

SenacvlebiTi transfuziis riski:

sikvdiloba - 3 SemTxveva 1000 transfuziaze56,57

SenacvlebiTi transfuziis dros garTulebis saxiT 5%-Si vlindeba57

- apnoe, bradikardia, cianozi, vazospazmi, Trombozi, nekrozuli

enterokoliti. aseve SeiZleba ganviTardes hipoqsiur-iSemiuri

encefalopaTia58.

sxva mkurnaloba1:

fenobarbitali – xels uwyobs bilirubinis koniugacias da amcirebs

Ssb dones. ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis

gamosayeneblad, rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi

meTodebi (mag. fotoTerapia).

referali1,3

referali maRali donis klinikaSi xorcieldeba, Tu:

ar aris fotoTerapiis Catarebis SesaZlebloba.

axalSobils sWirdeba fotoTerapia da ar aris Ssb gansazRvris

saSualeba

fotoTerapiis miuxedavad:

⇒ Ssb ar mcirdeba ⇒ Ssb izrdeba an aRemateba 342 µmol/L

siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas

dadgenili “saSiSi siyviTle”. mwvave bilirubinuli encefalopaTia bilirubinis maRali saaTobrivi namati 8.5 µmol/L/sT (>0.5 mg/dl/sT).

24

ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlesTan erTad vlindeba sxva daavadebis niSnebi (mag. sefsisi)

pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri

bilirubini Ssb-s 50%-ze metia)

riskis Sefaseba samSobiarodan gaweramde1

rekomendacia: • yvela axalSobilis gaweramde unda Sefasdes

hiperbilirubinemiis ganviTarebis riski, yvela ganyofilebas

unda hqondes protokoli siyviTlis SefasebisTvis, aseTi

Sefaseba gansakuTrebiT mniSvnelovania im

axalSobilebisaTvis romlebic ewerebian dabadebidan 72 sT-ze

adre (rekomendacia C). • riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma

(calcalke an kombinaciaSi): gaweris win bilirubinis

gansazRvra (Ssb an tkb) da/an klinikuri risk-faqtorebis

Sefaseba8,9,22,59-61 risk-faqtorebis arseboba an Ssb maRali

maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis

aucilebelobis Cvenebaa (rekomendacia C). • yvela samSobiarom unda miawodos mSobels zepiri da/an

werilobiTi informacia binaze siyviTlis Sefasebis da

saSiSroebis niSnebis Sesaxeb (rekomendacia D).

8. meTvalyureoba rekomendacia1

• yvela axalSobili samSobiarodan gaweris Semdeg ramdenime

dReSi unda Sefasdes kvalificiuri samedicino

profesionalis mier (rekomendacia C). • fasdeba - siyviTlis arseboba, axalSobilis wona, kvebis

efeqturoba, Rebinebis arseboba (rekomendacia C). • meTvalyureobis grafiki: Tu axalSobili samSobiarodan

ewereba 48-72 sT-Si, samedicino Sefaseba tardeba 120 sT-is (5

dRe) asakSi (rekomendacia C). • Tu samSobiarodan gaweris Semdeg meTvalyureoba

SeuZlebelia da arsebobs hiperbilirubinemiis ganviTarebis

risk-faqtorebi, axalSobilis gawera unda gadaidos, sanam

ar iqneba uzrunvelyofili Sesabamisi meTvalyureoba an

sanam gaivlis maRali riskis periodi (72-96sT)

(rekomendacia D) 11. gaidlainis gadasinjvisa da ganaxlebis vada – 3 weli

C

C

C

C

D

C

D

25

12. gaidlainis miRebis xerxi/wyaro

gaidlainis SemuSavebis meTodologia

• axalSobilTa hiperbilirubinemiis prevenciis, diagnostikisa da

marTvis principebis Sesaxeb arsebobs samecniero

mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi

raodenoba. mocemuli gaidlainis Semqmnis procesSi samuSao

jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve

arsebuli praqtikuli rekomendaciebi. moxda arsebuli

rekomendaciebis adaptirebuli variantis SemuSaveba, romelic

erTis mxriv pasuxebs saerTaSoriso moTxovnebs, xolo meore

mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa

rogorc adamianur, ise teqnikur resursebs.

• rekomendaciaTa moZieba xorcieldeboda eleqtronuli

monacemTa bazis gamoyenebiT.

cxrili 2

qveyana da resursis

dasaxeleba

internet-misamarTi

aSS

US National Guideline Clearinghouse (NGC)

http://www.guideline.gov

Centers for Disease Control and Prevention (CDC)

http://www.phppo.cdc.gov/CDCRecommends/AdvSearchV.asp

Agency for Healthcare Research and Quality (AHRQ)

http://www.ahrq.gov/clinic/cpgsix.htm

Health Services Technology Assessment Text (HSTAT) and National Library of Medicine (NLM)

http://hstat.nlm.nih.gov

Institute of Clinical Systems Improvement (ICSI)

http://www.icsi.org

American Medical Association http://www.ama-assn.org

Canadian Medical Association (CMA)

http://mdm.ca/cpgsnew/cpgs/index.asp

Health Canada – Population and Public Health Branch (PPHB)

http://www.hc-sc.gc.ca/pphb-dgspsp/dpg_e.html

didi britaneTi National Institute for Clinical Excellence (NICE)

http://www.nice.org.uk

Sheffield Evidence for Effectiveness and Knowledge (SEEK)

http://www.shef.ac.uk/seek/guidelines.htm

26

National electronic Library for Health (NeLH)

http://www.nelh.nhs.uk/guidelinesfinder

PRODIGY Clinical Guidance http://www.prodigy.nhs.uk/ClinicalGuidance

Scottish Intercollegiate Guidelines Network (SIGN)

http://www.sign.ac.uk

German Guideline Information Service (GERGIS)

http://www.leitlinien.de/english/english/view;

avstralia Australian National Health and Medical Research Council (NHMRC)

http://www.health.gov.au/hfs/nhmrc/publicat/cp-home.htm

axali zelandia

New Zealand Guidelines Group (NZGG)

http://www.nzgg.org.nz/library.cfm

mtkicebiTi medicinis

specialistTa

regionTaSorisi

sazogadoeba

http://www.osdm.org

klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi

wyaroebi da meTodebi

• koxreinis biblioTeka - The Cochrane Library 2006, Issue 2, • amerikis samedicino biblioTekis mier Seqmnil eleqtronul

bibliografiul monacemTa baza - medlaini – MEDLINE • jandacvis msoflio organizaciis reproduqciuli janmrTelobis

biblioTeka

publikaciebis CarTvis/gamoricxvis kriteriumebi

• arCeul iqna kvlevebi Semdegi dizainiT: randomizebuli,

kontrolirebadi, sistemuri mimoxilvebi da meta-analizi,

erTmomentiani, kohortuli kvlevebi

• rekomendaciis momzadebisas ZiriTadad dadgenili iyo drois 12

wliani SezRudva. Tumca zogjer gamoyenebuli iyo ufro

adreuli publikaciebi, romlebic dResac aqtualuria da

safuZvlad udevs sxva Tanamedrove mtkicebulebebs.

• dadgenili iyo enobrivi SezRudvebi, radganac samuSao jgufs

SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod

inglisur da rusul enebze.

moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi

• samuSao jgufis mier tardeboda moZiebuli wyaroebis analizi.

Catarebuli Ziebis Sedegad miRebuli iyo ramdenime klinikuri

meToduri rekomendacia axalSobilTa hiperbilirubinemiis marTvis

sakiTxebze, romlebic Seicavda jgufis miznis Sesaferis saWiro

informacias. am rekomendaciebis Sefasebisas gamoyenebuli iyo

27

rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (94,96-98). samuSao jgufi xelmZRvanelobda saqarTvelos Sromis

janmrTelobisa da socialuri dacvis saministros samedicino

standartebisa da normebis sammarTvelos mier mier SemuSavebuli

nacionaluri gaidlainebis gzamkvleviT. Sefasebis Sedegad

amorCeuli iyo qvemoT CamoTvlili organizaciebis gaidlainebi:

⇒ amerikis pediatrTa akademia

⇒ msoflo jandacvis organizacia

⇒ kanadis pediatrTa sazogadoeba – nayofi da axalSobilis

komiteti

⇒ britaneTis reproduqciuli janmrTelobis programa

• rekomendaciebis mtkicebulebaTa doneebis gansazRvrisas

gamoyenebuli iyo saqarTvelos Sromis janmrTelobisa da

socialuri dacvis saministros samedicino standartebisa da

normebis sammarTvelos mier mowodebuli mtkicebulebebis donisa da

rekomendaciebis xarisxis sqema.

mtkicebulebaTa doneebisa da rekomendaciebis xarisxis sqema

done mtkicebulebis siZlieris

done (Muir Gray) xarisxi rekomendaciis xarisxi

(Cook et al) I Zlieri mtkicebuleba,

eyrdnoba minimum erT

sistemur mimoxilvas,

romelic efuZneba swori

dizainis mqone

randomizebul

kontrolirebad kvleva

A eyrdnoba I donis

mtkicebulebas da

Sesabamisad mtkiced

rekomendebulia

II Zlieri mtkicebuleba,

eyrdnoba minimum erTi

swori dizainis mqone

randomizebul

kontrolirebad kvleva

B eyrdnoba II donis

mtkicebulebas da

Sesabamisad mtkiced

rekomendebulia

III klinikuri kvleva

randomizaciis gareSe,

kohortuli da SemTxveva-

kontrolis kvlevebi

C eyrdnoba III donis

mtkicebulebas SeiZleba

CaiTvalos Sesabamisad

IV araeqsperimentuli

multicentruli kvlevebi

D eyrdnoba IV da V donis

mtkicebulebas saWiroebs

konsesuss

Va avtoritetul

profesionalTa mosazreba

Vb klinikuri gamocdileba,

aRwerilobiTi kvlevebi an

eqspertTa angariSi

28

13. alternatiuli gaidlaini ar arsebobs 14. gamoyenebuli literatura

1. American Academy of Pediatrics - Subcommittee on Hyperbilirubinemia Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation CLINICAL PRACTICE GUIDELINE, PEDIATRICS (ISSN 0031 4005). Copyright © 2004

2. Ronald J Wong, David K Stevenson, MD - Clinical features and management of unconjugated hyperbilirubinemia in term and near term infants - ©2005 UpToDate www.uptodate.com

3. World Health Organization - Managing Newborn Problems – A Guide for doctors, nurses and midwives – 2003

4. Nelson - Textbook of pediatrics 2005 5. Cloherty - Manual of neonatal care, 2004 6. Jaundice in the healthy term newborn – Newborn guideline 4. British Columbia

Reproductive Care Program, Original – April 1993, Revised April 2002 7. Newman TB, Liljestrand P, Escobar GJ. Jaundice noted in the first 24 hours after birth in a

managed care organization. Arch Pediatr Adolesc Med. 2002;156:1244–1250 8. Bhutani V, Gourley GR, Adler S, Kreamer B, Dalman C, Johnson LH. Noninvasive

measurement of total serum bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia. Pediatrics. 2000;106(2). Available at: www.pediatrics.org/cgi/content/full/106/2/e17

9. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103: 6–14

10. Newman TB, Xiong B, Gonzales VM, Escobar GJ. Prediction and prevention, of extreme neonatal hyperbilirubinemia in a mature health maintenance organization. Arch Pediatr Adolesc Med. 2000;154:1140–1147

11. Maisels MJ, Kring EA. Length of stay, jaundice, and hospital readmission. Pediatrics. 1998;101:995–998

12. Gale R, Seidman DS, Dollberg S, Stevenson DK. Epidemiology of neonatal jaundice in the Jerusalem population. J Pediatr Gastroenterol Nutr. 1990;10:82–86

13. Soskolne El, Schumacher R, Fyock C, Young ML, Schork A. The effect of early discharge and other factors on readmission rates of newborns. Arch Pediatr Adolesc Med. 1996;150:373–379

14. Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Am J Dis Child. 1969;118:454–458

15. M Kaplan, C Hammerman - American Academy of Pediatrics guidelines for detecting neonatal hyperbilirubinaemia and preventing kernicterus Arch. Dis. Child. Fetal Neonatal Ed 2005;90;450-451

16. Moyer VA, Ahn C, Sneed S. Accuracy of clinical judgment in neonatal jaundice. Arch Pediatr Adolesc Med. 2000;154:391–394

17. Tayaba R, Gribetz D, Gribetz I, Holzman IR. Noninvasive estimation of serum bilirubin. Pediatrics. 1998;102(3). Available at: www.pediatrics. org/cgi/content/full/102/3/e28

18. Johnson LH, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatr. 2002;140:396–403

19. Volpe JJ. Neurology of the Newborn. 4th ed. Philadelphia, PA: W. B. Saunders; 2001 20. Kim MH, Yoon JJ, Sher J, Brown AK. Lack of predictive indices in kernicterus. A

comparison of clinical and pathologic factors in infants with or without kernicterus. Pediatrics. 1980;66:852–858

21. Garcia FJ, Nager AL. Jaundice as an early diagnostic sign of urinary tract infection in infancy. Pediatrics. 2002;109:846–851

29

22. Kaplan M, Hammerman C, Feldman R, Brisk R. Predischarge bilirubin screening in glucose-6-phosphate dehydrogenase-deficient neonates. Pediatrics. 2000;105:533–537

23. Maisels MJ, Kring E. Transcutaneous bilirubinometry decreases the need for serum bilirubin measurements and saves money. Pediatrics. 1997;99:599–601

24. Ip S, Glicken S, Kulig J, Obrien R, Sege R, Lau J. Management of Neonatal Hyperbilirubinemia. Rockville, MD: US Department of Health and Human Services, Agency for Healthcare Research and Quality; 2003. AHRQ Publication 03-E011

25. Bhutani V, Gourley GR, Adler S, Kreamer B, Dalman C, Johnson LH. Noninvasive measurement of total serum bilirubin in a multiracial predischarge newborn population to assess the risk of severe hyperbilirubinemia. Pediatrics. 2000;106(2). Available at: www.pediatrics.org/cgi/content/full/106/2/e17

26. Yasuda S, Itoh S, Isobe K, et al. New transcutaneous jaundice device with two optical paths. J Perinat Med. 2003;31:81–88

27. Maisels MJ, Ostrea EJ Jr, Touch S, et al. Evaluation of a new transcutaneous bilirubinometer. Pediatrics. 2004;113:1638–1645

28. Ebbesen F, Rasmussen LM, Wimberley PD. A new transcutaneous bilirubinometer, bilicheck, used in the neonatal intensive care unit and the maternity ward. Acta Paediatr. 2002;91:203–211

29. Rubaltelli FF, Gourley GR, Loskamp N, et al. Transcutaneous bilirubin measurement: a multicenter evaluation of a new device. Pediatrics. 2001;107:1264–1271

30. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2002:220–224

31. Bertini G, Dani C, Trochin M, Rubaltelli F. Is breastfeeding really favoring early neonatal jaundice? Pediatrics. 2001;107(3). Available at: www.pediatrics.org/cgi/content/full/107/3/e41

32. Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics. 1990;86:171–175

33. De Carvalho M, Holl M, Harvey D. Effects of water supplementation on physiological jaundice in breast-fed babies. Arch Dis Child. 1981;56: 568–569

34. American College of Obstetricians and Gynecologists - Prevention of Rh D alloimmunization. 1999 May (reviewed 2004) http://www.guidelines.gov

35. Sameer Wagle - Hemolytic Disease of Newborn Last Updated: June 22, 2006 http://www.emedicine.com/PED/topic959.htm

36. American Family Practice Notebook, LLC – Phototherapy - 2002, 37. Kearns GL, Williams BJ, Timmons OD. Fluorescein phototoxicity in a premature infant. J

Pediatr. 1985;107:796–798 38. Maisels MJ. Phototherapy—traditional and nontraditional. J Perinatol.2001;21(suppl

1):S93–S97 39. Fiberoptic phototherapy systems. Health Devices. 1995;24:132–153 40. Thor WR Hansen, MD, PhD, MHA, Jaundice, Neonatal - eMedicine Neonatology Last

Updated: June 8, 2006 41. Fetus and Newborn Committee, Canadian Paediatric Society (CPS) - Approach to the

management of hyperbilirubinemia in term newborn infants Paediatrics & Child Health 1999;4(2):161-164 Reference No. FN98-02 Revision March 2002

42. Yasuda S, Itoh S, Isobe K. New transcutaneous jaundice device with two optical paths. J Perinat Med 2003;31:81-8.

43. Maisels MJ, Kring E. Bilirubin rebound following intensive phototherapy. Arch Pediatr Adolesc Med. 2002;156:669–672

44. Rubaltelli FF, Jori G, Reddi E. Bronze baby syndrome: a new porphyrinrelated disorder. Pediatr Res. 1983;17:327–330

45. Meisel P, Jahrig D, Theel L, Ordt A, Jahrig K. The bronze baby syndrome: consequence of impaired excretion of photobilirubin? Photobiochem Photobiophys. 1982;3:345–352

30

46. Cremer RJ, Perryman PW, Richards DH. Influence of light on the hyperbilirubinemia of infants. Lancet. 1958;1(7030):1094–1097

47. Johnson LH, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatr. 2002;140:396–403

48. Gottstein R, Cooke R. Systematic review of intravenous immunoglobulin in haemolytic disease of the newborn. Arch Dis Child Fetal Neonatal Ed. 2003;88:F6–F10

49. Rubo J, Albrecht K, Lasch P, et al. High-dose intravenous immune globulin therapy for hyperbilirubinemia caused by Rh hemolytic disease. J Pediatr. 1992;121:93–97

50. Hammerman C, Kaplan M, Vreman HJ, Stevenson DK. Intravenous immune globulin in neonatal ABO isoimmunization: factors associated with clinical efficacy. Biol Neonate. 1996;70:69–74

51. Volpe JJ. Neurology of the Newborn. 4th ed. Philadelphia, PA: W. B. Saunders; 2001 52. Harris M, Bernbaum J, Polin J, Zimmerman R, Polin RA. Developmental follow-up of

breastfed term and near-term infants with marked hyperbilirubinemia. Pediatrics. 2001;107:1075–1080

53. Ahlfors CE. Criteria for exchange transfusion in jaundiced newborns. Pediatrics. 1994;93:488–494

54. Intensive Care Nursery House Staff Manual - Hemolytic Disease of the Newborn - The Regents of the University of California Copyright © 2004

55. Philip Beeby - Department of Neonatal Medicine Nursing Protocols Royal Prince Alfred HospitalJaundice Exchange Transfusion Revised May, 2006

56. Keenan WJ, Novak KK, Sutherland JM, Bryla DA, Fetterly KL. Morbidity and mortality associated with exchange transfusion. Pediatrics. 1985; 75:417–421

57. Hovi L, Siimes MA. Exchange transfusion with fresh heparinized blood is a safe procedure: Experiences from 1069 newborns. Acta Paediatr Scand. 1985;74:360–365

58. Jackson JC. Adverse events associated with exchange transfusion in healthy and ill newborns. Pediatrics. 1997;99(5):e7. Available at: www.pediatrics.org/cgi/content/full/99/5/e7

59. Alpay F, Sarici S, Tosuncuk HD, Serdar MA, Inanc¸ N, Go¨kc¸ay E. The value of first-day bilirubin measurement in predicting the development of significant hyperbilirubinemia in healthy term newborns. Pediatrics. 2000;106(2). Available at: www.pediatrics.org/cgi/content/full/106/2/e16

60. Carbonell X, Botet F, Figueras J, Riu-Godo A. Prediction of hyperbilirubinaemia in the healthy term newborn. Acta Paediatr. 2001;90:166–170

61. Stevenson DK, Fanaroff AA, Maisels MJ, et al. Prediction of hyperbilirubinemia in near-term and term infants. Pediatrics. 2001;108:31–39

62. Fetus and Newborn Committee, Canadian Paediatric Society (CPS) - Approach to the management of hyperbilirubinemia in term newborn infants - Paediatrics & Child Health 1999;4(2):161-164 Reference No. FN98-02

63. a. kvezereli-kopaZe, m. kvezereli-kopaZe, z. mTvareliZe – anemiebi

bavSvTa asakSi - 2003w.

31

15. avtorTa jgufi:

⇒ maia xerxeuliZe – medicinis doqtori, Tbilisis saxelmwifo

samedicino universitetis pediatriis departamentis asistent-

profesori. pediatrTa da neonatologTa kavSiri “alternativa”

⇒ dimitri abelaSvili - medicinis doqtori, Tbilisis saxelmwifo

samedicino universitetis diplomis Semdgomi da uwyveti

samedicino ganaTlebis instituti, m. iaSvilis saxelobis bavSvTa

centraluri klinikuri saavadmyofos reanimaciisa da

gadaudebeli daxmarebis samsaxuris ufrosi, axalSobilTa

reanimaciis ganyofilebis gamge. pediatrTa da neonatologTa

kavSiri “alternativa”

⇒ maka mSvildaZe _ neonatologi, CaCavas sax. mean-ginekologiisa da

perinatologiis instituti, saqarTvelos Sromis, janmrTelobisa

da socialuri dacvis saministros eqsperti

⇒ nani yavlaSvili – medicinis doqtori, Tbilisis saxelmwifo

samedicino universitetis pediatriis departamentis asistent-

profesori. pediatrTa da neonatologTa kavSiri “alternativa”

eqspertebi:

⇒ avTandil kvezereli-kopaZe – profesori, pediatriis s/k

institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli,

pediatrTa sazogadoebis Tavmjdomare

⇒ Tamaz korZaxia – neonatologi, samSobiaro saxli “hera”,

generaluri direqtori

⇒ qeTevan nemsaZe – medicinis mecnierebaTa doqtori, Tbilisis

saxelmwifo samedicino universitetis pediatriis departamentis

profesori;

⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros janmrTelobis dacvis

departamenti;

⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da

socialuri dacvis saministros janmrTelobis dacvis

departamenti.