hiperbilirubinemiis martva axalsobil bavsvebsi, romelta ... · pdf fileetiopatogenezi mizezebi...

hiperbilirubinemiis marTva axalSobil bavSvebSi romelTa

gestaciuri asaki 35 da meti kviraa

klinikuri rekomendaciis mizania

rArr samedicino personalisTvis mtkicebulebebze dafuZnebuli uaxlesi samecniero informaciis miwodebis gziT axalSobilTa hiperbilirubinemiis prevenciis diagnostikisa marTvis Tanamedrove principebis danergva da drouli referalis ganxorcieleba

rArr Seamciros mZime hiperbilirubinemiis da misi garTulebebis ganviTarebis riski

gaidlaini gankuTvnilia

rArr samedicino personalisaTvis romelic muSaobs axalSobilTan rogorc samSobiaro saxlSi ise stacionarsa Tu pirveladi jandacvis rgolSi ndash neonatologi pediatri ojaxis eqimi

rArr gaidlaini aseve SeiZleba gamoyenebuli iyos umaRlesi da saSualo samedicino dawesebulebis pedagogebis mier uwyveti samedicino ganaTlebisaTvis

gaidlainis samizne jgufirArr 35 kviris da meti gestaciuri asakis axalSobilebi romelTac

ganuviTardaT hiperbilirubinemia

gaidlainis gacnobis Semdeg samedicino personals ecodineba rom aucilebelia

1 ZuZuTi kvebis propaganda da mxardaWera2 saeqTno protokolebis Sedgena hiperbilirubinemiis identifikaciisa

da SefasebisaTvis 3 Ssb da tkb gansazRvra axalSobilebSi romelTac siyviTle

gamouvlindaT dabadebidan pirvel 24 sT-Si4 siyviTlis xarisxis gansazRvrisTvis siyviTlis intensivobis

vizualuri SefasebasTan erTad laboratoriuli kvlevis Catareba (mxolod vizualuri Sefasebisas xSiria daignostikuri Secdoma gansakuTrebiT muqkanian axalSobilebSi)

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

1

1 daavadebis definicia sinonimebi klasifikacia da terminologia

axalSobilTa siyviTle axalSobilis kanis da sklerebis yviTeli Seferilobaa rac ganpirobebulia qsovilebSi bilirubinis CalagebiT

axalSobilebSi siyviTle vlindeba roca bilirubinis Semcveloba sisxlis SratSi gadaaWarbebs 5 mgdl (85 micromolL) (AMERICAN ACADEMY OF PEDIATRICS 2004)

fiziologiuri siyviTle msubuqi arakoniugirebuli (arapirdapiri) bilirubinemiaa romelic vlindeba sicocxlis 48-120 sT-Si bilirubinis Semcvelobis pikuri done sicocxlis III dRisTvis uxSiresad 5-8 mgdl-ia (86-136 micromolL) Semdeg xdeba misi donis daqveiTeba 12 mgdl-mde mateba fiziologiurad iTvleba 35-37 kv gestaciuri asakis axalSobilebSi Bbilirubinis donem SeiZleba maqimums miaRwios dabadebidan me-7 dRes

arakoniugirebuli hiperbilirubinemiis ufro maRali done sxvadasxva paTologiuri mdgomareobebis dros vlindeba (Ronald J Wong 2005)

hiperbilirubinemia paTologiuria roca Sratis saerTo bilirubinis done (TSB) gadaaWarbebs 95 percentils butanis nomogramaSi (Ronald J Wong 2005)

butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT

mwvave bilirubinuli encefalopaTia - axalSobilobis pirvel kviraSi manifestirebuli bilirubinuli toqsiurobis mwvave periodi

kerniqterusi _ gamoiyeneba bilirubinis toqsiurobis qronikuli da permanentuli klinikuri gamosavlis asaRwerad

gamoyenebuli Semoklebebi

Sbs ndash Sratis saerTo bilirubinitkb ndash transkutanuri bilirubiniba - bilirubinis da albuminis Sefardebards ndash respiraciul distres sindromi

epidemiologiafiziologiuri siyviTle viTardeba dRenaklul axalSobilTa

umravlesobasa da droul axalSobilTa 25-50-Si janmrTel droul axalSobilTa 61-Si Sratis bilirubinis maqsimaluri done aRemateba 129mgdl 3 -Si ki _ 15mgdl

multinacionaluri kvlevebis monacemebiT 30 saaTis asakisaTvis axalSobilTa 5 ndash 40 -Si Sratis saerTo bilirubinis done aWarbebs 95 percentils butanis nomogramaSi 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 5 SemTxveva

2

etiopaTogenezi

mizezebi (Ronald J Wong 2005)(AMERICAN ACADEMY OF PEDIATRICS 2004)

hiperbilirubinemia SesaZlebelia mimdinareobdes arapirdapiri an pirdapiri bilirubinis donis momatebiT gaZlierebuli hemolizi bilirubinis koniugaciis unaris Semcireba iwvevs arapirdapir bilirubinemias xolo naRvlis eqskreciis darRveva ndash pirdapir bilirubinemias

1 fiziologiuri siyviTle

bull erTrocitebis da hemoglobinis maRali Semcveloba

bull fetaluri hemoglobinis Semcveli eriTrocitebis hemolizi

bull RviZlSi bilirubinis koniugaciis unaris umwifroba

bull bilirubinis gazrdili enterohepatuli cirkulacia

bull RviZlis mier plazmidan bilirubinis moxmarebis Semcireba

2 paTologiuri siyviTle eriTrocitebis hemolizis gaZliereba

bull sisxlis jgufuri da rezus SeuTavsebloba

bull Tandayolili membrano (sferocitozi da sxv) fermento (glukoza 6 fosfatdehidrogenazas - g6fd ndash ukmarisoba da sxv) da hemoglobinopaTia (Talasemia da sxv)

bull policitemia

bull kefalohematoma sisxlCaqcevebi

bull infeqciabilirubinis koniugaciis Semcireba

bull dRenakluloba

bull iSviaTi Tanadayolili daavadebebi (Jilberis krigler-naiaris sindromi da sxva)

bull bilirubinis metabolizmis da eqskreciis darRveva (rotoris da dubin-jonsonis sindromi)

bilirubinis reabsorbciis gazrda gastrointestinuri traqtidanbull asfiqsia

bull kvebis gvian dawyeba iSviaTi kveba

bull nawlavTa obstruqcia

bull mekoniumis pasaJis Seferexeba

3 naRvlis eqskreciis darRveva

bull sefsisi

bull saSvilosnosSida infeqcia

bull hepatiti

bull qolestazuri sindromi

bull biliaruli atrezia

bull cisturi fibrozi (mukoviscidozi)

4 siyviTle ZuZuTi kvebis dros

bull 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)

3

bull ZuZuTi kvebis araswori reJimiT ganpirobebuli iSviaTi ZuZuTi kvebis SemTxevaSi arasakmarisi raodenobiT rZis miReba iwvevs enterohepaturi cirkulaciis gazrdas

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) daan nekroziT yvelaze metad ziandeba bazaluri ganglia da Tavis tvinis Reros okulomotoruli da auditoruli funqciebis makontrolebeli birTvebi

Tu droul axalSobilebSi bilirubini gadaWarbebs 25-30 mgdl (428 - 513 micromolL) maRalia bilirubinis toqsiuri moqmedebis ganviTarebis riski Ssb toqsiuroba variabeluria da damokidebulia axalSobilis janmrTelobis mdgomareobaze da gestaciur asakze

mZime hiperbilirubinemiis ganviTarebis risk-faqtorebi mZime hiperbilirubinemiis ganviTrebis riski miT ufro maRalia rac

ufro meti riskis faqtoria gamoxatuli axalSobilTanmaRali riski (AMERICAN ACADEMY OF PEDIATRICS 2004) (Ronald J Wong 2005)

minus dabadebidan pirvel 24sT-Si gamovlenili siyviTle minus gaweris win Ssb an tkb done butanis nomogramaze maRali riskis

zonaSi

minus sisxlis jgufuri SeuTavsebloba dadebiTi pirdapiri antiglobulinuri testiT sxva cnobili hemolizuri daavadeba (mag g6fd deficiti)

minus gestaciuri asaki 35-36 kvira minus da-Zmas Catarebuli aqvs fotoTerapia

minus kefalohematoma an mniSvnelovani sisxlCaqcevebi (Newman TB 2000)minus araxSiri ZuZuTi kveba rodesac aReniSneba wonaSi mkveTri kleba

(gt12-ze meti) (Newman TB 2000 dabali riski

gaweris win Ssb an tkb-is done butanis nomogramaze maRali gardamavali riskis zonaSi

gestaciuri asaki 37-38 kvira (Newman TB 2000 da-Zmis anamnezSi siyviTle diabetiT daavadebuli dedis makrosomuli axalSobili

dedis asaki ge 25 welze (Newman TB 2000) mamrobiTi sqesi (Newman TB 2000 )

mdgomareobebi romlis drosac mZime hiperbilirubinemiis ganviTarebis riski Zalian dabalia

minus gestaciuri asaki ge 41 kviraze (Newman TB 2000)minus srulyofili enteraluri kveba (Newman TB 2000)minus gawera stacionaridan 72 sT-is Semdeg

minus Ssb dabali riskis zonaSi

4

klinikuri simptomatika

rekomendacia - siyviTlis monitoringi unda moxdes yvela axalSobilTan rutinulad vitaluri funqciebis Sefasebisas ara nakleb 8-12 sT-Si erTxel (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)siyviTlis arsebobis Sefaseba unda moxdes kargad ganaTebul oTaxSi umjobesia dRis Suqze fanjarasTan siyviTle Cveulebriv pirvelad vlindeba saxeze da Semdeg progresirebs kaudalurad sxeulsa da kidurebze siyviTlis ukeT gansazRvrisaTvis tardeba kanze TiTis zewolis testi zewola lokalurad amcirebs kanis perfuzias da xels uwyobs siyviTlis diagnostikas rodesac bilirubini 4-8 mgdl (68-137 micromolL) Cveulebriv iqterulia saxe da sklera Tu bilirubini gt15 mgdL (257 micromolL) siyviTle vlindeba mTel sxeulze xelis da fexisgulebis CaTvliT Ssb an tkb mizanSewonilia gaizomos Tu siyviTle vlindeba Wipis qvemoT

siyviTlis simZimis Sefaseba lokalizaciis mixedviT (WHO 2003) cxrili 1

asaki (dRe) siyviTlis lokalizacia daskvna

1 nebismieri

2 kidurebi

ge 3 terfebi mtevnebi

laquosaSiSiraquo siyviTle

sicocxlis I dRes nebismier adgilas an II dRes kidurebze gamovlenili siyviTle saWiroebs dauyovnebliv fotoTerapiis dawyebas analizis pasuxis miRebamde

krameris modificirebuli sqema cxrili 2

zona1 2 3 4 5

Ssb micromolL 100 150 200 250 gt250

krameris modificirebuli sqema saSualebas iZleva siyviTlis gavrcelebis mixedviT vivaraudoT Tu ramdenia Sratis saerTo bilirubinis done

siyviTlis xarisxis gansazRvra siyviTlis intensivobis mxolod vizualuri SefasebiT xSirad iwvevs daignostikur Secdomas gansakuTrebiT muqkanian axalSobilebSi

(rekomendacia C) (AMERICAN ACADEMY OF PEDIATRICS 2004)

axalSobilTa siyviTlisGgarTulebebimwvave da qronikuli (kerniqterusi) bilirubinuli encefalopaTiamwvave bilirubinuli encefalopaTia (AMERICAN ACADEMY OF PEDIATRICS 2004) mwvave bilirubinuli encefalopaTias axasiaTebs ganviTarebis 3 faza

5

C

1 adreuli faza vlindeba ramdenime dReSi da axasiaTebs leTargia hipotonia susti wova da sustad gamoxatuli ldquotvinismieri kivilirdquo

2 gardamavali stadia viTardeba kviris bolos da axasiTebs zomieri stupori agznebadoba da hipertonia axalSobils SeiZleba aReniSnos cxeleba mkveTrad gamoxatuli ldquotvinismieri kivilirdquo 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 ldquotvinismieri kivilirdquo apnoe cxeleba sakvebis autanloba Rrma stupori komamde zogjer krunCxvebi da sikvdili

kerniqterusi (AMERICAN ACADEMY OF PEDIATRICS 2004)Bmwvave bilirubinuli encefalopaTiis Semdeg gadarCenil

axalSobils sicocxlis pirveli wlis manZilze uviTardeba bilirubinuli encefalopaTiis mZime qronikuli forma romelic 3 ZiriTadi gamovlinebiT xasiaTdeba

motoruli darRvevebi - aTetoiduri cerebluri dambla tremori qorea

mxedvelobis darRvevebi smeniTi disfunqcia inteleqtualuri darRvevebi SedarebiT iSviaTia damatebiT SeiZleba

ganviTardes kbilis emalis hipoplazia kerniqterusis dros 70-Si aRiniSneba nevrologiuri darRvevebi da

10-Si sikvdiloba

diferenciuli diagnoziaxalSobilTa siyviTlis dros unda ganisazRvros siyviTle

fiziologiuria Tu paTologiuri

fiziologiuri siyviTle paTologiuri siyviTle

vlindeba ara uadres 2 dRisa da qreba me-10-14 dRisTvis

vlindeba pirvel 24 saaTSi an7 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

dedis rZiT ganpirobebuli siyviTlis sadiagnostikod (samkurnalod) SeiZleba Semdegi maCveneblebis gamoyeneba

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

bull 24-48sT-is ganmavlobaSi ZuZuTi kvebis Sewyveta da alternatiul sakvebis miwodeba iwvevs bilirubinis donis daqveiTdebas

6

axalSobilTa hiperbilirubinemiis difdiagnozi ix algormiTi 1

gamokvlevis sqema

rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004) tkb daan Ssb unda ganesazRvros yvela axalSobils

romelsac siyviTle gamouvlinda sicocxlis pirvel 24sT-Si (ix algoriTmi I da cxrili 3 ) (rekomendacia C)

tkb daan Ssb ganmeorebiTi gansazRvris dro da saWiroeba damokidebulia bilirubinis doneze (sqema 2) axalSobilis asakze hiperbilirubinemiis dinamikaze rekomendaciebi Ssb gansazRvrisaTvis dabadebidan 24 sT-is Semdeg mowodebulia I algoriTmsa da cxrilSi 3

tkb daan Ssb unda ganesazRvros yvela axalSobils romelsac gamouvlinda asakTan Seusabamo mkveTri siyviTle (rekomendacia D)

bilirubinis donis Sefaseba unda moxdes axalSobilis asakis (saaTebSi) gaTvaliswinebiT (sqema 2) (rekomendacia

C) Tu axalSobils utardeba fotoTerapia an aReniSneba

bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze 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 damatebiTi laboratoriuli gamokvlevebi unda Catardes Tu anamneziT da obieqturi gamokvelevebiT saeWvoa sefsisi (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)

Tu pirdapiri an koniugirebuli bilirubinis done momatebulia rekomendirebulia damatebiTi gamokvlevebi qolestazis sadiagnostikod (rekomendacia C)

glukoza-6-fosfat dehidrogenazas donis gansazRvra saWiroa im axalSobilebTan romelTa ojaxuri anamnezi an eTnikuri an geografiuli warmoSoba miuTiTebs g6fd-s deficitze da utardebaT fotoTerapia daan axalSobilebTan Tu fotoTerapia uefeqtoa (sqema 3) (rekomendacia C)

7

C

D

C

D

C

C

C

D

D

cxrili 3 35 da meti gestaciuri asakis axalSobilSi gamovlenili siyviTlis laboratoriuli Sefaseba (AMERICAN ACADEMY OF PEDIATRICS 2004)

Cveneba laboratoriuli kvlevapirvel 24 sT-Si gamovlenili siyviTle

bull tkb daan Ssb gansazRvra

asakisaTvis Seusabamo mkveTri siyviTle kanze G


axalSobils utardeba fotoTerapia an aReniSneba bilirubinis swrafi mateba (sqema 2 ndash butanis sqemaze maCvenebeli kveTs percentilebs) rac ar aixsneba obieqturi gamokvleviT da anamnezuri monacemebiT

bull sisxlis jgufi da rezusi kumbsis testi Tu ar aris gakeTebuli Wiplaris sisxlSi

bull sisxlis saerTo analizi da nacxi formiani elementebis morfologiis Sesaswavlad

bull pirdapiri (koniugirebuli) bilirubinis gansazRvra

bull Tu SesaZlebelia isazRvreba retikulocitebis ricxvi g6fd

bull Ssb ganmeorebiT isazRvreba 4-24 sT-Si axalSobilis asakisa da Ssb donis Sesabamisad

fotoTerapia uSedegoa an Ssb aRwevs dones romelzec naCvenebia SenacvlebiTi transfuzia


momatebulia pirdapiri (koniugirebuli) bilirubinis done

bull Sardis anlizi

bull Sardis kultura

bull gamokvleva sefsisze Tu misi arseboba saeWvoa anamneziT an obieqturi gamokvleviT

siyviTle sami kviris asakis an avadmyof axalSobilSi

bull saerTo da pirdapiri (koniugirebuli) bilirubini

bull pirdapiri bilirubinis momatebisas tardeba kvleva qolestazis sadiagnostikod

bull skriningi hipoTireozsa da galaqtozemiaze

bull axalSobilis Sefaseba hipoTireozis simptomebis gamosavlenad

sqema 1 butanis nomograma

8

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 2-3 mgdl (34-54micromolL) variabelobiT bevr SemTxvevaSi xdeba Sratis bilirubinis gansazRvris Canacvleba transkutanuri gansazRvriT gansakuTrebiT maSin roca Ssb lt 15 mgdl (257 micromolL)

fotoTerapiis dros kanis vizualuri SefasebasTan erTad aucilebelia Sratis bilirubinis gansazRvra radgan fotoTerapia ldquoaTeTrebsrdquo kans (American Academy of Pediatrics 2004)

pirveladi profilaqtika

rekomendacia (American Academy of Pediatrics 2004) bull eqimma unda urCios dedas ganaxorcielos moTxovnilebiTi ZuZuTi kveba dReSi 8-12-jer (rekomendacia C) - arasrulyofili kaloriebis miRebam daan dehidrataciam SeiZleba gamoiwvios Hhiperbilirubinemiis ganviTareba

bull ZuZuTi kvebis SemTxevaSi Tu axalSobils ar aReniSneba dehidratacia ar aris rekomedirebuli wylisa da deqstrozis rutinulad damateba (rekomendacia B da C) -

9

C

B

C

wylis da deqstrozis damateba ar axdens hiperbilirubinemiis ganviTarebis profilaqtikasa da Ssb-s Semcirebas

bull yvela Rh (D) negatiur orsuls an melogines mizanSewonilia Cautardes anti D imonoglobuliniT profilaqtika (rekomendacia A)

minus orsulobis 28 kviraze (garda im SemTxvevebisa rodesac bavSvis mamac Rh (D) negatiuria)

minus mSobiarobidan 72 sT-is gamnavlobaSi Tu axalSobili Rh (D) pozituiria

minus orsulobis pirvel trimestrSi ganviTarebuli abortis da invaziuri procedurebis dros rogorica amniocentezi nayofis invaziuri procedurebi

meoradi profilaqtikarekomendacia klinicistma unda moaxdinos axalSobilTa hiperbilirubinemiis ganviTarebis riskebis sistemuri Sefaseba neonatalur periodSi (rekomendacia B)(AMERICAN ACADEMY OF PEDIATRICS 2004)

sisxlis jgufobriobarekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)

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 igis 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)

mkurnalobis sqemamkurnalobis ZiriTadi principebia

fotoTerapia SenacvlebiTi transfuzia

mkurnaloba iwyeba fotoTerapiiTfotoTerapiis dros kanis zeda SreebSi Calagebuli arapirdapiri bilirubini iSleba fotoqimiuri gziT wyalSi xsnad koniugatebad romlebic gamoiyofa SardiT da naRveliTrekomendacia yvela samSobiaro saxli unda iyos aRWurvili mowyobilobiT romelic saWiroa intensiuri fotoTerapiisaTvis (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)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

10

A

B

B

B

C

D

hiperbiliruminemias (hemolizuri daavadeba g6fd deficiti asfiqsia mkveTrad gamoxatuli leTargia temperaturis arastabiluroba sefsisi acidozi an hipoalbuminemia lt30 gdl)

amerikis pediatriuli akademiis rekomendaciiT gamoiyeneba sqema (sqema 2) romelic axalSobilis asaksa da bilirubinis donesTan erTad iTvaliswinebs risk-faqtorebsa da gestaciur asaks mocemuli sqemis mixedviT ldquointensiurirdquo fotoTerapia iwyeba Semdegi principebiT

dabali riskis axalSobili (janmrTeli risk-faqtorebis gareSe gestacia gt 38 kvira) ndash Ssb gt12 mgdl (205 micromolL) 24 sT-Si Ssb gt15 mgdl (257 micromolL) 48 sT-Si Ssb gt18 mgdl (308 micromolL) gt72 sT

saSualo riskis axalSobili (gestacia gt 38 kvira da risk-faqtorebi an gestacia 35-37 kvira risk-faqtorebis gareSe gareSe) ndash Ssb gt 10 mgdl (171 micromolL) 24 sT-Si Ssb gt13 mgdl (222 micromolL) 48 sT-Si Ssb gt15 mgdl (257 micromolL) gt72 sT gestaciis 35 kviris axalSobilebSi fotoTerapia SeiZleba daiwyos ufro dabal maCveneblebze

maRali riskis axalSobili (gestacia 35-37 kvira da risk-faqtorebi) - Ssb gt 8 mgdl (137 micromolL) 24 sT-Si Ssb gt11 mgdl (188 micromolL) 48 sT-Si Ssb gt135 mgdl (231 micromolL) gt72 sT

Tu dabali riskis axalSobilebSi Ssb done 2-3 mgdl-iT dabalia moyvanil monacemebze SesaZlebelia mkurnalobis dawyeba ldquoCveulebrivirdquo fotoTerapiiT

bull stacionarSi gamoxatuli siyviTliT Semosul axalSobils utardeba ldquointensiurirdquo fotoTerapia bilirubinis maCveneblis gansazRvramde

bull ldquointensiurirdquo fotoTerapia aseve rekomendebulia hemolizuri daavadebis dros

Sratis pirdapiri bilirubinis maCvenebeli ar unda gamoakldes saerTo bilirubinis maCvenebels fotoTerapiasa da SenacvlebiT transfuziaze gadawyvetilebis miRebis dros

janmos rekomendacia fotoTerapiis dawyebis Cvenebebis Sesaxeb mocemulia cxrilSi 4

cxrili 4 fotoTerapiis Cveneba Ssb mixedviT (janmo)

asaki (dRe) drouli janmrTeli nebismieri risk-faqtoris mqone axalSobili

mgdl micromolL mgdl micromolLI gamoxatuli siyviTleII 15 260 13 220III 18 310 16 270

IV da meti 20 340 17 290janmos rekomendaciiT fotoTerapia iwyeba Tu siyviTlis

lokalizaciis mixedviT siyviTlis simZimis Sefasebisas (cxrili 1) dadginda ldquosaSiSi siyviTlerdquo

Tu ar aris bilirubinis gansazRvris saSualeba Ssb savaraudo donis dasadgenaT SeiZleba krameris modificirebuli sqemis gamoyeneba

11

sqema 2 fotoTerapiis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (AMERICAN ACADEMY OF PEDIATRICS 2004)

rekomendacia Tu Sratis albuminis maCvenebeli naklebia 30 gdl-ze fotoTerapiis dawyeba rekomendebulis ufro dabali maCveneblebis dros (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)

fotoTerapiis ukuCveneba pirdapiri (koniugirebuli) hiperbilirubinemia (pirdapiri

bilirubini Ssb-s 50-ze metia) (American Family Practice Notebook 2002 ) (AMERICAN ACADEMY OF PEDIATRICS 2004)

Tandayolili porfiria an porfiriis ojaxuri anamnezi (AMERICAN ACADEMY OF PEDIATRICS 2004)

fotoTerapiis teqnikafotoTerapiis efeqturoba damokidebulia dozaze fotoTerapiis doza anu speqtruli iradiacia damokidebulia naTuris simZlavreze sinaTlis wyarosa da bavSvs Soris manZilsa da dasxivebis farTobze sinaTlis wyarofotoTerapiis sinaTlis speqtri damokidebulia sinaTlis wyaroze da filtrze yvelaze farTod gavrcelebuli fotoTerapiis mowyobiloba Seicavs dRis Suqis gril TeTr cisfer an ldquospecialur cisferrdquo fluorescentul naTurebs manZils sinaTlis wyarodan axalSobilamde didi mniSvneloba eniWeba sasurvelia axalSobili moTavsdes sinaTlis wyarodan im minimalur manZilze romelic miTiTebulia fotoTerapiis mowyobilobis instruqciaSi halogenis fotoTerapiis naTurebi ar SeiZleba moTavsdes axalSobilTan axlos radgan SeiZleba gamoiwvios damwvroba

12

DD

sxeulis zedapiris farTobibilirubinis maRali Semcvelobisas mniSvnelovania fotoTerapiis dros dasxivdes sxeulis zedapiris rac SeiZleba meti farTobi

ldquoCveulebrivi fotoTerapiardquo - sinaTlis speqtris iradiacia dabalia (6-12 microWcm2nm) (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 monacemebsldquointensiuri fotoTerapiardquo - lurj-mwvane speqtris iradiacia (talRis

sigrZe daaxloebiT 430-490 nm) sul cota 30 microWcm2nm-ia (isazRvreba axalSobilis kanze fototerapiis aparatis centris qveS) gazomva xdeba im warmoebis radiometriT romelic mowodebulia fotoTerapiiis sistemis aparatis mwarmoeblis mier sinaTlis talRis asareklad TeTreuli unda iyos TeTri kuvezi da sawolis gverdebi daifaros TeTri qsoviliT an aluminis folgiT

fotoTerapiis procedura da monitoringi

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 metia metia 3750C saWiroa oTaxis temperaturis daqveiTeba an fotoTerapiis droebiT Sewyveta sanam bavSvis temperatura ar iqneba normis farglebSi (365-3750C)

fotoTerapia mimdinareobas mudmivad igi wydeba mxolod im procedurebis dros romelTa warmoeba ra SeiZleba sinaTlis wyaros qveS

centraluri cianozis arsebobis Sesafaseblad fotoTerapia unda Sewydes mcire droiT

fotoTerapiis dros unda gagrZeldes bavSvis kveba

rArraxalSobilTan 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

rArrTu bavSvi ikvebeba gamowvelili rZiT formuliT an parenteralurad misawodebeli sakvebis an siTxis raodenoba izrdeba dRiuri normis 10 -iT

rArr Tu bavSvi ikvebeba zondiT an parenteralurad fotoTerapia mimdinareobs uwyvetad

rArrCveulebriv fotoTerapiis dros axalSobils ar esaWiroeba damatebiT siTxis an sakvebis miwodeba damateba naCvenebia mxolod araefeqturi ZuZuTi kvebis sxeulis masis paTologiuri danakargis (gt10-ze mesame dRisTvis) da dehidrataciis SemTxvevaSi

13

C

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

rArr adeqvatur kvebaze miuTiTebs 4-6 sveli safeni 24 sT-Si da nawlavTa moqmedeba 3-4 jerdReSi meoTxe dRisaTvis

janmrTeli drouli axalSobilis nawlavTa moqmedeba da diurezi (minimaluri maCveneblebi) cxrili 5 (Fetus and Newborn Committee 1999)

dRe nawlavTa minimaluri moqmedeba24sT

sveli safeni24sT

1 1 12 1 23 1 gardamavali 34 2 yviTeli fafisebri 45 2YyviTeli fafisebri 5-6

rArrdehidrataciaze miuTiTebs Semdegi niSnebis arseboba - masis paTologiuri kleba (gt10-ze mesame dRisTvis)- anuria 4-6 sT- Cacvenili Tvalebi- Cavardnili yoflibandi - - daqveiTebuli kanis elastiuroba (kanis naoWi swordeba

nela)- daqveiTebuli kanis kapilaruli avseba (gt3 wm)- taqikardia- Sratis Na gt145 HCO3 lt17

bilirubinis monitoringi fotoTerapiis dros (American Aacademy of Pediatrics 2004)

sawyisi bilirubinis maCveneblis Semcireba 6-20-iT standartuli da 30-40-iT intensiuri fotoTerapiis dawyebidan 24sT-Si mis efeqturobaze miuTiTebs

bull Tu Ssb ge 25 mgdL (428 micromolL) ganmeorebiTi gansazRvra 2ndash3 sT-Si

bull Tu Ssb 20ndash25 mgdL (342ndash428 micromolL) ganmeorebiTi gansazRvra 3-4 sT-Si

bull Tu Ssb lt20 mgdL (342 micromolL) ganmeorebiTi gansazRvra 4ndash6 sT-Si Tu Ssb agrZelebs daqveiTebas ganmeorebiTi gansazRvra 8-12 sT-Si

bull 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

bull intensiur fotoTerapiis miuxedavad Ssb-is ucvleli done an mateba miuTiTebs hemolizze

14

rArr anemiahemolizis Sefaseba SesaZlebelia sisxlis saerTo analizis mixedviT - Hgblt 130 glLHct lt 40 retikulocitebi - gt 6

bull Ssb lt 13ndash14 mgdL (239 micromolL) fotoTerapia wydeba

bull fotoTerapiis Sewyvetidan 24 sT-Si kontroldeba Ssb Tu Ssb moimata im donemde romelzec daiwyo fotoTerapia fotoTerapia ganmeorebiT iwyeba

fotoTerapiis garTulebebi

fotoTerapiis garTulebebi (Ronald J Wong 2005 American Aacademy of Pediatrics 2004)

rArrmwvane feris ganavalidiarea (mkurnalobas ar saWiroebs)

rArr dehidratacia

rArr muclis Seberva (mkurnalobas ar saWiroebs)

rArr Tvalis SesaZlo dazianeba yvelaze seriozuli magram iSviaTi klinikuri garTulebaa brinjaos

axalSobilis sindromi romelic vlindeba qolestazuri siyviTlis mqone axalSobilSi kanis Sratis da Sardis muqi nacrisfer-yavisferi SeferilobiT brinjaos axalSobilis sindromi ar vlindeba qolestazis mqone yvela axalSobilTan Tu arsebobs fotoTerapiis Cveneba pirdapiri hiperbilirubinemia ar warmoadgens fotoTerapiis winaaRmdeg Cvenebas 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

rArr purpura

rArr bulozuri gamonayari

mzis ultraiisferi sxivebiT TerapiamarTalia mzis sxivebs gaaCniaT mniSvnelovani iradiacia 425-475 nm magram radganac maRalia axalSobilis damwvrobis ganviTarebis riski (SiSveli axalSobilis mzeze yofnis gamo) es meTodi rekomendebuli ar aris

(Ronald J Wong 2005 (American Aacademy of Pediatrics 2004)

intravenuri imunoglobulinis gamoyenebarekomendacia izoimunuri hemolizuri daavadebis dros rekomendebulia intravenuri imunoglobulinis gamoyeneba (05-1 gkg 2 sT-s ganmavlobaSi) Tu Ssb imatebs intensiuri fotoTerapiis miuxedavad an Ssb aris 2-3 mgdl-iT (34-51mkmoll) naklebi SenacvlebiTi transfuziis Cvenebis doneze (fighellip4) aucilebelobis SemTxvevaSi intravenuri imunoglobulinis es doza SeiZleba ganmeordes 12 sT-Si (rekomendacia B) American Aacademy of Pediatrics 2004)

15

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

B

kvlevebiT dadgenilia rom intravenuri imunoglobulini amcirebs SenacvlebiTi transfuziis saWiroebas Rh da ABO hemolizuri daavadebis dros

SenacvlebiTi transfuzia

SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleluli unda iyos Semowmebuli da dasxivebuli gadasasxmeli sisxlis raodenoba Seadgens 170-180 mlkg

rekomendacia SenacvlebiTi transfuzia unda Caataros mxolod gamocdilma samedicino personalma intensiuri Terapiis ganyofilebaSi monitoringisa da srulyofili reanimaciis SesaZleblobis pirobebSi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)

SenacvlebiTi transfuziis Cvenebebi (rekomendacia D) (AMERICAN ACADEMY OF PEDIATRICS 2004)

mwvave bilirubinuli encefalopaTia intensiuri fotoTerapiis miuxedavad Ssb mateba an ucvleli

monacemi samSobiarodan gawerili axalSobilebis hospitalizaciis

SemTxvevaSi Ssb-s maRali maCvenebeli - aRemateba SenacvlebiTi transfuziis dawyebis maCvenebls (sqema 3) (transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia) (ix cxrili 6)

ba Sefardeba Ssb maCvenebelTan (cxrili 6) erTad gamoiyeneba rogorc damatebiTi faqtori SenacvlebiTi transfuziis dawyebis gansasazRvravad


sqema 3 SenacvlebiTi transfuziis gaidlini 35 kviris da meti gestaciuri asakis hospitalizebul axalSobilebSi (American Academy of Pediatrics 2004)

16

D

D

cxrili 6 bilirubinisa da albuminis Sefardeba rodesac saWiroa SenacvlebiTi transfuzia (AMERICAN ACADEMY OF PEDIATRICS 2004)

riskis kategoria

ba Sefardeba rodesac saWiroa SenacvlebiTi

transfuziaSsb mgdl alb gdl

Ssb micromolL alb micromolL

axalSobilebi gestaciuri asaki - ge38 kvira 80 094

janmrTeli axalSobilebi gestaciuri asakiT an riskis jgufis axalSobilebi

gestaciuri asakiT ge38 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti

72 084

riskis jgufis axalSobilebi gestaciuri asakiT 35ndash36 kvira an izoimunuri hemolizuri daavadeba an g6fd deficiti

68 080

janmos rekomendacia sisxlis SenacvlebiTi gadasxmis Cvenebebis Sesaxeb mocemulia cxrilSi 7

cxrili 7 SenacvlebiTi transfuziis Cveneba Ssb mixedviT (janmo)


mgdl micromolL mgdl micromolLI 15 260 13 220II 25 425 15 260

17

III 30 510 20 340IV 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

teqnika (AMERICAN ACADEMY OF PEDIATRICS 2004

bull mwvave bilirubinuli encefalopaTiis dros SenacvlebiTi transfuzia iwyeba dauyovnebliv

bull sxva SemTxvevaSi transfuziamde iwyeba ldquointensiurirdquo fotoTerapia da Tu saWiroa rehidratacia Ssb isazRvreba yovel 2-3 sT-Si erTxel da Tu Ssb rCeba SenacvlebiTi transfuziis Cvenebaze maRali 6 sT-is Semdeg iwyeba SenacvlebiTi transfuzia

bull SenacvlebiTi transfuziis dros gamoiyeneba mTliani sisxli Rh SeuTavseblobis dros gamoiyeneba O(I) Rh(-) xolo ABO SeuTavseblobis dros O(I) Rh Sesabamisi sisxli sisxli gamokvleuli unda iyos Semowmebuli da dasxivebuli

bull gadasasxmeli sisxlis raodenoba Seadgens axalSobilis mocirkulire sisxlis ormag raodenobas saSualod 170-180 mlkg an gadasasxmeli sisxlis gamosaTvleli formula gamoiTvleba 85 x axalSobilis wona kg x 2

bull 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 367-3700C-mde

bull dRenaklulebsa da mZime mdgomareobaSi myof axalSobilebSi Senacvleba xdeba 5-10 ml-iT

axalSobilis momzadeba

bull kuWis SigTavsis aspiracia zondiT 8F da Ria zondis datoveba kuWSibull SeiZleba saWiro gaxdes bavSvis dabma

bull SeiZleba sawovaras gamoyeneba

bull Sardis Semkrebis gamoyeneba diurezis kontrolisTvisaxlSobilis winaswar Sefaseba

bull temperatura

bull guliscema

bull sunTqva

bull wneva

bull glukoza SratSi

bull Sardis analizi

bull ganavlis analizi sisxlis Semcvelobaze

bull kanis feri

bull tonusi

bull qcevauSualod transfuziis dros fasdeba vitaluri niSnebi (yovel 15 wT-Si)

18

bull temperatura

bull guliscema (mwvervalze) (umjobesia kardiomonitoriT)

bull sunTqva

bull kanis feri

bull qceva

monitoringi transfuziis Semdeg bull grZeldeba fotoTerapia

bull kardio monitoringi

bull sisxlis wneva proceduris damTavrebis Semdeg

bull saaTobrivad 6 sT-is ganmavlobaSi temperatura guliscema (mwvervalze) sunTqva

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

bull muclis garSemoweriloba 3-4 sT-Si 24 sT-is ganmavlobaSi nawlavebis peristaltikis auskultacia

bull Sardis analizi

bull ganavali sisxlis Semcvelobaze

bull sakvebis autanlobis niSnebi Rebineba muclis Seberva

bull Ssb 6 sT-Si erTxel

SenacvlebiTi transfuziis riskisikvdiloba - 3 SemTxveva 1000 transfuziaze SenacvlebiTi transfuziis dros garTulebis saxiT 5-Si vlindeba

- apnoe bradikardia cianozi vazospazmi Trombozi nekrozuli enterokoliti aseve SeiZleba ganviTardes hipoqsiur-iSemiuri encefalopaTia da SeZenili imunodeficitis sindromi

sxva mkurnalobafenobarbitali ndash xels uwyobs bilirubinis koniugacias da amcirebs

Ssb dones ar arsebobs sakmarisi mtkicebulebebi fenobarbitalis gamosayeneblad rodesac arsebobs siyviTlis mkurnalobis ufro efeqturi meTodebi (mag fotoTerapia)

referali AMERICAN ACADEMY OF PEDIATRICS 2004)referali maRali donis klinikaSi xorcieldeba Tu

ar aris fotoTerapiis Catarebis SesaZlebloba fotoTerapiis miuxedavad

rArr Ssb ar mcirdeba

rArr Ssb uaxlovdeba SenacvlebiTi transfuziis Cvenebis dones da ar aris transfuziis saSualeba

rArr Ssbalbuminis Sefardeba aWarbebs cxrilSi mocemul dones (ix cxrili 6)

Tu siyviTle gamovlinda I dRes siyviTlis lokalizaciis mixedviT siyviTlis simZimis Sefasebisas

(cxrili 1) dadgenili ldquosaSiSi siyviTlerdquo

bilirubinis maRali namati 85 micromolLsT (gt05 mgdlsT)

gaxangrZlivebuli siyviTle (14 dRe da meti) ojaxur anamnezSi mZime siyviTlis an kerniqterusis arseboba siyviTlis dros sxva daavadebis niSnebis arseboba (mg sefsisi)

19

riskis Sefaseba gaweramde

rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)

bull yvela axalSobilis gaweramde unda Sefasdes hiperbilirubinemiis ganviTarebis riski yvela ganyofilebas unda hqondes protokoli siyviTlis SefasebisTvis aseTi Sefaseba gansakuTrebiT mniSvnelovania im axalSobilebisaTvis romlebis ewerebian dabadebidan 72 sT-ze adre (rekomendacia C)

bull amerikis pediatrTa akademiis rekomendaciiT riskis SefasebisaTvis gamoyenebuli unda iqnas 2 midgoma (calcalke an kombinaciaSi) gaweris win bilirubinis gansazRvra (Ssb an tkb) daan klinikuri risk-faqtorebis Sefaseba risk-faqtorebis arseboba an Ssb maRali maCveneblebi gaweris Semdeg Sesabamisi meTvalyureobis aucilebelobis Cvenebaa (rekomendacia C)

bull yvela samSobiarom unda miawodos mSobels zepiri daan werilobiTi informacia binaze siyviTlis Sefasebis da saSiSroebis niSnebis Sesaxeb (rekomendacia D)

meTvalyureoba

rekomendacia (AMERICAN ACADEMY OF PEDIATRICS 2004)bull yvela axalSobili samSobiarodan gaweriis Semdeg ramdenime dReSi unda Sefasdes kvalificuri samedicino profesionalis mier (rekomendacia C)

bull fasdeba - siyviTlis arseboba axalSobilis wona kvebis efeqturoba Rebinebis arseboba (rekomendacia C)

bull meTvalyureobis grafiki Tu axalSobili samSobiarodan ewereba 48-72 sT-Si samedicino Sefaseba tardeba 120 sT-is (5 dRe) asakSi (rekomendacia C)

bull 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 ndash 2 weli

12 gaidlainis miRebis xerxiwyaro

gaidlainis SemuSavebis meTodologia

bull 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

20

C

C

C

C

D

C

D

rekomendaciebis adaptirebuli variantis SemuSaveba romelic erTis mxriv pasuxebs saerTaSoriso moTxovnebs xolo meore mxriv iTvaliswineba saqarTvelos samedicino dawesebulebaTa rogorc adamianur ise teqnikur resursebs

bull rekomendaciaTa moZieba xorcieldeboda eleqtronuli monacemTa bazis gamoyenebiT

cxrili 2

qveyana da resursis dasaxeleba

internet-misamarTi

aSS

US National Guideline Clearinghouse (NGC)

httpwwwguidelinegov

Centers for Disease Control and Prevention (CDC)

httpwwwphppocdcgovCDCRecommendsAdvSearchVasp

Agency for Healthcare Research and Quality (AHRQ)

httpwwwahrqgovcliniccpgsixhtm

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

httphstatnlmnihgov

Institute of Clinical Systems Improvement (ICSI)

httpwwwicsiorg

American Medical Association httpwwwama-assnorg

Canadian Medical Association (CMA)

httpmdmcacpgsnewcpgsindexasp

Health Canada ndash Population and Public Health Branch (PPHB)

httpwwwhc-scgccapphb-dgspspdpg_ehtml

didi britaneTi

National Institute for Clinical Excellence (NICE)

httpwwwniceorguk

Sheffield Evidence for Effectiveness and Knowledge (SEEK)

httpwwwshefacukseekguidelineshtm

National electronic Library for Health (NeLH)

httpwwwnelhnhsukguidelinesfinder

PRODIGY Clinical Guidance httpwwwprodigynhsukClinicalGuidance

Scottish Intercollegiate Guidelines Network (SIGN)

httpwwwsignacuk

German Guideline Information Service (GERGIS)

httpwwwleitliniendeenglishenglishview

avstralia

Australian National Health and httpwwwhealthgovauhfsnhmrcpublicatcp-

21

Medical Research Council (NHMRC) homehtmaxali zelandia

New Zealand Guidelines Group (NZGG)

httpwwwnzggorgnzlibrarycfm

mtkicebiTi medicinis specialistTa regionTaSorisi sazogadoeba

httpwwwosdmorg

klinikuri rekomendaciebis da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi

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

bibliografiul monacemTa baza - medlaini ndash MEDLINEbull jandacvis msoflio organizaciis reproduqciuli janmrTelobis

biblioTeka

publikaciebis CarTvisgamoricxvis kriteriumebi

bull arCeul iqna kvlevebi Semdegi dizainiT randomizebuli kontrolirebadi sistemuri mimoxilvebi da meta-analizi erTmomentiani kohortuli kvlevebi

bull 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

bull dadgenili iyo enobrivi SezRudvebi radganac samuSao jgufs SesaZlebloba hqonda literaturis wyaroebi Seeswavla mxolod inglisur da rusul enebze

moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi

bull 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 rekomendaciaTa atestaciisa da eqspertizis kiTxvari - AGREE (9496-98) 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

rArr amerikis pediatrTa akademia

rArr msoflo jandacvis organizacia

rArr kanadis pediatrTa sazogadoeba ndash nayofi da axalSobilis komiteti

rArr britaneTis reproduqciuli janmrTelobis programa

22

bull 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


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

13 alternatiuli gaidlaini ar arsebobs

14 gamoyenebuli literatura

15 avtorTa jgufi

bull klinikuri rekomendaciis SemuSavebisTvis Seqmnili iyo multidisciplinuri jgufi romelSic CarTuli iyo yvela dainteresebuli mxare problemis srulyofili ganxilvisTvis

bull jgufis SemadgenlobaSi Sediodnen neonatologebi pediatrebi hematologebi

rArr maia xerxeuliZe ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori

23

rArr maka mSvildaZe _ neonatologi CaCavas sax mean ginekologiisa da perinatologiis instituti saqarTvelos Sromis janmrTelobisa da socialuri dacvis saministros eqsperti

rArr nani yavlaSvili ndash medicinis doqtori Tbilisis saxelmwifo samedicino universitetis pediatriis departamentis asistent-profesori

eqspertebi

rArr avTandil kvezereli-kopaZe ndash profesori pediatriis sk institutis bavSvTa hematologiuri ganyofilebis xelmZRvaneli

rArr Tamaz korZaxia ndash neonatologi samSobiaro sxli ldquoherardquo generaluri direqtori

24

1 daavadebis definicia sinonimebi klasifikacia da terminologia

axalSobilTa siyviTle axalSobilis kanis da sklerebis yviTeli Seferilobaa rac ganpirobebulia qsovilebSi bilirubinis CalagebiT

axalSobilebSi siyviTle vlindeba roca bilirubinis Semcveloba sisxlis SratSi gadaaWarbebs 5 mgdl (85 micromolL) (AMERICAN ACADEMY OF PEDIATRICS 2004)

fiziologiuri siyviTle msubuqi arakoniugirebuli (arapirdapiri) bilirubinemiaa romelic vlindeba sicocxlis 48-120 sT-Si bilirubinis Semcvelobis pikuri done sicocxlis III dRisTvis uxSiresad 5-8 mgdl-ia (86-136 micromolL) Semdeg xdeba misi donis daqveiTeba 12 mgdl-mde mateba fiziologiurad iTvleba 35-37 kv gestaciuri asakis axalSobilebSi Bbilirubinis donem SeiZleba maqimums miaRwios dabadebidan me-7 dRes

arakoniugirebuli hiperbilirubinemiis ufro maRali done sxvadasxva paTologiuri mdgomareobebis dros vlindeba (Ronald J Wong 2005)

hiperbilirubinemia paTologiuria roca Sratis saerTo bilirubinis done (TSB) gadaaWarbebs 95 percentils butanis nomogramaSi (Ronald J Wong 2005)

butanis nomograma saSualebas iZleva ganisazRvros ramdenad maRalia mZime hiperbilirubinemiis ganviTarebis riski axalSobilis asakis (saaTebSi) da Sratis bilirubinis koncentraciis gaTvaliswinebiT

mwvave bilirubinuli encefalopaTia - axalSobilobis pirvel kviraSi manifestirebuli bilirubinuli toqsiurobis mwvave periodi

kerniqterusi _ gamoiyeneba bilirubinis toqsiurobis qronikuli da permanentuli klinikuri gamosavlis asaRwerad

gamoyenebuli Semoklebebi

Sbs ndash Sratis saerTo bilirubinitkb ndash transkutanuri bilirubiniba - bilirubinis da albuminis Sefardebards ndash respiraciul distres sindromi

epidemiologiafiziologiuri siyviTle viTardeba dRenaklul axalSobilTa

umravlesobasa da droul axalSobilTa 25-50-Si janmrTel droul axalSobilTa 61-Si Sratis bilirubinis maqsimaluri done aRemateba 129mgdl 3 -Si ki _ 15mgdl

multinacionaluri kvlevebis monacemebiT 30 saaTis asakisaTvis axalSobilTa 5 ndash 40 -Si Sratis saerTo bilirubinis done aWarbebs 95 percentils butanis nomogramaSi 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 5 SemTxveva

2

etiopaTogenezi












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6


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7

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D

C

D

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C

C

D

D















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8








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17

III 30 510 20 340IV da meti 30 510 20 340















bull temperatura

bull guliscema

bull sunTqva

bull wneva

bull glukoza SratSi

bull Sardis analizi


bull kanis feri

bull tonusi


18

bull temperatura


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bull kanis feri

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19






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C

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didi britaneTi


httpwwwniceorguk







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avstralia


21





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22




















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17

III 30 510 20 340IV da meti 30 510 20 340















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bull guliscema

bull sunTqva

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bull glukoza SratSi

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18

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19






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20

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21





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22




















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23



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17

III 30 510 20 340IV da meti 30 510 20 340















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18

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19






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20

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didi britaneTi


httpwwwniceorguk







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avstralia


21





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biblioTeka











22




















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24





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17

III 30 510 20 340IV da meti 30 510 20 340















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18

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19






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didi britaneTi


httpwwwniceorguk







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avstralia


21





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22




















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17

III 30 510 20 340IV da meti 30 510 20 340















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18

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19






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17

III 30 510 20 340IV da meti 30 510 20 340















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18

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19






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21





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22




















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17

III 30 510 20 340IV da meti 30 510 20 340















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18

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19






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22




















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17

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18

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17

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18

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17

III 30 510 20 340IV da meti 30 510 20 340















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18

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19






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21





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22




















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17

III 30 510 20 340IV da meti 30 510 20 340















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18

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21





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17

III 30 510 20 340IV da meti 30 510 20 340















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68 080





17

III 30 510 20 340IV da meti 30 510 20 340















bull temperatura

bull guliscema

bull sunTqva

bull wneva

bull glukoza SratSi

bull Sardis analizi


bull kanis feri

bull tonusi


18

bull temperatura


bull sunTqva

bull kanis feri

bull qceva







bull Sardis analizi

















19






meTvalyureoba









20

C

C

C

C

D

C

D



cxrili 2


internet-misamarTi

aSS


httpwwwguidelinegov






httphstatnlmnihgov


httpwwwicsiorg






didi britaneTi


httpwwwniceorguk







httpwwwsignacuk



avstralia


21





httpwwwosdmorg




biblioTeka











22




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24







rArr dehidratacia





rArr purpura





15



B












16

D

D


riskis kategoria







72 084


68 080





17

III 30 510 20 340IV da meti 30 510 20 340















bull temperatura

bull guliscema

bull sunTqva

bull wneva

bull glukoza SratSi

bull Sardis analizi


bull kanis feri

bull tonusi


18

bull temperatura


bull sunTqva

bull kanis feri

bull qceva







bull Sardis analizi

















19






meTvalyureoba









20

C

C

C

C

D

C

D



cxrili 2


internet-misamarTi

aSS


httpwwwguidelinegov






httphstatnlmnihgov


httpwwwicsiorg






didi britaneTi


httpwwwniceorguk







httpwwwsignacuk



avstralia


21





httpwwwosdmorg




biblioTeka











22




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24












16

D

D


riskis kategoria







72 084


68 080





17

III 30 510 20 340IV da meti 30 510 20 340















bull temperatura

bull guliscema

bull sunTqva

bull wneva

bull glukoza SratSi

bull Sardis analizi


bull kanis feri

bull tonusi


18

bull temperatura


bull sunTqva

bull kanis feri

bull qceva







bull Sardis analizi

















19






meTvalyureoba









20

C

C

C

C

D

C

D



cxrili 2


internet-misamarTi

aSS


httpwwwguidelinegov






httphstatnlmnihgov


httpwwwicsiorg






didi britaneTi


httpwwwniceorguk







httpwwwsignacuk



avstralia


21





httpwwwosdmorg




biblioTeka











22




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24


riskis kategoria







72 084


68 080





17

III 30 510 20 340IV da meti 30 510 20 340















bull temperatura

bull guliscema

bull sunTqva

bull wneva

bull glukoza SratSi

bull Sardis analizi


bull kanis feri

bull tonusi


18

bull temperatura


bull sunTqva

bull kanis feri

bull qceva







bull Sardis analizi

















19






meTvalyureoba









20

C

C

C

C

D

C

D



cxrili 2


internet-misamarTi

aSS


httpwwwguidelinegov






httphstatnlmnihgov


httpwwwicsiorg






didi britaneTi


httpwwwniceorguk







httpwwwsignacuk



avstralia


21





httpwwwosdmorg




biblioTeka











22




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24

III 30 510 20 340IV da meti 30 510 20 340















bull temperatura

bull guliscema

bull sunTqva

bull wneva

bull glukoza SratSi

bull Sardis analizi


bull kanis feri

bull tonusi


18

bull temperatura


bull sunTqva

bull kanis feri

bull qceva







bull Sardis analizi

















19






meTvalyureoba









20

C

C

C

C

D

C

D



cxrili 2


internet-misamarTi

aSS


httpwwwguidelinegov






httphstatnlmnihgov


httpwwwicsiorg






didi britaneTi


httpwwwniceorguk







httpwwwsignacuk



avstralia


21





httpwwwosdmorg




biblioTeka











22




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24

bull temperatura


bull sunTqva

bull kanis feri

bull qceva







bull Sardis analizi

















19






meTvalyureoba









20

C

C

C

C

D

C

D



cxrili 2


internet-misamarTi

aSS


httpwwwguidelinegov






httphstatnlmnihgov


httpwwwicsiorg






didi britaneTi


httpwwwniceorguk







httpwwwsignacuk



avstralia


21





httpwwwosdmorg




biblioTeka











22




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24






meTvalyureoba









20

C

C

C

C

D

C

D



cxrili 2


internet-misamarTi

aSS


httpwwwguidelinegov






httphstatnlmnihgov


httpwwwicsiorg






didi britaneTi


httpwwwniceorguk







httpwwwsignacuk



avstralia


21





httpwwwosdmorg




biblioTeka











22




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24



cxrili 2


internet-misamarTi

aSS


httpwwwguidelinegov






httphstatnlmnihgov


httpwwwicsiorg






didi britaneTi


httpwwwniceorguk







httpwwwsignacuk



avstralia


21





httpwwwosdmorg




biblioTeka











22




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24





httpwwwosdmorg




biblioTeka











22




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24




















konsesuss



eqspertTa angariSi



15 avtorTa jgufi




23



eqspertebi



24



eqspertebi



24

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