naadrevi mSobiaroba –

Tanamedrove aspeqtebi

mamuka nemsaZe,

akad.o.RuduSauris sax. erovnuli samedicino centri,

sameano ganyofilebis ufrosi

Tbilisi, 2014

naadrevi mSobiaroba ganmarteba

naadrevi ewodeba mSobiarobas orsulobis 22+0 kviridan 37+0

kviramde (36+6 kv).

• naadrevi mSobiaroba gestaciis adreul vadaze (22+0 kvira -

33+6 kvira);

• naadrevi mSobiaroba gestaciis mogvianebiT vadaze (34+0 kvira -

36+6 kvira)

naadrevi mSobiaroba – esaa saSvilonos regularuli SekumSvebi

(6 da meti 1 saaTis ganmavlobaSi) da: saSvilosnos yelis

damokleba da/an gaxsna (> 2 sm), an saSodan sisxlovani gamonadeni,

an sanayofe siTxis daRvra.

• naadrevi SekumSvebi (False labor)– saSvilosnos SekumSvebi sxva

niSnebis gareSe orsulobis 37+0 kviramde.

naadrevi mSobiarobis dinamika

aSS-Si (1990-2008 ww)

CDC/NCHS, National Vital Statistics, NCHS Data Brief Number 39, May 2010

naadrevi mSobiarobis struqtura

• spontanuri naadrevi mSobiaroba • spontanurad ganviTarebuli naadrevi samSobiaro moqmedeba;

• sanayofe wylebis naadrevi daRvra • inducirebuli (iatrogenuli) naadrevi mSobiaroba

daRvra

inducirebuli

spontanuri

Tucker JM, Goldenberg RL, Davis RO, Copper RL, Winkler CL, Hauth JC. Obstet Gynecol 1991;77(3):343-7

naadrevi mSobiarobis struqturis

cvlileba: aSS, 1989-2000

Ananth CV, Joseph KS, Oyelese Y, Demissie K, Vintzileos AM. Obstet Gynecol 2005;105:1084-91

gviani naadrevi mSobiaroba

yvelaze xSiria

March of Dimes PeriStats

34-35

32-33

28-31

<28

naadrevi axalSobili orsulobis

mcire vadaze

latimesblogs.latimes.com

gviani naadrevi axalSobili

wn.com

naadrevi mSobiaroba - statistika

• naadrevi mSobiaroba perinataluri sikvdilobis 65%-

ze metisa da cns-is dazianebis 50% SemTxvevebis, maT

Soris bavSvTa cerebruli damblis mizezia.

• naadrevi mSobiarobis daaxloebiT 80%-is mizezia

spontanuri naadrevi samSobiaro moqmedeba an sanayofe

wylebis naadrevi daRvra.

• bolo wlebSi naadrevi mSobiarobis sixSire

ganviTarebul qveynebSi ar Secvlila da Seadgens 7-

11%.

Andrew H Shennan, 2003

naadrevi mSobiaroba - statistika

• janmos monacemebiT msoflioSi yovelwliurad

dabadebul 130 mln axalSobilidan 8 mln kvdeba 1

wlis asakamde.

• aSS-Si am jgufSi Semavali axalSobilebis 17-dan 34%-

mde kvdeba naadrevobasTan dakavSirebuli

problemebis gamo da am SemTxvevaTa mxolod 50%-Sia

identificirebuli naadrevi mSobiarobis mizezi.

• ganviTarebul qveynebSi perinataluri sikvdilobis 50-

60% modis 1000g-ze naklebi wonis mqone bavSvebze (

yvela mSobiarobis 1%-ze naklebi)

Martin JA et al, 2002

avadmyofobis tvirTi 0-14 wlamde asakis bavSvebSi

saqarTveloSi da evropis regionSi

(DALYs 1000 mosaxleze), 2002

საქართველო ევროპის რეგიონი

axalSobilTa daavadebebi = mcire masa dabadebisas, asfiqsia, samSobiaro travma

32,4 11,8

zeda da qveda sasunTqi gzebis infeqciebi 7,1 7,4

mZime Tandayolili anomaliebi 1,7 6,3

neirofsiqiuri aSlilobebi 6,0 6,0

iodis deficiti 4,3 3,8

arawinaswarganzraxuli travmebi 1,4 3,3

asTma 2,3 1,9

janmrTelobis dacva, saqarTvelo 2009, statistikuri cnobari

cocxladSobilTa da mkvdradSobilTa wona gramebSi dabadebisas, saqarTvelo, 2009

sul 500-999 1000- 1499

1500- 2499

2500- 3999

4000+

daibada cocxali 61468 121 331 3300 52257 5459

% cocxalSobil-Ta saerTo raodenobidan

100,0 0,2 0,5 5,4 85,0 8,9

daibada mkvdari 665 265 120 132 128 20

% mkvdradSobil-Ta saerTo raodenobidan

100,0 39,8 18,0 19,8 19,2 3,0

janmrTelobis dacva, saqarTvelo 2009, statistikuri cnobari

• stacionarebSi dabadebuli cocxladSobilebidan 8,7% daibada avadmyofi an gaxda avad

• 5328 avadmyof cocxladSobilTa Soris 2234-s (41,93%)-s aReniSneboda perinataluri periodisaTvis damaxasiaTebeli respiratoruli darRvevebi.

mSobiarobis dawyebis meqanizmi

• progesteronis done – funqciuri daqveiTeba

– progesteronis receptorebis izoformebis donis

cvlileba;

– progesteronis receptorebis koaqtivatorebisa da

korepresorebis donis cvlileba;

– anTebiT gamowveuli mainhibirebeli meqnizmebi

• endokrinuli gansxvaveba, progesteronTan dakavSirebuli

genebis Tanmimdevrobebis divergencia => adamianis

mSobiarobis meqanizmebis unikaluroba.

Mendelson CR. Minireview: fetal-maternal hormonal signaling in pregnancy and labor. Mol Endocrinol 2009;23:947-954

naadrevi mSobiarobis gamomwvevi

faqtorebi

• mSobiarobis normaluri meqanizmebis naadrevi

aqtivacia;

• mSobiarobis aRZvra paTologiuri zegavleniT

• faqtorebis sami tipi:

– socialuri stresi da rasa;

– infeqcia da anTeba;

– genetika

Muglia L, et all, N Engl J Med 362;6 2010

naadrevi mSobiarobis risk faqtorebi

• asaki 16 weli an naklebi

• dabali socialuri statusi A

• wona/simaRlis dabali maCvenebeli

• Tambaqo

• anamnezSi naadrevi mSobiaroba

• mravalnayofiani orsuloba

• isTmur-cervikaluri ukmarisoba

• saSvilosnos paTologia

• infeqcia

Chandraharan E et al, 2003

socialiuri stresi da rasa

• siRaribe;

• dedis mwiri ganaTleba;

• dedis axalgazrda asaki;

• qorwinebisgareSe statusi;

• arasakmarisi prenataluri movla;

• rasa

Kistka ZA-F, Palomar L, Lee KA, et al. Racial disparity in the frequency of recurrence of preterm birth. Am J Obstet Gynecol 2007;196(2):131131.e6.

infeqcia da anTeba

• naadrevi mSobiarobis mizezTgan naxevari

ucnobia;

• aseT situaciaSi infeqcia isaxeba rogorc

yvelaze savaraudo “damnaSave”;

• qorioamnioniti

– klinikuri niSnebi;

– histologiuri monacemebi;

– mikroorganizmTa kultura

infeqcia da anTeba mikrobiologiuri kvlevis SedegebiT dasturdeba, rom

infeqcia 25%-Sia naadrevi mSobiarobis mizezi;

79%

11%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

baqteriuli kolonizacia

23 kvira

31-34 kvira

Watts DH, et all, The association of occult amniotic fluid infection with gestational age and neonatal outcome among women in preterm labor. Obstet Gynecol 1992;79:351-357

anTeba iwvevs normaluri mSobiarobis kaskadis CarTvas

proinflamatoruli mediatorebis -

prostanoidebisa da citokinebis inducirebiT.

infeqcia da anTeba I. naadrevi mSobiarobis umetes SemTxvevebSi infeqciis

klinikuri niSnebi araa gamoxatuli;

• saxezea anTebis histologiuri markerebi:

– mosavardni garsis;

– amnionisa da qorionis;

– Wiplaris.

anTeba SeiZleba gaxdes adgilobrivi an sistemur

infeqciis mauwyebeli, romelic sanayofe siTxis

standartuli kulturaluri kvelvebiT ver vlindeba.

Romero R, et all, Am J Obstet Gynecol 1989;161:817-824; Goldenberg RL, et all, N Engl J Med 2000;342:1500-1507; Smith R. N Engl J Med 2007;356:271-283

infeqcia da anTeba

II naadrevi mSobiaroba – esaa ara specifiuri

mikroorganizmis mier gamowveuli infeqciis Sedegi,

aramed saSos baqteriuli ekosistemis cvlileba, mag.

rogoricaa baqteriuli vaginozi.

• samwuxarod, baqteriuli vaginozis, iseve rogorc

sxva msubuqi, qronikuli infeqciis (triqomoniazi,

periodontiti) antibiotikoTerapia ar iZleva

naadrevi mSobiarobis sixSiris Semcirebas.

Nygren P, et all, an update review for the U.S. Preventive Services Task Force. Ann Intern Med 2008;148:220-233

infeqcia da anTeba

III qronikuli infeqcia da maspinZlis sistemuri

anTebiTi pasuxi saSarde gzebis infeqciebis

antibiotikebisadmi rezistentuli SemTxvevebis

dros.

biofilmebi (Biofilm) – mikrobebis gaerTianeba,

enkafsulirebuli maT mierve producirebuli

polimeruli matricis SigniT.

infeqcia da anTeba - biofilmi

1. biofilmis formireba; 2. Staphylococcus aureus –is mier warmoqmnili biofilmi

3. Bact. Termophillus 20 mm-iani apki; 4. baqteriuli Wilobi Yellowstone-s nac. parkSi

• aSS-s CDC-s SefasebiT, adamianis infeqciaTa

65% mimdinareobs biofilmebis warmoqmniT da

isini xels uwyoben periodontitebis, saSarde

gzebis infeqciebis, endokarditebisa da sxva

qronikuli infeqciebis mimdinareobas.

• Romero, 2008 - aRmoCenilia biofilmebi sanayofe

siTxeSi

infeqcia da anTeba - biofilmi

Donlan RM, Costerton JW. Biofilms: survival mechanisms of clinically relevant microorganisms. Clin Microbiol Rev 2002;15:167-193

infeqcia da anTeba

• Joshua Ledeberg – amerikeli molekuluri biologi, nobelis premiis laureati (1958 w) 33 wlis asakSi • terminis “mikrobiomi” Semotana • adamianis sxeulSi dasaxlebuli baqteriebi ganxilul unda iqnen rogorc adamianis genomis nawili maT mier adamianis fiziologiaze arsebuli gavlenis gamo

qalis mikrobiomis Seswavla naTels mohfens Tu rogor ayalibebs maspinZel-mikrobis urTierTqmedeba imunur pasuxs, gazardos an Seamciros albaToba imisa, rom anTebiTi pasuxi mimarTuli iyos nayofisaken an asaxos SemoWrili paTogenis gavlena.

Turnbaugh PJ, et all. The Human Microbiome Project. Nature 2007;449:804-810

infeqcia/anTeba

klinikurad gamoxatuli qorioamnioniti

infeqciis klinikuri niSnebi

amnionis Rrus mikrobuli invazia (MIAC)

amnionuri siTxis dadebiTi mikrobuli kultura/pjr/16s rRNA

iintraamnionuri anTeba (IAI)

citokinebis maRali done amnionur siTxeSi

intraamnionuri anTebis gavlena nayofze da cerebraluri damblis ganviTareba

sami wlis asakisaTvis

levitonis Teoria (1993) – dedis infeqcias SeuZlia gamoiwvios

rogorc naadrevi mSobiaroba, asve nayofis sisxlsa da tvinSi

proinflamatoruli citokinebis donis momateba, rac Tavis tvinis

dazianebasa da cerebruli damblas iwvevs

• kohortuli kvleva, 123 naadrevi axalSobili;

• IL-6, IL-8-s momateba amnionur siTxeSi;

– daskvna: intraamnionuri anTebis zegavlena da nayofis sistemuri

anTebiTi pasuxis (funisiti) arseboba 3 wlis asakisaTvis

cerebraluri damblis ganviTarebis myari da damoukidebeli risk-

faqtoria

Yoon BH, Romero R, et al,Fetal exposure to an intra-amniotic inflammation and the development of cerebral palsy at the age of three years. Am J Obstet Gynecol. 2000 Mar;182(3):675-81

genetikuri faqtorebi

• anamnezSi naadrevi da vadagadacilebuli

mSobiaroba;

• naadrevi mSobiaroba CaiTvalos, rogorc

zogadi rTuli darRveva, romelic moicavs geni-

geni da geni-garemo urTierTqmedebas.

• adamianis genomis gamokvleva – orsulobis

xangZlivobaze gavlenis mqone genebi.

• norvegiis mSobiarobis samedicino reestri – 1967-

2004 ww;

• naadrevad dabadebuli dedebis riski imSobiaron

naadrevad - droulad dabadebul dedebTan

SedarebiT aris 1.54 (95% CI, 1,42-1.67)

• igive riskis Sedareba mamebs Soris iyo 1.12 (95% CI,

1,01-1,67);

• mamis geni naklebad axdens gavlenas naadrev

mSobiarobis riskze.

genetikuri faqtorebi

Wilcox AJ, Skjaerven R, Lie RT. Familial patterns of preterm delivery: maternal and fetal contributions. Am J Epidemiol 2008;167:474-479

naadrevi mSobiarobis

paTofiziologia

spontanuri naadrevi mSobiaroba fiziologiurad

heterogenuri sindromia. ganixileba oTxi

mimarTuleba:

1. miometriumisa da sanayofe garsebis zomaze meti

gadaWimva;

2. decidualuri sislisdena;

3. nayofis endokrinuli sistemis naadrevi aqtivacia

4. saSvilosnosSida infeqcia an anTeba

Romero R,et all, The preterm labor syndrome. Ann N Y Acad Sci 1994;734:414-429;

Lockwood CJ,et all, Paediatr Perinat Epidemiol 2001;15:Suppl 2:78-89

naadrevi mSobiarobis diagnozi

saSvilonos regularuli SekumSvebi (6 da meti 1

saaTis ganmavlobaSi) da saSvilosnos yelis

damokleba da/an gaxsna.

• es monacemebis skirnigisaTvis gamousadegaria

Tavisi dabali specifiuribisa da

mgrZnobelobis gamo

King JF, et all, Beta-mimetics in preterm labour: an overview of the randomized controlled trials. Br J Obstet Gynaecol 1988;95:211-222

• sistemuri mimoxilva: pacientTa 30%-Si naadrevi

mSobiaroba SeCerda spontanurad;

• Semdgom kvlevebSi – hospitalizirebul

pacientTa 50%-ma imSobiara droulad;

• siZneleebi ganasxvavo “namdvili” naadrvi

mSobiaroba “crusagan” - Terapiis efeqturobis

Sefasebis ZiriTadi xelisSemSleli faqtoria,

Tundac imitom rom aranamkurnalevi (an

placeboTi namkurnalevi) pacientebis 50% ar

mSobiarobs naadrevad

naadrevi mSobiarobis diagnozi

King JF, et al, Beta-mimetics in preterm labour: an overview of the randomized controlled trials. Br J Obstet Gynaecol 1988;95:211-222 McPheeters ML, et al. The epidemiology of threatened preterm labor: a prospective cohort study. Am J Obstet Gynecol 2005;192:1325-1329

• nayofis fibroneqtinis gansazRvra (fFN);

• saSvilosnos yelis ultrabgeriTi Sefaseba

maTi cal-calke an erToblivi gamoyeneba

naadrevi mSobiarobis diagnozi

Honest H, et al, Accuracy of cervicovaginal fetal fibronectin test in predicting risk of spontaneous preterm birth: systematic review. BMJ 2002;325:301-301 Gomez R, Romero R, Medina L, et al. Cervicovaginal fibronectin improves the prediction of preterm delivery based on sonographic cervical length in patients with preterm uterine contractions and intact membranes. Am J Obstet Gynecol 2005;192:350-359[Erratum, Am J Obstet Gynecol 2005;193:308-9.]

საშვილონოს ყელის სიგრძის ტრანსვაგინალური გაზომვა ნაადრევი მშობიარობის

პროგნოზირებისათვს: მეტა-ანალიზი

28 ნაშრომი აკმაყოფილებდა SerCevis კრიტერიუმს • მშობიარობა მომართვიდან 1 კვირაში, საშვილონოს ყელის <15 მმ-ზე ნაკლები

სიგრძის ჯამური სენსიტიურობა და სპეციფიურობა, LR+ და LR-, შესაბამისად 60%

და 90%, 5,71 და 0,5 CI;

• 34 კვირამდე ნაადრევი მშობიარობის პროგნოზირება, საშვილონოს ყელის <15 მმ-ზე

ნაკლები სიგრძის ჯამური სენსიტიურობა და სპეციფიურობა, LR+ და LR-,

შესაბამისად 46% და 94%, 4,31 და 0,63 (95% CI, 0,38-1.04)

დასკვნა: saSvilosnos yelis sigrZis gazomva simptomebis mqone qalebSi

SesaZleblobas iZleva ganisazRvros maT Soris kontigenti, romelic 1

kviraSi imSobiarebs da amiT moxdes maTi marTvis racionalizacia.

Sotirtadis et al, Transvaginal cervical length measurement for prediction of preterm birth in women with threatened preterm labor: a meta-analysis.Ultrasound Obstetr Gynecol 2010 Jan.35(1) 54-64

ნაყოფის ფიბრონექტინი

• ნაყოფის ფიბრონაქტინი (ნფნ) გლიკოპროტეინია,

რომელიც ნანახია მაღალი კონცენტრაციით

უშუალოდ დროული მშობიარობის წინ

ცერვიკოვაგინალური სეკრეტში.

• ნფნ ნანახია ქორიონისა და მოსავარდნი გარსისის

ზედაპირზე

• ნფნ-ის კონცენტრაცია გესტაციის 22-დან 35

კვირამდე < 50ნგ/მლ;

• კონცენტრაციის მომატება 50 ნგ/მლ-ის ზევით

ზრდის ნაადრევი მშობიარობის რისკს;

• PPV: 15-25%, NPV: 97-99.5% (larsis et al, 1995, Joffe at al 1999,

Loclowood et al 1991)

naadrevi mSobiarobis sqema

nayofis fibroneqtinis gansazRvris

teqnika

cervikovaginaluri fibroneqtinis testis sizuste spontanuri naadrevi mSobiarobis prognozirebisaTvis:sistemuri momixilva

Honest H, et al, Accuracy of cervicovaginal fetal fibronectin test in predicting risk of spontaneous preterm birth: systematic review, BMJ 2002;325:301

• 28 kvleva asimptomur da 40 asimptomur pacientSi, sul 26 876 qali ; • daskvna: cervikovaginaluri fn uaxloesi 7-10 dRis manzilze naadrevi

mSobiarobis prognozirebis yvelaze zusti testia simptomur qalebSi mosalodneli naadrevi mSobiaobiT.

ნაყოფის ფიბრონექტინი, როგორც უმოკლეს ვადაში ნაადრევი მშობიარობის წინასწარმეტყველი

სიმპტომურ პაციენტებში: მეტა-ანალიზი

• მთლიანი მოცულობა (35 naSromi, 5 355 qali), შეფასდა:

• სენსიტიურობაზე 76,1% (95% CI 69.1-81.9)

• სპეციფიურობა 81,9% (95% CI 78,9-84,5)

LR ნფნ -ის ტესტის როგორც დადებითი, ასევე უარყოფითი მონაცემისათვის შეადგენდა 4,20-ს (95% CI 3,53-4,99) და 0,29 (95% CI 0,22-0,38) შესაბამისად;

• მეტა-რეგრესულმა ანალიზმა აჩვენა, რომ ტესტის სიზუსტე დამოკიდებული იყო შემთხვევათა სიხშირეზე, გამოკვლევის წელზე, და კვლევის დიზაინზე;

• როდესაც ქვეჯგუფებში გაკეთდა ერთნაირი მეთოდიკით შესრულებელი კვლევების ანალიზი, შედეგები ერთნაირი იყო

• daskvna: simptomur qalebSi uaxloes 7 dReSi mSobiarobis

prognozirebisaTvis nayofis fn-is gansazRvras SeRuduli sizuste

gaaCnia

Sanchez-Ramos, et al, Fetal Fibronectin as a short-term predictor of preterm birth in symptomatic patients : a mete-analysis, Obstet Gynecol. 2009 Sep;114(3):631-40.

daskvnebi

• saSvilonos yelis sigrZe >30 mm-ze 100% uaryofiTi

prognozuli niSani <35 kviraze naadrevi mSobiarobisaTvis;

• yelis sigrZe araumetes 15 mm-sa 70% dadebiTi prognostuli

niSani ≤riskis mqone qalebSi;

• naadrevi mSobiarobis prognozirebis gaumjobeseba:

– anamnezi, liaboratoriuli maCvneblebi, yelis sigrZe <15/25 mm,

cervikaluri jirkvlebis are da nayofis fibroneqtini

• Tu yvela markeri dadebiTia, 32 kviramde naadrevi

mSobiarobis riski Seadgens 50%-s.

• nayofis fn aumjobesebs saSvilnos yelis sigrZiT miRebuli

monacemebis prognostul Rirebulebas, gansakuTrebiT iseT

SemTxvevebSi, roca yelis sigrZe Sualeduria (10-20 mm)

naadrevi mSobiarobis dros

sikvdilobisa da avadobis Semcireba

• perinataluri movlis regionalizacia

• kortikosteroidebis antenataluri gamoyeneba

• antibiotikebis gamoyeneba mSobiarobis dros

• axalSobilTa intensiuri Terapiis

ganyofilebis organizacia (1960 wlidan)

• filtvebis ventilaciis meTodebis srulyofa

• surfanqtantis gamoyeneba

• gaumjobesebuli neonataluri movla

Goldenberg RL et al, 1998

naadrevi mSobiarobis klasifikacia

• asimptomuri maRali riskis pacientebi:

– winamorbedi naadrevi mSobiaroba;

– anamnezSi 2-ze meti gviani aborti (12 kviris

zeviT);

– saSvilonos yelis sigrZe 25 mm-ze naklebi;

– mravalnayofiani orsuloba.

• pacientebi gamoxatuli simptomatikiT:

– naadrevi SekumSvebi;

– naadrevi mSobiaroba.

mkurnalobis strategia

• saSvilosnos SekumSvebis SeCereba-tokolizi;

• pirveli tokolizuri agenti ritodrini 1980 wels.

• pacientTa 80%-s, romelTac CautardaT mkurnaloba

tokolizuri preparatebiT, gauxangZlivdaT

orsuloba mxolod 24-48 saaTi;

• dRes arsebuli tokolizuri preparatebis

SezRuduli efeqturoba gamowveulia miometriumis

aqtivaciis gamomwvev fundamentur procesebze

zegavlenis warumateblobiT.

Gyetvai K, et al, Tocolytics for preterm labor: a systematic review. Obstet Gynecol 1999;94:869-877

mkurnalobis strategia

miuedavad imisa, rom SekumSvebis daTrgunva ver axdens

naadrevi mSobiarobis SeCerebas, ramodenime mizani

mainc miiRweva:

• kortikosteroidebis Seyvana, romelic amcirebs:

– axalSobilTa rds-s;

– ivh;

– (m)nek;

– mTlian perinatalur sikvdilobas.

• dedis usafrTxo transportireba regionaluri

specializirebul dawesebulebaSi.

Crowley P. Prophylactic corticosteroids for preterm birth. Cochrane Database Syst Rev 2000;2

naadrevi mSobiarobis Tavidan

acilebis ZiriTadi mizani

axalSobilis garTulebebisa da

sikvdilis riskis minimalizacia

tokolizuri preparatebis moqmedebis

samizne adgilebi

*Hyagriv N. Simhan, M.D., M.S.C.R., and Steve N. Caritis, M.D.N Engl J Med 2007; 357:477-487

tokolizuri preparatebis

moqmedebis gzebi

1. ujredSida mesenjeris generacia an alteracia:

1. beta-adrenomimeturi saSualebebi;

2. azotis oqisdis donorebi;

3. magnumis siulfati;

4. kalciumis arxebis blokatorebi

2. mometriumis cnobili mastimulirebeli agentebis

sinTezis inhibireba an blokireba:

1. prostaglandinebis sintezis inhibitorebi;

2. oqsitocinis antagonistebi.

I. β-adrenerguli receptoris

agonistebi

• ujredSida camf-is momateba;

• protein kinazis aqtivacia;

• miozinis msubuqi jaWvis kinazis inaqtivacia;

• miometriumis kumSvadobis daTrgunva

Caritis SN.et al. Am J Obstet Gynecol 1979;133:557-578

• meta-analizi: 11 rkk, 1320 qali. placebosTan SedarebiT, β-

adreno-mimetikebi:

– ayovnebs mSobiarobasa da amcirebs naadrevi mSobiarobis

sixSires uaxloesi 48 saaTis ganmavlobaSi (RR 0,63; 95% CI

0,53-0,75), Tumca ar amcirebs 7 dRis ganmavlobaSi

mSobiarobis raodenobas;

– amcirebs mcire wonis axalSobilis dabadebis sixSires;

– ar cvlis perinatalur (RR 0,84; 95% CI 0,46-0,1.55) da

neonatalur sikvdilobas (RR 1,00; 95% CI 0,48-2.09)

– 8 naSromi, 1239 qali: araa nanaxi raime mniSvnelovani

gansxvaveba neanataluri rds-is TvalsazrisiT (RR 0,83; 95% CI

0,71-1,08)

β-adrenerguli receptoris

agonistebi

Anotayanonth S, et al, Betamimetics for inhibiting preterm labour. Cochrane Database Syst Rev 2004;4

axalSobilis garTulebebisa da sikvdilis riskis minimalizacia

amgvarad, orsulobis gaxangZlivebisa

da naadrevi mSobiarobis riskis aSkara

Semcirebis miuxedavad, ar iqna nanaxi

perinataluri avadobisa da

sikvdilobis mniSvnelovani Semcireba

β-adrenerguli receptoris

agonistebi

Anotayanonth S, et al, Betamimetics for inhibiting preterm labour. Cochrane Database Syst Rev 2004;4

II. NO-s donorebi

cikluri guanozin monofosfati

miozinis msubuqi jaWvis kinaza miometriumis relaqsacia

3 izoforma: I da II tipi – miometriumSi da endoTelSi, III tipi – mxolod endoTelSi

NO => xsnadi guanililciklaza

L-arginini=>L-citrulini

NO azotis oqsid sinTza

Yallampalli C, et al, Role and regulation of nitric oxide in the uterus during pregnancy and parturition. J Soc Gynecol Investig 1998;5:58-67 Ledingham MA, Thomson AJ, Greer IA, Norman JE. Nitric oxide in parturition. BJOG 2000;107:581-593

• intravenuri nitroglicerinisa da magniumis

sulfatis randomuli Sedareba;

• es ukanaskneli ufro ayovnebs mSobiarobas

minimum 12 saaTiT;

• rkk: transdermuli nitroglicerini umjobesia

placeboze orsulobis 48 saaTiT

gaxangZlivebis TvalsazrisiT.

II. NO-s donorebi

El-Sayed YY, et al, Randomized comparison of intravenous nitroglycerin and magnesium sulfate for treatment of preterm labor. Obstet Gynecol 1999;93:79-83 Smith GN, et al, Randomised, double-blind, placebo controlled pilot study assessing nitroglycerin as a tocolytic. Br J Obstet Gynaecol 1999;106:736-739

• rkk: (245 obieqti) transdermuli

nitroglicerini VS. ritodrini;

• orsulobis 48 saaTiT, da 37 kviramde

prolongirebis erTnairi efeqti;

II. NO-s donorebi

Lees CC, et al. Glyceryl trinitrate and ritodrine in tocolysis: an international multicenter randomized study. Obstet Gynecol 1999;94:403-408

III. magniumis sulfati

• gamoiyeneba, rogorc tokolizuri

saSualeba 1960 wlidan.

• moqmedebis eqstraceluluri da

intraceluluri meqanizmi

• pkrk: ar aCvena, rogorc tokolizurma

agentma placebosTan SedarebiT

orsulobis prolongirebaze raime

dadebiTi efeqti

Cox SM, et al, Randomized investigation of magnesium sulfate for prevention of preterm birth. Am J Obstet Gynecol 1990;163:767-772

III. magniumis sulfati

• meta-analizi: 11 kvleva: 881 qali iRebda magniumis

sulfats, placebos an sxva tokolizur preparats;

• magniumis sulfatis gamoyenebisas aranairi

mniSvnelovani gansxvaveba 48 saaTSi naadrevi

mSobiarobis riskis TvalsazrisiT (RR 0,84; 95% CI 0,46-

0,1.55);

• 7 kvleva, 727 qali: axalSobilisa da pediatriuli

sikvdiloba momatebuli iyo magniumis sulfatiT

namkurnalev SemTxvevebSi (RR 2,82; 95% CI 1,20-6,62)

Crowther CA, et al, Magnesium sulphate for preventing preterm birth in threatened preterm labour. Cochrane Database Syst Rev 2002;4

III. magniumis sulfati

• Grimes DA, Nanda K. Magnesium sulfate

tocolysis: time to quit. Obstet Gynecol

2006;108:986-989

• liteaturaSi ar uWeren mxars

magniumis sulfats, rogorc

tokolizur agents.

IV. kalciumis arxis blokatorebi

ablokirebs:

1. kalciumis arxebs ujredis membranaSi

2. sarkoplazmuri retikulumidan ujredSida kalciumis gamoTavisuflebas

miozinis msubuqi jaWvis kinaziT aqtivirebuli fosforilacia (rac Ca++-zea damokidebuli)

moimetriumis relaqsacia

• sistemuri mimoxilva: 12 rkk, 1029 qali;

• sxva tokolizur gentebTan (ZiriTadad beta-

mimetikebTan)SedarebiT, Ca-arxis blokatorebi amcireben

– uaxloesi 7 dRis manilze namSobiarebTa ricxvs (RR 0,76; 95% CI 0,60-0,97)

– 34 kviris vadamde namSobiareTa ricxvs (RR 0,83; 95% CI 10,69-0,99)

– amcirebs axalSobilTa rds-is, (RR 0,83; 95% CI 10,69-0,99) (m) nek (RR 0,21; 95%

CI 0,05-0,96), intraventrikuluri sisxlCaqcevisa (RR 0,59; 95% CI 0,36-0,98) da

axalSobilTa siyviTlis sixSires (RR 0,73; 95% CI 0,57-0,93)

kalciumis arxis blokatorTa gamoyeneba mniSvnelovnad

aumjobesebs gamosavals.

IV. kalciumis arxis blokatorebi

King JF, et al, Calcium channel blockers for inhibiting preterm labour. Cochrane Database Syst Rev 2003;1

V. ciklooqsigenazas inhibitorebi

• cog-1 (mosavardni garsi, miometriumi,

sanayofe garsebi) da cog-2

(mosavardni garsi)

• araqidonis mJavis konvertacia

prostaglandin H2-mde.

• indometacini, cog-is araspecifiuri

inhibitori.

V. ciklooqsigenazas inhibitorebi

• meta analizi: indometacinis Sedareba

placebosTan:

• 37 kviramde mSobiarobis Semcireba (RR 0,21);

• gestaciuri vadisa da dabadebis wonis gazrda;

– sxva tokolizur agentebTan Sedarebisas

mcirdeboda 37 kviramde mSobiroba (RR

0,53)

King J, et al,. Cyclo-oxygenase (COX) inhibitors for treating preterm labour. Cochrane Database Syst Rev 2005;2

VI. oqsitocinis receptorebis

antagonistebi

• meta-analizi: 6 naSromi, 1695 qali;

• atosibani ar amcirebs naadrevi

mSobiarobis sixSires, neonatalur

gamosavals placebosTan SedarebiT

Papatsonis D, et al, Oxytocin receptor antagonists for inhibiting preterm labour. Cochrane Database Syst Rev 2005;3

VI. oqsitocinis receptorebis

antagonistebi • pkrk 2 kvleva: 613 qali:

– axalSobilis dabali wona (wonis saSualo

Semcireba 138 g, 95% CI 28-249)

– wamlismieri gverdiTi reaqcia (RR 4,02; 95% CI 2,05-

7,85)

• beta-mimetur saSualebebTan SedarebiT: 575

axalSobili

– gaizarda 1500 gramze naklebi wonis

axalSobilTa raodenoba (RR 1,96; 95% CI 1,15-3,35)

Goodwin TM, et al,. The effect of the oxytocin antagonist atosiban on preterm uterine activity in the human. Am J Obstet Gynecol 1994;170:474-47

VI. oqsitocinis receptorebis

antagonistebi

• pkrk kvleva Romero: 531 axalSobili:

– pirveli wlis ganmavlobaSi axalSobilTaA

sikvdilobis gazrda (RR 6,15; 95% CI 21,39-27,22)

– qalTa umetesoba iRebda atosibans 26 kviramde,

rac ganapirobebda axalSobilTa sikvdilobis

aseT zrdas.

– amis gamo FDA-s mier atosibanis, rogorc

tokolizuri preparatis gamoyeneba araa

nebadarTuli.

Romero R,et al,. An oxytocin receptor antagonist (atosiban) in the treatment of preterm labor: a randomized, double-blind, placebo-controlled tri with tocolytic rescue. Am J Obstet Gynecol 2000;182:1173-1183

mosalodneli naadrevi mSobiarobis

prevencia maRali riskis asimptomuri

pacientebisaTvis

saSvilonos yelze nakeris dadebis Cveneba

• anamnezSi saSvilonos yelis ukmarisobiT gamowveuli 2-ze meti

TviTnebiT aborti –

• saSvilonos yelis sigrZe – orsuli anamnezSi winamorbedi naadrevi

mSobarobiT saWiroebs saSvilonos yelis sigrZis yovelkvireul (17-

25 kv) saSosmxriv ultrasonografiul kontrols. saSvilosnos

yelis sigrZis 25 mm-mde Semcirebis SemTxvevaSi -

.

• asimptomur pacientebSi saSosmxrivi manualuri gasinjvisas yelis

gaxsna 2 sm-ze metad -

*saSvilosnos yelze cirkularuli nakeris dadeba ukunaCvenebia:

mravalnayofiani orsulobis, sanayofe siTxis daRvris, mtkivneuli

SekumSvebisa da intraamnionuri infeqciis SemTxvevaSi.

mosalodneli naadrevi mSobiarobis

prevencia maRali riskis asimptomuri

pacientebisaTvis

progesteroni

• qals, romelsac anamnezSi spontanuri naadrevi mSobiaroba

hqonda ukeTdeba: kviraSi erTjer 17-hidroqsi progesteron

kaproati 250 mg, an yoveldRiurad progesteronis 200 mg-is

vaginaluri forma orsulobis 16-dan 35 kviramde;

• orsulobis 16 kviridan 25 kviramde saSvilonos yelis 15 mm-

mde damoklebis SemTxvevaSi, eZleva yoveldRiurad

progesteronis 200 mg-is vaginaluri forma orsulobis 35

kviramde

progesteronis prenataluri gamoyeneba

naadrevi mSobiarobis profilaqtikis

mizniT riskis mqone qalebSi – janmos komentari

Sedegebi Sefasda Semdeg jgufebSi:

• anamnezSi spontanuri naadrevi mSobiaroba;

• mokle saSvilonos yeli;

• mravalnayofiani orsuloba;

• mosalodneli naadrevi mSobiaroba;

• sxvadasxva riskis mqone qalebi

González R. December 2009. The WHO RHL

progesteronis prenataluri gamoyeneba

naadrevi mSobiarobis profilaqtikis

mizniT riskis mqone qalebSi – janmos komentari

daskvnebi:

• anamnezSi spontanuri naadrevi mSobiarobismqone erTnayofian

orsulebSi mcirdeba 37 da 34 kviramde mSobiarobis riski;

• mcirdeba 2500 gramade wonis axalSobilis dabadebis riski;

• rekomendebulia progesteronis gamoyeneba qalebSi, romelTac

aRmoaCndaT mokle saSvilonos yeli;

• ar uWers mxars mravalnayofiani orsulobisas progesteronis

gamoyenebas*;

• dReisaTvis ucnobia, aumjobesebs Tu ara dedisa da nayofismxriv

gamosavals orsulobis gaxangZliveba;

• mimoxilvaSi gamoyenebulia ganviTarebul qveynebSi Catarebuli

kvlevebi. ganviTarebadi qveynebi?

*Norman J, et al,Progesterone for the prevention of preterm birth in twin pregnancy (STOPPIT): a randomised, double-blind, placebo-controlled study and meta-analysis, The Lancet,373;9680; 2034-2040, june 2009

progesteroni naadrevi mSobiarobis

profilaqtikisaTvis: sistemuri mimoxilva

• ganxilulia 11 rkk;

• 2,425 qali da 3,187 axalSobili;

• jgufebi: anamnezSi naadrevi mSobiaroba, mokle

saSvilonos yeli, naadrevi mSobiaroba;

• gamosavali:

– perinataluri sikvdili;

– naadrevi mSobiaroba < 34 kviraze

Dodd JM, et al, Progesterone for the prevention of preterm birth: a systematic review, Ob?gyn 2008

progesteroni naadrevi mSobiarobis

profilaqtikisaTvis: sistemuri mimoxilva

- Sedegebi

• anamnezSi mosalodneli naadrevi mSobiaroba:

– Semcirebuli naadrevi mSobiaroba 34 kviramde (RR 0.15, 95% CI 0.04-

0.64, NNT 7, 95% CI 4-17) ;

– aranairi gansxvaveba perinataluri sikvdilobis mxriv;

• mokle yeli:

– Semcirebuli naadrevi mSobiaroba 34 kviramde (RR 0.58, 95% CI 0.38-

0,87, NNT 7, 95% CI 4-25) ;

– aranairi gansxvaveba perinataluri sikvdilobis mxriv

• mravalnayofiani orsulobis, naadrevi mSobiarobisa da

“sxva” risk-faqtorebis mqone orsulTa jgufebSi

gansvaveba ar iqna nanaxi

Dodd JM, et al, Progesterone for the prevention of preterm birth: a systematic review, Ob?gyn 2008

progesteronis gamoyenebis riski

• izrdeba gestaciuri Saqriani

diabetis riski (12,9% 4,9%-is

winaaRmdeg);

• nayofis Seyovneba saSvilonos

mtrul garemoSi

Rebarber et al, 2007; Dodd et al. 2008

mosalodneli naadrevi mSobiarobis

marTva da mkurnaloba simptomuri

pacientebisaTvis

sawyisi Sefaseba:

• saSvilonos yelis sigrZis gazomva saSosmxrivi

ultrasonografiiT da misi mdgomareobis Sefaseba

saSosmxrivi gasinjviT;

• saSvilonos SekumSvaTa sixSiris gansazRvra

(palpaciiT an kardiotokografiT);

• saSodan gamonadenis Sefaseba;

• nayofis mdgomareobis Sefaseba

naadrevi SekumSvebi

• regularuli SekumSvebis arsebobisas, Tu

saSvilosnos yelis sigrZea ≥ 30 mm da

daxurulia an gaxsnilia < 2-sm, sisxliani

gamonadeni ar aReniSneba -

– nifedipini 20 - 40 mg peroralurad erTjeradad;

– mdgomareobis xelaxali Sefaseba 2-4 saaTSi;

– saSvilosnos yelis sigrZe ≥ 30 mm – binaze

gawera

naadrevi mSobiarobis marTva – saSvilonos yelis sigrZe 15-30 mm

• orsulobis vada 22-24 kvira:

– nifedipini 20-40 mg 3-jer

– indometacini 100 mg/dReSi 48 saaTis ganmavlobaSi

– ganixileT: sakiTxi hospitalizaciis Sesaxeb,

saSvilosnos yelis gaxsnis xarisxis mixedviT;

• orsulobis vada 34-37 kvira

– nifedipini 20-40 mg, binaze gawera da yovelkvireuli

ambulatoriuli meTvalyureoba.

– deqsametazoni – 6 mg yovel 12 saaTSi, 48 saaTis

ganmavlobaSi (maqsimaluri doza 24 mg) 34 6/7 kviris

CaTvliT

naadrevi mSobiarobis marTva – saSvilonos yelis sigrZe 15-30 mm

• orsulobis vada 24-34 kvira:

– nifedipini 20-40 mg 3-jer;

– da/an indometacini 100 mg/dReSi 48 saaTis ganmavlobaSi 27

kviramde;

– deqsametazoni – 6 mg yovel 12 saaTSi, 48 saaTis ganmavlobaSi

(maqsimaluri doza 24 mg)

– hospitalizacia. ganixileT sakiTxi orsulis axalSobilTa

reanimaciis ganyofilebis mqone samedicino centrSi gadayvanis

Sesaxeb.

kortikosteroidebis “gadarCenis (ganmeorebiTi) doza”

SesaZlebelia gamoyenebul iqnes 30 kviramde, Tu gasulia 2

kvira pirveli dozis Seyvanidan.

naadrevi mSobiarobis marTva – saSvilonos yelis sigrZe <15 mm da

saSvilosnos yelis gaxsna > 2 sm

• orsulobis vada 22-24 kvira:

– nifedipini 20-40 mg 3-jer 48 saaTis ganmvlobaSi;

– indometacini 100 mg/dReSi 48 saaTis ganmavlobaSi

– hospitalizacia.

– saSosmxrivi progesteroni 200 mg dReSi erTjer 35 kviramde;

• orsulobis vada 24-34 kvira:

– nifedipini 20-40 mg 3-jer;

– da/an indometacini 100 mg/dReSi 48 saaTis ganmavlobaSi 27

kviramde;

– meore rigis tokolizuri preparatebi – ß-mimetikebi, mxolod

intravenuri gamoyenebisaTvis;

naadrevi mSobiarobis marTva – saSvilonos yelis sigrZe <15 mm da

saSvilosnos yelis gaxsna > 2 sm

• orsulobis vada 34-37 kvira

– mzadyofna SesaZlo mSobiarobisaTvis, saWiroebis SemTxvevaSia

sasurvelia orsulis (in utero) gadayvana Sesabamisi resursis

mqone samedicino dawesebulebaSi;

– deqsametazoni* – 6 mg yovel 12 saaTSi, 48 saaTis ganmavlobaSi

(maqsimaluri doza 24 mg) 34 6/7 kviris CaTvliT.

– Tu pacinetis mdgomareoba stabiluria 24 saaTis ganmavlobaSi,

SesaZlebelia binaze gawera.

• yvela zemoaRniSnul SemTxevvaSi nawarmoeb iqnas kvleva B

jgufis streptokokze saTanado GBS - protokolis mixedviT

alternatiuli tokolizuri

prepartatebi

• heqsoprenalini:

– mwvave tokolizi - 10 mkg heqsoprenalini gaxsnili 10 ml fiziologiur

xsnarSi intravenurad 10-15 wuTis ganmavlobaSi, aucileblobis SemTxvevaSi

preparatis Seyvana grZeldeba 0,3 mkg/wT i/v infuziiT;

– intensiuri tolkolizi – 50 mkg heqsoprenalini gaxsnili 500 ml

fiziologiur xsnarSi 25 wveTi/wuTSi siCqariT (0,125 mkg/wT). saWiroebisas

dozis gazrda SesaZlebelia yovel 5 wuTSi 5 wveTiT. minimaluri siCqarea 10

wv/wT-Si, maqsimaluri – 60 wv/wT.

(!) heqsoprenalinis miRebisas saWiroa dedis pulsis, arteriuli wnevisa da nayofis

guliscemis kontroli. calkeul SemTxvevebSi heqsoprenalinis infuziis dros

kortikosteroidebis erTdroulma miRebam SesaZloa gamoiwvios filtvebis SeSupeba.

• terbutalini – 0.25 mg kanqveS yovel 20 wuTi - 3 saaTis intervaliT

(mkurnalobis Sewyveta >120 pulsis SemTxvevaSi)

• magniumis sulfatis gamoyeneba mizanSewonilia 32 kviramde

neiroproteqtoruli mizniT (sawyisi doza 5 g da SemanarCunebeli doza 2 g/sT

pirveli 12-24 saaTis ganmavlobaSi, mSobiarobaSi myofi pacientisaTvis);

woliTi reJimi, SemanarCunebeli

tokolizuri Terapia da intravenuri

hidratacia

amgvari RonisZiebebi araefeqturia mosalodneli naadrevi

mSobiarobis prevenciisa da mkurnalobisaTvis.

• Tu mainc saWiro CaiTvala mkurnalobis gagrZeleba 48 saaTis

Semdegac, es umjobesia ganxorcieldes nifedipiniT 20-40 mg 3-

jer dReSi 34 kviramde.

• papaverinis sanTlebis, ginipralis tabletebis, Jangbadis

wveTebisa da sxvaTa gamoyeneba usafuZvlo da araefqturia, ris

gamoc maTi daniSvna araa rekomendebuli.

• woliTi reJimis nacvlad rekomendebulia fizikuri aqtivobis

Semcireba.

• orsulisaTvis rekomendebula dReSi minimum 2-2,5 litri wylis

miReba

tokolizuri Terapiis Sejameba

• balansi usafrTxoebasa da efeqturobas Soris;

• nifedipini, beta-adrenomimetur saSulebebTan

SedarebiT, safuZvliani arCevania sawyisi

tokolizisaTvis, nebismieri getaciuri asakisaTvis.

• orsulobis 32 kviramde indometacini – nifedipinis

alternativa.

• beta-adrenomimeturi saSualebebi – meti

arasasurveli gverdiTi efeqti nifedipinTan

SedarebiT, efeqti – igive.

tokolizuri mkurnalobis gverdiTi

efeqtebi

– dedismxrivi: metaboluri hiperglikemia, hiperinsulinemia,

hipokalemia, antidiurezuli moqmedeba, farisebri jirkvlis

disfunqcia, fiziologiuri tremori, gulis friali, agznebadoba,

gulisreva an Rebineba, cxeleba, halucinaciebi;

– nayofisa da axalSobilis mxrivi : axalSobilis taqikardia,

hipoglikemia, hipokalemia, hiperbilirubinemia, hipotenzia,

parkuWSida sisxlCaqceva

– dedismxrivi : wamoxureba, Zilainoba, Tavis tkivili, kunTovani

sisuste, mxedvelobis gaoreba, piris simSrale, filtvis SeSupeba,

gulis gaCereba;

– nayofisa da axalSobilis mxrivi: Zilianoba, hipotonia, sunTqvis

daTrgunva, gaxangZlivebuli gamoyenebisas – demineralizacia;

tokolizuri mkurnalobis gverdiTi

efeqtebi

– dedismxrivi: wamoxureba, Tavis tkivili, gulisreva, gardamavali

hipotenzia. sifrTxiliT gamoiyeneba pacientebSi Tirkmlis daavadebiTa

da hipotenziiT. damatebiT, kalciumis arxebis blokatorebisa da

magniumis sulfatis erToblivi gamoyeneba potenciurad sazianoa da

SeiZleba gamoiwvios kardiovaskuluri kolafsi;

– nayofisa da axalSobilis mxrivi: jer-jerobiT araa gamovlenili;

– dedismxrivi: gulisreva, gulZmarva;

– nayofisa da axalSobilis mxrivi: arteriuli sadinaris daxSoba,

filtvis hipertenzia, Tirkmlis funqciis Seqcevadi daTrgunva

mcirewylianobiT, parkuWSida sisxlCaqceva, hiperbilirubinemia,

manekrotizirebeli enterokoliti.

gaiTvaliswineT: tokolizuri preparatebis erToblivi gamoyeneba potenciurad zrdis

dedis avadobasa da amitom gamoyenebul unda iqnes sifrTxiliT.

RCT: cervikaluri pesaria erTnayofiani orsulobisas

gamoTiSvis kriteriumi -nayofis anomalia; -SekumSvebi; -sisxldena; -placentis winmdeb; -arsebuli serklaJi

-PROM

721 yeli ≤ 25 MM

18.230 informirebuli Tanxmoba

190 pesaria 190 mkurnalobis gareSe PECEP TRIAL “Pesario Cervical para Evitar Prematuridad”

11.870 daeTanxma eqos

6360 uaryo

380 randomizacia

341 uaryo

BASELINE CHARACTERISTICS

Maternal Age

Body-mass index

Nulliparous

Parous with no PP

Parous with >= 1PP

Smoker

Race

caucasian

latino

others

GE at randomization

CL at randomization

Pessary (n=175)

29 (18-40)

23.7 (16-28)

86 (49.1%)

71 (40.6%)

18 (10.3%)

31 (17.7%)

106 (60.6%)

52 (29.7%)

17 (9.7%)

22.4 (21.1-23.6)

19 (7-25)

No treatment (n=174)

30 (19-43)

24.9 (17-30)

92 (52.9%)

70 (40.2%)

12 (6.9%)

37 (21.3%)

104 (59.8%)

54 (31%)

16 (9.2%)

22.3 (21.2-23.4)

18 (9-25)

P

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

RCT: cervikaluri pesaria erTnayofiani orsulobisas

PREGNANCY OUTCOME

Spontaneous delivery < 28w

Spontaneous delivery < 34w

Gestational Age at delivery (weeks+days) at delivery (mean, range)

Pessary (n=175)

3 (1.7%)

8 (5.1%)

38.3 (27.4-42)

No treatment (n=174)

15 (8.6%)

48 (28.2%)

35.1 (24.1-41)

P

ns

0.0001

0.001

P= 0.0001

RCT: cervikaluri pesaria erTnayofiani orsulobisas

PERINATAL OUTCOME

Fetal Death

Neonatal Death

Birth weight < 2500 g

Birth weight < 1500 g

Adverse outcomes

Necrotizing Entercolitis

Intraventricular hemorrhage

Respiratory distress sd

Retinopathy

Treatment for Sepsis

Composite adverse outcome

Pessary (n=175)

0

0

11 (6.3%)

3 (1.7%)

0

0

5 (2.8%)

0

3 (1.7%)

8 (4.5%)

No treatment (n=174)

0

1

52 (29.9%)

15 (8.6%)

2 (1.1%)

2 (1.4%)

23 (13.2%)

3 (1.7%)

11 (7.6%)

29 (20.1%)

P

ns

ns

0.0001

ns

ns

ns

0.03

ns

ns

0.001

RCT: cervikaluri pesaria erTnayofiani orsulobisas

Goya M, et al,Cervical pessary in pregnant women with a short cervix (PECEP): an open-label randomised controlled trial, The Lancet, Early Online Publication, 3 April 2012

daskvna: cervikalur pesarias SeuZlia xeli SeuSalos naadrevi mSobiarobis ganviTarebas saTanadod SerCeul, II trimestrSi saSvilosnos yelis sigrZis ultrabgeriTi Sefasebis Sedegad riskis mqone qalTa populaciaSi

didi madloba yuradRebisaTvis!