Placenta Praevia

placentis winamdebareoba da winamdebare placentis mixorceba

klinikuri rekomendaciebi

Tbilisi 2006

avtorTa jgufi:

Tengiz AasaTiani, FRCOG, mean ginekologi, Tssu postdiplomuri samedicino ganaTlebis da uwyveti profesionaluri ganviTarebis institutis reproduqciuli janmrTelobis departamentis xelmZRvaneli, asocirebuli profesori, saqarTvelos mean ginekologTa asociaciis prezidenti.

zaza boxua - mean ginekologi, saqarTvelos Sromis, janmrTelobis da socialuri dacvis jandacvis departamentis ufrosis moadgile, saqarTvelos mean ginekologTa asociaciis generaluri mdivani.

Tamaz Jojua - S.p.s m.SaraSiZis samedicino centris anesTeziologi

aleqsandre TaraSvili- S.p.s m.SaraSiZis samedicino centris mean-ginekologi

nino abulaZe – Tssu reproduqciuli janmrTelobis departamentis aspiranti

saeqsperto Sefaseba:

aleko goxelaSvili - anesTeziologi, #5 samSobiaro saxli

petre lomaia - mean ginekologi, medicinis mecnierebaTa kandidati, m.SaraSiZis samedicino centris sameano ganyofilebis gamge, saqarTvelos mean ginekologTa asocoaciis wevri

akaki baqraZe – £# 2 samSobiaro saxlis mean ginekologi, medicinis mecnierebaTa kandidati, saqarTvelos Sromis, janmrTelobis da socoaluri dacvis eqsperti meanoba ginekologiaSi, saqarTvelos mean ginekologTa asocoaciis gamgeobis wevri

mamuka xoStaria – mean ginekologi, sagarejo S.p.s. £# 5 saavadmyofo-poliklinikuri gerTianrbis qalTa konsultaciis gamge, saqarTvelos mean ginekologTa asocoaciis gamgeobis wevri

klinikuri rekomendaciebis zogadi mizani

am rekomendaciis mizans warmoadgens placentis winamdebareobisa da

winamdebare placentis mixorcebis marTvis meTodebis standartizacia dedisa da

axalSobilis gamosavlis gasaumjobeseblad.

ganxiluli klinikuri sakiTxebi

am rekomendaciebSi ganxilulia placentis winamdebareobisa da winamdebare

placentis mixorcebis diagnostireba da am mdgomareobebis mkurnaloba rogorc

antenatalur periodSi, aseve mSobiarobis dros.

visTvis aris gankuTvnili mocemuli klinikuri rekomendacia

mocemuli klinikuri rekomendaciebi gankuTnilia stacionarSi momuSave mean-

ginekologebisaTvis, aseve jandacvis pirveladi rgolisE mean-ginekologebis,

bebiaqalebisa da ojaxis eqimebisaTvis, romelTac aqvT mSobiaresTan kontaqti

an exebaT mSobiarobis warmarTva. rekomendacia SeiZleba gamoyenebuli

iyos rogorc diplomamdeli, ise diplomisSemgomi uwyveti samedicino ganaTlebis

mizniT.

Ziebis, mtkicebulebaTa Sefasebisa da rekomendaciebis formulirebis aRwera

placentis winamdebareobisa da winamdebare placentis mixorcebis aqtualobis

gamo arsebobs meTodologiaTa sakmarisi raodenoba, romlebic Seicaven

samecniero mtkicebulebebze dafuZnebul rekomendaciebs. amitom samuSao

jgufis mier gadawyvetili iyo ukve arsebuli praqtikuli rekomendaciebis moZieba

da Sefaseba da rekomendaciebis adaptirebuli formis Seqmna, romlebic erTis

mxriv, upasuxebdnen saerTaSoriso moTxovnebs, xolo meores mxriv, misaRebi

iqnebodnen saqarTvelos jandacvis pirobebSi gansaxorcieleblad. samuSao jgufis

mier daSvebuli iyo is SesaZlebloba, rom arsebul rekomendaciebSi ar iqneboda

ganxiluli yvela klinikuri sakiTxi da am SemTxvevaSi warmoiSveboda

mtkicebulebaTa damoukidebeli moZiebis aucilebloba konkretul klinikur

sakiTxebTan dakavSirebiT.

klinikuri rekomendaciebisa da mtkicebulebebis moZiebis damatebiTi wyaroebi da meTodebi

klinikuri rekomendaciebis, epidemiologiuri monacemebisa da mtkicebulebebis

Semdgomi moZieba xorcieldeboda inglisurenovani (Yahoo, AltaVista, Google,

DoctorGuide da rusulenovani (Yandex, Rambler) saZiebo operatorebis meSveobiT,

aseve inglisurenovani samedicino monacemebis eleqtronuli bibliografiuli

monacemTa bazis, „medlainis,, (MEDLINE) meSveobiT, sakvanZo sityvebis

gamoyenebiT. pirvel rigSi moZiebuli iyo (National Guidelines Clearinhouse, TRIP,

SumSearch) placentis winamdebareobisa da winamdebare placentis mixorcebis

analogiuri rekomendaciebi, romlebic SemuSavebulia Sesabamisi profesionaluri

jgufebis mier.

calkeuli, aseve ara srulad ganxiluli klinikuri sakiTxebis Sesaxeb mtkicebulebaTa

moZieba warmoebuli iyo kohreinis monacemTa bazaSi The Cochrane Library 2006,

Issue 3 da jandacvis msoflio organizaciis reproduqciuli janmrTelobis biblioTekaSi

#9. ar iyo Catarebuli ruxi literaturis moZieba (konferenciebi, Tezisebi,

gamouqveynebeli masalebi).

moZiebuli klinikuri rekomendaciebisa da mtkicebulebebis analizi

Catarebuli Ziebis Sedegad miRebuli iyo ramodenime klinikuri meToduri

rekomendacia, romlebic moicavda jgufis miznis Sesaferis saWiro informacias. am

rekomendaciebis saboloo Sefasebisas gamoyenebuli iyo formaluri Sefasebis

meTodi 1 Sefasebis Sedegad amorCeuli iyo ramodenime rekomendacia, romlebic

safuZvlad daedo Semdgom analizsa da adaptacias. am rekomendaciaSi

mocemuli debulebebi Sejamebuli iyo cxrilebSi da warmodgenili iyo samuSao jgufis

wevrebis mier Sefasebis mizniT. cxrilSi Sedioda debulebis originaluri versia da

mtkicebulebis done wyaros mixedviT. samuSao jgufs unda Seefasebina

rekomendaciebis vargisianoba saqarTvelos jandacvis stacionaluri daxmarebis

pirobebSi. rekomendacia miiReboda, Tu mis sasargeblod xmas aZlevda

SemqmnelTa samuSao jgufis umravlesoba.

konfliqtTa interesebis deklaracia

muSaobis dawyebamde mocemuli klinikuri rekomendaciis proeqtSi, samuSao

jgufis yvela wevrma ganacxada Tanxmoba, werilobiT formaSi gamoecxadebina

farmacevtul kompaniebTan finansuri kavSirebis Sesaxeb. saavtoro koleqtivis arc

erT wevrs ar hqonda finansuri daintereseba an sxva interesTa konfliqti

farmacevtul kompaniebTan da sxva organizaciebTan SesamuSavebel

rekomendaciasTan dakavSirebiT.

klinikuri rekomendaciebis Sida recenzireba

Catarebuli iyo klinikuri rekomendaciebis Sida recenzireba (sia Tan erTvis)

rekomendaciebis mowodebis sizustis gamosavlenad, maTi efeqturobisa da

usafrTxoebis Sesafaseblad da praqtikuli gamoyenebis TvalsazrisiT. recenziebis

miRebis Semdeg ganxiluli iyo Sedegebi da samuSao jgufis mier Setanili iyo

cvlilebebi klinikuri rekomendaciebis SinaarsSi.

klinikuri rekomendaciis gadaxedvis vada - 2009w.

mtkicebulebaTa doneebisa da rekomendaciebis gradaciis sqema

yvela ZiriTadi rekomendacia Seesabameba garkveul gradacias, romelic

aRiniSneba laTinuri asoebiT A-dan C-mde. (Agency for Health Care Policy and Research

(AHCPR), 1994 Sesabamisad). amasTan erTad, yovel gradacias Seesabameba

monacemTa mtkicebulebis Sesabamisi done. es niSnavs, rom rekomendaciebi

dafuZnebuli iyo kvlevebis monacemebze, romlebsac gaaCniaT mtkicebulebis

garkveuli done. rac ufro maRalia rekomendaciis gradacia, miT ufro maRalia

kvlevis mtkicebuleba, romelzedac is aris dafuZnebuli. qveviT moyvanilia sqema,

romelSic aRwerilia rekomendaciebis gradaciis sxvadasxva doneebi, romlebic

CarTulia am saxelmZRvaneloSi.

A

saWiroebs ZiriTadi literaturuli wyaros arsebobas, minimalurad erT

randomizirebul sakontrolo kvlevas, romelic Catarebulia kargi xarisxiTa da

SinaarsiT, rac specifiurad Seesabameba mocemul mtkicebulebas an

rekomendacias, an sistematiuri mimoxilva

B saWiroebs maRali xarisxis klinikuri, magram ara randomizirebuli kvlevis

Catarebas, romelic Seesabameba rekomendaciis Sinaarss.

C

saWiroebs mtkicebulebebis arsebobas, romlebic dafuZnebulia eqspertTa

komisiis daskvnaze an maT azrze da/an dafuZnebulia am dargSi cnobili

avtoritetuli warmomadgenlebis azrze. miuTiTebs xarisxiani kvlevebis ar

arsebobaze am sakiTxTan dakavSirebiT.

am mimarTulebiT muSaobis erT-erT Sedegs warmoadgens mocemuli

klinikuri rekomendacia. am dokumentSi asaxulia placentis winamdebareobisa da

winamdebare placentis mixorcebis Tanamedrove Sexedulebebi da aRwerilia

mkurnalobis ZiriTadi meTodebi.

Sesavali

placentis winamdebareobisa da masTan dakavSirebuli garTulebebi mniSvnelovan

ricxvs aRwevs 2-8, xolo perinataluri sikvdiloba oTxjer maRalia normalurad

mimdinare orsulobasTan SedarebiT. pacienti xSirad saWiroebs hospitalizacias.

sakeisro kveTis Semdeg placentis winamdebareobis gamo histereqtomiis sixSire

aRwevs 5.3%. 9-17

placentis winamdebareoba ewodeba mdgomareobas, rodesac placenta

mTlianad an nawilobvrivad mimagrebulia saSvilosnos qveda segmentSi. Tu is

srulad faravs yelis Sida pirs, am mdgomareobas ewodeba placentis sruli

winamdebareoba, xolo Tu ara - arasruli winamdebareoba.

tradiciuli klasifikacia dafuZnebulia imaze Tu ramdenadaa placenta miaxlovebuli

saSvilosnos yelis Sida pirs (dabali, kidiTi, nawilobrivi da sruli) da ganisazRvreba

ultrasonografiuli kvlevis SedegebiT. placentis winamdebareobis dros qalis

mkurnaloba damokidebulia klinikur da ultrasonografiul monacemebze.

skriningi da diagnozi

miuxedavad imisa, rom placentis winamdebareobis diagnostikaSi didi roli

eniWeba klinikur ganWvretas, am mdgomareobis umravlesobis saboloo

diagnostireba xdeba ultrasonografiuli kvlevis dros. im SemTxvevebSic ki, rodesac

ultrasonografiuli kvlevis monacemebi normaluria, yvela qalSi saSodan sisxldeniT

an winamdebare nawilis maRla dgomiT, aseve nayofis araswori mdebareobiT

unda gamoiricxos placentis winamdebareoba.

ultrasonografiuli kvleva placentis dabali mimagrebis skriningisa da placentis winamdebareobis diagnostikisaTvis

Catarda ramodenime prospeqtuli observaciuli kvleva transvaginaluri

ultrasonografiuli kvlevis Sesaxeb placentis winamdebareobis dros. gamokvlevis

dros arc erTxel ar ganviTarebula hemoragiuli garTulebebi, ramac daadastura

meTodis usafrTxoeba 18-22. arsebobs mxolod erTi, mcire rkk, romelSic

transabdominaluri ultrasonografia Sedarebulia transvaginalurTan placentis

winamdebareobis diagnostirebis mizniT, romelSic aseve dadasturda

transvaginaluri meTodis usafrTxoeba. 23

Tu meore trimestrSi saSvilosnos qveda segmenti ar aris formirebuli, mogvianebiT

placentis winamdebareobis Camoyalibebis skriningi aucileblad migviyvans cru

dadebiT Sedegamde transabdominaluri kvlevis Catarebisas 24, radganac yvela

qvemoT ganlagebuli placenta ar persistirebs. transvaginaluri kvleva aumjobesebs

vizualizacias. meore trimestrSi transabdominaluri ultrasonografiiT dadgenili

placentis dabali mimagrebis SemTxvevaTa 26-60% transvaginaluri kvleviT

diagnozi ar dasturdeba21,25,26, xolo mesame trimestrSi transabdominaluri kvleviT

diagnostirebuli placentis winamdebareobis 32 qalidan mxolod 12,5%-Si ar iyo

dadasturebuli transvaginaluri kvlevis dros.27 gamoavlinda, rom transvaginaluri

ultrasonografiis mgrZnobeloba placentis winamdebareobis diagnostirebaSi (II da

III trimestrebSi) Seadgens 87,5%, specifiuroba - 98,8%, dadebiTi prognozuli

Rirebuleba - 93,3%, uaryofiTi prognozuli Rirebuleba - 97,6%, cru uaryofiTi Sedegis

sixSire - 2,33%.

erT rkk-Si gamokvleuli iyo 38 qali, romlebSic gamovlinda transvaginaluri

ultrasonografiis upiratesoba transabdominalurTan SedarebiT, gansakuTrebiT

placentis mimagrebisas saSvilosnos ukana kedelze, aseve aRiniSna

skanirebisaTvis daxarjuli drois Semcireba28.

magnitur rezonansuli kvleva (mrk) gamoyenebuli iyo placentis

winamdebareobis dros im SemTxvevaSi, rodesac transabdominaluri

ultrasonografiuli kvlevis Sedgegebi aradamakmayofilebeli iyo.29 mrk Catareba

mizanSewonilia imis gamo, rom is ar saWiroebs Sardis buStis avsebas da misi

Catarebisas gamoricxulia operatoris Secdoma. misi gamoyeneba aseve

mizanSewonilia placentis ukana kedelze mimagrebisas30. mrk ar iyo Sedarebuli

transvaginalur ultrasonografiasTan, radganac ar iyo amis saWiroeba, garda im

SemTxvevebisa, rodesac mrk gamoyenebuli iyo kvleviTi miznebisaTvis.

placentis winamdebareobis dros transvaginaluri ultrasonografia aris usafrTxo meTodi da placentis lokalizaciis dadgenis TvalsazrisiT ufro zusti, vidre transabdominaluri ultrasonografia

Semdgomi transvaginaluri kvleva esaWiroebaT im qalebs, romelTac aReniSnebaT

placentis mimagreba saSvilosnos yelis SigniTa piris doneze (an faravs SigniTa

pirs) Semdegis gaTvaliswinebiT:

qalebi, romelTac aReniSnebaT sisxldena, gamokvleulebi unda iyon

individualuri gegmis mixedviT;

placentis asimptomuri arasruli winamdebareobis dros gamokvleva SeiZleba

gadaidos 36 kviramde;

B

im SemTxvevaSi, rodesac arsebobs eWvi placentis srul winamdebareobaze,

ultrabgeriTi kvleva unda Catardes 32 kviraze, imisTvis, rom daigegmos

Semdgomi meTvalyureobisa da mSobiarobis meTodi.

placentis migracia mimdinareobs meore da mesame trimestris dros 31-33, rasac

xels uwyobs saSvilosnos qveda segmentis Camoyalibeba, magram es ufro

iSviaTad xdeba, rodesac placenta ganlagebulia saSvilosnos ukana kedelze 34 an

qals gadatanili aqvs sakeisro kveTa 35.

placentis winamdebareobiT 714 qalis retrospeqtulma mimoxilvam gamoavlina,

rom 20-30 kviraze placentis kidiTi winamdebareobis SemTxvevaSic ki (rodesac

placentis kide uaxlovdeboda saSvilosnos yelis Sida pirs) placentis

winamdebareobis persistireba, romelic moiTxovda mSobiarobas bunebrivi gziT,

Seadgenda 11% im SemTxvevaSi Tu saSvilosnoze ar iyo nawiburi da 50%

gadatanili sakeisro kveTis Semdeg.36

sxva kvlevaSi, sadac monawileobda 55 qali placentis sruli an arasruli

winamdebareobiT, 18-23 kviraze, rac diagnostirebuli iyo transvaginaluri

sonografiiT, mSobiarobis momentisaTvis mxolod 5-s aReniSna placentis

winamdebareoba da yvela SemTxvevaSi placentis kide faravda yelis Sida pirs 15

milimetriT.37

miuxedavad imisa, rom placentis mniSvnelovani migracia naklebad savaraudoa

maSin, rodesac placenta nawilobriv faravs yelis Sida pirs (23 mm 11-14 kviraze,38

25 mm-ze metad 20-30 kviraze39 da 20 mm 26 kviraze 40), migracia mainc

SesaZlebelia 50% SemTxvevaSi Tu placentis sruli winamdebareoba dadgenilia 20

kviraze41.

am mizezebis gamo, mesame trimestrSi unda Catardes gamokvleva imisaTvis,

rom daigegmos Semdgomi meTvalyureobis gegma. im SemTxvevaSi, rodesac

placentis arasruli an kidiTi mimagreba diagnostirebulia meore trimestrSi,

diagnozis dasadastureblad ultrabgeriTi kvleva unda ganmeordes 36 kviraze.42 im

SemTxvevaSi, Tu arsebobs eWvi placentis srul winamdebareobaze, saWiroa

dawvrilebiTi gamokvleva da analizi Semdgomi taqtikis gansazRvrisaTvis. am

gegmaSi aseve unda Sediodes ganmeorebiTi ultrabgeriTi kvleva 32 kviraze. am

vadaze sruli placentis winamdebareobis diagnostireba miuTiTebs imaze, rom es

mdgomareoba SenarCundeba SemTxvevaTa 90%-Si

antenataluri meTvalyureobis programaSi CarTuli unda iyos transvaginaluri ultrasonografiis Catareba im SemTxvevebSi, B

rodesac orsulobis 20-24 kviraze transabdominaluri kvlevis dros gamovlindeba placentis dabali mimagreba

placentis sruli Sezrdis diagnostireba

qalebi placentis winamdebareobiT imyofebian maRali riskis jgufSi placentis

mWidro mimagrebisa da Cazrdis TvalsazrisiT im SemTxvevaSi, rodesac

winamdebare placenta ganlagebulia wina kedelze an anamnezSi aRiniSneba

gadatanili sakeisro kveTa43-46. es riski izrdeba gansakuTrebiT im SemTxvevaSi,

rodesac sakeisro kveTasa da Casaxvas Soris aRiniSneboda mcire drois intervali.47

antenataluri kvlevis dros SesaZlebelia am mdgomareobis diagnostireba rogorc

ultrasonografiuli kvlevisas,48,49 aseve mrk-sa da doplerografiuli kvleviT.

80 qalis prospeqtul kvlevaSi placentis winamdebareobiT transabdominaluri da

doplerografiuli gamoyenebiT placentis Cazrda mSobiarobis dros gamovlinda 17

SemTxvevaSi. doplerografiuli kvleviT placentis winamdebareobaze eWvi Setanili

iyo 16 SemTxvevaSi, saidanac dadasturda 14 SemTxveva, 2 cru dadebiTi SedegiT,

xolo 3 SemTxvevaSi placentis Cazrda ar iyo diagnostirebuli, ramac gamoavlina

mgrZnobeloba 82,4%, xolo specifiuroba 96,8%. dadebiTi da uaryofiTi prognozuli

Rirebuleba Seadgenda Sesabamisad 87,5% da 95,3%,-s.

winaswari Sedegebi cxadyofs, rom samganzomilebiani feradi dopleruli kvlevis

danergva SeiZleba damxmare meTodi iyos sxva teqnologiebTan erTad

antenataluri meTvalyureobis dros.50,51 retrospeqtul kvlevaSi magnitur rezonansuli

meTodi 13 qalSi Sedarebuli iyo transabdominaluri sonografia, rodesac placentis

Cazrda dadasturebuli iyo histologiuri kvleviT.52 9 qalidan mxolod 4-s daudasturda

swori diagnozi, rodesac ultrabgeriTi kvleviT gamokvleuli 13 qalidan mxolod 4-s

daudasurda swori diagnozi. mgrZnobeloba, romelic Seadgenda Sesabamisad

38% da 33%-s iyo Zalian mcire klinikuri efeqturobis dasadastureblad da aqedan

gamomdinare, feradi doplerografiuli kvleva aris yvelaze mizanSewonili

gamokvlevis meTodi manamde, sanam ar gaumjobesdeba magnitur rezonansuli

kvlevis xarisxi.

antenataluri meTvalyureobis dros qalebSi, romlebSicdiagnostirebulia placentis winamdebareoba da romlebic imyofebian placentis Cazrdis risk-jgufSi, unda Catardes doplerografiuli ultrasonografia. Tu es SeuZlebelia, aseTi qalebis meTvalyureoba unda gagrZeldes ise, rogorc placentis Cazrdis SemTxvevaSi, sanam ar moxdeba diagnozis dazusteba

B

Ted, 08.04.08,

mkurnaloba antenatalur periodSi

orsulebi placentis sruli winamdebareobiT moiTxoven did yuradRebas radganac

is mimdinareobs asimptomaturad. SesaZloa ganviTardes masiuri da sicocxlisaTvis

saSiSi sisxldena, romelic moiTxovs saswrafo Carevas. tradiciuli mkurnaloba

placentis sruli winamdebareobis dros gulisxmobda hospitalizacias mesame

trimestris bolos (30-32 kviridan) qalebSi, romlebsac anamnezSi ar aReniSnebodaT

sisxldena. arsebobs rigi observaciuli kvlevebisa, romlebic miznad isaxavda imis

garkvevas, Tu ra kategoriis qalebSi viTardeba sisxldena yvelaze xSirad.

gamovlinda, rom alfa-fetoproteinis donis momateba 15-20 kviris vadaze53,

placentis iseTi mdebareoba, rodesac is faravs yelis Sida pirs54,55, sqelia misi qveda

nawili da vlindeba turbulentoba mis qveda kideze56 ultrasonografiuli kvlevis dros,

yvelaze xSirad iyvnen dakavSirebuli mSobiarobamdel sisxlisdenasTan.

Catarda 3 rkk, romelSic mTlianad CarTuli iyo 114 qali placentis winamdebareobiT:

erT kvlevaSi Sedarebuli iyo saxlis pirobrbSi mkurnaloba samSobiaroSi saxlSi

mkurnalobasTan57; danarCen orSi gamokvleuli iyo saSvilosnos Yyelis serklaJis

efeqti58-60. kvlevaSi Sedarebuli iyo 26 qali, romelTac mkurnalobdnen saxlSi 27

qalTan, romlebic mkurnalobdnen stacionaris pirobebSi. erTaderT mniSvnelovan

gansxvavebas warmoadgenda saavadmyofoSi gatarebuli sawol-dReebis

raodenobis Semcireba. or sxva retrospeqtul mimoxilvaSi Seswavlili iyo im 86 qalis

gamosavali, romelTa mkurnaloba mimdinareobda mocdiTi taqtikiT saxlSi 90

qalTan SedarebiT, romlebsac mkurnalobdnen stacionarulad61,62 am kvlevebiT

gamovlinda, rom gansxvaveba jgufebs Soris mdgomareobda mxolod

hospitalizaciis dReebis raodenobasa da fasSi.

aseTi mcire kvlevis SedegebiT rTulia usafrTxoebis, Tanamedrove standartis an

sxva maCveneblebis Sesaxeb msjeloba. amitom placentis winamdebareoba

mesame trimestris bolos warmoadgens garkveul problemas, gansakuTrebiT

saqarTvelos pirobebSi, rodesac xangZlivi hospitalizacia pacientis did xarjebTan

aris dakavSirebuli. saerTaSoriso azri ufro liberaluria, magaliTad, avstraliisa da axli

zelandiis meanTa da ginekologTa koleji iZleva rekomendacias, rom is qalebi

placentis winamdebareobiT, romlebic arian maRali riski jgufSi sisxldenis

ganviTarebis TvalsazrisiT, orsulobis mesame trimestrSi unda imyofebodnen

saavadmyofosTan axlo manZilze.63

retrospeqtulma mimoxilvebma aCvenes, rom placentis winamdebareobis dros

gamosavali qalebisaTvis sxvadasxvagvaria da misi prognozireba antenataluri

movlenebis mixedviT yovelTvis ver xerxdeba64,65 magram im qalebSi, romelTac

placentis winamdebareobisas ganuviTardaT sisxldena, ufro 66,67 vlindeba

tendencia naadrevi mSobiarobisaken68-70.

orsulebi placentis winamdebareobiT, romlebsac anamnezSi aReniSnebaT sisxldenis epizodi, hospitalizirebulebi unda iyvnen gestaciis 34 kviraze. im pacientebSi, romlebsac aReniSnebaT placentis sruli winamdebareoba, magram arasodes ar hqoniaT sisxldena da ar aReniSnebaT simptomatika, unda Catardes saguldagulo konsultireba antenataluri meTvalyureobis dagegmvisaTvis. nebismieri mkurnaloba, romelic saxlis pirobebSi tardeba, unda iyos mWidrod dakavSirebuli stacionarTan informirebuli Tanxmobis safuZvelze da aseve qals gverdze unda hyavdes Tanmxlebi piri.

orsulebi , romlebic rCebian saxlis pirobebSi, darwmunebulebi unda iyon sakuTar usafrTxoebaSi da yovelTvis kompanionis daxmarebiT mzad unda iyvnen hospitalizaciisaTvis

yoveli orsuli qali, romelic rCeba saxlSi, unda flobdes informacias, rom nebismieri saxis sisxliani gamonadenis, tkivilis an saSvilosnos SekumSvis dros maT unda mimarTon stacionars.

mSobiarobis win orsuli da misi axloblebi unda gaecnon informacias SesaZlo garTulebebis, sisxldenis, sisxlis transfuziis, histereqtomiisa da ZiriTadi qirurgiuli Carevebis Sesaxeb

Catarda 2 kvleva cervikaluri serklaJis Sesaxeb71,72, romelic moicavda aseve

kohreinis mimoxilvas73. mxolod erT kvlevaSi gamovlinda serkliaJis potenciuri

sargeblianoba74 (mSobiaroba 34 kviramde da 2 kilogramamde wonis dabadebuli

bavSvebis ricxvis Semcireba).

C

orsulobis prolongirebisa da sisxldenis Semcirebis TvalsazrisiT cervikaluri serklaJis mxardasaWerad mtkicebulebebi ara sakmarisia, amitom ar SeiZleba misi rekomendireba klinikuri kvlevebis farglebs gareT.

placentis winamdebareobis dros sisxldenis ganviTareba gamowveulia

saSvilosnos qveda segmentis formirebiT, magram is SeiZleba aseve gamowveuli

iyos saSvilosnos SekumSviTac. am situaciebSi meanTa nawili irCevs e.w.

„agresiul konservatul mkurnalobas“, romelSic igulisxmeba tokolizi.75,76

C

es sakiTxi gamokvleulia rkk-Si, romelSic monawileobda 60 qali, romlebic

stacionarSi moTavsebuli iyvnen placentis winamdebareobisas ganviTarebuli

sisxldenis gamo 28-34 kviraze77. Catarda tokolizi 10 mg ritodrinis gamoyenebiT

intramuskularuli inieqciiT yovel 6 saaTSi erTxel 7 dRis ganmavlobaSi, rac

Sedarebuli iyo SemTxvevebTan, rodesac ar tardeboda aranairi mkurnaloba.

mkurnaloba dakavSirebuli iyo orsulobis prolongirebasTan (25,33 dRe+- 17,7 dRe,

14,47 dRe+-20,33 dResTan SedarebiT, p<0,05) da axalSobilis wonis zrdasTan

(2,27+-0,59kg, 1,95+-0,55 kg-Tan SedarebiT, p <0,05) ar gamovlenila gverdiTi

efeqtebi dedisa da nayofis mxriv da sisxldenis momatebuli riski.

SemTxvevaTa seriebis yvelaze didi raodenoba, romlebSic ganxiluli iyo placentis

winamdebareobis dros ganviTarebuli sisxldenis mkurnaloba tokoliziT mesame

trimestrSi 105 dan 76 qalSi, mocemulia retrospeqtul mimoxilvaSi65 da

gamoavlina, rom am mkurnalobis gamoyeneba ar aris dakavSirebuli avadobisa

da sikvdilianobis momatebasTan. amave dros, profilaqtikurad terbutalinis

gamoyeneba sisxldenis profilaqtikisaTvis ar aris dakavSirebuli aranair

sargeblianobasTan qalebSi placentis winamdebareobiT.78

vinaidan ar aris dadgenili Bbetamimetikebis optimaluri doza da Seyvanis rejimi

da misi gamoyeneba dakavSirebulia mniSnelovan gverdiT efeqtebTan,

saqarTvelos pirobebSi betamimetikebis gamoyeneba placentis

winamdebareobis dros ar aris naCvenebi

mSobiaroba

mSobiarobis gzis arCevis rekomendacia ultrasonografiuli kvlevis Sedegebze

dayrdnobiT rTulia imis gamo, rom am sakiTxTan dakavSirebuli kvlevebi aris

observaciuli da xSirad retrospeqtuli. Caatares transvaginaluri kvleva 127 qalSi

mesame trimestrSi, romelTaganac 52-s aReniSneboda placentis

winamdebareoba. 31 SemTxvevaSi aRiniSneboda placentis sruli

winamdebareoba, xolo 21 SemTxvevaSi – placentis nawilobrivi winmdebareobiT

saSualo manZili saSvilosnos SigniTa piris donidan placentis kidemde iyo

mniSvnelovnad gansxvavebuli im qalebSi, romelTac imSobiares sakeisro kveTis

gziT imaTgan gansvavebiT, romelTac imSobiares bunebrivi gziT. (2sm

saSvilosnos yelamde) (p=0,0004).

axlaxan Catarda prospeqtuli observaciuli kvleva, romelic moicavda 63 qals

placentis winamdebareobiT. kvlevaSi gamovlinda, rom im qalebSi, romlebSic

Catarda saSosmxrivi mSobiaroba, manZili placentis kidesa da saSvilosnos yelis

SigniTa pirs Soris iyo 2 sm placentis ganlagebisas wina kedelze da 3 sm placentis

ganlagebisas ukana kedelze79.

sxva retrospeqtul kvlevaSi, romelic moicavda 121 qals, 40 qalSi, romlebSic

manZili Seadgenda 0,1- 2,0sm-s CautardaT saSosmxrivi mSobiaroba, xolo 39

qalidan 22-s, romlebSic distancia Seadgenda 2 sm-s imSobiares saSosmxrivad80.

am kvlevaSi ar iyo gamaxvilebuli yuradReba imaze, Tu saSvilosnos romel

kedelze iyo ganlagebuli placenta.

gadawyvetileba mSobiarobis gzis Sesaxeb mxedvelobaSi unda iyos miRebuli

klinikuri faqtorebis gaTvaliswinebiT, maT Soris ultrasonografiuli kvlevis

Sedegebis gaTvaliswinebiT, gansakuTrebiT, rodesac nayofis Tavi mcire menjis

RruSia. ultrabgeriTi kvleva am SemTxvevaSi iZleva damatebiT informacias imis

Sesaxeb, Tu ra urTierTganlageba aqvs nayofis Tavsa da placentis kides.

placentis sisqe aseve axdens gavlenas mSobiarobis gzis arCevaze: rac ufro

sqelia winamdebare placentis kide, (1 sm meti) miT ufro metia mSobiarobis

albaToba sakeisro kveTis gziT (p=0,02)81.

B

mSobiarobis gza yvela SemTxvevaSi unda efuZnebodes klinikur Sefasebas da ultrasonografiuli kvlevebis monacemebs. Tu placentis kide saSvilosnos yelis Sida piris donidan daSorebulia 2 sm-ze naklebi manZiliT, sasurvelia sakeisro kveTis Catareba, gansakuTrebiT im dros, rodesac placenta ganlagebulia saSvilosnos ukana kedelze.

gadaudebeli operaciis drois gansazRvra damokidebulia individualur

SemTxvevaze, magram, rodesac aris amis SesaZlebloba, eleqtiuri sakeisro kveTa

unda gadaidos 38 kviris vadamde imisaTvis, rom Semcirdes neonataluri avadobis

sixSire.

CmSobiarobis dros sisxli unda iyos swrafad xelmisawvdomi. sisxlis saWiro raodenoba damokidebulia individualur SemTxvevasa da adgilobriv sisxlis bankze.

Cyvela orsuls, romelic saoperacioSi xvdeba placentis winamdebareobis gamo, operacia unda Cautaros gamocdilma qirurgma . operacias unda eswrebodes gamocdili anesTeziologi. axalgazrda eqimebi ar unda marTvadnen msgavs SemTxvevebs.

qirurgiuli Careva placenta accreta, increta and percreta dros

amerikis, axali zelandiisa da avstraliis meanTa da ginekologTa kolejma

SeamuSava Sexeduleba82 da miiRo saerTo gadawyvetileba83 imis Sesaxeb, rom

rodesac dagegmilia histereqtomia am paTologiis dros, unda iyos qalisagan

miRebuli informirebuli Tanxmoba amis Sesaxeb. amasTan erTad, mSobiaroba

unda Catardes multidisciplinaruli gundis mier iseT adgilze, sadac swrafad aris

xelmisawvdomi hemotransfuziisaTvis aucilebeli sisxlis produqtebi.

C

qalebi placentis winamdebareobiT, romlebsac anamnezSi aReniSnebaT sakeisro kveTa, imyofebian maRali riskis jgufSi placentis mWidro mimagrebis TvalsazrisiT da gamokvleulebi unda iyon antenatalur periodSi. rodesac Cndeba eWvi placenta accreta Taobaze, konsultanti meani da anesTeziologi valdebulni arian, dagegmon da marTon mSobiaroba. xelmisawvdomi unda iyos Tanamosaxele sisxli da saWiroebismebr marTvaSi CarTulebi unda iyon saWiro specialobis kolegebi.

Cplacenta accreta SemTxvevaSi, sisxldenis, hemotransfuziis da histereqtomiis SesaZlebloba ganxiluli unda iyos pacientTan konsultaciis dros.

masiuri sisxldena

placentas winamdebareobisas ganviTarebuli masiuri sisxldenis dros yvela

qirurgiuli intervencia Catarebuli unda iyos gamocdili qirurgis mier. damatebiTi

daxmarebis gamoZaxeba misasalmebelia.

uterotonuli saSualebebis gamoyeneba mizanSewonilia raTa gamoviwvioT

SedarebiT atoniuri saSvilosnos qveda segmentis SekumSva84. sxva damxmare

meTodebTan erTad bimanualuri kompresia, hidrostatiuli baloniT kaTeterizacia an

saSvilosnos tamponireba85, iseve rogorc aortis kompresia SesaZlebelia efeqturi

iyos drois mogebis TvalsazrisiT manam, sanam ar gamocxaddeba ufrosi meani.

damatebiT qirurgiul manevrebs miekuTvneba B-linCis nakeri,86 saSvilosnos87 an

TeZos SigniTa arteriis ligireba88 an histereqtomia. aRwerilia aseve arteriis

embolizaciis SemTxvevebic89.

(ixileT gaidlaini – msobiarobis Semdgomi sisxlisdena)

.

Cyovel samSobiaro blokSi unda iyos masiuri sameano sisxldenis marTvis protokoli. masiuri sisxldenebis mkurnaloba unda xdebodes am protokolis mixedviT.

CSemuSavebuli unda iyos gadaudebeli klinikuri scenarebi masiuri sameano sisxldenis dros da saswrafod xelmisawvdomi unda iyos sisxlis produqtebi.

auditis sakiTxebi

iyo Tu ara gamoyenebuli transvaginaluri ultrasonografia placentis

winamdebareobis diagnostikisaTvis?

iyo Tu ara gaTvaliswinebuli placentis Sezrdis arsebobis SesaZlebloba?

iyo Tu ara Sesabamisi antenataluri mkurnaloba da konsultireba im

qalebSi, romlebSic placentis winamdebareoba persistirebda mesame

trimestrSi.

mSobiarobis gza; Sesabamisi konsultireba da informirebuli Tanxmoba

anesTeziis SerCeva; Sesabamisi konsultireba da informirebuli

Tanxmoba

garTulebebis SesaZlebloba; Sesabamisi konsultireba da informirebuli

Tanxmoba

sakeisro kveTis dros operatorisa da anesTeziologiis done

mniSvnelovani sameno sisxldenis mkurnaloba klinikaSi miRebuli

protokolis mixedviT

Reference List

1. Appraisal of guideline for research and evaluation. The AGREE collaboration. file . 2001.

Ref Type: Electronic Citation

2. Gielchinsky Y, Rojansky N, Fasouliotis SJ, Ezra Y. Placenta accreta: summary of 10 years: a survey of 310 cases. Placenta 23: 210-4.

3. Ananth CV, Smulian JC, Vintzileos AM. The effect of placenta praevia on neonatal mortality: a population based study in the United States,1989 through 1997. Am J Obstet Gynecol 188: 1299-304.

4. Ananth CV, Smulian JC, Vintzileos AM. The association of placenta praevia with history of caesarean delivery and abortion: a meta-analysis. Am J Obstet Gynecol 177: 1071-8.

5. Frederiksen MC, Glassenberg R, Stika CS, Placenta p, Am JOG. 1999. 180.

6. Gilliam M, Rosenberg D, Davis F. The likelihood of placenta praevia with greater number of caesarean deliveries and higher parity. Obstet Gynecol 99: 967-80.

7. Lyndon-Rochell M, Victoria LH, Easterling TE, Martin DP. First birth caesarean and placental abruption or praevia at second birth. Obstet Gynecol 97: 765-9.

8. Faiz AS, Ananth CV. Etiology and risk factors for placenta praevia: an overview and meta-analysis of observational studies. J Matern Fetal Neonatal Med 13: 175-90.

9. Hall MH, Lewis G, Drife J. Haemorrhage. Why Mothers Die 2000–2002 The Sixth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom London: RCOG Press 2004; 86-93.

10. Iyasu S et al. The epidemiology of placenta praevia in the United States. Am J Obstet Gynecol 1424-9.

11. Rossiter CE. Maternal mortality. Br J Obstet Gynaecol 92(Suppl 5): 100-15.

12. McShane PM, Heyl PS, Epstein MF. Maternal and perinatal morbidity resulting from placenta praevia. Obstet Gynecol 65: 176-82.

13. Sheiner E et al. Placenta praevia: obstetric risk factors and pregnancy outcome. J Matern Fetal Med 10: 414-9.

14. Groom KM, Paterson-Brown S. Placenta praevia and placenta praevia accreta: a review of aetiology, diagnosis and management. Fetal Mat Med Review 12: 41-66.


16. Ananth CV, Smulian JC, Vintzileos AM. The effect of placenta praevia on neonatal mortality: a population based study in the United States,1989 through 1997. Am J Obstet Gynecol 188: 1299-304.

17. Salihu HM, Li Q, Alexander GR. Placenta praevia:neonatal death after live births in the United States. Am J Obstet Gynecol 188: 1305-9.

18. Oyelese KO, Holden D, Awadh A, Coates S, Campbell S. Placenta praevia: the case for transvaginal sonography. Cont Rev Obstet Gynecol 11: 257-61.

19. Smith RS et al. Transvaginal ultrasonography for all placentas that appear to be low-lying or over the internal cervical os. Ultrasound Obstet Gynecol 9: 22-4.

20. Leerentveld RA, Gilberts ECAM, Arnold MJC, Wladimiroff JW. Accuracy and safety of transvaginal sonographic placental localisation. Obstet Gynecol 76: 759-62.

21. Lauria MR et al. The use of second-trimester transvaginal sonography to predict placenta praevia. Ultrasound Obstet Gynecol 1996; 8: 337-40.

22. Oppemheimer LW et al. What is a low-lying placenta? Am J Obstet Gynecol 165: 1036-8.

23. Sherman SJ, Carlson DE, Platt LD. Mediaris AL.Transvaginal ultrasound: does it help in the diagnosis of placenta praevia? Ultrasound Obstet Gynecol 2: 256-60.

24. McClure N, Dornan JC. Early identification of placenta praevia. Br J Obstet Gynaecol 97: 959-61.

25. Smith RS et al. Transvaginal ultrasonography for all placentas that appear to be low-lying or over the internal cervical os. Ultrasound Obstet Gynecol 9: 22-4.

26. Leerentveld RA, Gilberts ECAM, Arnold MJC, Wladimiroff JW. Accuracy and safety of transvaginal sonographic placental localisation. Obstet Gynecol 76: 759-62.

27. Oyelese KO, Holden D, Awadh A, Coates S, Campbell S. Placenta praevia: the case for transvaginal sonography. Cont Rev Obstet Gynecol 11: 257-61.

28. Sherman SJ, Carlson DE, Platt LD. Mediaris AL.Transvaginal ultrasound: does it help in the diagnosis of placenta praevia? Ultrasound Obstet Gynecol 2: 256-60.

29. Powell MC, Buckley J, Price H, Worthington BS, Symonds EM. Magnetic resonance imaging and placenta praevia. Am J Obstet Gynecol 154: 656-9.

30. Powell MC, Buckley J, Price H, Worthington BS, Symonds EM. Magnetic resonance imaging and placenta praevia. Am J Obstet Gynecol 154: 656-9.

31. Becker RH, Vonk R, Mende BC, Ragosch V, Entezami M. The relevance of placental location at 20–23 weeks for prediction of placenta praevia at delivery: evaluation of 8650 cases. Ultrasound Obstet Gynecol 17: 496-501.

32. Dashe JS, McIntire DD, Ramus RM, Santos-Ramos R, Twickler DM. Persistence of placenta praevia according to gestational age at ultrasound detection. Obstet Gynecol 99: 692-7.

33. Mustafa SA et al. Transvaginal ultrasonography in predicting placenta praevia at delivery: a longitudinal study. Ultrasound Obstet Gynecol 20: 356-9.

34. Ghourab S, Al Jabari A. Placental migration and mode of delivery in placenta praevia: transvaginal sonographic assessment during the third trimester. Ann Saudi Med 20: 382-5.



37. Taipale P, Hiilesmaa V, Ylцsstalo P. Transvaginal ultrasonography at 18–23 weeks in predicting placenta praevia at delivery. Ultrasound Obstet Gynecol 12: 422-5.

38. Mustafa SA et al. Transvaginal ultrasonography in predicting placenta praevia at delivery: a longitudinal study. Ultrasound Obstet Gynecol 20: 356-9.

39. Becker RH, Vonk R, Mende BC, Ragosch V, Entezami M. The relevance of placental location at 20–23 weeks for prediction of placenta praevia at delivery: evaluation of 8650 cases. Ultrasound Obstet Gynecol 17: 496-501.

40. Oppenheimer L, Holmes P, Simpson N, Dabrowski A. Diagnosis of low-lying placenta: can migration in the third trimester predict outcome. Ultrasound Obstet Gynecol 18: 100–2-10102.


42. Routine Care for the Healthy Pregnant Woman. Antenatal Care.


44. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta praevia–placenta accreta. Am J Obstet Gynecol 177: 210-4.

45. Clark SL, Koonings PP, Phelan JP. Placenta praevia/accreta and prior caesarean section. Obstet Gynecol 66: 89-92.

46. Zaki ZMS, Bahar AM, Ali ME, Albar HAM, Gerias MA. Risk factors and morbidity in patients with placenta praevia accreta compared to placenta praevia non-accreta. Acta Obstet Gynecol Scand 77: 391-4.

47. Wax JR, Seiler A, Horowitz S, Ingardia CJ, Inter-pregnancy ia. Conn Med. 2000 659: 661.

48. Finberg HJ, Williams JW. Placenta accreta: prospective sonographic diagnosis in patients with placenta praevia and prior caesarean section. J Ultrasound Med 11: 333-43.

49. Chou MM, Ho ESC, Prenatal diagnosis of placenta praevia accreta with power amplitude ultrasonic angiography. - Am J Obstet Gynecol 177: 1523-5.

50. Chou MM, Tseng JJ, Ho ES, Hwang JI. Three dimensional color power Doppler imaging in the assessment of uteroplacental neovascularization in placenta praevia increta/percreta. Am J Obstet Gynecol 187: 515-6.

51. Chou MM, Tseng JJ, Ho ES. The application of threedimensional color power Doppler ultrasound in the depiction of abnormal uteroplacental angioarchitecture in placenta praevia percreta. Ultrasound Obstet Gynecol 19: 620-2.

52. Lam G, Kuller J, McMahon M. Use of magnetic resonance imaging and ultrasound in the antenatal diagnosis of placenta accreta. J Soc Gynecol Investigation 9: 37-40.

53. Butler EL, Dashe JS, Ramus RM. Association between maternal serum alpha-fetoprotein and adverse outcomes in pregnancies with placenta praevia. Obstet Gynecol 97: 35-8.

54. Bhide A, Prefumo F, Moore J, Hollis B, Thilaganathan B. Placenta edge to internal os distance in the late third trimester and mode of delivery in placenta praevia. BJOG 110: 860-4.

55. Dola CP, Garite TJ, Dowling DD. Friend D,Ahdoot D,Asrat T. Placenta praevia: does its type affect pregnancy outcome? Am J Perinatol 20: 353-60.

56. Saitoh M, Ishihara K, Sekiya T, Araki T. Anticipation of uterine bleeding in placenta praevia based on vaginal sonographic evaluation. Gynecol Obstet Invest 54: 37-42.

57. Wing DA, Paul RH, Millar LK. Management of the symptomatic placenta praevia: a randomised, controlled trial of inpatient versus outpatient expectant management. Am J Obstet Gynecol 175: 806-11.

58. Arias F. Cervical cerclage for the temporary treatment of patients with placenta praevia. Obstet Gynecol 71: 545-8.

59. Cobo E, Conde-Agudelo A, Delgado J, Canaval H, Congote A. Cervical cerclage: an alternative for the management of placenta praevia. Am J Obstet Gynecol 179: 122-5.

60. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Statement: Placenta accreta.

61. Droste S, Keil K. Expectant management of placenta praevia: cost benefit analysis of outpatient treatment. Am J Obstet Gynecol 170: 1254-7.

62. Mouer JR. Placenta praevia: antepartum conservative management, inpatient versus outpatient. Am J Obstet Gynecol 170: 1683-6.


64. Love CDB, Wallace EM. Pregnancies complicated by placenta praevia: what is appropriate management? Br J Obstet Gynaecol 103: 864-7.

65. Groom KM, Woo YL, Paterson-Brown S. Management of placenta praevia. J Obstet Gynaecol 20: 552-3.





70. Lam CS, Wong SF, Chow KM, Ho LC. Women with placenta praevia and antepartum haemorrhage have a worse outcome than those who do not bleed before delivery. J Obstet Gynaecol 20: 27-31.


72. Cobo E, Conde-Agudelo A, Delgado J, Canaval H, Congote A. Cervical cerclage: an alternative for the management of placenta praevia. Am J Obstet Gynecol 179: 122-5.

73. Neilson JP. Interventions for suspected placenta praevia. Cochrane Database Syst Rev 2.


75. Cotton DB, Read JA, Paul RH, Quilligan EJ. The conservative aggressive management of placenta praevia. Am J Obstet Gynecol 137: 687-95.

76. Silver R et al. Placenta praevia: aggressive expectant management. Am J Obstet Gynecol 150: 15-22.

77. Sharma A, Suri V, Gupta I. Tocolytic therapy in conservative management of symptomatic placenta praevia. Int J Gynecol Obstet 84: 109-13.

78. Magann EF, Johnson CA, Gookin KS, Roberts WE, Martin RW. Morrison JC. Placenta praevia: does uterine activity cause bleeding? Aust N Z J Obstet Gynaecol 33: 22-4.

79. Ghourab S, Al Jabari A. Placental migration and mode of delivery in placenta praevia: transvaginal sonographic assessment during the third trimester. Ann Saudi Med 20: 382-5.

80. Bhide A, Prefumo F, Moore J, Hollis B, Thilaganathan B. Placenta edge to internal os distance in the late third trimester and mode of delivery in placenta praevia. BJOG 110: 860-4.

81. Ghourab S. Third trimester transvaginal ultrasonography in placenta praevia: does the shape of the lower placental edge predict clinical outcome. Ultrasound Obstet Gynecol 18: 103-8.

82. American College of Obstetricians and Gynecologists.ACOG committee opinion. Placenta accreta. Int J Gynecol Obstet 77: 77-8.


84. Merrikay AO, Mariano JP. Controlling refractory atonic postpartum haemorrhage with Hemabate sterile solution. Am J Obstet Gynecol 162: 205-8.

85. Maier RC. Control of postpartum haemorrhage with uterine packing. Am J Obstet Gynecol 169: 317-23.

86. Lynch C, Coker A, Lawal AH, Abu I, Cowen MJ. The BLynch surgical technique for the control of massive postpartum haemorrhage: an alternative to hysterectomy? Five cases reported. Br J Obstet Gynaecol 104: 372-5.

87. O’Leary JA. Uterine artery ligation in the control of postcesarean hemorrhage. J Reprod Med 40: 189-93.

88. Clark SL, Phelan JP, Yeh SY, Bruce PR, Sr. Hypogastric artery ligation for obstetric haemorrhage. Obstet Gynecol 66: 353-6.

89. Hansch E et al. Pelvic arterial embolisation for control of obstetric haemorrhage: a five year experience. Am J Obstet Gynecol 180: 1454-60.

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