Cvilobis asakis

bavSvTa nevrologiis
safuZvlebi
 Cvilobis asakis
bavSvTa nevrologiis
safuZvlebi

kolin kenedi

sauThemptonis universitetis klinikuri

neiromecnierebis departamentis profesori,
sauThemptonis universitetis klinikis
sapatio konsultanti, bavSvTa nevrologi,
sauThemptoni, gaerTianebuli samefo

2012
Mac Keith Press
©2012 Mac Keith Press

redaqtori: Hillary M. Hart

aRmasrulebeli direqtori: Ann-Marie Halligan
gamomcemeli: Udoka Ohuonu
proeqtis menejeri: Mirjana Misina

yvela ufleba daculia. akrZalulia aRniSnuli wignis an misi

nawilis gavrceleba, Senaxva an nebismieri formiT (eleqtronu-
li, fotokopireba, Cawera an sxva) gamoyeneba saavtoro ufle-
bis mqone pirTan winaswari werilobiTi Tanxmobis gareSe.

yvela ufleba daculia. akrZalulia aRniSnuli wignis an misi

nawilis gavrceleba, Senaxva an nebismieri formiT (eleqtronu-
li, fotokopireba, Cawera an sxva) gamoyeneba gamomcemlo-
basTan winaswari werilobiTi Tanxmobis gareSe.

pirveli gamocema daibeWda 2012 wels Mac Keith Press-is mier

6 Market Road, London N7 9PW, UK

British Library Cataloguing –in-Publication data

A catalogue record for this book is available from British Library

ISBN: 978-1-908316-35-6

Printed by Latimer Trend & Company, Plymouth, UK

Mac Keith Press is supported by Scope
 mTargmneli da mTavari redaqtori
sofio baxtaZe

Tbilisis saxelmwifo samedicino universitetis

asocirebuli profesori, evropis pediatriuli
nevrologiuri sazogadoebis sabWos wevri,
saqarTvelos bavSvTa nevrologiis da qceviTi darRvevebis
asociaciis generaluri mdivani

redaqtorebi
nana gelaZe

Tbilisis saxelmwifo samedicino

universitetis bavSvTa nevrologiis
departamentis xelmZRvaneli, profesori,
saqarTvelos bavSvTa nevrologiis da qceviTi darRvevebis
asociaciis prezidenti

nana xaWapuriZe

Tbilisis saxelmwifo samedicino

universitetis asocirebuli profesori,

5
 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

saxelmZRvanelo

avtori - kolin kenedi, didi britaneTis sauThemptonis

universitetis profesori, bavSvTa nevrologi,
evropis pediatriuli nevrologiis sazogadoe-
bis prezidenti, didi britaneTis pediatriuli
nevrologiis asociaciis prezidenti

Tbilisis saxelmwifo samedicino universitetis saxe-

liT, msurs madloba movaxseno gamomcemlobas MacKeith Press
da piradad profesor kolin kenedis, romelTa keTili nebiT
mogveca winamdebare saxelmZRvanelos Targmnis da gamoce-
mis SesaZlebloba. es profesor kolin kenedis, evropis pe-
diatriuli nevrologiis sazogadoebis da Tbilisis sa-
xelmwifo samedicino universitetis bavSvTa nevrologiis
departamentis nayofieri TanamSromlobis gamovlineba da
Sedegia.
saxelmZRvaneloSi ganxilulia Cvilobis da bavSvTa
asakis nevrologiuri darRvevebis diagnostikis da mkurna-
lobis Tanamedrove aspeqtebi; aseve, masSi didi yuradReba
eTmoba pacientisa da mSoblebis uflebebis da bavSvebze
mzrunvelobis eTikur da samedicino sakiTxebs.
saxelmZRvanelo Rirebuli SenaZenia umaRlesi same-
dicino skolebis studentebisaTvis. vfiqrob, igi saintere-
so iqneba, aseve, neonatologebis, pediatrebis, reanimato-
logebis, genetikosebis, fsiqologebis, ojaxis eqimebis, so-
cialuri muSakebisa da am sferoTi dainteresebuli rezi-
dentebisaTvis.

profesori zurab vadaWkoria,

Tbilisis saxelmwifo samedicino universitetis
reqtori

6
 sarCevi
avtorTa jgufi 10
Sesavali 16
winasityvaoba 18

nawili 1: Cvilobis asakis bavSvTa

nevrologiis safuZvlebi

1 terminebi, definiciebi da koncefciebi 20

Colin Kennedy

2 interprofesiuli aqtivobebi: momxmareblis 28

da meurvis monawileobiT
Audrone Prasauskiene and Maryze Schoneveld van der Linde

3 klinikuri epidemiologia da mtkicebulebebze 42

dafuZnebuli medicina
Andrew L. Lux

4 bavSvis ganviTarebis xelSewyoba 64

Boika Rechel and Dainius Puras

5 nevrologiuri da neiroganviTarebis Sefaseba 79

Leena Haataja, Vittorio Belmonti and Giovanni Cioni

6 CvilTa nevrologiuri daavadebis prevencia 97

Jane Williams and Colin Kennedy

7 Tavis tvinis gamosaxviTi meTodebi 119

BrigitteVollmer

8 neirofiziologiuri gamokvlevebi 140

Bernhard Schmitt and Varsine Jaladyan

9 bioqimiuri da hematologiuri kvlevebi 161

Valerie Walker and Mary Morgan

7
 sarCevi

10 preparatebiT mkurnaloba: preparatebi,

vitaminebi da mineralebi 187
Imti Choonara and Peter Baxter

11 arafarmakologiuri mkurnaloba 200

Ilona Autti-Ramo

nawili 2: klinikuri praqtikis safuZvlebi

12 neonataluri encefalopaTia 206

Gian Paolo Chiaffoni and Daniele Trevisanuto

13 neonataluri gulyrebi, maT Soris

metaboluri epilefsiuri encefalopaTiebi 234
Barbara Plecko

14 mwvave arafebriluri encefalopaTia 255

Tiina Talvik, Fenella Kirkham, Tuuli Metsvaht and Inga Talvik

15 cxelebiT mimdinare mwvave nevrologiuri

daavadebebi: meningiti, encefaliti da infeqciuri
moculobiTi dazianebebi 289
Rachel Kneen and Charles Newton

16 postneonataluri epilefsiuri gulyrebi 317

Hans Hartmann and J.Helen Cross

17 araepilefsiuri paroqsizmuli darRvevebi CvilebSi 339

John B.P. Stephenson and Alla Nechay

18 makrocefalia, maT Soris hidrocefalia 252

Colin Kennedy

19 mikrocefalia, maT Soris Tandayolili infeqciebi 369

Richard Chin and Vlatka Mejaski-Bosnjak

20 dune Cvili 382

Ulrika Aden and Thomas Sejersen

8
 sarCevi

21 ganviTarebis adreuli dazianebani da

nevrologiuri darRvevebi dabadebis dros 390
Richard W.Newton, Ilona Autti-Ramo and Audrone Prasauskiene

22 cerebruli dambla 423

Florian Heinen and Peter Baxter

23 centraluri nevruli sistemis dazianebiT

gamowveuli moZraobiTi darRvevebi, romlebic
ar ganekuTvnebian cerebrul damblas 444
Peter Baxter and Florian Heinen

24 unarebis progresuli regresi 457

Meral Topcu, Dilek Yalnizoglu and Richard Newton

danarTi 1: fizikuri ganviTarebis cxrilebi 469

sagnobrivi saZiebeli 473

feradi sqemebi 479

9
 Tavi 5
nevrologiuri da neiroganviTarebis
Sefaseba
Leena Haataja, Vittorio Belmonti and Giovanni Cioni

mTavari gzavnilebi
-paTologiuri ganviTarebis diferencireba normaluri ganviTare-
bisgan
-standartuli protokolebis gamoyeneba nevrologiuri da neiro-
ganviTarebis SefasebisaTvis
-gaiTvaliswineT, rom ar arsebobs standartuli kriteriumebi:
sxvadasxva protokols aqvs sxvadasxva miznebi

ZiriTadi Secdomebi
- normaluri variantis araswori interpretacia paTologiurad
- eWvis mitana nevrologiur daavadebaze detaluri gamokvlevis ga-
reSe.
- mozrdilTa nevrologiidan miRebuli nevrologiuri gamokvlevis
adaptaciis SeuZlebloba Cvilebis gasinjvis dros
- diagnozis da intervenciis dagvianeba

rodis unda viyoT frTxilad

- moZraobebis paTologiuri raodenoba da xarisxi
- devianturi nevrologiuri monacemebi
- ganviTarebis etapebis dayovneba
- ganviTarebis unarebis dakargva nebismier asakSi
- mxedvelobis da smenis problemebi (warmodgenili rogorc
mSoblebis, ise eqimebis mier).

79
 nawili 1 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

normaluri nevrologiuri ganviTareba

normaluri nevrologiuri ganviTareba sakmaod individualuria.
ganviTarebadi Cvili avlens kompleqsuri moZraobebis sakmaod did
diapazons. axali gamRizianeblis mimarT Sinagani interesi Cvils
aZlevs saSualebas TandaTanobiT ganaviTaros moZraobiTi da qcevi-
Ti aqtebi mocemul garemoSi. arsebobs ganviTarebiTi unarebis
miRwevis didi biologiuri variaciebi. magaliTad, damoukideblad
siaruli nevrologiurad normalur CvilTan SeiZleba gamovlindes
drois nebismier SualedSi 8-dan 18 Tvemde. normaluri ganviTare-
bisTvis damaxasiaTebeli sxvadasxva unarebis Camoyalibeba garkveu-
li TanmimdevrobiT. Cveulebriv, arsebobs axali unarebis SeZenis
swrafi progresis periodebi, romelsac Caenacvleba ganviTarebis
stabiluri epizodebi. marTalia normaluri ganviTareba ar aris
uwyveti procesi, magram Cvili SedarebiT naklebad aqtiur periodSi
ar kargavs ukve SeZenil unarebs. normaluri ganviTareba dinamiuri
da mravalferovani procesia, romelsac esaWiroeba zusti Sefaseba.
Tumca, ganviTarebis formaluri skriningis meTodebi gvaZlevs saSu-
alebas movaxdinoT ganviTarebis problemebis mqone Cvilis adreuli
identifikacia, rac aumjobesebs misi mkurnalobis perspeqtivas.

tipiuri nevrologiuri ganviTarebis mTavari niSnebi

morfologiuri da funqciuri ganviTareba
es nawili ar aris gankuTvnili embriogenezisa da nervuli sistemis
struqturebis momwifebis etapebis Sesaxeb detaluri informaciis
mowodebisTvis, Tumca zogierTi sakiTxebi, romelic mniSvnelovania
gaSuqebuli iqneba klinikuri Sefasebis mizniT. centraluri nervu-
li sistemis (cns) ganviTarebis mTavari etapebi da Sesabamisi darRve-
vebi mocemulia cxrilSi 5.1.

mTavari gzavnili aris is, rom morfologiuri darRvevebi (mag, cns

malformaciebi) SeiZleba aRmocendes nebismier dros da nebismieri
mizeziT, rac gulisxmobs ara marto genetikur mizezs, aramed gare-
gan faqtorebsac. es faqtorebi kompleqsuria da umetes SemTxvevaSi
ucnobi, maSin rodesac aRniSnuli malformaciis TiToeuli paternis
(fenotipis) aRmocenebis dro SedarebiT ufro stabiluria. amgva-
rad, yvela tradiciuli klasifikaciis sqema umetesad emyareba fe-
notipur da sivrciT kriteriumebs (magaliTad, rogoricaa prolife-
racia, migracia, organizacia da a.S). cns-is malformaciebis Sefase-
bis aRniSnuli meTodi Canacvlda ufro integrirebuli meTodiT,

80
 Tavi 5 nevrologiuri da neiroganviTarebis Sefaseba

romelic moicavs etiologiur kriteriums (gansakuTrebiT geno-

tips). klinikuri TvalsazrisiT morfologiuri dazianeba, aRmoce-
nebis drois gaTvaliswinebiT, maT Soris Tavis tvinis perinataluri
da postnataluri dazianebebi, etiologiasTan SedarebiT, ufro
aadvilebs klasifikacias. aRniSnulis magaliTs warmoadgens ce-
rebruli damblis yvelaze Tanamedrove klasifikacia, romelic da-
zianebis dros ganixilavs fundamentur kriteriumad.

marTalia, dabadebis Semdeg Tavis tvinis umetes ubnebSi neironebi

ar agrZeleben proliferaciis process, Tumca dadgenilia, rom
momwifebis procesebi grZeldeba postnatalur periodSi sakmaod
xangrZlivad, mozrdilobis periodamdec ki. dazianebebis Semdeg Ta-
vis tvinis plastiuroba da reorganizacia unda iyos momwifebis yve-
laze sasurveli Sedegi. umwifar Tavis tvinis sxvadasxva ubnebs
aqvT gamtari gzebis impresiuli reorganizaciis unari. magaliTad,
metyvelebis ubnebs SeuZliaT dominanturi hemisferodan kontrala-
teralur hemisferoze gadanacvleba, maSin rodesac dazianebul pri-
velad motorul ubans SeuZlia reorganizacia dazianebis irgvliv
kontralateralurad, dazianebis aRmocenebis drois da masStabis
gaTvaliswinebiT.

buneba Tu wvrTna?
mkvlevarebi didi xania davoben ra aris wamyvani adamianis TvisebebSi
“buneba” (memkvidruli da konstituciuri faqtorebi), Tu qceviTi
profili (garemo, sazogadoeba). mkvlevarebis umetesoba amJamad mi-
iCnevs, rom orive maTgans Tanabari roli gaaCnia.

yvelaze mniSvnelovania imis dadgena, Tu riTi SeiZleba aixsnas

normaluri nevrologiuri ganviTarebis aseTi didi variacia. uka-
nasknel ramdenime dekadaSi Catarebulma gamosaxviTma da neirofizi-
ologiurma meTodebma saSualeba mogvca gagvego, rom Cvilis moto-
ruli aqtivoba aris kompleqsuri procesi da xorcieldeba afe-
rentuli informaciis, spinaluri da supraspinaluri makontrole-
beli qselebis urTierTkavSiris saSualebiT. Tanamedrove neironu-
li jgufis seleqciis Teoria (njsT) emyareba genetikur da garemos
determinantebs Soris sinergizms, romelic axdens zegavlenas Cvi-
lis ganviTarebaze. njsT Teoriis mixedviT, motoruli qcevebis re-
pertuaris Warbi variaciebi viTardeba fetaluri periodidan da

81
 nawili 1 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

grZeldeba mTeli Cvilobis periodi. erT konkretul etapze xdeba

funqciurad (ufro) efeqturi motoruli paternis SerCeva.

norma da misi variantebi

bavSvis ganviTareba Sedgeba msxvili motoruli, natifi motoruli,
metyvelebis, kognituri da socialur-qceviTi aspeqtebisgan. normis
variantebi sakmaod variabeluria. aqedan gamomdinare, ganviTarebis
nebismieri xarisxiT gamoxatuli paTologia saWiroebs xangrZliv
dakvirvebas. ganviTarebis mogvianebiTi Seferxeba an ukve arsebuli
ganviTarebis unarebis dakargva warmoadgens wiTel droSas, rac miu-
TiTebs ganviTarebis paTologiaze.

cxrili 5.1 centraluri nervuli sistemis ganviTarebis mTavari

etapebi da gestaciuri asakis piki ZiriTadi darRvevebis aRmoce-
nebisTvis (adaptirebulia Aicardi, 2009)

gestaciuri asaki cns-is ganviTarebis etapi darRveva, romelic Se-

2 kvira nervuli firfitis ganviTa-
reba
3-4 kvira dorsaluri induqcia/neu-
rulacia (nervuli mili da
jvaredini Camoyalibebu-
lia)
4-7 kvira dorsaluri induqcia/kau-
daluri nervuli milis
formacia
5-6 kvira ventraluri induqcia (wina
tvinis da saxis Camoyalibe-
ba; wina tvinis gayofa or
cerebrul buStukad, di-
encefalonis da optikuri
da ynosvis nervebis ele-
mentebis gaCena)
8-16 kvira neironuli da gliis proli-
feracia (ujrdebis proli-
ferirdebian ventrikulur
da subventrikulur zone-
bad; aRiniSneba nei-
roblastebis da gli-
oblastebis adreuli dife-
rencireba)
iZleba gamovlindes
enterogenuri kista an
fistula
blastopaTiebi (mag,
anencefalia, encefa-
loceleebi, raSis ku-
di, meningoceleebi)
diastematomielia, de-
ndi-uolkeris sindro-
mi, naTxemis hipoplazia
ventraluri induqciis
darRvevebi (holopro-
zencefalia, saxis medi-
aluri napralis
sindromi)
proliferaciis
darRvevbi (mikrocefa-
lia, megalencefalia)

82
 Tavi 5 nevrologiuri da neiroganviTarebis Sefaseba

12-20 kvira migracia (ZiriTadad neiro- migraciis darRvevebi

nebis radialuri migracia
qerqisken)
24 kvira organizacia (gadanacvleba,
qerquli neironebis ori-
entacia da Sreebad ganawi-
leba, sinaptogenezi, ujre-
debis daprogramebuli
sikvdili, gliuri prolife-
racia da diferencireba)
gestaciis 24 kvi- mielinizacia
ridan dabadebi-
dan 2 wlamde
(mag, lisencefalia-
qerqqveSa qsovilis he-
terotopia-paqigiriis
speqtri, kvanZovani he-
terotopia), korZiani
sxeulis agenezia
organizaciis darRve-
vebi (mag, polimikrogi-
ria, fokaluri qerqu-
li displazia)
dismielinizacia,
(gestaciis 24-36 kvira-
ze aRiniSneba Rrma
TeTri nivTierebis da-
zianeba; 36 kviraze:
qerquli da qerqqveSa
dazianeba)

msxvili motoruli unarebis ganviTarebis etapebi

msoflio jandacvis organizaciis zrdis Semswavleli multi-
centruli kvlevis (2006) farglebSi moxda 4-24 Tvemde 816 bavSvis mo-
nacemebis Segroveba eqvsi msxvili motoruli unaris (damouki-
deblad jdoma, fexebiT da xelebiT cocva, dgoma daxmarebiT, dgoma
damoukideblad da siaruli damoukideblad) ganadan, indoeTidan,
norvegiidan, omanidan da aSS-dan (aRniSnuli zrdis cxrilebi mowo-
debulia danarTSi 1, romlis gadmotvirTvac SesaZlebelia
http://www.who.int/childgrowth/standards/en/). am asakis ganviTarebis TiToe-
uli punqtis normaluri variantebi aRwerilia e.w “fanjris”
koncefciiT. es niSnavs drois intervals, romelic iTvleba normad
TiToeul SemTxvevaSi, rodesac bavSvi swavlobs specifiur moto-
rul unarebs.

83
 nawili 1 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

cxrili 5.2 motoruli unarebis ganviTarebis asakis zeda zRvari

Cvilobis periodSi

ganviTarebis maxasiaTebeli
asaki (TveebSi)

jdoma daxmarebis gareSe 9

xelebiT da muxlebiT cocva 14
dgoma daxmarebiT 11
siaruli daxmarebiT 14
dgoma damoukideblad 17
siaruli damoukideblad 18

sainteresoa is faqti, rom Cvilebis 4.3% arasodes xoxavs xelebiT da

muxlebiT, romelic aRwerilia bevr kvlevebSi da amgvarad, es moto-
ruli unari gamotovebuli SeiZleba iyos normaluro ganviTarebis
bavSvTan. Cvilebis 90%-Si motoruli unarebi yalibdeba fiqsirebu-
li TanmimdevrobiT. aqedan yvelaze xSiri Tanmimdevroba, romelic
aRiniSneba 42%-Si aris jdomis, cocvis, dgomis, daxmarebiT da daxma-
rebis gareSe siarulis unari. dagdenilia, rom motoruli unarebis
ganviTarebis mxriv gansxvaveba gogonebsa da biWebSi ar arsebobs. Tu
Cvili dRenaklia, maSin miCneulia, rom umjobesia Cvilis unarebi See-
daros Cvilis koregirebul asaks. motoruli unarebis ganviTarebis
zeda zRvari ZiriTadi eqvsi motoruli CvevisTvis mowodebulia
cxrilSi 5.2, xolo diapazoni naCvenebia cxrilSi 5.1. yvelaze martivi
Sefasebaa, rom Cvili unda dajdes damoukideblad 10 Tvis asa-
kisTvis, xolo siaruli unda daiwyos damoukideblad 18 Tvis asa-
kisTvis.

natifi moZraobebis ganviTarebis etapebi

natifi moZraobebis gamocalkeveba msxvili motoruli unarebisgan
sicocxlis pirvel wels sadavoa, radgan am ori unaris ganviTareba
mimdinareobs erTdroulad, magaliTad, pozis kontroli da damou-
kideblad jdoma warmoadgens xelis funqciebis ganviTarebis pre-
rekvizits. natifi moZraobebis Camoyalibebis zeda asakobrivi zRva-
ri warmodgenilia cxrilSi 5.3. yvelaze martivi formulirebaa, rom
Cvilma unda SeZlos saganze CaWideba 5 Tvis asakisTvis da gamoavli-
nos TiTebis natifi moZraobebi 10 Tvis asakisTvis.

84
 Tavi 5 nevrologiuri da neiroganviTarebis Sefaseba

metyveleba da socialuri unarebi

ganviTarebadi Cvili gamoscems sxvadasxva refleqsur bgerebs Sina-
gani moTxovnilebis gaTvaliswinebiT (mag, tirili, rodesac mSieria).
xmovani bgerebis gamocema iwyeba 2-dan 6 Tvemde asakSi, xolo RuRuni
(romelic moicavs Tanxmovnebs) 6-dan 10 Tvis asakSi. xmamaRla sicili
Cveulebriv iwyeba 6 Tvis asakSi. mimarTuli metyvelebis gageba Se-
saZlebelia eqspresiuli metyvelebis ganviTarebamde . Cvili igebs
sakuTar saxels 8 Tvis asakisTvis da iwyebs erTeuli sityvebis gage-
bas 8-dan 10 Tvis asakisTvis. Cveulebriv, normaluri smenis mqone Cvi-
li iwyebs sityvebis warmoTqmas 10-12 Tvis asakisTvis.

ganviTarebis saerTo wesia is, rom 8 TvisTvis Cvili iwyebs RuRuns da

reagirebs daZaxilze. 12 Tvis asakisTvis, normaluri ganviTarebis
mqone Cvili kargad igebs ramdenime sityvas. Tu arsebobs bgerebis
produqciis da/an metyvelebis aRqmis darRvevis eWvi, maSin yo-
velTvis mizanSewonilia smenis gamokvleva. Tu smena normaluria, ma-
Sin SeiZleba adgili hqondes metyvelebis specifiur darRvevas, au-
tisturi speqtris darRvevebs an adreuli ganviTarebis zogadi xasi-
aTis Senelebas.

normaluri ganviTarebis mqone Cvili iRimeba garegani gamRizia-

neblis sapasuxod 2 Tvis asakisTvis, xolo seleqtiuri socialuri
Rimili, magaliTad, dedis xmis sapasuxod, iwyeba 3 Tvis asakisTvis.
daaxloebiT 7 Tvis asakSi Cvils SeuZlia ganasxvavos ojaxis wevrebi
da ucxo adamianebi erTmaneTisgan. amave asakSi maT SeuZliaT
SfoTvis gamovlena ucxo adamianTan kontaqtis dros. 8-10 Tvis
asakSi Cvilebi cdiloben CaerTon interaqtiur TamaSSi. 12 Tvis asa-
kisTvis Cvils Seswevs unari iTamaSos micema-da —gamorTmevis TamaSe-
bi da xeli daaqnios damSvidobebis aRsaniSnavad.

Rimilis, rogorc socialuri pasuxis ararseboba warmoadgens wiTel

droSas, romelic saWiroebs Sefasebas. interaqtiuri TamaSis unaris
ararseboba da erToblivi aqtivobebis dabali done 12 Tvis asa-
kisTvis saWiroebs bavSvis fsiqosocialuri garemos detalur
Seswavlas, aseve aucilebelia samedicino diferenciuli diagnozis
gatareba metyvelebis specifiuri darRvevebiT gamowveuli socia-
luri unarebis ganviTarebis darRvevebTan.

85
 nawili 1 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

sqema 5.1 eqvsi ZiriTadi motoruli unaris ganviTarebis fanjara.

wyaro: msoflio jandacvis organizaciis multicentruli zrdis
Semswavleli jgufi: eqvsi mTavari msxvili motoruli unarebis
ganviTarebis fanjrebi. Acta Paediatrica Supplement, 2006, 450: 86-95. mo-
wodebulia John Wiley & Sons Inc nebarTviT.

cxrili 5.3 natifi motoruli unarebis ganviTarebis zeda zRvari

Cvilobis asakisTvis

motoruli unari asaki (TveebSi)

saganze wvdoma 4
CaWideba mTlianad zeda kiduriT 5
sagnis gadatana erTi xelidan me- 7
oreSi
natifi CaWideba 8-10

86
 Tavi 5 nevrologiuri da neiroganviTarebis Sefaseba

klinikuri nevrologiuri gamokvlevis mTavari sakiTxebi da

SesaZlo standartuli protokolebi
klinikuri nevrologiuri Sefaseba yovelTvis moicavs sam mTavar
aspeqts: istoriis Segrovebas, fizikalur gamokvlevas da nevrolo-
giur Sefasebas. istoriis Segrovebis Sesaxeb detaluri informacia
mowodebuli cxrilSi 5.4

fizikaluri gamokvleva moicavs zrdis paterns (ixileT zrdis cxri-

lebi danarTi 1, gansakuTrebiT qalas garSemowerilobis mateba dro-
Ta ganmavlobaSi zrdis cxrilis Sesabamisad z qulis an asakis gaTva-
liswinebiT centilebis mixedviT (ixileT Tavebi 18, 19, 21 da 24).

eqimma aucileblad unda gaiTvaliswinos Cvilis fizikuri da klini-

kuri mdgomareoba, gansakuTrebiT 1 wlamde asakSi. nevrologiuri Se-
fasebis optimaluri dro Zalian mniSvnelovania. tirilis da agzne-
bis dros miRebuli monacemebi SeiZleba ar iyos zusti. neonataluri
Sefasebis dros umjobesia pacientis Sefaseba moxdes kvebebs Soris
drois intervalis Sua mesamedSi, raTa ar moxdes zegavlena Cvilis
Zilis ciklze da movaswroT Sefaseba Semdegi sakvebis miRebamde,
vidre Cvili iqneba mSieri.

farTod aRiarebuli Dubowitz-is Skala emyareba Cvilis struqturi-

rebul Sefasebas. Dubowitz-is Skala moicavs 34 punqts, romelTagan
mTavari komponentebi warmodgenilia cxrilSi 5.5.

cxrili 5.4 istoriis Segriovebis ZiriTadi punqtebi

 orsulobis mimdinareoba da dabadeba

 ganviTarebis unarebis Camoyalibeba (mag, pirveli gaRimeba,
gverdze gadabruneba)
 uCveuli qceviTi paternebis Seswavla
 manamde arsebuli da amJamindeli janmrTelobis problemebi
 manamde arsebuli da amJamindeli preparatebi
 mSoblebis mier warmodgenili Civilebi
 ojaxis socialuri mdgomareoba
 nevrologiuri darRvevebis ojaxuri istoria

87
 nawili 1 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

cxrili 5.5 axalSobilis Sefasebis ZiriTadi punqtebi

 orientacia da qceva
 tonusi rogorc zurgze, ise mucelze wolis dros
 neonataluri refleqsebi: myes-ZvalTa refleqsebi, wovis, xe-
lisgulis/plantaruli taceba, moros refleqsi
 moZraobebi: xarisxi da raodenoba
 paTologiuri niSnebi: xelis/fexis paTologiuri poza, Warbi tre-
mori, startli

cxrili 5.6 klinikuri niSnebi, romlebic miuTiTeben centraluri

nervuli sistemis dazianebaze

 cnobierebis Secvlili done

 gulyrebi
 tonusis cvlilebebi
 paTologiuri moZraobebi
 paTologiuri smeniTi an mxedvelobiTi reaqciebi
 wovis/ylapvis problemebi
 xelebis da fexebis paTologiuri poza

es meTodi iZleva saSualebas Sefasdes axalSobili sicocxlis

pirvel dReebSi. igive meTodis gamoyeneba SesaZlebelia dRe-
naklebSic. amgvarad, dRenakl axalSobilebSi droulebTan Sedare-
biT vlindeba momxrelTa susti tonusi da Tavis susti daWera. garda
amisa, dRenakl axalSobilebSi agzneba SedarebiT ufro advilad xde-
ba (gacxovelebuli myes-ZvalTa refleqsebi, startli, tremori) da
aqvT naklebad momwifebuli mxedvelobiTi qcevis unari droul
axalSobilebTan SedarebiT. mniSvnelovania dRenakli axalSobilebis
Sefasebis normaluri maCveneblebis codna (ixileT Cioni da Mercuri,
2007; Dubowitz et al, 1999).

Dubowitz- is Sedegad miRebuli izolirebuli paTologiuri maCve-

neblebi klinikurad naklebad Rirebulia, Tumca miuTiTebs Semdgo-

88
 Tavi 5 nevrologiuri da neiroganviTarebis Sefaseba

mi Sefasebis aucileblobaze. paTologiuri niSnebi, romelic Cveu-

lebriv moiTxovs Semdgom dakvirvebas mocemulia cxrilSi 5.6.

Hammersmith-is CvilTa nevrologiuri gamokvleva (HINE) warmoadgens

Cvilis struqturirebuli Sefasebis yvelaze karg magaliTs. HINE
emyareba igive meTodologiur princips, rasac Dubowitz-is neonata-
luri Sefasebis Skala. igi Seiqmna neonataluri periodidan 24
Tvemde asakis bavSvis SefasebisaTvis. gamokvleva moicavs 26 punqts,
romlis mixedviTac fasdeba poza, aqtiuri da pasiuri tonusi, krani-
uli nervebis, moZraobebi, refleqsebi da dacviTi reaqciebi (cxrili
5.7). gamokvlevis standarti Seiqmna 12-dan 18 Tvemde asakis dabali
riskis mqone Cvilebis monacemebis safuZvelze. Cvilis Sefaseba Se-
saZlebelia dRenakli Cvilebis koreqciuli asakis 6 TvisTvis, xolo
nevrologiuri maCveneblebi koreqciuli asakis 9 TvisTvis. am gziT
SesaZlebelia 2 wlis asakisTvis mosalodneli motoruli funciebis
prediqcia.

cxrilSi 5.7-Si mowodebuli monacemebis garda, sasurvelia Cvilis

sistematuri Sefaseba, miT umetes, Tu arsebobs eWvi nevrologiuri
paTologiebis, smenis, mxedvelobis, zrdis da fizikaluri paTolo-
giebis arsebobaze, romlebic kavSirSi arian nevrologiur daavade-
bebTan (ZiriTadad aqsialuri, proqsimaluri da distaluri kunTTa
masis, tonusis da Zalis darRvevebTan) (ixileT aseve Tavi 20).

cxrili 5.7 Hammersmith-is Cvilis Sefasebis punqtebi

 kraniuli nervebis funqciis Sefaseba: saxis gamometyveleba, Tva-

lebis Sefaseba, smenis Sefaseba, mxedvelobiTi reaqciebi, wo-
va/ylapva
 poza: Tavis da sxeulis, xelebis, fexebis poza jdomis da dgomis
dros,
 spontanuri moZraobebi: raodenoba da xarisxi
 tonusi: Sarfis niSani, mxrebis pasiuri aweva, pronacia/supinacia,
ganzidva, muxlis kuTxe, koWis dorsifleqsia
 refleqsebi da reaqciebi: myes-ZvalTa refleqsebi; zeda kidure-
bis dacviTi reaqciebi; xelis ganzidva Tavis qvemoT daxris dros
(wina paraSuti)

89
 nawili 1 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

sicocxlis pirvel wels nevrologiuri Sefasebis damatebi-

Ti meTodebi
Sesavali
1980 wels heinc prextlma SeimuSava axalSobilis Sefasebis ZiriTadi
moTxovnilebebi. Sefaseba unda iyos arainvaziuri, swrafi da varia-
ciebisadmi sensitiuri. spontanuri moZraobebis Sefaseba da katego-
riebad dayofa sicocxlis pirvel Tves aadvilebs ramdenime moto-
ruli normaluri da paTologiuri paternis identifikacias. egreT
wodebuli zogadi moZraobebi (zm) ewodeba mimdinare globalur
moZraobebs, romelic moicavs sxeulis yvela nawils. am tipis moZra-
obebis aRmoCenam misca biZgi prextls SeemuSavebina meTodi, ro-
melsac ewodeba dRenakli da drouli Cvilebis, aseve mcire asakis
Cvilebis zogadi moZraobebis xarisxobrivi Sefasebis prextlis me-
Todi (Einspieler et al, 2005).

zm Sefaseba: meTodologia da miznebi

marTalia zm Sefaseba emyareba globalur da xarisxobriv maxasia-
Teblebs, igi warmoadgens cerebruli damblis, natifi nevrologiu-
ri, retis sindromis, kognituri da autisturi speqtris prediqciiis
yvelaze sarwmuno meTods.

cxrili 5.8 zogadi moZraobebis normaluri paternebis mimdinare-

obis xangrZlivoba

paterni asaki (kvireebi post- aRweriloba

menstrualuri asaki)
xoxviTi diapazoni: 9-49 sxvadasxva amplitudis, neli an
moZrao- piki: 40 (drouli) saSualo siCqaris, tipiurad ki-
bebi duris elifsoiduri traeqtori-
is sagitalur sibrtyesTan axlos,
Sereuli rotaciul moZrao-
bebTan
talRi- diapazoni: 46-64 ufro mcire, vidre xoxviTi
seburi piki: 52 moZraobebi, saSualo siCqaris
moZrao- sxvadasxva mimarTulebis mqone,
bebi migrirebs sxeulis yvela nawilSi.
grZldeba xangrZlivad RviZilis
dros, mcirdeba tirilis da yu-
radRebis fokusirebis dros

90
 Tavi 5 nevrologiuri da neiroganviTarebis Sefaseba

normaluri zm-ebi moicavs mTel sxeuls xelis, fexis, kisris da

torsis moZraobebiT. maTi intensivoba, Zala da siCqare izrdeba da
mcirdeba da aqvT TandaTanobiTi dasawyisi da dasasruli. kidurebis
RerZis garSemo rotacia da moZraobebis mimarTulebis mciredi
Secvla xdis am moZraobebs plastiurs da qmnis kompleqsurobis da
variabelobis STabeWdilebas. zm-bebi Cndeba postmenstrualuri asa-
kis 9-12 kviraze da grZeldeba dabadebis Semdeg maTi formis mniSvne-
lovani cvlilebebis gareSe dabadebis asakis miuxedavad. normaluri
zm-bebis paternebis tipiuri mimdinareoba mocemulia cxrilSi 5.8.

cerebruli darRvevebis mqone Cvilis zm-ebs ar aqvT kompleqsuroba,

plastiuroba da/an variabeloba. paTologiuri zm-ebis paternebi
iyofa or jgufad imisda mixedviT Tu romel moZraobebs vamCnevT:
xoxviT Tu talRiseburs (cxrili 5.9). talRiseburi moZraobebis pe-
riodSi, sxvdasxva motoruli paternebi TandaTan Cndeba da Seereva
zm-ebs. Sedegad viTardeba egreT wodebuli asocirebuli motoruli
repertuari, romlis mravalferovneba da asakTan Sesabamisoba
mniSvnelovnad gansazRvravs mogvianebiT motorul koordinacias.

moZraobis xarisxis “globaluri”mxedvelobiTi aRqma (Gestalt

perception) warmoadgens mZlavr da sarwmuno instruments, Tumca is sa-
Wiroebs specifiur treinings am sferoSi. standartizebuli Sefase-
bis detaluri aRweriloba mocemulia Einspieler at al- is mier (2005).
aRsaniSnavia, rom standartuli zm Sefaseba emyareba video Canawers,
Tumca didi roli eniWeba eqimis Sefasebas da gamocdilebas.

cxrili 5.9 zogadi moZraobebis ZiriTadi darRvevebi

paterni aRweriloba
(a) xoxviTi moZraobebis (xm) periodi
Raribi repertuari (Rr) monotonuri Tanmimdevroba,
moZraobis mxolod ramdenime
komponenti, ganmeorebiTi da arc
iseTi kompleqsuri, rogorc
normaluri xoxviTi moZraobebis
dros. plastiuroba SeiZleba ase-
ve Semcirdes (Cveulebriv ufro
Senaxulia, vidre kompleqsuroba
da mravalferovneba).

91
 nawili 1 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

kramp-sinqronizebuli (ks) kompleqsuroba, plastiuroba da

moZraoba
qaoturi moZraobebi (qm)
(b) talRiseburi moZraobebis (tm) periodi
tm-bebis ararseboba
paTologiuri tm-bebi
mravalferovneba ar aris; yvela
kiduris da sxeulis kunTebis Se-
kumSva da moduneba xdeba sponta-
nurad.
didi amplitudis, xSiri krTomi-
Ti da qaoturi tipis moZraobebi
plastiurobis gareSe. iSviaTad
gardaiqmneba krampebad.
tm-bebi ar aRiniSneba mTeli peri-
odis ganmavlobaSi
talRiseburi moZraobebis
msgavsi moZraobebi, Tumca ampli-
tuda, saSualo siCqare da krTo-
miTi moZraobebis intensivoba mo-
matebulia

zm-ebis Sefasebis diagnostikuri da prognozuli sarwmuno-

oba
marTalia arsebobs ramdenime ganviTarebiTi darRveva, romelic da-
kavSirebulia zm-bebis paTologiasTan, zm-ebis Sefasebis yvelaze
sarwmuno markerebi emyareba cerebruli damblis prediqcias. am
markerebidan aRsaniSnavia (1) kramp-sinqronizebuli paterni (ks)
xoxviTi moZraobebis periodSi da (2) talRiseburi moZraobis ararse-
bobis paterni. cerebruli damblis diagnozis dros gaxangrZlivebu-
li kramp-sinqronuli paterni arc Tu ise xSiria da aqvs 100% speci-
fiuroba, maSin rodesac talRiseburi moZraobis ararsebobis pa-
terns aqvs rogorc maRali sensitivoba, ise maRali specifiuroba.
sxva paTologiuri paternebi naklebad Rirebulia, radgan ar iwveven
mZime nevrologiur gamosavals. unilateraluri cerebruli
damblis dros, distaluri moZraobebis damatebiTi Sefaseba gvexma-
reba dazianebis mxaris dadgenaSi.

neiroganviTarebis struqturirebuli Skalebi

neiroganviTarebis struqturirebuli Skalebi warmoadgens xelmi-
sawvdomi Skalebis farTo speqtrs. Sefasebis mizania specifiuri Ska-
lis SerCeva. nevrologiuri Sefasebis instrumentuli meTodebisgan

92
 Tavi 5 nevrologiuri da neiroganviTarebis Sefaseba

gansxvavebiT, neiroganviTarebiTi Skalebis mizans ar warmoadgens

mkveTri da saboloo diagnozis Camoyalibeba (mag, cerebruli dambla
an qceviTi darRvevebi), aramed misi mizania ganviTarebis mocemul
etapze Cvilis funqcionirebis Sefaseba. Skalebis umetesoba
mrvalfunqciuria da erTkomponentiani Skalebisgan gansxvavebiT,
uzrunvelyofs ganviTarebis bevri aspeqtis Sefasebas. erTkompo-
nentiani Skalebi iZleva specifiurad motoruli, an kognituri an
metyvelebiTi funqciebis Sefasebis saSualebas. yvela struqturi-
rebuli Skala unda iqnas gamoyenebuli mxolod gamocdili eqimis mi-
er. isini nevrologiur SefasebasTan SedarebiT saWiroeben ufro
met dros. struqturirebul Skalebs aqvT gacilebiT meti klinikuri
Rirebuleba maRali riskis mqone Cvilebis Sefasebisas, romelTac
aqvT ganviTarebis erTi an ramdenime unaris, gansakuTrebiT kognitu-
ri, mxedvelobiTi, motoruli unarebis daqviTeba. aRniSnuli unare-
bis daqveiTeba Cvilobis da saskolo asakis bavSvebSi organul nevro-
logiur daavadebebTan SedarebiT gacilebiT ufro xSirad gvxvdeba.
ufro metic, neiroganviTarebiTi Sefaseba gvexmareba intervenciu-
li protokolebis dagegmvasa da monitoringSi, aseve am protokole-
bis individualur SerCevaSi TiToeul konkretul CvilTan imisda mi-
xedviT, Tu romeli funqciuri sferos gaumjobesebis miRweva aris
prioritetuli.

standartuli testebis erT-erTi mniSvnelovani maxasiaTebelia

standartuli qulebis danergva. Tumca testebis standartizacia ar
warmoadgens misi sarwmunoobis garantias. skriningis meTodebi
ufro naklebad sarwmunoa, vidre detaluri Skalebi. TiToeuli Ska-
lis SerCevisas unda gaviTvaliswinoT sxva parametrebic, rogoricaa
xelmisawvdomoba, dadasturebuli sarwmunooba daavadebebis speci-
fiuri jgufebisTvis an risk faqtorebi (mag, dRenakli Cvilebi,
mxedvelobiTi da smeniTi defeqtebi) an piradi gamocdileba. yvelaze
mniSvnelovania imis gaTvaliswineba, SeiZleba Tu ara aRniSnuli Ska-
lebis gamoyeneba mocemuli populaciisTvis (mag, arainglisurenova-
ni populacia). dabadebidan 2 wlamde Cvilebis ganviTarebis Sefase-
bis standartuli Skalebi mowodebulia cxrilSi 5.10.

praqtikuli daskvnebi
Tanamedrove kvlevis meTodebi, rogoricaa genetikuri testebi,
eleqtrofiziologiuri meTodebi (eeg, gamowveuli potencialebi)
da neirogamosaxva ver Caanacvlebs klinikur nevrologiur Sefase-

93
 nawili 1 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

bas diagnozis, mkurnalobis da prognozis gansazRvris dros. eqimma

unda SeZlos ganasxvavos “normaluri” an ufro zustad, “tipiuri”
ganviTareba ganviTarebis biologiuri variaciebisa da paTologiuri
ganviTarebisgan.

detaluri da standratuli protokolebis gamoyeneba yovelTvis mi-

zanSewonilia. unikaluri standartuli kriteriumi ar arsebobs,
amitom eqimi unda flobdes informacias Sefasebis meTodis upirate-
sobis da naklis Sesaxeb. spontanuri da detaluri msxvili da natifi
motoruli unarebi, aRqma, socialuri da yuradRebis funqciebi au-
cileblad unda iyos Setanili Sefasebis gegmaSi. detaluri nevro-
logiuri Sefaseba ar aris izolirebuli procesi, is kompleqsuri me-
Todia, romelic gvaZlevs informacias ganviTarebis traeqtoriis
Sesaxeb. amgvarad, SesaZlebeli xdeba ganisazRvros ganviTarebis di-
namika misi pozitiuri mimarTulebiT an piriqiT, dadgindes ganviTa-
rebis statikuri, gauaresebuli an progresuli mimdinareoba. Sede-
gad, SesaZlebeli gaxdeba gamomwvevi mizezis dadgena da Sesabamisi
mkurnalobis meTodis SerCeva.

cxrili 5. 10. dabadebidan 2 wlamde asakis Cvilebis ganviTarebis

Sefasebis standartizebuli Skalebi (adaptirebulia Johnson da
Marlow-gan, Cioni da Mercuri, 2007).

saxelwode- asakobrivi xangrZli- Sefasebis sfero

ba diapazoni voba
Cvilis 1-42 Tveebi 25-60 wuTi mentaluri ganviTareba (MDI),
ganviTare- motoruli ganviTareba (PDI),
bis Bayles-is qcevis Sefasebis Skala (BRS)
Skalebi, me-2
gamocema
(BSID-II)
Cvilis da 1-42 Tveebi 30-90 wuTi kognituri, metyvelebis, mo-
adreuli toruli, socialur-emociu-
asakis ri (mSoblebis informaciiT),
bavSvis adaptaciur qceviTi (mSoble-
ganviTare- bis informaciiT)
bis Bayles-is
Skalebi, me-3

94
 Tavi 5 nevrologiuri da neiroganviTarebis Sefaseba

gamocema
(Bayley-III)
Griffiths-is dabadebi- 35-60 wuTi lokomotoruli, personolo-
mentaluri dan 23 giur-socialuri, smeniTi da
ganviTare- Tvemde metyvelebis, TvaliT-xelTan
bis Skalebi koordinaciis unari
(Griffiths-is
Skala: 0-2)
adreuli dabadebi- 15-30 wuTi msxvili motorika, natifi mo-
daswavlis dan 5 wlis 8 (asakis mi- torika, mxedvelobiTi aRqma,
Mullen-is Ska- Tvis asa- xedviT) receptiuli metyveleba,
la (MSEL) kamde eqspresiuli metyveleba
Battelle-is dabadebi- 1-2 saaTi personologiur-socialuri,
ganviTare- dan 8 adaptaciuri, motoruli, ko-
bis batarea II wlamde munikaciuri, kognituri
(BDI-II)
Merrill-Palmer- 1 Tvidan 6 30-40 wuTi kognituri, natifi motoru-
is Skala (M- wlis 6 Tvis li, receptiuli metyeveleba,
P-R) asakSi mexsiereba, mxedvelobiT-mo-
toruli, aRqmis siCqaris,
eqspresiuli metyvelebis,
msxvili motoruli unarebis,
socialur-emociuri,
TviTmomsaxurebis/adaptaci-
is unari
Cvilis mo- dabadebi- 20-30 wuTi msxvili motoruli unarebi
toruli Se- dan 18 (fasdeba oTx pozaSi)
fasebis Tvemde
Alberta-s Ska-
la (AIMS)
Peabody-s dabadebi- 45-60 wuTi msxvili da natifi motoruli
ganviTare- dan 5 wlis unarebi
bis motoru- 11 Tvemde
li Skalebi,
me-2 gamoce-
ma (PDMS-2)

95
 nawili 1 Cvilobis asakis bavSvTa nevrologiis safuZvlebi

gamoyenebuli literatura
Aicardi J. Diseases of the nervous system in childhood, 3rd ed. London, Mac keith
press, 2009
Cioni G, Mercuri E. Neurological assessment in the first two years of life. Clinics in
developmental medicine 176. London, Mac Keith Press, 2007.
Dubowitz LMS, Dubowitz V, Mercuri E. The neurological assessment of the preterm
and fullterm newborn infant. Clinics in developmental meidicine 148,
2nd ed. London, Mac Keith Press, 1999.
Einspieler C eta l. Prechtl’s method on the qualitative assessment of general
movements in preterm, term and young infants. Clinics in
developmental medicine 167. London, Mac Keith Press, 2005.
WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards.
Acta Paediatrica Supplement, 2006, 450.

resursebi
Heinemann KR, Hadders-Algra M. Evaluation of neuromotor function in infancy. A
systematic review of available methods. Journal of Developmental and
Behavioral Pediatrics, 2008, 29 (4): 315-323.
WHO. The WHO Child G

96
 Tavi 12
neonataluri encefalopaTia
Gian Paolo Chiaffoni and Daniele Trevisanuto

mTavari gzavnilebi
 dadgenilia, rom yovelwliurad 81400 axalSobilis sikvdili mSo-
biarobis dros ganviTarebuli mizezebiTaa gamowveuli. maTi
umravlesoba (99%) gxvdeba saSualo-Semosavlis mqone qveynebSi
 antenataluri mzrunvelobis, profesionali eqimebis da aRWurvi-
lobis arseboba mkveTrad amcirebs mkvdradSobadobas da aumjobe-
sebs perinatalur gamosavals
 asfiqsiuri axalSobilis marTvis qvakuTxeds warmoadgens
efeqturi neonataluri reanimacia.
 mwvave encefalopaTiis dros umTavresia axalSobilis klinikuri
Sefaseba, yoveldRiuri samedicino mzrunveloba da axalSobilis
dakvirveba dinamikaSi.
 asfiqsiur axalSobilebSi saSualo xarisxis gaxangrZlivebuli hi-
poTermia amcirebs sikvdilianobis risks da zrdis normaluri ga-
mosavlis albaTobas.
 miuxedavad imisa, rom perinataluri asfiqsia iTvleba neonatalu-
ri encefalopaTiis mTavar mizezad, aucilebelia sxva gamomwvevi
faqtorebis gaTvaliswineba.

ZiriTadi Secdomebi
 apgaris dabali qula, xSirad SecdomiT interpretirdeba Tavis
tvinis perinataluri dazianebis maCveneblad

206
 Tavi 12 neonataluri encefalopaTia

 klinikuri Sefaseba ar aris standartizebuli da miiCneva rTul

procesad
 nerofiziologiuri/neirogamosaxviTi kvlevebi ganixileba,ro-
gorc meTodebi, romelTa saSualebiTac SesaZlebelia Tavis tvi-
nis dazianebis aRmoCena mxolod neonatalur periodSi.
 asfiqsiuri axalSobilis hiperoqsigenaciazogjer arasworad mi-
iCneva, rogorc cerebruli proteqciis saukeTeso gza.
 cnobilia, rom bevri preparatiT mkurnaloba ,,icavs’’ Tavis tvins
postasfiqsiuri dazianebisgan.

rodis unda viyoT frTxilad

 rodesac droul axalSobils ar SeuZlia daiwyos an SeinarCunos
damoukidebeli sunTqva.
 rodesac droul axalSobils aReniSneba aqtivobis daqveiTeba,
gulyrebi da apnoe
 rodesac axalSobils pirveli kviris Semdegac aReniSneba gulyre-
bi da centraluri nervuli sistemis darRvevis ramdenime niSani.

gansazRvreba
neonataluri encefalopaTia (ne) aris klinikuri- da ara etiologi-
uri termini, romelic gulisxmobsgasinjvis procesSi gamovlenil
axalSobilis cnobierebis Secvlil dones. ne klinikuri sindromia,
romelic xasiaTdeba Semdegi maCveneblebis kombinaciiT : cnobiere-
bis Secvlili done, gulyrebi, kunTTa tonusis, moZraobis da
refleqsebis cvlilebebi, sunTqvis kontrolis da suti wovis arse-
bobasTan erTad an maT gareSe. miuxedavad imisa rom ne SesaZloa ga-
mowveuli iyos hipoqsiuri iSemiuri encefalopaTiiT (hie), is yo-
velTvis ar gulisxmobs hie-s arsebobas; ne ufro metad gamoiyeneba
im axalSobilis mdgomareobis aRwerisaTvis, romelsac dabadebisas
aReniSneba daTrgunva. misi mizezi SesaZloa iyos ara marto hie, ara-
med metaboluri darRvevebi, infeqciebi, sxvadasxva preparatis
moxmareba, insulti da malformaciebi. xSirad aucilebelia movaxdi-
noT ne-s da masTan dakavSirebuli terminebis zusti gansazRvreba.

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 nawili 2 klinikuri praqtikis safuZvlebi

sxva xSirad gamoyenebuli da arazusti terminebi mowodebulia qve-

moT.

hie
hie-s definicia mowodebulia zemoT, Tumca damatebiT aRsaniSnavia,
rom misi meqanizmi hipoqsiur-iSemiuri genezisaa. niSnebis da simpto-
mebis kombinaciis mixedviT, hie SeiZleba iyos msubuqi, saSualo da
mZime.

perinataluri hipoqsia, anoqsia da hipoqsemia

aRniSnuli terminebi gulisxmobs Tavis tvinisTvis saWiro Jangbadis
an masTan miwodebuli sisxlis naklebobas.

iSemia
sxvadasxva organoebTan, maT Soris Tavis tvinTan, miwodebuli
sisxlis nakadis Semcireba (nawilobrivi) an Sewyveta (sruli), rac
iwvevs, rogorc Jangbadis, ise saWiro nivTierebebis miwodebis
darRvevebs.

perinataluri asfiqsia
es aris nayofis an axalSobilis insulti respiratoruli airebis
cvlis darRvevis gamo, rac iwvevs hipoqsias da hiperkapnias da Se-
iZleba asocirebuli iyos iSemiasTan. aRniSnul procesSi SeiZleba
CaerTos sxvadasxva organoebi. intensivobis da xangrZlivobis
gaTvaliswinebiT, man SeiZleba gamoiwvios funqciuri da/an bioqimiu-
ri cvlilebebi (mag, laqtat acidozi). asfiqsia iwvevs sisxlSi aci-
dozis gaRrmavebas (mcirdeba pH), romlis mizezia rogorc Jangbadis
nakleboba (cnobili, rogorc metaboluri acidozi), ise hiperkapnia (
cnobili, rogorc respiratoruli acidozi). tutovani deficiti
warmoadgens acidozis respiratorul da metabolur komponentebs
Soris balansis maCvenebels, ufro metad metaboluri (an ufro
naklebad respiratoruli) komponentis TanxlebiT, rasac mivyavarT
ufri negatiur tutovan deficitamde.

perinataluri asfiqsia ganisazRvreba Semdgomi kriteriumebiT (ame-

rikis pediatriuli akademiis mixedviT, 1997):

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 Tavi 12 neonataluri encefalopaTia

 Wiplaris arteriis pH<7,0 da absoluturi tutovani maCvenebeli < -

12 mmEq/l
 apgaris qula 0-3 me- 5 wuTze
 gulyrebi
 multiorganuli (Tirkmlis, kardiovaskuluri, filtvis da kuW-
nawlavis) disfunqciis/ukmarisobis niSnebi.
hipoqsiuri iSemiuri instultis ganviTarebis drois dadgena ar aris
martivi. cxrilSi 12.1 mocemulia miaxloebiTi procentuli monace-
mebi, romlebic gvxvdeba sxvadasxva dros da maTi savaraudo mizeze-
bi.

cxrili 12.1 hipoqsiuri iSemiuri insultis ganviTarebis dro da

masTan dakavSirebuli mizezebi

insultis ganvi- sruli raode- SesaZlo dakavSirebuli mize-

Tarebis dro nobis daaxloe- zebi
biTi procenti

antenataluri/ 20 dedis hipotenzia saSvi-

mSobiarobamde losnos hemoragiiT, muclis
travma, saSvilosnosSida
zrdaSi Seferxeba (szS),
ramdenime nayofiT orsuloba
perinataluri/ 35 araswori pozicia, maSebiT
mSobiarobisas eqstraqcia, placentis
gaskdoma, Wiplaris movardna,
dedis hiperTermia
perinataluri+ - 35 WinTvebis da mSobiarobis
antenataluri dros stresi mSobiarobamde
arsebuli rTuli mdgomareo-
bebiT (dedis diabeti, pre-
eklampsia,saSvilosnosSida
zrdaSi Seferxeba)
postnataluri 10 mZime apnoes epizodebi, gulis
Tandayolili daavadeba,
iatrogenuli mizezebi

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 nawili 2 klinikuri praqtikis safuZvlebi

Tavis tvinis hipoqsiur iSemiuri dazianeba

aRniSnuli mdgomareoba gulisxmobs hipoqsiiT da/an iSemiiT ganpi-
robebul Tavis tvinis dazianebas, romelic dadasturebulia bioqi-
miuri kvlevebiT, eleqtroencefalografiiT (eeg), neirogamosaxviTi
(magnitur-rezonansuli kvleva - mrt, kompiuteruli tomografia) an
paTologanatomiuri monacemebiT (gardacvalebis Semdeg).

neonataluri depresia
es aris zogadi termini, romelic aRwers postnatalur periodSi (si-
cocxlis pirveli saaTi) axalSobilis mdgomareobas. mas ar aqvs rai-
me specifiuri kavSiri perinatalur mdgomareobasTan da postnata-
lur periodSi Catarebul kvlevebTan.

gavrceleba
dabadebisas asfiqsiis sixSire Seadgens 1-1.5-s yovel 1000 axalSo-
bilze da 0.5-s gestaciis >36 kviraze dabadebul yovel 1000 axalSo-
bilze. msoflioSi axalSobilTa sikvdilis mizezis 23% Seadgens da-
badebisas ganviTarebuli asfiqsia. dadgenilia, rom yovelwliurad
814 000 axalSobilis sikvdilianoba gamowveulia mSobiarobasTan da-
kavSirebuli mizezebiT, amaTgan umetesoba (99%) fiqsirdeba dabali-
Semosavlebis mqone qveynebSi. garda amisa, WHO msoflios jandacvis
monacemebiT (WHO, 2005), yovelwliurad, dabadebis dros ganviTare-
buli asfiqsiisgan gadarCenil 1 milionamde bavSvs, SesaZloa ganuvi-
Tardes cerebruli dambla, inteleqtualuri da sxva tipis
unarSezRuduloba, daswavlis siZneleebi.

axalSobilis neiroqceviTi Sefaseba

mTavar komponents axalSobilis pirveli Sefasebis dros kvlevis
sxva meTodebTan SedarebiT, warmoadgens klinikuri Sefaseba, yo-
veldRiuri dakvirveba da Semdgomi Sefaseba dinamikaSi.

axalSobilis klinikuri neiroqceviTi Sefasebis mizania

 gestaciuri asakis dadgena, romelic SeiZleba dakavSirebuli iyos

specifiur klinikur mdgomareobasTan

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 Tavi 12 neonataluri encefalopaTia

 centraluri nervuli sistemis dazianebis niSnebis aRmoCena da

mokle- da grZelvadiani marTvis dagegmva
 prognozis droebiTi da winaswari Sefaseba
mTavari kiTxvebi, romlebsac unda gaeces pasuxi, moyvanilia qvemoT

 ra moxda? nervuli sistemis dazianeba struqturulia Tu funqciu-

ri?
 sad aris dazianeba lokalizebuli centralur/periferiul
nervul sistemaSi?
 rodis moxda es? iyo es mSobiarobamde, mSobiarobisas Tu mSobiaro-
bis Semdgom?
 ratom da rogor moxda es?
klinikuri neiroqceviTi Sefaseba unda ganvixiloT rogorc mimdina-
re procesi, romelic saWiroebs dakvirvebas droSi, axalSobilis
asakTan da klinikur statustTan adaptirebasa da normis
sazRvrebTan Sedarebas. aucilebeli komponentia anamnezi, zogadi
Sefaseba, neiroqceviTi Sefasebis warmarTva standartizebuli gziT,
garemos da mzrunvelobis xarisxis Sefaseba da dakvirveba.

anamneziT unda dadgindes romeli specifiuri mdgomareoba SeiZleba

iyos dakavSirebuli ne-sTan: ojaxSi janmrTelobis problemebi
(gansakuTrebiT auxsneli da/an ramodenime Cvilis/bavSvis sikvdili,
mkvdradSobadoba, aborti, genetikuri da/an nevrologiuri daavade-
bebi, gulyrebi, cerebruli dambla, inteleqtualuri unarSezRudu-
loba), dedis avadobebi, medikamenturi mkurnaloba an arajansaRi
qcevebi (alkoholi, Tambaqo, wamalze damokidebuleba) orsulobamde
an orsulobis dros, nayofis perinataluri da postnataluri
problemebi. perinataluri da postnataluri problemebis ga-
mokvlevis dros gansakuTrebuli yuradReba unda gamaxvildes
Semdeg sakiTxebze:

 axalSobilis klinikuri statusi dabadebisas da apgaris qula 1 da

5 wuTze;
 dabadebisas reanimaciis saWiroeba da masze droul reagireba;

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 nawili 2 klinikuri praqtikis safuZvlebi

 axalSobilis dabadebisSemdgomi klinikuri statusi: RviZili, ti-

rili, socialuri kontaqti, poza, tonusi da moZraobebi, stimulze
reaqcia, sunTqvis tipi, kveba da Zili, ZuZuTi kvebis mcdeloba, ka-
niT-kanTan kontaqti.
 ,,uCveulo’’ niSnebis arseboba, rogoricaa wovis gaZneleba, uCveulo
moZraobebi/poza rogoricaa mokrivis, wriuli, muStebiT, uCveulo
qcevebi, rogoricaa xSiri mTqnareba da cemineba;
 rogor gamoiyureba bavSvi dRiTi-dRe dinamikaSi dakvirvebisas:
stabiluri, gaumjobesebuli an gauaresebuli.
anamnezis Segrovebisas deda, mama da sxva damxmare pirebi unda ganvi-
xiloT, rogorc sando adamianebi, romelTac aqvT bavSvTan mudmivi
kontaqti. amitomac, mzrunvel pirebs unda mieceT specifiuri reko-
mendacia Tu rogor unda moaxdinon axalSobilis movlisas sxva-
dasxva momentebis aRnusxva.

axalSobilis Sefaseba unda moxdes RviZilis mdgomareobaSi, Cum,

wynar garemoSi, xelisSemSleli faqtorebis gareSe. umjobesia deda
daeswros gasinjvis process. ne-is eWvis an nervuli sistemis sxva pa-
Tologiis dros, erTi saxis Sefaseba sakmarisi ar aris da Cveu-
lebriv saWiroa ganmeorebiTi gasinjvis Catareba dReSi orjer an
zogjer ufro xSiradac ki.

Sefasebis detaluri aRweriloba mocemulia ramdenime Zalian Rire-

bul literaturul wyaroSi (Volpe, 2008; Amiel-Tison and Gosselin, 2009),
romelTa gaTvaliswinebiTac Sefasebis ZiriTadi kriteriumebi Seja-
mebulia Semdegnairad:

 gestaciuri asaki: fasdeba anamneziT, morfologiuri da neiroqce-

viTi kriteriumebiT (mag: dubovicis an axali balardis standarti-
zebuli gasinjva qulebiT);
 zogadi mdgomareoba: mizania sunTqvis, sisxlis mimoqcevis, tempe-
ratoruli kontrolis, sakvebis miRebis da monelebis, RviZilis do-
nis dadgena da malformaciebis da dismorfuli niSnebis amocnoba.

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 Tavi 12 neonataluri encefalopaTia

 Tavis qala: zoma (Subl-kefis garSemoweriloba centilebSi),

forma, yiflibandi da nakerebi, Suili (ismis stetoskopiT wina
yiflibandze), travma, kraniosinostozi, qalas zrdis tempi.
 travmis niSnebi: Tu arsebobs unda dadgindes es aris dabadebis
procesTan dakavSirebuli da/an moicavs Tavis qalas, tans, xerxe-
mals, kidurebs,romelime funqciis SezRudvas an tkivils.
 Zili da RviZili: maTi Sefaseba nevrologiur statusTan mimarTe-
baSi Zalian informatiulia, maTi amocnoba SesaZlebelia gestaciis
28-e kviridan, rogorc wesi cvalebadia dRis manZilze, saukeTeso
SemTxvevaSi Sefaseba unda moxdes Tvalebis gaRebis, sunTqvis,
spontanuri moZraobebis da tirilis tipTan erTad.
 mxedvelobiTi da smeniTi komunikacia: mzeris fiqsacia da mzeris
gayoleba ganisazRvreba mtirali axalSobilis pasuxiT xmaze an
damSvidebaze.
 poza da tonusi - saukeTesod fasdeba dabadebidan 24 sT-Si.
o drouli axalSobilis spontanuri poza TaviT winmdebareobis
dros aris oTxive kiduris sruli moxra.
o pasiuri tonusi: ganisazRvreba rogorc kunTovani tonusi mosvene-
bisas; es aris mosvenebul mdgomareobaSi myofi kunTebis minimaluri
moxra, yvelaze kargad fasdeba poziT da moZraobebisa da
standartuli manevrebis monacvleobiT (mag: pirdapiri mimarTule-
biT daWimva, muclisken moxra).
o aqtiuri tonusi: dakvirveba xdeba spontanuri moZraobebisas, yve-
laze kargad fasdeba motoruli aqtivobisas,
o spontanuri moZraobebi: fasdeba rogorc spontanuri da/an stimu-
laciis Sedegad gamowveuli moZraobebisas, normaSi isini mSvidia, si-
metriuli da sxvadasxvanairi; paTologiuri moZraobebi SeiZleba
iyos neli da stereotipuli, an paroqsizmuli da umizno, an ReWviTi
da ganmeorebiTi enis win wamoweviTi moZraobebi.
 refleqsebi: rogorc myes-ZvalTa Rrma, ise primitiuli refleqse-
bi SeiZleba gamovlindes/an ar gamovlindes, iyos daqveiTebuli,
gacxovelebuli an asimetriuli. primitiuli (an Tandayolili avto-
maturi) refleqsebi aris avtomaturi pasuxi, romelic Cndeba orsu-

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 nawili 2 klinikuri praqtikis safuZvlebi

lobis meore naxevarSi, vlindeba dabadebisas da TandaTanobiT qreba

6 Tvis asakisTvis. paTologiurad miCneulia is mdgomareoba, rode-
sac aRniSnuli refleqsebi ar iwveva dabadebisas (cns-is daTrgunvis
gamo) an refleqsebi ar qreba im asakisTvis, rodesac maTi gaqroba sa-
valdebuloa (cns-is dazianebis gamo).
rutinuli Sefasebisas gamoiyeneba Semdegi kriteriumebi:

o moros refleqsi,
o taceba da wamowevaze reaqtiuloba
o avtomaturi nabijebi
o wova
o kisris asimetriuli tonuri refleqsi
 kranialuri nervebi specifiurobidan gamomdinare, fasdeba ro-
gorc mgrZnobelobiTi, ise motoruli funqciebiT. maT Sorisaa re-
aqcia sinaTleze, quToTos aweva (II,III), eqstra-okularul moZraobe-
bi (III, IV,VI), saxis mgrZnobeloba, ReWva (V), saxis momoZravebeli
funqcia, gemovneba (VII), smena, vestibuluri reaqciebi (VIII), wova,
ylapva, vokalizacia, gemovneba, Rebinebis refleqsi(IX da X), Tavis
da kisris moZraoba(XI), enis moZraoba(XII)
 periferiuli nervebi: unda davakvirdeT dazianebas mxris wnulis
(umoZrao, modunebuli zeda kiduri), cdomili nervis (dispnoe), saxis
nervis (saxis asimetria), xaxis nervis (stridori, dispnoe), SuaTana
nervis, sxivis nervis (xelis normaluri pozis da moZraobis darRve-
va), weli-gavas wnulis, sajdomi nervis, peroneuli nervis doneze;
unda moxdes agreTve generalizebuli neiropaTiis Sefaseba: Tanda-
yolili an qronikuli sensoruli an sensomotoruli neiropaTia,
mwvave polineiropaTia;
 avtonomiuri funqciebi: respiratoruli, kardiovaskuluri, kuW-
nawlavis da Sardis buStis funqciebi
 umaRlesi kognituri funqciebi: socialuri kontaqti da urTi-
erTkavSiri, qceviTi pasuxi taqtilur, Termul, mtkivneul, vizua-
lur da smeniT gamRizianebelze, sapasuxo reaqciebis latenciis ,
miCvevis, modulaciis/stereotipulobis specifiuri kvleva.

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axalSobilTa cns-is dazianebis saeWvo niSnebi vlindeba Semdegi kli-

nikuri simptomebiT:

 cns-is daTrgunva gvxvdeba ne-s, travmis da sxva encefalopaTiebis,

preparatebiT intoqsikaciis dros: xasiaTdeba RviZilis, kunTTa to-
nusis, moZraobebis da refleqsebis daqveiTebiT, susti woviT;
 agznebadoba/gulyrebi: gvxvdeba ne-is msubuqi formebis dros,
romlis mizezebia hie, infeqcia, mwvave dismetabolizmi (hipoglike-
mia, hipokalcemia), preparatis Sewyveta (opoidebi, kokaini, sxva fsi-
qotropuli prepratebi); gulyrebi klinikurad tremorisgan
gansxvavdebian Tvalebis paTologiuri moZraobebiT, kidurebis pasi-
ur moxraze reaqtiulobis ararsebobiT, apnoes SesaZlo gamovline-
biT, bradikardiiT da cianoziT, paTologiuri darRvevebiT eeg-ze,
Tu misi Catareba SesaZlebelia. gaiTvaliswineT, rom neonataluri
gulyrebi SeiZleba iyos SeumCneveli da gamovlindes mxolod mzeris
paTologiuri fiqsaciiT, Tvalebis xamxamiT, woviT da sxva operku-
luri moZraobebiT, curviTi moZraobebiT, pedalirebiT.
 intrakraniuli hipertenzia aRiniSneba mwvave mZime infeqciis,
intrakraniuli hemoragiis, intrakraniuli moculobiTi procesis
dros. niSnebi SeiZleba moicavdes qalas garSemowerilobis zrdas da
nakerebs Soris manZilis matebas, savse da mopulsire yiflibands,
RviZilis donis daqveiTebas, qvemoT yurebisas TeTr skleras (Camava-
li mzis niSani), bradikardias, apnoes, Rebinebas, mTqnarebas, hi-
pertonias, gadaWimul pozas, opistotonuss;
 kunTTa generalizebuli hipotonia gvxvdeba hie-s (sawyis etapze);
intrakranialuri hemoragiis, infeqciis, birTvuli siyviTlis, pre-
paratebis moxmarebisas: daqveiTebulia pasiuri da aqtiuri tonusi.
 sxeulis zeda nawilis hipotonia, Tavis/zeda kidurebis CarTviT:
gvxvdeba hie-s (msubuqi formis dros an aRdgenis stadiaze): Tan Se-
iZleba axldes RviZilis, wovis/ylapvis darRvevebi.
 aqsialuri (mag: kisris da sxeulis kunTebi) gamSlelebis hiperto-
nia: iSviaTia da mZime, gvxvdeba hie-s, masiuri intrakraniuli hemora-
giis, infeqciis, hiperekpleqsiis dros (rigiduli bavSvis sindromi;

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ix. 17 Tavi da Gastaut & Villeneuve, 1967), romelic dakavSirebulia

start-reaqtiulobis gacxovelebasTan da apnoesTan.
rodesac eWvs mivitanT ne-ze, maSin misi aRmocenebis drois da etio-
logiis dadgenaSi dagvexmareba Semdegi klinikuri niSnebi:

 axalSobili iyo normis farglebSi dabadebis dros, xolo Semdgom

aReniSna darRvevebi; gaiTvaliswineT Semdegi perinataluri/postna-
taluri mizezebi:
o intraventrikuluri hemoragia
o hie
o mwvave/Tandayolili dismetabolizmi
o infeqcia
o degeneraciuli daavadeba
o preparatis miRebis Sewyveta
 axalSobils aReniSna darRvevebi dabadebis dros, xolo Semdgom
gaumjobesda/gauaresda:
gaiTvaliswineT Semdegi mizezebi:

o hie
o travma
o intrakraniuli hemoragia
o degeneraciuli/metaboluri daavadebebi
 axalSobils aReniSna darRvevebi dabadebis dros da SemdgomSi misi
mdgomareoba gaxda stabiluri: gaiTvaliswineT Semdgomi prenatalu-
ri mizezebi:
o cns-is malformacia da ganviTarebis darRvevebi
o infeqciebi (TORCH; TO-toqsoplazmozi; R-wiTela, C-citomegalo-
virusi, H-martivi herpes virusi. ix. agreTve Tavi 19)
o Tavis tvinis prenataluri hipoqsiuri iSemiuri dazianeba
o degeneraciuli/metaboluri daavadeba.

hie-s klinikuri gamovlineba multiorganuli ukmariso-

biT/an mis gareSe
hie-s mqone drouli axalSobilis prognozuli riskis gansazRvri-
saTvis yvelaze farTod gamoiyeneba sarnat da sarnatis 1976 wlis

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 Tavi 12 neonataluri encefalopaTia

klasifikacia. es klasifikacia dafuZnebulia klinikur da eeg mona-

cemebze da axdens hie-s mqone pacientebis dayofas 3 prognozul
jgufad dabadebidan 24-48 sT-Si (ix. cxrili 12.2). cxril 12.2-Si moce-
muli safexurebi mWidrod asaxavs gestaciis 36 kviraze ufrosi
bavSvebis klinikuri mdgomareobas.

perinataluri asfiqsia iwvevs procesSi ramdenime organos (garda

Tavis tvinisa) sxvadasxva xarisxiT CarTvas. misi klinikuri gamovli-
neba da gankurnebis SesaZlebloba mocemuli cxrilSi 12.3.

hie-s diagnozi da diferenciuli diagnozi

saeWvo hie-s dros saWiroa diferencialuri diagnozis gatareba
iseT mdgomareobebTan, romlebic Zalian gavs hie-s. aseTebia:

 metabolizmis Tandayolili darRvevebi mag: araketoturi hi-

perglicinemia, purinuli metabolizmis darRvevebi, Sardovanas
ciklis defeqtebi, zelvegeris sindromi, mitoqondriuli darRveve-
bi
 preparatis moxmareba, abstinenciis sindromi, wamlis moxsna;
 insulti
 nerv-kunTovani daavadebebi, maT Soris neonataluri miopaTiebi;
 Tavis tvinis simsivne
 ganviTarebis defeqtebi
 infeqciebi.
arsebobs Tanamedrove teqnologiuri meTodebi, romelTa saSuale-
biTac SesaZlebelia cns-is dazianebis dokumentireba adreul
etapze, Tumca rogorc ukve avRniSneT, klinikur gasinjvas eniWeba
centraluri roli ne-is amocnobasa da SefasebaSi.

laboratoriuli kvlevebi hie-s dros

hie klinikuri diagnozia, radgan misi diagnostireba xdeba anamnezis,
fizikaluri da nevrologiuri gasinjvis safuZvelze, Tumca mas
mniSvnelovnad amyarebs bioqimiuri, neirogamosaxviTi da/an eeg
kvlevebi. Tavis tvinis dazianebis simZimis da sistemuri organoebis

217
 nawili 2 klinikuri praqtikis safuZvlebi

funqciuri statusis Sesafaseblad xSirad tardeba didi raodenobis

gamokvlevebi. laboratoriuli kvlevebi unda moicavdes Semdegs:

 arteriul sisxlSi gazebis analizi: sisxlSi gazebis monitoringi

gamoiyeneba mJava-tutovani statusis Sesamowmeblad da hiperoqsiisa
da hipoqsiis, agreTve hiperkapnia da hipokapniis Tavidan acilebis
mizniT.
 SratSi eleqtrolitebis donis gansazRvra: mZime SemTxvevaSi, au-
cilebelia SratSi yoveldRiurad eleqtrolitebis Sefaseba Cvilis
statusis gaumjobesebamde. mniSvnelovnad dabali natriumis, kaliu-
mis da qloris done SratSi Semcirebul SardovasTan da wonis mate-
basTan erTad aris mwvave tubularuli dazianebis niSani an antidiu-
rezuli hormonis (SIADH) Seusabamo gamoyofis sindromis Sedegi,
gansakuTrebiT sicocxlis 2-3 dRes.

cxrili 12.2 sarnat da sarnatis (1976) klasifikacia

safexuri 1 (msu- safexuri 2 (sa- safexuri 3 (mZime)

buqi) Sualo)
cnobierebis hiperagznebu- leTargiuli an stuporozuli, koma-
done li,gaRizianebu- mivardnili tozuri
li
nervkunTova- Tavisufali, spontanuri spontanuri moZrao-
ni kontroli zedmetad aqti- moZraobebis Se- bebis Seferxeba an ar
uri ferxeba arseboba
kunTTa tonu- normaluri mciredi hipo- dune
si tonia
poza msubuqad gamo- mkveTrad gamo- gardamavali dece-
xatuli moxra xatuli moxra rebracia
distalur distalur
segmentebSi segmentebSi
kunTTa da- zedmetad re- zedmetad re- Sesustebuli an ar
Wimvis aqtiuli aqtiuli, Tavi- arsebobs
refleqsebi sufali
segmenturi aris an ar arse- arsebobs ar arsebobs
mioklonusi bobs
rTuli norma daqveiTebuli ar arsebobs
refleqsebi
wova susti susti an ar wovs ar wovs
moro Zlieri, dabali susti, arasru- ar aqvs
zRurbli li, maRali
zRurbli

218
 Tavi 12 neonataluri encefalopaTia

okulovesti- norma zedmetad re- susti an ar arsebobs

buluri aqtiuli
kisris tonusi mcire Zlieri ar aqvs
autonomiuri generalizebu- generalizebu- orive sistema Se-
funqciebi li simpaTikuri li parasimpaTi- sustebulia
kuri
gugebi midriazi miozi gansxvavebulia, xSi-
rad araTanabaria, si-
naTlis refleqsi
sustia
sunTqva spontanuri spontanuri, perioduli, apnoe
xandaxan apnoe
pulsi taqikardia bradikardia sxvadasxvanairi
bronquli da iSviaTi profuzuli sxvadasxvanairi
nerwvis sekre-
cia
gastro- normaluri an gaZlierebuli, sxvadasxvanairi
intestinuri Senelebuli diarea
peristaltika
gulyrebi ar aris xSiria, fokalu- iSviaTia (decerebra-
ri an multifo- ciis gamoricxviT)
kaluri

eeg monacemebi norma (RviZili) dasawyisSi: dasawyisSi: periodu-

daqveiTebuli li paterni izoe-
amplituda, ga- leqtruli mo-
xangrZlivebuli nacvleobiT. mogvia-
delta da Teta nebiT: sruli izoe-
aqtivoba; leqtruli xazi
mogvianebiT: pe-
rioduli pa-
terni (RviZili);
gulyra foka-
luri an multi-
fokaluria; 1.0-
1.5 Hz spaik-
talRa
xangrZlivoba < 24sT 2-14 dRe saaTebidan kviree-
bamde
gamosavali daaxloebiT 80% normaluri; daaxloebiT 50%- le-
100% normaluri paTologiuri taluri gamosavali;
Tu simptomebi gadarCenilebs aRe-
grZeldeba 5- niSnebaT mZime
7dReze metxans garTulebebi
msgavsi simptomebi SeiZleba Segvxvdes gamojanmrTelebis drosac;
gaZlierebuli Sardvis nakadi gulisxmobs mimdinare tubularul da-

219
 nawili 2 klinikuri praqtikis safuZvlebi

zianebas da natriumis gaZlierebul kargvas, dakavSirebulia siTxis

kargvasTan.

 Tirkmlis funqcia: umetes SemTxvevebSi sakmarisia SratSi Sardova-

nas da kreatininis donis da kreatininis klirensis gansazRvra.
 gulis da RviZlis fermentebi: maTi monacemebi damxmare para-
metrebia sxva organoebis hipoqsiuri iSemiuri dazianebis xarisxis
Sesafaseblad, romelTa saSualebiTac SesaZlebelia miviRoT
informacia anTebis arsebobis Sesaxeb sxva organoebSi, magaliTad,
rogoricaa kuW-nawlavis traqtSi.
 hematologiuri da koagulaciuri sistemis Sefaseba: aRiniSneba wi-
Teli sisxlis ujredebis mateba, neitropenia an neitrofilozi da
Trombocitopenia. koagulopaTia moicavs proTrombinis drois da
nawilobriv Tromboplastinis drois da fibrinogenis donis cvli-
lebebs.

cxrili 12.3 multisistemuri organuli dazianebebi

klinikuri ga- aRdgenis

organo/sistema mgrZnobeloba
movlineba unari

Tavis tvini ++++ apnoe, hipoqsia, +

encefalopaTia, ko-
ma, gulyrebi

Tirkmelebi +++ Tirkmlis mwvave +++

ukmarisoba

filtvebi +++ PPHN, ARDS, pulmo- ++++

naluri hemoragia

RviZli ++ transaminazebis ++++

disfunqcia, koagu-
lopaTia

220
 Tavi 12 neonataluri encefalopaTia

guli ++ kardiogenuli Soki, ++++

sarqvlovani re-
gurgitacia

sisxli ++ Trombicitopenia, ++++

DIC
sisxlZarRvebi ++ kapilaruli Jonva- ++++
doba, sklerema

kuW-nawlavis ++ kvebiTi autanloba, ++++

traqti manekrozebeli
enterokoliti

ARDS- mwvave respiratoruli distres sindromi; DIC - diseminirebu-

li sisxlZarRvSida Sededeba; PPHN axalSobilebis persistuli
pulmonuri hipertenzia; mgrZnobeloba: + vlindeba naklebad,++++
vlindeba umeteswilad; aRdgenis unari: + iSviaTia sruli aRdgena
garTulebebis arsebobis gareSe, ++++ umeteswilad xdeba sruli
aRdgena garTulebebis gareSe.

neirogamosaxviTi da neirofiziologiuri kvlevebi hie-s

dros
unda ganvixiloT perinataluri asfiqsiis marTvis sami faza: antena-
taluri, mSobiarobis dros da postnataluri marTva (ix. crili 12.4.
agreTve 7 da 8 Tavi).

hie-s prevencia
fetaluri asfiqsiis prevencia efeqturi sameano movliT warmo-
adgens asfiqsiuri axalSobilis marTvis saukeTeso gzas. asfiqsiis
ganviTarebisTanave efeqturi reanimaciis mTavari mizania sasi-
cocxlo organoebisTvis, gansakuTrebiT ki Tavis tvinisTvis
sisxlis da Jangbadis adeqvaturi miwodebis aRdgena. aRniSnulis
miRweva SesaZlebelia neonataluri reanimaciis gziT. didi mniSvne-
loba eniWeba dabadebis asfiqsiis risk-faqtorebis codnas dedis,
saSvilosno-placentaruli sistemis da saSvilosnoSida darRvevebis
kuTxiT. aseve aranakleb gasaTvaliswinebelia eqTnebis, bebia qalebis

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 nawili 2 klinikuri praqtikis safuZvlebi

da eqimebis codna da unar-Cvevebi dabadebis asfiqsiis mqone axalSo-

bilis marTvaSi. asfiqsiuri axalSobilis dabadebisas optimaluri
marTva unda iyos sistemuri (ix. cxrili 12.4), Tumca mTavari aqcenti
gadatanili unda iyos Tavis tvinis funqciuri srulyofis aRdge-
nisken.

cxrili 12.4 perinataluri asfiqsiis marTvis 3 faza: antenatalu-

ri, samSobiaro blokSi da postanatalur periodebSi.

problema rekomendaciebi

a) antenataluri faza
klinikuri garemo sufTa da Tbili (26 0 C) garemo; aRWurvilo-
bis mzadyofna: sxivuri saTbobi (37 C), sa-
tumbi sistema (maqs. wneva 100 mm/vws), Jangba-
di (nakadis siCqare: 5 l/wT), TviTgaSladi
ambu, saxis niRabi, neonataluri traqealu-
ri saintubacio mili, medikamentebi (epi-
nefrini (adrenalini), moculobis Se-
mavseblebi, natriumis bikarbonati.

nayofis pulsis da ganixileT saswrafo sakeisro kveTa.

riTmis paTologiebi
da/an sqeli mekoniu-
mis arseboba. nayofis
iSviaTi moZraobebi

b) samSobiaro blokis faza

apnoe da/an pulsi <100 dartyma/wT- neonataluri reanimacia moicavs
Si; cianozi, hipotonia dadebiTi wneviT ventilacias,
gulmkerdis kompresias, prepara-
tebs (ix. Perlman et al. 2010)

222
 Tavi 12 neonataluri encefalopaTia

aspeqti mizani ras unda moveridoT (da

ratom)
g) postnataluri marTva
ventilacia CO2-s normis hiperkapnia (iwvevs ce-
sazRvrebSi SenarCu- rebrul vazodilataci-
neba (35-45 mm/vws) as), hipokapnia,
CO2<25mm/vws (amcirebs ce-
rebrul sisxlis nakads)
oqsigenacia O2-is normis hiperoqsia (izrdeba Ta-
sazRvrebSi SenarCu- visufali radikalebis
neba (SaO2 85-95%) dazianeba da mcirdeba
cerebruli sisxlis naka-
di)
temperatura sxeulis temperatu- hiperTermia (SeiZleba ga-
ris normis aZlieros Tavis tvinis
sazRvrebSi SenarCu- dazianeba)
neba (36.5-37.5 0С), ga-
iTvaliswineT saSua-
lo temperaturuli
hipoTermia (33-34 0 С
72 saaTis manZilze)
sisxlis mimoqceva sisxlis wnevis da he- hipotenzia da anemia (Se-
moglobnis normis iZleba daqveiTdes ce-
sazRvrebSi SenarCu- rebruli da intraorga-
neba (ganixileT nuli perfuzia).
sisxlis gadasxma) siTxis zedmeti miwodeba
siTxis mizanmimarTu- (SeiZleba gamoiwvios ce-
li marTva rebruli SeSupeba da ge-
(60ml/kg/dReSi), gani- neralizebuli SeSupeba
xileT inotropebi SIDH-is gamo)
(dopamini)
metaboluri mdgomareoba sisxlis glukozis hipoglikemia (SeiZleba
donis normis moaxdinos amgznebi ami-
sazRvrebSi SenarCu- nomJavebis potencireba),
neba (2.2-6.6 mmol/l) hiperglikemia (SeiZleba
gaaZlieros Tavis tvinis
SeSupeba, laqtatis
dagroveba).
kalciumis donis hipokalcemia (SeiZleba
normis sazRvrebSi Se- gamoiwvios gulyrebi da
narCuneba (1.98-2.65 gulis kumSvadobis Semci-
mmol/l) reba)

223
 nawili 2 klinikuri praqtikis safuZvlebi

hiperkalcemia (SeiZleba
gamoiwvios gulis gaCere-
ba)
nevrologiuri probleme- gulyrebis kontroli
bi antikonvulsantebiT
(fenobarbitali, fe-
nitoini, lorazepami)
da metaboluri
darRvevebis koreqcia
(hipoglikemia, hipo-
kalcemia,hiponatre-
mia)
Tirkmlis problemebi Sardis gamoyofis mo- moerideT siTxiT ga-
nitoringi datvirTvas
hematologiuri proble- koagulaciis pro-
mebi filze (INR >1.5) da
Trombocitebis rao-
denobaze dayrdnobiT
axali gayinuli
plazmis da Trombo-
citebis gadasxmis au-
cileblobis ganxilva
gastrointestinuri kvebis frTxilad moerideT didi porcie-
problemebi dawyeba biT kvebas mwvave fazis
dros (manekrozebeli
enterokoliti)
RviZlis funqcia transaminazebis (ala-
nin transferaza,
aspartat trasfera-
za), Sededebis
(proTrombinis dro,
PTT, fibrinogeni),
glukozis, cilis, bi-
lirubinis, amoniumis
Sefaseba. wamlebis me-
tabolizmis da/an
RviZliT gamoyofis
monitoringi
INR- saerTaSoriso normalizebuli Sefardeba, PTT- nawilobrivi
Tromboplastinis dro, SIADH- antidiurezuli hormonis arasaTana-
do sekreciis sindromi. normis sazRvrebi ixileT me-9 TavSi.

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 Tavi 12 neonataluri encefalopaTia

sqema 12.1 perinataluri asfiqsiis fazebi

energiis pirve- latenturi pe- energiis meo- ujredis

ladi ukmariso- riodi radi ukmariso- sikvdili
ba ba
≈ 30 wT 6-15 sT 3-7 dRe

insulti reoqsigenizacia/reperfuzia

neiroproteqtoruli strategia
perinataluri asfiqsia viTardeba 2 etapad: energiis pirveladi da
meoradi ukmarisobis etapebad (sur. 12.1). energiis meoradi ukmari-
sobis dros, arsebobs 4 ZiriTadi meqanizmi, romelic gansazRvravs
ujredis sikvdils. esenia: (1) eqsitotoqsikuri, rodesac adenozin
trifosfati (ATP) da glutamati Warbadaa sinafsur sivrceebSi; (2)
ujredSida kalciumis dagroveba; (3) Tavisufali radikalebis Camo-
yalibeba; da (4) anTebiswina citokinebis produqcia. eqsperi-
mentulma kvlevebma aCvena, rom Terapiuli hipoTermia SesaZlebelia
gamoviyenoT am procesebiT gamowveuli dazianebis Sesamcireblad.
1320 axalSobilze (gestaciuri asaki >36 kviraze) Catarebuli 10
randomizebuli klinikuri kvlevis meta-analizis Tanaxmad, 72 saaTis
manZilze Catarebuli saSualo xarisxis hipoTermia (33-34 0 C) warmo-
adgens sakmaod efeqtur meTods. misi moqmedebis Sedegebi warmodge-
nilia cxrilSi 12.5. meta-analizis Sedegebi adasturebs asfiqsiur
axalSobilebSi gaxangrZlivebuli saSualo hipoTermiis efeqturo-
bas (Edwards et al,. 2010) (ix. cxrili 12.2)

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 nawili 2 klinikuri praqtikis safuZvlebi

cxrili 12.5 saSualo xarisxis hipoTermiis efeqti (33-340 C) 72 saa-

Tis ganmavlobaSi

riskis fardoba mkurnalobisTvis sa-

(95% Cl) Wiro raodenoba (95%
Cl)

sikvdili an Rrma 0.81 (0.71-0.93) 9 (5-25)

unarSezRuduloba

gadarCena normaluri 1.53 (1.22-1.93) 8 (5-17)

gamosavliT

sikvdilianoba 0.78 (0.66-0.93) 14 (8-47)

gadarCenilebSi Rrma 0.71 (0.56-0.91) 9 (5-30)

unarSezRuduloba

gadarCenilebSi ce- 0.69 (0.54-0.89) 8 (5-24)

rebruli dambla

adaptirebulia Edwards et al,. 2010.

ne-s mimdinareoba da gamosavali

ne-is diagnozis dasmis da misi marTvis dawyebisTanave ojaxis da sxva
mzrunveli pirebis mTavar problemas warmoadgens mosalodneli/ sa-
eWvo xanmokle da xangrZlivi gamosavalis Sesaxeb informaciis miRe-
ba. aRniSnuli informacia mniSvnelovnad gansazRvravs ojaxis moma-
vals. Tu gamosavali aris arakeTilsaimedo, maSin is cxadia, uaryo-
fiT zegavlenas axdens ojaxze. mSoblebis winaSe dgas amocana, Tu
rogor Seeguon isini bavSvis problemebs da moaxdinon bavSvis
adaptacia sazogadoebaSi misi specialuri moTxovnilebebis gaTva-
liswinebiT. ne-is prognozis gansazRvra, misi etiologiis, aRmoce-
nebis drois, diagnozis , marTvis meTodebis da garemo faqtorebis
variabelobis gamo sakmaod rTulia.

neonataluri hie-s gamosavali

cnobilia, rom perinataluri asfiqsiis gamo ganviTarebuli ne, ro-

226
 Tavi 12 neonataluri encefalopaTia

melic gamowveulia Tavis tvinis hipoqsia/iSemiiT, warmoadgens

axalSobilTa avadobis da sikvdilianobis mTavar mizezs. gamosavali
damokidebulia Tavis tvinze araxelsayreli faqtorebis moqmedebis
xangrZlivobasa da simZimeze, aseve gestaciur asakze, gulyrebis
arsebobasa da xangrZlivobaze, infeqciasTan dakavSirebul proble-
mebze, travmis da metaboluri darRvevebis gamovlinebaze. cnobilia
perinataluri hipoqsia/iSemiis Semdeg sikvdilianobis da nevrolo-
giuri avadobis ramodenime prediqtori.

 Zalian dabali apgaris qulebis (3 an naklebi) gaxangrZlivebul pe-

riodSi (20 wuTi da meti)
 dabadebis Semdgom spontanuri sunTqvis xangrZlivad dayovneba
 dabadebisas metaboluri acidozis simZime da xangrZlivoba (Wipla-
ris arteriis pH naklebia 7.00)
 neonataluri nevrologiuri Sefasebis monacemebi
 Tavis tvinis radiologiuri kvlevis (ultrabgera, mrt) monacemebi
 eeg an amplituda-integrirebuli eeg-s monacemebi
 mxedvelobiTi, tvinis Reros smeniTi, somatosensoruli gamowveu-
li potencialis monacemebi.
neonataluri nevrologiuri gasinjvis gaTvaliswinebiT, (Sarnat and
Sarnat, 1976, Finer et al., 1981; Robertson and Finer, 1985; Low et al., 1985;
Levene et al., 1986), aseve axalSobilTa Semdgomi dakvirvebiT
dadginda, rom msubuqi hie-s SemTxvevaSi, arakeTilsaimedo gamo-
savlis (sikvdili an neiroganviTarebis mZime unarSezRuduloba)
albaToba sakmaod mcirea; saSualo xarisxis hie iwvevs mcire raode-
nobis sikvdilianobas, xolo gadarCenil bavSvTa 75%-Si mZime nevro-
logiuri deficiti ar aRiniSneba; mZime hie-s aqvs arakeTilasaimedo
gamosavali, 50-100% sikvdilianobis sixSiriT, xolo gadarCenilTa
75%-Si vlindeba mZime unarSezRuduloba (cerebruli dambla, inte-
leqtualuri unarSezRuduloba, neirosensoruli sisuste, epi-
lefsia).

227
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228
 Tavi 12 neonataluri encefalopaTia

sxva kvlevebis safuZvelze, (Thompson et al., 1997, Müller et al., 2004) gani-
sazRvra naadrevi nevrologiuri niSnebis gamosavali ricxobrivi Se-
fasebis sistemiT. dadginda, rom hie-s mqone bavSvTa prognozi damo-
kidebulia nevrologiuri darRvevebis simZimesa da xangrZlivobaze.
mZime hie-s Semdgom aRiniSneba sikvdilianobis maRali riski, xolo
saSualo an mZime hie-s dros ki ganviTarebis mniSvnelovani darRveve-
bi.

sicocxlis pirveli kviris bolos, nevrologiuri Sefasebis sa-

fuZvelze SesaZlebelia moxdes axalSobilis Tavis tvinis daziane-
bis simZimis winaswari gansazRvra:

 msubuqi, Tu axalSobili meSvide dRes avlens Semdegs:

o agzneba
o kunTTa tonusis cvlileba
o gulyrebis ararseboba
o cns-is dazianebis ararseboba
 saSualo simZimis, Tu axalSobili meSvide dRes avlens Semdegs:
o kunTTa tonusis cvlileba
o 2 an 2-ze naklebi izolirebuli gulyra
o cns-is dazianebis niSnebi
 mZime, Tu axalSobili meSvide dRes avlens Semdegs:
o ganmeorebiTi gulyrebi, da
o cns-is dazianebis mravlobiTi mniSvnelovani niSnebi
cudi gamosavlis klinikuri winaswari maCvenelia Semdegi:

 izolirebuli mudmivi paTologiuri nevrologiuri niSnebi

 perioduli Sefasebisas mudmivad nevrologiuri niSnebis kombina-
cia
 paTologiuri nevrologiuri niSnebis arseboba koregirebuli asa-
kiT 40 kviris dros
 qalas garSemowerilobis zrdis Seferxeba 2 standartuli deviaci-
is qvemoT da saSualo maCveneblisgan dacilebiT (mikrocefalia)
 kisris da zeda kidurebis tonusis mateba; tacebis refleqsis arse-
boba koregirebuli asakis 3 Tveze ufro xangrlivad.

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 nawili 2 klinikuri praqtikis safuZvlebi

 paTologiuri monacemebi motoruli ganviTarebis TvalsazrisiT

o aRdgeniTi resursebis sisuste
o stereotipuli moZrobebi da moqmedebis iniciativis ararseboba
 Tavis daWeris unaris ararseboba, socialuri Rimilis ararseboba
koregirebuli asakis 3 TvisTvis, Semdegi ganviTarebiTi unarebis
ararseboba Sesabamisi asakis mixedviT:
o mzeris fiqsacia da Tvalis gayoleba 3 Tvis asakisTvis,
o nivTebze wvdoma 5 Tvis asakisTvis,
o damoukideblad jdoma 10 Tvis asakisTvis,
o damoukideblad siaruli 18 Tvis asakisTvis,
o sityvebis gamoyeneba mniSvnelobiT 18 Tvis asakisTvis, da
o sityvebis kombinireba 30 Tvis asakisTvis.
Ellis et al. (1999)-is mixedviT, ganviTarebad qveynebSi arsebobs Zalian
mcire kvlevebi hie-s mqone gadarCenil pirebSi gamosavlis Sesaxeb.
arsebuli monacemebis mixedviT, sxvadasxva xarisxis hie-s mqone
bavSvTa mxolod 36%-Si aRiniSneboda ganviTarebis normaluri maCve-
neblebi 1 wlis asakisTvis. gansakuTrebuli yuradReba miiqcia hie-s
mqone gadarCenili SedarebiT mozrdili bavSvebis im jgufma, ro-
melTac aReniSnebodaT mcire motoruli darRvevebi, yuradRebis
deficitis da hiperaqtivobis sindromi, mniSvnelovani perceptuli-
motoruli an kognituri sirTuleebi da Tavis tvinis sxvadasxva sa-
xis darRvevebi (Barnett 2002; Moster et al., 2002; Marlow et al., 2005).

prognozis adeqvaturi Sefaseba SesaZlebelia droSi mudmivi klini-

kuri dakvirvebis safuZvelze. es procesi, mSoblebis da bavSvze
mzrunveli pirebis socialuri donis gaTvaliswinebiT, moicavs qce-
vis Seswavlas postnataluri asakis Sesabamisad (koregirebuli asa-
kis 2 wlamde periodSi), aseve dayovnebuli/darRveuli ganviTarebis
parametrebis amocnobas. koregirebuli asakis 8-12 Tvemde miRebul
nebismier xangrZliv prognozs aqvs cdomilebis didi diapazoni.

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