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danarTi 1

axalSobilebSi Tandayolili

hipoTireozis skriningi da

mkurnaloba

klinikuri praqtikis nacionaluri rekomendacia

(gaidlaini)

damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris 2010 wlis 30 seqtembris

# 317/o brZanebiT

miRebulia “klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo

standartebis (protokolebi) SemuSavebis, Sefasebisa da danergvis erovnuli sabWos"

2009 wlis 30 dekembris #2 sxdomis gadawyvetilebis Sesabamisad

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axalSobilebSi Tandayolili hipoTireozis

skriningi da mkurnaloba

Sesavali

klinikur praqtikaSi bavSvis gonebrivi ganviTarebis Seferxeba xSir SemTxvevaSi adreul etapze amoucnobi hipoTireozis savalalo Sedegia. Tandayolili hipoTireozi (Th) pediatriul endokrinologiaSi erT-erTi yvelaze gavrcelebuli daavadebaa. Th-is gavrceleba saSualod Seadgens 1:3500-4000 cocxal axalSobilze.

Th-is mizezi SeiZleba iyos fj-s aplazia-hipoplazia, hormonTa sinTezis da sekreciis genetikuri defeqtebi da sxva. axalSobilobis asakSi Th-is klinikuri niSnebi metad araspecifiuria, xolo roca klinikuri suraTi aSkara xdeba, umravles SemTxvevaSi ukve gvianaa, radgan rogorc wesi, Tavis tvini dazianebulia. marTalia mkurnaloba am asakidan uzrunvelyofs bavSvis zrdis normalur temps, magram igi samudamod rCeba gonebrivad arasrulfasovani.

Th-is dros cns-is dazianebis Seuqcevadoba ganpirobebulia axalSobilis Tavis tvinis ganviTarebis TaviseburebiT. Tavis tvinis yvelaze swrafi da aqtiuri neirogenezi mimdinareobs pirveli 6 Tvis ganmavlobaSi. sicocxlis II da III welze es procesi SedarebiT neldeba. Tavis tvini maqsimaluri zrdis kritikul periodSi yvelaze mgrZnobiarea araxelsayreli pirobebis mimarT, kerZod Tiroqsinis deficitisadmi, rac aferxebs mis momwifebas da ganapirobebs Seuqcevad fsiqiur CamorCenas. Th-is adreuli diagnostika da am movlenebis Tavidan acileba SesaZlebelia axaSobilTa skriningiT da dabadebidan 2 kviris vadaSi mkurnalobis dawyebiT. msoflios mraval qveyanaSi tardeba neonataluri skriningi, romlis mTavari mizania – Tandayolili hipoTireoziT gamowveuli gonebrivi CamorCenilobis eradikacia.

mkurnalobisaTvis arCevis preparats warmoadgens levoTiroqsini. mkurnalobis mizania, rac SeiZleba male moxdes T4-is normalizeba, SemdgomSi ki levoTiroqsinis im dozirebis SerCeva, romelic uzrunvelyofs Tireoiduli funqciis myar kompensacias da Sesabamisad bavSvis normalur fsiqiur ganviTarebas.

skriningisa da mkurnalobis Tanamedrove meTodebis gamoyenebiT SesaZlebelia pacientebSi Th-iT gonebrivi ganviTarebis mniSvnelovani gaumjobeseba. masStaburi klinikuri sargeblis garda, ekonomikuri Sefasebis mixedviT, Th-is skriningis Rirebuleba gacilebiT naklebia gviandel asakSi Tandayolili hipoTireozis diagnostirebis Rirebulebaze.

gaidlainis mizania Tandayolili hipoTireozis drouli gamovlena skriningis pirobebSi, adeqvaturi mkurnaloba da gonebrivi ganviTarebis Seferxebis

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Tavidan acileba; swori da adekvaturi prevenciuli RonisZiebebis danergva da gatareba jandacvis sistemaSi.

abreviaturebi

Th – Tandayolili hipoTireozi

fj – farisebri jirkvali

T4 – Tiroqsini

FT4 – Tavisufali Tiroqsini

T3 – triiodTironini

Tg – Tireoglobulini

TSH – Tireotropuli hormoni

TSH-r – Tireotropuli hormonis receptori

gaidlaini gankuTvnilia

samSobiaro saxlebis neonatologebisa da saSualo medpersonalisaTvis, pirveladi jandacvis rgolis eqimebisaTvis (ojaxis eqimi, pediatri, endokrinologi).

1. definicia

hipoTireozi ganisazRvreba, rogorc fj-is hormonTa deficiti.

Th – es aris heterogenul daavadebaTa jgufi, gamowveuli fj-is an hipoTalamo-hipofizuri sistemis disgeneziiT an Tireoidul hormonTa sinTezis genetikuri defeqtebiT an sxvadasxva egzogenuri moqmedebiT (medikamentebi, dedis mablokirebeli antisxeulebi da sxva), romlebic xels uwyoben organizmSi hipoTireozis ganviTarebas. SeiZleba iTqvas, rom termini Tandayolili hipoTireozi aRniSnavs nebismieri etiologiis hipoTireozs, romelic manifestirdeba da diagnoscirdeba dabadebisas.

2. epidemiologia

Th-ze skriningis SemoRebamde (70-iani wlebidan) iTvleboda, rom am daavadebis gavrceleba ar aRemateboda 1:5000-10000 axalSobilze. Tanamedrove warmodgeniT ki igi Seadgens 1:3500-4000 axalSobilze. es daavadeba orjer ufro xSirad gvxvdeba gogonebSi, vidre vaJebSi. Th-is ganviTarebis riski maRalia daunis sindromis mqone bavSvebSi.

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Tandayolili hipoTireozi (Th) pediatriul endokrinologiaSi erT-erTi yvelaze gavrcelebuli daavadebaa. Th-is gavrceleba saSualod Seadgens 1:3500-4000 cocxal axalSobilze.

3. etiologia

Th-is SemTxvevaTa 90% sporadulia da ZiriTadad fj-is disgeneziis Sedegia. SemTxvevaTa 15%-Si mas iwvevs T4-is sinTezis darRvevebi an farisebri jirkvlisadmi dedis antisxeulebis efeqtebi. praqtikulad kazuistikad iTvleba axalSobilebSi meoradi hipoTireozis (centraluri, hipofizuri) ganviTareba. qvemoT moyvanilia Th-is ZiriTadi mizezebi da avadobis maCveneblebi calkeuli etiologiuri formebis mixedviT:

cxrili #1. Th-is ZiriTadi mizezebi da avadobis maCveneblebi etiologiuri formebis mixedviT

Th-is mizezi axal SemTxvevaTa sixSire

saerTo gavrceleba 1:3000-4000 farisebri jirkvlis disgenezia agenezia (22-42%) hipoplazia (24-36%) distopia (35-43%)

1:4500

T4-is sinTezis Tandayolili defeqtebi Tiroperoqsidazas defeqti Tireoglobulinis defeqti natrium-iodiduri simporteris defeqti pendredis sindromi Tiroidul hormonTa deiodinazebis defeqti

1:30000

meoradi Th 1:25000-100000 dedis antisxeulebiT gamowveuli Th 1:25000-100000

farisebri jirkvlis disgenezia

fj-is aplazia, hipoplazia an eqtopia gvxvdeba Th-is SemTxvevaTa 2/3-Si. misi gavrceleba 2-jer ufro xSiria gogonebSi, vaJebTan SedarebiT. is faqti, rom fj-is disgenezias aqvs garkveuli eTnikuri variabeloba, migviTiTebs genetikuri winaswarganwyobis SesaZlo rolze. magaliTad, TeTri rasis warmomadgenlebSi igi 10-jer ufro xSirad gvxvdeba, vidre Savi rasis warmomadgenlebSi.

aRmoCenilia transkrifciis mTeli rigi faqtorebi, romelTac aqvT principuli mniSvneloba fj-is embriogenezisaTvis. arsebobs mravali kvleva, romlebic adastureben Th-is paTogenezSi am faqtorTa makodirebeli genebis mutaciebis mniSvnelobas. es faqtorebia: transkrifciis Tireoiduli

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faqtorebi 1 da 2 (thyroid specific transcription factors: TTF-1 & TTF-2), agreTve TSH da TSH-r genebi, romelTa mutacia iwvevs fj-is disgenezias.

T4-is sinTezis Tandayolili defeqtebi

darRvevaTa es varianti gvxvdeba Th-is 10-15%-Si da SeiZleba Seexos Tireoidul hormonTa sinTezis, sekreciis da uSualo efeqtebis ganxorcielebis nebismier etaps.

Tireoiduli dishormogenezis variantTa umravlesobis damemkvidreba xdeba autosomur-recesiuli gziT. T4-is sinTezis defeqtis yvelaze xSiri variantia Tireoglobulinis da Tiroperoqsidazas genTa mutacia, ris Sedegadac viTardeba Th CiyviT. am SemTxvevaSi fj-is gadideba SeiZleba arsebobdes ukve dabadebisTanave, magram ZiriTadad mainc mogvianebiT viTardeba.

natrium-iodiduri simporteri (NIS) ganapirobebs iodis aqtiur transports Tirocitis SigniT. Sesabamisi genis mutaciis dros ki, fj ver STanTqavs iods, rac iwvevs Th-is ganviTarebas.

Tandayolili Ciyvi Tandayolili neirosensoruli siyruiT 1896 wels aRwera v.pendredma. iTvleba, rom am sindromze modis smenis darRvevaTa 5-7.5%. geni (PDS), romlis mutacia iwvevs pendredis sindroms, klonirebul iqna 100 wlis Semdeg, 1997 wels. igi akodirebs cila pendrins, romelic ganapirobebs iodisa da qloridis natriumze damoukidebel transports TirocitSi. am dros viTardeba iodis organifikaciis nawilobrivi darRveva. fj, rogorc wesi, diddeba zomierad, xolo hipoTireozs subklinikuri xasiaTi aqvs, ris gamoc daavadeba iSviaTad vlindeba neonataluri skriningis pirobebSi. pendredis sindromis dros pirvelad xdeba smenis daqveiTebis aRmoCena, SemdgomSi Ciyvis, Tireoiduli funqciis sxvadasxva xarisxiT darRvevis TanxlebiT.

meoradi Th (centraluri, hipofizuri)

skriningul programaTa umravlesoba, romelSic isazRvreba mxolod TSH, mimarTulia pirveladi Th-is aRmosaCenad. arsebobs programebi, romlebic TSH-is paralelurad sazRvraven T4-s (oregonis Stati, aSS). maTi monacemebiT, meoradi Th gvxvdeba 1:29000 axalSobilze. am mdgomareobisaTvis damaxasiaTebelia hipoglikemia (74%), mikropenisi da kriptorqizmi vaJebSi (71%) da prolongirebuli siyviTle (44%). SeiZleba Segvxvdes septo-optikuri displazia, zeda tuCisa da sasis Tandayolili naprali, goloprozencefalia, neirofibromatozi da sxva. agreTve aRsaniSnavia hipofizis tropul hormonTa deficiti da mTeli rigi mZime anomaliebi.

am darRvevaTa paTogenezi ucnobia, Tumca dReisaTvis gamovlenilia mTel rig genTa (Prop-1, Pit-1, SHH, SIX-3, ZIC-2, HESX-1 da sxva) defeqtebi, romlebzec damokidebulia hipofizis ujredTa ganviTareba da funqcionireba.

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dedis autoantisxeulebiT ganpirobebuli Tandayolili hipoTireozi

Th-is SemTxvevaTa 5%-Si gvxvdeba TSH-r-is antisxeulebis transplacenturi gadatana. procesi TviTlimitirebadia (3-6 Tve), ris gamoc Th-is tranzitoruli xasiaTi aqvs. Th-is am variantze eWvi unda mivitanoT, rodesac dedas an mis danarCen Svilebs aqvT autoimunuri Tireoiduli paTologia an aRmoaCndebaT TSH-r-is mablokirebeli antisxeulebi. unda aRiniSnos, rom dedis antisxeulebs Tg-s an TPO-s mimarT msgavsi movlenis gamowveva ar SeuZliaT.

tranzitoruli hiperTireotropinemia

es termini gulisxmobs skriningis pirobebSi aRmoCenil TSH-is tranzitorul matebas. Tu erTdroulad T4-c aris daqveiTebuli, maSin saqme gvaqvs tranzitorul hipoTireozTan.

tranzitoruli hiperTireotropinemiis da tranzitorul hipoTireozis diferenciuli diagnostika sakmaod rTulia.

tranzitoruli hiperTireotropinemiis mizezebi SeiZleba iyos:

- iodis deficiti; - dRenakloba; - antenataluri hipotrofia, dabadebis mcire masa; - saSvilosnos Sida infeqciebi; - orsulobis dros Tireostatiuri preparatebis miReba; - dedis autoimunuri daavadebebi.

neonataluri hiperTireotropinemiis yvelaze xSiri da ufro metad Seswavlili mizezi aris ioddeficiti. tranzitoruli hiperTireotropinemiis sixSire evropis im qveynebSi, sadac SenarCunebulia iodis deficiti, 8-jer aRemateba analogiur monacemebs CrdiloeT amerikaSi, sadac ar fiqsirdeba ioddeficiti. axalSobilebi mgrZnobiare arian iodis msubuqi deficitis mimarTac ki, rac ganpirobebulia maT fj-Si iodis sakmaod dabali SemcvelobiT Tireoidul hormonTa Zalian maRali cvlis fonze.

iodis deficitis simZimesTan erTad matulobs axalSobilTa ricxvi tranzitoruli hiperTireotropinemiiT. ufro metic, jandacvis msoflio organizaciis rekomendaciiT ioddeficitur darRvevaTa simZimis Sefasebis erT-erTi epidemiologiur kriteriumad miCneulia neonatalur skriningSi TSH-is maCveneblebi. Tu mocemul regionSi skriningis pirobebSi TSH>5 s.e./ml-ze gvxvdeba axalSobilTa 3-19%-Si, dgindeba msubuqi xarisxis, 20-40%-Si saSualo xarisxis, >40%-ze ki - mZime xarisxis ioddeficiti.

bavSvis Semdgom ganviTarebaze arasasurveli gavlena SeiZleba moaxdinos aramarto tranzitorulma hipoTireozma, aramed tranzitorulma hiperTireotropinemiamac. am bavSvebSi gazrdilia nevrologiuri darRvevebis riski, 25%-Si vlindeba antiTireoiduli antisxeulebi, ris gamoc momavalSi SeiZleba maT ganuviTardeT subklinikuri hipoTireozi.

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4. klinikuri simptomatika

klinikuri simptomebi, rogorc wesi, ver gvexmarebian Th-is adreul diagnostirebaSi. Th-is klinikuri gamovlinebani da simptomebi damokidebulia daavadebis ganviTarebis vadebze, dazianebis donesa da Tireoiduli ukmarisobis xarisxze.

Th-ze eWvis mitana klinikuri niSnebis mixedviT SesaZlebelia axalSobilTa mxolod 5%-Si, radgan klinikuri simptomebi araspecifiuria, umniSvneloa an SeiZleba sulac ar iyos gamoxatuli. es gamowveulia dedis hormonTa damcavi moqmedebiT, agreTve T3-is normaluri raodenobiT daqveiTebuli T4-is fonze. Th-is simptomebis gamoxatuleba damokidebulia hipoTireozis mizezsa da simZimeze. Tu aSkara simptomebi aRiniSneba sicocxlis pirvelive dReebSi, SeiZleba vivaraudoT fj-is aplaziiT an mkveTri hipoplaziiT gamowveuli Th-is mudmivi forma. fj-is zomieri hipoplaziiT, eqtopiiT an hormonogenezis darRveviT gamowveuli hipoTireozi gamovlindeba SedarebiT gvian, 2-6 Tvis asakSi. palpirebadi fj an didi Ciyvi, rogorc wesi, miuTiTebs dishormonogenezze an hipoTireozis tranzitorul xasiaTze. Th-is adreul simptomebs ekuTvnis:

- prolongirebuli hiperbilirubinemia (>7 dReze); - boxi xma; - Seberili muceli; - Wipis Tiaqari; - hipotonia; - gadamwifebuli nayofi; - didi ukana yiflibandi; - makroglosia; - fj-is gadideba.

Tu mkurnaloba ar iqna dawyebuli droulad, SemdgomSi me-3-4 Tveze Cndeba iseTi simptomebi, rogoricaa:

- daqveiTebuli mada; - ylapvis gaZneleba; - sxeulis masis cudi mateba; - meteorizmi; - yabzoba; - kanis simSrale, sifermkrTale, siuxeSe; - hipoTermia; - kunTTa hipotonia; - zedmeti Zilianoba; - SeSupeba; - bradikardia, kardiomegalia.

5-6 Tvis Semdeg aranamkurnaleb bavSvebSi aSkarad SesamCnevia fizikuri da fsiqomotoruli ganviTarebis CamorCena. bavSvis sxeulis proporciebi uaxlovdeba qondrodisplaziurs, xolo farTo, unagira cxviri,

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hipertelorizmi, daviwrovebuli Tvalis napralebi zemoTCamoTvlil klinikur niSnebTan erTad qmnis klasikur hipoTireoidul habituss.

5. skriningi

skriningis dasabuTeba

skriningi, es aris farulad mimdinare daavadebebze im pirTa gamokvleva, romlebic ar iTvlebian daavadebulebad.

dReisaTvis klinikur epidemiologiaSi mkafiod aris formulirebuli skriningis organizaciis mecnieruli principebi. rogorc wesi, skriningisaTvis gamoiyeneba iafi, martivi, arainvaziuri diagnostikuri procedurebi, romelTac amave dros aqvT maRali mgrZnobeloba.

arsebobs rigi aucilebeli kriteriumebisa, romelic unda dakmayofildes, raTa gadawydes ama Tu im daavadebis dros skriningis Catareba. Th mTlianad akmayofilebs am moTxovnebs, radgan:

1. Th sakmaod gavrcelebuli daavadebaa, gvxvdeba 4-5-jer ufro xSirad, vidre fenilketonuria;

2. Th-is dros gonebrivi ganviTarebis CamorCenis acileba SesaZlebelia SenacvlebiTi Terapiis maqsimalurad adreul vadebSi dawyebiT, idealur variantSi, sicocxlis pirvelive dReebSi;

3. Th-is diagnostika daavadebis adreul etapze metad rTulia klinikur simptomTa araspecifiurobis da xSir SemTxvevaSi ararsebobis gamo;

4. arsebobs skrininguli testi, romelic gamoirCeva maRali mgrZnobelobiT da specifiurobiT;

5. Th-is mkurnaloba SedarebiT martivia, maRalefeqturi da ar aris Zviri; 6. skriningis ekonomikuri efeqturoba Seadgens 7/1 – 11/1.

skriningis istoriidan

gasuli saukunis 70-ian wlebSi medicinaSi dagrovilma klinikurma gamocdilebam aCvena, rom Th-is dabadebidan pirvel 2 kviraSi dawyebulma Terapiam SeiZleba minimumamde daiyvanos bavSvis neirofsiqiuri gadaxrebi.

marTalia im dros arsebobda TSH-is da T4-is gansazRvris meTodebi, magram kvleva saWiroebda Sratis did raodenobas, rac skriningis Catarebis did organizaciul sirTuleebTan iyo dakavSirebuli. kanadelma eqimma Jan dusom romelic xelmZRvanelobda Tireoidologiur laboratorias, sruliad SemTxveviT SeamCnia, rom gverdiT mdebare laboratoriaSi fenilketonuriaze kvleva tardeboda filtris qaRaldze datanili sisxlis mSrali wveTis gamoyenebiT. am SemTxvevam daudo saTave axalSobilTa skrinings Th-ze, romelic dRes msoflios praqtikulad yvela qveyanaSi tardeba. populaciuri kvlevebis monacemebiT msoflioSi yovelwliurad skriningul gamokvlevas gadis 25 mln-mde axalSobili. daavadebis gavrcelebis mixedviT Tu

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vimsjelebT, yovelwliurad skriningis pirobebSi Th-is diagnozi ismeva 6-8 aTas axalSobilSi.

skriningis meTodebi

arsebobs Tandayolili hipoTireozis skriningis 2 ZiriTadi meTodi:

1. pirveladad TSH-is gansazRvriT da Semdgom T4-is kvleviT dadasturebuli;

2. pirveladad T4-is gansazRvriT da Semdgom TSH-is kvleviT dadasturebuli.

3. garda amisa, sul ufro da ufro meti qveyana iyenebs kombinirebul meTods _ TSH–isa da T4-is erTdrouli gansazRvriT.

pirveladad TSH-is gansazRvriT da Semdgom T4-is kvleviT dadasturebuli meTodi

evropis qveynebSi, iaponiaSi, kanadaSi, meqsikasa da aSS-s zogierT StatSi ZiriTadad gamoiyeneba pirveladad TSH-is donis gansazRvra, misi momatebis SemTxvevaSi ki - diagnozis dasadastureblad T4-is analizi. Aam meTodiT ver moxerxdeba bavSvebis gamovlena TSH-is mogvianebiTi matebiT, Tireoid-SemakavSirebeli globulinis naklebobiT, centraluri hipoTireoziT da hipoTiroqsinemiiT. TSH-is mogvianebiTi momateba sakmaod xSiria mcire (<2500gr) da Zalian mcire wonis (<1500gr) axalSobilebSi.

pirveladad TSH-is kvlevis meTodisTvis Zalian didi mniSvneloba aqvs skriningis Catarebis dRes. am meTodis uzustobas zrdis axalSobilebis samSobiaro saxlebidan dabadebidan pirvel 48 saaTSi gaweris tendencia. am SemTxvevaSi skriningisTvis gankuTvnili biomasala swored cxovrebis pirveli 48 saaTis ganmavlobaSi miiReba. Aarada adreul postnatalur periodSi normaSic gvxvdeba TSH-is mateba, rac Sesabamisad gazrdis cru dadebiTi Sedegebis ricxvs. am movlenis Tavidan acilebis mizniT gamoiyeneba TSH–is asakis Sesabamisad Sesworebuli normuli maCveneblebi. sxvadasxva qveynebSi aseTi midgomiT araswori pasuxebis ricxvi 50%-iT Semcirda.

yvelaze gavrcelebulia TSH–is kvleva sicocxlis me-4-5 dRes, rodesac xdeba

TSH–is fiziologiuri kleba. Tumca unda aRiniSnos, rom neonatalur periodSi TSH–is done mniSvnelovnad gansxvavdeba ufro ufrosi asakis analogiuri maCveneblebisgan (ix.danarTi #1).

sisxlSi TSH–is kvlevis Tanamedrove imonofluorometruli meTodi gamoirCeva maRali mgrZnobelobiT da specifiurobiT. am meTodiT gansazRvruli TSH-is done ar aris iseTi maRali, rogoric is iyo adrindeli teqnologiebis gamoyenebisas da rogorc wesi, 20-25 s.e./ml–ze naklebia, ris gamoc swored es ricxvi warmoadgens axalSobilTa skriningis dros gadarCevis zRurbls.

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pirveladad T4-is gansazRvra Semdgom TSH-iT dadasturebuli meTodi

meTodi gulisxmobs pirveladad T4-is gansazRvras da Tu misi done <10 percentilze, - TSH-is gamokvlevas. es meTodi gamoavlens axalSobilebs _ T4-

is dabali an normis dabali maCvenebliT da TSH-is momatebiT, anu pirvelad hipoTireozs, agreTve TireoidSemakavSirebeli globulinis naklebobas da centralur hipoTireozs. aseve SesaZlebeli iqneba hiperTiroqsinemiis gamovlena (gavrceleba 1:20000/40000), Tumca SesaZlebelia gamorCes TSH-is mogvianebiTi mateba.

kombinirebuli meTodi

arsebobs meTodebi, romlebic orive kvlevis (T4, TSH) erToblivad Catarebas gulisxmobs (DELFIA Data). rac praqtikulad idealur variantad SeiZleba CaiTvalos. sanam kombinirebuli meTodi ar iqneba xelmisawvdomi praqtikulad yvela bavSvisTvis, klinicistebma unda gaiTvaliswinon Tandayolili hipoTireozis skriningis konkretuli meTodis potenciuri SezRudvebi.

saqarTveloSi Tandayolili hipoTireozis skriningis meTodad gamoiyeneba TSH-is pirveladad gansazRvra. saeWvo SemTxvevebSi eqimis mier unda dainiSnos FT4, TSH-is konfirmaciuli kvleva (ixileT danarTi #2).

skrininguli kvlevisTvis saWiro masalis momzadeba

axalSobilTa skriningisaTvis sisxlis nimuSis aReba unda moxdes samSobiaro saxlSi dabadebidan aranakleb 48 saaTis Semdeg (rekomendebulia dabadebidan 72-96 saaTSi). sisxlis aReba xdeba quslidan. Cxvleta sasurvelia ganxorcieldes erTjeradad da yvela kvlevisaTvis saWiro nimuSebis momzadeba moxdes erTdroulad. pirvel 24-48 saaTSi aRebuli nimuSis kvlevam SeiZleba mogvces TSH-is cru dadebiTi Sedegi, Tumca metad mniSvnelovania yvela axalSobilis kvleva, amitom aucilebelia TSH-is aReba gaweramde an transfuziamde. cru uaryofiTi Sedegebi SeiZleba miviRoT transfuziis Semdgom an mZime avadmyofi bavSvis gamokvlevisas. Tu axalSobili aris dRenakli an daibada binaze, an imyofeba kritikul mdgomareobaSi, kvleva unda Catardes dabadebidan 7 dRis vadaSi da ganmeordes yovel 2 kviraSi, raTa ar gamogvrCes TSH-is mogvianebiTi mateba.

gansakuTrebuli yuraRReba unda mieqceT axalSobilebs intensiuri Terapiis ganyofilebebSi. janmrTelobis mdgomareobis simZimis gamo SeiZleba maT ver CautardeT aucilebeli skrininguli kvleva. sxva ganyofilebaSi an klinikaSi gadasvlis Semdeg samedicino dokumentSi unda iqnes miTiTebuli, CautardaT Tu ara maT skrininguli kvleva da Tu ar aris Sesabamisi informacia, maSin masala unda aiRos mimRebma klinikam .

skriningis Sedegebi mniSvnelovnad aris damokidebuli sisxlis wveTis sworad aRebis teqnikaze. teqnikurad arasworad Sesrulebuli masala ar unda iqnes gamoyenebuli sakvlevad. specialur filtris qaRalds, romelic

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gamoiyeneba sisxlis dasawveTeblad, aqvs beWduri wreebi. sisxli unda iqnes dawveTebuli am wreze filtris qaRaldis mxolod erTi mxridan da unda gamoSres oTaxis temperaturaze. filtris qaRaldi ar unda moxvdes maRali temperaturis zemoqmedebis qveS, an svel zedapirze, ar unda dasveldes yaviT, rZiT an sxva siTxiT.

Tu sisxlis wveTis moculoba ver avsebs beWdur wres xelmeored dawveTeba ar SeiZleba. arasrulyofili sisxlis wveTis gamo SeiZleba miviRoT TSH-is cru uaryofiTi pasuxi.

skrininguli kvlevis Sedegis interpretacia da hipoTireozis verifikacia

dabali T4 - maRali TSH

axalSobils dabali T4-iT da TSH > 40 s.e./ml-ze savaraudod aqvs pirveladi hipoTireozi. aucilebelia aseTi pacientebis dauyovneblivi kvleva diagnozis dasadastureblad, magram levoTiroqsiniT mkurnaloba unda iqnes dawyebuli ganmeorebiTi analizis Sedegebis miRebamde, xolo Tu TSH>100 s.e./l-ze, Th-is diagnozi eWvs ar iwvevs.

im SemTxvevaSi, roca 20< TSH>40 s.e./ml da konkretuli programa ar iTvaliswinebs ganmeorebiT skrinings, eqimis mier iniSneba konfirmaciuli kvleva.Ees metad mniSvnelovania, radgan dadasturebuli hipoTireozis mqone bavSvTa 10%-s TSH-is koncentracia skrininguli kvlevisas swored 20-dan 40 s.e./ml diapazonSi aqvT. rac ufro maRalia TSH-is sawyisi done, ganmeorebiTi kvlevisas miT ufro xSirad gamovlindeba Th.

normaluri T4 - maRali TSH

aseT mdgomareobas ewodeba izolirebuli hiperTirotropinemia da axasiaTebs neonatalur periodSi sisxlSi TSH-is koncentraciis mateba normaluri T4-is da FT4-is fonze. etiologia heterogenulia da SesaZlebelia iyos fj-is, rogorc tranzitoruli, aseve permanentuli paTologia an hipoTalamo-hipofizuri RerZis momwifebis Seferxeba. mudmivi hiperTirotropinemia da Tandayolili hipoTireozi xSiria bavSvebSi daunis sindromiT. tranzitoruli hiperTirotropinemia araiSviaTad normalizdeba 1 wlis asakSi mkurnalobis gareSe, Tumca zogierT SemTxvevaSi persistirebs 10 wlis an met asakamde.

TSH-is koncentracia iTvleba hipoTalamo-hipofizuri RerZis mier T4-is nakle-bobis aRqmis yvelaze mgrZnobiare indikatorad. im SemTxvevaSi Tu bazaluri TSH-is koncentracia rCeba 10 s.e./ml -ze meti 2 kviris asakis Semdeg, pacientebi saWiroeben mkurnalobas. Tu raime mizezis gamo ar moxdeba mkurnalobis dawyeba, maSin FT4-is da TSH-is monitoringi unda Catardes me-2 da me-4 kviraze. Tu monacemebi ar normalizda, maSin axalSobils aucileblad unda daewyos mkurnaloba.

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ar arsebobs konsensusi iseTi axalSobilebis mkurnalobis Sesaxeb, romelTac dabadebidan erTi Tvis Semdeg aReniSnebaT TSH-is mateba 6-10 s.e./ml-ze farglebSi. normaSi sicocxlis pirvel TveebSi SesaZlebelia TSH-is zomieri mateba. 2-20 kviris bavSvebSi TSH-is norma meryeobs 1.7-9.1 s.e./ml-ze. ris gamoc aucilebelia asakisaTvis Sesabamisi TSH-is normis gamoyeneba, romelic gansxvavdeba mozrdilTa normisgan (ixileT danarTi #1).

dabali FT4 - normaluri TSH

iseT axlSobilebs, romelTac aReniSnebaT TSH-is normaluri koncentracia da dabali FT4 (<10mkg/dl), SesaZloa hqondeT Tireoiduli ukmarisoba. aseTi kombinacia gvxvdeba axalSobilebis 3-5 %-Si. es SeiZleba iyos hipoTalamusis umwifrobis Sedegi, gansakuTrebiT dRenakl axalSobilebSi an iseTi mZime daavadebebisas, rogoricaa Tiroid-SemakavSirebeli globulinis deficiti, centraluri genezis hipoTireozi, an pirveladi hipoTireozi, TSH-is dagvianebiTi matebiT. axalSobilebSi dopaminis an kortikosteroidebis xangrZlivma gamoyenebam agreTve SeiZleba gamoiwvios TSH-is daTrgunva.

dRenakli axalSobilisaTvis tranzitoruli hipoTiroqsinemia ar aris iSviaTi mdgomareoba. hipoTalamo-hipofizuri RerZis umwifroba SeiZleba fiziologiur, kompensatorul reaqciad CaiTvalos. dRenaklebSi T4 da FT4-is koncentracia naklebia droul axalSobilebTan SedarebiT, magram TSHTiTqmis igivea. am SemTxvevaSi unda ganisazRvros FT4, romelic SeiZleba arc iyos iseTi dabali, rogorc T4. magram im kombinaciisaTvis, roca FT4-is donec dabalia normaluri TSH-is fonze, mkurnalobis konsensusi ar arsebobs.

am jgufis pacientebSi (centraluri hipoTireozis da TSH-is dagvianebiTi matebis garda) levoTiroqsiniT mkurnalobam araviTari dadebiTi Sedegi ar aCvena. isini saWiroeben dakvirvebas dinamikaSi.

dabali T4 - TSH-is dagvianebiT mateba

rogorc wesi, axalSobilTa umetesoba, romelTac pirveladi kvlevisas aReniSnebodaT dabali T4 da normaluri TSH, xolo mogvianebiT TSH-is koncentraciis mateba, arian dRenaklebi, mcire an Zalian mcire masis, an kritikul mdgomareobaSi myofni. aseT pacientebSi pirveladi hipoTireozisaTvis damaxasiaTebel koncentraciamde TSH-is done sicocxlis pirveli ramdenime kviris manZilze matulobs. ucnobia, aseT axalSobilebs hipofiz-fariseburi jirkvlis funqcia darRveuli aqvT ioddeficitiT gamowveuli tranzitoruli hipoTireozis gamo, Tu aReniSnebaT mudmivi Tandayolili hipoTireozis msubuqi forma. aseTi bavSvebis katamnezi Seswavlili ar aris. aucilebelia FT4-is da TSH-is koncentraciis Seswavla iseT bavSvebSi, visac T4-is Zalian dabali done an hipoTireozis klinikuri niSnebi aqvT. teqnikuri Secdomebis an subieqturi faqtorebis gamoricxvis

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Semdegac Tandayolili hipoTireoziT mcire an Zalian mcire masis axalSobilebis 5-10%-s SeiZleba skriningis normaluri pasuxi hqondes.

zogierTi skrininguli programebiT ganmeorebiT analizs akeTeben 2-6 kviris vadaze, an/da akontroleben yvela axalSobils, visac aqvs T4–is done <3 percentilze orjeradi kvlevis Sedegad. 2 kviris vadaze ganmeorebiTi gamokvleva gansakuTrebiT aucilebelia monozigotur tyupebSi, vinaidan mucladyofnis dros sisxlis Sereva iwvevs realuri suraTis SeniRbvas.

TSH-is tranzitoruli mateba

gamokvleuli axalSobilebis mcire ricxvs skriningis dadebiTi SedegiT aReniSneba tranzitoruli hipoTireozi, rasac ganmeorebiTi testirebis an konfirmaciuli kvlevis dros T4-is da TSH-is normaluri maCveneblebi adasturebs. am mdgomareobis Sesaxeb zemoT iyo aRniSnuli. analogiuri Sedegebi SeiZleba miviRoT postnatalur periodSi iodidebis Warbi gamoyenebis dros, (mag: antiseptiluri mizniT an sakontrasto nivTierebebis saxiT). iodiT gamowveuli tranzitoruli hipoTireozi dabadebisTanave ar vlindeba da SesaZlebelia dabadebidan ramdenime dReSi Catarebuli skriningiT ar gamovlindes.

zogierT SemTxvevaSi pirveladi kvlevebiT hipoTireozis tranzitoruli xasiaTi amocnobili ver iqneba, magram standartuli mkurnaloba unda Catardes im dromde, vidre ar moxdeba ganmeorebiTi Sefaseba. im axalSobi-lebSi, romlebic dedis mier miRebuli medikamentis zegavlenis qveS arian, T4-

isa da TSH-is normalizeba moxdeba mkurnalobis gareSe 1-3 kviraSi.

6. etiologiuri dignostika

Tu TSH-is SenacvlebiTi Terapia urgentuli aucileblobaa axalSobilebisaTvis, raTa SevinarCunoT normaluri fsiqiuri ganviTareba, etiologiuri diagnostika neonatalur periodSi ar warmoadgens pirveli rigis amocanas. igi ufro gamarTlebulia Tireoidul hormonTa mosazRvre cvlilebebis dros, raTa ar gamogvrCes fj-is funqciis tranzitoruli cvlilebebi, xolo TSH-is genetikuri variantebis kvleva mniSvnelovania mediko-genetikuri konsultirebis poziciidan.

qvemoT moyvanilia testebi, romelic gamoiyeneba Th-is diagnostirebisaTvis.

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cxrili #2. Th-is diagnostikis testebi

diagnozis verificireba TSH, FT4

etiologiuri diagnostika

1. scintigrafia 99mTc an 123I 2. testi perqloratiT 3. fj-is ultrasonografia 4. Tireoglobulinis gansazRvra 5. iodis eqskreciis gansazRvra 6. TSH-r-is mablokirebeli

antisxeulebis gansazRvra dedisa da bavSvis sisxlSi

radgan Th-is yvelaze xSiri mizezi fj-is disgeneziaa, yvelaze informaciul diagnostikur tests warmoadgens scintigrafia. arCevis izotopi aris 123I, romelic sxivuri datvirTvis minimizirebis saSualebas iZleva. SeiZleba 99mTc-is gamoyeneba, magram igi koncentrirdeba mxolod Tirocitebis mier da ar xdeba misi organifikacia. eqtopirebuli fj-is qsovilis aRmoCena adasturebs disgenezias. Tu ar xdeba izotopis STanTqma, rogorc wesi, saqme gvaqvs fj-is ageneziasTan (aTireozi), Tumca unda gvaxsovdes, rom msgavsi suraTi SeiZleba miviRoT TSH-r-is defeqtis, fj-Si iodis transportis darRvevis an dedis mablokirebeli antisxeulebis receptorebis blokadis dros.

ultrasonografia saSualebas iZleva davadginoT fj-is gadideba an ararseboba anatomiurad Cveul topografiul adgilas, magram igi arainformaciuli iqneba eqtopiis dros.

iodis organifikaciis defeqtis dros mizanSewonilia perqloratiT testis Catareba, roca perqloratis Seyvanis Semdeg radiofarmpreparatis CarTva mcirdeba.

Tg-is gansazRvra metad informaciulia. Tu Tg-is done ar isazRvreba da scintigrafiiT izotopis CarTva ar xdeba, dasturdeba ageneziis diagnozi. magram Tu scintigrama normaluria Tg-is ararsebobis fonze – adgili aqvs Tg-is sinTezis defeqts. Tg-is donis mateba aRiniSneba bavSvebSi Th-iT, romelTac aqvT T4-is sinTezis defeqti, magram fj-s SenarCunebuli aqvs unari gamoimuSavos Tg.

dedis TSH-r-is antisxeulebis aRmoCena gvafiqrebinebs, rom axalSobilebSi Th swored am antisxeulebis mier aris gamowveuli. igive antisxeulebi eqneba axalSobilsac. scintigrafiiT miviRebT fj-is blokadis suraTs, rogorc aplaziis dros, magram sonografiiT fj iqneba normaluri zomis Cveuli anatomiuri lokalizaciis adgilas.

Tu cnobilia, rom dabadebis Semdeg axalSobilis organizmSi moxvda didi raodenobiT iodi (magaliTad, garegani antiseptikuri saSualebis an

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sakontrasto nivTierebis saxiT), Th-is mizezebis diferenciuli diagnostikis mizniT mizanSewonilia SardSi iodis eqskreciis gansazRvra.

7. mkurnaloba

yvela axalSobils, visac aqvs dadasturebuli Th, CiyviT Tu Ciyvis gareSe dauyovnebliv unda daewyos mkurnaloba Tireoiduli hormonebiT. optimaluri gamosavali damokidebulia droul da adeqvatur mkurnalobaze, gansakuTrebiT iseT mZime SemTxvevebSi, roca T4<5 mkg/dl. Mmkurnalobis mizania T4-is norma-lizeba rac SeiZleba male, SemdgomSi ki levoTiroqsinis im dozis SerCeva, romelic uzrunvelyofs Tireoiduli funqciis myar kompensacias.

arCevis meTodad iTvleba mkurnaloba levoTiroqsiniT. miuxedavad imisa, rom T3 biologiurad ufro aqtiuria, misi gamoyeneba monoTerapiis an kombinirebuli preparatebis saxiT ar aris rekomendebuli, vinaidan cirkulaciaSi myofi T3 ar axdens gavlenas Tavis tvinis ujredebze. Tavis tvinSi arsebuli T3 am ujredebSi myofi T4-is monodeiodirebis Sedegad aris warmoqmnili. Ggamoyenebuli unda levoTiroqsinis mxolod tabletirebuli forma. Aabi unda daifSvnas da gaixsnas wyalSi. Ppreparati ar unda iqnas miRebuli rkinis, soios da ujredisiT mdidar sakvebTan erTad.

levoTiroqsinis Sewovas xels uSlis kalciumis Semcveli preparatebi, antikonvulsantebi da agreTve malabsorbciiT mimdinare daavadebebi.

levoTiroqsinis rekomendebuli sawyisi dozaa 10-15 mkg/kg dReRameSi. iTvleba, rom es doza usafrTxoa axalSobilebSi hiperTireozis ganviTarebis TvalsazrisiT. Aam SemTxvevaSi T4 normalizeba xdeba erT kviraSi.

mkurnalobis dawyebidan 2 kviraSi T4–ma unda moimatos 10mkg/dl-mde, xolo FT4-

ma - 2ng/dl-ze metad, TSH ki unda normalizdes 1 TveSi. mkurnalobis dawyebidan erT kviraSi T4-is gansazRvriT SesaZlebelia mkurnalobis adeqvaturobis Sefaseba. T4-is dozis koregireba unda moxdes individualuri pasuxis mixedviT, FT4-isa da TSH-is koncentraciaze dayrdnobiT.

mkurnalobis ganmavlobaSi, pirveli 3 wlis manZilze, sisxlSi saerTo T4 da FT4

unda SenarCundes normis zeda zRvaris farglebSi T4 - 10-16 mkg/dl (130-206 nmol/l); FT4 - 1.4-2.3 ng/dl (18-30 nmol/l), xolo TSH-is koncentracia ki 0.5-2.0 s.e./ml. 3 wlis manZilze bavSvi unda imyofebodes eqimis mudmivi meTvalyu-reobis qveS da utardebodes xSiri gasinjvebi. aseve aucilebelia mSoblebis informirebaze mudmivi zrunva.

Tu CanacvlebiTi Terapiis dros 6 Tvis asakis Semdeg aRiniSneba TSH-is arasak-marisi supresiis (>5 s.e./ml) 4 epizodze meti es SemdgomSi gavlenas moaxdens bavSvis akademiur moswrebaze. rogorc wesi, amis mizezi SeiZleba iyos mSoblebis uyuradReboba, an/da preparatis SewovasTan dakavSirebuli problemebi.

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cxrili #3. levoTiroqsinis saorientacio dozebi Th-is SenacvlebiTi Terapiis dros

asaki levoTiroqsini mkg/kg

dReRameSi sawyisi doza 10-15 0-3 Tve 8-12 3-6 Tve 7-10 6-12 Tve 6-8 1-3 weli 4-6 3-10 weli 3-5

xangrZlivi monitoringi

optimaluri zrda-ganviTarebisa da farisebri jirkvlis normaluri funqciis uzrunvelsayofad pirveli 3 wlis manZilze aucilebelia bavSvis zrdis da fsiqomotoruli ganviTarebis 3 TveSi erTxel Sefaseba. bavSvebs Tandayolili hipoTireoziT aqvT sxva Tandayolili anomaliebis ganviTarebis maRali riski - daaxloebiT 10%-mde, rac saerTo populaciaSi ar aRemateba 3%-s. gansakuTrebiT xSiria kardio-vaskularuli paTologiebi: filtvis arteriis stenozi, winagulTaSoris Zgidis defeqti, parkuWTaSoris Zgidis defeqti.

sisxlSi TSH-isa da FT4-is kontroli unda moxdes Semdegi sqemiT:

1. mkurnalobis dawyebidan - 2-4 kviraSi; 2. pirveli 6 Tvis manZilze yovel - 1-2 TveSi; 3. 6 Tvidan 3 wlamde - 3-4 TveSi erTxel; 4. zrdis dasrulebamde - 6-12 TveSi; 5. an ufro xSirad, Tu:

- mkurnaloba araefeqturia; - hormonebi ar aris normaSi; - medikamentis doza an miRebis wesi Seicvala; - 4 kviraSi erTxel T4-is dozis nebismieri cvlilebis dros.

mkurnalobis mizania optimaluri zrda-ganviTarebis uzrunvelyofa pirveli wlis manZilze T4-isa da FT4-is koncentraciis normis zeda zRvarze da TSH-is 0.5-2.0 s.e./l-is farglebSi SenarCuneba.

T4-is donis normis zeda zRvarze arsebobis miuxedavad zogierT bavSvs TSH unarCundeba 10-20 s.e./ml-is farglebSi, rac mucladyofnis periodSi ganviTarebuli hipoTireoziT aris gamowveuli. TuMmkurnalobidan 2 kviris Semdeg FT4 ar gaizarda da 4 kviraSi TSH<20 s.e./ml-mde ar daiwia, aucilebelia mkurnalobis sqemis, preparatis miRebis wesis da dozis gadamowmeba. sayuradReboa, rom Warbi dozireba metad arasasurvelia, radgan iwvevs Tavis qalas nakerebis naadrevad gaZvalebas. aucilebelia rentgenografiuli kvleva – “Zvlovani asakis” yovelwliuri Sefaseba.

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fsiqiuri ganviTarebis da inteleqtis Semowmeba pirvelad tardeba 1-1,5 wlis asakSi, meored 5 wlis asakSi.

gamosavali

bavSvebs, romelTac uwyveti da adeqvaturi mkurnaloba utardebaT _ zrdis tempi da saboloo simaRle normaluri aqvT. saukeTeso gamosavali aReniSnebaT pacientebs, romelTac 2 kviris asakamde daewyoT mkurnaloba da iRebdnen levoTiroqsins saSualod 9.5 mkg/kg-ze yoveldRiurad. Aam SemTxvevaSi Zalian mcirea gansxvaveba inteleqtis koeficientis (IQ) donis, skolaSi moswrebasa da neirofsiqologiur testebSi adreuli asakidan namkurnaleb hipoTireozian bavSvebsa da maT janmrTel Tanatolebs Soris.Ggansxvaveba ZiriTadad Seexeba mxedvelobis, seleqciuri mexsierebis da sensomotorul sferoebs.

Tu skriningis pirobebSi Tavidanve ar iqna dadgenili Tandayolili hipoTireozi da mkurnaloba 2 Tvis Semdeg daiwyo, miuxedavad kargi fizikuri ganviTarebisa, bavSvebs eqnebaT IQ-is daqveiTeba. agreTve tvinis dazianebis iseTi niSnebi, rogoricaa angariSis, unaris, metyvelebisa da wvrili motorikis SezRudva. hipoTireozis simZimesTan erTad gamosavals ganapirobebs mkurnalobis drouloba, uwyvetoba da preparatis swori dozireba.

orsulobis pirvel trimestrSi, nayofis tvins Camoyalibebis procesSi dedis farisebri jirkvlis hormonebi icavs, Aamitom pirvel trimestrSi dedis hipoTireozi neiroganviTarebis mZime, Seuqcevad darRvevas iwvevs. farisebri jirkvlis ararsebobis SemTxvevaSic ki, marTalia axalSobils T4-is koncentracia normis 25-50% aqvs, magram mainc gadamwyvet rols asrulebs tvinis ganviTarebaSi. amitom, SeiZleba CaiTvalos, rom adreuli asakidan namkurnaleb pacientebSi inteleqtis dabali done arasrulfasovani mkurnalobis Sedegia.

hipoTireozis mudmivobis Sefaseba

Tandayolili hipoTireozi mudmivia, Tu dadginda farisebri jirkvlis eqtopia (radioizotopuri skanirebiT), aTireozi (SesaZlebelia ultrasonografiiT dadasturdebac) an TSH done dabadebidan erTi wlis Semdegac aRemateba 10 s.e./ml-s.

Tu skanirebiT ar gamovlinda hipoTireozis permanentuli mizezi, TSH-is done normaluria mTeli dakvirvebis periodSi, levoTiroqsinze moTxovna minimaluria, xolo sonografiiT farisebri jirkvali normaSia an gadidebuli, 2-3 wlis asakSi unda moxdes levoTiroqsiniT mkurnalobis 30

dRiT Sewyveta, ris Semdegac unda ganisazRvros sisxlSi FT4 da TSH. Tu FT4-is done daiwevs, xolo TSH moimatebs, mudmivi hipoTireozis arseboba dasturdeba da unda moxdes CanacvlebiTi Terapiis ganaxleba. Tu mkurnalobis 30-dRiani Sewyvetis Semdeg hormonebi normis farglebSia, maSin mdgomareoba fasdeba, rogorc tranzitoruli HhipoTireozi, magram bavSvebi rCebian eqimis

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meTvalyureobis qveS, raTa recidivis SemTxvevaSi moxdes drouli diagnostireba da Careva.

anamnezSi mZime hipoTireoziT namkurnalev bavSvebSi, magram mocemul etapze Tireoiduli funqciis myari kompensaciiT mkurnalobis Sewyvetis Sedegad SeiZleba ganviTardes hipoTireoiduli mdgomareoba. amitom rekomendebulia 30 dRis ganmavlobaSi dozis ganaxevreba da ara sruli Sewyveta. Aamis Semdeg, Tu TSH> 20 s.e./ml-ze, sabolood dadasturdeba permanentuli hipoTireozi da bavSvi rCeba levoTiroqsiniT mudmiv SenacvlebiT Terapiaze. Mmagram arsebobs mcire Sansi, rom TSH-is momateba ar moxdes. am SemTxvevaSi mkurnaloba sruliad wydeba kidev 30 dRiT da ganmeorebiT xdeba FT4 da TSH-is Sefaseba.

zogadad skriningis normaluri pasuxis SemTxvevaSi eqimma unda gaiTvaliswinos, rom hipoTireozi SeiZleba skriningis Semdegac ganviTardes, an subieqturi Tu obieqturi faqtorebis gamo testi iyos mcdari. amitom Tu saxezea hipoTireozis niSnebi, dauyovneblivi unda iqnes gamokvleuli FT4 da TSH.

8. gaidlainis gadasinjvisa da ganaxlebis vada - 2 weli.

9. gaidlainis miRebis xerxi/wyaro

gaidlainis SemuSavebis meTodologia:

- axalSobilebSi Tandayolili hipoTireozis skriningisa da mkurnalobis Sesaxeb arsebobs mecnieruli mtkicebulebis safuZvelze Seqmnil rekomendaciaTa sakmarisi raodenoba. mocemuli gaidlainis Seqmnis procesSi samuSao jgufis gadawyvetilebiT moZiebuli da Sefasebuli iqna ukve arsebuli praqtikuli rekomendaciebi. moxda arsebuli rekomendaciebis adaptirebuli variantis SemuSaveba, romelic erTi mxriv pasuxobs saerTaSoriso moTxovnebs, xolo meore mxriv iTvaliswinebs saqarTvelos samedicino dawesebulebaTa rogorc adamianur, ise teqnikur resursebs.

- rekomendaciaTa moZieba xorcieldeboda eleqtronul monacemTa bazis gamoyenebiT:

- http://pediatrics.aappublications.org/cgi/content/full/117/6/2290.

10. alternatiuli gaidlaini - ar arsebobs

1

0

19

11. gamoyenebuli literatura:

1. Флетчер Р., Флетчер Ф., Вагнер Э. Клиническая эпидемиология. Основы доказательной

медицины. М: Медиа Сфера, 1998.

2. Gruters A, Biebermann H, Krude H. Neonatal thyroid disorders.Horm Res. 2003;59(suppl

1):24–29

3. Heindel JJ, Zoeller RT. Thyroid hormone and brain development: translating molecular

mechanisms to population risk. Thyroid. 2003;13:1001–1004

4. Kopp P. Perspective: genetic defects in the etiology of congenital hypothyroidism.

Endocrinology. 2002;143:2019–2024

5. Radetti G, Zavallone A, Gentili L, Beck-Peccoz P, Bona G.Foetal and neonatal thyroid

disorders. Minerva Pediatr. 2002; 54:383–400

6. Kester MH, Martinez de Mena R, Obregon MJ, et al. Iodothyronine levels in the human

developing brain: major regulatory roles of iodothyronine deiodinases in different areas. J Clin

Endocrinol Metab. 2004;89:3117–3128

7. Haddow JE, Palomaki GE, Allan WC, et al. Maternal thyroid during pregnancy and subsequent

neuropsychological development of the child. N Engl J Med. 1999;341:549–555

8. de Escobar GM, Obregon MJ, del Rey FE. Maternal thyroid hormones early in pregnancy and

fetal brain development. Best Pract Res Clin Endocrinol Metab. 2004;18:225–248

9. Working Group on Neonatal Screening of the European Society for Paediatric Endocrinology.

Revised guidelines for neonatal screening programmes for primary congenital hypothyroidism.

Horm Res. 1999;52:49–52

10. LaFranchi SH, Snyder DB, Sesser DE, et al. Follow-up of newborns with elevated screening T4

concentrations. J Pediatr. 2003;143:296–301

11. DeLange F, Burgi H, Chen ZP, Dunn JT. World status of monitoring iodine deficiency disorders

control programs. Thyroid. 2002;12:915–924

12. Glinoer D. Pregnancy and iodine. Thyroid. 2001;11:471–481

13. Heyerdahl S, Oerbeck B. Congenital hypothyroidism: developmental outcome in relation to

levothyroxine treatment variables. Thyroid. 2003;13:1029–1038

14. Murphy N, Hume R, van Tor H, et al. The hypothalamicpituitary- thyroid axis in preterm

infants: changes in the first 24 hours of postnatal life. J Clin Endocrinol Metab. 2004;89: 2824–

2831

15. LaFranchi SH, Hanna CE, Krainz FL, Skeels MR, Miyahira RS, Sesser DE. Screening for

congenital hypothyroidism with specimen collection at two time periods: results of the

Northwest Regional Screening Program. Pediatrics. 1985;76:734–740

16. Fisher DA. Disorders of the thyroid in the newborn and infant. In: Sperling MA, ed. Clinical

Pediatric and Adolescent Endocrinology. Philadelphia, PA: Saunders; 2002:164

17. Calaciura F, Motto RM, Miscio G, et al. Subclinical hypothyroidism in early childhood: a

frequent outcome of transient neonatal hyperthyrotropinemia. J Clin Endocrinol Metab. 2002;

87:3209–3214

18. Brown RS, Bellisario RL, Botero D, et al. Incidence of transient congenital hypothyroidism due

to maternal thyrotropin receptor- blocking antibodies in over one million babies. J Clin

Endocrinol Metab. 1996;81:1147–1151

19. Daliva AL, Linder B, DiMartino-Nardi J, Saenger P. Three-year follow-up of borderline

congenital hypothyroidism. J Pediatr. 2000;136:53–56

20. Cody D, Kumar Y, Ng SM, Didi M, Smith C. The differing outcomes of hyperthyrotropinaemia.

J Pediatr Endocrinol Metab. 2003;16:375–378

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2

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21. Asakura Y, Tachibana K, Adachi M, Suwa S, Yamagami Y. Hypothalamo-pituitary

hypothyroidism detected by neonatal screening for congenital hypothyroidism using

measurement of thyroid-stimulating hormone and thyroxine. Acta Paediatr. 2002;91:172–177

22. Kok JH, Briet JM, Van Wassenaer AG. Postnatal thyroid hormone replacement in very preterm

infants. Semin Perinatol. 2001;25:417–425

23. Markou K, Georgopoulos N, Kyriazopoulou V, Vagenakis AG. Iodine-induced hypothyroidism.

Thyroid. 2001;11:501–510

24. Kreisner E, Camargo-Neto E, Maia CR, Gross JL. Accuracy of ultrasonography to establish the

diagnosis and aetiology of permanent primary congenital hypothyroidism. Clin Endocrinol.

2003;59:361–365

25. Cassio A, Cacciari E, Cicognani A, et al. Treatment for congenital hypothyroidism: thyroxine

alone or thyroxine plus triiodothyronine? Pediatrics. 2003;111:1055–1060

26. Elmlinger MW, Kuhnel W, Lambrecht HG, et al. Reference intervals from birth to adulthood

for serum thyroxine (T4), triiodothyronine (T3), free T3, free T4, thyroxine binding globulin

(TBG) and thyrotropin (TSH). Clin Chem Lab Med. 2001; 39:973–979

27. Baloch Z, Carayon P, Conte-Devolx B, et al. Laboratory medicine practice guidelines:

laboratory support for the diagnosis and monitoring of thyroid disease. Thyroid. 2003;13:3–126

28. Morin A, Guimarey L, Apezteguia M, Ansaldi M, Santucci Z. Linear growth in children with

congenital hypothyroidism detected by neonatal screen and treated early: a longitudinal study. J

Pediatr Endocrinol Metab. 2002;15:973–977

29. Oerbeck B, Sundet K, Kase BF, Heyerdahl S. Congenital hypothyroidism: influence of disease

severity and L-thyroxine treatment on intellectual, motor, and school-associated outcomes in

young adults. Pediatrics. 2003;112:923–930

30. Rovet JF. Congenital hypothyroidism: an analysis of persisting deficits and associated factors.

Child Neuropsychol. 2002;8: 150–162

31. Rovet J, Daneman D. Congenital hypothyroidism: a review of current diagnostic and treatment

practices in relation to neuropsychologic outcome. Paediatr Drugs. 2003;5:141–149

32. Song SI, Daneman D, Rovet J. The influence of etiology and treatment factors in intellectual

outcome on congenital hypothyroidism. J Dev Behav Pediatr. 2001;22:376–384

33. Eugster EA, LeMay D, Zerin JM, Pescovitz OH. Definitive diagnosis in children with

congenital hypothyroidism. J Pediatr. 2004;144:643–647

34. Indicatorsfor Assesing iodine deficiency disorders and their control through salt iodization. N6.

WHO\NUT. Geneva, 1994.

35. International thyroid testing guideilnes. National academy of clinical biochemistry. Los

Angeles, 2001.

12. avtorTa jgufi:

avtorebi:

marina gordelaZe - medicinis doqtori, Tbilisis saxelmwifo samedicino universitetis Sinagani medicinis departamentis asistent-profesori endokrinologiaSi

maka gumberiZe-RvinefaZe - pediatri, “rostropoviC-viSnevskaias fondi saqarTveloSi bavSvTa janmrTelobisa da momavlisaTvis”, proeqtis menejeri.

21

eqspertebi:

daviT virsalaZe – v.iverielis saxelobis saqarTvelos endokrinologTa sazogadoebis Tavmjdomare;

maia xerxeuliZe - saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros eqsperti pediatri;

lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

TaTia ZagniZe - saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti.

22

danarTebi

danarTi #1

FT4-isa da TSH-is normativebi (National academy of clinical biochemistry, 2001)

asaki

TSH-is donis Sefardeba bavSvebsa da mozardebSi

TSH, s.e./ml

FT4-is donis Sefardeba bavSvebsa da mozardebSi

FT4, pmol/l (ng/dl)

nayofi orsulobis Sua periodSi

2.41 0.7-11 0.2 2-4 (0.15-0.34)

axalSobilebi mcire masiT (Wiplaris sisxlis Srati)

4.49 1.3-20 0.8 8-17 (0.64-1.4)

drouli axalSobilebi

4.28 1.3-19 1.0 10-22 (0.8-1.9)

me-3 dReze 3.66 1.1-17 2.3 22-49 (1.8-4.1) 10 kviramde 2.13 0.6-10 1.0 9-21 (0.8-1.7) 14 Tvemde 1.40 0.4-7.0 0.8 8-17 (0.6-1.4) 5 wlamde 1.20 0.4-6.0 0.9 9-20 (0.8-1.7) 14 wlamde 0.97 0.3-5.0 0.8 8-17 (0.6-1.4) mozrdilebi 1.0 0.3-4.0 1.0 9-22 (0.8-1.8)

23

danarTi #2

Th-is skriningisa da mkurnalobis sqema

algoriTmi

1

3

TSH dabadebidan 48 saaTis Semdeg

>100 s.e./ml

40-100 s.e./ml

20-40 s.e./ml

konfirmaciuli

kvleva (FT4, TSH)

<20 s.e./ml

(gadarCevis zRurbli)

norma Tandayolili hipoTireozi

iniSneba mkurnaloba (ix. gaidlaini) da

bavSvi imyofeba xangrZlivi dakvirvebis qveS

mkurnaloba iniSneba

konfirmaciuli kvlevis

Sedegebamde (ix. gaidlaini)

FT4, TSH normaSia FT4, TSH ar aris

normaSi