Deadly bombardments pounded the last opposition holdout in Syria's Eastern Ghouta on Saturday, after regime troops resumed a military blitz to pressure rebels to withdraw.
Backed up by Russia's firepower, Syrian President Bashar al-Assad has ousted his armed opponents from nearly all of Ghouta, their last stronghold on the edge of the capital.
The regime has used a combination of a fierce military onslaught and two negotiated withdrawals to empty out 95 percent of the enclave, but rebels are still entrenched in its largest town of Douma.
As Moscow pursued talks with Jaish al-Islam, the Islamist faction that holds Douma, bombing subsided and military operations appeared to be on hold for around ten days.
But the negotiations crumbled this week and air strikes resumed on Friday, killing 40 civilians according to the Syrian Observatory for Human Rights.
Another eight civilians were killed on Saturday as more bombing raids slammed into the town, the Britain-based Observatory said.
It could not confirm whether the strikes were carried out by Syrian government warplanes or those of its ally, Russia.
Firas al-Doumi, a rescue worker inside the battered town, told AFP military planes and helicopters were circling overhead.
"The bombing has not stopped. We can't even count all the wounded," said Mohammed, a young doctor inside Douma.
"There are some wounded who we couldn't operate on in time, and they died," he told AFP.
Six civilians were also killed and dozens more wounded as Douma rebels shelled the capital Damascus on Saturday, Syrian state media said.
State television broadcast live footage from a hospital in Damascus, where pools of blood stained the floor and wounded could be heard wailing in pain.
One woman cried over the lifeless body of a young man on a stretcher. Another said she had been riding in a taxi when the shelling started, and the car crashed head-on into a wall.
Assad is keen to recapture Ghouta to eliminate the opposition from the outskirts of Damascus and end years of rocket fire on the capital.
Abbas, a retired 57-year-old Syrian man, said his neighbourhood in the capital's west was being hit hard on Saturday.
"It looks like Douma is the end of the story, and endings are always hard," he told AFP.
"I'm waiting for the end of the fighters in Douma so people can live in peace. We've been waiting for this for years, whether in Ghouta or in Damascus," said Abbas.
The regime's offensive on Ghouta since February 18 has killed more than 1,600 civilians. It sliced the area into three isolated pockets each held by different rebel factions.
The first two were evacuated under Russian-brokered deals last month that saw more than 46,000 rebels and civilians bussed to opposition-held Idlib province in the northwest.
Tens of thousands also fled into government-controlled territory through safe passages opened by Russia and Syrian troops.
Moscow stepped in to negotiate a deal for Douma, the third and final pocket where Jaish al-Islam had been angling for a reconciliation agreement that would allow them to stay as a police force.
Following a preliminary accord announced by Russia on Sunday, nearly 3,000 fighters and civilians were evacuated from Douma to northern Syria.
But as talks dragged on, Syria and its Russian ally threatened Jaish al-Islam with a renewed military assault if they did not agree to withdraw.
It remains unclear exactly why the talks fell apart this week.
SANA said they faltered when Jaish al-Islam refused to release detainees they were holding in Douma, adding that the military assault would only stop if hostages are released.
Others have pointed to internal rebel divisions over the withdrawal process.
Top Jaish al-Islam political figure Mohammad Alloush on Friday blamed power struggles between the regime's allies.
"The talks were going well... Their only shared interests is the blood of civilians," he said.
Syrian troops were matching their renewed bombing with a ground operation in the orchards surrounding Douma.
On Saturday, fresh artillery fire hit those fields, said the Observatory.
"The regime is trying to tighten the noose around Douma from the west, east, and south," said Observatory head Rami Abdel Rahman.
Nawar Oliver, an analyst at the Omran Institute, told AFP Jaish al-Islam was facing "massive" military pressure.
"The negotiations failed and the regime wants its conditions -- the air strikes are a taste of what could happen if its conditions are not implemented," he said.