The number of people killed in the Damascus suburb of Eastern Ghouta has reached 179 after a little over two weeks of government and Russian bombardment, according to the UK-based Syrian Observatory for Human Rights (SOHR).
Government forces backed by Russian warplanesbegan a campaign to take the rebel-held district on December 29, relying mainly on artillery barrages and air attacks.
SOHR, which gathers details of casualties from a network of sources inside the country, said on Friday that those killed in the latest escalation in violence include 51 children and 38 women
Syrian activists on social media have been posting images said to be from Eastern Ghouta, which show children being pulled out dead or heavily wounded from mounds of rubble.
Al Jazeera has not independently verified the images or figures.
Eastern Ghouta, which has been under siege by pro-government forces since 2013, is home to close to 400,000 people.
The four-year siege has led to a major humanitarian crisis, with severe food and medicine shortages.
In November, the UN Special Envoy for Syria, Jan Egeland called the situation in the area a "man-made disaster" and warned that many of its residents were "acutely malnourished" and close to dying.
The violence in Eastern Ghouta coincides with a government offensive in the northern province of Idlib where some estimates put the number of those who have fled fighting at 280,000.
Like in eastern Damascus, the Syrian government is trying to dislodge an array of rebel groups, but Idlib holds special significance for the opposition as one of its last remaining strongholds.
The region is located within one of the so-called de-escalation zones demarcated by Russia, Iran, and Turkey, where fighting was expected to cease.
Ankara has summoned Russian and Iranian diplomats over the fighting.
However, buoyed by victories elsewhere in the country and with momentum on its side, the Syrian government has pushed to reclaim the area.
Syria's Civil War has raged on since 2011, claiming close to half a million lives and sending millions to neighbouring countries and Europe as refugees.