Chuyn 20: a i Cu 1: a i cp, chn on v x tr a i l lng nc i nhiu hn bnh thng cng tui thai.

hai. Bnh thng nc i tng cho n khi tui thai 36ws, lc ny lg nc i vo khong 1000ml, nhng sau lg nc i s gim dn, nu lg nc i > 2000ml c gi l a i. a i cp khi lng nc i tng rt nhanh trong vng 2-3j, thng xra vo 3 thng gia thai k (thng 4, 5) 1. Triu chng 1.1 Lm sng a. C nng Bng to nhanh, cng v au tc t ngt lm sn ph c cm gic mun v bng ra au vng tht lng lan ra sau, xung i Kh th, tc ngc nhiu khi ko nm c phi ngi Bun nn, nn, n ung km, mt ng C th c dh chn p BQ, trc trng: i tiu tin kh Bng to nhanh -> SP chm chp, nng n Tinh thn lo lng, s hi, mt mi, hc hc Ph: do TC to, chn p vo cc TM ln + Ph 2 chi di, m h v thnh bng vi c im ph trng, mm, n lm + Cng c th ph ton thn Mch nhanh, HA bnh thng, ko st TH nng c th thiu niu Da bng cng bng, ph n, c np rn da mi xh mu tm. Bng to ln r tng ngy, bng to, trn u TC kch thc ln hn tui thai, to ln nhanh trong vng vi ngy, vi gi c th tng gp i, TC trn u Chiu cao TC ln hon nhiu so vi tui thai

b. Ton thn

c. Thc th

S nn: kh x cc phn ca thai nhi. C dh bp bnh cc ni khi nn vo cc phn ca thi Tim thai m or ko nghe thy bng ng nghe g Thm : CTC gin rng, mng i cng phng, kh x ngi thai

1.2 Cn lm sng a. Siu m Lng nc i nhiu, nh gi da vo ch s i: l tng s o chiu su ca 4 ti i ln nht 4 gc ca thnh bng ngi m, o theo phng thng ng (> 24cm) nh gi hnh thi hc ca thai nhi, pht hin d dng thai nhi b. Chc nc i xt nghim TB hc, NST c. Xt nghim x nguyn nhn t m: ure, cre mu, protein niu, ng niu, ng mu, men gan, nhm mu Rh m con 2. Chn on 2.1 X: da vo tr/ch LS v CLS (b l siu m) 2.2 Phn bit C chng/ BN c thai Thai to TC cng ln hn so vi tui thai Nhng bng to ln t t, tng u trg sut thai k Nn r cc phn ca thai Bng to thg b ngang, rn li, c tun hon bng h Dh sng v G c vng thp C th tm thy nguyn nhn c chng: x gan, K gan, suy tim... Siu m gip chn on phn bit Bng ko to ln t ngt, t au tc bng TC ko trn u S thy cc phn ca thai, tim thai (+) C th b rong huyt trc S: phn bit

C thai km u x TC, u nang BT, khi u trong bng

a thai -

Tim thai nghe r S: phn bit, x trng lg thai Bng to nhanh, u sut thai k Nghn nhiu Thai my nhiu v tr Tim thai nghe r, nhiu S: phn bit Ging: Bng to ln nhanh, au bng, tim thai ko nghe r or mt Khc: Thng vo 3 thng cui ca thai k au bng d di Ra mu ko ng, en, long Thng c HC tin sn git C chong mt mu TC tng trng lc, cng tnh, co cng S: khi mu t sau rau, xt nghim: SSH gim or = 0

Rau bong non

BQ y nc tiu Chn on x nh t sonde BQ thy bng bt cng, nc tiu chy ra Hay gp trg k u thai k Ra mu t nhin, t mt, dai dng, mu en hCG rt cao S: hnh nh tuyt ri, chm nho, rut bnh m trg BTC, ko c h/ thai U nang BT xon BN c thai TS c chn on khi u nang BT au bng t ngt, d di Chong do au, mt mu Phn ng thnh bng, kh s thy cc phn ca thai, TT (+) Thm : s thy khi u, chm vo au chi S: thy thai v u nang BT Cha trng

Khi u to trg bng Bnh din bin t t: khi u mc treo, u thn S gip chn on phn bit

3. X tr 3.1 Thi x tr a i thg km theo d dng thai nhi -> cn lm xt No (NST, S...) pht hin d dng Nu thai d dng, ko cn kh nng sng -> ch ng ly thai ra Nu thai bnh thg, tnh trng ca SP tt, c gi ti thng, ch chuyn d t nhin 3.2 X tr tng th ca a i a. Th nh C 1 ti i m chiu su theo phng thng ng 8-11cm Theo di, ko cn tr g C 1 ti i m chiu su theo phng thng ng 12-15cm Ngh ngi ti ging, n nht, gim lng nc ung. Theo di BN, nu c tr/ch kh th, au bng phi nhp vin ngay + Li tiu: Lasix dng km vi Kali, ko nn dng ko di + An thn, KS B-Lactam (do vim nhim mng i -> tng tit) + Liu php Indomethacin 1,5 3 mg/kg/j Td: Gim ch tit dch phi Tng hp thu dch phi Gim bi tit nc tiu ca thai nhi Tng tnh thm qua mng thai Chc i lm xt nghim TB hc, NST S nhiu ln theo di tin trin bnh, pht hin bt thng ca thai Chiu su ca 1 ti i theo phng thng ng > 15cm, thng km theo d dng thai Cho thai ph ngh ngi, n nht, hn ch ung nc, dinh dng tt Dng li tiu: Lasix km Kali, ko nn dng ko di

b. Th va

c. Th nng

KS: B-Lactam, an thn Seduxen 5mg 1v/ti Gim co: Papaverin 0.04mg 2-4 v/j Chc i + Gip lm gim tr/ch cho m + Lm xt nghim TB hc, NST + Mi ln ly ra 1500ml nc i, m bo v trng, chc i di s hng dn ca S + BC: v i, NT, vim mng i Liu php Indomethacin 1,5 3 mg/kg/j S theo di thng xuyn tin trin ca bnh, pht hin bt thng ca thai

Nu thai d dng th bm i cho . Nu thai ko bt thng, tr ni khoa c p ng -> gi thai n khi thng CTN khi: Lng nc i vn tng nhanh sau chc i v tr ni khoa ko kt qu -> bm i (lu tia i gim p lc t t trnh sa dy rau), thng sau khi v i s c cn co TC v cuc chuyn d bnh thg Sau khi s thai d b TC, st rau, st mng -> KSTC 1 cch c h thng, thuc co hi TC, KS phng NK Theo di tnh trng ca SP: M, HA, ra mu , NK 4. Tin trin v tin lng Tin trin + au nhiu, kh th do lng nc i nhiu, tng nhanh -> chc i gip sn ph d chu nhng d gy chuyn d + Sau cn kch pht, th tch TC tng nhanh hn bnh thg -> v i t ngt -> non Tin lng: thg gy sy thai, non, st rau sau , TC, t vong con

Cu 2: a i mn, chn on v x tr a i l lng nc i nhiu hn bnh thg cng tui thai. a i mn l lg nc i tng t t, thg xh trong 3 thng cui ca thai k, lg nc i tng va phi Thai thng: lg nc i > 2000ml -> a i, 1000-2000ml l i Bnh thng thai 28ws = 1000 ml 36ws = 900ml 40ws = 800ml 1. Triu chng 1.1 Lm sng a. C nng: tr/ch t rm r nh a i cp Cm gic tc vng bng di, mi 2 bn tht lng Thng ko gy kh th or kh th t

Thai c v p t C th c dh chn p: i tiu tin kh t thay i, c th mt mi, nng n C th ph 2 chi di, ph mm trng n lm Bng to, trn u, da bng cng va, c th c tun hon bng h, np rn da (c mi v c) TC to hn so vi tui thai (o chiu cao TC v vng bng) S cc phn ca thai kh, thai c v nh Tim thai nghe kh Thm : Ngi thai cao, lng CTC h m, u i phng on di cng phng

b. Ton thn

c. Thc th

Khi chuyn d + TC co bp ko tt + Ngi thai bnh chnh km + CTC xa m km + Nu i v t nhin d gy sa chi, sa dy rau

1.2 Cn lm sng a. Siu m Lng nc i nhiu hn bnh thg da vo ch s i: l tng s o chiu su ca 4 ti i ln nht 4 gc trn thnh bng ngi m, o theo phng thng ng Pht hin d dng thai nh gi s lg thai v tnh trng TC Ngoi ra cn gip pht hin bnh l khc ca m

b. Chc i: xt nghim TB hc, NST c. Xt nghim tm nguyn nhn t m: ure, cra mu, G mu, G niu, protein niu, men gan 2. Chn on 2.1 X: da vo tr/ch LS v CLS, ch yu l S

2.2 Phn bit (cu 1) C chng/ c thai Thai to a thai U x TC/ c thai U nang BT/ BN c thai Bng to ko u C khi di ng, bit lp vi TC, ranh gii r S: i bnh thg, thy h/nh u nang

BQ y nc tiu 2.3 Chn on nguyn nhn Thg kt hp vi m c bnh tiu ng, ngi ng min dch Thai d dng h thng TK trung ng v tiu ha (thai v s kt hp vi teo thc qun) 2/3 TH a i l t pht 3. X tr 3.1 Thi x tr iu tr ni khoa l chnh, ch can thip sn khoa v ngoi khoa khi tr ni tht bi 3.2 Ni khoa Ngh ngi ti ging, n nht, gim lg nc ung Theo di ton trng ca m v thai trn LS, S An thn: Seduxen 5mg Thuc gim co TC: Papaverin 40mg, Spasmaverin 40mg Li tiu: Lasix ng 20mg, vin 40mg + C: lng nc tiu < 800ml/24h + Dng km Kali nhng ko nn dng ko di KS: B-Lactam Liu php Indomethacin 1,5 3 mg/kg/j + Td: Gim ch tit v tng hp thu dch phi Gim bi tit nc tiu Tng tnh thm qua mng thai

Chc i + Gip lm gim tr/ch cho m + Lm xt nghim TB hc, NST + Mi ln ly ra < 1500ml nc i, m bo v khun v tr 1/4 di tri ca bng, chc di hng dn ca S. Thi gian dn lu < 6h. + BC: v i, vim mng i, rau bong non... Theo di trg qu trnh tr: ton trng SP, lg nc i, thai nhi trg TH thai ko d dng

Nu p ng tr -> gi thai n thng, ch CD t nhin, nu ko k or tht bi MLT Nu ko p ng tr ni or a i mn m thai d dng th CTN ngay 3.3 Sn khoa Trc khi ly thai ra, bm i, ch chuyn d t nhin Khi thai thng + Nu CD: cn co TC tha, yu, CTC m ko tt, ngi thai bnh chnh km (hay gp), nu i cha v, thai ngi chm -> c th tia i ri bm i trnh sa dy rau, sa chi + Nu ko k or tht bi th m ly thai + Nu cuc CD din ra bnh thng, theo di tip tc ng di Sau s thai + Phng trnh TC, bng huyt do TC cng gin, rau bong chm KSTC 1 cch c h thng Thuc co hi TC: Oxytocin or Ergotamin + xoa TC Nu ko p ng c th phi ct TC bn phn cm mu + KS phng NK Hi sc s sinh tt, ktra xem c d dng ko Theo di tnh trng m: ra mu m o, co hi TC, NK -> pht hin sm BC

Cu 3: Nguyn nhn v c ch ca a i cp v mn 1. i cng a i l hin tng lg nc i nhiu hn bnh thg cng tui thai Lng nc i thg thay i theo tui thai a s tc gi cho rng khi thai thng, lg nc i > 2000ml l a i, t 10002000ml l i Thai 28ws, lng nc i l 1000ml Thai 36ws, lng nc i l 900ml Thai 40ws, lg nc i l 800ml a i l bnh l hay gp, t l a i ty thuc vo pp thm d (S nh gi ch s i) 2. C ch Bnh thg lg nc i ko thay i, mc d c ch sn sinh v tiu th nc i lun din bin lin tc trg i sng ca thai nhi trg TC. Sn sinh v tiu th nc i c gi mc cn bng -> lm cho lg nc i hng nh theo tui thai a i xh khi + Sinh nc i tng m tiu th bnh thg + Sinh nc i bthg m tiu th nc i gim + Sn sinh nc i tng m tiu th gim C ch lm tng sn sinh nc i + Tng ch tit do vim nim mc + Tng sx nc tiu ca thai nhi C ch lm gim tiu th nc i + Teo or tc ng tiu ha, thai nhi ko ung c nc i + Gim thm phn nc i qua ng h hp ca thai nhi + Gim thm phn qua mng m v gim chnh lch p sut thm thu gia nc i v h thng tun hon di mng m 3. Nguyn nhn v yu t nguy c 3.1 Do thai v rau thai U mu rau

 Thai n non Thai d dng + D dng h thng thn kinh: thai v s, no ng thy, thot v ct sng + D dng h thng tiu ha: teo rut, teo thc qun + D dng h thng tun hon v tim mch: tim BS, thng lin tht + D dng khc: u bng, ph thng 3.2 Do ngi m M b T, ng huyt thai cao lm tng sx nc tiu, tng p lc keo trg i nn ko nc i vo bung i Bt ng nhm mu m con M b tng huyt p khi c thai M b NT: giang mai, Leptospira, Toxoplasma Bnh ni khoa: bnh tim th nng, vim thn, suy thn, bo ph Tin sn git 3.3 Nguyn nhn ko r rng Cn tr c gii: Rau qun c, nt xon dy rau, u mch mu bnh rau Vim nhim mng i Ph thai rau 4. Phn loi 4.1 Theo thi gian a i cp + t gp + Thg xh 3 thng gia ca thai k + Th tch nc i tng nhanh trg vng vi ngy, LS rm r thg km theo thai d dng a i mn + Thg gp 3 thng cui + Nc i tng ln chm hn nn tr/ch LS kn o hn a i cp 4.2 Theo mc

 Th nh: Khi c 1 ti nc i o theo phng thng ng c chiu su 811cm Th TB: Khi c 1 ti nc i o theo phng thng ng c chiu su 1215cm

Th nng: Khi c 1 ti nc i o theo phng thng ng c chiu su

16cm 5. X tr 5.1 Nguyn tc x tr a i thg km theo d dng thai nhi, v vy cn lm xt No pht hin sm cc d dng thai nhi Nu thai d dng: t vn, CTN (bm i, tia i cho ng di) Nu thai ko d dng: c gng tr bo tn n khi thng 5.2 X tr c th Ni khoa a. Th nh: Theo di, ko cn phi tr Khm thai nh k b. Th va: Theo di BN nu c tr/ch kh th, au bng -> nhp vin Cho thai ph ngh ngi, n nht, hn ch ung nc, dinh dng tt Li tiu: Lasix dng km vi Kali, ko nn dng ko di An thn, KS B-Lactam (do vim nhim mng i -> tng tit) Liu php Indomethacin 1,5 3 mg/kg/j Td: Gim ch tit dch phi Tng hp thu dch phi Gim bi tit nc tiu ca thai nhi Tng tnh thm qua mng thai Chc i lm xt nghim TB hc, NST S nhiu ln theo di tin trin bnh, pht hin bt thng ca thai c. Th nng Cho thai ph ngh ngi, n nht, hn ch ung nc, dinh dng tt Dng li tiu: Lasix km Kali, ko nn dng ko di KS: B-Lactam, an thn Seduxen 5mg 1v/ti

 Gim co: Papaverin 0.04mg 2-4 v/j

Chc i + Gip lm gim tr/ch cho m + Lm xt nghim TB hc, NST + Mi ln ly ra 1500ml nc i, m bo v trng, chc i di s hng dn ca S + BC: v i, NT, vim mng i Liu php Indomethacin 1,5 3 mg/kg/j S theo di thng xuyn tin trin ca bnh, pht hin bt thng ca thai Tm v tr cc nguyn nhn gy a i t pha m Sn khoa Nu thai ko bt thng, tr ni khoa p ng -> gi thai n thng CTN khi lng nc i vn tng nhanh sau chc i, tr ni khoa tht bi, thai d dng -> bm i (lu tia i gim p lc t t, trnh sa dy rau, sa chi), thg sau khi v i s c cn co TC v cuc chuyn d bnh thg. a. Khi chuyn d CD trong a i thng ko di, cn co TC tha, yu, CTC m ko tt, ngi thai bnh chnh km (hay gp), nu i cha v, thai ngi chm -> c th tia i ri bm i trnh sa dy rau, sa chi Nu ko k or tht bi th m ly thai Nu cuc CD din ra bnh thng, theo di tip tc ng di b. Sau s thai Phng trnh TC, bng huyt do TC cng gin, rau bong chm + KSTC 1 cch c h thng + Thuc co hi TC: Oxytocin or Ergotamin + xoa TC + Nu ko p ng c th phi ct TC bn phn cm mu KS phng NK Hi sc s sinh tt, ktra xem c d dng ko

 Theo di tnh trng m: ra mu m o, co hi TC, NK -> pht hin sm BC