nh gi sc khe thai V Th Thy Diu YKHOA.

NET
NH GI SC KHE THAI
V Th Thy Diu
nh gi sc khe thai trc sanh nhm gim bnh sut v t sut chu sinh. Cc phng php nh gi sc
khe thai hin hnh bao gm m c ng thai, nonstress test, stress test, trc sinh vt l, siu m doppler.
Tng phng php u c nhng gii hn ring. Khng th c mt phc theo di sc khe thai tuyt i
p dng cho mi i tng bnh nhn. Vic tin hnh cc phng php th nghim nn da vo nhng
nguyn tc ch o chung. Bi tng quan ny da trn vic tra cu danh b Th nghim lm sng Nhm Thai
k v Sinh sn ca Cochrane cp nht mi nht vo thng 3/2007; nu ln nhng u th cng nh cc mt tn
ti ca tng phng php ngi c c mt thi la chn cc phng php nh gi sc khe thai mt
cch hp l nht t c tnh chun xc v st tht nht v tnh trng thai.
Assessment of fetal well-being
Antepartum fetal assessment is indicated in a hope to improve perinatal outcomes. Current options include the
fetal movement count, the nonstress test, the stress test, the biophysical profile and the doppler velocimetry.
All these modalities have limitations. There is no consistent protocol of antepartum fetal surveillance
applicable to all patients. The testing options could be implemented according to the general principles. The
review was carried out using the Cochrane Pregnancy and Childbirth Group trials register, last updated on
March 2007, highlighting the advantages and disadvantages of the current testing options. The results could
enhance the readers to implement the best testing options appropriately to their current condition.


Khoa Sn bnh, Bnh vin Hng Vng, 128 Hng Bng, Qun 05, Tp. HCM (VTT Diu ThS.BS)
Lin h: VTT Diu (email: vttdieu1975@yahoo.com.vn )


I. M u
nh gi sc khe thai (GSKT) c tm quan
trng hng u trong chm sc tin sn v c
nh hng n kt cc ca thai k cng nh s
pht trin tm sinh l ca b trong tng lai.
Theo Hip hi Sn Ph khoa (SPK) Hoa k
1999, mc tiu chm sc tin sn l ngn nga
cht thai [1]. Mt nghin cu hi cu ln trn
38.000 cc trng hp sanh t 1977-1985 ti
bnh vin a khoa Leeds, Anh Quc cho thy
khong 1/3 cc trng hp thai cht trc sanh
c th c ngn chn bng cc phng tin
mi trong vic nh gi sc khe thai i vi
cc thai k nguy c cao [2]. Trong cc trng
hp t vong chu sinh, khong 85,9% cc trng
hp cc b m khng c ch chm sc tin
thai hp l [3]. Tht vy, s kh khn v kinh
t vo cui nm 1984 Nigeria gy p lc v
chi ph y t, khin s lng cc thai ph n
khm v sanh ti bnh vin gim ng k.
Chnh v vy, t l t vong chu sinh nm 1984 l
38,7/1.000 tng ln v t nh cao l
110,5/1.000 vo nm 1987 ti bnh vin Wesley
Guild, Nigeria [4]. Ti Canada, t l t vong chu
sinh nm 2001 l 7,7/1.000 ca sinh sng, l t l
thp nht th gii [5]; mc d vy, cc tc gi
vn khng nh rng mt phn trong t l t
vong vn c th ngn chn c nu c ch
chm sc tin sn hp l. iu ny cng khng
nh vai tr ca n v chm sc tin sn.
Tuy nhin, hin nay trn th gii vn cha
c s ng thun v s nhn nh ngha v
gi tr ca cc phng php nh gi sc khe
thai (PPGSKT), iu ny khin cho cng tc
thc hnh lm sng lun gp nhng tr ngi
trong vic ch nh cng nh din gii kt qu
ca cc th nghim GSKT. Vi mong mun
c c ting ni chung gia cc nh sn khoa,
chng ti tng quan ti liu v cc PPGSKT
nhm cung cp nhng thng tin, nhng quan
im nhn nhn vn cc kha cnh khc
nhau c nhng thi hp l nht trong
nhng quyt nh lm sng.
II. Cch tng quan ti liu
Ngun d liu: cc ti liu gio khoa, cc mng
in t y khoa c th truy cp c; cc
khuyn co chnh thc ca cc Hip hi sn
ph khoa (SPK) uy tn v cc tng quan ca th
vin Cochrane c u tin nh gi.
T kha: antenatal fetal assessment,
antepartum fetal surveillance, fetal movement,
fetal kick count, Nonstress Test, Stress Test,


nh gi sc khe thai V Th Thy Diu YKHOA.NET
Biophysical profile, Doppler velocimetry.
Qun l ti liu tng quan: phn mm END
NOTE 10.0.2.
III. Ch nh nh gi sc khe thai
Cu hi lm sng trong cng tc thc hnh
lun c t ra l hin sc khe thai c ang
b e da v s dng bin php GSKT no
t tnh hp l v hiu qu nht. Ty nhm
thai k nguy c cao hay thp m c nhng cch
thc nh gi ring.
Thai k nguy c thp:
c qui vo nhm ny khi khng c bt k
yu t nguy c no. Cc phng php qui c
v thng dng nht GSKT i vi nhm thai
k nguy c thp bao gm [6]: theo di c ng
thai [7], o b cao t cung (BCTC), v nghe tim
thai
Thai k nguy c cao:
Khi c bt k yu t no sau y [8]:
Bnh l ca thai:
(i) Thai chm pht trin, (ii) Bt thng NST:
Trisomy 13, 18, 21, (iii) Nhim trng: TORCH,
st rt, HIV, giang mai, (iv) a thai
Bnh l ca m:
bnh tim bm sinh tm, cao huyt p, i tho
ng, bnh l thn, bnh t min, bnh l
tuyn gip, thai ph b suy dinh dng
Bt thng thai k:
(i) Gim c ng thai (xem thm phn III.1.),
(ii) Xut huyt m o bt thng, (iii) Thai
qu ngy, (iv) au bng khng r nguyn
nhn, (v) V i
Nhm thai k nguy c cao ty thuc vo tui
thai, bnh l km theo, s s dng c chn
la cc PPGSKT c nu sau.
IV. Cc phng php GSKT
1. m c ng thai (CT)
Mt trong nhng cch GSKT n gin nht l
m CT. V cm nhn thai my l mt cm
nhn ch quan nn mi ngi m s cm nhn
khng ging nhau. iu quan trng l mi
ngi m phi t bit c mc hot ng
ca thai nhi v bit c s ln thai my trung
bnh t mt thay i v tn s thai my
c th l yu t bo trc c bt thng thai
nhi. Trc thp nin 90, khi m cc phng
tin GSKT cn ngho nn, vic m CT
c xem nh l mt phng php tm sot c
hiu qu, cc nghin cu bo co t l t vong
chu sinh gim t 8,7/1.000 xung cn 2,1/1.000
ca sinh sng bng cch m CT [3, 4].
Tuy nhin, nm 2000 ti trng i hc
Oxford, mt nghin cu th nghim lm sng
ngu nhin c i chng trn 68.000 thai ph
nhn thy vic m CT thng qui trong
thng cui khng lm gim t l t vong chu
sinh, m cn lm tng s s dng cc bin
php khc, tng nhu cu nhp vin, tng chi
ph. Vic theo di CT p dng trn 1.250 thai
ph ch ngn mt trng hp cht thai trc
sanh [9]. Theo di CT cng ch gip xc nh
thai hin c yu t nguy c no khng, m
hon ton khng c ngha tin lng hu vn
thai (bng chng mc IB).
Mt nghin cu qua 292 thai ph than phin
CT gim ti bnh vin Weiler, trng i hc
Yeshiva, Bronx, New York nm 1991 xc
nh t l kt cc xu cng nh nh ra nhu cu
cn nhng th nghim tip theo. Cc thai ph
khai CT gim s c ch nh thc hin hai
loi th nghim ban u gm NST v siu m.
Kt qu nghin cu cho thy c 1,7% trng
hp thai cht qua 2 th nghim ban u ny;
4,4% cn m sanh ngay; 5,8% c kt qu bt
thng cn c theo di thm; 52% trng
hp c kt qu bnh thng. Nhm c kt qu
th nghim ban u bnh thng ny tip tc
c nh gi bng cc th nghim k tip. Kt
qu nghin cu cho thy cc th nghim b
sung k tip l hon ton khng cn thit nu
th nghim ban u (NST v siu m) bnh
thng v nu thai ph hon ton khng than
phin vic thai my gim thm hn [7]. Tuy
nhin, cho n hin ti, nghin cu vn cha
xc nh c phng php theo di thai tip
sau no hu hiu nht khi thai ph khai CT
gim.
V thai ph l ngi tip cn thai nhi ca
mnh thng xuyn hn hn bt k nhn vin
y t no nn mc d gi tr ca vic theo di
CT cn cha r, cc thai ph vn c
khuyn khch t theo di CT v bo vi nhn
vin y t trong mi ln khm thai. Kt lun
gim c ng thai ch c sau khi chc chn
thai ph thng sut vic theo di CT ng
qui cch.
2. Nghe tim thai
Vic nghe tim thai ch cho bit thng tin rng
thai cn ang sng, hon ton khng c bng
chng cho thy xc nh thai c ang b e da
hay khng hay vic nghe tim thai s gp phn


nh gi sc khe thai V Th Thy Diu YKHOA.NET
ci thin kt cc thai. Mc d vy, trong thc
hnh lm sng, vic nghe tim thai vn cn c
khuyn co mt cch thng qui.
3. Nonstress test (NST)
Nonstress test (NST) l th nghim da trn
gi thuyt rng nhp tim ca thai nhi trong
trng hp khng c nhim toan do thiu oxy
m hay b c ch thn kinh s nht thi tng
ln p ng vi c ng thai. NST c gii
thiu u tin bi Freeman, Lee v cng s vo
nm 1975. Vo cui thp nin 70, NST tr
thnh PPGSKT hng u.
c nhiu nh ngha khc nhau v mt
NST c xem l c p ng. Cc nh ngha
khc nhau v s lng, bin v thi gian ca
nhp tng, cng nh v thi gian thc hin th
nghim. nh ngha c khuyn co bi Hip
hi Sn ph khoa Hoa k 1999: NST c xem
l c p ng khi c t nht l 2 nhp tng vi
nh nhp tng 15 nhp so vi nhp cn bn,
mi nhp tng ko di t nht 15 giy, v tt c
u phi xy ra trong 20 pht u ca th
nghim v biu ghi nhp tim thai phi thc
hin t nht l 40 pht trc khi kt lun rng
NST khng p ng.
Miller v cng s (1996) nghin cu kt
cc ca thai nhi sau khi m NST c cho l
khng p ng v ch c duy nht mt nhp
tng. H kt lun rng mt nhp tim thai
tng cng ng tin cy trong vic d on tnh
trng thai nhi khe mnh nh khi c hai nhp
tng [10, 11].
Mc d s lng v bin bnh thng
ca nhp tng phn nh tnh trng sc khe
thai, nhng mt nhp tng khng y
khng phi lc no cng d on c tnh
trng suy thai. Thc vy, mt vi nh nghin
cu a ra nhng t l NST dng tnh gi
vt qu 90 % khi m nhp tng c cho l
khng y [12, 13].
Thai mnh khe c l khng c ng lin
tc n 75 pht, chnh v vy, Brown v Patrick
(1981) nhn xt rng thi gian thc hin th
nghim lu hn c l s lm tng gi tr tin
on dng ca NST khng p ng [14].
Devoe v cng s (1985) kt lun rng, NST
khng p ng trong vng 90 pht hu nh l
lun lun (93%) kt hp vi bnh l chu sinh c
ngha [15]. Do vy, thiu nhp tng, trong
trng khng do m dng thuc an thn, l mt
bng chng ng ngi.
Nghin cu ca Phelan t 07/1977 n
10/1979 vi 3.000 NST c thc hin trn
1.452 thai k nguy c cao, trong s NST c
p ng l 85,4 %, khng p ng l 14 % v
khng tha ng l 0,6 %. Trong khi nhm
thai k c NST c p ng hu ht c kt cc
chu sinh thun li, nhm c NST khng p
ng cho thy lm tng t l m ly thai v suy
thai v tng t l t vong. V kt lun ca tc
gi a ra l NST vn l bin php GSKT c
gi tr i vi thai k nguy c cao [16]. Cho n
nay NST vn c xem nh l phng php
u tay hiu qu trong vic GSKT [17].
Tui thai cng nh hng n s p ng
ca tim thai. Pillai v James (1990) nghin
cu v vn ny trong thai k bnh thng v
cho kt qu: t l ca cc c ng thai km theo
dao ng tng ca nhp tim thai v cng
ca nhng nhp tng ny u tng ln cng vi
tui thai [18]. Guinn v cng s (1998)
nghin cu cc kt qu NST t tui thai 2528
tun 188 thai ph c nhng kt cc bnh
thng sau . Ch 70 % trong s nhng thai
nhi bnh thng ny chng t l c nhp tim
thai tng t nht 15 nhp/pht . Mc tng t
hn ca nhp tim thai (10 nhp/pht) xy ra
90% cc trng hp c th nghim [19]. Hi
ngh v monitoring nh gi thai nhi ca Vin
quc gia v sc khe tr em v pht trin con
ngi (NICHHD) nm 1997 nh ngha v
nhp tim thai tng da trn tui thai nh sau:
nh ca nhp tng phi ln hn hoc bng 15
nhp/pht so vi nhp c bn, v nhp tng phi ko
di t nht l 15 giy nhng khng qu 2 pht
tui thai t 32 tun tr i. Trc 32 tun, nhp tim
thai tng c xc nh l ln hn hoc bng 10
nhp so vi nhp c bn v ko di t nht 10 giy.
i vi thai non thng, 50% trng hp thai
24-28 tun bnh thng c NST khng p ng
do s non yu ca h giao cm (bng chng
mc II-2B).
Ngoi ra, thiu vng nhp tng kt hp vi
mt dao ng ni ti ca nhp tim thai c l
mang ngha bnh l ca tnh trng thai.
Bng 1. Gi tr tin on (GTT) ca NST
Salamal-
ekis [25]
Lenstrup
[26]
Bhide
[27]
NST c
p ng

GTT(-) 91.2% 97.3%
chuyn 85.4%
NST khng
p ng

GTT(+) 28.1% 34.8% 23.1%


nh gi sc khe thai V Th Thy Diu YKHOA.NET
nhy 40.9% 65.6%
Tuy nhin, theo Oncken v cng s 2002, s
khng p ng ca nhp tim thai cng c th
do kt hp vi chu k thc ng, hoc l do
dng thuc c ch thn kinh hay do m c ht
thuc l [20]. Mt NST khng p ng hay mt
nhng dao ng ni ti t n khng cho php
thc hin mt chn on nhng y l mt du
hiu bo ng. Gi tr tin on NST trong vic
pht hin tnh trng toan chuyn ha lc sinh
thp, khong 44%. Tuy nhin, khng c
php l l vi mt NST khng p ng m cn
phi lm cc bc nh gi k tip. Theo Hip
hi Sn ph khoa Canada 2000: NST khng p
ng s c nh gi tip theo bng ST hay
BPP.
Do s nhn nh v kt qu NST rt khc
nhau nh bn lun trn nn Hage v cng
s 1985 phn cc biu NST cho 5 nhm
bc s kim nh v s thng nht cch din
gii v CTG, nhn thy cc kt qu c CTG
hon ton khng tng ng nhau [21-24].
ng thi, nhm nghin cu lp trnh phn
mm cho vic phn tch CTG/NST bng my
tnh, kt qu t ra chnh xc hn cc nh lm
sng v kh nng d bo tnh trng nhim toan
ca thai cng nh ch s Apgar (bng chng
mc III-B) theo Hip hi SPK Anh Quc
2001.
4. Stress test (ST)
Stress test (ST) l th nghim c thc hin
da trn s p ng ca nhp tim thai khi c
cn co t cung. Ngi ta lun tin rng s cung
cp oxy cho thai nhi s tm thi b gim i khi
c cn co t cung. Chnh v vy, ST l th
nghim nh gi chc nng t cung-nhau, trong
khi NST l th nghim ch yu v tnh trng thai.
Vi nh ngha ny, ST c vai tr l mt th
nghim nhm lng gi kh nng chu ng
ca thai khi vo chuyn d, ngha l gi tr ca
ST l nhm quyt nh phng thc sanh ca
thai k, hoc sanh ng m o hoc m sanh.
iu ny c ngha rng chng ta ch thc hin
ST khi c ch nh chm dt thai k. Tuy
nhin, iu ny khng hon ton hn th ! Vn
c rt nhiu phc v cc nghin cu mt
s khu vc trn th gii s dng ST sau mt
NST nghi ng, bt k tui thai. iu ny dng
nh kh chp nhn theo tnh logic hc. Tht
vy, ST cng nh bt k mt th nghim no
u c nhng tc dng ngoi khng mong
i, c th l ST c th gy ra hi chng qu
kch cn co t cung cng nh kh nng c th
a n mt cuc chuyn d sanh non nu
thc hin trn mt thai k cha trng thnh;
v kt cc l mt tr non thng ra i vi y
nhng yu t ri ro nu trng hp ch n
thun cn GSKT m cha c ch nh chm
dt thai k. Mc d t l ny khng nhiu
nhng khng phi hon ton khng c, v nh
th c th vi phm y c v mt nghin cu
hc. Hn th na, ST nhm GSKT trng thi
ng, mt trng thi stress to bi cc cn co
chuyn d, trong khi , NST, BPP, Doppler l
nhng th nghim kho st sc khe thai
trng thi tnh, giai on c th ko di thm
thai k nu c. Chnh v vy, bt k mt s
so snh no v hai nhm th nghim ny, theo
chng ti suy lun, dng nh qu thin lch,
khp khing.
Mt vn khc rng gi tr ca ST c tht
s hu ch trong vic tin on d hu thai? C
rt nhiu nghin cu kho st mi tng quan
gia NST, ST, BPP, Doppler nhm phc v cho
cc quyt nh lm sng. Kt qu cc nghin
cu rt khc nhau.
Nghin cu ca MW Keane v cng s 1981
thc hin trong vng 18 thng, 1.328 NST v
tip sau l ST c thc hin trn 566 thai
ph. Th nghim cui cng thc hin trong
vng 1 tun trc sanh c so snh vi kt
cc thai nhi chu sinh. C tng cng 1.118
(84,2%) NST c p ng v 210 (15,8%) khng
p ng. V kt qu ST, c 1.249 (94,1%) trng
hp m tnh, 52 (3,9%) dng tnh, 16 (1,2%)
nghi ng, v 11(0,8%) khng tha mn. Mi
tng quan gia NST c p ng v ST m
tnh l rt ln (99,4%), trong khi gia NST
khng p ng v ST dng tnh l rt ngho
nn (24,8%) [28]. Mc d ST c chng t l
yu t d bo bnh l tt hn NST, nhng c
hai th nghim u l nhng th nghim tin
on c ngha thng k cao (p<0,001). Nhng
thai nhi c NST khng p ng v ST m tnh
th nguy c bnh l khng tng ln. Nghin
cu ny ng h cho quan nim rng ch cn
NST c din gii chnh xc s l cng c tm
sot lng gi tnh trng sc khe thai
thai k nguy c cao. Chnh v vy, ST lun
c bt u bng vic thc hin mt NST,
nhiu khi cho php loi tr vic thc hin mt
ST khng cn cn thit thm ch tr thnh
nguy him cho bo thai. Mt NST c p ng
loi b vic thc hin ST.
Mt nghin cu khc so snh OCT v NST


nh gi sc khe thai V Th Thy Diu YKHOA.NET
ca Quaas L, c 1985, qua 247 thai k c nguy
c cao v chc nng tun hon t cung nhau,
nhn thy: 20% NST khng p ng, 19% OCT
c nhp gim mun n thun, khi kt hp tiu
chun nhp gim mun v mt dao ng ni
ti, t l OCT bnh l l 29%. Nu ch da vo
nhp gim mun, OCT khng ni tri hn so
vi NST. Ch khi nhp gim mun kt hp vi
mt nhp tng th mi tng gi tr tin on ca
OCT so vi NST. Hn na, nhp gim mun
m vn c nhp tng th gi tr tin on khng
hn so vi mt dao ng ni ti [29].
Theo Shalev (1993), khi so snh gi tr ca
NST, OCT, S/D Doppler, BPP trong vic tin
on tnh trng toan ha thai nhi (pH tnh
mch rn nhng thai chm tng trng), ghi
nhn kt qu: NST, OCT, BPP c cng gi tr
GTT(+): 57,1%, GTT(+) S/D MR rt thp:
14,3%. Ch duy nht s phi hp ca NST v
OCT mi lm tng gi tr tin on: 66,7% [30].
Tuy nhin, s kt hp ny lm tng t l m
sanh nn y li l vn cn cn nhc thm.
Mt nghin cu khc ca Figueras, bnh
vin Barcelona, Ty Ban Nha 2003 khi so snh
gi tr Doppler ng tnh mch (ductus venosus)
v ST qua 68 thai ph nhm thai chm tng
trng >26 tun sau khi c NST khng p ng
v hin tng ti phn b huyt ng hc. Kt
qu cho thy gi tr tin on ca ST v t l s
sinh cn nhp n v sn sc s sinh tch cc l
45%, bnh sut s sinh l 13%, cn t ni kh
qun l 26%, pH ng mch rn <7,10 l 29%.
Trong khi gi tr tin on ca dng sng
bt thng ng tnh mch (abnormal ductus
venosus waveform) tun t l 81,5%, 26%, 48%
v 55%. Kt lun c rt ra rng khi NST
khng p ng v km hin tng ti phn b
huyt ng hc thai chm tng trng,
Doppler ng tnh mch t ra hn hn ST trong
vic GSKT [31].
Chnh v gi tr tin on ca ST khng
nng ln nhiu khi so vi vic thc hin n
thun cc phng php khc m li tng t l
m sanh nhiu nn hin nay cc nc pht
trin (Canada,...), ST khng cn c s dng
thng dng na; tuy nhin ST vn cn l mt
chn la trong nh gi sc khe thai ti cc
trung tm khng c iu kin s dng BPP.
Hn th na, ST vi vai tr l mt th nghim
nhm lng gi kh nng chu ng qua mt
cuc chuyn d sanh ng m o vn cn mang
tnh cht kinh vin trong cc bi ging l thuyt
ca cc trng i hc y khoa nn chng ti
nhn thy cn nhiu tho lun hn ca cc
chuyn gia sn khoa v vic s dng th
nghim trong thc hnh lm sng sn khoa
hin i ngy nay.
5. Trc sinh vt l (Biophysical profile)
Manning v cng s nm 1980 ngh vic
s dng kt hp 5 thng s sinh vt l nh l
phng tin GSKT chnh xc hn bt k mt
phng tin dng ring l no. H a ra
gi thuyt rng vic xem xt chung c 5 thng
s c th lm gim c t l dng tnh gi v m
tnh gi.
Manning v cng s nm 1993 m t mt
nghin cu trn 493 thai nhi, trong im s
sinh vt l c lm ngay trc khi o gi tr
pH mu tnh mch rn qua chc d cung rn.
Khong 20 % cc thai nhi c th nghim c
chm tng trng, v s cn li c thiu mu
tn huyt d min dch [32]. Theo Manning,
im s sinh vt l bng 0 lun lun kt hp
vi tnh trng toan huyt c ngha ca thai
nhi, trong khi im s bnh thng t 8-10
im li kt hp vi gi tr pH bnh thng.
Chnh v vy, Manning s dng BPP trong
tin lng bi no [33]. Mt kt qu nghi ng -
6 im - l mt yu t d bo kt cc bt
thng ngho nn. Nu c hin tng gim
im s t 2-4 im xung 0 im th li chnh
xc hn trong vic tin on hu vn bt
thng thai nhi.
Salvesen v cng s (1993) so snh mi
tng quan gia bng im Manning vi pH
mu tnh mch rn 41 trng hp i tho
ng thai k [34]. H cng nhn thy rng gi
tr pH bt thng kt hp c ngha vi im
s sinh vt l bt thng. Tuy nhin, h kt
lun rng im s sinh vt l vn cn b hn
ch trong vic d on pH thai nhi, bi v c 9
trng hp thai nhi c toan mu nh m li c
cc th nghim trc sinh bnh thng. Weiner
v cng s (1996) nh gi ngha ca cc
th nghim v sc khe thai 135 trng hp
thai chm tng trng trong t cung v cng
i n kt lun tng t. H thy rng bnh
sut v t sut thai chm tng trng nng
c xc nh trc tin bi tui thai v cn
nng lc sinh ch khng phi bi cc th
nghim nh gi thai nhi bt thng.
H thng im s Manning cho php t
c mt t l m sai c iu chnh l 0,7%,
ngha l c mt nhy cm rt cao. H thng
im s ny tr thnh mt bin php lng
gi sc khe thai nhi ng tin cy. Nhc im


nh gi sc khe thai V Th Thy Diu YKHOA.NET
ca trc sinh vt l l tnh chi tit v i hi
rt nhiu thi gian thc hin. Ging nh vi
cc bin php kho st sc khe thai nhi khc
nu, cn ch loi tr nhng yu t nh
hng n kt qu ca kho st nh tui thai,
cc dc cht c s dng cng nh cc tnh
trng bt thng ca bo thai. Tht vy, thc
hin BPP cc trng hp thai non thng <34
tun s xut hin vn c ng thai gim do
tnh trng non thng, do im s BPP khng
cn chnh xc. y l vn cn cn nhc khi
thc hin BPP thai non thng.
Tuy vy, vn cha c s ng thun v hiu
qu ca BPP trong nh gi sc khe thai. Mt
nghin cu cohort ln Canada 2000 cho thy
vic s dng BPP lm gim t l bi no ng
k mt cch kh quan: t 4,74/1.000 nhm
khng thc hin BPP thuc thai k nguy c
thp xung cn 1,33/1.000 nhm thc hin
BPP thuc thai k nguy c cao (bng chng
mc II-3B) [33]. Ngc li, trong tng quan
Cochrane 2000, Alfirevic v Neilson kt lun
rng cha d liu nh gi gi tr ca
BPP i vi thai k nguy c cao [35].
6. Trc sinh vt l ci bin (Modified BPP)
Trong khong cui tam c nguyt th hai v
tam c nguyt th ba, lng nc i phn nh
s sn sinh ra nc tiu ca thai nhi. Ri lon
chc nng nhau thai c l s gy ra tnh trng
gim lng dch qua thn thai nhi, iu ny
dn n hin tng thiu i. Do vy, vic nh
gi th tch lng nc i rt hu ch lng
gi chc nng t cungnhau [36]. iu ny a
n vic hnh thnh nn trc sinh vt l ci
bin (Modified biophysical Profile MBPP).
MBPP kt hp 2 thng s l NST (ch im
tnh trng thai trong thi gian ngn) v ch s
i AFI (ch im chc nng nhau thai trong thi
gian di).
Trc sinh vt l bin i ngy cng c
s dng ph bin hn trn th gii bi tnh d
dng v n gin hn so vi trc sinh vt l
y , nhng vn khng mt i vai tr quan
trng nht ca mnh: nh gi tnh trng sc
khe ca thai nhi. Khi nghin cu v kt cc
ca thai nhi thai k nguy c cao khi c lm
MBPP , Bnh Vin B M ti Long Beach, CA
,USA (1995) th nghim trn 2.774 thai ph
i tho ng thai k, v 17.429 th nghim
MBPP c thc hin. Nhng thai ph c kt
qu MBPP bt thng (NST khng p ng
hoc AFI5) th c tip tc lm ST v BPP.
Kt qu, t l t vong chu sinh cha hiu chnh
l 2,9/1.000. T sut chung cho nhng kt cc
bt li (cht thai, m sanh v suy thai trong 2
gi u chuyn d, Apgar 5 pht <7, xut huyt
thn kinh trung ng III-IV) l 7% [37]. Khi
so snh vi nhng bnh nhn c kt qu MBPP
lun bnh thng th nhng bnh nhn phi
lm thm th nghim h tr c t l kt cc chu
sinh bt li cao hn c ngha (9,3% so vi 4,9
% , p <0,001), v t l tr non thng cng cao
hn (5,2 % so vi 2,4 %, p <0,001). V kt lun
do nhm nghin cu a ra l Trc sinh vt
l ci bin tht s l mt phng php theo di
thai rt tt v c th nh ra c nhm bnh
nhn nguy c cao c kt cc chu sinh bt li v
sinh tr non thng.
Bn thn ring th tch lng i cng c
ngha quan trng trong tin lng d hu thai
[38]. S dng MEDLINE, truy cp tt c cc
nghin cu v ch s i v kt cc thai t 1987
n 1997, 18 bi bo co gm 10.551 thai ph.
Ch s i <5 trc sanh gy tng nguy c m
sanh v suy thai (RR: 2,2; 95%CI: 1,5-3,4), tng t
l Apgar 5 pht <7 (RR: 5,2; 95%CI: 2,4-11,3).
Cng vy, ch s i AFI<5 trong chuyn d gy
tng nguy c m sanh v suy thai (RR: 1,7;
95%CI: 1,1-2,6), tng t l Apgar 5 pht <7 (RR:
1,8; 95%CI: 1,2-2,7) [39].
Bn cnh , mt s trung tm tin hnh
nghin cu so snh gi tr ca ch s th tch i
so vi NST trong GSKT trc sanh, nhn thy
o xoang i c gi tr hn NST n thun [40,
41].
Ngoi ra, c mt th nghim lm sng so
snh k thut o mt xoang i so vi ch s AFI
trong BPP, nhn thy o mt xoang gim t l
chn on thiu i m khng nh kt cc xu
hn [42].
7. Siu m Doppler trong thai k nguy c cao
Siu m (SA) Doppler c s dng cc
trung tm nh gi nh gi tr khng
mch mu, nh gi lu lng mu trong
nhng bnh l c s thay i h thng ng
hc (dynamic system). Trc khi c mt
Doppler, phng php duy nht nh gi
h thng tun hon l mch mu
(angiography), mt phng php xm ln.
Nm 1983, Campbell nh gi tun hon t
cung-nhau, ghi nhn dng sng tng khng lc
trng hp tin sn git. Nm 1997,
Fitzgerald l ngi u tin kho st ng
mch rn (MR). Sau , SA Doppler c s
dng ti nhiu trung tm trong vic tin on
nhng thai ph c nguy c tin sn git, thai


nh gi sc khe thai V Th Thy Diu YKHOA.NET
chm tng trng [43, 44].
a. Doppler ng mch rn
C nhiu mch mu khc nhau ca m v thai
nhi c lng gi qua phn tch hnh dng
sng siu m Doppler nh gi v nguy c
c d hu chu sinh bt li hay khng. Kt qu
nghin cu th nghim lm sng ngu nhin c
i chng ca Alfirevic Z, Neilson 2000 cho
thy MR c gi tr tin on tnh trng thai tt
nht cho nhm thai k nguy c cao [45, 46].
Bnh sut v t sut chu sinh gia tng cng
vi nhng bt thng ca dng sng MR
[47]. Karsdorp v cng s c tnh t s chnh
OR ca t sut i vi mt sng tm trng l
4 v o ngc sng tm trng l 11. Mc d
hu ht cc nghin cu b nghi ng c hin
tng nghch l trong iu tr (xem thm trong
phn bn lun), nhng trong cc nghin cu
ny, kt qu Doppler c giu kn cc nh
lm sng.
Siu m Doppler MR tt hn cc bin
php GSKT khc (CTG, BPP) trong vic phn
bit trng hp thai nh bnh thng hay thai
nh bnh l (Harman 2003, Soothil 1993).
Nhng can thip da vo dng sng bt
thng ca MR lm gim t l t vong chu
sinh khong 38% thai k nguy c cao (95%CI:
15-55%) (IA) theo Hip hi SPK Canada 2000.
Cng vy, mt nghin cu 146 thai ph t
11/1987-12/1988 ti i hc Alabam so snh gi
tr ca Doppler MR so vi cc bin php
GSKT khc trong vic tin lng hu vn
thai. Kt qu ghi nhn nu S/D MR 4 v
NST/OCT bt thng th c mi lin h mt
thit vi cc kt cc xu ca thai nh: 47% thai
chm pht trin trong t cung, 67% suy thai
cn m sanh, 86% cn nhp sn sc s sinh tng
cng. Tuy nhin, nu kt qu NST/OCT bnh
thng th Doppler MR bt thng cng
khng quyt nh mt chn on v hng x
tr tip theo no c [48].
Ngc li, theo Jensen OH, Guimaraes MS.,
Bnh vin i hc Aker, Oslo, Norway 1991
qua nghin cu thai chm tng trng:
nhy ca S/D MR l 71%, gi tr tin on l
57%, chuyn bit l 77%. Trong khi , NST
c cc gi tr tng ng l 39%, 65% and 90%.
Kt lun rng Doppler nhy hn CTG trong
nh gi thai chm tng trng. iu quan
trng l khi phi hp gia Doppler v CTG
nhn thy lm tng nhy ln 79%. Nhng
trng hp Doppler bnh thng, ch cn theo
di thng qui bng CTG [49].
Trong khi , mt nghin cu ca L. A.
Bracero, R. Figueroa, D. W. Byrne and H. J.
Han, Trung tm Y khoa Maimonides, Brooklyn,
NY, USA, qua 207 thai ph i tho ng thai
k so snh gi tr ca NST, BPP, S/D MR ca
thai 28-35 tun, ng thi nhm mc ch tm
thi im thch hp chm dt thai k.
Nghin cu rt ra rng [50]: (i) Vi S/D MR
>3,0, RR v kt cc thai xu 2,6 (95% CI: 1,9-3,5,
P < 0,001), (ii) Vi BPP <6: RR v kt cc thai
xu 1,7 (95% CI: 0,9-2,9, P = 0,109), v (iii) Vi
NST khng p ng: RR v kt cc thai xu 1,7
(95% CI: 1,2-2,5, P = 0,009).
Williams cng cng s Vin trng Y khoa
Yale, New Haven, M thc hin mt nghin
cu th nghim lm sng ngu nhin c i
chng so snh gi tr tin on ca NST v
Doppler trn 1360 thai ph qua 36 thng i
vi nhng thai k nguy c cao 32 tun thai. T
l m sanh v suy thai thp ng k trong
nhm Doppler so vi nhm NST (30 [4,6%] so
vi 60 [8,7%]; p <0,006). Kt lun ca nghin
cu rng Doppler MR c vai tr hn NST
trong GSKT thai k nguy c cao, lm gim
t l m sanh khng cn thit m khng lm
tng bnh sut s sinh [51].
Cc khuyn co ca Hip hi SPK Hoa K
1999 kt lun rng Sau khi cn nhc k, cc
bng chng hin hu ngh rng bin php
hng u theo di trc sanh nhng trng
hp nghi ng thai chm tng trng trong t
cung bng Doppler ng mch rn c th t
c, t nht l tng ng (v c th tt hn)
v d hu thai nhi v s sinh nh i vi vic
theo di bng NST. Hn na, tn sut s dng
bin php theo di trc sanh v cc kha cnh
can thip v sn khoa u gim hn khi s
dng Doppler [1]. Hip hi SPK Hoa K cng
pht biu rng Nu nh Doppler ng mch
rn c s dng, cc quyt nh lin quan
n thi gian sanh nn kt hp thng tin t
siu m Doppler v nhng th nghim GSKT
khc, nh nh gi lng i, NST, ST v BPP
[1].
Cng theo khuyn co ca Hip hi SPK
Hoa K, Ngoi ch li i vi thai chm tng
trng trong t cung th Doppler MR khng
c ch li g khc c chng t, nh i vi
thai qu ngy, i tho ng, lupus ban
hay hi chng anti-phospholipid. Siu m
Doppler khng c chng minh l c gi
tr nh l th nghim tm sot tnh trng suy
thai ni chung v do vic s dng n cho


nh gi sc khe thai V Th Thy Diu YKHOA.NET
mc ch ny khng c khuyn co [1].
Bng 2. Kt cc thai so vi sng tm trng MR
(Hip hi SPK Canada 2000)
Kt cc EDV (+) EDV (-) EDV o
ngc
Cht thai 6(03%) 25(14%) 16(24%)
Cht s sinh 2(01%) 48(27%) 34(51%)
Sng 206(96%) 105(59%) 17(25%)
Tng cng 214(100%) 178(100%) 67(100%)
EDV: End Diastolic Velocity

Tuy nhin, mt phn tch meta c xut
bn gn y ca 20 th nghim lm sng c i
chng v siu m Doppler th cho rng, c
bng chng thuyt phc v nhng kt qu ca
siu m Doppler ci thin c d hu chu
sinh thai k nguy c cao, gim c t l phi
nhp vin, t l khi pht chuyn d v m ly
thai v suy thai v gim c t l t vong chu
sinh ti 36% [52-54]. ng thi, Goffinet (1997)
tng quan v nhng th nghim ngu nhin
c i chng v Doppler ng mch rn thai
k nguy c thp, v kt lun rng Khng c
bng chng no cho rng vic s dng thng
quy Doppler ng mch rn trong dn s
chung hoc nguy c thp dn n ci thin sc
khe ca m v b. Doppler ng mch rn
khng c khuyn co nh l mt th
nghim thng quy thai k nguy c thp
[52].
Phn tch meta cho thy vai tr SA Doppler
MR khi so snh vi cc phng php khc
lm gim 29% t l t vong chu sinh (95%CI: 0-
50%) [55].
b. Doppler ng mch no gia, ng mch TC
Cc nghin cu cha tm thy s khc bit v
nhng ri lon thn kinh vn ng tr 2 tui
khi c bt thng v dng sng ng mch no
gia. Tuy nhin, khi tr 5 tui, s khc bit biu
hin r nt. Hin nay, cha c nghin cu th
nghim lm sng ngu nhin c i chng v
lu lng mu ng mch no gia cho tnh
thuyt phc cao hn. i vi ng mch t
cung, bt thng sng tun l 11-14 v 23 d
bo kh nng thai k b tin sn git nng hoc
thai chm tng trng [56]. iu ny cho php
liu php d phng vi Aspirin liu thp hoc
b sung vitamin. Sau 34 tun, cc bt thng
sng ng mch t cung lm tng nguy c kt
cc thai xu gp 4 ln.
8. trng thnh nhau
S xut hin hnh nh bnh nhau trn siu m
thay i theo tui thai. Ch duy nht mt
nghin cu th nghim lm sng ngu nhin c
i chng v vic nh gi trng thnh
nhau thng qui nhm thai k nguy c thp.
Nghin cu cho thy nhm c theo di
thng qui c kt cc thai tt hn. Tuy nhin,
nghin cu cha c nh gi cao v c mu
nh nn cha cho thy s khc bit c ngha
thng k. Cn nhiu nghin cu hn na cho
c nhm nguy c cao v nhm nguy c thp.
Thc t hin nay cha s dng trng
thnh nhau trong thc hnh lm sng.
9. Trnh t xut hin nhng bin i ca cc
th nghim nh gi sc khe thai
Bn nghin cu c gng m t trnh t xut
hin nhng bin i ca cc th nghim
GSKT. Tuy nhin, iu ny gp nhiu vn
kh khn v vn y c: khng th tr hon
vic cho sanh mt thai ang b e da, v th
nghim c s dng quyt nh thi im
chm dt thai k khi c biu hin bnh l xem
nh l thay i cui cng. Mc d vy, nhng
bt thng v dng sng ca ng mch rn
(MR) c khuynh hng xut hin u tin,
tip n l hin tng ti lp tun hon no,
thay i dng sng ca tnh mch, c ng h
hp gim, th tch i gim, dao ng ni ti
gim, MR mt sng tm trng hay o
ngc, c ng thai bt thng, trng lc thai
gim, v nhp tim thai chm l bin c sau
cng. Khi thai mt hin tng Sparing, BPP bt
u biu hin bt thng [57].
V. Bn lun
Kt qu ca cc nghin cu cho thy gi tr tin
on ca cc PPGSKT rt khc nhau theo
tng i tng thai k nguy c cao: bnh l sn
c, tui thai, rt khc nhau gia cc n v tin
hnh nghin cu. Cc chuyn gia hng u v
sn khoa nhiu ln ngi li vi nhau l gii
cho s vic ny. H a ra mt s lun c,
khuyn co nhng nh lm sng sn khoa khi
s dng cc PPGSKT cn thng sut mt s
im c bn sau di con mt ca nh dch t
hc.
1. Nhng hiu bit ca chng ta v Suy
thai ban u bt ngun t nhng th nghim
trn ng vt bng cch lm hp nhng mch
mu nui thai, gy ra hin tng thiu nng
oxygen mn tnh (chronic hypoxemia). Chnh


nh gi sc khe thai V Th Thy Diu YKHOA.NET
v vy, nhng phc chn on v x tr trn
ngi c rt ra t y s khng th t mc
chun xc tuyt i.
2. Hn th na, nh gi gi tr tin on
ca mt th nghim GSKT, chng ta thng
xt s tng hp cc kt qu gi tr ca cc th
nghim so vi cc thng s o lng kt cc
thai. Cc thng s ny chia lm 2 nhm: thng
s tc thi v kt cc tuyt i (S 1). Cc
thng s o lng tc thi bao gm: pH mu
cung rn, Apgar ti thi im 5 pht, s cn
thit nhp n v sn sc s sinh tch cc, bnh
no s sinh [58]. Kt cc tuyt i bao gm: T
vong, Bi no (Bi no c nh ngha l lit
cng t chi, ri lon phi hp ng tc), Km
pht trin tm thn vn ng (Km pht trin
tm thn vn ng c nh ngha l gim
hoc mt kh nng thc hin cc ng tc i,
ngi, s dng bn tay hoc iu khin u).
Chnh kt cc tuyt i ny mi l thng s c
gi tr thuyt phc, l nhng thng s phn nh
tht s hot ng no b ca tr [59]. Tuy
nhin, o lng cc thng s kt cc tuyt
i ny, cc nghin cu phi thc hin trong
khong thi gian di, t nht l n tui
b bt u n trng, 6 tui, thm ch mt s
tc gi khuyn co c nhng chc nng tm
thn vn ng ch hon thin khi tr 18 tui.
Trong thc t, rt him nhng nghin cu so
snh vi cc kt cc tuyt i nh nu trn v
hin tng mt du trong nghin cu, m ch
so vi nhng thng s tc thi. Do mi lin
quan gia cc th nghim v kt cc tht s
ca thai (t l t vong thai cng nh bi no)
vn cha xc nh r rng nn vic din gii
ngha cc th nghim hy cn nhiu iu kh
mng lung.
3. Cc kt qu ca nhng th nghim nh
gi khe thai khng nn cho cc nh lm sng
bit trnh nhng nghch l trong iu tr
(treatment paradox). C th l, khi kt qu th
nghim cho rng tnh trng thai ang b e da,
nu nh lm sng bit c kt qu y, s cho
nhng bin php can thip iu tr qu tch cc
hn tht s cn thit (chng hn cho thai sanh
ngay); kt cc l thai sng; trong trng hp
, kt qu th nghim c cho l dng tnh
gi. Ngc li, khi kt qu th nghim ch l
dng tnh gi, nhng b nh lm sng pht
hin, h ngh l mt tnh trng e da thai
cp cn phi can thip ngay. S can thip sm
n ni b t vong v nhng bin chng ca
tnh trng non thng. i ngi thay, nhng kt
cc th nghim ny li c xem nh l dng
tnh tht, c gi tr tin lng v ci cht ca
thai. Phng php duy nht trnh hin
tng nghch l ny l giu kn cc kt qu th
nghim, khng cho cc nh lm sng trc tip
iu tr bnh nhn c bit. Tuy nhin, chnh
s giu kn ny li phm y c v l nhng
thng tin lm sng quan trng. y l iu kh
khn v cng l im yu cho cc nghin cu
c nh gi c tnh chun mc v
thuyt phc cao.
4. S din gii ngha ca kt qu th
nghim lun cn da vo cc yu t nguy c
hin c cng nh c ca thai ph. Chng
hn, mt trng hp c BPP 6 im thng
gy kh khn cho cng tc chn on ca cc
nh lm sng v y l im s trung chuyn.
Tuy nhin, nu BPP 6 im xy ra trn mt thai
ph c tin cn 2 ln thai cht, hin c cao
huyt p v xut huyt m o th y l mt
du hiu d bo xu cho thai k ln ny. Trong
khi , BPP 6 im mt thai ph con so,
khng cao huyt p, khng triu chng bt
thng, ch nh thc hin BPP ch v qu lo
lng th trng hp ny hon ton c tin
lng kh hn nhiu (xem thm phn III.5).
5. V tn sut t vong chu sinh thp, nn
c th rt ra c nhng kt lun tht xc ng
v gi tr ca cc phng php nh gi sc
khe thai th cn c nhng nghin cu ln, vi
c mu t nht 10.000 ca mi c th em li
nhng khuyn co thc hnh c ngha [60].
Cc phn tch meta cng nh tng quan
Cochrane vn cha s lng nghin cu
c xem nh chun lm c s rt ra nhng
khuyn co ngh chung [61]. Chnh v vy,
cho mi n hin nay, cha c mt phc
chun no c xut cho cng tc thc hnh
lm sng chung. Nam M, BPP c xem
nh th nghim thng dng nht trong vic
quyt nh kt thc thai k, trong khi ,
Chu u, CTG kt hp vi Doppler c xem
nh thng dng hn. Hu ht cc nghin cu
khng nh rng cc PPGSKT ch c ch i
vi thai k nguy c cao. ng thi, cc khuyn
co ln u cho rng tng n v thc hnh
nn c nhng phc ring v 4 vn c bn:
(1) Ch nh; (2) Phng php; (3) Tn s tin
hnh th nghim; (4) X tr nhm c nhng
bng chng thit thc hn. Theo Hip hi SPK
Hoa K 2004: khng phng php no l ti
u, vai tr, hiu qu, tnh chnh xc ca tng
phng php cn ty thuc vo tnh trng sinh


nh gi sc khe thai V Th Thy Diu YKHOA.NET
l bnh sn c ca bnh nhn. S phi hp v
lp li ca cc phng php c gi tr hn hn
mt th nghim n c (bng chng mc
Ib-A).


nh gi sc khe thai V Th Thy Diu YKHOA.NET
S 1. Th nghim v kt cc















VI. Kt lun
GSKT l mt cng vic ht sc cn thit i
vi cc nh lm sng , c bit l i vi nhng
thai k nguy c cao. Cu hi lun c t ra
l liu trong s nhng th nghim ny, th
nghim no l tt nht tin on c hu vn
chu sinh? Theo khuyn co ca Hip Hi Sn
Ph Khoa Hoa K 1999, khng c mt th
nghim GSKT no l tt nht c! (no best
test) [1, 62]. Trong s tay hng dn bnh
nhn pht hnh nm 2002 ca Hip hi SPK
Hoa K vn tt li nh sau: Monitoring
gip bn v bc s ca bn trong lc bn mang
thai bng cch ni cho bn bit v sc khe ca
con bn. Nu nh kt qu ca th nghim ni
rng c vn , th iu khng lun lun c
ngha l con bn c vn . n gin l iu
mun ni rng bn cn s chm sc c bit
hn hoc cn lm thm nhng th nghim
khc. Hy tho lun nhng cu hi bn mun
hi vi bc s ca bn.
Cc khuyn co v nh gi sc khe thai
theo Hip hi SPK Hoa K 2000 (mc B)
[63]:
1. Cc thai k nguy c cao cn s dng cc
bin php nh gi sc khe thai nh: Theo di
c ng thai, Nonstress test (NST), Stress Test
(ST), Biophysical Profile (BPP), hay BPP ci
tin.
2. Thi im bt u nh gi: t 32 n 34
tun. Trng hp i tho ng loi R hay F,
i tho ng km thai chm tng trng, i
tho ng km cao huyt p [64] hoc thai
ph qu lo lng v thai th c th thc hin vic
nh gi sm hn, t 26 n 28 tun.
3. Nu cc kt qu trong gii hn bnh
thng, th nghim s c lp li 1-2 ln/tun
ty loi th nghim cho n khi sanh. Bt k s
bin chuyn no v tnh trng bnh l ca m
hoc s gim c ng thai u cn c nh
gi li ngay (bng chng mc II-3B).
4. NST hay BPP ci tin vi kt qu bt
thng cn c nh gi thm bi ST hay
BPP c in. Vic x tr tip theo da vo kt
qu ca ST hay BPP, tui thai, th tch i v
tnh trng thai ph.
5. Nu khng c chng ch nh sn khoa,
tip theo sau cc kt qu bt thng ca cc
PPGSKT l vic khi pht chuyn d vi vic
theo di tim thai cn co lin tc. Nu nhp gim
mun lp i lp li s c m sanh ngay.
6. Theo quan im hin nay, nh gi sc
khe thai trc sanh bnh thng s khng cn
theo di bng monitor trong chuyn d
7. i vi thai k khng nguy c, Doppler
MR khng c gi tr (bng chng mc
IIIB); ngc li, rt c gi tr i vi thai chm
tng trng, tin sn git (bng chng mc
IA). Quyt nh thi im ly thai cn da vo
nhng thng tin t siu m Doppler kt hp
vi nhng bin php nh gi thai khc, cng
lc vi vic theo di cn thn tnh trng ca
m.
VII. Vn thc tin trong thc hnh lm
sng
1. Ti khoa Sn bnh bnh vin Hng
Vng (BVHV), s bnh nhn ni tr tin sn
khong 50 ca/ngy. Cc trng hp ny nhp
khoa tin sn ng nhin l cc thai k nguy
c cao. Nh vy, nhu cu cn c GSKT kh
nhiu. Trong 50 ca tin sn ny c khong 20 ca
Th nghim nh gi
sc khe thai
Thng s o
lng tc thi
Kt cc
tuyt i
pH mu cung rn
Apgar 5 pht
Cn nhp n v sn
sc s sinh tch cc
Bnh no s sinh
CT
Nghe TT
NST
ST
BPP
MBPP
Doppler
T vong
Bi no
Km pht trin tm
thn vn ng


nh gi sc khe thai V Th Thy Diu YKHOA.NET
bnh mi cn mc CTG lc vo khoa, 30 ca cn
li do bnh theo di ang lu tr, v khng
phi tt c 30 ca ny u cn mc CTG m ch
khong 50% s ca, l khong trung bnh 15 ca.
Nh vy, c khong 20ca bnh mi + 15 ca
bnh lu cn mc CTG = 35 ca/ngy. Trc mt
c xem nh cc ca ny cn mc CTG vi thi
gian ti thiu 20 pht trc (s ca cn thm thi
gian pht sinh v OCT hay v NST khng p
ng s c tnh ph tri sau). Nh vy, thi
gian cn s dng: 35 ca x (20pht + 5pht) =
875 pht (5 pht l thi gian hao tn gia cc
ca chun b bnh nhn) = khong 15
gi/ngy/ cho 1 my monitor.
Hin khoa c 3 my monitor hot ng, cho
rng 1 my c dnh cho vn pht sinh
nu trn (OCT hay NST khng p ng). Nh
vy, cn 1 my trng. Tuy nhin, thc t khng
bao gi 3 my tm ngh m lun hot ng.
Vn nm u? Trn y l ta cho thi gian
gn 1 CTG l tng l 20 pht. Nhng thc t
lun cn thi gian di hn. V sao? V s nhn
nh ca ngi c CTG cha an tm vi on
CTG y mc d CTG tht s khng biu hin
e da. Vn l s nhn nh kt qu CTG
cn cha chun, vn cha thng nht. Tnh
hnh ny khng phi ch BVHV. Nh trong
phn bn lun v gi tr ca NST (phn III.3.3),
mt s ni trn th gii trang b my tnh x
l cc kt qu CTG to s thng nht v vic
din gii CTG. Do , nu bnh vin trang b
thit b phn tch CTG vi tnh ha th liu c th
gim thiu phn no gnh nng thi gian cn
thit mc CTG chng?
2. MBPP l phng php nh gi sc khe
thai kh n gin, ch da vo 2 thng s: NST
v AFI. Cc nghin cu trn th gii phn
no nu ra nhng li im ca BPP so vi cc
PPGSKT khc. Trong tnh hnh qu ti bnh
nhn nh hin nay, nn chng tin hnh nghin
cu v vai tr ca MBPP nhm tm ra gii php
hu hiu nht?
3. ST l th nghim tn nhiu thi gian, t l
dng tnh gi nhiu, ngy cng dn km vai
tr tin on tnh trng thai so vi cc phng
php khc. Do , cn tin hnh nghin cu
xc nh gi tr tin on ca ST nhm p ng
s tin li v hiu qu trong cng tc thc
hnh.
4. Tui thai l mt yu t nhiu trong
phn din dch kt qu ca PPGSKT. GSKT
non thng l c mt vn ln do s cha
trng thnh ca h thn kinh t ch [65]. Vic
ng dng hp l cc PPGSKT cho tng tui
thai l mt ngh thut ca nh sn khoa. iu
ny cn kh nhp nhng! Xy dng phc c
th cho khoa tin sn ca bnh vin l mt vic
lm cn c khuyn khch.
Ti liu tham kho
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