1

B Y T

HNG DN CHN ON V IU TR
CC BNH SN PH KHOA
(Ban hnh km theo Quyt nh s 315/Q-BYT ngy 29/01/2015)

H NI - 2015

B Y T

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

S: 315/Q-BYT

H Ni, ngy 29 thng 01 nm 2015

QUYT NH
V vic ban hnh ti liu chuyn mn
Hng dn chn on v iu tr cc bnh sn ph khoa
B TRNG B Y T
Cn c Lut khm bnh, cha bnh nm 2009;
Cn c Ngh nh s 63/2012/N-CP ngy 31/8/2012 ca Chnh Ph quy
nh chc nng, nhim v, quyn hn v c cu t chc ca B Y t;
Theo ngh ca Cc trng Cc Qun l Khm, cha bnh,
QUYT NH:
iu 1. Ban hnh km theo Quyt nh ny ti liu chuyn mn Hng dn
chn on v iu tr cc bnh sn ph khoa.
iu 2. Ti liu Hng dn chn on v iu tr cc bnh sn ph khoa
ban hnh km theo Quyt nh ny c p dng ti cc c s khm bnh, cha
bnh.
Cn c vo ti liu ny v iu kin c th ca n v, Gim c c s khm
bnh, cha bnh xy dng v ban hnh ti liu hng dn chn on v iu tr cc
bnh sn ph khoa ph hp thc hin ti n v.
iu 3. Quyt nh ny c hiu lc k t ngy k ban hnh.
iu 4. Cc ng, b: Chnh Vn phng B, Chnh Thanh tra B, Cc trng
Cc Qun l Khm, cha bnh, Cc trng v V trng cc Cc, V thuc B Y
t, Gim c cc bnh vin, vin c ging bnh trc thuc B Y t, Gim c S
Y t cc tnh, thnh ph trc thuc trung ng, Th trng Y t cc B, Ngnh v
Th trng cc n v c lin quan chu trch nhim thi hnh Quyt nh ny./.
Ni nhn:
- Nh iu 4;
- B trng B Y t ( b/c);
- Cc Th trng BYT;
- Bo him X hi Vit Nam ( phi hp);
- Cng thng tin in t BYT;
- Website Cc KCB;
- Lu VT, KCB.

KT. B TRNG
TH TRNG
( k)

Nguyn Vit Tin

Ch bin: PGS.TS. Nguyn Vit Tin

Ban bin son:

PGS.TS. Nguyn c Hinh
PGS.TS. Lu Th Hng
PGS.TS. L Hoi Chng
PGS.TS. Nguyn Quc Tun
PGS.TS. Trn Danh Cng
PGS.TS. L Thanh Vn
PGS.TS. Nguyn V Quc Huy
TS. V B Quyt
THS. L Quang Thanh
TS. L Thin Thi
TS. L Hong
TS. Nguyn Duy nh
Ths. Nguyn Minh Trc
Ths. Trn Diu Linh
Ban th k:
Ths. Nguyn c Tin
Ths. ng Th Hng Thin
Ths. Ng Th Bch H
Ths. V Vn Khanh

CH VIT TT
aCL

: AntiCardioLipin antibody

: m o

AIDS

: Acquired immunodeficiency Syndrom

AFI

: Amnionic fluid index

aPL

: AntiPhosphoLipid antibody

APS

: AntiPhospholipid Syndrome

APTT

: Activated partial thromboplastin time

ALT

: Alanine aminotranferease

AST

: Aspartate aminotransferase

CMV

: Cytomegalovirus

CTM

: Cng thc mu

CRP

: C- Reaction Protein

HA

: Huyt p

hCG

: Human chorionic gonadotropin

HELLP:
H -- hemolysis (the breakdown of red blood cells)
EL -- elevated liver enzymes
LP -- low platelet count
HIV

:Human immunodeficiency virus

LA

: Lupus Anticoagulant antibody

LDH

: Lactate dehydrogenase

LMWH

: Low-molecular-weight heparin

LNMTC

: Lc ni mc t cung

MTX

: Methotrexat

MRI

: Magnetic resonance imaging

NST

: Nhim sc th

PET

: Positron emission tomography

PGD

: Preimplantation genetic diagnosis

TM

: Tnh mch

MC LC
CHNG 1: SN KHOA ........................................................................................7
1. DA SY THAI SY THAI...........................................................................7
2. SY THAI LIN TIP .....................................................................................12
3. DA NON, NON ..................................................................................17
4. THAI CHT LU TRONG T CUNG ...........................................................20
5. THAI CHM PHT TRIN TRONG T CUNG ...........................................25
6. TIN SN GIT SN GIT ........................................................................29
7. A I ................................................................................................................35
8. THIU I ..........................................................................................................37
9. RAU TIN O ..............................................................................................39
10. RAU BONG NON ...........................................................................................43
11. THAI QA NGY SINH ...............................................................................47
12. BNH TIM MCH V THAI NGHN .........................................................49
13. THIU MU V THAI NGHN ...................................................................54
14. BASEDOW V THAI NGHN .....................................................................56
15. I THO NG V THAI NGHN ......................................................59
16. VIM GAN B V THAI NGHN .................................................................65
17. HIV/AIDS V THAI NGHN .......................................................................68
18. ST TRONG KHI C THAI ..........................................................................73
19. SINH L CHUYN D .................................................................................77
20. NGI MNG ..................................................................................................82
21. NGI VAI .......................................................................................................86
22. I V SM, I V NON ..............................................................................88
23. SUY THAI TRONG T CUNG .....................................................................93
24. TC MCH I ...............................................................................................96
25. V T CUNG .................................................................................................99
26. CHY MU SAU ..................................................................................103

27. NHIM KHUN HU SN ........................................................................107

CHNG 2: PH KHOA ...................................................................................113
1. P XE V .......................................................................................................113
2. CC TN THNG V ...............................................................................115
3. TN THNG LNH TNH C T CUNG ...............................................123
4. VIM PHN PH ..........................................................................................128
5. VIM M O ..............................................................................................132
6. CHA NGOI T CUNG .............................................................................135
7. CHA VT M ..........................................................................................141
8. SA SINH DC ................................................................................................143
9. U NANG BUNG TRNG ............................................................................149
10. U X T CUNG (FIBROID) .......................................................................154
11. LC NI MC T CUNG ..........................................................................157
12. TIN UNG TH V UNG TH M H TN THNG TIN UNG TH .163
13. UNG TH M H .......................................................................................164
14. CHA TRNG .............................................................................................169
15. U NGUYN BO NUI ..............................................................................174
16. UNG TH C T CUNG ............................................................................178
17. UNG TH NIM MC T CUNG .............................................................183
18. UNG TH BUNG TRNG .......................................................................187
19. RONG KINH RONG HUYT ......................................................................195
20. V KINH .......................................................................................................201
21. MN KINH TIN MN KINH.................................................................206
22. V SINH N ................................................................................................210
23. V SINH NAM .............................................................................................215
CHNG 3: S SINH .........................................................................................220
1. CHM SC TR NON THNG ...................................................................220
2. HI SC S SINH NGT .............................................................................227
3. NHIM KHUN S SINH ............................................................................234

4. H THN NHIT TR S SINH .................................................................240

5. VNG DA S SINH.......................................................................................243
6. SUY H HP S SINH .................................................................................249
PH LC 1: THUC TRNH THAI..255
PH LC 2: DNG C T CUNG261
PH LC 3: X TR D TT BM SINH CP CU..267

TI LIU THAM KHO278

CHNG 1: SN KHOA
DA SY THAI SY THAI
1. KHI NIM
Sy thai l hin tng kt thc thai nghn trc khi thai c th sng c. Vi
khi nim ny, sy thai c nh ngha l trng hp thai b tng ra khi bung t
cung trc 22 tun hay cn nng ca thai di 500g.
2. CHN ON
2.1. Lm sng: sy thai t nhin din ra 2 giai on: da sy thai v sy thai.
2.1.1. Da sy thai:
- C thai (chm kinh, nghn), ra mu m o (mu ti, ln t nhy, c khi
mu sm hay en, mu ra t mt, lin tip), au bng (thng khng au bng
nhiu, ch c cm gic tc nng bng di hay au m vng h v).
- Khm: c t cung tm nhng cn di, ng kn, kch thc thn t cung to
tng xng vi tui thai.
2.1.2. Sy thai
- C thai nh chm kinh, nghn
- Ra mu m o: mu , lng nhiu, mu long ln mu cc
- au bng: au bng nhiu tng cn vng h v
- Khm: c t cung xa, m, phn di t cung phnh to do bc thai b y
xung pha c t cung lm cho c t cung c hnh con quay, i khi s thy bc
thai nm ng c t cung.
2.2. Cn lm sng
- hCG: dng tnh
- Siu m: c hnh nh ti i trong bung t cung, c m vang phi v tim thai
(khi thai > 6 tun bng siu m u d m o). Vi sy thai, c th thy hnh nh
ti thai tt xung thp hay trong ng c t cung.
2.3. Chn on th bnh

- Da sy thai
- Sy thai hon ton
Ngi bnh c du hiu ca c thai v ang sy thai. Sau khi au bng, ra
mu, thai ra c bc, sau ra mu t dn.Khm thy c t cung ng, t cung nh
hn tui thai. Siu m bung t cung sch.
- Sy thai khng hon ton
Ngi bnh c du hiu ca c thai v ang sy thai. Sau khi thy thai ra ri
vn cn au bng, cn ra mu ko di. Khm c t cung m v t cung cn to.
Siu m c hnh nh m vang khng ng nht trong bung t cung.
- Sy thai cht
+ Ngi bnh c du hiu ca c thai.
+ C du hiu ca thai cht lu: gim nghn, ra mu en ko di, khm thy t
cung nh hn tui thai, siu m thy hnh nh ti i mo m khng c m vang phi
hay c phi thai nhng khng thy hot ng ca tim thai.
+ C du hiu ca da sy thai, ang sy thai, sy thai hon ton hay khng
hon ton.
- Sy thai lin tip
+ c nh ngha l c hin tng sy thai t nhin 2 ln.
+ 2 xt nghim c khuyn co: nhim sc ca 2 v chng v hi chng
khng phospholipid (AntiPhospholipid Syndrome - APS).
2.4. Chn on phn bit
2.4.1. Cha ngoi t cung th gi sy
C thai, au bng, ra mu, c t chc ging khi thai sy ra t bung t cung.
Phn bit: khm c khi cnh t cung n au, cng y, au. Siu m thy
khi cnh t cung. Gii phu bnh khi sy khng thy hnh nh gai rau m thy
mng rng.

2.4.2. Thai lu
Ngi bnh c thai, ra mu (mu en, t mt, ko di), khng au bng. Siu
m thy ti i b mo, khng c m vang thai hay c phi thai nhng khng c hot
ng ca tim thai. i khi rt kh phn bit khi tui thai cn nh. Xt nghim
hCG theo di v siu m li sau mt tun
2.4.3. Cha trng thoi trin
C thai, ra mu. Khm c th thy t cung to hn tui thai. Siu m thy
hnh nh rut bnh m, hCG cao > 200.000UI/L).
2.4.4. Rong kinh rong huyt
c bit trong trng hp ngi bnh c kinh nguyt khng u. Khm thy
t cung bnh thng, hay cng to hn bnh thng nhng chc (u x t cung), hCG
m tnh, siu m thy khng thy thai trong bung t cung. No nim mc t cung
xt nghim gii phu bnh l.
3. IU TR
3.1. Da sy thai: cha c liu php iu tr da sy thai no c cho l ti u
- Nm ngh, n nh, ch n trnh gy to bn. B sung vin st, a.folic
- Thuc gim co tht c trn nh papaverin 40mg, spasmaverin 40mg x 4 vin
chia 2 ln/ngy
- Thuc ni tit nh progesteron 25mg x 2 ng/tim bp/ngy, nu c bng
chng ca s thiu ht ni tit, hay dng progesteron lm mm c t cung.
- Khng sinh: chng nhim trng do hin tng ra mu.
- Khu vng c t cung cp cu: trong trng hp thai trn 3 thng da sy,
nu c hin tng bin i c t cung, sau khi khng ch nhim trng m o,
c t cung v cn co t cung, khu vng c t cung cp cu
3.2. ang sy thai v sy thai
- ang sy thai: bc thai nm trong m o hoc trong ng c t cung, gp
bc thai bng km qu tim, sau no li bung t cung m bo khng st rau.

10

Thuc co hi t cung sau khi no (oxytocin 10UI tim bp, hoc ergometrin 0,2mg
x 1 ng/tim bp). Khng sinh phng nhim khun
- Sy thai hon ton: kim tra bng siu m thy bung t cung sch, khng
no li. Cho khng sinh phng nhim khun.
- Sy thai khng hon ton: ty khi cn li trong bung t cung v ra mu m
o m tin hnh ht, no li bung t cung hay dng misoprostol 400mcg ngm
di li gip co hi t cung v tng nt t chc cn li. Cho khng sinh phng
nhim khun.
- Sy thai nhim khun: khng sinh liu cao, kt hp thuc co hi t cung. Sau
6h dng khng sinh, nhit gim, tin hnh ht hay no li bung t cung. Ch
th thut d gy thng t cung hn bnh thng. T vn cho ngi bnh v ngi
nh nguy c ct t cung nu tnh trng nhim khun khng c ci thin.
- Sy thai bng huyt: tch cc hi sc, truyn dch, truyn mu (nu cn
thit). Ht, no li bung t cung ly ht t chc cn st li. Dng thuc co hi t
cung gip t cung co tt. Cho khng sinh phng nhim khun.
3.3. Sy thai lin tip
- Tm nguyn nhn gy sy thai lin tip
- iu tr theo nguyn nhn:
+ H eo t cung: khu vng c t cung.
+ Thiu ht ni tit: b xung ni tit nh progesteron 25mg x 2 ng/tim bp
su / ngy, estrogen (progynova 2mg/ngy).
+ M b hi chng khng phospholipid: dng thuc chng ng.
+ iu tr cc bnh l ton thn ca m nh i tho ng, giang mai, vim
thn hay cc bnh ni tit nh thiu nng gip trng, basedow
+ M bc nhn x trong u x t cung, m ct vch ngn t cung
+ Ri lon nhim sc th: nn tham kho li khuyn v di truyn xem ngi
bnh c nn c thai li na khng.

11

5. TIN LNG V PHNG BNH

Tin lng v phng sy thai cho ln c thai sau ty thuc vo nguyn nhn
gy sy thai.
- Vi thiu ht ni tit: ch ng b sung ni tit ngay khi ngi bnh c thai.
- Vi h eo t cung: khu vng c t cung ch ng ln c thai sau.
- Khi m b APS: dng aspirin liu thp trc khi c thai, dng thuc chng
ng khi ngi bnh c thai.
- Ch ng iu tr cc bnh l ton thn ca m (nu c).
- Vi nguyn nhn b hoc m b ri lon nhim sc th: tin lng c
con bnh thng rt kh khn, nn t vn v di truyn xem c nn c thai na khng.

12

SY THAI LIN TIP

1. KHI NIM
Sy thai lin tip l hin tng c t 2 ln sy thai lin tc tr ln, thai nhi b
tng xut khi bung t cung trc 22 tun.
Nguy c thay i ty theo s ln sy thai, tng sinh con cn sng v c con
b d tt hay khng.
2. CHN ON
2.1 Lm sng
- Phn ln ngi bnh n khm khi ang c thai vi tin s sy thai, hay c
tin s sy thai lin tip
- ngoi thi k mang thai, khm lm sng c th pht hin c mt s
nguyn nhn gy sy thai lin tip nh u x t cung, h eo t cung, t cung nhi
tnh, t cung d dng, m c bnh l ton thn
2.2. Cn lm sng
2.2.1. Nhim sc
C th pht hin c bt thng s lng hay cu trc nhim sc th ca mt
hay 2 v chng c tin s sy thai lin tip.
2.2.2. Khng th khng phospholipid
- aPL: antiPhosphoLipid antibody: IgM v IgG
- aCL: antiCardioLipin antibody: IgM v IgG
+ Dng tnh: IgM v IgG cao hn trung bnh ko di > 6 tun
- LA: Lupus Anticoagulant antibody
+ Dng tnh: khi nng cao hn mc trung bnh ko di > 6 tun
+ Nhy cm vi cc trng hp c tin s huyt khi
- 2-GpI: Anti beta 2 Glycoprotein I:
+ Gi tr tin on dng tnh cao (87,5%)
- Khc: khng th khng nhn, khng th khng DNA
+ Khng thng dng

13

+ p dng trong APS th pht

Trn lm sng, xt nghim aPL v aCL thc hin trc, nu hai xt nghim
ny m tnh s tip tc th vi LA v 2-GpI. Hi chng khng PhosphoLipid c
chn on l dng tnh nu c t nht mt trong cc xt nghim trn dng tnh.
Cc xt nghim khc
- Siu m: pht hin cc trng hp bt thng t cung nh u x t cung,
t cung d dng, t cung nhi tnh
- Chp t cung: pht hin t cung d dng, t cung c vch ngn, dnh bung
t cung...
- Xt nghim ni tit: tm mt s nhng ri lon ni tit nh i tho ng,
bnh tuyn gip, suy hong th sm
- Mt s xt nghim vim nhim khc: Toxoplasma, CMV, giang mai
3. IU TR
Da vo nguyn nhn gy sy thai lin tip
3.1. Ri lon nhim sc th
- T vn v di truyn xem ngi bnh c nn c thai na hay khng.
- Trng hp c thai t nhin: tin hnh cc xt nghim chn on trc sinh,
chc i hoc sinh thit gai rau cho tt c thai k c b hoc m mang bt thng
nhim sc th (NST).
- Trong th tinh trong ng nghim: tin hnh sinh thit chn on tin phi (k
thut PGD) nhm loi b nhng phi mang bt thng di truyn gy sy thai hoc
c nguy c gy d tt bm sinh cao.
3.2. Hi chng khng PhosphoLipid
3.2.1. Cc thuc s dng trong Hi chng khng PhosphoLipid
Thuc chng ng mu: Heparin trng lng phn t thp hoc Heparin khng t
on .Thi gian tc dng ko di tim 1 ln/ngy
+ Fraxiparin 50 60UI/kg/ngy (bm 0,3ml/ngy - 2850UI, tim di da bng)
+ Lovenox 20 - 40mg/ngy tim di da
c ch tiu cu: Aspirin (ASA)

14

- iu tr liu thp: 75 - 100mg/ngy

- Theo di s lng tiu cu, yu t ng mu
- Ngi bnh c gim tiu cu: khng nn dng
c ch min dch
- Thng s dng cho APS th pht hay CAPS (catastrophic APS)
- Corticoid liu ti thiu 1mg/kg/ngy (1 l methylped 40mg)
- Gammaglobulin:
+ Cc trng hp qu nng
+ Liu 0,4g/kg/ngytrong 5 ngy hoc 1g/kg/ngy trong 2 ngy
3.2.2. Phc iu tr
Bnh cnh

Khng c thai

C thai

Hi chng khng

- Khng iu tr

- LMWH + ASA liu thp

PhosphoLipid vi bin

- ASA liu thp

- B sung Ca v Vit D

chng sn khoa
Hi chng khng

Warfarin, duy tr - ASA liu thp + Liu

PhosphoLipid vi tin s

INR: 2 3

huyt khi

LMWH ti a m khng qua

c rau thai (gp 3 - 4 ln)

Hi chng khng

iu tr theo

c ch min dch nu cn thit

PhosphoLipid th pht hay

chuyn khoa

LMWH + ASA

CAPS

3.2.3. Thi gian iu tr

+ ASA: ngay khi th hCG (+) nu trc khng dng
- Dng bt c khi no sau 36 tun, nn dng 7 - 10 ngy trc khi ly thai
- Thai ph c tin s huyt khi: tip tc dng ASA trong, sau (d phng
huyt khi quan trng hn so vi chy mu v ASA)
- Khng c mi lin quan gia ASA liu thp v bnh l ng sm ng ng
mch, chy mu sau

15

+ LMWH: dng khi siu m c tim thai hay ngay khi c thai
- Sut thi k c thai v dng trc khi ly thai 24h (ang nghin cu)
- APS c tin s sy thai, thai cht lu < 3thng + khng tin s huyt khi,
Doppler bnh thng tui thai 34 tun c th dng LMWH
- Thi k sau sinh: dng LMWH ko di sau 6 - 12 tun, sau c th thay
bng warfarin v theo di INR
3.2.4. Qun l thai nghn
- T vn k v bnh l ny ngi bnh cng theo di: Du hiu ca huyt
khi cc v tr, du hiu ca tin sn git, thai chm pht trin trong t cung, sy
thai, thai lu v du hiu cc tc dng ph ca thuc
- Theo di thai: siu m Doppler 3 tun/ln t tui thai 18 tun (nu thai bnh
thng), hay theo ch nh nu Doppler nu c du hiu bt thng. Theo di
monitoring sn khoa thng xuyn t tui thai 20 tun
- Theo di tc dng ph ca thuc (tiu cu, APPT): 3 tun u 1ln / tun.
Sau 4 tun/ln (nu khng c bt thng)
3.2.5. Kt thc thai nghn
- Thi im kt thc thai nghn: PARA + can thip sm
+ Thai bnh thng: tui thai 39 tun
+ Thai c bin chng: tin sn git, thai chm pht trin trong t cung theo ch
nh sn khoa + PARA + can thip sm.
- Phng php kt thc thai nghn: theo ch nh ca sn khoa
- Gim au trong APS ch nh binh thng nn dng LMWH trc 24h, xt
nghim ng mu bnh thng, tiu cu > 70G/l
3.3. iu tr nguyn nhn khc
- H eo t cung: khu vng c t cung, gim co.

16

- Thiu ht ni tit: b xung ni tit nh progesteron, estrogen.

- M bc nhn x trong u x t cung, m ct vch ngn t cung
- iu tr cc bnh l ton thn ca m nh i tho ng, giang mai, vim
thn hay cc bnh ni tit nh thiu nng gip trng, basedow
4. TIN LNG V PHNG BNH
Tin lng v phng sy thai cho ln c thai sau ty thuc vo nguyn nhn
gy sy thai lin tip.
- Vi thiu ht ni tit: ch ng b sung ni tit ngay khi ngi bnh c thai.
- Vi h eo t cung: khu vng c t cung ch ng ln c thai sau.
- Khi m b hi chng khng PhosphoLipid: dng aspirin liu thp trc khi
c thai, dng thuc chng ng khi ngi bnh c thai.
- Ch ng iu tr cc bnh l ton thn ca m (nu c).
- Vi nguyn nhn b hoc m b ri lon nhim sc th: tin lng c con
bnh thng rt kh khn, nn t vn v di truyn xem c nn c thai na khng.

17

DA NON, NON
1. KHI NIM:
- nh ngha: theo T chc Y t th gii, non l cuc chuyn d xy ra t
tun th 22 n trc tun 37 ca thai k tnh theo kinh cui cng.
- S sinh non thng c t l t vong v mc bnh cao hn rt nhiu so vi tr
thng, nguy c cao b di chng thn kinh vi t l 1/3 trc tun 32, gim
xung 1/10 sau 35 tun. D phng v iu tr da non - non lun l mt vn
quan trng i vi sn khoa, s sinh v ton x hi.
- Ti Vit nam, cha c thng k trn ton quc, nhng theo nhng nghin
cu n l, t l non khong 8-10%.
2. CHN ON:
2.1. Da non:
2.1.1. Triu chng c nng :
- au bng tng cn, khng u n, tc nng bng di, au lng
- Ra dch m o dch nhy, ln mu
2.1.2. Triu chng thc th :
- Cn co t cung tha nh (2 cn trong 10 pht, thi gian co di 30 giy)
- C t cung ng, hoc xa m di 2cm
2.2. non:
- Triu chng c nng: au bng cn, u n, cc cn au tng dn. Ra dch
m o, dch nhy, mu, nc i
- Triu chng thc th: cn co t cung (tn s 2-3, tng dn). C t cung xa
trn 80%, m trn 2cm. Thnh lp u i hoc v i.
2.3. Cn lm sng:
- Test fibronectin : test dng tnh khi nng fibronectin > 50ng/ml, kh
nng xy ra non trong vng 7 ngy nhng thai ph ny s cao hn 27 ln so
vi nhng ngi c test m tnh.

18

- o chiu di c t cung bng siu m ng bng, ng m o hoc tng

sinh mn. Di 35mm thai 28-30 tun th nguy c sinh non l 20%.
- nh lng hCG dch c t cung: trn 32mUI/ml nguy c non s cao hn
xp x 20 ln.
- Monitoring sn khoa: cho php theo di, nh gi tn s, di, cng
cn co t cung.
- Mt s xt nghim tm nguyn nhn v tin lng : xt nghim vi khun
c t cung, nc tiu, CRP, huyt hc, sinh ha mu, men gan...
2.4. Chn on phn bit :
- Cc tn thng c t cung, ng sinh dc di gy chy mu m o.
- Rau tin o, rau bong non, v t cung.
3. IU TR :
3.1. Nguyn tc chung :
- Tr hon chuyn d iu tr da non,
- Chuyn sn ph n c s c kh nng chm sc s sinh non thng
3.2. iu tr c th:
3.2.1. Ngh ngi tuyt i ti ging, nghing tri, trnh kch thch
3.2.2. Thuc gim - ct cn co t cung:
- Thuc hng b ta giao cm: Salbutamol.
Chng ch nh trong bnh tim, cng gip, tng huyt p, i tho ng
nng, chy mu nhiu, nhim khun i. Tc dng ph: tng nhp tim, tng ng
huyt, h Kali mu. Dng thuc nu nhp tim >120ln/pht.
Salbutamol : 5mg pha trong 500ml Glucose 5%, truyn tnh mch 20 git/pht
(10mcg/pht), liu ti a 45 git/ pht. Khi ct c cn co, chuyn sang liu
duy tr : vin 4mg, ngm 1 - 2 vin/ngy.
- Thuc chn knh calci : c th dng 1 trong cc thuc sau :
+ Nifedipine : liu tn cng 20mg ngm di li trong 20 pht, ti a 03
liu. Sau khi ct cn co duy tr Nifedipine chm 20mg, ung 6-8h /ln. Theo di
huyt p khi dng thuc, chng ch nh nu huyt p thp < 90/50mmHg.

19

Tc dng ph: nng bng mt, bun nn, tt HA thong qua.

+ Magnesium Sulfate: liu tn cng 4-6g pha trong 100ml Glucose 5%, truyn
TM trong 20 pht. Liu duy tr: 2g/h truyn tnh mch trong 12h, sau 1g/h trong
24h. Tai bin: nng bng mt, gim phn x gn xng, c ch h hp, ngng th,
ngng tim. Cn theo di nng ion Mg huyt thanh 5-7mg/dL.
+ Thuc i khng cnh tranh vi oxytocin: Atosiban c tc dng cnh tranh
vi oxytocin trn cc th th ti mng t bo c t cung lm gim s p ng ca
c t cung vi oxytocin.
Ch nh iu tr da non t tun 24-33 ca thai k. Chng ch nh: i v
non, thai suy, thai chm pht trin, chy mu nng, tin sn git, rau tin o, rau
bong non.
Liu dng : 75mg Atosiban (10ml) pha trong 90ml dung dch Glucose 5%
hoc NaCl 0,9%. Truyn tnh mch 24ml/h, sau 3h gim xung 8ml/h. Thi gian
iu tr khng nn qu 48h, khng qu 3 t iu tr trong thai k.
3.2.3. Liu php Corticoid : tng cng sn xut surfactan, thc y s trng
thnh ca m lin kt, lm gim suy h hp tr non thng. Ch nh cho thai t 28
n ht 34 tun tui, c th s dng mt trong cc thuc sau cc tuyn y t.
- Bethamethasone 12mg, 2 liu tim bp cch nhau 24h.
- Hoc Dexamethasone 6mg/ln, tim bp 4 ln cch nhau 12h.
3.2.4. X tr non khi c ch chuyn d khng thnh cng :
- Trnh sang chn cho thai : bo v u i n khi c t cung m ht, hn ch
s dng oxytocin, ct tng sinh mn rng, m ly thai nu c ch nh.
- Chng nhim khun nu i v sm, d phng st rau, chy mu sau .
- m bo hi sc, chm sc tr s sinh non thng.

20

THAI CHT LU TRONG T CUNG

1. KHI NIM
Thai cht lu trong t cung l tt c cc trng hp thai b cht m cn lu li
trong t cung trn 48 gi.
2. CHN ON
2.1. Thai cht lu di 20 tun
2.1.1. Lm sng
- Nhiu trng hp khng c triu chng lm cho pht hin mun, mt s
trng hp ngi bnh thy bng b i hoc khng to ln d mt kinh lu.
- Bnh cnh lm sng hay gp:
+ Ngi bnh c du hiu ca c thai nh chm kinh, hCG dng tnh, siu
m thy c thai v hot ng ca tim thai.
+ Ra mu m o: mu ra t nhin, t mt, mu sm hay nu en.
+ au bng: thng khng au bng, ch au bng khi da sy hay ang sy
thai lu.
- Khm: thy t cung b hn tui thai, mt t cung i khi chc hn so vi
mt t cung c thai sng.
2.1.2. Cn lm sng
- hCG:
+ hCG trong nc tiu ch m tnh sau khi thai cht mt thi gian.
+ Nng hCG: thp hn so vi tui thai hay tc tng ca hCG khng
theo qui lut ca thai sng.
-

Siu m: l thm d c gi tr, cho chn on sm v chnh xc:

+ Thy m vang thai r rng m khng thy hot ng tim thai. Hnh nh ti
i rng (ch nhn thy ti i m khng thy m vang thai), ti i rng vi b
mo m, khng u. Trong trng hp nghi ng, nn kim tra li sau 1 tun
xem tin trin ca ti i
+ C m vang thai : khng thy hot ng tim thai.

21

2.1.3. Chn on phn bit

- Cha ngoi t cung: chm kinh, au bng, ra mu en m o, t cung nh
hn so vi tui thai. Trong cha ngoi t cung, siu m khng c ti i trong
bung t cung, cnh t cung thy khi bt thng nghi ng khi cha, c th c
dch cng .
- Cha trng: d nhm vi cha trng thoi trin v bnh cnh lm sng c th
ging y ht nhau. Gii phu bnh l t chc no bung t cung cho chn on xc nh.
- Da sy thai: c bit khi tui thai nh hn 6 tun m siu m cha thy tim
thai. Phn bit: mu m o ti ch khng sm mu, thng c au bng km
theo. Siu m c th cha thy phi thai v tim thai nhng b ti i cng trn, c ti
non hong. Siu m kim tra li sau 1 tun l cn thit.
- T cung c u x: ra mu m o bt thng, t cung to hn tui thai. Siu
m c thai km u x t cung.
- Thai sng: phi lm thm khm, theo di trnh nhng chn on nhm ln
ng tic xy ra.
2.2. Thai cht lu trn 20 tun
2.2.1. Lm sng: triu chng thng r rng lm ngi bnh phi i khm
ngay.
- Bnh cnh lm sng :
+ Du hiu c thai, c bit l c c ng thai, s nn thy phn thai, nghe
thy ting tim thai.
+ Ngi bnh khng thy thai c ng na, khng thy bng to ln, thm ch
b i (nu thai cht lu ngy).
+ Hai v tit sa non.
+ Ra mu m o: him gp.
+ au bng: khi chun b sy , thai lu.
+ Nu ngi bnh b mt s bnh km theo nh nghn nng, tin sn git,
bnh tim...th bnh t thuyn gim, ngi bnh cm thy d chu hn.
- Khm:

22

+ T cung b hn so vi tui thai, c bit c gi tr nu thy chiu cao t

cung gim i gia hai ln o.
+ Kh s nn thy cc phn thai.
+ Khng nghe thy ting tim thai.
2.2.2. Cn lm sng
- Siu m: cho kt qu chnh xc, chn on sm v chc chn. Khng thy
hot ng ca tim thai. u thai mo m, c th thy hin tng chng khp s hay
du hiu hai vng xng s do da u b bong ra. Nc i t hay ht i.
- Cc phng php thm d X quang nh chp bng khng chun b, chp
bung i...ngy nay khng cn c s dng do nguy him cho m v cho thai nu
thai cn sng.
- nh lng Fibrinogen trong mu: nh gi nh hng ca thai n qu trnh
ng mu. y l xt nghim quan trng v cn thit trc khi can thip cho thai ra.
2.2.3. Chn on phn bit:
t t ra vi thai trn 20 tun b cht lu v triu chng lm sng v siu m
cho kt qu chnh xc.
3. IU TR
3.1. iu chnh tnh trng ri lon ng mu (nu c) trc khi can thip ly thai
+ Fibrinogen truyn tnh mch.
+ Mu ti ton phn.
+ Cc thuc chng tiu sinh si huyt nh: transamine...
+ Heparin: liu 5000 10000UI/ngy. Cn nghin cu thm p dng iu
tr m bo an ton cho ngi bnh.
3.2. Nong c t cung, no bung t cung
- p dng cho cc trng hp thai lu m th tch t cung b hn t cung c
thai 3 thng (hay chiu cao t cung di 8cm).
- Th thut kh hn no thai sng v rau thai lu x ha bm cht vo t cung.
Ch phi gim au tt v th thut kh, ch ng dng thuc co hi t cung v
khng sinh sau no. Theo di chy mu

23

3.3. Gy sy thai, gy chuyn d

- p dng cho tt c cc trng hp thai cht lu m th tch t cung to hn t
cung c thai 3 thng.
+ Phng php Stein ci tin: dng estrogen trong 10mg/ngy trong 3 ngy,
n ngy th t truyn oxytocin tnh mch gy cn co t cung, liu ti a
30UI/ngy, mi t 3 ngy lin, cc t cch nhau 7 ngy. Thng thng thai b
tng ra sau 1 n 2 ngy truyn u tin.
+ Truyn oxytocin tnh mch n thun: ging phng php Stein ci tin
nhng khng dng trc estrogen. u im ca phng php ny l rt ngn c
thi gian iu tr m kt qu thnh cng c v cng tng t nh Stein.
+ Dng Prostaglandin: l phng php c a chung nht hin nay. Cc
thuc hay c dng thuc nhm Prostaglandin E2. Liu thuc ph thuc vo tui
thai. ng dng c th l t m o, t hu mn hay ngm di li.
Ch cc chng ch nh ca Prostaglandin v Oxytocin.
+ Vi cc trng hp kh: nu khng c ri lon ng mu, khng c nhim
trng, ch i chuyn d t nhin l thi c th chp nhn c
4. TIN TRIN V BIN CHNG
4.1. nh hng n tm l, tnh cm ca ngi m
Thai cht lu bao gi cng gy ra nhng hu qu tm l nng n cho ngi m
v mt i mt a con ang c mong i. Tm l s khi mang ci thai cht.
Thy thuc cn gii thch cn k, lm an lng v thng cm vi ngi m.
4.2. Ri lon ng mu
- Nguyn nhn: thromboplastin c trong nc i v t chc thai cht i vo
tun hon mu m - c bit khi t cung c cn co, hay khi can thip vo bung t
cung, hot ha qu trnh ng mu gy ra ng mu ri rc trong lng mch, lm
fibrinogen trong mu tt xung thp.

24

- Din bin: qu trnh ri lon ng mu c th din ra t t vi thi gian tim

tng trn 4 tun hay cp tnh khi c cn co t cung hay can thip vo bung t cung.
- Lm sng: chy mu din ra t t, mu khng ng, xut hin sau khi can
thip vi gi. Hay chy mu nhiu, mu khng ng, gy mt mu cp tnh.
- Xt nghim: fibrinogen rt thp hay khng c, sn phm phn hy ca
fibrinogen tng cao, gim plasminogen, gim hot tnh yu t antithrombin III, gim
tiu cu.
4.3. Nhim trng
- Khi mng i cn: khng s nhim trng.
- Khi i v, c bit khi i v lu: nhim trng s rt nhanh v nng v
ngoi cc vi khun thng gp cn c th nhim cc vi khun ym kh.
5. PHNG BNH
- D phng thai cht lu l mt vn phc tp v khng tm thy nguyn nhn.
- Trong chn on cn thn trng c bit khi tui thai nh.
- Trong iu tr: trnh vi vng cho thai ra m khng tm sot ri lon ng
mu v gy ra nhng bin chng ca vic no thai, thai lu.

25

THAI CHM PHT TRIN TRONG T CUNG

1. NH NGHA
Khi nim thai nh cn l khi thai thng, trng lng thai lc sinh di
2500gr
Trong thc t, khi nim thai chm pht trin trong t cung bao gm trng
lng thai ti thi im thm khm v s pht trin ca thai. xc nh thai thc
s c chm pht trin hoc ngng pht trin th phi o kch thc v c lng
trng lng thai t nht 2 ln thm khm lin tip cch nhau 01 tun. Ty tng tc
gi, ty tng nhm nghin cu m gii hn ca thai chm pht trin trong t cung
thay i, nm di ng bch phn v th 10, th 5 hoc th 3.
2. CHN ON
2.1. Lm sng
Khng c du hiu c trng
C th c mt s gi :
- Tin s con chm pht trin trong t cung
- M tng cn t hn bnh thng
- Chiu cao t cung nh hn tui thai
- Pht hin c mt s nguyn nhn: HA cao, m b bnh l mn tnh
2.2. Siu m
L phng php gip chn on hu hiu
So snh i chiu cc kch thc ca thai nhi vi kch thc chun ( cc ch s
v kch thc thai c xy dng da trn cc nghin cu m t ct ngang) nh
gi thai chm pht trin trong t cung cn i hay khng cn i
2.2.1. Ch s: ng knh lng nh
70% cc trng hp thai chm pht trin trong t cung c kch thc ng
knh lng nh nh hn so vi tui thai
2.2.2. Ch s: chu vi bng

26

y l mt ch s thng c s dng nht d on thai chm pht trin

trong t cung. Chu vi bng c gi tr d on thai chm pht trin trong t cung cao
hn ch s ng knh lng knh, chu vi u v chiu di xng i.
Tc tng trng ca ng knh chu vi bng ng vai tr quan trng trong
chn on thai chm pht trin trong t cung mt s trng hp ngi m khng nh
chnh xc ngy kinh, khng nh gi c tui thai, nu tc tng ca chu vi bng
di 10 mm trong 15 ngy th c th ngh ti thai chm pht trin trong t cung.
2.2.3. Ch s: chiu di xng i
Ch s ny khng c gi tr c bit trong chn on thai chm pht trin trong
t cung.
2.2.4. Tnh trng nc i
C n 90% cc trng hp thai chm pht trin trong t cung c tnh trng
thiu i, ngc li nu km theo a i th phi ngh ti cc nguyn nhn thai bt
thng nh ri lon NST, bnh l gen..
2.2.5. trng thnh bnh rau
Khng c nhiu gi tr trong chn on v d bo thai chm pht trin trong t cung.
2.2.6. c lng trng lng thai
Rt kh c mt cng thc tnh chnh xc trng lng thai nhi trong t cung,
chng ta ch c th c on trng lng thai trong khong cng tr 10 % ca gi
tr trung bnh, i chiu vi biu pht trin trng lng thai theo tui thai
chn on thai chm pht trin trong t cung. Ngoi ra cn mt s ch s tham kho
khc nh: chu vi i, t l gia chiu di xng i v chu vi i, t l gia chu vi
u v chu vi bng
2.2.7. Ch s Doppler ng mch
- Doppler ng mch rn v ng mch t cung bnh thng : t nguy c bin
chng trong thi k chu sinh, thng gp trong thai chm pht trin trong t cung
do nguyn nhn bt thng NST
- Doppler ng mch t cung bt thng: l du hiu bnh l h tun hon
ca ngi m, sn ph c nguy c tin sn git v ri lon tng huyt p trong

27

nhng thng cui dn ti thai chm pht trin trong t cung, nguy c thai cht lu
trong t cung. Theo di huyt p nh k, s lng tiu cu, chc nng gan thn
nhm pht hin sm nguy c cho m v thai c quyt nh chm dt thai nghn
thi im thch hp.
3. THI X TR
- Hin nay cha c phng php iu tr hu hiu
- Phi theo di rt cht ch v t vn k cho sn ph v gia nh
- iu tr THA vi nhng trng hp xc nh thai chm pht trin trong t
cung do m ri lon THA thai k.
- Ch ngh ngi, hn ch lao ng nng
- Ci thin cung cp oxy cho m v truyn dung dch ng tng th tch tun
hon c khuyn co cho mt s trng hp thai chm pht trin trong t cung
nng cui qu 2 ca thai k, tuy nhin phng php ny cng khng cho kt qu
kh quan.
- Tm nguyn nhn: nu xc nh thai bt thng nhim sc th, a d tt,
nhim CMV th nn nh ch thai nghn. Nu ch c 1 d tt n c th hi chn
vi cc trung tm chn on trc sinh, vi bc s phu thut nhi c hng x
tr ngay sau khi sinh.
- Dng corticoid cho tui thai t 28 n ht 34 tun: Bethamethasone 12mg, 2
liu tim bp cch nhau 24h. Hoc Dexamethasone 6mg/ln, tim bp 4 ln cch
nhau 12h.
- Theo di lin tc nhp tim thai bng Monitoring sn khoa:
+ Theo di t tui thai 26 tun
+ nh gi dao ng ca tim thai v bin i ca nhp tim thai.
- Theo di khng can thip: nhp tim thai dao ng km, thai di 28 tun, cn
nng di 800gr
- nh ch thai nghn ( CTN) ch t ra sau khi cn nhc tui thai, tnh trng
ca ngi m, tin s sn khoa, v c bit l cc bnh l km theo kt hp vi mt
s bin i trn Monitoring. CTN t ra trong mt s trng hp sau:

28

+ Tui thai trn 31 tun khi nhp tim thai dao ng km, dao ng khng
lin tc qua mt s ln theo di, nhp chm n c, ko di, lp li nhiu ln
+ Tui thai t 34 tun khi Doppler ng mch rn vi dng tm trng bng
khng v bt thng Doppler ng mch no, thai c biu hin ngng tin trin
+ Tui thai t 37 tun khi bt thng Doppler ng mch rn, ng mch no,
monitor.
Lu : Doppler ng mch rn bnh thng kim tra li sau 8 ngy, nh gi
s pht trin thai 15 ngy mt ln. Doppler ng mch rn bt thng nhng tc
dng tm trng cha bng khng, theo di nhp tim thai lin tc trn Monitoring 3
ln mt tun v nh gi s pht trin thai, kt hp Doppler ng mch no.
- Cch thc : trng hp chuyn d t nhin hoc nh ch thai nghn nu
khng c chng ch nh ng di th theo di nh mt cuc thng.
Trng hp suy thai, i gim, c thm cc yu t bt li khc nh ngi ngc, rau
bm thp th m ly thai v lun phi c bc s hi sc s sinh tham gia vo thi
im ly thai.
4. PHNG BNH
- T vn di truyn cho cp v chng nu xc nh nguyn nhn thai chm pht
trin trong t cung do bt thng NST hoc bnh l gen cho cc ln mang thai tip
theo. T b mt s thi quen xu nh nghin ht, ung ru, dng cht kch thch
trc khi mang thai. Ci thin ch dinh dng v lm vic.
- Trng hp thai chm pht trin trong t cung do nguyn nhn tun hon
ca ngi m c th iu tr d phng bng Aspirin liu thp t tun th 15 ca
thai k.

29

TIN SN GIT SN GIT

1. KHI NIM
Tin sn git, sn git l bin chng ni khoa thng gp nht ph n mang
thai vi t l t 2% - 8%. Triu chng thng gp l ph, huyt p tng v protein
niu. L 1 trong nhng nguyn nhn chnh gy t vong cho m v thai.
Theo di v qun l thai nghn, iu tr thch hp tin sn git, sn git nhm
gim bin chng nng n cho m v thai.
2. PHN LOI V CHN ON
2.1. Tin sn git
2.1.1.Tin sn git nh
- Huyt p (HA) 140/90 mmHg sau tun 20 ca thai k.
- Protein/ niu 300 mg/24 gi hay que th nhanh (+)
2.1.2.Tin sn git nng:
+ Huyt p 160/110 mm Hg.
+ Protein/ niu 5 g/24 gi hay que th 3+ (2 mu th ngu nhin).
+ Thiu niu, nc tiu < 500 ml/ 24 gi.
+ Creatinine / huyt tng > 1.3 mg/dL.
+ Tiu cu < 100,000/mm3.
+ Tng men gan ALT hay AST (gp i ngng trn gi tr bnh thng).

+ Axt uric tng cao

+ Thai chm pht trin.
+ Nhc u hay nhn m.
+ au vng thng v hoc h sn phi.
2.2. Sn git
Sn git c chn on khi c cn co git xy ra ph n mang thai c triu
chng tin sn git v khng c nguyn nhn no khc gii thch. Cc cn co
git trong sn git thng l ton thn, c th xut hin trc, trong chuyn d hay

30

trong thi k hu sn. Sn git c th d phng c bng cch pht hin v iu tr

sm tin sn git
2.2.1. Triu chng lm sng
Trn c s ngi bnh b tin sn git xut hin cn git 4 giai on:
- Giai on xm nhim .
- Giai on git cng
- Giai on git gin cch.
- Giai on hn m
2.2.2. Cn lm sng
+ Tng phn tch t bo mu.
+ Acid uric. Bilirubin (ton phn, gin tip, trc tip).
+ AST-ALT.
+ Chc nng thn.
+ ng huyt.
+ m huyt.
+ Protein niu 24 gi.
+ ng mu ton b.
+ Soi y mt (nu c th).
3. IU TR
3.1. Tin sn git nh: ch yu iu tr ngoi tr
3.1.1. iu tr ni khoa:
- Cho thai ph ngh ngi, yn tnh ch n nhiu m, nhiu rau v tri cy ti.
- Khm thai mi 3- 4 ngy/ln. Theo di tnh trng sc khe ca b m. Theo
di tnh trng thai nhi, siu m thai mi 3 4 tun, nc tiu 2 ln/ tun.
3.1.2. Nu HA > 149/ 90mmHg v Protein / niu ++: nhp vin.
- Lm sng:
+ Khm lm sng pht hin triu chng nh nhc u, ri lon th gic, au
thng v v tng cn nhanh, theo di cn nng lc nhp vin v mi ngy sau,
lng nc tiu.

31

+ o huyt p t th ngi 4 gi/ ln, tr khong thi gian t na m n sng.

- Thng xuyn nh gi sc khe thai: siu m thai, monitoring thai.
- Xt nghim:
+ Xt nghim protein / niu mi ngy hoc cch hai ngy.
+ nh lng creatinine mu, hematocrit, m tiu cu, men gan, LDH, acid
uric tng. (ch lm xt nghim ng mu khi tiu cu gim v men gan tng).
3.1.3. Cch x tr tip theo ty thuc vo: nng ca tin sn git, tui thai.
Tnh trng c t cung. Tin sn git nh kt thc thai k tui thai 37 tun.
3.2. Tin sn git nng
- D phng v kim sot cn co git bng magnesium sulfate.
- H p khi huyt p cao: huyt p tm trng 100-110mm Hg, hoc huyt
p tm thu 150-160 mmHg (ACOG 2012).
- Chm dt thai k sau khi chng co git v h huyt p 24 gi.
- Trnh s dng li tiu. Hn ch truyn dch tr khi c tnh trng mt nc nhiu.

3.2.1. Magnesium sulfate: d phng v chng co git, dng trc, trong v

duy tr ti thiu 24 gi sau sinh.
- Liu tn cng: 3- 4,5g Magnesium sulfate 15% /50ml glucose 5% tim tnh
mch chm 15-20 pht.
- Duy tr 1- 2g /gi truyn tnh mch. Pha 6g Magnesium sulfate 15% vi
Glucose 5% 500ml truyn tnh mch XXX git/ pht.
- Tim bp gin on: tim bp su mi gi 1g hoc mi 4 gi 5g, thm
Lidocain 2% gim au.
- Bm tim in: pha 6g Magnesium sulfate 15% + 2ml nc ct, 7ml/gi.
- Ng c Magnesium sulfate:
+ Theo di cc du hiu: phn x gn xng (c), nhp th (>16 ln/pht),
lng nc tiu (>100ml/ 4 gi).
+ Nguy c bng huyt sau sinh. Gim dao ng ni ti nhp tim thai.
+ o nng Mg huyt thanh mi 12 gi v iu chnh liu duy tr gi
c nng Mg 4- 7mEq/L (4,8-8,4mg/dL).

32

+ Lin quan nng Magnesium/huyt thanh.

9,6 12mg/dl (4,0 5,0 mmol/L): mt phn x gn xng.
12 18 mg/dl (5,0 7,5 mmol/L): lit c h hp.
-24 30 mg/dl (10 12,5 mmol/L): ngng tim
+ X tr ng c Magnesium sulfate :
Ngng Magnesium sulfate.
Thuc i khng: calcium gluconate, tim tnh mch 1g.
t ni kh qun v thng kh cu sng ngi bnh nu c suy h hp,
ngng th.
3.2.2. Thuc h huyt p
Thuc h p c th nh hng bt li trn c m v thai. nh hng trn thai
nhi hoc gin tip do gim lu lng tun hon t cung nhau hoc trc tip trn tim
mch. Do vy cn cn nhc gia li ch v nguy c khi s dng thuc h p.
- Ch nh
Khi HA tm thu 150-160 mmHg, HA tm trng 100mmHg.
HA t sau iu tr: HA trung bnh khng gim qu 25% so vi ban u sau 2
gi. HA tm thu mc 130 150mmHg. HA tm trng mc 80 100mmHg.
- Chng ch nh trong thai k
Nitroprusside, thuc c ch men chuyn.
- Cc loi thuc h HA dng trong thai k: c th dng mt trong cc thuc sau
+ Labetalol (Beta Bloquant)
Bt u 20 mg tnh mch, cch 10 pht sau tnh mch 20 n 80mg. Tng
liu < 300 mg. V d: tnh mch 20mg, tip theo 40 mg, 80mg, tip 80mg. C th
truyn tnh mch 1mg - 2mg/pht. HA s h sau 5-10 pht v ko di t 3-6 gi.
+ Hydralazine
C th gy h huyt p hn nhng thuc khc, khng phi l chn la s 1
nhng c dng rng ri.
Tim tnh mch 5mg hydralazine/1-2 pht.Nu sau 15-20 pht khng h p
c cho 5- 10mg tnh mch tip. Nu tng liu 30 mg khng kim sot c HA

33

nn dng thuc khc. HA s h sau 10-30 pht v ko di t 2-4 gi. Hydralazine

c chng minh c hiu qu trong phng nga xut huyt no.
+ Nicardipine
ng 10mg/10ml pha vi 40ml nc ct hoc NaCl 0,9 . Tn cng: 0,5-1 mg
(2,5-5ml) tim tnh mch chm. Duy tr bm tim in 1-3mg/ gi (5-15 ml/gi).
Nu khng p ng sau 15 pht tng 2,5mg/gi ti a 15mg/gi.
3.2.3. Li tiu: ch dng khi: c triu chng da ph phi cp, ph phi cp.
+ Lasix (Furosemide) 1 ng 20mg x 8 ng tim tnh mch chm.
+ Khng dng dung dch u trng.
+ C th truyn Lactate Ringer vi tc 60 124ml/gi
3.2.4. Chm dt thai k
Cc ch nh nh ch thai nghn
- Tin sn git nh, thai > 37 tun.
- Tin sn git nng:
+ Huyt p tm trng

110mmHg.

+ Tng HA khng p ng vi iu tr.

+ Protein niu

5g/24 gi, +++ qua 2 ln th cch nhau 4 gi.

+ Thiu niu (lng nc tiu < 500ml/24 gi hoc < 30ml/gi)

+ Nhc u, hoa mt, au vng thng v hoc au h sn phi.
+ Suy gim chc nng gan, thn, Creatinin huyt tng, gim tiu cu.+.
+ C hi chng HELLP (tan huyt, tng SGOT, SGPT, gim tiu cu)
+ Ph phi cp.
+ Thai suy trng din hoc suy cp. NST khng p ng, thiu i, thai suy
dinh dng trong t cung, siu m Doppler gim ti mu ng mch.
+ Rau bong non, chuyn d, v i.
3.2.5. H tr phi thai nhi
+ Tui thai t 28-34 tun: gip trng thnh phi thai nhi
+ Betamethasone: 4mg x 3 ng tim bp, lp li ln 2 sau 12-24 gi
3.2.6. Khuynh hng tr hon thai k

34

+ Tui thai < 34 tun khuynh hng tr hon chm dt thai k sau 48 gi hay
n khi thai c 34 tun.
+ Theo di sc khe thai bng Monitoring sn khoa, siu m Doppler.
+ Lu : nguy c nhau bong non, sn git, ri lon ng mu, suy thn, xut
huyt no
3.2.7. Phng php chm dt thai k
+ Khi pht chuyn d. Nu c t cung thun li c th gy chuyn d bng
Oxytocin v theo di st bng monitoring, gip sinh bng Forceps khi iu kin.
+ Nu c t cung khng thun li: m ly thai.
3.3. Sn git
iu tr ging nh tin sn git nng
+ Oxy, cy ngng li, ht m nht, m bo thng h hp.
+ Chng co git.
+ H huyt p.
+ Chm dt thai k.
+ D phng cc bin chng: xut huyt no, v niu, ph phi cp, nhau bong
non, phong huyt t cung-nhau.
Phng php chm dt thai k
+ Nu ngi bnh v niu, co git: phi gy m, m ly thai.
+ Nu ngi bnh n nh, 24 gi sau cn co git cui cng, khi pht chuyn
d nu c t cung thun li v gip sinh bng Forceps khi iu kin.

35

A I
1. KHI NIM
a i xut hin trong khong 1% thai k. Chn on xc nh da vo siu m.
Hu ht cc nh nghin cu nh ngha: a i khi ch s i (amnionic fluid index: AFI)
ln hn 24 - 25cm; hay khi ln hn v bch phn th 95 hay 97 theo tui thai.
Cch o AFI: chia t cung thnh 4 phn bng nhau, o su ln nht ca
mi khoang i, AFI l tng 4 s o trn.
a i l mt trng hp thai nghn nguy c cao cho sn ph v nguyn nhn
a i v cnh bo nguy c sinh non trong qu trnh thai nghn .
2. CHN ON
a i cp c th din tin mau trong vng vi ngy vi cc triu chng cp
nh au cng bng nhiu, kh th, i khi b tm ti, nhp tim nhanh, nn, ph
ton thn (chi, m h, thnh bng, mt) . Him gp hn l tnh trng thiu niu
do niu qun b t cung chn p. a i trong trng hp ph thai c th gy ra
hi chng gng thai ph (mirror syndrome), m t ln u tin bi Ballantyne
nm 1892: tnh trng ca m bt chc thai nhi, nh ph, tiu m; v hu qu
l tin sn git.
a i mn, dch i gia tng dn nn thai ph c th chu ng c tnh trng
cng chng bng.
Du hiu u tin trn lm sng gi mt trng hp a i l t cung rt to so
vi tui thai, cng, dn n kh khn khi s nn cc phn thai v nghe tim thai.
Chn on phn bit a i vi c chng hay u bung trng to bng nhng hnh
nh trn siu m.
3. HNG X TR
a i mc nh n trung bnh him khi i hi cc bin php can thip.
Cn thit nhp vin khi thai ph kh th, au bng hay i li kh khn.
Ngh ngi ti ging, li tiu, hn ch dch truyn v mui khng em li hiu
qu r rt. Ht bt nc i cng gip ci thin triu chng kh th thai ph ng
thi ly dch i xt nghim di truyn hay xc nh s trng thnh phi ca thai nhi.
Th thut ny c th gy tai bin nh: v i, nhim trng, hay rau bong non.

36

Cn lu a i khng r nguyn nhn trong gn mt na cc trng hp a i l

s gia tng lng nc i khng lin quan vi bt thng bm sinh, tiu ng m,
cc bnh l min dch, nhim trng, khi u ca thai nhi hay tnh trng a thai. Tuy
nhin, thm ch khi kho st hnh nh hc thai nhi bnh thng, vn nn tin lng mt
cch thn trng bi d tt thai nhi v bt thng nhim sc th c th gp.
3.1. a i xut hin ba thng gia thai k
- Ch nh siu m kho st hnh thi hc thai nhi chuyn su tm cc d tt
bm sinh c th i km.
- Nghim php dung np ng cho thai 24-28 tun
- Hi chn trung tm chn on trc sinh t vn, cn nhc tin hnh cc
xt nghim di truyn tm nguyn nhn bt thng NST, nhim trng thai k.
- Nn tip tc theo di, qun l thai k nguy c cao (khm thai tin sn)
3.2. a i ba thng cui thai k
- Kim tra biu tng trng thai nhi.
- Loi tr cc nguyn nhn bnh ni khoa ca m.
- Ty theo kt qu xt nghim sng lc qu 1, 2: t vn hng xt nghim di
truyn cho thai nhi.
- Thuc trng thnh phi do nguy c non
- Can thip (ht bt dch i) khi cc triu chng a i cp nh hng n ton
trng ngi bnh ( kh th, chn p tim phi). T vn cc tai bin ca th thut
cho thai ph v gia nh.
3.3. Chuyn d
Hay gp cc nguy c kh nh ngi bt thng, kh do ri lon cn co t
cung, tun th ch nh bm i. phng rau bong non, bng huyt sau sinh.
4. TAI BIN
Nhng bin chng thng gp nht cho thai ph nhng thai k c km a i
l nhau bong non, ri lon cn g t cung hay bng huyt sau sinh. Ngoi ra, cn c
bin chng sa dy rn, ngi bt thng, t cung sau hay can thip phu thut.
Thai nhi bt thng thai, chn on c trong khi mang thai hay sau

37

THIU I
1. KHI NIM
Thiu i l tnh trng nc i t hn bnh thng, khi ch s i (AFI) nh hn
5cm v mng i cn nguyn vn. T l xut hin thiu i c bo co t cc
nghin cu b nh hng bi s khc bit trong tiu chun chn on, dn s nghin
cu (nguy c thp hay nguy c cao, siu m tm sot hay chn lc), tui thai ti
thi im siu m.
Nhn chung, thiu i xut hin sm trong thai k t gp v c tin lng ngho
nn. Ngc li, nhng thai qu ngy sinh, thai chm pht trin trong t cung, s
gim lng nc i c l thng gp hn.
Chn on xc nh ch yu da vo siu m thai v nc i.
2. BIN CHNG CA THIU I
S xut hin thiu i trong giai on sm ca thai k lm tng nguy c thiu
sn phi cho thai nhi. Kilbride v cng s (1996) tin hnh quan st trn 115 thai
ph b v i trc 29 tun, c 7 ca thai lu, 40 tr s sinh t vong, v c tnh t l
t vong chu sinh l 409/1000. Nguy c thiu sn phi gy cht thai khong 20%.
Thiu i sm thng lin quan n nhng bt thng ca thai nhi. Tnh trng
nc i t cng gy tr ngi trong qu trnh kho st hnh thi hc ca thai nhi qua siu
m (nu c). Trong trong hp ny, ch nh truyn i cng c th c cn nhc.
Bin chng thiu i xut hin mun trong thai k ty thuc vo tui thai, mc
thiu i v tnh trng bnh l km theo ca m. Hng dn sn ph ung nhiu
nc hay truyn dch cn nhiu tranh ci trong vic ci thin lng nc i.
H tr trng thnh phi cho thai nhi l cn thit trong trng hp thai non
thng. nh gi sc khe thai nhi.
3. HNG X TR
- Hi bnh s v xt nghim dch m o (Nitrazine test) loi tr r i/i v.

38

- Siu m tin sn nhm kho st v pht hin cc bt thng hnh thi thai,
c bit bnh l h niu ca bo thai nh cc trng hp lon sn thn, tc nghn
ng niu.
- T vn li ch v cc tai bin, tin hnh th thut truyn i trong trng hp
nc i qu t gy cn tr cho qu trnh kho st hnh thi thai, ngoi ra c th ng
thi ly nc i xt nghim min dch, di truyn, gim chn p cho dy rn, vn
ng ca thai nhi.
- Siu m tim thai, siu m Doppler (AFI, Doppler ng mch no gia),
monitor sn khoa trong trng hp c km thai chm pht trin trong t cung.
- Nu thai c d tt bm sinh h niu, ch nh chm dt thai k trong trng
hp nng ch nn quyt nh sau khi tin hnh hi chn a chuyn khoa (bc s tin
sn, siu m tin sn, s sinh v phu thut nhi, nh di truyn hc). Theo di v
qun l thai ti trung tm ln, chuyn khoa su trng hp thiu i xut hin sm.
- Ch nh h tr phi l cn thit.
- Phng php chm dt thai k:
+ Khi pht chuyn d chm dt thai k thai thiu i trng thnh hay
liu h tr phi thai non thng c th nui c.
+ M ly thai nhng thai ht i (AFI < 2cm) hoc c nhng du hiu nghi
ng thai suy cp, thiu i.

39

RAU TIN O
1. KHI NIM
Rau tin o l rau bm mt phn hay ton b vo on di t cung gy chy
mu vo 3 thng cui ca thai k, trong chuyn d v sau . Rau tin o c th
gy t vong hoc bnh l mc phi cho m v cho con do chy mu v non.
Theo gii phu rau tin o c chia thnh 5 loi l: rau tin o bm thp,
rau tin o bm bn, rau tin o bm mp, rau tin o bn trung tm, rau tin o
trung tm.
2. CHN ON
2.1. Triu chng lm sng:
2.1.1. Trc chuyn d:
- Triu chng c nng: chy mu m o vo 3 thng cui ca thai k, chy
mu t nhin bt ng, khng thy au bng, mu ti, c khi km mu cc,
lng mu c th chy nhiu, t, sau chy t dn v t cm d c hay khng
iu tr. Chy mu ti pht nhiu ln vi tn sut v mc ngy cng tng.
- Triu chng ton thn: thiu mu ty thuc lng mu mt m sn ph thy
mt mi, hoa mt, chng mt, chong
- Triu chng thc th: khng c triu chng c hiu, hay gp ngi u cao
hoc ngi ngang, ngi mng.
2.1.2. Khi chuyn d:
- Triu chng c nng: thng c qu trnh ra mu trong 3 thng cui thai k,
t nhin ra mu t, mu ti ln mu cc, c au bng do cn co t cung.
- Triu chng ton thn: thiu mu ty mc mt mu. Sn ph c biu hin
chong nu mt mu nhiu.
- Triu chng thc th: nn ngoi c th thy ngi thai bt thng. Tim thai
c th thay i nu chy mu nhiu
- Khm m o bng m vt thy mu trong c t cung (CTC) chy ra, loi tr
cc tn thng CTC

40

- Thm : s thy rau qua c t cung

+ Rau tin o bm mp: thy mp di bnh rau bm ti l trong c t cung.
+ Rau tin o bn trung tm: thy bnh rau che lp mt phn l trong c t
cung nhng khng che ht.
+ Rau tin o trung tm: thy bnh rau che lp hon ton l trong c t cung.
Ngi thai bt thng .
Ch khng c khm tm rau v gy chy mu.
2.2. Triu chng cn lm sng
- Cng thc mu: thiu mu ty theo lng mu mt.
- Siu m vi bng quang y xc nh v tr bm ca bnh rau:
+ Rau tin o trung tm: bnh rau bm hon ton vo on di t cung v
che lp l trong c t cung.
+ Rau tin o bm mp: mp bnh rau bm n l trong c t cung.
+ Rau tin bm bn, bm thp: khong cch gia mp di bnh rau n l
trong c t cung < 20mm.
- Siu m rt c gi tr chn on trong trng hp rau tin o - rau ci rng
lc vi cc hnh nh sau: mt khong sng sau rau ti v tr rau bm, ph Doppler
mu thy cc mch mu i xuyn qua thnh c t cung hoc bng quang. Hnh nh
gi u bng quang (bnh rau y li vo lng bng quang).
- Chp MRI cng xc nh c rau tin o ci rng lc nhng nhy
thp, hin t dng do c s pht trin ca siu m chn on.
- Soi bng quang ch nn tin hnh khi nghi ng rau ci rng lc m xuyn
c bng quang v ngi bnh c biu hin i mu.
3. X TR
3.1. Nguyn tc chung
- Cm mu cu m l chnh. Ty theo tui thai, mc mt mu v kh nng
nui dng s sinh m quyt nh ko di tui thai hay ly thai ra. Lun lun nh
gi mc mt mu truyn b mu cho ph hp.

41

- Khi nghi ng rau tin o phi chuyn ngi bnh ln tuyn huyn c trung
tm phu thut ; nghi ng hoc chn on rau tin o - rau ci rng lc th chuyn
ngi bnh ln tuyn tnh hoc tuyn trung ng.
3.2. iu tr c th
3.2.1. Khi cha chuyn d:
- Ngh ngi, hn ch i li, n ung tng cng dinh dng.
- Thuc gim co nh: spasmaverin 40mg (1 4 vin/ ngy), Salbutamol,
progesterone
- Nn dng corticoid trng thnh phi thai nhi sm.
- Trng hp thai nhi thng: m ly thai ch ng i vi trng hp rau
tin o trung tm. Cc trng hp rau tin o khc c th cn nhc theo di ch
chuyn d.
- Trng hp rau tin o chy mu nhiu e da tnh mng ngi m th m
ly thai bt k tui thai no.
3.2.2. Trong khi chuyn d:
- Rau tin o trung tm, rau tin o bn trung tm: m ly thai.
- Rau tin o bm mp: m ly thai cp cu nu ra mu nhiu. ra mu t, ngi
th v c t cung thun li th bm i v x mng i v pha khng c bnh rau
cm mu, nu sau khi x mng i vn ra mu th nn m ly thai, nu khng ra mu
th theo di ng m o.
- Rau tin o bm thp, bm bn: m ly thai nu ra nhiu mu, nu ra mu t
hoc khng ra mu th theo di chuyn d nh cc trng hp thng thng khc.
- K thut cm mu khi m trong rau tin o: sau khi ly thai v rau m
chy mu th nn khu cm mu bng cc mi ch X cm mu, vn chy mu th
nn ct t cung bn phn thp vi ngi bnh con.
Ngi bnh cha c con cn bo tn t cung: tht ng mch t cung
hoc tht ng mch h v, ng mch dy chng t cung bung trng; khu mi
B-lynch; chn bng hay gc vo bung t cung. Nu khng kt qu th vn phi
ct t cung.

42

3.2.3. Rau tin o - rau ci rng lc:

- Rau tin o - rau ci rng lc l hnh thi lm sng nng n nht ca rau
tin o v mch mu tng sinh on di t cung nhiu, m xuyn vo bng
quang, hay gp ngi c vt m c nn phu thut kh khn, mt mu rt
nhiu v thng tn thng bng quang.
- Chn on c rau tin o - rau ci rng lc th cn chuyn ngi bnh
ln tuyn tnh hoc tuyn trung ng nm vin iu tr.
- M ly thai ch ng khi thai thng. Cn chun b kp phu thut vin v
kp gy m hi sc c kinh nghim; chun b nhiu mu v cc phng tin hi sc
- Nn ch ng m dc thn t cung pha trn ch rau bm hoc y t cung
ly thai, trnh rch vo bnh rau trc khi ly thai ra, sau khng bc rau v
ch ng ct t cung hn ch ti a lng mu mt.
4. BIN CHNG
4.1. Cho m
- T vong do mt mu cp, thiu mu.
- Ct t cung cm mu.
4.2. Cho con
Non thng, cht trong chuyn d , bnh l tr s sinh do thiu mu, non thng

43

RAU BONG NON

1. KHI NIM
1.1. nh ngha
Rau bong non l rau bm ng v tr nhng bong mt phn hay ton b bnh
rau trc khi s thai.
Rau bong non l mt cp cu sn khoa, thng xy ra 3 thng cui thi k
thai nghn, din bin nng e da tnh mng ca thai nhi v sn ph. y l bnh
l ca h thng mao mch, xy ra t ngt c th tin trin rt nhanh t th nh
thnh th nng.
1.2. Phn loi: 4 th theo hnh thi lm sng:
- Rau bong non th n
- Rau bong non th nh
- Rau bong non th trung bnh
- Rau bong non th nng.
2. CHN ON
2.1. Chn on xc nh
2.1.1. Triu chng c nng
- Thng c du hiu tin sn git: cao huyt p, ph, protein niu
- au: au t t cung sau lan khp bng, nhp cn au ngy cng mau
mnh, trng hp nng triu chng au b che lp do sc.
- Ra mu m o: mu thm, long, khng ng
2.1.2. Triu chng ton thn:
- Ngi bnh c biu hin chong do au v do mt mu: da xanh, nim mc
nht, v m hi, chi lnh, th nhanh, ..
- Huyt p thng khng thay i trong nhng gi u (do ngi bnh thng
c tin s cao huyt p t trc), mch nhanh.
2.1.3. Triu chng thc th
- T cung co cng lin tc hoc t cung co cng nh g trong th nng.

44

- Khng nn c cc phn thai nhi do t cung co cng.

- Chiu cao t cung tng dn do s hnh thnh khi mu cc sau rau.
- Nghe: nhp tim thai chm, khng u, hoc mt tim thai trong th nng.
- Khm m o: ra mu m o, mu en, khng ng; u i cng phng,
nu i v thy nc i ln mu. Du hiu ton thn i khi khng ph hp vi s
lng mu chy ra ngoi m o.
2.1.4. Cn lm sng
- Siu m: thy khi mu t sau rau, thng l khi tng m vang hoc khi
m vang khng u. Tuy nhin siu m trong rau bong non tin cy khng cao v
nu siu m khng thy khi bt thng sau rau cng cha loi tr rau bong non khi
c du hiu lm sng gi . Siu m cng thy s bin i ca nhp tim thai hoc
xc nh thai cht.
- Monitoring: nhp tim thai bin i: DIP I, DIP II, DIP bin i hoc khng
bt c nhp tim thai.
- Xt nghim mu: s lng hng cu gim, haemoglobin gim, tiu cu gim,
fibrinogen gim, ATTP tng hn so vi mc bnh thng.
- Xt nghim nc tiu thng c protein.
2.2. Cc th lm sng
2.2.1. Th n
Khng c du hiu lm sng r rt, cuc chuyn d bnh thng, s sinh khe
mnh. Chn on c sau khi s rau thy c mu t sau rau. Ngy nay nhiu
trng hp chn on c nh siu m thy khi mu t sau rau.
2.2.2. Th nh
- Triu chng khng y , c th c tin sn git, cn co t cung hi cng
tnh, tim thai bnh thng hoc nhanh 160-170 ln/pht.
- Chn on c sau khi s rau thy c mu t sau rau hoc siu m thy
khi mu t sau rau.
2.2.3. Th trung bnh
- Thng c tin sn git. C th chong nh hoc va.

45

- Sn ph au va, t cung tng trng lc.

- Ra mu m o lng va, en, long, khng ng.
- Suy thai.
- Chn on phn bit vi: rau tin o, thai cht lu, da v hoc v t cung.
2.2.4. Th nng (phong huyt t cung rau hay hi chng Couvelaire)
C cc triu chng nng, in hnh:
- Tin sn git nng hoc trung bnh.
- Chong nng.
- Chy mu m o nhiu hoc t khng tng xng vi mc mt mu.
- T cung to ln nhanh, co cng nh g.
- Tim thai mt.
- Ri lon ng mu: c th c du hiu chy mu do ri lon ng mu cc
tng khc ngoi t cung nh phi, d dy, thn, rut,
3. X TR
3.1. Nguyn tc chung
- X tr ty thuc vo hnh thi rau bong non v du hiu lm sng
- iu tr ton din, kp thi, cu m l chnh. Hi sc tch cc nu c du
hiu chong v ri lon ng mu.
- Chuyn ln tuyn c kh nng phu thut, nu ngi bnh nng phi mi
tuyn trn v h tr.
- M ly thai k c khi thai cht.
3.2. Hi sc ni khoa
- nh gi v theo di cc du hiu sinh tn: mch, huyt p, nhp th.
- Cho sn ph nm u thp, m, th oxy. Thng tiu v theo di lng
nc tiu.
- Lp ng truyn tnh mch, b khi lng tun hon bng truyn dch ng
trng Ringer lactat, Natrichlorua 0,9%; dung dch cao phn t nh Gelafuldin,
Heasteril; truyn mu v cc ch phm ca mu, cc yu t ng mu. Lng dch,
mu truyn v tc truyn ph thuc tnh trng sn ph v lng mu mt.

46

- iu tr triu chng nu c: HA cao, v niu, ri loan ng mu. Khng sinh

iu tr.
3.3. X tr sn khoa
- Nu c chn on l rau bong non th nn m ly thai ngay cu con v
phng bin chng nng hn cho m. Bo tn t cung: nu tn thng nhi mu
t cung khng qu nhiu, t cung cn co hi c. Nu sn ph con, nhiu tui,
tn thng nhi mu t cung nng hay khng p ng vi thuc co c t cung th
nn ct t cung hon ton hay bn phn ngay trnh nguy c chy mu sau m.
- Nu chn on rau bong non sau khi s thai th tin hnh ngay cc bin php
d phng chy mu sau do ri lon ng mu.
4. BIN CHNG
4.1. Cho m
- Chong do mt mu v au. Ri lon ng mu. Hoi t cc tng do nhi
mu v thiu mu, nguy him nht l suy thn.
- Ct t cung.
- T vong c m v con .
4.2. Cho thai:
- Suy thai. Thai cht trong t cung. Non thng nh cn.
- Thiu mu.

47

THAI QA NGY SINH

1. KHI NIM
Thai qu ngy sinh l nhng trng hp thai nghn ko di qu 42 tun hoc
qu 294 ngy tnh t ngy u ca k kinh cui cng.
iu quan trng nht l phi xc nh c tui thai chnh xc bng ngy u
ca k kinh cui cng hoc siu m trong 12 tun u ca thai k.
2. CHN ON
- Da vo tui thai (tnh t ngy u ca k kinh cui, c gi tr nu
vng kinh bnh thng).
- Da vo siu m xc nh tui thai i vi thai trc 20 tun nu ngy
u k kinh cui khng xc nh hoc kinh khng u.
- Xc nh tnh trng thai v phn ph thai ( nc i, rau)
3. X TR

3.1. Theo di: 2 ngy mt ln

- Siu m
+ Theo di lng nc i: thiu i l du hiu ca suy tun hon rau-thai v
nguy c thiu oxy cho thai nhi.
+ Theo di qua siu m: c ng thai ( thn, chi, th ), nhp tim thai, rau thai
v lng nc i.
- Monitoring theo di tim thai bng test khng kch. Nu khng p ng
th lm cc test kch (v nm v, truyn oxytocin).
3.2. Gy chuyn d: gy chuyn d thai 41 tun, khng nn ch n 42 tun

48

- Nu c t cung thun li (ch s Bishop > 5) th gy chuyn d bng bm i

v truyn oxytocin tnh mch.
- Nu c t cung khng thun li (Bishop < 5) th lm chn mui c t cung bng:
+ Prostaglandin: Prostaglandin E2 (Dinoproston) 2,5ml dng gel t vo ng
c t cung. Nu sau 6 -12 ting, c t cung vn cha thun li th t li liu 2.
+ Phng php khc: nong c t cung bng ngn tay, cht ht m, t bng c
t cung
- Trong chuyn d: thai qu ngy sinh c nguy c suy thai v thai nhi a phn
su trong qu trnh chuyn d. Do cn theo di st thai nhi trong qu trnh chuyn
d bng monitor pht hin sm suy thai. M ly thai nu thai suy, nc i gim ,
c t cung khng thun li.

49

BNH TIM MCH V THAI NGHN

1. KHI NIM:
Bnh tim ph n mang thai gy ra nhiu nguy c cho m v con trong khi
mang thai, sau khi v c bit trong chuyn d. Tn sut mc bnh Vit nam
khong 1-2% ph n mang thai. Theo di, tin lng, x tr bnh i hi s phi
hp cht ch gia chuyn khoa sn v tim mch.
nh hng ca bnh tim mch v thai nghn:
- i vi thai:
+ Da sy thai, sy thai, da non, non
+ Thai chm pht trin trong t cung. Thai d dng
+ Thai cht lu trong t cung, thai cht trong chuyn d.
- i vi thai ph
+ Suy tim cp, ph phi cp
+ Ri lon nhp tim
+ Tc mch phi. Vim tc tnh mch sau
2. LM SNG V CHN ON:
2.1. Triu chng lm sng:
- Kh th: thng gp t qu II thai k, c gi tr tin lng bnh, tng dn
theo tui thai. Kh th gng sc hay thng xuyn c khi nm ngh.
- Hi hp, nh trng ngc, au tht ngc, chong ngt.
- Ho ra mu: khi tng p ng mch phi nng, ph phi cp
- i t, nc tiu sm mu
- Ph: khu tr chn, mm, n lm, khng thay i theo thi gian
- Tm mi v u chi, tin trin lu c ngn tay di trng, mng tay khum
- Gan to, tnh mch c ni. Gan to kh pht hin do t cung chim ch trong bng
- Nghe tim: rung tm trng, thi tm thu, T1 anh, T2 tch i, ri lon nhp:
nhp tim nhanh, ngoi tm thu, lon nhp hon ton
- Nghe phi: r ro ph nang gim, rales ngy, rales rt, rales m

50

2.2. Cn lm sng:
- Xquang: bng tim to, b ngang, rn phi m
- Siu m tim: thm d c gi tr cho php nh gi tn thng van, tn
thng bt thng bm sinh, chc nng cc tm tht, p lc ng mch phi..
- in tm : pht hin cc ri lon nhp, suy vnh
- Xt nghim ng mu: theo di iu tr chng ng
2.3. Phn suy tim theo chc nng (NYHA- Hi tim mch New York):
- 1: cha b hn ch hot ng th lc
- 2: kh th khi gng sc, gim nh hot ng th lc
- 3: kh th khi gng sc nh, hot ng th lc gim
- 4: kh th c khi ngh ngi, hot ng th lc gim nhiu.
2.4. Chn on phn bit:
- Thiu mu nng: kh th, nhp tim nhanh, thi tm thu, da nim mc nht,
xt nghim mu, in tm gip chn on phn bit
- Ri lon nc - in gii: khi mang thai c ph do gi nc v mui.
- Thai ph c bnh tim, tnh trng ny cng trm trng d gy bin chng suy
tim, ph phi cp.
3. IU TR
3.1. Nguyn tc chung: phi hp iu tr ni khoa, tim mch can thip v sn
khoa. Theo di, d phng cc tai bin, x tr sn khoa ty thuc vo mc bnh,
c cn nhc n nguyn vng sinh con ca thai ph.
3.2. iu tr c th:
3.2.1. Qun l thai nghn:
Qun l thai nghn cht ch. Trnh hot ng th lc, nm nghing tri, thay
i t th thng xuyn. Hn ch tng cn, ch n trnh mui, ng; n y
cht dinh dng, chng thiu mu
3.2.2. iu tr ni khoa:
Tr tim, li tiu, chng huyt khi, d phng nhim khun ty thuc giai on
mang thai, th bnh tim mch v mc bnh.

51

Can thip tim mch: thc hin trong qu 2 ca thai k ph thuc vo th, mc
bnh l tim mch. Nong van, nong vnh qua da, t d bt l thng lin tht, lin nh.
3.2.3. X tr sn khoa:
Trong khi c thai, cha c suy tim:
+ Thai ph sinh ln u: theo di qun l thai nghn cht ch, nhp vin sm
trc khi 2 tun.
+ Thai ph sinh ln 2 tr ln: nn nh ch thai nghn nu thai nh, di 3
thng. Nu thai ln, cn theo di cht ch tim mch - sn khoa, gi thai n khi
thng, ch chuyn d h tr th thut hoc m ly thai nu c ch nh
Trong khi c thai c suy tim:
- Thai ph sinh ln u:
+ Suy tim 1-2: thai nh di 20 tun nn nh ch thai nghn.
+ Nu thai trn 20 tun: theo di, iu tr, d phng bin chng. Nu khng
p ng iu tr cn nh ch thai nghn bt k tui thai no.
+ Suy tim 3- 4: nh ch thai nghn bt k tui thai, iu tr ni khoa trc,
trong v sau khi nh ch.
- Thai ph sinh ln 2 tr ln: nn nh ch thai nghn. Nu thai gn thng
nn iu tr tch cc n thng ri m ly thai ch ng.
+ La chn phng php nh ch thai nghn:
Ht thai bng bm chn khng thng thng nu thai nh, di 12 tun
Gy chuyn d hoc phu thut ct t cung c khi nu thai 12-20 tun.
- Gy chuyn d hoc m ly thai tht hai vi t cung nu thai trn 20 tun.
+ Cn gim au tt. m bo v khun, khng sinh d phng trc v sau
phu thut - th thut hn ch nhim khun. Ch ng ngn nga tc mch do
huyt khi sau phu thut - th thut bng thuc chng ng mu.
3.2.4. Khi chuyn d:
+ H tr ng di c can thip th thut cn phi hp bc s sn khoa,
tim mch, s sinh v gy m hi sc cuc din ra an ton.

52

+ Tip tc dng thuc tr tim, chng ng, pht hin sm cc bin chng suy
tim cp, ph phi cp. Th oxy, an thn, hn ch truyn dich, nu cn dng
oxytocin pha m c trnh qu ti tun hon.
+ Khi s thai: h tr s thai bng Forceps trnh gng sc cho sn ph
+ Trong thi k s rau: h thp chn, chn tnh mch ch di trnh mu v
tim t ngt gy suy tim cp. Kim tra k bnh rau trnh st rau.
+ M ly thai nu c ch nh, nu c ch nh c nh nn m ly thai ch
ng. dng thuc chng ng 1 tun trc khi phu thut.
3.2.5. Thi k hu sn:
+ iu tr khng sinh chng nhim khun, t nht 1 tun. Nn s dng khng
sinh phi hp chng vi khun Gr m v k kh.
+ D phng huyt khi: vn ng sm, thuc chng ng (Heparine, Dicoumaron).
+ C th cho con b nu cha suy tim hoc suy tim 1. Nu khng cho con
b nn ct sa bng Bromocriptine, khng s dng thuc c estrogene.
4. BIN CHNG
4.1. Ph phi cp: do tng p lc ng mch phi , suy tim phi cp
- Triu chng: kh th t ngt, tc ngc, v m hi, chn tay lnh, tm mi
u chi, huyt p tt, kt. Nhp tim nhanh, c th pht hin ting bnh l (rung tm
trng, nga phi). Rales m nh ht y phi, cng ngy cng dng cao. p lc
tnh mch trung tm cao, Xquang phi m
- X tr: hi sc, th oxy liu cao 8-12 l/pht, li tiu, tr tim, H huyt p nu
c tng HA. C th h tr t ni kh qun, th my.
+ X tr sn khoa: m ly thai cp cu
4.2. Lon nhp tim
- Lon nhp nhanh: thng gp nhp nhanh xoang >100 l/pht. C th gp cn
lon nhp nhanh kch pht trn tht
- Lon nhp chm: nhp tim < 60 l/pht. Hi chng Adam Stock, nhp tim <
40l/pht, ngi bnh chong ngt do thiu mu no.

53

- Lon nhp khng u: ngoi tm thu trn tht, ngoi tm thu nhp i, nhp
ngoi tm thu > 5% l nguy c cao.
- Lon nhp hon ton: thng gp trn cc ngi bnh mc bnh van tim lu
ngy, tn thng nng, thiu mu c tim, vim c tim. Tin lng nng
X tr: dng thuc hp l v nh ch thai nghn thi im thch hp, u tin
bo v sc khe v tnh mng ca thai ph.
4.3. Tc mch do huyt khi
Hay gp trong thi k hu sn (75%), vim tc tnh mch chi di, ngoi ra c
th no, mch vnh, mch phi, mc treo rut..
- Ngi bnh c biu hin st, sng nng au vng bp chn dc theo
ng i tnh mch, ph tm chi di. Xt nghim huyt hc c bch cu tng cao,
siu m Doppler tnh mch chi di thy hnh nh gin tnh mch, gim lu lng
mu. Nu cc mu ng di chuyn gy tc mch cc ni khc nh no, mch vnh,
mch phi. c du hiu lit khu tr, au tht ngc, ho ra mu, tin lng nng n.
- iu tr bng khng sinh liu cao, phi hp, ko di t nht 2 tun phi hp
thuc chng ng (Heparine, Dicoumaron).
5. PHNG BNH V T VN
- Pht hin sm, qun l thai nghn cht ch cc thai ph c bnh tim. Phi hp
gia chuyn khoa tim mch v sn khoa theo di, iu tr, tin lng ngi bnh.
- T vn cho thai ph cc du hiu bt thng, cc bin chng nguy him
trong khi mang thai v khi chuyn d, sau .
- T vn trnh thai, khng nn dng thuc trnh thai c estrogen.
Nn nh sn nu c con v bnh tim khng ci thin bng iu tr ni khoa.

54

THIU MU V THAI NGHN

1. KHI NIM
- Thiu mu trong thai nghn khi t l hemoglobin (Hb) < 110g/l
- Thiu mu nng nu Hb < 70g/l mu.
- Thiu mu trong thai nghn chia thnh cc loi sau:
+ Thiu mu do thiu st
+ Thiu mu do thiu acid folic
+ Thiu mu do tan mu
2. CHN ON
2.1. Lm sng
- Thiu mu: da, nim mc nht nht, suy nhc c th, nhp tim nhanh, kh
th, tai, chng mt.
- C th vim li (3 thng cui thai k)
- Vng da nh: c th do thiu Folat
- C th thy lch to trong trng hp thiu mu do tan mu: Thalasemia, tan
mu t min
2.2. Cn lm sng
- Cng thc mu: hng cu gim, Hemoglobin gim < 11g/100ml mu.
- Xt nghim huyt : hng cu nh, hng cu to, hng cu bnh thng ty
theo loi thiu mu.
- Xt nghim st huyt thanh, Acide folic, Folat u gim.
3. IU TR
- Nu t l Hb > 70g/l cho sn ph dng (st) Fe vi liu 200mg mi ngy l
. C th dng cc loi nh: Tardyferon 80 mg, Tardyferon B9, Ferrous sulfat,
Folvit, Felatum...
- Nu ngi bnh khng dng thuc st qua ng tiu ha (trong 3 thng u
thai nghn nu nn nhiu) c th dng ng tim truyn: Jectofer 100 mg,
Venofer

55

- Nu t l Hb < 70g/l c th truyn mu thm cho sn ph. Nn truyn mu

trc tun l th 36 hay trong iu tr da non, phi hp iu tr thm st ti
thiu mt thng phng mt b mu lc v sau s rau.
- iu tr d phng bng cch cho sn ph dng st sut thai k (c bit
nhm sn ph c nguy c thiu mu, thiu st : mang thai sinh i, bnh l ni
khoa, tin s thiu mu, rau tin o)
4. TIN LNG
4.1. Cho m
- Tnh trng thiu Oxygen lm m mt, nhp tim nhanh ln.
- Nu chy mu thm trong thai k, lc chuyn d, sau ... th tnh trng sn
ph nng hn so vi sn ph bnh thng.
- Trong giai on hu sn, thiu mu thng lm tng nguy c nhim trng
hu sn (vim tc tnh mch)
4.2. Cho con
- Nguy c non, suy dinh dng thai nhi.
- Nguy c thai bt thng
- Tng th tch bnh rau.
5. PHNG BNH
- Pht hin nguy c thiu mu trong thai nghn
- Xt nghim cng thc mu: thng th t ca thai nghn
- Nu khm pht hin hay nghi ng c bnh l v mu th cn mi thm
chuyn khoa huyt hc truyn mu cng hi chn v iu tr.

56

BASEDOW V THAI NGHN

1. I CNG
Khong 1-2% s ph n mang thai c ri lon chc nng tuyn gip, tng mt
cch tng i ngi ph n ln tui
Do 2 nguyn nhn:
- Thiu Iot do thai nghn.
- S thay i v min dch do thai nghn dn n ri lon chc nng ca
tuyn gip.
2. CHN ON:
2.1. Lm sng
- Thai ph c tin s gia nh, tin s bn thn hc thai ph c bu gip
- Biu hin:
+ Mt li
+ Tim nhanh > 100 ln /pht
+ Run tay
+ Gim cn hay khng c tng cn v nn nng ko di.
+ Tuyn gip to ty giai on bnh
- Tin trin: cho m v thai ni chung l tt khi qun l thai nghn v thm
khm tuyn gip tt. Ni chung bnh Basedow c xu th c ci thin tt dn
trong qu trnh c thai bt u sau 20 tun do s n nh v min dch. Cn nhng
trng hp khc, cc bin chng ca m v ca thai c th l thm ha, c bit l
na sau ca thai k.
2.2. Cn lm sng
- Nng TSH c th thp vo giai on u ca thai k
- nh lng T4 t do m nng T4 tng nhiu trong trng hp cng gip.
- Trong trng hp khng tng thch cn b sung xt nghim T3 t do.

57

- Xt nghim v tim mch: in tm . siu m tim

- Chp v siu m tuyn gip
3. IU TR V THEO DI
3.1. iu tr
- S dng cc thuc khng gip tng hp liu ti thiu t c mc
bnh gip.
- S dng cc ch phm ca Theo-Uracil (PTU, Basdne) v kh nng qua rau
thai ca n thp v nguy c gy ra bt thng thai cng rt thp.
- Ct b tuyn gip thng khng c ch nh lm trong khi c thai
- Vic s dng phng php iu tr bng Iot phng x l chng ch nh
tuyt i trong sut thi gian c thai.
2.2. Theo di:
- ngi m theo di nng T4 trong sut qu trnh c thai.
- thai nhi cn theo di siu m pht hin bu gip ca thai, theo di tin
trin ca n di iu tr ngi m.
4. TIN TRIN V BIN CHNG
4.1. Cc bin chng v pha m:
- C th gp suy tim, tin sn git
- Thiu mu hay nhim trng.
- Cn cng gip khi chuyn d
4.2. nh hng n thai v tr s sinh:
- Thai cht lu, cht tr s sinh
- Chm pht trin
- Bt thng ca xng nh hp s, mt s d dng khc nh thai v s, khe
h mi, mn hu, khng c hu mn, suy tim
- non chim 53% v bu gip tr s sinh.
- Suy gip bm sinh
4.3. Cng gip thai nhi:
- Cng gip s sinh hay thai nhi rt him gp vi mt t l 1/4000-1/40000.

58

- Ly mu thai nhi c th c ch nh trong nhng trng hp nghi ng c

ri lon chc nng tuyn gip vo tui thai 25-27 tun.
- S dng nhng thuc chng cng gip c th ci thin mt cch nhanh
chng tin trin ca cng gip thai nhi. S dng PTU ( propyl-theo-uracil) tt
hn l methimazole.
4.4. Cng gip tr s sinh
- Cng gip tr s sinh gp 1% cc tr m ngi m mang khng th
khng cc th cm quan ca TSH.
- Cng gip tr s sinh c pht hin thng qua du hiu tng ng ca tr
s sinh, n nhiu nhng tng cn t, nn nhiu, a chy, st, tim nhp nhanh, tng
tit m hi v ban . Bu gip ch c th gp mt na s trng hp. Suy tim
tr s sinh l mt trong nhng nguy c ca tr s sinh cho nn cn phi chn on
v iu tr sm trnh nguy s suy tim tr s sinh
- iu tr mt cch kinh in l PTU 5-10mg/kg kt hp vi cc thuc
Betabloquant

59

I THO NG V THAI NGHN

1. I CNG
T thai nghn (TTN) l s gim dung np glucose hoc T (i tho
ng) c pht hin ln u trong lc mang thai (khng loi tr ngi bnh c
gim dung np glucose hoc T t trc nhng cha c pht hin).
TTN t l pht hin ch yu giai on mun ca thai k, phn ln cc
trng hp sau sinh glucose c th bnh thng tr li. Tuy nhin nhng trng hp
c tin s TTN ny c nguy c pht trin thnh T tup 2 trong tng lai.
2. PHT HIN TTN
TTN thng khng c triu chng lm sng r, pht hin bnh cn thc
hin chng trnh sng lc ch ng.
Test sng lc c s dng hin nay c p dng bng cch cho sn ph
ung 50g glucose vo gia tun 24-28 ca thai k bt k thi im no trong ngy,
bt k thi gian no sau n. Nu glucose huyt 1 gi sau test 140mg/dL (7,8
mmol/L), nhng ngi ny cn tip tc lm nghim php dung np glucose bng
ng ung xc nh chn on T.
2.1. Chin lc tm sot pht hin TTN da trn cc nguy c:
- Nguy c thp: khng i hi test glucose thng quy nu c tt c cc c
im sau:
+ Thuc chng tc c t l TTN thp
+ Khng c ngi thn thuc gn (first degree) b T.
+ Tui dui 25.
+ Th trng bnh thng trc thai k (BMI < 26kg/m2).
+ Khng c tin s bt thng chuyn ho glucose.
+ Khng c tin s xu v sn khoa.
- Nguy c trung bnh: ngi bnh thiu 1 cc c im trn: thc hin test
glucose mu vo 24-28 tun, s dng mt trong 2 cch sau:

60

+ Th tc 2 bc: test 50g glucose, nu glucose trn chun sng lc, thc hin
tip nghim php dung np glucose.
+ Th tc 1 bc: thc hin nghim php dung np glucose trn tt c cc i tng.
- Nguy c cao: ngi bnh c 1cc c im sau:
+ Bo ph r (BMI > 40kg/m2)
+ Tin s gia nh T tp 2 r .
+ Tin s bn thn b TTN, gim dung np glucose, glucose niu.
+ Thc hin test glucose mu cng sm cng tt, p dng cc bc th tc nu trn.
+ Nu TTN cha c chn on, cn lm li vo 24-28 tun, hoc ti bt
k thi im no ngi bnh c biu hin gi tng glucose mu.
2.2. Chn on
Hi ngh quc t TTN ln th 4 ngh nn s dng tiu chun ca
Carpenter-Coustan vi test 100g glucose ung.
Tiu chun chn on TTN
OSullivan-Mahan

Nhm d kin T

Carpenter-Coustan

Mu ton Somogy-

quc gia

Huyt tng-Glucose

Nelson(mg/dl[mmol/l]) Huyt tng

oxidase(mg/dl[mmol/l])

T phn tch
(mg/dl[mmol/l])
i

90 [5,0]

105[5,8]

95[5,3]

1 gi

165[9,2]

190[10,6]

180[10,0]

2 gi

145[8,1]

165[9,2]

155[8,6]

3 gi

125[6,9]

145[8,1]

140[7,8]

Test vi 100g glucose thc hin vo bui sng, nhn i qua m t nht 8
gi nhng khng qu 14 gi, sau 3 ngy n khng king ( 150g
carbohydrate/ngy) hot ng th lc bnh thng, i tng ngi ngh, khng
ht thuc trong qu trnh test.

61

Ngi bnh c 2 tr s glucose huyt tng bng hoc cao hn tr s quy

nh l tiu chun chn on
3. IU TR T V THAI NGHN
3.1. Theo di v iu tr thng quy :
- i vi trng hp c tin s TTN: cn nh gi li kh nng dung np
glucose trc khi mang thai c thi thch hp.
- i vi trng hp c T tp 2 trc lc mang thai: phi c iu tr
bng insulin.
- Ni chung tt c cc trng hp bit T t trc hoc TTN, mc
ch iu tr l duy tr glucose huyt trc v sau n bnh thng nhm trnh nhng
nguy c tc thi v lu di cho thai nhi.
3.1.1. Theo di:
Cn tm ceton niu trc ba im tm nhm xem xt lng carbohydrate cung
cp nhu cu hay khng. Thai ph c T t trc nn tm ceton niu khi glucose
>150mg/dL. Vi TTN thnh thong nn theo di glucose i, 1 gi, 2 gi sau n.
Ngi bnh dng insulin cn theo di glucose i v lc i ng iu chnh liu.
Tt c i tng cn theo di HbA1C 3 thng u mang thai gip nh gi
nguy c d tt bm sinh.
3.1.2. Dinh dng:
- Nguyn tc c bn nhm gp phn kim sot tht cht ch T sut trong
qu trnh mang thai l ch v k hoch n ung.
- Mi ngy cn chia ra 3 ba n chnh v 3 ba n ph nhm trnh h glucose
huyt ban m v trc cc ba n.
- Trng hp b h glucose huyt, cn iu tr tht hp l, khng lm dng lm
tng glucose thi qu gy hi cho thai. Trng hp h glucose huyt km ri lon tri
gic cn tim glucagon ( c th hng dn cho ngi thn thc hin khi cn).
3.1.3. iu tr insulin:
Yu cu iu tr: vi TTN yu cu kim sot glucose cht ch hn so vi
ngi bnh T ni chung, c th glucose huyt lc i: 60-95mg/dL, glucose huyt

62

sau n: 100-129mg/dL. Ngi bnh cn c o glucose huyt mao mch nhiu ln

mi ngy ti nh, ti ni lm vic iu chnh liu insulin iu tr tht thch hp.
Yu cu glucose huyt c th cho cc giai on nh sau:
-Trc khi mang thai: xc nh glucose huyt sau n (GHSA).
-Ba thng u thai k: GHSA < 160mg/dL, gip lm gim nguy c sy thai,
gim nguy c d tt, kim sot ceton mu.
-Ba thng gia thai k: GHSA < 130mg/dL, gip kim sot leucine, threonine,
acid bo t do, tng th glucose huyt v gip gim nguy c thai ln.
-Ba thng cui thai k: GHSA < 130mg/dL gip gim nguy c hi chng suy
kit h hp, thai lu, kim sot ceton mu
-Sau sinh: GHSA < 180mg/dL.
i vi tp 1: cn iu tr tch cc vi nhiu mi tim trong ngy , v d 3 mi
insulin tc dng nhanh trc 3 ba n, 1 mi insulin chm lc 21 gi. iu chnh
liu lng mi 1-2 tun tu nhu cu, lu gn cui 3 thng u nhu cu insulin
thng gim, sau tng dn ln vo 3 thng cui c th n gp 3 ln liu lng
dng trc lc mang thai.
Cng c th tim 2 mi/ngy loi insulin hn hp: loi 70% insulin NPH v 30%
insulin tc dng nhanh cho trc n sng 2/3 tng liu ca ngy, loi 50% insulin NPH
v 50% insulin tc dng nhanh cho trc n chiu 1/3 tng liu ca ngy.
i vi tp 2: cng cn iu tr vi insulin.
i vi TTN: cha c 1 chun mc no thng nht, tuy nhin a s ng
dng insulin ngay, khi glucose huyt lc i 126mg/dL, ngay c vi glucose
huyt >105mg/dL v < 126mg/dL vi 2 ln xt nghim cch bit, cng nn dng
insulin sau khi tit thc tht bi.
3.1.4. Trong khi chuyn d v sau sinh:
Vi T ni chung, mc tiu iu tr l duy tr glucose mc sinh l (70120mg/dL). trnh tng glucose mu, ngi bnh nn c hn ch n ung v
truyn cc dch khc. Truyn tnh mch ng dextrose tc 5-8g/gi, dng

63

ng 10% truyn 50-80ml/gi. Tt c nhng dch truyn khc phi khng c

glucose. Theo di glucose mi 1-4 gi.
Insulin c cho theo nhu cu: hoc truyn tnh mch lin tc (0,01-0,04v/kg
c th hin ti/gi), hoc bng ng tim di da loi insulin nhanh mi 3-6 gi.
Nhu cu glucose, insulin iu chnh theo kt qu xt nghim glucose huyt
tng lc, thi gian v ng tim cui cng, v thi gian ca ln cung cp nng
lng trc lc sinh.
Tc ng ca vn ng th lc trong lc sinh n c th lm tng s tiu th
glucose, nhng cng c th c iu chnh thng qua vic gy t tu sng lin tc
trong cuc sinh.
Vi TTN thng khng cn dng insulin trong lc sinh, ngay c i vi
mt s trng hp T tp 2 nh cng vy.
Nhu cu insulin gim nhanh chng ngay sau khi sinh( c th gim n 5090%) do liu insulin/ngy cn gim xung ch cn khong 30% hoc gim hn
na so vi liu trc lc sinhNu nhu cu insulin vn cao sau sinh c th l du
hiu ca nhim trng hu sn.
Insulin TM trc s nhanh chng ht tc dng, nn chuyn t TM qua
ng di da ngay sau khi sinh, thng th nhu cu insulin nhanh chng tr li
nh trc khi sinh.
Sn ph T ph thuc insulin nhng ngy u sau sinh thng ch cn liu
nh thm ch khng cn iu tr insulin
3.2. Cc phng tin iu tr khc:
Tp th dc thai ph cn thn trng v c th gy co tht t cung, sinh non,
tim thai chm, nht l nhng thai ph trc y khng h tp luyn. Du sao th
dc nh nhng nh i xe p t ra an ton v hu ch.
4. TIN TRIN V BIN CHNG
4.1. Cho con
- S pht trin ca thai nhng ngi m T ni chung c th c nhng d
tt nh hng ln n tng lai ca tr:

64

+ Tn ng thn kinh
+ D tt bm sinh tim v mt s thng tn khc.
- Thai qu pht trin do tng tch cha m, gia tng chiu di, gia tng t l
bng/u hoc ngc/u
- Thai km pht trin c th gy nhiu bin chng tc hi khc cho thai.
- a i, a i thng i lin vi thai to, gy kh chu v gy sinh non
- Mt s nguy c khc cho thai nhi c th gp do tng insulin nh: hi chng
suy h hp, h glucose huyt, tng billirubin mu, h calci mu, km n.
4.2. Cho m
- Ph n c bin chng tim mch v/hoc T l nguy c ln v bnh tt v
t vong trong sut qu trnh mang thai.
- Nhiu bin chng bnh tt do T ph n mang thai tr li gp phn lm
ri lon thm chuyn ho t tc ng xu ln s kim sot glucose huyt.
- Nhim toan ceton thng xy ra vo 6 thng sau ca thai k, y l giai on
s mang thai c tc ng mnh nht ln T. Nhim toan ceton l mt nguy c gy
t vong cho m cng nh t vong chu sinh cho thai nhi.

65

VIM GAN B V THAI NGHN

1. KHI NIM
Vim gan virus l bnh truyn nhim thng gp. Trc y phn lm 2 loi
vim gan do virus vim gan A v B. Ngy nay tm ra 5 loi vim gan l A, B, C,
D, E. Vim gan do virus B, C, D thng gy nn vim gan mn tnh v x gan.
ng ly truyn: ly truyn t ngi m mc bnh vim gan truyn sang con
trong qu trnh c thai ch yu qua bnh rau, trong chuyn d, v khi cho con b.
2. CHN ON
2.1. Chn on xc nh
- Triu chng lm sng
+ Thi k bnh: trung bnh 2-4 tun. Nhim virus xy ra bt k giai on
no ca thai nghn.Trong thi gian bnh thng khng c triu chng c hiu.
Nu c ch l mt mi, chn n, bun nn hay nn, d nhm vi triu chng nghn.
+ Thi k pht bnh: khi c triu chng th bnh nng, du hiu lm sng
r rt. Mt mi chn n, st cn, au vng gan, hay vng thng v, bun nn, nn
v st. Nc tiu t dn, mu vng sm, vng da, vng mt, nga ton thn hay gp
(75%). Gan to, n au vng gan.
- Triu chng cn lm sng:
+ Xt nghim khng c hiu: men gan tng cao, tng globulin mu.
+ Xt nghim c hiu: HBsAg, HBeAg, PCR(nh lng vi rt trong mu).
2.2. Chn on phn bit:
- mt do thai nghn hay ti pht.
- Vim gan km theo nhim khun tit niu
- Tin sn git nng
2.3. Hu qu v tin lng: nguy him cho c m v thai.
- Bin chng
+ Vim gan cp, hoi t t bo gan gy teo gan vng cp, hn m gan, t vong 80%.
+ Suy chc nng gan, gim yu t ng mu gy chy mu khi , sy thai.

66

+ X gan, ung th gan.

+ M mang khng nguyn HBsAg c th ly truyn cho con. Nu b nhim
trong 10 tun u thai nghn thng gy d dng thai, sy thai. Nu b nhim t sau
tun th 12, tr c th b vim gan cp, bnh hay xy ra thng th 3 sau , khng
c du hiu lm sng, i khi ch c du hiu gan to.
- Tin lng
+ Cho m: chy mu khi sy thai hay , gy ri lon ng mu v t vong.
Nu vim gan ti cp s b ri lon chc nng gan dn n hn m gan, lu di c
th dn n x gan, ung th gan
+ Cho thai: tin lng d dt, sy thai, non, thai cht lu, vim gan.
Bng 1. Nguy c ly truyn virus vim gan B t m sang thai
Xt nghim khng th Nguy c ly truyn cho s Hng x tr
ph n c thai 3 thng sinh khi hay sau
cui
HBsAg+/ HBeAg+

90-100%

Huyt thanh- vaccine

HBsAg+/ HBeAg

20%

Huyt thanh- vaccine

HBsAg- /antiHBc+

Cha bit, t l thp

Vaccine

HBsAg- / anti HBs+

Khng ly

vaccine

3. IU TR
- Cho n nay cha c iu tr c hiu, ch c iu tr triu chng v d phng,
thai ph ngh ngi hon ton, dinh dng tt phng thiu mu, suy dinh dng
- Li tiu ng y.
- Trong thi gian mang thai khm chuyn khoa xt nghim PCR ti lng vi
rt trong mu , iu tr thuc dit virus.
- iu tr ri lon ng mu nu c
- Trnh chn thng vng gan
- Trnh phu thut, th thut nu khng c ch nh cp cu. Trong v sau
iu tr chy mu, chun b hi sc v truyn mu.

67

4. PHNG BNH
- Gim bnh ly truyn qua ng tnh dc
- Pht hin sm thai ph c vim gan qun l v t vn khi c thai, trong
khi , v sau . Khuyn khm li chuyn khoa gan mt sau 3 thng.
- Khng cho b m
- Tim globulin min dch vim gan B v vaccine cho tr s sinh, cho nhng
ngi chm sc.
Vaccin vim gan B: c 2 loi
+ Vaccin th h 1: sn xut t khng nguyn HbsAg ca virus trong huyt
thanh ngi bnh, mc an ton khng cao, hin nay t c s dng.
+ Vaccin th h 2: ly gene t virus cy vo nm men bia s cho mt sn
phm mi ging virus (ti t hp ADN), an ton cao v hiu qu to min dch
tt, ang c s dng rng ri
+ nhng ni c dch t hc vim gan B cao, ngi nhim virus vim gan B
cao th khuyn khch tim vaccin vim gan B cho tt c cc em b m m khng
c chn on sng lc
+ Vaccin phi hp vi HBIg c ch nh cho tt c con ca b m mang
virus vim gan B

68

HIV/AIDS V THAI NGHN

1. KHI NIM
- HIV (Human immunodeficiency virus) l virus gy suy gim min dch
ngi, tn cng h thng min dch ca c th, tiu hy dn cc t bo min dch
to thun li cho cc nhim trng c hi, ri lon thn kinh, v cc khi u gy t
vong cho ngi bnh.
- AIDS (acquired immunodeficiency syndrom): hi chng suy gim min dch
mc phi l hi chng nng n, giai on mun ca bnh do HIV gy nn.
Cc phng thc ly truyn:
+ Quan h tnh dc: quan h ng gii v khc gii.
+ ng mu: truyn mu b nhim (95%), nghin ma ty dng cng bm
tim (0,67%), cn b y t b kim chm (0,4%).
+ T m sang con: ly truyn HIV t m sang con (LTMC) l s ly truyn t
ngi m b nhim HIV sang tr s sinh trong cc giai on mang thai (trong t
cung), qu trnh chuyn d, cho con b. Nu khng c iu tr d phng, t l ly
truyn HIV t m sang con l khong 25-40%.
2. CHN ON
2.1. Cc giai on lm sng: 4 giai on
- Giai on s nhim: hi chng gi bnh tng bch cu n nhn nhim trng
hoc gi cm: st, au u, mt mi, au c. Sng hch c, nch. Pht ban dng
si hoc sn nga trn da, vim mng no nc trong. Nhng biu hin ny s ht
trong vng 7-10 ngy
- Giai on suy gim min dch sm (s lng TB CD4 > 500 TB/ ml): ngi
bnh khng c biu hin g trn lm sng nhng trong mu c HIV v tr thnh
ngun ly cho ngi khc. Giai on ny ko di t 5-20 nm hoc lu hn.
- Giai on suy gim min dch trung gian (200 < CD4 < 500 TB/ml): st ko
di trn 38o C, st cn di 10% trng lng c th m khng c l do. Vim da,
nim mc ming, sn nga, vim nang lng, zona da.

69

- Giai on suy gim min dch nng n (TB CD4 < 200 TB/ml: nguy c
nhim trng c hi nng hoc u c tnh ca AIDS. Hi chng suy mn: st cn trn
10% trng lng c th, st, tiu chy ko di. Vim phi do Pneumocystis carinii,
Toxoplasma no, nm thc qun, lao ngoi phi, Kaposi sarcoma.
2.2. Xt nghim:
- Xt nghim HIV: pht hin cc khng nguyn hoc khng th lin quan n
HIV trong mu bnh phm.
+ Phng php gin tip: test nhanh (Determine HIV-1/2, Oralquick HIV
1&2, HIV Spot, Genie I HIV1/HIV2). Min dch men ELISA. Western Blot: xt
nghim khng nh, min dch in di, c hiu cao do xc nh c cc khng
th c hiu ca cc khng nguyn khc nhau ca HIV. Ngoi ra cn c xt nghim
khng th hunh quang gin tip (IFA) v min dch kt ta phng x (RIPA).
+ Phng php trc tip: pht hin trc tip HIV thng qua tm khng
nguyn P24 ca virus, tm gen ca virus HIV l ARN hay AND ca tin virus, nui
cy phn lp virus
- Cc phng cch xt nghim HIV ti Vit Nam, ph thuc vo mc tiu:
+ Phng cch I (p dng cho cng tc truyn mu): dng tnh vi 1 trong
cc th nghim nh ELISA, SERODIA, hay th nghim nhanh.
+ Phng cch II (p dng cho gim st trng im): dng tnh c 2 ln xt
nghim bng 2 loi sinh phm vi nguyn l v chun b khng nguyn khc nhau.
+ Phng cch III (p dng cho chn on cc trng hp nhim HIV): dng
tnh vi c 3 ln xt nghim bng 3 loi sinh phm vi nguyn l v chun b khng
nguyn khc nhau. Nu kt qu khng ng nht, phi xt nghim li hoc gi mu
mu xt nghim ni khc.
- Chn on HIV tr em sinh ra t m nhim HIV.
Tt c tr em ny xt nghim pht hin khng th u cho kt qu dng tnh.
Khng th HIV ca m tn ti lu di tr nh, vi tr khng b nhim HIV, lng
khng th ny mt dn v s ht vo thng 9 n trc 18 thng tui. Tr 18 thng
tui, xt nghim khng th dng tnh theo phng thc III ngha l tr b nhim

70

HIV. Chn on bng xt nghim trc tip HIV PCA-AND pht hin tin virus
tr 6 tun tui c hiu qu cao.
1. D phng

2. Phng trnh

3. Can thip cho ph

4. Cc dch v

sm ly truyn

mang thai

n nhim HIV mang

chm sc, h tr

HIV cho ph

ngoi mun

thai

v iu tr thch

cho ph n

hp cho cp m v

nhim HIV

con sau sinh

-Thng tin, gio

-T vn v cung -Chm sc thai nghn

-Cc dch v can

dc v truyn

cp cc bin

-T vn v xt nghim thip cho b m .

thng thay i

php trnh thai.

-nh gi giai on

-Cc dch v can

hnh vi .

-T vn xt

lm sng v min dch

thip cho tr phi

-T vn v XN

nghim HIV

-iu tr DPLTMC

nhim .

HIV cho ph n

-T vn thc

-Thc hnh sn khoa

-Cc dch v can

-Khuyn khch

hin tnh dc an

an ton.

thip cho tr nhim

tr hon quan h

ton

-iu tr cho tr sinh

HIV.

tnh dc i vi

ra t b m nhim

thanh thiu nin

HIV.

-Thc hnh tnh

-T vn nui dng

dc an ton

tr sau sinh

-Pht hin sm
v iu tr kp
thi cc nhim
khun ly truyn
qua ng tnh
dc

3. CC CAN THIP LY TRUYN HIV T M SANG CON: 4 thnh t

3.1. S dng thuc khng retrovirus
Mc tiu: gim ti lng virut ngi m v gim s phi nhim ca thai.

71

- iu tr phng ly truyn m con (LTMC): s dng ngn hn ARV gim ly

truyn HIV m-con. Nguyn tc: iu tr ARV cng sm cng tt..
- iu tr bnh: s dng lu di ARV do sc khe ngi m (TCD4 350 t
bo /mm3 khng ph thuc giai on lm sng; hoc giai on lm sng 3, 4, khng
ph thuc TCD4) v cng c tc dng d phng LTMC.
Phc phng LTMC (B y t, ban hnh ngy 2/11/2011):
AZT (Zidovudine) 300mg x 2ln/ngy, ung
M

Khi mang thai

hng ngy t tun thai th 14 hoc ngay khi

pht hin nhim HIV sau tun thai th 14
cho n khi chuyn d
- AZT 600mg + 3TC 150mg + NVP 200mg.

Khi chuyn d

- Sau 12 gi mt ln AZT 300mg + 3TC

150mg cho n khi .

Sau

AZT 300mg + 3TC 150 mg ngy 2 ln trong

7 ngy

M iu tr AZT NVP liu n 6mg ung mt ln ngay sau

trc sinh trn 4 sinh + AZT 4mg/kg ung ngy 2 ln
Con

tun
M iu tr AZT NVP liu n 6mg ung mt ln ngay sau
trc sinh cha khi sinh + tip tc AZT 4mg /kg ung 2 ln
4 tun

mt ngy trong 4 tun

3.2. Cc can thip sn khoa trong giai on chuyn d v sinh con

Mc ch: gim ti a s phi nhim ca thai nhi vi HIV t cc dch c th
ca m, v cc yu t nguy c LTMC.
- Tun th nguyn tc v khun chung. St khun ng sinh dc trong qu
trnh bng dung dch Chlorua de Benzalkonium hay Chlorhexidin 0,2.
- Cn b y t m bo cuc chuyn d v sinh con an ton, nhit tnh, chu o
khng k th, phn bit i x.

72

- Hn ch ti a th thut gy tn thng da v nim mc cho m v con khi

chuyn d (khng bm i sm, Forceps, gic ht, t in cc vo u thai nhi,
khng ct TSM qu sm hn ch chy mu).
- M ly thai: m ly thai ch ng hoc trc khi v i c th lm gim nguy
c ly truyn m con t 50-80% khi phi hp vi ARV. Do nguy c ca phu thut,
khng khuyn co m ly thai h thng cho sn ph nhim HIV. B Y T quy nh
ch m ly thai khi c ch nh sn khoa.
- Trm y t x khng c kh nng iu tr d phng ARV cho m v s sinh
khi chuyn d v sau do vy cn gii thiu sn ph nhim HIV ti cc c s sn
khoa (ti thiu tuyn huyn) c cung cp dch v PLTMC.
3.3. Can thip sau sinh
- Chm sc sn khoa: theo di hu sn, co hi t cung, chy mu, nhim trng
- iu tr d phng ly truyn HIV tip tc theo phc
- T vn v gii thiu chuyn tip n c s chm sc v iu tr HIV/AIDS
v khng nh tnh trng nhim HIV. T vn phng thc nui con an ton.
Chm sc s sinh:
+ Ct rn sm ngay sau , cng sm cng tt.
+ Tm ngay sau khi ct rn hoc lau kh dch trn ngi tr bng khn mm,
d thm nc, hn ch lau v k trn b mt da.
+ Hn ch ht dch ng mi - hu - hng, bng cc loi sonde mm, p
lc <100mmHg hoc dng bng ht, thao tc nh nhng,trnh tn thng mi hng,
+ Tr s sinh sau tt nht phi c d phng ARV trc 72h.
+ Khi xut vin cn gii thiu a tr n cc c s nhi khoa khi tr c 6
tun tui, dng thuc d phng cc bnh nhim trng khc, theo di v xt
nghim cho n khi khng nh tnh trng HIV, ng thi vi vic theo di tng
trng v tim chng.

73

ST TRONG KHI C THAI

1. KHI NIM
Sn ph st (nhit 38C) trong thi k thai nghn hoc trong chuyn d
v sau .
2. CC HNH THI LM SNG, CHN ON
2.1. St do cc bnh ni/ ngoi khoa trong thi gian c thai
2.1.1. Vim rut tha cp:
- Chn on:
+ St, au h chu phi m v tng dn
+ Nn, bun nn, b trung i tin.
+ Phn ng h chu phi, Mac burney (+).
+ T cung c thai bnh thng
- X tr: phu thut ct rut tha qua ni soi hay m m, khng sinh, thuc
gim cn co t cung, gi thai.
2.1.2. Vim ng tit niu:
- Vim bng quang:
+ i kh, i au, i but, i rt, au bng vng sau mu.
+ Xt nghim nc tiu c hng cu, bch cu, protein
+ iu tr: Amoxicilin 500mg ung 4v/ngy trong 5-7 ngy. Nu ti pht c
th iu tr tip n khi .
-Vim thn b thn cp:
+ St cao, rt run, i kh, i rt, au bng vng tht lng, n au ti
xng sn
+ Xt nghim bch cu a nhn trung tnh tng. Cy nc tiu tm vi khun.
+ Siu m i b thn gin, niu qun gin. Thai bnh thng.
+ iu tr: chng chong. iu tr khng sinh theo khng sinh , Unasyn 1,5g
x 2l. Tim TM, Metronidazol 1g truyn TM cho n khi ht st 48h chuyn sang
thuc ung Amoxicillin 1g x 3 ln /ngy trong 12 ngy

74

2.1.3. Vim phi

- Du hiu chnh : st, kh th nhanh, au ngc, ho c m
+ Hng xung huyt, phi c ran n, ran m.
+ Chp phi c hnh m thy phi (ch tm ch bo v thai nhi).
- X tr: cng sm cng tt, chuyn ni khoa iu tr khng sinh Erythromycin
500mg x 4 ln /ngy trong 7 ngy, kh dung xng hng.
2.1.4. St rt.
- Du hiu chnh
+ St rt khng c bin chng: rt run, st nng, ra m hi c chu k (hng
ngy hay cch ngy), nhc u, au khp, au c. C th lch to
+ St rt c tnh c bin chng nng: st rt km thm thiu mu, hn m, i
ra huyt sc t, c th co git, vng da.
- Xt nghim: phin mu ngoi vi tm k sinh trng, test nhanh tm khng th.
- X tr:
+ Chloroquin liu khi u 10mg/kg cn nng1 ln/ngy trong 2 ngy, sau
5mg/kg ngy th 3.
+ Sulfadoxin /pyrimethamin 3v ung liu duy nht.
+ Mui quinine 10mg/kg cn nng ung 3l/ngy trong 7 ngy
2.1.5. Thng hn.
- Triu chng: st tng dn, au u, to bn ban u, ho khan, mt mi, chn
n, lch to sau i ngoi phn lng. C du hiu bng ngoi khoa (thng rut). C
th m sng, dn.
- Cy phn, cy mu lm khng sinh
- X tr: khm v iu tr ti khoa truyn nhim. Ampicillin 1gx 4 ln/ngy
hay Amoxycillin 1g x3 ln/ ngy trong 14 ngy.
2.1.6. Vim gan do virus.
- Triu chng: st, mt mi, chn n, vng da, nc tiu vng, gan to. C th
au c, au khp, ni m ay, lch to.

75

- Xt nghim: chc nng gan, men gan tng cao, khng th khng nguyn
virus HbSAg, HbEAg, nh lng phin bn virus trong mu (PCA).
- Tin trin: vim gan do virus din ra trong giai on chuyn d rt nng v
suy gan cp, chy mu do ri lon ng mu, hn m gan do suy gan.
- Chn on phn bit: tin sn git nng, hi chng HELLP
- iu tr: chuyn khm v iu tr ti khoa truyn nhim, Ngh ngi nng cao
th trng. Thuc gim lng virus trong mu .
- Trong khi chuyn d ch chy mu, chun b mu v cc yu t ng mu.
- Phng bnh cho s sinh: tim khng th khng virus (HEBA BIG) + vaccine
trong vng 72g sau .
2.1.7. St do vim ng h hp trn:
- Triu chng: y l bnh thng gp, thng c st v du hiu ch im ti
ng h hp nh au hng, ho, khn ting, chy nc mi, nc mt.
- Khm tai mi hng, ly bnh phm cy vi khun lm khng sinh .
- iu tr: khng sinh nhm beta lactamin ph rng, khng c cho thai, kt
hp chuyn khoa tai mi hng iu tr ti ch (gim tit dch, nh mi, xng hng).
2.1.8. St do virus: cm v Rubella;
- Triu chng: st cao 38-40 C, vim long ng h hp trn, au mi ton
thn, du hiu st ht sau 1 tun.
- Ni ban mt, tay, ton thn.
- Xt nghim tm khng th trong mu IgM, IgG.
- iu tr: iu tr triu chng nng cao th trng, h st hn ch nh hng
n thai.
- Thai 3 thng u cn ch kh nng nh hng n thai, gy d dng thai.
Chuyn tuyn trung ng chn on sm v t vn ngng thai nu nhim Rubella.
2.1.9. St c lin quan n thai nghn
- Nhim khun thai:

76

+ Triu chng: st, ra kh h hi, t cung cng au, c th au bng di,

phn ng thnh bng, ra mu m o ko di, m chy ra t c t cung, c th
sy thai, thai cht lu.
+ X tr: khng sinh cng sm cng tt. Ly thai v rau ra khi t cung bng
thuc (misoprostol) hay bng dng c.
- Nhim khun i.
+ Triu chng: thng gp trong i v non, v sm x tr khng ng, i khi
trong chuyn d ko di. St l triu chng thng gp, st cao, rt run, dch m
o hi, au bng, tim thai nhanh. T cung cng au, nc i c mi hi.
Cy dch i c vi khun, xt nghim mu bch cu a nhn trung tnh cao, CRP (+).
+ X tr: khng sinh liu cao, phi hp theo khng sinh . X tr thai ty
theo ch nh sn khoa, c khi cn m ly thai, trong trng hp nng c th phi
ct t cung.
- Nhim khun m o: t gp hnh thai vim n thun, thng phi hp vi
nhim khun t cung hoc nhim khun i.
+ Triu chng: st, dch m o nhiu, c mi hi. Du hiu nhim khun ton
thn c th cha r. Cy dch m o c vi khun gy bnh.
+ X tr: khng sinh ton thn ( theo khng sinh ), lm thuc m o v x
tr sn khoa tch cc.

77

SINH L CHUYN D
1. KHI NIM
Chuyn d l mt qu trnh sinh l lm cho thai v phn ph ca thai c
y ra khi t cung v ng sinh dc ca ngi m.
2. PHN LOI
- thng l cuc chuyn d din ra bnh thng theo sinh l, thai nhi c
qua ng m o, khng can thip g.
- thng l cuc chuyn d t u tun th 38 (259 ngy) n cui tun
th 41 (287 ngy).
- non thng khi tui thai t 22 tun (154 ngy) n 37 tun.
- Thai gi thng khi tui thai qu 41 tun ( 287 ngy)
- Sy thai l s chm dt thai nghn trc khi thai c th sng c, thai di
22 tun, nng di 500g
3. CC C IM CA CHUYN D
3.1. Chuyn d c 3 giai on
- Giai on xa m c t cung
- Giai on s thai
- Giai on s rau
3.2. ng lc ca cuc chuyn d
Cn co t cung l ng lc ca cuc chuyn d . Ri lon co bp ca t
cung c th lm cho cuc chuyn d b ko di hoc gy cc tai bin cho ngi m
v cho thai nhi.
3.3. c im c co t cung
- Cn co t cung xut hin mt cch t nhin ngoi mun ca sn ph. Cn
co t cung gy au. Ngng au ph thuc theo tng sn ph. Khi p lc cn co t
ti 25-30 mmHg, sn ph bt u cm thy au. Cn au xut hin mun, sau khi
c cn co t cung v mt i trc khi ht cn co t cung.

78

- im xut pht ca cn co t cung nm mt trong hai sng ca t cung.

Thng thng sng phi t cung. S lan truyn cn co t cung cng theo hng
t trn xung di. Tc lan truyn cn co 1-2cm/ giy.
- Cn co t cung c tnh chu k v u n, mau dn ln, di dn ra, khi bt
u chuyn d ch di 15 n 20 giy, sau t ti 30 - 40 giy cui giai on xa
m c t cung. Cng cn co t cung cng tng dn ln. p lc cn co khi mi
bt u chuyn d t 30-35 mmHg tng dn ln n 50 - 55 mmHg.
- Cn co t cung c tnh cht ba gim: p lc cn co t cung gim dn t trn
xung di, thi gian co bp ca c t cung cng gim dn t trn xung di
- S lng cn co t cung trong mt cuc chuyn d thay i t 70- 180,
ph thuc vo s ln , d hay kh v cht lng c t cung.
3.4. Cn co t cung v cn co thnh bng trong giai on s thai:
Trong giai on hai ca cuc chuyn d , cn co thnh bng phi hp vi
cn co t cung y thai ra ngoi. C honh c y xung thp trong bng, cc
c thnh bng co li lm gim th tch bng, p lc ca bng tng ln p vo y t
cung gp phn y thai xung. p lc cn co t cung cui giai on hai tng cao
cng vi cn co thnh bng s to thnh p lc trong bung i tng ln ti 120150mmHg. Nh vy l p lc cn co thnh bng rt cao m mt na p lc ny do c
honh gy ra. Do vy vic hng dn sn ph bit cch rn rt c gi tr.
4. NHNG THAY I V PHA M V THAI, PHN PH
4.1. Thay i v pha ngi m
S xa m c t cung v thnh lp on di:
Thi gian xa m c t cung din ra khng u. Trong giai on u (Ia) t
khi c t cung xa n khi m c 4cm thi gian mt 8-10 gi. Giai on sau (Ib)
thi gian m t cung t 4cm n m ht khong 4-6 gi, tc trung bnh m
1cm/1 gi.
S xa m c t cung nhanh hay chm ph thuc vo cc yu t: u i t
vo c t cung nhiu hay t, tnh trng c t cung dy cng, so x c. Cn co t
cung c ng b v mnh hay khng.

79

Gia ngi con so v ngi con r c s khc bit nhau v hin tng xa m
c t cung. ngi con so c t cung xa ht ri mi m v on di t cung
thnh lp t cc thng cui ca thai nghn. Cn ngi con r, c t cung va xa,
va m v on di t cung ch thnh lp khi mi bt u chuyn d. Thi gian
m c t cung ngi con r nhanh hn so vi ngi con so
- Thnh on di lp: on di t cung thnh lp do eo t cung gin rng, ko
di v to ra. T 0.5-1 cm, khi on di c thnh lp hon ton cao n 10cm.
- Thay i y chu:
Do p lc ca cn co t cung ngi thai xung dn trong tiu khung. p lc
ca ngi thai y dn mm xng ct ra pha sau, ng knh mm ct h v thay
i t 9.5cm thnh 11 cm bng vi ng knh mm cng- h v. Sc cn ca cc
c pha tng sinh mn sau y ngi thai hng ra pha trc.
Tng sinh mn trc phng to ln, vng hu mn m h di ra gp i (t
3- 4cm gin ra 12-15cm). Do c tc dng ca cn co t cung v cn co thnh bng,
tng sinh mn sau b ngi thai vo gin di ra, l hu mn m rng xa ht cc
np nhn, m mn m rng, thay i hng dn dn nm ngang. S tin trin ca
ngi thai thng gy sn i v nu trc trng cn phn th phn s thot ra ngoi
hu mn khi ngi thai xung thp trong tiu khung.
4.2. Thay i v pha thai:
Khi on di c thnh lp, ngi thai cng t t tt dn xung p st vo
on di lm cho ngi thai st vi c t cung, to iu kin thun li cho vic m
c t cung. Trong qu trnh chuyn d , thai nhi c mt s hin tng un khun.
- Hin tng chng xng s. Hp s ca thai nhi gim bt kch thc bng cch
cc xng chng ln nhau. Hai xng nh chng ln nhau, xng chm v xng trn
chui xung di xng nh. Hai xng trn cng c th chng ln nhau.
- Thnh lp bu thanh huyt. l hin tng ph thm thanh huyt di
da, i khi rt to. V tr bu thanh huyt thng nm phn ngi thai thp nht,
gia l m ca c t cung. Bu thanh huyt ch xut hin sau khi v i. Mi mt
ngi thai thng c v tr ring ca bu thanh huyt

80

4.3. Thay i phn ph ca thai: cn co t cung lm cho mng rau (trung sn

mc v ni sn mc) cc di ch c t cung m b bong ra, nc i dn xung
to thnh ti i hay u i
-Tc dng ca u i:
+ Gip cho c t cung xa v m trong chuyn d do u i p vo c t cung
+ Bo v thai nhi vi cc sang chn bn ngoi
+ Trnh nguy c nhim khun ngc dng t m o vo bung i
Cc hnh thi i v:
+ V i ng lc l v i khi c t cung m ht
+ V i sm l v i xy ra khi c chuyn d nhng c t cung cha m ht
+ V i non l v i xy ra khi cha c chuyn d.
- Rau bong v s rau: sau khi s thai , cn co t cung tip tc xut hin sau
mt giai on ngh ngi sinh l lm cho rau thai v mng rau bong ra, xung dn
trong ng sinh dc ngi m v s ra ngoi. T cung co cht li to thnh khi
an ton gy tc mch sinh l cm mu sau khi rau s.
4.4. Mt s thay i khc
- V pha ngi m:
Thay i v h hp: s tng thng kh trong cc cn co t cung c th gy nn
tnh trng kim h hp. Trong khi s thai , cc cn rn lm tng PCO2 v tnh
trng tng h hp s lm tng thm vo tnh trng toan chuyn ha.
Thay i v huyt ng: t th sn ph nm nga, t cung thng lch sang
phi nn tnh mch ch bng b chn p lm gim tun hon rau thai dn n suy
thai. Cho sn ph nm nghing tri s loi b c tc dng xu ny.
Cc cn co t cung mnh hoc gng sc rn s chn p ng mch ch
bng dn ti gim lu lng tun hon rau thai v gy suy thai. Gim huyt p
ng mch do gin mch hoc do lit mch v gy t quanh ty sng cng c th
dn n suy thai.
M b chy mu nhiu trong chuyn d lm gim khi lng tun hon v km
theo tnh trng co mch cng gy ra suy thai.

81

Thay i v chuyn ha: trng lng c th m gim t 4-6 kg sau khi , bao
gm trng lng thai nhi, bnh rau, nc i, mu v cc dch tit t da, phi,
thn. ng huyt cng gim do tng tiu th . Cc gng sc chu ng ca c
trong cc cn co t cung, rn c th dn n tnh trng toan mu v tnh trang
toan mu ny c th chuyn sang con. S lng bch cu cng tng ln trong qu
trnh chuyn d .
Tnh trng lo lng v au: trong chuyn d , tnh trng au do cn co t
cung v lo lng s lm tng bi tit cortisol v cc cathecholamin gy ra tnh trng
co mch lm trm trng thm tnh trng toan do acid lactic. V vy phi bng mi
cch gim au v trn an cho sn ph.
- S p ng ca thai: tim thai thay i trong cn co t cung. Tim thai hi
nhanh ln khi t cung mi co bp sau chm li trong cn co t cung. Ngoi cn
co t cung, tim thai dn dn tr li bnh thng
5.6. Thi gian chuyn d
ngi con so, thi gian chuyn d trung bnh t 16 - 20h. ngi con r,
thi gian chuyn d ngn hn, trung bnh t 8 - 12h. Cc cuc chuyn d qu
24h gi l chuyn d ko di

82

NGI MNG
1. KHI NIM
Ngi mng l mt ngi c kh nng ng di nhng d mc u hu v
vy nu khng c chn on sm, tin lng tt v x l thch hp th nguy c
cho m v thai s rt cao, c th lm tng t l t vong i vi thai nhi v tng tai
bin i vi m.
1.1. nh ngha: Ngi mng l ngi dc m cc u y t cung, cc mng trnh
din trc eo trn ca khung chu ngi m.
1.2. Phn loi : c 2 loi ngi mng
- Ngi mng hon ton: mng v 2 chn trnh din trc eo trn.
- Ngi mng khng hon ton (ngi mng thiu): c 3 kiu (kiu mng, kiu
u gi, kiu bn chn)
1.3. Mc ngi v ng knh lt
- Mc ngi mng l nh xng cng.
- ng knh ln nht ca ngi lng i - 9 cm, hin nay c cho l
ng knh lt ca ngi.
2. CHN ON
2.1. Trong thi k c thai (3 thng cui)
2.1.1. Lm sng:
C th au tc h sn phi do u n vo gan, thai p nhiu pha di. T
cung hnh tr, hay lch mt bn.
S: cc di mm, to, khng lin tc, lng l mt din phng, cc trn l u
trn, u, rn.
Nghe tim thai: nghe r trn rn.
Thm m o: s c mng, nh xng cng, hu mn, b phn sinh dc,
chn thai (nu mng hon ton hay mng khng hon ton kiu bn chn).

83

2.1.2. Cn lm sng:
Siu m: c gi tr chn on v nh gi tin lng, hin nay siu m c
trang b ti tuyn c s, d s dng, khng c hi. Siu m c th nh gi c
tnh trng u, tnh trng thai, trng lng thai, rau, i.
X quang: nh gi u ci hay nga, ch lm khi tht cn thit.
2.2. Khi chuyn d
2.2.1. Lm sng
Triu chng nh khi c thai. Kh s hn v c cn co t cung do xc nh
c cc cc ca thai kh hn.
Khi thm trong: kh khi i cn, khi i v th d hn. C th s thy mng,
xng cng, hu mn, b phn sinh dc, chn.
2.2.2. Cn lm sng: siu m, X quang.
2.2.3. Chn on th, kiu th: lng bn no th bn .Tm mc ngi l nh
xng cng xc nh kiu th. Cng - chu - tri - trc: gp 60% (CgCTT).
Cng - chu - phi - sau : gp 30% (CgCFS). Cng - chu - tri - sau : gp
10% (CgCTS). Cng - chu - phi - trc: rt him gp (CgCFT). Cng- chu- tringang (CgCTN). Cng- chu- phi- ngang (CgCFN)
2.3. Chn on phn bit
Ngi chm: d nhm vi ngi mng khng hon ton kiu mng khi i cha
v nu ch nn ngoi. Cn xc nh r ngi chm c cc thp v ng khp khi
thm trong. c bit cn phn bit r vi ngi chm sa chi.
Ngi mt: c th nhm vi ngi ngc khng hon ton kiu mng, kh khi
bu huyt thanh to khng s thy xng. Nhm mm vi hu mn, hai mng vi
hai g m, mi vi xng cng. Ngi mt c th s thy mi to v mm, h mt
hai bn.
Ngi ngang: cn khm k c th nhm vi ngi ngc hon ton do cn
xc nh r cc u. Phn bit chn v tay thai nhi.

84

3. HNG X TR
3.1. Trong thi k c thai (trong 3 thng cui)
Qun l thai nghn tt ti c s c iu kin trang thit b, chuyn mn.
nh gi tnh hnh thai m. Tm cc yu t khng thun li: con so ln tui, thai to,
so t cung, tin s sn khoa kh khn. i vi trng hp kh khn cn theo di
cc c s c iu kin trang thit b, chuyn mn tt. C th m ly thai khi
thng hay khi bt u chuyn d.
3.2. Khi chuyn d
nh gi tnh trng m, thai, rau, tnh trng i. Xc nh ngi, th kiu th ca
ngi. Nu cc yu t khng thun li: thai to, con so ln tui, so m t cung, tin
s kh, him con, c th m ly thai.
Trong qu trnh chuyn d nu khng thy c suy thai, i v non, i v sm.
Tin trin ngi v cn co t cung bnh thng th theo di ng di. Nu c
cc yu t khng thun li c th m ly thai.
3.3. Khi x thai theo di chuyn d tch cc. Chun b ngi bnh tt theo di,
t tng sn ph, truyn oxytocin, chun b u hu.
- Ngi ngc khng hon ton kiu mng
Trnh mi can thip, tn trng tin trin t nhin, mng s nong gin tng sinh
mn v thai s dn, khi x gn ht chi di th mng, ni dy rn, khi gc di
xng b vai qua m h th cho x tay hay h tay.
- Ngi ngc hon ton
Trnh li ko thai. Gi tng sinh mn theo phng php Tschovianop mc
ch lm cho ngi lt xung tiu khung nong gin t t c t cung, m o v tng
sinh mn, khi tng sinh mn nong gin tt th cho x mng, i mng s, khuyn
khch ph sn rn khi s ht chi di th mng, ni dy rn khi s thn, gc di
xng b vai qua m h cho x tay hoc h tay.

85

- S u hu
Chung cho c ngi mng hon ton v khng hon ton. u hu ra nhanh khi
cn co tt, sn ph rn tt, tng sinh mn gin n tt. u hu xung tt: ct tng
sinh mn u hu nh nhng theo phng php Bracht.
u hu kh khng c bng phng php Bracht th p dng phng
php Mauriceau, Forceps u hu
-Tm li:
Vn kh khn trong ngi ngc l u hu, cn theo di tch cc, ch i,
trnh can thip c th gy sa dy rau, dui ngc tay, mc u thai nhi. iu quan
trng l tin lng tt v x l thch hp cho tng trng hp.

86

NGI VAI
1. KHI NIM
Ngi vai l ngi m thai khng nm theo trc dc m nm ngang trong t
cung. Trong ngi vai, khng phi lc no hai cc u v cc mng cng u ngang
nhau m mt cc h chu cn cc kia vng h sn. Khi chuyn d thc s, vai
s trnh din trc eo trn. Mc ca ngi vai l mm vai. Ngi vai khng th
c khi thai sng thng , nn khng c c ch .
2. CHN ON
2.1. Khi cha chuyn d
- Tin s sn khoa: cha nhiu ln, c ln thai trc c ngi vai
- Nhn t cung b ngang
- Nn cc di tiu khung rng khng thy cc u hay mng. Nn hai bn
mt bn thy u (khi trn, cng, bp bnh), mng sn hoc h chu bn kia
nn thy cc mng (khi trn khng u, to hn u, ch cng ch mm). Nn gia
hai cc u v mng s thy lng l mt din phng (nu lng pha trc) hoc
thy ln nhn cc chi (nu lng pha sau)
- Nghe tim thai: v tr nghe tim thai ty thuc vo v tr cc u, l ni s thy
mm vai. Tim thai s nghe rt r nu lng nm pha trc
- Thm m o thy tiu khung rng
- Siu m thy thai nm ngang
2.2. Khi chuyn d
- Hi tin s, nhn, s nn nh trong khi c thai, nhng s nn kh hn do
c cn co t cung.
- Thm m o:
+ Khi i cha v thy i phng, tiu khung rng, cn thm khm nh nhng
trnh lm i v sm
+ Khi i v, s thy mm vai, cc xng sn v h nch, vai bn no
tc u bn .

87

2.3. Chn on kiu th : Vai - chu - tri - trc. Vai - chu - phi - trc. Vai chu - phi - sau. Vai - chu - tri - sau.
- Chn on kiu th da vo hai yu t: u v lng hay vai v lng .V d
u tri lng trc th kiu th l vai - chu tri trc
- Trong trng hp tay thai nhi sa ra ngoi m o hay ngoi m h, lc
da vo bn tay xc nh kiu th. Du hiu ngn tay ci: t bn tay thai nhi
nga, ngn tay ci ch vo i m, nu i m l i tri th tay thai nhi l tay tri,
nu i m l i phi th tay thai nhi l tay phi
2.4. Chn on phn bit
- Ngi u sa chi: ngi u thng cao, khi s thy tay thai nhi b sa, phi tm
xem eo trn c u khng. Vi ngi vai, khng s thy u thai nhi eo trn
- Ngi ngc hon ton: s thy nh xng cng d nhm vi mm vai,
nhng khng tm thy hm nch v cc xng sn nh trong ngi vai.
3. X TR
3.1. Trong khi c thai
Thai ph phi c khm nh k trong 3 thng cui, khi pht hin ngi vai, cn
khuyn thai ph nm ngh ngi vo thng cui phng i v non, i v sm.
3.2. Trong khi chuyn d
- Thai thng hoc gn thng, cn sng: m ly thai ngay phng v
i sa dy rau, sa tay
- Ni xoay thai ch thc hin nhng thai nh, ngi th hai ca song thai
- Nu thai cht: ngy nay ch yu l m ly thai, ch ct thai trong nhng
trng hp iu kin th thut thun li.
4. PHNG BNH
- Khm thai v qun l thai nghn tt. Khi pht hin ngi vai phi chuyn thai
ph n trung tm sn khoa c th m l thai c
- Khi thai thng nn m ly thai ch ng phng cc bin chng cho
m v cho thai
- Nhng bc s c kinh nghim mi nn m ly thai trong ngi ngang trnh
tai bin gy tay, gy chn thai nhi

88

I V SM, I V NON
1. KHI NIM
- i v sm l i v xy ra sau hoc cng lc vi chuyn d, trc khi c t
cung m ht. V khng c nhiu ngha trn lm sng nn hin nay thut ng ny
khng cn c nhc n trong y vn nc ngoi.
- V i non l v t nhin ca mng i v mng m ti bt k thi im no
trc khi c chuyn d
2. CHN ON I V NON
2.1. Lm sng
- Xc nh tui thai
Xc nh tui thai da vo ngy kinh cui cng nu vng kinh u v sn ph
nh ngy kinh. Da vo siu m chn on tun thai lc 3 thng u vi sn ph
kinh nguyt khng u hay khng nh ngy kinh cui cng.
- Xc nh i v, thi im v thi gian v i. Hi k tin s ra nc m o
t ngt ra nc lng nhiu, long, mu trong hoc ln cn c, thi gian ra nc.
Tin s vim nhim ng sinh dc di. ng kh theo di
- t m vt theo di dch , vim nhim CTC-.
2.2. Cn lm sng : xc nh nc i:
2.2.1. Nghim php Valsalva hoc ho: khi t m vt, cho sn ph rn hoc ho
s quan st thy c nc i chy ra t l trong c t cung.
2.2.2. Nitrazine test:
- Thc hin khi quan st khng thy r c nc i chy ra hay khng khi thc
hin nghim php ni trn.
- t m vt, lau sch m o, cho sn ph rn hoc ho sau dng tm bng
v trng nhng vo dch ng ti cng sau m o ri pht ln giy th Nitrazine.
- pH ca dch m o c tnh acid (pH = 4,4 5,5) khc vi pH nc i mang
tnh kim (pH = 7 7,5). Nu c i v, nc i chy vo m o s lm pH ca dch
m o tr nn kim ha v s lm i mu giy th t mu vng sang mu xanh.

89

- (+) gi trong trng hp c ln mu, tinh dch, Trichomonas, dch nhy c

t cung, cc dung dch st khun c tnh kim v nc tiu.
2.2.3. Chng nghim kt tinh hnh l dng x:
- Dng que nh qut vo ti cng sau m o ri pht ln mt phin knh,
kh ri quan st di knh hin vi.
- S hin din ca hnh nh dng x gip chn on xc nh i v non vi
nhy khong 96%.
- (-) gi (+) gi: pht dch nhy c ngoi hoc c ln tinh dch
2.2.4. Siu m:
- Chn on (+ ) theo di lng i thng qua ch s i thiu i hoc ht i.
- c lng cn nng, xc nh ngi thai, v tr dy rn v nhng bt thng
2.3. Chn on xc nh
Ch cn hi bnh s, khm lm sng, nghim php Valsalva , th nghim
Nitrazine, chng nghim kt tinh l dng x th chn on chnh xc ln n 93,1%
2.4. Chn on phn bit
- Sn tiu: thng th khng ra nc nhiu v cng khng r r lin tc nh
trong v i. Ngoi ra nc tiu c mi khai v c pH acid.
- Kh h: i khi nhiu v long lm d lm vi v i. Phn bit bng cch hi
bnh s k v khm lm sng cn thn.
- Cht nhy c t cung: giai on cui thai k hoc bt u chuyn d, c t
cung h m s tng nt nhy l c t cung ra ngoi: nhy, dai v thng c ln t
mu hng.
3. X TR
3.1. Thai 22 31 tun: c gng dng thai
3.1.1. Thuc trng thnh phi thai: Tim bp Betamethasone 12mg/24 gi x
2 ngy hoc Dexamethasone 6mg/12 gi x 2 ngy.

90

S dng trn 2 t c th gy gim cn nng thai nhi, gim chu vi vng u v

chiu di c th
3.1.2. Qun l nhim khun
- Hn ch thm khm bng tay c th theo di bng khm m vt
- Cy dch c t cung, m o, hu mn
- S dng khng sinh ph rng ngn nga nhim trng cho c m v thai, ngoi
ra cn lm gim t l chuyn d do c khuyn co s dng thng quy trong
trng hp cn ko di thai k khi i v non kch thch trng thnh phi thai.
Hin nay cc nghin cu u ng thun s dng khng sinh khng nn qu
7 ngy, v vic ko di thi gian s dng khng sinh nhng thai k ny l khng
cn thit, m cn lm tng khng thuc ca vi khun
- Theo di m: Ngh ngi, ng bng v sinh sch. Theo di du hiu sinh
tn 4 ln/ngy, cng thc mu, cng thc bch cu, CRP. Cy dch m o1 3
ln/tun.
- Theo di thai: monitor sn khoa 3 ln/ngy. Siu m nh gi thai, rau, nc i
3.1.3. S dng thuc gim co.
3.2. Thai 32 33 tun
3.2.1. Xc nh tnh trng sc khe ca thai nhi ti thi im tip nhn. Theo
di monitor tim thai lc nhp vin. Xc nh thai chm pht trin trong t cung.
3.2.2. Corticoid trng thnh phi thai nhi
3.2.3. Qun l nhim trng. Hn ch thm khm bng tay, nn khm bng m
vt trnh nhim trng. Khng sinh d phng.
3.2.4. Thuc gim co
3.2.5. Khi pht chuyn d khi c bng chng trng thnh phi, nhim
khun, thai suy.
3.3. Thai 34 36 tun
3.3.1. Xc nh tnh trng sc khe ca thai nhi ti thi im tip nhn
3.3.2.Corticoid: khng khuyn co .
3.3.3. Chm dt thai k:

91

Hu ht ngi bnh (90%) s chuyn d t nhin trong vng 24 gi sau khi v i.

Ch chuyn d t nhin hay khi pht chuyn d ty tnh trng i, thai v
nhim khun. Nn t vn vi ngi bnh vic ko di thai k c nguy c nhim
trng t cung v vim mng i, thiu i, nhau bong non, suy thai, thiu sn phi,
bin dng chi. Nu c bng chng trng thnh phi th chm dt thai k ngay.
3.3.4. Nu gi thai qun l nhim trng (tng t nh trn)
3.3.5. Thuc gim co: khng c ch nh i vi thai k > 36 tun
3.4. Thai > 37 tun
- ACOG 2009 khuyn co chm dt thai k i vi thai >37 tun b v i
sm, khng i 12 24 gi nhm gim bin chng cho m v thai. Nn khi pht
chuyn d ngay trong 6 12 gi hoc nu thun li th nn chm dt thai k cng
sm cng tt.
Chm dt thai k ty tnh trng c t cung, ngi thai, tnh trng thai, c nhim
trng hay khng.
+ Ngi bt thng hoc c nhng bng chng cho thy thai nhi khng chu
ni cuc chuyn d m ly thai
+ Nu c bng chng nhim trng trn lm sng v khng c chng ch nh
ng m o, cho khng sinh v khi pht chuyn d ngay lp tc.
+ Khi c t cung thun li gy chuyn d bng truyn oxytocin.
+ Khi c t cung khng thun li lm chn mui c t cung
- phng nhim trng:
+ Chuyn ln tuyn c n v chm sc tr non thng nh cn.
+ Khng sinh thng quy khi i v nhng thai > 37 tun: dng khng sinh
lm gim c ngha t l vim mng i v nhim trng hu sn m nhng khng
hiu qu ci thin kt cc nhim trng chu sinh.
=> Mt s tc gi khuyn co ch s dng khng sinh phng nga tc nhn
streptococcus nhm B nu c bng chng cy (+) tun 35 37 thai k, hoc v
mng i > 18 gi nhng ngi bnh khng c kt qu cy.

92

4. TIN TRIN V BIN CHNG

4.1. Chuyn d t nhin: thai cng non thng cng ko di thi gian tim tng, phn
ln cc thai trng thnh s chuyn d t nhin trong vng 24 gi. 50% trng hp
v i sau 37 tun s t chuyn d trong vng 5 gi.V i tui thai t 32 34 tun
trung bnh 4 ngy sau s chuyn d v 93% trng hp trong vng 1 tun .
4.2. Nguy c cu i v non ko di:
+ Nhim khun i, nhim khun hu sn, suy h hp s sinh, nhim khun s sinh.
+ Thiu i thiu sn phi, bin dng chi, chn p dy rn.
+ Rau bong non, thai cht trong t cung
5. PHNG BNH
- Nhanh chng chuyn thai ph ln tuyn c n v chm sc tr non thng
nh cn.
- S dng khng sinh ng ch nh
- Khi pht chuyn d ng thi im.

93

SUY THAI TRONG T CUNG

1. KHI NIM
Tun hon t cung rau thai m nhim vic cung cp oxy cho thai, nu v
mt nguyn nhn no nh hng n tun hon t cung rau thai lm gim
lu lng mu n h huyt, hoc t gai rau n thai, s lm gim lng oxy n
thai v gy suy thai. Hin tng ny c th xy ra trong qu trnh thai nghn v c
bit l khi chuyn d. Mc thiu oxy nhiu hay t, trng din hay cp tnh, s
nh hng n mc thai suy v dn n t vong.
2. CHN ON
2.1. Suy thai trong thi k c thai
Triu chng:
- Chiu cao t cung pht trin chm (biu hin thai km pht trin)
- Gim c ng thai (t 23 gi tr i c ng thai di 12 ln trong 2 gi) hay
thay i c ng thai
- Nhp tim thai thay i (trn 160 ln/pht hay di 120 ln/pht)
Xt nghim:
- i: nc i c mu xanh (cn soi i nhiu ln)
- Monitor sn khoa, truyn ocytocin hay v nm v c xut hin Dip I, Dip II,
tim thai khng p ng test khng kch
- Siu m xc nh ch s nc i (c gi tr trong thai gi thng).
2.2. Suy thai trong chuyn d
- Nc i c mu xanh (khi v i hoc bm i)
- Nghe nhp tim thai (bng ng g) thay i trn 160 ln/pht hay di 120
ln/pht

94

- Theo di lin tc nhp tim thai bng my monitor sn khoa thy xut hin
nhp tim thai chm mun (DipII) hoc nhp tim thai bin i hoc nhp tim thai dao
ng t di 5 nhp
- Siu m : xc nh lng nc i gim (ch s nc i gim)
- pH mu u thai nhi v mu rn ngay sau
3. TIN TRIN
- Thiu oxy ban u thai cn c p ng b tr: iu chnh s phn b mu
cung cp oxy y cho no, tim, gan; gim cung cp oxy ti rut, da.
- Thiu oxy nhiu hoc ko di, thai khng cn kh nng p ng b tr thiu
oxy no, tim, thiu oxy t chc, chuyn ha nng lng gim trong iu kin
ym kh, pH s gim, thai nhim toan v cht trong t cung, hoc cht sau khi ra.
4. X TR
4.1. Trong khi c thai: khm thai v theo di, c bit nhng thai nhi c nguy c
pht hin suy thai
- Theo di nhp tim thai (ng nghe) sau khi v nm v trong v sau cn co
pht hin nhp tim thay i
- Soi i nhiu ln pht hin nc i xanh
- Th nghim ocytocin hay v nm v theo di bng my monitor sn khoa
nu c.
- Xc nh trng thnh ca thai nh ch thai trong trng hp c ch nh
Siu m: ng knh lng nh (trn 90mm, thai trn 38 tun), ng knh
trung bnh bng (trn 94mm, thai nng trn 2500g), canci ha bnh rau 3, ch
s nc i (nc i gim) trn thai 42 tun.
- Ch s nc i: 28mm thng phi m ly thai, 28-40mm th phi nh ch
thai nghn (gy chuyn d , nu tht bi th m ly thai), 40-60mm theo di st,
trn 60mm l bnh thng

95

4.2. Khi chuyn d

- Pht hin suy thai ly thai ra kp thi . Theo di th trng, bnh l ngi
m, o nhp tim thai 10-15 pht/ln, theo di cn co t cung ph hp vi giai on
chuyn d, nu tng cng , nhp phi dng thuc gim co.
- Theo di nhp tim thai lin tc bng my monitor sn khoa pht hin
DipII, Dip bin i, nhp tim thai dao ng it hn 5 nhp. Nu c Dip II, Dip bin
i, tim thai dao ng t iu kin th ch nh lm Forceps, khng iu kin
lm Forceps th m ly thai.
- o lng nc i cc trng hp thai nghn qu ngy sinh, lng nc i
gim, c phn su snh c th nn m ly thai, khng nn th thch ng di.

96

TC MCH I
1. KHI NIM
- Tc mch i l mt bin chng sn khoa rt nguy him, t l t vong cao,
khng th on trc v khng th d phng c.
- Tc mch i l do nc i, t bo ca thai nhi, cht gy, tc, lng t hoc cc
mnh m khc lt vo tun hon ca ngi m, gy ra suy h hp v suy tun hon
cp tnh.
- Yu t nguy c:
+ Sn ph trn 35 tui, con r nguy c cao hn con so.
+ M ly thai, c can thip th thut Forcep, gic ht, chc i.
+ a i, a thai, rau tin o, rau bong non, sn git....
+Tn thng t cung hoc c t cung.
- Thi im tc mch i: rt khc nhau 12% s trng hp xy ra tc mch i
khi mng i cn nguyn, 70% xy ra trong chuyn d, 11% xy ra sau qua
ng m o. 19% xy ra trong m ly thai khi c chuyn d hay khi cha c
chuyn d.
2. CHN ON
2.1. Hnh nh lm sng c trng:
Xut hin t ngt vi cc du hiu theo trnh t thi gian. Khi u l suy h
hp, tm ti xy ra t ngt trong vi pht v tip n l tt huyt p, ph phi,
chong, biu hin thn kinh nh: l ln, mt thc v co git. Trn 80% s trng
hp ngi bnh c biu hin ngng tim, ngng th trong vi pht u tin. C n
50% s trng hp t vong ngay trong gi u xut hin triu chng.
Nu ngi bnh thot qua c giai on ny (khong 40% s trng hp) s
c biu hin chy mu d di nhiu ni do t cung (nu sau ) v do ng mu
ri rc trong lng mch. Chy mu t t cung khng th cm c. S trng hp
c biu hin ph phi giai on ny cng cao.

97

2.2. Tiu chun chn on:

Hi sn ph khoa Hoa K v Anh khuyn co 4 tiu chun chn on tc
mch i nh sau (phi ng thi c c 4 tiu chun): tt huyt p hay ngng tim.
Thiu xy cp tnh. Bnh l ng mu hay chy mu nng m khng c cc l gii
khc. Tt c xy ra trong chuyn d, m ly thai hay trong vng 30 pht sau m
khng c cc l gii khc cho cc du hiu ny.
2.3. Cn lm sng: xt nghim kh trong mu; cng thc mu; ng mu. X quang
phi: thng khng thy du hiu c hiu, c th c du hiu ph phi. in tm
: c th thy nhp tim nhanh, phn ST v sng T thay i.
2.4. Chn on phn bit: chn on phn bit vi rt nhiu hi chng khc: tc
mch do huyt khi, tc mch do kh, chong nhim khun, nhi mu c tim cp
tnh, chong phn v do cc nguyn nhn khc nhau, rau bong non hay phn ng
ca gy t vng.
2.5. Chn on xc nh: da vo kt qu m t thi tm thy t bo ca thai v
thnh phn nc i trong ng mch phi m.
3. X TR
- Duy tr cung cp oxy cho sn ph (t ni kh qun, th my).
- t hn 2 ng truyn tnh mch, nng huyt p bng dung dch cao phn t.
- Hi sc tim nu ngng tim: Adrnaline tim tnh mch 1 mg, hoc qua
ng ni kh qun 3 mg, hoc Xylocaine 1 mg/kg tim tnh mch chm (trong 2
pht). C th tim nhc li sau mi 3 5 pht. Tuy nhin, liu tng cng ca
xylocaine khng c qu 3 mg/kg.
- Lm cc xt nghim cp cu: kh trong mu, cng thc mu, ng mu
- Theo di bng monitor.
- Truyn mu v cc ch phm ca mu nu kt qu ng mu khng tt km
chy mu d di: truyn mu ton phn hay khi hng cu v huyt tng,
Tuy nhin trn y ch l nhng x tr triu chng nhm hi phc du hiu
sinh tn ca ngi bnh, khng x l c cn nguyn.V tai bin ny hay xy ra
t ngt v tin trin nhanh nn hu ht ngi bnh u t vong. Nu thai cha x

98

th hu ht thai nhi khng c cu kp, ngi ta c th m ngay cu thai nhng

tnh may ri cng rt ln.
4. HU QU V BIN CHNG:
4.1. T vong m, con.
4.2. Hu qu v tinh thn v vn ng cho m v con do thiu oxy no.
4.3. Hi chng Sheehan: chy mu nng c th dn ti hoi t mt phn hoc
ton b thy trc tuyn yn gy suy tuyn yn, biu hin bng du hiu v kinh,
rng lng, rng tc, suy tuyn gip, suy tuyn thng thn, mt sa.
4.4. Bin chng khc: s mt mu nhiu gy nh hng ti sc khe v tinh thn
ca sn ph, c th gy suy gan, suy thn, suy a tng, ri lon ng mu v d
nhim khun hu sn. Bn cnh vic truyn mu iu tr chy mu sau lm
tng cc nguy c v bin chng ca truyn mu.
5. PHNG BNH
Khng d phng c do ngi ta vn khng hiu ti sao nc i vo tun
hon ch xy ra mt s t ngi m khng xy ra nhiu ngi khc cng nh
khng bit vai tr ca mc , s lng mnh m thai, loi mnh m thai (c cha
km theo phn su hay khng) hay mt s yu t no ca ngi m nn tc mch
i ch mt t l rt nh ph n.

99

V T CUNG
1. KHI NIM
V t cung l mt trong cc tai bin sn khoa c th gy t vong m v thai
nhi. Hin nay nh tin b ca khoa hc trong lnh vc gy m hi sc cng nh
trnh chuyn khoa sn c nng cao cng vic m rng mng li qun l thai
nghn, hn ch cc th thut th bo, ch nh m ly thai kp thi nn t l v t
cung gim i nhiu.V t cung c th xy ra trong thi k mang thai, nhng
thng xy ra trong giai on chuyn d.
2. CHN ON
2.1. V t cung trong thi k thai nghn: thng t gp
2.1.1. Triu chng c nng: c th xy ra bt k tui thai no. au chi vng
h v t ngt (t nhin hoc sau chn thng vng bng).
2.1.2. Triu chng ton thn:
- Chong nh hay nng ty theo mc mt mu.
2.1.3. Triu chng thc th:
- T cung: c im au chi vng vt m c hoc s thy mt ranh gii t
cung bnh thng. C th thai nm trong bng. Khng cn hot ng tim thai.
- m o ra mu , ngi thai thay i c bit trng hp thai vo trong
bng. nc i c mu .n au vng vt m,
2.1.4. Triu chng cn lm sng:
- Siu m: thai nm trong bng, khng thy hot ng tim thai.
- Cng thc mu: hng cu gim, hemoglobin gim, hematocrit gim.
2.2. V t cung trong thi k chuyn d:
2.2.1. Da v t cung.
- Sn ph au nhiu do cn co t cung mau, mnh.
- T cung co tht hnh qu bu nm.
- Vng Bandl (ch tht thnh vng gia on di v thn t cung) ln cao.
Thn t cung b y ln cao th s thy 2 dy chng trn b ko di( du hiu Frommel)

100

- Thai suy: tim thai nhanh, hoc chm, hoc khng u.

- Thm m o: thy nguyn nhn kh (bt tng xng thai- khung chu,
ngi bt thng, u tin o,).
2.2.2. V t cung: chn on da vo cc triu chng sau:
- Triu chng lm sng:
+ C triu chng ca da v t cung, tr trng hp c so m c t
cung.
+ Thai ph ang au d di, sau mt cn au chi t ngt, ri bt au dn.
+ Thng c du hiu chong: mt ti nht, v m hi, mch nhanh, huyt p
tt v ngt i.
+ T cung khng cn hnh dng bnh thng, khng cn du hiu vng Bandl
+ Bng chng, nn au.
+ S thy phn thai di da bng
+ Mt cn co t cung .
+ Tim thai khng cn hot ng.
+ Ra mu m o.
- Khm trong: khng xc nh c ngi thai.
+ C th thy nc tiu c mu
+ Nhiu khi chy mu sau , kim tra pht hin v t cung.
- Triu chng cn ln sng:
+ Siu m c th thy thai nm trong bng, khng thy hot ng tim thai,
thy t thng t cung, dch trong bng
+ Xt nghim cng thc mu: thiu mu
- Cc hnh thi lm sng
+ V t cung hon ton: t cung b tn thng ton b cc lp t nim mc,
n c t cung v phc mc. Thng thai v rau b y vo trong bng.
+ V t cung di phc mc: t cung b tn thng lp nim mc v c, lp
phc mc cn nguyn vn. Thai v rau vn nm trong t cung.

101

+ V t cung phc tp: v t cung hon ton km theo tn thng tng xung
quang nh bng quang, niu qun, mch mu, i- trc trng,
+ V t cung ngi c so m c: thng vt m b nt mt phn, t chy
mu. Nhiu khi ch chn on c khi m ly thai hoc khi kim sot t cung.
- Chn on phn bit vi rau tin o, rau bong non.
3. X TR:
3.1. Nguyn tc:
- Gi gip , huy ng nhng phu thut vin c kinh nghim tham gia phu
thut cho ngi bnh.
- Hi sc ni khoa song song vi x tr sn khoa.
- Phu thut cp cu. Nu ti c s khng c kh nng phu thut th phi
nhanh chng chuyn tuyn hay mi tuyn trn xung gip .
3.2. X tr c th:
3.2.1. Da v t cung:
- X tr ngay bng thuc gim co t cung v ly thai.
- Nu iu kin th ly thai ng di bng Forceps, nu khng iu
kin th m ly thai.
3.2.2. V t cung:
Hi sc ni khoa:
- nh gi v theo di cc du hiu sinh tn: mch, huyt p, nhp th.
- Cho sn ph nm u thp, m, th oxy.
- Lp ng truyn tnh mch, b khi lng tun hon bng truyn dch ng
trng Ringer lactat, Natrichlorua 0,9%; dung dch cao phn t nh Gelafuldin,
Heasteril; truyn mu v cc ch phm ca mu. Lng dch, mu truyn v tc
truyn ph thuc tnh trng sn ph v lng mu mt.
- Khng sinh liu cao.
- Thng tiu v theo di lng nc tiu.
Phu thut:
- M ly thai nu khng iu kin ly thai ng m o.

102

- Ty tn thng t cung v nguyn vng sinh ca sn ph m quyt nh

ct t cung hay bo tn t cung.
- Ch bo tn t cung khi iu kin cho php: ngi bnh tr tui mun cn
sinh , vt rch mi, gn khng nham nh.
- Phu thut ct t cung bn phn hoc hon ton. Nu c tn thng c t
cung th nn ct t cung hon ton.
- Kim tra k cc tng lin quan, nht l niu qun v bng quang x tr cc
tn thng kp thi trnh b st.
4. BIN CHNG
4.1. T vong m v thai: nu khng c x tr kp thi, nht l v t cung xy ra
cc tuyn khng c kh nng phu thut.
4.2 Ct t cung: t l ct t cung cao nhng trng hp v t cung
4.3. Tn thng tng: c th tn thng bng quang, niu qun, mch h v, i trc trng khi v t cung v trong khi phu thut x tr v t cung.
5. PHNG BNH:
- Qun l thai nghn, pht hin cc trng hp thai nghn c nguy c cao
chy mu sau nh nhiu ln, c vt m t cung, bt tng xng thaikhung chu,
- S dng thuc tng co t cung ng ch nh v liu lng.
- Thc hin cc phu thut, th thut sn khoa ng ch nh, iu kin v
ng k thut.

103

CHY MU SAU
1. KHI NIM
Chy mu sau l tai bin sn khoa thng gp nht v l nguyn nhn t
vong m hng u. Chy mu sau l chy mu sau khi s thai trn 500ml hoc c
nh hng xu n ton trng ca sn ph.
Chy mu sau c th xy ra sm trong vng 24 gi sau hoc xy ra
mun n 6 tun ca thi k hu sn.
2. CHN ON
2.1. Lm sng:
- Chy mu ra ngoi m o: chy mu nhiu, c khi chy t thnh tia
ti hoc ln mu cc; nhiu khi chy mu r r lin tc lm cho nhn vin y t
khng nh gi c lng mu mt nu khng o lng mu sau thng quy
v khng theo di st sau .
- T cung: trong cc trng hp mu chy t t cung ra ta thy t cung to, mt
mm; xoa nn t cung s thy mu ti ln mu cc chy nhiu ra ngoi m o.
- Ton thn: biu hin tnh trng thiu mu cp tnh nh da xanh, nim mc
nht; nhng trng hp mt mu nng c biu hin sc nh mch nhanh, huyt
p tt, v m hi, tay chn lnh, thiu niu, tinh thn ht hong, l m, c khi
hn m
- Ty theo nguyn nhn m c cc triu chng thc th khc nhau.
2.2. Cn lm sng:
Cc xt nghim cn lm l s lng hng cu, hemoglobin, hematocrit
nh gi tnh trng mt mu; xt nghim tiu cu, fibrinogene, prothrombin nh
gi tnh trng ri lon ng mu; v xt nghim nhm mu truyn mu.
3. X TR
3.1. Nguyn tc:
- Hi sc ni khoa song song vi x tr sn khoa.
- Tm nguyn nhn sn khoa v x tr theo nguyn nhn.

104

3.2. X tr c th:
3.2.1. Hi sc ni khoa:
- nh gi v theo di cc du hiu sinh tn: mch, huyt p, nhp th.
- Cho sn ph nm u thp, m, th oxy.
- Lp ng truyn tnh mch, b khi lng tun hon bng truyn dch ng
trng ringer lactat, natrichlorua 0,9%; dung dch cao phn t nh gelafuldin,
heasteril; truyn mu v cc ch phm ca mu. Lng dch, mu truyn v tc
truyn ph thuc tnh trng sn ph v lng mu mt.
- Thng tiu v theo di lng nc tiu.
3.2.2. X tr sn khoa: xc nh nguyn nhn v x tr theo nguyn nhn.
Rau cha bong:
- Nguyn nhn l rau bm cht, rau cm t hoc rau ci rng lc.
- Bc rau nhn to v kim sot t cung sau khi hi sc v gim au cho
sn ph.
- Dng thuc co bp t cung sau khi kim sot t cung: oxytocin, ergometrin,
duratocin hoc misoprostol. Khng sinh d phng nhim khun.
- Trong qu trnh bc rau c th chn on xc nh rau ci rng lc. Nu rau
ci rng lc hon ton th tin hnh ct t cung ngay. Nu rau ci rng lc bn
phn th ty mc gai rau m xuyn vo lp c t cung nhiu hay t m x tr:
bo tn t cung nu c th bc c hon ton bnh rau bng tay, nu khng bc
rau c phi ct t cung cm mu.
Rau bong:
- Nguyn nhn l t cung, st rau, chn thng ng sinh dc, ln t cung
hoc ri lon ng mu.
- Kim sot t cung sau khi gim au cho sn ph: ly ht rau, mng rau v
mu cc trong bung t cung; kim tra s ton vn ca t cung.
- Dng thuc tng co t cung v khng sinh.
- p t cung bng 2 tay v xoa bp t cung nu t cung.

105

- Kim tra c t cung v m o. Khu cc vt rch c t cung v m o. Nu

c khi mu t ng sinh dc gy chy mu th phi ly khi mu t v khu
cm mu.
- Nu chn on ln t cung th cn gim au tt cho sn ph (gy m nu
cn) ri nn li t cung v tim ergometrin lm t cung co bp cht li sau mi
rt tay ra.
Phu thut x tr chy mu sau :
- Ct t cung: ch nh ct t cung hay bo tn t cung ty thuc vo tn
thng t cung ( t cung khng hi phc, v t cung, rau ci rng lc, chy
mu ti v tr rau tin o) v nhu cu sinh ca sn ph.
- Tht ng mch t cung.
- Tht ng mch h v.
- Khu mi B-lynch.
Vi cc trng hp chy mu sau mun:
- Nu st rau, polyp rau: no bung t cung kt hp vi thuc co bp t cung
v khng sinh chng nhim khun.
- Nt ng mch t cung nu c ch nh.
4. HU QU V BIN CHNG:
4.1. Phi ct t cung: do khng cm mu c trong m hoc rau ci rng lc.
4.2. T vong m: l nguyn nhn hng u gy t vong m, nht l cc nc
ang pht trin.
4.3. Tn thng tng: c th tn thng bng quang, niu qun, mch h v, itrc trng trong khi m x tr chy mu sau .
4.4. Hi chng Sheehan: chy mu nng c th dn ti hoi t mt phn hoc ton
b thy trc tuyn yn gy suy tuyn yn, biu hin bng du hiu v kinh, rng
lng, rng tc, suy tuyn gip, suy tuyn thng thn, mt sa.
4.5. Bin chng khc: s mt mu nhiu gy nh hng ti sc khe v tinh thn
ca sn ph, c th gy suy gan, suy thn, suy a tng, ri lon ng mu v d

106

nhim khun hu sn. Bn cnh vic truyn mu iu tr chy mu sau lm

tng cc nguy c v bin chng ca truyn mu.
5. PHNG BNH:
- Qun l thai nghn, pht hin cc trng hp thai nghn c nguy c cao chy
mu sau nh nhiu ln, c vt m t cung,
- S dng thuc tng co t cung ng ch nh v liu lng.
- Thc hin cc phu thut, th thut sn khoa ng ch nh, iu kin v
ng k thut.
- X tr tch cc giai on 3 ca chuyn d.

107

NHIM KHUN HU SN
1. KHI NIM
Nhim khun hu sn l cc nhim khun xut pht t b phn sinh dc trong
thi k hu sn, ng vo ca vi khun t b phn sinh dc theo ng mu,
nhim khun ngc dng t m o, c t cung qua tn thng ng sinh dc
trong v sau .
2. CC HNH THI LM SNG
2.1. Nhim khun tng sinh mn, m h, m o
- y l hnh thi nh nht. Do rch hoc khng ct tng sinh mn m
khng khu hoc khu khng ng k thut, khng m bo v khun, st gc
trong m o.
- Triu chng: st nh 380C 38,50C, vt khu tng sinh mn sng ty, au,
trng hp nng c m. T cung co hi bnh thng, sn dch khng hi
- Tin trin tt nu iu tr kp thi
- iu tr:
+ Ct ch tng sinh mn nu vt khu ty c m. V sinh ti ch hng ngy
bng oxy gi (vt khu c m), hoc Betadin
+ Khng sinh (ung hoc tim)
2.2. Vim nim mc t cung:
- y l hnh thi hay gp, nu khng iu tr kp thi c th dn n cc bin
chng khc nng hn nh: vim t cung ton b, vim phc mc ton b, nhim
khun mu.
- Nguyn nhn: do st rau, st mng, nhim khun i, chuyn d ko di, th
thut bc rau, kim sot t cung khng m bo v khun.
- Triu chng:
+ St xut hin sau 2- 3 ngy. Mch nhanh >100 ln/ pht, ngi mt mi
+ Sn dch hi, c th ln m. T cung co hi chm
+ Cy sn dch tm nguyn nhn v khng sinh .

108

+ No ht bung t cung gi gii phu bnh

- iu tr
+ Khng sinh ton thn (tim), theo khng sinh + thuc co t cung
+ Ht st kim tra bung t cung bng dng c v m bo khng cn st rau.
2.3. Vim c t cung
- Hnh thi ny him gp, nhim khun ton b c t cung, nhng m trong
lp c t cung, thng xy ra sau vim ni mc t cung hoc b sn dch.
- B sn dch l hnh thi trung gian. Triu chng ging nh vim ni mc t
cung nhng khc l khng thy sn dch hoc c rt t. Tin lng ph thuc vo
chn on v iu tr. Bin chng c th l vim phc mc v nhim trng mu.
- Triu chng:
+ St cao 390C 40oC, biu hin nhim trng nng
+ Sn dch ln mu, hi hoc thi.
+ T cung to, mm, n au.
- iu tr
+ Cy sn dch, cy mu (lm khng sinh )
+ Khng sinh ph rng (tt nht theo khng sinh ), phi hp 2-3 loi.
+ Nng cao th trng, b nc in gii, truyn mu (nu cn thit).
+ Ct t cung.
2.4. Vim dy chng rng v phn ph
T nhim khun t cung c th lan sang cc dy chng (c bit l dy
chng rng) v cc phn ph nh vi trng, bung trng
- Triu chng: xut hin mun sau 8 - 10 ngy.
+ Nhim trng ton thn, ngi mt mi, st cao.
+ Sn dch hi, t cung co hi chm
+ Thm m o thy khi rn au, b khng r, t di ng. Nu l vim dy
chng rng phn trn hoc vim phn ph th khi u cao, nu l vim y ca
dy chng rng, nn v phi hp thm m o s thy khi vim thp, ngay ti

109

cng, c khi khi vim dnh lin vi ti cng, di ng hn ch. Kh phn bit vi
m qunh rut tha.
- Tin trin: c th khi nu iu tr kp thi, bin chng thnh vim phc mc tiu
khung khi m (u mm, nhit dao ng). Nu m v vo bng gy ra vim phc
mc ton th. Nu khi m thp c th v vo bng quang, trc trng, m o.
- iu tr
+ Ngh ngi, chm lnh, gim au, chng vim
+ Khng sinh ph rng (da vo khng sinh ), phi hp trong 2 tun
+ Dn lu qua ng cng nu abces Douglas
+ Ct t cung trong trng hp nng
2.5. Vim phc mc (VPM) tiu khung:
- VPM th pht l hnh thi nhim khun lan t t cung, dy chng rng, phn
ph, y chu
- VPM nguyn pht l nhim khun t t cung c th khng qua cc b phn
khc m i theo ng bch mch hoc lan trc tip n mt sau phc mc, lan n
ti cng sau, rut, bng quang lan n u s hnh thnh gi mc v phc mc s
dnh vo nhau ti , phn ng sinh ra cc ti dch, cht dch c th l mt cht
dch trong (th nh), cht dch c th c ln m hoc mu (th nng).
- Tin trin c th khi hoc li di chng dnh nu l th nh; tin trin v
khi m vo m o, bng quang, trc trng nu th nng. Nu m v vo bng
s gy vim phc mc ton b.
- Triu chng: 3 -15 ngy sau , sau cc hnh thi khc ca nhim khun hu sn
+ St cao 390C 400C, rt run, mch nhanh. Nhim trng, nhim c nng.
+ au h v, tiu tin but, rt, c hi chng gi l
+ T cung to, n au, di ng km, ti cng au khi khm
- iu tr
+ Ni khoa: nng cao th rng, khng sinh ph rng, phi hp 2 3 loi .
+ Ngoi khoa: ch m khi c bin chng, hoc dn lu m qua ti cng sau

110

2.6. Vim phc mc ton th

- C 2 th: VPM nguyn pht v VPM th pht
- Nguyn nhn:
+ Trong m ly thai do khng m bo v khun, khu t cung khng tt, st
rau, tn thng rut, bng quang. St gc trong bng.
+ Nhim khun i
+ V t cung km theo tn thng bng quang, thng t cung do no ht thai,
c bit do ph thai phm php khng pht hin thng t cung
+ C th l bin chng ca cc hnh thi nhim khun nh: vim t cung ton
b, vim dy chng phn ph c m, vim phc mc tiu khung iu tr khng tt
- Triu chng VPM nguyn pht: sm 3-4 ngy sau m , sau no thng t
cung. Mun 7 10 ngy sau thng trc c nhng du hiu ca cc hnh
thi nhim khun b phn sinh dc giai on thnh m. M v vo bng nn c
cc du hiu vim phc mc mt cch t ngt.
+ St cao 390C 400C, rt run, mch nhanh nh. Nhim trng, nhim c
+ Nn v bun nn. Bng chng, cm ng phc mc.
+ C t cung h m, t cung to n au, ti cng y au.
- Triu chng VPM th pht: kh chn on v triu chng rm r ca nhim
khun mu che lp cc triu chng VPM ton b. Triu chng ton thn: st cao
400C, mch nhanh, kh th, nn, mt hc hc, bng hi chng, au t, khng c
phn ng thnh bng, g c vng thp. Thm m o cc cng au.
- Cn lm sng: cng thc mu: bch cu tng, Hematocrit cao, thiu mu tn
huyt. CRP tng. Ri lon in gii v toan chuyn ha, ri lon chc nng gan thn.
+ Cy sn dch, cy mu (lm khng sinh )
+ Siu m: bng c dch, cc quai rut gin.
+ XQ bng khng chun b: tiu khung m, mc nc, hi
- Chn on phn bit:
+ Gi vim phc mc sau : th trng bnh thng, khng st, tuy bng
chng v b trung i tin. Khng c ch nh phu thut, iu tr ni khoa: t

111

sonde d dy ht dch, t sonde hu mn cho huyt thanh mn u trng v

prostigmin
+ Vim phc mc tiu khung: au h v, c khi mm, gianh gii khng r,
th trng t thay i. iu tr ni khoa: ngh ngi, chm lnh, khng sinh, theo di
st pht hin bin chng vim phc mc ton th
- Tin lng:
+ Tt: nu c chn on sm v iu tr kp thi.
+ Xu: khi chn on mun v thng li di chng dnh, tc rut c th t vong
- iu tr
+ Ni khoa: nng cao th trng, bi ph nc in gii, khng sinh liu cao,
ph rng, phi hp
+ Ngoi khoa: phu thut ct t cung , ra bng v n lu.
7. NHIM KHUN HUYT
- Hnh thi nng nht. C th li nhiu di chng thm ch t vong.
- Nguyn nhn: thm khm v th thut khng v khun. iu tr khng ng.
Hay gp trong ph thai to v thng, t gp trong ph thai nh v m ly thai
- Triu chng: sau can thip th thut t 24 n 48 h
+ Hi chng nhim c nng. Hi chng thiu mu. Du hiu chong nhim
c HA tt, ri lon vn mch v tnh trng toan mu
+ Sn dch hi bn. C t cung h m, t cung to mm n au
+ C th xut hin nhim khun cc c quan khc (phi, gan, thn)
+ Cn lm sng: cng thc mu, bch cu tng, CRP tng, chc nng gan,
thn suy gim, Ri lan cc yu t ng mu. Cy mu, cy sn dch (+)
- iu tr
+ Ni khoa:hi sc chng chong, khng sinh ph rng, phi hp (da vo
khng sinh ), ko di.
+ Ngoi khoa: ct t cung (sau iu tr khng sinh ti thiu 6 - 24 gi), dn
lu bng.

112

2.8. Vim tc tnh mch:

Vim tc tnh mch t gp Vit Nam, hay gp cc nc Ty u trong
nhng trng hp sau m hoc sau
Nguyn nhn: chuyn d ko di, kh, chy mu nhiu, nhiu ln, ln tui
- Mu chy chm trong h tnh mch, khng lu thng d dng t di ln trn.
- Mu d ng do tng sinh si huyt, tng s lng tiu cu.
- Do yu t thn kinh giao cm ca h tnh mch chi di hoc bng
Triu chng:
- Thng xy ra mun ngy th 12 -15 sau , st nh, mch tng
- Tc tnh mch chn hay gp: ph trng, n au, cng, nng t i tr xung,
gt chn khng nhc c khi ging.
- Tc ng mch phi: kh th t ngt, au tc ngc, khc ra mu
- Tc mch mc treo: au bng t ngt, d di, ri lon tiu ha
- Cn lm sng: cng thc mu (ch tiu cu), CRP, cc yu t ng mu,
Siu m Doppler mch, chp mch.
iu tr:
- Tc tnh mch chn: bt ng chn 3 tun sau khi ht st, khng sinh, chng
ng (Lovenox, Fraxiparin), theo di yu t ng mu v tiu cu 1ln/1 tun
- Tc mch cc c quan khc: x tr theo tng chuyn khoa
3. D PHNG
- m bo iu kin v khun khi , khi thm khm, cc th thut, phu
thut. m bo khng st rau trong t cung, x tr tt cc tn thng ng sinh
dc khi .
- Pht hin sm v iu tr tch cc cc trng hp nhim khun ng sinh
dc trc trong v sau .

113

CHNG 2: PH KHOA
P XE V
l. KHI NIM
Bin chng nng n nht, hu qu ca vim ng dn sa khng c iu tr
tt. Tc tia sa, vim ha m to nn nhng m ti v
Thng gp sau , ang cho con b (t l 2-3%).
2. CHN ON
- St cao 40 , rt run
- V sng nng au, khi nm thy cc nhn mn, cm gic c cha dch
n lm. Hch nch n au, vt sa ln ming bng thy c mnh nh vng nht( c
m trong sa).
- Siu m: nhiu cha dch, CTM bch cu trung tnh tng, CRP dng tnh.
- Chc d c m, cy vi khun lm khng sinh .
Chn on phn bit: Tuyn v ph, hin tng li ging (xut hin nhiu v
theo ng nch trc).
Ung th v: nu nghi ng lm sinh thit t bo hc, khm chuyn khoa.
3. IU TR
- Ngh ngi, khng cho b bn tn thng, vt b sa.
- Khng sinh (Rovamyxin 500mg x 2v / ngy trong 15 ngy, phi hp cc
thuc chng vim). Thuc dit nm cho c m v con.
- Gim au paracetamol 500mg/ln. ti a 3g trong 24g
- Vt l tr liu: xoa bp, chm nng.
- Chch p- xe, dn lu, ch ph v cc m. ng rch theo hnh nan hoa
khng chm vo qung v, khng tn thng ng dn sa, rng dn lu m,
ra vt chch bng oxy gi, thuc st khun betadin, t meches dn lu, thay bng
hng ngy, n khi ht m.
- Khuyn khch m tip tc cho con b ngay trong khi c m

114

4. TIN TRIN V TIN LNG

- D sa: do tn thng ng dn sa. Chm sc ti ch t lin, cai sa.
- Ht sa do tc tia sa, khng cho con b.
- Lot v, u v: h v , tip xc vi nh nng mt tri, v sinh v bi cc
m c cha vitamin A, E, bi dung dich eosin 1%, glyxerin borat
- ap xe tn d, ti pht.
- Vim x tuyn v, ung th v.
5. D PHNG
- Cho b sm v b ht sa c 2 v, khng ht phi ht ht sa trnh ng sa
v kch thch to sa mi.
- Phng php lm bt cng au v: dng gc m p ln v trc khi cho b,
xoa bp c v lng ngi m, ngi m nn t sa trc khi cho b v lm t u
v gip tr b d dng hn. Sau khi cho b phi nng v bng mt bng ngc,
dng gc lnh p ln v gia nhng ln cho b, dng thuc gim au nu cn thit.
- Cai sa: gim dn cho b, ung t nc, mc o con cht. Thuc gim au
(Paracetamon 4v/ ngy trong 3 ngy),
Parlodel 2,5mg 2v/ ngy ti thiu 5 ngy, ti a 20 ngy.
Estradiol 2mg 2v/ngy x 3 ngy

115

CC TN THNG V
1. KHI NIM
V l t chc m thnh phn chnh l cc t chc tuyn v m m, trong
t chc tuyn gm cc tuyn tit sa v cc ng tuyn dn sa, pht trin rt mnh
trong thi gian mang thai v nui con,
Bt k s thay i no ca cc t chc v u c th gy ra cc khi u ti v,
nu nh tui sinh , nht l khi nui con th khi u thng gp nht l p - xe
ca tuyn v ng dn sa, nhng n tui quanh mn kinh v mn kinh th do s
thiu ht ca cc hormone bung trng cng dn n mt s triu chng bt thng
nh au tc vng v, mt tuyn v khng ng nht do hin tng lon dng
ca t chc v v c bit ngi ph n cm nhn thy r rng l s teo gim v
kch thc cng mt , tnh chun gin ca v.
Cc bnh v v nu c pht hin sm v iu tr sm th tin lng thng tt.
2. CHN ON V X TR KHI U V LNH TNH:
2.1. Bnh x nang tuyn v:
L khi u khu tr do x ho tuyn v qu sn biu m tuyn v hnh thnh
nang xy ra khi mt cn bng ni tit estrogen, progesterone, prolactin.
S thy cc khi mm, ranh gii khng r xut hin na sau chu k kinh,
gp na ngoi v hoc c th c 2 bn v. Gy au hoc cm gic cng, trong
nhiu trng hp th cm gic ny xut hin r hn khi sp n ngy hnh kinh,
v thi im ny s thy khi u c th to ra v khin cho v c th mt cn
xng. Tuy nhin cng c mt s ph n c cm gic cng, au khng lin quan
vi chu k kinh.
Triu chng au v, tng kch thc v v c nhiu khi x nang cn phi
phn bit vi cc khi nhn x lnh tnh hoc tn thng ca ung th v.
Chn on chnh xc da vo sinh thit lm gii phu bnh. iu tr bng
thuc m ch yu l progesterone dng bi, ung hay dn da nhm cn bng li
ni tit. i khi c th dng thm khng sinh v cc thuc gim au.

116

2.2. Nhn x v: bnh l lnh tnh thng gp cc ph n tr , trong khong 20

nm u sau dy th, nhiu nhn c th gp mt bn hay c 2 bn v (chim 10
15%). Trn lm sng mt nhn x v in hnh thng l mt khi trn u, cng
chc, ranh gii r, di ng, nn khng au, kch thc thay i t 15 cm. Pht
hin nhn x v kh d dng v thng do t pht hin thy mt cch ngu nhin,
tuy nhin i vi nhng ph n trn 30 tui th cn phn bit vi nang v (siu m
hay chc ht) hoc vi ung th v . Nhn x v thng khng xut hin sau mn
kinh, tuy nhin nhng ph n mn kinh c s dng thuc ni tit b sung vn c th
thy xut hin nhn x. Bc nhn x rch da theo hnh nan hoa hoc theo vng
qung v hoc cc v tr c th che c vt so, ch khng ct vo cc tuyn v
v nhn x thng c ranh gii r, d bc.
2.3. Cystosarcoma phyllodes: l loi nhn x v vi cc t bo m m pht trin
rt nhanh, to thnh mt khi u rt to, cng chc, thm ch chim ton b v. Bnh
thng lnh tnh nhng cng c mt t l nh c tnh. Phu thut ly b ton b
khi u v vng t chc lnh xung quanh khi u phng nga ti pht.
2.4. Bnh nang v:
Thng lin quan n ni tit.
Nang l nhng khi ring r, ranh gii r, di ng, mt cng. Kch thc
nang to nh khc nhau, thng c nhiu nang mt hay c hai v, khi siu m s
thy cc vng gim m ng nht, ranh gii r, v mng.
Chc ht dch nang c mu vng xanh hoc nu. Nu nhiu nang nh c th
khng cn can thip.
2.5. Hoi t t chc m:
L bnh l lnh tnh him gp, thng gp sau chn thng hoc sau sinh
thit. Khm c khi cng, thng i km vi co ko da hay nm v (phi sinh thit
loi tr ung th v). Cm gic cng au c th xut hin hoc khng. Khi u c
th t mt m khng cn iu tr.

117

2.6. Absces v:
Trong giai on mang thai hay cho con b c th xut hin vng ty , cng
au, khng cng. l hin tng absces do nhim khun ngc vo cc ng,
tuyn v ri lan to ra xung quanh.
Giai on u ca vim c th vn cho con b v ng thi iu tr khng sinh.
Giai on mun, khi vim c th ho m khu tr ti ch thnh khi, au v
n lm, i khi c th t v khi m. Trong cc trng hp ny cn m thng khi
m v dn lu (thng bng gc chn vo va cm mu va dn lu).
t gp hn l cc khi absces vng di qung v thng gp cc ph n tr
hay trung nin khng cho con b. Cc trng hp ny ngoi vic chch dn lu cn
phi lm gii phu bnh t chc cng.
2.7. Tit dch nm v: phn ln cc trng hp tit dch v bt thng thng lin
quan vi u nh (papilloma) ng tuyn v, x nang gy gin ng tuyn, hoc ung th
v. chn on nguyn nhn cn phi hi bnh v thm khm theo cc bc sau:
- Tnh cht dch tit: dch trong, hay mu hay g khc
- i km theo khi u hay khng
- Mt hay hai bn
- Tit dch mt hay nhiu ng.
- Tit dch t nhin, lin tc hay t qung, hay phi bp mi chy ra
- Dch chy ra khi n vo mt v tr hay phi p ton b v
- Lin quan vi kinh hay khng
- Tin mn kinh hay mn kinh
- Tin s c dng thuc trnh thai ung hay s dng estrogen thay th nhng
ph n mn kinh.
Tit dch trong hay c ln mu thng gp cc trng hp u nh ng tuyn,
t gp hn l do ung th ng tuyn v.
Tit dch mu phi ngh ti ung th tuyn v, nhng thng l do u nh ng
tuyn v. Xt nghim t bo dch tuyn v cho php xc nh c phi c tnh hay
khng, tuy nhin d c m tnh th cng khng loi tr c tnh nhng ph n trn 50

118

tui. Trong trng hp ny, nui km vi khi u th nn c ct b dng hnh chp

bng cch tim cht ch th mu nh xanh methylen xc nh vng nh ct b.
tui cha mn kinh th tit dch v nhiu u ng tuyn v mt hay
c hai bn, tng ln r khi sp hnh kinh, thng do x nang tuyn v. Sinh thit
loi tr ung th nu dch mu xanh hay nu. Nu c khi u th cng cn phi
ly b..
Tit dch sa khng lin quan vi nui con thng gp mt s hi chng
(Chiari-Frommel, Argonz-Del Castillo) c lin quan vi tng tit prolactin ca
tuyn yn. Mt s thuc, nh h chlorpromazine v vin thuc trnh thai kt hp
cng c th gy tit sa.
Dch m thng do vim nhim gy ra, trng hp ny cn loi b khi vim.
2.8. D dng v
Ph i v mt hay c hai bn thng cn phi phu thut to hnh thu nh li.
3. KHI U V C TNH:
Ung th v c hai loi chnh l ung th th ng (ductal carcinoma) v ung th
th thu (lobular carcinoma).
3.1. Chn on khi u ung th v da vo:
- 70% cc trng hp ung th v khm pht hin thy : khi u n, khng
cng, cng chc, vi b kh xc nh. Tuy nhin ti 90% khi u c pht hin bi
chnh ngi bnh, nht l nhng khi u nh < 1 cm. Chp v thng c tin hnh
trong trng hp nghi ng. Cc triu chng t gp hn l au v, tit dch. Pht hin
mun hn, nht l khi khi u ln > 5 cm th c th thy khi u co ko da v nm v,
v to ln, da ging cam snh, au, khi u dnh vo da hay thnh ngc, khm h
nch thy c hch. Thm ch c lot, hch trn n, ph tay, di cn xng, phi,
gan, no..
T l ung th v thng gp cc v tr:
+ 45% phn t trn ngoi
+ 10% phn t di ngoi
+ 15% phn t trn trong

119

+ 5% phn di trong
+ 25% vng qung v
- Chp v (mammographie): c th pht hin rt sm t 2 nm trc khi s
thy. Khong 35% cc trng hp c pht hin ch nh chp v sng lc.
- MRI v gip xc nh tnh cht khi u ranh gii khng r rng vi cc t
chc xung quanh, c hin tng tng sinh mchv mc thm nhim ca khi u
ra xung quanh nht l so vi c ngc.
- Sinh thit: tiu chun vng xc nh v phn loi ung th v c 30% ngh
ti ung th trn lm sng nhng sinh thit lnh tnh v 15% ngh lnh tnh nhng
sinh thit l c tnh
- Chp x hnh xng bng technetium 99m- labeled phosphonates, l
phng tin quan trng nh gi di cn v. T l di cn xng tng ln cng
giai on bnh, nu Stages I v II th ch khong 7% v 8% c (+), trong khi giai
on III l 25% (+)
- Positron emission tomography (PET) ha hn l cng c tt nh gi giai
on v tin trin ca bnh. Thng c ch nh khi c ti pht, hay di cn v
theo di nh k s p ng iu tr.
3.2. Mt s dng c bit ca ung th v:
- Bnh Paget: c s thay i mu sc da vng nm v di dng chm v
99% l c tnh. 60% s thy c khi u nm di, cc khi u ny 95% c pht
hin l do ung th di cn, m phn ln l do ung th ng tuyn thm nhim. Bnh
Paget him gp (ch chim khong 1% cc trng hp ung th v) nhng li thng
pht hin mun v triu chng khng r rng nn thng c chn on v iu tr
nh vim da hay nh nhim khun. Nu c pht hin sm, bnh Paget him khi
di cn vo hch nch. iu tr c th phu thut ct b v rng, bao gm tia x sau
m vi > 90% sng khng bnh ti > 8 nm .
- Ung th v dng vim: c pht hin di dng tn thng ecdema lan
rng da vng v, ty vng b xung quanh, v thng khng s thy khi u
di. y l bnh c tnh cht c tnh nht v khi pht hin ra th c ti > 35%

120

trng hp c di cn, nhng may mn l bnh ch chim < 5% cc trng hp

ung th v. Trong trng hp nghi ng bnh vim da nhng sau 1 2 tun m
khng p ng nhanh vi mt t iu tr khng sinh th cn tin hnh sinh thit
chn on.
- Ung th v trong thi gian mang thai v cho con b: him gp vi t l 1:
3000 ti 1: 10.000. Tin lng bnh khng c nhiu khc bit so vi khi khng c
thai. nh ch thai nghn c ch nh 6 thng u ca thai nghn cng khng
cho thy s ci thin v tin lng bnh, thm vo l chng ch nh tia x v
ho cht. Trong phn ln cc trng hp th ct b v rng l phng thc iu tr
ti thiu c la chn. Nu thai mun hn 3 thng cui ca thai nghn c th ch
ct b khi u v tia x ngay sau .
- Ung th v hai bn: t l khng nhiu nu cng lc, ch khong < 1%, nhng
c t l cao hn t 5 8% vi nhng trng hp ung th mun v th 2. Ung th
v hai bn thng gp ph n < 50 tui v thng l ung th tiu thu. Nhng
ngi bnh ung th v nn c chp mammographie bn kia trc khi iu tr v
sau vn phi theo di nh k pht hin tn thng bt thng v i din.
3.3. Giai on:
c xp giai on theo h thng TMN (tumor, node, metastasis) ca Hi
phng chng ung th quc t:
Tis : ung th ti ch

N1: hch nch, di ng

T1:

N2: hch nch dnh.

T1 mic: Tn thng vi th < 0,1 cm

N3: Hch vng xng n

T1a >0,1 cm nhng 0,5cm

M1: di cn xa

T1b >0,5 cm nhng 1,0 cm

T1c > 1,0 cm nhng 2,0cm
T2: > 2cm nhng 5cm
T3: > 5cm
T4:
T4a: lan ti thnh ngc

121

T4b: ph, lot da

T4c: Gm c 4a v 4b
T4d: Khi ung th vim
3.4. Cc bin php nhm pht hin sm ung th v
- Mammographie lun l la chn hng u v tt nht cho vic sng lc
nhm pht hin sm ung th v. Khm lm sng v chp v trong chp v gip
pht hin ti 40% cc trng hp ung th giai on sm v 40% khc c pht
hin qua s nn. Nhn chung, tu thuc vo tui ca ph n v mt ca v th
nhy ca chp v l 70 90% v c hiu > 90%. Chp v c th 2-3 nm mt
ln ln nhng ph n t 40 49 tui v hng nm nhng tui ln hn.
- Siu m v thng ch gip chn on phn bit u nang v nhn x. Siu m
ch nn c coi nh l mt bin php b sung cho khm lm sng v chp v trong
sng lc ung th v.
- T khm v tin hnh trong thi gian sau sch kinh 5- 7 ngy.
- Xt nghim gen: nhng bnh nhn c tin s gia nh ung th v, vi vic
pht hin dng tnh vi 2 gen BRCA1 v BRCA 2, ng ngha vi tng nguy c
ung th v cng nh ung th bung trng, i trng, tin lit tuyn v ung th tu.
- Receptor ni tit vi progesterone (RP) v estrogen (RE) ca khi u ung th
v cho bit kh nng p ng iu tr vi thuc ni tit. Tuy nhin c khong 10%
trng hp ung th v di cn mc d c RE m tnh nhng vn c iu tr thnh
cng bi liu php hormone.
3.5. iu tr ung th v
Ct b v rng c Halsted thc hin ln u ti M vo nm 1882. Cho ti
nhng nm 1950 th ngi ta bt u tin hnh thm vic no hch nch. Sau
cho ti nhng nm 1980 th ngi ta bt u ch ct b khi u v hoc mt phn v
hay mt phn t v bo tn, thng c ch nh nhng giai on sm ca
bnh (I v II)
iu tr bo tn nu ch c mt tn thng c ng knh < 2cm. Tuy nhin,
iu tr bo tn phi i km vi kim tra m hc ngay tc th vng ra xung quanh

122

bo m ct ht t chc ung th, tt hn c nu nh tin hnh x vng vt m

ngay khi ngi bnh trn bn m sau khi c ly ht t chc u. Vt hch vng
h nch i km.
iu tr ct b v theo phng php Patey thng c ch nh ti Vit nam,
bt k giai on no ca bnh, km theo vt hch nch.
Tia x, ho cht v ni tit l nhng liu php iu tr b xung trong ung th v.
iu tr ni tit thng ko di trong 5 nm. Cn ch , nu ngi bnh cn kinh
nguyt v cm th RE (+) v RP (+) th nn c loi b 2 bung trng trc khi iu
tr bng tia x hoc ni soi ct b (thng c la chn) v 6 thng phi kim tra
dy nim mc t cung qua siu m pht hin tnh trng qu sn nu c.

123

TN THNG LNH TNH C T CUNG

1. KHI NIM
C t cung (CTC) l on thp nht ca t cung, c phn nm trong m o
v phn nm trn m o. Phn trong m o chu tc ng trc tip ca mt lot
cc thay i sinh l hoc bnh l khc nhau, trong c th k n s thay i ni
tit t sinh dc n, tui tc v hot ngg sinh sn, pH acid mi trng m o, cc
tc nhn nhim trng bao gm virus, vi khun v k sinh trng, to nn nhiu tn
thng lnh tnh khc nhau.
2. CHN ON
2.1. Lm sng
2.1.1. Tn thng vim:
- Thng gp vim m o v c t cung phi hp di trng thi cp tnh /
bn cp tnh hoc mn tnh.
- C t cung , c kh h bm trn b mt. Nu vim ng c t cung c th
thy cht nhy ng c t cung c nh m.
- Soi c t cung: vim, chm , vt trt, hnh nh bu tri sao
2.1.2. Tn thng lon dng:
- Thng do thiu nng oestrogen, gp ph n sau mn kinh: suy bung
trng, ct 2 bung trng, tia x vng chu, sau mn kinh.
- C t cung teo, biu m mng, nht mu, d xut huyt di nim mac, test
Lugol (-) hoc nht mu.
2.1.3. Polype c t cung:
- L cc khi lnh tnh pht trin t m m c t cung v c che ph bi
biu m tr, v sau do hin tng chuyn sn tr thnh biu m lt, thng xut
pht t ng c t cung, c chn hoc khng c chn, kch thc c th thay i t
vi mm n vi cm, thng quan st thy ph n sinh nhiu ln.
- Ngi bnh thng khng c triu chng nhng cng c th ra kh h nhiu,
rong huyt, ra mu sau giao hp.

124

2.1.4. L tuyn c t cung v vng ti to ca l tuyn:

L tuyn CTC l tnh trng biu m tr c trong lan xung hoc l ra phn
c ngoi, ni bnh thng ch c biu m lt.
Triu chng chnh ca l tuyn l ra kh h nhy, nhn bng mt thng thy
khng c biu m lt tng, thay vo c nhiu n nh, mu hng m hn biu
m lt, c cht nhy bn trn.
Vng ti to ca l tuyn: l vng l tuyn c, trong biu m lt c
ngoi lan vo thay th v che ph cc tuyn, gi l s ti to ca biu m lt hay
biu m ho.
Ca tuyn v o tuyn: l nhng vng hp hoc rng ca biu m tuyn
tuyn cn st li trong vng biu m lt c ngun gc chuyn sn, tip tc ch
tit cht nhy.
Nang Naboth l trng hp biu m lt che ph biu m tuyn, nhng cha
thay th c m tuyn di nn cc tuyn vn tip tc ch tit cht nhy, lu
ngy to thnh nang. Nang c kch thc to nh khc nhau, mu trong, trng c
hoc vng nht, trn b mt c th c cc mch mu, trong nang cha dch nhy do
biu m tuyn ch tit.
2.1.5. Si mo g c t cung:
Tn thng si mo g c th gp c thnh m o v c t cung hoc ch
trn b mt c t cung. Trong thai k si mo g thng lan trn nhanh v nhiu.
2.1.6. Lc ni mc t cung:
L nhng nt mu xanh tm hay en sm, nh, n c hoc ri rc quanh c
t cung
2.1.7 U x c t cung:
Thng l u li ra, chc, i khi che lp c t cung hoc lm xa c t cung.
2.2. Cn lm sng
- Soi ti, nhum Gram pht hin cc tc nhn thng gp nh nm Candida,
trng roi m o, lu cu, Gardnerella vaginalis.
- Xt nghim t bo c t cung: hnh nh bnh thng hoc cc bin i lnh tnh.

125

- Soi c t cung: vim, chm , vt trt, hnh nh bu tri sao. L tuyn c

t cung sau khi bi acid acetic 3% thy cc tuyn hnh nh "chm nho" v khng
bt mu iod.
- Sinh thit c t cung: kt qu m bnh hc bnh thng hoc bin i lnh tnh.
3. IU TR
3.1. Nguyn tc chung, mc tiu iu tr
Ngi bnh c tn thng lnh tnh c t cung cn c loi tr tn thng
tin ung th hoc ung th trc khi iu tr. Mt s tn thng lnh tnh c t
cung nh vng ti to/nang Naboth, l tuyn hp khng c triu chng c nng
khng cn phi iu tr. Cc phng php iu tr tn thng c t cung bao gm
t thuc, ct/t in, p lnh, ha hi bng laser.
3.2. iu tr c th:
3.2.1. Tn thng vim:
Khng sinh c hiu theo tc nhn.
3.2.2. Tn thng lon dng:
Dng thuc t hoc bi ti ch cha estrogen (Ovestin, Colposeptine,
Colphotrophine).
3.2.3. Polype c t cung:
- Ch nh iu tr:
+ Polyp c t cung to.
+ Polyp c t cung c triu chng: ra kh h nhiu, rong huyt, ra mu sau
giao hp.
+ Nghi ng c tn thng tin ung th/ung th.
- Chng ch nh: ang c vim m o: tr hon n khi iu tr khi vim m o.
- Chun b: xt nghim t bo c t cung /m bnh hc loi tr cc tn
thng tin ung th/ung th
- Cc bc tin hnh:
Bc 1: St khun m o, bc l c t cung, xc nh chn polyp: c cung,
khng c cung, xut pht t c ngoi hay ng c t cung.

126

Bc 2: Dng kp hnh tim kp polyp v xon quanh cung cho n khi cung
t. Nu polyp to khng c cung cn dng dao in ct b chn.
Bc 3: Bi cht dnh Monsel v p vo v tr cung/din ct cm mu. C
th nht gc di m o cm mu.
Bc 4: St khun li m o. Gi bnh phm ct lm m bnh hc.
3.2.4. L tuyn c t cung v vng ti to ca l tuyn:
- Ch nh: nguyn tc l ch iu tr khi c triu chng
+ L tuyn rng, tit dch nhiu.
+ L tuyn + vim m o c t cung ti din.
+ C ch nh iu tr khc: l tuyn + v sinh, l tuyn rng + c nhu cu t
dng c t cung
- iu kin: khng c vim nhim, test acid acetic (-), t bo c t cung khng
c bt thng t bo biu m. Thi im sau sch kinh 2 - 3 ngy, ti a khng qu
ngy th 10 ca vng kinh.
- Cc phng php iu tr: t in, p lnh, laser. Ph hy biu m tuyn
n ranh gii biu m lt - tr. Trng hp nang Naboth cn iu tr th chc v t
m tuyn pha di.
- Theo di sau iu tr:
+ Khng sinh ng ung 5 ngy
+ King giao hp ti thiu 4 tun
+ T vn cho khch hng/ngi bnh bit cn n ngay c s y t khm li
nu c mt trong cc du hiu nguy him sau: st hn 2 ngy, ra mu m o nhiu,
ra kh h nhiu, hi; au bng di nhiu
+ Hn ti khm sau 3 thng
3.2.5. Si mo g c t cung:
t in, t laser hoc p lnh.
3.2.6. Lc ni mc t cung:
t lc ni mc.
3.2.7. U x c t cung:
Ct u x c t cung.

127

4. TIN TRIN V BIN CHNG

Polype c t cung thng lnh tnh, nhng c khong 1% cc trng hp c
chuyn dng c tnh, bn cnh mt s ung th c t cung c th biu hin mt
khi dng polype, do cn ct polype xt nghim m bnh hc.
Sau l tuyn, thng qua hin tng chuyn sn c th thay th hon ton biu
m tuyn thnh biu m lt bnh thng. Nu s thay th din ra khng hon ton
s li cc ca tuyn, o tuyn, nang Naboth, l cc bin i lnh tnh. Nu c
cc yu t nguy c tc ng lu di vo vng chuyn tip (nhim HPV nguy c cao,
tn ti dai dng) c th hnh thnh tn thng tin ung th v ung th.
5. TIN LNG V PHNG BNH
Phn ln tn thng lnh tnh c t cung khng nguy him n tnh mng, tuy
nhin cn khm ph khoa nh k hng nm v/hoc sng lc ung th c t cung
theo khuyn co loi tr ung th c t cung.

128

VIM PHN PH
1. I CNG
Vim nhim ng sinh dc l mt trong nhng bnh ph bin ph n n
lin quan mt thit vi quan h tnh. Ngoi ra n cn l hu qu ca cc bin chng
trong sinh nh no st nhau, bc rau sau , t dng c t cung (DCTC) khng
o m v khun v nht l trong cc trng hp ph thai an ton.
Tu theo vi khun gy bnh, bnh cnh lm sng thng biu hin di dng
cp tnh, bn cp tnh v mn tnh
Phn ph ngi ph n bao gm: bung trng, vi t cung (vi trng),
dy chng rng. Vim phn ph thng bt u t vim vi t cung, sau lan
ra xung quanh.
2. TRIU CHNG
2.1. Hnh thi cp tnh
Vim phn ph cp thng xy ra sau , sau sy thai hoc sau cc can thip
th thut vng tiu khung nh no ht, t vng, tho vngv sau vim m o
cp do vi khun lu.
2.1.1. Triu chng lm sng:
- Ni bt l au vng bng di t ngt ph n, au tng khi i li, thng
au c hai bn ( chim 90%)
- Ri lon kinh nguyt xy ra trong 50% cc trng hp, du hiu nng n
kch thch vng bng nh mt rn, i nng, tiu kh, tiu khng ht nc tiu
(chim 15-25% cc trng hp).
- St l du hiu km theo cc triu chng ny, nhit ln n 39o C.
- C th nn hoc bun nn.
- Khm bng thy khng bng vng di, nhng khng co cng thnh
bng, c du gim p - Blumberg (+).
- t m vt: c nhiu kh h, c khi l m, chim t 39-65% cc trng hp,
ta nn ly dch m o lm xt nghim.

129

- Thm khm phi hp bng 2 tay tng m o v trn bng, ta thy t cung
mm, khi lay ng s thy t cung s gy au, hai phn ph n au. i khi pht
hin thy khi cnh t cung thng mt sau ca t cung, dnh khng di ng.
2.1.2. Cn lm sng
Cng thc mu c bch cu tng, c bit bch cu trung tnh tng cao.
CRP tng.
Cy mu c th pht hin vi khun gy bnh. Xt nghim dch c t cung
pht hin thy khi cnh t cung pht hin vi khun lu v Chlamydia. Trn thc t
xt nghim khng phi lc no cng cho kt qu dng tnh v vim phn ph c th
xy ra do tp khun. Siu m pht hin cc khi vim nhim v p xe phn ph.
2.2. Hnh thi bn cp: chim 30% cc trng hp.
2.2.1. Triu chng lm sng: thng nh hn vi:
- au m vng bng h v hoc tht lng.
- Rong kinh thng hay gp.
- Kh h khng r rng, khng c hiu.
- St nh 37,5 -38
- Khm bng: thng thy bng mm, khm thy c khng cc b vng
bng di.
- Khm m o: c th thy au mt hoc hai bn ca phn ph, c khi n
kh phn bit ranh gii vi t cung. C du hiu au khi lay ng t cung.
- Khm trc trng: ngi bnh rt au khi khm.
2.2.2.Cn lm sng
- Bch cu tng vi bch cu trung tnh va phi.
- CRP tng
- Siu m xc nh c khi phn ph vi m vang hn hp.
- Ni soi bng: c th gp cc thng tn phi hp vim phn ph, vim
quanh gan dng mng dnh gia gan v c honh, hoc mt trn gan vi thnh
truc bng nh cc si dy n violon (hi chng Fitz- Hugh- Curtis: vim
quanh gan th pht sau vim sinh dc khng c hiu. c cc du hiu st, au

130

h sn phi lan ln vai, c cc du hiu ca tiu khung lm ngh n vim phn

ph. Tuy nhin khng c vng da, cc xt nghim chc nng gan v siu m
ng mt u bnh thng).
2.3. Hnh thi mn tnh
2.3.1. Nguyn nhn: do vim phn ph cp tnh khng c iu tr y kp
thi.
2.3.2. Triu chng:
- C nng:
+ au: au vng h v hy hai bn h chu, thng c mt bn tri hn au
thay i v cng thi gian tng cn hay lin tc; khi i li niu lm vic nng
au tng, khi ngh ngi au t hn.
+ Kh h: khng nhiu, khng c hiu
+ Ra mu: c th ra mu bt thng trc v sau khi hnh kinh hoc rong kinh.
- Thc th:
+ Khm m o phi hp nn bng pht hin.
+ T cung di ng hn ch khi lay ng
+ C th c khi cnh t cung, n au, ranh gii khng r do vi t cung dnh
vi bung trng thnh mt khi.
3. CHN ON PHN BIT
- au do bnh ng tiu ho v tit niu
- Vim rut tha cp: vim phn ph thy au c 2 bn, im ca phn ph
phi thp hn im au ca rut tha vim.
- Vim m b thn
- Vim i trng
- Cha ngoi t cung.
+ Chm kinh, au bng mt bn h chu, rong huyt
+ HCG(+)
+ Siu m: khng thy ti i trong bung t cung
- Vim, nc vi t cung do lao.

131

4. TIN TRIN
- Vim phc mc y chu:
- p xe phn ph
- p xe bung trng:
- Vim ty lan ta y chu.
- Vim phc mc ton th:
- Di chng: di chng thng gp ca vim nhim h chu l:
+ V sinh do tc vi t cung hai bn, dnh tua loa vi
+ Thai ngoi t cung.
+ au vng chu kinh nin.
5. PHNG BNH
- nh k t chc khm ph khoa tuyn c s pht hin v iu tr sm, c
bit nhm nguy c hoc nhng ngi lm vic trong mi trng nc bn.
- Pht hin sm, iu tr tch cc vim nhim ng sinh dc di ngay khi
mi nhim.
- Pht hin v iu tr vim niu o nam v n c hiu qu.
- S dng bao cao su nhng ngi c nguy c cao vi bnh ly truyn qua
ng tnh dc.
- Tn trng nguyn tc v khun khi lm cc th thut sn ph khoa.
- Tuyn truyn, hng dn v sinh kinh nguyt, v sinh c nhn, v sinh giao
hp. Tuyn truyn li sng lnh mnh.
- Vn ng sinh c k hoch trnh c thai ngoi mun.

132

VIM M O
1. I CNG
- Mm bnh hay gp: lu cu khun, chlamydia trachomatis, hemophilus
ducreyl, tricomonas vaginalis, gardnerella vaginalis, candida albicans, virus u nh,
virus herpes.
ng ly: quan h tnh dc, ni sinh, thy thuc khm bnh khng m bo
v trng
- Cc yu t thun li: b phn sinh dc n c cu to gii phu c bit vi
nhiu ngc ngch, nhiu np nhn, nhiu l tuyn thun li cho mn bnh c tr v
pht trin. ng sinh dc n thng vo bng u loa vi trng lm iu kin
cho vi khun pht trin vo phc mc gy vim tiu khung, hnh kinh hng thng
km theo bong nim mc t cung li tn thng trong bung t cung, mu kinh
l mi trng nui cy vi khun thun li nn vim nhim cng d pht trin
2. CC HNH THI CA VIN M O.
2.1. Vim do vi khun:
- Mm bnh: Gardenerella vaginalis, Mycoplasma homitis, vi khun k kh
- Triu chng: Kh h hi, nga b phn sinh dc, m o c nhng nt
- Xt nghim: bnh phm trn phin knh + KOH => bc mi tanh c
- iu tr: tht m o axt axetic 1%
Metronidazol 1g/ngy x 7 ngy, hoc ung liu duy nht 2g
t Metronidazol mi ti 1v x 2 tun
Ti pht c th dng 2 t
2.2. Vim m o do Trichomonas
- Mm bnh: trng roi Trichomonas vaginalis
- Khi thm khm hoc t m vt: Thnh m o c nhng nt trn hoc bu dc.
- Soi ti thy hnh nh trng roi
- iu tr: c v v chng: Metronidazol 1g/ngy x 7 ngy.

133

- V: t thm Metronidazol trong vng 10 ngy.Tiu chun khi l tm

Trichomonas 3 vng kinh lin tip (-)
2.3. Vim m o do nm
- Mm bnh: Candida albicans
- Yu t thun li: kh nng t bo v c th gim st: i ng, c thai
- Triu chng: nga m h, c vt lan sinh dc ngoi
- Xt nghim: c si nm, test tanh c(-)
- iu tr: t Nystatin 100mg m o mi ti 1vin
Mycostatine, Meconazol 100mg mi ti 1vin trong vng 3 ti
Tht m o bng Natri bicacbonat 1-2%, bm Glyceryl borat 30%
2.4. Bnh lu
- Mm bnh: lu cu khun Neisseria gonorrhoea thng gy vim m h m
o, c t cung, vi trng
- Triu chng: thi gian bnh 2- 6 ngy
Kh h m o nh m xanh, vng. Chng c tin s i dt i but, i ra m
- Bin chng: vim tiu khung, v sinh, cha ngoi t cung, sy thai, nhim
khun, non, lu mt tr s sinh
- iu tr: khng sinh cephalosporin th h th 3
2.5. Giang mai
- Mm bnh: xon khun giang mai Treponema pallidum. Sau khi b nhim
bnh tr thnh bnh ton thn, vi khun c th ly sang con qua rau thai
- Triu chng: gm 3 giai on
+ Thi k 1: xut hin sau giao hp khong 3 tun, tn thng m h l
sng (chancre) giang mai, vt lot trn, b cng hi ni cao trn mt da, khng au,
khng nga km theo hch bn, c th gp sng m o v c t cung. Sng
thng t khi sau 2- 6 tun d khng iu tr.
+ Thi k 2: xy ra sau 6 tun --> 9 thng sau nhim bnh, vi khun vo
mu d ly lan. Tn thng l ban v chi si dnh li thnh tng m, b cng,

134

xut tit v hoi t, khp ni trn c th nh da, lng bn tay, gt chn, nim mc
ming, c km theo hch bn
+ Thi k 3: tn thng l gm (gumma) giang mai, l nt lot, c th au,
ph n do bi nhim, c hch vim i km.
- Xt nghim: cc phn ng huyt thanh VDRL(Veneral Disease Research
Laboratory) v RPR (Rapid Plasma Reagin) ngoi ra c th thy xon khun trong
bnh phm ly t sng hoc hch bn
- iu tr: Benzathin penicillinG 2,4 triu/tun x 3 tun (iu tr c chng vi
liu tong t)
- Bin chng: sy thai lin tip, a i, d dng thai, giang mai bm sinh
2.6. Vim m o do thiu Estrogen
Do thiu estrogen nn biu m m o b teo, t bo gim glycogen, pH, m
o khng toan, khng t bo v v chng vi khun c
- Nguyn nhn: ph n mn kinh, ph n ct b 2 bung trng
- Triu chng: m h kh, teo, au. t m vt m o au, thnh m o
mng, d chy mu, c t cung nh
- iu tr: Mycrofollin 0,05mg 1v/ngy.Ti ch Colpotrophine trong 10-20 ngy
2.7. Si mo g (Condyloma):
L bnh do virus loi Papilloma nhm 6 hay 11, bnh 3- 6 thng
Tn thng l cc khi si da vng mi ln, mi b, tin nh, m o, c t
cung mu hng nht
- iu tr: t in, t nhit, bi thuc Podophylin trn b mt khi u, iu tr
cho c chng nu b.
3. PHNG BNH
Ra sch mi ln i v sinh
Quan h tnh dc vi mt ngi
S dng bao cao su khi quan h tnh dc.
Khi ra kh h cn i khm ngay.

135

CHA NGOI T CUNG

l. KHI NIM:
Cha ngoi t cung l trng hp thai khng lm t trong bung t cung. C
th gp nhiu v tr khc nhau nh vi t cung, bung trng, ti ng c t cung
hoc ti cc v tr khc nhau trong bng, thm ch ngoi phc mc. Tuy nhin,
khong hn 95% trng hp cha ngoi t cung xy ra vi t cung (55% loa,
25% eo, 17% on bng v ch 2% on k)
2. CHN ON
2.1. Lm sng:
- C nng:
+ Chm kinh: nhiu trng hp khng r v i khi ra mu trc thi im d
bo c kinh.
+ Ra mu m o vi tnh cht: ra t mt, sm mu, ra lin tc dai dng.
+ au bng: thng xut hin do vi t cung b cng gin v nt v hoc mu
trong bng gy kch thch phc mc, thng au v tr ch cha. i khi au
bng km theo mt rn khi trc trng b kch thch.
- Ton thn:
C th chong ngt do au, do v khi cha
Hoc c du hiu thiu mu mn tnh, da hi nh vng nht trong th huyt t
thnh nang.
- Thc th:
+ Khm bng c im au, phn ng thnh bng trong trng hp c mu
trong bng.
+ Khm m vt: du hiu c thai nh c t cung tm kh pht hin, nhng m
o c mu t l c t cung ra, s lng t, mu sm mu ging nh b caf.
+ Thm m o: t cung to hn bnh thng nhng khng tng xng tui
thai. S nn thy c khi cnh t cung, mm, ranh gii khng r, au khi di ng t
cung. Ti cng sau y v rt au khi c chy mu trong. c trng l ting ku

136

Douglas khi chm vo ti cng sau lm ngi bnh au git ny ngi v ht tay
thy thuc ra.
2.2. Cn lm sng:
- Phn ng chn on c thai: xt nghim HCG/ nc tiu dng tnh hoc
HCG/mu > 5UI/ml
+ Trong 3 thng u lng HCG tng gp i sau 48h
+ Trong cha ngoi t cung mc tng HCG chm nn cn kt hp vi
siu m.
- Siu m: khng thy hnh nh ti i trong bung t cung kt hp vi nng
HCG ngh nhiu n cha ngoi t cung.
Tm khi cha xung quanh, cnh t cung, c th c dch ti cng Douglas.
Hnh nh ti i gi trong bung t cung do mu v mng rng ng li.
Siu m ng bng nhn thy ti i trong bung t cung l khong 6 tun
(chm kinh 2 tun, HCG t 3000-3500 mUI/ml). Siu m ng m o c th
nhn thy ti i sm hn khong 5 ngy ( HCG t 1000- 2000mUI/ml). Khi cha
n cc thi im ny hay di cc gii hn ny th khng quan st thy ti i trong
bung t cung cng l bnh thng.
- Mt s thm d khc:
+ No bung t cung tm phn ng Arias-Stella, ch lm nhng trng hp
nghi ng m li khng mun gi thai. C th kt hp vi kim tra nng hCG
trc v sau no, hoc soi tm lng rau.
+ Chc d ti cng sau m o c mu khng ng
+ Soi bng: gip chn on sm v iu tr.
2.3. Chn on xc nh:
- Da vo lm sng: chm kinh + au bng di + ra mu m o.
- C th s thy khi cha cnh t cung
- Da vo cn lm sng: siu m + hCG (hoc hCG nu cn)
2.4. Cc th lm sng:
2.4.1. Th cha ngoi t cung cha v

137

Ton trng bnh thng, khng mt mu. Thm trong c th nn thy khi
cnh t cung, khu tr r v au, cc ti cng thng khng y, khng au. Siu m
khng c mu trong bng.
2.4.2. Th lt mu bng
Bnh cnh ni bt l au v chong nng do chy mu trong, xut hin t ngt.
Bng trng, n au khp bng.Siu m dch nhiu cng v trong bng.
2.4.3. Th gi sy
Khi c bin i ni tit ton b ni mc t cung bong ra v b tng ra ngoi
lm d nhm vi sy thai, b st cha ngoi t cung. Xt nghim gii phu bnh t
chc no ra thy hnh nh mng rng, khng thy lng rau - hnh nh Arias Stella.
2.4.4. Th huyt t thnh nang
Do mu chy t mt, ng li sau rut, cc tng v mc ni phn ng,bc
li thnh khi huyt t. Chn on thng kh v triu chng khng in hnh.
Ton thn c tnh trng thiu mu. Chc d ht ra mu en ln cn.
2.4.5. Cha bung trng
Thng ch chn on c sau khi m bng hay ni soi. Chn on khi
thy ti thai nm bung trng. Theo tiu chun ca Spiegelberg th c im ca
cha bung trng l:
+ Ti i nm trn vng bung trng
+ Khi cha lin tc vi t cung bi dy chng t cung - bung trng
2.4.6. Cha trong bng
Thai nm ngoi hon ton t cung, thng pht trin kh ln, thm ch c th
s nn thy thai ngay di da bng. V tr cha c th bt k v tr no trong
bng, thng l vng h v nhng cng c th gp vng gan, vng lch, thm
ch sau phc mc
2.4.7. Cha ng c t cung
Him gp, l trng hp thai lm t pha di l trong c t cung. Triu
chng ngho nn, khng c hiu, khm thy c t cung phnh ra mt cch bt
thng. Hu qu gy thai cht lu hoc sy thai, rau ci rng lc, khi rau bong d

138

dang lm chy mu kh cm. No khng cm c mu m thng phi tin hnh

ct t cung.
2.4.8. Cha so m t cung
2.4.9. Phi hp cha trong t cung vi cha ngoi t cung
Rt him gp, d b st. Hin nay hay gp trong trng hp th tinh ng nghim
3. CHN ON PHN BIT
- Sy thai, do sy thai: siu m trc quan st thy hnh nh ti i trong
bung t cung.
- Vim phn ph: c tnh trng nhim khun, phn bit c th dng xt
nghim nh lng HCG v soi bng
- V nang non: trng hp chy mu trong bng gy chong th buc phi
phu thut cm mu v ra bng, thng chn on sau khi m bng.
- Khi u bung trng: khng c du hiu c thai, triu chng thng xut hin
khi co bin chng, thm trong c khi cnh t cung nn cn siu m phn bit.
- Vim rut tha: au h chu phi, c biu hin nhim trng v ri lon tiu
ho, khng c phn ng thai nghn. Phn bit m qunh rut tha vi huyt t
thnh nang.
4. IU TR
4.1. Nguyn tc chung
L cp cu sn khoa cn chn on sm v iu tr sm.C th iu tr ni
khoa hay ngoi khoa tu thuc vo th bnh v biu hin lm sng ca cha ngoi
t cung.
4.2. iu tr c th:
4.2.1. Phu thut:
iu kin: tun hon khng n nh, c du hiu shock do v, do v

139

C cc bnh ni khoa kt hp nh suy thn, suy gim min dch hCG > 5000
mIU/ml, siu m nhiu dch bng
D ng vi Methotrexat (MTX) hoc khng chp nhn iu tr MTX
+ Th lt mu trong bng: m cp cu ct khi cha cm mu, ng thi
hi sc tch cc, bi ph th tch tun hon mt.
+ Th cha v: bo tn vi t cung bng cch rch dc b t do vi t cung
ly khi thai nu khi cha nh on loa, bng v sau phi theo di nng
hCG sau m, nu nng HCG khng gim hoc thm ch cn tng th phi iu
tr tip tc bng tim MTX. Thng ct b khi cha v t l thnh cng c thai li
thp v li c nguy c cha ngoi d con li cao.
+ Th huyt t thnh nang: m bn cp cu trnh v th pht hay trnh
nhim khun. Ly ht mu t v khi cha, cm mu, lau ra sch khoang cha
mu, ch khi m khng gy tn thng rut, bng quang khi tch dnh.
+ Th cha trong bng: nn m khi thai nh di 32 tun, thai trn 32 tun
nu sng c th theo di thm. Khi m ly thai khng nn vi vng v s kh trong
x l bnh rau, i khi bnh rau b bong gy chy mu rt kh cm, hoc khi bnh
rau bm rng v cht vo t chc trong bng th phi chn gc tht cht ri rt
dn trong nhng ngy sau.
+ Th cha ng c: thng phi ct t cung cm mu.
4.2.2. Ni khoa:
iu kin: khi cha c kch thc di 3,5 cm.
Khng c hot ng ca tim thai
Huyt ng hc n nh
Nng hCG < 5000mIU/ml
+ Theo di thai ngoi t cung thoi trin t nhin: khong 3% vi nng
hCG thp, khi cha b.

140

+ Dng Methotrexat ton thn n liu hay a liu:

Methotrexat tim bp, nng tu thuc vo din tch da bnh nhn, thng
dung n liu 50 mg. Cn theo di cng thc mu, chc nng gan, thn. Theo di
nng HCG gim t nht 15% khong thi gian t ngy th 4 n th 7 sau khi
tim. Nu nng hCG gim t hay khng thay i my th c th tim thm mi
MTX th 2 hoc phu thut.
Ngng theo di khi nng HCG di 10 mIU/ml. Nhng i khi c th
thy au bng tr li, thm ch s thy khi cnh t cung to ln, nhng hCG v
bnh thng th vn coi l iu tr ni thnh cng v theo di them. Sau iu tr 6
thng mi c c thai tr li.
+ iu tr ti ch bng cch tim vo phi cc cht ph hu phi khi chn
on xc nh v tim di hng dn ca siu m ng m o.
5. TIN TRIN
Kh nng sinh ca nhng ph n b m cha ngoi t cung l rt kh
khn: 50% b v sinh v 15% b ti pht cha ngoi t cung. Vi nhng ph n
tr cha c con c th phu thut bo tn vi t cung, nhng kt qu cng rt
hn ch.

141

CHA VT M
1. KHI NIM
Cha vt m l mt dng thai ngoi t cung do thai lm t vt so m trn
c t cung. y l dng bnh l him gp nht ca thai ngoi t cung v thng
gy ra hu qu sy thai sm, rau ci rng lc, v t cung.
2. CHN ON:
2.1. Lm sng:
- Chm kinh
- Ra mu m o bt thng
- au bng lm rm
2.2. Cn lm sng:
Siu m: - bung t cung trng, khng c ti i trong bung t cung
- Tim thai nm thnh trc on eo t cung c c t cung phn
cch gia ti thai vi bang quang
- C s phn b mch mu quanh ti thai khi kt hp siu m
Doppler cho thy gia tng mch mu quanh ti thai
- Mt hay thiu lp c bnh thng gia bang quang v ti thai
2.3. Chn on phn bit:
- Thai on eo t cung
- Sy thai ang tin trin
- U nguyn bo nui
3. IU TR:
3.1. Nguyn tc iu tr:
- Ly khi thai trc khi v
- Bo tn kh nng sinh sn
3.2. Chn la cc phng thc iu tr, vic iu tr thng phi hp nhiu
phng thc v c cn nhc trn tng ngi bnh
- Hu thai trong ti i

142

- Ly khi rau thai:

+ Nong v no: tuy nhin c nguy c xut huyt cao.
+ Phu thut: mc ch ly khi rau thai, bo tn t cung khi khng p
ng iu tr ni v khi rau thai xm ln nhiu hoc ct t cung khi chy mu kh
cm hay thai kh to
- Chn bng ng c t cung:
kim sot chy mu r r sau th thut ht thai
S dng sonde Folley t nh nhng vo c t cung ri bm cng bng bng
30ml nc mui sinh l chn ti ch trong 12h
- Ho tr ton thn :thng iu tr h tr
Mc ch gim s phn b mch mu khi thai v tiu hu t bo rau
S dng Methotrexat 1 mg/kg tim bp
Theo di din bin qua hCG v siu m.
C th lp li liu sau 1 tun.
- Tc mch mu nui:
Mc ch: chun b cho phu thut hoc kt hp vi ho tr
Cc phng php: tht ng mch t cung qua ng m o hay tht ng
mch chu trong.
4. TIN TRIN V BIN CHNG:
Trng hp dung ho tr ton than yu cu ngi bnh nga thai t nht 3 thng.
Khm li ngay khi c bin chng xut huyt nhiu
C th dung thuc nga thai hn ch s ra mu

143

SA SINH DC
1. KHI NIM
- Sa sinh dc l hin tng t cung sa xung thp trong m o hoc sa hn ra
ngoi m h, thng km theo sa thnh trc m o v bng quang hoc thnh sau
m o v trc trng.
- Sa sinh dc l mt bnh kh ph bin ph n Vit Nam, nht l ph n lm
vic nng, sinh nhiu, khng an ton, thng gp trong la tui 40-50 tui tr
ln. Ngi cha ln no cng c th sa sinh dc nhng t gp hn v ch sa c t
cung n thun.
- y l bnh khng nguy him n tnh mng nhng nh hng nhiu n
sinh hot, lao ng.
2. CHN ON
2.1. Lm sng
c im ca bnh l tin trin rt chm c th t 5 n 20 nm, v sau mi ln
, lao ng nng trng din, sc kho yu, mc sa sinh dc li tin trin thm.
- C nng:
Tu thuc tng ngi sa nhiu hay t, sa lu hay mi sa, sa n thun hay phi
hp. Triu chng thng l kh chu, nng bng di, tiu rt, sn tiu, tiu khng t
ch, c khi i tin kh. Triu chng trn ch xut hin khi bnh sa lu, mc cao.
- Thc th
Khm thy khi sa nm di m o hoc thp th m mn, trng hp
nng nht s sa ra ngoi m h, bao gm thnh trc m o, c t cung, thn t
cung, thnh sau m o. Phn khi sa ra ngoi c th sng ha hoc b lot do c
st, bi nhim.
2.2. Cn lm sng
Xt nghim phin c t cung: loi tr tn thng c tnh c t cung.
Thm d niu ng hc: kho st tnh trng sn tiu.

144

2.3. Chn on xc nh: ch yu da vo khm lm sng.

2.4. Phn loi th, mc
2.4.1. Phn loi c in
Sa I:
- Sa thnh trc m o (km theo sa bng quang)
- Sa thnh sau ( km theo sa trc trng)
- C t cung thp nhng cn trong m o, ngang vi hai gai to, cha
nhn thy ngoi m h.
Sa II:
- Sa thnh trc m o (km theo sa bng quang )
- Sa thnh sau m o (km theo sa trc trng)
- C t cung thp th m h
Sa III :
- Sa thnh trc m o (km theo sa bng quang)
- Sa thnh sau m o (km theo sa trc trng)
- T cung sa hn ra ngoi m h
2.4.2. H thng phn Pelvic Organ Prolapse Quantification (POP-Q)
Nm 1996, Hip hi quc t a ra h thng phn Pelvic Organ Prolapse
Quantification (POP-Q) (Bump, 1996) da trn 6 im mc m h, m o v c
t cung. Da trn h thng POP-Q, sa sinh dc c chia thnh 5 mc t 0 n
IV. Hin nay h thng ny c dng kh ph bin nhiu quc gia.
2.5. Chn on phn bit
- Ln t cung.
- C t cung di, ph i n thun nhng ph n cn tr, cha .
- Polyp c t cung.
- Khi u m o.
3. IU TR
3.1. Nguyn tc chung, mc tiu iu tr
iu tr h tr nhm gim nh cc phin toi do tnh trng sa sinh dc gy ra
hoc iu tr trit bng cc phu thut.

145

3.2. iu tr c th (ni khoa, ngoi khoa, hng dn chuyn tuyn)

3.2.1. iu tr ni khoa
Ch nh: nhng ngi bnh qu ln tui, mc cc bnh mn tnh, khng c
iu kin phu thut.C 3 phng php:
- Phc hi chc nng, c bit l tng sinh mn: hng dn cc bi tp co c
phc hi c nng vng y chu. Phng php ny c th lm mt cc triu
chng c nng v li li thi gian phu thut. Nu phi phu thut, th vic phc hi
trng lc c y chu cng lm hn ch ti pht sau m.
- Vng nng t trong m o:
- Estrogen (Ovestin, Colpotrophine): C th tc dng tt vi mt s trng
hp c triu chng c nng nh au bng quang, giao hp au, c tc dng tt
chun b phu thut.
3.2.2. iu tr ngoi khoa
- C nhiu phng php phu thut trong iu tr sa sinh dc. Mc ch phu
thut nhm phc hi h thng nng t cung, nng bng quang, lm li thnh
trc, thnh sau m o, khu c nng hu mn v ti to tng sinh mn. Phu thut
sa sinh dc ch yu bng ng m o hn l ng bng. Ngoi ct t cung n
thun, n cn ti to li cc thnh m o, v vy phu thut trong sa sinh dc cn
mang tnh cht thm m. y l u im ch yu m phu thut ng bng khng
th thc hin c.
- Cc yu t c lin quan n la chn phng php phu thut:
+ Tui v nhu cu sinh sau khi phu thut.
+ Kh nng sinh l tnh dc
+ Th trng chung ca ngi bnh
+ Mc sa sinh dc
+ nh hng ca sa sinh dc n cc c quan ln cn: tnh trng sa bng
quang, sa trc trng; ri lon tiu tin, i tin?.
+ Tnh trng m o, c t cung bnh thng hay vim nhim. Nu c vim c
t cung, m o cn t thuc v v sinh hng ngy trc m.

146

+ T cung, hai phn ph c u cc khng?

+ Bng c vt m c khng ? tin lng mc dnh vng tiu khung ?
+ iu kin trang b ca c s y t v trnh phu thut vin.
- Phng php Manchester
Ch nh ch yu cho ph n cn tr, mun c con v sa II. Phu thut ny
cng c th p dng cho nhng ngi bnh gi sa sinh dc III m khng chu
c mt cuc phu thut ln.
Cc bc phu thut chnh:
+ Ct ct c t cung.
+ Khu ngn dy chng Mackenrodt
+ Khu nng bng quang
+ Lm li thnh trc m o.
+ Phc hi c t cung bng cc mi khu Sturmdorft.
+ Lm li thnh sau m o
- Phng php Crossen
+ Ch nh: sa sinh dc III.
+ Cng nh phu thut Manchester, phu thut Crossen ch c tin hnh khi
c t cung khng b vim lot.
Cc bc phu thut chnh:
+ Ct t cung hon ton theo ng m o.
+ Buc cho cc dy chng Mackenrodt v dy chng trn bn kia treo
mm ct khu vo nhau thnh ci vng chc, chng sa rut.
+ Khu nng bng quang.
+ Lm li thnh trc m o.
+ Khu c nng hu mn, lm li thnh sau m o.
- Phu thut lm bt m o:
+ Phng php Lefort khu bt m otng i n gin, p dng cho ngi
gi khng cn quan h tnh dc,cn c s ng ca c hai v chng.

147

Ch nh: sa sinh dc II hoc III, ngi bnh gi trn 60 tui, khng cn

quan h tnh dc na, m o c t cung khng vim nhim,
+ Phu thut Ameline Huguier:
Khu treo t cung vo mm nh bng mt vt da hay cht liu tng hp, ch
nh cho nhng ngi bnh tr b sa sinh dc II, III.
+ Phu thut Shirodkar:
Lm ngn dy chng t cung cng v nh n vo eo trc t cung, p dng
cho ph n tr, cha sinh , b sa sinh dc II.
3.2.3. Hng dn chuyn tuyn
- Ngi bnh sa sinh dc cn c khm v x tr bi bc s sn ph khoa t
tuyn huyn tr ln.
- Ngi bnh c ch nh iu tr ni khoa c th c theo di ti tuyn x tr ln.
4. TIN TRIN V BIN CHNG
4.1. Tin trin
Y vn khng c bo co v tnh trng t thoi trin ca sa sinh dc, tuy nhin
nu mc sa khng nng th s dng vng nng di ngy c th ci thin ng k
tnh trng sa. Do thng khng c triu chng c nng, sa sinh dc ch c pht
hin khi c khi sa ra ngoi.
4.2. Bin chng
- Lot trt c t cung, vim lot khi sa.
- Tiu kh, sn tiu, nhim trng ng tiu
- i tin kh, to bn.
5. TIN LNG V PHNG BNH
5.1. Tin lng
Sa sinh dc l bnh him khi gy nguy him n tnh mng, tuy nhin gy ra
nhiu phin toi trong cuc sng v lm gim ng k cht lng sng.

148

5.2. Phng bnh

- Khng nn nhiu, sm, dy. Nn nh h sinh hoc c s y t
iu kin.
- Khng chuyn d ko di, khng rn qu lu. Thc hin cc th thut
phi m bo kiu kin, ng ch nh v ng k thut.
- Cc tn thng ng sinh dc phi c phc hi ng k thut.
- Sau khng nn lao ng qu sm v qu nng.
- Trnh tnh trng to bn.
- Cn pht hin v iu tr sm cc bnh mn tnh gy tng p lc bng thng
xuyn (to bn trng din, ho ko di) l nguyn nhn dn n sa sinh dc.

149

U NANG BUNG TRNG

1. KHI NIM
U nang bung trng l nhng u c v bc ngoi, bn trong cha dch, c th
gp mi la tui. U nang bung trng c th gy ri lon kinh nguyt, gy kh
chu ti ch, lm gim chc nng sinh sn, i khi gy suy nhc c th hoc c th
gy t vong do cc bin chng: tin trin thnh ung th, tc rut.
2. CC LOI U BUNG TRNG
2.1. Cc nang c nng
2.1.1. Nang bc non:
Nang bc non do nang De Graff khng v vo ngy qui nh, ln dn ln,
thng t 3-8 cm hoc ln hn.
- Triu chng: khng r rng, i khi c ra mu, nang to c th gy au tiu
khung, au khi giao hp, c th gy ra chu k kinh di, hoc ngn. Nang c th b
xon hoc v gy bnh cnh cp cu.
- Chn on phn bit vi: vim vi trng, lc ni mc t cung, nang hong
th, khi u khc.
- X tr: thng nang t bin mt trong khong 60 ngy, khng cn iu tr.
C th dng thuc trnh thai gy vng kinh nhn to.
Nu nang tn ti trn 60 ngy vi chu k kinh u th c kh nng khng phi
nang c nng.
2.1.2. Nang hong th:
C hai loi nang hong th: nang t bo ht v nang t bo v.
- Nang hong th t bo ht: l nang c nng, gp sau phng non, cc t bo
ht tr nn hong th ho.
+ Triu chng: au vng chu, gy v kinh hoc chm kinh, d nhm vi cha
ngoi t cung, c th xon nang, v nang gy chy mu phi soi bng hoc m
bng cm mu.

150

- Nang hong th t bo v: loi nang ny khng to, hay gp hai bn bung

trng, dch trong nang mu vng rm. Loi nang ny thng gp trong bung trng
a nang, cha trng, chorio hoc qu mn trong kch thch phng non.
+ X tr: nang thng bin mt sau iu tr nh no trng, iu tr chorio.
- Bung trng a nang (Hi chng Stein-Leventhal):
Gp hai bn bung trng, gy v kinh, v sinh, thiu kinh, 50% c mc ru
v bo. Nhiu trng hp gy v sinh th pht. Nhng ri lon c lin quan n ri
lon chc nng vng di i.
Bung trng a nang c v b sng ha, b mt trng ng, nhiu nang nh
nm di lp v dy ging hnh con s.
Xt nghim: 17 - ketosteroid tng nh nhng estrogen v FSH bnh thng,
LH cao.
Chn on: da vo khai thc tin s, khm thc th, dy th sm, mt kinh
ko di, xt nghim LH tng cao, theo di nhit c th khng c biu hin phng
non. Bung trng to khi khm qua tiu khung gp trong 50% trng hp.
Chn on xc nh: triu chng lm sng, LH/FSH>1,5, nu > 2 chc chn,
siu m nhiu nang non nm b mt v bung trng v soi bng.
iu tr: Chlomifen 50-100 mg trong 5-7 ngy kt hp Pregnyl 5000 n v
gy phng non, i khi phi ct gc bung trng. Ngi ta thy ct gc bung
trng em li thnh cng trong iu tr v sinh.
Ngi b bung trng a nang thng khng phng non trng din do
nim mc t cung chu nh hng ca estrogen nn b qu sn, c th gp c qu
sn khng in hnh do cn kt hp iu tr thm bng progestatif.
- Nang hong th trong thai nghn
L nhng nang gp trong khi c thai, c th c hai bn bung trng, kch
thc khong < 5cm
2.2. U nang bung trng thc th:
2.2.1. U nang biu m bung trng: chim 60-80% tt c cc loi u nang gm:
u nang nc, u nang nhy, lc ni mc t cung, u t bo sng, u Brenner, u m
bung trng.

151

- U nang nc:
L loi u c v mng, cung thng di, cha dch trong, kch thc thng
to, c khi chon ht bng, l loi khi u lnh tnh, c th c nh mt trong hoc
mt ngoi v nang. Nhng khi u lnh tnh thng c v nhn, cha dch vng nht.
Nu c nh thng l c tnh.
+ Triu chng: gp mi la tui, nhng hay c pht hin tui 20-30,
cng gp c tui tin mn kinh v sau mn kinh.
+ Khm tiu khung thy khi u.
+ X tr: m ct b nang, trong khi m nn ct lnh chn on loi tr ung th.
- U nang nhy:
Chim khong 10-20% cc loi khi u biu m, v khong 85% u nang nhy
l lnh tnh, tui thng gp t 30-50.
U nang nhy v mng v nhn, t khi c nh, v nang gm 2 lp: t chc x
v biu m tr. U nang gm nhiu thu ngn cch bi cc vch ngn, trong cha
cht dch nhy vng, kch thc thng to nht trong cc u bung trng.
X tr: m ct b u nang.
- Lc ni mc t cung ti bung trng:
Thng pht hin c qua soi bng hoc trong phu thut 10-25% do tuyn
ni mc t cung lc ch bung trng.
Cu to v nang mng, bn trong cha dch mu chocolate (mu kinh), khi u
thng dnh, d v khi bc tch.
Chn on: da vo cc triu chng au h v, au bng khi hnh kinh, au
khi giao hp, khm tiu khung v soi bng pht hin khi u.
- Khi u t bo sng (Mesonephroid tumour) ging u lc ni mc t cung. Ch
chn on xc nh c bng gii phu bnh.
- Khi u Brenner: 80% l lnh tnh, c ngun gc t mt nang De Graff,
chim khong 1-2 % ca khi u bung trng nguyn pht thng ch gp mt bn
bung trng.

152

Khm tiu khung: pht hin khi u, mt khi u c ch mm ch cng, do

d nhm vi u x t cung, b ra c mu vng hoc trng, kch t

hc khi u

khng to, ng knh 5-8cm.

X tr : m ct b khi u
2.2.2. U nang b (Dermoid cyst):
Chim t l 25% khi u bung trng.Hay gp l teratome, khi u cha t chc
pht sinh t t bo mm. Trong nang cha cc t chc nh rng, tc, b u. U
nang b thng lnh tnh nhng cng c th tr thnh c tnh. Hay c pht hin
la tui 20-30. Khong 20% pht trin c hai bn bung trng.
- Triu chng: thng t triu chng. Pht hin khi m ly thai hoc chp Xquang thy rng trong khi u.
- iu tr: phu thut l phng php ti u. Nu nang nh nn ct b phn u,
li phn bung trng lnh.
3. TIN TRIN V BIN CHNG
Ni chung cc khi u nu khng c x tr ct b s ln dn ln, gy chn p
cc tng trong bng, c th b xon hoc b ung th ha.
Bin chng hay gp l:
- Xon nang: hay gp khi u c kch thc nh, cung di, khng dnh, xon
nang c th xy ra khi ang mang thai (nht l trong nhng thng u thai nghn),
hoc sau khi .
Triu chng: au t ngt, d di, v m hi, chong, nn.
X tr: m cp cu.
- V nang: thngxy ra sau khi nang b xon hoc sau chn thng vng
bng di.
- Nhim khun nang: xy ra khi xon nang. Nhim khun lm nang to ln,
dnh vo cc tng xung quanh. Biu hin lm sng ging vim ni mc t cung.
- Chn p tiu khung: khi u vo trc trng, bng quang. Nang to, tin trin
trong nhiu nm chon ht bng, chn p tnh mch ch di gy ph, tun hon
bng h, c chng.

153

- C thai km u nang bung trng:

c chn on qua khm thai nh k hoc qua siu m.
C th gp bt k loi nang no, nhng hay gp l nang hong th hay u nang
b, t khi gp nang c tnh.
Nu nn m vo thi gian sau 13 tun v lc ny rau thai tit hocmon
nui dng thai, nu l nang hong th th thng gim kch thc hoc khng pht
trin na, c th khng cn phi m.
Nu u pht trin to nn trong 3 thng gia thai k, th nn m ngay, tr khi ch
pht hin c trong thi k cui thai nghn.
4. NGUYN TC IU TR:
- Khi chn on u nang thc th nn m ct u sm.
- Nang nc gp ngi ln tui nn ct c hai bung trng
- Nang nhy cn ct b c hai bn bung trng trnh ti pht.
- Nang b ct b khi u c gng bo tn nhu m lnh.
- Nu nang bung trng hai bn ngi tr tui cn bo tn bn lnh.
- Nang ngi c thai nu c ch nh gi thai nn bc nang vo thng th t.
- U nang c du hiu nt v cn sinh thit tc th phng ung th.
- U nang to ngi gi ch trnh lm gim p lc t ngt bng.
- Nu cc u nang pht trin trong y dy chng rng, bc tch cn thn
phng chm niu qun, rut, bng quang.

154

U X T CUNG (FIBROID)
1. KHI NIM
U x t cung l khi u lnh tnh, c ngun gc t c trn ca t cung, thng
gp ph n trong tui sinh , tui thng gp 35-50; kch thc khi u
thng gp khong di 15cm. U x t cung thng t c triu chng nhng khi
khi u ln c th gy ri lon kinh nguyt, au do chn p v v sinh .
2. TRIU CHNG V CHN ON
2.1. Triu chng c nng:
- Ra huyt t bung t cung: l triu chng chnh gp trong 60% trnghp,
th hin di dng cng kinh, dn dn kinh nguyt ri lon: rong kinh ko di v
ra nhiu mu.
- Ton thn b thiu mu, xanh xao, gy st nu ra mu ko di.
- au vng h v hoc h chu, au kiu tc, nng bng di,(40%
trnghp) do khi u chn p vo cc tng bn cnh hoc do vim khung chu.
- Ra kh h long, hoc ra kh h do vim m o, vim nim mc t cung.
2.2. Triu chng thc th :
- Nhn c th thy khi u g ln vng h v, nu khi u to.
- Nn bng: c th thy khi u (nu to) vng h v, mt chc, di ng lin
quan n t cung.
- t m vt: c th thy polip c cung nm ngoi c t cung.
- Thm m o kt hp nn bng thy ton b t cung to, chc, c khi thy
nhiu khi ni trn mt t cung; di ng c t cung th khi u di ng theo.
2.3. Cn lm sng:
- Siu m: thy t cung to, o c kch thc nhn x, siu m bm nc
bung t cung c th pht hin polyp bung t cung.
- Soi bung t cung: chn on v iu tr cc polip di nim mc.
- Xt nghim t bo hc: pht hin cc tn thng c t cung km theo

155

2.4. Chn on phn bit

- Vi t cung c thai: hi bnh, khm lm sng, th thai, siu m.
- Khi u bung trng: thng c v tr v di ng bit lp vi t cung, siu m
- Ung th nim mc t cung: hi bnh, khm lm sng, xt nghim t bo hc
v siu m.
3. TIN TRIN V BIN CHNG
- U x t cung thng tin trin chm, c th ngng pht trin sau khi mn kinh.
- Bin chng:
+ Chy mu: rong kinh, rong huyt, ko di gy thiu mu.
+ Chn p cc tng chung quanh gy au, to bn, b tiu.
+ Thoi ha, hoi t v khun.
4. U X T CUNG V THAI NGHN
- Chm c thai hoc v sinh.
- Khi c thai:
+ Khi u x thng to ln.
+ u x c th gy sy thai, non, ngi thai bt thng.
- Gy rau tin o, rau bong non.
- Khi : gy ri lon cn co, tr thnh khi u tin o, chuyn d ko di.
- Thoi ha khi u gy au bng
5. X TR
5.1. Tuyn x:
Pht hin ra u x t cung, nu:
- Khi u nh, khng nh hng n kinh nguyt hay khng c nhng ri lon
khc hn theo di khm nh k sau 6- 12 thng.
- U x t cung bng huyt ( loi tr cc nguyn nhn khc), tim bp
oxytocin 5UI x 2 ng, chuyn tuyn trn.
5.2. Tuyn huyn:
- iu tr ni khoa ch nh i vi mt s khi u nh mc ch hn ch s
pht trin ca khi u v hn ch rong kinh rong huyt. Thuc c th s dng:

156

Medroxyprogesteron acetat 10mg / ngy x 10 ngy t ngy 16 k kinh hoc dng

thuc Danasol 200mg / ngy x10 ngy
- iu tr ngoi khoa (m ni soi hay m m):
+ U x c bin chng rong kinh, rong huyt , iu tr ni khoa khng kt qu.
+ U x phi hp vi cc tn thng khc nh: u nang bung trng, lon sn
c t cung, sa sinh dc ...
+ U x to, gy chn p.
+ U x lm bin dng bung t cung, u x di nim mc gy chy mu v
nhim khun.
Ty theo tui, s ln c thai, mong mun c thai quyt nh cch x tr: bc
nhn x bo tn t cung, gy tc mch hay ct t cung bn phn hoc hon ton .

157

LC NI MC T CUNG
1. KHI NIM
- Lc ni mc t cung (LNMTC) l bnh l lin quan n s hin din ca cc
tuyn ni mc t cung v m m bn ngoi t cung. S hin din ny to nn
tnh trng vim mn tnh, pht trin v thoi ha theo chu k kinh nguyt chu nh
hng ca ni tit sinh dc.
- Tn sut gp khong 5 10% ph n trong tui sinh . Tn sut cao r
rt ph n v sinh
- Yu t nguy c:
+Tin s gia nh c ngi b LNMTC
+ Cu trc ng sinh dc bt thng v tc nghn hnh kinh
+ Cha sinh, hay him mun
2. LM SNG V CHN ON
2.1. C nng:
- au lin quan n chu k kinh nguyt, mc au khng lin quan n s
lng LNMTC m ch yu lin quan n mc xm nhp ca tn thng.
- T s thy khi u h v
- V sinh
2.2. Thc th:
- TC c th to v dnh
- Khi u bung trng
2.3. Cn lm sng
- Siu m: ng bng hay ng m o
+ Pht hin cc khi u t cung c bit pht hin cc khi u 2 bung trng
- Chp cng hng t (MRI)
+ Pht hin v nh gi y v v tr v mc ca khi LNMTC
+ Chn on phn bit vi khi u vng h v khc

158

- Xt nghim CA 125: thng tng trong lc ni mc t cung tuy nhin t c

gi tr v khng c hiu
- Xt nghim khc: soi bng quang, soi i trng trong nhng trng hp
cn thit.
- Ni soi bng: l tiu chun vng trong chn on lc ni mc t cung
2.4. Chn on: da vo lm sng v cn lm sng c bit l ni soi bng
3. IU TR
Nguyn tc iu tr LNMTC: ch nn iu tr khi c triu trng au hay v
sinh hoc c hai
Mc tiu iu tr: gim au, gim mc tin trin v ti pht bnh, tng kh
nng c thai
La chn iu tr da trn mc tiu iu tr: gim au hoc c thai
3.1. Mc tiu gim au
Phc iu tr au nghi LNMTC
Chn on ban u

iu tr ni khoa bc 1
Tht bi

Thnh cng

Trao i v la chn iu tr bc 2

tng bc iu tr
ni khoa

Tht bi

Chn on v phu thut bo tn

Khng p ng
Thnh cng

iu tr ni khoa h tr sau PT

Theo di
Ti pht

Phu thut tn cn

Xem li chn on: xt nghim b

sung

159

3.1.1.iu tr ni khoa bc 1
- Thuc gim au
+ Gii php tm thi
+ Cc liu php iu tr au do LNMTC c th cn t nht mt chu k bt
u gim au
+ Gip ngi bnh d chu hn cho ti khi iu tr ni khoa chnh c hiu
qu: NSAID / Opioid
- Vin nga thai kt hp (CHC)
Khuyn co dng thuc lin tc
+ Khng hnh kinh nn gim au
+ Hp l vi gi thuyt tro ngc mu kinh, nhng CHC khng hiu qu
gim au trong LNMTC lin quan n th th estrogen v progestin trong LNMTC
lc ch.
Ko dng qu 3 thng nu ko gim au
3.1.2. iu tr ni khoa bc 2
- Progestin ng ung
- Progestin ng tim( Depot progestin - DMPA)
- Progestin phng thch trong t cung(LNG IUS)
+ Gii phng 20g/ngy ti vng chu
+ Gn 60% ngi bnh: teo ni mc v v kinh
+ Khng c ch rng trng
+ > 50% ngi bnh hi lng vi iu tr sau 6 thng
u im:
+ iu tr lin tc 5 nm
+Tp trung progestin ti vng chu cao
+ t vo h tun hon: gim tc dng ph ton thn
Nhc im :
+ T l ri dng c khong 5%
+ Nguy c nhim trng vng chu khong 1,5%

160

- Danazol
- Liu php ng vn GnRH
+ GnRH agonist/addback l chn la trn ngi bnh:
Khng p ng vi CHC hoc progestin
Ti pht triu chng
C ch: GnRH c ch bi tit FSH, ngn chn bung trng tit estrogen & to
nn tnh trng suy gim estrogen. Lm bt hot m LNMTC => gim au
Nn dng kt hp vi addback
Hn ch:
Tnh trng suy gim estrogen
- Bc ha, tot m hi, kh m o, mt xng
- Khng khuyn co GnRHa > 6 thng: mt xng
Ti pht sau khi ngng iu tr GnRHa
3.2. iu tr ngoi khoa
3.2.1. Ch nh:
- au vng chu:
+ Khng p ng iu tr ni khoa
+ Tnh trang au cp nghi do xon hay v nang
+ Xm nhp c quan ln cn: t cung, bang quang, rut
- Nghi ng c LNMTC th bung trng
- Him mun c thm yu t phi hp
3.2.2..Phng php m:
- Ni soi l phng php c la chn rng ri nhiu u im so vi m m.
Vi mc tiu l ly i cc tn thng phc hi gii phu vng chu v gim au
- Trong LNMTC th bung trng:
Xem xt nguyn vng c thai ca ngi bnh quyt nh mc can thip:
+ Ni soi dn lu v t lng nang, khuyn co vi cc nang < 3cm
+ Ni soi bc nang, khuyn co vi cc nang > 3cm, tuy nhin tng nguy c
suy tuyn bung trng.

161

Khuyn co ASRM 2004: iu tr ni trc m lm ngng chu k kinh

nguyt, gip gim vim, gim kch thc khi LNMTC v mch mu, t gim
nguy c chy mu trong m v nguy c dnh hu phu
T l ti pht sau phu thut n thun: 15 - 36% trong nm u v 33 64%
trong 5 nm
Hip hi ASRM khuyn co: iu tr ni khoa sau phu thut nhm ph hy
tn gc cc tn thng cn st li cng nh nguy c ti pht.
iu tr ni khoa h tr 3 -6 thng sau m gip gim nguy c ti pht.
3.3. Mc tiu iu tr c thai
S iu tr v sinh trn ngi bnh LNMTC mong c thai
Chn on v sinh
nh gi d tr bung trng

Phn tch tinh dch

H tr sinh sn
nh gi vi dn trng

Phu thut

IVF tc thi nu d
tr bung trng gim
IVF nu khng th
th thai t nhin

Khng phu
thut trc
h tr sinh
sn
IVF hoc ICSI

Theo di th thai t nhin t 618 thng

Nu khng th thai

c ch bung trng GnRHa 3-6

thng

- IUI kt hp kch thch bung trng ci thin kh nng th thai ngi bnh
b LNMTC nh n trung bnh, vi iu kin vi dn trng bnh thng
- Hiu qu ch yu do kch thch bung trng, v IUI n thun c th khng c li.

162

Th tinh trong ng nghim

- Thng c ch nh bc 1 trn ngi bnh LNMTC nng v chc nng
vi dn bt thng, hoc trn ph n ln lui hoc/ v cht lng tinh trng gim.
- T l thnh cng thp hn bnh l khc
- iu ha gim th th tuyn yn di hn trc IVF / ICSI bng GnRHa ci
thin t l mang thai lm sng.
Phu thut c ch nh khi c nhng tn thng theo c ch:
- A2 = dnh gy mt di ng ca ng dn trng
- T2 = tc nghn hon ton v 2 bn
- O2 = lc ni mc t cung vi gim d tr bung trng
- RVS 1 v 2 = lc ni mc t cung v tr trc trng m o (c hoc khng
nh hng n ng tit niu, c hoc khng tn thng trc trng)
- Khng phi lc no cng c gii hn r rng gia m lnh v m lc ni mc.
- Ph hy m rng bng t in khi tnh trng vim vng chu lan rng
- Nguy c ph hy cc m chc nng (vi trng, bung trng)

163

TIN UNG TH V UNG TH M H TN THNG TIN UNG TH

1. KHI NIM
Da ph vng m h l mt tp hp cc t bo biu m sinh dc, tri rng t
phn ngoi cng ca m o ti vng tng sinh mn v quanh l hu mn. Tng
sinh non (neoplasia) vng da m h thng i km vi nhiu v tr lon sn
ng sinh dc thp.
2. TRIU CHNG LM SNG V CHN ON
Bnh din bin m thm m khng c triu chng g ni tri, phn ln ngi
bnh VIN c triu chng nga (chim 60%), do vy vic chn on ch yu da
vo s quan st k bng mt v qua soi m h nhm pht hin ra nhng v tr tn
thng nghi ng sinh thit.
Chn on tn thng tin ung th: khong 1-2% ph n tr c lon sn c t
cung th cng c nhiu tn thng bnh l pht trin 1/3 trn m o, m h, vng
da tng sinh mn v xung quanh hu mn. Cc tn thng ny c th ch l cc lon
sn trung bnh cho n ung th ti ch vi hnh nh in hnh l tn thng mu
trng, sng ho, nhng cng c th c mu sc bt thng khc nh mu xanh xm,
hng, hoc nu. i khi cng c th thy xut hin mch mu bt thng ti m h
v khi thng i km vi tn thng lon sn nng hay ung th. Sinh thit
khng nh chn on l tiu chun vng.
3. IU TR TN THNG TIN UNG TH
- Bao gm ct b rng tn thng, km theo t b bng laser nhng tn
thng nh, bi 5-fluorouracil (5-FU). nhng ph n tr i khi tn thng c
th t thoi trin.
- Cc trng hp VIN III (ung th ti ch) c khong 10- 22% l giai on
ung th vi xm nhp, nhng trng hp ny iu tr tt nht l ct m h, nht l
nhng ph n ln tui.
- Ngi bnh cn c theo di sau iu tr t nht trong vng 2 nm, c 6
thng khm li mt ln kt hp vi soi m h.

164

UNG TH M H
1. KHI NIM
Ung th m h chim khong 5% trong s nhng ung th ph khoa v ng
hng th t trong s nhng ung th ng sinh dc, sau ung th ni mc t cung,
c t cung, bung trng. La tui mc bnh khong 60 70, vi tui trung bnh l
65, trong 75% ngi bnh > 50 tui, tuy nhin cng c khong 15% gp ph
n di 40 tui v c xu hng tng ln trong thi gian gn y nhng ph n tr
t 20 40 tui do c mi lin quan r rt vi nhim HPV.
Ung th m h c th xut pht t da, t chc di da, cc thnh phn tuyn
ca m h hoc t t bo biu m 1/3 di m o. Khong 90% l ung th biu
m vy. Tn thng t gp nht l bnh Paget, ung th tuyn Bartholin, ung th t
bo y, t bo sc t, sarcoma v di cn t cc c quan khc n.
2. NGUYN NHN
Cc tn thng ung th m h c phn ra tu theo ngun gc v m bnh hc.
2.1. T bo biu m vy
Thng gy tn thng na trc ca m h, 65% khi u nm mi ln v
mi b, 25% nm m vt hay tng sinh mn. Hn 1/3 cc ca l c tn thng c
hai bn. Thng c km theo di cn hch . Tn thng bt u di dng da vng
dy ln, phng v trng do qu sn, ri dn dn dn n lot, hoi t v lan rng
gy nhim trung th pht v c mi hi thi.
2.2. Ung th tuyn Bartholin:
Chim khong 1% cc ung th m h. Khong 50% c dng t bo biu m
vy. Phi lun chn on phn bit vi nang tuyn Bartholin lnh tnh, v vy
nhng ph n > 40 tui m c nang tuyn Bartholin th nn c lm gii phu
bnh loi tr ung th v tui ny t khi l vim n thun. Do c th ca ung
th tuyn Bartholin l nm su di hai mi ln nn khi u ung th thng c xu
hng lan rng ngay vo vng trc trng v h chu. Hu qu l thng c di cn
trc tip vo h thng hch chu cng nh hch bn.

165

2.3. Ung th t bo y
Chim khong 1-2% ung th m h. Thng gp l nhng tn thng nh vi
lot gia v b cun vo trong. i khi di dng nh u sc t, u nt rui, hay
n gin ch l vng ty do nga m gi. Carcinoma t bo y xy ra trn tt c
nhng vng c lng trn c th v i khi xy ra ti da vng mi ln: (1) dt hoc
mng lng mu hoc nu (2) khi u nh vi vng trung tm b lot. c im
ca tn thng ny l pht trin chm, thm nhim ti ch v khng bao gi di cn
hch. iu tr ct b rng khi u l bin php tt nht phng nga ti pht. (nguy
c ti pht l 20% nu khng ct rng)
2.4. Ung th hc t
Chim t l khong 5%, ng hng th hai trong cc ung th m h. Tn
thng hay gp mi nh v m vt v thng lan rng trn b mt hng vo m
o v niu o. Biu hin tn thng l u hc t en, c bit ging nh nt rui
dnh nhau. Bnh c xu hng di cn sm ngay t giai on u theo h thng hch.
Mi u sc t nghi ng u phi c sinh thit sm, nu tn thng nh nn ly ra
ngoi t 0,5 1cm ca vng da bnh thng xung quanh.
iu tr: ct b khi u ti ch rng v ly hch bn mt bn hoc ct m h
trit , no vt hch bn i hai bn.
2.5. Bnh Paget
Chim < 1%. l tn thng trong biu m ca m h hoc
adenocarcinomati ch. Bnh thng tin trin chm, tn thng xut hin hai
vng khc nhau: 1) tn thng Paget ti v. 2) Tn thng Paget ti m h. Nhng
khng ging vi Paget v, t nht 20% bnh Paget m h i km vi tn thng
adenocarcinoma ung th tuyn b lng, tuyn Bartholin v loi ny thng di cn
theo h thng hch v i xa.
Chn on: bnh thng gp nhng ph n gi khong 70 tui nhng cng
c th tr hn vi biu hin lm sng thng gp l nga, au, kh chu m h,
triu chng ny c th ko di c nm trc khi c biu hin lm sng.

166

Tn thng c dng chm vi vy mu , ni ln nhng mng trng nh

ging nh vt trng, nga khu tr mt bn mi hoc lan rng ra ton b vng m
h. iu tr bng cch ct b tn thng rng ti ch ly ht phn tuyn ngoi
tit ca da xt nghim t bo hc xem c adenocarcinoma km theo khng. Nu
c adenocarcinoma km theo th phi phu thut ct b m h trit km theo no
vt hch bn i hai bn.
Bnh Paget m h c t l ti pht ti ch cao, ngay ti ch ct b hay tn
thng v tr khc ca m h. Khi c ti pht phi ct rng li v thm ch ct b
m h.Nu khng c di cn hch th tin lng thng tt.
2.6. Adenocarcinoma dng mn cm
Tn thng c biu hin si nh sp l hoc c nh ging nh si mo g, tn
thng ny trc kia c gi l si mo g khng l Buscheke Lewenstein, tn
thng thng ch xm nhim ti ch, him khi di cn hch. Sinh thit cho php
phn bit tn thng ny vi si mo g v u nh, cn sinh thit su v nu sinh
thit nng th rt kh c. Hnh nh gii phu bnh: khi u nh tng sng ho hoc
sng ho bnh thng, t bo cu gai c nhng nh n su vi biu m bit ho cao
khng c nhn qui nhn chia. iu tr bng ct b rng tn thng ti ch, v tia
x phi hp khi t bo hc l carcinoma khng bit ho.
2.7. Sarcoma m h
Chim 1- 2% cc trng hp ung th m h, thng l leiomyosarcoma. Biu
hin trn lm sng c th di dng l nhng u hch di da hoc c th l nhng u
dy, chc. iu tr bng ct rng tn thng ti ch, tt nht l ct b m h, no
vt hch, kt hp vi iu tr bng tia x v ho cht. Tin lng thng l ti, v
tu thuc loi t bo.
3. Triu chng lm sng
- Ung th m h thng i km vi mt s bnh l ton thn khc, khong
10% ngi i tho ng, 30 50% bo ph v cao huyt p hay nhng bnh l
tim mch.

167

- Nga m h hay khi u m h l nhng triu chng thng gp nht chim

khong > 50%. Mt s ngi bnh khc n khm v chy mu hay au m h,
nhng cng c khong 20% ngi bnh khng c triu chng g v khi u ch c
pht hin qua khm ph khoa nh k.
4. CHN ON XC NH
chn on xc nh v phn bit vi cc tn thng khc m h th vic
sinh thit xt nghim m bnh hc l chnh xc nht.
5. CC GIAI ON CA BNH
5.1. Phn loi theo Hi sn ph khoa Quc t
- Giai on 0 CIS: nh bnh Bowen, bnh Paget khng xm nhim.
- Giai on 1 T1 N0 M0: khi u cn khu tr ti m h, t 2 cm tr xung,
hch bn khng s thy hoc s thy cng bn nhng khng to v cn di ng.
- Giai on 2 T2 N0 M0: khi u cn khu tr ti m h, t 2 cm tr ln, hch
bn khng s thy hoc s thy cng bn nhng khng to v cn di ng.
- Giai on 3 T3 N0 M0 hoc T3 N1 M0: khi u bt k kch thc no:
(1) lan ra niu o hoc m o, tng sinh mn, hu mn; (2) T1 N1 M0 hoc
T2 N1 M0: C th s thy 1 hoc 2 bn bn hch to, chc, di ng v cha dnh.
- Giai on 4: khi u bt k kch thc no: T1 N2 M0 hay T2 N2 M0(1)
xm nhim bng quang, nim mc bang quang, nim mc trc trng hoc c hai,
bao gm c phn trn ca nim mc niu o; (2) Bt k T, Bt k N, M1: dnh vo
xng hoc di cn xa, gm c hch chu
5.2. Phn loi theo h thng TNM
T: khi u nguyn pht.
T1: khi u khu tr ti m h, ng knh ln nht < 2cm.
T2: khi u khu tr ti m h, ng knh ln nht > 2cm.
T3: khi u bt k kch thc no lan ti niu o v / hoc m o v /
hoc tng sinh mn v / hoc hu mn.

168

T4: khi u bt k kch thc no xm nhim ti nim mc bang quang v /

hoc nim mc trc trng bao gm c phn trn ca nim mc niu o v / hoc
dnh vo xng.
N: hch ti ch
N0: khng s thy.
N1: s thy hch bn cng bn, khng to, di ng (v mt lm sng khng
ngh ti hch c tnh).
N2: s thy hch mt bn hoc hai bn bn, to, chc, di ng (v lm sng
nghi ng hch c tnh).
N3: hch dnh nhau, khng di ng hoc lot.
M: di cn
M0: khng c biu hin lm sang di cn xa.
M1A: c th s thy hch bn chu su.
M2A: nhng di cn xa khc.
6. IU TR
Nguyn tc iu tr ung th m h l phu thut. Nu giai on u ca
bnh v tu loi ung th th c th ct b rng ton b tn thng, tuy nhin phi
khm tng th ton b ng sinh dc pht hin cc bnh l khc ca t
cung, c t cung i km theo, nht l khi c chy mu i km v a s ngi
bnh ln tui, mn kinh. Nu tn thng lan rng th tt nht l ct b m
h km theo no vt hch vng bn hoc thm ch c h thng hch chu. Kt
hp tia x v ho cht sau no (thng l Cisplatin v 5 - FU). Mt s nghin
cu cho thy vic iu tr v ho cht trc m cho hiu qu iu tr tt hn v
gim t l bnh phi phu thut ct b rng.

169

CHA TRNG
1. KHI NIM
Cha trng (hydatidiform mole) l mt bin i bnh l ca nguyn bo nui.
Bnh c trng bng s thoi ho nc ca cc gai rau (hydropic degeneration) v
s qu sn ca cc nguyn bo nui (trophoblastic hyperplasia).
C 2 loi cha trng: cha trng bn phn l khi ch mt s gai rau tr thnh
cc nang nc, trong bung t cung c th c phn thai nhi. Cha trng hon ton
l ton b cc gai rau tr thnh nang nc, trong bung t cung khng c phn thai.
Cha trng l bnh lnh tnh nhng c khong 15% trng hp cha trng
hon ton v khong 3% cha trng bn phn tr thnh ung th nguyn bo nui.
2. CHN ON
2.1. Lm sng
2.1.1. C nng
- Ngi bnh c hin tng chm kinh.
- Rong huyt chim trn 90% trng hp cha trng. Mu ra m o t
nhin, mu sm en hoc long, ra ko di.
- Nghn nng: gp trong 25-30% cc trng hp, biu hin nn nhiu, i khi
ph, c protein niu.
- Bng to nhanh.
- Khng thy thai my.
2.1.2. Thc th
- Ton thn: mt mi, biu hin thiu mu.
- T cung mm, kch thc t cung ln hn tui thai (tr trng hp cha
trng thoi trin).
- Khng s c phn thai.
- Khng nghe c tim thai.
- Nang hong tuyn xut hin trong 25-50%, thng gp c 2 bn.

170

- Khm m o c th thy nhn di cn m o, mu tm sm, thng thnh

trc, d v gy chy mu.
- C th c du hiu tin sn git (10%)
- C th c triu chng cng gip (10%)
- Tuy nhin do hin nay vic chn on cha trng thng rt sm vi tui
thai trung bnh l 9 tun so vi trc kia l khong 13 tun , v c xu hng ngy cng
sm hn nn cc triu chng lm sng ngy cng khng in hnh nh nu trn.
2.2. Cn lm sng
2.2.1. Siu m: trn siu m thy hnh nh tuyt ri hoc l ch nh t ong, c
th thy nang hong tuyn hai bn, khng thy phi thai (cha trng ton phn).
Trong cha trng bn phn th kh phn bit hn vi thai lu, c th thy mt phn
bnh rau bt thng .
2.2.2. nh lng -hCG: l xt nghim c bn chn on v theo di cha
trng. Lng -hCG tng trn 100 000mUI/ml.
2.2.3. nh lng estrogen: trong nc tiu estrogen di dng cc estrone,
estradiol hay estriol u thp hn trong thai thng, do s ri lon ch tit ca rau
v do khng c s bin i estradiol v estriol xy ra tuyn thng thn ca thai
nhi. Nhng t ngha v khng s dng trong thc t v s khc bit ny ch thy r
khi tui thai t 14 tun tr ln.
2.2.4..Xt nghim nh lng HPL: (Human placental lactogen), thng cao
trong thai thng, nhng rt thp trong cha trng.
2.2.5. Gii phu bnh
- i th: c 2 loi thai trng:
+ Cha trng ton phn: ton b gai rau pht trin thnh cc nang trng.
+ Cha trng bn phn: bn cnh cc nang trng cn c m rau thai bnh
thng, hoc c c phi, thai nhi thng cht trong giai on 3 thng u.
ng knh nang trng t 1-3mm. Cc nang trng dnh vo nhau nh nhng
bc trng ch hoc chm nho.

171

Trong cha trng, bung trng b nh hng bi hormon hCG. Nang hong
tuyn xut hin mt hoc hai bn bung trng. ng knh t vi cm n vi
chc cm, trong cha dch vng. Nang hong tuyn thng c nhiu thu, v nang
mng v trn lng.
- Vi th: cc gai rau ph v thoi ha nc trc lin kt, khng cn cc t bo
x, si v cc huyt qun. Trc lin kt cha dch trong. Cc nguyn bo nui qu sn
nhiu hng (hnh thi ging cc nguyn bo nui bnh thng tuy nhin cng c th
gp mt s nguyn bo nui c nhn khng in hnh hoc cc hnh nhn chia), mt
cn i gia t l hp bo nui v nguyn bo nui. Hnh thnh cc m nguyn bo
nui t do. Trong cha trng bn phn, ngoi cc hnh nh gai rau thoi ha trc lin
kt v qu sn nguyn bo nui cn gp cc gai rau c hnh thi bnh thng.
2.3. Chn on xc nh
Ch yu da vo hnh nh siu m v nng -hCG
2.4. Chn on phn bit
- Triu chng ra mu m o cn phn bit vi:
+ Do sy thai thng: t cung khng to hn tui thai, lng -hCG khng cao.
+ Thai ngoi t cung: ra mu m o, t cung nh, c khi cnh t cung au.
+ Thai cht lu: t cung nh hn tui thai, hCG thp, v c tit sa non. C
th nhm vi cha trng bn phn, ch phn bit c nh gii phu bnh.
- T cung ln cn phn bit vi:
+ U x t cung to rong huyt
+ Thai to
+ a thai
- Triu chng nghn phn bit vi nghn nng trong thai thng, a thai.
3. IU TR
3.1. No ht trng: no ht trng ngay sau khi c chn on phng sy t
nhin gy bng huyt.
K thut: ht trng + truyn oxytocin + khng sinh.
- Thng dng my ht di p lc m ht nhanh, chy mu.

172

- Trong khi ht phi truyn tnh mch dung dch Glucose 5% pha vi 5 n v
Oxytocin gip t cung co hi tt, trnh thng t cung khi no v cm mu.
- C th no li ln 2 sau 2 - 3 ngy nu ln th nht khng m bo ht trng.
Ngy nay, di hng dn, kim tra ca siu m thng nao sch ngay trong ln u.
- Sau no phi dng khng sinh chng nhim trng.
- Gi t chc sau no lm xt nghim gii phu bnh.
Hin nay do thng c pht hin sm nn thai nh c th ht bng xylanh
Karman nh ht thai thng, tt nht l ht di hng dn ca siu m, m bo
sch v an ton nn ch cn ht mt ln v ch dng thm thuc co hi t cung khi
c chy mu (mt s tc gi cho rng vic dng Oxytocin hay misoprostol lm tng
co bp t cung c th dn n s khuch tn cc nguyn bo nui v lm tng t l
u nguyn bo nui).
3.2. Phu thut ct t cung d phng
Ct t cung ton phn c khi hoc ct t cung ton phn sau no ht trng
thng c p dng cc ph n khng mun c con na hoc trn 40 tui v
trng hp cha trng xm ln lm thng t cung.
3.3. Theo di sau no trng
- Lm sng:
+ Ton trng, triu chng nghn, triu chng ra mu m o, s nh li ca
nang hong tuyn v s co hi t cung.
- Cn lm sng:
+ nh lng hCG mi tun mt ln cho n khi m tnh 3 ln lin tip. Sau
nh lng mi thng mt ln cho n ht 12 thng.
+ Siu m: tm nhn di cn, theo di nang hong tuyn.
- Tin trin bnh l: nhng tin trin khng tng ng vi cc tiu chun lnh
bnh c coi l tin trin khng thun li. Bao gm:
+ T cung vn to, nang hong tuyn khng mt i hoc xut hin nhn di cn.
+ -hCG: phng tin chnh theo di v chn on bin chng sau loi b
thai trng (bao gm c cc trng hp c ct t cung d phng).

173

Nng hCG ln th sau cao hn ln th trc

Nng hCG sau 3 ln th k tip khng gim (gim di 10%)
Nng hCG >20 000 UI/L sau no trng 4 tun
Nng hCG >500 UI/L sau no trng 8 tun
Nng hCG >5 UI/L sau no trng 6 thng
- Thi gian theo di
+ Thi gian theo di: 2 nm, t nht 12 - 18 thng.
+ Trnh thai 1 nm v c bin php nga thai ph hp.
4. BIN CHNG
Bng huyt, thng t cung, bin chng ung th nguyn bo nui.
5. PHNG BNH
- Tng cng sc kho, ci thin yu t x hi, nng cao mc sng, sc khng.
- phng cc din bin xu ca bnh.
- Theo di nh k v y , nhm pht hin sm bin chng ca bnh.

174

U NGUYN BO NUI
1. KHI NIM
U nguyn bo nui l nhng khi u c ngun gc rau thai. U c nhiu dng:
t dng c xu hng c tnh nh cha trng xm ln, n nhng dng c tnh nh
ung th nguyn bo nui, u nguyn bo nui vng rau bm v u nguyn bo nui
dng biu m.
iu lu l khng nht thit ln mang thai cui cng dn ti pht sinh u.
2. CHN ON
2.1. Lm sng
- Tin s: cha trng c coi l yu t nguy c hng u dn ti u nguyn
bo nui, trong a s xut hin u nguyn bo nui sau cha trng ton phn
(70%). Bnh thng xut hin trong 4 thng u sau no thai trng.
- Triu chng c nng
+ Nhiu khi khng c du hiu g bt thng, ngoi tr c th ra mu ko di
sau hay sau no ph thai.
+ Cc du hiu di cn nh kh th, au u.
- Triu chng thc th
+ Ra mu m o: l du hiu hay gp nht
+ T cung ln hn bnh thng. Mt t cung mm, co hi t cung km.
Nhng nhiu trng hp t cung vn c th bnh thng
+ C th thy nhn di cn m o, m h mu tm sm, thng mt trc
m o.
2.2. Cn lm sng
-hCG: nng hCG tng tr li sau cha trng l du hiu quan trng
chn on sm bnh u nguyn bo nui.
- Siu m v siu m Doppler c t cung v ng mch t cung c th thy
nhng khi u trong c t cung, xm ln vo lp c t cung v tng sinh mch mu,
ng thi siu m gip pht hin cc di cn ti gan, thn.

175

- Chp X quang lng ngc tm nhn di cn ti phi

- Chp CT scanner v MRI: pht hin nhn di cn no,gan, di cn xng.
- Chc d nc no tu nu nghi ng di cn ty sng hay ngi bnh c biu
hin bnh l ty.
- Sinh thit: sinh thit cc tn thng l cn thit nhng khng lm nu ngi
bnh c nguy c xut huyt nng.
- Chn on gii phu bnh
+ i th: t cung to hn bnh thng, kch thc thay i ty thuc vo mc
tn thng. Mt ngoi nhn tr khi u pht trin ra thanh mc hoc gy thng t
cung. Khi u t cung c kch thc thay i, ph hy c t cung to mu
thm, hoi t, chy mu ln cc vng m mu vng nht, khng thy cc nang
trng. C th pht hin thy cc nhn di cn m o.
+ Vi th: m u cho thy vng hoi t huyt rt rng, ph hy c t cung vi s
hin din ca cc nguyn bo nui c tnh (c hp bo nui v n bo nui c
tnh). Khng thy gai rau, khng thy phn ng ca m m, hu nh khng thy t
bo rng.
2.3. Chn on xc nh
- Chn on bnh u nguyn bo nui da vo nh lng hCG sau no trng:
+ Nng hCG ln th sau cao hn ln th trc
+ Nng hCG sau 3 ln th k tip khng gim (gim di 10%)
+ Nng hCG >20 000 UI/L sau no trng 4 tun
+ Nng hCG >500 UI/L sau no trng 8 tun
+ Nng hCG >5 UI/L sau no trng 6 thng
- Gii phu bnh t cung cho thy c u nguyn bo nui.
2.4. Phn loi
Theo phn loi ca T chc Y t th gii (2003), bnh u nguyn bo nui gm:
+ Cha trng xm ln (Invasive mole) l dng c cha trng c xu hng c tnh
+ Ung th nguyn bo nui(Choriocarcinoma)
+ U nguyn bo nui vng rau bm (Placental site trophoblastic tumour)

176

+ U nguyn bo nui dng biu m (Epithelioid trophoblastic tumour)

Phn loi cc yu t tin lng u nguyn bo nui theo WHO (2006)
im im
Yu t tin lng
Tui (nm)
Tin s sn khoa

< 40

> 40

Cha trng

Sy,no thai

Thai thng

<4

4-<7

7 - < 13

13

< 103

103 - 104

104 - 105

> 105

35

>5

Lch, thn

Rut

Gan, no

14

>4-8

>8

S thng t ln c thai
cui n lc iu tr
(thng)
hCG (IU/1)
Kch thc khi u(cm)
V tr di cn

Phi

S lng nhn di cn
iu tr ho cht trc

n ho cht

Hai ho
cht

Cch iu tr da vo im tin lng:

im 0 - 6: gguy c thp
im

7: nguy c cao

khi pht iu tr n ha cht.

khi pht iu tr a ha cht

3. IU TR
3.1. Ha tr liu
- n ha tr liu:
Ch nh cho nhm c nguy c thp: bnh giai on I, II, hoc III vi im
tin lng theo WHO < 7 im.
MTX 0,4mg/kg tim bp, tim tnh mch trong 5 ngy nhc li sau 12-14 (7-9
ngy).
MTX 1mg/kg tim bp, tim tnh mch ngy 1,3,5,7. Axit foclic 0,1mg/kg tim
bp, tim tnh mch ngy 2,4,6,8 nhc li sau 15 - 18 ngy (7-9 ngy).
Dactinomycin 10mcg/kg/ngy tnh mch ngy 1 -5. Chu k 14 ngy

177

- a ha tr liu:
Ch nh cho nhm c nguy c cao: bnh giai on I, II hoc III m c im tin
lng theo WHO 7 hoc bnh giai on IV.
Phc khi u l EMA-CO. Nu xut hin khng ha cht th chuyn sang
phc EMA-EP v sau l BEP hoc paclitaxel + cisplastin/ etoposide
- Chng ch nh iu tr ha cht: d ng vi mt trong cc thnh phn ca
thuc; suy thn, suy gan nng; nghin ru; bnh h thng to mu (suy tu, gim
bch cu...); ang nhim khun; lot ng tiu ho; vt thng va m.
- Tc dng khng mong mun: tc dng ph thng gp l nn, bun nn,
kh nut, lot ming, vim hng, gim bch cu, gim tiu cu, lot ng tiu
ho, rng tc, vim thn, vim gan.
- Theo di bin chng: lm cc xt nghim nh gi cng thc mu,
creatinin, BUN, SGOT v SGPT.
- Sau khi hCG m tnh th tip tc iu tr thm 1 3 t ha cht.
3.2. X tr: ch nh cho cc khi di cn c nguy c chy mu nghim trng cha th
phu thut c.
3.3. Phu thut: ct t cung cho cc trng hp khng ha cht, loi b khi di
cn tn ti phi, gan
4. THEO DI SAU IU TR U NGUYN BO NUI
Khm lm sng
nh lng hCG 2 tun mt ln trong vng 3 thng sau mi thng mt
ln n 12 thng v 6 thng mt ln n 5 nm.

178

UNG TH C T CUNG
1. KHI NIM
Ung th c t cung l u c tnh nguyn pht c t cung, c th xut pht t
cc t bo biu m vy, biu m tuyn hoc cc t bo ca m m. Tuy nhin, hu
ht cc ung th c t cung l ung th biu m, trong ch yu l ung th biu m
vy.
Ung th c t cung ng th 3 trong tng s cc ung th ph n, sau ung
th v, ung th i trc trng.
Kt qu iu tr ung th c t cung ph thuc vo thi im chn on, nu
bnh giai on mun, kt qu iu tr rt thp.
2. CHN ON
2.1. Lm sng
- Giai on ti ch, vi xm nhp:
giai on ny, cc triu chng c nng rt ngho nn. Khi khm c t cung
c th thy hnh thi bnh thng hoc c vt lot trt hoc vng trng khng in
hnh hoc tng sinh mch mu.
- Giai on ung th xm nhp:
+ Ra mu m o bt thng hay ra mu sau giao hp.
+ Khm bng m vt thng thy khi si, d chy mu khi chm vo.
+ Giai on mun c th thy c t cung bin dng, c lot su hoc c t
cung mt hn hnh dng.
+ Suy gim sc khe ton thn, i mu, i tin ra mu, au hng lng...
2.2. Cn lm sng
2.2.1. Soi c t cung:
- Cc hnh nh bt thng:
+ Vt trng n
+ Vt trng
+ Chm y.

179

+ Lt
+ Vng biu m khng bt mu lugol
+ Mch mu khng in hnh.
- Nghi ng ung th xm ln qua soi c t cung: vng lot, si, tn thng lot si.
- Soi c t cung khng t: khng thy vng chuyn tip gia biu m lt v
biu m tr, vim nhim nng, c t cung khng th nhn thy do m o hp.
Cc tn thng nghi ng khi soi c t cung cn c bm sinh thit lm m
bnh hc.
2.2.2. Chn on t bo hc ph khoa:
C cc loi k thut: Papanicolaou (Pap) thng thng, k thut Thin Prep v
phng php t bo hc cht lng th h 2 (LiquiPrep). Cc k thut Thin Prep v
Liqui Prep c u im l hnh nh m hc p hn, d c hn qua lm tng
nhy, c hiu ca vic pht hin cc t bo biu m bt thng v vn c gi
tr d bo dng tnh, trong , k thut LiquiPrep c nhiu u im hn so vi
ThinPrep. Chn on t bo hc theo phn loi Bethesda ci tin 2001 nh sau:

T bo vy:

T bo biu m tuyn

- T bo vy khng in hnh

- Khng in hnh

+ ngha cha xc nh (ASCUS)

+ T bo tuyn c t cung lin quan tn

+ Khng th loi tr tn thng ni biu

sn c tnh

m vy cao (ASCUS-H)

+T bo tuyn lin quan tn sn c tnh

- Tn thng t bo ni biu m vy

- Ung th t bo biu m tuyn c t

thp (LSIL), bao gm HPV, Lon sn nh/

cung ti ch

CIN I

- Ung th t bo biu m tuyn

- Tn thng t bo ni biu m vy cao

+ Biu m tuyn c t cung

(HSIL), bao gm lon sn trung bnh, lon

+Biu m tuyn ni mc t cung

sn nng, CINII/CINIII

+Biu m tuyn ngoi t cung

- C du hiu nghi ng ung th xm nhp

+Biu m tuyn khng nh loi (NOS)

- Ung th t bo biu m vy

180

2.2.3. Sinh thit c t cung:

Sau khi soi c t cung v xc nh c tn thng nghi ng hoc c kt qu t
bo khng bnh thng. Sinh thit hai mnh: mt mnh ranh gii lt - tr, mt
mnh chnh gia tn thng. Nu nghi ng tn thng trong ng c t cung th
dng tha no sinh thit. Khi cc tn thng nm hon ton trong c t cung
Khot chp c t cung.
2.2.4. Chn on hnh nh:
nh gi y v chnh xc mc lan trn ca ung th c t cung c
th ch nh mt s xt nghim sau: chp MRI, PET CT
2.3. Chn on xc nh
- Ung th ti ch v vi xm ln: Da vo phin m o kt hp soi v sinh
thit c t cung hoc no ng c t cung, LEEP hoc khot chp c t cung.
- Giai on mun: da vo triu chng lm sng v kt qu sinh thit.
2.4. Phn loi giai on lm sng
Giai on

M t tn thng

Ung th ti ch (CIS), ung th ni biu m

Ung th ch gii hn ti c t cung

IA
IA1
IA2

Ung th tin lm sng, ch chn on c bi vi th

Xm nhp r ti thiu cht m.Tn thng su 3mm t mng
y, rng 7mm t b mt hay tuyn m n pht sinh;
Tn thng su 5mm, rng 7mm, nu rng hn th nhm Ib
Tn thng c kch thc ln hn giai on Ia d c thy

IB

c trn lm sng hay khng. Tn thng vng khng gian c

trc khng lm thay i vic nh giai an m cn ghi li c
bit dng cho nhng quyt nh iu tr tng lai

IB1

ng knh ln nht ca tn thng 4 cm

IB2

ng knh ln nht ca tn thng 4 cm

II

Ung th xm ln qu c t cung nhng cha n thnh xng

chu hay cha n 1/3 di m o

181

IIA

Cha xm ln dy chng rng

IIB

Xm ln dy chng rng

III
IIIA

IIIB
IV

Ung th lan n thnh xng chu v/hoc ti 1/3 di m o

hoc n niu qun
Ung th lan n 1/3 di m o, nhng cha n thnh xng
chu
Ung th lan n thnh xng chu chn p niu qun, lm thn
nc hoc mt chc nng
Ung th lan n ngoi khung chu hay l xm ln nim mc
bng quang v trc trng

IVA

Xm ln cc c quan ln cn

IVB

Di cn xa

2.5. Chn on phn bit: trn lm sng, cc ung th c t cung cn phn bit
vi cc tn thng sau c t cung:
- L tuyn, lot trt c t cung
- Polip c t cung
- Lc ni mc c t cung
- Giang mai c t cung
- Lao c t cung.
3. IU TR
3.1. Ung th c t cung giai on ti ch
Khot chp c t cung v theo di hoc ct t cung hon ton ty nhu cu
sinh con tip theo.
3.2. Ung th c t cung giai on IA1
Nu c nhu cu sinh con th khot chp c t cung v kim tra din ct: nu
cn ung th ti din ct th phi ct t cung. Nu khng cn nhu cu sinh con th
ct t cung hon ton.
3.3. Ung th c t cung giai on IA2

182

Nu c nhu cu sinh con th khot chp c t cung v ly hch chu hai bn:
kim tra din ct v hch chu. Nu cn ung th ti din ct th phi ct t cung
hon ton. Nu c di cn hch th x tr h hch chu. Nu khng c nhu cu sinh con
th ct t cung hon ton, ly hch chu hai bn v x tr nu c di cn hch chu.
3.4. Ung th c t cung giai on IB IIA
3.4.1. i vi giai on I B1: phu thut Wertheim
p dng cho ph n tr cn bo tn bung trng v c kch thc u 2cm
Phng php: ct t cung m rng , mt phn m o v ly hch chu 2 bn
Tia x sau phu thut
3.4.2. i vi giai on I B2 IIA: x tr kt hp vi phu thut.
- X tr tin phu:
+ U < 4cm: x p st
+ U 4cm: x ngoi thu nh u sau x p st
- Phu thut: tin hnh sau khi ngh x tr 4 6 tun, ct t cung m rng v
ly hch chu hai bn
- X tr hu phu
3.4.3. Phng php x tr trit cn
3.5. Ung th c t cung giai on IIB III:
- Phng php x tr trit cn
- Phng php ha tr kt hp x tr
- Sau x s nh gi li tn thng xem c nn phu thut khng
3.6. Ung th c t cung giai on IV:
- Nu cn kh nng phu thut th vt y chu sau kt hp ha tr v x
tr sau m. (t lm)
- Nu khng cn kh nng phu thut: ha v x tr
4. PHNG BNH
Tim phng HPV cho cc ph n tr. Khm pht hin sm cc tn thng c
t cung tin ung th iu tr sm.

183

UNG TH NIM MC T CUNG

1. KHI NIM
Ung th biu m ni mc t cung l u biu m c tnh nguyn pht t biu
m ni mc t cung, thng bit ha dng tuyn, n c kh nng xm nhp lp c
v lan n nhng ni xa.
2. CHN ON
2.1. Lm sng
2.1.1.Triu chng c nng
+ Ra mu m o bt thng ph n mn kinh hoc rong kinh, rong huyt
ph n tin mn kinh hoc cn kinh. Triu chng ny hay gp khong (80%).
+ Chy dch hi m o c th gp khong 30% cc ngi bnh. Chy dch
thng do nhim khun, mu ln cht hoi t to mi hi.
+ au vng h v thng xut hin mun khi khi u lan trn hoc xm ln
vo cc b phn khc trong h chu, triu chng ny c th gp khong 20,4%.
2.1.2. Triu chng thc th
Cc du hiu thm khm lm sng thng t thy. t m vt chn on loi
tr trng hp ra mu t c t cung. Nu ngi bnh n giai on mun c th
thy thn t cung to, hoc c xm ln c t cung, m o hay c du hiu di cn
xa.
2.2. Cn lm sng
- Siu m: Siu m, c bit l siu m u d m o c s dng nh gi
ban u vi nhng ngi bnh nghi ng ung th ni mc t cung. Siu m cho
php nhn bit chiu dy bt thng ca ni mc t cung, xm ln u.
- Chp bung t cung c thuc cn quang: hin b t dng
- Chp MRI: cho php nh gi chn on u ti ch v cc cc mc xm
nhp u cng nh nhng tn thng nghi ng di cn.

184

- Sinh thit ni mc t cung: sinh thit ni mc t cung l yu cu bt buc trong

chn on ung th ni mc t cung. Nhm nh gi tn thng l lnh tnh hay c tnh v
m hc, tp m bnh hc v ung th nguyn pht ni mc t cung hay ca c t cung.
- Soi bung t cung :soi bung t cung cho php nhn thy tn thng, xc nh
mc lan rng b mt v nh hng cho sinh thit ng v tr tn thng chn
on m bnh hc.
- Cht ch im sinh hc: cc cht ch im nh CA-125, TAG-72, CA 15-3,
LSA c th tng trong ung th ni mc t cung. Tuy nhin, cc cht ch im
ny thng ch tng trong giai on mun ca bnh.
2.3. Chn on xc nh
Da vo chn on sinh thit nim mc t cung.
2.4. Phn loi th, mc
Phn loi m hc cc ung th ni mc ca WHO 2003 hin nay c s
dng rng ri, gm cc loi sau:
- Ung th biu m tuyn dng ni mc t cung (Endometrioid
adenocarcinoma)
+ Bin th vi bit ha vy (Variant with squamous differentiation)
+ Bin th tuyn nhung mao (Villoglandular variant)
+ Bin th ch tit (Secretory variant)
+ Bin th t bo c lng (Ciliated cell variant)
- Ung th biu m tuyn nhy (Mucinous adenocarcinoma)
- Ung th biu m tuyn thanh dch (Serous adenocarcinoma)
- Ung th biu m tuyn t bo sng (Clear cell adenocarcinoma)
- Ung th biu m tuyn hn hp (Mixed adenocarcinoma)
- Ung th biu m t bo vy (Squamous cell carcinoma)
- Ung th biu m t bo chuyn tip (Transitional cell carcinoma)
- Ung th biu m t bo nh (Small cell carcinoma)
- Ung th biu m khng bit ha (Undifferentiated carcinoma)

185

2.5. Chn on giai on(FIGO 1988)

Giai on

Tiu chun

U khu tr thn t cung

IA

U gii hn ni mc t cung

IB

U xm ln di c t cung

IC

U xm ln trn c t cung

II:

U xm ln ti c t cung nhng khng lan ra khi

IIA

t cung

IIB

Xm ln tuyn c t cung

III:

Xm ln m m c t cung

IIIA

U lan ra ngoi t cung nhng cn khu tr trong

khung chu

IIIB

U xm ln ti thanh mc v/ hoc phn ph v /

IIIC

hoc t bo hc dch ra phc mc dng tnh

IV:

U lan ti m o
U lan ti khung chu v/ hoc hch cnh ng

IVA

mch ch

IVB

U xm ln ti nim mc bng quang v/ hoc

nim mc i trng Sigma hoc di cn xa
U xm ln nim mc bng quang v/ hoc nim
mc i trng sigma
Di cn xa bao gm c hch bng v hch bn

3. IU TR
3.1. Nguyn tc chung
Trong cc phng php iu tr ung th ni mc, phu thut c coi l bin
php u tin hng u. C hai phng php phu thut: Phu thut m bng v phu
thut ni soi. X tr l phng php iu tr hu hiu th hai trong iu tr ung th ni
mc t cung. iu tr x tr, ha tr v ni tit cho cc trng hp giai on mun.

186

3.2. iu tr c th
Ch nh iu tr da vo phn loi bnh theo FIGO:
+ Giai on I: ct t cung hon ton, phn ph hai bn v ly hch chu, hch
cnh ng mch ch. iu tr tia x b tr khi c cc yu t tin lng xu.( m
hc 2 hoc 3, hoc c xm ln trn chiu su lp c). Nu ung th nim mc t
cung lan xung ng c t cung v thm nhim th phi p dng phu thut
Wertheim.
+ Giai on II: ct t cung hon ton, hai phn ph v ly hch. Sau 4-6 tun
tin hnh tia x hu phu ton khung chu sau x p st. Trng hp tn
thng ti c t cung ln th tia x trc, sau 4 6 tun mi tin hnh phu thut.
+ Giai on III: phu thut v x tr vn l phng php iu tr chnh. Nu
m c th ct t cung hon ton v x tr, nu khng th x bng kim radium t
ti ch v ha tr liu hormon.
+ Giai on IV: ngi bnh giai on mun hoc ti pht cc v tr xa, c
th iu tr tia x chng au, chng chy mu v chn p. iu tr ni tit v iu
tr bng progestatif.
4. THEO DI
Theo di nh k 3 thng/ln trong 2 nm u, 6 thng /ln trong 2 nm tip
theo v sau mi nm mt ln.
5. PHNG BNH
nhng ph n >40 tui nu xt nghim t bo ph khoa c cc m tuyn
ni mc cn c ht bung t cung lm xt nghim m bnh hc, nhng ph
n ra mu sau mn kinh cn siu m nh gi dy ni mc, soi bung t
cung v ly bnh phm lm xt nghim m bnh hc, nht l nhng ngi bnh
bo ph hoc c tin s iu tr Tamoxifen.

187

UNG TH BUNG TRNG

1. KHI NIM
Bung trng thuc c quan sinh dc n va c ngun gc bo thai phc tp,
va c chc nng to giao t v cn l tuyn ni tit, ng thi n cng chu nh
hng ca nhng tuyn ni tit khc. C ch bnh sinh cc u biu m bung trng
rt phc tp v do vy, hnh thi v cu trc ca m u rt phong ph v a dng
hn bt k m tng no khc trong c th ngi.
Trn th gii, t l ung th bung trng chim khong 30% tng s cc ung
th sinh dc n.
2. CHN ON
2.1. Lm sng
Cc u bung trng c tnh hu ht thuc nhm biu m (t 80-90% cc ung
th bung trng). Biu hin lm sng ty thuc vo giai on bnh.
- Giai on sm: khi u nh hu nh t c triu chng lm sng c hiu.
- Giai on mun:
+ C nng: kh chu bng, cm gic nng bng, y bng v bng ln
Ri lon kinh nguyt
Ri lon tiu ho
Ri lon tiu tin
+ Thc th:Nu l u ln c th s c trn bng
Khm m o phi hp vi khm bng: khi cnh t cung, di ng hay t di
ng, c lp vi t cung, u c th xm ln vng chu hay khng.
Cc u c ngun gc m m-dy sinh dc thng c hot ng ch tit gy
nn nhng biu hin c trng: ch tit estrogen gy dy th sm v ri lon kinh
nguyt, ch tit androgen gy nn tnh trng v teo, t cung teo, mt kinh v cc
c tnh sinh dc nam biu hin ngy cng r; mc ru, lng kiu nam gii, thay
i dng ngi, ging ni trm, m vt to ln, i khi thay i c tm l. Cc du
hiu khc c th gp nh trong hi chng Meigs, Cushing, Peutz-Jeghs

188

2.2. Cn lm sng
2.2.1. Siu m
c im chung ca cc u bung trng c tnh trn siu m l: Khi c
thng c kch thc ln, thnh dy, ranh gii kh xc nh. Cu trc m l khi
hn hp xen ln phn c, phn dch do hoi t. Khi thng c vch, nh trong
lng khi c kch thc ln, b nh nham nh ging hnh supl. nh gi dch
bng.
2.2.2. Chp ct lp vi tnh
Gip nh gi tnh trng xm ln v di cn ca khi u.
2.2.3. Xt nghim cc cht ch im khi u
CA-125 tng cao trong hn 80% ung th biu m bung trng v c th tng
trong mt s tnh trng lnh tnh.
AFP v hCG c th tng trong cc trng hp u t bo mm.
HE4: nhy v c hiu cao hn CA - 125
2.2.4. T bo hc
T bo hc dch bng tm t bo ung th.
2.2.5. Soi bng
Soi bng gip nh gi c tn thng, giai on bnh, ng thi sinh
thit bnh phm lm xt nghim m bnh hc. Tuy nhin, soi bng c nguy c
gy v u hoc lm lan trn ung th ra bng v thnh bng. V vy, ch nn tin
hnh sinh thit khi c nghi ng v vi nhng u cn nh ng thi nn tin hnh
nhng c s c kh nng phu thut tt.
2.2.6. M thm d v chn on sinh thit tc th
Sinh thit tc th l mt phng php chn on m bnh hc trong lc m
trn cc tiu bn c ct t my ct lnh (Cryostat). Phng php ny gip cc
nh phu thut c mt thi x l ng n, lm gim s ln phu thut, rt ngn
thi gian iu tr, gp phn quan trng trong iu tr cc khi u v ung th ni
chung. chnh xc, c hiu ca xt nghim ny vi u bung trng vo
khong 98,2% v 100%.

189

2.2.7.Chn on m bnh hc
Chn on m bnh hc l chn on quyt nh v cn thit trc khi tin
hnh iu tr cho ngi bnh. chn on chnh xc cn ly ng vng m u,
trnh ly vo vng hoi t, ly nhiu vng khc nhau v cn c nh bnh phm
ngay sau khi ly ra khi c th vi dung dch formol trung tnh 10% trc khi gi
xung khoa Gii phu bnh. Theo phn loi ca T chc y t th gii (2003), cc
ung th bung trng c chia thnh cc nhm chnh sau:
Nhng u thanh dch c tnh

Nhng u ch nhy c tnh

- Ung th biu m tuyn

- Ung th biu m tuyn

- Ung th biu m tuyn nh b mt

- Ung th biu m tuyn x

- Ung th biu m tuyn x

Nhng ung th t bo sng

Nhng u dng ni mc c tnh

- Ung th biu m tuyn

- Ung th biu m tuyn khng k

- Ung th biu m tuyn x

tn

Nhng ung th t bo chuyn tip

- Ung th biu m tuyn x

- Ung th biu m t bo chuyn

- U hn hp Muller c tnh

tip

- Saccm tuyn

(khng phi loi Brenner)

- Saccm m m dng ni mc t

- U Brenner c tnh

cung ( thp)

Ung th biu m t bo vy

- Saccm bung trng khng bit ho

Ung th biu m khng bit ha

U t bo mm c tnh: Bao gm ung

U t bo steroid (Bit ha cao v

th t bo mm nguyn thy v u qui

c tnh)

khng thnh thc.

190

2.4. Phn loi giai on lm sng. Theo FIGO2013

Giai on

M t

U gii hn bung trng hoc vi t cung

U gii hn mt bung trng (v bc cn nguyn vn)

IA

hoc vi t cung; khng c khi u trn b mt bung

trng hoc vi t cung; khng c t bo c tnh dch
bng hoc dch ra mng bng .
U cn gii hn c hai bung trng (v bc cn

IB

nguyn vn) hoc vi t cung; khng c u b mt

bung trnghoc vi t cung; khng c t bo c tnh
dch bng hoc dch ra mng bng.

IC
IC 1
IC 2
IC 3

U gii hn mt hoc c hai bung trng hoc vi t

cung khng c km theo bt k du hiu no di y:
V khi u trong phu thut
V v khi u trc phu thut hoc c khi u trn b
mt bung trng hoc vi t cung
C t bo c tnh dch bng hoc dch ra mng
bng.
U mt hoc hai bung trng hoc vi t cungc lan

II

trn vo khung chu (di gii hn ca tiu khung)

hoc khi u bt u di cn phc mc

IIA
IIB

Lan n v/hoc xm ln vo t cung v/hoc ng dn

trng v/ hoc bung trng
Xm ln nhng t chc trong phc mc tiu khung
U mt hoc hai bung trng hoc vi t cung hoc

III

khi u bt u di cn phc mc vi t bo hc hoc gii

phu bnh khng nh c lan trn n phc mc ngoi
tiu khung v/hoc di cn hch lymphosau phc mc

IIIA1

Ch c hch lympho sau phc mc dng tnh (t bo

191

hc hoc gii phu bnh minh chng)

IIIA1 (i)

ng knh ln ca hch di cn 10mm

IIIA1 (ii)

ng knh ln ca hch di cn > 10mm

Di cn vi th phc mc ngoi tiu khung (trn gii hn

IIIA2

ca TK) cng vi hoc khng c hch sau phc mc

dng tnh
Di cn i th phc mc ngoi tiu khung c ng

IIIB

knh ln 2cmcng vi hoc khng c hch sau phc

mc dng tnh
Di cn phc mc ngoi tiu khung, c ng knh ln>

IIIC

2cm cng vi hoc khng c hch sau phc mc dng

tnh (bao gm khi u lan ti v ca gan v lch, cha
lan n nhu m cc c quan ny)

IV

Di cn xa ngoi tr di cn phc mc

IVA

Trn dch mng phi vi t bo hc dng tnh

IVB

Di cn ti nhu m v di cn c quan ngoi bng (bao

gm hch bn v hch ngoi bng)

3. IU TR
3.1. Nguyn tc chung, mc tiu iu tr
Mc tiu ca iu tr nhm loi b khi u trit nht (c th) bng phu thut
sau c th kt hp ha tr hay x tr. Vi cc ung th giai on mun, cn ha tr
trc nhm gim tng lng khi u v chuyn thnh giai on c th phu thut c.
3.2. iu tr
3.2.1. Phu thut
Ch nh phu thut: phu thut c ch nh cho hu ht cc trng hp
ung th bung trng, tr khi u giai on IV.

192

Phu thut giai on sm.

- Phu thut chun i vi tt c cc ngi bnh ung th bung trng giai
on sm l: ct t cung hon ton v 2 phn ph v mc ni ln.
- i vi ung th biu m: nhng ngi bnh mong mun bo tn chc nng
sinh sn m bnh giai on Ia, Ib v m bnh hc I th c th ct phn ph
bn c u v gi t cung v phn ph bn lnh.
- i vi trng hp u t bo mm: nh hiu qu cao ca ho tr liu, trong
trng hp khi u hai bn, kt qu ct lnh l c tnh th vic bc khi u 1 hoc 2
bn bung trng ch p dng vi mt s ngi bnh c la chn cho nhng
ngi bnh rt tha thit bo tn chc nng sinh sn.
- Lun ly dch ra tiu khung lm t bo nh gi giai on bnh.
- Sinh thit c honh.
- Vt hch chu hai bn v hch cnh ng mch ch hoc ch sinh thit
hch.
- Sinh thit mc ni ln.
- Sinh thit phc mc cnh trc trng v b mt khung chu.
- Sinh thit bung trng bn i din nu nghi ng.
- Ct rut tha trong trng hp ung th biu m nhy.
Phu thut giai on mun.
a s ngi bnh ung th bung trng pht hin giai on mun v gn
75% khi u lan ln pha trn bng. Do iu quan trng l cn la chn c
ngi bnh no c th phu thut ct b ht khi u trong bng hay phi iu tr
ho cht tn b tr trc.
Ct t cung hon ton v hai phn ph ng m bng,
Ct mc ni ln hon ton.
- Ct b tt c cc khi u c th nhn thy c. Phu thut ly khi u ti a (
phn u cn li < 1cm).
- Phu thut ct lch: trong cc trng hp di cn ti rn, v hoc nhu m
lch, khong 6% trng hp.

193

- Ct i trng Sigma khi khi u thm nhim vo cng .

Phu thut m bng thm d li (Second- look)
3.2.2. Ha tr liu
Ha tr c ch nh trong nhiu tnh hung khc nhau:
+ Giai on sm c nguy c cao: ha tr mang tnh h tr sau phu thut tn
gc nhm gim thiu nguy c ti pht.
+ Giai on lan rng: C nhiu kiu phi hp ha tr gy p ng vi phu thut
tng thm thi gian sng thm ton b cng nh thi gian sng thm khng bnh.
- Ha tr i vi ung th biu m: ha tr da trn cht platinum (cisplatin,
carboplatin) n c hoc phi hp Alkyl ha hoc phi hp paclitaxel
- Ha tr cc ung th t bo mm v dy sinh dc
U t bo mm c tnh: khng cn iu tr ha cht cho u qui khng trng
thnh mc I, giai on Ia phu thut th khng cn iu tr ha cht thm.
Cc trng hp khc th iu tr ha cht sau phu thut: Phc BEP, PVB hoc
VAC.
Cc u dy sinh dc i vi giai on I, ha cht c p dng cho ph n <
40 tui v cc giai on sau. Phc thng dng l: PVB hoc cisplatin +
doxorubicin + etoposide.
3.3. Chm sc ton din
Ngi bnh ung th bung trng ngy nay thng c chm sc v iu tr
bng nhiu phng php phi hp (Interdisciplinary). Cc ung th c khuynh
hng din tin ti ch, ti vng trong thi gian di v thng c iu tr bng
cc phng php nhm vo ti ch v ti vng (phu tr, x tr) trong giai on tn
thng cn khu tr. Tuy th, ngay c cc ngi bnh ung th bung trng giai
on sm c kh nng iu tr tn gc, bn cnh vic xem xt iu tr ti ch, ti
vng th ngi bnh cng cn c chm sc ton din:
- iu tr ton trng chung, bao gm c vn tm l ngi bnh v gia nh
h cng tc tt v tip nhn vic iu tr c hiu.

194

- iu tr, chm sc cc triu chng lin quan n cc tn thng ung th c

th c (au, bi nhim).
- iu tr, chm sc cc triu chng do vic iu tr gy ra (au do phu
thut, nn do ho tr, bng lot do x tr...).
- Cn nhc ch nh, hiu qu v tc dng ph ca cc bin php iu tr h
tr ton thn.
4. TIN TRIN
Cc ung th bung trng hin c t l mc kh cao, c xu hng gia tng.
cc triu chng ca ung th bung trng rt ngho nn, din bin bnh phc tp.
Hu ht cc trng hp ung th bung trng thng c chn on mun nn
vic iu tr ht sc kh khn.
5. TIN LNG
T l sng thm 5 nm tng quan trc tip ti giai on bnh. Giai on I
sng thm 5 nm t 60 - 80% . Giai on II sng thm 5 nm khong 40%. Giai
on III t 15 - 20% v giai on IV t l sng thm 5 nm ch cn di 5%. Giai
on I c bit ho cao v va sng thm 5 nm l 90%.

195

RONG KINH RONG HUYT

1. KHI NIM
- Chy mu bt thng t nim mc t cung, thng c gi l rong kinh
rong huyt l mt vn thng gp trong lm sng ph khoa vi rt nhiu
nguyn nhn khc nhau. Rong kinh, rong huyt u l triu chng ca nhiu tnh
trng hoc bnh l khc nhau.
- Rong kinh l hin tng ra mu t ng sinh dc ko di qu 7 ngy,
c chu k.
- Rong huyt l hin tng ra mu t ng sinh dc ko di trn 7 ngy,
khng c chu k.
2. CHN ON
2.1. Lm sng
Khai thc bnh s: tn sut, thi gian v lng kinh, xc nh chy mu c
chu k hay khng. Chy mu c chu k thng lin quan vi c phng non. Cc
c im khc bao gm tui ngi bnh, tin s tnh dc (xc nh nguy c ca
bnh ly truyn qua ng tnh dc), cc bnh ph khoa trc , s dng thuc
hoc cc hormon nga thai v cc bnh ni khoa mn tnh.
Tm cc du hiu ton thn khi khm thc th. Cn c bit ch n cc
du hiu v triu chng ca nhc nng gip, bnh gan, tng prolactin mu, cc ri
lon n ung v bnh ng mu.
Khm ph khoa cn thn,nn bao gm c khm trc trng phi hp vi nn
bng xc nh c hay khng c cc tn thng thc th trn ng sinh dc n.
2.2. Cn lm sng
Ty theo tng tnh hung ch nh xc xt nghim, thm d ph hp:
- Cng thc mu.
- Test th thai i vi ph n trong tui sinh .
- T bo c t cung

196

- Siu m ph khoa (ng bng ng m o) kho st t cung v 2 phn

ph
- Xt nghim ni tit t ph khoa: estrogen, progesteron, FSH, LH, prolactin.
- Xt nghim dch m o - c t cung tm lu cu hoc Trichomonas
vaginalis nu nghi ng.
- Soi bung t cung
- No sinh thit tng phn ng c t cung v nim mc t cung.
2.3. Chn on xc nh
Da vo kt qu khm lm sng v xt nghim cn lm sng.
2.4. Chn on phn loi
2.4.1. Rong kinh, rong huyt tui tr
Trc kia ngi ta cho rng cng estrogen (tn ti nang non) lm cho nim
mc t cung qu sn tuyn nang. Ngy nay, ngi ta thy estrogen c th thp,
bnh thng hoc cao. C bn l do FSH v LH khng y kch thch bung
trng, nguyn do ri lon hot ng ca vng di i. Thng l giai on hong
th km, khng phng non, khng c giai on hong th.
Biu hin lm sng:
- Kinh nguyt ko di, thng l mu ti, xy ra sau mt vng kinh di
(chm kinh).
- Ton trng thiu mu.
- Khm thc th nhiu khi t cung to mm, c t cung h m (cn phn bit
vi sy thai)
2.4.2. Rong kinh, rong huyt tin mn kinh
Cc trng hp ri lon kinh nguyt tin mn kinh cn phi loi tr cc
nguyn nhn c tnh.
- Trong giai on tin mn kinh sinh thit nim mc t cung thng c hnh
nh qu sn dng tuyn nang, gp nhiu gp 10 ln so vi la tui 20 - 45.
- Trong giai on sau mn kinh hay gp hnh nh nim mc t cung teo, nim
mc t cung khng hot ng.

197

2.4.3. Cng kinh (kinh nhiu)

So vi hnh kinh bnh thng, lng huyt ra nhiu. Thng km vi rong kinh.
- Nguyn nhn
Phn ln do tn thng thc th t cung, u x t cung, polype t cung, lc
ni mc t cung ti c t cung lm t cung khng co bp c, nim mc t cung
kh ti to nn kh cm mu. Cng c th do t cung km pht trin.
Cng kinh c nng t gp hn.
2.4.4. Rong kinh do chy mu trc kinh
C th do tn thng thc th nh vim nim mc t cung, polype bung t
cung, nhng cng c th do giai on hong th ngn v hong th teo sm,
estrogen v progesteron gim nhanh.
2.4.5. Rong kinh do chy mu sau kinh
- Thc th: kh thng gp, c th do vim nim mc t cung, u x t cung,
polyp bung t cung, u c tnh trong bung t cung.
- C nng: c th do nim mc t cung c nhng vng bong chm hoc
nhng vng ti to chm.
- iu tr
2.5. Chn on phn bit:
Ra mu t ng tiu ho: tr, ung th ng tiu ha thp.
Ra mu t ng tit niu: nhim trng ng tiu, u ng tiu, si ng tiu.
3. IU TR
3.1. Nguyn tc chung, mc tiu iu tr
iu tr rong kinh rong huyt bao gm iu tr nguyn nhn (nu c), lm
ngng tnh trng ra mu t nim mc t cung, ti lp chu k kinh bnh thng (nu
ngi ph n nm trong tui sinh ) v iu tr h tr, nng cao th trng.
3.2. iu tr c th mt s rong kinh rong huyt thng gp (ni khoa, ngoi
khoa, hng dn chuyn tuyn)

198

Rong kinh rong huyt cn c bc s sn ph khoa iu tr ti c s y t

tuyn Huyn tr ln. Trong phn ny ch yu cp n x tr rong kinh rong
huyt c nng.
3.2.1. Rong kinh, rong huyt tui tr
Bc u tin l loi tr nhng nguyn nhn c tnh, cc bnh v mu nht l
nhng ngi con gi trong ln thy kinh u tin b rong kinh, sau mi t
vn iu tr cm mu.
No bng hormon: tim progesteron hoc ung progestagen 20mg/ ngy.
Thng thng 4 - 5 ngy cm mu. Ngng thuc 2 - 3 ngy ra huyt tr li lm
bong trit nim mc t cung. Thi gian v lng mu khi ra huyt tr li tng
t nh huyt kinh ca ngi bnh thng.
phng rong kinh trong vng kinh sau cho tip vng kinh nhn to, c th
cho progestagen n thun vo na sau d kin ca vng kinh, c th cho kt hp
estrogen vi progestagen nh kiu vin thuc trnh thai.
C th cho thuc kch thch phng non nh clomifen.
Kt hp vi cc thuc cm mu, thuc co hi t cung (oxytocin, ergotamin).
Nu trong nhng trng hp rt hn hu, iu tr bng mi bin php khng
kt qa mi phi no bung t cung bng dng c.
cm mu nhanh c th dng loi estrogen phc hp sulfat tan trong nc:
Premarin 25mg, tim tnh mch, c th cm mu trong vng na gi.
Bng 1: La chn iu tr ni khoa trong rong kinh c nng
Loi
chy
mu

Cp

La chn iu tr

Bn lun

Thuc nga thai ung 2-3v/ngy trong 7

ngy s cm c mu sau duy tr
1v/ngy trong 14 ngy

S dng thuc trnh thai 1

pha liu thp

Estrogen phc hp (Premarin) 25 mg

TM mi 4-6 gi x 1 ngy, hoc 1,25mg
ung mi 4-6 gi x 1 ngy, sau ung
thuc trnh thai nh trn.

Tt c cc bin php iu tr
ch c estrogen phi c
theo sau bi progestin

199

Mn

Thuc nga thai vin kt hp ung

1vin/ngy

Cc ph n quanh mn kinh
nn s dng vin 20mg

Medroxyprogesterone

Chy mu xut hin sau vin

acetate,

10mg/ngy x 10 ngy /thng

cui cng 2-7 ngy

Clomiphen Citrate (Clomid, Serophen,

Ovofar), 50-150mg/ ngy vo cc ngy

S dng cho nhng ph n

mong mun c thai.

5-9 ca vng kinh

3.2.2. Rong kinh, rong huyt tin mn kinh
iu tr triu chng tt nht l no nim mc t cung, c 3 li ch:
+ Cm mu nhanh ( mt mu).
+ Gii phu bnh l (loi tr c tnh).
+ Xc nh r rng tnh trng qu sn nim mc t cung (iu tr hormon tip theo).
Ngy no c tnh l ngy u tin ca k kinh ti.
Thng thng cho progestin t ngy th 16 ca vng kinh, mi ngy 10mg,
ung trong 10 ngy, ung trong 3 vng kinh lin.
3.2.3. Rong kinh, rong huyt tui sinh (18 - 45 tui)
- Cng kinh (kinh nhiu)
+ Tr tui:
T cung co bp km: thuc co t cung.
T cung km pht trin: vng kinh nhn to hoc cho vin thuc trnh thai
na sau chu k kinh.
+ Ln tui:
Nu c tn thng thc th nh cha c ch nh phu thut c th ch nh
progestin vi ngy trc khi hnh kinh. Cng c th cho progestin liu cao (gy
v kinh 3 - 4 thng lin).
Trn 40 tui, iu tr thuc khng hiu qu nn m ct t cung.
- Rong kinh do chy mu trc kinh

Trn 35 tui: no nim mc t cung.

Thuc: progestin hoc thuc ung trnh thai na sau vng kinh.

200

- Rong kinh do chy mu sau kinh

Trc ht phi loi tr nguyn nhn thc th.
Nu do hong th ko di th cho progestin hoc estrogen kt hp vi
progestin vo cc ngy 20 - 25 ca vng kinh. Sau khi ngng thuc vi ngy, nim
mc t cung s bong gn v khng rong kinh.
Nu do nim mc t cung ti to chm c th cho Ethinyl - estradiol 0,05mg
mi ngy 1 - 2 vin trong cc ngy 3 - 8 ca vng kinh.
- Rong kinh do qu sn tuyn nang nim mc t cung
+ No nim mc bung t cung (50% khi trong mt thi gian di)
+ Thuc: Progestin 10mg/ngy trong 10 ngy, k t ngy th 16 ca vng
kinh trong 3 thng.
+ C th xem xt m ct t cung ph n trn 40 tui, con.
3.2.4. iu tr h tr
Truyn mu/cc sn phm t mu nu thiu mu nng.
Tng cng dinh dng giu m, b sung st.
4. TIN TRIN V BIN CHNG
Cc trng hp rong kinh rong huyt c nng ko di nu khng c iu
tr sm v ng phng php s dn n thiu mu nhc sc, suy nhc c th.
5. TIN LNG V PHNG BNH
Rong kinh rong huyt c nguyn nhn thc th c tin lng ty theo tng
bnh cnh lnh tnh hay c tnh.
Rong kinh rong huyt c nng nhn chung c tin lng tt.
d phng cn khm ph khoa nh k hng nm v n khm sm ti c
s y t nu c hin tng ra mu bt thng t ng sinh dc.

201

V KINH
1. NH NGHA
V kinh l tnh trng khng c kinh nguyt lin tc tm thi hoc vnh vin
do ri lon chc nng vng di i, tuyn yn, bung trng , t cung hoc m
o. V kinh thng c chia ra 2 loi: v kinh nguyn pht (n khi 15 tui vn
khng c kinh nguyt) v v kinh th pht (khng c kinh nguyt t 3 chu k hoc
t 6 thng tr ln nhng ph n tng c kinh nguyt).
Chu k kinh nguyt thng d b nh hng ca cc yu t bn ngoi nn mt
kinh nguyt trong vng mt chu k thng khng qu nghim trng. Ngc li, nu
v kinh ko di c th l mt du hiu sm ca ca mt ri lon no trong c th.
2. V KINH TH PHT
2.1. Cc bc chn on v kinh th pht
- Bc 1: loi tr mang thai bng xt nghim hCG nc tiu hoc beta hCG
huyt thanh.
- Bc 2: hi bnh gi n nguyn nhn v kinh
C b stress, thay i cn nng, ch n ung, tp luyn th thao.
C dng thuc no c th gy v kinh (thuc ni tit trnh thai, danazol,)
C b trng c, rm lng,
C b cc triu chng chn p thn kinh do u vng h yn: au u, nhn m,
chn n, i nhiu,
C cc triu chng ca thiu estrogen: bc ha, kh m o, y l cc du
hiu ca suy bung trng. V kinh do vng di i cng lm cho estrogen mu
thp nhng khng gy ra cc triu chng ny.
C tin s no ph thai, vim nim mc t cung.
- Bc 3: khm lm sng
o ch s BMI. Nu BMI <18,5 kg/m2 th nghi ng v kinh do vng di i
vi cc triu chng ri lon n ung, cc bnh l ton thn gy gim cn nhanh
chng. Nu BMI >30 kg/m2 th nghi ng bung trng a nang.

202

Khm cc triu chng ca trng c, rm lng, cng androgen, khm v

xem c tit sa, khm m o xem c triu chng ca gim estrogen. khm
tuyn gip tm u hay tuyn gip to,
- Bc 4: xt nghim cn lm sng.
Sau khi lm xt nghim hCG loi tr thai nghn, BN s c lm thm
nh lng nng prolactin, FSH, TSH mu. Nu lm sng nghi ng c cng
androgen th nn nh lng testosteron mu v DHEA-S.
- Bc 5: theo di ngi bnh sau xt nghim
nh gi tnh trng estrogen: kt hp vi FSH gip tm nguyn nhn v kinh
v nh hng iu tr. Nu estrogen thp, BN nn c dng estrogen thay th
trnh long xng.
Nng prolactin mu cao: nu prolactin mu cao mc ranh gii th nn
lm li xt nghim ny trc khi chp MRI h yn, nhng BN ny cng cn c
khm tuyn gip v suy gip cng lm prolactin tng cao. Chp MRI h yn tm
cc u ca tuyn yn hay u vng h yn chn p vo tuyn yn.
Nng FSH cao: gi suy bung trng sm. Nhng BN ny nn c lm
nhim sc tm hi chng Turner (mt mt phn hay hon ton nhim sc th X).
Quan trng hn na l nhim sc s khng nh c hay khng nhim sc th Y.
Nng FSH bnh thng hoc thp: FSH thp kt hp cng vi estrogen
thp s ch ra suy vng di i th pht.
Cc xt nghim ni tit bnh thng v c tin s can thip sn khoa vo
bung t cung: gi dnh BTC sau th thut.
Nng androgen mu cao: kt hp vi cc triu chng lm sng chn
on bung trng a nang hay c khi u tit androgen t bung trng hay tuyn
thng thn.
2.2. iu tr: ph thuc vo nguyn nhn gy ra v kinh.
- V kinh do vng di i
Thay i cch sng v sinh hot, ch n: m bo calo vi cc vn
ng vin, t vn dinh dng v vi nhng ngi ri lon v n ung.

203

B xung estrogen chng long xng.

- Do prolactin cao: ph thuc vo nguyn nhn gy prolactin cao v nhu cu
sinh con ca ngi bnh.
- Suy bung trng sm: b xung estrogen chng long xng.
- Dnh bung t cung: ct dnh bng soi bung t cung sau iu tr
estrogen phc hi nim mc t cung.
3. V KINH NGUYN PHT
3.1. Cc bc chn on v kinh nguyn pht
chn on v kinh nguyn pht ch yu tp trung vo s pht trin ca v
(phn nh chc nng ca bung trng v hot ng ca cc receptor ca estrogen),
c hay khng c t cung v nng FSH
Nu v khng pht trin v nng FSH tng th c kh nng chn on l
khng pht trin tuyn sinh dc v cn lm thm karyotype. Rt c kh nng
nhng ngi bnh ny mang gen 46,XY.
Nu siu m khng thy t cung v FSH bnh thng th c kh nng lon
sn ng Muller hoc hi chng v cm vi androgen.
Nu FSH bnh thng, v pht trin bnh thng v t cung bnh thng th
nn i tm nhng nguyn nhn ca v kinh th pht.
- Bc 1: hi tin s
dy th hon ton cha: s pht trin ca c th, lng mu v lng nch,
tuyn v pht trin. Nu dy th cha hon thin th cn ngh ti nhng nguyn
nhn suy bung trng hoc tuyn yn hoc bt thng nhim sc th.
Tin s gia nh c dy th mun khng.
Chiu cao ca ngi bnh c yu t gia nh khng hay tim n hi chng
Turner hoc bnh di i v tuyn yn.
Thi k s sinh v tr nh ca ngi bnh, xem xt cng tuyn thng thn
bm sinh.
Gn y c s thay i v ch n ung, sinh hot, tp luyn,
C dng thuc g khng,

204

- Bc 2: khm lm sng
nh gi s pht trin tui dy th
nh gi s pht trin v
Khm b phn sinh dc, ch n kch thc m vt, lng mu, mng trinh
c l thng khng, sau ca m o, c c t cung, t cung v bung trng.
Khm da xem v trng c, rm lng,
Khm tm cc c im ca hi chng Turner
- Bc 3: xt nghim
Siu m xem c t cung, c t cung v m o, xem c s tc nghn trn
ng i ca kinh nguyt.
Khng c t cung: cn inh lng testosteron v lm karyotype phn bit
lon sn ng Muller hay bt thng nhim sc th.
C t cung: tm xem c lon sn ng Muller v mng trinh kn, vch ngn m
o hay khng c m o. Nn lm thm hCG, FSH v cc hormon khc loi
tr thai nghn v tm nhng nguyn nhn v kinh th pht.
Nu FSH cao phn nh suy bung trng nguyn pht. Cn lm karyotype
xem xt mt hay t bin nhim sc th X, c nhim sc th Y khng.
Nu FSH bnh thng hoc thp th ngh n nguyn nhn v kinh do ri lon
chc nng vng di i tuyn yn. Nn chp MRI nn s tm cc bnh ti di
i v tuyn yn. Lm thm prolactin v hormon tuyn gip, c bit l khi c tit
sa.
Nu c du hiu cng tuyn thng thn th cn lm xt nghim testosteron
v DHEA tm u tuyn thng thn.
Nu ngi bnh cao huyt p th cn kim tra c thiu ht enzym CYP17.
3.2. iu tr
Ph thuc vo nguyn nhn gy v kinh m c mc ch iu tr c th: sa
cha li cc bt thng (nu c th), gip ph n c thai (nu c nhu cu) hay
ch l ngn nga cc bin chng ca bnh (iu tr estrogen thay th).

205

- T vn vi ngi bnh tnh trng bnh, c bit l bt hot ng Muller hay

c nhim sc th Y.
-Phu thut vi nhng ngi bnh c nhim sc th Y hoc c cc tn thng
sinh dc khc. Phc hi hoc to hnh m o mu kinh thot ra c.
- Ngi bnh suy bung trng sm cn iu tr hormon thay th.
- Bung trng a nang cn iu tr ph thuc vo nhu cu ngi bnh v
ngn nga cc bin chng di hn (qu sn ni mc t cung, bo ph, ri lon
chuyn ha).
- Cc nguyn nhn v kinh th pht iu tr ging vi phn v kinh th pht.

206

MN KINH TIN MN KINH

l. KHI NIM
Tin mn kinh - mn kinh l hin tng sinh l bnh thng ca ngi ph n
xy ra khi nng estrogen gim. Tui mn kinh bao gm thi k trc, trong v
sau mn kinh.
Tui mn kinh trung bnh t 48 - 52 tui. Nu mn kinh trc 40 tui gi l
mn kinh sm, v nu sau 55 tui gi l mn kinh mun.
Mn kinh c chn on ch yu da trn lm sng, khi mt ph n t
trc vn c kinh u mi thng li t nhin ngng, khng c kinh trong 12 chu
k lin tip.
Khi mt ph n cn tr (di 40 tui m v kinh lin tip 12 thng) hoc mt
ph n b ct t cung m c mt s cc triu chng c nng ca mn kinh,
mun chn on l mn kinh cn lm cc xt nghim nh lng ni tit bung
trng v tuyn yn.
Mn kinh thng l t nhin, nhng cng c th do phu thut ct b hai
bung trng v bnh l, do x tr.
2. TIN MN KINH
L giai on ko di khong 2 n 5 nm trc khi kinh nguyt dng hn
2.1. Lm sng v chn on
Ri lon kinh nguyt di dng chu k kinh ngn li hay tha ra, rong kinh,
rong huyt , cng kinh
Xut hin hi chng tin kinh: tng cn, lo u, cng thng, au v
Xt nghim ni tit khng c ngha v thi k ny ni tit trong tnh trng
khng n nh
Chn on ch yu da vo lm sng
Cn chn on phn bit vi nguyn nhn thc th gy ri lon kinh nguyt,
c bit l cc bnh l ung th ph khoa.

207

2.2. iu tr
- Thuc nga thai kt hp, c bit loi th h mi
- Progestins dng trong 10 ngy mi thng
3. MN KINH
Mn kinh l khi ngi ph n mt kinh lin tip 12 thng
3.1. Triu chng thng gp khi mn kinh.
3.1.1. Tt kinh.
Mt kinh lin tip 12 thng.
3.1.2. Ri lon vn mch.
+ Cn bc nng mt.
- Thng xy ra t ngt, t nhin cm thy bc nng mt, c, ngc.
- Cn bc nng xy ra chng vi pht, c th ngn hn, ch vi giy, nhng
thng km theo triu chng v m hi. Thng cc cn bc nng hay xy ra vo
ban m hoc trong khi c stress
- Triu chng ny thng ko di 6 thng n vi nm, c th 2 - 3 nm
nhng cng c ngi n 5 nm.
+ V m hi.
- C th km theo cn bc nng mt hay xy ra n l.
- V m hi cng thng xy ra vo ban m nn gy mt ng, kh chu.
3.1.3. Triu chng thn kinh tm l.
- Hi hp, mt mi, kh chu.
- Mt ng, gim cm gic khi quan h tnh dc hay lo lng, cu gt, trm cm.
- au nhc xng khp, c th xut hin cn au nhc na u (migrain).
3.1.4. Triu chng tit niu - sinh dc.
- m o kh teo, giao hp au, d b vim, nhim khun, khm m o thy
nim mc mng, kh, nht nht.
- Cc dy chng gi t cung v cc c quan vng chu mt tnh n hi v sc
cng nn d a n sa sinh dc.

208

- T cung v c t cung teo nh. Ni mc t cung mng, khng cn c hin

tng phn bo hay ch tit, rt t mch mu.
- Nim mc ng tit niu cng teo mng, d nhim khun tit niu, sn tiu
hay i dt, tiu khng t ch.
3.2. Xt nghim cn lm sng
- Xt nghim nh lng FSH v estradiol
- Cholesterol ton phn, triglycerid, HDL, LDL, lipoprotein.
- Chc nng gan, thn, in tim.
- Chp v.
- Sng lc ung th c t cung, ni mc t cung bng t bo m o - c t
cung, soi c t cung, no sinh thit nim mc t cung, o mt xng.
3.3. Chn on.
- mt ph n t 45 - 52 tui ang hnh kinh, t nhin khng c kinh 12
thng lin tip, c mt s triu chng c nng ca mn kinh, c th ngh n hi
chng mn kinh.
- Nu ngi ph n di 40 tui khng cn hin tng kinh nguyt na, c
th cho lm xt nghim nh lng FSH v estradiol. Nu FSH > 40 mIU/ml
v/hoc estradiol < 50pg/l c th chn on mn kinh.
Hi tin s: bn thn, gia nh: v long xng, tim mch, cc bnh ung th
3.4. iu tr: ni tit v t vn cho ngi bnh.
3.4.1. Nguyn tc s dng ni tit: liu thp nht c hiu qu.
- Thi gian s dng ty thuc vo th trng v yu cu tng ngi.
- Phi hp estrogen/progestogen nu cn t cung.
- ging vi sinh l, estrogen c dng l estrogen t nhin hoc gn
ging vi t nhin
- Hin nay trn th trng c nhiu loi thc phm chc nng gn ging vi
estrgen t nhin c s dng rng ri
3.4.2. Chng ch nh s dng ni tit.
- C ung th hay nghi ng ung th.

209

- C thai hay nghi ng c thai.

- C khi u lin quan n ni tit.
- b vim tc tnh mch hay ng mch.
- ang b xut huyt m o bt thng cha chn on c nguyn nhn.
3.4.3. Ch dinh dng, sinh hot.
- Gi tinh thn thanh thn, vui ti, cm thy c ch cho gia nh v x hi
- Cn c hot ng chn tay km theo hot ng tr tu.
- Dinh dng theo khoa hc
- Ung b sung cc loi vitamine, vi khong, n nh vo bui ti
- Cung cp thng tin v cc triu chng c nng ca tui mn kinh v gii
thch r nguyn nhn ca cc triu chng l nhng thay i ni tit ch khng phi
bnh l
- Cung cp kin thc v nhng bnh l m tui mn kinh thng gp, cch d
phng, chn on sm v iu tr
- Cung cp kin thc v cc bin php iu tr v d phng cc triu chng v
bnh l ni trn, phn tch r v hiu qu cng nh cc tc dng ph c th c ca
cc cch iu tr, a ra lch theo di v thi gian cn iu tr i vi mi triu
chng v bnh l
- Cn gii thch rcc bnh ung th c th xy ra cho ph n tui mn kinh, c
gng tp trung hng dn lm cc xt nghim pht hin sm cc loi ung th
ph n cao tui nh ung th c t cung, ung th v...

210

V SINH N
1. NH NGHA
Theo T chc Y t th gii, mt cp v chng gi l v sinh khi sng cng
nhau trn mt nm v khng dng bin php trnh thai no m vn khng c thai.
2. PHN LOI V SINH
2.1. V sinh nguyn pht (v sinh I):
Hai v chng cha bao gi c thai, mc d sng vi nhau trn mt nm v
khng dng bin php trnh thai no.
2.2. V sinh th pht (v sinh II):
Hai v chng trc kia c con hoc c thai, nhng sau khng th c
thai li mc d ang sng vi nhau trn mt nm v khng dng bin php trnh
thai no.
3. NGUYN NHN
3.1. Bt thng phng non: vng kinh khng phng non do nh hng ca trc
di i - tuyn yn - bung trng.
3.2. Nguyn nhn do vi t cung: cc bnh l c th gy tn thng vi t cung
nh vim nhim ng sinh dc, bnh ly qua ng tnh dc, tin s phu thut
vng chu v vi t cung, lc ni mc t cung vi t cung, bt thng bm sinh
vi t cung hay do trit sn.
3.3. Nguyn nhn ti t cung: u x t cung, vim dnh bung t cung, bt thng
bm sinh (d dng t cung hai sng, t cung c vch ngn, khng c t cung...)
3.4. Nguyn nhn do c t cung: cht nhy km, khng th khng tinh trng, tn
thng c t cung do can thip th thut (khot chp, t in...), c t cung ngn.
3.5. Nguyn nhn do lc ni mc t cung
3.6. V sinh khng r nguyn nhn
Khong 10% v sinh khng th tm nguyn nhn chnh xc sau khi thm
khm v lm tt c cc xt nghim cn thit thm d v chn on.
4. CC BC KHM V THM D

211

4.1. Hi bnh: khai thc thng tin v c hai v chng:

- Tui, ngh nghip v a d.
- Thi gian mong mun c con v qu trnh iu tr trc y.
- Tin s sn khoa mang thai, sy, sinh thng hay no ph thai.
- Kh nng giao hp, tn sut, tnh trng xut tinh v nhng kh khn gp phi.
- Tin s mc cc bnh ni ngoi khoa v cc thuc ang dng hin ti.
- Tui bt u hnh kinh, tnh cht kinh nguyt, thi gian ca mi k kinh,
lng kinh nhiu hay t, c au bng khi hnh kinh khng.
- Tin s vim nhim sinh dc v cch iu tr.
- Tin s mc cc bnh l ph khoa hay cc phu thut c bit l vng tiu khung.
4.2. Khm lm sng
- Quan st ton thn: tm vc, tnh cht sinh dc ph nh lng, tc, lng mu,
lng nch, mc pht trin ca v, m vt, mi ln, mi b...
- Khm ph khoa gm khm v, nh gi mc pht trin ca v, s tit sa,
quan st qua m vt xem nhng tn thng v ng sinh dc, tnh trng vim nhim,
ch mc ch tit ca c t cung, sch v pht trin nim mc m o....
- Thm m o kt hp vi nn bng nhm pht hin cc khi u ph khoa.
Ngoi ra t th bt thng ca t cung l mt im cn lu , t cung v mt
pha l mt nguyn nhn gy cn tr tinh trng thm nhp ln ng sinh dc trn.
Nhn x trong bung t cung cng c th l mt nguyn nhn v sinh.
4.3. Cn lm sng
- Xt nghim ni tit: ni tit t hng sinh dc (LH, FSH), ni tit sinh dc
(estrogen, progesteron), ni tit thai nghn (hCG)... Tin hnh cc th nghim ni
tit nh gi chc nng ca vng di i - tuyn yn hay bung trng qua p
ng ca ni tit t.
- Thm d phng non: o thn nhit c s, ch s t cung, sinh thit ni mc
t cung nh ngy... Khi c phng non xy ra, ng biu din thn nhit c 2 th,
ch s c t cung sau phng non vi ngy phi gim xung 0.0.0.0 do hin din
progesteron t hong th tit ra. Sinh thit nim mc t cung t ngy 21 24 ca

212

chu k kinh 28 ngy, tm thy hnh nh ch tit, ch s dng 1 ln trc khi iu tr

chn on khi cc xt nghim ni trn khng r rng.
- Th nghim sau giao hp: s sng ca tinh trng trong ng sinh dc n
ph thuc vo s di chuyn nhanh chng tinh trng vo nim dch c t cung. y
l c s ca th nghim sau giao hp (Huhner test). T 2-10 gi sau giao hp ht
dch t ng c t cung. Th nghim dng tnh nu t nht tm thy c 5 tinh
trng kho trong mt mi trng vt knh x 40. Th nghim sau giao hp n
thun khng nh gi kh nng sinh sn ca chng v khng thay th xt nghim
tinh dch c. Vim m o, c t cung c th lm sai lc vic nh gi nghim
php, cn thit iu tr khi vim nhim trc khi th tin hnh th nghim.
- Chn on hnh nh: siu m ph khoa, siu m theo di s pht trin nang
non, chp phim t cung vi trng, chp tuyn yn bng X quang thng quy hoc
ct lp vi tnh.
- Ni soi chn on v can thip: chn on cc bt thng sinh dc, ni soi
g dnh vi trng, bung trng, bm thng vi trng, t im bung trng...
- Xt nghim nhim sc th : pht hin cc bt thng di truyn
5. IU TR
5.1 Ri lon phng non
Ngi bnh c ri lon phng non khng phi do suy bung trng c nhiu
phng php iu tr. T chc Y t th gii (WHO) chia ri lon phng non lm 3 loi:
Suy Di i - tuyn yn (Hypogonaldotropic Hypogonadal Anovulation):
ngi bnh b v kinh do suy di i. Ngi bnh chn n, BMI thp (<17). Biu
hin v ni tit: Estrogen thp, FSH v LH thp, Prolactin bnh thng. Khng p
ng vi th nghim Progesterone.
iu tr: thay i cch sng, ci thin dinh dng, ch n ung. Nu khng
kt qu c th iu tr bng Gonadotropins.
Ri lon Di i Tuyn yn (Normogonadotropic Normoestrogenic
Anovulation): y l loi hay gp nht. Ngi bnh c kinh t, c th b Bung trng a
nang (PCOS), tng t l LH/FSH, tng Androgens, bung trng to c nhiu nang.

213

iu tr:
- Thay i cch sng, gim cn.
- Kch thch phng non (clomiphene citrate..)
- Metformin ci thin p ng vi clomiphene ngi bnh PCOS
- IUI, IVF
Suy bung trng (Hypergonadotropic Hypoestrogenic Anovulation): ngi
bnh c biu hin suy sm bung trng. LH, FSH cao, Estrogen thp
iu tr: Xin non lm IVF. Liu php hormon thay th iu tr triu chng
v phng nga long xng.
Khng phng non do prolactin mu cao (Hyperprolactinemic Anovulation):
ngi bnh c biu hin v kinh c th km theo tit sa. Ni tit: prolactin tng
cao, estradiol thng gim.
iu tr: cn phi chp MRI loi tr khi u tuyn yn. iu tr bng
Dopamine ng vn.
5.2. Nguyn nhn do vi t cung:
Vi t cung b so hoc b tc ngn cn non gp tinh trng th tinh.
Thng gp ngi bnh c tin s vim phn ph, bnh nhim trng tiu khung,
Lc ni mc t cung, phu thut bng 75% bnh vi t cung c lin quan n
b nhim Chlamydia trc , thng khng c biu hin lm sng. Cn chp t
cung vi trng nh gi thng ca vi t cung.
iu tr: phu thut m thng vi trng qua m bng hoc qua ni soi. IVF
khi phu thut khng em li kt qu.
5.3. Lc ni mc t cung
Lc ni mc t cung c th gy nn v sinh do dnh gy nn tc vi t cung,
do gim nhu ng ca vi t cung
iu tr: c th phu thut bc nang lc ni mc t cung, tch dnh iu tr
ni khoa. Kch thch phng non, IUI nu c vi t cung bnh thng. IVF nu
phu thut, kch thch phng non IUI tht bi hoc lc ni mc t cung to.
5.4. Nguyn nhn do t cung:

214

Bt thng t cung thng gy nn sy thai hoc non lin tip. cc bnh l

thng gp : U x t cung di nim mc, polyp bung t cung, t cung c vch
ngn, dnh bung t cung.. gy kh khn cho qu trnh lm t ca phi.
iu tr:
- U x t cung: nn phu thut khi v tr v kch thc khi u nh hng n
bung t cung.
- Polyp bung t cung: nn phu thut ct polyp qua soi bung t cung
- T cung c vch ngn v dnh bung t cung: soi bung t cung phu thut.
5.5. Nguyn nhn do c t cung:
Thng gp do : cht hp l c t cung, sau phu thut hoc ct ct c t cung
do lon sn hoc do vim mn tnh c t cung
iu tr:
- IUI, IVF
- iu tr vim c t cung
5.6. V sinh khng r nguyn nhn
Chim 10-15%. y l nhng trng hp cha pht hin ra nguyn nhn bng
cc xt nghim hin nay.
iu tr:
- kch thch bung trng, IUI
- Nu tht bi chuyn IVF

215

V SINH NAM
1. I CNG
V sinh nam chim khong 20% cc cp v chng v sinh. Thm d cc
nguyn nhn v sinh nam gii cng rt hn ch, xt nghim tinh dch gn nh
l thm d duy nht nh gi kh nng sinh sn ca nam gii.
Kt qu xt nghim tinh dch bt thng cho php tm ra c nguyn nhn
nhng kt qu bnh thng cng khng cho php loi tr nguyn nhn v sinh do
nam gii. Mt khc xt nghim tinh dch li thay i rt nhiu, ph thuc vo
thi im lm xt nghim, chnh v vy khi kt qu bt thng th cn phi kim tra
li sau mt thi gian m bo tnh khch quan v chnh xc.
2. CHN ON
2.1. Lm sng
2.1.1. Hi bnh
- Tin s thi quen ht thuc, ung ru, nhim c, tip xc ho cht,
- Tin s hn nhn v thai sn: Ly v my nm, thi gian t khi mun c con
n nay.
- Tin s bnh tt: Quai b, bnh mn tnh, bnh vim nhim-ly truyn qua
ng tnh dc,
- c im nhu cu sinh l, sinh hot tnh dc, c ri lon cng dng, ri
lon xut tinh, ?
- Tin s gia nh v sinh sn: Trong gia nh c ai chm con khng?
- Pha v: khm cho v cha? Cc bt thng lin quan n sc kho sinh
sn ca ngi v: Nhu cu i hi v sinh l, tnh hnh kinh nguyt (chu k kinh,
mu sc kinh nguyt, au khi c kinh), au khi giao hp,
2.1.2. Khm bnh
- Ton thn: trng thi tinh thn kinh, hnh dng bn ngoi, v, h thng lng
(lng mu, lng nch),
- Thc th: bnh ni tit, tim mch, h tit niu,

216

- Ti ch: b phn sinh dc ngoi: D tt (khng c tinh hon trong bu, l i

thp, cong vo dng vt, ), vim nhim, chy m hoc dch bt thng.
+ Nhn: v tr l niu o; cc hnh dng v kch thc khc nhau ca dng
vt v bu, cch mc lng mu.
+ S: S tinh hon nh gi hnh dng, kch thc, mt , v tr
S nn mo tinh hon (gin, nang mo tinh,)
S nn m ri tnh mch tinh
ng dn tinh (xem c ng dn tinh khng, tnh cht ng dn tinh, hay bt sn
ng dn tinh)
2.2. Cn lm sng
2.2.1. Xt nghim tinh dch
Cc iu kin ly mu xt nghim tinh dch : king giao hp t 2 ngy n
7 ngy, dng ng ng tinh dch tiu chun v v khun. Khng nn ly tinh dch t
nh mang n, khng c dng bao cao su thng thng khi ly mu (v cc bao
cao su thng thng c cha cht dit tinh trng)
- nh gi i th:
+ S ho lng ca tinh dch (< 60 pht/37oC)
+ Th tch v mu sc (bnh thng mu trng sa)
+ Xc nh pH ( 7,2). (nu < 7,2 th c th tc ng dn tinh 2 bn)
- nh gi vi th:
+ Tnh cht di ng ca tinh trng. Da vo tc di chuyn ca tinh trng
chia thnh 4 loi: (A) di ng nhanh v pha trc ( 25 m/s), (B) di ng chm
chp hoc l v pha trc (5 m/s - < 25 m/s), (C) Di ng ti ch, khng tin
ti (< 5 m/s) v (D) nm im, khng di ng (vn tc = 0)
+ Mt tinh trng
+ Cc t bo khc: tin tinh trng, t bo biu m, bch cu

217

+ Ngng kt tinh trng (tinh trng kt m). Nu cc tinh trng ngng kt,
dnh vo nhau nhiu s hn ch kh nng di chuyn ca tinh trng v hn ch kh
nng th tinh.
+ Hnh thi tnh trng
- Ngoi ra, cn c th dng cc test v chc nng tinh trng:
+ Cc test nh gi s trng thnh nhn t bo
+ Cc test kho st tnh cht nguyn vn ca mng tinh trng
+ Tnh trng cc u ca tinh trng:
Kch thch phn ng cc u trong mi trng th nghim
+ Tng tc gia tinh trng v non
Test thm nhp non Hamster (HOP-test)
K thut xm nhp na vng trong sut
+ Phn tch tinh trng c h tr bng my tnh (CASA)
Phn tch cc vt di chuyn ca tinh trng
2.2.2. Xt nghim sinh ho tinh dch
Ti tinh cha nhiu fructose, tuyn tin lit cha phosphatase acid v km,
mo tinh hon cha carnitin v -glucosidase. Da vo cc c im ny c th
chn on tc on no ca ng xut tinh.
2.2.3. Xt nghim khng th khng tinh trng
2.2.4. Xt nghim ni tit t
nh lng cc gi tr c bn ca cc ni tit t LH, FSH, prolactin, estradiol,
testosterone. Testosterone l mt ch im quan trng nht v chc nng ca tinh hon.
Ngoi ra, c th nh lng inhibin B. Bn cnh FSH, inhibin B l mt ch im
ni tit quan trng nht ca qu trnh sinh tinh (chc nng ngoi tit ca tinh hon).
Khi c ri lon qu trnh sinh tinh th nng inhibin B thp v FSH tng cao
Cc chn on chc nng (cc test kch thch hormon):

218

Test hCG (pht hin c kh nng hot ng v ni tit ca tinh hon do

ging cu trc vi LH)
Test kch thch GnRH (kim tra kh nng sn xut ni tit t hng sinh dc
ca tuyn yn)
Cc chn on ni tit chuyn su:
Bnh v to: ngoi xt nghim nh lng estradiol, lm thm xt nghim fetoprotein, hCG, LDH-cholesterol
Cc ri lon tng hp testosterone: nh lng cc cht chuyn ho trung gian
Khng androgen: phn tch sinh hc phn t cc th th ca androgen,.
2.2.5. Xt nghim v di truyn hc
Xt nghim v di truyn hc (nhim sc th, gen) nh gi mc ri lon
nhim sc th v gen.
2.2.6. Xt nghim v m hc
- Chc ht dch mo tinh hon tm tinh trng.
- Sinh thit tinh hon (dng kim sinh thit hoc m sinh thit).
2.2.7. Chn on hnh nh
- Siu m h tit niu - sinh dc (lu : tuyn tin lit, ti tinh, tinh hon, mo
tinh hon, tnh mch tinh) xem c bt thng khng? C gin tnh mch tinh
khng? o kch thc tinh hon
- Chp ng dn tinh: mc ch tm ch tc trn ng dn tinh. Cch thc lm:
gy t ti ch, rch da bu, bc l ng dn tinh, m ng dn tinh, bm thuc cn quang
vo ng dn tinh v chp X-quang. ng dn tinh lu thng tt khi thy thuc cn
quang lm hin r ng dn tinh, ti tinh, bng tinh v bng bng quang trn phim X
quang. Nu thy thuc cn quang dng li trn ng i chng t c bt tc.
3. KT LUN
V sinh do nam gii cng chim mt t l tng ng vi v sinh n gii.
Chn on v sinh do nam gii khng phc tp nh chn on v sinh n gii,

219

xt nghim thm d n gin, khng xm nhp, chnh v vy khi thm d nguyn

nhn v sinh bao gi cng phi lm song song cho c hai cp v chng.
Vic iu tr nguyn nhn v sinh do nam gii cng kh khn hn cho n gii,
v hu ht cc trng hp iu tr cho ngi chng li phi tin hnh iu tr v
thc hin cc th thut trn ngi v (kch thch bung trng, bm IUI, thm ch
chc ht non, chuyn phi). Vi s pht trin ca cc k thut trong h tr sinh
sn vic iu tr v sinh cho nam gii cng da vo nhiu cc k thut ny, c bit
l k thut tim tinh trng vo bo tng non. Tuy nhin cng khng nn qu lm
dng vo cc k thut ny v chi ph rt tn km. Cn cn nhc cc phng php
iu tr hp l cho tng ngi bnh c th.

220

CHNG 3: S SINH
CHM SC TR NON THNG
1. I CNG
Tr non thng l tr c sinh ra trc 37 tun thai v c th sng c.
Tr thp cn l tr c cn nng < 2500g .
Hu ht tr non thng mc va v nh (xp x 80%) tui thai t > 32 37
tun, cn nng > 1500g 2500g. Nhng tr ny vn t vong cao v thiu chm sc
c bn nh: gi m, nui dng sa m, v sinh phng chng nhim khun.
Khong 10 -13% tr 28 32 tun nhng nc thu nhp thp > 1/2 s tr ny b t
vong nhng vn c th cu c vi nhng chm sc c kh thi, khng k hi sc
tch cc nh th my.
2. NGUYN NHN NON
2.1. Do m:
- M c tin s non thp cn.
- Tui < 17tui hoc > 40 tui.
- Kinh t kh khn trnh hiu bit km.
- Sang chn tm l.
- Mc bnh nhim trng: cm, st rt, vim phi.
- Bnh mn tnh: lao, vim gan, bnh tim mch, thn, i ng, tng huyt p.
- M mc bnh sn ph khoa: d dng t cung, u x t cung, t cung i, h
eo t cung, nhim trng ph khoa
- Nhim c thai nghn, rau tin o a i, bt ng nhm mu Rh
- Nguyn nhn ngoi khoa: tai nn , sang chn , m khi mang thai
2.2. T pha con:
- a thai, d tt
- a s non khng r nguyn nhn

221

3. NGUY C TR NON
3.1. Ngt v suy h hp ( SHH)
Hu qu ca trung tm h hp iu ha km, phi non, thiu ht Surfactan, c
h hp yu, lng ngc hp d bin dng dn n xp phi. Tr di 32 tun hay b
SHH mc d c s dng corticoid trc sinh cho m.
- Bnh phi mn tnh, lon sn ph qun phi do non thng.
3.2. Kh khn nui dng, d vim rut hoi t, hay b tro sa ra ngoi, d b
sc, thiu men tiu ha, ng sa
- Nhu cu dinh dng ln vy cng lm tr d b ri lon.
3.3. Nhim trng
- Da, nim mc rng, mng, km tnh khng khun d b vi khun xm nhp.
- Chu nhiu th thut nh tim truyn, ly mu, t ni kh qun, sonde d
dy
- Bch cu chc nng km.
- B th, cc globulin min dch km.
3.4. Thiu mu, xut huyt:
- Mt mu giai on bo thai, xut huyt, tan mu do hng cu non, ly mu
xt nghim
- Thiu nguyn liu tng hp hng cu, st, protein. Ty cha trng thnh.
- Xut huyt no, nhuyn no cht trng, hay gp trong 3 ngy u
3.5. Vng da c bit d vng da nhn no.
Nguyn nhn do hng cu ch yu Hb bo thai d v, chc nng chuyn ha
Bilirubin km, o thi qua phn v nc tiu km, ngng hang ro mu no thp.
3.6. Ri lon thn nhit: mt nhit nhanh, to nhit km, lp m di da mng
3.7. Bnh l tim mch
- L Botal v ng Botal ng chm v d b m ra nu c SHH hoc tng khi
lng tun hon.
- D tng p lc ng mch phi.
-

H thng mch mu non, d v gy xut huyt.

222

3.8. Ri lon chuyn ha

- H ng mu do nhu cu cao mu thun v d tr km, cung cp.
- H canxi mu, ri lon in gii.
- Ri lon toan kim.
4. IU TR V CHM SC TR NON THNG - THP CN
4.1. Hi sc s sinh sm v y
Cc chuyn gia khuyn co hi sc c bn cho tr non thng ngay ti phng
sinh gim t vong. Ring vi tr non ch cn tr hon hi sc vi pht th tr
nhanh chng xu i v c th dn n t vong.
4.2. Gi m: k thut gi m c bn
- Bin php n gin l : lau kh, si m, qun t, i m, hon tm ln u
t nht 6h, thc hin liu php Kangaroo
- Trang thit b lm m nh: m m, ging si, n si, lng p ti khoa S sinh.
- Ti Nilon bc cho tr cc k non thng trnh bay hi mt nhit.
4.3. H tr nui dng.
a. Dinh dng tnh mch:
Lng dch a vo c tnh theo cng thc:
lng dch a = lng n + truyn + thuc pha+ mt nc khc
Bng 4.1: Cch tnh lng dch nui dng tnh mch.
Nhu cu

1-2 ngy

3-7 ngy

>1 tun

Dch ml/kg/d

1500g:70-90
>1500: 60-80

90- 130

130-180ml

60-100

100-130

Nng
Kcal/kg/d

lng 40- 50

Protein g/kg/d

1,5 2

0,5g/kg/ngy(2-3,5g)

3,54g (1000-1800g
4-4,5( <1000g )

Lipid g/kg/d

0,5g/kg/ ngy(1-3g)

3-4

Glucid

4-8mg/kg/1

Na

2-3

3-7

1-2

2- 5

Khi c nc tiu
++

Ca

0,5- 1,5

1,5

1,6- 2,5

223

- Cng thc tnh c th:

dch truyn = dch protid + lipid+ glucid + in gii+ dch tim
- Nhu cu tng: chiu n+ 20%, lng p + 10%, st tng 10C tng ln 10-20%
-Nhu cu gim 10-20%: ngt chu sinh, suy tim, cn ng ng mch, suy thn
khng do gim th tch tun hon
b. Dinh dng ng tiu ha.
- Khng chng ch nh tr < 32 tun, bt u sm, u tin sa m.
- S lng sa: ngy 1: t 20-30ml/kg/24 gi nhng ngy tip theo tng trung
bnh 20ml/kg/ngy n ngy 7 140ml/kg.
T tun 2 tr i tng dn 10ml/kg/ngy ti khi t 200ml/kg/ngy
- Hng dn chung:
Tr < 1000g

tng 10 ml/kg/ngy

Tr 1000-1500g :

tng 20ml/kg/ngy

Tr 1500g

tng 20-30ml/kg/ngy

- Cch cho n: < 1000g cho n 2h/1ba, 1000g cho 3h/1 ba kch thch
nhu ng ng rut, ch dng bm my hoc nh git trong 1 s trng hp c
bit nh:
Gim nhu ng rut ko di, km dung np tiu ha.
- Theo di du hiu khng dung np:
- Tr sa, bng chng vng bng tng > 2cm. i mu da bng, phn mu,
cung lng phn tng
- Triu chng ton thn xu nh cn ngng th, cn tm, tim chm, li b
Kim tra dch d dy v x tr:
+ Nu 50% th tch cho n, mi xut hin dch xanh, dch d dy nu, 3050% dch n x 3 ln lin tc - nhn n, theo di vim rut hoi t.
+ 30-50% th tch ton trng tt- bm li d dy, gim lng sa bng dch d.
+ < 30% th tch hay 3ml nui n ti thiu, lm sng n nh - bm li d
dy, gim lng sa bng dch d

224

Ch : kim tra bng xilanh nh 5ml, gy nh bng ngn tay ci trnh ht p

lc cao
4.4. Chng nhim khun.
- Ra tay bng x phng vi nc sch, lau kh trc khi tip xc
- V sinh mi trng, trang thit b y t, hng thng bng thuc st trng.
Trnh vic tch m khng cn thit v nm chung ging, lng p vi tr khc.
iu tr khng sinh nhng tr c du hiu nhim khun, nhng tr phi can
thip xm ln nh t NKQ, nui dng TM, th CPAP mi.
4.5. Chng suy h hp
- Th Oxy liu php khi tr c suy h hp
- S dng sm CPAP ngay t gi u vi p lc 6-7 CmH20 vi tr 32 tun
tr xung cho hiu qu cao.
- Surfactan s dng iu tr thiu ht Surfactan tr non thng liu
100mg/kg bm ni kh qun, 3-5 t th nga, nghing phi, tri, u cao, thp.
Bng 4.2: Hng dn s dng surfactant
Tui thai
27 tun

Corticoid
trc sinh
Khng

Thng kh

S dng surfactant

t NKQ sm s dng thuc D phng sm

Nu th phi t NKQ v th D phng sm
my ngay sau .

CPAP sm nu khng n nh iu tr cp cu
phi t NKQ th my.
CPAP sm nu n nh.

Tr 28 C
34 tun
> 34 tun

khng

Khng dng surfactant

hoc CPAP sm sau nu phi t iu tr cp cu

NKQ th my.
C bng chng bnh mng iu tr cp cu
trong, phi t NKQ.

225

- Th my khuyn co nn dng ch kim sot p lc vi PIP xp x

20cmH20 v PEEP xp x 5cmH20.
4.6. iu tr vng da
Thm khm hng ngy pht hin vng da iu tr
Bng 4.3: Tiu chun chiu n v thay mu tr non thng.
Tui

<1500g(Mmol/l)

1500-2000g(Mmol/l)

>2000g(Mmol/l)

(gi)

Thay mu

Thay mu

Thay mu

<24h

70

170

70

255

85

270

24-48h

85

120

255

140

310

48-72h

120

155

270

200

320

>72h

140

170

290

240

340

>255

Tun u khng nn cho tr <2000g ra vin nu khng c chm sc y t ti nh.

4.7. Phng xut huyt, thiu mu.
- Tim Vitamin K1 liu 1500g cho 1mg, tr <1500g cho 0,5mg. Tr b chy
mu liu iu tr trong 3 ngy lin tip, 3 liu/ngy.
- Truyn khi tiu cu nu TC <50000/mm3 tr c xut huyt, hoc tr c TC
<30000/mm3 khng c xut huyt.
- Truyn mu nu c thiu mu Hb < 13g trong 24 gi u. Sau 1 tun: Hb
<11g% tr c kh th, tim nhanh, tng cn km hoc Hb < 8g%.
- Cho tr ung st 2 4 mg/kg/d sau 2 tun.
- Tim h tr Erythropoietin liu 300IU/kg, tun 3 ln.
4.8. S dng Corticoid v thuc khc giai on s sinh:
- Khuyn co: mc d c t hiu qu trong thi gian ngn, khng c bng
chng gim t vong v lon sn phi, hn na tng t l bi no, chm pht trin
thn kinh v th cht. V vy s dng Corticoid sau sinh nn hn ch.
- Nu tr phi th my ko di >1 tun, nhu cu Oxy khng gim dng
Corticoid c tng t l cai my thnh cng.

226

- Mt s p dng nc pht trin nhng cha c khuyn co ton cu v

thiu bng chng lin h ti nc ngho. V d: s dng Cafein Citrate gim
nguy c ngng th
5. PHNG BNH:
5.1. Trc khi c thai
- Tuyn truyn kin thc sinh sn, trnh phi can thip nhiu vo t cung.
- Trnh c thai nhiu ln, ch ngh nghip phi di chuyn nhiu khi c thai
s khng tt.
- Ch h tr dinh dng tt l rt quan trng, b xung Multivitamin khng
c hiu qu gim non, b xung acid folic trc khi c thai ch khuyn co d
phng d tt.
5.2. Khi c thai
- Khng ht thuc l, cung cp dinh dng v b sung vitamin.
- Nhim trng vng quanh tiu khung sng lc v iu tr thch hp
- T chm sc: dinh dng y , trnh stress, , khm nh k theo ch nh
- S dng Corticoid trc sinh cho nhng b m da non trc 34 tun.
Steroid s qua hng ro rau thai sang tr kch thch phi sn xut surfactant.
- Khi v i s dng khng sinh d phng cho b m v chuyn ln tuyn trn
c n v hi sc s sinh tt , gi l chuyn vin trong t cung.

227

HI SC S SINH NGT
1. NH NGHA
Ngt l tnh trng tr ra khng th, khng khc gy thiu oxy, tha CO2
m, nu ko di s b di chng hoc t vong.
Theo WHO khong gn 1 triu tr cht mi nm lin quan n ngt. Khong
10% tr s sinh cn h tr khi pht nhp th ban u, 1% cn hi sc tch cc
cu sng, 90% c th t hon tt sang kiu tun hon s sinh v t th.
Cc bc hi sc ABC bao gm: m bo thng thong ng th, m
bo h hp, m bo tun hon v m bo tr m
2. CHUN B 4 NHM DNG C
Mi cuc sinh cn c chun b y cc dng c hi sc.
Yu cu tt c cc dng c u phi sch v sn sng trong Gc hi sc.
Bn hi sc s sinh kch thc 60x80 cm, b mt phng v cng, t ngay ti
phng sinh, khng b gi la.
2.1. Nhm dng c lm kh m
- n si hoc ngun nhit khc bt sn
- 3 mnh vi kh sch: 1 k di vai,1 n v lau kh ln 1, 1 gi m sau
lau kh.
- Tri ga sch, qun o, m, chn m cho tr.
2.2. Nhm dng c hi sc h hp
- Dng c ht: bu ht, my ht, sonde ht 8F, 10F,12F.
- Cung cp oxy m - m: bnh oxy, oxy trung tm, dy, sonde, mask.
- Bng bp th tch 250-400ml, Mt n: s 1, 0.

228

- n soi thanh qun, ng NKQ cc s 2,5; 3,0 v 3,5.

2.3. Dng c v sinh lm rn
Bng cn, gc v trng, gng tay, panh, ko, kp hoc ch tht rn.
2.4. Thuc v dch cp cu
Adrenalin, Natriclorua 9%0, Ringerlactat.
Bm tim 1, 3, 5, 10, 20ml.
3. NH GI TR NGT
3.1. Ch s APGAR
Du hiu

H hp

Khc to, th bnh thng

Khc yu, rn

Khng th

Tim

100 l/p

< 100 l/p

Khng c

Mu da

Hng

Tm

Ti nht

Trng lc

Tt

Yu

Nho

Phn x

C ng tt

Nhn mt

Khng

nh gi:
8-10: bnh thng, 6-7: ngt nh, 4-5: ngt nng, 3: ngt rt nng.
Thi im nh gi: 1, 5, 10 pht.
Ba du hiu quyt nh hi sc (h hp, nhp tim, mu da) cng l 1 phn
ca thang im, hai phn (trng lc c, phn x) phn nh tnh trng thn kinh.

229

3.2. nh gi tr cn hi sc hay khng

230

4. CC BC HI SC S SINH
Theo nguyn tc A, B, C, D.
4.1. Nguyn tc A: khai thng ng th
- Nc i trong
+ Tr khe lau kh, gi m, chnh t th thng
ng th.
+ Tr khng khe: ht sch ming, mi; ming
khng qu 5cm, mi khng qu 3cm

- Nc i c phn su
+ Tr khe: ht sch phn su ming,
mi,lau kh, gi m, chnh t th
thng ng th..
+ Tr khng khe : dng sonde ln
12F ht sch ming, hng, mi tr.
Dng n soi thanh qun nhn r
thanh mn v ht sch

sau t

NKQ va ht va rt NKQ ra
Sau khi lm thng ng th, lau kh, t li v tr u, kch thch h
hp, nh gi tr 3 vn : H HP, NHP TIM, MU DA.
4.2. Nguyn tc B: h tr h hp

231

-Cung cp oxy: Oxy lu lng t do

5l/pht
+ Ch nh: khi tr th c nhng
tm trung tm.
+ Cc phng php cung cp oxy:
Mt n oxy.
Dy oxy bng cch khum tay ging

Cung cp oxy lu lng t do

nh mt n
Ch khng dng mt n gn bng
t phng sau gn vi dy oxy
qua bng v nh vy khng m bo
oxy qua .
- H hp nhn to (thng kh p lc dng)
+ Ch nh:
Th oxy lu lng t do sau 30 giy tr vn tm.
Ngng th hoc th nc.
Nhp tim < 100 l/p mc d tr ang t th
+ K thut: m bo 4 tiu chun
t mt n kn mi, ming.
Bp bng tn s 40-60 l/p (m bo tn s ta m nhm: Th - Hai Ba - Th - Hai - Ba).
p lc va phi dng lc 2-3 ngn tay khng cn bp c bn tay.
Lun duy tr ng th thng- thng
+ nh gi p ng khi thng kh
Sau mi ln bp lng ngc phng ln l c hiu qu.
Ci thin nhp tim, nhp th, mu sc da ca tr
+Nu lng ngc khng phng ln khi thng kh lp tc kim tra:
Thng thong ng th, t li t th u ca tr

232

t li mt n cho kht vi mt tr
Bng c thng khng.
- t NKQ thng kh
+ Ch nh:
i c phn su tr khng khe t NKQ sau va ht va rt NKQ.
Bp bng tr khng ci thin, ngng th nhu cu thng kh ko di.
Cn phi hp n tim ngoi lng ngc.
t NKQ dng thuc
Thot v c honh.
+ Kch thc ng NKQ
Cn nng

S NKQ

<1500gr

2,5

1500 3000gr

3,0

3000gr

3,5

+ su ng NKQ = Cn nng tr (P- kg) + 6 cm.

4.3.Nguyn tc C : h tr tun hon
- Ch nh: Khi nhp tim < 60 l/p mc d c 30 giy thng kh p lc
dng c hiu qu (tc l sau 30 giy bp bng qua mt n hoc NKQ vi oxy
100%)
- K thut n ngc: m bo 4 yu cu
+ V tr: 1/3 di xng c,
hay di ng lin nm v 1
khot ng tay tr.
+ Tn s: 120 140 l/p phi
hp vi bp bng theo t l
Bp bng/n ngc = 1/3 (Mt

233

v hai v ba v Bp v Mt v
hai.).
+ p lc: ln khong 1/3
ng knh trc sau ca
lng ngc tr.
+ n thng gc vi k thut
ngn tay ci, tay khng ri v
tr n tim trn lng ngc

4.4. Nguyn tc D: thuc cp cu ( Epinephrin 1/1000)

+ Ch nh: Nhp tim <60 l/p mc d thng kh p lc dng phi hp
n ngc ng v hiu qu.
+ Liu: pha long nng 1/10.000
Bm NKQ : 0,3ml - 1ml.
ng TM : 0,1ml 0,3ml
+ Nu khng kp cn: 1,5ml/ln qua NKQ, 0,5ml/ln tim TM.
Trong v sau khi bm Adrenalin vn tip tc phi hp bp bng v n
ngc.
Chm sc hiu qu khc
- Ch khng lm cc ng tc:
+ Gp i vo bng tr.
+ Dc ngc u tr v v vo mng, lc a tr.
+ Ngoy vo hu mn tr.

234

NHIM KHUN S SINH

1. I CNG
Nhim khun s sinh (NKSS) l tnh trng tn thng vim ca mt hay nhiu
c quan trong c th do nhim trng gy ra thi k s sinh.
Mc d c nhng phng php iu tr hin i vi nhng khng sinh mi ra
i nhng t l t vong do nhim khun vn cao. T l t vong ca NKSS sm dao
ng t 25-50% s tr b nhim khun.
2. NGUYN NHN V YU T NGUY C
2.1. Nguyn nhn:
Thy u, vim gan, HIV, Coxsackie, Echo virus, Lin cu tan huyt nhm B,
Listeria, Haemophilus Influenzae, ph cu, st rt.
Nhim khun ngc dng do r i hoc v i ko di: E.coli, Klebsiella,
Pseudomonas, Proteus, Bacteria, t cu, lin cu nhm B
+ T cu vng, Ph cu, Clostrodium, trc khun m xanh, Coliform, nm
candida.
Nguyn nhn gy NKSS rt a dng v phc tp. Ty v tr khc nhau m tnh
cht nhim khun khc nhau.
2.2. Yu t nguy c
2.2.1. ng mu:
Vi khun i qua ng mu trong trng hp m b nhim khun huyt:
- M b st, bch cu tng cao, CPR (+)
- Vim ni mc t cung
- Nhim khun bnh rau
2.2.2. Qua mng i:
- Nhim trng i, mng i, i c m, mi bt thng
- Thi gian v i > 18 gi
- Thi gian chuyn d ko di > 12 gi.

235

2.2.3. Tip xc trc tip:

- m o b nhim khun gy vim da, nim mc.
- Chm sc v sinh km: v sinh tay, ging bnh, lng p, phng bnh
- Qu trnh thc hin th thut: t NKQ, Catheter, th Oxy, truyn TM.
- Nhim khun cho do nm chung
- Tr b ngt, suy h hp, non thng, thp cn.
3. TRIU CHNG LM SNG, XT NGHIM V CHN ON
3.1. Biu hin lm sng
Thng rt ngho nn, khng in hnh nht l tr non thng thp cn,
thng nhm ln vo bnh cnh khng nhim trng tr s sinh, do cn hi tin
s sn khoa v gia nh pht hin thm.
- Biu hin ton thn:
+ Ri lon thn nhit st, h nhit hoc nhit dao ng.
+ Da ti, ti mu da km, mu sc da xu, ni vn tm, c khi ri rc cc nt
xut huyt di da, i khi ph cng b.
+ V mt nhim trng, nhim c, hc hc, mi kh, st cn.
- Thn kinh: li b, trng lc c gim, gim vn ng, c khi li kch thch.
+ C th co git, co cng, i khi thp phng nu vim mng no.
- H hp: th rn, n bt cua, co rt lng ngc, ri lon nhp th, phi ran m
2 bn nu c vim phi.
- Tnh trng tm ti do thiu oxy.
- Tiu ha: km n, sau c th b b, nn ch, bng chng, dch d dy
ng, a chy, gan , lch to
- Tit niu: tr c th thiu niu, v niu, i khi i mu.
- Nhng biu hin nhim trng: rn sng ty , c m hoc mi hi, mn
m da, vim hoi t da lan ta
3.2. Xt nghim:
- Cy tm vi khun trong mu, dch no ty, dch m, th tch ti thiu 1 ml

236

Cy hc t nhin nh: Tai, mi, dch d dy, hng, b mt c th nu (+) trn

2 mu cng c gi tr nh hng VK
CTM, bch cu > 25.000/mm3, hoc < 5000/mm3; tiu cu < 100.000/mm3.
CRP (+) > 10mg/l
- Xquang phi hnh nh vim phi
- Cc xt nghim do hu qu nhim trng gy ra: G, kh mu, ng,
Protein, Ure, Creatinin, men gan c th bin lon
3.3. Chn on xc nh
Chn on khng nh nhim trng lin quan cht ch ti tnh trng a tr:
ngy tui, kt qu cy bnh phm, triu chng lm sng, mc nng ca bnh.
Tc gi Chiesa v cng s 2004 ngh nhng tnh hung lm sng sau cn iu tr
nhim trng s sinh:
- Khng nh biu hin nhim trng trn lm sng km theo:
+ Xt nghim (+) => iu tr nhim trng.
+ Khng xt nghim hoc xt nghim (-)

=>

iu tr nhim trng.

- Lm sng nghi ng v
+ Xt nghim (+) => iu tr
+ Xt nghim (-) => theo di
- Lm sng khng khng nh, xt nghim (+) hoc (-) c th xem xt cha
cn iu tr.
Chn on mc nng ca nhim trng
Hi Ngh Quc T Nhi khoa 2010 phn loi mc nhim trng nng nh sau:
Nhim trng s sinh km theo 1 trong cc du hiu sau:
- Suy gim chc nng tim mch ( c suy tun hon)
- Suy h hp cp tin trin ( ARDS)
- Suy gim chc nng 2 c quan khc nhau trong c th.

237

4. IU TR NHIM TRNG S SINH

4.1. Khng sinh chng nhim khun
4.1.1. La chn khng sinh
- i vi nhim trng s sinh sm:
Dng 2 loi khng sinh kt hp: lactamine v Aminoside. Khi cha c kt
qu khng sinh c th cho Peniciline hoc Ampiciline phi hp vi Getamycine
hoc Amikacine. Nu ngi m c s dng khng sinh trc m tr nghi ng
nhim vi khun khng Ampiciline (E.coli, Enterobacter) chn: Claforn, Ceftriaxone,
Imepenem phi hp Aminoside.
- Trng hp nhim trng mc phi ( nhim trng mun):
+ Nu nghi ng do t cu: kt hp 3 loi khng sinh: Cephalosporine th h 3
+ Vancomycine + Aminoside.
+ Nu nghi ng trc khun Gram(-):Cephalosporine th h 3 + Imepenem. i
khi Quinolon phi hp Aminoside hoc Colymixin.
+ Nu nghi ng vi khun k kh chn Metronidazol phi hp.
S dng khng sinh Cephalosporine th h 3 rng ri, ko di l mt yu t
nguy c nhim khun nm Candida. Nu tr ang dng khng sinh ko di m tnh
trng lm sng xu i th phi hp khng sinh chng nm nhm Conazol.
Khi c khng sinh th phi iu chnh li khng sinh cho ph hp.
4.1.2. Liu khng sinh thng dng:
Ampiciline: 75mg -100mg/kg/ngy
Cefotaxime: 100mg 200mg/kg/ngy
Ceftriaxone: 50-100mg/kg/ngy
Amikacine: 15mg/kg/ngy
Gentamycine, Kanamycine: 4-5mg/kg/ngy
Vancomycine: 10mg/kg/ngy.
4.1.3. Thi gian s dng khng sinh
Nhim trng mu: 10 ngy
Vim mng no m: 14-21 ngy

238

Vim phi: 7-10 ngy

- Nu nghi ng nhim khun mu nhng cy mu (-) th ngh s dng
khng sinh kt hp ko di > 5 ngy.
- Nu do t cu vng: thi gian iu tr t 3-6 tun.
Khi s dng nhm Aminoside c th gy ic nn khng dng qu 7 ngy
i vi tr s sinh, ngng > 48 gi c th s dng t mi.
4.2. V sinh
- Ra tay sch, st khun tay nhanh khi chuyn sang tip xc tr khc.
- Thay qun o Blue hng ngy, c m, khu trang, gng tay khi lm th thut
- Thay chn, ga, gi v khun, tit khun ging, lng p hng ngy. Lau sn
nh bng thuc st khun, khng c qut sn.
- Hng thng c lch tng v sinh tit khun phng, phng tin, trang thit b.
- Nm phng ring trnh tip xc ngi nh, ch nn thm theo gi.
- Loi b vi khun: vi nhim trng da, rn, mn m, p xe phi ct lc ht t
chc hoi t, dn lu m, ra sch bng nc mui sinh l. Nu c khe, hc nhiu
th ra sch bng oxy gi, lau kh v dng thuc Betadine 2,5% st trng ti ch.
Chm xanh Methylen vo nt mn phng trn da hoc bi kem khng sinh.
4.3. Liu php h tr
4.3.1. Cn bng thn nhit:
+ Nu tr st 38,50 th dng Paracetamol: 10-15mg/kg/1 ln, khng qu 4
ln / ngy.
+ Nu tr b h nhit < 36,50 : m bng lng p hoc Kanguru.
4.3.2. Cn bng nc, in gii, toan kim:
Nui dng ng ming y , truyn dch phi hp 50-100ml/kg/24 gi.
Nu c gim ti mu : dng Dopamin 5-15g/kg/1 pht nng huyt p.
4.3.3. Chng suy h hp cp: Oxy liu php,th CPAP, h hp h tr.
4.3.4. Chng ri lon ng mu:

239

Plasma ti, truyn yu t ng mu, VitaminK1. Truyn khi tiu cu khi

tiu cu < 50.000/mm3 m c xut huyt hoc tiu cu < 30.000/mm3 mc d khng
c xut huyt.
4.3.5. Thay mu.
Thay mu mt phn trong trng hp nhim trng nng, c tc dng gim c
t v nng vi khun.
4.3.6. Thuc tng cng min dch
- Truyn Human Immunoglobulin liu 300-500mg/kg/ngy x 3 ngy: c tc
dng gim t l t vong tr nhim trng.
5. PHNG NHIM KHUN
- Gio dc thc v sinh, nui dng tr bng sa m trong 6 thng u.
- B tp tc lc hu: king tm gi, nm bung ti, kn gi.
- Khm thai nh k, dinh dng y
- D phng khng sinh cho b m b nhim lin cu nhm B. Tuy vy li lm
tng t l s dng khng sinh sm tr v thi gian nm vin lu hn khi b bnh.
Edward v cng s (2008) thy s dng vaccine tim phng thy 85-90% b
m c khng th chng GBS, khng th t m truyn sang con c hiu qu ko di
n 2 thng v cn hiu lc ngi m sau 2 nm.
Khi tr ra i:
- Ra tay sch khi tip xc tr
- m bo v sinh phng bnh, v trng lng p, c lch tit khun nh k
- Tm gi v sinh sch hng ngy, st trng h rn.
- Nhng trng hp nguy c cao nh : m i v > 18 gi, m st, nc i bn,
nhim khun i cho khng sinh d phng.

240

H THN NHIT TR S SINH

1. I CNG
- H thn nhit l tnh trng bnh l hay gp tr s sinh, c bit l tr
non, do qu trnh iu ha than nhit b mt cn bng ( qu trnh sinh nhit vqu
trnh tn nhit)
- Qu trnh sinh nhit : chuyn ha v c c
- Qu trnh mt nhit: thng qua 4 c ch
+ C ch bay hi
+ C ch truyn nhit
+ C ch i lu
+ C ch bc x
- nh ngha h than nhit: khi nhit ca tr < 35oC (95oF) gi l h thn nhit
- Mc h thn nhit
+ Nh: nhit 32 - 35oC
+ Nng: nhit < 32o C
2. NGUYN NHN
H thn nhit tr s sinh thng do cc nguyn nhn sau
- Tr non v:
+ T l din tch da/cn nng ln hn tr thng tr non d b h thn nhit
+ Lng m di da c bit l lp m nu t kh nng sinh nhit km
+ Thiu nng lng chuyn ha v sinh nhit
+ D mc suy h hp do cc vn phi
- Tr ngt gy thiu oxy cho chuyn ha t bo
- Tr hoc nui trong mi trng lnh: nhit trong phng lnh, gi la,
tr khng c m, o t b t do i, a, tm tr qu lu, nc tm lnh
- Cp cu hi sc hoc tim truyn cho tr trong thi gian ko di m tr
khng c m
- Tr b nhim trng v bnh l khc lm tr b cn kit nng lng v h thn nhit

241

3. TRIU CHNG
- Tim mch:
+ Giai on u: tng nhp tim, co mch ngoi bin duy tr ti mu c quan
+ Giai on sau: nhp tim chm, rung nh, rung tht
- H hp: lc u tr th nhanh, h thn nhit nng tr th chm dn v b toan
chuyn ha
- Thn kinh trung ng: ti mu no gim nn giai on u tr kch thch,
bt rt sau tr li b,hn m, co git
- Thn: giai on u tr tng bi niu, giai on sau tr thiu niu, tng ure
mu, hoi t ng thn
- Huythc: gim BC, TC, ri lon ng mu, xut huyt phi
4. X TR
4.1. iu tr cp cu cc chc nng sng c bn
- H hp:
+ Lm thng thong ng th: t tr t th trung gian
+ H tr h hp nu tr tm ti, ngng th
-Tun hon: truyn dch v thuc nu tr c suy tun hon
4.2. Phc hi thn nhit cho tr
4.2.1. H thn nhit nh
- t tr trong phng m( 26-28oC), c l si hoc n si
- Ci b o t t
- Lau kh ngi tr, lau kh m ri, cc cht tit
- o, t, m, tt tay chn ,chn c lm m nhit 38-40oC trc khi mc
vo cho tr
- m tr theo phng php da k da
- o than nhit ca tr 1 gi/ln vt heo di cc du hiu nguy him
4.2.2. H than nhit nng
- Lm tng t nh 3 bc u phn h thn nhit nh
- t tr vo lng p :t nhit lng p cao hn thn nhit tr 1-1.5oC

242

- Kim tra nhit lng p mi gi mt ln trong vng 8 gi u sau 3 gi

mt ln
- o thn nhit ca tr 1 gi mt ln.
+Nu thn nhit ca tr tng thm 0.5oC/1 gi v lin tc trong 3 gi l tin
lng tt. Khi thn nhit ca tr n nh trong gii hn bnh thng phi theo di
tip 3 gi /ln trong 12 gi
+ Nu thn nhit ca tr khng tng hoc tng di 0.5oC/ gi kim tra h
thng si, tng nhit lng p 0.5oC / gi
4.3. iu tr nguyn nhn v cc h tr khc
- iu tr suy h hp, cc bnh l nhim trng
- m bo nng lng, dinh dng
+ Cho tr b m nu tr cn b c
+ Nu tr khng b c cho tr n qua ng thng d dy
- Truyn dch nui dng ng tnh mch, theo di cht ng mu, khng
h ng mu
Ch : dch nui dng, sa, ch phm mu u phi l mm 40-42oC trong
sut qu trnh truyn cho tr
5. PHNG NGA
- Chm sc, qun l tt thai nghn d phng tr non, ngt
- m bo mi trng chm sc tr phi c nhit 25o-28oC, khng c gi
la, thi gian tm tr < 10 pht, t lt qun o tr phi c lm m trc khi mc.
- Nng cao cht lng chm sc v iu tr tr s sinh bnh l.

243

VNG DA S SINH
1. GII THIU
- Vng da l mt triu chng thng gp tr s sinh do nhiu nguyn nhn
gy nn.
- Vng da l do lng bilirubin tng > 120 mol/l ( >7 mg/dl) trong mu tr
s sinh.
- Hu ht cc trng hp tr vng da c hm lng bilirubin/ mu khng nguy
hi v khng cn iu tr
- Bilirubin c to ra do s d ha ca hemoglobin trong c th
+ Chuyn ha bilirubin trong bo thai: s thanh lc bilirubin trong huyt
tng thai nhi do m m nhim. Bilirubin gin tip ca thai qua rau thai gn vi
albumin ca m n gan m v bilirubin trc tip v c o thi ra ngoi. Ch
c mt phn rt nh bilirubin c bin i ti gan thai nhi v c chuyn xung
rut, c trong phn su.
+ Chuyn ha bilirubin sau khi sinh: ngay sau khi sinh, tr phi t m nhn
chuyn ha bilirubin trong khi chc nng chuyn ha bilirubin ca nhiu c quan
cn cha hon thin.
- C 2 th vng da tr s sinh:
+ Vng da do tng bilirubin gin tip ( t do)
+ Vng da do tng bilirubin trc tip ( kt hp)
2. VNG DA TNG BILIRUBIN GIN TIP
2.1. Tm tt chuyn ha bilirubin trong c th v ti sao tr s sinh li d b
vng da
- Hng cu v phng thch bilirubin vo mu do
+ S lng hng cu /kg/ tr s sinh ln hn ngi ln
+ i sng hng cu thai nhi ngn hn ngi ln
+ Thiu enzyme G6PD

244

- Vn chuyn bilirubin vo gan v qu trnh kt hp bilirubin ti gan : qu

trnh ny tr s sinh cn hn ch do
+ Men gan ( glucuronyl transferase) cha hon chnh
+ Lng Albumin trong mu thp
+ Tr s sinh thiu oxy nng ( ngt), nhim khun, nhim toan, dng mt s
thuc cnh tranh vi bilirubin (cafein, heparin, rocephin)
- Bi tit bilirubin : Bilirubin c bi tit qua ng tiu ha v ng tit
niu, qu trnh ny b nh hng do
+Nhu ng rut ca tr km Bilirubin b ti hp thu qua chu trnh rut gan
+ Chc nng thn cha hon chnh
2.2. Vng da sinh l
- Xut hin sau ngy th 3
- T khi sau 1 tun
- Vng da nh n mt, ngc
- Ton trng tr n nh
- XN Bilirubin : tr thng < 12 mg/dl, tr non thng < 15 mg/dl
2.3. Vng da bnh l:
2.3.1. nh ngha: khi nng bilirubin tng cao hn mc sinh l
Bilirubin gin tip > 12 mg/dl ( tr thng),> 15 mg/dl ( tr non thng)
2.3.2. Cch xc nh vng da ng
- Quan st tr di nh sng t nhin v nu nhn di nh sng n th tnh
trng vng da c th nng hn hoc nu thiu nh sng th khng th pht hin c
vng da
- Dng ngn tay n nh ln da trong 2 giy ri b ra, lm nh vy c th nhn
r mu da v t chc di da
2.3.3. Mc vng da: da vo
- Thi gian xut hin vng da
+ Vng da xut hin sm < 24 gi tui
+ Vng da xut hin sau 3 ngy: ph bin

245

+ Vng da xut hin mun( ngy 14 tr i)

-Theo tc tng bilirubin: tng bilirubin nhanh > 0.5 mg/dl/gi
- Tnh trng tr: cc du hiu i km nh c cn ngng th, li b, nn, b km,
thn nhit khng n nh,co git, tng trng lc c, xon vn.
- Cc yu t thun li:
+ Tr ngt gy thiu oxy mu
+ Tr non, nh cn
+ Tr h thn nhit, h ng mu
+Tr toan mu
+ Tr gim albumin mu
+Tr chm i ngoi phn su, nn dch vng
+ Tin s m
o C tr s sinh b vng da ln trc
o M dng thuc oxytocin kch thch
o Tin s thai nghn c nguy c : tin sn git, tiu ng, nhim khun
- V tr vng da
+ Theo nguyn tc Krammer
NGUYN TC KRAMMER
Vng
Bilirubin/mu

5-7

8-10

11-13

13-15

>15

(mg/dl)
Bilirubin/mu

85-119

136-170 187-221 221-255

(mol/l)

+ Theo ngy tui sau :

Tui

V tr vng da

Phn loi

Ngy 1

Bt c v tr no

Vng da nng

Ngy 2

Cnh tay v cng chn

Vng da nng

Ngy 3 tr i

Bn tay v bn chn

Vng da nng

>255

246

2.3.4. Xt nghim
- Bilirubin mu
- Cng thc mu
- Nhm mu (ABO; Rh m -con)
- Test Coombs trc tip
2.3.5. iu tr: da vo mc bilirubin mu, cn nng, tui sau : (xem hnh)
- Chiu n: l k thut d thc hin, khng xm ln v t tc dng ph, bin chng
Hng dn chiu n
+ Bc l da tr n mc ti a
+ Che mt cho tr
+ t tr vng trung tm ca nh sng n v iu chnh khong cch thch
hp t bng n chiu n tr l 30 -40 cm
+ Theo di mc Bilirubin trong mu : nu tr vng da sm 48 gi th lm xt
nghim mi 6- 8 gi , nu thy mc Bilirubin mu khng tng hoc tng trong gii
hn bng trn th tip tc chiu n v xt nghim li sau 24 gi. Nu tr vng da
sau 48 gi th lm xt nghim bilirubin sau 24 gi.
+ Theo di thn nhit ca tr:
+ Theo di pht hin cc tc dng ph do chiu n ( da, phng da, mt
nc, phn lng).
-Thay mu : l k thut cao, xm ln, c nhiu nguy c, bin chng. c ch
nh khi lng bilirubin trong mu qu cao, chiu n khng hiu qu, phng
vng da nhn no
- iu tr h tr khc
+ Truyn dung dch Glucose 10% liu 80-100 ml/kg/ngy tng cng chc
nng kt hp bilirubin ca gan
+Truyn albumin:
o Khi albumin mu < 30 g/l, t l bilirubin ton phn/albumin >8
o Liu 1-2g/kg pha vi dung dch glucose 5% pha long 2-3 ln. (1g albumin
gn 8.5 mg/dl bilirubin)

247

+ Thay mu mt phn nu c a hng cu

+ Cho tr dng sa m sm tng thi bilirubin qua rut
+ Gii quyt d tt bm sinh ng tiu ha nu c

Bng ch nh iu tr vng da da vo mc Bilirubin gin tip trong mu, cn

nng v ngy tui ca tr.
Mc Bilirubin bng l mc thay mu,ch nh chiu n khi mc Bilirubin
bng t na mc thay mu tr ln.
2.3.6. D phng:
- Hng dn m theo di v pht hin sm du hiu vng da ca tr kp
thi a tr n c s y t
- Chiu n d phng cc trng hp tr c nguy c ( v d: tr non, a
hng cu, ngt, bu huyt)
3. VNG DA TNG BILIRUBIN TRC TIP
3.1. nh ngha :vng da tng bilirubin trc tip khi nng bilirubin trc tip
vt qu 2.0 mg/dl v chim > 10 % bilirubin ton phn
3.2. c im
3.2.1. Lm sng
- Vng da xut hin mun v ngy cng tng

248

- Vng da xn, c km vng mt v nim mc, gan to, c th c lch to

- Bin i mu sc phn (vng sm hoc bc mu) v nc tiu vng sm
- C th c km theo xut huyt di da, chy mu rn, ng tiu ha
3.2.2. Xt nghim
- Xt nghim kho st chc nng gan
+ Bilirubin ton phn, trc tip
+Men gan: SGOT, SGPT
+Chc nng ng mu: PT,APTT
+Nng Albumine, Cholesterol, Phosphatase kim
+ ng mu
+ Amoniac mu ( nu nghi ng c suy gan)
- Cc xt nghim tm nguyn nhn
+ Huyt thanh chn on nhim trng bo thai
+ Cy mu, nc tiu
- Cc xt nghim pht hin teo ng mt
+ Siu m gan mt, bng
+ Chp ng mt c cn quang
+ Sinh thit gan ( di hng dn ca siu m)
3.3. iu tr
- Ni khoa: bo v chc nng gan, iu tr nhim trng, b sung vitamin tan
trong du
- Ngoi khoa: Trong teo ng mt, u nang ng mt ch

249

SUY H HP S SINH
1. NH NGHA
Suy h hp l tnh trng ri lon chc nng h hp do nhiu nguyn nhn, ti
phi hoc ngoi phi gy ra tht bi trong qu trnh trao i kh dn n thiu oxy
v tng CO2 trong mu, do khng cn kh nng duy tr PaO2, PaCo2, pH mc
c th chp nhn c.
L hi chng thng gp nht v l nguyn nhn hng u gy t vong s
sinh i hi phi cp cu nhanh chng v x tr ng.
2. NGUYN NHN
2.1. Nguyn nhn ti ng h hp
- Thng gp: bnh mng trong, hi chng ht, vim phi trong t cung, chm
tiu dch phi, tng p ng mch phi.
- t gp: chy mu phi, trn kh mng phi, thiu sn phi
- Him gp: kn kh bm sinh, tt l mi sau
2.2. Nguyn nhn ngoi ng h hp
- D tt: d dng lng ngc, tim bm sinh, thot v c honh
- Ri lon chuyn ha: h ng mu, h thn nhit, toan mu
- Bnh h thn kinh: xut huyt trong s, vim mng no, ng c morphin
- Do tun hon: mt mu cp, a hng cu.
3. CHN ON
3.1. Lm sng
3.1.1. Hi tin s
- Tr non:
+ Phi cha trng thnh, thiu surfactant bnh mng trong
+ H thn kinh cha hon chnh cn ngng th
+ M nhim trng gy non vim phi / t cung
- Tr ngt: tun hon phi gim, nguy c ht
- Tr m: nguy c chm tiu dch phi th nhanh thong qua

250

- M tiu ng nh hng tng hp surfactant bnh mng trong

- M i v sm, st, nc i bn hi vim phi/ t cung
- Da tr nhum mu phn su ht phn su
- Tr b lnh, au, mt s bnh l khc tng tiu th oxy
3.1.2. Cc du hiu lm sng :tr c 1 trong cc du hiu sau
- Da tm, ti
- Nhp th nhanh > 60 ln/pht hoc th chm < 30 ln/pht
- Cn ngng th > 20 giy hoc < 20 giy km theo nhp tim < 100 ln/pht
- Cnh mi php phng ( p cnh mi)
- Th rn( th th ra )
- SaO2< 90%
3.1.3. Mc suy h hp: da vo ch s Silverman
im

Cng chiu

t hn bng

Ngc chiu

Co ko lin sn

Khng

Lm c

Khng

p cnh mi

Khng

Th rn

Khng

Qua ng nghe

Nghe t xa

Du hiu
Di ng lng ngc

nh gi : im Silverman 5 Suy h hp nh
im Silverman > 5 Suy h hp nng
3.2. Cn lm sng
3.2.1. Xt nghim kh mu ng mch: c gi tr chn on xc nh
- PaO2< 50 mmHg v/ hoc PaCO2> 60 mmHg
- pH< 7.25

251

3.2.2. XQ tim phi: gip pht hin c cc bnh l km theo hoc cc

nguyn nhn gy suy h hp nh trn kh, trn dch mng phi, thot v c honh,
bnh mng trong v.v
3.2.3. Xt nghim mu: cng thc mu ngoi bin, CRP, ng mu, G.
4. IU TR
4.1. Nguyn tc iu tr
- Chng suy h hp
- Chng toan mu
- Chng nhim khun
- Chng kit sc
- iu tr theo nguyn nhn
4.2. iu tr c th
4.2.1. Chng suy h hp
- Ht mi hng
- t tr t th thng ng th: u hi nga ra sau, c th k gi mng
di vai
- Kch thch tr th ( xoa vo vng lng ca tr trong 10 giy)
- Dn lu d dy lm gim chng bng
- Cung cp oxy ngay: ty mc suy h hp m s dng cc phng php
khc nhau t th oxy qua sonde (0.5 l/ph) hoc qua lu (8-10 l/ph) hay phi thng
kh p lc dng qua mt n, qua NKQ hay cho tr th my h tr.
- Theo di bo ha oxy qua da ca tr (92-95%) iu chnh nng oxy
kh th vo
4.2.2. Chng toan mu
- B kim da vo kt qu kh mu l l tng nht v khi tr c thng
kh tt
+ S mEq (Natribicarbonat) = BE x P x 0.3 (P cn nng tr tnh bng kg)
+ Trng hp toan h hp( PaCo2> 70 mmHg) thi CO2 bng my th
- Khi khng lm c kh mu th b m theo cng thc 2mEq/kg

252

- Ci thin lu lng mu n phi

+ Chong nghi do gim th tch : dung dch Natriclorua 0,9% 10-20 ml/kg/15 pht
+ Xt nghim Hct < 35% truyn hng cu 10 ml/kg
+ Xt nghim Hct > 65% ( mu tnh mch) thay mu mt phn
4.2.3. Chng nhim khun
- m bo v sinh trong chm sc tr c bit cc trng hp tr cn t NKQ
- Chn loi khng sinh ph rng khi suy h hp km i v sm, nc i hi,
m st trc hoc khi kh phn bit gia vim phi v cc nguyn nhn khc
- Dng khng sinh theo khng sinh l tt nht
4.2.4. Chng kit sc
- m bo thn nhit cho tr 36o5 37oC
- Cung cp oxy m v m
- Cung cp nng lng (50 -100 kcal/kg/ngy)
- Chng h ng mu
4.2.5. iu tr nguyn nhn: (mt s nguyn nhn suy h hp ni khoa thng
gp)
- Chm tiu dch phi
+ Nguyn nhn gy suy h hp l do trong lng ph nang cn dch gy cn tr
thng kh v trao i kh
+ Thng gp nhng tr m khi cha c chuyn d, tr lt qu nhanh,
m dng thuc c ch .
+ Mc suy h hp ty thuc vo tnh trng dch ph nang.
+ XQ phi: phi km sng do ph nang cn cha nhiu dch, c th thy t
dch gc mng phi, dy rnh lin thy.
+ Tin trin: thng tnh trng suy h hp c ci thin < 24 gi iu tr.
Nu > 24 gi tr vn ph thuc vo oxy, l nhng trng hp tng tiu th
surfactant hoc surfactant bi tit cha
+ iu tr: th p lc dng lin tc, cn nhc dng surfactant trong mt s
trng hp

253

- Hi chng ht phn su
+ Nguyn nhn gy suy h hp l do trong lng ph nang cha y phn su
do tr b suy thai trong t cung gy thi phn su vo nc i v gy ng tc ht
vo trc sinh lm nc i c phn su trn vo ng h hp gy cn tr thng kh
v trao i kh
+ L nguyn nhn gy suy h hp rt nng n, tr b nhim toan nng, t vong
nhanh nu khng c x tr kp thi. Thng gp thai qu ngy sinh
+ XQ phi: xen k vng phi m v vng phi tng sng, c th thy c vng
phi xp
+ X tr: phi ngay lp tc ht kh qun tr qua n soi kh qun cho n khi
khng cn ht ra c dch phn su na, t NKQ bm surfactant cng sm cng
tt. Khng sinh ph rng
+ phng bin chng trn kh mng phi
- Vim phi trong t cung
+ Thng gp nhng tr m nhim khun trc do lin cu B, E.Coli
+ Tr suy h hp tng dn sau , phi nghe c ran m nh ht
+ XQ phi hnh nh vim ph qun phi
+ iu tr: khng sinh ph rng, h hp h tr, cn nhc bm surfactant
- Chy mu phi
+ L bnh th pht sau thiu oxy nng ko di hoc do ri lon ng mu
+ Tr suy h hp, si bt hng, tro mu ti qua mi ming v t vong rt nhanh
+ X tr: t NKQ, cho tr th my PEEP 7-8 cmH2O, truyn mu ti,
chng ri lon ng mu, cn nhc dng surfactant.
- Bnh mng trong
+ L t ng dng trn lm sng ni v tnh trng thiu ht v mt chc nng
cht surfactant phi, thng gp tr rt non
+ Suy h hp xut hin sm c th ngay sau , tr th nhanh, nng, co rt v
tm ti suy sp rt nhanh nu khng c iu tr kp thi
+ XQ phi: bnh c 4 giai on

254

o Giai on 1: Nt m dng ht khp 2 ph trng phi

o Giai on 2: Nt m dng ht nhiu v hnh nh kh trong ph qun
o Giai on 3: Nt m dng ht rt nhiu v hnh nh kh trong ph qun
nhng cn thy r b tim
o Giai on 4: Phi m u 2 bn v khng thy r b tim
+ X tr: h tr h hp bng my CPAP hoc my th, dng surfactant 100
- 200 mg/kg/ liu. Dng liu nhc li sau 6-8 gi nu tr vn c cc du hiu suy
h hp nng v khng gim c nhu cu FiO2, hoc XQ phi vn m v gin
n phi km.
5. PHNG BNH
- Theo di v qun l thai nghn tt pht hin v iu tr kp thi cc sn
ph c nguy c .
- Dng glucocorticoid cho cc b m da non c tui thai < 35 tun
- Tp hun nng cao k nng hi sc s sinh cho cn b y t ti phng ,
phng m nhm nng cao hiu qu hi sc tr ngay sau .

255

PH LC 1
THUC NGA THAI
1. KHI NIM
L bin php nga thai tm thi, hiu qu cao, an ton v phc hi nhanh
Ty theo thnh phn hormone trong thuc nga thai, chia 2 loi :
- Thuc nga thai kt hp gm ESTROGEN v PROGESTIN
- Thuc nga thai ch c PROGESTIN
- Thuc ni tit nga thai c nhiu ng dng:
- ng ung
- ng tim
- Ming dn da
- Que cy di da
- Vng m o
- Dng c t cung.
2. CHNG CH NH :
2.1. Thuc nga thai kt hp :
2.1.1. Chng ch nh tuyt i.
- C thai hoc nghi ng c thai.
- ang cho con b trong vng 6 tun sau sinh.
- Ln tui ( 35 tui) v ht thuc thng xuyn 15 iu/ngy.
- C nhiu nguy c b bnh mch vnh (ln tui, ht thuc l, i tho ng
v tng huyt p)
- Tng huyt p nng (HA tm thu 160 mmHg, HA tm trng 100 mmHg).
- hoc ang b bnh l tim mch v ng mu nh:
+ Bnh l mch mu
+ Thuyn tc tnh mch su
+ Thuyn tc phi
+ Bnh l ng mu

256

+ Bnh thiu mu c tim

+ Bnh l van tim phc tp
+ Tai bin mch mu no
+ C a huyt khi di truyn.
- Sp phu thut i hi nm trn 1 tun.
- au na u (Migrain).
- ang b ung th v.
- i tho ng c bin chng (thn, thn kinh, vng mc, mch mu).
- ang b lupus ban h thng v c khng th khng phospholipid
- ang b bnh gan nng c suy gim chc nng gan trm trng.
2.1.2. Chng ch nh tng i :
- ang cho con b sau sinh t 6 tun n 6 thng hoc khng cho con b trong
vng 4 tun sau sinh.
- Ln tui ( 35 tui) v ht thuc < 15 iu/ngy.
- hoc ang b cao huyt p trung bnh (HA tm thu 140 - 159 mmHg, HA
tm trng 90 - 99 mmHg).
- hoc ang b tng lipid mu hoc tng cholesterol do ung thuc trnh thai.
- tng b ung th v v khng c biu hin ti pht trong vng 5 nm tr li.
- Si mt ang iu tr ni khoa hoc x gan cn b
- ang s dng mt s loi thuc nh rifampicin/rifabutin, thuc khng virus
nhm c ch protease Ritonavir-booster (Ritonavir-booster protease inhibitor) v
mt s thuc chng co git nh phenytoin, carbamazepin, barbiturat, primidon,
topiramat, oxcarbazepin hoc lamotrigin.
2.2. Thuc nga thai ch c progestin
2.2.1. Chng ch nh tuyt i :
- C thai hoc nghi ng c thai.
- ang b ung th v.
2.2.2. Chng ch nh tng i :
- Thuyn tc tnh mch su/thuyn tc phi.

257

- Tng huyt p (HA tm thu 160 mmHg hoc HA tm trng 100 mmHg)
(/v thuc tim nga thai)
- Lupus ban h thng v c khng th khng phospholipid .
- Tin cn ung th v.
- X gan mt b.
- hoc ang b tai bin mch mu no hoc thiu mu c tim
- au na u c km m mt
- ang s dng mt s loi thuc nh rifampicin/rifabutin, thuc khng virus
nhm c ch protease Ritonavir-booster v mt s thuc chng co git nh
phenytoin, carbamazepin, barbiturat, primidon, topiramat, oxcarbazepin
3. U V KHUYT IM CA CC DNG THUC
3.1. Thuc nga thai kt hp
Thuc nga thai kt hp: nh thnh phn estrogen c th c nhng thun li nh
- t gy ri lon kinh nguyt
- Duy tr v ci thin mt xng
Tuy nhin estrogen c th c nhng bt li :
- Tc dng ph: nn, cng v, nhc u, chng mt...
- Nguy c: tc mch
- Khng s dng nu c cc chng ch nh vi estrogen.
C nhiu ng dng khc nhau: vin ung, ming dn da, thuc tim, vng
t m o.
Cc loi vin nga thai kt hp hu nh c hiu qu nh nhau, tuy nhin cc
loi vin nga thai kt hp khc nhau v:
- Hm lng estrogen trong mi vin thuc(Ethinyl estradiol 35mcg,
30mcg, 20mcg)
- Thnh phn progestin(levonorgestrel,desogestrel, norgestimate,
drospirenone...)
- Hm lng estrogen v progestin ging nhau hoc khc nhau gia cc vin
trong cng 1 v thuc (1 pha, 2 pha, 3 pha)

258

- S ngy dng thuc v ngng thuc trong 1 chu k

Cc s thay i ny nhm gim tc dng ph bt li, tng cng cc tc dng
c li, ng thi vn m bo hiu qu nga thai tt.
Vng trnh thai t m o phng thch 15mcg Ethinyl estradiol v 120mcg
etonogestrel mi ngy. Mi vng s dng trong 3 tun, ngh 1 tun. Phng php
ny thng ph hp vi la tui v thnh nin.
3.2. Thuc nga thai ch c progestin :
Thun li chnh ca thuc nga thai ch c progestin l c th s dng trong thi
gian di, khch hng khng th qun s dng (dng thuc tim, cy di da, dng c
t cung). C t chng ch nh hn v c th c li hn trong mt s bnh l.
C nhiu ng dng khc nhau : vin ung, thuc tim, que cy, dng c t cung.
Vin thuc ung ch c progestin liu thp hng ngy c c im:
- Hay lin quan ti cc ri lon chy mu t cung bt thng
- T l tht bi hi cao hn vin nga thai phi hp
- C ch tc dng ch yu ln cht nhy c t cung, gy c ch rng trng ch
khong 57%, so vi vin thuc nga thai kt hp gy c ch rng trng 95-97%
- Phi dng thuc u n mi ngy, khng c ngy ngh. S dng chm tr
vi gi c th gim hiu qu nga thai.
- Thng c ch nh cho cc ph n ang cho con b mun nga thai
Thuc tim nga thai ch c progestin (DMPA) hiu qu cao, d hi phc,
khng cn dng hng ngy, tim mt ln c tc dng trong 3 thng. C nhng
u im:
- Gim lng mu kinh
- Gim nguy c vim vng chu
- Gim nguy c ung th ni mc t cung
- C th s dng trong cc trng hp khng th dng thuc nga thai c
estrogen nh :
o Nhc u migrain lin quan vi estrogen
o ang dng thuc chng co git

259

o Thiu mu hng cu lim (Sicle cell anemia)

o U x t cung
o Ln tui v c ht thuc l
Dng c t cung c progestin ch yu phng thch thuc ti ni mc t cung,
lng thuc phng thch vo tun hon rt thp. Thng ph hp vi cc trng
hp c km bt thng ti ch nh tng sinh ni mc t cung, cng kinh, lc ni
mc trong c t cung...
4. NH HNG CA THUC I VI C TH :
4.1. Cc tc dng c ch :
- Gim au bng kinh, gim lng mu kinh
- Gim mn trng c v cc du hiu nam ha khc
- Mt s loi c th gy tng ham mun tnh dc
- ng dng iu tr trong mt s bnh l ph khoa : rong kinh rong huyt, lc
ni mc t cung...
- Gim nguy c vim vng chu, au vng chu.
- C tc dng bo v i vi ung th bung trng v ung th ni mc t cung
4.2. Cc tc dng bt li :
- Bun nn, nn, nhc u, chng mt, mt mi, gim th lc
- Sm da, rng tc, tng cn, au v
- Tng cn do gi nc v tng chuyn ha ng m
- Ra huyt t cung bt thng, v kinh.
4.3. Cc bin chng :
- Nguy c gy tc mch huyt khi
- Thay i chuyn ha
- nh hng ln chc nng gan
- Tng huyt p
5. CCH DNG THUC :
Ty dng thuc, c thi im bt u, ng dng, s ngy dng trong chu k, ...
khc nhau. Cn tun th ng theo khuyn co m bo hiu qu nga thai tt nht.

260

- Vin thuc nga thai kt hp :

+ Bt u trong 5 ngy u ca chu k kinh hoc trong vng 7 ngy sau ht
thai/ sy thai
+ C th bt u bt c thi im no nu bit chc l khng c thai. Cn phi
s dng thm BPTT (bin php trnh thai) h tr (nh trnh giao hp hoc s dng
bao cao su) trong 7 ngy k tip
+ Sau sinh bt u t tun th 4 nu khng cho con b
+ Ung mi ngy 1 vin, nn vo gi nht nh d nh, theo chiu mi tn
trn v thuc .
+S ngy dng thuc v ngng thuc trong mi chu k khc nhau ty tng
loi thuc, cn phi tun th ng khuyn co ca nh sn xut.
- Vin thuc nga thai ch c progestin :
- Bt u trong 5 ngy u ca chu k kinh; trong vng 7 ngy sau ht thai/
sy thai hoc 4 tun u sau sinh ( c th bt u ngay khi c sa)
+ C th bt u bt c thi im no nu bit chc l khng c thai. Cn phi
s dng thm BPTT h tr (nh trnh giao hp hoc s dng bao cao su) trong 2
ngy k tip
+ Ung mi ngy 1 vin, phi ung vo mt gi nht nh, theo chiu mi
tn trn v thuc. Ung thuc tr 3 gi tr ln phi c x tr nh qun thuc.
+ Dng v k tip ngay sau khi ht v u, khng ngng gia hai v.
- Thuc tim trnh thai ( DMPA) :
+ Bt u trong vng 7 ngy u ca chu k kinh u tin; ngay sau ph thai,
sy thai hoc bt c lc no trong vng 21 ngy hu sn (v khng cho con b)
+ Bt u bt c thi im no nu bit chc l khng c thai. C th cn s
dng BPTT h tr trong 7 ngy k tip
+ Thi gian dng mi tip theo sau 3 thng

261

PH LC 2
DNG C T CUNG
1. KHI NIM :
Dng c t cung (DCTC) l phng php trnh thai n gin, r tin, hiu qu
cao v d hi phc. Ngy nay, cc DCTC thng c cho thm ng hay
Progestin gia tng hiu qu nga thai.
C 3 loi DCTC:
- DCTC tr : DANA, Lippes
- DCTC cha ng c lm t mt thn plastic vi cc vng ng hoc dy
ng. C nhiu hnh dng khc nhau v hm lng ng khc nhau (TCu
380A, Multiload 375, TCu 200) . DCTC TCu-380A c tc dng trong 10 nm
- DCTC cha progestin ( Progestin- releasing IUDs): Vit Nam c Mirena
gm mt thn ch T bng polyethylen cha 52 mg levonorgestrel, gii phng 20 g
hot cht/ngy, c tc dng ti a 5 nm.
2. HIU QU, U - KHUYT IM :
2.1. Hiu qu :
y l phng php nga thai c hiu qu cao v t ph thuc vo ngi s
dng. T l trnh thai cao 95 - 97%. T l c thai trong nm u tin i vi ngi
s dng DCTC c ng l khong 0,5 - 0,8%. i vi DCTC c progestin, t l
tht bi thp hn, khong 0,1% trong nm u.
2.2. u im :
- Cc DCTC hin i l bin php nga thai an ton, hiu qu, phc hi nhanh
v t tc dng ph.
- t nh hng n sc khe ton thn.
- R tin, tin dng, t mt ln c th s dng nga thai c nhiu nm.
- Ngi ph n c th ch ng yu cu t DCTC trnh thai
2.3. Khuyt im :

262

- Tt DCTC xy ra 2-5%, thng xy ra trong nhng thng u sau t. Nu

khng pht hin c d b mang thai ngoi mun.
- Thay i v chy mu thng gp: ra mu thng nhiu v ko di hn, km
au bng, c bit l trong 3-6 thng u sau t.
- Thng ra nhiu kh h m o do phn ng tng tit dch ca nim mc t cung.
- C th gy triu chng au trn nng h v, co tht TC, au lng.
- C th gy cc bin chng nng khi t nh thng t cung, nhim trng,
vng xuyn c, tn thng cc tng ln cn
- C th c thai trong hoc ngoi t cung khi ang mang DCTC
- Ngi ph n phi n cc c s chuyn mn t DCTC ch khng
t t c
- Mi loi DCTC c thi hn s dng, cn n cc c s chuyn khoa thay
khi n hn.
3. CH NH
- Ph n trong tui sinh , mun p dng mt bin php trnh thai tm
thi, di hn, hiu qu cao v khng c chng ch nh.
- Trnh thai khn cp (ch i vi DCTC cha ng).
4. CHNG CH NH
4.1. Chng ch nh tuyt i
- C thai.
- Nhim khun hu sn.
- Ngay sau sy thai nhim khun.
- Ra mu m o cha c chn on nguyn nhn.
- Bnh nguyn bo nui c tnh hoc c tnh trng hCG vn gia tng.
- Ung th c t cung, ung th nim mc t cung.
- ang b ung th v (ch i vi DCTC gii phng levonorgestrel).
U x t cung hoc cc d dng khc lm bin dng bung t cung.
- ang vim tiu khung.
- ang vim m c t cung hoc nhim Chlamydia, lu cu.

263

- Lao vng chu.

4.2.Chng ch nh tng i:
- Trong vng 48 gi sau sinh (ch i vi DCTC gii phng levonorgestrel).
- Trong thi gian t 48 gi n 4 tun u sau sinh (k c sinh bng phu thut).
- ang b bnh lupus ban h thng v c khng th khng phospholipid (ch
i vi DCTC gii phng levonorgestrel) hoc c gim tiu cu trm trng.
- Bnh nguyn bo nui lnh tnh c tnh trng tnh trng hCG gim dn.
- tng b ung th v v khng c biu hin ti pht trong 5 nm tr li (ch
vi DCTC gii phng levonorgestrel), hoc b ung th bung trng.
- C nguy c b nhim khun ly truyn ng tnh dc cao.
- Bnh AIDS c tnh trng lm sng khng n nh.
- ang b thuyn tc mch (ch chng ch nh vi DCTC gii phng
levonorgestrel).
- ang hoc b thiu mu c tim, chng au na u nng (ch chng ch
nh vi tip tc s dng DCTC gii phng levonorgestrel), hoc ang b x gan
mt b c gim chc nng gan trm trng, hoc u gan (ch vi DCTC gii phng
levonorgestrel).
- ang s dng mt s thuc khng virus thuc nhm c ch sao chp ngc
nucleotid (NRTIs) hoc khng nucleotid (NNRTIs) hoc nhm c ch men protease
Ritonavir-booster.
5. THI IM T DCTC :
- Nn t trong 12 ngy u chu k kinh.
- C th t bt c thi im no nu bit chc l khng c thai.
- Sau sinh : t trong vng 48 gi hoc sau 4 tun
- Sau ph thai/sy thai : c th t ngay nu khng st nhau, khng nhim trng.
Nu t sau 12 ngy cn phi chc chn l khng c thai.
- Nga thai khn cp: t trong vng 5 ngy sau khi giao hp khng c bo v.
- DCTC c progestin: nn t trong vng 7 ngy u ca chu k kinh, nu tr
hn cn dng thm bin php h tr hoc king giao hp trong 7 ngy k tip.

264

6. K THUT T DCTC
- T vn k v khm cn thn trc t.
- o bo nguyn tc v khun v ng k thut.
t DCTC loi TCu 380-A
Chun b t
- Kim tra dng c v bao ng DCTC (thi hn s dng, bao cn nguyn vn).
- Cho khch hng i tiu.
- Khch hng nm trn bn theo t th ph khoa.
- Gii thch cho khch hng cc th thut chun b tin hnh.
- Khm trong xc nh t th, th tch t cung v phn ph.
- Thay gng v khun.
- St khun b phn sinh dc ngoi (kp st khun 1).
- Tri khn v khun.
- T th thy thuc: ngi trn gh, khong gia 2 i ca khch hng. Nu c
ngi ph th ngi ph ngi bn tri thy thuc (i gng v khun tay cm van
hoc dng c
Cc thao tc t DCTC
- Bc l c t cung.
+ M m o bng van.
+ St khun c t cung v ti cng m o bng Betadin (kp st khun 2).
+Cp c t cung bng kp Pozzi v ko nh xung.
- o bung t cung.
+ a thc o vo t cung theo hng ca n trong tiu khung, khng chm
vo m h v thnh m o.
+ Xc nh su bung t cung.
- Lp DCTC vo ng t
+ Lp DCTC trong bao.
+ iu chnh nc hm trn ng t ng hng v ng su bung t cung.

265

- a DCTC vo trong t cung

+ Cm ng t ng t th, ng hng, tay kia cm kp Pozzi ko c t cung
v pha m mn ri nh nhng a ng t (c DCTC) qua c t cung vo trong n
khi nc hm chm vo l ngoi CTC.
+ Gi nguyn cn y, ko ng t xung gii phng cnh ngang ch T.
+ Gi nguyn ng t, rt cn y ra ngoi.
+ y nh ng t ln m bo b phn hm ti st c t cung.
+ Rt ng t.
+ Ct dy DCTC li t 2 - 3 cm v gp vo ti cng sau m o.
- Tho dng c
+ Tho kp Pozzi.
+ Kim tra chy mu v cm mu nu cn.
+ Tho van hay m vt.
- Thng bo cho khch hng bit cng vic xong.
t DCTC loi Multiload
Chun b t
- Nh cch chun b t TCu 380-A.
Cc thao tc t DCTC
- Bc l c t cung (nh vi TCu 380-A).
- o bung t cung (nh vi TCu 380-A).
- a DCTC vo trong t cung
+ M bao b, t nc hm ng hng v su bung t cung.
+ Mt tay cm kp Pozzi ko c t cung v pha m mn, tay kia gi ng t
(c DCTC) ng hng (theo nc hm), y DCTC vo qua c t cung theo ng
t th t cung cho ti khi chm y.
+Rt ng t ra ngoi.
+Ct ui DCTC li 3 cm, gp vo ti cng sau m o.
6. CH NH THO DCTC
- V l do y t:

266

+ C thai (nu thy dy DCTC mi c tho).

+ Ra nhiu mu.
+ au bng di nhiu.
+ Nhim khun t cung hoc tiu khung.
+ Pht hin tn thng c tnh hoc nghi ng c tnh t cung, c t cung.
+ DCTC b tt thp.
+ mn kinh (sau khi mt kinh 12 thng tr ln)
+ DCTC ht hn (10 nm vi TCu 380-A, 5 nm vi Multiload): sau khi
tho c th t ngay DCTC khc (nu khch hng mun)
- V l do c nhn:
+ Mun c thai tr li.
+ Mun dng mt BPTT ( bin php trnh thai) khc.
+ Thy khng cn dng BPTT no na

267

PH LC 3
X TR D TT BM SINH CP CU
1. GII THIU
- D tt bm sinh xy ra khong 3% tr s sinh. Nu khng c can thip
phu thut khong 1/3 s tr ny s t vong do cc d tt ny lm tr khng thch
ng c vi i sng bn ngoi t cung.
- D tt bm sinh c nhiu kiu bt thng v hnh thi. Tuy nhin cc ri lon
chc nng ng vai tr chnh trong quyt nh thi x tr cp cu hn l cc
hnh thi biu hin bn ngoi.
- Nguyn nhn gy d tt bm sinh a s khng r rng:
+ Yu t mi trng : 10%
+ Yu t di truyn : 20%
+ Khng r nguyn nhn : 70%
-Cc tc nhn nh hng bao gm:
+ Tc nhn vt l :tia phng x, bc x
+ Tc nhn ha hc : Thalidomide, nitrofen, vitamin, thuc ni tit
+ Tc nhn nhim trng : Virus, k sinh trng, xon khun
+ Tc nhn di truyn : ri lon NST, gen.
2. CC D TT BM SINH NGOI KHOA THNG GP
2.1. Cc d tt vng ngc
2.1.1. Thot v honh bm sinh
- L tnh trng cc tng trong bng thot v ln lng ngc qua cc l khim
khuyt ca c honh. Thng xy ra bn trai nhiu hn bn phi, 85-90% thot v
qua khe Bochdaleck, 1-5% thot v 2 bn

268

- Chn on giai on sau sinh

+ Tam chng kinh in: Tm ti, kh th, tim
lch phi
+ Khm: Bng xp, lng ngc phng, ting tim
nghe bn phi, nghe ting nhu ng rut trong
lng ngc

:
+ XQ lng ngc ( th in hnh)
o Bng hi rut trong lng ngc
o Trung tht b y lch sang phi
o Rt t nhu m phi phi

- X tr :
+ Khng c dng bng v mt n h tr h hp
+ t ng NKQ v cho tr th my
+ t ng thng d dy
+ Nui dng tnh mch, khng sinh
+ iu chnh ri lon nc in gii, thng bng toan kim
+ Chuyn phu thut nu tr n nh sau 24 gi
2.1.2. D dng ph qun v phi bm sinh
D tt ny thng c pht hin trc sinh qua siu m. Nu pht hin sau
sinh thng tnh c qua chp phi nhng tr c biu hin suy h hp. Cc tn
thng bao gm:

269

- Kn ph qun: l cc thng tn dng

+ Kn cha y kh nu c thng thng vi ph qun hoc
+ Dng c nu khng thng thng vi ph qun hoc
+ Dng mc kh dch nu va cha kh v dch
-Nang tuyn bm sinh : bao gm mt khi nhiu nang nh nm trong nhu m
phi c s gia tng ca cc cu trc ph qun, ph nang
- X tr : ch can thip khi c du hiu suy h hp
2.2.Cc d tt ng tiu ha
2.2.1. Teo thc qun
- Phn loi th lm sng theo GROSS : 5
type
+ u di thng vi kh qun (82%)
+ Thc qun mt hn 1 on (9%)
+ D kh thc qun, thng vi nhnh PQ gc
(6%)
+ 2 u thng vi kh qun nhng khng thng
nhau (2%)
+ u trn thng vi kh qun (1%)

- Du hiu lm sng sau khi sinh (th in hnh)

+ Tng tit nc bt
+ Tm ti, ho sc khi b
+ Phi nghe nhiu ran m
+ t ng thng d dy s 8-10 b nghn, bm hi qua ng thng s nghe
thy v tr tc nghn trn lng ngc
+ Tm cc d tt phi hp : hi chng VACTERL = d tt ct sng, hu mn,
tim mch, d kh thc qun, thn tit niu, t chi

270

- XQ ngc bng:
+ Xc nh ti cng trn qua v tr ng thng d
dy
+ Xem c hi trong ng tiu ha xc nh
d kh thc qun, xem c d dang tiu ha khc
phi hp nh tc t trng
+ nh gi tnh trng vim phi
+ Trng hp nghi ng c th chp phim ngay
sau khi bm thuc cn quang qua ng thng d
dy ( sau phi ht thuc cn quang ra ngay,
thng thc hin ti bnh vin c kh nng phu
thut)

- X tr trc phu thut

+ t tr t th u cao 45o
+ Ht nc bt qua ng thng t ti cng thc qun bng bm tim 5 ml
mi 30 pht 1 gi
+ H tr h hp nu c suy h hp
+ Nui dng ng tnh mch
+ Khng sinh
2.2.2. Tc rut
2.2.2.1. Tc rut l cp cu ngoi khoa thng gp nht tr s sinh. Gm 3
loi
+ Tc rut ni sinh (Teo rut) : do tn thng ngay ti ng tiu ha
+ Tc rut ngoi sinh: tc nghn do tc ng t bn ngoi ng tiu ha (mc
treo chung, dy chng)
+ Tc rut chc nng :

271

o Do ri lon nhu ng rut: tr s sinh non thng do m ri mc treo

cha pht trin hon chnh hoc trong nhng trng hp gim nhu ng do v hch
o Do ri lon c ca phn : tc rut phn su, bnh qunh nim dch
2.2.2.2. Cc nguyn nhn tc rut s sinh
- Tc t trng : l do teo t trng, hp t trng do mng ngn nim mc, do ty
nhn, do dy chng Ladd , do t trng i
- Teo rut non
- Teo i trng v trc trng
- Tc rut phn su
2.2.2.3. Triu chng lm sng:
- Tr nn dch mt: tr nn dch mt l triu chng quan trng ( cn XQ bng
cp cu loi tr xon rut.). Tr trng hp tc t trng trn bng Valter ( him
gp) tr nn dch trong
- Tr khng i phn su : trong trng hp tc t trng do mng ngn khng hon
ton hoc cc trng hp tc rut khng hon ton do hp rut tr vn i phn su.
- Bng chng: chng ton bng khi tc rut thp, chng di rn nu tc
rut cao
- Kch thch thy c sng nhu ng hoc du hiu rn b
- Thm trc trng khng c phn su m ch thy t kt th nhy trng ( trng
hp hp rut vn c phn su)

272

2.2.2.4. Xt nghim chn

on:
- XQ bng khng chun b: l
XN bt buc, thng l
xc nh tc rut(c hnh mc
nc v hi) v v tr tc nh
trong tc t trng c 2 mc
nc v hi . Tc thp hn
nu c nhiu mc nc v hi
. Nu c hnh nh calci ha
gi thng rut trc sinh.
C th c hnh nh lim hi.
- Chp lu thng rut l xt nghim c hiu, thng
ch nh khi tc nghn chc nng (Hirschsprung, tc
rut phn su) . L xt nghim c th gy nguy him cn
thc hin cc trung tm ln.

2.2.2.5. X tr :
- t ng thng d dy dn lu
- Nui dng tnh mch
- Khng sinh ph rng, vitamin K
- Chuyn c s phu thut nhi
2.3. Vim phc mc phn su
- L vim phc mc do phn su v khun hin din trong bng sau thng
ng tiu ha, xy ra khong t thng th 5 ca thai k n nhng gi u sau
khi ng tiu ha cha c vi khun

273

- Cc hnh thi ca vim phc mc phn su

+ Vim phc mc dnh : thng ng tiu ha trong thi k bo thai, phn su
v khun gy vim phc mc ha hc, l thng c hn gn to thnh qu trnh
dnh v calci ha.
+ Vim phc mc hnh thnh nang gi : thng ng tiu ha, phn su trn
vo bng nhng c rut non v mc ni ln bao bc khu tr li thnh nang
thng h sn phi.
+ Vim phc mc kt bc : thng ng tiu ha, phn su trn vo bng
nhng khng thng ng tiu ha, phn su trn vo bng nhng khng c khu
tr l nn trn ngp vo bng, lm rut non dnh li vi nhau, phc mc phn
ng vim mnh nn rt dy
+ Vim phc mc t do : thng ng tiu ha xy ra quanh , phn su trn
ngp bng
- Lm sng :
+ Bng chng cng s nn c cm gic chng di tay, trn da bng thy
nhiu tnh mch gin, g c vng thp
+ Nn: xut hin sm sau sinh, nn dch xanh hoc vng
+ Khng i phn su
- XQ bng c th c cc hnh nh
+ Mt mc nc v hi ln khu tr mt phn ca bng gp trong cc
trng hp hnh thnh nang gi
+ bng m c, c mt s bng hi nm gia bng, pha trc ct sng
hoc mt hnh mc ncv hi ln nm ngang bng gp trong cc trng hp
vim phc mc kt bc
+ Hnh lim hi ln di c honh 2 bn hoc mt hnh mc nc v hi ln
nm ngang trong bng gp trong vim phc mc t do
- X tr :
+ t ng thng d dy dn lu

274

+ Nui dng tnh mch

+ Khng sinh ph rng, vitamin K
+ Chuyn c s phu thut nhi
2.2.3. Thot v rn v khe h thnh bng
- Thot v rn l tnh trng vng rn trong
thi k bo thai khng khp li c, nguyn
nhn thng do trung trng sau thi k pht
trin ngoi bng khng tr li v tr bnh
thng trong bng. Trong thot v rn, ton
b ni tng c bao bc bi mt ti gm
phc mc bn trong v mng i bn ngoi,
cung rn nm bn trn ti.
- Thot v qua khe h thnh bng l thot v
rut qua khe h thnh bng thng bn phi
rn, do tnh trng thoi ha bt thng ca tnh
mch rn phi gy nn. H thnh bng ng
knh khong 2-4 cm, cc quai rut thot ra
ngoi khng c phc mc che ph, thng
bn phi thnh bng bn cnh cung rn

- Hai d tt ny tuy v mt gii phu v phi thai hc hon ton khc nhau
nhng li c cng cch x tr bc u nh nhau trong giai on chu sinh
- X tr:
+ Chng h thn nhit :
o Tt nht l dng ti plastic bao bc quanh cc tng thot v hoc qun gc
tm betadine xung quanh tun th nguyn tc v khun
o t tr nm lng p hoc di n si m
- t tr nm nghing phi trong trng hp h thnh bng

275

- t ng thng d dy
- Bi ph nc v in gii, khng sinh
-Thm khm k pht hin cc d tt phi hp
- Chuyn c s phu thut nhi
2.2.4. Khng hu mn
D tt khng hu mn c phn lm 2
th
- Th thp: gp trong 90% trng hp,
tin hnh phu thut to hnh hu mn
1 th. Th ny c tin lng tt
- Th cao : tr hon ton khng c vt
tch ca hu mn. Tin hnh phu thut

Xquang u dc: xc

to hnh hu mn l 2 th, th 1 lm hu

nh khong cch t

mn nhn to, th 2 lm hu mn tht

ti cng n vt tch

sau th 1 vi thng. Hu mn ny c

hu mn.

nong dn, n khi t kch thc bnh

thng s ng hu mn nhn to

2.3. Thot v mng no ty v tt nt t sng

- V tr thot v hay gp l vng ct sng tht lung
(chim 80%), vng chm
- Ti v tr thot v c mt nang phng ln, bn trong
nang cha dch no ty v thng thng vi khoang

276

di nhn
+ Th nh: khi thot v c che ph bng lp da v
lng hay mt u m che ph bn ngoi
+ Th nng: khi lp mng no l ra ngoi km theo
d dch no ty
- Chm sc tr trnh lm sang chn v lm tng p
lc ni thng tn
- Ph gc m ln ch thot v, phi dng gc tm
Betadine che ph vng thot v nu trng hp v
bao thot v
- Trnh dy phn vo ch thot v
-Chuyn c s phu thut nhi

2.4. Teo tt l mi sau

- Tr sinh ra hon ton khng c l mi sau hoc c u nang chn p gy tt
mi, hoc l mi sau c mt mng ngn c l nh thng qua mng. C th b mt
hoc c hai bn.C th km theo cc d tt khc.
- Triu chng lm sng: ph thuc vo tc hon ton hay c mng ngn c l,
tnh trng suy h hp s rt nng nu l mi b tt hon ton.
- Chn on:
+ t ng thng qua mi, khng lun su ng thng vo qua l mi sau c.
+ Bm 0.5 ml xanh metylen 1% qua l mi, dng n soi NKQ khng thy
thuc xung thnh sau hng
- X tr : cn chuyn ngoi gii phng ng th ngay khi teo tt hon ton
l mi sau. Trong trng hp c th tr hon s phu thut khi iu kin tr cho
php t 4 -12 thng tui.
3. D PHNG:

277

- Ph n mang thai trnh tip xc vi cc tc nhn gy nh hng ti qu trnh

pht trin ca thai nh : tia phng x, bc x, tc nhn ha hc (Thalidomide, nitrofen,
vitamin, thuc ni tit), tc nhn nhim trng (Virus, k sinh trng, xon khun).
- Tng cng chn on trc sinh sng lc v x tr sm cc bnh l bt
thng bm sinh.

278

TI LIU THAM KHO

1.

Ting Vit
Bi ging Sn ph khoa tp I (2011), Nh xut bn Y hc.

2.

Bnh vin Ph Sn Trung ng (2012). Sn Ph khoa- bi ging cho hc

vin sau i hc- NXB Y hc.

3.

B mn Nhi Trng i hc Y H Ni, Hi chng nhim khun s sinh,

chng II: S sinh; Bi ging Nhi khoa tp I, 2000, P 171-180.

4.

B mn Ph Sn Trng i hc Y H ni (2006). Bi ging Sn Ph khoa

dnh cho sau i hc- NXB Y hc.

5.

B mn Ph Sn Trng i hc Y Dc Hu. Cc tn thng lnh tnh c

t cung. Trong: Sn Ph khoa, Nh xut bn Y hc, H Ni, 2007.

6.

B mn Ph Sn Trng i hc Y Dc Hu. Sa sinh dc. Trong: Sn Ph

khoa, Nh xut bn Y hc, H Ni, 2007.

7.

B Y t- V khoa hc o to (2007). Sn Ph khoa- NXN Y hc.

8.

B Y t. Hng dn sng lc, iu tr tn thng tin ung th d phng

th cp ung th c t cung. H Ni, 2011.

9.

Hi ngh Nhi khoa Vit Nam. Khuyn co iu tr dinh dng cho tr sinh
non,nh cn. Nh xut bn tng hp TP HCM 18/1/2013.

10.

Hng dn quc gia v cc dch v chm sc sc khe (2009), B Y t.

11.

Nguyn B c (2002), Ung th bung trng (khng phi t bo mm), Ho

cht iu tr bnh ung th, Nh xut bn y hc, H Ni, tr. 130-137.

12.

Nguyn B c(2008): Chn on v iu tr bnh ung th.

13.

Sn ph khoa tp 1, B mn ph sn, i hc Y Dc TP.H Ch Minh: a

i; Thiu i, trang 308-320

14.

Thc hnh cp cu Nhi khoa, ch bin GS-TS Nguyn Cng Khanh, GSTSKH L Nam Tr, Chng 3 Cp cu tr s sinh Nh xut bn Y hc H
Ni. 2010. Trang 287-327

279

15.

Vin Hn lm Nhi khoa v Hi Tim mch Hoa K Hi sc cp cu s

sinh. Xut bn ln th 5,Nh xut bn Y hc. 2006

Ting Anh
16.

Abalos, E, Duley, L, Steyn, DW, Henderson-Smart, DJ. Antihypertensive

drug therapy for mild to moderate hypertension during pregnancy (Cochrane
Review). Cochrane Database Syst Rev 2007; :CD002252.

17.

Adam H Balen (2008). Infertility in Practice. Informa healthcare.

18.

ACOG practice bulletin. Diagnosis and management of preeclampsia and

eclampsia.Obstet Gynecol. 2002 Jan;99(1):159-67.

19.

Alkushi A., Abdul-Rahman Z. H., Lim P., Schulzer M., Coldman A.,
Kalloger S. E.,

Miller D. & Gilks C. B. (2005), "Description of a novel

system for grading of endometrial carcinoma and comparison with existing

grading systems", Am J Surg Pathol, 29(3).
20.

American College of Obstetricians and Gynecologists (2008), ACOG

Practice Bulletin No. 99: management of abnormal cervical cytology and
histology. Obstet Gynecol.

21.

American pregnancy Association. Care for the premature Baby. Copy right 20002013 http://www.americanpregnancy.org/laborbirth/carepremature.htm

22.

Ayhan. B, Mano A, Falcao A, Godinho I, Santos J, Leitao F, Oliveira C,

Caramona M (2005), CA-125 AUC as a new prognostic factor for patients
with ovarian cancer. Gynecol Oncol;97:529534.

23.

Basta A. Decidual ectopy of the uterine cervix. In: The Cervix, 2nd ed.
Blackwell Publishing, 2006.

24.

Bardara Wilson- Clay. Breastfeeding premature babies_ the importance of

breastmilks.http://www.babyzone.com/newborn/premature
babies/breatsfeeding.1/16/2013

25.

Berkowitz R. S, Goldstein D. P (2003).Gestational trophoblastic Disease",

Novak 's Gynecology13th, Chapter

280

26.

Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of

female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet
Gynecol.1996;175:13.

27.

Brubaker L et al. Pelvic Organ Prolapse. In: Incontinence. International

Continence Society, 2009.

28.

Christianne, A.L., A.C. Ansink (2006), Treatment and prognosis of post term
choriocarcinoma in The Netherlands, Gynecologic Oncology.

29.

Copeland LJ, Landon MB (2012), Malignant diseases and pregnancy. In:

Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics - Normal and Problem
Pregnancies. 6th ed. Philadelphia, PA: Elsevier Saunders; chap 47.

30.

Claudio Chiesa, Alessandra Panero, John F. Osborn, Antonella F. Simonetti,

Lucio Pacifico, Diagnosis of neonatal sepsis: A clinical laboratory
challenge. Clinical chemistry 50, No.2, 2004. P. 279-287

31.

Creasman William T (2007), "Clinical gynecologic oncology", Elsevier Inc.

32.

Current Diagnosis and Treatement Obstetrics and Gynecology. 10th editionMcGraw-Hill 2007.

33.

David B. Seifer; Robert L. Collins (2002). Office-Based Infertility Practice.

Springer-Verlag New York.

34.

David EF, John BP, Chapter 2 Resuscitation of the newborn infant. In:
Care of the high risk neonate, Third edition, 1986. P31-51

35.

Davila GW, Ghoniem GM, Wexner SD. Pelvic Floor Dysfunction. Springer,
London, 2006.

36.

Desai NR, Gupta S, Said D et al (2010), Choriocarcinoma in a 73 year-old

woman : a case report and review of the literature. J med Case Report.

37.

Duley, L, Henderson-Smart, DJ, Meher, S. Drugs for treatment of very high

blood pressure during pregnancy. Cochrane Database Syst Rev 2006;
3:CD001449.

38.

Edmund S. Sabanegh (2010). Male Infertility: Problems and Solutions.

Humana Press.

281

39.

Franco Muggia & Esther Oliva (2009), "Uterine Cancer Screening,

Diagnosis, and Treatment", Humana Press.

40.

F.Gary Cunnningham, Williams Obstetrics (2005) 22Th ed, Mc GRAW

HILL, p 761-798

41.

F.Gary Cunnningham, Williams Obstetrics (2009) 23Th ed, Mc GRAW

HILL, chapter 34.

42.

Fortnightly review: management of hypertension in pregnancy. BMJ 1999

May 15;318(7194):1332-6.

43.

Gaetano Clirico, Cristina Lada. Laboratory and to the diagnosis and

therapy of infection in the neonate. Pediatic Reports 2011; Volume 3; e1

44.

Ghoniem GM, Davila GW. Practical Guide to Female Pelvic Medicine.

Taylor & Francis, London, 2006.

45.

Gilad Twig et al. Anti Phospho Lipid Syndrome- pathophysiology. Recurrent

Pregnancy Loss- Cause, Controversies and Treatment. Iforma Helth Care,
2007: 107-114.

46.

Goldstein DP, Berkowitz RS (2008), Gestational trophoblastic disease. In:

Abeloff MD, Armitage JO, Niederhuber JE, Kastan MB, McKenna WG,
eds. Abeloffs Clinical Oncology. 4th ed. Philadelphia, PA: Elsevier
Churchill Livingstone; chap 94.

47.

Hoffman B, et al. Benign disorders of the lower reproductive tract. In:

Williams Gynecology, The McGraw-Hill Companies, Inc, 2012.

48.

Hope S. Consultation for an abnormal menstrual cycle. In: The abnormal

menstrual cycle. Rees M, Hope S, RavnikarV (editors). Taylor & Francis,
UK, 2005.

49.

Huang KG, Abdullah NA, Adlan AS, Ueng SH, Ho TY, Lee CL (2013),
Successful

surgical treatment of

recurrent choriocarcinoma with

laparoscopic resection of intraperitoneal pelvic tumor. Taiwan J Obstet

Gynecol. 2013 Jun;52(2).

282

50.

International Federation of Gynecologists and Obstetricians (FIGO) (2000).

"Staging classification and clinical practice guidelines of gynaecologic
cancers".

51.

Iurain JR (2007), " Berek & Novak's Gynecology", Lippincott Williams &
Wilkins.

52.

Ivan Damjanov (2013), Cancer Grading. Manual ISBN 978-3-642-34515-9

ISBN 978-3-642-34516-6.Springer Heidelberg New York Dordrecht London.

53.

James P Neilson, Gillian ML Gyte,Martha Hickey, Juan C Vazquez, Lixia

Dou (2013) Medical treatments for incomplete miscarriage, Chochrane
database Syst Rev.2013 Mar 28;3:CD007223

54.

Jiang W, Lv S, Sun L, Singer G, Xu C, Lu X (2013), Diagnosis and

Treatment of Retroperitoneal Ectopic Pregnancy: Review of the Literature.
Gynecol Obstet Invest. 2013

55.

Joyce M.K, WilliamJ.K Group B Streptococcus and Early Onset Sepsis

in the Era of maternal Prophylaxis. Pediatr Clin North Am. 2009 June;
56(3): 689 Contents. Doi: 10.1016/J.Pcl.2009.04.003

56.

Jurkovic D.,

Hillaby K.,

Woelfer B.,

Lawrence A.,

Salim R.,

Elson C.J.

Cesarean scar pregnancy Ultrasound Obstet Gynecol 2003 ; 21 : 220-227

57.

Kavanagh JJ, Gershenson DM (2012), Gestational trophoblastic disease:

hydatidiform mole, nonmetastatic and metastatic gestational trophoblastic
tumor: diagnosis and management. In: Katz VL, Lentz GM, Lobo RA,
Gershenson DM, eds.Comprehensive Gynecology. 6th ed. Philadelphia, PA:
Elsevier Mosby; chap 35.

58.

Kamura

T, Ushijima

(2013),

Chemotherapy

for

advanced

or

recurrent cervical cancer. Taiwan J Obstet Gynecol.

59.

Kimmig R, Wimberger P, Buderath P, Aktas B, Iannaccone A, Heubner M

(2013).

60.

Kumar, Vinay, ed. (2010). Pathologic Basis of Disease(8th ed.). Saunders

Elsevier

283

61.

Larsen J.V., Solomon M.H. Pregnancy in a uterine scar sacculusan unusual cause
of postabortal haemorrhage. A case report S Afr Med J 1978 ; 53 : 142-143

62.

Lewis V. Reproductive Endocrinologyand Infertility. Lasndes Biosciences,

Texas, 2007.

63.

Mayeaux Jr. EJ, Cox JT. Modern Colposcopy Textbook and Atlas. American
Society for Colposcopy and Cervical Pathology, 2011.

64.

Mayo

Clinic.com.

Premature

Complications

birth:

http://www.mayoclinic.com/heath/premature_birth/DS00137/DSEC.DEC.29,2011
65.

Maymon R., Halperin R., Mendlovic S., Schneider D., Vaknin Z., Herman A.,
and al. Ectopic pregnancies in caesarean section scars: the 8-year experience of
one medical centre Hum Reprod 2004 ; 19 : 278-284

66.

National Cancer Institute (27 June, 2005). "Paget's Disease of the Nipple:
Questions and Answers". Retrieved 2008-02-06.

67.

Nancy K. Lowe (2013),

Cervical Cancer Screening Guidelines 2012

Journal of Obstetric, Gynecologic, & Neonatal Nursing. Volume 42, Issue 1.

68.

Ngan, H., L.-C. Wong (2003), Staging and classification systems, Gestational
trophoblastic disease, Chapman & Hall Medical, London - New York Tokyo.

69.

Noller KL (2007), Intraepithelial neoplasia of the lower genital tract (cervix,

vulva): Etiology, screening, diagnostic techniques, management. In: Katz
VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology
. 5th ed. Philadelphia, Pa: Mosby Elsevier.

70.

Novaks

Textbook

of

Obstetrics,

14th

edition.

70. Obrtetrics: Normal and Problem Pregnancies. Sixth edition- Saunder

Elsevier 2012.
71.

Pak Cheung Ng. Diagnostic markers of Infection in neonates, Review. Arch

Dis Child Fetal Neonatal Ed 2004; 89: F229-F235.

72.

Peter Braude; Alison Taylor

problem. BMJ.

(2003). ABC of subfertility: Extent of the

284

73.

Trachtenbarg DE, Goleman TB. Do premature babies need special care? May 15,
1998. Created 01/1999. http://familydoctor.org/familydoctor/en/pregnancynewborn/

74.

Tscherne, G. Menstrual Irregularities. In: Pediatric and adolescent gynecology:

evidence-based clinical practice, SultanC (edit.). Karger, Basel, 2004.

75.

Sierra B, Sanchez M, Cabrerizo JL et al (2008), Choriocarcinoma with

pulmonary and cerebral metastases. Singapore Med J.

76.

Stage Information for Gestational Trophoblastic Tumors and Neoplasia at

The National Cancer Institute (NCI), part of the National Institutes of Health
(NIH), in turn citing: FIGO Committee on Gynecologic Oncology.: Current
FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational
trophoblastic neoplasia. Int J Gynaecol Obstet 105 (1), 2009.

77.

Scully RE, Sobin LH (2003), Histological typing of ovarian tumors. Second

Edit. Wolrd Health Organization, International Histological Classification of
Tomours. Springer.

78.

Sergio C Oehninger; Thinus F Kruger (2007). Male Infertility: Diagnosis

and Treatment. Informa healthcare.

79.

Siriwan Tangjitgamol & al (2009), "Management of endometrial cancer in

Asia: consensus statement from the Asian Oncology Summit 2009", the
Lancet oncology.

80.

Raymond E.L., Robert T.O., Ted G. (2001), Ovarian and fallopian tube
cancers, Clinical Oncology, American Cancer Sosiety, pp. 477-486.

81.

Recurrent Pregnancy loss Causes, Controversies and Treatment Informa, 2007.

82.

Vulvar Cancer - October 1, 2002 - American Family Physician". Retrieved

2010-006.

83.

"Vulvar Cancer". Gynecologic Neoplasms. Armenian Health Network,

Health.am. 2005. Retrieved 2007-11-08.