B Y T

-------

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
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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

Nguyn Vit Tin

1

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)
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

A:

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
1. DA SY THAI - SY THAI
2. SY THAI LIN TIP
3. DA NON, NON
4. THAI CHT LU TRONG T CUNG
5. THAI CHM PHT TRIN TRONG T CUNG
6. TIN SN GIT - SN GIT
7. A I
8. THIU I
9. RAU TIN O
10. RAU BONG NON
11. THAI QU NGY SINH
12. BNH TIM MCH V THAI NGHN
13. THIU MU V THAI NGHN
14. BASEDOW V THAI NGHN
15. I THO NG V THAI NGHN
16. VIM GAN B V THAI NGHN
17. HIV/AIDS V THAI NGHN
18. ST TRONG KHI C THAI
19. SINH L CHUYN D
20. NGI MNG
21. NGI VAI
22. I V SM, I V NON
23. SUY THAI TRONG T CUNG
24. TC MCH I
25. V T CUNG
26. CHY MU SAU
27. NHIM KHUN HU SN
CHNG 2: PH KHOA
1. P XE V
2. CC TN THNG V
3. TN THNG LNH TNH C T CUNG
4. VIM PHN PH
5. VIM M O
6. CHA NGOI T CUNG
7. CHA VT M
8. SA SINH DC
9. U NANG BUNG TRNG
10. U X T CUNG (FIBROID)
11. LC NI MC T CUNG
12. TIN UNG TH V UNG TH M H TN THNG TIN UNG TH

13. UNG TH M H
14. CHA TRNG
15. U NGUYN BO NUI
16. UNG TH C T CUNG
17. UNG TH NIM MC T CUNG
18. UNG TH BUNG TRNG
19. RONG KINH RONG HUYT
20. V KINH
21. MN KINH - TIN MN KINH
22. V SINH N
23. V SINH NAM
CHNG 3: S SINH
1. CHM SC TR NON THNG
2. HI SC S SINH NGT
3. NHIM KHUN S SINH
4. H THN NHIT TR S SINH
5. VNG DA S SINH
6. SUY H HP S SINH
PH LC 1: THUC TRNH THAI
PH LC 2: DNG C T CUNG
PH LC 3: X TR D TT BM SINH CP CU
TI LIU THAM KHO

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. 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 sung 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.
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.
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

+ 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)
- 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

Hi chng khng PhosphoLipid vi - Khng iu tr

bin chng sn khoa
- ASA liu thp

C thai
- LMWH + ASA liu thp
- B sung Ca v Vit D

Hi chng khng PhosphoLipid vi Warfarin, duy tr INR: 2 - ASA liu thp + Liu LMWH ti a m
tin s huyt khi
-3
khng qua c rau thai (gp 3 - 4 ln)
Hi chng khng PhosphoLipid
th pht hay CAPS

iu tr theo chuyn
khoa

c ch min dch nu cn thit

LMWH + ASA

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
+ 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 1 ln/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 bnh 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.
- Thiu ht ni tit: b sung 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.

10

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.
- 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.

11

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
>120 ln/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.
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 57mg/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.
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.

12

- 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 quy 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.
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:
+ 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.

13

- 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
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.
- 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.

14

- 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.
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
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

15

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 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:
+ 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.

16

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.
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 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

17

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.
+ 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.

18

- 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).
+ 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 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.

19

+ 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
+ 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.

20

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.
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

21

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
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.
- 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.

22

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
- 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.

23

- 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.
- 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.
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.

24

4.2. Cho con

Non thng, cht trong chuyn d, bnh l tr s sinh do thiu mu, non thng
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.
- 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.

25

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.
- 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.
- iu tr triu chng nu c: HA cao, v niu, ri lon 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

26

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.
THAI QU 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
- 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.

27

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
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.

28

- 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.
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.
+ 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.

29

+ 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.
- 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.
THIU MU V THAI NGHN

30

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
- 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.

31

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.
- 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

32

- 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.
- 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
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 di 25.
+ Th trng bnh thng trc thai k (BMI < 26kg/m2).

33

+ Khng c tin s bt thng chuyn ha 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:
+ 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 1 cc 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
O Sullivan-Mahan
Mu ton Somogy Nelson(mg/dl mmol/l)

Nhm d kin T quc

gia
Huyt tng - T phn tch
(mg/dl[mmol/l])

Carpenter-Coustan
Huyt tng-Glucose
oxidase(mg/dl [mmol/l])

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.
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.

34

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 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 ty 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 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 ty 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.

35

Nhu cu insulin gim nhanh chng ngay sau khi sinh(c th gim n 50-90%) 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:
+ 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
ha 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.
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.

36

+ 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.
+ 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 ph n Nguy c ly truyn cho s sinh khi
c thai 3 thng cui
hay sau

Hng x tr

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.
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.

37

- 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
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 38 oC, 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.
- 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).

38

+ 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 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 sm ly 2. Phng trnh
truyn HIV cho ph mang thai ngoi
n
mun cho ph n
nhim HIV

3. Can thip cho ph n

nhim HIV mang thai

- Thng tin, gio dc

v truyn thng thay
i hnh vi.

- T vn v cung cp - Chm sc thai nghn

cc bin php trnh
- T vn v xt nghim
thai.
- nh gi giai on lm
- T vn v XN HIV - T vn xt nghim
sng v min dch
cho ph n
HIV
- iu tr DPLTMC
- Khuyn khch tr
- T vn thc hin
hon quan h tnh dc tnh dc an ton
- Thc hnh sn khoa an
i vi thanh thiu
ton.
nin
- iu tr cho tr sinh ra t
- Thc hnh tnh dc
b m nhim HIV.
an ton
- T vn nui dng tr sau
- Pht hin sm v
sinh
iu tr kp thi cc
nhim khun ly
truyn qua ng tnh
dc

4. Cc dch v chm
sc, h tr v iu tr
thch hp cho cp m
v con sau sinh
- Cc dch v can thip
cho b m.
- Cc dch v can thip
cho tr phi nhim.
- Cc dch v can thip
cho tr nhim HIV.

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.
- 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/mm 3 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):
M

Khi mang thai

AZT (Zidovudine) 300mg x 2ln/ngy, ung hng ngy

t tun thai th 14 hoc ngay khi pht hin nhim HIV
sau tun thai th 14 cho n khi chuyn d

Khi chuyn d

- AZT 600mg + 3TC 150mg + NVP 200mg.

39

- Sau 12 gi mt ln AZT 300mg + 3TC 150mg cho

n khi .
Sau
Con

AZT 300mg + 3TC 150 mg ngy 2 ln trong 7 ngy

M iu tr AZT trc sinh NVP liu n 6mg ung mt ln ngay sau sinh + AZT
trn 4 tun
4mg/kg ung ngy 2 ln
M iu tr AZT trc sinh NVP liu n 6mg ung mt ln ngay sau khi sinh +
cha 4 tun
tip tc AZT 4mg/kg ung 2 ln 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.
- 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.
ST TRONG KHI C THAI
1. KHI NIM
Sn ph st (nhit 38oC) 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:

40

+ 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
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 x 3
ln/ngy trong 14 ngy.
2.1.6. Vim gan do virus.

41

- 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.
- 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 38-40oC, 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:
+ 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.
SINH L CHUYN D

42

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.
- 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 120-150mmHg. 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:

43

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.
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 0.51 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
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:

44

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.
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
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.

45

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).
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). Cngchu- tri- ngang (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.
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

46

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.
- 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.
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 .
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

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- 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 ly 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
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.

48

- (+) 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.
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

49

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:
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.
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 ca 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.
SUY THAI TRONG T CUNG

50

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
- 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
4.2. Khi chuyn d

51

- 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 t 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.
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.
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).

52

- 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 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.
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.

53

- 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)
- 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.
+ 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.

54

- 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.
- 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 thai - khung 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.
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:

55

- 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.
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.
- 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 :

56

- 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, i - trc 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 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.
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 38oC - 38,5oC, 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:

57

- 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 .
+ 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 39oC - 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 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

58

+ 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 39oC - 40oC, 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
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 39oC - 40oC, 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 40 oC, 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 sonde d dy ht dch, t sonde hu mn cho
huyt thanh mn u trng v prostigmin

59

+ 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 lon
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.
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 1 ln/1 tun
- Tc mch cc c quan khc: x tr theo tng chuyn khoa
3. D PHNG

60

- 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
.
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
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 dch 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.

61

- 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
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 ha 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.
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:

62

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.
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 ta 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 ha 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 tui. Trong trng hp ny, nu i 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, ArgonzDel 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 thy (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

63

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
+ 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 mch v 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% 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 ha 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 thy. 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.

64

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
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, ty 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 ty.
- 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 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, ha cht v ni tit l nhng liu php iu tr b sung 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.
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

65

nhau, trong c th k n s thay i ni tit t sinh dc n, tui tc v hot ng 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 mc, 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.
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 ha.
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.

66

- Xt nghim t bo c t cung: hnh nh bnh thng hoc cc bin i lnh tnh.

- 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.
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

67

+ 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.
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.
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.
Ty 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 39 oC.
- C th nn hoc bun nn.
- Khm bng thy khng bng vng di, nhng khng co cng thnh bng, c du gim p Blumberg (+).

68

- 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.
- 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 trc 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 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 nhiu 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

69

- au do bnh ng tiu ha 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.
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.
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:

70

- 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.
- 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 1 vin
Mycostatine, Meconazol 100mg mi ti 1 vin 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, 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.

71

- 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.
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.

72

+ 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 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
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

73

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 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, da 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 ha, 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 ty
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, da v
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:

74

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.
+ Dng Methotrexat ton thn n liu hay a liu:
Methotrexat tim bp, nng ty 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 thm. Sau iu tr 6 thng mi c c thai tr li.
+ iu tr ti ch bng cch tim vo phi cc cht ph hy 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.
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

75

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
- Hy thai trong ti i
- 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
- Ha tr ton thn:thng iu tr h tr
Mc ch gim s phn b mch mu khi thai v tiu hy 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 ha 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 ha 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
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 khe yu, mc sa sinh dc li tin trin thm.
- C nng:
Ty 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.

76

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.
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 ta, 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.
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.

77

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.
+ 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 o tng i n gin, p dng cho ngi gi khng cn quan h
tnh dc,cn c s ng ca c hai v chng.

78

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.
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.
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:

79

Nang bc non do nang De Graff khng v vo ngy quy 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
ha.
+ 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.
- 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.
- 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.

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+ 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 thy 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.
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 X- quang 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: thng xy 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.
- C thai km u nang bung trng:
c chn on qua khm thai nh k hoc qua siu m.

81

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.
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% trng hp, 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% trng hp) 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
2.4. Chn on phn bit

82

- 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: 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.
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

83

- 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
- 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

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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.
Khng dng qu 3 thng nu khng 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%

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+ Nguy c nhim trng vng chu khong 1,5%

- 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.
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

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- 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.
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 tui 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)
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.

87

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 ha, 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 5fluorouracil (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.
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 ty 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.
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

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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.
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 ha
hoc sng ha bnh thng, t bo cu gai c nhng nh n su vi biu m bit ha 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 ha.
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 ha cht.
Tin lng thng l ti, v ty 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.
- 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

89

- 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.
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 ty 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 ha cht sau no (thng l
Cisplatin v 5 - FU). Mt s nghin cu cho thy vic iu tr v ha cht trc m cho hiu qu iu
tr tt hn v gim t l bnh phi phu thut ct b rng.
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 ha 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.

90

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.
- 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.
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 thy, v nang mng v trn lng.

91

- 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:
+ Da 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.
- 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:

92

+ 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).
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 khe, 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.
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.

93

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.
- 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 ty 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)
+ 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
S thng t ln c thai cui
n lc iu tr (thng)
hCG (IU/1)

< 40

> 40

Cha trng

Sy, no thai

Thai thng

<4

4-<7

7 - < 13

13

< 103

103 - 104

104 - 105

> 105

3-5

>5

Lch, thn

Rut

Kch thc khi u (cm)

V tr di cn

Phi

94

Gan, no

S lng nhn di cn

1-4

iu tr ha cht trc

>4-8

>8

n ha cht

Hai ha cht

Cch iu tr da vo im tin lng:

im 0 - 6: nguy c thp khi pht iu tr n ha cht.
im 7: nguy c cao 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
- 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 ty, gim bch cu...); ang nhim khun; lot ng
tiu ha; 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 ha, 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.
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

95

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.
+ 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 Liquy 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 sn

c tnh

+ Khng th loi tr tn thng ni biu m

vy cao (ASCUS-H)

+T bo tuyn lin quan tn sn c tnh

- Tn thng t bo ni biu m vy thp

(LSIL), bao gm HPV, Lon sn nh/CIN I

- Ung th t bo biu m tuyn c t cung ti

ch

- Tn thng t bo ni biu m vy cao

(HSIL), bao gm lon sn trung bnh, lon
sn nng, CINII/CINIII

- Ung th t bo biu m tuyn

- C du hiu nghi ng ung th xm nhp

- Ung th t bo biu m vy

+ Biu m tuyn c t cung

+ Biu m tuyn ni mc t cung
+ Biu m tuyn ngoi t cung
+ Biu m tuyn khng nh loi (NOS)

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

96

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

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

IA1

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;

IA2

Tn thng su 5mm, rng 7mm, nu rng hn th nhm Ib

IB

Tn thng c kch thc ln hn giai on Ia d c thy 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

IIA

Cha xm ln dy chng rng

IIB

Xm ln dy chng rng

III

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

niu qun

IIIA

Ung th lan n 1/3 di m o, nhng cha n thnh xng chu

IIIB

Ung th lan n thnh xng chu chn p niu qun, lm thn nc

hoc mt chc nng

IV

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.

97

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
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.
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

98

+ 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.
- 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)
2.5. Chn on giai on(FIGO 1988)
Giai on

Tiu chun

99

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 t cung

IIA

Xm ln tuyn c t cung

IIB

Xm ln m m c t cung

III:

U lan ra ngoi t cung nhng cn khu tr trong khung chu

IIIA
IIIB
IIIC

U xm ln ti thanh mc v/hoc phn ph v/hoc t bo hc dch

ra phc mc dng tnh

IV:

U lan ti m o

IVA

U lan ti khung chu v/hoc hch cnh ng 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.
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.

100

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 ha
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
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

101

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%.
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 tn

- Ung th biu m tuyn x

- Ung th biu m tuyn x

Nhng ung th t bo chuyn tip

- U hn hp Muller c tnh

- Ung th biu m t bo chuyn tip (khng

phi loi Brenner)

- Saccm tuyn
- Saccm m m dng ni mc t cung (
thp)
- Saccm bung trng khng bit ha

- U Brenner c tnh
Ung th biu m t bo vy
Ung th biu m khng bit ha

U t bo mm c tnh: Bao gm ung th t bo U t bo steroid (Bit ha cao v c tnh)

mm nguyn thy v u qui khng thnh thc.
2.4. Phn loi giai on lm sng. Theo FIGO2013
Giai on
I

M t
U gii hn bung trng hoc vi t cung

IA

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

IB

U cn gii hn c hai bung trng (v bc cn 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

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

km theo bt k du hiu no di y:

IC 1

V khi u trong phu thut

IC 2

V v khi u trc phu thut hoc c khi u trn b mt bung trng

hoc vi t cung

IC 3

C t bo c tnh dch bng hoc dch ra mng bng.

II
IIA

U mt hoc hai bung trng hoc vi t cungc lan trn vo khung

chu (di gii hn ca tiu khung) hoc khi u bt u di cn phc mc
Lan n v/hoc xm ln vo t cung v/hoc ng dn trng v/hoc

102

bung trng
IIB

Xm ln nhng t chc trong phc mc tiu khung

III

U mt hoc hai bung trng hoc vi t cung hoc 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 lympho sau phc
mc

IIIA1

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

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

IIIA2

Di cn vi th phc mc ngoi tiu khung (trn gii hn ca TK) cng vi

hoc khng c hch sau phc mc dng tnh

IIIB

Di cn i th phc mc ngoi tiu khung c ng knh ln

2cmcng vi hoc khng c hch sau phc mc dng tnh

IIIC

Di cn phc mc ngoi tiu khung, c ng knh ln > 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.
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 ha 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.

103

- 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 ha 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.
- 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.
- 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 ha 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 ha cao v va sng thm 5 nm l 90%.

104

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
- 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.

105

- Trong giai on sau mn kinh hay gp hnh nh nim mc t cung teo, nim mc t cung khng hot
ng.
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 ha: 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)
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 qu 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

106

Loi chy
mu

Cp

Mn

La chn iu tr

Bn lun

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

S dng thuc trnh thai 1 pha liu
cm c mu sau duy tr 1v/ngy trong 14
thp
ngy
Estrogen phc hp (Premarin) 25 mg TM mi 4-6 Tt c cc bin php iu tr ch c
gi x 1 ngy, hoc 1,25mg ung mi 4-6 gi x 1 estrogen phi c theo sau bi
ngy, sau ung thuc trnh thai nh trn.
progestin
Thuc nga thai vin kt hp ung 1 vin/ngy

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

Medroxyprogesterone acetate, 10mg/ngy x 10

ngy/thng

Chy mu xut hin sau vin cui

cng 2-7 ngy

Clomiphen Citrate (Clomid, Serophen, Ovofar), S dng cho nhng ph n mong

50-150mg/ngy vo cc ngy 5-9 ca vng kinh mun c thai.
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.
- 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.

107

+ 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.
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.
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.

108

- 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.
B sung 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 sung 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,

109

- 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).
- 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.
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.

110

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.
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.
- 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

111

- 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.
- 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 r cc 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...
V SINH N
1. NH NGHA

112

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
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

113

- 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 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 khe 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.
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.

114

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:
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
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 ha 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,

115

- 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 khe 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,
- 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 ha 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
+ 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 ha tinh dch

116

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):
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, LDHcholesterol
Cc ri lon tng hp testosterone: nh lng cc cht chuyn ha 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, 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.
Chng 3:

S SINH
CHM SC TR NON THNG
1. I CNG

117

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 < 17 tui 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
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.

118

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.
3.8. Ri lon chuyn ha
- H ng mu do nhu cu cao mu thun vi 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

90-130

130-180ml

>1500: 60-80
Nng lng
Kcal/kg/d

40-50

60-100

100-130

Protein g/kg/d

1,5 - 2

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

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

Lipid g/kg/d

Glucid

4-8mg/kg/1

Na+
+

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

3-4

2-3

3-7

1-2

2- 5

Khi c nc tiu
Ca

++

0,5- 1,5

1,5

1,6- 2,5

- 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

119

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/1 ba, 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, 30-50% 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
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, 35 t th nga, nghing phi, tri, u cao, thp.
Bng 4.2: Hng dn s dng surfactant
Tui thai

Corticoid
trc sinh
Khng

27 tun

Thng kh
t NKQ sm s dng thuc

S dng surfactant
D phng sm

Nu th phi t NKQ v th my ngay

D phng sm
sau .
C

CPAP sm nu khng n nh phi t

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

120

Khng dng surfactant

Tr 28 - 34
tun

C hoc khng

CPAP sm sau nu phi t NKQ

th my.

iu tr cp cu

C bng chng bnh mng trong, phi

iu tr cp cu
t NKQ.

> 34 tun

- Th my khuyn co nn dng ch kim sot p lc vi PIP xp x 20cmH 2O v PEEP xp x

5cmH2O.
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.
<1500g(Mmol/l)

1500-2000g(Mmol/l)

>2000g(Mmol/l)

Tui
(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.
- 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 sung Multivitamin khng c hiu qu gim non,
b sung 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

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- 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.
HI SC S SINH NGT
1. NH NGHA
Ngt l tnh trng tr ra khng th, khng khc gy thiu oxy, tha CO 2 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.
- 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:

122

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.
3.2. nh gi tr cn hi sc hay khng

4. CC BC HI SC S SINH
Theo nguyn tc A, B, C, D.
4.1. Nguyn tc A: khai thng ng th

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- 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
- 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 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 .
Cung cp oxy lu lng t do
- 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.

124

 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
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 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

125

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.
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 (+)

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- 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.
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
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:

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- 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.
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
Vim phi: 7-10 ngy

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- 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 38,5o th dng Paracetamol: 10-15mg/kg/1 ln, khng qu 4 ln/ngy.
+ Nu tr b h nhit < 36,5o: 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:
Plasma ti, truyn yu t ng mu, Vitamin K1. Truyn khi tiu cu khi tiu cu < 50.000/mm 3 m
c xut huyt hoc tiu cu < 30.000/mm 3 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

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- 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.
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 v qu 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 < 35 oC (95oF) gi l h thn nhit
- Mc h thn nhit
+ Nh: nhit 32 - 35oC
+ Nng: nhit < 32oC
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
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
- Huyt hc: 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

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- 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 38-40 oC trc khi mc vo cho tr
- m tr theo phng php da k da
- o than nhit ca tr 1 gi/ln v theo 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 1-1.5 oC
- 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 0.5 oC/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 40-42 oC 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 25 o-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.
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

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+ 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
- 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

132

+ 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
(mg/dl)

5-7

8-10

11-13

13-15

>15

Bilirubin/mu
(mol/l)

85-119

136-170

187-221

221-255

>255

+ 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

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

133

+ 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)
+ 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)

134

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
- 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
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 CO 2 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

135

- 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
- 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

Di ng lng ngc

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

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
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

136

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
- 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

137

+ 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
- 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
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 FiO 2,
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

138

- 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 .

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
+ 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.

139

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.
- 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)

140

- 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
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

141

- 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.
- 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

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 TCu380A c tc dng trong 10 nm

142

- 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:
- 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.
- Lao vng chu.
4.2.Chng ch nh tng i:

143

- 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.
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.

144

+ 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.
- 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:
+ 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.

145

+ 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

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
- 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

146

+ 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:
- 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

147

+ 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
- 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:
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

148

- 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)
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
- 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

149

+ 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
+ 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
- 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

150

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 to hnh
hu mn l 2 th, th 1 lm hu mn nhn to,
th 2 lm hu mn tht sau th 1 vi thng.
Hu mn ny c nong dn, n khi t
kch thc bnh thng s ng hu mn
nhn to

Xquang u dc: xc nh khong cch t ti cng

n vt tch hu mn.

2.3. Thot v mng no ty v tt nt t

sng
- V tr thot v hay gp l vng ct sng tht
lng (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 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:

151

- 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.
TI LIU THAM KHO
Ting Vit
1. 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 hcNXB 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), Ha 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 308320
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