i hc Y Dc TP.

H Ch Minh
B mn Ph Sn

Oxytocics trong sn khoa

GING VIN PH TRCH
Bc s Phm Vn c. E-mail: phamvanduc1998@gmail.com
MC TIU
Sau khi hon thnh bi hc, sinh vin Y khoa nm th T c kh nng
1. Trnh by c cc ch nh v cc chng ch nh ca oxytocin trong sn khoa
2. Trnh by c cch dng oxytocin trong khi pht chuyn d
3. Trnh by c cch dng oxytocin trong thc y chuyn d
4. M t c cch s dng cc oxytocics khc
T KHA
Oxytocin, Ergometrine, methylergometrine, Prostaglandin E2, 15-methyl prostaglandin F2,
Misoprostol

OXYTOCIN
Vai tr sinh l ca oxytocin trong thai k. Oxytocin l mt hormone c tng hp trong nhn trn th v cnh no tht
ca h i, hot ng nh kt hp vi protein c bit l oxytocin-neurophysin. Oxytocin c tit ra t nhng u tn
cng thn kinh c bit thy sau tuyn yn. Oxytocin tc ng ln cc th th ca n trn c trn t cung, kch thch
cn co t cung lm tng v tn s, cng , thi gian ca cn co t cung. Tnh nhy cm ca c t cung i vi
oxytocin xut hin t tun l th 20 ca thai k, gia tng chm t tun l 20 n 30 v n nh t tun l 34 cho n gn
ngy d sanh. Nng oxytocin gia tng rt nhanh gp i, gp ba khi bt u chuyn d, v t ti a vo giai on s
thai cho n khi co hi t cung.
Oxytocin c hp thu tt bng ng ngoi rut. Trong ng tiu ha, oxytocin b phn hy bi pepsin ca d dy.
V th, ng vo thng c s dng ca oxytocin l tim bp tht (k c tim vo c t cung) v ng truyn tnh
mch chm.
Chuyn ha. Oxytocin c tc dng ngay sau khi truyn tnh mch 3-4 pht. Nng huyt tng ca oxytocin tng dn
khi cho thuc v t c s n nh sau 40 pht. Hormon ny c thi tr ti gan, thn, tuyn v. Thi gian bn hy
trung bnh ca oxytocin l 5 pht.

CH NH

Khi pht chuyn d

Thc y chuyn d, tng cn co t cung

D phng v iu tr bng huyt sau sanh hay sau m bt con do t cung

CHNG CH NH
Chng ch nh tuyt i

Suy thai cp

Bt xng u chu tuyt i

Phi ht sc thn trng khi ch nh trong nhng trng hp sau

Pht khi chuyn d hoc tng co trn thai ph c vt m c m sanh v km theo tng nguy c
ca nt vt m

Pht khi chuyn d hoc tng co trn thai ph a sn v km theo tng nguy c v t cung

Pht khi chuyn d trn ngi ngc c th lm tng nguy c cho s sinh khi so vi m ch ng

LTLS: Oxytocis trong sn khoa

i hc Y Dc TP. H Ch Minh
B mn Ph Sn

KHI PHT CHUYN D BNG OXYTOCIN

Nguyn tc chung

khi pht chuyn d, oxytocin c dng bng ng truyn tnh mch chm. Oxytocin c
pha vo dung dch ng glucose 5%, truyn tnh mch bng bm tim in hay nh git tnh
mch.

Do tnh nhy cm vi oxytocin thay i ty theo thai ph nn liu oxytocin cn thit c hiu
qu rt thay i gia cc thai ph. Cn iu chnh cn thn lu lng bm in hoc s git dch
truyn c oxytocin n khi t c 3 cn g trong 10 pht, mi cn ko di trong 40 giy.
Khng c vt qu 3 n 4 cn co trong 10 pht. Duy tr tc truyn ny ti khi sanh.

m bo sn ph nm nghing tri. Theo di mch, huyt p trong qu trnh khi pht chuyn
d. Cn g t cung v tim thai phi c theo di cht ch, bng monitor sn khoa nu c.

Mi 30 pht mt ln, thc hin khm v ghi chp trn sn v (1) thi gian, tn s cn co t
cung trong 10 pht, v (2) nhp tim thai ngay sau cn g t cung.

Gim hay ngng truyn oxytocin ngay nu c ri lon cn co c hoc khng km bt thng v
nhp tim thai (di 100 ln/pht qua ng nghe hoc nhp gim e da thai trn CTG). Nu vn
vn khng c gii quyt, s dng gim co.

Lu quan trng
Chm

sc cn thn sn ph c dng oxytocin

Khng

nn sn ph ang dng oxytocin mt mnh

K THUT KHI PHT CHUYN D BNG OXYTOCIN

C s chng c ca thc hnh
C nhiu phc thc hnh khc nhau lin quan n khi pht chuyn d bng oxytocin. Cc phc
ny khc nhau liu khi u, nhp v bin tng liu, liu ti a. Da vo 3 c im trn,
c th phn cc phc ny thnh 2 nhm chnh

Phc liu thp vi c im l liu khi u thp, tng liu chm v liu ti a thp

Phc liu cao vi c im l liu khi u cao, tng liu nhanh v liu ti a cao

Cc c s chng c sau y c ghi nhn

Phc liu thp khng i km vi vic tng can thip trn cuc sanh

Tng liu oxytocin vi nhp iu gn hn 1 ln mi 30 pht i km vi ri lon cn co t cung

kiu cng tnh

Phc liu cao i km vi tng tn xut ca chuyn d cc nhanh

Phc thng dng ti Vit Nam

Ti Vit Nam, phc s dng ph bin l phc liu thp
Khi u oxytocin

Lp ng truyn tnh mch vi dung dch Glucose 5%, chai 500 ml, chnh git n tc thp
nht c th c, thng l VII git/ph.

Ha 5 n v quc t (IU) oxytocin vo chai dch truyn. Tng ng vi tc 3mIU/pht.

Nu dng bm tim in, bt u vi tc 2 n 2.5 mIU/pht.

Tng liu oxytocin

LTLS: Oxytocis trong sn khoa

i hc Y Dc TP. H Ch Minh
B mn Ph Sn

Nu cn co khng t yu cu (3 cn co trong 10 pht, mi cn 40 giy), tng tc truyn

oxytocin dn dn, mi ln iu chnh tng git cch nhau 30 pht. Bin mt ln iu chnh l
1.5 n 2.5 mIU.

Khi t cn co mong mun, duy tr tc truyn n nh cho n khi sanh. Trong phn ln cc
trng hp, tc truyn 12mIU/pht s gip mang li cn co hiu qu.

Nu cn co t cung khng t yu cu tc truyn 20 mIU/pht (40 git/pht), c th xem

xt tng nng oxytocin trong dch truyn nhm mc ch gim th tch dch truyn cn thit v
d iu chnh liu oxytocin. Mt im rt quan trng cn lu rng tc 20 mIU/pht l mt
tc rt cao. Quyt nh vt qu gii hn 20mIU/pht bng cch tng nng pha oxytocin
trong dch truyn cn phi c cn nhc k.

Sau khi truyn ht 5,000 mIU m vn cha to c cn co cn thit, cn tm ngng pht

khi chuyn d v thc hin li vo ngy hm sau

Nu n gii hn 32mIU/pht m vn khng khi pht c chuyn d, c th xem nh

khi pht chuyn d tht bi. Vi phc th s dng tc truyn oxytocin cao hn, tuy
nhin khng c bng chng rng hnh ng ny c th lm cho pht khi chuyn d thnh
cng.

X tr cc ri lon xut hin trong qu trnh truyn oxytocin

Trong qu trnh khi pht chuyn d c th xy ra cc s kin nghim trng nh suy thai, ri
lon cn co cng tnh v v t cung.

Nu t cung tng kch thch (mi cn co ko di qu 60 giy), hay nhiu hn 4 cn g trong 10

pht

Gim hoc ngng truyn oxytocin.

Nu cn thit: Salbutamol 10 mg pha trong 1000 mL dch (NaCl 0.9% hay Ringers lactated)
truyn tnh mch X git/1 pht.

Khng s dng oxytocin 10 UI trong 500 mL (20 mIU/mL) ngi con r v ph n c so m c

ly thai.
CCH DNG OXYTOCIN TRONG TNG CO

Tng co l vic dng oxytocin iu chnh cn co t cung t nhin, nhm t c cn c t

cung thch hp vi giai on ca chuyn d v cng , bin , tn s c th c c mt
din tin thun li ca c t cung v ngi thai.

Trong cc oxytocics, ch c oxytocin l c th dng cho tng co. Khi tng co, oxytocin ch c
dng bng ng truyn tnh mch, l tng l qua h thng bm t ng, d dng iu chnh
tc truyn.

ng nh git tnh mch: 5 IU oxytocin pha trong 500 mL dung dch Glucose 5%, truyn
tnh mch tc 4 mUI/pht (VIII git/pht). Lu chnh s git dch truyn trc khi pha
oxytocin vo chai. 1 git/pht tng ng 0,5mIU/pht.

Bm tim t ng 5 IU oxytocin pha trong 49 mL dung dch Glucose 5%, tc 2,4ml/gi.

Theo di nghim ngt cn co v tim thai, l tng bng monitoring. Sau mi 15-20 pht nh gi
li cn co v cng , tn s, thi gian.

Nu cn co cha tt, tng liu. Bin mi ln tng l 4mUI/pht, liu ti a 20mUI/pht. Vic
tng qu liu ti a cn phi c cn nhc k. Khi vt qu liu ti a, cn tng nng
oxytocin trong chai v chnh li tc truyn t u.

Hiu qu ca tng co th hin qua c tnh ca cn co thu c v qua tc ng ca cn co trn

xa m c t cung v din tin ngi thai.

LTLS: Oxytocis trong sn khoa

i hc Y Dc TP. H Ch Minh
B mn Ph Sn

Ghi chp cn co

Ghi li tin trin c t cung v ngi thai trn sn mi 1-2 gi ty tnh trng chuyn d

Trong qu trnh tng co, nu c cn co cng tnh, CTG c biu hin e da thai, cn ngng
oxytocin v gim co nu cn. Tip tc thc hin monitoring, nu tnh trng hi phc nhanh c th
tip tc tin trnh tng co bng cch bt u chnh li s git cho ph hp.

Khi tng co c hiu qu, nn duy tr tc truyn oxytocin mc thp nht c th qu

trnh sanh tin trin.

S DNG OXYTOCICS TRONG D PHNG & IU TR BNG HUYT SAU SANH

Oxytocin

Ergometrine/ Methylergometrine

Liu v
Truyn tnh mch: 20 IU
Tim bp hay tnh mch
ng dng trong 1000 mL dch truyn, (chm): 0.2 mg
truyn 60 git / pht

15-methyl Prostaglandin
F2
Tim bp: 0.25 mg

Tim bp: 10 UI
Liu tip
theo

Tnh mch: : 20 IU trong

Lp li 0.2 mg tim bp sau 0.25 mg mi 15 pht
1000 mL dch truyn, truyn 15 pht
40 git / pht
Nu cn, tim bp hay tnh
mch 0.2 mg (chm) mi 4
gi

Liu ti a

Khng truyn qu 3000 mL 5 liu (tng cng 1.0 mg)

dch c cha oxytocin

Chng ch
nh

Tim tnh mch trc tip

8 liu (tng cng 2 mg)

Tin sn git, tng huyt p, Hen ph qun

bnh tim mch

CC PROSTAGLANDINS
PHN LOI PROSTAGLANDINS

Cc prostaglandins phn ln l cc paracrine/autocrine hormone, tc l cc hormone c tc ng

cc b ln cc t bo ln cn, ti v tr sn xut ra chng.

Cc nhm prostaglandins thng c nhc n l: PGE1, PGE2, PGF2 v prostacyclin.

M t cung c nhiu acid arachidonic, l tin cht bt buc ca cc prostaglandins nhm 2.

Mng rng m l ngun gc chnh ca PGF2.

Cc mng bo thai, c bit l mng i, sn xut ch yu PGE2.

C t cung sn xut ch yu l prostacyclin.

thai trng thnh ln thai non thng, gia tng sinh tng hp cc prostaglandins nhm E v F
trong t cung l mt yu t chc chn ca giai on bo chuyn d.

C CH TC DNG

Kho st in-vitro, c PGF2 ln PGE2 u gy ra cn co t cung.

Kho st in-vivo, PGF2 t mng rng tc ng ch yu l thc y cn co t cung, trong khi

PGE2 c v quan trng cho s chn mui c t cung.

LTLS: Oxytocis trong sn khoa

i hc Y Dc TP. H Ch Minh
B mn Ph Sn

Cc ch phm PGE2 ngoi sinh thc y s chn mui c t cung mnh hn so vi PGF 2 ni
sinh.

Khc vi oxytocin, p ng ca t cung vi prostaglandins thay i khng ng k trong sut

thai k. Do c th dng rng ri prostaglandins vi mc ch chm dt thai k trong tam c
nguyt th II hoc khi pht chuyn d cc trng hp thai cht lu tam c nguyt th II.

CC CH PHM

Ch phm PGE2 dng ng m o ph bin nht l dinoprostone gel. So vi khi c t ti

cng sau m o, PGE2 gel t bn trong knh c t cung s gy mt hiu ng r rng hn trn
s chn mui c t cung.

Mt ch phm khc ca PGE2 l Cervidil 10 mg. u im ca ch phm ny l, do khng ging

nh gel, n c th d dng c ly i trong trng hp c cc din tin lm sng khng thun
li nh nhp nhanh hoc t cung tng trng lc.

15-methyl Prostaglandin F2 ch yu gy co t cung, thng c s dng sau sanh.

Cc cht tng t PGE1 nh misoprostol (Cytotec, Alsoben) c dng lm chn mui c t

cung v ng thi cng to cn co t cung. Misoprostol c th c dng bng nhiu ng
khc nhau: ng m o, ng ung, ng ngm cnh m hoc ng trc trng. Ty giai
on ca thai k cng nh ty theo ch nh, misoprostol c dng vi nhng liu khc nhau.
Misoprostol c hiu qu tng t nh PGE2 trong vic lm chn mui c t cung v khi pht
chuyn d. Cn co cng tnh thng gp hn nu dng misoprostol. Tuy nhin, gi ca
misoprostol r hn nhiu so vi bt k ch phm PGE2 no.

CH NH

Chm dt thai k mi tui thai

Khi pht chuyn d

D phng bng huyt sau sanh

iu tr bng huyt sau sanh

CHNG CH NH

T cung c vt so m c

PGE2 LM CHN MUI C T CUNG TRONG KHI PHT CHUYN D

PGE2 c dng vi nhiu dng (vin 3 mg t ti cng sau m o hoc gel 2-3 mg t ti c t
cung), lp li mi 6 gi khi cn.

Theo di mch, huyt p v cn co t cung v nhp tim thai, ghi li trn partograph.

Thc hin monitoring cn g t cung v tim thai cho mi khi pht chuyn d vi prostaglandins

Khng tip tc dng prostaglandins. Chuyn sang dng oxytocin khi:

Mng i v

C t cung thun li

Chuyn d tht s

Sau 12 gi dng

Oxytocin ch c bt u sau liu cui prostaglandins t nht l 6 gi

LTLS: Oxytocis trong sn khoa

i hc Y Dc TP. H Ch Minh
B mn Ph Sn

CHT TNG T PGE1 (MISOPROSTOL) TRONG KHI PHT CHUYN D

Misoprostol c th c dng khi pht chuyn d, trong cc ch nh nu mc trn, do kh

nng lm chn mui c t cung ng thi vi kh nng pht khi cn co t cung. Vi mc ch
ny, Misoprostol c s dng bng ng m o.

Misoprostol 25 mcg t ti cng sau trong m o, lp li mi gi

Nu khng p ng vi hai liu 25 mcg, th tng ln 50mcg mi 6 gi.

Khng c s dng qu 50mcg cho mt ln v khng qu 4 liu trong ngy (200mcg)

Khng s dng oxytocin trong vng 8 gi dng misoprostol, theo di g t cung v tim thai bng
monitor

ERGOMETRINE, METHYLERGOTMETRINE
C CH TC DNG

Trn c t cung: co tht c t cung ko di, trng lc tng ko di

S p ng ca co c t cung vi ergot tng dn trong thai k

Khng dng trong thai k, ch dng sau sanh

Trn tim mch: gy tng huyt p do co tht mch mu

HP THU, CHUYN HA V THI TR

Tim bp sau 20 pht c t cung mi p ng

Tim tnh mch c t cung p ng sau 5 pht

Nng cao nht trong huyt tng sau tim bp 2 gi

Chuyn ha ti gan, 90% bi tit qua mt

Thi gian bn hy khong 2 gi

CH NH

Kim sot tnh trng mt mu sau sanh, t cung (xem phn oxytocics trong d phng v iu
tr bng huyt sau sanh)

CHNG CH NH

Tng huyt p, tin sn git cha c kim sot

Bnh l tim mch

TI LIU THAM KHO

1. World Health Organization. Managing Complications in Pregnancy and Childbirth. A guide for
midwives and doctors.
http://www.who.int/reproductive-health/impac/
2. Royal College of Obstetricians and Gynaecologists. Induction of labour (Evidence-based
clinical guideline number 9).
http://www.rcog.org.uk/resources/public/pdf/rcog_induction_of_labour.pdf
3. World Health Organization. Recommendations for the prevention of post-partum haemorrhage.
http://www.who.int/reproductive-health/publications/pph/recommendations_pph.pdf

LTLS: Oxytocis trong sn khoa