V T CUNG

I CNG [2]
V t cung l mt cp cu sn khoa, xut pht t s gin on trong cu trc ca thnh t cung,
thng xy ra nht l trong cuc sanh v chuyn d, nhng i khi cng c th xy ra trong lc
mang thai. VTC l mt cp cu ng s, vi t sut t vong v bin chng cao m v con. T l
mi mc ca VTC trn TC khng c so l vo khong 1 trn 10000 cuc sanh; tuy nhin, n
tng ln ti gn 1% nhng ph n c VMC. VTC dn ti mt lot cc hu qu nng n, t v
sinh do tn thng t cung khng hi phc v phi phu thut ct b t cung, cho ti t vong m
v con nu nh chn on v iu tr phu thut b chm tr.
Mc d VTC l mt bin c him khi xy ra trong thc hnh lm sng sn khoa ngy nay, t l
ph n m ly thai ngy cng tng cc nc phng Ty c th lm cho t l mi mc ca
VTC tng theo. VTC c th xy ra thi k mang thai, nht l khi c s hin din ca so m
ly thai kinh in. Tuy nhin, VTC thng xy ra nht vo thi im trong chuyn d sau khi
xut hin nhng cn g TC. VTC thng xy ra trn mt TC c so m c hn, nhng nhng
nc ang pht trin c dch v chm sc y t cn km, VTC c th xy ra trn TC khng c so
m v a thai hay cc yu t khng mong mun nh chuyn d ko di hay chuyn d ngng
tin, c bit l do bt xng u chu khng c chn on.

NH NGHA:

C 2 loi v t cung. V t cung hon ton bao gm gin on ton b dy ca thnh t

cung. V khng hon ton xy ra khi lp phc mc tng vn cn nguyn vn. Vic phn chia ny
quan trng v c s khc bit v mt triu chng lm sng v t l bin chng gia 2 loi v ny.
[8]

DCH T:

SINH L BNH [5]

 V trn bnh nhn VMC
Trong thi i ngy nay, hn 50% s ca VTC c lin quan ti VMC. Trong thai k, thng l
ng so c in s d gy ra v t cung hn ng so on di, c th l v s lnh so b
gin on (v on trn lun co bp trong thi k hu sn nn t cung khng c ngh ngi),
hoc l do nhau bm trn vt m c. Mt nguyn nhn khc c th l do qu trnh ng mu
khng hon ton v nhim trng trong lc lnh so. Qu trnh v t cung din ra thm lng v
cc triu chng c nng cng nh thc th c th lm ta lm tng y l kiu v thm lng.
Thng thng vt so s v vo khong tun 34 ti 38 ca thai k khi gin ca t cung t
nh im, tuy nhin cng c cc bo co ghi nhn rng v t cung c th xy ra tun 24.
Trong cc ca v thm lng, ti thai tri qua vt so v sau t cung s co ngn li. Gn nh
khng c chy mu trong qu trnh ny, v nhng ca v t cung ny gn nh l v hon ton.
Nu nh nhau bm trn vt so, t cung s thng v hn v c tin lng xu hn bi v chy
mu nhiu hn do b m thng bi nhau. Mt khc, vt so on di thng thng s ch v
trong lc chuyn d v hu ht cc trng hp n l dng bung vt m c.

V trong lc chuyn d

V trong lc chuyn d thng xy ra sau khi chuyn d ko di. on trn t cung co bp v co

ngn li trong khi on di gin v ko mng ra cho n khi hnh thnh vng tht bnh l
Bandl. Vy nn, v t cung thng l on di ngay trong khu vc c t cung gin ngang v
cho. V t cung cng c th nh hng ti c t cung v m o, hoc thm ch nh hng ti
bng quang v c th lan rng ln on trn t cung.

Thai nhi c th b hon ton tng ra ngoi vo trong khoang phc mc v c th xut huyt vo
trong khoang phc mc, hoc thai nhi cng c th b tng ra ngoi mt phn nu nh phn trnh
din lt xung h chu. Trong v t cung khng hon ton, xut huyt thng lan rng ra vo
dy chng rng v c th gy ra khi mu t sau phc mc v thm ch c th lan rng ti vng
phc mc sau thn.
 Hnh. Vng Bandl [5]

GPB
NGUYN NHN

YU T NGUY C
TRIU CHNG LM SNG [2]
https://reference.medscape.com/article/275854-overview#a5 - Phn ny phi lm tht k,
nht l coi k Table 2 trong trang ny

VTC c th th hin bng mt lot cc triu chng c nng v thc th ph thuc vo
v tr, rng v thi im v. Trong khi bung vt m c t cung c th khng c
triu chng, mt TH v hon ton c th th hin l mt cp cu sn khoa vi cc
 hu qu khn lng cho c m v con. Triu chng kinh in bao gm au bng lin
tc v ko di xuyn sut gia cc cn g, chy mu m o ti, "au so m",
bng chng suy thai (thay i tim thai c bn) v thay i hnh dng ca bng sn
ph v c th d dng s chm cc phn ca thai nhi. Him khi c th pht hin c
ht tt c cc triu chng mt bnh nhn v trong lc thc hnh phi lun c
nhy lm sng cao.
Cc dng ng tim thai c bn bt thng c th c pht hin trn CTG. Trn
CTG cng pht hin ngng cn g t cung thng xy ra ngay sau khi cn g cng
tnh hoc tng trng lc cn g, gim dao ng ni ti, nhp gim mun hoc bt
nh, hoc nhp gim duy nht ko di. Nhng c ch dn ti nhng biu hin trn
CTG ny bao gm sa dy rn qua vt so m c b v dn ti nhp gim bt nh v
bong bnh nhau dn ti nhp gim mun hoc nhp gim ko di.
Mt s triu chng khc nh tiu mu, n au bng quang, c bit vt so m c
trn on di t cung, cng nh nhp nhanh tim sn ph v cc du hiu sc gim
th tch c th dn ti suy thai v thm ch t vong m nu nh khng hi sc tc thi
v iu tr bng phu thut b chm tr.
VTC c th l mt s kin xy ra trong cuc sanh nhng n cng c th xy ra trong
thi k tin sn v rt him xy ra trong thi k hu sn.

V t cung trong thi k tin sn

au bng l triu chng quan trng nht trong VTC thi k tin sn. C th c chy mu m
o, nhng xut huyt th c th xy ra trong bng, dn ti kch thch c honh v gy au
quy chiu ln ngc v vai. VTC c th xy ra sm trong thai k nhng BN c so on
trn v khng c lin quan ti cn g [8].
Bnh nhn c th th hin triu chng sc, ch yu l sc gim th tch, nhng cng c th
do sc thn kinh. Lc thm khm n bng c th au, c bit nu c lin quan ti chy mu
trong khoang phc mc v s hin din ca cc phn thai nhi trong khoang bng; tuy nhin,
n au vt m t cung khng phi l du chng tin cy ca VTC.

VTC trong cuc sanh

Thng gp nht. au bng l triu chng thng thy, TH c in l au cp tnh m khng
gim gia cn g. Trn CTG ghi nhn mt cn g trn CTG cng lc , ngay trc c
th c cn g cng tnh hoc tng trng lc cn g. VTC c th s kh phn tch trong
ng cnh chuyn d nhng vn phi nghi ng trong TH v t cung v bong bnh nhau. "au
so m", thay i hnh dng t cung v s chm c cc phn ca thai nhi c th gi
VTC. Nhng du hiu ny c nhy cao nhng c hiu thp nn thng khng ng
tin cy. C th c chy mu m o. C th c tiu mu nu nh c tn thng phi hp vi
bng quang.

Theo di tim thai c khuyn co tt c cc ph n m ly thai mun sinh ng m o.

Mt s nghin cu cho thy mi tng quan gia s thay i tim thai c bn v VTC. Nhp
gim ko di, gim dao ng ni ti v cn g cng tnh c cho l nhng dng thng
gp ca tim thai trong VTC [6, 7].
Phn trnh din ca thai b tht li ("mt lt") c th l mt du hiu VTC, nu nh phn
trnh din ca thai vo eo trn trc khi t cung v. Khm m o v khm bng c th xc
nh phn trnh din ni ln trn eo trn.

V t cung hu sn
y l mt bin c cc him thng biu hin bng au bng v xut huyt hu sn. Khi
khm m o, i khi c th s c vt m bung trn thnh t cung v nu nh v hon
ton th c th a cc ngn tay vo khoang phc mc. Tuy nhin, cc nghin cu cho thy
khm m o bng tay c h thng BN sinh ng m o sau m ly thai khng ci thin kt
qu iu tr. Hn na n cn lm tng nguy c v t cung [3], do nn trnh vic thm
khm m o bng tay. Hnh 24.2 cho thy bung vt m c trn t cung xy ra trong lc sn
ph rn ch ng, v ngay sau l sn ph bt tnh trong thi k hu sn.
Hnh 24.2 Bung so m c t cung trong giai on 2 chuyn d km vi khi mu t bn di
phc mc tng trong khi phu thut m bng [2]

Cc du hiu tm thy lc phu thut m bng

on di t cung l on hay b v nht trong VTC, vi mt s bo co ln ti 92% s ca. Tuy
nhin, cc phn khc ca t cung cng c th b tn thng, nht l trn vt m ly thai kinh
in, hoc tn thng c t cung nhng BN c t cung lnh ln. V on di TC c th m
rng ra pha trc hng v pha bng quang, v ra ngoi hng v pha dy chng rng. iu
quan trng l phi thm khm t cung v cc tng vng bng khc mt cch c h thng m
bo xc nh r rng cc vng c tn thng lin quan. Rch mt sau TC him xy ra nhng c
th xy ra TC d dng, chuyn d ngng tin v sanh gip bng dng c.

CLS
Mt bi bo co gn y bao gm 21 bi vit m t v mi tng quan gia dy on di
t cung v VTC hay bung so m c t cung trong chuyn d. H tm thy ngng dy
on di TC t 3.1-5.1 mm v ngng dy lp c TC t 2.1-4.0 mm l yu t tin on
dng mnh cho VTC trn mt BN c VMC sinh ng m o. Cn ngng dy ca c t
cung t 0.6 ti 2 mm l mt yu t tin on dng mnh cho VTC. Tuy nhin, khng tm c
ngng l tng h tr thc hnh lm sng [4]
Siu m rt hu ch trong vic chn on sm v t cung. Trn nhng bnh nhn c tin cn m
ly thai, Hip hi Sn Ph khoa Hoa K a ra nhng con s v v t cung c lin quan ti
th thch chuyn d: 1-7% vi ng rch dc on di, 4-9% vi so hnh ch T v c in,
v 0.5% vi so ngang on di. [1]

Chn on

Phn chn on phi phi hp k vi phn TCLS

 X TR [5]
https://reference.medscape.com/article/275854-overview#a7
Hng x tr (Hng dn iu tr 2016 SYT-TPHCM BV Hng Vng)
1.Da v t cung
- Lp ng truyn TM
- Thng tiu
- MLT cp cu
- S dng gim g trong thi gian chuyn bnh i m
2.V t cung
- Hi sc tch cc
-M cp cu
-X l t cung
+ Bo tn TC nu tng trng cho php, cn tr, cha con, nt hoc vt v n gin,
cha c du hiu nhim trng.
+ Lt t cung ton phn nu chong nng, c nhim trng, vt v phc tp, con.
Hng x tr
Hi sc tch cc bng dch qua ng tnh mch
Sp xp c th truyn mu cho bnh nhn
Gy m su v thng tin ti bc s gy m
Khng sinh cephalosporin th h 3 v gentamycin ph cc vi khun gram (-) v
ggram (+) v ph c cc vi khun k kh bng mt khng sinh thch hp.
t sonde Foley theo di lng nc tiu
Sp xp phu thut m bng khn
Chi tit
Phu thut m bng khn phi c thc hin tt c cc ca v t cung. Khng c cho sinh
ng m o.
Sau khi sinh em b v nhau, tm ch tn thng ngay lp tc. Trong trng hp vt m c
on di, ta c th phc hi vt so nu nh n nh; b khng b lm chm v nhim trng
v c l do thuyt phc bo tn t cung (vd: khng c con ni di). C th trit sn nu
nh sinh con. Thnh trc t cung b v thng gp nht. i khi c th rch bng quang
v vt rch c th lan rng xung m o hoc lan ra ngoi vo dy chng rng. V pha sau
on di c th xy ra trong trng hp ko u cao bng forcep hoc u ra sau trong ngi
mng.
Trong tt c cc trng hp cn li, nu vt so rch lm chm khng th hi phc, nn phu
thut ct b t cung. Tc x tr l rt quan trng trong nhng trng hp nh vy. Nu bnh
nhn c th chu c, v trong trng hp c rch m o phi hp, ct b t cung l phng
php tt nht. Nu khng th ct t cung bn phn (ct b ti ni b rch). Nu bng quang b
rch, khi phc vt rch 2 lp v t sonde Foley dn lu lin tc trong 2 tun.

X tr trn trng hp pht hin tr - Tin lng rt xu v, cn c xut huyt v nhim trng
lu. Bi v bnh nhn sng st xut huyt ban u, truyn morphine, gi m v truyn mu
lng ln khn y huyt p ln 90-100 mmHg trc khi phu thut m bng, nhng ng
i qu lu.
Giai on hu phu
Nhng gi u tin sau phu thut rt quan trng chnh sa li vic sc ca bnh nhn (khi
phc sc bng truyn mu). Ri lon in gii v toan cetone mu gy ra bi chuyn d sinh kh
nn c x tr mt cch cn thn, trnh gy qu ti dch. C th t sonde mi d dy cho
trng hp v b b st cho ti khi nghe thy nhu ng rut.
Tip tc truyn dch tnh mch, truyn mu v khng sinh. Tm cc du hiu ca nhim trng
mu. Gi sonde Foley t nht 2 tun nu v t cung xy ra sau chuyn d sinh kh hoc cho ti
khi khi phc c vt rch bng quang.
Tn thng vng sn chu
Trong qu trnh sinh con, sn chu phi chu sc nn t u thai nhi v p lc hng xung do
ngi m rn, dn ti cc s thay i v chc nng v gii phu ca cc c, thn kinh v cc m
lin kt. Tt c nhng s thay i ny u tr v bnh thng (ging nh t cung v cc c quan
khc) trong thi k hu sn. Tuy nhin trn nhng ca chuyn d sinh kh b b st, c th thy
c tn thng nhiu mc khc nhau. Loi tn thng c th thay i, t rch tng sinh
mn, tiu hay i tin khng t ch n sa sinh dc.
Tt c cc tn thng phi c phc hi cn thn trong lc bnh nhn c gy m.

TIN LNG (Overview - Uterine Rupture in Pregnancy Medscape)

M:

Mt mu nng hoc thiu mu.

Shock mt mu.

Chn thng bng quang ca m.

Ct b t cung.

T vong (hin nay tuy nguy c t vong m < 1% nhng nu khng chn on v
x tr kp thi th t vong m l hu qu tt yu), t l ny cn ph thuc vo
nhiu yu t: nguyn nhn, v tr, tnh trng vt thng, thi gian can thip,v
trnh chuyn mn.

Con:

Ngt.

Toan thai.

Nguy c nhp chm sc tch cc.

 T sut chu sinh 30%.

Nu tr sng s c nhng di chng thn kinh lu di trong khong 10% trng

hp.

Th vin ti liu tham kho

1. (2010), ACOG Practice bulletin no. 115: Vaginal birth after previous cesarean delivery.
Obstetrics and gynecology, 116(2 Pt 1), 450-63.
2. Carrillo AP, Chandraharan E. (2016). Rupture of the Uterus. In Arulkumaran SS (Ed.),
Best Practice in Labour and Delivery (2 ed., pp. 293-300). Cambridge: Cambridge University
Press.
3. Dinglas C, Rafael T, Vintzileos A. (2015), Is manual palpation of the uterine scar
following vaginal birth after cesarean section (VBAC) helpful? The Journal of Maternal-Fetal &
Neonatal Medicine, 28(7), 839-41.
4. Kok N, Wiersma I, Opmeer B, De Graaf I, Mol B, Pajkrt E. (2013), Sonographic
measurement of lower uterine segment thickness to predict uterine rupture during a trial of labor
in women with previous Cesarean section: a metaanalysis. Ultrasound in Obstetrics &
Gynecology, 42(2), 132-9.
5. Malik S, Salhan S. (2007). Abnormal Labor Dystocia: Dysfunctional Labour. In Salhan S
(Ed.), Textbook of Obstetrics. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd.
6. Ridgeway JJ, Weyrich DL, Benedetti TJ. (2004), Fetal heart rate changes associated with
uterine rupture. Obstetrics & Gynecology, 103(3), 506-12.
7. Sheiner E, Levy A, Ofir K, Hadar A, Shoham-Vardi I, Hallak M, et al. (2004), Changes
in fetal heart rate and uterine patterns associated with uterine rupture. The Journal of
reproductive medicine, 49(5), 373-8.
8. Turner MJ. (2002), Uterine rupture. Best practice & research Clinical obstetrics &
gynaecology, 16(1), 69-79.