hướng-dẫn-chẩn-đoán-và-điều-trị-sản-phụ-khoa

7/26/2019 Hng-dn-chn-on-v-iu-tr-Sn-ph-khoa

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BY T

!"# %" &!"'(" )*+, -.CC BNH SN PHKHOA

(Ban hnh km theo Quyt nh s315/Q-BYT ngy 29/01/2015)

H NI - 2015


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B Y T

S: 315/Q-BYT

CNG HA X HI CH NGHA VIT NAMc lp - T do - Hnh phc

H Ni, ngy29 thng 01 nm 2015

QUYT NHV vic ban hnh ti liu chuyn mn

Hng dn chn on v iu tr cc bnh snph 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 quynh 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 dnchn on v iu tr cc bnh sn ph khoa.

iu 2. Ti liu Hng dn chn on v iu tr cc bnh sn ph khoaban hnh km theo Quyt nh nyc p dng ti cc c s khm bnh, chabnh.

Cn c vo ti liu ny v iu kin c th ca n v, Gim c c s khmbnh, cha bnh xy dng v ban hnh ti liu hng dn chn on v iu tr ccbnh 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, Vthuc B Yt, Gim c cc bnh vin, vin c ging bnh trc thuc B Y t, Gim c SY t cc tnh, thnh ph trc thuc trung ng, Th trng Y t cc B, Ngnh vTh trng cc n v c lin quan chu trch nhim thi hnh Quyt nh ny./.

Ni nhn:-Nh iu 4;- Btrng 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 TRNGTH TRNG

( k)

Nguyn Vit Tin


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Chbin:PGS.TS. Nguyn Vit Tin

Ban bin son:

PGS.TS. Nguyn c Hinh

PGS.TS. Lu ThHng

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 ThHng Thin

Ths. Ng ThBch H

Ths. V Vn Khanh


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CHVIT 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 aminotransferaseCMV : 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 -- lowplatelet count

HIV :Human immunodeficiency virus

LA : Lupus Anticoagulant antibody

LDH :Lactate dehydrogenase

LMWH : Low-molecular-weight heparin

LNMTC : Lc ni mc tcung

MTX : MethotrexatMRI : Magnetic resonance imaging

NST : Nhim sc th

PET : Positron emission tomography

PGD : Preimplantation genetic diagnosis

TM : Tnh mch
http://www.nlm.nih.gov/medlineplus/ency/article/002372.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003647.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003647.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/002372.htm


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

CHNG 2: PHKHOA ...................................................................................113

1.P XE V .......................................................................................................113

2.CC TN THNG V ...............................................................................115

3.TN THNG LNH TNH CTCUNG ...............................................123

4.VIM PHN PH ..........................................................................................128

5.VIM M O ..............................................................................................132

6.CHA NGOI TCUNG .............................................................................135

7.CHA VT M ..........................................................................................141

8.SA SINH DC ................................................................................................143

9.U NANG BUNG TRNG ............................................................................149

10.U X TCUNG (FIBROID) .......................................................................154

11.LC NI MC TCUNG ..........................................................................157

12.TIN UNG TH V UNG TH M HTN THNG TIN UNG TH.163

13.UNG TH M H .......................................................................................164

14.CHA TRNG .............................................................................................16915.U NGUYN BO NUI ..............................................................................174

16.UNG TH CTCUNG ............................................................................178

17.UNG TH NIM MC TCUNG .............................................................183

18.UNG TH BUNG TRNG .......................................................................187

19.RONG KINH RONG HUYT ......................................................................195

20.V KINH .......................................................................................................201

21.MN KINHTIN MN KINH.................................................................206

22.V SINH N ................................................................................................210

23.V SINH NAM .............................................................................................215

CHNG 3: S SINH .........................................................................................220

1.CHM SC TRNON THNG ...................................................................220

2.HI SC S SINH NGT .............................................................................227

3.NHIM KHUN S SINH ............................................................................234


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CHNG 1: SN KHOA

DA SY THAISY THAI

1. KHI NIM

Sy thai l hin tng kt thc thai nghn trc khi thai c thsng c. Vi

khi nim ny, sy thai c nh ngha l trng hp thai btng ra khi bung t

cung trc 22 tun hay cn nng ca thai di 500g.

2. CHN ON2.1. 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, chc cm gic tc nng bng di hay au m vng hv).

- Khm: c tcung tm nhng cn di, ng kn, kch thc thn tcung 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 hv

- Khm: ctcung xa, m, phn di tcung phnh to do bc thai by

xung pha c tcung lm cho c tcung c hnh con quay, i khi s thy bc

thai nm ng ctcung.

2.2. Cn lm sng

- hCG: dng tnh

- Siu m: c hnh nh ti i trong bung tcung, c m vang phi v tim thai

(khi thai > 6 tun bng siu m u d m o). Vi sy thai, c ththy hnh nh

ti thai tt xung thp hay trong ng ctcung.

2.3. Chn on thbnh


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- 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 cbc, sau ra mu t dn.Khm thy ctcung ng, tcung nh

hn tui thai. Siu m bung tcung 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 mv t cung cn to.

Siu m c hnh nh m vang khng ng nht trong bung tcung.

- 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 nhhn 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 khnghon ton.

- Sy thai lin tip

+ c nh ngha l c hin tng sy thai tnhin 2 ln.

+ 2 xt nghim c khuyn co: nhim sc ca 2 vchng v hi chng

khng phospholipid (AntiPhospholipid Syndrome - APS).

2.4. Chn on phn bit2.4.1. Cha ngoi tcungthgisy

C thai, au bng, ra mu, c tchc ging khi thai sy ra tbung tcung.

Phn bit: khm c khi cnh tcung n au, cng y, au. Siu m thy

khi cnh tcung. Gii phu bnh khi sy khng thy hnh nh gai rau m thy

mng rng.


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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 bmo, 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

tcung 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 tcung. No nim mc tcung

xt nghim gii phu bnh l".

3. IU TR

3.1. Da sy thai:cha c liu php iu trda sy thai no c cho l ti u- Nm ngh, n nh, chn trnh gy to bn. Bsung 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 sthiu ht ni tit, hay dng progesteron lm mm c tcung.

- Khng sinh: chng nhim trng do hin tng ra mu.- Khu vng ctcung cp cu: trong trng hp thai trn 3 thng da sy,

nu c hin tng bin i ctcung, sau khi khng chnhim trng m o,

ctcung v cn co tcung, khu vng ctcung cp cu

3.2. ang sy thai v sy thai

- ang sy thai: bc thai nm trong m o hoc trong ng c tcung, gp

bc thai bng km qutim, sau no li bung tcung m bo khng st rau.


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Thuc co hi tcung 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 tcung sch, khng

no li. Cho khng sinh phng nhim khun.

- Sy thai khng hon ton: ty khi cn li trong bung tcung v ra mu m

o m tin hnh ht, no li bung tcung hay dng misoprostol 400mcg ngm

di li gip co hi tcung v tng nt tchc cn li. Cho khng sinh phng

nhim khun.

- Sy thai nhim khun: khng sinh liu cao, kt hp thuc co hi tcung. Sau6h dng khng sinh, nhit gim, tin hnh ht hay no li bung tcung. Ch

"ththut dgy thng tcung hn bnh thng. T vn cho ngi bnh v ngi

nh nguy c ct tcung 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 tcung ly ht tchc cn st li. Dng thuc co hi t

cung gip tcung co tt. Cho khng sinh phng nhim khun.

3.3. Sy thai lin tip

- Tm nguyn nhn gy sy thai lin tip

- iu trtheo nguyn nhn:

+ Heo tcung: khu vng ctcung.

+ Thiu ht ni tit: bxung ni tit nh progesteron 25mg x 2 ng/tim bp

su / ngy, estrogen (progynova 2mg/ngy).

+ Mbhi chng khng phospholipid: dng thuc chng ng.

+ iu trcc bnh l"ton thn ca mnh i tho ng, giang mai, vim

thn hay cc bnh ni tit nh thiu nng gip trng, basedow

+ Mbc nhn x trong u x tcung, mct vch ngn tcung

+ Ri lon nhim sc th: nn tham kho li khuyn vdi truyn xem ngi

bnh c nn c thai li na khng.


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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: chng bsung ni tit ngay khi ngi bnh c thai.

- Vi heo tcung: khu vng ctcung chng ln c thai sau.

- Khi mbAPS: dng aspirin liu thp trc khi c thai, dng thuc chng

ng khi ngi bnh c thai.

- Chng iu trcc bnh l"ton thn ca m(nu c).

- Vi nguyn nhn bhoc mbri lon nhim sc th: tin lng c

con bnh thng rt kh khn, nn t vn vdi truyn xem c nn c thai na khng.


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SY THAI LIN TIP

1. KHI NIM

Sy thai lin tip l hin tng c t2 ln sy thai lin tc trln, thai nhi b

tng xut khi bung tcung trc 22 tun.

Nguy c thay i ty theo sln sy thai, tng sinh con cn sng v c con

bdtt hay khng.

2. CHN ON

2.1 Lm sng

- Phn ln ngi bnh n khm khi ang c thai vi tin ssy thai, hay c

tin ssy 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, tcung ddng, mc bnh l"ton thn

2.2. Cn lm sng

2.2.1. Nhim sc

C thpht hin c bt thng slng hay cu trc nhim sc thca mt

hay 2 vchng c tin ssy thai lin tip.

2.2.2. Khng thkhng phospholipid

- aPL: antiPhosphoLipid antibody: IgM v IgG

- aCL: antiCardioLipin antibody: IgM v IgG

+ Dng tnh: IgM v IgGcao 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 shuyt khi

- 2-GpI: Anti beta 2 Glycoprotein I:

+ Gi trtin on dng tnh cao (87,5%)

- Khc: khng thkhng nhn, khng thkhng DNA

+ Khng thng dng


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+ p dng trong APS thpht

Trn lm sng, xt nghim aPL v aCL thc hin trc, nu hai xt nghim

ny m tnh stip tc thvi 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 tcung nh u x tcung,

tcung ddng, tcung nhi tnh

- Chp tcung: pht hin tcung ddng, tcung c vch ngn, dnh bung

tcung...

- Xt nghim ni tit: tm mt snhng ri lon ni tit nh i tho ng,

bnh tuyn gip, suy hong thsm

- Mt sxt 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 vdi truyn xem ngi bnh c nn c thai na hay khng.- Trng hp c thai tnhin: tin hnh cc xt nghim chn on trc sinh,

chc i hoc sinh thit gai rau cho tt c thai kc bhoc mmang bt thng

nhim sc th(NST).

- Trong thtinh trong ng nghim: tin hnh sinh thit chn on tin phi (k

thut PGD) nhm loi bnhng phi mang bt thng di truyn gy sy thai hoc

c nguy c gy dtt bm sinh cao.

3.2. Hi chng khng PhosphoLipid

3.2.1. Cc thuc sdng trong Hi chng khng PhosphoLipid

Thuc chng ng mu: Heparin trng lng phn tthp hoc Heparin khng t

on .Thi gian tc dng ko di tim 1 ln/ngy

+ Fraxiparin 5060UI/kg/ngy (bm 0,3ml/ngy - 2850UI, tim di da bng)

+ Lovenox 20 - 40mg/ngy tim di da

c chtiu cu: Aspirin (ASA)


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- iu trliu thp: 75 - 100mg/ngy

- Theo di slng tiu cu, yu tng mu

-Ngi bnh c gim tiu cu: khng nn dng

c chmin dch

- Thng sdng cho APS thpht hay CAPS (catastrophic APS)

- Corticoid liu ti thiu 1mg/kg/ngy (1 lmethylped 40mg)

- Gammaglobulin:

+ Cc trng hp qu nng

+ Liu 0,4g/kg/ngytrong 5 ngy hoc 1g/kg/ngy trong 2 ngy

3.2.2. Phc iu tr

Bnh cnh Khng c thai C thai

Hi chng khng

PhosphoLipid vi bin

chng sn khoa

- Khng iu tr

- ASA liu thp

- LMWH + ASA liu thp

- Bsung Ca v Vit D

Hi chng khng

PhosphoLipid vi tin shuyt khi

Warfarin, duy tr

INR: 23

- ASA liu thp + Liu

LMWH ti a m khng quac rau thai (gp 3 - 4 ln)

Hi chng khng

PhosphoLipid thpht hay

CAPS

iu trtheo

chuyn khoa

c chmin dch nu cn thit

LMWH + ASA

3.2.3. Thi gian iu tr

+ ASA: ngay khi thhCG (+) nu trc khng dng

- Dng bt ckhi no sau 36 tun, nn dng 7 - 10 ngy trc khi ly thai

- Thai phc tin shuyt khi: tip tc dng ASA trong, sau (dphng

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


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+ LMWH: dng khi siu m c tim thai hay ngay khi c thai

- Sut thi kc thai v dng trc khi ly thai 24h (ang nghin cu)

- APS c tin ssy thai, thai cht lu < 3thng + khng tin shuyt khi,

Doppler bnh thng tui thai 34 tun c thdng LMWH

- Thi ksau sinh: dng LMWH ko di sau 6 - 12 tun, sau c ththay

bng warfarin v theo di INR

3.2.4. Qun l"thai nghn

- T vn kvbnh l ny ngi bnh cng theo di: Du hiu ca huytkhi cc v tr, du hiu ca tin sn git, thai chm pht trin trong tcung, sy

thai, thai luv du hiu cc tc dng phca thuc

- Theo di thai: siu m Doppler 3 tun/ln ttui 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 ttui thai 20 tun

- Theo di tc dng phca thuc (tiu cu, APPT): 3 tun u 1ln / tun.Sau 4 tun/ln (nu khng c bt thng)

3.2.5. Kt thc thai nghn

- Thi im kt thc thai nghn: PARA + can thip sm

+ Thai bnh thng: tui thai 39 tun

+ Thai c bin chng: tin sn git, thai chm pht trin trong tcung theo ch

nh sn khoa + PARA + can thip sm.

- Phng php kt thc thai nghn: theo chnh ca sn khoa

- Gim au trong APSchnh binh thng nn dng LMWH trc 24h, xt

nghim ng mu bnh thng, tiu cu > 70G/l

3.3. iu trnguyn nhn khc

- Heo tcung: khu vng ctcung, gim co.


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- Thiu ht ni tit: bxung ni tit nh progesteron, estrogen.

- Mbc nhn x trong u x tcung, mct vch ngn tcung

- iu trcc bnh l"ton thn ca mnh 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: chng bsung ni tit ngay khi ngi bnh c thai.- Vi heo tcung: khu vng ctcung chng ln c thai sau.

- Khi mbhi chng khng PhosphoLipid: dng aspirin liu thp trc khi

c thai, dng thuc chng ng khi ngi bnh c thai.

- Chng iu trcc bnh l"ton thn ca m(nu c).

- Vi nguyn nhn bhoc mbri lon nhim sc th: tin lng c con

bnh thng rt kh khn, nn t vn vdi truyn xem c nn c thai na khng.


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DA NON, NON

1. KHI NIM:

- nh ngha: theo Tchc Y tthgii, non l cuc chuyn dxy ra t

tun th22 n trc tun 37 ca thai ktnh theo kinh cui cng.

- S sinh non thng c tltvong v mc bnh cao hn rt nhiu so vi tr

thng, nguy c cao bdi chng thn kinh vi t l1/3 trc tun 32, gim

xung 1/10 sau 35 tun. Dphng v iu trda 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, tlnon 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 mu2.1.2. Triu chng thc th:

- Cn co tcung tha nh(2 cn trong 10 pht, thi gian co di 30 giy)

- Ctcung ng, hoc xa mdi 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 tcung (tn s2-3, tng dn). Ctcung xa

trn 80%, mtrn 2cm. Thnh lp u i hoc vi.

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 phny scao hn 27 ln so

vi nhng ngi c test m tnh.


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- o chiu di ctcung 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 ctcung: trn 32mUI/ml nguy c non scao hn

xp x20 ln.

- Monitoring sn khoa: cho php theo di, nh gi tn s, di, cng

cn co tcung.

- Mt sxt nghim tm nguyn nhn v tin lng : xt nghim vi khun

ctcung, nc tiu, CRP, huyt hc, sinh ha mu, men gan...

2.4. Chn on phn bit :

- Cc tn thng ctcung, ng sinh dc di gy chy mu m o.

- Rau tin o, rau bong non, vtcung.

3. IU TR:

3.1. Nguyn tc chung:

- Tr hon chuyn diu trda non,

- Chuyn sn phn c sc khnng chm sc s sinh non thng

3.2. iu trcth:3.2.1. Nghngi tuyt i ti ging, nghing tri, trnh kch thch

3.2.2. Thuc gim - ct cn co tcung:

- Thuc hng b ta giao cm: Salbutamol.

Chng ch nh trong bnh tim, cng gip, tng huyt p, i tho ng

nng, chy mu nhiu, nhim khun i. Tc dng ph: tng nhp tim, tng ng

huyt, hKali mu. Dng thuc nu nhp tim >120ln/pht.

Salbutamol : 5mg pha trong 500ml Glucose 5%, truyn tnh mch 20 git/pht

(10mcg/pht), liu ti a 45 git/ pht. Khi ct c cn co, chuyn sang liu

duy tr : vin 4mg, ngm 1 - 2 vin/ngy.

- Thuc chn knh calci : c thdng 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 chnh nu huyt p thp < 90/50mmHg.


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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 xgn xng, c chh hp, ngng th,

ngng tim. Cn theo di nng ion Mg huyt thanh 5-7mg/dL.

+ Thuc i khng cnh tranh vi oxytocin: Atosiban c tc dng cnh tranh

vi oxytocin trn cc ththti mng tbo c tcung lm gim sp ng ca

ctcung vi oxytocin.

Chnh iu trda non ttun 24-33 ca thai k. Chng chnh: 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 d ch Glucose 5%

hoc NaCl 0,9%. Truyn tnh mch 24ml/h, sau 3h gim xung 8ml/h. Thi gian

iu trkhng nn qu 48h, khng qu 3 t iu trtrong 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 trnon thng. Chnh cho thai t28n ht 34 tun tui, c thsdng 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. Xtr non khi c chchuyn dkhng thnh cng :

- Trnh sang chn cho thai : bo vu i n khi ctcung mht, hn ch

sdng oxytocin, ct tng sinh mn rng, mly thai nu c chnh.

- Chng nhim khun nu i vsm, dphng st rau, chy mu sau .

- m bo hi sc, chm sc trs sinh non thng.


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THAI CHT LU TRONG TCUNG

1. KHI NIM

Thai cht lu trong tcung l tt ccc trng hp thai bcht m cn lu li

trong tcung trn 48 gi.

2. CHN ON

2.1. Thai cht ludi 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 tnhin, t mt, mu sm hay nu en.

+ au bng: thng khng au bng, chau bng khi da sy hay ang sy

thai lu.- Khm: thy tcung b hn tui thai, mt tcung i khi chc hn so vi

mt tcung c thai sng.

2.1.2. Cn lm sng

- hCG:

+ hCG trong nc tiu chm tnh sau khi thai cht mt thi gian.

+ Nng hCG: thp hn so vi tui thai hay tc tng ca hCG khng

theo qui lut ca thai sng.

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

+ Thy m vang thai r rng m khng thy hot ng tim thai. Hnh nh ti

i rng (chnhn 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.


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2.1.3. Chn on phn bit

- Cha ngoi tcung: chm kinh, au bng, ra mu en m o, tcung 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: dnhm vi cha trng thoi trin v bnh cnh lm sng c th

ging y ht nhau. Gii phu bnh l"tchc no bung tcung cho chn on xc nh.

- Da sy thai: c bit khi tui thai nhhn 6 tun m siu m cha thy tim

thai. Phn bit: mu m o ti chkhng sm mu, thng c au bng km

theo. Siu m c thcha thy phi thai v tim thai nhng bti i cng trn, c ti

non hong. Siu m kim tra li sau 1 tun l cn thit.

- Tcung c u x:ra mu m o bt thng, tcung to hn tui thai. Siu

m c thai km u x tcung.

- 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 tun2.2.1. 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 cng thai, snn thy phn thai, nghe

thy ting tim thai.

+ Ngi bnh khng thy thai cng 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 bsy , thai lu.

+ Nu ngi bnh b mt s bnh km theo nh nghn nng, tin sn git,

bnh tim...th bnh tthuyn gim, ngi bnh cm thy dchu hn.

- Khm:


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

cung gim i gia hai ln o.

+ Kh snn thy cc phn thai.

+ Khng nghe thy ting tim thai.

2.2.2. Cn lm sng

- Siu m: cho kt quchnh xc, chn on sm v chc chn. Khng thy

hot ng ca tim thai. u thai mo m, c ththy hin tng chng khp shay

du hiu hai vng xng sdo da u bbong ra. Nc i t hay ht i.

- Cc phng php thm d X quangnh chp bng khng chun b, chp

bung i...ngy nay khng cn c sdng do nguy him cho mv 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 bcht lu v triu chng lm sng v siu m

cho kt quchnh xc.3. IU TR

!"#" i% &'(' )*(' )+(, +- ./n ng mu (nu c) tr& 0'- &1( )'-2 .3 )'1-

+ Fibrinogen truyn tnh mch.

+ Mu ti ton phn.

+ Cc thuc chng tiu sinh si huyt nh: transamine...

+ Heparin: liu 500010000UI/ngy. Cn nghin cu thm p dng iu

trm bo an ton cho ngi bnh.

3.2. Nong ctcung, no bung tcung

- p dng cho cc trng hp thai lu m thtch tcung b hn tcung c

thai 3 thng (hay chiu cao tcung di 8cm).

- Ththut kh hn no thai sng v rau thai lu x ha bm cht vo tcung.

Ch " phi gim au tt v ththut kh, chng dng thuc co hi tcung v

khng sinh sau no. Theo di chy mu


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3.3. Gy sy thai, gy chuyn d- p dng cho tt ccc trng hp thai cht lu m thtch tcung 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 trm kt quthnh cng c vcng tng tnh Stein.

+ Dng Prostaglandin: l phng php c a chung nht hin nay. Cc

thuc hay c dng thuc nhm Prostaglandin E2. Liu thuc phthuc vo tui

thai. ng dng c thl t m o, t hu mn hay ngm di li.

Ch "cc chng chnh ca Prostaglandin v Oxytocin.+ Vi cc trng hp kh: nu khng c ri lon ng mu, khng c nhim

trng, chi chuyn dtnhin l thi c thchp nhn c

4. TIN TRIN V BIN CHNG

4.1. nh hng n tm l!, tnh cm ca ngi m

Thai cht lu bao gicng gy ra nhng hu qutm l"nng ncho ngi m

v mt i mt a con ang c mong i. Tm l"skhi 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 tchc thai cht i vo

tun hon mu m- c bit khi tcung 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.


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- Din bin: qu trnh ri lon ng mu c thdin ra ttvi thi gian tim

tng trn 4 tun hay cp tnh khi c cn co tcung hay can thip vo bung tcung.

- Lm sng: chy mu din ra t t, mu khng ng, xut hin sau khi can

thip vi gi. Hay chy mu nhiu, mu khng ng, gy mt mu cp tnh.

- Xt nghim: fibrinogen rt thp hay khng c, sn phm phn hy ca

fibrinogen tng cao, gim plasminogen, gim hot tnh yu tantithrombin III, gim

tiu cu.

4.3. Nhim trng

- Khi mng i cn: khng snhim 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 thnhim cc vi khun ym kh.

5. PHNG BNH

- Dphng thai cht lu l mt vn phc tp v khng tm thy nguyn nhn.

- Trong chn oncn 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.


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THAI CHM PHT TRIN TRONG TCUNG

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 spht trin ca thai. xc nh thai thc

sc 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 tcung

thay i, nm di ng bch phn vth10, th5 hoc th3.

2. CHN ON

2.1. Lm sng

Khng c du hiu c trng

C thc mt sgi ":

- Tin scon chm pht trin trong tcung- Mtng cn t hn bnh thng

- Chiu cao tcung nhhntui thai

- Pht hin c mt snguyn nhn: HA cao, mbbnh 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 chs

vkch thc thai c xy dng da trn cc nghin cu m tct ngang) nh

gi thai chm pht trin trong tcung cn i hay khng cn i

2.2.1. Chs:ng knh lng nh

70% cc trng hp thai chm pht trin trong tcung c kch thc ng

knh lng nhnhhn so vi tui thai

2.2.2. Chs:chu vi bng


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y l mt chsthng c sdng nht don thai chm pht trin

trong tcung. Chu vi bng c gi trdon thai chm pht trin trong tcung cao

hn chsng 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 tcung mt strng hp ngi mkhng 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 thngh ti thai chm pht trin trong tcung.

2.2.3. Chs:chiu di xng i

Chsny khng c gi trc bit trong chn on thai chm pht trin trong

tcung.

2.2.4. Tnh trng nc i

C n 90% cc trng hp thai chm pht trin trong tcung 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 trtrong chn on v dbo thai chm pht trin trong tcung.2.2.6. c lng trng lng thai

Rt kh c mt cng thc tnh chnh xc trng lng thai nhi trong tcung,

chng ta chc thc on trng lng thai trong khong cng tr10 % ca gi

tr trung bnh, i chiu vi biu pht trin trng lng thai theo tui thai

chn on thai chm pht trin trong tcung. Ngoi ra cn mt schstham kho

khc nh: chu vi i, tlgia chiu di xng i v chu vi i, tlgia chu vi

u v chu vi bng

2.2.7. ChsDoppler ng mch

- Doppler ng mch rn v ng mch tcung bnh thng : t nguy c bin

chng trong thi kchu sinh, thng gp trong thai chm pht trin trong tcung

do nguyn nhn bt thng NST

- Doppler ng mch tcung 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


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nhng thng cui dn ti thai chm pht trin trong tcung, 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 mv thai c quyt nh chm dt thai nghn thi im thch hp.

3. THI XTR

- Hin nay cha c phng php iu trhu hiu

- Phi theo di rt cht chv t vn kcho sn phv gia nh

- iu trTHA vi nhng trng hp xc nh thai chm pht trin trong t

cung do mri lon THA thai k.

- Chnghngi, hn chlao ng nng

- Ci thin cung cp oxy cho mv truyn dung dch ng tng thtch tun

hon c khuyn co cho mt s trng hp thai chm pht trin trong tcung

nng cui qu"2 ca thai k, tuy nhin phng php ny cng khng cho kt qu

khquan.

- Tm nguyn nhn: nu xc nh thai bt thng nhim sc th, a d tt,

nhim CMV th nn nh ch thai nghn. Nu chc 1 d tt n c th hi chn

vi cc trung tm chn on trc sinh, vi bc sphu thut nhi c hng x

tr ngay sau khi sinh.

- Dng corticoid cho tui thai t28 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 ttui 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 chthai nghn ( CTN)cht ra sau khi cn nhc tui thai, tnh trng

ca ngi m, tin ssn khoa, v c bit l cc bnh l"km theo kt hp vi mt

sbin i trn Monitoring. CTN t ra trong mt strng hp sau:


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+ Tui thai trn 31 tun khi nhp tim thai dao ng km, dao ng khng

lin tc qua mt sln theo di, nhp chm n c, ko di, lp li nhiu ln

+ Tui thai t34 tun khi Doppler ng mch rn vi dng tm trng bngkhng v bt thng Doppler ng mch no, thai c biu hin ngng tin trin

+ Tui thai t37 tun khi bt thng Doppler ng mch rn, ng mch no,

monitor.

Lu : Doppler ng mch rn bnh thng kim tra li sau 8 ngy, nh gi

spht 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 spht trin thai, kt hp Doppler ng mch no.

- Cch thc : trng hp chuyn dtnhin hoc nh chthai 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 tbt li khc nh ngi ngc, rau

bm thp th mly thai v lun phi c bc shi sc s sinh tham gia vo thi

im ly thai.

4. PHNG BNH

- T vn di truyn cho cp vchng nu xc nh nguyn nhn thai chm pht

trin trong tcung do bt thng NST hoc bnh l"gen cho cc ln mang thai tip

theo. Tbmt sthi quen xu nh nghin ht, ung ru, dng cht kch thch

trc khi mang thai. Ci thin chdinh dng v lm vic.

- Trng hp thai chm pht trin trong tcung do nguyn nhn tun hon

ca ngi mc thiu trdphng bng Aspirin liu thp ttun th15 ca

thai k.


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TIN SN GITSN GIT

1. KHI NIM

Tin sn git, sn git l bin chng ni khoa thng gp nht phn mang

thai vi tlt2% - 8%. Triu chng thng gp l ph, huyt p tng v protein

niu. L 1 trong nhng nguyn nhn chnh gy tvong cho mv thai.

Theo di v qun l"thai nghn, iu trthch hp tin sn git, sn git nhm

gim bin chng nng ncho mv 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 gihay que thnhanh (+)

2.1.2.Tin sn git nng:

+ Huyt p 160/110 mm Hg.

+ Protein/ niu 5 g/24 gihay que th3+ (2 mu thngu 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 trbnh thng).

+ Axt uric tng cao

+ Thai chm pht trin.

+Nhc u hay nhn m.

+ au vng thng vhoc hsn phi.

2.2. Sn git

Sn git c chn on khi c cn co git xy ra phnmang 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 thxut hin trc, trong chuyn dhay


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trong thi khu sn. Sn git c thdphng c bng cch pht hin v iu tr

sm tin sn git

2.2.1. Triu chng lm sng

Trn c sngi bnh btin 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 tbo 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: chyu iu trngoi tr

3.1.1. iu trni khoa:

- Cho thai phnghngi, yn tnh chn 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 34 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 thgic, au

thng v v tng cn nhanh, theo di cn nng lc nhp vin v mi ngy sau,

lng nc tiu.


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+ o huyt p t thngi 4 gi/ ln, trkhong thi gian tna 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. (chlm xt nghim ng mu khi tiu cu gim v men gan tng).

3.1.3. Cch xtr tip theo ty thuc vo: nng ca tin sn git, tui thai.

Tnh trng ctcung. Tin sn git nhkt thc thai ktui thai 37 tun.

3.2. Tin sn git nng

- Dphng v kim sot cn co git bng magnesium sulfate.

- Hp khi huyt p cao: huyt p tm trng 100-110mm Hg, hoc huyt

p tm thu 150-160 mmHg (ACOG 2012).

- Chm dt thai ksau khi chng co git v hhuyt p 24 gi.

- Trnh sdng li tiu. Hn chtruyn dch trkhi c tnh trng mt nc nhiu.

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

duy tr ti thiu 24 gisau sinh.- Liu tn cng: 3- 4,5g Magnesium sulfate 15% /50ml glucose 5% tim tnh

mch chm 15-20 pht.

- Duy tr 1- 2g /gi truyn tnh mch. Pha 6g Magnesium sulfate 15% vi

Glucose 5% 500ml truyn tnh mch XXX git/ pht.

- Tim bp gin on: tim bp su mi gi 1g hoc mi 4 gi 5g, thm

Lidocain 2% gim au.

- Bm tim in: pha 6g Magnesium sulfate 15% + 2ml nc ct, 7ml/gi.

- Ngc 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 giv iu chnh liu duy tr gi

c nng Mg 4- 7mEq/L (4,8-8,4mg/dL).


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+ Lin quan nng Magnesium/huyt thanh.

9,612mg/dl (4,05,0 mmol/L): mt phn xgn xng.

1218 mg/dl (5,07,5 mmol/L): lit c h hp.

-2430 mg/dl (1012,5 mmol/L): ngng tim

+ Xtr ngc 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 hhuyt p

Thuc hp c thnh hng bt li trn cmv thai. nh hng trn thai

nhi hoc gin tip do gim lu lng tun hon tcung nhau hoc trc tip trn tim

mch. Do vy cn cn nhc gia li ch v nguy c khi sdng thuc hp.

-Chnh

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 2gi. HA tm thu mc 130150mmHg. HA tm trng mc 80100mmHg.

-Chng chnh trong thai k

Nitroprusside, thuc c chmen chuyn.

-Cc loi thuc hHA dng trong thai k: c thdng 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 shsau 5-10 pht v ko di t3-6 gi.

+ Hydralazine

C thgy hhuyt p hn nhng thuc khc, khng phi l chn la s1

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


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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 chsi (amnionic fluid index: AFI)

ln hn 24 - 25cm; hay khi ln hn vbch phn th95 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 so trn.

a i l mt trng hp thai nghn nguy c cao cho sn phv nguyn nhn

a i v cnh bo nguy c sinh non trong qu trnh thai nghn .2. CHN ON

a i cp c thdin tin mau trong vng vi ngy vi cc triu chng cp

nh au cng bng nhiu, kh th, i khi btm 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 btcung chn p. a i trong trng hp ph thai c thgy ra

hi chng gng thai ph(mirror syndrome), m tln u tin bi Ballantyne

nm 1892: tnh trng ca mbt chc thai nhi, nh ph, tiu m; v hu qul tin sn git.

a i mn, dch i gia tng dn nn thai phc thchu ng c tnh trng

cng chng bng.

Du hiu u tin trn lm sng gi "mt trng hp a i l tcung 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 cchng hay u bung trng to bng nhng hnh

nh trn siu m.3. HNG X TR

a i mc nhn trung bnh him khi i hi cc bin php can thip.

Cn thit nhp vin khi thai phkh th, au bng hay i li kh khn.

Nghngi ti ging, li tiu, hn chdch truyn v mui khng em li hiu

qur rt. Ht bt nc i cng gip ci thin triu chng kh ththai phng

thi ly dch i xt nghim di truyn hay xc nh strng thnh phi ca thai nhi.

Ththut ny c thgy tai bin nh: vi, nhim trng, hay rau bong non.


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

sgia 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. Tuynhin, thm ch khi kho st hnh nh hc thai nhi bnh thng, vn nn tin lng mt

cch thn trng bi dtt thai nhi v bt thng nhim sc thc thgp.

3.1. a i xut hin ba thng gia thai k

" Chnh siu m kho st hnh thi hc thai nhi chuyn su tm cc dtt

bm sinh c thi 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 ccxt nghim di truyn tm nguyn nhn bt thng NST, nhim trng thai k.

"Nn tip tc theo di, qun l"thai knguy c cao (khm thai tin sn)

3.2. a i ba thng cui thai k

- Kim tra biu tng trng thai nhi.

" Loi trcc nguyn nhn bnh ni khoa ca m.

"Ty theo kt quxt 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 phv gia nh.

3.3. Chuyn d

Hay gp cc nguy c kh nh ngi bt thng, kh do ri lon cn co t

cung, tun thchnh bm i. phng rau bong non, bng huyt sau sinh.4. TAI BIN

Nhng bin chng thng gp nht cho thai phnhng thai kc km a i

l nhau bong non, ri lon cn g tcung hay bng huyt sau sinh. Ngoi ra, cn c

bin chng sa dy rn, ngi bt thng, tcung sau hay can thip phu thut.

Thai nhi bt thng thai, chn on c trong khi mang thai hay sau


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THIU I

1. KHI NIM

Thiu i l tnh trng nc i t hn bnh thng, khi chsi (AFI) nhhn

5cm v mng i cn nguyn vn. T l xut hin thiu i c bo co t cc

nghin cu bnh hng bi skhc bit trong tiu chun chn on, dn snghin

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 kt 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 lthng gp hn.

Chn on xc nh chyu da vo siu m thai v nc i.

2. BIN CHNG CA THIU I

Sxut hin thiu i trong giai on sm ca thai klm tng nguy c thiu

sn phi cho thai nhi. Kilbride v cng s(1996) tin hnh quan st trn 115 thai

phbvi trc 29 tun, c 7 ca thai lu, 40 trs sinh tvong, v c tnh tltvong 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 trngi trong qu trnh kho st hnh thi hc ca thai nhi qua siu

m (nu c). Trong trong hp ny, chnh truyn i cng c thc cn nhc.

Bin chng thiu i xut hin mun trong thai kty thuc vo tui thai, mc

thiu i v tnh trng bnh l"km theo ca m. Hng dn sn phung 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 sv xt nghim dch m o (Nitrazine test) loi trri/i v.


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- Siu m tin sn nhm kho st v pht hin cc bt thng hnh thi thai,

c bit bnh l"hniu ca bo thai nh cc trng hp lon sn thn, tc nghn

ng niu.

- T vn li ch v cc tai bin, tin hnh ththut truyn i trong trng hp

nc i qu t gy cn trcho qu trnh kho st hnh thi thai, ngoi ra c thng

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 tcung.

- Nu thai c dtt bm sinh hniu, chnh chm dt thai ktrong trng

hp nng chnn 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.

- Chnh htrphi l cn thit.

- Phng php chm dt thai k:

+ Khi pht chuyn dchm dt thai kthai thiu i trng thnh hay liu htrphi thai non thng c thnui c.

+ Mly thai nhng thai ht i (AFI < 2cm) hoc c nhng du hiu nghi

ngthai suy cp, thiu i.


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RAU TIN O

1. KHI NIM

Rau tin o l rau bm mt phn hay ton bvo on di tcung gy chy

mu vo 3 thng cui ca thai k, trong chuyn dv sau . Rau tin o c th

gy tvong hoc bnh l"mc phi cho mv 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 thchy nhiu, t, sau chy t dn v tcm 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 phthy

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 tcung.

- Triu chng ton thn: thiu mu ty mc mt mu. Sn phc biu hin

chong nu mt mu nhiu.

- Triu chng thc th: nn ngoi c ththy ngi thai bt thng. Tim thai

c ththay i nu chy mu nhiu

- Khm m o bng mvt thy mu trong ctcung (CTC) chy ra, loi tr

cc tn thng CTC


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- Thm: sthy rau qua ctcung

+ Rau tin o bm mp: thy mp di bnh rau bm ti ltrong ctcung.

+ Rau tin o bn trung tm: thy bnh rau che lp mt phn ltrong ct

cung nhng khng che ht.

+ Rau tin o trung tm: thy bnh rau che lp hon ton ltrong ctcung.

Ngi thai bt thng .

Ch "khng ckhm 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 vtr bm ca bnh rau:

+ Rau tin o trung tm: bnh rau bm hon ton vo on di tcung v

che lp ltrong ctcung.

+ Rau tin o bm mp: mp bnh rau bm n ltrong ctcung.

+ Rau tin bm bn, bm thp: khong cch gia mp di bnh rau n l

trong ctcung < 20mm.

- Siu m rt c gi trchn on trong trng hp rau tin o - rau ci rnglc vi cc hnh nh sau: mt khong sng sau rau ti vtr rau bm, phDoppler

mu thy cc mch mu i xuyn qua thnh c tcung hoc bng quang. Hnh nh

giu 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 spht trin ca siu m chn on.

- Soi bng quang chnn tin hnh khi nghi ngrau ci rng lc m xuyn

c bng quang v ngi bnh c biu hin i mu.

3. XTR

3.1. Nguyn tc chung

- Cm mu cu ml chnh. Ty theo tui thai, mc mt mu v khnng

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.


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- Khi nghi ngrau tin o phi chuyn ngi bnh ln tuyn huyn c trung

tm phu thut ; nghi nghoc chn on rau tin o - rau ci rng lc th chuyn

ngi bnh ln tuyn tnh hoc tuyn trung ng.

3.2. iu trcth

3.2.1. Khi cha chuyn d:

- Nghngi, hn chi 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: mly thai chng i vi trng hp rau

tin o trung tm. Cc trng hp rau tin o khc c thcn nhc theo di ch

chuyn d.

- Trng hp rau tin o chy mu nhiu e da tnh mng ngi mth 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: mly thai.- Rau tin o bm mp: mly thai cp cu nu ra mu nhiu. ra mu t, ngi

thv ctcung thun li th bm i v x mng i vpha khng c bnh rau

cm mu, nu sau khi x mng i vn ra mu th nn mly thai, nu khng ra mu

th theo di ng m o.

- Rau tin o bm thp, bm bn: mly thai nu ra nhiu mu, nu ra mu t

hoc khng ra mu th theo di chuyn dnh 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 chX cm mu, vn chy mu th

nn ct tcung bn phn thp vi ngi bnh con.

Ngi bnh cha c con cn bo tn tcung: tht ng mch tcung

hoc tht ng mch hv, ng mch dy chng tcung bung trng; khu mi

B-lynch; chn bng hay gc vo bung tcung. Nu khng kt quth vn phi

ct tcung.


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3.2.3. Rau tin o - rau ci rng lc:

- Rau tin o - rau ci rng lc l hnh thi lm sng nng nnht 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.

- Mly thai chng khi thai thng. Cn chun bkp phu thut vin v

kp gy m hi sc c kinh nghim; chun bnhiu mu v cc phng tin hi sc

- Nn chng mdc thn tcung pha trn chrau bm hoc y tcung

ly thai, trnh rch vo bnh rau trc khi ly thai ra, sau khng bc rau v

chng ct tcung hn chti a lng mu mt.

4. BIN CHNG

4.1. Cho m

- Tvong do mt mu cp, thiu mu.

- Ct tcung cm mu.4.2. Cho con

Non thng, cht trong chuyn d, bnh l"trs sinh do thiu mu, non thng


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RAU BONG NON

1. KHI NIM

1.1. nh ngha

Rau bong non l rau bm ng vtr nhng bong mt phn hay ton bbnh

rau trc khi sthai.

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 hthng mao mch, xy ra t ngt c thtin trin rt nhanh tthnh

thnh thnng.

1.2. Phn loi: 4 ththeo hnh thi lm sng:

- Rau bong non thn

- Rau bong non thnh

- Rau bong non thtrung bnh

- Rau bong non thnng.

2. CHN ON2.1. 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 tcung sau lan khp bng, nhp cn au ngy cng mau

mnh, trng hp nng triu chng au bche 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 mhi, chi lnh, thnhanh, ..

- Huyt p thng khng thay i trong nhng giu (do ngi bnh thng

c tin scao huyt p ttrc), mch nhanh.

2.1.3. Triu chng thc th

- Tcung co cng lin tc hoc tcung co cng nh gtrong thnng.


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

- Chiu cao tcung tng dn do shnh thnh khi mu cc sau rau.

- Nghe: nhp tim thai chm, khng u, hoc mt tim thai trong thnng.

- Khm m o: ra mu m o, mu en, khng ng; u i cng phng,

nu i vthy 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 tsau 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 trrau bong non khi

c du hiu lm sng gi . Siu m cng thy sbin 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: slng hng cu gim, haemoglobin gim, tiu cu gim,

fibrinogen gim, ATTP tng hn so vi mc bnh thng.- Xt nghim nc tiu thng c protein.

2.2. Cc thlm sng

2.2.1. Thn

Khng c du hiu lm sng r rt, cuc chuyn dbnh 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 nhsiu m thy khi mu tsau rau.

2.2.2. Thnh

- Triu chng khng y , c thc tin sn git, cn co tcung 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 tsau rau.

2.2.3. Thtrung bnh

- Thng c tin sn git. C thchong nhhoc va.


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

iu tr.

3.3. Xtr sn khoa- Nu c chn on l rau bong non th nn mly thai ngay cu con v

phng bin chng nng hn cho m. Bo tn tcung: nu tn thng nhi mu

tcung khng qu nhiu, tcung cn co#$c. Nu sn phcon, nhiu tui,

tn thng nhi mu tcung nng hay khng p ng vi thuc co c tcung th

nn ct tcung hon ton hay bn phn ngay trnh nguy c chy mu sau m.

- Nu chn on rau bong non sau khi sthai th tin hnh ngay cc bin php

dphng 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 tcc tng do nhi

mu v thiu mu, nguy him nht l suy thn.

- Ct tcung.

- Tvong cmv con .4.2. Cho thai:

-Suy thai. Thai cht trong tcung. Non thng nhcn.

- Thiu mu.


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THAI QA NGY SINH

1. KHI NIM

Thai qu ngy sinh l nhng trng hp thai nghn ko di qu 42 tun hoc

qu 294 ngy tnh tngy u ca kkinh cui cng.

iu quan trng nht l phi xc nh c tui thai chnh xc bng ngy u

ca kkinh cui cng hoc siu m trong 12 tun u ca thai k.

2. CHN ON

- Da vo tui thai (tnh t ngy u ca kkinh cui, c gi trnu

vng kinh bnh thng).

- Da vo siu m xc nh tui thai i vi thai trc 20 tun nu ngy

u kkinh cui khng xc nh hoc kinh khng u.

- Xc nh tnh trng thai v phn phthai ( nc i, rau)

3. XTR .

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 dthai 41 tun, khng nn chn 42 tun


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- Nu ctcung thun li (chsBishop > 5) th gy chuyn dbng bm i

v truyn oxytocin tnh mch.

- Nu ctcung khng thun li (Bishop < 5) th lm chn mui ctcung bng:

+ Prostaglandin: Prostaglandin E2 (Dinoproston) 2,5ml dng gel t vo ng

ctcung. Nu sau 6 -12 ting, ctcung vn cha thun li th t li liu 2.

+ Phng php khc: nong ctcung bng ngn tay, cht ht m, t bng c

tcung

- 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

dbng monitor pht hin sm suy thai. Mly thai nu thai suy, nc i gim ,

ctcung khng thun li.


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BNH TIM MCH V THAI NGHN

1. KHI NIM:

Bnh tim phnmang thai gy ra nhiu nguy c cho mv con trong khi

mang thai, sau khi v c bit trong chuyn d. Tn sut mc bnh Vit nam

khong 1-2% phnmang thai. Theo di, tin lng, x tr bnh i hi sphi

hp cht chgia 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 tcung. Thai ddng

+ Thai cht lu trong tcung, 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 tqu"II thai k, c gi tr tin lng bnh, tng dn

theo tui thai. Kh thgng sc hay thng xuyn ckhi 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 cni. Gan to kh pht hin do tcung chim chtrong 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 phnang gim, rales ngy, rales rt, rales m


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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 trchng ng

2.3. Phn suy tim theo chc nng (NYHA- Hi tim mch New York):

- 1: cha bhn chhot ng thlc

- 2: kh thkhi gng sc, gim nhhot ng thlc

- 3: kh thkhi gng sc nh, hot ng thlc gim

- 4: kh thckhi nghngi, hot ng thlc 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 ginc v mui.

- Thai phc bnh tim, tnh trng ny cng trm trng dgy bin chng suytim, 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, dphng cc tai bin, xtr sn khoa ty thuc vo mc bnh,

c cn nhc n nguyn vng sinh con ca thai ph.

3.2. iu trcth:

3.2.1. Qun l"thai nghn:

Qun l"thai nghn cht ch. Trnh hot ng thlc, nm nghing tri, thay

i t ththng xuyn. Hn chtng cn, chn trnh mui, ng; n y

cht dinh dng, chng thiu mu

3.2.2. iu trni khoa:

Trtim, li tiu, chng huyt khi, dphng nhim khun ty thuc giai on

mang thai, thbnh tim mch v mc bnh.


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Can thip tim mch: thc hin trong qu"2 ca thai kphthuc vo th, mc

bnh l"tim mch. Nong van, nong vnh qua da, t d bt lthng lin tht, lin nh.

3.2.3. Xtr sn khoa:

Trong khi c thai, cha c suy tim:

+ Thai phsinh 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 chtim mch - sn khoa, githai n khi

thng, chchuyn dhtrththut hoc mly thai nu c chnh

Trong khi c thai c suy tim:

- Thai phsinh ln u:

+ Suy tim 1-2: thai nhdi 20 tun nn nh chthai nghn.

+ Nu thai trn 20 tun: theo di, iu tr, dphng bin chng. Nu khng

p ng iu trcn nh chthai nghn bt ktui thai no.

+ Suy tim 3- 4: nh chthai nghn bt ktui thai, iu trni khoa trc,

trong v sau khi nh ch.- Thai phsinh ln 2 trln: nn nh chthai nghn. Nu thai gn thng

nn iu trtch cc n thng ri mly thai chng.

+ La chn phng php nh chthai nghn:

Ht thai bng bm chn khng thng thng nu thai nh, di 12 tun

Gy chuyn dhoc phu thut ct tcung ckhi nu thai 12-20 tun.

- Gy chuyn dhoc mly thai tht hai vi tcung nu thai trn 20 tun.

+ Cn gim au tt. m bo v khun, khng sinh dphng trc v sau

phu thut - th thut hn chnhim khun. Chng ngn nga tc mch do

huyt khi sau phu thut - ththut bng thuc chng ng mu.

3.2.4. Khi chuyn d:

+ Htrng di c can thip ththut cn phi hp bc ssn khoa,

tim mch, s sinh v gy m hi sc cuc din ra an ton.


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+ Tip tc dng thuc trtim, 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

oxytocinpha m c trnh qu ti tun hon.

+ Khi sthai: htrsthai bng Forceps trnh gng sc cho sn ph

+ Trong thi ksrau: hthp chn, chn tnh mch chdi trnh mu v

tim t ngt gy suy tim cp. Kim tra kbnh rau trnh st rau.

+ M ly thai nu c chnh, nu c chnh cnh nn m ly thai ch

ng. dng thuc chng ng 1 tun trc khi phu thut.

3.2.5. Thi khu sn:

+ iu trkhng sinh chng nhim khun, t nht 1 tun. Nn sdng khng

sinh phi hp chng vi khun Gr m v kkh.

+ Dphng huyt khi: vn ng sm, thuc chng ng (Heparine,Dicoumaron).

+ C thcho con b nu cha suy tim hoc suy tim 1. Nu khng cho con

b nn ct sa bng Bromocriptine, khng sdng 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 tht ngt, tc ngc, v mhi, chn tay lnh, tm mi

u chi, huyt p tt, kt. Nhp tim nhanh, c thpht hin ting bnh l"(rung tm

trng, nga phi). Rales m nhht y phi, cng ngy cng dng cao. p lc

tnh mch trung tm cao, Xquang phi m

- Xtr: hi sc, thoxy liu cao 8-12 l/pht, li tiu, trtim, Hhuyt p nu

c tng HA. C thhtrt ni kh qun, thmy.

+ Xtr sn khoa: mly thai cp cu

4.2. Lon nhp tim

- Lon nhp nhanh: thng gp nhp nhanh xoang >100 l/pht. C thgp cn

lon nhp nhanh kch pht trn tht

- Lon nhp chm: nhp tim < 60 l/pht. Hi chng Adam Stock, nhp tim 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

Xtr: dng thuc hp l v nh chthai nghn thi im thch hp, u tin

bo vsc khe v tnh mng ca thai ph.

4.3. Tc mch do huyt khi

Hay gp trong thi khu sn (75%), vim tc tnh mch chi di, ngoi ra c

thno, 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 trbng 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 chcc thai phc 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 trni khoa.


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THIU MU V THAI NGHN

1. KHI NIM

- Thiu mu trong thai nghn khi t l hemoglobin (Hb) < 110g/l

- Thiu mu nng nu Hb < 70g/l mu.

- Thiu mu trong thai nghn chia thnh cc loi sau:

+ Thiu mu do thiu st

+ Thiu mu do thiu acid folic

+ Thiu mu do tan mu

2. CHN ON

2.1. Lm sng

- Thiu mu: da, nim mc nht nht, suy nhc c th, nhp tim nhanh, kh

th, tai, chng mt.

- C th vim li (3 thng cui thai k)

- Vng da nh: c th do thiu Folat

- C th thy lch to trong trng hp thiu mu do tan mu: Thalasemia, tanmu t min

2.2. Cn lm sng

- Cng thc mu: hngcu 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


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-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.


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BASEDOW V THAI NGHN

1. I CNG

Khong 1-2% sphnmang thai c ri lon chc nng tuyn gip, tng mt

cch tng i ngi phnln tui

Do 2 nguyn nhn:

- Thiu Iot do thai nghn.

- Sthay i vmin dch do thai nghn dn n ri lon chc nng ca

tuyn gip.

2. CHN ON:

2.1. Lm sng

- Thai phc tin sgia nh, tin sbn thn hc thai phc 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 mv 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 sn nh vmin dch. Cn nhngtrng hp khc, cc bin chng ca mv ca thai c thl thm ha, c bit l

na sau ca thai k.

2.2. Cn lm sng

- Nng TSH c ththp vo giai on u ca thai k

- nh lng T4 tdo m nng T4 tng nhiu trong trng hp cng gip.

- Trong trng hp khng tng thch cn bsung xt nghim T3 tdo.


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

- Chp v siu m tuyn gip

3. IU TRV THEO DI

3.1. iu tr

- Sdng cc thuc khng gip tng hp liu ti thiu t c mc

bnh gip.

- Sdng cc chphm ca Theo-Uracil (PTU, Basdne) v khnng qua rau

thai ca n thp v nguy c gy ra bt thng thai cng rt thp.

- Ct btuyn gip thng khng c chnh lm trong khi c thai

- Vic s dng phng php iu tr bng Iot phng x l chng ch nh

tuyt itrong sut thi gian c thai.

2.2. Theo di:

- ngi mtheo 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 trngi m.

4. TIN TRIN V BIN CHNG4.1. Cc bin chng vpha m:

- C thgp suy tim, tin sn git

- Thiu mu hay nhim trng.

- Cn cng gip khi chuyn d

4.2. nh hng n thai v trs sinh:

- Thai cht lu, cht trs sinh

- Chm pht trin

- Bt thng ca xng nh hp s, mt sddng khc nh thai v s, khe

hmi, mn hu, khng c hu mn, suy tim

- non chim 53% v bu gip trs sinh.

- Suy gip bm sinh

4.3. Cng gip thai nhi:

- Cng gip s sinh hay thai nhi rt him gp vi mt tl1/4000-1/40000.


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- Ly mu thai nhi c thc chnh trong nhng trng hp nghi ngc

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. Sdng PTU ( propyl-theo-uracil) tt

hn l methimazole.

4.4. Cng gip trs sinh

- Cng gip trs sinh gp 1% cc trm ngi mmang khng th

khng cc thcm quan ca TSH.

- Cng gip trs 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 mhi v ban . Bu gip chc thgp mt na strng hp. Suy tim

trs sinh l mt trong nhng nguy c ca trs sinh cho nn cn phi chn on

v iu trsm trnh nguy s suy tim trs sinh

- iu tr mt cch kinh in l PTU 5-10mg/kg kt hp vi cc thuc

Betabloquant


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I THO NG V THAI NGHN

1. I CNG

T thai nghn (TTN) l sgim dung np glucose hoc T (i tho

ng) c pht hin ln u trong lc mang thai (khng loi trngi bnh c

gim dung np glucose hoc T ttrc nhng cha c pht hin).

TTN t lpht hin chyu giai on mun ca thai k, phn ln cc

trng hp sau sinh glucose c thbnh thng trli. Tuy nhin nhng trng hp

c tin sTTN ny c nguy cpht trin thnh T tu"p 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 chng.

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 kbt kthi 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 bngng 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 ccc c

im sau:

+ Thuc chng tc c tlTTN thp

+ Khng c ngi thn thuc gn (first degree) bT.

+ Tui dui 25.

+ Thtrng bnh thng trc thai k(BMI < 26kg/m2).

+ Khng c tin sbt thng chuyn ho glucose.

+ Khng c tin sxu vsn khoa.

- Nguy ctrung bnh: ngi bnh thiu 1 cc c im trn: thc hin test

glucose mu vo 24-28 tun, sdng mt trong 2 cch sau:


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+ Thtc 2 bc: test 50g glucose, nu glucose trn chun sng lc, thc hin

tip nghim php dung np glucose.

+ Thtc 1 bc: thc hin nghim php dung np glucose trn tt ccc i tng.

- Nguy ccao: ngi bnh c 1cc c im sau:

+ Bo ph r (BMI > 40kg/m2)

+ Tin sgia nh T tp 2 r .

+ Tin sbn thn bTTN, gim dung np glucose, glucose niu.

+ Thc hin test glucose mu cng sm cng tt, p dng cc bc thtc nu trn.

+ Nu TTN cha c chn on, cn lm li vo 24-28 tun, hoc ti bt

kthi im no ngi bnh c biu hin gi tng glucose mu.

2.2. Chn on

Hi ngh quc tTTN ln th 4 ngh nn s dng tiu chun ca

Carpenter-Coustan vi test 100g glucose ung.

Tiu chun chn on TTN

OSullivan-Mahan

Mu ton Somogy-Nelson(mg/dl[mmol/l])

Nhm dkin T

quc giaHuyt tng

Tphn tch

(mg/dl[mmol/l])

Carpenter-Coustan

Huyt tng-Glucoseoxidase(mg/dl[mmol/l])

i 90 [5,0] 105[5,8] 95[5,3]

1 gi 165[9,2] 190[10,6] 180[10,0]

2 gi 145[8,1] 165[9,2] 155[8,6]

3 gi 125[6,9] 145[8,1] 140[7,8]

Test vi 100g glucose thc hin vo bui sng, nhn i qua m t nht 8

gi nhng khng qu 14 gi, sau 3 ngy n khng king ( 150g

carbohydrate/ngy) hot ng th lc bnh thng, i tng ngi ngh, khng

ht thuc trong qu trnh test.


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

nh l tiu chun chn on

3. IU TR T V THAI NGHN3.1. Theo di v iu trthng quy :

- i vi trng hp c tin s TTN: cn nh gi li khnng 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 ccc trng hp bit T t trc hoc TTN, mc

ch iu trl duy tr glucose huyt trc v sau n bnh thng nhm trnh nhng

nguy ctc 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 phc T ttrc nn tm ceton niu khi glucose

>150mg/dL. Vi TTN thnh thong nn theo di glucose i, 1 gi, 2 gisau n.

Ngi bnh dng insulin cn theo di glucose i v lc i ngiu chnh liu.Tt ci tng cn theo di HbA1C 3 thng u mang thai gip nh gi

nguy cdtt bm sinh.

3.1.2. Dinh dng:

- Nguyn tc cbn nhm gp phn kim sot tht cht chT sut trong

qu trnh mang thai l chv khoch n ung.

- Mi ngy cn chia ra 3 ba n chnh v 3 ba n phnhm trnh hglucose

huyt ban m v trc cc ba n.

- Trng hp bhglucose huyt, cn iu trtht hp l", khng lm dng lm

tng glucose thi qu gy hi cho thai. Trng hp hglucose huyt km ri lon tri

gic cn tim glucagon ( c thhng dn cho ngi thn thc hin khi cn).

3.1.3. iu trinsulin:

Yu cu iu tr: vi TTN yu cu kim sot glucose cht ch hn so vi

ngi bnh T ni chung, cthglucose huyt lc i: 60-95mg/dL, glucose huyt


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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 trtht thch hp.

Yu cu glucose huyt cthcho cc giai on nhsau:

-Trc khi mang thai: xc nh glucose huyt sau n (GHSA).

-Ba thng u thai k: GHSA < 160mg/dL, gip lm gim nguy csy thai,

gim nguy cdtt, kim sot ceton mu.

-Ba thng gia thai k: GHSA < 130mg/dL, gip kim sot leucine, threonine,

acid bo tdo, tng thglucose huyt v gip gim nguy cthai ln.

-Ba thng cui thai k: GHSA < 130mg/dL gip gim nguy chi chng suy

kit h hp, thai lu, kim sot ceton mu

-Sau sinh: GHSA < 180mg/dL.

i vi t"p 1: cn iu trtch cc vi nhiu mi tim trong ngy , v d3 mi

insulin tc dng nhanh trc 3 ba n, 1 mi insulin chm lc 21 gi. iu chnh

liu lng mi 1-2 tun tu nhu cu, lu " gn cui 3 thng u nhu cu insulin

thng gim, sau tng dn ln vo 3 thng cui c thn gp 3 ln liu lng

dng trc lc mang thai.Cng c thtim 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 trvi 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 dv sau sinh:

Vi T ni chung, mc tiu iu tr l duy tr glucose mc sinh l"(70-

120mg/dL). trnh tng glucose mu, ngi bnh nn c hn chn ung v

truyn cc dch khc. Truyn tnh mch ng dextrose tc 5-8g/gi, dng


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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

cthhin 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 thlc trong lc sinh nc thlm tng stiu th

glucose, nhng cng c thc iu chnh thng qua vic gy t tusng lin tc

trong cuc sinh.

Vi TTN thng khng cn dng insulin trong lc sinh, ngay ci vi

mt strng hp T tp 2 nhcng vy.

Nhu cu insulin gim nhanh chng ngay sau khi sinh( c thgim n 50-

90%) do liu insulin/ngy cn gim xung chcn 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 tTM qua

ng di da ngay sau khi sinh, thng th nhu cu insulin nhanh chng tr li

nhtrc khi sinh.

Sn phT phthuc insulin nhng ngy u sau sinh thng chcn liu

nhthm ch khng cn iu trinsulin

3.2. Cc phng tin iu trkhc:

Tp thdc thai phcn thn trng v c thgy co tht tcung, sinh non,

tim thai chm, nht l nhng thai phtrc y khng htp luyn. Du sao th

dc nhnhng nhi xe p tra an ton v hu ch.

4. TIN TRIN V BIN CHNG

4.1. Cho con

- Spht trin ca thai nhng ngi mT ni chung c thc nhng d

tt nh hng ln n tng lai ca tr:


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+ Tn ng thn kinh

+ Dtt bm sinh tim v mt sthng 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 thgy 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 snguy ckhc cho thai nhi c thgp do tng insulin nh: hi chng

suy h hp, hglucose huyt, tng billirubin mu, hcalci mu, km n.

4.2. Cho m

- Phnc bin chng tim mch v/hoc T l nguy cln vbnh tt v

tvong trong sut qu trnh mang thai.

- Nhiu bin chng bnh tt do T phnmang thai trli gp phn lm

ri lon thm chuyn ho t tc ng xu ln skim sot glucose huyt.

- Nhim toan ceton thng xy ra vo 6 thng sau ca thai k, y l giai on

smang thai c tc ng mnh nht ln T. Nhim toan ceton l mt nguy cgy

tvong cho mcng nhtvong chu sinh cho thai nhi.


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+ X gan, ung th gan.

+ Mmang khng nguyn HBsAg c th ly truyn cho con. Nu b nhim

trong 10 tun u thai nghn thng gy ddng thai, sy thai. Nu bnhim tsau

tun th12, trc thbvim gan cp, bnh hay xy ra thng th3 sau , khng

c du hiu lm sng, i khi chc du hiu gan to.

- Tin lng

+ Cho m: chy mu khi sy thai hay , gy ri lon ng mu v tvong.

Nu vim gan ti cp sbri lon chc nng gan dn n hn m gan, lu di c

thdn 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 tmsang thai

Xt nghim khng th

ph n c thai 3 thng

cui

Nguy c ly truyn cho s

sinh khi hay sau

Hng xtr

HBsAg+/ HBeAg+

HBsAg+/ HBeAgHBsAg- /antiHBc+

HBsAg- / anti HBs+

90-100%

20%Cha bit, tlthp

Khng ly

Huyt thanh- vaccine

Huyt thanh- vaccineVaccine

vaccine

3. IU TR

- Cho n nay cha c iu trc hiu, chc iu trtriu chng v dphng,

thai phnghngi 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 trthuc dit virus.

- iu trri lon ng mu nu c

- Trnh chn thng vng gan

- Trnh phu thut, ththut nu khng c chnh cp cu. Trong v sau

iu trchy mu, chun bhi sc v truyn mu.


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4. PHNG BNH

- Gim bnh ly truyn qua ng tnh dc

- Pht hin sm thai phc vim gan qun l v t vn khi c thai, trong

khi , v sau . Khuyn khm li chuyn khoa gan mt sau 3 thng.

- Khng cho b m

- Tim globulin min dch vim gan B v vaccine cho trs 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 sdng.

+ Vaccin th h 2: ly gene t virus cy vo nm men bia s cho mt sn

phm mi ging virus (ti thp ADN), an ton cao v hiu quto min dch

tt, ang c sdng rng ri

+ nhng ni c dch thc vim gan B cao, ngi nhim virus vim gan B

cao th khuyn khch tim vaccin vim gan B cho tt ccc em b m mkhng

c chn on sng lc+ Vaccin phi hp vi HBIg c chnh cho tt c con ca b mmang

virus vim gan B


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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 tbo 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 htnh dc: quan hng gii v khc gii.

+ ng mu: truyn mu b nhim (95%), nghin ma ty dng cng bm

tim (0,67%), cn by tbkim chm (0,4%).

+ Tmsang con: ly truyn HIV tmsang con (LTMC) l sly truyn t

ngi mb nhim HIV sang trs sinh trong cc giai on mang thai (trong t

cung), qu trnh chuyn d, cho con b. Nu khng c iu trdphng, tllytruyn HIV tmsang con l khong 25-40%.

2. CHN ON

2.1. Cc giai on lm sng: 4 giai on

- Giai on s nhim: hi chng gibnh tng bch cu n nhn nhim trng

hoc gicm: 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 sht

trong vng 7-10 ngy

- Giai on suy gim min dch sm (slng 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 t5-20 nm hoc lu hn.

- Giai on suy gim min dch trung gian (200 < CD4 < 500 TB/ml): st ko

di trn 38oC, st cn di 10% trng lng c thm khng c l"do. Vim da,

nim mc ming, sn nga, vim nang lng, zona da.


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- iu trphng ly truyn mcon (LTMC): sdng ngn hn ARV gim ly

truyn HIV m-con. Nguyn tc: iu trARV cng sm cng tt..

- iu trbnh: sdng lu di ARV do sc khe ngi m(TCD4 350 t

bo /mm3 khng phthuc giai on lm sng; hoc giai on lm sng 3, 4, khng

phthuc TCD4) v cng c tc dng dphng LTMC.

Phc phng LTMC (By t, ban hnh ngy 2/11/2011):

M Khi mang thai

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

hng ngy ttun thai th14hoc 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.

- Sau 12 gimt ln AZT 300mg + 3TC

150mg cho n khi .

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

7 ngy

Con

M iu tr AZTtrc sinh trn 4

tun

NVP liu n 6mg ung mt ln ngay sausinh + AZT 4mg/kg ung ngy 2 ln

M iu tr AZT

trc sinh cha

4 tun

NVP liu n 6mg ung mt ln ngay sau

khi sinh + tip tc AZT 4mg /kg ung 2 ln

mt ngy trong 4 tun

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

Mc ch: gim ti a sphi nhim ca thai nhi vi HIV tcc dch c th

ca m, v cc yu tnguy c LTMC.

- Tun thnguyn tc v khun chung. St khun ng sinh dc trong qu

trnh bng dung dch Chlorua de Benzalkonium hay Chlorhexidin 0,2.

- Cn by tm bo cuc chuyn dv sinh con an ton, nhit tnh, chu o

khng kth, phn bit i x.


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- Hn chti a ththut gy tn thng da v nim mc cho mv con khi

chuyn d (khng bm i sm, Forceps, gic ht, t in cc vo u thai nhi,

khng ct TSM qu sm hn chchy mu).

- Mly thai: mly thai chng hoc trc khi vi c thlm gim nguy

c ly truyn mcon t50-80% khi phi hp vi ARV. Do nguy c ca phu thut,

khng khuyn co mly thai hthng cho sn phnhim HIV. BY Tquy nh

chmly thai khi c chnh sn khoa.

- Trm y tx khng c khnng iu trdphng ARV cho mv s sinh

khi chuyn dv sau do vy cn gii thiu sn phnhim HIV ti cc c ssn

khoa (ti thiu tuyn huyn) c cung cp dch vPLTMC.

3.3. Can thip sau sinh

- Chm sc sn khoa: theo di hu sn, co hi tcung, chy mu, nhim trng

- iu trdphng ly truyn HIV tip tc theo phc

- T vn v gii thiu chuyn tip n c schm sc v iu trHIV/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 trbng khn mm,

dthm nc, hn chlau v ktrn bmt da.

+ Hn ch ht dch ng mi - hu - hng, bng cc loi sonde mm, p

lc


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ST TRONG KHI C THAI

1. KHI NIM

Sn phst (nhit 38C) trong thi kthai nghn hoc trong chuyn d

v sau .

2. CC HNH THI LM SNG, CHN ON

2.1. St do cc bnh ni/ ngoi khoa trong thi gian c thai

2.1.1. Vim rut tha cp:

- Chn on:

+ St, au hchu phi m v tng dn

+ Nn, bun nn, b trung i tin.

+ Phn ng hchu phi, Mac burney (+).

+ Tcung c thai bnh thng

- X tr: phu thut ct rut tha qua ni soi hay mm, khng sinh, thuc

gim cn co tcung, githai.

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

thiu trtip n khi .

-Vim thnbthn 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 bthn gin, niu qun gin. Thai bnh thng.

+ iu tr: chng chong. iu trkhng 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


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2.1.3. Vim phi

- Du hiu chnh: st, kh thnhanh, au ngc, ho c m

+ Hng xung huyt, phi c ran n, ran m.

+ Chp phi c hnh mthy phi (ch "tm ch bo vthai nhi).

- Xtr: cng sm cng tt, chuyn ni khoa iu trkhng 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 mhi c chu k(hng

ngy hay cch ngy), nhc u, au khp, au c. C thlch to

+ St rt c tnh c bin chng nng: st rt km thm thiu mu, hn m, i

ra huyt sc t, c thco git, vng da.

- Xt nghim: phin mu ngoi vi tm k"sinh trng, test nhanh tm khng th.

- Xtr:

+ Chloroquin liu khi u 10mg/kg cn nng1 ln/ngy trong 2 ngy, sau

5mg/kg ngy th3.+ 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

thm sng, dn.

- Cy phn, cy mu lm khng sinh

- X tr: khm v iu tr ti khoa truyn nhim. Ampicillin 1gx 4 ln/ngy

hay Amoxycillin 1g x3 ln/ ngy trong 14 ngy.

2.1.6. Vim gan do virus.

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