no Y TE CONG HOA xA HOI CHU NGHiA VIET NAM. . .

s6:b~o /QD-BYT

DQcl~p - TV do - H~nh phuc

Hit N9i, ngityL6thimg ~ nom 2019

QUYETDlNHV~vi~c phe duy~t tai li~u

"HU'O'ngdftn Him sang xu tri u XO' co tic cung"

uo TRUONG no Y TE

Can cir Nghi dinh s6 75/2017IND-CP ngay 20/6/2017 cua Chinh phu Quydinh chirc nang, nhiem vu, quyen han va co cfLU t6 chirc cua BQY t~;

Can cir Quyet dinh s6 2013/QD-TTg ngay 14 thang 11 nam 2011 cua Thuwang Chinh phu v~ phe duyet Chi~n hroc Dan s6 Sue khoe sinh san Viet Nam giaidoan 2011-2020;

Theo d~ nghi cua Vu tnrong Vu Sire khoe Ba me - Tre em, BQY tS;

QUYETDlNH

Di~u 1. Phe duyet tai lieu "Huang dftn lam sang xu tri u xo co ill cung" kernthea Quyet dinh nay.

Di~u 2. Quyet dinh nay c6 hieu hrc k€ ill ngay ky, ban hanh.Di~u 3. Cac ong, ba: Chanh Van phong BQ,Vu tnrong Vu Sire khoe Ba me -

Tre em, Chanh thanh tra BQva cac V\l truang, C\lCtruang, T6ng C\lCtruang cua BQY tS; Giam d6c cac Vi~n, B~nh vi~n trvc thuQc BQY tS; Giam d6c cac HQc vi~n,Hi~u truang cac truemg D~i hQc c6 dao t~o nhan h.rcy t~; Thu truang Y t~ nganh;giam d6c Sa Y tS cac tinh, thanh ph6 trvc thuQcTrung uang va Thu truang cac danvi lien quan chiu trach nhi~rn thi hanh Quy~t dinh nay.!.

-Website BQY t~;

Nui nh{in:- Nhu Di€u3;- BQtru6ng (d~bao C{lO);

- Oic Thu truang (de bi~t);

- C6ng Thong tin di~n tu BQY t~- Luu: VT, BMTE.

BQYTE

HU'6'NG DAN LAM SANG?, ?xu TRI U XO' cO' TU' CUNG

(Ban hanii kern thea quyet djnh s6?tf1.~QD-BYT ngaiffhdng 8niim2019 cila B() tnrCrngB(}Yte]

Ha n(Ji,2009

BAN CHi £>1:\0GS.TS. BS.Nguy~n Viet Tien

GS.BS.Nguy~nThlNgQcPh~qng

GS.TS. BS.Cao Ngoc Thanh

GS.TS. BS.Tran Thl Phuong Mai

ThS. BS.Nguy~n DLrcVinh

BAN CHUYEN GIAGS.TS.BS.Tran Thl Lqi

PGS.TS.BS.Le Hong Cam

PGS.TS.BS.tuu Thl Hong

ThS. BS.Tong Tran Ha

ThS. BS.Nghiern Th] Xuan Hanh

PGS.TS. BS.Nguy~n vo Quoc Huy

TS.BS.Vuong Th] Ngoc Lan

ThS. BS.Ho Manh Tirong

PGS.TS.BS.Huynh Nguy~n Khanh Trang

BS.CKII.Nguy~n HCi'u01,1'

PGS.TS. BS.Iran Danh Cvong

PGS.TS.BS.Le Hoang

PGS.TS.BS.Ho Sy Hung

ThS. BS.LeQuang Thanh

TS.BS.Hoang Th] Di~m Tuyet

TS. BS.Tran Dlnh Vinh

TS. BS.Huynh Thl Thu Thuv

BS.CKII.Hoang Thl My YThS. BS.Nguy~n Th] Quy Khoa

PGS.TS. BS.Nguy~n Duy Anh

TS.BS.VOVan Tam

BS.CKII. Nguyen BaMy Nhi

BS.CKI.Au Nhut l.uan

ThS. BS.D~ng Quang Vinh

TS.BS.Tt;!Thl Thanh Thuy

TS. BS.BuiChiTh~O'ng

TS.BS.Tran Nh~t Thang

Ml)C Ll)C

Trang 1 Chuong I.Dai cuong

Trang 3 Chuorig II. Dich te h9Cva cac yeu to nguy CO'

Trang 5 Chuorig III. Phan loai u XO'CO' ttl' cung

Trang 7 Chuong IV. Trieu clnrng Himsang cua u XO'CO' ttl' cung

Trang 11 Chuong V.Chan doan u XO'CO' ttl' cung

Trang 15 Chuong VI. Bien chung u XO'CO' ttl' cung

Trang 18 Chuong VII. Tiep can va Xtl'tri cac truong h9'P u XO'CO' ttl' cung

kh6ng co chi dinh can thiep nQi ngoai khoa

Trang 20 Chuong VIII.Dieu tri nQikhoa u XO'CO' ttl' cung

Trang 27 Chuorig IX.Dieu tri ngoai khoa u XO'CO' ttl' cung

Trang 36 Chuong X.Cac thu thuat thay the ph§u thuat

Trang 39 Chuong XI.Chuan bi benh nhan truce ph§u thuat

Trang 42 Chuong XII. UXO'CO' ttl' cung va hiern muon

Trang 45 Chuong XIII. UXO'CO' ttl' cung trong thai kY

Trang 49 Chuong XIV.Nhirng dieu can ghi nho ve Xtl'tri u XO'CO' ttl' cung

Trang 54 Chuorig XV.Tom tat huorig d§n lam sang Xtl'tri u XO'CO' ttl' cung

Trang 60 Bieu do 1. Phac do Xtl'trf u XO'CO' ttl' cung

Trang 61 Bieu do 2. UXO'co ttl' cung da chan doan xac dinh, co sieu am

Trang 62 Bieu do 3. Phac do dieu tri nQi khoa u XO'CO' ttl' cung bang UPA

Trang 63 Bieu do 4. Phac do Xtl'tri u XO'CO' ttl' cung L2 hoac da nhan L2-Ls & phu nil' tudlsinh de

Trang 64 Tai lieu tham khao

CHU'O'NG I.D~I CU'O'NG

Uxo co til cung (leiomyoma - UXCTC),trurrc day thuorig dUQ'Cgoi thea u xotil cung, la khci u lanh tinh kh6ng r6 nguyen nhan do su' phat trien qua rmrccua soi co tron va m6 lien ket a til cung (Breech va cs, 2003). Benh co khuynhhuang di truyen,

UXCTCthuorrg kh6ng co trieu chirng (Sciarra va cs, 1986), duo'c phat hien tinhco qua kharn hay sieu am. Trong m<)tso truong hop u xo gay bien cluing nhucuo'ng kinh gay thieu mau, dau vung chau, trieu chirng chen ep ... UXCTCcobien chung gay anh huang den chat luong cuoc song va anh huang den khanang sinh san cua nguot phu nu. Do thuong kh6ng co trieu chimg nen kh6ngxac dinh duo c chinh xac tan suat UXCTCtrong dan so chung. Ty l~ moi maccua UXCTCtang thea tudi, khoang 20 - 50% neu phu nfr > 30 tudi (Payson vacs, 2006) uoc tinh tY l~mot mac a phu nfr 50 tudi la 70 % (Cao va cs, 2017;Khan va cs, 2014).

Chan doan UXCTCdva vao hoi tien can, kham lam sang va chan doan hinh anh.Can chan doan phan bi~t vai sarcoma til cung. Trong tong so cac truang hQ'pduQ'c cat til cung vi nhieu ly do, tY l~ sarcoma ca tran than til cung khoang0,26% bang vai tan suat 0,27% khi dan so duQ'ckhao sat la ph\! nfr co khoi uvung ch~u phat trien nhanh. Nhu v~y m<)tUXCTCda duQ'cphM hi~n tulau d<)tng<)tIan nhanh a nguai ph\! nfr tuoi man kinh hay mai xuat hi~n khi da mankinh la m<)tdau hi~u nghi nga ac tfnh cao (Vilos va cs, 2015).

UXCTCkh6ng co tri~u chung kh6ng can can thi~p. Kh6ng nen dieu tr! dVphong de tranh bien chung trong tuang lai vi kh6ng co yeu to tien lUQ'ngdangtin c~yve sv tien trien clla UXCTC.Trong m<)tso truang hQ'pco the dieu trt dVphong ngan say thai a UXCTCduai niem (neu nguai nay dv d!nh mang thai)va u xa nam trong day chang r<)nggay tac nghen duang tiet ni~u dua den th~nu nuac.

UXCTCco tri~u chung (ra huyet am d~o bat thuang, dau, chen ep) can duQ'cdieu tr!. Phuang thuc va thai gian dieu tr! dVa tren m<)tso yeu to anh huangnhu: phan lo~i UXCTC,muc d<)tri~u chung, kich thuac, V!td, soluQ'ng khoi uxa, tuoi nguai b~nh, ke ho~ch sinh sim va tiEmcan sim khoa, tinh trC;lngb~nhn<)ikhoa kern theo, nguy ca thoai hoa ac tinh, tinh tr~ng sap man kinh va mongmuon bao ton t& cung Cllangm'yiph\! nfr. Trong nhfrng nam qua UXCTCla m<)t

1

trong cac chi dinh thucrig g~p nhat cho d.t tu cung tren toan cau, Tuy nhien,d.t tu cung gay nhieu bien chirng cling nhir tang ganh nang kinh te cho nguo'ibenh (Philippines Society for Reproductive Medicine, 2017).

Cac thu the cua estrogen (ER) va cua progesterone (PR) duoc tim thay nhieutren cac soi co cua UXCTChon la tren cac soi co binh thuorig cua tu cung.Nhu vay d. hai hormones steroids, estrogen va progesterone deu co anhhuang len su phat trien cua UXCTC.Neu bi d.t nguon steroids, hau het cac uXO'se co chieu huang thoai trien, Progesterone dong vai tro quan trong trongsu' phat trien cua UXCTC(Carranza va cs, 2015). Dua tren d~c tinh do, dieu trin(>ikhoa bang each dieu hoa cac thu the cua hormones steroids dong vai troquan trong trong dieu tri UXCTC.Xuat phat tir nhimg phuong phap dieu trimoi ra doi da duQ'cnghien cuu va co nhfrng chung cu y h9Cmuc d(>cao, huangd§.nlam sang danh rieng cho xu trf u XO'cO'tu cung duQ'c ra dai. N(>idung cuahuang d§.nse bao gam thea d6i khong dieu trL dieu trt n(>ikhoa, dieu trt ngoC;likhoa, d~c bi~t vai u XO'duai niem mC;lc,u XO'anh huang den kha nang sinh sanva thai kyo

Ml,lCtieu cua huang d§.nthl,l'chanh lam sang xu trf UXCTCla dua ra cac khuyennght trong chan doan va dieu trt cho b~nh nhan UXCTCtC;liVi~t Nam dl,l'atrencac bang chung y khoa va kinh nghi~m lam sang hi~n co, nham dua den cachxu trf thong nhat trong nganh san phl,lkhoa Vi~t Nam.

2

CHU'O'NG II.DICH TE HQC vA cAc YEU TO NGUY CO'

UXCTC la khdi u lanh tinh cua ti'r cung phf bien nhat & phu nu. Da so cactnrong hop UXCTC kh6ng co bieu hien Him sang (Pavone va cs, 2018), uoctinh chi co khoang 25% UXCTC co bieu hien lam sang & phu nCrtrong dQ tudisinh san va khoang 25% trong so do co trieu chirng nang can dieu tri (Stewartva cs, 2017).

Tl l~ moi mac UXCTC la 217 - 3.745/100.000 m6i nam va tl l~ hien mac 4,5-68,6% (Stewart va cs, 2017). Cac ti l~ nay dao dong rat nhieu, phu thuoc vanphuong phap nghien ciru va dan so nghien cuu (da so cac nghien cuu duoctien hanh & doi tuorig phu nCrco bieu hien trieu chung hoac sau phau thuat)(Stewart va cs, 2017).

Co nhieu yeu to nguy co- lam gia tang ti l~ phat sinh UXCTCbao gam (Stewartva cs, 2017, Pavone va cs, 2018):

Tuoi. Tan suat xuat hi~n UXCTC tang thea tuoi (Pavone va cs, 2018). Phl;l nCrtren 40 tuoi co nguy cO'bj UXCTC cao han 4 Ian phl;l nCrdU'ai 40 tuoi (OR 4,1;KTC 95%, 3,3 - 5,0) (Selo-Ojeme va cs, 2008). Phl;l nCr& nhom tuoi 41 - 50(RR, 10,4, KTC 95%, 3,8 - 30,2), nhom tuoi tu 51- 60 (RR 10,6, KTC 95%, 3,9- 31,S) co nguy cO'phat hi~n UXCTCcao han 10 l~mnhom tuoi 21- 30 (Lurieva cs, 2005). Ngoai ra, khi tuoi cua ngmYi phl;l nCr gia tang thi UXCTC clingthmyng co kfch thU'ac Ian han, so IU'qng u xO'cling nhieu han va ti l~ phai nh~pvi~n vi UXCTC cling cao han. Dieu nay phan anh dien tien tv nhien thea thaigian cua UXCTC (DeWaay va cs, 2002). Tuy nhien, ti l~ mac b~nh se giam &nhom phl;l nCrtuoi man kinh.

Chung tQc. Ti l~ mai mac UXCTCkh6ng khac bi~t giCrangU'(Yida trang, chau A.va My Latin. Tuy nhien, ngU'ai da den co nguy Co' phat trien UXCTC cao han 2den 3 Ian. Ngoai ra, nguy Co' suot dai doi vai UXCTC la gan 70% & ngU'aj datrang, va tren 80% & ngU'ai da den. Phl;l nCrda den thU'ang dU'qc chan doanUXCTC& dQ tuoi tre han, u xO' thU'ang nhieu va Ian han, dang thai cling gayra cac tri~u chung nghiem tn.mg han & cac nhom chung tQc khac. NhCrng khacbi~t nay phan nao gqi y Sl,l' khac nhau ve sinh tong hqp estrogen, chuyen hoava di truyen (Stewart va CS, 2017, Pavone va cs, 2018).

3

TiEm si'Y gia dinh. M9t nghien ciru & Thai Lan cho thay, tien sU:gia dinh b]UXCTClam tang nguy co cho ngtro: phu nil hon 3 Ian (OR3,47; KTC95%, 2,55- 4,71) (Lumbiganon va cs, 1996).

Cac yeu to di truyen, M9t so gene [nhir MED12,HMGA2,CYP1A1,va CYP1B1)(Styer va cs, 2016) va cac bat thuong nhiem s~c the (trisomy 12; dao doan12q, 6p, 10q, 13q; va mat dean 7q, 3q, 1p) (Mehine va cs, 2013) duoc tim thayco lien quan den S11hinh thanh va phat trien cua UXCTC.

Khoang each so v&i Ian sinh con truc-e day. M9t so nghien ClJ:'U cho thaykhoang each tir 5 narn tro len lam tang nguy co phat trien UXCTClen 2-3 Ian(Wise va cs, 2004, Terry va cs, 2010).

Giai doan tien man kinh co nguy co bi UXCTCcao hon den 10 Ian giai doanman kinh (Chiaffarino va cs, 1999). Dong thai, ti l~ UXCTCco trieu chtmg cungcao hon 3 Ian (Templeman va cs, 2009).

Roi loan chuyen hoa: Beo phi, khang insulin, hoi chirng buong tnrng da nang,tang lipid mau, tang huyet ap ... la nhung yeu to gay ra h9i clnrng chuyen hoava deu gop phan lam gia tang nguy co phat trien UXCTC(Stewart va cs, 2017,Pavone va cs, 2018). Rieng phl,lnil co b~nh ly tang huyet ap co the lam gia tanggan 5 Ian (OR 4,90; KTC95%,2,31- 10,38) nguy cO'phat trien UXCTCso veriphl,lnil kh6ng tang huyet ap (Takeda va cs, 2008).

Loi song va ehe dQ an uong cung co the lien quan den nguy cO'gia tangUXCTC,tuy nhien rat kho nghien ClJ:'U va danh gia vi co nhieu yeu to nhi~u. ithOC;ltd9ng the chat va nhieu stress lam gia tang nguy cO'b! UXCTC.Cac lo?ith11cpham chua nhieu acid beDnguon goc d9ng v~t, sU:dl,lngnhieu th!t bo, th!tdo, thieu vitamin D, tieu thl,l nhieu thuc uong co con, caffeine co nguy cO'lamgia tang ti l~ UXCTC(Stewart va cs, 2017, Pavone va cs, 2018).

Cae eholt ph1,;lgia su: dl,lng trong che bien va bao quan th11cpham lam tangnguy cO'phM trien UXCTCden 3 Ian (OR3,17; KTC95%, 2,25 - 4,46) (Shen vacs,2013).

Ben qnh do, cung co rat nhieu yeu to du<;yccoi la yeu to bao v~ nhu mang thaiva sinh con nhieu Ian, hOC;ltd9ng the chat thuCrng xuyen, an nhieu ea va rauxanh, trai cay, vitamin A co nguon goc d9ng v~t (Stewart va cs, 2017, Pavoneva cs, 2018).

4

CHUaNG III.A ?

PHAN LO~I U XO' Co' TU CUNG

UXCTCduoc phan IOC;lithea hai each, thea tinh chat va thea vi tri khoi u.

Theo tinh chat, u XO' co 2 dang: khong trieu clumg va co trieu chung, Hau hetUXCTCthuoc dang khong trieu chung, thuong khong can dieu trio UXCTCcotrieu clurng can duoc dieu tr] va thea d6i (Murase va cs, 1999; Vilos va cs,2015).

Theo vi trf, hi~n nay, h~ thong phan IOC;liUXCTCcua Hiep hQi San Phu khoaQudc te FIGO nam 2011 duoc su dung phd bien nhat (Munro va cs, 2011).Phan IOC;liduoc mo ta chi tiet thea hinh ben durri,

CacUXCTCLO,L1, L2 thuong gay trieu chtmg xuat huyet tu cung bat thuorig,co the la nguyen nhan cua vo sinh va say thai. Nhorn nay can duoc dieu tribang phuong phap nQi soi huang tu cung (Lefebvre va cs, 2003).

UXCTCL3 cling co the gay trieu chirng xuat huyet tu cung bat thuong hoackhong, {)jeu tr] nhorn nay thuong U'Utien dung thudc de lam giarn klch thU'ackhoi u truac khi mang thai (Lefebvre va cs, 2003).

CacUXCTCL4-8 thU'ang khong gay xuat huyet ti'r cung bat thuang. UXO' nh6mnay can dieu tri khi kfch thuac to ho~c u chen ep gay th~n unuac ho~c bi tieuho~c tao bon. Co the can nhac dieu tri nQi khoa ho~c phau thu~t bac u doi vaiph\}nfr con nguy~n v9ng mang thai.

5

Bang 1. Philo loai UXCTC theo FIGO, 2011.

UXCTC o Co cuong, trong buong tlr cung

> 50% trong buong nr cung

2

O-Khlic 3

4

5

6

7

8

::::50% trong buong tlr cung

Duoi niem nhung 100% trong co nr cung

Hoan toan n~m trong co tlr cung

Duoi thanh mac, 2: 50% trong co nr cung

Duoi thanh mac, < 50% trong co nr cung

Duoi thanh mac, co cuong

Vi tri khac (cb nr cung, cac co quan quanh illcung)

Neu u xo n~m tron trong co va 16ira duoi niem va duoithanh mac, co the co 2 sBchi vi tri khBi u, 2-5, each nhauh~ng 1 gach nBi. Theo quy tree, sBdAuchi khBiu gAnniern mac, s6 sau chi khBiu gAnthanh mac.

UXCTC(L2-5)

Duoi niem va diroi thanh mac « 50% n~mtrong long nr cung va < 50% 16ira duoithanh mac, huang vao (, bung),

6

CHUO'NG IV.TrutU CHfrNGLAM SANG CDAUXO' CO'TfrCUNG.

UXCTCthuong nho va khong co trieu chung nen thuorig duoc phat hien tlnhco thong qua tham kharn, sieu am phu khoa. Tuy nhien, nhieu phu nfr coUXCTCcling g~p nhieu van de lam anh huang CU9Csong nhu xuat huyet tilcung bat thuong, dau bung hay vo sinh. Nhirng trieu chirng cua UXCTCthuonglien quan den so luong, kich thuoc va vi tri cua khfii UXCTC.

TRItU CHUNG CO' NANG

Nhimg trieu chung cua UXCTCgorn rong kinh, cuong kinh, bung to, cam giactran nang vung ha vi, dau, tieu kho, tao bon (Stewart va cs. 2015).

Trong so cac trieu chirng bat thuong do UXCTCgay ra thi xuat huyet til cungbat thuong la trieu chimg phd bien nhat, chiem 26 - 29%, cac trieu chungkhac chiern tY l~ it han.

Ra kinh nhieu hoac keo dai la trieu cluing xuat huyet til cung bat thuongdien hinh nhat trong UXCTCva la trieu chung thuang g~p nhat do UXCTCgayra (Fraser va cs, 2007). Tinh trC;lngcua xuat huyet til cung bat thuang phI.).thu9C nhieu nhat van v! tri khoi u, sau do la den kfch thu&c khoi u:

UXCTCdu&i nH~mmC;lcnho van trong long til cung, du nh6 (nhu LO,Ll, L2thea phan IOC;liFIGO2011), thuang lien quan v&itinh trC;lngchay mau kinhnhieu. (Buttram va cs, 1981; Wamsteker va cs, 1993; Wegienka va cs,2003; Munro va cs, 2011)

UXCTCtrong Co'til cung cling co the gay ra tinh trC;lngchay mau kinh nhieuho~c keo dai nhung UXCTCdu&i thanh mC;lCthuang khong duqc xem languyen nhan chinh gay ra tinh trC;lngnay.

UXCTCa co til cung neu nam gan kenh co til cung cling co the gay ra tinhtrC;lngxuat huyet til cung bat thuang. UXCTCa co til cung thmyng gay giaohqp dau.

Tri~u chung do chen ep thay doi nhieu, phI.).thu9C van kich thu&c, hinh dC;lngva v! tri cac khoi UXCTC.Nhfrng tri~u chung nay bao gom cam giac kho ch!uhay dau vung ch~u, th~n u nu&c neu chen ep ni~u qulm, bi tieu ho~c di tieukho neu chen ep bang quang hay co bang quang, tao bon neu chEmep trt).'ctrang, chen ep tlnh mC;lch.

7

Cam giac kho chiu, dau vung chau - Trieu chung tran nang, dau vung chauam ithuorig g~p ITphu nO:bi UXCTCto. Tuy nhien, trieu chirng nay it xuathien han xuat huyet til cung bat thuong,

Dau bung kinh duoc ghi nhan ITnhieu phu nO: co UXCTC.Thuong tinhtrang dau bung kinh nay thuong xuat hien kern hien tuong chay mau kinhnhieu, co mau dong.

Dau khi giao hop hien con la mot trieu chung chua r5 co mdi lien quan voiUXCTChay khong. Tuy nhien, nhirng tnrong hop co UXCTCnam ITthanhtnroc, ITco til cung, hoac ITvung day co the co cam giac dau sau khi giaohop. (Ferrero va cs, 2006)

Trieu chimg dau lung cling co the xuat hien trong UXCTC,can loai trir cacnhorn benh ly khac co the gay ra trieu chung nay.

Trong mot nghien cuu doan h~ nho cho thay trong 14% truong hop phunO:co UXCTCxuat hien tinh trang than lr nurrc, thuong ITben phai, co thedo UXCTCnam trong day chang r(lng, chen ep phai ni~u quan phai. KichthU'ac UXCTCIan nhat trung binh khoang 6 cm va kich thU'ac ca til cungkhoang thai 18 tuan thU'ang co s\!' lien quan vai tinh tr~ng th~n lr nuac(Fletcher va cs, 2013).

Chen ep tinh m(:lch- UXCTCrat Ian co the chen ep tinh m~ch chu va lamtang nguy cO'tile m~ch do huyet khoi. Nghien ClrUda chlrng minh nguy cO'thuyen tac tinh m(:lchdo huyet khoi do UXCTCto cao han nguy cO'sau phauthu~t (Fletcher va cs, 2009).

UXCTCthoai hoa ho~c xoan (thuang la UXCTCL7) cling co the gay ra tri~uchung dau bl:lngcap tinh. Bau bl:lngvung ch~u do UXCTCthoai hoa thU'angco the xuat hi~n kern tri~u chung sot nh~, til cung dau khi sa ch(:lm,tangb~ch cau, ho~c dau cam lrng phuc m(:lc.B~c bi~t, UXCTCtrong thai kythuang to nhanh, m~ch mau nuoi tang trU'ITngthea khong kip dua denho~i til vo trung, dau rat nhieu va keo dai. Tinh tr~ng dau bl:lngdo UXCTCthoai hoa thU'ang giai h'iln trong vai ngay den vai tuan va dap t'rng vaithuoc giam dau NSAIDS.

Chan doan UXCTCthoai hoa thU'ang d\!,a thea s\!' ton t~i cua UXCTCcungcac tri~u chung dien hinh. Khi sieu am, tri~u chung dau khi quet dau dotr\!,c tiep vung UXCTCla tri~u chung giup dinh hU'ang chan doan. Trongtrm'mg hqp khong r5 chan doan, chl:lPMRIvung ch~u co the duqc sil dl:lngvai gadolinium giup vi~c chan doan co the r5 han thong qua dau hi¢u vungUXCTCthoai hoa khong tang d(l tuO'ng phan khi sil dl:lng gadolinium

8

(Laughlin va cs, 2011). Trong tnrorig hop dau bung cap tinh nghi ngo doUXCTC thoai hoa va co chi dinh phau thuat thi can 10C;litnr can than cacbenh ly khac co the gay tinh trang dau vung chau cap nhu lac nQi mac tucung, can dau quan than, hay cac benh ly it g~p nhu lao vung chau, (Mollicava cs, 1996; Moore va cs, 2008)

TRI~U CHUNG THl}'C THE: KHAM TONG QUAT vA KHAM PHl} KHOA

Sot: hiem g~p, thuorig chi g~p trong truong hop UXCTC thoai hoa,

Thien mau: xuat hien khi tinh trang xuat huyet tu cung nang va/hoac keo dai,co the gay anh huang sinh hieu (mach nhanh, huyet ap tuot) nhung hiem,thuong g~p han la tinh trang da xanh, niem nhot, Co the su dung xet nghierntong phan tlch mau toan bQ de danh gia chinh xac han mire dQ thieu mau,

Kham rna vit: co the thdy khoi UXCTCtal co ngoai co tu cung hoac thay UXCTCduai niem nam nho ra ngoai co tu cung, thuang duqc chan doan phan bi~t vaipolyp nQi mC;lctu cung bang dQ chac clla khoi u va giai phau b~nh I:Y.

Kham: nen kham kY de danh gia kich thuac, V! tri, dQ di dQng clla khoi UXCTC,khi kham nen ket hqp kham tay trong am dC;lOva tay ngoai thanh bt).ng.

Kich thuac clla tu cung co UXCTCkhi tham kham thuang duqc uac tinhtuO'ng duO'ng vai kich thuac mQt tu cung khi mang thai song.

MQt tu cung to, di dQng vai duang vi{~nkhong deu, cam giac nhieu khoinh6 Ion nhon tren be m~t la mQt tu cung da nhan xO'.

Tu cung to nhung it di dQng ho~c khong di dQng, chung ta nen nghi tai tinhtrC;lngviem nhiem ho~c ket hqp vai lC;lCnQi mC;lctu cung.

TRI~U CHUNG cAc BIEN CHUNG

Vo sinh la tinh trC;lngco the g~p phai thuang lien quan vai khoi UXCTC lambien dC;lnglong tu cung nhu UXCTC duai niem mC;lcho~c UXCTC trong Co' tucung co 1phan nho vao buang tu cung. Nhfrng cau truc nay du nh6, cling c6the la nguyen nhan lam can tra qua trinh tht). thai cling nhu tang nguy Co'saythai, say thai lien tiep (Pritts va cs, 2009). (Xin xem phan "UXCTC va hiemmUQn")

Bien chll'ng san khoa: UXCTCcling da duqc chung minh la lam tang cac bienchung san khoa nhu nhau bong non, thai ch~m tang truCrng trong tlr cung,ngoi thai bat thuang va sinh non (Qidwai va cs, 2006). (Xin xem phan "UXCTCtrong thai k)r")

9

Thoai hoa ac tinh: rat hiern g~p. Nen nghi t&i tlnh trang UXCTCthoai hoa actinh khi khdi u to nhanh, nhat la tren phu nfr tudi man kinh. Sieu am co thethdy tlnh trang xuat huyet hoac hoai tir. (Xin xem phan "Bien chirng cuaUXCTC")

10

CHU'O'NG V.CHAN DoAN U XO' CO' rtr CUNG

CHANDoAN tic DJNH

Chan doan dua tren trleu chung HImsang

Hau het tnrorig hop UXCTCdeu kh6ng bieu hien trieu chung va duoc chandean tinh cO-khi kharn phu khoa va sieu am vung chau (Divakar, 2008). Tuynhien cfing co nhtmg truong hop UXCTCgay trieu chung ram r9 tren lam sangnhu xudt huyet tu cung bat thuorig, dau vung chau, thieu mau ... (Stewart vacs.2015).

Chan doan UXCTCtren kharn lam sang dua tren cac dau hieu thu ong gap baogam (Corazon va cs, 2017): (1) tu cung to, phat tridn cham (2) xuat huyet tucung bat thuong (roi loan kinh nguyet, ra kinh nhleu hoac keo dai), (3) dau,ding tire vung chau do thoai hoa hay do chen ep cac co quan xung quanh gaydi tieu kho, bi tieu, tao bon, than u nurrc, (4) say thai lien tiep,

Chan doan dua tren hinh anh

SH~uam nga am dao: la ky thu~t hinh anh dau tay trong chan doan UXCTC.f)~c diem cua UXCTCdien hinh tren sieu am bao gam: khoi u gi&ihCilnr5, hinhcau, co the co dau calcium hoa, phan bo mCilchmau vien quanh ton thuO'ng trensieu am doppler (Levy va cs, 2013).

Hinh 1. UXCTC qua sieu am ngil am d~lO. Ngu6n: B~nh vi~nMy Dtrc.

SH~uam nga b\lng: giup danh gia tong quat vung ch~u, dem soluQ'ng khoiu, quan sat cac khoi u l&n.Ngoai ra, sieu am nga b\mg con co the giup danhgia bien chung chen ep ni~u quan, bang quang, trl!C trang.

11

Sieu am doppler: danh gia phan bo mach mau trong UXCTC,chan doanphan biet dang phan bo xuyen ton thuong trong benh tuyen-co tu cung(adenomyosis). Ngoai ra, sieu am doppler danh gia chi so d~p (PI) va chiso khang tro' (RI) dQng mach cling giup ich trong chan doan phan bi~tUXCTCva benh tuyen-co tu cung.

Sieu am born nu-oc buong til' cung: thuong chi dinh trong chan doanUXCTCduot niern mac (L 0-2 thea phan loai cua FIGO).

Trong tnrong hop UXCTCkh6ng dien hinh, kh6ng the chan doan xac dinhhoac can chan doan phan biet vot benh tuyen-co tu cung co the su dungcong huong tir (MRI). Phan Ian nhtrng tnrong hop kh6ng the phan bietUXCTCva benh tuyen-co tu cung tren sieu am la dang ket hop ca hai benhly (Podasca va cs, 2016). MRI con co uu diem la giup danh gia tong quatcac co quan vung ch~u, phat hi~n b~nh ly di kern ho~c bien chlfng.

CHAN DoAN PHAN BI~T

Can chan doan UXCTCva cac b~nh ly sau:

Tu cung to do co thai.

Polyp nQim'i\ctu cung (trU'ang hQ'pUXCTCdU'ai niem m'i\c).

Khoi u buang trlfng (trU'ang hQ'pUXCTCdU'ai thanh m'i\cco cuong).

Leiomyosarcoma: sarcoma tu cung dU'Q'cchan doan xac dinh dl;l'atren ketqua giai ph~u b~nh. Chan doan lam sang sarcoma tu cung th~t Sl;l'la mQtthach thlfc, bai Sl;l'bi~t hoa da d'i\ngclla sarcoma, dau hi~u lam sang ngheonan, kh6ng d~c hi~u. Can d~c bi~t IU'uy trU'ang hQ'pUXCTCdQt ngQt tangnhanh kich thU'ac ho~c mai xuat hi~n tren phl.!nfr tuoi man kinh. D~cdiemclla sarcoma tu cung tren sieu am thU'ang la khoi d~c vai phan am kh6ngdang nhat; kern tang sinh m'i\chmau mlfc dQtrung binh tra len (Ludovisiva cs, 2019).

12

ve chan dean hinh anh, can chan doan phan biet UXCTCva benh tuyen-co tucung:

A B C D

Hinh 2. Chin doan phan bift UXCTC va bfnh tuyen-co tir cung (adenomyosis) tren sieuam. Nguon: B~nh vien My Dll'c

A: phan b6 mach mau quanh UXCTC tren sieu am doppler

B: UXCTC tren sieu am thang xarn nga am dao

C: benh tuyen-co illcung (adenomyosis) tren sieu am thang xam riga am dao

D: phan b6 mach dam xuyen qua t6n thirong (mach hroi) benh tuyen-co illcung (adenomyosis)tren sieu am doppler

D~c di~m UXCTC di~n hinh B~nh tuyen-co tir cung(Adenomyosis)

Duong bo thanh mac tU cung Phan thuy hoac bo d~u Ttr cung hinh du, tang kichtlnroc

Gioi han t6n thuong Gioi han ro Gioi han kh6ng ra

Su d6ng nh~t cua thanh nr cling Thanh nr cling kh6ng d6ngnh~t trong vung t6n thuO'nggi&i lwn ra

Thanh truce - sau co nr clingkh6ng d6ng nh~t

Duang ba t6n thuO'ng Gi&ilwn ra, tran hing Ba kh6ng ra, kh6ng d6ng nh§t

Hlnh d\lng Tron, oval, phan thuy Kh6ng co hlnh d\lng nhilt dinh

Vi~n t6n thuang Phan am kern ho?c day Kh6ng co vi~n t6n thuO'ng

Bong (lung) Bong lung a ba ho?c bentrong t6n thuO'ng(thuang cohlnh re qU\lt)

Kh6ng co bong lung a ba t6ntlmang, bong lung hlnh re qU\lt

DQ h6i am D6ng nh~t: co th@d6ng am,giam am ho?c tang amKh6ng d6ng nhilt: phan amh6n hgp

Kh6ng d6ng nhk phan amh6n hgpNhi~u nang, nhi€u Vllngtangam, nhi€lI dm'mg phan am SQC

du&iNMTC

13

n,c di~m B~nh tuy~n-cO' tfr cung(Adenomyosis)

UXCTC di~n hinh

Phan b6 mach mau Quanh tbn thirong M\lch dam xuyen qua tbnthuong (mach lucri)

Vung n6i

Day vung n6i, tinh d6ng nhAt

Vung n6i gian doan

Khong day, d~u hoac khongquan sat thAyMAtlien tuc hoac gian 6 vungc6 UXCTC LJ-3 thea FIGO

Day vung n6i, khong d~u hoacgioi han khong roVung n6i mAtlien tuc (ngay cakhi khong quan sat thAytbnthuong khu tru)

Ngufm: Van Den Bosch va cs, 2019.

14

CHIrO'N G VI.A" ?

BIEN CHIrNG U XO' CO' TIr CUNG

Hau het phu nil' co UXCTCnho khong co trieu clumg. UXCTCto, gay chen ep,gay xuat huyet tu cung bat thuong lam cho phu nil' 10lang va den kham phukhoa.

XUAT HUYET Tir CUNG BAT THU'O'NG

Xuat huyet tLl'cung bat thuong la bien chirng thuong g~p nhat, do UXCTCnamtrong buong tu cung hay nho ra lam bien dang buong tu cung (LO,L1, L2).Xuat huyet tu cung bat thuong la cuong kinh (30%, Lumsden MAva cs, 1998),rong kinh va xuat huyet giil'a chu ky kinh. CO'che xuat huyet tu cung batthuong do UXCTCvan chua duoc hieu r6, giai thich duoc chap nhan nhieunhat la tang dien tich be mat niern mac, bat thuorig mach mau tu cung ket hopvot SlJ'thay doi h~ thong cam mau tal nQimac tu cung (Miura va cs, 2006).

Mire dQxuat huyet phu thuoc VaGV!tri han la kich thurrc khdi u. UXCTCduoiniern mac (LO,L1, L2) du nho nhung van co the gay cuong kinh.

UXCTCduot niem mC;lcco the giai quyet bang phau thu~t nQisoi buang tu cung(LO, L1, L2) hay dieu tr! nQi khoa (L2, L3) bang thuoc dieu haa th\). theprogesterone co ch9n 19C;thuoc ngua thai; GnRH dang v~n; LNG-IUS(vangMirena) sau khi da cat bo UXCTCLOva L1; tranexamic acid.

CHEN EP

UXCTCco the to len va chen ep cac cO'quan Ian c~n trong vung ch~u. Chen epni~u quan gay th~n u nuac, chen ep bang quang gay roi lo~mdi tieu ho~c chenep trlJ'Ctrang gay nen tao bon. Cac tri~u chung lien quan den tieu ti~n nendll'Q'ctham kham va 10C;litru cac nguyen nhan khac truac khi ket lu~n cac tri~uchung nay lien quan den UXCTC.(Lumsden va cs, 1998). MQtso it trm'mg hQ'pkhoi UXCTCto chen ep tinh mC;lchvung ch~u, dan den SlJ'(r mau tC;livung ch~uva dan den thuyen tac mC;lch.UXCTCg~p (y dQtuoi tien man kinh co nguy cO'lien quan den thuyen ta,chuyet khoi tlnh mC;lchsau va thuyen tac phoi (Tanakava cs, 2002).

15

DAU

Dau do UXCTCft g~p va thuong lien quan den thoai hoa, Da cling co the doUXCTC co cudng xoan va co the ket hop voi benh tuyen-co tu cung(adenomyosis) va/hoac 19-cnQimac tu cung. Dau do UXCTCkhong dap imgvot dieu tri nQikhoa cling la mot trong nhtrng chi dinh cua dmu tri ngoai khoa(Carranza va cs, 2015)

THOAIHOA

Thoai hoa la bien chirng cling thuorig g~p cua UXCTC.Thoai hoa duoc phanchia thanh nhieu dang khac nhau nhu thoai hoa kinh, thoai hoa nang, hoai sinhvo khuan hoac hoa voi.

Thoai hoa kinh la loai thoai hoa thuorig g~p nhat, chiem 60%.

Thoai hoa nang g~p khoang 4% va thuorig xay ra sau khi co thoai hoa kinh.

H09-isinh vo khuan thuong g~p trong khi mang thai, khoang 8% UXCTCtrong thai ky, khoang 3% cho cac UXCTCnoi chung (Kawakami va cs,1994).

Thoai hoa ac tfnh (sarcomatous degeneration) hiem xay ra, tY l~ khoang 0,2%cho tat d cac lO9-iUXCTC.Can d~c bi~t chu y den cac khai UXCTCphM triennhanh ho~c nhfrng khai u m&i xuat hi~n khi da man kinh. Tri~u chung cuathoai hoa ac tfnh co the la dau va xuat huyet tu cung bat thuang (Yanai H vacs, 2010). Khi ph~u thu~t boc nhan XO'ho~c cat tu cung, neu khai u to, m~t catmau vang ho~c nau, mem, co dam xuat huyet hay h09-itu thi nghi nga thoaihoa ac tfnh. Chan doan duqc xac dinh bang giai phau b~nh lY.

HIEMMUQN

Anh huang cua UXCTClen kha nang sinh san luon la van de duqc quan tamnhung chua duqc hieu biet r6 rang. UXCTCdO'nthuan khong phai la nguyennhan tuy~t dai gay hiem mUQn,nhmu b~nh nhan co UXCTCvan co thai rnakhong can can thi~p. UXCTCdu&i niem lam giam kha nang co thai, tang nguycO'say thai, UXCTCdu&i niem (LO, L1, L2) phai duqc xu trf bang phau thu~tn9i soi buang tu cung. Trong khi do, UXCTCtrong cO'co the khong co anhhuang r6 rang, tuy nhien neu gay bien d9-nglong tu cung thi co the anh huangden kha nang thl,l thai cling nhu tang nguy cO'say thai, say thai lien tiep(Carranza va cs, 2015) (Xin xem phan UXCTCva hiem mu9n).

16

cAc BIEN CHtrNG LIEN QUAN THAI KYTan suat phat hien UXCTCtrong thai ky phu thuoc vao cac nghien ciru sieu am,chung tQcva dQtuai (Laughlin va cs, 2009).

Hau het cac nghien ctru sieu am cho thay UXCTCco the to len, nho di hoac giil'kfch thuo'c nhir trurrc khi co thai (Laughlin va cs, 2010; DeVivo va cs, 2011).

MQtvai nghien ctru hoi cuu cho thay anh huang cua UXCTCva ket cue thai kyoPhan tich gQPvao narn 2008 cho thay co tang nguy co ng6i bat thuong, rna laythai va sinh non (Klatsky va cs, 2008). Vao narn 2010, mot nghien ciru bao gom72.000 phu nil' cho thfy tang nguy co nhau tien dao, nhau bong non, va oi sam,sinh non < 34 tuan va thai luu, Tuy nhien khac bi~t nay < 2% va kh6ng co ynghia thong ke. Dieu nay cho thay UXCTC(d~c biet cac khdi UXCTCIan) vathai ky nen duoc thea d6i chat che de co ket cue san va nhi khoa tot (Stout vacs, 2010) (Xin xem phan UXCTCva thai kY).

17

CHU'O'NG VII.,..., " " ? ,.

TIEP CAN VA XU' TRI."" '>CACTRU'O'NGHqPUXO'CO'TU'CUNG

, '>

CHU'A CO CHI DINHCAN THI~P N(n - NGO~I KHOA

UXCTCla loai khdi u vung chau thuong g~p nhat a phu nil trong d9 tudi sinhsan. Hien nay, dong thuan cua cac Hiep h9i San Phu khoa the gioi (Divakar,2008; Lefebvre va cs, 2003; Myers va cs, 2002; Perez-Lopez va cs, 2014) choding cac tnrorig hop UXCTCkh6ng co trieu chung va nguct benh kh6ng nhucau mang thai thi kh6ng can dieu trioDo do, chi dinh dieu tri n9i khoa va ngoaikhoa chi d~t ra khi UXCTCco bien chimg gay nen nhtrng trieu chirng lam anhhuang den chat hrorig cuoc song va kha nang sinh san cua phu nil.

Tuy kh6ng can phai dieu tri, cac truong hop UXCTCkhong co chi dinh canthiep n9i khoa hay ngoai khoa v§.ncan duoc tiep can, thea doi de du phongcac bien chung co the xay ra (Singh va cs, 2015).

De tiep c~n va thea doi cac truong hop nay, co the phan thanh 2 doi tUQ'ng:

UXCTC (r ph\( nft trong lu:a tuoi sinh san

- Theo d5i SIJ phat trien kfch thuac Cllakhoi u bang cac so do clla sieu amm6i 6 thang - 1 nam tuy vi trf, kfch thuac Cllakhoi u.

- Theo d5i SIJ xuat hi~n cac tri~u chung lien quan den cac bien chung: khaithac b~nh su, tham kham m6i 6 thang - 1 nam

UXCTC (r ph\( nft man kinh

- Vi UXCTCco khuynh huang giam kfch thuac m9t cach dang ke, th~m chfbien mat 6' phl,lnCrman kinh, vi v~y 6' doi tU'Q'ngnay thi thai d9 th~n trQngthea d5i la m9t chQn llJa toi uu han la m9t bi~n phap can thi~p khac(Bulun, 2013). Theo d5i SIJ phat trien ve kfch thuac, tfnh chat clla khoi uqua khao sat sieu am m6i 3-6 thang. Chil y kha nang hoa ac khi khoi u tonhanh, hinh anh ho~i tu trong long khoi u.

- Doi vai nhilng pht.t nil man kinh co dieu tri n9i tiet thay the, thi can duQ'ccanh bao ding UXCTC c6 the se khong giam kfch thuac va c6 the xugt hi~nm9t so tri~u chung lien quan clla UXCTC(Ryan va cs, 2005). Neu co xuat

18

huyet am dao, can thea doi sat de xac dinh kha nang ac tinh. Can do be dayniern mac tu cung (y m6i Ian sieu am va nao sinh thiet tang neu n9i mac tucung day.

19

CHUO'NG VIII.DIEU TRI N(n KHOA U XO' CO' rtr CUNG

Hien nay, cac Hiep hQiSan Phu Khoa deu dong thuan ding viec dieu tri UXCTCchi diroc d~t ra khi UXCTCco bien chimg gay nen nhimg trieu clumg lam anhhuang den chat IUQ'ngcuoc song va kha nang sinh san cua phu nfr (Mas va cs,2017; Breech va cs, 2003).

Vi~cdieu tri UXCTCnen duoc ca the hoa dua tren tudi, trieu chtmg, kich thurrcUXCTC,nhu cau mang thai va cac tac dung phu co the co cua cua tung phuo'ngphap,

Trutrc day, cac truo'ng hop UXCTCco bien clurng thuorig dtro'c chi dinh phauthuat, Tuy nhien, dieu tri nQi khoa co nhieu tien bQva xu huang dieu tri baoton tang len do yeu cau cua ban than nguct phu nfr va do co nhtrng bang chimgcho thay phu nfr cat til cung, chua 1hoac 2 buong tnrng, co nguy co man kinhsam hon 2-3 narn so vot nhorn cluing (Moorman va cs, 2011).

Nhieu nhom thudc duoc nghien cuu va buac dau mang IC;liket qua kha quantC;lothem nhieu Iva ch9n phil hQ'p cho tung b~nh nhan va giup bao ton khanang sinh san.

Dieu tr1 nQikhoa co the dUQ'Cap dVng cho cac truCrng hQ'p:

UXCTCgay rong kinh rong huyet nhung chua anh huang nghiem tr9ngden the trC;lngcua b~nh nhan nhu gay sut, thieu mau n~ng, chat luQ'ng cUQcsong suy giam tram tr9ng.

UXCTCkhong gay chen ep long til cung, vo sinh ho~c say thai lien tiep.

UXCTCkhong gay chen ep n~ng ni~u quan, th~n u nuac, suy th~n man sauth~n do tac nghen.

De giam kich thuac khoi u va til cung, cclithi~n tinh trC;lngthieu mau cuab~nh nhan truac khi mo.

TRANEXAMIC ACID

Tranexamic acid la mQt chat chong ly giai fibrin. Tranexamic acid dUQ'cchungminh lam giam IUQ'ngmau kinh ke ccl khi co UXCTC(Telner va cs, 2007).Khuyen caa:

20

Co bang chimg ung hQ SU dung tranexamic acid tren benh nhan CU(Yngkinh va kiern soat chay mau trong phau thuat, (Khan va cs, 2014; Laughlinva cs, 2011; Wellington va cs, 2003)

Dieu tri ket hop thudc ngira thai va tranexamic khong duo'c khuyen cao,(Peitsidis va cs, 2014)

Tranexamic acid khong duoc khuyen cao tren benh nhan co benh ly dongmau bam sinh hoac co tien can huyet khdi, Cach su dung:

o Duong uong: vien Transamin 250 mg hoac 500 mg, 1vien x 3 Ian m6ingay den khi ngirng xuat huyet, Lieu toi da: 750 mg - 2.000 mg/24 gio.

o Hoac duong tiem (ong thudc co ham hrong 250 mg hoac 500 mg/Sml.): 250 - 500 mg/ngay tiern bap hay tinh mach, dung 1 - 2 lan/ngay trucekhi rna hoac neu xuat huyet trong hay sau phau thuat 500 - 1.000rug/Ian tiern tinh mach hoac 500 - 2.500 mg pha trong 500 mL dungdich glucose 5% hay dung dich co chat di~n giai, truyen nho giot tinhmach 24 gio.

o Can than tren benh nhan dang dieu tr! huyet khoi tInh m~ch, suy th~nhay qua man v&icac thanh phan cua thuoc.

o Luu y tac d\lng ph\l co the g~p bao gom thong kinh, non oi, buon non dukhong thuang xuyen xuat hi~n.

THU6c VIEN TRANH THAI N(n TIET KET HQ'P (TVTTNTKH)

Khuyen cao:

Co bang chung ung hQ su d\lng TVTTNTKHde dieu tr! tri~u chung xuathuyet tu cung n~ng lien quan t&iUXCTC,sau khi da dieu tr! dqt xuat huyetcap. (Vilos va cs, 2015)

Chong chi d!nh tren b~nh nhan co nguy cO'thuyen tac tInh m~ch, beD phi,tang huyet ap va hut thuoc. (Practice Committee of the American Societyfor Reproductive Medicine, 2017)

Nguy cO'co the g~p gom ung thu vu, nhoi mau cO'tim, dQt quy duqc xem lathap d,!a tren cac chung cu hi~n co (Kiley va cs, 2007). Ngoai ra, thuoc con cocac tac d\lng ph\l khac nhu dau dau, buon non, cang ng,!c.

21

PROGESTINS-DljNG cu rtr CUNG CHlrA LEVONORGESTREL(LEVONORGESTREL INTRAUTERINE SYSTEM - LNG-IUS)

Khuyen cao:

LNG-IUSduo'c chi dinh dieu tri trieu clurng cuong kinh va co the la bienphap dieu tri thay the de tranh nguy co phau thuat trong tnrong hopcuong kinh la trieu chimg chinh cua benh nhan,

LNG-IUSco the cai thien nang de)haemoglobin.

LNG-IUSkhong duoc khuyen cao cho nlnrng benh nhan xuat huyet am daobat thuong chua xac dinh nguyen nhan,

Benh nhan can dtro'c dieu tri on dinh qua dot xuat huyet cap, duo'c ne)isoibuong tu cung cat cac khdi UXCTCLO,Ll, L2, va dieu tri cac benh laytruyen qua duong tinh due (neu co) tnroc khi d~t vong LNG-IUS.

LNG-IUSlam giarn dang ke IUQ'ngmau mat bang each giarn phan bao ne)imactu cung, tang cirong chet te bao thea chuang trinh (Maruo va cs, 2001).

LNG-IUSlam giam 80% IUQ'ngmau kinh trong 4 thang dau tien, co the gay vakinh trong vang 2 nam. Haemoglobin tang 7,8% trong 4 thang dau dieu tr!(Dhamangaonkar va cs, 2015). LNG-IUScai thi~n chat IUQ'ngsong, tang mucde)hai long cua b~nh nhan va tiep tl,lCduy tri qua trinh dieu trL tranh bat chid!nh ph~u thu~t (Qiu va cs, 2014).

Ty l~ rO'ivang tuy thap nhung co the xay ra, d~c bi~t & nhfrng truang hQ'pcoUXCTCto duai niem ho~c trong Co'(Khan va cs, 2014).

Cac thuoc chua progestins khac cling co the lam giam chay mau nhu que caychua etonogestrel (Implanon).

GnRH DONG V~N(GONADOTROPIN RELEASING HORMONE AGONIST)

Khuyen cao:

GnRH dong v~n duQ'c su dl,lng dieu tr! UXCTCco tri~u chung, co the lamgiam kich thuac khoi u xO'va tu cung. Co the su dl,lng truac ph~u thu~t 1-3 thang de giam IUQ'ngmau mat va rna d~ han.

GnRH dong v~n dUQ'ckhuyen cao su dl,lng trong truang hQ'p UXCTCcotri~u chung nham cai thi~n nang d9 huyet sac to truac ph~u thu~t.(Lethaby va cs, 2000)

22

Ngung GnRH dong van trong khoang 2 tuan tnroc khi phau thuat,

Khong nen sir dung GnRH dong van keo dai tren 6 thang, trir khi co kethop them cac dieu tri bo sung nharn din bang nhtrng roi loan do n('>itiet tosinh due, Co bang chirng cho thay GnRHdong van gay giam mat d('>xuongkh6ng hoi phuc du da bo sung estrogen trong qua trinh dieu tri, (Palombava cs, 1999; Palomba va cs, 2002)

GnRH dong van gay nen nhirng trieu chirng cua man kinh nhu bdc hoa,viern teo am dao va giarn mat d('>xuong do do chi nen chi dinh ngan han(duoi 6 thang] truce khi phau thuat nharn lam giam kich thuo c u XO' vacai thien tinh trang thieu mau cho benh nhan,

Luu y, UXCTCco the tai phat rat nhanh dong thai keo thea cac trieu chung lienquan sau khi ngung dieu tr] GnRHdong van (Letterie va cs, 1989).

THUDC DIEU HOA CHQN LQC THl) THE PROGESTERONE(SELECTIVE PROGESTERONE RECEPTOR MODULATORS-SPRMS)

Mifepristone

Khuyen cao:

Mifepristone duqc khuyen cao chi d!nh trong truang hqp UXCTCco xuathuyet tir cung bat thuCrng, tran n~ng hf:lvL thieu mau va thong kinh(Gurusamy va cS, 2016; Islam va cS, 2013; Khan va cS, 2014; Shen va cS,2013; Singh va cS, 2015; Tristan va cS, 2012).

Mifepristone chong chi d!nh sir dvng trong thai kY va b~nh nhan da dieutr! steroids trong 3 thang truac do. (Bagaria va cS, 2009; Tristan va cS,2012)

Luu y:

Khoang 63% b~nh nhan duqc ghi nh~n day niem m~c tir cung khi dieu tr!vai mifepristone (Bagaria va cS, 2009).

Nhfrng thaydoi tren n('>im~c tir cung duqc gQila tlthay doi n('>im~c tir cunglien quan den dieu hoa thv the progesterone-PAEC", co the thoai trien khingung li~u trinh dieu tr!. Sv thay doi nay kh6ng phai tang sinh n('>im~c tircung hay ung thu n('>im~c tir cung (Chabbert-Buffet va cs, 2014).

Can luu Y, mifepristone kh6ng duqc dang ky chinh thuc de dieu tr! UXCTC(off-label).

23

Thufic diEmhoa chon loc thu the Progesterone (SPRMs)

Ulipristal acetate (UP A)

Khuyen cao:

UPA hien duoc khuyen cao la lua chon dau tay trong dieu tri nQi khoaUXCTC.

UPA duo'c khuyen cao dieu tri lam giam trieu chtmg cuong kinh va trannang ha vi do co tac dung lam giarn luong mau kinh (lieu 5mg co the lamgiarn luong mau kinh tren 91% benh nhan va 50% benh nhan se ngungxuat huyet trong vong 10 ngay dau dieu tri (Donnez va cs, 2012)) va giarnkich thuoc khdi u khoang 25% kich thuoc sau 13 tuan (Donnez va cs,2012; Talaulikar va cs, 2012).

UPAco the duoc chi dinh truoc phau thuat de lam nho kich thurrc khdi uva tu cung, cai thien tinh trang thieu mau cua benh nhan,

Khong can thict su dung dong thai thucc ngira thai nQi tiet vaprogestogens voi UPA (Talaulikar va cs, 2014).

SPRMskhong anh huang tren te bao cO'tu cung binh thuang va kh6ng ucche hoan toan hO(:ltd(>ngtrl;lc nQi tiet nen kh6ng gay ra tinh tr<;lnggiongman kinh (Chabbert-Buffet va cs, 2014). SPRMs gay chet te bao theachuO'ng trinh (apoptosis) cua cac s9'i cO'trong u, giam chat nen khoi u. Dodo khoi UXCTCva cac tri~u chung it tai phat sau khi ngung dieu trio

Ulipristal acetate (UPA) la thuoc du9'c su dl;lng rQng rai va cho nhieu ketqua kha quan nhat trong nhom SPRMshi~n nay (Farris va cs, 2019).

UPAco du9'c sua dl;lngnham (Odejinmi va cs, 2017):

• Cai thi~n kha nang co thai a phl;lnCrhiem muQn.

• Cai thi~n tri~u chung gay ra bai UXCTCcho phl;lnCrgan tuoi man kinh.

• Tranh ph~u thu~t cho b~nh nhan mang UXCTCco tri~u chung, do mQtso UXCTCse giam kich thuac khi duQ'cdieu tri vai UPA. Tu do cciithi~nkha nang d~u thai.

• Tranh ph~u thu~t cho b~nh nhan kh6ng muon ph~u thu~t.

• Kiem soat tri~u chlrng a nguai phl;lnCrkh6ng du dieu ki~n ph~u thu~t.

• Ngan ngua tai phat UXCTCa phl;lnCrda du9'c ph~u thu~t boc u xO'.

Lieu dung: UPA 5 mg 1 vien/ngay trong 3 thang. Neu muon dung l?p l<;liphai ngung 2 thang roi cho d9't thlr nhi 3 thang. Co the dung toi da 8 d9't.

24

Chong chi dinh cua UPA bao gom co thai, xuat huyet am dao bat thuorigchua ra nguyen nhan va benh ly ac tinh (Talaulikar va cs, 2014).

Cac tac dung phu thuong g~p cua UPAduoc ghi nhan gorn dau dau, dingnguc, dau bung, tuy nhien cac trieu chimg nay cling rat it gap (Donnez vacs,2012).

NQimac tu cung day lien quan v&iUPA diro'c ghi nhan, co the do day nangtuyen, it lien quan den tang sinh nQimac tu cung (Talaulikar va cs, 2012).Dieu tri UPA thai gian dai can thea doi dQ day nQi mac tu cung qua sieuam, d~c biet (y thai diem gifra cac dot dieu tri,

T'inh an toan cua UPA da duoc Uy Ban Chau Au ve Du9'CPham (EuropeanMedicines Agency - EMA) yeu cau xem xet lai tir thang 11 narn 2017 vaden thang 05 narn 2018 da ket luan va cho phep tiep tuc su dung UPA,v&icac ly Ie nhu sau:

• Tren 1.800 benh nhan su d1;lngUPA 2,5 mg ho~c 5 mg moi ngay x 3thang moi d9't x 1 - 8 d9't: khong thay co dau hi~u UPA gay dQc chogan.

• Khong co b~nh nhan nao uong 5 mg UPAmoi ngay trong 1 ho~c nhieud9't 3 thang co men gan ALT hay ASTtang gap 3 Ian muc dQcao binhthuang va khong co b~nh nhan nao ton thuO'ng gan do thuoc thea tieuchuan quoc te (Hy's Law).

ComQt so ca bao cao ve ton thuO'ng gan xay ra sau khi UPAdu9'c luu hanhtren th1 truang (8/765.000 ca dang su d1;lngUPA- ty l~ # 1/100.000).

UPA khong nam trorig nhom thuoc gay ton thuO'ng gan (drugs-inducedliver injuries - DILl).

Trong thai diem hi~n tC;li,tren th1 truang khong co mQt lOC;lithuoc naongoai UPA da du9'c chung minh co hi~u qua dieu tr1 u XO'cO'tty cung cobien chung n~ng ho~c trung binh, du9'Ccap phep dieu tr1.

Ton thuO'ng gan co the du9'C lOC;litrtr khi su d1;lngUPA bang cach xetnghi~m chuc nang gan nhu sau:

• Tru&c khi bat dau dieu tr1: xet nghi~m chuc nang gan, neu AST(aspartate aminotransferase) ho~c ALT (alanine transaminase) > 2Ian gia tr1 binh thmyng, khong nen chi d~nhUPA.

• Trong 2 d9't dieu tr! dau, xet nghi~m AST,ALT moi thang.

• Nhfrng d9't dieu tr1 tiep thea: xet nghi~m AST,ALT tnr&c khi bat daud9't dieu tr! ho~c khi lam sang co tri~u chung lien quan.

25

• Cudi m6i dot dieu tri: xet nghiern AST,ALT sau 2-4 tuan ket thuc dot,

• Ngimg ngay UPAneu men gan tang gap 3 Ian gi&ihan tren va chuyenbenh nhan kham chuyen khoa gan mat,

(Donnez va cs, 2018)

Dieu tr] nQikhoa UXCTCbang UPAla mQt bien phap:

C6the si'r dung truce ph~u thuat lam nho khdi u va ti'r cung, cai thien tinhtrang thieu mau,

C6 the si'r dung lau dai,C6 the thay the ph~u thuat, nhat la cho phu nft sap man kinh hoac mongmuon c6 con, dap img nguyen vong gift ti'r cung mot each an toan cho hauhet benh nhan,

26

CHIrO'N G IX.'A ?

DIEU TRJ NGO~I KHOA U XO' CO' TIr CUNG

Trong thai gian gan day, dieu tri nQi khoa UXCTC duo c phat trien nhieu vi conhieu thudc moi dieu tr] hieu qua. MQt so truorig hop v~n can dieu tri ngoaikhoa nhu:

UXCTC to, gay cam giac kho chiu nhieu cho benh nhan Ian tudl, khongI?ong co them con.

UXCTCgay bien chung nang nhu xu at huyet til cung bat thuong nang, saythai lien tiep,

- f)ieu tri nQi khoa that bai (it gap).

CHUAN B! rmroc MD1. Lam glam kich thiro-c khdi u truc-e phau thuat [rmrc dt) chungcu: manh]

GnRH dong v~n: Theo mot phan tich gQP cua Cochrane 2001 gam 26 thunghiern lam sang cho thfy sil dung GnRH dbng van trong 3-4 thang trurrc phauthuat lam giam kich thuoc til cung va kfch thuoc khcl UXCTC nen giam thaigian ph~u thuat, giam hrong mau mat va thai gian narn vien,

Nen tien hanh phau thuat sau khi ngung GnRH dong van trong yang toi da 2tuan.

SPRMs (selective progesterone receptor modulators): MQt thtr nghiemlam sang bao gam nhtrng ngiroi benh UXCTC co tri~u chung dlfqC sil dl;lngUPA 5 mg/ngay (n=96) ho~c 10 mg/ngay (n=98) trong 13 tuan so vai nhomgia dlfqC (n=48) cho thay, ket qua kiem soat dlfqC tinh tr~ng chay mau n~ng91-92% so vai nhom chung la 19% dong thai giam kich thlfac va khOi IlfqngUXCTCco y nghia thong ke (Donnez va cs, 2012).

2. Lo~i trir cac ton thU'O'ng ung thU' nt)i m~c til' cung hay co til' cungtrU'o-c ph§.u thu~t

Tat ca nhfrng trlfang hqp co xuat huyet til cung bat thlfang can dlfqc lo~i truung thu truac khi tien hanh ph~u thu~t bang cach thvc hi~n cac thli thu~t n<;losinh thiet tung phan, soi co til cung, phet te bao co til cung, bam sinh thiet cotil cung neu co chi dlnh.

27

3. Can khao sat ky truc-e phau thuat:

Yeu to nguoi benh: mire 09 tram trong cua xuat huyet [thieu mau hay anhhuang oen sinh hoat), trieu chung lien quan (dau vung chau, vo sinh), cacbenh ly n9i khoa mac phai, nguy co tiem an huyet khfii, vi trf, kich thuo'cva so luong UXCTC,tudi, PARA,mong muon co thai. (Stewart va cs, 2017;Templeman va cs, 2009)

Yeu to phau thuat vien: qua trinh dao tao, ky nang va kinh nghiern,

- Yeu to co sa y te: trang thiet bi y te - ky thuat san co, du trfr mau va cacthanh phan cua mau, chat luong cua 09i ngii h6 tro.

4. Giai thich va cung cap day diI thong tin cho nguoi benh ve dieu tri n9ikhoa va oieu tri ngoai khoa, dieu tri ngan han va dieu tri dai han, Ngtroi benhcan kY cam ket bim oong thu~n dieu tr~.

5.D~t sonde JJ ooi vai cac UXCTCto, UXCTCco gay bien chung chen ep ni~uquan, th~n u nuac.

Tat ccl b~nh nhan co UXCTCto gay bien chung chen ep ni~u quan, th~n u nuactren sieu am nen ouqc ch\lp h~ ni~u can quang (Urographie intra veineuse­mV) nham xac o~nh muc 09 tac nghen. CTscan ho?c MRI cling co the la ch9nIlJa neu can khao sat ky hO'nve h~ ni~u, be th~n va neu omu ki~n cO'sa y te cosan.

Nhfrng b~nh nhan co tac nghen tren mv muc 09 nhieu can ouqc O?t sonde JJtruac rna nham giup ph~u thu~t vien (PTV) co the o~nhv~ouqc v~trf ni~u quanm9t cach thu~n lqi trong CU9Cmo. Trong m9t so truang hqp nhu khi UXCTCto, hinh anh th~n u nuac tren sieu am va khong thlJc hi~n ouqc mv vi nhieuly do, co the can nhac O?t sonde JJ thuang quy truac ph~u thu~t.

Dieu nay rat co lch vi giup PTVh<;lnche ouqc bien chung ton thuO'ng ni~u quankhi boc nhfrng UXCTCnam a v~trf kho, gan ni~u quan. Ngoai ra neu co xay rabien chung ton thuO'ng ni~u quan trong luc rna, PTVco the d~ dang phat hi~nsam va h9i chan bac SI chuyen khoa ngo<;lini~u k~pthai oe xu trf.

cAc PHU'O'NG PHAp DIEU TRJ NGO~I KHOA

A. BOC U XO' CO' Tlr CUNG

BocUXCTCla m9t IlJa ch9n vai truang hqp UXCTCco bien chung nhung mongmuon bao ton tu cung oe mang thai. Bang chung eho thay boc UXCTClam tang

28

tY l~ co thai phu nll' < 35 tudi co hiern muon, ty l~ say thai giarn co y nghiathong ke (p < 0,001) (Machupalli va cs, 2013; Li va cs, 1999).

Chi dinh:

Co UXCTCnhung nguot benh muon gill' tl'r cung de bao ton chirc nangmang thai (nguoi benh con mong muon co thai).

Benh nhan tre co xuat huyet tl'r cung nang gay thieu mau (Milton va cs,2019), co UXCTClam bien dang buong tl'r cung (LO,L1, L2).

Benh nhan tre co UXCTCgay dau vung chau. (Milton va cs, 2019)

• Dau vung chau cap

• Dau man tinh vung chau hoac that lung hoac bi de n~ng vung chau

UXCTCgay hiem muon hoac say thai lien th~p (Philippines Society forReproductive Medicine, 2017).

Benh nhan khong muon cat tl'r cung.

Ttr van nguy co':

Co the cat tl'r cung trong qua trinh ph~u thuat boc UXCTC,do ton thuongqua nhieu, phirc tap,

Khoang 15% tai phat sau boc UXCTC,10% cat tl'r cung sau 5 - 10 nam,

Nguy co va tu cung trong thai ky sau phau thuat boc UXCTCd~c biet lanhfrng tnrong hop boc nhieu nhan XO'.

Lira chon nga th\fc hi~n boc u XO': Tuy thuQc van so luqng cua khoi u, kfchthu6'c, v! trf, muc dQ dfnh va kinh nghi~m cua ph~u thu~t vien rna ch9n ngath\fc hi~n boc u XO'. Kiem soM va xu tri tinh tr':lng chay mau trong qua trinhboc u XO' la uu tien hang dau de d':ltket qua tot nhat sau phau thu~t. (Kovac vacs,2002).

1. Philu thugt nt); so; buang til' cung cat UXCTC

Chi dinh: Hi~p hQi Phc1u Thu~t NQi Soi Phl,l khoa Hoa Ky (AmericanAssociation of Gynecologic Laparoscopists, 2012) khuyen ngh! ding phc1uthu~t nQi soi buang tu cung cat u XO' la l\fa ch9n dau tay cho cac truang hqpUXCTCdu6'i niem LO,L1, L2 co bien chung gay xuat huyet n~ng, va sinh, saythai lien tiep, va kfch thu6'c khoi u < 5 cm.

MQt nghien cuu t':li Hoa Ky gam 1422 b~nh nhan ghi nh~n nQi soi buang tucung cat u XO' LO,L1, L2 d':lt ket qua cao trong vi~c dieu tr! xuat huyet tu cung

29

bat thuorig. Tuy nhien, ty l~ tai phat tir 14,5 - 30% sau 3 - 4 narn,MQt nghiencuu tien elm khac cling tai Hoa Ky trong 3 nam cho ket qua kha quan khi94,1 % nguoi benh da kiem scat duo'c xuat huyet tu cung bat thuong, Tuongtty thea tac gia Piecak va Milart, 2°17, phau thuat cat bo UXCTC diroi niernmac giup cai thien tinh trang mang thai.

Ph~u thuat vien co kinh nghiern se thuc hien duo'c viec cat UXCTCdtro'i niern(LO,L1, L2) co kich thiroc 4 - 5 em qua nQi soi buong tu cung. CIt UXCTCdurriniern L2 co nhieu kha nang thuc hien phau thuat 2 thi so voi LO,L1 vi nguy cohap thu dich cao va thung tu cung trong phau thuat, Can than trong khi u XO'duoi niern each lap thanh mac tu cung duoi 5 mm (Puri K va cs, 2014).

Tai bien:

Chay mau: Trong phau thuat nQi soi cat dot u XO'LO,L1, L2, ty l~ chay maukhoang 0,1- 6,0%, su dung bong sonde Foleyborn 30 ml mro'c muoi sinhly co hi~u qua cam mau (Piecak va Milart, 2017)

T6'n thU'O'ng ti:r cung: nguy cO'chit h~p co tu cung, thung tu cung thu&ngtrong xay ra trong thi nong co tu cung, thung tu cung trong thi cat dot cothe gay ton thuO'ng rUQt, bang quang va cac m9-ch mau Ian c~n (Piecak vaMilart, 2017)

Dfnh huang ti:r cung: La bien chung thu&ng g~p trong ph~u thu~t nQi soibuang tu cung cat dot UXCTCLO,Ll, L2. Ty l~ dinh buang tu cung sau ph~uthu~t 35-45% duqc bao cao neu su dl).ng nang luqng dO'n ctyc nhung neusu dl).ng nang luqng luang ctyc thi tY l~ nay giam xuong con 7,5% (Roy vacs, 2017). Hi~n nay t9-iVi~t Nam, mQt so b~nh vi~n da su dl).ng bQ dot luangctyc trong nQi soi phl). khoa.

MQt so phuO'ng phap chong dinh buang tu cung sau ph~u thu~t, duqc chohi~u qua thap nhu d~t dl).ng Cl).tu cung, li~u phap hormone, trong khi cacphuO'ng phap co hi~u qua chong dinh buang tu cung tot hO'n nhu su dl).ngbong cua ong thong Foley, gel hyaluronic. Khuyen cao nen su dl).ngphuO'ng phap chong dinh trong khoang 6-8 tuan sau ph~u thu~t (Piecakva Milart, 2017).

Neu cUQcrna kho, keo dai, can bO'm nhieu dtch van buang tu cung, co thegay ra tang tai hap thl). dtch d~n den qua tai tuan hoan, phu phoi cap, phunao cap. Neu su dl).ng dung dtch glycine rna truyen qua nhieu se gay matcan bang di~n gicli (h9- natri mau, h9-protein mau va hematocrit thap) gaybuan non, non, nhuc dau va lu l~n (Piecak va Milart, 2017).

30

2. M{j hi} thanli bunq boc UXCTC

Chi djnh:

Nhieu nhan XO',to, trong co tu cung 0- vi tri L2 den L7.

UXCTCco bien chung nang, khong dieu tri duoc bang nQikhoa.

Benh nhan muon bao ton tu cung hoac dang mong con.

Trong qua trinh ph~u thuat, can giarn luorig mau mat bang each tiernvasopressin hoac cac chat khac (xem phan cac thufic lam giarn chay mau trongboc UXCTC).

Ty l~ va tu cung, md lay thai thap han so vot phau thuat nQi soi 0 bung boc uxo.

Co the bee nhan xo nga bung bang duong rach nho < 8 cm neu cac khdi ukhong qua to.

Phau thuat boc UXCTCnga bung bang duong rach nho la mot lua chon nhamgiarn su xam Ian tren nguoi benh co UXCTCIan va nhieu khrii.

Duong rach da < 8 ern, cho phep phau thuat vien co the sa nan cac khdi u xonarn trong co tu cung va qua trinh khau ph\lc hoi cac lap cO'cua tu cung thea3 lap tieu chuan d~ dang han.

Tai bien trong trong ph~u thu~t thuang la mat mau nhieu nen can dl;l'trumau cung nhom.

Tai bien sau ph~u thu~t

Chay mau trong vet khau sau boc nhan xO'neu khong khau ph\lc hoi Co' tucungkY·

Nhi~m trung, nhat la khi co Wmau nO'ikhau ph\lc hoi Co' tu cung.

- Va tu cung trong l~mmang thai sau, chiem ti 1~0 - 4%.

Do bang quang-am d<:lo-trl;l'ctrang, ton thuO'ng ni~u quan.

3. Phdu thu(lt ni); so; {j bl}.ngboe nhdn XO' (mwe di) ehwng ew: mfmh)

Chi djnh:

UXCTCduai thanh m<:lcva trong Co' co bien chung.

Kfch thuac nhc han 10cm.

31

----------------------------. -- .. ------------------------------------

Tai bien trong phau thuat

Chay mau nhieu, thai gian ph~u thuat keo dai,

f)oi voi cac nhan XO'to sau khi duo'c boc bang n9i soi, khong the lay khfii ura khoi a bung qua dirong rach n9i soi rat nho, nhieu phau thuat vien daSlYdung may bao lay mo. Tuy nhien, sl'r dung may bao lay rna UXCTCconhieu diem khong thuan 19'inhir thai gian gay me keo dai, kha nang khdiu da hoa ac tinh (sarcoma). Bao khdi u co the lam roi vai cac te bao ungthu trong a bung gay di can cho benh nhan (Wong va cs, 2018) tong ket33723 truong h9'P UXCTCITTrung Quoc duoc boc qua n9i soi a bung, coSlYdung may bao dien. Trong so nay co 62 ca u da hoa ac tinh (0,18%) dogiai phau benh ly xac nhan, Do do, neu sl'r dung may bao thi phai d~t khdiu van trong bao.

ron tturonq rutn:- bemgquang - cac mach mau Ian do dam Trocar la bienchirng do 16iky thuat cua ph~u thu~t vien va thuang it khi g~p (Piecak vaMilart, 2017).

rhuyen tac khf la m9t bien chung het suc nguy hiem. Ph~u thu~t vien vabac SIgay me phai thea d6i sat va phat hi~n sam thuyen tac khi neu co xayra de <lieutri kip thai (Piecak va Milart, 2017).

Tai bien sau ph~u thu~t

Chay mau sau mo.

Nhi~m trung: viem n9i m(;lctl'r cung trong thai gian h~u ph~u chiem tY l~1-S%,nhi~m trung cO'tl'rcung, nhi~m trung vung ch~u d~n den cat tl'r cung.Khang sinh d1.,l'phong co the co hi~u qua de giam thieu ty l~ nhi~m trungsau mo.

- Va tlYcung trong thai ky Ian sau: dao d9ng til 0 - 10%.

Theo d6i sau boc nhan XO'

Tai kham dinh ky:

• 1thang sau mo.

• M6i 6 - 12 thang t3i kham 1Ian.

Theo d6i co thai t1.,l'nhien khong? Neu chU'a co thai sau rna 6 - 12 thang,can nhac tu van cho b~nh nhan phU'O'ngphap TTTON sau khi kham lamsang va Idem tra buang tl'r cung.

Mo lay thai chu d9ng sau boc nhan xC'.

32

4. Phdu thugt boc nhiin XO' CO' tv eung nga am dqo {mire di) ehvng ev:yeu)

Ph~u thuat boc u XO'co t& cung nga am dao, khong rach da la mot ph~u thuatkho, chi nen duoc thuc hien dei vai UXCTCnho, narn & vi tri thuan 19'i (clingdo sau). Phau thuat nay doi hoi phau thuat vien phai co ky nang cao va nhieukinh nghiern,

B. cAT Tlr CUNG DO U XO' co rtr CUNG

Ph~u thuat cat t& cung va hai eng d~n tnrng la phuong phap dieu tri tan gecUXCTCco bien chimg. cat t& cung hien nay la phau thuat thuorig gap, chi dungsau rna lay thai tai cac benh vien chuyen nganh San Phu khoa (Blandon va cs,2007).

Chi dinh

Nghi ngo UXCTCthoai hoa ac tinh.

- Da nhan XO'co TC, khong can rna lanh, khong the boc duoc.

Trong khi boc UXCTC rna khong kiem soat duo'c tinh trang chay mau.

Ph\.).nfr Ian tuoi va du con.

Co b~nh If kern thea nhu b~nh tuyen-cO' t& cung ho~c b~nh If co t& cung.

Neu cUQcrna kho khan, co the cat t& cung ban phan va hai eng d~n trung.

Nen cat 2 buong trung neu b~nh nhan tren 50 tuoi. Tuy nhien, can Sl;l'dongthu~n cua b~nh nhan bang van ban.

TU'van

- Cac nguy cava tai bien cua ph~u thu~t cat t& cung nhu ton thuO'ng duangtiet ni~u, rUQt neu dinh nhieu.

- Ph~u thu~t dit t& cung co the gay ra man kinh sam khoang 2-3 nam.

- C;£tt& cung co the lam thay doi cau truc san ch~u (mat nut trung tam daych~u tl;l'nhien nen co the gia tang ty l~ sa t(;1ngch~u sau rna, thuang b;£t dau5 nam sau mo. Giam Libido, rei 10(;1nchuc nang tam If (co the tram cam)(Blandon va cs, 2007; Ewalds-Kvist va cs, 2005).

- Cac thu thu~t thay the ph~u thu~t: 19'iich va nguy ca.

33

1. Phau thuat dit til' cung qua md hir nga bung

Chi dinh: khi UXCTCqua Ion, Ian tea, nhieunhan, hoac cac tnrong hop chongchi dinh phau thuat cat tu cung nga am dao hoac nQi soi a bung,

2. Phau thuat nQisoi 0 bung cat til' cung

Chi dinh: thuc hien tren tu cung co kich thurrc < 14 tuan va khong dinh.

La lua chon tot han so voi phau thuat ho cat tu cung nga bung do chat IUQ'ngsong tot han va giam bien chimg hau phau, Tuy nhien, de thuc hien loai phauthuat nay, can phai danh gia can than kich thurrc tu cung, cling nhu kinhnghiern, ky nang cua phau thuat vien va trang thiet bi nQisoi cua benh vien deco chi dinh phil hop,Co the thuc hien tren nguot benh chua tung co thai, chuasanh nga am dao hoac da co phau thuat nga bung truce do, neu khong dinhnhieu vilng ch~u. Ph\lc hoi nhu dQng rUQtsam trong thai gian h~u ph~u.

Tai bien trong ph~u thu~t:

Thuyen ta.c khL

Ton thuO'ng rUQt,bang quang, mq.chmau Ian do 16idam trocar.

Ton thuO'ng ni~u quan.

Tai bien sau ph~u thu~t:

Nhi~m trilng.

Do am dq.o-trl!Ctrang, bang quang-am dq.o,ni~u quan-am dq.o.

3. Phau thu~t cclttil' cung nga am d~oDay la phuO'ng phap it xam Ian va chi phi re nhat. Tuy nhien, tuO'ng tl! nhuph~u thu~t bac UXCTCnga am dq.o,day la mQtph~u thu~t kha thl!c hi~n, nhieunguy cO'bien chlmg nhu chay mau nhieu, sa tq.ngch~u, ton thuO'ng ni~u quan.Phau thu~t nay doi hoi phau thu~t vien phai co ky nang va nhieu kinh nghi~m.Can thea d6i sat tinh trq.ng b~nh nhan sau rna a cO'sa y te co du trang thiet b~kY thu~t thea d6i de phat hi~n sam cac bien chung ve ni~u khoa (bi tieu, tonthuO'ng ni~u quan), chay mau sau mo. Cothe cat tu cung co UXCTCnga am dq.ovai Sl! trQ'giup cua nQisoi a bt,mg.

Hi~n nay, da co ph~u thu~t nQi soi cih tu cung duQ'c ap d\lng rQng rai va hi~uqua, do do bac SIll!a ch9n cat tu cung nga am dq.ocan can nhac kY nguy cavabien chung co the xay ra.

34

GIAM MAT MAu TRONG BOC UXCTC

Vasopressin: La mQt loai thuoc duoc ua chuong trong phau thuat phu khoa.Su dung 30 - 40 ml dung dich vasopressin truyen trong rna duo'c chirng minhla co hi~u qua giam hrong rnau mat (p=O,OOOl)va nhu cau truyen mau trongphau thuat boc UXCTC,mac du kh6ng co S1;1' khac biet co y nghla ve viec lamgiam thai gian phdu thuat va bien chirng hau phiiu (Kongnyuy va cs, 2011;Ginsburg va cs, 1993; Fletcher va cs, 1996; Zhao va cs, 2011).

Misoprostol: D~t true trang 400 ug truce phau thuat cat tu cung riga bung 1gto lam giarn luong mau mat va thai gian ph au thuat so voi nhorn chirng (574± 194,8 ml vs 874 ± 171,5 ml), them mra luong Hemoglobin giarn trong thaigian hau phau thap han so v&inhorn chung (Abdel-Hafeez va cs, 2015).

Oxytocin: tang S1;1' co hoi co' tu cung dan den giam dong mau t&i tu cung lamgiarn tinh trang chay mau trong qua trinh phau thuat, Su dung oxytocin phfiihop voi misoprostol [mot trong nhirng yeu to gay co co tu cung) trong phauthu?t cat tu cung nga am d<;loco ho trq cua nQisoi a bl,lng duQ'Ccho la co hi~uqua giam luqng mau mat, thai gian phau thu?t ngan han va giam thai giannam vi~n.

Lieu su dl,lng30 dan v! pha trong 500 ml dung d!ch Natri Chlorua 0,9% truyentlnh m<;lchcho thay giam the tfch mau mat so v&inhom chung co y nghla thongke. Nhu cau can truyen mau thap han (y nhom truyen Oxytocin co y nghlathong ke, tY l~ truyen mau (y nhom co truyen Oxytocin la 7,5% va nhom kh6ngtruyen Oxytocin la 25% (P < 0,001).

Antifibrinolytics: Tranexamic acid da cho thay hi~u qua trong vi~c cam mauva giam tY l~ truyen mau trong phau thu?t, S1;1' khac bi~t co y nghla thong ke (p< 0,001). V&ilieu 19 tiem/truyen tInh m<;lchlam giam luqng mau mat trongphau thu?t cat tu cung (p = 0,004), giam IU'C;rngmau mat> 500 ml (p = 0,003)va giam ty l~ phai phau thu?t l<;lido bien chung xuat huyet nQi (p = 0,034)(Topsoee va cs, 2016).

35

CHUO'NG X., ?" ,..." ~ "

CAC THU THUAT THAY THE PHAU THUAT. .THUYEN TAc DONG M~CH rtr CUNG(UTERINE ARTERY EMBOLISATION - UAE)

Thuyen tac dQngmach til cung (nut mach til cung) la thu thuat it xam Ian trongdieu tri UXCTC,giup bao tan til cung va benh nhan nhanh ch6ng hot phuc,Phuong phap dieu tri thuc hien bang each tiem cac hat nho vao mach mau dentil cung, muc dich chan viec cung cap mau cho u XO'de giam trieu chung vagiarn kich tluro'c cua UXCTC.

C6bang chimg cho thay thuyen tac dong mach til cung c6 hieu qua giam trieuclurng ngan va trung han mot each dang ke:

Giarn 43% khdi hro'ng u XO'sau 2 thang va 59% sau 6 thang (Burn va cs,2000).

Giam trieu chirng 80% trong so 1387 benh nhan trong khoang thai gian24 thang,

Cai thien dang ke cuoc sdng trong vong 3 narn thea d6i (p < 0,001) (Linden,2012).

UAEc6 hieu qua trong dieu tri hQi chirng chen ep va cuong kinh tuy nhienthieu hieu qua trong dieu trt UXCTCduai niem va xuat huyet til cung batthuang (Laughlin va Stewart, 2011; Telner va Jakubovicz, 2007).

Chong chi dtnh: Mong con, khoi u nghi nga ac tinh, man kinh, nhan XO'cO'tilcung c6 cuong, nhan XO'cO'til cung duai niem mqC(Smeets va cs, 2010).

Cac bien chlrng duqc ghi nh~n bao gam: Nhai mau til cung, ton thuO'ng bangquang va am hQ, ton thuO'ng buang trlrng, hQi chlrng sau tac mqch (Post­embolization syndrome), dau, tang tiet dtch am dqo, man kinh sam (Linden,2012).

Sau 5 nam dieu trt ti l~ tai phat la 10 - 20% (cao hO'nUXCTCduai nH~m)vacan duqc dieu trt lqi ho~c ph§.u thu~t (Memtsa va Homer, 2012). Tuy UAEtonit phi thl!c hi~n hO'nso vai ph§.u thu~t nhung sau d6 can thea d6i sat hO'n,dmnhieu khao sat hinh anh, va thai gian thea d6i sau thu thu~t dai hO'n(The RESTInvestigators, 2007).

36

Benh nhan can duoc tu van ve nguy co that bai dieu tr], nguy co tai phat vacan can thiep bo sung. Phuong phap UAE khong phai la lira chon dau tay chocac phu nfr dang mong con.

TIEU H(IV UXCTC BANG NHI~T

MRI - Guided Focused Ultrasound (MRgFUS) hay High-Intensity FocusedUltrasound (HIFU) la phuong phap tap trung cac chum sieu am nang luongcao vao mot rna dich, bien thanh nhiet nang.

Neu nhiet d9 tal rna muc tieu Ian hon 550C thi se lam bien doi protein rna dichkhien chet te bao va hoai tty (Hindley va cs, 2004). Cac rna xung quanh c6 thebi anh huang am len nhung khong bi hoai tty do nhi~t.

Chi dinh:

Benh nhan c6 UXCTCmong muon bao ton tty cung.

Benh nhan khong muon phau thuat b6c nhan XO'co dien,

Chong chi dinh: Mang thai, dirong kinh u XO'Ian hon 10cm, Hct < 25%, cannang tren 113 kg, benh ly tim mach (Hindley va cs, 2004; Lefllang va cs, 2010),seo rna cii tren Quang di cua tia sieu am, u XO'co tty cung vi trf kh6 tiep can,benh nhan c6 chong chi d!nh vai MRIc6 can quang hay sieu am c6 can quang.

NhU'Q'cdiem: Kh6 xac dtnh chfnh xac duqc ml;!ctieu dfch (Tempany va cs,2003), kh6 danh gia hi~u qua nhi~t len cO'quan dfch do hq_nche cua sieu amtrong danh gia hi~u qua nhi~t.

B~nh nhan nhanh ch6ng hoi phl;!c sau 24 den 48 gia (LeBlang va cs, 2010).Hi~u qua giam kfch thuac khoi u XO'cO'tty cung phl;! thuQc vao the tfch tU'aimau sau khi dieu trt bang tieu huy UXCTCbang nhi~t. Theo Zhang, thi c6 thegiam kfch thuac khoi u hO'n 90,1%, giam r5 r~t tri~u chung kinh nguy~t(Zhang va cs, 2010).

Yeu cau: Huang cua sieu am tu thanh bl;!ngtrU'ac den u XO'cO'tty cung khangdi qua bang quang va ruQt, khoang each tu thanh mq_cden u XO'dfch Ian hO'n15 mm(LeBlangva cs, 2010). Cac b~nh nhan c6 dl;!ngcl;!tty cung phai duqc layra truac thu thu~t (Ren va cs, 2007; Wang va cs, 2012).

Tac d1Jng ph1J: Vet bong da nho, rat da, ml;!n nU'ac thanh bl;!ng trU'ac(Tempany va cs, 2003; Wang va cs, 2012). B~nh nhan can duqc tU'van trU'acve thieu dfr li~u an toan ve kha nang c6 thai va mang thai sau dieu trt MRgFUS,nguy cO'va tty cung khi mang thai, nguy cO'tai phat.

37

TIEU nuy UXCTC BANG SONG CAD TAN (Radiofrequency Myolysis)

La phuong phap mot trong dieu tri UXCTC. UXCTC thuong duoc dieu tri thunho kich thurrc truce thu thuat bang GnRHdong van (Goldfarb, 2008). Hiennay tai Vi~t Nam, thu thuat dil duoc burrc dau trien khai tai benh vien Tir Dfi,

38

CHU'O'NG XI.cHuKNBJBeNHNHANTRU'&CPHAuTHU~T

CHUAN B! TRU'O'C MDHoi ky benh su va tien can benh nhan va gia dinh di trng thucc [te, me) haythtrc an, thudc dang dung, co ngungthokhi ngu khong, nghien nrou hay thudc,benh: phdi, tim, gan, than, tuyen giap, dai thao duong cao huyet ap ... (Hilditchva cs, 2008)

Tu van cac nguy co cua phau thuat cat tu cung, boc UXCTC( n9i soi, rna bung]va n9i soi cat nhan XO' TCduoi niern mac, nguy co tai phat khi boc va nguy cova tu cung khi co thai (xem dieu tri ph~u thuat UXCTC).

Ky cam ket phfiu thuat

1. Xet nghiem thuo-ng quy: (O'Neill va cs, 2016)

Cong tlurc mau, nhorn mau, Hemoglobin/Hct. Thai gian prothrombin(PT), thai gian activated partial thromboplastin (aPTT).

- XH nghiem HbsAg, giang mai va HIV (sau khi tu van va benh nhan dongy).

- Duong huyet,

Clnrc nang gan.

Chirc nang than creatinine/ huyet thanh

- Benh nhan trong tufii sinh de nen duoc tlur ~-hCG. (O'Neill va cs, 2016)

- Tong phan tich nuac tieu.

- Xquang phoi.

- Di~n giai do: khong can xet nghi~m thuang quy tru khi b~nh nhan co tiencan bat thuang.

ECGkhong can xet nghi~m thuang quy a b~nh nhan khong co tri~u ch(rnghay b~nh ly tim m(;lch(ACC/ AHA)

- Phet te bao co tu cung (PAP) ho~c soi co tu cung neu chua co ket qua PAP.

39

2. Chan doan hinh anh: SH~uam de xac dinh sd luong kich thuo'c va vi tri cuaUXCTC.

Sieu am bung de xac dinh than co lr mrrrc khong,

Sieu am bam nutrc buong tu cung neu nhan xo LO,Ll, L2.

MRIgiup tranh bo sot khi boc nhan xo co tu cung, phan biet voi benh tuyen­co nr cung (adenomyosis) va sarcoma tu cung, glup phan biet LO-3.

3. Nao sinh thiet: benh nhan xuat huyet tu cung bat thuorig co nguy co tangsinh nQi mac tu cung hay ung thtr nen duo'c nao sinh thiet va co GPB trucephau thuat,

4. Dieu tr] truoc phau thuat:

GnRHdang van lam giam kich thuo'c khci u giup phau thuat nQi soi tranh rnabung, Giarn mat mau (xem dieu tr] nQi khoa). Ulipristal acetat (UPA) co thedUQ'Csu dung de giam the tich khdi u va tu cung, cai thien tinh trang thieumau cua b~nh nhan (xem dieu trt nQikhoa).

DVphong thuyen t~k m~ch ho~c thuyen tac phoi neu cUQc rna keo dai han 30phlit a b~nh nhan co nguy cO'trung binh hay cao. (thrombophilia, ung thu, d~tcatheter TM trung tam, co thai, dung thuoc vien ngua thai hay nQi tiet thaythe, dung tamoxifen, suy tim , b~nh tim bam sinh, hQichlrng anti phospholipid,bee phi, suy gan, th~n, b~nh viem ruQt, > 65 tu6i ...). Quyet dtnh dung haykhong dVa van IQ'iich va nguy cO'chay mau khi ph~u thu~t (Gould va cs, 2012).

Thieu mau do thieu sat: nen dieu chinh thieu mau truac ph~u thu~t bangtruyen sat, khong nen truyen mau truac mo.

5. Chuan b! d~i tnlng: khong can thiet tru truang hQ'pco nguy caton thuO'ngruQt khi ph~u thu~t (Fanning va Valea, 2011).

6. Thao bi>het tat ca niYtrang hay khuyen deo (y miii, IU'o-i,mi~ng. NeunQisoi buang tu cung nen lay DCTCtruac mo. B~nh nhan nen tam dem homtruac ph~u thu~t, tot nhat bang dung dich chlohexidine gluconate ("Top CDCRecommendations to Prevent Healthcare-Associated Infections").

TRONG PHONG MDKhang sinh dt):'phong: cefazolin, cefoxitin hay cefotetan 2 gr tiem TM truacphau thu~t 60 phut. Cothe dung khang sinh thay the ampicillin - subactam 2gr

40

TM hay Clindamycin 900 mg TM hay Vancomycin 2 g TM (American Collegeof Obstetricians and Gynecologists practice bulletin no. 104,2009).

Bac sl phau thuat vien: nen kharn vung chau tnroc khi phau thuat,

D~t sonde JJ trong cac truong hop c6 chi dinh (xem bai Xu trf ngoai khoaUXCTC)

Chuan b] vung phdu thuat: (American College of Obstetricians andGynecologists practice bulletin no. 195, 2018, Pellegrini va cs, 2017) ngannhiern trung vi trf phau thuat bang chlohexidine gluconate 4% vai 70%isopropyl alcohol tot hon la povidone-iodine va iodone - alcohol (Darouicheva cs, 2010). Chuan b] am dao: bang povidone-iodine neu di img se dungchlorhexidine gluconate 4% (Chlor se kh6ng hieu qua khi ra huyet am dao),

Ngay trtroc khi ph~u thuat:

Thuc hien kiem tra ten tudi benh nhan trtro'c mo.

Danh dau vi tri phau thuat [phai bao dam van con nhin thay sau khi sattrung va trai sang mo.

Time-out ngay truce khi phau thuat de xac dinh dung benh nhan, phuongphap phau thuat, vi tri phau thuat, du kien thai gian va cac phuong phapngan ngira bien chung, (The Joint Commission on Accreditation ofHealthcare Organizations protocol for surgical time-out, 2017)

(Time-out = ky thu~t vien d1.).ngc1.).phong mo d9C ten, nam sinh, sieu am, chidinh mD, cach mo cho cci d9i phau thu~t vien, gay me hoi suc va b~nh nhancungnghe).

41

CHlfO'N G XII.? "A'"U XO' CO' rtr CUNG VA HIEM MUQN

UXCTCla loai khoi u thuong g~p nhat, xuat hien a 20 - 40% phu nil' trong d<)tudi sinh san va a 5 - 10% phu nil' hiem muon (Cook va cs, 2010). Anh huangcua UXCTClen kha nang sinh san luon la van de dtroc quan tam nhung chuaduoc hieu biet r5 rang. UXCTCdon thuan khong phai la nguyen nhan tuyet doigay hiem muon, nhieu benh nhan co UXCTCvan co thai rna khong can canthiep, Tuy nhien, mot so dang UXCTCco lien quan den tinh trang hiem muonnhir diroi niern mac hay trong co tu cung rna co gay bien dang long tu cunglam giarn tY I~ thai, tY l~ tre sinh song, tang nguy co' say thai dien tien va sinhnon. UXCTCduoi thanh mac khong lam anh huang toi kha nang sinh san(Pritts va cs, 2009; Sunkara va cs, 2010).

xu TRi UXCTC IT B~NHNHAN HIEM MUQN

1. Khao sat toan dien cac yeu to lien quan den hiem muon truce khi quyetdinh can thiep UXCTC.

2. Benh nhan co UXCTCco trieu chimg lam sang: can thiep UXCTCnen ganvoi thai diem mong muon co thai (> 6 - 12 thang) de giam kha nang taiphat cua UXCTC.

3. Sieu am danh gia ky UXCTCve vi tri, kich thu&c va so luqng.

4. Quyet dinh can thi~p tuy thea vi tri, kfch thu&c cua UXCTCva xem xet quatrinh dieu tri hiem mu<)ncua b~nh nhan

UXCTCdu&i niem m<;lc(FIGOLO,L1, L2) gay bien d<;lnglong tu cung lamgiam kha nang co thai.

• UXCTC(FIGOLO,L1, L2): n<)isoi buang tu cung boc UXCTCdu&i nh~mtru&c khi dieu tri ho trq sinh san.

• UXCTC(FIGOL2), neu kfch thuac UXCTC> 3 cm: n<)isoi 6 bl;!ngde b6cUXCTC.

• Can tu van cho b~nh nhan cac nguy cO'lien quan den ton thuO'ng longtu cung, dfnh long tu cung tru&c tien hanh phau thu~t. Nguy cO'dfnhlong tu cung sau n<)isoi buang tu cung khoang 7,5% (Valle va cs,1988).

42

UXCTCtrong co tu cung (FIGO L3-5)

• Kich thutrc UXCTC > 4 ern hay UXCTC< 4 em nhung that bat chuyenphe: nhieu chu ky thu tinh ong nghiern m~c du phoi tot hay ket cuethai ky xau (say thai, sinh non): Boc UXCTC(nl)i soi hay rna rna)(Oliveira va cs, 2004; Kolankaya va cs, 2006).

UXCTCco kich thuo'c to, V!trf can tro qua trinh choc hut de dieu tri thutinh ong nghiern co the duoc xem xet boc truo'c khi dteu tri, Neu V!trikhong gay can tro viec choc hut tnrng va benh nhan tren 35 tudi, can nhackich thich buong tnmg, tao ph ai, tnr phoi toan bl) rai boc nhan XO'va cho1 narn sau chuyen phoi.

Cac bien phap dieu tri thay the:

• Ap dung cho cac truong hop:

o UXCTC(FIGOL3-5) kich thurrc < 4 cm a benh nhan that bai nhieuchu ky thu tinh ong nghiern nhieu chu ky va b~nh nhan khangmuon rna boc UXCTC.

o UXCTCco lien quan ket Cl;lCthai ky xau.

o Phau thu~t UXCTCtien luqngthanh cang kern nhu da UXCTC,nguycaton thuO'ng long tu cung, dinh buang tu cung.

• Dieu tr! thay the:

o N(>ikhoa: Ulispristal Acetate (UPA). UPAla ml)t chat dieu hoa thl;lthe progesterone co ch9n 19C.Trong cac nghien cuu giai dOC;ln3 dephM trien UPA, co 21 b~nh nhan dang trong thai gian thu nghi~m,mong con; 15 trong so nay da co thai 18 Ian (15/21 = 71%). Trongso do, 12 nguai da sinh 13 chau, kh6e mC;lnh,binh thuang can 6Ian co thai kia da bt say thai (Luyckx va cs, 2014).

Ky thu~t MRgFUS(kY thu~t dieu tr! UXCTCbang nang luqng songsieu am tan so cao) cung co the duqc ap dl;lngv&i cac truang hqpco UXCTCnh6. Tuy nhien, cac bang chung t&i hi~n tC;litrong y vanchua ling hI)vi~c su dl;lngthuang quy MRgFUStrong dieu tr! UXCTCa phl;lnfr mong muon duy tri ho~e cai thi~n kha nang sinh san.

UXCTCdan thuan khang la nguyen nhan tuy~t doi gay hiem mul)n. Ml)t sodC;lngUXCTCeo lien quan den tinh trC;lnghiem mul)n. Xu tri UXCTCa b~nhnhan hiem mul)n ean xem xet to~mdi~n cae nguyen nhan gay hiem mul)n va

43

quyet dinh can thiep UXCTC dua vao tudi benh nhan, vi trf, kich thUD-C, soluong nhan xo va qua trinh dieu tri hiem muon cua benh nhan,

44

CHUaNG XIII.? "U XO' Co' TU CUNG TRONG THAI KY

MaVAU

Ti l~mot mac UXCTCtrong thai ky uoc tinh dao d(>ngnr 2,7% a nhtrng thaiphu phat hien tren sieu am tam ca nguyet hal, 12,5% tren nhtrng thai phu dieutri thu tinh trong ong nghiern va co the len den 25% a nhtrng thai phu xintnrng (Lee va cs, 2010).

TI l~mot mac cua UXCTCtang thea tudi nen ti l~ thai phu co UXCTCcung tangthea tudi va tien Str thai san. Hien tal chua co dtr li~u ve ti l~ hien mac UXCTCtrong thai ky a cac vung tren the gioi, Nhung tl l~ do duoc nhan thay la tuythuoc vao d(>tudi, thai diem sieu am va chung toe.

ANH HUaNG eOA THAI KY LEN UXCTC

UXCTCthuorrg tang kich thuxrc tu tam ca nguyet mot den hai, nhung co xuhuang nho di dang ke tir tam ca nguyet ba den luc sinh.

StJtang tnrong cua UXCTCphu thuoc vao cac hormones steroids. Estrogen lahormone chinh trong thai ky lam tang kich thuac cua UXCTCdo UXco nhieuth\! the n(>itiet han vai estrogen. Tuy nhien gan day, co bang chlrng cho thaystJ phat trien cua UXCTCcung co l~ thu(>cvao progesterone, trong do th\! thePR-Bco tac d\!ng lam tang kich thuac UXCTC,th\! the PR-Akhong lam thay doikich thuac UXCTC.Da so cac nghien ClrUcho thay UXCTCvan khong thay doikich thuac khi co thai (Aharoni va cs, 1988; Lev-Toaffva cs, 1987; Muram vacs, 1980; Neiger va cs, 2006; Rosati va cs, 1992; Strobelt va cs, 1994; Winer­Muram va cs, 1983). Th~m chi,UXCTCco hi~n tuqng nh6 di ttJ nhien tren 80%ph\! nfr trong 6 thang dau h~u san (Laughlin va cs, 2011). Nhfrng nghien ClrUgan day cung cho thay kich thuac UXCTCon d!nh trong thai ky (tang giam <10% the tich) trong 50 - 60% truang hqp, tang len trong 22 - 32% va giam dia 8 - 27% thai ph\! (Aharoni va cs, 1988; Lev-Toaff va cs, 1987; Rosati va cs,1992).

StJgiam kich thuac UXCTCtrong thai ky co lien quan den stJ thieu mau nuoi alap n(>im~c va cO'ttr cung khi gan sinh. StJ thieu mau nuoi nay van tiep Wchi~n di~n trong giai do~n h~u san, bao gom ca stJ tai cau truc cua h~ thongm~ch mau ttr cung (Aharoni va cs, 1988; Ciavattini va cs, 2016; Lev-Toaffvacs, 1987; Rosati va cs, 1992).

45

ANH HU'CrNG CUA UXCTC LEN THAI KY

Say thai

Trong tam ca nguyet mot, bien chirng thuong g~p nhat la say thai. So luongcling nhu vi tri UXCTCla yeu to tien luong trong say thai. Cac UXCTCa vi triLO,Ll, L2 thea phan 10<:J.iFIGOthi co nguy co' gay say thai cao han so voi cacV! trf khac, Styhien dien nhieu UXCTCtrong co (L4-5) co the kh6ng gay saythai. Trong tam ca nguyet hai, hau het cac nghien ciru kh6ng cho thay bien cobat loi san khoa nao dang chu <; (Benson va cs, 2001).

Sinh non

M9t trong nhirng nguyen nhan gay ra cac ket cue bat loi cho so' sinh tren thaiphu co UXCTCchinh la sinh non. M9t nghien ciru doan h~ hoi ciru cho thay tll~ sinh non cao han a nhtrng thai phu co UXCTC,d~c biet la nhom co UXCTC>3 cm (19,2% vs 12,7%, p < 0.001) (Lai va cs, 2012). Thai diem sinh trung binha cac san phu kh6ng co UXCTC,co UXCTCs 5 em va co UXCTC> 5 em Ian luotla 38,6, 38,4 va 36,S tuan, khac biet nay co <; nghia thong ke (Shavell va cs,2012). Ben canh do, san phu co UXCTCduo! niern < 3 cm co nguy co sinh nontang them 7% (OR 1,5; KTC95%, 1,3-1,7) (Klatsky va cs, 2008). Ngoai ra, phunfr co nhieu UXCTCkhi mang thai cling co nguy cO'sinh non cao han.

Ngoi bat thU'frng

Ngoi thai bat thuang cling kha thuang g~p trong UXCTC.Nhfrng UXCTCtoduai niem lam bien d<:J.nglong tu cung ho~c u xO'nam a dO<:J.nduai co moi lienh~ den tinh tr<:J.ngng6i bat thuang (OR 2,9; KTC95% 2,6-3,2) (Klatsky va cs,2008). M9t nghien cuu tren 72000 thai kY dan thai tu nam 1990 den 2007cho thay ti l~ thai ng6i m6ng tang len dang ke a nhom thai ky co UXCTC(OR1,5; KTC95% 1,3-1,9) (Stout va cs, 2010). M9t vai nghien cuu khac cho thaycac yeu to nhu da UXCTC,UXCTCnam sau banh nhau ho~c dO<:J.nduai tu cung,UXCTCto > 10 cm lam tang ti l~ ng6i thai bat thuang (Lev-Toaff va cs, 1987;Qidwai va cs, 2006; Rice va cs, 1989; Worthen va Gonzalez, 1984).

Thai ch;llm tang trU'Crng

UXCTCanh huang rat ft va gan nhu kh6ng anh huang den stytang truang cllathai (OR 1,4; KTC95% 1,1-1,7) (Exacoustos va Rosati, 1993; Lev-Toaffva cs,1987; Rice va cs, 1989; Shavell va cs, 2012). Tuy nhien nhfrng UXCTCto vaithe tfch > 200 ml co the lien quan den can n~ng tre So' sinh nh6 so vai tuoi thai« bach phan V! 10 clla tuoi thai luc sinh) (Rosati va cs, 1992). UXCTCnam t<:J.i

46

vi tri banh nhau cling co lien quan den thai cham tang tnrong do lam giamtuan hoan tu cung nhau thai.

Oi vfr nonDa so nghien ciru khong ghi nhan sir lien quan gifra UXCTCva oi va non.

Nhieu nghien elm cho thdy UXCTClam tang nguy co nhau bong non, dac bietla nhtrng UXCTCnarn tal vi trf sau banh nhau.

TRItU CHlfNG UXCTC TRONG THAI KYDa so cac UXCTCkhong co trieu chimg trong thai ky. M9t so tnro ng hop co theg~p trieu cluing dau do UXCTCthoai hoa, di kern sot, buon non, non, bach cautang (Katz va cs, 1989). Tan suat dau co mdi lien h¢ voi kich thiroc va thuorigg~p a nhtrng thai phu co UXCTC> 5 ern (Exacoustos va Rosati, 1993; Rice vacs, 1989). Dau thuorig xuat hien a cudi tam ca nguyet mot va dau tam canguyet hai, hie UXCTCa kich thuo'c Ian nhat va co nguy co hoai trr nhat. Hoaitu vo trung UXCTCkhong do thoai hoa trong thai ky thuong rat dau, dieu tr!de gifr thai den du thang rat kho. Dau tren thai phl.1co UXCTCcon duQ'c ly giaila do Sl,l'thuyen t~k m9t phan cac m~ch mau nuoi u XO'khi tu cung phat triento dan trong thai ky (Parker, 2007).

DIEU TR! vA THEO Den

Phl.1nfr mang thai co UXCTCgay ra tri~u chung dau co the can phai nh~p vi~nde dUQ'Cdieu tr! phu hQ'p.

Dieu tr! ho trQ'va giam dau acetaminophen la can thi¢p ban dau. Nhfrng thuocgiam dau opioid vai lieu chuan ho~c giam dau non-steroids keo dai trong 48gia co the dUQ'cdung neu nhu cac bi~n phap giam dau khac khong hi~u qua.Giam dau vai ibuprofen (indomethacin) chi nen dU'Q'csu dl.1ngdoi vai nhfrngthai nh6 hO'n 32 tuan do nguy cO'co the lam dong ong d9ng m~ch sam, lamtang ap ph6i sO'sinh, da ai, va th~m chi la roi lo~n chuc nang tieu cau cho thai(Dildy va cs, 1992).

M6 lay thai (MLT) tren thai phl.1co UXCTCchi nen thl,l'chi¢n khi co chi d!nhsan khoa (UXCTCtien d~o) ho~c chi d!nh lien quan den thai (ngoi bat thU'ang,CDngung tien trien, thai suy cap).

Kh6ng nen phau thu~t boc UXCTCtrong MLT m9t cach thU'ang quy. Can danhgia ky nguy cO'- lQ'ifch cling nhU' can nh~k ky nang va kinh nghi¢m cua phauthu~t vien, lU'Q'ngmau dl,l'tru, so lU'Q'ng,V!trf va kich thU'ac cua UXCTC.

47

Kh6ng co sty lien quan gifra phau thuat boc UXCTC trong MLT voi nhtrng ketcue bat loi lau dai,

Nhirng UXCTCnam {y thanh truce doan duoi tu cung co tien hrong rna lay thaikho hon u XO' nam {y cac vi tri khac, UXCTCnam thap doan duot co kha nanggay be san dich sau rna dan den bien clnmg viern n9i mac tu cung neu kh6ngdiroc xu tri kip thai. Do do co the can nhac boc nhan XO' khi rna lay thai. Hausan hay hau phau rna lay thai {y nhtrng benh nhan co UXCTCdean duoi, candanh gia san dich m6i ngay ve hrong, tfnh chat (mau, mui] va kham am dao,co tu cung, danh gia sinh hieu de phat hien kip thai dau hieu be san dich, Neuco hien tuong be san dich, can nong co tu cung de xu trf.

Boc UXCTC{y vi tri thanh tnroc doan duoi tu cung, UXCTCco cudng, duoithanh mac (LS-6-7) trong cuoc MLT kh6ng lien quan den cac yeu ta bat lqiquanh phau thu~t va duqc xem la an toano

a nhfrng b~nh nhan da tung boc UXCTCdOC;lnduai tu cung trong hIc MLT, cothe cho thu sinh nga am dC;lO{y nhfrng Ian mang thai ke, nhung phai thea d6irat sat.

48

CHU'O'NG XIV.NHfrNGDiliUClNGHINH&',,?, ?

VE XU' TRI U XO' CO' TU' CUNG

UXCTCla khdi u vung chau lanh tinh thuong g~p nhat a phu nu.

Yeuto nguy co gam: chung toe da den, tudi, tinh trang tien man kinh, cao huyetap, benh si'r gia dinh, thai gian ke tir Ian sinh truce dai (han 5 narn], phu giathuc pham va sua dau nanh, Yeu to giam nguy Co' gam hut thudc la, chi so khdiCo' the thap, da san, dung thuoc vien ngira thai hay DMPA.

Benh ly UXCTCkh6ng duoc hieu r5 tuy nhien nQi tiet steroids dong vai trothen chdt, Trong do thu the progesterone dong vai tro quyet dinh trong su'phat trien cua UXCTC.

Da so kh6ng co trieu chimg Himsang.

Phan loai UXCTCthea FIGOgop phan giai thich trieu chung rna khdi u gay racling nhu anh huang den phuorig phap va ket qua dieu tri, U xo' duoi niemmac thuorrg duoc phan Ioai thea STEP-w.

Can chan doan phan biet vot benh tuyen-co ti'r cung (adenomyosis) vasarcoma Co' trO'n ti'r cung (leiomyosarcoma), xuat huyet ti'r cung bat thuang vakhoi u vung ch~u nhu u buang trung.

Bien chung thuang g~p cua UXCTCla xuat huyet tu cung bat thuang, thoaihoa, dau va chen ep. Bien chung hiem g~p gam thuyen tac m~ch, suy th~n, xuathuyet trong phuc m~c, huyet khoi tinh m~ch m~c treo rUQtva thoai hoa mu.Thoai hoa ac rat hiem.

Sieu am la phuO'ng phap dau tay giup chan doan UXCTCva phan bi~t vai b~nhtuyen-cO' ti'r cung (adenomyosis). MRI la phuO'ng phap chan doan hinh anhchinh xac nhat cho phM hi~n, v! tri va phan lo~i khoi u. CTgia tr! thap do kh6ngphan d!nh dUQ'cu vai niem m~c hay Co' ti'r cung. Sieu am bam nuac long tucung dUQ'cde ngh! cho u xO'duai niem m~c. Sieu am 3 D va nQi soi buang ti'rcung gia tr! giai h~n trong chan doan. Sieu am mau kh6ng giup phan bi~t ulanh hay ac.

49

DIEU TRJ

Phu nu khong co trleu chimg: din thea dot can than Slf phat trtencua u

Nen theo d5i dinh ky m6i narn tnr tnrorig hop UXCTCgay than u nurrc miredQtrung binh hay nang, hoac u xo' duoi niem mac va muon co thai.

Phu nil' man kinh: phan Ian sau man kinh khdi u se thoai trien, tuy nhien phunil' beo phi va dung noi tiet thay the u xo' se kh6ng nho di.

Nen loai tnr sarcoma (y phu nil' man kinh khi co u vung chau Ian nhanh haymoi xuat hien, Tan suat sarcoma la 1-2% &phu nil' man kinh neu u to nhanh,hay moi xuat hien, ra huyet am dao bat thuong hay dau vung chau

Dieu tr] nQi khoa UXCTC

Di'eu tri giiim chiiy mau nhieu va giiim kich thtnrc kh{ii u

Gam khang viern non-steroids, thudc vien ngira thai ket hop, Letrozole,Carbegoline, Progesterone va chat dieu hoa chon 19Cthu the estrogen: quacac nghien cuu RCTcho muc dQchung cu thap.

RCTcho thay LNG-IUSgiam mat mau va giam kich thuac khoi u so vai thuocvien ngua thai ket hQ'ptuy nhien m~u nho (n=58).

Dung GnRHdong v~n truac ph~u thu~t la co hi~u qua han so vai progesteroneuong va LNG-IUStrong cuang kinh n~ng va giam kfch thuac UXCTC.Hau hetcac UXCTCse phcit trien tr& l'ilingay khi ngung GnRH.Neu dmu trt GnRHkeodai han 6 thang se gay thieu h\!t estrogen va progesterone.

Chat dieu hoa ch9n 19Cth\! the progesterone (SPRM): hi~u qua dieu trt giamxu;1t huyet n~ng va giam kich thuac khoi UXCTC.So vai GnRH, dieu tr! vaiSPRMit tac d\!ng ph\! han va cho hi~u qua keo dai han. SPRMgay bien doi nQim'ilctu cung nhung se hoi ph\!c hoan toan sau dieu trio

Dieu trj phdu thuQ-t UXCTCco tri~uch(rngDieu tr! ph~u thu~t UXCTCcan phai duQ'c tu van day du va kY cam ket, hyach9n phuang phap ph~u thu~t dtya tren nhu cau suc khoe cua b~nh nhan.Trong boi canh co nhieu tien bQ trong dieu tr! nQi khoa va moi quan ng'ilivetang nguy Co' man kinh sam 2-3 nam tren ph\! nil' ca.t tu cung chua 1-2 buongtrung, chi dinh ph~u thu~t can dUQ'ccan nhac thtyc hi~n tren tung doi tUQ'ngC\!the.

50

Cac phau thuat gam boc nhan XO'co til cung (nQi sol, rna bung] cat til cung(nQi sol, rna bung), nQi soi buong til cung cat nhan XO'.Lira chon loai phauthuat tuy thuoc VaG:trieu clnmg, V!tri kich thurrc so hrorig nhan XO',tudi, socon va mong muon co thai trong tuong lai, tuy thuoc VaGphau thuat vien vatrang thiet bi cua benh vien,

Roc u XO' co tir cung

a nguot muon bao ton til cung chi dinh boc UXCTCcho tnrong hop u XO'cobien chimg gay chay mau nang, dau, chen ep, vo sinh va say thai tai phat, Phunfr nen duoc tham van ve nguy co cat til cung trong luc phau thuat, Khoang15% u XO'se tai phat va khoang 10% u XO'tai phat phai rna lai ca.t til cung 5-10 nam sau khi phau thuat,

Mo'bung nen thuc hien doi voi nhtrng u XO'Ian. Co the rna bung voi duorigrach da nho cho nhtmg u XO'Ian hay da u XO'.NQisoi boc nhan XO'nen th\fchi~n a nhfrng khoi u XO'duai thanh m~c hay trong ca. Co the ket hqp nQi soiboc nhan xO'va rna bl;lngnh6 trong nhfrng ca UXCTCIan va nhieu nhan. Robottrq giup nQi soi boc nhan xO'cho den nay khong thay co lqi so vai chi nQisoi.

NQisoi buang til cung la ch9n l\fa dau tien cho boc nhan xO'trong buang tilcung.

Boc nhan xO'qua nga am d~o co the th\fC hi~n a nhfrng nhan xO'nam a cungdo sau.

Nguy cava til cung a thai phl;l co tien can rna boc UXCTC.Nguy cO'0-4% neurna bl;lng 0-10% neu nQi soi boc u. Tranh dot nhieu va khau nhieu lap khi bocnhan xO'de giam nguy cava til cung khi co thai. Hi~n nay may bao khong nensil dl;lngkhi boc nhan xO'nQisoi do nguy cO'lam rO'ivai te bao ung thu, a bl;lngb~nh nhan khong duqc biet la ung thu til cung. Nen lay u trong bao.

Cattircung

Cit til cung la dieu tr! tri~t de cho nhfrng truang hqp UCTCco bien chung. Chid!nh: UXCTCkhong co tri~u chung nhung to a phl;l nfr man kinh khong dungnQitiet thay the. UXCTCgay xuat huyet rna dieu tr! nQi khoa that b~i, UXCTCco tri~u chung n~ng, du con, mong muon duqc dieu tr! tri~t de.

Dieu trj thay the phfiu thm~t

Thuyen tac dQngm~ch til cung (Nut m~ch tu cung - UAE)co the can nhac thaycho phau thu~t a phl;l nfr UXCTCco bien chung nhung khong con muon duytri kha nang sinh san. Tuy nhien hi~u qua cua phuO'ng phap nay khong cao.

51

--------------------------------------------------------------- _. ----------------

UAE chong chi dinh a UXCTCco curing, duot niern mac, kich thuo'c u qua Ion,co tien can that dong mach ha V! va chua co con. Sau UAEco 14,4% can phaican thiep them nhu rna cat til cung, boc nhan xo.

Cho den nay bang chimg yeu ve hieu qua cua sieu am tan so cao duoi huangd~n cua MRItrong dfeu tri UXCTC.

UXCTC dtnri niem

GnRHva SPRMhieu qua giam chay mau a phu nil trong tudi sinh san co nhanxo' dtroi niern (bang chtrng manh).

Leuprolide va SPRMtrurrc ph~u thuat nQisoi cho hieu qua cai thien ket cuocphau thuat, nhung hien nay chua co bang chtmg dung thuorig quy trurrc nQisoi buong til cung cat nhan xo diroi niern mac,

NQisoi buong til cung hieu qua trong cat UXCTCduot niem, can nhac nQisoibung hay rna bung trong tnrorig hop phirc tap UXCTCkich thuo'c > 4cm). NQisoi buong til cung cat nhan xo se lam tang tY l~ co thai a phu nil va sinh.

Cac phurmg phap lam chin muoi co til cung nhu laminaria, prostaglandin E1lam giarn thai gian ph~u thuat nQisoi buang til cung.

Chuc}n b! phftu thu~t

Truac ph~u thu~t cac GnRHva SPRMlam cai thi~n ket cUQc ph~u thu~t, chatuc che aromatase, thao duqc khong co bang chung co lqi, Danazol co h<;li(chung cu m<;lnh).

Trong ph~u thu~t: tiem vasopressin giam chay mau khi boc u (bang chungm<;lnh).Bang chung yeu khi tiem bupivacain ket hqp epinephrine, tranexamicacid, dinoprostone, bUQtquanh co til cung hay quanh co til cung va day changrQng de giam chay mau khi boc nhan xa. Oxytocine, k~p dQng m<;lchtil cungt<;lmthai khong co hi~u qua giam mat mau.

Tranh dinh: khong co hi~u qua.

UXCTC va hiem mUQn

UXCTCanh huang xau len kha nang sinh san do yeu to ca h9Cva sinh h9C.NennQi soi buang til cung cat nhan xa duai niem de lam tang tY l~ co thai. Chuadu bang chung boc u xa kich thuac Ian trong ca se tang ty l~ co thai. Neu b~nhnhan lam thl,l tinh trong 6ng nghi~m that b<;linen can nhac boc UXCTC.UXCTCduai thanh m<;lckhong anh huang den va sinh. UXCTCduai niem va gay bien

52

dang long ttr eung gay say thai lien th~p va that bai lam ta nhieu Ian nen duocphau thuat,

UXCTC va thai

Tan suat khoang 2,7%. Thuong to len trong tam ca nguyet 1 va 2 cua thai ky,thoai trien (y tam ca nguyet 3 hay hau san.

UXCTCco the gay sinh non, oi va non, nhau tien dao, nhau bong non, thai champhat trien trong ttr cung, thai chet, bang huyet sau sinh, ngct bat thuong,chuyen da keo dai,

Khong nen boc nhan XO' thuorig quy khi rna lay thai (y thai phu co nhan XO' cottr cung, can nhac gifra lot ich va nguy co, kha nang mat mau, trinh d9 va kinhnghiern cua phau thuat vien, vi tri kich thuoc cua u XO' va lira chon cua benhnhan,

53

TOM TATHUUNGDANTHVCHANH LAM SANG

?,. ?

XU TRI U xo co TU CUNG (UXCTC)

Chu yeu la u lanh tinh cua til cung, ty l~ thoai hoa ac tinh rat thap (# 0,16- 0,28%).

- Tien trien thuong cham, lang Ie, qua nhieu narn, khong trieu chirng: neu uto nhanh, nhat la a tudi quanh man kinh hoac sau man kinh, (khoang tir40 den 60), can nghi ngay den thoai hoa ac tinh,

- U phu thuoc vao hormones sinh due, estrogens, progesterone, vatestosterone.

- U c6 the gay ra nhieu bien clnrng nang, thuorig g~p nhat do vi trf cac khdiu, la xuat huyet til cung bat thuong (XHTCBT)va cac trieu chung do chenep cac co quan Ian can, UXCTCco the co anh huang den thai ky, hiemmuon, say thai va say thai lien tiep.

FIGO (Hiep hQi San Phu Khoa Qutic te) dira ra bang phan I09-imoi, narn2011, da duoc dong thuan sil dung tren toan cau, dua tren vi tri va sohrorig khdi u.

54

Bang 1.Phan loai UXCTC tbeo FIGO, 20ll.I±] •

UXCTC o Cocuong, !rong bu6ng tU cung

> 50% trong bu6ng til cung

2 ::;50% trong bu.dngtU cung

3 Duoi niem nhung 100% trong co nr cungO-Kbac

4 Hoan toan nk trong co ro cung

:5 Dum thanh mac, ?: 50% trong CCI nr cung

6 Duoi thanh mac, < 50% trong co tU cung

7 Duoi thanh mac, co cudng

8 Vi tri khac (cd to- cung, cac co quan quanh tvcung)

N~uu XO' n&:ntrou trong co va !6i ra duoi niem va duoithanh mac, co th~ co 2 s6 cbl vi tri khdi u, 2-S, each MaUbdng 1 gach nBi.Theo quy IlOC, s6 dau chi kh6i u giinniemmac, s6 san chi kh6i u giln thanh mac,

UXCTC Duoi niem va duoi thanhmac « 50% nk(L2.S) !rong long tU cung va < 50% 16ifa duoi thanh

m;lC, hooug "ao d b\}ng).

Chan doan dva vao tri~u ch(mg Himsang va sieu am dau do am d~o, sieuam nga b\mg, sieu am co bam nuac, sieu am Doppler. Doi khi, de chandoan phan bi~t, can co cQnghuang tu (MRI).

Dieu tri:

• Xu huang hi~n nay la giam bot chi dinh ph~u thu~t cat til cung, keca boc nhan xO'vi da co nhieu lo~i thuoc giup dieu tr! nQikhoa rat hi~uqua.

• Neu u khong co trieu chung: khong dieu tr! rna chi can thea d6i cactri~u chlrng XHTCBTva tri~u chlrng chen ep. Doi vai ph\).nCrtuoi mankinh can thea d6i tien trien sang ac tinh, nhat la khi u to nhanh. Huangd~n b~nh nhan kham ph\).khoa d!nh kY 6 - 12 thang mQt Ian, moi Iang~p, nen hoi va danh gia ky cac tri~u chlrng lam sang, sieu am thea d6isv phat trien cua khoi u.

• Neu u co trieu chfrng XHTCBTnang hoac chen ep nang. nhat la anguai da Ian tuoi, co du con, nen can nhac chi d!nh ph~u thu~t sau khitu van kY ve cac thu~n 19'iva nguy cO'cua tung bi~n phap dieu tr! va deb~nh nhan tv Iva chQn, co cam ket bang van ban. Neu co UXCTClo~i

55

LO,Ll, L2: <lieu tri n9i khoa de cham dut xuat huyet, tien hanh n9i soibuong tu cung, cat cac khdi u. Neu benh nhan chua can co thai ngay,co the d~t dung cu tu cung co chua progestin (levonorgestrel) de nganchan dinh buong tu cung va tai phat trieu chung,

• Neu cac trieu ch..rng khong nang: co the <lieutri n9i khoa ngay, ke cacac truong hop da nhan XO'hay nhan XO'to, loat L3.

cAc THUnC co THE sir D1)NGTRONGDIEU TR! N(n KHOAUXCTC

1. Tranexamic acid chong ly giai fibrin. Co the su dung:

Duong ucng: vien Transamin 250 mg hoac 500 mg, 1vien x 3 Ian m6i ngayden khi ngirng xuat huyet, Lieu toi da: 750 mg - 2000 mg/24 gio.

Hoac duong tiern (ong thudc co ham luong 250 mg hoac 500 mg/5mL) :250 - 500 mg/ngay tiem bap hay tinh mach, dung 1 - 2 lan/ngay truce khimd hoac neu xuat huyet trong hay sau phftu thuat 500 - 1000 mg/lan tiemtinh mach hoac 500 - 2500 mg pha trong 500 mL dung dich glucose 5%hay dung dich co chat di~n giai, truyen nho giot tinh mach 24 gio.

Can than tren benh nhan dang <lieutr! huyet khoi tinh mqch, suy th~n hayqua mftn v&ithuoc.

2. Thuoc vien nQi tiet ket hQ'p tranh thai (TVNTKHTT) co the su dl,lngnhung hi~u qua thuang ch~m.

3. Cac lo~i Progestins, uong hay d~t trong dl,lngCl,ltu cung (LNG-IUS- vangMirena), hi~n nay it su dl,lng vi sQ'i cO' cua UXCTC co nhieu thl,l theprogesterone cling nhu estrogens nen co the lam u to len. Yang Mirena co theduQ'Csu dl,lng sau khi dieu tr! ngung XHTCBT.

4. GnRH dong v~n uc che tuyen yen che tiet FSHva LHsau tiem khoang 7 -10 ngay (do tac dl,lng flare-up ngay sau tiem). Do uc che n9i tiet nen giam cachormones steroids &buang trung, khoi UXCTCgiam the tich, giam xuat huyettu cung. Khi ngung thuoc, khoi u to tr& lqi cung vcYicac tri~u chung. Lieu sudl,lng: Zoladex 3,6 mg ho~c Dipherelin 3,75 mg m6i ong, tiem dUcYida ho~ctiem bap, 4 tuan m9t Ian. Cothe tiem toi da 6 Ian vi cac tac dl,lngphl,lgay tri~uchung giong man kinh va lam giam m~t d9 xuO'ng.Co the su dl,lngGnRHdangv~n 3 thang, ngung khoang 2 tuan trucYcmo.

5. Thuoc dieu hoa th1;1the progesterone co chQn IQc (SPRMs):

56

Mifepristone: (su dung off-label de dieu tri UXCTC),chu yeu gan vao thuthe PR-Anen co the lam giam the tich khoi u va tu cung khoang 50% sau3 thang va cung lam ngirng XHTCBT.Lieu su dung: co the 5 - 10 mg, udngm6i ngay mot vien den khi ngung xuat huyet, Mifepristone co the gay dayNMTC,nhung khong phai la tang san hay ung thu, Can theo d6i dQ dayNMTCtrong khi uong, Do co che tac dung la ll'Cche nQitiet, nen khi ngungsu dung, co tai phat,

Ulipristal acetate (UPA): CO'che tac dung la lam tang chet te bao thea l~ptrinh (apoptosis) va lam giam mo nen trong khai u nen it ta! phat sau khingung thudc, UPAkhong co tac dung tren sot co binh thuong cua khci u,khong ll'Cche true ha dai-tuyen yen-buong tnrng nen khong gay trieuchirng man kinh nhu GnRHdong van, Ucng UPA5 mg, mot vien m6i ngayco the lam ngung XHTCBTtren 91% b~nh nhan va lam ngung xuat huyetsau 10 ngay dieu tr1 tren 50% b~nh nhan. kfch thuac khoi u giam 25% sau13 tuan.

each sir dung UPA:

• Kham va xet nghi~m toan di~n, chu y chll'c nang gan truac khi cho sudl;lng UPA. Neu AST va/ho~c ALT tang gap 2 Ian gia tr! cao binhthuang, khong cho su dl;lng.

• Uang UPA 5 mg, m6i ngay 1vien x 3 thang mQt dqt. Trong khi dieu tr1,xet nghi~m chll'c nang gan m6i thang mQt lan, neu AST va/ho~c ALTtang gap 2 Ian, ngung su dl;lng. Sau 13 tuan, ngung su dl;lng va xetnghi~m l<;l.ichll'c nang gan.khoang 2 -3 tuan sau.

• Neu chll'c nang gan v~n binh thuang, cho uang tiep dqt 2 sau khi nghithuac 2 thang, lieu luqng va thea d6i nhu tren.

• Neu can thiet, co the ho uang den 4 - 8 dqt, hai dqt each nhau 2 thang.

• Nhfrng dqt sau, chi xet nghi~m truac va sau m6i dqt dieu tr!.

Tac dung phu UPA: nhll'c dau, dau bl;lng,cang ngV'c,lam day NMTCnhungkhong phai tang san hay ung thu. Co the lien quan den ton thuO'ng gannhung chua du chll'ng Cll',ty l~ 8/765000 b~nh nhan da va dang su dl;lng.Sau dieu trL b~nh nhan co the co thai tV'nhien hay ho trq. UPAco the giamchi d!nh ph~u thu~t cat tu cung truac dieu tr! UPA.

57

Dieu tri n(H khoa UXCTCbang UPA la mot bien phap:

• C6 the sfr dung truoc phau thuat lam nho khdi u va trr cung, cai thientinh trang thieu mau,

• C6 the su dung lau dai,

• C6 the thay the phau thuat, nhat la cho phu nu sap man kinh hoacmong muon c6 con, dap irng nguyen vong giu tu cung mot each an toancho hau het benh nhan.

DIEU TR! NGO~I KHOA UXCTC

MQtso tnrorig hop c6 the v§.ncan chi dinh dieutri ngoai khoa: phau thuat b6cnhan XO'tu cung hoac cat tu cung:

1. Hocnhan XO' til' cung: doi voi nhtrng phu ntr

C6 UXCTCc6 bien chimg nhung v§.n muon giu TC rna dieu tri nQi khoakhong thanh cong hoac tien IU'Q'ngkh6 thanh cong vi u to, nhieu nhan,muon diro'c dieu tri nhanh de mang thai.

C6 UXCTCgay hiem muon hoac say thai lien tiep, thuong la khdi u narntrong buong TChoac durri niern mac TC (LO, Ll, L2).

Benh nhan tre, c6 UXCTCgay XHTCBTnang, thieu mau va/ho?c lam biend<;lngbuang TC,ho?c gay dau vung ch~u khong the chiu dl.,l'llgthem.

2. cat til' cung va hai Dngd~n trung: doi vai nhung phI) nu

C6UXCTCnghi nga thoai h6a ac tinh.

C6 qua nhieu nhan XO',dl! kien con rat it ho?c khong con mo lanh sau khib6c het nhan XO'.

Trong khi b6c nhan XO'rna khong kiem soat dU'Q'cchay mau.

PhI) nu Ian tuoi da c6 dli con.

C6b~nh ly kern thea nhU'l<;lcNMTCn?ng, ho?c co b~nh ly co TC.

Neu khi mo cat TC qua kh6 vi TC dinh nhieu vai rUQtva cac cO'quan Ianc~n, c6 the cat TCban phan va 2 ong d§.ntrung.

Doi vai b~nh nhan tren 50 tuoi, can giai thich, cung cap thong tin, va thaolu~n trU'ac vai b~nh nhan ve vi~c nen cat 2 buang trung, khi b~nh nhanva gia dinh c6 quyet dtnh dong y hay khong dong y, nen de nght neu r5trong ta cam ket dong thu~n.

58

Can tu van ey:Co the cat TC qua mo ha thanh bung hay qua n9i soi, duorig am dao haynga bung,

Cac nguy co' va tai bien cua tung phuong phap,

Cung cap thong tin day du nhu, dit TC,du co de lai 2 buong tnmg, v~n cothe lam cho phu nCrman kinh sam 2 - 3 narn ...

Cat 2 ong d~n tnrng kern vo: cat TC la de giarn tY l~ ung thir buong tnrng.

Cat TClam thay doi cau true san chau, co the lam gia tang ty l~ sa tang chausau mo.

Neu benh nhan va gia dinh khong hieu r5 anh huang cua viec cat TC, cothe dira den roi loan chirc nang tam ly, giam libido, anh huang hanh phucgia dlnh sau nay.

3. Chon phuong phap phau thuat de boc nhan XO'hay cat TC: co the bangrna bung ha hay n9i soi, nga bung hay duong am dao, tuy thea cac dieu kienco phau thuat vien dtroc dao tao dung mire va nhieu kinh nghiern, co trang bimay n9i soi va dl;lngCl;lday du, cO'sa co kha nang cap cuu tot, co du cO'so mauva cac thanh phan cua mau. Phai can nhac th~n tr9ng trong tu van cho b~nhnhan, giai thich va thong tin day du ve thu~n lQ'icling nhu nguy cO',tai bien cothe co, de b~nh nhan cung bac Sl ch9n cach xu trf thfch hQ'pnhat.

Tuy b~nh nhan co tham gia vao quyet dinh ch9n phuO'ng phap ph~u thu~t,nhung chung ta can nha, bac Sl ph~u thu~t vien va gay me hai suc v~n la nguaichiu trach nhi~m chinh khi co tai bien xay ra.

59

Biiu ita 1.Phdc ita xu trl u xa ca tii' cung.

I xli TRfu xo co Tli CUNG IDi'eu trj nQikhoa

- Dieu trj sam, khi co tri~u chlrng dau.

- Giam dau va giam wang kinh:• Khangviem khong steroids.• Tranexamic acid.• Thudc vien nQitiat kat hQ'ptranh thai l+-• Progestins

- Dieu trj goc:• GnRHdfJng v~n.• SPRMs

o Mifepristone.o Ulipristal acetate.

3phltang ____.phap

dieu tr]

Dieu trj ngo,i khoa

- Boc nhan XO':

• NQisoi buong t.r cung (LO,Ll, l2)

• NQisoi e bung.• Me bunghc1.

- dt t.r cung ± 2 buong trlrng• Qua nQisoi e bung

• Qua me hc1.

Thu thu,t thay the phiu thu,t

- Tic mach t.r cung b~ng UAE.

- Tieu huy nhan u XO' ca t.r cung b~ng nhi~t.

- Tieu huy nhan u XO' ca tli cung b~ng songcao tan.

60

Bi€u aJ 2. U xu ca Iii' cung ali chOn dodn xdc dinh, co sieu tim, co Irifu clueng.

covE

~'!:J (<11c -5". C.I:. "<00. "E

e·0v

C<Q)

I~~.'iii 2-5 0'0 ~u"" uc )("Q.

'<11 0.s::.s::....<0..;..l;).s::U

-,;)'u VI ..cou C C

-.-~..~',. 'E ~~ eco .B:c V') ~x VI :.:: ::>Q) Q) t- o ""c ""2 \!) .B 1i:co £~t= 52..::>

61

Bi€u db 3. Phdc db tliJu tri nri khoa u xa co tii' cung bdng UPA.

~:::>\.!:)z

"<1:CO\.!:)Z:::>u;!::lI-'bu~:::><1:o:r::::.:::

<0'ZiX'I-:::>

,<U.Jas,<0Ci:Iu'<1::r:Q.

r0-os:..>::.sc

E<(],)':.ceoc...,,(],)x

00c:.",

:5MX>-.",OJ)

~E'"«Q.:;)

c!ibtlI)C'('0

"11----1 Cu''!:ls:uE.(],).

1-0----.1 :.ceoc...,,(],)x

62

Bi€u (/6 4. Phdc (/6 xi( trt u xa co Ii( cung L2 ho(icda nhtin xu L2-L5 if phI! nii' luJi sinh (/e•

TAllI~U THAMKHAo

._. 0..c ....C C

!en:! !(C't!> >tlD :lC -<0B~.~ U+01 ltV.tlD 0C..t::.,<g L..c (~.:l -

<Q) >Z ""'0

'n; c£ ~~·o..t::.u C.~~...t::. ....I-

63

Abdel-Hafeez, M., Elnaggar,A., Ali, M., Ismail, A. M., & Yacoub, M. (2015). Rectal misoprostol for myomectomy: A randomisedplacebo-controlled study. The Australian & New Zealand Journal of Obstetrics & Gynaecology, 55(4), 363-368.https://doi.org/l0.llll/ajo.12359

Aharoni, A., Reiter, A., Golan, D., Paltiely, Y.,& Sharf, M. (1988). Patterns of growth of uterine leiomyomas during pregnancy.A prospective longitudinal study. British Journal of Obstetrics and Gynaecology, 95(5), 510-513.https://doi.org/l0.ll11/j.1471-0528.1988.tb12807.x

Alizadeh, r; Faramarzi, S., Saidijam, M., Alizamir, T., Esna-Ashari, F., Shabab, N., & Farimani Sanoee, M. (2013). Effect ofintramural myomectomy on endometrial HOXAI0 and HOXAll mRNAexpression at the time of implantation window.Iranian Journal of Reproductive Medicine, 11(12), 983-988.

American Association of Gynecologic Laparoscopists (AAGL):Advancing Minimally Invasive Gynecology Worldwide. (2012).AAGL practice report: Practice guidelines for the diagnosis and management of submucous leiomyomas. Journal ofMinimally Invasive Gynecology, 19(2), 152-171. https://doi.org/1O.1016/j.jmig.2011.09.005

American Association of Gynecologic Laparoscopists (AAGL):Advancing Minimally Invasive Gynecology Worldwide. (2014).AAGL practice report: Morcellation during uterine tissue extraction. Journal of Minimally Invasive Gynecology, 21(4),517-530. https://doi.org/l0.l016/j.jmig.2014.05.010

American College of Obstetricians and Gynecologists (ACOG) Committee opinion no. 557 (2013): Management of acuteabnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol, 121(4), 891-896.https://doi.org/l0.l097/01.AOG.0000428646.67925.9a

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Gynecology. (2001). ACOGpractice bulletin No. 16. Surgical alternatives to hysterectomy in the management of leiomyomas. May 2000 (replaceseducational bulletin number 192, May 1994). International Journal of Gynaecology and Obstetrics: The Official Organof the International Federation of Gynaecology and Obstetrics, 73(3),285-293.

American College of Obstetricians and Gynecologists (ACOG)Committee Opinion No 701. (2017). Obstetrics & Gynecology,129(6), e155-e159. https://doi.org/l0.l097/aog.0000000000002112

American College of Obstetricians and Gynecologists (ACOG)Practice Bulletin No. 96: Alternatives to Hysterectomy in theManagement of Leiomyomas. (2008). Obstetrics & Gynecology, 112(2), 387-400.https://doi.org/l0.1097/AOG.Ob013e318183fbab

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins Gynecology. (2009). ACOGpractice bulletin No. 104: Antibiotic prophylaxis for gynecologic procedures. Obstetrics and Gynecology, 113(5), 1180-1189. https:j/doi.org/l0.l097 /AOG.Ob013e3181a6dOl1.

American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 128. (2012). Obstetrics & Gynecology,120(1), 197-206. https://doi.org/l0.l097/aog.Ob013e318262e320

American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin No. 195: Prevention of Infection AfterGynecologic Procedures. (2018). Obstetrics and Gynecology, 131(6), el72-e189.https://doi.org/l0.1097/AOG.0000000000002670

ASEANclincal practise guidelines on managing symptomatic uterine fibroids.

Bagaria, M., Suneja, A., Vaid, N. B.,Guleria, K.,& Mishra, K. (2009). Low-dose mifepristone in treatment of uterine leiomyoma:A randomised double-blind placebo-controlled clinical trial. Aust N Z J Obstet Gynaecol, 49(1), 77-83.https://doi.org/l0.1111/j.1479-828X.2008.00931.x

Ben-Nagi, J., Miell, J., Mavrelos, D., Naftalin, J., Lee, c., & Jurkovic, D. (2010). Endometrial implantation factors in women withsubmucous uterine fibroids. Reproductive BioMedicine Online, 21(5), 610-615.https://doi.org/l0.l016/j.rbmo.2010.06.039

Benson, C. B., Chow, J. S.,Chang-Lee,W., Hill, J.A., & Doubilet, P.M. (2001). Outcome of pregnancies in women with uterineleiomyomas identified by sonography in the first trimester. Journal of Clinical Ultrasound: JCU, 29(5), 261-264.https://doi.org/l0.1002/jcu.l031

Bhave Chittawar, P., Franik, S., Pouwer, A. W., & Farquhar, C. (2014). Minimally invasive surgical techniques versus openmyomectomy for uterine fibroids. The Cochrane Database of SystematiC Reviews, (10), CD004638.https://doi.org/l0.l002/14651858.CD004638.pub3

Blandon, R.E.,Bharucha, A. E.,Melton, L. J.,Schleck,C. D., Babalola, E.0.,Zinsmeister, A. R.,& Gebhart, J. B. (2007). Incidenceof pelvic floor repair after hysterectomy: A population-based cohort study. American Journal of Obstetrics andGynecology, 197(6), 664.el-7. https://doi.org/l0.l016/j.ajog.2007.08.064

Borah, B.J., Laughlin-Tommaso, S.K.,Myers, E.R.,Yao,X.,& Stewart, E.A. (2016). Association Between Patient Characteristicsand Treatment Procedure Among Patients With Uterine Leiomyomas. Obstetrics & Gynecology, 127(1), 67-77.https://doi.org/l0.l097/aog.0000000000001160

Breech LL Rook JA. (2003). Leiomyomata uteri and myomectomy. In Te linde's operative gynecology. In RockJA , Jones III HWr eds (9th ed.). Philadelphia: PA:JBLippincott Co.

Bulun, S. E. (2013). Uterine Fibroids. New England Journal of Medicine, 369(14), 1344-1355.https://doi.org/l0.l056/nejmra1209993

64

Burn, P. R., McCall, J. M., Chinn, R. J., Vashisht, A., Smith, J. R., & Healy, J. C. (2000). Uterine Fibroleiomyoma: MR ImagingAppearances before and after Embolization of Uterine Arteries. Radiology, 214(3), 729-734.https://doi.org/1O.1148/radiology.214.3.rOOfe07729

Buttram, V. c., & Reiter, R.C. (1981). Uterine leiomyomata: Etiology, symptomatology, and management. Fertility and Sterility,36(4), 433-445. https://doi.org/10.1016/s0015-0282(16)45789-4

Cao, M., Qian, L., Zhang, X., Suo, X., Lu, Q., Zhao, H., ... Suo, S. (2017). Monitoring Leiomyoma Response to Uterine ArteryEmbolization Using Diffusion and Perfusion Indices from Diffusion-Weighted Imaging. BioMed Research International,2017. https://doi.org/10.1155/2017/3805073

Carranza-Mamane, B., Havelock, J., Hemmings, R., Reproductive Endocrinology And Infertility Committee, & SpecialContributor. (2015). The management of uterine fibroids in women with otherwise unexplained infertility. Journal ofObstetrics and Gynaecology Canada. 37(3), 277-285. https://doi.org/10.1016/S1701-2163(15)30318-2

Centers for Disease Control and Prevention. "Top CDC Recommendations to Prevent Healthcare-Associated Infections".Retrieved from https://www.cdc.gov/HAI/pdfs/hai/top-cdc-recs-factsheet.pdf.

Chabbert-Buffet, N., Esber, N., & Bouchard, P. (2014). Fibroid growth and medical options for treatment. Fertil Steril, 102(3),630-639. https://doi.org/10.1016/j.fertnstert.2014.07.1238

Chiaffarino, F., Parazzini, F., Vecchia, c., Marsico, S., Surace, M., & Ricci, E. (1999). Use of oral contraceptives and uterinefibroids: Results from a case-control study. BJOG:An International Journal of Obstetrics and Gynaecology, 106(8), 857-860. https://doi.org/l0.1111/j.1471-0528.1999.tb08409.x

Ciavattini, A., Delli Carpini, G., Clemente, N., Moriconi, L.,Gentili, C., & Di Giuseppe, J. (2016). Growth trend of small uterinefibroids and human chorionic gonadotropin serum levels in early pregnancy: An observational study. Fertility andSterility, 105(5), 1255-1260. https://doi.org/l0.l016/j.fertnstert.2016.0l.032

Cook, H., Ezzati, M., Segars, J. H., & McCarthy, K. (2010). The impact of uterine leiomyomas on reproductive outcomes.Minerva Ginecologica, 62(3), 225-236.

Darouiche, R.0., Wall, M. J., Itani, K.M. F.,Otterson, M. F.,Webb, A. L., Carrick, M. M., ... Berger, D. H. (2010). Chlorhexidine­Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. New England Journal of Medicine, 362(l}, 18-26.https://doi.org/1O.1056/NEJMoa0810988

DayBaird, D., Dunson, D. B.,Hill, M. c., Cousins,D.,& Schectman, J.M. (2003). High cumulative incidence of uterine leiomyomain black and white women: Ultrasound evidence. American Journal of Obstetrics and Gynecology, 188(1), 100-107.https://doi.org/10.1067/mob.2003.99

De Vivo, A., Mancuso, A., Giacobbe, A., Maggio Savasta, L., De Dominici, R., Dugo, N., ... Vaiarelli, A. (2011). Uterine myomasduring pregnancy: A longitudinal sonographic study. Ultrasound in Obstetrics & Gynecology, 37(3), 361-365.https://doi.org/l0.l002/uog.8826

DeWaay, D. (2002). Natural history of uterine polyps and leiomyomata. Obstetrics & Gynecology, 100(l}, 3-7.https://doi.org/l0.l016/s0029-7844(02)02007-0

Dhamangaonkar, P. c., Anuradha, K.,& Saxena,A. (2015). Levonorgestrel intrauterine system (Mirena): An emerging tool forconservative treatment of abnormal uterine bleeding. J Midlife Health, 6(1), 26-30. https://doi.org/10.4103/0976-7800.153615

Dildy, G. A., Moise, K. J., Smith, L. G., Kirshon, B., & Carpenter, R.J. (1992). Indomethacin for the treatment of symptomaticleiomyoma uteri during pregnancy. American Journal of Perinatology, 9(3), 185-189. https://doi.org/10.1055/s-2007-999317

Divakar, H. (2008). Asymptomatic uterine fibroids. Best Practice & Research. Clinical Obstetrics & Gynaecology, 22(4), 643-654. https://doi.org/l0.l016/j.bpobgyn.2008.0l.007

Donnez, J.,Tatarchuk, T. F., Bouchard, P.; Puscasiu, L.,Zakharenko, N. F., Ivanova, T., ... Group, P. I. S. (2012). Ulipristal acetateversus placebo for fibroid treatment before surgery. N Engl J Med, 366(5), 409-420.https://doi.org/l0.l056/NEJMoa1103182

Donnez, Jacques, Arriagada, P., Marciniak, M., & Larrey, D. (2018). Liver safety parameters of ulipristal acetate for thetreatment of uterine fibroids: A comprehensive review of the clinical development program. Expert Opinion on DrugSafety, 17(12), 1225-1232. https://doi.org/l0.l080/14740338.2018.1550070

Ewalds-Kvist,S.B.M., Hirvonen, T., Kvist, M., Lertola, K.,& Niemela, P.(2005). Depression, anxiety, hostility and hysterectomy.Journal of Psychosomatic Obstetrics & Gynecology, 26(3), 193-204. https://doi.org/l0.1080/01443610400023163

Exacoustos, c., & Rosati, P. (1993). Ultrasound diagnosis of uterine myomas and complications in pregnancy. Obstetrics andGynecology, 82(l}, 97-10l.

Faivre, E., Surroca, M. M., Deffieux, X., Pages, F., Gervaise, A., & Fernandez, H. (2010). Vaginal Myomectomy: LiteratureReview. Journal of Minimally Invasive Gynecology, 17(2), 154-160. https://doi.org/l0.l016/j.jmig.2009.12.007

Fanning, J., & Valea, F. A. (2011). Perioperative bowel management for gynecologic surgery. American Journal of Obstetricsand Gynecology, 205(4), 309-314. https://doi.org/l0.l016/j.ajog.2011.05.010

Farris, M., Bastianelli, c., Rosato, E., Brosens, I., & Benagiano, G. (2019). Uterine fibroids: An update on current and emergingmedical treatment options. Ther Clin RiskManag, 15, 157-178. https://doi.org/l0.2147/TCRM.S147318

65

Ferrero, S., Abbamonte, L., Giordano, M., Parisi, M., Ragni, N., & Remorgida, V. (2006). Uterine myomas, dyspareunia, andsexual function. Fertility and Sterility, 86(5), 1504-1510. https://doi.org/l0.1016/j.fertnstert.2006.04.025

Fleisher Lee A., Fleischmann Kirsten E., Auerbach Andrew D., Barnason Susan A., Beckman Joshua A., Bozkurt Biykem, .Wijeysundera Duminda N. (2014). ACC/AHAGuideline on Perioperative Cardiovascular Evaluation and Management ofPatients Undergoing Noncardiac Surgery: Executive Summary. Circulation, 130(24), 2215-2245.https://doi.org/10.1161/CIR.0000000000000105

Fletcher, H., Frederick, J., Hardie, M., & Simeon, D. (1996). A randomized comparison of vasopressin and tourniquet ashemostatic agents during myomectomy. Obstetrics and Gynecology, 87(6), 1014-1018.

Fletcher, H. M., Wharfe, G.,Williams, N. P.,Gordon-Strachan, G., & Johnson, P. (2013). Renal impairment as a complication ofuterine fibroids: A retrospective hospital-based study. Journal of Obstetrics and Gynaecology, 33(4), 394-398.https://doi.org/l0.3109/01443615.2012.753421

Fletcher, H., Wharfe, G., Williams, N. P.,Gordon-Strachan, G., Pedican, M., & Brooks, A. (2009). Venous thromboembolism asa complication of uterine fibroids: A retrospective descriptive study. Journal of Obstetrics and Gynaecology, 29(8), 732-736. https://doi.org/10.3109/01443610903165545

Fraser, I. 5., Critchley, H. O. D., Munro, M. G., & Broder, M. (2007). A process designed to lead to international agreement onterminologies and definitions used to describe abnormalities of menstrual bleeding •. Fertility and Sterility, 87(3), 466-476. https://doi.org/l0.1016/j.fertnstert.2007.01.023

Ginsburg, E.S., Benson, C. B., Garfield, J. M., Gleason, R. E., & Friedman, A. J. (1993). The effect of operative technique anduterine size on blood loss during myomectomy: A prospective randomized study. Fertility and Sterility, 60(6), 956-962.

Glasser, M. H. (2005). Minilaparotomy myomectomy: A minimally invasive alternative for the large fibroid uterus. Journal ofMinimally Invasive Gynecology, 12(3), 275-283. https://doi.org/l0.1016/j.jmig.2005.03.009

Goldfarb, H. A. (2008). Myolysis Revisited. JSLS: Journal of the Society of Laparoendoscopic Surgeons, 12(4),426-430.

Gould, M. K.,Garcia, D. A., Wren, S. M., Karanicolas, P.J.,Arcelus, J. I., Heit, J.A., & Samama, C. M. (2012). Prevention ofVTEin nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College ofChest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141(2 Suppl), e227S-e277S.https://doi.org/10.1378/chest.11-2297

Gurusamy, K. S., Vaughan, 1., Fraser, I. S., Best, L. M., & Richards, T. (2016). Medical Therapies for Uterine Hbroidsa "ASystematic Review and Network Meta-Analysis of Randomised Controlled Trials. PLoS One, 11(2), e0149631.https://doi.org/l0.1371/journal.pone.0149631

Milton, S.H., Chelmow, D., Talavera, F.,Rivlin, M. E. (2019). Gynecologic Myomectomy: Background, History of the Procedure,Problem. Retrieved from https://emedicine.medscape.com/article/267677-overview

Heavy menstrual bleeding: Assessment and management I Guidance I NICE. (n.d.). Retrieved August 2, 2019, fromhttps://www.nice.org.uk/guidance/ng88

Hilditch, W. G., Asbury, A. J., Jack, E., & McGrane, S. (2003). Validation of a pre-anaesthetic screening questionnaire.Anaesthesia, 58(9), 874-877. https://doi.org/10.1046/j.1365-2044.2003.03335.x

Hindley, J., Gedroyc, W. M., Regan, L., Stewart, E., Tempany, C., Hynnen, K., ... Jolesz, F. (2004). MRI Guidance of FocusedUltrasound Therapy of Uterine Fibroids:Early Results. American Journal of Roentgenology, 183(6), 1713-1719.https://doi.org/10.2214/ajr.183.6.01831713

Hodge, J.c., & Morton, C. C. (2007). Genetic heterogeneity among uterine leiomyomata: Insights into malignant progression.Human Molecular Genetics, 16(R1), R7-R13. https://doi.org/10.1093/hmg/ddm043

Islam, M.S., Protic, 0., Giannubilo, S. R., Toti, P., Tranquilli, A. L., Petraglia, F., ... Ciarmela, P. (2013). Uterine leiomyoma:Available medical treatments and new possible therapeutic options. J Clin Endocrinol Metab, 98(3), 921-934.https://doi.org/l0.1210/jc.2012-3237

Kawakam, S., Togashi, K., Konishi, I., Kimura, I., Fukuoka, M., Mori, T., & Konishi, J. (1994). Red Degeneration of UterineLeiomyoma. Journal of Computer Assisted Tomography, 18(6), 925-928. https://doi.org/l0.1097/00004728-199411000-00014

Khan, A. T., Shehmar, M., & Gupta, J. K. (2014). Uterine fibroids: Current perspectives. Int J Womens Health, 6, 95-114.https://doi.org/10.214 7/IJWH.S51083

Kido, A., Ascher, S. M., Hahn, W., Kishimoto, K., Kashitani, N., Jha, R. c., ... Spies, J. B. (2014). 3 T MRI uterine peristalsis:Comparison of symptomatic fibroid patients versus controls. Clinical Radiology, 69(5), 468-472.https://doi.org/10.1016/j.crad.2013.12.002

Kiley, J., & Hammond, C. (2007). Combined oral contraceptives: A comprehensive review. Clin Obstet Gynecol, 50(4), 868-877. https://doi.org/10.1097/GRF.Ob013e318159c06a

Kitaya, K.,& Yasuo,T. (2010). Leukocyte density and composition in human cycling endometrium with uterine fibroids. HumanImmunology, 71(2), 158-163. https://doi.org/10.1016/j.humimm.2009.11.014

Klatsky, P.C.,Tran, N. D., Caughey,A. B.,& FUjimoto, V. Y. (2008). Fibroids and reproductive outcornes: A systematic literaturereview from conception to delivery. American Journal of Obstetrics and Gynecology, 198(4), 357-366.https://doi.org/10.1016/j.ajog.2007.12.039

66

Kolankaya, A., & Arici, A. (2006). Myomas and Assisted Reproductive Technologies: When and How to Act? Obstetrics andGynecology Clinics of North America, 33(1), 145-152. https://doi.org/10.1016/j.ogc.2005.12.008

Kongnyuy, E. J., & Wiysonge, C. S. (2011). Interventions to reduce haemorrhage during myomectomy for fibroids. TheCochrane Database of Systematic Reviews, (11). CD005355. https://doi.org/l0.1002/14651858.CD005355.pub4

Kovac, S. R., Barhan, S., Lister, M., Tucker, L., Bishop, M., & Das, A. (2002). Guidelines for the selection of the route ofhysterectomy: Application in a resident clinic population. American Journal of Obstetrics and Gynecology, 187(6). 1521-1527. https://doi.org/10.1067/mob.2002.129165

Lai,J.,Caughey, A. B.,Qidwai, G. I.,& Jacoby,A. F.(2012). Neonatal outcomes in women with sonographically identified uterineleiomyomata. The Journal of Maternal-Fetal & Neonatal Medicine: The Official Journal of the European Association ofPerinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of PerinatalObstetricians, 25(6). 710-713. https://doi.org/10.3109/14767058.2011.572205

Laughlin, S. K., Baird, D. D., Savitz, D. A., Herring, A. H., & Hartmann, K. E. (2009). Prevalence of Uterine Leiomyomas in theFirst Trimester of Pregnancy. Obstetrics & Gynecology, 113(3). 630-635.https://doi.org/10.1097/aog.Ob013e318197bbaf

Laughlin, S. K., Hartmann, K. E.,& Baird, D. D. (2011). Postpartum factors and natural fibroid regression. American Journal ofObstetrics and Gynecology, 204(6), 496.el-6. https://doi.org/l0.1016/j.ajog.2011.02.018

Laughlin, S.K.,Herring, A. H., Savitz, D.A., Olshan,A. F., Fielding, J.R.,Hartmann, K.E.,& Baird, D. D. (2010). Pregnancy-relatedfibroid reduction. Fertility and Sterility, 94(6). 2421-2423. https://doi.org/1O.1016/j.fertnstert.201O.03.035

Laughlin, S. K., & Stewart, E. A. (2011). Uterine leiomyomas: Individualizing the approach to a heterogeneous condition.Obstetrics and Gynecology, 117(2 Pt 1), 396-403. https://doi.org/10.1097/AOG.Ob013e31820780e3

LeBlang,S.D., Hoctor, K., & Steinberg, F. L. (2010). Leiomyoma Shrinkage After MRI-Guided Focused Ultrasound Treatment:Report of 80 Patients. American Journal of Roentgenology, 194(1). 274-280. https://doi.org/1O.2214/ajr.09.2842

Lee, H. J., Norwitz, E. R.,& Shaw, J. (2010). Contemporary Management of Fibroids in Pregnancy. Reviews in Obstetrics andGynecology, 3(1). 20-27.

Lefebvre, G., Vilos, G., Allaire, c., Jeffrey, J., Arneja, J., Birch, c., ... Clinical Practice Gynaecology Committee, Society forObstetricians and Gynaecologists of Canada. (2003). The management of uterine leiomyomas. Journal of Obstetrics andGynaecology Canada: JOGC= Journal d'obstetrique et Gynecologie Du Canada: JOGC,25(5). 396-418; quiz 419-422.

Lethaby, A., Vollenhoven, B., & Sowter, M. (2000). Pre-operative GnRH analogue therapy before hysterectomy ormyomectomy for uterine fibroids. Cochrane Database Syst Rev, (2), CD000547.https://doi.org/10.1002/14651858.CD000547

Letterie, G. S.,Coddington, C.c., Winkel, C. A., Shawker, T. H., Loriaux, D. L.,& Collins, R.L. (1989). Efficacy of a gonadotropin­releasing hormone agonist in the treatment of uterine leiomyomata: Long-term follow-up. Fertil Steril, 51(6), 951-956.(2498132).

Lev-Toaff, A. S., Coleman, B. G., Arger, P. H., Mintz, M. c., Arenson, R. L., & Toaff, M. E. (1987). Leiomyomas in pregnancy:Sonographic study. Radiology, 164(2). 375-380. https://doi.org/10.1148/radiology.164.2.3299488

Levy, G., Dehaene, A., Laurent, N., Lernout, M., Collinet, P., Lucot, J.-P., ... Poncelet, E. (2013). An update on adenomyosis.Diagnostic and Interventionallmaging, 94(1), 3-25. https://doi.org/10.1016/j.diii.2012.10.012

Li,T.c., Mortimer, R.,& Cooke, I. D. (1999). Myomectomy: A retrospective study to examine reproductive performance beforeand after surgery. Human Reproduction (Oxford, England). 14(7), 1735-1740.https://doi.org/10.1093/humrep/14. 7.1735

Linden, B. (2012). NICE guidance on off-pump coronary artery bypass graftingNational Institute for Health and ClinicalExcellence (2011a) Off Pump Coronary Artery BypassGrafting. [Interventional Procedures Guidance 377J. Www.nice.Org.uk/guidance/IPG377 (accessed 16 December 2011). British Journal of Cardiac Nursing, 7(1). 8-9.https://doi.org/10.12968/bjca.2012.7.1.8

Ludovisi, M., Moro, F., Pasciuto, T., Di Noi, S.,Giunchi, S., Savelli, L., ... Testa, A. C. (2019). Imaging of gynecological disease:Clinical and ultrasound characteristics of uterine sarcomas. Ultrasound in Obstetrics & Gynecology: The Official Journalof the International Society of Ultrasound in Obstetrics and Gynecology. https://doi.org/10.1002/uog.20270

Lumbiganon, P.,Rugpao,S., Phandhu-fung, S.,Laopaiboon, M., Vudhikamraksa, N.,&Werawatakul, Y. (1996). Protective effectof depot-medroxyprogesterone acetate on surgically treated uterine leiomyomas: A multicentre case-control study.BJOG: An International Journal of Obstetrics and Gynaecology, 103(9), 909-914. https://doi.org/10.1111/j.1471-0528.1996.tb09911.x

. Lumsden, M. A., & Wallace, E. M. (1998). 2 Clinical presentation of uterine fibroids. Bailliere's Clinical Obstetrics andGynaecology, 12(2). 177-195. https://doi.org/10.1016/s0950-3552(98)80060-6

Lurie, S., Piper, I., Woliovitch, I., & Glezerman, M. (2005). Age-related prevalence of sonographicaly confirmed uterinemyomas. Journal of Obstetrics and Gynaecology, 25(1), 42-44. https://doi.org/10.1080/01443610400024583

Luyckx, M., Squifflet, J.-L., Jadoul, P., Votino, R., Dolmans, M.-M., & Donnez, J. (2014). First series of 18 pregnancies afterulipristal acetate treatment for uterine fibroids. Fertility and Sterility, 102(5), 1404-1409.https://doi.org/10.1016/j.fertnstert.2014.07.1253

67

Machupalli, S., Norkus, E. P., Mukherjee, T. K., & Reilly, K. D. (2013). Abdominal Myomectomy Increases Fertility Outcome.Gynecology & Obstetrics 3(2),1-4. doi: 10.4172/2161-0932.1000144

Maruo, T., Laoag-Fernandez, J. B., Pakarinen, P., Murakoshi, H., Spitz, I. M., & Johansson, E. (2001). Effects of thelevonorgestrel-releasing intrauterine system on proliferation and apoptosis in the endometrium. Hum Reprod, 16(10),2103-2108. https://doi.org/l0.l093/humrep/16.10.2103

Mas, A., Tarazona, M., Dasi Carrasco, J., Estaca,G., Cristobal, I., & Monle6n, J. (2017). Updated approaches for managementof uterine fibroids. International Journal of Women's Health, 9, 607-617. https://doi.org/l0.214 7/IJWH.S138982

Matsuzaki, S.,Canis,M., Darcha, c., Pouly, J.-L.,& Mage, G. (2009). HOXA-l0 expression in the mid-secretory endometrium ofinfertile patients with either endometriosis, uterine fibromas or unexplained infertility. Human Reproduction, 24(12),3180-3187. https://doi.org/l0.l093/humrep/dep306

Mehine, M., Kaasinen, E., Makinen, N., Katainen, R., Kampjarvi, K., Pitkanen, E., ". Aaltonen, L. A. (2013). Characterization ofUterine Leiomyomas by Whole-Genome Sequencing. New England Journal of Medicine, 369(1), 43-53.https://doi.org/l0.l056/nejmoa1302736

Memtsa, M., & Homer, H. (2012). Complications Associated with Uterine Artery Embolisation for Fibroids. Obstetrics andGynecology International, 2012, 1-5. https://doi.org/l0.1155/2012/290542

Miura, S., Khan, K. N., Kitajima, M., Hiraki, K., Moriyama, S., Masuzaki, H., ". Ishimaru, T. (2006). Differential infiltration ofmacrophages and prostaglandin production by different uterine leiomyomas. Human Reproduction, 21(10), 2545-2554. https://doi.org/l0.l093/humrep/deI205

Mollica, G., Pittini, L., Minganti, E., Perri, G., & Pansini, F. (1996). Elective uterine myomectomy in pregnant women. Clinicaland Experimental Obstetrics & Gynecology, 23(3), 168-172.

Moore, A. R., Rogers, F. M., Dietrick, D., & Smith, S. (2008). Extrapulmonary Tuberculosis in Pregnancy Masquerading as aDegenerating Leiomyoma. Obstetrics & Gynecology, 111(2, Part 2), 550-552.https://doi.org/l0.l097/01.aog.0000285482.21168.a7

Moorman, P. G., Myers, E. R., Schildkraut, J. M., Iversen, E. S.,Wang, F.,& Warren, N. (2011). Effect of Hysterectomy WithOvarian Preservation on Ovarian Function. Obstetrics and Gynecology, 118(6), 1271-1279.https://doi.org/l0.l097/AOG.Ob013e318236fd12

Munro, M. G., Critchley, H. O. D., Broder, M. S.,& Fraser, I. S. (2011). FIGOclassification system (PALM-COEIN)for causes ofabnormal uterine bleeding in nongravid women of reproductive age. International Journal of Gynecology & Obstetrics,113(1), 3-13. https://doi.org/l0.l016/j.ijgo.2010.11.011

Munro, M. G., Critchley, H. O. D., & Fraser, I. S. (2011). The FIGOclassification of causes of abnormal uterine bleeding in thereproductive years. Fertility and Sterility, 95(7), 2204-2208.e3. https://doi.org/l0.l016/j.fertnstert.2011.03.079

Muram, D., Gillieson, M., & Walters, J. H. (1980). Myomas of the uterus in pregnancy: Ultrasonographic follow-up. AmericanJournal of Obstetrics and Gynecology, 138(1), 16-19. https://doi.org/l0.1016/0002-9378(80)90005-8

Murase, E., Siegelman, E.S.,Outwater, E. K., Perez-Jaffe, L. A., & Tureck, R.W. (1999). Uterine Leiomyomas: HistopathologicFeatures, MR Imaging Findings, Differential Diagnosis, and Treatment. RadioGraphics, 19(5), 1179-1197.https://doi.org/l0.1148/radiographics.19.5.g99se131179

Myers, E.R.,Barber, M. D., Gustilo-Ashby, T., Couchman, G., Matchar, D. B., & McCrory, D. C. (2002). Management of uterineleiomyomata: What do we really know? Obstetrics and Gynecology, 100(1), 8-17.

Neiger, R.,Sonek, J. D., Croom, C. S.,& Ventolini, G. (2006). Pregnancy-related changes in the size of uterine leiomyomas. TheJournal of Reproductive Medicine, 51(9), 671-674.

Odejinmi, F.,Oliver, R.,& Mallick, R.(2017). Isulipristal acetate the new drug of choice for the medical management of uterinefibroids? Res ipsa loquitur? Women's Health (London, England), 13(3), 98-105.https://doi.org/l0.1177/1745505717740218

Oliveira, F.G., Abdelmassih, V. G., Diamond, M. P.,Dozortsev, D., Melo, N. R.,& Abdelmassih, R. (2004). Impact of subserosaland intramural uterine fibroids that do not distort the endometrial cavity on the outcome of in vitro fertilization­intracytoplasmic sperm injection. Fertility and Sterility, 81(3), 582-587.https://doi.org/l0.l016/j.fertnstert.2003.08.034

O'Neill, F., Carter, E., Pink, N., & Smith, I. (2016). Routine preoperative tests for elective surgery: Summary of updated NICEguidance, BMJ, i3292. https://doi.org/l0.1136/bmj.i3292

Palomba,S., Affinito, P., Di Carlo, c., Bifulco, G., & Nappi, C. (1999). Long-term administration of tibolone plus gonadotropin­releasing hormone agonist for the treatment of uterine leiomyomas: Effectiveness and effects on vasomotor symptoms,bone mass, and lipid profiles. Fertil Steril, 72(5), 889-895. (10560995).

Palomba, S.,Orio, F.,Jr., Morelli, M., Russo,T., Pellicano, M., Nappi, C, ". Zullo, F. (2002). Raloxifene administration in womentreated with gonadotropin-releasing hormone agonist for uterine leiomyomas: Effects on bone metabolism. J ClinEndocrinol Metab, 87(10), 4476-4481. https://doi.org/l0.1210/jc.2002-020780

Parker, W. H. (2007). Etiology, symptomatology, and diagnosis of uterine myomas. Fertility and Sterility, 87(4), 725-736.https://doi.org/l0.l016/j.fertnstert.2007.01.093

68

Pavone, D., Clemenza, S., Sorbi, F., Fambrini, M., & Petraglia, F. (2018). Epidemiology and RiskFactors of Uterine Fibroids. BestPractice & Research Clinical Obstetrics & Gynaecology, 46, 3-11. https://doi.org/lO.l016/j.bpobgyn.2017.09.004

Payson, M., Leppert, P., & Segars,J. (2006). Epidemiology of myomas. Obstetrics and Gynecology Clinics of North America,33(1), 1-11. https://doi.org/l0.l016/j.ogc.2005.12.004

Peitsidis, P., & Koukoulomati, A. (2014). Tranexamic acid for the management of uterine fibroid tumors: A systematic reviewof the current evidence. World J Clin Cases,2(12), 893-898. https://doi.org/10.12998/wjcc.v2.i12.893

Pellegrini, J. E.,Toledo, P., Soper, D. E., Bradford, W. C, Cruz, D.A, Levy, B.S.,& Lemieux, L.A (2017). Consensus Bundle onPrevention of Surgical Site Infections After Major Gynecologic Surgery. Obstetrics & Gynecology, 129(1), 50-61.https://doi.org/10.1097/aog.0000000000001751

Perez-Lopez,F. R.,Ornat, L., Ceausu, I., Depypere, H., Erel, C.T., Lambrinoudaki, I., ... EMAS.(2014). EMASposition statement:Management of uterine fibroids. Maturitas, 79(1), 106-116. https://doi.org/l0.1016/j.maturitas.2014.06.002

Philippines Society for reproductive medicine. Clinical Practice Guideline for Uterine Leiomyomas. (2017).

Piecak, K., & Milart, P. (2017). Hysteroscopic myomectomy. Menopausal Review, 16(4), 126-128.https://doi.org/10.5114/pm.2017.72757

Podasca, c., Banciu, S., Moga, M. A, Mironescu, A, Dracea, L. L., Ples, L., & Barabas, B. (2016). Preoperative diagnosis ofadenomyosis, leiomyoma and intricate situations. https://doi.org/10.18643/gieu.2016.126

Practice Committee of the American Society for Reproductive Medicine (2017). Combined hormonal contraception and therisk of venous thromboembolism: A guideline. Fertility and Sterility, 107(1), 43-51.https://doi.org/10.1016/j.fertnstert.2016.09.027

Pritts, E.A, Parker, W. H., & Olive, D. L. (2009). Fibroids and infertility: An updated systematic review of the evidence. Fertilityand Sterility, 91(4), 1215-1223. https://doi.org/lO.1016/j.fertnstert.2008.01.051

Puri, K., Famuyide, A. 0., Erwin, P. J., Stewart, E. A, & Laughlin-Tommaso, S. K. (2014). Submucosal fibroids and the relationto heavy menstrual bleeding and anemia. American Journal of Obstetrics and Gynecology, 210(1), 38.e1-38.e7.https://doi.org/10.1016/j.ajog.2013.09.038

Qidwai, G. I., Caughey, A. B., & Jacoby, A. F. (2006). Obstetric outcomes in women with sonographically identified uterineleiomyomata. Obstetrics and Gynecology, 107(2 Pt 1), 376-382.https://doi.org/l0.l097/01.AOG.0000196806.25897.7c

Qiu, J., Cheng, J., Wang, Q., & Hua, J. (2014). Levonorgestrel-releasing intrauterine system versus medical therapy formenorrhagia: A systematic review and meta-analysis. Med Sci Monit, 20, 1700-1713.https://doi.org/10.12659/MSM.892126

Rackow, B. W., & Taylor, H. S. (2010). Submucosal uterine leiomyomas have a global effect on molecular determinants ofendometrial receptivity. Fertility and Sterility, 93(6), 2027-2034. https://doi.org/lO.1016/j.fertnstert.2008.03.029

Ren, X.-L., Zhou, X.-D., Zhang, J., He, G.-B., Han, Z.-H., Zheng, M.-J., ... Wang, L. (2007). Extracorporeal Ablation of UterineFibroids With High-Intensity Focused Ultrasound. Journal of Ultrasound in Medicine, 26(2), 201-212.https://doi.org/10.7863/jum.2007.26.2.201

Rice,J. P., Kay, H. H., & Mahony, B. S. (1989). The clinical significance of uterine leiomyomas in pregnancy. American Journalof Obstetrics and Gynecology, 160(5 Pt 1), 1212-1216. https://doi.org/10.1016/0002-9378(89)90194-4

Richards,P. (1998). The ultrastructure offibromyomatous myometrium and its relationship to infertility. Human ReproductionUpdate, 4(5), 520-525. https://doi.org/10.1093/humupd/4.5.520

Robboy, S.J., Bentley, R.c., Butnor, K.,& Anderson, M. C. (2000). Pathology and Pathophysiology of Uterine Smooth-MuscleTumors. Environmental Health Perspectives, 108(s5), 779-784. https://doi.org/lO.1289/ehp.00108s5779

Rosati, P., Exacoustos, c., & Mancuso, S. (1992). Longitudinal evaluation of uterine myoma growth during pregnancy. Asonographic study. Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound inMedicine, 11(10), 511-515.

Ross,R.K., Pike, M. c., Vessey, M. P., Bull, D., Yeates, D., & Casagrande,J.T. (1986). Risk factors for uterine fibroids: Reducedrisk associated with oral contraceptives. Br Med J (Clin Res Ed), 293(6543), 359-362.https://doi.org/10.1136/bmj.293.6543.359

Roy, K. K., Metta, S., Kansal, Y., Kumar, S., Singhal, S., & Vanamail, P. (2017). A Prospective Randomized Study ComparingUnipolar Versus Bipolar Hysteroscopic Myomectomy in Infertile Women. Journal of Human Reproductive Sciences,10(3), 185-193. https://doi.org/10.4103/jhrs.JHRS_134_16

Ryan,G. L., Syrop, C. H., & Van Voorhis, B.J. (2005). Role, Epidemiology, and Natural History of Benign Uterine Mass Lesions.Clinical Obstetrics and Gynecology, 48(2), 312-324. https://doi.org/10.1097/01.grf.0000159538.27221.8c

Sciarra J, Dilts PVJr. (1986). Gynecology and obstetrics. Philadelphia: PA:JBLippincott.

Selo-Ojeme, D., Lawai, 0., Shah, J., Mandai, R., Pathak, S., Selo-Ojeme, U., & Samuel, D. (2008). The incidence of uterineleiomyoma and other pelvic ultrasonographic findings in 2,034 consecutive women in a north London hospital. Journalof Obstetrics and Gynaecology, 28(4), 421-423. https://doi.org/10.1080/01443610802149863

69

Shavell, V. I., Thakur, M., Sawant, A, Kruger, M. L., Jones, T. B., Singh, M., ... Diamond, M. P. (2012). Adverse obstetric outcomesassociated with sonographically identified large uterine fibroids. Fertility and Sterility, 97(1), 107-110.https://doi.org/10.1016/j.fertnstert.2011.10.009

Shen, Q., Hua, Y., Jiang, W., Zhang, W., Chen, M., & Zhu, X. (2013). Effects of mifepristone on uterine leiomyoma inpremenopausal women: A meta-analysis. Fertil Steril, 100(6), 1722-6 el-l0.

https://doi.org/10.1016/j.fertnstert.2013.08.039

Shen, Y., Xu, Q., Xu, J., Ren, M. L., & Cai,Y. L. (2013). Environmental exposure and risk of uterine leiomyoma: An epidemiologicsurvey. European Review for Medical and Pharmacological Sciences, 17(23), 3249-3256.

Singh, S.S.,& Belland, L. (2015). Contemporary management of uterine fibroids: Focuson emerging medical treatments. CurrMed ResOpin, 31(1), 1-12. https://doi.org/10.1185/03007995.2014.982246

Smeets, A. J., Nijenhuis, R.J., van Rooij, W. J.,Weimar, E.AM., Boekkooi, P. F., Lampmann, L. E.H., ... Lohle, P. N. M. (2010).Uterine Artery Embolization in Patients with a Large Fibroid Burden: Long-Term Clinical and MR Follow-up.CardioVascular and Interventional Radiology, 33(5), 943-948. https://doi.org/l0.1007/s00270-009-9793-2

Stephenson, J. (2014). FDA Warns Against Procedure Used in Removing Fibroids. JAMA, 311(19), 1956.https://doi.org/l0.l00l/jama.2014.5182

Stewart, E. A. (2015). Uterine Fibroids. New England Journal of Medicine, 372(17), 1646-1655.https://doi.org/l0.l056/nejmcp1411029

Stewart, E.,Cookson, c., Gandolfo, R.,& Schulze-Rath, R.(2017). Epidemiology of uterine fibroids: A systematic review. BJOG:An International Journal of Obstetrics & Gynaecology, 124(10), 1501-1512. https://doi.org/l0.1111/1471-0528.14640

Stout, M. J., Odibo, A. 0., Graseck, AS., Macones, G. A., Crane, J. P., & Cahill, A. G. (2010). Leiomyomas at routine second­trimester ultrasound examination and adverse obstetric outcomes. Obstetrics and Gynecology, 116(5), 1056-1063.https://doi.org/l0.l097 /AOG.Ob013e3181f7496d

Strobelt, N., Ghidini, A, Cavallone, M., Pensabene, I., Ceruti, P.,& Vergani, P. (1994). Natural history of uterine leiomyomas inpregnancy. Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine,13(5), 399-401.

Styer, A. K., & Rueda, B. R. (2016). The Epidemiology and Genetics of Uterine Leiomyoma. Best Practice & Research ClinicalObstetrics & Gynaecology, 34, 3-12. https://doi.org/l0.l016/j.bpobgyn.2015.11.018

Sunkara, S.K., Khairy, M., EI-Toukhy,T., Khalaf, Y.,& Coomarasamy, A (2009). The effect of intramural fibroids without uterinecavity involvement on the outcome of IVF treatment: A systematic review and meta-analysis. Human Reproduction,25(2), 418-429. https://doi.org/l0.l093/humrep/dep396

Takeda, T., Sakata, M., Isobe, A, Miyake, A., Nishimoto, F., Ota, Y., ... Kimura, T. (2008). Relationship between MetabolicSyndrome and Uterine Leiomyomas: A Case-Control Study. Gynecologic and Obstetric Investigation, 66(1), 14-17.https://doi.org/l0.1159/000114250

Talaulikar, V. S.,& Manyonda, I. (2014). Ulipristal acetate for use in moderate to severe symptoms of uterine fibroids. WomensHealth (Lond), 10(6),565-570. https://doi.org/l0.2217/whe.14.60

Talaulikar, V. S., & Manyonda, I. T. (2012). Ulipristal acetate: A novel option for the medical management of symptomaticuterine fibroids. Adv Ther, 29(8), 655-663. https://doi.org/l0.l007/s12325-012-0042-8

Tanaka, H., Umekawa, T., Kikukawa, T., Nakamura, M., & Toyoda, N. (2002). Venous thromboembolic diseasesassociated withuterine myomas diagnosed before hysterectomy: A report of two cases. Journal of Obstetrics and GynaecologyResearch, 28(6), 300-303. https://doi.org/l0.l046/j.1341-8076.2002.00059.x

Telner, D. E., & Jakubovicz, D. (2007). Approach to diagnosis and management of abnormal uterine bleeding. Can FamPhysician, 53(1), 58-64. (17872610).

Tempany, C. M. C.,Stewart, E.A., McDannold, N., Quade, B.J.,Jolesz,F.A., & Hynynen, K. (2003). MR Imaging-guided FocusedUltrasound Surgery of Uterine Leiomyomas: A Feasibility Study. Radiology, 226(3), 897-905.https://doi.org/l0.1148/radioI.2271020395

Templeman, c., Marshall, S. F., Clarke, C. A., DeLellis Henderson, K., Largent, J., Neuhausen, S., ... Bernstein, L. (2009). Riskfactors for surgically removed fibroids in a large cohort of teachers. Fertility and Sterility, 92(4), 1436-1446.https://doi.org/l0.1016/j.fertnstert.2008.08.074

Terry, K. L., DeVivo, I., Hankinson, S.E.,& Missmer, S.A. (2010). Reproductive characteristics and risk of uterine leiomyomata.Fertility and Sterility, 94(7), 2703-2707. https://doi.org/lO.1016/j.fertnstert.2010.04.065

The Joint Commission on Accreditation of Healthcare Organizations. Time-outs and their role in improving safety and qualityin surgery. (2017, June 1). Retrieved August 4,2019, from The Bulletin website: http://bulletin.facs.org/2017/06/time­outs-and-their-role-in-improving-safety-and-quality-in-surgery/

The RESTInvestigators. Uterine-Artery Embolization versus Surgery for Symptomatic Uterine Fibroids. (2007). New EnglandJournal of Medicine, 356(4), 360-370. https://doi.org/l0.l056/nejmoa062003

Tocci, A., Greco, E., & Ubaldi, F. M. (2008). Adenomyosis and 'endometrial- subendornetnel myometrium unit disruptiondisease' are two different entities. Reproductive BioMedicine Online, 17(2), 281-291. https://doi.org/l0.l016/s1472-6483(10)60207-6

70

Topsoee, M. F., Bergholt, T., Ravn, P., Schouenborg, L., Moeller, c., Ottesen, B., & Settnes, A. (2016). Anti-hemorrhagic effectof prophylactic tranexamic acid in benign hysterectomy-a double-blinded randomized placebo-controlled trial.American Journal of Obstetrics & Gynecology, 215(1). 72.el-72.e8. doi: 10.1016/j.ajog.2016.01.184

Tristan, M., Orozco, L. J., Steed, A., Ramirez-Morera, A., & Stone, P. (2012). Mifepristone for uterine fibroids. CochraneDatabase Syst Rev, (8). CD007687. https://doi.org/l0.l002/14651858.CD007687.pub2

Valle, R. F.,& Sciarra, J.J. (1988). Intrauterine adhesions: Hysteroscopic diagnosis, classification, treatment, and reproductiveoutcome. American Journal of Obstetrics and Gynecology, 158(6), 1459-1470. https://doi.org/l0.l016/0002-9378(88)90382-1

Van den Bosch, T., de Bruijn, A. M., de Leeuw, R. A., Dueholm, M., Exacoustos, c., Valentin, L., ... Huirne, J. A. F. (2019).Sonographic classification and reporting system for diagnosing adenomyosis. Ultrasound in Obstetrics & Gynecology,53(5),576-582. https://doi.org/l0.l002/uog.19096

Viios, G. A., Allaire, C., Laberge, P. Y., Leyland, N., & Special, C. (2015). The management of uterine leiomyomas. J ObstetGynaecol Can, 37(2). 157-178. https://doi.org/l0.l016/S1701-2163(15)30338-8

Wamsteker, K., Emanuel, M. H., & de Kruif, J. H. (1993). Transcervical hysteroscopic resection of submucous fibroids forabnormal uterine bleeding: Results regarding the degree of intramural extension. Obstetrics and Gynecology, 82(5),736-740.

Wang, W., Wang, Y.,Wang, T., Wang, J.,Wang, L., & Tang, J. (2012). Safety and efficacy of US-guided high-intensity focusedultrasound for treatment of submucosal fibroids. European Radiology, 22(11), 2553-2558.https://doi.org/l0.l007/s00330-012-2517-z

Wegienka, G., Baird, D. D., Hertz-Picciotto, I., Harlow, S.D., Steege, J. F., Hill, M. c., ... Hartmann, K. E. (2003). Self-ReportedHeavy Bleeding Associated With Uterine Leiomyomata. Obstetrics & Gynecology, 101(3). 431-437.https://doi.org/l0.l097/00006250-200303000-00005

Wellington, K.,& Wagstaff, A. J. (2003). Tranexamic acid: A review of its use in the management of menorrhagia. Drugs, 63(13),1417-1433. https://doi.org/l0.2165/00003495-200363130-00008

Winer-Muram, H. T., Muram, D., Gillieson, M. S., Ivey, B.J., & Muggah, H. F. (1983). Uterine myomas in pregnancy. CanadianMedical Association Journal, 128(8),949-950.

Wise, L. A. (2004). Reproductive Factors, Hormonal Contraception, and Risk of Uterine Leiomyomata in African-AmericanWomen: A Prospective Study. American Journal of Epidemiology, 159(2), 113-123. https://doi.org/l0.1093/aje/kwh016

Wise, L. A., & Laughlin-Tommaso, S.K. (2016). Epidemiology of Uterine Fibroids. Clinical Obstetrics and Gynecology, 59(1). 2-24. https://doi.org/l0.l097/grf.0000000000000164

Wong, M., De Wilde, R. L., & Isaacson, K. (2018). Reducing the spread of occult uterine sarcoma at the time of minimallyinvasive gynecologic surgery. Archives of Gynecology and Obstetrics, 297(2). 285-293. https://doi.org/lD.1007/s00404-017-4575-6

Worthen, N. J., & Gonzalez, F. (1984). Septate uterus: Sonographic diagnosis and obstetric complications. Obstetrics andGynecology, 64(3 Suppl), 345-385.

Yanai, H., Wani, Y., Notohara, K., Takada, 5., & Yoshino, T. (2010). Uterine leiomyosarcoma arising in leiomyoma:Clinicopathological study of four cases and literature review. Pathology International, 60(7). 506-509.https://doi.org/l0.1111/j.1440-1827.2010.02549.x

Yoshino, 0., Nishii, 0., Osuga, Y.,Asada, H., Okuda,S., Orisaka, M., ... Hayashi, T. (2012). Myomectomy Decreases AbnormalUterine Peristalsis and Increases Pregnancy Rate. Journal of Minimally Invasive Gynecology, 19(1), 63-67.https://doi.org/l0.l016/j.jmig.2011.09.0lD

Zhang, L., Chen, W.-Z., Liu, Y.-J.,Hu, X., Zhou, K., Chen, L., ... Wang, Z.-B. (2010). Feasibility of magnetic resonance imaging­guided high intensity focused ultrasound therapy for ablating uterine fibroids in patients with bowel lies anterior touterus. European Journal of Radiology, 73(2). 396-403. https://doi.org/l0.l016/j.ejrad.2008.11.002

Zhao, F., Jiao, Y., Guo, Z., Hou, R.,& Wang, M. (2011). Evaluation of loop ligation of larger myoma pseudocapsule combinedwith vasopressin on laparoscopic myomectomy. Fertility and Sterility, 95(2). 762-766.https://doi.org/l0.l016/j.fertnsterI.2010.08.059

71

BAN THU' KY BIEN SO~N

BSCKII. Bui £>6 Hieu

BS CKI. VU'O'ng ro NhU'

BS CKII. He Cao CU'cYng

BS CKI. Chau Ngoc Minh

BS CKI. Bui Quang Trung

BS CKI. Le Van Khanh

ThS. BS. He Thanh Nh§ Yen

BS CKI. Trieu Thi Thanh Tuven

BS CKI. Le TiE~uMy

BS CKI. vc Nh~t Khang

BS. He Ngoc An h vaBS. Nguy~n Minh Nh~t

BS. Le Van Thanh

BAN THU' KY HANH CHANHNguy~n Thach Thao Nguyen

vo Thi Ha

Tran HCi'uYen Ngoc

72