บทที่ 8 - tmchnetwork.comtmchnetwork.com/sites/default/files/2.Experience of tocolytic...

บทท 8 ประสบการณการดแลรกษา สตรตงครรภทมภาวะเจบครรภ คลอดกอนกำหนดในโรงพยาบาลศรราช

√Õß»“ µ√“®“√¬å ·æ∑¬åÀ≠‘ß “¬Ωπ ™«“≈‰æ∫Ÿ≈¬å

¿“§«‘™“ Ÿµ‘»“ µ√å-π√’‡«™«‘∑¬“ §≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈

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∫∑∑’Ë 8 ª√– ∫°“√≥å°“√¥Ÿ·≈√—°…“ µ√’µ—Èß§√√¿å∑’Ë¡’¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥„π‚√ßæ¬“∫“≈»‘√‘√“™

ประสบการณการดแลรกษาสตรตงครรภทมภาวะ เจบครรภคลอดกอนกำหนดในโรงพยาบาลศรราช

√Õß»“ µ√“®“√¬å ·æ∑¬åÀ≠‘ß “¬Ωπ ™«“≈‰æ∫Ÿ≈¬å

¿“§«‘™“ Ÿµ‘»“ µ√å-π√’‡«™«‘∑¬“ §≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈

บทนำ

ªí®®ÿ∫—π ¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥‡ªìπªí≠À“ ”§—≠„π√–¥—∫ª√–‡∑» ‡æ√“–∑“√°‡°‘¥°àÕπ°”Àπ¥

¡—°‡ ’Ë¬ßµàÕ¿“«–·∑√°´âÕπ àßº≈„Àâ‡°‘¥ªí≠À“„π™à«ß·√°§≈Õ¥ ‡π◊ËÕß®“°¡’§à“„™â®à“¬ Ÿß µ≈Õ¥®π‡°‘¥º≈°√–∑∫

µàÕ§√Õ∫§√—« ·≈– —ß§¡„π°“√¥Ÿ·≈·≈–øóôπøŸ ÿ¢¿“æ¢Õß∑“√° ‡π◊ËÕß®“° à«π„À≠à¢Õß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ

°”Àπ¥‰¡à∑√“∫ “‡Àµÿ °“√«“ß·ºπªÑÕß°—π ·≈–°“√æ¬“°√≥å¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥®÷ß∑”‰¥â¬“° ¥—ßπ—Èπ

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‡æ’¬ß™—Ë«§√“« ·µà¬—ß‰¡à “¡“√∂°”®—¥ªí®®—¬°√–µÿâπ„Àâ‡°‘¥°√–∫«π°“√‡®Á∫§√√¿å§≈Õ¥À√◊Õ∑”„Àâ‡°‘¥ ¿“«–ª°µ‘¢Õß

¡¥≈Ÿ°°àÕπ‡¢â“ Ÿà°√–∫«π°“√‡®Á∫§√√¿å§≈Õ¥ ¬“∑’Ë™à«¬¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥ à«π„À≠à¬—ß‰¡à “¡“√∂¬◊¥√–¬–‡«≈“

°“√µ—Èß§√√¿å‡ªìπ —ª¥“ÀåÀ√◊Õ‡ªìπ‡¥◊Õπ ·µà®–™à«¬¬◊¥√–¬–‡«≈“‡æ◊ËÕ„Àâ°≈Ÿ‚§§Õ√åµ‘§Õ¬¥åÕÕ°ƒ∑∏‘Ï‰¥â‡µÁ¡∑’Ë ªí®®ÿ∫—π∑“ß

‚√ßæ¬“∫“≈»‘√‘√“™‰¥âπ”¬“ Nifedipine ¡“„™â¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥§ÿ°§“¡ ·≈–«“ß·ºπ∑’Ë®–π”¡“

„™â„π°≈ÿà¡∑’Ë¡’Õ“°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥∑—Ë«‰ª ¥—ß®–°≈à“«„π√“¬≈–‡Õ’¬¥µàÕ‰ª

การยบยงภาวะเจบครรภคลอดกอนกำหนด

วตถประสงค1

1. ‡æ◊ËÕ¬◊¥√–¬–‡«≈“§≈Õ¥ÕÕ°‰ªÕ¬à“ßπâÕ¬ 48 ™—Ë«‚¡ß „Àâ°≈Ÿ‚§§Õ√åµ‘§Õ¬¥åÕÕ°ƒ∑∏‘Ï¡“°∑’Ë ÿ¥ ‚¥¬

°≈Ÿ‚§§Õ√åµ‘§Õ¬¥å®–™à«¬≈¥§«“¡‡ ’Ë¬ßµàÕ°“√‡ ’¬™’«‘µ¢Õß∑“√°‡°‘¥°àÕπ°”Àπ¥ ≈¥Õÿ∫—µ‘°“√≥å respiratory distress

syndrome ¿“«–‡≈◊Õ¥ÕÕ°„π‚æ√ß ¡Õß ·≈–¿“«–≈”‰ â‡πà“‡ªóòÕ¬

2. ‡æ◊ËÕ„Àâ Ÿµ‘·æ∑¬å “¡“√∂ àßµàÕ µ√’µ—Èß§√√¿å‰ª¬—ß ∂“πæ¬“∫“≈∑’Ëæ√âÕ¡ ·≈– “¡“√∂„Àâ°“√¥Ÿ·≈√—°…“

∑“√°‡°‘¥°àÕπ°”Àπ¥∑’ËÕ“®¡’ªí≠À“„π™à«ßÀ≈—ß§≈Õ¥

3. ‡æ◊ËÕ„Àâ‡«≈“ ”À√—∫°“√√—°…“ “‡Àµÿ¢Õß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥∑’Ë “¡“√∂√—°…“‰¥â ‡™àπ

√–∫∫∑“ß‡¥‘πªí “«–Õ—°‡ ∫ ‰ âµ‘ËßÕ—°‡ ∫ ‡ªìπµâπ

229

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à«π„À≠à°“√«‘®—¬‡√◊ËÕß«‘∏’°“√√—°…“¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥∑”‰¥â¬“° ‡π◊ËÕß®“°¡’¢âÕ¡Ÿ≈

à«ππâÕ¬∑’Ë‡ª√’¬∫‡∑’¬∫√–À«à“ß°“√√—°…“·≈–°“√‰¡à√—°…“‡π◊ËÕß®“°º‘¥®√‘¬∏√√¡ °“√»÷°…“‡ª√’¬∫‡∑’¬∫√–À«à“ß¬“

·µà≈–™π‘¥¬—ß«“ß√–‡∫’¬∫ß“π«‘®—¬‰¡à¥’æÕ2 πÕ°®“°π’È¬—ß‰¡à “¡“√∂„Àâ¬“°≈Ÿ‚§§Õ√åµ‘§Õ¬¥å·°à µ√’µ—Èß§√√¿å∑’Ë¡’¿“«–

‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥∑ÿ°√“¬ ®÷ßª√–‡¡‘πº≈°“√√—°…“‰¥â¬“°

จะเรมใหการรกษาเมอไร

ªí®®ÿ∫—π¬—ß‰¡à¡’·π«∑“ßªØ‘∫—µ‘∑’Ë™—¥‡®π„π°“√‡√‘Ë¡„Àâ°“√√—°…“¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥

√«¡∑—Èß·π«∑“ß°“√«‘π‘®©—¬¬—ß‰¡à‡ªìπ‰ª„π∑‘»∑“ß‡¥’¬«°—π3 ¥—ßπ—Èπ ‚¥¬∑—Ë«‰ª®÷ß¡—°‡√‘Ë¡∑”°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å

§≈Õ¥°àÕπ°”Àπ¥ ‚¥¬„™â·π«∑“ßµàÕ‰ªπ’È

1. µ√’µ—Èß§√√¿å®–‰¥â√—∫°“√«‘π‘®©—¬«à“¡’¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ ‡¡◊ËÕ¡’°“√À¥√—¥µ—«¢Õß¡¥≈Ÿ°

Õ¬à“ß ¡Ë”‡ ¡Õ√à«¡°—∫¡’°“√‡ªî¥¢Õßª“°¡¥≈Ÿ° ·≈–/À√◊Õ µ√«®æ∫°“√∫“ßµ—«¢Õßª“°¡¥≈Ÿ° ·µà¬—ß‰¡à “¡“√∂∫Õ°

‰¥â™—¥‡®π«à“ µ√’µ—Èß§√√¿å°≈ÿà¡π’È®–¡’¿“«–§≈Õ¥°àÕπ°”Àπ¥®√‘ß ‡π◊ËÕß®“°√âÕ¬≈– 30 ¢Õß¿“«–¥—ß°≈à“« “¡“√∂

À“¬‰ª‰¥â‡Õß ·≈–√âÕ¬≈– 50 ¢Õß µ√’µ—Èß§√√¿å∑’Ë√—∫‰«â√—°…“„π‚√ßæ¬“∫“≈¡’°“√§≈Õ¥„π™à«ß§√√¿å§√∫°”Àπ¥4-6

°“√«‘π‘®©—¬¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥¡’§«“¡·µ°µà“ß°—π„π·µà≈–ß“π«‘®—¬ ‡™àπ ¡¥≈Ÿ°À¥√—¥µ—«

Õ¬à“ßπâÕ¬ 4 §√—Èß„π 20 π“∑’ À√◊Õ 8 §√—Èß„π 60 π“∑’7 À√◊Õ∂ÿßπÈ”§√Ë”·µ°·≈–ª“°¡¥≈Ÿ°‡ªî¥ 1-3 ‡´πµ‘‡¡µ√ À√◊Õ

¡’§«“¡∫“ßµ—«¡“°°«à“√âÕ¬≈– 50 À√◊Õ¡’°“√‡ª≈’Ë¬π·ª≈ß¢Õß°“√‡ªî¥ ·≈–°“√∫“ßµ—«¢Õßª“°¡¥≈Ÿ°®“°°“√µ√«®‡ªìπ

√–¬–8,9 à«π°“√µ√«®ª√–‡¡‘πª“°¡¥≈Ÿ°¥â«¬Õ—≈µ√â“´“«¥å ·≈–°“√µ√«®À“ “√™’«‡§¡’¬—ß‰¡à‡ªìπ∑’Ëπ‘¬¡‡™àπ‡¥’¬«°—∫

°“√ª√–‡¡‘π∑“ß§≈‘π‘°

2. Õ“¬ÿ§√√¿å∑’ËπâÕ¬ ·≈–¡“°∑’Ë ÿ¥„π°“√¬—∫¬—Èß°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ ¢≥–π’È¬—ß‰¡à¡’¢âÕ √ÿª

”À√—∫Õ“¬ÿ§√√¿å∑’ËπâÕ¬∑’Ë ÿ¥10 ∫“ß√“¬ß“π„Àâ°“√«‘π‘®©—¬¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥„π™à«ßÕ“¬ÿ§√√¿åµ—Èß·µà

15 —ª¥“Àå ´÷ËßÕâ“ß«à“ “¡“√∂«‘π‘®©—¬¿“«–·∑âß∫ÿµ√‡π◊ËÕß®“°‚§√‚¡‚´¡º‘¥ª°µ‘ÕÕ°‰ª·≈â« ·µà∫“ß√“¬ß“π‡√‘Ë¡„™â∑’Ë

Õ“¬ÿ§√√¿å 20 —ª¥“Àå ‡æ√“–Õâ“ß«à“°àÕπÕ“¬ÿ§√√¿åπ’È ∂◊Õ‡ªìπ°“√·∑âß∫ÿµ√¡“°°«à“®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥

Õ¬à“ß‰√°Áµ“¡ °“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥‰¡à¢÷Èπ°—∫Õ“¬ÿ§√√¿å ·µà¡’§«“¡ —¡æ—π∏å°—∫

“‡Àµÿ¢Õß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ ‡™àπ µ√’∑’Ë¡’¿“«–‡®Á∫§√√¿å®“°°“√∫‘¥µ—«¢Õß∂ÿßπÈ”∑’Ë√—ß‰¢à ·≈–®”‡ªìπ

µâÕß‰¥â√—∫°“√ºà“µ—¥ ¡—°¡’§«“¡®”‡ªìπ∑’ËµâÕß„Àâ°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥·¡â®–æ∫„π™à«ß‰µ√¡“ ·√° ‡æ√“–‡¡◊ËÕ

∑”°“√√—°…“ “‡Àµÿ ®–‰¡à¡’¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥‡°‘¥¢÷ÈπÕ’°11,12

‡ªìπ∑’Ë¬Õ¡√—∫°—π«à“ Õ“¬ÿ§√√¿å¡“°∑’Ë ÿ¥„π°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥§◊Õ 34 —ª¥“Àå

‡æ√“–‡ªìπ™à«ß‡«≈“∑’Ëæ∫°“√‡ ’¬™’«‘µ·≈–§«“¡æ‘°“√¢Õß∑“√°πâÕ¬∑’Ë ÿ¥ πÕ°®“°π’È¬—ßæ∫¿“«–·∑√°´âÕπ„π µ√’

µ—Èß§√√¿åπâÕ¬10,13

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ขอหามของการยบยงภาวะเจบครรภคลอดกอนกำหนด

‰¡à§«√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥„π°√≥’µàÕ‰ªπ’È

1. ∑“√°‡ ’¬™’«‘µ„π§√√¿å

2. ¡’§«“¡º‘¥ª°µ‘√ÿπ·√ß∑’Ë∑”„Àâ∑“√°‰¡à “¡“√∂¡’™’«‘µÕ¬Ÿà‰¥â

3. °“√‡µâπ¢ÕßÀ—«„®∑“√°º‘¥ª°µ‘

4. ∑“√°‡®√‘≠‡µ‘∫‚µ™â“„π§√√¿å

5. µ√’µ—Èß§√√¿å¡’¿“«–§√√¿å‡ªìπæ‘…√ÿπ·√ß°àÕπ™—° À√◊Õ¿“«–§√√¿å‡ªìπæ‘…√–¬–™—°

6. µ√’µ—Èß§√√¿å¡’¿“«–‡≈◊Õ¥ÕÕ°·≈–°“√‡ª≈’Ë¬π·ª≈ß¢Õß√–∫∫°“√‰À≈‡«’¬π‚≈À‘µ

7. µ√’µ—Èß§√√¿å¡’¿“«–µ‘¥‡™◊ÈÕ„π∂ÿßπÈ”§√Ë”

°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥®–‰¡à‰¥âº≈À“°¡’°“√µ‘¥‡™◊ÈÕ„π∂ÿßπÈ”§√Ë”14 ®÷ß¡’¢âÕ √ÿªµ√ß°—π

«à“ ‰¡à§«√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥À“°¡’°“√µ‘¥‡™◊ÈÕ√ÿπ·√ß ‡æ√“–Õ“®∑”„Àâ‡°‘¥Õ—πµ√“¬µàÕ µ√’

µ—Èß§√√¿å·≈–∑“√°„π§√√¿å‰¥â15 ·µà¬—ß‰¡à¡’¢âÕ √ÿª«à“ µ√’µ—Èß§√√¿å∑’Ë¡’¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥´÷Ëß‰¡à¡’Õ“°“√

¢Õß°“√µ‘¥‡™◊ÈÕ §«√‰¥â√—∫°“√ª√–‡¡‘π‡√◊ËÕß°“√µ‘¥‡™◊ÈÕÀ√◊Õ‰¡à ·≈–ªí®®ÿ∫—π¬—ß‰¡à¡’«‘∏’µ√«®«‘π‘®©—¬∑’Ë‡À¡“– ¡

à«π∑“√°Õ“¬ÿ§√√¿åµË”°«à“ 34 —ª¥“Àå ∑’Ë‰¥â√—∫°“√µ√«®æ∫«à“ªÕ¥¬—ß‡®√‘≠‡µ‘∫‚µ‰¡à ¡∫Ÿ√≥å §«√‰¥â√—∫

°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ ‡æ√“–Õ“®¡’¿“«–·∑√°´âÕπ ‡™àπ ¿“«–‡≈◊Õ¥ÕÕ°„π‚æ√ß ¡Õß µ‘¥‡™◊ÈÕ

hyperbilirubinemia À√◊Õ§«“¡º‘¥ª°µ‘Õ◊Ëπ ®÷ß§«√‰¥â√—∫°“√¬—∫¬—Èß¿“«–®Á∫§√√¿å§≈Õ¥ ·≈–„Àâ°≈Ÿ‚§§Õ√åµ‘§Õ¬¥å‡æ◊ËÕ

ª√–‚¬™πå¢Õß∑“√°

°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥®–‰¡àª√– ∫§«“¡ ”‡√Á® À“°ª“°¡¥≈Ÿ°‡ªî¥¡“°°«à“

3 ‡´πµ‘‡¡µ√ ·µà§«√„Àâ°“√¬—∫¬—Èß∂â“¡’«—µ∂ÿª√– ß§å‡æ◊ËÕµâÕß°“√„Àâ°≈Ÿ‚§§Õ√åµ‘§Õ¬¥åÀ√◊Õ àß µ√’µ—Èß§√√¿å‰ª√—∫

°“√√—°…“„π ∂“π∫√‘°“√Õ◊Ëπ∑’Ë‡À¡“– ¡3

คำแนะนำทวไปสำหรบการดแลรกษาสตรตงครรภทมภาวะเจบครรภ คลอดกอนกำหนด

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°“√„™â¬“ „π‡√◊ËÕßª√– ‘∑∏‘¿“æµâÕß§”π÷ß∂÷ß∑“√°‡ªìπÀ≈—° ‡™àπ ¬“∑’Ë„™â§«√™à«¬≈¥¿“«– RDS À√◊Õ°“√‡ ’¬™’«‘µ¢Õß

∑“√°‡°‘¥°àÕπ°”Àπ¥¡“°°«à“¬“∑’Ë “¡“√∂¬◊¥√–¬–‡«≈“„π°“√µ—Èß§√√¿å„Àâπ“π∂÷ß 48 ™—Ë«‚¡ßÀ√◊Õ 7 «—π ¬“∑’Ë„™â§«√

ª≈Õ¥¿—¬µàÕ∑—Èß µ√’µ—Èß§√√¿å ∑“√°„π§√√¿å ·≈–∑“√°™à«ß·√°‡°‘¥

∂â“‰¡àª√– ∫§«“¡ ”‡√Á®„π°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥¥â«¬¬“°≈ÿà¡ first line drugs §«√æ‘®“√≥“

À¬ÿ¥¬“ ·≈–‡ª≈’Ë¬π¡“„™â¬“°≈ÿà¡ second line drugs ‚¥¬§«√æ¬“¬“¡µ√«®À“À≈—°∞“π¢Õß°“√µ‘¥‡™◊ÈÕ„π∂ÿßπÈ”§√Ë”

‡æ√“– µ√’µ—Èß§√√¿å∑’Ë‰¡àª√– ∫§«“¡ ”‡√Á®®“°°“√„™â first line drugs æ∫¡’°“√µ‘¥‡™◊ÈÕ„π∂ÿßπÈ”§√Ë” Ÿß∂÷ß√âÕ¬≈– 6516

231


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tachycardia ∑—Èß„π µ√’µ—Èß§√√¿å·≈–∑“√°„π§√√¿å §«√À¬ÿ¥¬“¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥ ·µà∂â“µ√«®‰¡àæ∫≈—°…≥–

Õ“°“√∑“ß§≈‘π‘°∑’Ë™—¥‡®π °“√‡®“–µ√«®πÈ”§√Ë”‡æ◊ËÕ§âπÀ“°“√µ‘¥‡™◊ÈÕ‚¥¬«‘∏’ gram stain À√◊Õµ√«®‡æ“–‡™◊ÈÕ °Á‡™◊ËÕ«à“

¡’ª√–‚¬™πå°àÕπ∑’Ë®–‡ª≈’Ë¬π‰ª„™â¬“„π°≈ÿà¡ second line drugs17

°“√„™â¬“À≈“¬™π‘¥æ√âÕ¡°—π§«√∑”¥â«¬§«“¡√–¡—¥√–«—ß3 ‡™àπ °“√„™â¬“ Ritodrine √à«¡°—∫ Magnesium

sulfate Õ“®∑”„Àâ‡°‘¥¿“«–·∑√°´âÕπµàÕ√–∫∫À≈Õ¥‡≈◊Õ¥À—«„®¡“°°«à“°“√„™â Ritodrine ™π‘¥‡¥’¬«18 ¿“«–

·∑√°´âÕπ∑’Ëæ∫ ‰¥â·°à Õ“°“√‡®Á∫Àπâ“Õ° °“√‡ª≈’Ë¬π·ª≈ß¢Õß EKG ‡π◊ËÕß®“°°≈â“¡‡π◊ÈÕÀ—«„®¢“¥‡≈◊Õ¥ πÕ°®“°π’È

ª√– ‘∑∏‘¿“æ¬—ß‰¡à‡æ‘Ë¡ Ÿß¢÷Èπ ®÷ß‰¡à§«√„™â Magnesium sulfate √à«¡°—∫ calcium channel blockers À√◊Õ beta-

adrenergic agonists ¡’√“¬ß“π«à“°“√„™â¬“√à«¡°—π√–À«à“ß Atosiban, Terbutaline, Sulindac ·≈–¬“ªØ‘™’«π– ª√– ∫

§«“¡ ”‡√Á®„π°“√¬—∫¬—Èß°“√‡®Á∫§√√¿å™à«ß 23-25 —ª¥“Àå19 πÕ°®“°π’È ¬—ß‰¡àæ∫ª√–‚¬™πå®“°°“√„Àâ°≈Ÿ‚§-

§Õ√åµ‘§Õ¬¥å´È”„π√“¬∑’Ë¡’Õ“°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥°≈—∫‡ªìπ´È” (recurrent preterm labour)

การนอนพก การใหสารนำ และยากดระบบประสาท

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‚√ßæ¬“∫“≈ ‡ª√’¬∫‡∑’¬∫°—∫°“√∑”°‘®«—µ√ª√–®”«—πª°µ‘ ‰¡à¡’§«“¡·µ°µà“ß„π‡√◊ËÕß¢Õß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ

°”Àπ¥20,21

2. ”À√—∫ µ√’µ—Èß§√√¿å·Ω¥ °“√πÕπæ—°„π‚√ßæ¬“∫“≈‰¡à™à«¬∑”„Àâ√–¬–‡«≈“°“√µ—Èß§√√¿å¬“«π“π¢÷Èπ

·µà®“°°“√»÷°…“¢Õß Cochrane database review æ∫«à“ µ√’µ—Èß§√√¿å·Ω¥∑’Ë„Àâ°“√ªÑÕß°—π¿“«–‡®Á∫§√√¿å§≈Õ¥

°àÕπ°”Àπ¥ ‚¥¬°“√πÕπæ—°„π‚√ßæ¬“∫“≈¡’§«“¡‡ ’Ë¬ßµàÕ°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ Ÿß°«à“°≈ÿà¡∑’Ë„ÀâπÕπæ—°

‡¡◊ËÕ‡°‘¥¿“«–·∑√°´âÕπ√–À«à“ß°“√µ—Èß§√√¿å22 ·≈–¬—ßæ∫«à“ Õ—µ√“°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥„π µ√’µ—Èß§√√¿å∑’Ë

πÕπæ—°„π‚√ßæ¬“∫“≈·≈–æ—°∑’Ë∫â“π‰¡à¡’§«“¡·µ°µà“ß°—π23 πÕ°®“°π’È ¡’°“√»÷°…“√–À«à“ß°≈ÿà¡∑’Ë¬—∫¬—Èß¿“«–

‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ ”‡√Á® ·≈–„Àâ°≈—∫‰ª∑”°‘®«—µ√ª√–®”«—πµàÕ ‡ª√’¬∫‡∑’¬∫°—∫°≈ÿà¡∑’Ëß¥°‘®«—µ√ª√–®”«—π

æ∫Õ—µ√“°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥‰¡à·µ°µà“ß°—π24

3. °“√„Àâ “√πÈ”∑“ßÀ≈Õ¥‡≈◊Õ¥ ·≈–°“√„Àâ¬“°¥√–∫∫ª√– “∑‰¡à™à«¬≈¥Õ—µ√“°“√§≈Õ¥°àÕπ°”Àπ¥25-27

ยาปฏชวนะ

“‡Àµÿ¢Õß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ Õ“®‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ„π√–∫∫Õ«—¬«– ◊∫æ—π∏ÿå ·µà¬“

ªØ‘™’«π–‰¡à¡’∫∑∫“∑„π°“√ªÑÕß°—π°“√§≈Õ¥°àÕπ°”Àπ¥„π µ√’µ—Èß§√√¿å∑’Ë¡’Õ“°“√ ®“° Cochrane review 200228 æ∫«à“ ¬“ªØ‘™’«π–‰¡à‰¥â™à«¬∑”„Àâ°“√µ—Èß§√√¿å¬◊¥√–¬–‡«≈“ÕÕ°‰ªÀ√◊Õ™à«¬≈¥°“√§≈Õ¥¿“¬„π 48 ™—Ë«‚¡ß

232


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∂ÿßπÈ”§√Ë”µ‘¥‡™◊ÈÕ endometritis ‚¥¬ √ÿª ¬“ªØ‘™’«π–‰¡à¡’ª√–‚¬™πå ”À√—∫°“√√—°…“¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥

·µàÕ“®¡’ª√–‚¬™πå ”À√—∫ µ√’µ—Èß§√√¿å∑’Ë¡’°“√µ‘¥‡™◊ÈÕ™π‘¥‰¡à¡’Õ“°“√

ประสบการณการดแลรกษาสตรตงครรภภาวะเจบครรภคลอดกอนกำหนดคกคาม (threatened preterm labour)

¿“«–§≈Õ¥°àÕπ°”Àπ¥ À¡“¬∂÷ß °“√§≈Õ¥°àÕπÕ“¬ÿ§√√¿å 37 —ª¥“Àå æ∫‰¥âª√–¡“≥√âÕ¬≈– 8-10

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√–∫∫ª√– “∑√âÕ¬≈– 5030 °“√¥Ÿ·≈√—°…“∑“√°πÈ”Àπ—°πâÕ¬À√◊Õ∑“√°‡°‘¥°àÕπ°”Àπ¥„πÀÕÕ¿‘∫“≈®–µâÕß„™â§à“„™â®à“¬

‡©≈’Ë¬ 170,000 ∫“∑µàÕ√“¬ ·≈–‡¡◊ËÕª√–¡“≥§à“√—°…“æ¬“∫“≈¢Õß∑“√°‡°‘¥°àÕπ°”Àπ¥∑—Ë«ª√–‡∑» æ∫«à“„π·µà≈–ªï

ª√–‡∑»‰∑¬®–µâÕß‡ ’¬§à“„™â®à“¬‰¡àµË”°«à“ 2,300,000,000 ∫“∑ ”À√—∫°“√¥Ÿ·≈√—°…“∑“√°‡°‘¥°àÕπ°”Àπ¥„π√–¬–

À≈—ß§≈Õ¥ª√–¡“≥ 15,000 √“¬ ∑—Èßπ’È¬—ß‰¡à√«¡§à“„™â®à“¬ ”À√—∫°“√¥Ÿ·≈√—°…“µàÕ‡π◊ËÕßÀ“°∑“√°¡’§«“¡æ‘°“√À√◊Õ

æ—≤π“°“√≈à“™â“31

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æ∫Õ—µ√“°“√§≈Õ¥°àÕπ°”Àπ¥√âÕ¬≈– 12.98 ∑“√°°≈ÿà¡π’È‡ªìπ∑“√°∑’Ë§≈Õ¥®“°¡“√¥“´÷Ëß¡“Ω“°§√√¿å∑’Ë‚√ßæ¬“∫“≈

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การรกษาภาวะเจบครรภคลอดกอนกำหนดคกคาม และการบรหารยา Nifedipine

°“√√—°…“¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥§ÿ°§“¡„π‚√ßæ¬“∫“≈»‘√‘√“™ ‡√‘Ë¡¥â«¬°“√∫√‘À“√¬“

Nifedipine (short acting) √Ÿª·∫∫‡¥‘¡√—∫ª√–∑“π¢π“¥ 20 ¡‘≈≈‘°√—¡ ´È”‰¥â∑ÿ° 30 π“∑’ ‡æ‘Ë¡‰¥â®π∂÷ß 60 ¡‘≈≈‘°√—¡

„π 90 π“∑’ (loading dose) ®“°π—Èπ„Àâ 20 ¡‘≈≈‘°√—¡ ∑ÿ° 8 ™—Ë«‚¡ß (maintenance dose) ‚¥¬µ√«®§«“¡¥—π‚≈À‘µ

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¿“¬À≈—ß®“°∫√‘À“√¬“ 72 ™—Ë«‚¡ß ®–‡√‘Ë¡„™â¬“ Nifedipine SR (SR=sustained release) „π¢π“¥

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(¬—ß‰¡à‰¥âπ”‡¢â“‚√ßæ¬“∫“≈»‘√‘√“™) ®π∂÷ßÕ“¬ÿ§√√¿å 34 —ª¥“Àå32-34

Nifedipine SR (SR=sustained release) Õ¬Ÿà„π√Ÿª·∫∫¬“‡¡Á¥ ∑’Ë¡’°“√ª≈àÕ¬·∫∫ sustained-release

¢π“¥ 20 ¡‘≈≈‘°√—¡35 ‡ªìπ vasodilator ®—¥Õ¬Ÿà„π°≈ÿà¡ calcium channel antagonist ¡’ƒ∑∏‘Ï antianginal ·≈–

antihypertensive effects ÕÕ°ƒ∑∏‘Ï ‚¥¬°“√¬—∫¬—Èß calcium ions ºà“π‡¢â“ Ÿà‡´≈≈å°≈â“¡‡π◊ÈÕÀ—«„® ·≈–°≈â“¡‡π◊ÈÕ‡√’¬∫

¢ÕßÀ≈Õ¥‡≈◊Õ¥ ∑”„Àâ√–¥—∫·§≈‡´’¬¡¿“¬„π‡´≈≈å≈¥≈ß ®÷ß‰ª¬—∫¬—Èß‡Õπ‰´¡å ATPase ´÷Ëß°√–µÿâπ„Àâ‡´≈≈å°≈â“¡‡π◊ÈÕ

À¥µ—« ®÷ß∑”„Àâ‡°‘¥°“√¢¬“¬µ—«¢Õß coronary ·≈– peripheral arteries ¡’¢âÕ∫àß„™â„π°“√√—°…“‚√§§«“¡¥—π‚≈À‘µ Ÿß

chronic stable angina, ·≈– variant angina36 µàÕ¡“‰¥âπ” Nifedipine SR ¡“„™â¬—∫¬—Èß°“√À¥√—¥µ—«¢Õß¡¥≈Ÿ°

‡π◊ËÕß®“°‡ªìπ¬“‡¡Á¥∑’Ë‡µ√’¬¡¡“‡©æ“– ®÷ß‰¡à§«√À—°·∫àß ∫¥ ‡§’È¬« À√◊Õ∑”„Àâ‡¡Á¥¬“·µ° ‡æ√“–®–∑”„Àâ§ÿ≥ ¡∫—µ‘°“√

ª≈¥ª≈àÕ¬µ—«¬“‡ ’¬‰ª ·≈–Õ“®∑”„Àâ‡°‘¥Õ“°“√¢â“ß‡§’¬ß∑’Ë‡ªìπÕ—πµ√“¬37 √–¥—∫¬“„π‡≈◊Õ¥®–¢÷Èπ∂÷ß Ÿß ÿ¥„π 90 π“∑’

À≈—ß√—∫ª√–∑“π·≈–¡’ half-life 5.67+1.5 ™—Ë«‚¡ß ®“°º≈°“√»÷°…“æ∫«à“ Nifedipine “¡“√∂¬—∫¬—Èß¿“«–§≈Õ¥

°àÕπ°”Àπ¥§ÿ°§“¡‰¥â¥’°«à“ Proluton depot ·≈–°“√πÕπæ—°‡©¬Ê Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘µ‘38

234


การรกษาภาวะเจบครรภคลอดกอนกำหนดคกคาม และการบรหารยาโปรเจสเตอโรน

‚ª√‡® ‡µÕ‚√π‡ªìπŒÕ√å‚¡π∑’Ë¡’ƒ∑∏‘Ï¬—∫¬—Èß°“√∫’∫√—¥µ—«¢Õß¡¥≈Ÿ° ·≈–®”‡ªìπ ”À√—∫°“√µ—Èß§√√¿å39,40

„π —µ«å∑¥≈Õßæ∫«à“ √–¥—∫ŒÕ√å‚¡π‚ª√‡® ‡µÕ‚√π®–≈¥≈ß‡¡◊ËÕ‡¢â“ Ÿà√–¬–§≈Õ¥‚¥¬‡™◊ËÕ«à“‚ª√‡® ‡µÕ‚√π≈¥√–¥—∫≈ß

‡Õß ·≈–°“√π”ŒÕ√å‚¡π™π‘¥π’È¡“„™â “¡“√∂™à«¬≈¥§«“¡‡ ’Ë¬ßµàÕ°“√§≈Õ¥°àÕπ°”Àπ¥‰¥â41,42 ŒÕ√å‚¡π‚ª√‡® -

‡µÕ‚√π “¡“√∂∫√‘À“√‰¥âÀ≈“¬√Ÿª·∫∫ ‰¡à«à“®–‡ªìπ°“√©’¥‡¢â“°≈â“¡‡π◊ÈÕ Õ¥∑“ß™àÕß§≈Õ¥À√◊Õ√—∫ª√–∑“π ¬—ß‰¡à

æ∫√“¬ß“π teratogenic effect „π¡πÿ…¬å ·µàæ∫Õ“°“√¢â“ß‡§’¬ß ‰¥â·°à ª«¥»’√…– §≈◊Ëπ‰ â ‰Õ ·≈–√–§“¬‡§◊Õß

‡©æ“–∑’Ë®“°°“√©’¥¬“‡¢â“°≈â“¡‡π◊ÈÕ ªí®®ÿ∫—π¬—ß¡’¢âÕ¡Ÿ≈„π‡√◊ËÕß¢π“¥¬“ «‘∏’∫√‘À“√¬“ Õ“¬ÿ§√√¿å ·≈–√–¬–‡«≈“∑’Ë„™â43,44 ‰¡à¡“°π—° ·µà®“°°“√»÷°…“æ∫«à“ °“√∫√‘À“√¬“∑“ß°≈â“¡‡π◊ÈÕ “¡“√∂≈¥Õ“°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ ·≈–

Õÿ∫—µ‘°“√≥å∑“√°πÈ”Àπ—°µË”°«à“ 2,500 °√—¡ ‡¡◊ËÕ∫√‘À“√¬“„π µ√’µ—Èß§√√¿å∑’Ë¡’ª√–«—µ‘‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥

à«π°“√∫√‘À“√¬“∑“ß™àÕß§≈Õ¥¡’ª√– ‘∑∏‘¿“æ„π°“√≈¥Õ“°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ ·µà¬—ß‰¡à¡’¢âÕ¡Ÿ≈™—¥‡®π

„π‡√◊ËÕßº≈√–¬–¬“«µàÕ∑—Èß¡“√¥“ ·≈–∑“√°45 ∑“ß‚√ßæ¬“∫“≈»‘√‘√“™‰¥âπ”ŒÕ√å‚¡π‚ª√‡® ‡µÕ‚√π¡“„™â¬—∫¬—Èß¿“«–

‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥§ÿ°§“¡„π√Ÿª·∫∫ Proluton depot „π¢π“¥ 250 ¡‘≈≈‘°√—¡ ∑ÿ° —ª¥“Àå ®π∂÷ßÕ“¬ÿ§√√¿å

34 —ª¥“Àå

ผลของการบรหารยา Nifedipine และ Proluton depot เพอยบยงภาวะ เจบครรภคลอดกอนกำหนดคกคาม

°“√π” Nifedipine ¡“„™â„π‚√ßæ¬“∫“≈»‘√‘√“™™à«ß·√°æ∫«à“ ∑”„Àâ‡°‘¥§«“¡¥—π‚≈À‘µµË”„π™à«ß 90 π“∑’

·√° ¿“¬À≈—ß°“√∫√‘À“√¬“46 ·µàÀ≈—ß®“°∑’Ë‡ΩÑ“ —ß‡°µÕ“°“√‡ªìπ√–¬–‡«≈“π“π¢÷Èπ §«“¡¥—π‚≈À‘µ®–‡æ‘Ë¡¢÷Èπ ‚¥¬

‰¡àæ∫°“√‡ª≈’Ë¬π·ª≈ß¢ÕßÕ—µ√“À—«„®¢Õß∑“√°„π§√√¿å ·≈–¬—ßæ∫«à“ª√– ‘∑∏‘¿“æ¥â“π°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å

§≈Õ¥°àÕπ°”Àπ¥§ÿ°§“¡ Ÿß¢÷Èπ‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫°“√πÕπæ—°47 ·≈–‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫ Proluton depot æ∫«à“

ª√– ‘∑∏‘¿“æ¢Õß Nifedipine ‰¡à·µ°µà“ß®“° Proluton depot ´÷Ëß¡’ª√– ‘∑∏‘¿“æ¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥

°àÕπ°”Àπ¥√âÕ¬≈– 7048 Õ¬à“ß‰√°Áµ“¡ °“√§âπÀ“ “‡Àµÿ·≈–«“ß·ºπªÑÕß°—π¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥

®– “¡“√∂™à«¬≈¥¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥≈ß‰¥â49

สรป

1. §«√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥‡æ◊ËÕ¬◊¥√–¬–‡«≈“°“√§≈Õ¥ÕÕ°‰ª

2. «—µ∂ÿª√– ß§å ”À√—∫°“√¬—∫¬—Èß°“√§≈Õ¥°àÕπ°”Àπ¥ ‰¥â·°à

2.1 √Õ‡«≈“„Àâ°≈Ÿ‚§§Õ√åµ‘§Õ¬¥åÕÕ°ƒ∑∏‘Ï‰¥â‡µÁ¡∑’Ë

2.2 ‡æ◊ËÕ àß µ√’µ—Èß§√√¿å‰ª√—∫°“√√—°…“„π ∂“πæ¬“∫“≈∑’Ë “¡“√∂¥Ÿ·≈√—°…“∑“√°‡°‘¥°àÕπ°”Àπ¥

2.3 ‡æ◊ËÕ¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥„π°√≥’∑’ËµâÕß°“√∑”ºà“µ—¥„π™àÕß∑âÕß

235


3. °“√‡≈◊Õ°„™â¬“¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥„Àâ§”π÷ß∂÷ßª√– ‘∑∏‘¿“æ·≈–§«“¡ª≈Õ¥¿—¬

‚¥¬„Àâæ‘®“√≥“®“°Õ—µ√“°“√‡ ’¬™’«‘µ¢Õß∑“√°·√°‡°‘¥À√◊ÕÕÿ∫—µ‘°“√≥å¿“«– RDS ¡“°°«à“°“√¬◊¥√–¬–‡«≈“°“√

§≈Õ¥„π 48 ™—Ë«‚¡ß À√◊Õ 7 «—π·√° ·≈–„Àâ§”π÷ß∂÷ß§«“¡ª≈Õ¥¿—¬¢Õß¡“√¥“ ∑“√°„π§√√¿å ·≈–∑“√°·√°‡°‘¥

4. ∂â“¬—∫¬—Èß°“√‡®Á∫§√√¿å§≈Õ¥¥â«¬¬“™π‘¥·√°‰¡à‰¥âº≈ ·π–π”„ÀâÀ¬ÿ¥¬“ ·≈–‡√‘Ë¡°“√√—°…“¥â«¬¬“

™π‘¥∑’Ë 2 (grade 2C) À“°ª√– ∫§«“¡≈â¡‡À≈«„π°“√„™â¬“™π‘¥‡¥’¬«‡æ◊ËÕ¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥

‰¡à§«√∫√‘À“√¬“À≈“¬™π‘¥„π‡«≈“‡¥’¬«°—π ‡æ√“–Õ“®∑”„Àâ‡°‘¥º≈¢â“ß‡§’¬ßµàÕ∑—Èß¡“√¥“·≈–∑“√° Õ’°∑—Èß¬—ß¢“¥¢âÕ¡Ÿ≈

¬◊π¬—π„π‡√◊ËÕßª√– ‘∑∏‘¿“æ °“√‡≈◊Õ°∫√‘À“√¬“À≈“¬™π‘¥æ√âÕ¡°—π§«√æ‘®“√≥“„π µ√’µ—Èß§√√¿å∑’Ë¡’Õ“¬ÿ§√√¿åπâÕ¬

5. §«√‡≈◊Õ°¬“∑’Ë “¡“√∂∫√‘À“√∑“ßª“° √“§“∂Ÿ° Õ“°“√¢â“ß‡§’¬ßπâÕ¬ ·≈– “¡“√∂≈¥°“√‡ ’¬™’«‘µ·≈–

§«“¡æ‘°“√¢Õß∑“√° Nifedipine ¡’ª√– ‘∑∏‘¿“æ„π°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ ·≈– “¡“√∂„™â„π∑ÿ°

Õ“¬ÿ§√√¿å (Grade 2B)

5.1 ¬“ first line drug ‰¥â·°à beta-adrenergic agonists ¡’ª√– ‘∑∏‘¿“æ„π°“√√—°…“¿“«–‡®Á∫§√√¿å

§≈Õ¥°àÕπ°”Àπ¥ ·µàæ∫¿“«–·∑√°´âÕπ Ÿß

5.2 ¬“ second line drug ∑’Ë·π–π”„Àâ„™â¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥°àÕπÕ“¬ÿ§√√¿å

32 —ª¥“Àå ‰¥â·°à indomethacin (Grade 2B) ‡ªìπ¬“∑’Ë¡’ª√– ‘∑∏‘¿“æ ·µà¡’¢âÕÀâ“¡„π µ√’µ—Èß§√√¿å¡’¿“«– platelets

dysfunction ‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘ µ—∫∑”ß“πº‘¥ª°µ‘ ¡’·º≈„π√–∫∫∑“ß‡¥‘πÕ“À“√ ‰µ∑”ß“πº‘¥ª°µ‘ À√◊Õ¡’¿“«–

ÀÕ∫À◊¥ ‰¡à§«√„™â¬“π’È„π µ√’µ—Èß§√√¿å∑’Ë¡’ª√–«—µ‘·æâ¬“ aspirin À√◊Õ¡’Õ“¬ÿ§√√¿å¡“°°«à“ 32 —ª¥“Àå ·≈–‰¡à§«√

∫√‘À“√¬“π“π‡°‘π 72 ™—Ë«‚¡ß ‡æ√“–Õ“®‡ªìπ “‡Àµÿ¢Õß premature closure of ductus arteriosus

6. ∂â“µ√«®‰¡àæ∫°“√µ‘¥‡™◊ÈÕ ·π–π”„ÀâÀ≈’°‡≈’Ë¬ß°“√„™â¬“ªØ‘™’«π–‡æ◊ËÕ¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ

°”Àπ¥ (Grade 2B) °“√„™â¬“ªØ‘™’«π–¡’¢âÕ∫àß™’È„π°√≥’∑’ËµâÕß°“√ªÑÕß°—π°“√µ‘¥‡™◊ÈÕ group B beta-streptococcus

‡©æ“–„π√“¬∑’Ë¡’Õ“°“√∑“ß§≈‘π‘°

7. Nifedipine ·≈– Proluton depot ‡ªìπ∑“ß‡≈◊Õ°Àπ÷Ëß ”À√—∫°“√¬—∫¬—Èß¿“«–‡®Á∫§√√¿å§≈Õ¥

°àÕπ°”Àπ¥§ÿ°§“¡„π‚√ßæ¬“∫“≈»‘√‘√“™ ∑—Èßπ’È‡æ◊ËÕªÑÕß°—π°“√‡ªî¥¢Õßª“°¡¥≈Ÿ° ∑’Ëπ”‰ª ŸàÕ“°“√‡®Á∫§√√¿å§≈Õ¥

°àÕπ°”Àπ¥®√‘ß

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