Sức khoẻ sinh sản, Tập 2 số 2

THNG TIN CHUYN NGNH SN PH KHOA

SC KHOE SINH SANHi Ph Sn Tp H Ch Minh Thng 07 nm 2012 K 2, S 2 Pht hnh t 2011

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1 nh gi tn thng Tn sinh trong thng m c t cung (CIN) qua soi c t cung v cch x tr

V Th Nhung,*PGS.TS.

6 Cc khuyn co phng nga v pht hin sm ung th c t cung nm 2012

Ngi dch: Nguyn Vn Thng, BS; Hunh Xun Nghim, BS; Trn Th Vn Anh, BS.

20 So snh Mifepristone v Misopros-tol vi Misoprostol n thun trong ph thai k gia

Nguyn Th Nh Ngoc, ThS.BS; Tara Shochet, TS; Sheila Raghavan, ThS; Jennifer Blum, TS; Nguyn Th Bch Nga, BS; Nguyn Th Hng Minh, BS; Phan Vn Quy, ThS.BS;Beverly Win-ikoff, TS.

30 Xc nh t l cc bnh l ni mc t cung ph n ra huyt hu mn kinh

Nguyn Duy Ti, *GS.BS.; Ngoc Xun Trang,**BS.

48 So snh hiu qu ca Duratocin v Oxytocin trong d phng chy mu sau m ly thai ti khoa ph sn bnh vin Bnh Dng

Phan Th Ha,*BS CKII v CS.

52 X tr chuyn d sinh non: Nifedi-pine hay Atosiban?

Ngi dch: L Quang Thanh, ThS.BS.

THNG TIN HOT NG

- Cc lp o to lin tc (CME)30/03/2012: CME Tip cn Bung trng a

nang: v sinh - bo ph

29/06/2012: CME Ph thai ni khoa

- Lp hun luyn soi c t cungPGS. BS. Quek Swee Chong

SC KHE SINH SN 3, Thng 07 2012 i

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1 nh gi tn thng Tn sinh trong thng m c t cung (CIN) qua soi c t cung v cch x tr

V Th Nhung,*PGS.TS.

6 Cc khuyn co phng nga v pht hin sm ung th c t cung nm 2012


13 Tng quan v ngoi xoay thai

Nguyn Th Tuyt Nhng, *BS.

17 c im v nguyn tc iu tr bo ph ph n mc Hi chng bung trng a nang

Th Ngc Dip,* BS.CKII; Trn Quc Cng, ThS.BS.

20 So snh Mifepristone v Misoprostol vi Mis-oprostol n thun trong ph thai ky gia

Nguyn Th Nh Ngc, ThS.BS; Tara Shochet, TS; Sheila Raghavan, ThS; Jennifer Blum, TS; Nguyn Th Bch Nga, BS; Nguyn Th Hng Minh, BS; Phan Vn Quy, ThS.BS;Beverly Winikoff, TS.

30 Xc nh t l cc bnh l ni mc t cung ph n ra huyt hu mn kinh

Nguyn Duy Ti, *GS.BS.; Ngc Xun Trang,**BS.

34 Cp nht x tr lc ni mc t cung

Ngi dch: L Quang Thanh,* ThS, BS

44 Nhn mt trng hp c thai v lao mng bng

Phan Vn Quyn,* BS.

48 So snh hiu qu ca Duratocin v Oxytocin trong d phng chy mu sau m ly thai ti khoa ph sn bnh vin Bnh Dng

Phan Th Ha,*BS CKII v CS.

52 X tr chuyn d sinh non: Nifedipine hay Atosiban?

Ngi dch: L Quang Thanh, ThS.BS.

56 Thc phm rau qu, hot ng th cht v t sut ph n ln tui trong cng ng

Ngi dch: Phan Vn Quyn, BS.

64 S dng bin php trnh thai dng tim c th lm tng nguy c ung th v ph n tr

Ngi dch: Phan Vn Quyn, BS.

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V d:

... Nhng bao cao a cng b gi y rng phac misoprostol hiu qua cao hn v it tac dung phu v bin chng hn nhng prostaglandins khac.412 ...

1. World Health Organization. Safe abortion: technical and policy guidance for health systems. Geneva (Switzerland): World Health Organization; 2003.

2. Tang OS, Ho PC. Medical abortion in the second trimester. Best Pract Res Clin Obstet Gynaecol 2002;16:23746.

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i cng

Tn sinh trong biu m c t cung (CIN) l tnh trng t bo bao ph c t cung pht trin bt thng . Nhng thay i ny mi din ra phn trn ca lp t bo y, cha xm ln vo m m c t cung (CTC). a s tn thng xy ra vng chuyn tip ca CTC (ranh gii gia biu m lt v biu m tr ). T thp nin 1970, qua nhiu nghin cu dch t ngi ta xc nh vai tr gy bnh dn n CIN ca Human Papilloma Virus (HPV). CIN thng pht trin trong khong 25-35 tui.

CIN trc y c gi l d sn CTC hay lon sn CTC hay nghch sn CTC l nhng tn thng thay i ty mc t nh (CIN1) n va (CIN2) v nng (CIN3). CIN c th tn ti lu hay t khi nh h min dch ca bnh nhn. Mt s nh trng hp c th tin trin thnh ung th, iu tr tn thng giai on CIN th c th phng nga ung th CTC.

Cc tn thng CIN c th chia lm 3 loi :

1. CIN1 (D sn nh): T bo pht trin bt thng 1/3 di ca lp biu m gai CTC, c th t khi nh phn ng min dch ca c th sau mt vi nm

2. CIN2 (D sn va) : Tn thng 2/3 di ca lp biu m gai CTC

3. CIN3 (D sn nng): Tn thng ton b lp biu m gai CTC, rt d nhm ln vi ung th ti ch c TC .

T CIN ln u tin c ni n vo nm 1968. n nhng nm 1980, nhng tn thng m hc do HPV gy ra (t bo

rng) c pht hin v v vy t nm 1990 khi nim ny dn n s phn loi n gin v tn thng m hc cn 2 mc l tn thng CIN thp bao gm CIN1 v t bo nhim HPV, tn thng CIN cao bao gm CIN2,3. CIN2,3 tht s l nhng tn thng tin ung th ca t bo biu m gai CTC. Nm 1991 h thng phn loi Bethesda (TBS) c p dng c nhng kt qu t bo hc c t cung v cng do h thng ny cm t tn thng trong biu m gai c t cung ( SIL) c hnh thnh. SIL gm 2 mc tn thng : thp (LSIL) v cao (HSIL)

nh gi theo h thng BETHESDA, CIN1 cng vi nhng bin i t bo do HPV c xp vo loi LSIL. Nhng tn thng CIN2,3 c xp vo loi HSIL. TBS c chnh sa li nm 2001 trong hi tho ca Vin nghin cu Ung th Quc gia Hoa K kt hp vi 44 Hi ngh nghip ca hn 20 Quc Gia trn th gii v c s dng n nay .

Phn loi theo H thng BETHESDA 20017

T bo biu m gai

Thay i t bo biu m gai khng in hnh (ASC: Atypical Squamous Cell) dng ch nhng thay i nh tm thy c t bo biu m gai m nguyn nhn khng xc nh c, gm 2 nhm:

- Thay i t bo biu m gai khng in hnh khng r ngha (ASC-US: Atypical Squamous Cell of Undetermined Significance)

nh gi tn thng Tn sinh trong thng m c t cung (CIN) qua soi c t cung v cch x trV Th Nhung,*PGS.TS.

* Hi Ph Sn TP H Ch Minh

Vit theo bi ging trong lp soi c t cung ca PGS Quek Swee Chong**** Parkway Gynaecology Screening and treatment center Gleneagles Hospital Singapore

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SC KHE SINH SN 3, Thng 07 20122

- Thay i t bo biu m gai khng in hnh nhng khng loi tr c l tn thng trong biu m gai cao ASC-H (HSIL: High-grade squamous intraepithelial lesions)

Thay i t bo biu m gai do tn thng trong biu m gai thp (LSIL: Low-grade squamous intraepithelial lesions), cn c gi l nghch sn nh hay tn sinh trong biu m gai 1 (CIN1). Phn loi ny dng ch nhng thay i nh ca t bo biu m v khng c khuynh hng tin trin thnh ung th, phn loi ny bao gm c nhng tn thng t bo do nhim HPV

Thay i t bo biu m gai do tn thng trong biu m gai cao (HSIL: High-grade squamous intraepithelial lesions): Phn loi ny ch cc thay i ca t bo c kh nng tin trin thnh ung th, bao gm: d sn trung bnh (CIN2), d sn nng (CIN2), ung th ti ch v nhng tn thng ung th nghi ng xm ln.

Ung th t bo biu m gai xm lm.

T bo biu m tuyn

T bo biu m tuyn khng in hnh (AGC: Atypical glandular cells):

T bo biu m tuyn khng in hnh, do tn sinh:

- Tn sinh ca t bo c t cung trong (knh c t cung)

- Tn sinh ca t bo ni mc t cung

Ung th ti ch t bo tuyn c t cung trong

Ung th t bo tuyn xm ln

Chn on CIN qua soi c t cung

Cc c im lm sng gip chn on biu m c t cung bt thng qua soi c TC

soi c t cung t yu cu, cn phi nhn thy r ton b ranh gii ca vng chuyn tip (TZ) c phn nh bi gii hn gn l ch ni tip nguyn thy gia t bo tuyn v t bo lt v gii hn xa c xc nh bi v tr xa nht ca cc ca tuyn hay nhng nang

Naboth 2 mp c TC ..

C th chn on CIN qua soi CTC da vo 4 c im sau y:

- Mc trng ca tn thng khi bi Acetic Acid

Sau khi bi Acetic Acid 3-5% , AA s lm t bo mt nc v lm ng c protein nhn t bo khin t bo c mu trng c. Tc dng ny cng tng trong nhng tn thng mc cao v ung th. Quanh cc ca tuyn trong tn thng cao c mu trng dy m gi l vin trng. Nhng vin ny trng hn, rng hn nhng b vin quanh ca tuyn bnh thng.

Hnh 1. Vin trng

- B v b mt ca vng tn thng khi bi Acetic Acid

Khi tn thng mc cng cao th b mt cng it nhn , ranh gii gia m bnh thng v bt thng vng chuyn tip rt sc nt, r rng, u n hn tn thng thp.

- Hnh nh mch mu

Nhng hnh nh chm y v lt c th th hay mn. Nu dng th th tng ng vi tn thng mc cao . Chm y v lt d nn thy hn khi mch mu phn nhnh bnh thng v nhng mch mu bt thng ny xm nhp su vo lp biu m nn gn st vi b mt biu m.

Chm y mn v lt mn c th thy tn thng thp.

Chm y th v lt th c th thy tn thng cao.

Khi 2 loi hnh nh ny xp chng ln nhau

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trong cng mt ni th cc vng mao qun xut hin gia mi mng gch lt. Hnh nh ny gi l rn gch lt (hnh 2).

Hnh 2. Rn gch lat

- S thay i mu sau bi Lugol

m o bnh thng, biu m gai c t cung v biu m chuyn sn trng thnh cha nhiu glycogen nn s nhum mu nu en sau khi bi lugol. Biu m c tn thng CIN cha t hay khng c glycogen nn khng nhum mu nu vi iode v vn gi mu vng hoa ci hay h phch. Biu m c t cung bt thng thng khng gn cht vi lp m m di nn khi bi cc dung dch ha cht nhiu ln ln c t cung c th lm trc lp biu m to thnh vt lot . Khi bi lugol ln th ni khng nhum mu nu.

ngi mn kinh, biu m c TC teo, thiu dng nn nhum mu lugol nht , iu ny khin s chn on kh khn i vi hu mn kinh (hnh 3 ngun: Indian Journal of Medical and Paediatric Oncology2).

Hnh 3. mu sau bi Lugol

Phn bit tn thng CIN v cc bin i lnh tnh khc ca c t cung qua soi c TC

Mt iu kin cn thit gip soi c TC t cht lng tt l phi nhn thy r ranh gii ca vng chuyn tip .Nhng du hiu bt thng xut hin vng chuyn tip (TZ) s lm tng kh nng c tn thng CIN.

Phi c kinh nghim phn bit gia tn thng CIN thp vi chuyn sn gai cha trng thnh v tn thng vim da vo mt s c im ca cc loi tn thng nh sau:

- LSIL (CIN1/HPV): khi bi acetic acid 3-5% s cho tn thng c mu trng lt , b mt bng phng, b c ranh gii r nhng khng u, ta nh lng chim hoc c hnh di nh ngn tay. C nhng tn thng v tinh, c hnh nh lt mn, him khi c chm y (hnh 4 ngun: Cancer Update - National Cancer Center Singapore Singhealth Volume 1,20058).

Hnh 4. LSIL

- HSIL: khi bi Acetic Acid 3-5% s cho tn thng mu trng dy, m, trng xm hay i khi c mu vng. Ranh gii r rng, b u, thnh thong c ch g cao v bong trc. C th tn thng lan su vo knh c t cung, b mt tn thng khng u, hnh nh chm y v lt th. Tn thng mc cao c khuynh hng xut hin 2 mp c t cung v nm su vo pha knh c t cung (hnh 5 ngun: Cancer Update - National Cancer Center Singapore Singhealth Volume 1,20058).

nh gi tn thng Tn sinh trong thng m c t cung (CIN) qua soi c t cung v cch x tr


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Hnh 5. HSIL - Ung th vi xm ln: khi bi acetic acid 3-5% s cho tn thng mu trng m, dy v thng c sc vng. Tn thng rng, b mt b trc, hoi t, c th c mch mu bt thng . Cn lu l mu sinh thit nh khng th gip chn on chnh xc ung th vi xm ln (hnh 6,7 ngun: Colposcopy management options 3,6 ).

Hnh 6,7. Ung th vi xm ln CTC- Chuyn sn gai cha trng thnh (Immature metaplasia)

Vng trng sau bi acetic acid 3-5% t m, trong sut hn vng trng ca CIN, khng c ranh gii r rng gia vng trng do chuyn sn v biu m bnh thng v ta rng t vng chuyn tip sang nhng phn khc ca biu m c TC. Biu m ni c chuyn sn lan ra vi hnh nh ging nh nhng ngn tay hay nhng li m hng tm v pha l ngoi c TC trong khi nhng vng trng ca tn thng CIN thng bt ngun t vng chuyn tip pht trin ra pha ngoi xa l c TC. Khng c b ranh gii gia biu m c TC bnh thng vi vng chuyn sn cng nh vi tn thng vim m cc t chc ny an xen vo nhau (hnh 8 ngun: Colposcopy management options 3,6).

Hnh 8. Chuyn san cha trng thnh CTC

iu tr

S tin trin ca CIN ko di trung bnh 15 nm , c th c nhng din bin theo bng sau 4 :

Thoi trin

Tn ti Tin trin

Khng xm ln

CIN 1 57% 32% 11% 1%

CIN 2 43% 35% 22% 5%

CIN 3 32% 12%

Ung th CTC thng tri qua tng giai on CIN1 CIN2 CIN3.

Tn thng biu m mc cao (HSIL) vn c th xy ra m khng cn phi c LSIL trc . Nhng tn thng mc cao (HSIL) c th pht trin t tn thng mc thp hoc trc tip t cc tn thng do nhim HPV tn ti ko di v 70% l do 2 tp virus HPV 16, HPV18. V th, vic tm sot pht hin tnh trng nhim HPV ht sc cn thit qun l sc kho sinh sn cng nh ra bin php can thip sm ph hp.

Phng php iu tr

CIN1 thng thng c th t thoi trin m khng cn iu tr. Cn lm li pht t bo 6 thng, 12 thng sau. Nu tn thng rng, vn tn ti sau 18-24 thng th iu tr bng t lnh (cryotherapy) hay LEEP.5

CIN2, 3 phi iu tr. Mc ch iu tr l ct b vng tn thng hoc ph hy cc t bo ca biu m CTC. chn phng php iu tr thch hp , ngi ta da vo s phn loi vng chuyn tip.


Phn loi mi ca TZ l :

- Type 1 : nhn thy ton b TZ c ngoi c TC.

- Type 2 : TZ c mt phn nm l trong c TC m gii hn cao ch thy c nh th thut h tr ca ngi soi c TC.

- Type 3 : TZ i su vo knh c TC v khng th nhn thy c.

Ph hy t bo thch hp cho TZ type 1 bao gm cc phng php:

- t lnh vi N2O

- t LASER CO2

- t in

Ct b tn thng thch hp cho TZ type 2,3 p dng bao gm cc phng php sau:

- Khot chp vi dao thng

- LEEP (Loop Electrosurgical Excision Procedure) hay LLETZ (Large Loop Excision of the Transformation Zone)

- Ct t cung

i vi trng hp bnh nhn cn tr di 25 tui c CIN 2 th khng nht thit phi iu tr v 62% cc trng hp c th c s thoi trin.1

Trng hp bnh nhn ang mang thai: Chn on thng da vo soi c t cung m khng c s khng nh ca sinh thit c TC, ch khi nghi ng c ung th xm ln th mi bm sinh thit. Tn thng thng tr nn nh li thi k hu sn so vi lc ang mang thai cng nh tn thng thng rt vo trong l c TC. C th sanh ng m o i vi tn thng CIN v phi chn on xc nh li 8-12 tun hu sn.

Theo di 5

Nu phi iu tr CIN1 th cn lm li pht t bo c TC 6 thng, 12 thng v 24 thng. Nu tt c u bnh thng th tr li theo chng trnh tm sot ty theo tui ngi bnh. Nn theo di sau 3-5 nm. Nu bnh vn tn ti th phi kho st k c hng iu tr ph hp nh t lnh, LEEP hay khot chp bng dao thng.

Sau khi iu tr CIN 2,3 th cn lm li pht t bo c TC 6 thng v 12 thng ri sau mi nm mt ln t 3-5 nm sau.

T l ti pht : 5-10%. Nu c ti pht th ct b m bnh bng LEEP hay LASER CO2 hay khot chp bng dao thng. Nu ti pht th ct t cung phng nga ung th CTC

D ct t cung nhng vn phi lm pht t bo m o vi tr mm m o bng phng php liquid-based cytology (Thinprep)

Ti liu tham kho1. Bree McAllum, Peter H.H. Sykes, Lynn Sadler,

Helene Macnab, Bryony J. Simcock,Adel K. Mekhail (2011), Is the treatment of CIN 2 always necessary in women under 25 years old? American Journal of Obstetrics & Gynecology Volume 205, Issue 5 , Pages 478.e1-478.e7, November 2011.

2. Gauravi A Mishra, Sharmila A Pimple, Surendra S Shastri (2011) An overview of prevention and early detection of cervical cancers Indian Journal of Medical and Paediatric Oncology 2011 Volume : 32 Issue : 3 Page : 125-132

3. Jean Ritter,Jean-Jacques Baldauf (2003) Basic colposcopic technique, Colposcopy management options (2003) pp 51-58.

4. John W. Sellors, R.Sankaranarayanan (2003), An introduction to cervical intraepithelial neoplasia (CIN) Colposcopy and treatment of cervical Intraepithelial neoplasia: A beginnersmanual (2003) pp 13-19.

5. John W. Sellors, R.Sankaranarayanan (2003), Management that provides continuity of care for women Colposcopy and treatment of cervical Intraepithelial neoplasia: A beginnersmanual (2003) pp 89-94.

6. Jonathan A Cosin, Leo B. Twiggs (2003) Invasive cervical cancer , Colposcopy management options (2003) pp 149.

7. Lauren Zoschnick, Thomas C Wright (2003) The AAFP 2003 Annual Clinical Focus on prevention and health promotion.Am Fam Physician. 2003 Nov 15;68(10):1992-1999.

8. Quek Swee Chong (2005) Preinvasive disease of the cervix Cancer Update - National Cancer Center

Singapore Singhealth Vol 1, 2005

nh gi tn thng Tn sinh trong thng m c t cung (CIN) qua soi c t cung v cch x tr


Khuyn co mi nht nm 2012 ca Hip hi Ung th M (ASC) nhm cp nht khuyn co cch y 10 nm v tm sot v pht hin sm cc tn thng tin ung th v ung th c t cung (CTC) da trn chng c n t 6 nhm tng quan v mt hi ngh thng nht kin ca cc t chc lin quan. Khuyn co mi nhm vo cc chng trnh tm sot da trn tui thch hp, vic s dng kt hp gia t bo v xt nghim HPV, vic theo di khi kt qu tm sot dng tnh cng nh khong cch gia 2 ln tm sot m tnh, tui no th khng cn phi tm sot, vic ch s dng xt nghim HPV nh l phng php tm sot u tin v quy trnh tm sot cho nhng ph n chch nga 2 type HPV 18 v 16 nh th no.

Tm sot ung th CTC theo tui

Tm sot ung th CTC lm gim mt cch r rt bnh xut cng nh t xut ung th CTC n 80-90%. Ti M, ung th CTC t v tr th nht trong gia th k 20 chuyn sang v tr th 14 trong nhng nm gn y sau khi pht t bo m o CTC c p dng rng ri. iu ny l do: pht hin cc tn thng ung th xm ln giai on sm vi t l sng sau 5 nm iu tr ln n 92%, vic pht hin v iu tr nhng tn thng tin ung th lm gim t l ung th xm ln.

Ngy nay chng ta bit gn nh 100%

cc ung th CTC u dng tnh vi HPV v vic nhim cc type HPV nguy c cao ko di l iu kin cn cho vic pht trin thnh cc tn thng tin ung th v ung th CTC. Trong HPV type 16 l type c kh nng sinh ung cao nht chim n 56-60% ung th CTC, HPV type 18 ng hng th hai vi 10-15% v 10 type HPV nguy c cao cn li chu trch nhim khong 25-35%. Type HPV 18 cn c xu hng gy ung th t bo tuyn hn l ung th t bo gai (32 so vi 8%).

Nhim HPV ch yu qua ng quan h tnh dc v tip xc b phn sinh dc. hu ht cc dn s, tn xut nhim HPV nh im thng vi nm sau tui bt u quan h tnh dc nh ti M l 17 tui. Gn nh 90% nhim HPV l tim n v khng pht hin c sau 1 n 2 nm. ph n tn ti nhim HPV ko di c nguy c tin trin thnh tn thng tin ung th. Tn ti nhim HPV ko di c bit l HPV type 16 l yu t tin lng mnh cho vic tin trin thnh tn thng nng hn CIN3 ln lt l 20% trong 1 nm v 30% trong 2 nm. Cc tn thng CIN3 nu khng iu tr th c th c 30% cc tn thng ny tin trin thnh ung th trong khi ch 1% tin trin thnh ung th nu c iu tr.

Vic tm hiu mi lin quan gia ung th CTC v nhim HPV cho thy c m hnh sinh ung theo tng cp bc: nhim HPV, tn ti nhim HPV ko di thay v b thi loi nh

Cc khuyn co phng nga v pht hin sm ung th c t cung nm 2012 Hi Ung th M, Hi Soi v Bnh hc c t cung M, Hi Bnh hc Lm sng M


Theo: American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society For Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer. Debbie Saslow, et all, the ACS-ASCCP-ASCP Cervical Cancer Guideline Committee 20, CA. CANCER J CLIN 2012;62:147-172.

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thng thng, tip theo l tin trin thnh cc tn thng tin ung th, ri ung th xm ln. Hiu c tin trnh t nhin ny gip ch rt nhiu trong chnh sch tm sot v iu tr cc tn thng tin ung th v ung th da theo tui.

Cn bng gia cc yu t c li v bt li khi tm sot

Mc ch cui cng ca chng trnh tm sot ung th CTC l lm sao c th gim c bnh xut v t xut ca ung th CTC. Mt chng trnh tm sot ti u l mt chng trnh c th tm v phn bit c nhng tn thng tin ung m c kh nng cao tin trin thnh ung th xm ln (ti u ha sng lc) trong khi trnh vic pht hin v iu tr qu tay nhng tn thng nhim HPV tim n cng nh nhng tn thng kh c th tin trin thnh ung th (gim thiu tc ng bt li ca sng lc).

Khuyn co s dng CIN3 nh l mt mc xc nh nhy ca xt nghim tm sot do phn ln cc tn thng CIN3 u tin trin thnh ung th nu khng iu tr. Tri li tn thng CIN2 vn c xem l mt chn on nc i bao gm nhng tn thng tin ung th nh CIN3 nhng cng bao gm c nhng tn thng khc c th t thoi trin nh CIN1. Mc d CIN2 vn c chp nhn rng ri trn lm sng nh l mc can thip iu tr nhng khuyn co vn cho rng CIN2 khng nn dng nh l mc tiu tm sot ung th CTC.

Hu ht nhim HPV v tn thng CIN1, CIN2 s thoi trin v t kh nng tin trin thnh CIN3 hay ung th.

Tuy nhin khi pht hin nhng tn thng ny c th gy nn nhng bt li sau: vic lo lng khi kt qu tm sot dng tnh, kh nng xu h ca ngi tham gia tm sot khi c chn on bnh l nhim trng ly qua ng tnh dc, khng thoi mi khi chn on (soi CTC, sinh thit) v iu tr (khot chp, ct t cung), chy mu khi iu tr v nh hng lu di ca iu tr khot chp lm tng nguy c bin chng thai k nh kh nng sanh non.

Ni dung khuyn co

Khuyn co nhm vo tm sot trn dn s thng qui, khng nhm trn dn s nguy c cao nh: tin s b ung th CTC, tin s m s dng diethylstilbestrol (DES) lc mang thai, suy gim min dch

Khi no bt u tm sot?

Tm sot ung th CTC nn bt u t 21 tui. Khng nn tm sot nhng ph n nh hn 21 tui bt k thi im bt u hot ng tnh dc hay nhng yu t nguy c khc.

T l ung th CTC rt him ph n tr v khng th phng nga c bng pht t bo. Tn sut ung th CTC cng khng thay i cho d c chnh sch tm sot rng ri trong 4 thp k qua. Tm sot tui ny c th dn n kh nng iu tr qu tay nhng tn thng tin ung th m c kh nng t hi phc cao m phi mt nhiu nm na nhng tn thng ny mi c th tin trin thnh ung th CTC bn cnh vic iu tr ny c th nh hng nhiu n sinh sn sau ny ca h. Phng nga ung th CTC tui thiu nin nn tp trung vo chin dch chch nga HPV rng khp s mang tnh hiu qu cao nht vi chi ph thp.

Khong cch gia 2 ln tm sot

Khng khuyn co tm sot hng nm bi bt k phng tin tm sot no cho bt k tui no.

Nhng bng chng v sinh bnh hc ung th CTC ngy cng nhiu v mnh cho thy chnh sch tm sot ung th CTC hng nm l c hi nhiu hn l li. Tm sot hng nm ch pht hin mt lng rt nh nhng tn thng tin ung th nhng li tn chi ph rt ln cho vic iu tr khng cn thit do a phn l tn thng lnh tnh t khi sau 2 nm hoc nu khng th cn rt nhiu nm mi c th tin trin thnh ung th.

Tui t 21 n 29

Tm sot bng pht t bo mi 3 nm cho ph n tui t 21 n 29. tui ny nu tm sot 2 ln m tnh th vn cha c bng chng ko di khong cch gia

Cc khuyn co phng nga v pht hin sm ung th c t cung nm 2012


2 ln tm sot hn 3 nm. Xt nghim HPV khng nn s dng d l s dng n c hay kt hp vi t bo cho tui ny.

C t nghin cu tp trung vo khong thi gian gia 2 ln tm sot tui ny. Chnh sch tm sot hng nm ch lm tng mt t vic pht hin nguy c ung th CTC nhng li tng gp i s ln soi CTC so vi chnh sch mi 3 nm. C 2 chnh sch ny u lm gim gnh nng ung th tng t nhau trong khong thi gian 10 nm. Khng c s khc bit c ngha trong vic gim t l ung th gia chnh sch tm sot mi 2 nm v 3 nm, do khuyn co chn khong cch mi 3 nm l tt nht trong vic cn bng gia li ch v tc hi khi tm sot tui ny. tui ny, t l nhim HPV cn rt cao nn HPV khng c khuyn co s dng.

Tui t 30 n 65

Ph n tui t 30 n 65 nn c tm sot vi kt hp gia t bo v HPV mi 5 nm (u tin hn) hoc ch pht t bo mi 3 nm (chp nhn c). Vn cha c bng chng cho vic thay i khong thi gian gia 2 ln tm sot nu trc tm sot nhiu ln m tnh.

Tm sot ch bng t bo

nhng ph n tui t 30 n 65, vn cha bng chng cho khong cch gia 2 ln tm sot l hn 3 nm ngay c nhng ln tm sot trc u m tnh. Cc nghin cu cho thy nhng ph n sau nhiu ln tm sot m tnh vn tng nguy c ung th CTC sau 3 nm. Ch mt nghin cu ti M so snh chnh sch tm sot bng t bo mi nm so vi mi 3 nm. Mt s nghin cu khc cho thy s gia tng nguy c ung th CTC theo tng khong cch t 1 nm n 3 nm n 5 nm. Do m hnh khong cch mi 3 nm l thch hp nht v cn bng c li ch v bt li cng nh cha bng chng ko di khong cch gia 2 ln tm sot hn 3 nm.

HPV kt hp vi t bo

Hu ht cc nghin cu u cho thy HPV kt hp vi t bo lm tng kh nng pht hin

cc tn thng CIN3 ng thi lm gim nhng tn thng nng hn CIN3 hoc ung th. iu ny c th cho php nhm nguy c thp vi tm sot m tnh ko di khong cch gia 2 ln tm sot ln 5 nm so vi 3 nm nu ch tm sot bng t bo. Vic kt hp ny cn gip pht hin nhiu tn thng ung th v tin ung th t bo tuyn hn so vi t bo gai do kh c th pht hin nhng tn thng t bo tuyn hn. Xt nghim kt hp HPV v t bo c khuyn co vo nm 2002 v 2004 vi khong cch gia 2 ln tm sot l 3 nm. Cc nghin cu cho thy nhng ph n trc c kt qu kt hp HPV v t bo m tnh th khi i tm sot ln th 2 c kt qu chn on tn thng nng hn CIN3 thp c ngha thng k; iu ny cng ng h cho khuyn co ko di thi gian gia 2 ln tm sot bng xt nghim kt hp. Cc m hnh nghin cu cho thy vi khong cch gia 2 ln xt nghim tm sot kt hp ph n 40 tui l 3 nm so vi 5 nm ch tng nh nguy c ung th CTC theo tui i ln lt l 0,39% v 0,61% trong khi li tng mt cch c ngha s lng soi CTC. Xt nghim kt hp thng xuyn hn mi 3 nm hay mi mt nm lm tng cc yu t bt li do lm tng s lng soi CTC v iu tr. Tuy nhin hu nh cc bng chng hin ti u da trn chnh sch tm sot t hn 3 nm/1 ln. Thiu bng chng c li vt tri nhng tng cc nguy c bt li do vic tm sot qu thng xuyn cng ng h cho khuyn co xt nghim tm sot kt hp mi 5 nm.

Tng nhy ca xt nghim tm sot kt hp

So vi t bo, xt nghim HPV c nhy cao hn nhng t c hiu hn trong vic tm sot nhng tn thng nng hn CIN3. Khi c 2 xt nghim u m tnh th nguy c mc cc tn thng nng hn CIN3 v nht l ung th CTC cng rt thp. Bn cnh mt s nghin cu ngu nhin c i chng cng cho thy khuynh hng gim cc tn thng nng hn CIN3 c ngha thng k sau 2 ln tm sot bng xt nghim kt hp (t 0,03% xung cn 0%). Nhng tc ng bt li chnh yu khi kt hp HPV v t bo nh lm tng

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s ln soi CTC v s lng tn thng CIN2 s c gim thiu bi khong cch gia 2 ln tm sot ko di n 5 nm.

Khong cch an ton gia 2 ln tm sot

Nguy c sau 6 nm tin trin thnh cc tn thng nng hn CIN3 khi HPV m tnh v xt nghim kt hp m tnh ln lt l 0,27% v 0,28% da trn 7 nghin cu quan st 24.295 ph n. Trong khi nguy c ny nu ch c t bo m tnh li cao hn nhiu (0,97%). Mt nghin cu quan st khc trn 330.000 ph n ti Chu u cho thy nguy c sau 3 nm tin trin thnh tn thng nng hn CIN 3 nu t bo m tnh l 0,17% v nguy c sau 5 nm nu HPV m tnh cng nh xt nghim kt hp l 0,17% v 0,16%. Cng cng nghin cu , nguy c tin trin thnh ung th ln lt l 0,018%, 0,019%, 0,016%. Qua chng ta c th s dng gi tr tin on m ca HPV m bo nguy c rt thp mc cc tn thng nng hn CIN3 sau 5 nm tm sot m tnh bng xt nghim kt hp.

Qun l trng hp HPV dng t bo m

Nhng ph n c kt qu xt nghim HPV dng v t bo m cha c khuyn co soi CTC ngay m c th la chn 1 trong 2 hng x tr sau:

1. Tm sot li bng xt nghim kt hp sau 12 thng. Nu c 1 trong 2 xt nghim dng tnh (HPV vn cn dng hoc t bo c tn thng nng hn t LSIL) th tin hnh soi CTC. Nu c 2 u m tnh (HPV m v t bo c ASC-US hoc m) th tm sot nh thng quy.

2. Xt nghim nh type HPV, nu HPV16 hoc HPV 16/18 dng (khng cn phi nh r cc type HPV khc) th soi CTC, nu m th tm sot li bng xt nghim kt hp sau 12 thng.

Hin ti cha c mt nghin cu ngu nhin c i chng nh gi tnh hung ny. Tuy nhin bng chng mnh t cc nghin cu quan st tin cu nh gi nguy c ngn hn mc CIN3 trong nhm dn s ny thp hn nguy c ca nhm c HPV dng km t bo ASC-US v LSIL c ch nh soi CTC l

8-10% trong 2 nm. Nguy c tin trin thnh tn thng nng hn CIN3 trong trng hp ny thay i t 0,8% n 4,1% v nguy c c tnh tr thnh ung th l 0,08%. Do chnh sch soi CTC ngay khi HPV dng m t bo m khng c ng h. Lp li xt nghim sau 12 thng da trn bng chng cho thy hu ht cc trng hp nhim HPV bin mt sau 12 thng, gip cho nhng ph n c th quay v tm sot thng quy m khng phi chu nguy c phi iu tr qu tay.

nhng ni c th xt nghim nh type HPV th c th thc hin thm nh type HPV 16 hay HPV16/18 trong trng hp HPV dng t bo m c th tin lng ngn hn nguy c mc cc tn thng nng hn CIN3 c th ch nh soi CTC ngay. Nguy c mc CIN3 ln n 10% sau khi nhim HPV 16 t 1 n 4 nm v nhim HPV18 t 2 n 5 nm. mt nghin cu khc nguy c mc cc tn thng nng hn CIN2 v CIN3 khi HPV 16/18 dng tnh ln lt l 11,4% v 9,8% v khi HPV 16 dng tnh ln lt l 13,6% v 11,7%. Trong khi nguy c ngn hn ca nhng type HPV khc th kh thp nn khng c s dng.

Qun l ASC-US vi HPV m

Nhng ph n c kt qu t bo ASC-US vi HPV m th nn c tip tc tm sot thng quy theo tui.

Nguy c st cc tn thng nng hn CIN3 ch c 0,28%, nguy c tin trin thnh cc tn thng nng hn CIN3 sau 5 nm l 0,54% v khng khc bit vi nhng ph n c c 2 xt nghim u m.

Ph n c HPV dng t bo ASC-US hoc t bo c bt thng nng hn ASC-US th cn phi soi CTC ngay do nguy c ung th CTC qu ln khng th chp chun tm sot thng quy c.

Tm sot ch vi HPV

Trong bi cnh lm sng hin ti, tm sot ch bng HPV cha c khuyn co thay th 2 chnh sch tm sot c chp nhn l chnh sch tm sot bng kt hp HPV v t bo hay chnh sch tm sot ch bng t bo.

Cc nghin cu ngu nhin c i chng



u cho thy HPV c nhy nhm pht hin cc tn thng nng hn CIN2 v CIN3 cao hn so vi t bo ngay trong ln u tm sot. Xt nghim HPV c nhy cao cng quan trng nh gi tr tin on m ca xt nghim ny trong vic qun l trong thi gian di v khi HPV m cng c ngha l c nguy c thp vi vic mc cc tn thng nng hn CIN3. Tuy nhin xt nghim HPV li cho c hiu thp gy nn s gia tng mc can thip nh soi CTC. Hin nay vn cha c bng chng r rng v cc tc ng bt li hay chnh sch lm thm t bo sau khi HPV dng tnh nn cha th p dng rng ri trong lm sng cho d chnh sch ch s dng xt nghim HPV tm sot c trin vng rt ln nh l mt xt nghim tm sot u tin. Bn cnh vic thiu cc tiu chun ni ti nhm m bo vic thu thp lng mu ca mt s xt nghim HPV nn c th gy m tnh gi. Do vy t bo kt hp vi HPV nhm gim nhng li ca xt nghim HPV do khng thu thp lng mu. V mt ng dng th cn phi c nhng nh gi thm na v chi ph hiu qu khi p dng chnh sch ny.

Ph n trn 65 tui

Ph n trn 65 tui c qu trnh tm sot ung th CTC trc m tnh (3 ln pht t bo m tnh, 2 ln xt nghim kt hp vi ln lm xt nghim gn y nht khng qu 5 nm) hoc c tin cn mc cc tn thng nng hn CIN2 theo di 20 nm khng nn tm sot tip tc vi bt k phng php tm sot no. Theo m hnh ton hc, nhng ph n tm sot m tnh y bng t bo mi 3 nm trc 65 tui th nu tip tc tm sot n 90 tui th cng ch pht hin thm c 1,6 trng hp ung th v 0,5 trng hp t vong do ung th trong 1000 ngi tham gia tm sot. Khi ngng tm sot th khng cn tm sot li vi bt k l do no ngay c khi c bn tnh mi.

Ph n trn 65 tui c tin cn c cc tn thng CIN2, CIN3, ung th tuyn ti ch cn c theo di t nht 20 nm t khi pht hin c th theo di s thoi trin ca cc tn thng ny.

Tn xut mc cc tn thng nng hn

CIN2 thp v tn xut ung th CTC him nhng ph n trn 65 tui c tm sot tt. Ti M ung th CTC thng gp ch nhm dn s khng tm sot hoc tm sot khng y . Da trn sinh bnh hc ca ung th CTC, nhng ph n sau 65 tui khng c kh nng tin trin thnh ung th CTC sau khi nhim HPV ri tin trin thnh CIN3 trong qung i cn li. Trong khi nhng ph n tm sot m tnh y s c nguy c mc cc tn thng nng hn CIN3 rt thp th nhng ph n c tin cn iu tr CIN2 vn cn nguy c cao hn gp 5 n 10 ln. Tm sot nhm ph n ln tui c th pht hin rt t nhng bt thng nng hn CIN2 mi v phng nga rt t ung th CTC hay t vong v ung th bi v vng chuyn tip CTC ca h nh v kh quan st thy cng nh ung th cng pht trin sau nhiu nm nhim.

Ph n sau ct t cung khng c tin cn mc cc tn thng nng hn CIN2

Ph n sau ct t cung khng c tin cn mc cc tn thng nng hn CIN2 khng khuyn co tip tc tm sot vi bt k phng tin no. Bng chng ca vic tm sot m tnh y trc cng khng cn thit. Khi ngng tm sot th khng cn tm sot li vi bt k l do no ngay c khi c bn tnh mi. Nhng ngi ny th pht t bo cng ch tm sot ung th m o. y l loi ung th ph khoa him gp nn cng khng cn thit phi tm sot.

Tm sot sau khi chch nga HPV

Vic tm sot ung th CTC nhm ph n chch nga HPV khng thay i so vi nhm khng chch nga.

C 2 vaccine nga HPV hin ti u nhm n 2 type HPV 16 v 18 gy ra 70% ung th CTC. Cc nghin cu ngu nhin c i chng cho thy hiu qu bo v i vi cc tn thng CIN2 v CIN3 ca cc loi vacine ny i vi nhm ph n chch nga cha c tip xc vi HPV trc . iu ny c ngha l cc ph n c bo v bi vaccine nga HPV cn c mt chnh sch ring nh thi im bt u tm sot tr hn, khong cch gia 2 ln tm sot xa hn so vi

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nhm dn s bnh thng. Tuy nhin khong 30% ung th CTC vn tip tc tin trin do vaccine th h hin nay ch phng nga c 2 type HPV 16 v 18. Theo khuyn co ca Hi ng T Vn Thc Hnh Min Dch, ph n c th chch nga HPV n 26 tui do vn c mt s ph n tng nhim HPV trc khi chch dn n hiu qu bo v gim xung. Bn cnh mc bao ph ca chch nga HPV ti M cng nh a s cc nc khc cha c rng khp nh cc nc c chnh ph ti tr nh Anh, c. Do hin ti vn cha c s liu ng h mt chng trnh tm sot ring cho nhm ph n

chch nga HPV.

Ni tm li, nhng khuyn co mi ny c cn nhc k lng da trn nhng chng c tt nht nhm phng nga ti a t xut v bnh xut ca ung th CTC bng nhng phng tin tm sot hin ti lm sao c th ti u ha vic phng nga ung th CTC nhng gim thiu nht nhng nguy c bt li i km theo do dng tnh gi ca xt nghim hoc do iu tr qu tay



PHC TM SOT UNG TH C T CUNG NM 2012

HI UNG TH M, HI SOI V BNH HC C T CUNG M, HI BNH HC LM SNG M

Dn s Phng php tm sot c khuyn co a

Qun l kt qu tm sot Bnh lun

< 21 tui Khng tm sot HPV khng c khuyn co s dng tm sot hay

qun l ASC-US

21-29 tui Ch pht t bo mi 3 nm

HPV dng + t bo ASC-US b hay t bo nng hn LSIL:

=> Theo phc

HPV khng c khuyn co s dng tm sot

T bo m hay HPV m+ASC-US:

=> Tm sot bng t bo mi 3 nm

30-65 tui Kt hp HPV v t bo mi 5 nm

(khuyn khch)


=> Theo phc

Tm sot ch bng HPV cha c khuyn co s dng

HPV dng + t bo m:

La chn 1: kt hp HPV + t bo sau 12 thng

La chn 2: nh type HPV 16 hay HPV 16/18

=> Nu dng: soi CTC

=> Nu m: kt hp HPV + t bo sau 12 thng

Xt nghim kt hp m hay HPV m +ASC-US:

=> Tm sot thng quy sau 5 nm

Ch pht t bo mi 3 nm (chp

nhn c)


=> Theo phc

T bo m hay HPV m +ASC-US:

=> Tm sot t bo sau 3 nm

Trn 61 tui Ngng tm sot nu tm sot trc y v m tnh

Tin cn c cc tn thng CIN2 hay nng hn th cn theo di t nht 20 nm

Sau ct t cung Ngng tm sot p dng cho mi ph n tr khi mc tn thng nng hn CIN2 trong vng 20 nm hay mc ung th CTC

Chch nga HPV Theo cc khuyn co da theo tui (ging ph n cha chch nga)

a: Chinh sach tm soat hng nm khng c khuyn cao vi bt k phng tin tm soat no v bt k tui no

b: Xt nghim HPV khi kt qua t bo ASC-US c khuyn cao

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Tnh hnh x tr ngi mng hin nay

Ngi mng l mt ngi bt thng, chim t 3-4% thai k thng. Ngi mng thng kt hp vi nhng kt cc chu sinh bt li do bin chng ca thai non thng, d tt bm sinh, sa dy rn, chn thng hoc ngt trong qu trnh sanh. C 3 thi x tr mt trng hp ngi mng thng:

- Ch chuyn d t nhin v sanh ngi mng ng m o

- M sanh ch ng trc khi vo giai on chuyn d

- Ngoi xoay thai

Sanh ngi mng ng m o tng c xem nh l mt thc hnh sn khoa bnh thng cho n nm 1959 ngi ta mi nhn ra c s gim bnh sut v t vong chu sinh khi thc hin m ly thai cho nhng trng hp ngi mng.1 Ngy nay, m ly thai thng qui cho ngi mng ang dn tr nn ph bin, t l m sanh v ngi mng gia tng ng k trong vng 20 nm qua,2,3 nht l sau khi nghin cu Term Breech Trial ca tc gi Hannah c cng b vo nm 2000.4

Nghin cu c tin hnh vi mc tiu so snh ch trng m ly thai ch ng cho ngi mng thng vi sinh ng m o ch ng thng qua nh gi cc kt cc thai k. Ban u th nghim c d nh ko di trong 5 nm c th thu nhn khong 2.800 trng hp nhng sau dng li sm hn d kin v nhng kt cc chu sinh c chng minh c li r rt qua qu trnh phn tch th. Nguy c t vong chu sinh, t vong s sinh hoc bnh sut s sinh trm trng trong nhm c m sanh ch ng (17/1039) thp hn ng k so vi nhm sanh ng m o (52/1039) (Nguy c tng i (NCT) 0,33; Khong tin cy (KTC) 95% 0,19 n 0,56).

Ngoi ra khng c s khc bit v bnh sut nng ca m gia hai nhm (NCT 1,24; KTC 95% 0.79 n 1.95).

Tuy nhin, trong Tng quan Cochrane nm 20035 khi tin hnh phn tch nhm nh so snh gia nhng nc c t sut chu sinh cao v thp, kt qu cho thy nguy c ca t vong s sinh, chu sinh hay nhng bnh sut s sinh trm trng ti nhng quc gia c t l t vong chu sinh cao (NCT 0,66; KTC 95% 0,35 n 1,24) gim t hn so vi nhng quc gia c t l t vong chu sinh thp (NCT 0,07; KTC 95% 0,02 n 0,29). iu ny cng c ngha l ti nhng nc ang pht trin th ch li ca vic sinh m ch ng thp hn nhiu so vi nhng nc pht trin. V th, ton b kt qu th nghim khng th p dng rng ri ti nhng nc ang pht trin. Hn na, tng quan Cochrane cn cho thy chnh sch m sanh ch ng cho ngi mng thng c kh nng lm gia tng bnh sut sn ph (NCT 1,29; KTC 95% 1,03 n 1,61) v vn cn thiu thng tin v hu qu lu di ca m ly thai c th l nguy c nhng ln c thai sau do so m trn t cung. Ngoi ra, vic p dng ch trng m sanh ch ng cho tt c cc thai thng ngi mng gy ra nhng quan ngi v mt dn k nng sanh ngi mng, cng nh i hi s u t thm rt nhiu nhng nc ang pht trin. Ngun lc cn phi s dng thc hin thm m ly thai ti nhng nc ny ht sc cao. V vy cn cn nhc nh gi tng trng hp c th cng nh nh gi ngun lc ca tng ni trc khi p dng cc kt qu ca nghin cu Term Breech Trial vo thc hnh lm sng.

ch li ca ngoi xoay thai

Ngoi xoay thai l mt trong nhng chn

Tng quan v ngoi xoay thaiNguyn Th Tuyt Nhng, *BS.

*BV Hng Vng


la x tr ngi mng, gip trnh phi sinh ngi mng. Ngoi xoay thai l mt th thut khng t tin, c th c thc hin ti phng khm ngoi tr. Thun li ca vic p dng ngoi xoay thai cho thai thng ch c th quyt nh ly thai ra ngay trong nhng trng hp xut hin bin chng v khi phi thai trng thnh, ng thi kh nng t xoay v ngi thun sau 36 tun tui thai ngi con so < 8%6 cng nh t l xoay ngc tr v ngi mng sau th thut ngoi xoay thai thnh cng ch xy ra < 5%.7 Vic tin hnh ngoi xoay thai em li ch li cho sn ph do trnh c cc nguy c ngn hn ca m sanh nh bng huyt, truyn mu, nhim trng, thuyn tc tnh mch su, ng thi trnh c cc nguy c lu di ca m sanh. Tng quan Cochrane v ngoi xoay thai cho nhng trng hp ngi mng thng8 chng minh rng ngoi xoay thai gip lm gim t l ngi thai khng phi l ngi u vo lc sanh (NCT 0,46; KTC 95% 0,31 n 0,66), gim t l m sanh do h thp c t l ngi mng (NCT 0,63; KTC 95% 0,44 n 0,90). Th thut ngoi xoay thai c xem l an ton, cc bin chng nh nhau bong non, v t cung, thuyn tc i, xut huyt thai-m, chn thng thai ch xy ra khong 0,5%, tim thai cn bn chm l biu hin thng thy khi thc hin th thut, tuy nhin y ch l nhng thay i thong qua.9-11

Chng ch nh ca ngoi xoay thai

Chng ch nh v pha m: a thai, t cung d dng, vt m c 2 ln tr ln, nhau tin o, c xut huyt t cung trong 7 ngy gn y, a sn, bo ph, bnh tim mch, bnh l tuyn gip, i tho ng.

Chng ch nh v pha thai: d tt bm sinh thai, thai chm tng trng trong t cung, u thai nga, dy rn qun c, i v non, c lng cn nng thai >4000g

K thut ngoi xoay thai

Trc khi tin hnh ngoi xoay thai:

- Xc nh li tui thai > 37 tun

- m bo sn ph thng hiu v tin trnh ngoi xoay thai cng nh li ch v

nguy c ca th thut

- Cho sn ph k vo giy ng thun thc hin ngoi xoay thai

- Siu m xc nh sinh trc hc thai, ngi thai, th tch nc i, v tr nhau bm

- Bit c nhm mu Rh

iu kin cn thit thc hin ngoi xoay thai

Ngoi xoay thai c th c thc hin ti phng khm ngoi tr, cn c cc iu kin sau:

- C th thc hin o CTG

- C my siu m kim tra tim thai trong qu trnh thc hin th thut

- C th di chuyn ln phng m mt cch nhanh nht (khi c nhng bin chng ca th thut m cn phi m sanh cp cu)

Tin hnh ngoi xoay thai:

- o CTG

- o mch v huyt p ca sn ph

- Dng thuc gim g t cung: tim di da Terbutaline 0,25 mg v ch trong 10-20 pht thuc c tc dng. (Chng ch nh ca Terbutaline: nhy cm vi thnh phn ca thuc, m c bnh l tim mch, tng huyt p, cng gip khng c kim sot tt, h kali mu).

- Thc hin ngoi xoay thai di hng dn ca siu m

- Quan st tim thai qua siu m trc v sau th thut. Nu th thut ko di th kim tra tim thai qua siu m trong khi thc hin th thut

- Bi gel hoc bt talc ln trn bng sn ph th thut c thc hin d dng hn

- Dng mt lc chc chn p vo mng thai nhi phn trnh din ca ngi thai c y ra khi khung chu ca sn ph v di chuyn sang bn. Tip tc duy tr lc y trn mng v u thai cho n khi th thut ngoi xoay thai c hon tt (hnh A, B, C).

- Nu khng thnh cng vi ln xoay u

TNG QUAN Y VN


tin th c th th xoay theo chiu ngc li (hnh D).

- Trong hu ht cc trng hp th th thut dng li sau 2 ln xoay khng thnh cng. Tuy nhin c th th xoay thm ln th ba nu sn ph ng v ngi thc hin th thut nh gi rng vn c c hi thnh cng

- Th thut c dng li khi: sn ph thy khng thoi mi tip tc th thut, tim thai bt thng ko di, sau 3 ln th m khng thnh cng

Sau th thut ngoi xoay thai:

o li CTG

- Nu sn ph mang nhm mu Rh m th s c tim bp anti-D

- Sn ph cn c theo di t nht l 1 gi sau th thut pht hin cc bin chng qua nhng du hiu sau:

- CTG bt thng

- Xut huyt t cung

- au bng

- i v

- Gim c ng thai

Nu ngoi xoay thai khng thnh cng cn tho lun vi sn ph v cch sanh v nu sn ph la chn m sanh th ln k hoch m sanh ch ng

Nu ngoi xoay thai thnh cng th sn ph s tr li siu m vo ngy hm sau chc chn rng ngi thai l ngi thun

Hnh: K thut ngoi xoay thai (Ngun: http://hetv.org/)

Tng quan v ngoi xoay thai


T l thnh cng v nhng yu t nh hng

T l thnh cng ca ngoi xoay thai vo khong 50%. Nhn chung t l thnh cng l 40% ngi con so v 60% ngi con r.12 Tng quan Cochrane nm 201213 c thc hin nh gi hiu qu ca mt s can thip h tr trong qu trnh ngoi xoay thai. S dng thuc gim co nhm kch thch beta lm tng kh nng sanh ngi u (NCT 1,68; KTC 95% 1,14 n 2,48), gim nguy c ngoi xoay thai tht bi (NCT 0,70; KTC 95% 0,60 n 0,82), gim m sanh (NCT 0,77; KTC 95% 0,67 n 0,88) trong khi cc nhm thuc gim co khc nh chn knh Canxi hay Nitric oxide khng chng minh c hiu qu lm thay i cc kt cc nu trn. Vic phi hp gy t vng v thuc gim co cng cho thy ch li khi lm gim nguy c tht bi vi ngoi xoay thai so vi ch s dng thuc gim co n thun (NCT 0,61; KTC 95% 0,43 n 0,86). Mt s bin php khc cng c cp nh kch thch thai bng m thoa, truyn nc vo bung i, tuy nhin khng bng chng nh gi hiu qu ca cc phng php ny.

Kt lun

Thc hnh ngoi xoay thai cho ngi mng thng l can thip duy nht c chng minh lm gim t l sinh ngi khng thun v t l m sanh m khng lm tng t sut chu sinh. y l th thut khng tn km, an ton cho m v thai khi thc hin thai thng. Nn tin hnh ngoi xoay thai ni c my siu m, c iu kin theo di tim thai bng monitor v m bo kh nng tip cn kp thi n phng m khi cn thit

Ti liu tham kho1. Wright RC. Reduction of perinatal mortality and

morbidity in breech delivery through routine use of cesarean section Obstetric and Gynecology 1959;14(6):758-63.

2. Rietberg CC, Elferink-Stinkens PM, GH. V. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants. BJOG 2005.9.:112:205.

3. Verhoeven AT, de Leeuw JP, HW. B. Breech presentation at term: elective caesarean section is the wrong choice as a standard treatment because of too high risks for the mother and her future

children. Ned Tijdschr Geneeskd 2005.149:220710.

4. Hannah ME, HannahWJ, Hewson SA, Hodnett ED, Saigal S, Willan. Term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000.356:137583.

5. Hofmeyr GJ, Hannah M. Planned caesarean section for term breech delivery. Cochrane Database of Systematic Reviews 2003. (2):CD000166.

6. Westgren M, Edvall H, et al. Spontaneous cephalic version of breech presentation in the last trimester. Br J Obstet Gynaecol. 1985;92:19-22.

7. Impey L, Lissoni D. Outcome of external cephalic version after 36 weeks gestation without tocolysis. J Matern Fetal Med 1999.8:203-7.

8. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database Syst Rev 1996 Copyright 2011 The Cochrane Collaboration. (1).

9. Grootscholten K, Kok M, Oei SG, Mol BW, JA. vdP. External cepjalic version-related risk: a meta-analysis. Obstet Gynecol 2008 Nov.51:112(5):1143.

10. Nassar N. Systematic review of adverse outcomes of external cephalic version and persisting breech presentation at term, Paediatr Perinat Epidemiology 2006.20:163-71.

11. Collaris. R. External cephalic version: a safe procedure? . Acta Obstet Gynecol Scand 2004.83:511-18.

12. RCOG Greentop Guideline No.20a. External cephalic version and reducing the incidence of breech presentation. Decem ber 2006.Reviewed 2010.

13. Cluver C, Hofmeyr GJ, Gyte GML, Sinclair M. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev 2012.

TNG QUAN Y VN


Dch t hc

Tn sut mc bo ph ang gia tng nhanh chng ti Vit Nam c bit l khu vc thnh th. Theo iu tra ca Trung tm Dinh dng ti TPHCM cho thy bo ph n gii cao so vi nam gii vi t l 31.6 % v 33.6% tng ng nam v n. tui trng thnh, bo ph ph n gia tng dn theo tui v t nh im nhm tui 40-49 sau gim dn. T l tha cn bo ph gia tng qua cc nhm tui 20-29, 30-39, 40-49 vi t l 18.4%, 26.2% v 33.9% ri sau gim xung cn 21.5% nhm tui 50-59 tui.1,2 T l tha cn bo ph ph n trong tui sinh sn 15-49 tui hin nay l 30.1% tng hn 300% trong vng 10 nm qua.3 Bo ph nh hng xu n sc kho sinh sn, lm gia tng tn sut hi chng bung trng a nang.

Hi chng bung trng a nang c quan tm khi ngy cng nhiu ph n la tui sinh sn mc phi. Nghin cu ti c cho thy c khong t 12-21% ph n la tui sinh sn c cc biu hin ca hi chng bung trng a nang.11

Bo ph rt hay gp cc ph n b hi chng bung trng a nang v c cho l hu qu ca tnh trng ri lon ni tit t.

Chn on bo ph

Chn on bo ph ch yu da vo ch s khi c th BMI (Body mass index).

Ngoi ra cn nhiu phng php khc cng c s dng nh gi s phn b ca lng m trong c th bao gm vng eo (tha cn khi vng eo n gii 80cm), t l eo trn mng, b dy np gp da

Phn loi tnh trng dinh dng theo WHO

BMI


Estrogen gp phn vo s khc bit trong phn b lng m trong c th. Estrogen gip gim tch ly lng m trong c th ni chung v gim tch t m trung tm hay m ni tng ni ring. Khi lng estrogen gim i ph n c nguy c tng cn v tch ly m ni tng m trung tm nhiu hn. Theo nhiu nghin cu cho thy t tui mn kinh, ngi ph n gia tng trung bnh 0,5 kg mi nm.9,10

Cc yu t hnh vi v mi trng

Bn cnh di truyn, hnh vi v mi trng gp phn vo nguyn nhn bo ph. Bo ph l do mt cn bng v nng lng mt thi gian di trong nng lng a vo qua ch n nhiu v hoc nng lng tiu hao qua vn ng t.

Yu t mi trng gm 3 mc mi trng: mi trng gia nh, mi trng lm vic v mi trng x hi. Trong cc mi trng trn, c nhiu yu t khuyn khch tng tiu th thc phm v hoc kh khn trong vn ng gp phn gia tng bo ph.

Hu qu ca bo ph trong hi chng bung trng a nang

Bo ph l biu hin ca hi chng bung trng a nang, nhng ng thi bo ph cng l l yu t nguy c dn n hi chng bung trng a nang.9,11

Bo ph cn dn n nhiu bin chng nguy him n gii bao gm gia tng nguy c tng huyt p, i tho ng, ri lon chuyn ha lipid, bnh tim mch, ri lon gic ng, t qu, t vong. Bo ph cng lm gia tng nguy c mt vi loi ung th n gii nh ung th ni mc t cung, ung th v hu mn kinh, ung th rut, thn. Ngoi ra bo ph cn lm cho ph n cm thy khng khe hn nam gii cng mc bo ph c th gii thch do quan im thm m ca x hi. 7,9,10

Nghin cu tin cu ca Shaw v cng s cho thy 35% bnh nhn hi chng bung trng a nang mc tin i tho ng, 10% mc i tho ng type 2, nguy c chuyn t tin i tho ng sang i tho ng type 2 bnh nhn hi chng bung trng a nang cao hn t 5-10 ln, nguy c c bin chng nguy him ca i tho ng type 2 cao hn t 4-7 ln, nguy

c bnh tim mch cao hn.12

Bo ph cng lm gia tng nguy c n cc tai bin sn khoa cho c m v con bao gm gia tng nguy c v sinh, sy thai, bin chng tc mch trong mang thai, tng huyt p thai k, thai lu, sinh non thng, chm pht trin thai k, i tho ng thai k. Tr em sinh ra t b m bo ph li gia tng nguy c bo ph v khng insulin hn tr em sinh ra t b m cn nng bnh thng. Mt s nghin cu kt lun bo ph ph n gp phn gia tng nguy c mc hi chng chuyn ha cho tr em ngay khi cn l giai on bo thai.5,8

Cc nguyn tc phng nga v iu tr bo ph

T c ch bnh sinh chng ta c th rt ra quan im u tin l phng nga bo ph n gii ngay t giai on mang thai. Mc tng cn trong thai k ty thuc vo tnh trng dinh dng trc . Ni cch khc, nu thai ph mp sn th c php tng cn t v ngc li trnh d m sau sinh.

i vi cc bnh nhn mc hi chng bung chng a nang, gim cn l bin php iu tr u tay. Nhiu trng hp triu chng lm sng c ci thin ch khi iu tr gim cn m khng cn iu tr dng thuc. Ch gim 5% trng lng bnh nhn hi chng bung chng a nang cho thy gim c nng insulin, gim nng testosterol, ci thin kinh nguyt, gim tnh trng rm lng v mn ngoi da cng nh tnh trng tm l ca bnh nhn.4,11 Trong cc gii php iu tr bo ph th u tin hng u l iu tr dinh dng kt hp vn ng m bo duy tr sc kho v m bo gim cn bn vng. Cn c ch nh gim cn quyt lit i tng tha cn bo ph c tch m dng to tc l mp trung tm do tch ly m ni tng v gan.

Nhm phng nga tng cn tr li sau iu tr, ch iu tr gim cn nn theo nguyn tc iu tr ti nh, s dng thc phm gia nh, n ung theo thi quen hng ngy, thay i thi quen xu, ci thin thi quen tt, cn bng dinh dng.

V ch dinh dng nn theo ch n gim nng lng cung cp hng ngy tu theo

TNG QUAN Y VN


mc bo ph, mc hot ng th lc v mi trng sng cng nh thi quen sinh hot. Cn theo ui ch n gim cht bo, tng cng cht x. Hn ch ti a n sau 20 gi. T l cc cht sinh nng lng m bo ng l 20%, 25% v 55% theo th t. Cht x theo nhu cu khuyn ngh cho ngi Vit Nam l 18-20 gam/ngi/ngy. Hn ch nhm tinh bt (cm, bnh m, cc loi bn, m , khoai..). Nn hn ch ti a loi ng n nh ng ma, mt, ma, cc loi bnh ko, nc ngt c ga, mt, qu kh.... Nn la chn cc thc phm giu carbohydrate c ch s ng huyt thp. Gim lng cht bo c bit l nhm cht bo no, nn di 10%, phn cn li l cht bo khng no. Cholesterol30

Phu thut gim cn ch l bin php cui cng khi cc bin php trn tht bi v bnh nhn qu mp kt hp bin chng nng do bo ph. Cc phng php phu thut thng dng nh t bng chong ch d dy, t ai tht d dyl nhng phng php t xm ln hn cc phng php ct on hay ni thng d dy

rut.

Mt s ch n hoc sn phm n king thp nng lng hay cc thp nng lng c hiu qu i vi i tng bo ph c bin chng nng cn gim cn nhanh. Cn lu cc ch n ny khng c thc hin qu 12 tun, phi b sung vitamin v khong cht trong qu trnh iu tr, cung cp nc cho bnh nhn v c theo di lm sng cht ch trnh mt s bin chng iu tr v d nh hn m do tng ceton mu trong ch n cc thp nng lng

Ti liu tham kho1. Trn Quc Cng, Michael Dibley, Steve Bowe. Tnh

trng dinh dng v cc yu t nguy c lin quan ngi trng thnh 20-60 tui sng ti ni thnh TPHCM. 2003-2004. Lun vn tt nghip Thc s y khoa i hc Newcastle Australia.

2. L Nguyn Trung c Sn v CS. Kho st tnh trng dinh dng v i tho ng ngi trng thnh trn 15 tui sng ti TPHCM nm 2001.

3. Th Ngc Dip, L Nguyn Trung c Sn v CS. Kho st tnh trng dinh dng v i tho ng ngi trng thnh trn 15 tui sng ti TPHCM nm 2009.

4. Leila Azarbad, Linda Gonder Frederick. Obesity in women. Psychiatr Clin N Am;2010;33: 423440.

5. Catalano PM, Farrell K, Thomas A, et al. Perinatal risk factors for childhood obesity and metabolic dysregulation. Am J Clin Nutr 2009.

6. Geer EB, Shen W. Gender differences in insulin resistance, body composition, and energy balance. Gend Med 2009;6:6075.

7. Hu FB. Overweight and obesity in women: health risks and consequences. J Womens Health 2003;12:16372.

8. Shi H, Clegg DJ. Sex differences in the regulation of body weight. Physiol Behav 2009;97:199204.

9. Giovanna M. Stramiello. Weight management strategies for women a review for nurses. Nurs Womens Health 2009 Oct 13 5 410-417.

10. Vivian M. Dickerson. Focus on primary care evaluation management and treatment of obesity in women. Obstet Gynecol Surv 2001 Oct 56 10 650 663.

11. Jean Hailes.Evidence-based guideline for the assessment and management of polycystic ovary syndrome. 2011.

12. Shaw, L., et al.. Postmenopausal women with a history of irregular menses and elevated androgen measurements at high risk forworsening cardiovascular event-free survival: results from the National Institutes of Health--National Heart, Lung, and Blood Institute sponsored Womens Ischemia Syndrome Evaluation. Journal of Clinical Endocrinology & Metabolism, 2008. 93(4): 1276-84.

c im v nguyn tc iu tr bo ph ph n mc Hi chng bung trng a nang


Tm tt

Mc tiu: nh gi li ch lm sng cua vic dung misoprostol kt hp iu tr trc bng mifepristone so snh vi dung misoprostol n thun cho ph thai ky gia. Phng php: Hai trm su mi ph n thai sng co tui thai t 1421 tun a tham gia vo mt th nghim ngu nhin, i chng gi dc, mu i ti Vit Nam. Ph n tho tiu ch thu nhn c nhn hoc mifepristone hoc gi dc ung ti nh v c hen trc tr li bnh vin vo ngy hm sau. Ti bnh vin, ph n c nhn 400 mg misoprostol ngm m mi 3 gi, co th n nm liu, cho n khi c thai v nhau c x ra. Hiu lc c nh gi 15 gi sau khi liu misoprostol bt u v qui trnh c xem l hon thnh nu sy thai trn c hon tt m khng co can thip ngoi khoa no. Kt qu: iu tr trc bng mifepristone cho kt qu sy thai hon ton cao hn gp 2 ln trong 15 gi (79,8% so vi 36,9%, RR 2.16, 95% CI 1,70 2,75). Khong thi gian ph thai trung bnh sy thai hon ton ngn hn (co ngha thng k) nhng ngi tham gia co iu tr trc bng mifepristone so vi nhng ngi ch dung misoprostol n thun (8,1, SD 2,8, t 2,514,8; v 10,6, SD 2,5, t 6,515,5 gi, P


t vn

Mc d trn ton th gii ch 1015% cc qui trnh ph thai l trong tam c nguyt th hai, nhng thng k sy thai giai on ny li c n hn 2/3 xy ra bin chng nghim trng.1 Nhng nh cung cp chm sc sc kho ngy cng tng cng s dng cc phng php ni khoa nh misoprostol, mt prostaglandin E1 nhn to hiu nghim dng ng ung, nh mt nhn t chun cho ph thai tam c nguyt hai.2,3

Misoprostol c th dng km hoc khng km iu tr trc bng mifepristone cho ph thai tam c nguyt hai. Nhng bo co cng b gi rng phc misoprostol hiu qu cao hn v t tc dng ph v bin chng hn nhng prostaglandins khc.412 Phc dng 200 hay 600 mg mifepristone iu tr trc theo sau liu 200 n 800 mcg misoprostol cng c bo co trong y vn.47,13 Hip hi Hong gia v Ph Sn v Hi ph sn quc t khuyn ngh liu 200 mg mifepristone theo sau 800 mcg misoprostol t m o 3648g sau v lp li liu 400 mcg misoprostol ung mi 3 gi.14,15

Khong thi gian t khi bt u n khi sy thai dng nh c nh hng n s chp nhn, bi v ngi ph n c khuynh hng mong mun hon thnh th thut cng nhanh chng cng tt.1621 Thm vo , khong thi gian ph thai ngn hn cng khin thi gian nm bnh vin ngn hn, rt c th s gip gim gi thnh iu tr. Nghin cu ch ra rng vic iu tr trc bng liu mifepristone thp hn trc khi dng misoprostol c kh nng t hiu lc so snh c vi vic thu ngn khong thi gian ph thai.22 C hai yu t ny bin lun y thuyt phc cho phc dng mifepristone v misoprostol so vi phc misoprostol n thun, nhng ni c sn mifepristone. Tuy nhin, ch c hai nghin cu nh cng b; mt nghin cu thu nhn ch nhng ph n thai cht lu trong t cung v mt nghin cu thu nhn ch

nhng ngi c thai d tt.22,23 C t thng tin v phc ni khoa chun dng mifepristone v misoprostol ph thai sng trong tam c nguyt hai.

Mc d ch c mt bo co cng b v hiu lc ca misoprostol n thun ngm m trong ph thai tam c nguyt hai,22 ng dng ny tr nn ngy cng ph bin vi phc ph thai ni khoa dng mifepristone v hin nay c khuyn ngh l chm sc chun trong ph thai ni khoa sm ti cc c s Planned Parenthood Hoa K.24 mc d ng dng ngm m c nng huyt thanh thp hn ng dng m o, nhng tc ng v hot ng t cung l tng ng.25 Mt th nghim so snh misoprostol ng ngm m v ng ung sau khi dng mifepristone trong ph thai ni khoa di 63 ngy t ngy kinh cui ghi nhn t l sy thai trn l 96.2% ph n dng misoprostol ng ngm m.26

Mc ch chnh ca nghin cu ny l c lng li ch lm sng ca vic dng misoprostol kt hp iu tr trc bng mifepristone trong ph thai tam c nguyt hai. Nghin cu cng ghi nhn ngi ph n c dng mifepristone (hay gi dc) an ton ti nh hay khng.

Phng php

Th nghim m i i chng ngu nhin ny so snh hai phc trong ph thai ni khoa thai k hai. Tt c ph n tm n kt thc thai k ti bnh vin Hng Vng (thnh ph H Ch Minh) v bnh vin Ph sn Trung ng (H Ni) tho tiu ch nhn vo c mi tham gia vo nghin cu. Tiu ch nhn vo gm tui thai nm trong khong 1421 tun da vo ngy kinh cui v chn on lm sng (c hoc khng c siu m), c c t cung ng kn v khng xut huyt m o, v sn lng tun theo phc nghin cu v cung cp chng nhn bng lng. Nhng ph n c phu thut rch t cung

So snh Mifepristone v Misoprostol vi Misoprostol n thun trong ph thai ky gia


trc y, chng ch nh vi misoprostol hay mifepristone (tin s d ng vi 2 loi thuc; iu tr corticosteroid trong thi gian di; suy thng thn mn; mu khng ng hay ang iu tr mu khng ng; hay ri lon chuyn ho porphyria di truyn) hay chn sinh ng m o, hay nhng ngi c chuyn d tch cc khng tiu chun nhn vo. Nghin cu c chp thun bi Hi ng Y c ti bnh vin Hng Vng v bnh vin Ph sn Trung ng v tt c nhng ngi tham gia u cung cp chng nhn bng lng vit tay. Tt c cc mu u c dch sang ting Vit v d liu thu thp cng bng ting Vit.

Ngi tham gia c phn vo 2 nhm nghin cu; ph n trong nhm mt c iu tr trc bng 200 mg Mifestad (Stada; mifepristone) dng ung ti nh; nhng ngi trong nhm hai nhn c gi dc (kch thc, hnh dng v mu sc ging ht nhau). Tt c ph n c yu cu quay tr li bnh vin vo ngy hm sau bt u iu tr vi Cytotec (Pfizer; misoprostol). Ngi tham gia c hng dn tr li bnh vin bt c khi no thy co tht mnh hoc xut huyt nng. Khi tr li, tt c ngi tham gia c yu cu khng nh h dng thuc nghin cu (hoc mifepristone hoc gi dc) ti nh. Sau h c nhn liu 400 mcg misoprostol ngm m u tin. Cc liu c lp li mi 3 gi, ti a 5 liu, cho n khi thai v nhau c tng xut. Sau khi dng liu misoprostol u tin, huyt p, nhit , tc dng ph v chy mu c theo di mi 3 gi. Thuc gim au ng ung hoc tim c cung cp nu cn.

Nu sn phm th thai c tng xut v y (gm c nhau) trong vng 15 gi sau liu misoprostol u tin, th thut c xem l hon tt v khng cn thm can thip no na. Nu thai khng tng xut trong vng 15 gi sau liu misoprostol u tin (3 gi sau liu cui), can thip c xem l tht bi v ngi ph n s c ht thai nh

thng quy. Tuy nhin, nu thai c tng xut nhng nhau vn cn trong t cung sau 30 pht, ngi ph n c th dng thm 400 mcg misoprostol ngm m tng nhau ra v ch thm 6 gi tng xut (21,5 gi sau liu misoprostol u tin). Nu nhau vn cha c tng ra, nhn vin y t c hng dn loi tr bt k sn phm tn ng no d l bng ngoi khoa hay ni khoa. Nhn vin y t trung cp ng thu nhn ngi ph n vo nghin cu, s cung cp mifepristone hoc gi dc dng ti nh, nhng liu misoprostol dng vo ngy hm sau ti bnh vin, v gim st ngi ph n thng xuyn. Bc s chu trch nhim quyt nh xem vic sy thai c hon tt hay cha v cung cp bt k can thip b sung no hon tt vic sy thai. Trc khi xut vin, ngi tham gia c yu cu tr li mt lot nhng cu hi xem ton b tri nghim ca h trong qui trnh v s bng lng ca h vi qui trnh . Ngi ph n c khuyn nn gi in hoc n bnh vin nu c bt k lo ngi no sau khi xut vin.

Nhng bao th c dn kn, khng nhn xuyn qua c cha phng thuc iu tr c phn sn (hoc mifepristone vi misoprostol hoc gi dc vi misoprostol) v c m theo th t nh s nghim ngt. C ngi cung cp v ph n u b lm m phn cng iu tr. Mt m ngu nhin tng cm 10 c to bi my tnh ti Gynuity Health Projects New York. Nhn vin Gynuity chun b nhng bao th v phn cng iu tr khng c tit l cho n khi vic thu thp v lm sch d liu c hon tt. Gim st nh k m bo rng cc bnh vin tun theo th t nh s phn cng iu tr v vic lm m c thnh cng.

260 ngi tham gia c nhn pht hin khc bit c ngha 98% so vi 86% s thai hon ton trong 15 gi (v s nhau trong 21,5 gi) nhm mifepristonemisoprostol so vi nhm misoprostol n thun, tng

NGHIN CU KHOA HC


ng, vi mnh 80% v khong tin cy 95% (CI). C mu c tnh pht hin khc bit c ngha v khong thi gian cn ph thai (c tnh l 7 gi nhm mifepristonemisoprostol v 11 gi nhm misoprostol n thun). D liu v tng s liu misoprostol dng, thi gian s thai v s nhau, ghi nhn ca bt k can thip cn thit no, nhng tc dng ph, v s hi lng ca ngi ph n s c thu thp v so snh gia hai nhm nghin cu bng kim nh ph hp, chi bnh phng hoc ttests. D liu c nhp ti Vit Nam bng phn mm SPSS 15. Tt c phn tch c thc hin vi phn mm Stata 11 v SPSS 19.

Kt qu

260 ph n c thu nhn t thng 8 nm 2008 n thng 9 nm 2009 (hnh 1). Ngi tham gia c phn ngu nhin cng bng gia hai nhm. Phn tch khng bao gm mt ph n m chng ta khng c thng tin trong nhm mifepristonemisoprostol sau khi bt u thu nhn v c y mt du sau ln khm u tin.

Chng ti kim tra cc c im ca nhng ngi tham gia, bao gm tui thai ph, tui thai, hc vn, tnh trng hn nhn, vic mang thai v tin s ph thai. Tui trung bnh ca ngi tham gia l 25 tui. Hn mt na (57%) c gia nh, v a s (63%) hc vn cao nht l n trung hc (d liu khng th hin). Nhng c im ny c so snh gia 2 nhm nghin cu (bng 1). Khc bit c ngha duy nht gia 2 nhnh 1 v 2 l trung bnh tui thai (16,6 v 17,2 tun, p=0,03). iu tr vi mifepristone cho kt qu sy thai trn cao gp hai ln nhm misoprostol n thun (RR 2,16, 95% CI 1,70 2,75). Khong 80% (79,8%) nhm mifepristonemisoprostol sy thai trn so vi 36,9% nhm misoprostol n thun (bng 2). Nh thy trong hnh 2, thi gian hon tt ch ra khc bit gia hai nhnh nghin cu

v % ph n mi nhm c sy thai trn trong giai on 15 gi (hnh 2; p=0,001). Th d, mc 10 gi, gn 60% ph n nhm mifepristonemisoprostol c sy thai trn, nhm misoprostol n thun thp hn 20%. ng ch , vi ph n sy thai trn sau 15 gi theo qui nh trong cng nhng l trc khi can thip b sung c thc hin. Nu chng ta ti phn loi nhng ph n ny, chng ta c mt t l hiu lc cao hn mc va phi: 81,4% nhm mifepristonemisoprostol v 41,5% nhm misoprostol n thun. Tui thai khng nh hng n t l sy gia nhng ph n c iu tr trc bng mifepristone; tuy nhin, t l sy thai trn c khc bit v tui thai nhng ph n trong nhm misoprostol n thun (13,056,3%) cho kt qu l khong cch gia t s nguy c ln gia hai phc (RR 1,42 6,13, 95% CI 1,012,00 v 2,0718,15).

S thai xy ra l 86.1% nhm mifepristonemisoprostol v 39,2% nhm misoprosol n thun (RR 2,19; 95% CI 1,752,75). Thi gian trung bnh s thai nhng ngi tham gia sy thai trn tng ng vi thi gian trung bnh s thai trn hai nhm nghin cu (bng 2). Chm sc b sung cho ph n s thai nhng cn nhau bao gm dng oxytocin, dng dng c gp, nong no, v misoprostol b sung (bng 2).

Thi gian cn ph thai sy thai trn ngn hn c ngha thng k nhng ngi c iu tr trc vi mifepristone so vi nhng ngi ch dng misoprostol n thun (8,1 v 10,6 gi, p=0,001). nhng ngi tham gia sy thai trn, s liu misoprostol trung bnh thp hn c ngha thng k nhm mifepristonemisoprostol (3) so vi nhm misoprostol n thun (4) (p=0,001; bng 2). Nhng tc dng ph ca hai phc khng khc bit c ngha. (bng 3). au c bo co kh thng thng trong cc tc dng ph, mt ph n bo co c mc au trong qu trnh. im cn au



trung bnh (khong 17) bo co l 4,4-1,4 nhm mifepristonemisoprostol v 4,0-1,4 nhm misoprostol n thun (p=0,048) vi phn ln ngi tham gia bo co nhn c thuc gim au y (90,7% nhm mifepristonemisoprostol, 89,9% nhm misoprostol n thun; p=0,99) (d liu khng trnh by). Cc tc dng ph khc c bo co bao gm nn, i, tiu chy, lnh run v au u. Ph n cng c hi v mc nghim trng ca tc dng ph; khc bit c ngha thng k duy nht gia hai nhm nghin cu l tiu chy v lnh run, c hai u nh nhm mifepristone-misoprostol (tiu chy nh: 75,9% so vi 53,2%, p=0,01; lnh run nh: 90,5% so vi 60,0%, p=0,03; d liu khng trnh by).

S hi lng kh cao c hai phc . Hn 90% ph n c 2 nhm mifepristonemisoprostol v misoprostol n thun cho rng h hi lng hoc rt hi lng vi ton b tri nghim ca mnh (97,7% v 93,0%, khng khc bit c ngha) v tc dng ph v thi gian nm vin l chp nhn c hoc rt chp nhn (tc dng ph: 96,1% hai nhm; thi gian nm vin: 96,9% v 92,3%, khng khc bit c ngha, bng 3). Thm vo , phn ln ph n (86.8% nhm mifepristone-misoprostol v 85,3% nhm misoprostol n thun, khng khc bit c ngha) nhn thy ng dng ngm m khng c kh khn g. Nhng ngi tham gia bo co kha cnh tch cc nht trong qu trnh l thi gian ca th thut (73,6% nhm mifepristonemisoprostol v 53,5% nhm misoprostol n thun; p=0,01), mc d chu (43,4% nhm mifepristonemisoprostol v 39,5% nhm misoprostol n thun; khng khc bit c ngha), v thi ca nhn vin y t v bc s (32,6% nhm trc v 40,3% nhm sau; khng khc bit c ngha). Tuy nhin, thi gian c bo co l mt nhn t tch cc c ngha thng k nhm ph

n dng mifepristonemisoprostol (73,6%) hn nhm misoprostol n thun (53,5%) (p=0,01). Khng k phc no, nhn t xu nht c ghi nhn l cn au (39,5% nhm mifepristonemisoprostol v 31% nhm misoprostol n thun; khng khc bit c ngha) v ni s (20,9% nhm trc v 27,1% nhm sau; khng khc bit c ngha).

Bn lun

Th nghim i chng gi dc ngu nhin ny so snh misoprostol c hoc khng c iu tr trc bng mifepristone trong ph thai ni khoa vi thai sng trong tam c nguyt hai. Khng ging vi nhng nghin cu trong tam c nguyt hai cng b trc y, thuc ph thai khng l mt phn trong cng nghin cu; th nghim ch thu nhn nhng ph n c thai sng. Thm vo , thi im cui xem l thnh cng c th cho l nghim nht hn nhng cng nghin cu khc. Cui cng, khng mt iu tr no khc (bao gm dng laminaria) c cho php. Li tip cn ny chng t c hiu lc tht s ca misoprostol, c hai cch c hoc khng c iu tr trc bng mifepristone, khng c s can thip b sung no khc v do cung cp s nh gi chnh xc hn v t l sy thai trn cho cc bc s quan tm dng ph thai ni khoa nhng c s ngun lc hn ch ni m thuc ph thai chnh v/hoc dng n laminaria u khng kh thi v khng c a chung. Nhng s liu ny cng cho thy nhng bng chng xa hn v tim nng ca vic dng misoprostol ng ngm m trong ch nh ny. ng dng ngm m c hiu qu v c xem l d dng i vi ngi tham gia.

Nhng kt qu ny khng nh vic iu tr trc vi mifepristone a n t l thnh cng cao hn cng nh khong thi gian ph thai ngn hn trong khi vn duy tr nhng tc dng ph v s chp nhn tng t. Nh

NGHIN CU KHOA HC


ch ra trong nghin cu ny, ph n c th s dng mifepristone ti nh thnh cng. ni no kh thi, mifepristone nn c a vo phc ph thai qu hai. Thc vy, ngay c khi iu tr trc bng mifepristone, ng ch l t l hiu lc thp hn nhng nghin cu trong qu hai khc dng loi thuc tng t.8 Mt ln na, chng ti tin rng iu ny c th l kt qu ca vic khng dng thuc ph thai trc khi dng mifepristone, misoprostol, hay c hai. Mc d d liu cha ng h hiu ng gy ra cht thai nhi trong thai k hai, mt nghin cu hi cu cng nh nhng bng chng cha chnh thng cho thy thuc ph thai c th lm gim khong thi gian cn ph thai.27,28 Thm vo , nghin cu ca chng ti c mt gii hn nghim khc tng xut thai, do gii hn di thi gian nhn vin y t c th tip tc dng thuc cho ngi ph n v cn nhc vic th thut c hon tt. Nghin cu tng lai nn thm d khong cch gia cc liu misoprostol v liu b sung c lm tng kh nng c hai phc nghin cu u cho kt qu ht thai trn ph n c thai sng hay khng.

Nghin cu ny c vi hn ch. Thi im cui nh gi kt cuc thnh cng (15 gi sau liu misoprostol u) ngn hn c ngha so vi thi im cui c bo co trong nhng nghin cu khc (2448 gi).5,6,9,10,21,22 a s ph n tng xut thai thnh cng trong 15 gi cng tng xut nhau trong cng thi gian ny. Mc d phc ny cho php mt liu misoprostol b sung (v thi gian b sung 6 gi) tng xut nhau nhm trnh can thip no khc, c mt s t ph n s nhau trong hn 30 pht sau s thai. Tht vy, khi chng ti nh gi kt cuc trong 24 gi, kt qu ca hai phc c th hnh dung c l cao hn v cho php so snh kt cuc ca chng ti vi nhng kt cuc c bo co trc y trong y vn d dng hn. Thm vo , chng ti chn phn loi ch nhng ngi tham gia tng xut thai v nhau

trong thi gian nu trn mi c xem l thnh cng, nh bung t cung hon ton trng, trong khi nhng bo co khc li chn phn loi tng xut bo thai n thun l kt cuc cui cng.21,22

C th vi hiu qu tt hn v khong thi gian ph thai ngn hn, phc iu tr trc bng mifepristone c th t tn km cho vic cung cp dch v trong tng lai. Mc d mifepristone hin nay t hn so vi misoprostol, ph n nhn c phc phi hp th hon tt vic ph thai ca h sm hn v c th c hng li t thi gian nm vin ngn hn, do lm gim tng chi ph cho ngi ph n v h thng chm sc sc khe.

Tri nghim ny cng m ng cho vic n gin ho dch v sinh cho nhng th thut trong thai k hai v chng ta thy ph n c th t s dng mifepristone iu tr trc ti nh v sau , thay v phi nhn mt th thut cho thai k hai, h c th c mt ti c s vo sng hm sau c chm sc mt c s ni tr c cung cp bi nhng nhn vin y t trung cp. Ti Hoa K, c th hnh dung nhng nh cung cp trung cp c th x l c qui trnh. Nh thy trong nghin cu ny, 8 trn 10 ph n dng phc mifepristonemisoprostol c th trng i sy thai trn trong khong 8 gi, gip vic iu tr ngoi tr tr nn kh thi.

V nhng phc tip tc c ci tin, c th hnh dung c ph thai ni khoa s thay th cc th thut ngoi khoa trong ph thai tam c nguyt hai. Ph thai ni khoa c th thc y cht lng chm sc bng cch loi b vic cn n th thut cho rt nhiu ph n. Nu l vy, nhng phng php ni khoa s cung cp mt bin php khc phc s kh khn trong vic thc hnh duy tr mt b khung gm cc k nng, thit b, v cc nh cung cp ngoi khoa kinh nghim nhng ni m cc th thut ny him khi c thc hin



Bang 1. c tinh i tng*

Misoprostol n thun (n=130)

Mifepristone kt hp misoprostol

(n=130)

Tui me (nm), TB SD 256.5 (13-43) 256.8 (15-49)

Tui thai (tun) 16.62.1 (14-21) 17.22.3 (14-21)

Trnh hc vn % (n)

Khng i hc 0.8 (1) 0.8 (1)

Tiu hc 6.9 (9) 3.8 (5)

Trung hc 63.1 (82) 63.9 (83)

Ngh 4.6 (6) 4.6 (6)

Cao ng/i hc/tr ln 24.6 (32) 26.9 (35)

Tnh trng hn nhn

c thn 56.9 (74) 56.9 (74)

Co gia nh/sng chung 40.8 (53) 41.6 (54)

Li d/go 2.3 (3) 1.5 (2)

Tin s thai ky

S ln co thai 2.01.3 (1-5) 1.91.3 (1-7)

S con sng 0.60.9 (0-3) 0.60.9 (0-3)

Con so 54.6 (71) 59.2 (77)

S ln ph thai trc 30.8 (40) 25.4 (33)

D liu trnh by TBSD (khoang) hoc % (n)

*Khac bit co y nghia thng k gia tui thai trung bnh (p


Bang 2. Ty l say thai trn v thi gian tng xut

Misoprostole n thun

(n=129)

Mifepristone v

misoprostol (n=130)

RR (95% CI) P

Sy thai trn* vi phc

nghin cu ban u, phn

theo tui thai (tun)

79.8 (103) 36.9 (48)

14-15 80 (32/40) 56.3 (18/32) 1.42 (1.01-2)

16-17 81.8 (18/22) 25 (9/36) 3.27 (1.8-5.96)

18-19 80 (12/15) 13 (3/23) 6.13 (2.07-18.15)

20-21 78.8 (41/52) 46.2 (18/39) 1.71 (1.18-2.47)

Thi gian hon tt ph

thai (gi)** trung bnh

8.12.8 (2.5-14.8) 10.62.5 (6.5-15.5) P


Bang 3. Tac dung phu

Misoprostole n thun (n=129)

Mifepristone v misoprostol (n=129)

P

Nhng tc dng ph c bo co bi ngi

tham gia

Bun nn 44.2 (57) 38 (49) 0.31

Nn oi 31.8 (41) 24.8 (32) 0.21

Tiu chy 41.9 (54) 48.1 (62) 0.32

Run 16.3 (21) 15.5 (20) 0.84

Nhc u 14 (18) 10.9 (14) 0.44

au 100 (129) 99.2 (128) 0.32

Khc 2.3 (3) 7.8 (10) 0.08

S chp nhn tc dng ph cua ngi tham gia

Rt chp nhn/chp nhn 96.1 (124) 96.1 (124)

Khng kin 3.9 (5) 3.9 (5)


Ti liu tham kho1. World Health Organization. Safe abortion: technical

and policy guidance for health systems. Geneva (Switzerland): World Health Organization; 2003.

2. Tang OS, Ho PC. Medical abortion in the second trimester. Best Pract Res Clin Obstet Gynaecol 2002;16:23746.

3. United Nations Development Program/United Nations Fund for Population Activities/World Health Organization/World Bank Special Programme of Research Development and Research Training in Human Reproduction. Annual technical report. 1997. Geneva (Switzerland): World Health Organization; 1998.

4. Hamoda H, Ashok PW, Flett GM, Templeton A. Medical abortion at 913 weeks gestation: a review of 1076 consecutive cases. Contraception 2005;71:32732.

5. Goh SE, Thong KJ. Induction of second trimester abortion (1220 weeks) with mifepristone and misoprostol: a review of 386 consecutive cases. Contraception 2006;73:5169.

6. Bartley J, Baird DT. A randomised study of misoprostol and gemeprost in combination with mifepristone for induction of abortion in the second trimester of pregnancy. BJOG 2002; 109:12904.

7. el-Refaey H, Hinshaw K, Templeton A. The abortifacient effect of misoprostol in the second trimester: a randomized comparison with gemeprost in patients pre-treated with mifepristone (RU486). Hum Reprod 1993;8:17446.

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12. Wong KS, Ngai CS, Chan KS, Tang LC, Ho PC. Termination of second trimester pregnancy with gemeprost and misoprostol: a randomized double-blind placebo-controlled trial. Contraception 1996;54:235.

13. Ashok PW, Templeton A. Nonsurgical mid-trimester termination of pregnancy: a review of 500 consecutive cases. Br J Obstet Gynaecol 1999;106:70610.

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15. Ho PC, Blumenthal PD, Gemzell-Danielsson K, Gomez Ponce de Leon R, Mittal S, Tang OS. Misoprostol for the termination of pregnancy with a

live fetus at 13 to 26 weeks. Int J Gynaecol Obstet 2007;99(suppl 2):S17881.

16. Ngoc NT, Nhan VQ, Blum J, Mai TT, Durocher JM, Winikoff B. Is home-based administration of prostaglandin safe and feasible for medical abortion? Results from a multisite study in Vietnam. BJOG 2004;111:8149.

17. Hajri S, Blum J, Gueddana N, Saadi H, Maazoun L, Che lli H, et al. Expanding medical abortion in Tunisia: womens experiences from a multi-site expansion study. Contraception 2004; 70:48791.

18. Schaff EA, Fielding SL, Westhoff C, Ellertson C, Eisinger SH, Stadalius LS, et al. Vaginal misoprostol administered 1, 2, or 3 days after mifepristone for early medical abortion: a randomized trial. JAMA 2000;284:194853.

19. Creinin MD, Fox MC, Teal S, Chen A, Schaff EA, Meyn LA; MOD Study Trial Group. A randomized comparison of misoprostol 6 to 8 hours versus 24 hours after mifepristone for abortion. Obstet Gynecol 2004;103:8519.

20. Shannon C, Wiebe E, Jacot F, Guilbert E, Dunn S, Sheldon WR, et al. Regimens of misoprostol with mifepristone for early medical abortion: a randomised trial. BJOG 2006;113:6218.

21. von Hertzen H, Piaggio G, Wojdyla D, Nguyen TM, Marions L, Okoev G, et al. Comparison of vaginal and sublingual misoprostol for second trimester abortion: randomized controlled equivalence trial. Hum Reprod 2009; 24:106 12.

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27. Ruano R, Dumez Y, Cabrol D, Dommergues M. Second- and third-trimester therapeutic terminations of pregnancy in cases with complete placenta previadoes feticide decrease postdelivery maternal hemorrhage? Fetal Diagn Ther 2004;19: 4758.

28. Borgatta L, Kapp N. Labor induction abortion in the second trimester. Contraception 2011 Mar 11 [Epub ahead of print].



NGHIN CU KHOA HC

Tm tt

Gii thiu: Xut huyt t cung bt thng l triu chng thng gp ph n man kinh. Nguyn nhn gy xut huyt rt a dng: lnh tnh nh teo ni mc t cung, vim ni mc t cung, polyp ni mc t cung hoc c tnh nh tng sinh ni mc t cung, ung th ni mc t cung. T l tng loi bnh ph thuc nhiu vo c tnh cua tng dn s nghin cu.

Phng php nghin cu: Mt bo co hng lot ca vi 292 ph n xut huyt t cung hu man kinh c thc hin nhm xc nh t l tng loi bnh l ni mc t cung xy ra cho i tng ny.

Kt qu: No sinh thit tng phn 292 ph n xut huyt t cung hu man kinh, chng ti ghi nhn 218 trng hp (74,66%) teo ni mc t cung, ch khong 74 trng hp (25,34%) ni mc t cung co bnh l, trong o vim ni mc t cung chim 13/74 trng hp (18%), tng sinh ni mc t cung in hnh (n gin hoc phc tp) chim 20/74 trng hp (27%), polyp lnh tnh ni mc t cung 4/74 trng hp (5%), tng sinh ni mc t cung khng in hnh (n gin hoc phc tp) chim 12/74 trng hp (16%) v con li 25/74 trng hp (34%) ni mc t cung co s tn ti cua cc t bo ung th.

Kt lun: Xut huyt t cung hu man kinh chu yu l do teo ni mc t cung. Tn thng tin ung th ung th NMTC tng t cc bo co trong y vn trc y, 12,67%, doi hi phi c loi tr hon ton bng no sinh thit tng phn.

T kha: xut huyt hu man kinh, bnh l ni mc t cung, t l ung th ni mc t cung.

Identify the prevalence of endometrial diseases in women with postmenopausal uterine bleeding.

Introduction: Abnormal uterine bleeding is a common clinical problem in menopausal women. The causes of bleeding are various: benign lesions, including atropic endometrium, chronic endometritis and polyps; or malignant lesions such as endometrial hyperplasia and cancer. The rates of endometrial diseases vary in different populations.

Methods: Case-series report on 292 women with menopausal bleeding.

Objectives: To identify the rates of endometrial diseases in women with postmenopausal uterine bleeding.

Results: From the diagnosis of partial curettage among 292 cases with postmenopausal bleeding, here are the findings: atropic endometrium (218 cases 74.66%) with only 74 cases (25.34%) having pathological endometrium in which 13/74 cases (18%) are with endometritis, 20/74 cases (27%) with endometrial typical hyperplasia (simple or complex), 4/47 cases (5%) with polyps, 12/74 cases (16%) with atypical hyperplasia (simple or complex), and 25/74 cases (34%) with endometrial cancer. The rates of endometrial cancer in women with postmenopausal bleeding are at about 12.67%.

Key words: postmenopausal bleeding, endometrial disease, prevalence of endometrial cancer.

Xc nh t l cc bnh l ni mc t cung ph n ra huyt hu mn kinhNguyn Duy Ti, *GS.BS.; Ngc Xun Trang,**BS.

*Ging vin chnh, b mn Sn HYD, HCM**Ging vin, b mn Sn HYD, HCM


Xc nh t l cc bnh l ni mc t cung ph n ra huyt hu mn kinh

t vn

Xut huyt t cung hu mn kinh l mt triu chng than phin thng gp cc phng khm ph khoa, vi tn sut khong 14,3/1.000 ph n ti Anh vo nm 200610. Nguyn nhn gy xut huyt c th ch do ri lon chc nng ni mc t cung (NMTC) teo NMTC hoc c th do nhng bnh l NMTC thc th nh vim NMTC, polyp NMTC, tng sinh NMTC hay ung th NMTC, trong bnh l tin ung th ung th NMTC chim t l kh cao, hn 10%. Chnh v th no sinh thit tng phn lun l ch nh tuyt i cc trng hp ny xc nh nguyn nhn xut huyt. Tuy nhin y thc s khng phi l mt gii php an ton v d dng cho cc ph n mn kinh. Hn na t l bnh l ung th NMTC ca chng ta l bao nhiu, c ngang bng vi t l UTNMTC c bo co trong y vn hay khng, ng chng ti phi no sinh thit ht tt cc trng hp ra huyt hu mn kinh hay khng? tr li cu hi ny chng ti tin hnh nghin cu: Kho st t l cc bnh l NMTC gy ra huyt hu mn kinh c tin hnh ti khoa Ni tit bnh vin Hng Vng trong thi gian t 1/6/2006 n 30/6/2008.

Phng php nghin cu

Thit k nghin cu: bo co hng lot ca.

i tng nghin cu gm cc ph n mn kinh t nht 12 thng tha tiu chun chn mu: ang b xut huyt t cung, khng s dng ni tit t hoc Tamoxifen trong vng 6 thng gn nht v khng c cc tiu chun loi tr: ang mc cc bnh l ni ngoi khoa nng.

C 292 ph n ra huyt hu mn kinh tha tiu chun chn mu v chp thun tham gia vo nghin cu

Tin hnh nghin cu: tt c cc bnh nhn tham gia nghin cu u c khm ph khoa, xt nghim cng thc mu v ng mu ton b, sau , bnh nhn s c no sinh thit tng phn ti phng m khi xt nghim. M no gm hai l: l ng m knh CTC v l ng m lng t cung. Hai l ny c gi n khoa gii phu bnh.

Kt qu m hc bao gm: teo NMTC, vim NMTC, polyp NMTC, tng sinh n gin in hnh, tng sinh n gin khng in hnh, tng sinh phc tp in hnh, tng sinh phc tp khng in hnh v ung th NMTC. X l s liu: s liu c phn tch bng phn mm STATA 10.0.

Vn y c: tt c cc bnh nhn tham gia nghin cu u c gii thch r rng tnh trng bnh. No sinh thit tng phn l phc ca khoa Ni tit bnh vin Hng vng nhm gip xc nh chnh xc nguyn nhn gy xut huyt c phng n iu tr thch hp.

Kt qu

Trong thi gian t 1/6/2006 n 30/6/2008 ti bnh vin Hng Vng c 292 trng hp c nghin cu vi nhng c im sau: tui trung bnh l 59,49,3 tui (42-82 tui), 70% cc trng hp mn kinh trn 3 nm, 53% trng hp n bnh vin sm trong vng 4 ngy u b xut huyt m o, bnh cao huyt p gp trong 54% cc trng hp, trong 2/3 trng hp b cao huyt p II (phn theo JNC 7), 29% trng hp c i tho ng type 2 v 5,4% trng hp c bnh l tuyn gip (bng 1).

Bang 1. Kt qua m hc NMTC bnh nhn rong huyt HMK

M hc n %

NMTC bnh thng 218 74,66Vim NMTC 13 4,45

Tng sn n gin in hnh 16 5,48

Tng sn phc tp in hnh 4 1,37

Polyp NMTC 4 1,37

Tng sn n gin khng in hnh 1 0,34Tng sn phc tp khng in hnh 11 3,77Ung th tuyn NMTC 25 8,56

Tng cng 292 100

Kt qu no sinh thit tng phn ca 292 ph n xut huyt t cung hu mn kinh cho thy ch c khong 74 trng hp (25,34%) NMTC c bnh l thc th, trong vim NMTC chim 13/74 trng hp (18%), tng


NGHIN CU KHOA HC

sinh NMTC in hnh (n gin hoc phc tp) chim 20/74 trng hp (27%), polyp lnh tnh NMTC 4/74 trng hp (5%), tng sinh NMTC khng in hnh (n gin hoc phc tp) chim 12/74 trng hp (16%) v cn li 25/74 trng hp (34%) NMTC c s hin din ca cc t bo ung th. i a s cc trng hp (74,66%) NMTC hon ton bnh thng khng c bnh l thc th .

Bn lun

Xut huyt t cung hu mn kinh l mt ch nh tuyt i ca no sinh thit tng phn ti bnh vin Hng Vng. Trong s 292 bnh nhn c no sinh thit c 74,66% trng hp xut huyt m kt qu m hc NMTC hon ton bnh thng (bng 1). Kt qu ny tng t kt qu nghin cu ca tc gi Karlsson(70%)4, Sadoon (76%)5 v nhng hi cao hn kt qu ca Ferrazzi (64%),1 Grigoriou (64,8%)3 v Giusa-Chiferi (65%)2 (Bng 2). V t l NMTC khng bnh l chim gn bng 3/4 dn s nghin cu nn chng ti ngh rng vic no sinh thit mt cch h thng tt c cc trng hp xut huyt hu mn kinh cha phi l mt phng php la chn ti u nht, v vn m t ra cho nghin cu ny l 218/292 ph n ny c tht s cn thit phi chu ng mt th thut nng n nh vy hay khng? Hn th na, trong 74 trng hp bnh l NMTC c pht hin qua no sinh thit th tn thng lnh tnh NMTC cng chim gn mt na cc trng hp ny (45%) (bng 1).

Bang 2. So sanh ty l NMTC bnh thng gia cac nghin cu

Nghin cu n %

Sadoon (2007)5 142 76Ferrazzi (1996)1 930 64Giusa-Chiferi (1996)2 80 65

Grigoriou (1995)3 250 64,8Karlsson B (1994)4 96 70

Nguyn Duy Ti v cs (2008) 292 74,6

Tuy nhin tn thng tin ung th - ung th ni chung trong nghin cu ny chim mt t l cng khng nh: 12,67%. Ung th NMTC

xut hin trong 25 trng hp (8,56%). T l ny thp hn nhiu so vi t l ung th NMTC trong nghin cu ca Giusa-Chiferi (20%), cao hn t l ung th trong nghin cu ca Tsuda (4%), nhng tng t vi hu ht cc nghin cu khc (bng 3). S khc bit gia nghin cu ny vi nghin cu ca Giusa-Chiferi v Tsuda c th do c im ca cc dn s nghin cu khng ging nhau, c bit l s khc bit v chng tc. iu ny tng c bo co trong cc nghin cu trc y. Chng hn trong nghin cu ca tc gi Phillip v cng s c nhn mnh t l ung th NMTC ngi da en cao hn ngi da trng,6 hoc theo nghin cu ca Hiroshi Tsuda v cng s th t l ung th NMTC ngi ph n c ngun gc phng Ty cao hn t l ung th NMTC ngi ph n c ngun gc phng ng.

Mt gi thuyt c a ra gii thch s khc bit ny l do m hc NMTC c lin quan n mt s cc yu t lm sng nh bo ph, li sng, chc nng bung trng khc nhau.6 .v.v.

Bang 3: Ty l ung th NMTC cua cac nghin cu

Nghin cu n %

Sadoon (2007)5 142 5Ferrazzi (1996)1 930 11,5Giusa-Chiferi (1996)2 80 20

Grigoriou (1995)3 250 9,6Karlsson B (1994)4 96 4

Nguyn Duy Ti v cs (2008) 292 8,56

Qua cho thy d t l tin ung th- ung th ca dn s bnh vin Hng Vng khng qu cao nhng cng khng thp hn cc nghin cu trong y vn. Do , vic nh gi v la chn phng tin loi tr cc bnh l ny cc i tng ra huyt hu mn kinh l bt buc. Tuy nhin chn phng tin no, no sinh thit tng phn c phi l la chn hng u hay khng ? C l i km vi triu chng ra huyt sau mn kinh, ta cn lu n b dy NMTC o c qua siu m. Hnh nh NMTC mng (< 4 mm) c th l gi teo NMTC hoc mt tn thng lnh tnh.


Xc nh t l cc bnh l ni mc t cung ph n ra huyt hu mn kinh

Kt lun

T l bnh l tin ung th ung th NMTC cc ph n ra huyt hu mn kinh trong nghin cu ny kh cao 12,67%. Do , vic sinh thit NMTC cc ph n ny c th khng th trnh khi, nhm trnh kh nng b st bt k trng hp ung th NMTC no nhng nhng thng tin trong nghin cu ny l tin quan trng cho chng ti thc hin nghin cu tip theo: No sinh thit tng phn c cn l gii php hng u cho cc ph n ra huyt hu mn kinh hay khng?

Ti liu tham kho1. Ferrazzi E, Torri V, Zannoni E, Filiberto S & Dordoni

D (1996), Sonographic endometrial thickness: a useful test to predict atrophy in patients with postmenopausal bleeding, An Italian multicenter study. Ultrasound Obstet Gynecol 7, pp. 315-321.

2. Giusa-Chiferi MG, Gonalves WJ, Baracat EC, Cavalcanti de Albuquerque L, Bortoletto CCR & Rodriques de Lima G (1996), Transvaginal ultrasound, uterine biopsy and hysteroscopy for postmenopausal bleeding. International Journal of Gynecology and Obstetrics 55, pp. 39-44.

3. Grigoriou O, Kalovidouros A, Papadias C, Antoniou G, Antonaki V & Giannikos L (1996), Transvaginal sonography of the endometrium in women with postmenopausal bleeding. Maturitas 23, pp. 9-14.

4. Karlsson B, Granberg S & Ridell B and Wikland M (1994), Endometrial thickness as measured by transvaginal sonography: interobserver variation. Ultrasound Obstet Gynecol 4, pp. 320-325.

5. Sadoon S, Salman G, Smith G, Henson C & McCullough (2007), Ultrasonographic endometrial thickness for diagnosing endometrial pathology in postmenopausal bleeding. J.Obstet Gynecol 27(4), pp. 406-408.

6. Tsuda H, Kawabata M, Kawabata K, Kumio Yamamoto, Hidaka A, Umesaki N & Ogita S (1995), Differences between Occidental and Oriental postmenopausal women in cutoff level of endometrial thickness for endometrial cancer screening by vaginal scan. Am J Obstet Gynecol 172, pp. 1494-1495.


Cp nht x tr lc ni mc t cungHip Hi San Phu khoa Hoa K

Ngi dch: L Quang Thanh,* ThS, BS

* Bnh vin T D

Theo: ACOG Updates Guideline on Diagnosis and Treatment of Endometriosis, Obstetrics & Gynecology, July 2010, vol 116,1, 223-226

Sức khoẻ sinh sản, Tập 2 số 2

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