THUOÁC GIAÛM CO

BS LEÂ VAÊN HIEÀN

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 CÔN CO TÖÛ CUNG
 Côn co Braxton-Hick
 Côn co chuyeån daï
 Côn co töï ñoäng
ng
 Ñeàu ñaën

 Thôøi gian co taêng daàn

 Thôøi gian nghæ giaûm daàn

 Co toaøn theå töû cung

 Ñöa ñeán xoùa môû CTC

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 CÔ CHEÁ CUÛA SÖÏ CO CÔ
 mimetic
Ca++
Ca++ — ATPase
MgSO4

Nife
cAMP
PO43-
AC (-) Keânh
ñieän theá
MLCK Actomyosin
Gs [Ca++]
(+)
 AR ATP Ca++
CaM-Ca++ Thuï
theå
Ca++
(-)
Indomethacin
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 CAÙC THUOÁC GIAÛM CO TÖÛ CUNG
 Beta-Adrenergic Agonists
 Terbutaline
 Salbutamol
 Ritodrine
 Anti-Prostaglandin
 Indomethacin
 Magnesium Sulfate
 Calcium Channel Blockers
 Nifedipine
 Nicardipine
 Oxytocin Antagonists
 Atosiban
 Nhoùm Nitrate
 Nitroglycerin

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 CÔ CHEÁ TAÙC DUÏNG
NG
2 adrenergic
receptor

 mimetic hoaït hoaù men Adenylate cylase

cAMP noäi baøo

(-) MLCK
(thoâng qua  Ca++ noäi baøo, - P )

Ngaên chaän söï töông taùc Actin-Myosin

ÖÙc cheá söï co cô

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 CAÙCH
CH SÖÛ DUÏNG
NG SABUTAMOL
Trình baøy: oáng
ng 0,5 mg/ 1ml
Ñaït noàng
ng ñoä ñænh sau 2-3h ( uoáng
ng)
T1/2 :2-5 h
90% thaûi qua nöôùc tieåu
IV: Caùch
ch 1 (Anh): 2,5mg (5 oáng
ng) / 500ml G5% # 5µg/ ml
Truyeàn toác ñoä 30ml / h. # X gioït/ phuùt
Lieàu toái ña 60ml / h.
Caùch
ch 2: thöôøng
ng söû duïng
ng hieän nay
Baét ñaàu 10µg/ ph taêng daàn moãi 10 ph, toái ña 45µg/ ph. cho ñeán khi caét ñöôïc
côn co, duy trì theâm 1 giôø, giaûm lieàu ½ trong 6 giôø
# 600- 2700µg/h (--- > 120-540ml/h - 40-180 gioït/ph)

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 CAÙCH
CH SÖÛ DUÏNG
NG SABUTAMOL(tt)
pha 1-2oáng/500ml
ng/500ml G5% # 1-2µg/ ml
X-XX-XXX gioït/ph # 60-120-180µg/h
Suppositoire: 2 – 4 vieân (vieân 1mg) / ngaøy.
ng: 4 vieân (vieân 2mg) / ngaøy
Uoáng
Sau 48 giôø neáu khoâng coøn goø  chuyeån uoáng
ng hoaëc nheùt haäu moân
ng, coøn goø nhöng < 3 côn / phuùt vaãn tieáp tuïc
Neáu sau 48 tieáng
truyeàn cho ñeán khi ngöng ñöôïc côn goø
Ngöng khi
ch  140 laàn / phuùt
Maïch
Khi sp khoâng chòu ñöôïc taùc duïng
ng phuï
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 CAÙCH
CH SÖÛ DUÏNG
NG SABUTAMOL(tt)
Trong ñieàu trò côn goø cöôøng
ng tính:
 0.5mg (1A)/10ml HTN 5% # 50µg/ml
1ml/TMC (1 laàn)
 0.25mg (1/2A)/5ml (TM) # 250µg
 0.5mg (1A) pha vaøo baàu (#5ml)
IV 100µg trong 2’--->laäp laïi sau 10’ 100µg
(clinical practice guideline 2002, Australia)
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 TAÙC DUÏNG
NG PHUÏ

 Maïch
ch nhanh, hoài hoäp, ñaùnh
nh troáng
ng ngöïc.
 Ñau ngöïc, thieâuù maùu cô tim
 Loaïn nhòp tim
 Haï HA
 Buoàn noân, noân, khoù tieâu
 Thôû nhanh noâng
 Taêng ñöôøng
ng huyeát, deã gaây nhieãm ceton acid
 Haï kali, haï canxi maùu
 Phuø phoåi
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 TAÙC DUÏNG
NG PHUÏ (tt)
A systematic review. Obstet Gynecol 1999;94:869-77.

âmimetic placebo
Hoài hoäp 48% 5%
Run 39% 4%
Buoàn noân 20% 12%
Nhöùc ñaàu 23% 6%
Ñau ngöïc 10% 1%
Phuø phoåi 1/425 0/427

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 TAÙC DUÏNG
NG PHUÏ (tt)
(RCT treân 733 thai phu N Engl J Med 1993;329:1602-7. BJOG
2001;108:133-42. and Am J Obstet Gynecol 2000;182:1191-9.ï)(Ib)
)(Ib)

âmimetic Atosiban
Ñau ngöïc 5% 1%
Hoài hoäp 16% 2%
Maïch ch nhanh 76% 6%
Haï HA 6% 3%
Khoù thôû 7% 0.3%
Booàn noân 16% 12%
Noân möûa 22% 7%
Nhöùc ñaàu 19% 10%
Phuø phoåi
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 TAÙC DUÏNG
NG PHUÏ (tt)

A meta-analysis.Acta Obstet Gynecol Scand

1999;78:783-8. (9 trials, 607phuï nöõ)
Taùc duïng
ng phuï cuûa betamimetic vôùi nifedipine: 45% vs
16%
A meta-analysis. Obstet Gynecol 2001;97:840-7
( 9 trials, 679 phuï nöõ)
khi so saùnhnh betamimetic vôùi nifedipine, giaùn ñoaïn
ñieàu trò do taùc duïng
ng phuï: 7% vs 0%
3 RCT (209w) so saùnh nh betamimetic vôùi indomethacin
ñeàu cho thaáy taùc duïng
ng phuï cuûa indomethacin it hôn
nhieàu so vôùi betamimetic
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 KHUYEÁN CAÙO

 Phuø phoåi caáp ñöôïc khuyeán caùo: deã xaûy ra khi

quaù taûi tuaàn hoaøn, ña thai, bònh tim tröôùc ñoù,
nhieãm truøng
ng ôû meï, söû duïng
ng chung vôùi
corticoid.
 Duøng
ng chung vôùi dung dòch ñieän giaûi?
Khoâng neân duøngng chung vôùi dd NaCl
ng nöôùc ñöa vaøo ≤ 2500-3000ml/24h
 Löôïng

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 CHOÁNG
NG CHÆ ÑÒNH
Meï
 Beänh
nh tim
 Beänh
nh phoåi
 Cao huyeát aùp
 Tieåu ñöôøng
ng
 Cöôøng
ng giaùp
 Xuaát huyeát tröôùc sanh (Nhau TÑ)
Thai
 Suy thai
 IUGR
 Dò taät
 NT oái

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 MAGNESIUM SULFATE
 Cô cheá taùc duïng
ng
 ÖÙc cheá söï daãn truyeàn TK tôùi cô trôn TC
(giaûm phoùng
ng thích Acetincholin ôû ñaàu taän cuøng
ng
TK) vaø ñoàng
ng thôøi ngaên caûn doøngng ñi vaøo cuûa
Ca taïi tbTK  öùc cheá daãn truyeàn TK.
 Taùc ñoäng
ng tröïc tieáp leân teá baøo cô trôn TC:
hoaït ñoäng
ng nhö moät chaát ñoái vaän
(antagonist) ñoái vôùi Ca ôû möùc ñoä teá baøo vaø
khoang ngoaïi baøo
 Mg++  hoaït hoaù Adenylate Cyclase 
cAMP  (-) MLCK  Relaxation
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 MAGNESIUM SULFATE
 Caùch
ch söû duïngng
 Taán coâng 4g bolus TM hoaëc 6g/15’
 Sau ñoù duy trì 2g/h
 Taêng moãi 1g/h cho ñeán khi goø (-) sau moãi giôø , hoaëc 0,5g/h moãi
30’
 Uoáng
ng: Sau khi ngöng truyeàn 12h (ít söû duïng ng do taùc duïng
ng phuï TH’)
 Thöôøng
ng ñoåi qua Terbutalin uoángng hoaëc Ritodrine uoángng
 Khi söû duïng
ng: Tdoõi ky õlöôïng
ng nöôùc xuaát nhaäp
 Khôûi ñaàu taùc duïng
ng: 30’ sau truyeàn TM
 1h sau tieâm baép
 Thôøi gian hoaït ñoäng:3
ng:3-4h
 Söï thaûi tröø hoaøn toaøn qua thaän sau bao laâu coøn tuyø thuoäc raát nhieàu
vaøo töøng
ng caù theå & tuyø vaøo chöùc naêng thaän cuûa moãi ngöôøi.

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 INDOMETHACIN

 Cô cheá taùc ñoäng

ng
 Prostaglandin: taùc ñoäng
ng leân cô TC baèng
ng 2
ñöôøng
ng:
 Ca++ noäi baøo  kích hoaït hoaù MLCK  gaây côn
co TC
  gap junction vaø taïo côn goø TC ñoàng
ng boä
 Nhö vaäy öùc cheá prostaglandin  öùc cheá côn
goø TC

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 INDOMETHACIN
 Caùch
ch söû duïng
ng
 Taán coâng:
100-200mg nheùt haäu moân
50-100mg uoáng
ng
 Duy trì 25-50 mg / moãi 4 giôø * 2 ngaøy (Ñaït noàng ng ñoä ñænh
sau 1-2 giôø / nheùt haäu moân)
 T1/2: 2.2 giôø
 Indomethacin gaây co thaét oángng ÑM, oáng ng ÑM ñoùng ng sôùm laøm
thieåu oái
 Söû duïng
ng cho nhöõng thai < 32 tuaàn khoâng coù thieåu oái
 Choïn löïa ñaàu tieân:khi DSN coù Ña oái keøm theo
 Td löôïng
ng oái moãi 48h hoaëc toát thieåu laø moãi tuaàn
ng > 3 ngaøy  SAÂ Doppler oáng
duøng ng ñoäng
ng maïchch
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 ÖÙC CHEÁ CANXI (NIFEDIPINE)
 Cô cheá taùc ñoäng
ng
 Ca ñi qua maøngng teá baøo thoâng qua 2 keânh phuï
thuoäc ñieän theá maøng
ng T&L vaø söï hieän dieän cuûa thuï
caûm theå
 Nifedipine öùc cheá keânh canxi chaäm loaïi L
 Taêng Ca++ töï do trong baøo töông  gaây co thaét,
 traùi laïi seõ gaây daõn cô  Nifedipine coù taùc duïng
ng
daõn cô.

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 ÖÙC CHEÁ CANXI (NIFEDIPINE)

 Caùch
ch söû duïng
ng
 Taán coâng: 10mg NDL 20’10mg
20’10mg, toái ña 4 vieân/giôø ñaàu.
 Duy trì: 4-6 vieân / ngaøy (uoáng
ng)

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 Atosiban

 Cô cheá taùc ñoäng

ng:
 Gaén keát tröïc tieáp leân oxytocin receptor,
nh tranh vôùi oxytocin  taùc duïng
caïnh ng
chuyeân bieät cao treân cô TC
 Ñang thöû nghieäm LS gñ III

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 Lieàu löôïng
ng

 Bolus 6,75mg
 Sau ñoù: 300µg/ ph trong 3 giôø

 Tieáp theo: 100µg/ ph cho ñeán 48 giôø

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 NHOÙM NITRATE: ( Nitroglycerine)

Cô cheá taùc ñoäng
ng:
 NO ñöôïc taïo ra töø quaù trình oxy hoaù L-
arginine thaønhnh L-citrunine, phaûn öùng
ng naøy
döôùi söï xuùc taùc cuûa men nitric oxide
synthase (NOS). Söï töông taùc giöõa NO vaø
sGC (soluble Guanyl Cyclase)-----> k’ thíchï
taïo cGMP, taêng cGMP ôû cô trôn--->hoaït hoaù
protein kinase----->khöû quaù trình phosphoryl
hoùa chuoãi nheï-----
-----> giaõn cô trôn.

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 Cô cheá taùc duïng
ng

 NOS NO >< sGC cGMP protein kinase

 L- arginine L-citrunine

(-) phosphoryl hoùa

Daõn Cô Trôn

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 NHOÙM NITRATE: ( Nitroglycerine)
Caùch
ch söû duïng
ng:
 Khôûi ñaàu coù taùc duïng
ng: < 1 phuùt
 T ½ : 1 –4 phuùt
 Lieàu löôïng
ng:
 Trong ñieàu trò DSN: daùn da 0,4- 0,8 mg/ h trong 16 giôø
 Hoaëc 60- 90  bolus TM
 Hoaëc 50- 100  bolus TM laäp laïi moãi 15 phuùt, duy trì 1- 10/ kg/ ph
 Ngoaïi xoay thai: 50- 100  bolus TM
 Noäi xoay thai ñaïi keùo thai thöù 2 trong song thai: 50- 150  bolus
TM
 (coù baùo caùo xaøi tôùi lieàu 1000 , nhöng coù bieán chöùng
ng haï aùp)
 hoaëc xòt döôùi löôõi 400- 800  (guideline 2002 R.W.H Aus)
 Moå sanh TC sieát chaët, laáy thai khoù: 100- 250 
 Loän TC: 100 
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 TÌNH HÌNH THEÁ GIÔÙI HIEÄN NAY

The new RCOG guideline on Tocolysis

(Last Updated 01-Oct-2003)
 Betasympathomimetics khoâng coøn ñöôïc
khuyeán caùo nöõa
 Magnesium sulphate ñöôïc söû duïng ng phoå bieán ôû
Myõ vaø moät soá nöôùc
 Nifedipine vaø Atosiban ñöôïc öa chuoäng ng hôn vì
ít taùc duïng
ng phuï vaø hieäu quaû cuûa noù
 Atosiban ñöôïc pheùp söû duïng ng ôû UK
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 Tuy nhieân, guideline 2002 thì salbutamol vaãn
coøn ñöôïc söû duïng
ng trong giaûm goø caáp cöùu

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