NICARDIPIN TRONG iU TR BNH NHN TiN SN GiT

Bs Nguyn Th Hng Vn

 Ho va ten: BUI TH KIM H

Chan oan: Tin Sn Git nng, Phu phoi cap. Benh s: BN nhap vien trong tnh trang huyet ap cao 16/12 cmHg, l , nhc au, phu (++), ho khan. Sau 3 ngay ieu tr tai khoa san A BN kho th, tm tai, bc rt,vat va, phu toan than, HA 20/12 cmHg, phoi ay ran am, ran no. Chuyn Hi sc

32 tuoi

Dch te hoc
@ Tan suat TSG = 6 8% cac trng hp mang thai 1 @ Tan suat san giat = 5/10.000 trng hp sinh @ Nguyen nhan th 3 dan au cua t vong me 2,3 Hoa Ky : 1995-7
Anh: : 2003-5 (Nguyen nhan trc tiep)

1. Am J Obstet Gynecol 2000;183:S1-22 2. MacKay AP et al. Paediatr Perinat Epidem. 2005; 19: 206-14 3. Confidential Enquiries into Maternal Death 2003-5; UK

Cac nh ngha tien san giat 1. Tang HA

Sau 20 tuan tuoi thai

HA tam thu 140 mm Hg HA tam trng 90 mm Hg

o moi 4 gi

HA tam thu 160 mm Hg HA tam trng 110 mm Hg

Tang HA nang :

Cac nh ngha tien san giat 2. Tieu am

300 mg protein trong nc tieu /24 g hay (Ton tai 1+ que th nc tieu dipstick: Mau nc tieu ngau nhien moi 4-6 g) Bai tiet nc tieu co protein : thay oi Nang : >5 g protein

Tieu chuan cua TSG nang

LAM SANG

@ HA > 160/110 @ Tieu am nghiem trong @ Thieu nieu (<500ml / 24g) @ au 1/3 bung tren phai/au thng v @ Roi loan nhn @ au au keo dai @ Th ngan ( SaO2/phu phoi)

Tieu chuan cua TSG nang

CAN LAM SANG Gim tieu cau < 100 x 109/L-1 Tan huyet Ton thng chc nang gan

PH PHI
Bin chng nng ca TSG chim t l 3%.. Biu hin lm sng: kh th nhiu hn khi nm + du hiu tn thng h hp: (th nhanh, tm ti, thiu oxy.)

Nguyn nhn
Gim p lc keo huyt tng, tng p lc thy tnh v tng tnh thm thnh mch mao mch phi.

Siu m tim gip chn on cc bnh l tim mch gy ra ph phi.

Nhau bam bnh thng

Nhau bam bat thng

Nguyn nhn cha r_ bnh nhau t bo ni m b tn thng

kt tp TC
TC, TMTH, men gan

sx cht gin mch

Mm tng nhy cm vi angiotensin, norepinerphine, co tht mch

tnh thm mao mch cu thn, m niu

HELLP

nhy cm vi cc cht gin mch

GFR v RBF

SVR THA

gi mui - nc
ph

TSG-SG

HOI CHNG HELLP

H = Tan huyet EL = Tang men gan LP = TC thap 10-20% trng hp nang vi TSG nang au vung thng v/au vung tren bung phai Tang HA/am nieu (-) Phan ln benh xuat hien 3 thang cuoi thai ky

SN GIT
- Co git/ hn m khng do nguyn nhn TKTU xut

hin trong thai k hay hu sn/ sn ph c tiu

chun ca TSG - SG l nguyn nhn gy t vong m hng u cc nc ang pht trin. - Xut hin t ngt trong tam c nguyt th 3 hay sau sanh (a s trong vng 24gi sau sanh, c th sau 22 ngy)

Chn an:

Khi pht cn co git: ng kinh, vim no, vim mng no, khi u no, chn thng s no ( nhng khng c triu chng g cho n khi xut hin co git). o o o o Cn co git: Khi pht t ngt, Bt u co cng mt Tip theo l giai on co git khang 15 - 20 giy Ngng th ko di khong 1 pht. S ln co git c th t 1- 2 n 100 ln(nu nng).

Bin chng: Th ngy, ngng tim ,ngng th, ht dch d dy.

Tin sn git
iu tr:
Chng co git: _ MgSO 4 IV 4-6mg/20pht, sau truyn TM
1-2g/gi. _ Theo di phn x xng bnh ch, NT,lng nc tiu. _ Nng Magnesium mu trong thi gian iu tr t 5 n 9mg/dL. _ iu tr ng c Magnesium: calcium gluconate 1g hoc calcium chloride 300mg.

ieu tr Magnesium
mmol / L Mc huyet tng bnh thng Khoang ieu tr Mat phan xa gan sau Liet c, c che ho hap Ngng tim 0.7-1 2-3 5 6-7.5 12 mg /dL 1.7-2.4 4.8-8.4 9.6-12 12-18 24-30

Thuc h p
Mc tiu d phng nguy hi m: Tng P ni s, xut huyt no, TMCB c tim ,suy tim mt b. Trnh thay i HA t ngt m. Mc tiu < MAP 15% n 20%, HA TTg ch 100 -105 Thng dng :hydralazin, labetalol, esmolol, sodium nitroprusside, nifedipine,nicardipin Tt c cc thuc u an ton cho thai nhi.

1. Hydralazine|dn c trn MM trc tip, c tc dng tt khi ung hoc dng TM tng ch s tim, gim khng lc mc ngoi vi, cng gia tng lu lng mu t cung- nhau v lu lng mu thn,
liu 5mg IV / 20 pht, c th n 20mg .

_ Nu cn phi hp vi labetalol (10-20mg) hoc nifedipine (10mg, ung/ngm di li)

Labetalol
_ khng vn alpha-beta adrenergic receptor
_ liu 10-20mg IV, c th tng gp i mi 10 pht, ti a 300mg _ truyn qua nhau thai, gy di chng trn tr s sinh (nhp tim chm, h HA, h ng huyt)

1. Nitroglycerin (NTG) _gin TM nhiu hn gin M _c tc dng nhanh, gy h p t ngt _liu 0.5-1g/kg/pht truyn bm in, tng dn mi 0.5 g/kg/pht _ hu ch trong iu tr THA do t NKQ 1. Sodium nitroprusside (SNP) _ gin M nhiu hn _ liu ban u 0.5 g/kg/pht, tng dn liu t HA mong mun(ti a 2 g/kg/pht _ng c cyanide khi truyn qu 4 g/kg/pht

CC THUC CHN KNH CALCI

Fleckenstein (1964) ln u tin a ra khi nim chn knh calci. Cc thuc thuc nhm ny gn c hiu v phong ta trn knh.

Phn loi Th h 1 l thuc chn knh Ca mng t bo v mng ti li ni bo; Th h 2 tc dng nh th h 1 nhng chn lc trn t bo c trn thnh mch hoc tim hn.

TRONG iU TR CAO HUYT P

Do lm gim lc co bp c tim, gim nhu cu oxy ca c tim, gim trng lc v sc cn mch ngoi bin Cho ti nay, n c coi l thuc iu tr THA an ton v c hiu qu. Verpamil, nifedipin, nicardipin v diltiazem u c hiu qu h p

Nifedipine
Thuc t c ch c tim nht v cho hiu qu gin mch tt. Tc dng ph : nhc u, mch nhanh, mt. Nifedipine nhanh chng h p sau khi cho dng ung hay dng di li (FDA khng khuyn co s dng di li). Sau khi ung liu u 10mg, c th lp li sau 30 pht dng liu duy tr t 10 n 20 mg mi 3 n 6 gi.

Nifedipine c s dng h p sau khi t ni kh qun BN TSG. Nifedipine kt hp vi magnesium sulfate c th gy nhng tc dng bt li ln c m v thai. Tt HA nng, c ch thn kinh c v nhp tim thai khng tt c bo co khi s dng ng thi hai thuc trn.

NICARDIPINE
L mt thuc c ch knh Canxi chm, thuc nhm phenyl dihydropyridine. nng thp, nicardipine c ch vn chuyn canxi vo t bo, ch yu l t bo c trn mch mu. Khi vo c th, nicardipine gy gin mch mnh nn lm gim sc cn mch mu ngoi bin, gy h HA, nhp tim tng v cung lng tim.

Gin mch vnh v mch mu no Xy ra c trn nhng ng mch nh v ng mch ln, lm tng lu lng mu v ci thin sc n hi ca thnh mch.

Ch nh s dng Nicardipine
iu tr cao HA km theo tn thng a c quan e da tnh mng Cao HA-TSG-Sn git Tng HA chu phu v phng Hi sc

Chng ch nh
Bnh nhn qu mn vi cc thnh phn ca thuc. Bnh nhn khng dung np frustose v thuc c cha sorbitol trong cng thc. Bnh nhn b au tht ngc (n nh v cp tnh).

Liu s dng
Liu tn cng:
Bolus 0,5-1mg Truyn tnh mch qua bm tim in: 13mg/ gi trong mt gi

Liu duy tr:

Truyn tnh mch qua bm tim in: 13mg/ gi trong 24 gi (Chnh liu theo HA bnh nhn)

HUYT P TM THU > 160 mmHg

HUYT P TM THU > 180 mmHg hay HUYT P TRUNG BNH > 140 mmHg IU TR TN CNG NICARDIPINE IV * Bolus 0,5 - 1 mg sau * Truyn: 1-3 mg trong vng 1 gi

HUYT P TM THU < 180 mmHg hay HUYT P TRUNG BNH < 140 mmHg IU TR DUY TR NICARDIPINE IV: 1 - 3mg / gi hay LABETALOL IV: 5 - 20 mg / gi

NH GI HIU QU & P NG IU TR SAU 30 PHT

HA TM THU < 140 mmHg HA TM TB< 100 mmHg 140 < HA TM THU < 160 mmHg 100 < HA TM < 120 mmHg HA TM THU > 160 hay HA TM TB < 120 mmHg Cc tc dng ngoi (nhc u, hi hp) 1. Gim liu Nicardipine v 2. Phi hp vi: hoc Labetalol: 5 - 20 ml / gi hoc Clonidine: 15 - 40 g / gi

Gim liu v ngng iu tr

iu tr duy tr
Nicardipine IV: 1 - 3 mg / gi hay Labetalol IV: 5 - 20 mg / gi

iu tr phi hp:
Nicardipine IV: 1-3 mg / gi phi hp vi hoc Labetalol: 5 - 20 mg / gi hoc Clonidine: 15 - 40 g / gi

NH GI HIU QA SAU 30 PHT SAU SAU MI Gi

 Mo luc 22h be can nang 1500 gr, Apgar 1 phut = 5; 5 phut = 6.

Sau mo: benh nhan bt tm tai, t th oxy qua mask, tnh tao, tiep xuc c, HA on nh. SpO2 99%, con ho khan, phoi con ran am. BN c ieu tr vi khang sinh lieu cao, dan mach vanh, duy tr h HA vi Nicardipin.

TNG TC THUC
Thuc Dantrolene Tng tc Rung tht iu tr Chng ch nh

Chn beta
Rifampicine

Gy tt HA, tt HA t th
Gim nhng nh hng ln tim mch

Kim sot tt HA
p ung theo liu

Cc thuc chng ng kinh,an thn

Cyclosporine

Gy tt HA do tng tc, iu tr triu chng tt HA t th

Lm tng nng trong huyt tng Tng HA ti pht p ng theo thuc

Corticoid

p ng ln iu tr sau

Thn trng khi dng

Nguy c s dng trong thai k:
Thuc nhm c C theo FDA Khng s dng trong 2 tam c nguyt u thai k, c th s dng trong tam c nguyt 3. t qua sa m. Cho php s dng trong vng mt tun sau sanh m khng nh hng trn thai nhi

Thn trng khi dng

Gim liu trn nhng bnh nhn suy gan- suy thn. Trnh dng nicardipine trong mt thng sau khi b nhi mu c tim.

CHN THNH CM N