Sản phụ khoa

Nguyn c Thng Y6B7.
cng n thi bc s ni tr Sn
cng n tp mn sn
Chuyn 1: cha ngoi t cung
Cu 1: Chn on v x tr cha ngoi t cung cha v I.nh ngha: Cha ngoi t cung l trng hp trng c th tinh lm t v pht trin ngoi bung t cung. II.Triu chng lm sng 1.Triu chng c nng + Du hiu c thai -Tt kinh thng mun kinh v ngy hoc c ri lon kinh nguyt.Phi hi k kinh nguyt ca 3,4 thng gn y -Triu chng ph v cng bun nn,nn + Ra huyt m o ra t mt,ko di, mu en,hoc mu chocolate c khi ln mng.Nhng s lng v mu sc khng ging mu kinh! + au bng: au m vng h v, au tng cn, sau mi ln au li ra mt t mu, au ngy cng tng. Thng au mt bn h chu + Ngt t gi tr 2.Triu chng thc th + t m vt: CTC ng kn,c t mu en chy ra + Thm m o kt hp vi nn bng thy CTC mm,T cung mm to khng tng xng vi tui thai. Cnh t cung c mt khi mm ranh gii khng r n vo rt au + Ti cng sau nu cha c mu ,dch th mm khng au.Nu c mu th chm vo ti cng Douglas bnh nhn rt au 3.Triu chng ton thn + Tu thuc vo tnh trng mt mu ca bnh nhn III. Cn lm sng + Xt nghim hCG + nh lng hCG thp hn khi cha cng tui. + Siu m chn on xc nh: Khng thy ti i, m vang thai,tim thai trong bung t cung.Cnh t cung thy mt khi m vang khng ng nht,ranh gii r.Hn hu c th thy m vang thai,tim thai hot ng ngoi bung t cung. Nu c r mu th ti cng Douglas c dch + Ni soi bng va chn on xc nh va iu tr:C th thy mt bn vi trng tm en phng cng chnh l khi cha
Hanoi Medical University LTL
Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn
+ No sinh thit nim mc t cung: khng thy hnh nh gai rau.Ch thy mng rng IV. Chn on xc nh + Da vo lm sang v cn lm sang k trn V. Chn on phn bit : 1. Do sy,sy thai + Ging + Du hiu c thai + au m vng h v + Ra mu m o + Khc + T cung to tng xng vi tui thai CTC h m,cnh t cung khng c khi bt thng + Nu ang sy th mu chy nhiu, ti.Bnh nhn c th chong ngt + No nimmc bung t cung lm gii phu bnh thy hnh nh gai rau! a. Vim phn ph + Ging + au m h v + i khi ra mu bt thng + C khi cnh t cung + Khc + Khng c du hiu c thai + Hi chng nhim trng + Kh h + T cung bnh thng + Ti cng bn dy dnh ranh gii khng r + hCG m tnh + iu tr khng sinh thy gim b. Vim rut tha + Ging + au m vng h chu phi + Khc + Khng c du hiu c thai + Hi chng nhim trng + im au cao hn + hCG m tnh VI. Chn on nguyn nhn + Vim vi trng lm Ing vi trng hp,nhu ng vi trng b hn ch + Khi u phn ph lm vi trng b chn p,hp vi trng.Vi + trng b ko di ra! + D dng bm sinh ca vi trng:Vi trng b hp hoc c ti ngch
VII. X tr
1. iu tr ni khoa
t dung ang th nghim iu kin :Mn cm vi thuc Kch thc khi cha nh hn 5cm Nng hCG nh hn 5000UI/l Douglas khng c dch Khng c ri lon huyt ng MTX 20-40mg tim mt liu duy nht tim bp hoc tim trc tip vo khi cha di hng dn ca siu m Sau 5 ngy th hCG nu gim 30% tr ln tc l p ng iu tr Nu khng gim hoc gim t c th tim liu th 2 Ti a tim 3 mi
2 .iu tr ngoi khoa

+ Chn on xc nh th nn m sm + Tu iu kin m m ni soi hay m m + Nu bnh nhn cha c con, cn tr th c th bo tn vi trng bng cch rch vi trng ly khi cha t in cm mu. + Hoc cp ct khi cha sau ni tn tn iu kin vi trng di hn 4 cm.Rch vi trng ly khi cha.Sau khu ngang bo tn vi trng + Nu khng bo tn th cp ct vi trng sau khu vi mm ct.Lau sch bng khng cn dn lu. + i vi ngi con v nhiu tui th cp ct khi cha, trit sn bn i din + Khng sinh sau m.
Cu 2 Chn on cha ngoi t cung v I.nh ngha:

+ Cha ngoi t cung l hin tng trng c th tinh nhng pht trin v lm t ngoi bung t cung! + Cha ngoi t cung v l mt bin chng nng ca cha ngoi t cung.Mt mu nhiu dn n t vong.
II.Triu chng lm sng: + Xy ra t ngt rm rbin chng chy mu sm hay mun tu theo v tr lm t ca trng: on k,eo th xy ra sm hn on bng,loa 1 .Triu chng ton thn + Hi chng mt mu cp:Mch nhanh,huyt p tt,da xanh nim mc nht.Bnh nhn vt v,ra nhiu m hi chi lnh kht nc.Th nhanh nng 2. Triu chng c nng + Du hiu c thai: Tt kinh,nghn, v cng bun nn. i khi bnh nhn vo vin trong tnh trngchong nng m khng c tin s chm kinh trc + Ra huyt m o: Mu nu en,chocolate ra mu t mt ko di.Khng tng xng vi triu chng ton than + au bng t ngt d di ,t nhin lm bnh nhn chong vnghoc ngt i. 3. Triu chng thc th + Khm bng: Hi chng chy mu trong bng + Bng chng nh,c phn ng thnh bng vng di rn,c th c cm ng phc mc + ng vo ch no cng au + G c vng thp + Thm m o: Ra huyt theo tay,lng mu chy ra khng tng xng vi tnh trng ca bnh nhn + CTC mm,tm, ng kn,di ng rt au.S t cung c cm gic bp bnh trong nc.Kh xc nh c knh thc ca t cung do bnh nhn au + Ti cng cng phng n rt au( ting ku Douglas ) III. Cn lm sng + hCG (+) + Siu m khng c ti i trong bung t cung.Cnh t cung c khi m vang khng ng nht.Douglas v bng c nhiu dch + Chc d Douglas t dung:C th thy mu long en khng ng! + Cng thc mu Hng cu, hemoglobin, hmatocrit gim IV. Chn on xc nh + Da vo lm sang v cn lm sang
V.Chn on phn bit 1. Sy thai bng huyt + Ging + Du hiu c thai: Chm kinh,nghn, hCG (+) + Chy mu m o c th c chong do mt mu nhiu + au bng vng h v, au tng cn + Khc + Ra mu m o ph hp vi tnh trng ca bnh nhn + Khng c hi chng chy mu trong:Bng chng, phn ng thnh bng,cm ng phc mc,g c vng thp,ti cng cng phng,ting ku Douglas 2.V tng c + Ging: + au bng + Chong mt mu + Hi chng chy mu trong + Khc: + Khng c du hiu c thai + Khng c ra mu m o + T cung bnh thng + C tin s chn thng + Siu m khng c khi cha 3. V nang Degraff,nang hong th,nang hong tuyn + Ging + au bng , chong + Khc + khng c du hiu c thai + t cung bnh thng di ng khng au 4. U nang bung trng xon + Ging + au bng d di t ngt + C chong + Siu m c khi cnh t cung + Khc : + Khng c du hiu c thai + Khng c hi chng chy mu trong + T cung bnh thng di ng khng au + Chong do au mch huyt p bnh thng + Tin s c u nang bung trng VI . X tr 1.Nguyn tc: + M cp cu ngay khng tr hon + va m va hi sc
2.C th + Va m va chng chong bng b nc in gii,mu,tr tim, th oxy + M bng tm ngay vi trng b v,cp ct ngang vi trng v.Sau khu vi.Lau sch bng khng cn dn lu + Khi khng c mu c th ly mu trong bng lc sch v truyn li cho bnh nhn nhng phi ch khu v khun + Hi sc tch cc sau m + Khng sinh sau m + Chng vim chng dnh sau m Cu 3:Chn on v x tr cha ngoi t cung th huyt t thnh nang
I. nh ngha
+ Cha ngoi t cung l hin tng trng c th tinh nhng pht trin v lm t ngoi bung t cung + Cha ngoi t cung th huyt t thnh nang l hin tng bc thai r mu hoc sy thai nhng khng chy mu t vo bng m chy mu t mt t t.Sau mu s ng li mt ni no trong bng.Rut, mc treo,mc ni ln,dn bao bc khu tr li to thnh khi huyt t
II. Triu chng lm sng

1.Triu chng c nng + Du hiu c thai :tt kinh,nghn,v cng,bun nn,nn + au bng h v au thnh cn, m ,c lc tri ln ri li gim i + Ra huyt m o t mt ko di mu en nu,chocolate 2. Triu chng ton thn + Hi chng thiu mu tan mu:Da hi xanh nh vng + Ton thn khng suy spnhng ngi mt mi st nh gy st 3. Triu chng thc th + Khm ngoi thy khi ranh gii khng r vng bng di + Thm m o thy khi chim c vng h chu ranh gii khng r n au tc. i khi dnh cht vo t cung thnh mt khi lm kh xc nh c th tch v v tr ca t cung
III. Cn lm sng
+ hCG m tnh chng t thai cht.Trc c th th hCG (+) + Siu m thy mt khi m m ngoi t cung
+ Chc d ti cng Douglas di hng dn ca siu m c th thy mu cc + Soi bng c th thy khi huyt t trng bng
IV. Chn on
1. Chn on xc nh + Da vo lm sang v cn l sang trn 2. Chn on phn bit a. m qunh rut tha + Ging: + au vng h chu phi + Khi trong h chu phi + hCG m tnh + Khc: + Khng c du hiu c thai trc + Hi chng nhim trng + Khng c chy mu m o + Chc do ti cng Douglas khng c mu b. U x t cung + Ging: + C khi cnh t cung + Dnh vo thnh t cung + Khc: + Khng c du hiu c thai + Khng ra mu m o + Chc d khng c mu cc
V. X tr
+ M cp cu c tr hon,khng v th pht + Khi m phi g dnh,tm cch vo mu t ly ht mu t lau sch ri khu kn trnh khoang rng + Nu cn khi cha th ct on vi trng cha khi cha.Khu vi cm mu + Nu cn chy mu c th chn cc mnh Spongen hoc gc cm mu.Dn lu ra ngoi,gc se c ly ra sau vi ngy + Ch khi m hn ch khu cm mu vlm tn thng n tng xung quanh + Trong khi m khng nn g dnh nhiu,tm ch t dnh m + Khng sinh sau m + Chng vim dnh
Cu 4:Chn on v x tr cha ngoi t cung th cha trong bng
nh ngha
+ Cha ngoi t cung l hin tng trng c lm t nhng pht trin v lm t ngoi bung t cung + Cha ngoi t cung th cha trong bng l hin tg thai pht trin v lm t trong bng.Thai c th pht trin n thng.Lc thai s lm t trong khoang rng trong bng.Rau thai lan rng bm vo rut mc treo v cc mch mu ln.Thng chn on kh
Triu chng lm sang

Triu chng c nng + Du hiu c thai: Chm kinh,nghn,bun nn,v cng + au bng m c nhng lc au tri ln tng cn.C th km theo ra mu m o t + Du hiu bn tc rut + Bun nn,nn ,b trung i tin Triu chng thc th + Khi thai cn nh s thy khi cnh t cung ranh gii khng r n au,di ng kh + Khi thai ln thng s thy thai ngay di thnh bng,khng thy hnh t cung.Kch thch t cung khng c cn co + Thm m o thy thai nm cnh t cung
Cn lm sang
+ Siu m thy t cung kicks thc bnh thng.Ti i , m vang thai,hot ng ca tim thai nm bit lp vi t cung,thai nm xen k vi quai rut + hCG dng tnh + Soi bng chn on khi thai cn b thy t cung v hai phn ph bnh thng.Khi thai nm ngoi t cung + Chp bng khng chun b :Khng thy hnh nh bong m t cung bao quanh khi thai + Thai thng nh hn tui thainm xen k gia cc quai rut + Test oxytocin khng thy khi thai p ng
Chn on
Chn on xc nh + Da vo lm sang v cn lm sang trn
2. Chn on phn bit U nang bung trng dnh + Ging + S thy c khi cnh t cung + C du hiu chn p + Khc + Siu m gip chn on phn bit + Khng c du hiu c thai Khi vim quanh t cung + Ging + C khi cnh t cung + Khc + Khng c du hiu c thai + Hi chng nhim trng + Siu m gip chn on phn bit Khi u mc treo + Ging + C khi trong h chu + Khc + Khng c du hiu c thai + Chn on phn bit bng siu m
X tr
+ Nu thai cht m cp cu,tranh gy ri lon ng mu + Nu thai < 32 tun M ly thai ngay d thai cn sng hay cht + Nu thai >32 tun C th thai pht trin thng sau m ch ng + Trong lc m cp rn v ct rn st vi bnh rau.Khng c bc rau v gy chy mu.Nu chy mu th chn gc cht sau rt gc nhng ngy sau m.
Chuyn 2:Thai cht lu

Cu 1: Chn on v x tr thai cht lu na u thi k thai nghn
nh ngha:
+ Thai cht lu l tnh trng thai b cht lu li trong t cung qu 48 gi! + Thai cht lu gy ra hai nguy c ln cho m: Ri lon ng mu di dng chy mu v ng mu ri rc trong thnh mch(CIVD) + Nhim trng nhanh nng khi v i + Ngoi ra cn nh hng n tm l ngi m. c bit l nhng ngi m him con
Triu chng lm sng

1 .Triu chng c nng + Bnh nhn c du hiu c thai trc nh:Tt kinh,nghn,bng to dn ln,hCG (+).Siu m thy ti i, m vang thai,hot ng tim thai trong bung t cung! + Ra huyt m o t nhin,mu en, thm, t mt ko di + Khng au bng + Bnh nhn thy bng b i hoc khng thy bng to ln mc d mt kinh lu ri! 2 .Triu chng ton thn + Thng t thay i.C th c xut huyt di da,nim mc nu nh c ri lon ng mu! 3 .Triu chng thc th + Thm m o kt hp vi nn bng thy + T cung b hn so vi tui thai + Mt t cung chc hn so vi khi c thai + CTC di, ng kn. + Mu en hoc thm m o III. Cn lm sng
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+ hCG dng tnh nu nh thai mi cht ,m tnh nu nh thai cht lu. + Siu m cho chn on sm v chnh xc rt c gi tr! + C th thy tim thai m khng c m vang thai trong bung t cung + C th thy ti i m khng c m vang thai.Hay cn gi l hnh nh ti i rng! + Hnh nh ti i rng cng chc chn khi m thai cht lu kch thc ln,b ti i mo m khng u + Nu nghi ng c th siu m li sau mt tun c kt lun chnh xc! + nh lng Fibrinogen mu(Bnh thng 4-4,5 g/l) Nu gim di 2 g/l th c nguy c ri lon ng mu + Cng thc mu ch n bch cu.Nu bch cu tng cao c nguy c nhim trng i!
IV. Chn on
Chn on xc nh + Da vo triu chng lm sng v cn lm sng (c bit l siu m) k trn Chn on phn bit A .Do sy thai sng,thai sng + Thng chn on nhm do vi vng khi khm!Do khi m nghi ng thai cht lu cn phi thm khm nhiu ln bi nhiu ngi c kinh nghim c chn on chnh xc B. Cha trng thoi trin + Ging + Du hiu c thai + Ra mu m o t nhin, en + Khng au bng + T cung b hn tui thai + Khc + Siu m c hnh nh tuyt ri + Nhiu khi cn phi da vo gii phu bnh mi chn on phn bit c. Cha ngoi t cung Ging + C du hiu c thai + Ra mu t mt mu nu en + au bng nu nh chun b sy + T cung b hn tui thai Khc + Cnh t cung c khi n au
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+ Siu m khng c ti i, m vang thai,tim thai trong bung t cung + Cnh t cung c khi m vang khng ng nht! d. U x t cung Ging + C ra mu m o Khc + Khng c du hiu c thai + Siu m c hnh nh ca nhn x Chn on nguyn nhn Nguyn nhn t m + Bnh mn tnh:Cao huyt p,vim gan,suy thn, thiu mu + Bnh ni tit: i tho ng ,Base dow + Tin sn git + Nhim k sinh trng vi rt :St rt c tnh,toxsoplasma,giang mai,vim gan B,si ,cm + Nhim c cp ,mn tnh:Thuc cha ung th, tia x + Mt s yu t thun li + Tui m cao(>40) hoc qu tr <15 + Dinh dng km,lao ng vt v + Tin s thai cht lu
Nguyn nhn do thai
+ Ri lon nhim sc th + D dng :No ng thu,v s + Bt ng nhm mu Rh + a thai

Nguyn nhn do phn ph
+ Dy rn: Tht nt,xon vn,dy ngn tuyt i + Bnh rau: X ho ,b bong + i : a i,thiu i + T cung d dng hoc nhi tnh,km pht trin + 20%-50% s trng hp thai cht lu l khng tm thy nguyn nhn!
V .X tr
Thi x tr + Khng vi vng trong chn on v x tr! + Ly thai cht lu ra khi t cung + iu chnh cc ri lon ng mu nu c + Chng nhim khun + ng vin an i b m
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2. C th A. iu chnh ri lon ng mu nu c + Nu Fibrinogen < 2g/l c nguy c CIVD v tan mu.Ta cn iu chnh li trc khi can thip ly thai ra: + Fibrinogen truyn tnh mch + Mu ti ton phn hoc mu mi ly < 3 ngy + Thuc chng tiu sinh si huyt : EAC 8-12 g.Transamine 250-1000mg truyn tnh mch + Mt s tc gi M cn dung Heparin 5000-10000 n v/24 gi.Nhng Vit Nam cha p dng B .Nong c t cung v no + Ch p dng cho t cung b hn t cung c thai < 3 thng hoc cao t cung < 8 cm + Th thut no kh hn so vi no thai sng v xng thai cng.Rau thai x ho bm chc vo t cung + Phi cho gim au trc no,thuc co t cungv khng sinh sau no + Chy mu thng xut hin sau no vi ting ng h nhng a s p ng tt vi iu tr ni khoa.Bo tn t cung vi iu kin trc khi iu tr ni phi m bo t cung sch,khng c rch c t cung + Gy sy thai, chuyn d + Khi m thai to khng th no c C .Phng php Stein + Bnh nhn c dung estrogen v quinine trc khi truyn Oxytocin + C th Benzogynestryl 10 mg/ngy trong 3 ngy + Ngy th 4 truyn Oxytocin tnh mch.Liu ti a 30 n v /ngy D . Truyn Oxytocin tnh mch n thun + Bnh nhn c truyn tnh mch ngay m khng cn phi dung estrogen trc E .Dng prostaglandin + l phng php c a chung nht hin nay.Thuc c a chung nht l Prostagandin E2 ng Prostine,Nalador. + Vit Nam dung vin Cytotex t m o ,vi liu 100microgam /1ln cch 12 gi t mt ln.Ngoi ra c th Cytotex ngm di li.Ch phi gi mng i cho CTC m ht + Theo di sau khi ly thai lu ra + Ri lon ng mu + Nhim khun + H tr ng vin cho sn ph
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Cu 2 Chn on v x tr thai cht lu trong na sau ca thi k thai nghn nh ngha:

+ Thai cht lu l tnh trng thai cht b lu li trong t cung trn 48 gi + Thai cht lu gy ra : + Ri lon ng mu di dng chy mu do ng mu ri rc trong lng mch(CIVD) + Nhim khun i + nh hng tm l tnh cm ngi m. c bit ngi m him con
Triu chng lm sng

1. Triu chng c nng + Bnh nhn c du hiu c thai:Thai my thng th 4, o c cao t cung,siu m thyhnh nh thai,hot ng ca tim thai trong t cung.Nghe ctim thai bng ng nghe g.S c cc b phn ca thai + Hin nay bnh nhn khng thy thai my na. y l l do chnh m bnh nhn phi i khm. + Bng khng thy to ln thm tr thy b i + V tit sa non. y l triu chng m bnh nhn ch ti + Ra mu m o rt t gp + Nu nh bnh nhn trc b tin sn git hoc b bnh tim th thy bnh gim ,hoc d chu hn 2.Triu chng thc th + Kh s thy cc phn ca thai + Khng nghe thy tim thai bng ng g + o chiu cao t cung thy gim so vi ln trc. c bit c ngha khi m cung mt ngi o! + Thm m o kt hp vi nn bng thy t cung nh hn tui thai + CTC ng kn.Nu CTC m th thy u i hnh qu l.
Cn lm sng
+ Siu m l thm d ch yu v cho kt qu chnh xc nht + Khng thy hot ng ca thai,ca tim thai + Moritoring khng thy hot ng ca tim thai + Xquang bng khng chun b,chp bung i t c s dng do c hi cho m v thai nhi nu nh thai cn sng + C th thy hnh nh chng khp s .Du hiu Spalding I,khi thai cht khong 10 ngy Hanoi Medical University LTL 14
+ Ct sng gp khc(Du hiu Spalding II) + Vng sng quanh u(Du hiu Devel) + Thy bong hi trong bung tim v mch mu ln(Du hiu Robert) + nh lng Fibrinogen nh gi nh hng ca thai nhi ln qu trnh ng mu + Bnh thng 4-4,5 g/l.Nu fibrinogen < 2g/l c nguy c gy ri lon ng mu d dng chy mu do ng mu ri rc thnh mch (CIVD).Nu n thai vn cn trong bung t cung th phi theo di fibrinogen hng tun. y l xt nghim khng th thiu c trc khi c can thip cho thai ra
Chn on
1. Chn on xc nh + Da vo lm sng,cn lm sng 2. Chn on phn bit + Trong trng hp ny t t ra 3. Chn on nguyn nhn Do m + Bnh l mn tnh: Cao huyt p,suy thn,vim gan mn tnh + Bnh l ni tit: i tho ng,Basedow + Tin sn git + Nhim k sinh trng,vi rt:K sinh trng st rt,vi rt si ,cm + Nhim c cp man tnh nh tia x ,thuc cha ung th Do con + Ri lon nhim sc th + Thai d dng: No ng thu,v s + Bt ng nhm mu :Rh,ABO + a thai + Do phn ph Dy rn: + Tht nt ,ngn tuyt i + Bnh rau vi ho,x ho ,b bong + i: thiu i hoc a i + T cung d dng,nhi tnh,km pht trin + 20-50% khng xc nh c nguyn nhn.
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X tr
1. Thi x tr + Khng vi vng trong chn on v iu tr + Ly thai ra hi t cung + iu chnh cc ri lon ng mu nu c. + Chng nhim khun nu c 2. iu tr c th + iu chnh ri lon ng mu + Nu fibrinogen < 2g/l th ta cn iu chnh ri lon ng mu trc khi can thip ly thai ra bng cch: + Fibrinogen truyn tnh mch + Truyn mu ti.Hoc mu mi ly<3 ngy + Cc thuc chng tiu sinh si huyt :EAC 8-12 g,transamine 250-1000mg truyn tnh mch + Mt s tc gi M dung Heparin 5000-10000 n v/24 gi.Nhng Vit Nam cha p dng
Gy sy thai,chuyn d Phng php Stein
+ Bnh nhn c dng trc estrogen v quinine sau truyn Oxytocin tnh mch + C th Benzogynestryl 10mg/ngy trong 3 ngy + n ngy th 4 truyn Oxytocin tnh mch liu ti a 30 nv/Ngy
Phng php Oxytocin n thun: Dng Prostaglandin l phng php c a chung nht hin nay
+ l s dng cc Prostaglandin E2 nh:Prostine,Nalador + Vit Nam dung vin Cytotex t m o 100 microgam c 12 gi t mt ln.Ngoi ra c th ngm di li Cytotex.Nu cn c th dung thm Oxytocin + Ch gi mng i cho ti khi CTC m ht! Theo di sau ly thai + nh gi ri lon ng mu + nh gi tnh trng nhim trng.Cho khng sinh d phng + T vn , ng vin an i cho bnh nhn + Ch : Khng vi vng trong chn on v iu tr!
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Chuyn 3: Cha trng

Cu 1 Chn on v x tr cha trng
I. nh ngha: + Cha trng l s pht trin bt thng ca gai rau,nguyn bo nui pht trin qu nhanh,cc t chc lin kt trong gai rau v mch mu trong gai rau pht trin khng kp, cc gai rau khng cn t chc lin kt v mch mu tr thnh cc bng nc. + Cha trng c hai loi + Cha trng hon ton v cha trng bn phn. II. Triu chng 1. Triu chng c nng + Du hiu c thai: Tt kinh,nghn,Quick stick dng tnh + Ra mu l triu chng quan trng u tin.Ra mu sm vo khong thng th 2 n thng th 4.Ra mu mu en, ,dai dng t mt + Nghn thng nng hn cc ln c thai bnh thng trc! + C th c du hiu tin sn gittng huyt p,ph,Protein niu. i khi c th c vng da + C th c tnh trng cng gip vi tuyn gip to,nhp tim nhanh,da bn tay m,run tay thng gp th nng! 2. Triu chng ton thn + Bnh nhn mt mi,hc hc. + Hi chng thiu mu:Da xanh nim mc nht,hoa mt chng mt! 3.Triu chng thc th + T cung mt mn,khng s thy cc b phn ca thai(ngoi tr trng hp c thaqi km theo + T cung to hn tui thai(Tr trng hp cha chng thoi trin) + Nghe tim thai khng c + Khm m o thy mu en hoc m o.Thnh m o c th c nhn di cn to bng u ngn tay mu tm,d chy mu khi cham phi + Phn ph c th s thy mt hoc hai nang hong tuyt to hai bn III. Cn lm sng + Phn ng sinh vt :lng hCG thng rt cao >30000 n v ch hoc60000 n v th + nh lng beta hCG thng cao > 100000 UI/l + Mt s t trng hp cha trng nhng beta hCG khng cao + Estrogen nc tiu di dng estrone, estradiol, estriol u rt thp so vi c thai thng
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+ hPL cng rt thp trong cha trng,nhng hPL rt cao trong c thai + Siu m rt quan trng trong chn on + Khng thy hot ng ca tim thai,khng thy ti i , m vang thai.Ch thy hnh nh lm m (hnh nh tuyt ri ,hnh chum nho,rut bnh m)trong t cung + Thy nang hong tuyn mt hoc hai bn + Xquang t cung khng chun b khng thy hnh nh ca xng thai m c hnh nh t ong + Chp bung t cung c bm thuc cn quang thy hnh nh t ong rt r.Nhung phng php ny hin nay khng lam na! + C th chp Xquang phi xem c di cn phi khng + Chp ng mch t cung pht hin cha trng xm ln,hnh nh t chim + Ngoi ra c th s dng mt s phng php hin i khc chn on cha trng nh: Nng aminopeptid IV. Chn on 1. Chn on xc nh + Da vo lm sang v cn lm sang trn 2. Chn on phn bit + Do sy,sy thai thng Ging + Tt kinh + Nghn, au bung(nu nh trng sy) Khc + T cung to tng xng vi tui thai + Siu m cho thy hnh nh ti i m vang thai ,hot ng tim thai trong bung t cung + Nng beta hCg thng nh hn 100000UI/l hoc nh hn 20000 n v ch Thai cht lu + Cn chn on phn bit vi cha trng, c bit l cha trng thoi trin Ging + Tt kinh + Nghn + Ra huyt mu en + Khng au bng , + khng nghe thy tim thai Khc + Siu m cho chn on xc nh + i khi cn phi nh ti gii phu bnh Cha ngoi t cung Ging + Chm kinh
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+ Ra mu m o + au bng vng h v(Trng sy c au bng) Khc + Tin s thai nghn bnh thng + T cung thng nh hn tui thai.Cnh t cung c mt khi s n au + Nng beta hCG thp hn thai thng + Siu m thy khi m vang khng ng nht cnh t cung Nghn nng trong thai thng Ging + Tin s chm kinh + Nghn nng Khc + T cung to tng xng vi tui thai + Siu m thy ti i, m vang thai,tim thai hot ng trong t cung + Nng beta hCG thng nh hn 100000UI/l C thai km theo u x Ging + Tt kinh + Nghn + Ra mu m o + T cung to hn tui thai Khc + Nghe c tim thai + S thy phn ca thai + Nng beta hCG < 100000UI/l + Siu m thy ti i, m vang thai,hot ng tim thai trong t cung,kem theo hnh nh ca nhn x Thai to, a thai Ging + Nghn nng + T cung to hn tui thai Khc + Khng ra mu m o + S thy cc phn ca thai,nghe c tim thai + Siu m thy c ti ti m vang thai tim thai hot ng trong bung t cung IV. X tr 1. Thi x tr + Cha trng l mt cp cu.Nu cha trng m ang chy mu th c coi l ti cp cu cn x tr ngay. + Nu chn on xc nh l cha trng th nn no trng sm hoc ct t cung trong trng hp b m> 40 tui v c con phng chy mu do sy thai. 2. X tr
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a. No ht thai trng + Nu c my ht:Di p lc chn khng ht nhanh, chy mu bung t cung + Nu khng c my ht: Dng kp hnh tim gp thai trng theo chiu ca t cung + Trc no : Gim au,nong CTC bng nn Hegar n s 12 + Trong khi ht,truyn nh git tnh mch Oxytocin 5 n v + 500ml Glucose 5% gip t cung co hi tt + Sau ht dung tha no to cn no li.C th siu m kim tra li xem no sch cha? + Sau 2-3 ngy c th no li + Cho khng sinh sau no phng nhim khun * 5-7 ngy + Thuc co hi t cung b. Ct t cung + Nu nh bnh nhn >40 tui con phng bin chng 3. Theo di sau no trng + Sau no phi lm gii phu bnh + phng nhim khun bng cch cho khng sinh trong 5 dn 7 ngy v thuc co hi t cung + Theo di lm sang: + S co hi t cung,pht hin nhn di cn,nang hong tuyn + Theo di bin chng:Chy mu,nhim khun,thng t cung,Ung th nguyn bo nui + Theo di nng hCG + nh lng hCG 1 tun/1 ln cho ti khi xt nghim 3 ln m tnh lien tip. + 2 tun /1 ln trong 3 thng tip theo + thang /1 ln trong 6 thng tip theo + thng /ln trong nm tip + Khuyn bnh nhn ch c c thai t nht sau 2 nm + S dng Bao cao su trnh thai.Khng dung dng c t cung,thuc trnh thai trnh thai 4. D phng bin chng. + Ct t cung d phng binchng ung th nguyn bo nui nu ph n > 40 tui , con + Dng ho cht d phng thy bin chng gim t,nhng tc dng ph suy tu,suy gan thn th nhiu.Do hin ti khng dung + iu tr sm bnh nguyn bo nui + Nhng triu chng ngh ti bin chng ung th nguyn bo nui: + Nu sau no trng m hCG tng cao bt thng,hoc sau m tnh li xut hin dng tnh. + Trong hai tun k tip,nng ln sau cao hn ln trc
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+ Trong 3 tun nng vn gi nguyn khng i + 4 tun sau no nng > 20000UI/l + 8 tun sau no>500UI/l + 6 thng sau nao>5UI/l + Ct t cung ph n c con,tui>40 + Vi ph n cn tr tui,mong mun c con th iu tr MTX 0.3-0.4 mg/kg/ngy trong 5 ngy ngh 7 ngy cho ti khi hCG< 5UI/l. Cu2 : Theo di sau no thai trng I. nh ngha: + Cha trng l s pht trin bt thng ca cc gai rau,nguyn bo nui pht trin qu nhanh nn t chc lien kt trong gai rau v mch mu khng pht trin kp,cc gai rau cn t chc lien kt khng c mch mu tr thnh cc bng nc + Cc t bo ca bnh nguyn bo nui ch tit mt lng ln hCG.Lng hCG s gim hoc tr v bnh thng khi m cha trng thoi trin hay l trng b no b.hCG tng ln khi m cha trng ang pht trin hoc c di cn.Do vic theo di nng hCG sau no trng l rt quan trng nhm nh gi kt qu iu tr v cc bin trng c th xy ra. II. Theo di tin trin ca bnh sau no trng! + Sau no trng cn phi gi cc t chc no lm gii phu bnh,tu v kt qu gii phu bnh m ta c hng x tr tip theo. + D phng nhim khun bng khng sinh sau no trong 5 ngy v thuc co hi t cung. 1. Theo di v lm sng + Theo di s co hi t cung,nang hong tuyn,nhn di cn,ra huyt m o.Bnh thng sau no trng 3-4 tun nhng c im v gii phu,sinh l v b phn sinh dc tr v bnh thng.Nu sau thi gian ,t cung cn to cn ra mu,nang hong tuyn khng mt ith phi ngh n bin chng thnh ung th nguyn bo nui.Nu xut hin nhn di cn th cng chc chn hn. + Theo di ton trng v biu hin di cn ca cc b phn khc nh: + Mt mi gy st + Di cn phi: Ho ra mu, au tc ngc. + Di cn m o c khi u mu tm thnh m o,d chy mu. + Di cn trc trng a mu + Di cn no c hi chng tng p lc ni s 2. Theo di bng cn lm sng + Quan trng nht l nh lng beta hCG trong mu Hanoi Medical University LTL 21
+ Sau no trng ta cn nh lng beta hCG 1 ln/1 tun cho n khi hCG m tnh trong 3 ln lin tip + Sau 2 tun nh lng li 1 ln trong 3 thng u + Sau 1 thng ng lng 1ln trong 6 thng tip theo nu nh ln trc m tnh! + Trong nm tip theo nh lng 2 thng 1 ln Ngh n Ung th nguyn bo nui khi: + Sau no trng nng beta hCG khng gim hoc gim t hoc tng ln. + Nng hCG cao bt thng + Nng hCG m tnh sau li dng tnh tr li + Sau 4 tun nng hCG > 20000UI/l + Sau 8 tun nng hCG > 500 UI/l + Sau 6 thng nng hCG >5UI/l Nu ngh n bin chng cn phi tm nhn di cn + Chp Xquang phi tm hnh nh th bong.Chp Xquang bung t cung thy bung t cung gin hay thy hnh khuyt hoc bung t cung nham nh + Siu m bng,chp nhp nhy tm nhn di cn gan.Siu m t cung xem cn st trng hay hnh nh khi u nguyn bo nui. + Chp scanner s no tm di cn no + Chp chn lc ng mch chu xem hnh nh nhn khi u,ri lon tun hon t cung v h chu do nhn khi u nguyn bo nui(hu nh by gi khng dng). 3.Thi gian theo di + Cn theo di trong vng 2 nm.V trong vng 2 nm phi tuyt i khng c thai.Ch nn dung bao cao su trnh thai.Khng c dung thuc trnh thai,hoc dng c t cung trnh thai trong qua trnh theo di + Nu sau 2 nm theo di m thy n nh th bnh nhn c th c thai tr li. + i vi nhng ph n cha trng c nguy c cao cn phi theo di st khi m h c cc yu t sau + Kch thc t cung trc no to hn tui thai 20 tun + C nang hong tuyn to hai bn + Tui m > 40 + Nng hCG rt cao + Cc bnh km theo cha trng nh: Tin sn git,cng gip vv + Cha trng lp li. III. Ngoi ra cn theo di cc tai bin sau no 1. Chy mu sau no a. Nguyn nhn + Do ht cha ht + T cung co hi km
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+ Thng t cung b.Biu hin lm sang: + Ra mu m o nhiu + Da xanh nim mc nht + Mnh nhanh nh,huyt p tt + T cung co hi km c.X tr + Cho thuc co hi t cung(Oxytocin) + X tr theo nguyn nhn 2. Thng t cung sau no a. Nguyn nhn + Do p lc ht mnh + Tha no sc + Cht lng c t cung km + No sai k thut b. Lm sang biu hin bng + Ra mu m o, au bng,Hi chng chy mu trong + Siu m c dch ti cng Douglas c. X tr + M cp cu ngay 3. Nhim khun sau no a. Nguyn nhn + Do v khun khng tt + No trng khi m sn ph ang b nhim khun b. Lm sng + St cao,Dch m o ra nhiu v hi,cng thc mu bch cu tng cao,Siu m loi tr st trng c. X tr + Khng sinh liu cao.Khi ht st c th no li bung t cung cho sch
Chuyn 4: Ung th nguyn bo nui

Cu 1: Ung th nguyn bo nui. Chn on v x tr I. nh ngha + Ung th nguyn bo nui l khi u c tnh pht trin t t bo nui ca rau thai ri xm lnvo t chc ngi m,c kh nng ch tit hCG.Thng xut hin trong 3 thng u sau no trng.
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II. Triu chng + C tin s lin quan n thai nghn, tng c thai,hoc thng,hoc tng sy thai,no ht,cha ngoi t cung c bit l cha trng 1 . Triu chng c nng + Ra mu m o ko di hoc ti pht sau no thai trng,sau sy no thai,cha ngoi t cung .Mu ra t mt mu hoc en,nu v nhn di cn m o th ra mu nhiu t ti + au bng do di cn ti ch hay do xon ,v nang hong tuyn. + Giai on mun c th c du hin di cn ti cc tng khc: + Di cn phi: Ho ra mu,kh th tc ngc + Di cn trc trng c a mu + Di cn no c lit m mt hn m. 2 . Triu chng ton thn + Hi chng thiu mu: Da xanh, nim mc nht + Ngi mt mi gy st n km 3 . Triu chng thc th + Thm m o kt hp vi nn bng thy: + C t cung mm h m + T cung mm,co hi chm,to hn bnh thng + Di ng tu theo mc lan trn ca khi u,c th s thy nhn di cn trn b mt T cung + m o mm c nhn di cn mu tm khng a,d chy mu, thnh trc m o + Phn ph c th thy nang hong tuyn mt hoc hai bn,di ng III. Cn lm sng + hCG nc tiu : nh lng bng phng php sinh vt + Bnh thng sau no trng 3-4 tun th hCG m tnh(<5 n v ch) + Nu sau thi gian trn m hCG vn dng tnh(>5 n v ch) hoc xung ri nay li tng ln th phi ngh ngay n bin chng Ung th nguyn bo nui + Beta hCG mu + Beta hCG mu t hang trm nghn UI/l sau no trng 6 tun th s v bnh thng. + Nhng trng hp sau cn ngh n Ung th nguyn bo nui + Nu sau 2 tun lien tip m beta hCG khng h,tng hoc h t. + ang h sau li tng ln + Sau 3 tun lien tip beta hCG gi nguyn khng i + 4 tun sau no beta hCG >20000UI/l + 8 tun sau no beta hCG > 500UI/l + 6 thng sau no > 5UI/l
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+ Gii phu bnh no sinh thit nim mc t cung,nhn di cn m o + Siu m + Xc nh xem c nhn ung th ,nang hong tuyn + Siu m bng tm hnh nh di cn gan thn + Chp X quang bung t cung gin hnh nh khuyt hay b nham nh + Chp ng mch chu chn lc xem hnh nh khi u,ri lon tun hon t cung(Hin nay khng dng na) + Pht hin di cn xa + Chp X quang phi hnh nh th bong + CT Scanner,MRI s no tm di cn no IV. Chn on 1. Chn on xc nh + Da vo tin s, + Lm sang,Cn lm sng trn. 2. Chn on phn bit St trng st rau sau no + Ging + Ra mu m o lien tc ko di sau no + T cung to mm + Khc + Hi chng nhim trng + Ra mu c th km theo m hoc kh h + Siu m thy st rau st trng + X tr khng sinh liu cao,no li bung t cung C thai li sau no trng + Ging + T cung to mm hn bnh thng + Khc + Tt kinh,nghn + Khng ra mu m o + T cung to tng xng vi tui thai + Test hCG v Siu m cho ta bit c thai hay ung th nguyn bo nui + Nu c thai li sau no thai trng trong vng 2 nm th nh ch thai nghn v th Gii phu bnh sau no. V. X tr 1 . Mc ch: + Loi b t chc ung th ti ch. + Dit t bo ung th di cn 2 . Cc phng php iu tr + Phu thut l v kh s mt loi tr t chc ung th ti ch + Ct T cung hon ton cng vi 2 phn ph.Cn nhc ct hai Phn ph ph n < 45 tui + Ch nh
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+ Ph n ln tui con + iu tr ho cht tht bi trong trng hp bo tn T cung. + Ct nhn di cn : Ct nhn di cn m o, ct pht phn thu phi nu di cn phi. + iu tr bng ho cht l phng php ch yu dit t bo ung th, c bit l t bo ung th di cn. + Ch nh + Tt c bnh nhn ung th nguyn bo nui u phi iu tr ho cht + Cc thuc v phc iu tr + MTX thuc nhm chng chuyn ho t bo. + Liu 0,3mg/kg/24 gi trong 5 ngy sau ngh 7 ngy .iu tr nhiu t ng ton thn. + Khi iu tr cn theo di triu chng ng c thuc nh rng tc,l ming l li ri lon tiu ho(Chn n bun nn au bng ) Bch cu gim< 3000/mm3(Bch cu a nhn trung tnh < 1500 mm3) + Tiu cu <100000 mm3,transamine huyt thanh tng cao.Nu c cc Triu chng trn cn ngng thuc v dung ngay Folatcanxi ,Truyn mu,Prednisolon 4-6 mg/24 gi.Testosteron 100mg/24 gi. + Actinomycin D Thuc nhm khng sinh chng ung th + Liu 12 mcg/kg/ngy trong 5 ngy ngh 7 ngy. iu tr nhiu t(Ti a 500 mcg/24 gi) + Cn theo di ng c ch yu l da v nim mc + Cc thuc khc Cyclophosphamide,chlorambucil. + Cch iu tr + S t iu tr ph thuc tnh trng bnh nhn( Mc bnh v p ng iu tr) + n tr liu Dng MTX hoc Actinomycin D + Ung th nguyn bo nui khng di cn + Ung th nguyn bo nui c di cn nguy c thp + a tr liu theo cng thc MAC, CHAMOCA,EMACO + Ung th nguyn bo nui di cn nguy c cao + n tr liu tht bi + i vi nhn di cn + Di cn m o c th tim trc tip MTX vo nhn di cn trc khi bc + i vi cc nhn di cn ch khc c th iu tr ho cht trc sau m ct nhn di cn + Theo di iu tr + Trc mi t iu tr cn nh gi kt qu iu tr ca cc t trc. + Cn theo di cng thc mu ,cng thc bch cu,mi ngy.Chc nng gan,thn., ng huyt, nh lng nng hCG.
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+ Theo di du hiu ng c thuc + Theo di du hiu khng thuc nh: + Sau mi t iu tr nng hCG khng gim hoc tng ln + Xut hin them nhn di cn mi. + Nu c cc du hiu trn cn thay i hoc phi hp them cc ho cht khc.Dng them cc bin php khc nh phu thut ,tia x, loi b ung th tai ch hay di cn. + Ngng iu tr ho cht khi: + C triu chng ng c thuc + C du hiu khng thuc. + iu tr bng quang tuyn. + Khi khng iu tr bng ho cht hoc phu thut c + Thng dung tia X hoc Cobalt chiu vo vng h v hoc m o hn ch s pht trin ca t bo ung th ti ch hoc di cn + Ch nh : ung th nguyn bo nui lan trn vo h chu hoc cc vng khng th phu thut c + Ch khi tia x vng h chu c th lm hng bung trng cho nn cn thn trng nhng ph n cn tr v mun c con. + iu tr min dch + Cc phng php u khng a li kt qu r rang! + Gy min dch th ng bng cch tim khng huyt thanh HLA chng li bch cu ca chng + Gy min dch ch ng khng c hiu bng BCG + Gy min dch ch ng bng cch tim bch cu ca chng hoc ghp da ca chng + iu tr c th + Cha di cn,bnh nhn cn tr,mong mun c con + Ho cht liu php ,bo tn t cung + Nu khng p ng th phi m ct T cung hon ton + Cha di cn,ngu con + Ct T cung hon ton v hai Phn ph + Phi hp ho tr liu nu cn + C di cn m o + Tim MTX vo nhn di cn + Sau ct T cung hon ton v hai Phn ph.Ho tr liu sau m + Di cn phi + Ho tr liu,ct T cung hon tonv hai Phn ph + Ct phn thu phi ly nhn di cn ( s lng 1-2 nhn b r) + Di cn tng khc + Ct T cung hon ton v hai Phn ph + Ho cht phi hp + Ch m di cn nu c bin chng cp + Tiu chn khi bnh
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+ Ba ln lien tip xt nghim hCG m tnh + Xt nghip hCG 2 tun/1ln trong 3 thng u + thng /1ln trong 3 thng tip theo + thng/1 ln trong 6 thng tip theo + 6 thng /ln trong nm cn li + Khm ph khoa + Chp X quang 3 thng /1 ln trong nm u + Cn trnh thai trong vng 2 nm bng bao cao su.Khng s dng thuc trnh thai v dng c t cung trnh thai trong qu trnh theo di. Cu 2:Hng x tr v din bin ca bnh ung th nguyn bo nui I. i cng + Ung th nguyn bo nui l khi u c tnh pht trin t nguyn bo nui ca rau thai ri xm ln vo t chc ngi m.c kh nng tit ra hCG II. Hng x tr ung th nguyn bo nui . 1) Mc tiu : + Loi b t chc ung th ti ch + Tiu dit t bo c tnh di cn 2) iu tr bng phu thut + L v kh s mt loi tr t chc ung th + Ch nh + Ct t cung hon ton v 2 phn ph cho nhng ph ln tui v con + Ct nhn di cn m o hoc phn thu phi nu nhn cn khu tr ti phn thu phi no . 3) iu tr bng ho cht + Khi bo tn t cung nhng ph n tr cn mun c con + MTX l thuc chng chuyn ho + liu 0,2-0,3 mg/kg/ngy dng trong 5 ngy ngh 7 ngy sau dung tip t 2 + Khi s dng cn theo di du hiu ng c thuc: Lot ming,li,ri lon tiu ho,BC < 3000mm3.TC < 100000mm3.Transamine mu tng. + Khi c du hiu ng c thuc cn dng thuc v ung Folatcanxi,Truyn mu,Prednisolon 4-6 mg/24 gi.Testosteron 100mg/24 gi + Actinomycin D :L khng sinh chng ung th + Liu dng 12mcg/kg/24gi(Khng dung qu 500mcg/24gi)dng ko di trong 5 ngy ngh 7 ngy + Ch cc du hiu ng c thuc Ch yu da nim mc + Ngoi ra cn c th s dng cc ho cht khc Cyclophosphamide,Chlorambucil. Hanoi Medical University LTL 28
+ n tr liu Tc l dung hoc Actinomycin D + a tr liu MAC,EMACO,CHAMOCA 4) iu tr bng quang tuyn + Thng dng tia X hoc Cobalt chiu vng h v + Khi ung th lan trn nhng vng khng th phu thut c,ho cht t tc dng nh Ung th lan vng h chu + Ch khi chiu x vng h chu c th lm hng bung trng nhng ngi bo tn phn ph. 5) iu tr bng min dch + Cc phng php ny u cha em li cc kt qu r rang + Gy min dch th ng bng tim khng HLA chng li bch cu ca chng + Gy min dch ch ng khng c hiu bng BCG + Gy min dch ch ng c hiu bng tim bch cu ca chng hoc ghp da chng III. iu tr c th 1) Ung th cha di cn,ph n cn tr,mong mun c con + Bo tn t cung, + Ho tr liu php: n a tr liu tu thuc vo tnh trng bnh nhn + Nu khng p ng phi ct t cung hon ton v 2 phn ph 2) Ung th cha di cn ph n ln tui c con + Ct t cung hon ton v 2 phn ph + Ho tr liu php + Ung th di cn m o + Tim MTX vo nhn di cn sau phu thut ct nhn di cn,t cung hon ton v 2 phn ph + Ho tr liu php + Ung th di cn phi + Phu thut ct t cung hon ton v 2 phn ph + Ct phn thu phi + Ho tr liu php sau m + Ung th di cn cc tng khc + Ct t cung hon ton v 2 phn ph + Ho tr liu php + Ch m nhn di cn khi c bin chng cp 3) Tiu chun bnh nhn ra vin + Ba ln lien tip xt nghim hCG m tnh. + Sau theo di nng hCG trong 2 nm + 2 tun /1 ln trong 3 thng u Hanoi Medical University LTL 29
1 thng / 1 ln trong 3 thng tip theo 2 thng /1 ln trong 6 thng tip 6 thng / 1ln trong nm cn li Khm ph khoa nh k Chp X quang phi 3 thng / 1ln trong nm u tin Trnh thai ti thiu 2 nm bng bao cao su.Khng c dung thuc trnh thai ,dng c t cung . 4) Din bin ca ung th nguyn bo nui a) Din bin khng thun li + Bnh nhn c pht hin mun. ung th di cn lan trn gy ra chy mu, thng t cung. Ung th nguyn bo nui c c im khc ung th khc l di cn theo ng mu.T bo ung th lan n au th pht trin + Thng di cn n phi no gan m o + Di cn m o d pht hin nht thy khi to bng u ngn tay r thnh trc m o mu tm mm,d chy mu + Di cn phi: Ho ra mu,au ngc,kh th. + Chp X quang c hnh nh th bong + Di cn no c du hiu tng p lc ni s,lit ,hn m . + Bin chng nguy him nht l chy mu v chy mu d di kh cm. + Nhim trng khi u ti ch hay ton than do khi u t cung,nn bnh nhn thng rt au + Xon nang hong tuyn cn phi phu thut + hCG tng cao b)Din bin thun li + Bnh nhn c pht hin bnh sm + Ung th cha di cn tin lng rt tt khi iu tr bng phu thut v ho tr liu php + Ung th di cn m o,phi nguy c trung bnh,tin lng tng i tt + Ung th di cn gan,no tin lng rt xu + Tiu chun c ra vin nh trn.
+ + + + + +
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Chuyn 5: Rau tin o

Cu 1 Cc loi rau tin o v hng x tr. I. nh ngha + Rau tin o l hin tng bnh rau bm vo on di hoc c t cung. + Rau tin o gy ra hin tng chy mu trong 3 thng cui ca thi k thai nghn,trong chuyn d v sau . Rau tin o c th gy t vong cho c m v condo chy mu v non. Rau tin o cn gy cn tr s bnh chnh ngi thai.Do rau tin o l mt cp cu trong sn khoa II. Phn loi 1) Theo gii phu:
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a) Rau bm thp: + Mt phn rau bm xung on di t cung. c chn on hi cu sau khi s rau.Bng cch o t mp bnh rau ti l rch mng rau < 10 cm. b)Rau tin o bm bn + Rau bm vo on di ca t cung nhng cha ti l trong c t cung .Chn on hi cu bng cch o t mp bnh rau ti l rch mng rau < 10 cm + Hai loi ny x tr khi chuyn d l bm i cm mu v ch chuyn d t nhin .Nu khng cm mu th m ly thai c) Rau tin o bm mp: + Mp bnh rau lan ti l trong c t cung + Chn on khi chuyn d , c t cung m ht s thy mp bnh rau st l trong c t cung . + X tr Khi chuyn d ,bm i x rng mng rau song song vi mp bnh rau cm mu, ch ng di,nu khng cm mu c th m ly thai. d)Rau tin o bn trung tm + Bnh rau bm lan qua l trong c t cung che lp 1 phn ca l trong c t cung + Khi chuyn d thm trong thy mng i v mi rau + X tr khi chuyn d bm i x rng mng i song song vi mp bnh rau cm mu sau m l thai. e) Rau tin o trung tm hon ton + L hin tng rau bm lan qua l trong c t cung v che kn l trong c t cung + Khi chuyn d c t cung m thm trong qua l trong c t cung thy bnh rau che kn ton b l trong c t cung . + X tr trc chuyn d th m ly thai ch ng + Khi chuyn d m ly thai cng sm cng tt sau khi tim thuc gim co cm mu. 2) Theo lm sang a) Th chy mu t + Thng gp l rau bm ,bn bm thp, bm mp + X tr l theo di ng di b)Th chy mu nhiu + Thng gp trong rau tin o bn trung tm v rau tin o trung tm hon ton. + X tr m ly thai ch ng + Loi ny rt nguy him cho m v chy mu nhiu v cho con v thng non thng. 3) Theo siu m; + Siu m khi thai thng v cha chuyn d
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+ o mp bnh rau ti l trong c t cung nu > 20mm th c kh nng ng di. + Nu mp bnh rau ti l trong c t cung < 20mm th khng c kh nng ng di.Phi m ly thai ch ng v d gy chay mu.Nu mp bnh rau lan ti l trong c t cung th khi chuyn d thng tr thnh rau tin o trung tm hon ton do kh c kh nng ng di.Nn m ch ng + Nu bnh rau lan qua l trong c t cung l rau tin o trung tm hon ton.M ly thai ch ng III. Hng X tr 1) Rau tin o trong 3 thng cui (trc chuyn d) a) iu dng + Khuyn bnh nhn vo vin d cm mu + Nm bt ng ti ging,hn ch i li ,khng nm chung vi chng. + n thc n giu dinh dng,hn ch cht kch thch.Ung nhiu nc , n nhiu cht x,chng to bn + Theo di tnh trng chy mu,thai bng lm sang v cn lm sang + Trnh thm khm nhiu, c bit khm trong bng tay. b)Thuc iu tr Cc thuc gim co: + Papaverin chlohydrat 40mg dung 40-400mg/ngy chia lm nhiu ln + Spasfon 40mg hoc spasmaverin 40mg + Progesteron 25-50mg/ngy tim bp su(Khng dung progesterone khi c chuyn d) + Isoprenalin vin 1mg ngm di li t 1/8 vin tng liu dn.Theo di mch.Nu mch > 100 ln/pht th phi gim liu hoc thay thuc + Salbutamol truyn < 20mcg/pht khng ch cn co t cung ri sau dung ng ung ri rc trong ngy. + Chng ch nh nhi mu c tim,suy vnh,tng huyt p,Basedow,Nhp nhanh. + Ch khi dung thuc cn phi theo di nhp tim. + Ritodrin HCl + Dng khi do non thai trn 20 tun.Hay suy thai cp.truyn tnh mch 150mcg/pht.Ung 4-10 mg/24 gi.Nu mch > 120 ln /pht th dng thuc. + Terbutalin sulphat: Thuc chng cn co t cung liu 57,5mg /ngy ti a 10-15 mg/ngy. + Chng ch nh nhy cm,nhp nhanh,cng gip.
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+ Aspirin dung cho thai < 32 tun.Nu > 32 tun c nguy c gy bnh cn ng ng mch ,ch nn dung 3-5 ngy,v thng dung phi hp vi khng sinh thuc nhm beta lactam. + Thuc chng to bn MgSO4,Na2SO4 + i vi bnh nhn thiu mu c th dung them vin st vitamin B12 Hay truyn mu ti. c) Tin trin iu tr + Khi iu tr c kt qu,bnh nhn khng cn chy mu th gi thai ti thng + Nn gi bnh nhn bnh vin v c nguy c chy mu bt c lc no. + Theo di s pht trin ca thai nhi,bnh rau, ton trng ca ngi m + Khi thai thng nh gi ton din nh trng lng thai,tui thai ,ngi thai,lai rau tin o c hng X tr thch hp. + Rau bm thp, bm bn , ( Mp bnh rau ti l trong c t cung > 20mm o trn siu m ),Ngi chm c th ch chuyn d t nhin. + Rau bm mp th c th bm i x rng mng i song song vi mp rau bm cm mu ,nu cm mu c th c th ch ng di,Nu khng cm mu th m ly thai. + Nu rau tin o bn trung tm c th bm i v x rng mng i song song vi mp bnh rau cm mu sau m ly thai. + Nu rau tin o trung tm th nn m ly thai ch ng + Nu iu tr ni khoa tht bi,mu vn chy th m cu m l chnh c chiu c ti con. 2) Rau tin o khi chuyn d a) Nguyn tc + Cu m l chnh + C chiu c ti con b)X tr tng loi + Rau tin o trung tm m ly thai cm mu k c trng hp thai cht.Trc khi m nn cho thuc gim co cm mu + Rau tin o bn trung tm + Bm i x rng mng i song song vi mp bnh rau cm mu sau th m ly thai. + Rau bm mp
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+ Bm i x rng mng i song song vi mp bnh rau nu cm c mu,ngi chm c th theo di ng di.Nu khng cm mu c th m ly thai. + Rau bm thp,rau bam bn ta bm i cm mu nu c chy mu.Theo di ng di.Nu khng cm c mu th m ly thai. K thut X tr trong rau tin o + K thut bm i cm mu : sau khi bm i ta phi x rng mng i song song vi mp bnh rau. + K thut m ly thai trong rau tin o :khi bnh rau bm vo mt trc trnh rch vo bnh rau,ta phi a tay lch mt mi rau bm ln pha y t cungti mng i ,ph v mng i ly thai + K thut cm mu sau khi ly thai c chy mu din bm rau. + Khu cm mu bng mi ch X,U vi ch catgut nu khng cm mu c th ct t cung bn phn thp i vi ngi con r hoc tht ng mch h v hoc ng mch t cung vi ngi con so .Trong trng hp khng tht ng mch c ct bn phn t cung thp khu mi ch X,U khng cm mu c th c th khu p mt trc vo mt sau ca thnh on di li. + i vi ng di sau khi kim sot t cung, bc rau nhn to m chy mu cho thuc co t cung khng c kt qu phi ct bn phn t cung thp on di rau bm. + Hi sc tch cc cho sn ph nh truyn mu + Nu cu c con cn hi sc cho con Sau + Tip tc hi sc tch cc cho m v con + Cho khng sinh. Cu 2 : Chn on rau tin o trong 3 thng cui.Hng x tr. I. nh ngha + Rau tin o l hin tng rau bm vo on di hoc c t cung II. Triu chng 1) Triu chng c nng + Chy mu trong 3 thng cui l triu chng hay gp nht (mt s trng hp rau tin o khng chy mu v c pht hin bng siu m) + Chy mu vi tnh cht : Mu ti, thm,km theo mu cc + Chy mu t nhin, t ngt + Khng km theo au bng
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+ Lng mu thng ra t lm bnh nhn ht hong sau th t cm cho d khng iu tr g. + S chy mu ny thng ti pht li nhiu ln vi tnh cht: + Lng mu ln sau ra nhiu hn ln trc. + Khong cch gia cc ln chy mu ngn li + Thi gian chy ln sau nhiu hn ln trc 2) Triu chng ton thn + Tu vo tnh trng mt mu nhiu hay t m biu hin du hiu thiu mu: Da xanh ,nim mc nht.Hoc c du hiu sock khi m mt mu nhiu :Mch nhanh huyt p tt,v m hi,chn tay lnh th nng vv 3) Triu chng thc th + Khng c triu chng c hiu cho rau tin o + Nhn c th thy t cung hnh trng hoc hnh b ngang tu thuc vo ngi thai + S : Thng thy ngi thai bt thng nh: Ngi mng,ngi vai,hay ngi u cao lng. + Nghe tim thai c th bnh thng,nhanh hoc chm tu thuc vo du hiu mt mu. + Thm trong : + Khng khm m o bng tay + Khm m o bng m vt hoc van m o loi tr cc trng hp chy mu do tn thng c t cung . III. Cn lm sng + Siu m : Rt quan trng gip ta chn on xc nh th rau tin o v cn nh gi tnh trng tim thai,ngi thai trng lng, ng knh lng nh,cc d tt ca thai nhi,theo di di chuyn ca rau thai,gip ta nh hng x tr + Cng thc mu nh gi tnh trng mt mu,hin tng bi nhim, IV. Chn on 1) Chn on xc nh + Da vo Triu chng lm sng v cn lm sng 2) Chn on phn bit a) Rau bong non Ging + Ra mu m o Khc + Du hiu tin sn git : Cao huyt p,ph ,Protein niu + au bng d di + Mu chy l mu khng ng + Bng to ln nhanh,t cung co cng,tng trng lc c + Tim thai thay i,hay c chong
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b)V t cung Ging + Ra mu m o Khc + Du hiu do v t cung + au bng nhiu,c chong + Du hiu chy mu trong + Khi v thy thai nhi di thnh bng,v c mt khi bn cnh + Khng c tin s chy mu 3 thng cui c) Do non Ging + Ra mu m o Khc + Ra mu r r,khng t cm + C cn co t cung + au bng vng h v + Siu m rau bm y t cung d)Bnh l c t cung Ging + Ra mu m o + Khng km theo au bng + Hay ti pht Khc + Khm m o bng van m o hoc m vt thy tn thng c t cung v chy mu ni tn thng. V. X tr 1) iu dng + Khuyn bnh nhn vo vin d mu cm + Khng nm chung vi ngi khc c bit l chng + Ngh ngi tuyt i ging + n thc n giu dinh dng,trnh cc thc n ung kch thch. n nhiu cht x chng to bn + Theo di s ln chy mu v ton trng b m v thai nhi trn lm sang v bng cn lm sang. + Ch khng khm m o bng tay 2) Thuc iu tr + Thuc gim co + Papaverin Chlohydrat vin 40 mg .Ung 40 n 400mg/ngy + Spasfon 40mg hoc spasmaverin 40 mg + Progesteron 25-50 mg/ngy tim bp 5-7 ngy
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+ Isoprenalin vin 1 mg.Ngm di li t 1/8 vin c th tng dn.Ch khi m mch > 100 ln/Pht th phi dng thuc. + Salbutamol truyn tnh mch 20 mcg/pht sau khi khng ch c cn co t cung th dng sang ng ung ri rc trong ngy. + Theo di nhp tim khi iu tr + Ritodrin HCl : truyn tnh mch 150mcg/pht,hoc ung 4-10 mg/ngy trong trng hp do sy thai > 20 tun hoc suy thai cp.Nu mch nhanh>120 ln/pht th phi dng thuc + Terbutalin sulphat liu dung 5-7.5 mg.Liu ti a 1015mg/ngy + chng ch nh trong trng hp nhy cm v cng gip + Aspirin dung cho thai < 32 tun v nu thai nhi ln hn c nguy c gy ra bnh ng ng mch.Thng dung km theo khng sinh nhm beta lactam v cc vi khun ng sinh dc tit niu sinh ra Prostaglandin l cht gy cn co t cung + Thuc chng to bn MgSO4,Na2SO4 + Vin st,vitamin B12,vitamin C, + Truyn mu nu mt mu nhiu Tin trin iu tr + Nu khi iu tr m cm c mu th c th gi thai n thng. + Nn g bnh nhn ti vin theo di s chy mu,ton trng ca b m v s pht trin ca thai nhi,loi rau tin o c 3). Hng X tr hp l + Rau tin o l loi rau bm thp,bm bn v ngi chm th c th ch chuyn d t nhin ng di. + Nu rau tin o bm mp v ngi chm th khi chuyn d bm i x rng mng i song song vi mp bnh rau.Nu cm mu c th cho ng di + Rau tin o bn trung tm ch khi chuyn d bm i cm mu sau m ly thai + Rau tin o trung tm hon ton th m ly thai ch ng + Nu iu tr ni khoa khng cm c mu th m cp cu cu m l chnh cho d con bt c tui thai no. Cu 3 Rau tin o khi chuyn d chn on v X tr . I. nh ngha
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+ Rau tin o l hin tng rau bm vo on di v c t cung + Rau tin o gy chy mu, non,cn tr s bnh chnh thai.L mt cp cu sn khoa. II. Triu chng lm sng 1) Triu chng c nng + Bnh nhn c tin s ra mu m o trong 3 thng cui vi tnh cht ra mu t nhin,khng au bng,ra mu ti c km theo mu ,ra t hoc nhiu tu thuc vo loi rau tin o ,t cm mu cho d khng iu tr g,ti pht nhiu ln. + Khi chuyn d thy ra mu m o nhiu hn,ra nhiu hay t ph thuc loi rau tin o: + Rau tin o trung tm hon ton v khng hon ton chy mu nhiu t,cng m c t cung th cng chy mu. + Rau tin o bm thp,bm bn ,bm mp th chy t hn,c tin s chy mu t mt v ti pht nhiu ln. + Km theo ra mu m o sn ph thy c cc cn au bng ngy cng tng, l du hiu au bng do cn co t cung khi chuyn d + Du hiu ra nhy hng khng r. 2) Triu chng ton thn + Tu thuc vo mc thiu mu m biu hin : + Thiu mu Mch nhanh,huyt p h,da xanh nim mc nht + Chong da mt nhiu mu Mch nhanh kh bt hoc khng bt c,huyt p tt hoc khng o c ,tinh thn hong ht,v m hi chn tay lnh vv 3) Triu chng thc th + Thy ra mu m o ti km theo mu cc + Nn bng thng thy ngi thai bt thng Ngi mng,Ngi vai,Hoc ngi u cao lng + Nghe tim thai c th bnh thng hoc thay i tu thuc vo tnh trng mt mu. + Thm m o + Thm bng tay d gy bong rau lm chy mu do trong rau tin o khng c thm m o bng tay. + Thm m o bng van m o hoc m vt:khi c t cung m ht thy r bnh rau ,mng i ngoi ra cn c th thy cc tn thng c t cung nu c. III. Cn lm sng + t dng
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+ i khi chn on kh c th dng Siu m xc nh v tr bnh rau,ngoi ra c th nh gi tnh trng thai nhi, c hng X tr thch hp. + Cng thc mu nh gi tnh trng thiu mu IV. Chn on 1) Chn on xc nh + Da vo lm sng v cn lm sng 2) Chn on phn bit a) Chuyn d Ging + Ra mu m o + au bng cn + C cn co t cung Khc + Khng c tin s chy mu trong 3 thng cui + Ra mu m o s lng t, t nh hng ti ton trng bnh nhn + Siu m thy v tr bm ca bnh rau bnh thng b)Rau bong non Ging + Ra mu m o + au bng + C th c chong Khc + Khng c tin s chy mu trong 3 thng cui + Thng sy ra t ngt d di + C du hiu tin sn git + Bng to dn + T cung co cng + Siu m thy cc mu sau rau,v tr rau bm bnh thng c) V t cung Ging + Ra mu m o + Chong + au bng Khc + Khng c du hiu chy mu trong 3 thng cui + C du hiu do v + Cn co t cung cng tnh + au bng d di + Khi v th s thy thai nhi ngay di thnh bng, c khi bn cnh + C du hiu chy mu trong Hanoi Medical University LTL 40
+ Tim thai mt d)Tn thng c t cung khi chuyn d Ging + au bng tng cn + C cn co t cung + Ra mu m o Khc + Ton thn bnh thng + S lng ra mu t + Thm m o bng van m o hoc m vt chn on phn bit + Siu m rau bm ng v tr V. X tr 1) Nguyn tc + Cu m l chnh + C chiu c n con 2) C th + Hi sc tch cc cho sn ph( truyn dch,truyn mu) + Tu tng loi rau tin o m X tr khc nhau + Rau tin o trung tm hon ton M cp cu cu m l chnh cho d thai cn sng hay cht.Trc m nn tim trcthuc gim co cm mu + Rau tin o bn trung tm : Bm i cm mu sau m ly thai + Rau tin o bm mp : Bm i, x rng mng i song song mp bnh rau nu cm c mu,ngi chm th theo di ng di.Nu khng cm mu th m ly thai + Rau tin o bm thp,bm bn : Bm i ,x rng mng i,nu cm mu,ngi thai l ngi chm th theo di ng di.Nu khng cm mu th m ly thai. K thut m ly thai + Nu rau bm vo mt trc: Ta trnh rch vo bnh rau m ta phi a tay lch qua mt mi rau ln pha y t cung sau ph i ly thai. + K thut cm mu sau khi ly thai c chy mu din rau bm. + Khu cm mu bng ch catgut bng mi ch X,U + Nu vn chy mu: Ta tht ng mch t cung ,hoc ng mch h v nhng ph n cn tr,cn mong mun c con + Nu ph n ln tui , con hoc khng cm c mu th ct t cung bn phn thp,khu p mt trc vo mt sau
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+ Nu ng di Sau khi s thai phi bc rau nhn to,kim sot t cung,cho thuc co hi t cung .Nu khng cm mu c th ct t cung bn phn thp di ch rau bm + Sau tip tc hi sc cho m v con + Cho khng sinh sau m
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Chuyn 6:Rau bong non

Cu 1 Chn on cc loi rau bong non I. nh ngha: + Rau bong non l hin tng rau bmng v tr nhng bong trc khi s thai II. Cc loi rau bong non 1) Th n + Khng c biu hin lm sng r rt + Chuyn d bnh thng,tr s sinh kho mnh. + Ch chn on c khi s rau thy c khi huyt t sau rau + C th chn on c bng Siu m 2) Th nh + au bng va ,ra mu m o t,mu long ,en ,khng ng + C th c hi chng tin sn git + T cung cng tnh + Tim thai bnh thng hoc nhanh + Sau kim tra thy c cc mmu sau rau + Sinh si huyt gim nh + Siu m c th thy khi huyt t sau rau 3) Th trung bnh + au bng va + Ra mu m o va phi ,mu en,long,khng ng + C hi chng tin sn git + C th c chong nh + T cung co cng.Kh nn thy cc phn ca thai. + Thm m o thy: on di cng, i cng phng.Nu v i thy i ln mu + Sinh si huyt gim.Protein niu cao. + Siu m thy c khi huyt t sau rau 4) Th nng + au bng d di.Ban u au vng t cung sau lan ra khp bng. + Ra mu m o mu en,long ,khng ng + Hi chng tin sn git nng + C chong nng + C th c hi chng xut huyt ton thn + Bng to nhanh,cng nh g,khng nn c cc phn ca thai nhi Hanoi Medical University LTL 43
+ Tim thai chm hoc mt + Thm m o c mu en khng ng. on di phng cng. i cng phng. i v c mu trong nc i. + Sinh si huyt gim nng hoc khng c + Protein niu tng rt cao + Siu m c khi huyt t sau rau. + Cc xt nghim khc nh: Tiu cu,hng cu,hemoglobin,hmatocrit,gim + thi gian mu chy mu ng ko di.PT gim Th Lm sng Cn lm sng Tin sn git Trng lc Tim thai Siu Sinh si huyt c t cung m n Bnh thng Bnh -/+ Bnh thng thng Nh -/+ cng tnh C th thay + gim nh i Trung ++ Cng Thay i ++ gim bnh Nng +++ Cng nh Mt,chm +++ Gim nng g III. Triu chng lm sng 1) Triu chng c nng + au bng:Lc u au vng t cung sau lan ra khp bng ri xung i + Ra mu m o mu en long khng ng + Bng to ln nhanh 2) Triu chng ton thn + C du hiu chong:Mch nhanh,huyt p tt,ht hong vt v,chn tay lnh vv + C hi chng thiu mu: Da xanh ,nim mc nht + Hi chng tin sn git : Tng huyt p,ph ,protein niu 3) Triu chng thc th + T cung cng tnh,co cng,hoc cng nh g.Kh nn thy cc phn ca thai nhi. + Bng to nhanh.Cao t cung tng r rt + Tim thai thay i t chm cho ti mt + Thm m o + C t cung h m,dy cng + on di cng phng + u i cng phng + Nc i c mu + Ngi u cao lng.
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+ Cn lm sng + Sinh si huyt ,tiu cu, huyt sc t ,hematocrit gim.Thi gian mu chy mu ng ko di,t l PT gim + Siu m c khi huyt t sau rau IV. Chn on 1) Chn on xc nh + Da vo lm sng v cn lm sng 2) Chn on phn bit a) Rau tin o Ging + Ra mu m o + Chong mt mu Khc + Khng au bng + C tin s chy mu trong 3 thng cui + Khng c hi chng tin sn git + T cung khng co cng + Siu m chn on xc nh b) V t cung Ging + au bng d di + Chong + T cung c cng + Ra mu m o Khc + C du hiu do v + Khng c hi chng tin sn git + Mu m o l mu ti c km theo mu cc + Khi v s thy thai nhi ngay di thnh bng c) Thai cht lu Ging + Ra mu m o en khng ng + Tim thai mt + Sinh si huyt gim Khc + Khng au bng + Bng nh i + T cung khng co cng + Nu c hi chng tin sn git th s gim i + Siu m cho Chn on xc nh d) a i cp Ging + Bng to nhanh + Kh khm thy cc phn ca thai
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+ Tim thai nghe kh Khc + Thng vo 3 thng gia ca thai k + Khng ra mu m o + Khng c chong + Khng c cn co t cung + Siu m thy c nhiu nc i Cu 2 Rau bong non th trung bnh: Chn on v x tr I. nh ngha + Rau bong non l rau bm ng v tr nhng bong trc khi thai s. II. Triu chng 1) Triu chng c nng + au bng vng h v,lc u au theo cn sau au nhiu hn + Ra mu m o s lng va,mu en long khng ng + Nu i v th nc i hng ln mu 2) Triu chng ton thn + Chong nh: Mt mi ,ht hong,vt v,v m hi ,chi lnh, kht nc, th nng, mch nhanh,huyt p tt. + Thiu mu : Da xanh ,nim mc nht. + Hi chng tin sn git Tng huyt p,ph ,protein niu cao.Cc triu chng c th r rng hoc khng. 3) Triu chng thc th + T cung tng trng lc, co cng nhiu,khong cch cc cn ngy cng ngn.Kh nn thy cc phn ca thai nhi. + Tim thai chm,ri rc hoc nhanh. + C th thy chiu cao t cung ngy cng tng ln do khi mu t sau rau ngy cng tng,l du hiu c gi tr ngng thng mun. + Thm m o: on di cng, i cng phng,nu v th nc i ln mu. III. Cn lm sng + Sinh si huyt gim ,thi gian Prothrombin ko di.FSP tng. + Cng thc mu : Thiu mu: hng cu gim, hemoglobin gim,hematocrit gim,tiu cu gim. + Siu m thy khi huyt t sau rau. + protein niu cao. IV. Chn on 1) Chn on xc nh + Da vo lm sng v cn lm sng 2) Chn on phn bit
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a) Rau tin o Ging + Ra mu m o + Chong Khc + Khng au bng + C tin s ra mu m o trong 3 thng cui vi tnh cht t nhin,ti pht ,t cm + T cung bnh thng,khng co cng + Siu m thy bnh rau bm v tr bt thng. b) V t cung Ging + Ra mu m o + au bng d di + Chong + T cung tng trng lc,cng tnh,co cng. Khc + Du hiu do v t cung + Ra mu m o l mu ti,ln mu cc + Khng c hi chng tin sn git + ang c cn co t nhin thy gim au,bng nh li,s thy thai nhi ngay di thnh bng bn cnh c mt khi khc. c) a i cp. Ging + Bng to nhanh + Tim thai nghe kh + Kh s thy cc phn ca thai nhi Khc + Thng xy ra vo 3 thng gia ca thai k + Khng hoc ra mu m o t + Khng c chong ,khng au bng nhiu + T cung bnh thng. + Siu m nc i nhiu. d) Thai cht lu Ging + Ra mu m o en khng ng + Tim thai mt + Sinh si huyt gim Khc + Khng au bng + Bng nh i + T cung khng co cng + Nu c hi chng tin sn git th s gim i Hanoi Medical University LTL 47
Siu m cho Chn on xc nh
V. X tr 1) Mc tiu iu tr + Hi sc tch cc chng chong. + Lm ngng chy mu + Ly thai v rau ra khi bung t cung mt cch nhanh nht. + iu chnh li thiu mu va ri lon ng mu. 2) Ni khoa + Hi sc tch cc chng chong do mt th tch mu, do au, do tc ng ca sn khoa + Chng chong bng Dopamin + Gim au Dolasan,Morphin + Tr tim bng Digoxin + Chng v niu bng lasix, t sonde bng quang theo di nc tiu. + Truyn nc v in gii, th oxy, chng nhim c + Tr lc bng vitamin + An thn seduxen 5 mg + Khng sinh lactam + Theo di tin trin,pht hin sm v iu chnh sm cc ri lon ng mu,chng chy mu. + B , nhanh chng khi lng mu mt phc hi chc nng tun hon,dinh dng cho gan,thn ,no. + Nn dngmu ti<3gi.Nu khng c th dng khi hng cu ,khi tiu cu Bi ph cc cht thay th mu ,chng chy mu: Khi hng cu,khi tiu cu ,sinh si huyt , cc yu t ng mu,fibrinogen(2-8g),EAC 24g,Transamine 250-1000mg. 3) Sn khoa + Gip thai ra sm + Nu c t cung m th bm i rt ngn thi gian chuyn d v theo di ng di.Nu thun li th sau phi kim sot t cung.Cho thuc co hi t cung(Oxytoxin),Khng sinh + Nu khng thun lihoc tin trin nng ln th m cp cu,ly thai sm ngay c khi thai cht + M ly thai khi: + Khng iu kin ng di: So m t cung ,m ln tui,tin s sn khoa nng n. + Bm i m c t cung khng tin trin. + Theo di thy c du hiu nng ln.
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+ Hin nay thng m ly thai sm m bo an ton cho c m ln con do bnh thng tin trin nhanh v sau khi thai ra thng gy bin chng chy mu. + Tip tc hi sc chng chong,chng chy mu nh trn. + Sau khi ly thai,tu tn thng t cung v mc chy mu m bo tn hay ct t cung bn phn cm mu. + Ct t cung khi : + Sau m ly thai tn thng Gii phu bnh nng + Tn thng Gii phu bnh nh nhng sn ph con,ln tui. + Tn thng Gii phu bnh nng ngi tr tui con so,nhng tim oxytocin khng cm c mu + Sau vn chy mu nhiu. + Nu t cung tm en,c nhiu hoi t, p gc khng hng tr li, con d th ct t cung hon ton cm mu cu m + Bo tn khi tn thng t cung t v khng chy mu.M tr,con so,cn nhu cu sinh v tnh trng nng nh ca m 4) Theo di sau . + Ton trng m v con. + Theo di tnh trng chy mu nht l khi cn t cung + Cho khng sinh + Tip tc hi sc tch cc cho m v con + Chng nhim c: Truyn dch, in gii,th oxy. + Theo di chc nng gan thn Cu 3: Chn on v X tr rau bong non th nng I. nh ngha : + Rau bong non l rau bm ng v tr nhng bong trc khi thai s. II. Triu chng lm sng 1- Triu chng c nng + Bng to ln nhanh, chng cng. + au bng vung di lc u au theo cn ,cc cn au ngy cng tng,ngy cng nhiu,sau au lin tc khp bng,xung i. + Ra mu m o nhiu mu en khng ng. + Nu i v th nc i ln mu. 2- Triu chng ton thn + Tnh trng chong nng + Ht hong,vt v,th nhanh, chi lnh,v m hi,mch nhanh,huyt p tt kt , v niu
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+ Thiu mu: Da xanh ,nim mc nht + Hi chng tin sn git nng ; Protein niu cao,tng huyt p, ph,cc du hiu thn kinh(au u,nhn m), au h sn phi. 3- Triu chng thc th + T cung to nhanh,co cng nh g.Khng s c cc phn ca thai nhi. + Tim thai mt. + Thm m o on di cng phng,ngi u cao lng. c t cung h m,cng, u i phng.Nu i v th nc i c mu + C th du hiu chy mu ton thn: Chy mu ph tng( Phi ,d dy ,gan ,thn.),chy mu m o nhiu cho d thai v rau s. III. Cn lm sng + Sinh si huyt gim nng hoc khng c.Thi gian prothrombin ko di.FSP tng + Cng thc mu: hng cu,hematocrit ,hemoglobin ,tiu cu gim + protein niu cao + men gan, ure,creatinin tng nu c tn thng gan thn IV. Chn on 1- Chn on xc nh + Da vo lm sng v cn lm sng 2- Chn on phn bit a) Rau tin o Ging + Ra mu m o + Chong Khc + Khng au bng + C tin s ra mu m o trong 3 thng cui vi tnh cht t nhin,ti pht ,t cm + T cung bnh thng,khng co cng + Siu m thy bnh rau bm v tr bt thng. b) V t cung Ging + Ra mu m o + au bng d di + Chong + T cung tng trng lc,cng tnh,co cng. Khc + Du hiu do v t cung + Ra mu m o l mu ti,ln mu cc
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+ Khng c hi chng tin sn git + ang c cn co t nhin thy gim au,bng nh li,s thy thai nhi ngay di thnh bng bn cnh c mt khi khc. c) a i cp. Ging + Bng to nhanh + Tim thai nghe kh + Kh s thy cc phn ca thai nhi Khc + Thng xy ra vo 3 thng gia ca thai k + Khng hoc ra mu m o t + Khng c chong ,khng au bng nhiu + T cung bnh thng. + Siu m nc i nhiu. V. X tr 1) Nguyn tc + Khn trng dng cc bin php kt hp cu m + Kt hp phu thut v chng sc. + M ly thai k c khi thai cht. + Ct t cung + Hi sc trc ,trong,sau khi m. 2) Ni khoa + Hi sc tch cc chng chong do mt th tch mu, do au, do tc ng ca sn khoa + Chng chong bng Dopamin + Gim au Dolasan,Morphin + Tr tim bng Digoxin + Chng v niu bng lasix, t sonde bng quang theo di nc tiu. + Truyn nc v in gii, th oxy, chng nhim c + Tr lc bng vitamin + An thn seduxen 5 mg + Khng sinh lactam + Theo di tin trin,pht hin sm v iu chnh sm cc ri lon ng mu,chng chy mu. + B , nhanh chng khi lng mu mt phc hi chc nng tun hon,dinh dng cho gan,thn ,no. + Nn dngmu ti<3gi.Nu khng c th dng khi hng cu ,khi tiu cu Bi ph cc cht thay th mu ,chng chy mu: Khi hng cu,khi tiu cu ,sinh si huyt , cc yu t ng mu,fibrinogen(2-8g),EAC 24g,Transamine 250-1000mg. 3) Sn khoa. Hanoi Medical University LTL 51
+ M ly thai k c khi thai cht. + Nu c chy mu nng th tht ng mch h v cm mu. + Ct t cung bn phn thp + Ct t cung hon ton khi: + Tn thng Gii phu bnh rng v nng + sn ph ln tui con + sn ph tr tui nhng tim oxytocin vn khng cm c mu. + Sau phu thut + Hi sc tip tc cho bnh nhn( Chng nhim c,chng chy mu.) + Theo di bin chng sau m nh: Chong,nhim khun,chy mu sau ( sinh si huyt gim,ri lon ng mu trong lng mch),chc nng gan thn + Hi sc tch cc nu thai cn sng. + Khng sinh.
a i cp, a i mn
Cu 1 : Chn on v X tr a i cp I. i cng + Bnh thng nc i tng dn cho n tui thai 36 tun khong 1000ml sau th gim dn + Nc i trn 2000ml c gi l a i
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+ a i cp l tnh trng tng nc i rt nhanh trong vi ngy thng xy ra trong 3 thng gia,thng c km theo d dng ca thai nhi II. Triu chng lm sng 1 C nng + Bng to nhanh v cng tc. au tc t ngt + Bun nn,nn, n ung km + Kh th,tc ngc,nhiu khi khng nm c m phi ngi + au vng tht lng,lan ra sau lan xung i + C th c du hiu chn p: i kh, i tin kh,to bn 2 Thc th + Da bng cng bng,ph n,c np dn da.Bng to ln tng ngy.Bng to ,trn u + Chiu cao t cung ln hn nhiu so vi tui thai, t cung to ln nhanh trong vng vi gi,ngy c th tng gp i + S nn kh xc nh cc phn ca thai nhi.C du hiu cc ni khi s nn vo cc phn ca thai nhi + Tim thai m hoc khng nghe thy + Thm m o thy c t cung gin rng,mng i cng phng,kh xc nh ngi thai 3 Ton thn + Bng to,sn ph chm chp,nng n + Tinh thn lo lng,mt mi ,hc hc + Ph do chn p vo cc tnh mch ln c bit ph chi di, m h thnh bngvi c im ph trng mm n lmx,cng c th ph ton thn + Tim p nhanh,mch nhanh ,huyt p c th bnh thng,khng st + Trng hp nng c th thiu niu III. Cn lm sng + Siu m : nh gi lng nc i da vo ch s i(L tng s o chiu su ca 4 ti i ln nht trong 4 gc trn thnh bng ca ngi m, o theo phng php thng ng) + nh gi hnh thi hc ca thai nhi,pht hin cc d dng ca thai nhi + Chc nc i xt nghim t bo hc,nhim sc th + Xt nghim tm nguyn nhn t m: nh Ure,creatinin, AST,ALT, ng mu,Protein niu, ng niu. IV. Chn on 1) Chn on xc nh
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+ Da vo triu chng lm sng v cn lm sng c bit l siu m 2) Chn on phn bit a) C trng/bnh nhn c thai Ging: + Bng to khng tng xng vi tui thai. + S nn kh thy c cc b phn ca thai + Nghe tim thai m hoc khng nghe c bng ng g Khc + Bng to ,b ngang,rn li,c tun hon bng h + C du hiu sng v + G c vng thp + C th tm thy nguyn nhn ca c trng + Siu m gip cho chn on phn bit b)Thai to Ging + Bng to hn so vi tui thai Khc + Bng to ln t t,tng u trong sut qu trnh mang thai + S thy r cc b phn ,cc cc ca thai + Tim thai nghe r + Siu m gip nh gi trng lng thai v loi tr a i c) a thai Ging + T cung to hn so vi tui thai Khc + Bng to nhanh, u trong sut qu trnh mang thai + Nghn nhiu + Thai my nhiu ni trn bng + S thy nhiu chi,nhiu cc trn bng + Tim thai nghe r,nhiu + Siu m c hnh nh a thai d)C thai km theo u x t cung,u nang bung trng,hoc khi u trong bng,hoc trong tiu khung Ging + Bng to khng tng xng vi tui thai Khc + Bng to khng t ngt + T cung khng to u + S thy cc phn ca thai + C th c rong kinh rong huyt trc + Siu m gip chn on phn bit e) Rau bong non Ging: Hanoi Medical University LTL 54
+ Bng to ln nhanh + au bng + Tim thai nghe ko r hoc mt. Khc + Rau bong non thng vo 3 thng cui ca thai k + au bng d di + Ra mu m o khng ng, en ,long + Thng c hi chng tin sn git + C chong mt mu + T cung tng trng lc cng tnh co cng + Siu m c khi mu t sau rau,sinh si huyt gim hoc bng 0 + Bng quang y nc tiu + Chn on xc nh bng t sonde bng quang f) Cha trng Ging + Bng to ln nhanh Khc + Hay gp 3 thng u ca thai k + Ra mu m o t nhin, dai dng t mt ,mu en + hCG rt cao + Siu m c hnh nh tuyt ri,rut bnh m, chm nho trong bung t cung,khng c hnh nh thai nhi g)U nang bung trng xon bnh nhn c thai Ging + t ngt c cm gic bng to ln Khc + au bng t ngt d di + Chong do au v chy mu + Phn ng thnh bng,kh s thy cc phn ca thai v au + Thm m o s thy khi u,chm vo au chi, c bit l vo cung khi u + Siu m thy thai v khi u nang bung trng + C th tin s c chn on u nang bung trng th ln ny chn on s d dng hn h)Khi u to trong bng + Bng thng to t t + Siu m gip chn on + Nguyn nhn + a i thng phi hp vi ngi m b i tho ng,ngi ng min dch + Thai d dng h thng thn kinh trung ng v tiu ho(Thai v s kt hp vi teo thc qun) Hanoi Medical University LTL 55
+ 2/3 trng hp l t pht V. X tr 1) Thi x tr + a i thng km theo d dng thai nhi,v vy cn lm cc xt nghim siu m ,nhim sc th pht hin tnh trng d dng ca thai nhi + Nu thai d dng ko cn kh nng sng th ch ng ly thai ra + Nu thai bnh thng tnh trng sn ph tt c gi thai ti thng ch chuyn d t nhin 2) X tr c th ca tng th cu a i a) Th nh + C 1 ti i m chiu su theo phng thng ng 8- 11 cm + X tr theo di ,ko cn iu tr g b)Th va + C 1 ti i m chiu su theo phng thng ng 12-15 cm + X tr ngh ngi ti ging, n nht,gim lng nc ung + Khi kh th , au bng phi nhp vin ngay + Li tiu lasix 40mg v KCl khng nn dng ko di. + Khng sinh lactam nh Amoxiciclin 2 g/ngy(Do vim nhim mng i gy tng tit) + An thn + Liu php Indomethacin 1,5-3 mg/kg/ngy + Tc dng + Gim ch tit dch phi + Tng hp thu dch phi + Gim bi tit nc tiu ca thai nhi + Tng tnh thm qua mng thai + Chc i lm xt nghim t bo hc,nhieemx sc th,siu m theo di s pht trin bt thng ca thai c) Th nng + Chiu su ca 1 ti i theo phng thng ng > 15 cm thng km theo d dng thai nhi + Chc i + Gip lm gim triu chng cho m + Lm xt nghim t bo hc v nhim sc thMi ln chc cho php ly ra 1500ml nhng ph m bo k thut v trng v d s hng dn ca siu m ,chc qua thnh bng ,rt ra vi tc 500ml/gi.Bin chng: V i, nhim trng i,vim mng i + Liu php Indomethacin 1,5-3 mg/kg/ngy
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+ Khng sinh nhm lactam + Theo di thai,Nu pht hin thy thai d dng th bm i cho + Ch sau khi s rau d b t cung,st rau st mng + An thn + Dinh dng tt 3) Tin trin v tin lng a) Tin trin + au nhiu, kh th do lng nc i nhiu,tng nhanh,chc i gip sn ph d chu nhng d gy chuyn d,sau cn kch pht, th tch t cung tng nhanh hnbnh thng c th dn n v i t ngt non b)Tin lng + Thng gy sy thai, non,st rau,st mng, t cung,t vong con. Cu 2: a i mn: chn on v x tr . I. i cng + Bnh thng nc i tng dn n tun th 36 lhong 1000ml,sau th nc i gim nh + Nc i trn 2000ml thai thng gi l a i + a i mn l a i m lng nc i tng t t,thng xut hin trong 3 thng cui ca thai k,lng nc i tng va phi II. Triu chng 1 . Triu chng c nng + Triu chng thng khng rm r nh a i cp + Cm gic tc vng bng di,mi hai bn tht lng + Thng ko gy kh th + Thai p t + C th c du hiu chn p: i tiu tin kh 2 . Triu chng thc th + Bng to , trn u,da bng cng va,c th c tun hon bng h,np rn da + T cung to hn tui thai + S cc phn ca thai kh,thai c v nh + Tim thai nghe kh + Thm m o: Ngi thai cao ,lng. on di cng phng.C t cung h m. u i phng + Khi chuyn d + T cung co bp khng tt + Ngi thai bnh chnh km + C t cung xo m km + Nu i v t nhin d gy sa chi,sa dy rau
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+ Triu chng ton thn + Mt mi + Khng c g c bit,c th c ph mm trng n lm chi di III. Cn lm sng + Siu m : nh gi lng nc i da vo ch s i(L tng s o chiu su ca 4 ti i ln nht trong 4 gc trn thnh bng ca ngi m, o theo phng php thng ng) + nh gi hnh thi hc ca thai nhi,pht hin cc d dng ca thai nhi + Chc nc i xt nghim t bo hc,nhim sc th + Xt nghim tm nguyn nhn t m: nh Ure,creatinin, AST,ALT, ng mu,Protein niu, ng niu. IV. Chn on 1) Chn on xc nh + Da vo triu chng lm sng v cn lm sng c bit l siu m 2) Chn on phn bit a) C trng/bnh nhn c thai Ging: + Bng to khng tng xng vi tui thai. + S nn kh thy c cc b phn ca thai + Nghe tim thai m hoc khng nghe c bng ng g Khc + Bng to ,b ngang,rn li,c tun hon bng h + C du hiu sng v + G c vng thp + C th tm thy nguyn nhn ca c trng + Siu m gip cho chn on phn bit b) Thai to Ging + Bng to hn so vi tui thai Khc + Bng to ln t t,tng u trong sut qu trnh mang thai + S thy r cc b phn ,cc cc ca thai + Tim thai nghe r + Siu m gip nh gi trng lng thai v loi tr a i c) a thai Ging + T cung to hn so vi tui thai Khc + Bng to nhanh, u trong sut qu trnh mang thai
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+ Nghn nhiu + Thai my nhiu ni trn bng + S thy nhiu chi,nhiu cc trn bng + Tim thai nghe r,nhiu + Siu m c hnh nh a thai d) C thai km theo u x t cung,u nang bung trng,hoc khi u trong bng,hoc trong tiu khung Ging + Bng to khng tng xng vi tui thai Khc + Bng to khng t ngt + T cung khng to u + S thy cc phn ca thai + C th c rong kinh rong huyt trc + Siu m gip chn on phn bit e) Rau bong non Ging: + Bng to ln nhanh + au bng + Tim thai nghe ko r hoc mt. Khc + Rau bong non thng vo 3 thng cui ca thai k + au bng d di + Ra mu m o khng ng, en ,long + Thng c hi chng tin sn git + C chong mt mu + T cung tng trng lc cng tnh co cng + Siu m c khi mu t sau rau,sinh si huyt gim hoc bng 0 + Bng quang y nc tiu + Chn on xc nh bng t sonde bng quang f) Cha trng Ging + Bng to ln nhanh Khc + Hay gp 3 thng u ca thai k + Ra mu m o t nhin, dai dng t mt ,mu en + hCG rt cao + Siu m c hnh nh tuyt ri,rut bnh m, chm nho trong bung t cung,khng c hnh nh thai nhi g) U nang bung trng xon bnh nhn c thai Ging + t ngt c cm gic bng to ln Khc Hanoi Medical University LTL 59
+ au bng t ngt d di + Chong do au v chy mu + Phn ng thnh bng,kh s thy cc phn ca thai v au + Thm m o s thy khi u,chm vo au chi, c bit l vo cung khi u + Siu m thy thai v khi u nang bung trng + C th tin s c chn on u nang bung trng th ln ny chn on s d dng hn h) Khi u to trong bng + Bng thng to t t + Siu m gip chn on + Nguyn nhn + a i thng phi hp vi ngi m b i tho ng,ngi ng min dch + Thai d dng h thng thn kinh trung ng v tiu ho(Thai v s kt hp vi teo thc qun) + 2/3 trng hp l t pht V. X tr 1) Thi x tr + iu tr ni khoa l chnh.Ch can thip sn khoa v ngoi khoa khi iu tr ni khoa tht bi X tr c th ca tng th cu a i mn 2) iu tr ni khoa + X tr ngh ngi ti ging, n nht,gim lng nc ung + Theo di ton trng ca ngi m v thai nhi qua lm sng v siu m + Li tiu lasix 40 mg,km theo KCl khng nn dng ko di + Khng sinh lactam nh Amoxiciclin 2 g/ngy(Do vim nhim mng i gy tng tit) + An thn: Seduxen 5mg + Thuc gim co t cung + Papaverin 40 mg.Spasmaverin 40 mg. + Liu php Indomethacin 1,5-3 mg/kg/ngy + Tc dng + Gim ch tit dch phi + Tng hp thu dch phi + Gim bi tit nc tiu ca thai nhi + Tng tnh thm qua mng thai + Chc i + Gip lm gim triu chng cho m
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+ Lm xt nghim t bo hc v nhim sc th.Mi ln chc cho php ly ra 1500ml nhng phi m bo k thut v trng,chc v tr di tri ca bng v di s hng dn ca siu m ,chc qua thnh bng ,rt ra vi tc 500ml/gi.Bin chng: V i, nhim trng i,vim mng i + Theo di trong qu trnh iu tr: Ton trng m,lng nc i,thai nhi nu thai ko c d dng + Nu p ng vi iu tr th gi thai ch chuyn d t nhin,nu khng th m ly thai + Nu khng p ng iu tr ni hoc thai d dng th nh ch thai nghn ngay. 3) iu tr sn khoa + Trc khi ly thai ra ,bm i ,ch chuyn d t nhin + Khi thai thng + Nu chuyn d: Cn co t cung,yu,c t cung m khng tt,ngi thai bnh chnh km.Nu i cha v,thai ngi chm c th tia i v bm i trnh sa dy rau,sa chi cho ng di + Nu tht bi th m ly thai + Nu cuc chuyn d xy ra bnh thng theo di tip tc ng di. + Sau thai s + Thuc co hi t cung: Oxytocin 5-10 UI hoc Ergotamin 0,2mg tim bp + Khng sinh + Hi sc s sinh tt,kim tra thai nhi xem c d dng kkng? + Theo di chy mu,nhim trng sau Cu 3:Nguyn nhn v c ch ca a i cp I. i cng + a i l hin tng nc i nhiu hn bnh thng cng tui thai + Bnh thng:Nc i tng dn n tun th 36 l khong 1000ml sau gim dn + Khi thai thng lng nc i > 2000ml th gi l a i.T 1000ml 2000ml gi l d i + Thai 28 tun lng nc i l 1000ml + 36 tun lng nc i l 900ml + 40 tun lng nc i l 800ml II. C ch + Bnh thng lng nc i khng thay i mc d c ch sn sinh v tiu th nc i lun xy ra lin tc trong i sng ca thai nhi trong t cung
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+ Sn sinh v tiu th nc i c gi mc cn bng lm cho lng nc i hng nh theo tui thai + a i xut hin khi: + Sinh nc i tng m tiu th nc i bnh thng + Sinh nc i bnh thng m tiu th nc i gim + Sinh nc i tng m tiu th gim C ch tng sinh nc i + Tng ch tit do vim nim mc + Tng sn xut nc tiu ca thai nhi C ch lm gim tiu th nc i + Teo hoc tc ng tiu ho,thai nhi khng ung c nc i + Gim thm phn nc i qua ng h hp thai nhi + Gim thm phn qua mng m v gim chnh p sut thm thu gia nc i v h thng tun hon di mng m III. Nguyn nhn v yu t nguy c Do thai v rau thai + U mu sau rau + Thai n non + Thai d dng ( D dng h thng thn kinh trung ng,h tiu ho,h tun hon,d dng khc nh u bng ph thng) Do m + M b i ng: ng huyt thai nhi tng cao lm sn xut nc tiu ,tng p lc keo trong nc i nn ko nc vo bung i + Bt ng nhm mu m con Rh + M tng huyt p khi mang thai + M b nhim trng : Giang mai , Leptospira,toxoplasma Nguyn nhn cha r: + Ngi ta cho rng do vim nhim cc mng i cng kch thch tng tit dch i gy a i.
Tin sn git v sn git

Cu 1: Bnh nn nng: Chn on v x tr I. i cng + Khi bt u c thai,bnh nhn xut hin tng tit nc bt,bun nn c gi nghn. + Khi cc du hiu ca nghn tng ln nh hng n sinh hot gi l chng nn o.Nu nng hn nh hng n sc kho,tnh mng ca thai ph gi l bnh nn nng II. Triu chng lm sng + Chia lm 3 giai on :nhng ko c ranh gii r rng v thi gian v biu hin lm sng.Bnh c th tin trin rt nhanh ti hn m.
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1) Giai on nn v gy mn. + Ko di 4-6 tun + Du hiu nn: Lc u nn lin quan n ba n,sau nn c ngy,c khi ang ng cng phi dy nn. + Cht nn lc u l thc n sau l nc dch c mi chua,sau cng l ra dch mt xanh,mt vng. + Nn nhiu lm cho vng thng v au,bnh nhn mt mi,hc hc,khng n ung c gy mn. + Nn nhiu dn n mt nc v ri lon in gii,ri lon toan kim v lng nc tiu t. 2) Giai on mch nhanh v ri lon chuyn ho + Ko di 2-3 tun + Nn ngy cng nhiu,gn nh lin tc + Nn khan do khng cn g trong d dy + Bnh nhn gy mn,mt trng,ming li kh,m hm,da nhn nheo,bng lm lng thuyn,hi th chua hoc mi aceton.Mch nhanh khong 100-120 ln/pht + Tinh thn hong s Cn lm sng + Hng cu, hematocrit tng + D tr kim gim + Ri lon in gii + Nhim toan chuyn ho + Ure mu tng nhng ko c biu hin ca vim thn 3) Giai on c bin c thn kinh + Tin trin 5-7 ngy + y l hu qu ca mt nc,suy dinh dng,ri lon in gii,ri lon chuyn ho ko di dn n tnh trng ng c thn kinh. + Thai ph ht hong,m sng ln cn co git,hn m + Nhp th nhanh nng.(40-50 ln /Pht).Hi th c mi acton,mch nhanh nh kh bt,nc tiu t ri gn nh v niu.Bnh nhn c th t vong trong tnh trng hn m v suy kit Xt nghim + Hng cu, hematocrit tng cao do mt nc + Ure mu tng + D tr kim gim,nhim toan chuyn ho,ri lon nc v in gii + Nc tiu c aceton , sc t mt v mui mt III. Chn on 1) Chn on xc nh: + Da vo lm sng v cn lm sng 2) Chn on phn bit
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Cc du hiu nn cn phn bit vi:Bnh nhn c thai km theo b: a) Vim rut tha: Ging : + Bun nn,nn Khc : + Vim rut tha th thng km theo au bng h chu phi, hi chng nhim trng r b) Tc rut Khc : + au bng qun, tng cn. + Nn xong thng bnh nhn thy au + B trung i tin. c) Vim no: Khc + Hi chng mng no + Hi chng nhim trng + au u, nn vt. d) Lot d dy t trng Khc + au bng vng thng v + Thng lin quan n ba n + C th nn ra mu + i ngoi phn en. + Du hiu mch nhanh cn chn on phn bit vi: e) Bnh tim mch khi c thai. Khc + Bnh nhn thng c cc triu chng ca tim mch + C th c gan to, tnh mch c ni vv f) Bnh basedow Khc + Bu c, c th c ting thi tm thu hoc + Da nng, m,mn, m hi nhiu. + Tng chuyn ho + Mt li Du hiu hn m cn phn bit vi : g) Hn m gan: Khc + Nc tiu vng sm + Chc nng gan gim: + Albumi mu gim + PT gim + Ure mu tng h) Hn m do i tho ng
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Ging + Hn m + Mt nc nng + Ri lon nc v in gii + Ri lon toan kim Khc + Nhp th kiu kussmaul + Hn m su vt v + ng huyt tng rt cao i) Hn m do nhim trng nhim c + Hi chng nhim trng r + C ng vo ca nhim khun + C di bnh: Gan to, lch to, phi c ran m 3) Chn on nguyn nhn + Cha r.C 3 gi thuyt chnh sau a) Gi thuyt do trng: + Cha trng, sinh i, a thai dn n nng hCG cao lm cho thai ph bun nn, nn nhiu. b) Thuyt d ng: + Thai l mt protein l vi c th m gy d ng cho m, thai ph bun nn v nn.Sau khi thai cht hoc xy thai th bun nn v nn bin mt c) Thuyt tiu ho + Nhng thai ph c tn thng c ng tiu ho nh vim rut tha, vim lot d dy t trng, khi cthai d gy ra phn x nn. IV. X tr 1) iu dng. + ng vin tinh thn bnh nhn, lm cho bnh nhn tin tng vo iu tr + Tp cho bnh nhn n trong hon cnh b nn + 2 ngy u bnh nhn n bng ng tnh mch , chng mt nc v in gii + 2 ngy tip theo bnh nhn n bng cch ngm lin tc nhng vin sa nu p ng + 2 ngy tip theo cho ung tng ngm sa lnh ,c dn tng cht dinh dng + 2 ngy tip theo cho n sp lnh + Trong qua trnh cho bnh nhn n,nu ngy tip theo bnh nhn khng chu c cch n mi th li cho bnh nhn n nh ngy hm trc,ri tp cho bnh nhn n nh bnh thng. + Cch li bnh nhn vi nhng ngi thn lm cho bnh nng thm nh m chng
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+ Theo di v nh gi s thay i du hiu lm sng v cn lm sng iu chnh v c bin php ph hp 2) Thuc iu tr triu chng + Chng mt nc , ri lon nc v in gii , ri lon toan kim ca mu bng cch b dch, in gii , dinh dng,truyn tnh mch NaCl 0,9%,Glucose 5%,dung dch Moriamin,NaHCO3 45% cn bng kim toan + Chng nn bng Primperan 10mg ung 3-4 vin /ngy trc ba n 30 pht + Thuc gim tit dch v Atropin 1/4mg + Chng d ng: Khng histamin : Pipolphen + Yu t vi lng khc nh vitamin B6,Mg B6,canxi + An thn Rotunda 30 mg 3) Sn khoa + Khi iu tr triu chng nh trn ko kt qu cn nh ch thai nghn cu m + Cht no cn lm gii phu bnh tm nguyn nhn + Tin trin v tin lng, phng bnh + Tin trin + Thng kh phn bit 3 giai on ca nn nng.Bnh c th tin trin nhanh t nh n nng + Tin lng nu chn on v iu tr sm c th gi c thai v trnh t vong cho m V. Phng bnh + Do nguyn nhn cha r v vy cn phi theo di thai nghn cn thn,pht hin v iu tr sm,kp thi bnh nn nng Cu 2 :Tin sn git nh,chn on v x tr . I. i cng: + Tin sn git l giai on xy ra trc khi ln cn sn git. + Giai on tin sn git c th ko di vi ngy ,vi gi,vi tu hoc ch thong qua tu theo mc nng nh ca bnh. Tin sn git c chn on v x tr kp thi c th phng nga c cn git,trnh nguy c e do tnh mng cho m v cho con + Tin sn git xy ra khong 5-10% trong thai nghn Cc yu t thun li: + Con so m ln tui + Ma lnh m + a thai, a i + Cha trng + Thai nghn km i tho ng ,bnh mn tnh, tng huyt p mn , bo ph.
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II. Triu chng lm sng 1) Tng huyt p + L du hiu quan trng v n l du hiu n sm nht v hay gp nht,c gi tr tin lng cho m v con. + Tng huyt p khi: + i vi ngi khng bit tr s huyt p bnh thng + Huyt p tm thu 140 mmHg. + Huyt p tm trng 90mmHg. + Hoc Huyt p tm thu tng trn 30mmHg,hoc huyt p tm trng trn 15mmHg. So vi tr s huyt p bnh thng trc khi c thai + Hoc huyt p trung bnh tng trn 20 mmHg so vi trc khi c thai. + Huyt p trung bnh =[HA ti a + 2(HA ti thiu) ]/3. + o huyt p c hai tay,ri ly huyt p tay bn no cao hn theo di. o huyt p t nht 2 ln mi ln cch nhau 6 h u cao gi l tng huyt p thc s (trc chuyn d), 2h trong chuyn d + c im tng huyt p trng tin sn git . + Thay i theo nhp sinh hc. + Huyt p tm thu v tm trng tng gim khng tng ng + Tng huyt p thng xut hin t tun th 32,nu xut hin sm hn th tin lng nng hn. 2) Ph + Biu hin l ph vo bui sng,ri ph c ngy,ph ngy cng tng dn,ph t thp ln cao,hay ph ton thn.Ph tng kh pht hin. nh gi ph bng cn nng l chnh xc nht: Tng > 500g/tun hoc 2250g/thng . 3) Protein niu. + L du hiu xut hin mun hn du hiu tng huyt p.Protein niu dng tnh khi: Lng proein niu >0,3g/l trong mu nc tiu 24 h(c gi tr chn on v theo di) hoc > 0,5 g/l mu nc tiu bt k + Mt s triu chng khc + Hi chng thiu mu + Phi c hi chng 3 gim. + Tim c th c ting thi c nng,hoc ting tim m,kh th nh + Bng c th c c trng + Mt c th c m mt do ph vng mc. III. Cn lm sng + Cng thc mu :hng cu ,hematocrit ,hemoglobin gim. + Chc nng thn:
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+ Mu : Ure,creatinin,acid uric tng. + Nc tiu: tr hng cu, tr bch cu, protein niu cao. + Chc nng gan: + Men gan SGOT,SGPT,phn ng Gross-Maclagan + nh lng protein mu gim,albumin mu gim + Soi y mt; ph gai th ,xut huyt vng mc. + Siu m nh gi tnh trng thai,phn ph ca thai. + Test CT,test NST,ch s sinh hc khi c thai, nh gi xem tnh trng thai suy yu mc no, c kh nng sng trong khng kh cha. IV. Chn on 1) Chn on xc nh: + Da vo lm sng nht 1 trong 3 triu chng tng huyt p,ph ,protein niu.v cn lm sng trn. 2) Chn on phn bit: a) Tng huyt p mn tnh/bnh nhn c thai. + Cao huyt p c t trc khi c thai hoc tng trc 20 tun tui thai . + Nu c acid Uric tng ln khi c thai th phi ngh n tin sn git . + Nu khi c thai km theo protein niu l tin sn git thm vo th tin lng xu cho c m v con. b) Bnh l thn mn v thai nghn. + Protein niu c trc khi c thai,tn ti dai dng.Bnh thn nng ln khi c thai. c) Ph : + Do cc bnh l khc nh ph do chn p,ph tim ,ph thn,ph dinh dng. V. X tr 1) Mc tiu diu tr a) i vi m + Ngn cn s tin trin ca bnh + Ci thin tnh trng bnh + Gim bin chng + Trnh t vong cho m. b) i vi con + m bo s pht trin ca thai + Hn ch nguy c suy dinh dng thai,thai cht lu + Gim t l mc bnh v t vong chu sn 2) Phng chm iu tr + Bo v m l chnh + C chiu c n con + Ngun gc ca bnh l thai + Cn nhc dng thuc
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3) iu dng chung + Ngh ngi ti ging, m,nm nghing tri,to cm gic yn tm,tin tng vo y hc cho bnh nhn + Ch n: Hn ch mui,tng m. + Ung: Nc ,khng c mui 1,5-2l/ngy + Theo di , nh gi 2 tun /1 ln nu cc du hiu khng tin trin hoc tr li bnh thng v lm sng v cn lm sng + Lm sng + Ton trng m,tnh trng thai + Cn nng + Bilan dch + s lng nc tiu + huyt p + 1 s triu chng khc nh m mt,tim ,phi. + Cn lm sng + Protein niu + Siu m thai + chc nng gan,thn,cng thc mu + t vn cho gia nh v s nguy him ca tin sn git v sn git . 4) iu tr a) Thai cha thng(< 37 tun) + i vi huyt p: Khng ch huyt p,khng tng v cng khng gim. + Thuc iu tr: Alpha methyldopa(Aldomet,Dopegyt)vin 250mg.Liu ti a khng qu 3g/24 gi. + Tc dng ph tt huyt p t th ng + Hydralazin vin 10mg, 25 mg,50mg + ti da 300mg/ngy + tc dng ph bun nn,nn,chn n,nhc u + Nifedipin 5-10 mg/24 gi (Ngm di li) + Khng dng chn bta giao cm + MgSO4 15% liu 3-4 g/ngy chia 2 ln tim tnh mch chm.Pha 4gMgSO415%/200ml glucose 5% truyn nh git tnh mch X git /pht. + Li tiu: Lasix km KCl khi lng nc tiu< 800ml?24 gi)Ch khng nn dng ko di. + Nu ph do gim p lc keo th tng n m,truyn m + Hn ch n mui + Khng sinh beta lctm phng nhim khun + B xung Ca gim bin chng sn git
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+ An thn: Seduxen 5mg + Yu t vi lng B6,MgB6 + Nu tnh trng thai cha trng thnh th dng corticoid(Dexamethason) + nh gi kt qu iu tr + Nu c p ng iu tr th gic thai n thng + Cc yu t tin lng cuc tt,ch s Bishop thun li gy chuyn d ( Bm i, truyn oxytocin) + Ch s Bishop khng thun li m ly thai ,khng nn thai nghn qu ngy sinh + Nu khng p ng vi iu tr th nh ch thai nghn ngay. b) Thai thng (> 37 tun) + Nu c t cung m th bm i gy chuyn d + Nu c t cung cha m,c th gy chuyn d(truyn oxytocin,bm i) hoc m ly thai. + Sau + M tip tc theo di chy mu,nhim khun,tin sn git ,sn git + Con : m bo h hp,gi m.Nu mt mu c th truyn mu 15-20 ml mu. + Phng bnh + iu tr cc bnh mn tnh n nh trc khi c thai + Qun l thai nghn ti y t c s tt. Cu 3 :Tin sn git nng, chn on v x tr . I. i cng: + Tin sn git l giai on xy ra trc khi ln cn sn git. + Giai on tin sn git c th ko di vi ngy ,vi gi,vi tu hoc ch thong qua tu theo mc nng nh ca bnh. Tin sn git c chn on v x tr kp thi c th phng nga c cn git,trnh nguy c e do tnh mng cho m v cho con + Tin sn git xy ra khong 5-10% trong thai nghn Cc yu t thun li: + Con so m ln tui + Ma lnh m + a thai, a i + Cha trng + Thai nghn km i tho ng ,bnh mn tnh, tng huyt p mn , bo ph. II. Triu chng lm sng + Cc triu chng tin sn git ko di v nguy kch hn
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1) Tng huyt p: + T ng huyt p trn 160/110 mmHg. o t nht hai ln cch nhau 4- 6 h 2) Ph : + Tng cn > 2kg /tun.ph ton bng 3) Protein niu + Protein niu> 5 g/l,cng cao bnh cng nng 4) Cc triu chng khc + Tiu t hoc v niu,nc tiu< 400ml/24 h + Th lc nhn m + Tim : Ting thi tm thu c nng,ting tim m + Phi c hi chng 3 gim + Bng c c trng t do + Hi chng thiu mu + C thm cc du hiu khc : + Du hiu thn kinh: Hoa mt ,chng mt,s nh sng. au u tng,dng thuc gim au ko ,tinh thn l ,th vi ngoi cnh,tng phn x + Du hiu tiu ho: au bng vng h sn phi,hoc vng thng v,Bun nn,nn + Du hiu th gic:Nhn m,th lc gim t t hoc gim t ngt III. Cn lm sng + Cng thc mu : hng cu ,hematocrit ,hemoglobin gim. bch cu ,tiu cu gim + Ho sinh mu:Protein mu gim + Chc nng thn: + Mu : Ure,creatinin,acid uric tng. + Nc tiu: tr hng cu, tr bch cu, protein niu cao. + Chc nng gan: + Men gan SGOT,SGPT,phn ng Gross-Maclagan + nh lng protein mu gim,albumin mu gim + Soi y mt; ph gai th ,xut huyt vng mc. + Siu m nh gi tnh trng thai,phn ph ca thai. + Test CT,test NST,ch s sinh hc khi c thai, nh gi xem tnh trng thai suy yu mc no, c kh nng sng trong khng kh cha. IV. Bin chng + Suy tim + Ph phi + Thai chm pht trin,thiu i + Sn git
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+ Nu c 1 trog cc bin chng trn th cho d cc triu chng chnh nh tng huyt p ,ph, protein niu c nh vn coi l tin sn git nng V. Chn on 1) Chn on xc nh: + Da vo lm sng v cn lm sng 2) Chn on hi chng Hellp + Tan mu: Vt m trn tiu bn mu,Billirubin ton phn tng > 1,2mg/dl + Men gan SGOT tng > 70UI/l + LDH>600Ui/l + Tiu cu gim <100.000 3) Chn on phn bit a) Du hiu v mt vi cc bnh mt khi c thai + nh lng protein niu, o huyt p chn on phn bit + Hoc khm chuyn khoa mt nu cn b)Du hiu tiu ho vi bnh l d dy,ti mt + au bng trong tin sn git khng lin quan n ba n, au tng ln khi huyt p tng + Bnh nhn c tin s vim lot d dy t trng hoc si mt vim ti mt c) Du hiu tng men gan vi bnh vim gan mn tnh khi c thai hoc thoi ho m + Vim gan do virus thng km theo vng da, tiu sm mu,men gan tng rt cao, Marker virus dng tnh d)Du hiu thn kinh vi bnh l thn kinh + nh lng protein v o huyt p chn on phn bit e) Du hiu suy tim ph phi cp khi c thai + Tin s bnh tim mch + Protein niu m tnh + Siu m tim c tn thng van tim VI. X tr 1) Mc tiu + Ngn nga cn sn git + Cu m l chnh c chiu c ti con + Nu p ng vi iu tr ,thai non thng gi thai n thng + Nu ko p ng nh ch thai nghn ngay 2) iu dng + Ngh ngi ti ging, m,nm nghing tri,to cm gic yn tm,tin tng vo y hc cho bnh nhn + Ch n: Hn ch mui,tng m.
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+ Ung: Nc ,khng c mui 1,5-2l/ngy + Theo di , nh gi 2 tun /1 ln nu cc du hiu khng tin trin hoc tr li bnh thng v lm sng v cn lm sng a) Lm sng + Ton trng m,tnh trng thai + Cn nng + Bilan dch + s lng nc tiu + huyt p + 1 s triu chng khc nh m mt,tim ,phi. b)Cn lm sng + Protein niu + Siu m thai + chc nng gan,thn,cng thc mu + t vn cho gia nh v s nguy him ca tin sn git v sn git . 3) iu tr + Ngn nga cn sn git v chng sn git + MgSO4 15% liu 3-4 g/ngy chia 2 ln tim tnh mch chm.hoc Pha 4gMgSO415%/200ml glucose 5% truyn nh git tnh mch X git /pht. + H huyt p tm trng xung di 100mmHg + + Thuc iu tr: Alpha methyldopa(Aldomet,Dopegyt)vin 250mg.Liu ti a khng qu 3g/24 gi. + Tc dng ph tt huyt p t th ng + Hydralazin 5mg tim tnh mch chm,nu ko h c th tim bp nhc li(ti a 20 mg) + tc dng ph bun nn,nn,chn n,nhc u + Nifedipin 5-10 mg/24 gi (Ngm di li) + Khng dng chn bta giao cm + Li tiu: Lasix km KCl khi lng nc tiu< 800ml?24 gi)Ch khng nn dng ko di. + B xung Ca gim bin chng sn git + An thn: Seduxen 5mg + Yu t vi lng B6,MgB6 + Nu ph do gim p lc keo th tng n m,truyn m + Hn ch n mui + Khng sinh beta lactam phng nhim khun + Nu tnh trng thai cha trng thnh th dng corticoid(Dexamethason)
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+ Nu p ng vi iu tr c th gi thai n thng + Nu ko p ng vi iu tr sau 3-5 ngy nh ch thai nghen ngay lp tc 4) Sn khoa a) Thai cha thng + iu tr ni tch cc ,theo di cht ch lm sng v cn lm sng .Nu p ng iu tr th gi thai n thng + Nu ko p ng th nh ch thai nghn. b)Thai thng + nh gi ch s Bishop nu thun li,thai ngi chm th gy chuyn d bng bp i v truyn oxytocin,cho bng forceps + Nu cc yu t tin lng cuc ko thun li th m ly thai + ang chuyn d + Thai ngi chm,cc yu t tin lng cuc thun li thi khi ct t cung m 4cm bm i t forceps ly thai + Khng thun li th m ly thai + Ch nh m ly thai khi: + iu tr tch cc ni m ko p ng + Ko iu kin ng di + Chuyn d ko di , c t cung m chm + Sau + Hi sc s sinh tt + Tip tc iu tr ni cho m + Theo di tin sn git,sn git,cc bin chng Cu 4 Sn git lm sng v x tr I. i cng + Sn git l bin chng ca tin sn git biu hin bng nhng cn co gitqua 4 giai on c th gy t vong cho m v con II. Triu chng lm sng + Trn c s ca tin sn git nng hoc xut hin cn git t ngt qua 4 giai on 1) Giai on thm nhim + Ko di 30-60 giy + C vng u mt c b kch thch, co git lin tc ko i xng + Nt mt nhn nhm,sc mt thay i + Li th ra tht vo + Mi mt nhp nhy,nhn cu o i o li ri lch sang mt bn + C c co git lin tip, u lc l,ng vo sang mt bn (cng pha vi mt b ko lch)
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+ Cc tuyn nc bt nc mt tng tit + Co git lan xung hai tay,ngn tay dm chm li chuyn sang giai on sau 2) Giai on git cng + Ko di khong 30 giy + Ton b c trong c th b co cng + Lng n cong + Tay chn n cong + u ng vo sang mt bn + Mt trng d,nhn cu trn ngc, ng t co nh + Hai hm rng cn cht + Ming si bt mp + C h hp co tht lm bnh nhn ngt th 3) Giai on git gin cch + Ko di 3-5 pht ,cng ko di cng nng + Trong giai on git cng,cc c h hp b co tht nn thiu oxy c ton thn gin ra trong chc lt,bnh nhn ht vo mt hi di tnh trng ngt th chm dt + Tip cc c li b kch ng co git lin tip khng u + Bnh nhn c ng lung tung, u nga ra saunt mt nhn nhmnhn cu o,li th ra tht vo + 2 tay co git ko ng u nh ngi nh trng + 2 chn hay co p , dy da nn d ng + Thn mnh n cong + C h hp lc co lc gin lm nhp th khng u,th rt ln,si bt mpdo tng tit nc btlm ting th lc sc v d b ngt th + Cc cn tha nh dn v bnh nhn ri vo tnh trng hn m 4) Giai on hn m + Nh hay nng tu thuc vo cn git + Hn m nh + Sau khi cn git nh, ngn, tha xy ra + Bnh nhn m man,ng ngc khong 5-7 pht ri tnh li + Bnh nhn thy bng hong,hong s nh va xy ra cn c mng + Hn m su + Sau cn git di ,nng + Mt tri gic,mt phn x(gic mc, ng t)C khi ch cn phn x nut + Bnh nhn a i dm d,kh th,ngy tc ting lc sc trong c hng do dch + Mt sng ph Hanoi Medical University LTL 75
+ Cn hn m ko di vi gi,vi ngy.Trong cn c th xut hin cn co git khc(bnh nhn c th c bin chng v t vng trong cn hn m III. Cn lm sng + Cng thc mu hng cu hematocrit hemoglobin ,bch cu ,tiu cu gim + Chc nng gan: SGOT,SGPT LDH tng cao ,t mu di bao + chc nng thn + Thiu niu hoc v niu + Protein niu cao > 5g/l + Ure, creatinin ,acid uric tng cao + Soi y mt: Xut huyt vng mc,ph gai th + No : in no bt thng trong vng 48 gi ca cn git, thng ph no + CT,MRI thiu mu no khi tr,xut huyt no + Siu m suy thai, thiu i, thai km pht trin trong t cung IV. Chn on 1) Chn on xc nh: + Da vo lm sng cn lm sng 2) Chn on phn bit a)Cn ng kinh + Tin s c cn ng kinh trc khi c thai + Khng bit trc khi ln cn + Khng c tin sn git + Khng hn m b)Cn tetani + C th c tin s thiu Ca + Cn co git xut hin t ngt hoc c du hiu bo trc: Tng thn nhit, au bng,cm gic nh b tay chn + Du hiu Trousseau,du hiu Chvostek,tng phn x + Khng hn m + Tim Ca ht triu chng ngay c)Hn m do i tho ng + Hn m vt v kch thch,mch nhanh,th kiu kussmaul,hi th mi aceton, ng t gin,thn nhit gim + ng mu tng cao d)Hysteria/C thai + Khng mt phn x,khng mt tri gic,mi ngi xung quanh ni vn bit + S biu hin cc cn git khng ging nhau e)Hn m do xut huyt no mng no
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+ Bnh nhn c tin s tng huyt p,khi c thai tng huyt p cao nn gy ra xut huyt no nhng khng c protein niu + Dch no tu c mu hng + Lit ngi + CT scanner chy mu no f) Hn m gan + Tin s bnh gan + Triu chng bnh gan: Gan to,vng da,tiu sm mu,c trng,Men gan tng cao,bilirubin tng cao g)Hn m do thn + Tin s c bnh thn + Hn m th nhanh, mi aceton, thiu niu hoc v niu + Ure,creatinin,acid uric tng cao + Siu m c th thy bnh l ca thn V. X tr 1) iu dng a)Chm sc + Nm ging c vn ngn,buc gi tay chn trnh ng + Ngng ming phng cn vo li + Nm nghing tri, m + Ht m di,t y qua cn + Sonde tiu, theo di lng nc tiu + Chng lot,chng bi nhim ngf h hp,tit niu b)Dinh dng + n lng,tng m,hn ch mui + Ung nc c)Theo di v nh gi + Lm sng cn sn git ,du hiu lm sng ,bin chng + Cn lm sng lm 2 ln /tun + Mu: hng cu ,bch cu ,tiu cu ,protein mu,men gan,acid uric,creatinin, ure + Nc tiu: nh lng protein niu/24 gi.Tm hng cu ,bch cu ,tr niu 2) iu tr ni khoa a)Chng cn sn git Dng MgSO4 + Truyn tnh mch 4g MgSO4 20% vi tc di 1g/pht + Sau tip tc dng 10gMgSO4 50% theo cch sau: Dng 5 g MgSO4 20% + 1ml lidocain 2% tim mng su. + Nu cn sn git cn sau 15 pht tim thm 2 g dung dch20% vo tnh mch vi tc <1g/pht.Nu bnh nhn to ln c th tim 4 g tinh mch chm
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+ Sau c 4 ting tim 5 g dung dch50% vo mng nhng phi m bo :Cn phn x u gi + Khng b suy h hp + o c lng nc tiu>100ml/4 gi + Tim MgSO4 khng lin tc sau Kt hp vi tim valium 10mg: + tim tnh mch,tim bp chng co git.Nu khng khng ch c cn git th tim ngay 2 ng seduxen tnh mch. + Nu cc triu chng nh i hockhng ct c cn git th gia 2 cn phi nh ch thai nghn ngay( M ly thai) b)Khng ch huyt p + Trong tng huyt p nng cn phi h huyt p tm trng xung cn 90-100mmHg.Trnh h huyt p thp qu nh hng n tun hon t cung rau + Hydralazin 5mg tim tnh mch chm cho ti khi huyt p h theo mong mun,nu khng h c th tim bp nhc li(ti a 20mg) + C th phi hp vi cc thuc khc nh nifedipin 10 mg ngm di li hoc alpha methyldopa 250 mg c)Li tiu + Dng lasix 20mg khi lng nc tiu < 800ml/24 gi.Dng km theo KCl. + Ch khng s dng ko di do nh hng n tun hon t cung rau d)Chng nhim khun + Cho khng sinh nhm beta lactam + Chng thiu oxy: Cho bnh nhn th oxy qua sonde mi,lin tc hoc ngt qung e)An thn seduxen 5mg f) Tr tim nu cu: Uabain,hoc digoxin g)Vi lng B6,MgB6 3) Sn khoa a)Cha chuyn d: + iu tr sn git n nh bng ni khoa,sau nh ch thai nghn ngay b)ang chuyn d: + Khng ch cn git n nh + M ly thai l tt nht hoc forceps c)Hu sn + Tip tc iu tr ni khoa bng MgSO4 duy tr sau 24 gi,hoc sau cn git cui cng tc truyn rt chm 3g/1gi,cho n khi lng nc tiu 100ml/24 gi,tng huyt p
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+ Chm sc s sinh tt,hi sc tch cc(th oxy,gi m,truyn mu nu cn) + iu dng tt: Phng bi nhim,chng lot
Ung th nim mc t cung

Cu 1: Ung th nim mc t cung: chn on v x tr I. i cng + Ung th nim mc t cung l khi u c tnhpht trin t nim mc t cung l lai ung th chu tc ng ca ni tit,hay gp ph n mn kinh + Ung th nim mc t cung c lin quan n mt s yu t nh: tui,cng estrogen,bo ph, i ng,tng huyt p hay iu tr hormon thay th sau mn kinh + i b phn ung th nim mc t cung l ung th biu m tuyn,ngoi ra cn gp ung th t bo snohy ung th bp dp gai khng bit ho II. Triu chng lm sng 1) Triu chng c nng + Thng gp ph n mn kinh. Triu chng thng ngho nn ,nht l trong giai on sm. + Ra mu m o + Bnh nhn mn kinh: + Ra mu m o t nhin hay do kch thch + Ra t mt tng t hay lin tc + Lc u ra t v sau cng ngy cng nhiu + ngi cha mn kinh + Ra huyt gia chu k kinh + Kh h m o + Lc u c th l dch trong + Sau th kh h ln mu m,rt nng mi,mu nu en + au bng vng h v,lc u au nh do cn co t cung y dch mu m ra ngoi,v sau khi t bo ung th lan trn tiu khung gy chn p th au lin tc, au nhiu 2) Triu chng ton thn + Mt mi,gy st,giai on munth suy kit
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+ Hi chng thiu mu + C th c st nh hoc st lin tc,st cao do m trong bung t cung 3) Triu chng thc th + t m vt hay van m o thy mu ra t t cung m khng thy tn thng c t cung + Thm m o bng tay kt hp nn bng thy: + Giai on sm c th khng thy g c bit + Giai on sau c th thy + T cung to hn bnh thng,khng ging nh t cung ca ngi mn kinh + T cung di ng nhiu hay t, au hay khng ph thuc vo giai on ung th + Hai phn ph,c t cung cha thy g c bit nu nh cha c di cn xm ln + Ngoi ra c th pht hin di cn thnh m o,c t cung ,phn ph nu giai on mun + C th thy di cn cc tng khc nh bng,phi III. Cn lm sng + Phin m ,c t cung :Thng m tnh dng loi tr ung th c t cung + Phin t bo ni mc t cung + Bnh phm l dch ht t bung t cung + Gi tr: C gi tr khi kt qu dng tnh,nhng c m tnh gi cao6-25% + Khng c lm khi c nhim khun,dnh c t cung + Siu m u d m o: tn thng in hnh l + Nim mc t cung dy>8mm + C th chy mu,hnh nh qu sn ni mc t cung + m vang khng ng nht,b mt ni mc t cung c hnh nh rng ca + Chp bung t cung c bm thuc cn quang + iu kin: Khng c nhim trng,chy mu + Hnh nh khuyt khng ng u,b rng ca, cn quang khng ng nht + nh gi c s lan to ca ung th + C gi tr chn on v nh vng sinh thit + Soi bung t cung + Nhn c vng tn thng + Xc nh c s lan to ca ung th + Cho bit hng ng v tr sinh thit + Sinh thit nim mc t cung + L xt nghim c gi tr chn on xc nh
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+ Trn tn thng nghi ng khi soi bung t cung + Trn tn thng nghi ng khi soi bung t cung .Nu thy t bo ung th th chn on xc nh.Nu m tnh th cha loi tr c cn phi kim tra li IV. Chn on 1) Chn on xc nh + Lm sng cn lm sng c bit l sinh thit nim mc t cung . ngi mn kinh th chn on thng d hn 2) Chn on giai on lm sng Da vo s lan trn ca bnh ,s c hay khng t bo ung th ng c t cung + Giai on 0 : ung th trong biu m + Giai on I: ung th khu tr bung t cung Ia: Bung t cung 8cm Ib: Bung t cung 8cm + Giai on II: ung th xm ln vo thn t cung ,c t cung nhng cha vt qu t cung + Giai on III ung th xm ln ra khi t cung nhng vn cn khu tr tiu khung + Giai on IV: xm ln vo bng quang, trc trng, v cc c quan khc. + IVa : Xm ln bng quang, trc trng + Ivb: Xm ln cc c quan khc Phn loi ung th theo FIGO + Giai on I Khu tr t cung Ia: Khi u gii hn nim mc t cung Ib: Xm nhp < chiu dy c t cung Ic: Khi u xm nhp > chiu dy c t cung + Giai on II Ung th lan xung c t cung IIa Khi u xm nhp vo nim mc ng c t cung IIb: Khi u xm nhp t chc m c t cung + Giai on III: Ung th lan vo tiu khung IIIa : ung th pht trin n phc mc hoc phn ph IIIb: ung th di cn m o IIIc Di cn hch chu + Giai on IV :Di cn xa,di dn ngoi bng 3) Chn on phn bit U x t cung,polyp t cung Ging: + Ra huyt m o + T cung to + Hi chng thiu mu Khc : + Thng khng au bng
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+ T cung to chc + Siu m v sinh thit chn on phn bit Ung th c t cung Ging: + Ra mu m o t nhin hay sau sang chn + Giai on mun c th au,thiu mu suy kit Khc : + t m vt hoc van m o th thy c tn thng c t cung,chm vo d chy mu + Phin m o c t cung dng tnh + Sinh thit v soi bung t cung chn on phn bit Ung th nguyn bo nui Ging : + Ra huyt m o + T cung to,mm Khc + Khng au bng + Thng tui sinh + Sau cha trng + C th c nhn di cn m o + Nang hong tuyn 1 hoc 2 bn + hCG tng rt cao vim t cung ngi gi Ging + Ra mu m o Khc + Ra mu m o t + Lm phin t bo m o,c t cung lm chn on phn bit + Phin m o,c t cung chn on phn bit + Qu sn nim mc t cung lnh tnh + Da vo sinh thit nim mc t cung chn on phn bit V. X tr 1) Mc ch + Loi b ung th nguyn pht + Hn ch l tiu dit t bo ung th di cn 2) Phng php iu tr a) Phu thut: + L phng php c bn nhng tu thuc vo th trng bnh nhn v giai on ung th + Ct t cung hon ton v hai phn ph
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+ ct t cung hon ton v 2 phn ph v ct 1 phn m o v vt hch trong trng hp ung th lan xung eo v c t cung b) Tia x + Tia x ti ch( mm m o)bng Radium + Tia x tiu khung bng Cobalt khi di cn hch c) Hormon liu php + Hiu qu cn ang tho lun nhng c ch nh lm gim cc triu chng lm sng + Dng Progesteron liu cao : Medroxyprogesteron 500mg dng 1000mg /tun d) Ho cht + t dng + Ch dng vi ung th c di cn xa + 5FU (Fluouracin) 3) iu tr c th: Tu thuc vo giai on Giai on I: + Ct t cung hon ton v 2 phn ph + Kim tra hch,nu c hch th no vt hch v tia x nu c lan vo lp c t cung Giai on II + Phi hp tia x v ct t cung rng(ct t cung hon ton v 2 phn ph 1 phn m o v no vt hch) + Nu c xm nhpc t cung th phi hp vi x tr ti ch hoc tiu khung v ct t cung rng. Giai on III: + Hoc khi ung th xm ln > chiu dy c t cung th ct t cung v tia x tiu khung Giai on IV: + Hormon v ho cht VI. Tin lng v d phng 1) Tin lng: + Tui:T l cht v ti pht tng theo tui + Giai on ung th : Cn sng trn 5nm 90% giai on I; 3% giai on II + S bit ho t chc : T bo bit ho ( ung th tuyn ni mc) tin lng tt hn t bo km bit ho ( ung th t bo sng) + Mc lan trn ca ung th: Cng lan rng th tin lng cng ti 2) D phng + Loi b cc yu t nguy c : i tho ng,tng huyt p,bo ph
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+ Thn trng khi dng estrogen,hormon thay th + Khm ph khoa c bit l ph n mn kinh + Khm nh k + Khm sm khi c bt thng + Theo di ph n mn kinh: Siu m u d m o + Trnh s dng thuc cha estrogen + iu tr bng progestatif cho ph n qu sn nim mc t cung trong 6 thng nu khng phi phu thut + iu tr hormon thay th sau mn kinh duy tr chiu dy nim mc t cung < 8mm + Test Progestatif cho ph n c nguy c cao + Test dng tnh :sau dng thuc 8 ngy bnh nhn xut hin chy mu cn lm thm xt nghim chn on xc nh + Test m tnh : Sau dng thuc 8 ngy khng c chy mu.
Ung th c t cung
Cu 1: Ung th c t cung cch pht hin sm v x tr! I. i cng: + L khi u c tnh xut pht t t bo biu m c t cung! + L loi ung th ng th 2 sau ung th v ph n.Bnh c th gp mi la tui nhng hay gp 35-45 tui. + Bnh lin quan n yu t thun li: Quan h tnh dc nhiu ngi hay quan h sm,nhim virus HPV, iu kin kinh t thp,nhim khun ph khoa,hay ht thuc l! II. Cch pht hin ung th c t cung sm 1) Ph n c biu hin lm sng bt thng! + Ra mu t nhin sau giao hp hoc sau thm khm + Kh h bn,mu en,ln m + au m ct sng tht lng,h v + Ch n cc i tng nguy c cao! + Nhiu bn tnh + Quan h tnh dc sm, sm! + Ht thuc l + i sng kh khn + iu kin v sinh km,vim nhim ng sinh dc sm(c bit l do nhim virus HPV) + Tn thng m o,c t cung ( Lon sn tuyn,l tuyn)
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+ Tuyn truyn gio dc cho ph n thy c vai tr quan trng ca khm ph khoa nh k h t nguyn i khm,pht hin sm cc tn thng v vim nhim ng sinh dc iu tr kp thi + Sinh c k hoch 2) Lm phin m o c t cung + Da vo nhng thay i v hnh dng t bo,nguyn sinh cht t bo ,nhn t bo , nh gi mc t bo v nh gi kh nng c tnh ca t bo .Nu thay i cng nhiu th kh nng c tnh cng cao! Cch nh gi phn loi t bo theo Papanicolaou (1943) + Loi I: T bo bnh thng + Loi II: Cc t bo c s thay i bt thng v cu trc nhng khng phi c tnh + Loi III: t bo bt thng nhn,nguyn sinh cht nhng cha biu hin r rng ca c tnh! + Loi IV: C t t bo ung th + Loi V: C nhiu t bo ung th Theo mc lon sn + Lon sn nh = CIN1 t bo bt thng 1/3 lp di biu m + Lon sn va = CIN2 t bo bt thng n 2/3 lp di biu m + Lon sn nng = CIN3 tn thng ln hn 2/3 lp di biu m + Lon sn nng tng t ung th trong biu m ( v mt tnh cht) + Nh vy loi 3 cn lm li phin gip chn on + Bt u lm phin m o c t cung t nm 25 tui( ngi c chng) + Nu kt qu bnh thng cn lm li 3 nm /1 ln 3) Soi c t cung + Rt c ch trong vic xc nh v trtn thng bm sinh thit -c bit ch vng ranh gii gia biu m lt v biu m tr n! + Tm cc tn thng nghi ng: + Vng tn thng si nh hoa l,chm vo d chy mu + Vt lot,vt trng ,d chy mu + Vng thm nhim cng + C lt ,sng ho,chm y,c t mu bt thng + Test schiller khng bt mu + Thng lm khi P III tr ln hay CIN 2 tr ln + Nu c nghi ng, soi c t cung 6 thng /ln hay khi c triu chng bt thng.
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4) Sinh thit c t cung + L phng php chn on chn on xc nh + L mt trong 3 phng php tt pht hin sng lc ung th c t cung giai on sm! + Ch nh sinh thit : Khi phin m o c t cung c t bo bt thng + V tr sinh thit + Ni c tn thng khi soi c t cung + Nu khng thy tn thng: No ng c t cung chn on + Kt qu sinh thit: Ph thuc vo s mt phn cc,d g ca t bo v mc xm ln ca t bo bt thng: CIN1,CIN2,CIN3,ung th ti ch(t bo ung th cha ph v mng y,t chc m cha b xm ln),ung th xm ln(khi t bo ung th ph hu mng y,pht trin xm ln vo m m 5) Khot chp,ct ct on c t cung + L phng php va chn on va iu tr + Ch nh: Khi lm t bo c t cung v sinh thit cho kt qu khc nhau + Sinh thit tng lp chn on xc nh ung th trong biu m hay xm ln, lm gii phu bnh III. X tr + Trong qu trnh tm v pht hin sm ung th c t cung , tu tn thng m c nhng thi x tr thch hp + Nu l tn thng vim nhim cn iu tr tnh trng vim nhim + Hn ch cc yu t nguy c + Vi cc tn thng lon sn + iu tr ngay khi c chn on + C th p dng cc phng php sau: 1) p lnh t in 2) t laser c t cung + Khot chp,ct ct c t cung + Khi pht hin ung th giai on sm + Giai on 0 : ung th trong biu m + Bnh nhn cn tr(<35 tui)cha c con 3) Khot chp ct ct c t cung , p lnh,laser + Sau theo di cht ch bng t bo hc 3 thng/ln,soi c t cung c thi x tr kp thi + Nu bnh nhn ln tui, con + Ct t cung hon ton , li 2 phn ph hoc ct 2 phn ph tu thuc vo tui ca bnh nhn + Giai on Ia:
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+ ung th xm ln tim tng ( t bo ung th cha ph v mng y).Ct t cung hon ton, li hoc ct 2 phn ph tu thuc vo tui v tnh trng ca bnh nhn + Giai on Ib v giai oan II: + Ch yu phu thut,c th b xung tia x trc v sau phu thut + Phu thut Weitheim ct t cung hon ton v 2 phn ph + Ct 1/3 phn trn m o + Ct t chc lin kt di 2 dy chng rng + No vt hch trong h chu,dc 2 niu qun 4) Tia x trc v sau phu thut + t Radium vo c t cung m o + Tia x Cobalt vo h v + Cc Giai on III,IV khng c ch nh phu thut,ch tia x n thun v iu tr triu chng + Cc trng hp sau phu thut: Lm li gi phu bnh c thi x tr tip. 5) Theo di bnh nhn st: + Ung th giai on 0: + Xt nghim phin m o c t cung 3 thng /1 ln trong 2 nm u.V lm 1nm/1 ln cc nm sau. + Trong cc trng hp ung th xm ln khi phu thut cn : Theo di lm sng( ton trng, m h , m o,gan,hch) + Theo di cn lm sng : T bo hc,siu m gan, thn,xquang phi: Nm u tin 3 thng /ln.Nm th 2,3 th 6 thng /ln.Cc nm sau 1 nm /1ln Cu 2:Chn on phn bit cc giai on ca ung th c t cung v x tr! I. i cng: + L khi u c tnh xut pht t t bo biu m c t cung! + L loi ung th ng th 2 sau ung th v ph n.Bnh c th gp mi la tui nhng hay gp 35-45 tui. + Bnh lin quan n yu t thun li: Quan h tnh dc nhiu ngi hay quan h sm,nhim virus HPV, iu kin kinh t thp,nhim khun ph khoa,hay ht thuc l! Da vo gi phu bnh ngi ta chia lm 2 loi ln: + Ung th trong biu m : L tn thng c tnh cht v t chc v t bo hc ging ung th nhng ch khu tr biu m b mt hay trong c t cung ,khng ph hu n lp m, mng y cn nguyn vn
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+ Ung th xm ln: Khi t bo ung th xm ln ,ph hu mng y ,xm ln lp m A.
Ung th trong biu m
+ Hay gp ph n tui 35-45 + Hu nh khng c biu hin lm sng, thng c pht hin khi bnh nhn n khm ph khoa nh k v lm phin m o c t cung II. Triu chng: 1) Triu chng c nng + Ra mu bt thng hay sau khi giao hp + Ra kh h nhiu,hi + Triu chng ton thn + Hu nh khng c bt thng. 2) Triu chng thc th + Thm khm lm sng hu nh khng thy g c bit + t m vt thy c t cung b tn thng khng c hiu ca biu m ,b tn thng r, tn thng khng bt mu Lugol III. Cn lm sng chn on xc nh + Xt nghim t bo hc + Lm phin m o c t cung c gi tr chn on sm: + Thy t bo ung th hay nghi ng t bo ung th (P III,P IV) + Soi c t cung :Nu thy t bo bt thng phi soi c t cung ,pht hin nhng tn thng nh lt ,vt lot,chm y + Xc nh v tr sinh thit + Test Schiller: Khng bt mu + Sinh thit c t cung v cc v tr tn thng nghi ng chn on xc nh + Sau khi pht hin tn thng cn sinh thit su vo lp m xc nh c phi l ung th khng, xm ln hay cha.; + Nu khng thy tn thng mt ngoi cn phi no ng c t cung IV. Chn on 1) Chn on xc nh + Da vo phin m o-c t cung v sinh thit c t cung cc tn thng nghi ng
B .Ung th xm ln
+ Thng gp ph n 45-55 tui I. Phn loi lm sng theo FIGO
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Giai on 0: Ung th trong biu m Giai on I : Ung th khu tr c t cung IA :Ung th xm ln tin lm sng,chn on da vo knh hin vi IA1 : Xm ln vi th vo lp m IA2 :Tn thng xm ln khng ln qu 5 mm tnh t lp y biu m hoc pht trin ngang khng qu 7 mm IB: Tn thng ln hn IA2 v c th nhn thy trn lm sng + Giai on II:Ung th vt qua khi c t cung nhng cha ti thnh chu hng,cha ti 1/3 di m o. IIA : Ung th cha xm ln vo dy chng rng IIB : Ung th xm ln vo dy chng rng gy ti cng hp + Giai on III:Ung th lan ti thnh chu hng , ti di m o gy nc thn hoc mt chc nng thn IIIA : Ung th lan ti thnh chu hng v 1/3 di m o IIIB: Ung th lan ti thnh chu hng gy nc thn hoc mt chc nng thn + Giai on IV: Ung th vt ra ngoi tiu khung ,di cn bng quang trc trng IVA: Ung th di cn ti bng quang trc trng IVB: Ung th di cn ti c quan khc II. Triu chng lm sng 1) Triu chng c nng + Ra mu m o ko di gia k kinh ,sau giao hp,sau thm khm + Kh h ln mu ,m ,hi + au vng tht lng ,xng ct ,h v hay hai h chu khi ung th giai on tin trin v mun 2) Triu chng ton thn + Th trng yu ,st cn,thiu mu giai on mun 3) Triu chng thc th + t m vt: Thy tn thng c t cung l lot si nh hoa l,thm nhim,chm vo chy mu + Thm m o : C t cung cng ,nn tn thng rn,cng hp,t cung di ng km + Thm trc trng: nh gi mc thm nhim ca ung th , di ng ca t cung,bng quang,trc trng III. Cn lm sng + Xt nghim t bo hc: Phin m o c t cung thy t bo loi P IV,PV c th c m tnh gi v vy cn lm li nhiu ln nu c nghi ng.
+ +
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+ Soi c t cung + Xc nh v tr tn thng,v tr sinh thit, c bit vng ranh gii gia biu m lt tng v biu m tr + Cn sinh thit vo v tr tn thng c t cung chn on xc nh + No ng c t cung khi c nghi ng c tn thng trong ng c t cung hoc khi thy c t bo bt thng nhng khng thy tn thng ngoi c t cung + Khot chp c t cung + L phng php va l chn on,va l iu tr + Soi c t cung khng thy ht ranh gii bin i + Sau khi bm sinh thit c chn on l ung th xm ln vi th + Khi khng thng nht kt qu gia chn on t bo hc v kt qu sinh thit + Cc xt nghim nh gi s lan trn ca ung th + Chp phi + Chp bch mch + Soi bng quang + Chp thn c chun b(UIV) + CT scanner IV. Chn on 1) Chn on xc nh: + Da vo lm sng,cn lm sng(Xt nghim t bo hc,sinh thit) 2) Chn on phn bit: L tuyn c t cung Khc : + Sau khi bi acid lactic 3%-Lugol soi c t cung s thy r cc tuyn hnh trn ,hnh bu dcchm li nh chm nho + iu tr thuc chng vim s khi Si mo g,lao c t cung,lot c t cung do bnh ly truyn qua ng tnh dc nh h cam,giang mai,do di cn ung th nguyn bo nui: + Cn lm t bo hc v sinh thit chn on phn bit V. X tr 1) Da vo lm sng,t chc hc vng ung th v tnh trng bnh nhn: Ung th xm ln Giai on 0 : + Ung th trong biu m + Bnh nhn cn tr(<35 tui)cha c con + Khot chp ct ct c t cung , p lnh,laser
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+ Sau theo di cht ch bng t bo hc 3 thng/ln,soi c t cung c thi x tr kp thi + Nu bnh nhn ln tui, con + Ct t cung hon ton , li 2 phn ph hoc ct 2 phn ph tu thuc vo tui ca bnh nhn Giai on Ia: + Ung th xm ln tim tng ( t bo ung th cha ph v mng y).Ct t cung hon ton, li hoc ct 2 phn ph tu thuc vo tui v tnh trng ca bnh nhn Giai on Ib v giai oan II: + Ch yu phu thut,c th b xung tia x trc v sau phu thut + Phu thut Weitheim ct t cung hon ton v 2 phn ph + Ct 1/3 phn trn m o + Ct t chc lin kt di 2 dy chng rng + No vt hch trong h chu,dc 2 niu qun + Tia x trc v sau phu thut + t Radium vo c t cung m o + Tia x Cobalt vo h v Cc Giai on III,IV + khng c ch nh phu thut,ch tia x n thun v iu tr triu chng + Cc trng hp sau phu thut: Lm li gi phu bnh c thi x tr tip. Ung th mm c t cung cn lI + Thng gp ngI gi, t l 0,7-10%. + Bnh nhn sau m ct t cung bn phn khong 10 nm,nu sm hn tin lng xu. + Phu thut kh khn hn v bng quang, rut,dnh vo mm ct. + Tia x cng kh khn hn v t cung b ct do khng t Radium t tia x ngoi. + Tin lng xu hn v t cung b ct,ung th di cn vo bng quang,trc trng nhanh Thai nghn vI ung th c t cung! VI ung th trong biu m + Theo di bnh nhn hng thng + Khng m o m phI m ly thai v iu tr nh trong iu tr ung th trong biu m VI ung th xm ln: + iu tr ch yu l trnh ly thai qua ng m o Trong 3 thng gia + Ct t cung hon ton, vt hch,
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+ Nu khng giai on phu thut c th phI gy sy thai bng thuc.sau tia x. Trong 3 thng cuI: + Khi thai c th sng c + M ly thai ct t cung hon ton,no vt hch tia x + Theo di sau iu tr v tin lng + Theo di bnh nhn st: Ung th giai on 0: + Xt nghim phin m o c t cung 3 thng /1 ln trong 2 nm u.V lm 1nm/1 ln cc nm sau. + Trong cc trng hp ung th xm ln khi phu thut cn : Theo di lm sng( ton trng, m h , m o,gan,hch) + Theo di cn lm sng : T bo hc,siu m gan, thn,xquang phi: Nm u tin 3 thng /ln.Nm th 2,3 th 6 thng /ln.Cc nm sau 1 nm /1ln.
U nang bung trng Cu 1:Cc loI u nang bung trng,chn on v x tr! I. I cng! + U nang bung trng l loI u lnh tnh,l loI u c v bc ngoi,bn trong c cha dch v mt vi loI m no ! + U pht trin t cc thnh phn cu trc ca bung trng,phi thai ca bung trng.Mt khi chn on l u nang bung trng thc th phI m ly uv xt nghim giI phu bnhv nguy c c th gp l bin chng thnh ung th! + U nang bung trng c th gp mI la tuI + U nang bung trng chia lm 2 loI chnh :U nang c nng v u nang thc th! II. U nang c nng
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+ U nang c nng l nhng u m:Sinh ra do rI lon chc phn bung trng,khng c tn thng giI phu,l nhng nang nh,v mng ,cng nc.Ch xy ra nhng ph n cn hnh kinh + Tin trin nhanh v c th mt i sau vi vng kinh 1) Nang bc non! + L trng hp nang DeGraff khng v vo ng ngy quy nh v tip tc ln vI ng knh 3-5 cm.Nang tip tc tit estrogen .Thng th nang c v mng v bn trong c cha dch trong + Hay gp trong trng hp qu sn tuyn nI mc t cung a) Triu chng Lm sng: + Thng khng c triu chng + i khi gp nng bng, chm kinh + au nhiu,rong huyt kh nang xon v + Thm m o c th thy khI u nh,cnh t cung b) Cn lm sng: + Th hCG m tnh chn on phn bit vI cha ngoi t cung + Siu m c gi tr chn on + Trong trng hp kh c th soi bng chn on phn bit c) Chn on xc nh: + Da vo lm sng v cn lm sng d) Chn on phn bit Cha ngoi t cung: + c bit khi nang c du hiu xon, v + Th hCG dng tnh + Cn thit c th siu m,nI soi chn on Nang hong tuyn + Sau no thai trng hay bnh nhn v sinh c iu tr bng hormon hng sinh dc liu cao + Thng khI u to (>10 cm) + hCG rt cao Nang hong th + Ch gp trong thI k c thai,c bit ngI b tin sn git. + hCG dng tnh. + Biu hin ca thai nghn + U nang thc th da vo siu m,tin s ,tnh cht khI u. e) X tr:
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+ Ph thuc vo kch thng,loI nang v triu chng + U nang nh: c th mt i trong vi vng kinh + Ung thuc trnh thai c th ngn nga s hnh thnh v pht trin + Phu thut c t ra khi: nang tn tI trn 3 thng + Nang to ln + C du hiu xon,v nang 2) Nang hong tuyn + Gp bnh nhn cha trng, chorio hay bnh nhn v sinh c iu tr bng hormon hng sinh dc liu cao + U thng ln hn nang bc non( >10cm) + V nang mng, trong cha dch lutein (do hCG tng cao) a) Chn on xc nh da vo: + au vng tiu khung + Khm thy khI u to(>10cm) + Trn bnh nhn cha trng,hay dng hormon hng sinh dc liu cao + hCG tng cao b) Chn on phn bit: Nang bc non: + Nang nh,hCG m tnh, + Nu cn thit c th siu m ,nI soi bng chn on phn bit Nang thc th + Da vo tin s,hCG m tnh,siu m. c) X tr: + iu tr theo nguyn nhn + Phu thut ch t ra khi xon nang ,v nang III. U nang thc th + C tn thng thc th ca t chc bung trng, thng lnh tnh,tuy nhin vn c kh nng tr thnh c tnh U nc U nhy U b TuI Thng tuI MI la tuI,hay gp trung nin tuI sinh Kch Trung bnh To,c th rt Nh hn hai loI kia thc to Cu to Mng,ch c Dy,hai lp t Ging da v t bo lt n bo:Lp x,lp thng b tr n Dch Cha dch Dch C cc t chc nh trong nhy,c,trong xng,tc,rng,tuyn c nhiu vch b c tnh 50% bin Lnh tnh,5% Thng l c tnh
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chng thnh c tnh ung th Khc C cung di. Cung di,c C ngun gc t bo Khng dnh th dnh vo thai. 20% hai bn. xung quanh. tng xung Thng gp quanh khi c 2 bn nh mc ra 1)Triu chng lm sng a) C nng: + KhI u bung trng thng khng c triu chng g r rt. + Khi khI u nh thng khng c triu chng g,ch tnh c pht hin c khi khm nh k,khm sinh c k hoch. + Khi khI u to: + Cm gic nng bng dI + au vng h chu + C khi c rI lon kinh nguyt + C th t s thy u h v + V sinh + Khi c bin chng xon, v au nhiu! b) Thc th: + Nu khI u to c th thy khI u g ln h v,lch 1 bn h chu + Nu khI u to c th nh thai thng. + U to c th chn p vo tnh mch ch dI gy ra tun hon bng h + + S thy u cng,di ng khng au. + Thm m o: + Nu u nh cn nm trong vng chu: khm thy t cung bnh thg c khi b y lch sang bn I din.KhI u nm cnh t cung,trn mt cng,bit lp vI t cung,di ng th thng dnh.Nu khI u to qu hay u trong dy chng rng th khng nh gi c di ng! 2)Cn lm sng: + Lm hCG: loI tr c thai + Siu m : Gip nh gi c kch thc ,tnh cht khI u,m vang ng nht hay khng ng nht,c mt hay nhiu thy,c vch hay khng,c dch bng khng,t cung,phn ph bn kia + U nang nc: Vch nang mng, cha dch thun nht + U nang nhy: Thng c vch trong lng,trong lng m vang km,v dy
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+ U nang b: C vng tng m,m m xem thn c nc khng do chn p niu qun. + XQ bng khng chun b thy vng vi ha l rng ,tc ,xng trong u nang b + Chp t cung vi trng thy t cung b y lch sang mt bn + Vi trng b ko di ra! + Soi bng trong nhng trng hp u nh kh chn on 3)Chn on a) Chn on xc nh: + Da vo lm sng v cn lm sng b) Chn on phn bit: Nu u to lan ln vng bng cn chn on phn bit vI: T cung c thai Khc : + C du hiu c thai: Tt kinh,nghn,du hiu Hegar. + T cung to mm di ng dnh lin vI c t cung + hCG dng tnh + Siu m c thai trong bung t cung Bng c dch c chng: Khc: + Tin s c lin quan n c chng(X gan,ung th gan) + G c vng thp,c 2 bn mng sn + Siu m c dch t do trong bng. U mc treo Khc : + Di ng ln trn nhiu,u cao + Chp khung I trng,siu m chn on + Th huyt t thnh nang ca cha ngoi t cung. + Tin s chm kinh,ra mu m o + Thm m o: C khI ranh giI khng r dnh vo t cung,n au + Test hCG dng tnh + Chc d qua ti cng Douglas dng tnh + Siu m Hnh nh phi thai hoc hot ng tim thai ngoi bung t cung Nu khI u nh nm trong tiu khung,cn phn bit: C thai trong t cung + D nhm do t cung mm,thn t cung nh tch ra khI c t cung.D nhm thn t cung vI u v c t cung vI thn t cung Khc:
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+ Tin s chm kinh,nghn + C t cung mm tm,hCG dng tnh + Siu m thy hnh nh ti I,tim thai trong bung t cung Cha ngoi t cung + Tin s chm kinh ,ra mu m o + C t cung mm tm + Cnh t cung c khI n au + Test hCG dng tnh + Siu m c th thy hnh nh phi thai,tim thai ngoi bung t cung Vim phn ph, nc vi trng Khc + Tin s vim nhim,kh h m o. + KhI u cnh t cung, di ng kh n au + U x tcung: c bit d nhm vI u x dI phc mc + Siu m gip chn on Nang hong tuyn + Tin s cha trng,chorio,dng thuc hormon hng sinh dc liu cao! + nh lng hCG rt cao! Nang bc non: + C th t mt i + Siu m gip chn on phn bit IV. X tr + Nu l u kch thc < 6cm th gh n nang c nng ,cn theo di thm trong vi vng kinh.Nu khng phn bit c u nang c nng hay u nang thc th(u nh khng bin mt trong vi vng kinh) th nn m nI soi chn on v x tr + MI trng hp c chn on l u thc th th cn m sm v gI giI phu bnh + Vic ct b u v bung trng ty trng hp c th + Nu u nh,ngI tr,cha c con c gng tch b u lI bung trng lnh + Nu u to v ph n ln tuI th ct b bung trng bn ,km theo ct t cung,phn ph cn lI ,mc nI ln nu nghi ng c tnh. + Trong phu thut cn ch + Khi u qu to cn ht bt dch + Khi u b dnh cn g dnh t t,trnh tn thng cc c quan xung quanh + Khi c xon u nang: Gim au,chng sc,hI sc trong v sau khi m.M cp ct b u khng tho xon + MI khI u u cn phI lm giI phu bnh
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+ Sau m phI theo di pht hin ti pht ung th + Tin trin v bin chng + Tin trin thng lng l nhng bt c lc no cng c th gy nhng bin chng cp ,bn cp hay ung th ha. V. Bin chng: + Xon nang + Chy mu trong nang + V nang + Nhim trng + Ung th ha + Nang chn p tiu khung + C thai km u nang Cu 2 : U nang bung trng xon cp: Chn on v x tr! I. I cng + U nang bung trng l khI u c v bc bn ngoi v bn trong c cha dch nhy hoc m no + U nang bung trng c th gp mI la tuI + C 2 loI u nang bung trng:C nng v thc th + U nang bung trng xon l u nang hay gp nht ca u nang bung trng + Thng xy ra cc u khng dnh,c cung di,trng lng va phI + Nguyn nhn gy xon ch r II. Triu chng lm sng 1) C nng: + Bnh nhn c chn on u nang bung trng t trc hoc khng + au bng t ngt,d dI,au khp bng,nhng sau khu tr vng cung b xon. + Km theo bun nn,nn + RI lon nhu ng rut 2) Ton thn: + Bnh nhn c th chong nh,mt xanh ti,lo lng,mch nhanh.huyt p tt v m hi,chi lnh. 3) Thc th: + Bng chng dn ln,phn ng thnh bng dng tnh + n c im au chi + Nn bng c th s thy khI u + Thm m o kt hp vI nn ngoi thy cnh t cung c mt khI chm vo rt au(c bit chm vo cung).Di ng t cung v khI u au III. Cn lm sng + Test hCG loI tr cha ngoi t cung
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+ Siu m c gi tr chn on xc nh thy khI u bit lp vI t cung,c th thy c dch,khI u ln mu + Cng thc mu laI tr chy mu trong bng IV. Chn on 1) Chn on xc nh: + Nu bnh nhn c tin s u nang bung trng th d chn on hn + Chn on da vo lm sng v cn lm sng(c bit l siu m) 2) Chn on phn bit a) Cha ngoi t cung v Ging: + au bng t ngt,d dI + Chong Khc: + Tin s tt kinh,nghn + Ra mu m o t mt,dai dng + C du hiu chy mu trong bng + Thm m o:Cm gic t cung bng bnh trong nc ,kh xc nh c th tch ca t cung + KhI cnh t cung nh + Ti cng sau y au( Ting ku Douglas) + Test hCG dng tnh + Siu m gip chn on phn bit b) V nang Degraff Ging: + au bng t ngt,d dI + Khng c tin s chm kinh + Test hCG m tnh Khc + Cnh t cung khng c khI au + Di ng t cung khng au c) V tng trong bng khng do sang chn Ging + au bng t ngt ,d dI + Chong + Khng c tin s chm kinh,nghn + Test hCG m tnh Khc + HI chng chy mu trong bng + Du hiu mt mu + Du hiu v tng + Nu tng rng: Xq thy kh trong bng + Nu tng c siu m thy ng v Hanoi Medical University LTL 99
d) Vim rut tha v Ging : + au bng vng h chu phi. + Test hCG m tnh Khc + C hI chng nhim trng + Siu m gip chn on xc nh e) Vim phn ph, nc, m vi trng Ging: + au bng + Test hCG m tnh + Cnh t cung c khI n au Khc + HI chng nhim trng + Tin s vim nhim phn ph + Ra kh h V. X tr + Khi chn on xc nh l u nang bung trng xon phI m cp cu ngay + M m hoc nI soi + Thai ph cn tr cha con ,khI u hng th m bc tch + con th ct bung trng + Nu khI u cha v th cp ct khI u,khng tho xon,kim tra bung trng bn kia + Nu khI u nang bung trng xon v th m cp cu cp ct khI u ,ra sch bng,khng cn dn lu + Nu bnh nhn sau no trng ang theo di ung th nguyn bo nui m b xon nang hong tuyn: Ct b nang hong tuyn b xon + Kim tra bung trng bn kia + Nu bnh nhn cn tr khng thy di cn b phn sinh dc khng cn ct bung trng ngay nu khng nghi ng + Bt k trng hp no cng cn phI kim tra bn I din + Ct khI u xong cn phI gI giI phu bnh c thi x tr tip + HI sc chng sc trong v sau m + Nu km theo c thai cn phI bo tn tI a bung trng nu c thau phI dng hormon tr thai + Khng sinh sau m + Theo di chy mu ,nhim khun Cu 3:Ung th bung trng cch pht hin v x tr I. i cng:
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+ Ung th bung trng l loi ung th thng gp, ng th 3 sau ung th v v ung th c t cung,gy t l t vong cao nht trong c bnh ung th ph khoa. Ung th bung trng ngy cng tng do c chn on sm hn nhng iu tr kh khn,tin lng xu. + c chia lm 2 loi: + Ung th nguyn pht:Pht trin t bung trng. + Ung th th pht : Di cn t ni khc ti hay gp nht l t d dy. II. Triu chng lm sng 1) Triu chng c nng : + Ung th bung trng thng thm lng,khng c triu chng bo trc nn 70% bnh nhn i khm vi l do l t s thy khi u bng hay i khm ph khoa thng thng m pht hin ra! + Tuy nhin c th gp cc triu chng sau: + Cm thy vng bng di to nhanh! + Cm gic nng bng, au tc vng h v c khi dng thuc gim au khng c kt qu! + C th ra mu m o bt thng! + Giai on mun c th thy : i kh , i mu,b i tiu tin,cc du hiu di cn cc tng khc( phi: c ho ra mu) 2) Triu chng ton thn + Mt mi gy st c khi suy kit(giai on mun c v mt bung trng) + C th st nh v chiu! 3) Triu chng thc th + Nu khi u nh:Thng khng c biu hin g + Khi khi u to( trn 5 cm ) th biu hin mi r. + Kch thc khi u tin trin nhanh + Mt khi u chc,b mt ln nhn,khng au,bit lp vi t cung .Ranh gii khng r. + Di ng hn ch v u pht trin c hai bn bung trng + C th c dch c trng( Giai on mun) + Nu ph n 40-60 tui c khi u > 5cm th phi ngh ti u bung trng c tnh + Ngoi ra cn c th thy ung th nguyn pht nh ung th d dy III. Cn lm sng : + T bo hc :Phin m o c t cungt c gi tr chn on + Cng thc mu: mu lng tng
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+ Siu m : C gi tr chn on v tr ,kicks thc,mt khi u + Dch bng + Xt nghim dch c trng + T bo hc dch c trng: + 96% ung th giai on mun t bo ung th rng phin m tnh + L phng php tt chn on v theo di tin trin ca bnh + Mu sc nc c trng + Mu vng chanh c tin lng xu + Mu : Tin lng cng xu( 70% bnh nhn cht trong nm u) + CA125 + L cht nh du khi u tt nht trong ung th bung trng + Ngi kho mnh 99% c nng CA125 < 35 UI/ml + Trong ung th bung trng ( Giai on III,IV) Nng CA125 tng cao + ngha Nng CA125 cho php theo di s tin trin ca bnh + CA125 cng tng trong 1 s ung th khc nh ung th c t cung , ung th nim mc t cung + CT scanner pht hin cc khi u di cn + Soi bng v sinh thit cho php chn on xc nh v l ung th nguyn pht hay th pht IV. Chn on 1) Chn on xc nh: + Da vo lm sng v cn lm sng 2) Chn on phn bit: a) U bung trng lnh tnh: + Tin trin chm,di ng,ranh gii r + Khng c dch c trng ( Nu c th t,dch trong,khng c t bo ung th ) + Sinh thit khng c tn thng ung th b) U x t cung : + Rong huyt + U lin tc,di ng cng t cung + T cung to chc + Cn thit: Siu m ,soi bng sinh thit chn on phn bit. c) Lao phc mc + C tin s lao cc c quan khc + C du hiu bn c khi g bng Hanoi Medical University LTL 102
+ dch mng bng c nhiu t bo lym pho,khng c t bo ung th + Khi kh chn on cn phi m bng thm d d) Sarcome t cung . + T cung to,kh h ra nhiu + Xt nghim t bo papanicolaou trong ng v bung t cung thng dng tnh + Siu m : t cung to, nim mc dy,c th c hnh nh m vang khng ng nht trong bung t cung + Sinh thit cho php chn on xc nh e) Khi vim bung trng tn ti lu ngy + Thng do lao do thng c triu chng lao trc 3) Mt s yu t nguy c: + Bt talc, n nhiu m,di truyniu tr cn nhiu kin do: + Vic pht hin bnh sm cn kh + Tnh cht gii phu bnh phc tp + Tin trin ,tin lng kh lng trc ca bnh V. X tr 1) Phu thut + L phng php u tin v quan trng a) Mc ch: + nh gi ton b khi u + Ly bnh phm gi gi phu bnh chn on xc nh + Gip iu tr bng ho tr liub xung c kt qu b) Phng php + Nu khi u cn di ng: M ct khi u,ct t cung hon ton v 2 phn ph,mc ni ln,no vt hch chu + Nu u di ng km + C th iu tr ho cht hay tia x trc m + Sau m ct b u v t cung hon ton,hai phn ph,mc ni ln,no vt hch + Sau m iu tr bng ho cht hoc tia x + Tt c khi u phi c gi gii phu bnh c thi x tr tip 2) Ho liu php + L phng php iu tr b xung quan trng, c tc dng c bit i vi cc tn thng nhiu ni,hoc khu tr su mt ni no m phu thut kh khn hay tia x khng ti c . + Cc nhm ho cht + Nhm hu hoi AND: Cyclophosphamid, clorambucil
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+ Nhm cc thuc chng chuyn ho: Fluouracin, Metrotrexat + Cc cht chng phn bo: Ciplastin + Khng sinh chng ung th : Bleomycin,Actinomycin + C th phi hp vi nhau theo cng thc MAC,CHAMOCA a) u im + a s bnh nhn chu c + C th iu tr ko di + C th iu tr theo nhiu giai on nh tn cng,cng c, duy tr b) Nhc im + Tc dng thay i trn tng bnh nhn v tng loi ung th + Sau mt thi gian c hin tng quen thuc + c cho h to huyt,gy gim min dch ( trc khi dng phi nh gi chc nng gan thn, cng thc mu ) + Phi iu tr ko di,nu ngh t ngt thng nguy him cho bnh nhn 3) Tia x a) u im + Hn ch c s pht trin,di cn ca khi u b) Ch nh + Khi u khng li ho cht + Khng ly ht c t chc ung th + U nhy cm vi tia x( U t bo mm) + Pht hin sm ung th bung trng nhng i tng c nguy c cao: + Ph n 40-60 tui c khi u > 5 cm vng h v + c chn on ung th ni khc + Tin s gia nh b ung th v, bung trng + Khi u bung trng hai bn, pht trin nhanh.
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Bnh tim v thai nghn

Cu 1 : Hng x tr tim sn thi k thai nghn: I. i cng + Khi c thai v trong qua trnh chuyn d ,h thng tim mch,tun hon chu nhiu bin i su sc .Nhng ngi bnh thng c kh nng bin i v thch nghi vi nhng thay i .Cn nhng ngic bnh tim thng khng thch nghi c + Do ngi ph n mc bnh tim khi cha c nhiu bin chng v d gy t vong + T l mc bnh tim v thai nghn khong 2,4% gn nh khng i nhng t l t vong ngy cng gim do pht hin v iu tr ngy cng tt hn II. Chn on bnh tim /c thai: + Bnh nhn c th c tin s b bnh tim v hin ti c thai 1) Triu chng c nng : + Kh th c bit t thng th 5 tr i + tc ngc do tim b chn p + Nng chn tiu t + Mt mi 2) Triu chng thc th + Tm mi, u chi tu mc + Nghe tim : Nhp tim nhanh hay lon nhp tim + Ting tim bnh l + Phi c th c ran m do ng mu hoc c biu hin ph phi cp + C th c gan to, tnh mch c ni + Xt nghim : Xquang tim b ra, c honh b y ln cao + in tim c rng Q D3 v + C nhng biu hin khc: Tng gnh tht , lon nhp + Siu m tim: C th thy nhng tn thng tim, van tim III. nh hng qua li ca bnh tim v thai nghn khi c thai 1) nh hng ca thai nghn ln bnh tim + Khi c thai ,nhu cu nui dng thai v oxy tng ln v vy c cc bin i sau:
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a) nh hng ln h tiu tun hon + Xquang phi: Hai rn phi m chng t c biu hin ng h tiu tun hon + Thng kh phi tng( th nhanh)PCO2 mu m gim t 40 xung 32 mmHg + Thng kh ti a gim do t cung c thai to dn, y c honh ln cao chn p vo phi dn n din tch thng kh gim nn gim thch nghi vi gng sc ,Gim kh nng trao i vi oxy dn n toan chuyn ho mu m b) nh hng ln h i tun hon v tim mch Tng din tch tun hon: + Do thai , bnh rau, t cung , v ca thai ph pht trin tng theo tui thai lm tng din tch ti mu ca tim v tun hon Tng khi lng mu tun hon ln 34% + Tng nhanh vo thng 4,5,6 v duy tr mc cao cho n sau , ri gim dn trong thi k hu sn + Ch yu l tng huyt tng,ch tng 20% hng cu v vy m hematocrit gim ch cn 25-30%.Hu qu l nc sinh l, gi nc trong c th thai ph Tng nhp tim: + Nhp tim tng hn 10l/pht so vi khi khng c thai + Lu lng tim tng: + Bnh thng trc khi c thai: 3-5 l/pht khi c thai lu lng tng dn ln, ti a n thng th 7 .T l tng ln c th t 40-50%,sau gim dn n cc thng cui v tr v bnh thng sau + T3-T4 tng ln 5,5 l/pht + T5-T7 tng ln 6,0 l/pht + T8-T9 tng ln 5,5l/pht Lu lng tng: + Do nhu cu tiu th oxy cho m , cho thai v phn ph ca thai + Lu lng tim tng phn nhiu l do nhp tim tng v kh nng co bp ca tim tng m biu hin l ch s tim tng( bnh thng 2,3l/pht/m2) Tc tun hon tng: + Bnh thng l 7 giy i vi tiu tun hon v 14 giy i vi i tun hon.Tng t thng th 3 n thng th 9 v gim dn vo nhng tun cui. + Trong 3 thng u tc tun hon 12,4 giy + Trong 3 thng cui tc tun hon 10,2 giy + Tc tun hon tng l do hnh thnh nhng shunt ni thng gia ng mch tnh mch h huyt, t cung
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+ Tc tun hon tng nhng p lc ngoi bin h nn huyt p ng mch khng tng T th tim thay i + Tim t ng chuyn thnh nm ngang do t cung y c honh ln cao,cc mch mu ln t tim ra b gp nh buc tim phi lm vic trong iu kin kh khn hn.Lc hot ng ca tim ln hn bm mu vo tun hon i nui c th + Cng hc ca tim=(huyt p ng mch trung bnh) x (lu lng tim) + Trong khi c thai , lu lng tim tng ,cng c hc ca tim tng xp x 50% Kt lun: + Cc bin ng tim sn trn ch c th thch nghi d dng thai ph kho mnh v bnh thng. i vi cc thai ph mc bnh tim,tim bnh khng th ng u vi nhng bin i trn nn thai nghn l mt gnh nng i vi tim b bnh lm cho tim bnh d b suy, ph phi cp,lon nhp tim 2) nh hng ca bnh tim ln thaI nghn + Thai nhi cn dinh dng( protein) v oxy cho qu trnh hnh thnh v pht trin. ngi m b bnh tim, do s p ng v oxy v dinh dng km nn tu theo mc v thi im m b thiu oxy m c nhng nh hng khc nhau ln thai nghn nh: + Sy thai, thai cht lu + Thai km pht trin trong t cung , suy dinh dng + Suy thai mn tnh dn n suy thai cp tnh trong chuyn d + C th b d tt 3) Nhng tai bin tim sn thng gp trong thi k thai nghn + Suy tim + Ph phi cp + Lon nhp tim + C th gp tc huyt khi IV. X tr tim sn trong thi k thai nghn 1) Ni khoa: a) Mc ch: + D phng v iu tr cc tai bin c th xy ra + Theo di st tnh trng bnh nhn hng tun t khi c thai pht hin sm nhng tai bin tim sn v iu tr kp thi + Ngh ngi n nht theo di st lng nc tiu, lm sng theo hng dn ca thy thuc( tt nht l bc s chuyn khoa tim mch) Hanoi Medical University LTL 107
b) Ch iu tr + Tr tim tu theo mch chm hay mch nhanh m dng digoxin hay Uabain + Li tiu : Lasix km theo KCl tng t + An thn: Seduxen + Phng nga nhim khun:Khng sinh nhm lactam + Phng nga huyt khi dng khi cn thai : Heparin 2) Sn khoa Phng chm: + Bo v m l chnh, c chiu c ti con theo nguyn tc da vo tnh trng suy tim nh sau a) Cha c suy tim: Con r: + nh ch thai nghn bt k tui thai no + Nu pht hin mun thai gn thng m tnh trng m cho php c th gi thai n thng ri tm bin php thch hp kt thc thai nghn( M, Forceps) Con so: + C th gi thai nhng cn c chm sc v theo di ca bs Chuyn khoa tim mch v sn khoa + Nm vin theo di 1 thng trc khi b) suy tim Con r + nh ch thai nghn bt k tui thai no bng nhng bin php an ton v trit nht + Tu mc suy tim, loi bnh tim v tui thai m chn phng php thch hp nh: No thai trit sn, m ct t cung c khi,m ly thai ct t cung bn phn + Nu pht hin mun , thai gaanf thng , tnh trng m cho php c th iu tr tch cc thm 1 thi gian n khi thai thng ri nh ch thai nghn Con so : + Cn s cn nhc k ca 2 thy thuc snr v tim mch + Suy tim I,II + Thai nh < 6 thng : Ph thai bo v m + Thai > 6 thng iu tr tch cc + Nu p ng vi iu tr th c th gi thai n thng + Nu khng p ng vi iu tr nh ch thai nghn bo v m + Suy tim III,IV + nh ch thai nghn bt k tui thai no + La chn thi im, phng php thch hp( nh iu tr suy tim cho tnh trng tt ln )ri mi nh ch thai nghn + Cc bin php iu tr thai nghn trong tim sn
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+ La chn phng php ph thuc vo: + Tnh trng bnh nhn, bnh tim trc + Tui thai v tnh trng thai + Cc bin php + Ht iu ho kinh nguyt v trit sn + No ph thai v trit sn + M ct t cung c khi + M ly thai v ct t cung bn phn + Lu trong qu trnh tin hnh bin php nh ch thai nghn Phng ngng tim t ngt + Thi im : Khi chm vo c t cung cp hoc nong c t cung d gy kch thch cho phn x ngng tim t ngt + Phng : Tin m hay gy m trc th thut c) Phng nga huyt khi Thi im trong v sau khi lm th thut( Thng nhng ngy sau) + Phng dng cc thuc chng ng Cch dng + Trc th thut 2 ngy: Heparin 500010000UI/ngy(tim di da,chia lm 2 ln cch nhau 12 gi) + Ngh 1 ngy trc khi lm th thut,phu thut. + Sau lm th thut 24 gi + Heparin 5000-10000 UI/ngy trong 2 ngy ( tim di da chia 2 ln mi ln cch nhau 12 gi) + Theo di: Du hiu chy mu lm sng + APTT hng ngy + x tr nu chy mu v APTT ko di: th ngng heparin,dng i khng protamin sulfat 5% ng 5ml tim tnh mch chm( 10mg trung ho c 1000 Ui heparin) + Tip theo liu php heparin nn dng thm liu php sintrom v theo di t l prothrombin + Ngng thuc v tim tnh mch vitamin K trung ho khi prothrombin thp < 25% + Lm sng c du hiu chy mu 3) Ngoi khoa + Hin nay, nhiu bnh tim nh hp hai l, thng lin nhi ,co ng mch c iu tr ngoi khoa c kt qu tt + Tui thai < 7 thng m b bnh tim c ch nh m vn c kh nng m tim v: + Nguy c sau m tim cho thai ph cng tng ng vi nguy c m tim ngoi thi k thai nghn. + Sau m tim cc bin chng tim sn gim so vi nhm khng iu tr ngoi khoa!
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Cu 2 :Bnh tim v thai nghn: Thi k chuyn d v sau ,hng x tr: I. i cng + Khi c thai v trong qua trnh chuyn d ,h thng tim mch,tun hon chu nhiu bin i su sc .Nhng ngi bnh thng c kh nng bin i v thch nghi vi nhng thay i .Cn nhng ngic bnh tim thng khng thch nghi c + Do ngi ph n mc bnh tim khi cha c nhiu bin chng v d gy t vong + T l mc bnh tim v thai nghn khong 2,4% gn nh khng i nhng t l t vong ngy cng gim do pht hin v iu tr ngy cng tt hn II. Chn on bnh tim /c thai: + Bnh nhn c th c tin s b bnh tim v hin ti c thai 1) Triu chng c nng : + Kh th c bit t thng th 5 tr i + tc ngc do tim b chn p + Nng chn tiu t + Mt mi 2) Triu chng thc th + Tm mi, u chi tu mc + Nghe tim : Nhp tim nhanh hay lon nhp tim + Ting tim bnh l + Phi c th c ran m do ng mu hoc c biu hin ph phi cp + C th c gan to, tnh mch c ni + Xt nghim : Xquang tim b ra, c honh b y ln cao + in tim c rng Q D3 v + C nhng biu hin khc: Tng gnh tht , lon nhp + Siu m tim: C th thy nhng tn thng tim, van tim III. nh hng ca bnh tim v thai nghn trong qu trnh chuyn d v sau 1) Khi chuyn d: a) nh hng ca thai nghn ln bnh tim Trong qua trnh mang thai + ,thai nghn c nhng nh hng lnn bnh tim nh lm tng din tch tun hon,tng khi lng tun hon ,tng tc tun hon,tng nhp tim tng cung lng n thi k chuyn d :
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+ Do c im ca qu trnh chuyn d m ngoi vic tn ti nhng nh hng ca thai nghn ln tim nh trong thi k thai nghn cn xut hin thm : + Tng nhu cu oxy lm nhp tim tng ln nhiu( Do t cung co bp) + Huyt p tng ln trong cn co t cung tng ln,ht cn co t cung th huyt p li gim xung l do trong cn co mu t c t cung dn v tun hon ca ngi m, khi ht cn co mu li v t cung + Tt c iu to nn tnh trng ri lon huyt ng,kt hp vi cng c hc ca tim tng( Do tng nhp tim v tng lu lng ) + S tng cng c hc t ngt v lin tc tim bnh khng p ng ni dn n suy tim , ph phi cp + Tng p lc cc bung tim phi,nht l nh phi (c bit trong hp hai l )Do mu nh tri, mu b li tiu tun hon,phi,lm mu gan + Trong khi , mu t tht tri c bm ra t gy thiu mu tun hon m nhu cu oxy m li rt cao, tht tri phi lm vic nhiu,dn n suy tim ton b b)nh hng ca bnh tim ln thai nghn trong qu trnh chuyn d + Trong qu trnh thai nghn , do nh hng ca bnh tim m thai d b suy dinh dng hay suy thai mn + Trong qua trnh chuyn d , nhu cu oxy cho cuc chuyn d cao , tim bnh khng p ng ni dn n thiu oxy cho thai d dn n suy thai cp trong qua trnh chuyn d, thai cht trong chuyn d + Tuy nhin chuyn d thng s nhanh v thai nh 2) Thi k s rau: C nhng hin tng sau + Sau s thai, tun hon t cung rau ngng hot ng t ngt + Mt mu nhiu khi bong rau , thiu hng cu vn chuyn oxy ti m + T cung co thnh khi an ton , dn mu t t cung vo tun hon ngi m,lm tng khi lng mu lu thng , to gnh nng tng i t ngt cho tim. p lc bng t ngt gim do t cung co nh li,mu t 2 chn dn v bng nhanh,dn ln nh phi, tht phi, v ln phi + Lng mu lu thng qua tim tng khong 20 % trong thi gian ngn + S thay i t ngt ny lm tim bnh khng th thch nghi c d b ngng tim v suy tim cp hay ph phi cp + y l thi k nguy him nht trong bin c tim sn 3) Khi rau bong Hanoi Medical University LTL 111
+ Mch mu vng rau bm xut hin tc mch sinh l,cc yu t ng mu tun hon ngi m hot ng mnh md dn n tai bin huyt khi + Nt cm mu mch mu vng rau bm li l ni d nhim khun, tin ca tai bin nhim khun hu sn 4) Thi k hu sn + Th tch mu tun hon do t cung co hi dn vo tun hon cha m vn cn v s gim dn trong thi k hu sn + Nhu cu oxy vn cn cao do 2 v pht trin, tng hp v to sa + Th tch nc gian bo trong c th ngi m s gim dn theo s gim estrogen .Hu qu gnh nng ca thai ln tim lm d tr nng lng ca tim kit qu + Ri lon huyt ng trong cuc cn tn ti nn vn cn kh nng gy suy tim, ph phi nht l nhng b m nui con bng sa m IV. Hng x tr 1) Nguyn tc + Bo v m l chnh c chiu c ti con + Ly thai bng phng php nhanh v an ton nht 2) Khi chuyn d + Cn tr tim, an thn , gim au , th oxy p ng nhu cu oxy ca cn co t cung v ca b m v trnh suy tim, ph phi cp + Tr tim + Mch nhanh dng Digoxin ng mg tim tnh mch + Mch chm dng Uabain tim tnh mch ng mg + Th oxy qua nc + An thn bng diazepam 5 mg + Gim au : Gim s chu ng cho bnh nhn + Cho sn ph nm t th Fowler + Theo di thng xuyn mch ,huyt p , nhit , ton trng m, tim thai, cn co t cung ( tt nht l bng Monitoring) + Cho khng sinh d phng nhim khun + Nu thai ngi chm , cc yu t chuyn d thun li , khi c t cung m 4 cm th bm i rt ngn chuyn d , gim thi gian ri lon huyt ng v gnh nng cho tim 3) Khi s thai + Khi iu kin t Forceps th nn bng Forceps trnh gng sc cho m khi rn + Trnh ri ln huyt ng khi s thai:
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+ Do khi thai ra , t cung nh i , p lc bng gim t ngt , mu t chn dn ln bng nhanh gy thm tnh trng ri lon huyt ng + Phng php t ti ct ln bng bnh nhn ng thi h 2 chn bnh nhn xung thp mu t dn v bng + Hn ch ti a m ly thai, ch nh m khi khng c iu kin ng di 4) Thi k s rau + Tn trng sinh l s rau thng + Hn ch kim sot t cung v kim tra bnh rau k phng st rau v st rau v thao tc kim sot t cung d gy nhim khun v dn n vim ni tm mc 5) Thi k hu sn + Tip tc theo di st ton trng ca m: mch, huyt p , nhp th, nhp tim + Theo di s co hi t cung , chy mu m o + Khng sinh phng nhim khun, theo di vim ni tm mc , huyt khi + Vn nui con bng sa m + Ch cho b ba thng u nu m khng suy tim + Trong qua trnh nui con bng sa m ,bnh nhn phi c theo di , nh gi cc tai bin tim sn,nu xut hin bt thng phi thi cho con b ngay + Nu m c suy tim , gan to, khng nn nui con bng sa m, k c vic b con + khuyn khch sn ph vn ng nh nhng sm phng bin chng vim tc tnh mch + Vn trit sn c t ra nhng sn ph bnh tim m ng di khi m n nh
Cu 3 : Cc tai bin tim sn: Cch x tr

I. i cng + Khi c thai v trong qua trnh chuyn d ,h thng tim mch,tun hon chu nhiu bin i su sc .Nhng ngi bnh thng c kh nng bin i v thch nghi vi nhng thay i .Cn nhng ngic bnh tim thng khng thch nghi c + Do ngi ph n mc bnh tim khi cha c nhiu bin chng v d gy t vong + T l mc bnh tim v thai nghn khong 2,4% gn nh khng i nhng t l t vong ngy cng gim do pht hin v iu tr ngy cng tt hn. + Cc tai bin tim sn c th xy ra bt c khi no trong thi k thai nghn , vic theo di st sn ph b bnh tim pht hin v x tr kp thi cc tai bin c ngha quan trng
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trong vic gim t l t vong cho m v p ng mong mun c con cho cc b m b bnh tim. II. Cc tai bin tim sn 1) Yu t thun li . + Mc nng nh ca bnh tim, loi bnh tim + Bnh hp van hai l l nng nht ,hp cng kht cng nng + Tn thng cng nhiu van tim cng nng + Tui sn ph: Suy tim 13,2% tui < 25; 41,5% tui t 25-29; 21,6 % tui t 30- 34 v 23,6% tui t 35 tr ln ( V bnh tim thng mc t b) + S ln + Con so t bin c hn con r + Cng nhiu ln nguy c cng cao + Tui thai: Tui thai cng ln cng d gy bin c + Thi k thai nghn : + 25 % tai bin xy ra khi c thai + 50% xy ra thi k s rau + 25 % xy ra sau + Yu t khc: S hi, tm l cng thng trong cuc 2) Nhng tai bin tim sn thng gp v cch iu tr a) Suy tim nh ngha v phn loi suy tim + Suy tim l tnh trng bnh l trong c tim gim hay mt kh nng cung cp mu i nui c th theo nhu cu ca c th lc gng sc v sau l ngaqy c lc ngh ngi. + Phn loi suy tim: Theo chc nng v theo lm sng( xp loi theo lng hot ng th lc) Theo lm sng : Xp theo hot ng th lc. + Loi A : Bnh nhn b bnh tim,nhu cu hot ng thng thng ca h khng b hn ch .L trng hp hn hu trong thai nghn( cha c suy tim) + Loi B: Bnh nhn b bnh tim cc nhu cu hot ng th lc thng thng b hn ch .nhng h c khuyn trnh gng sc ( Suy tim I) + Loi C : Bnh nhn b bnh tim m hot ng th lc thng thng b hn ch mc trung bnh v c gng tch cc hn b gin on v kh th.( suy tim II) + Loi D: Bnh nhn b bnh tim m hot ng th lc thng thng ca h b hn ch ng k , ch ngi th( Suy tim III) + Loi E: Bnh nhn b bnh tim phi ngi ngh hon ton hay phi ngi th cng kh th( Suy tim IV)
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Chn on nguyn nhn v nhng yu t thun li gy suy tim thai nghn + Nhim khun: ng h hp , vim ni tm mc do vi khun + huyt ; Dch a vo qu nhiu do ung, tim truyn + Qu gng sc : Ht ng th lc v tinh thn. + Ri loi nhp tim + Thiu mu + Bo bu + Cng gip trng + Bin chng tc huyt khi Chn on xc nh suy tim. Lm sng : + Tin s bnh tim + Kh th , au tc ngc + Ph phi , tiu t + Nhp tim nhanh hay lon nhp , ting tim bnh l + Gan to + Phi : C th c rale m ( ng) Cn lm sng + Xquang : Tim to, c honh b y ln cao ( Do t cung to) + in tm : Tng gnh cc bung tim, ri lon nhp tim + Siu m : Tn thng van tim,chc nng cc bung tim X tr Suy tim Thuc tr tim. Suy tim nhp nhanh. Thuc c chn l Digoxin + Tc dng ca thuc: Tng cng co bp c tim + Tng trng lc c tim + chm nhp tim + Gim trng lc mu ngoi vi + Li tiu Liu lng + Tn cng: 2 vin hay 2 ng mg /ngy chia lm 2 ln dng trong 1 n 2 ngy u + Duy tr : 1 vin /ngy trong 3 ngy tip theo ri ngh thuc 2 ngy + Tip liu duy tr : Cch ngy dng 1 vin + hoc dng liu 5 ngy ngh 2 ngy Chng ch nh + Nhp tim < 90 l/p + Bloc nh tht cp 2 cp 3 Hanoi Medical University LTL 115
+ Rung nh, rung tht + Nhi m c tim + Kali mu thp + Theo di : Du hiu ng c: Biu hin lm sng l ngoi tm thu X tr: + L ngng thuc ngay Suy tim nhp chm + Uabain mg + 10 ml dung dch Glucose 5% tim tnh mch chm .Liu 2 ng /ngy Thuc li tiu Furosemid ( Lasix) ng 10, 20 mg, vin 40 mg Liu lng :Tu vo tnh trng ca tng bnh nhn. + Ung km Kali + Dng tng t ngn , khng ko di , d gy tnh trng mt nc + Chng ch nh: Bnh no, x gan, d ng sulfamid, b tiu, mt nc Oxy liu php: + Th oxy qua sonde mi An thn: + Seduxen 5mg Chm sc , n nht, hn ch i li, vn ng nh gi iu tr + Nu p ng vi iu tr, thai gn thng th tip tc iu tr ni khoa, sau ch ng m ly thai trnh ri lon huyt ng trong chuyn d + Nu khng p ng vi iu tr , suy tim khng gim th nh ch thai nghn cu m l chnh b) Ph phi cp i cng + Ph phi cp c th xut hin trong suy tim hoc ph phi cp n thun + Hay gp trong hp hai l + Khi u bng mu nh tri , mu phi, ph phi , ri ph phi cp gy thiu mu oxy, kh th km theo l tng sc cn ngai vi do tr tun hon ca suy tim hay do tng huyt p + T l ph phi cp chim khong 15% cc bin c tim sn nhng li chim 50% t vong tim sn. Lm sng v chn on Cn ph phi cp + Hay xy ra t ngt vo bui sng
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+ Ban u bnh nhan cm thy kh chu, lo lng, tc ngc , nga c hng,hng hng ho + Sau t ngt kh th, phi ngi dy th,mc kh th ngy cng tng ri khc ra bt hng. + Thi gian t khi c cm gic kh chu n khi khc ra bt hng ch trong vng vi pht Thc th + Mt my xanh tm, v m hi, vt v, phi ngi da th + Phi : Lng ngc trong vang + Nhiu rale m nh ht t y phi dng ln nhanh nh thu triu dng + Tim : Lon nhp tim,ting nga phi + Ting bnh l tim trc , i khi kh nghe v ting phi lm m i Th lm sng : Th ti cp + Bnh nhn t ngt kh th rt nng,cc triu chng din ra rt nhanh, i khi cht ngay m cha kp khc ra bt hng + Th nh kh th t , khc t bt ln mu.Thng xut hin sau gng sc iu tr cn ph phi cp + H p lc tiu tun hon: Bnh nyhn t th Fowler + Garo 3 chi lun phin + Oxy liu php + Phi lm thng thong ng h hp trn trc khi th oxy: Ht m di + Oxy chy qua l nc c pha cn th qua sonde mi + Trong trng hp nng: Phi t ni kh qun thao tc d v h hp h tr. + Li tiu mnh h th tch mu: Dng liu cao lasix sao cho sau 1 gi c 1-2 l nc tiu.Thng bt u t 20mg tim tnh mch + An thn chng xut tit: Morphin 0,01 g tim tnh mch, tim bp + Tr tim : Digoxin hay Uabain tu mch nhanh hay chm nh gi sau cn ph phi cp Nu bnh nhn ang c thai + Sau khi iu tr cn ph phi cp c kt qu th tip tc iu tr thm chng 3- 5 ngy na cho tnh trng ph phi n nh
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+ Sau khi n nh th m ly thai ngay khng tnh n tui thai v nu chn ch lu bnh nhn c th ln cn ph phi cp khc rt nguy him cho tnh mng ca m. Nu bnh nhn ang chuyn d + y l tnh trng rt nguy him, m ly thai hay Forceps u e do t vong m, tt nht lc ny l tr hon cuc trnh ri lon huyt ng trong chuyn d v rt kh khn trong gy m + Nu bnh nhn c tin s ph phi cp , nay ang c thai, ph phi cp rt d ti pht , nn nh ch thai nghn khi c iu kin c) Lon nhp tim: + Xp loi lon nhp tim theo im xut pht v dn truyn : Lon nhp xoang + Nhp xoang xut pht t nt Keith- Flack + C th thay i + in tm xut hin 2 phn nh tht + Lon nhp ngoi nt Keith- Flack: khng c kh nng thay i + in tm thiu 1 phn nh hay tht + Xp loi lon nhp tim theo lm sng Lon nhp u + Cc loi : + Nhp nhanh: 80-120 l/p nhanh t nt Keith-Flack + 120-140l/p + 140-200 l/p cn nhp nhanh Bouverett + Nhp trung bnh + 70l/p + Nhp chm + t 40-60 l/p chm t nt Keith- Flack + Di 40 l/p : Block nh tht Chn on : + m mch /pht + Lm in tm + Lon nhp khng u(Ngoi tm thu) + C lung thn kinh xut pht mnh hn bnh thngt mt trung tm kch thch trong hay ngoi lung dn truyn lm tht co bp sm hn + V tht co bp sm ( ngoi tm thu ) nn sau thi gian ngh ko di hn gi l thi gian b Triu chng c nng: + Trng ngc p + Cm gic ht hng
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+ Khi ng bnh nhn b git mnh + Triu chng thc th : Tim p khng u c lc b nhp + Ngoi tm thu > 5% coi nh bnh l + Ngoi tm thu kp nhiu nguy c cao hn + in tm + Ngoi tm thu trn tht: QRS khng bin dng + Ngoi tm thu tht: QRS c bin dng Lon nhp hon ton + Nhp tim khng u c v thi khong v bin do rung nh , hin tng phn ly nh tht + Hu qu : Tim ph i ri suy, mu li nh( nht l trong hp hai l)dn n ng mu trong nh ri tip l bnh huyt khi Chn on + Bnh nhn cm thy hi hp kh chu + Mch quay nhanh khng u + in tm : Mt sng p cc o trnh + khong R-R khng u nhau iu tr + Kh cn hi chn vi chuyn khoa tim mch + C th s dng cc thuc sau + Amidazon, lidocain,digoxin, quinidine + iu tr tm thi cn Bouverett: n nhn cu cng d) Tc huyt khi i cng: + Huyt khi hnh thnh t nh + Hay gp trong hp hai l + V tr hay tc : Mch vnh , phi , no Lm sng v chn on + Hay gp nht tun th 2 sau , sau m v tun th 1 sau no , sau sy thai . + au ni tc : Lc u au thnh cn sau au lin tc + Du hiu v hu qu ca tc + No : Lit ngi + Tc mch vnh : h huyt p hay ngng tim + mc treo rut: C du hiu bng ngoi khoa Tin lng + Khi c tc , iu tr ni khoa kh, d li di chng + Tt nht l ngn cn t l Prothrombin khng tng qu cao gy huyt khi iu tr + hnh thnh huyt khi : Cha c thuc tan cc huyt khi c hiu, c th dng urokinase, streptokinase, alteplase Hanoi Medical University LTL 119
+ chng au, chng lot + c nh chi b huyt khi + Phng huyt khi: Khng ch t l Prothrombin < 60% + Sintrom 4 mg liu ph thuc vo t l Prothrombin + Heparin tim di da trc m v sau m, sau + Liu ph thuc vo t l Prothrombin, thng l 500010.000UI tim 48gi trc m ly thai e) Vim ni tm mc bn cp Nguyn nhn sau + Vng rau bm sau khi s rau cso cc nt cm mu nn d nhim khun. + Vi khun nim mc t cung vo mu gy vim ni tm mc bn cp + Mt khc sau , sc khng gim cng d nhim khun Chn on : Triu chng ton thn + St cao lin tc hay tng cn, c th km rt run + Hi chng nhim trng : mi khl i bn hi th hi + Sn khoa: T cung co hi chm + Sn dch hi + c t cung h m + Di ng t cung au Xt nghim : + cng thc mu :Bch cu a nhn trung tnh tng cao. + Cy mu v tm vi khun lm khng sinh ( dng tnh trong - 1/3 trng hp) iu tr + Loi b nhim khun + iu tr triu chng + H st + An thn + Khng sinh: Theo khng sinh + Nu khng c khng sinh : khng sinh ph rng , ko di + iu tr d phng c ngha quan trng + V khun tt trong chuyn d + Thc hin ng ch nh sn khoa + Khng sinh nhm beta lactam Cu 4: Hng x tr tim sn I. i cng + Khi c thai v trong qua trnh chuyn d ,h thng tim mch,tun hon chu nhiu bin i su sc .Nhng ngi bnh thng c kh nng bin i v thch nghi vi nhng Hanoi Medical University LTL 120
thay i .Cn nhng ngic bnh tim thng khng thch nghi c + Do ngi ph n mc bnh tim khi cha c nhiu bin chng v d gy t vong + T l mc bnh tim v thai nghn khong 2,4% gn nh khng i nhng t l t vong ngy cng gim do pht hin v iu tr ngy cng tt hn II. X tr tim sn trong thi k thai nghn 1) Ni khoa: a) Mc ch: + D phng v iu tr cc tai bin c th xy ra + Theo di st tnh trng bnh nhn hng tun t khi c thai pht hin sm nhng tai bin tim sn v iu tr kp thi + Ngh ngi n nht theo di st lng nc tiu, lm sng theo hng dn ca thy thuc( tt nht l bc s chuyn khoa tim mch) b) Ch iu tr + Tr tim tu theo mch chm hay mch nhanh m dng digoxin hay Uabain + Li tiu : Lasix km theo KCl tng t + An thn: Seduxen + Phng nga nhim khun:Khng sinh nhm lactam + Phng nga huyt khi dng khi cn thai : Heparin 2) Sn khoa a) Phng chm: + Bo v m l chnh, c chiu c ti con theo nguyn tc da vo tnh trng suy tim nh sau b) Cha c suy tim: Con r: + nh ch thai nghn bt k tui thai no + Nu pht hin mun thai gn thng m tnh trng m cho php c th gi thai n thng ri tm bin php thch hp kt thc thai nghn( M, Forceps) Con so: + C th gi thai nhng cn c chm sc v theo di ca bs Chuyn khoa tim mch v sn khoa + Nm vin theo di 1 thng trc khi c) suy tim Con r + nh ch thai nghn bt k tui thai no bng nhng bin php an ton v trit nht + Tu mc suy tim, loi bnh tim v tui thai m chn phng php thch hp nh: No thai trit sn, m ct t cung c khi,m ly thai ct t cung bn phn Hanoi Medical University LTL 121
+ Nu pht hin mun , thai gaanf thng , tnh trng m cho php c th iu tr tch cc thm 1 thi gian n khi thai thng ri nh ch thai nghn Con so : + Cn s cn nhc k ca 2 thy thuc sn v tim mch Suy tim I,II + Thai nh < 6 thng : Ph thai bo v m + Thai > 6 thng iu tr tch cc + Nu p ng vi iu tr th c th gi thai n thng + Nu khng p ng vi iu tr nh ch thai nghn bo v m Suy tim III,IV + nh ch thai nghn bt k tui thai no + La chn thi im, phng php thch hp( nh iu tr suy tim cho tnh trng tt ln )ri mi nh ch thai nghn + Cc bin php iu tr thai nghn trong tim sn + La chn phng php ph thuc vo: + Tnh trng bnh nhn, bnh tim trc + Tui thai v tnh trng thai Cc bin php + Ht iu ho kinh nguyt v trit sn + No ph thai v trit sn + M ct t cung c khi + M ly thai v ct t cung bn phn + Lu trong qu trnh tin hnh bin php nh ch thai nghn d) Phng ngng tim t ngt + Thi im : Khi chm vo c t cung cp hoc nong c t cung d gy kch thch cho phn x ngng tim t ngt + Phng : Tin m hay gy m trc th thut + Phng nga huyt khi + Thi im trong v sau khi lm th thut( Thng nhng ngy sau) + Phng dng cc thuc chng ng Cch dng + Trc th thut 2 ngy: Heparin 500010000UI/ngy(tim di da,chia lm 2 ln cch nhau 12 gi) + Ngh 1 ngy trc khi lm th thut,phu thut. + Sau lm th thut 24 gi + Heparin 5000-10000 UI/ngy trong 2 ngy ( tim di da chia 2 ln mi ln cch nhau 12 gi) + Theo di: Du hiu chy mu lm sng + APTT hng ngy
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+ x tr nu chy mu v APTT ko di: th ngng heparin,dng i khng protamin sulfat 5% ng 5ml tim tnh mch chm( 10mg trung ho c 1000 Ui heparin) + Tip theo liu php heparin nn dng thm liu php sintrom v theo di t l prothrombin + Ngng thuc v tim tnh mch vitamin K trung ho khi prothrombin thp < 25% + Lm sng c du hiu chy mu 3) Ngoi khoa + Hin nay, nhiu bnh tim nh hp hai l, thng lin nhi ,co ng mch c iu tr ngoi khoa c kt qu tt + Tui thai < 7 thng m b bnh tim c ch nh m vn c kh nng m tim v: + Nguy c sau m tim cho thai ph cng tng ng vi nguy c m tim ngoi thi k thai nghn. + Sau m tim cc bin chng tim sn gim so vi nhm khng iu tr ngoi khoa! III. Hng x tr tim sn trong thi k chuyn d v sau 1) Nguyn tc + Bo v m l chnh c chiu c ti con + Ly thai bng phng php nhanh v an ton nht 2) Khi chuyn d + Cn tr tim, an thn , gim au , th oxy p ng nhu cu oxy ca cn co t cung v ca b m v trnh suy tim, ph phi cp + Tr tim + Mch nhanh dng Digoxin ng mg tim tnh mch + Mch chm dng Uabain tim tnh mch ng mg + Th oxy qua nc + An thn bng diazepam 5 mg + Gim au : Gim s chu ng cho bnh nhn + Cho sn ph nm t th Fowler + Theo di thng xuyn mch ,huyt p , nhit , ton trng m, tim thai, cn co t cung ( tt nht l bng Monitoring) + Cho khng sinh d phng nhim khun + Nu thai ngi chm , cc yu t chuyn d thun li , khi c t cung m 4 cm th bm i rt ngn chuyn d , gim thi gian ri lon huyt ng v gnh nng cho tim 3) Khi s thai + Khi iu kin t Forceps th nn bng Forceps trnh gng sc cho m khi rn + + Trnh ri ln huyt ng khi s thai:
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+ Do khi thai ra , t cung nh i , p lc bng gim t ngt , mu t chn dn ln bng nhanh gy thm tnh trng ri lon huyt ng + Phng php t ti ct ln bng bnh nhn ng thi h 2 chn bnh nhn xung thp mu t dn v bng + Hn ch ti a m ly thai, ch nh m khi khng c iu kin ng di 4) Thi k s rau + Tn trng sinh l s rau thng + Hn ch kim sot t cung v kim tra bnh rau k phng st rau v st rau v thao tc kim sot t cung d gy nhim khun v dn n vim ni tm mc + Thi k hu sn + Tip tc theo di st ton trng ca m: mch, huyt p , nhp th, nhp tim + Theo di s co hi t cung , chy mu m o + Khng sinh phng nhim khun, theo di vim ni tm mc , huyt khi 5) Vn nui con bng sa m + Ch cho b ba thng u nu m khng suy tim + Trong qua trnh nui con bng sa m ,bnh nhn phi c theo di , nh gi cc tai bin tim sn,nu xut hin bt thng phi thi cho con b ngay + Nu m c suy tim , gan to, khng nn nui con bng sa m, k c vic b con + khuyn khch sn ph vn ng nh nhng sm phng bin chng vim tc tnh mch + Vn trit sn c t ra nhng sn ph bnh tim m ng di khi m n nh IV. Phng bnh + Pht hin v x tr sm nhng ph n b bnh tim mong mun c con + Tng cng cng tc chm sc sc kho ban u v bnh tim v thai nghn + Chm sc v qun l thai nghn tt:Pht hin sm v c bin php chm sc thch hpj cho sn ph b bnh tim + Sau : Sn ph phi c chm sc , theo di , khm nh k v cc bin c tim sn u c th xy ra trong thi gian nui con, c bit nhng sn ph nui con bng sa m + Vn sinh k hoch + Nu c bin php trnh thai tm thi hay vnh vin cho cc ph n b bnh tim nh bao cao su, tht ng dn trng,
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tht ng dn tinh, xut tinh ngoi m o,tnh chu k rng trng + Chng ch nh: Khng dng thuc trnh thai + Khng t dng c t cung
Chy mu sau
Cu 1: Chy mu sau : Nguyn nhn v x tr I. i cng: + Chy mu sau l chy mu ra ng m o s lng nhiu hn bnh thng ( > 500g)trong vng 24 gi sau + Mu chy ra c th t vng rau bm, t nhng tn thng t cung nh v tu , ln t cung hay nhng tn thng ng sinh dc i khi l do ri lon ng mu sau . + Chy mu sau hin nay vn l mt tai bin sn khoa hay gp v vn l mt nguyn nhn chnh gy t vong cho sn ph + Cp cu chy mu sau i hi phi phi hp hi sc ph vi can thip sn khoa , i khi c ngoi khoa + C nhiu nguyn nhn gy chy mu sau , do cn phi theo di st c thi x tr ph hp II. Cc nguyn nhn v cch x tr : 1) t cung + L du hiu c t cung khng cht li thnh khi an ton sau thc hin tc mch sinh l , do gy chy mu sau C 2 mc t cung + t cung cn hi phc : C t cung gim trng lc sau nhng cn p ng vi cc kch thch c hc, ho hc , l hc + t cung khng hi phc : C t cung khng cn kh nng p ng vi cc kch thch l hc ho hc, c hc a) Nguyn nhn ca t cung + Cht lng c t cung km : nhiu ln, t cung c so m, t cung d dng + Do t cung b cng dn qu mc v a thai, a i , thai to + Chuyn d ko di: + Nhim khun i + St rau trong bung t cung ( t cung th pht) + Sn ph suy nhc , thiu mu, tng huyt p , tin sn git b) Triu chng v chn on :
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+ Chy mu sau khi thai v khi s rau l triu chng ph bin nht + Mu t ch chy ra ca rau bm ng li bung t cung ri mi khi c cn co t cung li y ra ngoi mt khi lng mu + Nu t cung hon ton, khng hi phc th mu chy ra lin tc, hoc khi n vo y t cung th mu chy ra t ra ngoi + T cung gin to, mm , cao trn rn khng thnh lp khi an ton, mt t cung nho + Khi cho tay vo bung t cung khng thy t cung co bps ly tay .Trong t cung ton mu cc v mu long + Ton trng sn ph ph thuc vo tnh trng mt mu + Nu mt mu nhiu : Mch nhanh , huyt p tt , v m hi , chn tay lnh, da xanh nht. c) X tr Nguyn tc + Khn trng + tin hnh song song khu cm mu v phc hi chc nng co bp ca c t cung + Hi sc chng chong. + Hi sc phi tin hnh nhanh, tch cc + t 1 ng truyn tnh mch tt + Nm theo t th Trendelenburg + Th oxy + Truyn dung dch cao phn t trong khi ch mu cng nhm( nu mt mu nhiu) + iu chnh ri lon ng mu: Fibrinogen, plasma ti( nu c) Cm mu: + n ng mch ch bng nu mu chy nhiu + Kim sot t cung ly mu cc v rau st nu c, sau khi chng chong + Gy phn x co bp t cung + Xoa bp t cung qua thnh bng phi vi tay kia trong bung t cung + Chn p t cung bng 2 tay + Thuc tng co bp t cung : oxytoxin: Tim thng vo c t cung qua thnh bng( Vng y t cung ) 5-10 UI + Truyn nh git tnh mch 5-10UI ho trong 500ml Glucose 5%. + Ergotamin 0,2 mg tim bp + Khng sinh thng dng l beta lactam Ngoi khoa:
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+ Khi thc hin cc bin php cm mu khng c kt qu( t cung khng hi phc) + Phng php tht ng mch h v 2 bn , ng mch t cung hai bn ( ngi cn tr). + M ct t cung bn phn ngi c con + phng t cung cc trng hp c nguy c ( nguyn nhn) + Truyn tnh mch chm oxytocin ngay sau khi thai s + Kim tra k bnh rau phng st rau + Cn thit tim trc tip oxytocin 5-10UI vo c t cung qua thnh bng 2) St rau a) Nguyn nhn + Tin s sy thai , no ht thai nhiu ln + nhiu ln, c ln st rau + non, thai lu + Tin s m , tin s vim nim mc t cung + Sai st trong k thut rau b) Triu chng v chn on + Chn on sm bng kim tra bnh rau thy thiu Chy mu : + L du hiu sm nht ca st rau , thng xut hin ngay sau khi s rau. + Ra mu r r hay ng li trong bung t cung lm t cung cng to khng co li c + C th c du hiu t cung th pht + Lng mu c th nhiu hay t , ti hay mu cc + T cung co hi km , c th c du hiu t cung + Khi ra mu t v chy mu ra ngoi t cung c th vn co c + Ton thn ph thuc vo lng mu mt + Khi mu mt nhiu : Mch nhanh, huyt p h , v m hi , da xanh nht. c) X tr : Kim sot t cung : + Khi Kim tra bnh rau thy st + Ra mu r r sau s rau + T cung khng c khi an ton + Phi ly ht rau v mng rau, ton b mu cc, long trong bung t cung Thuc co hi t cung + Oxytocin 5-10UI vo c t cung + Ergotamin 0,2 mg tim bp + Hi sc truyn mu nu c du hiu thiu mu cp Hanoi Medical University LTL 127
Khng sinh 3) Rau ci rng lc + L khi gai rau bm trc tip vo c t cung , c khi gai rau xuyn su vo chiu dy lp c t cung ging nh cc rng ca ca 1 chic lc + C hai loi rau ci rng lc + Rau ci rng lc ton phn: Ton b bnh rau bm vo lp c nn rau khng bong ra c v khng chy mu + Rau ci rng lc bn phn:Ch 1 phn bnh rau bm su vo c t cung , bnh rau c th bong ra mt phn gy chy mu + Lng mu chy nhiu hay t ph thuc vo tnh trng co rt ca lp c t cung v mc bong rau a) Nguyn nhn + No ht thai nhiu ln + C tin s vim nim mc t cung, kim sot t cung + C so m t cung + nhiu ln, c tin s rau ci rng lc + Rau tin o. b) Chn on : Rau ci rng lc ton phn: + Sau khi s thai 1 gi rau vn khng bong c + Khng chy mu Rau ci rng lc bn phn: + Rau khng bong + Chy mu nhiu hay t tu thuc vo din rau bong rng hy hp + Th bo rau khng c kt qu + Ch boc c mt phn v chy mu nhiu Rau bm cht + Rau kh bong do lp xp km pht trin + C th bc bng tay c Rau cm t + Rau bong nhng khng s ra ngoi c v b mc kt sng no ca t cung + Ch cn cho tay vo l ly c rau ra c) X tr + Nu chy mu trong thi k s rau hoc trn 1 gi m rau khng bong th phi bc rau nhn t v kim sot t cung + Nu rau ci rng lc: M ct t cung bn phn ngay + Nu rau tin o ci rng lc : M ct t cung bn phn thp hoc ct t cung hon ton cm mu
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+ Nu mt mu nhiu : Hi sc truyn mu trong v sau m 4) Ln t cung + L khi t cung b y ln y vo trong bung tcdu hay trong m o + L mt bin chng rt him gp song rt nng + L mt cp cu phi c chn on v x tr ngay + Chia lm 2 th: + Ln t cung khng hon ton : Khi y t cung b y ln vo trong bung t cung + Ln t cung hon ton: Khi ton b y t cung v bung t cung chiu qua c t cung vo m o, ko theo c 2 phn ph , dy chng rng,dy chng trn ln theo a) Nguyn nhn: + nhiu , nhanh , ng + Dy rau ngn , dy rau cun c nhiu vng + Ly rau khng ng qui cch + n ln y mt t cung mm b) Lm sng v chn on : + Chong do au v chy mu + Nhn thy mt khi mu tt ra khi m h , mu chy t khi + S trn bng khng thy khi an ton t cung + S pha trn khi ra trong m thy c vnh ca ct t cung ( su trong m o) + Cn chn on phn bit vi Polyp t cung c) X tr : Nguyn tc : + Phi chn on v x tr ngay v t l t vong m rt cao + Nu ln t cung trc 5 pht ( c chn on ) + Nn li t cung ngay sau tim thuc gim au : Lc nn phi tc ng ln thnh hn l ln nh + Nn xong Ergotamin 0,2mg truyn tnh mch + Hi sc + Khng sinh + Nu ln t cung c bit sau 5 pht + Chng chang tch cc + Khng sinh trc khi nn li t cung + Cn gy m Phng php nn + St khun, tri khn v khun + Nn li t cung bt u t vng gn c t cung nht + Nu rau cn st, bc bng tay sau nn Sau nn : Hanoi Medical University LTL 129
+ Ngay sau khi t cung tr v hnh dng c phi tim Ergotamin lm t cung co bp cht li sau s mi rt tay ra + ng bng v sinh v khun + Truyn oxytocin nh git tnh mch phng ln t cung li + Tip tc chng chong + Khng sinh sau th thut + Nu trng hp kh nn li, nn nhng tht bi phi ct t cung ngay. 5) Rch ng sinh dc + L nguyn nhn gy chy mu t ch rch v xy ra ngay sau khi s thai, nu khng x tr kp thi s lm mt mu nng, gy t cung v ri lon ng mu. a) Nguyn nhn + sai k thut + nhanh , thai to + c t cung cha m ht m rn + Do can thip th thut forceps, ventous b) Triu chng v chn on + Chy mu ngay sau khi thai s, lng mu mt nhiu hay t ph thuc tn thng nng hay nh + Mu ti chy ra ri r hay tng dng lin tc + Sau khi xoa bp cho t cung co li mu vn chy + Ton trng ph thuc vo lng mu mt c) Chn on : + Phi bc rau nhn to v kim sot t cung ngay phng sang chn t cung + Rch tng sinh mn, v m o d quan st thays ( Rch tin nh chy mu nhiu) + Chn on rch m o bng tay , nhng bng van m o th tt hn + Chn on rch c t cung v cng : chn on bng cch cho 2 ngn tay theo b ngoi c t cung st ti cng , nu ti ch khuyt l rch c t cung .Dng van v 2 km hnh tim ko tng on c t cung quan st tm ch rch d) X tr + Hi sc chng chong nu chy mu nhiu + Khu li ch rch khng li khong trng + Khng sinh sau th thut 6) Nt t cung a) Nguyn nhn:Do t cung c so m c + Lm sng v chn on : + Chy mu t mt ngay sau s thai t bung t cung , mu ti
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b) Chn on xc nh: + Bng bc rau nhn to v kim sot t cung c) X tr : + Khu li vt nt nu nt nh gn 7) Ri lon ng mu a) Nguyn nhn : + Ri lon ng mu nhng trng hp chy mu nhiu x tr kp thi , khng y + Ri lon ng mu nhng sn ph b tin sn git , rau bong non b) Lm sng v chn on + Mu chy sau khi s thai , s rau + Chy lin tc k c sau khi kim sot t cung kim tra tn thng ng sinh dc + Mu long ti + Mu khng ng hoc c cc cc mu nh tan ra ngay sau khi chy ra + Mu chy ra ngoi m h c tnh cht mu tnh mch + Mu chy khng ngng ngay c khi cho thuc co t cung v t cung co tt c) Xt nghim : + Thy c s suy gim cc yu t ng mu + Tiu cu gim < 100.000/mm3 + Fibrinogen,2,5 g/l + Yu t ng mu gim:Nht l yu t II, VII + Sn phm tiu hu Fibrinogen dng tnh( tng) d) X tr iu tr ni khoa + Hi sc + Bi ph yu t ng mu: Fibrinogen, transamin , EAC, truyn mu + Khng sinh ton thn + iu tr nguyn nhn + Tin sn git . Cu 2: Chy mu sau , chn on v x tr I. i cng: + Chy mu sau l chy mu ra ng m o s lng nhiu hn bnh thng ( > 500g)trong vng 24 gi sau + Mu chy ra c th t vng rau bm, t nhng tn thng t cung nh v tu , ln t cung hay nhng tn thng ng sinh dc i khi l do ri lon ng mu sau .
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+ Chy mu sau hin nay vn l mt tai bin sn khoa hay gp v vn l mt nguyn nhn chnh gy t vong cho sn ph + Cp cu chy mu sau i hi phi phi hp hi sc ph vi can thip sn khoa , i khi c ngoi khoa + C nhiu nguyn nhn gy chy mu sau , do cn phi theo di st c thi x tr ph hp II. Chn on 1) Chn on dng tnh + Chy mu sau bao gm + Chy mu t vng rau bm vi s lng > 500ml.Xy ra trong vng 24 gi sau + Chy mu lin quan n tn thng ng sinh dc nh : v t cung + Tn thng phn mm ng sinh dc 2) Lm sng + Chy mu ra pha ngoi nhiu + Mu chy ra pha ngoi khng nhiu nhng r rch, lin tc + Mu ng li trong t cung lm cho t cung to dn ln , khi n y t cung ra 1 lng ln mu cc long + p dng nguyn tc theo di sau + Theo di ti phng ti thiu 2 gi + Kim tra 15 pht 1 ln : Mch , huyt p , mu sc da , s lng mu chy ra ngoi, tnh trng t cung 9 s, n y t cung ) 3) Chn on mc nng nh nh gi mc mu mt: + Quan st v nh gi s lng mu chy ra : Ch c tnh cht ch quan + Cn s lng mu cc, mu long chy ra + Tnh trng ton thn do nh hngca s mt mu + nh gi tnh trng ri lon ng mu: Khi mu khng ng hoc cc mu ng nhanh chng b tan ra + Tnh trng ton thn, tnh trng chy mu ti ch tin trin tt ln hoc xu imc d tch cc iu tr ton thn, can thip sn khoa, ngoi khoa. 4) Chn on nguyn nhn III. p dng thc hin cc bc sau pht hin nguyn nhn gy chy mu sau Bc 1: Trong trng hp rau cha s: Cn bc rau nhn to v kim sot t cung Trong trng hp s rau cn kim sot t cung
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+ T c th hng ti cc nguyn nhn: + Rau khng bong, st rau + Rau khng bong hon ton hoc khng bong 1 phn + Hu qu ca 1 hay nhiu nguyn nhn sau + Ri lon v co bp: t cung , t cung tng trng lc + Bt thng v v tr rau bm : Rau tin o + Rau ci rng lc + Bt thng v hnh thi bnh rau: Bnh rau ph, bnh rau qu ln + Sai st v k thut : Ko dy rau qu sm , day y t cung + Bc rau nhn to v kim ot t cung khng nhng cho php chn on m cn l ng tc iu tr t cung ( 50%) + T cung mm , khng c trng lc , trong bung t cung c cha nhiu mu cc , long Nguyn nhn + Cht lng c t cung km : nhiu ln, t cung c so m, t cung d dng + Do t cung b cng dn qu mc v a thai, a i , thai to + Chuyn d ko di: + Nhim khun i + St rau trong bung t cung ( t cung th pht) + Sn ph suy nhc , thiu mu, tng huyt p , tin sn git + V t cung , nt t cung (v t cung di phc mc) + Trn nhng bnh nhn c : So m c t cung , c t cung . nhiu Ln t cung + y t cung , bung t cung ln ra ngoi ging nh ln ngn tay ca gng phu thut Nguyn nhn : + nhiu , nhanh , ng + Dy rau ngn , dy rau cun c nhiu vng + Ly rau khng ng qui cch + n ln y mt t cung mm Bc 2 : + Mu vn tip tc chy sau kim sot t cung , t cung co tt + Khm bng van m o tm tn thng ng sinh dc Nguyn nhn + sai k thut + nhanh , thai to Hanoi Medical University LTL 133
+ c t cung cha m ht m rn + Do can thip th thut forceps, ventous Bc 3 + Mu vn tip tc chy sau 2 bc kim tra trn khng tm thy nguyn nhn + Mu chy vi tnh cht + Mu long ti + Mu khng ng hoc c mu cc nh tan ra ngay sau khi chy ra + Mu chy ra ngoi m h c tnh cht mu tnh mch + Mu chy khng ngng ngay c sau khi cho thuc co t cung v triu chng co tt + Xt nghim thy tiu cu gim < 100.000/mm3 + Fibrinogen < 2,5 g/l + Sn phm tiu hu Fibrinogen dng tnh + Yu t ng mu gim c bit l yu t V v VII < 80 % + Nguyn nhn IV. Thi x tr + Hi sc nhanh , tch cc tin hnh trc nhng canthip sn khoa , ngoi khoa, t 1 ng truyn tnh mch tt + Nm nghing Trendelenburg + Th Oxy + Truyn dch , dung dch cao phn t , truyn mu khi cn thit + + iu chnh ri lon ng mu bng fibrinogen , plasma ti 1) X tr sn khoa, ngoi khoa + Trong trng hp rau khng bong ( hon ton , bn phn) hay st rau + Bc rau nhn to, kim sot t cung + t cung + Kim sot t cung + Xoa bp t cung + Tim truyn oxytocin, thm ch tim trc tip vo c t cung + Tim bp hoc tim tnh mch Ergotamin + Trong 1 s trng hp tim Prostaglandin tng hp ( Nalador) + Trng hp tn thng phn mm sinh dc : khu phc hi + Trong trng hp c ri lon ng mu : iu tr ni khoa v iu tr nguyn nhn Hanoi Medical University LTL 134
2) X tr ngoi khoa + iu tr bo tn: nhng sn ph cn tr , cn mong mun c con + Mc ch: Ngn chn v kim sot tnh trng chy mu trong trng hp + Rau tin o + t cung ti pht + Bt u c ri lon ng mu + K thut : Tht ng mch + H v hai bn + ng mch t cung hai bn + Phng php T siruluikov (Tht ng mh t cung , ng mch vi trng -bung trng, ng mch daayf chng trn) + Ct t cung cm mu : bn phn hoc ton phn Ch nh + Rau ci rng lc + Rau tin o chy mu nhiu + V t cung vt rch nham nh + Ln t cung khng y ln c + Ri lon ng mu nguy c e do n tnh mng
Nhim khun hu sn
Cu 1:Chn on v x tr vim t cung hu sn I. i cng + Sn dch l mi trng thun li cho vi khun pht trin trong thi k hu sn. + Bung t cung rng m thng ra ngoi, lun cha mt t sn dch.Thng thng s t bo v ti ch ca t cung hn ch s pht trin ca mm bnh + Nhng vic nhim khun rt d dng xy ra .nhim khun c th l do ly nhim trc hay ng thi vi lc , hay th pht sau mt nhim khun ngc dng + Nhim khun hu sn l nhim khun xut pht t b phn sinh dc , thng thng nht t bung t cung , nht l ni rau bm, xy ra trong thi k hu sn( 6 tun sau ) + Nhng trng hp nhim khun m ng vo ca vi khun khng phi l t b phn sinh dc th khng phi l nhim khun hu sn + Cng vi s pht trin ca y hc,vic tm ra cc nguyn nhn gy bnh cng vi cc yu t thun li cng nh vic pht trin ngy cng hin i ca cc phng php v khun , ca khng sinh hn ch c t l mc bnh v t l t vong ca nhim khun hu sn
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+ C nhiu hnh thi ca nhim khun hu sn: Nhim khun tng sinh mn, m h , m o, vim t cung , vim quanh t cung v phn ph, vim phc mc hu sn, vim tc tnh mch v nhim khun huyt hu sn Vim t cung hu sn c hai hnh thi + Vim nim mc t cung + Vim t cung ton b II. Chn on 1) Vim ni mc t cung + y l hnh thi nh ca nhim khun t cung nhng nu khng iu tr hu hiu, c th dn n bin chng nng hn nh vim t cung ton b , vim phc mc, nhim khun huyt a)Nguyn nhn: + i v non,sm, nhim khun i + Chuyn d ko di + St rau, st mng, bc rau nhn to, kim sot t cung khng m bo v khun + Cc th thut can thip khng m bo v khun + B sn dch b)Triu chng c nng + Sau 3-4 ngy + Ngi mt mi kh chu + St nng 38-39 , c khi gai rt + Sn dch hi i khi ln m. Nng mi hn nu nhim khun k kh c)Triu chng thc th + Mch nhanh, huyt p c th thay i + T cung to , co hi ch,mm n au + c t cung h m + Thm ti cng m o khng au + Khm v : khng thy c cng sa d)Xt nghim : + cng thc mu : bch cu tng + Cy sn dch xc nh vi khun v lm khng sinh + Gii phu bnh : T cung mm , nho + Vng rau bm g gh ,c th c cc mu hay mi rau hoi t + B mt ni mc t cung c th thy lp sn dch, hi bn e)X tr + Khng sinh: Dng ton thn theo khng sinh , nu khng c khng sinh : Dng khng sinh ph rng, kt hp nhiu khng sinh + Sn khoa: Thc hin sau khi hoc ht st
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+ Nu l do b sn dch th nong c t cung + No sch bung t cung ly rau , mng rau st + Thuc co hi t cung 2) Vim t cung ton b + y l hnh thi vim t cung nng hn , nhim khun lan rng n lp c t cung, c khi c nhng m trong lp c .Tin trin c th lm thng t cung gy vim phc mc hoc nhim khun huyt a)Nguyn nhn + Tng t nh vim nim mc t cung nhng do khng c pht hin iu tr kp thi v lm nhim khun lan rng. b)Triu chng ton thn + Nng n hn vim ni mc t cung + Ton thn tnh trng nhim trng nng + St cao 39-40 + M kh , li bn , hi th hi + th trng suy sp Th nng + au bng tng cn + Ra kh h mu en nng mi. + C th ra huyt ngy th 8 - th 10 sau c)Triu chng thc th : + T cung h m + T cung to mm, n au c bit l 2 sng t cung v eo t cung .i khi c ting lo xo nh c hi d)Xt nghim + Cng thc mu : bch cu tng, mu lng tng + Cy sn dch v lm vi khun, khng sinh + Gii phu bnh : B mt t cung xung huyt + C nhng hc cha m to nh khc nhau e)X tr Ni khoa + Khng sinh ton thn liu cao theo khng sinh v phi hp khng sinh + (nu khng c khng sinh phi dng khng sinh ph rng, phi hp khng sinh) + Sn khoa: Nu iu tr ni khoa ,no sch bung t cung , thuc co hi t cung + Nu khng th m ct t cung bn phn Cu 2: Vim phc mc hu sn: Chn on v x tr
i cng
+ Sn dch l mi trng thun li cho vi khun pht trin trong thi k hu sn.
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+ Bung t cung rng m thng ra ngoi, lun cha mt t sn dch.Thng thng s t bo v ti ch ca t cung hn ch s pht trin ca mm bnh + Nhng vic nhim khun rt d dng xy ra .nhim khun c th l do ly nhim trc hay ng thi vi lc , hay th pht sau mt nhim khun ngc dng + Nhim khun hu sn l nhim khun xut pht t b phn sinh dc , thng thng nht t bung t cung , nht l ni rau bm, xy ra trong thi k hu sn( 6 tun sau ) + Nhng trng hp nhim khun m ng vo ca vi khun khng phi l t b phn sinh dc th khng phi l nhim khun hu sn + Cng vi s pht trin ca y hc,vic tm ra cc nguyn nhn gy bnh cng vi cc yu t thun li cng nh vic pht trin ngy cng hin i ca cc phng php v khun , ca khng sinh hn ch c t l mc bnh v t l t vong ca nhim khun hu sn + C nhiu hnh thi ca nhim khun hu sn: Nhim khun tng sinh mn, m h , m o, vim t cung , vim quanh t cung v phn ph, vim phc mc hu sn, vim tc tnh mch v nhim khun huyt hu sn Vim phc mc hu sn thng xut hin sau vim t cung hu sn, nhim khun lan cc c quan ln cn ri gy vim phc mc C 2 hnh thi vim phc mc:
A. Vim phc mc tiu khung:

Nguyn nhn v ng lan truyn + T cc nguyn nhn gy vim t cung nh: Nhim trng i, st rau, st mng, th thut can thip khng v khun( kim sot t cung , bc rau nhn to)B sn dch + Vi khun t t cung qua vi trng , bung trng n phc mc tiu khung.Cng c khi nhim khun t t cung qua ng bch huyt gy vim phc mc m khng qua cc tng khc + Nhim khun lan ti ti cng sau , manh trng, bng quang, trc trng + Nhim khun lan n u , s hnh thnh cc gi mc lm phc mc dnh vo nhau , cm ng phc mc s sinh ra , cc ti dch ln mu, m , c th v vo cc tng xung quanh v bng II. Triu chng + Thng xut hin vo ngy th 7 sau ( sm vo ngy th 3, mun l ngy th 15) 1) Triu chng ton thn
I.
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+ Nhit tng dn hay t ngt 39-40 , km theo rt run + Mt mi , hc hc , mch nhanh + Li trng 2) Triu chng c nng + au bng vng h v, au m hay d di + Sn dch nhiu, hi + C th c triu chng ca m , ng h v nh: i but , i rt, to bn + Nu m ng ti cng s gy ra hi chng gi l, mt rn au bng phn t 3) Triu chng thc th + Bng chng nh, c phn ng thnh bng vng h v,cc vng khc mm , khng c phn ng + C t cung h m + T cung to, km di ng , au + Ti cng sau , ti cng bn dy, ph n, au + Thm m o kt hp vi tay nn bng thy vng h chu c khi rn , khng di ng , au + Thm trc trng cng s thy khi u + Chc d ra m III. Xt nghim + Cng thc mu ; bch cu tng cao, mu lng tng cao + Cy sn dch t c t cung tm vi khun v lm khng sinh + Xquang bng : Cng v tiu khung m (v c dch ) + Siu m thy cc khi dch h v IV. Chn on 1) Chn on xc nh + da vo lm sng v cn lm sng 2) Chn on phn bit a) Vim phc mc ton b + Ton trng suy sp nng + C du hiu tc rut, bn tc + Phn ng ton b bng + Xquang m ton b bng+ du hiu tc rut b) Vim quanh t cung hu sn + au nhiu vng h v, sn dch nhiu, hi + Khng c phn ng thnh bng di, chng bng + Thm m o: Khi mm au, b khng r, di ng kh + Khi cao nu vim phn ph + thp nu vim y dy chng rng c) U nang bung trng xon hay kt Douglas sau + au h v d di Hanoi Medical University LTL 139
+ Khng c hi chng nhim trng + Shock + Phn ng thnh bng r + Thm m o: C t cung , t cung bnh thng + Sn dch t, khng hi + T cung c th b y ra trc hay ra sau + Siu m khi ranh gii r cnh t cung V. X tr 1) iu tr ni khoa l chnh + Nm ngh ngi, chm , vitamin C + Khng sinh ton thn liu cao theo khng sinh ( nu khng c khng sinh th phi dng khng sinh ph rng , phi hp) + Khng sinh tip tc dng nhiu ngy sau khi nhit gim 2) iu tr ngoi + Nu m ti cng th dn lu qua ng m o + Ch m bng khi c bin chng vim phc mc ton b 3) Tin trin Trong iu kin iu tr khng kp thi v liu khng , vim phc mc tiu khung s tin trin thnh : a) Apces Douglas : Triu chng nhim khun vn tng + au chi tiu khung + Thm m o : t cung b y ra trc , c t cung b cht di v + Cng sau c khi au,b khi vt qu cnh t cung + Thm trc trng thy r khi apces iu tr + iu tr ni khoa kt hp vi trch ti cng sau, tho dn lu m phng r trc trng m o v phng vim phc mc ton b b) Vim vi trng m + t gp + Thm c khi n, au, bit lp vi t cung + iu tr khng sinh v phu thut ct b khi vi trng m + Vim ty dy chng rng: Khi ny c th cao ( h v) hoc thp hn + Thm m o : Khi lan to c hai bn , y t cung ra trc + iu tr khng sinh liu cao
B. Vim phc mc ton b
I. Nguyn nhn v ng lan truyn:

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+ y khng nu ln vim phc mc ton b sau m ly thai,sau no thai + Vim phc mc ton b xy ra sau vim nim mc t cung , t cung II. Nguyn nhn v ng dn truyn: + T cc nguyn nhn gy vim t cung nh: Nhim trng i, st rau, st mng, th thut can thip khng v khun( kim sot t cung , bc rau nhn to)B sn dch + Vi khun t t cung qua vi trng , bung trng n phc mc tiu khung.Cng c khi nhim khun t t cung qua ng bch huyt gy vim phc mc m khng qua cc tng khc + Nhim khun lan ti ti cng sau , manh trng, bng quang, trc trng + Nhim khun lan n u , s hnh thnh cc gi mc lm phc mc dnh vo nhau , cm ng phc mc s sinh ra , cc ti dch ln mu, m , c th v vo cc tng xung quanh v bng + Cng c khi vim phc mc ton b pht trin t vim phc mc tiu khung hay t apces Douglas, ca vim vi trng m III. Triu chng + Sau c nhng du hiu nhim khun ca b phn sinh dc giai on c m + Khong 7-10 ngy sau , t ngt xut hin nhng triu chng ca vim phc mc ( Do m t ngt v vo bng gy vim) 1) Triu chng c nng + au khp bng , au d di + Nn + C th c i t + C hi chng bn tc rut hay tc rut + C khi c i phn lng , khm 2) Triu chng ton thn + Du hiu nhim trng nhim c nng: St cao , rt run, mi kh, mt trng , mch nhanh mt mi, suy sp 3) Triu chng thc th + Bng chng + C phn ng thnh bng hay cm ng phc m (i khi triu chng ny m i do cc c thnh bng cn nho sau ) + Triu chng co hi km, au + Thm m o : C t cung h m
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+ T cung to mm , n au + Sn dch hi + Ti cng phng cng au IV. Xt nghim : + Cng thc mu : bch cu tng, mu lng tng + Cy sn dch t bung t cung v dch bng tm vi khun lm khng sinh + Xquang + C du hiu mc nc mc hi + bng m, quai rut gin , thnh rut dy + Siu m nhiu dch trong bng + Ure , creatinin tng nu c tn thng thn V. Chn on 1) Chn on xc nh : + Da vo lm sng v cn lm sng 2) Chn on phn bit a) Vim phc mc tiu khung + au h v + Hi chng nhim trng nh hn + Phn ng thnh bng khu tr vng h v cc vng khc khng c phn ng + Xquang, siu m ch thy du hiu c dch vng tiu khung + Gi vim phc mc sau + Bng chng, b i tin, trung tin kh + Ton trng bnh thng, hi chng nhim trng m tnh + t sonde d dy , sonde hu mn , cho prostismin bng chng , au + Khng c phn ng thnh bng b) Vim phc mc do nguyn nhn khc + Thng s c cc du hiu gi ca nguyn nhn gy bnh VI. X tr : + M cp cu cng sm cng tt + Trc trong v sau m phi hi sc tch cc + M ct t cung bn phn v 2 phn ph nu c tn thng + Ra sch bng , khng sinh ra k , lau kh + t dn lu + T ch thp nht ca thnh bng ra thnh bn + ng dn lu to + Rt khi ht dch ( thng khong 24-72 gi) + Kt hp vi iu tr ni
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+ Khng sinh ton thn liu cao theo khng sinh ( nu khng c khng sinh th khng sinh ph rng kt hp vi nhiu loi) + Hi sc tch cc trc , trong , sau m + Chng ri lon in gii, chng suy nhc VII. Tin lng + Tin lng tt khi chn on sm v m kp thi + Tin lng xu thm ch gy t vong nu m chm .Nu c khi th cng hay gy di chng dnh rut , tc rut + Phng bnh + Ch v khun , kh khun khi khm m o, khi lm cc th thut t cung , khng st rau , iu tr tch cc cc hnh thi ca nhim khun hu sn Cu 3: Nhim khun huyt hu sn: Chn on v x tr I. i cng + Sn dch l mi trng thun li cho vi khun pht trin trong thi k hu sn. + Bung t cung rng m thng ra ngoi, lun cha mt t sn dch.Thng thng s t bo v ti ch ca t cung hn ch s pht trin ca mm bnh + Nhng vic nhim khun rt d dng xy ra .nhim khun c th l do ly nhim trc hay ng thi vi lc , hay th pht sau mt nhim khun ngc dng + Nhim khun hu sn l nhim khun xut pht t b phn sinh dc , thng thng nht t bung t cung , nht l ni rau bm, xy ra trong thi k hu sn( 6 tun sau ) + Nhng trng hp nhim khun m ng vo ca vi khun khng phi l t b phn sinh dc th khng phi l nhim khun hu sn + Cng vi s pht trin ca y hc,vic tm ra cc nguyn nhn gy bnh cng vi cc yu t thun li cng nh vic pht trin ngy cng hin i ca cc phng php v khun , ca khng sinh hn ch c t l mc bnh v t l t vong ca nhim khun hu sn + C nhiu hnh thi ca nhim khun hu sn: Nhim khun tng sinh mn, m h , m o, vim t cung , vim quanh t cung v phn ph, vim phc mc hu sn, vim tc tnh mch v nhim khun huyt hu sn + Nhim khun huyt hu sn l hnh thi nng nht ca nhim khun hu sn.L nhim khun th pht sau cc hnh thi nhim khun hu sn khc , bt ngun t ng sinh dc ch yu t vng rau bm t cung II. Nguyn nhn : + Thng l do vi khun c c t cao nh t cu vng, lin cu tan huyt , Ecoli, vi khun ym kh Hanoi Medical University LTL 143
+ Cc yu t a n nhim khun hut + T cc yu t gy nhim khun hu sn nh b sn dch, nhim trng i , chuyn d ko di , st rau st mng , bc rau nhn to , kim sot t cung khng v khun,cc th thut thm khm khng m bo v trng, m ly thai khng v khun.T vim nim mc t cung , qu trnh nhim khun lan rng ra xung quanh, hoc vo su lp c t cung , theo ng mu, t trng thi vi khun vng lai trong mu tr thnh nhim khun huyt + iu tr cc hnh thi nhim khun hu sn khc khng ng , khng kp thi , khng ng khng sinh III. Triu chng 1) Triu chng ton thn + Sau 1 tun xut hin triu chng + St cao lin tc hoc dao ng, km theo rt run + Th trng nhim trng nhim c nng: Mt mi suy sp, thn kinh li b, v mt hc hc , mi kh , li bn , hi th hi + Trng hp nng c th shock nhim khun: Hn m, bn hn m, mch nhanh , nh kh bt , huyt p h , kh th km theo thiu niu, v niu , vng da + Ri lon in gii, nhim toan chuyn ho 2) Triu chng thc th Thm khm + Sn khoa: C t cung h m, t cung to, co hi chm, di ng t cung au + Sn dch rt hi, c mu , m c th ln mng rau thi ( nu st rau) + Thm khm cc c quan khc c th thy di bnh nh gan to, lch to, bng chng , phi c rale m.C th gp nhim khun xng khp , da nim mc , vim mng no , pces no , vim ni tm mc IV. Xt nghim + Cy mu tm vi khun. Cy mu lc st cao ,4 gi 1 ln x 3 ln, khi cha c khng sinh + Cy sn dch ( t bung t cung ), cy nc tiu( Sonde tiu) , lm khng sinh + Cng thc mu : Bch cu tng , mu lng tng, hng cu , hematocrit gim + Siu m thy t cung to , co hi chm , nhiu dch trong bung t cung , c th thy st rau + Cc xt nghim tm di bnh : Chc nng gan, thn , siu m bng , Xquang phi , nh lng cc yu t ng mu + Ri lon nc v in gii Hanoi Medical University LTL 144
+ Ri lon toan kim V. Chn on 1) Chn on xc nh: + Da vo lm sng v cn lm sng ( kt qu cy mu) tm di bnh.Tuy nhin nu cy mu m tnh nhng lm sng in hnh th vn phi x tr nh nhim khun huyt VI. Bin chng + Suy gan, thn, vim thn cp,apces phi, vim ni tm mc , apces no, vim mng no + Hnh thc nng nht l shock nhim khun, d t vong VII. iu tr 1) Nguyn tc + Khng sinh liu cao, phi hp theo khng sinh + Hi sc tch cc + Tm v iu tr nhim khun ban u + iu tr triu chng khc v cc di bnh nu c 2) iu tr c th + Khng sinh liu cao, ton thn , ng tim hoc truyn tnh mch.Tt nht l theo khng sinh .Nu khng c khng suinh th phi hp thucnh sau: Cephalosporin th h 3 vi aminosid vi Metronidazol + Dng khng sinh thm 7 ngy sau khi ht st + Hi sc tch cc:Th oxy, truyn dch , tr tim, vn mch( nu c shock nhim khun) + Gii quyt nhim khun bng cch ct t cung v 2 phn ph sau khi ht st 3) iu tr h tr khc : + H st , an thn, iu chnh cn bng in gii, thng bng kim toan 4) iu tr cc di bnh nu c Cu 4: Nhim khun hu sn: Nguyn nhn v x tr I. i cng + Sn dch l mi trng thun li cho vi khun pht trin trong thi k hu sn. + Bung t cung rng m thng ra ngoi, lun cha mt t sn dch.Thng thng s t bo v ti ch ca t cung hn ch s pht trin ca mm bnh + Nhng vic nhim khun rt d dng xy ra .nhim khun c th l do ly nhim trc hay ng thi vi lc , hay th pht sau mt nhim khun ngc dng + Nhim khun hu sn l nhim khun xut pht t b phn sinh dc , thng thng nht t bung t cung , nht l ni rau bm, xy ra trong thi k hu sn( 6 tun sau )
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+ Nhng trng hp nhim khun m ng vo ca vi khun khng phi l t b phn sinh dc th khng phi l nhim khun hu sn + Cng vi s pht trin ca y hc,vic tm ra cc nguyn nhn gy bnh cng vi cc yu t thun li cng nh vic pht trin ngy cng hin i ca cc phng php v khun , ca khng sinh hn ch c t l mc bnh v t l t vong ca nhim khun hu sn + C nhiu hnh thi ca nhim khun hu sn: Nhim khun tng sinh mn, m h , m o, vim t cung , vim quanh t cung v phn ph, vim phc mc hu sn, vim tc tnh mch v nhim khun huyt hu sn II. Nguyn nhn 1)Tc nhn gy bnh: + Vi khun gram m hay gp nht + Ecoli v cc Enterobacter khc + Vi khun gram dng: Lin cu, t cu + Vi khun k kh : Clostridium, Bacteroides + Cc vi khun t c th sn ph, ngi xung quanh, t dng c , t cc th thut ly thai, nhng th thut trong bung t cung ( bc rau nhn to, kim sot t cung ) 2)ng lan truyn : + Vi khun t m h vo m o vo c t cung n t cung ln vi trng v vo phc mc + Vi khun c th theo ng bch huyt , tnh mch Cc yu t thun li: + Dinh dng km + V sinh km + Tin sn git + Vim m o , vim c t cung t trc + thiu mu + M b bnh mn tnh + V i non, sm + Cc th thut ly thai, rau , bc rau nhn to , kim sot t cung + Chuyn d ko di + Thm khm nhiu + M ly thai + B sn dch III. X tr : 1)Nguyn tc : + Nhim khun hu sn c nhiu hnh thi lm sng khc nhau, mi hnh thi lm sng c cch iu tr c th ring, tuy nhin cn theo nguyn tc sau:
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+ Khng sinh ton thn liu cao theo khng sinh , nu khng c khng sinh th dng khng sinh ph rng liu cao , phi hp khng sinh + Khi ht st vn phi sng thm khng sinh 7 ngy na + Tm v iu tr trit nhim khun khi nhit v bnh thng + Ct t cung v phn ph khi c ch nh + Chng shock nu c + iu tr triu chng v cc ri lon km theo + H st, an thn, nng cao th trng 2)iu tr c th a) Vi nhim khun ng sinh dc ( tng sinh mn, m h, m o): + Ch yu l v sinh ti ch bng thuc st khun + Ct ch khi c mng m + Khng sinh ng ung ( nu c khng sinh l tt nht) b) Vim nim mc t cung + Khng sinh liu cao ton thn theo khng sinh ( nu khng c khng sinh phi phi hp khang sinh ph rng) + Sau khi hay ht st: No li bung t cung , nong c t cung ( nu b sn dch) + iu tr triu chng : + H st, an thn, dinh dng c) Vim t cung ton b + Khng sinh liu cao ton thn theo khng sinh ( khng c khng sinh th phi phi hp khng sinh ph rng) Sn khoa + iu tr ni th no sch bung t cung cho thm thuc co hi t cung + iu tr ni khng : m ct t cung bn phn + Vim quanh t cung v phn ph + Ngh ngi hm , nng cao th trng + Khng sinh liu cao ton thn theo khng sinh ( hoc khng sinh ph rng , phi hp cc khng sinh) + iu tr triu chng d) Vim phc mc Vim phc mc tiu khung + Ngh ngi chm , vitamin + Khng sinh liu cao ton thn theo khng snh ( hoc khng sinh ph rng kt hp)Tip tc dng 7 ngy sau khi ht st Ngoi khoa: + Nu m ti cng th dn lu qua ng m o
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+ Ch m bng khi c vim phc mc ton b + iu tr triu chng Vim phc mc ton b + M cp cu cng sm cng tt + trc trong v sau m phi hi sc tch cc + Ct t cung bn phn v 2 phn ph( nu c tn thng) + Ra sch bng, lau kh + t dn lu thp nht ca bng ra thnh bn t dn lu to, rt khi ht dch (24-48 gi) + kt hp vi iu tr ni: iu tr ni : + Khng sinh ton thn liu cao theo khng sinh , nu khng c khng sinh th phi phi hp khng sinh ph rng + Cng thc Beta lactam + Aminosid + Metronidazol + Vancomycin 3-6 g/24h + Gentamycin 80mg /24 h + Metronidazol 500mg/100ml/24h + Pha 500ml Glucose 5% truyn tnh mch + Hi sc tch cc, chng suy nhc , chng ri lon nc v in gii + iu tr triu chng e) Nhim khun huyt hu sn + Khng sinh ton thn liu cao , phi hp , tt nht l theo khng sinh + Cephalosporin th h 3 vi Aminosid + Metronidazol + Dng thm 7 ngy sau khi ht st + Hi sc tch c + Truyn dch , truyn mu, tr tim, th oxy + Gii quyt nhim khun bng cch ct t cung v 2 phn ph khi ht st + iu tr h tr khc : H st, an thn , li niu, chng ri lon nc v in gii , chng ri lon toan kim , nng cao th trng + iu tr cc di bnh nu c f) Vim tc tnh mch + Bt ng chi b tc t nht 3 tun sau khi ht st + Vim tc tnh mch nng cn iu tr chng vim kt hp vi chn p ti ch + Khng sinh ton thn kt hp vi corticoid sau vi ngy iu tr khng sinh + Thuc chng ng + Heparin 25000UI/kg/24h Hanoi Medical University LTL 148
+ Tim tnh mch ch 2-4 gi 1 ln trong 15 ngy hoc truyn nh git tnh mch duy tr nng heparin trong mu + Kim tra xt nghim gim ng mu bng 1,5 3 ln thi gian so vi nhm chng + Dicoumarol ( Coumadine) + Loi ung 2-10mg ( l loi khng vitamin K, tc dng chm) liu 2-10 mg/24 gi + Theo di kt qu xt nghim thi gian Howell v Quick + Kim tra kt qu: Duy tr thi gian Quick l 20-35% + ang s dng heparin m thay th sang dng Dicoumarol th phi dng tip heparin cho ti khi Dicoumarol c tc dng + Phu thut lm thng ch tc ch t ra nu huyt khi mi b cc mch mu chu i.
Thuc trnh thai.

Cu 1:Vin thuc trnh thai phi hp: Ch nh, chng ch nh,c ch tc dng I. i cng + Thuc trnh thai l mt phg php trnh thai c hi phc bng cch dng ni tit t(estrogen v progesterol) lm c ch phng non hay gy tr ngi qu trnh th tinh v lm t ca trng + Vim thuc trnh thai kt hp l thuc c kt hp bi 2 loi hormon progestrin va estrogen. Trong progestrin l thnh phn trnh thai ch yu, estrogen gii quyt chy mu thm git ca prgestrin v gy ra mu kinh Phn loi vin trnh thai kt hp: Nu da vo lng estrogen trong mi vin thuc , c 2 loi: + Vin trnh thai liu cao: Hm lng EE( EthinylEstradiol) l 50 mcg trong mi vin thuc + Vin trnh thai liu thp: Hm lng EE l 20-40 mcg/vin Nu da vo s phi hp gia 2 loi hormon th c 4 loi + Vin trnh thai phi hp hm lng EE v progestatif ging nhau trong mi vin thuc ca v thuc (ovidon,marvelon) + Dng k tip: Phn u ca v thuc ch c estrogen , phn sau c c 2 loi estrogen v progestatif. + Dng 2 pha: Hm lng EE v progestatif thay i 1 ln trong v thuc + Dng 3 pha : Hm lng EE v progestatif thay i 2 ln trong v thuc II. C ch tc dng:
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Tc dng ln 3 ni: 1) trung tm di i tuyn yn: + Tc dng quan trng nht. + c ch phng non do c ch trc di i - tuyn yn dn ti gim FSH- LH.Khi gn n ngy phng non khng c nh cao LH , do c ch bung trng phng non 2) ni mc t cung + Lm teo ni mc t cung + Lm lon dng ni mc t cung , cc tuyn khng vo thi k ch tit , tuyn t, mng, teo b, khng c tiu ng mch xon.Mng rng xut hin sm. + V vy nim mc t cung khng thch hp cho trng lm t 3)Tc dng ln tuyn c t cung : + Lm gim tit nhy c t cung c qunh, cn tr s xm nhp ca tinh trng + Vai tr ni tri ca tng c ch khc nhau tu theo s kt hp ca tng loi thuc. III. Ch nh : 1)Mc ch trnh thai: + Cho tt c ph n mong mun trnh thai tm thi c hiu qu cao nu khng c chng ch nh. + Trnh thai khn cp 2)Ch nh ngoi mc ch trnh thai : + au bng kinh + Cha trng c trc tui v thnh nin + Ri lon kinh nguyt do mt cn bng ni tit + B thiu mu v hnh kinh nhiu. IV. Chng ch nh: 1)Chng ch nh tyt i: + ang c thai cho d ngi ta khng thy tc hi ca thuc trnh thai vi m v con + ang cho con b( thuc lm gim lng sa) + Tin s huyt khi ngmch v vim tc tnh mch + Bnh l c nguy c b bnh huyt khi: Bnh tnh mch, sau phu thut, phi nm lu + Tin s hoc hin ti c thiu mu c tim + Tng huyt p , tai bin mch mu no( tin s hoc hin ti) + i tho ng ph thuc Insulin + Tng lipid mu + Bnh l gan mt tin trin, vng da mt, vim gan B, x gan, ung th gan
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+ Bnh l nguyn bo nui( cha trng, chorio)( ang b hoc tin s) + Bnh ung th ph thuc ni tit: Ung th nim mc t cung, ung th v + Nghin thuc l ngi trn 35 tui + Suy thn + au na u 2)Chng ch nh tng i + Bo ph + tin s gia nh c tng lipid mu, i tho ng, tai bin mch no + Cng tuyn gip + U x t cung + i tho ng khng ph thuc insulin + Mt s bnh iu tr lu, thuc c phan ng vi thuc trnh thai kt hp. + Bnh trm cm + Tin s trong lc c thai tng cn qua mc hoc tng huyt p V. Tc dng ph + Ri lon kinh nguyt : S lng kinh t, s ngy ra t,ra m gia 2 k kinh( do estrogen gim) + Ra mu thm git + Bun nn nhc u,sau 2 thng triu chng ny s gim ( do tc dng ca estrogen ) + au v, cng v , c bit gia k kinh( do tc dng ca estrogen ), i khi gy cm gic nh nghn + Trng c , xm mt ( tc dng ca progesterol) + Gim lng sa m( khng dng khi ang cho con b) Tng cn do nc , cao huyt p ( do estrogen) + Tng ng mu,do tng sinh si huyt, tng kt dnh tiu cu , nguy c huyt khi,tc mch do tng ng mu + Tng cholesterol mu do tng chuyn ho lipid + nh hng khng tt n ni tit , lm nng thm Basedow, i tho ng + Gy vng da mt, lm tng si ti mt + Trm cm, thay i tm tnh VI. Cch ung Bt u ung t ngy th 1-5 ca vng kinh ( chm l ngy th 3).V thuc 28 vin=21 vin trnh thai v 7 vin gi khng c thuc trnh thai .Ung lin tc ri sang v khc + Nu dng v 21 vin th ung ht 21 vin ri ngh 7 ngy sau ung tip v khc
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+ Ung u hng ngy v nn ung vo 1 gi nht nh( bui ti).Ung theo chiu mi tn ch trn v thuc.Hiu qu trnh thai ngay trong chu k u tin + Nu qun thuc 1 ngy th sng ngy hm sau ung 1 vin b v ti ung 1 vin nh thng l + Nu qun ung 2 ngy th hm sau , hm sau na ( trong vng 2 ngy ) phi ung mi ngy 2 vin . ng thi p dng bin php trnh thai khc h tr trong 7 ngy + Nu qun > 2vin th b v thuc ,bt u dng v thuc mi v dng bin php trnh thai khc h tr trong 7 ngy Ngng dng thuc khi phu thut ( trc m 4 tun), nn ngng thuc trc khi c thai t nht 3 thng ni mc t cung tr v bnh thng, hn ch t l a thai.Nu c thai khi ang dng thuc th din bin ca thai nghn bnh thng , khng c ch nh ph thai + Sau no ht thai nn dng loi vin k tip gip cho ni mc t cung ti to tt, hn ch dnh bung t cung u im + Hiu qu rt cao , l phng php trnh thai c hi phc , d s dng, thun tin + Gim mt s hi chng ph khoa,gim au bng kinh, gim rong kinh,gim kinh nhiu gim vim phn ph + Gim cha ngoi t cung v khi u lnh tnh bung trng , ung th ni mc t cung , ung th v + Hon ton khng lin quan ti giao hp + Gim nguy c thiu mu thiu Fe Nhc im: + Cn ung thuc u n + Gi thnh t + Phi nh ung thuc hng ngy + Nhiu tc dng ph + Khng phng trnh c cc bnh ly qua ng tnh dc + Khng s dng c cho ngi cho con b. Vin thuc trnh thai khn cp Ch nh + Ph n sau giao hp khng s dng bin php bo v + S dng bin php trnh thai tht bi + B hip dm Cch dng + Ung 4 vin cng sm cng tt trong 72 gi u sau giao hp + 12 gi sau ung tip 4 vin na Theo di:
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+ Khm li ngay nu thy chm kinh + Nu b nn trong vng 2 gi sau khi ung phi ung li + Khng dng qu 2 ln trong 1 thng + Khng nn dng thng xuyn Cu 2:Vin thuc trnh thai n thun:C ch,ch nh, chng ch nh. I. i cng + Thuc trnh thai n thun l trong thnh phn ch c progestin II. C ch trnh thai + c ch khng hon ton trc di i tuyn yn , c ch s phng non + Lm gim v c qunh cht nhy c t cung , ngn cn tinh trng xm nhp vo bung t cung + Gy teo mng ni mc t cung , khng ph hp cho trng lm t + Lm hong th teo sm III. Ch nh + Ngi ang cho con b v ngi ph n c nhu cu trnh thai bng thuc m c chng ch nh vi estrogen ,nh bnh tim mch, tng huyt p , o tho ng, ri lon ng mu, huyt khi. + Mun trnh thai khn cp ( ung progesterol liu cao ) IV. Chng ch nh + C thai hoc nghi c thai + Ri lon kinh nguyt cha r nguyn nhn + Ung th ph thuc ni tit : ung th v, ung th bung trng, ung th c t cung + Bnh l gan mt: vim gan, x gan + ang dng thuc chng co git khng sinh chng lao V. Cch dng : v 28 vin + Nu dng cho sn ph sau v cho con b ,tt nht l bt u ung sau thi k hu sn + Mi ngy ung 1 vin vo gi nht nh + Vin u ung ngy u ca chu k kinh nguyt , ung lin tc khng ngh , ht v ny dng v khc + Nu qun sau khi nh li ung b ngay + Qun thuc ung b chm qu 3 gi th cn phi s dng bin php trnh thai h tr khc cho ti khi c kinh + Nu qun 2 vin tr ln th tt nht l ngng thuc , i ra kinh nguyt th bt u ung li t u.Hoc vn tip tc ung thuc nhng king giao hp trong 7 ngy Nu mun trnh thai khn cp :
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+ Dng Postinor (0,75 mg levonorgestrel :Ung vin th nht cng sm cng tt trong vng 72 gi sau cuc giao hp khng c bo v, vin th 2 ung sau vin th 1 12 ting u im + Hiu qu trnh thai cao + L phng php trnh thai c hi phc, khng nh hng n kh nng sinh sn sau ny + Khng lm gim lng sa m, dng c cho ph n cho con b + Ph hp vi ph n c chng ch nh vi estrogen + Hon ton khng lin quan n giao hp Nhc im: + Tn km + Phi nh ung thuc ng gi + Hiu qu khng cao bng vin kt hp + Khng phng c bnh ly qua ng tnh dc + Tc dngph + Ri lon kinh nguyt : kinh tha, nu dng ko di c th v kinh + Ra mu thm git ngoi chu k Cu 3: So snh vin thuc trnh thai kt hp v n thun I. Ging nhau: L phng php trnh thai c hi phc bng cch s dng ni tit t lm c ch phng non hoc gy tr ngi qu trnh th tinh v lm t + u c progestin C ch tc dng ging nhau do cng c progestin + c ch phng non do c ch trc di i tuyn yn gim tit FSH, LH + Lm gim v c qunh nhy ca c t cung , ngn cn tinh trng xm nhp vo bung t cung + Lm teo nim mc t cung + Lm gim nhu ng vi trng Hiu qu trnh thai rt cao,l phng php trnh thai c hi phc , khng nh hng ti kh nng sinh sn sau ny + D s dng, kn o v khng lin quan ti giao hp Ch nh: + Cho ph n mun trnh thai m khng c chng ch nh + Dng trnh thai khn cp Chng ch nh: + Cho ph n ra mu m o bt thng , bnh gan mt, i tho ng, khi u ph thuc ni tit Nhc im :
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+ u phi nh ung thuc u dn , + t, + khng phng c bnh ly qua ng tnh dc II. Khc nhau Vin trnh thai kt hp Vin trnh thai n thun Thnh phn : + C estrogen v + ch c progestin liu thp Progestin liu thp C ch : + c ch hon ton + c ch khng trc di i tuyn yn hon ton trc di i tuyn yn + c ch phng non hon ton + c ch phng non khng r rng Tc dng ph: + Nhiu tc dng ph + t tc dng ph do estrogen gy ra hn do khng c estrogen + Gim sa m,tng nguy c ri lon ng + Khng nh mu.Bun nn,nhc hng ti tit sa u,v cng v cm gic + Khng gy triu nh nghn. chng ging nghn + Khng gy chy + C th gy mu thm git chy mu thm git + Gim trng c ngoi k kinh. Ch nh : + Dng ph bin cho + Dng ph bin ph n trong tui cho ph n tui sinh v c nhu cu sinh c nhu cu trnh thai kp thi trnh thai tm thi nhng c chng ch + iu tr mt s nh vi thuc trnh bnh ,trng c ,thng thai kt hp v kinh,rong kinh ang cho con b Chng ch nh + Tt c ph n ang + Khng c c bnh hoc tin s c chng ch nh vi bnh m khi s dng nhng bnh m estrogen c th lm estrogen lm nng bnh nng thm nh: thm + Ri lon ng mu + Tng huyt p ,tai bin mch no + Tc mch ,bnh
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tim,tng lipid mu + Ngi nm lu : Sau phu thut,tai bin mch no + Bnh nguyn bo nui + Khng s dng cho ph n cho con b Hiu qu: + Hiu qu trnh thai hn thuc trnh thai n thun
+ Thp hn thuc trnh thai kt hp
Dng c t cung
Cu 1: Dng c t cung : c ch ,ch nh v chng ch nh. I. i cng + Dng c t cung trnh thai l phng php trnh thai tm thi cho n. l nhng dng c c t vo trong bung t cung ,c tc dng ngn nga thai .L phng php trnh thai n gin, r tin ,hiu qu cao,d c thai li khi ly dng c ra + Phn loi dng c t cung + Theo hnh dng: Dng c t cung kn: Vng Dana + Dng c t cung h: T cung,multiload + Theo cu trc: Dng c t cung khng c hot chtlm bng cht do poly ethylen + Dng c t cung c hot cht sinh hc nh dng c qun dy ng T cung 380A,dng c c cha progestatif II. C ch tc dng: 1) Ti ni mc t cung + Gy vim ti ch,xut hin hng ro c lympho bo,bch cu a nhn, i thc bo s thc bo tinh trng v trng. ( y l c ch u tin ca dg c t cung) + Dng c t cung gy x ho nim mc t cung ti din tip xc vi dng c t cung khng thun li cho vic lm t + Dng c t cung lm t bo ni mc b nh hngdn n ri lon ch tit,lm gim cc cht cn thit cho s lm t ca trng nh: Glycogen gim, men tiu m gim 2) Tc dng ti t cung v vi trng: + Tng co bp t cung y trng a ngoi + Dng c t cung c tc dng lm tng nhu ng vi trng khin cho trng di chuyn nhanh v bung t cung trong khi nim mc t cung cha chun b tt cho vic lm t ca trng 3) bung t cung :
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+ Gy c cho phi bo + i vi dng c t cung c gn ng , ng c tc dng: + Gy c cho giao t (gy c cho tinh trng) + Gy bin i mnh nim mc t cung , lm cn tr trng lm t ti bung t cung + Thay i cht nhy c t cung ,cn tr tinh trng xm nhp vo bung t cung + i vi dng c cha progestatif: + Lm c cht nhy c t cung + Ni mc t cung b teo 4) nh hng n nhu ng ca vi trng + Cc tc dng ca dng c t cung lm bt li ho qu trnh th tinh v lm t ca trng III. Ch nh: + Cho tt c ph n tui sinh mong mun trnh thai tm thi m khng c chng ch nh + L tng nht l cho ph n c con m b my sinh dc bnh thng c nguyn vng trnh thai + T cung c so m ly thai vn c th t dng c t cung + Dng c t cung cn c th dng nh mt bin php trnh thai khn cp IV. Chng ch nh: 1) Chng ch nh tuyt i + C thai hoc nghi c thai + Vim nhim ng sinh dc cha iu tr khi + ri lon ng mu + Bnh l tim mch + khi ung th c quan sinh dc: ung th c t cung , ung th t cung , ung th bung trng , ung th v + Rong kinh rong hut chy mu ph khoa cha r nguyn nhn + Sa sinh dc 2,3 , l tuyn c t cung + H eo t cung ,rch c t cung , c t cung loe rng + D ng vi ng(i vi cc dng c c ng) 2) Chng ch nh tng i: + Bung t cung bt thng( u x,d dng) + ang iu tr bng thuc chng ng mu + Tin s nhim khun ng sinh dc trn + Tin s cha ngoi t cung + Cha c con + Thiu mu, suy nhc c th V. Thi gian t, theo di, tho 1) Th gian t Hanoi Medical University LTL 157
Nguyn tc : + C th t dng c t cung vo bt k ngy no trong vng kinh khi chc chn khng c thai , tuy nhinnn t sau 2-3 ngy sch kinh(dao ng n 10 ngy),trc khng giao hp. + C th t sau khi ph thai nu m bo khng st rau , khng nhim khun.Nhng su no ht thai nn i kinh tr li 1 ln ri mi t dng c t cung + Khng nn t dng c t cung ngay sau v t l tt dng c t cung l rt cao.Nn t sau 8 tun 2) Theo di + Ngh ngi 2-3 ngy sau t, khng lm vic nng trong 2-3 thng + Trnh giao hp 2 tun u sau t,v sinh ti ch hng ngy + Khm li 1 tun sau t + Sau khm li 1 thg 1ln, 3 thng -6 thng 1 ln1nm 1 ln 3) Ch nh tho vng + Thay bng phng php khc + Mun c thai li + C bin chng chy mu nhim khun + Ht hn s dng + Ht tui sinh + au khi giao hp, au nhiu khi hnh kinh + Vng b tt 1 phn + L do v y t + t dng c t cung nhng vn c thai + Nhim khun ng sinh dc + Thiu mu nng + Pht hin tn thng c tnh t cung , c t cung VI. Tc dng ph v x tr + Chy mu trong nhng ngy u hoc ri lon kinh nguyt, rong kinh, cng kinh + X tr ngh ngi , cho thuc chng tiu si huyt, thuc bo v thnh mch,thuc khng protaglandin.Nu khng , thay dng c t cung khc hoc dng bin php trnh thai khc + au tiu khung, thng kinh + X tr gim au bng aspirin , gim co (papaverin).Nu au nhiu ko di th thay bng dng c t cung khc + Gy au khi giao hp.Do t sai v tr, hoc do dy tha qu di + X tr kim tra t li hoc thay bng vng khc
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+ Ra kh h do phn ng ca nim mc t cung + X tr nu kh h nhiu v hicho khng sinh.Nu kh h ra ko di th tahy dng c t cung khc VII. Bin chng + Thng t cung Do cha c kinh nghim t dng c t cung (t gp) + Thng ngay sau t cn phu thut khu tn thng + Nhim khun nng do th thut khng v khun hoc t vng c nhim khun sinh dct cn khng sinh liu cao + tho vng + Tt dng c t cung : Do k thut sai, t sai + C thai cng vi dng c t cung : khng bt buc phi tho dng c t cung bu mun gi thai, cuc chuyn d khng c g c bit + Dng c t cung v cha ngoi t cung chn on da vo lm sng v siu m + Dng c t cung chui vo bng ( him gp) chn on bng siu m v chp xquang bng 1) u im + Hiu qu trnh thai cao + t 1 ln c hiu qu nhiu nm + k thut t tho d dng + Sau khi tho c thai tr li nhanh + Khng lin quan n giao hp , khng s qun thuc + Khng nh hng n ni tit + Gi thnh r 2) Nhc im: + phi c cn b y t c chuyn mn t v tho + Mt s tc dng ph: Rong kinh , ri lon kinh nguyt , au lng, au bng trc v trong khi hnh kinh v khi giao hp,ra kh h + Mt s bin chng c th xy ra : Thng t cung , nhim khun nng, ri dng c t cung , c thai, cha ngoi t cung , dng c t cung chui vo trong bng + Khng c tc dng phng trnh cc bnh ly qua ng tnh dc. Cu 2 : So snh dng c t cung : T cung 380A v Mutiload. I. Ging nhau + V cu to: u l dng c t cung vng h, lm bng polyetylen c gn hot tnh sinh hc ng + Cu trc trc dc ng knh 4 mm + C 1 lp ng 0,4mm bao bc , ui gn vi ui nilon + Tiu chun cn quang nh nhau
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+ L bin php trnh thai tm thi ph n, hiu qu trnh thai cao, tin li r tin,d c thai li sau khi tho vng + u c chung c ch trnh thai v c cng gn hot tnh sinh hc ng + Ch nh chng ch nh, thi giant vng,tai bin,tc dng ph ca 2 loi dng c t cung ny ging nhau v ging cc loi dng c t cung khc + C 2 loi u c s dng rng ri II. Khc nhau S khc nhau gia 2 loi T-Cu 380A v Multiload T-Cu 380A Muliload 375 Hnh dng Hnh ch T vi 2 cnh Hnh xng c vi 2 cnh thng di ng Tit din ng 380mm2 375mm2 Gn trn trc dc ca dng Gn trn tt c cc xng c v 2 nhn ng gn trn ca dng c ngnh ngang m bo ion ng khuych tn tn y t cung Ch nh t t cho bung t cung t cho bung t cung < 7cm 7cm Hiu qa trnh thai Cao hn Muliload Thp hn T-Cu 380 t 99% t 96-98% Thi gian s dng Di hn Ngn hn Thng 4-8 nm th ko 4-5 nm di 10 nm Tc dng ph Gy au v chy mu nhiu t au, chy mu t hn so hn do cnh ngang cng vi T-Cu 380 do 2 cnh di ng Kch thc Di 36mm x 32mm Di 29mm x 18 mm
nh sn n
Cu 1: nh sn n ch nh, chng ch nh,tai bin v x tr. I. i cng + nh sn n l phng php phng trnh thai vnh vin nhm mc ch khng cho tinh trng gp trng vi trng bng phng php gy mt s lu thng ca vi trng
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+ L phng php cn can thip ngoi khoa c tc dng vnh vin v vy khi mun c con li l khng th nn cn c t vn ,gii thch r cho cp v chng no c yu cu trit sn II. Nguyn tc + L lm gin on hai vi trng dn n non khng gp c tinh trng hin tng th tinh khng xy ra + Thi im trit sn + Trong lc m ly thai + Trit sn v lyd od y hc (bnh mn tnh nng,thng tn ng sinh dc) + Sn ph c nguyn vng t trc + Sau ng m o + y t cung cn cao gn rn ,k thut trit sn d dng , khng ko di thi gian nm vin + Nn tin hnh trit sn trong 72 gi sau nhm hn ch nhim khun ngc dng vi trng + Hn ch + C th b chy mu + Tnh trng cha a b cha c chc chn + Trit sn sau no thai,ht thai: Khi m bo chc chn khng st mng + Trit sn trong 1 vng kinh bnh thng + Tt nht l nn tin hnh na u ca vng kinh nhm m bo bnh nhn cha c thai III. Phng php v k thut + Trit sn c th thc hin qua: M bng thng thng: + Trit sn trong khi m ly thai,m cha ngoi t cung , m khi u bung trng M bng nh : ng rch bng 3-4 cm + Ch p dng lm trit sn 2 vi trng + p dng khi tin hnh trit sn ch mt s ng bnh nhn 1 a im ti ch no ng m o + Phng php: i qua cng sau m o ti 2 vi trng + p dng tt nht khi c s ng bnh nhn Qua soi bng + iu kin phi c phng tin k tht + Cng c th thc hin vi s ng bnh nhaan trong 1 chin dch + Qua soi bung t cung : + T l tht bi kh cao:10-30%
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+ Phng php : Bm silastic vo 2 vi trng + t dng c vo vi trng + Dng laser YAG ph hu phn k ca vi trng + Cc k thut trit sn 2 vi trng : + Cc k thut tht , ct 2 vi trng , thng lm on eo ca vi trng , cch sng t cung khong 2-3cm v khong v mch ca mc treo vi trng. Phng php Irving + Phng php : tin hnh ct mt on vi trng , u gn ca vi trng c vi vo lp c t cung mt sau. u xa c vi vo gia hai l ca mc treo vi trng. + T l tht bi thp nht + K thut phc tp hn + Tai bin chy mu nhiu hn Phng php Pomeroy + y l phng php n gin, c p dng ph bin nht nc ta hin nay + Nhc 1 on eo vi trng ln, buc vi nhau v ct phn vi trng va mi nhc ln.Sau khi ct xong 2 u vi trng cn li nm cnh nhau nh khu sng hai nng.Dng ch tiu buc hai u vi trng sau ny ch tiu i, hai u vi trng cch xa nhau. Phng php Parkland: + Dng ch tiu buc 2 ni trn vi trng cch nhau 2 cm.Ct on gia 2 nt buc + T l tht bi 1/400 Phng php Kroener + Dng ch lanh buc 2 ln gn tua vi ri ct ton b cc tua loa vi trng Phng php Madlener + Tng t nh phng php Pomeroy, ch khc l trc bu ch , dng km kp nton vi trng ni nh buc + T l tht bi 7% Trit sn qua soi bng + Dng dao in lng cc ct i vi trng ch t + Dng kp Hulka hay vng Yoon nh sn u im: + Ca cc phng php dng kp l kh nng phc hi lu thng vi trng kh d dng v cho kt qu cao IV. C ch tc dng + Ngn cn vnh vin khng cho non gp tinh trng bng cch + Ct b on vi trng
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+ Lm gin on vi trng bng ch tht hay bng cc loi kp + Lm tc vi trng bng t in V. Ch nh, chng ch nh Ch nh: + Cho ph n ang tui sinh , c s con mong mun ,cc con kho mnh , t nguyn dng mt bin php trnh thai vnh vin khng hi phc + Ph n sau m 2 ln c t nht 1 con sng + Cho nhng ph n c bnh l khng th c thai nh suy tim, Basedow nhng khng p dng c bin php trnh thai khc + iu kin nh sn n: + Hai v chng phi t nguyn v chp nhn thi trong bt k hon cnh no + N trn 30 tui tr nn c hai con kho mnh + C c s m , trang thit b phu thut Chng ch nh + V l mt phu thut c th c tai bin nn c chng ch nh trong cc trng hp sau: + ang c thai + ang trong tnh trng nhim khun ton thn hoc nhim khun ti ch + Bnh thiu mu nng hoc thiu dinh dng nng + Ri lon ng mu, chy mu , i tho ng + Bnh tim, h hp c th gy suy h hp + Thn trng vi nhng bnh nhn c phu thut bng trc kia hoc ph n qu bo + C u vng tiu khung hoc cc bnh l ph khoa cn phi m trong mt thi gian gn y VI. u nhc im u im + HIu qu trnh thai rt cao , tht bi 0,5% + Hiu qu kinh t cao + Khng c tc dng ph + Khng nh hng n sc kho ni tit v tnh dc Nhc im: + L can thip phu thut nn c nguy c nhim khun, nguy c ca gy m, gim au v bin chng + Chc nng sinh sn khng hi phc + Cn c kp cn b y t c hun luyn, c trang thit b phu thut + Khng phng c bnh ly qua ng tnh dc VII. Tai bin v x tr
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Khi ang thc hin + Shock do au, lo lng ( phng php khng gy m ton thn) + X tr t vn tt trc khi tin hnh + Cho thuc gim au an thn, th oxy + B dch, in gii + Tn thng bng quang rut,rch mc treo vi trng gy chy mu:Khu vt rch, cm mu tt, khng sinh ton thn + Khi m ni soi chc vo mch mu gy chy mu nhiu th m cp cu cm mu Sau phu thut + Chy mu trong bng: + Nguyn nhn: Cm mu khng k,nt ch buc khng cht + Pht hin bng vic theo di st tnh trngton thn ca bnh nhn sau m, mch , huyt p VIII. X tr : + M li cm mu khi chy mu nhiu Nhim khun Nguyn nhn : + k thut khng v khun, gy vim phc mc , nhim khun vt m Chn on + Da vo tnh trng nhim trng,bng chng,c cm ng phc mc X tr : + Nu vim phc mc tiu khung: NGh ngi , chm , khng sinh ton thn, dn lu m ti cng Douglas qua ng m o + Nu vim phc mc ton th: M cp cu li, lau ra bng, cho khng sinh liu cao ng tnh mch + Nu nhim khun vt m: Ct ch sm, ra vt m hng ngy bng nc mui sinh l, khng sinh Dnh rut Chn on + B trung i tin, bng chng , du hiu rn b ,chp Xquang bng khng chun b thy bng m , c mc nc hi + Nu bn tc rut: x tr bng truyn dch , sonde d dy ht lin tc ,kch thch nhu ng rut bng Prostigmin.Sau khi bnh nhn trung tin c triu chng s + Nu tc rut hon ton th m cp cu + Tht bi ca phng php nh sn n, bnh nhn c thai:
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Nguynnhn : + Do tht nhm dy chng trn + Do tut ch buc hay buc ch khng cht X tr + Tu trng hp m nh ch thai nghn , m khi cha ngoi t cung + Theo di ngay sau khi trit sn: + Du hiu sinh tn trong 6 gi sau m + C th cho bnh nhn v nh khi n nh + Khng sinh trong 5-7 ngy + Gim au bng paracetamol.
Cc phng php nh ch thai nghn
Cu 1:Cc phng php nh ch thai nghn 3 thng u: Ch nh, chng ch nh, tai bin I. i cng: + nh ch thai nghn l vic s dng phng php no , c th l th thut, phu thut hay thuc, kt thc s mang thai, a cc sn phm thai nghn ra khi ng sinh dc ca ngi m. + Vic nh ch thai nghn c th tin hnh bt k tui thai no .Vic la chn thi im nh ch thai nghn tu thuc vo l do phi nh ch thai nghn nh ch thai nghn trong 3 thng u ch yu l do: + C thai ngoi mun + Mt s t do bnh l ca m khng cho php duy tr thai nghn + Bnh l ca thai II. Cc phng php 1) Ht iu ho kinh nguyt- ht thai( ph thai bng phng php ht chn khng ) a) Ch nh + Ht iu ho kinh nguyt + Cho cc ph n c chm kinh < 2 tun( 6 tun v kinh) + Thng dng bm Kartmann mt van + Ht thai + Cho ph n chm kinh < 8 tun ( 12 tun v kinh) + Dng bm Kartmann 2 van + iu kin khi ch nh + Phi c chn chn l c thai trong t cung ( Chm kinh, hCG + , siu m c hnh nh ti thai trong t cung ) + Dng nh ch thai nghn cho m khng c bnh l + c t vn v tnh nguyn b) Chng ch nh:
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+ C vim nhim ng sinh dc cha iu tr khi + ang c nhim khun ton thn cha iu tr khi + Khng thc hin tuyn x vi ngi c bnh mn tnh 2) No thai( ph thai bng phng php nong v no) a) Ch nh + Cho tt c cc ph n<12 tun v kinh m c chn on c thai trong t cung ( chm kinh, hCG+, siu m c m vang thai trong t cung) + Khng c bm Kartmann ht thai + Dng ph thai nh l + c t vn v tnh nguyn b) Chng ch nh + Nhim khun ton thn hay ng sinh dc cha iu tr khi + Khng thc hin tuyn x nu sn ph c bnh mn tnh + Tui thai > 12 tun 3) Dng thuc Dng thuc Prostaglandin E1 ( Cytotec) kt hp vi RU486 a) Ch nh : + Ph n v kinh < 7 tun, c chn on c thai trong t cung + c t vn v t nguyn ph thai + Khng c d ng vi prostaglandin b) Chng ch nh: + T cung c so m c + D ng vi thuc + Bnh l tim mch, ri lon ng mu III. Tai bin Do vic ht thai , no thai 1) Chong trong hay sau no ht thai a) Nguyn nhn + Do tm l, do au , do chy mu hay do thng t cung b) X tr + T vn trc th thut + Gim au , an thn + Kim tra nguyn nhn chy mu x tr + B dch nu mt mu ( trc khi c ch nh truyn mu) + Nu l thng t cung cn x tr 2) Chy mu a) Nguyn nhn: + Do no ht cha sch, cn st rau, st mng + T cung co hi km + Thng t cung
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b) X tr : + Ht no li + Thuc co hi t cung + Khng sinh phng nhim khun + Nu l thng t cung m khu phc hi + Nu l cha ngoi t cung m ct khi cha + Rch c t cung th khu phc hi 3) Thng t cung a) Nguyn nhn + T cung qu mm, t th khng thun li ( gp trc hoc gp sau qu + Ht no thai sai k thut, th bo b) X tr + M khu l thng + Khng sinh liu cao 4) Nhim khun a) Nguyn nhn + Do st t chc + Khng m bo v khun klhi lm th thut b) X tr + Ht no li + Khng sinh liu cao 5) Thai vn pht trin a) Nguyn nhn + Do no ht khi cn qu smm t cung li t th khng thun li no, ht + Ngi lm thiu kinh ngim b) X tr + No ht li + Khng sinh + Nu l cha ngoi t cung th m ct khi cha 6) Tai bin xa: + Dnh bung t cung + Hp hay tc vi trng + Nguy c rau tin o cho nhng ln c thai sau Tai bin do dng thuc + D ng , shock, tc dng ph ca thuc + X tr :Ngng thuc ngay , hi sc thch cc chng shock, th oxy, tr tim, truyn dch, an thn + nh ch thai nghn bng phng php khc IV. Theo di v chm sc: + Theo di mch, huyt p , ra mu m o t nht 30 sau lm th thut + Khng sinh Hanoi Medical University LTL 167
+ T vn + Hn khm li sau 2 tun Cu 2: nh ch thai nghn trong 3 thng gia -3 thng cui : Ch nh, chng ch nh, tai bin v x tr I. i cng: + nh ch thai nghn l vic s dng phng php no , c th l th thut, phu thut hay thuc, kt thc s mang thai, a cc sn phm thai nghn ra khi ng sinh dc ca ngi m. + Vic nh ch thai nghn c th tin hnh bt k tui thai no .Vic la chn thi im nh ch thai nghn tu thuc vo l do phi nh ch thai nghn Trong 3 thng gia l do ch yu l: + C thai ngoi mun m 3 thng u cha c pht hin + Bnh l ca m + Bt thng ca thai Trong 3 thng cui, nh ch thai nghn thng l: + Cu con, cu m khi m vic duy tr thai nghn bt li cho m, con , hay c 2 II. Cc phng php nh ch thai nghn trong 3 thng gia C nhiu phng php c p dng nhng sau 1 thi gian ngn , 1 s phng php t ra khng hiu qu , nn hin nay dng cc phng php sau Phng php t ti nc ngoi bung i ( Kovacs ci tin) Ch nh + Tui thai 18- 24 tun( cao t cung 16-20 cm) + nh ch thai nghn khng phi l bnh l + c t vn v t nguyn Chng ch nh + M b bnh nhim khun ton thn hay b phn sinh dc cha iu tr khi + Thai lu + M b bnh mn tnh + C s y t khng c kh nng phu thut Tai bin Chong Nguyn nhn + Do au, do s, do chy mu X tr + T vn k trc + Gim au an thn + B nc v in gii, truyn mu nu mt mu nhiu
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Chy mu: Nguyn nhn + K thut t ti nc sai + Do bong rau, st rau,st mng + T cung o hi km X tr + Nu thai cha ra th ly thai v rau nhanh bng nong c t cung v gp thai ,rau + Nu thai ra :Kim sot t cung bng tay hoc no li bng dng c + thuc co hi t cung + Khng sinh chng nhim khun Nhim khun Nguyn nhn: + Do a vt l vo trong bung t cung , nht l sau v i + K thut khng v khun X tr + Khng sinh liu cao, ton thn C t cung khng m c X tr + Nong c t cung v gp thai V t cung Nguyn nhn : + Do k thut t sai X tr + Nong c t cung gp thai ra + M khu t cung Phng php dng thuc Nguyn tc + Dng thuc prostaglandin( cytotec) ng ung hoc t m o vi liu 100-200cmg 6gi/1ln.Theo di thai rau ra nh cuc non,sau kim sot t cung bng tay hoc no li bng dng c Ch nh + nh ch thai nghn 3 thng gia + Sn ph t nguyn sau khi c t vn k Chng ch nh + Sn ph d ng vi thuc + Sn ph c so m c t cung + Sn ph c bnh l tim mch, huyt khi Tai bin Shock phn v do thuc Nguyn nhn + Do thuc
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X tr : + Ngng ngay thuc + Tr tim + Th oxy + Truyn dch V t cung Nguyn nhn + Do cn co t cung qu mnh + T cung c so m c X tr + M khu vt rch hay ct t cung bn phn tu vo tnh trng + Khng sinh + Mt s tc dng ph ca thyuc + Tiu chy, st Phng php nong v gp sau khi lm mm c t cung Nguyn tc + Lm mm c t cung bng thuc cytotec, ri nong c t cung v gp thai hoc no thai + Dng 400mcg cytotec t m o hoc ngm trong m lm mm v m c t cung + Theo di va ch 4-6 gi .Dng tip liu khc nu cn + Sau nong thm v gp, no bng dng c chuyn bit Chun b bnh nhn + Khai thc li tin s ,ni ngoi, sn khoa + Khm ton thn + Xc nh tui thai + Siu m + Xt nghim mu : cng thc mu ,mu chy mu ng + Cam kt t nguyn ph thai Ch nh + Thai t 13 dn18 tun Chng ch nh + Thai > 18 tun + Thai ph d ng vi thuc + D dng sinh dc + C so m c t cung + Sn ph b bnh tim mch, ri lon ng mu + Bnh l nhim khun ton thn , hoc ti ch m cha iu tr khi + C s y t khng c kh nng phu thut Tai bin v x tr Chong Hanoi Medical University LTL 170
Nguyn nhn + Do au, do s, do chy mu X tr + T vn k trc + Gim au an thn + B nc v in gii, truyn mu nu mt mu nhiu Chy mu: Nguyn nhn + Do st rau,st mng ,st thai + T cung co hi km + Thng t cung ,rch c t cung X tr + No li + Thuc co hi t cung Nu thng tu m khu li + Nu rch c t cung khu li + Khng sinh chng nhim khun Nhim khun Nguyn nhn: + Cn st t chac nh: Thai, mng rau, rau thai + K thut khng v khun X tr + No li t chc st + Khng sinh liu cao, ton thn Thng t cung Nguyn nhn : + Do k thut sai + T cung qu mm, t th khng thun li X tr + M khu t cung + Khng sinh liu cao + Tai bin xa + Dnh bung t cung + Hp tc vi trng + Nguy c rau tin o nhng ln c thai sau Phng php m ly thai hoc ct t cung bn phn c khi Ch nh + Khi tnh trng bnh l ca sn ph khng cho php p dng cc phng php nh ch thai nghn khc + Cn tr tin o: + U tin o, rau tin o trung tm + Bnh l ca sn ph : + Suy tim mt b
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+ Tng huyt p ,tai bin mch no iu tr ni khoa khng hiu qu + Tin s m sa sinh dc,r bng quang m o.R trc trng m o + T cung c so m c + Ung th c t cung ti ch hoc xm ln Tai bin + Shock phn v do gy m + Chy mu nhim khun + Tn thng cc tng xung quanh III. Cc phng php nh ch thai nghn trong 3 thng cui Dng oxytocin tryn nh git Ch nh: + Cho cc trng hp nh ch thai nghn trong 3 thng cui m khng c chng ch nh Chng ch nh + Ch s Bishop <7 + Khung chu bt thng + U tin o + Rau tin o + Sn ph c bnh ni khoa nng + Sn ph c tin s m sa sinh dc ,r bng quang m o, r trc trng m o + Ung th c t cung ti ch hoc xm ln + Nu con c th sng c m ngi thai bt thng , a thai, c du hiu suy thai + Ti c s y t khng c kh nng phu thut Tai bin V t cung Nguyn nhn: + Khng tin lng, nh gi c cc yu t khng thun li nh t cung c so m c , u tin o,bt tng xng khung chu v thai + Dng thuc qu liu X tr + An thn + gim co + M cp cu ly thai ra v x tr v t cung Chy mu Nguyn nhn + Rau bong non,sau st rau,st mng + T cung co hi km + t cung sau s thai + V t cung ,rch c t cung
172
X tr + Kim sot t cung + Thuc co hi t cung + Khng sinh d phng nhim khun + Nu thng t cung m khu + Rch c t cung cn khu li + Nu rau bong non cn m ly thai Nhim khun Nguyn nhn + Do st t chc thai, rau thai, mng rau + Khng m bo v khun X tr + No li nu st t chc + Khng sinh liu cao Dng cytotec(Misoprostol) Ch nh + Cho cc trng hp nh ch thai nghn 3 thng cui m khng c Chng ch nh + Sn ph d ng vi thuc + Sn ph c so m c t cung + Bt tng xng thai v khung chu + Bnh l tim mch v huyt khi + Ti c s y t c kh nng phu thut Tai bin Tc dng ph ca thuc + D ng thuc + Shock X tr + ngng thuc ngay + Hi sc chng shock V t cung Nguyn nhn + Khng nh gi, tin lng c cc yu t khng thun li ca cuc X tr + m khu l thng hoc ct t cung bn phn nu cn Phng : + Theo di st cn co t cung khi dng thuc + Khng dng cho ngi c tin s m t cung Chy mu Nguyn nhn + V t cung + t cung sau ly thai
173
+ Rch c t cung + St rau ,st mng X tr + Kim sot t cung + Thuc co hi tu + Khng sinh d phng + Nu thng t cung m khu hoc ct tu tnh trng tne thng + Rch c t cung khu cm mu Phng php m ly thai Ch nh: + Cc trng hp khng th s dng cc phng php khc hoc khng c php s dng cc phng php khc + Vi m + Khung chu bt thng + Cn tr tn o : U tin o, rau tin o trung tm + T cung c so m c + Bnh l ni khoa nng + m o cht hp bm sinh + T cung i, t cung 2 sng + Tin s m sa sinh dc, r bng quang m o, r trc trng m o + Vi con + Du hiu suy thai + Ngi thai bt thng + a thai + Phn ph ca thai + Rau tin o + Cn i + Sa dy rau/Thai cn sng Ch nh m cp cu + Chy mu do + Rau tin o trung tm + Rau bong non th trung bnhf, nng + Do v t cung + Sa dy rau/thai cn sng + Ch nh m trong chuyn d + kh d c t cung khng tin trin + kh do nguyn nhn c hc, nghim php lt ngi chm tht bi + kh do ri lon cn co t cung + Suy thai cp trong chuyn d
174
Chng ch nh + Cn ph phi cp + Cn sn git Tai bin + Shock phn v do gy m + Chy mu + Nhim khun + Tn thng cc tng xung quanh
Ngi ngc
Cu 1:Chn on v x tr ngi ngc I. i cng: 1) nh ngha + Ngi ngc l mt ngi dc m cc u pha y t cung , cn cc mng pha di c t cung v mng trnh din trc eo trn ca khung chu ngi m( khi chuyn d) + Ngi mng c kh nng ng di nhng d mc hu v vy l ngi kh trong sn khoa + T l : 3.3-4.2 % 2) Nguyn nhn Pha m + nhiu ln + T cung d dng, km pht trin + U x txu , u tin o + Khung chu hp Pha thai: + Thai nh,non thng,thai km pht trin + a thai + No ng thu Phn ph ca thai + a i, thiu i + Rau tin o + Dy rau ngn,dy rau qun c 3) Phn loi Chia lm 2 loi chnh
175
Ngi ngc hon ton: + C mng v chn trnh din trc eo trn ca khung chu ngi m + ng knh lt: Cng chu = 9cm khi chuyn d bnh chnh cn 6 cm. Ngi ngc khng hon ton: (Hay ngi mng thiu) + L ngi trnh din trc eo trn ch c mng hoc chn hoc u gi Ngi mng thiu kiu mng: + Mng trnh din trc eo trn,hai chn vt ngc,hai bn chn vt ln vai, u gp st bng,cng chn thng vi u. ng knh lt l cng v = 6 cm Ngi mng thiu kiu u gi: + Thai nhi qu trong bung t cung Ngi mng thiu kiu bn chn: + Thai nhi ng trong bung t cung .Trong chuyn d s tr thnh ngi mng th pht Mc ca thai:L nh xng cng,, ng knh lt ln nht l lng ngi + 9,5 cm II. Triu chng Thi k 3 thng cui 1) C nng + Thy thai p di rn.Thnh thong thy khi ni ln vng thng v hoc h sn phi,thc vo h sn phi.Nhng triu chng ny khng c hiu v t c gi tr 2) Thc th: Nhn : + T cung hnh trng hoc hnh tr lch mt bn S : + Cc di mm ,to khng lin tc , kh di ng + Lng l mt din phng nu kiu th trc,ln nhn cc chi nu kiu th sau. + Cc trn : Rn ,trn u,di ng d.C th c du hiu lc lc ca u thai nhi Nghe: + Thy tim thai v tr trn rn. + Thm m o + V c t cung cn ng kn nn kh xc nh c mc ca ngi + Thm ti cng khng c cm gic khi trn v rn m l mt khi mm, thng cao gi l ngi mng. i khi li cn km theo 1 khi nh gi ngi mng III. Cn lm sng 1) Siu m :
176
+ C gi tr chn on v tin lng,xc nh v tr ca u ,lng, mng. o c cc ng knh thai nhi( Lng nh, ng knh bng,chiu di xng i) + Theo di s pht trin ca thai,trng lng thai,tnh trng ngi,nc i,v tr rau bmT a ra hng x tr ,tin lng chnh xc hn 2) Xquang + Hin nay t dng + C th nh gi c tnh trng khung chu, u thai nhi ci tt hay khng + ,pht hin mt s bt thng ca h thng xng IV. Chn on xc nh + Lm sng v cn lm sng + Ch chn on vo thng cui hay khi chuyn d v thai nhi khng cn thi gian quay Khi chuyn d 1) C nng + Thng khng thy r,c th thy thai p vng di rn, au tc h sn phi do u thai nhi n vo gan 2) Thc th Nhn + t cung hnh trng,tr hoc lch mt bn S + nn t cung di ch thy 1 khi to,mm ,kh di ng.Lng l mt din phng nu kiu th trc,ln nhn chi nu kiu th sau.Nn cc trn thy 1 khi trn rn + Nhiu khi kh nn r cc phn ca thai nhi do c cn co t cung Nghe + Tim thai trn rn hoc ngang rn khi thai xung thp + Thm m o + Khi c t cung ang xo m,mng i cn,trnh v i do thm khm.Qua mng i c th thy + Cm thy khi mm to ch khng phi l khi trn rn + Nu s thy mng v 1 hoc c hai bn chn thai nhi th ngh ti ngi mng + Nu ch thy khi mng hoc chn thai nhi c th l ngi mng thiu + Khi khm trong cn xc nh c sa dy rau trong bc i khng + Thm trong khi c t cung mv mng i v hon ton,s d khm hn
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+ Nu nn thy xng cng,l hu hn gia hai mng,b phn sinh dc ca thai,bn chn thai th d chn on l ngi mng + Nu cm thy ch s thy xng cng v l hu mn gia hai mng th ngh n ngi ngc ko hon ton.Cn phn bit vi ngi mt v c ming gia 2 m + + Nu ch cm thy c mng v bn chn thai nhi cn phn bit ngi chm sa chi. Phn bit chn v bn tay ca thai nhi + Ngn tay ci hi xa cch ngn cn li.Cc ngn di xp gn li c hnh ch V ngc v ko c gt nn c th vut thng c + Bn chn :Cc ngn chn 5 ngn xp lin nhau v gn nh thng hng ngang nhau.Bn chn gp gc vi cng chn v c gt + Nu ch s thy u gi th l kiu u gi + Nu ch s thy bn chn th l kiu bn chn V. Cn lm sng + Chn on ngi mng khi chuyn d d dng v c t cung m ht.Tuy nhin i khi cng cn c Siu m chn on xc nh + Siu m c gi tr chn on v tin lng: + Xc nh c ngi thai, u ,lng,mng, nh gi s pht trin ca thai, o dc cc ng knh lng nh,chiu di xng i,trung bnh bng + Phn ph ca thai: V tr rau bm, ch s i + Xquang hin nay rt t khi dng VI. Chn on 1) Chn on xc nh + Da vo lm sng v cn lm sng 2) Chn on th kiu th: + Th l mc ca ngi bn phi hay bn tri khung chu ngi m.Trong ngi ngc lng bn no th th bn + Kiu th + Xem mc ca ngi tng ng vi v tr no trn trn khung chu ngi m.Mc ca ngi ngc l nh ca xng cng + C 4 kiu th lt v 2 kiu th s + kiu th lt + Cng chu tri trc (60%): nh xng cng mo chu lc bn tri ca khung chu ngi m
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+ Cng chu tri sau(10%) nh xng cng khp cng chu tri ca ngi m + Cng chu phi sau(10%):nh xng cng khp cng chu phi ca ngi m + Cng chu phi trc:Him gp, nh xng cng mo chu lc bn phi khung chu ngi m. + 2 kiu th s + Cng chu tri ngang: nh xng cng nm im gia g v danh tri khung chu ngi m + Cng chu phi ngang: nh xng cng nm im gia g v danh phi khung chu ngi m 3) Chn on phn bit Ngi chm: + D nhm vi ngi ngc ko hon ton kiu mng khi i cha v. + Khi khm ngoi vng h v ngi mng thiu cng c cm gic nh v rn nh u thai nhi nhng thm trong ko thy tc ,thp sau v ng lin khp dc ca ngi chm + Siu m cho chn on phn bit chnh xc Ngi chm sa chi : Nu m ngi chm sa chn d nhm vi ngi ngc hon ton + Khm ngoi thy cc u di , cc mng y t cung . + Thm trong thy c tc, thp trc,thp sau Nu ngi chm sa tay cn phn bit chn vi tay thai nhi + Siu m cho chn on phn bit chnh xc + Ngi mt: Khi i v 2 m thai nhi b un khun,nhm ming vi l hu mn,c th nhm vi ngi ngc ko hon ton kiu mng + Khm ngoi thy cc u di ,cc mng y t cung + Ngi mt s s thy mi ,h mt ,cm,s vo mm c cm gic mt + Siu m gip chn on phn bit Ngi ngang + Ngi mng chch m u thai nhi h sn phi ,ngi thai nhi h chu tri nn khi khm ngoi d nhm vi ngi ngang.Thm trong mm vai d nhm vi nh xng cng. +
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Nguyn c Thng Y6B7.

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

2 .iu tr ngoi khoa

Cu 2 Chn on cha ngoi t cung v I.nh ngha:

Hanoi Medical University LTL

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Hanoi Medical University LTL

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

II. Triu chng lm sng

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Cu 4:Chn on v x tr cha ngoi t cung th cha trong bng

Triu chng lm sang

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Hanoi Medical University LTL

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Chuyn 2:Thai cht lu

Triu chng lm sng

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

+ Ri lon nhim sc th + D dng :No ng thu,v s + Bt ng nhm mu Rh + a thai

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Cu 2 Chn on v x tr thai cht lu trong na sau ca thi k thai nghn nh ngha:

Triu chng lm sng

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Hanoi Medical University LTL

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Hanoi Medical University LTL

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Chuyn 3: Cha trng

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Chuyn 4: Ung th nguyn bo nui

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Hanoi Medical University LTL

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Chuyn 5: Rau tin o

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Hanoi Medical University LTL

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Hanoi Medical University LTL

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Hanoi Medical University LTL

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn

Nguyn c Thng Y6B7. cng n thi bc s ni tr Sn