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1. HOI CHNG TIEN SAN GIAT - SAN GIATH?I CH?NG HELLP BSCKII. Huynh Van Nhan
2. 1.Cao huyet ap thai ky HA ? 140/90mmHg lan au tien xuat hien trong luc co thai
Khong co protein-nieu
HA tr ve mc bnh thngtrong vong 12 tuan sau sinh
Chan oan cuoi cung ch c khang nh sau thi ky hau san
Co the co cac trieu chng cua tien san giat nang nh au vung ha v hay giam tieu cau
3. 2. Tien san giat *Tieu chuan toi thieu e chuan:
HA ?140/90mmHg xuat hien sau tuan le th 20 cua thai ky
Protein-nieu ? 300mg/24 gi hay 1 + th bang que
4. *Trieu chng khang nh chan oan TSG nang :
HA ? 160/100 mmHg
Protein nieu ? 2g/24 gi hay ? 2+ th bang que.
Creatinin huyet ? 1,2 mg/dL tr trng hp a co trc khi mang thai
Tieu cau < 100.000/mm3
Tieu huyet vi the (tang LDH)
Men gan tang cao ( SGOT,SGPT)
Nhc au keo dai, hay cac trieu chng than kinh khac nh hoa mat
au vung thng v keo dai
5. 3.San giat Khi co cn co giat khong the giai thch c bang nguyen nhan khac tren mot phu n mang thai co trieu chng tien san giat san.
6. 4.Tien san giat ghep them tren cao huyet ap man tnh Protein-nieu mi xay ra = 300 mg/24 gi tren phu n mang thai a co san cao huyet ap nhng khong co protein nieu trc tuan le th 20 cua thai ky.
Hoac tang thnh lnh huyet ap va protein nieu hay giam tieu cau <100.000 mm3 mau tren mot phu n cao huyet ap va co protein nieu trc tuan le th 20 cua thai ky.
7. 5.Cao huyet ap man HA =140/90 mmHg trc khi mang thai hay c chan oan trc tuan le th 20 cua thai ky.
Hay cao huyet ap c chuan oan trc tuan le th 20 va sau tuan le 12 hau san
8. Bang phan loai TSG nang va TSG nhe
9. X TR TIEN SAN GIAT NANG 1.Muc ch ieu tr: La ngan chan s tien trien sang san giat bang cach :
D phong cac cn co giat
Kiem soat HA benh nhan
Cham dt thai ky
10. Can thc hien cac khao sat sau ay co he thong :
Kham lam sang chi tiet va can than xem co cac trieu chng nh nhc au , roi loan th giac, au thng v va tang can nhanh hay khong.
o HA moi gi
nh lng creatinine mau, hematocrit, em tieu cau, men gan. (tien san giat cang nang, cang phai th thng xuyen)
11. Khong can nam ngh tuyet oi suot ngay cung nh khong can cho thuoc an than va thuoc ngu.
Khong s dung qua nhieu am va calories qua dch truyen ma nen tang them trong che o an.
Khong nen gii han va cam uong nc va an thc an co muoi.
o nang cua tien san giat c xac nh bang co hay khong s hien dien cua cac dau hieu a neu.
Tuoi thai
Tnh trang co t cung.
12. 2.Cach ieu tr
13. A.ieu tr noi khoa * Chong co giat : Sulfat Magnesi co the s dung 2 cach:
Truyen tnh mach lien tuc
lieu au 4-6g sulfat magnesi pha trong dung dch tiem trong 15-20 phut
bat au 2g moi gi trong 100ml truyen tnh mach
o Mg++ huyet thanh moi 4-6 gi va ieu chnh lieu duy tr e gi c sulfat magnesi nong o 4-7 mEq/l (4,8-8,4 mg/dL)
Sulfat magnesi c ngng s dung sau sanh 24 gi.
14. Tiem bap gian oan
Cho 4g sulfat magnesi USP tao thanh dung dch 10% tiem tnh mach trong 15 phut
Tiep theo ngay lap tc 1g cua dung dch sulfat magnesi 50% chia lam 2 tiem sau vao tren ngoai moi ben mong bang kim dai 3 inch (bo sung 1ml lidocaine 2% e giam au)
15. Moi 4 gi sau tiem 5g di dang dung dch 50% sau vao tren ngoai mong. Can am bao :
a.Mg++ huyet thanh t 4-7 mEq/L
b.Phan xa xng banh che (+)
c.Khong suy ho hap
d.Nc tieu trong 4 gi au tren 100ml
Sulfat magnesi ngng s dung 24 gi sau sanh.
16. *S dung Ha huyet ap ( s dung trc sanh):
1. Alpha methyl dopa 250mg 1V x 2 (U)
(Thuoc c che Apha nhom C khong co anh hng trong thai ky va luc cho con bu)
2. Nifedipine 20 mg 1V x 2(U)
(Thuoc c che calci, nhom C co anh hng trong thai ky, khong co anh hng tiet sa cho con bu, gay d tat va nhiem oc thai loai vat, het sc can than khi dung cho thai phu)
3. Hydralazine
Khi huyet ap toi thieu ? 110mmHg oi vi benh nhan tren 35 tuoi va tren 100mmHg oi vi benh nhan tre .
Cach dung
Tiem tnh mach 5mg hydralazine moi 30 phut en khi HA toi thieu <100mmHg
Uong 25-100mg/ngay ,khong dung qua 300mg/ngay. Thuoc thai hoan toan sau 24 gi.
Hydralazine c chng minh co phong nga xuat huyet nao.
17. *Thuoc ha ap khi HA ong mach trung bnh > 140 mmHg
ieu tr tan cong:
1. Nicardipine (Loxen)
(Thuoc c che Calci nhom C cha thay tac dung trong thai ky va cho con bu)
0,5 1mg / lan Tiem TM
Co the tiem nhac lai e ha huyet ap trung bnh xuong < 104 mmHg
ieu tr duy tr:
2. Sau o duy tr bang bm tiem ien
Nicardipine ( Loxen) 1mg 3mg/ gi
Labetalol (trandate) 0,5mg 20 mg /gi
(Thuoc c che Apha nhom C khong anh hng trong thai ky va luc cho con bu)
Theo doi sat tai phong hoi sc
18. at hieu qua va dung nap tot :
HA trung bnh < 100 mmHg -> ngng thuoc
100 < HA TB < 120 mmHg -> ieu tr duy tr
HA TB > 120 mmHg
19. S dung thuoc ha ap sau sanh :
Cho con bu:
Aldomet (Apha methyl dopa) 1000 -1500 mg/ ngay
(Thuoc c che Apha nhom C khong anh hng trong thai ky va luc cho con bu)
Amlor 5-15mg /ngay
(Thuoc c che calci nhom B khong gay anh hng trong thai ky va cho con bu, gay d tat va nhiem oc thai loai vat, het sc can than khi dung cho thai phu)
Trandate (labetalol) 200 600 mg/ngay
Neu huyet ap tang cao ngng cho con bu:
Phoi hp thuoc chen giao cam la atenolol (thuoc c che Beta chon loc nhom D co anh hng trong thai ky va cho con bu) va thuoc c che men chuyen.
Chong ch nh dung thuoc cat sa Bromocriptine (Parlodel) ( nhom C )
oi vi san phu TSG nang v co nguy c xuat hien:
Cn tang huyet ap kch phat
Cn co giat
Tai bien mach mau nao
Nhoi mau c tim
20. *An than
Diazepam lieu nhe 10 mg tiem tnh mach moi 4 gi
Khi chuyen da co the dung Dolargan (Dolosal, Meperidine) 50mg tiem tnh mach cham moi 2 gi. Ngng tiem Dolargan neu d oan se so thai trong vong 2 gi.
21. * Li tieu: Ch dung khi :
HA toi a > 170 mmHg
Co trieu chng doa OAP
Furosemide (Lasix) 20mg/1 ong x 8 tiem tnh mach cham
Khong dung dung dch u trng
22. * Tr tim
Khi co trieu chng doa OAP
Digoxin 0,5mg hay Cedilanide 0,8mg tiem tnh mach e co tac dung nhanh, hoac Risordan 5 mg ngam du li moi 15 phut.
23. *Dch truyen :
Glucose 5% gi tnh mach
Tranh cac dung dich u trng va tranh truyen dch nhanh.
Chuan b san : cay ngang li , thanh ging cao
24. B. Cham dt thai ky: Cac ch nh cham dt gom + HA toi thieu ? 110mmHg trong 24 gi
+ Protein nieu ? 2g/24 gi
+Creatinin huyet tang
+Nhc au hay hoa mat hay au vung thng v keo dai- xuat huyet ay mat
+ Suy giam chc nang gan
+ Giam tieu cau
+ Co hoi chng HELLP (tan huyet, tang SGOT, SGPT, giam tieu cau)
+ e doa san giat
+ e doa phu phoi cap
+ Thai suy trng dien hoac suy cap
25. Trc khi lay thai: d
Thai k? t? 28 34 tu?n nn s? d?ng Corticoid (Betne 5,2 mg, Betamethasone 4mg)
?t 1
- L?n 1 : Betne 5,2 mg 1 ?ng x 3 tim TM ch?m
- L?n 2 : cch 24 gi? sau l?n 1 (nhu li?u 1)
- N?u sau 2 l?n s? d?ng s?n ph? v?n chua sanh th s? d?ng d?t 2
?t 2 : s? d?ng li?u nhu d?t 1
M?c tiu s? d?ng Corticoid tru?c khi ch?m d?t thai k? d? tang surfactan gi?m suy h h?p so sinh
?i v?i tru?ng h?p m? b? ti?u du?ng c th? s? d?ng corticoid d?n thai k? tu?n l? th? 36
26. Phng phap cham dt thai ky
e tranh cac nguy c cho me, co gang sanh nga am ao la bien phap u tien cac trng hp SG.
Nguy c bien chng nang giam nhieu nhng trng hp sanh c bang nga am ao
27. C. San giat
28. 1. Muc ch ieu tr Chong co giat
Ha huyet ap
D phong cac bien chng: xuat huyet nao, vo nieu, phu phoi cap, nhau bong non, phong huyet t cung nhau
29. 2. Nguyen tac ieu tr: Khan trng tch cc la 1 cap cu so 1 trong san khoa
Can nam ro benh s qua hoi than nhan, xac nh so cn xay ra tai nha, cn co giat cuoi cung cach luc nhap vien bao lau.
ieu tr giong nh oi vi tien san giat nang
Phai theo doi, cham soc tai khoa san soc ac biet, co u oxy va cac phng tien hoi sc khac
30. 3. Cach ieu tr ieu tr noi khoa : Nh trong tien san giat nang
Chong co giat
Ha ap
An than neu can thiet
Tr tim
Gi tnh mach bang dch truyen
Li tieu neu can thiet
31. Them :
Oxy
Cay ngang li
Hut am nht
32. Theo doi:
Dau hieu sinh ton: huyet ap, nhp th, nhiet o
Phan xa gan xng
Nc tieu
Ap lc tnh mach trung tam
Soi ay mat
Cn go, tim thai
33. Neu benh nhan co giat lien tuc, khong ap ng vi Sulfate Magnesi, can phai s dung Thiopental 300mg tiem tnh mach cham e cat cn
34. ieu tr san khoa
Ch nh cham dt thai ky neu :
ieu tr noi khoa khong ket qua (dung u lieu lng thuoc ma benh nhan van con co giat, huyet ap van khong giam, hoac cac tnh trang doa phu phoi cap, vo nieu van xay ra)
Tnh trang benh nhan on nh sau ieu tr 24 gi
35. Cach lay thai
Neu benh nhan vo nieu, co giat : phai gay me, mo lay thai
Neu benh nhan on nh, 24 gi sau cn co giat cuoi cung: th khi phat chuyen da bang oxytocin truyen tnh mach
Khi cn go tot, tach rong mang oi va khi co t cung m khoang 3cm co the tia oi e thuc ay chuyen da nhanh hn
ong thi khi cn go tot, co t cung 3cm, cho Meperidine (Dolargan) 50mg tnh mach e an than va giam au
Khi co t cung m tron, au lot thap, phai giup sanh bang forceps
37. H?I CH?NG HELLP
38. H?I CH?NG HELLP HELLP l t? vi?t t?t c?a : Hemolysis (tn huy?t)
Elevatedo liver enzymes (tang men gan)
Low Platelet (gi?m ti?u c?u)
H?i ch?ng x?y ra ? 10% b?nh nhn mang thai b? ti?n s?n gi?t n?ng. ? ngu?i b? ti?n s?n gi?t n?ng, khi th?y ti?u c?u gi?m <100.000/mm3 nen xem ph?t mu ngo?i bien v xt nghi?m ch?c nang gan d? tm h?i ch?ng ny.
39. 1. Nguyen nhan c?a h?i ch?ng HELLP chua du?c bi?t
2.Tri?u ch?ng:
Tri?u ch?ng c?a h?i ch?ng HELLP thu?ng x?y ra vo thai k? th? ba m?c d h?i ch?ng c th? b?t d?u s?m hon. Tri?u ch?ng cung c th? xu?t hi?n trong 48 gi? dd au sau sinh. Cc TC c?a b?nh bao g?m:
au thu?ng v? ho?c h? su?n ph?i
Bu?n non ho?c non ?i
M?t m?i
Nh?c d?u
40. 3. Nguy co c?a h?i ch?ng HELLP:
N?u khong di?u tr? k?p th?i, h?i ch?ng HELLP c th? gay ra nh?ng nguy co nghiem tr?ng cho c? m? l?n thai nhi.
Tren ngu?i m? b?nh c th? gay hu h?i gan nghiem tr?ng , hi?m hon c th? gay v? gan, suy th?n, r?i lo?n dong mu, d d?t qu? v t? vong.
Khi ngu?i m? b? nh?ng bi?n ch?ng nghiem tr?ng, thai nhi s? nguy hi?m tnh m?ng. H?i ch?ng HELLP lm tang nguy co nhau bong non tru?c khi sanh, dde d?a tnh m?ng m? v thai nhi cung nhu tang nguy co sanh non.
41. 4.i?u tr?
Ki?m sot huy?t p
Truy?n ti?u c?u n?u ti?u c?u <20.000/mm3 ho?c <40.000/mm3 km theo r?i lo?n c?m mu.
Truy?n h?ng c?u l?ng n?u hct<30%
Ch?m d?t thai k? ngay d? phng ng?a nh?ng bi?n ch?ng n?ng.
N?u thai k? < 34 tu?n, c th? tr hon kho?ng 48 gi? d? di?u tr? ngu?i m? b?ng cotticoides. Thu?c ny gip d?y nhanh qu trnh tru?ng thnh c?a phi thai nhi v phng ng?a bi?n ch?ng sanh non. M?t s? nghin c?u d? ngh? dng corticoides li?u cao d? c?i thi?n tri?u ch?ng c?a ngu?i m?.
Sau khi sanh, nh?ng b?t thu?ng v? gan v huy?t h?c s? m?t di sau vi ngy.
B?nh nhn b? h?i ch?ng HELLP c nguy co <5% b? l?i h?i ch?ng ny trong nh?ng l?n mang thai khc, nhung nh?ng ngu?i ny l?i b? tang nh?ng nguy co khc nhu ti?n s?n gi?t, nhau bong non v sanh non.
42. BI?N CH?NG
43. S?N PH? N?u ch?n don b?nh mu?n th di?n ti?n c?a m? r?t tr?m tr?ng, t? l? t? vong 1-5%. Bi?n ch?ng thu?ng g?p theo Sibai khi chua di?u tr? b?o t?n:
21% r?i lo?n dng mu d?ng (CIVD)
16% huy?t t? sau nhau
8% suy th?n c?p
6% ph ph?i c?p
2% xu?t huy?t n?i ph?i m? b?ng
1% mu t? du?i bao gan v bong vng m?c
44. Nh?ng nguyn nhn gy huy?t t? sau nhau (he1matome re1tro placentaire) thu?ng g?p trong: r?i lo?n dng mu, suy th?n c?p, ph ph?i c?p
H?i ch?ng HELLP gy ra nguy co bang huy?t sau sanh r?t cao, nguy co ny thu?ng xu?t hi?n do h?u qu? c?a dng mu n?i m?ch lan t?a m khng ph?i do bang huy?t sau sanh. t c lin quan d?n gi?m ti?u c?u v bi?n ch?ng ny. Vi?c truy?n ti?u c?u phng ng?a cung khng th? ngan du?c bang huy?t sau sanh.
45. THAI NHI T? l? t? vong thai d?i t? 6%-37%. Abramovici nghin c?u 269 tru?ng h?p:
Nhm d?u tin c d?y d? tri?u ch?ng c?a h?i ch?ng HELLP
Nhm th? hai: HELLP t?ng ph?n
Nhm th? ba: b?nh TSG n?ng khng c lin quan d?n h?i ch?ng HELLP
Abramovici d nh?n xt h?i ch?ng HELLP khng ?nh hu?ng d?n tnh hnh b?nh t?t c?a so sinh v chnh s? sanh non gp ph?n gia tang t? l? t? vong so sinh.