0662.indd 1 6/17/2562 BE 14:43

● ∑’˪√÷°…“»“ μ√“®“√¬å𓬷æ∑¬å¿‘‡»° ≈ÿ¡æ‘°“ππ∑å

● ª√–∏“πæ≈Õ“°“»‚∑𓬷æ∑¬å°“√ÿ≥ ‡°àß °ÿ≈

● ºŸâ√—Èßμ”·Àπàߪ√–∏“π√Õß»“ μ√“®“√¬å𓬷æ∑¬å«‘∑¬“ ∂‘∞“æ—π∏å

● √Õߪ√–∏“π 1𓬷æ∑¬åæ‘…≥ÿ ¢—πμ‘æß…å

● √Õߪ√–∏“π 2ºŸâ™à«¬»“ μ√“®“√¬å𓬷æ∑¬å≥—∞æß»å Õ‘»√“ß°Ÿ√ ≥ Õ¬ÿ∏¬“

● ‡≈¢“∏‘°“√√Õß»“ μ√“®“√¬å𓬷æ∑¬åÕ√√≥æ „® ”√“≠

● ‡À√—≠≠‘°√Õß»“ μ√“®“√¬å·æ∑¬åÀ≠‘ßæ√æ‘¡≈ ‡√◊Õß«ÿ≤‘‡≈‘»

● °√√¡°“√°≈“ß√Õß»“ μ√“®“√¬å𓬷æ∑¬å°”∏√ 惰…“π“ππ∑廓 μ√“®“√¬å𓬷æ∑¬å‚°«‘∑ §”æ‘∑—°…å√Õß»“ μ√“®“√¬å𓬷æ∑¬å™‡ππ∑√å «π“¿‘√—°…å√Õß»“ μ√“®“√¬å·æ∑¬åÀ≠‘ß∞‘μ‘¡“  ÿπ∑√ —®√Õß»“ μ√“®“√¬å𓬷æ∑¬å¥‘∞°“πμå ∫√‘∫Ÿ√≥åÀ‘√—≠ “√√Õß»“ μ√“®“√¬å𓬷æ∑¬åæ—≠êŸ æ—π∏å∫Ÿ√≥–»“ μ√“®“√¬å𓬷æ∑¬å«√æß»å ¿Ÿàæß»å𓬷æ∑¬å«‘ ‘∑∏‘Ï  ÿ¿—§√æß…å°ÿ≈√Õß»“ μ√“®“√¬å𓬷æ∑¬å»—°π—π ¡–‚π∑—¬»“ μ√“®“√¬å·æ∑¬åÀ≠‘ß»‘√‘«√√≥ μ—Èß®‘μ°¡≈𓬷æ∑¬å‚ÕÓ√‘° ¡ÿ ‘°«ß»å

● ∫√√≥“∏‘°“√√Õß»“ μ√“®“√¬å𓬷æ∑¬åÕ√√≥æ „® ”√“≠

● °Õß∫√√≥“∏‘°“√»“ μ√“®“√¬å𓬷æ∑¬å‚°«‘∑ §”æ‘∑—°…å𓬷æ∑¬å™“≠™—¬ ∫ÿ≠Õ¬Ÿà𓬷æ∑¬å∏’√«ÿ≤‘ ¢—πª√–°Õ∫𓬷æ∑¬åª√– ‘∑∏‘Ï «‘√‘¬–°‘®‰æ∫Ÿ≈¬å𓬷æ∑¬å‚ÕÓ√‘° ¡ÿ ‘°«ß»å·æ∑¬åÀ≠‘ß≈—≈∏æ√ æ—≤π“«‘®“√¬å

● ‡≈¢“πÿ°“√π“¬πæ¥≈ ¡≥’°ÿ≈

● ºŸâ™à«¬‡≈¢“πÿ°“√π“ß “«√—™¥“«—≈¬å æŸ≈ª√–‡ √‘∞ π“ß “««π“æ√ ‡ß‘π‡¬Áπ

‡ªìπÀπ—ß ◊Õ¿“¬„π¢Õß√“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ·≈–‡ªìπ ◊ËÕ°≈“ß√–À«à“ß ¡“™‘°„π°“√·≈°‡ª≈’ˬπ¥â“π«‘™“°“√ ∑—»π§μ‘¢âÕ§‘¥‡ÀÁπ °“√∫√‘À“√ß“π ·≈–Õ◊ËπÊ ¢Õß√“™«‘∑¬“≈—¬œ ∫∑§«“¡¢âÕ§‘¥®¥À¡“¬ ‡ªì𧫓¡‡ÀÁπ¢ÕߺŸâ‡¢’¬π‡∑à“π—Èπ ¡‘„™à§«“¡‡ÀÁπ¢Õß√“™«‘∑¬“≈—¬œ

√“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ™—Èπ 8 Õ“§“√‡©≈‘¡æ√–∫“√¡’ ı ªï ´.»Ÿπ¬å«‘®—¬

∂.‡æ™√∫ÿ√’μ—¥„À¡à ∫“ß°–ªî À⫬¢«“ß °∑¡. 10310 ‚∑√»—æ∑å : 0-2716-5721 - 22, 0-2716-5725 ·ø° å : 0-2716-5720

www.rtcog.or.th E-mail : pr_rtcog@rtcog.or.th, sc_rtcog@rtcog.or.th

Àπâ“

∫√√≥“∏‘°“√·∂≈ß 3

 “√®“°ª√–∏“π√“™«‘∑¬“≈—¬œ 4

 Ÿμ‘π√’‡«™ - ®√‘¬∏√√¡ “∏° 5

°“√§“¥°“√≥å°“√§≈Õ¥°àÕπ°”Àπ¥‡æ◊ËÕªÑÕß°—π°”Àπ¥ 8

§”·π–π”°“√ºà“μ—¥‡π◊ÈÕßÕ°¡¥≈Ÿ°‡æ◊ËÕμâ—Èߧ√√¿å 16

Interhospital Conference §√—Èß∑’Ë 5/2560 20

P_2 20/6/19, 14:482

3©∫—∫∑’Ë 1/2562

 «— ¥’§√—∫  ¡“™‘°√“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬å·Ààߪ√–‡∑»‰∑¬∑ÿ°∑à“π

 Ÿμ‘π√’·æ∑¬å —¡æ—π∏å©∫—∫π’È ‡ªìπ©∫—∫·√°π—∫μ—Èß·μà∑à“πª√–∏“π ·≈–§≥–°√√¡°“√∫√‘À“√√“™«‘∑¬“≈—¬œ ™ÿ¥„À¡à¡“√—∫ªÆ‘∫—μ‘Àπâ“∑’Ë ´÷Ë߉¥â¡’°“√ “πμàÕß“π®“°ºŸâ∫√‘À“√™ÿ¥∑’˺à“π¡“ √«¡∂÷ß¡’¿“√–°‘® ”§—≠„À¡àÊ ¥—ß∑’˪√“°Æ„π “√®“°ª√–∏“π√“™«‘∑¬“≈—¬œ

∫∑§«“¡ Ÿμ‘π√’‡«™-®√‘¬∏√√¡ “∏° ‡√◊ËÕß çHumannized health care/°“√¥Ÿ·≈ºŸâªÉ«¬¥â«¬À—«„®∫πæ◊Èπ∞“π¢Õߧ«“¡√Ÿâé ‚¥¬∑à“π√Õߪ√–∏“π Õ“®“√¬åæ‘…≥ÿ ¢—πμ‘æß…å „π©∫—∫π’ȇªìπ‡√◊ËÕß燧√◊ËÕß¡◊Õ ◊ËÕ “√ ªí®®—¬ ”§—≠„π°“√¥Ÿ·≈√—°…“§π‰¢âé ´÷Ëß∑à“π‰¥â∂à“¬∑Õ¥‡√◊ËÕߥ—ß°≈à“«®“°ª√– ∫°“√≥å„π°“√∑”ß“π¡“‡ªìπ√–¬–‡«≈“π“π μàե⫬∫∑§«“¡«‘™“°“√®“°§≥–Õπÿ°√√¡°“√Õπ“¡—¬·¡à·≈–‡¥Á° ‡√◊ËÕß ç°“√§“¥°“√≥å°“√§≈Õ¥°àÕπ°”Àπ¥‡æ◊ËÕ°“√ªÑÕß°—π√—°…“é ‚¥¬»“ μ√“®“√¬å·æ∑¬åÀ≠‘ßÕÿàπ„® °ÕÕπ—πμ°ÿ≈ Õ¥’μª√–∏“π§≥–Õπÿ°√√¡°“√œ πÕ°®“°π’Ȭ—ß¡’∫∑§«“¡«‘™“°“√ ®“°§≥–Õπÿ°√√¡°√√¡‡«™»“ μ√å°“√‡®√‘≠æ—π∏ÿå ‡√◊ËÕß ç§”·π–π”°“√ºà“μ—¥‡π◊ÈÕßÕ°¡¥≈Ÿ°‡æ◊ËÕ°“√μ—Èߧ√√¿åé ‚¥¬ ∑à“π√Õß»“ μ√“®“√¬å𓬷æ∑¬å ÿ¿—°¥’ ®ÿ≈«‘®‘μ√æß…å Õ¥’μª√–∏“πÕπÿ°√√¡°“√œ ·≈–‡™àπ‡§¬ °—∫∫∑§«“¡√“¬ß“π°“√ª√–™ÿ¡ Interhospital Conference§√—Èß∑’Ë 5/2560 ´÷Ë߇ πÕ°√≥’ºŸâªÉ«¬∑’Ëπà“ π„® ‚¥¬ ·æ∑¬åª√–®”∫â“π ¿“§«‘™“ Ÿμ‘»“ μ√å-π√’‡«™«‘∑¬“§≥–·æ∑¬»“ μ√å«™‘√欓∫“≈ ¡À“«‘∑¬“≈—¬π«¡‘π∑√“∏‘√“™ ·≈–ªî¥∑⓬‡≈ࡥ⫬§”∂“¡ ·≈–¿“殓°°‘®°√√¡μà“ßÊ §√—∫

∑“ß°Õß∫√√≥“∏‘°“√√≥√ߧå„Àâ‡À≈à“ ¡“™‘°√—∫ Ÿμ‘π√’·æ∑¬å —¡æ—π∏å©∫—∫Õ‘‡≈§∑√Õπ‘° å‡æ◊ËÕ≈¥‚≈°√âÕπ  ¡“™‘°∑à“π„¥ª√– ß§å∑’Ë®–√—∫ Ÿμ‘π√’·æ∑¬å —¡æ—π∏å©∫—∫ Õ‘‡≈§∑√Õπ‘° å„π√Ÿª·∫∫ PDF file ∑“ß E-mail, Line À√◊Õ Facebook°√ÿ≥“·®âß¡“∑’Ë E-mail address: sc-rtcog@rtcog.or.th À√◊Õ QR Code

‰¥â§√—∫

æ∫°—π„À¡à©∫—∫Àπâ“π–§√—∫

P_3 6/17/19, 2:50 PM3

4  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

‡√’¬π∑à“πÕ“®“√¬å æ’ËπâÕß ‡æ◊ËÕπ Ÿμ‘π√’·æ∑¬å º¡·≈–§≥–°√√¡°“√∫√‘À“√™ÿ¥„À¡à

‰¥â√à«¡°—π∑”ß“π¡“·≈â« 6 ‡¥◊Õπ „π∑’¡™ÿ¥π’È º¡‰¥â‡√’¬π‡™‘≠∑à“πÕ¥’μª√–∏“π√“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ».πæ.¿‘‡»° ≈ÿ¡æ‘°“ππ∑å ¡“‡ªìπ∑’˪√÷°…“¢Õߧ≥–°√√¡°“√

∫√‘À“√√“™«‘∑¬“≈—¬œ ¥â«¬ μ“¡À≈—°°“√∫√‘À“√ “°≈ ∑’Ë®–‡™‘≠ Immediate past president¡“‡ªìπ∑’˪√÷°…“‡æ◊ËÕ„À⇰‘¥ª√–‚¬™πå Ÿß ÿ¥μàÕ°“√∫√‘À“√√“™«‘∑¬“≈—¬œ Õ¬à“ßμàÕ‡π◊ËÕß „π√–¬–

·√°π’È §≥–°√√¡°“√∫√‘À“√œ ‰¥â∑∫∑«π ·≈–·μàßμ—Èߧ≥–Õπÿ°√√¡°“√™ÿ¥μà“ßÊ „Àâ§√∫∂â«πμ“¡¿“√°‘® ”§—≠¢Õß√“™«‘∑¬“≈—¬œ ¿“√°‘®‡√àߥà«π§◊Õ °“√ª√—∫‡ª≈’ˬπÀ≈—° Ÿμ√°“√Ωñ°Õ∫√¡·æ∑¬åºŸâ‡™’ˬ«™“≠∑ÿ° “¢“ √«¡∂÷ß°“√μ√«®√—∫√Õß ∂“∫—πΩñ°Õ∫√¡∑ÿ°·Ààß„À⇪ìπμ“¡¡“μ√∞“π

WFME 2015 μ“¡π‚¬∫“¬¢Õß·æ∑¬ ¿“  à«π¿“√°‘®ª√–®”Õ◊ËπÊ ¥”‡π‘π‰ª¥â«¬¥’§√—∫ ¥â«¬§«“¡ “¡“√∂™—Èπ‡¬’Ë¬¡ ¢Õߧ≥–Õπÿ°√√¡°“√∑ÿ°™ÿ¥

¥â“π°“√μà“ߪ√–‡∑» √“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ¡’π‚¬∫“¬™—¥‡®π„π°“√‡æ‘Ë¡∫∑∫“∑„π The Asia and Oceania Federation of Obstetrics & Gynaecology

(AOFOG) ∑à“π ».πæ.¿‘‡»° ≈ÿ¡æ‘°“ππ∑å Õ¥’μª√–∏“π√“™«‘∑¬“≈—¬œ ¢Õ߇√“ ªí®®ÿ∫—π‡ªìπVice president ¢Õß AOFOG ·≈–‰¥â √â“ߧÿ≥Ÿª°“√„Àâ°—∫√“™«‘∑¬“≈—¬œ Õ¬à“ß¡“° „πÕπ“§μ‡√“À«—ß«à“∑à“π®–‡ªìπ·æ∑¬å‰∑¬§π·√°∑’ˇªìπª√–∏“π AOFOG

¿“√°‘® ”§—≠¡“°∑’Ë¢Õ‡√’¬π„Àâ∑à“π∑√“∫‡√◊ËÕßÀπ÷Ëߧ◊Õ „πªïÀπâ“ ªï æ.».2563√“™«‘∑¬“≈—¬ Ÿμ‘π√’·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ®–¡’Õ“¬ÿ§√∫ 50 ªï ‡√“®–®—¥°‘®°√√¡‡æ◊ËÕ‡©≈‘¡©≈Õß

«“√–¡ß§≈§√∫√Õ∫ 50 ªï (Golden Jubilee) ¢≥–π’ÈÕ¬Ÿà√–À«à“ß°“√‡μ√’¬¡°“√Õ¬à“ß√Õ∫§Õ∫§√—∫

æ≈.Õ.∑.πæ.°“√ÿ≥ ‡°àß °ÿ≈

P_4 20/6/19, 13:004

5©∫—∫∑’Ë 1/2562

ªíí íí í≠À“„π°“√μ‘¥μàÕ·æ∑¬å‡æ◊ËÕ°“√¥Ÿ·≈√—°…“§π‰¢âπ—Èπ∂◊Õ‡ªìπ‡√◊ËÕß ”§—≠ ‚¥¬‡©æ“–Õ¬à“߬‘Ëß„π¬“¡«‘°“≈À√◊ÕπÕ°‡«≈“√“™°“√®÷ß®”‡ªìπμâÕß¡’«‘∏’μ‘¥μàÕ∑’Ë¡’ª√– ‘∑∏‘¿“æ‡π◊ËÕß®“°·æ∑¬å°Á‡ªìπªÿ∂ÿ™π∏√√¡¥“¬àÕ¡μâÕß¡’∏ÿ√– à«πμ—«∑’ËμâÕßÕÕ°‰ªπÕ°‚√ß欓∫“≈∫â“ßªí®®ÿ∫—π‡§√◊ËÕß¡◊Õ ◊ËÕ “√¡’„Àâ‡≈◊Õ°„™â¡“°¡“¬∑”„Àâßà“¬μàÕ°“√μ‘¥μàÕ·æ∑¬å ∑”„Àâ·æ∑¬å¡’™’«‘μª√–®”«—π∑’Ë¥’¢÷Èπ “¡“√∂¡’°‘®°√√¡‡À¡◊Õπ§πÕ◊Ëπ Ê ‰¥â∫â“ß Õ¬à“߉√°Áμ“¡®–μâÕß¡—Ëπ„®„π√–∫∫μ‘¥μàÕ«à“ “¡“√∂μ“¡·æ∑¬å„Àâ¡“¥Ÿ§π‰¢â‰¥â„π™à«ß‡«≈“∑’Ë°”Àπ¥

‚¥¬∑—Ë«‰ª·æ∑¬å‡ªìπÀ—«Àπâ“∑’¡„π°“√¥Ÿ·≈√—°…“§π‰¢â ‡π◊ËÕß®“°¡’Àπâ“∑’Ë„π°“√ —Ëß°“√√—°…“À≈—ß®“°«‘π‘®©—¬‚√§®“°°“√´—°ª√–«—μ‘μ√«®√à“ß°“¬·≈– àßμ√«®æ‘‡»…Õ◊Ëπ Ê μ“¡§«“¡‡À¡“– ¡ Õ¬à“߉√°Áμ“¡∫“ß√“¬π—Èπ‚√§∑’ˇªìπÕ“®¡’§«“¡´—∫´âÕπ∑”„À≡ࠓ¡“√∂„Àâ°“√«‘π‘®©—¬‰¥â„π√–¬–·√° ®”‡ªìπμâÕß¡’°“√μ‘¥μ“¡ —߇°μÕ“°“√‡ª≈’ˬπ·ª≈ßμà“ß Ê ∑’Ë®–∑”„Àâ«‘π‘®©—¬‚√§‰¥â™—¥‡®π¢÷ÈπÀ√◊Õ§π‰¢â∫“ß√“¬À≈—ß«‘π‘®©—¬‚√§æ√âÕ¡ —Ëß°“√√—°…“·≈â«Õ“®‡°‘¥ªí≠À“·∑√° âÕπ®“°μ—«‚√§∑’ˇ®Á∫ªÉ«¬‡Õß À√◊Õ‡ªìπÕ“°“√‰¡àæ÷ߪ√– ß§å®“°°“√√—°…“°Á‰¥â®÷ß®”‡ªìπμâÕß¡’°“√μ‘¥μàÕ·æ∑¬åºŸâ∑”°“√√—°…“ À√◊Õ·æ∑¬å‡«√‰¥âμ≈Õ¥‡«≈“‡æ◊ËÕ„Àâ√—∫∑√“∫ªí≠À“·≈–ª√–‡¡‘π§π‰¢â‡æ◊ËÕ°“√√—°…“μàÕ‰ª

„πÕ¥’μ§√—Èß∑’˺¡®∫·æ∑¬å„À¡à Ê π—Èπ°“√μ‘¥μàÕ·æ∑¬å¡’‡æ’¬ß‚∑√»—æ∑å‡∑à“π—ÈπÕ“®‡ªìπ‚∑√»—æ∑å¿“¬„πÀ√◊Õ¿“¬πÕ°‚√ß欓∫“≈ ‚∑√»—æ∑å “∏“√≥–®÷ß¡’§«“¡À¡“¬¡“° ∫“ߧ√—ÈßÕ¬Ÿà‡«√‡ √‘¡À√◊Õ‡«√ on call ∑’Ë “¡“√∂®–Õ¬Ÿà∑’Ë„¥°Á‰¥â ·μàμâÕß “¡“√∂μ‘¥μàÕ·≈–¡“™à«¬¥Ÿ·≈§π‰¢â‰¥â∑—π∑à«ß∑’  ¡—¬∑’Ë√—∫√“™°“√Õ¬Ÿà‚√ß欓∫“≈‡∫μß¡’‡®â“Àπâ“∑’Ë™«π‰ª¥ŸÀπ—ß (¿“æ¬πμ√å) ÷Ëß¡’Õ¬Ÿà‡æ’¬ß·Àà߇¥’¬« ‡√“°Á∫Õ°°—∫欓∫“≈‡«√‰«â«à“¡’Õ–‰√„Àâμ“¡‰¥â∑’Ë‚√ßÀπ—߇æ√“–¡’«‘∏’°“√∑’Ë “¡“√∂μ“¡·æ∑¬å‰¥â ∫“ߧ√—Èߢ≥–°”≈—ߥŸÀπ—ß πÿ° Ê ¢â“߮ծ–ª√“°Øμ—«Àπ—ß ◊Õ®“°‡§√◊ËÕß©“¬‚ª√‡®§‡μÕ√å«à“ çÀ¡Õæ‘¥πÿ°√ÿ≥“°≈—∫‚√ß∫“≈¥à«π¡’‡§ ºà“μ—¥é º¡°Á®–μâÕߧàÕ¬ Ê À≈∫ÕÕ°¡“®“°‚√ßÀπ—ß°≈—∫‚√ß欓∫“≈‡æ◊ËÕ‰ª¥Ÿ·≈§π‰¢â

5©∫—∫∑’Ë 1/2562

º¡¡—°¢Õ√âÕß

„Àâ·æ∑¬å∑ÿ°§π

‡ªî¥¡◊Õ∂◊Õ‰«âμ≈Õ¥‡«≈“

·≈–欓¬“¡‰¡à‡ª≈’ˬπ

‡∫Õ√å∫àÕ¬ ‡æ◊ËÕ„Àâ§π

∑’ˇ¥◊Õ¥√âÕπ “¡“√∂

‚∑√»—æ∑åª√÷°…“‰¥â∑ÿ°‡«≈“

é

é

P_5-7 6/17/19, 2:58 PM5

6  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

‡¡◊ËÕ¡“‡√’¬πμàÕ‡ªìπ·æ∑¬åª√–®”∫â“π∑’Ë‚√ß欓∫“≈√“™«‘∂’ ¢≥–π—Èπ‡√‘Ë¡¡’«‘∑¬ÿμ‘¥μ“¡μ—« À√◊Շ殇®Õ√å¢π“¥‡∑à“´Õß∫ÿÀ√’Ë ™à«ßπ—Èπ®–‡ÀÁπ∫√√¥“§ÿ≥À¡Õæ°μ‘¥∑’ˇի∑ÿ°§π ‡ªìπ∫√‘°“√¢Õß°“√ ◊ËÕ “√œ „Àâ‡™à“‡ªìπ√“¬‡¥◊Õπ„™â∂à“π‰ø©“¬¢π“¥‡≈Á° Õß°âÕ𠇫≈“μ“¡®–μâÕß‚∑√œ ·®âß∑’Ë ° ∑. ‡æ◊ËÕ àߢâÕ§«“¡ —Èπ Ê À√◊Õ‡∫Õ√å‚∑√œ „Àâμ‘¥μàÕ°≈—∫ ∑”„Àâ™’«‘μ¢Õß·æ∑¬å¡’§«“¡ ÿ¢¢÷Èπ¡“°∑’Ë “¡“√∂‡¥‘π∑“߉ª‰Àπ‰¥â∫â“ß Õ¬à“߉√°Áμ“¡‡¡◊ËÕ‡√‘Ë¡∑”ß“π∑’Ë‚√ß欓∫“≈‡™’¬ß√“¬ª√–™“πÿ‡§√“–Àå ¢≥–π—Èπ¡’‡æ’¬ß‚∑√»—æ∑å “¬„π‚√ß欓∫“≈ ·≈–¡’‡§√◊ËÕß√—∫ àß«‘∑¬ÿ¡◊Õ∂◊Õ (walkie-talkie) „Àâ·æ∑¬å‡«√∂◊Õμ‘¥μ—« „π ¡—¬π—Èπμ—«‡§√◊ËÕß¡’¢π“¥„À≠à Àπ—° æ°≈”∫“° ª√– ‘∑∏‘¿“æ°Á‰¡à¥’√—»¡’∑”°“√§àÕπ¢â“ß·§∫ ‡«≈“„™â°Áøí߉¡à§àÕ¬√Ÿâ‡√◊ËÕß ∫“ߧπ„™â°Á‰¡à‡ªìπ °¥ªÿÉ¡∑’Ë„™â ”À√—∫查լŸàμ≈Õ¥‡«≈“À√◊Õ‰¡à°Á查 «π‰ª‡≈¬ ‚¥¬‰¡à√Ÿâ«à“Õ’°ΩÉ“¬‰¡à‰¥â¬‘π ·μàæ«°§ÿ≥À¡Õ°Á™Õ∫∂◊Õ‡æ√“–¥Ÿ‡∑॒ ‰¡à‡À¡◊Õπªí®®ÿ∫—π∑’Ëæ—≤π“®π¡’¢π“¥‡≈Á°æ°ßà“¬¡’ ’ —ππà“„™â øí߇ ’¬ß‰¥â™—¥‡®π·≈–¡’√—»¡’∑”°“√‰°≈‡ªìπ°‘‚≈‡¡μ√ ´÷Ëߧπ„™â§«√μâÕ߇√’¬π√Ÿâ°“√„™â√À— ·≈–«‘∏’°“√„™âÕ¬à“ß∂Ÿ°μâÕß®÷ß®–‰¥âª√–‚¬™πå ¡∫Ÿ√≥å

º¡‡æ‘Ë߉¥â‡ÀÁπ ·≈–„™â‚∑√»—æ∑凧≈◊ËÕπ∑’˧√—Èß·√°‡¡◊ËÕ 20 ªï°àÕπ„π°“√ª√–™ÿ¡«‘™“°“√°√–∑√«ß “∏“√≥ ÿ¢∑’‚√ß欓∫“≈æ√–ª°‡°≈â“ ®—π∑∫ÿ√’‡ªìπ‚∑√»—æ∑å Hot line „™â‡§√◊Õ¢à“¬¥“«‡∑’¬¡ ¢Õß∫√‘…—∑ Ericson¡’¢π“¥„À≠à·∫∫°√–‡ªÜ“À‘È«§ÿ≥¿“懠’¬ß¥—ß™—¥‡®π¥’ ·μà√“§“§à“‚∑√»—æ∑å·æß¡“° À‘È«‰ª‰Àπ≈”∫“° ·μà°Á‡ªìπ∑’ËŒ◊ÕŒ“°—π¡“°¢≥–π—Èπ ®π°√–∑—Ëßæ—≤π“¡“‡ªìπ¡◊Õ∂◊Õ·∫∫∑’Ë∂◊Õ‰ª‰Àπ¡“‰Àπ‰¥â –¥«°¢÷Èπ¢π“¥‡∑à“°—∫°√–μ‘°πÈ”μ‘¥‡ “Õ“°“» 查°—π«à“„™â‡ªìπÕ“«ÿ∏ªÑÕß°—πμ—«„π¿“«–§—∫¢—π‰¥â „™â‡§√◊Õ¢à“¬‚∑√»—æ∑å Õ—μ√“§à“‚∑√»—æ∑å®÷ß∂Ÿ°≈ß·μà√“§“§à“‡§√◊ËÕß·æß¡“° 2 - 3 À¡◊Ëπ∫“∑ ·≈–μâÕ߇ ’¬§à“ª√–°—π‡≈¢À¡“¬Õ’°√“« 2.5 À¡◊Ëπ∫“∑  —≠≠“≥¡’§àÕπ¢â“ß®”°—¥‡æ’¬ß∫“ßæ◊Èπ∑’Ë „§√¡’„™â„π™à«ßπ—Èπ∂◊Õ«à“‚°â¡“° À≈—ß®“°π—Èπ¡’°“√æ—≤π“¡“Õ¬à“ßμàÕ‡π◊ËÕß®π∂÷ßªí®®ÿ∫—π¡’√–∫∫ 3G, 4G  “¡“√∂„™â‰¥â§√Õ∫§≈ÿ¡‡°◊Õ∫∑ÿ°æ◊Èπ∑’Ë  à߉¥â∑—Èß¿“æ·≈–‡ ’¬ßÀ√◊Õ«‘¥‘∑—»πå ∑”„Àâμ‘¥μàÕ·æ∑¬å·≈– àß¿“æ‡Õ°´‡√¬å À√◊Õº≈‡≈◊Õ¥®“°ÀâÕߪؑ∫—μ‘°“√‰¥âμ≈Õ¥‡«≈“ ∑—È߬—ß “¡“√∂ àߢâÕ¡Ÿ≈∂÷ß°—π‡ªìπ°≈ÿࡉ¥â¥â«¬ ∑”„Àâ –¥«°„π°“√¢Õ§”ª√÷°…“‰¥âμ≈Õ¥‡«≈“

Õ¬à“߉√°Áμ“¡‰¡à«à“®–¡’‡§√◊ËÕß¡◊Õ ◊ËÕ “√∑’Ë¡’ª√– ‘∑∏‘¿“æ‡æ’¬ß„¥ ·μà°Á¬—ߧߡ’ªí≠À“„π°“√μ“¡·æ∑¬å‚¥¬‡©æ“–„π¿“«–«‘°ƒμ‘ º¡®÷߇™◊ËÕ«à“§«“¡√—∫º‘¥™Õ∫„πÀπâ“∑’Ë¢Õß·æ∑¬å‡ªìπ ‘Ëß ”§—≠∑’Ë ÿ¥ ‡§¬¡’Õ¬Ÿà§√—ÈßÀπ÷Ëß∑’Ëμ“¡μ—«·æ∑¬å‡«√‰¡à‰¥âÀ≈—ß®“°æ¬“¬“¡μ“¡∑ÿ°™àÕß∑“ß·≈â«∂÷ß¢π“¥„Àâ √ª¿. ‰ª‡§“–ª√–μŸÀâÕßæ—°°Á¬—߉¡à¬Õ¡‡ªî¥Õâ“ß«à“‰¡à‰¥â¬‘π‡æ√“–πÕπÀ≈—∫ π‘∑ º¡√Ÿâ‡≈¬«à“ªí≠À“‡À≈à“π’È®–‡°‘¥°—∫·æ∑¬å‡æ’¬ß∫“ߧπ´È”·≈â«´È”‡≈à“ ®÷ß √ÿª‰¥â‡≈¬«à“°“√μ“¡·æ∑¬åπ—Èπ¢÷Èπ°—∫®√‘¬∏√√¡ ®√√¬“∫√√≥¢Õßμ—«·æ∑¬å‡Õß¡“°°«à“«‘∏’°“√ ◊ËÕ “√ ®÷ß®”‡ªìπμâÕß √â“ß√–∫∫„Àâ “¡“√∂μ“¡·æ∑¬å‰¥â∑—π‡«≈“„π°“√¥Ÿ·≈§π‰¢â ‡æ◊ËÕ„À⇰‘¥§«“¡ª≈Õ¥¿—¬μàÕ§π‰¢â∑ÿ°‡«≈“‡™àπ ∂â“μ“¡·æ∑¬å§π∑’ËÀπ÷Ë߉¡à‰¥â®–μâÕßμ“¡„§√μàÕ‰ª ‡ªìπμâπ

º¡¡—°¢Õ√âÕß„Àâ·æ∑¬å∑ÿ°§π‡ªî¥¡◊Õ∂◊Õ‰«âμ≈Õ¥‡«≈“ ·≈–欓¬“¡‰¡à‡ª≈’ˬπ‡∫Õ√å∫àÕ¬ ‡æ◊ËÕ„Àâ§π∑’ˇ¥◊Õ¥√âÕπ “¡“√∂‚∑√»—æ∑åª√÷°…“‰¥â∑ÿ°‡«≈“ §√—ÈßÀπ÷ËßÀ≈“¬ªï¡“·≈⫇«≈“ª√–¡“≥μ’ Õß¡’‡ ’¬ß‚∑√»—æ∑å¡◊Õ∂◊Õº¡¥—ߢ÷Èπ ∑ÿ°§√—Èß„π¬“¡«‘°“≈ ‡«≈“√—∫ “¬º¡®–查ÕàÕπÀ«“π‡ªìπ摇»…‡π◊ËÕß®“°‡¢â“„®«à“§π∑’Ë‚∑√»—æ∑å ¡“π—Èπ°”≈—߇¥◊Õ¥√âÕπ ∂Ⓡ√“查®“‰¡à¥’À√◊Õ· ¥ßÕ“√¡≥剡àæÕ„® §π∑’Ë‚∑√»—æ∑å¡“®–√Ÿâ ÷°º‘¥À«—ß·≈–‡ ’¬„® ‡¡◊ËÕº¡√—∫ “¬·≈â« ‡∏Õ®÷߇≈à“„À⺡øíß«à“‡ªìππ—°»÷°…“¡À“«‘∑¬“≈—¬¡’™◊ËÕ·ÀàßÀπ÷Ë߇ªì𥓫¢Õߧ≥– ·≈–‡√’¬π‡°àß√–¥—∫‡°’¬√μ‘π‘¬¡ ∑’Ë ”§—≠§ÿ≥·¡à‡∏Õ‡§¬∫Õ°«à“º¡‡ªìπ§π∑”§≈Õ¥ ‡∏Õ∫Õ°™◊ËÕ§ÿ≥·¡à ·≈–∫â“π∑’ˇ™’¬ß√“¬ (º¡®”‰¡à‰¥âÀ√Õ°‡æ√“–∑”§≈Õ¥¡“π—∫À¡◊Ëπ√“¬) ‡∏Õ‚∑√»—æ∑åÀ“‡π◊ËÕß®“°®–√∫°«π„À⺡‰ªæ∫§ÿ≥·¡à‡∏Õ„πμÕπ‡™â“

P_5-7 6/17/19, 2:58 PM6

7©∫—∫∑’Ë 1/2562

Ω“°∫Õ°«à“‡∏Õ√—°·¡à¡“° ™“μ‘Àπâ“®–¢Õ‡°‘¥¡“‡ªìπ≈Ÿ°·¡àÕ’° ‡∏Õμ—Èß„®®–∑“π¬“πÕπÀ≈—∫®πÀ¡¥¢«¥‡æ√“–‰¡àμâÕß°“√μ◊Ëπ¢÷Èπ¡“Õ’°º¡∂“¡∂÷߇Àμÿº≈ ‡∏Õ∫Õ°«à“·øπ´÷Ëߧ∫°—π¡“μ—Èß·μà‡√’¬π¡—∏¬¡ª≈“¬¥â«¬°—π¢Õ‡≈‘°°—∫‡∏Õ«—π°àÕπ‡π◊ËÕß®“°¡’·øπ„À¡à·≈â« ·≈–‡ªìπ‡æ◊ËÕπ‡∏Õ∑’ˇ√’¬π§≥–‡¥’¬«°—π ‡∏Õ∑”„®‰¡à‰¥â μâÕß°“√®–°‘π¬“쓬‡æ◊ËÕ· ¥ß„Àâ‡ÀÁπ«à“‡∏Õ√—°·øπ·§à ‰Àπ º¡®÷ß∂“¡«à“∂Ⓡ∏Õ쓬‰ª®√‘ß Ê ·≈â«·øπ®–‡ ’¬„®À√◊Õ‰¡à ‡∏ÕÕ÷È߉ª —°§√Ÿà·≈â«®÷ßμÕ∫«à“§ß®–‡ ’¬„®¡—Èß º¡®÷ß∂“¡„À¡à«à“∂Ⓡ∏Õ쓬 §ÿ≥·¡à §ÿ≥æàÕ®–‡ ’¬„®À√◊Õ‡ª≈à“ ‡∏ÕμÕ∫∑—π∑’«à“‡ ’¬„®·≈–‡ ’¬„®¡“°¥â«¬ º¡®÷ß∂“¡Õ’°«à“æ’ËπâÕߪŸÉ¬à“쓬“¬ ·≈–‡æ◊ËÕπ π‘∑®–‡ ’¬„®‰À¡ ‡∏Õ°Á∫Õ° ‚¥¬‰¡àμâÕߧ‘¥«à“‡ ’¬„® º¡®÷ß∫Õ°°—∫‡∏Õ«à“°“√∑’ˇ∏Õ®–쓬‡æ◊ËÕæ‘ Ÿ®π姫“¡√—°„Àâ·øπ‡ÀÁπ‚¥¬∑’Ë·øπÕ“®‰¡à π„®À√◊Õ‡ ’¬„®‡∑à“‰√°—∫°“√∑’˧π∑’Ë√—°‡√“¡“°¡“¬®–μâÕ߇ ’¬„®∑’ˇ√“쓬 ¡—π§ÿâ¡°—π·≈⫇À√Õº¡√Ÿâ ‰¥â®“°πÈ”‡ ’¬ß‡∏Õ∑’ËÕàÕπ≈ß«à“§ß ∫“¬„®¢÷Èπ®÷ß™«π§ÿ¬‡√◊ËÕß°“√‡√’¬π ·≈–∑—Ë« Ê ‰ª®π‡°◊Õ∫μ’ “¡ ‡∏Õ®÷ß∫Õ°«à“ßà«ß·≈â« º¡√Ÿâ‰¥â‡≈¬«à“‡∏Õ®–‰¡à°‘π¬“πÕπÀ≈—∫·≈â« º¡°Á≈◊¡‡√◊ËÕßπ’ȉª π‘∑®π°√–∑—ËßÕ’° ÕߪïμàÕ¡“ º¡‰¥â√—∫‚∑√»—æ∑宓°‡∏ÕÕ’°§√—Èß√“« ’Ë∑ÿà¡πÈ”‡ ’¬ß ¥„ ‰¡à‡À¡◊Õπ§√—Èß°àÕπ‡∏Õ∫Õ°«à“‚∑√»—æ∑å¡“¢Õ∫§ÿ≥∑’˙૬„Àâ‡∏Õ‰¥â§‘¥ ·≈–∫Õ°≈“‡æ◊ËÕ‰ª»÷°…“μàÕμà“ߪ√–‡∑»‚¥¬∑ÿπ√—∞∫“≈

∑ÿ°§√—Èß∑’Ëπ÷°∂÷߇√◊ËÕßπ’È∑”„À⺡√Ÿâ ÷°Õ‘Ë¡‡Õ¡„®∑’Ë ‰¥â™à«¬„À⇥Á°¥’ Ê §πÀπ÷Ë߉¥â§‘¥ ‰¡à∑”„π ‘Ëß‚ßà Ê ¥â«¬Õ“√¡≥å‡æ’¬ß ™—Ë««Ÿ∫ ¢Õ‡æ’¬ß·μà¡’„§√ —°§π„Àâ‡∏Õ‰¥âª√÷°…“‡∑à“π—Èπ ‡Àμÿ°“√≥åπ’È®– Õπ„Àâ‡∏Õ·°√àߢ÷Èπ‡‡≈–®–‡ªìπ°”≈—ß ”§—≠„Àâª√–‡∑»μàÕ‰ª„πÕπ“§μ º¡‰¡àÕ¬“°π÷°‡≈¬«à“∂â“«—ππ—Èπº¡‰¡à√—∫ “¬·≈⫇∏Õ‡°‘¥§‘¥ —È𠔇√Á®‡√“®–μâÕ߇ ’¬§π¥’ Ê ‰ªÕ’°Àπ÷Ëߧπ·≈–∑”„ÀâÕ’°À≈“¬ Ê §π‡ ’¬„® º¡®÷ߢÕ√âÕß„Àâ·æ∑¬å∑ÿ°§π°√ÿ≥“‡ªî¥¡◊Õ∂◊Õ¢Õß∑à“πμ≈Õ¥‡«≈“ ·≈–√—∫ “¬∑ÿ°§√—Èߥ⫬°“√¡’ μ‘∑’ËÕ¬“°™à«¬‡À≈◊Õ§πÕ◊Ëπ„Àâ ¡°—∫∑’ˇ√“‡≈◊Õ°¡“‡ªìπ·æ∑¬å§√—∫

ç¢Õ∫§ÿ≥∑’ˇªìπ§π¥’é

º¡®÷ߢÕ√âÕß„Àâ·æ∑¬å

∑ÿ°§π°√ÿ≥“‡ªî¥¡◊Õ∂◊Õ

¢Õß∑à“πμ≈Õ¥‡«≈“ ·≈–

√—∫ “¬∑ÿ°§√—Èߥ⫬°“√¡’ μ‘

∑’ËÕ¬“°™à«¬‡À≈◊Õ§πÕ◊Ëπ

„Àâ ¡°—∫∑’ˇ√“‡≈◊Õ°¡“‡ªìπ

·æ∑¬å§√—∫

é

é

P_5-7 6/17/19, 2:58 PM7

8  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

°“√§≈Õ¥°àÕπ°”Àπ¥„πª√–‡∑»‰∑¬ ¬—߇ªìπªí≠À“∑’Ë ”§—≠∑“ß Ÿμ‘°√√¡ æ∫Õÿ∫—μ‘°“√≥凩≈’ˬ∑’Ë√âÕ¬≈–10 - 12 „π 180 ª√–‡∑»∑—Ë«‚≈°æ∫Õÿ∫—μ‘°“√≥凩≈’ˬ∑’Ë√âÕ¬≈– 5 - 18 ¢Õß°“√‡°‘¥¡’™’æ 100 √“¬ °“√§≈Õ¥

°àÕπ°”À𥇪ì𠓇Àμÿ ”§—≠¢Õß°“√쓬·≈–¿“«–∑ÿææ≈¿“æ¢Õß∑“√°·√°‡°‘¥ ¿“«–∑ÿææ≈¿“欗ßÕ“®§ßÕ¬ŸàμàÕ‡π◊ËÕß„π√–¬–¬“« ∑—Èß∑’ˉ¥â√—∫°“√¥Ÿ·≈√—°…“Õ¬à“߇À¡“– ¡ §à“„™â®à“¬¢Õß°“√¥Ÿ·≈√—°…“ Ÿß¡“° °“√¥Ÿ·≈ªÑÕß°—π√—°…“°àÕπ°“√μ—Èߧ√√¿å ·≈–‡¡◊ËÕμ—Èߧ√√¿å (secondary prevention) ®÷ß¡’∫∑∫“∑ ”§—≠ „πªï §.». 2016

Õߧ尓√Õπ“¡—¬‚≈° (World Health Organization, WHO) ·π–π”°“√Ω“°§√√¿åÕ¬à“ßπâÕ¬ 8 §√—Èß°—∫∫ÿ§≈“°√∑“ß “∏“√≥ ÿ¢ ‚¥¬‡©æ“–‡√◊ËÕß°“√¥Ÿ·≈ªÑÕß°—π√—°…“°“√§≈Õ¥°àÕπ°”Àπ¥ ‡™àπ °“√„À⧔·π–π”

‡√◊ËÕß‚¿™π“°“√∑’ˇÀ¡“– ¡ À≈’°‡≈’ˬ߰“√„™â¬“·≈– “√‡ æμ‘¥ °“√μ√«®μ‘¥μ“¡∑“√°„π§√√¿å √«¡∑—Èß°“√μ√«®¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß‡æ◊ËÕ°”Àπ¥Õ“¬ÿ§√√¿å ·≈–°“√«‘π‘®©—¬§√√¿å·Ω¥ °“√ ◊∫§âπ·≈–„Àâ°“√¥Ÿ·≈ªí®®—¬‡ ’ˬß

Õ◊Ëπ Ê

«—μ∂ÿª√– ß§å¢Õß∫∑§«“¡π’ȇæ◊ËÕ√«∫√«¡§«“¡√Ÿâ‡™‘ߪؑ∫—μ‘ (practical knowledge) ®“°°“√»÷°…“μà“ß Ê

„π‡√◊ËÕß°“√§“¥°“√≥å (prediction) ‡æ◊ËÕ°“√ªÑÕß°—π√—°…“°“√§≈Õ¥°àÕπ°”Àπ¥ μ“¡ª√–‡¥ÁπμàÕ‰ªπ’È

1. °“√μ√«®§—¥°√Õß2. °“√ªÑÕß°—π√—°…“¥â«¬¬“ŒÕ√å‚¡π‚ª√‡® ‡∑Õ‚√π3. °“√ªÑÕß°—π√—°…“¥â«¬°“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°

4. °“√ªÑÕß°—π√—°…“¥â«¬ Cervical Pessaries

°“√μ√«®§—¥°√Õ߇ªìπæ◊Èπ∞“π‡∫◊ÈÕßμâπ∑’Ë ”§—≠¢Õß°“√ªÑÕß°—π°“√§≈Õ¥°àÕπ°”Àπ¥ ‡æ◊ËÕ§âπÀ“°≈ÿࡇ ’ˬߠŸß∑’Ëπ‘¬¡„™â„πªí®®ÿ∫—π

§◊Õ

A.ª√–«—μ‘-À≠‘ßμ—Èߧ√√¿å∑’Ë¡’§«“¡‡ ’ˬßμàÕ°“√§≈Õ¥°àÕπ°”À𥂥¬‡©æ“–°≈ÿà¡∑’Ë¡’ª√–«—μ‘ °“√§≈Õ¥

°àÕπ°”Àπ¥¡“°àÕπ ‚¥¬‡√‘Ë¡®“°°“√ —°ª√–«—μ‘¥â“𧫓¡‡®Á∫ªÉ«¬∑“ßÕ“¬ÿ√°√√¡ ª√–«—μ‘°“√μ—Èߧ√√¿å·≈–°“√§≈Õ¥·≈–ªí®®—¬‡ ’ˬßμà“ß Ê ¢Õß°“√‡°‘¥°“√§≈Õ¥°àÕπ°”Àπ¥ §«“¡º‘¥ª°μ‘∑—ÈßÀ¡¥§«√‰¥â√—∫°“√·°â‰¢ ·≈–„Àâ°“√√—°…“μ“¡ “‡ÀμÿÕ¬à“߇À¡“– ¡‡æ◊ËÕªÑÕß°—π°“√‡°‘¥´È” πÕ°®“°π’Ȫ√–«—μ‘¢Õß°“√μ—Èߧ√√¿åªí®®ÿ∫—𠇙àπ ¿“«–‡≈◊Õ¥

8  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

P_8-15 20/6/19, 13:378

9©∫—∫∑’Ë 1/2562

ÕÕ°º‘¥ª°μ‘∑“ß™àÕߧ≈Õ¥ °“√μ—Èߧ√√¿å·Ω¥ ‡ªìπμâ𠇪ìπªí®®—¬‡ ’ˬߢÕß°“√§≈Õ¥°àÕπ°”Àπ¥¥â«¬‡™àπ°—π

ª√–«—μ‘°“√§≈Õ¥∑—Èß°àÕπ°”Àπ¥ ·≈–/À√◊Õ°“√§≈Õ¥§√∫°”Àπ¥ “¡“√∂欓°√≥姫“¡‡ ’ˬߢÕß°“√‡°‘¥°“√§≈Õ¥‰¥â ®“°°“√»÷°…“¢Õß Beta J ·≈–§≥–(1) æ∫«à“À≠‘ß∑’Ë¡’ª√–«—쑧≈Õ¥§√∫°”Àπ¥‡¡◊ËÕμ—Èߧ√√¿å„À¡à

®–¡’§«“¡‡ ’ˬߢÕß°“√§≈Õ¥°àÕπ°”Àπ¥≈¥≈߇°◊Õ∫§√÷ËßÀπ÷Ë߇ª√’¬∫‡∑’¬∫°—∫°“√μ—Èߧ√√¿å·√° À≠‘ß∑’Ë¡’ª√–«—쑇§¬§≈Õ¥°àÕπ°”Àπ¥‡¡◊ËÕμ—Èߧ√√¿å„À¡à®–¡’§«“¡‡ ’ˬߢÕß°“√§≈Õ¥°àÕπ°”Àπ¥ Ÿß¢÷ÈπÕ¬à“ßπâÕ¬ 2 ‡∑à“‡ª√’¬∫‡∑’¬∫°—∫°“√μ—Èߧ√√¿å·√° ‚¥¬§«“¡‡ ’ˬ߮–‡æ‘Ë¡¢÷Èπμ“¡®”π«π§√—ÈߢÕߪ√–«—μ‘°“√§≈Õ¥°àÕπ°”Àπ¥ ·≈–

º°º—πμ“¡Õ“¬ÿ§√√¿å∑’˧≈Õ¥°àÕπ°”Àπ¥ ª√–«—쑇§¬§≈Õ¥°àÕπ°”Àπ¥®÷߇ªìπªí®®—¬‡ ’ˬß∑’Ë ”§—≠¢Õß°“√‡°‘¥°“√§≈Õ¥°”Àπ¥„π°“√μ—Èߧ√√¿å∑’Ëμ“¡¡“ ¥—ß· ¥ß„π√Ÿª∑’Ë 1(1)

√Ÿª∑’Ë 1(1) · ¥ß odds ratios ·≈–™à«ß§à“§«“¡‡™◊ËÕ¡—Ëπ∑’Ë√âÕ¬≈– 95 ¢Õß°“√§≈Õ¥°àÕπ°”Àπ¥„πÀ≠‘ß∑’Ë¡’ª√–«—μ‘°“√§≈Õ¥∑—Èß°àÕπ°”Àπ¥·≈–À√◊Õ§≈Õ¥§√∫°”Àπ¥

πÕ°®“°π’È¡’ß“π«‘®—¬Õ◊Ëπ(2) ∑’Ë π—∫ πÿπ¢âÕ¡Ÿ≈π’ȇ™àπ°—π ¥—ß· ¥ß„πμ“√“ß∑’Ë 1 ·≈– 2

μ“√“ß∑’Ë 1(2) · ¥ß§«“¡‡ ’ˬߠ—¡æ—∑∏å (relative risk, RR) ¢Õß°“√§≈Õ¥°àÕπÕ“¬ÿ§√√¿å 37  —ª¥“Àå

„π°“√μ—Èߧ√√¿å∑’Ë 2 ®“°¢âÕ¡Ÿ≈Õ“¬ÿ§√√¿å∑’˧≈Õ¥„π§√√¿å·√° (®”π«π°“√μ—Èߧ√√¿å 50,607 §√—Èß)

P_8-15 20/6/19, 13:379

10  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

μ“√“ß∑’Ë 2(2) · ¥ß§«“¡‡ ’ˬߠ—¡æ—∑∏å (relative risk, RR) ¢Õß°“√§≈Õ¥°àÕπÕ“¬ÿ§√√¿å 37  —ª¥“Àå

„π°“√μ—Èߧ√√¿å∑’Ë 3 ®“° ¢âÕ¡Ÿ≈Õ“¬ÿ§√√¿å∑’˧≈Õ¥„π§√√¿å·√°·≈–§√√¿å∑’Ë 2(®”π«π°“√μ—Èߧ√√¿å 10.819 §√—Èß)

 ”À√—∫ª√–«—μ‘ªí®®—¬‡ ’ˬßÕ◊Ëπ Ê ‡™àπ ¿“«–∑ÿæ‚¿™π“°“√ ‚√§ª√–®”μ—« °“√ Ÿ∫∫ÿÀ√’Ë °“√„™â¬“À√◊Õ ‘Ë߇ æμ‘¥ ª√–«—μ‘°“√μ‘¥‡™◊ÈÕ·≈–°“√ºà“μ—¥¢Õß√–∫∫ ◊∫æ—π∏ÿå ‡ªìπμâπ ¬—ß§ß¡’§«“¡ ”§—≠∑’ËμâÕß„Àâ°“√¥Ÿ·≈√—°…“‡æ◊ËÕªÑÕß°—π ·μà®–‰¡à°≈à“«∂÷ß„π∫∑§«“¡π’È

°“√μ√«®§—¥°√Õߥ⫬°“√‡°Á∫ “√§—¥À≈—Ëß„π™àÕߧ≈Õ¥·≈–ª“°¡¥≈Ÿ° (cervico-vagina) ‡æ◊ËÕ àßμ√«®

Fetal fibronectin ®–‰¡à°≈à“«„π∫∑§«“¡π’ȇ™àπ°—π ‡π◊ËÕß®“°¡’§à“„™â®à“¬ Ÿß·≈–¬—߉¡àπ”¡“„™â‡ªìπ°“√μ√«®§—¥°√Õß„πª√–‡∑»‰∑¬

B. °“√μ√«®«—¥§«“¡¬“«ª“°¡¥≈Ÿ°¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß

ªï§.». 1996 Iam ·≈–§≥–(3) æ∫§«“¡‡ ’ˬߢÕß°“√§≈Õ¥°àÕπ°”Àπ¥‡æ‘Ë¡¢÷Èπ„πÀ≠‘ßμ—ÈßÕ“¬ÿ§√√¿å24  —ª¥“Àå∑’Ë ‰¥â√—∫°“√μ√«®¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß∑“ß™àÕߧ≈Õ¥·≈–æ∫§«“¡¬“«ª“°¡¥≈Ÿ° —Èπ Õ—μ√“‡ ’ˬß

‡æ‘Ë¡¢÷Èπº°º—πμ“¡§«“¡¬“«ª“°¡¥≈Ÿ°∑’Ë≈¥≈ß πÕ°®“°π’Ȭ—ß¡’ß“π«‘®—¬Õ◊Ëπ Ê  π—∫ πÿπ°“√μ√«®§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß∑“ß™àÕߧ≈Õ¥„π‰μ√¡“ ∑’Ë Õ߇ªìπ°“√μ√«®§—¥°√Õß∑’Ë¡’§«“¡‰« Ÿß„πÀ≠‘ßμ—Èߧ√√¿å‡¥’ˬ«∑’Ë¡’ª√–«—μ‘∑“ß Ÿμ‘°√√¡‰¡à¥’(4) °“√μ√«®§—¥°√Õß„π°≈ÿà¡∑’Ë¡’§«“¡‡ ’ˬßμË” ‰¥â·°à °“√μ—Èߧ√√¿å‡¥’ˬ«∑’ˉ¡à¡’Õ“°“√º‘¥ª°μ‘

¬—ßæ∫§«“¡‰«μË” °“√π”∑—Èߪ√–«—쑇§¬§≈Õ¥°àÕπ°”Àπ¥¡“„™â√à«¡°—∫°“√μ√«®«—¥§«“¡¬“«ª“°¡¥≈Ÿ°¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿßæ∫«à“ “¡“√∂ª√–‡¡‘𧫓¡‡ ’ˬ߷∫∫ individualized - specific risks ‚¥¬æ∫§«“¡‰«

 Ÿß¢÷Èπ(5)

„π°≈ÿà¡∑’Ëμ√«®§—¥°√Õßæ∫§«“¡¬“«ª“°¡¥≈Ÿ°πâÕ¬°«à“À√◊Õ‡∑à“°—∫‡ªÕ√凴Áπ‰∑≈å∑’Ë 10 ∑’ËÕ“¬ÿ§√√¿åπ—Èπ

(À√◊Õ < 25 ¡‘≈≈‘‡¡μ√) ‡¡◊ËÕ„Àâ°“√ªÑÕß°—π√—°…“¥â«¬‚ª√‡® ‡∑Õ‚√πæ∫«à“¡’ª√– ‘∑∏‘º≈∑’Ë¥’ (reproducibleefficacy)

● ®”π«πÀ≠‘ßμ—Èߧ√√¿å∑’ËμâÕßμ√«®§—¥°√Õ߇æ◊ËÕ°“√ªÑÕß°—π√—°…“°“√§≈Õ¥°àÕπÕ“¬ÿ§√√¿å 34  —ª¥“Àå1 √“¬ §◊Õ 125 √“¬ (95% CI, 88 - 288)

● ®”π«πÀ≠‘ßμ—Èߧ√√¿å∑’ËμâÕßμ√«®§—¥°√Õ߇æ◊ËÕ°“√ªÑÕß°—π√—°…“°“√§≈Õ¥°àÕπ°”Àπ¥ ‡æ◊ËÕ≈¥

¿“«–∑ÿææ≈¿“æ·≈–À√◊Õ°“√쓬¢Õß∑“√° 1 √“¬ §◊Õ 225 √“¬ (95% CI, 150 - 1013)(6)

¡’°“√»÷°…“∑’ˉ¡à π—∫ πÿπ„Àâμ√«®§—¥°√Õߥ⫬«‘∏’π’ȇªìπ°‘®«—μ√ ∑—Èß„π°≈ÿà¡∑’Ë¡’Õ“°“√À√◊Õ°≈ÿà¡∑’ˉ¡à¡’

Õ“°“√¢Õß°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥ ‡π◊ËÕß®“°æ∫«à“Õ“®‰¡à¡’ª√– ‘∑∏‘¿“æ‡æ’¬ßæÕ(7) ®“°ªí≠À“„π

P_8-15 20/6/19, 13:3710

11©∫—∫∑’Ë 1/2562

‡√◊ËÕß¡“μ√∞“π¢Õß«‘∏’°“√μ√«®«—¥∑’ËμâÕßÕ“»—¬∑—°…–°“√μ√«® (credentialed ultrasonographer) Õ“¬ÿ§√√¿å

∑’Ëμ√«® √«¡∂÷ߪí≠À“√à«¡∑“ß Ÿμ‘°√√¡Õ◊Ëπ Ê ∑’ËÕ“®¡’º≈μàÕ°“√μ√«®§—¥°√Õß ‡™àπ °“√μ—Èߧ√√¿å·Ω¥ °“√¡’Õ“°“√‡®Á∫§√√¿å°àÕπ°”Àπ¥À√◊Õ°≈ÿà¡∑’Ë ‰¡à¡’Õ“°“√ ‡ªìπμâπ „π°“√¥Ÿ·≈ªÑÕß°—π√—°…“‚¥¬„™â°“√μ√«®§—¥°√Õß

¥â«¬«‘∏’π’ȇªìπÀ≈—°®÷ߧ«√¡’¢âÕμ°≈ßÀ√◊Õ·π«ªØ‘∫—μ‘∑’Ë°”À𥉫âÕ¬à“ß™—¥‡®π

°“√ªÑÕß°—π√—°…“¥â«¬¬“ŒÕ√å‚¡π‚ª√‡® ‡∑Õ‚√πŒÕ√å‚¡π‚ª√‡® ‡∑Õ‚√𠇪ìπŒÕ√å‚¡πÀ≈—°∑’Ë∑”Àπâ“∑’˪√–§—∫ª√–§Õß°“√μ—Èߧ√√¿å ÕÕ°ƒ∑∏‘Ï∑’Ëμ—«¡¥≈Ÿ°

(uterine quiescence) πÕ°®“°π’È¡’ ¡¡μ‘∞“πÕ◊Ëπ§◊Õ°“√‡ªìπ “√μâ“π°“√Õ—°‡ ∫‚¥¬ÕÕ°ƒ∑∏‘Ï∫√‘‡«≥ª“°¡¥≈Ÿ°·≈–μ”·Àπàß maternal-fetal interface °“√≈¥≈ߢÕߌÕ√å‚¡π

‚ª√‡® ‡∑Õ‚√π∑”„À⇰‘¥°“√‡®Á∫§√√¿å ŒÕ√å‚¡π‚ª√‡® ‡∑Õ‚√π®÷ß∂Ÿ°π”¡“„™â‡æ◊ËÕªÑÕß°—π√—°…“°“√§≈Õ¥°àÕπ°”Àπ¥ ¬“∑’Ë„™â¡’ 2 ™π‘¥§◊Õ

1. ‚ª√‡® ‡∑Õ‚√π∏√√¡™“μ‘ (Natural progesterone) ¬“∑’Ë„™â„Àâ Õ¥À√◊Õ„ à∑“ß™àÕߧ≈Õ¥¡’ 2 √Ÿª

·∫∫§◊Õ

1.1 Vaginal micronized progesterone ·∫∫ oil capsule ¢π“¥ 200 ¡°. „™â Õ¥∑“ß™àÕߧ≈Õ¥

«—π≈–§√—Èß

1.2 Vaginal micronized progesterone ·∫∫ bio adhesive gel ¢π“¥ 90 ¡°. „™â„ à∑“ß™àÕߧ≈Õ¥ «—π≈–§√—Èß

°“√»÷°…“·∫∫ meta-analysis ®“°¢âÕ¡Ÿ≈ºŸâªÉ«¬√“¬∫ÿ§§≈ (individual patient data) „πÀ≠‘ßμ—Èߧ√√¿å‡¥’ˬ«∑’Ë¡’ª“°¡¥≈Ÿ° —Èπ°«à“ 25 ¡¡. ∑’Ë ‰¥â√—∫°“√ªÑÕß°—π√—°…“¥â«¬¬“‚ª√‡® ‡∑Õ‚√π Õ¥∑“ß™àÕߧ≈Õ¥

°≈ÿà¡∑’ˉ¡à¡’ª√–«—쑇§¬§≈Õ¥°àÕπ°”Àπ¥ æ∫§«“¡‡ ’ˬߢÕß°“√§≈Õ¥°àÕπ°”Àπ¥∑’ËÕ“¬ÿ§√√¿åπâÕ¬°«à“ 33  —ª¥“Àå≈¥≈ß√âÕ¬≈– 35 (RR 0.65: 95% CI, 0.45-0.94) °≈ÿà¡∑’Ë¡’ª√–«—쑇§¬§≈Õ¥°àÕπ°”Àπ¥ æ∫§«“¡‡ ’ˬß≈¥≈ß

√âÕ¬≈– 41 (RR 0.59: 95% CI, 0.40-0.88)(8)

2. ‚ª√‡® ‡∑Õ‚√π —߇§√“–Àå (Synthetic progesterone, pregnancy category B)

√Ÿª·∫∫∑’Ë„™â§◊Õ 17-alpha hydroxyprogesterone caproate (17-OHP-C) ¢π“¥ 250 ¡°. ©’¥‡¢â“

°≈â“¡  —ª¥“Àå≈–§√—Èß ·π–π”„™â„π°≈ÿࡇ ’ˬß∑’Ë¡’ª√–«—쑇§¬§≈Õ¥°àÕπ°”Àπ¥ ®“°ß“π«‘®—¬·∫∫ ÿà¡∑’Ë¡’°≈ÿࡧ«∫§ÿ¡æ∫«à“°≈ÿà¡ŒÕ√å‚¡π —߇§√“–Àå ‰¡à·π–π”°“√„™â„π°≈ÿà¡°“√μ—Èߧ√√¿å·Ω¥(9) πÕ°®“°π’Ȭ—ß¡’°“√»÷°…“(10)

æ∫«à“°“√„™â¬“°≈ÿà¡π’È ‰¡à¡’ª√– ‘∑∏‘¿“ææÕ„π°“√ªÑÕß°—π°“√‡°‘¥´È”¢Õß°“√§≈Õ¥°àÕπ°”Àπ¥ ·≈–æ∫‡∫“À«“π

¢≥–μ—Èߧ√√¿å‡æ‘Ë¡¢÷Èπ ·≈–æ∫«à“ 17-OHP-C ‰¡à¡’º≈¥â“π local anti-inflammatory ∑’˪“°¡¥≈Ÿ°À√◊Õμ”·Àπàßmaternal-fetal interface

‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°“√„™â¬“ Õ¥∑“ß™àÕߧ≈Õ¥·≈–¬“©’¥ 17-OHP-C æ∫«à“°“√„™â¬“ Õ¥∑“ß™àÕߧ≈Õ¥¡’ª√– ‘∑∏‘¿“æ∑’Ë Ÿß°«à“ ¥—ß· ¥ß„π√Ÿª∑’Ë 2(11)

P_8-15 20/6/19, 13:3711

12  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

√Ÿª∑’Ë 2(11) Forest plot · ¥ß§«“¡‡ ’ˬߠ—¡æ—∑∏å∑’Ë≈¥≈ß [relative risk 0.71, (0.53-0.95)]¢Õß°“√‡°‘¥´È”¢Õß°“√§≈Õ¥°àÕπ°”Àπ¥„π°“√μ—Èߧ√√¿å‡¥’ˬ«∑’ˇ§¬§≈Õ¥°àÕπ°”Àπ¥ ‚¥¬‡ª√’¬∫‡∑’¬∫

°“√√—°…“·∫∫ ÿࡥ⫬¬“‚ª√‡® ‡∑Õ‚√π Õ¥∑“ß™àÕߧ≈Õ¥°—∫¬“ 17-OHP-C ©’¥‡¢â“°≈â“¡

°“√„™â‚ª√‡® ‡∑Õ‚√π∏√√¡™“μ‘¡’º≈¢â“߇§’¬ßπâÕ¬°«à“‚ª√‡® ‡∑Õ‚√π —߇§√“–Àå ‰¥â·°à Õ“°“√ßà«ß ‡¡◊ËÕ¬·≈–Õ“°“√ª«¥»’√…– ¢âÕ¥’Õ◊Ëπ Ê §◊Õ æ∫°“√√—°…“¢Õß∑“√°·√°‡°‘¥„πÀÕÕ¿‘∫“≈πâÕ¬≈ß §à“„™â®à“¬¢Õ߬“πâÕ¬°«à“

(„πμà“ߪ√–‡∑») À≠‘ßμ—Èߧ√√¿å‡≈◊Õ°„™â¬“ Õ¥∑“ß™àÕߧ≈Õ¥¡“°°«à“ §«“¡æ÷ßæÕ„®·≈–§«“¡μàÕ‡π◊ËÕߢÕß°“√√—°…“¡’¡“°°«à“(11)

°“√ªÑÕß°—π√—°…“¥â«¬¬“‚ª√‡® ‡∑Õ‚√π™π‘¥ Õ¥∑“ß™àÕߧ≈Õ¥ „π°≈ÿà¡°“√μ—Èߧ√√¿å·Ω¥ Õß„π‰μ√¡“  Õß∑’Ë ‰¡à¡’Õ“°“√º‘¥ª°μ‘·μàμ√«®¥â«¬§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿßæ∫ª“°¡¥≈Ÿ° —Èπ ™à«¬≈¥§«“¡‡ ’ˬߢÕß°“√

‡°‘¥°“√§≈Õ¥°àÕπ°”Àπ¥™à«ßÕ“¬ÿ§√√¿å 30 - 35  —ª¥“Àå °“√쓬·≈–¿“«–∑ÿææ≈¿“æ¢Õß∑“√°≈¥≈ß ‚¥¬‰¡àæ∫º≈°√–∑∫¢Õ߬“μàÕ°“√æ—≤π“¢Õß√–∫∫ª√– “∑„π™à«ß«—¬‡¥Á°(12)

Õ¬à“߉√°Áμ“¡¡’°“√»÷°…“·∫∫ À ∂“∫—π·∫∫ ÿà¡ ‚¥¬°“√„™â¬“‚ª√‡® ‡∑Õ‚√π Õ¥∑“ß™àÕߧ≈Õ¥‡ª√’¬∫‡∑’¬∫°—∫¬“À≈Õ° ‡æ◊ËÕªÑÕß°—π°“√§≈Õ¥°àÕπ°”Àπ¥„π°“√μ—Èߧ√√¿å‡¥’ˬ« æ∫«à“°“√ªÑÕß°—π√—°…“¥â«¬

¬“‚ª√‡® ‡∑Õ‚√π‰¡à‰¥â≈¥§«“¡‡ ’ˬߢÕß°“√§≈Õ¥°àÕπ°”Àπ¥ ‚¥¬‰¡àæ∫∑—Èߺ≈‡ ’¬À√◊Õº≈¥’¢Õß°“√„™â¬“μàÕ∑“√°·√°‡°‘¥·≈–„π™à«ß«—¬‡¥Á°∂÷ßÕ“¬ÿ 2 ªï(13)

ªï §.» 2012  ”π—°ß“π§≥–°√√¡°“√Õ“À“√·≈–¬“·Ààß À√—∞Õ‡¡√‘°“ (U.S. Food and DrugAdministration, FDA)(14) ‰¥â √ÿª«à“¬—߉¡à “¡“√∂æ∫ª√–‚¬™πå∑’Ë√–∫ÿ‰¥â (identified benefit) ®“°°“√„™â¬“

‚ª√‡® ‡∑Õ‚√π Õ¥∑“ß™àÕߧ≈Õ¥‡æ◊ËÕ≈¥§«“¡‡ ’ˬߢÕß°“√§≈Õ¥°àÕπ°”Àπ¥„π°≈ÿࡪ√–™“°√À≠‘ߢÕß À√—∞Õ‡¡√‘°“ FDA ®÷ß≈¥°“√ π—∫ πÿπ°“√„™â¬“

 √ÿª À≠‘ßμ—Èߧ√√¿å∑’Ë¡’ª√–«—쑇§¬§≈Õ¥°àÕπ°”Àπ¥ ·≈–/À√◊Õ°“√μ√«®°√Õßæ∫§«“¡¬“«ª“°¡¥≈Ÿ°πâÕ¬°«à“‡ªÕ√凴π‰∑≈å∑’Ë 10 ∑’ËÕ“¬ÿ§√√¿åπ—Èπ (À√◊Õ§«“¡¬“«πâÕ¬°«à“À√◊Õ‡∑à“°—∫ 25 ¡¡.) ·π–π”„Àâ°“√ªÑÕß°—π

√—°…“¥â«¬¬“‚ª√‡® ‡∑Õ‚√π∏√√¡™“μ‘ Õ¥∑“ß™àÕߧ≈Õ¥ ‡√‘Ë¡∑’ËÕ“¬ÿ§√√¿å√–À«à“ß 16 - 24  —ª¥“Àå ∂÷ßÕ“¬ÿ§√√¿å√–À«à“ß 34 - 36  —ª¥“Àå

Õ¬à“߉√°Áμ“¡°“√ªÑÕß°—π√—°…“¥â«¬«‘∏’π’Ȭ—߉¡à‡ªìπ¢âÕμ°≈ß “°≈ (Generate universal agreement)

P_8-15 20/6/19, 13:3712

13©∫—∫∑’Ë 1/2562

°“√ªÑÕß°—π√—°…“¥â«¬°“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ° (Cervical cerclage)°“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°¡’¢âÕ∫àß„™â„π°√≥’∑’˪“°¡¥≈Ÿ°‰¡à¡’ª√– ‘∑∏‘¿“æÀ√◊Õ∫°æ√àÕß (cervical insuffi-

ciency) °“√«‘π‘®©—¬¿“«–π’ȉ¥â®“°ª√–«—μ‘°“√·∑âßÀ√◊Õ°“√§≈Õ¥°àÕπ°”Àπ¥„π‰μ√¡“ ∑’Ë 2 ¢Õß°“√μ—Èߧ√√¿å

‚¥¬‰¡à¡’Õ“°“√‡®Á∫§√√¿å∑’Ë™—¥‡®π‡°‘¥π”¡“°àÕπ ·≈–À√◊Õμ√«®¿“¬„πæ∫ ª“°¡¥≈Ÿ°¥â“π„π ‡ªî¥ πÿà¡À√◊Õ∫“ß≈ß¿“«–π’ȇªì𠓇Àμÿ∑’Ë ”§—≠¢Õß°“√·∑âßÀ√◊Õ°“√§≈Õ¥°àÕπ°”Àπ¥ ∑—Èßπ’È°“√∑” cerclage ‡æ◊ËÕªÑÕß°—π cervical

insufficiency ‡√‘Ë¡∑’ËÕ“¬ÿ§√√¿å 11 - 13  —ª¥“Àå À≈—ß°“√μ√«®§≈◊Ëπ‡ ’¬ß§«“¡∂’Ë Ÿß‰¡àæ∫§«“¡º‘¥ª°μ‘¢Õß∑“√°„π§√√¿å

·π–π”°“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°„π 3  ∂“π°“√≥å§◊Õ

1. À≠‘ßμ—Èߧ√√¿å∑’Ë¡’ª√–«—μ‘°“√§≈Õ¥°àÕπ°”Àπ¥∑’Ë ‰¡à¡’Õ“°“√‡®Á∫§√√¿å (mid trimester recurrentloss) ·≈–‰¥â√—∫°“√«‘π‘®©—¬‡ªìπ cervical insufficiency

2. °√≥’∑’Ëμ√«®æ∫ª“°¡¥≈Ÿ° —Èπ°«à“ 25 ¡¡. °àÕπÕ“¬ÿ§√√¿å 24  —ª¥“Àå √à«¡°—∫¡’ª√–«—쑇§¬§≈Õ¥°àÕπÕ“¬ÿ§√√¿å 34  —ª¥“Àå ‚¥¬æ∫«à“°“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°¡’º≈¥’μàÕ∑“√°·√°‡°‘¥ ¥—ß· ¥ß

„π√Ÿª∑’Ë 3(15)

√Ÿª∑’Ë 3(15) Forest plot · ¥ß§«“¡‡ ’ˬߠ—¡æ—∑∏å∑’Ë≈¥≈ß [risk ratio 0.70 (0.55-0.89)] ¢Õßperinatal mortality ·≈– perinatal morbidity „π°≈ÿà¡∑’Ë√—°…“¥â«¬°“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°

‡ª√’¬∫‡∑’¬∫°—∫°≈ÿà¡∑’Ë ‰¡à‰¥â√—∫°“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°

∑—Èßπ’È°“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°„π°“√μ—Èߧ√√¿å‡¥’ˬ«∑’ˉ¡à¡’ª√–«—쑇§¬§≈Õ¥°àÕπ°”Àπ¥ ·μàμ√«®æ∫ª“°¡¥≈Ÿ° —Èπ°«à“25 ¡¡.(16) ‰¡à “¡“√∂ªÑÕß°—π°“√§≈Õ¥°àÕπ°”Àπ¥À√◊Õ‡°‘¥º≈¥’μàÕ∑“√°·√°‡°‘¥

3. °“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°·∫∫ rescue (rescue cerclage) ∑”„π°√≥’∑’ˇ°‘¥¿“«–‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥§ÿ°§“¡ (threatened preterm labor) °“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°·∫∫ rescue „π°“√μ—Èߧ√√¿å

·Ω¥ Õß∑’Ëμ√«®æ∫ª“°¡¥≈Ÿ°‡ªî¥„π‰μ√¡“ ∑’Ë 2 æ∫«à“¡’º≈¢Õß∑“√°·√°‡°‘¥¥’°«à“‡ª√’¬∫‡∑’¬∫°—∫°≈ÿà¡∑’ˉ¡à ‰¥â√—∫°“√‡¬Á∫(17) °“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°„π°“√μ—Èߧ√√¿å·Ω¥‡æ◊ËÕ°“√ªÑÕß°—π¬—߉¡àæ∫

perinatal outcome ∑’Ë¥’¢÷Èπ

πÕ°®“°π’È°“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ°Õ“®¡’ª√–‚¬™πå„π°√≥’∑’˪“°¡¥≈Ÿ° —Èπ¡“° (<10 ¡¡.)

P_8-15 20/6/19, 13:3713

14  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

°“√ªÑÕß°—π√—°…“¥â«¬ Cervical pessariesFDA ¢Õß À√—∞Õ‡¡√‘°“¬—߉¡à√—∫√Õß°“√„™â Cervical pessaries ‡æ◊ËÕªÑÕß°—π°“√§≈Õ¥°àÕπ°”Àπ¥(18)

·≈–º≈®“°ß“π«‘®—¬∑’Ëæ∫«à“‰¡à‰¥â™à«¬≈¥Õ—μ√“°“√§≈Õ¥°àÕπ 34  —ª¥“Àå(19)

ªí®®ÿ∫—π·π–π”°“√„™â Pessary prophylaxis ‡©æ“–„πß“π«‘®—¬∑’Ë¡’ research protocol ‡∑à“π—Èπ

‡Õ° “√Õâ“ßÕ‘ß1. Beta J, Ranjit Akolekar R, Ventura W, et al. Prediction of spontaneous preterm delivery

from maternal factors, obstetric history and placental perfusion and function at 11-13

weeks. Prenat Diagn 2011; 31: 75-83.2. Laughon SK, Albert PS, Leishear K, Mendola P. The NICHD Consecutive Pregnancies

Study: Recurrent preterm delivery by subtype. Am J Obstet Gynecol 2014; 210: 131.e1-131.e8.3. Iams JD, Goldenberg RL, Meis PJ, Mercer BM, Moawad A, Das A, et al. The length of the

cervix and the risk of spontaneous premature delivery. National Institute of Child Health

and Human Development Maternal Fetal Medicine Unit Network. N Engl J Med 1996;334: 567-72.

4. Mella MT, Berghella V. Prediction of preterm birth: cervical sonography. Semin Perinatol2009; 33: 317-24.

5. Celik E, To M, Gajewska K, Smith G. C. S., Nicolaides KH, on behalf of The Fetal Medicine

Foundation Second Trimester Screening Group. Cervical length and obstetric historypredict spontaneous preterm birth: development and validation of a model to provide

individualized risk assessment. Ultrasound Obstet Gynecol 2008; 31: 549-54.6. Conde-Agudelo A, Romero R. Vaginal progesterone to prevent preterm birth in pregnant

women with a sonographic short cervix: clinical and public health implications. Am J

Obstet Gynecol 2016; 214: 235-42.7. Berghella V, Baxter JK, Hendrix NW. Cervical assessment by ultrasound for preventing

preterm delivery. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.:CD007235. DOI: 10.1002/14651858.CD007235.pub3.

8. Romero R, Conde-Agudelo A, Da Fonseca E, et al. Vaginal progesterone for preventing

preterm birth and adverse perinatal outcomes in singleton gestations with a short cervix:a meta-analysis of individual patient data. Am J Obstet Gynecol 2018; 218: 161-80.

9. OûBrien JM, Lewis DF. Prevention of preterm birth with vaginal progesterone or 17-alpha-hydroxyprogesterone caproate: a critical examination of efficacy and safety. Am JObstet Gynecol 2016; 214: 45-56.

P_8-15 20/6/19, 13:3714

15©∫—∫∑’Ë 1/2562

10. Nelson DB, McIntire DD, McDonald J, et al. 17-alpha Hydroxyprogesterone caproate did

not reduce the rate of recurrent preterm birth in a prospective cohort study. Am J ObstetGynecol 2017; 216: 600.e1-9.

11. Saccone G, Khalifeh A, Elimian A, Bahrami E, Chaman-Ara K, Bahrami MA, Berghella V.Vaginal progesterone vs intramuscular 17?-hydroxyprogesterone caproate for preventionof recurrent spontaneous preterm birth in singleton gestations: systematic review and

meta-analysis of randomized controlled trials. Ultrasound Obstet Gynecol†2017;49:315-21.12. Romero R,†Conde-Agudelo A,†El-Refaie W,†Rode L,†Brizot ML,†Cetingoz E,†et al.

Vaginal progesterone decreases preterm birth and neonatal morbidity and mortality inwomen with a twin gestation and a short cervix: an updated meta-analysis of individualpatient data. Ultrasound Obstet Gynecol 2017; 49: 303-14.

13. Norman JE,†Marlow N,†Messow CM,†Shennan A,†Bennett PR,†Thornton S,†etal;†OPPTIMUM study group. Vaginal progesterone prophylaxis for preterm birth (the

OPPTIMUM study): a multicenter, randomized, double-blind trial. Lancet 2016; 387: 2106-16.14. U.S. Food and Drug Administration. Background document for meeting of advisory

committee for reproductive health drugs, January 20, 2012. Available at: www.fda.gov /

down l o ad s/ adv i s o r y c ommi t t e e s / c ommi t t e emee t i n gma t e r i a l s /d rug s/reproductivehealthdrugsadvisorycommittee/ucm287987.pdf.

15. Berghella V,†Rafael TJ,†Szychowski JM,†Rust OA,†Owen J. Cerclage for short cervix onultrasonography in women with singleton gestations and previous preterm birth: a meta-

analysis.†Obstet Gynecol 2011;117:663-71.16. Berghella V, Ciardulli A, Rust OA, et al. Cerclage for sonographic short cervix in singleton

gestations without prior spontaneous preterm birth: systematic review and meta-analysis

of randomized controlled trials using individual patient-level data. Ultrasound ObstetGynecol 2017; 50: 569-77.

17. Roman A, Rochelson B, Martinelli P, Saccone G, Harris K, Zork N, Spiel M, et al. Cerclagein twin pregnancy with dilated cervix between 16 to 24 weeks of gestation: retrospectivecohort study. Am J Obstet Gynecol.†2016;215: 98. e1-98. e11

18. Society†for†Maternal-Fetal†Medicine†(SMFM). The role of cervical pessary placement toprevent preterm birth in clinical practice. Am J Obstet Gynecol 2016; 215: B8.

19. Nicolaides†KH,†Syngelaki A,†Poon LC,†Picciarelli G,†Tul N,†Zamprakou A, et al . Arandomized trial of a cervical pessary to prevent preterm singleton birth. N Engl J Med2016; 374: 1044-52.

P_8-15 20/6/19, 13:3715

16  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

Myoma uteri ‡ªìπ‡π◊ÈÕßÕ°™π‘¥‰¡à√⓬·√ß∑’Ëæ∫∫àÕ¬∑’Ë ÿ¥¢ÕßÕ«—¬«– ◊∫æ—π∏ÿå μ√’(1-2)  “¡“√∂·∫àß™π‘¥¢Õß myoma uteri μ“¡π‘¬“¡¢Õß the International Federation of Gynecology and Obstetrics (FIGO)‰¥â¥—ßμ“√“ß(1, 2)

Submucous myomasubmucous myoma ∑’Ë¡’°“√°¥‡∫’¬¥‚æ√ß¡¥≈Ÿ° ¡’º≈‡ ’¬μàÕ°“√μ—Èߧ√√¿åμ“¡∏√√¡™“μ‘·≈–°“√μ—Èߧ√√¿å

∑’ˇ°‘¥®“°‡∑§‚π‚≈¬’™à«¬°“√‡®√‘≠æ—π∏ÿå ‚¥¬√∫°«π°“√Ωíßμ—«¢Õßμ—«ÕàÕπ ‡π◊ËÕß®“°∑”„Àâ‚æ√ß¡¥≈Ÿ°º‘¥√Ÿª ¡’§«“¡º‘¥ª°μ‘¢Õ߇ âπ‡≈◊Õ¥∑’Ë¡“À≈àÕ‡≈’Ȭ߇¬◊ËÕ∫ÿ‚æ√ß¡¥≈Ÿ° ·≈–Õ“®∑”„À⇰‘¥°√–∫«π°“√Õ—°‡ ∫∑’Ëμ”·Àπàß∑’Ë¡’‡π◊ÈÕßÕ°¡¥≈Ÿ° πÕ°®“°π’Ȭ—߇æ‘Ë¡§«“¡‡ ’ˬßμàÕ°“√·∑âß∫ÿμ√(3, 4) °“√ºà“μ—¥ hysteroscopic myomectomy ‚¥¬‡©æ“–Õ¬à“߬‘Ëß type 0 ·≈– 1 ®–∑”„Àâ‡æ‘Ë¡‚Õ°“ μ—Èߧ√√¿å¿“¬À≈—ß°“√¬â“¬μ—«ÕàÕπ ·≈–Õ“®™à«¬≈¥°“√·∑âß∫ÿμ√„π‰μ√¡“ ·√°¢Õß°“√μ—Èߧ√√¿å(3)

16  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

P_16-19 6/17/19, 3:20 PM16

17©∫—∫∑’Ë 1/2562

Intramural myoma ‡π◊ÈÕßÕ°¡¥≈Ÿ°™π‘¥ intramural myoma ∑’Ë°¥‡∫’¬¥‚æ√ß¡¥≈Ÿ°®–√∫°«π°“√Ωíßμ—«¢Õßμ—«ÕàÕπ °“√∑”myomectomy Õ“®™à«¬‡æ‘Ë¡Õ—μ√“°“√μ—Èߧ√√¿å®“°°“√„™â‡∑§‚π‚≈¬’°“√‡®√‘≠æ—π∏ÿå ≈¥§«“¡‡ ’ˬßμàÕ°“√·∑âß∫ÿμ√·≈–º≈‡ ’¬μàÕ°“√μ—Èߧ√√¿å„π°√≥’∑’ˇπ◊ÈÕßÕ°¡¥≈Ÿ°¡’¢π“¥¡“°°«à“ 5 ‡´π쑇¡μ√(5, 6)

‡π◊ÈÕßÕ°¡¥≈Ÿ°™π‘¥ intramural myoma ∑’ˉ¡à°¥‡∫’¬¥‚æ√ß¡¥≈Ÿ° ®“°°“√»÷°…“∑’˺à“π¡“ ¬—߉¡à¡’¢âÕ √ÿª∑’Ë™—¥‡®π«à“°âÕπ‡π◊ÈÕßÕ°¢π“¥‡∑à“„¥∑’Ë ¡§«√®–∑”°“√ºà“μ—¥ ‚¥¬¡’∫“ß√“¬ß“πæ∫«à“°âÕπ‡π◊ÈÕßÕ°∑’Ë¡’¢π“¥¡“°°«à“ 3 ‡´π쑇¡μ√ ®–∑”„Àâ¡’‚Õ°“ μ—Èߧ√√¿åÀ≈—ß°“√¬â“¬μ—«ÕàÕπ≈¥≈ß ¢≥–∑’Ë∫“ß√“¬ß“π∫Õ°«à“¢π“¥∑’ËπâÕ¬°«à“ 5 ‡´π쑇¡μ√ ‰¡à∑”„Àâ‚Õ°“ °“√μ—Èߧ√√¿å≈¥≈ß √«¡∂÷߉¡à‡æ‘Ë¡§«“¡‡ ’ˬßμàÕ°“√·∑âß∫ÿμ√¥â«¬(6)

‡π◊ÈÕßÕ°¡¥≈Ÿ°∑’Ë¡’¢π“¥πâÕ¬°«à“ 3 ‡´π쑇¡μ√ ‰¡àæ∫«à“¡’º≈°√–∑∫μàÕ¿“«–·∑√° âÕπ¢Õß°“√μ—Èߧ√√¿å·μà¡’√“¬ß“π«à“∂â“¡’¢π“¥¡“°°«à“ 5 ‡´π쑇¡μ√ Õ“®®–‡æ‘Ë¡§«“¡‡ ’ˬßμàÕ°“√‡®Á∫§√√¿å§≈Õ¥°àÕπ°”Àπ¥·≈–‡ ’¬‡≈◊Õ¥¡“°„π√–À«à“ߧ≈Õ¥∫ÿμ√  à«π‡π◊ÈÕßÕ°¡¥≈Ÿ°∑’Ë¡’¢π“¥¡“°°«à“ 10 ‡´π쑇¡μ√ Õ“®∑”„À⇰‘¥ fetal com-pression syndrome ‰¥â ‚¥¬®”°—¥°“√¢¬“¬¢Õß‚æ√ß¡¥≈Ÿ°∑”„Àâ∑“√°∂Ÿ°°¥‡∫’¬¥·≈–Õ“®‡°‘¥§«“¡æ‘°“√‰¥â(5)

Subserous myomasubserous myoma ‰¡à àߺ≈μàÕ°“√μ—Èߧ√√¿å∑—Èß‚¥¬°“√μ—Èߧ√√¿åμ“¡∏√√¡™“μ‘·≈–°“√√—°…“¥â«¬

‡∑§‚π‚≈¬’™à«¬°“√‡®√‘≠æ—π∏ÿå √«¡∑—Èß¿“«–·∑√° âÕπ√–À«à“ß°“√μ—Èߧ√√¿å·≈–°“√§≈Õ¥∫ÿμ√(3, 5, 6)

§«“¡‡ ’ˬß∑’ËÕ“®®–‡°‘¥®“°°“√ºà“μ—¥‡π◊ÈÕßÕ°¡¥≈Ÿ°μàÕ°“√μ—Èߧ√√¿å

¿“«–·∑√° âÕπ∑’ËÕ“®‡°‘¥„π¢≥–μ—Èߧ√√¿å¿“¬À≈—ß°“√ºà“μ—¥‡π◊ÈÕßÕ°¡¥≈Ÿ°∑’Ë√ÿπ·√ß¡“°∑’Ë ÿ¥ §◊Õ¡¥≈Ÿ°·μ° ‚¥¬Õ“®‡°‘¥μ“¡À≈—ß°“√ºà“μ—¥‡π◊ÈÕßÕ°ºà“π°≈âÕß àÕß™àÕß∑âÕ߉¥â√âÕ¬≈– 1.26 ´÷Ëß„°≈⇧’¬ß°—∫°“√ºà“μ—¥·∫∫‡ªî¥Àπâ“∑âÕß (√âÕ¬≈– 0.2) ¿“«–π’È¡—°‡°‘¥„π‰μ√¡“  “¡¢Õß°“√μ—Èߧ√√¿åÀ√◊Õ„π√–¬–‡®Á∫§√√¿å§≈Õ¥‡π◊ËÕß®“°¡’·√ߥ—π„π¡¥≈Ÿ° Ÿß(5) ªí®®—¬‡ ’ˬß∑’Ë ”§—≠μàÕ°“√‡°‘¥¡¥≈Ÿ°·μ°¢≥–μ—Èߧ√√¿å§◊Õ°“√ºà“μ—¥‡¢â“‚æ√ß¡¥≈Ÿ°°“√„™â®’È ‰øøÑ“¡“°„π¢≥–ºà“μ—¥ ·≈–°“√‡¬Á∫´àÕ¡¡¥≈Ÿ°‡æ’¬ß™—Èπ‡¥’¬« ‚¥¬°“√‡¬Á∫‡æ’¬ß™—Èπ‡¥’¬«π’È®–∑”„Àâ¡’‚Õ°“ ‡°‘¥¡¥≈Ÿ°·μ°¡“°°«à“°“√‡¬Á∫´àÕ¡ 2 ™—Èπ∂÷ß 4 ‡∑à“ πÕ°®“°π’È°“√μ‘¥‡™◊ÈÕÀ≈—ߺà“μ—¥À√◊Õ°“√‡°‘¥hematoma Õ“® à߇ √‘¡„À⇰‘¥¿“«–·∑√° âÕππ’È¡“°¢÷Èπ(7, 8)  à«π§”·π–𔇰’ˬ«°—∫√–¬–‡«≈“ ∑’˧«√√Õ®π°«à“·º≈ºà“μ—¥∑’Ë¡¥≈Ÿ°®–À“¬¥’·≈â«®÷ß®–μ—Èߧ√√¿å‰¥âπ—Èπ ¬—ß‰¡à¡’¢âÕ √ÿª∑’Ë™—¥‡®π ‚¥¬¡’§”·π–π”„Àâμ—Èߧ√√¿å‰¥âÀ≈—ߺà“μ—¥·≈⫇ªìπ√–¬–‡«≈“‰¡àπâÕ¬°«à“ 3 ∂÷ß 6 ‡¥◊Õπ ¢÷ÈπÕ¬Ÿà°—∫μ”·Àπàß·≈–¢π“¥¢Õß°âÕπ‡π◊ÈÕßÕ°¡¥≈Ÿ°(8, 9)

P_16-19 6/17/19, 3:20 PM17

18  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

μ“√“ß √ÿªª√–‚¬™πå¢Õß°“√ºà“μ—¥‡π◊ÈÕßÕ°¡¥≈Ÿ°μàÕ°“√μ—Èߧ√√¿å·≈–°“√·∑âß∫ÿμ√

 √ÿª§”·π–π”„π°“√ºà“μ—¥‡π◊ÈÕßÕ°¡¥≈Ÿ°

1. ™π‘¥ submucous myoma type 0, 1, 2● °“√∑” hysteroscopic myomectomy ™à«¬‡æ‘Ë¡Õ—μ√“°“√μ—Èߧ√√¿å‰¥â‚¥¬‰¡à«à“®–‡ªìπ°“√μ—Èß

§√√¿åμ“¡∏√√¡™“μ‘À√◊Õ®“°°“√„™â‡∑§‚π‚≈¬’°“√‡®√‘≠æ—π∏ÿå √«¡∑—ÈßÕ“®≈¥Õÿ∫—μ‘°“√≥å¢Õß°“√·∑âß∫ÿμ√‰¥â

2. ™π‘¥ intramural myoma ∑’Ë°¥‡∫’¬¥‚æ√ß¡¥≈Ÿ°● °“√∑” myomectomy Õ“®™à«¬‡æ‘Ë¡Õ—μ√“°“√μ—Èߧ√√¿å®“°°“√„™â‡∑§‚π‚≈¬’°“√‡®√‘≠æ—π∏ÿå √«¡

∑—Èß®–™à«¬≈¥º≈‡ ’¬μàÕ°“√μ—Èߧ√√¿å‡¡◊ËÕ‡π◊ÈÕßÕ°¡¥≈Ÿ°¡’¢π“¥μ—Èß·μà 5 ‡´π쑇¡μ√ ¢÷Èπ‰ª

3. ™π‘¥ intramural myoma ∑’Ë ‰¡à°¥‡∫’¬¥‚æ√ß¡¥≈Ÿ°● ‡π◊ÈÕßÕ°¡¥≈Ÿ°¡’¢π“¥πâÕ¬°«à“ 3 ‡´π쑇¡μ√ ‰¡à·π–π”„Àâ∑”ºà“μ—¥ myomectomy

 à«π¢π“¥√–À«à“ß 3 - 5 ‡´π쑇¡μ√ „Àâæ‘®“√≥“μ“¡·μà°√≥’ ∂â“¡“°°«à“ 5 ‡´π쑇¡μ√ ·π–π”„Àâ∑”°“√ºà“μ—¥ ‡æ√“–Õ“®‡æ‘Ë¡Õ—μ√“°“√μ—Èߧ√√¿å®“°°“√„™â‡∑§‚π‚≈¬’°“√‡®√‘≠æ—π∏ÿå ·≈–Õ“®∑”‰¥â„π°√≥’∑’Ë¢π“¥°âÕπ„À≠à¡“°°«à“ 10 ‡´π쑇¡μ√ ‡æ◊ËÕ≈¥°“√‡°‘¥ fetal compressionsyndrome

Submucous Increase Increase +/- Decreasetype 0,1,2

Intramural +/- Increase Decrease Decrease(Cavity (∂â“¢π“¥ > 5 ´¡.) (∂â“¢π“¥ > 5 ´¡.)distorting)

Intramural NS +/- NS +/-(Non-cavity (¢π“¥ > 5 ´¡.) (¢π“¥ > 10 ´¡.)distorting)

Subserous NS NS NS NS

‚Õ°“ „π°“√μ—Èߧ√√¿åμ“¡∏√√¡™“μ‘

(spontaneous pregnancy)

‚Õ°“ „π°“√μ—Èߧ√√¿å®“°°“√„™â‡∑§‚π‚≈¬’™à«¬°“√‡®√‘≠æ—π∏ÿå

°“√·∑âß∫ÿμ√º≈‡ ’¬μàÕ°“√

μ—Èߧ√√¿å

P_16-19 6/17/19, 3:20 PM18

19©∫—∫∑’Ë 1/2562

4. ™π‘¥ subserous myoma● °“√∑” myomectomy ‰¡à™à«¬‡æ‘Ë¡Õ—μ√“°“√μ—Èߧ√√¿å‰¡à«à“®–‡ªìπ°“√μ—Èߧ√√¿åμ“¡∏√√¡™“μ‘

À√◊Õ®“°°“√„™â‡∑§‚π‚≈¬’°“√‡®√‘≠æ—π∏ÿå ·≈–‰¡à≈¥Õÿ∫—μ‘°“√≥å¢Õß°“√·∑âß∫ÿμ√ ·μàÕ“®∑”‰¥â„π°√≥’∑’Ë¢π“¥°âÕπ„À≠à®π àߺ≈„À⇰‘¥¿“«–·∑√°´âÕπ√–À«à“ß°“√μ—Èߧ√√¿å ·≈–/À√◊Õ°“√§≈Õ¥∫ÿμ√

5. ·π–π”„Àâμ—Èߧ√√¿åÀ≈—ߺà“μ—¥·≈⫉¡àπâÕ¬°«à“ 3 ‡¥◊Õπ ∑—Èßπ’È¢÷ÈπÕ¬Ÿà°—∫¢π“¥·≈–μ”·ÀπàߢÕß°âÕπ‡π◊ÈÕßÕ° ‡æ◊ËÕ≈¥§«“¡‡ ’ˬßμàÕ°“√‡°‘¥¿“«–¡¥≈Ÿ°·μ°„π¢≥–μ—Èߧ√√¿åÀ√◊Õ√–À«à“ߧ≈Õ¥∫ÿμ√

‡Õ° “√Õâ“ßÕ‘ß

1. Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on MenstrualDisorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterinebleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011;113:3-13.

2. Munro MG, Critchley HO, Fraser IS; FIGO Menstrual Disorders Working Group. TheFIGO classification of causes of abnormal uterine bleeding in the reproductive years.Fertil Steril 2011;95:2204-8, 2208 e1-3.

3. Pritts EA, Parker WH, Olive DL. Fibroids and infertility: an updated systematic review ofthe evidence. Fertil Steril 2009;91:1215-23.

4. Johnson G, MacLehose RF, Baird DD, Laughlin-Tommaso SK, Hartmann KE. Uterineleiomyomata and fecundability in the Right from the Start study. Hum Reprod 2012;27:2991-7.

5. Milazzo GN, Catalano A, Badia V, Mallozzi M, Caserta D. Myoma and myomectomy:Poor evidence concern in pregnancy. J Obstet Gynaecol Res, 2017;43:1789-1804.

6. Practice Committee of the American Society for Reproductive Medicine. Removal ofmyomas in asymptomatic patients to improve fertility and/or reduce miscarriage rate: aguideline. Fertil Steril 2017;108:416-425.

7. Bujold E, Bujold C, Hamilton EF, Harel F, Gautheir RJ. The impact of a single-layer ordouble-layer closure on uterine rupture. Am J Obstet Gynecol 2002;186:1326-30.

8. Koo YJ, Lee JK, Lee YK, Kwak DW, Lee IH, Lim KT, et al. Pregnancy outcomes and riskfactors for uterine rupture after laparoscopic myomectomy: A single-center experienceand literature review. J Minim Invasive Gynecol, 2015;22:1022-8.

9. Tian YC, Long TF, Dai YM. Pregnancy outcomes following different surgical approachesof myomectomy. J Obstet Gynaecol Res 2015;41:350-7.

P_16-19 6/17/19, 3:20 PM19

20  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

𔇠πÕ‚¥¬π”‡ πÕ‚¥¬π”‡ πÕ‚¥¬π”‡ πÕ‚¥¬π”‡ πÕ‚¥¬ ·æ∑¬åª√–®”∫â“π ¿“§«‘™“ Ÿμ‘»“ μ√å-π√’‡«™«‘∑¬“ §≥–·æ∑¬»“ μ√å«™‘√欓∫“≈·æ∑¬åª√–®”∫â“π ¿“§«‘™“ Ÿμ‘»“ μ√å-π√’‡«™«‘∑¬“ §≥–·æ∑¬»“ μ√å«™‘√欓∫“≈·æ∑¬åª√–®”∫â“π ¿“§«‘™“ Ÿμ‘»“ μ√å-π√’‡«™«‘∑¬“ §≥–·æ∑¬»“ μ√å«™‘√欓∫“≈·æ∑¬åª√–®”∫â“π ¿“§«‘™“ Ÿμ‘»“ μ√å-π√’‡«™«‘∑¬“ §≥–·æ∑¬»“ μ√å«™‘√欓∫“≈·æ∑¬åª√–®”∫â“π ¿“§«‘™“ Ÿμ‘»“ μ√å-π√’‡«™«‘∑¬“ §≥–·æ∑¬»“ μ√å«™‘√欓∫“≈¡À“«‘∑¬“≈—¬π«¡‘∑√“∏‘√“™¡À“«‘∑¬“≈—¬π«¡‘∑√“∏‘√“™¡À“«‘∑¬“≈—¬π«¡‘∑√“∏‘√“™¡À“«‘∑¬“≈—¬π«¡‘∑√“∏‘√“™¡À“«‘∑¬“≈—¬π«¡‘∑√“∏‘√“™

ª√–«—μ‘ºŸâªÉ«¬π√’‡«™°√√¡● ºŸâªÉ«¬À≠‘߉∑¬ Õ“¬ÿ 52 ªï  ∂“π¿“æ : §Ÿà

●  —≠™“μ‘ ‰∑¬ π—∫∂◊Õ»“ π“ æÿ∑∏ Õ“™’æ : √—∫®â“ß´àÕ¡‡ ◊ÈÕºâ“

● ¿Ÿ¡‘≈”‡π“ ®.°“≠®π∫ÿ√’  ‘∑∏‘Ï°“√√—°…“: ∫—μ√∑Õß √æ.æÀ≈æ≈æ¬ÿÀ‡ π“ ®.°“≠®π∫ÿ√’

● Admit 22/5/2560

Chief complaint : ‡≈◊Õ¥ÕÕ°º‘¥ª°μ‘∑“ß™àÕߧ≈Õ¥ 10 «—π°àÕπ¡“‚√ß欓∫“≈

Present illness :

2  —ª¥“Àå°àÕπ¡“‚√ß欓∫“≈ ¡’Õ“°“√ª«¥∑âÕßπâÕ¬∑—Ë« Ê ·∫∫∫’∫ Ê ª«¥Õ¬Ÿà‡°◊Õ∫μ≈Õ¥‡«≈“ ª«¥‰¡à¡“° Õ“°“√ª«¥‡ªìπ¡“°¢÷Èπ‡¡◊ËÕ‡§≈◊ËÕπ‰À«À√◊Õ‡¥‘π °‘π¬“æ“√“‡´μ“¡Õ≈·≈â«Õ“°“√ª«¥¥’¢÷Èπ‡≈Á°πâÕ¬

10 «—π°àÕπ¡“‚√ß欓∫“≈ ¡’Õ“°“√‡≈◊Õ¥ÕÕ°∑“ß™àÕߧ≈Õ¥º‘¥ª°μ‘‡ªóôÕπ™—Èπ„π 1 §√—Èß ‡∑à“«ß‡À√’¬≠ ‘∫∫“∑À≈—ß®“°π—Èπ‰¡à¡’ÕÕ°Õ’°‡≈¬ ‰¡à¡’Õ“°“√Àπâ“¡◊¥ ‡«’¬π»’√…– À√◊Õ„® —Ëπ Õ“°“√ª«¥∑âÕ߬—ߧ߇ªìπ‡∑à“ Ê ‡¥‘¡

ºŸâªÉ«¬‰ªæ∫·æ∑¬å∑’Ë‚√ß欓∫“≈√—∞∫“≈·ÀàßÀπ÷Ëß  ß —¬°âÕπ‡π◊ÈÕßÕ°√—߉¢à μ√«®‡≈◊Õ¥æ∫ B-hcG  Ÿß 565,000 μ√«®CT abdomen ®÷ß àßμ—«¡“√—°…“μàÕ∑’Ë‚√ß欓∫“≈«™‘√–

√—∫ª√–∑“πÕ“À“√‰¥âª°μ‘ ‰¡à‡∫◊ËÕÕ“À“√ ‰¡à¡’πÈ”Àπ—°≈¥ ‰¡à¡’Õ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π Õÿ®®“√–‰¥âª°μ‘ ‰¡à¡’

∑âÕߺŸ°À√◊Õ∑âÕ߇ ’¬ ªí  “«–‰¥âª°μ‘ ‰¡à· ∫¢—¥À√◊Õ∫àÕ¬¢÷Èπ‰¡à‡§¬§≈”æ∫°âÕπ∑’Ë∑âÕßπâÕ¬ ‰¡à¡’μ°¢“«º‘¥ª°μ‘ ‰¡à¡’‰¢â

‰¡à¡’ª√–«—μ‘°âÕπ‡π◊ÈÕÀ√◊Õμ‘Ë߇π◊ÈÕ¬◊ËπÕÕ°¡“∑“ß™àÕߧ≈Õ¥„Àâª√–«—μ‘«à“‡§¬μ√«®§—¥°√Õß¡–‡√Áߪ“°¡¥≈Ÿ° 10 ªï°àÕπº≈ª°μ‘

20  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

P_20-28 19/6/19, 17:4820

21©∫—∫∑’Ë 1/2562

Past history:

● ‚√§ª√–®”μ—« simple goiter ‰¡à‰¥â√—∫°“√√—°…“„¥ Ê

● ªØ‘‡ ∏ª√–«—μ‘°“√¥◊Ë¡ ÿ√“À√◊Õ Ÿ∫∫ÿÀ√’Ë

● ªØ‘‡ ∏°“√„™â¬“ ¡ÿπ‰æ√ ¬“μâ¡ ¬“À¡âÕ À√◊Õ¬“≈Ÿ°°≈Õπ

● ªØ‘‡ ∏ª√–«—μ‘‚√§¡–‡√Áß„π§√Õ∫§√—«

● ªØ‘‡ ∏ª√–«—μ‘°“√ºà“μ—¥

● ªØ‘‡ ∏ª√–«—μ‘°“√·æ⬓À√◊Õ·æâÕ“À“√

Obstetric and gynecological history:

● Menarche 15 years old

● LMP ‡¥◊Õπ¡’π“§¡ 2560, PMP ‡¥◊Õπ¡°√“§¡ 2560

● ™à«ßª°μ‘ ª√–®”‡¥◊Õπ¡“ interval 28 days, duration 3-4 days, amount 2-3pads/day, regularcycle

● „π√–¬– 1 ªï°àÕπ ª√–®”‡¥◊Õπ‡√‘Ë¡¡“∑ÿ° Ê 2 - 3 ‡¥◊Õπ

● P2002 last 32 year, normal labor, No history of obstetric complication

● First SI; age 20 years old, Single partner, Active SI

● No history of hormonal used or contraception

Physical examination at OPD

● V/S BT 37 ÌC, BP 96/68 mmHg, PR 80/min, RR 16/min

● BW 54 kg Height 150 cm BMI 24.5 kg/m(2)

● GA: Good consciousness, no jaundice, normal activity

● HEENT: Eye: No exophthalmos,

Neck: Thyroid nodule size 2 x 2 cm at Right lobe, smooth surface, not tender,no erythematous

● Abdomen: soft, not tender, abdominopelvic mass in mildline size 1/3 > pubic symphysis,firm consistency, smooth surface, slightly moveable, mild tenderness

● Extremities: no tremor.

● Lymph node: no lymphadenopathy at supraclavicular groin and axillary region

● Pelvic examination:

MIUB : normal

Vagina: normal discharge, no lesion

Cervix: Os close, no lesion, no cervical motion tenderness

P_20-28 19/6/19, 17:4821

22  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

Uterus: Enlarge size 12 cm, smooth surface, firm consistency, rather soft on left side of uterus,

mild tenderness Indurate soft tissue mass at right posterolateral to uterus, size about 10 cm, softconsistency, not tenderness, slightly movable

Adnexa - no mass on left side, not tender

CDS: no bulging, no nodularity

PRM; free both side

RV; smooth rectal mucosa, no mass

Problem list

● Abdominal pain for 2 weeks

● Abnormal uterine bleeding 10 days ago

● Missed period for 2 months and irregular menstrual cycle for 1 year

● Enlarged uterus

● CT abdomen suspected right ovarian tumor

● High level B-hCG

● Thyroid nodule

Differential diagnosis

➣ Obstetrical condition

- Molar pregnancy with ovarian tumor

➣ Gynecological condition

- GTN

- Extrauterine choriocarcinoma; fallopian tube, ovary, etc.

Investigation

P_20-28 19/6/19, 17:4822

23©∫—∫∑’Ë 1/2562

TVS:

➣ Uterus size 13.46 x 9.17 x 7.78 cm,

➣ Heterogenous hypohyperechogenic mass locate at right side of uterus include lowersegment, hypervascularity seen.

➣ Not seen right ovary

➣ Left ovary size 3.25 x 1.79 cm; look normal

➣ No free fluid in cul de sac

À≈—ß®“°μ√«®¿“¬„π·≈–Õ—≈μ√“´“«πå ¢≥–ºŸâªÉ«¬≈ÿ°¢÷Èππ—Ëß¡’Õ“°“√‡«’¬π»’√…–·≈–Àπâ“¡◊¥§≈⓬®–‡ªìπ≈¡ „® —Ëπ‰¡à¡’Õ“°“√ª«¥∑âÕß ∂“¡μÕ∫√Ÿâ ÷°μ—«¥’ ®÷ß«— ¥ BP ‰¥â 80/40 mmHg, PR 78/min ∑à“𧑥∂÷ß¿“«–„¥·≈–®–∑”Õ¬à“߉√

Management

➣ Rest; Supine position

➣ RLS 1,000 ml iv load 500 ml

➣ Dtx stat = 107 mg%

➣ Observe consciousness and vital sign

À≈—ß observe 5 π“∑’

ºŸâªÉ«¬¬—ß√Ÿâ ÷°μ—«¥’ ∂“¡μÕ∫√Ÿâ‡√◊ËÕß ¬—ß¡’Õ“°“√Àπâ“¡◊¥ ·≈–„® —Ëπ √Ÿâ ÷°ª«¥∑âÕß¡“°¢÷Èπ repeat BP ‰¥â 70/40mmHg PR 110/min

PE: Abdomen; mild distend, tender at suprapubic, no rebound tenderness, no guarding

∑à“𧑥∂÷ß¿“«–„¥„π¢≥–π’È·≈–®–∑”Õ¬à“߉√μàÕ‰ª ??

P_20-28 19/6/19, 17:4823

24  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

Ruptured tumor with intraabdominal hemorrhage with Hypovolemic shock

➣ Admit

➣ Resuscitation; IV no.18 ‡ âπ∑’Ë 2 Acetar iv 120 ml/hr

➣ Retain foleyûs catheter

➣ Set OR for exploratory laparotomy emergency

➣ HCT stat = 25%

➣ M/G PRC 6 u, FFP 4 u → Blood transfusion

➣ Antibiotics prophylaxis surgical site infection

➣ Re-evaluation; Ultrasonography bedside

Operative Findings

➣ Hemoperitoneum 1,400 ml

➣ Uterus 15 x 10 x 8 cm

P_20-28 19/6/19, 17:4824

25©∫—∫∑’Ë 1/2562

➣ Uterus 15 x 10 x 8 cm, dark brown mass 7 x 5 cm

suspected tumor necrosis in uterine cavity, multiple cystic nodule invade myometrium at right

fundus and right lateral wall near serosa, uterine rupture at right lower uterine segment size 2.5 cmwith active bleeding from rupture site

➣ Tumor invade right uterine artery with active bleeding

➣ Dark brown tumor at rectal serosa size 3 cm

➣ Normal surface of liver, spleen, peritoneal, diaphragm and omentum

Pathological report

● Uterus: invasive mole into myometrium, invading through the uterine serosa, completehydratidiform mole,

● Intrauterine content: complete hydratidiform mole

● Lesion at rectal serosa: negative for chorionic villi and malignancy

P_20-28 19/6/19, 17:4825

26  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

● Diffuse villous enlargement with marked hydropic changes

● Cistern formation and marked trophoblastic hyperplasia in a circumferential pattern

● Remarkable cytologic atypia present

● Mitosis

● The stromal changes of molar villi, which include stromal mucin and stromal nucleardebris (apoptosis).

Villi with features of mole (complete) invade the myometrium.

Operation

Exploratory laparotomy with TAH with excision tumor at rectal serosa

EBL 2,500 ml (Hemoperitoneum 1,400 ml)

Diagnosis

Invasive mole with uterine rupture with hypovolemic shock

Investigation for management?

P_20-28 19/6/19, 17:4826

27©∫—∫∑’Ë 1/2562

Thyroid function test

● TSH <0.008 uIU/ml (0.55-4.78 uIU/ml)

● FT4 1.69 ng/dl (0.89-1.76 ng/dl)● FT3 6.18 pg/ml (2.3-4.2 pg/ml)

Management

● Evaluate staging and risks score of GTN● Consult endocrinologist

PTU (50) 4 tab rectal support stat then PTU (50) 4 tab rectal support then q 8 hr➣ Step diet➣ No intermediate and early complication from surgery

➣ Correct anemia➣ F/U B-hcG and thyroid function test

➣ Discharge from hospital at post-op day4

P_20-28 19/6/19, 17:4827

28  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

Gestational trophoblastic disease

«‘π‘®©—¬ invasive mole stage II with high risk GTN

‰¥â√—∫ Chemotherapy Multiple agent chemotherapy EMA-CO

P_20-28 19/6/19, 17:4828

29©∫—∫∑’Ë 1/2562

 ”À√—∫ – ¡§–·ππ CME

1.  “‡Àμÿ∑’Ë ”§—≠∑’Ë ÿ¥¢Õß°“√§≈Õ¥°àÕπ°”Àπ¥°.† ¡’‡≈◊Õ¥ÕÕ°º‘¥ª°μ‘∑“ß™àÕߧ≈Õ¥

¢.† ¡’‚√§ª√–®”μ—«∑“ßÕ“¬ÿ√°√√¡°àÕπμ—Èߧ√√¿å

§.† ¡’ª√–«—μ‘°“√§≈Õ¥°àÕπ°”Àπ¥„π°“√μ—Èߧ√√¿å°àÕπß.† ¡’¿“«–∑“√°πÈ”Àπ—°μ—«‡°‘π‡°≥±å„π°“√μ—Èߧ√√¿åªí®®ÿ∫—π

®.† μ√«®æ∫°“√∫’∫μ—«¢Õß¡¥≈Ÿ°„π™à«ßÕ“¬ÿ§√√¿å°àÕπ§√∫°”Àπ¥

2. . ¢π“¥§«“¡¬“«ª“°¡¥≈Ÿ°∑’Ëæ∫«à“‰¥â√—∫°“√√—°…“¥â«¬¬“‚ª√‡® ‡∑Õ‚√π·≈⫉¥âª√– ‘∑∏‘º≈∑’Ë¥’°.† §«“¡¬“«ª“°¡¥≈Ÿ°πâÕ¬°«à“À√◊Õ‡∑à“°—∫‡ªÕ√凴Áπ‰∑≈å∑’Ë10†∑’ËÕ“¬ÿ§√√¿åπ—Èπ

¢. </= 4.0 cm§. </= 3.5 cmß. </= 3.0 cm

®.† æ∫§«“¡πÿà¡¢Õߪ“°¡¥≈Ÿ°¡“°‡°‘π‡°≥±å¡“μ√∞“π®“°°“√μ√«®æ‘‡»…

3. °“√„Àâ°“√ªÑÕß°—π√—°…“¥â«¬¬“‚ª√‡® ‡∑Õ‚√π∏√√¡™“μ‘ Õ¥∑“ß™àÕߧ≈Õ¥§«√‡√‘Ë¡∑’ËÕ“¬ÿ§√√¿å‡∑à“„¥°. 8  —ª¥“Àå

¢. 10  —ª¥“Àå§. 12  —ª¥“Àå

ß. 14  —ª¥“Àå

®. 16  —ª¥“Àå

P_29-30 19/6/19, 17:4929

30  Ÿμ‘π√’·æ∑¬å —¡æ—π∏å

1. °≈ÿà¡‚√§¡–‡√Á߇μâ“π¡·≈–√—߉¢à∑’Ë∂à“¬∑Õ¥∑“ßæ—π∏ÿ°√√¡ (hereditary breast and ovarian cancer syndrome:HBOC) ∑’ˇ°‘¥®“°°“√°≈“¬æ—π∏ÿåÀ√◊ÕÀ“¬‰ª¢Õ߬’π BRCA1 ·≈– BRCA2 ‡ªì𠓇Àμÿ¢Õß¡–‡√Áß√—߉¢àª√–¡“≥√âÕ¬≈–‡∑à“‰√

¢. √âÕ¬·≈– 10 ·≈–√âÕ¬≈– 3-5 ¢Õß¡–‡√Á߇μâ“π¡

2. ¢âÕ„¥‰¡à∂Ÿ°μâÕ߇°’ˬ«°—∫°“√ºà“μ—¥π”√—߉¢à·≈–∑àÕπ”‰¢àÕÕ°‡æ◊ËÕ≈¥§«“¡‡ ’ˬßμàÕ°“√‡°‘¥¡–‡√Áß√—߉¢à

(risk reducing bilateral salpingo-oophorectomy: RRBSO) °.  ”À√—∫ μ√’∑’Ë¡’∫ÿμ√§√∫·≈â« À√◊Õ‰¡àμâÕß°“√¡’∫ÿμ√·≈â«„Àâæ‘®“√≥“∑” RRBSO ‡≈¬

3. ¢âÕ„¥‰¡à∂Ÿ°μâÕ߇°’ˬ«°—∫°“√‡μ√’¬¡μ—«°àÕπºà“μ—¥ RRBSOß. °àÕπ∑’Ë®–‰¥â√—∫°“√ºà“μ—¥ RRBSO §«√‡μ√’¬¡°“√„π°“√μ√«® frozen section ∑ÿ°√“¬

4. ¢âÕ„¥‰¡à∂Ÿ°μâÕ߇°’ˬ«°—∫¢—ÈπμÕπ„π°“√ºà“μ—¥ RRBSOß. ·π–π”„Àâμ—¥¡¥≈Ÿ°æ√âÕ¡°—∫°“√ºà“μ—¥ RRBSO  ”À√—∫ μ√’∑’Ë¡’°“√°≈“¬æ—π∏ÿå¢Õ߬’π BRCA

5. ¢âÕ„¥‰¡à∂Ÿ°μâÕ߇°’ˬ«°—∫ºŸâªÉ«¬¿“¬À≈—ß°“√ºà“μ—¥ RRBSO

§. §«√À≈’°‡≈’ˬ߰“√„™âŒÕ√å‚¡π∑¥·∑π√—∫ª√–∑“π„πºŸâªÉ«¬°≈ÿà¡¥—ß°≈à“«

„π°√≥’∑’˺ŸâªÉ«¬¡’ªí≠À“™àÕߧ≈Õ¥∫“ß ¡’Õ“°“√‡®Á∫¢≥–¡’‡æ» —¡æ—π∏å À“°„™â “√À≈àÕ≈◊Ëπ™à«¬¢≥–¡’‡æ» —¡æ—π∏å·≈⫉¡à‰¥âº≈°Á “¡“√∂„™âŒÕ√å‚¡π‡Õ ‚μ√‡®π∑“ß™àÕߧ≈Õ¥‰¥âÕ¬à“ߪ≈Õ¥¿—¬

4. ¢âÕ„¥∂Ÿ°μâÕ߇°’ˬ«°—∫†vaginal micronized progesterone†‡¡◊ËÕ‡ª√’¬∫‡∑’¬∫°—∫17-alpha hydroxyprogesterone caproate (17-OHP-C)°.† æ∫º≈¢â“߇§’¬ß®“°°“√√—°…“¡“°°«à“

¢.† æ∫º≈¢Õß°“√√—°…“¡’ª√– ‘∑∏‘¿“æ Ÿß°«à“§.† §«“¡æ÷ßæÕ„®·≈–§«“¡μàÕ‡π◊ËÕߢÕß°“√√—°…“πâÕ¬°«à“

ß.† æ∫∑“√°·√°‡°‘¥μâÕß√—∫°“√√—°…“„πÀÕÕ¿‘∫“≈¡“°°«à“

®.† æ∫º≈°√–∑∫μàÕ°“√æ—≤π“¢Õß√–∫∫ª√– “∑„π™à«ß«—¬‡¥Á°¡“°°«à“

5. . °“√‡¬Á∫ºŸ°ª“°¡¥≈Ÿ° “¡“√∂∑”‰¥â„π ∂“π°“√≥å„¥∫â“ß°. Antepartum hemorrhage

¢. Painful cervical dilatation

§. Prior preterm birth < 34 weekß. Short cervical length < 10 mm®. History of recurrent pregnancy loss

§”∂“¡∑⓬∫∑ Risk reducing bilateral salpingo-oophorectomy: RRBSO

√».πæ.π‘æπ∏å ‡¢¡–‡æ™√

P_29-30 19/6/19, 17:4930

31©∫—∫∑’Ë 1/2562

P_31 20/6/19, 15:0331

32.indd 32 6/20/2562 BE 13:43