Sản phụ khoa

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

cng n tp mn snChuyn 1: cha ngoi t cungCu 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 chaHanoi Medical University LTL

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+ 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 ngchHanoi Medical University LTL

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VII. X tr

1. iu tr ni khoat 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.

Hanoi Medical University LTL

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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


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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 scHanoi Medical University LTL

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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 sng1.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 cungHanoi Medical University LTL

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+ 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 on1. 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 dnhHanoi Medical University LTL

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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 sangTriu 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 onChn on xc nh + Da vo lm sang v cn lm sang trnHanoi Medical University LTL

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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.


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Chuyn 2:Thai cht luCu 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 sng1 .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 sngHanoi Medical University LTL

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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 onChn 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 auHanoi Medical University LTL

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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 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 thngHanoi Medical University LTL

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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 kinhHanoi Medical University LTL

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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 trHanoi Medical University LTL

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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 trcHanoi Medical University LTL

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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 kmHanoi Medical University LTL

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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 nuiCu 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.Hanoi Medical University LTL

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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) 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/lHanoi Medical University LTL

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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 nhHanoi Medical University LTL

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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 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.Hanoi Medical University LTL

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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 bngHanoi Medical University LTL

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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 chongHanoi Medical University LTL

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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 nghaHanoi Medical University LTL

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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 sauHanoi Medical University LTL

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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 nonCu 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.Hanoi Medical University LTL

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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 thaiHanoi Medical University LTL

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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 bitHanoi Medical University LTL

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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 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 cungHanoi Medical University LTL

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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 gitCu 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.Hanoi Medical University LTL

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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 bitHanoi Medical University LTL

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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 ngHanoi Medical University LTL

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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 chngHanoi Medical University LTL

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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.Hanoi Medical University LTL

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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:Hanoi Medical University LTL

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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 thucHanoi Medical University LTL

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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 gitHanoi Medical University LTL

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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 hnHanoi Medical University LTL

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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 gitHanoi Medical University LTL

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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 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 noHanoi Medical University LTL

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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 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 pHanoi Medical University LTL

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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 cungCu 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 kitHanoi Medical University LTL

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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 nhHanoi Medical University LTL

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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 bngHanoi Medical University LTL

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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 phHanoi Medical University LTL

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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 cungCu 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)Hanoi Medical University LTL

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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.Hanoi Medical University LTL

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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(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 tnhHanoi Medical University LTL

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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 dyHanoi Medical University LTL

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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:Hanoi Medical University LTL

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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 bnhHanoi Medical University LTL

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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 cungHanoi Medical University LTL

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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:Hanoi Medical University LTL

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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 tngHanoi Medical University LTL

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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, clorambucilHanoi Medical University LTL

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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 nghnCu 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:Hanoi Medical University LTL

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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 cungHanoi Medical University LTL

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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 snHanoi Medical University LTL

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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 : Ti

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