Chuyên đề ối vỡ trước chuyển dạ chẩn đoán, điều trị và dự phòng

ĐẠI HỌC Y DƯỢC HỒ CHÍ MINH CHUYÊN ĐỀ ỐI VỠ TRƯỚC CHUYỂN DẠ CHẨN ĐOÁN, ĐIỀU TRỊ VÀ DỰ PHÒNG NCS: HỒ VIẾT THẮNG Người hướng dẫn: GS.TS VÕ MINH TUẤN THÀNH PHỐ HỒ CHÍ MINH – THÁNG 01 NĂM 2022 MỤC LỤC ĐẶT VẤN ĐỀ MỤC TIÊU CHƯƠNG 1: ĐẠI CƯƠNG VỀ ỐI VỠ TRƯỚC CHUYỂN DẠ 1.1 Một số định nghĩa: 1.2 Cấu trúc màng bào thai 1.3 Cơ chế ối vỡ trước chuyển 1.3.1 Sự thay đổi thành phần collagen, cấu trúc chuyển hóa 1.4 Yếu tố nguy liên quan đến thối hóa collagen tự vỡ màng ối 1.4.1 Nhiễm trùng 1.4.2 Hormone 11 1.4.3 Sự chết tế bào theo chương trình 11 1.4.4 Sự căng dãn màng ối mối liên quan với ối vỡ non 12 1.4.5 Chảy máu trước chuyển 12 1.4.6 Tiền ối vỡ thai kỳ trước 13 1.4.7 Hút thuốc 14 CHƯƠNG 2: CƠNG CỤ CHẨN ĐỐN ỐI VỠ TRƯỚC CHUYỂN DẠ 16 2.1 Chẩn đoán ối vỡ 16 2.1.1 Bệnh sử lâm sàng ối vỡ 16 2.1.2 Chứng nghiệm đổi màu giấy Nitrazine[36] 16 2.1.3 Chứng nghiệm kết tinh dương xỉ (Ferning test)[65] 18 2.1.4 Xét nghiệm số protein chuyên biệt dịch ối 18 2.1.5 Xét nghiệm nồng độ β‐human chorionic gonadotropin (βhCG) dịch âm đạo 19 2.1.6 Xét nghiệm insulin growth factor binding protein-1 placental alpha microglobulin-1 dịch âm đạo 20 2.1.7 Xét nghiệm nồng độ ure creatinine dịch âm đạo chẩn đoán ối vỡ 26 2.1.8 Các xét nghiệm khác 26 CHƯƠNG 3: ĐIỀU TRỊ ỐI VỠ TRƯỚC CHUYỂN DẠ 28 3.1 Xử trí ối vỡ trước chuyển 28 3.1.1 Tuổi thai từ 37 0/7 tuần 29 3.1.2 Tuổi thai từ 34 0/7 đến 36 6/7 tuần 31 3.1.3 Tuổi thai từ 24 0/7 đến 33 6/7 tuần 34 3.1.4 Tuổi thai từ 22 0/7 đến 23 6/7 tuần 35 3.2 Các điều trị cụ thể 37 3.2.1 Chất bịt kín màng ối 37 3.2.2 Truyền ối 39 3.2.3 Liệu pháp corticosteroid 41 3.2.4 Tầm soát điều trị ổ nhiễm trùng 50 3.2.5 Thuốc giảm gò 55 CHƯƠNG 4: DỰ PHỊNG TÌNH TRẠNG ỐI VỠ TRƯỚC CHUYỂN DẠ 59 Các gốc oxy hóa hoạt động (ros) sở lý luận dự phòng ối vỡ trước chuyển 59 4.2 Các biện pháp dự phòng ối vỡ trước chuyển 60 4.2.1 Các bệnh lý nhiễm trùng 60 4.2.2 Progesterone 63 4.2.3 Khâu vòng cổ tử cung 64 4.2.4 Khoảng cách hai lần sinh 65 4.2.5 Các liệu pháp dinh dưỡng 65 KẾT LUẬN 70 TÀI LIỆU THAM KHẢO 71 TIẾNG VIỆT 71 TIẾNG ANH 71 4.1 DANH MỤC BẢNG Bảng 2-1: Bảng màu độ pH 17 Bảng 2-2: Giá trị xét nghiệm chẩn đoán ối vỡ 22 Bảng 2-3:So sánh độ xác xét nghiệm chẩn đoán ối vỡ 22 Bảng 2-4: Các nghiên cứu giá trị PAMG-1 IGFBP-1 chẩn đoán ối vỡ 22 Bảng 2-5: Giá trị xét nghiệm PAMG-1 IGFBP-1 chẩn đoán ối vỡ 26 Bảng 3-1: Kết cục sơ sinh phụ nữ ối vỡ non 37 tuần 30 Bảng 3-2: Kết cục lâm sàng mẹ, trẻ sơ sinh ối vỡ trước chuyển 37 tuần 31 Bảng 3-3: Kết cục mẹ thai nghiên cứu PPROMT 33 Bảng 3-4: So sánh kết cục thai kỳ nhóm 35 Bảng 3-5: Kết cục lâm sàng hô hấp trẻ sơ sinh non tháng- có sử dụng Betamethasone thai kỳ 43 Bảng 3-6: Mức độ khuyến cáo sử dụng liệu pháp Corticosteroid trước sinh theo tuổi thai 45 Bảng 3-7: Đối tượng nguy cao mắc bệnh STDs 53 Bảng 3-8: Các thử nghiệm ngẫu nhiên có đối chứng ối vỡ trước chuyển có giảm gị 56 HÌNH Hình 1-1: Mơ tả cấu trúc lớp màng bào thai lúc đủ tháng Cấu trúc chất ngoại bào lớp sản xuất metaloproteinases (MMP) chất ức chế MMP (TIMP) biểu thị Hình 2-1: Chứng nghiệm kết tinh dương xỉ dương tính 18 Hình 2-2: Khả chẩn đốn xét nghiệm nhóm ối vỡ 24 Hình 2-3: Khả chẩn đốn xét nghiệm nhóm khơng có ối vỡ 25 Hình 2-4: Khả chẩn đốn xét nghiệm dân số nghiên cứu chung 25 Hình 3-1: Mơ tả q trình truyền tiểu cầu kết tủa lạnh 37 Hình 3-2: Thủ thuật truyền ối trường hợp ối vỡ trước chuyển qua đường âm đạo 39 Hình 3-3: Thủ thuật truyền ối trường hợp ối vỡ trước chuyển qua đường bụng 40 Hình 3-4: Tỉ lệ nhiễm trùng ối theo tuổi thai thời điểm có vỡ ối non 50 Hình 4-1:Vai trò vitamin C (xanh lam nhạt) vitamin E (xanh lam đậm) để kích thích tăng cường bảo vệ collagen màng ối màng đệm để tránh ối vỡ trước chuyển thai non tháng 66 DANH MỤC VIẾT TẮT ACOG AJOG betaHCG BV CDC IGFBP-1 KTC MNP OR PAMG-1 ROS RR SDP The American College of Obstertricians and Gynecologists American Journal of Obstertrics and Gynecology β‐human chorionic gonadotropin Bacterial vaginosis Centers for Disease Control and Prevention insulin growth factor binding protein-1 Khoảng tin cậy Odd ratio placental alpha microglobulin-1 Reactive Oxygen Species Relative risk Single deepest pocsket measurement DANH MỤC ANH VIỆT Tiếng Anh American Journal of Obstertrics and Gynecology Bacterial vaginosis Centers for Disease Control and Prevention Reactive Oxygen Species Single deepest pocsket measurement The American College of Obstertricians and Gynecologists Tiếng Việt Tạp chí sản phụ khoa Hoa Kỳ Nhiễm khuẩn âm đạo Trung tâm kiểm soát ngăn ngừa bệnh tật Gốc oxy hoạt hóa Độ sâu xoang ối lớn Hiệp hội sản phụ khoa Hoa Kỳ ĐẶT VẤN ĐỀ Ối vỡ trước chuyển tình trạng khơng tồn vẹn màng đệm màng ối, dẫn đến chảy nước ối chưa vào chuyển Ối vỡ trước chuyển xảy thai chưa đủ trưởng thành (PPROM) thai trưởng thành (PROM) Ba biến chứng thường gặp ối vỡ trước chuyển sinh non, nhiễm trùng ối giảm sản phổi Ối vỡ trước chuyển thai non tháng (PPROM) nguyên nhân chủ yếu biến chứng Chẩn đoán, điều trị quản lý biến chứng ối vỡ trước chuyển Là thách thức khơng ngành y tế mà cịn với kinh tế - xã hội đất nước [22],[122] Ối vỡ trước chuyển ba nguyên nhân sinh non (cùng với chuyển sinh non tự nhiên sinh non định y khoa) Ối vỡ trước chuyển thai non tháng xảy 3-4% thai kì liên quan đến 30-40% trường hợp sinh non Mỗi năm, Mỹ có khoảng 560.000 trẻ sinh non, chiếm 12% thai kỳ, khoảng 150.000 ca có liên quan với PPROM, chiếm khoảng 3% biến chứng Quản lý điều trị ối vỡ trước chuyển biện pháp dự phòng cấp mục tiêu cải thiện kết cục chu sinh trẻ sinh non, phương án dự phòng sinh non phổ biến hiệu sản khoa đại [1] [2][98] Mặc dù có tiến chẩn đốn, điều trị chăm sóc nhi sơ sinh ối vỡ trước chuyển nói chung cịn biến cố sản khoa quan trọng Một tình trạng ối vỡ trước chuyển xảy thai 28-37 tuần, 50% thai phụ vào chuyển vòng 24 80% vào chuyển vòng ngày Trong ối vỡ trước chuyển thai đủ tháng, 50% thai kì vào chuyển sinh vịng 33 giờ, 95% sinh 94-107 có tăng co Oxytocin Prostaglandin [53] Hậu nguy hiểm thời gian theo dõi nguy nhiễm trùng, nguy tăng tỉ lệ thuận với thời gian vỡ ối Trong số thai phụ có thai non tháng bị vỡ ối trước chuyển dạ, nhiễm trùng ối xảy với tỉ lệ 15-35% trường hợp nhiễm trùng hậu sản khoảng 15-25% tỷ lệ tỷ lệ nghịch với tuổi thai [13] [64] [88] Do đó, chúng tơi thực chun đề “Ối vỡ trước chuyển dạ: Chẩn đốn, điều trị dự phịng” MỤC TIÊU Định nghĩa phân loại tình trạng ối vỡ trước chuyển Cơ chế yếu tố nguy tình trạng ối vỡ trước chuyển Cơng cụ chẩn đốn ối vỡ trước chuyển Điều trị ối vỡ trước chuyển Dự phịng tình trạng ối vỡ trước chuyển 70 KẾT LUẬN Sinh non ối vỡ trước chuyển nói chung biến cố sản khoa quan trọng, thách thức không y tế mà với kinh tế-xã hội đất nước Cơ chế tình trạng ối vỡ trước chuyển phức tạp, có liên quan đến nhiều yếu tố nguy dự phịng Cơng cụ chẩn đốn ối vỡ trước chuyển đa dạng, cân yếu tố tiềm lực độ xác để chọn cơng cụ phù hợp cho đơn vị Điều trị ố vỡ trước chuyển phụ thuộc nhiều vào tuổi thai thời điểm ối vỡ Kháng sinh liệu pháp corticosteroid điều trị chủ đạo Chất bịt kín màng ối điều trị hứa hẹn, cần có thêm chứng thuyết phục TÀI LIỆU THAM KHẢO TIẾNG VIỆT Bệnh Viện Hùng Vương (2020), "Màng Ối Vỡ Non", Hướng Dẫn Điều Trị Sản Phụ Khoa 2020, Nxb Tổng Hợp Thành Phố Hồ Chi Minh, Thành Phố Hồ Chí Minh, tr.34850 Lê Văn Điển (2005), "Sự phát triển thai phần phụ thai", Sản Phụ Khoa, Nxb Thành Phố Hồ Chí Minh, TP HCM, tr.87-90 TIẾNG ANH Abdelazim Ibrahim A, Makhlouf Hanan H %J Archives of gynecology, obstetrics (2012), "Placental alpha microglobulin-1 (AmniSure® test) for detection of premature rupture of fetal membranes" 285 (4), pp 985-989 Abenhaim H A., Fraser W D (2007) "Review: planned early birth after prelabour rupture of membranes at term has benefits for mother and infant" Arch Dis Child Educ Pract Ed, 92 (4), pp ep125 ACOG (2020), "Prelabor Rupture of Membranes: ACOG Practice Bulletin, Number 217" Obstetrics & Gynecology, 135 (3), pp e80-e97.17N 1M 1V Alger L S., J C Lovchik, J R Hebel, L R Blackmon, M C Crenshaw (1988) "The association of Chlamydia trachomatis, Neisseria gonorrhoeae, 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