ĐẶC điêm lâm SÀNG, cận lâm SÀNG và kết QUẢ điều TRỊ VIÊM RUỘT THỪA ở PHỤ nữ MANG THAI

B GIO DC V O TO B Y T TRNG I HC Y H NI THAI DINAL ĐặC ĐIÊM LÂM SàNG, CậN LÂM SàNG Và KếT QUả ĐIềU TRị VIÊM RUộT THừA PHụ Nữ MANG THAI Chuyờn ngnh: Ngoi khoa Mó s : CNG LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS Trnh Vn Tun TS Nguyn Ngc Hựng H NI - 2016 MC LC DANH MC BNG DANH MC HèNH T VN Viờm rut tha cp hin l mt nguyờn nhõn ph bin nht chn oỏn phu thut ngoi khoa v cng l nguyờn nhõn gõy hu qu nhiu nht quỏ trỡnh can thip phu thut ca ph n thi k mang thai Viờm rut tha mang thai chim t l t khong 1/1250 v 1/1500 ph n mang thai [1];[10];[11];[23];[38] Thi k mang thai l mt giai on ca cuc sng ú cỏc triu chng bnh lý cú th c coi nh l nhng thay i sinh lý, thay i ni tit gõy bun nụn, nụn, chua, tro ngc d dy-thc qun v niu o gión thai k, t cung to lờn lm nh hng n v trớ ca cỏc cn au [12] Do vy d t bỏc s chn oỏn nhm v khú khn v lõm sng v siờu õm bnh nhõn b viờm rut tha [3];[5];[17];[24] Theo Vừ Duy Long v ỡnh Cụng tui sinh , viờm rut tha thng b chn oỏn lm vi bnh sn ph khoa Nguyờn nhõn thng ớt biu hin cỏc triu chng v sn ph khoa v cha khai thỏc y cỏc triu chng ca sn ph khoa [39] T l m lm cũn cao t 20-40% c bit ph n tui sinh [40];[41] Mt khỏc v vic quyt nh phu thut hay khụng phu thut (hoc trỡ hoón) cng l mt khú khn vỡ nu rut tha v ra, gõy bin chng thỡ t l sy thai hoc sinh non sau m v cỏc bin chng khỏc cng tng lờn Sy thai thng xy 3-15% ph n viờm rut tha cú bin chng tam cỏ nguyt u tiờn, nhiờn cú th tng lờn ti 20-30% [20];[29], vi t l non l 15-45% [20] v tng nguy c sy thai t nhiờn, non, tng t l mc bnh v t vong chu sinh [28] T l t vong ph n mang thai b viờm rut tha cp t 2,5% - 3%, cao hn 10 hoc nhiu ln so vi khụng cú thai [6],[27],[36] Trc õy, phu thut ct b rut tha bnh nhõn cú thai thng c thc hin qua ng m m vựng h chu phi ng cnh gia hoc ng trng gia Hin vi s tin b ca chuyờn ngnh phu thut ni soi v s tin b ca chuyờn ngnh gõy mờ hi sc, ó cú nhiu trung tõm phu thut ln trờn th gii cng nh nc v phu thut ni soi ct rut tha, ct tỳi mt, cỏc u phn ph khỏctrờn ph n mang thai nhiu mc v gúc khỏc vi kt qu kh quan Hin ti Bnh vin Hu ngh Vit-c, phu thut ct rut tha c m m v ni soi ph n mang thai ó c ỏp dng rt nhiu Vỡ vy gúp phn cú mt kt lun khoa hc khng nh tớnh an ton v hiu qu ca phu thut, chỳng tụi chn ti Nghiờn cu c im lõm sng, cn lõm sng v kt qu iu tr phu thut ct rut tha ph n mang thai ti Bnh vin Hu Ngh Vit c nhm mc tiờu: Mụ t c im lõm sng v cn lõm sng ca viờm rut tha ph n mang thai ỏnh giỏ kt qu iu tr phu thut ct rut tha ph n mang thai ti Bnh Vin Hu Ngh Vit c nm 2012-2017 Chng TNG QUAN 1.1 LCH S NGHIấN CU BNH VIấM RUT THA Rut tha c mụ t ln u tiờn vo nm 1522 bi Berengarius Carpus, giỏo s phu thut ti Pavia Pologna ễng ta ó mụ t rut tha l phn thờm vo on cui manh trng, chiu rng nh hn ngún tay ỳp v chiu di khong inches hoc xp x [4] Claudius Amyand (1735) ó ghi li vic ct b rut tha ca ngi quỏ trỡnh phu thut thoỏt v Mestivier (1759) ó núi vi Handcock v m ỏp xe rut tha u tiờn, iu ny c xem l s mụ t cn c vo bnh lý ca viờm rut tha Nm 1886 Reginald H Fitz Boston quan sỏt thy triu chng ca 209 trng hp viờm phỳc mc tng t triu chng ca 257 trng hp quan sỏt thy rut tha thng, v khuyn cỏo rng ct rut tha l phng phỏp iu tr tt cho kt qu tt nht v phi c thc hin giai on sm ca bnh ễng ta ngh dựng t viờm rut tha thay th cho thut ng viờm quanh manh trnh n nm 1989 McBurney a cỏc triu chng kinh in chn oỏn v cỏc loi vi khun gõy bnh viờm rut tha ễng cng a cỏc mc bnh lý, ng m v cỏch thc phu thut m n c ỏp dng [4] 1.2 GII PHU SINH Lí RUT THA 1.2.1 Gii phu rut tha v v trớ rut tha Rut tha l on cui ca manh trng, lỳc u cú hỡnh chúp nún ln ngc u v phớa ca manh trng, nhng quỏ trỡnh phỏt trin khụng ng u ca manh trng ch yu bờn phi phớa trc lm rut tha xon dn vo phớa sau v lờn trờn ngi trng thnh ba di dc c ca manh trng gp ti ch ni manh trnh v rut tha cỏch gúc hi manh trng khong 2,5cm ngi Vit Nam, theo Xuõn Hp, rut tha di t 20cm ng kớnh t 57mm [43] Gc RT l c nh, nhng u RT li cú nhiu v trớ khỏc bng so vi manh trng [19] Theo Nguyn Quang Quyn (1993) RT HCP chim 53,3%, RT sau manh trng: 30%, cũn li RT tiu khung, sau hi trng v vo bng gia cỏc quai rut [18] Ngoi y vn, mt s v trớ c bit ca RT cng c nờu v cng gp thc t lõm sng nh: - Rut tha sau phỳc mc - Rut tha mc sau manh trng - Rut tha h chu trỏi trng hp o ngc ph tng - Rut tha quỏ di, u rut tha chy sang h chu trỏi viờm gõy au vựng h chu trỏi - Rut tha cú th thng v, cnh d dy hay di gan phi trng hp rut xoay khụng hon ton - Khụng cú rut tha - Cú rut tha Hỡnh 1.1 v trớ ca rut tha ph n cú thai, th tớch t cung to dn lờn theo tui thai, lm thay i v trớ ca rut tha bng rut tha b y lờn T cung thai di 10 tun T cung thai 11 n 20 tun T cung thai 21 n 30 tun T cung thai 31 n 40 tun Hỡnh 1.2 v trớ ca rut tha mang thai 1.2.2 Cu trỳc mụ hc: Cu trỳc rut tha tng t vi cu trỳc manh trng, th t cỏc lp gm: - Lp mc rt mng, chớnh l phỳc mc tng bao bc quanh rut tha v liờn tc vi lỏ ca mc treo rut tha Lp mc dớnh vi lp c, nhng rut tha viờm cú th búc tỏch d dng - Lp c: gm lp c vũng v lp c dc; hai lp c ny kộm phỏt trin - Lp di niờm mc l t chc liờn kt bao gm cỏc dõy thn kinh v mch mỏu - Lp niờm mc: Gm ba lp: lp biu mụ, lp m, lp c niờm + Biu mụ: ging biu mụ i trng ba loi t bo ú l nhng t bo hp thu, t bo hỡnh i tit nhy v t bo a bc + Lp m: l mụ liờn kt cú nhiu tuyn Lieberkuhn, nhng nang bch huyt ln v nh phỏt trin xung c lp di niờm mc + Lp c niờm: l di c trn khụng liờn tc, mng v b ngt quóng bi nang bch huyt Lp niờm mc v di niờm mc rt dy nờn lũng rut tha rt hp v cú b bớt li ngi gi, s lng v kớch thc ca cỏc nang bch huyt ny gim, song song vi quỏ trỡnh ny l s phỡ i ca niờm mc v gia tng t chc x lp di niờm mc [42],[43] Hỡnh 1.3 cu trỳc mụ hc ca rut tha 10 1.2.3 Sinh lý Cỏc nghiờn cu cho thy rut tha cú chc nng chớnh: - Chc nng dch: Gorgollon cho rng rut tha l t chc lympho phỏt trin vi chc nng dch Fichtelius xem rut tha nh l c quan bch huyt trung tõm, liờn quan n quỏ trỡnh trng thnh ca t bo lympho B - Chc nng bo v: E.I Sinhennhicop v Gross cho rng rut tha cú nhiu ỏm bch huyt úng vai trũ quan trng chc nng bo v c th chng li vi trựng Chc nng phũng chng nhim trựng ca rut tha (h thng bch huyt rut tha) cng khụng kộm phn quan trng nh chc nng ca h thng bch huyt ca Amygdale vũm hng - Chc nng tiờu húa: rut tha tit cht dch kim, gm cỏc men nh Amylaza, Pepsin v cht nhy Trong 24 gi rut tha ngi trng thnh tit khong 2ml dch nhy, Amylaza v cỏc men tiờu Protide 1.3 GII PHU BNH Lí: Phõn loi gii phu bnh: Mac Burney ch phõn bit hai loi: - Viờm rut tha khụng thng Viờm rut tha thng Vit Nam, Nguyn Quý To [50] phõn viờm rut tha lm ba loi: - Viờm rut tha long: tn thng gii hn lp niờm mc, di niờm mc - Viờm rut tha lan rng: tn thng ti lp c v mc - Viờm rut tha hoi t: cú hin tng hoi t, thng, v Theo Nguyn Vn Khoa [48] phõn loi giai on sm, mun ca tn thng chia lm ba mc : - Mc I: viờm xung huyt, viờm ty Mc II: viờm m, viờm hoi t cha v 29 Nhn xột: 3.2 IU TR V KT QU IU TR 3.2.1 Phng phỏp phu thut Bng 3.10 phng phỏp phu thut theo tui thai Phu Thut M m Tui thai n % Ni soi n % Tng n % 12 tun 13 24 tun > 24 tun Tng s P Nhn xột: 3.2.2 V trớ ca rut tha bng Bng 3.11 V trớ ca rut tha phu thut Phu thut V trớ ca RT Vựng HCP Khỏc Tng s p M m n % M ni soi n % Tng n % 30 Nhn xột: 31 3.2.3 Tỡnh trng rut tha bng Bng 3.12 Tỡnh trng rut tha bng Tỡnh trng rut tha Bỡnh thng Xung huyt Tỡnh trng rut tha Viờm m Hoi t, hoi t ó v u V trớ v Thõn Gc Bỡnh thng Tỡnh trng gc RT N + mn n % Nhn xột: 3.2.4 Tỡnh trng bng Bng 3.13 Tỡnh trng bng Tỡnh trng bng Khụng cú dch Dch bng Cú dch M Gi mc n % Nhn xột: 3.2.5 X lý tỡnh trng bng Bng 3.14 X lý tỡnh trng bng Phng phỏp x lý bng Lau bng + khụng dn lu Lau bng + dn lu S trng hp T l % 32 S dn lu Nhn xột: 3.2.6 Thi gian phu thut Bng 3.15 Thi gian v phng phỏp m Phu thut Thi gian (phỳt) 60 60-120 >120 Tng s p M m n % M ni soi n % Tng n % Nhn xột: 3.2.7 Kt qu gii phu bnh ca rut tha Bng 3.16 Kt qu gii phu bnh lý ca rut tha Kt qu RT khụng viờm RT xung huyt viờm cp RT viờm m RT hoi t Tng s n T l (%) Nhn xột: 3.2.8 Khỏng sinh sau m Bng 3.17 S dng khỏng sinh sau m Khỏng sinh Khỏng sinh Tng n T l (%) 33 Nhn xột: 3.2.9 Thi gian dựng khỏng sinh sau m Bng 3.18 Thi gian dựng khỏng sinh sau m Phu thut Thi gian 1-5 ngy 6-10 ngy 11-15 ngy Tng s p Nhn xột: M m n % M ni soi n % Tng n % 34 3.2.10 Thi gian dựng thuc gim co c sau m Bng 3.19 Thi gian dựng thuc gim co c sau v phng phỏp m Phu thut Thi gian 1-5 ngy 6-10 ngy 11-15 ngy Tng s p M m n % M ni soi n % Tng n % Nhn xột: 3.2.11 Thi gian dựng thuc gim au sau m Bng 3.20 Thi gian dựng thuc gim au v phng phỏp m Phu thut Thi gian 1-3 ngy 4-5 ngy ngy Tng s p Nhn xột: M m n % M ni soi n % Tng n % 35 3.2.12 Thi gian nm vin sau m Bng 3.21 Thi gian nm vin v phng phỏp m Phu thut Thi gian 1-5 ngy 6-10 ngy 11-15 ngy 16 ngy Tng s p M m n % M ni soi n % Tng n % Nhn xột: 3.3 BIN CHNG SAU M 3.3.1 Bin chng sm sau m Bng 3.22 Bin chng sm v phng phỏp m Phu thut Bin chng M m n % M ni soi n % Tng n % Nhiờm trựng vt m p xe tn d Nhim trựng l trocart Khỏc Khụng bin chng Tng s p Nhn xột: 3.3.2 Bin chng sn khoa sau m rut tha Bng 3.23 Bin chng sn khoa v phng phỏp m Phu thut Bin chng M m n % M ni soi n % Tng n % 36 Khụng biờn chng Da non non Da sy thai Sy thai Tng s p Nhn xột: CHNG D KIN BN LUN D KIN KT LUN D KIN KIN NGH 37 TI LIU THAM KHO Brown JJ, Wilson C, Coleman S, Joypaul BV (2009) Appendicitis in pregnancy an ongoing diagnostic dilemma Colorectal Dis; 11 116-22 Robert Ohle, Fran OReilly, Kirsty K OBrien (2011), Tom Fahey and Borislav D Dimitrov-The Alvarado score for predicting acute appendicitis a systematic review; Ohle et al BMC Medicine, 9;139,1-13 Deniz imek, ệzgỹr Deniz Turan, Ahmet Mete Ergenolu, Halit Batuhan Demir, Taylan ệzgỹr Sezer, ầada ahin (2015) Pregnancy Outcomes and Surgical Management of Pregnancy Complicated By Appendicitis Obstetrician View- Meandros Medical and Dental Journal;1643-9 Arthur C- McCarty MD (1927) professor of medicine- History of Appendicitis Antụnio Henriques de Franca Neto (2015) Melania Maria Ramos Amorim, Bianca Maria Souza Virgolino Núbrega Acute appendicitis in pregnancy literature review, Rev Assoc Med Bras; 61(2)170-177 Hee P, Viktrup L (1999) The diagnosis of appendicitis during pregnancy and maternal and fetal outcome after appendectomy International Journal of Gynaecology and Obstetrics, 65, 129 -135 Al-Fozan H, Tulandi T (2002) Safety and risks of laparoscopy in pregnancy Current Opinion in Obstetrics and Gynecology, 14(4), 375-379 Conron R.W, Abbruzzi K, Cochrane S.O et al (1999) Laparoscopi procedures in pregnancy Obstetrical and Gynecological Survey, 54(10), 613-676 Amos J.D, Schorr S.J, Norman P.F et al (1996) Laparoscopic surgery 10 during pregnancy The American surgeons, 171, 435-437 Tamir IL, Bongard FS, Klein SR (1990) Acute appendicitis in the pregnant 11 patient Am J Surg; 160;5715; discussion,575576 Mazze, RI, Kallen, B (1991) Appendectomy during pregnancy A Swedish 12 Registry study of 778 cases Obstet Gynaecol.;77835840 Lờ Th Thanh Võn (2010) Nhim khun nguy hi thai nghộn Nh 13 xut bn y hc H Ni, 15-22 A.T.Gurbuz, M.E.Peetz (1997) The acute abdomen in the pregnant patient 14 Surg Endosc (1997) 11 98102 Chinnusamy Palanivelu, Muthukumaran Rangarajan, Ramakrishnan Parthasarathi (2006) Laparoscopic Appendectomy in Pregnancy a Case Series of Seven Patients Journal of the Society of Laparoendoscopic 15 Surgeons, JSLS (2006) 10:321-325 P Lemieux, P Rheaume, I Levesque, E Bujold, G Brochu (2009) Laparoscopic appendecot0my in pregnant patients a review of 45 cases, 16 Surg Endosc 23, 1701-1705 Eran Sadot Dana A Telem, Manjit Arora, Parag Butala, Scott Q Nguyen, Celia M Divino (2010) Laparoscopy a safe approach to appendicitis 17 during pregnancy Surg Endosc 24383389 Lemaire BMD, Van Erp WFM (1997) Laparoscopic surgery during 18 19 pregnancy Surg Endosc; 11- 1518 Nguyn Quang Quyn (1993) Gii phu bng Nh xut bn Y hc H Ni Nguyn c Ninh (1997): "Ct b rut tha", Phu thut ng tiờu hoỏ, Nh 20 xut bn Y hc H Ni, 165-197S Palanivelu C, Rangarajan M, Senthilkumaran S, Parthasarathi R (2007) Safety and efficacy of laparoscopic surgery inpregnancy experience of a 21 single institution J Laparoendosc Adv Surg Tech A; 17 186190 Tracey M, Fletcher H.S (2000) Appendicitis in pregnancy The American 22 surgeon, 66, 555-559 B mụn Ngoi Trng i hc Y H Ni (2004) Bnh hc ngoi khoa 1, 119-134 23 Thomas Holzer, Gianmaria Pellegrinelli, Philippe Morel and Christian Toso (2011) Appendectomy during the third trimester of pregnancy in a 27-year old patient case report of a near miss complication; Holzer et al Patient 24 Safety in Surgery, 511:1-4 Augustin G, Majerovica M (2007) Non-obstetrical acute abdomen duringNon-obstetrical acute abdomen during pregnancy; European Journal of 25 Obstetrics & Gynecology and Reproductive Biology, 131, 4-12 Radwan M, Maciolek-Blewniewska G, Malinowski A (2007) Spontaneous heterotopic pregnancy and acute appendicitis treated by laparoscopy 26 International Journal of Gynaecology and Obstetrics, 96(2), 129 Baer J.L, Reis R.A, Arens R.A (1932) Appendicitis in pregnancy with changes in position and axis of the normal appendix in pregnancy The 27 Journal of the American Medical Association, 98, 1359-1364 Borst A.R (2007) Acute appendicitis: pregnancy complicates this diagnosis 28 Journal of the American Academy of Physician Assistants, 20, 36-38 C.Wilasrusmee, B Sukrat, M McEvoy, J Attia (2012) Systematic review and meta-analysis of safety of laparoscopic versus open appendicectomy 29 for suspected appendicitis in pregnancy, Br J Surg 99 1470-1478 Andersen B, Nielsen TF (1999) Appendicitis in pregnancy diagnosis, 30 management and complications Acta Obstet Gynecol Scand, 78 758762 Cunningham F.G, McCubbinJ.H (1975) Appendicitis Complicating Pregnancy, The American College of Obstetricians and Gynecologists, 31 45(4), 415-420 Nguyn ỡnh Hi (1988) Viờm rut tha, Bnh ngoi khoa ng tiờu 32 húa, i hc Y dc Thnh ph H Chớ Minh, tr 113-161 David A.G., Chantelle B.G., John S.M (1995) Use of neutrophil: lymphocyte ratio in the diagnosis of appendicitis, The american surgeon, Vol 61, p 257-259 33 Malangoni M.A (2003) Gastrointestinal surgery and pregnancy 34 Gastroenterology Clinics of North America, 32, 181-200 Freeland M, King E, Safcsak K et al (2009), Diagnosis of appendicitis in 35 pregnancy American Journal of Surgery, 198, 753-758 Munoz M, Usatine R.P (2005) Abdominal pain in pregnant woman Journal 36 of Family Practice, 54, 665-668 . (2007) , , 37 .. .,24 Cariati A, Brignole E, Tonelli E, et al (2001) Laparoscopic or open appendectomy Critical review of the literature and personal experience G 38 Chir, 22 (10), 353-357 A Upadhyay, S Stanten, G Kazantsev, R Horoupian, A Stanten Laparoscopic management of a nonobstetric emergency in the third 39 trimester of pregnancy Vừ Duy Long, ỡnh Cụng (2006) Nguyờn nhõn chn oỏn lm bnh viờm rut tha vi bnh sn ph ph n tui sinh Y Hc TP H 40 Chớ Minh Vol 10 Supplement of No - 10 12 Flum DR, Morris A, Koepsell T et al (2001) Has misdiagnosis of 41 appendicitis decreased over time, JAMA, 286 1748 1753 Rothrock SG (1995) Misdiagnosis of appendicitis in nonpregnant women 42 of childbearing age J Emerg Med, 13(1) 1-8 Trn Thu H (1995), Tỡnh trng v nguyờn nhõn viờm rut tha gp 43 Bnh vin Vit c gn õy, Tp ngoi khoa 9, tr 297-300S Xuõn Hp (1968) Manh v trựng trng Gii phu bng Nh xut bn 44 Y hc v th dc th thao, 211- 220 Lyass S, Pikarsky A, Eisenberg VH, Elchalal U, Schenker JG, Reissman P (2001) Is laparoscopic appendectomy safe in pregnant women? Surgical Endoscopy, 15(4), 377-379 45 Nguyn Vn Khoa (2010), Viờm rut tha cp, Bnh hc ngoi khoa 46 bng, Hc vin Quõn Y, tr 23-35 Pritchart JA, Baldwin R.M, Dickey D.C et al (1962) Blood volume changes in pregnancy and the puerperium: Red blood cell loss and changes in apparent blood volume during and following vaginal delivery, cesarean section, and cesarean section plus total hysterectomy American Journal of 47 Obstetrics and Gynecology, 84(10), 1271-1282 Mc Gee (1989) Acute appendicitis in pregnancy Australian and New 48 Zealand Journal of Obstetrics and Gynaecology, 29(4), 378-385 Nguyn Vn Khoa (1996), Nghiờn cu c im lõm sng, cn lõm sng v chn oỏn viờm rut tha cp tớnh, Lun ỏn phú tin s khoa hc Y 49 Dc, H Ni Hong Cụng c (2006), Viờm rut tha, Bnh hc ngoi dựng cho sau 50 i hc, 1, i hc Y H Ni, Nh xut bn Y hc, tr 171 187 Nguyn Quý To (1986) Viờm rut tha, Gii phu bnh cỏc ph tng H Quõn y, 65-66