Lâm sàng phụ khoa và giải phẫu bệnh

GS.BS OINH VAN TUNG, FACOG, FASCP lA m s A n g ph u khoa vA g ia i p h Au ben h IflM SANG PHU KHOfl v a Glffl PHfiU B€NH B ien dich ban sach xuat bcin Ian thu hai GS.BS DINH VAN TUNG MD, FACOG, FASCP Giao su San phu khoa Giao su Giai ph6u benh Bo m o n S a n p h u - T rtfa n g D a i h p c Y G a lv e to n - T e x a s 0^1 HQC THAI TKJNG TAM HQC Lilli N h a x u a t b a n Y hpc Hd Noi - 0 B ie n d ich : - BS DANG THE CAN - BS NGUYEN PHI HUNG - BS DAO TIEN C'U'C - BS TRAN NAM THANG - BS TRAN VAN THUAN S Y L L A B U S OI G Y N E C O L O G I C P A T H O L O G Y WI T H C L I N K AI C O R R E L A T I O N S L()I tua LAN XUAT BAN LAN THL/ Trong nhieu nam, giao su' Dinh da say me nghien cu'u nganh giai phau benh phu khoa, va gianh nhieu cong sue viec giang day bo mon cho cac sinh vien y khoa va bac si noi tru chuyen khoa Toi cung ehia se niem say me eua ong va cung nhu ong deu tiec thay hien tain quan eua viec giang day giai phau benh phu khoa cho sinh vien y khoa va bac sT noi tru chuyen khoa chua du'oc chu y Su' hieu biet nhung van de co ban ve giai phau benh phu khoa hoan loan la dieu can thiet doi vo'i nhung thay thuoc lain sang ve cac benh phu nu' Neu khong co nen tang thi ngu'di thay thuoc lam sang se khon g the phat trien von hieu biet ve lich sir tu' nhien cua can benh va nhung nguyen tac chii'a tri Lan xuat ban thir hai cuon sach la mot su' cong xuat sac No rat de doc va lam theo, no cung cap rat nhieu thong tin va nhu'ng dieu quy bau Theo y kien toi cuon sach la giao trinh ma tat ca sinh vien deu phai hoc qua trinh hoc san phu khoa cung nhu' bac si noi tru du'oc dao tao ve Ilnh vuc Cac thay thuoc chuyen khoa lam sang thirc hanh cung se lam tot hon co cuon sach tay nhu' mot tai lieu tra cu'u nhanh Cuon sach du'oc vict tot chinh xac va nhieu thong tin Moi chirong deu co bang tra cu'u rieng tong hop de ngu'di doc quan tam co the tra cu'u them nhung thong tin chi tiet R aym on d H K au fm an MI) T ru o n g dai hoc Y khoa B aylor H ouston, Texas A m ho ■ I Ban thai hoc II Mo hoc III Cac benh da thirong gap IV Cac ton thirong am ho cac benh he thong V Nhiem trung VI Cac u lanh tinh VII Cac ton thu'ong bieu mo khong u VIII Cac t6n thu'ong noi bieu mo u IX Cac u ac tinh xam nhap I Bao thai hoc A Bo phan sinh due ngoai bat dau bang mot giai doan khong biet hoa d tuan thur Cu sinh due cac nep nieu due va cac loi biu- am ho deu co nguon goc tir ngoai bi B C a c d a c tru'ng v& g id i duo'c x a c d i n h o' t u a n thu' Co' q u a n s i n h d u e n g o a i diroc h i n h t h a n h d a y d u o' t u a n thu' 12 C Cu sinh due hinh am vat nep nieu- due hinh cac moi nho, loi biu- am ho hinh cac moi Ion mu va cac mep sau am ho D Cac tuyen Bartholin: Duo'c hinh tir xoang nieu due (co nguon goc noi bi) tuo'ng ung voi cac tuyen hanh nieu dao o' nam E Tien dinh: La viing giua mang trinh va moi nho du'o'c gidi han bdi ham moi am ho d phia sau Am dao va nieu dao m d d day Tien dinh co nguon goc noi bi II Mo hoc (da) A M oi Ion • Thu'ong bi duo'c tao bdi bieu mo vay lat tang • Chan bi cd cac nang long va ba loai tuyen - Tuyen nguyen ven (tuyen mo hoi) - Tuyen toan buy (tuyen ba) - Tuyen ban buy la tuyen dac hieu cho cac \i ing am ho, quanh ong hau mon, nach va vu Bat dau che tie! theo chu ky co kinh nguyet, gom cac te bao Ion co bao tirong m au hong B M oi nho Khac vo'i moi Ion, lop bieu m o cua moi nho khon g co lop hat khong co nang long, it tuyen tiet rung d^u cac tuyen ba th a ns len be mat da C A m vat • G o m hai the hang ( m o cu'ong mach) • Khac vo'i dirong vat la khong co the xop D C ac tuyen Bartholin (cac tuyen ti£n dinh chfnh) • Cac tuyen tui: Duo'c tao boi cac te bao bieu mo tru che nhay • Cac ong du’oc lot boi cac te bao chuyen tiep • Mieng ong du’oc lot boi bieu mo lat tang giong cua am dao • Cac tuyen phu vung lien dinh: o xung quanh tien dinh • La vung nhat cua ong sinh due nu' co nguon goc noi bi E Nieu dao • Duo'c lot boi bieu mo chuyen tiep 16 nieu dao dirge lot boi bieu mo lat tang • Cac ong Skene (khong phai tuyen) a lo nieu dao diroc lot boi bieu mo vay • Nieu dao phia ngoai co cac tuyen nho bao q ua nh (la noi hay bi nhiem trung va hinh cac nang) III Cac benh da thuong gap A \ iem da tiep \ u c (viem am ho phan irng) • Do kich thich tai cho: nu'oc hoa thuoc \it mvi ton>_: hop cac dung cu tranh thai am dao • Da viem phu lie • Di6u in: Loai ho cac tac nhan gay benh dung cac Corticosteroid tai cho de giam ngu'a B V iem da m an tinh - Da i the: T n thu'ong co m au hoi do, x a m h o ac tr ang ( g i o n g voi q u a san bieu m o vay ho ac loan dirdng tang san ng u’di g ia ) - Vi the: Day sung, tang gai, xam nhap viem m an tmh - Dieu trj: Rita hoac boi kern Fluorinated Corticosteroid, tiem diro'i da Triamcinolone C H a m - Vet nut cua da bj ngam cac nep gap gian dui va gian moi a cac benh nhan beo phi - DiSu tri: Tranh am, giam beo, chong ngu'a bang Eurex hoac cac corticosteroid tai cho D Benh vay nen - Dai the: Cac m a n g da du'oc bao phu boi cac vay bac (dau hieu Auspitz) Cac ma ng da co the xuat hien cac vung khac nliau tren co' the o' am ho ton thirong co the bi che lap boi sir am u'ol va co the giong vo'i mot viem da khong dac hieu - Vi the: A sung, mao bieu mo thong noi hinh truy va hinh tlion dai lop bieu m o tren cac nhu mong nhieu mao mach cac nhu chan bi Khong co ap- xe Munro lop thuo'ng bi - Dieu tri: Cac Corticosteroid Fluorinated tai cho nhu Cyclosporine, Methotrexate Trong tnrdng hop phiic tap nen tliam kliao cac bac sy da lieu E Benh n am d a dui • Nliiem trung be mat o' ben va plian tren dm cac nam da thirong ket hop \6'i nam da cac \i tri khac (ngon c h a n \ \ ) • I’on thu'ong da kliu till, bogioi han ro Ngu'a tir n den nhieu - La trirang hap phan tach sdm rau thai sau 20 tuan - Rau bong tai trung tarn, hoac ria, ban phan hoac toan bo - Kham dai the la cuc ky quan trong chain doan rau bong non: Vung xuat huyet lan vao mo rau va thay the no - Vi the co vai tro chain doan rat it - V a xoang ria: Rau bong tai ria, dugc xep vao loai rau bong ban phan - Lam sang: Th u an g ket hap vdi n h i i m doc thai nghen, tang huyet ap, chan thuong Dau hieu: Dau, soc, tir cun g co cung, suy thai hoac chet thai, giam fibrinogen mau, suy than cap IV Rau thai benh ly thai A Nhiem doc thai • Kh dng cd tdn thua ng m d hoc dac trung • Cac tdn thuong thudng gap la mac h mau cd nhoi m au rau thai rong va tu mau sau rau thai • Dai the’: Rau thai nho thudng nhuom mau phan xu • Vi the - Nhoi m au cap hoac man (ngung tap long rau vdi su tac cac khoang lien long rau) - X a vua cap cac tieu dong mac h m a n g dem cua me (hoai tu dang x a mach mau, tap trung dai thuc bao chua md tham nhiem bach cau da n nhan q ua nh m ac h mau) - Tap trung not hop bao cao tai cac vung khong nhdi mau (dau hieu Tennev-Parker hay hinh “ ban c d ' ') 186 B Churng tang nguyen hong cau thai • Rau thai to va phu: ti le thai: rau < 3: • Dai the: Rau thai nang voi mui rau lan, mau xanh xam, hoac xam vang, mun • Vi the: Long rau nd to - Nguyen bao nuoi chua trudng cd lien quan tdi giai doan mang thai: Hop bao day cung tdn tai vdi nguyen bao nuoi - Mo dem long rau phu va qua san: nhieu te bao Hofbauer; giam so luo'ng mach mau: mach mau gian chua hong cau cd nhan (binh thudng hdng cau cd nhan khong gap long rau sau nua ky thai nghen) C Lao • Hiem gap • Dai the: Cd nhung viing nho xam chac tren be mat thai doi cd ba dau (cu lao) • Vi the: Tang sinh te bao noi mac te bao khong Id da nhan true khuan lao D Giang mai • Hiem gap 187 • Dai the: Rau thai lan va nhay ban mui rau Ion mau xanh xam, tran va mun • Vi the: Long rau Ion hinh mu tang sinh x a m d dem giam mach mau thai viem noi mac dong mach mat trudng long rau tung d hoac toan bo Tuy nhien nhurng thay doi khong dac trung cho giang mai va co the thoai trien sau thai chet • Co the gap cac xoan khuan rau thai loai va chung co the xam nhap qua hang rao rau thai tai bat ky thdi diem nao cua qua trinh mang thai E Dai thao duong • Dai the: Rau thai to va phu Nguy co' mot ng ma ch ron tang (3-5%) • Vi the: Khong cd dac diem dac hieu: long rau chua trudng thanh, phu long rau, va tang sinh nguyen bao nuoi V Cac benh viem A Viem mang di va mang dem • Thud ng gap (10% tong so ca de) • Nhiem khuan nguoc dong cd the true tiep tdi duo c cac mang va cd the qua rau thai vao tuan hoan me 188 • Vi khuan thu'ong gap nhat la: Echerichia coli tu cau lien cau lan huyet (3 nhom B • Vi the!: Cac te bao viem tai mang dem va mang di phia dudi B Viem rau thai • Mo long rau bi ton thuong thu phat sau cac mang nuoi bi tdn thuong hoac vi khuain cd the tdi rau thai qua mau me • Vi the: Tham n h i i m te bao viem long rau (viem long rau) • Tru'c khuain Listeria monocytogetv Tao cac vi ap-xe long rau, cac ma ng va cac co' quan cua thai • Toxoplasmia: Tham n h ii m limpho bao vao long rau; vi khuain gap dien cat cac mang • C y t o m e g a l o v i r u s ( C M V ) : Cd ca c the vui tr on g n h a n u'a acid tr on g cac te bao noi m a c , te bao H o f b a u e r , hoac ng u ye n bao nuoi la cac da c d i e m chain d o a n b e n h nhi en hiem cd the xac dinh Hoai tu' m o d e m long rau, tha m nh iem limpho-tu'o'ng bao va vie m m a c h go'i y kha nang nh ie m k h u a n C M V Ti le thai nhi m a c n h i e m k h u a n thai nhi la 0.2% d e n 2 % t ro n g td n g so ca de so ng VI U lanh (u mach mang dem) va cac ton thuong nguyen bao nuoi khong u A U mach mang dem 189 • La tdn thuang lanh tmh thuang gap nhat cua rau thai • U tron, chac, mau sam co vo hoc ki'ch thudc thay doi (< cm), thudng nam rau thai • Vi the: Kieu m ao mach biet hoa ro; noi mac va m o x a vdi cac te bao dem mang dem; mao ma ch chu a mau thai • Lam sang: La n g u y e n nhan hie m g a p c u a rau thai k h d n g hieu qua, k e m the o vdi cac bat th u d n g v i d ic h di va thai nhi, de non B Cac ton thirong nguyen bao nuoi khong phai u • Vi tri rau thai to bat thudng - T h a m n h i i m nguyen bao nuoi trung gian va h a p bao nuoi vao noi mac tu cung va co' tu cung tai vi tri rau bam - Xay chua trung, thai binh thudng hoac say thai - Cd the kho phan biet vo'i u nguyen bao nuoi tai vi tri rau thai (PSTT) - Cac tien trien sinh ly se duoc g ia i quyet tu nhien sau mang thai • Not tai vi tri rau thai - La su ngung tap nho cac nguyen bao nuoi trung gian gap nao thai 190 - Cau tao gom cac vi the cac chat kinh kem theo nguyen bao nuoi trung gian thoai hoa - Co nhung vung nho vi tri rau bam tu nhung lan mang thai trudc - Khong co vai tro tren lam sang VII Benh ac tmh: Benh nguyen bao nuoi thai (GTD) A Phan loai benh nguyen bao nuoi thai • Chua trung - Hoan toan (kinh dien) - Ban phan • Chua trung xam nhap • Ung thu bieu mo rau • U nguyen bao nuoi tai vi tri rau thai (PSTT) B Phan giai doan benh nguyen bao nuoi thai • Giai doan I: G TD khu tru tai than tu cung • Giai doan II: G TD lan rong to'i phan phu va cac cau true sinh due khac • Giai doan III: G T D lan rong tdi phoi kem theo vdi ton thuong dud ng sinh due hoac khong 191 '• Giai doan IV: Di can cac vi tri khac C Chua trung (hoan toan hoac ban phan) • T;'in so: 1/2500 trudng hop thai tai M y 1/125 tai Dai loan • Dai the: La mot khoi nang ktch thudc thay doi (tron dudng kmh cm); cd the cd cac ma nh rau thai binh thudng neu la chira trung ban phan • Vi the - Long rau truong to chua dich be chua trung tarn (cac khoang lom duoc mo trung m d bao quanh) - Mat hoan toan hoac rat it ma ch mau thai - T a n g sinh cac te bao nuoi go m cd: N gu ye n bao nuoi, nguyen bao nuoi trung gian va hop bao nuoi • L am sang: Chay mau am dao, tien san giat trudc 24 tuan mang thai; cuong giap trang tu cung to hon tuoi thai nang hoang the vd HCG tang cao hinh anh sieu am kieu bao tuyet Tien trien khong bien chung 80% cac trudng hop (V4 trudng hop tieii trien chira trung xam laii hiem chuve n ung thu bieu md rau • Dieu tri: Nao hut: cat tir cung neu benh nhan de nhieu 192 D Su khac giua clnia trung toan bo va chua trung ban phan • Chua trung toan bo: Co nguon goc tir bo: kieu nhan XX (96%) va XY (4r/ r ): long rau nude, khong co phoi 18% chuyen dang ac tmh • Chira trung ban phan: Co su gop phan tir ngudi me; kieu nhan: Boi nhiihn sac the bat thudng (thudng gap nhat la tarn boi); long rau nude hdn hop vdi long rau binh thuong; cd phoi, day ron va mang thai: cac mang long rau va nhung dam vui nguyen bao nuoi; 2.1% chuyen dang ac tmh (T Kajii va K O ma ) • Theo ddi: Dinh luong (3HCG hang loat (chira trung toan bo va chira tru'ng ban phan); dieu tri hoa chat ham luo'ng (3HCG hinh cao nguyen hoac gia tang (Methotrexate Actinomycin D) • Chira trung ban phan chiem 25% tdng so trudng hop thai trung E Chua tru'ng xam nhap (u tuyen m a n g de m pha huy) • Thuc te khong the chi dua vao nao thai de chan doan: thuong chan doan thong qua benh phaim cat tir cung • Vi the: Long rau nude xam Ian ldp co' tir cung: sinh san qua muc nguyen bao nuoi • Lam sang: Chay mau khong cam va HCG tang cao sau hut thai trung; u khu tru tai tir cung hiem di can phoi am 193 dao, hoac am ho: chay mau am dao nang hoac chay mau o phuc mac • Di^u tri: D i e u tri hoa c t k e m th e o h o ac k h o n g vdi cat tu c un g • Tien luong tot F Ung thu bieu md rau • U ac tmh tang trudng nguyen bao nuoi khon g duoc kiem soat • 50% cd t i l n sir chira trung trudc do; 30% say thai; 20% thai binh thudng • Dai the: U m l m chay mau • Vi the: Thieu long rau va tang sinh ngu yen bao nuoi trung gian, ngu yen bao nuoi va hop bao nuoi; chay mau: hoai tir • La m sang: Chay mau; HC G cao, di can phoi nao than, gan, ruot non lach va am dao • Dieu tri: Dieu tri hoa chat (A ctinomycin D Methotrexate, Chlorambucil) • Tien lu o n g d be n h n g u y e n ba o nuoi k h o n g di can: G a n n h u c h u a khoi c h u a khoi % 194 100%; b e n h n g u y e n b ao n uo i di ca n • Cac yeu to tien Iirgng xau: Di thang), ham luong HCG trudc didu tri cao ( > 0 mlU/mL) di can nao hoac gan, dac biet trudc di6u tri hoa chat, u nguyen bao nuoi thai sau thdi ky thai G U nguyen hao nuoi tai vi tri rau ham (PSTT) • Duoc Kurman Norris va Scully md ta nam 1976 • La dang hiem gap nhat cua benh nguyen bao nuoi thai • Cd the nham vdi ung thu bieu md rau • Dai the: Mot khoi dang polip buong hoac thudng gap nhat la tu' cung • Vi the - Nguyen bao nuoi trung gian cau tao gom cac dai te bao mot nhan da dien ldn vdi nhan da hinh thai va bao tu'ong bat nhuom kep - Khong cd quan the hai loai te bao nguyen bao nuoi va hop bao nuoi khdng chay mau hoac hoai tu, duon g tmh manh vdi Lactogen rau thai ngu'di - Tien luong xau neu so luong te bao gian phan > MF/HPF (Scully) 195 • Lam sang: Vo kinh hoac chay mau am dao tu cung to bang kfch thuoc thai 8-16 tuan xet nghiem thai duo'ng tmh 1/3 so trudng hop, thu thuat nong va nao (D&C) thudng lam thiing tu cung (5/12 trudng hop), HCG thap • Da p ung kem vdi hoa tri • Tien luong tot vdi cat tir cung (50 trudng hop thi trudng hop chet) • D uoc coi nh u phan ung tai vi tri rau thai cuc ky cao (viem hop bao c o tir cung) ■ VIII Cac u th itp h a t A Di can rau thai tir u cua me • Di can tdi rau thai qua dud ng mau va chi xay d benh nhan cd benh lan toa rong • Theo tan so giam dan la: Ung thu hac to, ung thu vu va ung thu phe quan • Rau thai d benh u hac to ac tinh: U cd the nhin thav duoc la cac not cd mau nau hoac mau den, kich thudc thav ddi md rau thai Vi the cho thay cac dai te bao hac toiiac tinh khoang long rau B I)i can rau thai cua u thai • Hiem gap Tir u nguyen bao than kinh 1% • Rau thai to mau xanh xam nang (1000 g) • Vi the: Nhung dam cac nguyen bao than kinh lam tac cac mach long rau cua thai 197 M UC LU C Tran £ 1-AmhO - NIEU D A O 31 3- AM D A O 35 4-COTUCUNG 47 5- N0I M A C T U C U N G 69 - C O TU C U N G 89 7- VOI TRUNG 99 8- BUONG TRUNG: ] 1] VIEM, C A C TON THUONG K HO NG U, SU BIET H O A G O TINH SINH DUC BAT THUONG VA SUY BUONG TRUNG SOM 9- KHAl QUAT VE KHOI U BUONG TRUNG 125 10- C A C KHOI U BIEU M O BUONG TRUNG 131 11 - C A C U TE BAO MAM BUONG TRUNG 145 12- C A C U OEM SINH DUC BUONG TRUNG 159 13- C A C U BUONG TRUNG KHAC 167 14- U M A C TREO VOI TU C U N G , DAY C H A N G TU 173 C U N G VA PHUC M AC 5- RAU THAI 198 177 NHA XUAT BAN Y HOC LAM SANG PHU KHOA VA GIAI PHAU BENH ■ ■ Chju trach nhiem xuat ban HOANG TRONG QUANG Bien tap: BS VAN CHI SCra ban in: NHOM BIEN D|CH Trinh bay bia: CHU HUNG In 1000 cuon, kho 14,5x20,5 cm tai Xi/dng in Nha xuat ban Y hoc Giay phep xuat ban so: 317 - 1522/XB - QLXB 20/12/2002 In xong va nop li/u chieu quy I nam 2003 [...]... Hiep hoi quoc te ve san phu khoa - Giai doan I: U gidi han d am ho va /hoac day chau dudng kmh Ion nhat < 2 cm: khong di can hach ►Gun iloan hr Ton thuong < 2 cm xam nhap mo dem < 1 mm Giai Joan lb: Ton thuong < 2 cm xam nhap mo dem > I mm - Giai doan II: U gidi han d am ho va/ hoac o d a \ chau: > 2 cm khong di can hach - Giai doan III: I bat ky kich thudc nao nhung co lan rone vao nieu dao duoi am... bieu m o vay xam nhap • Chiem toi 90% cac u ac tinh cua am ho 5% cac u ac tinh cua he sinh due nu' • Benh tlurdng gap d lira tuoi 70 -90: Neu mac cac benh u hat benh xuat hien sd m hon 20 nam (1/ 25.000 d lua tuoi 60- 7