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14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23

The Nhan Huynh
The Nhan Huynh

Bi gi畉ng si棚u 但m s畉n ph畛 khoa 2017

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C畉P NH畉T VAI TR C畛A SIU M 2D V SIU M DOPPLER TRONG NH GI THAI CH畉M TNG TR蕩畛NG (IUGR, FGR) Bs. NGUY畛N QUANG TR畛NG website: www.sieuamvietnam.vn, www.cdhanqk.com (L畛p Si棚u 但m SPK, kh坦a 23, HYPNT-MEDIC, 2017) Ng藤畛i ta ch畛 th畉y nh畛ng g狸 ng藤畛i ta 藤畛c chu畉n b畛 畛 th畉y" Ralph Waldo Emerson
畉i c動董ng. Vai tr嘆 c畛a si棚u 但m Doppler. L動u 畛 s畛 d畛ng c叩c th担ng s畛 Doppler trong ch畉n o叩n FGR kh畛i ph叩t s畛m v mu畛n. Ph但n chia giai o畉n FGR v h動畛ng theo d探i, x畛 tr鱈. i畛m nh畉n th畛c hnh. Thai ch畉m tng tr動畛ng ch畛n l畛c (sFGR). Thai 担i thi畉u m叩u-a h畛ng c畉u (TAPS). N畛I DUNG
畉I C蕩NG Andrea DallAsta et al. Early onset fetal growth restriction. Maternal Health, Neonatology, and Perinatology (2017) 3:2 畛nh ngh挑a Thai ch畉m tng tr藤畛ng (IUGR - Intrauterine growth restriction; FGR- Fetal Growth Restriction)?
Theo ACOG (American College of Obstetricians and Gynecologists), thai ch畉m tng tr藤畛ng trong t畛 cung (Intrauterine growth restriction - IUGR) l m畛t trong nh畛ng v畉n 畛 th動畛ng g畉p v ph畛c t畉p nh畉t trong s畉n khoa ngy nay. 動畛c xem l IUGR khi 藤畛c l藤畛ng c但n n畉ng c畛a thai (estimated fetal weight EFW) < 10th percentile (b叩ch ph但n v畛) t動董ng 畛ng v畛i tu畛i thai do b畛nh l箪 (due to pathologic process). Thu畉t ng畛 m畛i: Fetal growth restriction (FGR). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
動畛c xem l Thai nh畛 so v畛i tu畛i (SGA - small-for- gestational-age) khi 藤畛c l藤畛ng c但n n畉ng thai (estimated fetal weight EFW) < 10th percentile t動董ng 畛ng v畛i tu畛i thai m kh担ng c坦 b畛nh l箪 (absence of pathologic process) (do th畛 t畉ng). FGR c坦 b畉t th藤畛ng v畛 ch畛c nng thai-nhau (feto- placental function) v k畉t c畛c chu sinh ngh竪o nn (poorer perinatal outcome), trong khi SGA c坦 ch畛c nng nhau-thai b狸nh th藤畛ng v k畉t c畛c chu sinh g畉n nh藤 b狸nh th藤畛ng (near-normal perinatal outcome). Do v畉y, ngoi si棚u 但m 2D, th狸 si棚u 但m Doppler l kh担ng th畛 thi畉u khi kh畉o s叩t thai nhi. Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
畛 叩nh gi叩 ch鱈nh x叩c tu畛i thai, c畉n ph畉i c坦 s畛 o chi畛u di 畉u m担ng (CRL) khi si棚u 但m thai qu箪 I, th畛i i畛m 11-13+6 tu畉n (sai s畛 +/- 3 ngy). WHO weight percentiles calculator Hadlock FP, et al., In utero analysis of fetal growth: a sonographic weight standard. Radiology. 1991 Oct;181(1):129-33.
L. J. SALOMON et al. Estimation of fetal weight: reference range at 2036 weeks gestation and comparison with actual birth-weight reference range. Ultrasound Obstet Gynecol 2007; 29: 550555
Thai ch畉m tng tr藤畛ng trong t畛 cung 動畛c ph但n chia thnh 2 th畛 畛i x畛ng v kh担ng 畛i x畛ng (Symmetric v Asymmetric IUGR). Th畛 kh担ng 畛i x畛ng (asymmetrical growth pattern): Chu vi v嘆ng b畛ng (AC) ph叩t tri畛n ch畉m h董n 動畛ng k鱈nh l動畛ng 畛nh (BPD) so v畛i tu畛i thai. Suy b叩nh nhau (Placental insufficiency) 動畛c xem l nguy棚n nh但n c畛a th畛 ny. Ng動畛c l畉i, nh畛ng r畛i lo畉i v畛 di truy畛n (genetic disorders), l畛ch b畛i nhi畛m s畉c th畛 (aneuploidy), nhi畛m tr湛ng thai nhi (fetal infections), d畛 t畉t b畉m sinh (congenital malformations) v c叩c h畛i ch畛ng kh叩c l nguy棚n nh但n c畛a th畛 畛i x畛ng (symmetrical growth pattern t畉t c畉 c叩c o 畉c 畛u nh畛 h董n so v畛i tu畛i thai). Susan Raatz Stephenson. Diagnostic Medical Sonography Obstetrics and Gynecology. 3rd edition. 2012 by Lippincott Williams & Wilkins.
Pilliod, Am J Obstet Gynecol. 2012
FGR kh畛i ph叩t s畛m (Early-Onset Fetal Growth Restriction): tr動畛c 32 tu畉n tu畛i, 20-30% s畛 tr動畛ng h畛p FGR. FGR kh畛i ph叩t mu畛n (Late-onset Fetal Growth Restriction): t畛 32 tu畉n tu畛i, 70-80% s畛 tr動畛ng h畛p FGR. Early-onset FGR (1 2%) Late-onset FGR (3 5%) THCH TH畛C: X畛 TR THCH TH畛C: CH畉N ON. B畛nh l箪 b叩nh nhau n畉ng, UA PI b畉t th藤畛ng, th動畛ng k畉t h畛p ti畛n s畉n gi畉t (preeclampsia). B畛nh l箪 b叩nh nhau nh畉, UA PI b狸nh th藤畛ng, 鱈t k畉t h畛p ti畛n s畉n gi畉t (preeclampsia). Thai thi畉u oxy n畉ng (hypoxia ++). Thai thi畉u oxy nh畉 (mild hypoxia). T畛 l畛 t畛 vong cao (high mortality). T畛 l畛 t畛 vong th畉p (low mortality), nh動ng th藤畛ng l nguy棚n nh但n g但y thai ch畉t non (stillbirth). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
Trong s畛 nh畛ng thai EFW < 10th percentile, nh畛ng thai no EFW < 3rd percentile th狸 藤畛c ch畉n o叩n ngay l Thai ch畉m tng tr藤畛ng (FGR), d畛 b叩o s畉 c坦 k畉t c畛c r畉t x畉u, kh担ng c畉n 畉n vai tr嘆 c畛a si棚u 但m Doppler. VAI TR C畛A SIU M DOPPLER Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
畛ng m畉ch t畛 cung 畛ng m畉ch r畛n 畛ng m畉ch n達o gi畛a 畛ng t挑nh m畉ch Eo 畛ng m畉ch ch畛 叩nh gi叩 s畛 nu担i d藤畛ng thai 叩nh gi叩 t狸nh tr畉ng s畛c kh畛e c畛a thai
Tr動畛c 但y ng動畛i ta d湛ng nhi畛u th担ng s畛: RI, PI, S/D ratioC叩c th担ng s畛 ny t畛 l畛 thu畉n v畛i nhau. Ngy nay ng藤畛i ta ch畛 y畉u d湛ng th担ng s畛 PI trong Doppler s畉n khoa. 叩nh gi叩 s畛 nu担i d藤畛ng thai: 畛ng m畉ch t畛 cung (UtA uterine artery). 畛ng m畉ch r畛n (UA umbilical artery). 叩nh gi叩 t狸nh tr畉ng s畛c kh畛e c畛a thai: 畛ng m畉ch n達o gi畛a (MCA middle cerebral artery). T畛 s畛 n達o nhau (CPR - cerebroplacental ratio). Eo 畛ng m畉ch ch畛 (AoI- aortic isthmus). 畛ng t挑nh m畉ch (DV ductus venosus). VAI TR C畛A SIU M DOPPLER Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
PI (pulsatility index ch畛 s畛 畉p) 畛ng m畉ch t畛 cung (UtA PI) c坦 th畛 b畉t th動畛ng trong khi PI 畛ng m畉ch r畛n (UA PI) b狸nh th動畛ng. G畛i l PI 畛ng m畉ch t畛 cung b畉t th藤畛ng khi > b叩ch ph但n v畛 th畛 95 (> 95th percentile). Th担ng th動畛ng ta ph畉i t鱈nh Mean UtA PI (trung b狸nh c畛ng tr畛 s畛 c畛a 畛ng m畉ch t畛 cung ph畉i v tr叩i). 畛NG M畉CH T畛 CUNG (UtA) Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
Trong m畛t nghi棚n c畛u 動畛c b畉o tr畛 b畛i FMF (The Fetal Medicine Foundation). Si棚u 但m qua ng達 但m 畉o 動畛c ti畉n hnh tr棚n 8335 s畉n ph畛 si棚u 但m thai qu箪 II (22-24 tu畉n, trung b狸nh 23 tu畉n), 8202 tr動畛ng h畛p l畉y 動畛c 畛ng m畉ch t畛 cung hai b棚n. 5% s畉n ph畛 c坦 mean UtA PI > 1.63 (> 95th percentile): 69% ti畉n tri畛n thnh Ti畛n s畉n gi畉t (pre-eclampsia) k竪m v畛i Thai ch畉m tng tr動畛ng (FGR), 24% ch畛 xu畉t hi畛n Ti畛n s畉n gi畉t, v 13% ch畛 ti畉n tri畛n Thai ch畉m tng tr動畛ng. 畛 nh畉y c畛a d畉u hi畛u t畛n t畉i khuy畉t ti畛n t但m tr藤董ng hai b棚n (bilateral notches) trong qu箪 II ti棚n o叩n Ti畛n s畉n gi畉t v/ho畉c Thai ch畉m tng tr動畛ng t藤董ng t畛 nh藤 s畛 gia tng c畛a UtA PI. A. T. Papageorghiou et al. Multicenter screening for pre-eclampsia and fetal growth restriction by transvaginal uterine artery Doppler at 23 weeks of gestation. Ultrasound Obstet Gynecol 2001; 18: 441449
Mean Uterine Artery PI b畉t th藤畛ng khi > 95th percentile. O. G坦mez et al. Reference ranges for uterine artery mean pulsatility index at 1141 weeks of gestation. Ultrasound Obstet Gynecol 2008; 32: 128132
畛NG M畉CH R畛N (UA) Trong m畛t kho畉ng th畛i gian di (th畉p ni棚n 80-90), PI 畛ng m畉ch r畛n (UA PI) 動畛c r畛ng r達i ch畉p nh畉n nh動 l ti棚u chu畉n 畛 x叩c 畛nh FGR, nh藤ng nay, n坦 kh担ng c嘆n 藤畛c xem l ti棚u chu畉n duy nh畉t n畛a. Quan i畛m c滴: thai SGA c坦 UA PI b畉t th藤畛ng 藤畛c ch畉n o叩n l FGR, ti棚n o叩n k畉t c畛c ngh竪o nn, c嘆n n畉u UA PI b狸nh th藤畛ng th狸 藤畛c xem l kh担ng c坦 b畛nh l箪 b叩nh nhau (thai SGA 董n thu畉n). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
Tuy nhi棚n, nh畛ng nghi棚n c畛u sau ny ch畛ng minh r畉ng, UA PI ch畛 b畉t th藤畛ng khi c坦 b畛nh l箪 b叩nh nhau n畉ng, 藤a 畉n FGR kh畛i ph叩t s畛m, n坦 b畛 s坦t b畛nh l箪 b叩nh nhau nh畉, che gi畉u nh畛ng tr藤畛ng h畛p FGR kh畛i ph叩t mu畛n. Nh藤 v畉y UA PI kh担ng th畛 s畛 d畛ng nh藤 ti棚u chu畉n duy nh畉t 畛 ph但n bi畛t gi畛a SGA v FGR. D湛 v畉y, gia tng UA PI c坦 gi叩 tr畛 l畛n 畛 ch畉n o叩n FGR, 董n 畛c hay k畉t h畛p v畛i t畛 s畛 CPR. Khi UA m畉t ho畉c 畉o ng藤畛c d嘆ng ch畉y cu畛i t但m tr藤董ng (UAAEDV or UA REDV) thai s畉 c坦 d畛 h畉u r畉t x畉u ho畉c t畛 vong (hi畛n di畛n trung b狸nh 1 tu畉n tr動畛c khi suy thai c畉p x畉y ra). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
C坦 t叩c gi畉 ch畛n v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau, c坦 t叩c gi畉 ch畛n v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, c坦 t叩c gi畉 ch畛n cu畛ng r畛n t畛 do trong khoang 畛i.
C坦 m畛t s畛 kh叩c bi畛t c坦 箪 ngh挑a khi kh畉o s叩t c叩c ch畛 s畛 Doppler t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, t畉i v畛 tr鱈 cu畛ng r畛n t畛 do v t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau6. Tr畛 kh叩ng cao nh畉t t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, v vi畛c thi畉u v畉ng ho畉c 畉o ng動畛c d嘆ng ch畉y cu畛i t但m tr動董ng c坦 th畛 動畛c th畉y tr動畛c nh畉t t畉i v畛 tr鱈 ny. Tr畛 s畛 tham kh畉o cho c叩c ch畛 s畛 Doppler t畉i c叩c v畛 tr鱈 ny 達 動畛c xu畉t b畉n7,8. 畛 董n gi畉n v ki棚n 畛nh, o 畉c c畉n 藤畛c ti畉n hnh t畉i v畛 tr鱈 cu畛ng r畛n t畛 do. Tuy nhi棚n, trong tr動畛ng h畛p a thai, v/ho畉c khi so s叩nh c叩c o 畉c l畉p l畉i, vi畛c kh畉o s叩t Doppler t畉i nh畛ng v畛 tr鱈 c畛 畛nh (cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, cu畛ng r畛n c畉m vo b叩nh nhau ho畉c cu畛ng r畛n t畛 do trong 畛 b畛ng) c坦 th畛 叩ng tin c畉y h董n. C叩c tr畛 s畛 tham kh畉o c畉n ph畉i t藤董ng 畛ng v畛i v畛 tr鱈 kh畉o s叩t. ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239
L藤u 箪: 1. 畛 a thai, kh畉o s叩t 畛ng m畉ch cu畛ng r畛n c坦 th畛 kh坦 v狸 kh坦 x叩c 畛nh cu畛ng r畛n thu畛c v畛 thai no. T畛t h董n h畉t ta kh畉o s叩t Doppler xung t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi. Tuy nhi棚n, tr畛 kh叩ng 畛 但y s畉 cao h董n t畉i v畛 tr鱈 cu畛ng r畛n t畛 do v v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau, v狸 th畉 c畉n 畛i chi畉u v畛i tr畛 s畛 tham kh畉o t動董ng 畛ng. 2. 畛 cu畛ng r畛n c坦 2 m畉ch m叩u, t畉i b畉t k畛 tu畛i thai no, 動畛ng k鱈nh c畛a 畛ng m畉ch r畛n 董n 畛c c滴ng l畛n h董n so v畛i hai 畛ng m畉ch r畛n th担ng th動畛ng, v do v畉y tr畛 kh叩ng s畉 th畉p h董n9 (Ghi ch炭 c畛a ng動畛i d畛ch: tr畛 kh叩ng th畉p h董n c坦 ngh挑a l c叩c ch畛 s畛 RI, PI v S/D ratio 畛u th畉p h董n so v畛i cu畛ng r畛n th担ng th動畛ng c坦 3 m畉ch m叩u). ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239
22 Acharya G et al. Reference ranges for serial measurements of blood velocity and pulsatility index at the intra-abdominal portion, and fetal and placental ends of the umbilical artery. Ultrasound Obstet Gynecol 2005; 26: 162169. Umbilical Artery PI b畉t th藤畛ng khi > 95th percentile. o t畉i v畛 tr鱈 cu畛ng r畛n t畛 do o t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng
23 Acharya G et al. Reference ranges for serial measurements of blood velocity and pulsatility index at the intra-abdominal portion, and fetal and placental ends of the umbilical artery. Ultrasound Obstet Gynecol 2005; 26: 162169. o t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau Umbilical Artery PI b畉t th藤畛ng khi > 95th percentile.
Tu畉n th畛 10 Tu畉n th畛 24 G畉n sinh DOPPLER 畛NG M畉CH CU畛NG R畛N BNH TH働畛NG
Tu畉n 16 Tu畉n 20 Tu畉n 24 Tu畉n 28 Tu畉n 32 Tu畉n 36 Tu畉n 40
Thai 35 tu畉n, S/D = 3,5 Thai 35 tu畉n, S/D = 3,76 B狸nh th動畛ng thai > 34 tu畉n: S/D ratio 3 IUGR
Absent end-diastolic flow SEVERE IUGR
Reversed end-diastolic flow SEVERE IUGR
Thai 28 tu畉n, S/D 4 Thai 28 tu畉n, S/D > 4 Thai 28 tu畉n, Absent end-diastolic flow Thai 28 tu畉n, Reversed end-diastolic flow B狸nh th動畛ng thai 26-30 tu畉n: S/D ratio 4 SEVERE IUGR IUGR
Ngu畛n: Ths. Bs. H T畛 Nguy棚n
i畛u 叩ng l動u 箪 l kh叩c v畛i ng動畛i l畛n, 畛 thai nhi, b狸nh th藤畛ng tr畛 kh叩ng c畛a 畛ng m畉ch n達o gi畛a kh叩 cao. Khi t狸nh tr畉ng thi畉u Oxy n達o m畉n t鱈nh x畉y ra, tu畉n hon n達o s畉 thay 畛i b畉ng c叩ch gi畉m tr畛 kh叩ng 畛 tng d嘆ng ch畉y trong th狸 t但m tr藤董ng. Ta g畛i 坦 l s畛 t叩i ph但n ph畛i tu畉n hon n達o (cerebral blood flow redistribution). MCA PI c坦 gi叩 tr畛 畉c bi畛t cho vi畛c x叩c 畛nh v ti棚n o叩n d畛 h畉u x畉u 畛 thai FGR kh畛i ph叩t mu畛n. MCA PI b畉t th藤畛ng (< 5th percentile) th畉y 畛 25% FGR kh畛i ph叩t mu畛n. 畛NG M畉CH NO GI畛A (MCA) Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
MCA PI b畉t th藤畛ng khi < 5th percentile. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
Ngu畛n: Ths. Bs. H T畛 Nguy棚n
IUGR Thai 28 tu畉n, kh担ng c坦 ph畛 cu畛i t但m tr動董ng 畛 M r畛n T叩i ph但n ph畛i tu畉n hon n達o C.M.Rumack et al. Diagnostic Ultrasound. 3rdEdition. 2005. p1459-1488
B狸nh th動畛ng, RI c滴ng nh動 PI c畛a 畛ng m畉ch n達o gi畛a lu担n cao h董n 畛ng m畉ch r畛n 畛 b畉t k畛 tu畛i thai no. V狸 th畉 CPR = CPI (cerebral PI) / UPI (umbilical PI) > 1 (Cerebro-placental ratio - CPR > 1). - G畛i l t叩i ph但n ph畛i tu畉n hon thai nhi (fetal flow redistribution, brain sparing) khi: CPR 1, ch鱈nh x叩c h董n ta n坦i CPR (t畛 s畛 n達o-nhau) b畉t th藤畛ng khi < 5th percentile. T畛 S畛 GI畛A 畛NG M畉CH NO GI畛A V 畛NG M畉CH R畛N (CPR - cerebroplacental ratio t畛 s畛 n達o nhau). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
T畛 s畛 n達o-nhau (CPR) c坦 畛 nh畉y h董n h畉n so v畛i n畉u ch畛 d湛ng UA v MCA ri棚ng l畉. Trong FGR kh畛i ph叩t mu畛n, UA th藤畛ng b狸nh th藤畛ng trong khi CPR b畉t th藤畛ng. S畛 gia tng tr畛 kh叩ng c畛a b叩nh nhau th動畛ng k畉t h畛p v畛i s畛 gi畉m tr畛 kh叩ng c畛a tu畉n hon n達o, nh動 th畉 c坦 th畛 UA PI v MCA PI c坦 th畛 c嘆n trong gi畛i h畉n b狸nh th藤畛ng trong khi CPR 達 th畛 hi畛n b畉t th藤畛ng. Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296. CPR b畉t th藤畛ng khi < 5th percentile.
Eo 畛ng m畉ch ch畛 ph畉n 叩nh s畛 c但n b畉ng gi畛a tr畛 kh叩ng c畛a n達o v tu畉n hon h畛 th畛ng, n坦 th畛 hi畛n b畉t th藤畛ng tr藤畛c 畛ng t挑nh m畉ch kho畉ng 1 tu畉n. AoI PI b畉t th藤畛ng g畉n li畛n v畛i d畛 h畉u x畉u. G畛i l b畉t th動畛ng khi > b叩ch ph但n v畛 th畛 95 (> 95th percentile). D嘆ng ch畉y 畉o ng動畛c th狸 t但m tr動董ng 畛 eo 畛ng m畉ch ch畛 (retrograde diastole AoI flow) l d畉u hi畛u thai m畉t b湛 n畉ng. EO 畛NG M畉CH CH畛 (AORTIC ISTHMUS)
Alfred Abuhamad et al. A Practical Guide to Fetal Echocardiography - Normal and Abnormal Hearts, 3rd Edition. 2016 Lippincott Williams & Wilkins Eo 畛ng m畉ch ch畛 (aortic isthmus) l o畉n 畛ng m畉ch ch畛 n畉m gi畛a ch畛 xu畉t ph叩t c畛a 畛ng m畉ch d動畛i 嘆n tr叩i v ch畛 畛ng 畛ng m畉ch 畛 vo 畛ng m畉ch ch畛 xu畛ng.
G. Acharya. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. Ultrasound Obstet Gynecol 2009; 33: 628633
Francisco G叩mez et al. Reference Ranges for the Pulsatility Index of the Fetal Aortic Isthmus in Singleton and Twin Pregnancies. Ultrasound Med 2015; 34:577584 | 0278-4297 LLA: longitudinal aortic arch view
Francisco G叩mez et al. Reference Ranges for the Pulsatility Index of the Fetal Aortic Isthmus in Singleton and Twin Pregnancies. Ultrasound Med 2015; 34:577584 | 0278-4297 3VT: three vessel-trachea view
G. Acharya. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. Ultrasound Obstet Gynecol 2009; 33: 628633 Aortic isthmus Ductus Arteriosus
G. Acharya. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. Ultrasound Obstet Gynecol 2009; 33: 628633 LLA: longitudinal aortic arch view 3 VT view
Ph畛 畉o ng動畛c nh畛 th動畛ng th畉y 畛 cu畛i th狸 t但m thu (end-systole) trong qu箪 III. Tuy nhi棚n, h狸nh 畉nh ny th動畛ng kh担ng th畉y tr動畛c 20 tu畉n tu畛i, v th動畛ng 鱈t th畉y 畛 l叩t c畉t 3 m畉ch m叩u-kh鱈 qu畉n (3VT view). Ph畛 畉o ng藤畛c su畛t th狸 t但m tr藤董ng ho畉c th畛i gian c畛a d嘆ng 畉o ng藤畛c > th畛i gian c畛a d嘆ng ch畉y t畛i (total retrograde flow > total antegrade flow) 畛 eo 畛ng m畉ch ch畛 lu担n lu担n l b畉t th藤畛ng. G. Acharya. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. Ultrasound Obstet Gynecol 2009; 33: 628633 (a), ph畛 i畛n h狸nh b狸nh th動畛ng trong qu箪 III, m滴i t棚n ch畛 ph畛 畉o ng動畛c ng畉n 畛 cu畛i t但m thu. (b), m滴i t棚n nh畛 ch畛 ph畛 畛ng t挑nh m畉ch 畛 ph鱈a sau. Ph畛 c畛a eo 畛ng m畉ch ch畛 b畛 畉o ng動畛c 畛 cu畛i t但m thu v ton b畛 th狸 t但m tr動董ng.
PIAF study: Placental insufficiency and aortic isthmus flow Type I: ph畛 d動董ng trong su畛t chu chuy畛n c畛a tim. Type II: kh担ng c坦 d嘆ng ch畉y t但m tr動董ng. Type III: xu畉t hi畛n ph畛 畉o ng動畛c t但m tr動董ng, nh動ng ch畛 y畉u v畉n l ph畛 d動董ng. Type IV (abnormal): th畛i gian c畛a ph畛 d動董ng v ph畛 但m b畉ng nhau. Type V (abnormal): ch畛 y畉u l ph畛 但m.
Francisco G叩mez et al. Reference Ranges for the Pulsatility Index of the Fetal Aortic Isthmus in Singleton and Twin Pregnancies. Ultrasound Med 2015; 34:577584 | 0278-4297 AoI PI b畉t th藤畛ng khi > 95th percentile.
60 cm/s 15 cm/s
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
Ph畛 Doppler 畛ng t挑nh m畉ch bao g畛m 3 pha: -S: t但m thu th畉t, 畛ng th畛i 畛ng TM co b坦p 畛 m叩u qua l畛 b畉u d畛c. -D: t但m tr動董ng th畉t, van 3 l叩 m畛 t畉o 叩p l畛c 但m, h炭t m叩u v畛 tim. -a: nh挑 (P) co b坦p cu畛i t但m tr動董ng t畉o ph畛 畉o ng動畛c. - B狸nh th動畛ng, S # 50-60cm/s, a > 0. - Doppler 畛ng TM b畉t th動畛ng khi: a = 0 ho畉c 但m (n坦i l棚n s畛 ch棚nh l畛ch 叩p su畉t cao 畛 nh挑 (P)). - Qu箪 I: Doppler 畛ng TM b畉t th動畛ng g畉p 畛 thai nhi b畉t th動畛ng NST v d畛 t畉t tim. - Qu箪 II & III: Doppler 畛ng TM b畉t th動畛ng g畉p 畛 thai ch畉m ph叩t tri畛n trong t畛 cung (IUGR) v thai d畛 t畉t tim. T畛 tu畉n 11-14: Doppler 畛ng t挑nh m畉ch b畉t th動畛ng g畉p 畛 5% thai nhi c坦 NST b狸nh th動畛ng, v g畉p 畛 80% thai nhi Trisomy 21. Ph畛 b狸nh th動畛ng v畛i a > 0.
DV l th担ng s畛 Doppler 董n 畛c, m畉nh m畉 nh畉t 畛 ti棚n o叩n thai ch畉t trong FGR kh畛i ph叩t s畛m. C叩c nghi棚n c畛u 達 ch畛ng minh r畉ng, DV b畉t th動畛ng ch畛 khi 畛 giai o畉n n畉ng c畛a thai nhi m畉t b湛. V畉ng ho畉c 畉o ng藤畛c s坦ng a g畉n li畛n v畛i t畛 vong chu sinh (40-100% trong FGR kh畛i ph叩t s畛m). Do 坦 th担ng s畛 ny 藤畛c d湛ng 畛 khuy畉n c叩o ch畉m d畛t thai k畛 vo b畉t k畛 tu畛i thai no sau khi hon thnh li畛u steroids h畛 tr畛 ph畛i. Trong 50% s畛 tr動畛ng h畛p, b畉t th動畛ng DV 畉n tr動畛c khi m畉t dao 畛ng n畛i t畉i tr棚n monitoring s畉n khoa i畛n t畛 (loss of short-term variability (STV) in computerized cardiotocography cCTG) v trong 90% s畛 tr動畛ng h畛p, n坦 畉n tr動畛c b畉t th動畛ng ch畛 s畛 sinh v畉t l箪 (BPP) kho畉ng 48-72 gi畛. Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
DV PI b畉t th動畛ng khi > 95th percentile.
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
Absent A
a: reverse flow IUGR
Ph畛 DV t畉i th畛i i畛m 13 ngy, 7 ngy v 48 gi畛 tr動畛c khi thai ch畉t trong TC, 25 tu畉n tu畛i, c但n n畉ng thai nhi < 500g
Ph畛 DV t畉i th畛i i畛m 16 ngy, 4 ngy v 24 gi畛 tr動畛c khi thai ch畉t trong TC, 23 tu畉n tu畛i, c但n n畉ng thai nhi < 500g
SEVERE IUGR Ph畛 畉o ng動畛c cu畛i t但m tr動董ng 畛 M r畛n T叩i ph但n ph畛i tu畉n hon n達o Ph畛 Doppler 畛 畛ng t挑nh m畉ch b狸nh th動畛ng
Ngu畛n: Ths. Bs. H T畛 Nguy棚n
Thai 28 tu畉n, IUGR T叩i ph但n ph畛i tu畉n hon n達o Kh担ng c坦 ph畛 cu畛i t但m tr動董ng 畛 M r畛n a = 0 畛 畛ng t挑nh m畉ch
THEO DI CC THNG S畛 DOPPLER V MONITORING 畛 FGR KH畛I PHT S畛M B畛nh l箪 b叩nh nhau 畉nh h藤畛ng m畛t ph畉n l畛n b叩nh nhau, v i畛u ny ph畉n 叩nh qua s畛 thay 畛i UA PI trong ph畉n l畛n c叩c tr藤畛ng h畛p. S董 畛 董n gi畉n h坦a qu叩 tr狸nh sinh b畛nh h畛c v s畛 thay 畛i t畛ng b動畛c qua c叩c ch畛 s畛 Doppler. B畉t k畛 t畛c 畛 ti畉n tri畛n, trong tr藤畛ng h畛p kh担ng i k竪m v畛i ti畛n s畉n gi畉t th狸 tr狸nh t畛 ny t藤董ng 畛i h畉ng 畛nh. Tuy nhi棚n, ti畛n s畉n gi畉t n畉ng c坦 th畛 lm thay 畛i di畛n ti畉n t畛 nhi棚n v thai suy c坦 th畛 x畉y ra b畉t c畛 l炭c no.
THEO DI CC THNG S畛 DOPPLER V MONITORING 畛 FGR KH畛I PHT MU畛N B畛nh l箪 b叩nh nhau nh畉, UA PI th藤畛ng b狸nh th藤畛ng. Bi畛u hi畛n c畛a s畛 th鱈ch 畛ng thai nhi, 動畛c ph叩t hi畛n t畛t nh畉t b畉ng CPR. Khi t狸nh tr畉ng thi畉u oxy x畉y ra, d畛 tr畛 c畛a b叩nh nhau ch畛 畛 m畛c t畛i thi畛u v thai suy c坦 th畛 x畉y ra nhanh ch坦ng, 藤a 畉n nguy c董 cao thai suy ho畉c thai ch畉t l藤u sau 37 tu畉n.
Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698 LI: labor Induction, CS: Cesarean Section.
Francesc Figueras et al. An integrated approach to Fetal Growth Restriction. Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 48-58.
Si棚u 但m 2D v SA Doppler l c担ng c畛 ch鱈nh 畛 qu畉n l箪 FGR. M畛c ti棚u th畛 nh畉t l x叩c 畛nh thai nh畛 (small fetus), s畛 d畛ng c但n n畉ng 動畛c o叩n (EFW) v畛i gi叩 tr畛 ng動畛ng l b叩ch ph但n v畛 th畛 10 (ti棚u chu畉n 動畛c s畛 d畛ng r畛ng r達i). M畛c ti棚u th畛 hai l ph但n bi畛t FGR v SGA b畛i v狸 ch炭ng 畉nh h動畛ng kh叩c nhau 畉n kho畉ng th畛i gian theo d探i v th畛i i畛m ch畉m d畛t thai k畛. Khi FGR 動畛c x叩c 畛nh, m畛c ti棚u th畛 ba l x叩c 畛nh kho畉ng th畛i gian theo d探i v th畛i i畛m ch畉m d畛t thai k畛. i畛u ny 畉t 動畛c t畛t nh畉t v畛i m畛t l動u 畛 k畉t h畛p d畛a tr棚n c叩c giai o畉n suy s畛p c畛a thai nhi. I畛M NH畉N TH畛C HNH (PRACTICE POINTS) Francesc Figueras et al. An integrated approach to Fetal Growth Restriction. Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 48-58.
THAI CH畉M TNG TR蕩畛NG CH畛N L畛C (Selective Fetal Growth Restriction - sFGR) Thai ph叩t tri畛n b畉t c但n x畛ng (discordant fetal growth) theo ACOG (the American College of Obstetricians and Gynecologists): kh叩c bi畛t EFW > 20% gi畛a hai thai. EFW discordance = (weight of larger twin weight of smaller twin)100)/weight of larger twin. 畉n th畛i i畛m hi畛n t畉i, bi畛u 畛 ph叩t tri畛n c但n n畉ng c畛a thai 担i d湛ng chung v畛i thai 董n. EFW discordance c畉n ph畉i 動畛c t鱈nh to叩n 畛 m畛i l但n si棚u 但m thai k畛 t畛 qu箪 II c畛a thai k畛. EFW discordance 25% lm gia tng r探 r畛t tai bi畉n chu sinh. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
THAI CH畉M TNG TR蕩畛NG CH畛N L畛C Thai ch畉m tng tr藤畛ng ch畛n l畛c (selective fetal growth restriction sFGR): m畛t trong hai thai c坦 EFW<10th centile v b畉t c但n x畛ng c但n n畉ng gi畛a hai thai (EFW discordance) > 25%. sFGR 畛 thai 担i MC ch畛 y畉u do s畛 ph但n chia kh担ng 畛ng 畛u ngu畛n m叩u nu担i t畛 b叩nh nhau chung. N畉u c畉 hai thai c坦 EFW<10th centile, th狸 動畛c xem l thai nh畛 so v畛i tu畛i (small-for-gestational age - SGA). Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
PHN LO畉I THAI I MC CH畉M TNG TR蕩畛NG CH畛N L畛C Classification of MC twin pregnancy complicated by sFGR Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263. Type 1: EDV c坦 gi叩 tr畛 d動董ng (positive end-diastolic flow) Type 2: EDV = 0 ho畉c 但m (absent or reversed end- diastolic flow - AREDF) Type 3: EDV l炭c d動董ng l炭c 但m (intermittent pattern of AREDF)
PHN LO畉I THAI I MC CH畉M TNG TR蕩畛NG CH畛N L畛C Classification of MC twin pregnancy complicated by sFGR Ph但n lo畉i sFGR 畛 thai 担i MC t湛y thu畛c vo d嘆ng ch畉y cu畛i t但m tr藤董ng (EDV end diastolic velocity) c畛a 畛ng m畉ch r畛n (UA umbilical artery). Type I sFGR: t畉n su畉t s畛ng c嘆n > 90%. Type II sFGR: nguy c董 thai ch畉m tng tr動畛ng ch畉t trong t畛 cung (29%: single intra-uterine death - single IUD) ho畉c sinh r畉t non, tr動畛c 30 tu畉n tu畛i (very preterm delivery) k竪m theo nguy c董 ch畉m ph叩t tri畛n tr鱈 tu畛 (15%) n畉u thai c嘆n l畉i s畛ng s坦t. Type III sFGR: nguy c董 thai ch畉m tng tr動畛ng ch畉t 畛t ng畛t trong t畛 cung (sudden death) (20%), v nguy c董 ch畉m ph叩t tri畛n tr鱈 tu畛 (20%) n畉u thai c嘆n l畉i s畛ng s坦t. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
Thai 担i DC: sFGR 動畛c theo d探i nh動 thai 董n FGR. Doppler thai m畛i 2 tu畉n. Thai 担i MC: sFGR ch動a c坦 nhi畛u ch畛ng c畛, c畉n 動畛c theo d探i Doppler m畛i 1 tu畉n. N畉u Doppler 畛ng m畉ch r畛n b畉t th動畛ng, c畉n ph畉i lm Doppler 畛ng t挑nh m畉ch. N畉u Doppler 畛ng t挑nh m畉ch b畉t th藤畛ng 畛 sFGR tr藤畛c 26 tu畉n tu畛i, c畉n ph畉i h畛y thai sFGR 畛 b畉o v畛 thai c嘆n l畉i. Qu畉n l箪 nh畛ng tr動畛ng h畛p ny l ph畛c t畉p, c畉n 動畛c ti畉n hnh 畛 c叩c trung t但m chuy棚n s但u. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
Khi c坦 1 thai ch畉t trong t畛 cung (single IUD), thai c嘆n l畉i c畉n 藤畛c theo d探i b畉ng si棚u 但m Doppler, 畉c bi畛t l MCA-PSV 畛 nh畉n bi畉t d畉u hi畛u thi畉u m叩u 畛 thai c嘆n l畉i, xem x辿t cho thai ra 畛 th畛i i畛m 34-36 tu畉n sau khi cho m畉 d湛ng steroids. N畉u MCA-PSV 畛 thai c嘆n l畉i th畛 hi畛n b狸nh th藤畛ng trong vi ngy 畉u, s畛 thi畉u m叩u 畛 thai c嘆n l畉i th藤畛ng kh担ng x畉y ra sau 坦. N達o c畛a thai c嘆n s畛ng c畉n 動畛c kh畉o s叩t 4-6 tu畉n sau c叩i ch畉t c畛a m畛t thai 畛 t狸m ki畉m tai bi畉n c坦 th畛 c坦. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
Ch畛 th畉y 畛 thai 担i MCDA v畛i t畉n su畉t 5%. Thai 担i thi畉u m叩u - a h畛ng c畉u (Twin anemia polycythemia sequence - TAPS): Ch畉n o叩n ti畛n s畉n TAPS d畛a vo b畉ng ch畛ng b畉t x畛ng PSV c畛a MCA. TAPS 動畛c tin l do th担ng n畛i 畛ng-t挑nh m畉ch nh畛 (miniscule arteriovenous anastomoses, <1 mm) cho ph辿p truy畛n m叩u ch畉m t畛 thai cho 畉n thai nh畉n, d畉n 畉n s畛 b畉t x畛ng cao v畛 n畛ng 畛 hemglobin gi畛a hai thai. L動u 箪 r畉ng ch畛ng ny c坦 th畛 th畉y 畛 13% tr動畛ng h畛p TTTS sau khi 動畛c i畛u tr畛 b畉ng laser. TWIN ANEMIA-POLYCYTHEMIA SEQUENCE - TAPS THAI I THI畉U MU A H畛NG C畉U Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
Sau sinh, thai cho th畛 hi畛n thi畉u m叩u m畉n t鱈nh, thai nh畉n th畛 hi畛n a h畛ng c畉u. Ch棚nh l畛ch n畛ng 畛 hemoglobin gi畛a hai thai > 8g/dL. Hi畛n di畛n nh畛ng th担ng n畛i r畉t nh畛 (< 1 mm) 畛 b叩nh nhau. Ch畉n o叩n ti畛n s畉n: Thai cho, MCA-PSV > 1.5 MoM (multiples of the median) (thi畉u m叩u) v thai nh畉n, MCA-PSV < 1.0 MoM (a h畛ng c畉u). 畛 h畛i 但m b叩nh nhau kh叩c nhau: b叩nh nhau dy h董n, h畛i 但m dy h董n 畛 thai cho; m畛ng h董n, h畛i 但m k辿m h董n 畛 thai nh畉n. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
donor recipient donor recipient donor recipient donor recipient
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
NH畛NG BI畉N CH畛NG CH畛 TH畉Y 畛 THAI I M畛T MNG 畛M COMPLICATIONS UNIQUE TO MONOCHORIONIC TWIN PREGNANCY Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263. ANTENATALAND POSNATAL STAGING OF TAPS Stage Antenatal Postnatal (Hb diff)(g/dL) I Thai cho MCA-PSV > 1.5 MoM Thai nh畉n MCA-PSV < 1.0 MoM Kh担ng c坦 th棚m d畉u hi畛u kh叩c > 8.0 II Donor > 1.7, recipient < 0.8 Kh担ng c坦 th棚m d畉u hi畛u kh叩c > 11.0 III Stage I or II 畛ng m畉ch r畛n: d嘆ng cu畛i t但m tr動董ng b畉ng 0 ho畉c 但m, TM r畛n 畉p, DV a b畉ng 0 ho畉c 但m > 14.0 IV Ph湛 thai cho > 17.0 V Ch畉t m畛t ho畉c c畉 hai thai > 20.0
P. KLARITSCH et al. Reference ranges for middle cerebral artery peak systolic velocity in monochorionic diamniotic twins: a longitudinal study. Ultrasound Obstet Gynecol 2009; 34: 149154
D畛 h畉u c畛a TAPS r畉t thay 畛i, n畉u n畉ng c坦 th畛 ch畉t m畛t ho畉c c畉 hai thai, n畉u nh畉 c坦 th畛 sinh ra hai tr畉 kh畛e m畉nh. 畛 t畉m so叩t TAPS, MCA-PSV c畉n 藤畛c kh畉o s叩t t畛 tu畉n th畛 20 tr畛 i, l藤u 箪 nh畛ng tr藤畛ng h畛p TTTS 藤畛c i畛u tr畛 laser. MCA-PSV l m畛t th担ng s畛 c畉n c坦 s畛 ch鱈nh x叩c, mu畛n v畉y ta c畉n ph畉i tu但n th畛 guidelines c畛a ISUOG v畛 si棚u 但m Doppler trong s畉n khoa. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
Trong khi g坦c Doppler l y畉u t畛 k畛 thu畉t kh担ng c畉n thi畉t khi o PI, th狸 khi o PSV c畉n ph畉i c坦 g坦c Doppler cng nh畛 cng t畛t, l箪 t藤畛ng l 00, c嘆n kh担ng 藤畛c th狸 ph畉i < 300. Eliza Berkley et al. SMFM Clinical Guideline-Doppler assessment of the fetus with intrauterine growth restriction. American Journal of Obstetrics & Gynecology APRIL 2012. ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239 Thanh i畛u ch畛nh g坦c ph畉i tr湛ng v畛i tr畛c c畛a d嘆ng ch畉y. i畛u ny 畉m b畉o cho vi畛c 叩nh gi叩 v畉n t畛c v d畉ng s坦ng 畉t hi畛u qu畉 t畛t nh畉t. S畛 sai l畛ch nh畛 v畛 v畉n t畛c do g坦c Doppler c坦 th畛 x畉y ra. N畉u g坦c Doppler l 100 th狸 s畛 sai l畛ch v畛 v畉n t畛c l 2%, trong l炭c g坦c Doppler l 200 th狸 s畛 sai l畛ch v畉n t畛c l 6%. Trong tr動畛ng h畛p v畉n t畛c th畉t s畛 l m畛t th担ng s畛 quan tr畛ng v畛 m畉t l但m sng (v鱈 d畛 畛ng m畉ch n達o gi畛a) v n畉u g坦c Doppler > 200 , c畉n ph畉i i畛u ch畛nh 畉u d嘆 sao cho g坦c Doppler nh畛 h董n. N畉u v畉n kh担ng th畛 l畉y 動畛c g坦c Doppler l箪 t動畛ng, th狸 ta c畉n ghi nh畉n v畉n t畛c o 動畛c k竪m theo l tr畛 s畛 g坦c Doppler trong k畉t qu畉 si棚u 但m. D湛ng Doppler mu 畛 nh畉n bi畉t a gi叩c Willis v 畛ng m畉ch n達o gi畛a g畉n 畉u d嘆. C畛a s畛 Doppler 畉t 畛 1/3 g畉n c畛a 畛ng m畉ch n達o gi畛a, g畉n ch畛 xu畉t ph叩t c畛a n坦 t畛 畛ng m畉ch c畉nh trong10 (PSV s畉 gi畉m d畉n khi i xa ch畛 xu畉t ph叩t).
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23
MCA PSV c嘆n 藤畛c d湛ng trong 叩nh gi叩 m畛c 畛 thi畉u m叩u c畛a thai nhi (董n).
TI LI畛U THAM KH畉O Dev Maulik. Doppler Ultrasound in Obstetrics and Gynecology. 2nd Edition. 2005 Peter M. Doubilet et al. Atlas of Ultrasound in Obstetrics and Gynecology. 2003 A. C. Fleischer et al. Sonography in Obstetrics and Gynecology. 6th Edition. 2001 Peter W. Callen et al. Ultrasonography in Obstetrics and Gynecology. 5th Edition. 2008. Saunders Elsevier. Gilles Grang辿 et al. Guide pratique de l'辿chographie obst辿tricale et gyn辿cologique. 2012, Elsevier Masson. Paula J. Woodward et al. Diagnostic Imaging Obstetrics. 1st edition. Amirsys. 2005. Diagnostic Medical Sonography: Obstetrics and Gynecology. 3rd edition. 2012 by Lippincott Williams & Wilkins. A. Pilalis et al. Screening for pre-eclampsia and fetal growth restriction by uterine arteryDoppler and PAPP-A at 1114 weeks gestation. Ultrasound Obstet Gynecol 2007; 29: 135140. C. K. H. YU et al. Prediction of pre-eclampsia by uterine artery Doppler imaging: relationship to gestational age at delivery and small-for-gestational age. Ultrasound Obstet Gynecol 2008; 31: 310313. Aris Antsaklis et al. Uterine Artery Doppler in the Prediction of Preeclampsia and Adverse Pregnancy Outcome. Donald School Journal of Ultrasound in Obstetrics and Gynecology, April-June 2010;4 (2): 117-122. Shivani Singh et al. Role of color doppler in the diagnosis of intra uterine growth restriction (IUGR). Int J Reprod Contracept Obstet Gynecol. 2013 Dec;2(4):566-572. K. MELCHIORRE et al. First-trimester uterine artery Doppler indices in the prediction of small-for-gestational age pregnancy and intrauterine growth restriction. Ultrasound Obstet Gynecol 2009; 33: 524529. Eliza Berkley et al. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol April 2012, Volume 206, Issue 4, Pages 300308. Beth M. Kline-Fath et al. Fundamental and Advanced Fetal Imaging Ultrasound and MRI. 2015 Wolters Kluwer Health. Flood K, Unterscheider J, Daly S, et al. The role of brain sparing in the prediction of adverse outcomes in intrauterine growth restriction: results of the multicenter PORTO Study. Am J Obstet Gynecol 2014;211:288.e1-5. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296. Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage- Based Management Protocol. Fetal Diagn Ther 2014;36:8698 Francesc Figueras et al. An integrated approach to Fetal Growth Restriction. Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 48-58.
14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23

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14. cap nhat vai tro cua sieu am 2 d va sa doppler trong danh gia thai cham tang truong.vsum.11.2017.vsum.medic.k23

  • 1. C畉P NH畉T VAI TR C畛A SIU M 2D V SIU M DOPPLER TRONG NH GI THAI CH畉M TNG TR蕩畛NG (IUGR, FGR) Bs. NGUY畛N QUANG TR畛NG website: www.sieuamvietnam.vn, www.cdhanqk.com (L畛p Si棚u 但m SPK, kh坦a 23, HYPNT-MEDIC, 2017) Ng藤畛i ta ch畛 th畉y nh畛ng g狸 ng藤畛i ta 藤畛c chu畉n b畛 畛 th畉y" Ralph Waldo Emerson
  • 2. 畉i c動董ng. Vai tr嘆 c畛a si棚u 但m Doppler. L動u 畛 s畛 d畛ng c叩c th担ng s畛 Doppler trong ch畉n o叩n FGR kh畛i ph叩t s畛m v mu畛n. Ph但n chia giai o畉n FGR v h動畛ng theo d探i, x畛 tr鱈. i畛m nh畉n th畛c hnh. Thai ch畉m tng tr動畛ng ch畛n l畛c (sFGR). Thai 担i thi畉u m叩u-a h畛ng c畉u (TAPS). N畛I DUNG
  • 3. 畉I C蕩NG Andrea DallAsta et al. Early onset fetal growth restriction. Maternal Health, Neonatology, and Perinatology (2017) 3:2 畛nh ngh挑a Thai ch畉m tng tr藤畛ng (IUGR - Intrauterine growth restriction; FGR- Fetal Growth Restriction)?
  • 4. Theo ACOG (American College of Obstetricians and Gynecologists), thai ch畉m tng tr藤畛ng trong t畛 cung (Intrauterine growth restriction - IUGR) l m畛t trong nh畛ng v畉n 畛 th動畛ng g畉p v ph畛c t畉p nh畉t trong s畉n khoa ngy nay. 動畛c xem l IUGR khi 藤畛c l藤畛ng c但n n畉ng c畛a thai (estimated fetal weight EFW) < 10th percentile (b叩ch ph但n v畛) t動董ng 畛ng v畛i tu畛i thai do b畛nh l箪 (due to pathologic process). Thu畉t ng畛 m畛i: Fetal growth restriction (FGR). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 5. 動畛c xem l Thai nh畛 so v畛i tu畛i (SGA - small-for- gestational-age) khi 藤畛c l藤畛ng c但n n畉ng thai (estimated fetal weight EFW) < 10th percentile t動董ng 畛ng v畛i tu畛i thai m kh担ng c坦 b畛nh l箪 (absence of pathologic process) (do th畛 t畉ng). FGR c坦 b畉t th藤畛ng v畛 ch畛c nng thai-nhau (feto- placental function) v k畉t c畛c chu sinh ngh竪o nn (poorer perinatal outcome), trong khi SGA c坦 ch畛c nng nhau-thai b狸nh th藤畛ng v k畉t c畛c chu sinh g畉n nh藤 b狸nh th藤畛ng (near-normal perinatal outcome). Do v畉y, ngoi si棚u 但m 2D, th狸 si棚u 但m Doppler l kh担ng th畛 thi畉u khi kh畉o s叩t thai nhi. Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 6. 畛 叩nh gi叩 ch鱈nh x叩c tu畛i thai, c畉n ph畉i c坦 s畛 o chi畛u di 畉u m担ng (CRL) khi si棚u 但m thai qu箪 I, th畛i i畛m 11-13+6 tu畉n (sai s畛 +/- 3 ngy). WHO weight percentiles calculator Hadlock FP, et al., In utero analysis of fetal growth: a sonographic weight standard. Radiology. 1991 Oct;181(1):129-33.
  • 7. L. J. SALOMON et al. Estimation of fetal weight: reference range at 2036 weeks gestation and comparison with actual birth-weight reference range. Ultrasound Obstet Gynecol 2007; 29: 550555
  • 8. Thai ch畉m tng tr藤畛ng trong t畛 cung 動畛c ph但n chia thnh 2 th畛 畛i x畛ng v kh担ng 畛i x畛ng (Symmetric v Asymmetric IUGR). Th畛 kh担ng 畛i x畛ng (asymmetrical growth pattern): Chu vi v嘆ng b畛ng (AC) ph叩t tri畛n ch畉m h董n 動畛ng k鱈nh l動畛ng 畛nh (BPD) so v畛i tu畛i thai. Suy b叩nh nhau (Placental insufficiency) 動畛c xem l nguy棚n nh但n c畛a th畛 ny. Ng動畛c l畉i, nh畛ng r畛i lo畉i v畛 di truy畛n (genetic disorders), l畛ch b畛i nhi畛m s畉c th畛 (aneuploidy), nhi畛m tr湛ng thai nhi (fetal infections), d畛 t畉t b畉m sinh (congenital malformations) v c叩c h畛i ch畛ng kh叩c l nguy棚n nh但n c畛a th畛 畛i x畛ng (symmetrical growth pattern t畉t c畉 c叩c o 畉c 畛u nh畛 h董n so v畛i tu畛i thai). Susan Raatz Stephenson. Diagnostic Medical Sonography Obstetrics and Gynecology. 3rd edition. 2012 by Lippincott Williams & Wilkins.
  • 9. Pilliod, Am J Obstet Gynecol. 2012
  • 10. FGR kh畛i ph叩t s畛m (Early-Onset Fetal Growth Restriction): tr動畛c 32 tu畉n tu畛i, 20-30% s畛 tr動畛ng h畛p FGR. FGR kh畛i ph叩t mu畛n (Late-onset Fetal Growth Restriction): t畛 32 tu畉n tu畛i, 70-80% s畛 tr動畛ng h畛p FGR. Early-onset FGR (1 2%) Late-onset FGR (3 5%) THCH TH畛C: X畛 TR THCH TH畛C: CH畉N ON. B畛nh l箪 b叩nh nhau n畉ng, UA PI b畉t th藤畛ng, th動畛ng k畉t h畛p ti畛n s畉n gi畉t (preeclampsia). B畛nh l箪 b叩nh nhau nh畉, UA PI b狸nh th藤畛ng, 鱈t k畉t h畛p ti畛n s畉n gi畉t (preeclampsia). Thai thi畉u oxy n畉ng (hypoxia ++). Thai thi畉u oxy nh畉 (mild hypoxia). T畛 l畛 t畛 vong cao (high mortality). T畛 l畛 t畛 vong th畉p (low mortality), nh動ng th藤畛ng l nguy棚n nh但n g但y thai ch畉t non (stillbirth). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 11. Trong s畛 nh畛ng thai EFW < 10th percentile, nh畛ng thai no EFW < 3rd percentile th狸 藤畛c ch畉n o叩n ngay l Thai ch畉m tng tr藤畛ng (FGR), d畛 b叩o s畉 c坦 k畉t c畛c r畉t x畉u, kh担ng c畉n 畉n vai tr嘆 c畛a si棚u 但m Doppler. VAI TR C畛A SIU M DOPPLER Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 12. 畛ng m畉ch t畛 cung 畛ng m畉ch r畛n 畛ng m畉ch n達o gi畛a 畛ng t挑nh m畉ch Eo 畛ng m畉ch ch畛 叩nh gi叩 s畛 nu担i d藤畛ng thai 叩nh gi叩 t狸nh tr畉ng s畛c kh畛e c畛a thai
  • 13. Tr動畛c 但y ng動畛i ta d湛ng nhi畛u th担ng s畛: RI, PI, S/D ratioC叩c th担ng s畛 ny t畛 l畛 thu畉n v畛i nhau. Ngy nay ng藤畛i ta ch畛 y畉u d湛ng th担ng s畛 PI trong Doppler s畉n khoa. 叩nh gi叩 s畛 nu担i d藤畛ng thai: 畛ng m畉ch t畛 cung (UtA uterine artery). 畛ng m畉ch r畛n (UA umbilical artery). 叩nh gi叩 t狸nh tr畉ng s畛c kh畛e c畛a thai: 畛ng m畉ch n達o gi畛a (MCA middle cerebral artery). T畛 s畛 n達o nhau (CPR - cerebroplacental ratio). Eo 畛ng m畉ch ch畛 (AoI- aortic isthmus). 畛ng t挑nh m畉ch (DV ductus venosus). VAI TR C畛A SIU M DOPPLER Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 14. PI (pulsatility index ch畛 s畛 畉p) 畛ng m畉ch t畛 cung (UtA PI) c坦 th畛 b畉t th動畛ng trong khi PI 畛ng m畉ch r畛n (UA PI) b狸nh th動畛ng. G畛i l PI 畛ng m畉ch t畛 cung b畉t th藤畛ng khi > b叩ch ph但n v畛 th畛 95 (> 95th percentile). Th担ng th動畛ng ta ph畉i t鱈nh Mean UtA PI (trung b狸nh c畛ng tr畛 s畛 c畛a 畛ng m畉ch t畛 cung ph畉i v tr叩i). 畛NG M畉CH T畛 CUNG (UtA) Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 15. Trong m畛t nghi棚n c畛u 動畛c b畉o tr畛 b畛i FMF (The Fetal Medicine Foundation). Si棚u 但m qua ng達 但m 畉o 動畛c ti畉n hnh tr棚n 8335 s畉n ph畛 si棚u 但m thai qu箪 II (22-24 tu畉n, trung b狸nh 23 tu畉n), 8202 tr動畛ng h畛p l畉y 動畛c 畛ng m畉ch t畛 cung hai b棚n. 5% s畉n ph畛 c坦 mean UtA PI > 1.63 (> 95th percentile): 69% ti畉n tri畛n thnh Ti畛n s畉n gi畉t (pre-eclampsia) k竪m v畛i Thai ch畉m tng tr動畛ng (FGR), 24% ch畛 xu畉t hi畛n Ti畛n s畉n gi畉t, v 13% ch畛 ti畉n tri畛n Thai ch畉m tng tr動畛ng. 畛 nh畉y c畛a d畉u hi畛u t畛n t畉i khuy畉t ti畛n t但m tr藤董ng hai b棚n (bilateral notches) trong qu箪 II ti棚n o叩n Ti畛n s畉n gi畉t v/ho畉c Thai ch畉m tng tr動畛ng t藤董ng t畛 nh藤 s畛 gia tng c畛a UtA PI. A. T. Papageorghiou et al. Multicenter screening for pre-eclampsia and fetal growth restriction by transvaginal uterine artery Doppler at 23 weeks of gestation. Ultrasound Obstet Gynecol 2001; 18: 441449
  • 16. Mean Uterine Artery PI b畉t th藤畛ng khi > 95th percentile. O. G坦mez et al. Reference ranges for uterine artery mean pulsatility index at 1141 weeks of gestation. Ultrasound Obstet Gynecol 2008; 32: 128132
  • 17. 畛NG M畉CH R畛N (UA) Trong m畛t kho畉ng th畛i gian di (th畉p ni棚n 80-90), PI 畛ng m畉ch r畛n (UA PI) 動畛c r畛ng r達i ch畉p nh畉n nh動 l ti棚u chu畉n 畛 x叩c 畛nh FGR, nh藤ng nay, n坦 kh担ng c嘆n 藤畛c xem l ti棚u chu畉n duy nh畉t n畛a. Quan i畛m c滴: thai SGA c坦 UA PI b畉t th藤畛ng 藤畛c ch畉n o叩n l FGR, ti棚n o叩n k畉t c畛c ngh竪o nn, c嘆n n畉u UA PI b狸nh th藤畛ng th狸 藤畛c xem l kh担ng c坦 b畛nh l箪 b叩nh nhau (thai SGA 董n thu畉n). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 18. Tuy nhi棚n, nh畛ng nghi棚n c畛u sau ny ch畛ng minh r畉ng, UA PI ch畛 b畉t th藤畛ng khi c坦 b畛nh l箪 b叩nh nhau n畉ng, 藤a 畉n FGR kh畛i ph叩t s畛m, n坦 b畛 s坦t b畛nh l箪 b叩nh nhau nh畉, che gi畉u nh畛ng tr藤畛ng h畛p FGR kh畛i ph叩t mu畛n. Nh藤 v畉y UA PI kh担ng th畛 s畛 d畛ng nh藤 ti棚u chu畉n duy nh畉t 畛 ph但n bi畛t gi畛a SGA v FGR. D湛 v畉y, gia tng UA PI c坦 gi叩 tr畛 l畛n 畛 ch畉n o叩n FGR, 董n 畛c hay k畉t h畛p v畛i t畛 s畛 CPR. Khi UA m畉t ho畉c 畉o ng藤畛c d嘆ng ch畉y cu畛i t但m tr藤董ng (UAAEDV or UA REDV) thai s畉 c坦 d畛 h畉u r畉t x畉u ho畉c t畛 vong (hi畛n di畛n trung b狸nh 1 tu畉n tr動畛c khi suy thai c畉p x畉y ra). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 19. C坦 t叩c gi畉 ch畛n v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau, c坦 t叩c gi畉 ch畛n v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, c坦 t叩c gi畉 ch畛n cu畛ng r畛n t畛 do trong khoang 畛i.
  • 20. C坦 m畛t s畛 kh叩c bi畛t c坦 箪 ngh挑a khi kh畉o s叩t c叩c ch畛 s畛 Doppler t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, t畉i v畛 tr鱈 cu畛ng r畛n t畛 do v t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau6. Tr畛 kh叩ng cao nh畉t t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, v vi畛c thi畉u v畉ng ho畉c 畉o ng動畛c d嘆ng ch畉y cu畛i t但m tr動董ng c坦 th畛 動畛c th畉y tr動畛c nh畉t t畉i v畛 tr鱈 ny. Tr畛 s畛 tham kh畉o cho c叩c ch畛 s畛 Doppler t畉i c叩c v畛 tr鱈 ny 達 動畛c xu畉t b畉n7,8. 畛 董n gi畉n v ki棚n 畛nh, o 畉c c畉n 藤畛c ti畉n hnh t畉i v畛 tr鱈 cu畛ng r畛n t畛 do. Tuy nhi棚n, trong tr動畛ng h畛p a thai, v/ho畉c khi so s叩nh c叩c o 畉c l畉p l畉i, vi畛c kh畉o s叩t Doppler t畉i nh畛ng v畛 tr鱈 c畛 畛nh (cu畛ng r畛n c畉m vo thnh b畛ng thai nhi, cu畛ng r畛n c畉m vo b叩nh nhau ho畉c cu畛ng r畛n t畛 do trong 畛 b畛ng) c坦 th畛 叩ng tin c畉y h董n. C叩c tr畛 s畛 tham kh畉o c畉n ph畉i t藤董ng 畛ng v畛i v畛 tr鱈 kh畉o s叩t. ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239
  • 21. L藤u 箪: 1. 畛 a thai, kh畉o s叩t 畛ng m畉ch cu畛ng r畛n c坦 th畛 kh坦 v狸 kh坦 x叩c 畛nh cu畛ng r畛n thu畛c v畛 thai no. T畛t h董n h畉t ta kh畉o s叩t Doppler xung t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng thai nhi. Tuy nhi棚n, tr畛 kh叩ng 畛 但y s畉 cao h董n t畉i v畛 tr鱈 cu畛ng r畛n t畛 do v v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau, v狸 th畉 c畉n 畛i chi畉u v畛i tr畛 s畛 tham kh畉o t動董ng 畛ng. 2. 畛 cu畛ng r畛n c坦 2 m畉ch m叩u, t畉i b畉t k畛 tu畛i thai no, 動畛ng k鱈nh c畛a 畛ng m畉ch r畛n 董n 畛c c滴ng l畛n h董n so v畛i hai 畛ng m畉ch r畛n th担ng th動畛ng, v do v畉y tr畛 kh叩ng s畉 th畉p h董n9 (Ghi ch炭 c畛a ng動畛i d畛ch: tr畛 kh叩ng th畉p h董n c坦 ngh挑a l c叩c ch畛 s畛 RI, PI v S/D ratio 畛u th畉p h董n so v畛i cu畛ng r畛n th担ng th動畛ng c坦 3 m畉ch m叩u). ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239
  • 22. 22 Acharya G et al. Reference ranges for serial measurements of blood velocity and pulsatility index at the intra-abdominal portion, and fetal and placental ends of the umbilical artery. Ultrasound Obstet Gynecol 2005; 26: 162169. Umbilical Artery PI b畉t th藤畛ng khi > 95th percentile. o t畉i v畛 tr鱈 cu畛ng r畛n t畛 do o t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo thnh b畛ng
  • 23. 23 Acharya G et al. Reference ranges for serial measurements of blood velocity and pulsatility index at the intra-abdominal portion, and fetal and placental ends of the umbilical artery. Ultrasound Obstet Gynecol 2005; 26: 162169. o t畉i v畛 tr鱈 cu畛ng r畛n c畉m vo b叩nh nhau Umbilical Artery PI b畉t th藤畛ng khi > 95th percentile.
  • 24. Tu畉n th畛 10 Tu畉n th畛 24 G畉n sinh DOPPLER 畛NG M畉CH CU畛NG R畛N BNH TH働畛NG
  • 25. Tu畉n 16 Tu畉n 20 Tu畉n 24 Tu畉n 28 Tu畉n 32 Tu畉n 36 Tu畉n 40
  • 26. Thai 35 tu畉n, S/D = 3,5 Thai 35 tu畉n, S/D = 3,76 B狸nh th動畛ng thai > 34 tu畉n: S/D ratio 3 IUGR
  • 29. Thai 28 tu畉n, S/D 4 Thai 28 tu畉n, S/D > 4 Thai 28 tu畉n, Absent end-diastolic flow Thai 28 tu畉n, Reversed end-diastolic flow B狸nh th動畛ng thai 26-30 tu畉n: S/D ratio 4 SEVERE IUGR IUGR
  • 30. Ngu畛n: Ths. Bs. H T畛 Nguy棚n
  • 31. i畛u 叩ng l動u 箪 l kh叩c v畛i ng動畛i l畛n, 畛 thai nhi, b狸nh th藤畛ng tr畛 kh叩ng c畛a 畛ng m畉ch n達o gi畛a kh叩 cao. Khi t狸nh tr畉ng thi畉u Oxy n達o m畉n t鱈nh x畉y ra, tu畉n hon n達o s畉 thay 畛i b畉ng c叩ch gi畉m tr畛 kh叩ng 畛 tng d嘆ng ch畉y trong th狸 t但m tr藤董ng. Ta g畛i 坦 l s畛 t叩i ph但n ph畛i tu畉n hon n達o (cerebral blood flow redistribution). MCA PI c坦 gi叩 tr畛 畉c bi畛t cho vi畛c x叩c 畛nh v ti棚n o叩n d畛 h畉u x畉u 畛 thai FGR kh畛i ph叩t mu畛n. MCA PI b畉t th藤畛ng (< 5th percentile) th畉y 畛 25% FGR kh畛i ph叩t mu畛n. 畛NG M畉CH NO GI畛A (MCA) Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 33. MCA PI b畉t th藤畛ng khi < 5th percentile. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296
  • 35. Ngu畛n: Ths. Bs. H T畛 Nguy棚n
  • 36. IUGR Thai 28 tu畉n, kh担ng c坦 ph畛 cu畛i t但m tr動董ng 畛 M r畛n T叩i ph但n ph畛i tu畉n hon n達o C.M.Rumack et al. Diagnostic Ultrasound. 3rdEdition. 2005. p1459-1488
  • 37. B狸nh th動畛ng, RI c滴ng nh動 PI c畛a 畛ng m畉ch n達o gi畛a lu担n cao h董n 畛ng m畉ch r畛n 畛 b畉t k畛 tu畛i thai no. V狸 th畉 CPR = CPI (cerebral PI) / UPI (umbilical PI) > 1 (Cerebro-placental ratio - CPR > 1). - G畛i l t叩i ph但n ph畛i tu畉n hon thai nhi (fetal flow redistribution, brain sparing) khi: CPR 1, ch鱈nh x叩c h董n ta n坦i CPR (t畛 s畛 n達o-nhau) b畉t th藤畛ng khi < 5th percentile. T畛 S畛 GI畛A 畛NG M畉CH NO GI畛A V 畛NG M畉CH R畛N (CPR - cerebroplacental ratio t畛 s畛 n達o nhau). Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 38. T畛 s畛 n達o-nhau (CPR) c坦 畛 nh畉y h董n h畉n so v畛i n畉u ch畛 d湛ng UA v MCA ri棚ng l畉. Trong FGR kh畛i ph叩t mu畛n, UA th藤畛ng b狸nh th藤畛ng trong khi CPR b畉t th藤畛ng. S畛 gia tng tr畛 kh叩ng c畛a b叩nh nhau th動畛ng k畉t h畛p v畛i s畛 gi畉m tr畛 kh叩ng c畛a tu畉n hon n達o, nh動 th畉 c坦 th畛 UA PI v MCA PI c坦 th畛 c嘆n trong gi畛i h畉n b狸nh th藤畛ng trong khi CPR 達 th畛 hi畛n b畉t th藤畛ng. Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 39. C. Ebbing et al. Middle cerebral artery blood flow velocities and pulsatility index and the cerebroplacental pulsatility ratio: longitudinal reference ranges and terms for serial measurements. Ultrasound Obstet Gynecol 2007; 30: 287296. CPR b畉t th藤畛ng khi < 5th percentile.
  • 40. Eo 畛ng m畉ch ch畛 ph畉n 叩nh s畛 c但n b畉ng gi畛a tr畛 kh叩ng c畛a n達o v tu畉n hon h畛 th畛ng, n坦 th畛 hi畛n b畉t th藤畛ng tr藤畛c 畛ng t挑nh m畉ch kho畉ng 1 tu畉n. AoI PI b畉t th藤畛ng g畉n li畛n v畛i d畛 h畉u x畉u. G畛i l b畉t th動畛ng khi > b叩ch ph但n v畛 th畛 95 (> 95th percentile). D嘆ng ch畉y 畉o ng動畛c th狸 t但m tr動董ng 畛 eo 畛ng m畉ch ch畛 (retrograde diastole AoI flow) l d畉u hi畛u thai m畉t b湛 n畉ng. EO 畛NG M畉CH CH畛 (AORTIC ISTHMUS)
  • 41. Alfred Abuhamad et al. A Practical Guide to Fetal Echocardiography - Normal and Abnormal Hearts, 3rd Edition. 2016 Lippincott Williams & Wilkins Eo 畛ng m畉ch ch畛 (aortic isthmus) l o畉n 畛ng m畉ch ch畛 n畉m gi畛a ch畛 xu畉t ph叩t c畛a 畛ng m畉ch d動畛i 嘆n tr叩i v ch畛 畛ng 畛ng m畉ch 畛 vo 畛ng m畉ch ch畛 xu畛ng.
  • 42. G. Acharya. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. Ultrasound Obstet Gynecol 2009; 33: 628633
  • 43. Francisco G叩mez et al. Reference Ranges for the Pulsatility Index of the Fetal Aortic Isthmus in Singleton and Twin Pregnancies. Ultrasound Med 2015; 34:577584 | 0278-4297 LLA: longitudinal aortic arch view
  • 44. Francisco G叩mez et al. Reference Ranges for the Pulsatility Index of the Fetal Aortic Isthmus in Singleton and Twin Pregnancies. Ultrasound Med 2015; 34:577584 | 0278-4297 3VT: three vessel-trachea view
  • 45. G. Acharya. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. Ultrasound Obstet Gynecol 2009; 33: 628633 Aortic isthmus Ductus Arteriosus
  • 46. G. Acharya. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. Ultrasound Obstet Gynecol 2009; 33: 628633 LLA: longitudinal aortic arch view 3 VT view
  • 47. Ph畛 畉o ng動畛c nh畛 th動畛ng th畉y 畛 cu畛i th狸 t但m thu (end-systole) trong qu箪 III. Tuy nhi棚n, h狸nh 畉nh ny th動畛ng kh担ng th畉y tr動畛c 20 tu畉n tu畛i, v th動畛ng 鱈t th畉y 畛 l叩t c畉t 3 m畉ch m叩u-kh鱈 qu畉n (3VT view). Ph畛 畉o ng藤畛c su畛t th狸 t但m tr藤董ng ho畉c th畛i gian c畛a d嘆ng 畉o ng藤畛c > th畛i gian c畛a d嘆ng ch畉y t畛i (total retrograde flow > total antegrade flow) 畛 eo 畛ng m畉ch ch畛 lu担n lu担n l b畉t th藤畛ng. G. Acharya. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. Ultrasound Obstet Gynecol 2009; 33: 628633 (a), ph畛 i畛n h狸nh b狸nh th動畛ng trong qu箪 III, m滴i t棚n ch畛 ph畛 畉o ng動畛c ng畉n 畛 cu畛i t但m thu. (b), m滴i t棚n nh畛 ch畛 ph畛 畛ng t挑nh m畉ch 畛 ph鱈a sau. Ph畛 c畛a eo 畛ng m畉ch ch畛 b畛 畉o ng動畛c 畛 cu畛i t但m thu v ton b畛 th狸 t但m tr動董ng.
  • 48. PIAF study: Placental insufficiency and aortic isthmus flow Type I: ph畛 d動董ng trong su畛t chu chuy畛n c畛a tim. Type II: kh担ng c坦 d嘆ng ch畉y t但m tr動董ng. Type III: xu畉t hi畛n ph畛 畉o ng動畛c t但m tr動董ng, nh動ng ch畛 y畉u v畉n l ph畛 d動董ng. Type IV (abnormal): th畛i gian c畛a ph畛 d動董ng v ph畛 但m b畉ng nhau. Type V (abnormal): ch畛 y畉u l ph畛 但m.
  • 49. Francisco G叩mez et al. Reference Ranges for the Pulsatility Index of the Fetal Aortic Isthmus in Singleton and Twin Pregnancies. Ultrasound Med 2015; 34:577584 | 0278-4297 AoI PI b畉t th藤畛ng khi > 95th percentile.
  • 58. Ph畛 Doppler 畛ng t挑nh m畉ch bao g畛m 3 pha: -S: t但m thu th畉t, 畛ng th畛i 畛ng TM co b坦p 畛 m叩u qua l畛 b畉u d畛c. -D: t但m tr動董ng th畉t, van 3 l叩 m畛 t畉o 叩p l畛c 但m, h炭t m叩u v畛 tim. -a: nh挑 (P) co b坦p cu畛i t但m tr動董ng t畉o ph畛 畉o ng動畛c. - B狸nh th動畛ng, S # 50-60cm/s, a > 0. - Doppler 畛ng TM b畉t th動畛ng khi: a = 0 ho畉c 但m (n坦i l棚n s畛 ch棚nh l畛ch 叩p su畉t cao 畛 nh挑 (P)). - Qu箪 I: Doppler 畛ng TM b畉t th動畛ng g畉p 畛 thai nhi b畉t th動畛ng NST v d畛 t畉t tim. - Qu箪 II & III: Doppler 畛ng TM b畉t th動畛ng g畉p 畛 thai ch畉m ph叩t tri畛n trong t畛 cung (IUGR) v thai d畛 t畉t tim. T畛 tu畉n 11-14: Doppler 畛ng t挑nh m畉ch b畉t th動畛ng g畉p 畛 5% thai nhi c坦 NST b狸nh th動畛ng, v g畉p 畛 80% thai nhi Trisomy 21. Ph畛 b狸nh th動畛ng v畛i a > 0.
  • 59. DV l th担ng s畛 Doppler 董n 畛c, m畉nh m畉 nh畉t 畛 ti棚n o叩n thai ch畉t trong FGR kh畛i ph叩t s畛m. C叩c nghi棚n c畛u 達 ch畛ng minh r畉ng, DV b畉t th動畛ng ch畛 khi 畛 giai o畉n n畉ng c畛a thai nhi m畉t b湛. V畉ng ho畉c 畉o ng藤畛c s坦ng a g畉n li畛n v畛i t畛 vong chu sinh (40-100% trong FGR kh畛i ph叩t s畛m). Do 坦 th担ng s畛 ny 藤畛c d湛ng 畛 khuy畉n c叩o ch畉m d畛t thai k畛 vo b畉t k畛 tu畛i thai no sau khi hon thnh li畛u steroids h畛 tr畛 ph畛i. Trong 50% s畛 tr動畛ng h畛p, b畉t th動畛ng DV 畉n tr動畛c khi m畉t dao 畛ng n畛i t畉i tr棚n monitoring s畉n khoa i畛n t畛 (loss of short-term variability (STV) in computerized cardiotocography cCTG) v trong 90% s畛 tr動畛ng h畛p, n坦 畉n tr動畛c b畉t th動畛ng ch畛 s畛 sinh v畉t l箪 (BPP) kho畉ng 48-72 gi畛. Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698
  • 60. DV PI b畉t th動畛ng khi > 95th percentile.
  • 64. Ph畛 DV t畉i th畛i i畛m 13 ngy, 7 ngy v 48 gi畛 tr動畛c khi thai ch畉t trong TC, 25 tu畉n tu畛i, c但n n畉ng thai nhi < 500g
  • 65. Ph畛 DV t畉i th畛i i畛m 16 ngy, 4 ngy v 24 gi畛 tr動畛c khi thai ch畉t trong TC, 23 tu畉n tu畛i, c但n n畉ng thai nhi < 500g
  • 66. SEVERE IUGR Ph畛 畉o ng動畛c cu畛i t但m tr動董ng 畛 M r畛n T叩i ph但n ph畛i tu畉n hon n達o Ph畛 Doppler 畛 畛ng t挑nh m畉ch b狸nh th動畛ng
  • 67. Ngu畛n: Ths. Bs. H T畛 Nguy棚n
  • 68. Thai 28 tu畉n, IUGR T叩i ph但n ph畛i tu畉n hon n達o Kh担ng c坦 ph畛 cu畛i t但m tr動董ng 畛 M r畛n a = 0 畛 畛ng t挑nh m畉ch
  • 69. THEO DI CC THNG S畛 DOPPLER V MONITORING 畛 FGR KH畛I PHT S畛M B畛nh l箪 b叩nh nhau 畉nh h藤畛ng m畛t ph畉n l畛n b叩nh nhau, v i畛u ny ph畉n 叩nh qua s畛 thay 畛i UA PI trong ph畉n l畛n c叩c tr藤畛ng h畛p. S董 畛 董n gi畉n h坦a qu叩 tr狸nh sinh b畛nh h畛c v s畛 thay 畛i t畛ng b動畛c qua c叩c ch畛 s畛 Doppler. B畉t k畛 t畛c 畛 ti畉n tri畛n, trong tr藤畛ng h畛p kh担ng i k竪m v畛i ti畛n s畉n gi畉t th狸 tr狸nh t畛 ny t藤董ng 畛i h畉ng 畛nh. Tuy nhi棚n, ti畛n s畉n gi畉t n畉ng c坦 th畛 lm thay 畛i di畛n ti畉n t畛 nhi棚n v thai suy c坦 th畛 x畉y ra b畉t c畛 l炭c no.
  • 70. THEO DI CC THNG S畛 DOPPLER V MONITORING 畛 FGR KH畛I PHT MU畛N B畛nh l箪 b叩nh nhau nh畉, UA PI th藤畛ng b狸nh th藤畛ng. Bi畛u hi畛n c畛a s畛 th鱈ch 畛ng thai nhi, 動畛c ph叩t hi畛n t畛t nh畉t b畉ng CPR. Khi t狸nh tr畉ng thi畉u oxy x畉y ra, d畛 tr畛 c畛a b叩nh nhau ch畛 畛 m畛c t畛i thi畛u v thai suy c坦 th畛 x畉y ra nhanh ch坦ng, 藤a 畉n nguy c董 cao thai suy ho畉c thai ch畉t l藤u sau 37 tu畉n.
  • 71. Francesc Figueras et al. Update on the Diagnosis and Classification of Fetal Growth Restriction and Proposal of a Stage-Based Management Protocol. Fetal Diagn Ther 2014;36:8698 LI: labor Induction, CS: Cesarean Section.
  • 72. Francesc Figueras et al. An integrated approach to Fetal Growth Restriction. Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 48-58.
  • 73. Si棚u 但m 2D v SA Doppler l c担ng c畛 ch鱈nh 畛 qu畉n l箪 FGR. M畛c ti棚u th畛 nh畉t l x叩c 畛nh thai nh畛 (small fetus), s畛 d畛ng c但n n畉ng 動畛c o叩n (EFW) v畛i gi叩 tr畛 ng動畛ng l b叩ch ph但n v畛 th畛 10 (ti棚u chu畉n 動畛c s畛 d畛ng r畛ng r達i). M畛c ti棚u th畛 hai l ph但n bi畛t FGR v SGA b畛i v狸 ch炭ng 畉nh h動畛ng kh叩c nhau 畉n kho畉ng th畛i gian theo d探i v th畛i i畛m ch畉m d畛t thai k畛. Khi FGR 動畛c x叩c 畛nh, m畛c ti棚u th畛 ba l x叩c 畛nh kho畉ng th畛i gian theo d探i v th畛i i畛m ch畉m d畛t thai k畛. i畛u ny 畉t 動畛c t畛t nh畉t v畛i m畛t l動u 畛 k畉t h畛p d畛a tr棚n c叩c giai o畉n suy s畛p c畛a thai nhi. I畛M NH畉N TH畛C HNH (PRACTICE POINTS) Francesc Figueras et al. An integrated approach to Fetal Growth Restriction. Best Practice & Research Clinical Obstetrics and Gynaecology 38 (2017) 48-58.
  • 74. THAI CH畉M TNG TR蕩畛NG CH畛N L畛C (Selective Fetal Growth Restriction - sFGR) Thai ph叩t tri畛n b畉t c但n x畛ng (discordant fetal growth) theo ACOG (the American College of Obstetricians and Gynecologists): kh叩c bi畛t EFW > 20% gi畛a hai thai. EFW discordance = (weight of larger twin weight of smaller twin)100)/weight of larger twin. 畉n th畛i i畛m hi畛n t畉i, bi畛u 畛 ph叩t tri畛n c但n n畉ng c畛a thai 担i d湛ng chung v畛i thai 董n. EFW discordance c畉n ph畉i 動畛c t鱈nh to叩n 畛 m畛i l但n si棚u 但m thai k畛 t畛 qu箪 II c畛a thai k畛. EFW discordance 25% lm gia tng r探 r畛t tai bi畉n chu sinh. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
  • 75. THAI CH畉M TNG TR蕩畛NG CH畛N L畛C Thai ch畉m tng tr藤畛ng ch畛n l畛c (selective fetal growth restriction sFGR): m畛t trong hai thai c坦 EFW<10th centile v b畉t c但n x畛ng c但n n畉ng gi畛a hai thai (EFW discordance) > 25%. sFGR 畛 thai 担i MC ch畛 y畉u do s畛 ph但n chia kh担ng 畛ng 畛u ngu畛n m叩u nu担i t畛 b叩nh nhau chung. N畉u c畉 hai thai c坦 EFW<10th centile, th狸 動畛c xem l thai nh畛 so v畛i tu畛i (small-for-gestational age - SGA). Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
  • 76. PHN LO畉I THAI I MC CH畉M TNG TR蕩畛NG CH畛N L畛C Classification of MC twin pregnancy complicated by sFGR Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263. Type 1: EDV c坦 gi叩 tr畛 d動董ng (positive end-diastolic flow) Type 2: EDV = 0 ho畉c 但m (absent or reversed end- diastolic flow - AREDF) Type 3: EDV l炭c d動董ng l炭c 但m (intermittent pattern of AREDF)
  • 77. PHN LO畉I THAI I MC CH畉M TNG TR蕩畛NG CH畛N L畛C Classification of MC twin pregnancy complicated by sFGR Ph但n lo畉i sFGR 畛 thai 担i MC t湛y thu畛c vo d嘆ng ch畉y cu畛i t但m tr藤董ng (EDV end diastolic velocity) c畛a 畛ng m畉ch r畛n (UA umbilical artery). Type I sFGR: t畉n su畉t s畛ng c嘆n > 90%. Type II sFGR: nguy c董 thai ch畉m tng tr動畛ng ch畉t trong t畛 cung (29%: single intra-uterine death - single IUD) ho畉c sinh r畉t non, tr動畛c 30 tu畉n tu畛i (very preterm delivery) k竪m theo nguy c董 ch畉m ph叩t tri畛n tr鱈 tu畛 (15%) n畉u thai c嘆n l畉i s畛ng s坦t. Type III sFGR: nguy c董 thai ch畉m tng tr動畛ng ch畉t 畛t ng畛t trong t畛 cung (sudden death) (20%), v nguy c董 ch畉m ph叩t tri畛n tr鱈 tu畛 (20%) n畉u thai c嘆n l畉i s畛ng s坦t. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
  • 78. Thai 担i DC: sFGR 動畛c theo d探i nh動 thai 董n FGR. Doppler thai m畛i 2 tu畉n. Thai 担i MC: sFGR ch動a c坦 nhi畛u ch畛ng c畛, c畉n 動畛c theo d探i Doppler m畛i 1 tu畉n. N畉u Doppler 畛ng m畉ch r畛n b畉t th動畛ng, c畉n ph畉i lm Doppler 畛ng t挑nh m畉ch. N畉u Doppler 畛ng t挑nh m畉ch b畉t th藤畛ng 畛 sFGR tr藤畛c 26 tu畉n tu畛i, c畉n ph畉i h畛y thai sFGR 畛 b畉o v畛 thai c嘆n l畉i. Qu畉n l箪 nh畛ng tr動畛ng h畛p ny l ph畛c t畉p, c畉n 動畛c ti畉n hnh 畛 c叩c trung t但m chuy棚n s但u. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
  • 79. Khi c坦 1 thai ch畉t trong t畛 cung (single IUD), thai c嘆n l畉i c畉n 藤畛c theo d探i b畉ng si棚u 但m Doppler, 畉c bi畛t l MCA-PSV 畛 nh畉n bi畉t d畉u hi畛u thi畉u m叩u 畛 thai c嘆n l畉i, xem x辿t cho thai ra 畛 th畛i i畛m 34-36 tu畉n sau khi cho m畉 d湛ng steroids. N畉u MCA-PSV 畛 thai c嘆n l畉i th畛 hi畛n b狸nh th藤畛ng trong vi ngy 畉u, s畛 thi畉u m叩u 畛 thai c嘆n l畉i th藤畛ng kh担ng x畉y ra sau 坦. N達o c畛a thai c嘆n s畛ng c畉n 動畛c kh畉o s叩t 4-6 tu畉n sau c叩i ch畉t c畛a m畛t thai 畛 t狸m ki畉m tai bi畉n c坦 th畛 c坦. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
  • 80. Ch畛 th畉y 畛 thai 担i MCDA v畛i t畉n su畉t 5%. Thai 担i thi畉u m叩u - a h畛ng c畉u (Twin anemia polycythemia sequence - TAPS): Ch畉n o叩n ti畛n s畉n TAPS d畛a vo b畉ng ch畛ng b畉t x畛ng PSV c畛a MCA. TAPS 動畛c tin l do th担ng n畛i 畛ng-t挑nh m畉ch nh畛 (miniscule arteriovenous anastomoses, <1 mm) cho ph辿p truy畛n m叩u ch畉m t畛 thai cho 畉n thai nh畉n, d畉n 畉n s畛 b畉t x畛ng cao v畛 n畛ng 畛 hemglobin gi畛a hai thai. L動u 箪 r畉ng ch畛ng ny c坦 th畛 th畉y 畛 13% tr動畛ng h畛p TTTS sau khi 動畛c i畛u tr畛 b畉ng laser. TWIN ANEMIA-POLYCYTHEMIA SEQUENCE - TAPS THAI I THI畉U MU A H畛NG C畉U Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
  • 81. Sau sinh, thai cho th畛 hi畛n thi畉u m叩u m畉n t鱈nh, thai nh畉n th畛 hi畛n a h畛ng c畉u. Ch棚nh l畛ch n畛ng 畛 hemoglobin gi畛a hai thai > 8g/dL. Hi畛n di畛n nh畛ng th担ng n畛i r畉t nh畛 (< 1 mm) 畛 b叩nh nhau. Ch畉n o叩n ti畛n s畉n: Thai cho, MCA-PSV > 1.5 MoM (multiples of the median) (thi畉u m叩u) v thai nh畉n, MCA-PSV < 1.0 MoM (a h畛ng c畉u). 畛 h畛i 但m b叩nh nhau kh叩c nhau: b叩nh nhau dy h董n, h畛i 但m dy h董n 畛 thai cho; m畛ng h董n, h畛i 但m k辿m h董n 畛 thai nh畉n. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
  • 84. NH畛NG BI畉N CH畛NG CH畛 TH畉Y 畛 THAI I M畛T MNG 畛M COMPLICATIONS UNIQUE TO MONOCHORIONIC TWIN PREGNANCY Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263. ANTENATALAND POSNATAL STAGING OF TAPS Stage Antenatal Postnatal (Hb diff)(g/dL) I Thai cho MCA-PSV > 1.5 MoM Thai nh畉n MCA-PSV < 1.0 MoM Kh担ng c坦 th棚m d畉u hi畛u kh叩c > 8.0 II Donor > 1.7, recipient < 0.8 Kh担ng c坦 th棚m d畉u hi畛u kh叩c > 11.0 III Stage I or II 畛ng m畉ch r畛n: d嘆ng cu畛i t但m tr動董ng b畉ng 0 ho畉c 但m, TM r畛n 畉p, DV a b畉ng 0 ho畉c 但m > 14.0 IV Ph湛 thai cho > 17.0 V Ch畉t m畛t ho畉c c畉 hai thai > 20.0
  • 85. P. KLARITSCH et al. Reference ranges for middle cerebral artery peak systolic velocity in monochorionic diamniotic twins: a longitudinal study. Ultrasound Obstet Gynecol 2009; 34: 149154
  • 86. D畛 h畉u c畛a TAPS r畉t thay 畛i, n畉u n畉ng c坦 th畛 ch畉t m畛t ho畉c c畉 hai thai, n畉u nh畉 c坦 th畛 sinh ra hai tr畉 kh畛e m畉nh. 畛 t畉m so叩t TAPS, MCA-PSV c畉n 藤畛c kh畉o s叩t t畛 tu畉n th畛 20 tr畛 i, l藤u 箪 nh畛ng tr藤畛ng h畛p TTTS 藤畛c i畛u tr畛 laser. MCA-PSV l m畛t th担ng s畛 c畉n c坦 s畛 ch鱈nh x叩c, mu畛n v畉y ta c畉n ph畉i tu但n th畛 guidelines c畛a ISUOG v畛 si棚u 但m Doppler trong s畉n khoa. Khalil A et al. ISUOG Practice Guidelines: role of ultrasound in twin Pregnancy. Ultrasound Obstet Gynecol 2016; 47: 247263.
  • 87. Trong khi g坦c Doppler l y畉u t畛 k畛 thu畉t kh担ng c畉n thi畉t khi o PI, th狸 khi o PSV c畉n ph畉i c坦 g坦c Doppler cng nh畛 cng t畛t, l箪 t藤畛ng l 00, c嘆n kh担ng 藤畛c th狸 ph畉i < 300. Eliza Berkley et al. SMFM Clinical Guideline-Doppler assessment of the fetus with intrauterine growth restriction. American Journal of Obstetrics & Gynecology APRIL 2012. ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol 2013; 41: 233239 Thanh i畛u ch畛nh g坦c ph畉i tr湛ng v畛i tr畛c c畛a d嘆ng ch畉y. i畛u ny 畉m b畉o cho vi畛c 叩nh gi叩 v畉n t畛c v d畉ng s坦ng 畉t hi畛u qu畉 t畛t nh畉t. S畛 sai l畛ch nh畛 v畛 v畉n t畛c do g坦c Doppler c坦 th畛 x畉y ra. N畉u g坦c Doppler l 100 th狸 s畛 sai l畛ch v畛 v畉n t畛c l 2%, trong l炭c g坦c Doppler l 200 th狸 s畛 sai l畛ch v畉n t畛c l 6%. Trong tr動畛ng h畛p v畉n t畛c th畉t s畛 l m畛t th担ng s畛 quan tr畛ng v畛 m畉t l但m sng (v鱈 d畛 畛ng m畉ch n達o gi畛a) v n畉u g坦c Doppler > 200 , c畉n ph畉i i畛u ch畛nh 畉u d嘆 sao cho g坦c Doppler nh畛 h董n. N畉u v畉n kh担ng th畛 l畉y 動畛c g坦c Doppler l箪 t動畛ng, th狸 ta c畉n ghi nh畉n v畉n t畛c o 動畛c k竪m theo l tr畛 s畛 g坦c Doppler trong k畉t qu畉 si棚u 但m. D湛ng Doppler mu 畛 nh畉n bi畉t a gi叩c Willis v 畛ng m畉ch n達o gi畛a g畉n 畉u d嘆. C畛a s畛 Doppler 畉t 畛 1/3 g畉n c畛a 畛ng m畉ch n達o gi畛a, g畉n ch畛 xu畉t ph叩t c畛a n坦 t畛 畛ng m畉ch c畉nh trong10 (PSV s畉 gi畉m d畉n khi i xa ch畛 xu畉t ph叩t).
  • 89. MCA PSV c嘆n 藤畛c d湛ng trong 叩nh gi叩 m畛c 畛 thi畉u m叩u c畛a thai nhi (董n).
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