![QU畉N L
Gi畉m g嘆 b畉ng Magie Sulfate
12/3/21 34
Th畛 nghi畛m in vitro
Magie Sulfate (5mmol/L)
[Ca2+]/t畉 bo c董 t畛 cung ng動畛i
Th畛 nghi畛m LS ng畉u
nhi棚n v畛i gi畉 d動畛c
KHNG c坦 t叩c d畛ng k辿o di thai k畛
Ph但n t鱈ch g畛p
i畛u tr畛 = Magie sulfate
PTB trong 48h: RR= 0.85 (95% CI, 0.58 to 1.25)
KHNG nguy c董 sinh non <37w hay <34w
T叩c d畛ng ph畛
畛 b畛ng m畉t au 畉u
Bu畛n n担n N担n
H董i th畛 ng畉n Nh狸n 担i](https://image.slidesharecdn.com/ptb-230521221538-f6729dce/85/PTB-pdf-34-320.jpg)
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PTB.pdf
- 1. CHUY畛N D畉 SINH NON GV: ThS.BS. V探 Th畛 Hu畛 B畛 m担n S畉n ph畛 khoa Khoa Y 畉i h畛c Nguy畛n T畉t Thnh 12/3/21 1
- 2. M畛C TIU Tr狸nh by 動畛c 畛nh ngh挑a sinh non Tr狸nh by 動畛c y畉u t畛 nguy c董 c畛a sinh non Tr狸nh by 動畛c c董 ch畉 b畛nh sinh c畛a chuy畛n d畉 sinh non Ch畉n o叩n 動畛c m畛t tr動畛ng h畛p sinh non Tr狸nh by 動畛c c叩c qu畉n l箪 c董 b畉n cho m畛t tr動畛ng h畛p CD sinh non 12/3/21 2
- 3. T畛NG QUAN ACOG: sinh non chi畉m 10,2% cu畛c sinh/2019 L nguy棚n nh但n ch鱈nh g但y t畛 vong s董 sinh S畛ng k竪m khi畉m khuy畉t: gi畉m th鱈nh gi叩c, th畛 l畛c, b畉i n達o, ch畉m ph叩t tri畛n, b畛nh ph畛i m畉n. H畛 tr畛 sinh s畉n tng, ch畉m d畛t thai k畛 s畛m v狸 ch畛 畛nh s畉n khoa tng tng t畛 l畛 sinh non(1) (1) Ananth CV, et al: Trends in preterm birth and perinatal mortality among singletons: United States, 1989 through 2000. 2005 3
- 4. Tu畛i thai Khi sinh C但n n畉ng C但n n畉ng th畉p khi sinh 12/3/21 4
- 5. 畛NH NGH懲A Chuy畛n d畉 v sinh x畉y ra sau 20 tu畉n v tr動畛c khi tr嘆n 37 tu畉n thai b畉t k畛 c但n n畉ng l炭c sinh(1). Ch畛u t畛 l畛 b畛nh t畉t/ s董 sinh, cu畛c 畛i do c董 quan ch動a tr動畛ng thnh 畛(2) Nguy棚n nh但n, nguy c董 t叩i ph叩t s畉y thai t畛 nhi棚n # 16-19 tu畉n(2) (1) Prediction and Prevention of Spontaneous Preterm Birth, ACOG, 2021. (2) Rethinking the definition of "term pregnancy", 2010, Alan R Fleischman et al (3) ACOG Committee Opinion No. 764: Medically Indicated Late-Preterm and Early-Term Deliveries, 2019 5 ACOG & SMFM(3) Non th叩ng mu畛n 34-36+6 tu畉n 畛 th叩ng s畛m 37-38+6 tu畉n
- 6. B畛NH T畉T V T畛 VONG CHU SINH C董 quan ch動a tr動畛ng thnh H畛i ch畛ng nguy ng畉p h担 h畉p (RDS) Lo畉n s畉n ph畉 qu畉n ph畛i (BPD) Xu畉t huy畉t trong n達o th畉t (IVH) 畛ng 畛ng m畉ch t畛n l動u (PDA) Vi棚m ru畛t ho畉i t畛 (NEC) Nhi畛m tr湛ng huy畉t, B畛nh l箪 v探ng m畉c non th叩ng (ROP) Nguy棚n nh但n g但y sinh non Thai gi畛i h畉n tng tr動畛ng trong t畛 cung Nhi畛m tr湛ng 畛i 畛i v畛 Sa d但y r畛n a thai c坦 bi畉n ch畛ng Thai d畛 t畉t T畛 vong Tu畛i thai, c但n n畉ng khi sinh, s畛 l動畛ng thai, v畛 tr鱈 畛a l箪, kh畉 nng ti畉p c畉n NICU, t狸nh tr畉ng b畛nh l箪 c畛a m畉 v thai g但y PTB 12/3/21 6
- 7. 12/3/21 7
- 8. Y畉U T畛 NGUY C Y畉u t畛 m畉 Nhi畛m tr湛ng ton th但n/ 動畛ng sinh d畛c Lo畉n khu畉n 但m 畉o(1) B畛nh nha chu(2) B畉t th動畛ng b畉m sinh 畛 t畛 cung H炭t thu畛c l叩 M畉 nh畉 c但n/ b辿o ph狸 tr動畛c mang thai(3,4) Ch畛ng t畛c da en (1) Kurki T, et al: Bacterial vaginosis in early pregnancy and pregnancy outcome, 1992 (2) Vergnes JN, Sixou M: Preterm low birthweight and maternal periodontal status: a meta-analysis, 2007 (3) Girsen AI, et al: Womens prepregnancy underweight as a risk factor for preterm birth: a retrospective study, 2016 (4) Cnattingius S, et al: Maternal obesity and risk of preterm delivery, 2013 8
- 9. M畉 動畛c sinh non th叩ng(1) TC th畛 thu畉t 畛 c畛 t畛 cung TC s畉y thai ho畉c sinh non 16 36 tu畉n(2) TC thai l動u/ CDTK khi thai 16 20 tu畉n (畉c bi畛t n畉u c坦 nong c董 h畛c v n畉o)(3,4) (1) Porter TF, et al. The risk of preterm birth across generations, 1997 (2) Laughon SK, et al: The NICHD Consecutive Pregnancies Study: recurrent preterm delivery by subtype, 2014 (3) Getahun D, et al. The association between stillbirth in the frst pregnancy and subsequent adverse perinatal outcomes, 2009 (4) Watson LF, et al. Modelling prior reproductive history to improve prediction of risk for very preterm birth, 2010 9 Y畉U T畛 NGUY C Ti畛n cn
- 10. Thai h畛 tr畛 sinh s畉n(1) Ch畉y m叩u 3 th叩ng 畉u(2) a thai c坦/kh担ng bi畉n ch畛ng Song thai 1 thai ti棚u bi畉n (1) Reddy UM, et al. Infertility, assisted reproductive technology, and adverse pregnancy outcomes: executive summary of a National Institute of Child Health and Human Development workshop. 2007 (2) Weiss JL, et al, Threatened abortion: a risk factor for poor pregnancy outcome, 2004. 10 Y畉U T畛 NGUY C Thai k畛 ny
- 11. NGUYN NHN(1) Chuy畛n d畉 sinh non t畛 nhi棚n v畛i mng 畛i nguy棚n v畉n 40-45% 畛i v畛 non t畛 ph叩t 30-35% Sinh do ch畛 畛nh c畛a m畉 ho畉c thai 30-35% a thai (1): Williams Obstetrics, McGraw-Hill Education, 25th, 2018. 11
- 12. NGUYN NHN CHUY畛N D畉 SINH NON T畛 NHIN 4 nguy棚n nh但n ch鱈nh(1) T畛 cung cng qu叩 m畛c Stress m畉 thai Bi畉n 畛i c畛 t畛 cung/thai non th叩ng Nhi畛m tr湛ng (1) Williams Obstetrics, McGraw-Hill Education, 25th, 2018 12
- 13. T畛 cung cng qu叩 m畛c 12/3/21 13 鐃 Contraction- associated proteins (CAPs) gens Gap-junction proteins connexin 43 oxytocin receptors prostaglandin synthase 鐃 Gastrin- releasing peptides (GRPs) Co c董 t畛 cung D嘆ng th叩c n畛i ti畉t thai b叩nh nhau Tng CRH & estrogen m畉 Ch鱈n m湛i CTC
- 14. ACTH:Adrenocorticotropic Hormone CRH: corticotropin-releasing hormone DHEA-S: dehydroepiandrosterone sulfate 14 Stress m畉 - thai
- 15. R畛i lo畉n ch畛c nng CTC (1) Akgul Y, et al: Hyaluronan in cervical epithelia protects against infectionmediated preterm birth, 2014 (2) Vornhagen J, et al: Perinatal group B streptococcal infections: virulence factors, immunity, and prevention strategies. 2017 15 T叩i c畉u tr炭c CTC s畛m Kh畛i ph叩t chuy畛n d畉 sinh non H畉u h畉t Bi畛u m担 CTC Ng畛a nhi畛m tr湛ng ng動畛c d嘆ng Nguy棚n v畉n B畛 ph叩 v畛 Chu畛t thi畉u glycosaminoglycan hyaluronan(1) Nhi畛m GBS ti畉t hyaluronidase(2) Ph但n c畉t hyaluronic acid 畛 bi畛u m担 CTC- 鐃 Nguy c董 PTB
- 16. Nhi畛m tr湛ng NT h畛 th畛ng 畛 m畉 lan truy畛n qua nhau NT khoang ph炭c m畉c ng動畛c d嘆ng qua v嘆i tr畛ng NT ng動畛c d嘆ng t畛 vi khu畉n 畛 但m 畉o & CTC Tng nguy c董 nhi畛m tr湛ng 畛i, 畛i v畛 s畛m, bi畉n ch畛ng chu sinh MMP: matrix metalloproteinases 16 Nhi畛m vi khu畉n Cytokines IL- 1硫 Prostaglandin/ c董 TC, mng 畛i Protease nh動 MMPs Ch鱈n m湛i CTC T畛nh gi畉c c董 t畛 cung 畛t g達y collagen & s畛i elastin/ ch畉t n畛n ngo畉i bo Mng thai & CTC m畉t ton v畉n
- 17. SINH L B畛NH Qu叩 tr狸nh chu畉n b畛 cho chuy畛n d畉 嘆i h畛i M畛m v ch鱈n m湛i c畛 t畛 cung Ho畉t ho叩 mng r畛ng/ mng 畛i Tng c董n co t畛 cung Con 動畛ng chung v畛i chuy畛n d畉 畛 th叩ng (sinh l箪) v non th叩ng (b畛nh l箪) 12/3/21 17
- 18. SINH L B畛NH Qu叩 tr狸nh b畛nh l箪 t叩c 畛ng kh担ng 畛ng b畛, tu畛 v畛 tr鱈 y畉u t畛 g但y SN t叩c 畛ng ch鱈nh 12/3/21 18 C畛 t畛 cung R畛i lo畉n ch畛c nng c畛 t畛 cung C董 t畛 cung C董n g嘆 t畛 cung/ thai non th叩ng Mng 畛i-nhau 畛i v畛 non tr棚n thai non th叩ng
- 19. CH畉N ON Tri畛u ch畛ng c董 nng C董n g嘆 t畛 cung: hi畉m khi 董n 畛c (h畉u nh動 lu担n c坦 ch鱈n m湛i CTC v ho畉t ho叩 mng r畛ng), 畛 au tr畛 kh叩ng, s畛 xo叩 CTC Tri畛u ch畛ng k竪m: n畉ng b畛ng d動畛i, au l動ng, co th畉t gi畛ng hnh kinh t畛ng c董n, tng ti畉t d畛ch 但m 畉o (n畉ng, dai d畉ng 鐚 CD b狸nh th動畛ng) 12/3/21 19
- 20. CH畉N ON Thm kh叩m X叩c 畛nh l畉i tu畛i thai 叩nh gi叩 ti畉n tri畛n c畛 t畛 cung C畉n l但m sng: si棚u 但m c畛 t畛 cung, fetal fibronectin? : chuy畛n d畉 gi畉 12/3/21 20
- 21. CH畉N ON 12/3/21 21 Qu叩 tr狸nh chu畉n b畛 cho CD Chuy畛n d畉 non th叩ng 50% SP nh畉p vi畛n v狸 CD sinh non sinh 畛 th叩ng X叩c 畛nh SP c坦 c董n g嘆 t畛 cung/thai non th叩ng th畉t s畛 sinh non: KH X叩c 畛nh SP nguy c董 cao PTB ho畉c PTB trong th畛i gian g畉n: KH ? Kh畛i 畉u li畛u ph叩p i畛u tr畛/ chuy畛n d畉 sinh non
- 22. C畉N LM SNG o chi畛u di k棚nh CTC (CL) CL > 30 mm t kh畉 nng PTB/c坦 TCCN Fetal fibronectin (FFN) n畉u CTC < 3cm Ch畛c 畛i 端 叩nh gi叩 tr動畛ng thnh ph畛i/nghi ng畛 tu畛i thai kh担ng ch鱈nh x叩c 端 Nghi ng畛 NT 畛i (Glucose < 20mg/dL, nhu畛m Gram, 畉m t畉 bo, c畉y) 端 Nghi ng畛 d畛 t畉t thai 12/3/21 22
- 23. Fetal fibronectin L Glycoprotein 動畛c t畉o b畛i t畉 bo gan, nguy棚n bo s畛i, t畉 bo n畛i n畛i m畉ch, t畉 bo 畛i thai N畛ng 畛 cao /m叩u m畉 & d畛ch 畛i fFN 50ng/mL positive ACOG: Kh担ng khuy畉n c叩o d湛ng t畉m so叩t PTB cho thai ph畛 kh担ng tri畛u ch畛ng 12/3/21 23
- 24. Gi叩 tr畛 Combine test ( CL v fFN) trong ti棚n l動畛ng nguy c董 sinh non trong 7 ngy 24
- 25. TEST kh叩c PAMG-1 (Placental alpha-microglobulin-1 ) Phosphorylated insulin-like growth factor binding protein-1 (pIGFBP-1) Ch畛 d畉u tng nguy c董 sinh non, Ch動a c坦 th畛 nghi畛m l但m sng ng畉u nhi棚n v l畛n 12/3/21 25
- 26. QU畉N L 叩nh gi叩 nguy棚n nh但n c坦 th畛 c畛a PTB t狸m nh畛ng t狸nh tr畉ng nguy hi畛m s畛c kho畉 m畉 v thai. VD: vi棚m i b畛 th畉n, vi棚m ph畛i, hen, vi棚m ph炭c m畉c, ti畛n s畉n gi畉t, nhau bong non, nhau ti畛n 畉o, nhi畛m tr湛ng 畛i 12/3/21 26
- 27. QU畉N L Ch畛 畛nh gi畉m g嘆 畛 k辿o di th畛i gian CD Chuy畛n vi畛n m畉 畉n BV c坦 h畛i s畛c s董 sinh Kh叩ng sinh d畛 ph嘆ng GBS Glucocorticoid tr動畛c sinh gi畉m RDS, IVH & Magie Sulfat/ PTB tr動畛c 32 tu畉n gi畉m b畉i n達o 12/3/21 27
- 28. QU畉N L D畛 ph嘆ng kh叩ng sinh(1) C畉y ho畉c NAAT d動董ng t鱈nh GBS NAAT 但m t鱈nh GBS + YTNC (thai <37 tu畉n, 畛i v畛 18 ti畉ng, m畉 s畛t 380C) NAAT: nucleic acid amplification test (1): Prevention of Group B Streptococcal Early-Onset Disease in Newborns , ACOG, 2019 28 Kh担ng d畛 畛ng Penicillin Penicillin G 5000UI (TM) + 3000UI (TM) m畛i 4 gi畛 or Ampicillin 2g (TM) + 1g (TM) m畛i 4 gi畛 D畛 畛ng Penicillin Th畉p: Cefazolin 2g (TM) + 1g (TM) m畛i 8 gi畛 Cao: Clindamycin 900 mg (TM) m畛i 8 gi畛 Vancomycin 20mg/kg m畛i 8 gi畛 (max 2g)
- 29. QU畉N L Li畛u ph叩p h畛 tr畛 ph畛i (1) Antenatal corticosteroid therapy for fetal maturation. ACOG. 2017 29 Glucocorticoid Betamethasone 12mg x 2 li畛u/24h Dexamethasone 6mg x 4 li畛u/ 12h t畛ng h畛p Surfactant kh畉 nng gi達n n畛 c畛a ph畛i t鱈nh th畉m thnh m畉ch/ph畛i 叩p 畛ng i畛u tr畛 Surfactant sau sinh tr動畛ng thnh c叩c c董 quan n達o, th畉n, ru畛t RDS, IVH, t畛 vong SS, NEC, PDA, BPD KHUY畉N CO: 24 33+6 tu畉n(1)
- 30. QU畉N L Ng畛a t畛n th動董ng n達o b畉i n達o m畛c 畛 n畉ng & trung b狸nh t畛 l畛 t畛 vong s董 sinh NNT = 端 <32-34 tu畉n: 56 端 <30 tu畉n: 46 Thai 28-32 tu畉n c坦 nguy c董 sinh trong 24h 12/3/21 30 Magnesium sulfate 端4g (bolus t挑nh m畉ch) 端 duy tr狸 1g/gi畛
- 31. QU畉N L Gi畉m g嘆 ATP: adenosine triphosphate cAMP: cyclic adenosine monophosphate; cGMP: cyclic guanosine monophosphate; COX: cyclooxygenase IP: inositol triphosphate PIP: phosphotidylinositol triphosphate. 31
- 32. QU畉N L Ch畛ng ch畛 畛nh gi畉m g嘆 TSG c坦 d畉u hi畛u n畉ng Xu畉t huy畉t 但m 畉o B畛nh l箪 tim m畉ch m畉 Thai 37 tu畉n Thai l動u ho畉c d畛 t畉t b畉m sinh n畉ng Nhi畛m tr湛ng 畛i mng 畛i Thai suy c畉p 12/3/21 32
- 33. QU畉N L Gi畉m g嘆 b畉ng 畛c ch畉 k棚nh Canxi 12/3/21 33 畛c ch畉 k棚nh Canxi so v畛i Gi畉 d動畛c Kh担ng c坦 th畛 nghi畛m LS -mimetics Magie Sulfate 畛c ch畉 COX sinh trong 7 ngy t畛i sinh < 34 tu畉n RDS, IVH, NEC, vng da t t叩c d畛ng ph畛 ng動ng i畛u tr畛 v狸 TD ph畛 T叩c d畛ng ph畛 Nifedipine H畉 huy畉t 叩p au 畉u 畛 b畛ng m畉t Hoa m畉t Hi畉m: nh畛i m叩u c董 tim Kh担ng ph畛i h畛p Beta-mimetics hay Magie Sulfate
- 34. QU畉N L Gi畉m g嘆 b畉ng Magie Sulfate 12/3/21 34 Th畛 nghi畛m in vitro Magie Sulfate (5mmol/L) [Ca2+]/t畉 bo c董 t畛 cung ng動畛i Th畛 nghi畛m LS ng畉u nhi棚n v畛i gi畉 d動畛c KHNG c坦 t叩c d畛ng k辿o di thai k畛 Ph但n t鱈ch g畛p i畛u tr畛 = Magie sulfate PTB trong 48h: RR= 0.85 (95% CI, 0.58 to 1.25) KHNG nguy c董 sinh non <37w hay <34w T叩c d畛ng ph畛 畛 b畛ng m畉t au 畉u Bu畛n n担n N担n H董i th畛 ng畉n Nh狸n 担i
- 35. QU畉N L Gi畉m g嘆 b畉ng 畛c ch畉 COX 35 Arachidonic acid Prostaglandin G2 Cyclooxygenase Cytokines phospholipases Endotoxin Corticosteroid Indomethacin sinh < 37w 鐃 tu畛i thai khi sinh 鐃 c但n n畉ng l炭c sinh T叩c d畛ng ph畛: 端H畉p 畛ng 畛ng m畉ch /thai 端Tng 叩p ph畛i s董 sinh 端Thi畛u 畛i Ch畛ng ch畛 畛nh: 端Thai b畉t th動畛ng th畉n 端Thi畛u 畛i 端B畛nh tim ph畛 thu畛c M 端H畛i ch畛ng TTTS C畉i thi畛n sinh non do a 畛i
- 36. QU畉N L Gi畉m g嘆 b畉ng Beta-mimetics 12/3/21 36 -mimetics Terbutaline Gi畉m nguy c董 sinh trong 48h RR= 0.63 (95% CI, 0.53-0.75) T叩c d畛ng ph畛 m畉: 端au 畉u 端Nh畛p tim nhanh 端Tr畛ng ng畛c 端N畉ng ng畛c 端Run 端Bu畛n n担n & N担n 端Tng Kali m叩u 端Tng 動畛ng huy畉t T叩c d畛ng ph畛 thai 端H畉 動畛ng huy畉t 端H畉 Calci m叩u 端Li畛t ru畛t FDA c畉nh b叩o: KHNG NN s畛 d畛ng Terbutaline 動畛ng ngoi ru畛t/動畛ng mi畛ng trong i畛u tr畛 hay ng畛a chuy畛n d畉 sinh non
- 37. QU畉N L Gi畉m g嘆 b畉ng ATOSIBAN (1) Aravinthan Coom, et al. Oxytocin antagonists for tocolysis in preterm labour -- a systematic review, 2002 (2) https://nursekey.com/drugs-that-affect-uterine-function/ 37 So v畛i gi畉 d動畛c Tng t畛 l畛 kh担ng sinh trong 48 gi畛 RR 1.13 (1.02, 1.26)(1) So v畛i beta-mimetics Tng t畛 l畛 kh担ng sinh trong 48 gi畛 RR 1.07 (0.98, 1.17) T叩c d畛ng ph畛 鱈t h董n(1) T叩c d畛ng ph畛: Ph畉n 畛ng t畉i ch畛 au 畉u & bu畛n n担n tho叩ng qua Tng t畛 vong v b畛nh t畉t 畛 thai < 28 tu畉n(2)
- 38. D畛 PHNG (1) Romero, et al. Vaginal progesterone decreases preterm birth 34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study, 2016 (2) Fonseca EB, et al. Progesterone and the risk of preterm birth among women with a short cervix. FMF Second Trimester Screening Group, 2007 (3) Berghella V, et al. Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data. 2005 38 Ti畛n cn PTB V/ho畉c CTC ng畉n <15-20mm Thai < 24 tu畉n Progesterone ()/ngy Thai 16-36 tu畉n PTB < 34w(1,2) a thai KHNG 畛i t畛 l畛 PTB CTC < 25 mm v Ti畛n cn PTB nguy c董 PTB CTC <15mm kh担ng ti畛n cn PTB ? gi畉m PTB(3) CTC ng畉n v a thai 鐃 nguy c董 PTB(3) Kh但u v嘆ng CTC