SIU M CHN ON

THAI NGOI T CUNG

TS. T TH THANH THYBV HNG VNG

M U

LL bbnh l gy ra do thai lnh l gy ra do thai lm tm t nnm ngom ngoi ni niimmc tc t cungcung

TT ll ngngy cy cng tng do tng nng tng do tng no pho ph thai + sthai + sddng dng dng cng c tt cung:cung: 1,61,6 2 % thai k2 % thai k

10% t10% t vong mvong m

NgNgy nay: phy nay: pht hit hin sn sm thai ngom thai ngoi ti t cung cha cung chavv nhnh vvoo Siu m Siu m u d m u d m o vo vi i phn giphn gii caoi cao

nh lnh lngng --hCG / mhCG / muu

M U

Bnh cnh lm sng ca TNTC cng thay i

T l v TNTC ngy cng gim

Tng t l TNTC cha v c chn on sm

gip cho nh lm sng c nhiu

chn la cho iu tr

M U

ccc trung tm c trung tm c trang bc trang b phng ti phng tinn

chchn on on tn tt, TNTC khng cn lt, TNTC khng cn l bbnh l enh l e

dda ma mng sng sng nh trng nh trc y nc y naa

Siu m Siu m u d m u d m o chio chim u thm u th trong chtrong chnn

oon vn v llm gim gim m ng kng k tt ll nni soii soi bbngng

chchn on on TNTCn TNTC

TRIU CHNG LM SNG

Thay i t khng c triu chng n nhng

trng hp chong nng

Tam chng tr kinh au bng ra huyt m

o khng phi lc no cng hin din

Bnh cnh i khi kh phn bit vi sy thai hoc

st nhau sau no thai

Hin tng xut huytkhi thai lm t

TRIU CHNG LM SNG

Khm lm sng: d chn on khi bnh nhn bchong mt mu Khng c gi tr nhng bnh nhn khng ctriu chngMt s t trng hp khm thy khi cnh tcung: khng th phn bit c vi nang c nngca bung trng trong nhng trng hp c thaitrong t cung bnh thng

DU HIU SIU M

A. Thai trong t cung

Siu m u d m o: chn on phn bit kh

chnh xc gia c thai trong t cung bnh thng,

thai trong t cung bt thng v thai ngoi t

cung

Siu m m o c th pht hin ti thai trong t

cung khi c kch thc 2 4 mm, tng ng

vi thai 33 34 ngy (k t ngy kinh cht)

DU HIU SIU M

Nng -hCG/ mu 1000 mU/ml (theo IRP):

thy c ti thai trong lng t cung

Ti thai tht:

nm khng i xng trong lng t cung

c hnh nh ti thai kp (double decidual sac

sign) to bi mng rng thnh (decidua vera) v

mng rng bao (decidua capsularis).

i vi ti thai 5 mm: khng c hnh nh ti

thai kp

Ti thai kp

DU HIU SIU M

Ti thai gi: do hin tng mu trong lng t

cung v phn ng mng rng ca ni mc t

cung

nm chnh gia lng t cung v khng c hnh

nh ti thai kp

Khi c thai trong t cung c xc nh, kh

nng c thai ngoi t cung i km l 1: 6000

(heterotopic pregnancy)

DU HIU SIU M

B. Khi cnh t cung

Hnh nh kinh in: ti thai nm ngoi t cung,c phi thai v hot ng tim thai: chn onchc chn TNTC chim 17 21%

Hnh nh khng in hnh: khng chn on chcchn TNTC:

C hnh nh ging ti thai v phi thai nhngkhng thy hot ng ca tim thai

Hoc ch thy hnh nh ging ti thai v ti nonhong

DU HIU SIU M

Ti thai trng bn cnh t cung thng gp hn

v cn phn bit vi nang hong th

Khi nm cnh t cung v bung trng, cu trc

phn m dy, phn m trng hoc hn hp: cho gi

tr chn on dng tnh 63 100% ty theo kinh

nghim v kh nng ca ngi lm siu m

DU HIU SIU M

Khng tm thy khi cnh t cung: khng th

loi tr TNTC khi nghi ng cn phi theo di

nhiu ln

Dch ti cng hoc dch vng chu: khng phi

du hiu trung thnh ca TNTC (thai trong TC

cng c dch vng chu)

Dch tui cung

DU HIU SIU M

Trong tr Trong trng hng hp khp kh chchn on on vn v

bbnh nhn khng cnh nhn khng c tritriu chu chng lmng lm

ssng: cng: cn kn kt ht hpp --hCG vhCG v siu m siu m

cc thth cho chcho chn on on chn chnh xnh xcc

SIU M DOPPLER

Tng gi tr chn on khi cnh t cung: nu

c hot ng mch mu trong khi u: cho

nhiu kh nng chn on TNTC

Biu sng Doppler: sng tm trng c

khng lc km, tuy nhin nu khng lc tm

trng cao cng khng loi tr thai

SIU M DOPPLER

Hot ng mch mu trong khi thai ngoi tcung cn gip tin lng iu tr bo tn

i vi nhng nh siu m c kinh nghim:ch cn siu m trng en cng chnon TNTC

SIU M DOPPLER

XT NGHIM SINH HA

chnh xc ca siu m chn on c

cng c nh vo xt nghim nh lng -hCG/

mu

Ch : c 2 h thng n v nh lng quc t

chnh:

1. First International Reference Preparation (IRP)

2. Second International Standard (SIS)

2 n v IRP = 1 n v SIS

XT NGHIM SINH HA

nh lng progesterone trong mu khng

gip ch nhiu trong vic chn on phn bit

gia TNTC v thai trong t cung bt thng

Nng -hCG / mu trong nhng trng hp

thai ngoi t cung rt a dng: c th thay i

t 14 mU/ml n 100.000 mU/ml

XT NGHIM SINH HA

ng dng -hCG trong chn on phn bit

TNTC v thai trong TC da vo thi gian bn

hy ca -hCG:

Nu < 1,4 ngy: kh nng sy thai (+++)

Nu > 7 ngy: kh nng TNTC (+++)

-hCG tng dn v khng thy thai trong t

cung: cnh gic TNTC

XT NGHIM SINH HA

-hCG c dng trong theo di v

tin lng thai ngoi t cung cha v:

nu nng -hCG gim dn: khng

cn can thip iu tr

VAI TR CVAI TR CAA --hCG VhCG V PROGESTERONEPROGESTERONE

S bin thin ca -hCG hu ch hn l mt hm

lng c nh: thay i rt nhanh theo thi gian

dng theo di TNTC

Progesterone khng bin thin nhanh nh -

hCG nn khng s dng theo di chn on

TNTC

BIN THIN CA -hCG

Thay i -hCG > 66% sau 48 gi: tiu chun

chn on thai trong TC. Th d:

Gi 0: -hCG 1.000 U/L

Gi 48: -hCG 1.660 U/L

Nh vy: t l tng -hCG sau 48 gi l 1,66

chn on thai trong TC vi

nhy 86%

chuyn bit 94 %

PHC CHN ON

NghiNghiGEUGEU

SA/SA/ADAD

--hCGhCG

LLppllii

--hCGhCG

Tng< 0,87

Tng1,66

Tng< 1,66

LLppllii

SA/SA/AA

Xc

nh

GIU

XcnhGEU

Lp li--hCGhCG

nu tng> 0,87

Thaithoitrin

Gi 0 Gi 48 Ngy 7

+GIU

CnhgicGEU

Theo di mi 48 gi

CC DNG KHC CATHAI NGOI T CUNG

Thai vi trng

Thai sng t cung (thai gc # thai on k)

Thai c t cung

Thai bng

TNTC mn: huyt t thnh nang

Thai bm vt m c

Thai sng TC

HTTN

Nhn x gc tri t cungv thai trong t cung

Chn on phn bitnh vo Doppler :-khng lc cao-dng chy thp

THAI BM VT M C

Mt dng khc ca thai ngoi t cung: thai

ngoi t cung so m ly thai (thai bm

VMC)

Lu : thai bm VMC khng phi thai c

t cung

Thai bm vt m c (thai VMC)

l mt dng him gp ca thai lc ch

do thai lm t ti m x so ca vt m ly thai c

T bo nui xm ln c t cung nh nhng trnghp nhau ci rng lc:

c nguy c cao gy bng huyt

v t cung

thm ch e da mng sng ngi ph n

THAI BM VT M C

Thi im pht hin thai bm VMC: 5 n 16 tun

tui thai ty trng hp

Khong cch t ln m sanh trc n khi c thai

bm VMC: 6 thng n 12 nm.

Chn on lm sng ca thai bm VMC trong giai

on sm thng rt kh khn

chn on b tr hon n khi v t cung hay

bnh nhn b xut huyt t nguy him tnh mng

THAI BM VT M C

Chn on: cn da trn tin s m ly thai v

nhng biu hin lm sng ca bnh nhn.

Biu hin lm sng c th l xut huyt m o bt

thng (t rt t n rt nhiu e da mng sng),

hoc au bng.

Yu t chn on quyt nh l siu m trng en 2

chiu v Doppler

THAI BM VT M C

Hnh nh siu m trng en

Siu m qua ng m o:

on di t cung phnh ln hn v c hin din

ca khi phn m hn hp hoc i khi thy r

hnh nh ti thai bm vo.

Phn c t cung on di rt mng dng

nh sp nt hoc v vo bng quang.

Tiu chun chn on thng gp:

Bung t cung trng

Knh c t cung trng

Ti thai nm thnh trc on eo t cung

trong khe h ca so c

to nn hnh nh t on ca c t cungthnh trc trn mt ct dc gia

Hnh nh ny gip chn on phn bit gia thaibm VMC vi thai on eo hoc thai c TC

Hnh nh siu m trng en

C dng chy quanh lp t bo nui (nhau thaitng lai).

Dng chy c khng lc thp v vn tc cao

vn tc nh c th t > 20 cm/s

S/D # 3

RI # 0,5

Du hiu ny gip chn on phn bit gia 1thai bm VMC sng vi 1 thai trong t cung cht.

Siu m Doppler

Thai bm VMC: siu m trng en 2 chiu + Doppler

Lu : du hiu trt (sliding organ sign)

Th hin: ti thai khng trt ra khi v tr ca n

so vi mc gii hn ca c trong TC

Cch lm: dng lc n nh u d m o kt

hp vi n y TC.

ng tc ny khng cn thit v i khi nguy

him v c th to 1 p lc ln ti thai (hoc khi

t mu) lm cho n b v ra

Phng tin chn on khc

Siu m 3-4 chiu kt hp vi siu m 3D power

Doppler

MRI cho chn on rt d dng, tuy nhin khng

nn s dng MRI lm cng c chn on thng

quy

Soi bng quang chn on kh nng xm nhp

bng quang ca thai bm VMC vi hnh nh c

hi

Khi mu t do thai VMC

Thai c nhau bm VMC