mỤc lỤc - panah.vnpanah.vn/documents/tailieugoc24042013.pdf · i mỤc lỤc tỔng quan..... 1...

i

MC LC

TNG QUAN ....................................................................................................... 1

C NHN HA NH GI NGUY C GY XNG PH N SAU MN KINH: TIN B V

THCH THC ............................................................................................................................................... 2

Nguyn Vn Tun

SN ....................................................................................................................... 4

QUARITE (CHT LNG CHM SC, QUN L YU T NGUY C V K THUT SN KHOA):

TH NGHIM LM SNG NGU NHIN TRN TNG NHM NH V CC CAN THIP TRN

NHIU PHNG DIN GIM T L T VONG M SENEGAL V MALI .................................. 5

Alexandre Dumon, Pierre Fournier, Michal Abrahamowicz, Mamadou Traor, Slim Haddad,

William D. Fraser

QUN L I THO NG THAI K V QUYT NH THI IM SANH .................................. 7

GC Di Renzo

CHN ON I V NON .......................................................................................................................... 14

G C Di Renzo, MD, PhD, FRCOG (hon) FACOG (hon)

NHN MT TRNG HP C THAI LI SAU IU TR BO TN TRONG NHAU CI RNG

LC ........................................................................................................................................................... 16

L Th Thu H, in c Thin Minh

CHN ON TRC SINH CHN ON HNH NH .......................... 17

QUAN IM HIN NAY V TM SOT SM TIN SN GIT .......................................................... 18

Walfrido W. Sumpaico

GI TR QF-PCR TRONG CHN ON NHANH TRC SINH RI LON NHIM SC TH ........ 19

Nguyn Khc Hn Hoan, Phng Nh Ton, Quch Th Hong Oanh, Trn Nguyn An Ph, Nguyn Th Nh Hong

TNG KT 5017 TRNG HP THC HIN K THUT NUI CY T BO I IN-SITU LM

NHIM SC TH TRONG CHN ON TRC SINH TI BNH VIN HNG VNG..........21

Nguyn Vn Thng, Nguyn Th Thanh Trc, ng L Dung Nghi, Phm Th Vn Anh, Bi Hong

Thanh Long, Nguyn Vn Trng

D TT TIM TRONG THAI K TI BNH VIN T D ....................................................................... 23

Bi Th Thu H, Ng Th Yn, Bi Thanh Vn

X TR CC TNH HUNG KH TRONG A THAI .............................................................................. 24

Tony Tan

D TT H THN KINH TRUNG NG: T SIU M N CNG HNG T .............................. 27

Nguyn Th Thu Trang, H T Nguyn

M HNH SNG LC TRC SINH: HNH THP O NGC ........................................................ 28

H T Nguyn

PH KHOA ........................................................................................................ 29

VAI TR SIU M TRONG CHN ON THAI BM SO M LY THAI C ................................. 30

H T Nguyn

CP NHT IU TR THAI NGOI T CUNG SO M LY THAI .............................................. 31

Phan Vn Quyn

ii

SIU M DOPPLER MU CHN ON AU VNG BNG DI MN TNH PH N DO

BNH L TNH MCH .............................................................................................................................. 34

Nguyn Hoi Thu

UNG TH PH KHOA .................................................................................... 35

X TR CC KHI BU T BO MM C TNH THNG GP V HIM GP CA BUNG

TRNG ......................................................................................................................................................... 36

TAY, Eng-Hseon

UNG TH M O: DCH T- CHN ON - IU TR ..................................................................... 37

Lu Vn Minh

SONG THAI VI MT THAI TRNG TON PHN V MT THAI SNG: BO CO HAI TRNG

HP V TNG QUAN Y VN .................................................................................................................. 38

L Quang Thanh, L T Phng Chi, Trnh Tin t, H T Nguyn

NI SOI SN CHU ...................................................................................... 39

DNH TRONG PHU THUT PH KHOA ............................................................................................... 40

D.K.TRAN

BIN CHNG NNG CA PHU THUT NI SOI ............................................................................... 41

Nguyn B M Nhi

HIU QU T VNG NNG (PESSARY) IU TR SA TNG CHU N TI BNH VIN T D:

C IM V CC YU T THNH CNG ......................................................................................... 42

Nguyn Th Vnh Thnh

H TR SINH SN .......................................................................................... 44

BO TN CHC NNG SINH SN N HNG DN THC HNH .................................................. 45

S. Samuel Kim

TR NG TRNG: T KHOA HC N THC HNH ..................................................................... 46

S. Samuel Kim

NGHIN CU CC YU T NH HNG N KT QU C THAI KHI S DNG PHC

GnRH ANTAGONIST TRONG TH TINH NG NGHIM TI BNH VIN PH SN TRUNG NG

...................................................................................................................................................................... 48

Phm Thy Nga, L Hong

NUI CY PHI NANG TRONG TH TINH TRONG NG NGHIM: Y HC THC CHNG ......... 49

H Mnh Tng CGRH & IVFAS

NH GI KT QU NUI CY PHI V CHUYN PHI NGY 5 ................................................. 52

V nh Tun, Hong Th Bch Tuyn, L Thi Lc

TO HNH THM M ..................................................................................... 53

CHN LA TI NGC TRONG PHU THUT NNG NGC BNG TI ........................................ 54

L Hnh

MT S NHN XT V CT DA, M BNG TRN NGI BO PH ............................................... 55

Nguyn Anh Tun v CS

NHN MT S TRNG HP THU NH NGC THEO NG M T O NGC .................... 56

Nguyn Anh Tun v CS.

THM M CM BNG PHU THUT CHNH HNH ........................................................................... 57

L Tn Hng

iii

LO HA DA V IU TR ...................................................................................................................... 58

Vn Th Trung

S SINH ............................................................................................................. 59

PHT HIN SM TN TT TR NON THNG, D B TN THNG KINH NGHIM THC

TIN TI LORIENT TRONG 5 NM: 2008-2012 ..................................................................................... 60

Gildas Trguier, Dominique Lamiot, Ngo Minh Xuan

PHT HIN SM TN TT TR NON THNG, D B TN THNG KINH NGHIM THC

TIN TI LORIENT TRONG 5 NM: 2008-2012 (PHN 2) .................................................................... 67


PHNG NGA VNG DA NHN ............................................................................................................. 78

Cam Ngc Phng

NHN MT TRNG HP BNH L RI LON CHUYN HO GALACTOSE .............................. 82

Ng Minh Xun, V T ng

LM TH NO BO V NO TRNH TN THNG T BNH L THIU OXY MU NO

DO SANH NGT BT C NI NO TRN TH GII. ...................................................................... 83

Masaki Shimizu

KT QU BC U KT HP M HNH SN NHI TRONG X TR CC D TT TIM BM SINH

...................................................................................................................................................................... 84

L Nht Trung,Trng B Lu , Nguyn MinhTr Vit

CHIN LC PHNG NGA BNH PHI MN TR SINH NON .................................................... 86

Nguyn Thu Tnh

POSTER ............................................................................................................. 87

HIU QU CA MISOPROSTOL T DI LI TRONG CHM DT THAI K THAI 23- 27

TUN I V NON ...................................................................................................................................... 88

Trn Th Nht Thin Trang, L Hng Cm

HIU QU KHI PHT CHUYN D BNG NG THNG FOLEY THAI D TT BM SINH 20

TUN TRN THAI PH C VT M LY THAI MT LN................................................................. 89

Phm Th M Hnh, L Hng Cm

SO SNH HIU QU KHI PHT CHUYN` D CA PROSTAGLANDIN E2 V NG THNG

FOLEY THAI 37 TUN THIU I ..................................................................................................... 91

Nguyn B M Ngc, Phm Vit Thanh

XY DNG QUY TRNH K THUT NUI CY GAI NHAU LM NHIM SC TH .............. 93

L Th Khnh Linh, ng L Dung Nghi, Nguyn Vn Thng , Nguyn Th Thanh Trc, Phm Th Vn Anh, Nguyn Vn Trng

BC U THC HIN K THUT PCR-ELISA TRONG CHN ON 10 T BIN THNG

GP GY BNH BETA THALASSEMIA............................................................................................... 95

L Nguyn Vn Khanh, Phm Hng Vn, Nguyn Vn Thng

PCOS- MT S TIP CN IU TR HIM MUN HIN NAY ........................................................... 96

V Thanh Lin Anh

KHO ST CC YU T NH HNG N CHN ON GIAI ON LM SNG UNG TH C

T CUNG TI BNH VIN UNG BU THNH PH H CH MINH T 08/2008 02/2009 ........... 98

Lu Minh Vn

iv

IU TR THAI NGOI T CUNG BM VT M C TUI THAI DI 12 TUN TI BNH

VIN T D .............................................................................................................................................. 100

Trng Dim Phng, Trn Th Li

SO SNH hMG V rFSH TRONG X TR P NG KM VI KCH THCH BUNG TRNG

TRONG TH TINH NG NGHIM TI BNH VIN PH SN TRUNG NG ............................... 101

o Lan Hng, Nguyn Vit Tin

BO CO TRNG HP XON T CUNG KHI C THAI 35 TUN TI BNH VIN PH SN H

NI ............................................................................................................................................................. 102

Nguyn Duy nh, L Th Anh o, Nguyn Thu Phng

KHO ST GI TR LM SNG, SIU M V MONITORING TRONG CHN ON V X TR

THAI GI THNG TRN NHNG THAI PH C THAI QU NGY SINH ...................................... 103

Phm Trng Ha v cng s

v

CONTENTS

WOMENS HEALTH .......................................................................................... 1

INDIVIDUALIZED ASSESSMENT OF FRACTURE RISK IN POSTMENOPAUSAL WOMEN:

PROGRESSES AND CHALLENAGES ......................................................................................................... 3

Nguyn Vn Tun

OBSTETRICS ...................................................................................................... 4

QUARITE (QUALITY OF CARE, RISK MANAGEMENT, AND TECHNOLOGY IN OBSTETRICS): A

CLUSTER-RANDOMIZED TRIAL OF A MULTIFACETED INTERVENTION TO REDUCE

HOSPITAL-BASED MATERNAL MORTALITY IN SENEGAL AND MALI ............................................ 6

Alexandre Dumont, Pierre Fournier, Michal Abrahamowicz, Mamadou Traor, Slim Haddad,

William D. Fraser

MANAGEMENT OF DIABETES IN PREGNANCY AND TIMING OF DELIVERY .............................. 10

GC Di Renzo

DIAGNOSIS OF PRETERM PREMATURE RUPTURE OF MEMBRANES ............................................. 15

G C Di Renzo

CASE REPORT: A WOMAN WITH CONSERVATIVE MANAGEMENT SUBSEQUENTLY HAD

SUCCESSFUL PREGNANCY ..................................................................................................................... 16


PRENATAL DIAGNOSIS ................................................................................. 17

CURRENT CONCEPTS IN EARLY SCREENING FOR PRE-ECLAMPSIA ............................................ 18


VALUES OF QF-PCR IN FAST PRENATAL DIAGNOSIS OF CHROMOSOME DISORDERS ............. 20

Nguyn Khc Hn Hoan, Phng Nh Ton, Quch Th Hong Oanh, Trn Nguyn An Ph, Nguyn Th Nh Hong

KARYOTYPE OF AMNIOTIC FLUID CELLS BY IN-SITU METHOD FOR PRENATAL DIAGNOSIS

IN HUNG VUONG HOSPITAL, VIET NAM: 5017 CASES ....................................................................... 22

Nguyn Vn Thng, Nguyn Th Thanh Trc, ng L Dung Nghi, Phm Th Vn Anh, Bi Hong

Thanh Long, Nguyn Vn Trng

FETAL HEART DEFECTS AT TU DU HOSPITAL ................................................................................... 23


MANAGEMENT OF DIFFICULT SCENARIOS IN MULTIPLE PREGNANCIES ................................... 25

Tony Tan

GYNECOLOGY ................................................................................................ 29

MANAGEMENT UPDATE OF CESAREAN SCAR ECTOPIC PREGNANCY ........................................ 32

Phan Vn Quyn

GYNECOLOGICAL ONCOLOGY ................................................................. 35

MANAGEMENT OF COMMON AND UNCOMMON MALIGNANT GERM CELL TUMOURS OF THE

OVARY ........................................................................................................................................................ 36

TAY, Eng-Hseon

vi

VAGINAL CANCER: EPIDEMIOLOGY DIAGNOSIS TREATMENT ............................................... 37

Lu Vn Minh

TWIN PREGNANCY WITH A COMPLETE HYDATIDIFORM MOLE AND CO-EXISTENT LIVE

FETUS: REPORT OF TWO CASES AND REVIEW OF LITERATURE ................................................... 38

L Quang Thanh, L T Phng Chi, Trnh Tin t, H T Nguyn

LAPAROSCOPY - PELVIPERINEOLOGY ................................................... 39

ADHERENCES EN CHIRURGIE GYNECOLOGIQUE ............................................................................. 40

D.K.TRAN

EFFICIENCY OF USING PESSARY IN TREATMENT FEMALE PELVIC ORGAN PROLAPSE AT TU

DU HOSPITAL: CHARACTERISTICS AND SUCCESS FACTORS ......................................................... 43

Nguyn Th Vnh Thnh

ASSISTED REPRODUCTIVE TECHNOLOGY ............................................ 44

FERTILITY PRESERVATION IN FEMALE: PRACTICE GUIDELINES ................................................. 45

S. Samuel Kim

OVARIAN CRYOBANKING: FROM SCIENCES TO CLINICAL PRACTICE ........................................ 47

S. Samuel Kim

FACTORS RELATED TO PREGNANCY OUTCOMES AMONG WOWEN UNDERGOING IVF USING

GnRH ANTAGONIST AT NATIONAL HOSPITAL OF OBSTETRICS & GYNAECOLOGY ................ 48

Phm Thy Nga, L Hong

RESULTS OF EMBRYO CULTURE AND TRANSFER ON DAY 5 ......................................................... 52

V nh Tun, Hong Th Bch Tuyn, L Thi Lc.

PLASTIC RECONSTRUCTIVE COSMETIC SURGERY ...................... 53

IMPLANT CHOICE IN IMPLANT BREAST AUGMENTATION ............................................................. 54

L Hnh

SOME COMMENTS ON ABDOMINOPLASTY FOR THE OBESE.......................................................... 55

Nguyn Anh Tun v CS

ON THE OCASSION OF BREAST REDUCTION WITH INVERTED-T TECHNIQUE ........................... 56

Nguyn Anh Tun v CS

GENIOPLASTY WITH ORTHOPEDIC SURGERY ................................................................................... 57

L Tn Hng

NEONATOLOGY .............................................................................................. 59

PRMATURIT, VULNRABILIT ET DTECTION PRCOCE

DES HANDICAPS EXPRIENCE BRETONNE SUR 5 ANS: 2008-2012 ............................................... 66


PRMATURIT, VULNRABILIT ET DTECTION PRCOCE

DES HANDICAPS EXPRIENCE BRETONNE SUR 5 ANS: 2008-2012

PRMATURIT, VULNRABILIT ET DTECTION PRCOCE DES HANDICAPS (2) ..................... 76


A REPORT OF GALACTOSEMIA DIAGNOSED AND MANAGED AFTER BIRTH AT TU DU

HOSPITAL, VIETNAM ............................................................................................................................... 82

Ng Minh Xun, V T ng

vii

HOW TO PROTECT THE BRAIN WITH HYPOXIC-ISCHEMIC ENCEPHALOPATHY IN THE ANY

COUNTRY. .................................................................................................................................................. 83

MasakiShimizu

INITIAL RESULTS OF MODEL APPROACH OF OBSTETRIC AND PEDIATRIC SPECIALISTS IN

MANAGEMENT OF CONGENITAL HEART DEFECTS .......................................................................... 85

L Nht Trung,Trng B Lu , Nguyn MinhTr Vit

STRATEGIES TO PREVENT CHRONIC LUNG DISEASE IN PRETERM INFANTS ............................. 86

Nguyn Thu Tnh

POSTER ............................................................................................................. 87

EFFICACY OF SUBLINGUAL MISOPROSTOL FOR PREMATURE RUPTURE OF THE

MEMBRANES BETWEEN 23 AND 27 WEEKS PREGNANCY TERMINATION ................................... 88

Trn Th Nht Thin Trang, L Hng Cm

THE EFFICACY OF USING FOLEY CATHETER TO INDUCE LABOUR OF 20-WEEK

PREGNANCY HAVING CONGENITAL FETAL ANOMALIES IN WOMEN WITH PRIOR CESAREAN

...................................................................................................................................................................... 90

Phm Th M Hnh, L Hng Cm

COMPARES THE EFFICIENCY OF INTRACERVICAL PROSTAGLANDIN E2 GEL AND FOLEYS

CATHETER FOR LABOR INDUCTION AT OLIGOHYDRAMNIOTIC PREGNANCY 37 WEEKS .. 92

Nguyn B M Ngc, Phm Vit Thanh

ESTABLISH KARYOTYPE PROCEDURE ON VILLIS SAMPLES ......................................................... 94

L Th Khnh Linh, ng L Dung Nghi, Nguyn Vn Thng , Nguyn Th Thanh Trc, Phm Th Vn Anh, Nguyn Vn Trng

DETECTION OF 10 COMMON MUTATIONS IN BETA THALASSEMIA USING PCR-ELISA THE

INITIAL ASSEMENT .................................................................................................................................. 95

L Nguyn Vn Khanh, Phm Hng Vn, Nguyn Vn Thng

EVALUATING THE INFLUENCES OF KNOWLEDGE ATTITUDE BEHAVIOR AND

SOCIOECONOMIC FACTORS IN DIAGNOSIS STAGES OF CERVICAL CANCER ............................ 99

Lu Minh Vn

TREATMENT OF CESAREAN SCAR ECTOPIC PREGNANCIES UNDER 12 WEEKS AT TU DU

HOSPITAL ................................................................................................................................................. 100

Trng Dim Phng, Trn Th Li

COMPARISON OF HMG AND RFSH EFFECTS IN POOR RESPONDER IVF PATIENTS

AT NATIONAL HOSPITAL OBSTRERIC & GYNACOLOGY ............................................................... 101

o Lan Hng, Nguyn Vit Tin

CASE REPORT: UTERINE TORSION AT 35 WEEKSGESTATION WITH A SINGLETON

PREGNANCY ............................................................................................................................................ 102

Nguyn Duy nh, L Th Anh o, Nguyn Thu Phng

DETERMINE THE VALUE OF CLINICAL DIAGNOSTIC, OBSTETRIC ULTRASOUND AND

OBSTETRIC MONITORING IN THE DIAGNOSIS AND TREATMENT FOR OLD FETAL IN

PREGNANT WOMEN WHO HAVE A OVERDUE DELIVERY BEFORE AND AFTER BIRTH ......... 104

Phm Trng Ha v cng s

1 Hi ngh Vit Php 2013

TNG QUAN


C NHN HA NH GI NGUY C GY XNG PH N SAU MN KINH: TIN B V THCH THC

Nguyn Vn Tun

Chng trnh nghin cu long xng v sinh hc xng

Vin nghin cu y khoa Garvan Sydney, Australia

Long xng v h qu gy xng l mt gnh nng cho dch v y t, v gy xng dn

n mt lot bin c nguy him nh ti gy xng v tng nguy c t vong. Nhng ngi cn

sng st sau gy xng b hn ch vn ng hng ngy v suy gim cht lng cuc sng. Mt

trong nhng pht trin quan trng trong thi gian gn y l s ra i ca cc m hnh tin lng

gy xng. Cc m hnh ny c th gip cho bc s nh gi nguy c gy xng, quyt nh iu

tr, v qun l bnh. Hai m hnh tin lng ph bin nht trn th gii hin nay l m hnh

FRAX

v Garvan Fracture Risk Calculator (GFRC) (1,2). Bi ny im qua nhng kt qu ca

nhng nghin cu nh gi tin cy ca hai m hnh trn, v ra mt s vn nh hng cn

nghin cu trong tng lai.

Cch nh gi tin cy ca mt m hnh thng qua ch s din tch di ng biu

din ROC (cn gi l AUC). Gi tr AUC cng cao phn nh mc phn nh gia nhng ca

gy xng v khng gy xng cng chnh xc. Cc nghin cu nh gi tin cy gn y cho

thy m hnh FRAX c gi tr AUC dao ng trong khong 0.61 n 0.83, v m hnh GFRC

dao ng trong khong 0.63 n 0.88. Tin lng gy c xng i c phn chnh xc hn cc

dng gy xng khc. Mt kt qu quan trng l m hnh FRAX thng c tnh nguy c gy

xng thp hn thc t, trong khi m hnh GFRC c tnh gn vi thc t hn (hoc cao hn

thc t trong cc nhm c nguy c cao). Kt qu phn tch hu nh ca cc cng trnh nghin

cu lm sng i chng ngu nhin cho thy hiu qu chng gy xng ca cc thuc nh

alendronate, clodronate, bazedoxifene, v denosumab thng cao hn bnh nhn c nguy c

gy xng cao. Tuy nhin, khng c mi tng quan no gia nguy c gy xng v hiu qu

chng gy xng ca cc thuc raloxifene v strontium ranelate.

Mc d nhng m hnh tin lng trn l mt tin b quan trng trong long xng,

nhng vn cn kh nhiu thch thc cn phi vt qua. Cc m hnh hin ti ch xem xt n cc

yu t lm sng v nhn trc, m cha s dng cc yu t nh gen. Mt s nghin cu tng

quan trn ton b nhim sc th (GWAS) gn y pht hin hn 50 gen c lin quan n gy

xng. Mi gen ny c nh hng thp n nguy c gy xng, nhng khi tt c cc gen c

phn tch cng mt lc th c th cung cp thm thng tin v nguy c gy xng cho mt c

nhn (3,4). Do , mt thch thc trong tng lai l s dng thng tin t nhng khm ph gen

kt hp vi cc yu t lm sng tin lng gy xng cho mi c nhn mt cch chnh xc

hn. Ngoi ra, mt trong nhng im yu ca cc m hnh tin lng gy xng l ch da vo

mt gi tr ban u m cha xem xt n s bin chuyn ca cc yu t lm sng theo thi gian

mi c nhn (chng hn nh mt xng suy gim theo tui). Do , mt trong nhng nh

hng trong tng lai l s dng nhng bin chuyn ca cc yu t lm sng c th tin

lng gy xng v t vong chnh xc hn cho mi c nhn.

Mc d cc m hnh tin lng FRAX v GFRC cha phi hon ho, nhng cc m hnh

ny c th gip cho bc s v bnh nhn i thoi v nguy c gy xng trong thi hn ngn (5

nm) i n nhng quyt nh sng sut v iu tr v qun l bnh. C nhn ha tin lng

gy xng cng cn phi xem xt n s cm nhn v nguy c v h qu ca mi c nhn.


INDIVIDUALIZED ASSESSMENT OF FRACTURE RISK IN POSTMENOPAUSAL WOMEN: PROGRESSES AND CHALLENAGES

Nguyn Vn Tun

Osteoporosis and Bone Biology Program - Garvan Institute of Medical Research -

Sydney, Australia

Osteoporosis and its consequence of fragility fracture impose a significant demand on

medical care and health services, because fracture is associated with a series of adverse events,

including re-fracture and mortality. One of the significant advances in osteoporosis research is

the the development of predictive models for identifying individuals at high risk of fracture for

early intervention and management. Risk prediction models, including the FRAX and Garvan

Fracture Risk Calculator (GFRC) (1,2), have been developed to provide a useful clinical

framework for communicating the risk of fracture. The present review examines the validation of

risk prediction models in osteoporosis and identifies some major challenges.

Recent validation studies suggested that the are under the receiver operating

characteristics curve in fracture discrimination ranged from 0.61 to 0.83 for FRAX, and from

0.63 to 0.88 for GFRC, with hip fracture having a better discrimination than fragility fractures as

a group. FRAX substantially under-estimated the risk of fracture, whereas the predicted risk by

GFRC was close to or slightly higher than the actual risk. Results of post-hoc analyses of clinical

trials indicated the anti-fracture efficacy of alendronate, coronate, bazedoxifene, and denosumab

was greater in patients with higher predicted risk of fracture. However, there was no correlation

between the anti-fracture efficacy and predicted fracture risk among patients on raloxifene and

strontium ranelate.

Nevertheless, there are several challenges to be addressed. Existing predictive models

include clinical factors and anthropometric characteristics and have not considered genetic

variants in the prediction. Recent genome-wide association studies (GWAS) have identified

several genetic variants relevant to fracture risk. These genetic variants are common in frequency

but have very modest effect sizes. A remaining challenge is to translate these genetic variants

discoveries to better predict the risk of fracture based on an individuals genetic profile (i.e.,

individualized risk assessment) (3,4). An important weakness of current fracture prediction

models is that they are based on a single measurement of risk factors, with the underlying but not

stated assumption that the risk factors do not change with time. Obviously, this assumption is

not true in many risk factors such as BMD and body weight that are known to decline or change

with time. Therefore, one important aspect of future model development should take the time-

varying nature of risk factors into account to achieve a better estimate of risk for an individual.

The prognostic performance of FRAX and GFRC for fracture prediction is not perfect,

but these predictive models can aid patients and doctors communicate about fracture risk in the

medium-term and to make rational decision. However, the application of these predictive models

in making decisions for an individual should take into account the individuals perception of the

importance of the risk of fracture and its severity outcomes.


SN


QUARITE (CHT LNG CHM SC, QUN L YU T NGUY C V K THUT SN KHOA): TH NGHIM LM SNG NGU NHIN TRN TNG NHM NH V CC CAN THIP TRN NHIU PHNG DIN GIM T L T VONG M SENEGAL

V MALI Alexandre Dumon, Pierre Fournier, Michal Abrahamowicz,

Mamadou Traor, Slim Haddad, William D. Fraser

Tng quan: T l t vong m cc nc Chu Phi cao hn so vi cc nc cng nghip,

v vy vic pht trin v cng nhn nhng can thip c hiu qu l iu rt cn thit. Chng ti

tin hnh 1 th nghim lm sng nh gi hiu qu ca cc can thip trn nhiu phng

din ci thin nh gi t vong m (MDR) v hun luyn v chm sc cp cu sn khoa

(EmOC) nhng bnh vin c t l t vong m cao.

Phng php nghin cu: Th nghim lm sng ngu nhin c nhm chng trn nhm

nh. Bn mi su bnh vin cng u tin v cc bnh vin th cp vi hn 800 trng hp

chuyn d sanh mi nm c ghi nhn Senegal v Mali, c phn loi theo quc gia v

bnh vin, v c phn chia 1 cch ngu nhin thnh 2 nhm cn bng nhau: 1 nhm (n=23) c

c can thip v 1 nhm (n=23) khng c can thip no t bn ngoi Tt c nhng thai ph

c tnh vo nghin cu l nhng ngi c chuyn d sanh nhng c s c tham gia nghin

cu trong giai on trc v sau can thip. Cc can thip c thc hin trong khong thi gian

2 nm cc tuyn bnh vin, vi mc tiu l chm sc sc khe 1 cch chuyn nghip. Nghin

c bao gm mt hi tho tng tc ban u v gio dc nh hng lm sng 3 thng 1 ln v v

xa hn l s thm khm da trn y hc chng c, tp trung vo nh gi t vong m (MDR) v

thc hnh lm sng tt nht c th. Mc tiu chnh l lm gim nguy c t vong ti vin cho m

sau khi can thip so vi trc khi c can thip. Phn tch theo nh iu tr v da trn cc c

tnh phng trnh tng qut (GEE) , phn m rng ca m hnh hi quy logic tnh ton trn

tng nhm nh bnh nhn trong cc bnh vin.

Kt qu nghin cu: Khng c bnh vin no ngng tham gia nghin cu. Nhng hnh

ng c th c trin khai ton din nng cao cht lng chm sc trong bnh vin.

Chng ti quan st thy khng c tc dng ngoi mun ca vic nh gi t vong m, chng

hn nh tranh chp hoc cc mi e da cho nhn vin. Tt c 19 1167 bnh nhn chuyn d

sanh ti cc bnh vin tham gia nghin cu c phn tch (95 931 trng hp c can thip v

95 236 trng hp khng c can thip).

Nhn chung, t l t vong gim ng k cc bnh vin c c can thip hn so vi ti

cc bnh vin nm trong nhm chng (OR = 0,85, 95% CI: 0,73-0,98, p = 0,0299), tuy s chnh

lch ny ch gii hn cc bnh vin tuyn trung ng v tuyn qun huyn. Khng c tc dng

trong bnh vin th cp bn ngoi th (OR = 1,02, 95% CI: 0,79 - 1,31, p = 0,89).

Din gii: Vic thng xuyn gh thm bi mt c vn vin o to v vic o to ti

ch to iu kin thun li cho nh gi t vong m (MDR) bng cch cung cp cc chuyn gia

chm sc sc khe vi nhng kin thc v s t tin thc hin cc xut ci tin cht lng

trong trong qu trnh kim tra. nh gi t vong m kt hp vi vic thc hnh lm sng tt nht

c hiu qu trong vic lm gim t vong m cc bnh vin tuyn u. Nghin cu su hn l

cn thit xc nh xem nhng li ch ca can thip nhng bnh vin th cp.


QUARITE (QUALITY OF CARE, RISK MANAGEMENT, AND TECHNOLOGY IN OBSTETRICS): A CLUSTER-RANDOMIZED TRIAL OF A MULTIFACETED INTERVENTION TO REDUCE

HOSPITAL-BASED MATERNAL MORTALITY IN SENEGAL AND MALI

Alexandre Dumont, Pierre Fournier, Michal Abrahamowicz,

Mamadou Traor, Slim Haddad, William D. Fraser

Background. Maternal mortality is higher in Africa than in most industrialized countries,

so it is essential to develop and validate effective interventions. We conducted a trial to evaluate

the effect of a multifaceted intervention to promote maternal death reviews (MDR) and on-site

training on emergency obstetric care (EmOC) in referral hospitals with high maternal mortality

rates.

Methods. Pragmatic cluster randomized controlled trial with hospitals as the units of

randomization and patients as the unit of analysis. Forty-six public first- and second-level

referral hospitals with more than 800 deliveries per year were enrolled in Senegal and Mali,

stratified by country and hospital type, and randomly assigned by the method of blocked

randomization in a balanced design to either the intervention group (n=23) or a control group

with no external intervention (n=23). All women who delivered in each of the participating

facilities during the baseline and post-intervention periods were included. The intervention,

implemented over a period of two years at the hospital level, targeted the health care

professionals. It consisted of an initial interactive workshop and quarterly educational clinically-

oriented and evidence-based outreach visits focused on MDR and best practices implementation.

The primary outcome was reduction of individual mothers risk of hospital-based mortality from

before to after the intervention. Analysis was by intention-to-treat and relied on the generalized

estimating equations (GEE) extension of the logistic regression model to account for clustering

of women within hospitals. This study is registered, number ISRCTN46950658.

Findings. No hospital was lost to follow-up. Concrete actions were implemented

comprehensively to improve quality of care in intervention hospitals. We observed no

unintended effect of MDR, such as litigation or threats to personnel. In all, 191,167 patients who

delivered in the participating hospitals were analyzed (95,931 and 95,236 in the intervention and

the control arms, respectively). Overall, mortality reduction in intervention hospitals was

significantly higher than in control hospitals (OR = 0.85, 95% CI: 0.730.98, p = 0.0299), but

this effect was limited to capital and district hospitals, which mainly acted as first-level referral

hospitals in this trial. There was no effect in second-level referral (regional) hospitals outside the

capitals (OR = 1.02, 95% CI: 0.79 1.31, p = 0.89).

Interpretations. Regular visits by a trained external facilitator and on-site training

facilitate MDR by providing health care professionals with the knowledge and confidence to

make quality improvement suggestions during audit sessions. MDR combined with best

practices implementation is effective in reducing hospital-based maternal mortality in first-level

referral hospitals. Further studies are needed to determine whether the benefits of the

intervention are generalizable to second-level referral hospitals.


QUN L I THO NG THAI K V QUYT NH THI IM SANH

GC Di Renzo

i tho ng thai k (GDM) theo nh ngha c in l khng dung np carbohydrate

dn n tng ng huyt khi pht hoc c pht hin ln u tin trong thai k, m khng

loi tr kh nng khng dung np ng t trc cha c nhn bit. Cc ri lon nh hng

5-7% sn ph v tn s ca n ang gia tng trn ton th gii.

Trong thai k bnh thng, tng khng insulin do tng ni tit nhau- thai nh

progesteron, cortisol, hormon tng trng prolactin v hPL. Tuyn ty bnh thng s b p

bng cch tng tit insulin, nhng khi tuyn ty khng tng tit, hoc tit insulin gim do gim

chc nng t bo beta, s gy ra i tho ng thai k. Nhng ngi m b i tho ng thai

k vi tng ng huyt in hnh s chuyn lng ng ln qua thai nhi, gy tng insulin bo

thai v pht trin qu mc cc m nhy cm insulin ( ch yu m m), hu qu l thai tng

trng mt cn xng, lm tng nguy c sang chn lc sanh, kt vai, m ly thai v t vong chu

sinh. Tng insulin cng c th gy ra nhiu bin chng chuyn ha tr s sinh nh h ng

huyt, tng bilirubin mu, h canxi mu, h magie mu, a hng cu, hi chng suy h hp, v

nguy c ln v lu di ca bnh tiu ng v bo ph tr em.

i tho ng thai k lm tng bin chng cho m nh tng huyt p, tin sn git v

m ly thai, km tng nguy c pht trin thnh bnh i tho ng v sau. Do sinh l bnh ca

GDM, phn ln cc ph n c GDM s b i tho ng loi 2, vi t l tch ly t 2,6%

n 70%.

QUN L GDM: BNG CHNG LM SNG

Nhng li ch y t v sn khoa tim nng ca qun l GDM l t bin chng b m v

thai nhi, trong v sau thai k, nhng cc tin ch ca sng lc GDM, v li ch ca b m v thai

nhi, gn y c cu hi c t ra, v vy vn quan trng l phi xem xt bng chng

nh gi tin ch tht s ca qun l GDM nghim ngt.

Ba nghin cu on h chng minh mt s hu qu i vi m v thai ( thai to, m ly

thai, tin sn git) cng xu, mc dung np ng ca m cng ln: iu quan trng ca nhng

nghin cu ny nm s bt dung np ng khng c chn on v do khng c

iu tr trong thai k, trong nghin cu kim tra v loi b cc yu t gy nhiu nh tui tc

v chng bo ph ca m.

Mi y cc bin chng trn thai ( thai lu, thai to, thai ln so vi tui thai, h ng

huyt, tng hng cu, tng bilirubin mu) c cho thy rng xy ra 59% ph n b GDM

khng c iu tr v 18% c iu tr, v xy ra 11% kim sot bnh thng.

Trung tm nghin cu bt dung np Carbohydrat ph n mang thai

c ( ACHOIS) chng minh rng iu tr GDM ( theo tiu chun ca WHO) ci thin kt cc m v thai nhi. T l bin chng chu sinh nghim trng tr s sinh thp hn ng k nhm

iu tr so vi nhm chng ( 1% so vi 4%, p= 0,01). V vy GDM cn phi c chn on v

iu tr.

GIM ST CHUYN HA:


Mc tiu ca qun l glucose trong GDM l gi gi tr glucose cng gn bnh thng

cng tt.

Hi ngh Hi tho Quc t ln th 5 ( FIWC) v GDM cho thy nng ng trong

mu mao mch di 96 mg/dl ( < 5,3 mmol/l) trc khi n v di 140 mg/dl ( < 7,8 mmol/l) 1

gi sau n, hoc di 120mg/dl ( < 6,7 mmol/l) 2 gi sau n. Mc ng huyt tham kho

ngh ca ADA l di 105mg/dl ( 5,8mmol/l) trc khi n v di 155 mg/dl ( 8,6 mmol/l) 1 gi

sau n, hoc di 130 mg/dl ( 7,2 mmol/l) 2 gi sau n.

l gi tr nhn mnh, tuy nhin, cc khuyn co khng xem xt gi tr ng huyt

cao hn so vi nhng ngi bnh thng ghi nhn trong thai k, h cp n mc ng

huyt lin quan n kt cc thai k. iu ny ch yu do cc nghin cu nh gi ng huyt

ph n mang thai bnh thng vn cn khan him, lin quan n s t ph n nhp vin v ch o

lng tr s glucose vo mt ngy trong 3 thng cui thai k.

MC NG HUYT V CC BIN CHNG CHU SINH:

Bin chng ca GDM ph bin nht tr s sinh c cho l thai to v nguy c sang

chn khi sanh cao. iu ny c chng minh rng t l thai to tng c ngha vi mc ng

trong mu cao hn 105 mg/dl, trong khi nguy c em b nh hn tui thai cao khi mc ng

trong mu gim di 87 mg/ dl; do trnh nhng bin chng ca thai, gi tr ng trong

mu nn c duy tr gia 87 v 105 mg/dl bnh nhn GDM.

T l t vong chu sinh ph bin hn ph n b GDM c chn on sm so vi cc

trng hp chn on mun. Mt t l t vong chu sinh cao hn c bo co nhng bnh

nhn GDM khng c iu tr so vi cc trng hp c iu tr. Bo co ca ADA cho thy

ng huyt lc i cao hn 105 mg/dl c nguy c t vong chu sinh cao bnh nhn GDM.

Ngoi ra cn c mi lin quan gia nng ng huyt trung bnh v t l t vong chu sinh, t

l 4% ph n b GDM c mc ng huyt trung bnh di 100mg/dl , 15% nu ng huyt

trung bnh 100 150 mg/dl, v l 24 % nu vt qu 150 mg/dl.

i vi cc bin chng khc ca GDM ln thai nhi, nh h ng huyt, h calci mu v

tng bilirubin mu, mc ng huyt di 100 mg/dl ( mt gi tr ging vi ph n c thai bnh

thng) lm gim cc bin chng trn. Nhng mt bi bo gn y cho thy r rng rng, ngay

c khi iu tr nghim ngt t c cc gi tr ng huyt ni trn, bin chng cho m v thai

nhi trong GDM vn cn cao hn so vi ph n mang thai bnh thng. Cc ngng ngn

chn bin chng cho m v thai nhi ca GDM s dng cho n nay cn phi c xem xt li,

cng theo nh nhng pht hin gn y ph n mang thai bnh thng theo di lng ng

huyt hoc s dng CGMS.

CGMS c th c vai tr quan trng, bi v gn y cc h thng ch ra rng, tri vi

nhn thc chung, ph n b GDM c th b h ng huyt, m c nhiu kh nng trong s

nhng ngi c iu tr insulin v khng c triu chng. T theo di ng huyt (SMBG)

khng xem xt nhng dao ng trong ngy, c chng minh c th gp phn gy mt s

bin chng tr s sinh. Mc d SMBG c thc hin chnh xc rt quan trng trong vic theo

di ph n mang thai mc bnh tiu ng, CGMS ng mt vai tr c bit bnh nhn

GDM dng xc nh nhng bnh nhn cn phng php iu tr khc hn iu chnh ch

n, v pht hin nguy c h ng huyt cc bnh nhn c iu tr insulin.

Qun l sn khoa l qun l v chuyn ha, phng php theo di thai, quyt nh thi

im tt nht v phng php sanh l rt quan trng.


Nhng bnh nhn GDM iu tr bng insulin, nhng bnh nhn kim sot chuyn ha

ng km v/ hoc c bnh km theo cn phi c theo di bng stress free tests sau tun

32 ca thai k, thc hin trc sinh vt l v Doppler velocimetry nh gi lu lng mu

rn, theo khuyn co ca IWC ln th t (Fourth IWC ) v GDM v ACOG. iu chnh ch

n iu tr trong GDM cha cho d qun l sn khoa cht ch nn i hi theo di c ng

thai trong 8 10 tun cui thai k. Theo ACOG v FIWC v GDM, nhng bnh nhn GDM

kim sot chuyn ha tt bng cch iu chnh ch n v tc tng trng ca bo thai thch

hp, c ng thai nn c theo di trong 8 10 tun cui thai k, v bt k s gim c ng

thai phi c bo ngay cho bc s sn khoa. Kt qu ca mt nghin cu ngu nhin a trung

tm ln so snh kt qu chu sinh ph n b GDM nh iu chnh ch n v/ hoc iu tr

bng insulin vi ph n khng iu tr c hiu s lm r cc chin lc c th qun l GDM.

Sng lc d tt bm sinh ch c ngh nhng bnh nhn GDM vi nng HbA1c

cao hn 7% hoc mc ng huyt lc i cao hn 120 mg/dl, vi nguy c cao ca bnh tiu

ng trc khi mang thai khng c chn on v do nguy c cao ca d tt bm sinh. Mt

im quan trng cn xem xt khi theo di GDM l c hi d bo v iu tr thai to, bin

chng ph bin nht ca tnh trng ny. Thit lp k hoch iu tr ngn thai tng trng qu

mc, chng ta cn bit khi no hin tng ny bt u. Mt nghin cu trn siu m (US) o

khi lng nc v cht bo ca thai ph n b GDM v ph n mang thai bnh thng cc

tui thai khc nhau ch ra rng trong GDM khi lng nc ca thai tng t tun 20 v khi

lng m tng lc 26 tun thai k. Tnh chnh xc ca siu m c tnh trng lng thai nhi

thng c th hin i dng nhy, c hiu, gi tr tin on dng v m, v t l c

tnh trong 10% trng lng sinh thc t: mt t l sai s 13% ( 2 SD) trong vic c tnh trng

lng thai nhi vi siu m nn c a vo bo co. Hn na gi tr tin on dng ca siu

m trong vic nh gi cn nng lc sanh trn bch phn v 95 ph n vi mc bt dung np

ng khc nhau ch c 50%. Trong mt nghin cu gn y tm thy rng siu m c tnh

trng lng thai, da trn chu vi bng, ng knh lng nh, chu vi vng u v chiu di

xng i, 4000g hoc hn trong vng 1 tun sanh, v ch s nc i cao hn bnh thng, kt

hp vi cc yu t nguy c lm sng ( s ln sanh ca ngi m, ch s BMI v bnh tiu

ng), gip ci thin d bo thai to t 61% - 71%. Cng ngh mi c pht trin, nh siu m

3D v chp cng hng t, trong bi cnh ny t ra rt chnh xc trong o lng trng lng

ca thai nhi t s nh gi th tch ca thai. Hu ht cc nghin cu ny c cng b cho n

nay l tham kho t vi trng hp, tuy nhin, t l gia chi ph li ch ca cc cng ngh ny

cn phi c xc nh trc khi xem xt p dng thng xuyn.

C bng chng t mt s nghin cu cho thy mt chu vi bng ca thai nhi ln hn bch

phn v 75 vi mc ng huyt lc i hn 105 mg/dl tng quan vi mt nguy c cao tr s

sinh ln hn so vi tui thai ( LGA):trong trng hp ny, mc tiu ng huyt cht ch hn (

80mg/dl khi i v 100 120 mg/dl 2 gi sau n) v iu tr insulin thng xuyn hn c th

lm gim tng trng LGA 50%. Do khuyn co ca FIWC v GDM nn nh gi chu vi

bng ca thai nhi bt u trong qu hai v lp i lp li cc php o mi 2 4 tun, cung cp

cc ch s hu ch trong iu tr GDM.

Vi s gp phn ca khi lng cht bo cho trng lng thai nhi, o dy m mm c

th chnh xc hn o ton b c th ( m m v nc). Phng php ny cho thy c nhy cao,

nhng c hiu thp, tuy nhin, o m m di da ca thai nhi c chng minh nhy v

c hiu. Nhng phng php ny vn cha tr nn thng dng trong theo di cc bnh nhn

GDM, tuy vy cn tip tc nghin cu c c li ch thc s cho bnh nhn v t l chi ph

li ch.

Do tng nguy c thai lu, c bit l sau 40 tun bnh nhn i tho ng kim sot

km, c s h tr khi pht chuyn d lc thai 38 tun. Tuy nhin cn xem xt thc t mt t l


phn trm nht nh thai cha trng thnh v c th pht trin RDS sau sanh. Vic nh gi

s trng thnh phi thai nhi t nc i trong nhng trng hp ny l chnh xc.

MANAGEMENT OF DIABETES IN PREGNANCY AND TIMING OF DELIVERY

GC Di Renzo

Gestational diabetes mellitus (GDM) is classically defined as a carbohydrate intolerance

resulting in hyperglycemia of variable severity with onset or first recognition during pregnancy

, which does not exclude the possibility of a prior unidentified glucose intolerance. The disorder

affects 5-7% of all pregnancies and its frequency is rising the world over .

Insulin resistance increases in normal pregnancy due to the progressively rising levels of

feto-placental hormones such as progesterone, cortisol, growth hormone, prolactin and human

placental lactogen. The pancreas normally compensates by increasing insulin secretion, but when

it does not, or when insulin secretion declines due to a beta cell function impairment , then GDM

develops. The maternal hyperglycemia typical of GDM determines a greater transfer of glucose

to the fetus, causing fetal hyperinsulinemia and an overgrowth of insulin-sensitive (mainly

adipose) tissues, with a consequent excessive, unbalanced fetal growth, meaning more trauma at

birth, shoulder dystocia, cesarean sections and perinatal deaths. Hyperinsulinemia can also cause

numerous neonatal metabolic complications, such as hypoglycemia, hyperbilirubinemia,

hypocalcaemia, hypomagnesaemia, polycythemia, respiratory distress syndrome, and a greater

long-term risk of diabetes and obesity in the child

GDM is related to maternal complications too, such as hypertension, preeclampsia and

cesarean section , plus a greater risk of developing diabetes later on. Given the pathophysiology

of GDM, most of the women who have had GDM will develop type 2 diabetes, with a

cumulative incidence ranging from 2.6% to 70% .

Managing GDM: clinical evidence

The potential benefits of medical and obstetrical GDM management are fewer maternal

and fetal complications, both during and after the pregnancy , but the utility of screening for

GDM, in terms of maternal and fetal benefits, has recently been questioned , so it is important to

consider the evidence to judge the real utility of strict GDM management.

Three cohort studies have shown that some adverse fetal and maternal outcomes

(macrosomia, caesarean section, preeclampsia) are worse, the greater the mothers glucose

tolerance: the importance of these studies lies in that the glucose intolerance had gone

undiagnosed and consequently untreated during the pregnancy, and in that patients were checked

for any confounding effects of maternal age and obesity.

Recently it has been shown that composite adverse fetal outcomes (stillbirth,

macrosomia, large for gestational age, hypoglycemia, erythrocytosis, hyperbilirubinemia)

occurred in 59% of untreated and 18% of treated GDM women, and in 11% of normal controls.

The Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS)

unequivocally demonstrated that treating GDM (as defined by WHO criteria) improves maternal

and fetal outcome. The rate of severe perinatal outcomes in newborn was significantly lower in


the treated group than in a control group (1% vs 4%, p=0.01). So GDM needs to be diagnosed

and treated.

Metabolic monitoring

The goal of glucose management in GDM is to keep glucose values as near normal as

possible.

The Fifth International Workshop Conference (FIWC) on GDM suggests capillary whole

blood glucose concentrations below 96 mg/dl (< 5.3mmol/l) before meals and either below 140

mg/dl (


CGMS can play a part - particularly in GDM patients - both to pinpoint those needing treatment

other than dietary measures, and to detect the risk of hypoglycemic episodes in insulin-treated

patients.

Obstetric management is just as essential as metabolic management, and fetal

surveillance techniques and deciding the best time and mode of delivery are very important.

GDM patients treated with insulin, those in poor metabolic control and/or with

comorbidities need to be monitored with stress-free tests after the 32nd

week of gestation, and

with a biophysical profile and Doppler velocimetry to assess umbilical blood flow, as

recommended by the Fourth IWC on GDM and the ACOG . In diet-treated GDM, it is not clear

whether strict obstetric management should entail more than monitoring fetal movements in the

last 8-10 weeks of pregnancy. According to the ACOG and the FIWC on GDM, in GDM

patients in good metabolic control achieved by dietary measures and with an appropriate fetal

growth, fetal movement should be monitored during the last 8-10 weeks of pregnancy, and any

reduction in the perceived fetal movements should be reported immediately to the obstetrician.

The results of a large randomized multicenter study comparing perinatal outcome in women with

mild GDM randomized to dietary and/or insulin therapy with women randomized to non-specific

treatment will clarify the optimal strategy for managing GDM.

Screening for congenital anomalies is only recommended in GDM patients with HbA1c

levels higher than 7% or fasting plasma glucose levels higher than 120 mg/dl, given the high

risk of undiagnosed pre-pregnancy diabetes and the consequently high risk of congenital

malformations.

An important point to consider when monitoring GDM is the chance to predict and treat

macrosomia, the most common complication of this condition. To plan any treatment designed

to contain excess fetal growth, we need to know when this phenomenon begins. An ultrasound

(US) study on fetus lean and fat mass of GDM and normal pregnant women at different

gestational ages has shown that in GDM fetus lean mass increases from the 20th

g.w. and fat

mass at 26 g.w. . The accuracy of US estimates of fetal weight is commonly expressed as

sensitivity, specificity, positive and negative predictive values, and proportions of estimates

within 10% of actual birth weight: a 13% error rate ( 2 SD) in estimating fetal weight with US

should be taken into account . Moreover, a recent study showed that the positive predictive value

of US in assessing birth weights above the 95th

percentile in women with varying degrees of

glucose intolerance is only 50% . In a recent study it has been found that US suggesting an

estimated fetal weight, based on abdominal circumference, biparietal diameter, head

circumference and femur length, of 4000 g or more within a week of delivery, and a higher than

normal amniotic fluid index, combined with clinical risk factors (maternal parity, BMI and

diabetes), improves the prediction of macrosomia from 61% to 71%.

Newly-developed technologies, such as 3D ultrasound and magnetic resonance imaging,

are promising in this setting, having proved highly accurate in measuring fetal weight from a

volumetric assessment of the fetus. Most such studies published to date refer to few cases,

however, and the cost-benefit ratio of these technologies needs to be determined before it can be

considered routinely applicable.

There is evidence from some studies that a fetal abdominal circumference higher than the

75th

percentile with fasting plasma glucose levels beyond 105 mg/dl correlates with a high risk

of newborn being large for gestational age (LGA): in such cases, stricter glycemic targets (80

mg/dl fasting and 100-120 mg/dl 2 h after meals) and more frequent use of insulin treatment can

reduce LGA growth by 50% . Hence the recommendation from the FIWC on GDM that fetal


abdominal circumference be assessed, starting in the second trimester and repeating the

measurement every 2-4 weeks, to provide useful indicators for the treatment of GDM.

Given the contribution of fat mass to fetal weight, measuring soft tissue thickness might

seem more accurate than whole body (fat and lean tissue) measurements. This method reveals a

high sensitivity, but a low specificity, however, while measuring subcutaneous fetal fat tissue has

proved sensitive and specific . These methods have yet to become routine in monitoring GDM

patients, however, and further studies are needed to establish their real utility and cost-benefit

ratio.

Given the increasing risk of in utero mortality , particularly after 40 weeks in poor

controlled diabetic patients, there is support to the attitude to induce labour at 38 weeks

gestation. However, this management should take into consideration the fact that a certain

percentage of fetuses are not still mature and may develop RDS after birth. The evaluation of

fetal lung maturity from amniotic fluid in these cases has a proper role.


CHN ON I V NON

G C Di Renzo, MD, PhD, FRCOG (hon) FACOG (hon)

Professor and Chairman, Dept Obstetrics and Gynecology, University of Perugia, Perugia, Italy

Khong 8% n 10% thai k s b v i sm (PROM) t nhin trc khi bt u chuyn

d. i v non (PPROM) - nh ngha l i v sm trc 37 tun ca thai k, chim 2% n 4%

ca tt c cc trng hp n thai v 7% n 20% cc trng hp song thai.

Mt s yu t nguy c i vi i v non t nhin c xc nh. V d: Nhim trng

i v nhau bong non xy ra t trc c th phng thch cc protease vo cc m gai nhau v

nc i dn n v mng i. Tht vy, nhau bong non c tm thy trong 4% n 12% thai k

c i v non v nhiu hn trong thai k c i v non trc 28 tun.

V mng i thng hoc c dch m o nhiu chy ra hoc chy thnh dng (steady

trickle). Chn on phn bit vi sn tiu (tiu khng t ch), vi tit dch m o qu nhiu nh

dch tit sinh l hoc nhim khun m o, vi cht nhy c t cung du hiu ca lc sp chuyn

d. Mt s yu t c bit l nh hng n thi gian ko di khong thi gian gia lc v

mng i ti bt u chuyn d, bao gm: tui thai, mc thiu i, dy myometrial qua siu

m, s lng thai, cc bin chng nh nhim trng i, nhau bong non, hoc chuyn d vo hot

ng.

Nhim trng m v thai nhi l bin chng nghim trng th hai lin tip sau i v non,

vim mng i chim 10-36% ca i v non. Chn on sm v chnh xc l cn thit qun l

thch hp bnh nhn i v sm v i v non, hn ch can thip khng cn thit nhng bnh

nhn khng c i v sm. Chn on sm v chnh xc i v non s cho php can thip sn khoa

c th vi ty tng tui thai ti u ha kt qu chu sinh v gim thiu cc bin chng nghim

trng nh sa dy rn v bnh l nhim trng (nhim trng i, nhim trng s sinh). Ngc li,

mt chn on dng gi ca i v non c th dn n s can thip sn khoa khng cn thit

nh nhp vin, s dng khng sinh, corticosteroid, thm ch khi pht chuyn d.

Cc xt nghim chn on "c in" da vo pH kim ca dch nhy c t cung m

o, thng c chng minh bng cch nhn thy dch tit bin giy qu mu vng chuyn

sang mu xanh (nitrazine test) hoc soi kh dch tit di knh hin vi c hnh l dng x. Ch

vi bng chng gim th tch dch i khng th xc nh chn on i v, nhng c th gip gi

i v trong trng hp lm sng ph hp. Cc du hiu lm sng ca i v non dn dn t

chnh xc khi i v lu hn mt gi. nh gi hnh l dng x, nitrazine test v siu m cho

thy rng chng t gi tr, t m vt kim tra khng du hiu no l chnh xc nh cc test

kim tra da trn cc cht nh du sinh ha. Cc nh nghin cu tm kim mt test ch yu da

vo vic xc nh trong cht nhy c t cung c mt hoc nhiu marker sinh ha lin quan n i

v nhng khng c nhng ph n c mng i nguyn vn. Cc marker sinh ha tt hn so vi

phng php truyn thng, v chng l protein c bit c tm thy trong nc i. V vy,

chng khng b nh hng bi hu ht cc cht gy nhim v c th l test chn on nhanh v

ng tin cy.

Test PAMG-1 (Amnisure ROM test, Boston, MA) l cng c hu ch nht trong vic

xc nh ph n c nguy c cao i v sm. Test th nhanh da trn PAMG-1 c v l test kim

tra ti ging chnh xc hn so vi nhng cch khc.


DIAGNOSIS OF PRETERM PREMATURE RUPTURE OF MEMBRANES

G C Di Renzo

Approximately 8% to 10% of term pregnancies will experience spontaneous premature

rupture of membranes (PROM) prior to the onset of uterine activity. Preterm PROM-defined as

PPROM, prior to 37 weeks of gestation complicates 2% to 4% of all singleton and 7% to 20%

of twin pregnancies.

A number of risk factors for spontaneous PPROM have been identified. Intra-amniotic

infection and decidual hemorrhage (placental abruption) occurring remote from term, for

example, may release proteases into the choriodecidual tissues and amniotic fluid, leading to

rupture of membranes. Indeed, placental abruption is seen in 4% to 12% of pregnancies

complicated by PPROM, and is more common in pregnancies complicated by PPROM prior to

28 weeks of gestation.

Rupture of the membranes tipically presents as a large gush of clear vaginal fluid or as a

steady trickle. The differential diagnosis includes leakage of urine (urinary incontinence);

excessive vaginal discharge, such as physiologic discharge or bacterial vaginosis, and cervical

mucus (show) as a sign of impending labor. Latency refers to the interval between rupture of the

membranes and the onset of labor. A number of factors are known to affect the latency period,

including: gestational age, degree of oligohydramnios, sonographic myometrial thickness,

number of fetuses, pregnancy complications such as intra-amniotic infection, placental

abruption, or active labor.

Maternal and fetal infection is the second major complication consecutive to PPROM, as

chorioamnionitis complicates 10 to 36 % of PPROM. Early and accurate diagnosis is necessary

to appropriately manage patients with PROM and PPROM and to limit unnecessary intervention

in patients without PROM. Early and accurate diagnosis of PPROM would allow for gestational

age-specific obstetric interventions designed to optimize perinatal outcome and minimize serious

complications, such as cord prolapse and infectious morbidity (chorioamnionitis, neonatal

sepsis). Conversely, a false-positive diagnosis of PPROM may lead to unnecessary obstetric

intervention, including hospitalization, administration of antibiotics and corticosteroids, and even

induction of labor.

Classic diagnostic tests are represented by an alkaline pH of the cervicovaginal

discharge, which is tipically demonstrated by seeing whether discharge turns yellow nitrazine

paper to blue (nitrazine test); and /or microscopic ferning of the cervicovaginal discharge on

drying. Evidence of diminished amniotic fluid volume alone cannot confirm the diagnosis, but

may help to suggest it in the appropriate clinical setting. The clinical signs of PPROM become

progressively less accurate when more than one hour has elapsed after membrane rupture.

Evaluation of ferning, nitrazine and or ultrasound has shown that they add little, if anything, to

speculum examination alone and that none of them is as accurate as the test based on

biochemical markers. Investigators searched for a test based primarily on the identification in the

cervicovaginal discharge of one or more biochemical markers that are present with ROM, but

absent in women with intact membranes . Biochemical markers are better than the traditional

methods, as they are specific to proteins found in amniotic fluid. Thus they are not affected by

most contaminating substances and enable a fast and reliable bedside diagnosis.

PAMG-1 test (Amnisure ROM Test, Boston, MA) is most useful tool in determining

women at high risk for premature rupture of fetal membranes.The rapid strip test based on

PAMG-1 seems to be the more accurate bedside test compared with others .


NHN MT TRNG HP C THAI LI SAU IU TR BO TN TRONG NHAU CI RNG LC


Nhau ci rng lc (NCRL) l mt bin chng sn khoa, thng km tng ng k bnh

sut v t sut cho m. NCRL do khim khuyt mng rng y, gy nn xm ln bt thng ca

m nhau vo t cung. Theo truyn thng, m ly thai ng thi ct hon ton t cung l chin

lc iu tr ch yu trong nhau ci rng lc. Vi phng thc iu tr ny, sn ph s vnh

vin khng c kinh v khng sinh sau ny; bn cnh , nguy c chu phu kh cao.Vi nhng

ph n c nhu cu gi li chc nng sinh sn, nhng ty chn cch x tr khc c m t.

Trong , bo tn t cung ( li bnh nhau ti ch) c th l mt chin lc thay th.

Chng ti bo co 1 trng hp nhau ci rng lc c iu tr bo tn . Sau 3 nm,

ngi ph n ny mang thai li v sinh m an ton.

CASE REPORT: A WOMAN WITH CONSERVATIVE MANAGEMENT SUBSEQUENTLY HAD SUCCESSFUL PREGNANCY


Placenta accreta is an obstetrical complication associated with significant maternal

morbidity and mortality. It is caused by a defect in the decidua basalis resulting in an

abnormally invasive placental implantation. Traditionally, caesarean hysterectomy at the

time of delivery has been the preferred management strategy for placenta accreta. Not only does

this approach preclude future fertility, but it is also a procedure synonymous with significant

perioperative risks. For women who wish to conserve their reproductive function, other

treatment options have been described. In some settings, uterine conservation (with the placenta

left in situ) may be an alternative strategy.

We report a case of placenta accreta in a nulliparous patient that was conservatively

managed with the placenta in situ. After three years, this woman has pregnancy and cesarean

section safe.


CHN ON TRC SINH CHN ON HNH NH


QUAN IM HIN NAY V TM SOT SM TIN SN GIT Walfrido W. Sumpaico

Hnh thp o ngc l mt quan im mi hin nay, n chuyn s tp trung tm sot

sang qu 1 thay v tm sot qu 2-3 thai k. Chng ta tm sot hi chng Down v cc lch

bi nhim sc th, v gi y chng ta ang pht trin khi nim tm sot tin sn git sm da

trn cc m hnh nh gi nguy c tui thai 11-14 tun. M hnh ny bao gm cc yu t:

Bnh s c yu t nguy c

o p lc trung bnh ng mch t cung

Cc ch s ng mch t cung

Cc ch s sinh ho, c bit l yu t tng trng bnh nhau (PlGF)

Kt qu ch s ny d on 95% nguy c t c th nh gi vic iu tr d phng tin

sn git s dng aspirin liu thp v canxi liu cao t tun 14 thai k.

CURRENT CONCEPTS IN EARLY SCREENING FOR PRE-

ECLAMPSIA


A new concept of inverting the pyramid of obstetric care by shifting emphasis from the

frequent 3rd

trimester visits and mid-trimester screening to newer developments in the 1st

trimester (Nicolaides, 2010). We therefore have witnessed prediction of Downs syndrome and

other aneuploidies. A new development is his groups concept of early prediction of

preeclampsia. The prediction process is based on a multimodal risk approach at 11-14 weeks

AOG using -

*History risk factors,

*Measurement of Mean Arterial Pressure (MAP = DP + 1/3 Pulse Pressure)

*Uterine artery Doppler Indices and

*Biomarkers, notably Placental Growth Factor (PlGF).

This prediction index has resulted in a prediction risk of 95% and at the same time leads

the way to early preventive measures with low-dose aspirin and high-dose calcium starting at 14

weeks.


GI TR QF-PCR TRONG CHN ON NHANH TRC SINH RI LON NHIM SC TH

Nguyn Khc Hn Hoan, Phng Nh Ton, Quch Th Hong Oanh,

Trn Nguyn An Ph, Nguyn Th Nh Hong

t vn : Hi chng Down v cc loi lch bi khc l nguyn nhn quan trng gy ra

sy thai v d tt bm sinh. QF-PCR l k thut mi trong CTS nhm pht hin v can thip

sm thai b cc bt thng ny.

Mc tiu: Kho st gi tr ca k thut QF-PCR trong chn on nhanh trc sinh ri

lon nhim sc th.

i tng v phng php: Cc trng hp thai c nguy c cao b ri lon nhim sc

th pht hin qua tin cn sinh con d tt bm sinh, xt nghim v siu m sng lc trc sinh

c chc i v CTS nhim sc th 13, 18, 21, X, Y bng k thut QF-PCR v so snh kt qu

vi k thut tiu chun vng l karyotype.

Kt qu: 400 thai c CTS, pht hin 36 thai c ri lon nhim sc th (36/400;

9,0%). T l tng hp v phn loi kt qu ca QF-PCR tng hp 100% vi kt qu

karyotype. QF-PCR c nhy l 100% (36/36), c hiu l 100% (364/364), gi tr tin

on dng l 100% (36/36) v gi tr tin on m l 100% (366/366). C 2 trng hp th

khm (46,XX/45,X0 v 46,XX/47,XX,+21) QF-PCR c tn hiu bt thng nhng khng th kt

lun c. QF-PCR pht hin c 2 trng hp bt thng loi trisomy nhng khng kho st

c bn cht cu trc ca chng l 46,XX,-13,+t(13/13) v 46,XX,dup(18). Thi gian ra kt qu ca QF-PCR trung bnh l 48 gi.

Kt lun: QF-PCR l k thut chn on nhanh, ng tin cy trong CTS ri lon s

lng nhim sc th nhng hn ch trong chn on th khm v bt thng cu trc. Cn ch

nh thut karyotype trong cc trng hp ny.

T kha: QF-PCR, ri lon nhim sc th, hi chng Down, chn on trc sinh.


VALUES OF QF-PCR IN FAST PRENATAL DIAGNOSIS OF CHROMOSOME DISORDERS

Nguyn Khc Hn Hoan, Phng Nh Ton, Quch Th Hong Oanh,

Trn Nguyn An Ph, Nguyn Th Nh Hong

Introduction: Down syndrome and aneuploidies are important issues causing

miscarriage and congenital abnormalities. QF-PCR is new method in prenatal diagnosis of those

disorders.

Objective: To evaluate the values of QF-PCR in fast prenatal diagnosis of chromosome

disorder.

Method: Pregnancies detected at high risk of chromosome disorders via history of

congenital abnormalities or biochemistry and ultrasound screening were performed

amniocentesis and analysed chromosome 13, 18, 21, X and Y with QF-PCR and compared to

gold standard karyotype.

Result: 400 pregnancies were diagnosed in which 36 fetuses are affected with

chromosome disorder (36/400; 9.0%). Results from QF-PCR were 100% concordant with

karyotype. The sensitivity, specificity, negative predictive value and positive predictive value

were 100% (36/36), 100% (364/364), 100% (36/36) and 100% (366/366), respectively. There

were two mosaicsm cases including 46,XX/45,X0 and 46,XX/47,XX,+21 which were

inconclusive with QF-PCR. Two trisomy cases detected with QF-PCR were 46,XX,-13,+t(13/13) and 46,XX,dup(18). Average turn around time of QF-PCR was 48 hours.

Conclusion: QF-PCR is a fast and reliable method in prenatal diagnosis of chromosome

disorders but limited in detecting mosaicsm and structural abnormalities. Karyotype is necessary

in such cases.

Key words: QF-PCR, chromosome disorder, Down syndrome, prenatal diagnosis.


TNG KT 5017 TRNG HP THC HIN K THUT NUI CY T BO I IN-SITU LM NHIM SC TH

TRONG CHN ON TRC SINH TI BNH VIN HNG VNG

Nguyn Vn Thng, Nguyn Th Thanh Trc, ng L Dung Nghi,

Phm Th Vn Anh, Bi Hong Thanh Long, Nguyn Vn Trng

Mc tiu: nh gi k thut nui cy t bo i in-situ lm nhim sc th trong chn

on trc sinh ti bnh vin Hng Vng v mt k thut, thi gian tr kt qu cng nh kh

nng chn on ca k thut.

Phng php: tng kt cc trng hp c thc hin cy i lm nhim sc th t

thng 12/2009 n thng 12/2012 ti bnh vin Hng Vng. 14 ml nc i c cy theo

phng php in-situ v nhum bng G. 15 phn bo t 15 khm t bo c phn tch lm

nhim sc th .

Kt qu: chng ti nui cy t bo i c 5.017 trng hp lm nhim sc th .

T l nui cy thnh cng ti trung tm chng ti ln n 99,5%. Thi gian tr kt qu theo bch

phn v th 10, 50, 90 ln lt l 15, 21 v 33 ngy trong sm nht l 8 ngy. Chng ti

pht hin 170 trng hp bt thng chim 3,4% tng s. Cc bt thng lch bi cc nhim sc

th 13,18,21 v gii tnh c th chn on c bng cc k thut chn on nhanh nh FISH,

QF-PCR chim 82% trong trisomy 21 chim t l cao nht (44%) k n l trisomy 18 (16%).

18% cc bt thng cn li gm cc bt thng v s lng khc v bt thng v cu trc

nhim sc th trong cc bt thng khng cn bng c th gy cc d tt nng cho thai chim

1/3 (6%) cc bt thng. Ni cch khc nguy c thai mc cc bt thng gy d tt nng m

khng chn on c bng cc k thut chn on nhanh nh FISH hay QF-PCR l 1/500

(0,2% tng s chc i).

Kt lun: chng ti xy dng thnh cng quy trnh k thut nui cy t bo i in-situ

gip cho n v chn on trc sinh c c cng c chn on mnh ng thi l tiu chun

vng chn on cc bt thng v s lng cng nh v cu trc nhim sc th. Vi quy trnh

ny thi gian tr kt qu nhim sc th sm nht l 8 ngy gip cho thai ph cng nh ngi

nh gim lo lng, hay c th c nhng quyt nh chm dt thai k sm hn khi c kt qu bt

thng.

T kho: nhim sc th , nui cy t bo i, FISH, QF-PCR, chn on trc sinh


KARYOTYPE OF AMNIOTIC FLUID CELLS BY IN-SITU METHOD FOR PRENATAL DIAGNOSIS

IN HUNG VUONG HOSPITAL, VIET NAM: 5017 CASES

Nguyn Vn Thng, Nguyn Th Thanh Trc, ng L Dung Nghi,

Phm Th Vn Anh, Bi Hong Thanh Long, Nguyn Vn Trng

Objective: To investigate the technique, turn around time and abnormality rate of the

karyotype of the amniotic fluid cells in Hung Vuong hospital, Viet Nam.

Method: Evaluate all the karyotype of the amniotic fluid cells from December 2009 to

December 2012 in Hung Vuong hospital. 14 ml amniotic fluid were cultured by the in-situ

method and stained by GTG-banding. 15 metaphases from 15 clones were karyotyped.

Result: A total of 5,017 cases was karyotyped by the in-situ culture method with the

successful culture rate up to 99.5%. The turn around time of the karyotype with the percentile 10,

50, 90 was 15, 21, 33 days, respectively. The earliest turn around time was 8 days. The abnormal

rate was 3.4% (170/5017). Trisomy 21 was the most common abnormalities (44%), followed by

trisomy 18 (16%). The rate of aneuploidy abnormalities which could be done by rapid

aneuploidy detection techniques (RAD) were 82 %. Unbalance abnormalities rate was 6%

(10/170). Substantial risk of RAD (FISH, QF-PCR) in fetus referred for abnormal phenotypic

outcome was 1/500 (0,2%, 10/5017).

Conclusion: We successfully establish the karyotype of amniotic fluid cells, which helps

prenatal diagnosis unit have a "gold standard" to detect chromosomic abnormalities of the fetus.

With the shortest turn around time at 8 days, karyotype can help reduce anxiety for pregnant

women or earlier abortion with an abnormal result.

Key word: Karyotype, amniocytes culture, FISH, QF-PCR, Prenatal Diagnosis


D TT TIM TRONG THAI K TI BNH VIN T D Bi Th Thu H, Ng Th Yn, Bi Thanh Vn

Mc tiu: Xc nh cc nhm thai ph cn c sng lc sm v siu m tim thai, theo y

vn. Mt s khuyn co t vn h tr cho thai ph c thai nhi d tt tim bm sinh. Ch nh chc

i vi mc ch ph hp.

Ni dung:

1. S lc mt s vn lin quan tm sot d tt tim bm sinh trong thai k:

- Ba nhm yu t nguy c cn ch nh siu m tim thai - Cc mc bnh l tim bm sinh - D tt tim bm sinh lin quan vi bt thng nhim sc th. 2. Qui trnh hin ti v khm v hi chn bnh tim bm sinh ti bnh vin T D.

3. Tnh hnh bnh tim bm sinh ti bnh vin T D t 01/01/2012 n 15/3/2013

Kt lun: Vai tr phi hp ca bc s sn khoa, bc s siu m tin sn, bc s siu m

tim chuyn khoa, bc s di truyn, bc s ni tim mch nhi v bs phu nhi trong pht hin, chn

on v x l cc d tt tim bm sinh trong thai k.

FETAL HEART DEFECTS AT TU DU HOSPITAL


Objectives:To determine pregnant population recommended to early routine screening

and indicated fetal heart ultrasound on literature basis. To introduce some counseling in case of

congenital heart defect(s) and select amniocentesis.

Contents: 1. Summary of main points related in screening congenital fetal heart: three high-risk groups that

fetal heart ultrasound needed, category of congenital fetal heart defect, cardiac defects associated

with chromosomal abnormality; 2.Current management of fetal heart defects at Tu Du hospital;

3. Overview of fetal heart defects at Tu Du hospital from January, 2012 to March, 2013.

Conclusions: Pregnant women get benefits from the cooperation of clinical obstetricians,

ultrasound obstetricians, fetal heart ultrasound specialists, genetic doctors, pediatricians in

finding, diagnosis and management of fetal heart defects.


X TR CC TNH HUNG KH TRONG A THAI Tony Tan

Gii thiu

Cc nguyn nhn chnh gy t vong v bnh tt a thai l sinh non, d tt thai, thai

chm tng trng trong t cung, y l nhng hu qu thng gp nhng trng hp song thai

cng trng c chung 2 lp mng m bn ngoi (monochorionic twins), v nhng hu qu ny

cn cao hn nhng trng hp a thai t 3 thai tr ln.

Sanh non

Sanh non trong a thai l do chuyn d sanh non, i v sm v sanh non do ch nh sn

khoa, c bit l i vi tin sn git - bnh l ny thng xy ra sm hn v nghim trng hn

nhng trng hp a thai.

C th d on trc c nhng trng hp chuyn d sanh non nh vo s kt hp

siu m o chiu di knh c t cung v cc xt nghim sinh ha. Khng c bng chng no cho

thy rng khu eo c t cung nhng trng hp a thai c th lm gim t l sinh non.

Vic dng corticosteroid thi im ph hp trong thai k lm gim nguy c cho tr

mc cc bnh l do sanh non, v vic theo di mt cch hp l sau khi tim corticosteroid s

lm gim nguy c chm dt thai k sm do ch nh y khoa khng ph hp.

Vic tim bp progesterone hng tun cho thy c th lm gim chuyn d sanh non

nhng trng hp n thai, v c th c p dng trong a thai. Vic tr hon chuyn d c th

l mt la chn ko di thai k cho 1 hoc nhiu thai cn li khi m thai u tin trong a thai

c sanh ng m o trc 30 tun tui thai.

Vic hy thai chn lc i vi nhng thai pht trin khng c th sng ngoi

bung t cung v nhng thai c chm tng trng trong t cung nhng trng hp tin sn

git nng khi pht sm c th gip km hm tin trnh pht trin ca tin sn git, cho php ko

di thai k cho ti khi s pht trin ca 1 hoc nhiu thai cn li tt hn m t lm tng nguy c

cho m.

D tt thai

D tt thai thng gp hn cc trng hp a thai. Cng vi nhng kh khn trong k

thut kho st cp song sinh, nhng d tt ca thai nhi c th b b qua, khng chn on c

trong a thai. Khuyn co nhng trng hp a thai nn c khm tm sot mt trung tm y

khoa c cht lng. Vic hy thai chn lc i vi thai d tt c th c xem xt vi nhng

bnh l c chn lc c th gy/khng gy t vong thai sau sanh.

Thai chm tng trng trong t cung

Thai chm tng trng trong t cung (IUGR) thng gp hn trong cc trng hp a

thai, v vy cn phi c theo di cht ch hn. S kh khn trong vic theo di v vic cn

thit xem xt thai chm tng trng trong t cung v thai pht trin bnh thng s gy th

thch cho vic a ra quyt nh chm dt thai k.

Nhng bin chng ring nhng trng hp song thai cng trng, 2 thai c chung

2 lp mng m ngoi cng

Nhng trng hp song thai cng trng c chung 2 lp mng m bn ngoi

(monochorionic twins) th c nguy c b sy thai, sanh non, thai chm tng trng trong t cung

(IUGR) cao hn nhng trng hp song thai 2 trng hoc song thai 1 trng phn chia sm (song

thai 1 trng 2 nhau, 2 ti i). S hin din ca ch ni mch mu trong trong trng hp 2 thai

c cng bnh nhau (chung 2 lp mng m) s tng nguy c b hi chng truyn mu song thai

(TTTS), ti mu ng mch o ngc trong song thai (TRAP) v nguy c cao t vong hoc

tn thng thn kinh trong trng hp c 1 thai lu. Vic theo di cht ch cho TTTS v IUGR


bng siu m Doppler cho php pht hin sm cc bin chng trong mt s trng hp, v do

nhng can thip sm bao gm gim i, iu tr bng laser chn lc v tr cc ch thng ni

mch mu nhau thai, theo di cht ch hn vi siu m v CTG, hoc chm dt thai k sm.

Nhng trng hp a thai t 3 thai tr ln

Nhng thai k c t 3 thai tr ln th c nguy c cao b sy thai, sanh non v thai chm

tng trng trong t cung. Nhng ci tin trong k thut h tr sinh sn v cc k thut can thip

trong thai k gip lm gim s xut hin nhng thai k c t 3 thai tr ln. Khi a thai t 4

thai tr ln, vic tin hnh th thut gim nhiu thai trong thai k (MFPR) l mt la chn

gim nguy c sy thai , sinh cc non, v cc bin chng do sinh cc non.

MANAGEMENT OF DIFFICULT SCENARIOS IN MULTIPLE

PREGNANCIES

Tony Tan

Introduction

The main causes of mortality and morbidity in multiple pregnancies are prematurity, fetal

anomalies, intrauterine growth restriction, specific consequences of monochorionic twins, and

higher order multiple pregnancies.

Prematurity

Prematurity in multiple pregnancies is due to premature labour, premature rupture of

membranes and iatrogenic premature delivery especially for preeclampsia which occurs earlier

and more severely in multiple pregnancies. Prediction of premature labour can be achieved

through a combination of ultrasound cervical length measurements and biochemical tests. There

is no evidence to show that cervical cerclage in multiple pregnancies reduce premature delivery.

Appropriate timing of corticosteroid administration reduces the risks of morbidity due to

prematurity, and appropriate monitoring after corticosteroid injection reduces the need for

inappropriate iatrogenic premature delivery. Weekly intramuscular progesterone injections have

been shown to reduce premature labour in singletons, and may be used in multiple pregnancies

as well. Delayed interval delivery may be an option to prolong the pregnancy for the remaining

fetus(es) when the first twin is delivered vaginally before 30 weeks. Selective fetocide of the

previable and severely growth restricted fetus in a multiple pregnancy with severe and early

onset preeclampsia may reverse the process of preeclampsia, allowing prolongation of the

pregnancy for the other appropriately grown fetus(es) with little risk to maternal well being.

Fetal Anomalies

Fetal anomalies are more common among multiple pregnancies. Combined with the

increased technical difficulty of assessment in twins, fetal anomalies may be more commonly

missed in multiple pregnancies. A screening scan at a good tertiary center is recommended for

multiple pregnancies. Selective fetocide of the anomalous fetus may be considered for selected

lethal and non-lethal conditions.

Intrauterine Growth Restriction

Intrauterine growth restriction (IUGR) is more common in multiple pregnancies,

necessitating a need for closer surveillance. Difficulty in monitoring and the need to consider

both the IUGR and appropriately grown fetuses often makes the decision to deliver a challenging

one to make.

Specific Complications Of Monochorionic Pregnancies

Monochorionic pregnancies are at higher risk of miscarriages, prematurity and IUGR

than di- or multi-chorionic pregnancies. The presence of vascular anastomoses in

monochorionic placentas specifically puts the pregnancy at risks of twin-twin transfusion


syndrome (TTTS), twin reversed arterial perfusion (TRAP) sequence and the high risk of death

or neurologic damage to the co-twin in the event of the death of one twin. Close surveillance for

TTTS and IUGR by ultrasound and Doppler techniques allows early detection of such

complications in some cases, and hence earlier intervention which includes amnioreduction,

selective laser ablation of placental vascular anastomoses, even closer surveillance with

ultrasound and cardiotocography (CTG), or early delivery.

Higher Order Multiple Pregnancies

Higher order multiple pregnancies are at high risk of miscarriage, prematurity and

intrauterine growth restriction. Improvements in assisted reproductive techniques and its

governance reduce the occurrence of higher order multiple pregnancies. When the multiple

pregnancy is that of quadruplets or higher order, multifetal pregnancy reduction (MFPR) is an

option to reduce the risk of miscarriage and extreme premature labour and the complications of

severe prematurity.


D TT H THN KINH TRUNG NG: T SIU M N CNG HNG T

Nguyn Th Thu Trang, H T Nguyn

Siu m l phng tin u tin v chnh yu nh gi thai qua cc giai on pht

trin, trong vic pht hin v chn on tt c cc bt thng ca thai. Cc hnh nh bnh thng

hay bt thng pht hin c trn siu m phi da vo cc hnh nh chuyn bit thu c, v

d hnh nh ca vng h sau, ca tiu no, ca thu nhng, ca thn no, ca ct sng c

c nhng hnh nh ny i hi t th thai phi thun li, thnh bng ca m khng qu dy,

nc i phi Cng hng t t b l thuc vo cc iu kin trn nn MRI d dng c c

nhng hnh nh r rng, cn thit gip ch cho vic chn on.

Mc ch: kho st cc tn thng ca no thai nhi trn siu m v cng hng t, nh

gi gi tr ca siu m v cng hng t trong vic chn on cc bnh l ca h thn kinh trung

ng.

Phng php: hi cu 207 ca thai vi tui thai t 18 38 tun c bt thng h thn

kinh trung ng c siu m tin sn v chp cng hng t trong mt tun sau ti bnh

vin T D t 01/01/2012 n 25/02/2013

Kt qu: Trn cng hng t, c 49,2% dn no tht, 25,6% bt thng h sau, 16,4%

bt sn th chai, 27.5% nhiu bt thng kt hp. 57% trng hp siu m v cng hng t c

chn on ging nhau; 15,4% trng hp cng hng t cung cp thm thng tin cho siu m;

27.5% ca cng hng t lm thay i hon ton chn on ca siu m. Cc trng hp cng

hng t lm thay i kt qu ca siu m-siu m khng nh gi c: 5.3% nhn no,3.8%

lon dng nhu m no (cerebral atrophy), 8.2% bt sn th chai, 3.8% xut huyt/nhi

mu/thoi ho nc nhu m no, 2.8% thiu sn bn cu tiu no/thn no,

Kt lun: Nhn chung, c cng hng t v siu m u gip chn on cc bt thng

ca h thn kinh thai nhi, nhng cng hng t vi li th v k thut, phn gii gip pht

hin v chn on vt tri hn siu m c bit l cc bnh l ca cht xm, cht trng, th

chai v h sau.


M HNH SNG LC TRC SINH: HNH THP O NGC

H T Nguyn

th k th 19, vic chm sc thai ph ch l lc vo chuyn d, hon ton cha c vic

chm sc trc sinh. Do vy t l t vong m v thai nhi kh cao. iu ny thc y vic cn

thit phi c s chm sc trc sinh. Do vy, vo nm 1929, b y t Anh ra khuyn co lch

trnh khm thai cho cc thai ph, ln khm thai u tin vo lc 16 tun, sau l 24 v 28 tun,

ri mi hai tun cho n 36 tun v mi tun cho n khi sanh. S quan tm chm sc c tp

trung qu 3 thai k v hu ht cc bin chng u xy ra 3 thng cui v chng ta cha sng

lc tin on c cc bin chng ny qu 1 v qu hai.

Tuy nhin trong vng 20 nm tr li y, m hnh chm sc tin sinh o ngc. Ln

khm thai u tin c khuyn co thi im 12 tun v nhiu xt nghim sng lc c p

dng nhm nhn din sm cc thai k nguy c cao t c th chn on sm hoc d phng

sm cc bin chng ny. Chng ta bit hn 90% cc lch bi c pht hin nh xt

nghim sng lc phi hp siu m o m da gy v xt nghim double test (PAPP-A v Beta

HCG) thi im 11-13 tun 6 ngy.

Do sanh non v tin sn git cng l nhng bin chng thng gp v nghim trng

trong thai k. D chng ta hiu nhiu hn v cc yu t lin quan cng nh c ch sinh bnh

hc ca chuyn d sanh non nhng t l sanh non vn khng gim trong 50 nm tr li y.

nhng quc gia pht trin, sanh non l nguyn nhn ca mt na t vong s sinh. Phi hp

siu m o chiu di c t cung ng m o v cc yu t nguy c c th hu hiu hn vic sng

lc ch da trn n thun mt yu t. Vi t l sng lc dng tnh 5%, s pht hin khong

70% cho cc trng hp sanh cc non, 45% sanh non, 40% sanh non trung bnh v 15% sanh

non nh. Nu t l sng lc dng tnh l 10% th t l pht hin l 80%, 60%, 55% v 30%.

Khc vi sanh non, vic sng lc v d phng tin sn git c v ang c nhng thnh

qu nht nh. Vic sng lc phi hp gia yu t tin cn ca thai ph, siu m o ch s PI

ng mch t cung, o huyt p ng mch trung bnh v sinh ho mu m ( PAPP-A v PlGF)

thi im 11-13 tun 6 ngy c th tm sot c 96% tin sn git khi pht sm. Vic d

phng Aspirine liu thp trc 16 tun cho thy gim c tn sut tin sn git 50% thai

k nguy c cao v t l sanh non gim 89%.

Ti liu tham kho: fetalmedicine foundation (FMF)


PH KHOA


VAI TR SIU M TRONG CHN ON THAI BM SO M LY THAI C

H T Nguyn

S lm t ca bnh nhau vt so m ly thai c thng gy ra nhng bin chng

nghim trng trong thai k nh v t cung, nhau tin o, nhau ci rng lc. Tin lng ca

thai bm so m c nu c chn on qu mt c tin lng tt hn nhau tin o- ci rng

lc c chn on qu ba thai k. Do vy ngi lm siu m cn thit phi chn on sm

v chnh xc loi bnh l ny gip bc s sn khoa c bin php can thip x tr sm, trnh

xy ra nhng bin chng nghim trng cho thai ph.

Gi thuyt v sinh l bnh ca bnh nhau lm t bt thng: do s thiu oxy m v mch

mu bt thng ti vng so m c nn bnh nhau c khuynh hng bm chc mt cch bt

thng.

Siu m c xem l phng tin u tay v rt c gi tr trong chn on thai bm so

m ly thai c.

1. Ti thai nm thp ti v tr so m ly thai

- Nm hon ton trong thnh trc t cung - Nm mt phn trong lng v mt phn trong thnh trc t cung - Khi echo hn hp: thng sau ht no

2. Khng c du hiu trt

3. C dng chy trn doppler mu ca lp nguyn bo nui

nhy ca siu m: 86.4% theo Ash v cs (2007)

Cn chn on phn bit vi: thai trong lng t cung bm thp ( ti thai nm gia lng t

cung, thnh trc v sau dy nh nhau), thai ang sy ( ti thai nm gia lng t cung, c du

hiu trt, khng c dng chy trn Doppler mu), thai c t cung ( ti thai nm di so m

ly thai c, khng c du hiu trt, c dng chy trn Doppler mu)

Cn thit o b dy c t cung thnh trc bao quanh ti thai c nh hng trong x

tr cho nh lm sng. V nhng ti thai c lp c t cung thnh trc bao quanh qu mng th

khng nn can thip ngoi khoa.


CP NHT IU TR THAI NGOI T CUNG SO M LY THAI

Phan Vn Quyn

Thai ngoi t cung so m ly thai (TNTCSMLT) c Larsen v Solomon bo co

t 1978. xut hin ca TNTCSMLT chim khong 1/1.800 -1/2.500 tng s sanh (Timor-

Tritsch). Khi thai bm vo c t cung qua khe h so m ly thai (MLT), v tr him gp.

Nhng bo co gn y cho thy xut hin c khuynh hng tng dn. theo s MLT v vi

ng dng rng ri siu m qua m o cng gip pht hin sm cc trng hp TNTCSMLT.

Cc triu chng thng rt t hay khng c. Chn on d nhm vi thai trong t cung,

sy thai hay thai ngoi t cung c t cung. Chn on thng kh khn, nu chn on sai c

th dn n tai bin nng v phi ct t cung.

Siu m qua u d m o l phng tin chn on xc nh, nhng trng hp nghi

vn c th cn MRI. Tiu chun chn on TNTCSMLT vi siu m ng m o v Doppler

mu gm: (1) bung t cung trng, (2) knh c t cung trng, (3) ti thai nm gia bng quang

v phn trc on eo t cung, lp c t cung gia bng quang v ti thai khng c hay rt

mng (


MANAGEMENT UPDATE OF CESAREAN SCAR ECTOPIC PREGNANCY

Phan Vn Quyn

A cesarean scar ectopic pregnancy (CSP) occurs when a pregnancy implants on a

cesarean delivery scar. The first case was reported by Larsen and Solomon in the English

medical literature in 1978. Generally considered among the rarest forms of ectopic pregnancies,

its prevalence is estimated between 1 per 1,800 and 1 per 2,500 pregnancies. However, the

incidence is rising with the increased incidence of cesarean deliveries, and the diagnosis is being

made earlier because of the increased use of transvaginal sonography.

The lack of specific clinical symptoms or signs may lead to a delay in diagnosis or

even failure to make a correct diagnosis, particularly if awareness of this condition is low. It can

sometimes be difficult to distinguish a failed pregnancy or miscarriage in progress and a cervical

ectopic pregnancy from a pregnancy implanted on a cesarean scar. The diagnosis is often

difficult, and a false-negative diagnosis may result in major complications, including a

hysterectomy.

The diagnosis is based on finding a gestational sac at the site of the previous cesarean

scar in the presence of an empty uterine cavity and cervix, as well as a thin myometrium adjacent

to the bladder. Early recognition of the transvaginal sonographic findings is critical because a

delay can lead to increased maternal morbidity and mortality. MRI is a valuable troubleshooting

tool when sonography is equivocal or inconclusive before therapy or intervention. Early

diagnosis by sonography directs therapy and improves outcomes by allowing preservation of the

uterus and future fertility. The following sonographic criteria have been put forward for early

diagnosis of cesarean scar pregnancies in the first trimester: (1) empty uterus with a clearly

visualized endometrium; (2) empty cervical canal; (3) gestational sac within the anterior portion

of the lower uterine segment at the presumed site of the cesarean scar; and thinned or absent

myometrium between the gestational sac and bladder (


2. Graesslin O, Dedecker F Jr., Quereux C, Gabriel R. Conservative treatment of ectopic pregnancy in a cesarean scar. Obstet Gynecol 2005; 105:869871.

3. Maymon, et all; Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy, J. Ultrasound Med. 2011;30:1179-1184.

4. Timor-Tritsch. Early placenta accreta and cesarean section scar pregnancy: a review. Am J Obstet G

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