Tap chi THONG TIN Y DUQC So 9 nam 2012
DAC DEVI \m SANG VA CAN XM SANG CUA SAN PHU MAC BBW VIBVI GAN B DE TAI BENH VIEN PHU SAN TRUNG UONG
LS Tiii Tftanti VSn\ Pli^m Thf Tl%anh Hien", Nguyin DuyHttng'"
TOM TAT
Muc tieu: md ti d$c dii'm lim sing, c$n lim sing sin phi^ viem gan B (HBV) d^ tai Benh vien Phi^ sin Trung utfng (BVPSTW) vi m$t s6' biin chuhg HBV inh hu'dng den me vi thai trong chuyen d^. Ddl tupng vi pttuVng ptiip: mo ti cSt ngang, hoi cut/ hd sd sin phij HBV di t^l BVPSTW trong 5 nSm tit thing 1/2006 - 12/2010. Ket qua: 152 ho sd b$nh an, ty le sin phy viem gan li 0,16%, co xu hutfng ngiy cing ting, nim 2009 cd ty le cao nhat (chiem 0,32%). Chan doin sdm dS'dup'c diiu trj tn/dc vi trong khi cd thai ngiy cing ting (33,3%
nim 2010). Trieu chuhg lim sing hay g$p nhit li m$t mdi (48,1 %), chin in (52,6%), ving da ving mit (22,4%). Ndng tf(5 blllrulln miu ting cao d52 BN (chiim 34,2%). Men gan ting cao d 80 BN (chiem 52,6%). Sinh s0i huyit (SSH) giim dudi 2 g/l, giy chiy miu sau de 22,7%.
Bien chuhg doi vdi thai nhi gay de non 24,3%, suy thai trong chuyin d? 21,1%, thai chit sau di 0,7%. Ket lu$n: tri$u chiihg lim sing khdng die hl^u, dui vio xet nghiem men gan yiu to ddng miu decha'n doan va tien lupng CUQC di.
SUMMARY
Clinical and laboratory features of pregnant women with hepatitis B at National hospital of obstetrics and gynecology
Objectives: to describe the clinical and laboratory features of pregnant women with hepatitis B at National hospital of obstetrics and gynecology and list some complications of hepatitis B affecting the mother and fetus during labor Methods: A cross-sectional retrospective research was conducted on 152 women with hepatitis B who had given birt^ in National hospital of obstetrics and gynecology during 6 years fi-om January 2006 to December 2010. Results: The rate of maternal hepatitis was 0.16% and showed an Increasing trend, the highest rate was 0.32% in 2009. The rate of early diagnosis and treatment before and during pregnancy reached 33.3% in 2010. The most common symptoms are fatigue (48.1 %), anorexia (52.6%), jaundice (22.4%). Bilirubin level was high in 52 patients (34.2%). Elevated liver enzymes occur In 80 patients (52.6%). Fibrinogen level falls below 2 g/l and the rate of postpartum hemorrhage was 22.7%. Complications to the ^tus: preterm labor (24.3%), fietal distress during labor (21.1%), fetal death after delivery (0.7%). Conclusions: The clinical symptoms are not specific, diagnosis and prognosis for delivery are based on levels of liver enzymes and clotting factors.
I. DAT VAN OE
HBV li mpt benh truyen nhilm, glp nhieu d cic nuidc dang phit trien, ty le mSc benh cao, hau qui ning ne, diy la benh mang ti'nh toan cau. Theo thdng ke ciia To chu'c Y te The gldl nlm 1997, ti-en the gldl cd khoing hdn 2 ty ngu'di nhiem HBV, trong dd cd 60 trieu ngu'di chet vi ung thu gan nguyen phit va 45 trieu ngu'di chet vi xd gan [8]. Viet Nam la nu'dc cd ty le HBV cao [1]. San phu nhiem HBV cd rat nhleu tai bign nhu" de non, thai chet lull, lay truyen tu* me sang con va die biet chay miu sau de v l hdn me gan, ty l | t\S vong cao [5,7,8].
"TS.; " T S . ; " T h S . , Oai hoc Y Ha Noi
De han che den miit thap nhat nhung tai bign do HBV, can phii phit hign bgnh sdm, co thai dp x\S tri dung din de dat du'dc ket qui tdt cho cl me v l con, chiing tdi nghien ciJu d§
tai vdl muc tigu: md t l d$c diem lim sang vi c|n lim sang sin phu viem gan B de tai BVPSTV/ vi mot sd bien chufng viem gan B inh hu^ng d§n me v l thai trong chuyen da.
I I . OOl T U O N G VA PHUONG PHAP 1. Dot tu'dng nghien cuti San phu dudc chan doan la vigm gan B chuydn da de tai BVPSTW ti-ong 5 nam ti^
thing 1/2006-12/2010.
24
lap chi THONG TIN YDVQC So 9 nam 2012
* Tieu chuin lu^ chon BN: cic benh i n cua san phu de tai BVPSTW n l m 1/2006 12/2010 du tigu chuan nghien ciili:
- Xet nghigm HbsAgC+) cd kem theo t i n g men gan (SCOT, SGPT >31 UI/L, bilirubin binh thu'dng t o i n phan >7 pmol/l, tryc tlep >4,3 pmol/l, gian tiep >12,7 pmol/l) va/holc xet nghigm HbeAg(-f) va Anti HbeAg(+).
- £>ay du cic bien so nghien ciili: bilirubin, SCOT, SGPT, SSH, protiirombln.
* Tieu chuan ioai tilt: cac benh an khdng day du tigu chul'n \\is chpn.
2. Ptnf dng phap nghien ah/
2.1. Thiit ke nghien cuti: md t l c3t ngang, hoi Cliu.
2.2. Tien hinh:
- Cd mau: lay theo thdi gian, ngn tat ca ddl tu'dng du tieu chuan nghien CLTU du'dc l l y v i o nghign ciiti.
- Ky t h u l t thu thap sd lieu: hoi ciilj benh i n theo mau phl§u in sSn.
- Bien sd nghien cu\j
+ B l c diem ddl tu'dng nghien ciitj, trieu chtfrig l i m sang, trieu chuYig can l i m sang.
Mdi tudng quan gluci ti-|gu chiiTig l i m sing va can lam sing.
+ Bien diiing cho me v l con: moi tudng quan nong do men gan vdi isoi diuhg me va con.
2.3. Xu'ly so Beu:\xivq phan mem SPS 16.0.
i n . Kit QUA
Qua nghien culi 152 ho sd chiing tdi thu dUdc ket qua sau:
l.Tyl$benh
Ty |g sin phu mac HBV so vdi sd san phu de
^1 VHn tixxig 5 nam 11 0,16%, cao nhit nlm 2009 la 0,32%.
3. Tri$u chihig can ISm sang Bing 2: Trieu chuhg cSn lam sing
2006 2007 2008 2009 2010
Bleu dd 1: Ty 10 chuyin Benh vien Y hoc lam sang vi <^c benh Nhiet ddi Trung Udng.
Ty le BN du'dc chuyen di dieu tri not khoa tai B^nh vien Y hpc lam sing v i cic benh Nhiet ddi Trung Udng i i 19,1%. Ty le tang dan theo tLrtig n l m , tii' 12,5% nam 2006 tang len 33,3% n l m ZOlO.Ty le BN dudc chan doan v i dieu trj trong thdi gian tn/dc khi chuyen da la 13,8% (21/152 BN).
2. Trieu chutig lam sang Bang 1: Trieu diuhg lam sang (n=152) THSu chihig
Of nang:
- Met moi - Chan 3 n - V a n q da Thut the:
- Xuat tiuyet - Co chuang - T e o g a n - Gan t o - t i c h to
SoBN
SO 73 34 3 4 3 9 5
TL<ii, 52,6 48,1 22,4 2 4,6 2 5,9 3,3 Trieu chiing lam sang chii yeu la cd ning:
met mdi 52,6%, chan an 48,1%.
X4t nghidm Bilinjbin tang:
Toan ph3n TruttieD Men gan tang:
SCOT S G I T SSH:
>2 9/l
<2q/l Prothmmbin:
Binh thu'dng Giam
1-2 Mn SoB/V
7 12 43 31
n%
4,6 7,9 28,3 20,4
3-4 an SoBN
3 4 16 3
71%
2 2,6 10,5 2
5-aan
SoBN9 3 13 17
n.%
5,9 2 8,6 11,2
9-16 an SoBN
16 8 3 3
TL%
10,5 5,3 2 2
SielSn SoBN
10 25 5 5
71%
6,6 16,4 3,3 3,3
TSmt SoBN
45 52 80 59 130 22 133 19
71%
29,6 34,2 52,6 38,9 85,5 14,5 87,5 12,5
Tfp chl THONG TIN YDVQC
!>i> V nam 1012NSng d$ bilirulin mdu tdng cao d 52 BN (chiem 34,2%). Men gan tSng cao H 80 BN (chiem 52,6%).
Bang 3: Bien chutig 661 vdi me vei thai Bien chihig
Chdy mdu sau d^
Oe non Suy thai Trd nhe cdn Chet chu sinh
SL 17 37 32 20 1
7 1 % 11,2 24,3 21,1 13,2 0,7 Bien chufng cho m? hay g^p 11 chly m l u sau dg (11,2%), khdng cd tru'dng hdp n i o tir vong hay hdn mg gan. Bien chiing cho con chO yeu la dg non (24,3%).
Bing 4: Lien quan giu^ SSH vi chiy miu saud^
Khcrtj chdy mai Co chay mdu Tonq
<2 SSBN
17 5 22
1/1 71%
77,3 22,7 100
« 2 SfS/V 120
10 130
f/l
TL%
92,3 'r?
100 P
<0,05 Ty le chly m l u sau de d nhdm cd SHH g i i m cao hdn so vdi nhdm cd SHH binh thu'dng {p<0,OS).
Bang 5: Lien quan glQei men gan va ty li de non
Denon Du thdng Tonq
Men gan binh thwdng BN 14 79 93
7 1 % 9,2 52,0 61,2
Men gan tSna BN 23 36 59
n%
15,1 23,7 38,8
P
<0,05 Ty lg de non d nhdm cd men gan t i n g cao hdn ( ; K O , 0 1 ) .
I V . BAN LUAN
Ty le vigm gan trong 5 n l m : dao dpng til 0,07-0,32%, t h i p hdn ket q u i a i a c i c t i c gia nu'dc ngoii nhu" tac g i i Nowell M.L. v i c$ng s y (1999) [7] la 0,3-17%. Cao hdn khdng dang ke vdi ket q u i a i a c i c tac g l l Vi?t Nam khic cung nghien ciilj tai BVPSTW v i o n l m 2006 l i 0,15% (Vu Thj Thu Huyen) [ 3 ] . Ty le khac nhau nhy vay cd t h l l i cich lay mau chi/a dai dien chung, s i n phu dg tuyen du'di khdng chan d o i n viem gan do virus. Thi/c te, ty le thai phu viem gan B tai H i Ndi la 10,6%
(Olnh Thi Binh 2000) [ 1 ] .
1. Lim sing vi c$n Hm sing sin phy viSm gan B di t^l BVPSTW
Vl§c chSn d o l n sdm viem gan B d phg nD' mang thai g$p khd k h i n do c i c ti-l^u chiing l i m s i n g khdng d i l n hinh. Tri?u chiing cd ning c h i n I n v l m§t mdi chi cd 52,6% m i thyc t g r l t khd p h l n biet vdl tinh trang met mdi khi cd thai. Chi cd 22,4% l l cd v i n g da v i n g m l t . Trl$u chiing thyc t h l khdng d§c hl§u, m i hiiu nhy khdng tim t h i y nhy gan to (5,9%), gan teo (2%), lich to 93,3%. Khi cd thai, k h i m gan rat khd, sigu i m cung l i mdt xgt nghidm h5 tr^, k i l m tra thai v l gan.
X^t nghidm chu'c n i n g gan l i Q n thiet vira cd g i i tri c h i n d o l n v l tign ly(?ng. 22,4%
s i n phi^ cd v i n g da v i n g m l t phu hdp vdl t^
!§ t i n g bilirubin t o i n p h l n 29,6% v l tii/c tiep l i 34,2%. Ndng dp bilirulin m i u t i n g cao d 52 BN (chilm 34,2%). Khi Bilirubin t i n g b^n 30 pmol/l se g i y vang da tren lam sing.
Hdi chiing hiiy hoai te b i o gan dydc bleu hi$n b l n g sy t i n g c i c men gan trong m i u , 52,6% t i n g SCOT v l 38,9% t i n g SGFT. Oa sd cic trydng hdp cd t i n g g l p 3 lan. Myc t i n g n i y thap hdn c i c nghien cu\j khic nhy Vu Thj Thu Huyen (2000) [3] t i n g gap 8-9 lan.
2. Bien chung viem gan B inh huidng din mf vi thai tmng €ituy&t da
s y c h i m soc su'c khde sinh s i n , quin ly thai nghen tdt hdn nen s i n phu dudc chan d o i n va dieu tri phoi hdp vdl Bgnh vien Y hpc l i m sang v i cic benh Nhiet ddi Trung udng ^ hdn, chuyen vi?n t i n g dan, n l m 2010 tSng g l p 3 lan n i m 2006. Oudc chan d o i n sdm va digu ti-j trudc khi sinh l i 58,3%. Vi vay ty le bien chiing chiy m i u sau de l i 22,7%, tiilp hdn cac t i c g i i trong v i ngoii nude, theo Medhat A., 1993 [7] la 18,8%, Nguyen Dy OSu, 2006 [2] l i 31,6%.
Biln chiing chay mau llgn quan chat che vdl sy giam SSH v l g i l m prothrombin. Theo bing 4, nhdm cd SSH >2 g/l t / le khdng chiy m i u sau dd diiem tdi 92,3%. Trong nhdm cd SSH <2 g/l thi tv' le cd chly mau sau de len tdi 22,7%. Khi chiit nang gan bi suy giim, t / le SSH v i prothrombin g i i m dot ngpt bao hlgu tinh ti-ang x l u ciia bgnh, d i n den chiy m i u , suy da phli tang, hdn me va tii' vong, Theo Nguyen Dy Dau 2006 [2], ty le hdn m l gan la 18%, tli" vong 16,5%. Theo nghien a i l i cua Vu Khinh Lln (1978) [5], tixing sd BN tii" vong, 43,3% tni'dnp hdn r n tv IS nmHimmhin n\sm
26
Tap chi THONG TIN YDlfQC So 9 nam 2012
nang dudi 50%. Trong nghien a i l i cua chiing tdi, khdng cd BN nao bi hdn mg gan hay t y vong sau de. Phai ching dydc chan doan va digu tn sdm HBV nen chiit nSng gan dn djnh, yeu td ddng mau it bi g i l m nen ket q u i lat hdn.
Tuy v | y , anh hydng HBV doi vdi thai vSn cdn nhieu, trong dd ty le de non chilm 4,3%, t i n g cao hdn nhung trydng hdP thai s i n phu binh thydng 11 10,9% theo Vu T i l n L i m , 2008 tai BVPSTW [4]. Martiin L., 1999 [6] nhan xet me bi viem gan do virus vao 3 t h i n g cudl thai ky thi nguy cd de non, thai c h i t luu t i n g .
Cd mdi llgn quan c h i t che glu'ia t i n g men gan v l ty le de non. Theo bing 5, men gan cang cao ty le de non cang cao (p<0,01).
Chiing td rSng khi gan cua me cd tdn thudng se Inh hudng den thai nhi. Vi v l y trong dieu tn thai phu viem gan B chiing ta p h l i quan tam den nguy cd cho thai, ket hdp dieu tri de non v i thai cham phat trien trong tit cung.
Suy thai trong chuyen da chiem 2 1 , 1 % , nguyen nhan suy thai 11 thai non t h i n g , thai suy dinh dydng trong t y cung, de ra tre nhe can (<2500 g) 13,2%, ty le tiiai chet sau de 0,7%. Theo nhleu tsc g i i [5,6,7], d nhUng thai phu vigm gan B, tien lydng cho thai phu thudc v i o mii'c dp nang cua bgnh. Cd che g i y chet thai gia thuyet cho rang l i do virus ti-uyen ti^ me qua thai lam cho thai cung bj nhiem virus gay suy thai, thai cham p h i t trien trong tii' cung. Bien chyng de non la do add m l t cd hoat tinh gidng oxytocin nen gay chuyen da sdm, thai suy la do t i n g nong dd acid mat d thai. Mudn lam sing t d nhiing nguyen n h l n n i y chiing ta phai tiep tue nghien ciJu sau hdn d tre sd sinh sau de.
V. KET L U A N
Qua nghien cufu dac diem lam sang va c i n lim sing 152 trydng hdp ttial phu viem gan B de tai BVPSTW trong 5 nam tii t h i n g 1/2006 - 12/2010, chung tdi nit ra mdt sd ket luan:
- Ty le s i n phu viem gan B de tai BVPSTW l i 0,16%.
Trieu chiing cd ning hay g l p nhat l i chin I n 52,6%, met mdi 4 8 , 1 % , vang da v i n g m i t 22,4%.
- Tri?u chiing thyc t h l khdng d§c hi^u.
- Ndng dp bilirulin m i u t i n g cao d 52 BN (chiem 34,2%).
- Men gan ting cao d 80 BN (chiem 52,6%).
- SSH gilm dudi 2 g/l g l / d i l y mau sau de 22,7%.
- Bien chiihg ddi vdi thai nhi: giy de non 24,3%, suy tiiai tixsng chuyen da 21,1%, tiiai chet sau dd 0,7%.
* Kiin nghi:
- Phdi hdp ch^t che giu'a thay thudc s i n khoa v i npi khoa nhSm phat hiln sdm va dieu tri sdm cic san phu h\ viem gan B.
- Phdng benh tdt: tigm phdng vaccin, kiem ti-a tru'dc khi cd tiiai phat hien benh sdm. Khi HbsAg(+) phai kiem tra chyc ning gan de tien lu'dng cupc de tdt cho ca me va thai.
T A I LIEU THAM KHAO
1. Dinh Thi Binh: Tinh trang sire khoe va bien dong cua cac dau an virus viem gan B d san phy mang HbsAg va con ciia ho. Li^n an ben syyiipc, Hoc wen QuSn y, 1998, tr.56-58.
2. NguySn Dif Dau: Nh|n xet thai phu bj viem gan vims chuyen da de tai Benh vien Phu san Trung u'dng trong 10 n3m 1996-2005. Luin van tot nghiep iiac sy ctiuyen Idioa cap II, Tm&ng Dai hoc Y Hi Noi, 2006.
3. Vu Thj Thu Huyen: Buific dau nhan xet tinh trang viem gan sifiu vi triing 6 phu nQ" c6 thai t^i Bgnh vien Phu san Trung u'dng trong 5 nam 1995-2000.
Luan vMn thacsy, Trudng Dai hoc YHk N&, 2000.
t . Vu Tien Lam: Tinh hinh san phu dga de non tai Benh vien Phu san Trung uWng trong 5 nSm 2003 - 20Q&. Luan vSn tiiac sy Y iigc, Tn/dng Dai hgc Y Ha N^, 1998.
^ Vu Khanh \An: Viem gan virus va thai nghen.
Luan vin tot nghiep bac sy chuyen khoa cap II, Tm&ng D^lhgc YHa N&, 1978.
6 Martin L : Viral hepatitis In pregnancy. Acta - Gastroenterol-Beig, 1999, 62(1), pp.9'21.
7 Medhat A.: Acute viral hepatitis in pregnancy. Qjirent d^Btrics and gynecologic, 1993, f^.468-469.
8. Nowell M.L.: Antenatal screening for hepatitis B infection. &--J- Obs^-Gynaecoi, 1999, 106 (1), pp.66-71.
9. World Health Organization. No scientific justification to suspend hepatitis B immunization.
Geneva, WHO, 1998.S
