TCNCYH Phu truung 80 (3A) - 2012 Summary
VALUE OF PARACLINICAL TESTS IN THE DIAGNOSIS OF MENINGEAL CEREBRAL HEMORRHAGE IN PREMATURE
Meningeal cerebral hemorrhage (MCH) causes very heavy neurologic sequelae and high mortality rate in premature. This study determine somes paradinical features of MCH. Results showed that children with level II MCH was seen the highest percentage (47.8%), then the level I (31.3%), the level IV was only 7.5%. Children had severe bleeding, the rate of complications and mortality was higher Up to 40% of children with level IV MCH died. Mild and moderate ane- mia accounted for 71.7%. Reduced hemoglobin (Hb <12 g/dl) was significant in MCH diagnostic with sensitivity 78 4%, specificity 84.4%. Low platelet counts, decreased ratio of prothrom- binemia was not significant on diagnosis MCH. pH < 7.20 on the diagnosis MCH with sensitivity 67.2%. specificity 83.6% In conclusion, reduced hemoglobin (Hb <12 g/dl), pH<7 20 were sig- nificants in MCH diagnostic
Keywords: premature, fontanel ultrasound, anemia, respiratory distress
OAC DIEM LAM SANG
C O A X U A T HUYiT NAO MANG NAO Q TRE OE NON
Pham Thi Xuan Tu, Trjnh Thj Dung, Nguyin Thi Quynh Hwong Trwdng Dai hoc Y Ha Noi
Xuit huyit nao mang nao a tre de non la mgt benh nguy hiim thwang di lai di chirng thin kinh va ty le tw vong cao Di tdi ndy dwoc nghidn ciru nhim nghien ciru mot sd dac diim lam sang cua xuit huyit nao mdng ndo 6 434 tr^ de non vdi 134 tre bi xudt huyit nao mang nao va 225 tre I<h6ng xuit huyit nao mang nao. Kit qui nghidn ciru cho thiy suy ho hip cip nang len gap nhiiu nhdt chidm 83,6% benh nhan. Thidu mau gdp 78,4%, sau dd Id H bi chidm 59,7%. Dac biet 16,4% Khdng cd biiu hidn iam sang Ll bi la tridu chwng lam sang cd do dac hieu cao nhit (91,6%). Tiip sau la suy ho hip cip nang ien (83,1%) va giam trwang Iwc co (82.2%). Xuit huyit la tneu chirng lam sdng cd do dac hieu cao nhif (95,5%). Tiip sau td thiiu mau cip (82,2%) va ha than Qhiet'(60%). Ty Id xuit huyit nao mang ndo gap l<it hap cao nhit vdi bdnh mdng trong (53%). sau dd Id cdn dng ddng mach Idn (24,6%). Tdm lai, trieu chwng lam sang gap nhtiu nhit la suy hd hip cap nang len sau dd la thidu mau va li bi. Xuit huydt Id tridu chwng lam sang cd do dac hieu cao nhit (95,5%). Benh mang trong la bdnh canh phdi hop hay gap nhit
TLC khoa: tre de non, benh mang trong, suy ho hip, xult huylt nao mang nao
I. DAT V A N D i ' 0,95% tdng s l tre sinh sing va-ehilm 30,5%
Xult huylt nao mang nao la benh kha p h i tdng s l tu vong sa smh [4] O Viet Nam, theo biln d tre de non va la nguyen nhan chlnh s l lieu cua vien Bao ve Sire khoe Tre em, ty cua cae di chirng t h i n kinh d tre de non va le tir vong eua xult huylt nao mang nao" la tham chl cd the gSy tir vdng Theo Alexander 23,4% cac trudng hgp xult huylt nao mang (1971) xult huylt nao mang nao chilm nao sa sinh, chilm 0,2% tdng s l tCr vong sa 39
TCNCYH Phu truung 80 (3A) - 2012 sinh [2] va 19,4% ting s l tir vong sa smh dudi 34 tuin thai [4] Mae du hien nay ty le xult huylt nao mang nao da giam nhung v i n edn la v i n d l nghiem trpng. Tir nam 1976 viec irng dung ehup c l t ldp va sau dd la sieu am qua thdp da giiip cho viec chin doan xult huylt nao mang nao d tre sa sinh Theo eae nghien ciru mdi day ty le mdi mie cua xult huylt trong nao thit chilm ldi 20 - 40% tre sa sinh de non dudi 32 t u i n va 50 - 60% tre dudi 28 tuan [5]. Tneu chirng lam sang cua xult huylt nao mang nao thudng ngheo nan, d l nham vdl cdc benh ly khac, d l giiip eae bae sy lam sang ehln doan sdm benh nay chiing tdi tiln hanh d l tai nay nham muc tieu: Nghien ci>u mot s6 dac diem lam sang cua xuat huyit nao mang nao d tre de non.
II. 0 6 l TU'gNG VA PHU'aNG PHAP 1. D6i tu'O'ng nghien CLPU Tieu chuin chon benh nhdn
Chin doan de non dua vao tuli thai tinh theo bang dilm danh gia tuli thai Finstrdm tai khoa sa smh benh vien Nhi Trung uang.
Benh nhan duac chia thanh 2 nhdm;
+ Nhdm xult huylt nao mang nao tre de non duac chin doan xult huylt nao mang nao
+ Nhdm khong xult huylt nao mang nao;
tre de non ed ciing can nang (± 100 gam).
tuli thai (± 1 tuin) dugc dilu tri tai khoa sa smh trong cung thdi gian tir 1/3/2008 d i n 31/7/2008
Tre dugc ehia thanh cac nhdm theo tuli thai;
Nhdm 1 (tuli thai < 28 tuan); nhdm 2 (tuli thai tir 29 - 31 tuin); nhdm 3 (tir 32 - < 37 tudn).
C h i n doan xuat huylt nao mang nao dua vao. sieu am qua thdp co hinh anh xult huylt nao mang nao va lam sang co bilu hien" thilu mau va/hoac thay d l i y thirc (tang kich thich, li bi, hon me sdu) va/
hoac c a t r l i loan t h i n kinh (co giat, tang
hoac giam truang luc ca, d i u hieu than kinh khu trii, thop cang, r l i loan t h i n kmh thuc vat ..) vd/hoac suy hd h i p d p .
Tieu chuin loai benh nhan: Tre cd tuoi thai
> 37 tuin thai hoac vao vien tren 3 ngay tudi.
2. Phu'ang phap nghien cu'u Nghien eiru md ta vdi ed mau thuan Igi tren 434 tre de non.
Danh gia vi tri t i n thuang xult huylt nao mdng nao dua vao ky thuat sieu am qua thdp lam tai khoa Sa sinh benh vien Nhi Trung uang do eac bdc sy khoa ehln doan hinh anh thuc hien tren may Nemio 30 Mitsubishi
^ CP770 dw vdl d i u dd 7MHZ.
Kham lam sang xuat huylt nao mang nao d tre de non
Thilu mau tuy theo mirc do chay mau, xult huylt.
Tmh than tang kich thich, li bi, hdn me Tang hoac giam truang lue ca.
Co giat; cuc bg hoae toan than.
D I U hieu than kmh khu tru; liet chi, liet nua ngudl, liet mat, sup mi.
Tang ap lue npi so thdp phlng, khdp so gian, tang vdng d i u (> 2SD)
Cae r l i loan t h i n kinh thuc vat r l i loan than nhiet, tang t i n s l tim, r l i loan van maeh
Suy hd h i p e l p nang len; ddi hoi phai tang ndng dp oxy khi tre dang thd oxy hoac thd CPAP hoac tre cd can ngirng thd, tim tai phai dat ndi khl quan thd mdy.
Cac benh \y k i t hgp xult huylt nao mang nao d tre de non
Mang trong. suy hd h i p xay ra tren tre de non, d p tinh trong nhirng gid d i u sau de, X - Quang. phdi it nd, n i t md lan toa hai p h i 40
TCNCYH PhiJ truong 80 (3A) - 2012 tru'crng, glam do sang cua nhu mo phoi, it khl
trong cac nhanh p h i quan.
Nhiem triing mau: co bilu hien nhilm khuln tren lam sang; bach c l u < 5.000/mm^
hoac > 30.000/mm', bach c l u da nhan trung tinh (BCBNTT) < 1.500/mm', bach c l u da nhan trung tinh (BCONTT) non (khong nhan)/
BCDNTT > 0,2, C - reactive protein (CRP) >
15mg/l, C l y mau (+).
Rdi loan dong mau: xult huylt da va niem mac, glam tilu clu; ty le prothrombin giam, thai gian hoat hoa rieng phln thromboplastin keo dai, nong do flbnnogen giam
Con 6ng dong mach Ion: Ing dong mach con t i n tai 72 gid sau khi sinh tren sieu am tim (du-ong kinh dpng mach c h l hep nhat
> 1,6 mm)
Sieu am qua thop- du'p'c tiln hanh tal giu'ong, lln 1 (trong 2 ngay d i u sau de), lln 2 (vao ngay thij' 3 - 7 sau de). Danh gia tiln triln xult huylt nao mang nao sau 1 tuan, 2 tuin, 3 tuin d l phat hien kip thai t i n thu'ong di chi>ng:
nao ung thuy hoac nhuyin nao chit trang.
Phan loai xult huyet nao mang nao theo Papile (1980):
Do I: xuat huylt duoi mang npi tuy.
Dp 11: xuat huylt trong nao thit, khong co gian nao thit
Dp III: xult huylt trong nao thit, co gian nao thit
Do IV xult huylt trong nao thit va xult huylt trong nhu mo nao.
Xet nghiem mau
Cong thLrc mau du'O'c lam tren may chay 18 thong s l Celltaet E tai khoa Huylt hoc benh vien Nhi Trung uong Danh gia tinh trang thilu mau: nhe (Hb. 10 - 12 g/dl), vira (Hb: 7 - 1 0 g/dl); nang (< 7g/dl)
Giam tilu c l u : < 100 000/mm^
Ty le prothrobin giam: giam nhe < 60%, giam nang < 30%, thoi gian hoat hoa rieng phln thromboplastin keo dai hon 1,5 lln so vol chirng. Fibrinogen giam < 1 g/l, toan mau nang (pH < 7,2); ha du'dng mau (< 2,2 mmol/
I), ha canxi mau (^ 1,8 mmol/l); ha natri mau (< 125 mmol/l)
3. XCr ly s6 lieu: Phan tich bing phln m i m SPSS 13.0. tinh do nhay, do dac hieu, gia tri chan doan duong tinh, gia tri chin doan am tinh.
II. KfiT QUA
1. Trieu chirng lam sang cua x u l t h u y l t nao mang nao a tre de non Bang 1. Trieu chipng lam sang Trieu chirng
Li bi
Tnr„.nnl,iTrn- ''"*"9 Giam Co giat
Thop cang Vong d i u (cm) > 2SD
.. Thieu mau Xuat huyet Giam Suy hd hap cap nang len Khong co bleu hien lam sang
n 80 4 88 18 4 4 105
21 4 65 112 22
2,9 65,7
59,7
%
13,4 2,9 2,9 78,4 15,7 2,9 48,5 83,6 16,4
TCNCYH Phu truong 80 (3A) - 2012
Nhan xet Suy ho h i p d p nang len gap nhilu nhlt chilm 83,6% benh nhan. Thilu mau gap 78,4%, sau do la li bi chilm 59,7%. Dac biet 16,4% Khong co bilu hien lam sang
2. Gia trj Chan doan cua cac trieu chirng lam sang
Bang 2. Gia trj chin doan cua cac trieu chirng: li bi, giam truxj'ng lire ca, suy ho hip nang len
Trieu chirng Co
Li bi Khong Tong
Se = 59,7%; Sp = Co
Giam TLC Khong Tong Se = 65,7%; Sp =
Co SHH cap nang len Khong
Tong Se = 83,6%, Sp :
Xu3t huyet nao mang nao
n, % 80 " 59,7 54 40,3 134 100
= 91,6%; Ppv = 80,8%; Npv = 88 65,7 46 34,3 134 100
= 82,2%; Ppv = 68,8%, Npv = 112 83,8
22 16,4 134 100
= 83,1%, Ppv = 74.7%; Npv =
Khong Xuat huyet nao mang nao n2
19 206 225 79,2%
40 185 225
^80,1%
38 187 225 ' 89,5%
8.4
%
91,6 100 17.8 82.2 100 16,9 83,1 100
Se do nhay; Sp: do dac hieu; Ppv gia tn chan doan duang tinh; Npv: gia th chan doan am tinh Li bi la trieu chung iam sang cd dp dae hieu eao nhlt (91,6%). T i l p sau la SHH d p nang len (83,1%) va glam TLC (82,2%).
Bang 3. Gia trj chin doan cua cac trieu chieng Trieu chii'ng
Co Ha than nhiet Khfing
Ting Se = 48,5%, Sp
Co Thieumaucap ^^^.^^
Tong Se = 78,4%.. Sp =
Co
Xult hiiylt Khong Ting Se = 15,7%, Sp =
= 60%,
' 82,2%
' 95,5%
Xuat huyet nao mang nao n, % 65 48,5 69 51,5 134 100 Ppv = 41,9%, Npv =
105 78,4 29 21,6 134 100 , Ppv = 72,4%, Npv
21 15,7 113 84,3 134 100 , Ppv = 67,7%, Npv
Khong nao 1
"2
90 135 225 66,2%
40 185 225
= 86,4%>
10 215 225
= 65,5%
xuat mans
: huyet 1 nao
%
40,0 60,0 100 17,8 82;2 100 4,4 95,6
100
Xult huylt la trieu chirng lam sang co dp dac hieu cao nhlt (95,5%). Tilp sau la thilu mau d p (82,2%>) va ha than nhiet (60%i).
Bang 4. Cac benh ly Cac benh ly kit hvp
kit
TCNCYH Phu truung 80 (3A) • hap vdi xult huylt nao mang nao
Xult huyet nao mang nao
n % -2012
Nhiem khuan huylt
Cd 16
Khdng
Tdng 100
Co 53,0
Benh mang trong Khong Ting Cdn dng dong mach Idn Khong
Ting Co Rdi loan ddng
mau Khdng 85.1
Tdng
Ty le xult huylt nao mang nao gap k i t hap cao nhlt vdi benh mang trong (53%), sau dd la edn Ing dgng mach ldn (24,6%).
IV. BAN LUAN
Cd 4 tre trong nghien eiru nay cc bilu hien ithi d p tinh. tre trong tinh trang hdn me sau, thop phlng, tang truang luc ea toan than, CO giat, ngirng thd hodn toan, thilu mau ro tren lam sang. NhCrng tre nay chin doan xult huylt nao mang nao r i t d l tren ldm sang.
Thilu mau d p gap d 78,3% trudng hap, p h l n ldn la t h i l u mau nhe va trung binh. Thilu mau d p tren lam sang cung la d i u hieu r i t cd y nghTa trong c h i n doan vdi dd nhay 78.4%, dd dac hieu 82,2%, gia tn chin doan duang tinh 72,4%, gia tri chin doan am tinh 86,4% Nghien ciru nay eung phii hap vdi N.T.T Ha. ty le t h i l u mau gap 62,7% benh nhan, p h l n ldn la t h i l u mau nhe va trung binh, t h i l u mau nang chi chilm 4.9% [1] va thilu mau la mdt b i l u
hien quan trong trong xuat huyet nao mang nao d tre sa sinh [7]. Theo N.C.Khanh thi tre tir 1 - 3 thang tuoi thi bilu hien thilu mau gap 99,1% cac benh nhan [3]. Su khac nhau nay la do nguyen nhan gay ra xult huylt nao mang nao: d tre de non xult huylt cd tinh ehlt khu trii trong vimg m i m va t l ehirc quanh nao thit, tinh trang xult huylt se ngirng lai khi khing e h i dugc eae y l u to nguy ea gay xuat huylt.
X u l t huylt nao mang nao d tre 1 - 3 thang tuli'thudng la do t h i l u vitamin K d i n d i n xult huylt nhilu nai trong nao va eae bp phan khae gdy ra m i t mau' nang, "i vay bilu hien thilu mau thudng rd rang tren lam sang.
Bilu hien than kinh cijng hay gap d tre de non nhung r i t khd danh gia va it cd gia tri khu trii t i n thuang. Bieu hien li bi hay gap
43
TCNCYH PhiJ truung 80 (3A) - 2012 nhlt chilm 59,7%, ed gia th trong chin doan xult huylt nao mang nao vdi dp dac hieu len tdi 91,6%, gia tri ehln doan duang tinh 80,8%, gid tri chin doan am tinh 79,2% mac du dp nhay chi la 59.7%. Giam truang luc ca gap 65,7% vdi dd dac hieu len tdi 82,2%, gia th ehln doan duang tinh 68,8%, gia tn chin doan am tinh 80,1% mac du do nhay chi la 65,7%. Dilu nay Id do viec danh gia nhQ'ng tneu chirng thin kmh nay rat khd va phai tal kham nhilu lln, han nii'a lai cung cd t h i gap benh ly toan t h i khae nhu nhilm trimg huylt, ha dudng huylt, ngat sau de Kit qua nghien ciru cua chiing tdi cung phu hgp vdi nghien ciru khac [6]. Tneu chung co giat cua chiing tdi gap 13,4% benh nhan, ty le ndy phu hap vdl nghien ciru khae [1, 7]. D i u hieu tang ap luc ngi sp chu y l u la thdp phong cang. vdng d i u tang gap d 4 benh nhan bj xult huyet nao mdng nao dd IV vao ngay thir 4 sau smh chilm 2,9%. D I U hieu nay gap kha nhilu d tre 1 - 3 thang tuli, theo N C Khanh gap 91,3% benh nhan cd thdp phdng [3]. Su khae nhau ndy la do xult huyet nao mang nao d tre de non. Su khae nhau nay la do xult huylt nao mdng nao d tre de non chii y l u d vLJng m i m edn d tre 1 - 3 thang tuli xult huylt nhieu nai trong nao dan d i n bilu hiln tang ap luc ndi sp thudng ed d tre 1 - 3 thang va it gap d tre de non.
Suy hd h i p d p la hoi chirng thudng gap nhlt d tre de non, doi khl dd Id bilu hien ndl trdi nhlt lam lu md cac d i u hieu thin kinh khac. Danh gia lam sdng tren tre de non xult huylt nao mang nao thly bieu hien suy hd h i p elp nang len ddi hdi phai tang ndng dp oxy khi tre dang thd oxy hoac CPAP hoac tre cd can ngirng thd, tim tai phai dat ngl khl quan thd may, ty le nay gap 83,6% Suy hd hip cung ed y nghTa trong ehan doan xult huylt nao mang' nao d tre de non vdi do nhay 83,6%, do dae hieu 83,1%. Gia tn chin
doan duang tinh 74.7%. gia th chin doan duang tinh 74.7%, gia tn chin doan am tinh 89,5%. Kit qua nghien ciru nay cung phu hgp vdl nghien eiru khac [7]
V. K^T LUAN
Tneu chung lam sang gap nhilu nhlt la suy hd hip d p nang len (83,6%), sau dd la thilu mau (78,4%) va li bl (59,7%).
Xuat huylt la trieu chirng lam sang cd do dac hieu cao nhlt (95,5%) Tilp sau li bi (91,6%).
Ty le xult huylt nao mang nao ggp kit hgp cao nhlt vdl benh mang trong (53%), sau dd la cdn Ing ddng mach ldn (24,6%).
T A I L I E U THAM K H A O 1. Nguyin Thj Thu Ha (2001). Nghien cicu mot s l yeu t l dich te va dac dilm lam sang, can lam sang cua xult huylt nao mang nao d tre sa sinh Luan van thac sy y hgc - Trudng Oal hgc Y Ha Ndi; 3 - 28.
2. To Thanh Hu-cng (1985). Dac dilm benh tat ciia tre sa sinh tai khoa sa sinh vien Bao ve sire khde tre em trong 5 ndm 1981 - 1985 Ky y l u edng trinh nghien ciru khoa hgc vien Bag ve sire khoe tre em trong 5 nam 1981 - 1985; 138- 145.
3. Nguyin Cong Khanh, Nguyin Van Thing, Ninh Thj U'ng va cong su> (2000).
Nghien ciru mgt s l y l u to dich t l , lam sang va dilu tn xult huylt nao mang nao d tre ngoai tuli sa sinh. Bao eao ting k i t d l tal khoa hgc d p Bd
4. Alexander J., Shehaffer O (1971). In- tracranial heamorrhage. Disease of nevirborn;
601 -610.
5. Blackman JA (1991). Development and behavior; the very young child. Pediatr Clin NAm, 38. 1351 - 1592
TCNCYH Phu truung 80 (3A) - 2012 6. Kliegman MR. (2006). Birth injury. germinal matrix - intraventricular hemorrhage Textbook of pediatrics, 15"^ Ed; 4 6 5 - 4 7 1 . of the premature infant, clinical feature and
7. Volpe JJ. (2005). Cranial hemorrhage diagnosis. Neonatology (11) 421 - 426.
Summary
CLINICAL FEATURES OF MENINGEAL CEREBRAL HEMORRHAGE IN PREMATURE BABIES
Meningeal cerebral hemorrhage in the premature baby is dangerous disease with neurologic sequence and high mortality rate. This study was to determine some clinical features of 434 premature baby with 134 children with meningeal cerebral hemorrhage and 225 children without meningeal cerebral hemorrhage. Results showed that the severe acute respiratory failure was seen 83.6% patients. 78.4% patients had anemia, Unconscious was accounted for 59 7%.
16 4% had no clinical manifestations. Unconscious as clinical symptoms was the highest speci- ficity (91.6%) for meningeal cerhbral hemorrhage, then the acute respiratory failure 83.1% and hypotonia (82 2%). Hemorrhagic symptoms was the highest specificity (95.5%>), then acute ane- mia (82.2%) and hypothermia (60%). The rate of meningeal cerebral hemorrhage was met with the highest combination hyalin membrane disease (53%), then a large patent ductus arteriosus (24 6%). In conclusion, the most frequent clinical feature was severe acute respiratory failure then was anemia and unconscious. Hemorrhagic symptoms was the highest specificity (95.5%>) Hyalin membrane disease was the most common in meningeal cerebral hemorrhage disease Keywords: premature, hyalin membrane disease, respiratory failure. Meningeal cerebral hemorrhage
DANH GIA BU'aC OAU CHAT LU'O'NG SONG O TRE EM SAU VIEM MANG NAO MU
Nguyin Phuvmg Hanh, Nguyin Van Lam, Pham Nhat An Nguyin Thanh Liem, Thanh Ngoc Minh, Nguyin Thj Hong Thuy Nguyin TuyitXwryng, Lai Thu Ha, Nguyen Xuan Nam Benh vien Nhi Trung wang Vidm mang nao mO Id bdnh dd lai cac di chwng thin kmh nang ni, gay nen cac vin di vi hoc tap,.
giao tiip va phat then xa hdi ciia tre, chit Iwang sing vi thi se hi giam siit. Nghidn cu'u nay nhim muc tieu ddnh gid chit luung sdng cua bdnh nhdn viem mang nao mu sau l<hi ra vien va tim hiiu mot s l yiu td lidn quan. Tudi trung binh cua benh nhdn nghien ciru la 39 ±18.6 thang. Khoang thai gian dwoc danh gia chit Iwang sdng sau khi tre bi bdnh la 25.6 ± 10 thdng. Co sw khac bidt vi chit twang sdng giOa nhdm benh vd nhdm chirng ca vi s6 diim lidn quan din chdt Iwang sing chung lin chirc nang sinh ly, cdm xuc, xd hdi, hoc dwdng (p < 0,001). Tuy nhidn, khdng xdc dinh dwac sw lien quan glQ-a chit Iwang sing cOa tre vdi cdc yiu td cdn nguyen gdy benh, can thidp ngoai khoa khi diiu tn, khu vwc sdng hay mirc dd r)ghe kdm Kit qud nghtdn ciru cho thiy chit Iwang sdng cua 'tre em sau viem mdng ndo mii bi giam sut so vdi cdc trd binh thwang
TCr khoa: chit liFcrng song, viem mang nao mu, tre em
45
