TOP CHi V - DVOC HOCOUSNSys66-2014 ^
NGHIEN CU'U ANH H U 6 N G C O A SUY GIAP THAI KY DEN ME VA THAI NHI TAI BENH VIEN PHU SAN HAI PHONG
Vu Van Tam*; Lwu Vu Dung*
TOM T A T
BSnh suy tuyin giap trang IS bSnh ndi ti6t pho biin d phu n(r mang thai dCrng thir 2 sau b$nh dii thao dudng. NhOng rli loan chirc nang tuyln giip d thdi dilm mang thai khdng chi inh hudng den mp m i con anh hudng din sire khde cua thai nhi v i cOa dira trd sau niy. Mgc tiSu: nghiSn ciru inh hudng cua suy giip (SG) trong thdi kj' mang thai din me v i thai nhi. fi6i tupng vS phuong phip nghiSn ciru: 2 100 thai phu dugc sing loc SG blng cSc xdt nghiem TSH, FT4, Ab-TPO. Theo doi inh hudng cua SG d nhom b§nh nhin (BN) SG va khdng bi SG trong qui trinh mang thai v i sau d i . Ket qua: thai phu SG chiim 2,8%. Thai phy SG Iim tang nguy co rau bong non, ting huyet ip, tiln san giit, say thai, sinh nen. Chua thly tang nguy co can nang thlp, thai chet luu v i d| tat bim sinh. Kit luin: thai phy SG Iim tang nguy co rau bong non, ting huylt ap, tien san gi§t, siy thai, sinh non.
* TCr khda: Suy giip; Suy giip thai kJ; Sin phy; Thai nhi.
DETERMINE EFFECTS OF HYPOTHYROIDISM DURING PREGNANCY TO MOTHER AND FETUS IN HAIPHONG
OBSTETRICS AND GYNECOLOGIC HOSPITAL
SUMMARYHypothyroidism is a common endocrine disease In pregnant women, ranked second after diabetes. The thyroid dysfunction at pregnancy penod affects not only the mother but also affect the health of the fetus and later, the child. Objective, study the effect of hypothyroidism during pregnancy to the mother and fetus. Subjects and methods: 2,100 pregnant women were screened for hypothyroidism with TSHtest FT4, TPO-Ab. Subschbe the effects of hypothyroidism in patients with hypothyroidism and normal thyroid activity in the process of pregnancy and postpartum. Result: there were 2.8% of pregnant women with hypothyroidism. Pregnant women with hypothyroidism had an increased risk of placental abruption, hypertension, pre- eclampsia, miscarriage, premature birth. We cannot find an increased risk of low weigtit, stillbirths and congenital malformations. Conclusion: pregnant women with hypothyroidism have an Increased risk of placental abruption, hypertension, pre-eclampsla, miscarriage, premature birth.
* Key words: Hypothyroidism; Hypothyroidism during pregnancy; Pregnant women; Fetus.
' Benh viin Phu sin Hal Phdng
Ngiraiphin hoi (Corresponding): VQ Vin Tim (dn/uvantam%yahoo.com) Ngiy nhin bii: 17/02/2014; Ngiy phin biin dinh gii bii bid: 30/05/2014
Ngiy bai bio dum: ding: 28/07/2014 132
TOP CHi V - DV^C HOC OVRN SV Sd' 6-2014 BAT VAN o e
Bdnh suy tuyln giip l i bpnh ly ndl tilt p h i biln dirng thir 2 sau bdnh d i l thap dudng d l i vdi phg nO' d lira t u l i sinh san [1, 2]. Dae biet khi mang thai, nhii'ng r l i loan chirc nang tuyln giip khdng nh&ng anh hudng d i n sire khde ngudi me ma cdn cd t h i anh hudng d i n sy phat triln eua thai nhi v i dira be sau niy. VI t h i ein phat hien sdm v i dieu tri kip thdi SG ca trude v i trong thdi gian mang thai. K i t qua nghien eiru ve suy tuyln giip va thai nghdn cho thay ty le SG tren b i me mang thai ehilm 2 - 2,5%) va la nguy ep cao g i y say thai, de non, tiln s i n gi§t, rau bong non [2, 3]. Doi vdi thai nhi va tre sp sinh, dp l i nguy CP thai cham phat triln, suy dinh dudng, d i n dpn tri tup v i suy tuyln giip bIm sinh.
DP dp, chiing tdi thyc hien d l t i l niy nham: Binh gii inh huimg ciia binh ly SG trong qui trinh mang thai a phu nir ddn khim vi quan ly thai nghen tai Hai Phdng.
e 6 l TU'O'NG VA PHU'aNG PHAP NGHIEN CLTU 1. Ddi lu'p'ng nghien ciru.
Thai phy d i n khim v i quan 19 thai nghen tai Benh vien Phy san Hai Phdng, ding y tham gia lay may Iim xet nghiem sing ipe benh ly SG say khi dupe tu v l n , giai thich.
2. Phu'O'ng phap nghien ciru.
- Tieu chuln lya chpn;
Mang thai dpn (ehi cc mpt thai), thai khdng dj dang hinh t h i trong l i n khim d l u tien (phit hien tren sieu am), thai phy dong "i tham gia d l t i l v i tuan thu quy trtnh lly m i u x i t nghiem.
- Tieu chuln loai trir; diing thule (trir vitamin, thule bd) trong q u i trinh theo ddi, eic trudng hpp ed ehi so hda sinh cao Iim anh hudng d i n k i t qua xet nghiem (theo hudng d i n eua hang Roche), thai bit thudng phit hien tren sieu am.
- Cd m i u ; tong so 2.100 thai phu d i n khim v i quan ly thai nghen tai bpnh vipn dupe l l y mau tai quy 1 eua thai ky (12 ± 1 tuin).
- Chi tieu thu thap v i danh g i i ; thai phu ed tuli thai phii hpp lam xet nghiem, TSH > 4,2 mUl/ml dupe chin doin l i SG v i Iim them c i e xet nghipm FT4 v i TPO- Ab (khing t h i khing tuyln giip). G i i tri tham khao eua xet nghiem (theo Hang Roche): TSH (0,4 - 4,2 mUi/ml), FT4 (12 - 22 pmol/L), TPO-Ab dupng tinh khi > 34 mUl/ml v i am tinh khi ^ 34 mUl/mi. Chin doan SG lam sang khi TSH > 4,2 mUi/mi v i FT4 < 12 pmol/i, SG can lam sing khi TSH > 4,2 mUl/ml va FT4 (12-22 pmol/l).
Thai phy bi SG va khdng SG dupe sp sinh dinh g i i c i e biln ehirng hay gap d me v i thai nhi trong q u i trinh mang thai va sau de.
ySy ly k i t qua bang cac phupng phip thing ke y hpc.
Phan tieh k i t qua TSH, FT4, TPO-Ab tren may miln dich dien hda phit quang Cobas E411 (Hang Roche) bang cp c h l mien dich bit cap.
KET QUA NGHIEN CLfU VA BAN LUAN 1. Ty Ip suy g i i p .
* Ty 1$ thai phu suy tuyen giip trang theo ket qua xet nghiem TSH:
133
TOP CHi V . DVOC HOC OUHN SV Sd' 6-2014 Ty ip BN dupe chin d o i n l i SG (TSH
> 4,2 mUl/mi); 58 BN (2,8%); khdng SG (TSH £ 4,2 mUl/mi); 2.042 BN (97,2%).
* Ty ie thai phu chan doin SG iim sang theo ket qui xet nghiem FT4:
SG lam sing (FT4 < 12 pmol/l); 16 BN (0,8%); SG can lam sing (FT4; 1 2 - 2 2 pmol/l); 42 BN (2,0%).
2. Anh hu'O'ng cua SG thai ky din me Bing 1:
' Ket qua xet nghiim Ab-TPO:
Dupng tinh (> 34 lU/ml): 22 BN (37,7%);
am tinh (£ 34 lU/ml); 36 BN (62,3%).
Thai phy ed TPO-Ab la nhdm nguy co eao cd t h i tien triln thanh SG bat eir iOc nio [3], thai phu SG cd khang t h i TPO-Ab dupng tinh dupe chiing tdi t u v l n kilm tra dinh kj benh tuyln giip ngay sau khi sinh a l phat hien sdm khi cd b$nh.
va thai nhi.
B l ^ N C H O N G T H A I K V
B i l n ctiLPng c h o m ? Rau bong non T3ng huyet ap T i l n sSn gi§t S i y thai Thai c h i t lipu Sinh non ( £ 3 7 t u i n ) B#nh vifim t u y l n g i i p sau sinh B i l n chi>ng cho thai nhi
c a n n | n g thap (£ 2.500 gr) Dl t$t b I m sinh
(1) SG CAN LAIVI S A N G
{n = 42)
2 (4,8%) 10(2,4%) 4 (9,5%) 4 (9,5%) 1 (2.4%) 6 (14,3%) 2 (4,8%)
5 (11,9%) 0 ( % )
(2) SG I - A M S A N G
(n = 16)
1 (6,3%) 3 ( 1 8 , 8 % ) . 2 (12,5%)
0 (0%) 0 (0%) 2 (12,5%) 2 (12,5%)
1 (6,3%) 1 (6,3%)
(3) S G (n = 58)
3 (5,2%) 13(13,8%) 6 (10,3%) 4 (6,9%) 1 ( 1 , 7 % ) 8(13,8%) 4 (6,9%)
6 ( 1 0 , 3 % ) 1 (1.7%)
(4) KHONG SG
(n = 2 042)
25(12,2%) 230 (12,3%)
86 (4,2%) 45 (2,2%) 40(1.9%) 89 (4,4%) 0 (0%)
180 (8,8%) 10 (0,5%)
Ty ie c i e biln chirng cho me v i thai nhi xult hipn trong thai ky giCra nhdm thai phy SG lam sing v i can i i m sing, nhdm thai phu SG va khdng SG khac nhau.
Sang 2; Lidn quan giira nIng dp TSH va mpt s l biln chu-ng d thai phy.
B l i N CHONG
N 6 N G D O TSH
> 4 , 2 m l U / m l ( n = 58) | < 4,2 mlU/ml (n = 2 042)
OR, Cl 95%
Bien chu-ng cho me Ran bong non Tang huyet i p T i l n san g i i t B#nh t u y l n g i i p sau sinh Say thai That c h l l lwu Sinh non {5 37 t u i n )
3 (5.2%) 13(22,4%) 6 ( 1 0 , 3 % )
4 (6,9%) 4 (6,9%) 1(1,7%) 8(13,8%)
25 (1,2%) 2 3 0 ( 1 1 , 3 % ) 86 (4,2%) 0 ( 0 % ) 45 (2,2%) 40 (1,9%) 89 (4,4%)
4,4; ( 1 , 3 - 1 5 ) , <0,05 2,3; ( 1 , 2 - 4 , 4 ) ; < 0,05 2,6; (1,1 - 6,3); < 0,05
3,3; ( 1 , 1 - 9 , 4 ) ; < 0,05 0,9, ( 1 , 2 - 6 , 9 ) ; > 0,05 3 , 1 ; ( 1 , 6 - 6 , 2 ) ; < 0 , 0 5 Bi^n chu'ng cho con
C i n n i n g thap (S 2.500 gr) Dj t^t b I m sinh
6 (10,3%) 1 (1,7%)
1 8 0 ( 8 , 8 % ) 10(0,5%)
1,2, ( 0 , 5 - 2 , 9 ) ; > 0,05 3,5, ( 0 , 5 - 2 8 ) ; < 0,05
134
Tnp CHi V - Diroc Hpc OU^N sy sd' 6-20i4
Nong dp TSH huyet thanh > 4,2 mUl/ml lam tang nguy co- bien chCfng cho m§ va thai nhi; nguy cc tang gap tu* 2,3 - 4,4 Ian n§u bj bi4n chi>ng rau bong non, tang huyet dp, ti^n san giat, sdy thai, sinh non, dj t i t bam sinh. Khong Iim t i n g nguy co- trong cac bi^n chu'ng b^nh tuyen giap sau sinh, thai ch^t lu'u, can nang thap. Sy khac bi$t u hai nhom nay hoan toan phu hg-p vdi nghien cCfu cua Casey [4], Abalovich [5].Bing 3: Lien quan glCra n6ng do FT4 v i mot s6 biin chu'ng a phu nO mang thai SG du'O'c chin doan trong thai ky.
B I S N CHiTNG
FT4
<12pmol/m(n = 16) | 12-22pmol/ml (n = 42) P Biln chirng cho me
Rau bong non Tang huylt ap Tiin san giat Benh tuyin giip sau sinti Say thai
Thai chet ILTU Sinh non (s 37 tuin)
1 (6,3%) 3(18.8%) 2 (12,5%) 2 (4,8%) 0 (0%) 0(0%) 2 (12,5%)
2 (4,8%) 10 (2,4%) 4 (9,5%) 2 (12,5) 4 (9,5%) 1 (2,4%) 6(14,3%)
>0,05
<0,05
>0,05
>0,05
p > 0,05 Biln chi>ng cho con
can nling thap (£ 2.500 gr) Di t^t bam sinh
1 (6,3%) 1 (6,3%)
5(11,9%) 0 ( % ) '
p < 0,05
- Ty le biln chirng tang huylt i p a thai phy cd FT4 < 12 pmol/ml cao hpn thai phy c6 FT4 binh thydng. Sy khac biet cd y nghTa thing ke (p < 0,05).
- Mpt s l biln chirng khic d phy nu' mang thai SG cc nlng dd FT4 thlp cDng cap hon SP vdl thai phu cc nong dp FT4 binh thydng, sy khac biet nay khdng cd y nghTa thing kd (p > 0,05).
Sang 4: Phan bo ty Ip mpt sd biln chirng d phu nir mang thai SG dypc chin doin trong thai kji theo nong dp TPO-Ab.
BI^N CHiTNG N 6 N G D O TPO-Ab
>34IU/ml(n = 22) j <34 lU/ml (n = 36) P Biln chi>ng cho me
Rau bong non Tang huylt ip Tien san giat Siy thai Thai chit lu'u Sinh non (s 37 tu^n)
2 (9,1%) 9 (40,9%) 4(18,2%) 3 (13,6%) 1 (4,5%) 6 (27,2%)
1 (2,8%) 4(11,1%) 2 (5,6%) 1 (2,8%) 0(0%) 2 (5,6%)
>0,05
<0,05
>0,05
>0,05
<0,05 Biln chirng cho con
Can nang thSp(£ 2.500 gr) Di tat bam sinh
5 (22,7%) 1 (4,%)
1 (2,8%) 0 (0%)
<0,05
135
TAP CHi V - Diroc HOC O U S N sir sd' 6-2014
Ty Id b i l n chirng tang huyet i p , sinh npn v i SP sinh c i n npng t h i p d thai phu cd TPO-Ab dypng tinh cao hpn cac thai phy cd TPO-Ab am tinh. S y khic biet cd y nghTa thing ke (p < 0,05).
Mpt s l b i l n chirng khac d phy nO"
mang thai SG cd TPO-Ab dypng tinh cung cao han so vdi thai phy cd TPO-Ab i m tinh, sy khic bl$t nay khdng cd y nghTa thing ke (p > 0,05).
Cac b i l n chirng sp sinh can nang thap, thai chit lu'u v i di tat bam sinh cung t h l y trong nghien ciru n i y . Tuy nhien, SG thai ky chya thyc s y la y l u t l nguy cp I i m t i n g c i e biln chirng n i y (p > 0,05). Mpt s l nghien ciru cho t h i y c i e b i me cd TPO-Ab dypng tinh cd ty id bien chirng tre SP sinh nhp can ( c i n nang < 2.500 g) cao hon [6, 7]. K i t qua cua chiing tdi oung phii hpp vdi nghidn cu'u tren. D i l u n i y i i hpp i'j, vl SG anh hydng tryc tiep d i n qua trinh chuyin hda d thai phy, g i y anh hydng d i n sy p h i t triln ciia thai nhi, trong dd cd trpng lypng thai. Di tat bam sinh chya phan i n h s y k h i c biet giya 2 nhdm thai phy nay.
K 6 T LUAN
Thai phy SG lam tang nguy cp rau bong non. t i n g huylt i p , t i l n san giat, say thai, sinh non.
TAI Lieu THAM K H A O 1. Nguyen Hit Thuy. B#nh tuy^n g i i p v i thai nghdn. Chan d o i n v i di^u tri b$nh tuy^n g i i p . 2000, tr.286-287.
2. Lazarus JH, Premawardhana LD. Screening for thynDid disease in pregnancy. J Clin. Parthol.
2005, 58, pp.449-452.
3. Davis TF, Vl/elss I Autoimmune thyroid desease and pregnancy. A m J Reprot Immunol.
1981,1,pp.187-192
4 Casey BM, Dashe JS, Wells CE, Mclntlre DD, Byrd W, Leveno KJ, Cunningham FG.
Subclinical hypothyroidism and pregnancy outcomes. Obstet Gynecol. 2006,105, pp. 239-245.
5 Abalovich M, Gutierrez S, Alcaraz G, Maccallinl G, Garcia A, Levalie O. Overt and subclinical hypothyroidism complicatng pregnancy Thyroid. 2002, 12 (1), pp.63-68.
6. WlknerBN, Sparre LS, Stiller CO, Kalian B & Asker C. lyiaternal use of thyroid hormone in pregnancy and neonatal outcome. Acta Obstet Gynecol Scand 2005, 87, pp.617-627.
7. Spnnger, Zima T, Limanova Z. Reference Intervals in evaluation of maternal thyroid function during the first tnmester of pregnancy.
European Journal of Endocrinology. 2009, 160, pp.791-797.
