CHAO Mi/NGHOINGH! KHOA HQC THUdNG NIEN Hdi HO HAP vlgT NAM
HEN VA THAI KY: NHfrNG DIEM CAN hVU V
Nguyen Nhu- Vinh*
T O M TAT
Hen va thai ky co the tac dpng qua lal lan nhau qua nhieu al che sinh benh hgc khac nhau.
Thai ky co the lam hen nSng them nhuTig cung CO the lam hen nhe hdn. Khi mang thai, 1/3 trttdng hpp hen se nang hdn, 1/3 tru-flng hpp hen nhe hdn va 1/3 trttdng hpp hen se khflng thay doi SO vdi trutSc khi co thai. NhDhg truSng hdp benh trd nang hcJn hay xay ra vao thang thtt 6, 7 cua thai ky tuy nhien se nhe dan vao nhOTig tuan le cuoi va cdn hen cap hiem khi xay ra trong qua trinh chuyen da. Hen se tac dpng xau den siic khoe ca me lan con neu nhtt khflng dttdc kiem soat tot. Cac nguy ctJ fl me nhtt tien san giat, xuat huyet am dao bat thttflng hay nhe hc^n la lam tSng tinh trang nfln nghen. Cac nguy cd doi vfll thai nhi gom giam oxy ttt me den nufli bao thai gay cham phat trien bao thai, sinh non, sinh nhe ky hoac t5ng h i vong chu sinh. Thuoc dieu tri hen da so la an toan trong thai ky nen lpi ich cua vl^c kiem soat hen t o t bang thuoc cao hdn nhi^u so vdi tac dung phu do thuoc dem lai cho ca me va con. Do vay, kiem soat hen tot d phu ntt CO thai la mgt muc tieu can dat dttpc va dieu nay da duHc chihig minh dem lai nhieu lpi ich cho sttc khoe ca me va con.
S U M M A R Y
Asthma and pregnancy can Interact with each other by many pathophysiologic mechanisms. Asthma may Improve, v^orsen, or remain unchanged In severity during pregnancy with estimated rate of one-third for each group.
• Bgi hpc r Duac Thdnh phi Ho Chl Minh Chju trach nhi?m chinh: Nguyin Nhu Vinh Email: [email protected] Ngay nhan bai: 18/9/2015 Ngay phan bipn khoa hpc: 16/10/2015 Ngay duy^t bai: 23/10/2015
Asthma events or loss of control occur primarily between 6 * and 7'" months gestation. Asthma symptoms or level of asthma control usually improve at some last weeks of gestation and asthma exacerbation rarely occur dunng delivering. Several studies showed that uncontrolled asthma Increases perinatal risks while controlled asthma reduces these risks. The mother's risks are preeclampsia, uterine hemorrhage, preterm labor or increased morning sickness. Baby's risks are prematurity, low birth weight due t o impair fetal oxygenation and Increased perinatal mortality. Most medications for asthma have good safety profiles In pregnant women, therefore, the benefit of using these drugs outweigh the risks. Maintaining good asthma control during pregnancy Is a must-be- achleved objectVe In asthma management In this group of patients which was proved to provide health benefit for both mother and baby.
I. TONG Q U A N HEN VA THAI K V Hen la mot tinh tr?ng y khoa thuong g|p nhat anh huomg den thai ky voi ty le 3-8%
phu nu CO thai va cfl the xay ra o nhttng nguai khflng bj hen truorc dfl [1,2,3,4,5]. Thai ky CO the lam thay dfli diln tien cua hen va ngugc l^i hen co the thay dfli ket cyc cua thai ky. Muc tieu chung cua quan ly hen la ngfln ngua con c i p va tfli uu hoa chuc nang ho hap. Miic tieu nay cung khflng thay dfli ttong thai ky n h i m dam bao sttc khoe tot nhat cho ca me va con [6]. Bflnh nhan mang thai nSn dugc tham kham djnh ky d i u dJn boi cac bac sT CO kinh nghiem va co t h i phai dung thuoc d i u dan tuy theo tinh trang benh cua minh.
D I dam bao tflt cho sttc khoe ca m? va con, nhan vien y t l cin bilt cac nguy co co the xay ra trong thai k^ n l u hen khflng dupe
18 i
Y HOC VIET NAM THANG 11 - SO CHUYEN DE - 2015
kiem soat t6t dk tu v4n cho benh nhan kha nang can thifp tuy theo timg giai doan ciia thai ky de giam thilu cac biSn c6 b4t lai nay.
Cac nguy ca co thS va each can thiep dugc chia thanh cac giai doan nhu sau.
1.1. Triro-c khi co thai
Phu nil bi hen khi chudn hi co thai c4n ducfc tu van ve cac van dk sau: (1) thai ky va hen suyen co the tac dpng qua I^i \kn nhau va CO thk gay ra cac hau qua khong t6t cho sue khoe ca me va con, (2) kilm soat t6t benh hen trong giai doEin nay la rat quan trpng cho thai ky sau nay v^ (3) thu6c dung dk tri hen thuong an t o ^ trong thai ky do vay nen du(?c tilp tuc su dung trong giai doan s§p co thai ma khong CEin ngung thude trong thoi gian chcr dgi co thai.
Vi nguy ca con cap co the xay ra, thuoc hen khong nen thay doi trong giai doan nay khi hen cua bfnh nhan dang dugc kilm soat tot hoSc da dung sau khi hg da biet co thai.
Tuy nhien, voi nhiing phii nii co ke hoach c6 thai va dang su dung corticoid dgng hit (ICS) thi budesonide la thuic an toan nhdt trong Dang xep loai nguy ca thai ky - nguy ca muc B theo xdp loai nguy co thai ky cua FDA' (miic A la tit nhat). Tuy nhien cac loai ICS khac cung chua co dii lieu la khong an toan trong thai ky va xip miic nguy ca miic C [7].
1.2. Cham soc tiln san
Khi mang thai, nhilu eo chl sinh ly thay dii CO thi lam n ^ g them hay cai thien tinh trang hen nhtmg van chua ro thay doi nao la gop phkn quan trgng nhdt lam thay doi linh trang b?nh hen nhu v$y. Do do, trong thai ky, muc do n ^ g cua hen co thi se thay doi va b?nh nhan hen nen dugc theo d5i chat ch6 hon dl can thiep kip thoi. Co khoang 1/3 truong hop hen sg x4u di nhung cOng din 1/3 t FDA: Food and Drug Administration: Cue
qukn iy Thuc pham va Dugc phgm Hoa K^truang hgp hen lai nhe hem va 1/3 con lai co tinh trang hen khong thay doi so vol truoc khi CO thai [8,9,10,11,12].
Muc tieu cua dieu tri hen trong thai ky la duy tri tinh trang hen dugc klSm soat de dam bao oxy dugc cung cap du cho su phat trien ciia bao thai cung nhu duy tri sue khoe va chat lugng cugc song ciia nguoi me. Cac thuoc diing trong thai ky thudng khong khac gi thuoc dung cho nguoi khong co thai [7],[11],[12]. Lieu thuoc, cung giong nhu khi.
chua CO thai, nen dugc diing a miic toi thieu de kiem soat trieu chiing va duy tri chiic nang phoi 6 miic binh thuang hay tot nhat.
Benh nhan tot nhat nen dugc theo dSi bang luu lugng dinh va tai kham moi 4 - 6 tudn [13]. Can CO su hgp tac gifta bac sTch&a hen va bac si cham soc thai de dam bao hen suyen dugc quan ly tot nhat.
Con hen cap co the lam giam oxy cung cap cho bao thai. Do vay bat cu; diln tien xau di nao ciia cac trieu chiing phai duge giai quyet nhanh chong. Cac yeu to khdfi phat con hen nen dugc tranh toi da neu co the dugc, dae biet la nhiing chat di iing dk biet.
1.3. Hen cap trong thai ky
Can hen cap thuong gay ra cac bien co
khong tot cho ca me va con trong thai ky va
xay ra khoang 20% a phu nu co thai va co den
6% can phai nhap vien [8],[14]. Do vay, can
phai theo doi va danh gia kiem soat hen dinh
ky trong suot thai ky [7],[13]. Hen kiem soat
kem se tang nguy co tien san giat, sanh non,
sanh nhe can va chet chu sinh va hen dugc
kiem soat tot se giam dugc cac nguy co nay
[7],[11],[12]. Con hen cap trong thai ky thucmg
CO cae dac diem nhu sau [8]: xay ra trong
khoang tuan 17-36 eua thai ky va thuong do
nliiem virus hay do khong su dung ICS deu
dan. ICS CO the lam giam nguy co can hen cdp
trong thai ky va trong nhiing trudng hgp cdn
CHAO MCMG HOIHGH! KHOA HOC THUdHG NIEH Hqi Hfl HAP VIET NAM
thilt, corticoid uflng vin co the ke toa cho thai phu khi cfl chi djnh lam sang.
1.4. Qua trinh sinh Bit
Ngoai trtt mgt so ca qua nang, benh hen khflng nen la ly do d l tu chfli cho san phu sinh ducmg am dao. Cac hi$p hfli y khoa chuyen nganh dang cfl gang de ty le sanh mfl o phu ntt bj hen khflng nen cao ban nhimg nguoi khflng bi hen. Nhilu nghiSn cuu cho thiy con hen c i p it thucmg gSp trong qua trinh sanh no [13].
1.5. Cham soc sau sinh
San phy sau sanh nen dugc tiep tuc danh gia hen djnh ky va nhan vien y te ckn luu y gia dinh benh nhan ve nguy c a gia tang benh hen cttng nhu cac b?nh hfl hdp khac a tre khi em be bj hut thuflc la th\i dflng [15]. Khuyen khich cho con btt bang stta me cung lam giam nguy ca hen a dtta tre, dac biet la a nhttng tt'e cfl gia dinh co tiln can bj dj ttng [16]. Sau khi sanh phii ntt vin co the cho con bu trong khi van tilp tuc dttng thuflc. Cac thuflc hen cfl the di vao stta m?, nhung nflng do thutag nhfl nen duong nhu khflng gay hji cho dtta tre [13].
1.6. Cac thuoc dttng trong thai ky va khi cho con btt
Dieu trj hen trong thai ky voi cac loai thuflc thich hgp d l duy tri kilm soat hen se an toan hon la khflng dttng thuflc va d l xay ra tri$u chttng cttng nhu can hen c i p [7],[11],[12]. Phin ]an thuflc dilu trj hen la an toan trong thai ky do vay dung thuoc hen tt-ong thai ky khflng khac biflt nhilu so vai khi khflng co thai va dac bi$t trong dgt c i p thi diSu trj cho ca hai dfli tugng nay la hoan toan giflng nhau. Trong thuc hanh lam sang, neu co chi djnh phai dttng corticoid uflng cho phu ntt bj hen thi khflng nen tri hoSn vai ly d o l a d a n g c 6 t h a i [ 7 ] , [ l l ] .
Nlu viec stt dung ICS la c i n thilt trong giai d o p truoc khi cfl thai, thi khi cfl thai cflng nfln tilp tyc duy tri [7]. Lilu ICS cung nen dttng a mttc tfli thilu c i n thilt d l kilm
soat trieu chttng va duy tri chttc nang phfli o muc binh thuong hoSc mttc tflt nhit cua hg [7]. Tuy nhien, stt dung corticoid uflng {dSc biet trong tam ca nguygt diu tien) cfl the lam tang nhe ty le ho mfli kem hay khflng kem ho ham ech. Bang chung nay dua tt-en mot s6 nho nghien cm tuy nhien nhung nghifln cmi nay khflng cfl thilt k l ban d i u d l danh gia nguy CO nay [11]. Co r i t it nghien cttu vl hieu qua va/hoac tinh an toan khi stt dung phfli hgp ICS+LABA (thuflc gian phi quan tac dung keo dai) trong thai ky [7] va cung chua CO nghien cttu nao tim hiiu aiih hudng cua LABA tren thai kj- [17]. Do vay, khong nen dttng salmeterol va formoterol khi bfnh nhan den kham mgt khi hg da bilt co thai nhung cfl dttng cac thuflc nay truac do va triflu chung da dugc kilm soat. Tuy nhien, neu cfl the thi cac l o ^ thuflc nay khflng nen cho trong tam ca nguyflt d i u tien. Dfli voi anti-leukotriene thi chua co nghien cttu nio ve tinh an toan cua nhom thuflc nay o phu n&
CO thai do vay chi nen dttng thuflc nay khi cac lo?ii thuflc khac khflng dat dugc miic tieu dilu tri [11].
II. K£T LUAN
Hen va thai ky cfl t h i tac dflng qua Iji lan nhau nen cfl the gay ra nhflng tinh huflng xau cho ca me Ian con do vay can tham kham ky luong va djnh ky trong giai dojn nay. M\ic tieu quan trgng nhat trong cham soc san phu bj hen la tranh gay ra thilu oxy cho thai nhi.
Dilu nay chi co the dam bao khi hen ciia nguoi me dugc kiem soat th^t tot. Hau het cac thuflc trj hen deu an toan do do khflng vl ly do sg tac dung phu etta thuoc hen ma de san phu mat kiem soat hen hay vao dgt cap.
N l u ca hai tinh huflng trfln (hen mit kiem soat hay c6 dgt cap) xay ra thi se rit nguy hiem cho ca me va con. Do v$y, nguoi thay thuflc can nim ro nhttng nguy eg co thfl xay ra trong thai ky cung nhu tac dung phv khflng dang k l etta thuoc dieu tri hen nhSm
Y HOC VI^T NAM T H A N G 11 - SO CHUVgN O i • 2015
tu van cho thai phu each cham soc hen an toan va tflt nhit.
Nhihig a i l m chinh
•- Hen kiem soat kem se lam tSng nguy ca tien san giat, sanh non, sanh con nhe can va nguy ca t u vong chu sinh. Hen dugc kilm soat tflt se giani dugc nhimg nguy ca nay.
- Hiu hit thuflc dilu trj hen la an toan cho phu ntt CO thai.
- Khflng nen tri hoan corticosteroid uflng d l dieu trj dgt cip khi co chi djnh vi ly do cfl thai.
- ICS khflng nen thay dfli a phu ntt co thai khi hen cfla hg kiem soat tflt. Tuy nhien, nhttng phu ntt co y djnh cfl thai va dang stt d\mg ICS thi nen chuyin sang budesonide, nhflm thuflc dugc xep loai B v l nguy co dung trong thai ky.
- Sahneterol va formoterol khflng nen ngung khi mgt nguoi co thai dang stt dung nfl, nhung nlu dugc, nen tranh stt dung cac thuflc nay trong tam ca nguyflt d i u tien.
- Khuyfln b^nh nhan va gia dinh ring hut thuflc la thu dgng cung lam tang nguy ca hen va cac b$nh phfli khac cho dtta tre.
TAI Lifu THAM KHAO
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