3,66 lan so vdi nhOmg gia dinh khdng c6 bd hoac anh em trai hut thudc; ThSi dp cua bd, me eUdng quyet cam hilt thudc thi ty le hpe sinh khong hut thudc cao gap 2,29 lan so vdi hpe sinh d gia dinh ma thai dp ciia bd, me khdng cUdng quyet
Nhan thifc cua hpe sinh ve tae hai ciia thudc IS in tren bao thudc cd ty le hiit thudc tha'p hdn 1,46 lan so vdi hpe sinh kh6ng nhan thifc dUdc.
Nhifng hpe sinh hut thudc thu dpng tai nha va hiit thudc thu dpng tai ndi khac eo y djnh hiit thudc trong 12 thSng tdi eao gap 1,7 lan va 1,86 lan so vdi nhifng hoc sinh kh6ng bj hiit thudc thu dpng.
TAI LIEU THAM KHAO
1. Bp Y te (2003), Dieu tra y te qudc gia 2001-2002, Nha xuSt ban Y hoc. Ha Npi, tr. 57- 67.
2. Ly Ngpc Kfnh, Phan Thj Hai, Nguyin Trpng Khoa, Nguyin Tua'n Lam, DSng Huy Hoang (2003), "Tinh hinh sir dung thudc la trong hpe sinh tudi 13-15 tai 5 tinh, thanh phd Viet Nam", Mgt sd cdng trinh nghien cifu ve kiim soil thudc la d Viet Nam giai doan 1999-2005, Y hoc thuc hanh sd 533, tr. 29-38.
3. ' Huynh VSn Thanh, Le ThSnh Tai (2005), Van dung va bude dau danh giS hieu qua ciia phUdng phSp giao due chii dpng trong ITnh vUc phong chdng hut thudc
la d hoc sinh trung hoc phd thong, K^ yeu cac con, rinh^
nghien cifu, Ung dung khoa hoc - cdng nghe tha:'.n phd Can Tha giai doan 2001-2005, Can Thd, tr. 251- 256.
4. Exposure to Secondhanhd Smoke Among Studend Aged 13-15 Worldwide,2000- 2007.http://vwvw.cdc.qov/mmwr/preview/ mmwrhtml/
mm5620 a2.htm
5. Robert S, Murray L (2007), Influence of smoking by family and best friends on adolescent tobacco smoking: Result from the 2002 New Zealand national survey of Year 10 students, Australian and Nev*^ Zealand journal of Public Health Vol. 31, No. 3, pp. 217-223.
6. Shafquat R, Zahid A, Saeed A (2007), Correlates of cigarette smoking among male college students in Karachi, Pakistan, BMC Public Health 7, tr. 312,
7. Sohaila S, et al (2005), Family characteristics and smoking among urban and rural adolescents living in China, Preventive Medicine 40, tr. 83- 91.
8. Wen X, Chen W, et al (2007;, Modifiable family and school environment factors associated with smoking status among adolescents in Guangzhou, China.
Preventive Medicine 45 (2-3), tr. 119-120.
TONG KET Y VAN THE GIOTI VE BENH LY
VA DIEU TRj NGOAI KHOA BENH CON ONG DONG MACH Of TRE S 0 SINH NON THANG
N G U Y I N V A N LINH, N G U Y I N L V THjNH TRLfdNG Benh vipn Nhi Trung Wang
N G U Y I N THANH HAI - Benh vien Nhi Trung Ifong Benh ly edn dng dpng mach IS sU tdn tai cua mpt
cau triic mach ndi giifa phan xudng ciia cua quai dpng mach chu va nhanh dpng mach phdi ehfnh g i n chd xuat phat eiia dpng mach phdi trSi[1-4]. Th6ng thudng, dng dpng mach tU ddng lai trong vong tif 24 den 48 gid sau sinh, neu sau 72 gid thi dUde coi IS benh ly[5-7].
DSy IS mpt dj tat phd bien vdi ty le khoang 57/100 000 tre sinh s6'ng[8], trong dd 1/3 tre sd sinh can nang tha'p tif 500 den 1500 gram. Them vao dd, 55%
sd tre ed cSn nang nhd hdn 1000 gram (la nhifng tre can nang rat tha'p) benh ly edn dng dpng mach cd bieu hien trieu chifng lam sang ma can thiet phai dieu tri. Mac dii c6 khoang 34% dng dpng mach tu ddng trong vong 2 - 6 ngay sau de vS trong nam dau tien d tre cd eSn nang rat thap, tuy nhien 60-70% sd tre de non dupe dieu trj bang thudc hoac bang phiu thuat de phong chdng sif mat bii ciia phdi, suy tim, chay mSu nao that, benii phdi man tinh, viem rupt hoai tur hoac chet[9J..
CAC TIEN BO VE KHOA HOC VA CONG NGHE Tim hieu cac cd che ddng cua dng dong mach Cac nguyen nhan gay nen sU tdn tai cua dng dpng mach dUde tim thay rat nhieu, tuy ntiien eSc yeu td dUde cho [S tao nen sif tdn tai nay trong vdng 24-48 gid d i u v i n con chua dUde hieu biet mdt cSch d i y dii[10]. O tre de du thang hau het cac trudng hdp xua't
hien mot each rdi rac nhimg lai cd nhieu bang chifng eho tha'y yeu td di truyen lai ddng mpt vai tro quan trpng trong sif tdn tai eua dng dpng mach. Ddi vdi tre sd sinh non thang ro rang da lam tang ty le mac benh vS eSc yeu td sinh ly lien quan chat che den sif tdn tai nSy hdn la nguyen nhan ve di truyen. O sd sinh non thang, ed 2 cd che ehfnh gay nen IJenh ly nSy va dUde chap nhan rpng rai.
Cd che ve hda sinh hoc
Su ton tai eua dng dpng mach d thai nhi dUde kiem soat bang nhieu yeu td va yeu td quan trpng nha't la Sp lUc oxy tha'p d thai nhi va cac san pham cua qua trinh chuyen hda trung gian ciia acid arachidonie (tien than cua protaglandin [PGE2] va prostacyclin [PGI2]. 6 thai nhi^ PGE2 va PG12 trong tuan hoan dUde sinh ra tai chd da giiip cho viec giif eho dng dpng mach gian thong qua tUdng tac vdi eSc thu the prostanoid d tai dng va PGE2, PGI2 dUde giif d mife cao bdi cSe san pham dUde tao ra bdi nhau thai vS SLf giam chuyen hoa d phdi cua thai nhi.
Sau khi sinh, sU tang dot bien ve ap lUc oxy ifc che cac kenh kali phu thupc dien the d cd trdn cua dng da dua canxi vao tao nen sif ddng dng dpng mach. Mife PGE2 va PGI2 giam xudng vi chuyen hoS ciia phdi thay ddi vS khong con nhau thai nifa. Ldp cd trdn ciia Idp So giifa cua dng dpng mach eo that laj ISm cho dng ngan lai, thSnh day len vS dong ki'n. SU
64 Y HOC THVC HANH (729) - SO 8/2010
dong kin nay thong thudng ket thiic trong vong tif 24 den 48 gid sau sinh d tre du thSng. Trong vong 2 den 3 tuan tiep theo, sU ga'p nep eiia Idp npi m6 vS sU tieu buy ciia ldp dUdi npi m6 tao nen qua trinh xd hoS vS ddng dng vTnh viln. Ket qua cua quS trinh nSy IS tao thSnh 1 dSy chang dpng mach. O tre sd sinh non thSng, dng dpng mach khdng eo that lai trong nhifng ngSy d i u sau de. Ngay ea ddi vdi nhifng trudng hdp da cd su CO that eiia dng thi ban than dng nSy th6ng thudng cung kh6ng the dat dUde sU thieu oxy mSu dii de ddng dng. Do dd rat nhieu tre sd sinh non thSng ma dng dpng mach da ddng v i n cd the bj thdng trd lai vS e6 t)ieu hien lam sang ciia benh ly edn tdn tai dng dpng mach.
Nhieu yeu td gian mach npi sinh dude hinh thSnh ngay trong thSnh mach, vi du nhu PGs vS nitric oxide, ngan chan sif ddng dng dpng mach. Trong sd cae loai prostaglandin, PGE2 dong vai trd quan trpng nha't cua su ngan chan nay. Bang each ifc ehe qua trinh oxy hoa de giam sU hinh thanh hdp chat PG se tao nen qua trinh co that eua dng nay[5]. Yeu td quan trpng thif hai lien quan den qua trinh nay d6 IS nitric oxide cung dUde sinh trong dng dpng mach. Nd dUde tim tha'y ca trong eSc te bao npi m6 Idng mach vS ca trong mach mSu nu6l dng dpng mach. Nhung dng dpng mach d tre de non thudng nhay cam hdn vdi ea PGs vS nitric oxide. Nhifng nghien cifu lam sSng cho thay cac yeu td ifc che PG hieu qua hdn khi cho vSo ngSy dau tien sau de hdn la vSo nhifng ngay tiep theo. Nghien cifu tren ngudi vS ddng vat cung chi ra rang ket hdp giiJa indomethaein vS chat ifc ehe phife hdp nitric oxide vSi ngay sau de hieu qua hdn IS ch!
dung indomethaein ddn dpc.
Ben canh nhiifng yeu td chinh neu tren, nhieu nghien cifu edn chi ra rang ed nhieu nguyen nhan khSc cung gdp phan ngan trd qua trinh ddng eiia dng dpng mach. Dau tien la su giam dSp ifng vdi indomethaein eua dng dpng mach d tre sd sinh non thang. Ngay sau de se cd mpt qua trinh gay viem tien trien trong thanh eiia dng dpng mach. QuS trinh nSy lien quan den sif xam nhap cua eSc te bSo m6n6 vS te bSo thUe bao khdng Id vao thSnh dng giai phdng eSc loai cytokine nhu interferon gamma va eae yeu td hoai tuf u alpha. CSc chat cytokine nSy cd tac dung gian mach rat hieu qua va boat dpng dpc lap vdi PGs va nitric oxide. Ly do khac lam giam quS trinh dSp ifng vdi sU co that cua dng ddi vdi indomethaein sau sinh phai ndi den nang lUdng trong thanh cua dng. O tre sd sinh non thSng, ngay ca khi Idng ong v i n md ciiuyen hoa nang lUdng ciia dudng, oxy, va ATP da bat dau giam xudng sau sinh. Mac dii qua trinh nSy khdng the ISm chet cac te bao va ngan can qua trinh tSi tao nhung nd cung can trd kha nang ddng cua dng. Ben canh viec giam dap ifng vdi indomethaein, dp day ciia thanh dng dpng mach cung ddng gdp vSo quS trinh ddng dng. Can chii y' rang d sd sinh non thSng ngay ca khi dng da ddng thi nd v i n cd phan ifng chdng lai qua trinh thieu oxy tram trpng ma nhifng tin bleu dau tien mang den bdi eSc te fcJSo chet vS nhCfng ddt viem IS ket qua cua sutSi tao.
Co che cd hpe:
Thong thudng, dng dpng mach d tre dii thang co ldp giifa ca'u tao bdi eae ldp ed trdn dpc va xoan e6 dp day vao khoang 1,2 mm[9]. DUdc chia thanh 2 ldp tach biet nhau bdi sif nuoi dudng: nifa trong dUde nuoi dUdng bing tham thau eac chat tU trong long mach, nifa ngoai dUde nuoi bang eae mach mau nuoi mach. Do d6, sau khi de, Slf eo that eiia mach mau dii Idn de can trd toan bp dong mau qua dng dpng mach va lam ngifng qua trinh nuoi dUdng mach vi no tao dUde viing thieu mau hoan toan. 6 tre sd sinh non thang, dp day ciia thanh dng mdng, dp day eiia Idp ngoai ehi khoang 200 mieromet, va n6 nhan dUde sU nuoi dudng bang tham thau tu ben trong. Trong qua trinh ddng dng, khong e6 VLing nao eiia thanh dng chju hau qua cua qua trinh thieu dinh dUdng, chi'nh vi the dng dpng mach d sd sinh thieu thang khong tao ra dUde mUe dp thieu oxy can thiet de dong dng.
Yeu td ve te bao hpe ma eu the d day la tieu eau tha'p cung ddng mpt vai tro quan trpng trong qua trinh ddng dng. Trong nghien eifu tren 123 tre de non tU 23-30 tuan, Eehtler va cpng su thay rang: sU giam sd lUdng tieu eau la 1 yeu td dU doan hoan toan dpc lap vdi sU bien ddi ve mat huyet dpng hpe. Cung tUdng tif nhU vay, eac yeu td nhiim triing cung lam tSng ty le benh, dieu d6 e6 the dUde cho la ehfnh cac cytokine ciia qua trinh viem da anh hudng den ehUe nSng eiia tieu cau do d6 ngSn chSn qua trinh hinh thanh huye't khdi trong long mach.
Ngoai ra, benh con dng dpng mach thudng tSng tan sd trong nhieu hpi chifng ve gen bao gdm nhufng bien ddi ve nhiim sac the (vf du: trisomy 21 va hpi chifng 4p), bien ddi ddn gen (nhu iipi chifng Carpenter va Holt- Oram), va dot bien ciia gen X. Nhiim Rubella trong 3 thang dau eiia thdi ky bao thai, dSc biet IS trong 4 tuan dau e6 nguy cd bj benh cao. Benh ly nay eung eon dUde bao cao c6 lien quan den eae yeu td ve moi trUdng, tuy nhien ehUa e6 mpt cd che chinh xac nao.
Benh ly hoc
Ludng mSu di tU trai sang phai la nguyen nhan chinh lam tSng lUdng mau len phdi. 6 tre non thang suy thd e6 kem theo giam ap lUc keo va tSng tinh tham thanh mach, Slf tdn tai eiia dng dpng mach se gay nen U djeh d khoang ke, cac nang phdi va giam tinh dap ifng eiia phdi. Hau qua la phai tSng cac chi sd diing may thd vdi thdi gian thd may keo dai va vdi Sp life oxy eao, eo the gay nen benh phdi man tfnh va loan san nang tuyen phdi. Ddi vdi tre eo can nSng thap hdn 1500 gram thUdng tdn eiia phdi thudng kem theo rdi loan chife nSng eiia ed tim do 2 nguyen nhan: tSng khdi lupng mau d that trSi va giam khdi lUdng mau do bi "hpi chifng danh cap mau". Do d6 d nhifng tre nay se tSng nguy cd thieu tudi mSu d cac tang quan trong gay nen cac benh ly nhu chay mau nao that, viem rupt hoai tif, va suy than. MSc dii c6 Slf lien quan chae chan eiia benh con dng dpng mach vdi nhifng benh ly tren tuy nhien thi vai tro cot loi vin khong thifc sif ro rang.
Die'u tn ddi vdi tre sasinh:
Dieu trj bang indomethaein da duac sif dung rpng rai va eho hieu qua ro ret, tuy nhien trong mpt sd trudng hdp can diing them nitric oxide. Nhifng dng dpng mach d tre de non thudng nhay cam hdn vdi ea PGs va nitric oxide.
Y HOC THVC HANH (729) - SO 8/2010 65
Nhifng nghien cifu lam sang eho tha'y cac yeu td ifc ehe PG hieu qua hdn khi eho vao ngay dau tien sau de hdn la vao nhufng ngay tiep theo. Nghien cifu tren ngudi va dpng vat eung chi ra rang ket hdp giifa indomethaein va cha't ifc che phUe hdp nitric oxide vai ngay sau de hieu qua hdn la chi diing indomethaein ddn dpc. Nhieu tae gia eho rang ddi vdi tre tha'p can can ban che truyen qua nhieu djeh, chi can duy tri d mUe 100-150 ml/kg/day. Tuy nhien, neu dieu tri npi khoa tha't bai thi ehi djnh duy nha't la dieu trj ed hpe dong dng bang dat dii hoac p h i u thuat.
Chi djnh cua phiu thuat:[9]
- That bai sau 2 lan dieu tri npi khoa (indomethaein hoac ibuprofen), hoac cho'ng ehi djnh vdi indomethaein
- Huye't dpng hpe ciia huyet ap dong mach (huye't ap trung binh) nho hdn so vdi tudi thai nhi
- Suy tim
- Chi sd left atrial-aortie root > 1,6
- Tdc dp trung binh d dpng mach phdi trai >0,6m/s - Ong dpng mach > 3 mm, hoSc dng qua idn gay bien ddi ve huye't dpng hoc
Thdi gian can thiep phiu thuat:
Hau het cae tae gia deu eo mpt nhan djnh ehung la nen phau thuat sdm vi, tuy nhien thdi gian nao la phii hdp nha't thi con nhieu tranh cai. Thong thudng thi viec dieu tri ngoai khoa chi bat dau sau khi dieu tri npi khoa that bai, nhUng eung c6 tac gia can thiep sdm hdn tU trUde khi dung lieu thif hai hoac vai sau de khi dng qua idn gay bien ddi ve huye't dpng hoc. Vdi tre sd sinh non thang, neu eo tdn tai dng dpng mach tren 14 ngay se lam ngifng phat trien va gay nen loan san nang tuyen phdi[9], tuy nhien viee that dng dU phong trong 24 gid dau cung khong lam giam ty le nay, mac dii n6 eung lam giam ty le viem rupt hoai tif. Tuy nhien tren eae bao eao thi thdi gian md tiiy thupc vao tifng nhdm nghien eifu:
Vladimiro va cpng su e6 thdi gian md trung binh la 16 ngay (12-22 ngay), Mandhan la 12-18 ngay va thdi gian thd may va thdi gian nam vien thudng keo dai, ty le gap bien chifng cao tU 6-15% bao gdm:
- Chay mau trong md - Tran khi mang phdi
- Ton thUdng day than kinh thanh quan quSt ngUde - Tran dUdng chap mang phdi
- Nhao ed hoanh
Lift chgn phuang phip phiu thuat:
Hien nay eo ra't nhieu phUdng phap p h i u thuat da dUde ap dung de dieu tri benh ly nay. Tuy nhien, viee lua chpn ra phUdng phap nao la phii hdp thi eon phu thupc vao nhieu yeu td: trinh dp ve gay me hdi sUc d tre sd sinh, trinh dp eiia phau thuat vien, trang thie't bj hien co... Hien nay, phau thuat md md chi dUde ap dung khi dUdng kinh eiia dng Idn (tren 10mm), eho nhifng trung tam ehUa phat trien ky thuat npi soi hoSe trong nhifng trudng hdp tai bien eua npi soi va flat coil. Phau thuat npi soi, va dat dii da dUdc phat trien va ap dung cho hau het eae trUdng hdp khong co chdng chi djnh. Tuy nhien trong vong 10 nam trd lai day, hau het cae bao eao tren the gidi deu.xoay quanh van de nen chpn phUdng phap nao m§c du sU cai tien va ddi mdi ky thuat khong ngifng dUde nang len.
PhUdng phap dat dii dUde rat hieu qua, thdi gian tien hSnh ngan, thdi gian nam vien ngan (thudng benh nhan dUde eho ra vien ngay trong ngay hoac ngay hom sau
CLia dieu •ri). Hdn nufa, do can thiep nay ehi narr' ben trong If ig 6'ng nen khong eo nguy ed ve tdn thirc-^i day than kinh thanh quan. Tuy nhien, can thiep nay cung g^p nhieu ban che. ThU nha't, phu thupc vao ngUdi co nhieu kinh nghiem hay khong, ngay ca khi ngUdi c6 nhieu kinh nghiem thi ty le thanh cong eung ehi dat 85% eac trUdng hdp can can thiep. ThU hai, trong mot so' trUdng hdp eo tai bien tupt dii kha nang la'y dii ra la rat khd. ThU ba, kha nang ap dung d tre sd sinh, dae biet d tre non thang eon ban che vi thiet bi va kinh nghiem con ban ehe. Thif tu, gia thanh ciia can thiep nay con cao.
PhUdng phap p h i u ttiuat npi soi co Uu diem la tien hanh hau het tren eae trudng hdp, chi trU eac trudng hdp khong co chi djnh nhu day dinh mang phdi, hoac khong co kha nang gay me, gia thanh thap, thdi gian nam vien khong dai. Tuy vay, thi phUdng phap nay cung con nhieu ban che eiia no nhU: can ngudi c6 kinh nghiem, d l gay tdn thUdng day than kinh thanh quan, cac tai bien do phiu thuat long ngU'c[9]. Ngay ea ddi vdi md npi soi va md md, viec lifa chpn diing clip dang ngay eang dUde lUa chpn nhieu hdn vi thdi gian md ngan, ky thuat ddn gian hdn de thay cho phUdng phap that dng bang ehi gay ra nhieu tai bien hdn.
KET LUAN
Benh ly con dng dpng mach d tre sd sinh la mot benh ly nang ne va phufc tap doi hdi dUde can thiep sdm, difng lue va dung phUdng phap phii hdp vdi tifng ed sd.
T A I L I E U T H A M KHAO
1. Silver, M.M., et al.. The morphology of the human newborn ductus arteriosus: a reappraisal of its structure and closure with special reference to prostaglandin E1 therapy. Hum Pathol, 1981. 12(12): p.
1123-36.
2. Record, R.G. and K.T. Me, Observations relating to the aetiology of patent ductus arteriosus. Br Heart J, 1953. 15(4): p. 376-86.
3. Gittenberger-de Groot, A.C., et al.. The ductus arteriosus in the preterm infant: histologic and clinical observations. J Pediatr, 1980. 96(1): p. 88-93
4. Desligneres, S. and J.C. Larroche, Ductus arteriosus. I. Anatomical and histological study of Its development during the second half of gestation and its closure after birth. II. Histological study of a few cases of patent ductus arteriosus in infancy. Biol Neonate, 1970.
16(5): p. 278-96.
5. Clyman, R.I., Ibuprofen and patent ductus arteriosus. N Engl J Med, 2000. 343(10): p. 728-30.
6. Kouchoukos, N., et al.. Patent ductus arteriosus. 3 ed. Cardiac Surgery, ed. R. Lampert and E.
Geisel. Vol. 1. 2003, Philadelphia: Churchill Livingstone.
928-945. i 7. Schneider, D.J. and J.W. Moore, Patent ductus
arteriosus. Circulation, 2006. 114(17): p. 1873-82.
8. Hoffman, J.I. and S. Kaplan, The incidence of congenital heart disease. J Am Coll Cardiol, 2002.
39(12): p. 1890-900.
9. Hamriek, S.E. and G. Hansmann, Patent ductus arteriosus of the preterm infant Pediatrics, 2010. 125(5):
p. 1020-30.
10. Hermes-DeSantis, E. and R. Clyman, Patent ductus arteriosus: Pathophysiology and management Journal of Perinatology, 2006. 26: p. S14-S18.
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