TAP CHl Y HOC VIET NAM Tij>P 459 - THANG 10 - SO 2 - 2017
DAC DIEM LAM SANG, CAN LAM SANG VA KET QUA DIEU TRI VIEM TUY CAP TANG TRIGLYCERIDE O PHU NU" CO THAI
T O M TAT
Myc tieu: Nhan xet dac diem lam sang, can lam sang va ket qua dieu trj viem tuy cap(VTC) do tang triglyceride ^ G ) 6 phu ntJ" cd thai, Ooi tu'dng va phu'dng phap: Nghien cihj mo ta tren 26 benh nhan viem tuy cap do tang triglyceride d phu niJ co thai dieu tri tai khoa Hoi sire b'ch cu'c benh vien Bach Mai trong thcii gian tir 08/2013 dSn 08/2017. Ket qua:
Viem tuy cap tang trilyceride d phu nQ' mang thai cd mire dp nhe chiem_^65,4%; mire do trung binh va nang chiem 34,6%. Tuoi ciia benh nhan nghienciru tir 21 den 43, trung binh 31 ± 4,5. Tuoi thai trung binh 25
± 6,28. Ti le benh nhan d ba thang giiJa thai ky va ba thang cuoi thai ky ian lu'dt la: 53,8% va 46,2%. Ti le ben sir c6 roi loan md mau va viem tuy cap tang triglyceride khi mang thai la 50%, Cac benh nhan co tinh trang thieu djch liic nhap vien. Amylase mau tang
> 3 lan binh thu'dng chiem 61,5%. Mire do tang triglyceride d nhom viem tuy cap nhe va nang khong CO su" khac nhau(22,9± 18,38 va 29,7 ± 0,91mmol/L;
p> 0,05). MLTC do tang triglyceride d ba thang giu'a va ba thang cuoi ciia thai ky cung khdng c6 su" khac nhau (24,2± 19,18 va 20,0 ± 5,55mmol/L; p>0,05). Co 17 (64,7%)_ benh nhan du'dc thay huyet tu'dng (PEX). PEX giam miTc do TG cd y nghla tir 26,9 ± 17,50 xuong 9,4
± 7,16. Dierh SOFA liic tru'dc PEX va sau PEX 24h c6 su" t^ay ddi d nhuYig benh nhan du'dc thay huyet tu'dng (2,1±1,17 va 0,7±i,72; p<0,05). NhCTng benh nhan du'dc PEX co mu'c triglyceride cao hdn va giam nhanh hOn so vdi nhiJng benh nhan khong dUdc PEX.
Khong CO benh nhan tir vong, t / le tir vong thai trong nhom benh nhan nghien ciilJ la 7,7%. Ket luan: Thay huyet tu'dng la bienjihap hieu qua giiip giam mii'c do tang TG va thay doi SOFA tru'dc va sau dieu tri d benh nhan viem tuy cap tang TG d phu nu' c6 ttiai.
Tur khoa.'viem tuy cap, viem tuy cap do tang tn'giycende, eo thai.
SUMMARY
CLINICAL AND LABORATORY FEATURES AND TREATMENT OF HYPERTRIGLYCERIDEMINA INDUCED ACUTE PANCREATITIS DURING
PREGNANCY
Objectives: To describe clinical features and laboratory features and treatment ofhypertri glyceridemia induced acute pancreatitis (HTGP) during pregnancy. Methods: An observational study was
^ Trddng f)ai hoc Y Ha Ngl
^Khoa hoi sue tich cut benh vien Bach t^ai Chju trach nhiem chinh: Dao Xuan Cd Email: [email protected] Ngay nhan bai: 14.7.2017 Ngay phan bien khoa hpc: 29.9.2017 Ngay duyet bai: 30.10.2017
Tran Phircmg', Dao Xuan Cff^
performed on 26 pregnant womenwith acute pancreatitis caused by hypertnglycendemia and treated at the intensive care unit of Bach Mai hospital from 8/2013 to 08/2017. Results:
Hypertnglycendemia induced acute pancreatitis (HTGP) during pregnancy were two groups, with 65,4% in mild acute pancreatitis (MAP); 34,6% in moderately severe acute pancreatitis (MSAP) and severe acute pancreatibs (SAP). The patient age ranged from 21 to 43 years old with a mean of 31±
4,5 years. The mean gestational age was 25 ± 6,28 weeks, with 53,8% in the second trimester, and 46,2% in the third tnmester A history was hypertnglycendemia and HTGP in 50%. Al! the patients were missing fluids. The percentage of serum amylase activity at least three times greater than the upper limit of normal was 61,5%. The mean serum tnglyceride (TG) levels in the MAP and MSAP -i- SAP were not significantly different (22,9± 18,38 vs. 29,7 ± O,91mmol/L, p>0.05, respectively). The mean serum tnglycende (TG) levels in the second tnmester and the third tnmester were not significantly different (24,2±
19,18 vs. 20,0 ± 5,55mmol/L, p>0.05, respectively).
There were seventeen patient5(64,7%) given plasma exchange(PEX) therapy. Plasmapheresis decreased TG level from 26,9± 17,50mmol/L 9,4 ± 7,16 to mmol/L (p<0.05). The serum TG off patients given PEX therapy was higher and decrease faster than patients given not PEX. The mean SOFA(Sequential Organ Failure Assessment) scores for before and after PEX were significantly different (2,1± 1,17 vs 0,7+1,72, p<0.05, respectively). There was not patient died. The fetal mortality rate were 7,7%. Conclusion: Plasma exchange may be effectively administered for HTGP patients during pregnancy wilti decreased serum tnglycende, mean SOFA scores for before and after treatment.
I. OAT VAN OE
Viem tuy cap (VTC) d phu nO" mang thai ed ty le 1/1500-4500 thai [1], Nguyen nhan chii yeu la soi mat va tang triglyceride. Viem tuy cap do tang triglyceride (TG) chiem khoang 1 % - 4 % trong tdng so benh nhan bj viem tuy cap, triglyceride mau > lOOOmg/dL thi can nghi ngd VTC do tang triglyceride mau [2]. Phu nu' mang thai luon cd su" thay doi ve npi t i e i trong ba thang cuoi eiia mang thai, eo sd gia tang gap ba lan triglyceride huyet thanh. Dieu nay du'dc cho la do estrogen gay ra tang tdng hdp triglyceride.
Tang triglyceride mau cd the nghiem trpng hdn d phu nu' mang thai cd tien sir gia dinh tang lipid mau [3]. Ciing vdi sd phat trien ciia xa hpi, chat lu'dng cuge song ngay cang nang cao, nhu'ng ngu'di phu nffa mang thai thu'dng cd che dp an khong hdp ly, nguy cd mac benh viem tuy cap
43
VIETNAM MEDICAL JOURNAL H°2 - OCTOBER - 2017 do tang triglyceride nhieu hdn. Mot so nghien
ciru cho thay VTC tang triglyceride d phu nu' mang thai ed ty le 10% so benh nhan viem tuy cap, tham chi len tdi 50% [4]. Tai Viet Nam chda cd nghien ciru nao ve viem tuy cap do tang TG d phu nd mang thai. Chi'nh vi vay chiing tdi tien hanh de tai vdi muc tieu sau: Nhan xet dac diem lam sang, can lam sang va ket qua dieu tri viem tuy cap do tang triglyceride d phu nu' ed thai.
II. D6\ TUpNG VA PHiraNG PHAP NGHIEN CU'U 2 . 1 . Ooi tu'dng nghien cu'u
- Gom 26 lio sd benh an eiia nhu'ng benh nhan ed thai, dddc chan doan viem tuy cap theo tieu chuan Atlanta 2012 [5] va triglyceride mau >
ll,3mmol/l (lOOOmg/dl)- triglyceride dddc xet nghiem 1 lan khi vao vien, vao khoa va xet nghiem lai sau an 12h [2]vao dieu trj npi tru tai khoa Hoi sdc b'ch cdc - Benh vien Bach Mai trong thdi gian tir thang 8 nam 2013 d^n ttiang 8 nam 2017.
- Tieu chuan loai trir: VTC dddc chan doan do cae nguyen nhan khac nhd soi mat, glun chui ong mat, VTC ed TG < l l , 3 m m o l / l .
2.2. Phu'dng phap nghien cu'u 2 . 2 . 1 . Thiet ke nghien cii'u: Mo ta hoi ciru 2.2.2. Cac budc tien hanh nghien cii'u:
Cac benh nhan la phu nu' ed thai, dddc chan doan viem tuy cap dieu trj tai khoa hoi sdc tich cu'c trong thdi gian nghien cdu thda man tieu ehuan chpn benh nhan du'dc lay vao nghien ciru ehlalam 2 nhom theo phan loai Atlanta 2012:
Nhom 1 (mii'c dp nhe), nhom 2 (mire dp trung binh va nang).
Phan loai mut dp nang eiia VTC tiieo Atlanta 2012;
Mii'c do
Nhe
Trung binh
Nang
Dinh nghla Khong ed suy tang - Khong cd bien chdng tai cho
hay toan than.
- Suy tang thoang qua (cai thien sau 48h) Va/hoac:
- Bien chiing tai chd va bien chirng toan than (khong cd suy tanq keo dai) - Suy tang keo dai (>48h):
Suy 1 tang hoac suy da tanq I. KET QUA NGHIEN CU'U
S.l.Oac diem chung.
3.2. Oac diem lam sang va can lam sang thdi diem nhap vien
Viem tuy cap tang trilyceride d phu nii' mang thai cd mi?c do nhe chiem 65,4%; mire do trung binh va nang chiem 34,6%. Tuoi trung binh la 31
± 4,5. Gap chu yeu 3 thang giiJa va 3 thang cuoi thai ky, ty le lan Iddt ta 53,8% va 46,2%. Tuoi thai trung binh 25 ± 6,28 tuan. Tien sir eo roi loan md mau va viem tuy cap tang triglyceride khi mang thai la 50%.
Nhom 2 ( n = 9 ) Chung
( n = 2 6 )
Nhom 1 Cn= 1 7 )
Nhip thd (an/phut)
21,3 ± 2,S
p< 0,05Mach (ian/phiit)
114,2 ± 16,02
p< 0,05BMI
21,7 ± 1,90 21,6 ± 1,90 21,9 ± 1,99 >0,05
CVP fcmH20i
6,8 ± 3,40
p > 0,05Het (%) p > 0,05
P/F
386,0 ± 103,97 422,9 ± 84,12 316,4 ± 106,28
P<0,05Triglyceride (mmol/L) P > 0,05
Cholesterol (mmol/L)
12,4 ± 6,43 12,0 ± 7,34
p > 0,05Amylase mau t a n g ^ 3 lan
binh thtfdnq (28-lOOUI/L)
61,5% (n=16) 64,7% (n=ll)
55,6% (n=5) p>0,OS Mach, nhip thcf cua nhom 2 cao hcJn nhom 1. Chi so P/F nhom 2 thap hdn nhom 1. Si/ khac biet^co y nglita thong ke. Cac benh nhan vao vien khong co tinh trang beo phi, Thieu dich luc vao v'^en.Triglyceride va Cholesterol tang cao. Amylase mau tang > 3 ^ n binh thu'dng chiem phan Idn. Kliong CO su" khac nhau giffa hai nhom.
3.3. Cac thang diem cua nhom b6nh nhan nghien cu'u
— — - _ _ ^ ^ ^ Nhom Bang fliem — — . _
APACHE I I SOFA r^ARSHALL
SIRS
Chung ( n - = 2 S ) 2,5 ± 1,77 1,9 ± 1,13 1,0 + 0,96 88,5% (n=23)
N h o m l ( n = 1 7 ) 1,9 ± 1,39 1,4 ± 0,79 0,6 + 0,62 82,4% {n=14)
Nhom 2 ( n = 9 ) 3,6 ± 2,00 2,9 ± 1,05 1,9 ± 0,93 100%(n=9)
P P < 0,05 P < 0,05 P< 0,05 0>0,05 J
JJ^P CHl Y HOC VIET NAM TAP 459 - T H A N G 10 • SO 2 - 2017
Biem APACHE I I , SOFA, MARSHALL cua nhom 2 cao hdn nhom 1. Nhu'ng deu d mifc thap. Sif khac biet CO y nghTa thong ke vdi p < 0,05.
3.4. Lien quan triglyceride vdi cac giai doan mang thai Quy 1X9-12 tuan)
• SD
Q u y I I L ( > 2 7 tuan) X ± SD Quy I I 1 1 3 - 2 7
tuan) X ± SD
Triglyceride
24,2 ± 19,18 20,0 ± 5,55
p> 0,05 Tang triglyceride trung binh giu'a cac giai doan mang thai khong co si/ khac nhau.
3.5. Dac diem di'eu trj
3 . 5 . 1 . The tich dich truyen trong 24 h d'au Chung ( n = 2 6 )
± S D
N h o m l ( n = 1 7 ) X ± S D
Nhom 2 ( n = : S D
9)
Dich truyen 24h dau I 5576,9 ± 1793,171 4905,9 ± 1096,281 6844,4 ± 2209,14 | p < 0,05 The tich djch trung binh bu ngay dau cua hai nhom deu cao va nhom 2 a n bu lu'dng djch nhieu hdn. SLT khac biet cd y nghla thong ke vdi p < 0,05
3.5.2. Dieu trj ha m 8 mau ciia laenh nhan nghien cu'u Chung ( n = 2 6 )
N h o m l ( n = 1 7 )
Nhom 2 ( n = 9 )
Thay huyet tifdng (PEX)
17(65,4) 11(64,7) 6(66,7)
C6 17 (65,4%) benh nhan du'dc thay huyet tu'dng 1 den 2 lan.
3,5.3. Thay doi trudc-sau PEX
— ~ — . Thdi diem Bac diem — — - — _ _
Triglyceride Cholesterol SOFA
Trirdc PEX ( n = 1 7 ) 26,9 ± 17,50
13,8 ± 7,12 2,1 ± 1,17
Sau PEX 24h ( n = 1 7 ) 9,4 + 7,16 8,4 ± 4,16 0,7 ± 1,72
P p<0,05 p<0,05 p<0,05 Thay huyet tu'dng (PEX) giam ed y nghTa mire dp TG, diem SOFA.
3.6. Ket qua dieu tri
3 . 6 . 1 . Thay doi triglyceride t h e q j h d i gian
NhiThg benh nhan cd PEX ed mii'c triglyceride cao hdn va giam nhanh hdn so vdi nhu'ng benh nhan khong PEX.' _
3.6.2. Ket qua dieu trj chung
Chung(n=26) Nhom l ( n = : 1 7 ) Nhom 2 ( n = 9 ) Ngay dieu
tri
7,0 + 2,87
6,0 ± 1,50
7,3 + 3,38
5,5 ± 1,51
6,5 + 1,76 17(100) 7,0 + 1,00 7(100)
Song
26(100)
T d vong
2(22,2)
T d vong thai 2(7,7)
Khong cd benh nhan tOr vong, t / le t d vong thai la 7, vien ciia hai niidm khong khac nhau
IV. BAN LUAN
- Viem tuy cap tang trilyceride d phu nD' mang thai CO mire do nhe chiem 65,4%; mire dp trung binh va nang chiem 34,6%. Tuoi trung binh nhom benh nhan nghien ciru cua chiing toi la 31
±4,5. Kiet qua nay giong vdi nghien cdu ciia
" l_ '-K'-'-i'-l ^ I
nam d nhom 2. Thdi gian trung binh nam
Huang [ 6 ] . Tuoi thai trung binh 25 ± 6,28 tuan, Quihui (25.74±17.00). Chung toi nhan 50%
benh nhan ed tien sd rdi loan md mau va viem tuy cap tang triglyceride khi mang thai.
- Ti le viem tuy cap tang trilyceride d phu nu"
mang thai vao 3 thang cuoi thai ky la 46,2%. thap
VIETNAM MEDICAL JOURNAL N°2 - OCTOBER - 2017 hdn ciia Huang (95%). Nguyen nhan nhom benh
nhan ciia chiing toi cd nhieu benh nhan cd tien sd tang TG va viem tuy cap do iang TG, do dd den 3 thang giuS ttiai ky mut do TG da tang cao [3]
- Cac benh nhan deu cd thieu dich liic nhap vien. Mach tang cao d nhdm 2 (trung binh va nang). Diem APACHE I I , SOFA, MARSHALL cua nhom 2 cao hdn nhdm 1. NhuVig deu d mire thap.
Sd khac biet cd y nghta thong ke vdi p < 0,05.
- Tang triglyceride trung binh giu^ nhdm ed mu'c dp viem tuy cap nhe va nang khong khac nhau: 22,9±18,38 va 21,7±7,83. Ket qua nay eiia chiing toi cung giong vdi nghien ciru ciia Huang (18.8 ±11.13 va 30.5+24.20). Chung toi cung nhan thay tang triglyceride trung binh giiJa ba thang giua va ba thang cuoi thai ky khong ed sd khac nhau (24,2±19,18 va 20,0±5,55).
- Lu'dng djch can bii dao dong tir 4000- 9000 ml trong 24 h dau. Nhdm 2 can bii lu'dng dich nhieu hdn. Sd khac biet cd y nghTa thong ke vdi p < 0,05. Viec bii dich sdm trong nhij'ng gid dau se giam nguy cd ton thu'dng tang
- Cd 65,4% benh nhan dddc PEX va giam miTc dp TG cd y nghTa tir 26,9±17,50 xuong 9,4±7,16.
Nhiitig benh nhan cd PEX cd mire triglyceride cao hdn va giam nhanh hdn so vdi nhuTig benh nhan khong PEX. Ket qua nay giong vdi cac nghien ciru Hernandez [1], Huang [6]. Chiing toi cung nhan ttiay giam co y nghTa diem SOFA tru'dc va sau Pex 24h tir 2,1 ± 1,17 xuong 0,7+1,72.
- Dieu trj ha TG bang thuoc la giai doan sau CLia benh, khi tinh trang lam sang da on dmh, BN bat d3u an dddc qua du'dng tieu hda. Fibrate (200mg/ngay) la thuoc dddc khuyen cao ha TG hieu qua, cd the sir dung trong thai ky [2].
- Khong cd benh nhan tir vong trong nhom nghien cud, ket qua nay tu'dng t d Qihui [7], thap hdn Huang (9,5%). Ti le tir vong thai 7,7%. Trong
nhutig nam gan day ti le bJ vong thai trong viem tuy cap d phu nti' cd thai la 0-18% [6].
V. KET LUAN
- Ti le viem tuy cap tang triglyceride d phu nu' cd thai mufc do nhe 65,4%; trung binh va nang 34,6%. Cd 46,2% benh nhan d quy 3 thai ky.
Cac benh nhan vao vien deu thieu dich. Mii'c do tang triglyceride d nhdm viem tuy cap nhe, trung binh va nang khong cd sd khac nhau.
- Thay huyet tu'dng la bien phap dieu tri hieu qua cho benh nhan viem tuy cap tang triglyeended phu nu' CO thai. Khdng ed benh nhan tir vong 6 nhdm nghien culi. Ti le tir vong thai 7,7%.
TAI LIEU T H A M KHAO
1. Hernandez A., Petrov M.S., Brooks D.C. va cong SI/. (2007). Acute pancreatitis and pregnancy: a 10-year single center experience. J Gastrointest Surg Off J Soc Surg Ailment Trad, 11(12), 1623-1627.
2. Scherer J., Singh V.P., Pitchumoni CS. va cong sd. (2014). Issues in hypertriglyceridemic pancreatitis: an update. J Clin Ga^roenterol, 48(3), 195-203,
3. Goldberg A.S. va Hegele R.A. (2012). Severe Hypertnglycendemia in Pregnancy. J Oin Endocrinol Metab, 97(8), 2589-2595.
4. Ewald N., Hardt P.D., va Kloer H.-U. (2009).
Severe hypertnglycendemia and pancrealjtis;
presentahon and management. Curr Opin Lipidol, 20(6), 497-504.
3. Banks P.A., Bollen T.L., Dervenis C. va CQng s\i.
(2013). Classification of acute pancreatitis—2012;
revision of the Atlanta classification and definitions by international consensus. Gut, 62(1), 102-111.
6. Huang C , Liu J., Lu Y. va cong s\f. (2016).
Oinical features and treatment of hypertriglyceridemia-induced acute pancreatitis during pregnancy: A retnaspective study: HTGP During Pregnancy. J Oin Apheresis, 31(6), 571-578.
7. Qihui C , Xiping Z., va Xianfeng D. (2012).
Clinical Study on Acute Pancreatitis in Pregnancy in 26 Cases. Gastroenterol Res Pract, 2012.
DANH GIA TINH TRANG TRE S a SINH SAU MO LAY THAI CCiA CAC S A N P H U TIEN SAN GIAT NANG D U g C VO CAM
BANG GAY M^ T O A N THAN HOAC GAY T t VUNG
Nguyen Due Lam*
r " Myc tieu: Danh gia tinh trang sd sinh sau mo lay thai ciia cac san phu tien san giat nang du'dc vo cam bang gay me toan than hoac gay te vung. Doi tirtng, phu'dng phap: Thir nghiem 13m sang ngau nhien co so sanh, 180 benh nhan tien san giat nang diTdc mo lay thai, chia lain 3 nhdm, nhdm 1 du'dc gay me n^
khi quan; nhom 2 dddc gay te tiiy song va nhom 3 dddc gay tS tiiy song - ngoai mang cirng phoi hdp.
Ket qua: Chi so Apgar phut thir nhat ciia ba nhom w\
*DaihocYHaNdi
Chiu trach nhiem' chinh: Nguyen Dii'e Lam Email: [email protected] Ngay nhan bai: 20.8.2017 Ngay phan bien khoa hoc: 3.10.2017 Ngay duyet bai: 9.10.2017
