Tieu dudng thai ky
Vu Bich Nga*
Dai thao dudng thai ky (DTDTK) la tinh trang rdi loan dung nap glucose d ba't ky miic do nao, khdi phat hoac dugc phat hien lan diu tien trong luc mang thai. Dinh nghfa nay dugc ap dung dii ngudi benh CO ciin phai diiu tri bang insulin hay chi cin diiu chinh che'do an va du cho diin bien sau de con tin tai DTD hay khong. Nhung da sd trudng hgp DTDTK se he't sau khi sinh.
I. CHAN DOAN DAI THAO DITONG THAI KY Chira cd tieu chuan thdng nhat dS chan doan DTDTK trSn toan thS gidi.
Tieu chuan cua Hoi nghi Quoc te (HNQT) lan Thdi diem lay mau
thu-4 vg IDTK tai Hoa Ky 1998: cac thai phu dugc lam nghiSm phip dung nap glucose (NPDNG) vdi 75g hoac lOOg glucose. Chin doan DTDTK khi thai phu cd it nhat hai gia trj ldn hon hoac bang dudi day:
Ngumig gia trj chan doan
Luc ddi 1 gid 2 gid 3 gid
,_ Tuy nhien cac tic gia ciing khuySn clo can cd nhung nghien ciiu chuySn sau ban dS cd thS dua ra tieu chuan chan doln DTDTK mang tinh thuyet phuc ban.
Thoi diem chan doan dai thao duwng thai
NPDNG 75g 5,3 mmol/l 10,0 mmol/l 8,6 mmol/l
NPDNG lOOg 5,3 mmol/l 10;0mmol/l 8,6mmol/l 7,8mmol/l
ky: nlm 1998, tai HNQT lln thu 4 vS DTDTK, cac ySu td nguy ca ciia DTDTK dugc chia lam ba mirc do: nguy ca cao, nguy ca trung binh, nguy ca thSp. Dua vio mtre do nguy ca dS Ip dung thdi gian sing Igc DTDTK (bang 1)
Bdng 1. Phdn loai nhdm nguy cffvd khuyin cdo sdng lgc tieu dudng cua HNQT ldn thutuve DTDTK
Nguy Cff
Nguy Cff cao
Nguy Cff trung binh
Nguy Cff thap
Dac diem Co mot hoac nhieu hon cac yeu to sau:
- Thua can, beo phi tawc khi mang thai.
- Trong gia drnh c6 nguai bj DTD.
-TiSn sur DTDTK.
- TiSn su de con to > 4000g.
- Glucose nieu duong tinh.
Khong CO cac dac diem cila nhom nguy co cao va nguy ca thap.
Co tat ca cac dac diem sau:
- Thuoc ehung toe ma ti le DTDTK rdt thdp: nguoi da den, tho dan chau My. dan dao Thai Binh Duong.
- Trong gia dinh khong c6 ai bi DTD - Tuoi < 25.
- Can nang truac mang thai va tang can trong qua trinh mang thai la binh thuang.
(9-12kg).
- Khong CO tiin sir DTDTK.
- Khong CO tien sir san khoa xSu.
Sang Ioc Sang lpc tir lan dau tien den kham thai, neu khong bj DTDTK thi nhac lai vao tuan thii 24 -28 ciia thai ky.
Trong thai gian tiJ tuSn thir 24 - 28 cua thai ky.
Khong can lam nghiem phap sang lpc.
' Khoa Ngi det,Dai thao dudng - Benh vien Bach Mai
1 0 IY HOC LAM SANG So 46 (Thang 11/2009)
II. HAU QUA COA DAI THAO DirdNG THAI KY 1. Hau qua ddi vdi me
LL Hdu qud trudc mat: thai pbii DTDTK cd nguy ca bj cle tai biSn san khoa cao ban cac thai phu binh thudng.
Tdng huyit dp: thai phii DTDTK dS bj tang buySt Ip ban cac thai phtj binh thudng. Ti IS bj tang huySt Ip trong thdi gian mang thai cd thS dat tdi 10%.
Tien sdn giat vd sdn giat: thai phu DTDTK cd nguy ca bi tien san giat cao han cic thai phu thudng. Tham chi cd benh nhan bj hdi chtrng HELLP rat rd gdm cac trieu chirng tan mlu, tang men gan, sd lugng tieu cau thap. Ti IS cac phu nu DTDTK bi tiSn san giat khoang 12%, cao ban cle phu nir khdng bj DTDTK (8%).
Say thai vd thai chet Ueu: ngudi DTDTK tang nguy ca bj say thai tu nhiSn nSu glucose mlu kiSm solt khdng tdt d 3 thing dau. Ngugc lai cic phtj nd hay bj say thai liSn tiSp khdng rd nguySn nhan thi can phai kiSm tra glucose man.
Cdc bien chdng khac: nhiem trung tiet nieu, de non, da di.
1.2. Hau qud lau ddi: thudng thi khoang 50%
phu nir cd tien sir DTDTK se bj DTD type 2 trong tucmg lai. Ti IS mac se tang theo thdi gian, nguy ca phlt triSn thanh DTD type 2 tang 3% mdi nam.
2. Hau qua doi vdi thai nhi 2.1. Hau qud trifffc mdt - Thai to.
- Ha glucose mlu sa sinh trong nhtrng ngly dau sau de: khi glucose mau me tang vao 3 thing cudi thai ky v l dac biet II vao giai doan chuySn da thi glucose mlu ciia thai ciing tang, diSu dd kich thich tuy thai tang san xuat insulin. Sau khi sinh, ngudn glucose mlu tir me cung cap cho thai ngung dot nggt nhung ndng do insulin trong mlu con van cdn cao, insulin cao llm cho cic md bat giir glucose nhiSu ban trong khi gan tre sa sinh van chua san xuat dugc dii glucose dan dSn ha glucose mlu. Thdi gian ha glucose mau keo dai tdi 24-72 gid sau khi sinh. Vi vay kiSm solt tdt glucose mlu cho cic thai phu DTDTK trong thdi gian mang thai va chuySn da se tranh dugc tai biSn nay. VI ciing vi vay m l can pbai theo ddi chat glucose mlu cho tre sa sinh trong 3 ngay dau sau de.
- CIc biSn chirng khlc: ha canxi mlu sa sinh, da hong cau, tang bilirubin mlu, hdi chiing suy hd bap cap chu sinh, tang ti IS tir vong chu sinh, dj tat bam sinh, cham phlt triSn trong tu cung, phi dai ca tim...
- VS lau dai: 10 den 20 nam sau: tang nguy ca beo phi d cle tre em, tang nguy ca DTD type 2.
III. DIEO TR! BENH DTDTK 1. Muc tieu Glucose mau
Bdng 2. Muc tieu glucose mdu cdn dgt cho thai phu DTDTK theo Hdi DTD Hoa Ky 2004
Cac thong so Glucose mau liic ddi Glucose mlu sau an 2 gid HbAlC
Muc tieu can dat
< 5,8 mmol/1
< 7,2 mmol/1
< 6 % 2. Tap luyen va che do an
Hdi DTD Hoa Ky khuyen clo d thai phu cd thai neu khdng cd chdng chi djnh vS san khoa va ndi khoa, thi nen bat d§u hoac tiSp hic tap luyen d mtic viia phai vi tap luyen cd tic dung lam giam glucose mlu d ngudi me. Di bg sau biia an 20 phiit la boat ddng nSn thuc hien d thai phu, giiip kiem soat glucose mau tdt ban.
Bai ciing la mdt bai tap tdt cho thai phu. Trong khi tap
nSn giu cho nhjp tim khdng vugt qua 140 l§n/phiit. TSt cl cac benh nhan DTDTK cSn dugc tu vin vS dinb dudng dS cd chS do an hgp ly, cung cap du calo va cac chat dinh dudng cho ngudi me, nhung phii phii hgp vdi muc tieu kiSm solt glucose man. ChS do an van dam bao du calo cho me va cho thai phat trien (1500 -1800 kcalo/ngay). ChS do an can bang khdng cd dudng h§p thu nhanh, gilu canci vl sat.
So 46 (Thang 11 /2009) Y HOC LAM SANG j 1 1
3. Thude vien ha Glucose
Theo Hdi DTD ThS gidi 2005 va mdi nhit theo Hdi DTD Hoa Ky 2006 chi metformin cd thS' dtrgc diing de diSu trj dii thIo dudng thai ky cho nhung phu nir bj hdi chirng budng trirng da nang. Tuy nhiSn cic nghiSn ciru sir dirng thuoc viSn diSu trj DTDTK trSn lam sing van chua dti sau vl rdng vS tinh an toan trong thdi gian mang thai, vi vay khong nSn sir dung dS diSu trj DTDTK. Chinh vi the ma insulin van la thude dau tay dS diSu trj dii thIo dudng trong thdi gian mang thai khi ml che do an dan thuan khdng dam bao kiSm solt dugc glucose mlu.
4. Insulin
4.1. Chi dinh dieu tri insulin cho thai phu DTDTK
Tbeo khuySn clo ciia Hdi DTD Hoa Ky 2004:
cic thai phu DTDTK cd muc glucose mlu lie ddi
<7mmoI/I v l glucose mau 2gid sau an
<11,1 mmol/1 dugc hudng dan chS do an vl luyen tap trong 2 tuan. NSu mirc glucose mlu dat muc tieu diSu trj thi tiSp ttrc theo chS do an. NSu mire glucose mlu khdng dat muc tiSu thi phdi hgp vdi lieu pblp insulin. CIc thai phtr DTDTK cd mirc glucose mlu lie ddi > 7mmol/I hoac glucose mlu sau In 2h > 11,1 mmol/1 can dugc phdi hgp che do an vl lieu pblp insulin ngay. Ngudi benb DTDTK can kiSm solt dudng mlu chat che hon, vi vay khdng chd dgi tat c l cic chi sd DM theo ddi dSu Idn han mtre tiSu mdi bat dau dirng insulin. Theo Caroline vl cdng sir, khi ngudi benh DTDTK chi can cd tu 2 lan DM liic ddi > 5,5mmoI/I hoac DM sau an 2 gid >7,0mmoI/I trong 2 tuan theo doi la phai bat dau diSu tri bang insulin. Cdn theo Thoma R Moore, khi ban 20% ndng do DM sau an 2 gid ciia benb nhan tang trSn 7,2mmol/I hoac ban 10%
nong do DM liic ddi budi sang tang trSn 5,5 mmol/l thi can tiSm insulin. Hoi DTD va Hoi San phti khoa Hoa Ky khuySn clo nSn bat dau dieu trj bang insulin khi cd > 2 gia trj DM Iiic ddi >
5,8mmoI/I vl hoac > 2 gil trj DM sau an 2 gid >
7,2 mmol/I trong 1-2 tuan theo ddi lien ttrc.
4.2. Cdch tinh lieu khoi ddu
Theo Hdi DTD Hoa Ky, nSu dudng mlu sau an cao tu 7,3 -lOmmol/1 thi lieu khdi diu cd thS ttr 2- 4 dan vj insulin nhanh trudc btra an dd, cdn nSu dudng mlu liic ddi budi sang cao tu 5,8 - 7 mmol/l
thi lieu khdi diu insulin bin cham toi trudc khi ngii II 8 dan vj hoac tinh theo can nang la 0,16-0,2 dvi /kg can nang. Tang giam liSu td 1 - 4 don vi cho mdi mdt Ian cbinb liSu phu thugc vao mirc dudng mlu ctia benh nhan thay ddi trong 2 ngly liSn tiSp. Cleh tinh liSu khdi dau ciia Thoma R Moore cung tuang tu, tic gia bat dau tir 4-8 dan vj insulin nhanh trudc bua an nSu DM 2 gid sau an cao va 6-8 dan vi insulin bin cham budi tdi trudc khi ngii neu DM lie ddi budi sing cao. Cleh tinh nly dan gian, de ap dting.
4.3. Tutheo doi dudng mdu
Ngudi benh DTDTK cin theo ddi DM it nhit II 4 lan/ngay vio cac thdi diSm nhu sau: mgt Ian DM Iiic doi budi sing va ba Ian DM 2 gid sau ba bira an chinh. Vdi ngudi benh DTDTK chi diSu trj bang chS do an dan thuan thi can theo ddi DM 4 lan/ngay nhu trSn vl it nhat la 2 ngly/tuan. Neu 2 gia trj DM/tuan vugt qua muc tiSu tbi can phai theo ddi DM nhiSu ngly/tuan han nira. NSu ngudi benh DTDTK diSu trj bang insulin thi phai theo ddi DM blng ngly. BIc sy chuySn khoa DTD se dua vio muc DM 2 gid sau an dS diSu cbinb liSu insulin nhanh tiSm trudc bira an dd, cdn mirc DM luc ddi buoi sing se II ca sd dS chinh liSu insulin bin cham tdi hdm trudc. Vdi cic benh nhan khd kiSm soat dugc DM thi can tu theo ddi DM 7 lan/ngay va cd thS nhiSu ban nda, vao cac thdi diSm nhu sau: ba lan Iiic ddi, ba lan 2 gid sau btra an chinh, mdt lan vao 3 gid sing dS phlt hien ha DM trong dem va bat kS thdi diSm nao cd trieu chirng ha DM.
4.4. Cdc xet nghiem khde
Djnh lugng HbAlC 1-2 thing/lin, tim ceton nieu 1 thing/lan vl bat ctr liic nao DM >11,1 mmol/I, protein nieu Ithlng/lin va bit cir thdi diSm nio ngudi benh cd THA, phii.
5. Dieu trj va theo doi trong cuoc de
KiSm solt chat glucose mlu trong cuoc de la viec lam rat quan trgng nham trinh thieu oxy cho thai, trinh suy hd hap vl ha glucose mlu sa sinh. Neu glucose mlu ctia ngudi me trong cude de trSn 8,3 mmol/1 cd thS gay thiSu oxy cho thai va suy thai. Do vay mijc tiSu glucose mlu trong cuoc de t6t nhit dao ddng tu 3,3-5,6mmoI/l. Vdi mirc glucose mau kiSm solt chat nhu vay se trinh duac c l e tai biSn cho thai vl tre sa sinh.
1 2 IY HOC LAM SANG So 46 (Thang 11/2009)
Trong khi sinh, ngudi ta vira truySn glucose, vira truySn insulin dS' duy tri him lugng glucose can thiSt dat muc tiSu. Tit ca cac thai phu dang diSu tri dii thIo dudng bang insulin thi khi cd dau hieu chuyen da se nhjn an v l dugc truyen djch Ringer lactat chua 5% dextrose vdi tdc do 100-125ml/gid. Diing insulin bam tiSm dien
pha nhu sau: 50 dan vj insulin nhanh pha trong djch mudi dang truang vua dii 50ml, truyen tTnh mach, chinh lieu insulin theo muc glucose mlu trong bang 3. Theo ddi glucose mlu bang miy do glucose mlu c l nban nen llm 1 g i d / I Ian cho san phu, vi nhiSu khi chi mdt lieu nhd insulin cirng cd thS gay ba glucose mau.
Bdng 3. Theo ddi glucose mdu vd chinh lieu insulin theo muc glucose mdu cho thai phu DTD trong cuoc chuyen dg de
Glucose mau(mmol/l)
<3,9 3,9-5 5,1-6,1 6,2-7,2 7,3-8,3 8,4-9,4 9,5-10,6
>10,6
Insulin(doii vi/gid) 0
0,5 1 2 3 4 5
KiSm tra ceton nieu v l bio bic sy
Trong cuoc de, viec theo ddi tan sd tim thai bang monitor II bat budc dS cd tiSn lugng diing va kjp thdi xu tri cic tinh hudng xay ra bat ngd.
Trudng hgp cuoc de phai can thiep phau thuat, thudng gay tS ngoli ming cirng. Sau phau thuat phai theo ddi glucose mlu 2 gid/lan. Nudi dudng bang dung djch glucose dang truang tmh mach.
Viec diing insulin phai can nhac than trgng vi sau khi lay hSt binh nhau, lugng HPL giam xuong nhanh chdng lam mat hien tugng khlng insulin, do dd dS gay ha glucose mau. Thudng 2 ngly dau sau phau thuat, benh nhan chua an dugc nSn it khi phai diing insulin. Tir ngly thir 3 sau phau thuat, benh nhan an trd lai, nSu glucose mlu cdn cao thi tiSp ttjc diing insulin.
6. Theo doi sau de
6.1. Theo ddi cho tre sff sinh
c i n theo ddi cho tre sa sinh chat che trong 3
ngay dau tiSn sau sinh dS phlt hien cic biSn chirng va diSu trj kjp thdi cho tre. Ngay sau de, tre can dugc cham sdc vl theo ddi tai khoa sa sinh:
-h Theo ddi tim mach, tinb trang hd hap, pbat hien kjp thdi hdi chtrng suy hd hap cap.
+ Ha glucose mlu sa sinh thudng xuat bien trong khoang thdi gian 1-3 gid sau sinh. Ha glucose mlu cd the cd trieu cbt^mg nhu la bii kem, hdn mS, co giat... Tuy nhiSn bci glucose mlu sa sinh cirng cd thS khong cd trieu chirng lam sang. Vi vay tat ca cic tre deu dugc theo ddi glucose mlu bang miy thir glucose mlu c l nhan: ngay sau de, sau dd 1 gid/lan trong 3 gid dau, trudc moi lan cho tre b l va bat cir thdi diSm nao tre cd trieu chirng ha glucose trong 3 ngay kS tir khi sinh. NSu glucose mlu 2,8 mmol/I can cho tre an ngay, nSu khdng an dugc thi dat sonde da day cho an. NSu sau khi bii ma glucose mlu van < 2,8mmoI/I thi can truySn glucose 10%
So 46 (Thang 11 /2009) Y HOC LAM SANG I 1 3
tTnh mach vdi tdc do 6-8mg/kg/phiit. Nhiing tre cd trieu chirng ha glucose mlu nang (nhu la truang luc ca giam, nbgt nhat, suy hd hap, co giat, hon mS...) can dugc tiSm tTnh mach dung djch glucose 10%
ngay lap ttrc vdi liSu 2ml/kg can nang tre, tiSm trong thdi gian 2-4 phiit, sau dd truySn tiep vdi tdc do 6 - 8mg/kg/phiit. Thai nhi cd su tang insulin man tinh khi cdn d trong tir cung gay gilm kha nang ly giai glycogen ciia gan, vi vay dat tre sa sinh cd nguy co ha glucose mlu khdng chi trong vli gid sau de ml cdn cd thS keo dai tdi vli ngly sau. Va cung vi vay ma can phii theo ddi chat glucose mlu va chi y cho tre bii tdt trong 3 ngly dau sau de.
+ Lay mlu 6 gid sau sinh lam XN: canxi, bilirubin, hematocrit, bdng cau.
-H Ngay 2 lay mau llm lai cic XN: cdng thirc mlu, canxi, bilirubin de phlt hien da hdng cau, ha canxi, tang bilirubin.
6.2. Theo doi glucose mdu cho me
-I- Theo ddi glucose mlu cho me sau sinh, da sd glucose mlu ctia me ngay sau sinh con se vS binh thudng (>95%), vi sau kbi bong binh rau thi ndng do cic hormon nhau thai giam xuong nhanh chong. Llm xet nghiSm glucose mlu me ngay sau khi sinh con, nSu glucose mlu ciia me
11,1 mmol/1 thi van phai diing insulin cho ine nbung liSu insulin giam mdt nira so vdi lieu trong thdi gian mang thai. Neu dii thIo dudng cdn tdn tai sau sinh con thi ngudi me tiSp ttic dugc diSu trj bang insulin trong sudt thdi gian
cho con bii. Vi insulin nSu di qua sira me thi se bi djch da day ciia con phan buy hSt cdn c i c thuoc viSn deu cd thS dugc bli tiSt qua sira me vl gay ha glucose mlu cho con. Can khuyen khich cic ba me dii thIo dudng thai ky cho con bii sdm v l keo d i i .
-I- Khi cic ba me bSt thdi ky bau san (vao thdi gian 6 tuan sau de) thi se dugc lam lai XN dS dinh gia cdn DTD hay khdng. Chan doln DTD dua vio tieu chuan cho ngudi khdng mang thai ctia td chirc y tS thS gidi • - - - - ^.
TAI LIEU THAM KHAO
1. American Diabetes Association(2004). "Gestational Diabetes MelUtiis". Diabetes Care, Vol.27 (Suppl I):
S88-S90. ,
2. ACOG Practice Bulletin (2001). "Gestational dia- betes". Obstet Gynecol; Number 30, September.98; 525-38.
3. Do Trung Quan (2007). "Ddi thdo dudng thai nghen". Ddi thdo dudng vd diiu tri NXBYH, 399 - 419.
4. Anne Sullivan, Michelle Howard, Chis Boorman and al(2002). "Diabetes and pregnancy ". Diabetes cen- tre: 5-34.
5. Metzger BE, Coustan DM, Organizing Committee (1998). "Summary and recommendations of the Fourth international Workshop Conference on Gestational Diabetes Mellitus". Diabetes Care;
21:Suppl2; B161-BI67.
1 4 IY HOC LAM SANG So 46 (Thang 11 /2009)
