6.
can cua can mac dui. Luan van Thac sf Y hpc, Tn/dng Dai hoc Y khoa Hue, 2005.
Bach B.R.., Nho SJ.: Anterior cruciate ligament:
Diagnosis and decision marking. Textbook of arthroscopy, Saunders, 2004, pp.633-643.
D'Amoto M., Bach B.R.: Knee injuries. Textbook of orthopaedic rehabilitation. Second Edition, Mosby, 2007, pp.375-546
Laffargue P., Dehalane J.L., Maillet M. et al.:
Reconstruction du ligament croise anterieur:
aritirotomie versus arthoscopie. Revue de chirurgie orthopedique, Masson, Pans, 1999, 85, pp.367-373.
Mccarty L.P., Bach B.R.: Complex Issues in anterior cruciate ligament reconstruction. Clinical sports medidne, Mosby Elsevier, 2006, pp.533-545.
Shelbourne K.D., Urch S.E.: Primary anterior cnjciate ligament reconstruction using contralateral autograft patellar tendon. The American Jourai of Sports Medidne, 2000, 28(5), pp.651-658.si
GIA TRI IBHCG HUYET THANH NGAY 14 VA NGAY 16 SAU CHUYEN PHOI TRONG TIEN LUONG SO LUONG PHOI LAM TO TRONG 6U0NG TU CUNG
Li Hoang*, Vu Thj Thu Trang**, Tham Chf Dung***
TOM TAT
Muc tiiu: xac dinh gii tri fihCG huyit thanh 14 va 16 ngiy sau chuyen phoi trong tien Iddng sd Iddng phoi. Doi tddng va phddng phap: nghien cdu mo ti cat ngang tien citu, 90 phii nd dddc thtj tinh trong ong nghiem (TTTON), trong do co 30 doi tddng chda 01 phoi, 30 chda 02 phoi vi 30 chda 03 phoi dddc chgn mau thuan tien, tai Trung tam Ho trd Sinh sin, Benh vien Phii sin Trung ddng (BVPSTW) trong thdi gian td 01/01/2010-30/6/2010. Kit qua: piiCG ngiy thd 14 vi 16 sau chuyen phoi co tddng quan thuan chieu d mdc do vda vdi so iddng phoi lim to trong td cung, tddng dng r=0,6 va r=0,5. Gii tri nong do fihCG huyit thanh ngiy thd 14 sau chuyin phoi dinh Iddng dddc >382,9mIU/ml co do nhay vi do dac hieu cao nhat (90,0%o vi 90,0%o) va ngiy thd 16 sau chuyen phoi dinh Iddng dddc >903,0mIU/ml co do nhay vi do die hieu cao nhat (93,3%o vi 80,0%o), thai phu co nhieu khi nang chda da phoi. Kit luan: gii tri nong do fShCG huyit thanh co thi ip dung detlen Iddng sdm da phoi. Can tht/c hien nghien cdU sau CO kiem soit nhieu tdi moi tddng quan gida nong do jihCG huyit thanh vi sd Iddng phoi SUMMARY
Serum beta-hCG value on t h e 14*^ and 16*^ day after e m b r y o transfer in predicting pregnancy outcomeg
Objectives: to descnbe the value of serum beta-hCG levels on the l4^ and 1&'^ day after embryo transfer and pregnancy outcome. Methods: a cross-sectional prospective study on 90 subjects who were selected for in vitro fertilization or intracytopiasmic sperm Injection (IVF/ICSI) with convenient sampling, in the National Center of Assisted Reproductive Technologies, National Hospital of Obstetrics and Gynecology from 1 January to 30 June 2010.
In which: 30 pregnant subjects had one embryo, 30 pregnancies had two embryos and 30 pregnancies had three embryos. Results: the value of serum beta-hCG levels on the l4^ and 1&'' day after embryo transfer positively correlated with the number of embryos In the uterus, r=0.6 and r=0.5, respectively. The value of serum beta-hCG level on the 14'^ day after embryo transfer was greater than >382.9mIU/mi with the sensivlty of 90.0%) and specificity of 90.0Vo;
And on the 1^ day was greater than >903.0mIU/ml with the sensivlty of 93.3%) and specificity of 80.0%o. It suggested more than one embryo in the pregnancy. Conclusions: the value of serum beta-hCG levels should be used for early prognosis of multiple embryos. A further study with larger sample size and have the control for potential confounding factors was recommended to be carried out to determine the association between the value of the serum beta-hCG levels on the l4^ and 1&^ day after embryo transfer and pregnancy outcome.
I.OAT VAN OE
phCG (Beta-human Chorionic Gonadotropin) la hormon hUdng sinh due rau thai &\itiz dPn bao nudi va hpp bao nudi che tiet, ed mat ti-ong mau hoac nUde tieu d thdi ky thai nghen. phCG dupc sif dung lam dau an de chan doan cd thai.
Xet nghiem nong dp phCG huyet thanh va nUde tieu ciia thai phu ho trp chan doan xac dinh cd thai va phat hien cd thai sdm. Hien nay, ky thuat cd dp nhay cao eho phep djnh lupng phCG d nong dp thifp tdi ImlU/ml va phat hien cd thai chi'nh xac trong vdng 8-12
"TS., BV Phu san TW;"BS., TrUdng DH Y Ha Noi;
32
ngay sau thu tinh. Xac djnh nong dp phCG trong nUdc tieu cd the phat hien sdm cd thai trong vdng 14-18 ngay. Trong nhifng thai ky binh thudng trong 3 thang dau, trung blnh lupng phCG tang gap ddi sau 48h. Ty le tang ft nhift la 66%, neu tang qua cao, qua thap hay khdng tang la bleu hien thai nghen khong binh thudng [2].
Donald P.E. cho rang qui luat tang gap ddi chi dung khi thai dupe 6 tuan tud'i [5]. Khi tud'i thai tren 6 tuan va nong dp phCG>6.000- lO.OOOmlU/ml, nhU vay phCG tang cham va khdng on djnh. Jouppila P. (2006) cho rang ket hdp giifa sieu am va djnh lUOng phCG la bien phap rat tdt theo ddi sU phat trien ciia thai.
Neu sieu am cd hinh anh thai tiep tuc phat trien, phCG tang thi dUPc coi la tien lUpng tdt.
Neu phCG giam, qua sieu am thai khdng phat trien nO'a thi tien lUpng xau [8]. Thdng thUdng d phu nif chifa da phdi, ham lUpng phCG se tang cao hPn so vdi thai nghen binh thUdng.
Huang X.Y. (2007) nghien cifu 384 thai phu ngay thif 11 sau chuyen phdi thay rang nhdm chifa da phdi cd nong dp phCG cao hOn nhdm dPn phdi. Neu phCG>250mIU/ml, gia trj tien doan dUPng tfnh ciia chifa da phdi la 83,3% va am tfnh la 74,4% [7]. Guth B. (1995) phat hien cd mdi tUOng quan gitfa nong dp phCG trong huyet thanh ngay thif 14 sau chuyen phdi vdi ket qua cd thai va chifa da phdi. Neu phCG Idn hPn 600mIU/ml, cd nhieu kha nang thai ky chifa da phdi [6].
Da thai la sU phat trien dong thdi nhieu thai trong tif cung. Day la mpt bat thudng ve sd lupng thai nhUng khdng phai la benh ly. Cd the gap 2, 3 hoac 4 thai,... hay gap nhat la 2 thai, cdn gpi la song thai. Da thai la tinh trang thai nghen cd nguy cP cao, lien quan tdi nhieu bien chifng xay ra cho ca me va con trong qua trinh mang thai va khi sinh. Vf du, ty le thai phu cd cac bien chifng san khoa trong 3 thang cudi ciia thdi ky thai nghen (tien san giat, san giat, thieu mau, rau tien dao, da 61,...) gap nhieu hPn so vdi chifa dPn thai [1]. Nghien cifu nay nham xac djnh gia tri phCG huyet thanh 14 va 16 ngay sau chuyen phoi trong
tien lupng sd lUpng phdi de chii ddng han che chifa da phdi d thai phu dUpe TTTON.
I I . O O I T U g N G VA PHU'aNG PHAP 1. Ddi tu'dng nghiin cdu
90 phu nif 6\itic TTTON, trong dd cd 30 ngUdi chifa 01 phdi, 30 chifa 02 phdi va 30 chifa 03 phdi dUdc chpn mau thuan tien tai Trung tam Ho trp Sinh san, BVPSTW trong thdi gian 6 thang (tif 01/01/2010 den 30/6/2010).
-I- Tieu chuan lUa chpn: Thai phu dap ifng tieu chuan lUa chpn vao nghien cifu neu: (1.) cd TTTON binh thUdng (IVF) va/hoac tiem tinh triing vao bao tUPng noan (IVF/ICSI), (2.) xet nghiem phCG >25mUI/ml 14 ngay sau chuyen phdi, (3.) sieu am cd tif 1-3 phdi thai trong tif cung 28 ngay sau chuyen phdi, (4.) cung ciip day dii cac thdng tin va yeu td nghien cifu.
-f Tieu chuan loai trif: cd chifa ngoai tif cung, ed tif 4 phdi thai lam td trong buong tif cung trd len, sau chuyen phdi cd diing hCG, TTTON tai nPi khac va khdng dii thdng tin
nghien eifu.
2. Phddng phap nghiin cdu
* Thiit ki nghien cdu: nghien cifu md ta cat ngang tien cifu.
* Cic bddc tien hanh:
Thu thap thdng tin ve tien sif, benh sif, thdi gian vd sinh bang phieu dieu tra dUng sin. Sau dd, ddi tUpng dupe cac bac sy kham lam sang va xet nghiem chan doan nguyen nhan vd sinh (npi tiet, chup X-quang tif cung theo quy trinh TTTON tieu chuan ciia Trung tam). phCG dUpc djnh lUdng vao ngay thif 14 va 16 sau chuyen phdi lam tren may IMx (Abbott, My) dUa tren nguyen ly xet nghiem mien djch men vi the. 6 ngay thif 14, neu phCG>25mIU/ml sau chuyen phdi la dUPng tfnh, nghTa la cd thai sinh hda. O ngay thif 16, phCG d nhdm dOn phdi thUdng ed ham lUpng tang gap ddi, trong khi khdng theo quy luat nay d nhdm da phdi (>2 phdi). Xac djnh su' lam to eiia phdi trong tif cung va sd lUpng phdi bang ky thuat sieu am dau dd am dao (tieu chuan vang) sau chuyen phdi 4 tuan de chan
doan cd thai lam sang khi cd hinh anh am vang thai va tim thai.
* Xd ly so lieu: bang phan mem Stata 10.0 (Texas, My, 2007).
I I I . KET QUA VA BAN LUAN
Tdng sd ed 90 ddi tUpng tai BVPSTW tham gia 3 nhdm nghien cifu. Tud'i tmng binh ciia cac tiiai phu la 31,9 tijo'i, tiiap nhat la 20 va cao nhift la 50 tudi. Thai phu tif 31-35 tud'i, nhdm trong dp tud'i sinh de, cd dieu kien thuan Ipi nhift cho kham va dieu tii vd sinh, npi tiet cdn tUPng ddi on djnh nen kha nang mang thai sau dieu tn eao, chiem ti/ le cao nhat (41,1%). Tiep theo la nhdm 26-30 tiJo'i (28,9%), ti-en 41 tud'i ehiem 4,4%
(p<0,001). Ket qua nghien eifu nay phii hpp vdi nghien culi tai Benh vien Tif Du, tud'i trung binh ciia nhdm ddi tUpng dieu trj TTTON nam 1998 la 35,9, nam 2002 la 35,6±5,2 [3].
Da sd thai phu dUPe TTTON lan dau (66,7%), nhdm thu tinh lan 2 chiem 23,3% va nhdm thu tinh lan 3 va lan 4 chiem 8,9% va 1,1%. Cd 65,6% trUdng hpp dUpe dieu trj bang each tiem tinh triing vao bao tUPng noan (IVF/ICSI) va 34,4% bang phUPng phap thdng thudng (IVF) (p<0,05). Ket qua tUPng tU nghien eifu ciia Vu Minh Ngpc (2006) tren benh nhan TTTON, ty le lan dau la 67,8% va lan 2 trd di la 32,2% [4]. NhU vay, ty le TTTON lan dau la pho bien. TTTON tai Viet Nam la ky thuat cdn mdi, gia thanh eao, cho nen viec ap dung ky thuat nay phu thupc vao ty le thanh cdng, da cd con hay chUa va dieu kien kinh te eiia ngUdi benh.
Bang 1: Tyle % sd phoi chuyen vio tdcung So phoi chuyen
2 phoi
3 phoi 4 phoi 5 phoi Tong
SL
6 9 47 28 90
7 1 % 6,7 10,0 52,2 31,1 100
eao nhat (52,2%). Da sd cac trUdng hpp cd chat lupng phdi chuyen tdt (2 diem), chiem ti/
le 95,6%. Chi cd 2 trUdng hpp cd chat lUPng phdi 0 diem (2,2%) va 2 trUdng hdp chiit lupng phoi 1 diem (2,2%). Sd phdi chuyen trung binh la 4,1±0,8. Benh vien Tif Du (2002) thUe hien chuyen sd phdi trung binh la 3,4±1,1 [3]. 6 Viet Nam, cac trung tam thUdng chuyen sd phdi trung binh tif 3-4 phdi trong 1 lan IVF nham tang ty le thu thai. Tuy nhien, dieu nay dong nghTa vdi tang ty le chifa da phdi va cac bien chifng lien quan den da phdi. Cac trUdng hpp chifa tif 3 phdi trd len se dUPc giam thieu phdi. Cac nUde khac nhau, luat phap va tdn giao ed anh hUdng khac nhau tdi quyet djnh chuyen phdi.
Bang 2: Nong do 0hCG (mUI/ml) tmng binh (±2SD) ngay thd 14 vi 16 sau chuyin phoi d nhom chii^ 1 phoi va nhom da phoi (n=90)
Nhom thai phu Chifa 1 phoi Chifa da phoi
SL
30 60
Ngay thdl4 207,5±162,1 997,9±707,9
Ngay thdlS 554,2±455,5 2524,2±2101,3
Nghien cifu cho thify, thai phu dUPe chuyen vao tif cung ft nhift la 2 phdi (6,7%), eao nhat la 5 phdi (31,1%), chuyen 4 phdi ehiem ty le
Nong dp phCG trung binh ngay thii 14 sau chuyen phdi d nhdm chifa da phdi (>2 phdi) la 997,9 (mlU/ml) va nhdm chifa 1 phdi la 207,5 (mlU/ml) (p<0,001). Nong dp phCG trung binh ngay thif 16 sau chuyen phdi d nhdm chifa da phdi (>2 phdi) la 2524,2 (mlU/ml) va nhdm chifa 1 phdi la 207,5 (mlU/ml) (p<0,001).
Huang X.Y. (2007) nghien cii'u tren 384 thai phu sau chuyen phdi ngay thif 11 thiiy rang d nhdm chifa da phdi nong dp phCG eao hdn so vdi nhdm chifa ddn phdi. Neu phCG d mifc Idn hPn 250mIU/ml, gia trj tien doan dUOng tfnh eiia chifa da phdi la 83,3%, gia trj tien doan am tfnh la 74,4% [7]. Guth B.
(1995) phat hien ed mdi tUOng quan giifa nong dp phCG huyet thanh 14 ngay sau chuyen phdi vdi ket qua thu thai cung nhU vdi sd lUPng phdi thai lam to trong tif cung. phCG trung binh ngay thif 14 sau chuyen phdi d mifc 200mIU/ml cd nhieu kha nang la chifa 1 phdi va d miic >600mIU/ml cd nhieu kha nang la
chifa da phdi [6]. i
hCG14-
Sothal
1.5 2.0 2.5 3.0
So thai
hCG16
12000.0}
hCG16p:4J9Te2TTl43.28 \ Sothai qii^T= 0.23 j
1.5 2.0 2.5 3.0
S6 thai
Hinh 1: Tddng quan gida nong do phCG ngay 14 (trii) va 16 (phii) sau chuyen phoi vdi so phoi thai lam to trong tdcung
Danh gia tUPng quan giifa nong dp phCG vdi sd phdi thai lam t d trong t i f cung de xac djnh xu hudng thay ddi ciia nong dp phCG huyet thanh theo ngay djnh lUPng sau chuyen phdi. Ket qua cho thiiy nong dp phCG ngay thif 14 va ngay thii' 16 sau chuyen phdi deu ed tUPng quan thuan chieu d mu'c dp vifa, tUPng
ifng r=0,6 va r=0,5 (Hinh 1). NhU vay, cd the eho rang sd lUPng phdi thai ed tac dpng den nong dp phCG huyet thanh ciia ngUdi me.
Nong dp phCG huyet thanh cd the dUPc col la ehi sd can lam sang tien lUpng tinh trang chifa ddn hoac da phdi thai
S-l
is
c o
0.50 Specificity
>. , „ „ ^«(underROCcurvB = 0.9417
1.00
t o
o
~ in . a>
(0
lO
o
o q -
^ ^ • — * - * ^
. \ \
\ ; \
\..^
\ ^ ^ ^
; \ ^
^"X.
. , !. . i ^
0.00 0.25 Afea under ROC cufve = 0.9361
0.50 Specificity
Hinh 2: Phan bo cua do nhay va dac hieu tien Iddng so Iddng phoi thai theo nong do phCG huyit thanh ngay 14 (trii) va 16 (phii) sau chuyen phoi
Nham xac dinh gidi han nong dp tUPng ddi ciia phCG huyet thanh, ky thuat dUdng cong ROC dupc sif dung de tham dd diem cat ciia gia tri phCG trong viec tien lUpng so lUpng phdi thai lam to trong t i f cung. Ket qua nghien
cii'u cho thay, vdi dien tfch dUdi dUdng cong ROC la 9 4 , 2 % , nong dp phCG ngay thif 14 sau chuyen phdi tai gia trj 382,9mIU/ml cd dp nhay va dp dac hieu cao nhat, tUPng ifng la 90,0% va 90,0%. Vdi dien tfch dUdi dUdng
cong ROC la 93,6%, nong dp phCG ngay thif 16 sau chuyen phdi tai gia trj 903,0mIU/ml ed dp nhay va dp dac hieu cao nhat, tUPng ifng la 93,3% va 80,0% (Hinh 2). NhU vay, gia trj 382,9mIU/ml la diem cat gdi y tien lUpng chan doan chifa da phdi vao ngay thif 14 sau chuyen phdi, ed nghTa neu thai phu ed nong dp PhCG huyet thanh >382,9mIU/ml cd nhieu kha nang chifa da phdi va <382,9mIU/ml la tien lupng chifa dPn phdi. Gia trj 903,0mIU/ml la diem cat gpi y tien lUpng chan doan chifa da phdi vao ngay thif 16 sau chuyen phdi, ed nghia neu thai phu ed nong dp phCG huyet thanh >903,0mIU/ml ed nhieu kha nang chifa da phdi va <903,0mIU/ml la tien lUpng chifa dPn phoi.
Nong dp phCG huyet thanh chi la mpt trong nhtfng ehi sd tham khao cd gia tri de tien lupng sd phoi thai lam to trong tif cung. Thai phu chifa da thai cdn phu thupc vao nhieu yeu td khac nhu tud'i me, kha nang dap ifng buong trifng, tinh trang vd sinh, chat lUpng phdi trong TTTON, dp day npi mac tif cung,... Cac yeu td nay can dUpc nghien eifu tiep vdi cd mau dii Idn va lUa chpn ngiiu nhien de kiem soat yeu td nhieu mdi quan he giifa nong dp phCG huyet thanh va sd lUpng phdi thai. DU bao sdm dUpe tinh trang da thai se ho trp qua trinh cham sde thai phu, dU phdng ed hieu qua cac bien chifng nhU tien san giat, san giat, thieu mau, rau tien dao, da di,... Thai nhi ciia me chifa da thai cd the gap nhieu tai bien khi cdn d trong tif cung, trong qua trinh chuyen da, vf du: say thai, de non, cham phat trien trong tif cung, thai chet lUu, dj dang thai, chi sd Apgar thap,... Ty le benh tat va tif vong ciia tre song thai cao gap 4 lan, tre 3 thai cao gap 6 lan so vdi ddn thai [1].
IV. KET LUAN
Nong dp phCG ngay thif 14 va ngay thii 16 sau chuyen phdi cd tUPng quan thuan chieu d mifc dp vifa, tUPng ifng r=0,6 va r=0,5 vdi sd
lupng phdi lam td trong tif cung. Gia tri nong dp PhCG huyet thanh ngay thif 14 sau chuyen phdi djnh lupng dUdc >382,9mIU/ml cd dp nhay va dp dac bleu cao nhat (90,0% va 90,0%) va ngay thif 16 sau chuyen phdi djnh lupng dupc >903,0mIU/ml cd dp nhay va dp dac hieu cao nhift (93,3% va 80,0%), thai phu cd nhieu kha nang chifa da phdi. Mpt nghien eifu ky ludng vdi cd miu dii Idn va dUpe chpn ngau nhien ve cac yeu td lien quan den tinh trang chifa da thai dUPc khuyen nghj thUe hien nham kiem soat kha nang gay nhieu tdi moi tUPng quan gitr'a nong dp phCG huyet thanh va sd lupng phdi thai lam to trong tif cung.
T A I LIEU THAM KHAO
1. Nguyin Thj Hanh: Nghien cUu mot so yeu to nguy cd cua de non trong song thai va each xir tri song thai khi chuyen da tai Benh vien Phu san Trung Udng tCf 1/2003 - 6/2004. Luan vin tot nghiep bac sf chuyen khoa 2, Tn/dng Dai hoc Y Ha Noi, 2004, tr.3-49.
2. VUdng Tien Hoa: Nghien cUu mot so yeu to gop phan chan doan sdm chifa ngoai tif cung. Luan an tien sy Y hoc, Tn/dng Dai hoc Y Ha Noi, 2002, tr. 12-18.
3. VUdng Thj Ngoc Lan va cs: Lien quan giu'a do day npi mac tif cung qua sieu am vdi ty le thai lam sang bang TTTON. Tap chi Phu san Viet Nam, 2002, 1(3), tr.76-83
4. Vu Minh Ngoc: Danh gia ket qua ciia phac do dai kich thfch buong trifng trong thu tinh trong ong nghiem tai Benh vien Phu san Trung Udng. Luan
van Thacsy Y hoc, TrUdng Dai hoc Y Ha Noi, 2006.
5. Donald P.E.: phCG dynamics in ectopic pregnancy.
Clinical Obstetrics and Gynecology, 1987, 30(1), pp. 129-138.
6. Guth B., Hudelson J., Higbie J., Solomon B., Polley S., Thomas S., Gentry W.L.: Predictive value of hCG level 14 days after embryo transfer.
Assist Reprod Genet, Jan 1995,12(1), pp. 13-14.
1. Huang X.Y., Zhang Y.N., Yu H.Q: Semm Beta-hCG of 11 Days after Embryo Transfer to Predict Pregnancy Outcome. Journal of Reproduction and Contraception, 9/2007, Volume 18, Issue 3, pp.213-219
8. Jouppila P. et al: Early pregnancy fairlure: study by ultrasonic and hormonal methods. Obstet and Gynecol, 1980, 55(1), pp.42-47i5'