🔙 Quay lại trang tải sách pdf ebook Sản khoa hình minh hoạ Ebooks Nhóm Zalo SAN KHOA H'lNH MINH HOA ■ NHA XUAT BAN Y HOC HA NOI - 2006 GS. DUONG TH( CUONG BS. DINH QUANG MINH BS. NGUYiN DANG THU MUC LUC ■ ■ Chiidng 1. Sinh ly sinh san 5 Chiidng 2. Sinh ly ngiidi me 24 Chiidng 3. Giai phau hoc san khoa 48 Chiidng 4. Chan doan hien tiidng co thai 61 Chiidng 5. San soc triidc khi sinh 69 Chiidng 6. Danh gia thai nhi trtfdc khi sinh 91 Chiidng 7. Cac benh toan than trong khi co thai 105 Chiidng 8. Cac benh khi mang thai 138 Chifdng 9. Chay mau am dao trong khi mang thai 164 Chiidng 10. Chxia da thai va cac bien chiing khac triicic khi sinh 205 Chiidng 11. Chuyen da de thiidng 234 Chifdng 12. Chuyen da de bat thifdng 263 Chiidng 13. Cac trang thai bat thiidng cua giai doan ba 303 ChifOng 14. Thu thuat - phau thuat san khoa va cac thifdng ton cua ngifdi me 314 Chifdng 15. Hau san binh thiidng va benh ly 355 Chiidng 16. Tre sd sinh 376 Chiidng 17. Tik vong me va thai nhi 418 Chiidng 18. Phong tranh thai 429 3 (Alitiotnj 1 SINH LY SINH SAN I. S1/ PHONG NOAN VA HIEN Tl/ONG KINH NGUYET 1. Cac thay doi theo chu ky cua buong trumg Hinh 1.1. Sir thay doi theo chu ky cua buong trilfng Trong vong kinh binh thiidng 28 ngay, nhiing thay doi ke tiep nhau xay ra 0 buong triing nhim tao ra mot noan triidng thanh, co the thu tinh diidc. S\1 ke tiep nay cung kiem soat ve mat khoi liidng va chat liidng cac steroid can thiet cho sil chuan bi tiep thu triing cua tiJ cung. 2. Sir kiem soat cua tuyen yen doi v6i buong trumg Nhiing thay doi d buong triing chu yeu do thuy triicic tuyen yen kiem soat, tuyen nay che tiet ra ba loai hormon: Hormon kich thich nang noan (FSH), co tac dung lam nang noan phat trien; hormon hoang the hoa (LH), kich thlch hien tiidng phong noan va tao nen hien tiidng hoang the hoa cac te bao hat sau khi thoat khoi noan, va prolactin ma tac dung cua hormon nay khong ro rang. 5 F S.H --TC------Prolactin LH .1 \ Ngay 1 :Q Ng^y 12 Ngay 28 Hinh 1.2. Sir kiem soat cua tuyen yen doi vdi buong triing 3. Nhumg thay doi d noi mac tu cung Hinh 1.3. Si/ thay doi cua noi mac tCr cung 3.1. Cac hormon buong trung \ \ \ \ N Estrogen J ■* ” " v \ •Progesteron^ —, N Ngay 1 Ngay 12 Ngay 28 3.2. Nhung thay doi 6 mach mau 3.2.1. Giai do?n tang sinh nhd co estrogen kich thich, noi mac tit cung diidc tai thiet. Cac tuyen thang va khong che tiet. 3.2.2. Giai doan che tiet chu yeu do progesteron kich thich, tai noi mac cac mach mau phat trien manh me. Cac tuyen phinh to len va ngo^n ngoeo, che tiet va dii tru glycogen, mucin cung nhiing chat khac; cac chat nay co kha nang nuoi diidng noan da thu tinh. Cac mach mau xoan lai nhieu hdn. 6 A- '& 2 J Ngay 28 Hinh 1.4. Sir thay doi b mach mau £ 2 3.2.3. Giai doan tien kinh (thoai then) sit phat trien cua noi mac tit cung dtoig lai 5-6 ngay trUdc khi kinh nguyet xuat hien. Triidc khi thay kinh, 16p noi mac nay nhan nhum lai vi liiu liidng mau tuan hoan giam sut, va chat che tiet diidc day ra ngoai. Tinh trang nay lam gia tang hien tiidng ngoan ngheo cua cac tuyen va cac mach mau. Sit che tiet cac kich due to" tuyen yen chiu sit kiem soat kep cua buong triing va mot trung tarn tai vung diidi doi thi. ___ Cac te bao tao ra yeu to phong thich Tien yen hormon Kich thich tien yen Kich thich Estrogen tiep tuc tang / Chi cac nang noan to o Oinh tang vot cua LH va FSH mOi co the Ion len Ngay 12Hoang the Hinh 1.5. Si/che tiet cac kich due to cua tuyen yen dudi siikiem soat cua buong triing va vung dudi doi Vao cuo'i vong kinh thi estrogen trong huyet tiidng thap, lam cho FSH diidc che tiet de kich thich sit triidng thanh cua nang noan. Estrogen trong mau tiep tuc tang len va cuoi cung kich thich vung diidi doi thi che tiet ra cac yeu to phong thich LH (feedback diidng), gay nen sit tang vot cua FSH va LH. dan den hien tiidng phong noan. Nhiing bien doi trong mau ve ham liidng cac hormon chu chot diidc gidi thieu trong bieu do kem theo. 7 Hinh 1.6. Si/thay doi ham li/dng hormon chu cho't. II. SIf THU TINH VA SU LAM TO CUA TRLfNG 1. Phong noan vao ngay thii 12 2. Thu tinh Hinh 1.7. Phong noan va si/thu tinh 8 Sau khi thu tinh trong voi Fallope thi hdp txt (noan da thu tinh) phan chia lien tiep de tao nen mot cau dac cac te bao goi la thai dau. No tiep c^n buong til cung vao ngay thii 7 sau khi thu tinh va lam to hoan chinh vao ngay thi! 14 sau i phong noan. III. MOI LIEN QUAN VE NOI TIET KHI MCJI MANG THAI Phong noan va thu tinh Ngay 1 Di qua voi Fallope Ngay 2 va 3 Hdp tu nam til do trong tii cung Ngay 4 Hien tiidng lam to b^t dau Ngay 7 Hien tiidng lam hoan thanh Ngay 14 Banh rau tiet ra kich due to" rau thai Tien yen l/c che Oz3O o< Hinh 1.8. Sd do moi lien quan ve noi tiet khi mdi mang thai Trong 14 ngay dau co thai, thi sil tang trildng cua til cung va mang rung (noi mac til cung hoai thai) diidc duy tri nhd hoang the dil6i anh hildng cua hormon hoang the hoa cua tuyen yen. Sau 14 ngay mang nuoi nguyen thuy tiet ra hormon hoang the hoa (kich due to' rau thai), dam nhiem vai tro kiem soat hoang the va lie che hoat dong cua kich due to" tuyen yen. 9 Hinh 1.9. Sd do moi lien quan dinh li/dng Duf6i anh hilcfng cua hormon hoang the hoa cua rau thai, hoang the tiep tuc tang trildng va tiet ra cac steroid de duy tri sil tang trildng cua mang rung tii cung. Liidng kich due to" rau thai tiet ra hang ngay dat t6i dinh cao nhat chung quanh 10- 12 tu&n, roi sau do giam di tdi mot ngildng on dinh cho tdi du thang. Vdi sU giam sut nay, hoat dong cua hoang the mat di, song svf san xuat steroid cua rau thai bat dau thay the no, khien cho liidng estrogen va progesteron che tiet ra hang ngay tang len deu dan. 1. Li/dng steroid tiet ra hang ngay cua buong trumg va rau thai Dinh cua giai doan hoang the Giai doan rau thai 20 tuan 40 tuan 2. Kich due to (KDT) rau thai tang len Progesteron/24 gid 30mg 75mg 250 - 300mg Estrogen nieu/24 gid 30mg 4-5mg Nhieu hdn 50mg Tuan mang thai Hinh 1.10. Cac steroid tiet ra khi m6i mang thai 10 IV. SL/ PHAT TRIEN CUA PHOI Khi con dang d trong voi Fallope thi noan da thu tinh phan chia lien tiep de tao nen mot khoi hinh tron cac te bao goi la thai dau. Hinh 1.11. Sy phat trien cua phoi Tiep vdi chang nay, khi thai dau vao tdi buong tii cung thi xuat hien mot khoang lech tam, dan den viec hinh thanh mot khoi cau rong hay nang mam vdi mot gd cac te bao d mot phla cua mat trong la khoi te bao phla trong. Vo ngoai cua nang mam trd nen mang nuoi chiu trach nhiem dinh dildng cho phoi. Cho tdi tan thdi diem nay, cac chat tiet trong voi triing va tut cung van du cho sU tang trildng ban dau cua hdp tii. Sil phat trien tiep tuc doi hoi nguon thiic an va oxy gia tang, va hdp tii phai tiep xuc vdi nguon cap huyet tuf me bang cach lam to trong 16p mang rung. Khoi te bao phla trong biet hoa va tao nen hai khoi rieng biet, khoi ngoai hay con goi la la ngoai bi va khoi trong hay la noi bi. Mot sil biet hoa tiep tao ra la thii ba. la la trung bi, d giiia hai la vila neu. La nay phat trien ra phla ngoai va lot boc nang mam. Su ket hdp cua ldp nguyen bao nuoi va trung bi nguyen thuy diidc goi la la nuoi. Co hai buong xuat hien, mot trong ldp ngoai bi tao thanh buong oi, tui kia trong ldp noi bi - la tui noan hoang. 11 Ngoai bi __ Trung bi Noi bi Mang nuoi Buong oi Tui noan hoang Hinh 1.12. Si/ biet hoa khoi te bao thanh 2 khoi rieng biet Hai khoi hinh cau nho nay diidc 16p trung bi bao phu, di chuyen vao giiia khoang nang mam, 16p trung bi tao ra cuong lien ket. Cac nhu cua^ nguyen bao la nuoi tang sinh (cac long rau nguyen thuy) xam nhap cac mach mau cua mang rung La nuoi Vung phoi Trung bi La nuoi Hinh 1.13. Si/tao ra cuong lien ket Nj Hai la ngoai bi va trung bi doi chieu vdi nhau cung to chCtc trung bi xen vao giiia diidc xep dat de hinh thanh phoi thiic sii. Sii phinh rong cua buong oi dien ra. Buong ox tiep tuc nd rong ra cho tdi khi noi san mac gap thanh cua nang mam. Cung luc, no boc lay ca tui noan hoang. Mot phan cua tui noan hoang chui vao trong phoi, trong khi do thi phan con lai tao nen ong con sot lai, diidc ap vao cuong trung bi nguyen thuy. Cac mach mau phat trien trong 16p trung bi cua phoi va trong 16p trung bi cua 16p nguyen bao nuoi. Sii keo dai cua cac mach mau nay theo doc cuong lien ket, din den sii hinh thanh cac dong mach ron va tinh mach. 12 Hinh 1.14. Su hinh thanh cac dong mach ron va tinh mach ron Cac mach mau tai cUc dau cua phoi biet hoa de hinh thanh tim. Sti hinh thanh mau dien ra trong cac mach mau nguyen thuy cua lcfp nguyen bao nuoi va thai nhi. Su trao doi giiia ngUdi me va thai nhi dUdc tao thuan ldi nhd sU hinh thanh he tuan hoan rau thai nay. Su hinh thanh va stf biet hoa cua he thong tao huyet mach xay ra vao giQa tuan le mang thai thii ba va thii tii. Tii luc nay, dien ra sii phat trien toan dien cua thai nhi. Hinh 1.15. Su hinh thanh biet hoa 6 tuan thu1 ba, tuan thCr tu" 13 Cac cau true hinh thanh tti cac ldp nguyen thuy Ngoai bi: da va cac to chufc phu thuoc, he than kinh ke ca ph&n tuy cua thUdng than, cac tuyen chang han nhu tien yen va tuyen ntfdc bot. Noi bi: ong da day - ruot, gan tui mat, dtfdng mat, tuyen tuy, dUdng thd va cac te bao mam cua tuyen sinh due. Trung bi: xifdng, cd, sun, mo lien ket, cac thanh mac, he tim mach, than va phan ldn difdng sinh due. V. SU PHAT TRIEN c Ga THAI NHI - HE TUAN HOAN Mau da dvfdc oxy hoa tii rau thai trd ve thai nhi qua dUdng tinh mach ron. Mach mau nay xuyen qua gan va phan nhieu nhanh nho cho tang nay. Dai bo phan mau dUdc don qua ong tinh mach de do vao tinh mach chu dudi, mach nay lai dan mau khong dUdc oxy hoa trd ve tijf cac chi dufdi, than, gan... Chi co mot phan cua hai dong mau hoa vao nhau va dai bo phan mau da oxy hoa dUdc don thang vao dau tren cua tinh mach chu dudi qua lo bau due do vao tam nhi trai, roi sau do xuong tam that va dong mach chu. Luong mau dUdc oxy hoa tufdng doi tot nay nuoi dUdng cho dau va cac chi tren. Phan con lai cua mau tii tinh mach chu tren hoa vdi mau cua tinh mach chu dudi, di tdi tam that phai roi sau do tdi dong mach phoi. Chi co mot lUdng mau rat nho di tdi hai phoi. Dai bo phan mau qua dUdng ong dong mach de vao dong mach chu d phia ngoai cac mach mau nuoi diidng dau va cac chi tren. Sau do, mau di theo dong mach chu xuong cung cap cho cac tang va cac chi dudi. Thilc sU co it mau di den cac S.V.C Ong dong mach Canh tay Lo bau Ong tinh TTnh mach ron Cac dong mach ron C§ng chan c in g chan Hinh 1.16. chi dildi. Dai bo phan mau d vi tri nay di vao cac dong mach ron; nhiing dong mach nay xuat phat tif cac dong mach chau trong. 14 Khi mdi sinh ra thi cac mach mau ron co lai. Hien tiidng thd pu p t^o ra ap am trong long ngufc, nhu vay hut them mau tif dong mach phoi vao p 01, am ec hudng khoi ong dong mach; ong nay dan dan diidc bit lai. Lo bau due la mot o van, bdm tif phla phai sang trai. Ap liic tam nhi trai tang len lam cho van bi bit lai. VI. SU PHAT TRIEN CUA CAC TANG - THCJI BI^U lang Biet hoa Cau tao hoan chinh Tuy song 3-4 tuan 20 tuan Nao 3 28 Mat 3 20-24 Cd quan khiiu giac 4-5 8 Cd quan thinh giac 4-5 24-28 He ho hap 5 24-28 Tim 3 6 Da day-ruot 3 24 Gan 3-4 12 Than 4-5 12 Cd quan sinh due 5 7 Mat 3-4 8 Cac chi 4-5 8 CAC TRUNG TAM COT HOA Dau Tuan le Chi tren Tuan le Ham dudi 7 Canh tay 8 XUdng cha’m 8-10 Xudng quay 8 Ham tren 8 Xiidng tru 8 XUdng thai dUdng 9 Xudng ngon tay 9-16 Xiidng budm 9-10 Xudng ban tay 9-12 XUdng mui 10 Chi dudi XUdng tran 9-10 Xudng dui 9 Me dao xUdng 17-20 Xudng chay 9 Rang 17-28 Xudng mac 9 XUdng mong 28-32 Dau xUdng quanh khdp goi 35-40 Than Xudng got 21-29 15 Xildng don Xutdng ba vai Cac xildng sildn 5,6,7 1, 3, 4, 8, 9, 10, 11 1 va 12 Xildng lie 7 8-9 8-9 9 10 21-24 Xildng sen Xildng hop Cac xildng ban chan Xildng dot song 24-32 40 9-12 9-12 VII. SU PHAT TRIEN CUA RAU THAI Ldp nguyen bao nuoi nguyen thuy cua noi san mac nhan nhum gam mon mang rung, pha huy cac tuyen va ldp dem, nhiing chifa lai cac tieu dong mach va cac tieu tinh mach cua me. Cac mach mau nay gian ra de tao nen nhiing xoang mach. Cac long rau, hien nam trong ho huyet cua me, phan chia lien tiep de tao nen nhiing cau true giong nhil hinh cay phtfc tap, trong do cac nhanh cua cac mach mau ron tao ra cac thac mach lien quan mat thiet vdi ldp bieu mo nguyen bao nuoi be mat. Hinh 1.17. Hinh cay phifc tap do sir phan chia cua cac long rau Cac nhanh cua cac long rau nguyen thuy gid day diidc goi la cac long rau, thuoc hai loai: dai bo phan cac long rau nay bdi til do trong mau me, diidc goi la cac long rau tan. Mot so" long rau bam vao to chiic thuoc ngildi me, day la cac long rau moc. Bieu do nguyen bao nuoi che phu toan bo khoang chila mau me, trong do treo Id liing cac long rau tan. Ldp noi bao la nuoi co mot so dac thu cua noi mac mach mau, trong so" cac thuoc tinh khac, co kha nang ngan ngtfa diidc huyet khoi. 16 Ldp hoi bao Long rau moc ® ® 0 _ e * ? / e e © 1 L’^'i • 'T' > ' y ’. ^ Cac te bao cCia ' * ldp nguyen bao nuoi Ldp te bao mang rung con lai Hinh 1.18. Ldp noi bao la nuoi Cac long rau hien dien tren toan bo mat ngoai cua nang mam. Trong khi nang mam ldn len thi no ap ldp mang rung nong (mang rung bao) va khoi thai loi vao trong buong tii cung. Hinh 1.19. Khoi thai loi vao trong buong tifcung Tinh trang bi ep cua mang rung bao d&n dan lam tuan hoan di qua no bi mat di. Dieu nay dan den hien tiidng teo va bien mat cua cac long rau cua no. Be mat cua nang mam trd nen nhan nhui, nen phan nay cua trung san mac diidc goi la trung san mac nhan. C) ciic doi dien cua nang mam, cac long rau tang sinh va day len, diidc goi la noi san mac nhan nhum. Cuong lien ket cua phoi diidc dinh vao thanh cua nang mam d diem nay. Cuoi cung, cung vdi sii phinh rong cua nang mam thi mang rung bao tiep xuc vdi mang rung thanh, va buong tii cung bi tkc lai. 17 Noi san mac nhan nhum Mang rung day , (banh rau thi/c thu) Hinh 1.20. Sir phat trien cua rau thai VIII. RAU THAI - SU PHAT TRIEN CUA DAY RON Banh rau da diidc cau tao hoan chinh la mot dia co be day khoang 1 inch, mong dan ve phla bia. Can nang chifng 500g, co mau do tham la do mau cua me trong cac khoang d giiia cac long rau tao nen. Day ron co hai dong mach ron va mot tinh mach, nim trong thach Wharton, la mot mo nhay co nguon goc trung bi. Thach nay co tac dung la mot dem thiic the nh&m ngan ngifa day ron bi that nut, tuan hoan bi can trc). Hinh 1.21. Su phat trien cua day ron Cac mach mau ron thiidng dinh vao gan vi tri trung tam banh rau. Cac mach nay phan chia lien tiep ngay, hinh thanh cac nhanh tren khap be mat banh rau. Cach phan nhanh nay diidc goi la banh rau kieu "mach phan tan". Doi khi, cac 18 mach mau chinh co the keo dai tdi tan vung bia banh rau triidc khi chia nhanh (tuy chung co the tach ra mot so" nhanh nho tren diidng di tdi vung bia). Day la banh rau kieu "mach phan tan". Nhanh noi giufa cac dong mach — Dong mach ron — I Hinh 1.21. Sir phat trien cua day ron Co mot nhanh noi ng&n giufa hai dong mach ron b ngay cho chung vtifa tiep can banh rau. Nhanh noi nay dung de can bing ap lufc va liiu liidng mau cho moi niia cua banh rau. VIII. CAC CHLfC NANG CUA BANH RAU Cac chiic nang cua rau thai phu thuoc vao cau true va sinh liic cua cac long rau. Cac long rau nay diidc ngam trong mau me, nhiing khong co sii tiep xuc triic tiep giiia mau cua thai va mau cua me. Cac cau true d giiia hai he tuan hoan nay tao nen cai goi la hang rao rau thai. o q o © 0 * 0 o o o ° o o ° t o 0 0 _ Lap h, ^ IX S C E X 2, Sif gia tang trong hien tUdng hit vao va thd ra dila den nhieu thay doi. Hit vao Ong ISn Lirpng oxy hit vao tang Oxy trong mau dfing mach cao Tho ra tang I6n I Li/gng CO j trong khi thd ra tang I6n I Khi C 0 2 trong mau me thcip Hinh 2.9. Si/thay doi khi dan den nhieu thay doi Vao cuoi thdi ky co thai sU di dong cua cd hoanh giam di nhUng sU gia tang trao doi ho hap van difdc duy tri nhd cac cU dong cua long ngUc. 1 TSng thong khi phoi = C 0 2 bi day ra khoi mau ' w \ i C 02 trong huyet tUOng ngifdi me thap I Nhu cau doi vdi cac cation luu hanh giam ti/dng doi LUdng cac cation (Na, K, Ca) di tdi thai nhi can cho hien tirong tang tracing cua thai Khong co thai Co thai Tong so 155.3 mEq 147.0 Nong do cation trong mau me Hinh 2.10. Nong do khi C 0 2 giCra co thai va khong co thai 32 Ap suat khi C 02 trong huyet tUdng thai nhi vUdt qua miic trong huyet tUdng ngUdi me tu: 4-8mmHg. Mac du vay, do hien tUdng tang thong khi phoi, nong do C 02 trong huyet tUdng ngUdi me thap hdn tii 6-10% so vdi ngUdi khong co thai. 2.6. Nhutig thay doi ve cac cation Su giam sut ve cation lUu hanh trong mau me chi co tinh chat tUdng doi, nghia la ve nong do. Tong lUdng cation lUu hanh lai tang len. 2.6.1. Natri 850mEq dUOng liidng diidc duy tri trong khi co thai. So" nay dUdc phan chia chu yeu thanh cac phan bang nhau giula ngUdi me va khoi thai. Me 850 Khoi thai mEq mEq mEq Mau me 145' / \ Dich ke 155 413 437 Thai nhi 280 Tii cung 78 mEq mEq •< Nude oi 100 Vu 35, Banh rau 57 2.6.2. Kali 316mEq dUdng liidng diidc du truf trong khi co thai, khoi thai hau nhu chiem nhieu hdn me, gap hai lan. Me 316 Khoi thai mEq mEq mEq Mau me 28 ' / \ Dich ke 5 117 199 yThai nhi 154 Tu cung 49 mEq mEq •< Nu6c oi 42 Vu 35 , v Banh rau 3 2.6.3. Calci 316mEq diidng lUdng dUdc du tru£ vao cuoi thdi ky co thai. Hau het lUdng nay di vao thai nhi (hoac khoi thai) III. HE THONG TIM - MACH Co nhiing nhu cau ro ret doi v6i h To chiic sdi ket dac chung quanh cac mach tii cung, va mach chau tdi can cua cac cd b san chau hong, d hai ben co tii cung va am dao. Khoang giiia cac nep phuc mac chiia mo te bao long leo. Buong triing khong dUdc day chang rong bao boc. Can mu- cd tCr cung Co tu cung va _ , . - . ^ True trang vom am dao Hinh 3.12. Cac phifdng tien nang tCr cung IX. CHAU HONG XUONG - THIET DO DlfNG DOC Gai hong Hinh 3.13. Thiet do diing doc chau hong xi/dng 54 X. CHAU HONG XUONG - EO TREN Khdp cung chau phai Dot song thlt lung 5 nho Day c h in g c u n g -c h a u - Day chang cung gai hong Day chSng cung-u ngoi Khdp mu Than xUOng cung -Day chang cung -gai hong - Gai hong ----- Mom chau - lupc D U dng kinh trU dc-sau h ay dUdng kinh lien hdp chin h d an h Duong kinh lien gai hong 0 giua dinh cua cac gai hong Day lei dUdng kinh ho chau nho Duong kinh cheo trai Di tU khdp cung-chau trai tdi mom chau-IUdc phai N DUdng kinh ngang. Phan rong nhat cua eo tren Hinh 3.14. Chau hong xi/dng - eo tren Binh dien cua eo tren dUdc gidi han bdi: - Phia trUdc la xUdng mu, phia ben la cac dUdng chau - lUdc (cac gd vo danh) - Phia sau la cac canh va mom nho cua xUdng cung. XI. CHAU HONG XUONG - HO CHAU NHO Ho" chau nho dUdc gidi han bdi: - Phia tren la binh dien cua eo tren. - Phia dudi la binh dien cua eo dudi. - Phia sau la xufdng cung. - Phia ben la cac day ch ln g cung - hong va cac xUdng canh chau. - Phia trUdc la cac lo bit, nganh len cua xUdng u ngoi va xUdng mu. Chu y la dien cua eo dudi gom hai phan tao vdi nhau thanh goc. 55 Binh dien cua phan giua ho chau nho (eo giufa) hay binh dien co cac dUdng kinh chau hong Idn nhat. Di tUphan giufa khdp mu tdi cho noi giCfa dot song cung 2 va 3. Binh dien cd cac dufdng kinh chau hong nho nhat. Di tu" khd p m u q u a c a c g ai hon g d en d ie m tan cu a xUdng cun g. Hinh 3.15. Chau hong xi/dng - ho chau nho DUdng lien hop cua eo tren. Day chang cung-u ngoi Day chang cung-gai hong Khdp mu U ngoi Xuong cut Xuong cung Hinh 3.15. Chau XII. CHAU HONG XUONG - EO DUCJl Binh dien cua eo ditdi diidc gidi han d: - Phia trUdc bdi vom xUdng mu. - Phia ben bdi cac day chfing cung - hong 16n va cac u ngoi. - Phia sau bdi dinh cua xUdng cut neu dinh vao mom tan cua xufdng cung. 56 ' Oi tU mom nhd cung tdi bd tren trong cua khdp mu. D U dng kinh c h e o lien h o p cu a eo tren. Di tU m o m n hd cu n g tdi b d dudi cu a khd p m u O u d n g kinh trUdc □ sa u c u a eo dudi. Oi tU bd dudi kh d p m u tdi d ie m tan cu a xUOng cu n g h o § c xUOng cut n eu din h v ao n h au Goc nghieng cua eo tren 50- 60 (thong thUdng 55) hong xi/dng - ho chau nho XU dng cung Cac so do trung binh cua cac dUdng kinh chau hong: trUdc sau eo tren: 11,5cm ngang eo tren: 13,0cm trUdc - sau va ngang: 12,0cm lien gai hong: 10,5cm trUdc - sau eo dudi: 12,5cm ngang eo dudi: 11,0cm XIII. CAC LOAI XlTONG CHAU Co bon loai xUOng chau dUOc mo ta. Dang nii (50%), dang vUdn ngUdi (25%), dang nam DUdng kinh n gang h ay dUdng kinh lien u ngoi (20%), dang det (5%). Trong nhieu trUdng hdp xUdng chau thuoc dang hon hdp. 1. Dang nur hay dang dan ba Eo tren la mot hinh bau due ngang - hau nhu hinh vong tron 2. Dang viidn ngudi hay dang dudi Udi Eo tren la mot hinh b&u due theo hu6ng trU6c - sau (dang nii quay 90°). Hinh 3.16. Chau hong xUOng - eo dudi DUdng kinh ngang (ndi rong nhat cua eo tren) va dufdng kinh ngang hiiu dung (di qua diem giufa cua dUdng kinh trUdc - sau cua eo tren), trung nhau trong khung chau dang nii va khung chau dang vUdn ngUdi. Phan sau cua khung chau la vung d phia sau cua dUdng kinh ngang va phan trUcic cua khung chau la vung doi dien. Cac dien tich nay dai khai bang nhau ca d loai khung chau dang nii va khung chau dang vUdn ngUdi. Goc cung DUdng cung Lo me hong Idn Cac gai hong Xuong cung Cac thanh ben ho chau nhd XUdng mu Goc vom mu DUdng kinh lUdng u ngoi DUdng kinh trUdc - sau cua eo dudi Dang nCr Khoang 100° Song song vdi xuong mu Nong, rong Khong loi ra nhieu Rong, nong, lom Song song vdi nhau Nhe va nong It nhat 85° Rong Dai Dang vUdn ngudi Nong, rong hon Ldn hdn 80° Hep hon Dai hon 57 Dang nuf Dang vUdn ngUdi Hinh 3.17. Cac loai xi/ong chau Hien tiidng de dau thai nhi qua cac dang khung chau nay co nhiing van de cd hoc nhu nhau d tat ca cac t&ng, nghia la neu de d mile eo tren thi no cung phai de dang trong ho" chau nho va d eo dudi. 3. Dang nam hay khung chau dan ong Eo tren gan nhu hinh tam giac. Dudng kinh ngang d gan phla xUdng cung. "DUdng kinh ngang hiiu dung" bi ngan lai. Dien cua chau hong sau bi thu hep va nong. Dien cua chau hong trUdc bi thu hep va nong d phla trUdc. Dang d e t Eo tren hinh than. Dudng kinh ngang va "dUdng kinh ngang hiiu dung" trung vdi nhau. Chau hong sau nong va dien bi thu hep lai. Chau hong trUdc cung nong va dien bi thu hep. Dang nam Dang det Goc cung 90° hay nho hdn L6n hon 90° Dudng cung Hoi ty Phan ky Lo me hong Idn Hep Rong,nong Cac gai hong Loi, map Khong loi Xuong cung Phing, hep dai Rong, ngan lorn Cac thanh ben chau hong Chum lai Loe ra XiTdng mu Map, sau Nong Goc vdm mu Hep lai L6n hdn 85° Dudng kinh li/dng u ngoi Hep lai Tang len Di/dng kinh tardc - sau cua eo dudi Ngan Dai hdn 58 Hinh 3.18. Cac dang chau hong Hien tUdng de d&u thai nhi gay nhieu van de kho khan khi dau cang xuong sau. Hien tUdng de dau thai nhi qua chau hong, loai nay gap kho khan d eo tren, nhung sau do thi cac kho khan giam di khi dau xuong sau hdn. XV. HOP SO THAI NHI Bregma hay thop Khdp thai di/dng Xi/dng thai di/dng Hinh 3.19. Hop so thai nhi. Cac difdng kinh: Ha cham-thop tri/dc Thi/Ong cham-clm. Ti/dinh cam tdi phia tren thop sau (14cm) Cham - tran TC/goc mui tdi loi cham (11,5cm) Ha cam-thop trade Tu1 di/di dim tdi giCra thop tri/dc (9,5cm) Mat = go'c mui tdi cho noi giCra dau va co Hinh 3.20. Cac duting kinh 59 Di/dng khdp doc gii (Khdp lien dinh) Thop sau XtfOng cham Di/dng khdp lambda (khdp dinh - cham) Bregma hay thop tri/dc Loi tran Goc mui ‘ Diidng khdp tran Diidng khdp vong (khdp tran - dinh) Chom: la vung diidc gidi han bdi cac thop triidc va sau cung vdi cac loi dinh. Hinh 3.21. Chom, cac loi dinh Cac dtfcfng kinh - Liidng dinh (9,5cm): d giiia hai loi dinh - Liidng thai diidng (8,5cm): la khoang cach xa nhat giufa hai nufa cua dUdng khdp vong. Cac vong dau: - Ha cham - thop trUdc X lUdng dinh (28cm) Day la cac dudng kinh lot cua ngoi chom cui tot. - Cham - tran X lUdng dinh (33cm) Day la nhiing diidng kinh lot cua ngoi chom ngufa, gap trong cac the cham - sau - C&m - thUdng cham X lUdng dinh (35cm) Day la vong dau to nhat, gap trong ngoi tran. 60 (Jhu'rftty 4 CHAN £>OAN HIEN TUONG CO THAI ■ ■ I. CAC TRIEU CHlfNG, DAU HIEU VA CAC XET NGHIEM THAI 1. Dai ctfdng TUAN l_l 0 4 8 12 16 20 24 28 32 36 40 Mat kinh ---------------------------------------------------------------------- Nghen ------------------ Cac xet nghiem thai bang nifdc tieu ------------------------------------------------------------------ Cac thay doi d vu — ------------------------------------------------------------ Cac trieu chifng bang quang Cac thay doi d cd tCr cung Sieu am do ------- Cac thay doi d tCf cung sd thay diroc Cac thay doi 6 am dao va am ho Dau hieu Osiander Dau hieu Hegar TCf cung sd di/Oc d o bung Dau hieu bap benh Cac dau hieu X quang | Thai may (ngifdi con ra) i Bung phat trien to len ------- ------- Thai may (ngtfdi con so) - Cac cOn co tCf cung sd difoc Cac cLf dong thai sd di/oc -------------------------{------- Nghe di/Oc tim thai (Pinard) Cac phan thai sd thay di/Oc Cac thay doi d da (rat bien dong) (Cac trieu chirng, dau hieu va xet nghiem thifdng gap hon di/Oc neu bang dudng vach keo dai). 61 2. Cac xet nghiem m iln djch hpc Cac xet nghiem nay diia tren thiic te la 14 ngay sau khi thu tinh, ldp trung san mac cua nang m&m tiet ra kich due to' rau thai (HCG). Ciic diem dat vao luc 10 den 12 tuan, va noi tiet nay diidc bai tiet qua nifdc tieu cua ngiidi me. Dung mot khang huyet thanh HCG co the phat hien ra sii hien dien cua hormon nay trong niidc tieu, nhiing dieu can thiet la phai lam cho phan Cfng cd the quan sat diidc va thiidng lam la dung cac hong cau co boc HCG. Khang huyet thanh va niidc tieu diidc tron vdi hong cau. Neu trong niidc tieu cd chtia HCG thi khang huyet thanh bi trung hoa va cac hong cau se ket tua (phan ting diidng tinh); neu khong cd HCG trong niidc tieu thi thay hien tiidng lang phan tan, la do phan ting giiia khang huyet thanh vdi cac hong cau cd boc noi tiet (phan iing am tinh). Ket qua ditctng tinh co the phat hien ra sau khi cham kinh 8-9 ngay. Xet nghiem mien dich huynh quang cd the thiic hien bang huyet tiidng hoac niidc tieu de phat hien beta - HCG. Bien phap nay la mot xet nghiem thai rat nhay va sdm. No cd the dac biet cd hieu qua trong triidng hdp nghi ngd chtia ngoai tii cung. Beta - HCG niidc tieu 10.000 ml U/ml 4.000 + 2 D.L.C Xet nghiem BETA — HCG 2.000 trung bi 1 .0 0 -2 D.L.C 400 200 100 50 30 Xet nghiem thai am tinh 4 8 12 16 20 Tuan 3. Sieu am Cd the phat hien diidc tui thai sau khi mat kinh 5-6 tuan va thay diidc cd dong cua tim thai tijf 7 tuan. Chda trong buong tti cung con rat sdm. Bang quang Tui thai. Khong thay mot ciic thai nao. 4. Tia X Ngay nay binh thiidng ngiidi ta khong sd dung tia X de chan doan thai. Tuy nhien, doi khi van cd the dung cac tia nay trong giai doan cuoi cd thai, dac biet khi nghi ngd chtia da thai. 62 5. Trieu chumg va dau hieu 4 tuan. Vo kinh Can luu y den cac nguyen nhan, chang han nhii mat can bang buong triing - tuyen yen, dung vien thuoc tranh thai va cac xuc dong ve tam ly. Hien tiidng phong noan co the da xay ra sdm hdn hoac muon hdn so vdi binh thiidng. Phu nii thUdng khong hay nh6 mot cach chinh xac ky hanh kinh cuoi cung cua minh. 4 tuan. Hien tUdng nghen Nhieu phu nii thay kho chiu d da day trong cac thang d&u, tijf miic buon non, chan an den oi miia lien tiep, dac biet xuat hien vao buoi sang. Ngiidi ta khong biet ro nguyen nhan va thiidng cho la tai ham liidng estrogen va HCG, ca hai tang len cao trong mau. Sii co bop cua da day giam di, va khi mdi co thai cd vong thiic quan dudi bi gian ra. 6 tuan. Cac trieu ching cl bang quang Hien tUdng dai rit xuat hien vao thang thijf 2 va thil 3 la do sii ket hdp cua tinh trang gia tang cac mach mau, va ap hie cua tii cung to len. Gan du thang, thi dai rat lai co the tai hien, chu yeu la do dau thai nhi de len bang quang. Cac dau hieu lam sang (Cac dau hi£u nay kem phan quan trong vi sii phat trien cac xet nghiem chan doan thai viia nhanh va nhay). Hien tUdng mem co til cung 6 tuan Hien tUdng nay dap d cac cung do ben am dao tang len (dau hieu Osiander) 8 tuan Mau niem mac am dao thlm lai (dau hieu Jacquemier) 8 tuan Hinh 4.1. Thai 7 tuan 63 Bay tuan. Til cung to len diidc, sd thay Thai diidc 7 tuan thi til cung to bing qua triing ga lcin. Thai dUdc 10 tuan thi til cung to bang qua cam. Thai dUdc 12 tuan thi til cung to bin g qua budi. 8 tuan. Dau hieu Hegar B ing cach tham kham hai tay, day la cam giac ma cac ngon tay tiep nhan dUdc nhu cham vao nhau. Hien tUdng nay la do doan dudi mem ra het silc. 6-8 tuan Cac trieu chiing va dau hieu sdm nhat - sii phat trien gia tang mach mau va cam giac nang ne, nhat la dau vu - xuat hien vao luc thai diidc 6 tu&n. Khi thai 8 tuan thi num vu va vung chung quanh - goi la quang vu nguyen phat - da dam mau ro ret hdn. Cac hat m ontgom ery. Cac tuyen ba loi len thanh nhiing hat mau do hong d quang vu. Hinh 4.2. Dau hieu Hegar 16 tuan Khi thai dUdc 16 tuan, vu tiet ra mot chat dich trong (siia non), co the vat ra dUdc. Luc thai 20 tuan thi quang vu thil phat lom dom dam nhat do nhiem them sic to", loi ro len. 64 14 tuan HIEN Tl/ONG BAP BENH BEN TRONG Hinh 3.5. Day nhe len phia tren va giur nguyen ngon tay ty vao co tCr cung 24 tuan Hinh 3.6. Thai nhi bi day len phia tren Hinh 3.7. Thai nhi chim xudng lam ngon tay co cam giac bj dung nhe vao HIEN TIT0NG BAP BENH BEN NGOAl Mot ban tay vo nhe vao bung, dong thdi day thai nhi di dong sang phia ben kia buong tU cung. Ban tay kia dat ap len tu cung, cam nhan dUdc xung dong. Cac nghiem phap nay hau nhu da bien khoi cong viec tham kham lam sang do sU dung rong rai sieu am. 1 5 tuan Bung to len Tu cung vUdt len o bung vao luc diidc 12 tuan, va kich thu6c cua bung gia tang ro khi thai dUdc 15 tuan. Hien tUdng giam chieu cao day tu cung xay ra vao giiia 38 va 40 tuan diidc goi la "hien ttfdng sut bung" la do d&u thai nhi xuong thap ti vao doan diidi va co tii cung, chuan bi cho cuoc chuyen da. Hien tifdng nay khong xay ra d cac phu nut da co thai lan trUdc, va nhu vay, chieu cao day tu cung khong phai la dieu hudng d in chSc ch&n cho hien ttidng du thang. 65 Hinh 3.9. Bung to dan len 16-18 tuan Thai may ("cam nhan cuqc song"): Cam giac ve c i dong thai nhi truyen tdi tan phuc mac thanh bung co than kinh thUc the chi phoi. No la mot cam giac rat thoang qua luc bat dau va d ngiidi con ra thi de nhan ra sdm hdn. No khong phai la dau hieu dang tin cay hoan toan, ngUdi me co the khong muon th ia nhan sii thieu vang cua dau hieu nay, ngay ca vdi chinh minh, va cac phu nii m ic chiing roi loan than kinh co khi mang thai tUdng tUdng ("ching gia chUa"), co the d i dang tu minh khang dinh ve sii hien dien cua hien ttidng thai may nay. 2 0 tuan Cac cdn co tii cung sd diidc (dau hieu braxton hicks) Tif cung co nhiing cdn co khong gay ra dau d6n tvi tuan le th i 9 den tu&n le thii 10 trd di, vao tuan ll thii 20 co the sd thay cac cdn co nay, thoat dau bang phtidng phap tham kham hai tay, ve sau bang nan bung. Cac cdn co nay khong theo nhip va cang ngay cang mau hdn khi thai cang tien trien, va vao nhiing tuin cuoi chung co the gay kho khan cho viec n&n bung. Viec phan biet cac cdn co Braxton Hicks vdi hien tiidng chuyen da sdm khong phai luon luon r5 rang. 24 tuan Nghe tim thai Co the dung ong nghe tim thai (Pinard) ap len thanh bung ting vdi thai nhi, de nghe tim thai. Tieng tim thai nghe r5 nhat d tren vung xiidng ba vai trai cua thai nhi, do do diem co cUdng do am thanh cao nhat thay doi tuy theo tu the cua thai nhi. 66 Hinh 3.10. Vi tri nghe tim thai luc thai 24 tuan Hinh 3.11. So nhip