Nghiên Cứu Đặc Điểm Lâm Sàng, Xét Nghiệm Một Số Yếu Tố Liên Quan Và Biện Pháp Can Thiệp Vàng Da Tăng Bilirubin Gián Tiếp Ở Trẻ Sơ Sinh.docx

BOYTE BENH VIENNHITRUNGUONG BAOC A O NGHIEMT H U C A P B 0DETAIKHOAHQCC O N G NG HE NGHIENCUIJDACDIEMPMSANG,XETNGHIE\ M,MOTSOYE IJTOLIENQUANVABIENPHAPCANTHIEPV A N G DATANGBILIRUBINGIANTIEPOTRESOSINH[.]

BENH VIENNHITRUNGUONG

BAOC A O NGHIEM T H U C A P B 0DETAI KHOAHQCC O N G N G

:BNHVIENNHITRUNGUONG

:TS.KhuThJKh:inhDung

B6tdongnhfi mmiiumeconC o n g thiicméu-tiéuc6uCoombstritetiépCoombSgi:intiep

Glucose6 phosphatd e h y d r o g y n a s e

Hfingc6uhemoglobinHfingcluluciiHi(ugiékh:ingtht:Khéngth6

Khfingbritdongnhfi mméumecon

MiéndichTruongl

Vangdatangbilirubingiéntic:p(GT)1émptbiéuhinkh:ithuénggapotrés 0 sinh,709otrédiith:ingv a 8 0 9otréthieut h : i n g t r o n g t u d n d d u c u a cuocsong[24].Dasoc:ictruénghppvilngdasosinh

Vangdasosinhtuythuénggap

nhimgd e bfiqua,dodfitinhtrangvangdauangd e doan h i é m d f i c th6nk i n h

h a y x é y r a trong nhfmgt r u é n g hppphéthi(nquam u o n diéunayk h 0 n g c h i xéyr a cinhfmgt r é nonthéng,b e n h 1 y , macongaponhtmgtrédiith:ingkhoémanhtrongnhfmgtu$nd:iusausinh

Diénb i é n t i t g i a i doanv i i n g d a sosinhng dotangb i l i r u b i n G T sanggiaidoanviingdanhttnthuéngxayrar4tnhanhva

phiictapdfiikhichitrongvongvatgif

Trong diéu kiénhientaioViet Nam,vi(cchando:in vatheodfiivéngdascisinhcic4ctuyénytéccsoconnhiéukh6khan,chuaccisuphfiihppchatchégiiracécnhastkhoavanhikhoa,chuacokéhoachtheodfiitréconguycccaotainhanhamph:ithienskinviingda,chando:invadieutrikipthoicactruéngh o p vangd a benhly ' Diéunaycothedobenhv an gd a scisinhchuadunechittrongdiingmiic,thi n chiconbibfisothoacbJxemthuéngcimotsoncii.

Ccirdtnhieunguyennh6nd¾t‹iivéngdatangbilirubinGT,trongdogapkh0aftg30odoBDNM me-concfinr6tnhieuc:ictruénghopcannguyenvchuacodieukienxacdinh dune

Cacnghienciiu vévangdacrnuoctaclingdaduocdécapchityeuvélinhvucdiéutrimaitdec6ptoidacdiém16msangciiavangdatheo

ruciiacactiicgiangvoiMy,mircbilirubintrungbinhtrongméurontréscisinhbinhthitétigla1,4-1,9mg/dL[44]

CPP(CollaborativePerinatalProject)nghienciiutren35000trétirnam1

th:ingl i i c mciisinhcon6ngdobilirubinkhfingvrrotqu:i12,9mg/dL,chiém6,2Woonguéida trang;4,5%trédadenco bilirubinin:iua13mg/dL[44]

bilirubinGTotrésosinh.Nongdfibilirubinmaubinh 1mgJdL.citréem3,39oGfimucbilirubinkh fi ng vuotquéling/

Nam1 9 9 5 , BenhvienNhiDongIco147truéinghopVNN.Nam1 9 9 6 la158truétnghpp.Nam1997la238truérnghpp

©benhvienTitDti,nam1 9 9 6 la29truénghop,nam1 9 9 7 la6truéngh pp[4][12]

1.2 DJchtéhocvangdasnsinh

Nhieunghienemuchoth4ytren569ctréscisinhvangdab(nhlykhfingrimthaynguy6nn h 6 n M a t k h i i c , n g u c r i t a c l i n g c h i i n g m i n h d u n e r a n g c

onhiéuyéutolienquandentangbilirubinmau,séducicmotatrongbangduoid6y[17],[44]

HeroinPhenytoinAntipyrineRuou

Kiéusinh

SinhduéngdufiiVoois‹imClinuangthapDenonGiéri nam

Chaink e p ron

Bilirubinin:iudayroncao

ChAmthéiphfinsuBfime

Cungc6pthiéucaloSutcilnsinhlynhiéu

Zn,mghuyétthanhthapDiingthuocchocon Chloralhydrate

c h i n h ciiabilirubinG T , vinotaorasuthénhlapc:icmoilienkétbangc:iccaunoihydrogenn0itébao.Chinhvilydonay,maphan1éinbilirubinkh6ngtantrongnuoc,m a laico:iilucvciiphospholipides,n o cothé1¾gdongtrénm an g tébaov a g a y

t o n t h u o n g t é b a o , n h a t l a c :i c tebaoth6n k i n h [ 1 2 ] , [38 ], [3 9 J ,[44]

Phant it bilirubinkh 6n gt an trongnufic,dedangtantrong

citechat ualipidekh:iclaratkhfiduncbai tiétnhungcokhangxuyénmangsinh

baitietkhfingquachuyenho:ivakhfi ngcokhauang

ng4mquamangtébaonénkh0ngg6y

thi(n.Conduéingbaitietbilirubinbaothailanhcrrauthai.Béiivithucsvt6tcabilirubinb a o thaiodangkhfingkéthop(giéntiép),nosexuyénquarauthaidiv a o v o n g

tanin:iunghiemt r p n g , khidcicosttichluycuabilirubinkhfing kéthpp.Bil

irubink6th ppkhfingdiquaduocrauthai,vacrithetichluytronghuyéttuongvac:icmokh:ie[ 4 4 ]

.Chuyénho:ibilirubinfttrésnsinh

Sutaothanhb i l i ru b i n x a y racih(lienviingnfiimo,lasanphamc u o ic

iingc i i a c h u y e n ho:ih e m e Gilll75tob i l i r u b i n dunet a o r a t i t h e m o g l

o b i n (Hb),ciiIgainHbsinhra35mgbilirubin.Khoang259odifoctaothanhtitciicng

uonkh:iclamyoglobin,cytochromes,catalase.Quétrinhnayxéyralanhcrt:icdungciiaEnzymhemeoxygenase.Neutinhtheocanng,nongdvhemeoxygenasetronggancuatrésosinhcaog6p61:insov‹iingucri1‹in Chinh

1.4.C:ienguyénnh:ing:iyvangdatiingbilirubinGTfttrésnsinh[45], l.[47]

Benhvangdakhfingtanmiiucotinhch6tgiadinh:benhGilberttypeI,

II+ Bénhgalactosehuyétbarnsinh

Cacnghiénc t i u vithechoth6yt6nthuongchit yeucu a naobinhuom

vangl a hoait i t , m6 tn e u r o n , t a n g s i n h thankinhdem Tuynh ie n

soviingnaomacdiihayph:ithi(n cotonthuonghoaitirnhimgitkhibinhufimvangnhu:

th6nkinhthinhgiiic,dacbi(tlaoctaivacii naosau[15],[20],[27],[68]

Cosutangnhayc:inncuatébaothk i n h doivrid éctinhcuabilirubinc m o t so

viingnaokhiodfihéngraoin:iunaobitfinthuong.M0tso

nguyénnhann h i r t h i é u o x y , thiéud i n h dur i g , rotl o a n diéngiéi,chant h

tebaonaotruocdfictinhciiabilirubin.Diéunayduocchiingminhtrongc:ienghienemudaithévavithetochiicnaociiatré denontirvongvivangdacokethppnhieu[66]

Theothuyét“bilirubingiiintiep”Wenberg(1991)[14],[44],[66],[67]

BilirubinngociitébéoBilirubint u

doginléntopphospholipid cuam‹ingtébcio,hachthankinh

Iet r é b i tonthuongn a o d o v gd a t a n miiu[44],sqi a n g bilirubing i : i n t i e p ha

yg i a m l u o n g a l b u m i n d u triilufing 6 y r a t r i ( u c h tmgb i t thuéngt r o n g d:ipKingth in h l u c nao.Diéun a y c h o phéplygiaivisaoVNNcothex é y r a n g a y c

é k h i b i l i r u b i n T P tangk h f i n g q i ac a o c i tréd é non,t r é c obenhkémtheo.C:icbenh1ynéyénhhuéngx6udenkhauangganalbuminvciibilirubin

Vait r o c u a b i l i r u b i n t u d o t r o n g V N N d w a c n h 6 n m a n h t r o n g

n g h i é n ctiuc i i a N a k a m u r a ( 1 9 9 2 )

[ 4 9 ] : v é r i t r é thlpctinn g a y c é khib i l i r u b i n t u do=0,8m g /

d L , d f i n h a y c a m v c i i t o n t h v o n g n a o l a 1009o,d f i d a c h i ( u la9 6 9oTrongkhi dfi,nongdObilirubinTP 11mg/dLdnhaycainciianaola80fio,dfidac hieula64Qo

Nongd f i bilirubint u dotiIenghichvc i i albumini n : i u du triibieuh i é n

quahangr a o m i i u n a o kh ichuabit o n thuong[ 4 4 ] ,

[71].Khauangg a n ciiaalbuminphuthuficvaohaiyeutochinh:khauanghttpd6ncuaalbuminvasucomatc i i a cacchaig a n canht r a n h t r o n g i n : i u S o vci

in g u c r i l é n , lvongalbumind U t r i i c i i a t r é s c i s i n h , t r é b ( n h ( d a c b i ( t k

h i c o t o n t h u o n g g a n d ovirus)thuérngrdtthap,khoang115-230mmolJl(sovéii535mmol/Iciianguciitin).K h a u a n g g a n c u a huyétt v o n g h a y l u o n g a l b u m i n

d u triis e tango trévangda,neudunethayin:iu[25], [26),[37],[61], [62),[63],[64]

Trésos i n h d i i t h : i n g , k h o é m a n h thib i l i r u b i n in:iut a n g 1mmol/1,albumindutrtichigiém0,2mmol/

I.Chinhvivy matrésosinhdiith:ingkhoémanhcothekhfi ngbianhhuénggikhibili

rubinin:iutangtcri20-25mmol/1[ 2 5 ]

Nguoclai,vérinhfmgtrétanin:iudob6td6ngRhcOSuSuygi:innuangkhéu

angg a n ciiahuyettuongtrong nhfmgngayd d u s a u sinh[26]

Clingt r e n c c scinay,n g u c ita d e xultp h u o n g p h : i p d i é u t r i t r é v a n g

d a bangbo xungalbuminnguoi chotré

Nam1 9 4 0 - 1 9 5 0 VNNgapchinyeucinhfmgtrévangdat gbilirubin

14

TirJ8ugoidéncoch4n,

+ Suyhfih6p,+ Thiéuin:iu,

Thayin:iu+ chiéudén

25-48 >1 2 ( 2 1 0 ) >1 5 (260) >20(340) 25(430)49—72 15(260) >1 8 ( 3 1 0 ) »2 0 ( 3 4 0 ) >3 0 ( 5 1 0 )

2 ChIdinhchiéudendéivétitrédénoncc›int sodiémkh:icbit sov6itré

l6ndotrédénonconhieunguycctonthuongnaohonn h u albumintrongin:iu

thaphontréduth:ingvahangréoméun 5o chuatruéngthanh.

DANHG I A KGQIA DIEUT O [

DISAVAOBILIRUBINTRONGMAU.-• Bilirubintrongin:iuducrimitecothégtiyvangnhannao.Cank i e m tralaiBilirubinsau12-24gicingimgchiéudén

• Kiémtrabilirubini n: iu ngaysa u thayin:iuvatieptucchochieudéndénkhidattiéuchudnrakhfiidén

2.4.Xirlystslieu

Sirdung chuongtrinhSPSS11.5t r é n méyvitinhdéphantichsoli(u

Sirdungphuongph:ipthongkéyh pc,testk h i binhphuong,test—

student,t i n h Xtrungbinhs o s:inh

B‹lng2.Phénbetb é n h nhénr‹ingdzitheocanuting

BDNMme-con n=112('7r)

KBDNMme-con n=503(9'o)

3.1.4 Mficdiivangda

fitrésosinhvangdaxuathi(ntrucictiénomatrfiiland6nxuongthtin,chan,t a

y t u o n g t i n g v o i n o n g d f i b i l i r u b i n t a n g d i n d u o c m o t a t h e o b a n gKramer(1969)[44],

[55].K é t quanghi6nciliiciiachungtfiivémiicdovangdaduoctrinhbaytheob:ingsau:

Tongs o co1 5 3 benhnhdncfibieuhi(n cactrieuc h i i n g t f i n thuongn

a o tTOlT dfi1 0 0 9ocfibieuhi(nlibi,b f i kémho cbfibti

Bring6 - Sosanhc a c triéuchimgternthuongn i i o

concaohonnhfimkhfi ngbaldingn h f i min:iumecon.Sukh:icbi(tnaycoynghiathingk

évcrip<0,05

29

Bring7 Liénquan giii:acacmécdotiingbilirubinmiiuvercactriéuchiing

Nhan xét:

Cosvkh:icbi(tcoynghiathongké(p<0,05)giiianhfi mtrécovakhfingc o batdongn

hfim in:iuvémiicd6t gbilirubingiéntiép

Nongd f i b i l i r u b i n t r u n g b i n h é nhfimb a t d i n g (438,1f156,9Jimol/1)

caohonsovciinhfimkhfingbatdong(308,2+121Mmol/1).

3.2.2 Xétnghi(mAlbuminin:iu

Béng9.-Albuminm t i u •

Albumin<30g/I Albumin>30g/I Tongso

Nh6n x é t :

Cosukh:icbi(t

coynghiathongkévemitedfithiéuméugiuanhfimb6tdongvanhfimkhfingbatdongv6ip<0,05.Cfcnhfi mcciBDNMme-

Bring1 1

-Moiliénquangiii:autingdoBilv i i mitedothiéumintrongtingli›aibutdci n gnhé mmtiu

C:icloaib:itdting Bil(pmol/I) HCL('7o) ( )

Nh6n x é t T r o n g nhfi

mBDNMme-con,b6tdongRhcotylebilirubintrongm é u caovaHbth:iphonhanso voic:ienhf

imb a t d o n g nhfi min:iumeconh(A B O , chiingtfimiicdotanin:iukh:imanhva

34

.Xétnghi(mdunglikh:i ngthé

Xétn g h i ( m d u n g li KTnhamt é c h K T megant r e n H C condékhangdinhtinhdachieuciiaKTmeg¼trénHCcon.Xétnghiemnaychithuchi(ncrcactruénghopb6tdongnhfimmaume—conheABO

( 2 + ) , c f i 7 truénghppduongtinh (3+).Nhfimbdtd6ngO B cotyledungliKT(

+)caohOIlRholTlB D OA(69,29oVa54,5to)

Bang1 5 HGKTmekhiingHCc o n tronghuyétt h a n h con

Nhémb:itdongn hémin:iu

Bring1 8 - Viingdaliénquandé‘ncécloaibétdéngnhé m nuiumecon

fliéiid‹ifi:likenlienquan me—certriiivti ngda

39

u c cci.Liénquand i n 3 truénghpplirvongc é b a iruénghppnaydéucobilirubincao

>700Jimo1/I,1truénghppb6td6ng Rh(-)

3.4.1 Diéutrichiéudén

Diénbiénbilirubinkhichiéudén.

Tatcabenhnh:in v a o vi(nvivéngdatgbilirubing i a n tiépdéuphaic h i é u dén,ketquéchiéudéntaingiamvangda,giamnongdobilirubind u n e trinhbaysauday :

72giii (n=56)

Tuoivaovi(n 4-7ngay >7ngay Tong

M Biit dong nhém in:i u me

■ChAn do:in kh:ie

ffcing2fi.7"fi‹ifgiondiéutri(ugly)

Tuoin hapvien

Thbigian chiéudén

Thiigiand iéutri

éutr]trungbinhc a o nh6tv i ngoaivéng dadenonconconhiéuyéut6nguycckh:i

c(p<0,05)

4.1 DacdiémI:innsang

Theonghienc i i u cuachiingtfiitir8J2003den8/2005khoascisinhBenhvi(nNhiTrungnongdatiepnhn tren7017trésosinhnhapvientrongdfitrévangdatangbilirubingiantiepchiémtyIe2 1 , 2 6 9 s sovciinam2002

thitiI(naycaohon ( 1 7 , 9 9o)

[2].Theoketqu énghienc i i u cuaPham'NgocD i e p Paulnam2002tiIegapvitng datiingbilirubingi:intiépbenhlycitrésosinhla15,119s.M6tnghiénermkh:icciingtaib(nhvi(nSaint-

r ] s c i m b i g chiéud é n k é t h p p vfiid i e u t r i d v phongb a n g thuocvatiénluongtrvoccrnhiiiigtré

conguyccvangdabenhlybangc:icxétnghiemb i l i r u b i n i n : i u c u 6 n g ron,n éu l

u o n g b i l i r u b i n t g tren6 mg/

dLt h i duacdiéutris‹5mtrongvong36giosaude(58].Matkhéc,viecdieutribang :inhsuingdvncthuchi(ntainhétuongdoiphfibién,conhiéuloaidén(déntiii,d“enchan(b

Phiinléntrésosinhcobiéuhi(nvéngdatit24-72gicrsaude,tuynhienonhfi mcobatdingnhfimin:iume-conxu6thi(nvangda

s‹5mhonngaytrong2 4 giodtiuso

voinhfi mkh6ngb6tding,sukhécbi(tnaycoynghiathfingkev c i i p<0,05(Biéu

dfi1).Tuoitrungbinhxulthienvangdala2,36, 7 2 ngay,nhimgk h fi n g c o sukhiicbiét giiianhfimb d t d o n g ABOvakh0ngb a t dong(2,34?

0,87ngaysovoi2,36I0,68ngay).(Béng3)

Vangdagapdasocrtrénhe c4nchiémty'le71,879o(Béng2).Nhtinxétnayciingphiihopvciimotsoc:ict:icgiakh:ie,tuynhiéntrongnhfimb6tdongnhf

i min:iuvangdagapnhieuotrédiithéng,ci›nfinhfimkh6ngb6tdongthic h i t y é u l a

i g a p c r trén h e c i l n ( B é n g 2 ) Su kh:icb i ( t c o yn g h i a t h o n g k é p<0,05.Trongnghienciiuciiachiingtottuoitrungbinhxuai

hiénvangdak h f i n gcosuk h i i c bi(tgifrahainhfimbatd6ngnhfimin:iuvékhfi

ngb6tdong(Br i g 3 ) , n h i m g t u o i xu6thi(nv a n g daciiatrédenont h i s6mhont r é diithéng(Béng4)

Clingnhirnhiennghiénciiutrongyvanvéngdatangbilirubin

GTlavangs:ingthvéngxu6thienomat,lanxufingth6n,ch

taytuongtingvciinongdbilirubint a n g d énd u o c mdt é theob:ingK r a m e r [ 2 ] ,[44].Vangd a thuéng

imonm i i u cungcdpchociithébaogiciciingnhiéuhono

viingd6u,mat,viv9ykhitanin:inthuéngth4ybiéuhienvangdacrviingmat dau tié:nNghiénc i i u 6 1 5 tréc h f i n g t f i i n h 8 n t h d y t r é traiv a n g d a n h i e u h o n t r égéichiémty'lb2:1.NhomcobdtdongABOvakhfingb4td6ngtiI D trétraituongKingl

a76,08Wo;63,599o.Diéunéyclingphiihppvfiinghienemucuanhiéut:ie

48

gia.Tuyn h i e n c h u a co gi ai thich r o r a n g v é n g u y é n n h a n c u a s u khiicb i (t

ma ula baonhiéuneunhukhfi nglamxétnghiemd|nhlvongbilirubinméu

Vivéytréntermséng

stkhongc o diéuk i é n xétn g h i é n b i l i r r u b i n mé ucothédnavetomitedov‹ingdath eobeingKrammerde’chld[nhchié‘ud én

Nghiénc t i u c i i a chiingtf ii c h o th6yhiiuh e t t r é v a o v i ( n d a codinh i e u v a n

g dahétv i i ng2 vé c h u y e n s a n g viing3 Kéth p p vciit u o i t r u n g b i n h x u a t

h i ( n v a n g dachiingtfiithaytuykh0ngcosukh:iebietv8tuoitrungbinhx u tithic:nvangdagifrahainhfimnhimgthéidiémxutithienvangdatrong24

gicidauciian h f i m b a t d o n g n h f i mm i i u c a o honc f i y n g h i a s o v6in h f i mk

h G n g b 6 t d o n g nhfimi n : i u p<0,05(Bieud f i 1 ) Miicdovangdadi n honh

ancinhfi mb : I t d6ngsovéiinhfimkh0ngb4tdong(58,79ctrévangdadenviing5cinhfi mb 6 t dongva20,879sc r nhfimkh0ngb4td6ng) (Big5)

KétquachiingHiThuthdpducicv8nconnhiingmevangdaviing2béivinhfmgtrénaylanhfmgtrédénonduocnhapvi(nngaysaudévaduocph:ithi(nviingdaskin,nhiingtru6nghppnaychoketqu:ir6ttotvidupechiéudénkipthc›i

Biéuhiéntainsitngciiavangdanhannao

49

h o m néycaohon

nhiéusovéiinhfimkh6ngbatdongvachiingtfiitimth4ysutunngquanthuangitiatrieuchimgbfikémhoacbfibitvoi nongdfibilirubinGTt r o n g miiu

Tuynhiénd6uhieubitkémhoacbfibitgaptrongr$tnhieuloaibn h lyososinh,vivaytrénbenhnhancovéngdakémtheodduhi(unaylamfitgoty'choc:iethaythuc lamsangcanphéi

Bié’uh iinmuonh o n chat o n thuongt h a n kinhn

ri glatang triiongl uc en,thuongl a d o t o n t h v o n g b f i t h : i p , t r é c o c : i c

da u h i e u m i i a vimhoacd u t i i ciing.Trvongluccccothétangtimgliic,kh6nglié

n

quandenviecdungchainhoacthamkh:innd 6 y chinhlad luhi6ud e ph6nb i (t v

é ri tang truo ng l u c cct r o n g uonv:in,thuéngtgkhicokichthich

dobilirubinin:inqu:icao>500jrmolJlvathuéngtienluongr a t x 6 u D a u h i é u n a

y d u n e q ua n s é t thayk h i tréc o themh i e n t u o n g tangcclvcciiac:icnhfi mcclimg,ccic6,ccimat.Vithénhiiiigtrénaythuéngc o tuthénamvéncongsaulimg,ngiracfi;tay,chanthuéngdcicaoduoiclingdongthcritronmat,nhn h f i mat,khficthét.D6

khfi nghfiiphuc.Dieutricangchainchéthitonthuongcangnhiéuvadichiingt h a n kinhlaicangtrtrong.

4.2 DacdiemcanI:innsang

.Niingdtibilirubinin:iutheonguyénnh:invangda

ChiingHinhanthayngaytaithéidiemvaoviendEcot6i629ob(nhnhancomitebilirubin>340;rmol/

1canphéichiéudéntichcuc,vémfitstc6nphéithayméungayv i dénqu:imufin.Sos:inhnongd0bilirubinGT trungbinhonhfi mcobatdongla(438,1I156,9jimol/1)c a o

h o n sovfiinhfimkh0ngbatd o n g la(308,21121pmol/1).Dacbi(tmitebilirubinmiiu>510Mmol/

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