Tài liệu Lâm sàng phụ khoa và giải phẫu bệnh phàn 1

GS.BS. OINH VAN TUNG, FACOG, FASCP lA m s A n g ph u khoa vA g ia i p h Au ben h IflM SANG PHU KHOfl v a Glffl PHfiU B€NH B ien dich ban sach xuat bcin Ian thu hai GS.BS. DINH VAN TUNG MD, FACOG, FASCP Giao su San phu khoa Giao su Giai ph6u benh Bo m o n S a n p h u - T rtfa n g D a i h p c Y G a lv e to n - T e x a s 0^1 HQC THAI TKJNG TAM HQC L illi N h a x u a t b a n Y hpc Hd Noi - 2 0 0 3 B ie n d ich : - BS. DANG THE CAN - BS. NGUYEN PHI HUNG - BS. DAO TIEN C'U'C - BS. TRAN NAM THANG - BS. TRAN VAN THUAN S Y L L A B U S OI G Y N E C O L O G I C P A T H O L O G Y WI T H C L I N K AI C O R R E L A T I O N S L()I tua LAN XUAT BAN LAN THL/ 2 Trong nhieu nam, giao su' Dinh da say me nghien cu'u nganh giai phau benh phu khoa, va gianh nhieu cong sue trong viec giang day bo mon nay cho cac sinh vien y khoa va bac si noi tru chuyen khoa. Toi cung ehia se niem say me eua ong va cung nhu ong deu tiec khi thay hien nay tain quan trong eua viec giang day giai phau benh phu khoa cho sinh vien y khoa va bac sT noi tru chuyen khoa chua du'oc chu y. Su' hieu biet nhung van de co ban ve giai phau benh phu khoa hoan loan la dieu can thiet doi vo'i nhung thay thuoc lain sang ve cac benh phu nu'. Neu khong co nen tang nay thi ngu'di thay thuoc lam sang se khon g the phat trien von hieu biet ve lich sir tu' nhien cua can benh va nhung nguyen tac chii'a tri. Lan xuat ban thir hai cuon sach nay la mot su' thanh cong xuat sac. No rat de doc va lam theo, no con cung cap rat nhieu thong tin va nhu'ng dieu quy bau. Theo y kien toi. cuon sach nay la giao trinh ma tat ca sinh vien deu phai hoc trong qua trinh hoc san phu khoa cung nhu' bac si noi tru du'oc dao tao ve Ilnh vuc nay. Cac thay thuoc chuyen khoa lam sang trong thirc hanh cung se lam tot hon khi co cuon sach nay trong tay nhu' mot tai lieu tra cu'u nhanh. Cuon sach du'oc vict tot. chinh xac va nhieu thong tin. Moi chirong deu co bang tra cu'u rieng tong hop de ngu'di doc quan tam co the tra cu'u them nhung thong tin chi tiet. R aym on d H. K au fm an MI) T ru o n g dai hoc Y khoa B aylor H ouston, Texas 1. A m ho ■ I. Ban thai hoc II. Mo hoc III. Cac benh da thirong gap IV. Cac ton thirong am ho trong cac benh he thong V. Nhiem trung VI. Cac u lanh tinh VII. Cac ton thu'ong bieu mo khong u VIII. Cac t6n thu'ong noi bieu mo u IX. Cac u ac tinh xam nhap I. Bao thai hoc A. Bo phan sinh due ngoai bat dau bang mot giai doan khong biet hoa d tuan thur 4. Cu sinh due. cac nep nieu due va cac loi biu- am ho deu co nguon goc tir ngoai bi. B. C a c d a c tru'ng v& g id i duo'c x a c d i n h o' t u a n thu' 9. Co' q u a n s i n h d u e n g o a i diroc h i n h t h a n h d a y d u o' t u a n thu' 12. C. Cu sinh due hinh thanh am vat. nep nieu- due hinh thanh cac moi nho, loi biu- am ho hinh thanh cac moi Ion. mu va cac mep sau am ho. D. Cac tuyen Bartholin: Duo'c hinh thanh tir xoang nieu due (co nguon goc noi bi). tuo'ng ung voi cac tuyen hanh nieu dao o' nam. E. Tien dinh: La viing giua mang trinh va moi nho. du'o'c gidi han bdi ham moi am ho d phia sau. Am dao va nieu dao m d ra d day. Tien dinh co nguon goc noi bi. II. Mo hoc (da) A. M oi Ion • Thu'ong bi duo'c tao bdi bieu mo vay lat tang • Chan bi cd cac nang long va ba loai tuyen - Tuyen nguyen ven (tuyen mo hoi) - Tuyen toan buy (tuyen ba) - Tuyen ban buy. la tuyen dac hieu cho cac \i ing am ho, quanh ong hau mon, nach va vu. Bat dau che tie! theo chu ky khi co kinh nguyet, gom cac te bao Ion co bao tirong m au hong. B. M oi nho Khac vo'i moi Ion, lop bieu m o cua moi nho khon g co lop hat. khong co nang long, it tuyen tiet rung d^u. cac tuyen ba do th a ns len be mat da. C. A m vat • G o m hai the hang ( m o cu'ong mach) • Khac vo'i dirong vat la khong co the xop. D. C ac tuyen Bartholin (cac tuyen ti£n dinh chfnh) • Cac tuyen tui: Duo'c tao boi cac te bao bieu mo tru che nhay. • Cac ong du’oc lot boi cac te bao chuyen tiep. • Mieng ong du’ c lot boi bieu mo lat tang giong cua am dao. o • Cac tuyen phu vung lien dinh: o xung quanh tien dinh. • La vung duy nhat cua ong sinh due nu' co nguon goc noi bi. E. Nieu dao • Duo'c lot boi bieu mo chuyen tiep. 16 nieu dao dirge lot boi bieu mo lat tang. • Cac ong Skene (khong phai tuyen) a lo nieu dao diroc lot boi bieu mo vay. • Nieu dao phia ngoai co cac tuyen nho bao q ua nh (la noi hay bi nhiem trung va hinh thanh cac nang). III. Cac benh da thuong gap A. \ iem da tiep \ u c (viem am ho phan irng) • Do kich thich tai cho: nu'oc hoa. thuoc \it. mvi ton>_: hop cac dung cu tranh thai am dao... • Da viem phu lie do. • Di6u in: Loai ho cac tac nhan gay benh. dung cac Corticosteroid tai cho de giam ngu'a. B. V iem da m an tinh - Da i the: T 6 n thu'ong co m au hoi do, x a m h o ac tr ang ( g i o n g voi q u a san bieu m o vay ho ac loan dirdng tang san ng u’di g ia ) - Vi the: Day sung, tang gai, xam nhap viem m an tmh. - Dieu trj: Rita hoac boi kern Fluorinated Corticosteroid, tiem diro'i da Triamcinolone. C. H a m - Vet nut cua da bj ngam trong cac nep gap gian dui va gian moi a cac benh nhan beo phi. - DiSu tri: Tranh am, giam beo, chong ngu'a bang Eurex hoac cac corticosteroid tai cho. D. Benh vay nen - Dai the: Cac m a n g do da du'oc bao phu boi cac vay bac min (dau hieu Auspitz). Cac ma ng do da co the xuat hien 6 cac vung khac nliau tren co' the. o' am ho ton thirong co the bi che lap boi sir am u'ol va co the giong vo'i mot viem da khong dac hieu. - Vi the: A sung, mao bieu mo thong noi hinh truy va hinh tlion dai. lop bieu m o tren cac nhu mong. nhieu mao mach trong cac nhu chan bi. Khong co ap- xe Munro trong lop thuo'ng bi - Dieu tri: Cac Corticosteroid Fluorinated tai cho nhu Cyclosporine, Methotrexate. Trong tnrdng hop phiic tap nen tliam kliao cac bac sy da lieu. E. Benh n am d a dui • Nliiem trung be mat o' ben va plian tren dm do cac nam da. thirong ket hop \6'i nam da 6 cac \i tri khac (ngon c h a n . . \ \ ) • I’on thu'ong do da kliu till, bogioi han ro. Ngu'a tir n den nhieu. • Dieu tri: Dung m o Imidazole F. Liken phang • Dai the: San tnn phang. thuong la cac m a ng trang o' am ho, co the t6n thuong o' am dao. • Vi the: Tang sung, tang gai. xam nhap limp ho dan g dai sat lop thu'ong bl • Dieu tri: M o Corticosteroid. IV. Cac ton thuong am ho trong cac benh he thong A. B en h C roh n • Hiern khi tcm thuong am ho. • Dai the: Hinh thanh duon g do true trang day chau hoac true trang am dao va cac xo ang din. • Vi the: X a m nhap viem va u hat khon g hoai tii ba dau • Dieu tri: N h u vo'i benh Crohn (khang sinh, Metronidazole va Steroid truoc va sau khi su' tri cac duo'ng do). B. B en h Behcet • Nguyen nhan: Khong r5, co the la benh tir rnidn hoac do virut. • Dac tru'ng boi mot hoi ch ung g o m 3 trieu chung: Loet o' mieng, co' quan sinh due ngoai va mat. • M o hoc: Xa m nhap viem day dac va viem mach. nhieu ma o ma ch bi tac. • Dieu tri: Corticosteroid. C. Dai tliao d u o n g • Viem am ho do nam Candida albicans. • Giai doan cap: Ban do 6 moi Ion va nho. • Giai doan man: T hu on g bl day man xam va loet. • Ditjii tri: Cac thuoc chong nam hien tai va kiem snai dai thao duo'ng. 10 D. T h ieu m au m an • Loet am ho. E. Lire huyet • . Cac ma ng m au vang nau a co' quan sinh due ngoai. F. L ao am ho • Rat hiem. do true khuain lao. • Do n h i i m true tiep tir ban tinh bi benh hoac do su lan rong theo d u a n g mau, hoac theo ducrng true tiep tir voi triing, noi mac tir cung. • Dai the’: Cue loet 6 cac moi am ho hoac o vung tien dinh, bo' ngo&n ngoeo m e o mo. • Vi the: Cac nang lao hoai tir ba dau kinh di6n co true khuan ua a xit. • Dieu tri: T huo c ch ong lao. V. Nhiem trung A. G ia n g mai • Benh hoa li£u. gay ra bo'i Tre po n e m a Pallidum, Anaerobic Spirochete. • M o ta ton thuong: - T6n thuong ng uye n phat (sang) ►U benh 3 tuan. ►Dai the: T6n thuong cung khong dau. co loet a giua. co the gap nhieu t6n thuong o' cac moi am ho hoac lo vao am dao. Viem hach ben khon g hoa mu. ►Vi the: Phan ung viem cap va man tfnh. phan ung viem q uan h m a c h m au 10 ret, co rat nhieu tuong bao va xoan khuan trong t6n thuong. Ton thuong giai doan II (u loi phang) 11 ►Xuat hien sau ton thuong nguyen phat tir 6 tuan den 6 thang. ► Dai the:: Hinh anh hoai tu mau xam, loi cao hinh cao nguyen. ►Vi the: Tang gai, qua san bieu mo, cac te bao viem man vdi rat nhieu tuong bao. viem dong mach. Ti m thay nhieu xoan khuain trong t6n thuong. - T6n thuong giai doan III (gom hoac loet) ►H iem gap, xuat hien sau vai thang den mot nam ke tir khi nhidm benh ducri dan g cac u gom hoac cac vet loet. ►Vi the: U hat vo'i cac te bao kh on g 16, cac te bao dan nhan va dan g bieu mo. Tang sinh m a nh m a o mac h va day thanh mach. X a m nhap tua ng bao ro ret. • Chan doan: Kfnh hien vi nen den, thir huyet thanh (RPR, V D R L ) va xet nghie m hap thu khang the T re po ne m a danh dau bang huynh q uan g (FTA- ABS). • Di6u tri: Benzathin, Penicillin hoac Tetracyclin, Doxycyclin. Benzathin Penicillin hoac Eryt hro my cin khi co thai. Giai m an cam cho cac benh nhan di ung vori Penicillin. B. Ha cam • Hiem gap, gay ra boi He mo phi lus ducreyi, mot loai vi khuan gram am khong chuye n do ng tren tieu ban va trong moi truang nuoi cay. • U benh: Tir 3- 10 ngay. • Dai the: Loet don doc hoac nhieu o, b o m e o mo khong deu kern viem hach ben. sang m e m dau. tang cam. • Vi the: Phan ung viem man vo'i nhieu lim p ho bao va tuong bao. • Chan doan: N h uo m gram va nuoi cay dich mu • Dieu tri: Ervthromvcin Azithromycin, Ceitriaxon. Ciprofloxacin. C. U hat ben (donovanosis) • Hiem gap, gay ra boi Calymmatobacterium granulomatis, true khuain hinh que co vo. gram am, thuoc ho Enterobacteriaceae. • U benh: 1 - 1 2 tuan • Dai the: Khoi dau la vet san me m nho, lan rong do loet be mat doc theo vung ben mu. loet khong dau, bo go cao. Co the co mot ton thuong a giai doan tien ac tinh trong giai doan man tinh cua benh. • Vi the: Phan ung viem man vo'i cac mo bao (te bao u hat), doi khi co qua san dang gia u bieu mo voi bi6u hien tang gai bat thuong, thuan thuc bat thuong o cac dinh mao thuong bi. Cac the’ Donovan trong cac m o bao lorn hoc hoa. • Chan doan: Cac th£ Donovan trong cac te bao don nhan tren cac phien do hoac cac mSu benh pham lay ra tir o loet. • Dieu tri: Tetracyclin, Ampicillin, Chloramphenicol trong 2-3 tuan. D. U hat Iim pho hoa lieu (benh Nicolas- Favre). • Gay ra boi C hl a m yd ia trachomatis tip L. • U benh 4- 21 ngay. • Dai the: Thu'ong bat dau bang nhung vet loet nho de bi bo qua va mot viem hach ben r5 ret. Tien trie!n thanh phu am ho va cac xoang bach m a c h dan den hep true trang va nieu dao. Co kha nang ac tinh o' giai doan man tinh (can sinh thiet). • Vi the: X am nh ap cac tuong bao va te bao don nhan Ion. gian bach m ac h va tang sinh noi mo. Tang sinh dang gia u bieu mo co the gap. • Chain doan: Bang cay mil hoac tim thay Chlamydia vo'i cac moi a-xit nhan. • Dieu tri: Tetracyclin, Doxycyclin, Ery thromycin. Azythromycin, Ofloxacin. Choc hut cac hach hoa mu. khong chfch rach hoac d i n liru. E. H erpes • La cac nhiem trung thong thuong do \ i r u t Herpes simplex gay ra, the loai Hominis tip 2 hoac 1(thuong gap tip 2). • U benh: 3 den 7 ngay • Dai the: Cac bong nuoc, sau do la cac o loet rat dau, thinh thoang ket hop voi phu am ho va cac hach ben thuong sung to, mem. • Sinh thiet: Cac te bao co nhieu nhan Ion co cac th£ vui ai toan trong nhan • Te bao hoc: Cac te bao co nhidu nhan hinh kinh m o ( ton thuong nguyen phat) va co cac the vui trong nh an o the: tai phat. • Chain doan h i u het dua vao te bao va nuoi cay • Dieu tri: Dung Betadine tai ch6, uong Acyclovir, Valacyclovis, hoac Famci- clovir. • Tliii thuat cesar o cac phu nu m a ng thai neu cac t6n thuong hoat dong. F. U m em lay • Do pox virut • Dai the: Cac khoi u tir 5- 8m m , lom o giua, ngua. thuong thanh dam. • Vi the’: Tang gai. lom cua lop thuong bi ( lam d o n g tien 0 trung tarn); trong te bao co cac the1vui ( the' vui u mdm). • Di^u tri : Nao bo hoac dot dien . • Ton thuong co the thoai trien mot cach n g i u nhien. G. M ao ga • Loai ton thirong pho bien, gay ra boi virut sinh u nhu 6 nguoi. ( thuong la HPV 6/1 1). • U benh : 1- 8 thang, trung b'inh 3 thang. • Dai the: U I6i don doc hoac nhiem diem khap am ho. • Vi thei: Tang sung, a sung, benh u nhu. tang gai, te bao co vong sang quanh nhan va viem man 6 lop chan bi. • Di6u tri: P h iu thuat Lazer, dong dien, p h i u thuat lanh, phau thuat rong, Podophyllin trong con thuoc Benzoin axit trichloracetic, m o Imiquimod, Gel Podofilox (chong chi dinh dung thuoc khi co thai). • Nen thuc hien thu thuat cesar trong truong hop mao ga Ian rong. Khong the ngan chan u nhu o' hong ti e so sinh bang thu thuat nay. • Kh on g sinh thiet t6n thuong m ao ga truoc 2 tuan sau khi dieu tri bang Podophyllin vi t6n thuong co the giong ung thu bieu m o tai ch6. H. V iem tuven m o hoi mu • N h i l m trung tuyen ban huy do Staphylococus aureus. • Cac cuc du'o'i da dau am i. Cac cuc nay co the’ thong noi thanh dam. t6n thuong tuong tu' nhu o' nach. • Dieu tri : Trich rach hoac mo' rong vung da bi nhiem khuan va dun g kliang sinh. I. Benh Fox F ord yce • Do cac tuyen ban huy bi tac. • Dai the: Cac not san nho ngu'a chac, loi len mat da. • Vi the: X a m nhap viem. gian cac tuyen tiii. tiet dich phu vao m o ke can. • D i e u tri : U o n g th u o c tr a n h thai va d u n g t h u o c g ia m ngu'a tai c h 6 J. V iem tuyen tien dinh • Cac tuyen nho 6 tien dinh sirng to thanh mot vong quanh lo vao am dao. • Viem gay ra cam giac dau rat bong va dau khi giao hop . • Tren cac manh sinh thiet. bie:u m o ch uy en tiep cua cac ong d i n co the bi hieu nham la ung thu bielu mo tai cho. • Dieu tri: Cat bo neu co trieu chung. VI. Cac u lanh tinh A . N an g • Nang ong Bartholin - Do tac va gian ong - Nan g duo'c lot bo'i bieu mo chu ye n tiep hoac bieu mo det tu cac tuyen tui tiet nhay lan can cua tuyen Bartholin. - Co the bi nhiem khuan bo'i Neisseria. Staphylococcus, hoac cac tac nhan khac va tao thanh ap-xe tuyen Bartholin. - Dieu tri: Thong tui hoac dat catheter trong vong 4-6 tuan. • Nang nhay: - Duo'c lot boi bieu mo tiet nhay hinh tru hoac hinh khoi - Sinh ra tu' ca c x o a n g nieu d u e ton d u h o a c tu cac tu y e n tien dinh - Dieu tri: Cat bo • Cac nang cua ong Nuck trong ong ben (cac n a n s duo'c lot boi phuc mac hoac trail dich am ho) - Tha\ 6 moi Ion hoac 6 ong ben. - 16 Tuong tu trail dich tilling tinh Sinh ra do phuc mac bi viii doc theo d a \ c h a n e iron. - Dieu tri: Cat va that tui tho ng noi vo'i k h o a n g phuc m a c ( ch an do a n phan hiet voi thoat vi. sun g hach ben. tinh hoan lac ch o ) • Cac nang bieu bi vui Duo'c lot bo'i mot lop bieu mo vay sung hoa min. nang chira chat ba dac - Do cac ong tuyen ba bi tac hoac do cac vet thuong vui bieu mo vao trong (thu thuat rach am ho). - Di6u tri: Cat bo neu co trieu chung. • Nang ong Skene: - Cac nang nho canh nieu dao. hiem khi gay tac nieu dao. - Du'oc lot boi bieu mo chuyen tiep - Dieu tri: Cat bo neu nang Ion B. U dac • Mun com co cuong (da tua. polfp xo bieu mo) - Dai the: U lanh. co cuong hoac khong. co the co kich tlurdc Ion. - Vi the: Thu'ong bi binh thu'ong vo'i mo xo lien ket thua (mo m o va mao mach) - Dieu tri: Cat bo non co trieu chung hoac co lo lang ac tfnh • U mau: - U mau dang qua dau ►Dai the: I 1 m e m mau do loi tren mat da ( 1mm- vai cm) nhin thay sau khi sinh. co the thoai trien. ►Vi the: Gian cac mao quan o' chan bi va cac mach man moi du'oc hinh thanh. ►Dieu tri: Theo doi hoac dot lanh. dot bang laser. - U mau the h a n g ^ l H Q C T H A n ^ u Y t . s TSUNG TAM HOC L I$i l7 ► Dai the: Khoi nhieu thuy mau tim. co the lan rong van am dao. xuat hien trong vong vai thang dau sau de. I co the lan rong hoac teo di sau mot vai nam. ►Vi the: Cac khoang clni'a mau Ion khong deu. duo'c loi boi cac te bao 1101 mo. ►Dieu tri: Dot lanh. laser, hoac phau thuat cat bo. - U mau nguo'i gia(u man dang anil dao): ►Dai the: Cac san m£m, nho, lio'i do, co the ep xuong duo'c. thu'ong thay o' cac phu nu' tru'o'c va sau man kinh. ►Vi the: Cac mao quan gian du'oc lot boi cac te bao noi mo det. ►Di£u tri: Khong can dieu tri. trir khi co ch a\ man ( laser, cat lanh. dot dien kho) - U ma ch sung ►Dai the: Ton thu'ong don doc hoac nhieu 6. mau do den. be mat san. ►Vi the: Cac m a o mac h bi gian nam a tren lop chan bi; T h u o n g bi co bieu hien tang sung. a sung, cac mao chan bi keo dai dang u nhu. ►Dieu tri: Phau tlniat cat bo u - U ma ch nhay tien trien. ►Dai the: Khoi me m 6 am ho ►Vi the: Rat nhieu mao quan trong mo dem nha\ Ions leo ►Dieu tri: Cat bo rong rai. U hay tai phat. - U tuyen mo hoi ►U lanh tinh cua tuyen ban huy. hiem gaponhutisj nsuoi da den ►Co the bi chan doan nham la ung ihu bieu mo tuven ►Dai the: I nho hon 2 cm. vi tri o' mo Ion hoac khe dira 2 moi IS ►Vi the: Co can true dang tuyen. gom nhieu ong nho va tuven tui, dirge lot hoi mot lop bieu mo tru ( bao tuong u'a loan, nhan hoe hoa) va mot lop te bao co' bieu mo ►Dieu tri: Phau thuat eat bo. Xet ngliiem mo hoc can than - U te bao Schwann hoac u nguyen bao co' te bao hat ►Dai Ilie: U cua vo day than kinh, bieu hien la cac cuc nho (2-3cm) duoi da moi Ion. ►Vi the: U gom cac o te bao da dien Ion, kich thuoc deu, bao tuong day dac cac hat u'a toan. Tren lop thuong bi thay qua sail gia dang bieu mo giong vo'i ung thu' bieu mo vay xam nhap. ►Dieu tri: Cat rong ton thu'ong. dien cat sach. - Not ruoi (no' vi) • Dai the: Ton thuong noi chung clni'a sac to, no' vi co the khong co sac to. • Vi the: Cac o te bao no' vi co nhan tron hoac trai xoan. nam o' vung tiep giap chan bi va thuong bi ( no vi chan bi- bieu bi), chan bi (no' vi chan bi) hoac ca 2 (novi plioi hop). ►Dieu tri: Cat bo de chan doan (Chan doan phan biet vo'i ung tlnr bieu mo tai cho, u liac to hoac benh sung gai) - Benh sung gai. ► the giong vo'i u hac to, novi hoac ung thu bieu mo tai cho Co ►Dai the: Ton thuong mau den. khong trieu cluing, khong co kha nang ac tinh. Ton thu'ong man nau co the gap bat ky noi nao tren co' the. ►\ ;i the: Tang sung, tang gai. benh nliii \ a cac nang sung ►Diem tri: Cat bo de chan doan (Khong can dieu tri neu chan doan da m bao chnili xae benh) - Vii phu ►Thuo ng gap tloc iheo du'ong su'a bao thai (nach. ngu'c du'o'i. bung Iren). hiem klu o'am ho.