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VETMO

  Sinh mổ từ lâu đã được nhiều thai phụ lựa chọn như một phương pháp vượt cạn nhiệm màu nhưng bên cạnh đó là vô số những nguy cơ tiềm ẩn cho lần sinh sau. Việc kiểm tra, theo dõi sát trên những thai phụ có vết mổ cũ là rất quan trọng để đảm bảo an toàn cho cả mẹ và thai.

1/. Vết mổ cũ (VMC) là gì?

  - Vết mổ lấy thai cũ.

  - Vết mổ bóc nhân xơ TC

  - Vết mổ trên thân TC vì những lý do khác như thủng TC trong khi nạo thai, phẫu thuật tạo hình TC…

Không gọi là VMC khi vết mổ không nằm trên TC mà mổ vì những lý do như thủng ruột, viêm ruột thừa, u nang buồng trứng, thai ngoài TC…

2/. Những nguy cơ khi mang thai lần sau với VMC là gì?

* Nứt VMC:

  Nứt VMC là một tai biến sản khoa, tai biến này có thể xảy ra trên thai phụ mang thai lần 2 sau sinh mổ trong vòng 6 – 9 tháng kể từ lúc sinh. Nứt VMC trong thai kỳ thường xảy ra ở 3 tháng giữa và 3 tháng cuối của thai kỳ.

* Thai bám VMC:

  Đối với những thai phụ đã từng sinh mổ hoặc phẫu thuật vùng TC sẽ có vết sẹo, khi làm tổ, trứng đã được thụ tinh có thể bám vào sẹo cũ và hình thành túi thai.

Hai dạng thai bám VMC:

– Dạng 1: Thai làm tổ ở VMC và phát triển trong buồng TC cho đến tam cá nguyệt thứ 2 thậm chí thứ 3. Nhau thai có thể kéo lên đoạn thân TC, khi nhau thai phát triển chúng có thể gây nên hiện tượng nhau bám thấp hoặc nhau cài răng lược do gai nhau đan xen vào cơ TC.

– Dạng 2: Thai cấy sâu vào cơ và lớp mô sợi ở TC tại VMC. Khi đến tam cá nguyệt thứ 2 hoặc thứ 3 các gai nhau bám vào bánh nhau sẽ ăn sâu vào cơ TC, thậm chí xuyên bàng quang dẫn đến nguy cơ cắt TC, có thể gây tử vong nếu vỡ TC.

* Nhau cài răng lược:

  Những trường hợp nhau tiền đạo, nhau bám thấp mặt trước ở những thai phụ có VMC thì nguy cơ nhau cài răng lược rất cao. Đối với những trường hợp này khi sanh phải mổ lại và nguy cơ phải cắt TC, truyền máu. Đôi khi tổn thương những cơ quan lân cận như bàng quang, ruột… do bánh nhau xâm lấn vào những cơ quan này.

* Nguy cơ cho bé:

Trường hợp những phụ nữ mang thai lần 2 cách lần sinh mổ trước dưới 18 tháng, trẻ có thể sẽ bị sinh non, nhẹ ký, vàng da, thính giác kém, kém phát triển về mặt trí tuệ, thể chất khi trẻ lớn lên.

3/. Tiêu chuẩn của một VMC lành tốt là gì?

  - Phải là vết mổ ngang đoạn dưới TC mà không phải là vết mổ dọc thân TC hay sẹo mổ bóc nhân xơ TC trong cơ.

  - Vết mổ không quá mới ( dưới 16 – 18 tháng).

  - Mới là vết mổ 1 lần.

  - Không phải vết mổ vá lại thân TC do vỡ lần trước.

  - Lần mổ trước không có nhiễm trùng ối và nhiễm trùng hậu phẫu.

4/. Thời điểm an toàn để mang thai trở lại sau sinh mổ là bao lâu?

  Thông thường, sau mổ lấy thai lần đầu từ 24 tháng trở đi, thai phụ mới được khuyên có thai trở lại. Tuy nhiên, một số trường hợp sau sinh mổ chưa đủ 24 tháng đã có thai trở lại do không áp dụng các biện pháp tránh thai. Những nghiên cứu gần đây cho thấy, không có sự khác biệt có ý nghĩa về chất lượng giữa sẹo mổ đoạn dưới tử cung trên 24 tháng và sẹo mổ dưới 24 tháng. Tuy nhiên, khi mổ lấy thai trở lại đối với những VMC dưới 24 tháng, nhất là dưới 12 tháng, vết mổ chưa thực sự liền tốt, dễ chảy máu, độ bền kém rõ rệt. Trong khi mang thai, thai phụ thường kêu đau ở bụng dưới, nhất là ngang vết mổ đoạn dưới TC.

5/. Những điều cần lưu ý khi mang thai có VMC là gì?

  - Ngay sau khi trễ kinh hoặc nghi ngờ có thai trở lại cần đến ngay cơ sở y tế chuyên khoa để kiểm tra xem có thai hay không, thai đã vào TC hay chưa và vị trí của túi thai trong TC để đề phòng trường hợp thai bám VMC.

  - Khám và quản lý thai định kỳ theo lịch hẹn tại cơ sở y tế chuyên về sản phụ khoa uy tín, đặc biệt là nơi có điều kiện phẫu thuật để phát hiện và xử trí kịp thời những bất thường xảy ra, nếu có.

  - Giữ kỹ giấy xuất viện của lần mổ trước, luôn mang theo khi đi khám thai, biết được lý do mổ là gì, thời gian từ lúc mổ đến nay là bao lâu, nằm viện bao nhiêu ngày sau mổ, có nhiễm trùng trong thời gian hậu phẫu không…

  - Tiêm nhắc lại một mũi văcxin ngừa uốn ván vào tháng thứ 4 hoặc thứ 5 nếu lần mang thai trước đã tiêm đủ hai mũi.

  - Chú ý các dấu hiệu đau VMC: đau ngang trên xương mu, đau liên tục, ấn vào đau nhói lên. Khi có các dấu hiệu này là có nguy cơ nứt VMC, cần phải đến ngay cơ sở y tế chuyên khoa gần nhất.

  - Nhập viện trước ngày dự sanh 1 – 2 tuần để được thực hiện đầy đủ các xét nghiệm, cận lâm sàng tiền phẫu và theo dõi sát quá trình chuyển dạ.

  - Cho con bú tiếp tục nếu sinh mổ trước 24 tháng, ăn uống đủ chất, tăng cường bổ sung dinh dưỡng và vi chất nhằm giúp cho thai phụ có sức khỏe để vừa nuôi thai vừa nuôi em bé.

6/. Sinh mổ hay sinh thường khi có VMC?

Quan điểm hiện nay khuyến khích thử thách sanh ngả âm đạo đối với thai phụ có VMC (VBAC) vì một số lợi ích như: giảm chi phí điều trị, giảm nguy cơ băng huyết sau sanh, giảm tỷ lệ nhiễm trùng…

  - Nếu không có các yếu tố đẻ khó, sản phụ vẫn có thể sinh thường được ở lần mang thai sau khi có VMC. Tuy nhiên tỉ lệ này là tương đối thấp vì nhiều lý do, trong đó có sự lo lắng quá mức của thai phụ. Một số nghiên cứu cho thấy tỷ lệ thành công của VBAC là 72 – 75%.

  - Những trường hợp có VMC vì thai to, khung chậu hẹp, dị dạng TC, ngôi thai ngược hay VMC dưới 24 tháng sẽ được chỉ định mổ lấy thai chủ động khi thai đã đủ tháng hoặc bắt đầu chuyển dạ. Nên đi khám thai đầy đủ theo hẹn và tuân theo chỉ định của bác sĩ để đảm bảo cuộc sinh nở được an toàn.

* Điều kiện VBAC:

  - Không có những chỉ định mổ lấy thai lại

  - Ngôi chỏm đầu cúi tốt

  - Có điều kiện phòng mổ can thiệp khi có biến chứng

  - Thai phụ được giải thích và chấp nhận khi có biến chứng.

* Chỉ định mổ lấy thai lại nếu:

  - Lý do mổ lần trước còn tồn tại

  - Vết mổ lần trước là vết mổ dọc thân TC

  - VMC bóc nhân xơ TC lớn hoặc vá lại TC thủng

  - Số lần mổ từ 2 lần trở lên.

  - Thời gian mổ dưới 16 – 18 tháng.

  - Nhiễm trùng hậu phẫu lần mổ trước.

  - VMC kèm theo bất thường thai kỳ lần này.

  - Đau VMC.

7/. Vấn đề kế hoạch hoá gia đình

  Tham vấn bác sĩ để chọn lựa một phương pháp ngừa thai an toàn và hiệu quả. Khi đã mổ lấy thai 2 lần, có đủ con, lớn tuổi thì nên triệt sản. Không nên để tử cung mang vết mổ phải thử thách nhiều lần vì tính mạng của thai phụ.

  Mang thai là điều vui mừng cho các cặp vợ chồng nhưng cũng có nhiều lo lắng đi kèm, đặc biệt là với những thai phụ đã có VMC. Vì vậy, tất cả các thai kỳ có VMC ở TC cần được đánh giá cẩn thận, kiểm tra và theo dõi sát tại bệnh viện có chuyên khoa Sản, giúp phát hiện kịp thời và xử trí sớm để ngăn ngừa các biến chứng.

* TÀI LIỆU THAM KHẢO<

1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 115: Vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010; 116:450–63.

2. Royal College of Obstetricians & Gynecologists, Green-top Guideline No.45, 2015, Birth After Previous Caesarian Birth

3. Âu Nhựt Luân, Đại học Y Dược TP Hồ Chí Minh, Bài giảng TBL Sản khoa Y4.

4. Bộ môn Phụ sản, Đại học Y Dược TP Hồ Chí Minh, Bài giảng Sản phụ khoa.

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