TONG QUAN Y VAN Ty Ié nhiém Streptococcus nhém B am dao - trwe trang & phu ni? mang thai 35 - 37 tuan va mot s6 yéu to lién quan Hé Ngoc Son,” Vi Thj Nhung” Dai cuong Ké tir thip nién 70 cla thé ky trie cho dén nay, Streptococcus nhém B (GBS) van duge xem 1a tac nhin hang dau gay bénh ly nhiém trang so sinh (NTSS) sém. Sy lay truyén doe tir me sang con c6 thé xy ra Khi thai phu ¢6 nhiém GBS am dgo - rye tring vio thoi diém chuyén da hoe 6i vo, sir lay nhiém nay 1a yéu 15 nguy eo quan trong clia NTSS sém, tin suat bénh ly NTSS sém do GBS khoang 1,5 truémg hop trén 1000 tré sinh séng va ty 1é tir vong so sinh (SS) cita bénh ly nhiém tring nay lén t6i 50%.* Bat dau tir gitta nhimg nam 1980, nhiéu thir nghigm lam sing x8 nghién cia quan st chimg minh khang sinh (KS) tiém tinh’ mach trong chuyén da 6 phy nit mang thai ¢6 nhiém GBS sé ngin duge nguy co truyén GBS cho tré so sinh (SS) va do dé c6 thé ngan ngira bénh NTSS sém . ‘Nam 1996, Trung tim Kiém soat va Phong bénh Hoa Ky (CDC), Higi San phu khoa Hoa Ky (ACOG), Vign Hin lim Nhi khoa Hoa Ky (AAP) ban hanh khuyén céo vé chién luge dy phong nhiém GBS dya vao ede yéu t8 nguy co 6 cdc thai phy. S6 ligu tir nhimg nghién ecru quy md 1én vé tinh higu qui cha chién Inge dy phing nhiém GBS di cho thiy sw gidm ngoan mye cia tin sudt bénh va ty Ié tir vong cia bénh ly NTSS sém do GBS, gidm ti 16 truyén doc tir me qua con, gidm 21% ty 18 bénh ly nhiém tring GBS 6 thai phy, gidm 70% bénh ly NTSS sém.? SBV.Da Khoa Khu Vie Nam Binh Thun, Email de:ngoeson67@ gmail.com, DD: 0918082009 ** Hoi Phy sin TP HM. Email: Dsvinhung@yahoo.com.va. DD: 0903383005 Chién luge sit dung KS dur phong dya yao két qua cia chong trinh tim soat GBS am_ dgo - tnvc trang 6 thai phu khi thai ky dat 35 — 37 wan di duge ap dung ti nim. 1996, Sau mt thdi gian dp dung song song 2 chién Inge, nhiig thir nghiém c6 quy mé én da duge tién hanh va két ludn: chién hrgc dy phing NTSS do GBS dua vio cay khuan tim sodt cho higu qui cao hon dua vao cde yéu t6 nguy co. Dé ld co sé dé CDC dua ra phién bin thir 2 vé Khuyén cao sir dung khang sinh dy phong nim 2002 nhim tdi wu héa tiéu chuan thai phy nhan KS dy phing. Ty Ig tir vong vi NTSS sém do GBS & My va céc nude phuong Tay gidm xuéng con 4% - 6%.° Vio nim 2010, CDC cap nhat ve Khuyén céo tim sodt, str dung KS dy phong va duge Té chite y (WHO) phé bién nhu mét chién luge tim Tai Vigt Nam_ cing 43 ¢6 nhing nghién cecu tim soat ty 1é nhim GBS trong thai ky trén déi tugng vio chuyén da, 6i vo non, sinh non nhung cho thay tinh img dung. cchura cao. Cac thay déi cila chién Ivgc phéng chéng GBS ctia CDC Nam 1996 CDC da ban hanh khuyén edo vé chién luge diéu tr} dy phing nhiém GBS dua vao céc yéu t6 nguy co 6 cc thai phy? bao gém: —Sinh non < 37 tuin Va bi> 18 gis —Nhiém tring i —Thai phy sit > 38°C —Lin sinh trade tré bj NTSS sém do GBSDaa eee DLO ELE Ti nam 2002, huéng dan cua CDC kin cio nén sir dung phuwong phap cay dé tdi wu héa vige xée dinh cde thai phy nén nhn duge KS dy phong trong chuyén dg dé phing ngiza tich eye va chi nhing thai phy nao khéng cé két qua cdy trude 46 (khong 16 tinh trang nhiém GBS) méi ap dun; phuong php phing ngira dya vao yéu t6 nguy co. ‘Nam 2010 CDC da cap nhit lai hung di phéng chéng NTSS sém do GBS, 6 1 sé diém quan trong.* — Khuyén nghi sang loc GBS trudc sinh cho tat ca cdc thai ky 35- 37 tuan 4@ tdi uu hoa s6 thai phy nhan duge KS dy phong khi chuyén da. = Thai phy chira biét nhiém GBS tai thoi digm chuyén da sé duge dy phong da vao yéu t6 nguy co. — Cip nhat phéc 6 dy phong danh cho thai phy di img véi penicillin, — Huéng dan chi tiét vé cach lay mau XN vi mé ring cde phurong phip XN xde dinh GBS, ké ca huéng din vé Khang sinh dé. — Khuyén nghj khéng ding KS dy phong cho thai phu nhiém GBS khi mé sinh ma chua bit dau chuyén da, di con nguyén ven. — Cp nhat quan ly dy phéng 6 thai phy de doa sinh non. — Cp nhat xir tri phong ngira thir cap cho NTSS sém do GBS. Dac diém vi sinh vat hoc GBS, hay cdn goi li Streptococcus agalactiae, 1a nhimg vi khuan hinh cdu hole hinh bau duc, dug kinh trung binh 0,6 — 0,8um, bat mau gram (+). Vi khudn xép thinh chudi vi phn chia trong mat phing thing géc véi truc cia chudi. GBS 6 men hemolysin lam tan hoan toan hong. cau, trén méi trong thach mau, khiim vi khuan durge bao quanh béi mgt vong tron nho trong suét, ¢6 thé lam tan méu dudi 3 hinh thie a, B, y tuy thuge timg nhém Streptococcus. 10 ir GBS bi cé lap c6 thé séng sét 6 méi truimg trong vai ngay nhiét 46 phong. Tuy nhién, sy phye hdi cia cde ching gidm trong 1 - 4 ngiy, die bigt 6 nhigt &6 cao. Mau nén duoc lun git 6 4°C truée khi cdy va xi ly trong vong 24 gid cia mau thu thap> Cae bénh phdm ly tir Am dao - rye tring c6 chita nhiéu loai vi khudn khéc nhau nén cdc KS trong méi trudng cdy (Gentamicin va Axit Nalidixic hodc Colistin) gitp logi trir nhimg loai vi khuan khdng phai li, GBS. Chat dinh durdng trong ‘méi truimg cay gitip GBS phat trién manh, tir dé lam ting kha nang phat hign cua phuong phap cay lén 50% so véi cach cay irye tiép bénh phim vao moi tru’mg thach mau‘. Vi vay, méi trong cdy nh Tood Hewitt phii hyp cho myc tiéu tim soat GBS. Lay bénh phim tir ca hai vi tri am dao — trye trang cho két qua phat hign GBS cao hon so véi truéng hop chi lay mau & am dgo, 6 CTC hoje quanh hiu mén Sie Hin 2: Hin th8 oda vi khualnlién eu du6% kinh idm vi c1000 [Nauén : Microbiology inpicture.comDich t8 hoe GBS chi yéu séng & dudng tiéu héa, am 4dgo thuéng {a noi bj lay nhiém. Cé khoang 10% - 30% thai phu bi nhiém GBS trong 4m dgo hode tryc tring. Nhiém GBS trong thd ky mang thai o6 thé thogng qua, timg dot, hay kéo di. Bj nhiém GBS trong thai ky truée sé ting nguy co nhiém 6 lin mang thai tip theo. Ty 18 nhiém bénh khong trigu chimg & phy nit mang thai thay ddi thy thude vio dan sé nghién ecu, dia ly, ky thuat léy bénh phim, ky thuat nudi cdy, dae bigt én nhiéu moi truimg trung gian hay chon lgc. Ty 1g nhiém GBS. fim dao - trye trang cao nhat & ngudi da den khong 30—40%.* ‘Tam soat nhiém GBS trong thai ky Vi tinh trang nhiém GBS cé thé thay déi trong qu trinh mang thai. Do 46, thai gian tim sodt dé xde dinh tinh trang nhiém 12 rit quan trong. Tinh trang nhiém GBS cé thé thodng qua. Nhiém sém trong thai ky khong phai 13 yéu t6 tién dodm cua bénh ly NTSS sm do GBS. Trong khi dé, nhiém GBS trong ba thang cudi da duge sit dung nhu 1a mot tign don cho nguy co liy nhigm trong chuyén da. Gié tr dy bio am cua cay GBS thye hign <5 tuan trude khi sinh 12 95% - 98%, Cée gid tri tién doin lam sang gidm khi cdy truéc khi sinh duge thye hign nhiéu hon 5 tuan vi sy sut giim gid tri tiém doan am. Cac mau cay mat thei gian tir 24 — 48 gids dé cd két qui nén khéng phi hop cho vigc khoi dau diéu tri KS dy phéng cho thai phu true sinh né tim sodt sau 37 twin hay vio hic chuyén da. Vige tigp can tim soat cae thai phu nhiém GBS 6 4m dgo - trye trang t6t nhat 4 thir diém 35 — 37 tuan cua thai ky.® Miu XN lay 6 phan thip am dao va truc trang (théng qua co thit hau mén) lam ting 17 Ié ding ké so vai vige lay mau 6 am dao ma khéng ly 6 trye trang. Mot vai nghién ctu 43 kiém tra két qua mudi cdy mau lay quanh hau mén hode m dao dé phat hign nhiém GBS, cae dit ligu cho thay mau cay fim dao - tryc tring cho ty 1é cao nhiit.* TONG QUAN Y VAN Mét sé céng trinh nghién c@u trong va ngoai nwéc vé nhiém GBS trong thai ky Nel cru ngoai nuée ‘Nam 1981, Cregan J.A va cong sw da thy hign mét nghién ciru hdi cia vé nhi GBS trén 6.706 thai phu & Hoa Ky va da ghi nhin c6 su gia tng t tan suat vo 6i non va sinh non truée 32 tudn trong nhém cdy GBS dwong tinh. Su khic biét c6 ¥ nghia thong ké voi P < 0,05. $6 ligu nay cho thay c6 méi lién quan gitta nhiém GBS va sinh non.® Nghién ctu cla Meyn L.A gém 1.248 phy nif tré cho thay hoat déng tinh due 1a mot yéu {6 nguy eo quan trong Hién quan t6i nhiém GBS, Tor - Udom $ (2006), nghién ctu tai BY Thammasat Thai Lan tién hanh dé tim m6 hinh khang khang sinh & phy nit mang, thai nhiém GBS, 406 phy nit mang thai di duge kiém tra GBS. Ty Ié nhiém GBS la 16%. Tit ea céc thai phy nhiém GBS cé két qua khang sinh dé déu nhay cam véi Ampicillin, Penicillin, Vancomycin. Ty 18 nhay vi Clindamycin (3%) | va Erythromycin (1,5%).!” Nghign citu ciia Namavar B va edng sit thye hign nm 2008 trén 1.197 thai phy e6 tir 24 — 37 tuan nhim phat hign tin suit nhiém GBS 4m dao - truc tring cia céc thai phy, déng thai so sénh nhimg bién chimg cla me va tré SS gita nhém nhiém GBS va nhém Khéng nhiém GBS. Két qui cho thay c6 363% thai phy chuyén da sinh non trong nhém nhiém GBS so véi 14,3% trong nhém khong nhiém GBS, sw Khie bigt ¢6 ¥ nghia thong ké (p= 0,001), Tan suat di vo non va 6i ve kéo dai > 18 gié trong nhém nhiém GBS. 1a 163% va 6.3% so véi nhém khong nhiém GBS la 6% va 0,5%, su khac biét c6. ¥ nghia théng ké véi p = 0,001. Nehién cu ndy da dia ra méi lién quan gitta tink trang nhiém GBS véi chuyén da sinh non va di vé non.'* Nghign citu ciia Kwatra G (2014), cho "Daa eee DLO ELE thdy phy nit mang thai 6 Nam Phi cé mét ty 1 nhiém cao GBS tryc trang - am dao c6 tudi thai tir 20 tuan tro di, va ty 1 nhigm GBS cao nhat 6 tam cd nguyét eudi."” Nghién itu trong nuée Neghién etru eda Nguyén Thi Ngge Khanh va cng sur thue hign tgi Vign bao vé ba me iré em tir nam 1998 - 2000, trén 602 thai phy séng tai Ha N6i duge cy bénh phim © Am dgo, két qua c6 4,5% déi tugng nghién ecru (DTNC) nhiém GBS duong am dao.!* Theo nghién ctu cit ngang cia Dé Khoa Nam (2006) trén 200 thai phu doe theo dai chuyén da sinh va sinh tai phong sinh BY Tir Di, tuoi thai tir 29 - 40 twain (véi nhém thai ky trén 37 tuan chiém da 86), ty 1é nhiém GBS duémg am dao - tree tring 1a 17%, ty 18 trayén doc tir me sang con la 50%, Nghién citu cho thay cé méi lign quan gitta ty Ie nhiém GBS am dgo - irye tring véi nai & ela thai phy. Cae dang GBS khang véi nhiéu loai KS nhung vin cén rat nhay voi Augmentin, Cefazolin va Vancomycin.’ Nehién edu cia Nguyén Thi Vinh Thinh nam 2007 véi e6 mau 376 thai phy dén kham thai tai bénh vign Tir Da, duge cay khudn am dao - true tring ¢ tudi thai 35- 37 tuan, két qua ty 1 nhiém GBS la 18,1%, ty 6 nay e6 lién quan dén tui thai phu (P= 0,015). C6 5,9% tré so sinh bi lay nhiém GBS duéng am dao - trye tring cia thai phu bi nhiém GBS sau khi di duoc digu tr] KS dy phéng theo phic 45 khi vao chuyén da, ty 1¢ nhiém GBS 6 tré so sinh phy thude vao phuong php sinh.'® Nghién ecu cia Bui Thi Thu Huong (2010) xdc dinh ty 18 nhiém GBS am dao - rye trang trén thai ky sinh non va mét s6 yeu t6 lign quan cho thay ty 1é nhiém GBS ‘im dao - truc trang trén thai ky non thing tir 28 — 36 tudn 6 ngay 18 17,5%, 06 lién quan gitta ty 18 nhiém GBS am dao - tree ring véi khu vyre eur tri ciia thai phy, cde 46i tugng 6 ndi thanh cé ty I¢ nhiém GBS 2 ir cao hon. Trong sé 41 tragng hgp nhiém: GBS c6 31 trung hop bj va i som, trong sé nay €6 3 thai phy bi sot Iie mp vign va thai gian vo di déu trén 12 gis! Nghién eitu ciia Hd Ngoc Son trén 230 thai phu 6 tudi thai tir 35 — 37 tuan tai BV da khoa Khu vye nam Binh Thuan tir thing 9/2015 dén thang 3/2016 cho thay ty 16 nhiém GBS am dao - true tring é cée thai phu 18 17,8%, trong dé nhiém lign quan v6i vi tri am dao 1a 6,1% va lién quan v« vj tri truc trang 1 16,9%. Phan tich da bien cho thay ty 1¢ nhiém GBS lién quan c6 ¥ nghia théng ké véi biéu hién lam sing viém 4m dao cia thai phu (OR = 42,7, KTC 95%: 5,6-332,4 - p = 0,001) GBS nhay cim cao véi cée khang sinh: Augmentine, Vancomycine. Nhay cim trung binh véi Penicillin, Ampicillin. GBS khang cao véi khang sinh Erythromycin, Clindamycin Két luan Khang sinh dy phong dya vio cay tam soat GBS dich am dgo - trye tring cho théy mang Iai higu qua tich eye, Trong digu kign chua tam soat duge bing cay dich am dgo - true tring, nén ding khing sinh dy phong dya vao yéu t6 nguy co nham giam ty Ig nhiém tring so sinh som. Tai ligu tham khao 4. Bul_Thi Thu Huong (2010), "Ty 18 nhiém Streptococcus nhém B am, dao-tnvc trang tren thai 4y sinh, non va mot s6 yéu t6 lin quan’, LLugn van T6t nghigp Thae sT Y hge, Dai hoc ¥ Duge TP.HCM. 2. CDC (1998). Provention of perinatal group B streptococcal disease: @ public health perspective, MMWR, Vol 45. 3. CDC (2002), Prevention of perinatal group B streptococcal disease: revised guidelines from CDG, MMWR, Vol 51: 1-22. 4. CDG’ (2010), Sexually transmitted diseases treatment guidelines, MMWR Vol 59: 18-36, 5. 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'Nauyn Thi Ngoc Khanh (2001), *Nhigm khudn dong sinh duc & phy no c6 thal tgi Ha NO”, Tap Chi ¥ hoc thyc han, $6 42, 167-70. Nguyén Thi Vinh Thanh, NgB Thi Kim Phung (2009), “Ty 18 thai phy nhiém lién cu Khun ‘nhém B tai benh vign Ty Do’, Tap chi ¥ hee TPLHOM, Tr: 82-86. Tor-Udom S, Tor-Udom P, Hirote W (2006) The prevalence of streptococcus agalact (group B) colonization in pregnant women at ‘Thammasat Hospital, J Med Assoc Thai, Vol 89(4): 411-415, B