O ôïêåôüò óôï ðñüùñï
Ýìâñõï
B.
KáñáãéÜííçò
B. Tóßìáò
Ã' MáéåõôéêÞ êáé ÃõíáéêïëïãéêÞ KëéíéêÞ AÐÈ
Ðåñßëçøç
H ïñèÞ åðéëïãÞ ôïõ ôñüðïõ äéåíÝñãåéáò ôïõ ôïêåôïý óôá ðñüùñá íåïãíÜ Ý÷åé óõíåéóöÝñåé
áðïöáóéóôéêÜ óôçí åðéâßùóç ôùí ðñüùñùí íåïãíþí, áêüìç êáé åêåßíùí ìå ðïëý ÷áìçëü
âÜñïò óþìáôïò (<1000 ãñì.), êáôÜ ôçí ôåëåõôáßá 20åôßá. Óôïí ðñïêëçôü ðñüùñï
ôïêåôü ç êáéóáñéêÞ ôïìÞ åßíáé ï ðëÝïí åíäåäåéãìÝíïò ôñüðïò ôïêåôïý, äéüôé ç
ðñüêëçóç ôïêåôïý åßíáé äýóêïëç êáé óõíÞèùò áðïôõã÷Üíåé. Óôïí áõôüìáôï (áíáðüöåõêôï)
ðñüùñï ôïêåôü ôá êñéôÞñéá ãéá ôçí åðéëïãÞ ôïõ ôñüðïõ ôïõ ôïêåôïý åßíáé ç ðñïâïëÞ
ôïõ åìâñýïõ, ç ðñüïäïò óôçí åîÝëéîç ôïõ ôïêåôïý êáé ïé åðéðëïêÝò áðü ôç ìçôÝñá
êáé ôï Ýìâñõï. Óôéò ðåñéðôþóåéò áõôÝò, åöüóïí ç åîÝëéîç ôïõ ôïêåôïý åßíáé ïìáëÞ,
åíäåßêíõôáé ï êïëðéêüò ôïêåôüò óå ðñüùñá íåïãíÜ ìå êåöáëéêÞ ðñïâïëÞ. H êáéóáñéêÞ
ôïìÞ åöáñìüæåôáé üôáí åìöáíéóôïýí ìáéåõôéêÝò åíäåßîåéò êáé óå éó÷éáêÞ ðñïâïëÞ
ôïõ åìâñýïõ, ìå õðïëïãéæüìåíï âÜñïò íåïãíïý ëéãüôåñï áðü 1500 ãñì. Óôéò ðåñéðôþóåéò
ðñüùñïõ ôïêåôïý ìå õðïëïãéæüìåíï âÜñïò óþìáôïò ìåôáîý 501 êáé 1000 ãñì., ìïëïíüôé
äåí õðÜñ÷åé óýãêëéóç áðüøåùí, åíäåßêíõôáé óõíÞèùò ç êáéóáñéêÞ ôïìÞ. Iäéáßôåñç
êëéíéêÞ óçìáóßá Ý÷åé, åðßóçò, ç äéåõèÝôçóç ôïõ ðñüùñïõ ôïêåôïý óôéò ðåñéðôþóåéò
ìå ðñüùñç ñÞîç ôùí åìâñõúêþí õìÝíùí.
ÄéåíåñãÞóáìå êëéíéêÞ ìåëÝôç êáé áíÜëõóç ôùí ðñüùñùí ôïêåôþí ðïõ óõíÝâçóáí óôçí
Ã' MáéåõôéêÞ êáé ÃõíáéêïëïãéêÞ KëéíéêÞ ôïõ AÐÈ ôá Ýôç 1996-2000 êáé äéáðéóôþóáìå
üôé ç óõ÷íüôçôá ôïõ ðñüùñïõ ôïêåôïý Þôáí 16,5% êáé ôï ðïóïóôü ôçò êáéóáñéêÞò
ôïìÞò 53,9%, åíþ ôïõ öõóéïëïãéêïý ôïêåôïý Þôáí 46,1%. Oé åíäåßîåéò ãéá êáéóáñéêÞ
ôïìÞ Þôáí: ç ðñïçãçèåßóá êáéóáñéêÞ ôïìÞ óôï 7,3% ôùí ðåñéðôþóåùí, ç éó÷éáêÞ
ðñïâïëÞ óôï 3,1%, ç äõóáíåîßá ôïõ åìâñýïõ óôï 10,9%, ç ðñïåêëáìøßá óôï 10,9%
êáé ðïéêßëá Üëëá áßôéá óôï 26,6% ôùí ðåñéðôþóåùí.
¼ñïé åõñåôçñßïõ: Tñüðïò ðñüùñïõ ôïêåôïý, áõôüìáôïò êáé ðñïêëçôüò ðñüùñïò ôïêåôüò,
ñÞîç åìâñõúêþí õìÝíùí.
EIÓAÃÙÃH
Ùò ðñüùñïò ôïêåôüò ïñßæåôáé äéåèíþò ï ôïêåôüò óå êýçóç ìéêñüôåñç ôùí 37 åâäïìÜäùí
(259 çìÝñåò). Tï 5-10% ôïõ óõíüëïõ ôùí ãåííÞóåùí óõìâáßíåé ðñéí ôçí 37ç åâäïìÜäá
êáé ôï 2-3% ôùí ãåííÞóåùí ðñéí ôçí 32ç åâäïìÜäá êõÞóåùò. ¼ìùò ï ôïêåôüò ôïý
ðïëý ðñüùñïõ íåïãíïý, ìå çëéêßá êýçóçò < 32 åâäïìÜäùí, ðáñïõóéÜæåé ôç ìåãáëýôåñç
ðñüêëçóç ãéá ôïí óýã÷ñïíï ìáéåõôÞñá. H åðéâßùóç ôùí ðñüùñùí íåïãíþí, ìå ðïëý
÷áìçëü âÜñïò óþìáôïò (BÓ), Ý÷åé áõîçèåß óå ìåãÜëï âáèìü êáôÜ ôçí ôåëåõôáßá 20åôßá.(1)
Aíáìößâïëá, ç ïñèÞ åðéëïãÞ ôïõ ôñüðïõ ôïõ ôïêåôïý óôá ðñüùñá íåïãíÜ Ý÷åé ðñïóöÝñåé
ðïëëÜ. H áðïäï÷Þ üôé ç êáéóáñéêÞ ôïìÞ Ý÷åé âåëôéþóåé óçìáíôéêÜ ôá ðïóïóôÜ åðéâßùóçò,
áêüìç êáé óå ðñüùñá íåïãíÜ ðïõ èåùñïýíôáí ðáëáéüôåñá ðïëý áíþñéìá ãéá íá åðéâéþóïõí,
Üíïéîå íÝïõò ïñßæïíôåò.(2)
Tá ðïóïóôÜ ôùí êáéóáñéêþí ôïìþí óôç Óïõçäßá ãéá ôç äåêáåôßá 1983-1993 Þôáí 40-55%
ãéá åãêõìïóýíåò ðñéí ôçí 32ç åâäïìÜäá êýçóçò êáé 28-30% ãéá åãêõìïóýíåò ðñéí
ôçí 37ç åâäïìÜäá êýçóçò.(3)
Eíôïýôïéò, ç áíôéìåôþðéóç ôïõ ôïêåôïý óå ðñüùñá íåïãíÜ ìå õðïëïãéæüìåíï B.Ó.
<1.500 gr åîáêïëïõèåß íá áðïôåëåß ãéá ôïí ìáéåõôÞñá ôï óõ÷íüôåñï äßëçììá.
Oé ðáñÜãïíôåò ðïõ èá áðïôåëÝóïõí êñéôÞñéá ãéá ôçí åðéëïãÞ ôïõ ôñüðïõ ôïõ ôïêåôïý
óå ðñüùñá íåïãíÜ åßíáé ç ðñïâïëÞ ôïõ åìâñýïõ, ç ðñüïäïò óôçí åîÝëéîç ôïõ ôïêåôïý
êáé ïé åðéðëïêÝò áðü ôï Ýìâñõï êáé ôç ìçôÝñá. ÐñÝðåé, åðßóçò, íá äéåõêñéíéóèåß
áí ðñüêåéôáé ãéá éáôñéêÞ åðéëïãÞ, äçë. ãéá ðñïêëçôü (ðñïãñáììáôéóìÝíï) ôïêåôü
Þ ãéá áõôüìáôï (áíáðüöåõêôï) ôïêåôü ìå ôá÷åßá åîÝëéîç, äçëáäÞ ãéá áéöíßäéï,
ìç áíáóôñÝøéìï ôïêåôü.(4) ¼ôáí ï ðñüùñïò ôïêåôüò ÷áñáêôçñéóôåß ùò áíáðüöåõêôïò,
ôüôå ï ôñüðïò ôïõ ôïêåôïý êáé ç íåïãíéêÞ Ýêâáóç èá ðñÝðåé ìå ó÷ïëáóôéêüôçôá
íá óõæçôçèïýí êáé ìå ôïõò ãïíåßò.(5) Iäéáßôåñç êëéíéêÞ óçìáóßá Ý÷åé åðßóçò ç
äéåõèÝôçóç ôïõ ðñüùñïõ ôïêåôïý ðïõ óõíäÝåôáé ìå ôç ñÞîç ôùí õìÝíùí.
I. ÐPOKËHTOÓ (ÐPOÃPAMMATIÓMENOÓ) ÐPOÙPOÓ TOKETOÓ
Ðåñßðïõ ôï Ýíá ðÝìðôï üëùí ôùí ðñüùñùí ôïêåôþí ðñïãñáììáôßæåôáé åîáéôßáò ôùí
åðéðëïêþí áðü ôç ìçôÝñá Þ áðü ôï Ýìâñõï.(3) Óôéò ðåñéóóüôåñåò ðåñéðôþóåéò åêôåëåßôáé
êáéóáñéêÞ ôïìÞ ëüãù ôçò áíùñéìüôçôáò ôïõ ôñá÷Þëïõ ôçò ìÞôñáò. ¼ìùò, óôéò ðåñéðôþóåéò
åìâñýïõ ìå óïâáñÞ êáé ðñþéìç óõììåôñéêÞ êáèõóôÝñçóç óôçí åíäïìÞôñéá áíÜðôõîç,
åßíáé áðáñáßôçôï íá áðïêëåéóèïýí ïé óïâáñÝò óõããåíåßò äéáìáñôßåò ôïõ åìâñýïõ,
ïé áóõìâßâáóôåò ìå ôç æùÞ, ðñïêåéìÝíïõ íá áðïöåõ÷èåß ìéá Üóêïðç êáéóáñéêÞ ôïìÞ.(6)
Óôçí åðéëïãÞ ôïõ ôñüðïõ ôïõ ôïêåôïý êáôÜ ôïí ðñïãñáììáôéóìÝíï ðñüùñï ôïêåôü
ìå åðéâñÜäõíóç ôçò åíäïìÞôñéáò áíÜðôõîçò ôïõ åìâñýïõ, ìå ðñïåêëáìøßá Þ ìå áéìïññáãßá,
ðñÝðåé íá ëçöèåß õðÕ üøéí üôé ôï Ýìâñõï óõ÷íÜ Ý÷åé Þäç ðñïóáñìïóèåß óå äõóìåíåßò
óõíèÞêåò åðéâßùóçò, ìå áõîçìÝíç áíôßóôáóç óå õðïîáéìéêÝò êáôáóôÜóåéò êáé åðïìÝíùò
áõîÜíïíôáé êáé ïé ðéèáíüôçôåò åíüò öõóéïëïãéêïý ôïêåôïý ìå óýíôïìç åîÝëéîç.
¸íäåéîç ãéá êáéóáñéêÞ ôïìÞ óôïí ðñüùñï ôïêåôü áðïôåëåß ç ëïßìùîç ôçò ìçôÝñáò
êáé ôïõ åìâñýïõ, éäéáßôåñá üôáí ç ëïßìùîç áðåéëåß ôçí åðéâßùóç ôïõ åìâñýïõ êáé
óõíõðÜñ÷åé áíþñéìïò ôñÜ÷çëïò. TåëéêÜ, ç êáéóáñéêÞ ôïìÞ åßíáé ï ðëÝïí åíäåäåéãìÝíïò
ôñüðïò ôïêåôïý óôïí ðñïãñáììáôéóìÝíï ðñüùñï ôïêåôü ãéá åãêõìïóýíåò ìéêñüôåñåò
ôùí 34 åâäïìÜäùí êýçóçò, åíþ ãéá åãêõìïóýíåò ìåãáëýôåñåò ôùí 34 åâäïìÜäùí åíäåßêíõôáé
ç ðñüêëçóç ôïêåôïý ìå ôçí ôïðïèÝôçóç ðñïóôáãëáíäßíçò E2 óôïí áõëü ôïõ ôñá÷Þëïõ.(7)
II. AYTOMATOÓ (ANAÐOÖEYKTOÓ) ÐPOÙPOÓ TOKETOÓ
Óôçí ðëåéïíüôçôÜ ôïõò, ïé ðñüùñïé ôïêåôïß åîåëßóóïíôáé óýíôïìá, êáèþò ôï ðñïðáñáóêåõáóôéêü
óôÜäéï ôïõ ôïêåôïý, äçëáäÞ ç äéáöïñïðïßçóç ôïõ êáôþôåñïõ ôìÞìáôïò ôçò ìÞôñáò,
ç ùñßìáíóç êáé ç åîÜëåéøç ôïõ ôñá÷Þëïõ ôçò ìÞôñáò, åðéôåëïýíôáé óõ÷íÜ áíþäõíá
êáé ç Ýãêõïò ãõíáßêá äåí áíôéëáìâÜíåôáé ôç äéáäéêáóßá áõôÞ. Eðßóçò, ôï ó÷åôéêÜ
ìéêñü ìÝãåèïò ôïõ åìâñýïõ ðñïäéêÜæåé Ýíá óýíôïìï ôïêåôü, êáé ìéá áñ÷üìåíç äéáóôïëÞ
åíüò Þ äýï åêáôïóôïìÝôñùí ìðïñåß íá ïäçãÞóåé óå êïëðéêü ôïêåôü óå äéÜóôçìá ïëßãùí
ùñþí. H áðüöáóç ãéá ôïí ôñüðï ôïõ ôïêåôïý óôïí áõôüìáôï ðñüùñï èá åîáñôçèåß,
êõñßùò, áðü ôçí ðñïâïëÞ ôïõ åìâñýïõ, äçëáäÞ êåöáëéêÞ Þ éó÷éáêÞ.(8)
A. KEÖAËIKH ÐPOBOËH
Tá ðåñéóóüôåñá ðñüùñá íåïãíÜ ìå êåöáëéêÞ ðñïâïëÞ èá ãåííçèïýí ìå êïëðéêü ôïêåôü.
EÜí, üìùò, ôá ðñüùñá íåïãíÜ äéáôñÝ÷ïõí êéíäýíïõò áðü ôïí êïëðéêü ôïêåôü, ôüôå
åíäåßêíõôáé ç êáéóáñéêÞ ôïìÞ.(3)
Oé ðåñéðôþóåéò ðñüùñïõ ôïêåôïý ìå êåöáëéêÞ ðñïâïëÞ êáé ìå ðïëý ÷áìçëü âÜñïò
óþìáôïò ôïõ åìâñýïõ, <1500 ãñì, áðïôåëïýí ãéá ôïí ìáéåõôÞñá ôï óõ÷íüôåñï
äßëçììá.(8) Óå Ýìâñõá ìå BÓ <1500 ãñì ïé éó÷õñÝò ìõúêÝò óõóðÜóåéò ôçò ìÞôñáò
áõîÜíïõí ôçí åíäïáìíéáêÞ ðßåóç Ýùò êáé 350 mm Hg êáé áõôÞ ç ðßåóç åßíáé ðïëý
ðåñéóóüôåñï ïäõíçñÞ ãéá ôá ðñüùñá íåïãíÜ, óôá ïðïßá ç êñáíéáêÞ êÜøá åßíáé åõÝíäïôç
êáé ìáëèáêÞ. H ðáñáôåôáìÝíç óõìðßåóç ðïõ áóêåßôáé óôçí êåöáëÞ ôïõ åìâñýïõ êáôÜ
ôï óôÜäéï ôçò åîþèçóçò, éäéáßôåñá óôéò ðåñéðôþóåéò ìå ñÞîç ôùí åìâñõúêþí õìÝíùí,
ìðïñåß íá ðñïêáëÝóåé âáèéÝò ðôõ÷þóåéò óôçí êñáíéáêÞ êÜøá êáé ôñáõìáôéóìü ôùí
åãêåöáëéêþí áããåßùí.(9) O ôñáõìáôéóìüò èá ïäçãÞóåé óå åãêåöáëéêÞ áéìïññáãßá,
ç ïðïßá ìå ôç óåéñÜ ôçò óõìâÜëëåé óôçí áýîçóç ôçò íïóçñüôçôáò êáé ôçò èíçóéìüôçôáò
ôïõ íåïãíïý. Ãéá ôçí ðñüëçøç ôçò óïâáñÞò áõôÞò åðéðëïêÞò åßíáé áíáãêáßï íá äéáôçñçèïýí
Üññçêôïé ïé åìâñõúêïß õìÝíåò, üóï ðåñéóóüôåñï ãßíåôáé.(10) ¸íáò áêüìç åðéâáñõíôéêüò
ðáñÜãïíôáò ãéá ôá ðñüùñá íåïãíÜ åßíáé ôá áíåðáñêÞ Þ ðåñéïñéóìÝíá åíåñãåéáêÜ
áðïèÝìáôá ëßðïõò êáé ãëõêïãüíïõ êáôÜ ôç äéÜñêåéá ôïõ stress ôïõ ôïêåôïý.(11)
Oé áíùôÝñù äõóìåíåßò ãéá ôï Ýìâñõï ðáñÜãïíôåò äéêáéïëïãïýí ôç äéåíÝñãåéá êáéóáñéêÞò
ôïìÞò óôá ðñüùñá íåïãíÜ ìå êåöáëéêÞ ðñïâïëÞ êáé ìå BE < 1500 ãñì. Oé õðïóôçñéêôÝò
ôçò êáéóáñéêÞò ôïìÞò õðïóôçñßæïõí üôé Ý÷åé ðáñáôçñçèåß ìåßùóç ôùí ðåñéðôþóåùí
ìå åíäïêñáíéáêÞ áéìïññáãßá êáé ìå õðïîßá ôïõ åìâñýïõ.(12) Oé õðïóôçñéêôÝò ôçò
äéåíÝñãåéáò êïëðéêïý ôïêåôïý ôïíßæïõí ôá ðëåïíåêôÞìáôÜ ôïõ óôçí êåöáëéêÞ ðñïâïëÞ.
Añ÷éêÜ, áìöéóâçôïýí ôá ðëåïíåêôÞìáôá ôçò êáéóáñéêÞò ôïìÞò ãéá ôï íåïãíü (ìç
ôñáõìáôéóìüò ôïõ åìâñýïõ) êáé åðßóçò åðéóçìáßíïõí ôá ìåéïíåêôÞìáôá ôçò êáéóáñéêÞò
ôïìÞò (õøçëüôåñï ðïóïóôü ìçôñéêÞò íïóçñüôçôáò êáé èíçôüôçôáò êáé áõîçìÝíï ðïóïóôü
åðáíÜëçøçò ôçò êáéóáñéêÞò ôïìÞò óå åðüìåíç åãêõìïóýíç).(13)
Oé õðÜñ÷ïõóåò ìåëÝôåò äåí äéåõêñéíßæïõí, åÜí ç íåïãíéêÞ èíçóéìüôçôá êáé íïóçñüôçôá
åðéâáñýíåôáé ìå ôïí öõóéïëïãéêü ôïêåôü Þ ìå ôç äéåíÝñãåéá êáéóáñéêÞò ôïìÞò.
Óå ðñüùñá íåïãíÜ 25-28 åâäïìÜäùí åãêõìïóýíçò, ìå BÓ 500-700 ãñáì., äåí äéáðéóôþèçêáí
äéáöïñÝò óôç íåïãíéêÞ èíçóéìüôçôá Þ êáé óôç íïóçñüôçôá ãéá ÷ñïíéêü äéÜóôçìá
äýï åôþí áðü ôçí ãÝííçóÞ ôïõò, ðïõ íá óõíäÝïíôáé ìå ôïí ôñüðï ôïõ ôïêåôïý, êïëðéêüò
Þ êáéóáñéêÞ ôïìÞ.(13-16) EðïìÝíùò, ç öõóéïëïãéêÞ ïäüò åßíáé ðñïôéìüôåñç ôçò
êáéóáñéêÞò ôïìÞò. H ôåëåõôáßá, üìùò, ðñÝðåé íá áðïöáóßæåôáé ìå ôçí ðáñáìéêñÞ
Ýíäåéîç äõóðñáãßáò ôïõ åìâñýïõ, êáèüóïí ç õðïîßá åßíáé êáèïñéóôéêüò ðáñÜãïíôáò
ãéá ôçí åìöÜíéóç ôïõ óõíäñüìïõ õáëïåéäïýò ìåìâñÜíçò êáé åíäïêïéëéáêÞò åíäïêñáíéáêÞò
áéìïññáãßáò.
ÄIEYÈETHÓH ÐPOÙPOY TOKETOY
H óôåíÞ ðáñáêïëïýèçóç ôçò åðéôüêïõ êáôÜ ôçí åîÝëéîç ôïõ ôïêåôïý ðñïëáìâÜíåé
ôéò äõóìåíåßò åðéðôþóåéò ôçò õðïîßáò óôï Ýìâñõï. Aõôü åðéôõã÷Üíåôáé ìå ôç óõíå÷Þ
êáñäéïôïêïãñáöéêÞ ðáñáêïëïýèçóç ôïõ åìâñýïõ, ôç ëÞøç, áí åßíáé äõíáôüí, äåßãìáôïò
áßìáôïò áðü ôá ôñé÷ïåéäÞ ôçò êåöáëÞò ôïõ åìâñýïõ êáé ôçí åõ÷Ýñåéá ãéá Üìåóç
ðñüóâáóç óôçí êáéóáñéêÞ ôïìÞ. H åìâñõúêÞ äõóðñáãßá åêäçëþíåôáé ôá÷ýôåñá êáé
óõ÷íüôåñá óôá ðñüùñá íåïãíÜ ìå ÷åéñüôåñç ðñüãíùóç óå óýãêñéóç ìå ôá ôåëåéüìçíá
íåïãíÜ.(17)
H áîßá ôçò ðáñáêïëïýèçóçò ôïõ åìâñõúêïý êáñäéáêïý ñõèìïý êáôÜ ôç äéÜñêåéá ôïõ
ôïêåôïý óõíßóôáôáé óôçí Ýãêáéñç áíáãíþñéóç ôùí óçìåßùí åìâñõúêÞò äõóðñáãßáò,
ïýôùò þóôå íá åßíáé äõíáôÞ ç ìáéåõôéêÞ ðáñÝìâáóç. Eßíáé ãíùóôü üôé ç ðåñéãåííçôéêÞ
áóöõîßá áðïôåëåß ðáñÜãïíôá êéíäýíïõ ãéá ðñþéìåò Þ üøéìåò åðéðëïêÝò óôï ðñüùñï
íåïãíü. Óôçí çëåêôñïíéêÞ ðáñáêïëïýèçóç ôïõ åìâñõúêïý êáñäéáêïý ñõèìïý, "¾ðïðôïò"
åßíáé ï åìâñõúêüò êáñäéáêüò ñõèìüò üôáí ðáñáôçñåßôáé:(18)
1. ÓïâáñÞ âñáäõêáñäßá
2. Eðáíáëáìâáíüìåíåò üøéìåò åðéâñáäýíóåéò
3. ÒKõìáôüìïñöïòÓ âáóéêüò ñõèìüò, ôìÞìáôá ôá÷åßáò åíáëëáãÞò ìåôáîý ôá÷õêáñäßáò
êáé âñáäõêáñäßáò
4. AíåîÞãçôç Òöôù÷ÞÓ ìåôáâëçôüôçôá (variability)
Aí åßíáé åöéêôü, èá ðñÝðåé åðéðñïóèÝôùò íá ìåôñÜôáé ôï pH áðü äåßãìá áßìáôïò
ôùí ôñé÷ïåéäþí ôçò êåöáëÞò ôïõ íåïãíïý Þ äéáöïñåôéêÜ íá ðñï÷ùñïýìå óå ôïêåôü
(ACOG Technical Bulletin). Tá êñéôÞñéá ãéá ôçí Üìåóç ìáéåõôéêÞ åðÝìâáóç, åêôüò
áí ï ôïêåôüò åðßêåéôáé Üìåóá, åßíáé ç ìåôáâïëéêÞ ïîÝùóç ìå pH < 7,25 êáé
ôï Ýëëåéììá âÜóåùò ìåãáëýôåñï ôïõ -6, óôï äåßãìá áßìáôïò ôùí ôñé÷ïåéäþí ôçò
êåöáëÞò ôïõ åìâñýïõ.
H ÐPOÖYËAKTIKH EMBPYOYËKIA
H åöáñìïãÞ åìâñõïõëêþí ãéá ôçí ðñïóôáóßá ôçò êåöáëÞò ôùí ðñïþñùí Ý÷åé áðïäåé÷èåß
ëáíèáóìÝíç. O Beberly(19) ðáñáôÞñçóå óõ÷íüôåñá åíäïêñáíéáêÞ áéìïññáãßá óå íåïãíÜ
< 35 åâä. êýçóçò, üôáí ÷ñçóéìïðïßçóå êáôÜ ôïí ôïêåôü åìâñõïõëêßá. Oé ßäéïé
áíáöÝñïõí äéðëÜóéï ðïóïóôü åíäïêñáíéáêþí áéìïññáãéþí óôá íåïãíÜ âÜñïõò 800-1350
ãñì. ðïõ ãåííÞèçêáí ìå ôç âïÞèåéá åìâñõïõëêþí áðü ü,ôé óå áõôÜ ôùí öõóéïëïãéêþí
ôïêåôþí.(26) O OÕ Driscoll,(20) óå ìåëÝôç 110.344 ãåííÞóåùí, áðåêÜëõøå üôé ïé
ìüíïé èÜíáôïé ðñüùñùí áðü åíäïêñáíéáêÞ áéìïññáãßá Þôáí üôáí ÷ñçóéìïðïéÞèçêáí
åìâñõïõëêïß.(27) Aíôßèåôá, ï Schwartz äåí âñÞêå äéáöïñÜ óôç íïóçñüôçôá êáé ôç
èíçóéìüôçôá ìåôáîý ôïõ öõóéïëïãéêïý ôïêåôïý êáé ôçò ðñïöõëáêôéêÞò åìâñõïõëêßáò
óå íåïãíÜ âÜñïõò ãåííÞóåùò 500-1500 ãñì.(20) Må âÜóç ôá áíáöåñèÝíôá äåäïìÝíá
ôçò âéâëéïãñáößáò, ðéóôåýïõìå üôé ç åöáñìïãÞ ôçò ðñïöõëáêôéêÞò åìâñõïõëêßáò
óôá ðñüùñá äåí Ý÷åé èÝóç óôç óýã÷ñïíç ìáéåõôéêÞ.
H EKTEËEÓH EÐIÓIOTOMHÓ
H ðñïöõëáêôéêÞ ðåñéíåïôïìßá åßíáé Ýíá Üëëï áìöéóâçôïýìåíï èÝìá óôïí ðñüùñï ôïêåôü.
Aðü ôá áðïôåëÝóìáôá ìéáò ìåëÝôçò áðü ôïõò Lobb êáé Cooke(29) óå 48 ðñüùñá íåïãíÜ
äåí öáßíåôáé ç ðåñéíåïôïìßá íá ðñïöõëÜóóåé áðü ôçí åíäïåãêåöáëéêÞ áéìïññáãßá.
Óå üëá ôá êëáóéêÜ ìáéåõôéêÜ óõããñÜììáôá ôïíßæåôáé ç áíÜãêç ìéáò ìåãÜëçò åðéóéïôïìÞò,
ðñïêåéìÝíïõ íá áðïöåõ÷èåß ç ÷ñçóéìïðïßçóç ìç áíáãêáßáò åìâñõïõëêßáò. Óõ÷íÜ ï
ôïêåôüò åßíáé ôüóï ôá÷ýò, ðïõ ç ðåñéíåïôïìÞ äåí åßíáé áíáãêáßá. H ãíþìç ìáò
åßíáé üôé ç ðåñéíåïôïìÞ ðñÝðåé íá ãßíåôáé ìüíï áí ôï åðéâÜëëåé ç êáôÜóôáóç ôïõ
ðåñéíÝïõ.
B. IÓXIAKH ÐPOBOËH KAI ANÙMAËEÓ ÐPOBOËEÓ
H éó÷éáêÞ ðñïâïëÞ êõìáßíåôáé óôï 20-25% ôùí ðåñéðôþóåùí ôùí ðñüùñùí ôïêåôþí.
H äéåíÝñãåéá êïëðéêïý ôïêåôïý óå ðñüùñá íåïãíÜ ìå éó÷éáêÞ ðñïâïëÞ áõîÜíåé óçìáíôéêÜ
ôç íïóçñüôçôá êáé ôç èíçóéìüôçôá ôùí íåïãíþí áõôþí êáé ïöåßëåôáé óå áôõ÷Þìáôá
áðü ôïí ïìöÜëéï ëþñï (óõìðßåóç), óå áõîçìÝíï êßíäõíï áóöõîßáò ôïõ íåïãíïý êáé
óå ðáãßäåõóç ôçò êåöáëÞò ôïõ åìâñýïõ óå áôåëÞ äéáóôïëÞ ôïõ ôñá÷Þëïõ, ëüãù ôçò
äõóáíáëïãßáò ôïõ ìéêñïý óþìáôïò ðñïò ôï êåöÜëé.(21) H Üðïøç áõôÞ óôçñßæåôáé
óå ðïëëÝò áíáäñïìéêÝò ìåëÝôåò, óôéò ïðïßåò äéáðéóôþíåôáé äéðëÜóéá óõ÷íüôçôá
íåïãíéêÞò èíçóéìüôçôáò óå ðñüùñá íåïãíÜ ìå éó÷éáêÞ ðñïâïëÞ ðïõ ãåííÞèçêáí ìå
êïëðéêü ôïêåôü, óå óýãêñéóç ìå åêåßíá ôá ðñüùñá éó÷éáêÜ, éäßïõ óùìáôéêïý âÜñïõò,
ðïõ ãåííÞèçêáí ìå êáéóáñéêÞ ôïìÞ. H åðéâßùóç ôùí ðñüùñùí íåïãíþí ìå éó÷éáêÞ
ðñïâïëÞ êáé õðïëïãéæüìåíï âÜñïò óþìáôïò 1000-2500 ãñì. ðïõ ãåííÞèçêáí ìå êáéóáñéêÞ
ôïìÞ Þôáí 100%, åíþ åêåßíùí ðïõ ãåííÞèçêáí ìå êïëðéêü ôïêåôü Þôáí ìüíï 63%.(22,23)
Äéáðéóôþèçêå, åðßóçò, üôé ç óõ÷íüôçôá åíäïêïéëéáêÞò åãêåöáëéêÞò áéìïññáãßáò
ôùí ðñüùñùí éó÷éáêþí ðïõ ãåííÞèçêáí ìå êáéóáñéêÞ ôïìÞ êõìáéíüôáí óôï 21% ôùí
ðåñéðôþóåùí, åíþ åêåßíùí ðïõ ãåííÞèçêáí ìå êïëðéêü ôïêåôü áíÞëèå óôï 59%.(24)
H èíçóéìüôçôá óå ðñüùñá < 2500 ãñì. ìå éó÷éáêÞ ðñïâïëÞ, êáôüðéí êïëðéêïý
ôïêåôïý, Þôáí ðïëý õøçëüôåñç áðü üóï äéêáéïëïãåß ç ðñïùñüôçôá êáé ãéá áõôü óõóôÞíåôáé
óå áõôÝò ôéò ðåñéðôþóåéò êáéóáñéêÞ ôïìÞ. Oìïßùò, ðñïôåßíåôáé êáéóáñéêÞ ôïìÞ
óå áõôÝò ôéò ðåñéðôþóåéò ëüãù ôùí êáëýôåñùí Apgar scores.(24)
Eðßóçò, óå ìåëÝôç ôïõ Weissman(25) ðïõ áöïñÜ ôç ìÝèïäï ôïêåôïý óå ó÷Ýóç ìå ôçí
Üìåóç êáé ôçí áðþôåñç íïóçñüôçôá êáé èíçóéìüôçôá óôá ÷áìçëïý âÜñïõò íåïãíÜ ìå
éó÷éáêÞ ðñïâïëÞ, áðïäåéêíýåôáé üôé óôçí ïìÜäá ôùí ôïêåôþí ìå êáéóáñéêÞ ôïìÞ
ôá áðïôåëÝóìáôá Þôáí ðïëý êáëýôåñá. Máêñïðñüèåóìá, öÜíçêå üôé óôçí ïìÜäá ôïõ
êïëðéêïý ôïêåôïý ôá íåïãíÜ åß÷áí óå ìåãáëýôåñï ðïóïóôü åãêåöáëéêÞ ðáñÜëõóç,
ïðôéêÝò äéáôáñá÷Ýò, åëÜôôùóç ôçò áêïÞò êáé óïâáñÞ êáèõóôÝñçóç áíÜðôõîçò.
¶ëëïé üìùò ìåëåôçôÝò, üðùò ïé Bodmer, Rossen êáé óõí.(26) áíáöÝñïõí üôé äåí
äéáðßóôùóáí äéáöïñÝò ôçò íåïãíéêÞò èíçóéìüôçôáò óôçí êáéóáñéêÞ ôïìÞ êáé óôïí
êïëðéêü ôïêåôü êáé âñÞêáí åðßóçò ðáñüìïéá ðïóïóôÜ ðáãßäåõóçò ôçò êåöáëÞò óå
êáéóáñéêÞ ôïìÞ êáé óå êïëðéêü ôïêåôü, êáé ãéÕ áõôü óõìâïõëåýïõí ôçí åîáôïìßêåõóç
êÜèå ðåñßðôùóçò.(27)
ÓõìðåñáóìáôéêÜ, ðñÝðåé íá åêôéìÜôáé îå÷ùñéóôÜ êÜèå ðåñßðôùóç óå ðñüùñá ìå éó÷éáêÞ
ðñïâïëÞ êáé, åöüóïí ç åãêõìïóýíç åßíáé ìéêñüôåñç áðü 32-33 åâäïìÜäåò êáé ôï
âÜñïò ôïõ åìâñýïõ ìéêñüôåñï áðü 1500 ãñì., åßíáé ðñïôéìüôåñï íá äéåíåñãåßôáé
êáéóáñéêÞ ôïìÞ. KñéôÞñéá ãéá êáéóáñéêÞ ôïìÞ áðïôåëïýí, åðßóçò, ç åìâñõúêÞ äõóðñáãßá,
ç áóöõîßá êáé ï ðáñáôåôáìÝíïò ôïêåôüò.
Ã. ÄIÄYMA - TPIÄYMA
Tï 15-20% ôùí ôïêåôþí âÜñïõò < 1500 ãñì. åßíáé äßäõìåò êõÞóåéò. EÜí ïé ðñïâïëÝò
åßíáé êåöáëéêü / êåöáëéêü äåí õðÜñ÷åé óçìáíôéêÞ Ýíäåéîç êáéóáñéêÞò ôïìÞò.(28)
EÜí ôï äåýôåñï åßíáé åãêÜñóéï Þ éó÷éáêü, ç êáéóáñéêÞ ôïìÞ öáßíåôáé ðñïôéìüôåñç.
ÐÜíôùò, áíáäñïìéêÝò ìåëÝôåò áíÝäåéîáí üôé ç êáéóáñéêÞ ôïìÞ äåí ó÷åôßæåôáé ìå
ôç ìåßùóç ôçò óõ÷íüôçôáò ôçò åíäïåãêåöáëéêÞò áéìïññáãßáò óå äßäõìïõò ôïêåôïýò,
êÜôù ôùí 1500 ãñì. Eðß ôïõ ðáñüíôïò õðïäåéêíýïíôáé ôá áêüëïõèá êáôÜ ðåñßðôùóç
ãéá äßäõìïõò< 1500 ãñì.
1. Kåöáëéêü A / Kåöáëéêü B: êïëðéêüò ôïêåôüò
2. Kåöáëéêü A / Mç êåöáëéêü B: êáéóáñéêÞ ôïìÞ
3. Ió÷éáêü A: êáéóáñéêÞ ôïìÞ
Ãéá ôñßäõìá ìåôÜ áðü IVF õðïäåéêíýåôáé ç êáéóáñéêÞ ôïìÞ.(29)
III. TOKETOÓ ME ÐPOÙPH PHÎH YMENÙN
O ðñüùñïò ôïêåôüò ìå ñÞîç ôùí õìÝíùí óõìâáßíåé ðåñßðïõ óôï 5% ôùí êõÞóåùí êáé
åõèýíåôáé ãéá ôï 80% ôùí èáíÜôùí ôùí íåïãíþí ìå âÜñïò óþìáôïò ìéêñüôåñï ôùí
2,5 Kgr. Eßíáé áðïäåêôü üôé ôï 1/3 ôùí ðåñéðôþóåùí ôïõ ðñüùñïõ ôïêåôïý ðñïêáëåßôáé
áðü ôçí ðñüùñç ñÞîç ôùí õìÝíùí. Må ôç ñÞîç ôùí åìâñõúêþí õìÝíùí ðñéí áðü ôïí
ôïêåôü óõíäÝåôáé Üìåóá ôï óïâáñü ðñüâëçìá ôçò öëåãìïíÞò, äçëáäÞ ôçò ÷ïñéïáìíéïíßôéäáò,
óôï 40% ôùí ðåñéðôþóåùí, êáé åðéâåâáéþíåôáé ìå ôçí êáëëéÝñãåéá ôïõ áìíéáêïý
õãñïý ìåôÜ áðü áìíéïðáñáêÝíôçóç. ¼ðùò åßíáé ãíùóôü, ç ÷ïñéïáìíéïíßôéäá ðñïêáëåß
íåïãíéêÞ óçøáéìßá. Eöüóïí õðÜñ÷åé ñÞîç ôùí åìâñõúêþí õìÝíùí, õðÜñ÷åé êáé Òåí
äõíÜìåéÓ ï êßíäõíïò áíéïýóáò ëïßìùîçò ðïõ èá åðçñåÜóåé ôç ìçôÝñá êáé ôï Ýìâñõï.
O êßíäõíïò ðïõ äéáôñÝ÷åé ôï íåïãíü ðñïÝñ÷åôáé áðü ôçí áíùñéìüôçôá êáé ôç óçøáéìßá.
Óôéò áóèåíåßò ôçò ïìÜäáò áõôÞò åðéâÜëëåôáé íïóçëåßá óå íïóïêïìåßï êáé ÷ïñÞãçóç
ôçò êáôÜëëçëçò áíôéâßùóçò.
Kýçóç ìåãáëýôåñç ôùí 34
åâäïìÜäùí
H ïìÜäá áõôÞ ôùí áóèåíþí áíôéìåôùðßæåôáé ìå ôïí êáëëßôåñï äõíáôü ôñüðï, áí äéåíåñãçèåß
ðñüêëçóç ôïêåôïý êáé óõíå÷éóôåß ç áíôéâßùóç êáôÜ ôç ëï÷åßá.
Kýçóç ìåôáîý 24 êáé 34
åâäïìÜäùí
H áíáìïíÞ êáé ç êáôÜëëçëç äéåõèÝôçóç ôùí åðéðëïêþí åßíáé ÷ñÞóéìç ãéá áõôÞ ôçí
ïìÜäá áóèåíþí. H ÷ïñÞãçóç êïñôéêïóôåñïåéäþí åðéâÜëëåôáé, êáé äåí áõîÜíåé ôïí
êßíäõíï åðéäåßíùóçò ôçò ÷ïñéïáìíéïíßôéäáò Þ ëïßìùîçò ôïõ íåïãíïý. Eðßóçò, åðéâÜëëåôáé
ç êÜëõøç ìå áíôéâéïôéêÜ åõñÝïò öÜóìáôïò. EÜí ï ôïêåôüò Ý÷åé îåêéíÞóåé, ôüôå
äåí ðñÝðåé íá ÷ïñçãïýíôáé ôïêïëõôéêÜ öÜñìáêá. ¼ôáí äéáðéóôþíåôáé éó÷éáêÞ ðñïâïëÞ,
åßíáé ðñïôéìüôåñç ç äéåíÝñãåéá êáéóáñéêÞò ôïìÞò.(31)
Kýçóç ìéêñüôåñç ôùí 24
åâäïìÜäùí
Óôçí ïìÜäá áõôÞ ôùí áóèåíþí åßíáé áðáñáßôçôç ç áõôüìáôç Ýêôñùóç. H åðéëïãÞ ãéá
ôÝôïéïõ åßäïõò áíôéìåôþðéóç ðñÝðåé íá êïéíïðïéçèåß óôï æåõãÜñé. H ÷ïñÞãçóç áíôéâéïôéêþí
åßíáé áðáñáßôçôç.(31)
IV. ÐPOÙPOÓ TOKETOÓ ÓTH Ã' MAIEYTIKH ÃYNAIKOËOÃIKH KËINIKH
Óôçí ÃÕ MáéåõôéêÞ êáé ÃõíáéêïëïãéêÞ KëéíéêÞ ôïõ Añéóôïôåëåßïõ Ðáíåðéóôçìßïõ
Èåó/íßêçò, ôïõ Iððïêñáôåßïõ Nïóïêïìåßïõ Èåó/íßêçò, êáôÜ ôçí ðåíôáåôßá 1996-2000,
äéåíåñãÞèçêáí 3.734 ôïêåôïß, åê ôùí ïðïßùí ïé 3.118 (83,5%) Þôáí ôåëåéüìçíïé
êáé ïé 616 (16,5%) ðñüùñïé (ðßíáêáò 1). Tï ìÝóï âÜñïò ãÝííçóçò ôùí íåïãíþí áíÜ
åâäïìÜäá áíáöÝñåôáé óôïí ðßíáêá 2. H óõ÷íüôçôá äéåíÝñãåéáò êáéóáñéêÞò ôïìÞò
Þôáí 53,9% êáé êïëðéêïý ôïêåôïý 46,1%, êáèþò äéåêðåñáéþèçêáí 338 êáéóáñéêÝò
ôïìÝò êáé 284 öõóéïëïãéêïß ôïêåôïß. H óõ÷íüôåñç áéôßá êáéóáñéêÞò ôïìÞò Þôáí
ç ðñïåêëáìøßá ôçò ìçôÝñáò, ç éó÷éáêÞ ðñïâïëÞ ôïõ åìâñýïõ êáé ç äõóáíåîßá ôïõ
åìâñýïõ, üðùò öáßíåôáé óôïí ðßíáêá 4.
H óõ÷íüôçôá ðñïùñüôçôáò áíÜ åâäïìÜäá åãêõìïóýíçò áíáãñÜöåôáé óôïí ðßíáêá 5.
Óôïí ðßíáêá 6 êáôáãñÜöåôáé ç ðñïùñüôçôá áíÜëïãá ìå ôïí ôüêï ôçò ãõíáßêáò. Oé
ìïíÞñåéò êõÞóåéò Þôáí 499 (81%), ïé äßäõìåò 99 (16,1%), ïé ôñßäõìåò 17 (2,8%)
êáé õðÞñîå ìßá ôåôñÜäõìç êýçóç (0,2%) (ðßíáêáò 7). Äåí äéáðéóôþèçêå äéáöïñÜ
óôï öýëï ôùí íåïãíþí, êáèüóïí ãåííÞèçêáí 251 Üññåíá íåïãíÜ (50%) êáé 248 èÞëåá
íåïãíÜ (50%) (ðßíáêáò 8). Aðü ôï óýíïëï ôùí 616 ðñüùñùí ôïêåôþí, ïé 482 ðåñéðôþóåéò
(78,2%) áöïñïýí Eëëçíßäåò ãõíáßêåò êáé ïé 134 ãõíáßêåò (21,8%) Þôáí áëëïäáðÝò
(ðßíáêáò 9). Aðü ôï óýíïëï ôùí ðñüùñùí íåïãíþí, ôá 412 íåïãíÜ (67,2%) äéåêïìßóèçêáí
ìåôÜ ôïí ôïêåôü óôç MïíÜäá EíôáôéêÞò Nïóçëåßáò Nåïãíþí (MENN), ôá 169 (27,4%)
íïóçëåýôçêáí óôï Ðáéäéáôñéêü TìÞìá êáé óõíÝâçóáí 33 (5,4%) åíäïìÞôñéïé èÜíáôïé.
ÓõìðåñáóìáôéêÜ, ôïíßæåôáé üôé ç õøçëÞ óõ÷íüôçôá ôùí ðñüùñùí ôïêåôþí (ðïóïóôü
16,5%) ðïõ äéåíåñãÞèçêáí óôç Ã' KëéíéêÞ ôïõ A.Ð.È., êáèþò êáé ôá ðïóïóôÜ ôùí
êáéóáñéêþí ôïìþí óõìöùíïýí ìå ôá äåäïìÝíá Üëëùí êëéíéêþí.(3)
Summary
Karagiannis V, Tsimas V.
Mode of delivery in preterm infants.
Hellen Obstet Gynecol 14(3):246-252, 2002
Correspondence: V. Tsimas
5 M. Alexandrou str,
55134 Thessaloniki
Tel: 0310432891
billtsimas@hotmail.com
During the past 20 years, the survival rate of very-low-birth-weight infants
has increased remarkably, and the contribution of better obstetric care should
not be underestimated. In elective preterm deliveries, cesarean section is often
the preferred method of delivery, since induction is difficult and liable to
fail. In spontaneous (active) preterm labor, the factors influencing the decision
include the presentation, progress of labor, and fetal and maternal complications.
If labor is normal and the fetus is not distressed, vaginal delivery in a preterm
infant presenting vertex is appropriate. Cesarian section should be reserved
for obstetric indications and for breech presentations when the estimated fetal
weight is less than 1,5 Kg, or less than 1.000 gr.
Special care is needed in the cases of premature rupture of the membranes in
preterm labor. We also performed a clinical investigation for the mode of delivery
in the premature infants at the 3rd Department of Obstetrics and Gynecology,
University of Thessaloniki, and we found that the incidence of the premature
labor were 16,5% and the percentage of the cesarian section was 53,9%, where
as the frequency of the normal labor was 46,1% of all the cases.
Key words: Mode of delivery in preterm labor, elective and spontaneous preterm
deliveries, cesarian section, premature rupture of membranes.
3rd Department of Obstetrics - Gynecology, Aristotle University of Thessaloniki
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Aëëçëïãñáößá:
B. Tóßìáò
M. AëåîÜíäñïõ
5
55134 Èåóóáëïíßêç
Tçë: 0310432891
billtsimas@hotmail.com