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

 

 

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