1. Ectopic pregnancy in a previous cesarean section scar, known as cesarean scar ectopic pregnancy (CSEP), occurs when a fertilized egg implants in a cesarean section scar in the uterus. 2. CSEP is diagnosed using ultrasound imaging which shows the gestational sac located in the cesarean section scar between the bladder and uterine cavity. 3. Treatment aims to remove the pregnancy from the scar while preserving the uterus and future fertility, and may include medical or surgical management depending on the severity of the case.

1. THAI NGOAI TU CUNG 0 SEO MO LAY THAI. BS Phan Van Quy€n
Thai ngoai ti'r cung as~o m6 lay thai (TNTCSMLT) da duqc Larsen vii Solomon Mo cao tir
1978.Khbi thai barn vao ca ti'r cung qua khe ha s~o m6 lay thai (MLT), vi trf hi€m g~p, nhung
theo nhii:ng bao cao giin day cho thay d9 xuat hi~n da c6 khuynh hu&ng tang diin. Di€u nay
phan anh do ti I~ m6 lay thai vii th! thai trong bng nghi~m d~u tang, them vao d6 v&i mg
dvng sieu am qua am dlO giup phat hi~n s&m cac tru&ng hgp TNTCSMLT.
TNTCSMLT c6 t€ bao nuoi xam !fin co· ti'r cung tuang tµ ciii rang luge nen c6 khuynh
hu&ng gay chay mau 6(t, c6 th€ de d9a m<:mg sbng. Tuy nhien trong TNTCSMLT t~ bao nu6i
xam !fin nhi€u han, vii xay ra rat s&m trong 3 thang diiu thai k)t. Do d6 c6 nguy cacao gay vo·
tlr cung vii bang huy€t.
D(>XUATHI¢N
Theo Timor d9 xufit hi~n cua TNTCSMLT chi~m khoang 1/1.800 -1/2.500 tbng sb sanh. Tuy
nhien d<) xufit hi~n th1,rc SI kh6ng th€ xac djnh vi cac truang hqp chi duqc ghi nh?n rai rac. f)c)
xufit hi~n TNTCSMLT c6 khuynh hu&ng tang do sb MLT tang. TNTCSMLT tlmimg g~p hon
TNTC t[i c6 tlr cung (Shih).
Dbi v&i phl nii: da MLT it nhfit I Iiin c6 th€ bi TNTCSMLT 5%. TNTCSMLT chi~m ti 1$
< I% cac tru&ng hqp TNTC. (hinh 15.1).
TNTC d 1fog din tnlng ts·K%
(.""''"'-' . / -
. 1;~- ~.../"' !
i t::·- ~ _,I.... .
;,. -~~Ji'i';r:;..."
TNTC d IC.o ML.T < 1%
ft / / 11'
Th•lbOng 6•~ng '"[ ·1 .·
TNTC d kt 2-3% ····- TNTC cl bOng
ITNTC~1~?;~ ""
- ~- ~
~---~-~
TNTC dB~ 3% TNTC d loa 11%
Hinh 15.1. TI 1$ thai ngoai tii cung theo vi tri (William's Obstetrics 231
h Hinh 15.2. Si;io MLT bi ha
ed,2010)
NGUYENNHAN
Nguyen nhan dua d€n TNTCSMLT chua ro. C6 nhi€u gia thuy~t giai thich b~nh sinh
TNTCSMLT, gia thuy€t duqc chfip nh~n nhi€u nhfit la ph6i nang d6ng vao co· tfr cung qua khe
163

2. SAN KHOA
h<'J o v€t syo tren ca TC do MLT, phfru thu?t tren ca tir cung, ho~c cac tdn thuang ca tir cung
sau khi b6c nhau b§ng tay (Fylstra), do nong n(lo ho~c l?c m)i m(lc trong ca nr cung. Thl tinh
trong 6ng nghi~m (TTTON) ciing c6 the gay ra TNTCSMLT (Seow), du khong c6 syo phfru
thu?t tren tfr cung.
Sau MLT, 60% (Krishna) SyO thucmg c6 cac khe ho (hinh 15.2), t(IO dibu ki~n cho
TNTCSMLT. Hi~n nay, v6i ti~n b(> trong tmg dlng sieu am nga am d?o v6i barn dich, Sl'
toitn Vyn ctia ca tli' cung c6 th~ khao sat luc kh6ng mang thai. N€u phat hi~n syo MLT bi
khi€m khuy€t nen lm1 ynguoi b~nh khi c6 thai d.n quan tam d€n nguy ca TNTCSMLT.
YEU TO NGUY CO
Cac y€u t6 nguy ca bi TNTCSMLT gbm c6 ti~n can nong n(lo tru6c d6, c6 tibn can nhau barn
bfrt thuong (Maymon), tibn can b6c nhau b~ng tay, tibn can TNTC, tibn can TITON vit cac
phfru thu?t c6 lien quan dSn ca tlr cung nhu MLT, b6c nhan xa, may tai t?O tlr cung, soi bubng
tfr cung. Pha thai c6 th~ dfrn den TNTC t?i c6 tir cung (Shinagawa). tdn thuang ca tlr cung t(lo
dibu ki~n phoi thai barn vao chi€m 21%. TNTCSMLT ciing g~p tren MLT do ngoi mong 63%
cac truang hqp, vi ngoi m6ng duqc thl'C hi~n MLT ch9n !9c Jue do(ln du6i chua phat tri€n
nen khi litnh SyO d~ c6 khe ho cha phoi dong sau nay. Theo y van khong ghi nMn c6 lien quan
d~c bi~t hay h?u qua nao gifra m6 !fry thai liin tru6c v6i cac Iiin mang thai sau d6 v6i
TNTCSMLT.
TRil):U CHUNG vADAU Hil):U
Tu6i thai khi phat hi~n TNTCSMLT thay ddi tir 5 t6i 16 tuiin. Khoang each tir Iiin MLT cu6i
t6i TNTCSMLT thay d6i tfr 6 thang t6i 12 nam.
Tri~u chtmg Jam sang TNTCSMLT khong d~c hi~u, philn 16n b~nh nhiln c6 xufrt huySt am
d?o chi€m 33%-44%. 25% c6 dau blng nhu bi sfry thai kh6ng tr9n. Han 50% b~nh nhiln
kMng tri~u chi'.mg va chi chfrn doan phat hi~n qua sieu am khi kham thai (Maymon, Rota).
Do khong c6 tri~u chi'.rng vii dfru hi~u chuyen bi~t baa d(>ng nen chfrn doan c6 th€ ch?m
tr~. M(>t s6 truang hqp chfrn doan sai chi xac dinh duqc khi c6 kSt qua giai phfru b~nh. Sai s6t
khong nh?n ra TNTCSMLT c6 th~ dfrn d€n h?u qua va tr cung khiSn b~nh nhan nguy kich.
Vi~c chfrn doan nhiim la thai trong nr cung nen d~ di~n bi€n (r nhien ciing nhu can thi~p nong
11(10 c6 th~ d~n d~n xu.it huySt 6 (It. Vi v?y cac thiiy thu6c Jam sang nen nghi ngo d€n
TNTCSMLT khi b~nh nhiln c6 tibn can m6 I§y thai.
CHAN DOAN
Tren Jam sang chfrn doan TNTCSMLT s6m rfrt kh6. Chfrn doan can ci'.r tren tibn sir, b~nh canh
liim sang nhu dau blng, rang huy€t va quan tr9ng nhfrt la sieu am Doppler mau, m(>t s6 truang
hqp kh6 d.n xac djnh bilng MRI (Godin) vii n(>i soi bu6ng tU cung cfing duqc dung trong chfrn
doan.
164

3. Thai ngoai ti'.r cung 6' seo m6 l~y thai
Tieu chu:in ch:in dean TNTCSMLT v6i sieu am nga am d?o (hinh 15.3, 15.4) va Doppler
mau (hinh 15.5): (Seow, Maymon, Fylstra).
a. Bubng tir cung trbng.
b. Kenh c6 tfr cung trbng.
c. TUi thai n~m gifta bang quang va ph§n tm6c do(ln eo ttr cung, lop ca tlr cung gifta
bang quang va tUi thai kh6ng c6 hay rat mong.
d. V6i sieu am 3D Doppler c6 phinh nwch mau quanh tui thai, c6 hinh iinb rn5t lien tvc
cua vach trn6c tir cung tren rn~t dt ngang qua tl1i 6i.
..Hinh 15.3. SE)O MLT ha, trU'&C khi c6 thai Hinh 15.4. TNTC 6' SE)O MLT
Hinh 5. M<;1ch mau quanh khoi thai, kh6ng con w TC
Tieu chu:in nay giup phiin bi¢t v6i TNTC dong t?i c6 tfr cung, eo t1r cung hay s~y thai.
Hinh iinh phinh 111!Ch mau quanh tl1i thai lit m(>t lqi di~m Clla Doppler dtmg d~ phan bi¢t gil'ra
thai s6ng t?i s~o v6i thai chSt trong tlr cung git1p quySt dinh di€u tri 119-p ly. Trong truerng ho'P
165

4. SAN KHOA
thai luu trong tlr cung quanh rui thai kh6ng CO mlCh mau, tui thai da tr6c ra khoi nhau barn.
Nguqc lli trong TNTCSMLT sdng, quanh tui thai vftn c6 nhieu mlch mau tren sieu am.
Sieu am d!iu do am dlo c6 d(> nhlY 84,6% (Rotas). Sieu am diiu do am dlo giup quan sat
r5 tui thai vii ti.rang quan v&i S!O MLT. K~t hqp sieu am qua thanh bµng tlO ra hinh anh r(>ng
Clla tlr cung Va phiin phµ Va do dUQ'C khming each gifra tlli thai Va bing quang. Qua do cling do
duqc d9 day vach ca tlr cung gifra bing quang vii rui thai, v&i phdi hqp hinh anh nhieu m~t vii
3D cho bio dam chiin doan.
MRI tren m~t c~t ngang c6 the thlly r5 rui thai n~m tm&c c6 tir cung (Godin). Nhung
Maymon kh6ng ciin dung MRI vi sieu am diiu do v&i Doppler ffilCh mau du cho chiin doan,
de phat hi~n xam Jin bang quang Valley da thl'c hi~n soi bing quang.
N(>i soi bubng tlr cung thlly S!O TNTCSMLT c6 hinh anh d6 nhu ca hbi.
Diem quan tr9ng cua chfrn doan chinh xac giup tranh sai s6t khi nhiim v&i thai trong tir
cung vii can thi~p v&i nong nlO diin d~n xufit huy€t 6lt ciin phfo thu~t khiin cip.
CHAN DOAN PHAN BIJ):T
Thai trong tir cung.
TNTC tli c6 tir cung.
siiy thai.
DIEN BIEN
Vial luu yTNTCSMLT di~n ti~n theo hai hu&ng khac nhau. Loli thu nhit rui thai dong tren
S!O v&i ti'.1i thai phat trien hu&ng vao trong khoang eo c6 tir cung hay bubng tir cung. Tm&ng
hqp nay c6 the ti€n trien d~n sanh s6ng, nhung c6 nguy ca xuit huy~t 6lt nai nhau barn. Loli
thr 2 tui thai c~m sau trong khe ho S!O MLT vii ti~n trien gay vfJ tir cung trong 3 thang d!iu.
Nguy ca va tir cung vii xuit huy~t n~ng c6 the nguy hiem tinh mlng b~nh nhan.
Phan bi~t gifra hai loli TNTCSMLT rit quan tr9ng. Loli I ciin theo doi lien tµc phat tri€n
thai v~ bubng nr cung, ciin can thi~p tm&c khi chuy€n dl khi thai da phat tri~n t6t vi 11guy ca
xuit huy€t 6lt do nhau cai rang luge c6 the phai c~t tir cung.
Giai phiiu b~nh cho thiy nhau barn vao dOln du&i khong c6 l&p ca tlr cung va l&p mang
rµng day va chi c6 it mo lien k€t. Cac b~nh nhan nay ciin duqc tham vin S!O MLT cua hQ rit
m6ng va nen MLT.
TAI BIEN
Hai tai bi€n thuimg g~p trong qua trinh dieu trj va theo doi TNTCSMLT la va tir cung va
chay mau 6jt ciin phifu thu~t cfrp Clru, neu cac bi~n phap ciim mau th~t d(>ng m1:1ch tU Cung
hay hi;l vi kh6ng hi~u qua ciin dt ill cung ciim mau (Bang 15.1).
166

5. Bang 15.1. Tai bi~n theo phll'O'ng phap di~u tr[
Elieu tri ban dau Tai bien %
MTX TB 62,1
Nang va N;;io 61,9
Thuyen t~c ElMTC 64,9
Soi bullng TC 18,4
MTX t;;ii ch6/vao thai 9.7
Timar-Tritsch. Early placenta accreta and cesarean section
scar pregnancy: a review. Am J Obstet Gynecol 2012.
XUTRi
Thai ngoai tli> cung 6' seo m6 l~y thai
Nguyen t~c di€u tri cling tuang tv nhu di€u tri TNTC tli cac vi tri khac gbm c6: lfry/lniy kh6i
thai !Ii SyO MLT vii bao t6n kha nang sinh san. Tuy theo mU:c d(l khfin dp cua di~n ti€n b~nh
ma c6 bi~n phap di€u tri phu hgp. N€u b~nh nhan c6 xufit huy€t 6 It ciln can thi~p phau thu(it
dp cU:u, c6 kha nang phai c~t ttr cung d€ cilm mau. N€u tinh trlng b~nh nhan 611 dinh, kh6ng
xu:it huy€t hay lugng it c6 nhi€u phuang phap di€u tri.
Tru6c 2012, chua c6 di@u tri t6i uu, c6 rfrt nhi€u each di€u tri. Sau khi Timor (2012) due
k€t cac kinh nghi~m trong y van da cho thfty TNTCSMLT di€u tri ban dfiu v6i MTX tiem tli
ch6/vao kh6i thai k€t hgp v6i toan than cho k€t qua t6t. Cac can thi~p ban dfru biing nong vit
nIO, MTX toan than, thuyen t~c d(lng 111!Ch TC d@u gay ra nhi€u bi€n chU:ng vii c6 khi phai
dt tlr cung.
Kh6i thai cimg 16'n tai bi€n cang nhi€u, do d6 khi dugc ch~n doan dung s6'm, tien lugng se
t6t han.
Khuynh hu6'ng hi~n nay Iii di€u tri bao tbn n(li khoa vii can thi~p ngo11i khoa tbi thi~u
nhiim k€t thuc thai kY s6m, nhcr d6 tranh phai ph~u thu(it 16n vii bao 1611 kha nang sinh san.
Di~u tri ni}i khoa
E>i€u tri v6i methotrexate (MTX) ap di.mg cho cac trucrng hgp thai nh6 han 16 tufrn, huy6t
d(lng 6n djnh va kh6ng c6 ch6ng chi dinh (Timor).
N€u chua c6 tim thai tiem MTX lli ch6 vao thai vii quanh kh6i thai + toiln than v6'i li@u
50mg/m2
di~n tich than th~.
N€u thai s6ng, huy thai biing tiem MTX (25mg) ho~c KC! vao tim thai qua hu6ng dan
sieu am phbi hgp MTX 25mg quanh kh6i thai +25mg MTX tiem b~p. Khi tiem MTX vao tui
thai, luc d6 se hut ca djch trong rui thai c6 k€t qua t6t h0'11 (Jurkovic).
Do d(l day thilnh tru6c ttr cung biing sieu am (Godin) n€u d(l day la l,2mm hay nh6 han
2mm ciln luu ynguy ca vfJ svo vii xu:it huy€t 6 It c6 th~ xay ra sau di€u tri n(li khoa, c6
trucrng hgp d€n sau 15 ngay sau di€u tri v6i MTX. Do nguy ca nay m(lt s6 tac gia d@ xu:it
ph6i hgp di€u tri n(li khoa v6i lam thuyen t~c d(lng l111Ch tlr cung ho~c tiem vasopressin vi10
trong c6 tlr cung kem v6i chi:n bong sonde 18 French Foley.
167

6. SAN KHOA
Sau di€u tri MTX da s6 b~nh nhan h6i plwc hoan toan khong dn can thi~p them va da s6
kh6ng c6 tac dmg phl.
Di~u tri ngoli khoa
Trong dibu tri c6 di~n TNTCSMLT, gfin nlnr dbu phai dt tlr cung vi phfrn l&n dbu dugc nong
11?0 vii phau thu~t.
Nong m;o: hi~n nay chi nen ap dlng trong m9t s6 nh6 truong hgp khi da c6 PHCG < 2.000
UI/I ho?c sau khi dibu tri MTX va PHCG < 2.000 UI/1va kh6i thai kh6ng giam kich thu&c.
Nong n;10 khong nen la di€u tri d~u tien vi co nguy ca thung tir cung va xm1t huySt 6 (It dn
phau thu~t dp cfru dt rir cung 50%. Vl phfrn l&n gai nhau barn vao ca rir cung nen khi nong
n(lo lfry t(1i thai ra c6 th~ lam tht'.mg rir cung va t6n thuang bang quang gay xu§t huySt nhi€u
nguy hi~m tfnh m(lng dn phau thu~t dp cru.
Phfiu tlrn{it: cac tnrong hgp huySt dc)ng kh6ng 6n djnh, xu§t huySt nhi€u c6 choang hay
kh6ng ho?c tu6i thai tren 16 tu§.n, thai s6ng c6 nguy ca va s~o tt'.r cung dn can thi~p phau
thu~t mo bmg dt b6 kh6i thai va bao t6n rir cung nSu dugc, n€u khong dugc phai dt tlr cung
hoan toan vi nguy ca chay mau nhibu. Phau thu~t dt kh6 khan vi kh6i nhau c6 th~ xam I§n
bang quang va dn duc;rc chu~n bi mau, djch truy€n dn thiSt. C6 tac gia cho r~ng phfo thu~t
d~ tranh tai phat lfrn c6 thai sau nho c~t b6 s(;!o cu vit may i(li ca tir cung.Tuy nhien khi xen
kh6i thai van gay ra dfnh va anh hu&ng dSn kha nang mang thai. Phau thu~t chi thvc sv danh
cho cac tnrang hgp duqc chi djnh, nhung phau thu~t khong c6 gia tri ngira tai phat
TNTCSMLT.
N<)i soi bu6ng tfr cung quan sat bu6ng tlr cung cung Jue xe va hUt kh6i thai qua n9i soi 6
bmg (Lee).
Ph6i hQ'P nhi~u ky thu~t
Tl1y theo mfrc phrc t(lp ct'.1a TNTCSMLT da c6 nhi€u bi~n phap di€u trj ph6i hgp d€ c6 k€t
qua t6t, phuang phap ph6i hgp theo rimg tmong hgp.
MTX f(li chB sau £16 11011g 11(10'. Nong n(IO chi ap dmg cho cac truong hgp 6n djnh, PHCG <
2.000Ul/l, va kh6i thai van kh6ng giam kfch thu&c sau MTX.
MTX t(li chB/to<ln th/in va th11ye11 t&c apng m(lch tll' cung (TTDMTC) . Co hi~u qua cao
trong cac tnrong hgp kh6i thai to c6 nhibu m(lch mau tang sinh..E>~c bi~t TTE>MTC hi~u qua
cho cac truimg hgp rong huy€t keo diti sau dibu trj MTX, kh6i thai da giam kfch thu&c va
PHCG giam v€ mrc binh thuang nhung kh6ng hSt tri~u chrng rong huy€t va cac truang hgp
c6 th€ t6n t(li thong d<)ng tinh m(lch vung s(;!o, va sau thuyen t~c d<)ng m(lch tir cung c6 k€t qua
tot.
Thuyen t&c apng m(lclt tlr cung va phflu t/111{it, nh~m hln ch€ chay mau (Yang va Yeng) thvc
hi~n cl19n l9c tru&c phau thu~t d€ giam tai bi€n va bilo t6n kha nang sinh san.
168

7. Thai ngoai til' cung 6' seo mb l~y thai
Chir dqi khong can thi~p vil theo doi
V&i TNTCSMLT Iii thai luu nh6 hon 8 tu5n, t6ng trlng 6n djnh, v&i ~HCG < l.000 Ul/l giam
d~u, chi dn theo doi. Khong dn can thi~p kh6i thai se (r h1y theo th6i gian viii tu5n t&i viii
thang. N€u ~HCG tang l1,1i h3.y khong giam d n can thi~p n<)i khoa hay ngoli khoa t(1y tirng
truong hqp. N€u dn c6 th~ dn n<)i soi bu6ng ttr cung danh gia l1,1i sang tlnrang.
Tnrcrng hqp TNTCSMLT va thai s6ng phat tri€n hu&ng vito bu6ng ttrcung, c6 th€ ct€theo
doi t&i khi thai tnr&ng thimh. Tien lm;mg thucmg pht'.rc t1,1p, vi se phat tri&n nhau citi rang luge
vii nhau barn thftp dn can thi~p chu d<)ng tnr&c chuy€n d1,1.
Th~n trQng trong tham kham, cham soc
Kh6i TNTCSMLT thuong kh6 phat hi~n tren lam sang, n€u tham kham nwnh tay c6 nguy ca
lam va vii xuftt huy€t 6 1,11 din philu thu~t dp cuu. B~nh nhan cling din duqc d~n do di lli nhy
nhang, khong nen clwy nhay, th€ tlmo, ho1,1t d<)ng nwnh vi c6 th€ lam vo· kh6i TNTCSMLT,
hay kh6i mau 11 con 1611 t1,1i kha lau sau di~u trj n<)i khoa.
Danh gia sau di~u tri
B~nh nhan duqc theo doi hang twin v€ lam sang vii flhCG cho t&i kJ1i khong con do duqc.
Sieu am theo doi m6i thang t&i kJ1i kJ16i thai bi~n mitt. flhCG tr& v~ binh tlnr6ng khoang 6 - I0
tuftn sau di~u trj t1,1i ch6 MTX (21-188 ngay) va kJ16i thai dn 2 thang t&i I nam sau MTX m&i
bi€n mitt tren sieu am Vi nhau cai trong 1110 SyO XO' nen bj hitp thu ritt ch~m.
MQT SO VAN DE CAN LUU YTRONG TNTCSMLT
Theo doi de tmimg hQ'P nguy CO' cao
Hi~n nay v6i ti€n b<) cua sieu am d§u do am d1,10 vii bam djch, cac t6n tlnrang vach tfr cung c6
th~ phat hi~n ngay tir l(1c clma c6 thai. Syo bi kJ1i€m khuy~t khi thfty c6 ke h& athimh tn.r&c ttr
cung hay khi l&p ca tfr cung day kh6ng b~ng 50% cua ca ttr cung c1,1nh SyO (Jurkovic). Khi€m
klmy€t n~ng chi€m 10% cac tnr6ng hqp 1116 Jity thai (Kirshna).
Si'ra s~o MLT bi hO·
Sua chiia SyO MLT tnr&c khi cho mang thai l1,1i se mitt nhiSu Ifin ph~u thu~t vii rftt 1611 kem
chua k€ n€u thIc hi~n philu thu~t sfra chiia c6 th€ g~p tai bi€n nhu SyO ch~m litnh, dinh, va c6
khi phai dt tfr cung. Han niia, sfra SyO cling khong ngfra duqc va tfr cung Jue chuy~n d1,1. Philu
thu~t stra Syo chi thIc SI dn thi€t trong m9t s6 nh6 tnr6ng hqp da bi tai phat TNTCSMLT vii
nhiing tru6ng hqp bi ho r(lng syo 1116 lfty thai. Hi~n nay da c6 m<)t s6 tac gia thanh c6ng sfra
SyO qua n<)i soi budng tfr cung.
Tranh hO' s~o bllng ky thu~t may co· tii' cung
Babu vii Gagon da ct€xuftt ky thu~t may l&p ca !tr cung trong MLT, v&i ky thu~t nay se plwc
hdi cac J&p thanh tfr cung tranh duqc khe ha khi Jimh SyO.
169

8. SAN KHOA
Co thai sau TNTCSMLT
B~nh nhiin da bi TNTCSMLT dn dugc hu6ng d~n khi c6 thai lftn sau nen sieu am s6m d~
xac dinh c6 thai trong tlr cung. Khi b~nh nhan c6 thai l?i nen m6 chu d<)ng khi ph6i thai da
tm6ng thanh. Ph1,1 nfr da bi TNTCSMLT c6 thai l?i ciing phai dugc theo doi dn th~n kha
nang nhau cai rang luge c6 th~ xay ra. NSu c6 dn thvc hi~n m6 liy thai va c~t tlr cung khi
tu6i thai 32 t&i 34 tuftn (Seow).
Sau TNTCSMLT, 76% c6 thai l(li, 88% c6 thai tv nhien trong d6 95% thai trong tlr cung
binh thuerng va tai phat thip chi 5%. Sau d6 65% phat tri~n binh thu6ng (35% sdy thai) va m6
I§.y thai 69% (Ben Nagi).
Trong TTTON nen chuy€n phoi vao sau han !6 trong c6 tlr cung 2: 4 cm d€ tranh
TNTCSMLThay TNTC tren c6 h'r cung (Soew).
NSu mang thai xay ra nen sanh m6 chu d<)ng khi ph6i thai nhi da du tru6ng thanh vi Jue
nay kha nang dan h6i cua S!O m6 Iiy thai khong dan kip v&i phat tri~n nhanh cua tlr cung
trong 3 thang cu6i thai ky.
Ngira thai sau TNTCSMLT
Benh nhan khong dugc mang thai sau TNTCSMLT it nhit 12 t&i 24 thang. C6 th€ dung thu6c
ngira thai vien phbi hqp ho~c Depoprovera lo(li tiem 1-3 thang.
KETLU~N
V&i cac xet nghiem va sieu am hi~n nay giup chdn doan s6m va chinh xac TNTCSMLT nher
d6 hu6ng dSn dieu trj hieu qua, duy tri kha nang sinh san. Da s6 tac gia chip nh~n ket thuc
thai k)' ngay khi da c6 chdn doan chinh xac. Cach dieu trj it tai bien nhit la dung MTX tiem
t;,ii ch6 vao thai va quanh kh6i thai +toan than. Khuynh hu6ng MLT cang ngay cang tang, thi
kha nang TNTCSMLT ciing tang theo. Phat hien s6m va dieu tri b:io t6n khong phai Jue nao
ding d;,it kSt qua tbi uu do d6 v~n de ca ban la lam the nao d~ giam dugc cac nguy ca d~n dSn
TNTCSML.
170

9. Thai ngoai tU> cung O> seo mo l~y thai
TAI ut:u THAM KHAO
I. Babu KM., Magon N. Uterine closure in cesarean delivery: a new technique, N Am J
Med Sci. 2012 August; 4(8): 358-361.
2. Ben Nagi J, Helmy S, Ofili-Yebovi D, Yazbek J, Sawyer E, Jurkovic D. Reproductive
outcomes of women with a previous history of Caesarean scar ectopic pregnancies.
Hum Reprod 2007; 22:2012-2015.
3. Fylstra DL, Pound-Chang T, Miller MG, Cooper A, Miller KM. Ectopic pregnancy
within a cesarean delivery scar: a case report. Am J Obstet Gynecol 2002; 187:302-
304.
4. Godin PA, Bassil S and Donnez J, An ectopic pregnancy developing in a previous
caesarian section scar. Fertil Steril, 1997, 67, 398-400.
5. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester
diagnosis and management of pregnancies implanted into the lower uterine segment
Cesarean section scar. Ultrasound Obstet Gynecol 2003; 21:220- 227.
6. He1111an A, Weinraub Z, Avrech 0, Maymon R, Ron-El Rand Bukovsky Y, Follow
up and outcome of isthmic pregnancy located in a previous caesarean section scar. Br
J Obstet Gynecol, 1995,102, 839-841.
7. Krishna S.,James E. S., Cesarean Section Scar Diverticulum: Appearance on
Hysterosalpingography, AJR, 2008; 190:870-874.
8. Larsen N , Solomon MH: Pregnancy in a uterine scar sacculus-an unusual cause of
postabortal haemorrhage. A case report. S Afr Med J 53(4): 142, 1978 Maymon, et all;
Fertility performance and obstetric outcomes among women with previous cesarean
scar pregnancy, J. Ultrasound Med. 2011;30:1179-1184.
9. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology,
diagnosis, and management. Obstet Gynecol 2006; 107: 1373- 1381.
10. Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar
pregnancy: issues in management. Ultrasound Obstet Gynecol 2004; 23:247-253.
11. Shih JC, Cesarean scar pregnancy: diagnosis with three-dimensional (3D) ultrasound
and 3D power Doppler ultrasound. Obstet Gynecol, 2004, 23, 306-307.
12. Shinagawa S and Nagayama M, Cervical pregnancy as a possible sequela of induced
abortion. Report of 19 cases. Am J Obstet Gynecol, 1969, 105, 282- 284.
13. Sugawara J., Senoo M., Chisaka H., Yaegashi N., Okamura K. Tohoku, Successful
Conservative Treatment of a Cesarean Scar Pregnancy with Uterine Artery
Embolization, J Exp Med, 1997,Vol.206;No.3;p261-265.
14. Timar-Tritsch. Early placenta accreta and cesarean section scar pregnancy: a review. Am J
Obstet Gynecol 2012.
15. Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet
Gynecol 2000; 16:592- 593.
171

10. SAN KHOA
172
16. Valley MT, Pierce JG, Daniel TB and Kaunitz AM, Cesarean scar pregnancy: imaging
and treatment with conservative surgery. Obstet Gynecol, 1998, 91, 838-840.
17. Yang MJ and Jeng MH, Combination of transarterial embolization of uterine arteries
and conservative surgical treatment for pregnancy in a cesarean section scar. J Reprod
Med, 2003,48, 213-216.
I8. Williams Obstetrics, 23ed 2010, Ch IO. Ectopic Pregnancy.