Benign Hematological Disorders

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Epistaxis in Children

12

Õ¿‘™“µ‘‚æ∏Õ‘–

ªí≠À“‡≈◊Õ¥°”‡¥“ÕÕ°„π‡¥Á° ‡ªìπªí≠À“∑’Ë ≈°—…≥–°“¬«¿‘“§¢Õß‚æ√ß®¡°Ÿ
æ∫‰¥â∫àÕ¬„π‡«™ªØ‘∫—µ‘ ´Ë÷ß∑”„ÀâºâŸªÉ«¬‡ ’¬‡≈◊Õ¥ ‚æ√ß®¡Ÿ° ‡ªìπ∫√‘‡«≥∑’Ë¡’‡≈◊Õ¥¡“‡≈’Ȭ߇ªìπ
·≈–‡°‘¥Õ—πµ√“¬µ“¡¡“‰¥â °“√´—°ª√–«—µ‘·≈–°“√ ª√¡‘“≥¡“° ∑ßÈ—Ωßòíºπß—¢“âß®¡°Ÿ (lateral nasal wall)
µ√«®‡æ◊ËÕ·¬°«à“‡≈◊Õ¥°”‡¥“∑Ë’ÕÕ°πÈ—π ÕÕ°¡“®“° ·≈–ºπß—°πÈ—™Õàß®¡°Ÿ (nasal septum) ‚¥¬ºπß—¢“âß
 à«π„¥„π‚æ√ß®¡Ÿ°¡’§«“¡ ”§—≠„π°“√«“ß·ºπ ®¡Ÿ° (lateral nasal wall) ¡’ à«π¢Õß°√–¥Ÿ°
°“√√—°…“‡æ◊ËÕÀ¬ÿ¥‡≈◊Õ¥°”‡¥“‰¥âÕ¬à“ß∂Ÿ°µâÕß ¬πË◊ ÕÕ°¡“ 3 ™πÈ‘ ‡√¬’°«“à turbinate À√Õ◊ concha
·≈–‡À¡“– ¡ ∫“ß√“¬Õ“®®”‡ªìπµâÕߪ√÷°…“‚ µ ‡√¬’ßµßÈ—·µ¥à“âπ∫π≈ß¡“≈“àߧÕ◊ superior, middle ·≈–
»Õ π“ ‘°·æ∑¬å ‡æ◊ËÕ„Àâ°“√√—°…“Õ¬à“ß∑—π∑à«ß∑’ inferior turbinate µ“¡≈”¥∫— „π·µ≈à– turbinate
Õ°’¥«â¬ ®–¡‡’¬ÕË◊ ∫®ÿ¡°Ÿª°§≈¡ÿÕ¬àŸ°“√¡’turbinate π®’È–™«à¬
‡æ¡‘ËæπÈ◊ ∑º’Ë«‘¢Õß‚æ√ß®¡°Ÿ¢π÷ÈÕ°’ª√–¡“≥ 150-200
Õÿ∫—µ‘°“√≥å ≈∫.´¡. ´÷Ëß°“√∑Ë’¡’æ◊Èπ∑’˺‘«‡æ‘Ë¡®–™à«¬„ÀâÕ“°“»

ªí≠À“‡≈◊Õ¥°”‡¥“ÕÕ°æ∫‰¥â∫àÕ¬„π Õß À√◊Õ≈¡À“¬„® —¡º— °—∫‡¬Ë◊Õ∫ÿ®¡Ÿ°‰¥â¡“°¢È÷π ∑”„Àâ
™«àßÕ“¬ÿ§Õ◊ ™«àß«¬—‡¥°Á Õ“¬πÿÕ⬰«“à 10 ªï·≈–«¬— Õ“°“»∑ÀË’“¬„®‡¢“≪¡§’«“¡Õπàÿ ™¡ÿà™π◊È ·≈– –Õ“¥
º„âŸÀ≠àÕ“¬‡ÿ°π‘ 50 ª1ï „πª√–‡∑»‰∑¬¡°’“√»°÷…“ ¡“°¢π÷È ·≈–¬ß—™«à¬„π°“√§¡ÿ°“√‰À≈‡«¬’π¢ÕßÕ“°“»
¢Õß Chaiyasate2 ·≈–§≥–æ∫«à“ ‡≈◊Õ¥°”‡¥“ ‚¥¬°“√¢¬“¬·≈–¬ÿ∫µ—«¢ÕßÀ≈Õ¥‡≈◊Õ¥ ∑Ë’Õ¬Ÿà„µâº‘«
ÕÕ°æ∫‰¥â∫àÕ¬„π‡æ»™“¬¡“°°«à“‡æ»À≠‘ß ‚¥¬ ‡¬Õ◊Ë∫®ÿ¡°Ÿ °≈“૧Õ◊ ‡¡Õ◊Ëturbinate¢¬“¬µ«—¢πÈ÷®–∑”„Àâ
æ∫Õ“¬ÿµ—Èß·µà12 ªï∂÷ß 87 ªïæ∫‰¥â∫àÕ¬„π™à«ß airflow ≈¥≈ß „π∑“ßµ√ß°π—¢“â¡ ‡¡Õ◊Ë turbinate ¬∫ÿ
‡¥◊Õπ¡°√“§¡ ∂÷߇¥◊Õπ‡¡…“¬π ‡πË◊Õß®“°„π™à«ß µ«—≈ß°®Á–∑”„Àâairflow ‡æ¡‘Ë¡“°¢πÈ÷ ™ÕàßÀ√Õ◊ ‚æ√ß„µâ
ƒ¥ÀŸπ“«µÕàƒ¥√ŸÕâ𠇪πì ™«àß∑Õ’Ë“°“»„πª√–‡∑»‰∑¬ turbinate ‡√¬’°«“à meatus ´ßË÷¡™’ÕË◊ ‡√¬’°‡™πà‡¥¬’«°π—
¡’§«“¡™È◊π —¡æ—∑∏åµË” ∑”„ÀâÕ“°“»·Àâß ®÷߇°‘¥ °∫— turbinate ππÈ—Ê ‰¥·â°àsuperior, middle ·≈–
‡≈Õ◊ ¥°”‡¥“ÕÕ°‰¥∫â Õର«“à™«à߇¥Õ◊ πÕπË◊ ´ßË÷µ√ß°∫— inferior meatus ¡§’«“¡ ”§≠— ‡πÕË◊ ß®“°®–¡√’‡Ÿª¥î
°“√»°÷…“„πµ“àߪ√–‡∑»¢Õß Pollice3 ·≈–§≥– ∑Ë’ ¢ÕßÕ«¬—«–¢“â߇§¬’ß∑ Ë’”§≠— §Õ◊ ‰´π — ¡“‡ª¥î ‡æÕ◊Ë
æ∫∫Õ଄π‡æ»™“¬¡“°°«“à‡æ»À≠ß‘ ·≈–æ∫„π™«àß ∂“ଇ∑Õ“°“»À√Õ◊  “√§¥—À≈ßË—4, 5
Õ“¬ÿ10 ªï·≈– 55 ªï‰¥∫â Õର«“à™«àßÕ“¬ÕÿπË◊

180 Õ¿‘™“µ‘‚æ∏Õ‘–

Superior meatus ¡’√Ÿ‡ªî¥¢Õß posterior ∫π·≈– «àπÀ≈ß—¥“âπ∫π¢Õߺπß—¢“âß®¡°Ÿ ·≈– «àπ
ethmoid sinus ¢Õߺπß—°π—È™Õàß®¡°Ÿ´ß÷ˇªπì  «à𠔧≠— ∑‡Ë’≈Õ◊ ¥°”‡¥“
Middle meatus ‡ªπì ∫√‡‘«≥∑¡’˧’«“¡ ”§≠— ®–ÕÕ°®“° «àππ‰È’¥∫â ÕଠπÕ°®“°π¬È’ß—„À·â¢π߇ªπì
„π欓∏ ‘√√’«∑‘¬“¢Õß‚√§‰´π — ‡πÕË◊ ß®“°¡√’‡Ÿª¥î¢Õß supraorbital ·≈– supratrochlear artery ‡≈’Ȭß
‰´π —À≈“¬‰´π —¡“‡ª¥î‡¢“â ‡™πà frontal, anterior  «àπ¢Õß frontal sinus Õ°’¥«â¬
ethmoid ·≈– maxillary sinus ´ß÷Ë∫√‡‘«≥π¡’È ’«àπ À≈Õ¥‡≈◊Õ¥ external carotid ‚¥¬ºà“π
¢Õß°√–¥°Ÿ·≈– «àπ¢Õ߇¬ÕË◊ ∫∑ÿ‡Ë’√¬’°«“àosteomeatal ∑“ß internal maxillary artery ´ß÷Ë®–„À·â¢πß∑ Ë’”§≠—
complex ∂“⡧’«“¡º¥‘ª°µ®‘–∑”„À¡â°’“√‰À≈‡«¬’π §Õ◊ sphenopalatine artery ∑Õ’ËÕ°¡“®“° spheno-
Õ“°“»·≈– “√§¥—À≈ߗˉ¡¥à∑’”„À‡â°¥‘¿“«–‰´π —Õ°—‡ ∫ palatine foramen ‡≈’Ȭߥâ“πÀ≈—ߢÕß®¡Ÿ° ∑È—ß
(sinusitis) µ“¡¡“‰¥â  «àπ¢Õߺπß—°πÈ—™Õàß®¡°Ÿ ·≈–ºπß—¥“âπ¢“âߢÕß®¡°Ÿ
Inferior meatus ¡’√Ÿ‡ªî¥¢Õß∑àÕπÈ”µ“ ‡°◊Õ∫∑È—ßÀ¡¥ ´Ë÷߇ªìπÀ≈Õ¥‡≈◊Õ¥¢π“¥„À≠à∑Ë’¡’
(nasolacrimal duct) ∑”Àπ“â∑∂’˓ଇ∑πÈ”µ“ÕÕ°‰ª §«“¡ ”§—≠Õ¬à“ß¡“° ”À√—∫°“√ºà“µ—¥„π‚æ√ß®¡Ÿ°
∑“ß‚æ√ß®¡Ÿ° ºâŸªÉ«¬∫“ß√“¬¡’·ºàπ‡¬◊ËÕ‡¡◊Õ°ªî¥Õ¬Ÿà ·≈–„π√“¬∑’ˇ≈◊Õ¥°”‡¥“ÕÕ°®“°∑“ߥâ“πÀ≈—ß
‡√¬’°«“à valve of hasner À√Õ◊ plica lacrimalis (posterior epistaxis) ¡—°ÕÕ°®“°·¢πߢÕß
´÷Ëß¡’§«“¡ ”§—≠‡πË◊Õß®“°‡ªìπ™àÕß∑“߇™◊ËÕ¡√–À«à“ß À≈Õ¥‡≈◊Õ¥π’È∑Ë’®–¡“√«¡°—π‡ªìπ√à“ß·À∑Ë’ à«π¥â“π
™Õàß‚æ√ß®¡°Ÿ°∫— maxillary sinus ‡æÕË◊ √–∫“¬ÀπÕß À≈—ߢÕß inferior ·≈– middle meatus ‡√’¬°«à“
À√Õ◊ °“√µ¥‘‡™Õ◊È ∑‡Ë’√¬’°«“à inferior antrostomy Õπ— nasopharyngeal plexus À√Õ◊ Woodruffûs plexus
Õ“®∑”„À⇰‘¥¿“«–·∑√°´âÕπ§◊Õ°“√∑”„Àâ√Ÿ‡ªî¥¢Õß πÕ°®“°πÈ’À≈Õ¥‡≈Õ◊ ¥ external carotid ¬ß—
∑Õàπ”ȵ“Õ¥ÿµπ— (nasolacrimal duct obstruction) „Àâ·¢πß∑Ë’ ”§—≠Õ’°·¢πßÀπË÷ߧ◊Õ superior labial
ºπß—°πÈ—™Õàß®¡°Ÿ (nasal septum) ·∫ßà°π—È artery ¡“‡≈’Ȭߠà«π¥â“πÀπâ“¢Õߺπ—ß°—Èπ™àÕß®¡Ÿ°
‚æ√ß®¡Ÿ°ÕÕ°‡ªìπ 2 ¢â“ß ‚¥¬¡’ à«πª√–°Õ∫∑Ë’ ‚¥¬„π∫√‘‡«≥ à«πÀπâ“¢Õߺπ—ß°È—π™àÕß®¡Ÿ°‡ªìπ
 ”§—≠§◊Õ°√–¥Ÿ°ÕàÕπ (septal cartilage) ´Ë÷ßÕ¬Ÿà  à«π∑Ë’¡’À≈Õ¥‡≈◊Õ¥·¥ß¡“ª√– “π°—π‡ªìπ√à“ß·À
¥“âπÀπ“â ¥ÿ ·≈–°√–¥°Ÿ·¢ßÁ(perpendicular plate) ‚¥¬¡·’¢πß∑ßÈ—®“° anterior ethmoidal, superior
¢Õß°√–¥Ÿ° ethmoid ∑—Èß Õß à«π®–∂Ÿ°§≈ÿ¡¥â«¬ ethmoidal, sphenopalatine ·≈– greater palatine
‡¬Õ◊Ë∫∑ÿ“߇¥π‘À“¬„® (respiratory mucosa) ¬°‡«πâ artery ‡√¬’°«“à Kiesselbachûs plexus À√Õ◊ littleûs
 «àπ¥“âπÀπ“â ¥ÿ 2-3 ¡¡. ‚¥¬¡º’«‘Àπß— (squamous area ´÷Ë߇ªìπµ”·Àπàß∑’ˇ≈◊Õ¥°”‡¥“ÕÕ°®“°∑“ß
epithelium) §≈ÿ¡ ´÷Ëߺπ—ß°È—π®¡Ÿ°¡’§«“¡ ”§—≠ ¥â“πÀπâ“ (anterior epistaxis) ‰¥â∫àÕ¬∑Ë’ ÿ¥ ¥—ß
µÕà°“√‰À≈‡«¬’π¢ÕßÕ“°“»‡¢“â¡“„π‚æ√ß®¡°Ÿ6, 7 · ¥ß„π√ªŸ∑’Ë12.1
À≈Õ¥‡≈◊Õ¥∑Ë’¡“‡≈’Ȭ߂æ√ß®¡Ÿ°‰¥â¡“®“°∑È—ß
®“°À≈Õ¥‡≈Õ◊ ¥ external ·≈– internal carotid „π µ”·Àπàß∑Ë’æ∫‡≈◊Õ¥°”‡¥“‰À≈  “¡“√∂·∫àß
√–∫∫À≈Õ¥‡≈Õ◊ ¥·¥ß ´ß÷Ë “¡“√∂®”·π°‰¥¥âß—πÈ’ ÕÕ°‰¥â‡ªìπ
À≈Õ¥‡≈Õ◊¥ internal carotid ‚¥¬º“àπ∑“ß 1. ‡≈◊Õ¥°”‡¥“ÕÕ°®“°¥â“πÀπâ“¢Õß‚æ√ß
ophthalmic artery ∑„Ë’À·â¢π߇ªπì anterior ·≈– ®¡°Ÿ (anterior epistaxis) æ∫‰¥¡â“°°«“à√Õâ¬≈–
posterior ethmoidal artery ‡≈’Ȭߠà«πÀπâ“¥â“π 90 ¢Õ߇≈◊Õ¥°”‡¥“‰À≈∑—ÈßÀ¡¥ ‚¥¬¡—°æ∫∫àÕ¬„π

ªí≠À“‡≈◊Õ¥°”‡¥“ÕÕ°„π‡¥°Á Epistaxis in Children 181

ºªŸâ «É¬‡¥°Á·≈–«π—√πÿà ∑¡Ë’ª’√–«µ—·‘§–®¡°ŸÀ√Õ◊ ¡ª’√–«µ—‘ plexus À√◊Õ littleûs area5 µ”·Àπàߥ—ß°≈à“«
‡¬Õ◊Ë∫®ÿ¡°ŸÕ°—‡ ∫  «àπ¡“°‡≈Õ◊ ¥¡°—ÕÕ°®“°∫√‡‘«≥  “¡“√∂¡Õ߇ÀÁπ‰¥âßà“¬®“°°“√µ√«®‚æ√ß®¡Ÿ°®“°
ºπ—ß°È—π®¡Ÿ°¥â“πÀπâ“ ´Ë÷߇ªìπµ”·Àπàß∑’Ë¡’À≈Õ¥ ∑“ߥ“âπÀπ“⠥ߗ· ¥ß„π√ªŸ∑Ë’12.2
‡≈◊Õ¥¡“√«¡°—π‡ªìπ√à“ß·À‡√’¬°«à“ Kiesselbachûs

√Ÿª∑Ë’12.1 °“¬«‘¿“§·≈–À≈Õ¥‡≈◊Õ¥ ”§—≠„π‚æ√ß®¡Ÿ° (ÕÕ°·∫∫·≈–«“¥‚¥¬ §ÿ≥«—π«‘ “¢å»√’æ‘π‘®)

√ªŸ∑’Ë12.2 ¿“«–‡≈Õ◊ ¥°”‡¥“ÕÕ°®“°¥“âπÀπ“â¢Õß‚æ√ß®¡°Ÿ (anterior epistaxis)
(ÕÕ°·∫∫·≈–«“¥‚¥¬ §≥ÿ «π—« ‘“¢å»√æ’π‘®‘)

182 Õ¿‘™“µ‘‚æ∏‘Õ–

√ªŸ∑Ë’12.3 ¿“«–‡≈Õ◊ ¥°”‡¥“ÕÕ°®“°¥“âπÀ≈ß—¢Õß‚æ√ß®¡°Ÿ (posterior epistaxis)
(ÕÕ°·∫∫·≈–«“¥‚¥¬ §≥ÿ «π—« ‘“¢å»√æ’π‘®‘)

2. ‡≈◊Õ¥°”‡¥“ÕÕ°®“°¥â“πÀ≈—ߢÕß‚æ√ß ·√ß°√–·∑°∑’Ë®¡Ÿ° (´Ë÷ßÕ“®¡’°√–¥Ÿ°¢Õß®¡Ÿ°·µ°
®¡°Ÿ (posterior epistaxis) æ∫‰¥πâ Õ⬰«“à ·≈– À°—√«à¡¥«â¬À√Õ◊ ‰¡°à‰Á¥)â °“√º“൥—„π‚æ√ß®¡°Ÿ ‡™πà
¡—°æ∫„πºâŸªÉ«¬∑Ë’¡’‚√§ª√–®”µ—« ‡™à𠧫“¡¥—π °“√º“൥—‡¬Õ◊Ë∫®ÿ¡°Ÿ °“√º“൥—ºπß—°πÈ—™Õàß®¡°Ÿ °“√
‚≈À‘µ Ÿß À√Õ◊ ¡‡’πÕ◊ÈßÕ°„π‚æ√ßÀ≈ß—®¡°Ÿ ‚¥¬‡≈Õ◊ ¥ º“൥—‚æ√߉´π — °“√„ ∑à Õà™«à¬À“¬„®º“àπ∑“ß®¡°Ÿ
°”‡¥“∑ÕË’Õ°¡—°ÕÕ°®“°¥â“πÀ≈—ߢÕß‚æ√ß®¡Ÿ°„π °“√„™¬â“ ‡µ¬’√Õ¬¥æå π஡°Ÿ (topical nasal steroid)
∫√‡‘«≥∑À’Ë≈Õ¥ ‡≈Õ◊ ¥¡“√«¡°π—‡ªπì√“àß·À‡√¬’°«“àna- À√◊Õ Ÿ¥¥¡‚§‡§π‡ªìπ√–¬–‡«≈“π“π °“√ Ë—ßπÈ”¡Ÿ°
sopharyngeal plexus À√Õ◊ Woodruffûs plexus5 ·√ßÊ À√◊Õ¡’°“√‡ª≈Ë’¬π·ª≈ߧ«“¡°¥Õ“°“»Õ¬à“ß
´Ë÷ßµ”·Àπàߥߗ°≈“૵√«®æ∫‰¥¬â“°°«“à ·≈–®”‡ªπì √«¥‡√«Á ‡™πà √–À«“àߢπÈ÷‡§√ÕË◊ ß∫π‘ À√Õ◊ ¥”πÈ” ‡ªπì µπâ
µÕâßÕ“»¬—°“√  Õàß°≈Õâßµ√«®„π‚æ√ß®¡°Ÿ‚¥¬ ‚ µ »Õ “‡Àµÿ¥—ß°≈à“«πÈ’®–∑”„Àâ‡≈◊Õ¥ÕÕ°‡πË◊Õß®“°¡’°“√
π“ °‘·æ∑¬åÕ¬“àß≈–‡Õ¬’¥ ¥ß—· ¥ß„π√ªŸ∑’Ë12.3 ©°’¢“¥¢Õ߇¬ÕË◊ ∫‚ÿæ√ß®¡°Ÿ ‡≈Õ◊ ¥∑Õ’ËÕ°¡°—¡ª’√¡‘“≥
‰¡à¡“° ‡ªìπ√–¬–‡«≈“ È—πÊ °“√∫“¥‡®Á∫∫√‘‡«≥
 “‡Àµÿ¢Õ߇≈Õ◊¥°”‡¥“‰À≈ »√’…–·≈–„∫Àπ“âÕ¬“àß√πÿ·√ß (´ßË÷Õ“®‚¥π∑®Ë’¡°Ÿ‚¥¬

‡√“ “¡“√∂®”·π° “‡Àµ¢ÿÕ߇≈Õ◊ ¥°”‡¥“‰À≈ µ√ßÀ√Õ◊ ‚æ√߉´π —) ®–∑”„À‡â≈Õ◊ ¥ÕÕ°®“°®¡°Ÿ‡ªπì
ÕÕ°‰¥‡âªπì 2  “‡Àµ„ÿÀ≠‰à¥·â°à ª√‘¡“≥¡“°„π√–¬–·√°‰¥â ·µà∂â“¡’‡≈◊Õ¥ÕÕ°®“°
1. “‡Àµ‡ÿ©æ“–∑†’ˉ¥·â°à ®¡°ŸÀ≈ß—®“°°“√∫“¥‡®∫Á„π√–¬–‡«≈“‡ªπì  ª—¥“Àπå πÈ—
†† 1.1 °“√√–§“¬‡§◊Õß À√◊Õ∫“¥‡®Á∫∫√‘‡«≥ §«√π°÷∂ß÷À≈Õ¥‡≈Õ◊ ¥‚ªßÉæÕß∑‡’Ë°¥‘®“°Õ∫ÿµ—‡‘Àµ¥ÿ«â¬
®¡Ÿ° ‡™àπ °“√·§–®¡Ÿ°∫àÕ¬®πµ‘¥‡ªìππ‘ —¬ ºâŸ∑’Ë¡’ à«π¿“«–Õ“°“»Àπ“« §«“¡™È◊πµ”Ë ®–∑”„À⇬◊ËÕ∫ÿ
π‘ —¬™Õ∫·§–®¡Ÿ°¡—°®–¡’π”È¡Ÿ°·Àâß°√—ß ‡¡◊ËÕ·§– ®¡Ÿ°·Àâß ·≈–¡’·π«‚πâ¡∑Ë’®–∑”„Àâ¡’°“√√–§“¬‡§◊Õß
ÕÕ°®–‡°‘¥·º≈∂≈Õ° ·≈–Õ“®‡ªìπ·º≈‡√◊ÈÕ√—ß‚¥¬ ∑”„À‡â≈Õ◊ ¥ÕÕ°‰¥ßâ“à¬
‡©æ“– «àπ¥“âπÀπ“â¢Õߺπß—°π—È™Õàß®¡°Ÿ °“√‰¥√â∫— † 1.2 °“√Õ°—‡ ∫„π‚æ√ß®¡°Ÿ ‡™πà ®“°°“√

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µ‘¥‡™◊ÈÕ‰«√—  ‚√§®¡Ÿ°Õ—°‡ ∫¿Ÿ¡‘·æâ ‰´π— Õ—°‡ ∫ ª√¡‘“≥¡“°§«√‰¥√â∫—°“√ Õàß°≈Õâßµ√«®„π‚æ√ß®¡°Ÿ
(rhinosinusitis)  Ë‘ß·ª≈°ª≈Õ¡„π®¡Ÿ° °“√ À√◊Õ‰¥â√—∫°“√µ√«®∑“ß√—ß ’«à“¡’‡πÈ◊ÕßÕ°‡ªì𠓇Àµÿ
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µàÕ¡π”ȇÀ≈◊Õß (malignant lymphoma) ¡–‡√Áß æ∫«“à “‡Àµ¢ÿÕß¿“«–‡≈Õ◊ ¥°”‡¥“ÕÕ°„π‡¥°Á √Õâ¬≈–
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184 Õ¿‘™“µ‘‚æ∏Õ‘–

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(¥¥—·ª≈ß®“°‡Õ° “√Õ“âßÕß‘À¡“¬‡≈¢ 15)

186 Õ¿‘™“µ‘‚æ∏Õ‘–

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‡Õ° “√Õ“âßÕß‘ assessment and management. J Fam Pract.
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15. Send T, Bertlich M, Eichhorn KW, Ganschow

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·≈â«≈Õ°À≈ÿ¥ÕÕ°¡“ ‡°‘¥‡ªìπ√Õ∫ª√–®Ì“‡¥◊Õπµ“¡ °“√‡ª≈¬’Ëπ·ª≈ߢÕ߇¬Õ◊Ë∫‚ÿæ√ß¡¥≈°Ÿµ“¡¡“
ª°µ‘ ‡≈◊Õ¥ª√–®Ì“‡¥◊Õπ∑’ˉÀ≈ÕÕ°¡“¿“¬πÕ°„π ŒÕ√‚å¡π∑§Ë’«∫§¡ÿ°“√‡°¥‘ª√–®“̇¥Õ◊ π
¿“«–ª°µ‘®–‡ªìπ ’·¥ß§≈È”„π™à«ß«—π·√° ·≈–„π ŒÕ√å‚¡π∑Ë’§«∫§ÿ¡°“√‡°‘¥ª√–®”‡¥◊Õπ¡’
™à«ß∑⓬∑’˪√–®”‡¥◊Õπ„°≈â®–À¡¥ ‡≈◊Õ¥∑Ë’ÕÕ°®–¡’ À≈“¬™π‘¥ ´÷Ëß “¡“√∂®”·π°µ“¡Õ«—¬«–∑’ËÀ≈Ë—ß
ª√‘¡“≥πâÕ¬≈ß·≈–‡ª≈’ˬπ‡ªìπ ’πÈ”µ“≈ ·≈–Õ“®¡’ ŒÕ√‚å ¡π‰¥Õâ Õ°‡ªπì 3 °≈¡ÿà „À≠à ‰¥·â °à
°≈‘ËπÕ—∫‡≈Á°πâÕ¬‡π◊ËÕß®“°¡’¡Ÿ°®“°ª“°¡¥≈Ÿ°·≈– 1. ŒÕ√å‚¡π∑Ë’À≈Ë—ß®“° ¡Õß  ¡Õß∑Ë’À≈Ë—ß
™Õà ߧ≈Õ¥ªπÕÕ°¡“ ‚¥¬∑«—ˉªª√–®”‡¥Õ◊ π¢Õß µ√’ ŒÕ√‚å ¡π∑„’Ë™§â «∫§¡ÿ√Õ∫ª√–®“̇¥Õ◊ π‰¥·â °à
®–¡ª’√¡‘“≥·≈–√–¬–À“à ߢÕß√Õ∫ª√–®”‡¥Õ◊ π·µ°µ“à ß 1.1 ‰Œ‚ª∑“≈“¡ —(hypothalamus)®–À≈ßË—
°—π„π·µà≈–∫ÿ§§≈ Àπ÷Ëß√Õ∫¢Õߪ√–®”‡¥◊Õπª°µ‘¡’ ŒÕ√‚å ¡π∑‡’Ë√¬’°«“à GnRH (gonotropin releasing
√–¬–‡«≈“ 21-35 «π— °“√π∫—√–¬–À“à ߢÕß√Õ∫‡¥Õ◊ π hormone) ∑”Àπ“â ∑„’Ëπ°“√§«∫§¡ÿ°“√À≈ßË—ŒÕ√‚å ¡π
 “¡“√∂π—∫‚¥¬°“√‡√Ë‘¡π—∫«—π·√°¢Õß°“√¡’ª√–®” FSH ·≈– LH
‡¥Õ◊ π‡ªπì«π—∑ÀË’πßË÷¢Õß√Õ∫‡¥Õ◊ π®π∂ß÷«π— ¥ÿ∑“â ¬°Õà π 1.2 µÕà¡„µ â¡Õß «àπÀπ“â (anterior pitui-
¡’ª√–®”‡¥◊Õπ√Õ∫„À¡à √–¬–‡«≈“¢Õß°“√¡’‡≈◊Õ¥ tary gland) ®–À≈ß—ËŒÕ√‚å ¡π∑¡Ë’º’≈µÕà ‡´≈≈ å ∫◊ æπ—∏åÿ
ª√–®”‡¥Õ◊ πª°µ‘§Õ◊ 3-7 «π— ‡≈Õ◊ ¥ª√–®”‡¥Õ◊ π∑Ë’ §Õ◊ gonadotropin ´ß÷˪√–°Õ∫¥«â ¬ŒÕ√‚å ¡π 2 ™π¥‘
ÕÕ°„π·µ≈à –√Õ∫¡ª’√¡‘“≥ 20-80 ¡≈.1, 2 ·≈–™«à ß ‰¥·â °à
√–À«“à ß√Õ∫‡¥Õ◊ π‰¡§à «√¡‡’≈Õ◊ ¥ÕÕ°°–ª√¥‘°–ª√Õ¬ 1.2.1 FSH (follicular stimulating hor-
∑“ß™àÕߧ≈Õ¥ À“°¡’§«“¡º‘¥ª°µ‘‡°‘¥¢È÷π Õ“®π” mone) ‡ªìπŒÕ√å‚¡π∑Ë’™à«¬°√–µâÿπ„À≢ࡒ°“√‡®√‘≠
‰ª àŸ‚√§∑’Ë¡’§«“¡√ÿπ·√ߵȗ߷µà‡≈Á°πâÕ¬®π∂÷ß¡’§«“¡ ‡µ∫‘‚µ
√πÿ·√ß¡“°µ“¡¡“‰¥â 1.2.2 LH (luteinizing hormone) ‡ªπì
ŒÕ√å‚¡π∑’˙૬„π°“√µ°‰¢à·≈–°“√‡®√‘≠‡µ‘∫‚µ¢Õß
 √’√«∑‘¬“¢Õß°“√‡°‘¥√Õ∫ª√–®“̇¥◊Õπ corpus luteum ´ß÷ˇ°¥‘„π™«à ßÀ≈ß—‰¢µà °

‡¡Ë◊ÕºâŸÀ≠‘߇¢â“ Ÿà«—¬√ÿàπ µàÕ¡„µâ ¡Õß®– √â“ß ŒÕ√‚å ¡π FSH ·≈– LH ®–À≈ß—Ë¡“°À√Õ◊ πÕâ ¬
ŒÕ√å‚¡π‡æ◊ËÕ¡“°√–µâÿπ„Àâ√—߉¢à∑Ì“ß“π ‚¥¬√—߉¢à‡¡◊ËÕ ¢È÷π°—∫°“√§«∫§ÿ¡®“° GnRH ∑’ËÀ≈Ë—ß®“°µàÕ¡„µâ

192 Õ¿™‘“µ‘‚æ∏Õ‘–

 ¡Õß «à πÀπ“â ª√¡‘“≥¢ÕߌÕ√‚å ¡π FSH ·≈– LH ŒÕ√‚å ¡π≈¥≈ß„π™«à ß∑‰’Ë¢µà ° ·µ„à π∑“ß°≈∫—°π— À“°
®–¡’ª√‘¡“≥¡“°πâÕ¬·µ°µà“ß°—π„π·µà≈–™à«ß¢Õß ‰¢‰à ¡‰à ¥√â ∫—°“√º ¡ ®–∑”„À√â –¥∫—ŒÕ√‚å ¡π FSH ·≈–
√Õ∫ª√–®Ì“‡¥◊Õπ ‚¥¬™à«ß‡«≈“∑’Ë¡’ª√‘¡“≥ŒÕ√å‚¡π LH §Õà ¬Ê ≈¥µË”≈ß ®π∑”„Àºâ πß—‡¬Õ◊Ë∫‚ÿæ√ß¡¥≈°Ÿ
LH  ßŸ ¥ÿ (LH surge) ®–µ√ß°∫—™«à ߇«≈“∑‰’Ë¢µà ° §Õà ¬Ê ≈Õ°µ«—·≈–‡°¥‘‡ªπìª√–®”‡¥Õ◊ πµ“¡¡“ ·≈–
(ovulation)3, 4 æÕ¥’ À≈—ß°“√‡°‘¥ª√–®”‡¥◊Õπ √–¥—∫ŒÕ√å‚¡π‡Õ ‚µ√‡®π
2. ŒÕ√‚å¡π∑ÀË’≈ßË—®“°√ß—‰¢à∑„Ë’™„â π°“√§«∫ ®–§Õà ¬Ê  √“â ߇æ¡Ë‘¡“°¢πÈ÷‚¥¬®–¡º’≈µÕà ‡¬Õ◊Ë∫‚ÿæ√ß
§¡ÿª√–®“̇¥Õ◊ 𠉥·â °à ¡¥≈Ÿ°§◊Õ ∑Ì“„À⇬◊ËÕ∫ÿ‚æ√ß¡¥≈Ÿ°¡’°“√ √â“߇πÈ◊Õ
2.1 ŒÕ√‚å¡π‡Õ ‚µ√‡®π (estrogen) §Õ◊ ‡¬ÕË◊ ¢πÈ÷¡“„À¡à ·∑π∑‡’ËπÕ◊ȇ¬ÕË◊ ‡¥¡‘∑ÀË’≈¥ÿ≈Õ°ÕÕ°‰ª
ŒÕ√å‚¡π‡æ»À≠‘ß µ—« Ì“§—≠¢ÕߌÕ√å‚¡π°≈ÿà¡π’ȧ◊Õ „π¢≥–‡¥¬’«°π—ŒÕ√‚å ¡π‡Õ ‚µ√‡®π®–¡º’≈µÕà √ß—‰¢§à Õ◊
‡Õ µ√“‰¥ÕÕ≈ (estradiol) ŒÕ√å‚¡π‡æ»À≠‘ß ∑”„À≢à„∫„À¡à¡’°“√‡®√‘≠‡µ‘∫‚µ∑¥·∑π ´Ë÷ß®–‡ªìπ
ª√–°Õ∫¥«â ¬Õ–µÕ¡¢Õߧ“√∫å Õπ (carbon) ®“Ìπ«π °√–∫«π°“√µÕà ‡πÕË◊ ߇™πà π∑’È°ÿÊ √Õ∫‡¥Õ◊ π ¥ß—· ¥ß
17 µ«— ŒÕ√‚å ¡π‡Õ ‚µ√‡®π¡À’π“â ∑ ’Ë”§≠— ∑“Ì„À‰â ¢∑à ’Ë „π√ªŸ∑Ë’13.1
Õ¬àŸ„π√—߉¢à¡’°“√‡®√‘≠‡µ‘∫‚µ ´÷Ëß„π√—߉¢à¡’‰¢àÕ¬àŸ‡ªìπ 2.2 ŒÕ√‚å¡π‚ª√‡® ‡µÕ‚√π (progesterone)
®Ì“π«π¡“°µ—Èß·µàÕ¬àŸ„π§√√¿å¡“√¥“ ‚¥¬∑—Ë«‰ª ª√–°Õ∫¥«â ¬Õ–µÕ¡¢Õߧ“√∫å Õπ (carbon) ®“Ìπ«π
·µà≈–‡¥◊Õπ¡’‰¢àµ°‡æ’¬ß 1 „∫‡∑à“πÈ—π∑’Ë®–‡®√‘≠ 19 µ—« °“√ √â“߇ՠ‚µ√‡®π ®–„™â‚ª√‡® ‡µÕ‚√π
‡µ∫‘‚µ‡æÕ◊Ë√Õ°“√º ¡°∫—Õ ®ÿ‘‡¡ÕË◊ √ß—‰¢‡à ®√≠‘ ‡µ∫‘‚µ ‡ªìπ “√µÈ—ßµâπ ‚¥¬‡Õ“Õ–µÕ¡¢Õߧ“√å∫Õπ¢Õß
‡µÁ¡∑Ë’®–¡’°“√ ÿ°¢Õ߉¢à ·≈–‡π◊ÈÕ‡¬Ë◊Õ∑Ë’Àâÿ¡‰¢àÕ¬àŸ®– °≈¡ÿà ‚ª√‡® ‡µÕ‚√πÕÕ° 2 µ«—®“° 19 ‡À≈Õ◊ 17 µ«—
©’°¢“¥ÕÕ° ‰¢à°Á®–À≈ÿ¥ÕÕ°¡“®“°√—߉¢à‡√’¬°«à“ °√–∫«π°“√π’ȇ√’¬°«à“ aromatization ‡πË◊Õß®“°
ç°“√µ°‰¢éà ´ßË÷®–µ√ß°∫—™«à ߪ√–¡“≥«π—∑’Ë14 À≈ß— °≈ÿà¡‚ª√‡® ‡µÕ‚√π “¡“√∂‡ª≈Ë’¬π‡ªìπ‡∑ ‚µ -
°“√¡’ª√–®Ì“‡¥◊Õπ√Õ∫°àÕπÀπâ“ ·≈–®–¡’√–¥—∫ ‡µÕ‚√π (testosterone) ´÷Ë߇ªìπŒÕ√å‚¡π‡æ»™“¬

√ªŸ∑Ë’13.1 °“√æ≤— π“¢Õ߉¢¿à “¬„π√ß—‰¢„à π√Õ∫‡¥Õ◊ πª°µ‘(ÕÕ°·∫∫·≈–«“¥‚¥¬ §≥ÿ «π—« ‘“¢å »√æ’π‘®‘)

ªí≠À“ª√–®”‡¥Õ◊ πº‘¥ª°µ‘„𫬗√ÿàπ Abnormal Menstruation in Adolescents 193

‰¥â ŒÕ√‚å ¡π‚ª√‡® ‡µÕ‚√π¡À’π“â ∑ ’Ë”§≠— ∑“Ì„À‡â ¬Õ◊Ë 2. Lutial phase of menstrual cycle
∫ÿ‚æ√ß¡¥≈Ÿ°Àπ“µ—«¢È÷π·≈–¡’‡≈◊Õ¥¡“‡≈È’¬ß¡“°¢÷Èπ À≈—ß®“°‰¢àµ° ª√‘¡“≥¢Õ߇ՠ‚µ√‡®π®–≈¥≈ß
´Ë÷ß®–¡’√–¥—∫ŒÕ√å‚¡π‡æ‘Ë¡ Ÿß¢÷Èπ¿“¬À≈—ß¡’°“√µ°‰¢à √–¬–πÈ’corpus luteum ®– √“â ß ‚ª√‡® ‡µÕ‚√π¡“°¢π÷È
‡æ◊ËÕ„À⇬◊ËÕ∫ÿ‚æ√ß¡¥≈Ÿ°æ√âÕ¡∑’Ë®–¡’°“√Ωíßµ—«¢Õß ´Ë÷ß‚ª√‡® ‡µÕ‚√π∑’Ë¡“°¢÷Èπ ®–∑Ì“„Àâ‡Õ ‚µ√‡®π
‰¢∑à ‰Ë’¥√â ∫—°“√º ¡‡√¬’∫√Õâ ¬ ·µ„à π∑“ß°≈∫—°π—∂“â ‰¢à °≈∫—¡“ ßŸ¢π÷ȉ¥„â À¡à ·≈–‚ª√‡® ‡µÕ‚√π®–¡ª’√¡‘“≥
‰¡‰à ¥√â ∫—°“√º ¡°∫—µ«—Õ ®ÿ‘‰¢®à –‡ ÕË◊ ¡ ≈“¬‰ª ∑“Ì ¡“°°«à“‡Õ ‚µ√‡®π„π√–¬– luteal phase  à«π
„À√â –¥∫—ŒÕ√‚å ¡π‚ª√‡® ‡µÕ‚√π∑ Ë’√“â ß®“°√ß—‰¢≈à ¥≈ß ª√¡‘“≥¢ÕߌÕ√‚å ¡π FSH ·≈– LH ®–Õ¬„àŸπ√–¥∫—
´ß÷Ë¡º’≈µÕà ‡¬Õ◊Ë∫‚ÿæ√ß¡¥≈°Ÿ ‚¥¬∑“Ì„À‡â ¬ÕË◊ ∫‚ÿæ√ß¡¥ µË”„π√–¬– luteal phase ‡¬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ°„π√–¬–
≈Ÿ°À≈ÿ¥≈Õ°µ—«·≈–¡’‡≈◊Õ¥ÕÕ°¡“‡√’¬°«à“ çª√–®Ì“ luteal phase ®–‡ª≈¬’Ëπ¡“‡ªπì·∫∫ secretory phase
‡¥Õ◊ πé ‚¥¬‡ πâ ‡≈Õ◊ ¥∑¡’Ë“‡≈¬È’ß‚æ√ß¡¥≈°Ÿ ·≈–µÕà ¡„π‚æ√ß
3. ŒÕ√å‚¡π∑Ë’ √â“߇©æ“–∑Ë’ à«π„À≠à √â“ß ¡¥≈°Ÿ (gland) ®–¡≈’°—…≥–§¥‡§¬È’«¡“°¢π÷È √–¬–∑’Ë
®“°√ß—‰¢à ∑¡’Ë∫’∑∫“∑„π°“√§«∫§¡ÿ√Õ∫ª√–®“̇¥Õ◊ π corpus luteum ‡√Ë‘¡ΩÉÕ ª√–¡“≥«—π∑Ë’28 ¢Õß
‰¥·â °à insulin-like growth factor (IGF), activin, √Õ∫ª√–®”‡¥◊Õπ √–¥—∫‡Õ ‚µ√‡®π ‚ª√‡® ‡µÕ‚√π
inhibin ‡ªπìµπâ 3, 4 ·≈– inhibin „π‡≈Õ◊ ¥ ®–∂ß÷®¥ÿµË”∑ ’Ë¥ÿ °“√∑’Ëinhibin
°“√‡ª≈Ë’¬π·ª≈ߢÕ߇¬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ° ≈¥µ”Ë≈ß ∑“Ì„À°â “√°¥ pituitary µÕà °“√À≈ßË—ŒÕ√‚å ¡π
(endometrium) FSH À¡¥‰ª ·≈–°“√∑Ë’ª√‘¡“≥¢Õ߇ՠ‚µ√‡®π
„π¿“«–ª°µ‘1 «ß√Õ∫¢Õߪ√–®“̇¥Õ◊ πª°µ‘ ·≈–‚ª√‡® ‡µÕ‚√πµË” ∑Ì“„À⇬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ°‡√Ë‘¡
®–„™â‡«≈“ 28 «—π ‚¥¬π—∫«—π·√°¢Õß√Õ∫ª√–®Ì“ ≈Õ°µ«—·≈–°≈“¬‡ªπìª√–®“̇¥Õ◊ πµÕà ‰ª5°Õà πÀπ“â ππÈ—
‡¥◊Õπ§◊Õ«—π·√°∑’˪√–®Ì“‡¥◊Õπ¡“ ‡¬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ° ª√‘¡“≥¢Õ߇ՠ‚µ√‡®π·≈–‚ª√‡® ‡µÕ‚√π∑Ë’ Ÿß ∑Ì“
π—Èπ®–¡’°“√‡ª≈’ˬπ·ª≈߉ª„π·µà≈–™à«ß¢Õß√Õ∫ „À‰â ª°¥°“√À≈ßË—ŒÕ√‚å ¡π GnRH ®“°‰Œ‚ª∑“≈“¡ —
ª√–®“̇¥Õ◊ π ‡πÕ◊Ëß®“°°“√‡ª≈¬’Ëπ·ª≈ߢÕߌÕ√‚å ¡π ‡¡Õ◊ˇ°¥‘°“√≈¥≈ߢÕ߇ՠ‚µ√‡®π·≈–‚ª√‡® ‡µÕ‚√π
µ“à ßÊ ∑¡’Ë“§«∫§¡ÿ¡¥≈°Ÿ ‚¥¬°“√‡ª≈¬Ë’π·ª≈ߢÕß ®–∑“Ì„ÀŒâ Õ√‚å ¡π GnRH À≈ßË—‡æ¡Ë‘¢πÈ÷ ∑“Ì„À¡â º’≈‰ª
‚æ√ß¡¥≈°Ÿ·∫ßà ‡ªπì 2 ™«à ß §Õ◊ °√–µÿâπ°“√À≈—ËߌÕ√å‚¡π FSH ·≈– LH ®“°µàÕ¡
1. Follicular phase of menstrual cycle „µâ ¡Õß à«πÀπⓇæË‘¡¢È÷π ‡æË◊Õ‡ªìπ°“√‡√Ë‘¡√Õ∫„À¡à
Õ¬„àŸπ™«à ߇«≈“ 14 «π—·√°¢Õß√Õ∫ª√–®“̇¥Õ◊ π ‚¥¬ ¢Õߪ√–®“̇¥Õ◊ πÕ°’§√ßÈ—3, 4 ¥ß—· ¥ß„π√ªŸ∑Ë’13.2
™«à ßπÈ’FSH ®–°√–µπâÿ„Àâ follicle ‡®√≠‘ ‡µ∫‘‚µ·≈– °≈à“«‚¥¬ √ÿª √–¬–‡«≈“µ—Èß·µà‰¢à‡√Ë‘¡¡’°“√
À≈ßË—ŒÕ√‚å ¡π‡Õ ‚µ√‡®π¡“°¢π÷ȇ√ÕË◊ ¬Ê ‡®√‘≠‡µ‘∫‚µ®π∂÷ß¡’°“√ ÿ°¢Õ߉¢à‡√’¬°«à“ ç§√Ë÷ß·√°
‡Õ ‚µ√‡®π®–°√–µâÿπ„À⇬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ°¡’ ¢Õß√Õ∫ª√–®“̇¥Õ◊ πé ¿“¬À≈ß—¡°’“√µ°‰¢à √ß—‰¢®à –
°“√·∫ßà µ«—(proliferative)∑“Ì„À¢â π“¥¢Õß‚æ√ß¡¥≈°Ÿ  √“â ߌÕ√‚å ¡π‚ª√‡® ‡µÕ‚√πÕÕ°¡“ ´ß÷Ë¡º’≈µÕà ‡¬Õ◊Ë
Àπ“¢πÈ÷ °“√∑‡’ËÕ ‚µ√‡®π  ßŸ¢πÈ÷∑“Ì„Àâ LH ∑ Ë’ߟ¢π÷È ∫ÿ‚æ√ß¡¥≈Ÿ° ∑Ì“„À⇬◊ËÕ∫ÿ‚æ√ß¡¥≈Ÿ°Àπ“µ—«¢È÷π·≈–
‡√ÕË◊ ¬Ê „π™«à ßÀ≈ß—¢Õß follicular phase ‚¥¬¿“«– ¡’‡≈◊Õ¥¡“‡≈’Ȭߡ“°¢È÷π ‡æ◊ËÕ„Àâæ√âÕ¡µàÕ°“√Ωíßµ—«
∑’ËLH  ßŸ¢π÷ȇ√¬’°«“à LH surge ‡¡ÕË◊ LH ¢πÈ÷ ßŸ ¥ÿ À“°‰¢à‰¥â√—∫°“√º ¡ ·µà∂Ⓣ¢à‰¡à‰¥â√—∫°“√º ¡°—∫
·≈«â ®–°√–µπâÿ„À‰â ¢µà ° (ovulation) ´ß÷Ë®–µ√ß°∫— µ—«Õ ÿ®‘‰¢à®–§àÕ¬Ê ‡ Ë◊Õ¡ ≈“¬‰ª ∑Ì“„Àâ√–¥—∫
«π—∑Ë’14 ¢Õß√Õ∫‡¥Õ◊ πæÕ¥’ ŒÕ√å‚¡π‚ª√‡® ‡µÕ‚√π∑Ë’ √â“ß®“°√—߉¢à≈¥≈ß ·≈–

194 Õ¿™‘“µ‘‚æ∏Õ‘–

√ªŸ∑Ë’13.2 °≈‰°°“√‡°¥‘ª√–®”‡¥Õ◊ π
(¥¥—·ª≈ß®“°‡Õ° “√Õ“â ßÕß‘À¡“¬‡≈¢ 3)
**FSH : follicular stimulating hormone, LH : luteinizing hormone

ªí≠À“ª√–®”‡¥◊Õπº‘¥ª°µ„‘𫬗√àÿπ Abnormal Menstruation in Adolescents 195

√â“ߌÕ√å‚¡π‡Õ ‚µ√‡®π‡æË‘¡¢÷Èπ ∑Ì“„À⇬Ë◊Õ∫ÿ‚æ√ß  “¡“√∂𬑓¡‰¥Àâ ≈“¬·∫∫†‡™πà
¡¥≈Ÿ°À≈ÿ¥≈Õ°µ—«ÕÕ°¡“‡ªìπª√–®”‡¥◊Õπ √–¬– † - Oligomenorrhea: ¡’√–¬–Àà“ߢÕß√Õ∫
‡«≈“µ—Èß·µà¿“¬À≈—ßµ°‰¢à®π∂÷ß«—π ÿ¥∑⓬°àÕπ∑Ë’®– ‡¥Õ◊ π¡“°°«“à 35 «π—
¡’‡≈◊Õ¥ª√–®Ì“‡¥◊ÕπÕÕ°¡“ ‡√’¬°«à“ ç§√Ë÷ßÀ≈—ߢÕß †††††††† - Polymenorrhea: ¡’√–¬–Àà“ߢÕß√Õ∫
√Õ∫ª√–®“̇¥Õ◊ πé „™√â –¬–‡«≈“ª√–¡“≥ 14 «π— ·≈– ‡¥Õ◊ ππÕâ ¬°«“à 21 «π—
«—π·√°∑’Ë¡’‡≈◊Õ¥ª√–®Ì“‡¥◊Õπ‰À≈ÕÕ°¡“π—∫‡ªì𠆆†††††† - Menorrhagia: ¡’√Õ∫‡¥◊Õπ∑Ë’ ¡”ˇ ¡Õ
«π—∑Ë’1 ¢Õß√Õ∫ª√–®“̇¥Õ◊ π6, 7 ‚¥¬∑«Ë—‰ª ‡¥°ÁºÀŸâ ≠ß‘ ·µ¡à ª’√¡‘“≥¡“°°«“à 80 ¡≈. À√Õ◊ π“π°«“à 7 «π—
®–‡√¡‘Ë¡ª’√–®“̇¥Õ◊ π§√ß—È·√°‡¡Õ◊ËÕ“¬ÿ12 ∂ß÷ 16 ª8ï †††††††† - Metrorrhagia: ¡√’Õ∫‡¥Õ◊ π∑‰Ë’¡ à ¡Ë”‡ ¡Õ
ª®í®∫ÿ𗇥°ÁºÀâŸ≠ß‘‰∑¬¡ª’√–®“̇¥Õ◊ π§√ßÈ—·√°‡¡ÕË◊ Õ“¬ÿ À√Õ◊ π“π°«“à 7 «π— ·µ¡à ª’√¡‘“≥ª°µ‘
‡©≈¬Ë’ 12.3 ∂ß÷12.5 ªï ºªâŸ«É ¬∑¡’Ë“¥«â ¬Õ“°“√‡≈Õ◊ ¥ÕÕ°∑“ß™Õà ߧ≈Õ¥
®–µâÕß´—°ª√–«—µ‘„Àâ·πà™—¥«à“‡ªìπ‡≈◊Õ¥∑’ËÕÕ°®“°
欓∏‘ √’√«‘∑¬“¢Õß°“√‡°‘¥¿“«–ª√–®Ì“‡¥◊Õπ ™àÕߧ≈Õ¥®√‘ßÊ ‚¥¬‡©æ“–„πºŸâªÉ«¬∑’Ë„Àâª√–«—µ‘«à“
º‘¥ª°µ·‘≈–°“√«π‘®‘©—¬·≈–·¬°‚√§ ‡ÀÁπ‡≈◊Õ¥„π™—°‚§√° µâÕß√–«—ßÕ«—¬«–¢â“߇§’¬ß∑’Ë

‚¥¬∑—Ë«‰ªª√‘¡“≥‡≈◊Õ¥∑Ë’ÕÕ°√–À«à“ß¡’ Õ“®‡ªπì “‡Àµ‰ÿ¥â ‡™πà ¿“«–‡≈Õ◊ ¥ÕÕ°®“°√¥‘ ¥’«ß
ª√–®”‡¥Õ◊ πª√–¡“≥ 40 ± 20 ¡≈. ·µ‰à ¡‡à °π‘ 80 ¡≈. ∑«“√∂“à ¬ª í “«–‡ªπì‡≈Õ◊ ¥À√Õ◊ ∂“à ¬Õ®ÿ®“√–‡ªπì‡≈Õ◊ ¥
µàÕ√Õ∫ª√–®”‡¥◊Õπ¡’√–¬–Àà“ß√–À«à“ß√Õ∫ª√–®” ´Ë÷ßµâÕßÕ“»—¬°“√´—°ª√–«—µ‘«à“‡≈◊Õ¥∑’ËÕÕ°π—Èπ¡’
‡¥Õ◊ πª√–¡“≥ 28 ± 7 «π— À√Õ◊ 21-35 «—π ·≈– ≈—°…≥–‡ªìπÕ¬à“߉√  ’·¥ß ¥À√◊Õ ’·¥ß§≈”È ¡’≈Ë‘¡
√–¬–‡«≈“∑¡Ë’ª’√–®”‡¥Õ◊ πª√–¡“≥ 4 ± 2 «π— ·µ‰à ¡à ‡≈◊Õ¥ªπ‰À¡ ª√‘¡“≥‡≈◊Õ¥∑’ËÕÕ°¡“°À√◊ÕπâÕ¬ „π
‡°π‘ 7 «π— ¿“«–ª√–®”‡¥Õ◊ πº¥‘ª°µÀ‘¡“¬∂ß÷ ¿“«– ºâŸªÉ«¬∑’Ë´—°ª√–«—µ‘·≈–µ√«®√à“ß°“¬æ∫«à“¡’Õ“°“√
∑Ë’¡’°“√‡ª≈’ˬπ·ª≈ߢÕߪ√–®”‡¥◊Õπ‚¥¬Õ“®®–æ∫ ‡≈Õ◊ ¥ÕÕ°∑“ß™àÕߧ≈Õ¥®√‘ßÊ µÕâ ß·¬°°“√«‘π®‘©—¬
‰¥âµ—Èß·µà¡’√–¬–Àà“ß√–À«à“ß√Õ∫¢Õߪ√–®”‡¥◊Õπ‰¡à Õ¬à“ß·√°°àÕπ«à“ºâŸªÉ«¬µ—Èߧ√√¿åÀ√◊Õ‰¡à ´÷ËßµâÕß
 ¡Ë”‡ ¡Õ ª√–®”‡¥Õ◊ π¡“∫Õà ¬† ª√–®”‡¥Õ◊ π¡ª’√¡‘“≥ ´—°ª√–«—µ‘ª√–®”‡¥◊Õπ«à“¡“ª°µ‘À√◊Õ‰¡à °“√§ÿ¡
¡“°¢È÷π À√◊Õæ∫À≈“¬≈—°…≥–√à«¡°—π ´÷Ëß¿“«– °”‡π¥‘·≈–ª√–«µ—°‘“√¡‡’æ» ¡—æπ—∏å ºªŸâ «É ¬∑¡’ËÕ’“°“√
ª√–®”‡¥◊Õπº‘¥ª°µ‘(¥—ß· ¥ß„πµ“√“ß∑Ë’13.1) ‡≈◊Õ¥ÕÕ°„π√–À«à“ß°“√µÈ—ߧ√√¿å §«√ àߪ√÷°…“ Ÿµ‘

µ“√“ß∑Ë’13.1 §”®”°¥—§«“¡¢Õߧ«“¡º¥‘ª°µ¢‘Õߪ√–®”‡¥Õ◊ π

§«“¡º¥‘ª°µ‘ √–¬–À“àß √–¬–‡«≈“∑¡Ë’ª’√–®”‡¥Õ◊ π ª√¡‘“≥
ª√–®”‡¥Õ◊ πª°µ‘ 21-35 «π— 4-6 «π— ‰¡‡à °π‘ 30 ¡≈.
Menorrhagia  ¡”ˇ ¡Õ π“π°«“à 7 «π— ¡“°°«“à 80 ¡≈.
Metrorrhagia ‰¡ à ¡”ˇ ¡Õ Õ“®®–π“π°«“à ª°µ‘ ª°µ‘
Menometrorrhagia ‰¡ à ¡Ë”‡ ¡Õ π“π°«“à 7 «π— ¡“°°«“à 80 ¡≈.
Hypermenorrhea  ¡Ë”‡ ¡Õ ª°µ‘ ¡“°°«“à 80 ¡≈.
Hypomenorrhea  ¡Ë”‡ ¡Õ πÕâ ¬°«“à 2 «π— πÕâ ¬≈ß
Oligomenorrhea  ¡Ë”‡ ¡Õ ‰¡·à ππà Õπ πÕâ ¬≈ß

196 Õ¿™‘“µ‘‚æ∏Õ‘–

π√’·æ∑¬å‡æË◊Õµ√«®À“ “‡Àµÿ¢Õ߇≈◊Õ¥ÕÕ°Õ¬à“ß µ“à ß°π—‰ª9, 10
≈–‡Õ¬’¥µÕà ‰ª ´ß÷Ë®–¢Õ‰¡≈à ß√“¬≈–‡Õ¬’¥„π∫∑πÈ’ 2.2 ¿“«–ª√–®”‡¥◊Õπº‘¥ª°µ‘∑Ë’‡°‘¥¢È÷π„π
„πºŸâªÉ«¬°≈àÿ¡∑Ë’‰¡à¡’°“√µ—Èߧ√√¿å∑Ë’¡’‡≈◊Õ¥  µ√∑’‰’Ë¡¡à °’“√µ°‰¢à(anovulatory DUB)
ÕÕ°∑“ß™Õà ߧ≈Õ¥ æ∫ “‡Àµ®ÿ”·π°‰¥‡â ªπì 2 °≈¡ÿà ‡ªπì¿“«–∑‡’Ë°¥‘®“°°“√‰¡µà °‰¢à ®ß÷∑”„À‰â ¡¡à ’
„À≠Êà ‰¥·â °à °“√ √â“ߧÕ√åªí ≈Ÿ‡µ’¬¡´÷Ë߇ªìπ·À≈àߺ≈‘µŒÕ√å‚¡π
1. §«“¡º¥‘ª°µ∑‘“ß°“¬«¿‘“§ (structural ‚ª√‡® ‡∑Õ√‚å √π ¥ß—ππÈ—√“à ß°“¬®ß÷¡Œ’Õ√‚å ¡π‡Õ ‚µ√‡®π
cause) ´÷Ëß„π·µà≈–™à«ß«—¬®–¡’¿“«–∑Ë’æ∫∫àÕ¬‰¥â ‡æ’¬ßÕ¬à“߇¥’¬« ∑”„À⇬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ°∂Ÿ°°√–µÿâπ
·µ°µà“ß°—π Õ“∑‘‡™àπ µË‘߇πÈ◊Õ‡¬◊ËÕ∫ÿ‚æ√ß¡¥≈Ÿ° „ÀâÀπ“µ—«¡“°¢È÷π‡√◊ËÕ¬Ê ∑”„À≡ࡒª√–®”‡¥◊Õπ„π
(endometrial polyp) ‡π◊ÈÕßÕ°¡¥≈Ÿ° (myoma ™à«ß·√° µàÕ¡“‡¡Ë◊Õ‡¬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ°Àπ“µ—«¡“°°Á
uteri) ‡¬ÕË◊ ∫‚ÿæ√ß¡¥≈°Ÿ‡®√≠‘ º¥‘∑Ë’(adenomyosis) ®–‡°‘¥°“√À≈ÿ¥≈Õ°‰¥âßà“¬ À“°°“√À≈ÿ¥≈Õ°‡°‘¥
À√◊Õ¿“«–‡≈◊Õ¥ÕÕ°®“°‚√§¡–‡√Áß∑“ßπ√’‡«™ √«¡ ¢πÈ÷‡æ¬’ß∫“ß®¥ÿ°®Á–∑”„À¡â ‡’≈Õ◊ ¥ÕÕ°°–ª√∫‘°–ª√Õ¬
∑—Èß„πºâŸªÉ«¬∑’ËÕ“®¡’°“¬«‘¿“§ª°µ‘·µàÕ“®¡’§«“¡ À“°‡°‘¥°“√À≈ÿ¥≈Õ°¢Õ߇¬◊ËÕ∫ÿ‚æ√ß¡¥≈Ÿ°‡ªìπ
º‘¥ª°µ‘¢Õ߇°≈Á¥‡≈◊Õ¥ (platelet dysfunction) ∫√‡‘«≥°«“â ß°®Á–∑”„À‡â ≈Õ◊ ¥ÕÕ°„πª√¡‘“≥¡“°9
À √◊ Õ § « “ ¡ º‘¥ ª ° µ‘¢ Õ ß ° “ √ · ¢Áß µ—« ¢ Õ ß ‡ ≈◊ Õ ¥ ≈—°…≥–∑“ߧ≈‘π‘°∑’Ë “¡“√∂„™â·¬°√–À«à“ß
(coagulopathy) À√◊Õ„πºâŸªÉ«¬∑’ˉ¥â√—∫¬“≈–≈“¬ ovulatory DUB ·≈– anovulatory DUB §◊Õ
≈¡Ë‘‡≈Õ◊ ¥ ovulatory DUB ¡°—®–¡ª’√–®”‡¥Õ◊ πÕÕ°¡“°·∫∫
2. §«“¡º¥‘ª°µ∑‘¡’Ë ’“‡Àµ¡ÿ“®“°°“√∑”ß“π menorrhagiaæ∫∫Õà ¬„πºÀâŸ≠ß‘«¬—‡®√≠‘æπ—∏™åÿ«à ßÕ“¬ÿ
¢Õß√–∫∫ŒÕ√å‚¡π‡æ»À√◊Õ∑Ë’‡√’¬°«à“ dysfunc- 30-40 ªï·≈–¡°—¡Õ’“°“√√«à ¡°Õà π¡ª’√–®”‡¥Õ◊ 𠇙πà
tional uterine bleeding (DUB) ´Ë÷ߪ√¡‘“≥ §¥—µß÷‡µ“â π¡ ª«¥ª√–®”‡¥Õ◊ π anovulatory DUB
·≈–√–¬–À“à ߢÕß√Õ∫ª√–®”‡¥Õ◊ π®–¡§’«“¡·µ°µ“à ß ¡—°®–¡’ª√–®”‡¥◊ÕπÕÕ°·∫∫ metrorrhagia
°π—‰ª„π·µ≈à –∫§ÿ§≈ amenorrhea ·≈⫵“¡¥â«¬ heavy bleeding ¡—°
¿“«–ª√–®”‡¥Õ◊ πº¥‘ª°µ¡‘ ’“‡Àµ¡ÿ“®“°°“√ æ∫„π«—¬√ÿàπ·≈–«—¬„°≈âÀ¡¥ª√–®”‡¥◊Õπ ¡—°‰¡à¡’
∑”ß“π¢Õß√–∫∫ŒÕ√‚å ¡π‡æ»À√Õ◊ ∑‡’Ë√¬’°«“à dysfunc- Õ“°“√°àÕπª√–®”‡¥◊Õπ Õ¬à“߉√°Áµ“¡Õ“®®–æ∫
tional uterine bleeding (DUB)  “¡“√∂·∫ßà ‰¥‡â ªπì ¿“«–¥—ß°≈à“«‰¥â„π µ√’«—¬‡®√‘≠æ—π∏å∑Ë’ —¡æ—π∏å
2 °≈¡àÿ„À≠Êà ‰¥·â °à °—∫¿“«– polycystic ovarian disease ´Ë÷ß∑”„Àâ
2.1 ¿“«–ª√–®”‡¥◊Õπº‘¥ª°µ‘∑Ë’‡°‘¥¢÷Èπ„π ‡°‘¥°“√‰¡àµ°‰¢à·∫∫‡√È◊Õ√—ß ≈—°…≥–∑“ߧ≈‘π‘°∑’Ë„™â
 µ√∑’¡Ë’°’“√µ°‰¢à(ovulatory DUB) „π°“√«‘π‘®©—¬·¬°‚√§√–À«à“ß anovulatory ·≈–
¡°—‡°¥‘„π µ√∑’¡’ËÕ’“¬√ÿ–À«“à ß 30-40 ªï «à π ovulatory DUB  “¡“√∂ √ªÿ‰¥â ¥ß—· ¥ß„πµ“√“ß
„À≠àÕ“°“√‡≈◊Õ¥ÕÕ°¡—°®–‰¡à√ÿπ·√ß ºâŸªÉ«¬®–¡’ ∑’Ë13.2
√–¬–¢Õß√Õ∫ª√–®”‡¥◊Õπ ¡”Ë‡ ¡Õ·≈–¡’Õ“°“√∑Ë’ °“√∑®’Ë–¡‡’≈Õ◊ ¥ÕÕ°º¥‘ª°µ‘À√Õ◊ DUB ππÈ—
 —¡æ—π∏å°—∫°“√¡’ª√–®”‡¥◊Õπ (premenstrual ®–Õ∏∫‘“¬®“° 4 °≈‰°11 À≈°—§Õ◊
syndromes) ‡™àπ §—¥µ÷߇µâ“π¡ ª«¥ª√–®”‡¥◊Õπ - Estrogen breakthrough bleeding §Õ◊
‡πË◊Õß®“°§«“¡º‘¥ª°µ‘∑’ˇ°‘¥¢÷Èπ„π ovulatory ¡’√–¥—∫ŒÕ√å‚¡π‡Õ ‚µ√‡®π∑Ë’‰¡àµË”≈ß §ß∑Ë’Õ¬àŸπ“π
DUB ´Ë÷ß¡’À≈“¬ “‡Àµÿ®÷ß∑”„À⇰‘¥Õ“°“√∑Ë’·µ° ∑”„À¡â °’“√°√–µπâÿ¢Õß follicular phase ¢Õ߇¬ÕË◊ ∫ÿ

ª≠í À“ª√–®”‡¥◊Õπº‘¥ª°µ„‘𫬗√ÿàπ Abnormal Menstruation in Adolescents 197

‚æ√ß¡¥≈°Ÿ¡“°¢πÈ÷‡√Õ◊Ë¬Ê ®π∑”„Àâ ‡¬Õ◊Ë∫‚ÿæ√ß¡¥≈°Ÿ ª°µ∑‘“ß™Õà ߧ≈Õ¥‰¥â
À𓇰‘𧫓¡ “¡“√∂∑Ë’ŒÕ√å‚¡π‡Õ ‚µ√‡®π®–™à«¬ - Progesterone breakthrough bleeding¡°—
„À§â ßµ«—‰«‰â ¥â ∑”„À‡â °¥‘ shedding (®“°°“√∑À’Ë≈Õ¥ ‡°‘¥„π§π∑’ˉ¥â√—∫¬“°≈ÿà¡ŒÕ√å‚¡π‚ª√‡® ‡µÕ‚√π
‡≈Õ◊ ¥‰ª‡≈¬’Èß™π—È∫πÊ ‰¡‡à 欒ßæÕ) ¡°—æ∫„π°√≥∑’Ë’ ‡ªπ쇫≈“π“𠇙πà °≈¡ÿà ©¥’¬“§¡ÿ™π¥‘ DMPA °≈¡àÿ
‰¢à‰¡àµ° (anovulation) ∑”„À≡ࡒ°“√ √â“ߢÕß ‰¥â√—∫¬“§ÿ¡™π‘¥∑’Ë¡’ à«πª√–°Õ∫¢ÕߌÕ√å‚¡π‚ª√
ŒÕ√å‚¡π‚ª√‡® ‡µÕ‚√π®“° corpus luteum ¡’·µà ‡® ‡µÕ‚√π‡ªπ쇫≈“π“π À√Õ◊ °≈¡àÿ∑‡’˪πì ovulatory
ŒÕ√å‚¡π‡Õ ‚µ√‡®π∑’Ë°√–µâÿπ‡¬◊ËÕ∫ÿ‚æ√ß¡¥≈Ÿ°„Àâ DUB ∑Ë’corpus luteum ∑”ß“ππ“π‡°π‘ 14 «π—¡’
Àπ“µ—«‰ª‡√◊ËÕ¬Ê ¥—ßπ—ÈπÀ≈—°°“√√—°…“ §◊Õ°“√„Àâ °“√ √â“ߢÕߌÕ√å‚¡π‚ª√‡® ‡µÕ‚√πµàÕ‡πË◊Õß ‡°‘¥
ŒÕ√å‚¡π‚ª√‡® ‡µÕ‚√π‡¢â“‰ª‡æ◊ËÕ„Àâ‡≈’¬π·∫∫ shedding ®“°°“√∑’ˇ¬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ°‰¡à “¡“√∂
ª√–®”‡¥Õ◊ πµ“¡∏√√¡™“µ‘À“°‰¡√à °—…“ª≈Õà ¬‰«‡â ªπì §ßµ«—Õ¬‰àŸ¥®â “°°“√∑ÀË’≈Õ¥‡≈Õ◊ ¥‰ª‡≈¬’Èß™πÈ—∫πÊ ‰¡à
chronic anovulation ºâŸªÉ«¬Õ“®æ—≤π“µàÕ‡ªìπ ‡æ¬’ßæÕ
¿“«–∑’Ë¿“¬„π√—߉¢à¡’∂ÿßπ”ÈÀ≈“¬„∫ À√◊Õ PCOS - Progesterone withdrawal bleeding
(polycystic ovarian syndrome) ‚¥¬ anovula- ‡°¥‘®“°°“√∑’Ëcorpus luteum ∑”ß“π π—ȇ°π‘‰ª „π
tion DUB ¡—°æ∫„π°≈ÿà¡«—¬√ÿàπ∑Ë’‡æ‘Ëß¡’°“√ √â“ß ™«à ß luteal phase ‡ªπìÕ°’°≈‰°∑Õ’Ë∏∫‘“¬ ovulatory
ŒÕ√å‚¡π„À¡à¬—ß √â“߉¥â‰¡à§ß∑Ë’·≈–«—¬„°≈âÀ¡¥ DUB†
ª√–®”‡¥◊Õπ´Ë÷ß√—߉¢à°”≈—ß®–ΩÉÕ À√◊Õ„π¿“«–Õ◊ËπÊ
‡™πà ¿“«–Õ«â π ·≈– PCOS ‡ªπìµπâ °“√´—°ª√–«µ—†‘
- Estrogen withdrawal bleeding ‡°¥‘
°“√´—°ª√–«—µ‘ª√–®”‡¥◊ÕπÕ¬à“ß≈–‡Õ’¬¥‡ªìπ
®“°°“√≈¥≈ߢÕߌÕ√å‚¡π‡Õ ‚µ√‡®π‡©’¬∫æ≈—π„π  ‘Ëß∑’Ë ”§—≠∑’Ë ÿ¥„π°“√·¬°¿“«–‰¡àµ°‰¢àÕÕ°®“°
™à«ß proliferative phase ∑”„À⇬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ°  “‡ÀµÿÕË◊π ª√–«—µ‘∑Ë’ ”§—≠‰¥â·°à √–¬–Àà“ߢÕß√Õ∫
‰¡ à “¡“√∂§ßµ«—Õ¬‰Ÿà ¥â ‡™πà °“√µ¥—√ß—‰¢Õà Õ°∑ßÈ— Õß ‡¥Õ◊ π ª√¡‘“≥ ®”π«π«π—∑¡’Ë√’Õ∫‡¥Õ◊ π °“√§¡ÿ°”‡π¥‘
¢â“ß °“√À¬ÿ¥°‘π¬“∑¥·∑πŒÕ√å‚¡π‚¥¬‡©æ“–∑’Ë ¥â«¬«‘∏’µà“ßÊ ª√–«—µ‘°“√¡’‡æ» —¡æ—π∏å‡æ◊ËÕ«‘π‘®©—¬
‡ªπìŒÕ√‚å ¡π‡Õ ‚µ√‡®π∑π—∑’°“√√°—…“¥«â ¬ŒÕ√‚å ¡π ·¬°‚√§„πºŸâªÉ«¬∑’˵—Èߧ√√¿å Õ“°“√°àÕπ¡’√Õ∫‡¥◊Õπ
‡Õ ‚µ√‡®π·≈â«À“°‰¡à‰¥â„ÀâŒÕ√å‚¡π‚ª√‡® ‡µÕ‚√π ®ÿ¥‡√‘Ë¡µâπ∑Ë’¡’√Õ∫‡¥◊Õπº‘¥ª°µ‘‚√§ª√–®”µ—« ·≈–
‡¢â“‰ª‡æ◊ËÕ„Àâ‡≈’¬π·∫∫ª√–®”‡¥◊Õπµ“¡∏√√¡™“µ‘ °“√„™¬â “µ“à ßÊ
°“√À¬ÿ¥ŒÕ√å‚¡π∑—π∑’∑”„ÀâºâŸªÉ«¬¡’‡≈◊Õ¥ÕÕ°º‘¥ †

µ“√“ß∑Ë’13.2 ≈°—…≥–∑“ߧ≈π‘°‘¢Õß ovulatory DUB ·≈– anovulatory DUB (¥¥—·ª≈ß®“°‡Õ° “√Õ“â ßÕß‘À¡“¬‡≈¢ 3)

≈°—…≥–∑“ߧ≈π‘°‘ Ovulatory DUB Anovulatory DUB

≈°—…≥–‡≈Õ◊ ¥∑Õ’ËÕ°∑æË’∫∫Õà ¬ Menorrhagia Metrorrhagia À√Õ◊ amenorrhea µ“¡¥«â ¬‡≈Õ◊ ¥ÕÕ°ª√¡‘“≥¡“°
Õ“¬ÿ 30-40 ªï «¬—√πàÿ·≈–«¬—„°≈Àâ ¡¥ª√–®”‡¥Õ◊ π
Õ“°“√°Õà π¡ª’√–®”‡¥Õ◊ π ¡’ ‰¡¡à ’
DUB = Dysfunction uterine bleeding

198 Õ¿™‘“µ‘‚æ∏‘Õ–

°“√µ√«®√“àß°“¬† ¡“°‚¥¬‰¡∑à √“∫ “‡Àµÿ
- °“√µ√«® ristocetin cofactor assay †
‡æÕË◊ ª√–‡¡π‘À“≈°—…≥–∑ Ë’¡—æπ—∏°å ∫—°“√‰¡µà ° d„πis√e“a¬s∑eË’ (ßv W—¬‡Dæ)◊ËÕ1µ4√«®À“¿“«– von Willebrand
‰¢à ‡™àπ ¢π¥°  ‘« º‘«¡—π πÈ”π¡‰À≈º‘¥ª°µ‘
µ√«®À“√Õ¬‚√§Õπ◊ËÊ ∑ Ë’“¡“√∂¡Õ߇ÀπÁ‰¥â µ√«®¥Ÿ - °“√µ√«®°“√∑”ß“π¢Õßµ—∫·≈–‰µ
¢π“¥·≈–≈—°…≥–¢Õß¡¥≈Ÿ° √«¡∑È—ßµ√«®À“
Õ“°“√· ¥ß¢Õß‚√§∑“ß√–∫∫ÕË◊πÊ ‡™àπ ‚√§¢Õß (liver and renal function) „πºªŸâ «É ¬∑ ’Ëß ¬—
µàÕ¡‰∑√Õ¬¥å ‚√§§«“¡º‘¥ª°µ‘¢Õß°“√∑”ß“π¢Õß ‚√§µ∫—·≈–‰µ
µ∫— ‰µ ·≈–Õ«¬—«–Õπ◊ËÊ - °“√µ√«®∑“ß欓∏«‘∑‘¬“¢Õ߇¬ÕË◊ ∫‚ÿæ√ß
† ¡¥≈Ÿ° ‡æË◊Õ·¬°¿“«–‡¬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ°Àπ“µ—«
°“√µ√«®∑“ßÀÕâߪؑ∫µ—°‘“√ (endometrial hyperplasia) À√Õ◊ ¡–‡√ßÁ∑“ßπ√‡’«™
- °“√∑”Õ—≈µ√“´“«¥å ‚¥¬‡©æ“–°“√∑”
‚¥¬∑—Ë«‰ª·≈â«„πºŸâªÉ«¬∑’Ë¡’‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘
®“°°“√‰¡µà °‰¢ à “¡“√∂∑®Ë’–„À°â “√«π‘®‘©¬—·≈–„À°â “√ ∑“ß™àÕߧ≈Õ¥ “¡“√∂∑’Ë®–·¬°æ¬“∏‘ ¿“æ¿“¬„π
√°—…“‰¥‡â ≈¬ ‚¥¬‰¡µà Õâ ß∑”°“√µ√«®‡æ¡‘ˇµ¡‘∑“ßÀÕâ ß ¡¥≈°Ÿ‰¥â ‡™πà µß‘Ë‡πÕÈ◊ ‡¬Õ◊Ë∫‚ÿæ√ß¡¥≈°Ÿ (endometrial
ªØ‘∫—µ‘°“√ ·µà„π°≈ÿࡺ⟪ɫ¬∑Ë’¡’§«“¡º‘¥ª°µ‘∑“ß polyp) ‡π◊ÈÕßÕ°¡¥≈Ÿ° (myoma uteri) √«¡∑È—ß
°“¬«‘¿“§ (structural cause) Õ“®®”‡ªìπµâÕß  “¡“√∂∫Õ°¢π“¥·≈–µ”·ÀπàߢÕß欓∏‘ ¿“æ
Õ“»—¬°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√‡æË◊ՙ૬„π°“√ ‡æ◊ËÕª√–‡¡‘π«à“ —¡æ—π∏å°—∫°“√‡°‘¥‡≈◊Õ¥ÕÕ°º‘¥
«π‘®‘©¬—·¬°‚√§12, 13 ¥ß—· ¥ß„π·ºπ¿¡Ÿ∑‘Ë’13.1 ª°µ‘À√◊Õ‰¡à °“√∑”Õ—≈µ√“´“«¥å¬—ß¡’ª√–‚¬™πå„π
- °“√µ√«®°“√µÈ—ߧ√√¿å (pregnancy °“√ª√–‡¡‘𧫓¡Àπ“¢Õ߇¬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ° ´÷Ëß∂â“
test) ‡æ◊ËÕ·¬° “‡Àµÿ∑’ˇ°‘¥®“°§«“¡º‘¥ª°µ‘¢Õß æ∫«à“¡’§«“¡Àπ“πâÕ¬°«à“ 4-5 ¡¡.πÈ—π ¡’§«“¡
°“√µß—ȧ√√¿Õå Õ°‰ª ‡ Ë’¬ßπâÕ¬¡“°∑’Ë®–¡’¿“«–‡π◊ÈÕßÕ°‚æ√ß¡¥≈Ÿ°À√◊Õ
- °“√µ√«® complete blood count ¡–‡√Áß∑“ßπ√’‡«™15 πÕ°®“°π’È°“√∑”Õ—≈µ√“´“«¥å
(CBC) ‡æË◊Õª√–‡¡‘π¿“«–‡≈◊Õ¥®“ß ª√‘¡“≥‡°≈Á¥ ∑“ß™àÕߧ≈Õ¥√à«¡°—∫°“√©’¥π”ȇ°≈◊Õ‡¢â“‰ª„π‚æ√ß
‡≈◊Õ¥ ·≈–°“√µ√«®°“√∑”ß“π¢Õ߇°≈Á¥‡≈◊Õ¥À“° ¡¥≈Ÿ° (saline infusion sonohysterography)
 ß ¬—§«“¡º¥‘ª°µ¢‘Õß°“√∑”ß“π¢Õ߇°≈¥Á‡≈Õ◊ ¥  “¡“√∂‡æ‘Ë¡§«“¡‰«·≈–§«“¡·¡à𬔄π°“√µ√«®
- °“√µ√«®√–¥∫—ŒÕ√‚å¡π‚ª√‡® ‡µÕ‚√π À“欓∏‘ ¿“æ„π¡¥≈Ÿ°‰¥â„°≈⇧’¬ß°—∫°“√ àÕß
„π°√–· ‡≈Õ◊ ¥ (serum progesterone)  “¡“√∂ °≈Õâ ßµ√«®‚æ√ß¡¥≈°Ÿ†
∫Õ°‰¥«â “à ¡°’“√µ°‰¢‡à °¥‘¢π÷È„π°√≥∑’√’Ë–¥∫—¡“°°«“à - °“√ àÕß°≈âÕßµ√«®¿“¬„π‚æ√ß¡¥≈Ÿ°
3 π°./¡≈. (hysteroscopy)  “¡“√∂„™â«‘π‘®©—¬æ¬“∏‘ ¿“æ
- °“√µ√«®√–¥∫—ŒÕ√‚å¡π∏¬—√Õ¬¥å(thyroid ¿“¬„π‚æ√ß¡¥≈°Ÿ √«à ¡°∫—„™„â π°“√√°—…“‰¥â
hormone) ‡æË◊Õµ√«®À“§«“¡º‘¥ª°µ‘¢ÕßµàÕ¡
‰∑√Õ¬¥å °“√ª√–‡¡‘𧫓¡√ÿπ·√ߢÕß¿“«–ª√–®”‡¥◊Õπ
- °“√µ√«®°“√·¢ßÁµ«—¢Õ߇≈Õ◊ ¥(coagulo- º‘¥ª°µ‘
gram) ‚¥¬‡©æ“–„πºŸâªÉ«¬∑Ë’¡’ª√–«—µ‘„πÕ¥’µÀ√◊Õ 1) Pictorial Blood Assessment Chart
ª√–«—µ‘§√Õ∫§√—« ºŸâªÉ«¬∑’Ë¡’‡≈◊Õ¥ª√–®”‡¥◊ÕπÕÕ° (PBAC)16 ‡ªπì°“√ª√–‡¡π‘ª√¡‘“≥ª√–®”‡¥Õ◊ π∑’Ë

ªí≠À“ª√–®”‡¥Õ◊ πº‘¥ª°µ‘„π«—¬√ÿàπ Abnormal Menstruation in Adolescents 199

·ºπ¿¡Ÿ∑‘’Ë13.1 ·π«∑“ß°“√«π‘®‘©¬—ºªŸâ «É ¬∑¡Ë’‡’≈Õ◊ ¥ÕÕ°∑“ß™Õà ߧ≈Õ¥

TSH = thyroid stimulating hormone, FSH = follicle stimulating hormone,
LH = luteinizing hormone, DHEAs; Dehydroepiandrosterone sulfate,
PBAC-Pictorial blood assessment chart,
VWF Ag = von Willerbrand factor antigen,
VWF:RCo = von Willerbrand factor: ristocetin cofactor activity

200 Õ¿™‘“µ‘‚æ∏‘Õ–

ÕÕ°∑ Ë’“¡“√∂∑”‰¥¥â «â ¬µ«—‡Õß ‚¥¬¡°’“√æ≤— π“¢π÷È ‰¡à¡“°‡∑à“ª√–®”‡¥◊Õπª°µ‘‰¡à¡’Õ“°“√·∑√°´âÕπ
¡“„™§â √ßÈ—·√°„πªï1990 ‚¥¬ Higham16 ·≈–§≥– ‡™àπ Àπâ“¡◊¥ ‡ªìπ≈¡ µâÕßÀ“ “‡Àµÿ¢Õ߇≈◊Õ¥ÕÕ°
‡ªπì°“√„À§â –·ππµ“¡ª√¡‘“≥‡≈Õ◊ ¥∑Õ’ËÕ°‚¥¬¥‡Ÿ≈Õ◊ ¥ º¥‘ª°µπ‘’È·µÕà “®∑”°“√√°—…“·∫∫ ºªâŸ«É ¬πÕ°‰¥â
∑’ˇªôóÕπ∫πºâ“Õπ“¡—¬À√◊Õ °âÕπ ”≈’∑Ë’„ à‡¢â“‰ª„π - √–¥—∫∑’Ë3 §◊Õ¡’¿“«–‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘
™Õà ߧ≈Õ¥ (tampon) ª√¡‘“≥≈¡‘ˇ≈Õ◊ ¥∑Õ’ËÕ°¡“ ·≈– ∑“ß™àÕߧ≈Õ¥®π∑”„À⇰‘¥Õ“°“√·∑√°´âÕ𠇙àπ¡’
‡≈◊Õ¥∑’ˉÀ≈≈âπºâ“Õπ“¡—¬ ‚¥¬æ∫«à“¡’§«“¡‰« Õ“°“√Àπ“â ¡¥◊ ‡ªπì≈¡ ÕÕà π‡æ≈¬’ ®”‡ªπìµÕâ ߉¥√â ∫—
(sensitivity) ·≈–§«“¡®”‡æ“– (specificity) °“√√°—…“¥«â ¬°“√„À‡â ≈Õ◊ ¥ ·≈–√∫—‡¢“â √°—…“·∫∫ºªŸâ «É ¬
Õ¬∑Ÿà ˪’√–¡“≥√âÕ¬≈– 80 „π°“√«π‘®‘©—¬¿“«–ª√–®” „π‡æ◊ËÕ∑”°“√µ√«®À“‚√§∑“ßπ√’‡«™ À√◊Õ‚√§∑“ß
‡¥Õ◊ πÕÕ°¡“° À“°¡·’µ¡â √«¡¡“°°«“à 100 ´ßË÷„πªï ‚≈Àµ‘«∑‘¬“Õ¬“à ß≈–‡Õ¬’¥µÕà ‰ª
2012 Sanchez17 ·≈–§≥– ‰¥â∑”°“√»÷°…“·≈– - √–¥—∫∑’Ë4 §◊Õ¡’¿“«–‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘
æ∫«à“ “¡“√∂„™â PBAC „π°“√ª√–‡¡‘πºâŸªÉ«¬‰¥â ∑“ß™àÕߧ≈Õ¥ ®π∑”„Àâ¡’ —≠≠“π™’懪≈Ë’¬π·ª≈ß
¥’·≈– “¡“√∂≈¥°“√√—°…“‚¥¬°“√ºà“µ—¥¡¥≈Ÿ° ®”‡ªπìµÕâ ߉¥√â ∫—°“√¥·Ÿ≈√°—…“Õ¬“à ß„°≈™â ¥‘ ¥ß—· ¥ß
(hysterectomy) ‰¥‚â ¥¬‰¡®à ”‡ªπì ·µÕà ¬“à ߉√°µÁ“¡ „πµ“√“ß∑’Ë13.3
„πªï2017 Jacobson18 ·≈–§≥–‰¥âæ—≤π“°“√
ª√–‡¡‘π PBAC ¥â«¬µπ‡Õß‚¥¬°“√„™â‚ª√·°√¡ °“√√—°…“¿“«–ª√–®”‡¥◊Õπº‘¥ª°µ‘¡’ “‡Àµÿ¡“
„π‚∑√»—æ∑å¡◊Õ∂◊Õ (mobile application) ·≈– ®“°°“√∑”ß“π¢Õß√–∫∫ŒÕ√å‚¡π‡æ»
æ∫«à“ “¡“√∂ª√–‡¡‘π‰¥â‡√Á«·≈–·¡à𬔰«à“°“√ † °“√√—°…“¿“«– DUB ®–·¬°µ“¡ “‡Àµÿ«à“
„™°â √–¥“… ‡πÕË◊ ß®“° “¡“√∂∑”‰¥∑â π—∑’·≈–≈¥¢Õâ ‡ªπì ovulatory À√Õ◊ anovulatory DUB ¥ß—πÈ’
®”°¥—∑ºË’ªŸâ «É ¬µÕâ ßæ°°√–¥“…‡æÕ◊Ë¡“ª√–‡¡π‘PBAC † °“√√°—…“¿“«– ovulatory DUB
µ¥‘µ«—‰«µâ ≈Õ¥ ®ß÷‡ªπì ß‘Ë∑πË’“à  π„®À“°®–„™â PBAC 1. °“√„™¬â“µ“âπ°“√Õ°—‡ ∫∑‰’Ë¡„à™ à‡µ¬’√Õ¬¥å
„π√Ÿª·∫∫¢Õß‚ª√·°√¡„π‚∑√»—æ∑å¡◊Õ∂◊Õ‡¢â“¡“„™â (nonsteroidal anti-inflammatory drugs)
∑¥·∑π ‡æÕË◊  –¥«°°∫—∑ßÈ—ºªâŸ«É ¬·≈–·æ∑¬ºå ∑Ÿâ ”°“√ ¬“°≈ÿà¡πÈ’®–ÕÕ°ƒ∑∏‘Ï„π°“√¬—∫¬È—ß°“√ √â“ß
√°—…“ ¥ß—· ¥ß„π√ªŸª√–°Õ∫∑’Ë13.3, 13.4, 13.5 æ≈Õ µ“·°≈π¥π‘ å ·≈– “¡“√∂≈¥ª√¡‘“≥‡≈Õ◊ ¥∑Ë’
2) World Health Organization bleed- ÕÕ°√–À«“à ß¡ª’√–®”‡¥Õ◊ π≈߉¥ªâ √–¡“≥√Õâ ¬≈–20∂ß÷
ing score19 ‡ªìπ°“√ª√–‡¡‘𧫓¡√ÿπ·√ߢÕß √Õâ ¬≈– 4020 ‡¡ÕË◊ ‡∑¬’∫°∫—°≈¡ÿà ∑‰Ë’¥√â ∫—¬“À≈Õ° ‚¥¬
¿“«–‡≈Õ◊ ¥ÕÕ°º¥‘ª°µ∑‘“ß™Õà ߧ≈Õ¥ ‚¥¬·∫ßà ÕÕ° ·π–π”„Àâ‡√‘Ë¡√—∫ª√–∑“𬓵—Èß·µà«—π·√°∑Ë’¡’ª√–®”
‡ªπì 4 √–¥∫—§«“¡√πÿ·√ß ‰¥·â °à ‡¥◊Õπ·≈–µàÕ‡π◊ËÕ߉ª„π√–À«à“ß∑’Ë¡’ª√–®”‡¥◊Õπ
- √–¥—∫∑’Ë1 §◊Õ¡’¿“«–‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘ †πÕ°®“°π’È√Õâ ¬≈– 7020 ¢ÕߺªŸâ «É ¬®–¡Õ’“°“√ª«¥
∑“ß™Õà ߧ≈Õ¥ (ª√¡‘“≥‡≈Õ◊ ¥∑Õ’ËÕ°πÕâ ¬°«“à ª√–®” ª√–®”‡¥◊Õπ≈¥≈ß®“°°“√„™â¬“„π√Ÿª·∫∫¥—ß°≈à“«
‡¥◊Õπ¡“° ‰¡à®”‡ªìπ∑’˵âÕß„™âºâ“Õπ“¡—¬ ·≈– ’¢Õß ¬“∑π’ˬ‘¡„™‰â ¥·â °à
‡≈◊Õ¥‰¡à‡¢â¡ §≈È” ‡À¡◊Õπª√–®”‡¥◊Õπ) ª√‘¡“≥ ë Mefenamic acid ¢π“¥ 500 ¡°. √∫—
‡≈°ÁπÕâ ¬ ª√–∑“π∑°ÿ 6-8 ™«—Ë‚¡ß
- √–¥—∫∑’Ë2 §◊Õ¡’¿“«–‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘ ë Ibuprofen ¢π“¥ 400 ¡°. √∫—ª√–∑“π
∑“ß™àÕߧ≈Õ¥ ª√‘¡“≥¡“°°«à“√–¥—∫∑Ë’1 ·µà ∑°ÿ 6-8 ™«—Ë‚¡ß

ªí≠À“ª√–®”‡¥◊Õπº¥‘ª°µ„‘𫬗√àπÿ Abnormal Menstruation in Adolescents 201

√ªŸ∑’Ë13.3 ·∫∫ª√–‡¡π‘ª√¡‘“≥ª√–®”‡¥Õ◊ π¥«â ¬µπ‡Õß

202 Õ¿‘™“µ‘‚æ∏Õ‘–

√ªŸ∑Ë’13.4 «∏‘°’“√π∫—·µ¡â PBAC ¥«â ¬µπ‡Õß
(ÕÕ°·∫∫·≈–¥¥—·ª≈ß®“°‡Õ° “√Õ“â ßÕß‘À¡“¬‡≈¢ 16, 18)

ª≠í À“ª√–®”‡¥Õ◊ πº¥‘ª°µ‘„𫬗√àπÿ Abnormal Menstruation in Adolescents 203

√ªŸ∑Ë’13.5 µ«—Õ¬“à ß°“√ª√–‡¡π‘ª√¡‘“≥ª√–®”‡¥Õ◊ π¥«â ¬µπ‡Õß ‚¥¬„™â PBAC

204 Õ¿™‘“µ‘‚æ∏Õ‘–

µ“√“ß∑’Ë13.3 √–¥∫—§«“¡√πÿ·√ߢÕߪ√–®”‡¥Õ◊ πº¥‘ª°µ‘(¥¥—·ª≈ß®“°‡Õ° “√Õ“â ßÕß‘À¡“¬‡≈¢ 19)

√–¥∫—§«“¡√πÿ·√ß Õ“°“√

√–¥∫—∑Ë’1 ‡≈Õ◊ ¥ÕÕ°º¥‘ª°µ∑‘“ß™Õà ߧ≈Õ¥‡≈°ÁπÕâ ¬ ‰¡®à ”‡ªπìµÕâ ß„™ºâ “â Õπ“¡¬—
√–¥∫—∑Ë’2 ‡≈Õ◊ ¥ÕÕ°º¥‘ª°µ∑‘“ß™Õà ߧ≈Õ¥ ·µ¡à ª’√¡‘“≥¡“°¢πÈ÷ ®”‡ªπìµÕâ ß„™ºâ “â Õπ“¡¬—
√–¥∫—∑’Ë3 ‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘∑“ß™àÕߧ≈Õ¥ ·µà¡ª’√‘¡“≥¡“°¢È÷π ®”‡ªìπµâÕß„™âºâ“Õπ“¡—¬ µâÕß√—°…“
√–¥∫—∑Ë’4 ¥«â ¬°“√„À‡â ≈Õ◊ ¥ ·≈–√∫—‡¢“â √°—…“·∫∫ºªâŸ«É ¬„π
‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘∑“ß™àÕߧ≈Õ¥ ·µà¡’ª√‘¡“≥¡“°¢È÷π ®”‡ªìπµâÕß„™âºâ“Õπ“¡—¬ µâÕß√—°…“
¥«â ¬°“√„À‡â ≈Õ◊ ¥ ·≈–¡ ’≠— ≠“≥™æ’‡ª≈¬’Ëπ·ª≈ß

ë Naproxen ¢π“¥ 275 ¡°. √∫—ª√–∑“𠬓§ÿ¡°”‡π‘¥™π‘¥ŒÕ√å‚¡π√«¡ “¡“√∂≈¥
∑°ÿ 6 ™«—Ë‚¡ß ª√¡‘“≥‡≈Õ◊ ¥∑Õ’ËÕ°√–À«“à ß¡ª’√–®”‡¥Õ◊ π‚¥¬°“√∑”„Àâ
·π–π”„À√â ∫—ª√–∑“𬓄π√ªŸ·∫∫¥ß—°≈“à «‡ªπì ‡¬ÕË◊ ∫‚ÿæ√ß¡¥≈°ŸΩÕÉ ·≈–≈¥ª√¡‘“≥‡≈Õ◊ ¥≈߉¥ªâ √–¡“≥
‡«≈“ 3-6 √Õ∫ª√–®”‡¥Õ◊ π ·¡«â “à „πª®í®∫ÿπ— ®–¬ß— √Õâ ¬≈– 409 ·π–π”„À„â ™µâ ¥‘µÕà °π—‡ªπ쇫≈“ 3-6 ‡¥Õ◊ π
¡¢’Õâ ¡≈Ÿ®”°¥—∂ß÷ª√– ∑‘∏¿‘“æ¢Õ߬“µ“â π°“√Õ°—‡ ∫ ª√–‚¬™πåπÕ°‡Àπ◊Õ®“°°“√™à«¬≈¥ª√‘¡“≥‡≈◊Õ¥
∑‰’Ë¡„à ™ à ‡µ¬’√Õ¬¥™å 𥑠selective COX-2 inhibi- ª√–®”‡¥Õ◊ π‰¥·â °à “¡“√∂„™‡â æÕË◊ °“√°“√§¡ÿ°”‡π¥‘‰¥â
tor „π°“√π”¡“„™â≈¥ª√‘¡“≥‡≈◊Õ¥∑Ë’ÕÕ°√–À«à“ß¡’ ®÷߇À¡“–°—∫ºŸâ∑’˵âÕß°“√§ÿ¡°”‡π‘¥Õ¬àŸ πÕ°®“°πÈ’
ª√–®”‡¥◊Õπ ·µà‡π◊ËÕß®“°¬“°≈ÿà¡πÈ’¡’°≈‰°„πÕÕ° ¬ß—™«à ¬≈¥Õ“°“√ª«¥ª√–®”‡¥Õ◊ π‰¥Õâ °’¥«â ¬
ƒ∑∏Ï‘∑Ë’‡¬◊ËÕ∫ÿ‚æ√ß¡¥≈Ÿ°‡™àπ‡¥’¬«°—∫∑Ë’æ∫„𬓵“â π 3.2 °“√√°—…“¥«â ¬°“√„ Àà «à ߧ¡ÿ°”‡π¥‘∑¡Ë’’
°“√Õ°—‡ ∫∑‰’Ë¡„à ™ à ‡µ¬’√Õ¬¥∑å ”„Àπâ “à ®– “¡“√∂π”¡“ ‚ª√‡® µπ‘†(IUD)
„™â≈¥ª√‘¡“≥‡≈◊Õ¥∑Ë’ÕÕ°√–À«à“ß¡’ª√–®”‡¥◊Õπ‰¥â °“√„™â progesterone-releasing intrauterine
‡™πà ‡¥¬’«°π— device ®–™à«¬≈¥ª√‘¡“≥‡≈◊Õ¥∑’ËÕÕ°√–À«à“ß¡’
2.† °“√„™¬â “ antifibrinolytic agent ª√–®”‡¥Õ◊ π≈߉¥ªâ √–¡“≥√Õâ ¬≈– 75 ∂ß÷√Õâ ¬≈– 959
¬“∑Ë’„™â‰¥â·°à tranexamic acid ÕÕ°ƒ∑∏‘Ï πÕ°®“°πÈ’¬—ß –¥«°„π°“√„™â‡πË◊Õß®“°‰¡àµâÕß
¬∫—¬ßÈ—°“√ √“â ß plasminogen ·π–π”„À„â ™¢â π“¥ 1 √∫—ª√–∑“π¬“Õ¬“à ßµÕà ‡πÕË◊ ß∑”„À‰â ¥√â ∫—°“√¬Õ¡√∫— ßŸ
°√—¡ √—∫ª√–∑“π∑ÿ° 6 ™—Ë«‚¡ß „π 4 «—π·√°¢Õß ·≈–¡’º≈¢â“߇§’¬ßπâÕ¬ ªí®®ÿ∫—π·π–π”„Àâæ‘®“√≥“
√Õ∫ª√–®”‡¥Õ◊ 𠇪π쇫≈“ 3-6 √Õ∫¢Õߪ√–®”‡¥Õ◊ π ∂÷ß°“√„™â progesterone-releasing intrauterine
‚¥¬®– “¡“√∂≈¥ª√‘¡“≥‡≈◊Õ¥∑Ë’ÕÕ°√–À«à“ß¡’ device ‡ªìπ°“√√—°…“Õ—π¥—∫·√° ”À√—∫¿“«–
ª√–®”‡¥◊Õπ‰¥âª√–¡“≥√âÕ¬≈– 40 º≈¢â“߇§’¬ß∑Ë’ ovulatory DUB
 ”§—≠‰¥â·°à Õ“°“√§≈Ë◊π‰ â·≈–°“√‡°‘¥µ–§√‘«∑’Ë 3.3 °“√„™Œâ Õ√‚å¡π™π¥‘Õπ◊Ëʆ
∫√‘‡«≥¢“9 Õ¬“à ߉√°Á¥’tranexamic acid ‰¡¡à ’º≈ ŒÕ√‚å ¡π™π¥‘Õπ◊ËÊ ∑¡’Ë°’“√π”¡“„™√â °—…“¿“«–
„π°“√™«à ¬≈¥Õ“°“√ª«¥ª√–®”‡¥Õ◊ π ovulatory DUB ‰¥â·°à ŒÕ√å‚¡π‚ª√‡® µ‘π™π‘¥
3. °“√„™Œâ Õ√‚å¡π √∫—ª√–∑“π danazol ·≈– GnRH agonist ‚¥¬¡’
3.1 °“√„™¬â “§¡ÿ°”‡π¥‘™π¥‘ŒÕ√‚å¡π√«¡† ª√– ‘∑∏‘¿“æ„°≈⇧’¬ß°—∫°“√„™â¬“µâ“π°“√Õ—°‡ ∫∑’Ë

ªí≠À“ª√–®”‡¥Õ◊ πº‘¥ª°µ‘„π«—¬√πÿà Abnormal Menstruation in Adolescents 205

‰¡à„™à ‡µ’¬√Õ¬¥å ¬“§ÿ¡°”‡π‘¥™π‘¥ŒÕ√å‚¡π† ·≈– ∑‡’ËÀ¡“– ¡°«“à
°“√„™âÀà«ß§ÿ¡°”‡π‘¥∑Ë’¡’‚ª√‡® µ‘π ·µà‡πË◊Õß®“°¡’ 2. °“√√—°…“‚¥¬°“√„™â¬“‡¡Á¥§ÿ¡°”‡π‘¥
º≈¢â“߇§’¬ß®“°°“√„™â¬“∑”„À≡àπ‘¬¡„™â„π°“√ ™π¥‘ŒÕ√‚å¡π√«¡
√°—…“≈”¥∫—·√° ¬“‡¡Á¥§ÿ¡°”‡π‘¥™π‘¥ŒÕ√å‚¡π√«¡ “¡“√∂
4.† °“√√°—…“¥«â ¬°“√º“൥— π”¡“„™√â °—…“ anovulatory bleeding ∑¡Ë’ª’√¡‘“≥
† ª√–°Õ∫¥â«¬°“√®È’∑”≈“¬‡¬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ° ¡“°·≈–√–¬–‡«≈“π“π‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ °“√
·≈–°“√µ¥—¡¥≈°Ÿ ´ß÷Ë®–‡≈Õ◊ °„™‡â ©æ“–„π√“¬∑‰’Ë¡‰à ¥â „™â¬“§ÿ¡°”‡π‘¥‡æË◊Õ√—°…“¿“«–‡≈◊Õ¥ÕÕ°º‘¥ª°µ‘¡’
º≈®“°°“√√°—…“¥«â ¬¬“¡“·≈«â ‡∑“à ππÈ— À≈“¬«‘∏’∑’Ë¡’ª√– ‘∑∏‘¿“æ„π°“√√—°…“‡∑à“°—π ‰¡à«à“
† °“√√°—…“¿“«– anovulatory DUB ®–‡ªπì
1. °“√√°—…“‚¥¬°“√„™‚âª√‡® µπ‘ - ¬“§ÿ¡°”‡π‘¥™π‘¥ monophasic ‚¥¬„Àâ
‚ª√‡® µπ‘(progestin) ¡ƒ’∑∏µÏ‘“â π‡Õ ‚µ√‡®π §√ßÈ—≈– 1 ‡¡¥Á «π—≈– 2 §√ß—ÈÕ¬“à ßµÕà ‡πÕË◊ ß  “¡“√∂
Õ¬“à ß√πÿ·√ß‚¥¬®–‰ª°√–µπÿâ 17beta-hydroxysteroid ∑”„À‡â ≈Õ◊ ¥ª√–®”‡¥Õ◊ πÕÕ°πÕâ ¬≈߉¥¿â “¬„π 24-48
dehydrogenase ·≈– sulfotransferase ∑”„Àâ ™—Ë«‚¡ß ‚¥¬„Àâª√‘¡“≥ 2 ‡¡Á¥µàÕ«—ππ“π 5-7 «—π
‡Õ ‚µ√‡®π∂°Ÿ‡ª≈¬Ë’π‡ªπì estrone sulfate ´ßË÷®– À≈ß—‡≈Õ◊ ¥≈¥≈ßÀ≈ß—®“°ππ—È·≈«â ®ß÷‡ª≈¬Ë’π‡ªπì«π—≈–1
∂Ÿ°¢—∫ÕÕ°®“°√à“ß°“¬‚¥¬‡√Á«21 πÕ°®“°πÈ’‚ª√‡® §√ßÈ—µÕà ‰ª®πÀ¡¥·ºß
 µπ‘¬ß—®–≈¥®”π«π receptor ¢Õ߇ՠ‚µ√‡®π ∑”„Àâ - ¬“§¡ÿ°”‡π¥‘™π¥‘monophasic∑¡’˪’√¡‘“≥
°“√Àπ“µ—«¢Õ߇¬◊ËÕ∫ÿ‚æ√ß¡¥≈Ÿ°≈¥≈ß ¥—ßπÈ—π„π ethinyl estradiol Õ¬“à ßπÕâ ¬ 30 ¡§°. «π—≈– 3 §√ß—È
°“√√°—…“ anovulatory DUB  “¡“√∂„™‚â ª√‡® µπ‘9 ®π‡≈◊Õ¥ÕÕ°πâÕ¬≈ß ®÷ߧàÕ¬Ê ≈¥¢π“¥¬“‡À≈◊Õ
‡æÕË◊ ∑”„À‡â °¥‘ progesterone withdrawal bleeding «π—≈– 2 §√ߗȇªπ쇫≈“ 5 «π— ·≈–≈¥≈ß®π‡À≈Õ◊ «π—≈–
‰¥â ‚¥¬¡«’∏‘°’“√„À¬â “µ“à ßÊ °π— ¥ß—πÈ’ 1 §√ßÈ— ®π§√∫ 21 «π— ‚¥¬æ®‘“√≥“«π—≈– 2 §√ß—È
- Medroxyprogesterone acetate 5-10 µàÕ‡πË◊Õß®π§√∫ 21 «—π „π°√≥’∑’Ë¡’‡≈◊Õ¥ÕÕ°¡“°
¡°. µÕà «π— ‡ªπì√–¬–‡«≈“ 10-14 «π—µÕà ‡¥Õ◊ π ‚¥¬ ¢≥–√∫—ª√–∑“𬓫π—≈– 1 §√ßÈ—25 „π°√≥∑’¡Ë’‡’≈Õ◊ ¥
‡√¡‘Ë„π«π—∑Ë’16-25 ¢Õß√Õ∫‡¥Õ◊ π22 À√Õ◊ Õ“®„À„â π™«à ß ÕÕ°ª√‘¡“≥¡“° °“√æ‘®“√≥“„À⬓§ÿ¡°”‡π‘¥™π‘¥
10-12 «π—·√°¢Õß∑°ÿ‡¥Õ◊ π23-25 ŒÕ√å‚¡π√«¡¢π“¥ Ÿß°Á‡ªìπ∑“߇≈◊Õ°∑Ë’‡À¡“– ¡
- Norethindrone acetate 5 ¡°. µÕà «π— ‚¥¬®–„™â¬“∑’Ë¡’estradiol 50 ¡§°. √à«¡°—∫
‚¥¬∑°ÿ„π™«à ß 10-12 «π—·√°¢Õß∑°ÿ‡¥Õ◊ π25 norgestrol 0.5 ¡°. À√Õ◊ norethindrone 1 ¡°.25
- Micronize oral progesterone 200 ¡°. „πºâŸªÉ«¬∫“ß√“¬∑Ë’¡’¢âÕÀâ“¡¢Õß°“√„™â‡Õ -
«π—≈– 1 §√ß—È „π™«à ß 12 «π—·√°¢Õ߇¥Õ◊ π À√Õ◊ ‡ªπì ‚µ√‡®π„π¢π“¥ Ÿß ‚¥¬‡©æ“–„πºŸâªÉ«¬∑Ë’¡’§«“¡
√–¬–‡«≈“ 12 «π— ‡√¡‘Ë®“°«π—∑’Ë14 ¢Õß√Õ∫‡¥Õ◊ π (À√Õ◊ ‡ ’ˬߵàÕ¿“«–À≈Õ¥‡≈◊Õ¥Õÿ¥µ—π Õ“®æ‘®“√≥“„À⬓
«π—∑Ë’10 ¢Õß√Õ∫‡¥Õ◊ πÀ“°¡ª’√–®”‡¥Õ◊ π¡“°Õà π)25 §Aÿ¡C°C”‡Pπ2‘¥6™π·‘¥π∑–Ë’¡π’·”µ„Àà‚ªâ√√–‡«®—ß °‡µ“√Õ„‚™√π⬓§„πÿ¡°°“”√‡ªπ√‘¥–∑™’Ë¡ÿ¡’
°“√„™â‚ª√‡® µ‘π‡ªìπ√Õ∫Ê π—È𠉥âº≈¥’„π
ºªŸâ «É ¬∑‰Ë’¡¡à °’“√µ°‰¢‡à °¥‘¢πÈ÷‡≈¬ ·µÀà “°ºªŸâ «É ¬¬ß—¡’ ŒÕ√‚å ¡π‡Õ ‚µ√‡®π„πºªŸâ «É ¬∑¡Ë’¿’“«–≈¡Ë‘‡≈Õ◊ ¥Õ¥ÿµπ—
°“√µ°‰¢Õà ¬∫àŸ“â ß À√Õ◊ µÕâ ß°“√∑®Ë’–§¡ÿ°”‡π¥‘¥«â ¬ππ—È ‚¥¬·π–π”„Àℙ⬓∑’Ë¡’ à«πº ¡¢ÕߌÕ√å‚¡π‚ª√
°“√„™â¬“‡¡Á¥§ÿ¡°”‡π‘¥™π‘¥ŒÕ√å‚¡π√«¡ ®–‡ªìπ«‘∏’ ‡® ‡µÕ‚√πÕ¬à“߇¥’¬«®–ª≈Õ¥¿—¬°«à“ À√◊ÕÕ“®„™â

206 Õ¿‘™“µ‘‚æ∏Õ‘–

tranexamic acid ·∑π„πºŸâªÉ«¬∑Ë’¡’‡≈◊Õ¥ÕÕ°∑“ß ¥≈.)11, 24
™àÕߧ≈Õ¥√–À«à“ß∑Ë’„™â¬“ ≈“¬≈Ë‘¡‡≈◊Õ¥ ·≈–‰¡à „πºªŸâ «É ¬∑¡Ë’§’«“¡≈”∫“°„π°“√√∫—ª√–∑“π¬“
·π–π”„Àâª√—∫≈¥¢π“¥¬“ ≈“¬≈Ë‘¡‡≈◊Õ¥ ‡æ√“–®– ‡¡Á¥§ÿ¡°”‡π‘¥  “¡“√∂∑Ë’®–„™â¬“§ÿ¡°”‡π‘¥™π‘¥©’¥
∑”„À¿â “«–À≈Õ¥‡≈Õ◊ ¥Õ¥ÿµπ—°≈∫—¡“‡°¥‘´È”‰¥â °≈“à « ‡¢“â °≈“â ¡ (depot-medroxyprogesterone acetate)
‚¥¬ √ÿª·π–π”„Àℙ⇪ìπ norethindrone acetate ¢π“¥ 150 ¡°. ©¥’‡¢“â °≈“â ¡∑°ÿ 3 ‡¥Õ◊ π ‡æÕË◊ §¡ÿ
(5-10 ¡°.) À√◊Õ micronized progesterone √Õ∫‡¥Õ◊ π·∑π‰¥â ·µÕà “®∑”„À‡â °¥‘‡≈Õ◊ ¥ÕÕ°°–ª√∫‘-
(200 ¡°.) √∫—ª√–∑“π∑°ÿ 4 ™«—Ë‚¡ß®π‡≈Õ◊ ¥À¬¥ÿ °–ª√Õ¬‰¥â ´Ë÷ßÕ“®∫¥∫—ßÕ“°“√¢Õß‚√§ÕË◊πÊ ‰¥â
·≈«â ®ß÷√∫—ª√–∑“π§√ßÈ—≈– 1 ‡¡¥Á «π—≈– 4 §√ßÈ—‡ªπì √ªÿ¬“§¡ÿ°”‡π¥‘∑„Ë’™∫â Õà ¬ ¥ß—· ¥ß„πµ“√“ß∑Ë’13.4
‡«≈“ 4 «π— «π—≈– 3 §√ß—È ‡ªπ쇫≈“ 3 «π— ·≈«â ®ß÷ 3. °“√√°—…“‚¥¬°“√„™ŒâÕ√‚å¡π‡Õ ‚µ√‡®π
µàե⫬«—π≈– 2 §√—ÈßÕ’° 2  —ª¥“Àå ‚¥¬À≈—ß®“° °“√∑’Ë¡’‡≈◊Õ¥ª√–®”‡¥◊ÕπÕÕ°¡“°·≈–π“π
À¬¥ÿ¬“®–¡‡’≈Õ◊ ¥ª√–®”‡¥◊ÕπÕÕ°¡“Õ°’§√ßÈ—„π 2-4 π—Èπ¡—° —¡æ—π∏å°—∫‡¬Ë◊Õ∫ÿ‚æ√ß¡¥≈Ÿ°∑’ËÀπ“µ—« ·≈–
«π— À≈ß—®“°ππ—È„À√â ∫—ª√–∑“𬓧¡ÿ°”‡π¥‘µ“¡ª°µ‘  “¡“√∂„Àâ°“√√—°…“‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ¥â«¬¬“
µàÕ‰ªÕ¬à“ßπâÕ¬ 3-6 ‡¥◊Õπ ®– “¡“√∂∑”„Àâ‡≈◊Õ¥ ‡¡Á¥§ÿ¡°”‡π‘¥ À√◊Õ‚ª√‡® µ‘π ·µà∫“ߧ√È—ß°“√¡’
ª√–®”‡¥◊Õπ≈¥≈߉¥â∂÷ß√âÕ¬≈– 60 ¢Õß√Õ∫‡¥◊Õπ ‡≈◊Õ¥ª√–®”‡¥◊ÕπÕÕ°¡“°π—Èπ°àÕ„À⇰‘¥‡¬Ë◊Õ∫ÿ‚æ√ß
ª°µ2‘2, 25 ·≈–¬ß— “¡“√∂≈¥Õ“°“√ª«¥ª√–®”‡¥Õ◊ π ¡¥≈Ÿ°∑’Ë∫“ß ´÷Ëß°“√„™â‡Õ ‚µ√‡®π¢π“¥ Ÿß‡ªìπ°“√
‰¥Õâ °’¥«â ¬ √—°…“‡∫È◊Õßµâπ∑Ë’¥’∑’Ë ÿ¥ ‚¥¬®–¡’«‘∏’°“√„À⬓∑Ë’·µ°
°“√√∫—ª√–∑“𬓧¡ÿ°”‡π¥‘‡æÕ◊˧¡ÿ√Õ∫‡¥Õ◊ 𠵓à ß°π—µ“¡ª√¡‘“≥¢Õߪ√–®”‡¥Õ◊ π∑Õ’ËÕ° ¥ß—πÈ’
„π√–¬–¬“«™à«ß 3-6 ‡¥Õ◊ πÀ≈ß—°“√√—°…“ππ—È ®–„™â - „π°√≥∑’‡’Ë≈Õ◊ ¥ª√–®”‡¥Õ◊ πÕÕ°¡“° „À„â ™â
¬“§ÿ¡°”‡π‘¥∑’Ë¡’ethinyl estradiol Õ¬à“ßπâÕ¬ 30 conjugated equine estrogen 25 ¡°. ∑“ßÀ≈Õ¥
¡§°. ‚¥¬√∫—ª√–∑“π 21 «π— À¬¥ÿ 7 «π— „π°√≥∑’Ë’ ‡≈Õ◊ ¥¥”∑°ÿ 4 ™«Ë—‚¡ß ®π‡≈Õ◊ ¥ÕÕ°πÕâ ¬≈ß3 ‡ªπì«∏‘’
¡¿’“«–‡≈Õ◊ ¥®“߉¡¡à “° (√–¥∫—Œ‚’¡‚°≈∫π‘¡“°°«“à 10 ∑’Ë¡’ª√– ‘∑∏‘¿“æ‚¥¬‡™◊ËÕ«à“°“√„Àâ‡Õ ‚µ√‡®π∑“ß
¡°./¥≈.) À√◊ÕÕ“®æ‘®“√≥“„À⬓§ÿ¡°”‡π¥‘·∫∫µÕà À≈Õ¥‡≈◊Õ¥¥”®–‰ª°√–µÿâπ°“√·¢Áßµ—«¢Õ߇≈◊Õ¥∑Ë’
‡π◊ËÕß ‡æË◊Õ≈¥ª√‘¡“≥‡≈◊Õ¥∑’ËÕÕ°„πºŸâªÉ«¬∑’Ë¡’¿“«– ∫√‡‘«≥À≈Õ¥‡≈Õ◊ ¥ΩÕ¬27, 28 †·µ‰à ¡§à «√„À‡â °π‘ 6 §√ß—È
‡≈Õ◊ ¥®“ß¡“° (√–¥∫—Œ‚’¡‚°≈∫π‘πÕâ ¬°«“à 10 ¡°./ ‡π◊ËÕß®“°¡’§«“¡‡ Ë’¬ßµàÕ°“√‡°‘¥≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π„π

µ“√“ß∑Ë’13.4 ™π¥‘¢ÕߌÕ√‚å ¡π·≈–°“√∫√À‘“√¬“‡æÕ◊Ë„™„â π°“√À¬¥ÿ‡≈Õ◊ ¥∑Õ’ËÕ°®“°¡¥≈°Ÿ (¥¥—·ª≈ß®“°‡Õ° “√
Õ“â ßÕß‘À¡“¬‡≈¢ 22, 25)

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‡Õ ‚µ√‡®π ¢π“¥·≈–«∏‘°’“√∫√À‘“√¬“
‡Õ ‚µ√‡®π
¬“‡¡¥Á§¡ÿ°”‡π¥‘™π¥‘ŒÕ√‚å¡π√«¡ 25 ¡°. ©¥’∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥” ∑°ÿ 4 ™«Ë—‚¡ß ®π‡≈Õ◊ ¥À¬¥ÿ
¬“‡¡¥Á§¡ÿ°”‡π¥‘™π¥‘ŒÕ√‚å¡π√«¡ 2.5 ¡°. √∫—ª√–∑“π ∑°ÿ 6-8 ™«Ë—‚¡ß‡ªπ쇫≈“ 7 «π—
√∫—ª√–∑“π 1 ‡¡¥Á ∑°ÿ 6-8 ™«—Ë‚¡ß‡ªπ쇫≈“ 7 «π—
√∫—ª√–∑“π 1 ‡¡¥Á ∑°ÿ 8 ™«Ë—‚¡ß„π 3 «π—·√°
∑°ÿ 12 ™«—Ë‚¡ß„π 3 «π—∂¥—‰ª

ªí≠À“ª√–®”‡¥◊Õπº¥‘ª°µ‘„π«—¬√àπÿ Abnormal Menstruation in Adolescents 207

ªÕ¥‰¥2â 8 ‡Õ ‚µ√‡®π¢π“¥ Ÿß„πºâŸªÉ«¬∑Ë’¡’ª√–«—µ‘§√Õ∫§√—«
- „π°√≥’∑Ë’‡≈◊Õ¥ª√–®”‡¥◊ÕπÕÕ°ª“π°≈“ß À√Õ◊ ‡§¬¡ª’√–«µ—‡‘ ¬’Ëß∑®’Ë–‡°¥‘≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—¡“°Õà π
„Àâ„™â conjugated estrogen 1.25 ¡°. À√◊Õ ·≈–º≈¢â“߇§’¬ß∑’Ëæ∫‰¥â∫àÕ¬Õ’°ª√–°“√Àπ÷Ëߧ◊Õ
micronized estradiol 2 ¡°. ∑°ÿÊ 4-6 ™«—Ë‚¡ß °“√‡°‘¥§≈◊Ëπ‰ âÕ“‡®’¬π ¥—ßπ—Èπ °“√„À⬓≈¥Õ“°“√
‡ªπ쇫≈“ 24 ™«—Ë‚¡ß ·≈«â ®ß÷≈¥¢π“¥¬“‡À≈Õ◊ «π—≈– §≈πË◊ ‰ â ‡™πà promethazine 12.5-25 ¡°. °Õà π°“√
1 §√ߗȵÕà Õ°’ 7-10 «π— „À¬â “ 1 ™«Ë—‚¡ß®–™«à ¬≈¥Õ“°“√‰¥¡â “°25
- „π°√≥’∑’ˇ≈◊Õ¥ª√–®”‡¥◊ÕπÕÕ°‡≈Á°πâÕ¬ 4. °“√√°—…“‚¥¬«∏‘°’“√¢¥Ÿ¡¥≈°Ÿ
 “¡“√∂„À√â ∫—ª√–∑“π conjugated estrogen 1.25 ‡ªìπ«‘∏’∑’Ë¡’ª√– ‘∑∏‘¿“æÕ¬à“ß¡“°„π°“√À¬ÿ¥
¡°. À√Õ◊ micronized estradiol 2 ¡°. «π—≈– 1 ‡≈◊Õ¥∑Ë’ÕÕ° ‚¥¬‡©æ“–„π√“¬∑Ë’¡’ —≠≠“≥™’æ
§√ßÈ—‡ªπ쇫≈“ 7-10 «π— ‡ª≈¬’Ëπ·ª≈ß∑‰Ë’¡‰à ¥‡â °¥‘®“°æ¬“∏ ‘¿“æÕπË◊ Ê29 À√Õ◊ „π
‰¡«à “à ®–„™¬â “«∏‘„’¥ §«√®–„À°â “√√°—…“µÕà ¥«â ¬ º∑⟉˒¡µà Õ∫ πÕßµÕà °“√„À‡â Õ ‚µ√‡®π¢π“¥ ßŸ9,30, 31
‚ª√‡® µπ‘À√Õ◊ ¬“‡¡¥Á§¡ÿ°”‡π¥‘™π¥‘ŒÕ√‚å ¡π√«¡µÕà
πÕ°®“°π°È’“√„™‡â Õ ‚µ√‡®π¬ß—¡ª’√–‚¬™π„å π°“√√°—…“ ∫∑ √ªÿ
progesterone breakthrough bleeding „πºâŸ∑’Ë ª≠í À“ª√–®”‡¥Õ◊ πº¥‘ª°µπ‘∫—‰¥«â “à ‡ªπìª≠í À“
√∫—ª√–∑“𬓇¡¥Á§¡ÿ°”‡π¥‘™π¥‘ŒÕ√‚å ¡π√«¡ À√Õ◊ ¬“ „À≠∑à æË’∫‰¥∫â Õà ¬„π µ√«’¬—‡®√≠‘ æπ—∏ÿå «¬—√πÿà °“√´°—
©¥’§¡ÿ°”‡π¥‘‰¥â ‚¥¬°“√„Àâ conjugated estrogen ª√–«µ—Õ‘¬à“ß≈–‡Õ’¬¥ °“√µ√«®√à“ß°“¬ ·≈–°“√ àß
1.25 ¡°. À√◊Õ micronized estradiol 2 ¡°. µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√‡æ◊ËÕ„À≥Ⱃ√«‘π‘®©—¬ π—∫
«π—≈– 1 §√ߗȇªπ쇫≈“ 7-10 «π— ‰¥â«à“‡ªìπæ◊Èπ∞“π¢Õß°“√√—°…“ºŸâªÉ«¬∑Ë’¡’ªí≠À“
¢Õâ §«√√–«ß—„π°“√„™‡â Õ ‚µ√‡®πª√¡‘“≥ ßŸ§Õ◊ ª√–®”‡¥Õ◊ πº¥‘ª°µ‘‚¥¬‡©æ“–Õ¬“à ߬ßË‘ À“°ºªŸâ «É ¬
°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π ‚¥¬‡©æ“–„πºâŸªÉ«¬∑’Ë¡’ ¡§’«“¡√πÿ·√ߢÕ߇≈Õ◊ ¥∑ÕË’Õ°¡“° ®”‡ªπìµÕâ ߉¥√â ∫—
ªí®®—¬‡ Ë’¬ß ¥—ßπÈ—π·æ∑¬å®÷ß®”‡ªìπµâÕßæ‘®“√≥“∂÷ß °“√«π‘®‘©¬—§«∫§‰Ÿà ª°∫—°“√√°—…“Õ¬“à ß∑π—∑«à ß∑’
¢âÕ¥’·≈–¢âÕ‡ ’¬¢Õß°“√√—°…“ ·≈–À≈’°‡≈Ë’¬ß°“√„™â

‡Õ° “√Õ“âßÕß‘ 3. Falcone T, Desjardins C, Bourque J, Granger
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6. OûConnor KA, Holman DJ, Wood JW. Menstrual functional defects in women with unexplained
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∫∑∑Ë’

¿“«–≈Ë¡‘‡≈Õ◊¥Õ¥ÿµ—π„π‚√ß欓∫“≈

14 Thromboembolism in Hospital

™“≠™¬— ‰µ√«“√’

¿“«–≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ— (thromboembolism) °“√√Õ¥™«’µ‘ ßŸ¢π÷È„πºªâŸ«É ¬‡¥°Á ¥ß—ππÈ—°“√¥·Ÿ≈ºªŸâ «É ¬
„π‡¥Á°æ∫«à“∂â“ “¡“√∂«‘π‘®©—¬·≈–√—°…“‰¥âÕ¬à“ß ‡¥Á°∑’Ë¡’¿“«–≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π„π‚√ß欓∫“≈‡ªìπÕ’°
√«¥‡√Á«®– “¡“√∂‡æË‘¡Õ—µ√“°“√√Õ¥™’«‘µ‰¥âÕ¬à“ß ‡√ÕË◊ ßÀπß÷Ë∑¡Ë’§’«“¡ ”§≠—
™—¥‡®π  “¡“√∂æ∫‰¥â„πÀ≈Õ¥‡≈◊Õ¥¥”·≈–À≈Õ¥
‡≈◊Õ¥·¥ß ‚¥¬Õÿ∫—µ‘°“√≥å°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π„π  “‡Àµÿ
‡¥°Á æ∫‰¥ªâ √–¡“≥ 0.07 ∂ß÷ 0.14 √“¬µÕà ‡¥°ÁÀπßË÷ 1. §«“¡º¥‘ª°µ∑‘“ßæπ—∏°ÿ√√¡(congenital
À¡Ë◊π√“¬À√◊Õª√–¡“≥ 5.3 √“¬ µàÕ‡¥Á°Àπ÷ËßÀ¡Ë◊π thrombophilia)
√“¬∑Ë’√—°…“µ—«Õ¬àŸ„π‚√ß欓∫“≈ ™à«ßÕ“¬ÿ∑’Ëæ∫‰¥â ºŸâªÉ«¬°≈ÿà¡π’È®–¡’ª√–«—µ‘§√Õ∫§√—«∑’Ë¡’≈‘Ë¡
∫Õà ¬§Õ◊ ™«à ß∑“√°·√°‡°¥‘ª√–¡“≥ 24 √“¬ µÕà ‡¥°Á ‡≈Õ◊ ¥Õ¥ÿµπ—  «à π„À≠®à –‡ªπì „π™«à ßÕ“¬πÿÕâ ¬  ”À√∫—
Àπ÷ËßÀ¡Ë◊π√“¬∑’ËÕ¬àŸ„π‚√ß欓∫“≈1  ”À√—∫Õ’°™à«ß  “‡Àµÿπ—Èπ‡ªìπ‰¥âÀ≈“¬ “‡Àµÿ·∫à߇ªìπ°≈àÿ¡§«“¡
Õ“¬ÿÀπË÷ߧ◊Õ„π™à«ß«—¬√àÿπ ‚¥¬æ∫«à“«—¬√àÿπÀ≠‘ß®–¡’ º‘¥ª°µ‘¢Õß plasma-based ‡™àπ °“√¢“¥¢Õß
Õ∫ÿµ—°‘“√≥¡å “°∂ß÷ 2 ‡∑“à  ”À√∫—Õ∫ÿµ—°‘“√≥≈å ¡Ë‘‡≈Õ◊ ¥ protein C, protein S ·≈– antithrombin À√◊Õ
Õÿ¥µ—π„π‡¥Á°„πª√–‡∑»‰∑¬2 ¡’√“¬ß“πÕÿ∫—µ‘°“√≥å °“√‡æË‘¡¢÷Èπ¢Õß lipoprotein(a) ‡ªìπµâπ ·≈–
À≈Õ¥‡≈Õ◊ ¥·¥ßÕ¥ÿµπ—„π ¡Õß√Õâ ¬≈– 27 ≈¡Ë‘‡≈Õ◊ ¥ °≈¡àÿ§«“¡º¥‘ª°µ¢‘Õß DNA-based ‡™πà factor V
Õÿ¥µ—π„πÀ≈Õ¥‡≈◊Õ¥¥”√âÕ¬≈– 16 ≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π leiden (FV Leiden)  ”À√∫— congenital throm-
„πªÕ¥·≈–À—«„®√âÕ¬≈– 20 ∑È—ßπÈ’ºâŸªÉ«¬‚√§¡–‡√Áß bophilia „π‡¥Á° “¡“√∂µ√«®æ∫‰¥âµ—Èß·µà√âÕ¬≈–
·≈–‚√§À«—„®¡Õ’∫ÿµ—°‘“√≥√å Õâ ¬≈– 74 ‰¥¡â °’“√»°÷…“ 10 ∂ß÷√Õâ ¬≈– 626-8 ¢πÈ÷Õ¬°Ÿà ∫—≈°—…≥–¢Õߪ√–™“°√
„πª√–‡∑»‰∑¬3 æ∫¿“«–≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π„πÀ≈Õ¥ ™π‘¥¢Õß≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π ·≈–«‘∏’°“√µ√«®∑“ßÀâÕß
‡≈◊Õ¥¥”„π‡¥Á°∑’Ë√—∫‰«â„π‚√ß欓∫“≈ ¡’§à“‡©≈Ë’¬‡æ‘Ë¡ ªØ‘∫—µ‘°“√„π·µà≈–‚√ß欓∫“≈  ”À√—∫„πª√–‡∑»
 ßŸ¢πÈ÷®“° 3.9 √“¬ µÕà ‡¥°ÁÀπß÷ËÀ¡π◊Ë√“¬‡ªπì 15.4 ‰∑¬√“¬ß“π à«π„À≠à‡°Ë’¬«¢âÕß°—∫ plasma-based
√“¬µàÕ‡¥Á°ÀπË÷ßÀ¡◊Ëπ√“¬ „πª√–‡∑» À√—∞Õ‡¡√‘°“4 ‡™àπ °“√¢“¥¢Õß protein C, protein S ·≈–
æ∫‡æ‘Ë¡¢È÷π√âÕ¬≈– 70 ∑È—ßπ’ÈÕ“®‡πË◊Õß¡“®“°À≈“¬ antithrombin ‚¥¬‰¡æà ∫§«“¡‡°¬Ë’«¢Õâ ß°∫— DNA-
ªí®®—¬5 ‡™àπ °“√«‘π‘®©—¬∑’Ë¥’¢È÷π √«¡∂÷ß°“√„™â “¬ based ‡™πà FV Leiden ∑æË’∫¡“°‡À¡Õ◊ π„πª√–‡∑»
 «πÀ≈Õ¥‡≈◊Õ¥À√◊Õ central venous catheter µ–«π—µ°
(CVC) ·≈–¡’°“√√—°…“∑Ë’æ—≤π“¢È÷π∑”„Àâ¡’Õ—µ√“ 2. §«“¡º¥‘ª°µ∑‘‡’Ë°¥‘¢π÷È¿“¬À≈ß—(acquired

212 ™“≠™¬— ‰µ√«“√’

prothrombotic risk factors) Õ“°“√·≈–Õ“°“√· ¥ß
ª√–°Õ∫¥«â ¬ 4  “‡Àµ„ÿÀ≠Êà 9 §Õ◊ 1. Õ“°“√„π√–∫∫À≈Õ¥‡≈Õ◊¥¥”
2.1 °“√„™â “¬ «πÀ≈Õ¥‡≈◊Õ¥æ∫‰¥âµÈ—ß·µà  «à π„À≠¢à π÷ÈÕ¬°Ÿà ∫—µ”·Àπßà ¢Õß≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—∑’Ë
„π∑“√°·√°‡°‘¥ æ∫≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π‰¥â∂÷ß√âÕ¬≈– À≈Õ¥‡≈Õ◊ ¥¥” «à π∫π (upper extremity) ®–æ∫
90 „π¢≥–∑’ˇ¥Á°‚µæ∫‰¥âª√–¡“≥√âÕ¬≈– 50 ‚¥¬ √«à ¡°∫—ºªâŸ«É ¬∑„’Ë à CVC ¡°—‰¡§à Õà ¬¡Õ’“°“√∑™Ë’¥—‡®π
ªí®®—¬¢Õß°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π‡À≈à“πÈ’ ¢÷Èπ°—∫ ·µ∂à “â ¡Õ’“°“√°®Á–ª√–°Õ∫‰ª¥«â ¬ Õ“°“√∫«¡∫√‡‘«≥
ªí®®—¬À≈“¬Õ¬à“ß ‡™àπ µ”·Àπàß ¢π“¥¢Õß CVC ·¢πÀ√Õ◊  º’«‘∑‡’˪≈¬’Ëπ  ”À√∫—„π√“¬∑¡Ë’≈’¡‘ˇ≈Õ◊ ¥Õ¥ÿ
√«¡∂ß÷√–¬–‡«≈“∑„’Ë 1à 0  «à π„À≠ªà ≠í À“π¡È’°—®–æ∫ µ—π¢π“¥„À≠à„πÀ≈Õ¥‡≈◊Õ¥¥”™—Èπ≈÷°Õ“®∑”„À⇰‘¥
„πºªŸâ «É ¬Àπ«à ¬‡«™∫”∫¥—«°‘ƒµ5‘, 11 superior vena cava syndrome  ”À√—∫°“√‡°‘¥
2.2 ‚√§¡–‡√Áß„π‡¥Á°  à«π„À≠à¡—°®–æ∫‰¥â ≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π„πÀ≈Õ¥‡≈◊Õ¥¥”∑’ˉµ (renal vein
∫àÕ¬ ‚¥¬¡’≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π„πÀ≈Õ¥‡≈Õ◊ ¥¥”  “‡Àµÿ thrombosis) ºªâŸ«É ¬Õ“®®–¡“¥«â ¬ª í  “«–‡ªπì ‡≈Õ◊ ¥
¢Õß°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π‡°‘¥®“°ªí®®—¬¢Õß°“√ À√◊ÕºŸâªÉ«¬∑’Ë¡’≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π„πÀ≈Õ¥‡≈◊Õ¥¥”∑Ë’
„ à CVC °“√„À⬓‡§¡’∫”∫—¥∑’Ë„™â‚¥¬‡©æ“–¬“ Õ¬Ÿà™È—π≈÷° (deep vein thrombosis) ∫√‡‘«≥¢“
L-asparaginase ·≈–¬“„π°≈àÿ¡ corticosteroid ‚¥¬‡©æ“–„π°≈¡àÿ«¬—√πàÿ´ß÷˵Õâ ß√–«ß—‡æ√“–Õ“®æ≤—π“
πÕ°®“°πÈ—π¬—ßæ∫√à«¡°—∫¿“«–°“√µ‘¥‡™◊ÈÕ·≈–°“√ „À⇰‘¥≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π∑Ë’À≈Õ¥‡≈◊Õ¥·¥ß„πªÕ¥
¢“¥π”È ‡ªπì µπâ  «à π¡“°®–æ∫‰¥„â π√–¬– induction (pulmonary embolism) ´ß÷˺ªŸâ «É ¬À≈“¬√“¬®–¡“
¥«â ¬¬“‡§¡∫’”∫¥—12,13 ¥«â ¬Õ“°“√ÀÕ∫‡ÀπÕ◊ˬ ‡®∫ÁÀπ“â Õ° ‡ªπì µπâ
2.3 °≈ÿà¡Õ“°“√µâ“πøÕ ‚ø≈‘ªî¥ ∑È—ßπÈ’°“√ 2. Õ“°“√„π√–∫∫À≈Õ¥‡≈Õ◊¥·¥ß
‡°‘¥¿Ÿ¡‘§ÿâ¡°—πµàÕøÕ ‚ø≈‘ªî¥ (antiphospholipid  ”À√—∫Õ“°“√≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π„πÀ≈Õ¥‡≈◊Õ¥
antibody) ‡™πà lupus anticoagulant (LA), anti ·¥ß„π‡¥°Á «à π„À≠‡à °¥‘®“°À≈ß—∑” cardiac cathe-
beta2-glycoprotein I (anti-B2-GPI) antibody terization æ∫‰¥∂â ß÷√Õâ ¬≈– 40 (·µæà ∫«“à ∂“â ¡°’“√„Àâ
·≈– anticardiolipin antibody (ACA) √«à ¡°∫— heparin ªÑÕß°—π‰«â°àÕπ®–≈¥Õÿ∫—µ‘°“√≥å≈¥‡À≈◊Õ
°“√¡’≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π∑’ˇ°’ˬ«¢âÕß°—∫¿“«– autoim- √âÕ¬≈– 8)15  ”À√—∫°≈àÿ¡ non-catheter related
mune ‡ªπì  «à π„À≠à ®–æ∫„π°≈ÿà¡¢Õß°“√ª≈Ÿ°∂à“¬Õ«—¬«–„π à«π¢Õß
2.4 ≈¡Ë‘‡≈Õ◊ ¥Õ¥ÿµπ—„πÀπ«à ¬‡«™∫”∫¥—«°‘ƒµ‘ °“√µÕà À≈Õ¥‡≈Õ◊ ¥·¥ßÀ√Õ◊ À≈Õ¥‡≈Õ◊ ¥·¥ß‚ªßÉ æÕß
æ∫«“à ºªâŸ«É ¬ „π°≈¡àÿ‚√§À«—„®æ°‘“√·µ°à ”‡π¥‘¡‚’Õ°“  ®“°‚√§ Kawasaki ‡ªπì µπâ
‡°‘¥≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π„πÀ≈Õ¥‡≈◊Õ¥·¥ß Ÿß ∑—Èßπ’ÈÕ“® 3. ≈¡‘Ë ‡≈Õ◊¥Õ¥ÿµπ—„π ¡Õß
‡°¥‘®“°¿“«–¢“¥π”È√«à ¡°∫—ª®í ®¬—‡ ¬Ë’ß®“°°“√„  à “¬  «à π„À≠¿à “«–≈¡Ë‘‡≈Õ◊ ¥Õ¥ÿµπ—„π ¡Õß„π‡¥°Á
cardiac catheterization À√◊Õ°≈àÿ¡ºâŸªÉ«¬∑Ë’¡’¿“«– ®–¡“¥â«¬Õ“°“√™—°‡ªìπÀ≈—° ‚¥¬∑’Ë≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π
disseminated intravascular coagulation „πÀ≈Õ¥‡≈Õ◊ ¥·¥ß16 ®–¡“¥«â ¬Õ“°“√‡°√ßÁ™°—·≈–¡’
(DIC) ∑¡’Ë¿’“«– antithrombin À√Õ◊ protein C µË” ·¢π¢“ÕàÕπ·√ßµ“¡¡“ ·µà‡ªìπ∑Ë’πà“ —߇°µ«à“„π‡¥Á°
µ≈Õ¥®πºŸâªÉ«¬∑’ˉ¡à‰¥â‡§≈Ë◊Õπ‰À« (immobili- ∑“√°·√°‡°‘¥Õ“®®–æ∫·µàÕ“°“√™—° ‚¥¬Õ“®®–
zation) °Á®–‡ªìπªí®®—¬‡ Ë’¬ßµàÕ°“√‡°‘¥≈‘Ë¡‡≈◊Õ¥ ‡ÀÁπÕ“°“√·¢π¢“ÕàÕπ·√߉¡à™—¥‡®π∑”„À≥â√—∫°“√
Õ¥ÿµπ—‰¥1â 4 «‘π‘®©—¬∑Ë’º‘¥æ≈“¥  ”À√∫—≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—„πÀ≈Õ¥

¿“«–≈¡‘Ë ‡≈◊Õ¥Õÿ¥µ—π„π‚√ß欓∫“≈ Thromboembolism in Hospital 213

µ“√“ß∑Ë’14.1 ™π¥‘¢Õß√ß— «’π‘®‘©¬—„πºªŸâ «É ¬≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—„π‡¥°Á

µ”·Àπßà ¢Õß≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ— ™π¥‘¢Õß√ß— «’π‘®‘©¬—„™‡â ªπì ¡“µ√∞“π ™π¥‘¢Õß√ß— «’π‘®‘©¬—„™„â π∑“ߪØ∫‘µ—‘

≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—„πÀ≈Õ¥‡≈Õ◊ ¥¥” CTV Doppler ultrasound
≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—„πÀ≈Õ¥‡≈Õ◊ ¥·¥ß∑ª’ËÕ¥ CTPA V/Q scan

≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—„πÀ≈Õ¥‡≈Õ◊ ¥·¥ß CTA Echocardiography
≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—„π ¡Õß CTA, CTV, MRA, MRV Doppler ultrasound

CT, MRI

CTV = computed tomography venography, CTA = computed tomography arteriography
MRV = magnetic resonance venography, MRA = magnetic resonance arteriography
V/Q scan = ventilation/perfusion scan, MRI = magnetic resonance imaging,
CT = computed tomography, CTPA = computed tomography pulmonary angiography

‡≈Õ◊ ¥¥” ºªâŸ«É ¬®–¡“¥«â ¬Õ“°“√™°—‡ªπì À≈°— √«¡∂ß÷  ”À√—∫«‘∏’¡“µ√∞“π (gold standard) §◊Õ °“√
¡Õ’“°“√¢Õß°≈¡àÿ increased intracranial pressure µ√«®‚¥¬°“√©¥’ “√∑∫÷√ß— º’“à 𠓬 «πÀ≈Õ¥‡≈Õ◊ ¥
‡™πà ª«¥»√’…– Õ“‡®¬’πæßàÿ ‡ªπì µπâ ‚¥¬®–¢Õ°≈“à « (angiogram) ·µà‡ªìπ°“√µ√«®∑Ë’Õ“®®–‡°‘¥¿“«–
√“¬≈–‡Õ¬’¥„π∫∑∑’Ë15 ·∑√°´Õâ π‰¥â ®ß÷¡°—π¬‘¡‡≈¬Ë’߉ª∑” doppler ultra-
sound, CTV, MRV µ“¡µ“√“ß∑’Ë14.1
°“√«‘π‘®©—¬‚√§ 3. °“√ª√–‡¡π‘¥«â ¬¿“æ√ß— «’π‘®‘©¬—„πºªŸâ «É ¬

1. °“√„™â D-dimer ‚¥¬«‘∏’quantitative ≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—„πÀ≈Õ¥‡≈Õ◊ ¥·¥ß„πªÕ¥ (pulmo-
enzyme-linked immunosorbent assay (ELISA) nary embolism) ‡ªìπ∑Ë’∑√“∫°—π¥’«à“ºŸâªÉ«¬∑’Ë
∂◊Õ«à“‡ªìπ°“√µ√«®∑’Ë¡’§«“¡‰« (sensitivity)  Ÿß ‡ªìπ≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π„πÀ≈Õ¥‡≈◊Õ¥¥”¡’‚Õ°“ ∑Ë’®–
√Õâ ¬≈– 85-90 ·µ¡à §’«“¡®”‡æ“– (specificity) µ”Ë æ—≤𓉪‡°‘¥À≈Õ¥‡≈◊Õ¥·¥ßÕÿ¥µ—π„πªÕ¥‰¥â∂÷ß
√Õâ ¬≈– 50-8017‡ªπì °“√µ√«®‡æÕË◊ „™§â ¥—°√Õß„πºªâŸ«É ¬ √âÕ¬≈– 30-5018  à«π¡“°®–‡ªìπ°“√„™â¿“æ√—ß ’
∑Ë’ ß —¬≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π ‚¥¬∂◊Õ§à“∑’Ë Ÿß°«à“ 500 «‘π‘®©—¬√à«¡°—π∑—Èß ventilation/perfusion scan
π“‚π°√—¡/¡≈. ‡ªìπ§à“∑Ë’º‘¥ª°µ‘∂â“æ∫«à“Õ¬àŸ„π (V/Q scan), CTA pulmonary artery ·≈–
‡°≥±åª°µ‘ “¡“√∂∫Õ°‰¥â«à“‰¡àπà“®–¡’≈Ë‘¡‡≈◊Õ¥ echocardiography ∑—ÈßπÈ’·π«∑“ß°“√«‘π‘®©—¬¬—߉¡à¡’
Õ¥ÿµπ—‰¥∂â ß÷√Õâ ¬≈– 90 °Æ‡°≥±∑å ·’Ëππà Õπ ¢πÈ÷Õ¬°àŸ∫—Õ“°“√∑º’ËªâŸ«É ¬¡“· ¥ß
2. ¿“æ√ß— «’π‘®‘©¬—Õ“°“√∑“ߧ≈π‘°‘ “¡“√∂ „π°√≥’∑Ë’ºŸâªÉ«¬¡“¥â«¬ÀÕ∫‡Àπ◊ËÕ¬·≈–‰¡à¡’Õ“°“√
¬◊π¬—π‚¥¬°“√„™â§≈Ë◊π‡ ’¬ß§«“¡∂’Ë Ÿß™π‘¥ doppler ¢“∫«¡·π–π”„Àâ µ√«® V/Q scan À√◊Õ CTA
(doppler ultrasound) ‡Õ°´‡√¬å§Õ¡æ‘«‡µÕ√å pulmonary artery ‡ªπì Õ¬à“ß·√° „π°√≥’∑Ë’¡’°“√
À≈Õ¥‡≈◊Õ¥¥”/·¥ß (computed tomography µ√«® doppler ultrasound ¢ÕßÀ≈Õ¥‡≈Õ◊ ¥¥”·≈«â
venography/arteriography (CTV/CTA)) ‰¡àæ∫≈‘Ë¡‡≈◊Õ¥Õÿ¥µ—π·µà¡’°“√ ß —¬≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π
‡Õ¡ÁÕ“√‰å ÕÀ≈Õ¥‡≈Õ◊ ¥¥”/·¥ß (magnetic resonance „πÀ≈Õ¥‡≈Õ◊ ¥·¥ß„πªÕ¥ §«√ ßà µ√«® V/Q scan
venography/arteriography/(MRV/MRA)) À√Õ◊ CTA pulmonary artery19 µ“¡·ºπ¿¡Ÿ‘∑’Ë14.1

214 ™“≠™—¬ ‰µ√«“√’

°“√ ∫◊§πâ ‡æ¡‘Ë ‡µ¡‘ ”À√∫— “‡Àµ≈ÿ¡‘Ë ‡≈Õ◊¥Õ¥ÿµπ— ‰ª¥«â ¬ protein C, protein S, antithrombin, LA
„πª®í ®∫ÿπ—°“√µ√«®‡æ¡‘ˇµ¡‘ ”À√∫— “‡Àµ≈ÿ¡Ë‘ ·≈– factor VIII(FVIII) activity ‡ªπì À≈°—  ”À√∫—
°“√µ√«® FV Leiden, prothrombin mutation
‡≈◊Õ¥Õÿ¥µ—π„π‡¥Á°¢’ÈπÕ¬àŸ°—∫À≈“¬ªí®®—¬ª√–°Õ∫ G20210A ·≈– lipoprotein(a) „Àâæ‘®“√≥“‡ªìπ
¥«â ¬20,21 ≈°—…≥–Õ“°“√∑æ’Ë∫ Õ“¬∑ÿ‡Ë’√¡‘ˇªπì µ≈Õ¥ √“¬Ê ‰ª ¢÷ÈπÕ¬àŸ°—∫≈—°…≥–Õ“°“√· ¥ß∑Ë’æ∫ Õ“¬ÿ
®πªí®®—¬‡ ’ˬߢÕßµ—«ºâŸªÉ«¬‡Õß °“√µ√«® throm- ·≈–™«à ߇«≈“∑§’Ë«√µ√«®‰¥ â √ªÿ‰«µâ “¡µ“√“ß∑’Ë14.2
bophilia testing  ”À√∫—„πª√–‡∑»‰∑¬ ª√–°Õ∫

·ºπ¿¡Ÿ ∑‘ ’Ë14.1 ·π«∑“ß°“√«π‘®‘©¬—¿“«– deep vein thrombosis (DVT) ·≈– pulmonary embolism
(PE) „π‡¥°Á

V/Q scan = ventilotion/perfusion scan,
CT = computed tomography, CTPA = computed tomography pulmonary arteriography

¿“«–≈¡Ë‘‡≈◊Õ¥Õ¥ÿµπ—„π‚√ß欓∫“≈ Thromboembolism in Hospital 215

°“√√°—…“ ∑Ë’ª√–¡“≥ anti Xa 0.35-0.7 ¬Ÿπ‘µ/¡≈.∑’Ë4-6
°“√„™âantithrombotic agent „π‡¥°Á ™¡.À≈—ß°“√„À⬓  ”À√—∫„π∑’Ë∑’ˉ¡à “¡“√∂µ√«®‰¥â
1. Unfractionated heparin (UFH) ‡ªπì „Àªâ √–‡¡π‘¥«â ¬ activated partial thromboplastin
¬“µâ“π°“√·¢Áßµ—«¢Õ߇≈◊Õ¥∑’ˇªìπ∑Ë’π‘¬¡„π™à«ß·√° time (APTT) ‚¥¬√—°…“„À≥â√–¥—∫ª√–¡“≥
¢Õß°“√‡°‘¥≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π ‚¥¬‡©æ“–„πÀπ«à ¬‡«™ 60-85 «π‘“∑’∑ß—Èπ’Èanti-Xa ¡§’«“¡·¡πà ¬”¡“°°«“à
∫”∫—¥«‘°ƒµ‘‡πË◊Õß®“°¡’half-life  —Èπª√–¡“≥ APTT ‡π◊ËÕß®“°§«“¡·µ°µà“ߢÕßπ”Ȭ“ APTT
2 ™—Ë«‚¡ß ·≈– “¡“√∂®–·°â (reverse) ‰¥â‚¥¬ reagent „π·µà≈– ∂“∫—π22 √«¡∂÷߉¡àæ∫§«“¡
¬“ protamine sulfate Õ¬à“߉√°Áµ“¡ºŸâªÉ«¬µâÕß¡’  —¡æ—π∏å¢Õß anti-Xa ·≈– APTT ‚¥¬‡©æ“–„π
venous access ∑¥Ë’’µ≈Õ¥®π√–¥∫— antithrombin ºªâŸ«É ¬‡¥°ÁÕ“¬πÿÕâ ¬°«“à 2 ª2ï 3 „π°√≥∑’ºË’ªâŸ«É ¬¡º’≈
§«√Õ¬àŸ„π‡°≥±åª°µ‘‡πË◊Õß®“°¬“µ—«π’È¡’§ÿ≥ ¡∫—µ‘ ∫«°¢Õß LA À√Õ◊ √–¥∫— factor VIII activity ∑’Ë
‡ªìπ polysaccharide ∑’Ë¡’º≈µâ“π°“√∑”ß“π¢Õß  AߟP¡T“T°°24«“à ‡π2ÕË◊ 5ß0®%“°°Õ““√®∑ ”ßà ߺ“≈π°¢√Õ–ß∑∫UµFàÕH°“‰√¥·∑â ª”≈ߺ“π≈
thrombin ·≈– factor Xa (FXa) ‚¥¬°“√‡√àß
°“√∑”ß“π¢Õß antithrombin ‡æ‘Ë¡‡ªìπ ª√–¡“≥ º“à π°“√∑”ß“π¢Õß antithrombin ¥ß—∑°Ë’≈“à «¡“¢“â ß
1,000 ‡∑à“ ·≈– “¡“√∂∂Ÿ°°”®—¥ÕÕ°®“°√à“ß°“¬ µπ⠥ߗππ—È„π°√≥∑’ºË’ªâŸ«É ¬¡√’–¥∫— antithrombin µ”Ë
∑“߉µ·≈– reticuloendothelial system Õ“®∑”„Àâ°“√∑”ß“π¢Õß UFH πâÕ¬≈ß ∑”„À⇰‘¥
¢π“¥¢Õ߬“∑„’Ë™§â «√‡√¡‘Ë¥«â ¬ loading dose ¿“«– heparin resistance ‚¥¬‡©æ“–„π°√≥∑’µ’ËÕâ ß
¢π“¥ 75 ¬πŸµ‘/°°. ‡¢“â ∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥” ¬°‡«πâ „™â UFH „π¢π“¥ ŸßÊ ‡™àπ 36 ¬Ÿπ‘µ/°°./™¡.
„πºªŸâ «É ¬∑¡Ë’§’«“¡‡ ¬’ËßµÕà ¿“«–‡≈Õ◊ ¥ÕÕ°(‰¡µà Õâ ß„Àâ ‡ªπì µπâ  ”À√∫—ª≠í À“π„È’πµ“à ߪ√–‡∑»¡°’“√„™â anti-
loading dose) µ“¡¥«â ¬¢π“¥¬“ (maintenance) thrombin ‡¢¡â ¢πâ (antithrombin concentrate)
28 ¬πŸµ‘/°°./™«—Ë‚¡ß„π∑“√°Õ“¬ÿ≤ 1 ªï ·≈– 20 ∑¥·∑π25 ‚¥¬æ®‘“√≥“„™‡â ªπì √“¬Ê ‰ª  ”À√∫—„π
¬πŸµ‘/°°./™¡.  ”À√∫—ºªâŸ«É ¬Õ“¬ÿ> 1 ªï µ“¡≈”¥∫— ª√–‡∑»‰∑¬‡π◊ËÕß®“°‰¡à¡’antithrombin ‡¢â¡¢âπ
 ”À√—∫°“√µ‘¥µ“¡√–¥—∫¬“πÈ—π„π∑’Ë∑’Ë “¡“√∂µ√«® Õ“®æ®‘“√≥“„™â FFP ∑¥·∑π„π¢π“¥ 10 ¡≈./°°.
¥«â ¬ anti-Xa ‰¥â §«√ª√–‡¡π‘·≈–√°—…“√–¥∫—¬“‰«â ∑°ÿ 24-72 ™«—Ë‚¡ß

µ“√“ß∑Ë’14.2 ≈°—…≥–¢ÕßÕ“°“√≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—·≈–°“√µ√«®∑“ßÀÕâ ߪØ∫‘µ—°‘“√

≈—°…≥–¢ÕßÕ“°“√ ™«àß∑‡Ë’®“– °“√∑¥ Õ∫ Lab ∑’˧«√∑¥ Õ∫

Purpura fulminans or non-sepsis DIC ™à«ß∑Ë’¡Õ’“°“√ ·π–π” protein C, S,
Neonates/children/adolescents with unprovoked VTE ™«à ßµ¥‘µ“¡Õ“°“√ ·π–π” antithrombin
Children/adolescents with recurrent (non-catheter related) VTE ™«à ßµ¥‘µ“¡Õ“°“√ ·π–π” thrombophilia
Neonates/children/adolescents with catheter-related VTE/ATE - ‰¡à·π–π” workup
thrombophilia
workup
-

DIC = disseminated intravascular coagulation, VTE = venous thromboembolism, ATE = arterial thromboembolism

216 ™“≠™¬— ‰µ√«“√’

¿“«–·∑√°´âÕπ®“°°“√„™â UFH Õ“®∑”„Àâ ‡ªπì ‰ª¥«â ¬§«“¡≈”∫“° ‚¥¬‡©æ“–‡¥°Á∑Õ’Ë“¬πÿÕâ ¬°«“à
‡°‘¥¿“«–‡≈◊Õ¥ÕÕ°À≈—ß®“°°“√„À⬓ ·≈–Õ“®‡°‘¥ 1 ªï ‡πË◊Õß®“°¡’§«“¡·ª√ª√«π¢Õ߬“√«¡∂÷ß°“√
heparin induced thrombocytopenia (HIT) ‰¥â √∫—ª√–∑“π¬“ªØ™‘«’π– °“√„™¬â “°π—™°— ‡ªπì µπâ ‚¥¬
Õ¬“à ߉√°µÁ“¡¢Õâ ¡≈Ÿ HIT „π‡¥°Áæ∫‰¥πâ Õâ ¬ª√–¡“≥ æ∫Õ∫ÿµ—°‘“√≥ªå ≠í À“‡≈Õ◊ ¥ÕÕ°ª√–¡“≥√Õâ ¬≈– 0.531
√Õâ ¬≈– 2.326,27 ‡¡Õ◊ˇª√¬’∫‡∑¬’∫°∫—¢Õâ ¡≈Ÿ„πº„âŸÀ≠à ‚¥¬¢π“¥¢Õ߬“·≈–°“√ª√∫—¢π“¥¬“32 antithrom-
2. Low molecular weight heparin botic agent „π·µ≈à –™π¥‘‰¥√â «∫√«¡‰«â µ“¡µ“√“ß
(LMWH)  “¡“√∂„™â∑—Èß„π√–¬–‡√‘Ë¡·√°¢Õß°“√ ∑’Ë14.3, 14.4, 14.5
‡°‘¥≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π·≈–„π√–¬–¬“«  ”À√—∫¢âÕ¥’
¢Õ߬“°≈ÿà¡πÈ’§◊Õ  “¡“√∂©’¥∑“ß„µâº‘«Àπ—ß ™π‘¥ °“√„™â¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥ (thrombolytic
¢Õ߬“∑’Ë„™â„πºâŸªÉ«¬‡¥Á° ‰¥â·°à enoxaparin ·≈– agent) „π‡¥°Á
tinzaparin ‡ªπì µπâ Õ¬“à ߉√°µÁ“¡ ¡°—π¬‘¡„™â LMWH ª√–°Õ∫¥«â ¬¬“À≈“¬™π¥‘33‡™πà streptokinase,
„πºªâŸ«É ¬∑‰Ë’¡¡à °’“√«“ß·ºπ∑”Àµ—∂°“√∑¡Ë’§’«“¡‡ ¬Ë’ß urokinase, t-PA (tissue plasminogen activator)
µàÕ¿“«–‡≈◊Õ¥ÕÕ°„π°√≥’∑’˵âÕßÀ¬ÿ¥¬“ ‡πË◊Õß®“° °“√„™â¬“ thrombolytic agent ®–π‘¬¡„π°≈ÿà¡
µâÕß„™â‡«≈“„π°“√À¬ÿ¥¬“ 12-24 ™—Ë«‚¡ß°àÕ𬓮– t-PA ‡ªìπÀ≈—°34 ‚¥¬¡’§ÿ≥ ¡∫—µ‘∑”Àπâ“∑Ë’„π°“√
¢—∫ÕÕ°®“°√à“ß°“¬ LMWH ‡ªìπ¬“∑’Ë¡’¢π“¥¢Õß ‡ª≈¬’Ëπ plasminogen ‡ªπì plasmin ¬“π„È’™‰â ¥ºâ ≈¥’
polysaccharide  È—π°«à“ UFH ¡’º≈®”‡æ“–„π „π°“√≈–≈“¬≈Ë‘¡‡≈◊Õ¥·∫∫ ¡∫Ÿ√≥å (complete
°“√¬∫—¬ß—È°“√∑”ß“π¢Õß FXa ¡“°°«“à thrombin resolution) ‰¥â√âÕ¬≈– 65-80 ·≈–∫“ß à«π
∑‡À”¡„À◊Õâπ„AπPUTTFH‰2¡8à‰¥¥â™—ßπà«È—𬄰π“°√µ“‘¥√ªµ√“–¡‡√¡–‘π¥√—∫–¬¥“—∫§¬«√“ ≈–≈“¬≈¡Ë‘‡≈Õ◊ ¥ (partial resolution) ‰¥√â Õâ ¬≈– 20
‡¡Ë◊Õ¬“‡¢â“ àŸ√à“ß°“¬¬“ t-PA ®–∂Ÿ°∑”≈“¬„πµ—∫
µ√«®¥â«¬ anti-Xa ‚¥¬„Àâ§à“Õ¬Ÿà√–À«à“ß 0.5-1.0 ¡’half-life 4-6 π“∑’
¬Ÿπ‘µ/¡≈. ∑Ë’4-6 ™Ë—«‚¡ßÀ≈—ß°“√À≈—ß°“√„À⬓ ª°µ‘systemic t-PA „π‡¥Á°®–¡’¢âÕ∫àß™’È
§√ßÈ—∑Ë’2 ¢Õß°“√„™â„π°≈àÿ¡ºŸâªÉ«¬ arterial stroke ∑Ë’‰¥â√—∫
3. Oral anticoagulant ¬“∑Ë’„™â„π‡¥Á°§◊Õ °“√«π‘®‘©¬—¿“¬„π 4-6 ™«—Ë‚¡ß °≈¡àÿ massive PE
warfarin29,30 ¬“µ—«πÈ’®–π‘¬¡„™â„π√–¬–¬“«À≈—ß À√Õ◊ °≈¡ÿà ∑¡’Ë°’Õâ π‡≈Õ◊ ¥Õ¥ÿµπ—™π¥‘ ¡∫√Ÿ≥„å πÀ≈Õ¥‡≈Õ◊ ¥
®“°‡ª≈’Ë¬π®“°°“√„™â UFH À√◊Õ LMWH Õ¬à“ß ·¥ß  à«π„À≠à®–¡’°“√„™â„πÀπ૬‡«™∫”∫—¥«‘°ƒµ‘
πâÕ¬ 5-7 «—π À≈—ß®“°‡√Ë‘¡¡’≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π ‚¥¬ ‡ªπì À≈°—35 ¬“µ«—π¡È’§’«“¡‡ ¬Ë’ßµÕà °“√‡°¥‘‡≈Õ◊ ¥ÕÕ°
¬“µ«—π¡’ȧ’≥ÿ ¡∫µ—À‘¬¥ÿ¬ßÈ—°“√∑”ß“π¢Õ߇Õπ‰´¡å 2 ßà“¬‰¥â  ”À√—∫°“√‡µ√’¬¡ºâŸªÉ«¬°àÕπ„À⬓ t-PA
™π‘¥ §◊Õ vitamin K epoxide reductase ·≈– §«√¡°’“√µ√«® complete blood count (CBC)
vitamin K reductase ∑”„À₪√µ’π∑Ë’™à«¬„π coagulogram ·≈– fibrinogen °Õà π„À¬â “ t-PA ‚¥¬
°“√·¢ßÁµ«—¢Õ߇≈Õ◊ ¥ (coagulation factor) ª√–°Õ∫ ºâŸªÉ«¬§«√¡’®”π«π‡°≈Á¥‡≈◊Õ¥ > 50,000 ‡´≈≈å/
¥â«¬·ø§‡µÕ√å II,VII,IX,X ·≈–‚ª√µ’πµâ“π°“√ ≈∫.¡¡. §“à coagulogram ª°µ‘·≈– fibrinogen
·¢Áßµ—«¢Õ߇≈◊Õ¥ (anticoagulation protein) > 100 ¡°./¥≈. „π∑“√°·√°‡°¥‘§«√¡‡’°≈¥Á‡≈Õ◊ ¥ >
ª√–°Õ∫¥«â ¬ protein C, protein S ≈¥≈ß ª≠í À“ 100,000 ‡´≈≈å/≈∫.¡¡. ·≈– fibrinogen > 150
°“√„™â¬“µ—«πÈ’„π‡¥Á°§◊Õ°“√µ‘¥µ“¡√–¥—∫¢Õ߬“ ¡°./¥≈.

¿“«–≈‘Ë¡‡≈Õ◊¥Õÿ¥µπ—„π‚√ß欓∫“≈ Thromboembolism in Hospital 217

‚¥¬ “¡“√∂„À¬â “ UFH ¢π“¥ 10 ¬πŸµ‘/°°./ 5. ‡¥Á°§≈Õ¥°àÕπ°”Àπ¥ (πâÕ¬°«à“ 32
™¡. °àÕπ°“√„À⬓ t-PA 30 π“∑’¢π“¥¢Õ߬“  ª—¥“À)å
t-PA ∑Ë’„™â “¡“√∂„Àâ„π¢π“¥ 0.5 ¡°./°°./™¡.
∑“ßÀ≈Õ¥‡≈Õ◊ ¥¥”‡ªπì ‡«≈“ 6 ™«—Ë‚¡ß ‚¥¬ “¡“√∂ ∫∑ √ªÿ
„À´â È”‰¥∑â °ÿ 12-24 ™«—Ë‚¡ß ·µ‰à ¡§à «√‡°π‘ 4 §√ß—È36 ¿“«–≈¡‘ˇ≈Õ◊ ¥Õ¥ÿµπ—„πÀ≈Õ¥‡≈Õ◊ ¥ (throm-
´÷Ëß¢π“¥¬“¥—ß°≈à“«‰¥âº≈„π°“√≈–≈“¬≈‘Ë¡‡≈◊Õ¥‰¥â
∑È—ßπÈ’‰¥â √ÿª¢π“¥¢Õ߬“ √–¬–‡«≈“°“√„Àâ·≈–·π« boembolism) „π‡¥Á°‡ªìπ¿“«–∑Ë’æ∫‰¥â„πªí®®ÿ∫—π
∑“ß°“√‡µ√¬’¡ºªâŸ«É ¬·≈–°“√√°—…“¢Õß°“√„™â t-PA ‚¥¬‡©æ“–„π ∂“π欓∫“≈∑Ë’‡ªìπ tertiary care
µ“¡·ºπ¿¡Ÿ∑‘’Ë14.2 ∑ß—Èπ¿È’“«–≈¡Ë‘‡≈Õ◊ ¥Õ¥ÿµπ—„π‡¥°Á¡§’«“¡·µ°µ“à ßÕ¬“à ß
 ‘Èπ‡™‘ß‡¡Ë◊Õ‡ª√’¬∫‡∑’¬∫°—∫„πºâŸ„À≠à ∑—Èß„π·ßà¢Õß
Õ¬“à ߉√°µÁ“¡‰¡§à «√„™â thrombolytic therapy ª®í ®¬—‡ ¬Ë’ßµÕà °“√‡°¥‘‚√§ °≈‰°°“√·¢ßÁµ«—¢Õ߇≈Õ◊ ¥
„πºªŸâ «É ¬‡¥°Á∑¡Ë’¿’“«–µÕà ‰ªπÈ’ ∑Ë’·µ°µà“ß°—π °“√√—°…“¥â«¬¬“ antithrombotic
agents ∑—Èßπ’È°“√√à«¡¡◊Õ√—°…“°—π‡ªìπ∑’¡ (multi-
1. ¡Õ’“°“√‡≈Õ◊ ¥ÕÕ°∑§Ë’«∫§¡ÿ‰¡‰à ¥Àâ √Õ◊ ‡°≈¥Á disciplinary) ¢Õß°¡ÿ“√·æ∑¬∑å “ß‚≈Àµ‘«∑‘¬“ √ß— ’
‡≈Õ◊ ¥µ”Ë(< 50,000 ‡´≈≈/å ≈∫.¡¡.) «‘π‘®©—¬ °ÿ¡“√·æ∑¬å∑“߇«™∫”∫—¥«‘°ƒµ µ≈Õ¥®π
欓∫“≈ºâŸ‡™’ˬ«™“≠¥â“π≈Ë‘¡‡≈◊Õ¥Õÿ¥µ—π„πºªâŸ«É ¬∑¡Ë’’
2. ¡ª’√–«µ—º‘“à µ¥—¿“¬„π 7-10 «π— §«“¡®”‡ªπì µÕâ ß„™¬â “°≈¡àÿπ’ȇæÕË◊ æ≤—π“§≥ÿ¿“晫’µ‘
3. ¡ª’√–«µ—º‘“à µ¥—‡°¬’Ë«°∫— ¡Õß¿“¬„π 1-3 ¢ÕߺªŸâ «É ¬°≈¡àÿπ’È„À¥â ¢’πÈ÷„πÕ𓧵
 ª—¥“Àå ¢πÈ÷Õ¬°àŸ∫—™π¥‘¢Õß°“√º“à µ¥—
4. ¡Õ’“°“√™°—¿“¬„π 48 ™«—Ë‚¡ß

µ“√“ß∑Ë’14.3 ¢π“¥¬“·≈–°“√µ¥‘µ“¡√–¥∫—¢Õ߬“¢Õß UFH (¥¥—·ª≈ß®“°‡Õ° “√Õ“â ßÕß‘À¡“¬‡≈¢ 32) 218 ™“≠™—¬ ‰µ√«“√’

Unfractionated Heparin (UFH) ·π«∑“ß°“√ª√∫—¢π“¥ UFH
Loading dose : 75 ¬πŸµ‘/°°.„π 10 π“∑’
(À“â ¡„™â„πºªâŸ«É ¬ Stroke) APTT Anti-factor Xa °“√‡ª≈¬’Ë π¢π“¥¬“ √–¬–‡«≈“∑§Ë’ «√
À≈ß—®“°ππÈ—„Àâ maintenance («π‘ “∑)’ (¬πŸ µ‘ /¡≈.) µ¥‘ µ“¡º≈
- 28 ¬πŸµ‘/°°./™.¡.  ”À√∫—‡¥°ÁÕ“¬ÿ≤ 1 ªï < 50 < 0.1 „À¬â “¢π“¥ 50 ¬πŸµ‘/°°. 4-6 ™.¡.
- 20 ¬πŸµ‘/°°./™.¡.  ”À√∫—‡¥°ÁÕ“¬ÿ> ªï 50-59 ·≈–‡æ¡‘Ë¢π“¥¬“ 20% 4-6 ™.¡.
µ√«® Õ∫ APTT 4 ™.¡. À≈ß—®“°„Àâ loading dose 60-85 0.1-0.34 ‡æ¡Ë‘¢π“¥¬“ 10% 24 ™.¡.
„π°√≥∑’‰Ë’¡‰à ¥â„Àâ loading dose „Àµâ √«® APTT À≈ß—6 ™.¡. 86-95 0.35-0.7 ‰¡µà Õâ ߪ√∫—¬“ 4-6 ™.¡.
ª√∫—√–¥∫— APTT „ÀÕâ ¬„Ÿà π™«à ß 60-85 «π‘“∑’ 96-120 0.71-0.89 ≈¥¢π“¥¬“ 10% 4-6 ™.¡.
À√Õ◊ „À≥√â –¥∫— anti-factor Xa 0.35-0.7 ¬πŸµ‘/¡≈. > 120 0.9-1.2 À¬¥ÿ¬“ 30 π“∑’ 4-6 ™.¡.
·≈–≈¥¢π“¥¬“ 10%
> 1.2 À¬¥ÿ¬“ 60 π“∑’
·≈–≈¥¢π“¥¬“ 15%

APTT = activated partial thromboplastin time

µ“√“ß∑’Ë14.4 ¢π“¥¬“ ·≈–°“√µ¥‘µ“¡√–¥∫—¢Õ߬“ LMWH (¥¥—·ª≈ß®“°‡Õ° “√Õ“â ßÕß‘À¡“¬‡≈¢ 32) ¿“«–≈‘¡Ë ‡≈Õ◊¥Õ¥ÿµ—π„π‚√ß欓∫“≈ Thromboembolism in Hospital

Enoxaparin °“√√°—…“ Tinzaparin °“√√°—…“ °“√ªÕÑß°π—

Õ“¬ÿ ¢π“¥¢Õ߬“‡√¡Ë‘µπâ ¢π“¥¢Õ߬“ ßŸ ¥ÿ Õ“¬ÿ ¢π“¥¢Õ߬“‡√¡‘˵πâ ¢π“¥¢Õ߬“∑„’Ë™â
≤ 2 ‡¥Õ◊ π 1.5 ¡°./°°./§√ßÈ— 3 ¡°./°°./§√ß—È 0-2 ‡¥Õ◊ π 275 ¬πŸµ‘/°°./∑°ÿ 24 ™¡. 75 ¬πŸµ‘/°°./∑°ÿ 24 ™¡.
> 2 ‡¥Õ◊ π 1 ¡°./°°./§√ßÈ— 2 ¡°./°°./§√ßÈ— 2 ‡¥Õ◊ π-1 ªï 250 ¬πŸµ‘/°°./∑°ÿ 24 ™¡. 75 ¬πŸµ‘/°°./∑°ÿ 24 ™¡.
©¥’„µºâ «‘Àπß—∑°ÿ 12 ™.¡. 1 ª-ï 5 ªï 240 ¬πŸµ‘/°°./∑°ÿ 24 ™¡. 75 ¬πŸµ‘/°°./∑°ÿ 24 ™¡.
Õ“¬ÿ 5 ª-ï 10 ªï 200 ¬πŸµ‘/°°./∑°ÿ 24 ™¡. 75 ¬πŸµ‘/°°./∑°ÿ 24 ™¡.
≤ 2 ‡¥Õ◊ π °“√ªÕÑß°π— 10 ª-ï 18 ªï 175 ¬πŸµ‘/°°./∑°ÿ 24 ™¡. 50 ¬πŸµ‘/°°./∑°ÿ 24 ™¡.
> 2 ‡¥Õ◊ π ¢π“¥ ·π«∑“ß°“√ª√∫—¢π“¥ LMWH
1.5 ¡°./°°./§√ß—È Anti-factor Xa (¬πŸµ‘/¡≈.) °“√‡ª≈¬’Ëπ¢π“¥¬“ √–¬–‡«≈“∑§’Ë«√µ¥‘µ“¡º≈
1 ¡°./°°./§√ß—È < 0.35 ‡æ¡Ë‘¢π“¥¬“ 25% µ√«®«π—√ßÿà ¢π÷È
©¥’„µºâ «‘Àπß—∑°ÿ 24 ™.¡. 0.35-0.49 ‡æ¡‘Ë¢π“¥¬“ 15% µ√«®«π—√ßàÿ¢π÷È

0.5-1 ‰¡µà Õâ ߪ√∫—¬“ 1  ª—¥“Àå

LMWH = low molecular weight heparin

219

µ“√“ß∑Ë’14.5 ¢π“¥¬“ ·≈–°“√µ¥‘µ“¡√–¥∫—¬“ warfarin (¥¥—·ª≈ß®“°‡Õ° “√Õ“â ßÕß‘À¡“¬‡≈¢ 32) 220 ™“≠™—¬ ‰µ√«“√’

Warfarin ·π«∑“ß°“√ª√∫—¢π“¥ warfarin „π√–¬– π—È À≈ß—®“°‡√¡Ë‘ „Àâloading dose
·π«∑“ß°“√‡√¡‘Ë ¬“ warfarin
‡√¡‘Ë„ÀÀâ ≈ß—®“°‡√¡Ë‘ UFH À√Õ◊ LMWH 5 - 7 «π— √–¥∫—§“à INR °“√‡ª≈¬’Ëπ¢π“¥¬“
Loading dose : 0.2 ¡°./°°./«π— 1.1-1.4 „À¬â “¢π“¥‡¥¡‘
¢π“¥¬“ ßŸ ¥ÿ‰¡§à «√‡°π‘ 10 ¡°. 1.4-3.0 ≈¥¬“≈ß 50%
∑ßÈ—π„È’πºªâŸ«É ¬ Fontan operation À√Õ◊ ¡§’«“¡º¥‘ª°µ¢‘Õßµ∫— 3.1-3.5 ≈¥¬“≈ß 25%
§«√‡√¡Ë‘¬“∑¢Ë’π“¥ 0.1 ¡°./°°./«π— ¡“°°«“à 3.5 „ÀÀâ ¬¥ÿ¬“«π—√ßàÿ¢πÈ÷®π°√–∑ß—ËINR < 3.5 ·≈«â ®ß÷≈¥¬“≈ß 50%

µ√«®√–¥∫— INR∑«’Ëπ—∑’Ë3-4 À≈ß—®“°‰¥¬â “ warfarin ·π«∑“ß°“√ª√∫—¢π“¥ warfarin „π√–¬–¬“« (maintenance)
§«√√°—…“√–¥∫— INR „À≥â 2-3 1.1-1.4 ‡æ¡Ë‘¢π“¥¬“ 20%
1.5-1.7 ‡æ¡‘Ë¢π“¥¬“ 10%
®–殑“√≥“„À«â µ‘“¡π‘‡§ 1-10 ¡°. ∑“ßÀ≈Õ¥‡≈Õ◊ ¥ 1.8-3.2 ‰¡µà Õâ ߪ√∫—¬“
‡ªπì antidote „π°√≥∑’’ËINR ≥ 9 À√Õ◊ ¡Õ’“°“√‡≈Õ◊ ¥ÕÕ° 3.3-3.5 ≈¥¢π“¥¬“ 10%
„π°√≥∑’Ë’INR > 3-8.9 „Àæâ ®‘“√≥“®“°µ“√“ߥ“â π¢«“¡Õ◊ ¡“°°«“à 3.5 „ÀÀâ ¬¥ÿ¬“«π—√ßàÿ¢π÷È®π°√–∑ß—ËINR < 3.5 ·≈«â ®ß÷≈¥¬“≈ß 20%
INR = international normalized ratio

¿“«–≈Ë¡‘‡≈Õ◊¥Õÿ¥µ—π„π‚√ß欓∫“≈ Thromboembolism in Hospital 221

·ºπ¿Ÿ¡‘∑’Ë 14.2 ·π«∑“ß°“√„™â systemic t-PA infusion protocol (¥—¥·ª≈ß®“°‡Õ° “√Õâ“ßÕ‘ß
À¡“¬‡≈¢ 36)

t-PA = tissue plasminogen activator
UFH = unfractionated heparin
FFP = fresh frozen plasma
CBC = complete blood count
INR = international normalized ratio

222 ™“≠™¬— ‰µ√«“√’

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∫∑∑Ë’
‚√§À≈Õ¥‡≈Õ◊¥ ¡ÕßÕÿ¥µ—π„π‡¥°Á
·≈–«—¬√àÿπ

15 Stroke in Children and Adolescents

¿√‘¥’ «ÿ√√≥¿°—¥’

‚√§À≈Õ¥‡≈Õ◊ ¥ ¡ÕßÀ√Õ◊ cerebrovascular À≈Õ¥‡≈◊Õ¥·¥ß·¢Áßµ—« (atherosclerosis) ‡ªìπ
disease (CVD) À√Õ◊ stroke ‡ªπì  “‡Àµ∑ÿ ’Ë”§≠—  «à π„À≠à  «à π‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õß„π‡¥°ÁππÈ—  “‡Àµÿ
¢Õß°“√‡ ¬’™«’µ‘·≈–¿“«–∑æÿæ≈¿“æ„π‡¥°Á WHO ∑’Ëæ∫∫àÕ¬‡°‘¥®“°§«“¡º‘¥ª°µ‘¢ÕßÀ—«„® À≈Õ¥
‰¥°â ”À𥧔𬑓¡¢Õß CVD ‰««â “à ‡ªπì °≈¡ÿà Õ“°“√ ‡≈Õ◊ ¥ ·≈–°“√·¢ßÁµ«—¢Õ߇≈Õ◊ ¥º¥‘ª°µ‘‚¥¬ “¡“√∂
∑ªË’√–°Õ∫¥«â ¬ ¿“«–¢Õß neurological deficit ∑Ë’ ·∫àß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„π‡¥Á°‡ªìπ 2 °≈ÿࡵ“¡
‡°¥‘¢πÈ÷‡©¬’∫æ≈π— ·≈–¡Õ’“°“√Õ¬πàŸ“π°«“à 24 ™«—Ë‚¡ß ·ºπ¿Ÿ¡‘∑Ë’15.1 ‰¥â·°à À≈Õ¥‡≈◊Õ¥„π ¡ÕßÕÿ¥µ—π
‚¥¬¡ ’“‡Àµ¡ÿ“®“°À≈Õ¥‡≈Õ◊ ¥ (ischemic stroke) ·≈–À≈Õ¥‡≈◊Õ¥„π ¡Õß·µ°
‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„π‡¥Á°·µ°µà“ß°—∫‚√§ (hemorrhagic stroke) ‚¥¬æ∫Õÿ∫—µ‘°“√≥å
À≈Õ¥‡≈Õ◊ ¥ ¡Õß„πº„âŸÀ≠Àà ≈“¬¥“â π∑ßÈ—  “‡Àµ°ÿ“√ ·µ°µ“à ß°π—√–À«“à ß°≈¡àÿ∑“√°·√°‡°¥‘(Õ“¬πÿÕâ ¬°«“à
‡°¥‘ Õ“°“√·≈–Õ“°“√· ¥ß °“√欓°√≥‚å √§ °≈“à « 28 «π—) ·≈–‡¥°Á (Õ“¬ÿ30 «π—-18 ª)ï „π∫∑§«“¡
§◊Õ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„πºâŸ„À≠à‡°‘¥®“°¿“«– π’È®–‡πâπ∂÷ß°≈àÿ¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„π‡¥Á°∑Ë’

·ºπ¿¡Ÿ∑‘Ë’15.1 °“√®”·π°‚√§À≈Õ¥‡≈Õ◊ ¥ ¡Õß„π‡¥°Á

Stroke Symptomatic

Ischemic Hemorrahagic intracerebral
Venous Arterial hemorrhage not
Intraparenchymal associated with
Subarachnoid ischemic infarction
Intraventicular (or trauma)
Subdural
CSVT AIS Epidural

Symptomatic thrombotic Acute focal neurological deficit with
disruption of flow in the neuroimaging evidence of cerebral
infarction in an arterial territory
cerebral sinovenous system

226 ¿√‘¥’ ÿ«√√≥¿°—¥’

‡°‘¥®“° “‡Àµÿ¢ÕßÀ≈Õ¥‡≈◊Õ¥„π ¡ÕßÕÿ¥µ—π „π „πªï æ.». 2522-2540 æß…»å °—¥‘Ï·≈–§≥–3
‡¥°Á∂ß÷«¬—√πÿà »÷°…“„πºŸâªÉ«¬∑Ë’¡’Õ“°“√À≈Õ¥‡≈◊Õ¥ ¡Õß 68 √“¬
æ∫«à“ 38 √“¬‡°‘¥®“° “‡ÀµÿÀ≈Õ¥‡≈◊Õ¥„π ¡Õß
欓∏‘°”‡π‘¥¢Õß‚√§À≈Õ¥‡≈Õ◊¥ ¡ÕßÕÿ¥µπ— Õ¥ÿµπ— ·≈–°“√»°÷…“¢Õß≥√ߧ·å ≈–§≥–4 „π™«à ߪï
°≈àÿ¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡ÕßÕÿ¥µ—π„π‡¥Á° æ.». 2538-2549 „πºªŸâ «É ¬ 109 √“¬ æ∫«“à ¡ ’“‡Àµÿ
(ischemic stroke) ·∫ßà µ“¡æ¬“∏°‘”‡π¥‘‡ªπì 2 °≈¡àÿ ®“°À≈Õ¥‡≈Õ◊ ¥„π ¡ÕßÕ¥ÿµπ— 35 √“¬ (√Õâ ¬≈– 32)
„À≠à µ“¡√“¬≈–‡Õ¬’¥„πµ“√“ß∑’Ë15.1 §Õ◊ ª®í ®¬—‡ ¬Ë’ß∑æ’Ë∫¡“°∑ Ë’¥ÿ§Õ◊ §«“¡º¥‘ª°µ¢‘ÕßÀ«—„®
1. À≈Õ¥‡≈Õ◊ ¥·¥ß„π ¡ÕßÕ¥ÿµπ— (arterial (√âÕ¬≈– 17) ·≈–§«“¡º‘¥ª°µ‘¢Õß√–∫∫‡≈◊Õ¥
ischemic stroke, AIS) (√Õâ ¬≈– 17)
2. ‚æ√ßÀ≈Õ¥‡≈Õ◊ ¥¥”„π ¡ÕßÕ¥ÿµπ— (cere-
bral sinovenous thrombosis, CSVT)  “‡Àµ·ÿ≈–ªí®®¬—‡ ’¬Ëß
ª√–¡“≥‡°◊Õ∫§√Ë÷ßÀπË÷ߢÕߺŸâªÉ«¬‡¥Á°‚√§
À≈Õ¥‡≈Õ◊¥·¥ß„π ¡ÕßÕ¥ÿµ—π À≈Õ¥‡≈◊Õ¥ ¡ÕßÕÿ¥µ—π‰¡àæ∫ªí®®—¬‡ Ë’¬ß∑’Ë™—¥‡®π
√–∫“¥«‘∑¬“
Õ¬à“߉√°Áµ“¡ ªí®®—¬‡ ’ˬß∑’Ëæ∫„π‡¥Á°‡°‘¥®“°À≈“¬
Õ∫ÿµ—°‘“√≥¢å ÕߺªâŸ«É ¬ AIS æ∫ 3.3 √“¬µÕà  “‡ÀµÿπÕ°®“°πÈ—π„πºâŸªÉ«¬∫“ß√“¬¡’ªí®®—¬‡ Ë’¬ß
ª√–™“°√ 100,000 √“¬1 ·≈–¥â«¬§«“¡‡®√‘≠ ¡“°°«à“ÀπË÷ßªí®®—¬ ªí®®—¬‡ ’ˬß∑Ë’ ”§—≠·≈–æ∫‰¥â
°“â «Àπ“â ¢Õ߇∑§π§‘∑“ß√ß— «’π‘®‘©¬— ∑”„Àæâ ∫Õ∫ÿµ—-‘ ∫Õà ¬ ‰¥·â °à
°“√≥å¢Õߺ⟪ɫ¬ AIS „πªí®®ÿ∫—π‡æ‘Ë¡¢È÷π‡√Ë◊Õ¬Ê ë §«“¡º¥‘ª°µ¢‘ÕßÀ«—„®
‚¥¬æ∫Õ∫ÿµ—°‘“√≥„å π™«à ß 10 ª∑ï ºË’“à π¡“¡º’ªŸâ «É ¬ AIS √Õâ ¬≈– ‡2ª5ìπª¢Õí®ß®º—¬ªŸâ ‡ «É ’ˬ¬‡ß¥∑°ÁË’æA∫I‰S¥5â∫à§Õ«¬“∑¡Ë’ ºÿ¥¥‘æª∫°µ‰¥¢‘â∂Õ÷ßß
2-6 §π µÕà ª√–™“°√ 100,000 §π2

µ“√“ß∑’Ë15.1 §«“¡·µ°µ“à ß√–À«“à ß CSVT ·≈– AIS

≈°—…≥– CSVT AIS

Occlusion Venous Arterial
Flow Slow Rapid
Result of occlusion Obstruction to blood outflow Obstruction to blood inflow
Thrombotic process Local, gradual, fluctuation, Local/embolic, rapid, çwhiteé
çredé clot, RBC rich/platelet clot-platelet rich
poor
Tissue damage Congestion Ischemic
Evolution Hours-days Minutes-hours
Clinical picture Diffuse/focal Usually Focal

CSVT = cerebral sinovenous thrombosis, AIS = arterial ischemic stroke

‚√§À≈Õ¥‡≈◊Õ¥ ¡ÕßÕÿ¥µπ—„π‡¥°Á·≈–«—¬√àπÿ Stroke in Children and Adolescents 227

À—«„®π—Èπ∑”„À⇰‘¥¿“«–À≈Õ¥‡≈◊Õ¥ ¡ÕßÕÿ¥µ—π‰¥â transient cerebral arteriopathy (TCA) §Õ◊
À≈“¬°≈‰° Õ“∑‘cardiogenic emboli ∑’ˇ§≈Ë◊Õπ ¿“«–∑¡’Ë°’“√µ∫’·§∫‡©æ“– «à π¢Õß∫√‡‘«≥ «à πª≈“¬
µ—«‰ªÕÿ¥µ—πÀ≈Õ¥‡≈◊Õ¥„π ¡Õß æ∫„πºâŸªÉ«¬∑’Ë¡’ ¢Õß internal carotid artery ·≈–∫√‡‘«≥ «à πµπâ ¢Õß
欓∏ ‘¿“æ¢ÕßÀ«—„® ‡™πà arrhythmia, valvular anterior À√◊Õ middle cerebral artery ∑”„Àâ
heart disease, intracardiac septal defect,  ¡Õߢ“¥‡≈◊Õ¥‡ªìπ√–¬–‡«≈“ÀπË÷ß ·≈–À“¬°≈—∫
rheumatic heart disease ‡ªπì µπâ À√Õ◊ °“√‡°¥‘≈¡Ë‘ ‡ªπì ª°µ‰‘¥¿â “¬„π 6 ‡¥Õ◊ π  “‡Àµ¬ÿß—‰¡∑à √“∫™¥—‡®π
‡≈◊Õ¥Õÿ¥µ—π®“°‡≈◊Õ¥∑Ë’¢âπ°«à“ª°µ‘„πºâŸªÉ«¬‚√§ ·µæà ∫«“à √Õâ ¬≈– 44 ¢ÕߺªŸâ «É ¬®–¡ª’√–«µ—°‘“√µ¥‘‡™ÕÈ◊
À«—„®™π¥‘‡¢¬’« πÕ°®“°ππÈ—„πºªŸâ «É ¬‚√§À≈Õ¥‡≈Õ◊ ¥ varicella zoster π”¡“°Õà π¿“¬„π√–¬–‡«≈“ 1 ªï
 ¡Õß∑‰Ë’¡∑à √“∫ “‡Àµÿ(cryptogenic stroke) ‡¡ÕË◊ ‡√¬’°¿“«–π«È’“à post-varicella arteriopathy7
µ√«® echocardiography ·≈– intravenous Moyamoya disease §◊Õ ¿“«– chronic
saline injection æ∫Õÿ∫—µ‘°“√≥å¢Õß patent progressive noninflammatory vasculopathy ‡°¥‘
foramen ovale (PFO) ∂ß÷√Õâ ¬≈– 40-506 ®“°°“√Õ¥ÿµπ—¢Õß internal carotid artery „π «à π
ë §«“¡º¥‘ª°µ¢‘Õß‚√§∑“ß‚≈Àµ‘«∑‘¬“ carotid siphon ∑”„À¡â ’new collateral vascular
„πµ“à ߪ√–‡∑»ª®í ®¬—‡ ¬Ë’ß∑æË’∫∫Õà ¬„π°≈¡ÿà π§È’Õ◊ network ‡™◊ËÕ¡√–À«à“ß internal carotid ·≈–
sickle cell disease ´ß÷Ëæ∫Õ∫ÿµ—°‘“√≥¡å “°„πºªâŸ«É ¬ external carotid artery ‡¡Õ◊˵√«®¥«â ¬ angiography
™“«Õ‡¡√°‘𗇙ÕÈ◊  “¬·Õø√°‘π— ¡‚’Õ°“ ‡°¥‘‚√§À≈Õ¥ ®–‡ÀÁπ‡ªìπ≈—°…≥–§≈⓬°≈ÿà¡À¡Õ°§«—π (puff of
‡≈Õ◊ ¥ ¡Õߠߟ∂ß÷200 ‡∑“à ¢Õߪ√–™“°√∑«—ˉª  ”À√∫— smoke) (√ªŸ∑’Ë15.1) „πºªâŸ«É ¬∫“ß‚√§ ‡™πà Down
ªí®®—¬‡ ’ˬß∑’Ëæ∫∫àÕ¬„πª√–‡∑»‰∑¬‡°‘¥®“°¿“«– syndrome, neurofibromatosis, sickle cell
∑’Ë¡’·π«‚πâ¡„π°“√·¢Áßµ—«¢Õ߇≈◊Õ¥ßà“¬º‘¥ª°µ‘ disease ¡‚’Õ°“ ‡°¥‘ secondary Moyamoya ‰¥â
(hypercoagulable state) ‡™πà „πºªâŸ«É ¬ protein C ∫Õà ¬ ‡√¬’°«“à Moyamoya syndrome
antithrombin À√Õ◊ protein S deficiency ºªâŸ«É ¬ fibromuscular dysplasia (FMD) ‡ªìπ
antiphospholipid syndrome ‡ªìπµâπ ‚¥¬æ∫«à“ ¿“«–∑’Ë¡’§«“¡º‘¥ª°µ‘¢ÕßÀ≈Õ¥‡≈◊Õ¥¢π“¥°≈“ß
„π°≈ÿà¡¢Õߺ⟪ɫ¬ protein C deficiency ¡’ ·≈–‡≈Á°∑Ë’‰¡à∑√“∫ “‡Àµÿ™—¥‡®π ·µà¡’≈—°…≥–∑’Ë
·π«‚π¡â ‡°¥‘´”È¢Õß¿“«–À≈Õ¥‡≈Õ◊ ¥ ¡ÕßÕ¥ÿµπ—‰¥â  ”§—≠®“° angiography §◊Õ typical string of
 ßŸ ª®í ®¬—‡ ¬Ë’ßÕπË◊ Ê ‡™πà polycythemia, throm- beads appearance
bocytosis æ∫«“à  ¡—æπ—∏°å ∫—°“√‡°¥‘ AIS ‡™πà °π— vasculitis §◊Õ °≈àÿ¡¢ÕßÀ≈Õ¥‡≈◊Õ¥Õ—°‡ ∫
ë §«“¡º¥‘ª°µ¢‘ÕßÀ≈Õ¥‡≈Õ◊ ¥ ∑Ë’‡°‘¥µ“¡À≈—ß°“√µ‘¥‡™◊ÈÕ ‚¥¬‡©æ“–‡ªìπ¿“«–
Õ“∑‘arterial dissection, transient cerebral ·∑√°´âÕπ®“° meningitis, encephalitis ¡’
arteriopathy (TCA), Moyamoya syndrome, √“¬ß“π«à“°“√µ‘¥‡™È◊Õ varicella, mycoplasma
fibromuscular dysplasia ·≈– vasculitis pneumoniae ·≈– parvovirus B19  ¡—æπ—∏°å ∫—°“√
arterial dissection ¡—°æ∫„πºŸâªÉ«¬‡¥Á° ‡°¥‘ AIS „π‡¥°Á πÕ°®“°πÈ’‚√§‡°Ë¬’«°—∫ collagen
™“¬∑Ë’¡’ª√–«—µ‘‰¥â√—∫Õÿ∫—µ‘‡Àµÿ¢Õß∫√‘‡«≥„∫Àπâ“·≈– vascular ‡™àπ systemic lupus erythematosus
≈”§Õ¡“°Õà π∑”„À‡â °¥‘°“√©°’¢“¥¢Õß™π—Ⱥπß—À≈Õ¥‡≈Õ◊ ¥ (SLE), mixed connective tissue disease À√◊Õ
·≈–¡‡’≈Õ◊ ¥‡´“–°Õà „À‡â °¥‘°“√Õ¥ÿµπ—„πÀ≈Õ¥‡≈Õ◊ ¥ °“√„™¬â “ cocaine °¡Á∫’∑∫“∑µÕà °“√‡°¥‘ AIS ®“°

228 ¿√‘¥’ ÿ«√√≥¿°—¥’

À≈Õ¥‡≈Õ◊ ¥Õ°—‡ ∫‡™πà °π— ·¢π ¢“ ÕÕà π·√ß ™°— 楟‰¡™à ¥— ª«¥»√’…– ·≈–¡’
ª®í ®¬—ÕπË◊ Ê ∑æË’∫‰¥·â µπà Õâ ¬ §Õ◊ metabolic °“√‡ª≈¬Ë’π·ª≈ߢÕß√–¥∫—§«“¡√ Ÿâ °÷µ«—  «à πºªŸâ «É ¬
disorders (homocystinuria, Fabry disease) §«√ ∑¡Ë’√’Õ¬‚√§¢ÕßÀ≈Õ¥‡≈Õ◊ ¥ ¡Õß «à πÀ≈ß—®–¡Õ’“°“√
§”π÷ß∂÷ß„π°√≥’∑Ë’¡’ª√–«—µ‘§√Õ∫§√—«‡ªìπ‚√§À≈Õ¥ ‡¥π‘‡´ ‡«¬’π»√’…– ∫“â πÀ¡πÿ Õ“‡®¬’𠇪πì µπâ
‡≈Õ◊ ¥ ¡Õß
°“√ àßµ√«®∑“ßÀâÕߪØ∫‘µ—‘°“√

Õ“°“√·≈–Õ“°“√· ¥ß ®ÿ¥¡àÿßÀ¡“¬À≈—°¢Õß°“√ àßµ√«®∑“ßÀâÕß

Õ“°“√·≈–Õ“°“√· ¥ß¢Õߺ⟪ɫ¬‚√§À≈Õ¥ ªØ∫‘µ—°‘“√„πºªŸâ «É ¬À≈Õ¥‡≈Õ◊ ¥ ¡Õß §Õ◊
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