多胞胎对早产儿坏死性小肠结肠炎的影响

Effects of multiple births upon the severity and outcomes of preterm infants with necrotizing enterocolitis

目的分析多胞胎早产儿坏死性小肠结肠炎(necrotizing enterocolitis,NEC)的临床特征,探讨多胞胎对NEC患儿临床表现和预后的影响。方法本研究为回顾性研究,纳入2014年7月至2021年6月上海市儿童医院收治的早产儿NEC患者234例作为研究对象,其中79例为多胞胎早产儿NEC病例,155例为单胎早产儿NEC病例。按出生胎儿数量,分为单胎组(A组,n=155)、多胞胎组(B组,n=79)。按顺产的双胞胎出生先后顺序,分为双胎之大组(C组,n=9)与双胎之小组(D组,n=4)。按双胞胎出生体质量,出生体质量大的为双胎之重组(E组,n=20),出生体质量小的为双胎之轻组(F组,n=45)。按双胞胎发育一致性,分为发育一致组(concordant twin,CT,G组,n=42)和发育不一致组(discordant twin,DT,H组,n=26),在发育不一致组中NEC患儿与同胞比较,出生体质量大的为DT之重组(I组,n=5),出生体质量小的为DT之轻组(J组,n=21)。分别比较各组患儿的基本情况(出生体质量、胎龄、生产方式等)、临床资料(NEC发生时间、出现症状前实验室检查、Bell分期等)、治疗情况(手术比例、有无肠穿孔、病变范围)、术后并发症和住院期间死亡率。结果纳入本研究的多胞胎NEC早产儿共79例,其中双胞胎75例,三胞胎4例。75例双胞胎NEC早产儿平均胎龄31.60周,出生体质量1476.51g,Bell分期Ⅰ、Ⅱ、Ⅲ期分别为35例、21例和19例,需要手术治疗18例(18/79,24%)。与A组相比,B组出生体质量较低[(1618.77±481.30)g比(1479.34±376.88)g,P=0.016],剖宫产率[84/155(54.2%)比65/79(82.3%),P<0.001]和采用辅助生殖技术比例[11/155(7.1%)比21/79(26.6%),P<0.001]较高,但两组患儿在基本情况、临床表现、实验室检查、治疗和预后等方面,差异无统计学意义(P>0.05)。C组与D组NEC患儿的基本情况、临床表现、实验室检查、疾病严重程度、手术治疗、术后并发症和住院期间死亡率差异均无统计学意义(P>0.05)。与E组相比,F组出生体质量较低[(1677.65±458.23)g比(1382.89±300.81)g,P=0.019],出现症状前48 h内外周血白细胞计数较低[(12.31±4.22)×10^(9)/L比(9.13±4.01)×10^(9)/L,P=0.023],全肠道型所占比例较高[5/11(45.4%)比0/7(0.0%),P=0.002],术后并发症也明显增多[11/11(100%)比3/7(42.9%),P=0.011]。但两组患儿在基本情况、临床表现、其他实验室检查、手术治疗和住院期间死亡率等方面,差异均无统计学意义(P>0.05)。与G组相比,J组患儿胎龄较大[(30.95±2.44)周比(32.71±2.30)周,P=0.027],剖宫产比例较高[30/42(71.4%)比20/21(95.2%),P=0.045]。结论多胞胎NEC患儿出生体质量较低,但手术比例、病变累及范围、术后并发症和住院期间死亡率均未明显增加,Bell分期无明显改变。低出生体质量双胞胎NEC患儿的肠管病变程度加重,术后并发症增加。出生顺序和发育不一致对双胞胎NEC患儿疾病严重程度、手术比例、术后并发症和住院期间死亡率无明显影响。

Objective To explore the clinical characteristics of multiple-birth preterm infants with necrotizing enterocolitis(NEC)and examine the effects of multiple births on clinical manifestations and outcomes of NEC infants.Methods In this retrospective study,234 premature infants with NEC admitted to Shanghai Children's Hospital from July 2014 to June 2021 were included as research objects,among which 79 were multiple premature infants with NEC and 155 were single premature infants with NEC.According to the presence of single/multiple birth,they were divided into two groups of singleton(group A,n=155)and multiple-birth(group B,n=79).Twin group of vaginal delivery was divided into primary birth(group C,n=9)and secondary birth(group D,n=4)based upon birth order.Twin group was also assigned into two groups of higher birth weight(group E,n=20)and lower birth weight(group F,n=45).And twin group was divided into two groups of concordant twins(CT,group G,n=42)and discordant twins(DT,group H,n=26).The latter group was further divided into DT with higher birth weight(group I,n=5)and DT with lower birth weight(group J,n=21).Demographic profiles(birth weight,gestational age&birth mode),clinical data(time of NEC onset,laboratory results&Bell stage),treatment(medical or surgical,intestinal perforation&extent of disease)and outcomes(postoperative complications&in-hospital mortality)were recorded.Results Seventy-nine cases of multiple preterm NEC infants were recruited,including 75 twins and 4 triplets.Seventy-five preterm NEC twins had a mean gestational age of 31.60 weeks and a mean birth weight of 1476.51 gram.Bell stage wasⅠ(n=35),Ⅱ(n=21)andⅢ(n=19).Eighteen cases(24%)underwent operation.As compared with group A,NEC infants in group B had a lower birth weight[(1618.77±481.30)g,(1479.34±376.88)g,P=0.016],higher rates of cesarean delivery[84(54.2%)vs.65(82.3%),P<0.001]and assisted reproductive technology[11(7.1%)vs.21(26.6%),P<0.001].However,no differences existed in demographic profiles,clinical manifestations,laboratory results,Bell stage,surgery or outcomes(P>0.05).There was no significant effect of birth order on demographic profiles,clinical manifestations,laboratory results,Bell stage,surgery or outcomes(P>0.05).As compared with group E,group F had a lower birth weight[(1677.65±458.23)g vs.(1382.89±300.81)g,P=0.019],lower WBC count[(12.31±4.22)vs.(9.13±4.01)×10^(9)/L,P=0.023],greater intestinal lesion[5(45.4%)vs.0(0.0%),P=0.002]and more postoperative complications[11(100%)vs.3(42.9%),P=0.011].No difference existed in demographic profiles,clinical manifestations,other laboratory results,Bell stage,surgery or in-hospital mortality(P>0.05).As compared with group G,group J had a greater gestational age[(30.95±2.44)vs.(32.71±2.30)week,P=0.027]and a higher rate of cesarean delivery[30(71.4%)vs.20(95.2%),P=0.045].However,no differences existed in demographic profiles,clinical manifestations,laboratory results,Bell stage,surgery or outcomes(P>0.05).Conclusions Multiple-birth NEC infants have no greater severity of Bell stage,more surgery,greater extent of intestinal lesion,more postoperative complications or higher in-hospital mortality.Twins with lower birth weight are prone to greater extent of intestinal lesion and more postoperative complications.However,birth order and discordance of twins have no significant effect on disease severity,surgery or in-hospital mortality.