中国14家医院超/极早产儿早期预后的多中心调查

Mortality and morbidity outcomes of preterm infants from the 14 neonatal care centers in China

目的报道国内14家医院产科收治的出生胎龄24～31周早产儿的早期病死率和主要并发症发生率,并分析其影响因素。方法收集2013年1月1日至2014年12月31日国内14家医院产科收治的出生胎龄24～31周早产儿的一般资料,分析各胎龄组早产儿的病死率和主要并发症如支气管肺发育不良(bronchopulmonary dysplasia,BPD)、新生儿坏死性小肠结肠炎(necrotizing enterocolitis,NEC)、早产儿视网膜病(retinopathy of prematurity,ROP)、脑室内出血(intraventricular hemorrhage,IVH)和败血症等的发生率,并分析其影响因素。结果 24～31周各胎龄组早产儿的存活率分别为0、28.0%、84.8%、83.5%、87.4%、90.7%、93.9%和96.0%,无严重合并症存活率分别为0、8.0%、60.6%、53.2%、62.3%、67.9%、79.1%和85.8%,随着胎龄的增加存活率及无严重合并症存活率均增加。胎龄<28周早产儿的产前激素使用率低于28～31周(28.0%～44.3%vs 49.7%～59.6%,P<0.05),总体使用率为56.0%,足疗程为32.3%。早产儿胎龄越小,并发症发生率越高。24～31周早产儿总体呼吸窘迫综合征的发生率为58.5%, BPD的发生率为12.5%,NEC的发生率为3.9%,IVH的发生率为15.4%,ROP的发生率为5.4%,动脉导管未闭的发生率为28.4%,败血症的发生率为9.7%。低胎龄(OR=0.891,95%CI:0.796～0.999,P=0.0047)、低出生体重(OR=0.520,95%CI:0.420～0.643,P=0.000)、小于胎龄儿(OR=1.861,95%CI:1.148～3.017,P=0.012)和5分钟低Apgar评分(OR=1.947,95%CI:1.269～2.987,P=0.002)是早产儿死亡的高危因素。低胎龄(OR=0.666,95%CI:0.645～0.688,P=0.000)、低出生体重(OR=0.921,95%CI:0.851～0.997,P=0.041)、男性(OR=1.235,95%CI:1.132～1.347,P=0.000)、小于胎龄儿(OR=1.511,95%CI:1.300～1.755,P=0.000)、5分钟时低Apgar评分(OR=2.262,95%CI:1.950～2.624,P=0.000)以及围产期合并症如前置胎盘(OR=1.452,95%CI:1.202～1.753,P=0.000)、胎盘早剥(OR=1.380,95%CI:1.082～1.760,P=0.010)、妊娠期高血压疾病(OR=2.262,95%CI:1.950～2.624,P=0.000)、多胎(OR=1.162,95%CI:1.056～1.278,P=0.002)和产前发热(OR=1.367,95%CI:1.228～1.521,P=0.000)等是早产儿并发症发生的高危因素。产前使用激素治疗可以降低超早产儿和极早产儿的死亡风险(OR=0.615,95%CI:0.483～0.801,P=0.033)。结论胎龄26周以下超早产儿的存活率较低,26～31周早产儿的存活率虽逐渐接近发达国家,但严重并发症的发生率较高,提高对围产期合并症的预防和管理有助于改善此类早产儿的生存质量。

Objective To describe the survival and morbidity rates of extreme to very preterm infants in 14 neonatal-intensive care hospitalsin China. Method Data were collected from January 1, 2013 to December 31, 2014 for preterm neonates with gestational age (GA) between24 to 31 complete weeks born in hospitals from our collaborative study group. The primary outcomes were survival and major morbiditiesprior to hospital discharge. Major morbidities included bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), necrotizingenterocolitis (NEC), retinopathy of prematurity (ROP), patent ductus arteriosus (PDA) and sepsis. Mutivariate logistic regression wasused to analyze the risk factor influencing on the outcomes.Result The survival rate prior to discharge was increased with increasing GA(0, 24 weeks; 28.0%, 25 weeks; 84.8%, 26 weeks; 83.5%, 27 weeks; 87.4%, 28 weeks;90.7%, 29 weeks; 93.9%, 30 weeks; 96.0%, 31weeks). Rate of survival and without severe morbidity according to GA were 0 at 24 weeks, 8.0% at 25 weeks, 60.6% at 26 weeks; 53.2%at 27 weeks; 62.3% at 28 weeks; 67.9% at 29 weeks; 79.1% at 30 weeks, 85.8% at 31 weeks respectively. Rate of antenatal steroid usewas 56.0%. The antenatal steroid use was lower in GA<28 weeks infants than that in GA between 28-31 weeks (28%-44.3% vs 49.7%-59.6%, P<0.05). Infants at the lowest GA had a highest incidence of morbidities. Overall, 58.5% had respiratory distress syndrome,12.5% bronchopulmonary dysplasia, 3.9% necrotizing enterocolitis, 15.4% intraventricular hemorrhage, 5.4% retinopathy of prematurity,28.4% patent ductus arteriosus, and 9.7% sepsis. Mortality and morbidity were influenced by gestational age (OR=0.891, 95%CI: 0.796-0.999, P=0.0047 and OR=0.666, 95%CI: 0.645-0.688, P=0.000, respectively), birth weight (OR=0.520,95%CI:0.420-0.643, P=0.000and OR=0.921, 95%CI:0.851-0.997, P=0.041, respectively), SGA (OR=1.861, 95%CI: 1.148-3.017, P=0.012 and OR=1.511, 95%CI:1.300-1.755, P=0.000, respectively), Apgar score<7 at 5 min (OR=1.947, 95%CI: 1.269-2.987, P=0.002 and OR=2.262, 95%CI:1.950-2.624, P=0.000, respectively). The survival rate was increased with more prenatal steroid use (OR=1.615, 95%CI: 1.233-1.901, P=0.033).Conclusion Although most of the preterm infants with GA≥26 weeks survived, a high complication in survivors still can be observed.Rate of survival of GA less than 26 weeks was still low, and quality improvement methods should be used to look into increasing the use ofantenatal steroids in the very preterm births.