超早产儿颅脑病变相关因素分析

Analysis of related factors of extremely preterm infants＇ abnormal neurological findings

目的了解各种产时及产后因素对超早产儿（出生胎龄〈28周）颅脑结局的影响。方法回顾性分析北京军区总医院附属八一儿童医院新生儿监护病房2010年11月至2013年6月收治的无出生缺陷、出生胎龄〈28周、生后12h内入院，并且住院治疗超过1周的早产儿62例的临床资料。所有病例资料录入出生情况、人院时血气、治疗中并发症、使用有创呼吸机情况、不同时段颅脑检查结果，并记录治疗结局。62例患儿出生胎龄23^＋6～27^＋6周，男33例、女29例。进行颅脑结局统计学分析时剔除死亡病例，分为未见颅脑病变组与颅脑病变组，采用t检验及x2检验或Fisher精确检验比较两组间差异。进行治疗结局统计学分析时全部患儿均纳入研究，分为存活组与死亡组，使用t检验及x2检验比较两组问差异。相关性分析采用Spearman相关系数。结果62例患儿住院治疗过程中死亡3例，放弃治疗后死亡3例，存活56例。颅脑病变组男7例、女13例，出生胎龄27～27^＋6周有7例、不足27周13例，出生体重（954±182）g；未见颅脑病变组男23例、女13例，出生胎龄27～27^＋6周29例，不足27周有7例，出生体重（1071±136）g；两组的性别、胎龄及出生体重差异均有统计学意义（x2=4．314、P=0．038，x2=11．622、P=0．001，t=2．728、P=0．009）；颅脑结局与性别、胎龄、出生体重密切相关（r=-0．278、0．456、0．364，P=0．038、0．000、0．006）。颅脑病变组双胎或多胎比率、肺出血发生率、手术治疗率均明显高于未见颅脑病变组[45％（9例）比3％（1例）、55％（11例）比17％（6例）、40％（8例）比11％（4例），x2=12．880、8．936、4．773，P=0．000、0．003、0．029]；以上各种因素均是颅脑病变的高危因素[比值比（OR）=28．64、6．11、5．33]；而分娩方式、羊水情况、孕母感染、窒息、坏死性小肠结肠炎、动脉导管未闭、败血症、有创通气、吸入一氧化氮治疗、血糖值、血气分析、使用多巴胺的量等两组差异均无统计学意义（P均〉0．05）。存活组体重明显高于死亡组[（1029±163）g比（870±144）g，=2．305，P=0．025]，进行Spearman相关分析，差异有统计学意义（r=0．29，P=0．022）；两组其余方面差异均无统计学意义（P均〉0．05）。结论超早产儿颅脑病变情况与其性别、胎龄及出生体重有关，多胎、肺出血、手术是颅脑病变的高危险因素。而超早产儿存活与否与出生体重有关。

Objective To observe the effect of intrapartum and postpartum factors on abnormal neurological findings in the extremely preterm infants. Method Clinical data of 62 premature infants （33 of male, 29 of female ） were retrospectively analyzed. None of the premature infants had birth defect; their gestational ages were all less than 28 weeks （23 ＋6 --27 ＋6 weeks）. They were hospitalized within 12 hours after birth in the neonatal intensive care unit （NICU） of BAYI Children＇s Hospital from November 2010 to June 2013. The blood gas, birth condition, complications, the mechanical ventilation and the ultrasonic encephalography were recorded. The 62 cases were divided into 2 groups, alive group and died group. Meanwhile, all cases of survial were divided into brain injuries group and normal brain group. Data were analyzed with t-test, Chi square test and Spearman correlation analysis. Result Fifty-six cases were alive, and 6 cases died （3 were during the treatment and 3 were after parents gave up）. The average birth weight of brain injuries group was （954 ± 182） g; and that of the normal brain group was （ 1 071 ± 136） g. There were significant differences between the two groups in gender （X2 = 4. 314, P = 0. 038）, gestational age （ X2 = 11. 622, P = 0. 001 ）, birth weight （ t = 2. 728, P = 0. 009 ）, which had significant correlation with neurological outcomes. The Spearman correlative coefficients were - 0. 278, 0. 456 and 0. 364 respectively. And P values were 0. 038, 0. 000 and 0. 006. The rates of multiple pregnancy, lung hemorrhage and surgical operation in brain injuries group were 45 % （ 9/20 ）, 55 % （ 11/20 ） , 40% （ 8/20 ） , which were significantly higher than those in normal brain group, 3% （1/36）, 17% （6/36） , 11% （4/36） （x2= 12. 800,8. 936, 4. 773 ,P all 〈0.05）. These three factors were the high risk factors for adverse neurological outcomes, the odds ratios were 28.64, 6.11 and 5.33 respectively. There was no significant difference in delivery mode, amniotic fluid, maternal infection, asphyxia, necrotizing enterocolitis, patent ductus arteriosus, sepsis, mechanical ventilation, inhaled nitric oxide therapy, blood glucose, blood gas analysis, doses of dopamine between brain injuries group and normal brain group. The birth weight in alive group was （1 029 ±163 ） g, which was significantly higher than those in died group （ 870 ±144） g （ r = 0.29,P = 0. 022）. There was no significant difference in other factors between alive group and died group （ P all 〉 0. 05 ）. Conclusion Gender, gestational age and birth weight may have relation with the neurological outcomes of extremely preterm infants. Multiple pregnancy, pulmonary hemorrhage and surgical operation are the risk factors of brain injuries. Birth weight is related to the survival of extremely pretenn infants.