中国13家医院住院分娩早产儿呼吸窘迫综合征前瞻性调查分析

Respiratory distress syndrome in inborn preterm neonates:a prospective study from 13 hospitals in China

目的了解国内住院分娩早产儿呼吸窘迫综合征（respiratory distress syndrome,RDS）的发生率、病死率、并发症特点、发生高危因素、产前激素应用对早产儿RDS的发生率及预后的影响。方法收集国内13家医院2014年1月1日至12月31日住院分娩的24周≤胎龄〈37周的全部早产儿共7684例。前瞻性分析RDS发生率、病死率、并发症、发生高危因素及产前应用地塞米松的效果。结果活产出生新生儿共75 360例,其中早产儿7 684例（其中入院早产儿6604例,非入院1080例）,早产儿发生率为10.2%。其中极早产儿957例,占12.5%;超早产儿92例,占1.2%。发生RDS 1 177例,发生率为15.3%。24周≤胎龄〈25周、25周≤胎龄〈26周、26周≤胎龄〈27周、27周≤胎龄〈28周、28周≤胎龄〈29周、29周≤胎龄〈30周、30周≤胎龄〈31周、31周≤胎龄〈32周、32周≤胎龄〈33周、33周≤胎龄〈34周、34周≤胎龄〈35周、35周≤胎龄〈36周、36周≤胎龄〈37周早产儿RDS发生率分别为100.0%、90.0%、85.0%、85.1%、81.0%、74.3%、55.4%、47.1%、33.1%、17.9%、9.6%、5.0%、1.9%。出生体重〈500 g、500~749 g、750~999 g、1 000~1 499 g、1 500~2 499 g、2 500~4 000 g、〉4 000 g早产儿RDS的发生率分别为100.0%、100.0%、79.2%、55.8%、15.0%、3.6%、9.5%。RDS早产儿病死率为10.5%,其中胎龄24周≤胎龄〈25周、25周≤胎龄〈26周、26周≤胎龄〈27周、27周≤胎龄〈28周、28周≤胎龄〈29周、29周≤胎龄〈30周、30周≤胎龄〈31周、31周≤胎龄〈32周、32周≤胎龄〈33周、33周≤胎龄〈34周、34周≤胎龄〈35周、35周≤胎龄〈36周、36周≤胎龄〈37周早产儿RDS病死率,分别为100%、70.0%、23.5%、20.0%、16.2%、10.3%、8.1%、9.6%、8.9%、6.0%、5.5%、8.8%、4.5%。RDS患儿颅内出血（ICH）、早产儿视网膜病（ROP）、支气管肺发育不良（BPD）、坏死性小肠结肠炎（NEC）、动脉导管未闭（PDA）、肺出血及败血症的发生率较非RDS早产儿高,差异有非常显著性（P〈0.001）。logistic回归分析显示：男性、胎龄〈33周、出生体重〈2 500 g、身长〈40 cm、新生儿窒息、产次≥2次、前置胎盘是早产儿RDS发病的危险因素;多胎妊娠是RDS的保护因素。胎龄〈33周早产儿RDS发病高危因素包括：男性、胎龄〈28周、出生体重〈2 500 g、身长〈40 cm、新生儿窒息、前置胎盘;产前应用地塞米松是RDS的保护因素。胎龄≥33周早产儿RDS发病高危因素包括：男性、胎龄〈35周、出生体重〈2 500 g、新生儿窒息、产次≥2次、剖宫产、前置胎盘;多胎妊娠是RDS的保护因素。产前应用地塞米松2 879例,占37.5%。胎龄〈33周地塞米松组RDS发生率较非地塞米松组低。地塞米松组胎龄〈33周RDS发生率、重度RDS发生率、病死率均较非地塞米松组低,差异有显著性;地塞米松组需要使用2剂以上肺表面活性物质的比例、机械通气比例、机械通气时间均较非地塞米松组低,差异无显著性;地塞米松组总吸氧时间较非地塞米松组高,差异无显著性;地塞米松组总住院时间较非地塞米松组长,差异有显著性。地塞米松组胎龄≥33周早产儿,除RDS发生率、重度RDS发生率、机械通气比例、总吸氧时间、总住院时间较非地塞米松组高且差异有显著性外,余差异均无显著性。结论国内早产儿发生率较前上升,早产儿及极早产儿、超早产儿救治存活率均较前明显提高。RDS患儿病死率及并发症发生率较高。胎龄〈33周的早产儿RDS的发病高危因素多为自身因素,产前应用地塞米松能有效减少RDS的发生率并改善预后;胎龄≥33周的早产儿RDS发病高危因素则多为围产期病理因素,产前地塞米松预防RDS的作用不明显。

Objective To investigate the morbidity, mortality, characteristics of the complications, high risk factors and the effects of antenatal corticosteroids on the morbidity and prognosis of respiratory distress syndrome in inborn preterm neonates in China. Method Data were collected from January 1, 2014 to December 31, 2014 for premature with gestational age 37 weeks born in Obstetric. The morbidity, mortality, characteristics of the complications, high risk factors, effect of antenatal corticosteroids were analysis retrospectively. Results From a total of 75 360 live birth newborns, there were 7 684 cases（10.2%） of preterm neonates, of which 957 cases（12.5%） were extreme prematurity and 92 cases（1.2%） were severe/moderate prematurity. Of these preterm neonates, a total of 1 177 were classified as RDS（15.3%）. The morbidity of RDS in neonates with 24≤GA25、25≤GA26、26≤GA27、27≤GA28、28≤GA29、29≤GA30、30≤GA31、31≤GA32、32≤GA33、33≤GA34、34≤GA35、35≤GA36 and36≤GA37 weeks were 100.0%、90.0%、85.0%、85.1%、81.0%、74.3%、55.4%、47.1%、33.1%、17.9%、9.6%、5.0% and 1.9%, respectively. The morbidity of RDS in preterm neonates with BW500,500-749, 750-999, 1 000-1 499, 1 500-2 499, 2 500-4 000 and more than 4 000 grams were 100.0%,100.0%,79.2%, 55.8%, 15.0%, 3.6% and 9.5%, respectively. The mortality of preterm neonates with RDS was 10.5%. The mortality of RDS in neonates with 24≤GA25、25≤GA26、26≤GA27、27≤GA28、28≤GA29、29≤GA30、30≤GA31、31≤GA32、32≤GA33、33≤GA34、34≤GA35、35≤GA36 and 36≤GA37 weeks were 100.0%,70.0%, 23.5%, 20.0%, 16.2%, 10.3%, 8.1%, 9.6%, 8.9%, 6.0%, 5.5%, 8.8% and 4.5%, respectively. The incidence of ICH, ROP, BPD, NEC, PDA, pulmonary hemorrhage and sepsis in preterm neonates with RDS were higher than those without RDS. Logistic regressions showed that male, GA33 weeks, BW2 500 grams, body length 40 cm, neonatal asphyxia production time≥2 times, and placenta praevia were risk factors for RDS. Multiple pregnancy was protection factor for RDS. In preterm neonates with GA33 weeks, male, GA28 weeks, BW2 500 grams, body length 40 cm, neonatal asphyxia and placenta praevia were risk factors for RDS. Prenatal dexamethasone was protection factor for RDS. In preterm neonates with GA≥33 weeks, male, GA35 weeks, BW2 500 grams, neonatal asphyxia, production time ≥2 times, cesarean delivery, placenta previawere risk factors for RDS. Multiple pregnancy was protection factor for RDS. 2 879 cases under went antenatal dexamethasone therapy, corresponding to 37.5%. There was a lower incidence of RDS in neonates with GA33 weeks in antenatal corticosteroids group compared with non-antenatal corticosteroids group. For neonates with GA33 weeks, the incidence of RDS and severe RDS, the mortalitywere lower in antenatal corticosteroids group compared with nonantenatal corticosteroids group. The proportion of patients received ≥2 doses of surfactant,the proportion of patients received mechanical ventilation and the median length of mechanical ventilation were lower in antenatal corticosteroids group compared with non-antenatal corticosteroids group,but the differences were not statistically significant. The mean duration of oxygen supplement were longer in antenatal corticosteroids group compared with non-antenatal corticosteroids group, but the differences were not statistically significan. The median length of stay in NICU were longer in antenatal corticosteroids group compared with nonantenatal corticosteroids group.For preterm neonates with GA≥33 weeks with RDS, the incidence of RDS and severe RDS, the proportion of patients received mechanical ventilation, the mean duration of oxygen supplement andthe median length of stay in NICU were higher in antenatal corticosteroids group compared with non-antenatal corticosteroids group. But the other differences between these two groups was not statistically significant. Conclusions The incidence of preterm neonates in China increased. The survival rate in preterm neonates, extreme prematurity and severe/moderate prematurity improved obviously than ever before. The mortality and morbidity of complications of preterm neonates with RDS was higher than those without RDS. Most of the high risk factors of RDS in preterm neonates with GA33 weeks were related to their immature lung development. Prenatal dexamethasone can effectively reduce the incidence of RDS and improve the prognosis. For preterm neonates with GA≥33 weeks, the high risk factors of RDS tended to be related to perinatal factors, the protective effect of dexamethasone was not obviously.