产前糖皮质激素对早产小于胎龄儿病死率和主要并发症的影响

Effect of antenatal corticosteroids therapy on the mortality and morbidity of small for gestational age infants born at 24-34 completed weeks： a retrospective multicenter study

目的 评价产前糖皮质激素（ACS）治疗对早产小于胎龄儿（SGA）早期病死率和主要并发症发生率的影响.方法 回顾性分析2013年1月1日至2014年12月31日14家综合性医院或妇幼保健院产科出生、无先天畸形和遗传代谢病、胎龄24～34＋6周早产SGA的临床资料,所有病例录入胎龄、出生体重、性别、分娩方式和主要围产期并发症,按产前是否使用激素分为ACS组和无ACS组,对比两组患儿出院前的病死率和主要并发症的发生率,包括新生儿呼吸窘迫综合征（RDS）、支气管肺发育不良（BPD）、新生儿坏死性小肠结肠炎（NEC）、早产儿视网膜病（ROP）、脑室内出血（IVH）和败血症等.采用多元Logistic回归分析ACS对早产SGA病死率和主要并发症发生率的影响.结果 在6 437例24 ～ 34＋6周早产儿中,产前使用激素3 432例（53.3％）SGA早产儿602例（9.4％）,男295例、女307例.胎龄24 ～31＋6周组：ACS组SGA早产儿的病死率和RDS的发生率以及重度RDS的发生率均明显低于无ACS组,差异均有统计学意义[16.9％（13/77）比32.1％ （17/53）,48.1％（37/77）比79.2％ （42/53）,33.8％ （26/77）比55.6％ （30/53）,x2=4.082、12.183和6.677,P均＜0.05],其他并发症NEC、BPD、PDA、ROP和败血症两组比较差异均无明显统计学意义（P均＞0.05）.胎龄32 ～34＋6周组：ACS组早产儿IVH的发生率明显高于无ACS组,差异有统计学意义[10.9％（27/248）比5.8％ （13/224）,x^2=3.921,P＜0.05];病死率和其他并发症RDS、NEC、BPD、PDA、ROP和败血症两组比较均无明显统计学意义（P均＞0.05）.多元回归分析显示,ACS组早产SGA发生死亡和RDS的风险明显低于无ACS组[比值比（OR） （95％ CI）：0.375（0.188 ～0.749）,0.697 （0.462～0.953）,P=0.005、0.041];其他并发症IVH、PDA、NEC、ROP、BPD和败血症的发生风险两组比较差异均无统计学意义（P均＞0.05）.结论 ACS在一定程度上可改善早产SGA的早期预后,提示对胎儿体重偏小,特别是存在宫内生长受限,并有早产风险的孕妇应积极给予ACS治疗.

Objective To assess the impact of antenatal corticosteroids （ACS） therapy on mortality and morbidities in small for gestational age （SGA） preterm infants.Method A retrospective database analysis was performed.Preterm infants born at 24-34 completed weeks who were diagnosed as SGA in 14 hospitals in China between 2013 and 2014 were evaluated for mortality and major morbidities including respiratory distress syndrome （RDS）,bronchopulmonary dysplasia （BPD）,intraventricular hemorrhage （IVH）,necrotising enterocolitis （NEC）,retinopathy of prematurity （ROP）,patent ductus arteriosus （PDA） and sepsis.These cases were classified into two groups：ACS group and non-ACS group （NACS）.Multivariate logistic regression analysis was performed to assess the effect of ACS on neonatal mortality and morbidities.Result Among the 6 437 infants born at 24-34 completed weeks,602 were SGA（9.4%）,and ACS was administered to 3 432 infants （53.3%）.Among SGA infants at gestational age （GA） of 24-31 completed weeks,ACS treatment were associated with decreased mortality （16.9% （13/77） vs.32.1% （17/53）,x2 =4.082,P 〈0.05）,incidence of RDS （48.1% （37/77） vs.79.2% （42/53）,x2 =12.183,P〈0.05） and incidence of severe RDS （33.8% （26/77） vs.55.6% （30/53）,x2 =6.677,P〈0.05）.The incidence of IVH was higher in ACS group than that in NACS group （10.9% （27/248） vs.5.8% （13/224）,x2 =3.921,P 〈 0.05） among 32-34 completed weeks infants.There were no significant differences between the ACS group and the NACS group in the incidence of BPD,NEC,ROP,PDA and sepsis （P all 〉 0.05）.Multivariate logistic regression analysis demonstrated a decreased mortality （OR =0.375,95% confidence interval （CI）：0.188-0.749,P =0.005） and incidence of RDS （OR =0.697,95% CI：0.462-0.953,P =0.041） in SGA infants exposed to antenatal steroids.There were no significant differences in BPD,IVH,NEC,ROP,PDA and sepsis risks in ACS group compared with NACS group （P all 〉0.05）.Conclusion ACS administration could reduce the mortality and major morbidities in SGA preterm infants less than 32 weeks GA.This study suggests that ACS should be given to growth restricted fetuses at risk of preterm delivery in order to improve perinatal outcome.