胎膜早破与晚发型败血症和(或)新生儿坏死性小肠结肠炎的临床观察

Clinical observation of premature rupture of membranes and late-onset sepsis and(or)neonatal necrotizing enterocolitis in newborns

目的探讨胎膜早破(PROM)与晚发型败血症(LOS)和(或)新生儿坏死性小肠结肠炎(NEC)的临床特点及其发病特征,为早期识别和诊断PROM与LOS和(或)NEC提供理论依据。方法选择2015年6月至2017年6月,在安徽医科大学第一附属医院分娩并且诊断为PROM与LOS、或PROM与NEC、或PROM与LOS及NEC的62例患儿为研究对象,并纳入重症感染组。选取同期于本院分娩,诊断为PROM且无感染性疾病的62例新生儿为对照组。采用回顾性分析方法,采集2组患儿的就诊时日龄、性别、娩出方式等一般临床资料,PROM孕妇的破膜时间、新生儿出生体重、出生胎龄,以及其母亲产前激素使用情况,妊娠期糖尿病、妊娠期高血压疾病发生情况等临床指标。采用Wilcoxon秩和检验,对2组患儿就诊时日龄、PROM孕妇的破膜时间进行比较。采用成组t检验,对2组患儿的出生体重、出生胎龄进行比较。采用χ~2检验,对2组患儿性别、娩出方式构成比及小于胎龄儿发生率进行比较。采用Spearman秩相关性分析,对重症感染组患儿LOS和(或)NEC发病日龄与PROM孕妇的破膜时间的相关性进行分析。本研究遵循的程序符合安徽医科大学第一附属医院人体试验委员会制定的伦理学标准,得到该伦理委员会批准。结果 (1)2组患儿就诊时日龄及性别、娩出方式构成比等一般临床资料比较,差异均无统计学意义(P>0.05)。(2)重症感染组PROM孕妇的破膜时间为72h(36～102h),长于对照组的48h(18～72h),2组比较,差异有统计学意义(Z=2.072,P=0.040)。重症感染组与对照组患儿出生体重分别为(1 562.2±487.7)g与(1 967.6±582.8)g,出生胎龄分别为(30.9±2.3)周与(32.9±2.5)周,2组患儿出生体重、出生胎龄分别比较,差异均有统计学意义(t=4.790、5.172,P<0.001)。重症感染组患儿小于胎龄儿发生率为16.1%(10/62),明显高于对照组的3.2%(2/62),并且差异有统计学意义(χ~2=5.905,P=0.015)。(3)重症感染组和对照组患儿出生胎龄构成比比较,差异有统计学意义(χ~2=30.75,P<0.001)。(4)重症感染组患儿LOS和(或)NEC发病日龄为1～42d,中位发病日龄为13.5d(9.8～18.0d)。重症感染组患儿LOS和(或)NEC发病日龄与PROM孕妇的破膜时间呈正相关关系(r秩=0.327,P=0.009)。结论 PROM孕妇分娩新生儿合并LOS和(或)NEC的破膜时间较长,新生儿出生胎龄更小,小于胎龄儿发生率更高。临床对于破膜时间≥72h、出生胎龄<34周及小于胎龄的PROM孕妇分娩的新生儿,应予以高度重视。

To investigate clinical manifestations of premature rupture of membranes(PROM)and late-onset sepsis(LOS)and(or)neonatal necrotizing enterocolitis(NEC),in order to provid theoretical basis for early identification and diagnosis of PROM and LOS and(or)NEC.Methods From June 2015 to June 2017,a total of 62 infants who were diagnosed as PROM and LOS,or PROM and NEC,or PROM and LOS and NEC in the First Affiliated Hospital of Anhui Medical University,were included as severe infection group.Meanwhile,another 62 neonates who were diagnosed as PROM without infectious diseases were included as control group.The following clinical items were retrospectively analyzed,including the general clinical data,such as days of visiting time,gender,delivery methods,and duration of membrane rupture,birth weight,gestational age at birth,and antenatal corticosteroid therapy,gestational diabetes mellitus,and gestational hypertension of the mothers.The differences between two groups in the aspects of days of visiting time and duration of membrane rupture were compared by Wilcoxon rank sum test,and the differences between two groups in the aspects of birth weight and gestational age at birth were compared by independent samples t-test.Furthermore,the differences between two groups in the aspects of constituent ratio of gender,constituent ratio of delivery method,and incidence of small for gestational age infant were compared by chi-square test.The relationship between days of the onset of LOS and(or)NEC and duration of membrane rupture of PROM pregnants was analyzed by Spearman rank correlation.The study protocol was approved by the Ethical Review Board of Investigation in Human Being of First Affiliated Hospital of Anhui Medical University.Results①There were no statistically significant differences between two groups in the aspects of days of visiting time,constituent ratio of gender and constituent ratio of delivery methods(P>0.05).②The median duration of membrane rupture in severe infection group was 72 h(36-102 h),which was significantly longer than 48 h(18-72 h)in control group(Z=2.072,P=0.040).The birth weight in severe infection group and control group were(1 562.2±487.7)g and(1 967.6±582.8)g,respectively;and gestational age at birth in severe infection group and control group were(30.9±2.3)weeks and(32.9±2.5)weeks,respectively,there were significant differences between two groups in the aspects of birth weight and gestational age at birth(t=4.790,5.172;P<0.001).Furthermore,the incidence of small for gestational age infants in severe infection group was 16.1%(10/62),which was significant higher than that of control group 3.2%(2/62),and the difference was statistically significant(χ2=5.905,P=0.015).③There was significant difference between severe infection group and the control group in constituent ratio of gestational age at birth(χ2=30.75,P=0.001).④The onset of LOS and(or)NEC in severe infection group was 1-42 d,and the median was 13.5 d(9.8-18.0 d).There was a positive correction between the days of the onset of LOS and(or)NEC and duration of membrane rupture of PROM pregnants(r rank=0.327,P=0.009).Conclusions PROM and LOS and(or)NEC has a longer duration of membrane rupture,smaller gestational age at birth and higher incidence of small for gestational age infants.We should strengthen the focus on neonates with the duration of membrane rupture longer or equal than seventy-two hours,gestational age at birth less than thirty-four weeks and small for gestational age.