超未成熟儿与超低出生体重儿产前糖皮质激素使用情况及其对预后影响的多中心调查

Antenatal corticosteroid administration in extremely preterm and extremely low birth weight infants and its effects on prognosis:a multicentre survey

目的探讨超未成熟儿(extremely preterm infant,EPI)与超低出生体重儿(extremely low birth weight infant,ELBWI)产前糖皮质激素使用情况及其对存活率和并发症发生率的影响。方法前瞻性纳入广东省26家三级甲等综合性医院及妇幼专科医院新生儿科2013年1月1日至2017年12月31日出院的EPI与ELBWI,调查产前糖皮质激素的使用情况。所有病例产前糖皮质激素使用均为地塞米松,其中使用满1疗程指产前使用地塞米松满4剂次,不满1疗程指产前使用地塞米松1~3剂次。采用χ2检验或趋势χ2检验比较产前激素使用情况及其对存活率及并发症发生率的影响。结果研究期间共纳入2392例EPI和ELBWI,出生胎龄为(27.8±1.9)周,出生体重为(919±158)g,产前使用糖皮质激素治疗1267例(53.0%),其中满1疗程者725例(30.3%),不满1疗程者542例(22.7%)。产前糖皮质激素在2013年至2017年逐年的使用率分别为45.9%(152/331)、49.5%(207/418)、53.9%(247/458)、57.1%(328/574)和54.5%(333/611),呈逐年上升趋势(χ2趋势=9.502,P=0.002);且与地区经济发展水平有关,广深地区使用率最高[54.8%(788/1438)],其次是余珠三角地区[50.8%(360/708)]和非珠三角地区[48.4%(119/246)](χ2趋势=5.209,P=0.022)。使用满1疗程组的存活率最高[70.8%(513/725)],其次是不满1疗程组[63.3%(343/542)],未使用组最低[52.4%(589/1125)](χ2趋势=64.309,P<0.001)。在并发症发生率方面,与未使用组比较,使用组新生儿呼吸窘迫综合征[85.8%(1087/1267)与92.7%(1043/1125)]、早产儿视网膜病变[37.8%(338/893)与44.1%(287/651)]和脑室周围白质软化[2.8%(29/1047)与6.5%(53/818)]发生率较低,但支气管肺发育不良[74.5%(641/860)与68.7%(400/582)]和动脉导管未闭[29.0%(359/1240)与24.5%(266/1087)]发生率较高(P值均<0.05)。结论产前使用糖皮质激素可以改善EPI与ELBWI的存活率,并降低部分并发症的发生率。但目前我国EPI与ELBWI产前糖皮质激素使用率较低,有待提高。

Objective To investigate the effects of antenatal corticosteroid exposure in extremely preterm infants (EPIs) and extremely low birth weight infants (ELBWIs) on their survival rates and the incidences of complications.Methods Birth and hospitalization data of EPIs and ELBWIs discharged from neonatal departments of 26 tertiary hospitals and maternal and child health hospitals in Guangdong Province from January 1, 2013 to December 31, 2017 were collected in this prospective survey. Prenatal corticosteroid (dexamethasone) exposure was analyzed. These patients were divided into two groups: treatment group (full-course subgroup receiving four doses of dexamethasone and uncompleted-course subgroup treated with 1-3 doses) and non-treatment group. The survival rates and incidences of complications were compared between different groups using Chi-square test and trend Chi-square test.Results A total of 2 392 EPIs and ELBWIs were enrolled with an average gestational age of (27.8±1.9) weeks and birth weight of (919±158) g. There were 1 267 cases (53.0%) received prenatal corticosteroids, of which 725 (30.3%) had a full-course treatment and 542 (22.7%) underwent an uncompleted course. The administration rates of prenatal corticosteroid from 2013 to 2017 were 45.9% (152/331), 49.5% (207/418), 53.9% (247/458), 57.1% (328/574) and 54.5% (333/611), respectively, showing an yearly increasing trend (χ2trend=9.502, P=0.002). Moreover, this figure was positively correlated with the local economic conditions with the highest in Guangzhou and Shenzhen [54.8% (788/1 438)], followed by other Pearl River Delta regions [50.8% (360/708)] and non-Pearl River Delta regions [48.4% (119/246)] (χ2trend=5.209, P=0.022). The highest survival rate was observed in the full-course subgroup [70.8% (513/725)], followed by that in the uncompleted-course subgroup [63.3% (343/542)] and the non-treatment group [52.4% (589/1 125)] (χ2trend=64.309, P<0.001). Compared with the non-treatment group, the incidences of neonatal respiratory distress syndrome [85.8% (1 087/1 267) vs 92.7% (1 043/1 125)], retinopathy of prematurity [37.8% (338/893) vs 44.1% (287/651)] and periventricular leukomalacia [2.8% (29/1 047) vs 6.5% (53/818)] were lower in the treatment group, but the incidences of bronchopulmonary dysplasia [74.5% (641/860) vs 68.7% (400/582)] and patent ductus arteriosus [29.0% (359/1 240) vs 24.5% (266/1 087)] were higher (all P<0.05).Conclusions Prenatal corticosteroid therapy could improve the neonatal survival rates and reduce the incidences of certain complications in EPIs and ELBWIs. The usage of antenatal corticosteroids in EPIs or ELBWIs in China is still low, where need to be improved.