出生胎龄33^(+0)~41周^(+6)新生儿侧脑室径线参考值的建立

Reference values for cerebral ventricular size in neonates with gestational age of 33^(+0)-41^(+6) weeks

目的建立出生胎龄33^(+0)~41周^(+6)新生儿侧脑室径线参考值,讨论各指标的影响因素,评估各指标的可靠性,预估各指标外科干预的界值。方法前瞻性纳入2021年2至8月在湖南省妇幼保健院出生或就诊,出生胎龄33^(+0)~41周^(+6)且7日龄内的新生儿。应用超声获取其脑室指数(ventricular index,VI)、侧脑室前角内径(anterior horn width,AHW)、丘-枕距(thalamo-occipital distance,TOD)、侧脑室体部内径(ventricular height,VH)的测量值,建立各指标的参考值和外科干预界值。采用分位数回归估计各指标与连续协变量(出生胎龄和出生体重)的相关性,采用独立样本Mann-Whitney U检验比较各指标中位数在不同分类协变量(男/女、左/右侧侧脑室、阴道分娩/剖宫产、单胎/多胎)组别之间的差异。使用双向混合模型、绝对一致性计算组内相关系数(intraclass correlation coefficient,ICC)评价组内一致性;使用双向随机模型、绝对一致性计算ICC评价组间一致性。ICC<0.50为一致性差,0.50~0.75为一致性一般,0.75~0.90为一致性好,>0.90为一致性极佳。结果研究期间共纳入1370例新生儿,其中555例(40.5%)早产儿AHW、TOD、VI、VH的参考值上限范围分别为2.7~3.5 mm、20.9~22.5 mm、12.6~13.7 mm、3.8~4.9 mm,815例(59.5%)足月儿AHW、TOD、VI、VH的参考值上限范围分别为3.4~4.3 mm、18.6~21.3 mm、14.2~14.7 mm、3.4~3.8 mm;外科干预界值为各指标的参考值上限+4 mm。AHW中位数与出生胎龄呈正相关[偏回归系数(partial regression coefficient,PRC)=0.12,P<0.05],TOD、VH中位数与出生胎龄呈负相关(PRC分别为-0.31和-0.06,P值均<0.05);VI、AHW、TOD中位数与出生体重呈正相关(PRC分别为0.46、0.23和0.97,P值均<0.05)。左侧侧脑室VH(2.0 mm)、AHW(1.8 mm)、TOD(13.6 mm)中位数分别大于右侧VH中位数(1.8 mm,U=836071.50)、AHW(1.7 mm,U=874141.50)、TOD(12.5 mm,U=738409.00)(P值均<0.05);男婴AHW(1.8 mm)和VI(11.1 mm)的中位数分别大于女婴AHW(1.7 mm,U=834124.00)和VI中位数(10.8 mm,U=884156.50)(P值均<0.05);阴道分娩新生儿AHW中位数大于剖宫产新生儿AHW中位数(2.0 mm与1.6 mm,U=685546.00,P<0.001),而剖宫产新生儿TOD中位数大于阴道分娩新生儿TOD中位数(13.1 mm与12.9 mm,U=850797.00,P=0.010);单胎新生儿AHW中位数大于多胎新生儿AHW中位数(1.9 mm与1.4 mm,U=356999.00,P<0.001)。各指标观察者自身ICC的95%CI下限均>0.75,观察者之间的ICC的95%CI下限均>0.50。结论初步建立了出生胎龄33^(+0)~41周^(+6)新生儿VI、AHW、TOD、VH参考值及外科干预界值,并验证了这些指标的可靠性。

Objective To establish the reference values and neurological intervention cutoffs for cerebral ventricular size in neonates born at 33^(+0)-41^(+6) weeks of gestation and to investigate the influential factors and reliability of the related indices.Methods This study prospectively recruited 13701-to 7-day neonates born or hospitalized at the Hunan Provincial Maternal and Child Health Care Hospital from February to August 2021.All the neonates,who were born between 33^(+0)and 41^(+6) weeks of gestation,were subjected to ultrasound scanning to obtain the indices,including ventricular index(VI),anterior horn width(AHW),thalamo-occipital distance(TOD),and ventricular height(VH).The reference value and neurological intervention cutoff for each index were set.Quantile regression was used to estimate the correlation between each index and continuous covariates[gestational age at birth(GA)and birth weight(BW)].Mann-Whitney U test was used to analyze the differences in the medians of indices in different categorical covariates groups(males/females,left/right lateral ventricles,vaginal delivery/cesarean section,and singleton/multiple births).Intraclass correlation coefficient(ICC)calculated by a two-way mixed effect model and absolute agreement was used to access intra-rater reliability;ICC via a two-way random effect model and absolute agreement was utilized to rate inter-rater reliability(pool reliability:ICC below 0.50;moderate reliability:ICC between 0.50 and 0.75;good reliability:ICC between 0.75 and 0.90;excellent reliability:ICC exceeding 0.90).Results The upper limits of reference values for AHW,TOD,VI,and VH in 555(40.5%)preterm neonates were 2.7-3.5 mm,20.9-22.5 mm,12.6-13.7 mm,and 3.8-4.9 mm,and in 815(59.5%)term newborns were 3.4-4.3 mm,18.6-21.3 mm,14.2-14.7 mm,and 3.4-3.8 mm,respectively.The cutoff of neurosurgical intervention for each index was the upper limit of reference value plus 4 mm.AHW median was positively correlated with GA[partial regression coefficient(PRC):0.12,P<0.05],while TOD and VH medians were negatively correlated with GA(PRC:-0.31 and-0.06,both P<0.05).VI,AHW,and TOD medians were positively associated with BW(PRC:0.46,0.23,and 0.97,all P<0.05).The medians of VH,AHW,and TOD in the left cerebral ventricular exceeded those in the right cerebral ventricular,respectively(VH:2.0 vs 1.8 mm,U=836071.50;AHW:1.8 vs 1.7 mm,U=874141.50;TOD:13.6 vs 12.5 mm,U=738409.00,all P<0.05).The medians of AHW and VI in male neonates were greater than those in female newborns,respectively(AHW:1.8 vs 1.7 mm,U=834124.00;VI:11.1 vs 10.8 mm,U=884156.50,both P<0.05).The neonates delivered vaginally had greater AHW median,but smaller TOD median than those delivered by cesarean section(AHW:2.0 vs 1.6 mm,U=685546.00,P<0.001;TOD:13.1 vs 12.9 mm,U=850797.00,P=0.010).The AHW median in singleton newborns exceeded that in multiple births(1.9 vs 1.4 mm,U=356999.00,P<0.001).The lower limits of 95%confidence intervals for intra-rater and inter-rater ICCs exceeded 0.75 and 0.50,respectively.Conclusion Reference values and surgical intervention thresholds for VI,AHW,TOD,VH of newborns with a gestational age of 33^(+0)-41^(+6) weeks were preliminarily established,and the reliability of these indicators were verified.