足月儿呼吸窘迫综合征高危因素及防治

近年来,随着择期剖宫产率等因素增加,足月儿呼吸窘迫的发生率也呈上升趋势,已引起广泛关注.本文从母婴两方面重点综述了发生足月儿呼吸窘迫综合征的高危因素及相关机制.发现选择性剖宫产、胎龄、胎儿性别以及某些妊娠合并症均能影响足月儿呼吸窘迫综合征的发病率.并指出一旦呼吸困难加重,要及时使用呼吸支持和尽早使用肺泡表面活性物质,各种综合措施联合使用可减少足月儿呼吸窘迫综合征的病死率.     

Developmental patterns of heart rate and variability in prematurely-born infants with apnea of prematurity

At equivalent post-conceptional ages, prematurely-born infants have higher heart rates and reduced heart rate variability, relative to full-term neonates. Premature birth might exert long-lasting effects on central and peripheral mechanisms that control cardiovascular activity. We assessed development of heart rate and heart rate variability in symptomatic preterm infants up to 6 months of age. Fifty 6.5-h evening recordings of EKG and breathing were obtained from prematurely-born infants (gestational ages: 24–35 weeks). Cardiac R-R intervals were captured with a resolution of ±0.5 msec. One-min epochs were selected from three periods of regular respiration in recordings from premature infants and 72 recordings of full-term infants at comparable post-conceptional ages. Mean heart rate and heart rate variability were determined for each recording. At 40 weeks post-conception, prematurely-born infants with apnea of prematurity showed higher heart rates and reduced heart rate variability than did full-term neonates. These differences between premature and full-term infants persisted throughout the next 6 months in those infants born prior to 30 weeks gestation, and in those infants born at 30–35 weeks who experienced respiratory distress syndrome (RDS) during the neonatal period. The findings suggest that premature delivery, or complications thereof, exerts long-lasting effects on cardiac control.     

Hyaline membrane disease and intraventricular haemorrhage in small for gestational age infants.

19 small for gestational age (SGA) infants with gestational ages less than or equal to 32 weeks were matched with 19 appropriate for gestational age (AGA) preterm neonates with similar risk factors for intraventricular haemorrhage and hyaline membrane disease. Gestational age, 1- and 5-minute Apgar scores, type of delivery, survival rate, use of corticosteroids before delivery, sex, twinning, presence of premature rupture of membranes, and birth date were comparable in the two groups. Gestational age of both groups was 30 (+/- 1.8) weeks, and birthweights were 919 (+/- 202) g (SGA group) and 1268 (+/- 212) g (AGA group). The incidences of hyaline membrane disease and intraventricular haemorrhage were different: 74 and 42% respectively for AGA neonates, 5 and 11% respectively for SGA infants. We suggest that a stressful environment in utero may enhance maturation and prevent hyaline membrane disease and intraventricular haemorrhage.     

Hyaline membrane disease and intraventricular haemorrhage in small for gestational age infants

19 small for gestational age (SGA) infants with gestational ages less than or equal to 32 weeks were matched with 19 appropriate for gestational age (AGA) preterm neonates with similar risk factors for intraventricular haemorrhage and hyaline membrane disease. Gestational age, 1- and 5-minute Apgar scores, type of delivery, survival rate, use of corticosteroids before delivery, sex, twinning, presence of premature rupture of membranes, and birth date were comparable in the two groups. Gestational age of both groups was 30 (+/- 1.8) weeks, and birthweights were 919 (+/- 202) g (SGA group) and 1268 (+/- 212) g (AGA group). The incidences of hyaline membrane disease and intraventricular haemorrhage were different: 74 and 42% respectively for AGA neonates, 5 and 11% respectively for SGA infants. We suggest that a stressful environment in utero may enhance maturation and prevent hyaline membrane disease and intraventricular haemorrhage.     

1108例新生儿呼吸衰竭的临床流行病学特征

目的 对1 108 例新生儿呼吸衰竭病例的临床流行病学特征进行分析,为提高临床治疗水平和开展多中心临床研究提供参考。方法 采用统一调查表收集1 108 例呼吸衰竭新生儿的临床资料,对原发疾病、临床治疗方法、治疗结局、病死率等流行病学指标进行统计学分析。结果 1 108 例患儿中位胎龄为37+1 周,中位出生体重为2 600 g,入NICU 中位日龄为0.71 d(17 h),男/ 女比例为3.1:1。主要原发疾病为呼吸窘迫综合征(30.51%)、肺部感染/ 败血症(23.55%)和湿肺(13.18%)。治疗中采用经鼻持续气道正压通气(nCPAP)占48.64%,高频振荡通气占12.81%、使用肺表面活性物质占13.45%、NO 吸入治疗占8.66%,病死率达24.19%。结论 呼吸窘迫综合征为新生儿呼吸衰竭的主要原发疾病,使用肺表面活性物质、nCPAP、高频振荡通气、NO 吸入治疗已经成为新生儿呼吸衰竭的主要救治手段,但新生儿呼吸衰竭的病死率仍然较高。     

Severe neonatal respiratory distress with linear inspiratory pressure-volume curve

Twenty-four newborns with severe respiratory distress, treated by mechanical ventilation, are investigated by inspiratory pressure-volume curve. The curves are obtained by slow continuous inflation technique. Two shapes are described: concave curve, ten newborns (group I), linear curve, fourteen newborns (group II). The gestational age is over 36 weeks in both groups. Determination of respiratory mechanics is indicated when mean AaDO2 is higher than 500 torr in both groups, and when there is a hypercapnia (PaCO2 = 53 +/- 11 torr, with p less than 0.05) in group II. Mechanical ventilation is conducted with individually adjusted PEEP in group I, and without PEEP in group II. Twelve hours after; mean AaDO2 in group I (260 +/- 101 torr) and in group II (420 +/- 188 torr) are significantly different (p less than 0.05). The variance analysis in group II shows that PaCO2 and pH are normalized (p less than 0.001). All the newborns in group I recovered. Three newborns in group II died. Group I can be assimilated to hyaline membrane disease in full-term neonates. Practically, the cases of neonatal respiratory distress in which PEEP is not indicated can be identified by the functional characteristics of group II.     

Minimizing the risk of respiratory distress syndrome

Respiratory distress syndrome, or hyaline membrane disease, remains one of the most significant causes of neonatal morbidity and mortality, despite advances in perinatal care. It is a condition predominantly affecting premature infants, with an incidence inversely related to gestational age. Whilst many infants will improve within a few days, more severely affected babies are at risk of developing chronic lung disease, and a range of extrapulmonary complications. Minimizing the risk of respiratory distress syndrome requires a combination of preventative strategies prior to and in the immediate aftermath of delivery and a balanced approach to treatment of established disease. The use of antenatal steroids and pulmonary surfactant have revolutionized perinatal medicine, however a number of controversies still exist for both treatments such as optimal dosing, timing, and repeat courses. This article reviews the current evidence for these treatments, as well as over viewing the other essential antenatal and perinatal concerns faced when managing an infant at risk of respiratory distress syndrome.     

选择性剖宫产与新生儿呼吸系统疾病相关性分析

目的 评估不同胎龄足月儿选择性剖宫产（ECD）分娩后呼吸系统疾病的发生风险,探讨减少新生儿呼吸系统疾病发生的ECD时机.方法 对2008年6月至2013年6月在郑州人民医院行ECD分娩的新生儿进行回顾性分析.入选标准：胎龄37 ～ 39周,单胎,母亲无妊娠期合并症和并发症,剖宫产前无胎膜早破及临产征象.分析胎龄37、38、39周三组新生儿的一般情况及呼吸系统疾病发生情况.结果 共有1152例胎龄37～39周的ECD新生儿纳入研究,37周组136例,38周组401例,39周组615例,因发生呼吸系统疾病转入新生儿科的病例94例,其中37周组20例,呼吸系统疾病发生率14.7％;38周组38例,呼吸系统疾病发生率9.5％;39周组36例,呼吸系统疾病发生率5.8％.胎龄越大,ECD新生儿呼吸系统疾病发生率越低,差异有统计学意义（P＜0.05）.胎龄37 ～ 39周ECD新生儿中,发生的呼吸系统疾病以湿肺、窒息及肺炎为主,湿肺共51例,占54.2％;窒息共9例,占9.6％;肺炎共17例,占18.1％.胎龄37周和38周进行ECD的新生儿呼吸系统疾病发生率均较胎龄39周增高（OR分别为2.5和1.8,P均＜0.05）.结论 胎龄37 ～ 38周进行ECD可增加新生儿呼吸系统疾病的发生率,ECD尽可能在妊娠39周后进行.     

Risk factors associated with the development of peri-intraventricular haemorrhage and periventricular leukomalacia

81 preterm infants of 34 weeks' gestation or less were prospectively and sequentially examined by means of real-time ultrasound in order to identify which clinical risk factors might be associated with the development of peri-intraventricular haemorrhage (PVH) and periventricular leukomalacia (PVL). Infants were allocated in three groups: group A (n = 44): with normal scans; group B (n = 24): with isolated PVH, and group C (n = 13): with PVL. 28 obstetrical and neonatal factors were compared within the three groups using two methods of statistical analysis (2 x 2 chi 2 analysis and multivariate logistic regression analysis). Hyaline membrane disease, acidosis, pneumothorax and Apgar score at 10 min were statistically associated with PVH. The multivariate logistic regression analysis showed that need for resuscitation, hyaline membrane disease, acidosis and gestational age were the most important factors. Gestational age, seizures, hyaline membrane disease, apnoea with hypoxaemia and bradycardia were strongly associated with PVL. These results suggest that a low gestational age, the need for resuscitation and a respiratory distress syndrome with its consequences might lead to PVH, whereas a low gestational age, hypoxaemia and cardiocirculatory disturbances might decrease cerebral perfusion and result into PVL.     

伊朗伊斯法罕新生儿重症监护中心新生儿气胸的发病因素、发生率和死亡率调查

目的：该研究旨在调查伊朗伊斯法罕新生儿重症监护中心(NICU) 住院新生儿气胸的发病因素、发生率和死亡率。方法：738 例入住NICU的新生儿中,43例发生了气胸。回顾性分析气胸患儿的临床资料,包括胎龄、出生体重、Apgar评分、出生方式、母亲年龄、产次、围产期窒息、出生时复苏、气胸发生部位、机械通气情况、肺表面活性物质治疗、肺部疾病等。结果：气胸患儿平均胎龄为31周,出生体重为1 596 g。12例（28%）患儿胎龄小于28周。28例（65%）出生体重低于1 500 g。共43 例(5.8%)新生儿发生了气胸。97%的气胸为单侧（n=63),双侧气胸仅占3%（n=2）。呼吸窘迫综合征(40/43, 93%)和机械通气(37/43, 86%)是导致气胸发生的常见原因。共28例(65%)患儿死亡。死亡患儿与幸存患儿出生体重、胎龄及胸管留置时间差异有统计学意义。需要肺表面活性物质治疗的气胸患儿死亡率显著增加,与无需表面活性物质治疗的气胸患儿比较差异有统计学意义。结论：该研究中气胸的发生率与死亡率高于其他报道,其原因可能是该研究中新生儿出生体重和胎龄都较低。呼吸窘迫综合征和机械通气是导致新生儿气胸发生的常见原因。患儿胎龄越小,体重越低,肺部疾病越严重,死亡率则越高。     

Comparison of single and repeated antenatal corticosteroid therapy to prevent neonatal death and morbidity in the preterm infant

INTRODUCTION: In the case of threatened preterm delivery, repeat administration of antenatal corticosteroids is a common practice in women who have not delivered 7-14 days after the first course of corticosteroids. However, the benefits of this policy as compared to single-course administration have not been proven. AIM: Our purpose was to compare neonatal death and morbidity after repeat antenatal courses of corticosteroids with neonatal death and morbidity after a single course. METHODS: We performed a cohort study with matched controls. Neonates treated with repeat antenatal courses of corticosteroids were matched with neonates treated with a single course. Matching criteria were sex, single or multiple gestation, route of delivery, gestational age at delivery and year of birth. Intrauterine growth-restricted infants were matched separately. We excluded neonates with congenital malformation and neonates with an unknown number of antenatal corticosteriod courses. Outcome measures were the incidences of neonatal death, respiratory distress syndrome, intraventricular haemorrhage and necrotizing enterocolitis. RESULTS: From the neonates treated with two or three courses of antenatal corticosteroids, 56 appropriate grown neonates and 24 intrauterine growth-restricted neonates could be matched. The incidences of neonatal death, respiratory distress syndrome, intraventricular haemorrhage and necrotizing enterocolitis did not show statistically significant differences after single and repeat courses of corticosteroids. Appropriate grown and intrauterine growth-restricted neonates showed the same results. CONCLUSION: From our study, it can be concluded that in preterm neonates, repetition of antenatal corticosteroids seems not to improve neonatal outcome.     

THE HYALINE MEMBRANE DISEASE–INTRAVENTRICULAR HEMORRHAGE RELATIONSHIP IN THE VERY LOW BIRTH WEIGHT INFANT: PERINATAL ASPECTS

ABSTRACT. A large retrospective clinical study is reported confirming pathologic studies upon the effect of hyaline membrane disease on the occurrence of intraventricular hemorrhage in very low birth weight infants. Two hundred and twenty infants with birth weight 1500 g and gestational age 32 weeks were studied. Infants with hyaline membrane disease (112) had 56 % incidence of intraventricular hemorrhage whereas of those without hyaline membrane disease (108) only 31% developed intraventricular hemorrhage ( p < 0.001). When controlled for gestational age, the more immature infants ( 1000 g) exhibited no difference in the occurrence of intraventricular hemorrhage whether hyaline membrane disease coexisted or not. In the 1001–1500 g group, the occurrence of hyaline membrane disease with intraventricular hemorrhage was significant ( p < 0.001). The association of lower Apgar scores and the influence of intermittent positive pressure ventilation in infants with intraventricular hemorrhage is discussed. Extreme immaturity negates all perinatal clinical expertise in determining neonatal outcome. Therefore, carrying pregnancies beyond 28 weeks gestation is mandatory. Beyond 28 weeks, pulmonary maturity and the influence of therapeutic modalities and maternal transport become increasingly important.     

Cord prealbumin values in newborn infants: effect of prenatal steroids, pulmonary maturity, and size for dates

We assessed cord prealbumin concentrations in 214 appropriate for gestational age newborn infants, 21 small for gestational age infants, and 27 large for gestational age infants to establish normal values and to assess the effect of intrauterine growth, prenatal steroids, and pulmonary maturity on prealbumin levels. Cord prealbumin values were significantly correlated with increasing gestational age (r = 0.33; P less than 0.001) and birth weight (r = 0.40, P less than 0.001) in the AGA neonates. Neonates born before 37 weeks gestation had significantly lower prealbumin levels than those born at term (P less than 0.001). The SGA infants had significantly lower levels than age-matched AGA controls (P less than 0.01), and LGA infants had significantly higher levels than age-matched AGA controls (P less than 0.001). In preterm infants, those with exposure to prenatal steroids (betamethasone or premature rupture of membranes) had significantly higher prealbumin values than control infants of comparable age and weight (P less than 0.001). Infants without respiratory distress syndrome had higher levels than those of comparable age and weight with hyaline membrane disease (P less than 0.05). This study demonstrates that a correlation of gestational age and birth weight exists with cord prealbumin levels, and that the large variability at each gestational age may be accounted for in part by appropriateness of size for dates, prenatal steroid exposure, and pulmonary maturity.     

The hyaline membrane disease-intraventricular hemorrhage relationship in the very low birth weight infant: perinatal aspects

A large retrospective clinical study is reported confirming pathologic studies upon the effect of hyaline membrane disease on the occurrence of intraventricular hemorrhage in very low birth weight infants. Two hundred and twenty infants with birth weight less than or equal to 1 500 g and gestational age less than or equal 32 weeks were studied. Infants with hyaline membrane disease (112) had 56% incidence of intraventricular hemorrhage whereas of those without hyaline membrane disease (108) only 31% developed intraventricular hemorrhage (p less than 0.001). When controlled for gestational age, the more immature infants (less than or equal to 1 000 g) exhibited no difference in the occurrence of intraventricular hemorrhage whether hyaline membrane disease coexisted or not. In the 1 001-1 500 g group, the occurrence of hyaline membrane disease with intraventricular hemorrhage was significant (p less than 0.001). The association of lower Apgar scores and the influence of intermittent positive pressure ventilation in infants with intraventricular hemorrhage is discussed. Extreme immaturity negates all perinatal clinical expertise in determining neonatal outcome. Therefore, carrying pregnancies beyond 28 weeks gestation is mandatory. Beyond 28 weeks, pulmonary maturity and the influence of therapeutic modalities and maternal transport become increasingly important.     

选择性剖宫产对(近)足月儿发生呼吸窘迫综合征的影响

目的 探讨选择性剖宫产对(近)足月儿呼吸窘迫综合征(RDS)发生的影响.方法 以2008年11月-2009年10月在郑州大学第三附属医院NICU住院的76例诊断为RDS的(近)足月儿为研究对象,分析其分娩方式、胎龄分布.RDS(近)足月儿根据分娩方式分为2组:选择性剖宫产组和阴道分娩组,比较不同分娩方式RDS发生风险的高低;足月儿选择性剖宫产组根据胎龄分为2组,37~38+6周组和39~41+6周组,比较不同胎龄选择性剖宫产RDS发生风险的高低.结果 76例RDS(近)足月儿中63例为选择性剖宫产,占82.9%.(近)足月儿选择性剖宫产组RDS发生风险显著高于阴道分娩组(OR=2.38,95%CI 1.06~5.33,P<0.05),随着胎龄增加,RDS发病例数逐渐降低,但差异无统计学意义(P>0.05).足月儿选择性剖宫产组RDS发生风险显著高于阴道分娩组(OR=4.14,95%CI 1.58~10.90,P<0.01),这种风险在37~38+6周组显著升高(OR=4.50,95%CI 1.10~18.20,P<0.05),39周之后不再升高,且与阴道分娩组相比差异无统计学意义(P>0.05).结论 选择性剖宫产是(近)足月儿发生RDS的重要危险因素,且选择性剖宫产时机对(近)足月儿发生RDS也很重要.如果条件允许,足月儿选择性剖宫产分娩应在39周以后进行,可显著减少RDS发生.     

Intrauterine versus postnatal transport of the preterm infant: a short-distance experience

AIM: The purpose of this study was to compare neonatal outcome (mortality, respiratory distress syndrome, intraventricular hemorrhage, necrotising enterocolitis, persisting ductus arteriosus, and septicaemia) after intrauterine transport versus neonatal transport in an area where short-distance transport is the rule. METHODS: The study was retrospective in nature. The files of all neonates delivered between 24 and 34 weeks from 1994 to 1998 and transported intrauterine or postnatally to the Antwerp University Hospital were reviewed. Cases of intrauterine fetal death and mothers discharged before delivery were excluded, as were infants with lethal congenital anomalies. RESULTS: A total of 328 deliveries after intrauterine transport, resulting in 416 neonates and 187 neonates transported postnatally were included. The maximum distance patients had to be transported was 40 km. Placental abruption was more frequent in the mothers of the neonatal transport group (13 vs. 5%, P=0.001). Corticosteroids were administered significantly less in the neonatal transport group (67 vs. 13%, P<0.0001). Preterm rupture of the membranes (36 vs. 20%, P<0.0001), preterm labour (73 vs. 36%, P<0.0001), and pre-eclampsia (10 vs. 7%, P<0.0001) were more frequent in the intrauterine transport group and this group had a lower mean birthweight and gestational age. There was no significant difference for overall neonatal mortality, respiratory distress syndrome, intraventricular hemorrhage, necrotising enterocolitis, persisting ductus arteriosus or septicaemia.     

Gastric necrosis in newborns: a report of 11 cases

Eleven neonates ranging in gestational age from 34 to 40 weeks presented with gastric necrosis. The 4 full-term neonates showed sudden-onset hemorrage and “coffee-ground” vomiting; in the 7 premature babies the initial clinical finding was abdominal distention. The criteria for diagnosis were: perinatal distress in prematures and transient neonatal respiratory distress in full-term babies. Radiographic evidence of gastric distention was typical and preceded clinical signs of hematemesis and gastric perforation. Surgery was performed in 8 patients; 3 received medical treatment. At surgery 1␣total and 3 subtotal gastrectomies and 4 segmental gastric resections were performed. Three of these patients died post-operatively as a consequence of multiorgan failure; a second look was necessary in one patient 1 week after surgery because of prepyloric perforation due to ulcers. Biopsy specimens taken from the site of perforation demonstrated extensive necrosis; ulceration was disseminated in the surrounding gastric mucosa; no signs of phlogosis were detected. The diagnosis, treatment, and physiopathologic considerations are reviewed. Accepted: 6 November 1997     

Longitudinal measurements of 17alpha-hydroxyprogesterone in premature infants during the first three months of life.

AIMS: To determine normal concentrations of 17alpha-hydroxyprogesterone (17OHP) for premature infants. METHODS: 17OHP was measured in 66 consecutive premature infants once a week during the first month, and once every two weeks thereafter, until the age of 3 months. The 17OHP values in 100 full term healthy neonates on the third day of life served as controls. Blood was sampled on filter paper using a neonatal radioimmunoassay kit. Findings were correlated with gestational age, birthweight, mode of delivery, Apgar scores, presence of respiratory distress syndrome and intake of maternal steroids. RESULTS: Mean 17OHP was raised at 7 days of age (138.9, 46.3, 53.3, 29.9 nmol/l, respectively, for infants whose gestational age was under 29 weeks, 29 to 30 weeks, 31 to 32 weeks, and 33 weeks and above). It fell sharply in the first two weeks after which it gradually decreased further, reaching 32.7, 23.6, 16.9, and 13.0 nmol/l, respectively, by the age of 90 days. The mean (SEM) 17OHP concentration in full term infants on day 3 of life was 17.8 (8.9) nmol/l. These values were independent of the presence and severity of respiratory distress syndrome and of prenatal maternal steroids. CONCLUSIONS: The increased 17OHP concentrations found at birth fell to those found in term infants during the first three months of life in infants over 31 weeks of gestation. Postconceptional age is the most important factor determining 17OHP concentration.     

呼吸窘迫综合征新生儿治疗后潮气呼吸肺功能检测

目的探讨不同胎龄以及不同程度的呼吸窘迫综合征(RDS)新生儿经治疗后肺功能的情况。方法 107例RDS新生儿分为小于34周早产儿组(65例),晚期早产儿组(21例)及足月儿组(21例),同时选取121例非RDS患儿作为对照组。根据RDS程度将RDS新生儿分为轻度RDS(1、2级)及重度RDS(3、4级)。于纠正胎龄44周时行潮气呼吸肺功能测定。结果不同胎龄RDS新生儿的肺功能参数未见明显差异;RDS组的达峰时间比(TPEF/t E)、达峰容积比(VPEF/VE)较同胎龄对照组小(P0.05);两组不同程度RDS新生儿于纠正胎龄44周时TPEF/t E、VPEF/VE也低于对照组(P0.05),且随着RDS程度加重,其值呈下降趋势。结论 RDS新生儿纠正胎龄44周时肺功能水平明显低于非RDS新生儿;RDS新生儿纠正胎龄44周时潮气呼吸肺功能水平与胎龄无关,主要与RDS严重程度有关。     

胎膜早破与足月新生儿呼吸窘迫综合征的相关分析

目的 明确胎膜早破(PROM)与足月新生儿呼吸窘迫综合征(RDS)的相关性.方法 采用病例对照研究的方法,选择2008年1月-2010年12月出生后在本院新生儿重症监护中心住院、胎龄在37周以上、诊断为RDS的患儿205例为病例组,同期入院、主要诊断为新生儿黄疸(除外感染因素所致者)的410例足月新生儿为对照组.对所有纳入对象的临床资料进行回顾性分析,记录相关信息,包括有无PROM、患儿性别、分娩方式、出生体质量、羊水污染等,探讨PROM与足月儿RDS的关系.结果 1.RDS组RPOM所占比例(30.2％,62/205例)明显高于对照组(15.5％,63/410例),差异有统计学意义(x2=12.276,P＜0.001).2.经单因素分析,PROM、选择性剖宫产、男性、小于胎龄儿、羊水量少、妊娠期血糖偏高及糖尿病、羊水Ⅲ度污染、宫内窘迫、出生时窒息等因素均与足月儿RDS具有相关性(Pa＜0.05),均为RDS的危险因素,而孕母年龄≥35岁、脐带绕颈、胎盘早剥与RDS均无相关性(Pa＞0.05).3.经Logistic回归分析:PROM、选择性剖宫产、男性、妊娠期血糖异常及糖尿病、出生时窒息等与足月儿RDS密切相关.结论 PROM与足月儿RDS密切相关,是足月儿RDS的高危因素之一.