目的:探讨以MRI诊断的早产儿脑损伤的危险因素。方法:收集2019年6月至2021年6月在本院出生于西北妇女儿童医院、入住本院新生儿科、胎龄 < 37周的298例早产儿的相关临床资料及头颅磁共振检查结果。以MRI诊断早产儿是否发生脑损伤,将早产儿分为脑损伤组和非脑损伤组。比较两组早产儿的产前、产时、产后因素,进行单因素分析,对单因素分析有统计学意义的因素行早产儿脑损伤独立危险因素的Logistic回归分析。结果:298例早产儿中,非脑损伤225例,脑损伤73例。两组早产儿的出生胎龄及出生体重差异均没有统计学意义(P > 0.05)。单因素分析:剖宫产、胎膜早破、使用肺泡表面活性物质、NRDS、败血症与早产儿脑损伤有统计学意义(P < 0.05)。多因素Logistics回归分析显示:新生儿呼吸窘迫综合征(OR = 3.034, 95%CI: 1.636~5.628)、胎膜早破(OR = 1.885, 95%CI: 1.010~3.516)、败血症(OR = 3.055, 95%CI: 1.312~7.114)是早产儿脑损伤的危险因素(P < 0.05);剖宫产(OR = 0.510, 95%CI: 0.265~0.983)是早产儿脑损伤的保护因素(P < 0.05)。结论:胎膜早破、新生儿呼吸窘迫综合征、败血症是脑损伤的危险因素,剖宫产是脑损伤的保护因素。 Objective: To explore the risk factors of preterm infants with brain injury, on the basis of MRI. Methods: The clinical data and head magnetic resonance imaging (MRI) findings of 298 preterm in-fants were collected born in Northwest Women’s and Children’s Hospital and admitted to our neo-natal unit from June 2019 to June 2021, with gestational age < 37 weeks. MRI was used to diagnose whether brain injury occurred in preterm infants, and preterm infants were divided into brain in-jury group and non-brain injury group. The prenatal, intrapartum and postnatal factors of the two groups were compared, and univariate analysis was performed, and logistic regression analysis of independent risk factors for brain injury in preterm infants was performed for factors with statisti-cal significance in univariate analysis. Results: Of the 298 preterm infants, 225 had non-brain injury and 73 had brain injury. The differences in birth gestational age and birth weight between the two groups of preterm infants were not statistically significant (P > 0.05). The results of single factor analysis showed that the differences between different gestational age, cesarean section, premature rupture of membranes, use of alveolar surface active substance, NRDS, hyperbilirubinemia, sepsis in the two groups were statistically significant (P < 0.05). Multivariate Logistic regression analysis showed that neonatal respiratory distress syndrome (OR = 3.034, 95%CI: 1.636~5.628), premature rupture of membranes (OR = 1.885, 95%CI: 1.010~3.516), and sepsis (OR = 3.055, 95%CI: 1.312~7.114) are risk factors for brain injury in premature infants (P < 0.05), cesarean delivery (OR = 0.510, 95%CI: 0.265~0.983) is a protective factor for brain injury in premature infants (P < 0.05). Conclusions: Premature rupture of membranes, neonatal respiratory distress syndrome, hyper-bilirubinemia, and sepsis are risk factors for brain injury in premature infants, cesarean delivery is a protective factor for brain injury in premature infants.
目的:探讨以MRI诊断的早产儿脑损伤的危险因素。方法:收集2019年6月至2021年6月在本院出生于西北妇女儿童医院、入住本院新生儿科、胎龄 < 37周的298例早产儿的相关临床资料及头颅磁共振检查结果。以MRI诊断早产儿是否发生脑损伤,将早产儿分为脑损伤组和非脑损伤组。比较两组早产儿的产前、产时、产后因素,进行单因素分析,对单因素分析有统计学意义的因素行早产儿脑损伤独立危险因素的Logistic回归分析。结果:298例早产儿中,非脑损伤225例,脑损伤73例。两组早产儿的出生胎龄及出生体重差异均没有统计学意义(P > 0.05)。单因素分析:剖宫产、胎膜早破、使用肺泡表面活性物质、NRDS、败血症与早产儿脑损伤有统计学意义(P < 0.05)。多因素Logistics回归分析显示:新生儿呼吸窘迫综合征(OR = 3.034, 95%CI: 1.636~5.628)、胎膜早破(OR = 1.885, 95%CI: 1.010~3.516)、败血症(OR = 3.055, 95%CI: 1.312~7.114)是早产儿脑损伤的危险因素(P < 0.05);剖宫产(OR = 0.510, 95%CI: 0.265~0.983)是早产儿脑损伤的保护因素(P < 0.05)。结论:胎膜早破、新生儿呼吸窘迫综合征、败血症是脑损伤的危险因素,剖宫产是脑损伤的保护因素。
早产儿,脑损伤,危险因素
Xiaoting Wan1,2, Wenhua Zhao1,2, He Nie1,2, Xin Lin1,2, Rui Yan2*
1Xi’an Medical University, Xi’an Shaanxi
2Department of Radiology, Northwest Women’s and Children’s Hospital, Xi’an Shaanxi
Received: Sep. 21st, 2022; accepted: Oct. 14th, 2022; published: Oct. 26th, 2022
Objective: To explore the risk factors of preterm infants with brain injury, on the basis of MRI. Methods: The clinical data and head magnetic resonance imaging (MRI) findings of 298 preterm infants were collected born in Northwest Women’s and Children’s Hospital and admitted to our neonatal unit from June 2019 to June 2021, with gestational age < 37 weeks. MRI was used to diagnose whether brain injury occurred in preterm infants, and preterm infants were divided into brain injury group and non-brain injury group. The prenatal, intrapartum and postnatal factors of the two groups were compared, and univariate analysis was performed, and logistic regression analysis of independent risk factors for brain injury in preterm infants was performed for factors with statistical significance in univariate analysis. Results: Of the 298 preterm infants, 225 had non-brain injury and 73 had brain injury. The differences in birth gestational age and birth weight between the two groups of preterm infants were not statistically significant (P > 0.05). The results of single factor analysis showed that the differences between different gestational age, cesarean section, premature rupture of membranes, use of alveolar surface active substance, NRDS, hyperbilirubinemia, sepsis in the two groups were statistically significant (P < 0.05). Multivariate Logistic regression analysis showed that neonatal respiratory distress syndrome (OR = 3.034, 95%CI: 1.636~5.628), premature rupture of membranes (OR = 1.885, 95%CI: 1.010~3.516), and sepsis (OR = 3.055, 95%CI: 1.312~7.114) are risk factors for brain injury in premature infants (P < 0.05), cesarean delivery (OR = 0.510, 95%CI: 0.265~0.983) is a protective factor for brain injury in premature infants (P < 0.05). Conclusions: Premature rupture of membranes, neonatal respiratory distress syndrome, hyperbilirubinemia, and sepsis are risk factors for brain injury in premature infants, cesarean delivery is a protective factor for brain injury in premature infants.
Keywords:Premature Infants, Brain Injury, Risk Factors
Copyright © 2022 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
随着围产技术和诊疗技术的发展,早产儿存活率有了显著提升。据世界卫生组织统计(WHO),全球每年约有1500万早产儿出生,约占新生儿的11% [
收集2019年6月至2021年6月在本院出生于西北妇女儿童医院、入住本院新生儿科、胎龄 < 37周的早产儿298例。本研究获得我院伦理委员会批准。参照《实用新生儿学》第3版中早产儿脑损伤的诊断标准,根据核磁共振结果来对早产儿脑损伤进行诊断,根据结果将早产儿分为两组:脑损伤组和非脑损伤组。本研究获得西北妇女儿童医院伦理委员会批准,MRI检查前所有患儿家属均签署知情同意书。
排除标准:1) 产前胎儿头颅超声或胎儿MRI检查发现已有颅内病变者;2) 严重先天性畸形、遗传代谢性紊乱所致脑损害、低血糖脑病、胆红素脑病、中枢神经系统感染等特定中枢神经系统疾病;3) 临床资料缺失者。
采用GE 1.5 T Signa HDxt磁共振扫描仪在新生儿科医师及患儿家属的陪同下进行检查。扫描时患儿应熟睡,不能入睡者予以苯巴比妥钠10 mg/kg静脉注射镇静;取仰卧位,头先进扫描,在检查过程中给患儿取舒适的体位,给患儿带上耳塞进行听力保护并在耳旁放置海绵垫予以固定头部。然后行常规轴位T2WI、T1FLAIR、T2FLAIR、DWI及T1FLAIR矢状位扫描。各扫描参数如下:1) 视野(FOV) 210 mm × 210 mm;2) 轴位T2WI、T1FLAIR、T2FLAIR、DWI序列层厚6 mm,层间距1.5 mm;T1FLAIR矢状位序列层厚5 mm,层间距1.0 mm;3) 轴位T2WI:FSE序列TR = 3920 ms,TE = 97 ms;T1FLAIR:FSE序列TR = 2260 ms,TE = 28 ms;T2FLAIR:FSE序列TR = 8402 ms,TE = 159 ms;DWI:EPI-SE序列TR = 5000 ms,TE = 84 ms,DWI b值 = 0、1000 s/mm2;矢状位T1FLAIR:FSE序列TR = 1876 ms,TE = 10 ms。
1) 产前因素:孕母妊娠期高血压及糖尿病、胎膜早破;
2) 产时因素:性别、出生胎龄、出生体重、分娩方式、围生期窒息、羊水污染;
3) 产后因素:使用肺表面活性物质(PS)、使用咖啡因、机械通气、新生儿呼吸窘迫综合征(NRDS)、支气管肺发育不良(BPD)、新生儿小肠结肠炎(NEC)、贫血、低血糖、败血症、宫内感染。
数据分析采用SPSS 27.0统计软件。符合正态分布的计量资料用均数±标准差( x ¯ ± s )表示,组间比较采用两独立样本t检验;非正态分布的计量资料用中位数(四分位间距) [M(P25, P75)]表示,组间比较采用Mann-Whitney U检验。计数资料以率(%)表示,组间比较采用χ2检验。多因素分析用Logistic回归分析。P < 0.05为差异有统计学意义。
298例早产儿中,脑损伤73例,发生率24.5%。非脑损伤组与脑损伤组早产儿在出生胎龄、出生体重方面比较差异均无统计学意义(P > 0.05)。见表1。
组别 | n | 胎龄/w | 出生体重/g |
---|---|---|---|
非脑损伤组 | 225 | 31.43 ± 2.39 | 1535 (1255, 1805) |
脑损伤组 | 73 | 31.23 ± 2.60 | 1570 (1325, 1845) |
t/z值 | 0.630 | −0.940 | |
P值 | 0.530 | 0.350 |
表1. 两组早产儿基本资料比较(n = 298)
单因素分析发现,两组早产儿的分娩方式、胎膜早破、使用肺泡表面活性物质、NRDS、败血症比较,差异有统计学意义(P < 0.05);两组患儿性别、围生期窒息、羊水污染、宫内感染、使用咖啡因、机械通气、孕母妊娠期高血压及糖尿病、BPD、NEC、贫血、低血糖等比较,差异无统计学意义(P > 0.05)。见表2。
以早产儿脑损伤作为因变量,选取单因素分析有统计学意义的剖宫产、胎膜早破、使用肺泡表面活性物质、NRDS、败血症作为自变量,构建多因素Logistics回归方程。结果发现:新生儿呼吸窘迫综合征(OR = 3.034, CI: 1.636~5.628)、胎膜早破(OR = 1.885, CI: 1.010~3.516)、败血症(OR = 3.055, CI: 1.312~7.114)是早产儿脑损伤的危险因素(P < 0.05);剖宫产(OR = 0.510, CI: 0.265~0.983)是早产儿脑损伤的保护因素(P < 0.05)。见表3。
变量 | 非脑损伤组(n = 225) | 脑损伤组(n = 73) | χ2值 | P值 |
---|---|---|---|---|
性别 | ||||
男 | 116 (51.6) | 44 (60.3) | 1.685 | 0.194 |
女 | 109 (48.4) | 29 (39.7) | ||
分娩方式 | ||||
顺产 | 51 (22.7) | 26 (35.6) | 4.824 | 0.028 |
剖宫产 | 174 (77.3) | 47 (64.4) | ||
围生期窒息 | 45 (20.0) | 18 (24.7) | 0.717 | 0.397 |
羊水污染 | 9 (4.0) | 2 (2.7) | 0.019 | 0.889 |
胎膜早破 | 56 (24.9) | 28 (38.4) | 4.938 | 0.026 |
宫内感染 | 8 (3.6) | 1 (1.4) | 0.308 | 0.579 |
使用PS | 78 (34.7) | 36 (49.3) | 5.007 | 0.025 |
使用咖啡因 | 115 (51.1) | 44 (60.3) | 1.859 | 0.173 |
机械通气 | 184 (81.8) | 62 (84.9) | 1.565 | 0.667 |
孕母妊娠期高血压 | 49 (21.8) | 12 (16.4) | 0.965 | 0.326 |
孕母妊娠期糖尿病 | 52 (23.1) | 19 (26.0) | 0.258 | 0.611 |
BPD | 45 (20.0) | 19 (26.0) | 1.187 | 0.276 |
NRDS | 78 (34.7) | 40 (54.8) | 9.336 | 0.002 |
NEC | 28 (12.4) | 7 (9.6) | 0.434 | 0.510 |
贫血 | 145 (64.4) | 40 (54.8) | 2.180 | 0.140 |
低血糖 | 14 (6.2) | 5 (6.8) | 0.000 | 1.000 |
败血症 | 16 (7.1) | 12 (16.4) | 5.633 | 0.018 |
表2. 两组早产儿脑损伤影响因素的单因素分析[n(%)]
变量 | 回归系数 | 标准误 | Wald 值 | df | P值 | OR值 | OR值的95% CI |
---|---|---|---|---|---|---|---|
NRDS | 1.110 | 0.315 | 12.402 | 1 | <0.001 | 3.034 | 1.636~5.628 |
剖宫产 | −0.672 | 0.334 | 4.049 | 1 | 0.044 | 0.510 | 0.265~0.983 |
使用PS | 0.187 | 0.359 | 0.271 | 1 | 0.602 | 1.205 | 0.597~2.434 |
胎膜早破 | 0.634 | 0.318 | 3.970 | 1 | 0.046 | 1.885 | 1.010~3.516 |
败血症 | 1.117 | 0.431 | 6.708 | 1 | 0.010 | 3.055 | 1.312~7.114 |
表3. 早产儿脑损伤高危因素的多因素Logistic分析
根据现有的流行病学调查结果我们发现在早产儿所有并发症中,早产儿脑损伤(Brain injury in premature infants, BIPI)发病率占所有早产儿疾病的15%左右,是早产儿主要的并发症 [
有研究表明,BIPI的危险因素有产前危险因素(胎儿窘迫、感染、绒毛膜羊膜炎、胎膜早破);产时危险因素(顺产);产后危险因素(窒息、新生儿呼吸窘迫综合征及机械通气) [
本研究显示NRDS早产儿脑损伤的独立危险因素。研究 [
胎儿胎膜早破更易发生脑损伤。胎膜早破是引发早产发生、导致新生儿脑损伤的重要原因,而有学者的研究指出,产妇发生胎膜破裂的原因主要为宫内感染 [
国外学者的研究结果显示感染是早产儿发生脑损伤的重要因素 [
本研究结果显示,剖宫产是早产儿脑损伤的发生具有保护因素,早产儿脑损伤与分娩方式有密切相关,与以往的研究结果相一致,可能是因为顺产使胎儿颅内静脉压增高,导致毛细血管破裂出血,进而引起新生儿脑损伤 [
本研究具有一定的局限性。① 本研究结论为仅纳入本院298例早产儿进行研究所取得阶段性成果,未来还需扩大样本量进行进一步的研究。② 本研究病例仅来源于西北妇女儿童医院一家医院,回顾性研究存在一定的局限性。本研究中所证实的危险因素在以后的研究中可通过多中心、大样本、前瞻性随机对照研究,进行进一步的验证。
综上所述,NRDS、胎膜早破、败血症是早产儿脑损伤的独立危险因素,剖宫产是其保护因素。围生期应定期行孕期体检尽可能避免这些危险因素的发生,以期降低早产儿脑损伤的发生率。
万晓婷,赵文华,聂 赫,林 欣,闫 锐. 298例早产儿脑损伤的危险因素分析The Risk Factors for Brain Injury in 298 Premature Infants[J]. 临床医学进展, 2022, 12(10): 9557-9563. https://doi.org/10.12677/ACM.2022.12101382