胎膜早破和羊水过少对胎龄<32周早产儿住院结局的影响

doi:10.12372/jcp.2024.23e0774

摘要/Abstract

摘要：

目的探讨未足月胎膜早破（PPROM）和羊水过少对于胎龄<32周早产儿住院结局的影响。方法回顾性分析2019年1月至2022年12月在儿科住院的胎龄<32周早产儿的临床资料。按是否存在胎膜早破分为PPROM组和正常组，将胎膜早破合并羊水过少的患儿纳入羊水过少组，比较各组间临床特征。采用logistic回归分析胎膜早破和羊水过少对于胎龄<32周早产儿住院结局的影响。结果共纳入195例早产儿，PPROM组83例，其中羊水过少22例；正常组112例。胎膜早破发生的中位胎龄为29.5（28.5~30.5）周，胎膜早破中位持续时间为48.0（13.8~85.8）小时。经多因素logistic 回归分析发现，羊水过少是出院前死亡、有血流动力学意义的动脉导管未闭（hsPDA）和持续性肺动脉高压（PPHN）发生的独立危险因素（P<0.05）；PPROM持续时间≥168 h显著增加了PPHN的发生率（P<0.05）。与仅存在PPROM组相比，PPROM合并羊水减少组PPROM持续时间延长，发生PPROM时胎龄更小，出生时孕周也更小，差异有统计学意义（P<0.05）。结论 PPROM和羊水过少对新生儿预后的影响不同。PPROM与早产儿死亡及新生儿相关疾病的发生无明显相关性，但如PPROM时间长及伴有羊水过少的PPROM对早产儿具有潜在危险。羊水过少与早产儿死亡、PPHN等的发生密切相关。

关键词: 未足月胎膜早破, 羊水过少, 早产儿

Abstract:

Objective To investigate the effects of premature rupture of membranes (PPROM) or oligohydramnios on in-hospital outcomes of preterm infants with gestational age<32 weeks. Methods The clinical data of preterm infants with gestational age<32 weeks who were hospitalized from January 2019 to December 2022 were retrospectively analyzed. The patients were divided into PPROM group and normal group according to the presence or absence of PPROM. PPROM patients combined with oligohydramnios were further included in the oligohydramnios group. The clinical features were compared among the groups. Multivariate logistic regression was used to analyze the effects of PPROM and oligohydramnios on in-hospital outcomes of preterm infants<32 weeks of gestational age. Results A total of 195 preterm infants were included, 83 in the PPROM group, 22 in the oligohydramnios group. There were 112 neonates in the normal group. The median gestational age of PPROM was 29.5 (28.5-30.5) weeks, and the median duration was 48.0 (13.8-85.8) hours. Multivariate logistic regression analysis showed that oligohydramnios was an independent risk factor for death before discharge, hemodynamically significant patent ductus arteriosus (hsPDA) and persistent pulmonary hypertension (PPHN) (P<0.05). The PPROM duration≥168h significantly increased the incidence of PPHN (P<0.05). Compared with the group with only PPROM, the group with both PPROM and oligohydramnios had a longer duration of PPROM, a smaller gestational age at the time of PPROM, and a smaller gestational age at birth, with statistically significant differences (P<0.05). Conclusions The effects of PPROM and oligohydramnios on neonatal prognosis are different. There was no significant correlation between PPROM and premature death and neonatal related diseases. However, PPROM with long duration and oligohydramnios is potentially dangerous for premature infants. Oligohydramnios is closely related to premature death, PPHN and other adverse outcomes.

Key words: preterm premature rupture of membrane, oligohydramnios, premature infant

朱晶文, 何玺玉. 胎膜早破和羊水过少对胎龄<32周早产儿住院结局的影响[J]. 临床儿科杂志, 2024, 42(7): 613-618.

ZHU Jingwen, HE Xiyu. Effects of premature rupture of membranes and oligohydramnios on in-hospital outcomes of preterm infants with gestational age <32 weeks[J]. Journal of Clinical Pediatrics, 2024, 42(7): 613-618.

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参考文献 30

[1]	殷张华. 晚期早产儿的母源性影响因素及其近远期风险[J]. 国际儿科学杂志, 2012, 39(1): 54-57.
[2]	Liu J, Feng ZC, Wu J. The incidence rate of premature rupture of membranes and its influence on fetal-neonatal health: a report from mainland China[J]. J Tropic Pediatr, 2010, 56(1): 36-42.
[3]	杨娜, 刘敬, 黄俊谨, 等. 胎膜早破致新生儿感染的病原学分析[J]. 中华全科医师杂志, 2012, 11(3): 199-201.
[4]	Sukhikh GT, Kan NE, Tyutyunnik VL, et al. The role of extracellular inducer of matrix metalloproteinases in premature rupture of membranes[J]. J Matern Fetal Neonatal Med, 2016, 29(4): 656-659. doi: 10.3109/14767058.2015.1015416 pmid: 25747952
[5]	Soylu H, Jefferies A, Diambomba Y, et al. Rupture of membranes before the age of viability and birth after the age of viability: comparison of outcomes in a matched cohort study[J]. J Perinatol, 2010, 30(10): 645-649. doi: 10.1038/jp.2010.11 pmid: 20220762
[6]	Miremberg H, Grinstein E, Herman HG, et al. The association between isolated oligohydramnios at term and placental pathology in correlation with pregnancy outcomes[J]. Placenta, 2020, 90(15): 37-41.
[7]	Wanchaitanawong W, Tantiworawit A, Piriyakhuntorn P, et al. The association between pre-transfusion hemoglobin levels and thalassemia complications[J]. Hematology, 2021, 26(1): 1-8. doi: 10.1080/16078454.2020.1856513 pmid: 33357151
[8]	杨舂艳, 武继平. 晚期特发性羊水量异常者羊水及血生化特点变化分析[J]. 中国医药导报, 2019, 16(2): 75-77.
[9]	Thibeault DW, Beatty EC Jr, Hall RT, et al. Neonatal pulmonary hypoplasia with premature rupture of fetal membranes and oligohydramnios[J]. J Pediatr, 1985, 107(2): 273-277.
[10]	Behram M, Oğlak SC, Başkıran Y, et al. Maternal serum IL-22 concentrations are significantly upregulated in patients with preterm premature rupture of membranes[J]. Ginekol Pol, 2021, 92(9): 631-636. doi: 10.5603/GP.a2021.0036 pmid: 33844260
[11]	占敏. 未足月胎膜早破患者残余羊水指数与妊娠结局和新生儿预后的关系[J]. 检验医学与临床, 2017, 14(16): 2422-2424.
[12]	邵肖梅, 叶鸿瑁, 丘小汕. 实用新生儿学[M]. 5版. 北京: 人民卫生出版社, 2019.
[13]	张兰, 沈暐, 陈超, 等. 早产儿HsPDA 危险因素及其并发症的临床分析[J]. 中华全科医学, 2019, 17(8): 1299-1301.
[14]	朱晶文, 张雪峰. 早发及晚发型新生儿败血症的临床特征分析[J]. 发育医学电子杂志, 2022, 10(2): 126-131.
[15]	Lorthe E, Ancel PY, Torchin H, et al. Impact of latency duration on the prognosis of preterm infants after preterm premature rupture of membranes at 24 to 32 weeks' gestation: a national population-based cohort study[J]. J Pediatr, 2017, 182: 47-52.
[16]	董会敏, 宋娟, 决珍珍, 等. 胎膜早破极早产儿的临床特征和主要不良结局的预测因素分析[J]. 中国当代儿科杂志, 2021, 23(6): 575-581.
[17]	Dammann O, Leviton A, Gappa M, et al. Lung and brain damage in preterm newborns, and their association with gestational age, prematurity subgroup, infection/inflammation and long term outcome[J]. BJOG, 2005, 112 (Suppl 1): 4-9.
[18]	Kallapur SG, Bachurski CJ, Le Cras TD, et al. Vascular changes after intra-amniotic endotoxin in preterm lamb lungs[J]. Am J Physiol Lung Cell Mol Physiol, 2004, 287(6): L1178-L1185.
[19]	Jakkula M, Le Cras TD, Gebb S, et al. Inhibition of angiogenesis decreases alveolarization in the developing rat lung[J]. Am J Physiol Lung Cell Mol Physiol, 2000, 279(3): L600-L607.
[20]	Haidar A, Ryder TA, Wigglesworth JS. Failure of elastin development in hypoplastic lungs associated with oligohydramnios: an electronmicroscopic study[J]. Histopathology, 1991, 18(5): 471-473. pmid: 1885168
[21]	刘敬. 胎膜早破对新生儿多器官系统的损害与临床管理[J]. 中国儿童保健杂志, 2017, 25(11): 1081-1085. doi: 10.11852/zgetbjzz2017-25-11-01
[22]	Yang LC, Taylor DR, Kaufman HH, et al. Maternal and fetal outcomes of spontaneous preterm premature rupture of membranes[J]. J Am Osteopath Assoc, 2004, 104(12): 537-542.
[23]	Everest NJ, Jacobs SE, Davis PG, et al. Outcomes following prolonged preterm premature rupture of the membranes[J]. Arch Dis Child Fetal Neonatal Ed, 2008, 93(3): F207-F211.
[24]	Gezer A, Parafit-Yalciner E, Guralp O, et al. Neonatal morbidity mortality outcomes in pre-term premature rupture of membranes[J]. J Obstet Gynaecol, 2013, 33(1): 38-42. doi: 10.3109/01443615.2012.729620 pmid: 23259876
[25]	Test G, Levy A, Wiznitzer A, et al. Factors affecting the latency period in patients with preterm premature rupture of membranes[J]. Arch Gynecol Obstet, 2011, 283(4): 707-710. doi: 10.1007/s00404-010-1448-7 pmid: 20306063
[26]	Pendse A, Panchal H, Athalye-Jape G, et al. Neonatal outcomes following previable prelabour rupture of membranes before 23 weeks of gestation - A retrospective cohort study[J]. J Neonatal Perinatal Med, 2021, 14(1): 9-19.
[27]	Figueroa L, McClure EM, Swanson J, et al. Oligo-hydramnios: a prospective study of fetal, neonatal and maternal outcomes in low-middle income countries[J]. Reprod Health, 2020, 17(1): 19. doi: 10.1186/s12978-020-0854-y pmid: 32000798
[28]	Hesson A, Langen E. Outcomes in oligohydramnios: the role of etiology in predicting pulmonary morbidity/mortality[J]. J Perinat Med, 2018, 46(8): 948-950. doi: 10.1515/jpm-2017-0281 pmid: 29924737
[29]	Lakshminrusimha S, Keszler M. Persistent pulmonary hypertension of the newborn[J]. Neoreviews, 2015, 6(12): e680-e692.
[30]	Chen CM, Chou HC, Wang LF, et al. Experimental oligohydramnios decreases collagen in hypoplastic fetal rat lungs[J]. Exp Biol Med (Maywood), 2008, 233(11): 1334-1340.

项目	正常组(n=112)	PPROM组(n=83)	统计量	P
出生胎龄[M(P₂₅~P₇₅)]/周	30.0(28.6~31.0)	29.4(28.3~30.4)	Z=2.07	0.039
出生体重[M(P₂₅~P₇₅)]/g	1 315.0(1 160.0~1 450.0)	1 210.0(1 100.0~1 350.0)	Z=2.41	0.016
小于胎龄儿[n(%)]	11(9.8)	7(8.4)	χ²=0.11	0.741
男性[n(%)]	65(58.0)	47(56.6)	χ²=0.04	0.844
多胎[n(%)]	3(2.6)	4(4.8)	－	0.462¹⁾
宫内窘迫[n(%)]	10(8.9)	6(7.2)	χ²=0.18	0.669
剖宫产[n(%)]	55(49.1)	45(54.2)	χ²=0.50	0.480
1分钟Apgar评分[M(P₂₅~P₇₅)]/分	9.0(8.0~10.0)	6.0(8.0~10.0)	Z=1.03	0.305
5分钟Apgar评分[M(P₂₅~P₇₅)]/分	10.0(9.0~10.0)	9.0(8.0~10.0)	Z=1.12	0.263
母亲年龄[M(P₂₅~P₇₅)]/岁	25.0(24.0~33.0)	31.0(25.0~35.0)	Z=1.73	0.083
初产[n(%)]	34(30.3)	27(32.5)	χ²=0.11	0.746
组织学绒毛膜羊膜炎[n(%)]	25(22.3)	38(45.7）	χ²=12.00	0.001
母亲糖尿病[n(%)]	29(25.8)	17(20.4)	χ²=0.77	0.379
胎盘早剥[n(%)]	6(5.3)	5(6.0)	－	0.842¹⁾
产前规范应用激素[n(%)]	85(75.8)	68(81.9)	χ²=1.03	0.311
试管婴儿[n(%)]	6(5.3)	3(3.6)	－	0.735¹⁾

项目	正常组(n=112)	PPROM组(n=83)	统计量	P
呼吸窘迫综合征(Ⅲ~Ⅳ)[n(%)]	102(91.0)	75(90.4)	χ²=0.03	0.866
大量肺出血[n(%)]	2(1.7)	2(2.4)	－	0.611¹⁾
PPHN[n(%)]	9(8.0)	9(10.8)	χ²=0.45	0.503
气漏综合征[n(%)]	3(2.7)	6(7.2)	－	0.173¹⁾
中重度BPD[n(%)]	42(37.5)	24(28.9)	χ²=1.57	0.210
机械通气时间[M(P₂₅~P₇₅)]/d	9.0(4.0~17.0)	7.0(4.5~13.5)	χ²=1.21	0.225
脓毒病[n(%)]	17(15.1)	9(10.8)	χ²=0.78	0.379
NEC[n(%)]	10(8.9)	5(6.0)	χ²=0.57	0.590
严重IVH[n(%)]	5(4.4)	5(6.0)	χ²=0.24	0.746
囊性PVL[n(%)]	8(7.1)	4(4.8)	－	0.562¹⁾
hsPDA[n(%)]	21(18.7)	14(16.8)	χ²=0.12	0.735
需要治疗ROP[n(%)]	4(3.5)	2(2.4)	－	1.000¹⁾
出院前死亡[n(%)]	2(1.7)	5(6.0)	－	0.116¹⁾
住院时间²⁾[M(P₂₅~P₇₅)]/d	49.0(36.0~60.0)	53.0(43.0~63.0)	Z=1.71	0.087
出院时体重²⁾[M(P₂₅~P₇₅)]/g	2 110.0(2 080.0~2 300.0)	2 100.0(2 090.0~2 305.0)	Z=0.76	0.450

项目	正常组(n=112)	羊水过少(n=22)	统计量	P
呼吸窘迫综合征(Ⅲ~Ⅳ)[n(%)]	102(91.0)	20(90.9)	－	0.981¹⁾
大量肺出血[n(%)]	2(1.7)	1(4.5)	－	0.446¹⁾
PPHN[n(%)]	9(8.0)	7(31.8)	χ²=9.89	0.002
气漏综合征[n(%)]	3(4.4)	3(13.6)	－	0.014¹⁾
中重度BPD[n(%)]	42(37.5)	10(45.4)	χ²=0.49	0.484
机械通气时间[M(P₂₅~P₇₅)]/d	9.0(4.0~17.0)	8.0(4.0~15.0)	Z=0.47	0.636
脓毒病[n(%)]	17(15.1)	5(22.7)	χ²=0.76	0.360
NEC[n(%)]	10(8.9）	3(13.6)	－	0.448¹⁾
严重IVH[n(%)]	5(4.4)	3(13.6)	χ²=2.76	0.124
囊性PVL[n(%)]	8(7.1)	1(4.5)	－	1.000¹⁾
hsPDA[n(%)]	21(18.7)	9(40.9)	χ²=5.20	0.023
需要治疗ROP[n(%)]	4(3.5)	1(4.5)	－	0.248¹⁾
出院前死亡[n(%)]	2(1.7)	4(13.6)	－	0.031¹⁾
住院时间²⁾[M(P₂₅~P₇₅)]/d	49.0(36.0~60.0)	50.0(39.0~63.5)	Z=1.95	0.052
出院时体重²⁾[M(P₂₅~P₇₅)]/g	2 110.0(2 090.0~2 300.0)	2 110.0(2 090.0~2 300.0)	Z=0.03	0.973

因素	气漏综合征¹⁾	PPHN²⁾	hsPDA³⁾	出院前死亡⁴⁾
PPROM	2.49(0.52~11.99)	1.60(0.51~5.01)	0.75(0.32~1.76)	0.74(0.32~1.73)
PPROM持续时间⁵⁾
<24 h	0.50(0.04~6.33)	1.78(0.37~8.46)	0.13(0.01~1.20)	0.04(0.00~19.13)
24~72 h	2.27(0.45~11.47)	1.23(0.21~7.07)	0.52(0.10~2.58)	－
72~168 h	2.39(0.08~69.22)	1.69(0.22~12.96)	4.09(0.94~17.81)	3.78(0.85~16.80)
≥168 h	2.15(0.22~21.37)	16.73(3.11~89.95)	2.71(0.52~4.19)	15.45(0.98~68.21)
羊水减少	0.62(0.10~3.67)	5.53(1.64~18.63)	4.40(1.15~12.80)	4.61(1.60~13.29)

项目	仅存在PPROM组(n=61)	PPROM合并羊水减少组(n=22)	Z值	P
PPROM持续时间[M(P₂₅~P₇₅)]/h	32.0(11.0~48.5)	48.0(12.3~174.0)	2.32	0.021
PPROM发生时胎龄[M(P₂₅~P₇₅)]/周	29.3(28.3~30.4)	27.2(26.3~29.3)	3.93	0.000
出生孕周[M(P₂₅~P₇₅)]/周	29.5(28.5~31.0)	28.2(27.0~29.6)	3.01	0.003