陳韻潔,李春亮
(1.解放軍第一八一醫(yī)院婦幼中心產(chǎn)科;2.新生兒科,廣西 桂林 541002)
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術(shù)前地塞米松對(duì)預(yù)防足月兒呼吸窘迫的臨床意義
陳韻潔1,李春亮2
(1.解放軍第一八一醫(yī)院婦幼中心產(chǎn)科;2.新生兒科,廣西 桂林 541002)
目的分析術(shù)前地塞米松肌肉注射對(duì)擇期剖宮產(chǎn)足月新生兒呼吸窘迫綜合征的臨床意義。方法回顧性分析解放軍第一八一醫(yī)院產(chǎn)科電子病例系統(tǒng)記錄的孕37~38+6周剖宮產(chǎn)病歷資料400例;隨機(jī)挑選術(shù)前使用地塞米松6mg肌肉內(nèi)注射,每12小時(shí)1次,共4次的患者200例為研究組,使用0.9%生理鹽水10mL注射的200例為對(duì)照組。采用單因素方差分析母親一般情況,采用趨勢(shì)檢驗(yàn)方法比較兩組患者剖宮產(chǎn)出生的新生兒呼吸窘迫綜合征的發(fā)生等情況。結(jié)果研究組與對(duì)照組新生兒Apgar 1分鐘評(píng)分比較差異有統(tǒng)計(jì)學(xué)意義(χ2=2.84,P<0.05),而5分鐘評(píng)分差異無統(tǒng)計(jì)學(xué)意義(P>0.05)。兩組的呼吸窘迫綜合征發(fā)生率和轉(zhuǎn)入重癥病房新生兒發(fā)生率比較差異均有統(tǒng)計(jì)學(xué)意義(χ2值分別為13.83、3.55,均P<0.05)。結(jié)論對(duì)孕37~38+6周擇期剖宮產(chǎn)患者施行地塞米松注射可有效降低新生兒呼吸窘迫綜合征的發(fā)生率。
地塞米松;擇期剖宮產(chǎn);風(fēng)險(xiǎn);足月新生兒呼吸窘迫綜合征
[Abstract]Objective To analyze the clinical significance of Dexamethasone intramuscularly injected before selective cesarean section on preventing neonatal respiratory distress syndrome in full-term neonates. Methods Retrospective analysis was conducted on medical data of 400 cases of selective cesarean section at gestational 37-38+6weeks recorded in obstetrics department of 181st Hospital of the Chinese People’s Liberation Army. Patients in experimental group were 200 cases intramuscularly injected with 6mg of Dexamethasone every 12 hours, for four times in total before operation. Control group (200 cases) received injection of 0.9% saline solution. Single factor variance analysis was conducted on general situation of mothers and trend analysis on occurrence of respiratory distress syndrome in neonates in both groups. Results Neonatal Apgar scores at one minute of two groups were statistically different (χ2=2.84,P<0.05), but Apgar scores at five minute were not significantly different (P>0.05). Statistical significance was observed both in occurrence of neonatal respiratory distress syndrome and rate of transferring to neonatal ICU in two groups (χ2value was 13.83 and 3.55, respectively, bothP<0.05). Conclusion The incidence of neonatal respiratory distress syndrome can be significantly reduced among neonates whose mothers have received intramuscular injection of Dexamethasone at gestational 37-38+6weeks.
[Key words]Dexamethasone; selective cesarean section; risk; neonatal respiratory distress syndrome in full-term neonate
剖宮產(chǎn)率逐年上升已成為世界性問題,尤其我國在剖宮產(chǎn)手術(shù)中擇期剖宮產(chǎn)占相當(dāng)?shù)谋壤?,但?duì)擇期剖宮產(chǎn)足月新生兒所發(fā)生的后果國內(nèi)關(guān)注不多。研究表明。在分娩發(fā)動(dòng)前手術(shù)的風(fēng)險(xiǎn)更高,而這種風(fēng)險(xiǎn)也存在于足月新生兒中[1]。擇期剖宮產(chǎn)更容易發(fā)生新生兒呼吸窘迫綜合征(RDS)。Tita等2009年研究認(rèn)為如無胎兒肺成熟的依據(jù),應(yīng)在妊娠39周后進(jìn)行擇期剖宮產(chǎn)。本文隨機(jī)選擇妊娠<39周擇期剖宮產(chǎn)患者200例于術(shù)前使用地塞米松6mg肌肉注射,另200例注射0.9%生理鹽水10mL,探討兩組RDS發(fā)生率情況。
1.1一般資料
研究對(duì)象選自解放軍第一八一醫(yī)院產(chǎn)科2010年1至12月、2014年1至12月電子病例系統(tǒng)記錄的孕37~38+6周擇期剖宮產(chǎn)患者的病歷資料400例,其無明確婦產(chǎn)科和內(nèi)外科合并癥,宮內(nèi)單活胎產(chǎn)兒。孕周以末次月經(jīng)為準(zhǔn),月經(jīng)不經(jīng)過B超校正。
1.2研究方法
隨機(jī)選擇術(shù)前使用地塞米松6mg肌肉內(nèi)注射每,12小時(shí)1次共4次的患者200例為研究組,術(shù)前使用0.9%生理鹽水10mL肌肉注射,每12小時(shí)1次共4次的患者200例為對(duì)照組。
1.3新生兒呼吸窘迫綜合癥的診斷
依據(jù)《實(shí)用新生兒學(xué)》(金漢珍等,1997年第2版)標(biāo)準(zhǔn):新生兒出生6~12小時(shí)內(nèi)出現(xiàn)呼吸困難逐漸加重,伴呻吟;有典型的X線表現(xiàn):早期兩肺野普遍透亮度降低,內(nèi)有均勻分布細(xì)小顆粒和網(wǎng)狀陰影,支氣管有充氣征,如肺不張擴(kuò)大至整個(gè)肺,則肺野呈毛玻璃樣,支氣管充氣征更清楚,整個(gè)胸廓擴(kuò)張良好,橫膈位置正常。
1.4觀察指標(biāo)
兩組新生兒體重、Apgar評(píng)分(1、5分鐘),出現(xiàn)RDS率以及因呼吸窘迫轉(zhuǎn)入重癥監(jiān)護(hù)室治療情況。
1.5統(tǒng)計(jì)學(xué)方法
2.1兩組的一般情況
兩組的年齡、孕次、產(chǎn)次、孕周、住院時(shí)體質(zhì)量指數(shù)及術(shù)中出血量比較差異均無統(tǒng)計(jì)學(xué)意義(均P>0.05),有可比性,見表1。
2.2兩組新生兒結(jié)局情況
兩組新生兒平均體重比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05);研究組與對(duì)照組新生兒的1分鐘Apgar評(píng)分差異有統(tǒng)計(jì)學(xué)意義(P<0.05),而5分鐘Apgar評(píng)分差異無統(tǒng)計(jì)學(xué)意義(P>0.05);兩組RDS發(fā)生率和新生兒轉(zhuǎn)入重癥病房發(fā)生率比較差異均有統(tǒng)計(jì)學(xué)意義(均P<0.05),見表2。
表1 兩組患者相關(guān)臨床指標(biāo)的比較結(jié)果±S)
組別體重(g) Apgar評(píng)分 1分鐘5分鐘RDS重癥病房研究組3318.1±185.79.7±0.710.0±0.22(1.0)0對(duì)照組3415.7±431.18.8±2.69.4±0.322(11.0)7(3.5)χ2902.212.843.1213.833.55P>0.05<0.05>0.05<0.05<0.05
2.3兩組剖宮產(chǎn)指征情況
研究組疤痕子宮、胎位異常、肝內(nèi)膽汁淤積及社會(huì)因素剖宮產(chǎn)的發(fā)生率均高于對(duì)照組,而前置胎盤、羊水因素及重度子癇發(fā)生率均低于對(duì)照組,但兩組比較差異均無統(tǒng)計(jì)學(xué)意義(均P>0.05),見表3。
表3 擇期剖宮產(chǎn)的指征的比較結(jié)果[n(%)]
3.1孕39周前剖宮產(chǎn)導(dǎo)致新生兒呼吸窘迫的主要原因
剖宮產(chǎn)作為解決難產(chǎn)及高危妊娠的有效手段,對(duì)降低圍產(chǎn)母嬰病死率起到了重要作用,但產(chǎn)程未啟動(dòng)前擇期剖宮產(chǎn)分娩的新生兒呼吸系統(tǒng)發(fā)病率明顯增高[2-3]。2010年世界衛(wèi)生組織報(bào)告指出,我國剖宮產(chǎn)率達(dá)到46.2%,而其中11.7%的手術(shù)無明確指征[4];Tita等2009年指出,妊娠37~38+6發(fā)生RDS的比例高于妊娠39周后,且擇期剖宮產(chǎn)出現(xiàn)新生兒呼吸困難癥狀則更重[5-6]。
3.2擇期剖宮產(chǎn)增加足月兒呼吸窘迫綜合征的主要機(jī)制
擇期剖宮產(chǎn)增加足月兒RDS發(fā)生率可能與以下幾方面有關(guān):①肺內(nèi)液體清除降低。在宮縮發(fā)動(dòng)分娩過程中,胎兒肺液分泌減少,吸收增加,同時(shí)刺激表面活性物質(zhì)釋放,Brown等1983年指出這一過程主要由胎兒對(duì)分娩啟動(dòng)后引起兒茶酚胺水平增高介導(dǎo),而未滿39周妊娠足月兒體內(nèi)兒茶酚胺水平明顯較低;②擇期剖宮產(chǎn)阻礙胎肺成熟。在宮縮未發(fā)動(dòng)時(shí)新生兒血卵磷脂/鞘磷脂比值明顯低于自然分娩或急診剖宮產(chǎn)者,其臍血中肺泡表面活性物質(zhì)蛋白-A(SP-A)濃度低于自然分娩或急診剖宮產(chǎn)者;③糖皮質(zhì)激素分泌相對(duì)不足。內(nèi)源性糖皮質(zhì)激素是胎肺成熟的重要刺激因子,未滿39周妊娠擇期剖宮產(chǎn)由于宮縮未發(fā)動(dòng),體內(nèi)兒茶酚胺水平明顯較低,與體內(nèi)分泌糖皮質(zhì)激素不足有關(guān)。
3.3地塞米松改善呼吸窘迫綜合征的機(jī)制
采用地塞米松改善RDS與以下幾方面有關(guān):①糖皮質(zhì)激素能促進(jìn)肺泡Ⅱ型上皮細(xì)胞內(nèi)表面活性蛋白基因轉(zhuǎn)錄,加快肺組織發(fā)育成熟[7-10];②肺泡表面活性物質(zhì)主要成分由肺泡Ⅱ型上皮細(xì)胞合成,主要作用降低肺泡表面張力,增加肺泡腔表面積/肺泡間隔表面積[10],糖皮質(zhì)激素能促進(jìn)肺泡表面活性物質(zhì)合成與分泌,從而促進(jìn)肺液排出,使得肺的順應(yīng)性和通氣量增加。
3.4術(shù)前運(yùn)用地塞米松對(duì)新生兒結(jié)局的影響
對(duì)擇期剖宮產(chǎn)未滿39周妊娠者預(yù)防性給予地塞米松肌注可以促進(jìn)體內(nèi)兒茶酚胺水平,促進(jìn)肺成熟以及肺表面活性物質(zhì)合成以及分泌[11],其一方面通過降低肺內(nèi)毛細(xì)血管滲透壓,減少肺水腫;另一方面增加肺泡腔表面積/肺泡間隔表面積使得肺的順應(yīng)性和通氣量增加,從而改善新生兒呼吸功能,減少RDS的發(fā)生[12-13]。本資料中研究組因術(shù)前使用地塞米松,新生兒出生1分鐘Apgar評(píng)分與對(duì)照組比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05);兩組RDS發(fā)生率和新生兒轉(zhuǎn)入重癥病房發(fā)生率比較差異均有統(tǒng)計(jì)學(xué)意義(均P<0.05),說明術(shù)前運(yùn)用地塞米松可降低RDS,改善新生兒出生結(jié)局。
3.5術(shù)前運(yùn)用地塞米松安全性評(píng)價(jià)
既然術(shù)前地塞米松臨床價(jià)值明顯,故可廣泛運(yùn)用于臨床,但是近年來有學(xué)者對(duì)產(chǎn)前地塞米松運(yùn)用的安全性提出了質(zhì)疑。楊慧霞2003年研究報(bào)道,與單療程相比,多療程糖皮質(zhì)激素的治療可能抑制早產(chǎn)兒神經(jīng)系統(tǒng)發(fā)育,敗血癥增加以及抑制腎上腺素功能,但對(duì)足月兒影響并無確切報(bào)導(dǎo)。對(duì)母體危害增加宮內(nèi)內(nèi)膜炎以及絨毛膜羊膜炎的發(fā)生率,導(dǎo)致妊娠期血糖升高,可能增加孕婦肺水腫,但單療程尤其地塞米松只有極弱的皮質(zhì)激素作用,故以上影響極少發(fā)生。因此小劑量單療程運(yùn)用地塞米松對(duì)母兒影響小、安全性高[14-17]。
綜上所述,針對(duì)妊娠37~38+6周的擇期剖宮產(chǎn)術(shù)應(yīng)有計(jì)劃地在術(shù)前給予小劑量(6mg)地塞米松注射,1次/12小時(shí),連續(xù)4次,可作為臨床上降低妊娠未滿39周擇期剖宮產(chǎn)RDS發(fā)生率的有效方法。
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[專業(yè)責(zé)任編輯:馬良坤]
Clinical value of pre-surgery injection of Dexamethason on preventing neonatal respiratory distress syndrome in full-term neonates
CHEN Yun-jie1, LI Chun-liang2
(1.Department of Obstetrics; 2.Department of Neonate, Maternal and Child Center of 181st Hospital of the Chinese People’s Liberation Army,Guangxi Guilin 541002, China)
2015-10-13
陳韻潔(1971-),女,副主任醫(yī)師,主要從事產(chǎn)科危急重癥及產(chǎn)前診斷工作。
10.3969/j.issn.1673-5293.2016.03.018
R725.6
A
1673-5293(2016)03-0335-03