摘要
目的比较孕周35周以上无急性胆红素脑病的同族免疫性溶血高胆红素血症新生儿强光治疗6 h后血胆红素水平降至换血阈值以下但降低水平<34μmol/L时,选择换血与继续强光治疗的效果。方法纳入2015年1月1日—2018年10月31日上海市儿童医院孕周35周以上同族免疫性溶血高胆红素血症新生儿60例,分为换血组(28例)和非换血组(32例),统计黄疸消退时间,头颅MRI、脑干听觉诱发电位(BAEP)、新生儿神经行为评分(NBNA评分)异常发生率,核黄疸确诊、可能、疑似的患儿比例,以及输血或血制品不良反应的发生率。结果住院期间,换血组黄疸消退时间为(6.5±1.2) d,显著短于非换血组的(9.5±1.8) d(P<0.01);首次BAEP异常的发生率为10.7%(3/28),有低于非换血组37.5%(12/32)的趋势,但差异无统计学意义(P>0.05);头颅MRI异常、NBNA评分异常和输血或血制品不良反应发生率分别为17.9%(5/28)、0和10.7%(3/28),与非换血组34.4%(11/32)、9.4%(3/32)和3.1%(1/32)的差异均无统计学意义(P值均>0.05)。住院期间发生输血或血制品不良反应的4例患儿中,换血组3例,均为血小板减少;非换血组1例,为皮疹。出院后3~<4个月复查,换血组和非换血组分别有2和5例失访,失访者均为住院期间首次MRI和BAEP正常者。换血组复查头颅MRI和BAEP异常的发生率均为3.8%(1/26),非换血组分别为18.5%(5/27)、14.8%(4/27),两组间的差异均无统计学意义(P值均>0.05)。两组均无核黄疸确诊和可能病例;换血组核黄疸疑似患儿比例为7.7%(2/26),有低于非换血组25.9%(7/27)的趋势,但差异无统计学意义(P>0.05)。9例核黄疸疑似患儿中,换血组BAEP异常和MRI异常各1例,均为住院期间首次BAEP或MRI异常患儿;非换血组MRI异常3例,BAEP异常2例,MRI和BAEP同时异常2例,均为住院期间首次BAEP或MRI异常患儿。两组均未发现住院期间首次BAEP或头颅MRI正常而出院后3~<4个月复查异常的患儿,非换血组住院期间首次BAEP异常的12例患儿中8例在出院后3~<4个月复查时恢复正常。结论孕周35周以上无急性胆红素脑病的同族免疫性溶血高胆红素血症新生儿,换血准备过程中强光治疗6 h后血胆红素水平降至换血阈值以下但降低水平<34μmol/L时,尽管换血治疗可以缩短黄疸消退时间,但并不能明确其对减轻听力损害和神经异常有确切作用,故需谨慎选择。
Objective To compare the effects of exchange transfusion(ET)and extensive phtototherapy in isoimmune hemolytic hyperbilirubinemia(IHH)newborns with gestational age≥35 weeks and without acute bilirubin encephalopathy(ABE)when total serum bilirubin(TSB)level declines below the exchange transfusion threshold(ETT)but the decline degree is within 34μmol/L after 6-hour extensive phototherapy.Methods Sixty IHH newborns with gestational age≥35 weeks and without ABE admitted to Shanghai Children’s Hospital from January 2015 to October 2018 were enrolled and divided into ET group(28 cases)and non ET group(32 cases).Jaundice remission time,the incidences of abnormal head magnetic resonance imaging(MRI),brainstem auditory evoked potential(BAEP)and neonatal behavioral neurological assessment(NBNA),the percentages of certain,probable,and possible kernicterus,the incidences of adverse effects of blood transfusion or blood product administration were recorded and compared between groups.Results Jaundice remission time in ET group was significantly shorter than that in non ET group([6.5±1.2]d vs.[9.5±1.8]d,P<0.01).The incidences of first abnormal BAEP,abnormal head MRI,NBNA,adverse effects of blood transfusion or blood products administration in ET group were 10.7%(3/28),17.9%(5/28),0 and 10.7%(3/28),in non ET group was 37.5%(12/32),34.4%(11/32),9.4%(3/32)and 3.1%(1/32),respectively.There were no significant differences in these indexes between the two groups(all P>0.05).Among the 4 cases with adverse effects of blood transfusion or blood product administration,there were 3 cases with thrombocytopnia in ET group and one with rash in non ET group.Two patients in ET group and five in non ET group were lost to follow-up,whose first head MRI and BAEP were all normal during hospitalization.The incidences of abnormal head MRI and BAEP at revisit in ET group were both 3.8%(1/26),and those in non ET group were 18.5%(5/27)and 14.8%(4/27),respectively.There were no statistical differences in the two parameters between the two groups(both P>0.05).No certain or probable kernicterus was found during follow-up.The incidence of possible kernicterus was 7.7%(2/26)in ET group and 25.9%(7/27)in non ET group(P>0.05).Among the 9 cases with possible kernicterus,there was one with abnormal BAEP and one with abnormal MRI in ET group;there were 3 cases with abnormal MRI,2 with abnormal BAEP,and 2 with abnormal MRI and BAEP in non ET group.Their examination results were abnormal during hospitalization.No abnormal MRI or BAEP was found in patients in both groups whose first MRI or BAEP were normal during hospitalization.BAEP became normal during follow-up in 66.67%patients(8/12)with abnormal BAEP during hospitalization in non ET group.Conclusion Although exchange transfusion can shorten jaundice remission time,it can not be confirmed that it can definitely reduce hearing impairment and neurological abnormality in IHH newborns with gestational age≥35 weeks and without ABE when TSB level declines below ETT but the decline is within 34μmol/L after 6-hour extensive phototherapy.Therefore exchange transfusion should be cautiously used in those newborns.(Shanghai Med J,2019,42:273-277)
作者
包涵
陈豪
龚小慧
裘刚
魏东
BAO Han;CHEN Hao;GONG Xiaohui;QIU Gang;WEI Dong(Department of Neonatology,Shanghai Children’s Hospital,Shanghai 200062,China)
出处
《上海医学》
CAS
北大核心
2019年第5期273-277,共5页
Shanghai Medical Journal
关键词
高胆红素血症
新生儿
核黄疸
光疗法
换血治疗
Hyperbilirubinemia,neonatal
Kernicterus
Phototherapy
Exchange transfusion
作者简介
通信作者:魏东,电子邮箱为1011weidong@163.com
