Method for postnatal persistence of haemodynamically significant open arterial duct in premature infants

FIELD: medicine.

SUBSTANCE: clinical, X-ray and echocardiographic examinations are performed in a premature infant on the third day of life. Gestation age, Apgar score, infant's reflexes, states of the muscular system, skin, oedemas, moist rale, increased pulmonary vascularity on the X-ray pattern, as well as echocardiographic values of final diastolic size, left atrium and right ventricle per one kilogram of infant's body weight are assessed, and a prognostic coefficient is determined by mathematical formula. If the prognostic coefficient is 10 points and more, the high risk of long persistence of a haemodynamically significant form of the open arterial duct in the premature infants is predicted; the prognostic coefficient falling within the range of 0 to 9 points shows the low risk of long persistence of the haemodynamically significant form of the open arterial duct.

EFFECT: method enables predicting the non-invasive prediction of the high risk of long persistence of the haemodynamically significant form of the open arterial duct in the premature infants on the third day of life, and specifying the further therapeutic approach to the infant and the absolute indications for persistent foetal communication correction.

2 tbl, 2 ex

 

The invention relates to medicine, namely to neonatology.

A major problem of modern Perinatology is nursing preterm infants. Morphofunctional immaturity of this group of newborns contributes to the preservation of a functioning arterial duct, hemodynamic significance of which adversely affects the condition of the respiratory system and peripheral circulation. Approximately one-third of patients in the period from the second through the sixth day of life there is a spontaneous closure of the arterial duct. However, its long persistence is associated with the development of a number of serious pathological conditions such as intraventricular hemorrhage, periventricular leucomalacia, bronchopulmonary dysplasia, necrotizing enterocolitis, retinopathy of the newborn, often ending in death or lead to disability. With the introduction of the records of premature infants with hemodynamically significant functioning appeared the opportunity of closing the duct intravenous drug ibuprofen, the efficiency of which varies from 70 to 85%. However, there are contraindications and side effects to the drug, therefore, of great practical importance is the question of allocation of prognostic criteria for persistent�AI flow dynamics in the neonatal period, to determine the tactics of differentiated treatment of this pathology.

Known method for predicting the state of the cardiovascular system in newborns (analog), based on the definition in pregnant total peripheral vascular resistance, stroke and minute indexes, and when values of total peripheral resistance 1376-1430 Dean. cm-5with, shock index 41-48 ml/m2, minute index, a 3.35-4.0 l/min/m2predict labile type of hemodynamics with the closing of the newborn fetal communications through 12-34 hours, lability of blood pressure and bradycardia; if the value of the total peripheral resistance 1431-1695 Dean. cm-5with, shock index 31-40 ml/m2, minute index 2,4-3,34 l/min/m2predict persistent hyperkinetic type of the closure of the fetal communication 4-5 days of life, hypertension and predisposition to bradycardia; and a value of total peripheral resistance 1696-2770 Dean. cm-5with, shock index 24-30 ml/m2, minute index 2,04-2,39 l/min/m2predict persistent hypokinetic type of hemodynamics with the closure of the fetal communication 5-6 days of life, an arterial hypotonia and a tendency to tachycardia (a Method of predicting the state of the cardiovascular system of the newborn, author Swee�iteljstvo USSR №1699425).

However, this technique has several limitations, as it allows only indirectly, on the basis of prenatal echocardiographic diagnosis of pregnant women to predict gross deviation hemodynamics in newborns and may not be applied to premature infants.

The closest analogue (prototype) of the proposed solution method is predict postnatal persistence of hemodynamically significant patent ductus arteriosus in preterm infants (Spivak, E. M. et al. Clinical and hemodynamic characteristics of patent ductus arteriosus in preterm newborn children, practical Pediatrics, 2013, vol. 8, No. 6, pp. 16-19), which consists in conducting clinical, radiological and echocardiographic studies, with the study on the third day of life of risk factors such as gestational age (GW) at the time of birth of 27 weeks or less, estimation on Apgar scale (AP) at the end of the first minute of 4 points or less, a sharp weakening or absence of reflexes of the newborn (RF), expressed muscular hypotonia (Msh), mottled skin (Mr), a pasty or soft tissue swelling (From), wet finely wheezing or crackling in the lungs (HR), increased lung pattern on the radiograph due to the interstitial (Rint) and/or vascular component (Rsos), HC�the increased rate end-diastolic size of the left ventricle (KDR), the increase of left atrium (La), the increase of the right ventricle (RV).

The disadvantage is the lack of consideration of the weight of the newborn by the time measurements of indicators such as the CRA, PL and RV. In addition, in the proposed method of forecasting are no criteria for low and high risk predict the preservation of hemodynamically significant patent ductus arteriosus (GSOEP), which reduces the accuracy of the forecast.

The aim of the proposed method is to increase the accuracy of predicting the risk of long-term persistence GSOAP in premature infants.

This goal is achieved by constructing a mathematical model for risk assessment using sequential statistical analysis by the method of A. Wald. On the third day of life the newborn examine risk factors such as life guards at the time of birth of 27 weeks or less, estimation on Apgar scale in the first minute of 4 points or less, a sharp weakening or absence of reflexes of the newborn, severe muscular hypotonia, mottled skin, a pasty or soft tissue swelling, wet finely wheezing and/or crepitus in the lungs, increased pulmonary pattern on the radiograph due to the interstitial and/or vascular component, the increase of the DLC from 13.2 mm or more / kg, the increase results�La La from 8.7 mm or more / kg, increase pancreas of 6.0 mm or more / kg, the presence of each of the signs is estimated at 1 point, no - 0 points, then calculate prognostic factor (PC) using the formula: PC=6,8×HS+1,8×AP+4,0×RF+8,8×Msh+4,0×MP+2,0×+5,0×XP+4,8×Rint+3,0×Rsos+4,7×KDR+11,8×PL+6,8×RV, and if the value of PC from 0 to 9 points, we predict a low risk of, and with PC by 10 points or more - high risk of long-term persistence of hemodynamically significant patent ductus arteriosus.

The novelty of the proposed method is that the calculation of the risk of long-term persistence of hemodynamically significant patent ductus arteriosus calculation of the CRA, PL, RV takes into account the body weight of the newborn and take into account both the presence of the characteristic, if the RIC and more from 13.2 kg; LP - and more from 8.7 kg; pancreas - from 6.0 or more per kilogram. The calculation of the predictive coefficient (PC) is carried out according to the formula: PC=6,8×HS+1,8×AP+4,0×RF+8,8×Msh+4,0×MP+2,0×+5,0×XP+4,8×Rint+3,0×Rsos+4,7×KDR+11,8×PL+6,8×RV.

The technical solutions that have the signs consistent with the distinctive features of our proposed method, not identified that allows to make a conclusion about conformity of the proposed method the criterion of "inventive step".

In the process of developing a method a survey was conducted 69 glubokovodnoe�tion newborns. The examination included clinical, laboratory and instrumental examination from the first by the third day, and echocardiography in the dynamics on the first, third, fifth and thirtieth day of postnatal life.

In the statistical analysis were selected independent of the signs of having a significant correlation with preservation GSOAP. The statistical significance of these signs with the dynamics of the RFP are presented in tables 1 and 2.

The presence of each of the signs is estimated as 1 point, no - 0 points. On the basis of mathematical processing of results of research on the method developed by A. Wald received the informative signs and formed a predictor of long-term persistence GSOAP, which is the definition of PC by the formula

PC=6,8×HS+1,8×AP+4,0×RF+8,8×Msh+4,0×MP+2,0×+5,0×XP+4,8×Rint+3,0×Rsos+4,7×KDR+11,8×PL+6,8×RV, and, if the value of PC from 0 to 9 points, predicts low risk, and with PC by 10 points or more - high risk of long-term persistence GSOAP.

The proposed method is as follows: first estimate of HS by the time of birth and the number of points on the Apgar score at the end of the first minute of birth, the attainment of a newborn 72 hours of life assess the reflexes of the newborn, the health of the musculoskeletal system, skin, subcutaneous fat clutched�, perform auscultation of the lungs, and carried out x-ray chest and echocardiography. Then evaluate the collected data, in the presence of HS at the time of birth of 27 weeks or less, estimation on Apgar scale in the first minute of 4 points or less, a sharp weakening or absence of reflexes of the newborn, severe muscular hypotonia, marbling of the skin, pastoznost or swelling of soft tissues, wet finely wheezing and/or crepitate in the lungs, increased pulmonary pattern on the radiograph due to the interstitial and/or vascular component, the increase in KDR of the left ventricle from 13.2 mm or more / kg, the increase of the PL from 8.7 mm or more / kg, the increase in pancreas of 6.0 mm or more / kg in each of these cases, add 1 point, and in their absence - 0 points. Then calculate PC by the formula PC=6,8×HS+1,8×AP+4,0×RF+8,8×Msh+4,0×MP+2,0×+5,0×XP+4,8×Rint+3,0×Rsos+4,7×KDR+11,8×PL+6,8×RV. Analyzing the coefficient estimate of predictive risk of long-term persistence GSOAP as follows: if the value of PC from 0 to 9 points, we predict a low risk of, and with PC by 10 points or more - high risk.

The proposed method is illustrated by the following examples of clinical use.

Example 1. Patient I., aged to m�the COP survey 72 hours born from the second pregnancy, the second birth. The pregnancy was complicated by preeclampsia. Delivery occurred at term of gestation 30 weeks by a large caesarean section. It was noted premature rupture of membranes with long waterless period.

Anthropometric indicators of child at birth: weight - 1200 grams, length - 36 cm, head circumference - 27 cm, chest circumference - 23 cm, the surface area of the body - 0,11 m2. Estimation on Apgar scale at the end of the 1st minute - 6 points, at the end of 5 minutes - 7 points.

The results of objective examination. The General condition heavy, the syndrome of pronounced Central nervous system suppression. Skin clean, subcarinate. Pronounced muscular hypotonia. Breathing puerile with the participation of auxiliary muscles, respiratory rate of 50 per minute. The region of the heart is not changed, the borders of relative cardiac dullness is within normal limits. The heart rate was 150 per minute. Heart sounds clear, rhythmic, auscultation of murmur over the heart and large vessels are not auscultated. The pulse on peripheral arteries of satisfactory quality. Systolic blood pressure (SBP) is 60 mm Hg.CT., diastolic blood pressure (DBP) - 39 mm Hg.CT., pulse blood pressure (PAD) - 21 mm Hg.CT., mean arterial blood pressure�e (srad) - 46 mm Hg.PT. Swollen stomach, peristalsis somewhat weakened, enlarged liver and spleen is not marked. Urine output General - 75 ml, hourly - 2,6 ml.

Chest x-ray in the direct projection without features.

The results of echocardiography: prospermatogonia, levomepromazine heart without valvular and septal defects. Logged functioning arterial duct with a diameter of 1.7 mm, hemodynamically significant. Retrograde diastolic flow in descending aorta - more than 50% of the magnitude of antegrade, direction of discharge of blood from left to right.

Cardiotonicescoe and functional indices: the CRA/kg -11,1 mm, PL/kg ratio was 5.83 mm, PG/kg - 3,33 mm, open oval window of 2.3 mm, the discharge cross.

When assessing the risk of long-term persistence of the duct using the proposed predictive formula total PC in this patient was equal to 8.8 points. When the threshold value of 10 points.

When observed in the dynamics on the fifth day of life the duct was not visualized.

Thus, this clinical example illustrates the favorable variant of the flow GSOAP, which is functionally closed by the fifth days of postnatal life.

Example 2. Patient S., age to the time of the survey 72 hours. The child was born from the third pregnancy, second birth. First pregnancy end�was a medical abortion. The pregnancy was complicated by preeclampsia at 21 weeks the woman has had SARS. Delivery when gestational age 27 weeks, without features.

Anthropometric measurements at birth: weight - 940 grams, length - 33 cm, head circumference is 24 cm, chest circumference is 22 cm, the surface area of the body - 0.09 m2. Estimation on Apgar scale at the end of 1 minute - 4 points, at the end of 5 minutes - 6 points.

The results of objective examination. The General condition heavy, the syndrome of pronounced Central nervous system suppression. Skin clean, ikterichnost. Pronounced muscular hypotonia, sponginess of the soft tissues of the limbs and trunk. Breathing puerile with the participation of auxiliary muscles, respiratory rate of 48 per minute. The region of the heart is not changed, the borders of relative heart dullness within normal limits. Heart rate is 140 per minute. Heart sounds clear, rhythmic, auscultation of murmur over the heart and large vessels are not auscultated. The pulse on peripheral arteries of satisfactory quality. GARDEN - 86 mm Hg.CT., DBP - 57 mm Hg.CT., PAD - 29 mm Hg.CT., srad - 67 mm Hg.PT. Swollen stomach, peristalsis somewhat weakened, enlarged liver and spleen is not marked. Diuresis total - 96 ml, hourly and 4.1 ml.

Chest x-ray in the direct projection - pulmonary pattern is reinforced through soudes�CSOs and intersticialnom components.

The results of echocardiography: prospermatogonia, levomepromazine heart without valvular and septal defects, logged functioning arterial duct with a diameter of 2.2 mm, hemodynamically significant. Retrograde diastolic flow in descending aorta - more than 50% of the magnitude of antegrade, direction of discharge of blood from left to right.

Cardiotonicescoe and functional indices: the CRA/kg - 13.5 mm, PL/kg - 9.4 mm, PG/kg - 5.3 mm, open oval window of 2.3 mm, the discharge cross.

When assessing the risk of long-term persistence of the duct using the proposed predictive formula total PC for this patient is $ 43.7 points with a threshold value of 10 points.

When observed in the dynamics on the fifth day of life the ductus arteriosus remains hemodynamically significant, there is an increase of a diameter of 2.3 mm.

So, this clinical example illustrates the worst case scenario of flow GSOAP in which the diameter of the duct by the fifth days of postnatal life increases.

The proposed method is tested in the Department of resuscitation and intensive therapy of newborns SBME Yao "Regional perinatal center" and can be used to predict the risk of long-term preservation persistence GSOAP in preterm and selection of children with absolute indications for e�about medical treatment.

Method predict postnatal persistence of hemodynamically significant patent ductus arteriosus in premature infants by conducting clinical, radiological and echocardiographic studies, while on the third day of life examine risk factors such as gestational age (GW) at the time of birth of 27 weeks or less, estimation on Apgar scale (AP) at the end of the first minute of 4 points or less, a sharp weakening or absence of reflexes of the newborn (RF), expressed muscular hypotonia (Msh), mottled skin (Mr), a pasty or soft tissue swelling (From), wet finely wheezing and/or crepitus in the lungs (HR), increased lung pattern on the radiograph due to the interstitial (Rint) and/or vascular component (Rsos), the increase in end-diastolic size of the left ventricle (CRA), the increase of left atrium (La), the increase of the right ventricle (RV), characterized in that the calculated predictive coefficient (PC) according to the formula PC=6,8×HS+1,8×AP+4,0×RF+8,8×Msh+4,0×MP+2,0×+5,0×XP+4,8×Rint+3,0×Rsos+4,7×KDR+11,8×PL+6,8×pancreas, in which the absence of each of the signs is estimated at 0 points, and the presence - at 1 point, and the calculation of indicators of the CRA, PL, RV takes into account the body weight of the newborn and take into account both the presence of the characteristic if the CRA from 13.2 �m or more per kilogram; PL - from 8.7 mm or more / kg; RV from 6.0 mm or more / kg; and PC from 0 to 9 points predict a low risk of, and with PC by 10 points or more - high risk of long-term persistence of hemodynamically significant patent ductus arteriosus.



 

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