Clinical and Experimental Pediatrics

The Korean Pediatric Society (대한소아청소년과학회)
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The risk factors and prognosis associated with neonatal pulmonary hemorrhage

신생아 폐출혈 발생에 영향을 미치는 위험 인자 및 예후에 관한 고찰

  • 박수진 (대구 파티마병원 소아청소년과) ;
  • 윤기태 (대구 파티마병원 소아청소년과) ;
  • 김원덕 (대구 파티마병원 소아청소년과) ;
  • 이상길 (대구 파티마병원 소아청소년과)
  • Received : 2010.01.31
  • Accepted : 2010.03.15
  • Published : 2010.04.15
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Abstract

Purpose : Although neonatal pulmonary hemorrhage is rare, it is associated with high mortality. We aimed to evaluate the risk factors associated with pulmonary hemorrhage in preterm infants and to describe the clinical course, including neonatal morbidity, of infants who developed pulmonary hemorrhage. Methods : We performed a retrospective case-control study of 117 newborn infants aged less than 37 gestational weeks admitted to the neonatal intensive care unit of Daegu Fatima Hospital between January 1995 and December 2008. Control group infants without pulmonary hemorrhage were matched according to the gestational age, duration of mechanical ventilation, and birth weight range (${\leq}100g$). Pulmonary hemorrhage was defined as the presence of hemorrhagic fluid in the trachea and severe respiratory decompensation. Results : Pulmonary hemorrhage occurred in 17 cases of very low birth weight infants (VLBW; birth weight < 1,500 g; median age, 3 days) and 22 cases of low birth weight infants (LBW; $1,500g{\leq}$ birth weight < 2,500 g; median age, 1 day). Antenatal maternal glucocorticoid treatment significantly reduced the incidence of pulmonary hemorrhage in VLBW infants. Low APGAR score (${\leq}3$ at 1 min) and acidosis at birth were associated with significantly high incidence of pulmonary hemorrhage in LBW infants. Conclusion : Antecedent factors and timing of pulmonary hemorrhage of LBW infants were different from those of VLBW infants. The mortality rates of VLBW and LBW infants were 88.2% and 45.5%, respectively. Pulmonary hemorrhage was the principal cause of death in 66.6% VLBW infants and 40.0% LBW infants.

목 적: 신생아 폐출혈은 드물긴 하나, 일단 발생한 환아는 높은 사망률을 보인다. 급성 좌심실 부전, 호흡 곤란 증후군, 동맥관 개존증, 패혈증, 혈소판 감소증 등이 폐출혈 발생에 영향을 미칠 수 있다고 보고되고 있다. 저자는 출생 체중에 따라 신생아의 폐출혈 발생에 영향을 줄 수 있는 위험 인자를 규명하고 예후를 알아보고자 하였다. 방 법: 1995년 1월부터 2008년 12월까지 본원 신생아 중환자실에 입원한 재태 기간 37주 미만의 미숙아 117명을 대상으로 출생 체중에 따라 두 군으로 구분하였다. 폐출혈의 정의는 임상적인 정의를 적용하였고, 각 군에서 폐출혈의 발생에 영향을 미치는 요인을 알고자 병력지를 기초로 후향적으로 조사하였다. 결 과: 대상 환아 총 117례 중 폐출혈은 39례(33.3%)에서 발생하였으며, 출생 체중에 따라 극소 저체중 출생아군에서는 대상환아 총 48례 중 17례(35.4%)에서 폐출혈이 있었고 산전 산모의 스테로이드 치료 여부는 환아의 폐출혈 발생과 유의한 관련이 있었다($P$=0.001). 1분 APGAR 점수가 3점 이하인 경우, 혈소판 감소증도 폐출혈 발생과 유의한 관련이 있었다($P$<0.05). 저체중 출생아군에서는 대상 환아 총 69례 중 22례(31.9%)에서 폐출혈이 있었고 1분 APGAR 점수가 3점 이하인 경우는 폐출혈 발생과 유의한 관련이 있었다($P$=0.025). 저혈압, 산혈증, 혈소판 감소증도 폐출혈 발생과 유의한 관련이 있었다($P$<0.05). 다변수 분석에서 극소 저체중 출생아군에서는 산전의 산모 스테로이드 치료가 환아의 폐출혈 발생을 의미있게 감소시켰으며(OR=0.203, 95% CI=0.044-0.934), 저체중 출생아군에서는 1분 APGAR 점수가 3점 이하인 경우(OR=5.992, 95% CI=1.145-31.351)와 산혈증(OR=4.434, 95% CI=1.279-15.376)이 환아의 폐출혈 발생과 유의한 관련이 있었다. 결 론: 출생 체중이 적은 군에서 비교적 폐출혈이 늦게 발생하나, 일단 발생하면 사망률은 더 높은 것으로 나타났다. 극소 저체중 출생아군에서는 산전의 산모 스테로이드 치료가 환아의 폐출혈 발생을 의미있게 감소시켰으며, 저체중 출생아군에서는 1분 APGAR 점수가 3점 이하인 경우와 산혈증이 환아의 폐출혈 발생과 유의한 관련이 있었다.

Keywords

References

  1. Raju TN, Langenberg P. Pulmonary hemorrhage and exogenous surfactant therapy: a metaanalysis. J Pediatrics 1993; 123:603-10. https://doi.org/10.1016/S0022-3476(05)80963-1
  2. Stevenson D, Walther F, Long W, et al. Controlled trial of a single dose of synthetic surfactant at birth in premature infants weighing 500 to 699 grams. J Pediatrics 1992;120:S3-12. https://doi.org/10.1016/S0022-3476(05)81226-0
  3. Pandit PB, O`Brien K, Asztalos E, Colucci E, Dunn MS. Outcome following pulmonary haemorrhage in very low brithweight neonates treated with surfactant. Arch Dis Child Fetal Neonatal Ed 1999;81:F40-4. https://doi.org/10.1136/fn.81.1.F40
  4. Cloherty JP, Stark AR. Manual of neonatal care. 6th ed. Philadelphia: Lippincott Williams & Wilkins Pub, 2008:366-368.
  5. Van Houten J, Long W, Mullett M, et al. Pulmonary hemorrhage in premature infants after treatment with synthetic surfactant: an autopsy evaluation. The American Exosurf Neonatal Study Group I and the Canadian Exosurf Neonatal Study Group [published erratum appears in J Pediatrics 1992;120:762]. J Pediatrics 1992;120:S40-4. https://doi.org/10.1016/S0022-3476(05)81232-6
  6. Sly PD, Drew JH. Massive pulmonary haemorrhage: a cause of sudden unexpected deaths in severely growth retarded infants. Aust Paediatric J 1981;17:32-4.
  7. Adamson TM, Boyd RD, Normand IC, Reynolds EO, Shaw JL. Haemorrhagic pulmonary oedema ("massive pulmonary haemorrhage") in the newborn. Lancet 1969;1:494-5.
  8. Cole VA, Normand IC, Reynolds EO, Rivers RP. Pathegenesis of hemorrhagic pulmonary edema and massive pulmonary hemorrhage in the newborn. Pediatrics 1973;51:175-87.
  9. Stastny B, Kind C. Acute pulmonary oedema due to transient myocardial dysfunction: an uncommon cause of respiratory distress in the term neonate. Eur J Pediatrics 1998;157:59- 62. https://doi.org/10.1007/s004310050767
  10. Fekete M, Nemeth A. Neonatal pulmonary haemorrhage, birthweight, gestational age and intrauterine growth. Acta Paediatr Hung 1985;26:65-73.
  11. The international classification of disease, 9th revision, clinical modifications, 2nd ed. Washington, D.C.: 1980; DHHS publication no. (PHS)80-1260.
  12. Hegyi T, Carbone MT, Anwar M, Ostfeld B, Hiatt M, Koons A, Pinto-Martin J, Paneth N. Blood pressure ranges in premature infants. I. The first hours of life. J Pediatrics 1994;124:627-33. https://doi.org/10.1016/S0022-3476(05)83146-4
  13. Gilstrap LC 3rd, Leveno KJ, Burris J, Williams ML, Little BB. Diagnosis of birth asphyxia on the basis of fetal pH, Apgar score, and newborn cerebral dysfunction. Am J Obstet Gynecol 1989;161:825-30. https://doi.org/10.1016/0002-9378(89)90410-9
  14. Lewis MJ, McKeever PK, Rutty GN. Patent ductus arteriosus as a natural cause of pulmonary hemorrhage in infants: a medicolegal dilemma. Am J Forensic Med Pathology 2004; 25:200-4. https://doi.org/10.1097/01.paf.0000136444.09294.75
  15. Kluckow M, Evans N. Ductal shunting, high pulmonary blood flow, and pulmonary hemorrhage. J Pediatrics 2000; 137:68-72. https://doi.org/10.1067/mpd.2000.106569
  16. Lodha A, Shah PS, Hellmann J. Pulmonary haemorrhage associated with neonatal neurological disease. Heart Lung Circ 2009;18:45-8. https://doi.org/10.1016/j.hlc.2008.07.001
  17. Ceballos R. Aspiration of maternal blood in the etiology of massive pulmonary hemorrhage in the newborn infant. J Pediatrics 1968;72:390-3. https://doi.org/10.1016/S0022-3476(68)80214-8
  18. Simmons MA, Palmer W, Fink AG, Blumhagen JA. Neonatal pulmonary hemorrhage associated with administration of hyperosmolal solution. Am J Dis Child 1978;132:208.
  19. Fenton AC, Tanner MS, Wandless JG. Pulmonary hemorrhage as a complication of neonatal anaesthesia. Anaesthesia 1988;43:156-7.
  20. Sheffield LJ, Danks DM, Hammond JW, Hoogenraad NJ. Massive pulmonary hemorrhage as a presenting feature in congenital hyperammonemia. J Pediatrics 1976;88:450-2. https://doi.org/10.1016/S0022-3476(76)80263-6
  21. West JB, Tsukimoto K, Mathieu-Costello O, Preliletto R. Stress failure in pulmonary capillaries. J Appl Physiol 1991; 70:1731-42.
  22. West JB, Colice GL, Lee YJ, et al. Pathogenesis of highaltitude pulmonary oedema: direct evidence of stress failure of pulmonary capillaries. Eur Respir J 1995;8:523-9.
  23. Gibson AT. Perinatal corticosteroids and the developing lung. Paediatr Respir Rev 2002;3:70-6. https://doi.org/10.1053/prrv.2002.0184
  24. Wapner R. Antenatal corticosteroids: we continue to learn. Am J Obstet Gynecol 2004;190:875. https://doi.org/10.1016/j.ajog.2004.01.045
  25. Lin TW, Su BH, Lin HC, Hu PS, Peng CT, Tsai CH, Liang WM. Risk factors of pulmonary hemorrhage in very-lowbirth- weight infants: a two-year retrospective study. Acta Paediatr Taiwan 2000;41:255-8.
  26. Hegyi T, Carbone T, Anwar M, Ostfeld B, Hiatt M, Koons A, Pinto-Martin J, Paneth N. The apgar score and its components in the preterm infant. Pediatrics 1998;101:77-81. https://doi.org/10.1542/peds.101.1.77
  27. Perkins RP, Papile LA. The very low birth weight infant: incidence and significance of low Apgar scores, "asphyxia" and morbidity. Findings at delivery. Am J Perinatol 1985;2: 108-13. https://doi.org/10.1055/s-2007-999925
  28. Svenningsen L, Eidal K. Lack of correlation between umblical artery pH, retinal hemorrhages and Apgar score in the newborn. Acta Obstet Gynecol Scand 1987;66:639-42. https://doi.org/10.3109/00016348709022071
  29. Pappin A, Shenker N, Hack M, Redline RW. Extensive intraalveolar pulmonary hemorrhage in infants dying after surfactant therapy. J Pediatrics 1994;124:621-6. https://doi.org/10.1016/S0022-3476(05)83145-2
  30. Halliday HL. Synthetic or natural surfactants. Acta Paediatr 1997;86:233-7. https://doi.org/10.1111/j.1651-2227.1997.tb08880.x
  31. Kaapa, Sepp nen M, Kero P, Saraste M. Pulmonary hemodynamics after synthetic surfactant replacement in neonatal respiratory distress syndrome. J Pediatrics 1993;123:115-9. https://doi.org/10.1016/S0022-3476(05)81553-7
  32. Bhutani VK, Abbasi S, Long WA, Gerdes JS. Pulmonary mechanics and energetics in preterm infants who had respiratory distress syndrome treated with synthetic surfactant. J Pediatrics 1992;120:18-24. https://doi.org/10.1016/S0022-3476(05)81228-4
  33. Clyman RI. Ontogeny of the ductus arteriosus response to prostaglandins and inhibitors of their synthesis. Semin Perinatol 1980;4:115-24.
  34. Enhorning G. Artificial surfactant to prevent and treat neonatal respiratory distress syndrome. Pediatrics 1980;66:799- 800.

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