Vieux Rachel, Fresson Jeanne, Hascoet Jean-Michel, Blondel Beatrice, Truffert Patrick, Roze Jean-Christophe, Matis Jacqueline, Thiriez Gerard, Arnaud Catherine, Marpeau Loic, Kaminski Monique
Department of Neonatalogy, Maternite Regionale Universitaire, Nancy, France.
Pediatrics. 2006 Jul;118(1):84-90. doi: 10.1542/peds.2005-2149.
Perinatal regionalization has been organized into 3 ascending levels of care, fitting increasing degrees of pathology. Current recommendations specify that very premature infants be referred prenatally to level III facilities, yet not all very preterm neonates require level III intensive care. The objective of our study was to determine the antenatal factors that, in association with gestational age, predict the need for neonatal intensive care in preterm infants, to match the size of birth with the level of care required.
Data were analyzed from a cohort of very preterm infants born in nine French regions in 1997. We defined the need for neonatal intensive care as follows: (1) the requirement for specialized management (mechanical ventilation for >48 hours, high frequency oscillation, or inhaled nitric oxide) or (2) poor outcome (transfer to a level III facility within the first 2 days of life or early neonatal death). Triplet pregnancies and pregnancies marked by fetal malformations or intensive care requirements for the mother before delivery were excluded.
We focused our study on 1262 neonates aged 30, 31 and 32 weeks' gestation, where the need for intensive care was 42.8%, 33.2%, and 22.8%, respectively. Multivariate analysis showed that the risk factors for intensive care requirement with low gestational age were twin pregnancies, maternal hypertension, antepartum hemorrhage, infection, and male gender. Antenatal steroid therapy and premature rupture of membranes were protective factors against intensive care requirement.
Infants <31 weeks' gestation should be referred to level III facilities. From 31 weeks' gestation, some infants can be safely handled in level IIb facilities. However, the quality of perinatal regionalization may only be fully assessed by long-term follow-up.
围产期区域化已被组织成3个逐步提升的护理级别，以适配不同程度的病理情况。当前建议明确指出，极早产儿应在产前被转诊至三级医疗机构，但并非所有极早早产儿都需要三级重症监护。我们研究的目的是确定与胎龄相关的产前因素，这些因素可预测早产儿对新生儿重症监护的需求，以便使出生规模与所需的护理级别相匹配。
对1997年在法国9个地区出生的极早早产儿队列数据进行分析。我们将新生儿重症监护需求定义如下：(1) 需要特殊管理（机械通气超过48小时、高频振荡或吸入一氧化氮）或(2) 预后不良（出生后2天内转至三级医疗机构或早期新生儿死亡）。排除三胎妊娠以及伴有胎儿畸形或母亲在分娩前需要重症监护的妊娠。
我们的研究聚焦于1262例孕龄为30、31和32周的新生儿，其重症监护需求分别为42.8%、33.2%和22.8%。多变量分析显示，孕龄较低时需要重症监护的风险因素包括双胎妊娠、母亲高血压、产前出血、感染和男性性别。产前使用类固醇治疗和胎膜早破是防止需要重症监护的保护因素。
孕龄小于31周的婴儿应转诊至三级医疗机构。孕龄达到31周后，一些婴儿可在二级乙等医疗机构得到安全处理。然而，围产期区域化的质量可能只有通过长期随访才能得到全面评估。
