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  • 學位論文

中山醫學大學附設醫院新生兒骨折之臨床分析

Clinical analysis of neonatal fracture in Chung Shan Medical University Hospital

指導教授 : 陳家玉

摘要


研究目的:中山醫學大學附設醫院新生兒骨折及早產兒骨質疏鬆發生與其相關的危險因子之探討。 研究方法及資料:本研究以回溯性病歷回顧之方式,獲得中山醫學大學附設醫院於2006年1月至2015年12月新生兒骨折病患資料,加以彙整後進行統計分析。同時,應用1:1.5病例對照研究設計,以邏輯斯迴歸分析早產兒骨質疏鬆之危險因子。 研究結果:在這十年間共收案45位骨折或早產兒骨質疏鬆的病患,其中18位於出生第一天被診斷骨折(活產數千分之1.3),1例為高處墜落引起的顱骨部骨折的二個月大嬰兒,及26位早產兒骨質疏鬆。因分娩所造成的新生兒骨折分析中,沒有明顯的危險因子。在早產兒骨質疏鬆病患中,有18位有明顯骨折,又以肋骨骨折最為常見(34.29%),三分之二骨折病患含2處以上之部位骨折。針對早產兒骨質疏鬆的分析發現,早產兒骨質疏鬆組因餵食不耐使起始餵食時間明顯延後(p = 0.009),逹全經腸道餵食時間 (p = 0.000)、靜脈營養時間(p = 0.001)及氧氣使用時間(p =0.018)也顯著增加。造成早產兒骨質疏鬆的危險因子包括持續性開放性動脈導管(p = 0.041)、開放性動脈導管綁紮術(p = 0.041)、慢性肺疾病(p = 0.001)及靜脈營養相關的膽汁鬱積(p = 0.001)。利用二元邏輯斯迴歸分析,調整出生週數及出生體重,早產兒骨質疏鬆與靜脈營養相關的膽汁鬱積(OR 14.7; 95% CI 2.6 - 81.6; p = 0.002)及靜脈營養使用時間(OR 1.004; 95% CI 1.004 - 1.076; p = 0.029)有顯著相關。此外,早產兒骨質疏鬆組的結合性膽紅素、丙胺酸轉胺酶、麩草醋酸轉胺脢及鹼性磷酯酵素都比對照組顯著地高,但在對照組部份,因該院是依臨床需求方抽血檢測這些生化指標,故部份資料缺失。 結論: 該院住院病患因產傷造成骨折現象雖不高,可是分娩相關骨折病患中,剖腹生產與自然生產個案數一樣多。對於高危險產婦及胎兒我們要提高警覺,但是分娩所造成的骨折是無法預料及避免的。在早產兒部份,靜脈營養相關的膽汁鬱積會增加早產兒骨質疏鬆的風險14.7倍,靜脈營養使用時間每增加一天,早產兒骨質疏鬆的風險即變成1.004倍。

並列摘要


Purposes: To identify the incidence and associated risk factors of neonatal fractures and rickets of prematurity in Chung Shan Medical University Hospital. Materials and Methods: As a retrospective case control study of all neonates admitted to Chung Shan Medical University Hospital between January 1, 2006 and December 31, 2015, we analyzed the incidence and the risk factors of neonatal fractures and rickets of prematurity using logistic regression analysis. Results: During these ten years, totally 45 infants had bone fractures or rickets of prematurity, of these, 18 infants were diagnosed on the first day of birth (incidence 1.3/1000 live births), 1 infant had skull fracture due to high fall accident at 2-month-old, and 26 rickets of prematurity were diagnosed. None significant risk factors were identified in birth related fractures. Among the infants of rickets of prematurity, bone fractures were found in 18 infants, ribs fracture is the most common sites (34.29%), and two- thirds infants had more than 2 sites of bone fractures. The infants of rickets of prematurity had prolonged times of beginning enteral feeding, duration of full enteral feeding, parenteral nutrition and oxygen dependence were also increased. In univariate analysis, infants with rickets had significantly higher incidence of patent ductus arteriosus (PDA), received PDA ligation, bronchopulmonary dysplasia and parenteral nutrition associated cholestasis (PNAC). In binary logistic regression analysis, adjusted for gestational age, birth weight and covariance, rickets significantly correlated with PNAC (OR 14.7; 95% CI 2.6 - 81.6; p = 0.002) and durations of parenteral nutrition (OR 1.004; 95% CI 1.004 - 1.076; p = 0.029). Conclusion: In our hospitals, birth related fracture was low, we should be cautious and alert to the high risk mothers and fetus before delivery. However, birth related fractures are unpredictable and unavoidable. In preterm infants, the incidence of PNAC and duration of parenteral nutrition used was significantly increased 14.7 and 1.004 times, respectively.

參考文獻


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