新生儿黄疸+母得志院长

,新 生 儿 黄 疸 Neonatal Jaundice,母 得 志 教授/主任医师 四川大学华西第二医院儿科华西儿童医学中心,概述Introduction,黄疸 (jaundice)：新生儿期常见足月儿(full term infants)：早产儿(preterm infants)：,50%,80%,概述Introduction continued,时间 (When)：多发生在出生后1周内部位 (Where)：巩膜、皮肤发黄血中胆红素浓度 (What)：胆红素超过5mg/dl,概述Introduction continued,Why Jaundice occurred?,生 成 (Producing)排 泄 (Excreting),Hemoglobin Globin + Heme,Heme,Bilirubin,Bilirubin Metablism,1. Bilirubin,Bilirubin Metablism,Y,Z,Z,Y,UDPGT,-glucuronidase,Fecal bilirubin,Urobilinogen,Reticuloendothelial,2. Bilirubin-Albumin Complex,Cytoplasmic,3.Conjugated bilirubin,4. Intestine,ENTEROHEPATICCIRC,Bacteria,SER,新生儿胆红素代谢特点,1、胆红素生成 (Bilirubin production) 8.8mg/kg/d in newborns3.8mg/kg/d in adults 2、与白蛋白结合 (Bilirubin - albumin complex) a. 早产儿 b. 酸中毒(Acidosis),Bilirubin Metablism,新生儿胆红素代谢特点 continued,3、肝细胞胆红素代谢(Bilirubin metabolism)肝细胞摄入(Hepatic uptake, Y, Z protein)结合胆红素(UDPGT)4、肠肝循环(Enterohepatic circulation),Bilirubin Metablism,胆红素的毒性作用 Bilirubin toxicity,结合胆红素(Conjugated bilirubin )：水溶性未结合胆红素(Unconjugated bilirubin)：脂溶性(Lipid-soluble) 胆红素脑病(Bilirubin-encephalopathy),Bilirubin Metablism,临床表现 Clinical Manifestations,黄疸(Jaundice appears)时间(when)：新生儿期部位(where)：面部 胸部 腹部 肢端,Clinical Manifestations,临床表现 Clinical Manifestations continued,评估(Evaluation of jaundice)肉眼：面部：5mg/dl; 腹部：10-15mg/dl; 肢端：15-20mg/dl经皮测胆红素：筛查血清胆红素： 标准,Clinical Manifestations,颜 面,躯 干,肢 端,新生儿黄疸皮肤黄染顺序,8.1mg/dl,14.3mg/dl,22.5mg/dl,临床表现 Clinical Manifestations continued,分类 (Classification)生理性黄疸 (Physiological Jaundice)病理性黄疸 (Pathological Jaundice),Clinical Manifestations,生理性黄疸 (Physiological Jaundice)原 因：与新生儿胆红素代谢有关出现时间：生后23天高峰时间：生后45天持续时间：足月儿2周,临床表现 Clinical Manifestations continued,Clinical Manifestations,早产儿4周,生理性黄疸 (Physiological Jaundice)胆红素峰值：足月儿12.9 mg/dl早产儿15 mg/dl 进 展 情 况： 每日增加2周，早产儿4周 或退而复现,临床表现 Clinical Manifestations continued,Clinical Manifestations,病理性黄疸 (Pathological Jaundice)胆红素峰值：足月儿12.9mg/dl 早产儿15mg/dl进 展 情 况： 每日增加 5mg/dl全 身 情 况： 原发病症状体征治 疗： 治疗原发病,临床表现 Clinical Manifestations continued,Clinical Manifestations,新 生 儿 溶 血 病 (Hemolytic disease of newborn, HDN),概述Introduction,同族免疫性溶血26个血型：ABO: 85.3% Rh: 14.6% MN: 0.1%,病因及发病机制 Pathogenesis,ABO incompatibility the mother: type O the infant：type A or B Rh incompatibility the mother： Rh（-） the infant： Rh（+）D, E, C, c, e,临床表现 Clinical Manifestations,ABO Rh1.黄疸: mild severe 2-3 day 24 h2.贫血: mild severe (3-6 weeks) heart failure3.肝脾大： rare common,胆红素脑病或核黄疸 Bilirubin Encephalopathy & Kernicterus,警告期 (warning stage)痉挛期 (convulsion stage)恢复期 (recovery stage)后遗症期 (sequelae stage),Clinical Manifestations,并发症 Complications,胆红素脑病或核黄疸 Bilirubin Encephalopathy & Kernicterus,Clinical Manifestations,并发症 Complications continued,角弓反张Opisthotonus,实验室检查 Laboratory tests,母子血型：血型不合高胆红素血症：未结合胆红素溶血检查血红蛋白 ： 网织RBC： 有核RBC：,实验室检查 Laboratory tests continued,血型抗体检查(antibody test)1. 直接抗人球蛋白试验 (+) confirm (Direct Coombs test) 2. 抗体释放试验 (+) confirm (Antibody release test)3. 游离抗体试验 (+) judge (Free antibody test),Laboratory tests,治 疗 Treatment,光照疗法 (Phototherapy) 换血疗法 (Exchange transfusion)药物治疗 (Drug therapy),光照疗法 Phototherapy continued,光源 (Light source)：波长425475的蓝光,Treatment,光照疗法 Phototherapy continued,适应症 (Indications)高未结合胆红素血症胆红素 12mg/dl有核黄疸高危因素放宽指针换血前,Treatment,光照疗法 Phototherapy continued,Treatment,副作用 (Side effects )腹泻 (Diarrhea)发热 (Fever)皮疹 (Skin rash)青铜症 (Bronze baby syndrome) (Conjugated bilirubin4mg/dl),Treatment,光照疗法 Phototherapy continued,光疗的副作用 (Side effects of phototherapy),皮 疹,青铜症,Treatment,换血疗法 Change transfusion continued,目的 (Aims of transfusions)换出抗体和致敏RBC，减少溶血换出胆红素，防止核黄疸纠正贫血,Treatment,适应症 (Indications)严重溶血病光疗效果差,Treatment,换血疗法 Change transfusion continued,指针 ( Indications )1）出生时Hb0.7mg/dl/h4）有核黄疸,Treatment,换血疗法 Change transfusion continued,血型的选择 ( Source of the blood ) mother newborns Rh 溶血： Rh ABOABO 溶血： “AB” plasma and “O” cells,Treatment,换血疗法 Change transfusion continued,换血量 (Volume)150180ml/kg ( 二倍于新生儿血容积 )方法 (Method)外周血管同步换血,Treatment,换血疗法 Change transfusion continued,Treatment,血清胆红素22.7mg/dl,换血疗法 Change transfusion continued,换血疗法 Change transfusion continued,Treatment,外周血管同步换血足背动脉头静脉,药物治疗 Drug therapy,苯巴比妥 (phenobarbital)Effects：Uptake，Conjugation白蛋白 (Albumin)：减少游离胆红素IVIG：阻止溶血微生态制剂：减少肠肝循环,Treatment,预 防 Preventions,ABO溶血 (ABO incompatibility): NoRh溶血 (Rh incompatibility) 300 g of human anti-D globulin within 72h after delivery,病 例 Case report,24h old male infant, gravida1, para 1. Mother: blood type “O”，father：“AB” PE: Jaundice appeared on face and trunk skin liver edge 3cm spleen edge 1cm tip,Case report,病例 Case report,Question:1. Reason?2. L