neonatal edema
Introduction
Introduction to neonatal edema Edema is one of the common symptoms in the neonatal period. Its outstanding performance is weight gain. It is caused by excessive accumulation of body fluids in the interstitial space, causing systemic or local swelling. Systemic edema is called fetal edema at birth ( Hydropsfetalis), often accompanied by serous effusion, edema caused by various causes after birth, called neonatal edema, more common in the limbs, back, face and perineum. The edema of the edema is called depression edema, and the depression is called non-recessed edema. In the fetus and newborn, the extracellular fluid is more than the intracellular fluid, so there is physiological edema. This edema disappears on its own within a few days after birth. basic knowledge The proportion of illness: 0.001% Susceptible population: newborn Mode of infection: non-infectious Complications: sepsis
Cause
Causes of neonatal edema
Cardiovascular disease (30%)
Myocarditis caused by intrauterine infection, severe arrhythmia, endocardial fibroelastosis, various serious congenital heart diseases such as pulmonary valve and tricuspid malformation, aortic stenosis, left ventricular dysplasia, atrioventricular common Cardiac failure caused by channel, single ventricle, etc.; or due to vena cava malformation, intrathoracic tumor compression of the vena cava, venous return is blocked, pressure increases and edema occurs.
Severe anemia (20%)
Immune fetal edema caused by Rh blood group incompatibility, in addition to the southeast and southwestern provinces such as Guangdong, Guangxi, Sichuan, due to G-6-PD deficiency, alpha thalassemia caused by fetal non-immune edema, fetal-fetal or fetal-fetal Serious blood transfusion can also be caused.
Plasma protein reduction (15%)
Congenital nephropathy fetal urinary protein excretion too much, congenital hepatitis or reduced cirrhosis protein synthesis can cause fetal protein edema caused by low plasma protein.
Other factors (10%)
Lung dysplasia, pulmonary lymphangiogenesis, gastrointestinal obstruction, congenital ovarian hypoplasia (Turners syndrome), pterygium syndrome (Noonan syndrome), 21-trisomy syndrome, placental abnormalities and diabetes in pregnant women Pregnancy-induced hypertension syndrome can cause edema in the fetus, and a few can not find the cause, such as arrhythmia can not be found in time.
Pathogenesis
1. Intravascular and extracorporeal fluid exchange disorders Under normal conditions, there is a dynamic balance between blood and interstitial fluid. This dynamic balance is determined by various factors, mainly due to vascular permeability and osmotic pressure. The whole body capillaries have a certain permeability, and water, inorganic salts, glucose and urea can pass through the blood vessel wall quite freely, while colloidal substances such as plasma proteins of macromolecules are not easily transmitted when blood flows in. When the capillaries are used, the strength of the arterial end is greater than the force of the reflux. The crystal material in the plasma enters the interstitial space with the water, forming an interstitial fluid, and the factor that prevents the liquid from being absorbed back into the blood from the interstitial space is the hydrostatic pressure in the capillaries ( The capillary osmotic pressure of the capillary pressure and the interstitial fluid, the flow rate at the venous end is greater than the filtered amount, and the crystal material of most of the interstitial fluid returns to the blood with the water passing through the capillary wall, preventing the liquid from being filtered out of the blood vessel and The factors that promote the return of fluid from the interstitial space are the hydrostatic pressure of the interstitial fluid and the colloid osmotic pressure of the plasma, and the other interstitial fluid passes through the lymphatic vessels. Factors that return to the blood vessels, clinically common intravascular, and external fluid exchange disorders are:
(1) Increased capillary pressure: When systemic or local blood circulation disorder occurs, the capillary pressure at the venous end increases, hindering the absorption of fluid between tissues to the blood circulation, and increasing the lymph fluid. When the amount of lymph fluid production exceeds the limit of lymphatic reflux ability The sputum causes the fluid to accumulate in the interstitial space to form edema, which is seen in congestive heart failure, cirrhosis, and the like.
(2) Plasma colloid osmotic pressure reduction: plasma colloid osmotic pressure is the main maintainer of intravascular blood. When the plasma colloid osmotic pressure is reduced, intravascular water oozing increases, reflux decreases, interstitial fluid accumulation is excessive, and edema is formed. The level of plasma colloid osmotic pressure depends on the plasma protein. When the total plasma protein is less than 4.5g%, albumin is less than 2g% or the ratio of albumin to globulin is inverted, edema can occur. Congenital nephrotic syndrome, cirrhosis And malnutrition edema is the case.
(3) Increased capillary permeability: Protein does not easily penetrate the normal capillary wall, but in pathological conditions, the permeability of the capillary wall can be increased, and the macromolecular protein colloid can enter through the capillary wall. Within the tissue, the colloidal osmotic pressure of the interstitial fluid is increased, and the interstitial fluid is increased, thereby causing systemic or local edema, and factors causing an increase in capillary wall permeability are:
1 tissue hypoxia, metabolic disorders, increased acidic metabolites, increased hydrogen ion concentration, etc., can cause denaturation and liquefaction of the basement membrane and reticular fiber components of capillary wall cells.
2 Some bacterial metabolites decompose.
3 The body produces certain vasoactive substances such as histamine, serotonin, bradykinin and chronic allergic substances.
4 inflammation, cold.
5 Edema caused by drug allergy is also associated with increased permeability of the capillary wall.
6 sympathetic tone increased, plasma protein of idiopathic edema is too low, in addition to increased catabolism, but also closely related to increased sympathetic tone.
(4) Lymphatic drainage disorder: Under normal circumstances, part of the interstitial fluid returns directly to the blood vessel from the interstitial space, and the other part returns from the lymph. Because of the permeability of the capillary lymphatic wall, the protein in the interstitial fluid can pass freely. Normally, about 100g of protein is filtered from the blood to the interstitial fluid every day, and about 95% of them are returned to the blood through the lymphatic vessels through the thoracic duct. When the lymphatic system is compressed, such as tumors, congenital hereditary diseases, etc., the interstitial fluid is made. When the blood can not be returned to the blood through the lymphatics, the interstitial fluid colloid osmotic pressure is increased, resulting in edema caused by edema, congestive heart failure, cirrhosis, ascites, etc., which is related to the speed of lymph fluid production exceeding the return vein velocity.
(5) intracellular, external liquid sodium excretion disorder: under normal circumstances, the internal and external cells maintain balance, mainly due to the role of crystal osmotic pressure, while the latter is affected by the concentration of potassium and sodium ions, sodium ions are extracellular fluid The main component, while potassium ion is the main component of the intracellular fluid. Sodium ion is the main factor affecting the intracellular and extracellular fluid balance. The osmotic pressure of the extracellular fluid is mainly determined by the sodium ion concentration. When the sodium is retained in the body, in order to maintain the inside and outside of the cell. The balance of the liquid is regulated by ingestion of water or kidney, which causes the water to stay, resulting in an increase in extracellular fluid volume and edema. The edema caused by heart and kidney disease in clinical practice is sodium and water retention.
2. Discharge of body fluids: excretion of body fluids mainly through the kidneys, the regulation of water and salt balance by the kidneys is accomplished by glomerular filtration and renal tubular reabsorption. Neonatal glomerular filtration per day It is 14L, and 80~100ml is discharged from the urinary mouth. It can be seen that 99% of the filtrate is reabsorbed by the proximal convoluted tubule, the medullary ridge, the distal convoluted tubule and the collecting duct. When the function of these parts is impaired, edema occurs. .
In the neonatal period, the kidney development is not mature, the renal filtration and reabsorption function is poor, and the endocrine system (with aldosterone, antidiuretic hormone, etc.) and the enzyme system are immature, often affecting the regulation of water and electrolytes in the kidney, easily causing edema Or dehydration, acidosis, in the absence of heat, the above functions are poor, more prone to edema.
Prevention
Neonatal edema prevention
1. Pregnant women's health and nutrition: the health of the fetus depends entirely on the health and nutritional status of the mother. Therefore, first of all, the health care of pregnant women should be ensured to ensure adequate nutrition, prevent anemia, hypocalcemia, hypoproteinemia, etc., and prevent vitamin E. The lack of iron, iodine, etc., prevention of congenital hypothyroidism and other diseases in the fetus, prevention of fetal and neonatal edema, and avoiding various infections, such as early pregnancy virus infection, often causing congenital heart disease, etc. Good pregnant women's health, avoid premature birth, can prevent a variety of neonatal diseases, such as neonatal scleredema.
2. Prevention of neonatal hemolysis: prenatal examination of blood type can understand the fetal situation as early as possible, and prepare various monitoring measures for neonatal hemolysis as soon as possible.
In addition, the antibody titer should be measured for pregnant women with type O blood. The examination time is: the first time is 16 weeks of pregnancy, the second time is 28 to 30 weeks of pregnancy, and every 2 to 4 weeks thereafter, more than half, more than half The blood type pregnant woman produces antibodies after 28 weeks. When the antibody titer is >1:128, it is alert to the possibility of hemolysis. In addition, B-ultrasound can also help to detect fetal hemolysis. When the fetus has skin edema, pleural effusion, liver Splenomegaly, placenta enlargement, should consider whether there is a possibility of maternal fetal blood group incompatibility.
Complication
Neonatal edema complications Complications sepsis
Easy secondary infection, sepsis, other different primary complications have different complications, such as renal edema can develop into renal failure, cardiogenic edema can develop into heart failure.
Symptom
Symptoms of neonatal edema Common symptoms Neonatal systemic edema, shortness of breath, low heart, low blunt body, edema, heart murmur, infant feeding difficulties, bloating, weight gain, hypoproteinemia, cardiogenic edema
1. Physiological: The total body fluid of normal newborns accounts for 80% of body weight, which is higher than other age groups. The increased part is mainly in extracellular fluid. Therefore, normal newborns have a certain degree of edema, especially in premature infants. Finger indentation occurs, which is obvious in the back of the hand, the back of the foot and the eyelids. It is related to the lower level of atrial natriuretic peptide in the blood circulation of newborns, especially premature infants, affecting the effect of sodium excretion and the discharge of water, along with physiological weight. After the excess fluid is discharged, the edema naturally disappears.
2. Anemia: severe anemia caused by various causes can cause edema after neonatal birth, and the degree of edema and anemia may not be completely parallel. Newborns, especially those with weight <1500g, have less vitamin E storage and grow faster after birth. Vitamin E needs a large amount. When it is lacking, it will have edema in the late stage of neonatal period. The following abdomen, vulva and thigh are more obvious. The anemia is more obvious after 6-8 weeks of life. At this time, reticulocytes increase, platelets increase or deflation occurs. Red blood cells, after treatment with vitamin E, increased urine output, and edema quickly disappeared.
3. Cardiac: a variety of severe arrhythmia, myocarditis, congenital heart disease and fibroelastosis can occur in the neonatal period of cardiac insufficiency, and edema, manifested as feeding difficulties, weight gain (80 per day increase) 100g), sweating on the face when eating milk, shortness of breath, rapid heart rate, low heart bluntness, galloping, pulse weakening, heart, congenital heart disease can have cyanosis, heart murmur, both lungs can be inhaled And fine wet voice, liver progressive swelling, edema began in front of the eyelids and tibia, severe edema worsened, and there is oliguria or no urine, limb tension is low, limbs are cold, X-ray examination shows heart enlargement, heart The pulsation is weakened, the lung texture is increased and thickened, and the electrocardiogram often has various arrhythmia (such as pre-systolic contraction, tachycardia), accompanied by conduction delay in the room or indoor, QRS low voltage, ST segment down, T wave low or Inversion, abnormal Q waves can occur in the V4RV1 lead. Echocardiography can indicate left ventricular enlargement and ventricular dysfunction. Serological tests show aspartate transferase, aspartate aminotransferase, lactate dehydrogenase and phosphocreatine kinase. Its isozymes can be increased to varying degrees.
4. Kidney-derived: Neonatal, especially premature infants, kidney function is immature, glomerular filtration rate is low. For example, sodium intake or excessive intravenous fluid is prone to edema, others such as congenital nephropathy, various urinary systems Malformation and renal vein thrombosis can also cause edema. Most of the congenital nephropathy has intrauterine asphyxia. After birth, there may be pale, abnormal crying, difficulty in breathing, edema, and edema. In severe cases, the chest and abdominal cavity may accumulate. Liquid, urine examination In addition to a large amount of proteinuria, common red blood cells under the microscope, mild amino aciduria and diabetes, hypoproteinemia, serum albumin and gamma globulin decreased, 2-lipoprotein increased, cholesterol may increase or No increase, uremia can occur in the late stage, blood pressure is not high, pregnancy is often accompanied by pregnancy poisoning, premature delivery, placenta is large, often more than 25% of the baby's weight, up to 40%, the vast majority died of infection within 1 year after birth There are also reports of successful kidney transplantation.
5. Hypoproteinemia: When plasma protein is less than 40g / L or albumin is less than 20g / L, it can cause edema, seen in liver, kidney and other diseases, its clinical manifestations are edema, more common in the face, eyelids, lower limbs, upper limbs and Neck, ankle, depression edema, edema can be aggravated with body position change, skin is cold, pale, slow heart rate, decreased urine output, plasma total protein and albumin decreased, hemoglobin and red blood cells decreased, urine normal or slight abnormal.
6. Neonatal scleredema: more common in the cold season, related to frostbite, infection, hypoxemia and other factors, may increase due to capillary permeability, interstitial fluid, can be concave edema, but also due to subcutaneous Tissue saturated fatty acid coagulation, non-concave edema, hard swelling begins in the calf, later spread to the buttocks, trunk, face, hard swelling with depressed edema, skin chills, dark red, severe blue-purple, low body temperature The crying is weak, the sucking power is weak or refuses to eat, the limb activity is less, and the incidence of premature infants is higher than that of normal newborns.
7. Endocrine: children with congenital hypothyroidism have mucous edema, thick skin, non-concave edema, often accompanied by low response, physiological jaundice prolongation and constipation, adrenal hyperfunction, neurohypophyseal vasopressin Or adrenal cortical aldosterone metabolism disorder can occur neonatal edema, sporadic dysplasia occurs in the late neonatal period, there may be mucous edema around the eyelids, no depression, the skin can be patterned, low body temperature, lethargy, less crying Difficulty in feeding, slow sucking, even refusal to eat, bloating, constipation, poor breathing, snoring, prolonged physiological jaundice, normal reflex muscle contraction and slower relaxation, X-ray examination of distal femur and proximal humerus dysplasia Serum protein combined with iodine decreased, lower in thyroid-free, serum thyrotropin radioimmunoassay, if the serum thyrotropin concentration is higher than 20 micro-units per ml at 72h, the diagnosis can be confirmed, serum T3, T4 concentration is reduced or At the marginal level, the thyroid iodine absorption rate is significantly reduced, and blood glucose and serum alkaline phosphatase are decreased.
8. Hypocalcemia: can cause systemic or only lower extremity edema in neonates. The pathogenesis has not been fully elucidated. It may be related to the involvement of calcium ions in regulating the permeability of renal tubular epithelial membranes, such as decreased calcium ions, increased permeability, and calcium. Ions are also closely related to the permeability of blood vessels. They can also increase the permeability of capillaries. The fluid enters the subcutaneous tissue space. The edema can disappear quickly after supplementation with calcium. This disease is more common in premature infants, full-term small samples or mothers. Newborns born from diabetes or pregnancy-induced hypertension syndrome often develop symptoms 3 to 5 days after birth. They are characterized by different degrees of edema on the sides of the legs, and the depression is depressed. Edema can also occur on the extremities of the extremities. , limited, accompanied by low calcium convulsions, blood calcium is generally less than 7.5mg / dl, blood phosphorus is normal or elevated, serum alkaline phosphatase is normal, albumin is high, and gamma globulin is low, Electrocardiogram examination may have prolonged QT interval, occasionally conduction block, bradycardia, prognosis of this disease is good, the course of disease is 3 to 7 days, can naturally recover.
9. Idiopathic edema: The cause is unknown, the general condition of the child is good, and the edema can naturally subside, called idiopathic edema.
Examine
Examination of neonatal edema
According to the condition, you should choose the following laboratory tests as appropriate.
1. Blood routine: red blood cells and hemoglobin in neonatal hemolysis, hypoproteinemia, anemia, etc. can be reduced, reticulocytes also increase in hemolysis, the total number of white blood cells in the inflammatory person is increased, when the condition is serious, the body response is low, the virus When infected, Staphylococcus aureus, etc., the total number of white blood cells can be decreased, but neutrophils are elevated.
2. Blood test
(1) Quantitative plasma total protein, albumin, and globulin can help diagnose liver cirrhosis, congenital nephrotic syndrome, and hypoproteinemia.
(2) Blood urea nitrogen, cholesterol, serum protein electrophoresis, etc. are helpful for the diagnosis of nephropathy. Checking serum electrolytes such as potassium, sodium, chloride, calcium and magnesium is of great significance for the clinical diagnosis of electrolyte imbalance.
(3) Anti-human globulin test, free antibody test IgG positive, according to blood type, clinically can determine ABO, Rh blood group incompatibility causes neonatal hemolysis.
(4) serum protein binding iodine decreased, serum T3, T4 determination, when the patient concentration decreased, it is meaningful for the diagnosis of sporadic dysplasia.
3. Urine analysis: including urine routine, urine specific gravity, urinary tricholic, urinary galactose and amino acid urine.
1. X-ray examination: chest fluoroscopy if necessary, bone X-ray examination has diagnostic significance for osteomyelitis and sporadic dysentery, suspected cardiac vascular malformation, feasible cardiac catheter or cardiovascular angiography.
2. Electrocardiogram and echocardiography: It is helpful for the diagnosis of myocardial lesions, especially the two-dimensional echocardiography can dynamically observe the heart function, the size of the atrioventricular and the thickness of the wall.
Diagnosis
Diagnosis and diagnosis of neonatal edema
diagnosis
According to the medical history, symptoms, signs and hematuria tests, the cause of neonatal edema can be diagnosed. For some rare causes, special immunity, endocrine, chromosome examination, etc. should be performed. Fetal edema should be made before birth. Diagnosis, the fetal skin thickness can be measured from B-ultrasound, such as 5mm or placenta enlargement, serous effusion can be used for preliminary diagnosis, heart malformation can be found by B-ultrasound, or fetal blood type can be detected by amniotic fluid, blood type immunity Substances, bilirubin, karyotype or DNA, and hemoglobin electrophoresis contribute to the diagnosis and treatment of etiologies.
Differential diagnosis
1. Lymphedema: mainly seen in idiopathic hereditary lymphedema, also known as congenital hereditary rubber disease or Milroy disease, due to peripheral lymphatic vessel dilatation caused by lymphatic drainage disorder, limb hypertrophy, fingerless indentation, more common in the lower limbs, no Symmetrical, individual can be combined with chylothorax and/or chylothorax.
2. Unilateral limb hypertrophy: for congenital dysplasia, single or unilateral limb hypertrophy, no other abnormalities.
