發(fā)布時間：2018-06-10 11:28

  本文選題：宮內(nèi)炎癥 + 母體炎癥反應(yīng)�。� 參考：《復(fù)旦大學(xué)》2012年博士論文

【摘要】：胎兒／新生兒期不僅是人一生中最易感染的時期,而且感染死亡率高。超過50%的新生兒死亡與宮內(nèi)／宮外感染有關(guān)。27%的新生兒死亡是由早產(chǎn)所致,而造成早產(chǎn)的一個重要因素是宮內(nèi)感染。另外,26%的新生兒死亡原因為敗血癥和肺炎。除了引起早產(chǎn)外,宮內(nèi)感染還可能影響早產(chǎn)兒的近、遠(yuǎn)期臨床結(jié)局。胎兒／新生兒對病原菌的易感性是由自身免疫特點決定。本課題通過較大樣本的隊列,前瞻性研究了宮內(nèi)感染／炎癥與早產(chǎn)新生兒臨床結(jié)局的關(guān)系。并通過比較分析了新生兒臍血免疫細(xì)胞TLR信號通路基因表達(dá)譜特征,初步探討了胎兒／新生兒感染性疾病易發(fā)的分子機(jī)制,以期進(jìn)一步豐富對胎兒／新生兒感染這一重要臨床問題的認(rèn)識。 第一部分宮內(nèi)炎癥與早產(chǎn)兒臨床結(jié)局的研究 目的研究宮內(nèi)炎癥與早產(chǎn)的關(guān)系以及對新生兒呼吸系統(tǒng)、腦損傷等臨床結(jié)局的影響,為臨床的有效干預(yù)提供依據(jù)。 方法2008年1月至2010年10月在在上海交通大學(xué)附屬國際和平婦幼保健院分娩、孕周34周的孕產(chǎn)婦,及其所分娩的216名單胎早產(chǎn)兒納入本研究。收集產(chǎn)前、產(chǎn)時以及新生兒臨床資料并輸入數(shù)據(jù)庫。對于轉(zhuǎn)出新生兒,隨訪并收集數(shù)據(jù)。根據(jù)胎盤病理,將宮內(nèi)炎癥分為母體炎癥反應(yīng)(Maternal inflammation response,MIR)和胎兒炎癥反應(yīng)(Fetal inflammation response, FIR)。其中95例早產(chǎn)兒完成床旁頭顱超聲篩查；76例產(chǎn)婦行宮腔支原體和細(xì)菌培養(yǎng)；36例早產(chǎn)兒于糾正胎齡1-3月完成頭顱MRI檢查；25名早產(chǎn)兒于糾正胎齡6月進(jìn)行聽覺腦干誘發(fā)電位檢查,以及于糾正胎齡12個月采用貝利發(fā)育量表進(jìn)行神經(jīng)發(fā)育評估。 結(jié)果(1)胎盤病理：104/216例(48.1%)胎盤病理檢查發(fā)現(xiàn)宮內(nèi)炎癥反應(yīng),其中53例(51.0%)僅為母體炎癥反應(yīng),51例(49.0%)炎癥反應(yīng)同時累及母體和胎兒。本組資料未見僅為胎兒炎癥的病理結(jié)果。根據(jù)炎癥反應(yīng)病理結(jié)果將早產(chǎn)兒分為母體和胎兒炎癥雙陰性組(MIR-FIR-組)、母體炎癥陽性而胎兒炎癥陰性組(MIR+FIR-組)以及母體和胎兒炎癥雙陽性組(MIR+FIFR+組)。(2)早產(chǎn)與宮內(nèi)炎癥的關(guān)系：依據(jù)胎齡將216名早產(chǎn)兒分為27-29周、30-32周以及33周三組。胎齡27-29周和30-32周兩組MIR+(不論是否累及胎兒)發(fā)生率分別50.0%和54.8%,顯著高于胎齡≥33周組35.4%的發(fā)生率(p0.05)。胎齡27-29周和30-32周兩組MIR+FIFR+發(fā)生率分別為27.8%和28.7%均顯著高于胎齡≥33周組12.1%的發(fā)生率(p0.05)。而三組MIR+FIR-發(fā)生率則無顯著性差異。(3)宮腔微生物培養(yǎng)結(jié)果：支原體陽性率為22.4%,細(xì)菌陽性率為18.4%,各組間支原體和細(xì)菌培養(yǎng)陽性率無差異。(4)宮內(nèi)炎癥與新生兒腦損傷的關(guān)系：95名早產(chǎn)兒完成頭顱超聲檢查,納入分析。盡管三組間腦室內(nèi)出血發(fā)生率總體無差異,但MIR+FIR+組腦室內(nèi)≥2度腦室內(nèi)出血發(fā)生率顯著高于其他兩組。logistic多元回歸分析發(fā)現(xiàn)MIR+FIR+顯著增加早產(chǎn)兒2度及以上腦室內(nèi)出血風(fēng)險,OR=4.08(95%CI,1.259-13.24)。(5)宮內(nèi)炎癥與新生兒呼吸窘迫綜合癥的關(guān)系：MIR+FIR-組和MIR+FIR+組RDS發(fā)生率顯著低于MIR-FIR-組,且早產(chǎn)兒需機(jī)械通氣率也顯著降低。logist多元回歸分析發(fā)現(xiàn)MR+FIR+顯著降低RDS的風(fēng)險,OR=0.08(95%CI,0.010-0.661)。(6)宮內(nèi)炎癥與新生兒敗血癥的關(guān)系：MIR+FIR+組、MIR+FIR-組和MIR-FIR-組早產(chǎn)兒早發(fā)型敗血癥發(fā)生率分別為15.7%、11.3%和7.1%。雖然宮內(nèi)炎癥暴露增加早發(fā)型敗血癥的趨勢明顯,但無統(tǒng)計學(xué)差異。(7)部分隨訪結(jié)果：對25名早產(chǎn)兒于糾正胎齡6月進(jìn)行聽覺腦干誘發(fā)電位檢查,以及于糾正胎齡12個月采用貝利發(fā)育量表進(jìn)行神經(jīng)發(fā)育評估,根據(jù)MIR(不論是否累及胎兒)將早產(chǎn)兒分為兩組。宮內(nèi)炎癥對聽覺功能、智力發(fā)展指數(shù)和運動發(fā)展指數(shù)無影響。 結(jié)論(1)胎盤、胎膜和臍帶病理是判斷宮內(nèi)炎癥的重要依據(jù)。母體炎癥反應(yīng)與胎兒炎癥反應(yīng)是既密切相關(guān)又明顯不同的病理現(xiàn)象；(2)低胎齡早產(chǎn)時宮內(nèi)炎癥更嚴(yán)重；伴有胎膜早破時,宮內(nèi)炎癥與胎齡呈負(fù)相關(guān)；(3)宮內(nèi)炎癥影響新生兒期臨床結(jié)局。宮內(nèi)炎癥累及胎兒時顯著增加2度及以上腦室內(nèi)出血的風(fēng)險；宮內(nèi)炎癥累及胎兒時顯著降低新生兒RDS發(fā)生風(fēng)險；宮內(nèi)炎癥有增加早產(chǎn)兒早發(fā)型敗血癥的趨勢； 第二部分LPS誘導(dǎo)臍血免疫細(xì)胞TLR信號通路基因表達(dá)特征的研究 目的通過比較新生兒臍血與成人外周血免疫細(xì)胞經(jīng)LPS刺激后TLR信號通路基因表達(dá)譜的差異性,探討新生兒抗感染固有免疫應(yīng)答的特點和易于感染的分子機(jī)制。 方法收集10份健康足月兒臍血和10份成人外周血,進(jìn)行全血細(xì)胞培養(yǎng)。分別于脂多糖(lipopolysaccharide, LPS)誘導(dǎo)刺激后0、2、4、6、8和24小時,分離收集單個核細(xì)胞,抽提RNA。采用SuperArray公司(USA)Oligo GEArray(?)人Toll樣受體(TLR)信號通路功能基因芯片,檢測分析臍血TLR信號通路基因表達(dá)譜的時序變化特點及與成人的差異,并應(yīng)用PCR array對結(jié)果進(jìn)行驗證。 結(jié)果基因表達(dá)譜芯片結(jié)果顯示,新生兒較成人差異性表達(dá)(≥2倍)的基因隨時間點不同而變化。LPS誘導(dǎo)后8小時,新生兒較成人差異性表達(dá)的基因個數(shù)達(dá)到最大,共有79個基因,其中上調(diào)40個基因,下調(diào)基因39個。時序特征分析提示LPS誘導(dǎo)臍血免疫細(xì)胞TLR信號通路基因表達(dá)于誘導(dǎo)后2小時達(dá)高峰,但持續(xù)時間較短,而成人則于誘導(dǎo)后6小時達(dá)高峰,持續(xù)時間較長。臍血部分基因在所有時間點或大部分(≥4個點)時間點上調(diào)或下調(diào)變化趨勢較為一致,如表達(dá)上調(diào)的基因有RP105、Tollip、GPC1、HRAS、HSPA4、FADD、IKKα、NFKBIL1、SAPK3、JNK2和JNK1,而表達(dá)下調(diào)基因有TLR1、TLR2、CD14、MyD88、HSPA1A、MAL、 IRAK3和RELB等。新生兒TLR信號通路中一些重要的負(fù)性調(diào)控基因表達(dá)較成人高,而促炎因子的表達(dá)普遍低于成人。 結(jié)論(1)LPS誘導(dǎo)的臍血TLR信號通路基因表達(dá)水平及時序變化與成人存在明顯差異；(2)新生兒TLR信號通路的基因表達(dá)特征以負(fù)性調(diào)控占優(yōu)勢,可能是其抗感染免疫應(yīng)答不足的重要機(jī)制之一。
[Abstract]:Fetal / neonatal period is not only the most susceptible period of human life, but also the mortality rate is high. More than 50% of newborn deaths associated with intrauterine / intrauterine infection related to.27% are caused by premature birth, and intrauterine infection is an important factor causing premature birth. In addition, 26% of the causes of neonatal death are septicaemia and pneumonia. Intrauterine infection may also affect the near and forward clinical outcome of preterm infants. The susceptibility of the fetus / newborn to the pathogenic bacteria is determined by the autoimmune characteristics. This subject has prospectively studied the relationship between intrauterine infection / inflammation and the clinical outcome of premature neonates through a large sample of samples. In order to further enrich the understanding of the important clinical problems of fetal / neonatal infection, the molecular mechanism of the TLR signaling pathway in fetal umbilical cord blood immune cells is preliminarily discussed.
Part one: intrauterine inflammation and clinical outcome of premature infants
Objective to study the relationship between intrauterine inflammation and premature delivery, and the effect on neonatal respiratory system and brain damage, so as to provide evidence for effective intervention in clinic.
Methods from January 2008 to October 2010, the pregnant and parturient women who delivered at the International Peace Maternity and child health care hospital, affiliated to Shanghai Jiao Tong University, 34 weeks of pregnancy, and 216 of the birth preterm infants were included in this study. The data of prenatal, intrapartum and neonatal clinical data were collected and entered into the database. The intrauterine inflammation was divided into Maternal inflammation response (MIR) and fetal inflammatory response (Fetal inflammation response, FIR). 95 preterm infants were screened by bedside cranial ultrasound screening; 76 cases of parturients were infected with Mycoplasma and bacteria; 36 premature infants completed 1-3 months' head MRI examination; 25 The premature infants were examined by auditory brainstem evoked potential in June and corrected for 12 months of gestational age. The Bailey developmental scale was used to assess neural development.
Results (1) placental pathology: 104/216 (48.1%) placental pathological examination found intrauterine inflammatory reaction, of which 53 cases (51%) were only maternal inflammatory reaction, 51 (49%) inflammatory reaction involved both mother and fetus. The data of this group were not only the pathological results of fetal inflammation. According to the pathological results of the inflammatory reaction, the preterm infants were divided into maternal and fetal inflammation. MIR-FIR- group (group MIR-FIR-), maternal inflammation positive and fetal inflammation negative group (group MIR+FIR-) and maternal and fetal inflammation double positive group (group MIR+FIFR+). (2) the relationship between premature birth and intrauterine inflammation: according to gestational age, 216 preterm infants were divided into 27-29 weeks, 30-32 weeks and 33 Wednesday groups. 27-29 and 30-32 weeks of fetal age, two groups, whether or not involved. The incidence of fetal) was 50% and 54.8% respectively, which was significantly higher than the incidence of 35.4% in the 33 weeks group (P0.05). The incidence of MIR+FIFR+ in two groups of two groups at the 27-29 and 30-32 weeks of gestational age was significantly higher than that of 12.1% in the gestational age group (33 weeks). The incidence of MIR+FIR- in the three group was no significant difference. (3) the results of microbiological culture in the uterine cavity were: The positive rate of Mycoplasma was 22.4% and the positive rate of bacteria was 18.4%. There was no difference in the positive rate of Mycoplasma and bacteria in each group. (4) the relationship between intrauterine inflammation and neonatal brain injury: 95 preterm infants completed the skull ultrasound examination and included the analysis. Although there was no difference in the incidence of intraventricular hemorrhage in the three groups, the cerebral ventricles of the MIR+FIR+ group were more than 2 degrees in the ventricles of the brain. The incidence of bleeding was significantly higher than the other two groups of.Logistic multivariate regression analysis found that MIR+FIR+ significantly increased the risk of intraventricular hemorrhage of 2 degrees and above in preterm infants, OR=4.08 (95%CI, 1.259-13.24). (5) the relationship between intrauterine inflammation and neonatal respiratory distress syndrome: the incidence of RDS in MIR+FIR- and MIR+ FIR+ groups was significantly lower than in the MIR-FIR- group, and the need for premature infants The rate of mechanical ventilation was also significantly reduced by.Logist multivariate regression analysis found that MR+FIR+ significantly reduced the risk of RDS, OR=0.08 (95%CI, 0.010-0.661). (6) the relationship between intrauterine inflammation and neonatal septicemia: the incidence of early onset sepsis in premature infants in group MIR+FIR+, MIR+FIR- and MIR-FIR- was 15.7%, 11.3% and 7.1%. although increased intrauterine inflammation increased The trend of early onset sepsis was obvious, but there was no statistical difference. (7) part of the follow-up results: 25 preterm infants were examined by auditory brainstem evoked potential in June, and the Bailey development scale was used for the assessment of neurodevelopment in 12 months of gestational age. Preterm infants were divided into two groups according to whether or not they were involved in the fetus. Inflammation had no effect on auditory function, intelligence development index and motor development index.
Conclusions (1) the pathology of placenta, fetal membrane and umbilical cord is an important basis for judging intrauterine inflammation. Maternal inflammatory reaction and fetal inflammation are closely related and distinct pathological phenomena; (2) intrauterine inflammation is more severe in premature birth of low fetal age; intrauterine inflammation is negatively correlated with fetal age, and (3) intrauterine inflammation affects newborns The risk of intrauterine intrauterine bleeding increased by 2 degrees and above, with intrauterine inflammation involving the fetus; intrauterine inflammation significantly reduced the risk of RDS in the newborn; intrauterine inflammation increased the trend of early onset septicemia in preterm infants;
The second part is about the gene expression characteristics of TLR signaling pathway induced by LPS in umbilical cord blood immune cells.
Objective to compare the difference of the gene expression profiles of TLR signaling pathway in neonatal umbilical blood and adult peripheral blood immune cells after LPS stimulation, and to explore the characteristics of neonatal anti infection inherent immune response and the molecular mechanism that is easy to infect.
Methods 10 healthy full moon umbilical cord blood and 10 adult peripheral blood were collected for whole blood cell culture. 0,2,4,6,8 and 24 hours after induced stimulation of lipopolysaccharide (LPS) were separately collected and collected to collect mononuclear cells, and RNA. was extracted from SuperArray company (USA) Oligo GEArray (?) Toll like receptor (TLR) signal pathway function gene chip. The temporal variation characteristics of umbilical cord blood TLR signaling pathway gene expression and its difference from adults were detected and analyzed, and the results were verified by PCR array.
The results of gene expression chip showed that the genes of differential expression (2 times greater than 2 times) of the newborns were different with time, and 8 hours after the induction of.LPS induction. The number of different genes expressed in the newborns reached the maximum, with a total of 79 genes, including 40 genes up and 39 down regulated genes. The sequence characteristic analysis suggested that LPS induced cord blood. The expression of TLR signaling pathway in the immune cells reached the peak at 2 hours after induction, but the duration of the gene was shorter, while adults reached the peak at 6 hours after induction, and lasted a long time. The genes in the umbilical cord blood were up to be up or down at all time points or at most (4 points) time points, such as RP105, Tollip, in the up regulated genes. GPC1, HRAS, HSPA4, FADD, IKK alpha, NFKBIL1, SAPK3, JNK2 and JNK1. Some of the important negative regulatory genes in the signaling pathway are higher in the newborn than in adults, while the expression of pro-inflammatory factors is generally lower than that of adults.
Conclusion (1) the change of TLR signaling pathway in umbilical cord blood induced by LPS is significantly different from that in adults. (2) the gene expression characteristics of TLR signaling pathway in newborn infants are negatively regulated, which may be one of the important mechanisms of its anti infection immune response.
【學(xué)位授予單位】：復(fù)旦大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2012
【分類號】：R722

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