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ID naloge: 144 Letnik: 2003 Predmet: ginekologija in porodništvo
DAJANJE KORTIKOSTEROIDOV ŽENSKAM V NOSECNOSTI, KI SE KONCAJO S PREZGODNJIM PORODOM
Avtor: Ana Pajtler, Alenka Pirih
Mentor: prof. dr. Živa Novak Antolic
Somentor: asist. Toncka Završnik
Izhodišce: Prezgodnji porod (PP) z rojstvom nedonošencka je povezan z neonatalno umrljivostjo, neonatalno obolevnostjo z dolgotrajnimi zdravstvenimi posledicami in motnjami v nevrološkem razvoju. Pojavnost PP v zadnjih letih kljub napredkom v perinatologiji ne upada. S poznavanjem etiologije in dejavnikov tveganja lahko poskušamo zaplete PP prepreciti tako, da pravocasno objektivno identificiramo nosecnice s povecanim tveganjem in jih primerno obravnavamo. Ce PP ne uspemo prepreciti, pa lahko s primernim preprecevanjem izboljšamo preživetje in zmanjšamo obolevnost prezgodaj rojenih otrok. Dokazano je, da je pri tem ucinkovito pravocasno dajanje kortikosteroidov (KS) vsaj 24 ur pred PP. Ucinkovitost preprecevanja PP se poveca, ce KS dobi cim vec nosecnic z visokim tveganjem za PP. Po analizi podatkov Nacionalnega perinatalnega informacijskega sistema, ki jih je opravil Inštitut za varovanje zdravja Republike Slovenije (IVZ RS) za leto 2000, je bilo preventive s KS v Porodnišnici Ljubljana deležno le 25,07 %, v Sloveniji pa le 21,4 % prezgodaj rojenih otrok z gestacijsko starostjo (GS) od 22 0/7 do 36 6/7 tedna. Višji je odstotek za prezgodaj rojene otroke z GS od 28 0/7 do 32 6/7 tedna, ki so bili deležni take preventive, in je bil v Porodnišnici Ljubljana 38,6 %, v Sloveniji pa 37,4 %.
Namen: 1) V nalogi smo želeli ugotoviti, zakaj je samo 38,6 prezgodaj rojenih otrok z GS od 28 0/7 do 32 6/7 tedna GS v Porodnišnici Ljubljana v letu 2000 dobilo KS. 2) Oceniti standardne vrednosti (senzitivnost (Se), specificnost (Sp), pozitivno in negativno napovedno vrednost (PNV in NNV)) testa za dolocanje fosforilirane oblike vezavnega proteina za inzulinu podoben rastni dejavnik tipa 1 (phIGFBP-1) iz cervikalnega izlocka v napovedi PP in povecati njegovo uporabo. 3) Priporociti ukrepe za povecano dajanje KS nosecnicam z visokim tveganjem za PP.
Hipoteze: Pricakovali smo, da je vec kot 38,6 % nosecnic, ki so rodile prezgodaj (od 28 0/7 do 32 6/7 tedna GS) dobilo KS, vendar to ni bilo zabeleženo v porodnem zapisniku (PZ). Želeli smo dolociti orientacijske standardne vrednosti testa za dolocanje phIGFBP-1 za porod v dveh tednih po testu. Pricakujemo, da se bo z našimi priporocili za ukrepe povecalo dajanje KS nosecnicam z visokim tveganjem za PP.
Metode: V retrospektivnem delu naloge smo pregledali popise porodnic, ki so rodile prezgodaj (od 22 0/7 do 33 6/7 tedna GS) v letu 2000 v Porodnišnici Ljubljana. V popisih hospitalizacije smo pregledali, koliko jih je dobilo KS, ali so jih dobile v vec kot 24 urah pred porodom in ali je bilo to pravilno zabeleženo v PZ. V prospektivnem delu smo nosecnicam, ki so bile hospitalizirane in /ali ambulantno pregledane na Klinicnem oddelku za perinatologijo Ginekološke klinike Klinicnega centra v Ljubljani v obdobju med 12.3.2002 in 13.2.2003, dolocili phIGFBP-1. Zajete so bile nosecnice od 22 0/7 do 34 0/7 tedna GS. Štirinajst dni po testu smo ocenjevali njegove standardne vrednosti.
Rezultati: Odstotek nosecnic, ki so dobile KS v Porodnišnici Ljubljana leta 2000 je bil še enkrat vecji kot kažejo uradni podatki. Pri PP od 22 0/7 do 33 6/7 tedna GS je dobilo KS 80 % nosecnic in 84,5 % nosecnic, ki so rodile od 28 0/7 do 32 0/7 tedna GS. Za ugotavljanje skupine nosecnic z visokim tveganjem za PP lahko poleg napovednih dejavnikov iz anamneze ter klinicnega pregleda uporabljamo tudi phIGFBP-1. V naši raziskavi na majhnem številu preiskovank so bile standardne vrednosti testa: Se 100 %, Sp 59 %, PNV 15 % in NNV 100 %.
Zakljucki: Namesto diagnoze grozec prezgodnji porod predlagamo natancno opredelitev dejavnikov tveganja za PP ob prvem pregledu v nosecnosti in sproti pozneje v nosecnosti, uporabo phIGFBP-1 zaradi visoke NNV ter dajanje KS, kadar je tveganje za PP visoko.
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[Abstract / English version]
DAJANJE KORTIKOSTEROIDOV ŽENSKAM V NOSECNOSTI, KI SE KONCAJO S PREZGODNJIM PORODOM
Author: Ana Pajtler, Alenka Pirih
Mentor: prof. dr. Živa Novak Antolic
Co-mentor: asist. Toncka Završnik
Background: Preterm delivery (PD) is associated with neonatal mortality, severe neonatal morbidity with long-term consequences and disturbances in neurologic development. The incidence of PD has not decreased in the last years despite improvements in perinatology. Through the knowledge of etiology and risk factors for PD, we can try to prevent complications by objectively identifying pregnant women at high risk of PD and subsequently managing them properly. However, when prevention of PD delivery is impossible, prevention with corticosteroids (CS) at least 24 hours prior to PD has been proved to reduce neonatal mortality and morbidity. By treating more patients with high risk for PD with CS, the efficiacy of prevention of complications of PD could be increased. According to data from National perinatal informational system of Slovenia (NPIS), analysed by Inštitut za varovanje zdravja Republike Slovenije (IVZ RS), in the year 2000 only 25,07% children born preterm between 22 0/7 and 36 6/7 weeks of gestational age (GA) obtained such preventative treatment in Porodnišnica Ljubljana, and in Slovenia only 21,4%. These percentage is higher for children born with GA between 28 0/7 and 32 6/7 weeks of GA, which was in Porodnišnica Ljubljana 38,6% and in Slovenia 37,4%.
Aim: Our aim was to find out why only 38,6% of children born between 28 0/7 and 32 6/7 weeks of GA in Porodnišnica Ljubljana in the year 2000 obtained antenatal CS. We tried to evaluate the standard values (sensitivity (Se), specificity (Sp), positive and negative predictive values (PPV, NNV)) of the test, which detects phosphorylated form of insulin growth factor binding protein type 1 (phIGFBP-1) in cervical fluid, for prediction of PD, and to increase its usage. Our aim was also to recommend how to increase the number of pregnant women with high risk of PD that are given CS.
Hypotheses: We expected that more than 38,6% of pregnant women, who delivered between 28 0/7 and 32 6/7 weeks of GA, were treated with CS. However, this was not marked in the delivery protocol (DP). We wanted to evaluate standard values of the test detecting phIGFBP-1. We expect our recommendations would increase the number of pregnant women with high risk of PD to be treated with CS.
Methods: In the retrospective part we have analysed perinatal data of women, who delivered between 22 0/7 and 33 6/7 week of GA in the year 2000 in Porodnišnica Ljubljana. We have analysed how many were given CS, whether they had it at least 24 hours prior to delivery and whether this was marked in DP. In the prospective part of the research, we determined the phIGFBP-1 in cervical fluid of 48 women pregnant between 22 0/7 and 34 0/7week of GA, who were either examined or hospitalised at the Department of Perinatology, Division of Ob/Gyn, University Medical Centre in Ljubljana, in the period between 12.3.2002 and 13.2.2003. Two weeks after the test we evaluated its standard values.
Results: The percentage of pregnant women, who were given CS in Porodnišnica Ljubljana in the year 2000 was twice as high as data from NPIS show. 80% of women, who delivered preterm between 22 0/7 and 33 6/7, and 84,5% of women who delivered between 28 0/7 and 32 0/7 week of GA, were treated with CS. Determination of phIGFBP-1 is, together with other risk factors, useful in prediction of PD. According to our research with low number of included patients its Se is 100%, Sp 59%, PPV 15% and NNV 100%.
Conclusions: We suggest objective determination of risk factors for PD at the first examination of pregnant women and then later on through whole pregnancy instead of diagnosis of threatened PD, using phIGFBP-1 for its high NPV and giving CS when there is high risk of PD.
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