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中华妇幼临床医学杂志(电子版) ›› 2018, Vol. 14 ›› Issue (02) : 172 -179. doi: 10.3877/cma.j.issn.1673-5250.2018.02.008

所属专题： 文献；

论著

心音信号分析正常、足月新生儿出生早期的心力储备
杨霄1, 冯丹1, 罗丹1,†(), 刘德顺1   
  1. 1. 610091　成都市妇女儿童中心医院妇产科
  • 收稿日期:2017-11-18 修回日期:2018-03-05 出版日期:2018-04-01
  • 通信作者: 罗丹

Evaluation of cardiac contractility reserve in normal and full term early newborns based on the heart sound signal analysis

Xiao Yang1, Dan Feng1, Dan Luo1,†(), Deshun Liu1   

  1. 1. Department of Gynecology and Obstetrics, Chengdu Women′s and Children′s Central Hospital, Chengdu 610091, Sichuan Province, China
  • Received:2017-11-18 Revised:2018-03-05 Published:2018-04-01
  • Corresponding author: Dan Luo
  • About author:
    Corresponding author: Luo Dan, Email:
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引用本文：

杨霄, 冯丹, 罗丹, 刘德顺. 心音信号分析正常、足月新生儿出生早期的心力储备[J]. 中华妇幼临床医学杂志(电子版), 2018, 14(02): 172-179.

Xiao Yang, Dan Feng, Dan Luo, Deshun Liu. Evaluation of cardiac contractility reserve in normal and full term early newborns based on the heart sound signal analysis[J]. Chinese Journal of Obstetrics & Gynecology and Pediatrics(Electronic Edition), 2018, 14(02): 172-179.

目的

采用心音图运动试验(PCGET)检测和评估正常、足月新生儿出生早期(0～7 d)的心力储备(CCR)。

方法

选择2013年1月1日至2015年1月1日，于成都市妇女儿童中心医院产科住院分娩的1 797例正常、足月的出生早期新生儿为研究对象。根据其出生后不同日龄，将其分为0～7 d组(n＝192、257、270、214、232、212、210、210)。采用前瞻性研究方法，检测和分析这些新生儿的第一心音(S1)与第二心音(S2)的幅值比值(S1/S2)、心脏舒张期时限(D)与收缩期时限(S)的比值(D/S)和应激后心力变化趋势(CCCTS)。采用Kruskal-Wallis H秩和检验，对8组新生儿安静时和哭泣后的S1/S2，哭泣后的CCCTS分别进行整体比较及组间两两比较。采用方差分析，对8组新生儿安静时和哭泣后的D/S分别进行整体比较，采用最小显著性差异(LSD)法进一步进行组间两两比较。采用配对设计的Wilcoxon符号秩和检验，对8组新生儿安静时和哭泣后的S1/S2进行组内比较；采用配对t检验，对8组新生儿安静时和哭泣后的D/S进行组内比较。采用Spearman秩相关性分析，对这些新生儿安静时的S1/S2与D/S相关性进行分析。采用多重线性逐步回归分析，对纳入研究新生儿安静时D/S的影响因素进行分析。本研究遵循的程序符合成都市妇女儿童中心医院人体试验委员会制定的伦理学标准，得到该委员会批准，分组征得受试儿监护人知情同意，并与监护人签署临床研究知情同意书。

结果

①8组正常、足月的出生早期新生儿安静时的S1/S2整体比较，差异有统计学意义(χ2＝847.5，P<0.001)，进一步进行组间两两比较的结果显示，0 d组的S1/S2显著低于1 d和2 d组，但是显著高于其余5组，并且差异均有统计学意义(P<0.05)；1 d组的S1/S2显著高于其余7组，并且差异亦均有统计学意义(P<0.05)；2～7 d组的S1/S2呈逐渐下降趋势，这6组的S1/S2两两比较，差异均有统计学意义(P<0.05)。②8组新生儿安静时的D/S整体比较，差异有统计学意义(F＝15.6，P<0.001)。进一步进行组间两两比较的结果显示，0 d组的D/S显著低于其余7组，并且差异均有统计学意义(P<0.05)；1 d组的D/S高于0 d组，但是显著低于其余6组，差异亦均有统计学意义(P<0.05)；2～7 d组的D/S组间两两比较，差异均无统计学意义(P>0.05)。③8组新生儿哭泣后的S1/S2整体比较，差异有统计学意义(χ2＝7.8，P<0.001)，进一步进行组间两两比较的结果显示，0～2 d组的S1/S2组间两两比较，差异均无统计学意义(P>0.05)，但是0～2 d组的S1/S2均显著低于3～7 d组，并且差异均有统计学意义(P<0.05)。④8组新生儿哭泣后的D/S和CCCTS分别整体比较，差异均有统计学意义(F＝3.2，P＝0.002；χ2＝8.9，P<0.001)。对D/S和CCCTS进行组间两两比较的结果显示，0 d组均显著低于其余7组，并且差异均有统计学意义(P<0.05)；但是其余7组组间分别两两比较，差异均无统计学意义(P>0.05)。⑤0 d组新生儿安静时和哭泣后的S1/S2组内比较，差异无统计学意义(P>0.05)；但是其余7组则显著低于同组新生儿哭泣后的S1/S2，并且差异均有统计学意义(P<0.001)。⑥8组新生儿安静时的D/S均显著高于组内新生儿哭泣后的D/S，并且差异均有统计学意义(P<0.001)。⑦纳入研究新生儿安静时的S1/S2与D/S呈负相关关系(rs＝－0.1，P<0.001)。⑧对纳入研究新生儿安静时D/S的影响因素进行多重线性逐步回归分析的结果显示，新生儿日龄越大、母亲孕次越少及新生儿性别为男性，其安静时的D/S越大。⑨本研究根据新生儿PCGET检测结果，计算出不同日龄正常、足月的出生早期新生儿安静时和哭泣后的CCR各项指标95%参考值范围。

结论

通过PCGET检测建立正常、足月的出生早期新生儿CCR评估体系，或许可为我国针对这类新生儿的心脏保健，提供理论依据。

关键词: 心音, 心肌收缩, 心力储备, 因素分析，统计学, 婴儿，新生
Objective

To measure and evaluate the cardiac contractility reserve (CCR) in normal and full term early newborns with 0-7-day age by phonocardiogram exercise test (PCGET).

Methods

From January 1, 2013 to January 1, 2015, a total of 1 797 normal and full term early newborns were included into this study. They were classified into eight groups (0-7 d groups) according to the day-age (n=192, 257, 270, 214, 232, 212, 210, 210). The ratio of the amplitude of the first heart sound and the amplitude of the second heart sound (S1/S2), the ratio of diastolic to systolic duration (D/S) and cardiac contractility change trend after stimulation (CCCTS) of these newborns all were measured and analyzed by perspective research method. The S1/S2 in quiet state and after crying and CCCTS after crying among 8 groups were compared by Kruskal-Wallis H rank test. The D/S in quiet state and after crying among 8 groups were compared by one-way ANOVA analysis, and least-significant difference (LSD) method was used to further comparison between different groups. The S1/S2 in quite state and after crying of each group was compared by Wilcoxon signed-rank test. The D/S in quite state and after crying of each group was compared by paired-samples t test. The relationship between S1/S2 and D/S in quite state was analyzed by Spearman rank correlation. Besides, the influencing factors of D/S in quite state were conducted by multiple linear stepwise regression. The study protocol was approved by the Ethical Review Board of Investigation in Human Beings of Chengdu Women′s and Children′s Central Hospital. Informed consent was obtained from participants′ guardians.

Results

① There was statistically significant difference in S1/S2 among 8 groups in quite state (χ2=847.5, P<0.001). Multiple comparison results showed the following results. The S1/S2 in 0 d group was lower than that of 1 d group and 2 d group, but higher than those of the other 5 groups, and all the differences were statistically significant (P<0.05). The S1/S2 in 1 d group was higher than those of the other 7 groups, and all the differences were statistically significant (P<0.05). And S1/S2 gradually decreased among 2-7 d groups, and all the differences among those 6 groups were statistically significant (P<0.05). ② There was statistically significant difference in D/S among 8 groups in quite state (F=15.6, P<0.001). Multiple comparison results showed the following results. The D/S in 0 d group was significantly lower than those of the other 7 groups, and all the differences were statistically significant (P<0.05). The D/S in 1 d group was higher than that of 0 d group, but lower than those of the other 6 groups, and all the differences were statically significant (P<0.05). There were no significant differences in the aspect of D/S among 2-7 d groups (P>0.05). ③ There was statistically significant difference in S1/S2 among 8 groups after crying (χ2=7.8, P<0.001). Multiple comparison results showed the following results. There were no significant differences in the aspects of S1/S2 among 0-2 d groups (P>0.05). The S1/S2 in 0-2 groups all were significant lower than those of 3-7 d groups, and all the difference were statistically significant (P<0.05). ④ There were statistically significant differences in the aspects of D/S and CCCTS among 8 groups after crying (F=3.2, P=0.002; χ2=8.9, P<0.001). Multiple comparison results showed the following results. The D/S and CCCTS in 0 d group were lower than those of the other 7 groups, and all the differences were statistically significant (P<0.05). There were no significant differences in the aspects of D/S and CCCTS among 1-7 d groups (P>0.05). ⑤ The S1/S2 in 0 d group after crying was not significantly different from that in quiet time (P>0.05). But the S1/S2 in other 7 groups in quite state were all lower than those after crying, and all the differences were statistically significant (P<0.001). ⑥ The D/S in 8 groups in quite state all were higher than those after crying, and all the differences were statistically significant (P<0.001). ⑦ The S1/S2 in quite state of all newborns in this study were negatively correlated with the D/S (rs=-0.1, P<0.001). ⑧ The multiple linear stepwise regression results showed that the day-age of newborns, gravidities of pregnant women and gender of newborns were the influencing factors of D/S in quite state, and the newborns with older day-age, fewer gravidities of pregnant women, and boy had higher D/S. ⑨ The 95% reference ranges of CCR indexes in normal and full term early newborns were calculated based on PCGET results in this study.

Conclusions

A new evaluation system for CCR in normal and full term early newborns which is based on heart sound signal analysis has established. This evaluation system could provide the credentials for the heart health care of normal and full term early newborns in our country.

Key words: Heart sounds, Myocardial contraction, Cardiac contractility reserve, Factor analysis, statistical, Infant, newborn
表1 8组正常、足月的出生早期新生儿安静时的CCR各项指标比较
组别 例数 S1/S2[M(P25～P75)] D/S(±s)
0 d组 192 1.1(0.7～2.4) 1.0±0.2
1 d组 257 1.9(1.5～2.5) 1.1±0.2
2 d组 270 1.1(0.8～1.5) 1.2±0.2
3 d组 214 0.9(0.6～1.2) 1.2±0.3
4 d组 232 0.8(0.6～1.0) 1.2±0.2
5 d组 212 0.6(0.4～0.7) 1.2±0.2
6 d组 210 0.5(0.3～0.7) 1.2±0.2
7 d组 210 0.4(0.3～0.6) 1.2±0.2
检验值 ? χ2＝847.5 F＝15.6
P值 ? <0.001 <0.001
表2 8组正常、足月的出生早期新生儿安静时的S1/S2和D/S 95%参考值范围
组别 例数 S1/S2 D/S
P2.5 P97.5 －1.96 s ＋1.96 s
0 d组 192 0.2 7.8 0.7 1.3
1 d组 257 0.8 4.2 0.7 1.6
2 d组 270 0.4 2.6 0.7 1.7
3 d组 214 0.3 2.0 0.6 1.7
4 d组 232 0.3 2.0 0.7 1.7
5 d组 212 0.2 1.2 0.8 1.6
6 d组 210 0.2 0.9 0.7 1.6
7 d组 210 0.2 1.2 0.7 1.6
表3 8组正常、足月的出生早期新生儿哭泣后的CCR各项指标比较
组别 例数 S1/S2[M(P25～P75)] D/S(±s) CCCTS[M(P25～P75)]
0 d组 192 1.3(0.8～2.3) 0.9±0.2 1.1(0.7～2.4)
1 d组 257 1.3(1.0～2.0) 1.0±0.2 1.3(1.0～1.8)
2 d组 270 1.4(1.0～1.9) 1.0±0.2 1.3(1.0～1.7)
3 d组 214 1.5(1.1～2.0) 1.0±0.2 1.3(1.0～1.8)
4 d组 232 1.5(1.1～2.0) 1.0±0.2 1.3(1.0～1.7)
5 d组 212 1.6(1.2～2.2) 1.0±0.2 1.3(1.1～1.7)
6 d组 210 1.6(1.2～2.2) 1.0±0.1 1.5(1.0～1.7)
7 d组 210 1.6(1.2～2.2) 1.0±0.1 1.4(1.2～1.7)
检验值 ? χ2＝7.8 F＝3.2 χ2＝8.9
P值 ? <0.001 0.002 <0.001
表4 8组正常、足月的出生早期新生儿哭泣后的CCR各项指标95%参考值范围
组别 例数 S1/S2 D/S CCCTS
P2.5 P97.5 －1.96 s ＋1.96 s P2.5 P97.5
0 d组 192 0.3 4.5 0.6 1.2 0.7 3.3
1 d组 257 0.6 3.3 0.6 1.4 0.6 3.0
2 d组 270 0.5 3.3 0.5 1.5 0.6 3.1
3 d组 214 0.6 4.3 0.6 1.4 0.7 2.7
4 d组 232 0.5 5.1 0.6 1.4 0.6 3.3
5 d组 212 0.6 3.6 0.6 1.4 0.7 2.8
6 d组 210 0.7 5.0 0.7 1.3 0.4 2.5
7 d组 210 0.8 2.9 0.7 1.3 0.8 2.9
表5 8组正常、足月的出生早期新生儿安静时和哭泣后的S1/S2组内比较[M(P25～P75)]
组别 例数 安静时的S1/S2 哭泣后的S1/S2 Z值 P值
0 d组 192 1.1(0.7～2.4) 1.3(0.8～2.3) －1.0 0.320
1 d组 257 1.9(1.5～2.5) 1.3(1.0～2.0) －8.6 <0.001
2 d组 270 1.1(0.8～1.5) 1.4(1.0～1.9) －5.1 <0.001
3 d组 214 0.9(0.6～1.2) 1.5(1.1～2.0) －10.5 <0.001
4 d组 232 0.8(0.6～1.0) 1.8(1.2～2.3) －12.4 <0.001
5 d组 212 0.6(0.4～0.7) 1.6(1.2～2.2) －12.6 <0.001
6 d组 210 0.5(0.3～0.7) 1.3(1.0～2.7) －12.6 <0.001
7 d组 210 0.4(0.3～0.6) 1.6(1.2～2.2) －12.5 <0.001
表6 8组正常、足月的出生早期新生儿安静时和哭泣后的D/S组内比较(±s)
组别 例数 安静时的D/S 哭泣后的D/S t值 P值
0 d组 192 1.0±0.2 0.9±0.2 8.4 <0.001
1 d组 257 1.1±0.2 1.0±0.2 7.5 <0.001
2 d组 270 1.2±0.2 1.0±0.2 12.2 <0.001
3 d组 214 1.2±0.3 1.0±0.2 10.6 <0.001
4 d组 232 1.2±0.2 1.0±0.2 6.9 <0.001
5 d组 212 1.2±0.2 1.0±0.2 12.6 <0.001
6 d组 210 1.2±0.2 1.0±0.1 13.1 <0.001
7 d组 210 1.2±0.2 1.0±0.4 5.7 <0.001
表7 正常、足月的出生早期新生儿安静时的D/S影响因素多重线性逐步回归分析的变量含义及其赋值
自变量/因变量 变量名 赋值
D/S y 表示新生儿安静时的D/S
新生儿日龄 x1 表示新生儿日龄
母亲是否合并心脑血管疾病 x2 x2＝1表示母亲合并心脑血管疾病，x2＝2表示母亲未合并心脑血管疾病
母亲年龄 x3 表示母亲年龄
母亲孕次 x4 表示母亲孕次
母亲产次 x5 表示母亲产次
母亲分娩孕龄 x6 表示母亲分娩时孕龄
分娩方式 x7 x7＝1表示自然分娩，x7＝2表示剖宫产术分娩，x7＝3表示阴道分娩产钳助产
新生儿性别 x8 x8＝1表示新生儿性别为男性，x8＝2表示新生儿性别为女性
出生体重 x9 表示新生儿出生体重
出生身长 x10 表示新生儿出生身长
表8 正常、足月的出生早期新生儿安静时的D/S影响因素多重线性逐步回归分析结果
变量 偏回归系数 偏回归系数标准误 标准化偏回归系数 t值 P值 95%CI
常数项 0.395 0.423 — 0.933 0.351 －0.436～1.225
新生儿日龄(x1) 0.025 0.004 0.2 5.853 <0.001 0.016～0.033
母亲孕次(x4) －0.019 0.006 －0.1 －3.336 0.001 －0.032～0.008
新生儿性别(x8) －0.037 0.014 －0.1 －2.720 0.007 －0.065～0.010
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