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Maternal D vitamini eksikliği ve preeklampsinin prematüre osteopenisi üzerine etkisi ve tübüler fosfor reabsorbsiyonunun osteopeni tanısındaki yeri

The effects of maternal vitamin D deficiency and preeclampsia upon the osteopenia of prematurity and the place of tubulary phosphorus reabsorption ratio concerning the diagnosis of osteopenia

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  1. Tez No: 293560
  2. Yazar: DUYGU BESNİLİ AÇAR
  3. Danışmanlar: DR. SULTAN KAVUNCUOĞLU
  4. Tez Türü: Tıpta Uzmanlık
  5. Konular: Çocuk Sağlığı ve Hastalıkları, Child Health and Diseases
  6. Anahtar Kelimeler: Belirtilmemiş.
  7. Yıl: 2011
  8. Dil: Türkçe
  9. Üniversite: Sağlık Bakanlığı
  10. Enstitü: İstanbul Kanuni Sultan Süleyman Eğitim ve Araştırma Hastanesi
  11. Ana Bilim Dalı: Çocuk Sağlığı ve Hastalıkları Ana Bilim Dalı
  12. Bilim Dalı: Belirtilmemiş.
  13. Sayfa Sayısı: 108

Özet

Bu çalışmada osteopeni riski taşıyan bebeklerin, maternal ve neonatal etkenler yönünden prospektif olarak incelenmesi, diğer tanı yöntemlerinin yanınında tübüler fosfor reabsorbsiyonu parametresinin etkinliğininin irdelenmesi amaçlandı.GEREÇ VE YÖNTEM:Bu çalışma Haziran 2009 - Mart 2011 tarihleri arasında T.C. Sağlık Bakanlığı Bakırköy Kadın Doğum ve Çocuk Hastalıkları Eğitim ve Araştırma Hastanesi'nde doğan, II. ve III. düzey yenidoğan yoğun bakım ünitelerinde yatan, 32 gebelik haftasından küçük ve/veya doğum ağırlığı 1500 gramın altındaki prematüre bebekler üzerinde prospektif olarak yapıldı.Annelerin yaşı, gebelik sayıları, gebelikte alınan kilo, düzenli takipte olup olmadıkları, vitamin desteği, antenatal steroid uygulaması, preeklampsi, D vitamini düzeyi çalışma formuna kaydedildi. Maternal risk faktörleri yönünden olgular gruplara ayrıldı. Grup I D vitamini eksikliği, Grup II preeklampsi, Grup III hem D vitamini eksikliği hem preeklampsi, Grup IV sorunsuz olan gebelerin prematüre bebekleri olarak dört grup belirlendi. Annelerden serum Ca, P, ALP ve 25- OH D vitamini çalışıldı.Bebeklerin postnatal birinci gününde serum Ca, P, ALP değerleri incelendi. Hastanede yattıkları dönemde geçirdikleri hastalıklar, yoğun bakımda kalış süreleri, mekanik ventilasyon ihtiyaçları, beslenme şekilleri, aldıkları ilaçlar ve vitamin desteği, kolestaz varlığı, TPN süreleri ve TPN'de verilen P süresi ve tam enteral beslenmeye geçiş yaşı ayrıntılı olarak çalışma formuna kaydedildi.Postnatal 40. haftasını dolduran olgular poliklinik kontrolüne çağrılarak yeniden muayene edildi. Kemik mineralizasyonunun değerlendirilmesinde; Ca, P, ALP, üre, kreatinin, GGT ölçümü için kan alındı. İdrar Ca, P ve tübüler fosfor reabsorbsiyonu düzeyleri için idrar örneği alındı.Tübüler fosfor reabsorbsiyonu (TRP) hesaplandı, TRP %95'in üzerindeki olgular osteopeni varlığı yönünden diğer parametrelerle birlikte değerlendirildi. Kemik mineralizasyonunun tayini için femur grafisi çekildi.BULGULAR:Maternal parametreler gruplar arasında değerlendirildiğinde; yaş, vitamin kullanım süresi, antenatal steroid uygulaması ve gebelikte geçirilen hastalıklar açısından anlamlı fark saptanmazken, grup IV'teki gebelerin anlamlı fazla kilo aldıkları saptandı. Prematürelerin demografik özellikleri incelendiğinde; Grup 1'de ortalama 30,10±2,38 GH'da 73 olgu, Grup II'de ortalama 29,89±2,58 GH'da 19 olgu, Grup III'te ortalama 30,13±2,42GH'da 31 olgu, Grup IV'te ortalama 29,8±2,30 GH'da 67 prematürenin yeraldığı görüldü. Doğum kilosu

Özet (Çeviri)

The purpose of the study was to evaluate the infants with risk of osteopenia of prematurity according to maternal and neonatal factors and to asses the diagnostic methods ancillary to tubulary phosporous reabsorption ratio.Subjects and MethodThis study was done prospectively between June 2009 - March 2011 on premature infants under 32 weeks of gestation and / or under 1500 grams birth weight born at T.C. Sağlık Bakanlığı Bakırköy Kadın Doğum ve Çocuk Hastalıkları Eğitim ve Araştırma Hastanesi and hospitalized in II. and III. level neonatal intensive care units.Mothers' age, number of previous pregnancies, weight gain from pregnancy, whether their pregnancy controlled regularly, use of medications and vitamins during pregnancy, antenatal steroid treatment and diseases contracted during pregnancy were surveyed and recorded to study form. Plasma levels of Ca, P, ALP, and 25 - OH vitamin D of mother were studied. Infants postnatal first day plasma Ca, P and ALP levels studied. The diseases contracted during inpatient treatment period, days spent in intensive care units, requirement of mechanical ventilation, nutrition route, drugs taken and vitamin supplementation, presence of cholestasis, days received total parenteral nutrition (TPN) and the amount of phosphorus received with TPN recorded.Subjects called to the outpatient clinics after postnatal 40 th week and clinicaly examined again. To assess the bone mineralization blood drawn to determine the blood levels of Ca, P, ALP, urea, creatinin, GGT. Urine collected to determine the levels of urinary Ca, P levels and tubular phosphorus reabsorption ratio. To assess bone mineralization femur-x ray graphy taken.ResultsMaternal parameters when compared between groups there was no statistically important difference with age, vitamin supplementation duration, antenatal steroid treatment and disease contracted during pregnancy but it was detected that pregnants in Group IV had statistically significant weight gain. When the demographic properties of premature infants evaluated; in the first group there was 73 subjects whose gestational age was between 25-32 weeks (mean 30,10±2,38) , in the second group there was 19 subjects whose gestational age was between 25-32 weeks (mean 29,89±2,58), in the third group there was 31 subjects whose gestational age was between 25-32 weeks (mean 30,13±2,42), in the fourth group there was 67 subjects whose gestational age was between 25-32 weeks (mean 29,8±2,30). The quantity of premature infants whose birthweight under 1000 gr was 14 in Group I, 5 in Group II, 8 in Group III and 18 in Group IV. In group 1 when the gender of 35 infant was female the other 38 was male; when 19 infants was delivered by vaginal route the other 54 was delivered by cesarean section, in Group II when the gender of 14 infant was female the other 5 was male; all of them was delivered by cesarean section, in Group III when the gender of 15 infant was female the other 16 was male; when 2 infants was delivered by vaginal route the other 29 was delivered by cesarean section, in Group IV when the gender of 28 infant was female the other 29 was male; when 17 infants was delivered by vaginal route the other 50 was delivered by cesarean section. When birthweight , birth length, head circumference and gestational ages were compared there were no statistically significant difference between four groups. When the modes of delivery was considered vaginal delivery rate in GroupI and Group IV and cesarean delivery rate in Group II and Group III was higher and it was statistically significant. When premature infants was compared according to the days spent in hospital, the days required mechanical ventilation and surfactant treatment, there was no statistically significant difference between groups. When the premature infants was compared taking account the acute term diseases of prematurity there was no statistically significant difference between groups. Considering the maternal biochemical parameters according to the levels of Ca and P there was no statistically significant difference between groups but ALP levels in Group I was statistically significantly higher than Group IV.When premature infants postnatal day 1 biochemical parameters evaluated calcium level of Group III was statistically significantly higher than Group I and 4, phosphorous level of Group II was statistically significantly lower than Group I and IV but there was no such difference when ALP considered. When the subjects 40 th weeks of pregnancy biochemical values compared with femur x-ray graphy and TRP ratios ,the subjects whose TRP ratio greater than %95 had ALP levels statistically significantly higher than the subjects with lower TRP ratios. There were no such relationship between TRP and Ca, P, femur x-ray graphy. When osteopenia detected subjects assessed according to maternal parameters there was no significant association between osteopenia and age, weight gain during pregnancy, antenatal steroid treatment, preeclampsia and blood vitamin D level. The osteopenia incidence of infants of pregnants who had taken multivitamins longer periods were statistically significantly lower. When the effects of the drugs the subjects had taken and the diseases they contracted on the osteopenia of prematurity assessed only aminophyllin treatment and indirect hyperbilirubinemia was important. When the subjects taking aminophyllin was evaluated gestational age and birthweight was statistically significantly lower. The results of the tubular reabsorption of phosphorus was performed with the coexistence of P and ALP. 6 out of 22 subjects whose TRP ratio %95 and over had a P level lower than 3.5mg/dL and ALP level over 400IU. The tests sensitivity and spesifity was detected as %27.27 and %82.74, respectively. The positive predictive value and negative predictive value seen as %17.15 and %89.68, respectively. TRP and femur X-ray graphy results were evaluated. 4 subjects out of subjects whose TRP ratio ? 95 had osteopenic changes at femur graphies. The tests sensitivity and spesifity was detected as %18.18 and %88.10 , respectively. The positive predictive value and negative predictive value seen as % 16.16 and %89.16, respectively.DiscussionIn our study we concluded that maternal risk factors vitamin Ddeficiency and/or preeclampsia was effective on the Ca and P metabolism of premature infants so detection of risk factors earlierand replacement of them and as early as starting balanced enteral feeding and shortening of TPN duration would prevent osteopenia development. Relationship between the acute term morbidities indirect hyperbilirubinemia and osteopenia must be considered and close pursuitof those infants is important. We think that tubulary phosphorus reabsorption ratio can be used as a ancillary test rather than primary test to the other diagnostic methods.

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