Neonatal generalized edema

Introduction Edema is one of the common symptoms in the neonatal period. Its outstanding performance is weight gain, which is caused by excessive accumulation of body fluids in the interstitial space, causing swelling of the whole body or part. Systemic edema at birth is called fetal edema (hydrops fetalis), often accompanied by serous effusion. Edema caused by various reasons after birth is called neonatal edema, more common in the limbs, back, face and perineum. Divided into immune and non-immune fetal edema, the former is more common in recent years, due to the application of anti-Rh D serum to prevent Rh blood group incompatibility hemolytic disease, the incidence has decreased, non-immune has become the main cause.

Cause

(1) Causes of the disease

Including the immune and non-immune fetal edema, the former is more common in recent years. In recent years, the use of anti-Rh D serum to prevent Rh blood group incompatibility, the incidence has decreased, non-immune has become the main cause.

Cardiovascular disease

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 Heart 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 is increased and edema occurs.

2. Severe anemia

Immune fetal edema caused by Rh blood group incompatibility, in addition to non-immune edema in the southeast and southwestern provinces such as Guangdong, Guangxi, Sichuan due to G-6-PD deficiency, alpha thalassemia. Fetal-mother or fetal-fetal transfusion can also be caused.

3. Plasma protein is low

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.

4. Other

Pulmonary 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. A few can not find the cause, such as arrhythmia failed to find in time.

(two) pathogenesis

1. Intravascular and extracorporeal fluid exchange disorders

Under normal conditions, there is a dynamic balance between blood and interstitial fluid, which is determined by a variety of factors. Among them, it is mainly affected by vascular permeability and osmotic pressure. The capillaries of the whole body have a certain permeability, and substances such as water, inorganic salts, glucose, and urea can pass through the blood vessel wall quite freely, and colloidal substances such as plasma proteins of macromolecules are not easily transmitted. When blood flows into the capillaries, the arterial end filters out more force than the reflux, and the crystalline material in the plasma enters the interstitial space with the water, forming an interstitial fluid. The factors that prevent liquid from being absorbed back into the blood from the interstitial space are the hydrostatic pressure (capillary pressure) in the capillaries and the colloid osmotic pressure of the interstitial fluid. At the venous end, the flow rate is greater than the filtered amount, and most of the intercrystalline fluid crystals return to the blood as the water passes through the capillary wall. The factors that prevent fluid from being filtered out of the blood vessels and 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. Another part of the interstitial fluid flows back into the blood vessels through the lymphatics. The factors common to clinical internal and external fluid exchange disorders are:

(1) Increased capillary pressure: In the case of systemic or local blood circulation disorders, 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 production exceeds the limit of lymphatic reflux ability, the sputum accumulates in the interstitial space to form edema. This condition 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 lowered, the intravascular water oozing increases, the reflux decreases, and the interstitial fluid accumulates too much to form edema. The level of plasma colloid osmotic pressure depends on plasma proteins. Edema can occur when the total plasma protein is less than 4.5 g%, albumin is less than 2 g%, or the ratio of albumin to globulin is inverted. This is the case with congenital nephrotic syndrome, cirrhosis and dystrophic edema.

(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. Factors that cause increased capillary wall permeability are:

1 tissue hypoxia, metabolic disorders, increased acid 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 from the interstitial space to the blood vessel, and the other part returns from the lymph. Due to the permeability of the capillary lymphatic wall, the proteins in the interstitial fluid can pass freely. About 100 g of protein is filtered from the blood to the interstitial fluid every day by normal people, and about 95% of them are returned to the blood through the thoracic duct through the lymphatic vessels. When the lymphatic system is compressed, such as tumors, congenital hereditary diseases, etc., the interstitial fluid can not be returned to the blood through the lymphatic vessels, and the interstitial fluid colloid osmotic pressure is increased, resulting in edema. Edema caused by congestive heart failure, cirrhosis, ascites, etc., is related to the rate at which lymph fluid production exceeds the rate of return to the vein.

(5) Intracellular and extracellular fluid sodium excretion disorder: Under normal circumstances, the intracellular and extracellular fluids remain in balance, mainly due to the action of crystal osmotic pressure, which is affected by the concentration of potassium and sodium ions. Sodium ion is the main component of the extracellular fluid, and potassium ion is the main component of the intracellular fluid. Sodium ions are the main factors affecting the balance of fluid inside and outside the cell. The osmotic pressure of the extracellular fluid is mainly determined by the sodium ion concentration. When sodium is retained in the body, in order to maintain the balance of the internal and external fluids, water is retained by the intake of water or the kidneys, and the water is retained, resulting in an increase in the amount of extracellular fluid and edema. Clinically seen edema caused by heart and kidney disease, that is, water and sodium retention.

2. Fluid discharge disorder

The excretion of body fluids mainly passes through the kidneys. The regulation of water and salt balance by the kidney is accomplished by glomerular filtration and tubular reabsorption. The neonatal glomerular filtration solution is 14L per day, and 80 to 100 ml is discharged from the urinary tract. It can be seen that 99% of the filtrate is reabsorbed by the proximal convoluted tubule, the medullary canal, the distal convoluted tubule and the collecting duct. When the function of these parts is impaired, edema occurs.

In the neonatal period, kidney development is not mature, 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, and edema is more likely to occur.

an examination

Related inspection

ECG renal function test

Physiological

The total amount of body fluid in 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, and even finger indentations may occur. It is obvious in the back of the hand, the back of the foot and the eyelids. It is associated with lower levels of atrial natriuretic peptide in the blood circulation of newborns, especially premature infants, affecting the role of renal sodium excretion and water excretion. As the physiological weight decreases, the excess fluid is discharged and the edema naturally disappears.

2. Anemia

Severe anemia caused by various causes can cause edema after the birth of the newborn, and the degree of edema and anemia may not be completely parallel. Newborns especially have less vitamin E storage, faster growth after birth, vitamin E needs a large amount, and edema in the late neonatal period when the deficiency occurs. The following abdomen, vulva and thigh are more obvious, and the anemia is more obvious after 6-8 weeks. At this time, reticulocytes are increased, platelets are increased or condensed red blood cells appear. After treatment with vitamin E, the amount of urine increased and the edema quickly disappeared.

3. Cardiogenic

All kinds of severe arrhythmia, myocarditis, congenital heart disease and fibroelastosis can cause cardiac dysfunction and edema in the neonatal period. The performance is difficult to feed, weight gain (80 to 100g per day), sweating on the face when eating milk, shortness of breath, rapid heart rate, low heart sounds, galloping, weak pulse, big heart. Congenital heart disease can have cyanosis and heart murmur. Both lungs can smell fine and wet at the end of inhalation. The liver is progressively enlarged. Edema begins in front of the eyelids and tibia. In severe cases, the edema is aggravated and there is oliguria or anuria. The limbs have low tension. The ends of the limbs are cool. X-ray examination showed that the heart was enlarged, the heartbeat was weakened, the lung texture was increased and thickened, and the electrocardiogram often had various arrhythmia (such as pre-systolic contraction and tachycardia), accompanied by intra- or indoor conduction delay, QRS low voltage, ST The segment moves down, the T wave is low or inverted, and an abnormal Q wave can appear in the V4RV1 lead. Echocardiography can suggest left ventricular enlargement and ventricular dysfunction. Serological examination showed that aspartate transferase, aspartate aminotransferase, lactate dehydrogenase and phosphocreatine kinase and their isoenzymes were elevated to varying degrees.

4. Renal origin

Neonatal, especially premature infants, have immature renal function and low glomerular filtration rate. For example, sodium intake or excessive intravenous fluid volume is prone to edema. Others such as congenital nephropathy, various urinary malformations and renal vein thrombosis can also cause edema. Most congenital nephropathy has intrauterine asphyxia. After birth, there may be pale, abnormal crying, difficulty in breathing, edema, and edema. In severe cases, fluid can be produced in the chest and abdominal cavity. Urine examination In addition to a large amount of proteinuria, common red blood cells under the microscope, mild amino acid urine and diabetes can also be seen. Hypoproteinemia, serum albumin and gamma globulin decreased. Alpha 2-lipoprotein rises. Cholesterol may or may not increase. Uremia can occur in the advanced stage, and blood pressure is not high. Maternal pregnancy often combined with pregnancy poisoning, premature delivery. The placenta is large, often exceeding 25% of the baby's weight, up to 40%, and the vast majority die from infection within 1 year after birth. There are also reports of successful kidney transplantation.

5. Hypoproteinemia

Edema can be caused when the plasma protein is lower than 40 g/L or albumin is lower than 20 g/L. Found in liver, kidney and other diseases. Its clinical manifestations are edema, which is more common in the face, eyelids, lower limbs, upper limbs, neck and ankles. It is a depressed edema, and edema can be aggravated with changes in body position. The skin is cold, pale, slower in heart rate, and reduced in urine output. Plasma total protein and albumin are reduced. Hemoglobin and red blood cells are reduced, and urine is normal or slightly abnormal.

6. Neonatal scleredema

More common in the cold season, and related to frostbite, infection, hypoxemia and other factors, due to increased capillary permeability, interstitial fluid increased, showing edema. It can also be caused by subcutaneous tissue saturated fatty acid coagulation, which is non-concave edema. The hard swelling begins in the calf and later spreads to the buttocks, torso, and face. The hard swollen area is accompanied by depressed edema, the skin is cold, and it is dark red. In severe cases, it is blue-purple. Low body temperature, weak crying, weak sucking or refusal to eat. Less physical activity. The prevalence of preterm 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. Neonatal edema can occur in adrenal hyperfunction, neurohypophyseal vasopressin or adrenocortical aldosterone metabolism disorders. Sporadic dysplasia occurs in the late neonatal period, there may be mucinous edema around the eyelids, and there is no depression. The skin can be patterned. Low body temperature, lethargy, less crying, difficulty feeding, slow sucking, and even refusal to eat, bloating, constipation. Poor breathing. There is a buzz. Physiological jaundice is prolonged. The tendon reflex muscle contracted normally and the relaxation was slower. X-ray examination showed dysplasia of the distal femur and proximal humerus. Serum protein binding to iodine is lower, and those without thyroid are lower. Serum thyrotropin radioimmunoassay can be diagnosed if the serum thyrotropin concentration is greater than 20 microunits per milliliter at 72 hours of birth. Serum T3, T4 concentrations are reduced or at the marginal level. The thyroid iodine absorption rate is significantly reduced. Blood sugar and serum alkaline phosphatase are reduced.

8. Hypocalcemia

It 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 and increased permeability. Calcium ions are also closely related to the permeability of blood vessels, which can also increase capillary permeability and enter the subcutaneous tissue space. Edema can disappear quickly after supplementation with calcium. The disease is more common in premature infants, full-term children or mothers with diabetes or pregnancy-induced hypertension. Symptoms often occur 3 to 5 days after birth, which is characterized by varying degrees of edema on the sides of the legs and depression. Edema can also occur on the extremities of the extremities, which is limited. At the same time accompanied by low calcium convulsions, blood calcium is generally lower than 7.5mg / dl, blood phosphorus is normal or elevated, serum alkaline phosphatase is normal. The amount of albumin is high and the gamma globulin is low. Electrocardiogram examination may have prolonged QT interval, and occasionally conduction block and bradycardia. The prognosis of this disease is good, the course of disease is 3 to 7 days, and it can be recovered naturally.

9. Idiopathic edema

The cause is unknown, the general condition of the child is good, and the edema can naturally subside, called idiopathic edema.

According to the history, symptoms, signs and hematuria tests, the cause of neonatal edema can be diagnosed. For some rare causes, special immune, endocrine, and chromosome tests are required. Fetal edema should be diagnosed before delivery, and the thickness of the fetus can be measured from B-ultrasound. For example, 5mm or placenta enlargement, serous effusion can be used for preliminary diagnosis. Cardiac malformations can also be found by B-ultrasound, or fetal blood type, blood group immune substances, bilirubin, karyotype or DNA, and hemoglobin electrophoresis can be detected by amniotic fluid to help diagnose and treat the cause.

Differential diagnosis

According to the history, symptoms, signs and hematuria tests, the cause of neonatal edema can be diagnosed. For some rare causes, special immune, endocrine, and chromosome tests are required. Fetal edema should be diagnosed before delivery, and the thickness of the fetus can be measured from B-ultrasound. For example, 5mm or placenta enlargement, serous effusion can be used for preliminary diagnosis. Cardiac malformations can also be found by B-ultrasound, or fetal blood type, blood group immune substances, bilirubin, karyotype or DNA, and hemoglobin electrophoresis can be detected by amniotic fluid to help diagnose and treat the cause.

1. Lymphedema: mainly seen in idiopathic hereditary lymphedema, also known as congenital genetic rubber disease or Milroy disease. Lymphatic reflux disorder due to peripheral lymphatic vessel expansion. Limb hypertrophy, fingerless indentation, more common in the lower limbs, asymmetry. Individuals can be combined with chylothorax and/or chylothorax.

2. Unilateral limb hypertrophy: for congenital dysplasia, single or unilateral limb hypertrophy, no other abnormalities.

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 appears, which is obvious in the back of the hand, the back of the foot and the eyelids. It is associated with lower levels of atrial natriuretic peptide in the blood circulation of newborns, especially premature infants, affecting the role of renal sodium excretion and water excretion. As the physiological weight decreases, the excess fluid is discharged and the edema naturally disappears.

2. Anemia: Severe anemia caused by various causes can cause edema after the birth of the newborn, and the degree of edema and anemia may not be completely parallel. Newborns especially have less vitamin E storage, faster growth after birth, vitamin E needs a large amount, and edema in the late neonatal period when the deficiency occurs. The following abdomen, vulva and thigh are more obvious, and the anemia is more obvious after 6-8 weeks. At this time, reticulocytes are increased, platelets are increased or condensed red blood cells appear. After treatment with vitamin E, the amount of urine increased and the 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. The performance is difficult to feed, weight gain (80 to 100g per day), sweating on the face when eating milk, shortness of breath, rapid heart rate, low heart sounds, galloping, weak pulse, big heart. Congenital heart disease can have cyanosis and heart murmur. Both lungs can smell fine wet and wet rales at the end of inhalation. The liver is progressively enlarged. Edema begins in front of the eyelids and tibia. In severe cases, the edema is aggravated and there is oliguria or anuria. The limbs have low tension. The ends of the limbs are cool. X-ray examination showed that the heart was enlarged, the heartbeat was weakened, the lung texture was increased and thickened, and the electrocardiogram often had various arrhythmia (such as pre-systolic contraction and tachycardia), accompanied by intra- or indoor conduction delay, QRS low voltage, ST The segment moves down, the T wave is low or inverted, and an abnormal Q wave can appear in the V4RV1 lead. Echocardiography can suggest left ventricular enlargement and ventricular dysfunction. Serological examination showed that aspartate transferase, aspartate aminotransferase, lactate dehydrogenase and phosphocreatine kinase and their isoenzymes were elevated 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 volume is prone to edema. Others such as congenital nephropathy, various urinary malformations and renal vein thrombosis can also cause edema. Most congenital nephropathy has intrauterine asphyxia. After birth, there may be pale, abnormal crying, difficulty in breathing, edema, and edema. In severe cases, fluid can be produced in the chest and abdominal cavity. Urine examination In addition to a large amount of proteinuria, common red blood cells under the microscope, mild amino acid urine and diabetes can also be seen. Hypoproteinemia, serum albumin and gamma globulin decreased. Alpha 2-lipoprotein rises. Cholesterol may or may not increase. Uremia can occur in the advanced stage, and blood pressure is not high. Maternal pregnancy often combined with pregnancy poisoning, premature delivery. The placenta is large, often exceeding 25% of the baby's weight, up to 40%, and the vast majority die from infection within 1 year after birth. There are also reports of successful kidney transplantation.

5. Hypoproteinemia: When the plasma protein is lower than 40g / L or albumin is less than 20g / L, it can cause edema. Found in liver, kidney and other diseases. Its clinical manifestations are edema, which is more common in the face, eyelids, lower limbs, upper limbs, neck and ankles. It is a depressed edema, and edema can be aggravated with changes in body position. The skin is cold, pale, slower in heart rate, and reduced in urine output. Plasma total protein and albumin are reduced. Hemoglobin and red blood cells are reduced, and urine is normal or slightly abnormal.

6. Neonatal scleredema: more common in the cold season, and related to frostbite, infection, hypoxemia and other factors, due to increased capillary permeability, interstitial fluid increased, showing edema. It can also be caused by subcutaneous tissue saturated fatty acid coagulation, which is non-concave edema. The hard swelling begins in the calf and later spreads to the buttocks, torso, and face. The hard swollen area is accompanied by depressed edema, the skin is cold, and it is dark red. In severe cases, it is blue-purple. Low body temperature, weak crying, weak sucking or refusal to eat. Less physical activity. The prevalence of preterm 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 and constipation. Neonatal edema can occur in adrenal hyperfunction, neurohypophyseal vasopressin or adrenocortical aldosterone metabolism disorders. Sporadic dysplasia occurs in the late neonatal period, there may be mucinous edema around the eyelids, and there is no depression. The skin can be patterned. Low body temperature, lethargy, less crying, difficulty feeding, slow sucking, and even refusal to eat, bloating, constipation. Poor breathing. There is a buzz. Physiological jaundice is prolonged. The tendon reflex muscle contracted normally and the relaxation was slower. X-ray examination showed dysplasia of the distal femur and proximal humerus. Serum protein binding to iodine is lower, and those without thyroid are lower. Serum thyrotropin radioimmunoassay can be diagnosed if the serum thyrotropin concentration is greater than 20 microunits per milliliter at 72 hours of birth. Serum T3, T4 concentrations are reduced or at the marginal level. The thyroid iodine absorption rate is significantly reduced. Blood sugar and serum alkaline phosphatase are reduced.

8. Hypocalcemia: It 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 and increased permeability. Calcium ions are also closely related to the permeability of blood vessels, which can also increase capillary permeability and enter the subcutaneous tissue space. Edema can disappear quickly after supplementation with calcium. The disease is more common in premature infants, full-term children or mothers with diabetes or pregnancy-induced hypertension. Symptoms often occur 3 to 5 days after birth, which is characterized by varying degrees of edema on the sides of the legs and depression. Edema can also occur on the extremities of the extremities, which is limited. At the same time accompanied by low calcium convulsions, blood calcium is generally lower than 7.5mg / dl, blood phosphorus is normal or elevated, serum alkaline phosphatase is normal. The amount of albumin is high and the gamma globulin is low. Electrocardiogram examination may have prolonged QT interval, and occasionally conduction block and bradycardia. The prognosis of this disease is good, the course of disease is 3 to 7 days, and it can be recovered naturally.

9. Idiopathic edema: The cause is unknown, the general condition of the child is good, and the edema can naturally subside, called idiopathic edema.

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