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Division of PerinatologyDepartment of Child Health Medical School
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Department of Child Health Medical SchoolUniversity of Sumatera Utara
Gestational age can be determined:Date of last menstrual period
Gestational age can be determined:Date of last menstrual periodDate of first fetal activity (16-18 weeks)First reported heart sound (10-12 weeks)Date of first fetal activity (16-18 weeks)First reported heart sound (10-12 weeks)First reported heart sound (10-12 weeks)USG examination (before 20 weeks)First reported heart sound (10-12 weeks)USG examination (before 20 weeks)AAP recommends:- birth weightAAP recommends:- birth weight- gestational age- gestational age
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CLASSIFICATIONCLASSIFICATIONCLASSIFICATIONCLASSIFICATION
Preterm (< 37 weeks)Term (37-41 weeks)Preterm (< 37 weeks)Term (37-41 weeks)Term (37 41 weeks)Postterm (>42 weeks)Term (37 41 weeks)Postterm (>42 weeks)
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CLASSIFICATIONCLASSIFICATIONCLASSIFICATIONCLASSIFICATIONClassification based on a combination of features:
Small for gestational age (SGA)2 t d d d i ti b l th i ht
Classification based on a combination of features:Small for gestational age (SGA)
2 t d d d i ti b l th i ht- 2 standard deviation below the mean weightfor GA
- or below the 10th percentile
- 2 standard deviation below the mean weightfor GA
- or below the 10th percentile- or below the 10 percentile- common in mother with hypertention,
preeclampsia, or who smoke
- or below the 10 percentile- common in mother with hypertention,
preeclampsia, or who smokep p ,- associated with TORCH, infection,
chromosomal abnormalities, congenital f
p p ,- associated with TORCH, infection,
chromosomal abnormalities, congenital f
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malformationmalformation
CLASSIFICATIONCLASSIFICATIONCLASSIFICATIONCLASSIFICATIONAppropriate for gestational age (AGA)Large for gestational age (LGA)Appropriate for gestational age (AGA)Large for gestational age (LGA)- 2 standard deviation above the mean
weight for GA - 2 standard deviation above the mean
weight for GA - or above 90 percentile- in infant of diabetic mothers
B k i h’ d i i ll l
- or above 90 percentile- in infant of diabetic mothers
B k i h’ d i i ll l- Beckwith’s syndrome, constitutionally largeinfants with large parents, hydrops fetalis
- Beckwith’s syndrome, constitutionally largeinfants with large parents, hydrops fetalis
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Rapid delivery room assessment- creases in the sole of the footRapid delivery room assessment- creases in the sole of the footcreases in the sole of the foot- size of the breast nodule
t f th l h i
creases in the sole of the foot- size of the breast nodule
t f th l h i- nature of the scalp hair- cartilaginous development of the ear lobe- nature of the scalp hair- cartilaginous development of the ear lobe- scrotal rugae and testicular descent in
males- scrotal rugae and testicular descent in
males6
METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
New Ballard Score- The score span from 10 (20 weeks New Ballard Score- The score span from 10 (20 weeks p (
gestation) to 50 (correlating with 44 weeks gestation)
p (gestation) to 50 (correlating with 44 weeks gestation)
- Best performed at <12h of age for infant <26 weeks gestation
- Best performed at <12h of age for infant <26 weeks gestation
- If infant > 26 weeks gestation, no optimal age of examination up to 96h
- If infant > 26 weeks gestation, no optimal age of examination up to 96h
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Accuracy- accurate whether the infant is sickAccuracy- accurate whether the infant is sickaccurate whether the infant is sickor well to within 2 weeks of GAO ti t GA b 2 4 d i
accurate whether the infant is sickor well to within 2 weeks of GAO ti t GA b 2 4 d i- Overestimates GA by 2-4 days ininfant 32-37 weeks gestation
- Overestimates GA by 2-4 days ininfant 32-37 weeks gestation
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Criteria- 6 neuromuscular criteriaCriteria- 6 neuromuscular criteria6 neuromuscular criteria
Passive tone is more useful thanti t i i di ti GA
6 neuromuscular criteriaPassive tone is more useful than
ti t i i di ti GAactive tone in indicating GA- 6 physical criteria
active tone in indicating GA- 6 physical criteria
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Procedures- administered twice by two differentProcedures- administered twice by two differenty
examination- data are entered on the chart
yexamination
- data are entered on the chartdata are entered on the chart- two part examination: neuromuscular
and physical maturity
data are entered on the chart- two part examination: neuromuscular
and physical maturityand physical maturity- 12 scores are totaled
and physical maturity- 12 scores are totaled
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
- maturity rating is expressed in weeks ofgestation
- maturity rating is expressed in weeks ofgestationg
- Part 2 of the form used to plotgestational assesment againts length
g- Part 2 of the form used to plot
gestational assesment againts lengthgestational assesment againts length,height, and head circumference todetermine whether the infant is SGA
gestational assesment againts length,height, and head circumference todetermine whether the infant is SGAdetermine whether the infant is SGA,AGA, or LGA
L b h h t
determine whether the infant is SGA,AGA, or LGA
L b h h t11
Lubchenco chartsLubchenco charts
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Neuromuscular maturityPosture
Neuromuscular maturityPosture- Score 0 if the arms and legs are
extended- Score 0 if the arms and legs are
extended- Score 1 if has beginning flexion of the
knees and hips with arm extended- Score 1 if has beginning flexion of the
knees and hips with arm extended- determined the other score based on the
diagram- determined the other score based on the
diagram
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Square window- Flex the hand on the forearm betweenSquare window- Flex the hand on the forearm betweenthe thumb and index finger of theexaminer.the thumb and index finger of theexaminer.
- Applay sufficient pressure to achieve asmuch as flexion as possibleVi ll h l b h
- Applay sufficient pressure to achieve asmuch as flexion as possibleVi ll h l b h- Visually measure the angle between thehypothenar eminence and ventral aspect of thef
- Visually measure the angle between thehypothenar eminence and ventral aspect of thef
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forearm.forearm.
METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Arm recoil- flex the forearms for 5 s then graspArm recoil- flex the forearms for 5 s then graspflex the forearms for 5 s, then grasp
the hand and fully extend the armd l
flex the forearms for 5 s, then graspthe hand and fully extend the arm
d land release.- If full flexion score 4
and release.- If full flexion score 4
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Popliteal angle- Hold the thigh in the knee-chest positionPopliteal angle- Hold the thigh in the knee-chest positiong p
with the left index finger and the thumbsupporting the knee
g pwith the left index finger and the thumbsupporting the kneesupporting the knee
- Extended the leg by gentle pressurefrom the right index finger behind the
supporting the knee- Extended the leg by gentle pressure
from the right index finger behind thefrom the right index finger behind theanklefrom the right index finger behind theankle
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Scarf Sign- Take the infant’s hand and try to put itScarf Sign- Take the infant’s hand and try to put it
around the neck posteriorly as far as possible over the opposite shoulderaround the neck posteriorly as far as possible over the opposite shoulder
Heel to ear- Keeping the pelvis flat on the tableHeel to ear- Keeping the pelvis flat on the tablep g p- Take foot and try to put it as close to the
head as possible without forcing it
p g p- Take foot and try to put it as close to the
head as possible without forcing it17
head as possible without forcing ithead as possible without forcing it
METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Physical maturitySkin
Physical maturitySkin- Extremly premature: sticky, transparent
skin score -1- Extremly premature: sticky, transparent
skin score -1Lanugo hairPlantar surfaceLanugo hairPlantar surface- measure foot leghth from the tip of the
great toe to the back of the heel- measure foot leghth from the tip of the
great toe to the back of the heel
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Breast- palpate any breast tissueBreast- palpate any breast tissueEye and ear- loosely fused eyelids: closed but gentleEye and ear- loosely fused eyelids: closed but gentle
traction opens them- Tightly fused eyelids: inseperable by
traction opens them- Tightly fused eyelids: inseperable by
gentle tractionGenitalia
gentle tractionGenitalia
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28 weeks” gestation :little cartilago pliable
36 weeks to term gestation : firm ear, well-formed marginlittle cartilago, pliable firm ear, well formed margin
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28 weeks’ gestation :No breast tissue, areola barely visible
32 weeks’ gestation :visible areola, little breast tissue
36 weeks gestation :well-defined areola, breast nodule
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breast nodule
Genitalia MaleGenitalia - Male
28 weeks’ gestation : 36 weeks to term gestation :28 weeks gestation :testis high in scrotum
36 weeks to term gestation : testis well descended, increased scrotal pigmentation
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F t lFoot sole creasescreases
32 weeks’ gestation : 36 weeks’ to term gestation :creases in anterior one third
36 weeks to term gestation : creases over the majority of the sole
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Direct ophthalmoscopy- Before 27 weeks: cornea is too opaque to
ll i li ti
Direct ophthalmoscopy- Before 27 weeks: cornea is too opaque to
ll i li tiallow visualization- After 34 weeks: atrophy of the vessels of
the lens occurs
allow visualization- After 34 weeks: atrophy of the vessels of
the lens occursthe lens occurs- Accurate determination: 27-34 weeks only
Reliable to 2 weeks
the lens occurs- Accurate determination: 27-34 weeks only
Reliable to 2 weeks- Reliable to 2 weeks- Must be performed within 48 h of birth
before vessels atrophy
- Reliable to 2 weeks- Must be performed within 48 h of birth
before vessels atrophy25
before vessels atrophybefore vessels atrophy
METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
- Grading systemGrade 4 (27-28 weeks): vessel cover the
- Grading systemGrade 4 (27-28 weeks): vessel cover the ( )entire anterior surface of the lens or the vessels meet in the center of the lens
( )entire anterior surface of the lens or the vessels meet in the center of the lensGrade 3 (29-30 weeks): vessels do not meet in the center but are close, central Grade 3 (29-30 weeks): vessels do not meet in the center but are close, central portion of the lens is not covered by vesselsportion of the lens is not covered by vessels
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METHODS OF DETERMININGMETHODS OF DETERMININGMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGEMETHODS OF DETERMINING POSTNATAL GESTATIONAL AGE
Grade 2 (31-32 weeks): vessels reach only to the middle-outer part of the lens, the Grade 2 (31-32 weeks): vessels reach only to the middle-outer part of the lens, the p ,central clear portion of the lens is largerGrade 1 (33-34 weeks): vessels are seen
p ,central clear portion of the lens is largerGrade 1 (33-34 weeks): vessels are seen Grade 1 (33 34 weeks): vessels are seen only at the periphery of the lensGrade 1 (33 34 weeks): vessels are seen only at the periphery of the lens
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