Prematurity: Complications Respiratory distress syndrome Bronchopulmonary dysplasia Apnea of...

Prematurity: ComplicationsPrematurity: Complications Respiratory distress syndromeRespiratory distress syndrome Bronchopulmonary dysplasiaBronchopulmonary dysplasia Apnea of prematurityApnea of prematurity Patent ductus arteriosusPatent ductus arteriosus Intraventricular hemorrhageIntraventricular hemorrhage Periventricular leukomalaciaPeriventricular leukomalacia Necrotizing enterocolitisNecrotizing enterocolitis SepsisSepsis AnemiaAnemia Retinopathy of prematurityRetinopathy of prematurity

Respiratory Distress Respiratory Distress SyndromeSyndrome

EtiologyEtiology Anatomic immaturity of the lungAnatomic immaturity of the lung

Increased interstitial and alveolar Increased interstitial and alveolar lung fluidlung fluid

Surfactant deficiencySurfactant deficiency

Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html

17Weeks

Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html

22Weeks

Courtesy of Professor Louis De Voshttp://www.ulb.ac.be/sciences/biodic/index.html

25Weeks

CXR: poor aeration, ground-glass CXR: poor aeration, ground-glass appearance, homogenous, air appearance, homogenous, air

bronchogramsbronchograms

Respiratory Distress Respiratory Distress SyndromeSyndrome

Management:Management: Prevention - antenatal steroidsPrevention - antenatal steroids

Positive pressure ventilationPositive pressure ventilation

OxygenOxygen

+/- Surfactant (requires intubation)+/- Surfactant (requires intubation)

Pressure (cmHPressure (cmH220)0)

Vol

um

e (m

l)V

olu

me

(ml)

Bronchopulmonary Bronchopulmonary DysplasiaDysplasia

Respiratory symptoms, x-ray Respiratory symptoms, x-ray abnormalities, and O2 req’t for > 28 d and abnormalities, and O2 req’t for > 28 d and persisting at 36 wks corrected GApersisting at 36 wks corrected GA

Pathophysiology: Disturbed alveolarization with increased

alveolar-to-capillary distance and decreased alveolar-to-capillary ration

Secondary to:• Lung inflammation• Mucociliary dysfunction• Airway narrowing• Hypertrophied airway smooth muscle• Alveolar collapse• Constriction of pulmonary vascular bed

Bronchopulmonary Bronchopulmonary DysplasiaDysplasia

Management:Management: Prevention: IM Vitamin A, CaffeinePrevention: IM Vitamin A, Caffeine NUTRITIONNUTRITION Oxygen +/- ventilationOxygen +/- ventilation +/- Diuretics+/- Diuretics +/- Steroids: systemic, inhaled+/- Steroids: systemic, inhaled +/- Bronchodilators+/- Bronchodilators

Prognosis:Prognosis: Increased respiratory illnesses in childhoodIncreased respiratory illnesses in childhood Decreased long-term lung functionDecreased long-term lung function BUT, fine in the playground by pre-school age (usually BUT, fine in the playground by pre-school age (usually

…)…)

Apnea of PrematurityApnea of Prematurity

Central, obstructive, or mixedCentral, obstructive, or mixed Majority of <32 weeksMajority of <32 weeks Treat with:Treat with:

Adequate positioningAdequate positioning OxygenOxygen Methylxanthines (i.e. Caffeine)Methylxanthines (i.e. Caffeine) CPAPCPAP Ventilation if necessaryVentilation if necessary

Patent ductus arteriosusPatent ductus arteriosus Seen in >60% of <1000 g babiesSeen in >60% of <1000 g babies Management strategies:Management strategies:

Preload/afterload reductionPreload/afterload reduction Adequate oxygenationAdequate oxygenation Optimize pHOptimize pH Indomethacin/IbuprofenIndomethacin/Ibuprofen Surgery (PDA ligation)Surgery (PDA ligation) Conservative managementConservative management

Prognosis:Prognosis: Multiple associations (NEC, CLD, etc …) but no Multiple associations (NEC, CLD, etc …) but no

proven causationproven causation

Metabolic Problems of Metabolic Problems of PrematurityPrematurity

HypoglycemiaHypoglycemia

Fluid/electrolyte imbalanceFluid/electrolyte imbalance

Hypocalcemia/hypomagnesemiaHypocalcemia/hypomagnesemia

HyperbilirubinemiaHyperbilirubinemia

HypothermiaHypothermia

Intraventricular hemorrhageIntraventricular hemorrhage Common in < 1500 gm babiesCommon in < 1500 gm babies Usually evident in 1st week of lifeUsually evident in 1st week of life

Reasons:Reasons: highly vascularized germinal matrixhighly vascularized germinal matrix less basement membrane to capillariesless basement membrane to capillaries abnormal cerebral autoregulationabnormal cerebral autoregulation

Prognosis:Prognosis: GoodGood - small amounts of bleeding in the - small amounts of bleeding in the

ventriclesventricles PoorerPoorer - large amount intraparenchymally or if - large amount intraparenchymally or if

post-hemorrhagic hydrocephaluspost-hemorrhagic hydrocephalus

Periventricular leukomalaciaPeriventricular leukomalacia

Pathophysiology:Pathophysiology: Ischemic lesion to watershed area Ischemic lesion to watershed area

around ventricles in premature infantsaround ventricles in premature infants Link to inflammation?Link to inflammation? Most often shows up 3-4 wks after Most often shows up 3-4 wks after

deliverydelivery

Prognosis:Prognosis: Correlated with cerebral palsyCorrelated with cerebral palsy

Necrotizing EnterocolitisNecrotizing Enterocolitis 1-5% NICU admissions1-5% NICU admissions Multi-factorial etiology:Multi-factorial etiology:

Feeds, Prematurity, Ischemia, InfectionFeeds, Prematurity, Ischemia, Infection Diagnosis:Diagnosis: clinical and radiologic clinical and radiologic Treatment:Treatment:

Decompression (NPO, NG tube)Decompression (NPO, NG tube) AntibioticsAntibiotics Surgery prnSurgery prn

Prognosis:Prognosis: 30% mortality if <1500 g30% mortality if <1500 g

SepsisSepsis Suboptimal immune function in preemies Suboptimal immune function in preemies

plus poor skin barrier, indwelling cathetersplus poor skin barrier, indwelling catheters

GBS and coliforms cause early onset sepsisGBS and coliforms cause early onset sepsis

< 5-7 days of life< 5-7 days of life

Nosocomial sepsis common in premsNosocomial sepsis common in prems Most common = coagulase negative Most common = coagulase negative

staphylococcusstaphylococcus Fungi can also be problematic in > 1 week of lifeFungi can also be problematic in > 1 week of life

Anemia of PrematurityAnemia of Prematurity

Reasons:Reasons: decreased hemoglobin at deliverydecreased hemoglobin at delivery decreased RBC survivaldecreased RBC survival blunted erythropoietin responseblunted erythropoietin response IATROGENICIATROGENIC

Treatment:Treatment: preventionprevention iron supplementationiron supplementation transfusiontransfusion EPOEPO

Retinopathy of PrematurityRetinopathy of Prematurity 40-70% NICU survivors < 1000 g40-70% NICU survivors < 1000 g

Etiology:Etiology: vasoconstriction leading to abnormal vasoconstriction leading to abnormal

vascular proliferationvascular proliferation

Diagnosis:Diagnosis: ScreeningScreening

Treatment:Treatment: Close monitoring, laser if necessaryClose monitoring, laser if necessary

Long Term Outcomes – 24 Long Term Outcomes – 24 weeksweeks

Local survival (2006-2008) ~ 60%

Risk of severe disability: very low IQ, unable to walk, blindness and/or deafness

~ 15-20% of survivors

Risk of moderate disability: low IQ, walk with aid, impaired vision and/or correctable hearing loss

~ 20-30% of survivors

Deafness ~ 2% of survivors

Blindness 1-10% of survivors

Overall, chance of being ‘normal’ or mildly impaired

~ 50-65% of survivors

Disorders of gestation Disorders of gestation length or of growthlength or of growth

Small for gestational age: <2SD Small for gestational age: <2SD belowbelow

Large for gestational age: >2SD Large for gestational age: >2SD aboveabove

Prematurity: <37 weeks gestationPrematurity: <37 weeks gestation

Postmaturity: >42 weeks gestationPostmaturity: >42 weeks gestation