2010 Prematurity 2

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A. Osei-Akoto

DCH,KNUST-KATH

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Question: A 17 yr old girl presents at 30 weeks gestation with LAP

and losing liquor for 16 hours. She is admitted butprogresses to deliver a male weighing 1.1 kg 3 days onadmission. The baby is found to have episodes ofcessation of breathing activity lasting 25 seconds onday 2.

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What diagnosis will you make with regard to the baby 3 MARKS

Briefly describe how you would confirm or refute thegestational age of the baby at the MBU as given in thehistory. 10 MARKS

List 6 additional medical problems (not mentioned in

the case) that the baby is at risk of. Using the above case-scenario, discuss briefly how

this neonatal condition could have been preventedand also indicate how one significant complication

could be minimized prior to the delivery3/2/2014

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Definition The estimated normal duration of pregnancy in

the human female is 280 days (40 weeks)

Live-born infant delivered before 37 completed wks of gestation (from the first day of the LMP)is referred to as PREMATURE--”WHO”

Features: LBW (<2.5KG), Immature physical

signs, and multisystem organ disorders The appearance, clinical problems, chances of

survival and long term prognosis depends onthe gestation. The longer the GA the better the

chance of survival.3/2/2014

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Definitions < 2500 grams- LBW

<1500 grams - VLBW

<1000 grams - ELBW

Preterm : Live-born infants delivered before 37wk fromthe 1st day of the LMP

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General considerations Prematurity is a major contributor to perinatal

mortality and morbidity.

it affects approximately 6-7% of births in developed

countries and 14-17% of births in developing countries.

The incidence of preterm birth seems to be increasingin many countries, especially in the United States

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By 2001, the direct causes of the neonatal deaths were preterm birth (24%), severe infections (32%),

complications of asphyxia and injuries (29%),congenital anomalies (10%), and others (5%).

The cost for the medical care of a preterm is veryhigh - approx. $10,000 a week in USA

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12% of babies in the United States are bornprematurely.

Since the early 1980s, the rate of prematurity has risenby 17%, and the rate of low birth weight has increasedby 10%.

Surfactant /medical and technological advances in

neonatal care has improved neonatal mortality ratesfor the smallest of infants, with survival rates of morethan 90% for VLBW , 80% for ELBW, and about 50%for ELBW

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In addition to the risk of death, babies born very

prematurely can face high odds of having some level oflearning disabilities or other developmentalimpairment.

In babies born before 26 weeks,

-20% will have no long-term problems.

- 34% will have a mild disability, such as cognitiveimpairment or near-sightedness.

-Another 24% will have a moderate disability, eg visual/hearing impairment or cerebral palsy with theability to walk.

-22% will have a severe disability, such as cerebral palsy

and no ability to walk, blindness or profound3/2/2014

http://learningdisabilities.about.com/od/learningdisabilitybasics/u/TypesofLearningDisabilities.htm

http://adam.about.com/encyclopedia/infectiousdiseases/Cerebral-palsy.htm

http://adam.about.com/encyclopedia/infectiousdiseases/Cerebral-palsy.htm

http://learningdisabilities.about.com/od/learningdisabilitybasics/u/TypesofLearningDisabilities.htm

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November 13 is Prematurity Awareness Day Babies born premature are 6x more likely to die

during their 1st of life, than full-term babies 50% of twins are born preterm ( WHO 2001). Twins are 5.4 times more likely to be born at < 37

weeks of gestation compared with singletonsand 8.2 times more likely to be born at < 33 weeks

of gestation ( Alexander 1998).

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http://127.0.0.1/media_20074/search/article.tes?href=clsysrev/CD0004/CD004733.xml&view=article





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Identifiable causes/ risk factors for

preterm birth FETAL

-Fetal distress, Multiple pregnancy,

PLACENTAL

-placenta praevia; Abruptio placentae

UTERINE

Bicornuate uterus, Incompetent cervix

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MATERNAL- pre-eclampsia, chronic medicalillness (eg. Cyanotic heart disease)

Infection during pregnancy (eg Listeriamonocytogesis, GB streptococuus, UTI)

OTHERS: premature rupture of membranes

polyhydramnios

Iaotrogenic

Inadequate or lack of ANC

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Associated factors Low socioeconomic status-

maternal malnutrition, anaemia, illness

Teenage pregnancy Close spacing of pregnancies

Smoking, alcohol, illegal drug use

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Domestic violence (poor spousal relationship)including- physical, sexual or emotional abuse)

Lack of social support, stress, long working hours, long periods of standing

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Gestational age assessment Physical signs-external appearance and

neurological findings are used to provide anestimate of gestational age

Number and severity of problems decline withincreasing gestational age - prognosis is normally good with higher age.

DUBOWITZ SCORING SYSTEM-commonly used;

accurate to ± 2wks

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Gestational assessment0 1 2 3 4 5

Skin Gelatinous,

red and

transparent

Smooth, pink

visible veins

Superficial

peeling, few

veins

Cracking, rare

veins

Parchment,

deep cracking

Leathery,

cracked &

wrinkled

Lanugonone abundant thinning Bald areas Mostly bald

Plantar

creases

none Faint red

marks

Anterior

transverse

crease only

Creases in

anterior two-

thirds

Creases over

entire sole

Breast Barely

perceptible

Flat areola,

no bud

Stippled

areola, 1-2mm

bud

Raised areola,

3-4mm bud

Full areola,

5-10mm bud

Ear Pinna flat &

stays folded

Soft pinna,

slow recoil

Soft pinna,

ready recoil

Formed, firm

pinna, instant

recoil

Thick

cartilage, stiff

ear

Male

genitalia

Scrotum

empty, no

rugae

Testes

descending,

few rugae

Testes down,

Good rugae

Testes

pendulous,

good rugae

Femaleenitalia

Prominentclitoris &

Minora&majora equal

Minora muchsmaller than

Clitoris andminora covered3/2/2014

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Approx. Gestational age (in wks)

Total score 2 5 7 10 12 15 17 20 22 25

Weeks

gestation

26 28 30 32 34 36 38 40 42 44

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LANUGO

HAIR

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LANUGO HAIR

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Ear recoil: Soft

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THIN AND TRANSPARENT SKIN;

BREAST TISSUE

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Genitalia: Prominent Labia and Clitoris

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PLANTAR CREASES

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Odds of a Premature Baby's Survival by

Length of Pregnancy

Length of Pregnancy Likelihood of Survival

23 weeks 17%

24 weeks 39%

25 weeks 50%

26 weeks 80%

27 weeks 90%

28-31 weeks

90-95%

32-33 weeks 95%

34+ weeks Almost as likely as a full-

term baby

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Problems/complications for the

premature infant Need for resuscitation

RESPIRATORY:--RDS, Apnoea, Broncopulmonary

dysplasia, pneumothorax CARDIOVASCULAR:- PDA, hypotension,

bradycardia

HAEMATOLOGIC:- Anaemia (early & late),

hyperbilirubinaemia (Jaundice), Vit.K deficiency(high risk for HDN), DIC

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METABOLIC-ENDOCRINE

hypoglycaemia, hypocalcaemia, hyperglycaemia,hypothermia

GIT : Poor GI function esp. motility, NEC, congenitalanomalies

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CNS :- Intraventricular haemorrhage, hypoxic-ischaemic encephalopathy, seizures, deafness,hypotonia, retinopathy of prematurity, Kernicterus

RENAL: hypo/ hypernatraemia, hyperkalaemia OTHERS : INFECTIONS- perinatal, nosocomial

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Thermal control Use of incubators or radiant warmers

In the district, use bulb over baby’s cot

In transit, use polythene or foil

Infant’s core temp should be maintained at 36.5 – 37.0°C

Humidity should be maintained at 40 – 60%

Appropriate nursery environment

Continuous monitoring of the infant’s temp

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Oxygen therapy Required for babies

In respiratory distress

Prolonged apnoeic attacks

Very small and fragile babies

Given via Facial mask

Nasal cannula

Endotracheal tube CPAP apparatus

Oxygen is a drug. Must be carefully regulated.

Hyperoxia in the preterm leads to retinopathy of

prematurity

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Fluid requirements Fluid needs vary according to

Gestational age

Environmental conditions Disease states

Insensible water loss is higher in preterm infantsbecause of

Immature skin Lack of subcutaneous tissue

Large exposed surface area

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Fluid requirements Environmental conditions eg.

Incubator or atmospheric humidity

Radiant warmers Phototherapy

Disease states eg.

Febrile infants

D&V Shock

Exomphalus/gastroschisis, etc.

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Guidelines for fluid requirements

Day 1 = 60ml/kg/day

Day 2 = 90mi/kg/dayDay 3 = 120ml/kg/day

Day 4 = 150ml/kg/day

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Recommended fluid requirementsBirth Wt (kg)

Dextrose (%)

Fluid rate (ml/kg/d)

<24 hr 24-48 hr >48 hr

<1.0 5-10 100-150 120-150 140-190

1.0-1.5 10 100-120 100-120 120-160

>1.5 10 60-80 80-120 120-160

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Total parenteral nutrition Enteral feeding may not be advisable because of

Extreme prematurity

cough reflex

swallowing reflex

sucking reflex

Immature digestive enzyme system, wk 28

Disease states eg.

RDS, NEC, GI atresia, etc

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Total parenteral nutrition I.V. infusions should provide

Sufficient fluids

Sufficient calories

Amino acids

Electrolytes

Vitamins

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Total parenteral nutrition Complications include

Sepsis esp.from central vein catheters (most commonbeing coagulase negative staph)

Hyperglycemia

Hypoglycemia

Accidental dislodgement of catheters

Thrombosis Phlebitis

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Feeding A healthy preterm or small neonate may be fed by

NG tube

Cup/bottle feeding

Breast

Method of feeding each preterm or LBW infantshould be individualized

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Feeding by breast or cup Must be established before discharge

Attempt oral feeding for infants

Who are well

Making sucking movements

Not in distress

No emesis

No abdominal distention ?Weighing 1500g or more

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RDS/HMD CAUSE: SURFACTANT deficiency

(may be secondary to hypoxia, acidosis,hypothermia). Production is inhibited in infants ofdiabetic mothers

Pathology- hyaline membrane formed leading toalveolar collapse and inadequate gas exchange

More preterm an infant, the higher the incidence(less in > 34 wks gestation)

Uncommon in term babies

Less severe in girls

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Hyaline membrane disease or

respiratory distress syndrome Incidence

Less than 28wk gestation = 60-80% incidence

Between 32-36 weeks = 15-30%

Beyond 37 weeks = 5%

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Respiratory distress syndrome Increased frequency in

Babies born todiabetic mothers

Preterm delivery

Multiple pregnancy

C/S deliveries

Precipitous delivery Birth asphyxia

Decreased frequency in

Hypertension inpregnancy

Prolonged rupture ofmembrane

Antenatalcorticosteroid use

Maternal opiateaddiction

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Clinical features May be evident at birth or within 4hrs of birth;

progresses over 48-72 hrs and improves

Tachypnoea Chest wall recession-ICR, SCR, ( in-drawing)

Expiratory grunting

Cyanosis

CXR - Diffuse granular or “Ground glass”appearance with air bronchogram

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Management of RDS 70-100% O2 by nasal prongs, CPAP

Infant can be weaned off within 72hrs

Exogenous surfactant-synthetic, pig or calfextracts or from human amniotic fluid

Monitor arterial O2 tension

CO2 tension Arterial pH

If PO2 < 50mmHg, or PCO2 > 60mmHg, or pH <7.2, then assisted ventilation is required

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Management of Preterm in

KATH KATH-O2 by nasal tubes/facial mask

Temperature regulation (radiant heater, incubatornursing)

IV Dextrose for 24-48 hrs

NG/Cup feeding and/or Breastfeeding--depending onage and clinical state

Management of other specific problems eg. Infection

KMC

Monitoring of weight every other day

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Infections Increased susceptibility to infections Poorly developed immune system Excessive handling/resuscitation

Prevention Strict compliance with handwashing and universal

precautions Limited nurse-to-patient ratios Avoiding overcrowding Minimize procedures One stethoscope + thermometer to a cot Encouraging early enteral feeding

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Necrotising Enterocolitis (NEC) A serious condition with a high incidence in

preterms (rarely affects term babies ).

Pathology: gut necrosis– gas accumulation insubmucosa of bowel (pneumatosis intestinalis)– progression of necrosis– perforation–sepsis–death

Bacteria- E.coli, staph, Clostridium perfringes;

Only 25% of cases are blood cultures positiveDistal ileum and proximal colon most affected

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Predisposing Factors

to NEC1. Preterm/VLBW

2. Ischaemia

3. Hypertonic milk (artificial) or medicines injures thegut mucosa

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Clinical manifestations of NEC Ill and septic

GI symptom

Abdominaldistension

Feedingintolerance

Vomiting

Bloody stools

Systemicsymptoms/signs

Fever or

hypothermia Lethargy

Hypoglycemia

Respiratorydistress

shock

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Investigations Blood C/S--- positive in only 25% of cases

CBC

Plain abdominal X’ray- distended loops of bowel ± fluid levels

- shows thickening of gut wall with intramural gas(pneumatosis intestinalis)

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Treatment AGGRESSIVE MANAGEMENT

STOP FEEDS--NPO ? 2 weeks

NG decompression IV fluids-resuscitation

Antibiotics- cover both aerobes and anaerobes

Surgery if perforation has occurred Prognosis: 20% mortality even in the best centres

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Hypothermia Common problem of the preterm or small neonate

Due to

Large surface area/body mass ratio Lack of subcutaneous fat

May be an indication of underlying illness

Hypoglycemia

Sepsis shock

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Thermal control Use of incubators, radiant warmers or bulbs

KMC-Kangaroo Mother Care

In transit, use foils or polythene

Infant’s core temp should be maintained at 36.5 – 37.0°C

Continuous monitoring of the infant’s temp

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Kangaroo Mother Care-KMC What is it

Practice

Evidence of advantages

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angaroo position – skin to skin contact

other and ilk (exclusive breastfeeding)

are and upport for the mother and baby

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2-Mar-14 Dr. Priscilla Wobil 65

Nutrition Position Support

Discharge Follow up3/2/2014

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2-Mar-14 Dr. Priscilla Wobil 66

Mother Baby Hospital Community

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Mother’s own cloth/wrap

Comfortable chairs

Beds Willing mothers

Supporting staff

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Hospital

Labour wards

Neonatal wards/NICUPostnatal wards

Well baby clinics

Follow up clinicsHome, Community etc

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Hospital KMC is at least as effective and safe as CIC

Feasible in different settings, acceptable to mothersof different cultures, and less expensive.

Increase in prevalence and duration of EBF

Useful in poor resource settings-India

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Better weight gain

Earlier hospital discharge

Higher rates of exclusive breast-feeding

Excellent adjunct to the routine preterm care in anursery

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KMC appears to reduce severe infant morbidity

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Ethiopia

Better survival in early kangaroo mother care (first 12hrs)

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Improves growth

Reduces morbidity

Simple and Acceptable to mothers

Can be continued at home

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Mothers more involved in care taking activities

KMC facilitates mother baby attachment in low birth weight infants

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Less hypothermia

Need to conduct large high quality randomisedcontrolled trials looking at long-term outcomes.

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Reduction in mortality

Better mental development - pretermbabies

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Apnoea Apnoea is defined as cessation of breathing for longerthan 20 seconds, or any duration if accompanied bycyanosis or sinus bradycardia

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Apnoea Very common problem in preterms

May be due to

Apnoea of prematurity (idiopathic)

Associated illness such as

RDS

Hypoglycemia

Shock

Seizures

Infections -septicemia, meningitis

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Idiopathic apnoea of prematurity Freq is inversely related to gestational age

Rare on the first day of life

Usually occurs on the 2nd – 7th day of life

Apnoea immediately after birth signifies an associatedillness

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Management of Apnoea Gentle cutaneous stimulation -for mild andintermittent episodes

For recurrent and prolonged apnoea

Bag and mask ventilation

Oxygen

Use of drugs eg. aminophylline

If due to precipitating illness Airway stability + oxygenation (as above)

Treat underlying disease

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Prevention-1 Intrauterine acceleration of fetal lung maturation

-Administration of steroids ante-natally decreasesmorbidity and mortality- speeds up foetal lungmaturation and reduces RDS, IVH, and NECsignificantly;

Risk of RDS is decreased when steroid is given to

mother >24hrs and ≤7days before birth.

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Prevention-2 Prevent preterm labour/delivery with the use oftocolytics ( betamimetics, prostaglandininhibitors, and calcium channel blockers)

Prevent teenage pregnancy, also women >35 yrsshould be discouraged from giving birth

ANC attendance should be encouraged

Prevent maternal infections

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DISCHARGE FROM HOSPITAL OF

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DISCHARGE FROM HOSPITAL OF

THE PRETEM Infant should be feeding well -breast or by cup.

Steady increase in weight (wt >1.8kg)

Stable temperature (out of incubator for at least48hrs)

No recent apnoic attack

No infection, anaemia

Home setting should be ready to receive baby(mother should be assessed to be able to cope)

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Advise and start Routine immunization

Regular schedule

Standard doses

Assess hearing and sight

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POST-DISCHARGE PROBLEMS Thinner than full-term normal birth weight

Increased risk for re-admission to hospital in the first year of life

Recurrent wheezing in those with BPD

Many neuro-developmental problems- visual/hearingimpairment, cerebral palsy, motor,learning orlanguage problems.

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Home work Short notes

Apnoea of Prematurity (AOP)

Retinopaty of prematurity (ROP)

Anaemia of prematurity

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Documents

2010 Prematurity 2