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
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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
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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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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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