department of child health medical school university of...

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


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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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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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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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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- 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


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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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.


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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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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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


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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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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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


- 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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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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