Division of PerinatologyDepartment of Child Health Medical SchoolUniversity of Sumatera Utara

Gestational age can be determined:Date of last menstrual periodDate of first fetal activity (16-18 weeks)First reported heart sound (10-12 weeks)USG examination (before 20 weeks)AAP recommends:- birth weight- gestational age

CLASSIFICATIONPreterm (< 37 weeks)Term (37-41 weeks)Postterm (>42 weeks)

CLASSIFICATIONClassification based on a combination of features:Small for gestational age (SGA)- 2 standard deviation below the mean weight for GA - or below the 10th percentile- common in mother with hypertention, preeclampsia, or who smoke- associated with TORCH, infection, chromosomal abnormalities, congenital malformation

CLASSIFICATIONAppropriate for gestational age (AGA)Large for gestational age (LGA)- 2 standard deviation above the mean weight for GA - or above 90 percentile- in infant of diabetic mothers- Beckwiths syndrome, constitutionally large infants with large parents, hydrops fetalis

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGERapid delivery room assessment- creases in the sole of the foot- size of the breast nodule- nature of the scalp hair- cartilaginous development of the ear lobe- scrotal rugae and testicular descent in males

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGENew Ballard ScoreThe score span from 10 (20 weeks gestation) to 50 (correlating with 44 weeks gestation)Best performed at

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEAccuracy- accurate whether the infant is sick or well to within 2 weeks of GA- Overestimates GA by 2-4 days in infant 32-37 weeks gestation

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGECriteria- 6 neuromuscular criteria Passive tone is more useful than active tone in indicating GA- 6 physical criteria

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEProcedures- administered twice by two different examination- data are entered on the chart- two part examination: neuromuscular and physical maturity- 12 scores are totaled

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGE- maturity rating is expressed in weeks of gestation- Part 2 of the form used to plot gestational assesment againts length, height, and head circumference to determine whether the infant is SGA, AGA, or LGA Lubchenco charts

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGENeuromuscular maturityPosture- Score 0 if the arms and legs are extended- Score 1 if has beginning flexion of the knees and hips with arm extended- determined the other score based on the diagram

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGESquare window- Flex the hand on the forearm between the thumb and index finger of the examiner.- Applay sufficient pressure to achieve as much as flexion as possible- Visually measure the angle between the hypothenar eminence and ventral aspect of the forearm.

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEArm recoil- flex the forearms for 5 s, then grasp the hand and fully extend the arm and release.- If full flexion score 4

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEPopliteal angle- Hold the thigh in the knee-chest position with the left index finger and the thumb supporting the knee- Extended the leg by gentle pressure from the right index finger behind the ankle

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEScarf Sign- Take the infants hand and try to put it around the neck posteriorly as far as possible over the opposite shoulder Heel to ear- Keeping the pelvis flat on the table- Take foot and try to put it as close to the head as possible without forcing it

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEPhysical maturitySkin- Extremly premature: sticky, transparent skin score -1Lanugo hairPlantar surface- measure foot leghth from the tip of the great toe to the back of the heel

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEBreast- palpate any breast tissueEye and ear- loosely fused eyelids: closed but gentle traction opens them- Tightly fused eyelids: inseperable by gentle tractionGenitalia

28 weeks gestation :little cartilago, pliable36 weeks to term gestation : firm ear, well-formed margin

28 weeks gestation :No breast tissue, areola barely visible32 weeks gestation :visible areola, little breast tissue 36 weeks gestation :well-defined areola, breast nodule

Genitalia - Male28 weeks gestation :testis high in scrotum36 weeks to term gestation : testis well descended, increased scrotal pigmentation

Foot sole creases32 weeks gestation :creases in anterior one third 36 weeks to term gestation : creases over the majority of the sole

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEDirect ophthalmoscopyBefore 27 weeks: cornea is too opaque to allow visualizationAfter 34 weeks: atrophy of the vessels of the lens occursAccurate determination: 27-34 weeks onlyReliable to 2 weeksMust be performed within 48 h of birth before vessels atrophy

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEGrading systemGrade 4 (27-28 weeks): vessel cover the 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 portion of the lens is not covered by vessels

METHODS OF DETERMINING POSTNATAL GESTATIONAL AGEGrade 2 (31-32 weeks): vessels reach only to the middle-outer part of the lens, the central clear portion of the lens is largerGrade 1 (33-34 weeks): vessels are seen only at the periphery of the lens