Jennel Joy C.

Marquez BSN II B

Prematurity
I. Definition The length of a normal pregnancy or gestation is considered to be 40 weeks (280 days) from the date of conception. Infants born before 37 weeks gestation are considered premature and may be at risk for complications. Description More than one out of every ten infants born in the United States is born prematurely. Advances in medical technology have made it possible for infants born as young as 23 weeks gestational age (17 weeks premature) to survive. These premature infants, however, are at higher risk for death or serious complications, which include heart defects, respiratory problems, blindness, and brain damage. II. Risk Factor Mothers with: Diabetes Heart disease Infection (such as a urinary tract infection or infection of the amniotic membrane) Kidney disease

Different pregnancy-related problems increase the risk of preterm labor: An "insufficient" or weakened cervix, also called cervical incompetence Birth defects of the uterus History of preterm delivery Poor nutrition right before or during pregnancy Preeclampsia the development of high blood pressure and protein in the urine after the 20th week of

pregnancy Premature rupture of the membranes (placenta previa) heavy bleeding during the pregnancy waters breaking early Other factors: African-American ethnicity (not related to socioeconomic status) Age (younger than 16 or older than 35) Lack of prenatal care Low socioeconomic status Use of tobacco, cocaine, or amphetamines III. Symptoms A premature infant's organs are not fully developed. The infant needs special care in a nursery until the organ systems have developed enough to sustain life without medical support. This may take weeks to months. A premature infant will have a lower birth weight than a full-term infant. Common physical signs of prematurity include:

Body hair (lanugo) Abnormal breathing patterns (shallow, irregular pauses in breathing called apnea) Enlarged clitoris (female infant) Problems breathing due to immature lungs (neonatal respiratory distress syndrome) or pneumonia Lower muscle tone and less activity than full-term infants Problems feeding due to difficulty sucking or coordinating swallowing and breathing Less body fat Small scrotum, smooth without ridges, and undescended testicles (male infant)

Soft, flexible ear cartilage Thin, smooth, shiny skin, which is often transparent (can see veins under skin) Not all premature babies will have these characteristics. The infant may have difficulty breathing and maintaining body temperature. IV. Causes The birth of a premature baby can be brought on by several different factors premature labor placental abruption, in which the placenta detaches from the uterus placenta previa, in which the placenta grows too low in the uterus premature rupture of membranes, in which the amniotic sac is torn, causing the amniotic fluid to leak out incompetentcervix, in which the opening to the uterus opens too soon maternal toxemia, or blood poisoning multiple pregnancy mothers who have a history of miscarriages or who have given birth to a premature infant in the past most important, identifiable causes of prematurity is drug abuse, particularly cocaine, by the mother. Doctors might decide that a baby needs to be born early if: he is not growing as well as he should in the uterus he has an abnormality

Or if the mother has: a medical condition which means it is safer for a baby to be born early pre-eclampsia placenta previa with heavy bleeding

V. Complications Possible complications that may occur while in the hospital include: Anemia Bleeding into the brain (intraventricular hemorrhage of the newborn) or damage to the brain's white matter (periventricular leukomalacia) Infection or neonatal sepsis Low blood sugar (hypoglycemia Neonatal respiratory distress syndrome, extra air in the tissue of the lungs (pulmonary interstitial emphysema), bleeding in the lungs (pulmonary hemorrhage) Newborn jaundice Patent ducturs arteriosus Severe intestinal inflammation (necrotizing enterocolitis)

Possible long-time complications include: Bronchopulmonary dysplasia (BPD) Delayed growth and development Mental or physical disability or delay Retinopathy of prematurity, vision loss, or blindness

Infants born prematurely may experience major complications due to their low birth weight and the immaturity of their body systems. Common problems among premature infants are: jaundice (yellow discoloration of the skin and whites of the eyes) apnea (a long pause in breathing)

 inability to breast or bottle feed Body temperature, blood pressure, and heart rate may be difficult to regulate in premature infants Respiratory distress syndrome (RDS) is the most common problem seen in premature infants. Babies born too soon have immature lungs that have not developed surfactant, a protective film that helps air sacs in the lungs to stay open. With RDS, breathing is rapid and the center of the chest and rib cage pull inward with each breath. Bronchopulmonary dysplasia is the development of scar tissue in the lungs, and can occur in severe cases of RDS. Necrotizing enterocolitis (NEC) is a further complication of prematurity. In this condition, part of the baby's intestines are destroyed as a result of bacterial infection. In cases where only the innermost lining of the bowel dies, the infant's body can regenerate it over time; however, if the full thickness of a portion dies, Intraventricular hemorrhage (IVH) is another serious complication of prematurity. It is a condition in which immature and fragile blood vessels within the brain burst and bleed into the hollow chambers (ventricles) normally reserved for cerebrospinal fluid and into the tissue surrounding them. Apnea of prematurity is a condition in which the infant stops breathing for periods lasting up to 20 seconds. It is often associated with a slowing of the heart rate. The baby may become pale, or the skin color may change to a blue or purplish hue. Apnea occurs most commonly when the infant is asleep. Retinopathy of prematurity is a condition in which the blood vessels in the baby's eyes do not develop normally, and can, in some cases, result in blindness. Premature infants are also more susceptible to infections. They are born with fewer antibodies, which are necessary to fight off infections. VI. Diagnosis The most accurate way of determining the gestational age of an infant in utero calculating from a known date of conception or using ultrasound imaging to observe development When a baby is born, doctors can use the Dubowitz exam to estimate gestational age. This standardized test scores responses to 33 specific neurological stimuli to estimate the infant's neural development. Once the baby's gestational age and weight are determined, further

tests and electronic fetal monitoring may need to be used to diagnose problems or to track the baby's condition. A blood pressure monitor may be wrapped around the arm or leg. Several types of monitors can be taped to the skin. A heart monitor or cardiorespiratory monitor may be attached to the baby's chest, abdomen, arms, or legs with adhesive patches to monitor breathing and heart rate. A thermometer probe may be taped on the skin to monitor body temperature. Blood samples may be taken from a vein or artery. X rays or ultrasound imaging may be used to examine the heart, lungs, and other internal organs. Common tests performed on a premature infant include: Blood gas analysis Blood tests to check glucose, calcium, and bilirubin levels Continuous cardiorespiratory monitoring (monitoring of breathing and heart rate)

VII. Treatment Treatment depends on the types of complications that are present. It is not unusual for a premature infant to be placed in a heat-controlled unit (an incubator) to maintain its body temperature. Infants that are having trouble breathing on their own may need oxygen either pumped into the incubator, administered through small tubes placed in their nostrils, or through a respirator or ventilator, which pumps air into a breathing tube inserted into the airway. The infant may require fluids and nutrients to be administered through an intravenous line in which a small needle is inserted into a vein in the hand, foot, arm, leg, or scalp. If the baby needs drugs or medications, they may also be administered through the intravenous line. Another type of line may be inserted into the baby's umbilical cord. This can be used to draw blood samples or to administer medications or nutrients. If heart rate is irregular, the baby may have heart monitor leads taped to the chest. Many premature infants require time and support with breathing and feeding until they mature enough to breathe and eat unassisted. Depending on the complications, the baby may require drugs or surgery.

A form of treatment that is being recommended by many mainstream practitioners as of 2003 is massage therapy. Research has shown that the risks of massaging preterm infants are minimal, and that the infants benefit from improved developmental scores, more rapid weight gain, and earlier discharge from the hospital. An additional benefit of massage therapy is closer bonding between the parents and their newborn child. VIII. Management If waters have broken, the fluid may be tested for a protein, called fetal fibronectin, which often indicates that your baby will be born soon. You'll have tests to see if you are carrying group B streptococcus bacteria in your vagina, urinary tract infection or other kind of vaginal infection. If you are, you will be given antibiotics, which are safe for your baby. Your baby's heartbeat will be monitored. If you want some pain relief, you will be advised against pethidine or similar drugs, because they can affect your baby's breathing. An epidural is the most likely option. If you are less than 34 weeks pregnant, your doctors can give you steroid injections to help your baby's lungs mature and a drug to try to delay the birth for a short while. Often you'll be able to have a vaginal birth. If you are more than 34 weeks pregnant, your doctors will probably let labor continue at its own pace. Your baby is likely to do well, even though he will be small. However, sometimes a cesarean section might be necessary if there are complications, for example, if you've had heavy bleeding or if your baby is in severe distress. If your baby is born: After 34 weeks, he may not need any treatment. He may look a bit small, but he may be able to go straight to the postnatal ward with you. Or he may be admitted with you to a special ward where there is a high ratio of staff to mothers. Before 34 weeks, he may need specialized care, because premature babies are more likely to have problems with breathing, feeding and infection. This may mean that your baby has to be taken straight to a neonatal intensive care unit (NICU) or special care baby unit (SCBU). You may only have a brief glimpse of him before he is whisked away. This can be very frightening and you will need lots of support. Before 28 weeks, he may need to be cared for in a hospital where there is specialist care for very premature babies. If your baby does need special care, you'll be encouraged to see him as often as you want to. You may feel that there is nothing you can do for him, but this isn't true. You can still change his diaper, stroke him, talk to him, and perhaps hold and feed him.

Remember that he needs the special comfort that only his parents can give him, every bit as much as he needs medical help. Find out more about caring for your premature baby. IX. Pharmacologic Management Corticosteroids One of the most useful tools in the obstetric armamentarium for reducing morbidity and mortality related to preterm birth, corticosteroids are the best-documented beneficial agents for use in preterm labor.The use of corticosteroids is indicated to prevent preterm birth in women between 26 and 34 weeks gestation who are at risk for preterm birth owing to preterm labor, PROM, or severe preeclampsia or other medical conditions that necessitate preterm delivery.2 In combination with delivery in a facility with a level III NICU, corticosteroids consistently improve outcomes of preterm birth. Corticosteroids administered as late as 12 to 24 hours before preterm birth reduce the incidence of neonatal complications after preterm labor, including respiratory distress syndrome (RDS), intraventricular hemorrhage, and necrotizing enterocolitis.1-3,8 Administered prior to 35 weeks gestation, corticosteroids activate the hypothalamic-pituitary-adrenal axis to enhance functional maturity in the fetus, specifically lung maturity. The American College of Obstetricians and Gynecologists (ACOG) recommends either betamethasone or dexamethasone to promote fetal lung maturity. Intramuscular administration of betamethasone 12 mg every 24 hours for two doses or dexamethasone 6 mg every 12 hours for four doses is indicated for women at risk for preterm birth between 26 and 34 weeks gestation. Repeat doses of corticosteroids are not beneficial for improving outcomes following preterm birth.3

Antibiotics: Preterm labor is often associated with infections and inflammation, and subclinical infection is associated with PPROM. However, most studies have not found that prophylactic antibiotic treatment confers a substantial benefit in preventing preterm labor or birth. Additionally, antibiotics do not reduce the occurrence of neonatal RDS or sepsis. Antibiotics do not affect preterm labor in patients with intact membranes.6 Among women with PPROM, antibiotics may reduce the risk of preterm birth within 48 hours of administration, but little evidence of benefit exists for other outcomes. Specifically, antibiotic administration may delay delivery after PPROM, which provides time for corticosteroid administration. Amoxicillin-clavulanate should be avoided in women who are at risk for preterm birth because of the increased chance of neonatal necrotizing enterocolitis. The ACOG does not support the use of antibiotics for pregnancy prolongation in women with intact membranes.

Bacterial vaginosis, an overgrowth of anaerobic bacteria, is associated with an increased risk of preterm birth; treatment of the vaginosis reduces the risk. Symptomatic bacterial vaginosis is often treated with oral clindamycin 300 mg twice daily for 7 days, metronidazole 500 mg twice daily for 7 days, or metronidazole 250 mg three times daily for 7 days.

Antibiotics are appropriate during preterm labor as prophylaxis against group B streptococcus (GBS) sepsis. Current guidelines consider IV administration of one dose of ampicillin 2 g followed by ampicillin 1 g every 6 hours for 48 hours to be adequate GBS prophylaxis in women who have tested positive for GBS, had a previous infant with GBS disease, had GBS bacteriuria during the current pregnancy, or whose GBS status is unknown.

Tocolytics: Tocolytic drugs inhibit uterine contractions. Four main classes of tocolytics, with varying degrees of safety and effectiveness, are used: beta-adrenergic agonists magnesium sulfate calcium channel blockers nonsteroidal anti-inflammatory drugs (NSAIDs) General contraindications to tocolysis include severe preeclampsia, maternal instability, placental abruption, intrauterine infection, lethal congenital or chromosomal abnormalities, advanced cervical dilation, fetal compromise or distress, and placental insufficiency. The choice of tocolytic should be based on maternal condition, potential adverse effects, gestational age, and cost. Once treatment is initiated, the patients response to tocolysis, including adverse effects, should be continuously monitored. Prolonged use of tocolytic agents is not recommended.

Magnesium sulfate, one of the most common obstetric drugs in the U.S., is used primarily for seizure prophylaxis in preeclampsia.16 Despite its lack of proven efficacy, magnesium sulfate is also the most commonly used tocolytic agent in the U.S.Magnesium sulfate can cause maternal lethargy, drowsiness, double vision, nausea, and vomiting. More serious maternal adverse effects include pulmonary edema, hypotension, muscle

paralysis, tetany, cardiac arrest, and respiratory depression.Magnesium sulfate can cause fetal toxicity at high doses.

While most tocolytics do not show a benefit in neonatal outcomes, magnesium sulfate has gained attention for its use in preventing cerebral palsy. Several studies have shown that, among women at risk for preterm birth, low-dose administration of magnesium sulfate reduced the risk of cerebral palsy among surviving neonates. The neuroprotective effect of magnesium sulfate results from a reduction in vascular instability and prevention of hypoxic and amino acid damage. The ACOG supports the administration of magnesium sulfate prior to anticipated preterm birth to reduce the risk of cerebral palsy. The recommended dose of magnesium sulfate is an IV bolus of 4 g to 6 g followed by 2 g to 3 g per hour.

Terbutaline, a beta-adrenergic agonist, is a potent cardiovascular (CV) stimulant that is associated with an increased risk of pulmonary edema and maternal and fetal CV abnormalities. A bronchodilator, it is approved to prevent and treat bronchospasms associated with asthma, bronchitis, and emphysema. The ACOG does not support the use of terbutaline to prevent preterm labor but states that, when it is used as a tocolytic, terbutaline should be administered as a subcutaneous 0.25-mg dose every 20 minutes to 3 hours.1 As a continuous infusion for tocolysis, terbutaline is initiated at a rate of 2.5 mcg/min to 10 mcg/min, and the rate can be increased gradually every 10 to 20 minutes to a maximum of 17.5 mcg/min to 30 mcg/min.

Terbutaline is not FDA approved as a tocolytic agent. In February 2011, the FDA released a safety announcement advising that terbutaline be used for tocolysis no longer than 48 to 72 hours owing to the risk of serious maternal CV problems that could lead to death. The FDA required that a boxed warning and contraindication be added to the labeling of both injectable and oral terbutaline. The FDA acknowledged that clinicians may continue to use terbutaline on an off-label basis to prevent preterm birth in urgent situations, but warned that the drug should never be used in the outpatient setting. The FDAs statement was based on postmarketing surveillance data that included 16 reports of maternal death and 12 cases of maternal CV events following terbutaline administration since the drugs approval in 1976.

Nifedipine, a calcium channel blocker, reduces the risk of preterm delivery within 7 days of treatment prior to 34 weeks gestation. Compared with beta-agonists, nifedipine also

lowers the risk of RDS, necrotizing enterocolitis, intraventricular hemorrhage, neonatal jaundice, and NICU admission.21 Nifedipine poses few maternal or fetal risks, but its use with magnesium sulfate has led to CV collapse in some pregnant women. For tocolysis, the ACOG recommends a loading dose of nifedipine 30 mg administered orally followed by 10 mg to 20 mg every 4 to 6 hours.

NSAIDs act as tocolytic agents by blocking the inflammatory process that triggers labor.NSAIDs have few maternal adverse effects, but they are associated with oligohydramnios and premature closure of the ductus arteriosis in the fetus. Also, neonates of mothers treated with NSAIDs may experience intraventricular hemorrhage, necrotizing enterocolitis, and bronchopulmonary dysplasia.2 These adverse effects are more common when NSAIDs are used after 32 weeks gestation, and NSAIDs are generally reserved for tocolysis earlier in pregnancy.The most commonly used NSAID for tocolysis is indomethacin. According to practice guidelines, a loading dose of 50 mg rectally or 50 mg to 100 mg orally followed by 25 to 50 mg orally every 4 to 6 hours for 48 hours is used for tocolysis.1,6 Ketorolac, also used as a tocolytic, is administered intramuscularly as a 60-mg loading dose followed by 30 mg every 6 hours for 48 hours. As a tocolytic, sulindac is administered at a dose of 200 mg orally every 12 hours for 48 hours.1

Progesterone: Maternal progesterone declines before labor, and low maternal progesterone levels are associated with miscarriage and preterm labor.Exogenous progesterone supplementation is indicated for women at risk for preterm labor and birth. Specifically, progesterone lowers the risk of preterm labor and birth by maintaining uterine inactivity.6 Administered as weekly intramuscular injections of 250 mg of 17-alphahydroxyprogesterone caproate (17-OHPC), progesterone reduces the risk of recurrent preterm birth by up to 50% when begun between 16 and 20 weeks gestation. Women with multiple gestations do not benefit from 17-OHPC treatment, and 17-OHPC does not prolong pregnancy in women with PPROM.Natural progesterone vaginal suppositories reduce the risk of preterm birth by up to 45% and decrease the incidence of respiratory distress and neonatal morbidity and mortality in pregnant women with a shortened cervix. In this situation, progesterone is commonly delivered at a dose of 100 mg daily, beginning between 16 and 24 weeks gestation and continuing through 34 to 36 weeks gestation. The ACOG supports the use of progesterone for prolonging pregnancy only in women with intact membranes and a history of spontaneous birth prior to 37 weeks gestation