PREMATURITY

HAMIZI HANAPIAH
 DEFINITION
• Premature: live born infants delivered <37
weeks from 1st day of LMP(WHO)
• Late preterm: births between 34w to 36w+6d
• Low birth weight: <2500g
• Very low birth weigh: <1500g
• Extremely low birth weight: <1000g
• Small for gestational age: < 10th centile or 2SD
below mean birth weight for gestational age
 Risk of prem
Fetal Maternal Others
Multiple gestation Placenta previa/abruptio Iatrogenic
IUGR Uterus abnormality Trauma
• Bicornuate uterus
• Cervival incompetence
• Myoma
Rh incompatibility Pre eclampsia Smoking
Fetal abnormality Chronic medical illness Drug abuse
Poly/oligohydramnnios Poor nutrition
Infection
• PROM
 Problems in premature infants
RESPIRATORY CARDIOVASCULAR BLOOD GASTROINTESTINAL

• RDS • PDA • Anemia • Paralytic ileus

• Apnea • Hypotension • Neonatal • NEC
• Pneumothorax • Bradycardia jaundice • Feeding
• Chronic lung • hypoprothrombi intolerance
disease/ nemia (poor motility)
bronchopulmon
ary dysplasia
ENDOCRINAL CNS RENAL OTHERS

• Hypothermia • IVH • Hyperkalaemia • Septicaemia

• Hypoglycemia/ • Periventricular • Metabolic • Neurodevelopm
hyperglycemia leukomalacia acidosis ental disability
• Rickets of • Retinopathy of • Psychosocial
prematurity prematurity problem
• Deafness
• hypotonia
Early complication
• Hypothermia: larger surface area, thin skin, less fat. Most of the heat loss
from evaporation, radiation, conduction and convection to surrounding
• Hypoglycemia
• Hyponatremia secondary to dehydration/transepidermal water loss and
immature kidney
• Hypocalcemia
• RDS: due to reduced surfactant and premature lung. Lungs mature at
35weeks.
• Apnea of prematurity: is pause of breathing >20s followed by
desaturation and bradycardia. Caused by immature respiratory centre,
lacks of pharyngeal ms tone and collapsed upper airway
• IVH : due to fragile blood vessels in germinal matrix above caudate
nucleus. Occurs in prem <32 weeks within 5days after birth
• Infection
• PDA
Late complication
• NEC: occurs within 1st week of life. Due to immature gut with
compromised circulation. Bacterial invasion within the ischemic
bowel.
• ROP: immature retina with limited blood supply  vascular
proliferation to ischemic area retinal detachment
• BPD/CLD: lung damage from prolonged use of artificial ventilation,
oxygen toxicity and infection
• PVL: necrosis of white matter at dorsal and lateral aspect of lateral
ventricle
• Anemia
• Prolonged jaundice
• Neurodevelopmental problem: cerebral palsy, mental retardation,
hearing loss, visual impairment, epilepsy
 Management
1. Before and during labor
– Know the antenatal and intrapartum history
– Prewarm incubator
– Prepare appropriate equipment for prem
2. Adequate resuscitation
– For extremley low birth weight use plastic wrapper upto neck to prevent evaporative
heat loss
3. Transfer from labor room/OT to NICU
– Use prewarmed transport incubator
– Continue CPAP/ventilate infant during transport and pulse oximetry monitoring if
available
4. Admission routine
– Quickly and accurately measure head circumfrence, weight, and length
– Placed on radiant warmer/ incubator
– Continue ventilation, maintain SaO2 90-94%
– Monitor vital sign
– Plot growth chart and asses gestational age by Ballad score
Ballard Score
Posture
Square window
Arm recoil
Popliteal angle
Scarf sign
Heel to ear
Skin
Lanugo
Plantar surface
Breast
Ear and eye
Male Genitalia
Female Genitalia
5. Immediate care for symptomatic infants
– Investigation necessary:
• Blood gases
• Blood glucose
• FBC
• Blood culture, CRP
• CXR
– Start on 10% dextrose drip or TPN as soon as possible
– Correct anemia/hypovolaemia
– Correct hypotension
– Starts inotroph infusion if hypotension persists
– Starts antibiotics
– Starts IV Aminophylline/ caffeine in prem <32 weeks
– Maintain SaO2 90-94% and PaO2 50-70mmHg
6. Immunization
– Hep B vaccine at birth if infant stable and BW>1.8kg
– BCG on discharge
– For long stayers, immunisation should follow chronological age
– Defer if presence of acute illness
7. Supplements
– IM Vitamin K o.5mg for BW<2.5kg, 1mg for BW>2.5kg at birth
– Once on full feeding, starts multivitamin drops 1mls OD, Vit D 400IU, Folic
acid 0.1mg OD
– Starting at 4 weeks of life, Elemental iron 2-3mg/kg/d for 3-4months
8. Screening
– Cranial USG at first week of life for IVH, at day 28 for PVL, and as clinically
indicated
– Screening for ROP at 4-6 weeks of age infant <32 weeks gestation and equal
to 1500g at birth. Also all prem <36weeks who receive oxygen
therapy(ventilated)
9. Discharge
– Discharge once showing good weight gain,
established oral feeding, age at least 35weeks,
and well upon Discharge
10. Prognosis

Gestation age Mortality rate Birth Weight Survival

>30 <5%
<1000g 80%
27-30 5-10%
25-26 10-50% 1000-1500g 90%
23-24 50-90%
>1500g 99%
<23w >97%
Reference:
• Peads Protocol for Malaysian Hospital 4th ed