COMPLICATIONS OF PREMATURITY Mona Khattab, MD Neonatal-Perinatal Fellow Yale University Children’s Hospital
I am not just a “Small” baby… I am a “Preterm” baby… I am not just a “Small” baby… I am a “Preterm” baby…. I am a “Unique Baby”… with “Unique Problems”!!
Definition-Magnitude of Problem Prematurity < 37 completed weeks Accounts for 1/3 of infant deaths in USA, 45% cerebral palsy, 35% vision impairment, and 25% cognitive or hearing impairment. Risk of complications increases with increasing immaturity
Classification based upon GA: Late preterm birth — GA between 34 and < 37 weeks Very preterm birth — GA < 32 weeks Extremely preterm birth — GA ≤ 28 weeks
Classification by BW Low birth weight (LBW) < 2500 g Very low birth weight (VLBW) < 1500 g Extremely low birth weight (ELBW) < 1000 g
YOUR TURN Short-term complications Long-term complications Proper stabilization in the DR is important to reduce risk of short-term complications decrease long term complications.
SHORT-TERM COMPLICATIONS Hypothermia Respiratory abnormalities: RDS, pneumothorax Cardiovascular abnormalities: PDA, hypotension Central nervous system: IVH, PVL Metabolic: Hypo/ hyperglycemia, hypo/hypernatremia, hypo/hyperkalemia Gastrointestinal: NEC, perforations Immune system: Sepsis, meningitis, UTI Eyes: Retinopathy of prematurity
EPIDEMIOLOGY NICHD 8515 VLBW study: Respiratory distress: 93% Retinopathy of prematurity: 59% Patent ductus arteriosus: 46% Bronchopulmonary dysplasia: 42% Late-onset sepsis: 36% Necrotizing enterocolitis: 11% Grade III and Grade IV IVH: 7 and 9% Periventricular leukomalacia: 3%
HYPOTHERMIA Relatively large body surface area and inability to produce enough heat. Heat loss by conduction, convection, radiation, and evaporation. Sequale: hypoglycemia, acidosis, apnea Greatest risk for hypothermia immediately after birth in the delivery room. Admission temperature is inversely related to mortality and late-onset sepsis.
Standard care in DR to prevent hypothermia Maintain the delivery room temperature Drying the baby thoroughly immediately after birth Removal of any wet blankets Use of prewarmed radiant heaters Polyethylene/polyurethane body wrap or bags, and polyethylene or stockinet caps) or External heat sources ( skin to skin care and transwarmer mattress)
RESPIRATORY COMPLICATIONS RDS: incidence and severity increase with decreasing gestational age. Bronchopulmonary dysplasia, CLD, defined as oxygen dependency at 36 weeks postmenstrual age (PMA) Apnea of prematurity: 25% of preterm infants. Incidence increases with decreasing gestational age
CARDIOVASCULAR COMPLICATIONS PDA: Symptomatic 30% VLBW Shunts blood flow from left-to-rightincrease pulmonary flow and decreased systemic circulation. Severity depends upon size and response of the heart and lungs. Significant shunting hypotension, oligurea, apnea, respiratory distress, or heart failure
CARDIOVASCULAR COMPLICATIONS Systemic hypotension : in the immediate postnatal period significant morbidity (IVH) and mortality. Volume expansion: crystalloid (eg, normal saline) and colloid (eg, fresh frozen plasma) Inotropic therapy: (dopamine, epinephrine) Systemic glucocorticoid therapy: refractory hypotension or those who required high dose inotropic therapy (adverse effects: intestinal perforation and long-term poor neurodevelopment outcome (eg, cerebral palsy)
CNS COMPLICATIONS Intraventricular hemorrhage: in the fragile germinal matrix and increases with decreasing BWbirth. Incidence of severe IVH (Grades III and IV) 12-15%in VLBW Preventive measures: prompt and appropriate resuscitation, avoid hemodynamic instability and conditions that impair cerebral autoregulation (eg, hypoxia, hypercarbia, hyperoxia, and hypocarbia).
METABOLIC COMPLICATIONS Glucose abnormalities: hypoglycemia or hyperglycemia Blood glucose concentration should be monitored routinely starting immediately after birth and continued until feedings are well established and glucose values have normalized “Other metabolic abnormalities will be discussed separately”
GI COMPLICATIONS Necrotizing enterocolitis (NEC): 2-10 percent of VLBW infants. associated with increase in mortality. Survivors are at increased risk for growth delay and neurodevelopmental disabilities.
INFECTION Classification: Early onset sepsis Late-onset sepsis Risk factors for infection: Prolonged intubation, BPD, prolonged intravascular access, PDA, and NEC. Neonatal sepsis is associated with increased likelihood of poor neurodevelopmental outcome and growth impairment.
EYE Retinopathy of prematurity (ROP): Developmental vascular proliferative disorder occurs in the incompletely vascularized retina of premature infants. Incidence & severity of ROP increases with decreasing gestational age or birth weight. Typically begins about 34 weeks(PMA), but may be seen as early as 30 to 32 weeks. Next to cortical blindness, ROP is the most common cause of childhood blindness in the USA.
Pathogenesis of ROP Hypotension, hypoxia, or hyperoxia, with free radical formation, injures newly developing blood vessels and disrupts normal angiogenesis neovascularization retinal edema, hemorrhage and abnormal fibrovascular tissue development.
LONG-TERM COMPLICATIONS Neurodevelopmental outcome: Impaired cognitive skills Motor deficits including mild fine or gross motor delay, and cerebral palsy Sensory impairment including vision and hearing losses Behavioral and psychological problems Poor growth compared to those born full-term Impairment of lung function
EFFECT ON ADULT HEALTH Insulin resistance Hypertension and vascular abnormalities Reproduction: Prematurity has been associated with decrease reproduction in adulthood.
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