Raja Nandyal, M.D; F.A.A.P; Associate Professor of Pediatrics Neonatal Section-Department of Pediatrics OUHSC July 22 nd 2011

Speaker Disclosure: I have no financial relationships or affiliations to disclose I am a full time faculty member of Oklahoma University Health Sciences center (the department of Pediatrics) and Oklahoma University Children’s Physicians group There is no reference to off-label or investigational use of drugs or products in my presentation I am a member of the National Perinatal Association’s Steering Committee working on “the Guidelines for the Care of the Late Preterm Infants” with 11 others. I am also the chairman of the Oklahoma Infant Alliance organization which in September 2010 published its Guidelines Dr. Tonse N.K. Raju of NICHD who worked on Late Preterm Infants’ project was one of my mentors. 2

OBJECTIVES: The audience at the end of the presentation: 1. Will be able to define the terms- Late Preterm and Early Term Infant 2. Will be able to list 3 common complications of Early Term Births 3. Will be able to state 3 common reasons for Early Term Delivery

Human contributions : Mona Lisa ( AD)- Leonardo da Vinci

Taj Mahal (1632 to 1653 AD)- Moghul Emperor Shah Jahan

A Term Infant: Nature’s Master Piece

Early Term : Another Unfinished MP- needs several finishing touches

DEFINITION of the WORDS- Preterm, Late Preterm, Term and Early Term.

The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) Defined a “preterm” infant as one who is born before the end of the 37th week (259th day) of pregnancy, counting from the first day of the last menstrual period A wide range of gestational-age combinations exist between 33 weeks and term Descriptive terms such as “marginally preterm,” “moderately preterm,” “minimally preterm,” and “mildly preterm” have been used to describe this subset of preterm infants Optimizing Care and Outcome for Late-Preterm (Near-Term) Infants. Tonse Raju et al. Pediatrics 2006; 118;

NICHD Consensus Panel The NICHD Consensus Panel suggested designating the gestational ages of 34 weeks and 0/7 days through 36 weeks and 6/7 days (239th–259th day) as “late preterm” and discontinue the use of the phrase “near term” The panel felt that “near term” conveyed an impression that these infants are “almost term,” resulting in underestimation of risk and less diligent evaluation, monitoring, and follow-up The panel confirmed that gestational age should be rounded off to the nearest completed week, not to the following week. Thus, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks Optimizing Care and Outcome for Late-Preterm (Near-Term) Infants. Tonse Raju et al. Pediatrics 2006; 118;

What is term then? What is term then? WHO defined a term pregnancy at a GA ranging between 37 0/7 weeks and 41 6/7 weeks) In USA, until the beginning of the last decade, a term pregnancy was considered- ranging between GA of 38 0/7 weeks to 41 6/7 weeks, because of evidence of increased morbidity in so called “37 weekers”. But, we changed (had to) our definition, to be in sync with “WHO” s definition. Lot of us are not happy as there was old data which showed 37 weekers (and even 38 weekers) had increased morbidity like transient tachypnea (wet lung), feeding problems, jaundice, increased readmissions etc.

Are there differences between and weeks? Currently, GA starting with 37 0/7 weeks and ending with 38 6/7 weeks is called as “the Early Term”. New data is now accumulating rapidly covering these GAs. EVERY WEEK COUNTS” AGAIN EMPHASIZING THE FACT THAT “EVERY WEEK COUNTS” I am going to present some available data looking at morbidity and mortality of 37 and 38 weekers when compared to 39 to 41 weekers

ACOG Evidence-Based Guidelines: No elective induction or elective cesarean delivery before 39 weeks unless evidence of fetal lung maturity To assess fetal lung maturity an amniocentesis is usually done to collect amniotic fluid for testing There are potential risks as for any invasive procedure ACOG Practice Bulletin no.10; November ACOG Practice Bulletin No. 10, November, 1999.

Inductions of Labor: ACOG Since 1979, ACOG has cautioned against inductions before 39 weeks in the absence of a medical indication. Confirmation of gestational age is CRITICAL: Ultrasound before 20 weeks gestation to establish accurate gestational age of the fetus Documentation of fetal heart tones for 30 weeks using Doppler ultrasonography Confirmation that it has been 36 weeks since a positive pregnancy test was obtained

Terminology: Modified from Drawing courtesy of William Engle, MD, Indiana University Raju TNK. Pediatrics, 2006; First day of LMP 0 Week # 37 0/7 41 6/7 PretermTermPost term 34 0/7 20 0/7 39 0/7 Late PretermEarly Term

Q1: The Preterm Birth Rate in US is- A: Increasing B: Decreasing because of major advances in OB care C: No change

Q1: The Preterm Birth Rate in US is- A: Increasing (most of the increase is because of increase of LPI) B: Decreasing because of major advances in OB care C: No change

What’s the BIG DEAL? (about these Early Term Infants?)

Change Change in Distribution of Births by G.A: United States, Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics Source: CDC/NCHS, National Vital Statistics Systems.

U.S. Cesarean Section and Labor Induction Rates- Among Singleton Live Births by Week of Gestation, 1992 and Source: NCHS, Final Natality Data, Prepared by March of Dimes Perinatal Data Center, April Induction 2002 C-S 1992 C-S 1992 Induction Early Term

Rates of Induction of Labor by Race and Hispanic Origin in the U.S. Martin JA, Hamilton BE, Sutton PD, Ventura SJ, et al. Births: Final data for National vital statistics reports; vol 57 no 7. Hyattsville, MD: National Center for Health Statistics

US Cesarean Section Rates: Final ; Preliminary 2007 and Vital Statistics, April 10, 2010

Elective Induction: Sounds like a good idea… (to a lot of Hospitals, Physicians and Families) Advanced planning Mother lives far away; history of quick labors Delivered by her doctor Maternal intolerance to late pregnancy Excess edema, backache, indigestion, insomnia Prior bad pregnancy And, it’s okay right? Clin Obstet Gynecol 2006;49:

Women’s Perceptions:

Obstetric Gynecol 2009;114:1254

The Gestational Age that Women Considered a Baby to be Full Term Obstet Gynecol 2009;114:1254

The Gestational Age that Women Considered it Safe to Deliver Obstet Gynecol 2009;114:1254 Weeks of Gestation

“Non-medical” Indications Often Given for Inductions Maternal intolerance to late pregnancy Excess edema, backache, indigestion, insomnia Prior labor complication Prior shoulder dystocia Suspected fetal macrosomia History of rapid labor/ lives far away Possible lower risk for mom or baby Lower stillbirth rate, less macrosomia, less preeclampsia

What Motivates Some Obstetricians to Perform Elective Inductions? Physician convenience Guarantee attendance at birth Avoid potential scheduling conflicts Reduce being woken at night … what’s the harm? Amnesia due to rare occurrence The NICU can handle it And… Clin Obstet Gynecol 2006;49:

Suspected Fetal Macrosomia (Non-Diabetic Population) Does not reduce risk of shoulder dystocia Doubles risk of cesarean delivery 262 pregnancies EFW >90% Elective group: 57% cesarean delivery rate 5.3% shoulder dystocia Spontaneous labor group: 31% cesarean delivery rate 2.5% shoulder dystocia Combs et al. Obstet Gynecol 1993; 81:

Obesity in Childbearing Years: Obesity epidemic is growing C-section likelihood increases Risk of late preterm infants increases May enhance future problems in this population

Still, What’s the Big Deal?? (about Early Term Deliveries!!)

Complications of Non-medically Indicated (Elective) Deliveries Between 37 and 39 Weeks: Clark 2009, Madar 1999, Morrison 1995, Sutton 2001, Hook 1997 Increased NICU admissions Increased transient tachypnea of the newborn (TTN) Increased respiratory distress syndrome (RDS) Increased ventilator support Increased suspected or proven sepsis Increased newborn feeding problems and other transition issues

Morbidity of Late Preterm Infants in Massachusetts Late preterm infants : 22.2% vs Term infants : 3% Sample: Term (377,638), Late Preterm (26,170) Morbidity rates doubled for each gestational week earlier than 38 weeks 40 wks: 2.5% 39 wks: 2.6% 38 wks: 3.3% 37 wks: 5.9% 36 wks: 12.1% 35 wks: 25.6% 34 wks: 51.9% Shapiro-Mendoza CK et al. Effect of late-preterm birth and maternal medical conditions on newborn morbidity risk. Pediatrics. 2008;121:e223–e232

Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Absolute Risk Adapted from Tita AT, et al. NEJM 2009;360:111

Adverse Neonatal Outcomes According to Completed Week of Gestation at Delivery: Odds Ratios Adapted from Tita AT, et al. NEJM 2009;360:111

NICU Admissions By Weeks Gestation Deliveries Without Complications, Oshiro et al. Obstet Gynecol 2009;113: NICU Admissions

RDS By Weeks Gestation Deliveries Without Complications, Oshiro et al. Obstet Gynecol 2009;113: RDS

Ventilator Usage By Weeks Gestation Deliveries Without Complications, Oshiro et al. Obstet Gynecol 2009;113: Ventilator Use

Proportion of Patients At Each EGA: ( Data Based on 434,665 NICU infants where Respiratory Support Type Was Reported, ) Source, Pediatrix Clinical Data Warehouse

Q2: The Brain volume of a 34 weeker is- A: 1/3rd of the size of the term baby’s brain B: 2/3rd of the size of the term baby’s brain C: 4/5 th of the size of the term baby’s brain D: same as the size of the term baby’s brain

Q2: The Brain volume of a 34 weeker is- A: 1/3rd of the size of the term baby’s brain B: 2/3rd of the size of the term baby’s brain C: 4/5 th of the size of the term baby’s brain D: same as the size of the term baby’s brain

Late Preterm Infants: Brain Development Huppi et al. Ann Neurol 1998; 43:224-35

Growth Charts: Head Circumference

Morbidity for Infants by gestational Age Morbidity = >5d in hospital, transfer for higher care level, or death Massachusetts Shapiro-Mendoza, et al., Pediatr., 121, 2008

Acquired GI Disease Proportion By EGA: Acquired GI Disease Proportion By EGA: Source, Pediatrix Clinical Data Warehouse

Singleton NMR by GA (weeks) by Race and Ethnicity Singleton NMR by GA (weeks) by Race and Ethnicity Reddy et al- Obstet Gynecol 2011; 117:

Infant Mortality Rate by GA among singleton live births Infant Mortality Rate by GA among singleton live births Reddy et al- Obstet Gynecol 2011; 117:

Infant Mortality among Late Preterm and Term Singletons, United States, Rate per 1,000 live births Late preterm is between 34 and 36 weeks gestation Source: National Center for Health Statistics, period linked birth/infant death data Prepared by March of Dimes Perinatal Data Center, 2007

Q3: Early Term infant’s Morbidities include- A: Respiratory distress B: Jaundice C: Feeding difficulties D: Hypoglycemia E: Temperature instability F: Sepsis G: All of the above

Q3: Early Term infant’s Morbidities include- A: Respiratory distress B: Jaundice C: Feeding difficulties D: Hypoglycemia E: Temperature instability F: Sepsis G: All of the above

After Finishing Touches:::::::::::::::::::::::::::::::::::::::

Questions???????????????? 72