1. COMPLICATIONS OF PREMATURITY
Mona Khattab, MD
Neonatal-Perinatal Fellow
Yale University Children’s Hospital

2. 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”!!

3. 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

4. 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

5. Classification by BW Low birth weight (LBW) < 2500 g
Very low birth weight (VLBW) < 1500 g
Extremely low birth weight (ELBW) < 1000 g

6. 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.

7. 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

8. 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%

9. 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.

10. 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)

11. 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

14. CARDIOVASCULAR COMPLICATIONS
PDA: Symptomatic 30% VLBW
Shunts blood flow from left-to-rightincrease 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

15. 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)

16. 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).

17. 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”

18. 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.

21. 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.

22. 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.

23. 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.

32. 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

33. EFFECT ON ADULT HEALTH Insulin resistance
Hypertension and vascular abnormalities
Reproduction: Prematurity has been associated with decrease reproduction in adulthood.

34. THANK YOU 