Nasterea prematura

Sarcina prelungita

Nou-nscutul prematur

Frecvena = 5-10% din numrul total de

nateri.
Prematur =copilul nscut la mai puin de 37 de
sptmni de gestaie, cu o greutate mai mic
de 2.500 g i o lungime mai mic de 47 cm.
Dup greutate, poate fi

eutrofic (ntre 10-90 percentile pentru vrsta

gestaional)
hipotrofic (sub 10 percentile)
mare (peste 90 percentile).

Definition
By Mayo Clinic staf Most pregnancies last about 40
weeks. By definition, a premature birth takes place
more than three weeks before the due date.
A premature birth gives a baby less time to develop
and mature in the womb. The result is an increased
risk of various medical and developmental
problems, including trouble breathing and bleeding
in the brain. If you go into labor too early, your
doctor may try to delay your baby's birth. Even if
premature birth is inevitable, a few extra days in
the womb can promote significant development.
Although the rate of premature birth seems to be
on the rise, there's good news. A healthy lifestyle
can go a long way toward preventing preterm labor
and premature birth.

Symptoms
By Mayo Clinic staf Prompt recognition of preterm
labor may help you prevent premature birth. Even
months before your due date, be on the lookout
for:
Contractions that occur more than six times each
hour (You'll feel a tightening sensation in your
abdomen, often reminiscent of menstrual cramps.)
Low, dull backache
Pelvic pressure or pain
Diarrhea
Vaginal spotting or bleeding
Watery vaginal discharge (This may be amniotic
fluid, which surrounds your baby in the uterus.)
If you're concerned about what you're feeling,
contact your health care provider. Don't worry
about mistaking false labor for the real thing.

Risk factors
By Mayo Clinic staf Often, the specific cause of preterm labor or
premature birth isn't clear. Many factors may increase the risk of
early labor and premature birth, however. The most common risk
factors include:
Having a previous preterm labor or premature birth
Pregnancy with twins, triplets or other multiples
Problems with the uterus, cervix or placenta
Smoking cigarettes, drinking alcohol or using illicit drugs
Some infections, particularly of the amniotic fluid and lower
genital tract
Some chronic conditions, such as high blood pressure and
diabetes
Being underweight or overweight before pregnancy
Stressful life events, such as the death of a loved one or domestic
violence
Multiple miscarriages or abortions
For unknown reasons, black women are more than twice as likely
to experience preterm labor and premature birth than are women
of other races. But preterm labor and premature birth can happen
to anyone. In fact, many women who have a premature birth have
no known risk factors.

When to seek medical advice

By Mayo Clinic staf Proper prenatal care can
help you prevent preterm labor and
premature birth. If you're at risk of preterm
labor or premature birth, your health care
provider may recommend more frequent
visits.
If you develop any signs or symptoms of
preterm labor such as a watery vaginal
discharge or regular contractions 10 minutes
apart or less contact your health care
provider or hospital right away. It's a good
idea to keep these phone numbers handy so
that you can find them quickly.

Tests and diagnosis

By Mayo Clinic staf If preterm labor seems
likely, your health care provider will check
to see if your cervix has begun to dilate
and whether the fetal membranes have
ruptured. The duration and spacing of your
contractions may be closely monitored. In
some cases, your health care provider may
use ultrasound to monitor the length of
your cervix. A swab from the cervical canal
may be tested for the presence of fetal
fibronectin, a glue-like tissue lost during
labor.
If you're in preterm labor, you and your
health care provider will discuss the risks
and benefits of trying to stop your labor.

Complications
By Mayo Clinic staf Preterm labor and premature birth may have various complications.
For mothers
Aside from starting too early, preterm labor typically resembles normal labor. Treatments used to
delay delivery may carry risks, however. Medications that halt uterine contractions may cause fluid
to collect in your lungs, which can make it difficult to breathe. Other side efects depend on the
medication used to stop labor. Some medications can lead to fatigue and muscle weakness. Others
may cause a rapid heartbeat, blood sugar abnormalities, headaches, dizziness or nausea.
Your health care provider will weigh the potential risks from medications used to stop labor against
the risks for your baby if he or she is born too soon.
For babies
The risks of premature birth vary depending on how soon a baby is born. Although survival is
possible for babies born as early as 23 to 26 weeks, the risks are greatest for the youngest babies.
Complications of premature birth may include:
Difficulty breathing
Episodes of stopped breathing (apnea)
Bleeding in the brain (intracranial hemorrhage)
Fluid accumulation in the brain (hydrocephalus)
Cerebral palsy and other neurological problems
Vision problems
Intestinal problems
Developmental delays
Learning disabilities
Less serious complications may include:
Yellowing of the skin and whites of the eyes (jaundice)
Lack of red blood cells (anemia)
Low blood pressure
For some premature babies, difficulties may not appear until later in childhood or even adulthood.
Not performing well in school is often a prime concern. Some studies suggest that premature babies
may face an increased risk of type 2 diabetes and cardiovascular disease in adulthood.
But not all preemies have medical or developmental problems. By 28 to 30 weeks, the risk of
serious complications is much lower. And for babies born between 32 and 36 weeks, most medical
problems

Treatments and drugs

By Mayo Clinic staf
CLICK TO ENLARGE
Intensive care for your premature baby

Treatment may focus on women in preterm labor or on newborns after delivery.

For mothers
If you're experiencing preterm labor, treatment depends on your stage of pregnancy
and how far labor has progressed. Sometimes rest is enough to stop premature
contractions.
If you're not having contractions but your cervix is opening, a surgical procedure
known as cervical cerclage may help prevent premature birth. During this procedure,
the cervix is stitched closed with strong sutures. The sutures are removed in the last
month of pregnancy.
In other cases, your health care provider may recommend medication. Some
medications stop contractions by relaxing smooth muscles, including those of the
uterus. Others block the production of substances that stimulate uterine contractions.
These drugs may be given intravenously or by injection. Unfortunately, these
medications typically stop labor only briefly perhaps long enough to accomplish
other goals, such as transferring you to a facility better equipped to care for a
premature baby.
If your pregnancy is between weeks 23 and 34, your health care provider may
recommend an injection of potent steroids to speed your baby's lung maturity. After
week 34, steroids may not be needed because fetal lung development is more
advanced.
In a 2007 study, the heart drug nitroglycerin showed promise in stopping preterm
labor and reducing newborn illness. Nitroglycerin, which can be absorbed through the
skin, is thought to prolong pregnancy by relaxing the smooth muscles of the uterus.
Researchers suspect that it might improve blood flow to the uterus and placenta as
well. It's important to note that other drugs to stop labor have had similar early
findings, only to be disappointing in practice. Additional studies are needed before
nitroglycerin becomes a routine way to manage preterm labor.

For newborns
Hospital neonatal intensive care units (NICUs) are designed
to provide round-the-clock care for premature babies and fullterm babies who develop problems after birth. In the NICU,
your baby will probably be kept in an incubator an
enclosed plastic bassinet that's kept warm to help your baby
maintain normal body temperature. Because preemies have
immature skin and very little body fat, they often need such
care to stay warm.
Sensors may be taped to your baby's body to monitor blood
pressure, heart rate, breathing and temperature. Caregivers
may also use ventilators to help your baby breathe. This
high-tech equipment may seem overwhelming at first, but it's
all designed to help your baby.
At first your baby may receive fluids and nutrients through an
intravenous tube. Breast milk may be given later through a
tube passed through your baby's nose and into his or her
stomach. When your baby is strong enough to suck, breastfeeding or bottle-feeding is often possible. The antibodies in
breast milk are especially important for preemies.
Your baby's caregivers will help you learn how to touch and
eventually hold and feed your baby. Talk or sing softly to your
baby, or simply provide quiet company.

Taking your baby home

Your baby is ready to go home when he or
she:
Can breathe without support
Can maintain a stable body temperature
Can breast- or bottle-feed
Is gaining weight steadily
Your baby's health care team will help you
learn how to care for your baby at home.
Keep in mind that preemies are more
susceptible than are other newborns to
serious infections, and their illnesses tend to
progress more quickly. Schedule frequent
checkups for your baby. Routine checkups
are a great time to ask questions about
caring for your baby.

Coping and support

By Mayo Clinic staf Caring for a premature baby can be physically
and emotionally exhausting. You may be anxious about your baby's
health and the long-term efects of premature birth. You may feel
angry, guilty or overwhelmed. Some of these suggestions may help
during this difficult time:
Learn everything you can about your baby's condition. In
addition to talking to your baby's doctor and other caregivers, read
books on premature birth and look for information online.
Take care of yourself. Get as much rest as you can and eat healthy
foods. You'll feel stronger and better able to care for your baby.
Establish your milk supply. Use a breast pump until your baby is
able to breast-feed. Ask the hospital staf for help, if needed.
Accept help from others. Allow friends and family to help you.
They can care for your other children, prepare food, clean the house
or run errands. This helps you save your energy for your baby.
Keep a journal. Record the details of your baby's progress as well
as your own thoughts and feelings. You may want to include pictures
of your baby so that you can see how much he or she changes from
week to week.
Seek good listeners for support. Talk to your partner or spouse,
friends, family or your baby's caregivers. If you're interested, your
baby's caregivers may be able to suggest a support group in your
area. Many parents find it particularly helpful to talk to other parents
who are caring for a preemie.
Remember, caring for a premature baby is a great challenge. Take it
one day at a time.

Prevention
By Mayo Clinic staf A healthy lifestyle can go a long way toward preventing preterm
labor and premature birth.
Seek regular prenatal care. Prenatal visits can help your health care provider
monitor your health and your baby's health. Mention any signs or symptoms that
concern you, even if they seem unimportant.
Eat healthy foods. During pregnancy, you'll need more folic acid, calcium, iron,
protein and other essential nutrients. A daily prenatal vitamin that contains at least 1
milligram of folic acid ideally starting a few months before conception can help
fill any gaps.
Manage chronic conditions. Remember, uncontrolled diseases such as diabetes
and high blood pressure increase the risk of preterm labor. Work with your health care
provider to keep any chronic conditions under control.
Follow your health care provider's guidelines for activity. If you develop signs
or symptoms of preterm labor, your health care provider may suggest working fewer
hours or spending less time on your feet. Sometimes it makes sense to scale back
other physical activities, too.
Avoid risky substances. If you smoke, quit. Smoking may trigger preterm labor.
Alcohol and recreational drugs are of-limits, too. Even over-the-counter supplements
and medications deserve caution. Get your health care provider's OK before taking
any medications or supplements.
Ask your health care provider about sex. It's not a concern for women who have
healthy pregnancies. But sex may be of-limits if you have certain complications,
such as vaginal bleeding or problems with your cervix or placenta.
Limit stress. Set reasonable limits and stick to them. Set aside some quiet time
every day. Ask for help when you need it.
Take care of your teeth. Brush and floss daily, and visit your dentist for regular
cleanings and dental care. Some studies suggest that gum disease may be
associated with preterm labor and premature birth.
If you have a history of premature birth or significant risk factors for premature birth,
your health care provider may suggest weekly shots of the hormone progesterone.
Although much remains to be learned about progesterone therapy, initial studies
suggest that progesterone may help prevent preterm labor and premature birth in
some women.

Nou-nscutul prematur
Particulariti morfofuncionale comparativ cu nou nscutul la termen:

Capul = mare i reprezint 1/3 din talie ; suturile craniene=

craniene= dehiscente, fontanelele largi, oasele
parietale pergamentoase.
Faa = mic, triunghiular, gura mare, brbia ascuit.
Urechile = jos inserate, pavilioanele sunt fr pliuri i schelet cartilaginos. Gtul este subire i pare
mai lung. Eritemul fiziologic este mai accentuat 3-4 zile, apoi este nlocuit de icterul neonatal i
de o tent mai palid a tegumentelor. Pliurile plantare sunt reduse numeric i superficiale.
esutul celular subcutanat este slab reprezentat sau absent pe tot corpul. Cordonul ombilical
este mai jos implantat i mai subire.subire.- risc crescut de infectii
Toracele este mai ngust i contrasteaz cu abdomenul mai voluminos.
Unghiile nu ating pulpa degetului.
Oasele = slab mineralizate.
Organele genitale externe sunt incomplet formate:
la biei, testiculii nu sunt cobori n scrot, iar scrotul este puin plicaturat i pigmentat ;
la fetie, labiile mari nu acoper labiile mici i clitorisul.
Activitatea motorie este slab i de scurt durat.
Prezint o hipotonie generalizat care intereseaz att musculatura striat, ct i pe cea neted.
Respiraia este de tip abdominal, neregulat, cu apariia uneori a crizelor de apnee. Schimburile
gazoase la nivelul plmnilor sunt limitate de incompleta capilarizare alveolar.
Mecanica ventilatorie i schimburile gazoase mai sufer, datorit:
hipotoniei musculaturii toracice;
osificrii slabe a cutii toracice;
deficitului de surfactant alveolar (cantitativ i calitativ), care imprim o accentuat
tendin de colabare a alveolelor n expir.
Prezint o imaturitate a reflexelor de tuse i deglutiie, care face posibil aspirarea lichidelor
alimentare i secreiilor nazo-faringiene (cale fals).

Nou-nscutul prematur

Termoreglarea prezint defeciuni majore, datorate:

termogenezei limitate (rezerve energetice mici);
termolizei crescute (suprafa cutanat mare n raport cu greutatea);
imaturitii termostatului hipotalamic;
absenei esutului grsos subcutanat (izolator termic).
Icterul neonatal este prezent constant i este prelungit (10-15 zile).
Zgomotele cardiace sunt mai slabe.
untul prin orificiile fetale este mai frecvent, mai persistent i poate
prejudicia circulaia visceral.
Capacitile digestive sunt mai mici, att morfologic, ct i funcional
Absena sau imaturitatea reflexelor de supt i deglutiie = alimentaia prin
sond la prematurii foarte mici.
Funciile renale sunt net diminuate fa de ale nou-nscutului la termen.
Marile deficiene imunitare (umorale i celulare) = vulnerabilitate n faa
infeciei.
Imaturitatea morfo-funcional plurivisceral cauzeaz :

boala membranelor hialine,

hemoragia peri- i intraventricular,
crizele de apnee,
persistena canalului arterial,
enterocolita ulcero-necrotic i infeciile; acestea fac din prematur un nou-nscut cu
foarte mare risc.

Nou-nscutul prematur
Definiie. Prematurul = nou-nscutul cu o vrst gestaional sub 37
de sptmni n momentul naterii (< 256-260 zile).
Clasificare. Prematurii pot fi mprii, n funcie de maturitate i de
concordana cu vrsta gestaional, n:
prematur cu greutate la natere corespunztoare cu vrst
gestaional (prematur AGA - appro-priate size for gestational age);
prematur cu greutate la natere mai mare dect cea
corespunztoare vrstei gestaionale (prematur LGA - large for
gestational age);
prematur cu greutate la natere mai mic dect cea
corespunztoare vrstei gestaionale (prematur SGA smallforgestational age).

O clasificare arbitrar a prematuritii, n funcie de greutatea la

natere, mparte aceti nou-nscui n:
prematur gr. I: GN = 2.500-2.000 g;
prematur gr. II: GN = 1.999-1.500 g;
prematur gr. III: GN = 1.499-1.000 g;
prematur cu greutate foarte mic la natere: GN < 1.000 g.

Nou-nscutul prematur
Elemente morfologice.
La natere,
pielea-acoperit de vernix caseosa,
Marii prematuri - aspect asemntor cu cel al malnutriilor,
cu esut celular subcutanat absent, tegumente subiri,
uscate, largi i un craniu ceva mai voluminos fa de talie.

Craniul = aproximativ 1/3 din talie, suturile sunt dehiscente

i oasele parietale pergamentoase. Pavilionul urechii este
moale i inform, cartilajul nefiind nc dezvoltat.
Toracele este mai ngust, cu baza mai larg i abdomenul
mai voluminos.
Organele genitale externe - dezvoltate incomplet: la sexul
feminin, labiile mari nu acoper labiile mici; la sexul
masculin, testiculii nu sunt cobori n scrot
Sistemul nervos = mai puin dezvoltat, activitatea motorie
este mai slab i de scurt durat.
Tonusul muscular i reflexele se perfecteaz n timp.

Probleme ale prematuritii.

Dificultile de adaptare la viaa extrauterin sunt explicate prin imaturitatea
organic i funcional a prematurului.
Aparatul respirator

Prematurii - mari dificulti n adaptarea respiratorie i pot prezenta depresie

respiratorie n sala de natere. Apneea datorat insuficienei respiratorii este mai
frecvent la vrste gestaionale mici, fiind necesar tratamentul de susinere.

Pulmonii - deficit de surfactant, au o complian redus, iar ventilaia la presiuni

ridicate poate fi necesar -Sindromul de detres respiratorie

apneea - datorit imaturitii mecanismelor de control a respiraiei. Oxigenarea

deficitar poate duce la ntrzierea n dezvoltarea neuropsihomotorie ulterioar.

Alte cauze ale afectrii respiratorii : dezvolarea insuficient a reelei capilaroalveolare, fora sczut a musculaturii toracice, osificarea mai slab a cutiei toracice,
atelectazia secundar prin aspiraia secreiilor nazofaringiene sau a lichidelor
alimentare.

Analgezicele i anestezicele care trec prin placent inhib respiraia mai mult la
prematuri dect la maturi.

Nou-nscutul prematur are un risc crescut pentru bronhodispalzie pulmonar,

afeciunea Wilson-Mikity sau insuficien pulmonar cronic.

Neurologic
risc crescut pentru afeciunile neurologice acute, cum sunt:
hemoragia intracranian i depresia perinatal.
Caracteristic pentru prematur este hemoragia
intraventricular i subarahnoidian, care este precedat
frecvent de hipoxie i manifestat prin semne de oc
circulator cu tulburri neurologice
Cardiovascular
poate fi hipotensiv prin hipovolemie (pierderile sunt
exagerate datorit dimensiunilor reduse ale prematurului)
sau prin disfuncii cardiace i/sau vasodilataie produs de
sepsis.

Persistena canalului arterial este frecvent i poate

determina insuficien cardiac congestiva.

Hematologic
Este vorba n special de anemia de diferite etiologii. La
prematuri apare frecvent hiperbilirubinemia.
Nutriional
Prematurul necesit ngrijiri speciale - absena reflexului de
supt i capacitatea gastric limitat impune alimentaia n
gavaj, completat n primele zile cu alimentaia
parenteral.
Gastrointestinal
Prematuritatea este cel mai important factor de risc pentru
enterocolita necrozant.
Metabolism
Sunt afectate metabolismele calciului i ale glucozei

Nou-nscutul prematur

Renal
Imaturitatea renal=filtrare glomerular sczut i instabilitate
n economisirea apei i n meninerea echilibrului acido-bazic.
Se produce ncrcare cu radicali acizi prin alterarea eliminrilor
de uree, cloruri i fosfai.
Imunologic
deficit n rspunsul umoral i celular -risc crescut la infecie
La acesta se adaug:

dificulti n alimentaie cu risc de aspiraie,

manevre i explorri multiple,
cateterizri i perfuzii prelungite,
apa din incubatoare. Toate acestea cresc riscul apariiei meningitei
i septicemiei.

Oftalmologie
Retinopatia prematurilor poate aprea prin imaturitatea
retiniana. Examinarea vaselor capsulei anterioare a
cristalinului arat dispariia lor, progresiv, n sptmnile 2734.

Nou-nscutul prematur

Ingrijirea prematurului

ngrijirea postnatal imediat n sala de

natere:
Este foarte important ca naterea s aib loc
n prezena medicului specialist de obstetric,
a medicului specialist neonatolog

Resuscitarea i echilibrarea nou-nscutului

prematur

Aportul adecvat de oxigen la natere, aspirarea

secreiilor nazofaringiene i meninerea unei
temperaturi constante sunt principalele msuri ce
se instituie imediat postnatal.

Ingrijirea neonatal n
secia de nou-nscui:

Meninerea unei temperaturi constante urmrete respectarea zonei de

neutralitate termic, care se definete prin temperatura mediului n care este plasat
nou-nscutul, la care consumul de oxigen este minim, dar suficient pentru
meninerea temperaturii coporale la un nivel constant.

Pentru marii prematuri- adugarea unui radiant (incubator deschis) deasupra nounscutului sau utilizarea unui incubator nchis .

Temperatura n incubator este de 32,5-35,5C. Se controleaz repetat temperatura

incubatorului i a prematurului pn la stabilizarea ei la 36,7C. Se controleaz i
umiditatea (50-65%).

Oxigenoterapia i ventilaia asistat (meninerea respiraiei) se realizeaz prin

utilizarea echipamentului de reanimare adecvat n sala de travaliu i n secia de nounscui;

reanimare n caz de hipoxie; oxigenoterapia n caz de cianoz;

observarea atent a prematurului n primele zile, pentru depistarea sindromului de

detres respiratorie, a crizelor de apnee, a cianozei, stridorului i convulsiilor.

Nou-nscutul prematur
Terapia hidroelectrolitic
contracareaza potenialul crescut de pierderi sensibile de ap, cu
meninerea unei hidratri corespunztoare i o concentraie
normal de glucoza i electrolii plasmatici.
Scderea fiziologic permis la prematuri este de 5-15% n
primele 5-6 zile.
Rspunsul la terapia hidroelectrolitic trebuie evaluat frecvent n
primele dou zile de via.

Pierderile de ap prin urin i piele ajung pn la 200 ml/kg/zi,

ceea ce reprezint 1/313 din apa total din organism.

pierderile de lichide prin urin i piele - hipernatremie, necesitnd

determinri frecvente ale electroliilor serici i o cretere a ratei de
fluide parenterale administrate. De asemenea, tolerana sczut
la glucoza poate duce la hiperglicemie, cu scderea perfuziei de
glucoza - se administreaz glucoza 5%.

Folosirea perfuziei de insulina pentru tratarea hiperpotasemiei

poate fi necesar, dar exist risc de hipoglicemie iatrogen.

Nutriia - limitat prin inabilitatea multor prematuri de a avea reflex eficient de supt i de nghiire sau
de a tolera alimentaia enteral, astfel nct s fie necesar gavajul sau alimentaia parenteral.
Alimentaia precoce la 4-8 ore de la natere scade riscul de hipoglicemie, hiperbiliru-binemie i
catabolismul excesiv.

Prematurii cu greutate >2.250 g, care nu au dificulti respiratorii, se pot alimenta la sn.

Infeciile sunt frecvente dup naterile premature.

Antibiotice cu spectru larg se administreaz cnd suspiciunea de infecie este evident.
antistafilococice la nou-nscuii cu greutate foarte mic la natere, cnd s-au fcut manevre
multiple, sau care necesit o perioad mai lung de spitalizare
Pentru prevenirea infeciilor trebuie respectate urmtoarele reguli:
secie separat, cu spaii largi pentru fiecare pematur;
personal separat;
splarea frecvent a minilor (nainte i dup manevrarea prematurului);
posibiliti de izolare n cadrul seciei;
dezinfecie regulat.

ngrijiri speciale ale nou-nscuilor prematuri amintim:

Persistena canalului arterial, de obicei, necesit tratament conservator: oxigenarea adecvat,

restricii de fluide i, posibil, intermitent, diuretice, n majoritatea cazurilor simptomatice poate fi
necesar utilizarea unui antagonist de prostaglandine, cum ar fi indometacinul. De asemenea, poate
fi necesar ligatura chirurgical.
Hiperbilirubinemia este inevitabil de cele mai multe ori la prematuri, dar ea poate fi, de obicei, bine
controlat prin monitorizarea atent a nivelului bilirubinei. Pentru icter este indicat fototerapia, iar
n cazurile severe este necesar exanguinotransfuzia.

Pentru tratarea icterului la prematuri:

1. < 1.000 g: fototerapie n primele 24 ore; exanguinotransfuzie
pentru valori ale bilirubinei de 10-12 mg/dl;
2. 1.000-1.500 g: fototerapie pentru o bilirubina de 7-9 mg/dl;
exanguinotransfuzie pentru o bilirubina de 12-15 mg/dl;
3. 1.500-200 g: fototerapie pentru o bilirubina de 10-12 mg/dl;
exanguinotransfuzie pentru o bilirubina de 15-18 mg/dl;
4. 2.000-2.500 g: fototerapie pentru o bilirubina de 13-15 mg/dl;
exanguinotransfuzie pentru o bilirubina de 18-20 mg/dl.

Complicaiile prematuritii
Sindrom de detres respiratorie idiopatica (boala membranelor
hialine);
Hemoragia intraventricular;
Retinopatia prematuritii (fibroplazia retro-lental);
Hiperbilirubinemia;
Anemia precoce a prematurului.

Nou-nscutul prematur
Prognostic i supravieuire
Sunt n funcie de gradul prematuritii (vrst gestaional i
greutate la natere), de afeciunile respiratorii, malformaii
congenitale majore i de prezena depresiei perinatale, a
infeciilor, hemoragiei intracraniene, displaziilor sanguine.
Cei mai afectai sunt nou-nscuii care sunt i prematuri i
dismaturi.
Prematuritatea reprezint cauza principal de deces neonatal:
prematuri gr. I -5-10% mortalitate;
prematuri gr. II - 10-40%;
prematuri gr. III-IV -30-100%.
Sunt cunoscute trei vrfuri de mortalitate:
Primele 24 h (cel mai mare), prin insuficien respiratorie;
Urmtoarele 24 h (mai redus), prin boli pulmonare i
hemoragie ventricular;
Al treilea vrf, mai mic i mai tardiv, prin infecie.

Nou-nscutul prematur
Criterii de externare

Iniial, s-a considerat c greutatea este cel mai important criteriu de externare. La nceput
se vorbea de 2.500 g, mai trziu de 2.250 g, iar mai nou, n majoritatea serviciilor,
greutatea nu mai este considerat un element determinant de externare. Mult mai
important dect greutatea specific este considerat acum starea general a nounscutului.

n general, un nou-nscut care nu este dependent de oxigen, care poate fi alimentat la sn,
care poate tolera temperatura normal din ncpere i care prezint o cretere ponderal
progresiv, fr apnee, este, din punct de vedere medical, pregtit pentru externare.

Este, de asemenea, important ca prinii s fie responsabili i s se simt apropiai afectiv

de aceti nou-nscui (majoritatea prinilor cu prematuri sunt stresai de luarea nounscutului acas). Cteva zile de contact cu nou-nscutul n sistemul rooming-in sunt foarte
indicate nainte de externare, pentru ca ei s nvee regulile de alimentaie i ngrijire a
acestor nou-nscui.

Majoritatea nou-nscuilor cu greutate foarte mic la natere pot fi mutai din incubator la
1.750-1.800 g, iar unii, care sunt mici pentru vrsta gestaional, dar cu aproximativ 36 de
sptmni de gestaie, pot fi mutai din incubator la greuti chiar mai mici.

Sunt unele circumstane n care nu toate criteriile de externare sunt ndeplinite, dar
externarea este posibil. De exemplu, unii nou-nscui cu bronho-displazie pulmonar, care
sunt oxigenodependeni, dar care au n rest o adaptare normal. Externarea cu administrare
de oxigen acas are multe beneficii (nu n ultimul rnd reducerea costului ngrijirii medicale
spitaliceti).

Un factor deosebit de important, de care depinde externarea prematurului, este reprezentat

de existena, acas, a unor condiii satisfctoare socio-economice.

Nou-nscutul prematur
Probleme, acas, dup externare

ngrijirea i urmrirea nou-nscutului la domiciliu se face de ctre medicul

de familie i sor.

Este important de tiut c nou-nscutul cu bronhodisplazie pulmonar,

afeciune foarte frecvent la nou-nscuii cu greutate foarte mic la natere,
poate necesita oxigenoterapie acas.
Aceti nou nscui au o susceptibilitate aparte la infecii cu virus sinciial
respirator.

Retinopatia prematuritii trebuie rezolvat nainte de externare.

Alte probleme oftalmologice, de exemplu strabismul, sunt frecvente la
prematuri.

Scderea sensibilitii auditive, care poate determina o ntrziere n

articulare i vorbire, trebuie urmrit la toi nou-nscuii cu greuti sub
1.500 g. Sunt necesare suplimentri de fier i multivitamine. n ciuda
acestor suplimentri, muli prematuri au o cretere ntrziat n greutate, cu
frecvente afeciuni medicale i intervenii chirurgicale.

n unele familii, naterea unui prematur exagereaz conflictele interfamiliale

nainte i dup externarea nou-nscutului. De asemenea, poate aprea i
sindromul copilului vulnerabil, cu prini care creeaz un mediu
hiperprotectiv. Acest fenomen poate fi prevenit prin intervenia medicului de
familie.

Nou-nscutul mic pentru vrsta gestaional

(cu malnutriie fetal, dismatur etc.)

Se definete ca nou-nscutul cu greutate la natere sub 10

percentile fa de vrsta gestaional.
Reprezint 3% din totalul naterilor i 33% din totalul nounscuilor cu greutate la natere mai mic de 2.500 g.
Dup criterii anatomo-clinice, se desting dou tipuri de
malnutriie fetal: forma hipotrofic sau tipul disarmonic i
forma hipoplazic sau tipul armonic.
Tipul disarmonic (asimetric) reprezint forma cea mai
frecvent ntlnit i pare a fi consecina unei disfuncii
placentare de ultim trimestru. Nou-nscuii prezint aspect
de copii slabi, subiri i lungi, cu craniu aparent voluminos,
faa triunghiular, fruntea ncreit, tegumente subiri, pliu
cutanat adesea persistent, mase musculare reduse.
Comparativ cu prematurul, au un comportament vioi,
privirea vie, reflexele arhaice exagerate, musculatura
hiperton, tremurturi ale extremitilor, apetitul n general
bun.

Tipul disarmonic (asimetric) reprezint forma

cea mai frecvent ntlnit i pare a fi
consecina unei disfuncii placentare de
ultim trimestru. Nou-nscuii prezint aspect
de copii slabi, subiri i lungi, cu craniu
aparent voluminos, faa triunghiular,
fruntea ncreit, tegumente subiri, pliu
cutanat adesea persistent, mase musculare
reduse. Comparativ cu prematurul, au un
comportament vioi, privirea vie, reflexele
arhaice exagerate, musculatura hiperton,
tremurturi ale extremitilor, apetitul n
general bun.

Tipul armonic (simetric) nu se poate diferenia uor de

prematuritate, deoarece ntrzierea n cretere intereseaz n
mod egal greutatea, talia, perimetrul toracic i organele
interne. Aceast form se instaleaz n prima parte a sarcinii
i este determinat de factori infecioi, aberaii
cromozomiale, malformaii congenitale. Dac hipotrofia este
asociat cu unul din semnele: purpur, icter,
hepatosplenomegalie, microcefalie, anomalii oculare, este
foarte evocatoare pentru o infecie fetal.
Strile morbide pe care le antreneaz malnutriia fetal sunt
precoce i tardive. Intre cele precoce enumerm: inhalaia
meconial, acidoza, anoxia cerebral, hipoglicemia,
hipocalcemia, poliglobulia, hipotermia i hemoragia
pulmonar. Dintre complicaiile tardive, menionm alterarea
ritmului de cretere corporal i microsechelele cerebrale.
Cele mai grave sechele neurologice apar la cazurile la care
malnutriia a debutat n primele 20 de sptmni de gestaie,
cnd multiplicarea nuronal este mai activ (microcefalie).
Disfuncii cerebrale se ntlnesc la aproximativ 25% din
totalul malnutriilor; adesea se semnaleaz, la distan,
comiialitatea.

Nou-nscutul postmatur

Postmaturul este copilul nscut dup 42 de sptmni de amenoree.

La postmatur lipsete vernix caseosa, pielea este palid, fisurat,
pergamentoas, uneori verzuie, datorit impregnrii cu meconiu (la
fel cordonul ombilical).
Paniculul adipos subcutanat este redus, ca i greutatea corporal,
datorit prelungirii anormale a gestaiei. Postmaturul are unghii lungi,
pr abundent, craniu aparent mai dur, ochii larg deschii i facies
vioi.
Postmaturul este un copil cu mare risc, are scorul APGAR sub 5 la 1
minut la 50% din cazuri i poate prezenta n primele ore (zile):

acidoz metabolic major,

detres respiratorie prin inhalaie amniotic,
semne de suferin cerebral,
hipoglicemie.

Prognosticul imediat i tardiv sunt rezervate i mortalitatea este de 24 ori mai crescut fa de celelalte categorii de nou-nscui.