Our Daily Bread: Trial by Fire

Blessed is the one who perseveres under

12 

trial because, having stood the test, that person will

receive the crown of life that the Lord has promised
to those who love him.

James 1:12
 The High
Risk Infant
Objectives
 Togive an overview on factors causing infants to
have high-risk for morbidity and mortality
 To discuss the risks brought about by:
 Multiple-gestation pregnancies
The High-Risk Infant
 High-risk infant – an infant who should be under close
observation by experienced personnel
 Risk should be identified as early as possible prenatally or
after birth to decrease neonatal morbidity and mortality
Factors the define an infant as being high-
risk
 Demographic Social Factors
 Past Medical History
 Previous Pregnancy
 Present Pregnancy
 Labor and Delivery
 Neonatal factors
Factors the define an infant as being high
risk
Demographic Social Past Medical Previous Pregnancy
Factors History • IUFD
• Genetic disorders • Neonatal death
• Diabetes Mellitus • Prematurity and IUGR
• Maternal age < 16 or • Congenital
• Hypertension
> 40 • malformation
Asymptomatic
• Illicit drug, alcohol, or • Incompetent cervix
bacteriuria • Blood group
cigarette use • Rheumatologic
• Poverty sensitization, jaundice
illness (SLE) • Neonatal
• Unmarried
• Immune-mediated thrombocytopenia
• Emotional or physical
diseases • Hydrops
stress • Medications • IEMs
Factors the define an infant as being
highrisk
Present Pregnancy
• Vaginal bleeding
• STIs
• Multiple gestation
• Preeclampsia
• PROM
• Short interpregnancy time
• Poly/oligohydramnios
• Acute medical or surgical
illness
• Inadequate prenatal care
• Hypercoagulable states
• Abnormal fetal UTZ
findings
• Infertitility treatments
Labor and Delivery Neonatal Factors
• Premature labor
• Postdates pregnancy • Birthweight <2.5 or >4
• Fetal distress • AOG < 37 or > 42
• Immature L:S ratio; weeks
absence of • SGA/LGA infant
phosphatidylglcerol • Respiratory distress
• Breech presentation • Cyanosis
• Meconium-stained • Congenital
• Nuchal cord malformation
• CS or forcep delivery • Pallor, plethora, and
• APGAR <4 at 1st MOL petechia
Examination of the placenta, cord, and
membranes
Remember!
 For any given duration of gestation, the lower the
birthweight, the higher the neonatal mortality
 For any given birthweight, the shorter the gestational
duration, the higher the neonatal mortality
 Highest risk: BW< 1000 grams and AOG < 28 weeks
 Lowest risk: BW 3000-4000 grams and AOG 39 – 41 weeks
 Multiple
Gestation
Pregnancies
Multiple Gestation Pregnancies
 Incidence: Highest in blacks and East Indians  European
whites  Asians
 Incidence of monozygotic twins – unaffected by familial
and racial factors
 Increasing overall incidence  infertility treatments and in
vitro fertilization
 Approximately 15% of ELBW infants are from multiple
gestation pregnancies
Polyovular pregnancies
 More frequent:
 Beyond 2nd pregnancy
 Older women
 Family history of polyovular twins
 May result from simultaneous maturation of multiple
ovarian follicles
 Conjoined Twins
 1/50,000 births  Site of connection:
  Thoroomphalogus – 28%
Most are female
 Thoracophagus – 18&
 Due to late monovular separation  Omphalogus – 10%
 Prognosis depends on possibility of  Craniphagus – 6%
surgical separation and extent of vital  Incomplete duplication – 10%
organs shared
Multiple Gestation Pregnancies
 Superfecundation – fertilization of an ovum by an
insemination taking place after 1 ovum has already been
fertilized
 Superfetalization – fertilization and subsequent
development of an embryo when a fetus is already
present in the uterus
Diagnosis
 Uterine size greater than expected
 2 fetal heart tones on auscultation
 Elevated maternal serum α-fetoprotein or β-hCG
 Confirmatory: Ultrasound
Monozygotic versus Dizygotic
Twins
 Different sex – dizygotic
 Same sex – zygosity should be determined at birth
 Examination of placenta
 Detailed blood typing
 Gene analysis
 Tissue (HLA) typing
Examination of the
Placenta
 Separate placentas – dichorionic
 Twins are not necessarily dizygotic, may be monozygotic
 ALL dizygotic twins are dichorionic
 Monochorionic twins are usually diamnionic with the
placenta usually as a single mass
Examination of the
Placenta
Postnatal Identification –
Physical Criteria
1. Both must be of the same sex;
2. Their features, including ears and teeth, must be obviously alike
3. Their hair must be identical in color, texture, natural curl, and
distribution
4. Their eyes must be of the same color and shade
5. Skin must be of the same texture and color
6. Hands and feet must be of the same conformation and of similar size
7. Anthropometric values must show close agreement
Problems of Twin
Gestation
 Polyhydramnios  Vasa previa
 Hyperemesis gravidarum  Velamentous insertion of
the umbilical cord
 Preeclampsia
 Abnormal presentations
 Premature rupture of (breech)
membranes
 Premature labor
Problems of Twin
Gestation
 Obstruction of the  Congenital anomalies
circulation secondary to  Compression deformation
intertwining of the  Vascular communications
umbilical cords
 Other unknown factors
 Widely discrepant size of
twins
 Risk of RDS and asphyxia
especially in second twin
 Intrauterine growth
restriction
 Twin-twin transfusion
Problems of Twin
Gestation
 Placental Vascular
Anastomoses
 Occur in monochorionic twins
 Artery-to-artery and vein-vein
anastomoses  acardiac fetus
secondary to twin reversed
arterial perfusion (TRAP)
syndrome
 Treatment: Nd:YAG laser ablation
Twin-twin transfusion
syndrome
 Artery from donor twin acutely or chronically delivers blood to the vein of the
recipient twin
 Difference of 5 g/dl hgb and 20% body weight develops with chronicity of
transfusion
 Donor twin may die in utero resulting to fibrin thrombi in recipient twin  DIC
 Treatment:
 Transfusion to donor twin and partial exchange transfusion to recipient twin
 Maternal digoxin, aggressive amnioreduction, selective twin termination and Nd:
YAG laser ablation
Twin-
twin
transfusio
n
syndrome
Prognosis
 Maternal complications are more common, as are
premature deliveries
 ~4x higher perinatal mortality than singletons

 increased
 Triplet and Higher order gestations
risk of death or neurodevelopmental impairment
 Higher mortality in 4 or more fetal gestations
Prematurity and
Intrauterine
Growth
Restriction
Post-term
Infants
 Large for
Gestational
Age Infants