Prematurity

5TH YEAR LECTURE

Definitions
 Preterm (or premature) infant
 infant born before 37 completed weeks of gestation

 Late preterm infant (a recently identified category)

 infant born between 34 and 36 weeks gestation

 Moderately preterm infant

 infant born between 32 and 36 completed weeks of gestation

 Very preterm infant

 infant born before 32 completed weeks of gestation

Sources: Iams JD, Creasy RK. Preterm labor and delivery, Chapter 34. In: Maternal-Fetal
Medicine: Principles and Practice, 5th ed., 2004; Davidoff MJ et al. Semin Perinatol 2006;30:8-15.
Definitions
 Low birthweight (LBW)
 infant who weighs less than 2,500 grams at delivery
 Very low birthweight (VLBW)
 infant who weighs less than 1,500 grams at delivery
 Extremely low birthweight (ELBW)
 infant who weighs less than 1,000 grams at delivery

Source: Iams JD, Creasy RK. Preterm labor and delivery, Chapter 34. In:
Maternal-Fetal Medicine: Principles and Practice, 5th ed., 2004.
Preterm Birth
A Common, Complex Disorder

 Genetic contribution
 Environmental influences
 Gene-environment interactions
Classification of Preterm Birth

What are the conditions leading to preterm birth?

 Spontaneous - 75%
 Preterm labor
 Preterm premature rupture of membranes (PPROM)
 Multiple gestation
 Cervical insufficiency
 Other related diagnoses

 Clinically Indicated - 25%

 Mother or fetus at risk

Sources: Goldenberg RL et al. Am J Public Health 1998;88:233-8; Meis PJ et al. Am J Obstet Gynecol
1995;173:597-602; Meis PJ et al. Am J Obstet Gynecol 1998;178:562-7.
Spontaneous Preterm Births
 Clinical presentations
 Preterm labor - 50-60%
 Preterm premature rupture of membranes (PPROM) - 40-50%

 Risk factors similar

 PPROM
 More often smokers, 2nd trimester bleeding, low socioeconomic status (SES)

 50% have no risk factors

Sources: Goldenberg RL et al. Am J Public Health 1998;88:233-8; Meis PJ et al. Am J Obstet Gynecol 1995;173:597-602;
Meis PJ et al. Am J Obstet Gynecol 1998;178:562-7.
Clinical Indications for Preterm Deliveries
 Preeclampsia 43%
 Fetal distress 28%
 Inadequate
intrauterine
fetal growth 10%
 Abruption 7%
 Fetal demise 7%

Source: Meis PJ et al. Am J Obstet Gynecol 1998;178:562-7.

Demographic Characteristics of
Populations at Risk for Preterm Birth

 Maternal age (<18 and >35 years)

 Low socioeconomic status (SES)
 Unmarried
 African-American ancestry
Known Risk Factors for
Preterm Birth
Epidemiologic
– history of preterm birth – environmental toxins
– unintended pregnancy – low pre-pregnancy weight
– previous fetal or neonatal death – obesity
– 3+ spontaneous losses – anemia
– assisted reproductive technology – lack of social support
(ART) – tobacco use
– genetic predisposition – alcohol abuse
– folic acid deficiency – illicit drug use

Source: Iams JD, Creasy RK. Preterm labor and delivery, Chapter 34.
In: Maternal-Fetal Medicine: Principles and Practice, 5th ed., 2004.
Known Risk Factors for
Preterm Birth (continued)

Inflammation Decidual hemorrhage

– systemic maternal disease – fetal / placental anomalies
– infections – bleeding
– preterm premature rupture of – trauma
membranes (PPROM)

Overdistension/uterine problems Activation of maternal

– multifetal pregnancy hypothalamic pituitary
– overdistension adrenal
– stress
(HPA) axis / violence
– uterine abnormalities
– cervical abnormalities

Source: Iams JD, Creasy RK. Preterm labor and delivery, Chapter 34.
In: Maternal-Fetal Medicine: Principles and Practice, 5th ed., 2004.
Common Risk Factors for Preterm Birth

 Multiple gestation  Prior preterm birth

 Infection  Uterine factors
– Cervical length
 Stress – Contractions
 Bleeding – Anomalies
– Distention
 Nutrition
 Excessive
 Ancestry and ethnicity
physical activity
Source: Martin JA et al. Natl Vital Stat Rep. 2005;54:1-116; Iams JD, Creasy RK. Preterm labor and delivery,
Chapter 34. In: Maternal-Fetal Medicine: Principles and Practice, 5th ed., 2004.
PREMATURITY
Why Prematurity is an Important Public Health Issue
PREMATURITY

Public Health focuses on promoting health

and preventing disease

Primary Prevention
Secondary Prevention
Tertiary Prevention
PREMATURITY

Primary Prevention

Decreasing the Rate of Preterm Births

Determining the Factors that Impact Preterm

Birth

Social
Biologic
Environmental
PREMATURITY

At Risk Populations

Low income women

Women of color
Women younger than 20 and older than 40
Women who were born preterm
Women with a history of previous preterm delivery
Women with multiple pregnancy
Women with uterine/cervical abnormalities
PREMATURITY

Other Risk Factors

Smoking, use of alcohol, other substance use

Infection
Stress
Trauma
Unintended pregnancy
Chronic health conditions like diabetes or high blood
pressure
In-vitro conception
History of repeated miscarriages or spontaneous abortions
PREMATURITY

Secondary Prevention

Improving the Outcome of Premature Infants

PREMATURITY

Preterm infants are

at higher risk for
poor health
outcomes than
infants born at
term
PREMATURITY

Increased Mortality

Preterm birth and low birth weight are the leading cause of
death in infants younger than one year.
Diagnosis

 Diagnosis of prematurity is done by assessing the

gestational age at birth.This is done by using expanded
ballard scoring system
 6 physical parameters: Skin,Lanugo hair,Ear (Pinna and
Recoil),Genitalia,Sole creases,Breast.
 6 neuromuscular parameters: Arm recoil,Scarf
sign,Popliteal angle,Dorsiflexion,Heel to ear and wrist
window + ventral suspension.
 UEURO-MUSCULAR MATIJR TY SCORE
GN
~ S GN SCORE
0 I

0 • )~
. \l
:> 1-

I
SI I

,
 NEURO-MUSCULAR MATURITY
::=S=IG=N =
::=S=IG=N=:::=,==::_:..11==0=:;.:1 SCORE
1 2 II 3 1-1 -==4::.

--,---:,
Square
Window r., ~ r
~ ee
 t~EllRO MUSCULAR MATURITY I

SIGU 'I · SIGtl

·1 t o SCORE
.T1 )l2 l 1 4 I SCORE
·-

r.rm ~ f ~ J. ;
~.. 'l. ~

U,!r
s

l{ } .
R~ ' u Jurr ''t: _ ..... l•
~ ,. 110. ''~l 110
 NEURO·l,\USCULAR
11
MATURITY SCORE
SIGN
II I[
I[
]I
-1
2 II
0 11
3
1
]I I
en d::J·~
4

CJ:)
l 11 1
l'ophteal
f..nale ~
,. ..."!
...
l,w"
5
•4<)
a:)
iee
a:)
se
ctj [
-
EJI I
NEURO·MUSCULAR NiATURITY SCORE

I I I ! I
.g
1 0 I 2 3 -

ft { ·B .§ I
4

~s~ - I I I I
 NEURO·MUSCULAR IM.TURJTY SCORE
SIGN
I
o ll 1 IIi ::::,
.--1
-]-=::;;::=:11===;;
@Skin
@ Lanugo
@ Plantar surface
@ Breast
@ Eye/ear
@ Genitalia
 PHYSICAL f.\ATURJTY SCORE
IGN ·1 II 0 II 2 1 .3

4 5
Stll'ky I aelaunou~, smooth superfk,al peelina I &t ~ I , pale pa,chment deep le thely,
kin tnable, red, IJlllK vlSible &for rash. 'e« areas. rare cracking, no cracked
tra~parent traf6h.cent \lelOS \I~ \leu,s 1/~S~

F II II 1
,
, .I II ,
SIGN
I
I -1
11
I PHYSICAL
1 II
tMTURITY SCORE
3 II 4
0 2 II :~
Lamgo none sparse I abundant thiming
bald areas mMtly bald
SIGtJ
I
[ -1
JI 0 I[ PHYSICAL
1
IC
MATURITY
2. SCOREI[ 3
~L"
11 heel-toe •50 mm anteriol transverse creases
Plantar 40·50mm. ·1 no faint red creases ant.
crease onl} CHt!!r ennre
Strlace <~mm: -2 crease marks 2/3
sole
Lb4R TR CE

PHYSICAL MATURITY SCORE SIGN

SIGN
-1 0 1 2 3 4 5 SCORE

stippled raised full

barely flat areola
imperce areola areola areola
Breast percept no bud
ptable 1-2 mm 3-4 mm 5-10
able
bud bud mm bud
 3 4 5

d formed thick
& firm cartilag
ut instant e
recoil ear stiff

PHYSICAL MATURITYSCORE
SIGN
-1
- 0 1 2
l lids lids sl. well-
fused open curved curve
Eye I loosely: pinna pinna; pinna;
Ear - 1 flat soft; soft b
t ightly: stays slow ready
- 2 folded recoil recoil
PHYS CAL MATURITYSCORE
N
-1 0 1 2 3 4 5
testes in testes testes
scrotum testes
nitals
scrotum empty,
upper descendi down, pendulo
flat, canal, ng, us,
Male) faint good
smooth rare few deep
rugae rugae
rugae rugae rugae

I
SIG

Ge
(
PHYS CAL MATURITYSCORE
SIGN

I
-1 0 1 2 3 4 5
promine
promine majora
clitoris nt majora majora
nt & minora
Genitals promine clitoris & large, cover
clitoris & equally
(Female) nt & small minora clitoris &
enlarging promine
labia flat labia small minora
minor a nt
minor a
The Morbidity of Prematurity
Neonatal Short term Long term
 Respiratory distress  Feeding and growth  Cerebral palsy
syndrome (RDS) difficulties  Sensory deficits
 Intraventricular  Infection  Special health care
hemorrhage (IVH) &  Apnea needs
periventricular  Neurodevelopmental  Incomplete catch-up
leukomalacia (PVL)
difficulties growth
 Necrotizing enterocolitis
 Retinopathy  School difficulties
(NEC)
 Transient dystonia  Behavioral problems
 Patent ductus
 Chronic lung disease
arteriosus (PDA)
 Infection
 Metabolic abnormalities
 Nutritional deficiencies
Source: Iams JD, Creasy RK. Preterm labor and delivery, Chapter 34.
In: Maternal-Fetal Medicine: Principles and Practice, 5th ed., 2004.
PREMATURITY

Late Preterm Infants

Mortality

Late preterm infants (34-37) weeks are 6 X more likely to die

in the first week of life and 3X more likely to die in the first
year
Prematurity

Late Preterm Infants

Morbidity

 Respiratory distress
 Hypothermia
 Sepsis
 Hypoglycemia
 Inadequate feeding/dehydration
 Hyperbilirubinemia
 Growth and developmental issues
 Immature brain
 Prematurity
The fetal brain at 34 weeks weighs only about 65% of
that of a full term infant brain
PREMATURITY

The Costs of Prematurity

 Physical/Medical
 Developmental
 Emotional
 Financial
 Psychosocial
 Educational
management

 Routine care;airway breathing,cord and eye care.

 Thermal control; thermal neutral environment-this
environment is a set of thermal conditions including
air,radiating surfcae temps,relative humidity and airflow at
which heat production(measured as oxygen consumption),
is minimal and the infants core temp is within the normal
range.
 Temp 36.5-37oC
 Humidity 40-60%
 FLUID REQUIREMENTS; depends on gestation
age,environmental condition and disease states.
 NUTRITION: TPN or enteral feeding.
 Infection : Treatment and /or prevention
Prematurity

References

Coming Home from the NICU. A Guide for Supporting Families in Early Infant Care and Development.
VandenBerg, K.A.; Hanson, Marci. Paul.H.Brookes Publishing. 2013.

Understanding My Signals. Help for Parents of Premature Infants. Hussey-Gardner, Brenda. Vort Corporation.
2013.

March of Dimes. www.marchofdimes.com

American Academy of Pediatrics:

Modified Recommendations for Use of Palivizumab for Prevention of Respiratory Syncytial Virus
Infections. Committee on Infectious Diseases. Pediatrics. 2009

Perinatal Origins of First-Grade Academic Failure: Role of Prematurity an Maternal Factors. Pediatrics. 2013

Early Childhood Development of Late Preterm Infants. A Systematic Review. Pediatrics. 2011.
PREMATURITY

References

American Academy of Pediatrics

Persistence of Morbidity and Cost Differences Between Late-Preterm and Term Infants
During the First Year of Life. Pediatrics. 2009.

Safe Transportation of Preterm and Low Birth Weight Infants at Hospital Discharge. Bull,
Marilyn J. and Engle, William A. Pediatrics. 2009.

“Late Preterm “ Infants. A Population at Risk. Engel, William A., Tomashek, Kay M., and
Wallman, Carol. Pediatrics. 2007.

Use of Soy Protein-Based Formulas in Infant Feeding. Bhatia, Jatinder, and Greer, Frank.
Pediatrics. 2008.
PREMATURITY

References

Getting to Know Your Baby. A Developmental Guide for Community Service Providers and Parents of
NICU Graduates. VandenBerg, K.; Browne, J.;Perez, L. 2003. www.wonderbabies.org

Multidisciplinary Guidelines for the Care of Late Preterm Infants. National Perinatal Association.2012.
www.nationalperinatal.org/lptguidelines.php

Infant Cues. Infant States. WIC California Baby Behavior Campaign. California WIC Program.
www.cdph.ca.gov/programs/wicworks/Pages/WICCaliforniaBabyBehaviorCampaign.aspx

Your Premature Baby. Volume 1, 2, 3. Injoy Videos. www.injoyvideos.com

The Effects of Prematurity on Development. Bell, M. www.prematurity.org