PRETERM

COMPLICATIONS & MANAGEMENT

Dr M. Rajasekhar,
PG in Pediatrics
Objectives

Define and categorize preterm babies

Risk factors for preterm babies
Identify problems of preterm and their
management
DEFINITION-MAGNITUDE OF
PROBLEM
Live born babies before 37 weeks form first day of last
menustral period are termed as Preterm-WHO

In india,27millions babies are born every year,out of

which 3.5 millions are born prematurely

Preterm birth is the leading cause of newborn

deaths,second leading cause of death after pneumonia in
children under five years

IMR- 43.19 deaths /1000 live births

 What is Preterm?

 Preterm is defined as a “baby born alive before 37

completed weeks of pregnancy”.

 Subcategories based on gestational age:

o Extremely preterm <28 weeks
o Very preterm 28 to 32 weeks
o Moderate to Late preterm 32 to 37 weeks
 Subcategories based on birth weight:

o LBW (Low birth weight) <2500 grams

o VLBW (Very Low birth weight) <l500 grams
o ELBW(Extremely Low birth weight) <1000 grams
Risk factors for preterm delivery….

H/o previous premature birth

Mother’s age<18yrs and >35 yrs
Multiple pregnancy
Conceiving through in vitro fertilization
Multiple miscarriages or abortions
Uterine, cervical or placental abnormalities
Poor nutrition
GESTATIONAL AGE ASSESMENT…

Physical criteria alone

Neurological examination criteria alone
Physical and neurological criteria together
Direct Ophthalmoscopy
Rapid Assesment of GA in delivery room
New Ballard score
Rapid Assesment of Gestational
age
Feature 36 Weeks and 37-38 Weeks 39 Weeks and
earlier beyond
Creases in soles of One or 2 transverse Multiple creases; Entire sole, including
feet creases; posterior anterior two-thirds of heel,
three fourths sole smooth covered with creases
of sole smooth

Breast nodule 2 mm 4 mm 7 mm

Scalp hair Fine and woolly; Fine and woolly; Coarse and silky;
each
hair single-stranded

Ear lobe No cartilage Moderate amount of Stiff ear lobe with

cartilage thick
cartilage

Testes and scrotum Testes partially ? Testes fully

descended; descended;
scrotum small, with scrotum normal size,
few with
rugae prominent rugae
New Ballard score…

• Score spans from 10( 20 wks GA) to 50( 44 wks

GA),best performed <12 hrs for GA <26 wks and for
infants >26 wks of GA no optimal age of examination
upto 96 hrs.
Accuracy-Accurate whether infant is sick or well
within 2wks of gestational age
Criteria-consists of 6 neuromuscular and 6 physical
criteria
Procedure-examination should be done by two
different examiners twice to ensure objectivity and
data are entered on chart
WHY PRETERMS ARE
MORE PRONE FOR
COMPLICATIONS????
 Problems of Prematurity…

 Immature Organ Functions and difficulty in

adapting to extra-uterine environment.

 Complications of therapy / interventions during

delivery & in immediate postnatal period.

 Problems due to specific disorders that have

caused the premature onset of labor.
 Respiratory…

 Poor adaptation to air breathing >> perinatal

depression in the delivery room.
 Surfactant deficiency >> Respiratory distress
syndrome
 Immaturity of breathing control >> Apnea of
prematurity
 Bronchopulmonary dysplasia, Pulmonary
dysmaturity syndrome
 Cardiovascular…

 Hypovolemia / sepsis >> hypotension

 Patent Ductus Arteriosus >> Congestive cardiac
failure

 Neurological….

 Intraventricular hemorrhage & periventricular

hemorrhage
 Perinatal depression
 Hematological…

 Anemia of prematurity

 Nutritional…

 Incoordination between sucking & swallowing >>

feeding problems
  Gastrointestinal…

 Necrotizing enterocolitis

 Metabolic…

 Hypoglycemia
 Hypocalcemia
  Renal..

 Immature kidneys >> low GFR

 Unable to handle water, solute and acid loads
 Fluid and electrolyte management can be difficult

 Temperature regulation..

 Susceptible to hypothermia and also hyperthermia

  Immunologic..

 Deficiency in both humoral and cellular response

>> greater risk of sepsis

 Ophthalmological..

 Retinopathy of prematurity
 LATE PROBLEMS..

Neurodevelopmental Problems :
Major handicaps - Cerebral palsy, Mental
Retardation
Minimal Cerebral dysfunction - Behavioural
disorders , ADHD, Language disorders , learning
problem
Sensory impairments - Hearing & Visual
impairment
 LATE PROBLEMS..

 Chronic Lung Disease (BronchoPulmonarydysplasia)

 Retinopathy of Prematurity
 Osteopenia of Prematurity
 Poor Growth –FTT
 Increased rates of Rehospitalisations – RTIs
 Increased frequency of congenital anomalies
 Inadequate Maternal – Infant bonding
 Sudden Infant Death Syndrome
 Risk for metabolic conditions- Obesity , T2DM
 Risk for CVS disorders – Hypertension , IHD
 HYPOTHERMIA

 Preterms have large body surface area and

decreased brown fat >> more prone for
hypothermia.
Can lead to hypoglycemia,bleeding
diathesis,acidosis,apnea,respiratory failure,shock
even death
Prevention: Maintain the ambient temperature of
the labour room at 26-28° C and ensure other
components of warm chain
Mechanism of heat loss
 PREVENTION OF HYPOTHERMIA :
THE WARM CHAIN…
1. Warm delivery room (26-28OC)
2. Warm resuscitation
3. Immediate drying
4. Skin-to-skin contact between baby and the mother
5. Breastfeeding
6. Postponing bathing and weighing
7. Appropriate clothing and bedding
8. Keeping mother and baby together
9. Warm transportation
10. Awareness of healthcare provider
 Polythene occlusive wraps:
Wrapping reduces evaporative heat loss, while
allowing radiant heat delivery to the baby.

 Incubators:
Incubators should be preferred over radiant warmer
for the care of preterm babies.
Incubators decrease the insensible water loss (IWL),
but radiant warmers rather increase the IWL.
 Radiant warmers:
Maintenance is easy and allows easy access for doing
procedures, but the disadvantage is that insensible
water loss is greater.

 Kangaroo mother care:

For LBW babies, who are stable, KMC is perhaps the
most effective way of keeping babies warm. KMC to
be ensured minimum 10-14 hrs a day.
KMC POSITION..

Skin to skin contact

between mother and infant
in vertical position,between
mother’s breast and her
clothes
Stopped when baby is
sweating,and wriggle to stay
in KMC.
Must be offered as long as
possible,alteast 1- 2 hr/sitting
provided infants tolerates
well
KMC HEPLS IN,
BETTER THERMAL
PROTECTION
INCREASE MILK
PRODUCTION
IMPROVES WEIGHT
EMOTIONAL
BONDING
REDUCES HOSPITAL
STAY
INCREASES BREAST
FEEDING RATES
Signs and symptoms…

Signs and symptoms may be subtle and non

specific,therefore high index of suspicion for
preterm babies needed
Common signs and symptoms
-lethargy
-Irritability
-Poor feeding,breathing difficulty(tachypnea/apnea)
-severe hypothermia may manifest with
hypoglycemia,sclerema,DIC, and internal bleeding
 Grading of hypothermia…

 Normal axillary temperature is 36.5 - 37.5°C.

 In hypothermia the temperature is below 36.5°C.

• Cold stress : 36.4 -36.0°C

• Moderate hypothermia : 35.9 -32.0°C
• Severe hypothermia : < 32°C (89.6°F)
 MANAGEMENT OF
HYPOTHERMIA…

MILD HYPOTHERMIA ….
 Skin to skin contact & KMC is the best method to rewarm
the baby.
If KMC isn’t practical, warm the room using radiant heater.
 Cover the baby adequately and remove the wet clothes.
 Continue breast feeding, monitor capillary refill and blood
glucose. Watch for apnea.
 Monitor temperature every 30 min till 36.5OC, then hourly
for 4 hrs, 2nd hrly for 12 hours there after 3 hourly.
SIGNIFICANT HYPOTHERMIA…
Remove wet clothes.
 Place under radiant warmer.
 Give Oxygen.
 Start I.V fluids.
 Monitor temperature every 15 minutes.
 Monitor blood pressure, heart rate, glucose.
 Give Vitamin K injection.
 HYPOGLYCEMIA

 Blood glucose level is variable and depends upon

factors like birthweight, gestational age, body stores
and feeding status.

 Hypoglycemia is plasma blood glucose

< 45 mg/dL
 MANAGEMENT..

 Asymptomatic: Low blood glucose level may not

clinically manifest and be totally asymptomatic.
 Symptomatic: Lethargy, difficulty in feeding,
convulsions, jitterness, apnea, cynosis, hypothermia,
weak and high pitched cry
 Management of asymptomatic
hypoglycemia
 Asymptomatic hypoglycemia of < 20 mg/dL needs
I.V. Glucose infusion at 6 mg/Kg/min.
 In asymptomatic hypoglycemia of 21-45 mg/dL, a
trial oral feed can be given.
Blood Glucose is re-assessed after 1hr. I.V. glucose
infusion to be started if it is found to be <45 mg/dL.
 Management of symptomatic
hypoglycemia
 For Symptomatic hypoglycemia, 2 mL/Kg of 10%
Dextrose bolus is to be given, followed by I.V. glucose
infusion at 6 mg/Kg/min.

 Monitor hourly till euglycemic and then 6 th hourly.

 If the blood sugar is still low, increase GIR by 2

mg/Kg/min each time, upto 12 mg/Kg/min
If > 50 mg/dl stable on IVfluids for 24 hrs,2 values
more than 50mg/dl
Wean at 2mg/kg/min every 6 hrly
Increases oral feed,continue monitoring 6 th hrly
Stop IV fluids,when rate is 4mg/kg/min
Stop monitoring when 2 values are more than
50mg/dl on full feeds.
 HYPOCALEMIA…

 Hypocalcemia in preterms is defined as total

serum calcium < 7 mg/dL, ionic serum calcium < 4
mg/dL.

 Preterms are prone to hypocalcemia due to

premature termination of transplacental supply,
increased calcitonin and diminished target organ
responsiveness to parathyroid hormone.
 HYPOCALEMIA - Symptoms

 May be asymptomatic or symptomatic

 Neuromuscular irritability - myoclonic jerks,
jitteriness, exaggerated startle, and seizures.
Tachycardia.Apnea, cyanosis, tachypnea, vomiting
and laryngospasm are other symptoms that are
noted.
 HYPOCALEMIA - Management
RESPIRATORY DISTRESS
SYNDROME…
Most common cause of respiratory distress in
Preterm babies
Distress since birth or 4 hours after birth
Incidence inversely related to gestational age
Assesed by silverman-Anderson scoring
Presents as tachypnea ,retractions, nasal flaring and
grunting
Surfactant deficiency is primary cause of RDS
SCORE UPPER CHEST LOWER XIPHOID NASAL GRUNT
RETRACTIONS CHEST RETRACTIONS FLARE
RETRACTION
S

0 SYNC NONE NONE NONE NONE

1 LAG ON INSP JUST VISIBLE JUST VISIBLE MINIMAL STETH ONLY

2 SEE-SAW MARKED MARKED MARKED NAKED EAR

A score of 7/more is indicative of impending resp. failure

• Low levels of surfactant causes increase in surface
tension
• Increased surface tension makes alveoli hard to
expand
• Results in affected lung to atelectatic at end
expiration when alveolar pressures are too low to
maintain alveoli in expansion
• Leads to failure to attain adequate lung inflation and
therefore reduced gaseous exchange
HMD
chest xray
showing,
-Air bronchogram
-Decreased lung
volumes
-Hazy lungs
Management..

• O2 therapy
• Nasal CPAP
• Early intubation and synchronised ventilation
• SURFACTANT administration by INSURE
technique
• Antenatal steroids
Antenatal steroids

• Treatment consists of two doses of 12 mg of

betamethasone given intramuscularly 24 hours
apart OR
• four doses of 6 mg of dexamethasone given
intramuscularly 12 hours apart.
• Optimal benefit begins 24 hours after initiation
of therapy and lasts 7 days
APNEA OF PREMATURITY...
• Apnea is defined as respiratory pause lasting more
than 20 secs accompanied with oxygen
desaturation or cyanosis and bradycardia
• It’s a unstable respiratory rhythm,reflecting the
immaturity of respiratory control system
• It can also be secondary to other pathological
conditions,that to be excluded diagnosing apnea of
prematurity
• AOP usually present after 1-2 days of life
Types…

• Central apnea-inspiratory efforts are absent

• Obstructive apnea-inspiratory efforts present in
presence of obstructive airway
• Mixed apnea-both central and obstructive
components present
Frequency-mixed>central>obstructive.
Secondary causes…

• CNS-birth trauma,meningitis,IVH,seizures,perinatal
asphyxia
• Respiratory-surfactant
deficiency,pneumonia,pulmonary haemorrhage
• CVS-Cyanotic congential heart disease,PDA
• GIT-NEC,GERD
• Hypo or
hyperthermia,hypoglycemia,anemia,acidosis,
sepsis
Management….

Maintain temperature
Provide tactile stimulation
I.V Aminophylline,5mg/kg loading dose,followed by
2mg/kg/dose,8 hrly
Caffeine citrate oral or IV,20mg/kg as loading
dose,followed by 8-10mg/kg once a day
Caffeine or aminophylline should be stopped, apnea
free for 1 week ,and may be continued till 34-35 wks
GA
Nasal CPAP
Synchronized mechanical ventilation
 CARDIOVASCULAR
COMPLICATIONS…
PDA, patent ductus arteriosus a major morbidity
seen in preterm infants.
Incidence being inversely related to gestational age

Ductus arteriosus, communication between

pulmonary artery and aorta,functionally closes in
term by 12-24 hrs and in preterm may be delayed by
3-5 days

PDA,refers to the failure of the closure process and

contuined patency of fetal circulation
 CONT…

Significant PDA represents on 3-7 days as respiratory

distress from HMD is improving upto first week of life

Hyperdynamic precordium
Wide pulse pressure
Bounding pulses
Murmur intially silent,systolic becoming continous
machinery like
Management….

• Fluid restriction(2/3maintenence)-input and output

monitering

• Serum electrolytes and renal function

• Weight monitoring twice daily

• INDICATIONS OF TREATMENT
Treatment should be considered on preterm
infants with ECHO proven hemodynamically
significant ductus arteriosus,with one of following

1.Features of congestive heart failure

2.Requiring prolonged respiratory support
3.unexplained O2 requirement(Fio2>30%)
4.Recurrent apnea ,requiring respiratory support
Two most widely studied and used non
selective COX inhibitors are
1.Ibuprofen

2.Indomethacin
Inhibits prostaglandin synthesis and
causes ductal constriction
• DOSES…
• Indomethacin-IV infusion over 30min 24hrly, 3 doses,

loading dose,0.2mg/kg/dose
subsequent doses( as per postnatal age)
<2days,0.1mg/kg/dose ,12 hrly, 2doses
2-7 days,0.2mg/kg/dose,12hrly,2 doses
>7 days,0.25mg/kg/dose,12 hrly ,2 doses

• Ibuprofen-IV /Oral ,loading dose,10mg/kg/dose

followed by 5mg/kg/dose at 24 and 48 hrs
Monitoring during therpy
Baseline-urine output,RFT,platelet count
Daily-urine output
Alternate day-RFT,platelet counts
contraindications
Urine output<0.6ml/kg/h,blood urea>40mg/dl
Creatnine >1.8mg/dl,IVH,NEC,platelet count
<60000
 NECROTISING ENTEROCOLITIS…

• Is an ischemic and inflammatory necrosis of bowel

primarily affecting premature neonates after
initiation of enteral feeds
• Its most common acquired GI emergency in
newborn
• Suspected in Preterm of <32 wks GA- feeding
intolerance,abdominal distension,coffee ground
aspirates, constipation some may have diarrhoea
• Abdominal radiography shows Pneumatosis
Intestinalis
Pneumatosis
intestinalis,note air
in bowel wall,the
in the bowel wall
gives Doubled
lined apperance
Management…

• Nil per orally

• Continious gastric aspirate
• Complete workup for sepsis
• Platelet count
• Abdominal X-ray,supine
• Pediatric surgery opinion if perforation is suspected
• Attempt feeds once gastric aspitates are nil for
atleast 24hrs with soft abdomen ,good bowel
sounds/baby starts passing stools
Monitor progression of disease during first 72 hrs
after onset
Abdominal girth-6th hourly
Continuous hemodynamic monitoring
Supine abdominal X ray-12th hourly for first 72
hrs thereafter as clinically indicated(look for dilated
loops,evidence of pneumatosis,compare with
previous X rays)
 INTRAVENTRICULAR
HEMORRFAGE/GERMINAL MATRIX
HAEMORRHAGE…
More common in preterm infants

Germinal matrix is highly vascular and

vulnerable to hypoxemia and ischemia, only
present during 24-32 weeks of gestational age

It’s a source of neuronal precursors,and its

capillary bed is vascular end zone of arterial
supply.

Principal mechanism is rupture of fragile

capillaries within germinal matrix
Risk factors

Natal- Birth asphyxia

Birth trauma
Post natal-RDS,complicated with
Hypoxia,hypercarbia
Acidosis
Flucatation/low cerebral blood flow
PDA
Coagulation disturbance
Pathogenesis..

Pathogenesis is multifactorial
Fluctutating cerebral blood flow in ventilated
preterm infant with RDS
Increase in cerebral blood flow
systemic HT-pressure passive circulation
hypercarbia
coagulation problems
VOLPE’S GRADING OF IVH…

• Grade I - Hemorrhage is confined to the germinal

matrix.
• Grade II - Intraventricular hemorrhage without
ventricular dilatation.
• Grade III - Intraventricular hemorrhage with
ventricular dilatation.
• Grade IV - Intraventricular rupture and hemorrhage
into the surrounding white matter.
PERIVENTRICULAR
LEUKOMALACIA…
• Seen in 5-10% of premature infants.
• Infarction of deep white matter.
• Occurs in the watershed zone, adjacent to trigone of
lateral ventricles.
• Seen as increased echogenecity (Greater than
choroid plexus.)
• Often missed easily, serial exams increase
sensitivity.
Neurological features….

• Evolution from hours to days

decreased level of consciousness
hypotonia
bulge of anterior fontanalle
pupils dilated not reacting to light
decreased spontaneous respirations/apnea
Most importantly, unexplained fall of
hematocrit/failure to rise hematocrit after
transfusion
Management….

• Antenatal steroids
• Avoidance of prolonged labour
• Avoidance of hemodynamic disturbances
Rapid elevation of BP and CBF and
avoid rough handling,prolonged tracheal
suctioning,rapid infusion of fluids/blood
.
• Supportive care-temperature regulation,
ventilation ,circulation and metabolic status
NEONATAL SEPSIS..
• It’s a clinical syndrome characterized by signs and
symptoms of infection with or without
accompanying bacteremia in first month of life
• Encompasses various systemic infections
Septicemia
Meningitis
Pneumonia
Arthritis
Osteomyelitis
Urinary tract infections
CONT….
Preterm babies are more prone for infections as
IgG transferred mostly in last trimester
Most infections occur after long stay at NICU
In sufficient cellular immunity
Excessive handling ,humid and warm
temperature,contaminated incubators and
resuscitators,expose them to organisms
Most common organisms E coli,klebisella and
staphylococcus aureus.
Often associated with poor neurodevelopment
Sepsis screen…

• Leukopenia(TLC<5000/mm3)
• Neutropenia(ANC<1800/mm3)
• Immature neutrophil to total neutrophil(>0.2)
• Micro ESR(>15mm 1st hour)
• CRP positive(>10mg/l)

• Sepsis is suspected clinically or

• Two or more risk factors in an asymptomatic baby
Risk factors…

• Prematurity,VLBW(<1500GRMS)
• PROM(>24hours)
• Foul smelling liquor
• Multiple >3 per vaginum examinations
• Intrapartum maternal fever>37.8C
• Lack of breast feeds
• Frequent handling
• Sepsis in neonatal units, improper hand washing
Diagnosis Duration

Meningitis (with or without positive 21 days

blood/CSF culture)

Blood culture positive but no meningitis 14 days

Culture negative sepsis (screen positive and 5-7 days

clinical course consistent with sepsis)
Drug Birth Weight <2000g Birth Weight >2000g
0-7 d >7 days 0-7 days >7 days

Amikacin 7.5 q12h 7.5 q8h 10 q12h 10 q8h

Ampicillin
Meningitis 100 q12h 100 q8h 100 q 8h 100 q6h
Others 25 q12h 25 q8h 25 q8h 25 q6h

Cefotoxime
Meningitis 50 q6h 50 q6h 50 q6h 50 q6h
Others 50 q12h 50 q8h 50 q12h 50 q8h

Gentamicin
Conventional 2.5 q12h 2.5 q8h 2.5 q12h 2.5 q8h
Single dose 4 q24 h 4 q24 hr 5 q24h 5 q24h
ANEMIA OF PREMATURITY…
Venous hemoglobin less than 12g/dl in premature baby
Physiological anemia occurs earlier,more severe and
prolonged
Causes are multifactorial due to
immature erythropoiesis
decreased erythropoietin
illness and repeated blood sampling
Symptoms-poor feeding,pallor,lethary,apnea
Treated with 2-4mg/kg of elemental iron from 4-6 wks
of age
 transfusion if needed
 RETINOPATHY OF PREMATURITY...

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 GA, but may be
seen as early as 30 to 32 weeks.
Next to cortical blindness, ROP is the most
common cause of childhood blindness
ROP - Pathogenesis

Immature retinal vessels.

Oxygen: Vasoconstriction & vaso-obliteration of
retinal vessels.
Hypoxia: Retinal neovascularization
Total retinal detachment
Clinical associations…

Birth weight
Gestational age
Prolonged Oxygen therapy
Sepsis
Apnea of prematurity
Blood transfusions
ROP – Whom to screen?

• Birth weight < 1500g

• GA < 32 wk
• Birth weight 1500-2000g / GA > 32 wks with need
for cardiorespiratory support, prolonged oxygen
therpary, apnea of prematurity, anemia with
requirement for blood transfusion, sepsis
ROP – When to screen?

• 32 wks of gestational age OR 4 wks of post-natal

(chronological) age – whichever is later.

A 26 wk ROP screening
newborn is should be done
admitted at 6 wks of life.

ROP screening
A 30 wk newborn
should be done at
is admitted
4 wks of life.
 ROP – How often to screen?
• Follow-up examinations,every one to two
weeks till the retina matures. (Complete
vascularization). OR
• If ROP shows regression (This normally
happens around 40-44 wks of GA age.)
 FEEDING IN PRE TERMS
REFERENCES…

• FBNC TRAINING MODULE 2014

• PGI NICU PROTOCOLS
• AIIMS NICU PROTOCOLS 2014
• CLOHERTY
• GOMELLA
• CARE OF NEWBORN,MEHARBAN SINGH
• NELSON
• A 34 WEEKS PRETERM WEIGHING 1600
GRMS,DELIVERED THROUGH LSCS PRESENTED ON DAY 2
OF LIFE
blood sugar-34mg/dl
axillary temperture-36.8c
How will you manage the case?
Thank you