PREMATURITY

BY: NURUL AIN ALAN HAFIFI

DEFINITION
Prem infant: <37 weeks gestation
LBW <2500 gram
VLBW <1500 gram
ELBW <1000 gram
SGA < 10TH centile of birth weight for age
(eg: 38 wk SGA if < 2.35kg
34 wk SGA if <1.95 kg)

Risk of prem
Pregnancy problem multiple gestation,
poly/oligohydramnios, placenta
previa/abruptio, fetal abnormality
Risky Behaviour smoking, substance
abuse, poor nutrition
Early delivery Rh Incompatibility, IUGR
Uterine/cervical abnormality, myoma,
hypertension

Complications in premature infant

EARLY COMPLICATIONS

LATE COMPLICATIONS

Hypothermia
IVH
Respiratory distress syndrome
Apnoe
Hypotension
Patent ductus arteriosus
Hypoglycemia,hyperglycemia
Infection
Fluid and electrolytes disorder

Neurodevelopmental disability
Periventricular leucomalacia
/PVL
ROP
Chronic lung disease
Necrotizing enterocolitis
Anemia
Osteopenia of prematurity
Septicemia

Why prem is vulnarable?

SKIN
large surface area relative to body mass, thin
skin, less fat
Allow them to lose heat easier
Hypothermia
Mx: Warmer, Incubator
care

RESPIRATORY

-Weak chest muscle-not allow them to take

effective breaths
-Immature nervous system may not provide
adequate stimulation to breath
-Immature lungs deficient in surfactant, making
ventilation difficult and injury from PPV more
likely

 RDS ( respiratory distress syndrome )

- reduced surfactant (phospholipid protein)
- Present in amniotic fluid at 24-28wks, mature at
35weeks
- decreased surface tension, prevent alveolar collapse
Sx: Tachypnoea, labored breathing, recessions, nasal
flaring, expiratory grunting, cyanosis
CXR: ground glass appearance, larger airway outlined,
no heart border
Prevention : IM Dexa, surfactant replacement
Respiratory supports : eg ETT,PPV,CPAP

 Apnea of prematurity
Sudden cessation of breathing that lasts for at least 20 secs or
is accompanied by bradycadia or
O2 desaturation (cyanosis) in infant <37 weeks
Symptomatic of underlying problems, commoner ones of which are:
RDS, pulmonary haemorrhage, pneumothorax,
upper airway obstruction, drugs,Sepsis , Hypoxaemia
,Hypothermia ,CNS abnormality ,Metabolic disturbances ,Cardiac
failure, congenital heart disease, anaemia,NEC
Vagal reflex: Nasogastric tube insertion, suctioning, feeding

Mx: Supportive O2, relieve obstruction (CPAP),

aminophyline to inhibit adenosin receptor (cause
respiratory depression), mechanical ventilation

EYE
Immature tissues may be damaged more easily by
excessive oxygen
ROP

retina working too early

- Retina is formed but blood supply is limited
- vascular proliferation to ischemic area
- retina detachment
Sign: white pupil ( retinal detachment)
Tx: laser therapy
ROP screening Indications: < 1.5kg, < 32weeks,
<36 wks with O2 therapy

BRAIN
Fragile capilaries within brain
IVH
- occurs in < 32wks (within 5 days after birth)
- Sx: pallor, shock, hypotonia, apnoea, seizure,
hydrocephalus
PVL (Periventricular leucomalacia)
- necrosis of white matter
complications: spastic displegia, cognitive and
intelectual deficit, visual deficit, seizure disorder

Classification of IVH
Grade I - bleeding occurs just in the germinal
matrix
Grade II - bleeding also occurs inside the
ventricles, but they are not enlarged
Grade III - ventricles are enlarged by the
accumulated blood
Grade IV - bleeding extends into the brain tissue
around the ventricles

Low Blood Sugar (Hypoglycemia) in

Premature Infants
Because premature infants have high energy
needs and low energy stores (glycogen), they are
prone to have hypoglycemia.

 NEC (necrotising enterocolitis)

- occurs within 1st week of life
- immature gut, compromised gut circulation , bacterial
invasion of ischemic bowel,causing serious intestinal
injury
Sx: Feeding intolerance, abdominal distension,
hematochezia, vomit milkcurd
/greenish bile, shiny skin abdomen, reduced BS
AXR: distended loops of bowel, thick
Mx: keep NBM, start paraenteral feeding (TPN/OGT),
antibx
Complications: bowel perforation, strictures,
malabsorption

 Osteopenia of prem
- rickets/chronic reduced Calcium,po4, ALP
CXR: Bone demineralization

IMMUNE
Immune system is immature, increasing the risk of
infection
-Sepsis

 Small blood volume makes them more

susceptible to the
hypovolemic effects of blood loss
PDA (patent ductus arteriosus)
sx: asymptomatic, brady/apnea,
increased O2 requirment
Systolic murmur at 2nd Left ICS
Ix:
ECHO
CXR= cardiomegaly, pulmonary
venous congestion

General measures for Prem baby

Monitor vital sign

Blood sugar
Keep warm
Infection control
Supplements
-IM VITAMIN K
-MVT
-FOLIC ACID
-ELEMENTAL IRON
CRANIAL ULTRASOUND
SCREENING FOR ROP
Weight gain monitoring

References
Paediatric Protocols 3rd edition
http://www.babymed.com/ultrasound/fetal-grow
th-and-weight-percentile-ultrasound-pregnanc
y
NRP 6th EDITION
Medscape
Wikiradiograph
http://pediatriceducation.org/2005/03/14/what
-is-the-classification-of-intraventricularhemorrhage-ivh/