COMPLICATIONS OF PREMATURITYMona Khattab, MDNeonatal-Perinatal FellowYale University Childrens Hospital

I am not just a Small baby I am a Preterm baby. I am a Unique Baby with Unique Problems!!

Definition-Magnitude of ProblemPrematurity < 37 completed weeks Accounts for 1/3 of infant deaths in USA, 45% cerebral palsy, 35% vision impairment, and 25% cognitive or hearing impairment.Risk of complications increases with increasing immaturity

Classification based upon GA:

Late preterm birth GA between 34 and < 37 weeksVery preterm birth GA < 32 weeksExtremely preterm birth GA 28 weeks

Classification by BW

Low birth weight (LBW) < 2500 gVery low birth weight (VLBW) < 1500 gExtremely low birth weight (ELBW) < 1000 g

YOUR TURN

Short-term complicationsLong-term complicationsProper stabilization in the DR is important to reduce risk of short-term complications decrease long term complications.

SHORT-TERM COMPLICATIONS

HypothermiaRespiratory abnormalities: RDS, pneumothoraxCardiovascular abnormalities: PDA, hypotensionCentral nervous system: IVH, PVLMetabolic: Hypo/ hyperglycemia, hypo/hypernatremia, hypo/hyperkalemiaGastrointestinal: NEC, perforationsImmune system: Sepsis, meningitis, UTIEyes: Retinopathy of prematurity

EPIDEMIOLOGYNICHD 8515 VLBW study:Respiratory distress: 93%Retinopathy of prematurity: 59%Patent ductus arteriosus: 46%Bronchopulmonary dysplasia: 42%Late-onset sepsis: 36%Necrotizing enterocolitis: 11%Grade III and Grade IV IVH: 7 and 9%Periventricular leukomalacia: 3%

HYPOTHERMIARelatively large body surface area and inability to produce enough heat. Heat loss by conduction, convection, radiation, and evaporation.Sequale: hypoglycemia, acidosis, apnea Greatest risk for hypothermia immediately after birth in the delivery room. Admission temperature is inversely related to mortality and late-onset sepsis.

Standard care in DR to prevent hypothermia

Maintain the delivery room temperatureDrying the baby thoroughly immediately after birthRemoval of any wet blanketsUse of prewarmed radiant heaters Polyethylene/polyurethane body wrap or bags, and polyethylene or stockinet caps) or External heat sources ( skin to skin care and transwarmer mattress)

RESPIRATORY COMPLICATIONSRDS: incidence and severity increase with decreasing gestational age. Bronchopulmonary dysplasia, CLD, defined as oxygen dependency at 36 weeks postmenstrual age (PMA)Apnea of prematurity: 25% of preterm infants. Incidence increases with decreasing gestational age

CARDIOVASCULAR COMPLICATIONSPDA: Symptomatic 30% VLBW Shunts blood flow from left-to-rightincrease pulmonary flow and decreased systemic circulation. Severity depends upon size and response of the heart and lungs.Significant shunting hypotension, oligurea, apnea, respiratory distress, or heart failure

CARDIOVASCULAR COMPLICATIONSSystemic hypotension : in the immediate postnatal period significant morbidity (IVH) and mortality.Volume expansion: crystalloid (eg, normal saline) and colloid (eg, fresh frozen plasma) Inotropic therapy: (dopamine, epinephrine)Systemic glucocorticoid therapy: refractory hypotension or those who required high dose inotropic therapy (adverse effects: intestinal perforation and long-term poor neurodevelopment outcome (eg, cerebral palsy)

CNS COMPLICATIONSIntraventricular hemorrhage: in the fragile germinal matrix and increases with decreasing BWbirth. Incidence of severe IVH (Grades III and IV) 12-15%in VLBW Preventive measures: prompt and appropriate resuscitation, avoid hemodynamic instability and conditions that impair cerebral autoregulation (eg, hypoxia, hypercarbia, hyperoxia, and hypocarbia).

METABOLIC COMPLICATIONSGlucose abnormalities: hypoglycemia or hyperglycemia Blood glucose concentration should be monitored routinely starting immediately after birth and continued until feedings are well established and glucose values have normalized

Other metabolic abnormalities will be discussed separately

GI COMPLICATIONSNecrotizing enterocolitis (NEC): 2-10 percent of VLBW infants. associated with increase in mortality. Survivors are at increased risk for growth delay and neurodevelopmental disabilities.

INFECTIONClassification:Early onset sepsisLate-onset sepsis Risk factors for infection: Prolonged intubation, BPD, prolonged intravascular access, PDA, and NEC. Neonatal sepsis is associated with increased likelihood of poor neurodevelopmental outcome and growth impairment.

EYERetinopathy of prematurity (ROP):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(PMA), but may be seen as early as 30 to 32 weeks. Next to cortical blindness, ROP is the most common cause of childhood blindness in the USA.

Pathogenesis of ROPHypotension, hypoxia, or hyperoxia, with free radical formation, injures newly developing blood vessels and disrupts normal angiogenesis neovascularization retinal edema, hemorrhage and abnormal fibrovascular tissue development.

LONG-TERM COMPLICATIONSNeurodevelopmental outcome: Impaired cognitive skillsMotor deficits including mild fine or gross motor delay, and cerebral palsySensory impairment including vision and hearing lossesBehavioral and psychological problemsPoor growth compared to those born full-termImpairment of lung function

EFFECT ON ADULT HEALTH

Insulin resistance Hypertension and vascular abnormalitiesReproduction: Prematurity has been associated with decrease reproduction in adulthood.

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