Transcript Complications of Prematurity - Yale medStation

COMPLICATIONS OF PREMATURITY
Mona Khattab, MD
Neonatal-Perinatal Fellow
Yale University Children’s Hospital
I am not just a “Small” baby… I am a “Preterm”
baby….
I am a “Unique Baby”… with “Unique
Problems”!!
Definition-Magnitude of Problem
Prematurity < 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:
oLate preterm birth — GA between 34 and < 37
weeks
oVery preterm birth — GA < 32 weeks
oExtremely preterm birth — GA ≤ 28 weeks
Classification by BW
oLow birth weight (LBW) < 2500 g
oVery low birth weight (VLBW) < 1500 g
oExtremely low birth weight (ELBW) < 1000 g
YOUR TURN 
Short-term complications
Long-term complications
Proper stabilization in the DR is important to
reduce risk of short-term complications
decrease long term complications.
SHORT-TERM COMPLICATIONS
o
o
o
o
o
Hypothermia
Respiratory abnormalities: RDS, pneumothorax
Cardiovascular abnormalities: PDA, hypotension
Central nervous system: IVH, PVL
Metabolic: Hypo/ hyperglycemia,
hypo/hypernatremia, hypo/hyperkalemia
o Gastrointestinal: NEC, perforations
o Immune system: Sepsis, meningitis, UTI
o Eyes: Retinopathy of prematurity
EPIDEMIOLOGY
NICHD 8515 VLBW study:
o Respiratory distress: 93%
o Retinopathy of prematurity: 59%
o Patent ductus arteriosus: 46%
o Bronchopulmonary dysplasia: 42%
o Late-onset sepsis: 36%
o Necrotizing enterocolitis: 11%
o Grade III and Grade IV IVH: 7 and 9%
o Periventricular leukomalacia: 3%
HYPOTHERMIA
o Relatively large body surface area and
inability to produce enough heat.
o Heat loss by conduction, convection,
radiation, and evaporation.
o Sequale: hypoglycemia, acidosis, apnea
o Greatest risk for hypothermia immediately
after birth in the delivery room.
o Admission temperature is inversely related to
mortality and late-onset sepsis.
Standard care in DR to prevent
hypothermia
oMaintain the delivery room temperature
oDrying the baby thoroughly immediately after
birth
oRemoval of any wet blankets
oUse of prewarmed radiant heaters
o Polyethylene/polyurethane body wrap or bags,
and polyethylene or stockinet caps) or
oExternal heat sources ( skin to skin care and
transwarmer mattress)
RESPIRATORY COMPLICATIONS
o RDS: incidence and severity increase with
decreasing gestational age.
o Bronchopulmonary dysplasia, CLD, defined
as oxygen dependency at 36 weeks
postmenstrual age (PMA)
o Apnea of prematurity: 25% of preterm
infants. Incidence increases with decreasing
gestational age
CARDIOVASCULAR COMPLICATIONS
PDA: Symptomatic 30% VLBW
Shunts blood flow from left-to-rightincrease
pulmonary flow and decreased systemic
circulation.
Severity depends upon size and response of the
heart and lungs.
oSignificant shunting  hypotension, oligurea,
apnea, respiratory distress, or heart failure
CARDIOVASCULAR COMPLICATIONS
Systemic hypotension : in the immediate postnatal
period significant morbidity (IVH) and mortality.
o Volume expansion: crystalloid (eg, normal saline)
and colloid (eg, fresh frozen plasma)
o Inotropic therapy: (dopamine, epinephrine)
o 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 COMPLICATIONS
Intraventricular 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 COMPLICATIONS
Glucose 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 COMPLICATIONS
Necrotizing enterocolitis (NEC):
2-10 percent of VLBW infants. associated with
increase in mortality.
Survivors are at increased risk for growth delay
and neurodevelopmental disabilities.
INFECTION
Classification:
o Early onset sepsis
o Late-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.
EYE
Retinopathy of prematurity (ROP):
o Developmental vascular proliferative disorder
occurs in the incompletely vascularized retina of
premature infants.
o Incidence & severity of ROP increases with
decreasing gestational age or birth weight.
o Typically begins about 34 weeks(PMA), but may
be seen as early as 30 to 32 weeks.
o Next to cortical blindness, ROP is the most
common cause of childhood blindness in the
USA.
Pathogenesis of ROP
Hypotension, 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 COMPLICATIONS
o Neurodevelopmental outcome: Impaired
cognitive skills
o Motor deficits including mild fine or gross
motor delay, and cerebral palsy
o Sensory impairment including vision and
hearing losses
o Behavioral and psychological problems
o Poor growth compared to those born full-term
o Impairment of lung function
EFFECT ON ADULT HEALTH
oInsulin resistance
oHypertension and vascular abnormalities
oReproduction: Prematurity has been associated
with decrease reproduction in adulthood.
THANK YOU 