Transcript NOU - NĂSCUTUL CU RISC

HIGH RISCK NEW BORN
BABY
PRETERM NEW BORN
PRETERM NEW BORN
Definition: Preterm new born is a baby with:
GA < 37 weeks,
 Wb < 2500g,
 Hb < 47cm.
Preterm new born has the adequate weight for the
gestational age.
Prematurity degrees
International Clasification Diseases (ICD)
New born
Gestational Age
Birth Weight
Low birth weight
(LBW)
Very low birth
weight (VLBW)
GA < 37 w.
Wb = 2499g –
1500g
GA < 32 săpt.
Wb =1499g – 1000g
Extremely low birth
weight (ELBW)
GA < 28 săpt.
Wb < 1 000g
PRETERM NEW BORN
Causes of prematurity:
Maternal causes:
 mother’s age < 14 years and > 35 years;
 mother’s height (<1,50m);
 mother’s weight (< 45 kg);
 Obstetrical causes:
- uterine: infantile uterus, uterine malformations,
tumors, chronic endometritis, uterine fibromatosis,
incompetence cervicoisthmic;
PRETERM NEW BORN
Maternal causes:
- placenta: retroplacentare hemorrhage,
early detachments of placenta, placenta praevia;
- premature rupture of membranes, repeated abortions,
narrow pool, oligo / polihidramnios, multiparous;
- acute diseases: influenza, pneumonia, hepatitis;
- chronic diseases: diabetes, feto - maternal
isoimmunization, thyroid disease, kidney or heart
disease, syphilis, tuberculosis;
PRETERM NEW BORN
Maternal causes:
- vascular-kidney syndrome;
- chronic poisoning: smoking, alcoholism, drugs
- self-intoxications: pregnant toxemia;
- history of infertility;
- pregnancies occurred in a too short time;
- hormonal imbalances.
PRETERM NEW BORN
Fetal Causes:
- twins;
- fetal chromosomal diseases;
- fetal malformations;
- erythroblastosis;
- Intrauterine Growth Retardation - IUGR;
- fetal chronic infections (TORCH).
PRETERM NEW BORN
Social causes:
- low socio-economic status;
- low education;
- poor diet;
- physical trauma and / or psychological;
- excessive effort;
- failure to comply with hygiene rules.
Cause unknown ~ 30% of premature births.
Clinical Features of premature new born
Clinical features - specific for duration of gestation.
HEAD:
- large dehiscence sutures, fontanelles wide open, hair
rarely
- face - small, triangular, senile aspect, large mouth,
sharp chin,
- ears – low position, stuck to his head, with poor
development of cartilage.
The neck is thin.
Clinical Features of premature new born
Chest: narrow, poorly mineralized, the ribs are
horizontal.
Abdomen:
- voluminous and flattened on the sides (large volume of
liver and muscle hypotonicity)
- frequently → dehiscence of rectus abdominis,
umbilical and inguinal hernia.
The legs are short and thin.
PRETERM NEW BORN
Clinical Features of premature new born
Skin:
- thin, red at birth, become pale after a week;
- lanugo: abundant on the face, limbs, back
trunk;
- vernix caseosa: small quantity / missing;
- physiological desquamation: prolonged, furfuraceous
or lamellar;
- hangs in folds.
Clinical Features of premature new born
Nails:
- soft, weak, lacking longitudinal ribs, do not touch
fingertips.
Subcutaneous tissue:
- diminished;
- turgor is flaccid.
Muscle:
- hypotonic.
Clinical Features of premature new born
Skeletal system: poorly mineralized.
External genitalia:
poor developed;
♂: - testis are not present in the scrotum (80%)
- scrotum is small, without pleats and poorly
pigmented.
♀ - vulva wide open
- labia majora, underdeveloped - do not cover labia
minora and clitoris.
- genital crisis is absent / appears later.
PREMATURE NEW BORN
Deficiency of the Respiratory Function:
- trachea and bronchisoles are narrow;
- lung elasticity is low;
- poor mineralization of the ribs, muscle hypotonia and
high position of lungs and diaphragm limites lungs
expansion and favors indrawing;
- qualitative and quantitative deficiency of surfactant
maintains high superficial tension and promote the
collapse of the alveoli;
Deficiency of the Respiratory Function:
- on expiration, the alveolar collapse is complete and a
new inspiration fills the alveoli from the beginning;
- circulation is poor, low alveolar perfusion;
- the high strength of the pulmonary circulation →
passage of blood through the ductus arteriosus and
foramen ovale;
These features → hypoxia → pulmonary
vasoconstriction → increased hypoxia → alveolar
epithelial injury → edema → hyaline membranes.
Deficiency of the Respiratory Function:
Respiratory center → three centers:
- apneustic - on the superior part of the medulla
oblongata;
- pneumotaxic – in pons;
- gasping - at the inferior part of the medulla oblongata.
Apneustic center → tonic contraction of respiratory
muscles → inspiration.
His action is discontinuous interrupted by pneumotaxic
center → expiration.
Deficiency of the Respiratory Function:
Hypoxia → apneustic center stops working →
automatism of gasping center → rudimentary
respiration, with sudden inspiration, jerky, spasmodic
movements of the mouth and jaw, followed by long
pauses in breathing.
Imperfection of the superior respiratory centers and the
automatism of the inferior respiratory centers = apneic
attack of the premature baby.
Deficiency of the Respiratory Function:
Apnea of the premature baby = cease breathing ~ 20
seconds, accompanied by bradycardia (HR<80 beats /
min) and cyanosis.
Types:
- Central apnea: cessation of breathing movements and
nasal airflow, favored by diaphragmatic fatigue and
impaired neurotransmission;
- Obstructive apnea: cessation of nasal airflow,
maintaining respiratory movements secondary airway
obstruction;
- Mixed apnea (the most common): combination of
central and obstructive apnea.
The deficiencies of respiratory → respiratory distress
Clinic:
- tachypnea (up to 100 – 120 breath/min)
- functional respiratory syndrome (expiratory moaning,
intercostal indrawing, thoraco-abdominal swing)
- cyanosis.
To reduce its severity
i.m. corticosteroid (Betamethasone) are recomanded to
all pregnant women with imminent premature delivery.
Cardio-vascular characteristics of premature new
born
Hypoxia → pulmonary vasoconstriction → high resistance in the
pulmonary circulation→ increase volume of the right ventricle
(EKG: the heart's electrical axis deviation to right).
Hypoxia and metabolic acidosis → Botal's hole permeability and
persistence of the ductus arteriosus (clinical: the corresponding
murmurs).
Low oxygenation of the myocardium and depletion of small
quantity of glycogen → heart failure.
PREMATURE NEW BORN
Haemodynamic
Features in new born baby
Blood pressure: low (45-70mmHg/30-45mmHg) →
peripheral irrigation is reduced and slow.
Cerebral arteries conjunctivo - elastic tunic is weak,
fragile → bleeding.
High permeability of capillaries + hypoproteinemia →
edema.

Haemodynamic
Features in new born baby
Hemoglobin:
90-100% fetal hemoglobin, persist for a long time.
Leukocytes:
- 8.000-10.000/mm3 birth, predominantly neutrophils,
- lymphocytes predominate after 2-3 weeks.
Platelets: 150000 - 200000/mm3.
Clotting factors:
low levels + capillary fragility → bleeding (in the brain
and adrenal) between the 3rd and 7th day after birth.
Deficiency of Digestive Function
Sucking reflex:
- absent in children GA<32-33 weeks.
Swallowing reflex:
- absent in most children with Wb <2000g.
In these children liquids are administered by gavage
feeding.
Reduced salivary secretion, dry and permeable oral
mucous membrane → stomatitis.
Salivary amylase is present at birth.
Deficiency of Digestive Function
Stomach:
- low capacity
- mucosa has few folds,
- glands and muscle fibers are less developed,
- evacuation is delayed,
- hydrochloric acid secretion is good,
- rennin, pepsin and gastric lipase are present at birth.
Deficiency of Digestive Function
Intestine:
- hypotonic musculature, → slow peristaltic movements
- bloating and constipation,
- much increased mucosal permeability,
- disaccharidases (invertase, maltase and lactase)
activity are normal at birth.
Pancreas:
- pancreatic amylase missing
- lipase activity is low
- trypsin activity is normal.
Deficiency of Digestive Function
Liver:
- embryonic-type structure, with haematopoietic centers,
- immature liver function:→ jaundice more frequently,
earlier, prolonged and intense (bilirubin can reach
150mg / l) as function of conjugation is deficient;
phototherapy and exchange transfusion rarely required;
→ hypoalbuminaemia which favors the occurrence of
edema;
→ vascular fragility ↑ + hypoprotrombinemie →
bleeding tendency;
→ hypoglycemia due to inappropriate storage of
glycogen in the liver.
Deficiency of Digestive Function
Digestion and absorption of milk proteins is the same as
that of full term new born.
Digestion and absorption of lipids in human milk is
made effective due to the existing milk lipases.
Carbohydrate digestion and absorption is satisfactory.
Pre term newborn can use the lactose in milk, despite
having a transient lactase deficiency in the first week of
life.
PRETERM NEW BORN
Deficiency of Urinary System
Kidneys → embryonar lobulated.
→ irrigation is low.
- glomerular filtration is deficient.
- dilution capacity and concentration are poor →
tendency to hyper / hyponatremia and the occurrence of
edema.
- increased glomerular permeability in the first days of
life → albuminuria.
- renal immaturity → imbalance in removing urea,
chlorides, phosphates.
Particularities of Hydro-mineral metabolism
- increased body fluid content (75-82%);
- predominates extracellular fluids;
- hydrolability slightly higher due to mobilization of
extracellular fluid;
- retention tendency for Na with edema appearance;
- tendency to hypocalcemia (Ca reserves are low due to
a short gestation, food intake does not cover high needs
of the premature baby).
Deficiency of Immune System
Nonspecific immunity:
Mechanical barrier:
- skin does not act as a barrier (lack of both stratum
corneum and skin acidity created by sudoriparous
glands).
- mucous: has no secretory Ig A.
Cellular Immunity: is poor because of weak leukocyte
chemotactic response.
Characteristics of serious infections:
- develops without an increase in the number of white
blood cells, sometimes with leukopenia,
- have non-specific clinical aspects, difficult to
recognize.
Deficiency of Immune System
Non-specific humoral immunity (opsonins,
complement, properdin, Lysozyme) is also low.
Specific immunity:
specific humoral immunity is very diminished (IgG
from mother to fetus passes in the last months of
pregnancy).
Personal immunogenesis - IgM and IgA – is deficient.
Cerebral Deficiency
Brain:
- convolution and grooves: only sketched;
- distinguish between white and gray matter is hardly
seen;
- cortical and subcortical low vascularization is a little
higher in periventricles region and for gray nuclei.
Nervous cerebral cells are less developed.
Cerebral Deficiency
Myelination process is almost absent (only the spinal
cord and medulla oblongata have a beginning of
myelination).
CML(cerebromedullary liquid):
-xanthochromic;
-albuminorrhachia, glycorrhachia and cellularity are
increased.
Primitive reflexes are barely sketched / missing in
most premature.
Deficiency of the Termoregulator Function
- tendency to hypothermia
- thermolysis → increased (subcutaneous tissue is
reduced)
- thermogenesis → deficient, is achieved primarily by
chemical mechanisms.
Maintaining body temperature at 36.5 ° to 37 ° C
is absolutely required to reduce energy costs and
nutrient intake.
Deficiency of the Termoregulator Function
Hypothermia:
→ vascular collapse,
→ diffuse capillary bleeding,
→ hypoglycemia
→ severe kidney disorders,
→ sclerema (irreversible waxy induration of the skin
and subcutaneous tissue).
The point of thermic neutrality at which the infant
has a minimum oxygen consumption is the temperature
of 32º C.
Preterm new born
Evolution and Prognosis
of Preterm New Born
Depends on:
- degree of prematurity;
- hypoxia at birth;
- the underlying cause of premature birth;
- nursing conditions and subsequent morbidity.
Immediate complications:
- intraventricular hemorrhage;
- ulcerative-necrotic enterocolitis;
- hyaline membrane disease;
- cholestatic liver;
- nutritional deficiencies;
- severe infections.
Evolution and Prognosis
of Preterm New Born
Late complications:
- Eye (premature n.b. retinopathy, strabismus, myopia);
- Auditory (hearing loss, deafness);
- Neurologycal (motor disability, mental retardation,
speech, learning, memory, attention and behavior
disorders);
- Lung (broncho-pulmonary dysplasia, chronic lung
disease)
- Deficiencies (anemia, rickets, malnutrition).
Premature New Born Care

Prevention of premature delivery: tocolytic
medication in pregnant women.
 In the delivery room:
Controlling respiratory deficit:
- gentle suction airways and mouth for improving the
breath;
- laterally recumbent position and head upper;
- in gastric stasis – suction of gastric content to make
easier the diaphragmatic movements;
- heated, humidified, discontinuous oxygen, 2-4 l / min
by nasal cannula, CPAP (Continuous Positive Airway
Pressure), tracheal intubation;
Premature New Born Care
Premature New Born Care
Thermoregulation Deficiency Control:
- delivery room`s temperature of 26° C;
- swaddling with warm clothes;
- ward`s temperature of 26 – 28° C;
- premature infants with W.b → T = 34° C;
for each additional 250g T→ minus 1° C;
per 250 g minus T is increased by 1° C.
Premature New Born Care
Premature New Born Care
Acidosis control:
- glucose solution + oxygen + 5% sodium bicarbonate
for mother during delivery and then for new born,
during the first days, depending on the values of Astrup.
Hemorrhage tendency control:
- smooth gestures;
- avoiding Trendelemburg position (increased risk of
intracranial hemorrhage);
- vitamins C and E (capillary - trophy);
- vit. K during the first days.
Premature New Born Care
Infections prophylaxis:
- small wards with their own circuits;
- access to foreign persons is forbidden;
- limiting contact between sick and the healthy new
born babies;
- cyclic and curent disinfection of wards, cots,
incubators;
- humidifiers` liquid and oxygenators will be changed
daily.
Premature New Born Care
Infections prophylaxis:
- prevention of air contamination in wards;
- the staff will be regularly checked clinically and
bacteriologically;
- thorough washing of hands before handling each baby;
- linens, dishes and medical instruments used will be
sterilized before each use;
- preventing contamination of milk.
Premature New Born Care
Nutrition in premature new born babies :
- individualized considering the degree of prematurity;
- ideal food is human milk;
- to premature Wb <1500g human milk fortifiers
will be added (eg FM85, FMS);
- in the absence of human milk will be used
special milk formula (Humana 0, Aptamil Prematil,
PreNAN).
Nutrition of Preterm New Born
Nutrition of Preterm New Born
Nutrition of Preterm New Born
Premature New Born Care
Criteria for discharge of the premature new born:
- receives all food ration (from bottle / breast);
- shows a steady increase in weight and reached 2500 g;
- is thermally stable outside the incubator;
- does not show recent crises of apnea or bradycardia.
We recommend periodic:
ophthalmologic,
acoustic
haematologycal evaluation.
INTRAUTERINE GROWTH
RETARDATION (IUGR)
IUGR NEW BORN
IUGR new born baby is also known as:
- dismature,
- malnourished in utero,
- small for gestational age (SGA).
Definition: IUGR new born baby is the child who`s W.b
is below the 10 th percentile on standard intrauterine
growth or less than 2 SD from the average over the
appropriate weight for GA.
IUGR NEW BORN
IUGR NEW BORN
Maternal factors:
- ↓ uteroplacentate flow (preexisting / pregnancyinduced hypertension,
preeclampsia, diabetes, chronic disease,
reno -vascular, collagen disease);
- hypoxemia (severe anemia, chronic lung disease,
cyanogen heart disease, hemoglobinopathyes, high
altitude);
IUGR NEW BORN
Maternal factors:
- malnutrition (poor diet, low maternal H and
W, anorexia nervosa);
- multiple pregnancy (inadequate prenatal nutrition);
- tobacco, alcohol, drugs;
- drugs (anticonvulsants, anticoagulants, etc.)
IUGR NEW BORN
Placental Causes:
- perfusion disorders;
- anatomical abnormalities (placental detachment, heart
attacks, cancer, abnormal cord insertion, umbilical vessel
thrombosis);
- inflammation (bacterial, viral, parasitic).
IUGR NEW BORN
Fetal Causes:
-chromosomal abnormalities (trisomy 13, 18,21, Turner
syndrome, etc.);
-intrauterine infection (TORCH, syphilis);
-malformations (anencephaly, gastrointestinal atresia,
cardiovascular anomalies except for tetralogy of
Fallot, transposition of great vasals).
IUGR NEW BORN
Classification:
Symmetric IUGR (harmonic, hypoplasia): W, H, HC
equally affected;
Asymmetric IUGR (disharmonic, hypotrophyc): H,
HC relatively normal, low abdominal circumference.
IUGR NEW BORN
Symmetric IUGR:
microcephaly and elements
suggesting genetic
abnormalities (dysmorphic
features), intrauterine infection
(jaundice, petechiae, liver splenomegaly, abnormal
eye).
IUGR NEW BORN
Asymmetric IUGR:
- n.b is thin, long, with a big head in contrast to the rest
of the body;
- the face is small, triangular, forehead is wrinkled;
- the skin is thin, wrinkled, sometimes translucent
and often persistent skin fold.
- subcutaneous tissue: diminished.
IUGR NEW BORN
Asymmetric IUGR:
- muscle mass: diminished, showing hypertonia.
- behavior: alert.
- archaic reflexes: exaggerated.
- ± tremor of the extremities.
- appetite: generally good.
IUGR NEW BORN
Complications:
Intrauterine death by:
- placental insufficiency;
- malformations incompatible with life;
- severe infections.
IUGR NEW BORN
Complications
Perinatal asphyxia and its sequelae:
- hypoxic-ischemic encephalopathy,
- meconium syndrome aspiration,
- persistent fetal circulation syndrome,
- respiratory distress syndrome,
- heart failure
- renal failure.
IUGR NEW BORN
Complications
Hypothermia secondary to disorders of thermogenesis
and increased heat loss.
Metabolic: disturbance of metabolism
- of glucose (hypo / hyperglycemia);
- of lipid (oxidation and diminished use of free
fatty acids and triglycerides);
- of protides (reduced absorption
and increased loss of protein).
IUGR NEW BORN
Complications
Polycythemia secondary to chronic fetal hypoxia.
Reduced immunological respondence and increased
infectious risk .
IUGR new born have higher risk of:
- Ulcerative-necrotic enterocolitis;
- Gastrointestinal perforations;
- Sudden death.
IUGR NEW BORN
Prognosis and evolution:
Symmetrical IUGR will have a more
reserved prognosis in terms of growth and neurological
development compared with asymmetrical IUGR.
Evolving → frequently neurological disturbances such
as:
cerebral palsy;
low IQ;
cognitive deficit;
behavioral problems.
IUGR NEW BORN
Prophylactic treatment:
- monitoring of pregnancy (clinical examination,
ultrasound screening for infections)
- low dose aspirin therapy (prevents utero-placental
thrombosis and infarction of the placenta)
- caesarean section birth (natural birth would result
in additional stress and aggravate pre-existing hypoxia).
IUGR NEW BORN
IUGR newborn care
In the delivery room:
- hypothermia and hypoxia control (the same
as premature);
- 26 ° C temperature in wards;
- gentle suction of upper airways - of
mucus, amniotic fluid, meconium;
- clamping and cutting immediately the umbilical
cord - concedering polycythemia;
- rebalancing via umbilical cord;
- careful clinical examination → congenital
malformations.
IUGR NEW BORN
In neonatal unit care:
correcting
- hypothermia: thermal neutrality (32 ° C);
- acidosis: solution of sodium bicarbonate;
- hypoglycemia: glucose solution 10%
- cerebral edema: mannitol in slow intravenous infusion
- polycythemia: liquid in intravenous infusion / exchange
transfusion with plasma according to Ht.
Nutrition: the same principles as in the preterm new
born, but has a better digestive tolerance.
POSTMATURE NEW BORN
POSTMATURE NEW BORN
Definition: The newborn with GA > 42 weeks,
regardless of W.b.
Etiology: incompletely elucidated, more frequently
in women with reproductive disorders and primiparous.
Intrauterine evolution normal up to 42 weeks,
but extended pregnancy lowers oxygen and nutrients
→ intrauterine death / acute fetal distress
(Apgar often < 5 at 1 minutes).
POSTMATURE NEW BORN
Clinic:
- aspect of a 2-3 weeks old child, thin, with wrinkled
face, alert and eyes wide opened;
- skin is pale, parchmenty, dry, cracked, sometimes
greenish (impregnated with meconium);
- lanugo and vernix caseosa missing;
- hair is long and abundant;
- nails are long;
- subcutaneous tissue is diminished;
- umbilical cord is impregnated with meconium.
POSTMATURE NEW BORN
POSTMATURE NEW BORN
Complications:
- asphyxia at birth
- meconium aspiration syndrome
- persistent pulmonary hypertension
- metabolic disorders (hypoglycemia, hypocalcemia)
- mechanical trauma at birth.
POSTMATURE NEW BORN
Postmature new born prognosis: reserved.
Higher morbidity in the newborn period due to
aspiration of amniotic fluid, meconium or central
nervous system distress.
Mortality can be reduced through appropriate obstetrical
measures.
POSTMATURE NEW BORN
Postmature new born care:
Immediately after birth → fighting against:
- aspiration syndrome of meconium and / or amniotic
fluid;
- hypoxia and acidosis.