PREMATURITY

DR MOSES KAZEVU
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WARM UP QUESTION: OSCE

• Shown in the image are
2 twin infants born to a
16-year-old
primigravida.
a. What is your
diagnosis?
b. List 5 complications
associated with the
condition
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PREMATURITY
• A baby born alive before 37 weeks (259 days) of gestation is considered
premature.
• Late preterm (34- 37 weeks)
• Moderate preterm (32-34 weeks)
• Very preterm (28-32 weeks)
• Extreme preterm (less than 28)
• Terms that refer to premature babies (Prematurity) are preterm and preemie.
• Preterm babies are at risk for a number of complications related to the fact that
their organs may not be mature at the time of birth.
• The earlier the baby is born the higher the risk of complications.
• Recall average birth weight= 3kg (2.5 – 3.5 kg)
• Babies born weighing between 1500-2500g= low birth weight (LBW).
• Babies born weighing between 1000-1500g= very low birth weight (VLBW).
• Babies less than 1000g= Extremely low birth weight (ELBW).

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• Most babies that are considered to have low birth weight are
premature however, other conditions can cause LBW in a baby born
after a full-term pregnancy, such as smoking during pregnancy.
• Babies with LBW who are full term (but underweight) and “premature
babies” with weights less than expected are termed small for
gestational age (SGA).
• Causes for intrauterine growth restriction include:
• Infections of the fetus before delivery
• Chromosome or gene abnormalities (S-SGA)
• Insufficient nutrition provided by placenta (A-SGA).
• Poor nutrition in the mother, other problems such as chronic
disease or smoking (A-SGA)

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CAUSES OF PREMATURITY
• Many factors are linked to premature birth. Some factors directly cause early labor and birth while others can make the mother or baby
sick and require early delivery.
• Maternal factors include:
➢ Pre-eclampsia (toxemia or high blood pressure of pregnancy occurring after 20 weeks of pregnancy)
➢ Gestational diabetes mellitus
➢ Chronic medical illness (such as heart or kidney disease, SCD)
➢ Infection (such as group B streptococcus, urinary tract infections, vaginal infections, infections of the fetal/placental tissues)
➢ Drug use (such as cocaine)
➢ Abnormal structure of the uterus
➢ Cervical incompetence (inability of the cervix to stay closed during pregnancy)
➢ Previous preterm birth
➢ Collagen disorders
• Factors involving the pregnancy
➢ Abnormal or decreased function of the placenta
➢ Placenta previa (low-lying position of the placenta)
➢ Placental abruption (early detachment of the placenta from the uterus)
➢ Infection of the placenta
➢ Premature rupture of membranes (amniotic sac)
➢ Polyhydramnios (too much amniotic fluid)
• Factors involving the fetus
➢ When the fetal behavior indicates the intrauterine environment is not healthy
➢ Multiple gestation (twins, triplets etc.)
➢ Congenital anomalies

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FEATURES AND COMPLICATIONS OF

PREMATURITY
• Every premature infant is different however features of prematurity include:
➢ Very small size (at 24 weeks- male 700g, female 620g)
➢ Very thin fragile skin with veins visible underneath (Dark red color all
over the body)
➢ Soft hair on the body: lanugo
➢ Ears: Pinna soft, no recoil, startles to loud noise
➢ Eyes: fused eyelids, infrequent eye movements.
➢ Faint cry
➢ Breast tissue: no breast tissue palpable
➢ Genitalia:
o Male: Scrotum lacks rugae (smooth), no testes in scrotum
(cryptorchidism)
o Female: prominent clitoris, labia majora widely separated, labia
minora protruding
➢ Little activity, weak cry
➢ Feeding problems: baby can’t suck or swallow normally
➢ Breathing problems: apnea of prematurity
➢ Limbs extended. Jerky movements

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CNS COMPLICATIONS
• Intraventricular hemorrhage with hydrocephalus.
➢ Intraventricular hemorrhage is rupture of germinal matrix blood vessels due to hypoxic or hypotensive injury.
➢ Predisposing factors: prematurity, RDS, hypo or hypervolemia and shock.
➢ Signs and symptoms: most asymptomatic, lethargy, poor suck, high-pitched cry and bulging fontanelle.
➢ Diagnosis: cranial ultrasound (through anterior fontanelle)
➢ Treatment: directed toward correction of underlying condition (RDS, shock etc.) In cases of associated hydrocephalus, placement of ventriculoperitoneal
shunt may be required.
• Hemorrhagic and periventricular white matter brain injury (periventricular leukomalacia)
• Cerebral palsy (difficult muscle control, stiffness)
• Learning disability/ Mental retardation
• Deafness
• Retinopathy of prematurity: this is a proliferative retinopathy
➢ Caused by proliferation of immature retinal vessels due to excessive use of oxygen.
➢ Can lead to retinal detachment and blindness in severe cases.
➢ Diagnosis: all very low birth weight infants should be screened for ROP with an ophthalmoscopic exam. A trained pediatric ophthalmologist should perform
the examination. Infants being screened should be monitored for 1-hour post instillation of eye drops for side effects from systemic absorption of
cyclopentolate or phenylephrine.
o Common side effects: vasoconstriction, tachycardia, hypertension, apnea and feeding intolerance
o All infants with GA<30 weeks or birth weight <1251 g (this may differ in other neonatal units) must be screened.
o The infant must be booked to be screen at 4 weeks chronological age.
▪ Write the date of screening on the front of the infant record chart
▪ Provide parents with information leaflet
▪ The ophthalmologist must be provided with a list (in order of screening before the start of the screening session).
➢ Treatment: Laser surgery may be needed in severe cases.
➢ See next slide
• Blindness

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RESPIRATORY COMPLICATIONS
• Respiratory distress syndrome (hyaline membrane disease): the lungs are immature and do not produce surfactant (which is
produced from the pneumocyte type II cells as early as 20 weeks but peaks at 35 weeks of gestation).
➢ Incidence: infants <32 weeks gestation
➢ Signs and symptoms: seen within first 3 hours of birth, tachypnea, grunting and cyanosis.
➢ Surfactant contains both Lecithin and sphingomyelin.
➢ The Lecithin-syphingomyelin ratio is a determining factor in lung maturity.
➢ A L-S ratio greater than 2.0 to 2.5 is indicative of lung fetal lung maturity.
• In addition, the alveoli are small, inflate with difficulty and do not remain gas filled between inspirations. The rib cage is weak
and compliant.
• There is high surface tension and propensity for alveolar collapse.
➢ Alveolar collapse results in progressive atelectasis, intrapulmonary shunting, hypoxemia and cyanosis.
• Apnea of prematurity: due to immaturity of the breathing center in the brain
➢ Apnea: cessation of breathing for more than 20 seconds associated with oxygen desaturation, cyanosis and/or
bradycardia.
➢ Types of apnea:
o Central: occurs when inspiratory efforts are absent
o Obstructive: occurs when inspiratory persists in the presence of airway obstruction
o Mixed type: has a component of both central and obstructive apnea.
➢ Apnea occurs in more than 50% of neonate <30 weeks and occurrence reduces with advancing gestational age. At 60
days post conceptual age the risk of apnea in neonates is the same as in term babies.

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RESPIRATORY COMPLICATIONS
➢ Apnea occurs in more than 50% of neonate <30 weeks and occurrence reduces with advancing gestational age. At 60 days post conceptual age the
risk of apnea in neonates is the same as in term babies.
➢ Apnea of prematurity is a diagnosis of exclusion because it is associated with other diagnoses including hypo/hyperthermia, hypoglycemia, anemia,
hyperbilirubinemia, sepsis, intraventricular hemorrhage, necrotizing enterocolitis, gastroesophageal reflux etc.
➢ Any neonate with apnea should be evaluated thoroughly.
➢ Evaluation:
o Preterm neonates less than 33 weeks of gestation are commenced on continuous oxygen saturation monitoring with alarm set at saturations
<88% and time lag for alarm to go off at 20 seconds. Prompt response to alarm is required to ascertain cause of desaturation.
o If no monitors are available it is important to observe the neonate for cyanosis, mottling and lack of breathing/no chest wall movements.
o Work up:
▪ Full blood count
▪ ESR and CRP
▪ Glucose
▪ Blood culture
▪ Serum electrolytes
▪ Serum aminophylline level if possible and cranial ultrasound scan
o If not tolerating feeds +/- abdominal distension suspect necrotizing enterocolitis.
➢ Management
o Prevention:
▪ Aminophylline/caffeine is given prophylactically to all preterm neonates <33 weeks gestational age or <1500g birth weight.
▪ Dose: Aminophylline load with 6mg/kg slowly over 20 minutes then start maintenance at 2.5mg/kg BD starting 24 hours after loading.
▪ Aminophylline may be given orally (usually reconstituted into liquid form) to stable preterm neonates at the same dosing. Stop once
infant has good suckling and swallowing coordination
▪ Therapeutic serum level is 9-14mg/dl
▪ Caffeine dose as below

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RESPIRATORY COMPLICATIONS
o Treatment:
▪ Establish cause and start
treatment for suspected cause.
▪ Commence CPAP with close
monitoring and during an apnea
episode stimulate infant, if not
arousable provide bag mask
ventilation.
▪ If episodes are frequent >3
episodes then mechanical
ventilation is needed.

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RESPIRATORY COMPLICATIONS
• Chronic lung disease/ bronchopulmonary dysplasia
➢ Need for supplemental oxygen beyond 28 days of life (months and sometimes to years).
➢ Characterized by squamous metaplasia and hypertrophy of small airways.
➢ Infants with bronchopulmonary dysplasia can be wheezing remember, “not all that wheezes is
asthma!”
➢ Treatment: supplemental oxygen, oral steroids, bronchodilators.
• Pneumothorax
• Pneumonia
• Note in extremely premature babies (23-25 weeks) the lung may be incompletely developed (in addition
to being immature) these rarely survive outside the womb.
• Recall the five stages of lung development include: (Every Premature Child Takes Air)
➢ Embryonic stage: 3-8 weeks
➢ Pseudoglandular stage: 5-16 weeks
➢ Canalicular stage-16- 26 weeks
➢ Terminal saccular-26-37 week
➢ Alveolar stage- birth until early childhood (8 years)

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CARDIOVASCULAR SYSTEM
• Persistent/patent ductus arteriosus
• Anemia of prematurity
• Hypotension
• Atrial septal defects
• Ventricular septal defects

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COMPLICATIONS OF PREMATURITY
• GASTROINTESTINAL SYSTEM
• Necrotizing enterocolitis
• Neonatal jaundice
• Poor feeding
• Gastroesophageal reflux
• GENITOURINARY SYSTEM
• Inguinal hernias with high risk of strangulation
• METABOLIC
• Hypoglycemia
• Hypothermia
➢ There is increased surface area to volume ratio leading to increased heat loss
➢ The immature skin cannot retain heat and fluid efficiently
➢ Reduced subcutaneous fat reduces insulation
• Electrolyte (Hypocalcemia) and fluid imbalance
• Osteopenia of prematurity
• OTHERS
• Rickets of prematurity
• Infections: neonatal sepsis, GBS infection and coliforms, pneumonia
• Perinatal asphyxia

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DIAGNOSIS
• History:
➢ Risk factors: Young maternal age, multiple pregnancy, infection, maternal illness (e.g.
pregnancy induced hypertension), cervical incompetence, antepartum hemorrhage
➢ Full obstetric history
➢ Condition at birth: APGAR score, resuscitation required
➢ Gestation: must be known to give accurate prognosis. Calculate from menstrual period, by
early dating ultrasound scan or by assessment of gestation after birth
➢ Associated problems such as twin pregnancy (much higher risk of poor neurological
outcome), congenital abnormalities or infection (chorioamnionitis may have been a trigger for
preterm labor)
➢ Antenatal steroids: if given, these reduce the incidence of respiratory distress syndrome and
intraventricular hemorrhage
• Examination: features of prematurity
• The external appearance and neurological findings can be scored to provide an estimate of an
infant’s gestational age (Ballard score).

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FETAL-INFANT GROWTH CHART FOR PRETERM INFANTS

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MANAGEMENT
• Admit to neonatal intensive care unit (NICU) for special care and monitoring.
• Temperature control: maintain temperature in an incubator at ideal.
➢ Parents are encouraged to participate in as much care of their baby as they are comfortable
providing. This may involve holding, Kangaroo care, diaper changes, giving baths, feeding.
• Feeding
➢ Total parenteral nutrition or intravenous feeding
➢ Gavage feeding: Preterms before the 34th week of gestation need to be fed through a nasogastric
tube or nasojejunal tube. Feeding should be done through NGT until 32-34 weeks when sucking
reflex is well developed.
➢ Breast feeding often has to be delayed. Expressed breast milk can be given in a bottle.
➢ Decisions about feeding depend on the infant’s particular circumstances.
➢ Maintain glucose above 2.6mmol/L
• Prevention of the infection: hand washing and aseptic techniques
• Treatment of complications.
• In anticipation of RDS secondary to surfactant deficiency, doses of dexamethasone (steroid) can be
given to the mother 48 hours before delivery- this is assuming that the lungs are already at the terminal
saccular stage thus they can be stimulated to produce surfactant.

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WARM UP QUESTION: OSCE

• Shown in the image are 2 twin
infants born to a 16-year-old
primigravida.
a. What is your diagnosis?
Prematurity
b. List 5 complications
associated with the
condition: Necrotizing
enterocolitis, Apnea of
prematurity, Anemia of
prematurity, respiratory
distress syndrome,
retinopathy of prematurity
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“SOMETIMES THE EASIER LIFE YOU WISH FOR IS ACTUALLY HARDER THAN THE ONE
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