HIGH RISK BABIES

BY SABEKO BATES ERINEO

 CONT’

• The term ‘High Risk Babies’

designates babies who should be
under close observation by
experienced health personnel
• These infants should be identified
early to decrease neonatal
morbidity and mortality
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• The observation can be for a few
hours to several weeks
• Generally speaking,
- The lower the birth weight, the
higher the neonatal mortality
- The smaller the gestational age the
higher the neonatal mortality
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 How to identify babies at high risk

a. Demographic social factors

• Maternal age <16 or >35 years
• Illicit drug, alcohol, cigarette use
• Poverty
• Unmarried
b. Past medical history
• Diabetes mellitus
• Hypertension
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 Cont’

c. During pregnancy
• IUGR
• Prematurity
• Incompetent cervix
• Congenital anomaly
• Multiple gestation
• APH
• STI
• PROM
• Polyhydromnios

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 Cont’

d. Labour and Delivery

• Premature labour
• Post maturity
• Foetal distress
• Breech presentation
• Caesarean section
• Instrumental delivery
• APGAR score of less than 4 at 1 minute

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 Cont’

e. Neonatal
• Birth weight of < 2.5kg or >4kg
• Small for gestational age (SGA) or
Large for gestational age (LGA)
• Tachypnoea, cyanosis
• Pallor, petechiae
• Blood or blood group incompatibility
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 1. LOW BIRTH WEIGHT

These are babies weighing less

than or equal to 2.5kg at birth

CAUSES
a. Maternal Factors
Loss of weight during pregnancy
Short stature
Teenage pregnancy

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 Short birth interval

malnutrition

Anaemia

Maternal infection during pregnancy i.e.

Malaria, TB and Chronic infection.
Pregnancy complications; toxaemia,
antepartum haemorrhage

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 Cont’

b. Fetal factors
• Preterm delivery (Born <37 weeks
gestation)
• Multiple pregnancy
• Intrauterine Infections
• Congenital abnormalities

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 Types of low birth weight
– Preterm babies
– Small for Gestation Age
• SGA babies are defined as those
whose weight falls below 10th
centile for their gestation. (Weight
below which 10% of normal
babies at that gestation are)

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 THE 10TH CENTILE FOR
DIFFERENT GESTATION
GESTATION 10TH CENTILE
WEIGHT
• 38 2.2kg
• 36 1.9kg
• 34 1.5kg
• 32 1.25kg
• 30 1.0kg
• 28 0.8kg

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 Causes of Low Birth weight

• Poor maternal nutrition

• Placental malarial infection
• Intrauterine infection

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PROBLEMS FACED BY PREMATURE AND
SGA

PREMATURE
• Respiratory Distress Syndrome
(hyaline membrane disease)
• Hypothermia
• Feeding problems
• Jaundice
• Acquired infections
• Bleeding (Hemorrhagic Disease of
the newborn)

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 Cont’

SGA
• Hypoglycemia
• Hypocalcaemia
• Meconeum Aspiration
• Congenital infections
• Chromosome Abnormalities

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 PRACTICAL “MATURITY”
ASSESSMENT

• This is done by looking at crease

on the soles, the genitalia, the
breasts, the ears, the skin and
posture and tone (especially at
wrist and ankles)=Dubowitz
system

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 cont

Feature Very Pre- Pre-term Term

term
Creases on soles None Few near toes All over soles

Genitalia male Smooth empty Scrotum has few Scrotum has many
scrotum rugae rugae
Female Protruding labia Labia minora Major cover minora
minora Equal to Majora
Breasts Faint, flat areola Nipple but no breast Breast tissue>10mm
tissue diameter

Ears Flat soft pinna Springy flat pinna Edged curved all
round
Skin over abdomen Thin, red skin, visible Pale skin, veins less Thick pale opaque
veins visible skin

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 Cont’

Posture Limbs Frog posture Full flexion

(on back) straight
Flexion at 90º window 45º window Full wrist
wrist flexion

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 Note:
• Pre-term babies behave differently from full term
because they are less mature.
• Thus they show different weight curve pattern after
birth.
• Babies of appropriate weight for gestation, a 2.5kg
baby should regain birth weight by 8 days, a 2.0kg by
10 days, a 1.5kg by 14 days and a 1.0kg baby by 17
days, if healthy. LBW mature babies (SGA) if not
severely affected can be expected to gain weight at a
rate appropriate for their gestation.

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Management a of LBW babies

Routine care of low birth weight infant;

 Weighing to monitor growth

 Breast feeding (Expressed Breast feeding)

to prevent Hypoglycemia
 Keep baby warm/kangaroo care method
(skin to skin method) or keep in incubator.

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 Cont’

 If presenting with bleeding, give

Vitamin k injection (prevent
hemorrhagic disease of the new born).
 Infections can be treated as Neonatal
Sepsis with X-pen + Gentamycin
 Lumbar puncture R/O Meningitis

 Check blood sugar R/O Hypoglycemia

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 Resuscitation of premature
babies

• Same as for term babies but

need to be admitted in
special care nursery for
warmth, feeding and oxygen

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 2. Babies born from diabetic Mothers

• Diabetic mothers have high incidence

of
- Polyhydromnios
- PIH
- Pyelonephritis
- Preterm labour
- Chronic hypertension
• Have high foetal morbidity and
mortality rates at all gestational ages,
especially after 32 weeks
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 Pathophysiology
• The pathogenic sequence is that maternal
hyperglycemias leads to foetal
hyperglycemias
• The foetal body is stimulated and leads to
foetal hyperinsulinemias
• These foetal hyperglycemias and
hyperinsulinemias lead to increased
hepatic glucose uptake and glycogen
synthesis
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 Cont’

• Hyperinsulinism and
hyperglycemias cause foetal
acidosis which later cause
stillbirths
• Hyperinsulinism also causes
hypoglycaemia
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 Clinical Features

02/29/24 KAYUNI L 26
 Cont’

• Cardiomegaly and heart failure

• Congenital anomalies like

ventricular or septal defects,
Coarctation of aorta, renal
agenesis, Hydronephrosis etc

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 Management

• Good antenatal care of all

diabetic mothers

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 3. Low APGAR Score Babies
• APGAR SCORE is a way of assessing for the
need of resuscitation
• It was discovered by Dr Virginia Apgar in
1953
• This is usually scored at 1, 5 and 10 minutes
• The maximum total score is 10
• All babies have peripheral cyanosis at 1
minute, therefore a score of 10 at 1 minute is
impossible
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 APGAR SCORE TABLE

0 1 2
Appearance (colour) Blue, pale Body pink, extremities Completely pink
blue

Pulse (heart rate) Absent <100 >100

Grimace (response to No response Grimace Crying

stimulation)

Activity (muscle tone) Limp Some flexion in Active movements

extremities

Respirations (respiratory Absent Slow, irregular Strong cry

effort)

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 CONT’

• It will give an indication of which babies need

special attention
• APGAR SCORE of 6 and above at 5 minutes need
cord care and wrapping to keep them warm
• APGAR SCORE of less than 6 at 5 minutes need
intervention or observation depending on their
respiratory and cardiac status
• Babies with low APGAR score at 5 minutes but who
are okay at 10 minutes, need not to be admitted in
nursery
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4. Blood Group Incompatibility
a. Erythroblastosis Fetalis (Hemolytic
disease of the newborn)
• Is caused by transplacental passage of
maternal antibody active against RBC
antigens of the infants
• Is characterized by increased
haemolysis of RBCs
• Causes anaemia and jaundice in
newborn infants.
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 Cont’

• Although more than 60 different RBC

antigens capable of eliciting an antibody
response have been identified,
significant disease is associated
primarily with the D antigen of the Rh
group and with incompatibility of ABO
factors

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• Rarely, it may be caused by C and E
antigens or by other RBC antigens such
as Cw, Cx, Du, K (Kell), M, Duffy, S, P,
MNS, Xg, Lutheran, Diego, and Kidd
• Anti-Lewis antibodies do not cause
disease
• Commoner in whites than in blacks

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 Pathophysiology
• When Rh +ve blood is infused into a Rh-ve
woman through error or small quantities of
Rh+ve fetal blood containing D-antigen
inherited from a Rh+ve father enter the
maternal circulation during pregnancy,
abortion or at delivery, antibody formation
against D-antigen may be induced in the
unsensitised Rh-ve recipient mother
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 Cont’

• Once sensitization has taken place, there

will be antibody formation, initially, there
will be a rise in IgM which is later
replaced by IgG antibody which crosses
the placenta leading to hemolysis in the
baby

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• Rarely occurs in first pregnancy because
transfusion of Rh+ve of fetal blood into a
Rh-ve mother tend to occur near the
time of delivery, too late for the mother
to be sensitized and transmit the
antibodies to her baby

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 Clinical features
• Anemia
• Hyperplasia of erythropoetic tissues
leading to their enlargement e.g.
hepatomegaly, splenomegaly
• Cardiomegaly due to anemia
• Respiratory distress due to anemia
• Jaundice at first day of life
• Massive anasarca due to heart failure
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 Investigations
• Coombs test – positive (detecting Rh antibodies on the
surface of RBC that precipitate proteins/globulins in the
blood serum)
• FBC – low HB
- nucleated RBCs
- High reticulocyte count
- WBC – Normal/elevated
- thrombocytopenia
• Bilirubin level – high
• Maternal IgG to D antigen - positive
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 Cont’

• Blood group incompatibility

should be known
• USS of the fetus – hydrops
fetalis (accumulation of fluid
in body tissues or cavities)

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• Antenatal Diagnosis
 History
- History of transfusion, abortion,
stillbirth or pregnancy in Rh-ve
women should suggest sensitization
- Using investigation findings
• Postnatal
 By using investigations
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 Management
• Main Goals

- Prevent intrauterine or
extrauterine death from severe
anemia and hypoxia

- Avoid neurotoxicity from

hyperbilirubinemia
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 Treatment
• In utero transfusion – intrauterine
tranfusion into fetal peritoneum
• Extrauterine transfusion via umblical vein
if the infant’s pulmonary is immature
• Exchange transfusion
• Vitamin K 20mg on day 0, 4 or 5 then day
30 (necessary for the formation of
prothrombin)
• Resuscitate the baby soon after birth
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 Cont’

• Supportive therapy
- Temperature control
- Oxygen therapy if respiratory
acidosis

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