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Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience
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Implementation of neurodevelopmental monitoring service for high risk newborns: Republic of Moldova experience

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International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

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  • 1. Implementation ofneurodevelopmental monitoringservice for high risk newborns:Republic of Moldova experience A.М. Kurtyanu Mother and Child Healthcare Research Institute Kishinev, Republic of Moldova
  • 2. Report goals• Abstract on psychomotor development of preterm infants on the basis of literature data• Structure and functions of Republican Diagnostics and monitoring Service for high risk neonates (Neonatal Follow-up).• Internal study results
  • 3. The highest obsterical risks - annual results Preterm labour 13 000 000 Costs 26 000 000 000 US$ Preterm labour rates 10-12 % 5,5 – 11,4 % ≥ 30% % of preterm labours in R. of Moldova, 1990-20125,2 5,1 5 5 4,79 12,1%4,8 4,68 4,54,6 4,374,44,2 4 Tracy SK et al, BJOG 2007,Langhoff-Roos, J et al BMJ 2006, 1990. 2000. 2005. 2010. 2011. 2012. Grijbovski AM, Public Heath 2005 According to findings of the study held in 184 countries (2010), the rates are as follow: R.. Moldova (11,0%), Ukraine (6,5%), Romania (7,3%), Switzerland (7,4%), USA (12,0%), Russia 3 (12,0%) worldwide (11,1%) (Born Too Soon: The Global Action Report on Preterm Birth, 2012).
  • 4. Prematurity & low birth weight (%) Characteristic RM Ukraine Romania USA Russia< 1,000 g 0,4 0,4 0,3 0,7 0,28Most of the (99,3%)preterm infants(live-born)1,000-2,500 g 63,9% 5,6 4,7 5,6 7,2 5,48-preterm infants> 2,500 g 94,0 94,3 91,1 92,1 94,27,6% - preterm infants
  • 5. Survival rates of newborns with different weight categories in R. of Moldova (2000-2012) 0,98 0,985 0,988 0,947 0,961 0,96 0,959 0,934 0,945 0,919 0,841 85% 0,863 0,814 0,806 0,777 1500-1999 0,601 2000-2499 500-999 0,522 42,70% 1000-1499 0,399 0,369 0,317 0,0538 0,0164 2000. 2005. 2009. 2010 2011. 2012.
  • 6. Survival of neonates in MACH RI at different gestational age , 2012 100100 100 80 94,9 98 97,9 95,9 100 80 91 92,9 50 50 65,2 60 68 32 40 50 50 34,8 49 50 51 47 42 20 48 54 20 0 23 22 0 02 5 8 14 25 Mortalitatea Mortalitate 0 0 nascuti 9 7,1 6,1 Nașteri Supravetuirea 22 s.g. 2 23 s.g. Supravețuirea 24 s.g. 0 2,1 25 s.g. 4,1 26 s.g. 27 s.g. 28 s.g. 0 29 s.g. 30 s.g. 31 s.g. 32 s.g. 33 s.g. 34 s.g. 35 s.g. 36 s.g. Concluzii: supravețuirea invers proporțională termenului de gestație:Conclusions: inverse proportion is observed between survival and gestational age 22 - 23 s.g. – supravețuire – 0% 26 – 28 s.g. – supravețuire - 61,0% 22-23 weeks – 0% 26-28 weeks – 61% 24 - 25 s.g. – supravețuire – 35,0% 29 – 32 s.g. – supravețuire - 96,2% 24-25 weeks – 35% 29-32 weeks – 96.2% 89,8%
  • 7. Abstract on psychomotor development of preterm infants on the basis of literature data Psychomotor, neurosensory , cognitive and behavioural disfunctions.
  • 8. Survival and short-term morbidity in preterm infants Mercer BM. Obstet Gynecol 2003;101:178-93
  • 9. Healthresults for preterm infants• Long-term • Intrauterine programming – 1 of 5 with mental – Weaker reproductive development delay health – 1 of 3 with poor vision – High risk of preterm – 50% of infants with labour for descendants cerebral palsy – Diabetes mellitus – 5 times higher risk of – Ishemic heart desease infant mortality: RR 1.5 • boys (22-32 weeks) • girls (22-28 weeks) Spong CY et al, Obstet Gynecol 2009
  • 10. Preterm infants health resultsSurvival with 23 weeks of GA.:1/3 cerebral palsy with blindness/deafness.Suvival with 24 weeks of GA.:Psychomotor development delay 22 - 45%.Suvival with 25 weeks of GA.:Multiple disfunctions of severe psychmotordevelopment 12 - 35%.These rates have not changed since 90-ies!!! Hack M; Fanaroff A
  • 11. Psychomotor development deficit in preterminfants born with extremely low birth weight (ELBW) - global trends Age at Values GA,Country / authors Years examination, weeks Number % years Conclusion: cerebral palsy value varies per country
  • 12. Number of neonates with severe form of psychomotor development depending on GA <26 s.g. Cerebral palsy Confidence Age, weeks. distribution, % interval 23 34 Insufficient data 24 22-45 6-48, 28-64 25 12-35 3-27, 15-59 Total value 3112 studies which investigated correlation between psychomotordevelopment and GA, at 12 and 36 month of corrected age
  • 13. Health results of preterm infants born live with ELBW at 18-22 month Incomplete FU Discontinued Died Severe disorders Mild disorders Normal develoment
  • 14. Mortality, morbidity and survival without severe adverse outcomesProspective study (120 days of life) from 01.1990 to 12.2002 in 16 centres of National Institute of ChildHealth & Human Development Neonatal Research Network. NICHD Neonatal Research Network centers (n = 16) [Fanaroff et all 2007]
  • 15. Survival factors• Gestational age: inverse ratio• Birth weight: infants with SBW have the weakest results• Gender: survival ↑ for girls• Labours at third level institutes: ↑ survival• Antenatal steroids: ↑ survival ; number of disabled is the same, at postnatal period • Labour conditions and intensive care: proper ↑ survival• Treatment with surfactant: ↑ survival; number of disabled is the same• Hypothermia prevention• Postnatal steroids administration decrease: ↓IVH• Monocyesis• Weight growth• Multiple birth: ↓ survival and ↑ morbidity• Sepsis: ↓ survival• Cesarean section (pelvic presentation): controversial data [4446 births at 22-25 weeks of GA Tyson et all 2008]
  • 16. Factors that affect the development of cerebral damage• Its development is influenced by the start, duration and severity of injury – Term / preterm infant – Extensive / local injury – Acute / chronic – Number of available injuring mechanisms (strokes)
  • 17. Prognosis factors MDI < 70 NICHD Data -- 1151 infants < 1000 g.
  • 18. Prognosis factors PDI < 70NICHD Data -- 1151 infants < 1000 g.
  • 19. Cerebral development phases Structuring of neurons Migration Myelination Proliferation Glial cells differentiation Subplate Cortical foldingWeeks 10 15 20 25 30 35 40of gestation 23 40 Latal, 2003
  • 20. Cortical development and differentiation Preterm infant (25 weeks) Term infant(IRM ponderee T2)
  • 21. Cortical development (surface) 27 weeks 32 weeks 35 weeks
  • 22. Effects of clinical interventions on CNS development• More detailed studies are needed to investigate the effectiveness and damaging impact of clinical interventions on CNS – For example, the use of corticosteroids at postnatal period Cerebral cortical gray matter volumes. 300 Cerebralcortical gray matter volume (cc) 250 200 150 100 50 0Cortical gray matter volume 35% in Term Preterm @ Term Preterm @ Term preterm infant treated with No Steroids Steroids dexametazone Murphy BP et al 2001
  • 23. Other factors affecting the development of CNS• Future development depends rather on gestational age than on the birth weight (BW) – The literature is mostly based on BW, which influences the results accuracy of the studies (bias)• The range and severity of development disorders are often underestimated if observation stops in the early childhood. – EPICURE ( 26 weeks of gestation): • No severe adverse effects at 30 months : 76% vs 63% at 6 years (sustainable result stays by 11 years) [Marlow et al 2009]
  • 24.  Mortality /  morbidity• Antenatal corticosteroid therapy: – 20%: 1990-1991 – 79%: 1997-2002• Ante/ intrapartum antibiotic therapy: – 31%: 1990-1991 – 70% 1997-2002• I (1982–1989) (n = 496)• II (1990–1999) (n = 749)• III (2000–2002) (n = 233) – At 20 months of corrected age • Between I and II:  survival from 49% to 68% =  morbidity • Between II и III:  CP from 13% to 5%   morbidity from 35% to 23% [Wilson-Costello et al 2007]
  • 25. Differences between the studies (I) Characteristic EPICURE EPICURE EPIPAGE Suede Ulm (short-term) (long-term) (long-term) 1992-1998 1996- 1995 1997 1999 Survival rate at 424 424 119 103 48 25 weeks of GA Examination age 30 months 6 years 5 years 3 years 5.6 years No poor 142 (76%) 118 (63%) Data available 70 (89%) 29 (71%) outcomes within only for 24-28 study period ( % of SA group total : infants admitted to 92% (out of NICU) examined infants) No poor 35 (24%) Data available outcomes ( % of only for 24-28 examined neonates) SA group total 52%Mid-term and long-term results in infants born at 25 weeks of GA in population studies and in onespecialized centre
  • 26. Differences between the studies (II)• Severe retardation is often diagnosed – < 2 years – by a well-trained pediatrician• Mild and moderate underdevelopment are diagnosed later and should be discovered – Specialized consultation
  • 27. Results / cerebral palsy• Severe retardation - Cerebral palsy about 10%• Moderate and mild • < 1500 g development deficit - – 5% 30 - 50%• No retardation • < 1000 g – 15-20% • Decreasing? [ Platt MJ et al 2007]
  • 28. Chronic lungs desease and survival in 385 neonates with ELBW in 11 centres of South America 100% According to the 90% studies development is 80% mostly influenced 70% by 50% respiratory 60% disfunctions than 50% by cerebral ones 40% 30% Survival at RDS 30% 20% BPD 10% 20% Mortality 0% A B C D E F G H I J K TOTAL GRUPO COLABORATIVO NEOCOSUR, J. Perinatol 2002;22:2-7
  • 29. Structure and functions of Republican Diagnostics and Monitoring Service forneonates from high risk groups (Neonatal Follow-up). 3 development phases 1. Establishment 2. Regionalizitation and reinforcement 3. Monitoring of functions as a part of Early Intervention Service
  • 30. Implementation of advanced technologies into intensive and routine neonatal care system1/01/2008, the Rupublic of Moldova adopted WHO and EU criteria and standards of live-born neonates registration
  • 31. 1. Standards. Documents issued within the framework of Neonatal Diagnostics and Monitoring Service• As a result, Order No. 455/137/131 of December 10, 2007 was jointly issued by the Ministry of Healthcare, Ministry of Information Technologies and National Bureau of Statistics in order to start official statistical registration of labours and neonates with birth weight over 500 g and gestational age over 22 weeks.• In order to comply with the requirements of Declaration of Millenium Development Goals and according to the activities regulated by National Healthcare Policy for 2007-2021 and Healthcare System Development Strategy for 2008-2017, there was a Republican Neonatal Diagnostics and Monitoring Service established and implemented according to the Order No. 118 of 19/02/2010 of the Ministry of Healthcare which covered high risk infants groups up to 2 years of corrected age.
  • 32. Standards (2). Documents issued within the framework of Neonatal Diagnostics and Monitoring Service1. Regulations on the Republican Neonatal Monitoring System for infants up to two years.2. Functional responsibilities of the person in charge from the Centre of Family Physicians who coordinates the operation of Neonatal Monitoring System.3. Instructions for family doctor and pediatrician regulating their responsibilities within the Neonatal Monitoring System.4. Documents regulating the introduction of Neonatal Monitoring Service into early development system for children up to five years.
  • 33. 2. Regionalization of Diagnostics and Monitoring Service for high risk neonates. 3. Equipment supply Kishinev Bălţi MACH RI Republican Centre of Regional Centre Neonatal Diagnostics and Monitoring Kishinev Municipal Hospital No. 1, Municipal Centre Ceadir-Lunga Cahul Regional Regional Centre Centre
  • 34. Structure of the Republican Centre of diagnistocs and monitoring for high-risk neonates Low and very low birth weight Neonatal neurologic Doctors room. neonates care unit Database unit Active invitation Pediatric examination Pediatric examination room with BSID tools room with BINS tools Screening cabinetUltrasound screening EEG examination (audiometry and room room ophthalmoscopy)
  • 35. 4. Medical personnel training• Theoretical and practical workshop on Neurological pathologies in term and preterm neonates, 2007- 40 neonatologists (33%)• 2 workshops on Neural development assessment for neonates discharged from NICU (with support of US instructors) – Giuleşti Hospital, Bucharest, Romania, 2007 – 3 specialists – MACHI, 2009 - 25 neonatologists and neonatal neurologists• 2 internships (1 neurologist) on EEG use - Giulesti hospital, Bucharest, Romania (2007), Follow up, clinical and social rehabilitation of neonates from hight risk groups, France - 1 month.• 1 training in the Centre Follow up, RCIT, Jaşi, Romania – 3 specialists• Visit that included theoretical and practical training at the working place (Dr. R.Ha Vin Leutcher, HUG, Switzerland, (2010), 12 specialists from MACI, HospitalNo. 1 Kishinev, and Beltz Rehabilitation Centre
  • 36. 4. Materials for medical personnel1. Neonatal observation map2. Booklet on Neonatal Diagnostic and Monitoring Centre operation3. Poster on Neonatal Diagnostic and Monitoring Centre
  • 37. 4. Materials for medical personnel and mothers (1)4. Preterm infants care basics5. Kinetic therapy for preterm infants6. Guideline for mothers of preterm infants
  • 38. Goals of the Republican Centre of diagnistocs and monitoring for high-risk neonates ↝ Specialized medical support for infants with high risk of poor neurological outcomes. ↝ Definition of poor neurological outcomes risks using BINS and BSID tools. ↝ Admission of infants with medium or high risk of poor neurological outcomes to the monitoring programme. ↝ Specialized neural examination of infants having high risk of poor neurological outcomes ↝ Paraclinical examinations: ultrasound, EEG, audiometry, ophthalmoscopy.
  • 39. The list of high risk neonates eligible for Monitoring Programme↝ Preterm infants with birth ↝ Periventricular leukomalacia weight ≤ 1500g ↝ Severe hyperbilirubinemia↝ Fetal growth and development (170 mmol/l within 24 hours or delay (two standard 300 mmol/l within 48 hours deviations) after delivery)↝ Visual and audial disorders ↝ CNS infections (meningitis,↝ Hypoxic-ishemic encephalitis) encephalopathy (Sarnat II-III) ↝ Ulcerous necrotizing↝ Seaizures at neonatal period enterocolitis↝ Respiratory support (ALV or ↝ Bronchopulmonary dysplasia CPAP ) ↝ Clear neurological symptoms↝ Intraventricular hemorrhage at discharge (grades III-IV)
  • 40. Personnel of the Republican Centre ofdiagnistocs and monitoring for high-risk neonates • Neonatologist • Neurologist • Rehabilitation / kinetic therapy specialist • Audiologist • Ophthalmologist • Ultrasound diagnostician • EEG specialist • Psychologist • Speech therapist
  • 41. Follow-up neonatal Database (2009-2012)• Total number of infants included into the database - 1265• Including 527 (41,7%) preterm infants with birth weight <1500 g• Number of infants who did not visit the centre "Follow-up neonatal" – 320 (25,3%)• 631 (49,8%) infants who survived up to 24 month of corrected age• 40 (31.6%) dead infants out of those who were included into the Follow-up
  • 42. Poor neurologic outcomes assessment tools - BINS and BSID Screening tests for risk Neurologic functions (muscle assessment tone, movement / (1-24 months) asymmetry) Expressive functions (motor functions) Receptive functions (visual, audial, speech) Cognitive functions
  • 43. Infants development scale (1-42 months)The test includes 5 Cognitive functions components: Communication (receptive, expressive) Motor function Social-emotional status Adaptive status
  • 44. Neonatal examinations calendar• At admission to resuscitation unit and at discharge• 3 months• 6 months• 12 months• 18 months• 24 months Corrected age is calculated for preterm infants at 34 weeks of gestation. Corrected age = Actual age + Gestational age - 40 weeks
  • 45. Psychomotor development results in infants at24 months of corrected age (155 cases) in RM. Internal study results
  • 46. Goal / Materials and methods• Goal: to study the outcomes of neurological development in preterm infants with BW ≤ 1500 g at 2 years of corrected age.• Methods. Design. Retrospective descriptive study at MACH RI from 01/01/2008 to 31/12/ 2009.• Analysis of health records of 93 newborns and 6 follow-up visits with the last one at 24 months.
  • 47. Profiles of the study population Total of premature infants with weight ≤ 1500 g born or referred to IIIrd level - 337 Died during neonatal Survived / dishcarged - 288 period - 49 Enrolled in Follow up program - 265 Died during Follow up Lost to Follow-up program Enrolled in period 159 follow-up 13 study at 2 y - 93 Never 1 visit Never Came Came ≥ 35 came 58 came 11 once 1 once l 2 visits 28 NDFU <1 y- 56 3 visits 15 4 visits NDFU ≥1 y - 45 18 5 visits 5
  • 48. Gestational age of newborns enrolled in the study GA, weeks Number %34-32 17 18,231-29 44 47,3 77,4%28-27 28 30,126-25 4 4,3Total 93 100
  • 49. Morbidity of examined newborns at discharge Pathology abs. nr. %Early sepsis 13 13,9 16%Late-onset sepsis 2 2,1Meningitis 7 7,2Pneumonia 66 70,9NEC 4 4,3RDS: Severe 8 8,6 47,3%Medium 36 38,7Mild 18 19,4IVH gr. I 16 17,2IVH gr. II 12 12,9 15%IVH gr. III 2 2,1PVL 2 2,1
  • 50. Results of psychological assessment using BSID III at 2 years of corrected age, 93 infants Motor Cognitiv Speech Test Explanation function Nr. % Nr. % Nr. %>85 Norm 79 84,9 73 78,4 80 85,470-84 Development 5 5,3 11 11,8 2 2,1 delay69 Severe 9 9,6 9 9,6 11 11,8 psychomotor delay Conclusions: at 24 month of corrected age mostly cognitive (14.9%) and speech (21.4%) functions have been observed, 85.4% of examined participants had normal neurological development.
  • 51. Neurological disorders discovered at 12, 18 and 24 months Nr. Pathology 12 months 18 months 24 months abs % abs % abs % 1 Healthy 69 53% 83 63,8% 100 76,9% 2 Minimal brain dysfunction 25 19,2% 24 18,4% 13 10 % 3 Moderate disorders (of 18 13,8% 7 5,3% 1 0,7% muscle tone) 4 Severe disorders 18 13,8% 16 12,3% 16 12,3% --- Cerebral palsy 9 6,9% 10 7,6% 11 8,4% ---Hydrocephalus/ 5 3,8% 3 2,3% 3 2,3% Ventriculomegaly 5 ROP 2 1,5% 6 Partial atrophy of optic nerve 0 3 2,6% 3 3,2% --- Microcephaly 1 0,7% 1 0,7% 1 0,7% --- Psihomot. retard. 3 2,3% 2 1,5% 1 0,7% Minimal and moderate dysfunctions discovered at 12,18 and 24 dynamically decrease and by 2 years of corrected age transform into the norm in 76.9% of all cases. Severe disorders discovered at 1 year stay unchanged by 2 years. Morbidities observed most often: cerebral palsy, ventriculomegaly / hydrocephalus.
  • 52. Conclusions• Survival of preterm neonates at ultimate vitality (over 26 weeks of gestation) is low (~5,4% in 2005 and 42,7% in 2012).• Development of national management standards for women with high risk of preterm labour and deeply premature newborns (from GA of 22-26 weeks) allowed to improve medical services quality, lower adverse effects including poor neurological outcomes for these neonates.• In our study of neural development disorders we received the results comparable with other authors which were influenced by low number of infants with GA before 26 weeks.• In terms of implementation of advanced technologies into resuscitation service and ELBW infants care, to establish Diagnostics and Monitoring System for high risk groups of infants is an important stage in supporting their psychomotor and somatic development.• Integration of Follow-up centres into early intervention service will improve and diversify these services, while regionalization of Follow-up service will contribute to lower numbers of disabled children.
  • 53. Thank you for attention!

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