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Prematurity and IUGR

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  • 1. Prematurity and IUGR Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
  • 2. • Preterm – born before 37 completed weeks of gestation• IUGR - birth weight is <10TH CENTILE FOR GESTATIONAL AGE or > 2 SDs below mean for GA.
  • 3. Types of IUGR• Symmetric IUGR: weight,length and head circumference are all below the 10 th percentile. (33 % of IUGR Infants)• Asymmetric IUGR: weight is below the 10 th percentile and head circumference and length are preserved. (55 % IUGR)• Combined type IUGR: Infant may have skeletal shortening, some reduction of soft tissue mass. (12 % of IUGR)
  • 4. Characteristics of IUGRSymmetric (chronic)• Early onset - Due to 1. intrinsic cong infection or chromosomal genetic defects 2. Extrinsic factor (early gestational life) – maternal malnutrition, alcohol, smoking• Normal ponderal index• Brain symmetrical to body• Decreased growth potentialExamples - Genetic causes, chromosomal - TORCH infections - Anomalad Syndromes
  • 5. Characteristics of IUGRAsymmetric (acute)• Late onset- Environmental factors• Brain sparing• Has better prognosisExamples• Hypoxia• Preeclampsia (PIH, PET)• Chronic hypertension
  • 6. Ponderal Index• Way of characterizing the relationship of height to mass for an individual. 3• PI = 1000 x Mass (kgs) Height (cms)• Typical values are 20 to 25.• PI is normal in symmetric IUGR.• PI is low in asymmetric IUGR.
  • 7. Causes of Preterm BirthFETAL• Fetal distress• Multiple gestation• Erythroblastosis• Nonimmune hydropsPLACENTAL• Placental dysfunction• Placenta previa• Abruptio placentae
  • 8. Causes of Preterm BirthUTERINE• Bicornuate uterus• Incompetent cervix (premature dilatation)
  • 9. Causes of Preterm BirthMATERNAL• Preeclampsia• Chronic medical illness (e.g., cyanotic heart disease, renal disease)• Infection (e.g., Listeria monocytogenes, group B streptococcus, urinary tract infection, bacterial vaginosis, chorioamnionitis)• Drug abuse (e.g.cocaine)
  • 10. Causes of Preterm BirthOTHER• Premature rupture of membranes• Polyhydramnios• Trauma
  • 11. Factors Associated with IUGRFETAL• Chromosomal disorders• Chronic fetal infections (e.g., cytomegalic inclusion disease, congenital rubella, syphilis)• Congenital anomalies–syndrome complexes• Irradiation
  • 12. Factors Associated with IUGRFETAL• Multiple gestation• Pancreatic hypoplasia• Insulin deficiency• Insulin-like growth factor type I deficiency
  • 13. Factors Associated with IUGRPLACENTAL FACTORS• Placental insufficiency ( most imp in 3rd trimester)• Villous placentitis (bacterial, viral, parasitic)• Infarction• Tumor (chorioangioma, hydatidiform mole)• Premature placental separation• Small Placenta• Twin transfusion syndrome
  • 14. Factors Associated with IUGRMaternal Factors:• Decrease Uteroplacental blood flow: - Pre eclampsia / eclampsia - chronic renovascular disease - Chronic hypertension• Maternal malnutrition, & chronic illness• Multiple pregnancy• Drugs - Cigarettes, alcohol, heroin, cocaine - Teratogens, antimetabolites and therapeutic agents warfarin, phenytoin
  • 15. Factors Associated with IUGR• Maternal hypoxemia - Hemoglobinopathies - High altitudes• Others - Short stature - Younger or older age (<15 and >45) - Low socioeconomic class - Primiparity - Grand multiparity - Low pregnancy weight - Previous h/o preterm IUGR baby
  • 16. • Small but plump • Wasted• Red or very pimk • White or pale pink• Length <50cm • Length ≥ 50 cm• HC<35cm • HC≥ 35 cm• Lanugo hair,vernix ++ • Thick,dark hair• Skin –shiny transparent • Skin – dry,loose thick thin,edematous • Ears,breast,genitalia –• Ears,breast,genitalia – mature premature • Good muscle tone• Hypotonic (floppy
  • 17. IUGR• Heads are disproportionately large for their trunks and extremities• Facial appearance has been likened to that of a “wizened old man”.
  • 18. Problems of IUGR (SGA) Infants• Hypoxia - Perinatal asphyxia - Persistent pulmonary hypertension - Meconium aspiration• Thermoregulation - Hypothermia due to diminished subcutaneous fat and elevated surface/volume ratio
  • 19. Problems of IUGR (SGA) Infants• Metabolic - Hypoglycemia - result from inadequate glycogen stores. - diminished gluconeogenesis. - increased BMR - Glucose needs of hypoxia - Hypothermia - Large brain - Hypocalcemia - due to high serum glucagon level, which stimulate calcitonin excretion
  • 20. Problems of IUGR (SGA) Infants• Hematologic - hyperviscosity and polycythemia due to increase erythropoietin level sec. to hypoxia• Immunologic - IUGR have increased protein catabolism and decreased in protein, prealbumin and immunoglobulins, which decreased humoral and cellular immunity.
  • 21. Problems of IUGR (SGA) Infants• Skeletal: Decreased ossification of endochondral & membranous cartilage.• Malformations: Increased incidence of Cong.malformations.
  • 22. Problems of IUGR (SGA) InfantsDysmorphology• Syndrome anomalads• chromosomal-genetic disorders• Oligohydramnios-induced deformations• TORCH infection• Pulmonary hemorrhage
  • 23. Problems with Premature InfantsRESPIRATORY• Respiratory distress syndrome (hyaline membrane disease)• Bronchopulmonary dysplasia• Pneumothorax, pneumomediastinum; interstitial emphysema• Congenital pneumonia• Pulmonary hypoplasia• Pulmonary hemorrhage• Apnea
  • 24. Problems with Premature InfantsCARDIOVASCULAR• Patent ductus arteriosus• Hypotension• Hypertension• Bradycardia (with apnea)• Congenital malformations
  • 25. Problems with Premature InfantsHEMATOLOGIC• Anemia (early or late onset)• Hyperbilirubinemia–indirect• Subcutaneous, organ (liver, adrenal) hemorrhage• Disseminated intravascular coagulopathy• Vitamin K deficiency
  • 26. Problems with Premature InfantsGASTROINTESTINAL• Poor gastrointestinal function–poor motility• Necrotizing enterocolitis• Congenital anomalies producing polyhydramnios• Spontaneous gastrointestinal isolated perforation
  • 27. Problems with Premature InfantsMETABOLIC-ENDOCRINE• Hypocalcemia• Hypoglycemia• Hyperglycemia• Late metabolic acidosis
  • 28. Problems with Premature InfantsRENAL• Dyselectrolytemia – hyponatremia, hypernatremia,hyperkalemia• Renal tubular acidosis
  • 29. Problems with Premature InfantsCENTRAL NERVOUS SYSTEM• Intraventricular hemorrhage• Periventricular leukomalacia• Hypoxic-ischemic encephalopathy• Seizures• Retinopathy of prematurity• Deafness• Hypotonia
  • 30. Problems with Premature Infants• Congenital malformations• Kernicterus (bilirubin encephalopathy)• Drug (narcotic) withdrawalOTHER• Infections (congenital, perinatal, nosocomial: bacterial, viral, fungal, protozoal)
  • 31. Management of IUGR• Delivery and Resuscitation• Hypoglycemia - close monitoring of blood glucose - early treatment ( IV dextrose, early feeding )• Hematological Disorder - Hct to detect polycythemia• Congenital infection - TORCH titer screening - Viral cx of urine, nasopharynx - Head CT to r/o calcification
  • 32. Management of IUGR• Genetic anomalies - screening- chromosomal analysis• Others - serum calcium to r/o hypocalcemia - Mx - meconium aspiration
  • 33. Management-PRETERM /LBW DELIVERY ROOM CARE• Warmth and drying• Resuscitation / Respiratory support • Oxygen blow-by • Bag-and-mask ventilation • Endotracheal intubation and ventilation • Exogenous surfactant • Nasal CPAP if required• Transfer to NICU in transport incubator
  • 34. CRITERIA FOR NICU ADMISSION OF LBW BABIES *• Gestational age <34 weeks• Birth weight < 1800 g• SGA with birth weight <3rd percentile• Any sick neonate, irrespective of BW and gestational age * Recommendations of the National Neonatology Forum
  • 35. NICU CARE• Temperature control• Respiratory support• Fluids and electrolytes• Nutritional support• Infection control• Cardiovascular support• Others- Skin care, Hyperbilirubinemia• Suplement
  • 36. 1. TEMPERATURE CONTROL• Aim: a) Maintaining temperature b) Prevent cold stress c) Reduce insensible water loss• Methods: – Radiant warmer (290 C-310 C) – Pre warmed incubator ( 320C- 350C) – Warm room – ( 210 C) – Heat shield – Warm clothing-cap, socks – KMC – Bath postponed
  • 37. KANGAROO MOTHER CARE• Benefits – Thermoregulation – Exclusive breast feeding – Physiologic stability – Decreased incidence of infection – Infant-mother bonding – Cost effective
  • 38. 2. RESPIRATORY SUPPORT• Free flow oxygen• Ventilatory support• Surfactant therapy
  • 39. 3. FLUID REQUIREMENTFluid requirements are higher in LBWinfants due to – Greater insensible water losses – Faster breathing rates – Decreased ability to concentrate urine – Greater use of radiant warmers – Greater use of phototherapy units
  • 40. RATE OF ADMINISTRATION* Birth weight Fluid rate(g) (ml/kg/day) 500 - 600 140 - 200 601 - 800 120 - 130 801 - 1000 90 - 110 1000 - 1500 80 - 100 >1500 60 - 80 *on first 2 days of life
  • 41. RATE OF ADMINISTRATION• Fluid rate can be increased by 10-20 ml/kg/d to gradually reach 150 ml/kg/d• Fluid requirements need to be individualized for each baby• Enteral nutrition has to be considered once the baby is stable
  • 42. FLUID COMPOSITION & MONITORING• Dextrose solutions to give 6 -8 mg/kg/min of glucose• Sodium supplementation from day 2• Frequent monitoring of • Serum glucose levels • Urine output & specific gravity • Weight (twice daily) • Serum electrolytes (ideally q8h – q12h) • Physical assessment
  • 43. 4. TOTAL PARENTERAL NUTRITION• Indications – Infants with BW ≤ 1000 g – Infants with BW ≤ 1500 g, done in conjunction with slowly advancing enteral nutrition – Infants with BW 1501-1800 g for whom enteral intake is not expected for > 3 days
  • 44. TOTAL PARENTERAL NUTRITION• Glucose : 6 - 8 mg/kg/min• Amino acids : 1.5 - 2 g/kg/d• Lipid : 0.5 - 1 g/kg/d• Sodium : 2 - 4 mEq/kg/d• Potassium : 2 - 3 mEq/kg/d• Chloride : 2 - 4 mEq/kg/d
  • 45. TOTAL PARENTERAL NUTRITION• Calcium• Phosphorous• Magnesium• Others: – Zinc – Copper – Chromium – Selenium – Molybdenum
  • 46. EARLY ENTERAL NUTRITIONTrophic feeding/ Gut priming Practice of feeding very small amounts of enteral nourishment to stimulate development of the immature GITAdv: Improves GI motility Enhances enzyme maturation Improves mineral absorption Lowers incidence of cholestasis Shortens time to regain birth weight
  • 47. ENTERAL NUTRITION• Breast milk or ½ or full strength preterm formula at 10ml/kg/d by intermittent gavage/ continuous nasogastric drip• Increase by 10-15 ml/kg/d to reach 150ml/kg/d• Increments not >20 ml/kg/d• IV fluids can be stopped once 120ml/kg/d is reached• On reaching 150ml/kg/d,calorie density can be increased
  • 48. FEEDING GUIDELINESPRETERMS• <1200 g/ <32 wks: IV fluids for first 2-3 days, once stable start gavage feeding• 1200-1800 g/ 32-34 wks: Start gavage feeding, once vigorous start spoon/ breast feeding
  • 49. FEEDING GUIDELINES• >1800 g/ >34 wks: Start breast feeding directly; if trial feed takes>20 mins or intake is less than required, switch to gavage feedingTERM IUGRs/ SGA• Breast feeding
  • 50. PRETERM HUMAN MILKAdvantages: – Higher concentrations of amino acids – Higher concentrations of essential fatty acids – Lower renal solute load – Specific bio-active factors provide immunity – Promotes intestinal maturation
  • 51. PRETERM HUMAN MILKDisadvantages: – Low concentrations of Vitamin D, Ca, P – Inadequate iron
  • 52. ENTERAL NUTRITION• Energy : 130 - 175 Kcal/kg/d• Protein :3.4 - 4.2 g/kg/d• Fat :6 - 8 g/kg/d• Na :3 - 7 mEq/kg/d• Cl :3 - 7 mEq/kg/d• K :2 - 3 mEq/kg/d• Ca :100 – 220 mg/kg/d
  • 53. 5. INFECTION CONTROL• LBW infants are at a greater risk of sepsis• Practices that can prevent/minimize infections: – Strict adherence to hand-washing – Minimal handling & clustering of procedures – Barrier nursing – Antibiotics
  • 54. 5. INFECTION CONTROL– Practices that can prevent/minimize infection:– Restriction of broad spectrum antibiotics use– Minimizing duration of mechanical ventilation– Early initiation of enteral feeds– Central & peripheral venous catheter care
  • 55. 6.CARDIOVASCULAR SUPPORT• Blood pressure maintenance with • Fluids • Pressor agents if required• PDA: – Fluid restriction – Diuretic therapy – Increased ventilatory support – Indomethacin therapy – Surgical ligation
  • 56. 7. SKIN CARE• Stratum corneum is deficient in preterms• Mature epidermal barrier is established by 2 weeks post natal age• Limited use of adhesives• Frequent repositioning of infant• Use of soft bedding or water mattress• Prophylactic use of emollients is no longer recommended• Jaundice – early management
  • 57. 8. SUPPLEMENTATION• Human Milk Fortifiers• Calcium:50-100 mg/kg/d from end of 1st week to 40 weeks post-conceptional age• Iron:2-2.5 mg/kg/d from 6-8 wks of age till 12 months of age• Vitamins – Vitamin A(1000U/d) & Vitamin D(400U/d) ,Vit C – 50mg/d from 2 weeks of age – Vitamin E -15 IU/d for VLBW infants till 37 weeks
  • 58. Outcome• Symmetric vs. Asymmetric IUGR - symmetric has poor outcome compare to asymmetric• Preterm IUGR has high incidence of abnormalities• IUGR with chromosomal disease has 100% incidence of handicap• Congenital infection has poor outcome - handicap rate > 50%• IUGR has higher rate of learning disability.
  • 59. “Long term” Morbidity of IUGR Factors associated with abnormal outcome ? Microcephaly Hypoxic ischemic encephalopathy Symptomatic hypoglycemia Symptomatic hyperviscosity
  • 60. Fetal Origins of Adult Diseases ? • Coronary artery disease correlates inversely with birth weight • Rate of non-insulin dependent diabetes mellitus is highest in the “thinnest” babies at birth (low ponderal index) • High serum cholesterol are linked to disproportionate size at birth (body smaller than head) • Increased rate of hypertension in infants who were thin, short, &/or proportionately small at birth
  • 61. Sequelae of Low Birth weight• Mental retardation• Poor school performance• Spasticity• Seizures• Hydrocephalus• Sensorineural injury-Hearing• Short-bowel syndrome• Malabsorption
  • 62. Sequelae of Low Birth weight• Visual impairment• Retinopathy of prematurity• Strabismus, myopia• Bronchopulmonary dysplasia,• Bronchospasm• Recurrent pneumonia
  • 63. Sequelae of Low Birthweight• Growth failure - Failure to thrive• Gastroesophageal reflux• PEM• Osteopenia, fractures,• Anemia
  • 64. Follow-up• Anemia• Retinopathy of prematurity• Hearing screenings• Cholestasis• Stable temperature regulation• Gaining weight on oral feedings• Nutritional support
  • 65. Follow-up• Breast-feeding• Appropriate immunizations• Ophthalmologic examination if <27 wk or <1,250?g at birth
  • 66. Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]

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