The document discusses preterm birth and summarizes key information. It defines a preterm baby as one delivered before 37 weeks of gestation. Worldwide, preterm birth complicates 5-18% of births, with rates of 5-9% in Europe and 12-13% in the USA. Prematurity is associated with short and long term complications affecting multiple organ systems. Prevention strategies aim to reduce preterm birth through screening and treating at-risk women. Treatment includes steroids, antibiotics, tocolysis and neonatal care to improve outcomes.

1. IRAGUHA BANDORA Yves
University of Rwanda
Medical Student
Doc IV.
Clinical Rotation:
Pediatric Department
@ King Faisal Hospital (KFH).
Monday, April 9th, 2018
E-mail: iraguhabandorayves@gmail.com / Tel:0736196204

2. Definition:
 A preterm baby is one who delivers before the 37th
completed week of gestation.
Epidemiology
 Preterm birth complicates the births of infants
worldwide affecting 5% to 18% of births.
 In Europe and many developed countries the
preterm birth rate is generally 5–9%, and in the USA
it has even risen to 12–13% in the last decades.
 As weight is easier to determine than gestational
age, the World Health Organization tracks rates of
low birth weight (< 2,500 grams), which occurred in
16.5 percent of births in less developed regions in
2000.

3. Classification

4. Relation between Prematurity and
birth weight

5. Signs and symptoms
Signs and symptoms of preterm labor include:
 four or more uterine contractions in one hour.
 In contrast to false labour, true labor is accompanied by
cervical dilatation and effacement.
 Also, vaginal bleeding in the third trimester, heavy
pressure in the pelvis, or abdominal or back pain could be
indicators that a preterm birth is about to occur.
 A watery discharge from the vagina may indicate premature
rupture of the membranes that surround the baby.
 While the rupture of the membranes may not be followed
by labor, usually delivery is indicated as infection
(chorioamnionitis) is a serious threat to both fetus and
mother.
 In some cases, the cervix dilates prematurely without pain
or perceived contractions, so that the mother may not have
warning signs until very late in the birthing process.

6. Diagnosis
 Placental alpha microglobulin-1 (PAMG-1) has been the
subject of several investigations evaluating its ability to
predict imminent spontaneous preterm birth in women
with signs, symptoms, or complaints suggestive of preterm
labor
 Fetal fibronectin (fFN) has become an important
biomarker—the presence of this glycoprotein in the
cervical or vaginal secretions indicates that the border
between the chorion and deciduas has been disrupted. A
positive test indicates an increased risk of preterm birth,
and a negative test has a high predictive value.
 Ultrasound Obstetric ultrasound has become useful in the
assessment of the cervix in women at risk for premature
delivery. A short cervix preterm is undesirable: A cervical
length of less than 25 mm at or before 24 weeks of
gestational age is the most common definition of cervical
incompetence.

7. medical problems affecting
different organ systems.
A study of 241 children born between 22 and 25 weeks
who were currently of school age found that:
 46 percent had severe or moderate disabilities such as
cerebral palsy, vision or hearing loss and learning
problems.
 34 percent were mildly disabled and 20 percent had no
disabilities,
 while 12 percent had disabling cerebral palsy.

8. complications
 RDS; Respiratory Distress Syndrome. Lack of endogenous
Surfactant leading to respiratory difficulties, oxygen
requirement and poor compliance of the lungs.
 APNOEA OF PREMATURITY; Cessation of breathing due
to immaturity of the brain stem.
 CLD; Chronic Lung Disease of prematurity. Long-term
damage to the alveoli caused by shearing forces of
mechanical ventilation oxygen toxicity in the preterm
neonate.
 Broncho-pulmonary Dysplasia (BPD) is another term
commonly used with respect to long-term structural
damage to lung alveoli.
 HYPOTENSION; Low blood pressure due to poorly
contractive heart and low blood volume.

9. Cont….
 ANAEMIA; Low haemoglobin level due to significant nadir
of Hb. A condition characterized by C erythrocyte mass,
which is most common in low- and very-lowbirth weight
infants (C Reticulocytes, C erythropoietin production).
 PDA; Patent Ductus Arterisosus. The duct connecting the
pulmonary artery with the aorta in-utero which remains
open or re-opens leading to unstable cardiovascular status.
 INFECTION; Sepsis due to many pathogens is more
common in the preterm neonate due to reduced defences.
 IVH; Intraventricular haemorrhage -Bleeding into the
germinal matrix of the immature brain ventricles which
can extend into the parenchyma.
 PVL; Periventricular Leukomalacia - a brain condition
affecting fetuses and newborns in which there is softening,
dysfunction, and death of the white matter of the brain.
 ROP; Retinopathy of Prematurity; abnormal growth of
blood vessels in the retina of the eyes.

10. Cont…
 THERMAL INSTABILITY / HYPOTHERMIA; Central temperature
generally < 36 C.
 HYPOGLYCAEMIA; Blood sugar less than 2.6 mmols as a generally
accepted threshold / norm for this group of neonates.
 JAUNDICE; Physiological jaundice is very common in the preterm
neonate foreasons s tated above.
 FLUID IMBALANCES; common due to kidney immaturity - Examples
are; delayed diuresis, inappropriate ADH (anti-diuretic hormone).
 NEC; Necrotising Enterocolitis; a serious inflammatory condition of
the intestine characterised by invasion of pathogens to a compromised
bowel.
 GUT DYSMOTILITY; Slow digestive motility due to bowel immaturity
and difficulties in feeding.
 OSTEOPENIA OF PREMATURITY; Metabolic Bone Disease, in which
decreased bone mineral content occurs mainly as a result of lack of
adequate calcium and phosphorus intake in extra uterine life.

11. .
CNS: Neurological problems include apnea of
prematurity,
Hypoxic-ischemic encephalopathy (HIE), retinopathy
of prematurity (ROP),
Developmental disability, transient hyperammonemia
of the newborn, cerebral palsy and intraventricular
hemorrhage, the latter affecting 25% of babies born
preterm, usually before 32 weeks of pregnancy.
Mild brain bleeds usually leave no or few lasting
complications, but severe bleeds often result in brain
damage or even death.
Neurodevelopmental problems have been linked to
lack of maternal thyroid hormones, at a time when
their own thyroid is unable to meet postnatal needs.

12. .
 CVS: Cardiovascular complications may arise from the
failure of the ductus arteriosus to close after birth: patent
ductus arteriosus (PDA).
 RS: Respiratory problems are common, specifically the
respiratory distress syndrome (RDS or IRDS) (previously
called hyaline membrane disease). Another problem can
be chronic lung disease (previously called
bronchopulmonary dysplasia or BPD).
GIT: Gastrointestinal and metabolic issues can arise from
neonatal hypoglycemia, feeding difficulties, rickets of
prematurity, hypocalcemia, inguinal hernia, and necrotizing
enterocolitis (NEC).
Metabolic: Hematologic complications include anemia of
prematurity, thrombocytopenia, and hyperbilirubinemia
(jaundice) that can lead to kernicterus. Infection: including
sepsis, pneumonia, and urinary tract infection

13. Following short and long term
complications

14. Risk factors
The causes of preterm labour are not well-understood but a
number of risk factors have been identified.
 Uterine abnormalities can cause preterm labour as can
trauma to the cervix.
 Chronic or acute maternal illnesses are also associated
with preterm labour.
 Intrauterine infections can cause labour to start and is
implicated as a major causative factor for preterm labour.
 Anything that causes increased stretching of the uterine
muscles appears to initiate preterm labour, particularly
multiple pregnancy or polyhydramnios - excess
production of amniotic fluid.
 Social factors are also associated with preterm labour -
being poor.
 Substance abuse - cigarettes, alcohol and drugs are also
major risk factors.

15. Prevention
Prevention and treatment of preterm labour is important in
order to reduce adverse events for the neonate Before
pregnancy, During pregnancy, Screening of low risk
women, Self-care, Reducing existing risks, Reducing
indicated preterm birth, Reducing spontaneous
preterm birth, Antibiotics, Progestogens, Cervical
cerclage:
 Bed rest has been commonly prescribed in the past but it is
not effective
 Cervical stitches will only work if there is cervical
incompetence.
 Tocolytic drugs can be used to relax the uterine muscles
but have side effects
 It is difficult to predict preterm labour or prevent it.

16. Treatment
A wide variety of agents have been advocated as
suppressing uterine contractions currently include
:Steroids, Antibiotics, Tocolysis, Mode of delivery,
Neonatal care
 Beta-agonists,
 Calcium channel blockers,
 Prostaglandin synthetase inhibitors,
 Nitric oxide donors and
 Oxytocin receptor antagonists.
 Ritodrine hydrochloride, a beta-agonist, remains the
most widely used

17. Degrees of Prematurity
There are varying degrees of prematurity that determine
outcome.
 It is the group born at extreme prematurity that
present the more significant problems with the
greatest morbidity and mortality.
 Neonates born at gestations greater than 28 weeks
have a much better chance of survival and intact
outcome

18. Related fetal development
There are stages during in –utero development that are
significant in relation to their capabilities once born.
 Fetuses are legally ‘viable’ at 24weeks gestation but
again, due to advances in technology and care, some
23 week gestation neonates survive.
 Viability at the 24 week stage is due to the state of lung
development as at this time, the secretory epithelial
cell or type 2 pneumocytes in the interalveolar walls of
the lungs have begun to secrete surfactant.
 This is still very early however in view of ability to
support breathing completely independently and RDS
is common.

19. Lung development in-utero
Neonates at extreme prematurity before 28 weeks are
vulnerable in relation to all body systems due to immaturity
and complete lack of third trimester growth and stability.
 Embryonic (weeks 4-5), then
 Pseudoglandular (weeks 5-17),
 Canalicular (weeks 16-25),
 Saccular (weeks 24 to term) and
 Alveolar (weeks 36 to years 2-5). Surfactant starts to be
produced in the canalicular
 stage by type 2 pneumocytes from approx. 24 weeks
gestation

20. End!
Reference:
 https://en.wikipedia.org/wiki/Preterm_birth#cite_not
e-rob2015-68
 Uptodate
 NICU-Chats @ KFH
 CHBH PROTOCOLS 2010 Revised 23 August 2010
 Henriette text book.