This document defines prematurity and related terms like low birth weight (LBW), small for gestational age (SGA), very low birth weight (VLBW), and extremely low birth weight (ELBW). It discusses the public health importance of prematurity, describing the high rates of prematurity globally and associated increased mortality. The document outlines maternal and fetal risk factors for prematurity and methods for differentiating preterm and SGA infants. It also provides extensive details on potential health complications in preterm infants and recommendations for management and prevention.

1. PREMATURITY
Magoda Anthony Mathew
MBChB ..MUK

2. Overview
 Definition
 Some Definitions: SGA, LBW, VLBW, ELBW
and preterm babies
 Public health importance
 Aetiology
 Comparing Preterm and SGA, Dubowitz method
 Management
 Prevention
 Complications

3. Preterm/ Premature Babies
 Babies born at less than 37 completed
weeks of gestation from the first day of the
last menstrual period.

4. LBW
 Low Birth Weight babies
 Those whose birth weight is 2500g or less

5. SGA
 Small for Gestational Age or Light for
dates babies.
 Those whose birth weight is lower than the
tenth centile for gestation.

6. Other definitions
 VLBW (very low birth weight babies) those
who weigh less than 1500g at birth.
 ELBW (extremely low birth weight babies)
those who weigh less than 1000g at birth.
 Term: 37-41 complete WOA.
 Post term: 42+ weeks.
 LGA: large for gestation age >90th centile.

7. Public Health Importance
 20 million LBW babies born worldwide in 1982.
 This is about 16% of the total births
 Of these, 15% were in Africa, 30% in India, Asia
20%, latin America 15%, Europe and North
America 10%
 LBW babies suffer increased mortality rates
during the perinatal, neonatal and postneonatal
period.
 They are 7 times more likely to die in the
perinatal period than babies weighing 2500g +.

8. Public health importance
 LBW babies comprised 71% of neonatal deaths in a
study done in Brazil.
 Postneonatal mortality is associated with respiratory
infections, diarrhoreal disease, and other infections.
 They thus merit intensive neonatal care because of the
associated high mortality.the improved management has
led to increased survival rates. The special care aims to
monitor the neonate in a stable environment to ensure
optimal growth and development.

9. Aetiology
 There are several associated factors
classified into maternal and neonatal
factors

10. Aetiology: Maternal factors
 Maternal illness like eclampsia, renal
disease, malignancy
 Uterine placental insufficiency due to
infection, fibrin deposition, abnormal blood
flow.
 Cervical incompetence
 Age: common in the under age (<18)
mothers

11. Aetiology: Maternal factors
 Abnormalities of the uterus eg bicornuate
uterus
 Preterm labour
 PROM (Premature rapture of membranes)
 Trauma
 Excessive smoking during pregnancy
 Maternal malnutrition

12. Aetiology: Maternal factors
 Drug abuse eg of Opiates, alcohol
 Endocrine abberations
 Short birth interval

13. Aetiology: Fetal factors
 Preterm delivery
 Multiple pregnancy
 Congenital / Chromosomal abnormalities
 Congenital infection like with TORCH
group
 Hydrops fetalis (Rh or other blood group
incompatibility – fetal oedema,
hypoalbumineamia, CHF)

14. Differentiating between Preterm
AND GA
Trait SGA
Skin Thin with visible veins and smooth Thick, difficult to see
veins, flaky
Lanugo Present Absent
Breast nipple and areolar may or may not
be seen
Nipple and areolar
present, bud is 5-10mm
Male Ruggae may not be visible or may
cover just part of the scrotum
Ruggae cover the entire
scrotum
Female Clitoris is prominent and labia
minora are flat.
Clitoris is covered and
labia majora are larger
Ear Soft and folds easily and recoils
slowly. Pinna is flat.
Pinna curved, ear resists
folding and recoils easily.
Posture Limbs are less flexed Arms are flexed to the
chest, hands fisted and
legs flexed to the
abdomen.

15. Differentiating between Preterm
and SGA
Trait Pre term SGA
Wrist flexion against fore
arm
Square window wrist: poor
flexion, makes 90 degrees
with the forearm. Very
immature does not make
90 degrees with forearm.
Wrist flexes completely
against forearm.
Arm recoil Responds by weak and
delayed flexion
Resists extension and
returns limbs briskly to
flexed postn
Popliteal angle Preterm has greater
popliteal angle
Has smaller angle
Scarf sign Elbow may reach opposite
shoulder
Elbow may not cross mid
line
Heel to ear Heel gets closer to head Head further from head.

16. Differentiating between Preterm
and SGA
CNS Trait Pre term SGA
Alertness Less alert Alert
Activity Passive Active
Suckling reflex Poor Well developed
Appetite Low High

17. Dubowitz Criteria
 There is the non neurological and neurological criteria.
 The two are recorded, the scores tallied and plotted on a
regression graph.
 Helps in assessing the gestational age of a premature
infant and also in differentiating it from one who is SGA.

18. Dubowitz table:
Non
neurological
criteria
 Non
neurologica
l criteria
added tp a
final score.

19. Dubowitz
Method:
Neurological
criteria.
 Neurological
criteria are
recorded and
added to a final
score.

20. Regression graph
 The total score is
plotted against
regression line
graph to obtain
gestation in
weeks.

21. Problems Associated with Premature
Infants
Respiratory
Respiratory distress syndrome—RDS (hyaline
membrane disease—HMD)* (Due to deficiency of
surfactant, sepsis, endocrine disorders. Presents as grunting, chest
in drawing, tachypnoea >60/min)
 Bronchopulmonary dysplasia—BPD*
 Pneumothorax, pneumomediastinum; interstitial
emphysema
 Congenital pneumonia, aspiration pneumonia
 Pulmonary hypoplasia

22.  Pulmonary hemorrhage
 Apnea* (Apnoeic attacks)
 Transient tachypnoea of the new born (TNN)
Cardiovascular
 Patent ductus arteriosus—PDA*
 Hypotension
 Hypertension
Problems Associated with Premature Infants

23. Problems Associated with Premature
Infants
 Bradycardia (with apnea)*
Congenital malformations
Hematologic
 Anemia (early or late onset)
 Hyperbilirubinemia—indirect*
 Hyperbilirubinemia—direct
 Subcutaneous, organ (liver, adrenal)
hemorrhage* (Hemorrhagic disease of the new born
whose onset is 24-72 hrs after birth)

24. Problems Associated with Premature
Infants
 Disseminated intravascular
coagulopathy.
 Vitamin K deficiency.
 Hydrops—immune or nonimmune.

25. Problems Associated with Premature
Infants
Metabolic–Endocrine
 Hypocalcemia
 Hypoglycemia*
 Hyperglycemia*
 Late metabolic acidosis
 Hypothermia*
 Euthyroid but low T4 status

26. Problems Associated with Premature
Infants
Central Nervous System
 Intraventricular hemorrhage*(small haemorrhages
into the germinal layer lining the lateral ventricles of
the brain)
 Periventricular leukomalacia (ischaemia or
infarction of the brain parenchyma)
 Hypoxic–ischemic encephalopathy
 Seizures
 Retinopathy of prematurity
 Deafness
 Hypotonia*

27. Problems Associated with Premature
Infants
 Congenital malformations
 Kernicterus (bilirubin encephalopathy)
 Drug (narcotic) withdrawal
Renal
 Hyponatremia*
 Hypernatremia*
 Hyperkalemia*

28. Problems Associated with Premature
Infants
 Renal tubular acidosis.
 Renal glycosuria.
 Edema.
Other.
 Infections* (congenital, perinatal, nosocomial:
bacterial, viral, fungal, protozoal). These are due
to delicate surfaces, limited immunological
competence. Common organisms include E.coli,
S. aureus, H.influenzae, Listeria.
 *Common.

29. Problems Associated with Premature
Infants :
Gastrointestinal:
 Feeding difficulties due to:
 Poor suckling reflex.
 Poor swallowing reflex.
 Reduced gut motility leading to abdominal distension.
 Poor absorption of fat and fat soluble vitamins A,D,E,K.
 Poor nutritional reserves of fat, glycogen, iron.
 Necrotizing enterocolitis (NEC).
 Common in preterms but cause is unknown but its probably due
to gut ischaemia and infection due to hypoxia from birth asphyxia
or RDS. Baby presents with shock, lethargy, poor feeding,
abdominal distension and passage of blood stained stool.

30. Problems Associated with Premature
Infants
Skin.
 Hypothermia: Due to.
• High Surface area to body weight ratio.
• Small brown fat stores.
• Immature temperature regulation by the hypothalamus.
• Loss of heat by evaporation, radiation and conduction. Skin
temp falls by 0.3deg/min while core temp falls by 0.1deg/min.
 Increased metabolism necessitates increased
Oxygen use which leads to low O2 blood levels
(Hypoxemia) and in tissues leads to acidosis.
 Increased glucose metabolism leads to
hypoglycemia, weight loss and poor weight gain.

31. Management
 Respiratory problems
 Suction at birth
 Keep dry and warm and stimulate to breathe
 Give oxygen
 Skin
 Prevent heat loss by
• Drying skin at delivery
• Wrap the whole baby including the head OR
• Do Kangaroo i.e. skin to skin contact.

32. Management
 GIT:
 Feed via NGT or via IV if child cannot breastfeed.
 1st day – 60ml/kg then add 20ml/kg till 180ml/kg/day.
 Feed 2 hourly.
 Give EBM whenever possible.
 NOTE: Baby can lose up to 15% body wt in first week.
 NEC: Stop oral feed for about a week. Use IV feeding.
 Give broad spectrum ABC with metronidazole.
 Haematological:
 Give Vit K supplements

33. Management
 Infection:
 Ensure stringent hygiene while handling the baby.
 Give broad spectrum ABC. (Ampicillin and Gentamicin)

34. Prevention
 Aim to prevent the preventable disposing factors
described earlier.
 This requires screening of the high risk patients
in ANC like diabetics, pre eclamptics, smokers,
alcoholics etc and managing their conditions
early enough before the effects are passed on to
the pregnancy.