Prematurity and IUGR

7,149 views

Published on

Published in: Health & Medicine
0 Comments
21 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
7,149
On SlideShare
0
From Embeds
0
Number of Embeds
33
Actions
Shares
0
Downloads
466
Comments
0
Likes
21
Embeds 0
No embeds

No notes for slide

Prematurity and IUGR

  1. 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. 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. 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. 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. 5. Characteristics of IUGRAsymmetric (acute)• Late onset- Environmental factors• Brain sparing• Has better prognosisExamples• Hypoxia• Preeclampsia (PIH, PET)• Chronic hypertension
  6. 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. 7. Causes of Preterm BirthFETAL• Fetal distress• Multiple gestation• Erythroblastosis• Nonimmune hydropsPLACENTAL• Placental dysfunction• Placenta previa• Abruptio placentae
  8. 8. Causes of Preterm BirthUTERINE• Bicornuate uterus• Incompetent cervix (premature dilatation)
  9. 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. 10. Causes of Preterm BirthOTHER• Premature rupture of membranes• Polyhydramnios• Trauma
  11. 11. Factors Associated with IUGRFETAL• Chromosomal disorders• Chronic fetal infections (e.g., cytomegalic inclusion disease, congenital rubella, syphilis)• Congenital anomalies–syndrome complexes• Irradiation
  12. 12. Factors Associated with IUGRFETAL• Multiple gestation• Pancreatic hypoplasia• Insulin deficiency• Insulin-like growth factor type I deficiency
  13. 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. 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. 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. 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. 17. IUGR• Heads are disproportionately large for their trunks and extremities• Facial appearance has been likened to that of a “wizened old man”.
  18. 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. 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. 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. 21. Problems of IUGR (SGA) Infants• Skeletal: Decreased ossification of endochondral & membranous cartilage.• Malformations: Increased incidence of Cong.malformations.
  22. 22. Problems of IUGR (SGA) InfantsDysmorphology• Syndrome anomalads• chromosomal-genetic disorders• Oligohydramnios-induced deformations• TORCH infection• Pulmonary hemorrhage
  23. 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. 24. Problems with Premature InfantsCARDIOVASCULAR• Patent ductus arteriosus• Hypotension• Hypertension• Bradycardia (with apnea)• Congenital malformations
  25. 25. Problems with Premature InfantsHEMATOLOGIC• Anemia (early or late onset)• Hyperbilirubinemia–indirect• Subcutaneous, organ (liver, adrenal) hemorrhage• Disseminated intravascular coagulopathy• Vitamin K deficiency
  26. 26. Problems with Premature InfantsGASTROINTESTINAL• Poor gastrointestinal function–poor motility• Necrotizing enterocolitis• Congenital anomalies producing polyhydramnios• Spontaneous gastrointestinal isolated perforation
  27. 27. Problems with Premature InfantsMETABOLIC-ENDOCRINE• Hypocalcemia• Hypoglycemia• Hyperglycemia• Late metabolic acidosis
  28. 28. Problems with Premature InfantsRENAL• Dyselectrolytemia – hyponatremia, hypernatremia,hyperkalemia• Renal tubular acidosis
  29. 29. Problems with Premature InfantsCENTRAL NERVOUS SYSTEM• Intraventricular hemorrhage• Periventricular leukomalacia• Hypoxic-ischemic encephalopathy• Seizures• Retinopathy of prematurity• Deafness• Hypotonia
  30. 30. Problems with Premature Infants• Congenital malformations• Kernicterus (bilirubin encephalopathy)• Drug (narcotic) withdrawalOTHER• Infections (congenital, perinatal, nosocomial: bacterial, viral, fungal, protozoal)
  31. 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. 32. Management of IUGR• Genetic anomalies - screening- chromosomal analysis• Others - serum calcium to r/o hypocalcemia - Mx - meconium aspiration
  33. 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. 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. 35. NICU CARE• Temperature control• Respiratory support• Fluids and electrolytes• Nutritional support• Infection control• Cardiovascular support• Others- Skin care, Hyperbilirubinemia• Suplement
  36. 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. 37. KANGAROO MOTHER CARE• Benefits – Thermoregulation – Exclusive breast feeding – Physiologic stability – Decreased incidence of infection – Infant-mother bonding – Cost effective
  38. 38. 2. RESPIRATORY SUPPORT• Free flow oxygen• Ventilatory support• Surfactant therapy
  39. 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. 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. 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. 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. 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. 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. 45. TOTAL PARENTERAL NUTRITION• Calcium• Phosphorous• Magnesium• Others: – Zinc – Copper – Chromium – Selenium – Molybdenum
  46. 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. 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. 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. 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. 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. 51. PRETERM HUMAN MILKDisadvantages: – Low concentrations of Vitamin D, Ca, P – Inadequate iron
  52. 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. 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. 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. 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. 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. 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. 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. 59. “Long term” Morbidity of IUGR Factors associated with abnormal outcome ? Microcephaly Hypoxic ischemic encephalopathy Symptomatic hypoglycemia Symptomatic hyperviscosity
  60. 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. 61. Sequelae of Low Birth weight• Mental retardation• Poor school performance• Spasticity• Seizures• Hydrocephalus• Sensorineural injury-Hearing• Short-bowel syndrome• Malabsorption
  62. 62. Sequelae of Low Birth weight• Visual impairment• Retinopathy of prematurity• Strabismus, myopia• Bronchopulmonary dysplasia,• Bronchospasm• Recurrent pneumonia
  63. 63. Sequelae of Low Birthweight• Growth failure - Failure to thrive• Gastroesophageal reflux• PEM• Osteopenia, fractures,• Anemia
  64. 64. Follow-up• Anemia• Retinopathy of prematurity• Hearing screenings• Cholestasis• Stable temperature regulation• Gaining weight on oral feedings• Nutritional support
  65. 65. Follow-up• Breast-feeding• Appropriate immunizations• Ophthalmologic examination if <27 wk or <1,250?g at birth
  66. 66. Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]

×