mzava_complications of prematurity063712.pptx

complications of prematurity

1. DODOMA REGIONAL REFERRAL HOSPITAL Department –Pediatrics Topic- Complications Of Prematurity Presenter- Yusuph Mzava Supervisor- Dr. Ruta

2. Presentation outline Introduction Epidemiology Complications of prematurity Short term complications Long term complications

3. Introduction Prematurity is a term for the broad category of neonates born at less than 37 weeks' gestation. Preterm birth is the leading cause of neonatal mortality and the most common reason for antenatal hospitalization

4. Classification of prematurity by birth weight or gestational age Birth weight Low birth weight (LBW) <2500 g Very low birth weight (VLBW) <1500 g Extremely low birth weight (ELBW) <1000 g Gestational age Late preterm 34 weeks to <37 weeks Moderate preterm 32 weeks to <34 weeks Very preterm <32 weeks Extremely preterm <28 weeks In using these definitions, the definition of VLBW infants includes ELBW infants, and the category of very preterm infants also includes those who are extremely preterm. This is an important consideration when one is reviewing published data of VLBW and very preterm infants. Graphic 119362 Version 2.0

5. Epidemiology Every year, an estimated 15 million babies are born preterm world wide(before 37 completed weeks of gestation), and this number is rising. Preterm birth complications are the leading cause of death among children under 5 years of age, responsible for approximately 1 million deaths in (WHO, 2015). In Tanzania, 236,000 babies are born too soon each year and 11,500 children under five die due to direct preterm complications (Tanzania profile of preterm and low birth weight prevention and care, 2017) In Tanzania, pre-term birth account for18.5% of all perinatal deaths( Mpembeni et al.,2015)

6. Complications of prematurity . Short Term Complications Long Term Complications Hypoglycemia Bronchopulmonary dysplasia Hypothermia Poor growth Respiratory Distress Syndrome Retinopathy of prematurity Apnea of prematurity Late anemia of prematurity NEC CNS dysfunction Infections Intra-ventricular hemorrhage (IVH) PDA Periventricular leukomalacia

7. Short term complications 1. Hypoglycemia (RBG <2.6 mmol/l as per STG Causes a. Decreased production of glucose Inadequate gluconeogenesis Inadequate glycogen / fat stores i.e. in prematurity, intrauterine growth restriction. b. Increased glucose consumption Hyperinsulinemia as seen in infants of a diabetic mother (IDM).

8. Signs & symptoms of hypoglycemia Feeding difficulties / poor sucking Weak or high-pitched cry Irritability Lethargy / stupor Hypothermia Diaphoresis Hypotonia Convulsions Apnea / grunting / tachypnea Tachycardia Cyanosis

9. Short term complications cont.. Management of Hypoglycaemia Give a bolus of D 10%, 2 ml/kg IV stat. Re-check RBG after 30 minutes while the newborn is on maintenance fluids appropriate for age.

10. Short term complications cont.. 2. Hypothermia (Temp< 36.5C) It occurs in preterm babies due to: Little subcutaneous fat, Muscular inactivity, Inadequate sweating mechanism, Decreased brown fat (metabolic heat production) , Immature heat regulation mechanism. Signs and symptoms CNS-Decreased reflexes, lethargy, hypotonia. RS - Tachypnea, apnea GIT- Poor feeding / feeding intolerance, vomiting CVS-Peripheral cyanosis, bradycardia / tachycardia, hypotension.

11. Short term complications cont.. Management of hypothermia Keep the baby dry (dry nappies and sheets) Cover the baby adequately with dry and warm sheets, as well nesting. KMC care (skin to skin contact) Radiant warmers and incubators Warm room Rub coconut oil to the body to prevent heat loss.

12. Hypothermia .

13. Short term complications cont.. 3 . Respiratory distress syndrome It is a disease of immature lungs, characterized by impaired surfactant synthesis and secretion which results into increased surface tension in the lungs leading into alveolar collapse and decreased lung compliance. More common in premature infants especially born six weeks or more before their due date.

14. Short term complications cont.. Surfactant production starts around 20wks of life and peaks at 35wks. Therefore any neonate less than 35wks is prone to develop RDS, without surfactant infants are unable to keep their lungs inflated Signs and symptoms Tachypnea , expiratory grunting, subcostal / intercostal recession / retraction, sternal retraction, nasal dilatation, cyanosis

15. Short term complications cont.. Management a. Respiratory support therapy: Put the baby on nasal continuous positive pressure ventilation (CPAP). CPAP offers both ventilation(Pressure support) and oxygenation for neonates with RDS. If the baby does not respond to CPAP i.e. has intractable apnea or respiratory failure then put the baby on a mechanical ventilator if not responding to CPAP.

16. Short term complications cont.. b. Surfactant replacement therapy: Give early pulmonary surfactant (survanta) 4ml/kg through ETT within 6h of life A repeated dose may be given at 6hrs to 12hrs interval followed by nasal CPAP if no improvement. If the baby is not responding to CPAP then will need mechanical ventilation

17. Short term complications cont.. c. Keep warm d. IV fluids (Dextrose 10%) e. Encourage feeding f. Treat with antibiotics until sepsis is ruled out Prevention: Prenatal administration of corticosteroids Decreases incidence and severity of RDS Given to women with high-risk of preterm birth at 24 – 34 weeks gestation Dose: IM Betamethasone 12mg od / 48 hours or IM Dexamethasone 6mg 12 hourly / 48 hours

18. Short term complications cont.. 4. Apnoea of prematurity Definition: cessation of breathing for more than 20 seconds, with bradycardia (<100bpm) or cyanosis Signs and symptoms : Periodic cessation of breathing for >20 seconds, periodic cessation of breathing >10 seconds with cyanosis or bradycardia

19. Short term complications cont.. Treatment : physical stimulation, Aminophylline IV (Loading dose: 6mg/kg, maintenance dose: 3mg/kg in 4 divided doses ) PO caffeine citrate (10-20mg/kg loading dose, 5-10 mg/kg maintenance dose) High flow oxygen (CPAP) for those with spontaneous breathing

20. Short term complications cont.. 5. Necrotizing Enterocolitis (NEC) Ischemic and inflammatory necrosis of the bowel after initiation of enteral feeding. Signs and symptoms : Abdominal distension, vomiting brownish materials, feeding intolerance, increasing gastric residual, occult or gross blood in stool, abdominal tenderness, apnoea, bradycardia, temperature instability

21. Short term complications cont.. Treatment : NPO, NGT for decompression, IV fluids , TPN, antibiotics, monitor fluid input and output, vitamine K, surgical consultation,

22. Short term complications cont.. 6. Infections Results from lack of maternal immunoglobulins (IgG), which are transferred across the placenta during the last trimester. In addition to this, delicate surfaces of skin and mucous membranes also predispose to infections. Insertion of IV cannula, endotracheal tubes, nasogastric tubes also increase the risk of infections.

23. Short term complications cont.. Signs and symptoms Temperature irregularity : hypo- / hyperthermia Change in behavior: lethargy, irritability, or change in tone, bulging fontanel, convulsions Feeding problems : Feeding intolerance, vomiting, diarrhea (watery loose stool), abdominal distention, passage of blood stained stool . Skin : Poor peripheral perfusion, Cyanosis, mottling, pallor, petechiae, rashes, sclerema, jaundice Cardiopulmonary: Tachypnea, respiratory distress(grunting, flaring, and retractions), apnea within the first 24 h of birth or of new onset (especially after 1 week of age), tachycardia, hypotension which tends to be a late sign. Metabolic: Hypo- or hyperglycemia or metabolic acidosis.

24. Short term complications cont.. Management Empirical antibiotics to premature below 32 weeks (1500 g) recommended for at least 48 hours A full course of antibiotics if there are signs of sepsis or mother with risk factors of infection: ( fever >38°C, membrane ruptured >18 hours before birth , foul smelling or purulent amniotic fluid ). Hygienic practices when handling premature infants.

25. Short term complications cont.. .

26. Short term complications cont.. 7 . Intra-ventricular hemorrhage (IVH) It is common in preterm infants due to; Immature vasculature Disturbed cerebral auto-regulation of blood flow Clotting factor deficiency.

27. Short term complications cont..

28. Short term complications cont.. Signs and symptoms coma, hypoventilation, decerebrate posturing, fixed pupils, bulging anterior fontanelle, hypotension, acidosis, or acute drop in hematocrit) Management Supportive; incubator care, oxygen therapy, IV fluids. Symptomatic treatment; convulsions ( IV phenobarbitone) Anemia (fresh , packed RBCs transfusion) Raise intracranial tension (mannitol IV, mechanical hyperventilation).

29. Short term complications cont.. 8. Periventricular leukomalacia Periventricular leukomalacia (PVL) is a type of brain injury that affects premature infants. The condition involves the death of small areas of brain tissue around fluid-filled areas called ventricles. The damage creates "holes" in the brain. " Leuko " refers to the brain's white matter. "Periventricular" refers to the area around the ventricles. Causes A major cause is thought to be changes in blood flow to the area around the ventricles of the brain. This area is fragile and prone to injury, especially before 32 weeks of gestation.

30. Short term complications cont.. Infection around the time of delivery may also play a role in causing PVL. The risk for PVL is higher for babies who are more premature and more unstable at birth. Premature babies who have intraventricular hemorrhage (IVH) are also at increased risk for developing this condition. Treatment There is no specific treatment for PVL. Supportive; incubator care, oxygen therapy, IV fluids.

31. Long term complications 1. Chronic lung disease (bronchopulmonary dysplasia) BPD is defined as an ongoing need for supplemental oxygen and/or respiratory support at either 28 days postnatal age or 36 weeks postmenstrual age (PMA) in a preterm neonate with radiographic evidence of parenchymal lung disease Prolonged ventilation and oxygen toxicity results in chronic oxygen dependency. Management Supportive Growth and nutrition — Nutrition is provided to meet the increased total energy needs of infants with BPD and to support lung growth and healing. Caloric demands are generally high to meet the metabolic requirements for growth and healing.

32. Long term complications Fluid restriction — For most infants with BPD, we suggest modest fluid restriction (140 to 150 mL/kg per day). In severely affected infants, fluid restriction to 110 to 120 mL/kg per day may be necessary. Based upon our clinical experience, modest fluid restriction appears to improve pulmonary function and reduces the risk of pulmonary edema Respiratory support — Respiratory care is supportive. The goal is to maintain adequate gas exchange while minimizing further lung injury supplemental oxygen therapy in neonates with BPD is to meet the metabolic needs of the neonate while avoiding high concentrations of oxygen, hyperoxia, and hypoxia. The initial target range for oxygen therapy is a peripheral oxygen saturation (SpO2) of 90 to 95 percent.

33. Long term complications Pharmacological Bronchodilators — Bronchodilator therapy is usually reserved for infant s who have episodes of acute pulmonary decompensation with evidence of airway reactivity. Glucocorticoids — F or extremely preterm (EPT) infants ( ie , GA <28 weeks) who remain ventilator-dependent and/or require oxygen supplementation >50 percent at two to four weeks postnatal age. In this high-risk population, we use systemic glucocorticoids to prevent development of severe BPD and other pulmonary morbidity. Diuretics - For patients with acute pulmonary exercerbation attributed to pulmonary edema

34. Long term complications 2. Poor growth Growth is restricted due to feeding problems, vitamin and iron deficiency which may lead to developmental delay Before 35 weeks of gestation sucking and swallowing not yet well coordinated leading to significant feeding difficulties, with risk of regurgitation(GERD) and aspiration . Stomach emptying and gut motility is slower. Abdominal distension due to a relatively atonic bowel aggravates feeding difficulties. Immaturity of digestive enzymes affects feed tolerance in some babies

35. Long term complications 3.Retinopathy of prematurity This is an abnormal vascularization due to immaturity and prolonged oxygen therapy leading to partial or complete blindness. After the initial injury, normal vessel development may follow abnormal vascularization which occur due to excessive vascular endothelial growth factor (VEGF) The process can regress at this point or may continue, with growth of fibrovascular tissue into the vitreous associated with inflammation, scarring, and retinal folds or detachment

36. Long term complications Signs and symptoms Gradually occurring astigmatism, retinal detachment, amblyopia. Management Mainly prophylactic Optimal oxygen therapy is essential for the least duration. Any premature exposed to prolonged oxygen therapy should be examined by ophthalmoscope at the age of 1 to 3 months.

37. Long term complications 4. CNS dysfunction Cerebral palsy Post hemorrhagic hydrocephalus Learning problems Deafness Mental sub normality

38. References Hay W, Deterding R (2018). CURRENT Diagnosis & Treatment Pediatrics, 24 th ed. McGraw Hill education Ministry of Health, Community Development, Gender, Elderly and Children(2019). National guideline for neonatal care And Establishment of neonatal care unit 1 st ed Mpembeni,R ., Jonathan, R. & Mughamba , J.(2015) Perinatalmortality and associated factorsamong deliveries in three municipal hospitals of Dar es Salaam, Tanzania.Journal ofPediatrics and Neonatal Care1 (4):00022 Wittenberg, D and Coovadia (2014). Coovadias paediatrics and child health, 7th ed South Africa, Oxford University Press Southern Africa https://emedicine.medscape.com/article/975909-overview https://www.who.int/news-room/fact-sheets/detail/preterm-birth

39. Thank you