Preterm infant,small for gestation age and postterm infant

Preterm infant,small for gestation age and postterm infant

1. PRETERM INFANT,SMALL FOR GESTATION AGE AND POSTTERM INFANT Mrs.Jagadeeswari.J M.Sc Nursing

2. Preterm infant DEFINITION: A baby born before 37 completed weeks of gestation calculating from the first day of last menstrual period is arbitrarily defined as preterm baby Babies born before 37 completed weeks usually weighing 2500gms or less.

3. incidence Preterm baby constitutes 2/3 rd of low birth weight babies. The incidence of low birth weight baby is about 30-40% in the developing countries as such the incidence of preterm baby is about 20-25%.

4. etiology Spontaneous Induced

5. spontaneous Health status of the mother Multiple pregnancy Advanced parental age Placental problems Preterm labour and premature rupture of membrane Low maternal weight Chronic and acute systemic maternal disease Ante partum haemorrhage Cervical incompetence Maternal genital colonization and infections Cigarette smoking during pregnancy Acute emotional stress Physical exertion Sexual activity Trauma Bicornuate uterus Congenital malformations

6. induced Maternal diabetes mellitus Placental dysfunction as indicated by unsatisfactory fetal growth Eclampsia Fetal hypoxia Ante partum haemorrhage Severe rhesus iso immunization

7. Clinical features Measurements: Size is small with relatively large head Crown- heel length is less than 47cm Head circumference is less than 33 cm But exceeds the chest circumference by more than 33 cm

8. Activity and posture: General activity is poor Automatic reflex response such as Moro response, sucking and swallowing are sluggish or incomplete Baby assumes an extended posture due to poor tone

9. Face and head: Face appears small large head size Sutures are widely separated Fontanels are large Small chin Protruding eyes Optic nerve is usually unmyelinated Ear cartilage is deficient or absent with poor recoil Hair appears woolly, and fuzzy and individual hair fibres can be seen separately

10. Skin and subcutaneous tissues: Skin is thin, gelatinous, Shiny and excessively pink Abundant lanugo Very little vernix caseosa Edema may be present Subcutaneous fat is deficient Breast nodule is small or absent

11. Genitals: MALE: testes undescended scrotum poorly developed FEMALES : labia majora widely separated exposing labia minora hypertrophied clitoris

12. CHARACTERISTICS OF PRETERM INFANTS Skin Bright pink, often translucent, depending on the degree of maturity Smooth and shiny ( may be oedematous) Small blood vessels clearly visible underneath the thin epidermis Fine lanugo hair is abundant

13. Ear cartilage Soft and pliable Soles and palms Minimal creases Smooth appearance Scarf sign Elbow may be easily brought across the chest with little or no resistance

14. Male genitalia Male infant’s scrotum is undeveloped and not pendulous Minimal rugae are present Testes may be in the inguinal canal or in the abdominal wall Female genitalia Clitoris is prominent Labia majora are poorly developed and gaping

15. COMPLICATIONS OF PRETERM BIRTH Central nervous system: Immaturity of central nervous system Poor cough reflex In coordinated sucking and swallowing Retrolental fibroplasias Intra ventricular and periventricular haemorrhage

16. Respiratory system Resuscitation difficulties at birth Hyaline membrane disease Breathing is periodic and associated with intercostal recessions due to soft rib Pulmonary aspiration Atelectasis Broncho pulmonary dysplasia

17. Cardio vascular system The closure of ductus arteriosus is delayed among preterm infants G I system Regurgitations and aspirations Abdominal distension and functional intestinal obstruction Enter colitis Hyperbilirubinemia Hypoglycaemia

18. Thermo-regulation Excess heat loss Infections Renal immaturity The blood urea nitrogen is high Acidosis Edema Toxicity of drug Nutritional problems anemia Deficiencies of folic acid and Vit E osteopenia and rickets Biochemical disturbance hypoglycaemia, hypocalcemia, hypoxia

19. management Care of preterm infant Intensive care protocol

20. Care of newborn Cushioned bed Avoid excessive light, excessive sound, rough handling and painful procedures. Use effective analgesia and sedation for procedures Provide warmth Ensure asepsis Cover the baby appropriately Provide effective and safe oxygenation Nutrition Tactile and kinaesthetic stimulation Prone position Photo therapy Prevention of nosocomial infection Weight record Immunizations Family support Discharge policy Follow up Home care of preterm babies

21. COMMON PROBLEMS OF PRETERM NEWBORNS Nosocomial infections Hypothermia Respiratory distress syndrome Aspiration Patent ductus arteriosus Chronic lung disease Necrotizing entercolitis Intraventricular haemorrhage Retinopathy of prematurity Late metabolic acidosis Nutritional disorders Drug toxicity

22. Small for gestational age/intra uterine growth retardation/ dysmaturity /chronic placental insuffiency

23. definition IUGR is said to be present in those babies whose birth weight is below the 10 th percentile of the average for the gestational age.

24. incidence Incidence: 3-10% of infants.

25. classification Depending on pathologic process and time of onset. Type I or symmetrical or intrinsic IUGR Type II or asymmetrical or extrinsic IUGR

26. etiology Maternal factors Fetal factors Placental factors unknown

27. Maternal factors Extremes of maternal age. Hypertension and vascular disease Constitutionally small mothers Chronic maternal hypoxia: d/t pulmonary disease, cyanotic heart disease & severe anemia Prothrombotic disorder: antiphospholipid syndrome Maternal malnutrition Infection: CMV, Toxoplasmosis, Varicella -Zoster, Malaria Substance abuse & cigarette smoking Teratogens: Folate antagonists, antineoplastic agents, anticonvulsants. History of IUGR in previous pregnancies. Assisted reproductive technologies

28. Fetal factors Congenital malformations Fetal infections: CMV, HIV, toxoplasma , etc. Chromosomal abnormalities: trisomy 21 & trisomy 18 Genetic: agenesis

29. Placental factors Circumvalate placentae Chronic placental abruption Placenta praevia Chrioangioma unknown 40% remain unknown cause

30. Risk factors MAJOR RISK FACTORS Maternal age >40 years Smoker > 11 cigarettes per day Cocaine Daily vigorous exercise Previous SGA baby Previous stillbirth Maternal SGA C/c HTN Diabetes & vascular diseases Renal impairment Antiphospholipid syndrome Echogenic bowel preeclampsia Severe pregnancy induced HTN Low maternal weight

31. MINOR RISK FACTORS Maternal age > 35 years Nulliparity BMI <20 BMI 25-29.9 Smoker 1-10 per day Low fruit intake per day Preeclampsia Pregnancy interval < 6 months

32. Complications-fetal Antenatal : c/c fetal distress, hypoxia & acidosis, fetal death After birth : Asphyxia and RDS Hypoglycaemia Meconium aspiration syndrome Hypothermia Pulmonary h’age Polycythemia Necrotizing enterocolitis Intraventricular h’age

33. Diagnosis of iugr 1. SCREENING: Accurate knowledge of gestational age Past history of IUGR & any maternal complication On obstetric palpation, height of uterus <4 weeks or more for the gestational age. Uterine fundal height: serial fundal height measurements throughout pregnancy.

34. diagnosis Ultrasound measurements: Fetal biometry: fetal parietal diameter(BPD),femur length (FL) &abdominal circumference(AC) are measured. Body proportions : HC/AC ratio, FL/AC ratio & ponderal index for asymmetric IUGR. HC/AC ratio : size of liver is disproportionately smaller than head circumference or length of femur Amniotic fluid volume : Oligohydraminos d/t ↓ fetal urine production. Doppler velocimetry: abnormal umbilical artery Doppler velocimetry increased systolic-diastolic ratio, absent or reverse end-diastolic flow.

35. Post mature infant definition Infants born of a gestation age that extends beyond 42 weeks as calculated from the mothers last menstrual period

36. Predisposing factors Pregnancy between the age of 15-19yrs Elderly women Wrong dates Multiple pregnancy Fetal anomalies hereditary

37. Clinical manifestation Absence of vernix caseosa Loose skin and little subcutaneous fat Absence of lanugo Abundant hair on the head and long nails Skin is wrinkles, cracked and peeling Umbilical cord is thin

38. Diagnostic evaluation History collection Fetal movement recording Electronic fetal monitoring Ultrasonography Biophysical profile Doppler flow study

39. Management immediate care of newborn Clear the airway Maintain thermoregulation Prevention of infection APGAR scoring Early beast feeding Card care Eye care Preventing hypoglycemia Administer vitamin K injection Assess the weight

40. Thank you