Neuroprotection from acute brain injury in preterm infants

Question 1

Highest risk period for IVH

Answer 1

72 hours (critical window)

Question 2

What antibiotic for mom with PPROM and expected to deliver =< 32+6?

Answer 2

Macrolide and penicillin
(or macrolide alone if pen allergic)

Protects against GBS and may help prolong pregnancy

Question 3

Antenatal steroid criteria?

Answer 3

Within 7 days for all expected deliveries =< 34+6 wk
Optimally 48 hours between last dose and delivery

Administer for 35+0-36+6 weeks GA in certain situations

Question 4

Magnesium sulfate criteria in newborns?

Answer 4

=< 33+6 wks

give to all women experiencing imminent preterm delivery

Question 5

Indications for inotropes in preterm babies

Answer 5

Hypotension
Prolonged cap refill
Decreased UO 
elevated lactate
echo findings (low cardiac output)

Question 6

CO2 goals in preterm infants?

Answer 6

Permissive hypercapnia: pCO2 45-55 in first 72 hours postdelivery for =< 32+6 wks

• Volume-targeted ventilation in first 72 hours post delivery

CO2 < 35 is risk for PVL
pCO2 > 60 is risk for IVH

Question 7

List neuroprotection measures for preterm infants

Answer 7

1. Treat maternal PPROM with macrolide & pen in mothers expected to deliver =< 32+6 weeks
2. Antenatal corticosteroids for =< 34+6
3. Mag sulf =< 33+6 wks
4. Mode of delivery -C/S for malpresentation
5. Cord clamping - delay 30-120 seconds
6. Hypothermia - bag for 31+6wk
7. Inotropes and hypotension - MAP < wk GA or <30 mmHg x 2 consecutive measures
   - association between use of pressors in prems with developing IVH
8. Prophylactic indo and ibu
9. Permissive hypercapnia (CO2 45-55)
   - monitor CO2 in =< 32+6 week infants
10. Head positioning - midline, HOB elevated 30 degrees
11. Nurturing environment

Question 8

What is PPROM (ROM > 72 hours) a risk for?

Answer 8

IVH or intraparenchymal hemorrhage

Question 9

How do you treat newborns of moms with PPROM and chorio?

Answer 9

Blood cx and antibiotics for newborns born at =<32+6 GA to mothers with suspected/confirmed chorio, PPROM, preterm labour, or unexplained onset of nonreassuring fetal status

• abx discontinued if cx negative at 36-48 hours

Question 10

What does mag sulf protect against in prems?

Answer 10

• anti-inflammatory effects and inhibits influx of calcium into cells
• decreases risk for CP and death

Question 11

What does delayed cord clamping protect against?

Answer 11

motor disabilities and acute brain injury

Question 12

How to prevent hypothermia in a prem?

Answer 12

for =< 31+6 wks

• Polyethylene wrapping or bag
• regulate temperature in delivery room 25-26 degrees
• use preheated servo-controlled radiant warmer with temperature sensor
• provide a thermal mattress,
• put hat on infant
• provide preheated transport incubator

Question 13

How do you promote a nurturing environment for a prem at risk of brain injury?

Answer 13

encourage skin-to-skin contact
maternal voice exposure and interaction
light cycling
low general noise level
early parenteral nutrition