Prematurity

Question 1

What defines a baby as premature?:

Answer 1

• Delivery before 37 weeks
• Extreme Preterm: before 28 weeks
• Very Preterm: 28-32
• Moderate to late preterm: 32-37 weeks

Question 2

What are some of the causes of Prematurity?

Answer 2

• emergency event such as placental abruption/ eclampsia
• Prelabour rupture of the membranes
• Preterm deliveries (Pre-eclampsia, renal disease and severe growth restrictions)

Question 3

What are the Risk factors for Prematurity?

Answer 3

• Multiple pregnancy
• Smoking/ illicit drug use
• Under/ Over weight
• Early Pregnancy within 6 months of previous pregnancy
• Infection
• Diabetes and Hypertension

Question 4

What clinical Features of Prematurity?

Answer 4

• From the History/ Examination an estimated due date is made
• The Dubowitz/ Ballard Examination is used to estimate neonatal examination
• Physical Features include skin, lanugo, ear, eye and genital formation

Question 5

What investigations would you do?

Answer 5

• Blood Gas: respiratory state
• FBC - infection, thrombocytopenia and anaemia
• Urea, Creatinine and electrolytes
• Blood Culture: infection
• CRP
• Direct Coombs Test

Question 6

What Imaging/ invasive Tests would you do?

Answer 6

• Chest Xray: every infant before the age of 32 weeks will need some form of respiratory support. If a baby is intubated and ventilated a CXR is required to assess the position of the Endotracheal Tube
• Abdo Xray: Neonates require parenteral nutrition through the umbilical veins and arteries. An abdo X-ray ensures the umbilical venous and arterial catheter are in the correct position after insertion. Necrotising enterocolitis, looking for signs of suspected perforation
• Cranial USS (CrUSS): The brains of preterm and very low birth weight infants are at increased risk of neurological insults. CrUSS is used routinely in infants born at less than 32 weeks to assess for any signs of intraventricular haemorrhage.

Question 7

What is the Initial Management for Prematurity?

Answer 7

• Give a course of antenatal steroids (reduces the risk of death, Intra-ventricular haemorrhage and respiratory distress syndrome)
  -Magnesium sulphate should be given as this is proven to be neuroprotective to the baby

Question 8

Which age before should resuscitation not be performed?

Answer 8

• Less than 23 weeks
• Less than 24 weeks

Question 9

When should resuscitation be performed?

Answer 9

• After 25 weeks
• After 24 weeks - unless the baby is thought to be severely compromised

Question 10

What are some of the complications of Prematurity?

Answer 10

• Respiratory (Respiratory Distress Syndrome - Surfactant)
• Cardiovascular (Hypotension - Inotrope infusions, fluid management, ibuprofen)
• Neurological (Intraventricular Haemorrhage - regular surveillance needs to be done with CrUSS)
• Gastrointestinal (Immature gut causing NEC - TPN and Abx)
• Renal/ Electrolyte (immature renal function)
• Metabolic (jaundice - phototherapy)
• Infection/ Immune (sepsis, increased infection due to central lines - IV abx therapy)
• Skin (immature skin barrier leading to increased insensible losses)
• Thermoregulation (immature thermoregulation)
• Eyes (retinopathy of prematurity)

Question 11

What are the Neurodevelopmental Outcomes for Prematurity?

Answer 11

• Earlier a baby is born the higher likelihood that they will have some neurodevelopmental delay
• Including gross motor delay, fine motor impairment, speech and language delay and learning/ behavioural difficulties

Question 12

What Family Support should there be for Prematurity?

Answer 12

• Early-stage parents should be involved in the care of their infant including Kangaroo Care/ Skin to Skin Care

Question 13

What Management can you offer to Women to delay birth?

Answer 13

• Prophylactic Vaginal Progesterone (Progesterone suppository in the vagina to discourage labour)
• Prophylactic Cervical Cerclage (suture in the cervix to hold it close)

Question 14

What Management can you offer to Women is Preterm labour is suspected ?

Answer 14

• Tocolysis with Nifedipine (CCB that supresses labour)
• Maternal Corticosteroids (before 35 weeks gestation to reduce neonatal morbidity and mortality)
• IV Magnesium Sulphate (before 34 weeks gestation to help protect the baby’s brain)
• Delayed Cord Clamping and Cord Milking (increase circulating blood volume and haemoglobin in the baby)

Question 15

What Management can you offer to Women is Preterm labour is suspected?

Answer 15

• Tocolysis with Nifedipine (CCB that supresses labour)
• Maternal Corticosteroids (before 35 weeks gestation to reduce neonatal morbidity and mortality)
• IV Magnesium Sulphate (before 34 weeks gestation to help protect the baby’s brain)
• Delayed Cord Clamping and Cord Milking (increase circulating blood volume and haemoglobin in the baby)