PREMATURITY

Case presentation 1

 Baby of madam M, delivered via SVD at 35week and 6 days of POA, was admitted into NICU due to difficulty in breathing which developed immediately after he was delivered.

 Madam M 31 years old nurse, married Gravida 2 Para 1 POA: 35 weeks and 6days LMNP: 26/2/10 EDD: 3/12/10 Was admitted through OGAC Due to preterm labour?

 Planned and wanted pregnancy Noted pregnant at 6/52 POA 8/52 POA: UPT done in panel clinic, antenatal booking, first U/S done, blood tests done Blood group: B positive VDRL/TPHA/HIV: negative Hep B: negative She was told that the baby growth was corresponding to the date

 Complicated antenatal: GDM on d/c MGTT @ 20wk: 8.0/ 9.0mmol/L Gestational hypertension diagnosed at 33weeks POA Admitted 2 times for BP stabilization on labetalol 40mg tds H/O PE at 2002- SVD at 34/52 (1st pregnancy) H/O subfertility for 3 years

 At 35/52+ 6/7 of POA: Contraction pain : increased frequency and duration No signs and symptoms of PE : blurring of vision, headache, nausea, vomit, epigastric discomfort or seizure BP : 190/110mmHg PR: 68mmHg P/E abdomen: singleton, longitudinal lining with cephalic presentation, head not engaged (5/5), fetal heart rate detected by daptone, smaller than date (32/52) ? Proteinuria 1+ CTG: appropriate for its gestation age u/s: growth up to date? Diagnosis: severe PE and was admitted to HDU

 Past medical history: No hypertension, DM, hepB carrier, heart disease No known allergy to any drug or food. Past obstetric history: 2002 SVD with severe PE at 34/52, baby boy, 1.8kg, well currently Family history: mother DM. No family history of hypertension. Social: married for 9 years, worked as a nurse in ppukm, husband worked as technician. No smoking, no consume alcohol.

 In HDU:

 Labour: Spontaneous onset ARM No maternal pyrexia Amniotic fluid: normal, non-foul smelling Medication: antihpt, steroids, tocolytic, pethidine, epidural, others?? First stage: Duration: Vertex presentation No fetal distress CTG(external): normal No meconium stained liquor Second stage: Duration: SVD, uncomplicated Normal placental, weight 580g

 Babys particular: baby boy 1650hours (25/12/10) Birth weight : 2.82kg, borderline premature at 35/52+ 6/7 APGAR : 8/9 Clear liquor at delivery, no instrument used for delivery.

 reason for referral: grunting at 1.5 hour of life mother gestational hypertension on 33/52 on T.labetalol 40mg tds admitted 2x for BP stabilization. BP 190/110 at PAC Gdm on diet control Subfertility 3 years- spontaneous conception h/o severe PE 8 years ago Baby - 35W+6D informed by S/N patient grunting at 1hr 20min of life.

Progress and management of baby

- Attended stat, patient was put under head box 8L/min. however persistently grunting - SpO2 88%-92% , temp: 36.8C - Silverman score: 2-3/10 - Patient was then put under nasal CPAP PEEP 5cmH20, FiO2 40% - Saturation maintained >95% - Dxt: 2.8mmol/L. not jittery. Given bolus 6cc D10%, then started on IVD maintainence 7cc/hr D10% (TF 60cc/kg/day) - CBG- mild respiratory acidosis

 re-examined: active, pink, good cry Vital signs: Silverman score: 1-2/10 on nasal CPAP PE: no abnormality detected.( facies, scalp, suture, fontanelle, ears, eyes, neck, nose, mouth, respiratory system, cvs system, abdominal, umbilicus, anus, spine, arms, hands, legs, hips, genitalia, tone, reflexes including grasp, moro and sucking)

 Problem: Borderline premature at 35w+6d 1) respiratory distress secondary to hypoglycemia 2) Respiratory distress syndrome secondary to infant of diabetic mother

Differential: congenital pneumonia

25/12, 8.35pm Review patient at 45 min on NCPAP Noted persistently grunting with mild SCR Spo2 fluctuating 85%-95% under FiO2 70% NCPAP PEEP 5cmH2O Post bolus 30min: dxt 12.9mmol/L Proceeded with intubation Suctioning noted yellowish secretion from oral and ETT Post-intubation: Spo2 95%-97% under FiO2 70% Mild SCP ? CRT <2s, pulse vol good, HR 140/min Temp: 36.7C Lung: equal breath sound, clear Diagnosis: congenital pneumonia Plan: admit NICU for ventilation Keep NBM (TF 60cc/kg/day, D10%: 7cc/hr) IV C.Penicillin 50000U/ kg, IV gentamicin 5mg/kg Dxt hourly till stable Investigation: bld culture and sensitivity, CXR, gastric aspirate(gram stain, culture and sensitivity), CBG

Further management and progression in NICU

General management: Keep baby warm in incubator Close vital signs monitoring oxygen saturation (keep more than 95%) dextrostix for glucose (> 3.3mmol/L) Fluid management Daily weight Intake and output charting

 26/12 10am: Start feeding 5cc/3hrly (TF 60cc/kg/day) 11.55am: Upon trying to cut down FiO2 to 30%, he desaturated to 80%, thus, FiO2 was increased to 50% and saturation regained to 95% 2.30am:Noted jaundice up to chest, but active and pink. CRT <2sec. There was minimal SCR and ICR, S/S 2/10. crepitations heard over the right lung, but breath sounds equal bilaterally. Surfactant was given.

 Able to reduce FiO2 to 36%. Feeding introduced 5cc 3hrly IVD 1/2NSD10% at 8.9cc/hr (TF 90cc/kg/day) post surfactant x-ray showed improving RDS

- Serum bilirubin -167, direct- 8 - BUSE: Na 136/ K 2.9/ Urea 1.7/ creat 54 - Intensive phototherapy level for 35 weeks (sick babies) is 135 -thus, he was put under intensive phototherapy and add 1g KCl/ pint of fluid

Case Presentation 2

 Baby boy of Madam S, 33 years old para2, delivered via emergency lower segment cesarean section (EMLSCS) at 33 weeks 5days of POA due to severe preeclampsia admitted to NICU whereby he was noted to have respiratory distress at 5 minutes of life.

Antenatal history of Madam S

33 years old, Malay government servant Gravida 2 para1 LMP:4/5/2010 EDD: 11/2/2011 POA:33weeks+5days History of previous scar, GDM on diet control, and preeclampsia Presented to OGAC at 33weeks +4 days with headache associated with high BP

 Planned and wanted pregnancy Antenatal booking @ 13 weeks of POA -dating scan done, confirmed the pregnancy -BG:O positive , VDRL,hep B, HIV: not reactive -BP:120/80mmHg with normal urinalysis (no proteinuria, no glycosuria) MGTT done @ 20 weeks due to obesity (BMI: 26) -preprandial :4.6mmol/L, 2 hours postprandial: 9.8 diagnosed with GDM BSP done @24 weeks -4.1/5.0/6.0/5.9, GDM on diet control

 Antenatal ultrasound scan:

14 weeks 21 weeks 26 weeks 29weeks Parameters correspond to date (13-14 weeks) Detailed scan for GDM, parameters correspond to date, no structural anomaly detected Breech presentation, parameters correspond to date(26-27weeks), EFW:948g, liquor adequate Cephalic presentation, parameters correspond to date (29-31weeks), EFW: 1.5kg, liquor adequate

 BP @ 32 weeks: 140/90mmHg Since then EOD BP: 120-140/80-90 Asymptomatic until presented to OGAC with headache @ 33 weeks +4days of POA, protenuria IV magnesium sulphate and IV labetolol given IM dexamethasone given once 5 hours prior to delivery

 Past obstetrics and gynecological history: Baby boy was born at full term via EMLSCS due to poor progress at 2008 in UKMMC with the birth weight of 2.75kg. No history of hypertension or diabetes during previous pregnancy Achieve menarche at 14yrs old Menstrual cycle:30 days, regular, no dysmenorrhea or menorrhagia Not taking oral contraceptive pill

No family history of hypertension in pregnancy or pre-eclampsia. Her mother is hypertensive, however no diabetes mellitus No significant past medical No known allergy to any drug or food Social history: married for 3 years Worked as government servant (secretary) Husband worked as plan drawer No smoking, not consume alcohol

Code pink standby at OT for prematurity

She delivered a baby boy at 1904hours, 29/12/2010. Premature at 33/52 + 5/7 Birth weight was 1.69kg (low birth weight) Apgar score:9 in 1min, 10 in 5min Clear liquor noted, placenta:350gm, EBL:200cc, pH:7.295 He was cleaned and wrapped and transferred immediately to radiant warmer

He cried at birth, APGAR: 9/10 Active, pink, not cyanosed, not pale, HR: 134/min, SpO2: 95%, Temperature: 36.4 He was noted to have nasal flaring, subcostal recession, intercostal recession, Silverman score: 3/10 at 5minutes of life Neopuff CPAP, FiO2: 21% Peep 5unit H2O started Silverman score: 0-1/10

Newborn Screening
Anthropometry General appearance Head Neck Face Birth weight was 1.69kg (low birth weight),head circumference: 29cm, length: 42cm between 10th and 50th percentile Pink, not jaundice, active on handling, comfortable, good muscle tone No microcephaly (head circumference between 10th and 50th percentile. Anterior fontanelle normotensive NAD No facial dysmorphism. Eyes: normal red reflex. Ears: normal auricles and auricular canal. Nose: nasal septum intact. Mouth: no cleft lip and palate. No natal teeth, no central cyanosis First and second heart sound heard with no murmur. Femoral pulses palpable. No chest wall deformity. Breath sounds equal bilaterally. No rhonchi and no crepitation heard. Abdomen soft, not distended. Umbilical stump:2arteries, 1 vein, anus: patent Male. Testis:descended NAD (no tuft of hair, no sacral pit Moros reflex not done. Sucking:poor No peripheral cyanosis. Hands and feet: no dysmorphism. Hips: stable,

Cardiovascular system Respiratory system Gastrointestinal system Genitalia Spine Immature reflexes Limbs

Problem list
1. 2. Prematurity at 33weeks +5days (dated scan at 13 weeks of POA) Respiratory distress secondary to mild respiratory distress syndrome/ transient tachypnea of newborn (IM Dexamethasone given once 5hours prior to delivery) Infant of maternal GDM and severe preeclampsia (IV magnesium sulphate and labetolol given) Poor sucking secondary to prematurity

3. 4.

Investigations
FBC: look for leukocytosis and its differential CRP Procalcitonin Placenta: swab and culture and sensitivity, HPE Gastric culture and sensitivity Blood culture and sensitivity

General management
Keep the baby in incubator. Closed vital signs monitoring. Oxygen saturation monitoring Dextrostix for glucose monitoring Intravenous fluid infusion Ryles tube feeding(poor sucking) Daily Weight I/O chart

In the OT
Admit to labour room for CPAP FiO2:21% Peep 5 units H2O, keep SpO2: 88-93%, MAP >33 Keep in view antibiotics if septic Ryles tube insertion and decompress 4 hourly (free flow) Keep in view Ryles tube feeding when more settle Intravenous drip (60mls/kg/day) Dextrostix monitoring

Day 1 (29/12/10)
He is comfortable on NCPAP 21% Silverman scoring: 0-1/10 DXT: 4.1mmol/L Investigation: CBG Plan: Start Rtles tube feeding 3cc 3 hourly, intravenous fluid (dextrose 10% 3.3ml/hour), total feeding: 60mg/kg/hour Trace results, KIV antibiotics if septic DXT 4hourly, keep DXT:>3.3mmol/L Try to off CPAP and put nasal prong If able to maintain SpO2 and stable, can transfer to NICU semi-intensive Observe BP

Day 2 (30/12/10) morning round

Comfortable on NCPAP When try to off, become more distressed, Silverman score:2/10 when try to off Clinically active, pink, weight:1.69kg Observed apnoic episodes while on NCPAP Tolerating 3cc 3hourly feeding BO once-meconium, urine output: 1.34cc/kg/hour HR:120/min, SpO2:98% on NCPAP, CRT: <2 s, good pulse volume Imp: apnea most likely secondary to maternal sedation (IV magnesium sulphate) IX results: Hb:18.1, HCT: 53.4, WCC: 6.2, platlet: 134, CRP: 0.03, PCT: 0.31, TSH:3.76, G6PD: normal Plan:
Keep NCPAP Observe BP and temperature Start IV C Penicilin and IV gentamicin Start oral caffeine, Apnea and bradycardia charting

Day 2 evening round

Pink, active on handling Silverman score:0/10 on air, HR: 135/min, SpO2: 98% on air No apnea and no bradycardia seen Tolerating feeds 5cc 3hourly via RT P22 Pass urine and BO I/O over 9hours:16/60(-44) Urine output: 3.94cc/kg/hour Plan: Increase feeding to 10cc 3 hourly, IVD 1/5 NS Dextrose 10% 3cc/hour If tolerate twice, increase feeding to 20cc3 hourly and off IVD

Day 3 (31/12/10)
Pink and active on handling, weight:1.6kg (reduce) BP:69/32, HR: 130/min, T: 36.8, SpO2: 99% under room air I/O: 148.1/112(BO thrice) balance: (+36.1) Urine output: 2.9cc/kg/hour Plan: Off IVD Increase feeding 25cc 3hourly (total feeding 120cc/kg/day) Trace all cultures KIV off antibiotic if culture negative (after completing 48hours) Monitor DXT per shift for 1 day, if stable off

PREMATURITY

Premature infant: <37 weeks of gestations Low birth weight(LBW): <2500g Very low birth weight(VLBW): <1500g Extremely low birth weight(ELBW): <1000g Small for gestational age: <10th centile of birth weight for age Large for gestational age; >90th centile
Paediatric protocol for Malaysia Hospital, 2nd edit. 2008

 Early Ballard Score allows for the estimation of age in the range of 26 weeks-44 weeks. The New Ballard Score introduced in 1991 is an extension to include extremely pre-term babies i.e. up to 20-44 weeks Each criteria are scored from -1 through 5 Neuromuscular and physical maturity

Neuromuscular maturity Posture Square window Arm recoil Popliteal angle Scarft sign Heel to ear

Physical maturity Skin Lanugo Plantar surface Breast eye/ear Genital-male Genital-female

Assessment
Neuromuscular Maturity
1. Posture: infant is placed supine and the waits until the infant settles into a relaxed or preferred posture 2. Square window: examiner straightens the infant's fingers and applies gentle pressure on the dorsum of the hand, close to the fingers 3. Arm recoil: take infant's hand and then briefly sets the elbow in flexion, then momentarily extends the arm before releasing the hand. The angle of recoil to which the forearm springs back into flexion is noted

4. Popliteal Angle: thigh is placed gently on the infant's abdomen with the knee fully flexed and wait for legs to relaxed 5. Scarf sign: The point on the chest to which the elbow moves easily prior to significant resistance is noted 6. Heel to ear: flexed lower extremity is brought to rest on the mattress alongside the infant's trunk.

Assessment (cont)
Physical Maturity 1. Skin: general inspection 2. Lanugo: inspect the upper and lower areas of the infant's back. 3. Plantar surface: measure distance from tip of great toe to back of heel and observe for creases

4.Breast: note the size of the areola and the presence or absence of stippling and then palpate the breast tissue 5.Eye/Ear: examine eye lids for fusion and examine pinna of ear for recoil 6.Genitals: Male document the normal side if cryptorchidism suspected Female abduct hip 45 degree and then assess clitoris, labia majora and labia minora

Neuromuscular Maturity

Neuromuscular maturity: 1. Posture

2. Square window

3. Arm recoil

4. Popliteal angle

5. Scarf sign

6. Heel to ear

Physical Maturity

Physical maturity: 1. skin

2. lanugo

3. Plantar surface

4. breast

5. Eye/ear

6. Genital-male Genital-

6. Genital-female Genital-

Possible scores then range from -10 to 50 Possible week range from 20 to 44

Dubowitz Score

Consist of 10 neurological assessment 11 physical assessment

Differences between Dubowitz and Ballard

Dubowitz


Modified Ballard


More time-consuming ( Sunjoh F et al, 2004) Cause more stress to the infant

More easier and faster to score

cause less stress to the already stressed preterm infants

 

More component:  neurological signs = 10  external signs = 11



Less component:  neurological signs = 6  external signs = 6

Scores of individual items vary from 0 to max 4 -Minimum score = 0 -Maximum score = 72
Estimated

Scores of individual items vary from -1 to max 5 -Minimum score = -10 -Maximum score = 50


gestational age: = (0.2642 X (total score)) + 24.595 Not specified recommended in research studies

gestational age: total score corresponds to its respective gestational age, eg -10 score = 20 weeks
Estimated

Can determine gestational age from 20 to 44 weeks

 

suitable in routine clinical practice

Dubowitz


Modified Ballard Research showed: 1.New Ballard score is more accurate and easier to administer than the Dubowitz (Sunjoh F et al. 2004) 2.The NBS is a valid and accurate gestational assessment tool for extremely premature infants (Ballard JL et al. 1991) 3.Require less clinical skill and accurate in low-resource setting (Feresu SA, 2003)


Research showed: 1.Dubowitz score is more valid and reliable than the Ballard, although among small-for-gestational-age infants, the Dubowitz score has been shown to overestimate gestational age (Sunjoh F et al. 2004) 2.Dubowitz scoring system significantly overestimated gestational age compared with the standard gestational age in preterm infants, especially those less than 34 weeks (Shukla H et al. 1987, Robillard PY et al. 1992) 3.Despite moderate agreement between Dubowitz score and BPD in the assessment of gestational age, agreement in the classification of lowbirth-weight infants as SGA and as premature births was good. (Vik T et al. 1997)

Other methods
Last Menstrual Period Eregie Score Method Farr Score Method Parkin Score Method Cappuro Score Method Finnstrom Score Method Ultrasound

RESPIRATORY DISTRESS SYNDROME

Risk factors: -preterm - Maternal diabetes - Perinatal asphyxia - Elective caesaerian section Clinical features : (present shortly after birth) - Tachypnoea - Chest wall recession (sternal,subcostal,intercostal) - nasal flaring - grunting 1.Tom Lissauer, Graham Clayden. Illustrated textbook of - cyanosis Paediatrics 3rd edition.
2.Ricardo J Rodriguez. Management of respiratory distress syndrome. Respiratory care. March 2003. Vol 48.

RADIOLOGICAL FEATURES
res:

-Bilateral homogenous ground-glass appearance of lungs field - air-bronchogram -indistinct heart border (in severe case) - loss of vessel outline

Management for RDS

Antenatal steroids for prevention

Given to patients who are at risk of premature delivery at 24 to 34 weeks of gestation.  Risk of preterm labour  Preterm premature rupture of membrane  Antepartum hemorrhage  Any condition requiring elective preterm delivery

Steroid and Dosage

IM Dexamethasone 12mg BD 12 hours apart. OR IM Betamethasone 12mg 24 hours apart.

Yun Hsuen Lim.2006.Handbook of Labour Room Practice,Department of O&G UKM

Advantage of betamethasone
Less risk of periventricular leukomalacia Better fetal lung affinity Better alveolar resorption

Surfactant replacement
Expensive Indication : In premature infant <32 weeks or birth weight <1.5kg More mature infant/larger if RDS is severe. 2 main classes of surfactant : Natural Synthetic Type of surfactant and dosage : Survanta (natural) Dose : 4ml/kg per dose.1st dose given in first 2 hours after birth. Repeat 6 hours later if needed.
Paediatric Protocols for Malaysian Hospital,2nd Edition

 Administration : Via endotracheal tube 2 therapeutic approaches : -Prophylactic (given within minutes after birth) -Rescue (established RDS requiring supplemental oxygen and mechanical ventilation) Advantage of prophylactic approach: Reduce incidence of BPD Reduce the need for mechanical ventilation or subsequent supplemental oxygen
Management of Respiratory Distress Syndrome : An Update Ricardo J Rodriguez MD, Respiratory Care Journal,March 2003 Vol 48 No 3

 Rescue approach : Advantage : Reduce cost and morbidity a/w unnecessary surfactant therapy. Disadvantage : Delay of replacement may decrease its efficacy and allow progression of lung injury

Management of Respiratory Distress Syndrome : An Update Ricardo J Rodriguez MD, Respiratory Care Journal,March 2003 Vol 48 No 3

Ventilatory Support
Goal : To maintain adequate oxygenation and ventilation,while minimizing ventilator-induced lung injury.

1.Continuous Positive Airway Pressure (CPAP) -positive pressure applied to the airways of a spontaneously breathing baby throughout the respiratory cycle -re-expands collapsed alveoli,splints airway,reduce work of breathing and improves the pattern and regularity of respiration.

Immediate respiratory management of the preterm infant Sunil K. Sinha, Samir Gupta, Steven M. Donn, Seminars in Fetal & Neonatal Medicine (2008) 13, 24-29

Mechanical Ventilator
Controlled Mode Ventilator (CMV)/Intermittent Positive Airway Pressure (IPPV) Patient is intubated. Used in severe RDS with lung disease to correct respiratory acidosis and hypoxemia. Disadvantage : 1.Pulmonary barotrauma esp pneumothorax. 2.Infection pulmonary 3.Complications due to prolonged intubationairway edema,tracheal stenosis,laryngeal ulcer.
Mechanical ventilation of lungs, MedchromeOnline Medical and Health Magazine

 Other types : Synchronized Intermittent Mandatory Ventilation (SIMV) Positive End Expiratory Pressure (PEEP) Inverse Ratio Ventilation (IRV) Biphasic Positive Airway Pressure (BiPAP)

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