Overview
Birth before 37 completed weeks gestation.
Classification of prematurity
- 32-37 weeks – late preterm
- 28-32 weeks – very preterm
- <28 weeks – extremely preterm
Predisposing Factors
- Idiopathic
- Maternal factors
- PET
- Chorioamnionitis
- GDM
- Previous preterm babies
- Poor socioeconomic status
- Fetal factors
- Congenital infections
- Multiple pregnancy
- Obstetric factors
- PROM
- Uterine and cervical malformations
- Placental pathology
- Polyhydramnios
Clinical Presentation
Gestational age is best approximated using the New Ballard Score.
- Birth weight <2.5kg
- Birth length < 47cm
- Head circumference <33cm
- Chest circumference <30cm
- Skin
- Thin, pink, very little subcutaneous fat
- Lanugo hair
- Nails don’t reach fingertips
- Ear – soft and shapeless due to little cartilage
- Breast nodule – little to no breast tissue with areola barely visible
- Genitalia
- Female – prominent labia minora and clitoris
- Male – smooth scrotum with undescended testes
- Soles
- Only anterior crease is present
- Creases don’t reach two thirds of sole
- Activity
- Weak cry
- Weak movement
- Hypotonia
- Sucking and swallowing is uncoordinated
Complications
- Respiratory
- RDS
- Apnoea of prematurity
- Congenital pneumonia
- Bronchopulmonary dysplasia
- Cardiovascular
- Patent ductus arteriosus
- Hypotension due to hypovolemia and cardiac dysfunction
- Bradycardia due to apnoea
- CNS
- Kernicterus due to immature blood brain barrier
- Intraventricular haemorhage
- Hypoxic-ischemic encephalopathy
- GIT
- Necrotising enterocolitis
- Hematology
- Iron and folic acid deficiency anemia
- More prone to bleeding due to deficient clotting factors
- Immunological
- Increased risk of infection due to immature immune system
- Nutritional
- Rickets
- Hypoglycemia due to insufficient glycogen stores
- Poor weight gain due to weak sucking and swallowing; poor digestion and absorption
- Hypothermia
- Large surface area to body weight ratio causing excessive heat loss
- Reduced subcutaneous fat stores
- Immature heat regulation centre
- Ophthalmology
- Retinopathy of prematurity
- Other
- Jaundice
Management
Antenatal care
- Avoid maternal smoking, irradiation & drugs
- Assessment ofthe foetus by ultrasound
- IM Steroids if <34 weeks
- In special situation amniocentesis or foetal blood sampling may be indicated.
Immediate post-natal care
- Place the baby under radiant warmer
- Drying of the baby & suction of secretions
- Apgar scoring & resuscitation if needed
- Complete examination newborn **
- Care of the skin and aseptic cutting of the umbilical cord
- Vitamin K (1 mg IM) is given for all neonates.
If the baby is large premature (> 2 kg) with no critical illness ~ discharge
If the baby is< 2 kg weight or has a critical illness~ incubator care
Incubator care
- Temperature – Is adjusted to keep body temperature 36.5-37.2 °C
- Humidity – Kept around 40-60%
- Oxygen therapy – Given in lowest concentration for the shortest period with gradual withdrawal
- Prevention of infection
- All medical personnel must wash their hands before and after examining the baby
- No person with infection should be admitted into the nursery
- Antibiotic administration if indicated
- Adequate feeds and fluids (follow protocol)
- Treatment of associations e.g. Phototherapy for hyperbilirubinaemia
Discharge criteria
Discharge from incubator if:
- Infant> 1750 grams with good suckling
- Can maintain temperature outside the incubator
- No critical illness
- Normal respiration
Instructions to the parents
- Maintain body temperature
- Keep infant away from infection by minimising handling and over crowding
- Schedule for feeding
- Schedule for vaccination
- Encourage follow up visits
- Ophthalmic examination for those exposed to prolonged oxygen therapy
