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Perinatology Division

Department of Child Health Medical School


Sumatera Utara University

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Preterm Neonate
 Whose birth occurs through the end of the
last day of the 37 week following onset of
the last menstrual period.

Incidence
• 12% of all US births
• 2% are less than 32 weeks gestation
• Demographic play in major role in the
incidence 2
Can be categorized by birth weight:
 LBW (low birth weight) = infant < 2500 g
at birth
 VLBW (very low birth weight) = infant <
1500 g at birth
 ELBW (extremely low birth weight) =
infant < 1000 g at birth
 ‘Micropremie’ if infant < 750 g at birth

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Etiology
1. Low socioeconomic status (SES)
 Family income

 Educational level

 Residency

 Sosial class

 Occupation

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Etiology
2. Women < 16 or >36

3. Maternal activity
 Long periods of standing

 Physical stress

4. Acute or chronic maternal illness

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Etiology
6. Multiple gestation birth
7. Prior poor births outcome
8. Obstetric factors
 Uterine malformation

 Uterine trauma

 Placenta previa

 Abruptio placenta

 Hypertensive disorder

 etc
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Etiology
9. Fetal condition
 Nonreassuring testing

 IUGR

 Severe hydrops

10. Inadvertent early delivery because of


incorrect estimation of gestational age

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Problems of prematurity
1. Respiratory
 Prenatal depression due to poor
adaptation to air breathing
 Respiratory distress syndrome
 Apnea due to immaturity in mechanisms
controlling breathing
 Chronic lung disease: bronchopulmonary
dysplasia, and chronic pulmonary
insufficiency of prematurity
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Problems of prematurity
2. Neurologic
 Perinatal depression

 Intracranial hemorrhage

3. Cardiovascular
 Hypotension due to: hypovolemia, cardiac
dysfunction, vasodilatation due to sepsis
 Patent ductus arteriosus (PDA)

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Problems of prematurity

4. Hematologic
 Anemia

 Hyperbilirubinemia

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Problems of prematurity
5. Nutritional
6. Gastrointestinal,
single greatest risk
factor for
necrotizing
enterocolitis, reflux

19 % of preterm babies on
treatment for reflux

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Necrotizing enterocolitis Clinical
Findings
 Non-specific: feeding intolerance,
abdominal distension, occult blood
(stool)

 GI: abdominal distension +


tenderness; abdominal wall edema,
↓/- bowel sound, bloody stool,
greenish NG aspirate

 General: thermal instability, apnea,


persistent acidosis, ↓ platelets,
↓Hct, ↓neutrophils, ↓BP, ↓urine
output, shock
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Problems of prematurity
7. Metabolic problems: glucose and calcium
metabolism
8. Renal: immature kidney low GFR 
inability to handle water, solute, and acids
loads; fluid and electrolyte management
9. Temperature regulation
10.Immunologic: deficiency of both humoral and
cellular response
11.Ophthalmologic: rotinopaty of prematurity in
infant <32 weeks or < 1500 g birth weight
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Management of the
premature infant
1. Immediate postnatal
management
 Delivery in an
appropriate equipped
and staffed hospital
 Resuscitation and
stabilization

2. Neonatal management
 Thermal regulation
 Oxygen therapy and
assisted ventilation

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Management of the
premature infant

 PDA with birth weight


>1000 g usually requires
only conservative
management:
- adequate oxygenation
- fluid restriction
- possibly intermittent
diuresis

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Management of the
premature infant
 Fluid and electrolite therapy
 must account for potentially high IWL
 Nutrition
 mother’s milk is the optimal primary
source of enteral nutrition
 Hyperbilirubinemia
- photothetapy
- exchange transfusion

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Composition of human milk

Colostrum Preterm Mature Milk


Calories Kcal / dl 67 67 68
Protein g/dl 3.1 1.4 1.05
Lactose g/dl 4.1 6.6 7.2
Fat g/dl 2 -2.5 3.5- 4 3.5 - 4.5

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Management of the
premature infant
 Infection
 broad-spectrum antibiotics should be
begun when suspicion is strong

 Immunization: HBV, DPT, polio, multivalent


pneumococcal, and HIB are given full
doses based on their chronologic age (i.e.
weeks after birth), not postconceptional
age

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Management of the
premature infant
 If the infant hospitalized at the
appropriate chronologic age (usually at 2,
4, and 6 months)
- acellular DPT
- multivalent pneumocaccal are given
- HIB
- Pertussis is contraindicated in infant with
possible or documented evolving
neurologic disorders
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Management of the
premature infant
 Oral polio vaccine should not be given
Administer inactivated polio vaccine (IPV)
 Mothers with HBsAg (+)

- resieve Hepatitis B immunoglobulin


within 12 hours of birth (always within
the 1st month of life)

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Management of the
premature infant
Mothers with HBsAg (-)
- optimal timing for HBV with birth weight
< 2 kg is not clear
- 1st vaccination for birth weight < 2 kg
should be delayed until just before
hospital discharge if weight 2 kg or
more, or until approximately 2 months

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Management of the
premature infant
- between 32 and 35 week with: plans for
day care during RSV season, smoker in
the houshold, other young children in
the household
- chronic lung disease
 Immunization should be given at least 48
hours to discharge so that any febrile
response will occur in the hospital
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Long-term problems
of prematurity
 Developmental disability
- Major handicaps (cerebral palsy, mental
retardation)
- Sensory impairments (hearing loss,
visual impairment
- Minimal cerebral dysfunction (language
disorder, learning disability, hyperactivity)

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Long-term problems
of prematurity
 Retinopaty of prematurity
 Chronic lung disease
 Poor growth
 Increased rates of postneonatal illness and
rehospitalization
 Increased frequency of congenital
anomalies

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Retinopathy of Prematurity

Confined to immature
retinal vascular system

Develops at border
between vascular and
avascular retina.

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