Dr.

Muhammad Farid Azraai

PREMATURITY & EARLY

Case study

Background

B/O MBL (TWIN 1)

Date of birth 28/03/2016 @ 6.47 pm
Birth weight :1.69kg
Born via EMLSCS @ 34week + 2days for DCDA
(Dichorionic diamniotic) twin with leading
twin in transverse lie in labour (Ballard score
34-36 weeks)
APGAR score 9/10/10
G6PD : normal

Maternal history
39 years old, Para 9 (1 set of twin)
Antenatally :
1.DCDA (Dichorionic diamniotic) twin
2.

GDM on T. Metformin 500mg BD

3.Bronchial Asthma on seretide II/II Bd and MDI

Salbutamol II/II PRN
Infective screening : non reactive
Blood group : O +ve

DCDA twin
Dating scan done at 16 weeks and was referred to
GOPD team for twin pregnancy
Through out pregnancy paramenters corresponds to
age
Counselled for LSCS + BTL at term

History of Presenting Illness

Mother, P9 ( 1 set of twin) at gestation 34 weeks
2 days, was referred to paeds standby for DCDA
twin with leading twin in transverse lie in
labour
Mother came in with contraction pain since 10
pm on 27/3/16 with no risk of sepsis.
Mother given x1 IM Dexamethasone at
10.25pm on 27/3/16

 Proceeded to EMLSCS
Intra-Op : Liquor Clear
Baby out vigorous (at 6.47pm), good breathing effort, good
tone, good cry
Initial steps done, HR> 100bpm, pink, and wrapped
APGAR 9/10/10

Birth Weight :1.69kg

At 5 minutes of life, noted child had nasal flaring, with

subcostal recession. Spo2 on room air 98%
Child was put under Neopuff then subsequently was
admitted to NICU level II for prematurity and RDS

Family Tree
Mother is a housewife
Mother has Bronchial
asthma
No history of prematurity
on previous pregnancy

Father is an office clerk at Jabatan Ukur dan Pemetaan (JUPEM)

No known medical illness
No consanguineous marriage

Immunization history

Vitamin K given post delivery 28.03.16

BCG given upon discharge 30.04.16
Hep B given upon discharge 30.04.16

Growth chart
Length 39 cm (below
5th percentile)
Head circumference :
30 cm (at 3rd to 10th
percentile)
Body weight : 1.69 kg
( 3rd to 10th
percentile)

General Examination
Upon admission
Active upon handling, CRT <2sec,
good pulse volume,
warm peripheries,
pink,
+tachypnic with RR 65 and subcostal recession, nasal flaring but no grunting

Vital signs

Blood Pressure : 85/54

MAP : 51

Heart rate : 128

Respiratory Rate : 65

Temperature : 36.6

Sp02 under BCPAP : 98%

DXT : 5.9

Neonatal Examination
Facies : No syndromic looking
Sutures : No overlapping sutures
Fontanelle : Anterior and posterior fontanelle normotensive
Scalp: No swelling, no caput, no cephalohematoma
Eyes : 2 eyes
Ears : 2 ears
Nose : 1 nose, 2 nostrils
Mouth : No cleft palate/ No cleft lips
Neck : No short neck

Chest & Lungs

: Good and symmetrical chest rise

+Nasal flaring with subcostal
recession
No grunting
On auscultation : Equal and good breath sound, no
crepitation
Respiratory Rate :65
Cardiovascular

: S1S2 heard no murmur

 Abdomen : soft, not distended, no

hepatosplenomegaly
Umbilicus : clean, 2 arteries, 1 vein
Femoral pulse : present, good bilaterally
Genitalia : normal male external
genitalia, testis bilaterally descended
Anus
: Patent
Hip
: Stable Barlow, Ortholani
negative
Limbs : normal, 5 fingers in each limb
Spine
: no tuft of hair, no spina bifida
CNS
: Moros complete

Clinical Summary
Baby boy (twin 1) born premature at 34weeks 2 days
via EMLSCS for leading twin in transverse lie in labour
(spontaneous prematurity) with respiratory distress

Diagnosis
1. Prematurity at 34 weeks 2 days
Ballard Score : 34-36 week
2. Respiratory Distress Syndrome
3. Presumed Sepsis
4. Infant of GDM mother

Diagnosis

Points support

Respiratory Distress
Syndrome

Maternal diabetes, pre

term, no completion of
dexamethason

Transient Tachypnic in
Newborn

caeserean section

Congenital pneumonia

Points against

Early pre term

No maternal fever,no
chorioamnionitis, PROM,
sign or symptoms of
sepsis, no fever,

1. Prematurity
1. Prematurity at 34 weeks 2 days
Ballard Score : 34-36 week
Corrected age 34 weeks 3 days

2. Respiratory Distress Syndrome

Initially child on BCPAP FiO2 21% Peep 5
At 3 hours of life ,child had episode of desaturation until
85-86%,tachypnea with suprasternal and subcostal
recession, RR 62 bpm
Increased to BCPAP Fio2 34% Peep 5, SpO2 only
maintained 88-90% (worsening respiratory distress)
Decided for Survanta at 4 hours of life
Reassessment after 1 hour post survanta, SpO2 maintain
>95% , no more nasal flaring, no chest recession, not
tachypnic
Subsequently, on next morning 29/3/16 child able to wean
off oxygen (12 hours of life)

Chest Xray :
Ground Glass appearance

3) Presumed Sepsis
Presumed sepsis for spontaneous prematurity
Started IV C-Penicillin 50,000 IU/kg BD
IV Gentamicin 3.5/kg OD
Blood C&S 48 H : No growth
Completed IV C-penicillin and IV Gentamycin for total 3
days

4) Prolonged jaundice 2 UTI

On day 2 of life noted baby jaundice down to abdomen
SB 181 PL:170 IP : 220 ET : 250
Started on single phototherapy 31/3/16 -25/4/16 (19 days)

On D21 of life, child still jaundice and prolonged

jaundice w/up was done - LFT & TFT : normal
1st Urine C&S (18/4/16) : Growth of Klebsiella sp.
Sensitive to Ciprofloxacin, Nitrofurantoin,
Trimethroprim/Sulfamethoxazole

Started on Oral Nitrofurantoin 3 mg QID

for 1 week.
2nd Urine c&s was repeated on Day 5 of antibiotic:
Growth of Klebsiella sp.
Sensitive to Ciprofloxacin,
Nitrofurantoin, Trimethroprim/Sulfamethoxazole

 Suprapubic aspiration done under USG guided on

30/4/16
UFEME sent : All negative
Patient was discharged with TCA clinic 1 week to review
urine c+s
To complete PO Nitrofurantoin 3 mg QID for total two
weeks.

Bilirubin
level

PL

ET

Day 3

181

240

340

Day 4

204

240

340

Day 5

256

240

340

Day 6

209

240

340

Day 8

186

240

340

Day 10

230

240

340

Day 11

190

240

340

Day 14

215

240

340

Day 21

211

240

340

Day 28

148

240

340

Action

Single
Phototherapy
Not on phototherapy
On single Phototherapy

Not on phototherapy

5 ) IVH grade 1 bilaterally

Day & Date

USG results

Day 1 (29/3/16)

Bilateral grade 1 IVH

Day 7 (4/4/16)

Bilateral no IVH

Day 14 (11/4/16)

Bilateral grade 1 IVH

Day 21 (18/11/16)

Bilateral grade 1 IVH

Day 28 (25/4/16)

Bilateral grade 1 IVH

Case Discussion

Definition
Preterm is defined as babies born alive before 37 weeks of
pregnancy .
Subcategories based on gestational age:
Extremely preterm ( < 28 weeks)
Very preterm (28 to <32 weeks)
moderate to late preterm (32 to < 37 weeks).
The categories for birth weight are:
Low birth weight (< 2500 g)
Very low birth weight (< 1500 g)
Extremely low birth weight (< 1000 g)

Complication of Preterm

Complication by System

The Lung

Respiratory Distress Syndrome

most common cause of respiratory distress in
premature infants
Vermont Oxford Network definition of RDS
requirement:
An arterial oxygen tension (Pa02) 50mmhg(hypoxia)
and central cyanosis
Characteristic chest radiographic appearance
(uniform reticulogranular pattern to
lung fileds with or without low lung
and air bronchogram)

volumes

Pathophysiology

Clinical Presentation
History
Preterm
h/o perinatal asphyxia

Physical Exam
Sign and symptoms of RDS

Diagnosis
CXR
ABG

 ABG initially shows hypoxemia and later worsening

of hypoxemia, hypercapnia and metabolic acidosis
On X-Ray Chest

Grade 1 (mild cases): symmetrical

reticulogranular pattern due to scattered atelectasis
Grade 2: widespread air bronchogram become
visible
Grade 3: reticulogranular pattern becomes
increasingly confluent leading to formation of
ground glass opacity due to marked underaeration
Grade 4: complete white lung fields with obscuring
of the cardiac shadow due to global atelectasis

Resp. Dis. Syn.

Initial X-ray may be normal

Typical pattern develop at 6-12 hours

Resp. Dis. Syn.

MANAGEMENT
-Antenatal- steroid (glucocorticoid) component of
surfactant
- Post natal
1. surfactant replacement therapy
(survanta)
2. Respiratory support (mechanical
ventilation)

Surfactant
A surface-active lipoprotein complex
(phospholipoprotein) formed by type II alveolar
cells.
Functions :
To increase pulmonary compliance
To prevent atelectasis (collapse of the lung) at the end of
expiration.
To facilitate recruitment of collapsed airways.
In malaysia, there are 2 types of surfactant
Survanta, a natural surfactant, bovine derived
4ml/kg per dose
Curosurf, a natural surfactant, porcine derived
1.25ml/kg per dose

Who to give surfactant to?

1. Depressed preterm infants who have no spontaneous
respiration after 30 seconds of ventilation
2. Preterm infants below 28 weeks gestation who are given
only CPAP from birth in delivery room
3. Preterm infants between 28-32 weeks to have CPAP from
birth in delivery room. To assess requirement for
surfactant in NICU based on oxygen requirement Fio2 >
30% & respiratory distress.
4. More mature or larger infants if RDS is severe.
5. Meconium aspiration syndrome with type II respiratory
failure.

Method of administration
Insert a 5 Fr feeding tube that has been cut to a suitable
length so as not to protrude beyond the tip of the
ETT on insertion, through the ETT.
Continue PPV in between doses and wait for recovery
before the next aliquot, with adjustments to settings if
there is bradycardia or desaturation. Administration over
15 minutes has been shown to have poor surfactant
distribution in the lung fields.
Alternatively the surfactant can be delivered through the
side port on ETT adaptor without disconnecting the
infant from the ventilator. There will be more reflux of
surfactant with this method.

Apnea of Prematurity
Definition :sudden absence of breathing that lasts at
least 20 seconds or is associated with bradycardia or
cyanosis (oxygen desaturation) in an infant < 37
weeks.
Incidence : occurs in >50% infants <1500g and 90%
of infants <1000g.

Causes
The abnormal control of breathing seen in apnea of
prematurity represents neuronal immaturity of the
brain.
Types :
Central : absence of respiratory effort with no gas
flow and no evidance of obstruction
Obstructive : continued ineffective respiratory
effort with no gas flow
Mixed central and obstrucctive : most common
type

 Management (immediate resuscitation)

Surface stimulation
(flick soles, touch baby)
Gentle nasopharyngral suction

Ventilate with bag and mask on previous

FiO2

Intubate, IPPV (intermittent positive

pressure ventilation)if child cyanosed or
apnoea is recurrent/persistent

Prevention
1. To prevent recurrence
Nurse baby in thermo neutral environment
Nursing in prone can improve thoroco abdominal
wall
KMC
2. Monitoring : Vital signs
3. Drug therapy : IV aminophylline/theophylline
PO caffeine citrate

Hematological Problems

Jaundice
Definition : level of bilirubin in the serum rises
above 85mmol/L (5mg/dL)
Mostly 80% premature babies will develop
jaundice in the first week of life while only 60 % in
term.
The main reason due to immature liver
Mechanism:
Increased bilirubin load in hepatocyte as result of
decreased erythrocyte survival
Decreased hepatic uptake of bilirubin from plasma
Defective bilirubin conjugation

Hypothermia

Definition
Newborn infant has immature
thermoregulation
According to WHO
Normal range : 36.5C- 37.5C
Cold stress : 36.0C- 36.5C
Moderate hypothermia :32.0C- 36.0C
Severe hypothermia : <32C

Hypothermia and excessive heat loss

Preterm infants are predisposed to heat loss because :
High ratio of surface area to body weight (5 times
more than adult)
Little insulating subcutaneous fat
Reduced glycogen and brown fat stores
Hypotonic frog like posture limits their ability to curl up
to reduce skin area exposed to the colder environment
Preterm baby lack of keratin, waterproof layer in the
corneum stratum of the skin and therefore will lose both
water and heat more rapidly
58

Brown fat adipose tissue

The more preterm a baby
is, the less brown fat
they will have
Brown fat is localized
around the adrenal
glands, kidneys, nape of
neck, inter scapular
area and axillary region.
Metabolism of brown fat
results in heat
production.
.

Consequences of hypothermia
When the body fails to compensate the
excessive heat loss, following
complications arise:
Clotting disorder
Shock
IVH

Management
Preparing and Maintaining a Warm
Environment
Plastic wrap in the Delivery Room
Delivery Room Temperature/radiant warmer
Caregiving & close monitor during NICU
Stabilization
Pre warmed in incubator or humidifier
KMC

Anemia of prematurity
At birth-> Normal value of infant >34 weeks is
Hb= 14-20g/dl
retic count 3-7%
Remain unchanged until 3rd weeks OL, then decline
to 11g/dL at 8-12 weeks OL (physiological anemia of
infancy)

Premature infant have slightly

lower Hb,
higher retic count and MCV
Decline is more rapid (up to 7-9g/dL)at 4-8 weeks OL

 Causes : repeated phlebotomy, shortened RBC survival,

rapid growth, and the physiologic effects of the transition
from fetal to neonatal life
Signs and Symptoms
-apnea
-poor weight gain
-pallor
-decreased activity
-tachycardia

 Management
PO Ferrous Ammonium citrate 30mg/kg OD(Start at
day 14 of life)
Asymptomatic neonates with Hb levels of 7g/dl or
lower may require transfusion
If transfusion is not provided, close monitoring is
required
Packed cell transfusion 10-20ml/kg is given at rate of
2-3ml/kg/hr

The Heart

1)Patent Ductus Arteriosus (PDA)

Persistent communication between descending aorta
and pulmonary artery (result from failed of normal
physiologic closure of fetal ductus)
In normal newborns, the DA is substantially closed
within 24-72 hours after birth.
completely sealed within 2-3 weeks
Premature babies are at high risk of the ductus
not closing (PDA)- occurs in 30% of VLBW
infants

Pathophysiology
Blood flows from aorta to pulmonary artery

Creating a left to right shunt

Resulting in left atrium & ventricle overload

Risk Factors

Prematurity
RDS and surfactant treatment
Fluid administration
Asphyxia
Congenital syndrome eg congenital rubella
syndrome

Diagnosis
Clinical Presentation

Tachypnea
Tachycardia
Apnea
Heart murmur
Hypotension
Respiratory deterioration
Hepatomegaly
Bounding pulses

Cxr
Echocardiography

Management
Ventilatory support
Fluid Restriction
Indomethacin a prostaglandin synthases
inhibitor that is effective in promoting ductal
closure OR
Ibuprofen-nonselective cyclooxygenase inhibitor
that close the duct.
Surgery

The Abdomen

1) Necrotizing Enterocolitis
An ischemic and inflammatory
necrosis of the bowel,
primarilly affecting premature
neonates after the initiation of
enteral feeding
Occurs in 6-7% of VLBW
infants, 90% occur in preterm
infant
Presents with

feeding intolerance
blood in stools
Bilious vomiting
abdomen distended
other nonspecific signs

Can result in bowel

perforation, septic shock

 MODIFIED BELLS STAGING OF NEC:

Classified into:
I. Suspected:
1. Systemic Signs (apnea, bradycardia, lethargy,
temperature instability)
2. Intestinal Signs ( feeding intolerance, recurrent
gastric residuals, abdominal distention)
3. Radiological Signs (Normal or non spesific)
II. Proven :
1. Systemic Signs (include stage I signs and abdominal
tensderness and thrombocytopenia)
2. Intestinal Signs ( Prominent abdominal distention,
tenderness, bowel wall edema, absent bowel
sound, gross bloody stool)
3. Radiological Signs (Pneumatosis with or without
portal venous gas)

III. Advanced:
1. Systemic Signs (respiratory and metabolic acidosis, respiratory
failure, hypotension, decreased urine output, shock,
neutropenia, DIC
2. Intestinal Signs (Tense, discolored abdomen with spreading
abdominal wall edema, induration, discoloration)
3. Radiological Signs (pneumoperitoneum)

Stage 1 NEC

Diffuse gaseous
distension of
intestine

Stage II NEC

Stage III NEC

Management:
-Nil by mouth to allow gastrointestinal rest 7-14days
-Gastric decompression
-Vital signs and abdominal circumference
-Strict input and output monitoring
-Laboratory monitoring (check Complete blood count,
electrolytes, blood and urine culture prior antibiotic
-metronidazole)
Surgical referal for confirmed stage II or III
Complications:
death (20-30%), stricture formation, short gut
syndrome (9%), frequent/loose stools, impaired growth,
worse neurodevelopmental outcome

The Brain

Intraventricular Hemorrhage (IVH)

Definition : Bleeding in the periventricular germinal matrix
(a layer of neuronal precursor cells)

Treatment:
Supportive
Shunting for hydrocephalus
Screening for IVH: day 1, 3 and 7 of life

IVH and neurodevelopmental

Outcomes
Grades I-II:
Developmental delay: 8%,
Cerebral palsy: 10.5%
Grades III-IV
Developmental delay: 17.5%
Cerebral palsy: 30%

Metabolism

1) Hypoglycemia
Premature baby, esp with low birthweight
have limited glycogen stores and immature
liver function
Sx includes: jitteriness, irritability, apnoea,
cyanosis, hypotonia, poor feeding, convulsion
Mx: prevention and early detection at birth

Identify risk of infant

Breastfeeding
Set up iv drip
Regular glucose monitoring

Hypoglycemia
Blood glucose (BG)< 2.6 mmol/L
BG <1.5mmol/L
Or symptomatic

BG 1.5-< 2.6 mmol/L

and asymptomatic

IV 10% Dextrose 2-3ml/kg

bolus
IV Dextrose 10% drip 6090ml/kg/day
Repeat BG in 30min

Repeat BG in 30min

Give supplement feeding

ASAP
If refuses
to feed, IV
Dextrose 10% drip
60ml/kg/day

If still hypoglycemia:
Reevaluate
Increase volume by 30ml/kg/day

If still hypoglycemia :
Reevaluate
Increase concentration to D 12.5%-D15%
Repeat BG in 30min

If glucose delivery>8-10mg/kg/min and Persistent

Hypoglycemia :
IV Glucagon 40 mcg/kg stat then 10-50mcg/kg/h.
IV Hydrocortisone 2.5-5 mg/kg/dose bd
PO Diazoxide 10-25mg/kg/day in 3 devided doses
SC Octreotide 2-10mcg/kd/day 2-3times/day

The immune system

Infection
Newborn are at risk of infection because their
immune systems are not yet mature, and this
is especially true for premature babies.
This is partly because they have a lower
immune function than term babies.
Some babies acquire an infection during the
birth process.
Usually cover with c-penicillin (for GBS) and
gentamicin (for gram negative bacteria)

Premature Counselling

 General approach to parents

Communicate effectively and empathetically
Eye level, take time to introduce yourself
Avoid abbreviations and percentage ( not all
people can comprehend)
Talk in unhurried manner

Content of counselling

Chances of survival
Possible complications
Long term outcomes
Give them opportunity to tour NICU so
that they can better see their own baby
underneath it all

Bedside manner
Avoid overloading information
Conveyed it in a caring, empathetic
manner
Understands that hope helps people get
through the most dire situations

 Risk of death ( the more immature baby,

the greater the risk of death)

 Prognosis and long term

neurodevelopmental outcome.

Reference
Paediatric Protocol For Malaysian Hospital, 3rd
edition, 2013, KKM.
Neonatology, Lange 7th edition, 2014.
Nelson Textbook of Pediatric, 17th edition, 2014
www.medscape.com