Preterm infant,small for gestation age and postterm infant

1. Mrs.Jagadeeswari.J
M.Sc Nursing

2. DEFINITION:
A baby born before 37
completed weeks of gestation
calculating from the first day of last
menstrual period is arbitrarily
defined as preterm baby
Babies born before 37
completed weeks usually weighing
2500gms or less.

3. Preterm baby constitutes 2/3
rd of low birth weight
babies. The incidence of low
birth weight baby is about
30-40% in the developing
countries as such the
incidence of preterm baby is
about 20-25%.

4. Spontaneous
Induced

5.  Health status of the mother
 Multiple pregnancy
 Advanced parental age
 Placental problems
 Preterm labour and premature rupture of membrane
 Low maternal weight
 Chronic and acute systemic maternal disease
 Ante partum haemorrhage
 Cervical incompetence
 Maternal genital colonization and infections
 Cigarette smoking during pregnancy
 Acute emotional stress
 Physical exertion
 Sexual activity
 Trauma
 Bicornuate uterus
 Congenital malformations

6. Maternal diabetes mellitus
Placental dysfunction as indicated
by
unsatisfactory fetal growth
Eclampsia
Fetal hypoxia
Ante partum haemorrhage
Severe rhesus iso immunization

7. Measurements:
Size is small with relatively large
head
Crown- heel length is less than 47cm
Head circumference is less than 33
cm
But exceeds the chest
circumference by more than 33 cm

8. Activity and posture:
General activity is poor
Automatic reflex response such as
Moro response, sucking and
swallowing are sluggish or
incomplete
Baby assumes an extended posture
due to poor tone

9.  Face and head:
 Face appears small
 large head size
 Sutures are widely separated
 Fontanels are large
 Small chin
 Protruding eyes
 Optic nerve is usually unmyelinated
 Ear cartilage is deficient or absent with poor
recoil
 Hair appears woolly, and fuzzy and individual
hair fibres can be seen separately

10. Skin and subcutaneous tissues:
Skin is thin, gelatinous, Shiny and
excessively pink
Abundant lanugo
Very little vernix caseosa
Edema may be present
Subcutaneous fat is deficient
Breast nodule is small or absent

11. Genitals:
MALE:
testes undescended
scrotum poorly developed
FEMALES :
labia majora widely separated
exposing labia minora
hypertrophied clitoris

12. Skin
Bright pink, often translucent,
depending on the degree of maturity
Smooth and shiny ( may be
oedematous)
Small blood vessels clearly visible
underneath the thin epidermis
Fine lanugo hair is abundant

13. Ear cartilage
Soft and pliable
Soles and palms
Minimal creases
Smooth appearance
Scarf sign
Elbow may be easily brought
across the chest with little or
no resistance

14.  Male genitalia
 Male infant’s scrotum is undeveloped and
not pendulous
 Minimal rugae are present
 Testes may be in the inguinal canal or in
the abdominal wall
 Female genitalia
 Clitoris is prominent
 Labia majora are poorly developed and
gaping

15. Central nervous system:
o Immaturity of central nervous
system
o Poor cough reflex
o In coordinated sucking and
swallowing
o Retrolental fibroplasias
o Intra ventricular and
periventricular haemorrhage

16. Respiratory system
 Resuscitation difficulties at birth
 Hyaline membrane disease
 Breathing is periodic and associated with
intercostal recessions due to soft rib
 Pulmonary aspiration
 Atelectasis
 Broncho pulmonary dysplasia

17. Cardio vascular system
 The closure of ductus arteriosus is delayed
among preterm infants
G I system
 Regurgitations and aspirations
 Abdominal distension and functional
 intestinal obstruction
 Enter colitis
 Hyperbilirubinemia
 Hypoglycaemia

18. Thermo-regulation
 Excess heat loss
Infections
Renal immaturity
 The blood urea nitrogen is high
 Acidosis
 Edema
Toxicity of drug
Nutritional problems
 anemia
 Deficiencies of folic acid and Vit E
 osteopenia and rickets
Biochemical disturbance
 hypoglycaemia, hypocalcemia, hypoxia

19. Care of preterm infant
Intensive care protocol

20.  Cushioned bed
 Avoid excessive light, excessive sound, rough handling and painful procedures.
 Use effective analgesia and sedation for procedures
 Provide warmth
 Ensure asepsis
 Cover the baby appropriately
 Provide effective and safe oxygenation
 Nutrition
 Tactile and kinaesthetic stimulation
 Prone position
 Photo therapy
 Prevention of nosocomial infection
 Weight record
 Immunizations
 Family support
 Discharge policy
 Follow up
 Home care of preterm babies

21.  Nosocomial infections
 Hypothermia
 Respiratory distress syndrome
 Aspiration
 Patent ductus arteriosus
 Chronic lung disease
 Necrotizing entercolitis
 Intraventricular haemorrhage
 Retinopathy of prematurity
 Late metabolic acidosis
 Nutritional disorders
 Drug toxicity

23. IUGR is said to be
present in those babies
whose birth weight is below
the 10th percentile of the
average for the gestational
age.

24. Incidence: 3-10%
of infants.

25. Depending on pathologic
process and time of onset.
 Type I or symmetrical or
intrinsic IUGR
 Type II or asymmetrical or
extrinsic IUGR

27. Maternal factors
Fetal factors
Placental factors
unknown

28.  Extremes of maternal age.
 Hypertension and vascular disease
 Constitutionally small mothers
 Chronic maternal hypoxia: d/t pulmonary disease,
cyanotic heart disease & severe anemia
 Prothrombotic disorder: antiphospholipid
syndrome
 Maternal malnutrition
 Infection: CMV, Toxoplasmosis, Varicella-Zoster,
Malaria
 Substance abuse & cigarette smoking
 Teratogens: Folate antagonists, antineoplastic
agents, anticonvulsants.
 History of IUGR in previous pregnancies.
 Assisted reproductive technologies

29. Congenital malformations
Fetal infections: CMV, HIV,
toxoplasma, etc.
Chromosomal abnormalities:
trisomy 21 & trisomy 18
Genetic: agenesis

30.  Circumvalate placentae
 Chronic placental abruption
 Placenta praevia
 Chrioangioma
unknown
40% remain unknown cause

31. MAJOR RISK FACTORS
 Maternal age >40 years
 Smoker > 11 cigarettes per day
 Cocaine
 Daily vigorous exercise
 Previous SGA baby
 Previous stillbirth
 Maternal SGA
 C/c HTN
 Diabetes & vascular diseases
 Renal impairment
 Antiphospholipid syndrome
 Echogenic bowel
 preeclampsia
 Severe pregnancy induced HTN
 Low maternal weight

32. MINOR RISK FACTORS
 Maternal age > 35 years
 Nulliparity
 BMI <20
 BMI 25-29.9
 Smoker 1-10 per day
 Low fruit intake per day
 Preeclampsia
 Pregnancy interval < 6 months

33.  Antenatal: c/c fetal distress, hypoxia &
acidosis, fetal death
 After birth:
 Asphyxia and RDS
 Hypoglycaemia
 Meconium aspiration syndrome
 Hypothermia
 Pulmonary h’age
 Polycythemia
 Necrotizing enterocolitis
 Intraventricular h’age

34. 1. SCREENING:
 Accurate knowledge of gestational age
 Past history of IUGR & any maternal
complication
 On obstetric palpation, height of uterus <4
weeks or more for the gestational age.
 Uterine fundal height: serial fundal height
measurements throughout pregnancy.

35. Ultrasound measurements:
 Fetal biometry: fetal parietal
diameter(BPD),femur length (FL) &abdominal
circumference(AC) are measured.
 Body proportions: HC/AC ratio, FL/AC ratio &
ponderal index for asymmetric IUGR.
 HC/AC ratio: size of liver is disproportionately
smaller than head circumference or length of
femur
 Amniotic fluid volume: Oligohydraminos d/t ↓
fetal urine production.
 Doppler velocimetry: abnormal umbilical artery
Doppler velocimetry increased systolic-diastolic
ratio, absent or reverse end-diastolic flow.

37. Infants born of a
gestation age that
extends beyond 42
weeks as calculated
from the mothers last
menstrual period

38. Pregnancy between the age of
15-19yrs
Elderly women
Wrong dates
Multiple pregnancy
Fetal anomalies
hereditary

39. Absence of vernix caseosa
Loose skin and little subcutaneous
fat
Absence of lanugo
Abundant hair on the head and long
nails
Skin is wrinkles, cracked and peeling
Umbilical cord is thin

40. History collection
Fetal movement recording
Electronic fetal monitoring
Ultrasonography
Biophysical profile
Doppler flow study

41.  Clear the airway
 Maintain thermoregulation
 Prevention of infection
 APGAR scoring
 Early beast feeding
 Card care
 Eye care
 Preventing hypoglycemia
 Administer vitamin K injection
 Assess the weight