Definitions:
•Perinatal period: Perinatal period extends
from the 22nd week of gestation (or weighing ≥
500 gm) to the 7th day of life (early neonatal
period).
•Perinatal mortality rate: Defined as late fetal.
(stillbirths) plus early neonatal deaths per 1000
total births.
• Neonatal period:Neonatal period extends
from birth up to 28 days of life. Early period
refers to first 7 days while late neonatal period
from 7 days up to 28 completed days of life.
• Neonatal mortality rate: Neonatal deaths
during 28 days of life per 1000 live births.
1. Gestational age groups: • Antenatal assessment:
1- Date of last menstrual period (LMP)
ENTRO OF NEONATALOG • Preterm babies with a gestational age of less than 37 completed wks (<259
days). 2- Uterine size.
•Term babies with a gestational age between 37- up to 42 wks of gestation (259- 3- Ultrasound estimation. (early + mid trimester)
293 days) More important:
•Post term (postmature) with a gestational age of 42 wks or more (z 294 days). BPD-2' trimester
CHL-1st trimester
2. Birth weight groups:
•Low birth weight; babies with a birth weight of less than 2500gm (irrespective The clinical assessment of gestation at birth by
of the gestational age). physical and neurological examination of the baby
•Very low birth weight: babies with a birth weight of less than 1500 gm. is more reliable as compared to estimation in-utero.
•Extremely low birth weight: babies with a birth weight of less than 1000 gm • Physical maturity:
Gestational Age Estimation and Birth The clinical assessment of (depending upon the degree of prematurity)
Weight Classification 3. Birth weight and Gestational age: gestation 1-Sole creases.
• Small-for-dates (SFD) (IUGR). 3-Ear cartilage.
Babies with birth weight of less than 10 percentile for their gestational age (or 2- Breast nodule.
less than- 2SD) 4- Scalp hair.
• Appropriate-for-dates (AFD) 5- External genitalia
Birth weight between 10th 90th percentile for the period of their gestational age • Neuromuscular maturity:
• Large-for-dates (LFD) Gestational age assessment
Birth weight of more than 90th percentile for the period of their gestationalage. Neuromuscular parameters are more reliable for
Precise delineation of gestational maturity of
Gestational age: preterm babies
It is a number of completed weeks that have elapsed between the, fitst day of last 1) Muscle tone: must be assessed by three
menstrual period and expected date of delivery of the fetus.40±2 wks parameters:
•1-Posture (attitude).
•2- Passive tone (popliteal angle and scarf sign).
•3- Active tone (traction response and recoil).
2) Joint mobility. (square-window) The degree of
flexion at ankle and wrist.
Intrauterine Growth Retardation 🔹 Scoring rystem for assessment of gestational
maturity by plrysical and neuromuscular
• Babies with a birth weight of less than 10 percentile for the period of their gestational age or below
(-2SD standard deviations). characteristics.
• Upto 50% of all babies are of low birth weight, 1/3 of all LBW are term but SGA.
🔹
See New Ballard Score.
The physical and neurologic scares are added
to calculated gestational age.
Etiology
1. Maternal factors
a. Genetic size
b. Demographics (age-extremes of reproductive lite, low SE status)
c. Factors interfering with placental flow and oxygenation:
• Cardiovascular, pulmonary, and rena diseases.
• Sickle-cell anemia and other hemoglobinopathies.
• Maternal substance abuse (drugs, smoking tobacco, and alcohol)
• Uterine anomalies.
d. Parity (nulliparity, grand multiparty).
e. Maternal infections (UTI, TB)
2. Placental factors (vascular malformation, abruption, previa).
3. Fetal factors:
a. Multiple gestations
b. Chromosomal and genetic disorders (trisomy, turner syndrome, & etc.)
c. Congenital infections especially TORCH (rubella, CMV and toxoplasmosis).
1- Malnourished (asymmetric IUGR) - late in gestation.
Common causes are:
• Infants born at a gestation of 42 weeks or later (294 days • Pregnancy induced hypertension, toxemia of pregnancy, postmaturity, abruption, previa placental
or more). dysfunction.
• Represents fewer than 12% of pregnancies •Maternal chronic systemic diseases (hypertension, chronic heart disease, renal diseases, bronchial
• The cause of prolonged pregnancy is unknown in most asthma, and sickle cell disease, and etc).
cases. •Maternal infections (malaria, TB, UTI, and recurrent diarrhea).
Post-Term Babies (Postmature) •Multiple gestation. Uterine anomalies and fibroids.
Post-dating of labor is common among: •Parity (nulliparity, grand multiparity)
1-Primiparous women. •Low maternal weight and height (nutritional, genetic, ethnic).
2- Fetus with anencephaly. •Demographics (age extremes of reproductive life, low SE status).
3- Trisomies 16 and 18.
4- Seckel's syndrome (bird-headed dwarfism). Physical characteristics:
5. Erroneous estimation of GA •Head circumference and length are less affected or unaffected in relation to body weight.
•Infant appears long, thin, and marasmic.
Clinical problemsrelated to postmaturity: Small-for- Gestational Types of small-for-date babies
•Loss musculature of trunk and limbs (reduced skin fold thickness).
•Loss subcutaneous fat (loose skin and often hangs in folds at buttocks).
1-Congenital malformations
.2- Perinatal hypoxia. Age
3- Meconium aspiration.
2- Hypoplastic (svmmetrical IUGR) - early in gestation.
4- Persistent pulmonary hypertension.
Post-Term Babies (Postmature) •Common causes are:
5- Hypoglycemia, hypocalcemia, and polycythemia.
•Intrauterine infection especially TORCH.
6- A higher risk of fetal, intrapartum, or neonatal death.
•Chromosomal and genetic disorders (trisomy syndrome, turner syndrome, various type of short limbed
dwarfism).
Management: •Fetal congenital malformations (CNS, skeletal, and etc)
1-Antepartum managementfor pregnancy advanced •Maternal substance abuse (narcotics, smoking tobacco, and alcohol).
beyond 41 weeks.Assess fetus for signs of distress (if Physical characteristics:
present, delivery is indicated) Mental and physical growth retardation.
2- Intrapartum management Preparation for possible All measurements are small (head, length, weight)
perinatal depression and meconium aspiration
3- Postpartum management Evaluation and management Their clinical problems and outcome are very different as compared to preterm babies, most
of clinical problems. clinical problems and biochemical abnormalities are limited to grossly SGA babies with a birth
Attention to proper nutritional support. weight of less than (-25D) or less than 3rd percentile.
Complications Related to IUGR Babies:
1. Fetal hypoxia and intrapartum death (due to placental dysfunction).
2. Severe birth asphyxia (intracranial hemorrhage).
Common causes of prematurity: 3. In-utero aspiration and meconium aspiration syndrome.
Events leading to prematurity are still not completely understood: 4- Symptomatic hypoglycemia and hypocalcemia.
1- Poor nutritional state of the mother (severe anemia, and low MUAC & 5- Congenital malformations (CNS, skeletal system, CHD, and etc).
BMI). 6- Pulmonary hemorrhage (due to unknown cause)
2-Inadequate or lack of Antenatal care 7- Polycythemia (due to chronic hypoxia).
3- Adolescent pregnancy (young mother < 18 yrs). 8- Thermoregulation may be unsatisfactory. Hypothermia due to scanty brown fat.
4- Maternal genital colonization and infections 9. Hyperbilirubinemia.
5- Antepartum hemorrhage (abruption or placenta previa). 10- Vulnerability to infections.
6- Acute or chronic systemic maternal disease (hypertensive disorders). Preterm babies are those born with a gestation of less than 37 completed 11- Poor growth potential on follow-up.
12- Increased risk of development of DM, HT and coronary artery disease in adult life.
Events leading to prematurity are still not completely understood:
7- Maternal uterine abnormalities (incompetent cervix, fibroids). 🔹
weeks (or less than 259days).
The morbidity and mortality of these infants are high due to anatomical and Complications Related to IUGR Babies
Note: In preterm small-for-dates babies, combined hazards of immaturity and intrauterine
8- Multiple gestations & congenital malformations.
9. Bad and harmful habits. 🔹
functional immaturity of various body organs.
About 28% of newborn deaths are directly due to complications of preterm birth,
and between 60-90% of newborn deaths occur in low birt weight babies, most of
growth retardation would be manifest.
10- Genetic susceptibility (a preterm 1st birth is the best predictor of a
preterm 2nd birth).
11-Any maternal medical condition requiring delivery (e.g. cancer). 🔹
whom are preterm.
Preterm infants usually show physical signs and medical problems of prematurity
inversely proportion to the gestational age.Based on gestational age,
12-Idiopathic- the cause is unknown in most cases.
preterm babies are classified in to:
1- Extreme prematurity (preterm born at less than 28 weeks of gestation).
2- Severe prematurity (preterm born at 28-31 weeks of gestation).
3- Moderate prematurity (Preterm born at 32-33 weeks). Neonatology
4- Late preterm (preterm born at 34-36 weeks).
• Babies with a birth weight of more than 90 percentile for the period oftheir gestational
age or (> 2SD standard deviations).
• Around 9%-13% of all deliveries.Large-for-Dates Babies (MACROSOΜΙΑ)
Central nervous system: Causes of macrosomia:
Respiratory System: 1. Lethargy, hypotonia and poor cough reflex. 1-Genetic or constitutional factors (tall and obese mother).
1. The breathing is mostly diaphragmatic, periodic and associated with 2-Uncoordinated sucking and swallowing-B W<1,800 gm, GA 34 wks or less 2-Mothers with uncontrolled diabetic mellitus (the commonest cause).
intercostal recessions due to soft ribs. 3-Intraventricular-periventricular hemorrhage (due to relative deficiency of 3-Croetinism (babies with congenital hypothyroidism).
2- Apnea or apneic attacks (immaturity of respiratory centre). vitamin-K dependent coagulation factors and immature cerebralvasculature). 4-Hydrops fetalis (erythroblastobis fetalis).
3- Hyalin membrane disease (surfactant deficiency). 4-Seizures (underlying cerebral or biochemical abnormality). 5-Transposition of the great vessels.
4- Aspiration pneumonia (weak gag and cough reflex and atelectasis. 5- Bilirubin encephalopathy (Kernicterus) due to inefficient blood brain barrier 6- Overgrown syndromes (rare) :
5- Chronic pulmonary insufficiency (due to bronchopulmonary dysplasia). and associated risks of perinatal distress factors (hypoxia, acidosis, a. Wiedemann-beckwith syndrome
hypoglycemia, hypothermia, hypoalbuminemia, sepsis, and ...ete); b. Marshall - smith syndrome.
c. Cerebral gigantism (Sotos syndrome).
Hematologic: Cardiovascular system:
Physiological handicaps (problems) of prematurity 1- Patent ductus arteriosus with or without congestive heart failure.
1- Anemia of prematurity (6-8wks) due to low storage of iron, folic acid, and 2-Thromboembolic complications and hypertension (due to indwelling venous Clinically well Asymptomatic and
vitamin E (short gestation). and arterial catheters) at gestational age of < 32 wks. normoglycemic baby:
2-Disseminated intravascular coagulopathy (DIC). 3- Bradycardia with apnea is common. -Early oral feeding with human or formula milk
3- Hemorrhagic disease of the newborn (Vitamin K deficiency). 4-Hypotension (hypovolemia, cardiac dysfunction, vasodilation due to sepsis) as soon as possible (within 1-3 hr of age and
continued at 2-3 hr interval for 24-48 hr) for
Gastrointestinal system: prevention of hypoglycemia
1- Regurgitation and aspiration (incoordinated sucking and swallowing, small -Laboratory monitoring of glucose, calcium,
magnesium, and hematocrit levels (blood
Metabolic (biochemical disturbances): capacity of stomach, incompetence of cardioesophageal junction, and poor Physiological handicaps glucose is checked within 1 hr of birth, then
cough reflex).
1- Hypoglycemia (low hepatic glycogen stores, delayed feeding, & birth 2-Abdominal distension and functional intestinal obstruction (hypotonia).
(problems) of prematurity every hour for the next 6-8 hr. then every 4-6 hr
asphyxia) 3- Necrotizing enterocolitis (prematurity of the gastrointestinal tract) until 24 hr, and at 48 hr after birth)
2-Hypocalcemia (immature parathyroid).
3- Metabolic acidosis.
4- Hyperbilitubinemia (indirect is common due to immaturity of glucurony! Preterm Babies Asymptomatic
-Intolerance or poor oral feeding give
transferase in the liver). peripheral intravenous glucose infusion at a
4-Hypothermia (large surface area, paucity of brown fat).(neonatal weight 500g) 5- Feeding problems require specific attention to the content, amount and route rate of 4-8mg/kg/min
of feeding. Large - for - Dates Babies
6- Decrease nutrient stores and enzymes. Management of infant of diabetic • Asymptomatic hypoglycemic baby:
(MACROSOMIA)
mother: Early and frequent feeding and or intravenous
Infections:
Perinatal, nosocomial infection (bacterial, viral, fungal, protozoal)
Renal: 🔹 Infants of diabetic mothers:
Women with diabetes in pregnancy (type 1, type 2, and gestational) are at increased risk for
•Expert medical management of diabetic
pregnant mother
glucose infusion
1- High blood urea nitrogen (low Glomerular filtration rate). hypoglycemia without convulsion:
due to low levels of IgG antibodies, inefficient cellular immunity, excessive
2- Edema (solute retention and low serum protein). adverse pregnancy outcomes. • Timed delivery depending upon fetal
handling, and contaminated incubators and resuscitators. Adequate glycemic control improves pregnancy outcome. well being and pulmonary maturity based Intravenous bolus of 200mg/kg (2 ml/kg) of
10% glucose After initial bolus, continue
on amniotic fluid SPC levels (amniotic glucose infusion at 8 mg/kg/min If
Others: Clinical features of infant of diabetic mothers: fluid L/S ratio of > 3.5 and the SPC level hypoglycemia recurs, the infusion rate and
1- Toxicity of drugs (poor hepatic detoxification and reduced renal clearance). - Large baby (>4kg) most infants. of> 1000 ug/dl are suggestive of mature
- Puffy, plethoric and moonfaced (cushingoid face). concentration increased until 15-20% glucose
2- Osteopenia and rickets of prematurity (poor calcium and phosphorus stores, indices is used
and impaired vitamin D conversion) -Hypertricosis and hairy-pinna.
- Jumpy, Jittery, and hyperexcitable (1st 3 day of life), may be hypotonia, lethargy, and poor • Cesarean section for large baby
sucking. hypoglycemia with convulsion:
1. Developmental disability.
- Head circumference corresponds to gestational age rather than birth weight. Intravenous bolus 4 ml/kg of 10% glucose, then
•Major handicaps (cerebral palsy, seizures, mental retardation).
Common clinical problems: continue glucose infusion as outlined above
-Sensory Impairments (hearing loss, visual impairment).
1- Increase morbidity or mortality rate.
Symptomatic
-Minimal cerebral dysfunction (learning, language, behaviour disorders, 1-Treat hypocalcemia, hypomagnesemia, and
2- Prematurity (large size fetus may be delivered preterm). hyperbilirubinemia if present
and attention deficit, hyperactivity disorder requiring specialized support
Long-term complications of 3- Metabolic disorders:Hypoglycemia: about 75% of infants of diabetic mother (IDM) and 2. Management of respiratory distress syndrome
for education).
prematurity 25%. of gestational diabetes (IGDM suffer from first-day asymptomatic. hypoglycemia, if present
2. Retinopathy of prematurity (oxygen toxicity) BW<1500 gm or GA <32
small 3. Severe polycythemia and hyperviscosity-
wks).
percentage of these infants become symptomatic. Hypocalcemia and hypomagnesemia exchange transfusion with plasm or physiologic
3. Chronic lung diseases (bronchopulmonary dysplasia).
(their pathogenesis is unclear.) saline
4. Poor growth.
4- Birth injuries due to large size (vaginal delivery): 4. Screening for congenital malformations
5. Increased rates of postneonatal illness and rehospitalization.
- Cephalohematoma, subdural hemorrhage, excessive bruising 5- Cardiac dysfunction (due to asymmetric
by fatema okoff - Facial palsy. Shoulder dystocia (Phrenic nerve palsy). hypertrophy of septum with subaortic
- There is a need to provide basic (essential) antenatal and perinatal medical -Brachial nerve palsy and fracture of clavicle obstruction)- furosemide and propranolol
care to all pregnancies. 5- Perinatal asphyxia. (digoxin may be deleterious in these infants).
- Perinatal adequate care to high-risk mothers. 6- HMD and transient tachypnea. Note: septal hyperthrophy resolves by 6 months
- Depending upon birth weight and gestational age, 7- Hyperbilirubinemia. of age.
three systems of neonatal care have been proposed for developing 8- Polycythemia Hyperviscosity Renal vein thrombosis. 6- Sluggish bowel activity (due to small left
countries: 9- Poor feeding without any obvious cause is seen in one-third of IDMs colon syndrome)-> enemas with gastrografin or
10- Congenital anomalies: half normal saline (5 ml/kg) and glycerine
1) Over 80% of newborn babies require minimal care which can be Congenital heart disease:cardiomegaly 30%, suppositories
- Prognosis for survival is directly related to the quality of obstetric services, birth provided by their mothers. Neonates weighing above 1800gm or having cardiac dysfunction 10%, asymmetric septal hypertrophy -> obstruction to the left
weight of the child, and quality of the neonatal care. gestational maturity of 34 wks or more belong to this category. The care can ventricle outflow, VSD or ASD, TOGV, tricuspid atresia.
-Neurological prognosis is adversely affected by degree of immaturity, intrauterine be provided at home with basic care at birth, provision of warmth, maintenance Neural tube defects, musculo-skeletal deformities and renal agenesis Pathophysiology:
growth retardation, severity of perinatal hypoxia, hypoglycemia, hyperbilirubinemia, Prognosis of asepsis, and promotion of breast feeding Principles of Management Small colon syndrome: presents as generalized abdominal distension because of inability
intraventricular hemorrhage, Periventricular leukomalacia, and severity of respiratory 2) 10-15% of newborns weighing between 1200-1800gm or having to pass meconium.
failure demanding assisted ventilation. gestational maturity of 30-34 wks should be provided intermediate • Caudal regression syndrome (lumbosacral agenesis):
neonatal care equipped with resuscitation, maintenance of thermoneutral characterized by various: degree of developmental failure involving legs, lumber, sacral,
environment, intravenous infusion, gavage feeding, phototherapy, and coccygeal vertebrae and corresponding segments of spinal cord with urinary incontinence
exchange BT. and dribbling.
3) About 3-5% of newborns require intensive neonatal care (NICU)
equipped with centralized oxygen, suction facilities, and servo-controlled Note: infants with congenital malformations may be small-for-dates.
incubation; vital signs and transcutaneous monitors, ventilation and infusion
pümps, and etc. Babies weighing less than 1200gm or those born before 30 wks
of gestation belong to this category care
•Perinatal period: Perinatal period extends
from the 22nd week of gestation (or weighing ≥
500 gm) to the 7th day of life (early neonatal
period).
•Perinatal mortality rate: Defined as late fetal.
(stillbirths) plus early neonatal deaths per 1000
total births.
• Neonatal period:Neonatal period extends
from birth up to 28 days of life. Early period
refers to first 7 days while late neonatal period
from 7 days up to 28 completed days of life.
• Neonatal mortality rate: Neonatal deaths
during 28 days of life per 1000 live births.
1. Gestational age groups: • Antenatal assessment:
1- Date of last menstrual period (LMP)
ENTRO OF NEONATALOG • Preterm babies with a gestational age of less than 37 completed wks (<259
days). 2- Uterine size.
•Term babies with a gestational age between 37- up to 42 wks of gestation (259- 3- Ultrasound estimation. (early + mid trimester)
293 days) More important:
•Post term (postmature) with a gestational age of 42 wks or more (z 294 days). BPD-2' trimester
CHL-1st trimester
2. Birth weight groups:
•Low birth weight; babies with a birth weight of less than 2500gm (irrespective The clinical assessment of gestation at birth by
of the gestational age). physical and neurological examination of the baby
•Very low birth weight: babies with a birth weight of less than 1500 gm. is more reliable as compared to estimation in-utero.
•Extremely low birth weight: babies with a birth weight of less than 1000 gm • Physical maturity:
Gestational Age Estimation and Birth The clinical assessment of (depending upon the degree of prematurity)
Weight Classification 3. Birth weight and Gestational age: gestation 1-Sole creases.
• Small-for-dates (SFD) (IUGR). 3-Ear cartilage.
Babies with birth weight of less than 10 percentile for their gestational age (or 2- Breast nodule.
less than- 2SD) 4- Scalp hair.
• Appropriate-for-dates (AFD) 5- External genitalia
Birth weight between 10th 90th percentile for the period of their gestational age • Neuromuscular maturity:
• Large-for-dates (LFD) Gestational age assessment
Birth weight of more than 90th percentile for the period of their gestationalage. Neuromuscular parameters are more reliable for
Precise delineation of gestational maturity of
Gestational age: preterm babies
It is a number of completed weeks that have elapsed between the, fitst day of last 1) Muscle tone: must be assessed by three
menstrual period and expected date of delivery of the fetus.40±2 wks parameters:
•1-Posture (attitude).
•2- Passive tone (popliteal angle and scarf sign).
•3- Active tone (traction response and recoil).
2) Joint mobility. (square-window) The degree of
flexion at ankle and wrist.
Intrauterine Growth Retardation 🔹 Scoring rystem for assessment of gestational
maturity by plrysical and neuromuscular
• Babies with a birth weight of less than 10 percentile for the period of their gestational age or below
(-2SD standard deviations). characteristics.
• Upto 50% of all babies are of low birth weight, 1/3 of all LBW are term but SGA.
🔹
See New Ballard Score.
The physical and neurologic scares are added
to calculated gestational age.
Etiology
1. Maternal factors
a. Genetic size
b. Demographics (age-extremes of reproductive lite, low SE status)
c. Factors interfering with placental flow and oxygenation:
• Cardiovascular, pulmonary, and rena diseases.
• Sickle-cell anemia and other hemoglobinopathies.
• Maternal substance abuse (drugs, smoking tobacco, and alcohol)
• Uterine anomalies.
d. Parity (nulliparity, grand multiparty).
e. Maternal infections (UTI, TB)
2. Placental factors (vascular malformation, abruption, previa).
3. Fetal factors:
a. Multiple gestations
b. Chromosomal and genetic disorders (trisomy, turner syndrome, & etc.)
c. Congenital infections especially TORCH (rubella, CMV and toxoplasmosis).
1- Malnourished (asymmetric IUGR) - late in gestation.
Common causes are:
• Infants born at a gestation of 42 weeks or later (294 days • Pregnancy induced hypertension, toxemia of pregnancy, postmaturity, abruption, previa placental
or more). dysfunction.
• Represents fewer than 12% of pregnancies •Maternal chronic systemic diseases (hypertension, chronic heart disease, renal diseases, bronchial
• The cause of prolonged pregnancy is unknown in most asthma, and sickle cell disease, and etc).
cases. •Maternal infections (malaria, TB, UTI, and recurrent diarrhea).
Post-Term Babies (Postmature) •Multiple gestation. Uterine anomalies and fibroids.
Post-dating of labor is common among: •Parity (nulliparity, grand multiparity)
1-Primiparous women. •Low maternal weight and height (nutritional, genetic, ethnic).
2- Fetus with anencephaly. •Demographics (age extremes of reproductive life, low SE status).
3- Trisomies 16 and 18.
4- Seckel's syndrome (bird-headed dwarfism). Physical characteristics:
5. Erroneous estimation of GA •Head circumference and length are less affected or unaffected in relation to body weight.
•Infant appears long, thin, and marasmic.
Clinical problemsrelated to postmaturity: Small-for- Gestational Types of small-for-date babies
•Loss musculature of trunk and limbs (reduced skin fold thickness).
•Loss subcutaneous fat (loose skin and often hangs in folds at buttocks).
1-Congenital malformations
.2- Perinatal hypoxia. Age
3- Meconium aspiration.
2- Hypoplastic (svmmetrical IUGR) - early in gestation.
4- Persistent pulmonary hypertension.
Post-Term Babies (Postmature) •Common causes are:
5- Hypoglycemia, hypocalcemia, and polycythemia.
•Intrauterine infection especially TORCH.
6- A higher risk of fetal, intrapartum, or neonatal death.
•Chromosomal and genetic disorders (trisomy syndrome, turner syndrome, various type of short limbed
dwarfism).
Management: •Fetal congenital malformations (CNS, skeletal, and etc)
1-Antepartum managementfor pregnancy advanced •Maternal substance abuse (narcotics, smoking tobacco, and alcohol).
beyond 41 weeks.Assess fetus for signs of distress (if Physical characteristics:
present, delivery is indicated) Mental and physical growth retardation.
2- Intrapartum management Preparation for possible All measurements are small (head, length, weight)
perinatal depression and meconium aspiration
3- Postpartum management Evaluation and management Their clinical problems and outcome are very different as compared to preterm babies, most
of clinical problems. clinical problems and biochemical abnormalities are limited to grossly SGA babies with a birth
Attention to proper nutritional support. weight of less than (-25D) or less than 3rd percentile.
Complications Related to IUGR Babies:
1. Fetal hypoxia and intrapartum death (due to placental dysfunction).
2. Severe birth asphyxia (intracranial hemorrhage).
Common causes of prematurity: 3. In-utero aspiration and meconium aspiration syndrome.
Events leading to prematurity are still not completely understood: 4- Symptomatic hypoglycemia and hypocalcemia.
1- Poor nutritional state of the mother (severe anemia, and low MUAC & 5- Congenital malformations (CNS, skeletal system, CHD, and etc).
BMI). 6- Pulmonary hemorrhage (due to unknown cause)
2-Inadequate or lack of Antenatal care 7- Polycythemia (due to chronic hypoxia).
3- Adolescent pregnancy (young mother < 18 yrs). 8- Thermoregulation may be unsatisfactory. Hypothermia due to scanty brown fat.
4- Maternal genital colonization and infections 9. Hyperbilirubinemia.
5- Antepartum hemorrhage (abruption or placenta previa). 10- Vulnerability to infections.
6- Acute or chronic systemic maternal disease (hypertensive disorders). Preterm babies are those born with a gestation of less than 37 completed 11- Poor growth potential on follow-up.
12- Increased risk of development of DM, HT and coronary artery disease in adult life.
Events leading to prematurity are still not completely understood:
7- Maternal uterine abnormalities (incompetent cervix, fibroids). 🔹
weeks (or less than 259days).
The morbidity and mortality of these infants are high due to anatomical and Complications Related to IUGR Babies
Note: In preterm small-for-dates babies, combined hazards of immaturity and intrauterine
8- Multiple gestations & congenital malformations.
9. Bad and harmful habits. 🔹
functional immaturity of various body organs.
About 28% of newborn deaths are directly due to complications of preterm birth,
and between 60-90% of newborn deaths occur in low birt weight babies, most of
growth retardation would be manifest.
10- Genetic susceptibility (a preterm 1st birth is the best predictor of a
preterm 2nd birth).
11-Any maternal medical condition requiring delivery (e.g. cancer). 🔹
whom are preterm.
Preterm infants usually show physical signs and medical problems of prematurity
inversely proportion to the gestational age.Based on gestational age,
12-Idiopathic- the cause is unknown in most cases.
preterm babies are classified in to:
1- Extreme prematurity (preterm born at less than 28 weeks of gestation).
2- Severe prematurity (preterm born at 28-31 weeks of gestation).
3- Moderate prematurity (Preterm born at 32-33 weeks). Neonatology
4- Late preterm (preterm born at 34-36 weeks).
• Babies with a birth weight of more than 90 percentile for the period oftheir gestational
age or (> 2SD standard deviations).
• Around 9%-13% of all deliveries.Large-for-Dates Babies (MACROSOΜΙΑ)
Central nervous system: Causes of macrosomia:
Respiratory System: 1. Lethargy, hypotonia and poor cough reflex. 1-Genetic or constitutional factors (tall and obese mother).
1. The breathing is mostly diaphragmatic, periodic and associated with 2-Uncoordinated sucking and swallowing-B W<1,800 gm, GA 34 wks or less 2-Mothers with uncontrolled diabetic mellitus (the commonest cause).
intercostal recessions due to soft ribs. 3-Intraventricular-periventricular hemorrhage (due to relative deficiency of 3-Croetinism (babies with congenital hypothyroidism).
2- Apnea or apneic attacks (immaturity of respiratory centre). vitamin-K dependent coagulation factors and immature cerebralvasculature). 4-Hydrops fetalis (erythroblastobis fetalis).
3- Hyalin membrane disease (surfactant deficiency). 4-Seizures (underlying cerebral or biochemical abnormality). 5-Transposition of the great vessels.
4- Aspiration pneumonia (weak gag and cough reflex and atelectasis. 5- Bilirubin encephalopathy (Kernicterus) due to inefficient blood brain barrier 6- Overgrown syndromes (rare) :
5- Chronic pulmonary insufficiency (due to bronchopulmonary dysplasia). and associated risks of perinatal distress factors (hypoxia, acidosis, a. Wiedemann-beckwith syndrome
hypoglycemia, hypothermia, hypoalbuminemia, sepsis, and ...ete); b. Marshall - smith syndrome.
c. Cerebral gigantism (Sotos syndrome).
Hematologic: Cardiovascular system:
Physiological handicaps (problems) of prematurity 1- Patent ductus arteriosus with or without congestive heart failure.
1- Anemia of prematurity (6-8wks) due to low storage of iron, folic acid, and 2-Thromboembolic complications and hypertension (due to indwelling venous Clinically well Asymptomatic and
vitamin E (short gestation). and arterial catheters) at gestational age of < 32 wks. normoglycemic baby:
2-Disseminated intravascular coagulopathy (DIC). 3- Bradycardia with apnea is common. -Early oral feeding with human or formula milk
3- Hemorrhagic disease of the newborn (Vitamin K deficiency). 4-Hypotension (hypovolemia, cardiac dysfunction, vasodilation due to sepsis) as soon as possible (within 1-3 hr of age and
continued at 2-3 hr interval for 24-48 hr) for
Gastrointestinal system: prevention of hypoglycemia
1- Regurgitation and aspiration (incoordinated sucking and swallowing, small -Laboratory monitoring of glucose, calcium,
magnesium, and hematocrit levels (blood
Metabolic (biochemical disturbances): capacity of stomach, incompetence of cardioesophageal junction, and poor Physiological handicaps glucose is checked within 1 hr of birth, then
cough reflex).
1- Hypoglycemia (low hepatic glycogen stores, delayed feeding, & birth 2-Abdominal distension and functional intestinal obstruction (hypotonia).
(problems) of prematurity every hour for the next 6-8 hr. then every 4-6 hr
asphyxia) 3- Necrotizing enterocolitis (prematurity of the gastrointestinal tract) until 24 hr, and at 48 hr after birth)
2-Hypocalcemia (immature parathyroid).
3- Metabolic acidosis.
4- Hyperbilitubinemia (indirect is common due to immaturity of glucurony! Preterm Babies Asymptomatic
-Intolerance or poor oral feeding give
transferase in the liver). peripheral intravenous glucose infusion at a
4-Hypothermia (large surface area, paucity of brown fat).(neonatal weight 500g) 5- Feeding problems require specific attention to the content, amount and route rate of 4-8mg/kg/min
of feeding. Large - for - Dates Babies
6- Decrease nutrient stores and enzymes. Management of infant of diabetic • Asymptomatic hypoglycemic baby:
(MACROSOMIA)
mother: Early and frequent feeding and or intravenous
Infections:
Perinatal, nosocomial infection (bacterial, viral, fungal, protozoal)
Renal: 🔹 Infants of diabetic mothers:
Women with diabetes in pregnancy (type 1, type 2, and gestational) are at increased risk for
•Expert medical management of diabetic
pregnant mother
glucose infusion
1- High blood urea nitrogen (low Glomerular filtration rate). hypoglycemia without convulsion:
due to low levels of IgG antibodies, inefficient cellular immunity, excessive
2- Edema (solute retention and low serum protein). adverse pregnancy outcomes. • Timed delivery depending upon fetal
handling, and contaminated incubators and resuscitators. Adequate glycemic control improves pregnancy outcome. well being and pulmonary maturity based Intravenous bolus of 200mg/kg (2 ml/kg) of
10% glucose After initial bolus, continue
on amniotic fluid SPC levels (amniotic glucose infusion at 8 mg/kg/min If
Others: Clinical features of infant of diabetic mothers: fluid L/S ratio of > 3.5 and the SPC level hypoglycemia recurs, the infusion rate and
1- Toxicity of drugs (poor hepatic detoxification and reduced renal clearance). - Large baby (>4kg) most infants. of> 1000 ug/dl are suggestive of mature
- Puffy, plethoric and moonfaced (cushingoid face). concentration increased until 15-20% glucose
2- Osteopenia and rickets of prematurity (poor calcium and phosphorus stores, indices is used
and impaired vitamin D conversion) -Hypertricosis and hairy-pinna.
- Jumpy, Jittery, and hyperexcitable (1st 3 day of life), may be hypotonia, lethargy, and poor • Cesarean section for large baby
sucking. hypoglycemia with convulsion:
1. Developmental disability.
- Head circumference corresponds to gestational age rather than birth weight. Intravenous bolus 4 ml/kg of 10% glucose, then
•Major handicaps (cerebral palsy, seizures, mental retardation).
Common clinical problems: continue glucose infusion as outlined above
-Sensory Impairments (hearing loss, visual impairment).
1- Increase morbidity or mortality rate.
Symptomatic
-Minimal cerebral dysfunction (learning, language, behaviour disorders, 1-Treat hypocalcemia, hypomagnesemia, and
2- Prematurity (large size fetus may be delivered preterm). hyperbilirubinemia if present
and attention deficit, hyperactivity disorder requiring specialized support
Long-term complications of 3- Metabolic disorders:Hypoglycemia: about 75% of infants of diabetic mother (IDM) and 2. Management of respiratory distress syndrome
for education).
prematurity 25%. of gestational diabetes (IGDM suffer from first-day asymptomatic. hypoglycemia, if present
2. Retinopathy of prematurity (oxygen toxicity) BW<1500 gm or GA <32
small 3. Severe polycythemia and hyperviscosity-
wks).
percentage of these infants become symptomatic. Hypocalcemia and hypomagnesemia exchange transfusion with plasm or physiologic
3. Chronic lung diseases (bronchopulmonary dysplasia).
(their pathogenesis is unclear.) saline
4. Poor growth.
4- Birth injuries due to large size (vaginal delivery): 4. Screening for congenital malformations
5. Increased rates of postneonatal illness and rehospitalization.
- Cephalohematoma, subdural hemorrhage, excessive bruising 5- Cardiac dysfunction (due to asymmetric
by fatema okoff - Facial palsy. Shoulder dystocia (Phrenic nerve palsy). hypertrophy of septum with subaortic
- There is a need to provide basic (essential) antenatal and perinatal medical -Brachial nerve palsy and fracture of clavicle obstruction)- furosemide and propranolol
care to all pregnancies. 5- Perinatal asphyxia. (digoxin may be deleterious in these infants).
- Perinatal adequate care to high-risk mothers. 6- HMD and transient tachypnea. Note: septal hyperthrophy resolves by 6 months
- Depending upon birth weight and gestational age, 7- Hyperbilirubinemia. of age.
three systems of neonatal care have been proposed for developing 8- Polycythemia Hyperviscosity Renal vein thrombosis. 6- Sluggish bowel activity (due to small left
countries: 9- Poor feeding without any obvious cause is seen in one-third of IDMs colon syndrome)-> enemas with gastrografin or
10- Congenital anomalies: half normal saline (5 ml/kg) and glycerine
1) Over 80% of newborn babies require minimal care which can be Congenital heart disease:cardiomegaly 30%, suppositories
- Prognosis for survival is directly related to the quality of obstetric services, birth provided by their mothers. Neonates weighing above 1800gm or having cardiac dysfunction 10%, asymmetric septal hypertrophy -> obstruction to the left
weight of the child, and quality of the neonatal care. gestational maturity of 34 wks or more belong to this category. The care can ventricle outflow, VSD or ASD, TOGV, tricuspid atresia.
-Neurological prognosis is adversely affected by degree of immaturity, intrauterine be provided at home with basic care at birth, provision of warmth, maintenance Neural tube defects, musculo-skeletal deformities and renal agenesis Pathophysiology:
growth retardation, severity of perinatal hypoxia, hypoglycemia, hyperbilirubinemia, Prognosis of asepsis, and promotion of breast feeding Principles of Management Small colon syndrome: presents as generalized abdominal distension because of inability
intraventricular hemorrhage, Periventricular leukomalacia, and severity of respiratory 2) 10-15% of newborns weighing between 1200-1800gm or having to pass meconium.
failure demanding assisted ventilation. gestational maturity of 30-34 wks should be provided intermediate • Caudal regression syndrome (lumbosacral agenesis):
neonatal care equipped with resuscitation, maintenance of thermoneutral characterized by various: degree of developmental failure involving legs, lumber, sacral,
environment, intravenous infusion, gavage feeding, phototherapy, and coccygeal vertebrae and corresponding segments of spinal cord with urinary incontinence
exchange BT. and dribbling.
3) About 3-5% of newborns require intensive neonatal care (NICU)
equipped with centralized oxygen, suction facilities, and servo-controlled Note: infants with congenital malformations may be small-for-dates.
incubation; vital signs and transcutaneous monitors, ventilation and infusion
pümps, and etc. Babies weighing less than 1200gm or those born before 30 wks
of gestation belong to this category care
