Preterm Delivery

Last updated 03.11.12

Index

Definition

- Delivery of fetus <37 weeks gestation

- Term = 37-40 weeks

Features

- 5-11% all labours

- 20% perinatal deaths

- 35% neonatal deaths

- May be indicated or unplanned

- Determine if

- Covered by steroids

- Received Abx in labour for prolonged ruptured membranes

- Maternal infectious serology

Risk Factors

- Indicated (induced)

- Pre-eclampsia, eclampsia

- APH

- Previous premature birth

- Ruptured membranes: PPROM

- Stretched uterus

- Multiparity: twins

- Polyhydramnios

- Fibroids

- Uterine abnormalities

- Infection: UTI, STI, chorioamnionitis

- Vaginal bleeding during pregnancy

- Chronic disease: HTN, DM, CRF..

- Previous TOP (esp 2nd trimester)

- Thrombophillia

- Smoking

- Short cervix

- <25mm more likely to dlivery early

- <15mm high risk

- Cervical surgery: cone biopsy..

Complications

- RDS

- Chronic Lung Disease

- Intracranial Haemorrhage (IVH..)

- Bulging ant fontanelle

- Usually in 1st 48-72 hrs

- Grade 1: Subepindymal

- Grade 2: IVH (Interventricular haemorrhage)

- Grade 3: IVH + ventricular dilation

- Grade 4: Cerebral haerorrhage

- Neurological sequelae: CP, hearing/visual/cognition/language problems

- Hydrocephalus, prosencephaly, periventricular leukomalacia

- Retinopathy of Prematurity (ROP)

- NEC

- CP

- Apnoea

- Anaemia

- Jaundice

- Hypoglycaemia

- Hypothermia

Ix

- APGAR

- Bloods

- ABGs: RDS

- Every week for 2 weeks then 2nd weekly

- CMP, ALP, Albumin (corrected Ca): bone mineral status

- Ablumin, Urea +/- transthyretin: protein assessment

- Hb, Retics: anaemia

- X-ray

- CXR: RDS

- AXR: NEC

- +/- wrist X-ray for bone age

- Ultrasound

- Cranial US

- Day 5: IVH

- Week 6: periventricular leukomalacia swiss chesse

- Bilateral Hip US

- DDH

- Week 6 post 40 weeks corrected gestation

- Ie: 35 weeks gestation at delivery --> US 11 weeks later

- Fundoscopy w dilation: ROP

- Careful use of O2: too high --> ROP

- Careful use of TPN: too high --> NEC

- Weight: aim for increase 15g/kg/day until 2kg then 20-30g/day 

- Length: aim for 1cm+/week

- HC: 1cm+/week

Mx

- IM Steroids

- Betamethasone, Dexamethasone

- 24hrs prior to birth

- Decreases: RDS, IVH, NEC, PDA

- Determine cause of prematurity

- Abx if indications of infection

- Determine if membranes ruptured

- If >18hrs Abx prophylaxis

- Tocolysis

- Referral to tertiary referral centre for premature babies

- Mx of Complications

- Ix as above

- RDS

- NEC

- DDH

- ROP

- High flow O2 (once Dx)

- Feeding

- IV fluids with Glucose until enteral feeds established

- 0.225% Sodium Chloride + 10% Glucose + 10mmol KCL in 500mls

- OR 10% Dextrose (Glucose) if hypoglycaemic

- If <35 weeks NGT for feeds as sucking reflex not present

- Bottle/breast always offered prior to NG feeds

- Sucking reflex usually present +/- 35 weeks --> NGT to PO

- Aim for enteral feeds at 2-5 days old

- Prime GIT if <1500g birth weight

- Establish feeds if >1500g birth weight

- Initiated with unfortified human milk (preferred) or preterm formula

- 10-20ml/kg/day

- After several days increase rate by 10-35ml/kg/day

- When tolerating 100ml/kg/day or unfortified milk 1 week increase energy intake

- Add fortifier (protein, Ca, PO4, Na, +/- Fe) or change formula

- Goal to reach

- 150-160ml/kg/day preterm formula

- OR 160-180ml/kg/day fortified human milk

- Iron supplementation up to 1yrs old

- +/- Vitamin D supplementation

References

Cochrane Review: Prophylactic Antibiotics for Inhibiting Preterm Labour with Intact Membranes, 15/04/2009