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