Management of Threatened Prematurity

Introduction:

Prematurity is the collective name for newborns born before 37 weeks of gestation (pregnancy period). Preterm delivery is the most frequent cause of prenatal hospitalization and the main contributor to neonatal mortality. Respiratory failure, illness, and congenital (present from birth) malformations are the three main reasons for the death of premature newborns with weights less than 1000 g.

What Are the Different Ages of Preterm Infants?

A baby's age may vary depending on how early they are born. These are as follows:

• Late Preterm Baby- Born between 34 and 36 full weeks of pregnancy.

• Moderate Preterm- Born between 32 and 34 weeks of pregnancy.

• Very Premature- Delivered at the end of a pregnancy before 32 weeks.

• Extremely Preterm- Delivered at or before week 25 of pregnancy.

How Do Doctors Determine Gestational Age In Premature Baby?

Based on physical and neurological traits, gestational age can be verified. After delivery, clinicians' primary method to determine gestational age is the physical examination with the Ballard scoring system. The following are the main anatomical features that are considered while assessing gestational age:

• Ear cartilage (for instance, a preterm child with a flattened pinna at 28 weeks of gestation has little ear cartilage).

• Sole (for instance, a 33-week-old preterm baby's foot sole only has an anterior crease).

• Breast tissue (a premature newborn at 28 weeks of gestation has no breast tissue and scarcely discernible areolae).

What Are the Diagnostic Tests for Prematurity?

In situations of prematurity, initial laboratory examinations are carried out to find problems, which, if treated, improve the patient's outcome. These tests consist of the following:

• Regular Blood Glucose Monitoring- This is crucial because premature newborns are vulnerable to hypoglycemia (decreased blood glucose) and hyperglycemia (increased blood glucose).

• CBC (Complete Blood Count)- It may be possible to detect anemia (decreased red blood cell) or polycythemia (increased red blood cell) that is not clinically visible.

• White Blood Cell Count (WBC)- Numerous immature neutrophil types and high or low WBC counts are present; an aberrant WBC count suggests a mild illness.

• Coombs Test- Blood-group incompatibilities between the mother and child are found through blood type and antibody testing known as the coombs test, which also identifies antibodies against fetal red blood cells (RBCs). These incompatibilities raise the risk of jaundice and kernicterus (yellow color of sclera).

• Levels of Serum Electrolytes: In extremely low birth weight (ELBW) infants, routine measurement of blood sodium, potassium, calcium, and glucose, together with daily weight and urine output monitoring, aids the clinician in controlling fluid and electrolyte balance.

• Imaging Tests- Imaging tests are unique to the damaged organ system. Chest radiography measures the heart's size and the lungs' parenchyma in babies with respiratory distress.

• Ultrasound- In premature newborns, cranial ultrasonography is used to find hidden cerebral bleeding.

• Lumbar Puncture- Premature newborns with positive blood cultures and those with clinical symptoms of a central nervous system infection are given lumbar punctures. Due to their size and surrounding clinical conditions, doing lumbar punctures on ELBW preterm infants can occasionally be challenging. However, lumbar puncture is done whenever it is practical; this will aid in figuring out how long antibiotic therapy should last.

What Is the Management and Treatment Plan for Premature Babies?

The management of premature babies consists of the following approaches:

• Considerations in the Approach Consultations- Neurodevelopmental issues are more likely to happen as gestational age and birth weight increase. Consider speaking with a developmental specialist in cases of preterm. Newborns should have a hearing test done before delivery. Stabilization in the delivery room and prompt respiratory and thermal care are essential for premature infants.

• Respiratory Control- Respiratory management consists of the following-

  1. In the newborn with respiratory distress, mechanical ventilation or surfactant is used, with continuous positive airway pressure (CPAP) provided nasally, by nasal mask, or with an endotracheal tube used to recruit and maintain adequate lung capacity.
  2. Using pulse oximetry to prevent hypoxia (decreased oxygen supply) or hyperoxia (increased oxygen supply). Use blended oxygen at a target oxygen saturation (SaO2) range of 90 to 95 %. The maximum alarm limit should not exceed 95 %, and the lower limits of the pulse oximeter alarm should be set closer to the lower saturation limit.
  3. When employing a mechanical ventilator, the aim should always be to prevent barotrauma and volutrauma. Tidal volume is typically 4 to 7 mL/kg.
  4. Early surfactant delivery (age 2 hours) is advised when necessary. It is not recommended to utilize prophylactic surfactant for preterm regularly.

Manual Versus Automated Oxygen Control- Studies have shown that automated oxygen control enhances oxygen saturation targeting in preterm infants receiving noninvasive and invasive respiratory assistance across various saturation levels. Automatic oxygen regulation lowers hypoxemia and hyperoxemia.

• Thermoregulation-

1. Maintaining a newborn's normal body temperature is crucial, but preterm infants need this maintenance the most. Generally, a normal body temperature of 36.5°C to 37.5 °C (97.7 to 99.5 °F) is maintained.

2. To control the desired temperature, use radiant warmers with skin probes. For newborns with ELBW, a warm and humidified isolette is ideal.

3. Immediate postpartum care for ELBW newborns can also be greatly aided by using food-grade plastic wrap or sheets to regulate humidity and stop heat loss. At least 25 °C (77 °F) should be kept as the ambient temperature.

• Management of Fluid and Electrolytes- For several reasons, preterm newborns need their fluid and electrolyte levels closely monitored because of several reasons such as:

1. Immature skin in preterm babies increases transepidermal water loss.

2. Immature kidney function.

3. The use of radiant warming.

4. Phototherapy.

5. Mechanical ventilation.

The key to managing ELBW newborns is carefully monitoring glucose, electrolyte levels, and acid-base balance. Monitoring input and output is essential. When managing fluids and electrolytes in premature newborns, checking for urine production, serum electrolyte levels, and daily weight are crucial. The level of prematurity determines the initial fluid management.

1. A glucose and water solution should be used as the first fluid.

2. Adding calcium to the original fluid is an option.

3. Starting whole parenteral feeding as soon as possible is advisable, especially for infants who are ELBW.

• Medication- Prematurity is not a particular disease. Preterm children receiving injections of the erythropoiesis-stimulating drug darbepoetin alfa (Darbe) may not require red blood cell transfusions. Preterm infants treated with erythropoietin (EPO) 400 U/kg, subcutaneously administered three times weekly; darbepoetin alfa 10 g/kg, subcutaneously administered. Weekly dose adjustments are made for body weight. Darbepoetin alfa and erythropoietin-treated infants show greater changes in absolute reticulocyte counts (cells that form different blood cells) and hematocrits (hemoglobin parameters). Using an erythropoiesis-stimulating drug may be beneficial, but the risks of neovascularization (abnormal blood vessel formation) and tumor development must also be considered.

What Are the Requirements for the Discharge of Preterm Infants?

Parents and other carers are competent. In other words, they can care for the baby's requirements. The following are the requirements for discharge in cases of prematurity:

• The baby is consuming enough calories to grow.

• The baby is no longer receiving further heat.

• Medical issues can be identified and treated at home.

• Both bradycardia (decreases heart rate) and apnea (episodes of the absence of breath) are absent.

Conclusion:

A preterm infant will require a longer hospital stay in a nursery unit. A newborn may be admitted to a neonatal critical care unit (NICU) or an intermediate care nursery, depending on the level of care needed. The doctors and trained specialists will care for the preterm infants. Concerned families should feel confident to ask questions. Immediately after delivery, the baby may require additional assistance with eating and acclimating. The medical staff can assist the mother in understanding the infant's requirements and treatment plan.