Approach to complications of prematurity (early): Clinical sciences

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Introduction0:00–0:28

Complications of prematurity or birth before 37 weeks of gestation can increase a newborn's risk of morbidity and mortality.
These complications are related to the newborn's developmental and functional immaturity and tend to increase in frequency and severity with decreasing gestational age and birthweight.
If a pediatric patient presents with a chief concern suggesting an early complication of prematurity. Perform an A B CDE assessment to determine if they are stable or unstable.

Unstable Patient0:28–1:11

These patients are typically unstable, so, stabilize their airway breathing and circulation and consider intubation. Next, obtain intravenous or intraosseous access or consider placing an umbilical venous catheter next.
Start IV fluids and begin continuous vital sign monitoring including heart rate, BP and pulse oximetry. Finally, if needed, don't forget to provide supplemental oxygen.

H&P1:11–2:29

Once you've stabilized, your patient obtain a focused history and physical examination which will often reveal nonspecific findings associated with various complications of prematurity.
These may include a history of apneic episodes, lethargy or poor feeding. As far as the exam goes, some signs to look out for include temperature, instability, tachycardia or hypotension.
A common complication to consider is sepsis, especially if there are risk factors such as chorioamnionitis exposure to group B streptococcus during delivery or prolonged rupture of membranes.
Next order blood cultures, possibly in combination with cerebrospinal fluid and urine cultures. Any bacterial growth of a pathogen confirms the diagnosis which should be treated promptly with broad spectrum IV antibiotics.
Now, keep in mind that your patient's cultures will be negative if there's no underlying infection or if not enough time has elapsed for an organism to grow.
Regardless of culture results, you'll need to continue your evaluation for other complications of prematurity. Start by assessing your patient's respiratory effort.

Assess Respiratory Effort2:29–2:46

Signs like nasal flaring, grunting and chest wall. Retractions indicate respiratory distress which could be related to an underlying cardiovascular or pulmonary pathology to investigate further assess for a heart murmur.

PDA2:46–3:47

If you hear a machinery like murmur at the left upper sternal border that radiates to the back, consider a patent ductus arteriosus or PDA.
Now, before birth, increased, pulmonary vascular resistance causes fetal blood to be shunted from the pulmonary artery to the aorta through a fetal vessel called the ductus arteriosus.
The decrease in pulmonary vascular resistance occurring after birth usually causes the ductus arteriosus to close. But in some newborns, it remains patent, which can cause pulmonary over circulation and respiratory distress.
Along with other findings like a widened pulse pressure and bounding peripheral pulses to evaluate further order an echocardiogram.
And if it reveals a PDA with left to right shunting, you've confirmed the diagnosis. On the other hand, if you don't hear a murmur, you should assess your patient's breath sounds.

PTX3:47–4:20

If you notice a unilateral decrease in breath sounds, consider a pneumothorax and urgently order a chest X ray. The presence of a visceral pleural line.
On imaging confirms the diagnosis. Patients with pneumothorax often develop respiratory distress suddenly and often have risk factors including neonatal rds and a history of mechanical ventilation on the flip side.

RDS4:20–5:21

If lung auscultation reveals poor air movement throughout both lung fields, consider neonatal respiratory distress syndrome or R DS.
Order A chest X ray which will reveal ground glass opacities with air bronchogram and low lung volumes. Confirming the diagnosis.
Neonatal R DS is caused by a deficiency of surfactant which is a complex of phospholipids and proteins that decreases alveolar surface tension and prevents collapse of the alveoli without enough surfactant.
These infants develop progressive atelectasis and are unable to generate enough inspiratory pressure to inflate their lungs.
In addition to prematurity, infants with RDS often have other risk factors such as cesarean delivery, maternal history of diabetes or a lack of antenatal corticosteroid administration.
Ok. Let's switch gears and discuss newborns whose exam reveals no signs of respiratory distress.

Hypothermia5:21–6:18

In this case, assess your patient's rectal temperature if it's below 35 °C diagnose hypothermia. Remember that premature newborns have a limited ability to generate body heat and are vulnerable to ambient temperature changes.
They tend to lose heat more quickly than term infants due to a decreased amount of insulating body fat. And because they lack the muscle tone to maintain a flexed position, which increases the surface area for heat loss.
The temperature gradient between the ambient temperature in the delivery room and the newborn skin temperature promotes heat loss.
So, if a preterm delivery is anticipated, the delivery room temperature should be maintained to at least 26 °C. Now, if your patient's rectal temperature is 35 °C or higher, your next step is to assess their blood glucose level.

Hypoglycemia6:18–7:02

If it's below the reference range for your patient's age, diagnose hypoglycemia in a premature newborn, hypoglycemia can present without symptoms or it can present with nonspecific symptoms like irritability, jitteriness or poor feeding factors that increase the risk of hypoglycemia in premature infants include maternal diabetes with resulting neonatal hyperinsulinemia, insufficient glycogen stores and an increased rate of glucose utilization.
However, if the blood glucose level falls within or above the reference range, your next step is to assess your patient's tolerance of enteral feedings.

NEC7:02–7:57

Infants who aren't tolerating enteral feedings might have gastric residuals, abdominal distension or bloody stools. Any of these signs suggesting feeding intolerance should lead you to consider necrotizing enterocolitis or neck and order an abdominal X ray pathognomonic radiographic findings for neck include dilated bowel loops with pneumatosis, intestinalis which is visible air within the intestinal wall.
In severe cases, radiographs may also reveal pneumoperitoneum or air within the abdominal cavity, which indicates intestinal perforation.
Any of these imaging findings confirm the diagnosis of neck. Now, if your patient demonstrates no signs suggesting feeding intolerance, your next step is to assess for an intraventricular hemorrhage or I VH perform a cranial ultrasound.

IVH7:57–9:19

And if it reveals blood in the germinal matrix with or without accumulation in the lateral ventricles, diagnose IV H factors that increase the risk of IV H include a history of stressors such as cardiopulmonary resuscitation, mechanical ventilation or neonatal transport.
Here's a high yield fact, I VH results from a combination of blood vessel immaturity and tissue fragility within the highly vascular germinal matrix of the premature infant's brain.
Most newborns with I VH are asymptomatic and have spontaneous bleeding without any preceding trauma. In these cases, a hemorrhage is usually identified through routine screening.
So remember that all infants born before 30 weeks of gestation should be screened between seven and 14 days of life. Also keep in mind that patients with severe intracranial bleeding may present with apnea, seizures, hypotonia or decreased alertness.
Finally, if the cranial ultrasound demonstrates no evidence of I VH. Your next step is to assess your patient for apneic episodes for premature infants.

AOP9:19–10:00

Apnea of prematurity or AO P for short is a consequence of their immature respiratory control mechanisms instead of an underlying pathology.
So, if a premature newborn with no identifiable underlying pathology experiences a pattern of recurrent cessation of breathing lasting 20 seconds or more or shorter respiratory pauses associated with bradycardia or decreased oxygen saturation, diagnose AOP.

Review10:00–10:44

All right, as a quick recap, a newborn presenting with an early complication of prematurity is often unstable and requires acute management.
After stabilizing, your patient consider sepsis and evaluate for conditions associated with respiratory distress. Like a PDA pneumothorax or R DS also be sure to assess for other complications like hypothermia, hypoglycemia and neck.
Remember to also screen for IV H which can be asymptomatic. Finally, infants with apnea in the absence of underlying pathology can be assumed to have apnea of prematurity.
Approach to complications of prematurity (early) | Osmosis