Approach to complications of prematurity (early): Clinical sciences

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 ABCDE assessment to determine if they are stable or unstable. 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, blood pressure, and pulse oximetry. Finally, if needed, don’t forget to provide supplemental oxygen.

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. 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. 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. 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.