Prenatal care and complications of prematurity Juan J Cardesa.

02/26/2007 Prenat
al Pediatrics.
PRENATAL CARE
• During the last decades, the main reason for the decline in infant mortality h
as been the increased survival of infants of low birth weight, not the reduction
of low birth weight (LBW).
• The incidence of low birth weight has increased as a result of the use of Assi
sted Reproductive Technologies:
- Increase the number of multiple pregnancies and at the same time - increases t
he frequency of low birth weight.
PRENATAL CARE. Prematurity.
12 percent of newborns born before term. The majority (about 83 percent) born be
tween 32 and 36 weeks of gestation. About 10 percent do between weeks 28 and 31.
The 6 percent before the age of 28 weeks.
PRENATAL CARE. Prematurity.
Percentage of Prematurity
1. 12 percent of newborns born before term. 2. The majority (about 83 percent) b
orn between 32 and 36 weeks of gestation. 3. About 10 percent do between weeks 2
8 and 31. 4. The 6 percent before the age of 28 weeks.
88%
12%
RN Term
Preterm newborns
Distribution of prematurity by EG
10%
84%
6%
32-36 weeks
28-31 weeks
<28 weeks
PRENATAL CARE. MORTALITY
Lubchenco LO, 1966
Thomas, P. 2000
PRENATAL CARE. Prematurity.
• Most of those born after the completion of 26 weeks of gestation survived (abo
ut 75 percent of those born at 26 weeks and about 85 percent of those born at 29
weeks) but may have to stay longer time in the neonatal intensive care unit. •
Nearly 30 percent of babies born before 26 weeks of gestation and about 20 perce
nt of those born between 26 and 29 weeks develop serious and lasting disabilitie
s
PRENATAL CARE. Prematurity. There are six groups of women who are at higher risk
for premature labor and give birth to a premature newborn: 1. Women who have ha
d a premature delivery or premature newborns. 2. Women expecting twins, triplets
or more babies. 3. IVF with one child. 4. Women with abnormalities in the uteru
s or cervix. 5. Women who are under 17 years old or over 35 years of age. 6. Wom
en with few resources
PRENATAL CARE. Prematurity.
Lifestyle Risk
Some studies have found that certain lifestyle factors can put a woman at risk f
or premature delivery. These factors are:
• Lack of prenatal care or late prenatal care begin • Smoking, drinking alcohol,
illicit drug use. • domestic abuse, including physical abuse, sexual or emotion
al • Lack of social support, low income. • High levels of stress • Work long hou
rs and standing for long periods of time
PRENATAL CARE. Prematurity.
Medical Risks
Certain medical conditions during pregnancy may increase the likelihood that a w
oman has a premature birth. The conditions are:
• Premature rupture of membranes. • Vaginal infections, urinary tract infections
, sexually transmitted infections, and possibly other infections • High blood pr
essure • Diabetes • Clotting disorders (thrombophilia) • Have an underweight bef
ore pregnancy • Obesity • Short periods between pregnancies ( less than 6-9 mont
hs between birth and the beginning of another pregnancy) • Certain malformations
. • Vaginal bleeding
PRENATAL CARE
Epidemiological data. 1. Unwanted pregnancy: 30-50% of the total and up to 75% i
n children under 20 years. 2. Unwanted pregnancies are associated with increased
morbidity and maternal and infant mortality:
Lifestyle: drugs, alcohol, snuff. STD. Poor feeding, poor food folic acid. Lack
of prenatal care in the first quarter to 50% of cases.
3. Up to 20% of unwanted pregnancies do not receive care in the first trimester
of pregnancy.
PRENATAL CARE IMPORTANT OBJECTIVES: 1. Eliminate exposure to unhealthy lifestyle
s:
Snuff, Alcohol, drugs. Adequate food. Sexual practices. Maternal stress.
2. Reduce the rate of low birth weight and preterm birth:
Intestinal tract infections, assisted reproduction techniques.
3. Improving antenatal care, applying techniques of screening and early detectio
n.
PRENATAL CARE
Most premature births due to preterm delivery (which may occur after premature r
upture of membranes). Not known with certainty the causes of preterm labor or pr
emature rupture of membranes€but recent research suggests that in many cases due
to the body's natural response to certain infections, such as those affecting t
he amniotic fluid and fetal membranes
PRENATAL CARE
Food Safety
The three risks of foodborne diseases for pregnant women
1. Listeria. Where is it? • refrigerated ready to eat foods: hot dogs and sausag
es, pates and pastries of meat, fish or refrigerated smoked seafood (NOT COOKED)
. • Milk and unpasteurized dairy products such as soft cheeses such as feta, Bri
e, Camembert, "blue-veined cheeses," "white cheese", "cheese."
PRENATAL CARE
Food Safety
The three risks of foodborne diseases for pregnant women
2. Metal Methylmercury can be found in some large predator fish, which live long
er, such as shark, snapper or golden dorado, mackerel, tuna and swordfish. Shoul
d be avoided during pregnancy. At high levels can harm the developing nervous sy
stem of an unborn child.
PRENATAL CARE
Food Safety
The three risks of foodborne diseases for pregnant women
3. Toxoplasma. Where is it?
Raw meat and undercooked, unwashed fruits and vegetables, soil, litter boxes and
cat dirty outdoor places where cat feces can find.
How to prevent the disease?
• • • • If possible, have someone else change the litter box. Otherwise, hand wa
shing with soap and warm water afterwards. Use gloves when doing yard work or wh
en handling sand from a sandbox. No new cat while you're pregnant. Thoroughly co
ok meat in general.
PRENATAL CARE Food Safety • Avoid the following:
- Swordfish, shark, face, golden snapper and tuna. These fish can contain potent
ially dangerous levels of mercury. - Raw fish, especially shellfish (oysters, cl
ams) - Meat, poultry, hot dogs (hot dogs), burgers, undercooked. Cook all meat,
poultry and seafood to kill bacteria. LIVER!
PRENATAL CARE Food Safety • Avoid the following during pregnancy:
- Cold cuts such as ham (?), Turkey, salami and pepperoni. - Refrigerated smoked
seafood, unless it has been cooked (as in a casserole). - Scrambled eggs and al
l foods made with raw or undercooked eggs. - Soft cheeses such as Brie, Camember
t, Roquefort, unless the label says they're made with pasteurized milk - unpaste
urized milk and any food derived from it.
PRENATAL CARE Caffeine safety of caffeine consumption during pregnancy is contro
versial. • Some studies suggest that moderate consumption of caffeine (less than
two average cups of coffee a day, 150-200 mg) may pose risk to the embryo or fe
tus, but other studies. • There is evidence that consumption of greater amounts
of daily caffeine during pregnancy may increase the risk of spontaneous abortion
, premature delivery, low birth weight.
PRENATAL CARE
Food Safety
1. Clean 2. Separate 3. Cook 4. Cool
PRENATAL CARE
Recommended vaccines according to the Centers for Disease Control and Prevention
 U.S. (CDC), the following vaccines are routinely recommended for pregnant women
at risk of infection: • Hepatitis B: Recommended for pregnant women at risk of
infection. • Influenza vaccine (made from inactivated virus): Recommended for wo
men who will be pregnant during flu season. • Tetanus / Diphtheria: Recommended
routinely to pregnant women. • Meningococcus: Recommended for pregnant women at
risk of infection. • Rabies: Recommended for those exposed to infection. Can be
recommended to those with a high risk of exposure.
PRENATAL CARE
• Vaccines to Avoid According to the CDC, the following live virus vaccines are
not recommended during pregnancy: • Flu vaccine with live virus. • * • Measles •
Mumps Rubella Varicella * • • BCG (tuberculosis) * If possible, women should av
oid becoming pregnant for one month after receiving the vaccine.
PRENATAL CARE
Special cases experts know very little about how these vaccinations can affect t
he fetus and the embryo: • Hepatitis A • pneumococcal vaccine • Polio • Anthrax
• Japanese Encephalitis • Smallpox • Typhoid • Yellow fever
PRENATAL CARE
THINGS TO AVOID Some drugs are especially damaging during the first weeks of pre
gnancy. These include: • Isotretinoin, Etretinate, Acitretin. In treatment for A
cne and Psoriasis. These drugs can be harmful even if taken up to three years be
fore pregnancy. • Thalidomide used to treat multiple myeloma and certain complic
ations of AIDS and leprosy. • ACE inhibitors can damage the kidneys and may caus
e fetal death when taken during the second and third trimester of pregnancy. Amo
ng them are the Captotril and Enalopril. • Aspirin just before the day of delive
ry, may increase the risk of excessive bleeding for both mother and child.
Diaphragmatic hernia
Ultrasound prenatal diagnosis
heart
Posterior stomach
Heart: four cameras
NORMAL prenatal ultrasound at 18-24 weeks: one can see the four chambers of the
heart and lung masses on the sides collapsed.
The movement of lung structures and the presence of abdominal viscera (stomach a
nd intestines at the left side, and liver on the right side), show the existence
of a diaphragmatic hernia prenatal
Diaphragmatic hernia.
PRENATAL DIAGNOSIS BY MRI
Prenatal MRI image of left diaphragmatic hernia showing compression and deviatio
n of the mediastinum lung
Bochdalek hernia. NEW TECHNIQUES FOR IMAGE DIANÓSTICO
Ultrafast MRI (≤ 1 sec) with fetal movements in utero can "freeze." Fetus of 22
weeks gestational age with left congenital diaphragmatic hernia. Sagittal: Stoma
ch. Portal vein. Liver.
Adzick and Dance, NEJM, 2000; 342:1726.
Diaphragmatic hernia. NEW TECHNIQUES FOR IMAGE DIANÓSTICO
P. left: 3.88 ml Plans: A transversal, sagittal B, C front
P. right 1.87 ml Plans: A transversal, sagittal B, C front
The three-dimensional ultrasound to calculate the volume of the lungs and the de
gree of pulmonary hypoplasia as a prognosis factor. In a case of right diaphragm
atic hernia, a three-dimensional ultrasound imaging technique was used to calcul
ate the rotational multiplanar volume of both lungs.
Ruano et al. Fetal Diagn There. 2004, 19:87-91.
Congenital diaphragmatic hernia. Prenatal and Perinatal THERAPEUTIC TECHNIQUES
a) c)
b) c)
Combining ultrasound with fetal endoscopy (FETENDO) have tested two techniques o
f tracheal obstruction: a) by clamping, initial technical, aggressive and comple
x, and abandoned-b) through an endotracheal cuff placement, a technique used tod
ay. In both cases, the goal is to prevent the leakage of fluid produced in the f
etal lung, which promotes their growth and makes entry of the abdominal viscera
into the chest cavity. The delivery and removal of the endotracheal balloon tech
nique is performed using the ex utero Intrapartum Treatment c) taking advantage
of still providing oxygenation to the placenta through the umbilical vessels. Sy
dorak and Harrison.
World J Surg. 2003, 27:68-76.
NEONATAL CARE main problem. • Thermoregulation. • Respiratory. • Immaturity enzy
me. • Poor kidney function. • neurological risk. • Tendency to bleeding. • Immun
ity. • Food.
Prematurity. COMPLICATIONS. Respiratory distress syndrome (RDS). Apnea. Metaboli
c: Hypoglycemia, HIPOCAS, acidosis, DH 4. Intraventricular hemorrhage (IVH). 5.
Ductus arteriosus (PDA). 6. Necrotizing enterocolitis (NEC). 7. Retinopathy of p
rematurity (ROP). 8. Anemia. Jaundice. 9. Bronchopulmonary dysplasia (BPD). 10.
Infections. 1. 2. 3.
PRENATAL CARE FOR LONG-TERM SEQUELAE prematurity and low birth weight. 1. Neurol
ogical disorders. 2. Learning disorders. 3. Developmental delay.
PRENATAL CARE
PRENATAL VISIT OF PARENTS TO PEDIATRICIAN.
OBJECTIVES.
1. Establish relationship between parents and physician. 2. Collect data and inf
ormation for parents, family situation, their needs and concerns, personal histo
ry, family, other pregnancies, siblings, knowledge of child care, etc. 3. Provid
e information and advice. 4. Teach techniques for care and childcare. 5. Identif
ying high-risk situations: teenagers, unmarried, poverty or lack of resources, g
enetic diseases, substance abuse, risk of domestic violence, maternal illness, e
tc.