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CHAPTER 1
INTRODUCTION
1.1 Background
1.1.1. Premature Baby
A premature baby is one who is born too early, before 37 weeks. Premature
babies may have more health problems and may need to stay in the hospital
longer than babies born later. They also may have long-term health problems that
can affect their whole lives. About 1 in 10 babies is born prematurely each year in
the United States.
The earlier in pregnancy a baby is born, the more likely he is to have health
problems. Some premature babies have to spend time in a hospital’s neonatal
intensive care unit (also called NICU). This is the part of a hospital that takes care
of sick newborns. But thanks to advances in medical care, even babies born very
prematurely are more likely to survive today than ever before.
Premature babies can have some health problems after birth. Health problems
that may affect premature babies include apnea, respiratory distress
syndrome(RDS), Intraventricular hemorrhage (IVH), Patent ductus arteriosus
(PDA), Necrotizing enterocolitis (NEC) and many more. But the most common
breathing problem in babies born before 34 weeks of pregnancy is the respiratory
distress syndrome. Babies with RDS don’t have a protein called surfactant that
keeps small air sacs in the lungs from collapsing.
Babies with RDS have some condition to go home from the hospital, like:
Weighs at least 4 pounds.
Can keep warm on his own, without the help of an incubator. An incubator is
an enclosed unit that helps premature babies stay warm.
Can breastfeed or bottle-feed
Gains weight steadily ( ½ to 1 ounce each day)
Can breathe on his own.
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CHAPTER 2
LITERATURE REVIEW
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2.1. Prematurity
2.1.1. Definition prematurity
Prematurity is a term for the broad category of neonates born at less than 37
weeks' gestation. Preterm birth is the leading cause of neonatal mortality and the
most common reason for antenatal hospitalization.For premature infants born
with a weight of less than 1000 g, the 3 primary causes of mortality are
respiratory failure, infection, and congenital malformation.
Trouble breathing
Low weight
Inability to maintain a constant body temperature
Lanugo (body hair)
Low body fat
Less activity than normal
Underdeveloped muscles
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Uteroplacental ischaemia
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2.1.4.Diagnosis
Laboratory studies
Initial laboratory studies in cases of prematurity are performed to identify issues
that, if corrected, improve the patient's outcome. Such tests include the following:
Complete blood count (CBC): May reveal anemia or polycythemia that is
not clinically apparent
White blood cell (WBC) count: A high or low WBC count and numerous
immature neutrophil types may be found; an abnormal WBC count may
suggest subtle infection
Blood type and antibody testing (Coombs test): These studies are
performed to detect blood-group incompatibilities between the mother and
infant and to identify antibodies against fetal red blood cells (RBCs); such
incompatibilities increase the risk for jaundice and kernicterus
Serum electrolyte levels: Frequent determination of serum sodium,
potassium, and glucose concentrations, in conjunction with monitoring of
daily weight and urine output in extremely low birth weight (ELBW)
infants, assist the practitioner in determining fluid requirements
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Imaging studies
Imaging studies are specific to the organ system affected. Chest radiography is
performed to assess lung parenchyma in newborns with respiratory distress.
Cranial ultrasonography is performed to detect occult intracranial hemorrhage in
ELBW newborns. Prematurity itself is not an indication for an imaging study.
Lumbar puncture
Lumbar puncture is performed in infants with positive blood cultures and in those
who have clinical signs of infection (presumed sepsis) and for whom a full course
of antibiotic coverage is planned.
2.1.5 Treatment
Management
Stabilization in the delivery room with prompt respiratory and thermal
management is crucial to the immediate and long-term outcome of premature
infants, particularly extremely premature infants.
Respiratory management
Recruitment and maintenance of adequate or optimal lung volume; in
infants with respiratory distress, this step may be accomplished with early
continuous positive airway pressure (CPAP) given nasally, by mask
(Neopuff), or by using an endotracheal tube when ventilation and/or
surfactant is administered
Avoidance of hyperoxia and hypoxia by immediately attaching a pulse
oximeter and, using an oxygen blender, keeping the oxygen saturation
(SaO2) between 86% and 93%
Prevention of barotrauma or volutrauma by using a ventilator that permits
measurement of the expired tidal volume and by keeping it at 4-7 mL/kg
Administration of surfactant early (< 2 hr of age) when indicated and
prophylactically in all extremely premature neonates (< 29 wk)
Thermoregulation
In the intensive care nursery, radiant warmers may be used to compensate for heat
loss in the premature infant. Incubators are more efficient than radiant warmers
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2.2.3. Pathogenesis
1. Transient tachypnea of the newborn
TTN is a parenchymal lung disorder characterized bypulmonary edema
thatresults from delayed resorption andclearance of fetal alveolar fluid in term
infants). Theexcess fluid in the lungs in TTN results in decreasedpulmonary
compliance and increased airway resistanceThe mechanism causing changes in
pulmonary function areprimarily associated with the extrinsic compression
ofsmall airways by fluid in the extra-alveolar interstitium.Tachypnea develops
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2.2.4. Pathofisiology
The primary cause of RDS is inadequate pulmonarysurfactant. The
structurally immature and surfactant-deficient lung has ↓ compliance anda
tendency to atelectasis; other factors in preterm infants that ↑ the risk of
atelectasis aredecreased alveolar radius and weak chest wall. With atelectasis,
well perfused but poorlyventilated areas of lung lead to V/Q mismatch (with
intra-pulmonary shunting) andalveolar hypoventilation with resultant hypoxemia
and hypercarbia. Severe hypoxemiaand systemic hypoperfusion result in
decreased O2 delivery, anaerobic metabolism and subsequent lactic acidosis.
Hypoxemia and acidosis may further impair oxygenatiob by causing pulmonary
vasoconstriction, resulting in right-to-left shunting at the levels of the foramen
ovale and ductus arteriosus. (Hermencan C,2007)
Other factors, such as baro/volutrauma and high FiO2, may initiate release of
inflammatory cytokines abd chemokines causing more endothelial and epithelial
cell injury. The injury results in reduced surfactant synthesis and function as well
as increased endothelial permeability leading to pulmonary edema. Leakage of
proteins into thealveolar space further exacerbatessurfactant deficiency by
causingsurfactant inactivation.Macroscopically, the lungs appearcongested,
atelectatic and solid.Microscopically, diffuse alveolaratelectasis and pulmonary
edema areseen. An eosinophilic membranecomposed of a fibrinous matrix
ofmaterials from the blood and cellulardebris (the hyaline membrane) lines the
visible airspaces that usually constitute dilatedterminal bronchioles and alveolar
ducts.
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Prematurity
Male gender
Familial predisposition
Cesarean section without labor
Perinatal asphasia
Cancasian race
Infant of diabetic mother
Chorioamnonitis
Non-Immune hydrops fetalis
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2.2.7. Diagnosis
RDS diagnosis can be enforced through clinical manisfestation and can be
confirmed with gas blood analysis. Clinical manisfestation that happen to
neonatal baby is:
Cyanosis
Apnea
Decreased urine output
Nasal flaring
Puffy or swollen arms and legs
Rapid breathing
Shallow breathing
Shortness of breath and grunting sounds while breathing
Increased oxygen requirement
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2.2.8 Management
The goals of management of an infant with RDS are to (Halliday, 2010)
Avoid hypoxemia and acidosis
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The three most important advances in prevention and treatment of RDS have
been:
a) antenatal glucocorticoids
b) continuous positive airway pressure (CPAP) and positiveend-
expiratory pressure (PEEP)
c) surfactant replacement therapy. These havedramatically decreased
morbidity and mortality from RDS.
1. Antenatal glucocorticoids
Antenatal administration of corticosteroids that pass through the placenta to
the foetus (betamethasone 24 mg; or dexamethasone 24 mg; or 2 g.
hydrocortisone) has been shown to decrease the incidence of RDS. Best results
are obtained if more than 24 hours and less than 7 days have elapsed between
commencement of treatment and delivery.
2. Exogenous surfactant
It has been shown in multiple randomized controlled trials that the use of
exogenous surfactant in preterm infants improves oxygenation, decreases air
leaks, reduces mortality due to RDS, and decreases overall mortality.
A. Timing of surfactant administration:
Two approaches have been used for surfactant delivery which is prophylactic
and rescue treatment.
Prophylactic administration
Involves giving surfactant soon after birth, as soon as the infant has been
stabilized. The theoretical benefit of this approach is that replacement of
surfactant before RDS develops will avoid or ameliorate lung injury. Animal
studies have shown that the lung epithelium of very premature subjects can be
damaged within minutes of onset of ventilation. The damage can result in protein
leak which subsequently interferes with surfactant function.
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Rescue administration
Involves giving surfactant to infants who have established RDS and require
mechanical ventilation and supplemental O2. The advantage of this approach is
that patients are not treated unnecessarily. Because surfactant currently can only
be given via an endotrachealtube, this would prevent intubation and mechanical
ventilation of infants who would do well without surfactant and avoid
unnecessary baro/volutrauma, adverse physiological effects of laryngoscopy, and
possible inadvertent hyperventilation. Past studies have shown greater reduction
in neonatal mortality with prophylactic administration versus rescue, especially in
infants greatest at risk for RDS (i.e., <27weeks GA). However, with the use of
nasal CPAP in VLBW infants and higher rates of antenatal steroid administration,
there exists controversy on the optimal timing of surfactant administration,
balancing the benefits of early surfactant administration with the advantages of
avoiding mechanical ventilation and volutrauma. The current approach to the
timing of surfactant therapy at UCSF is summarized in Table 1.
For prophylactic administration, the position of the endotracheal (ET) tube should
be verified by two people before surfactant is given. Attach the surfactant syringe
to the side port of the ET tube, occlude end of ET tube, and administer surfactant
as a single aliquot over ≈ 5 sec. For rescue therapy, obtain chest radiograph to
confirm tube position. Administer surfactant through a feeding tube inserted to
(but not past) the end of the ET tube. Administer in same manner as with
prophylactic treatment. Slower administration may interfere with its efficacy.
After administration, the infant should be hand ventilated and may transiently
require higher ventilatory support. Several studies have shown that two doses, 12
h apart, may be more effective than single dose therapy. More than 2 doses is
rarely required and is rarely effective. The dose of surfactant is:
Infasurf 3mL/kg
Survanta 4 mL/kg
Rescue treatment with surfactant should be given to preterm infants who have:
• Respiratory distress, necessitating intubation and assisted ventilation,
• No radiological evidence of another disease process, and require either
• FIO2 > 0.3 or a mean airway pressure ≥7 cmH2O
D. Complications
3. Oxygen
Oxygen should be administered to preterm infants in concentrations sufficient
to maintain PaO2 between 50-70 mmHg or saturation (by pulse oximetry)
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hyperventilation, hyperoxia and over distension of the lung, all of which can
result in lung injury. Although it may be necessary to wean FIO2, inspiratory
pressure and ventilator rate, one should decrease PEEP with extreme caution.
Infants in the early phases of RDS will rarely maintain adequate lung inflation if
PEEP is <5 cmH2O, even after administration of surfactant. Recently, much
effort has been directed towards other, less invasive modalities of respiratory
support to prevent lung injury, specifically nasal CPAP. CPAP, as treatment for
RDS, was first described in 1971 by George Gregory at UCSF. Modifications in
the nasal CPAP delivery system have generated renewed interest in nasal CPAP
for the ventilatory management of RDS. Randomized controlled trials have
shown a decreased need for mechanical ventilation in VLBW infants treated with
nasal CPAP, although the impact on mortality and chronic lung disease have not
been defined.
Furthermore, recent reports indicate that approximately 70% of infants with birth
weight <1,000 g will not be adequately managed with nasal CPAP and will
require intubation and mechanical ventilation. Nevertheless, in order to minimize
ventilator-induced lung injury, early extubation to nasal CPAP is a reasonable
strategy. Criteria for extubation to nasal CPAP in the first week of life are:
3. Antibiotic therapy
The clinical and radiographic features of pneumonia may be indistinguishable
from RDS at birth. As a result, all infants with RDS should have blood cultures
and CBC drawn, and should receive empiric antibiotic therapy (Ampicillin and
Gentamicin). Generally, antibiotics may be discontinued if the blood culture has
no growth after 48 hours, unless prenatal history or clinical scenario warrants
extended treatment.
4. Thermoregulation
Careful temperature control is imperative in all VLBW infants and is especially
important in infants with RDS to minimize metabolic demands and oxygen
consumption. RDS can limit oxygen uptake leading to hypoxia which limits the
ability of an infant to increase their metabolic rate when cold stressed, resulting in
a falling body temperature. An incubator or radiant warmer must be utilized to
maintain a neutral thermal environment for the infant.
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CHAPTER III
CASE REPORT
3.1 Objective
The objective of this paper is to report a case of a 1 hour old boy with a diagnosis
of premature birth and respiratory distress.
3.2 Case
Baby AD, a 1 hour old boy, with 1.33 kg of birth weight and 38 cm of body
height, was admitted in Perinatology Division on 20 th July at 6.30 AM with chief
complaint of premature birth.
History of medication :-
History of family :-
History of parent’s medication :-
History of pregnancy : The age of the patient’s mother was 25
during pregnancy. The gestational age was
28 weeks.
History of birth : Birth was assisted by obstec in RSUP
HAM.. The patient was born paravaginal
and cry immediately after birth. Body
weight at birth was 1330 gram, body length
at birth was 38 cm and head circumference
was 26 cm. Cyanosis (+), Jaundice (-).
Patient was placed in preheated infant
warmer and suctioned through mouth and
nasal. Patient was given oxygen ½ litre per
minute via nasal canule. Patient was dried
with cloth and the baby cried louder, gained
good muscle tone, skin appears reddish and
active movement. Umbilical was wrapped
with strerile gauze.
History of feeding : Breast feeding was given 7 days after birth.
Physical Examination:
Present status:
Sensorium : compos mentis Body temperature: 36.0°C
HR: 150 bpm
RR: 56 bpm
BW: 1.33 kg
BL: 38 cm
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4) Suspect of sepsis
Laboratory finding:
Complete blood analysis (July 20th 2016 / 0932WIB)
Test Result Unit References
Hemoglobin 17.2 g/dL 17 – 22
Erythrocyte 4.73 106/µL 4.50 – 6.50
Leucocyte 23.3 103/µL 10 – 30
Thrombocyte 391 103/µL 150 – 450
Hematocrite 50 % 31 – 59
Eosinophil 0.30 % 1–3
Basophil 0.70 % 0.00-1.00
Neutrophil 72.80 % 50 – 70
Lymphocyte 13.70 % 20 – 40
Monocyte 12.50 % 2–8
Neutrophil absolute 16.97 103/µL 5.5-18.3
Lymphocyte absolute 3.19 103/µL 2.8-9.3
Monocyte absolute 2.92 103/µL 0.5-1.7
Eosinophil absolute 0.07 103/µL 0.02-0.70
Basophil absolute 0.16 103/µL 0.1-0.2
MCV 106 fL 80-97
MCH 36.4 Pg 26.5-33.5
MCHC 34.4 g/dL 31.5 -36
Theraphy :
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FOLLOW UP
CHAPTER IV
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DISCUSSION
Theory Case
Definition
Prematurity is a term for the broad The gestational age was 28 weeks.
category of neonates born at less than
37 weeks' gestation. Preterm birth is
the leading cause of neonatal mortality
and the most common reason for
antenatal hospitalization. For premature
infants born with a weight of less than
1000 g, the 3 primary causes of
mortality are respiratory failure,
infection, and congenital malformation
Clinical Manifestation Patient AD had small amount of ear
Confirmation of gestational age is cartilage and no breast tissue was
based on physical and neurologic
found. The areola barely visible.
characteristics. The Ballard Scoring
System remains the main tool
clinicians use after delivery to confirm
gestational age by means of physical
examination. The major parts of the
anatomy used in determining
gestational age include the following:
-Ear cartilage (eg, a preterm infant
at 28 weeks’ gestation has a small
amount of ear cartilage and/or a
flattened pinna)
-Sole (eg, a preterm infant at 33
weeks’ gestation has only an
anterior crease on the sole of the
foot)
-Breast tissue (eg, a preterm infant
at 28 weeks’ gestation has no breast
tissue, and the areolae are barely
visible)
-Genitalia
Diagnosis - Numerous neutrophil types
found
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Laboratory studies
Initial laboratory studies in cases of
prematurity are performed to identify
issues that, if corrected, improve the
patient's outcome. Such tests include
the following:
Theory Case
Definition Baby AD is a preterm baby with
Neonatal respiratory distress syndrome gestational age 28 week.
(RDS) is a condition of pulmonary
insufficiency that in its natural course
commences at or shortly after birth and
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- Shallow breathing
- Shortness of breath and grunting
sounds while breathing
- Increased oxygen requirement
- Paradoxical chest wall movement
with breathing
- Breath sounds that include rales
- Poor lung aeration
- Accessory muscle usage
- Chest x-ray showing atelectasis, air
bronchograms, and granular
infiltrates
SUMMARY
Baby AD, a boy, 1 hour old, with 1.33 kg of BW and 38 cm of BH, came to
RSUP Haji Adam Malik Medan on 20thJuly at 6:30 AM with premature birth as
a chief complaint. No history of milk feeding after birth. History of turning
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blue found after birth and according to parents, blue has been found in lips,
fingers and toes. There’s no fever and history of fever also not found. Patient
found to have difficulty in breathing when admitted to Perinatology Division.
Patient was diagnosed with premature birth, Respiratory Distress ec dd/ Hyalin
Membrane Syndrome, neonatal pneumonia, low birth weight and suspect of
sepsis. Patient was treated with Infant Radiant Warmer Theraphy with target
skin temperature 36,5-37,5, total fluid requirement: 150 cc/kgBW/day = 210cc/
day, parenteral 150cc/kgBW/day = 210cc/day, IVFD D5% NaCl 0,225%
(500cc) + D40% (50cc) + KCl 10 mEq + Ca Gluconas 10cc: 4cc/hour ;GIR: 7.3
kg/kgBW/minute (D8%), Aminosteril 6% 2gr/kgBW/day = 2,8 gr/day =
47cc/day = 1,9cc/hour/iv, Enteral: Fasting for 24 hours, Ceftazidime injection
65mg/12 hour/iv, Gentamicin injection 6.5mg/36 hour/iv.
REFERENCE