Prematurity and High-Risk Infants

Introduction

Prematurity is a significant healthcare problem occurring on over 10% of live birth every year. The World Health Organization (WHO) estimates there are 15 million preterm births every year. The WHO categorizes preterm birth into the following three categories:

• extremely preterm (< 28 weeks)
• Very preterm (28–32 weeks)
• Moderate to late preterm (32–36 weeks)

Complications of Preterm Birth

Preterm infants have an increased risk for neurodevelopmental disorders and delayed growth with some developing neurological sequelae such as cerebral palsy, decreased intelligence and delayed neurodevelopment.Neurodevelopment and growth in preterm infants can be affected by:

• gestational age
• birth weight
• length of hospitisation
• Apgar score
• cardiopulmonary resuscitation (CPR)
• ventilation
• breastfeeding

Infants born at an earlier gestational age are at a higher risk for complex medical conditions, recurrent hospitisations and neurodevelopmental impairments. Developmental delays and chronic diseases that result from preterm birth may persist into adulthood and consequently, require a heavy burden on the patients, families and healthcare system.

Complications

The third trimester of pregnancy is marked by rapid organ maturation and growth. Without proper organ development, preterm infants are at an increased risk for chronic respiratory, cardiac, renal and endocrine systems disorders later in life. The following paragraphs as described by Pravia et al., (2020) delineate each system increased risk for disease due to prematurity and management recommendations.

Pulmonary

Risks:

• Obstructive disease,
• Pulmonary hypertension

Management:

• Evaluate previous asthma diagnosis

• Consider baseline pulmonary function testing

• Avoid smoking, maintain healthy weight, promote exercise

• Keep current on influenza and Pneumococcus vaccinations

Renal

Risks:

• Chronic kidney disease

Management:

• Monitor blood pressure regularly

• Avoid nephrotoxins

• Control blood pressure (consider an angiotensin-converting enzyme inhibitor if a hypertension medication is needed)

• Limit salt intake

• Consider periodic urine microalbumin screening, renal ultrasonography

Cardiovascular

Risks:

• Hypertension
• Ischemic heart disease
• Congestive heart failure
• Peripheral vascular disease

Management:

• Monitor blood pressure regularly

• Avoid smoking
• Maintain healthy weight
• Promote exercise

• Consider baseline echocardiogram with appropriate cardiovascular risk assessment

Endocrine

Risks:

• Diabetes
• Metabolic syndrome
• Obesity
• Osteoporosis

Management:

• Monitor blood glucose
• Body mass composition, lipids

• Maintain healthy body weight and abdominal girth

• Ensure appropriate calcium and vitamin D supplementation

• Promote weight-bearing exercise
• Limit medications associated with causing metabolic abnormalities, dyslipidemia, worsening bone density

Central Nervous System

Risks:

• Autism
• Mood disorders
• Intellectual disabilities

Management:

• Be alert to need for early evaluation and support

Prevention

Knowing all of the potential sequelae, it is important to try and identify ways to prevent preterm birth. A list of these preventions by the Global Action Report on Preterm Birth are seen below:

• Preconception care package, including family planning (e.g., birth spacing and adolescent friendly services)
• Education and nutrition especially for girls,
• Sexually transmitted infections (STI) prevention

• Antenatal care packages for all women, including screening for and management of STIs, high blood pressure and diabetes;
• Behavior change for lifestyle risks
• Targeted care of women at increased risk of preterm birth
• Provider education to promote appropriate induction and cesarean
• Policy support including smoking cessation and employment safeguards of pregnant women

Management of Preterm Labor

Preterm labor may still occur despite all of the precautions above. In this scenario, there are several ways to manage preterm labor to promote the best possible outcome:

1. Tocolytics to slow down labor
2. Antenatal corticosteroids
3. Antibiotics

Care of the Premature Baby

Managing preterm birth with various techniques can help improve the outcome for the newborn child. Some of these strategies are listed below:

• Essential and extra newborn care, especially feeding support
• Neonatal resuscitation
• Kangaroo Mother Care
• Chlorhexidine cord care
• Comprehensive neonatal intensive care, where capacity allowsDespite taking preventions for preterm labor

Management of Pregnant Women at Higher Risk of Preterm Birth

• Identification and treatment of hypertensive disease in pregnancy
• Monitoring multiple pregnancies
• Administration of progesterone to prolong pregnancy
• Identification and treatment of structural abnormalities (e.g., cervical cerclage, cervical pessary)
• Management of women in preterm labor including:
• Tocolytics to slow down labor
• Antenatal corticosteroids to reduce mortality in the newborn
• Antibiotics to prevent infection
• Provision of magnesium sulphate for neuro-protection of the newborn
• Promote antenatal and skilled delivery care for all women
• Smoking cessation and reducing exposure to secondhand smoke and other pollutants
• Policies to support safe motherhood and universal access to antenatal care
• Workplace policies regulating working hours and strenuous working conditions
• Professional and hospital policies to regulate infertility treatments and to reduce cesarean birth rates and early induction of labor