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PRESENTED BY VISSALINI JAYABALAN 090100432
SUPERVISED BYDR. BUGIS MADINA LUBIS SP.A (K)
RESPIRATORY DISTRESS SYNDROME IN A PREMATURE BABY
PREMATURE BABY
A baby born before 37 weeks of gestation have passed. The current World Health Organization definition of prematurity is a baby born before 37 weeks of gestation, counting from the first day of the Last Menstrual Period (the LMP).
Classification Of Preterm And Low Birth Weight Babies
Different degrees of prematurity are defined by gestational age (GA) or birth weight.
Newborn classification based on gestational agePreterm (premature) — born at 37 weeks' gestation or lessTerm — born between the beginning of week 38 and the
end of week 41 of gestationPost-term (postmature) — born at 42 weeks' gestation or
moreNewborn classification based on birth weightLow birth weight (LBW) — less than 2500 g Very low birth weight (VLBW) — less than 1500 gExtremely low birth weight (ELBW) — less than 1000 g
Classification On Birth WeightIn relation to birth weight, most preterm
babies are low birth weight or very low birth weightLow birth weight:
born with birth weight between 1,500-2,499 gm
usually be managed safely at home with some extra care and support.
Very low birth weight:born with birth weight less
than 1,500 gmA life-threatening problem in
such tiny babies is that suckling, swallowing and breathing are not well coordinated, so they require special attention in order to feed them adequately and safely
difficulty in maintaining their body temperature, so they are at increased risk of hypothermia
Classification on gestational agepremature baby
Preterm baby Very preterm baby
•baby born before 37 completed weeks of pregnancy
•Babies born between the gestational ages of 32-36 weeks of gestation•calculated from the mother’s last normal menstrual period (LNMP date). •can usually be managed safely at home with some extra care and support
•born between the gestational ages of 28-31 weeks as calculated from the LNMP date•Like very low birth weight babies •have problems in feeding and maintaining their body temperature
premature baby Preterm baby
Very preterm
baby
Term baby
Classification of newborn babies according to birth weight and gestational age.
Birth weight and gestational age Classification Action
Weight less than 1,500 gm Very low birth weight
Refer URGENTLY to a hospital, making sure to keep the baby warm on the journey
Gestational age less than 32 weeks Very preterm
Keep the newborn baby warm and refer it soon.
Weight 1,500 to 2,500 gm Low birth weight
If there is no other problem:counsel on optimal breast feeding, prevention of infection and keeping the baby warm
Gestational age 32-36 weeks Preterm As above for low birth
weight babiesWeight equal to or above 2,500 gm; gestational age equal to or above 37 weeks
Normal weight and full term
As above for low birth weight and preterm
Associated FactorsMaternal Low socioeconomic status Lack of prenatal care Substance abuse, smoking Maternal age < 16yrs or > 35yrs Maternal illness e.g. renal, heart, lung, HPT, DM, etc Multiple gestation Prior preterm delivery Obstetric factors e.g. uterine malformations, cervical
incompetence, polyhydramnios, premature rupture of membranes, infection (e.g. chorioamnionitis), placenta praevia, abruptio, etc
Abdominal trauma / surgeryFoetal
Foetal distress, IUGR, etc
SIGNSCORE
SIGN SCORE-1 0 1 2 3 4 5
Posture
Square Window
Arm Recoil
Popliteal Angle
Scarf Sign
Heel To Ear
TOTAL NEUROMUSCULAR SCORE
NEUROMUSCULAR MATURITY
BALLARD SCOREUse this score sheet to assess the gestational
maturity of your baby. At the end of the examination the total score determines the gestational maturity in weeks.
SIGNSCORE SIGN
SCORE-1 0 1 2 3 4 5
SkinSticky, friable, transparent
gelatinous, red, translucent
smooth pink, visible veins
superficial peeling &/or rash, few veins
cracking, pale areas, rare veins
parchment, deep cracking, no vessels
leathery, cracked, wrinkled
Lanugo
none sparse abundant thinning bald areas mostly bald
Plantar Surface
heel-toe40-50mm: -1 <40mm: -2
>50 mmno crease
faint red marks
anteriortransverse crease only
creases ant. 2/3
creases over entire sole
Breast imperceptable
barely perceptable
flat areolano bud
stippled areola1-2 mm bud
raised areola3-4 mm bud
full areola5-10 mm bud
Eye / Earlids fusedloosely: -1tightly: -2
lids openpinna flatstays folded
sl. curved pinna; soft; slow recoil
well-curved pinna; soft but ready recoil
formed & firminstant recoil
thick cartilageear stiff
Genitals (Male)
scrotum flat, smooth
scrotum empty,faint rugae
testes in upper canal,rare rugae
testes descending,few rugae
testes down,good rugae
testes pendulous,deep rugae
Genitals (Female)
clitorisprominent & labia flat
prominentclitoris & small labia minora
prominentclitoris & enlarging minora
majora & minora equally prominent
majora large,minora small
majora cover clitoris & minora
TOTAL PHYSICAL MATURITY SCORE
PHYSICAL MATURITY
TOTAL SCORE (NEUROMUSCULAR + PHYSICAL) WEEKS
-10 20
-5 22
0 24
5 26
10 28
15 30
20 32
25 34
30 36
35 38
40 40
45 42
50
MATURITY RATING
Newborn first exam: Apgar score
Factor Score 0 Score 1 Score 2 Heart rate No heart rate Below 100
beats/min Above 100 beats/min
Breathing No breathing Slow and irregular Good Muscle tone
Limp and loose Some flexing of arms and legs
Actively moving
Reflexes No reflex responses
Grimaces or frowns when reflexes are stimulated
Vigorously cries when reflexes are stimulated
Colour Blue and pale Body is pink but hands and feet are blue
Entire body is pink
Characteristics of premature babies• may be reddened. The skin may be thin so blood
vessels are easily seen.Skin• there is a lot of fine hair all over the baby’s body.Lanugo• the limbs are thin and may be poorly flexed or
floppy due to poor muscle tone.Limbs• appears large in proportion to the body. The
fontanelles (open spaces where skull bones join) are smooth and flat.
Head size• no breast tissue before 34 weeks of pregnancy.Chest
• weak or absent.Sucking ability• in boys the testes may not be descended and the
scrotum may be small; in girls the clitoris and labia minora may be large.
Genitals• creases are located only in the anterior (front) of
the sole, not all over, as in the term babySoles of feet
Possible Complications
Respiratory distress syndrome (Hyalin Membran disease)Respiratory distress is a symptom complex arising from disease processes that cause failure to maintain adequate gaseous exchange
•Tachypnea (>60bpm)
•Grunting, Flaring, Retractions/ recessions (GFR)
•Cynosis
•Reduced air entry
>> premature infants, correlating with structural and functional lung immaturity
>> infants born at fewer than 28 weeks’ gestation
1/3 of infants born at 28 to 34 weeks’ gestation
< 5 % of those born after 34 weeks’ gestation.
The condition is more common in boys, and the incidence is approximately six times higher in infants whose mothers have diabetes, because of delayed pulmonary maturity despite macrosomia1.
Obstruction of the airway Lung parenchymal disease 1- Choanal atresia 2- Congenital stridor 3- Tracheal or bronchial stenosis
1- Meconium aspiration 2- Respiratory distress syndrome 3- Pneumonia 4- Transient tachypnea of the newborn
(retained lung fluid) 5- Pneumothorax 6- Atelectasis 7- Congenital lobar emphysema
Non-pulmonary causes Miscellaneous 1- Heart failure 2- Intracranial lesions 3- Metabolic acidosis
1- Disorders of the diaphragm e.g. (diaphragmatic hernia)
2- Pulmonary haemorrhage 3- Pulmonary hypoplasia
CAUSES OF RESPIRATORY DISTRESS
Distinguishing Feature of TTN, RDS and MAS
In Silverman-Anderson score, inspection or auscultation of the upper and lower chest and nares are scored on a scale of 0, 1 or 2 using this system are:
A score greater than 7 indicates that the baby is in respiratory failure.
0 1 2
Cyanosis None In room air In 40% FIO2
Retractions None Mild Severe
Grunting None Audible with stethoscope
Audible without stethoscope
Air entry Clear Decreased or delayed Barely audible
Respiratory rate Under 60 60-80 Over 80 or apnea
Score: > 4 = Clinical respiratory distress; monitor arterial blood gases > 8 = Impending respiratory failure
DOWNE’s SCORING OF RESPIRATORY DISTRESS
RISK FACTORS•Neonates younger than 33-38 weeks•Weight less than 2500g•Maternal diabetes•Cesarean delivery without preceding labor•Precipitous labor•Fetal asphyxia•Second of twins•Cold stress•Previous history of RDS in sibling•Males•whites
ETIOLOGY AND PATHOPHYSIOLOGY.
Surfactant deficiency is the 1O cause of RDS. Low levels of surfactant cause high surface
tension High surface tension makes it hard to expand the
alveoli.Tendency of affected lungs to become atelectatic
at end-expiration when alveolar pressures are too low to maintain alveoli in expansion
Leads to failure to attain an adequate lung inflation and therefore reduced gaseous exchange
Pulmonary Surfactant decreases surface tension
PATHOPHYSIOLOGY
RadiographyHomogenous
opaque infiltrates and
air bronchograms,
indicating contrast in airless lung tissue seen against air-
filled bronchi, decreased lung volumes also
can be detected
Oxygenation with blow-by oxygen, nasal cannula, or mechanical ventilation (CPAP).
Corticosteroid therapy accelerates fetal lung maturation by increasing formation and release of surfactant.
Surfactant replacement therapies Nutrition
MANAGEMENT
Management of Neonatal
Respiratory Distress
THANK
YOU
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