Category Archives: Diseases Of The Baby First Month

Persistent Pulmonary Hypertension In Newborns

Persistent pulmonary hypertension in newborns is a life threatening condition, which occurs when the pulmonary arteries carrying blood to the lungs remain constricted in the infant, reducing blood flow to the lungs and resulting in poor oxygenation of the blood.

  • Persistent pulmonary hypertension is the result of extreme respiratory distress occurring in infants born at full term as well as in post-term babies. It may be caused if the mother uses some NSAID drugs during pregnancy too.
  • Rapid breathing and bluish color of the skin termed cyanosis are the usual symptoms.
  • The typical symptoms indicate the disorder, but an echocardiogram helps in confirming the diagnosis.
  • Dilating the pulmonary arteries which lead to the lungs by providing supplementary oxygen, while the infant is hooked onto a ventilator, is the usual treatment procedure.
  • Nitric oxide in small amounts is introduced into the oxygen supply provided to the infant to facilitate the opening up of pulmonary arteries.
  • A technique called extracorporeal membrane oxygenation, or ECMO, may be necessary in severe cases of persistent pulmonary hypertension.

The circulatory pattern of the fetus is different from that of the newborn. The placenta is supplying oxygenated blood to the fetus, so the blood flow from the fetal heart is directed away from the lungs as long as the infant is connected to the placenta. The pulmonary arteries which carry the blood from the heart into the lungs remain constricted during this time. When the infant is born, and the umbilical cord is severed, the lungs begin functioning. The air sacs which were previously filled with fluid become dry and get filled with the air inhaled by the infant. In the meantime, the blood flow to the lungs through the pulmonary artery should begin too, so that the oxygenation of blood can take place in the lungs. The opening up of the pulmonary artery normally facilitates the blood flow to the lungs. In some cases, the pulmonary arteries remain constricted even after the lungs start functioning, resulting in the condition called persistent pulmonary hypertension. The infant may be breathing, but the oxygenation of blood fails to take place as the blood does not reach the lungs. Poor oxygenation precipitates the typical symptom cyanosis, wherein the skin of the infant appears bluish.

Prolonged labor and complications during delivery causing fetal distress, is thought to be a risk factor for developing persistent pulmonary hypertension. Other causes include extreme respiratory distress resulting from other disorders of the lungs present in the infant, or due to meconium aspiration. Certain NSAIDs like aspirin as well as indomethacin taken during pregnancy also can cause pulmonary hypertension.

Causes

Pulmonary hypertension in newborns is prevalent in post term infants as well as in babies born at term. Excessive use of aspirin and another non steroidal anti-inflammatory drug named indometacin during pregnancy is known to cause this condition in infants. Respiratory distress present in the newborn due to meconium aspiration syndrome or any other disorders of the lung such as pneumothorax, lung infections and pneumonia can initiate pulmonary hypertension. However, in rare cases, persistent pulmonary hypertension develops without any lung disorders too.

Symptoms and Diagnosis

Rapid breathing, cyanosis or bluish tinge to the skin, and if lung disorders are present, respiratory distress due to them, are the usual symptoms. If the infant develops low blood pressure, characteristic symptoms of hypotension such as rapid heartbeat, weak pulse and pale, clammy skin also may be present. Some infants show symptoms of persistent pulmonary hypertension right from the time of birth. It may develop later also, but usually within the first two days of birth.

Diagnosis of persistent pulmonary hypertension is based on the symptoms as well as the presence of risk factors such as difficult delivery, meconium aspiration syndrome, other lung disorders resulting in respiratory distress, and the medical history of the mother taking aspirin or indometacin excessively in pregnancy. An x-ray of the chest may not show any abnormality, unless lung disorders are present. An echocardiogram, showing high pressure persisting in the arteries leading to the lungs (pulmonary arteries), confirms the diagnosis.

Treatment

Persistent pulmonary hypertension in newborns is treated by keeping them in a special environment saturated with oxygen. High oxygen content in the infant’s blood can help open up the arteries leading to the lungs. When persistent pulmonary hypertension is severe, ventilator support is necessary to provide 100% oxygen to the baby.

Occasionally, a small amount of nitric oxide gas is introduced into the oxygen supply provided to the infant. Nitric oxide has the property of opening up arteries. When used in the infants, it helps in reducing the constriction of the pulmonary artery and relieving pulmonary hypertension. The treatment with nitric oxide may have to be continued for many days. Another treatment option called extracorporeal membrane oxygenation, or ECMO for short, is considered when the other treatments fail. The blood of the infant is taken out of the body and fed into a machine that purifies the blood by removing carbon dioxide and enriching it with oxygen. In short, ECMO takes over the function of the lungs temporarily. ECMO is the only option in many cases when infants with pulmonary hypertension are not helped by other available treatments. This procedure has helped save many lives by keeping the infant alive till pulmonary hypertension is resolved and normal circulation is restored.

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Meconium Aspiration Syndrome

Meconium aspiration syndrome is a breathing difficulty occurring in newborns due to the aspiration of meconium present in the amniotic fluid at the time of birth or prior to it. It is characterized by severe respiratory distress in the infant.

  • Fetal distress and oxygen insufficiency are the usual reasons causing the fetus to pass the fecal matter meconium while they are still in the womb.
  • The fetus may gasp as a reflex reaction to reduced oxygen supply in the womb, resulting in the inhalation of meconium along with the amniotic fluid into the lungs.
  • Meconium aspiration syndrome typically displays the symptoms of respiratory distress such as bluish discoloration of the skin, and labored or rapid breathing with a grunting sound during exhalation.
  • Presence of meconium in the amniotic fluid detected at the time of delivery, combined with breathing difficulty in the newborn, leads to the diagnosis of meconium aspiration syndrome. A chest x-ray may help confirm the diagnosis.
  • Oxygen is immediately administered to the infant displaying meconium aspiration syndrome, but additional respiratory assistance or even ventilator support may be necessary.
  • If given immediate medical care, infants with meconium aspiration syndrome may recover, but in severe cases, the condition may become fatal.

The intestine of the fetus is filled with a greenish black sticky substance called meconium. After the infant is born, the meconium is normally passed in the first few bowel movements as the infant begins to feed. However, in certain situations, the fetus passes the meconium within the womb, causing it to be mixed with the amniotic fluid. Fetal distress, usually resulting from inadequate oxygen supply to the fetus via the placenta, is the most common cause of meconium being passed within the womb. The distressed fetus tends to gasp reflexively, resulting in the aspiration of the meconium-tainted amniotic fluid into its lungs.

When the infant is born and it tries to breathe in air, the aspirated meconium may cause blockages in the airway. It may result in the collapse of some areas of the lungs. When partial blocks occur in the airway, the air reaches the lungs during inhalation but it is not expelled on exhalation. When this is repeated, that part of the lung may get overfilled, causing the air sacs to over-expand. Eventually, the overstretched tissue becomes weak, leading to rupture as well as collapse of the infant’s lung. It results in a condition called pneumothorax in which the air fills the chest cavity or thorax around the collapsed lung.

Pneumonitis or severe lung inflammation may be caused by the aspiration of meconium into the lungs. There is a very high risk of developing lung infections too. Persistent pulmonary hypertension is a very serious, and often fatal, condition that has a higher chance of occurring in infants with meconium aspiration syndrome.

The severity of meconium aspiration syndrome depends on the amount of the substance inhaled by the fetus. Postmature infants are often severely affected as they inhale larger amounts of the substance. This happens because the reduced quantity of amniotic fluid towards the end of gestation results in a higher concentration of meconium in the fluid which is aspirated by the fetus.

Symptoms and Diagnosis

Typical symptoms of respiratory distress such as rapid breathing, and grunting sound while exhaling, are displayed by infants who have meconium aspiration syndrome. Breathing is labored and every time a breath is taken, the chest below the breastbone is drawn deep in. Cyanosis or bluish discoloration to the skin, typically indicating low oxygen levels in the blood, may be present. The baby may have low blood pressure too.

When meconium is detected in the amniotic fluid when the baby is being delivered, and if the infant is showing signs of respiratory distress, meconium aspiration syndrome is diagnosed. A chest x-ray can confirm the condition.

Treatment

When meconium is present in the amniotic fluid at the time of delivery, it indicates the possibility of meconium aspiration. Often the infant may not be breathing and the limp body may be coated with meconium. The nose and mouth of the baby are cleaned immediately and the substance is sucked out from the throat. A suction tube is introduced into the windpipe also, to remove the meconium that may have been aspirated by the infant. This procedure may have to be repeated several times to clear the trachea of all the meconium.

Antibiotic treatment is given to the infant to prevent possible infections. Oxygen is administered to the baby to help with breathing, and if required, ventilator support is also given. The baby is closely monitored for any complications like pneumothorax developing. Pulmonary hypertension is another potentially fatal complication to watch out for in babies who have aspirated meconium.

With immediate medical intervention and adequate treatment, babies who develop meconium aspiration syndrome have a very good chance of recovery. But in some cases, the various complications which develop, especially persistent pulmonary hypertension, may result in a fatal outcome.

Watch This Video About Meconium Aspiration Syndrome:

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Transient Tachypnea of the newborn (TTN)

Transient tachypnea of the newborn (TTN) is a respiratory distress occurring in both premature and full-term infants, characterized by rapid as well as labored breathing for a period, due to presence of excess amounts of fluid in the lungs. This temporary respiratory problem causes low levels of oxygen in the blood.

  • Rapid breathing with an audible grunt during exhalation is the typical symptom. The skin of the infant may have a bluish tinge due to decreased oxygen levels in the blood.
  • Transient tachypnea is very common in premature, as well as full-term infants, delivered by caesarean section before labor has started.
  • The typical symptoms help in diagnosis. An x-ray of the chest can confirm the diagnosis.
  • Transient tachypnea is a temporary condition, and gets resolved within two or three days, in most cases.
  • Supplemental oxygen is given to infants affected by transient tachypnea; some infants may require respiratory support.

Transient tachypnea of  newborn (TTN) is a temporary breathing difficulty found to occur in infants who are born a few weeks premature, as well as in those who are born at full term. In fact, TTN is the most common type of respiratory distress found in full-term infants. It occurs more frequently in infants delivered by caesarean section, especially if the delivery has taken place before labor had started in the mother, as in the case of emergency situations, as well as in scheduled caesarean operations.

The alveoli or air sacs of the fetus’ lungs contain fluid before birth. As soon as the baby is born, the lungs should be cleared of the fluid so that the infant can breathe in air normally. During a normal vaginal delivery, as the fetus passes through the birth canal, the pressure exerted on the chest causes most of the fluid in the air sacs of the baby’s the lungs to be squeezed out. The remaining fluid is usually absorbed into the lining of the alveoli.

Certain hormones which are released in the mother during labor cause rapid absorption of the fluid into the lining of the air sacs, leaving the alveoli dry and ready for breathing air, by the time the baby is born.  However, when the baby is delivered quickly by a caesarean section, the alveoli continue to have fluid inside, which hampers the normal breathing of the newborn. The breathing difficulty continues till all the fluid gets slowly absorbed and the lungs become dry.

Symptoms and Treatment:

The symptoms of transient tachypnea include respiratory distress characterized by rapid, labored breathing. While the breath is being taken in, the wall of the chest below the breast bone is drawn in, and while breathing out, a grunting sound is heard. Cyanosis or blue coloration of the skin and the extremities may be present if blood levels of oxygen become too low. The presence of fluid in the infant’s lungs can be detected in an x-ray of the chest.

Infants who have transient tachypnea usually begin to breathe normally in two or three days. During the period of respiratory distress, supplemental oxygen is often required. In some cases, oxygen may have to be supplied by the continuous positive airway pressure technique. Oxygen or oxygen-rich air is supplied under slight pressure through nose prongs to make the infant’s breathing easier. Rarely, ventilator support may be necessary in severe cases.

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Infant Respiratory Distress Syndrome ( RDS Disease) Hyaline Membrane Disease

Infant Respiratory distress syndrome is a disorder commonly found in premature infants, which makes breathing difficult, due to the collapse of the air sacs in the lungs of the newborn.

This condition, also called hyaline membrane disease or RDS disease, is caused by the absence or insufficiency of a substance called surfactant which normally helps in the expansion of the alveoli or air sacs in the lungs and in keeping them open during exhalation.

  • Infants with respiratory distress syndrome display labored breathing and their skin develops a bluish tinge due to inadequate oxygenation of blood.
  • Lack or insufficiency of surfactant, common in infants born prematurely, or in those born to mothers who have diabetes, is the usual cause of respiratory distress syndrome in newborns.
  • The typical symptoms help diagnose the condition in newborns. The abnormally low levels of oxygen in the blood, and an x-ray of the chest, can confirm the diagnosis.
  • Without immediate medical intervention and adequate respiratory support, brain damage, as well as death, may result from continued respiratory distress.
  • When the pregnancy is expected to end before completing the normal term, and when insufficiency of surfactant is anticipated, as a preventive measure, corticosteroid injections are given to the mother, to accelerate surfactant production in the fetus.
  • When the newborn infant shows respiratory distress, supplementary oxygen is administered, or ventilator support is provided, as necessary.
  • Surfactant is administered into the trachea of infants who have respiratory distress due to deficiency of the substance.

For the normal functioning of the lungs, the alveoli or air sacs in the lungs should get filled with inhaled air easily, and they should remain open without collapsing between breaths. Surfactant is a substance produced by the lungs, which forms a coating on the air sacs and helps in lowering the surface tension, making it easy for the air sacs to expand and to stay open during the entire cycle of respiration. The substance is produced only towards the end of the normal gestational period, typically after the fetus completes 32 weeks in the mother’s womb. As the pregnancy progresses, more and more of the surfactant is deposited in the lungs. When the infant is born before term, the insufficiency of the surfactant leads to infant respiratory distress syndrome. The severity of the condition depends on how premature the infant is, when it is delivered. The infants born to mothers who are diabetic are more prone to developing this disorder. Although, an inherited form of this syndrome is found to occur in rare cases, respiratory distress syndrome is considered almost exclusively to be a complication of prematurity.

Symptoms and Diagnosis

When newborns have respiratory distress syndrome, their lungs cannot expand well and easily as they remain stiff. More effort is needed to fill the lungs with air during inhalation, and when the air is exhaled, the alveoli or the air sacs collapse again. In extremely premature infants, the stiffness of the lungs may prevent the filling up of the air sacs and the newborn cannot breathe at all without the help of mechanical ventilation. More often, the premature infants with immature lungs can breathe, but with a lot of effort. The breathing is labored, and the blood levels of oxygen remain low. This condition is known as respiratory distress syndrome.

The visible symptoms of this disorder include the nostrils flaring up wide during inhalation, and a grunting sound during exhalation. The chest is drawn in below the infant’s rib cage, and a bluish tinge to the skin known as cyanosis appear due to poor oxygenation of blood. Eventually, the muscles involved in the respiratory process begin to tire out from the extra effort needed, and more and more air sacs begin to collapse, as the little surfactant present in the lungs gets exhausted. Without timely medical intervention and adequate respiratory support, the brain and the other organs get damaged due to lack of oxygen supply, and death may result.

Respiratory distress syndrome is diagnosed from the symptoms displayed by the newborn. It is confirmed by the abnormally low oxygen levels in the infant’s blood. A chest x-ray can also show the abnormal condition of the lungs.

Prevention and Treatment

Premature infant Respiratory distress syndrome can be prevented if the delivery is delayed till the lungs become mature enough for independent function. Sufficient amount of the substance called surfactant, which lowers the surface tension, and facilitates the easy extension of the air sacs in the lungs, is necessary to prevent the lungs from collapsing every time the air is pumped out. If it is not possible to delay delivery, a corticosteroid such as betamethasone may be injected into the mother. The steroid crosses the placenta and reaches the fetus. The drug works by accelerating surfactant production and maturation of the infant’s lungs. Within two days of the injection, the lungs of the fetus may become ready for independent function after birth. If a slight respiratory distress is displayed, it may be much milder and the infant may not require ventilator support.

When the newborn is having a mild form of respiratory distress syndrome, oxygen is given either through an oxygen hood placed over the infant’s head, or using prongs which are placed in the nose. The infant breaths normally, but the oxygen-rich air helps to maintain the blood oxygen levels. But supplemental oxygen may have to be administered by another technique called continuous positive airway pressure or CPAP, if the respiratory distress is severe. In this technique, the infant takes in the breaths normally but the air or oxygen supplied via prongs in the nostrils is pressurized to keep the airway open, and to prevent the lungs from collapsing. In extremely severe cases of respiratory distress syndrome, even CPAP may not be sufficient. In such cases, an endotracheal tube is inserted into the trachea or windpipe of the infant, and ventilator support is given, to assist with breathing.

It is mainly the lack of sufficient amount of surfactant in the lungs that causes respiratory distress syndrome in the newborns, especially in those who are born pre-term. To counteract this, a surfactant can be administered as soon as the infant is born. It can prevent the rupture of lungs which may otherwise lead to the potentially fatal condition called pneumothorax. This life-saving measure can be initiated even before the symptoms of respiratory distress appear in the newborns, and prevent its occurrence. Premature babies who are exhibiting the symptoms of respiratory distress are also given surfactant treatment as early as possible. The surfactant administered to the infant through the endotracheal tube functions exactly like the naturally occurring surfactant. Repeated administration of the surfactant over the first few days may be necessary, till the symptoms of respiratory distress syndrome disappear and the infant can be taken off the ventilator support.

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Large for Gestational Age Babies(LGA)

An infant weighing more than the weight of 90% of infants born at the same gestational age is said to be large for gestational age. It is irrespective of whether the infant is born premature, postmature or at term, as its birth weight is compared with the birth weight of babies born at the same gestational age.

  • Heredity is a reason, as babies born to large-sized parents tend to be large in size at birth.
  • Mothers who are diabetic usually have large for gestational age babies
  • Large for gestational age babies are often delivered by caesarean section.
  • When diabetes of the mother is the reason for the large size of the baby, the risk of being obese in adulthood is high

Large for gestational age infants are more often born to mothers who have diabetes. Obese women, and those who have previous history of giving birth to large sized babies, have an increased risk of having large for gestational age babies. Sometimes, certain genetic conditions such as Sotos’ syndrome or Beckwith-Wiedemann syndrome may be the reason for large for gestational age stature of infant.

When an abundant quantity of nutrition is available in the womb, the fetus tends to grow larger. In women with diabetes, the fetus receives a larger than usual amount of glucose via the placenta. Consequently, the pancreas of the fetus produces higher levels of the hormone insulin to utilize the glucose. This leads to increased growth of the fetus, resulting in large size. All the organs of the fetus, except the brain, also grow faster.

Symptoms and Complications

Some of the complications usually occurring in large for gestational age babies, and the associated symptoms are:

Polycythemia or abnormally large number of red blood cells: When babies are born large for gestational age, they may have a reddish tint to the skin due to the excess of red blood cells present; a condition known as polycythemia. When a large number of these red blood cells break down, it results in large amounts of bilirubin in the blood. The liver may not be competent enough to handle the overload of bilirubin. When feeding is insufficient, the removal of bilirubin via the digestive process also may be minimal. Accumulation of this substance in the blood causes jaundice, characterized by the yellowing of the skin and the whites of the eye.

Hypoglycemia or Low blood levels of glucose: When mothers have diabetes, the growing fetus in the womb is used to a higher level of glucose supplied by the placenta. Consequently, the pancreas of the fetus is conditioned to producing higher levels of insulin. When the infant is delivered, and its connection to the maternal supply is severed, the availability of glucose suddenly stops, but the insulin production remains high. This leads to severe hypoglycemia or abnormally low blood sugar levels. The infant usually does not display any symptoms of hypoglycemia, but in some cases, lack of muscle tone and listlessness may indicate this condition. The large babies born to diabetic mothers are poor feeders in the initial days after delivery, which is another factor contributing to hypoglycemia.

Respiratory problems: When the mother has diabetes, the lung development in the fetus may be delayed. Problems with the lungs and breathing are common in babies born by caesarian delivery. Premature babies are especially prone to developing a condition called respiratory distress syndrome due to extreme immaturity of their lungs even when their prematurity is only by a few weeks.

Higher risk of having birth injuries: Large sized infants are at higher risk of suffering birth injuries during delivery, including fractures of the collar bone or clavicle. The nerves running to the arms may get stretched, resulting in injuries to the brachial plexus. The risk of severe birth injuries is further increased if the fetus is in a breech position as the large head may have difficulty passing through the mother’s pelvis. Large for gestational size babies are usually delivered by a C-section, especially when the fetus is in breech position.

When the mother has diabetes, the risk of the baby having birth defects is much higher when compared to babies born to mothers without the disorder. When babies are born large for gestational age due to the sole reason of their mothers being diabetic, they have a higher risk of being obese as adults. Since they are already genetically predisposed to Diabetes mellitus, (type 2 diabetes), obesity further increases their risk of developing the condition.

Treatment

The treatment depends on the symptoms and the complications present. Frequent oral feedings are given to avoid hypoglycemia or low blood sugar. Sometimes the infant is fed through a feeding tube passed into the stomach. Occasionally, intravenous administration of glucose may be necessary to prevent hypoglycemia. If respiratory distress syndrome is present, oxygen is given nasally via a tube. The baby may have to be hooked to a ventilator to assist respiration, if severe respiratory distress is present. Phototherapy is given to infants who show symptoms of jaundice.

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Small for Gestational Age Babies

An infant weighing less than the weight of 90% of infants born at the same gestational age is said to be small for gestational age. It applies to all babies whether they are born premature, postmature or at term, as the birth weight is compared with that of babies of the same age.

  • Placental insufficiency during the growth of the fetus, medical disorders of the mother, the effect of certain drugs used by the mother or consumption of alcohol while pregnant, may be the reason for the small size.
  • Heredity has its role, as small frame parents usually have small-for-gestational-age babies.
  • If genetic disorders or infections and other diseases in the newborn are not the cause of smaller size, small for gestational age babies grow up normally without any difficulties.
  • In some cases, babies born small for gestational age may have small stature as adults too.

The reasons for babies being born small for gestational age are many. The genetic make-up of the infant may predispose it to smaller size. It may be due to genes inherited from smaller-sized parents or because of a genetic disorder which causes small size. Growth retardation inside the mother’s womb, due to poor nutritional support resulting from placental insufficiency, is another reason for smaller birth weight. Placental insufficiency may be caused by several disorders present in the mother, such as diabetes, high blood pressure, kidney disease, or preeclampsia during pregnancy. Viral infections, especially an infection by the cytomegalovirus before birth, may result in growth retardation. Smoking or tobacco use, alcohol consumption, use of harmful drugs etc., during pregnancy may impair the proper growth and development of the fetus.

Premature babies have many complications as their organ systems are not mature enough for independent life. On the other hand, when small-for-gestational-age infants are born at full term, the usual complications of prematurity are not present, as their organs are fully developed. But they have higher chances of having one or more of the problems listed below:

  • Aspiration of meconium, resulting in respiratory problems.
  • Polycythemia, a disorder characterized by increased red blood cell count.
  • Hypoglycemia or decrease in the blood glucose levels.
  • Problems with the regulation of body temperature.
  • Reduced immunity.

If viral infections or genetic disorders are not the cause of being born small-for-age, the babies may not have any difficulties. If placental insufficiency and the resultant nutritional deficiency are the reasons for growth retardation inside the uterus, the babies may have accelerated growth when they are given proper nutrition and care after birth. However, in some cases, the growth retardation may be so severe that the infant fails to develop normally and may remain small in stature all through life. If the smaller size at birth is because of small frame parents, the baby may grow up normally, but may have a smaller frame as adult.

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Post Term Pregnancy, Postmature Baby and Postmaturity

An infant delivered after it has completed 42 weeks of gestation is said to be a postmature baby and the whole pregnancy is called a post term pregnancy . Postmaturity has its own set of problems but they are not as severe as those of prematurity.

  • Postmaturity does not occur as frequently as prematurity. The exact reason or the risk factors for postmaturity are not known.
  • As the pregnancy nears the end of the normal term, the placenta starts aging and its functional capacity reduces, resulting in lesser nutritional and respiratory support to the unborn baby.
  • Babies born postmaturely look weak and emaciated due to lack of adequate nutrition towards the end of their stay in the womb. Skin may be dry and hanging loose; it may be peeling at places too.
  • The treatment involves providing nutritional support and care to the infant. It may be necessary to resuscitate some babies born postmaturely.

Placental insufficiency which develops towards the end of gestation is a risk to the life and well-being of the fetus as it remains inside the mother’s womb even after completing the term. Nearer to term, placenta begins to shrink and the nutrition and oxygen passed on to the fetus reduce considerably. To make up for the reduced nutritional support the fetus uses up its store of fat tissue and carbohydrates for energy. A post term pregnancy usually leads to weight loss and growth retardation.

The fetus is severely distressed by the reduced oxygen supply and may pass its intestinal content called meconium into the amniotic fluid. During delivery, if the placenta has become too inadequate, the severe lack of oxygen can lead to brain damage and injury to vital organs. The amniotic fluid tainted with meconium may be inhaled by the fetus as it gasps for breath due to lack of oxygen supply, resulting in meconium aspiration syndrome when the infant is delivered. This can precipitate low oxygen levels in the blood even when the infant starts breathing on its own. The newborn baby remains lethargic due to this.

The postmature baby usually has hypoglycemia or low blood levels of glucose as it may have already exhausted its store of fats and sugars. The skin becomes wrinkled and loose, as the subcutaneous fat tissue (the layer of fat under the skin) has been used up.

Symptoms

The most noticeable symptom of a postmature baby is the appearance of its skin. It is loose and dry, and it may be peeling away at places. Severe loss of subcutaneous fat gives an emaciated look to the postmature baby. Nails on the fingers and toes may be very long. They may look greenish if meconium from the digestive tract of the baby had got mixed in the amniotic fluid. Umbilical cord also may become green due to this.

Treatment

When the baby is born with fetal distress due to lack of sufficient oxygen supply, it is resuscitated immediately. Presence of meconium in the amniotic fluid indicates the possibility of meconium aspiration by the fetus. If the baby is found to be listless, a tube is inserted into the trachea or the windpipe to remove as much of the inhaled meconium as possible by suctioning it out. Ventilator support is given to the newborn if respiratory distress continues, as the meconium may have entered the lungs.

To prevent hypoglycemia and maintain normal blood sugar levels, glucose is administered intravenously. The baby is breastfed frequently, or frequent feeds of formula milk are given. Additional nutritional support is also given, if necessary.

If the infant is not showing any sign of complications due to postmaturity, adequate nutritional support and good post natal care will help the baby gain weight rapidly and catch up with other infants of the same age.

Watch This Video about How is a post-term pregnancy handled :

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Premature Babies, Preterm Babies Or Prematurity

Infants born before completing 37 weeks in their mothers’ uterus are called  premature babies or preterm babies.  The different organ systems of the baby may not have become well developed and mature enough to function independently yet.

  • High blood pressure in the mother, poor nutrition, absence of adequate prenatal care, multiple births, and previous history of premature delivery, are some of the risk factors of premature birth.
  • Since the organ systems are not yet fully developed, premature babies usually have difficulties associated with feeding and breathing.
  • Premature babies are predisposed to brain hemorrhage and prone to acquiring infections.
  • The degree of prematurity is directly proportional to the risk of the baby having functional and developmental problems. The earlier the baby is born, the more severe the problems encountered.
  • The problems due to prematurity may eventually resolve as the infant grows and matures. Most will not have any lasting effects of prematurity after the first few months.
  • Some of the surviving premature babies may have permanent difficulties resulting from prematurity.

The risk of having premature deliveries can be significantly reduced if proper prenatal care is initiated early.Imminent premature deliveries can be delayed for sometime by administering drugs which stop or slow down the uterine contractions of the mother.

If premature delivery is anticipated, the mother is given corticosteroid injections to accelerate the fetus’s lung development so that it may have less breathing related problems even if born early. Corticosteroid therapy helps in preventing intraventricular hemorrhage in the brain too.

The normal term of a pregnancy is 37 weeks to 40 weeks. Approximately 12 % of babies are born earlier than 37 weeks and are called premature or preterm babies. When they are born just two or three weeks premature, they may not be affected by the adverse effects of prematurity. But those who are born several weeks early can have serious and potentially fatal complications after birth. The earlier the baby is born, the more severe the complications of prematurity. Of all the factors responsible for infant mortality, extreme prematurity is the main factor, accounting for the majority of cases. Extremely premature babies who manage to survive are more likely to have permanent problems including serious developmental delays and learning disabilities. However, with adequate medical care immediately after birth, most premature babies develop normally without long-term problems. Adequate prenatal care, when initiated sufficiently early, may significantly reduce prematurity as well as its adverse effects.

Causes

The exact reason for spontaneous premature birth is not always clear. Some mothers are found to be more prone to having premature babies. Some of the factors that predispose expectant mothers to early labor are:

  • Very young mothers (teenagers) and older women are prone to early labor.
  • Poor socio-economic status is found to be a factor in increasing the risk of premature labor.
  • Lack of prenatal care is found to be a reason for many premature births.
  • Women carrying multiple fetuses usually have early delivery.
  • Previous history of premature births predisposes an expectant mother to preterm delivery.
  • Mothers having heart disease or kidney disease may not be able to carry the pregnancy to full term.
  • Mothers with high blood pressure or preeclampsia may not be able to continue with the pregnancy when their condition becomes critical.
  • Uterine infections such as chorioamnionitis may necessitate early delivery.

Symptoms

Babies born prematurely typically have low birth weight, mostly below five and a half pounds or 2.5 kilograms. Some may be much smaller, weighing just about 1pound or 500 grams. When pregnancy is confirmed, an ultrasound scan is done to determine the exact age of the developing fetus. It would help the doctors calculate the gestational age of the premature baby at the time of birth. Examining the newborn for characteristic age related developmental features also help to determine its age.

The symptoms of prematurity vary from infant to infant depending on how immature the different organ systems are. In most babies born prematurely, the brain and the lungs are not often fully matured. They may have problems with breathing and temperature regulation of the body. Regulation of blood sugar levels also may be difficult. Premature babies often have underdeveloped excretory and immune systems too.

Complications: The complications arising from immaturity are directly related to how premature the infant is, and also to the reason for prematurity. Certain diseases and abnormal conditions in the mother, such as preeclampsia or high blood pressure and diabetes may be the reason for premature delivery.

Complications due to Underdeveloped Brain:  When the brain and the nervous system remain immature, the infant may have several problems:

  • Irregular breathing: Breathing irregularities may be present in premature babies if the brain centers regulating breathing are still very immature. Their breathing may be intermittent, often dotted with pauses which last up to 20 seconds or even longer.
  • Difficulty in breathing while eating: The brain centers responsible for controlling and coordinating the various mouth, as well as throat movements, involved in swallowing food are still immature in many preterm babies. They may find it difficult to suck in and swallow the food normally. Simultaneous breathing and feeding needs a lot of coordination of different muscle sets, and premature babies may take longer to achieve it.
  • Brain hemorrhage: Severely premature infants, especially those who are born before reaching at least 28 weeks of gestation, are at very high risk of brain hemorrhage. It usually starts in the germinal cortex part of the brain, and may reach the ventricles of the brain, which are chambers filled with fluid. The bleeding may be initiated at the time of labor or during delivery. Bleeding may start when the baby displays symptoms of respiratory distress too. Minor hemorrhages resolve by themselves and do not usually precipitate any lasting damage. However, severe hemorrhages may show symptoms such as lethargy in the infants and seizures. It may lead to coma too. The chances of lasting damage to the brain are also higher.

If the brain hemorrhage has been minor or moderate, it may not affect the normal development of the baby. However, newborns that have had severe hemorrhages are likely to have cerebral palsy, delayed development or learning disabilities as they grow. The postnatal care the newborn receives, as well as continued sensory stimulation provided by parents, through holding the baby, singing or playing music, reading etc, go a long way in improving the outcome. Some premature infants succumb to severe brain hemorrhage.

Complications due to Underdeveloped Digestive Tract and Liver: Infants born with immature liver and digestive system due to prematurity have many complications:

  • Regurgitation or spitting-up food: The reflux for sucking, as well as swallowing, is not as strong in premature babies as it is in full-term babies. Their stomach is very small and immature, and the digestion, and the movement of food, is slow, resulting in reflux or spitting up of food frequently.
  • Damage to the intestines: Babies born extremely prematurely are prone to a condition called necrotizing enterocolitis in which, portions of the intestines become severely damaged and perforated, necessitating surgical repair.
  • Jaundice: When red blood cells normally breakdown, the yellow pigment bilirubin accumulates in the blood. It is the function of the liver to remove this yellow pigment from the blood. But when the liver is immature, it cannot clear up the bilirubin efficiently, resulting in yellowing of the eyes and the skin, a condition referred to as jaundice. Soon after birth, premature babies often develop jaundice. When feedings improve and as bowel movements become more frequent, the bilirubin gets removed through the feces, making it bright yellow in color. If high levels of the pigment remain in the blood for prolonged periods, it may lead to a condition called kemicterus, which is brain damage resulting from bilirubin deposits in the brain.

Underdeveloped Immune System: Prematurely born babies are highly susceptible to infections as their antibody levels are extremely low. The antibodies that help fight infections are formed in the mother’s body as she is exposed to various common infective organisms. These substances are transferred into the fetus through the placenta, towards the end of the normal term. Hence, premature babies are deprived of these disease-fighting substances and are prone to infections, especially sepsis, a serious infection of blood, which often has potentially fatal consequences. Since premature babies need several invasive procedures early in life to connect to life saving support systems such as endotracheal tubes for assisted breathing, catheters connecting to the blood stream and feeding tubes, their chances of acquiring infections are also much higher, compared to full-term babies.

Underdeveloped Kidneys: In the mother’s womb, the excretory functions of the fetus are taken care of, by the placenta. When the baby is born, their kidneys should handle the excretory function. The immature kidneys of the premature babies are not capable of handling this new task. There may be problems with the regulation of fluids and salt in the body. Eventually, as the kidneys become more mature, the excretory function also improves.

Underdeveloped Lungs: The respiratory system of the premature babies is one of the least developed as its maturation usually happens towards the last few weeks of pregnancy. That is the reason for a condition called respiratory distress syndrome, very commonly encountered in infants born too early. This condition is characterized by difficulty in breathing, and a bluish tinge to the skin known as cyanosis. Nostrils’ flaring as the breath is taken in, and a grunting sound accompanying exhalation, are signs of respiratory distress. Low blood oxygen level is responsible for the change in skin color. Immature lungs lack a substance called surfactant which lines the air sacs in the lungs, giving them structural stability. In premature infants, the air sacs collapse each time the air is exhaled.

Difficulty Regulating Blood Sugar Levels: Babies born prematurely usually have feeding difficulties due to which their blood glucose levels may decrease to very low levels. Often, glucose supplementation is given intravenously to prevent severe hypoglycemia. Some babies have symptoms such as weakness and listlessness as the blood glucose levels become low, but most remain asymptomatic. They are at risk of hyperglycemia too, if the intravenous administration of glucose becomes excess. Hence, it is essential to keep monitoring the blood sugar of premature babies to maintain optimum levels.

Difficulty Regulating Body Temperature: Premature babies lose heat rapidly from their body, as the surface area of the skin is more, in relation to their body weight, when compared to normal weight infants born at full-term. While newborns born at term needs to be kept warmly covered to prevent loss of body heat, prematurely born infants need to be kept in an artificially heated environment such as an incubator or a crib warmed by a heater. If the premature infant is not kept warm enough, their heart beat increases in an attempt to enhance circulation and warm up the baby. The increased metabolic activity draws much of the energy expenditure towards it; consequently, the infant fails to gain weight, in spite of nutritional support.

Prognosis

With the advances in neonatal care, the survival rate of babies born prematurely has increased over the last few decades. Premature babies have brighter long term prospects too, if adequate care is provided immediately after birth. Mortality, as well as the risk of developmental problems, has reduced significantly in babies who have completed at least 26 weeks in the mother’s womb. However, in those babies born earlier than 26 weeks of gestational age, the risk of cerebral palsy, blindness, and developmental delays is very high. While most premature babies display normal intelligence, some may have learning disabilities necessitating special schooling.

Prevention

It is always better to prevent prematurity in the babies, whenever possible, by treating the conditions in the mother that may lead to early delivery. An expectant mother should look after her health, and should have adequate amount of nutritious food during pregnancy. Habits detrimental to the well-being of the fetus, such as smoking and alcohol consumption, should be stopped. All kinds of drugs should be avoided during pregnancy unless it is specially prescribed by the doctor and unavoidable due to serious health conditions. Prenatal care should be initiated as early as possible and regular visits to the doctor will help in diagnosing and treating complications such as high blood pressure and diabetes which may necessitate early delivery. Prenatal care is especially important for those who are at higher risk of preterm deliveries.

When labor begins early, the expectant mother is usually given drugs which may delay the delivery as long as possible, by slowing down or stopping uterine contractions. Simultaneously, corticosteroids like betamethasone are administered, which would accelerate lung development in the fetus. This would prevent respiratory distress in the in the infant when it is born prematurely. Risk of intraventricular hemorrhage, which occurs frequently in premature babies, is also significantly reduced with the use of corticosteroids.

Treatment

Prematurity is treated as soon as the baby is born preterm. If the newborn has respiratory distress, respiratory support is provided through a ventilator, till the baby’s lungs become capable of independent function. Hyperbilirubinemia or high levels of bilirubin in blood, is treated by phototherapy. Premature babies whose digestive system is not ready yet, are given intravenous nutritional support initially, till they can be fed through tube inserted into the stomach. Eventually, oral feeding is started as the digestive system matures. The ideal food for the baby is the mother’s milk and it reduces the risk of necrotizing enterocolitis, which often affects the intestines of premature babies. Premature babies usually stay longer in the hospital, often many weeks and even months depending on the extent of prematurity as well as the complications resulting from it.

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Birth Trauma, Newborn Brain Injuries and Perinatal Asphyxia

Birth Trauma refers to the physical damage or injury caused to the baby during the different stages of the birth process.  

  • Minor injuries are common in newly delivered babies.
  • Occasionally, nerve damage and fractures may have occurred.
  • Birth injuries often require no treatment.

When the baby is larger than usual, or when the mother’s birth canal is too narrow, it may cause complications during the delivery, and may result in injuries to the baby. Mothers who are diabetic tend to have larger babies, and the risk of birth injury is increased in such cases. The wrong position of the baby inside the uterus prior to birth, such as a breech position, may increase the chances of injury during birth. Advancements in prenatal screening have significantly lowered the number of birth trauma  in recent years. If abnormalities which may lead to a difficult delivery are detected through ultrasound tests, the doctor can opt to deliver the baby by a caesarean section.

Perinatal Asphyxia: It may occur during delivery when blood flow to the fetus gets cut off so that the fetal tissues do not get enough blood supply. When the oxygen content in the blood gets lowered due to some reason, it may result in perinatal asphyxia. This condition may occur because of different reasons; but in some cases, it may not be possible to determine the reason. A few of the factors responsible for perinatal asphyxia are:

  • Abnormal genetic conditions resulting in abnormally developed fetus
  • Getting exposed to harmful drugs when the fetus is inside the womb
  • Certain infections affecting the fetus within the uterus
  • Umbilical cord getting compressed or a blood clot forming in the cord which obstructs the flow of blood to the fetus
  • Severe blood loss occurring suddenly
  • placental insufficiency towards the end of pregnancy
  • Placental separation from the uterine wall at the time of labor, compromising blood and oxygen supply to the baby.

Newborns affected by perinatal asphyxia are born pale, with abnormally low heart rate and weak breathing. Some may appear almost lifeless, with apparently no breathing, and barely perceptible pulse. If the cause of asphyxia has been severe blood loss, the baby may be in shock. However, immediate intervention may save the newborn’s life. Fluids are administered into the vein and a blood transfusion is initiated. Ventilator support may be necessary to assist with breathing. Circulation support also is given, if necessary. Blood glucose levels should be checked and maintained, while the baby is kept in the incubator for maintaining warmth.

Multiple organ systems may be affected by asphyxia, and some irreversible damage may have occurred, but often, babies recover from the adverse effects with timely intervention and adequate medical care. If brain is affected, the newborn may be lethargic, and may have seizures. They may go into coma too. If kidneys are affected due to oxygen insufficiency, urine output may be low, but it is often a temporary problem. The lungs may be affected too, resulting in troubled breathing.

Asphyxiated infants may recover completely in many cases, but some may survive with certain permanent disabilities arising from irreversible injury to the brain that may have occurred due to poor blood and oxygen supply for prolonged periods. The resultant effects of neurological damage may manifest as development delays, or mild learning difficulties. In severe cases, cerebral palsy may result. In some cases, perinatal asphyxia may have a fatal outcome.

If the causes of asphyxia are identified, appropriate treatments may be initiated for better outcome. If an infection in the blood is causing this condition, it may be treated with antibiotics. If blood loss is the cause, transfusions can remedy it. To prevent brain injury, and reduce neurological damage, due to asphyxia, a new procedure has been helpful in the case of babies born at full-term. The baby’s head is rapidly cooled and kept at low temperature for many hours immediately after birth because it has been found that the oxygen needs of the brain is significantly reduced at low temperatures.

Head and Brain Injury: Most babies are born head first, and consequently, head experiences the most compression as it enters the narrow birth canal. During delivery also, the head gets bruised, especially if vacuum or forceps is used to assist the process. Swellings, bruises and a misshapen head may result, but they are not usually serious, and rapidly resolve without any treatment.

There may be soft swellings called cephalohematomas, which may grow further after birth. They are accumulations of blood under the thick covering of the skull plates called periosteum. When the bony plates shift and overlap as the head gets squeezed in the birth canal, it may result in bleeding, and this blood gets collected under the periosteum. It may take a few weeks or even a month or two for these bulges to resolve, but they eventually do disappear without any treatment.

It is rare for skull fractures to occur, but occasionally one or two bony plates may be fractured, but they heal fast, except in the case of a depressed fracture which is otherwise called an indentation.

Bleeding in the Brain: Bleeding in the brain, also called intracranial hemorrhage, is often caused when blood vessels inside the skull get ruptured. The bleeding may have resulted from deformed bones of the skull, or due to lack of adequate oxygen content. Premature babies are more prone to intracranial hemorrhage, and the usual reason is either ischemia, or reduced supply of blood to the brain, or hypoxia, characterized by abnormally low blood oxygen levels.

Intracranial bleeding may not precipitate any external symptoms, but poor feeding and sluggishness of newborns may be due to this condition. It may cause seizures in the newborn too.

Bleedings occurring in different areas of the brain are classified as:

Subarachnoid hemorrhages:

These are the most frequently occurring type of hemorrhages, especially in babies born at full-term. The bleeding takes place under the inner layer of the double membrane enclosing the brain. When subarachnoid hemorrhage occurs, the newborns may have seizures in the initial period after birth, but long term prospects are usually good.

Subdural hemorrhages:

In this type of hemorrhage, the blood enters the space between the outer and inner layers of the membranes covering the brain. Subdural hemorrhages can exert pressure on the the brain and compress it. Babies who suffer from this type of hemorrhage may have several problems including seizures. The bilirubin levels in their blood are usually elevated, resulting in jaundice. Improvements in the delivery techniques have reduced the frequency of subdural hemorrhages in recent years.

Intraventricular hemorrhages:

In an intraventricular hemorrhage, the bleeding is occurring into the ventricles or the chambers of the brain which are normally filled with fluid. In intraparenchymal hemorrhage, the blood seeps into the cellular tissue of the brain. These two types of hemorrhages are more common in premature babies whose brains are severely under-developed. Hence, intraparenchymal and intraventricular hemorrhages are not considered birth injuries, but as the effects of prematurity.

Babies who suffer from hemorrhages should get special care, including intravenous administration of fluids, and support for other functions of the body such as breathing and circulation, depending on the requirement. Surgical intervention may be necessary in case of a subdural hemorrhage.

Nerve Injury: Nerve injuries occurring during delivery may be due to compression of nerves, or tearing of nerve fibers as a result of extreme stretching. When the nerve on one side of the face gets compressed during a forceps assisted surgery, it can cause muscle weakness only on that side. If a side of the baby’s head is pressed against the pelvis of the mother, then also, this may happen. The face of the newborn looks asymmetrical, especially when the baby is crying. This condition gets resolved eventually, without any specific treatment, but it may take two to three months.

When the delivery is difficult, especially in the case of larger babies, a large vein running into the baby’s arm can get stretched too much, resulting in damage to that nerve. It may cause the arm or hand to be paralyzed. In such cases, the baby should be handled in such a way that the shoulder is prevented from moving too much, to help the nerves heal faster. If the hand does not improve even after a period of many weeks, surgical repair of the nerve fibers which had got torn may be necessary.

When one of the nerves supplying the diaphragm is damaged during delivery, one side of the diaphragm gets paralyzed. The diaphragm is the large muscular membrane separating the chest cavity from the abdomen, and its contraction and relaxation helps in breathing. Paralysis of this membrane results in breathing difficulty, which may gradually improve, and completely resolve in a few weeks’ time. If the spinal cord is overstretched at the time of delivery, it may get damaged. The usual outcome of spinal cord injury is paralysis of the body below the location of the injury. Spinal cord injury is rare, but, when it has occurred, the effects are usually permanent.

Injury to the Bones: A complicated delivery may occasionally cause bone fractures in the newborn. One of the common fractures encountered is that of the collarbone, which is called clavicle. The bone of the upper arm known as humerus, and that of the upper leg, namely femur, also suffer fractures occasionally, but it is not very common. A cast or sling may be needed to keep the fractured bones from moving, so that it can heal faster. Usually, within a short period, complete healing is achieved in case of fractures sustained during delivery.

Skin and Soft Tissue Injury: The skin of the newborn may suffer bruises in several places where compression has occurred at the time of contractions. The passage through the birth canal may precipitate damage to the skin and the fat tissue which may show up as swellings or bruises afterwards. When the baby is delivered face-first, injuries are observed commonly on the face and around the eyes. A breech-delivery may result in injuries to the external genital parts and the buttocks of the baby.

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