Introduction:
Basic terminology:
A live born child is a fetus that shows at least one sign of life after birth and weighs at least 500 g or, in case of lower birth weight, survives 24 hours after birth. Signs of life are breathing, beating of the heart, pulsation of the umbilical cord or definite movement of voluntary muscles.
A fetus that shows none of these signs of life and weighs 1000 g or more is classified as still born child.
If fetus shows no sign of life and weighs less than 1000 g, the termination of pregnancy is classified as abortion.
Assessement of the live born child
Introduction:
Developed by Dr. Virginia Apgar, an anesthesiologist, in 1953 for the purpose of providing a simple, clear classification or grading of newborn infants which can be used as a basis for discussion and comparison of the results of obstetric practices, types of maternal pain relief and the effects of resuscitation.
Classification:
Body | 0 | 1 | 2 |
Heart action | None | Under 100/min | Over 100/min |
Breathing | None | Slow, irregular | Regular, cry |
Muscle tone | None | Weak | Normal |
Reaction to irritation | None | Grimase | Cry |
Skin color | General cyanosis and paleness | Acrocyanosis | Pink |
The scoring system comprises 5 signs: heart rate, respiratory effort, muscle tone, reflex irritability and color, each of which is given zero, one or two points. The total score ranges from zero to ten points.
The baby is scored at 1, 5 and 10 minutes after birth.
A score of 7 – 10 is considered normal, 4 – 7 intermediate, 0 – 3 poor; the infant requires immediate resuscitation
Clinical signs:
The Apgar score significance
Rapid standardized assassement of the clinical status of the newborn infant and the need for prompt resuscitation A change in score is a useful index of the response to resuscitation. On the other hand the Apgar score has limitations. It is affected by gestational age, maternal medication, resuscitation, congenital anomalies, infections and trauma.
Apgar score in preterm infants
Signs as tone, color or reflex irritability paritally depend on the physiologic maturity of the infant. The healthy preterm infants may receive a low score only because of immaturity.
Apgar score and asphyxia
In is innapropriate to use an Apgar score alone to establish the diagnosis of asphyxia. Other factors such as abnormalities in umbilical arterial blood gases, clinical cerebral function, placental pathology and multisystem organ dysfunction need to be considered.
Apgar score and prediction of neurological outcome in the term infant
A low 1-minute Apgar score alone does not correlate with the infants future outcome. An Apgar score of 0 to 3 at 5 minutes may correlate with neonatal mortality but alone does not predict later neurologic dysfunction. (75% of children with cerebral palsy have normal scores at 5 minutes). The risk of poor neurological outcome increases when the Apgar is 3 or less in 10, 15 and 20 minutes.
Classification:
Newborn classification based on gestational age
Newborn classification based on birth weight
Low birth weight (LBW) — less than 2500 g Very low birth weight (VLBW) — less than 1500 g Extremely low birth weight (ELBW) — less than 1000 g
Newborn classification based on birth weight and gestation is valuable in predicting the outcome. At any gestation the poorest outcome is seen in infants with marked intrauterine growth retardation.
Clinical signs:
Evaluation of newborns enables to predict complications which may occur during fetal to neonatal transition period. Premature infants are at main risk of organ system immaturity espacially respiratory. Hyperbilirubinemia and hypothermia is a frequent problem, there is an increased risk of infection and sepsis. SGA infants are at high risk of birth asphyxia, there is often transient hypoglycemia and hypothermia even in term hypotrophic infants and increased incidence of cogenital anomalies and intrauterine infections as the underlying condition of growth failure.
Introduction:
A premature birth is one that occurs before 37 weeks of gestation.
The incidence of premature labor in the Czech republic is almost 8% and the number is continously increasing.
Etiology:
Clinical signs:
Spontaneous preterm birth
Partus prematurus in cursu with uterine contractions
Preterm premature rupture of membranes (PPROM) — spontaneous rupture of membranes before the onset of labor prior to 37 weeks. PPROM is most likely due to chorioamnionitis.
Elective preterm delivery because of problems with the pregnancy.
The most common reason is preeclampsia, eclamptic convulsions or HELLP syndrome, placental abruption, intrauterine growth retardation or certain fetal anomalies (hydrops).
Clinical management of PPROM
Immediate labor: in case of chorioamnionitis, advanced labor, fetal distress, placental abruption and fetal lung maturity
Conservative management: on the condition that there is no intra-amniotic infection. The vast majority of women otherwise preceed to active labor and delivery soon. With therapy (tocolytics, antibiotics) and conservative management approximately 50% of remaining pregnancies deliver during the subsequent week after PPROM. Steroids given to a mother in preterm labor improve pulmonary function in the infant with increased surfactant synthesis and secretion and significantly reduce mortality and morbidity of preterm delivery. Optimal benefit starts 24 hours after the onset of treatment and lasts 7 days.
The main risk of premature rupture of membranes is ascending infection. The risk increases with duration of PPROM.
Prognosis is extremely poor if PPROM occurs before fetal viability and especially before 20 weeks of gestation. Lethal pulmonary hypoplasia is the result of early severe oligohydramnios (Potter's sequence).
Pictures
Potter's sequence in 28-week gestation neonate. Elective preterm delivery because
of prolonged rupture of membranes and anhydramnios from 19 weeks's gestation. Early
neonatal death from lung hypoplasia.
Potter's sequence, Macro, autopsy (73878)Potter's sequence, Macro, autopsy (73879)Potter's sequence, Macro, autopsy (73876)Potter's sequence, Macro, autopsy (73877)
Potter's sequence, twin A. Preterm delivery at 29 week's gestation with prolonged
rupture of membranes 6 weeks before delivery (dichorionic diamniotic twins). The baby
was dependent on ventilatory support untill death at 3 months of age. The baby died of
respiratory failure due to bronchopulmonary dysplasia complicated by pneumonia. Note
lower extremity deformities.
Potter's sequence, Macro, autopsy (73880)
Immaturity (24-week), hypoplastic lungs, apoplexia:
Immaturity, lung hypoplasia, apoplexia, Macro, autopsy (74408)Immaturity, lung hypoplasia, apoplexia, Macro, autopsy (74409)Immaturity, lung hypoplasia, apoplexia, Macro, autopsy (74410)
Introduction:
Birth after 42 weeks of gestation.
Etiology:
Macroscopic appearance:
Clinical signs:
Possible complications
Introduction:
There is a rapid somatic growth which is roughly linear for most of the second and third trimestr slowing down from about 38 weeks of gestation until delivery. Growth and developement are affected by genetic and enviromental factors. Particular patterns of deviation from normal may occur.
Etiology:
Hypoplastic type
Malnutrition type
Other causes of growth failure
Clinical signs:
Potential complications (especially in cases of uteroplacentar hypoxia)
Pictures
Early neonatal death in term infant with intrauterine growth retardation
(birth weight 1800 g) from birth asphyxia (pH a. umbilicalis 9.69). The autopsy
revealed massive meconium aspiration. Note the wrinkled skin with meconium staining.
Asphyxia, meconium stain, Macro, autopsy (73824)Asphyxia, meconium stain, Macro, autopsy (73823)Asphyxia, meconium stain, Macro, autopsy (73825)
Growth-retarded neonate with chromosomal aberation (trisomy 18). Birth at 37 week's
gestation with birth weight 1770 g. The baby with multiple
malformations lived for 10 days. Phenotypic features are typical for trisomy 18.
Trisomy 18, Edwards, Macro, autopsy (73888)
Introduction:
An infant weighing 4000 g or more at term.
Etiology:
Clinical signs:
Potential complications
Pictures
Large for gestational age stillbirth of diabetic mother with birth weight 5900 g.
Vaginal delivery was difficult and complicated by shoulder dystocia.
Diabetic fetopathy, Macro, autopsy (73791)
Macroscopic appearance:
Physiological term newborn