Recién nacidos

Pretermino tardio
34-36.6 sem
 Outcome† 37 Weeks 38 Weeks 39 Weeks 40 Weeks
Any adverse outcome or death 2.1 (1.7-2.5) 1.5 (1.3-1.7) Reference 0.9 (0.7-1.1)

Nacimientos espontáneos ?
Adverse respiratory outcome
RDS 4.2 (2.7-6.6) 2.1 (1.5-2.9) Reference 1.1 (0.6-2.0)
TTN 1.8 (1.2-2.5) 1.5 (1.2-1.9) Reference 0.9 (0.6-1.3)
RDS or TTN 2.5 (1.9-3.3) 1.7 (1.4-2.1) Reference 0.9 (0.6-1.2)
Admission to NICU 2.3 (1.9-3.0) 1.5 (1.3-1.7) Reference 0.8 (0.6-1.0)
Newborn sepsis‡ 2.9 (2.1-4.0) 1.7 (1.4-2.2) Reference 1.0 (0.7-1.5)
Treated hypoglycemia 3.3 (1.9-5.7) 1.3 (0.8-2.0) Reference 1.2 (0.6-2.4)
La EG (RNT) 40-41s ………… 39-38s
Hospitalization ≥5 days 2.7 (2.0-3.5) 1.8 (1.5-2.2) Reference 1.0 (0.8-1.4)

Reducción
*Odds ratio (95%
†
PVDC
confidence interval).
All outcomes are adjusted for maternal age (as a continuous variable), race or ethnic group, number of previous cesarean deliveries, marital status, payer,
‡
Incremento
smoking status, and presence or inducciones 22%
absence of diet-controlled gestational diabetes mellitus.
Newborn sepsis included suspected infections (with clinical findings suggesting infection) and proven infections.
Incremento
NICU, Neonatal intensive care unit;de RDS,cesareas 30%?
respiratory distress syndrome; TTN, transient tachypnea of the newborn.
Adapted from Tita AT, et al: Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009;360:111.
Cesarea a pedido materno 10%.
10 10 accurate only to ±1 to 2 weeks’ gestational age. Combined
with the fact that developmental variability exists during
Percent of late preterm births (34–36 weeks)

Stillbirths and infant deaths per 1000 births

fetal maturation, and conditions such as maternal obesity
and PROM can cause an overestimation or underestima-
9 Infant deaths 9 tion of gestational age, the task of accurate gestational age
Late preterm prediction is even more challenging. In an attempt to
births reduce mortality among post-term gestations, ACOG in
1989 recommended induction of labor at 43 weeks.3
8 8 The Society of Obstetricians and Gynecologists of Canada
later recommended induction at 41 weeks.15 The ACOG
more recently issued guidelines that cesarean delivery or
induction on maternal request should not be performed
7 7
Stillbirths before 39 weeks’ gestation or without evidence of lung
maturity.1 This gradual shift toward lower gestational age
along with the inaccuracies of gestational age measure-
6 6
ment might have led to the increasing proportions of late
preterm births.
0 0 Tocolysis and antenatal steroids are routinely recom-
1990 1995 2000 2005 mended only for women at less than 34 weeks’ gestation
because infants born at 34 weeks’ gestation and beyond
Year
are believed to have mortality rates similar to that of term
 • 15 millones/año RNPT
• 1/10 RN nace antes de tiempo (<28, <32, <37)
• 1/15 millones muere por prematuridad
Prematuridad en • RNPT 2da causa de muerte en el mundo <5ª

el Mundo • Brecha 90/10: (<28sem)

• > 90% fallece P. Bajos Recursos
• < 10% fallece P. altos recursos

• Muchos de los sobrevivientes enfrentan una vida de discapacidad, incluyendo problemas

de aprendizaje y problemas visuales y auditivos.
 Pretérmino
ü Parto prematuro espontáneo 45%
ü RPPM 25%
Espontáneo
üIndicaciones medicas (30%):
Indicacion
• Placenta previa –desprendimiento- Materna/Fetal

• Hipertensión, DBT
• Colestasis materna
• RCIU RPPM

• Preeclampsia
 Los nacimientos prematuros en números:

• 5-18% es el rango de tasas de

nacimientos prematuros en 184 países
del mundo.
• >80% de los nacimientos prematuros
ocurren entre las 32- 37s
• >75% de las muertes por nacimientos
prematuros pueden ser prevenidas con
cuidado no intensivos.
• 7 países han reducido a la mitad su
número de muertes por nacimientos
prematuros en los últimos 10 años
Prematuridad • EEUU 11%
• ARG 8-9%
• Bolivia 9%
America Latina: 35.000
• En total, unos 35,000 niños y niñas mueren cada año en América Latina por complicaciones
del nacimiento prematuro.
• Brasil 9.000 cada año,
• México (6.000),
• Colombia (3.500),
• Argentina (2.400),
• Venezuela (2.200),
• Perú (2.000),
• Guatemala (1.900),
• Bolivia (1.600),
• Ecuador (1.500)
• Honduras (1.100).
Prematuridad
Argentina (RNPT)
 100-400 publicaciones por año

• 2006 Pretermino tardio(LPT)

reemplaza RN-casi a termino.
• 2007 March of Dimes
• 2011 NICHD guías criterios finalización
embarazos LPT SMFM.
• 2012 NICHD/SMFM LPT-Termino
temprano.
• 2016 >500 publicaciones sobre >
morbilidad respiratoria, metabólica,
etc.
• 2016-2017 reducción de LPT Europa-
EEUU.
• 2016 Trials MPF-LPT
 Preterminos Tardios Termino Temprano
RNPT-tard RNT-temp

Pretermino RN Término
First day of last preterm term

2006 NICHD: Near term a Late preterm:

menstrual period
ay # 1 239 259 260 274 294
Figure 42-1 Definition of late preterm and

De casi a termino a pretermino tardio…

early term. (Modified from Engle WA, Komini-
ek # 0/7 34 0 7 36 67 37 07 38 67 41 6 7 arek MA. Late preterm infants, early term infants,
and timing of elective deliveries. Clin Perinatol.
Preterm Term Post-term 2008;35:325.)

39 weeks 37–38 weeks

28.3% 26.9%
32–33 weeks
<37 weeks 12.6%
12%
28–31 weeks
10.1%

RNPT RNPT <28 weeks

5.9%

34–36 weeks
42 or more weeks 71.4%
5.5% Preterm birth rate as a
percentage of all preterm births
40–41 weeks
27.3%
ure 42-2 Birth rate by gestational age as a percentage of all live births in the United States. (Data from Martin JA, Hamilton BE, Ventura SJ,
. Births: final data for 2010. National vital statistics reports. Vol 61. no 1. Hyattsville, MD: National Center for Health Statistics; 2012.)
 Pretermino tardio RNPT-t (34-36.6 sem)
”70-7”
• Frecuentemente confundidos con ”prematuros grandes”

• Representan 70-75% de los RNPT

• RNPT incremento en los ultimos 15 años

• 20% RNPT
• 25% RNPT-PTt
• 50% RNT-temp

• 5-10% RNV 1995-2005 USA/Canada/Brasil/Arg.

 580 PART 7 • PROVISIONS FOR NEONATAL CARE

Causas RNPT-tard
BOX 42-1 ETIOLOGY OF LATE PRETERM BIRTHS
MEDICALLY INDICATED • Maternal willingness to accept risk on behalf of the
Preterm labor infant
PROM • Convenience for mother and family
Preeclampsia GESTATIONAL AGE ASSESSMENT AND OBSTETRIC
PRACTICE GUIDELINES
MEDICAL INTERVENTIONS AND IATROGENIC
Inaccurate gestational age assessment during elective
Increased medical surveillance and interventions deliveries
Cesarean or planned induction of labor. Medical

• Incremento monitoreo
Maternal obesity
indications: Presumption of fetal maturity at 34 weeks’ gestation
• Abnormal presentation, abnormal placentation, mater- Decreasing gestational age criteria for inductions and
nal or fetal conditions (e.g., PROM without labor, fetal increased rate of stillbirths beginning at 39 weeks’
hydrocephalus) gestation
• Repeat cesarean section

Cesarea electiva/ Inducciones fallida

Cesarean or planned induction of labor. No medical ADVANCED MATERNAL AGE, ASSISTED REPRODUCTIVE

•
indication: TECHNOLOGIES, AND MULTIPLE BIRTHS
• Induction of labor or cesarean section on maternal Increase in multifetal pregnancies
request Delayed childbearing and increased risk for prematurity
• Fear of fetal and neonatal risks with vaginal delivery Use of assisted reproductive technologies (multifetal preg-
• Increased rate of stillbirths beginning at 39 weeks’ nancies) and increased risk for complications associated

Cesarea a pedido materno

gestation

•
with premature delivery (e.g., preeclampsia, diabetes)
• Hypoxic-ischemic encephalopathy, brachial plexus,
and other birth traumas PHYSICIAN PRACTICE PATTERNS AND RISK/BENEFIT
• Fear of maternal risks with vaginal delivery DETERMINATION
• Risk for genital tract, anus, and perineal injury and Concern for risk of adverse outcomes
sexual dysfunction Convenience

Miedo materno/Falsa seguridad Cs

• Perception that cesarean delivery is “easier” and “less

•
Liability
stressful” than vaginal delivery
• Fear of the second stage and having to “push the baby
out”

PROM, Premature rupture of membranes.

• Falla calculo de EG/Obesidad, DBT mat

Adapted from Engle WA, Kominiarek MA. Late preterm infants, early term infants, and timing of elective deliveries. Clin Perinatol. 2008;35:325.

could be found and where maternal choice was the with cesarean section rates, and there was a shift toward
leading factor, cesarean delivery on maternal request.63 earlier gestations in both groups.17 In 2005, 22% of all

TRA/gemelares
Although the exact number of such deliveries is hard singleton live births were induced. Of those, late preterm

• to track, it is believed that 10% of cesarean sections may

be performed at maternal request.72 Declercq and col-
leagues18 examined demographic and medical risk factors
from 1991 to 2002, and found no association between
and term births had the largest increase in induction
rates. Overall, the induction rates for late preterm births
have increased 130% since 1990, and these rates have
increased 175% for the early term group.53 Although
changes in the maternal risk profile and the observed medically indicated interventions have led to a decrease

• Conveniencia medica?
shifts in the primary cesarean section rates, implying that in the number of stillbirths, we do not know how much
changes in maternal characteristics are not responsible this has contributed to the increase in the preterm birth
for the increasing rate of cesarean sections. Davidoff and rate or whether the gains realized in preventing stillbirths
colleagues,17 looking at birth certificate data from 1992 are offset by increased NICU admissions and complica-
to 2002, showed that all categories of live births have had tions associated with prematurity (Figure 42-5). More

• Medicas:
an increase in late preterm (34-36 weeks’ gestation) and recently, many states have implemented quality improve-
early term (37-39 weeks’ gestation) birth rates. Although ment programs to decrease elective deliveries before 39
spontaneous births and births from PROM declined weeks’ gestation. In one multistate collaborative under-
during this period, births from medical interventions taken over 12 months, elective scheduled early-term
increased, with cesarean section accounting for most of deliveries decreased from 27.8% in the first month to

• TP-pretermino
the medical intervention group. 4.8% in the 12th month; in addition, rates of elective
Although elective cesarean sections are discouraged scheduled singleton early-term inductions and cesarean
before 39 weeks’ gestation, a study by Tita and associ- deliveries decreased significantly.66
ates84 found that nearly 36% of elective repeat cesar- Some evidence suggests that 2.5% to 18% of live births

• PROM
ean sections were performed before 39 weeks’ gestation. are delivered by cesarean section on maternal request.60,63
Among these elective cesarean births, infants born at Other studies disagree,19,57 claiming that the increasing
37 and 38 weeks had greater than 1.5 times the odds cesarean section rates stem from the changing practice
of death or complications, including respiratory com- standards of medical professionals and their willingness

• Preeclampsia/colestasis
promise, hypoglycemia, sepsis, and admission to the to perform cesarean sections because of the perceived
NICU (Table 42-1).84 Induction rates have also increased safety and protection from malpractice litigation. Further
sport in the same direction, either through aquaporins or by diffusion. CNGC,
ry morbidity in late-preterm infants: prevention is better than cure! Am J Perinatol.

Complicaciones
Morbilidad general I
s CLINICAL OUTCOMES
a-
41 Morbilidad grave
Temperature

m
y instability
Full term • 34 52%
Near term
e
ir Hypoglycemia • 35 26%
of • 36 12%
p- Intravenous
a infusion
s
e Respiratory
n- distress
e Días de Internación
e Clinical
jaundice
d,
i-
e- 0 10 20 30 40 50 60
d (%)
d Figure 42-8 Graph of clinical outcomes in near-term (35-36 6 7
t- weeks) and full-term infants as percentage of patients studied. (From
Wang ML, et al. Clinical outcomes of near-term infants. Pediatrics.
2004;114:372.)

s- organ system is affected in late preterm infants (Figure

Pronóstico adverso: RNT- tempranos
with infants born at 39 to 41 weeks’ gestation (3.09 vs. Kleiner and co-workers showed that term and near-term
1.98).56 Most of us are under the assumption that the infants delivered by cesarean section before the onset of
increased risk of morbidity and mortality is limited to the labor had much higher probability of having severe RDS.
Mortalidad general RNPT- tardios
immediate neonatal period, but a study looking at nearly
675,000 singleton births in Sweden (between 1973 and *References 14, 24, 58, 74, 88, and 89.

TABLE 42-2 Mortality Rates and Risk Ratios for Death According to Gestational Age
Gestational Age Early Neonatal Mortality Rate (1-7 Days) Infant Mortality Rate (1-365 Days)
(weeks) Mortality Rate* Risk Ratio Mortality Rate* Risk Ratio
34 7.2 25.5† 12.5† 10.5
35 4.5 16.1† 8.7† 7.2
36 2.8 9.8† 6.3† 5.3
Primera semana Primer año
37 0.8 2.7† 3.4† 2.8
38 0.5 1.7 2.4† 2.0
39 0.2 0.8 1.2 1.2
40 0.3 Reference 1.4 Reference

*Mortality rates are per 1000 live births.

†
Risk ratios are significantly different from 40 weeks.
Adapted from Young PC, et al. Mortality of late-preterm (near-term) newborns in Utah. Pediatrics. 2007;119:e659.
 Morbilidad general RNPT- tardios

• Dificultad respiratoria
• Hipoglucemia
• Hipotermia
• Inestabilidad térmica 28% (hnas stress-grasa parda)- cortisol, norepi, TRH.
• Dificultad en alimentacón (<presion negativa, hipotonia faringe, incoordinacion)
• Hipoglucemia
• Sepsis x 4-5.2
• 1/3 requirio cultivos y ATB s SDR, trast glucemia y/o temp.
• Ictericia
• Acc. Vascular RR 6.8
• Apneas
• >N dias internación. 34s 11dias -35s 6 dias -36s 4 dias
 Respiratorio
• Patologias mas frecuentes son:
• Algun tipo de asist Resp 33-30-23% (34-35-36)
• Taquipnea transitoria x4.4
• EMH x8-17
• Necesidad de ARM: 34s 6%-35s 3% -36s 2%
• Falla Resp hipoxemica severa
• HTTP/ Falla respiratoria hipoxemica severa (15-
21% del grupo ECMO) LPT/Early term.
• Prematuridad + cesarea + ausencia TP
• 11% desarrollan DBP
Dificultad respiratoria/ RNPT-tar/ Via parto
• Corticoides:
• + sintesis
• + actividad
• - degradación Respiratorio
• NNT: 35/

• 24%hipoglucemia!
 Neurodesarrollo
• RNT 70% masa cerebral

• RNPT-34-36s 50%
• Incremento sust gris, blanca, cerebelo, circuitos sinapticos
• ictericia,
• acidosis,
• hipoglucemia,
• sepsis
• Peso cerebral @ 34s es 60% del RNT.
• 32-36s mayor riesgo de Trast a mediano y largo plazo: neurodesarrollo
• HIC x 4.9
• Mortalidad x 3-4.4 (Neo) y x1.3-1.5 a los 36ª
• SMSL x2-5
• Costo economico al sist de salud
• RNPT-moderado (32–33s) y RNPT-tar (34–36s) riesgo incrementado de:
• discapacidad que requiera intervencion oportuna y soporte educativo.
• discapacidad neurologica (PC, TDHA, TEA, etc)
• falla escolar,
• trast del comportamiento y trast. psiquiátricos.
• OR:
• 33 to 36 ws, 1.53 (CI, 1.43–1.63);
• 37 weeks, 1.36 (CI, 1.27–1.45);
• 38 weeks (CI, 1.19; CI, 1.14–1.25),
• 39 weeks, 1.09 (CI, 1.04–1.14).

• La mayoria de los programas de seguimiento estan planificados para RNPT-MBP/extremos.

Trast. Neurologicos, apoyo educativo

TDHA
Apoyo escolar
Hipoglucemia

• Menos reservas de glucógeno

• Glucogenolisis y lipolisis (inmadurez enzimatica)
• Menor neoglucogénesis y cetogénesis.
Hipoglucemia
• Journal of Pediatrics 2016

• Usar las guías de la AAP durante las primeras 24

horas

• Promover lactancia materna y evitar innecesarios

ingresos a UCIN

• Entre 0-48 horas los niveles deberían ser mayores a

≥ 45 mg/dl

• >48hs Glucemias ≥ 70 mg/dl

• Retrasar el alta de los RN que requirieron glucosa EV,

o los que tuvieren cifras en el límite hasta que, luego
de las 48 horas de vida, tengan valores por encima
de 70mg/dl
Ictericia
• Patologia sumamente frecuente en RNPT: >80%.
• RNPT-tar factor de riesgo más prevalente de HB severa y kernicterus
• La hiperbilirrubinemia es en ellos más pronunciada y prolongada

• Captacion hepática
• Conjugacion
• Circulacion entero-hepática
• Pico mas tardio 6-7 DDV
 • Clinical report from the Pilot USA Kernicterus Registry
• (1992 to 2004) L Johnson, VK Bhutani, K Karp, EM Sivieri and SM Shapiro

Ictericia (x8)
• Journal of Perinatology (2009) 29, S25–S45

• 176 casos, 125 analizados

• Prematuros tardíos están
desproporcionadamente representados
• Edad: la mayoría antes de 7mo día
• La mayoría se alimentaban con
lactancia materna exclusiva y habían
recibido poca información y apoyo.
 Lactancia
Menos tasa de inicio de alimentación al pecho (p < .0001) y de lactancia a ≥ a
10 meses (p < .0001). Hwang S; Pediatrics 2013

•2.772 RN. En el análisis de regresión logística PT al mes de vida menos

lactancia en relación con RNT (OR 0.44; 95% IC 0.28–0.69; p≤0.0001). Hackman
N. Breastfeeding Medicine 2016

• 11.729 RN. Menor prevalencia de lactancia a las 6 semanas que los RNT
(OR 0.67, 95% IC 0.49-0.92).

• El haber recibido apoyo durante y después de la internación se asoció en

los PT con mejores resultados a los 10 días. Rayfield S;BMJ2015
Lactancia
 Lactancia
• Factores maternos asociados a menor
lactancia:

• Alto IMC
• Diabetes
• Hipertensión inducida por embarazo
• Parto pretérmino
• Reposo prolongado
• Cesárea
• Complicaciones intraparto. Excesiva
pérdida de sangre
• Medicamentos
 Reinternación (x3-4): Por qué se reinternan?

• 60-70% Ictericia
• 30% Dificultades con la
alimentación
• 17% Mal progreso de peso
•20% Infecciones/sospecha
Planificación del Alta
• No alta precoz (<48hs)
• EG y ausencia de condiciones médicas que requieran re-internaciones
• Peso > 1.900 grs?/ EG >36s?
• Descenso de peso no > 3%/dia
• Tener al menos 1 deposicion/dia
• Estabilidad cardio-respiratoria y en la regulación de la temperatura,
alimentación.
• Adecuado asesoramiento familiar
• Identificar factores de riesgo medio-ambientales
• Asegurar seguimiento pos-alta adecuado 36-48 hs, 7, 14 dias.
 Planificacion del alta
• Controlar ictericia durante la internación (Tc)
• Bilirrubina pre-alta? ( Nomograma Bhutani)
• Tratar de evitar el alta temprana
• Restringirla a>38s,
• Proveer asesoramiento y apoyo en lactancia.
• Pezoneras ultrafinas, asesoria en lactancia, control precoz
• Dar pautas de alarma a los padres
• Indicaciones escritas
• Planear un adecuado seguimiento pos-alta
• Control precoz
• Equipo de seguimiento
Mensaje corto para la guardia
(RNPT-tar): (síntesis)
• Son 34-36.6 sem
• Causas: cesarea/HTA/Doppler?
• > riesgo: SDR/TT/hipotermia/hipoglucemia/ictericia/Dific.Lactancia
• Largo plazo: ND
• Recomendación:
• Evitar cesareas <39sem / ojo con corticoides prenatales.
• Cuidado atento al nacer
• Control precoz al alta
• Seguimiento adecuado
Gracias