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73 Neonatal Morbidities of Prenatal and Perinatal Origin

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73 Neonatal Morbidities of Prenatal and Perinatal Origin 73 Neonatal Morbidities of Prenatal and Perinatal Origin JAMES M. GREENBERG, MD | BETH HABERMAN, MD | VIVEK NARENDRAN, MD | AMY T. NATHAN, MD | KURT SCHIBLER, MD Obstetric Decisions and COMMON MORBIDITIES OF PREGNANCY AND Neonatal Outcomes NEONATAL OUTCOME The nature of obstetrics clinical practice requires consideration Complications of pregnancy that affect infant well-being may of two patients: mother and fetus. The intrinsic biological inter- be immediately evident after birth, such as hypotension related dependence of one with the other creates unique challenges not to maternal hemorrhage, or may present hours later, such as typically encountered in other realms of medical practice. Often hypoglycemia related to maternal diabetes, or thrombocyto- there is a paucity of objective data to support the evaluation of penia related to maternal preeclampsia. Anemia and thyroid risks and benefits associated with a given clinical situation, disorders related to transplacental passage of maternal immu- forcing obstetricians to rely on their clinical acumen and expe- noglobulin G (IgG) antibodies to fetal red blood cell anti- rience. Family perspectives must be integrated in clinical deci- gens or to thyroid, respectively, may even present days after sion making, along with the advice and counsel of other clinical delivery. providers. This chapter reviews how to best utilize neonatology Diabetes during pregnancy can serve as a prototypic expertise in the obstetric decision-making process. example. Infants born to women with diabetes are often macro- somic, increasing the risk of shoulder dystocia and birth injury. THE PERINATAL CONSULTATION AND THE After delivery, these infants may have significant hypoglycemia, ROLE OF THE NEONATOLOGIST polycythemia, and electrolyte disturbances, which require close surveillance and treatment. Lung maturation is delayed in the Optimal perinatal care often derives from collaboration between infant of a diabetic mother (IDM), increasing the incidence the obstetrician and neonatologist during pregnancy, and espe- of respiratory distress syndrome (RDS) at a given gestational cially around the time of labor, to eliminate ambiguity and age. The IDM also has delayed neurologic maturation, with confusion in the delivery room and to assure that patients and decreased tone typically leading to delayed onset of feeding families understand the rationale for obstetric and postnatal competence. Less common complications include an increased management decisions. The neonatologist can provide infor- incidence of congenital heart disease and skeletal malforma- mation regarding risks to the fetus associated with delaying or tions. Most neonatal complications of maternal diabetes are initiating preterm birth and can identify the optimal location managed without long-term sequelae, but may prolong length for delivery to ensure that skilled personnel are present to of hospital stay. Anticipatory guidance for parents can decrease support the newborn infant. anxiety and improve readiness for hospital discharge. Neonatal In addition to contributing information about gestational complications for the IDM are a function of maternal glyce- age–specific outcomes, the neonatologist can also anticipate mic control; thus careful screening by physicians and attention neonatal complications related to maternal disorders such as by patients will reduce neonatal morbidity due to maternal diabetes mellitus, hypertension, and multiple gestation, or pre- diabetes. natally detect fetal conditions such as congenital infections, Other morbidities of pregnancy and their effects on neonatal alloimmunization, or anomalies. When a lethal condition or outcome are summarized in Table 73.1. The list is not exhaus- high risk of death in the delivery room is anticipated, the neo- tive, and does not take into account how multiple morbidities natologist can assist with the formulation of a birth plan and may interact to create additional complications. Any of these develop parameters for delivery room intervention. problems may contribute to increased length of hospital stay Preparing parents by description of delivery room man- after delivery as well as long-term morbidity. agement and resuscitation of a high-risk infant can demystify Chorioamnionitis has diverse effects on the fetus and on the process and reduce some of the fear anticipated by the neonatal outcome. It is associated with premature rupture of expectant family. Making parents aware that premature infants membranes and therefore preterm birth. Elevated levels of pro- are susceptible to thermal instability will reduce their anxiety inflammatory cytokines may predispose neonates to cerebral when the newborn is rapidly moved to a warming bed after injury.2 While suspected or proven neonatal sepsis is more birth. The need for resuscitation is determined by careful common in the setting of chorioamnionitis, many neonates evaluation of cardiorespiratory parameters and appropri- born to mothers with histologically proven chorioamnionitis ate response according to published Neonatal Resuscitation are asymptomatic and appear unaffected, with normal preg- Program guidelines.1 nancy outcomes. Animal models and associated epidemiologic 1309 Downloaded for Rodrigo Terra ([email protected]) at Clinica Alemana de Santiago - JCon from ClinicalKey.com by Elsevier on October 19, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. 1310 PART 6 The Neonate TABLE Other Morbidities of Pregnancy and Their Effects on Neonatal Outcome 73.1 Malformation Management Considerations Clefts Alternative feeding devices (e.g., Haberman Feedera), genetics evaluation, occupational/ physical therapy Congenital diaphragmatic hernia Skilled airway management, pediatric surgery, immediate availability of mechanical ventilation, nitric oxide (ECMO) Upper airway obstruction/micrognathia Skilled airway management, otolaryngology, genetics evaluation/management, immediate availability of mechanical ventilation, tracheostomy tube placement Hydrops/hydrothorax/peritoneal effusion Skilled airway management, nitric oxide, ECMO, chest tube placement, paracentesis, immediate availability of mechanical ventilation Ambiguous genitalia Endocrinology, urology, genetic consults available for immediate evaluation; assessment of electrolytes Neural tube defects Sterile, moist dressing to cover defect and prevent desiccation; IV fluids; neurosurgery, urology, orthopedics evaluation/management Abdominal wall defects Saline-filled sterile bag to contain exposed abdominal contents and prevent desiccation, IV fluids, pediatric surgery, genetics evaluation/management Cyanotic congenital heart disease IV access, prostaglandin E1, immediate availability of mechanical ventilation aAthrodax Healthcare Limited, Gloustershire, United Kingdom. ECMO, Extracorporeal membrane oxygenation; IV, intravenous. data suggest that chorioamnionitis can accelerate fetal lung (caloric intake <1000 kcal/d). Mothers experienced significant maturation as measured by surfactant production and function. third-trimester weight loss and offspring were underweight.9 However, preterm infants born to mothers with chorioamnio- Low maternal body mass index (BMI) is associated with nitis are more likely to develop bronchopulmonary dysplasia increased risk of preterm birth.10 There is now growing evi- (BPD).3–5 The neonatal consequences of chorioamnionitis are dence that infants undernourished during fetal life have higher likely related to the timing, severity, and extent of the infection risk for development of “adult” diseases such as atherosclero- and associated inflammatory response. sis and hypertension. Poor maternal nutrition during intra- The effects of preeclampsia on the neonate are well known uterine life may signal the fetus to modify metabolic pathways and include intrauterine growth restriction (IUGR), hypo- and blood pressure regulatory systems with long-term health glycemia, neutropenia, thrombocytopenia, polycythemia, and consequences lasting into late childhood and beyond.11 Con- electrolyte abnormalities such as hypocalcemia. Most of these versely, maternal overnutrition as defined by excessive caloric problems relate to placental insufficiency with diminished intake predisposes mothers to insulin resistance and large-for- oxygen and nutrient delivery to the fetus. With delivery and gestational-age infants. In general, maternal BMI and birth supportive care, most of these problems will resolve with time, weight have increased over time even though mean gestational although some patients will require treatment with intravenous age at delivery has declined.12–15 Elevated maternal BMI is asso- calcium and/or glucose in the early neonatal period. Similarly, ciated with excess stillbirth and neonatal mortality, and may severe thrombocytopenia may require platelet transfusion increase the risk for preterm birth.16 Maternal obesity (BMI therapy. Some studies suggest preeclampsia may protect against >30) is a risk factor for developmental delay within a cohort of intraventricular hemorrhage (IVH) in preterm infants, perhaps extremely preterm infants and for cerebral palsy (CP) among a because of maternal treatment or other unknown factors.6 In term population.17,18 contrast to intrauterine inflammation, preeclampsia does not Neonatal anemia may be a consequence of perinatal events appear to accelerate lung maturation.7 Predicting the conse- such as placental abruption, ruptured vasa previa, or fetal-
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