Brain bleeding in Prematurity

Intraventricular hemorrhage (IVH) occurs in approximately 45% of infants born weighing 500-750 grams.  The overall incidence of IVH in newborns weighing <1500 grams is about 20%.  To better describe the anatomy involved in this condition I have included a representation of the brain.

Typically in pre-mature babies an Ultrasound is performed 7 days after birth to evaluate for a bleed.  If one is found it is graded on a 1-4 scale.  A 1 or 2 grade bleed is a small amount of bleeding that typically does not require intervention and does not have any long-term consequence.  A grade 3-4 bleed however have a higher amount of blood which can place pressure on the brain potentially causing damage or blocking the normal flow of spinal fluid.  If this happens a condition called hydrocephalus can occur in which there is an accumulation of fluid in the brain.  This may require surgical intervention with the use a drain called a shunt to direct the extra fluid from the brain to an area where it can be reabsorbed by the body naturally.

Here are some resources that can be of more help in learning about this condition.

Intraventricular hemorrhage of the newborn

Brain Problems in the Premature Baby

Happy Father's Day

Sunday, 6/15/14

Happy Father's Day to all of those who are celebrating their 1st Father's Day and those that are celebrating another year of being a Dad.  For me this day is more special than I could have ever imagined.  As a preemie parent we go through a lot to watch our little one's fight to survive then face challenges and obstacles we could never imagine as an adult.  For me, my son Carter has taught me so much and I have yet had the opportunity to teach him anything.  I am eager to have the opportunities to constantly teach him every day.  To all of those Dads out there enjoy your babies, toddlers, infants, adolescent, tween, teen, and adult not only today but everyday.  Always be grateful, proud and patient.    

I am now on Twitter so follow me @powerpreemies for updates and information!!

Retinopathy of Prematurity

Retinopathy of Prematurity (ROP)



Like most terms that parents will hear in the NICU your first reaction to this term is what is that and what does it mean for my baby.  Simply put ROP has to do with the vascularization, or blood supply to the retina in the eye.  The retina is the light sensitive layer of tissue in the back of the eye that provides the message to our brain so that we can process what we are seeing.   It is very important that the retina is supplied with blood so that it develops properly however in ROP too many vessels grow which can cause damage to the retina.  Prior to 16 weeks gestation there is no blood supply to the retina.  This vascularization begins to occur between 15 and 18 weeks gestation and continues to progress through the 40th week of gestation.   In some cases the development of the blood supply to the retina is delayed all the way out to 48 or 52 weeks post-menstrual age.  The cause of this condition is not well known however it is believed that certain factors such as a lack of oxygen, too much oxygen, and low blood pressure injures newly developing vessels or the formation of new vessels that will bring blood to the retina.  All of the following factors may also play a role in ROP; low birth weight, low gestational age, assisted ventilation for longer than one week, surfactant therapy, high blood transfusion volume, cumulative illness severity, hyperglycemia, and insulin therapy.



One of the most confusing things I found during the report after an eye exam was the staging for ROP.  You may hear the ophthalmologist spout off something like ROP stage II zone 3.  The zone is the location of the retinopathy (see image below).

Image from Up To Date, http://www.uptodate.com/contents/retinopathy-of-prematurity?source=search_result&search=retinopathy+of+prematurity&selectedTitle=1%7E51



The stage indicates the severity of the disease with a stage 1 being an early stage and stage 5 being the most severe stage.  In some situations the term Plus Disease will be used and this is typically an ominous sign for retinal detachment which can lead to blindness.



ROP will occur in approximately 68% of babies born that weigh less than 1251g or 2.78 pounds.  In addition, gestational age at birth plays a role.  Babies born earlier have a higher incidence of ROP.



The good news is that in the majority of cases ROP will totally resolve on its own.  The ophthalmologist will perform serial exams about 2 weeks apart as long as there is nothing to warrant a weekly exam to monitor the progress of the disease.   Here is a general rule of when follow-ups occur based on the severity of the disease.



Follow-up within one week is recommended for infants with

●Immature vascularization in zone I, without ROP

●Immature retina that extends into posterior zone II, near the boundary of zone I

●Stage 1 or 2 ROP in zone I

●Stage 3 ROP in zone II

●Suspected aggressive posterior ROP

Follow-up within one to two weeks is recommended for infants with:

●Immature vascularization in posterior zone II

●Stage 2 ROP in zone II

●Regressing ROP in zone I

Follow-up within two weeks is recommended for infants with:

●Stage 1 ROP in zone II

●Immature vascularization in zone II, without ROP

●Regressing ROP in zone II

Follow-up within two to three weeks is recommended for infants with:

●Stage 1 or 2 ROP in zone III

●Regressing ROP in zone III

    If treatment becomes necessary it can be done with a procedure called photocoagulation in which a laser is used to destroy the extra vessels that have developed causing the condition.  In some cases these extra blood vessels will strain the retina causing it to detach.  For these cases a surgical procedure can be done.



No matter what degree of ROP your baby has it can and will be a scary time.  It is always important to have a good communication with the nurses, doctors and practitioners so that you have a good understanding of what the diagnosis means for your baby.  Never be shy to ask questions.  Remember that understanding what your baby is going through is imperative to making the right choices for them.

New research on placenta

This is a very interesting article that discusses how the placenta can play a role in premature birth.  Just a snip-it of the potential causes yet to be revealed.

http://www.parents.com/blogs/parents-news-now/2014/05/22/pregnancy/placenta-found-to-have-significant-impact-on-newborns-health/?socsrc=pmmfb1405276

Patent Ductus Arteriosus

Patent Ductus Arteriosus

Also known as PDA this condition is fairly common in preterm babies.  In babies born less than 28 weeks gestation the incidence is as high as 60% then this incidence decreases to 20% in preterm births older than 32 weeks gestation.  For term babies the incidence is a mere 0.02%.  In most situations the PDA will close within the first 3 days of life.  This condition can cause significant issues in preterm babies if not treated properly.

First it is important to understand what a PDA is and how it affects other systems in the body.  Patent means "open" and the ductus arteriosus is a vessel that is vital in fetal blood circulation.  Before birth this vessel connects two arteries in the body together, the aorta and the pulmonary artery.  The aorta is an artery that carries blood away from the heart after it has been oxygenated to the rest of the body.  The pumonary artery is similar in that it is a vessel that carries blood however the blood it carries does not contain high oxygen levels since it is carrying the blood to the lungs to be oxygenated.  During fetal development the baby gets oxygenated blood from mom therefore the lungs are bypassed while they continue to develop.  Typically the ductus arteriosus closes shortly after birth when the lungs are now used for oxygenation.  However, in some instances it remains open.  This causes oxygen rich blood from the aorta to mix with oxygen poor blood from the pulmonary artery.


Taken from: http://www.nhlbi.nih.gov/health/health-topics/topics/pda/

A PDA in a preterm baby who already has immature lungs can cause worsening shortness of breath, or require more work to breath.  Sometimes additional oxygen or ventilator support is necessary while the condition is corrected.

Correcting a PDA can be done in a variety of ways.  These include:

• Conservative treatment - Waiting for the PDA to close itself.  It has been found that upwards of 70-90% will close within 3 days of birth if left alone or with adjustments to ventilator settings.

• Medicines - The use of Indomethacin or ibuprofen have been shown to be a first line medicine to close the PDA.

• Surgery - If all other treatments fail a surgical ligation can be performed in which the vessel is tied off to prevent the flow of blood through the vessel.

The medical team will advise you that it is important to give the baby a chance to close this vessel themselves since medicines and surgery have potential complications that could further complicate the already difficult course that babies have in the NICU.  How aggressively the PDA is treated is primarily dependent on the problems that it is causing for the respiratory system.  Another important note about a PDA is that when it closes it can still re-open so the medical team will pay close attention to the heart exam and watch the baby clinically to ensure no unexplained symptoms are occurring.

My above explanation is just brushing the surface so for more detailed information feel free to refer to the below reliable sites.

http://www.nhlbi.nih.gov/health/health-topics/topics/pda/

http://emedicine.medscape.com/article/891096-overview#a0101

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2675417/

The Prevalence of Prematurity

Preterm Labor, A Fear Realized

A baby is considered premature when they are born 3 weeks prior to their due date or previous to 37 weeks gestation.  Each year there are approximately 500,000 premature births and 35% of infant deaths can be attributed to complications from prematurity.  There are certain factors that would place a female at risk for having a premature baby.  These include:  low or high maternal age, black race, infection, previous preterm birth, carrying more than one baby, high blood pressure during pregnancy, tobacco or alcohol use, substance abuse, late prenatal care, and stress.

Although it is difficult to predict if a female will have preterm labor there are important warning signs that should not be ignored.  These may include:

• Backache
• Contractions
• Cramping
• Fluid leaking from the vagina
• Flu-Like Symptoms such as nausea, vomiting and diarrhea
• Increased pressure in the pelvis or vagina
• Increased vaginal discharge
• Vaginal bleeding

Any of these signs during a pregnancy should prompt a call to the obstetrician for potential further evaluation.

Your baby is surrounded by a membrane called the amniotic sac that is filled with fluid and protects the baby during development.  In a situation when the membrane breaks due to a tear or hole in the membrane it is called rupture of membranes.  Premature rupture of membranes (PROM) occurs in about 8% of pregnancies and is marked by rupture of the membrane prior to labor beginning.  In less that 2% of pregnancies this will occur in a situation where the pregnancy is preterm and is referred to preterm premature rupture of membranes (PPROM).  The following resource provides organized details of each condition that can occur leading to premature labor and their potential causes.

http://www.fpnotebook.com/ob/antepartum/PrmtrRptrOfMmbrns.htm

These additional links are to resources that are helpful in understanding the terminology that is commonly encountered.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2589108/

http://www.whattoexpect.com/pregnancy/pregnancy-health/complications/preterm-rupture-of-membranes.aspx

http://www.webmd.com/baby/premature-labor

When my wife had PPROM leading to the birth of our son 14 weeks early it was a scary moment.  Preparation and understanding the terminology and potential outcomes are essential in empowering yourself to remain calm during a time that is all but easy.

Welcome to Preemie Power Parents

Saturday, 5/24/14

Welcome to Preemie Power Parents.  As you have probably already seen, my wife gave birth to our first child at 26 weeks and 3 days.  It was the scariest time of our life during a time that should have been filled with excitement and calculated preparation.  As many preemie parents our initial questions were why.  What happened, what did we do?  The answer is simple, in most situations there was nothing that we could have done differently.  Although we live in an age of significant technological advancements we still have no answers for the cause of most cases of premature births.  This experience was made even more difficult with my back ground as a Physician Assistant understanding nearly all that was happening to my wife and our baby.  After 84 days in the NICU our baby boy was able to come home.  Throughout our time in the NICU we endured many tough times and celebrated many accomplishments with our little boy.  Now he is finally home and doing well.  This blog is dedicated to the strength that preemies display in fighting for their life and the parents of those preemies who live every second of every minute of every hour of every day not knowing what is next.  With my career in medicine as a resource I hope to impart parents of preemies and others with the knowledge necessary to understand conditions that their preemies may have throughout their journey so that they can spend less time wondering what will happen in the next second and more time being empowered to make informed decisions and focusing on their family.