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Almost But Not Quite Term: Special Risks for Late Preterm and Early Term Infants. Sarah N. Taylor, M.D. Assistant Professor, Division of Neonatology Medical University of South Carolina February 4, 2012. What is a “Late Preterm Infant”?. Near-term does not

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Almost but not quite term special risks for late preterm and early term infants

Almost But Not Quite Term: Special Risks for Late Preterm and Early Term Infants

Sarah N. Taylor, M.D.

Assistant Professor, Division of Neonatology

Medical University of South Carolina

February 4, 2012


What is a late preterm infant
What is a “Late Preterm Infant”? and Early Term Infants

  • Near-term does not

    • “capture how immature and vulnerable”

Moderately preterm

Near term

Minimally preterm

Marginally preterm

Late Preterm

NICHD workshop July 2005


Late preterm infant definition
Late Preterm Infant Definition and Early Term Infants

  • NICHD: 34 0/7 to 36 6/7 weeks gestation

    • 34th week chosen secondary to obstetrical decision to not give antenatal steroids at that gestation

  • Other possibility: gestational age associated with “normal” birth weight (≥ 2500g) and can be admitted to normal newborn nursery (≥ 35 weeks)

    • 35 0/7 to 36 6/7 weeks gestation

37 0/7 - 37 6/7 weeks can also be “immature and vulnerable”

Escobar GJ et al Semin Perinatol 2006;

Ramachandrappa A & Jain L et al Pediatr Clin North Am 2009; Raju TN et al Pediatr 2006


Acog has an opinion
ACOG Has An Opinion and Early Term Infants

  • Fetal pulmonary maturity should be confirmed before scheduled delivery at less than 39 weeks of gestation unless fetal maturity can be inferred from historic criteria (criteria suggesting 39 weeks of gestation)

ACOG Practice Bulletin No. 97 2008


New definition early term birth
New Definition: Early-Term Birth and Early Term Infants

  • 37 0/7 to 38 6/7 weeks

  • Based on ACOG guidelines to delay elective deliveries to 39 0/7

    • Supported by The March of Dimes, NICHD, Society for Maternal-Fetal Medicine

Gyamfi-Bannerman C Semin Perinatol 2011; Clark SL et al Am J Obstet Gynecol 2009;

Tita AT et al N Engl J Med 2009; Ashton DM Curr Opin Obstet Gynecol 2010; Spong CY et al Obstet & Gynecol 2011


How many late preterm infants are there
How Many Late Preterm Infants Are There? and Early Term Infants

  • 34-36 weeks gestation

    • 75% of preterm infants in U.S.

  • 35-36 weeks gestation

    • 7% of all live births in U.S.

    • 58.3% of preterm births in U.S.

  • Increasing population since 1990

    • <34 weeks, by 10%

    • 34-36 weeks, by 25%

Ramachandrappa A & Jain L Pediatr Clin North Am 2009;

Sharpiro-Mendoza CK et al Pediatr 2008; Escobar GJ et al Semin Perinatol 2006


How many early term infants born by elective repeat c section
How Many Early Term Infants Born By Elective Repeat C/section?

  • 24,077 at 19 centers 1999-2002

  • 13,258 elective

  • 35.8% before 39 completed weeks

    • 6.3% at 37 weeks

    • 29.5% at 38 weeks

    • 49.1% at 39 weeks

  • Increased respiratory disease, mechanical ventilation, newborn sepsis, hypoglycemia, admission to NICU, and hospital stay >5 days

    • 37 weeks, adjusted odds 1.8-4.2

    • 38 weeks, adjusted odds 1.3-2.1

Tita AT NEJM 2009


Despite the size and growth of this population, C/section?minimal evidence-based practice and/or research available


Despite the size and growth of this population, C/section?minimal evidence-based practice and/or research available

Therefore, this group is scary for both neonatologists and pediatricians


So why so many late preterm infants
So, Why So Many Late Preterm Infants? C/section?

  • Delivery at 34 weeks considered “safe”

    • Cut-off for antenatal steroids

  • Increased fertility/multiples

  • Increased mothers with medical conditions

    • Pregnancy and non-pregnancy-related

  • Increased fetal monitoring

  • Babies are bigger

Verklan MT Crit Care Nurs Clin North Am 2009; Davidoff MJ et al Semin Perinatol 2006; Raju TN Clin Perinatol 2006

Ramachandrappa A & Jain L Pediatr Clin North Am 2009; Shapiro-Mendoza CK et al Pediatr 2008; Escobar GJ et al Semin Perinatol 2006


So why so many late preterm infants1
So, Why So Many Late Preterm Infants? C/section?

  • Delivery at 34 weeks considered “safe”

    • Cut-off for antenatal steroids

  • Increased fertility/multiples

  • Increased mothers with medical conditions

    • Pregnancy and non-pregnancy-related

  • Increased fetal monitoring

  • Babies are bigger

  • “I want this baby out”

Verklan MT Crit Care Nurs Clin North Am 2009; Davidoff MJ et al Semin Perinatol 2006; Raju TN Clin Perinatol 2006

Ramachandrappa A & Jain L Pediatr Clin North Am 2009; Shapiro-Mendoza CK et al Pediatr 2008; Escobar GJ et al Semin Perinatol 2006


Higher induction and cesarean section rates
Higher Induction and Cesarean Section Rates C/section?

  • Nearly 1 in 4 births born by induction

  • One in 3 births by cesarean section

  • Repeat c/section in 92% of women with primary c/section

  • Increases in inductions and c/sections are predominately in the late preterm and early term (34-39 weeks)

  • Most frequent length of a singleton pregnancy is now 39 weeks instead of 40 weeks gestation

  • Mean age of twin delivery: 35.3 weeks

Verklan MT Crit Care Nurs Clin North Am 2009; Lee YM et al Clin Perinatol 2006;

Ramachandrappa A & Jain L Pediatr Clin North Am 2009; CDC 2005


Intermountain healthcare system had a problem
Intermountain Healthcare System Had a Problem C/section?

  • 9 hospitals involved in process improvement

  • Pre-test: 28% of elective deliveries were <39 weeks

  • Intervention: presentation of the morbidities associated with delivery at <39 weeks

    • Rate of NICU admissions for normal pregnancies

      • 37 weeks: 8.9%

      • 38 weeks: 4.5%

      • 39 weeks: 3.3%

    • Rate of ventilator use for uncomplicated deliveries

      • 37 weeks: 1.4%

      • 38 weeks: 0.5%

      • 39 weeks: 0.3%

Oshiro BT, Henry E et al. Obstet & Gyn 2009


Results of intervention
Results of Intervention C/section?

Oshiro BT, Henry E et al. Obstet & Gyn 2009


Nichd and society for maternal fetal medicine workshop 2 2011
NICHD and Society for Maternal-Fetal Medicine Workshop 2/2011

  • Timing of Indicated Late Preterm and Early Term Births

From Spong CY, Mercer BM, D’Alton M et al. Timing of indicated late-preterm and early-term birth. Obstetr and Gynecol 2011;118:323-33.


Definition of indicated late preterm
Definition of Indicated Late Preterm 2/2011

  • Multiple reasons

    • Indicated: Preterm labor, rupture of membranes, pre-eclampsia, intrauterine growth restriction with abnormal testing, acute abruption,

    • Debatable Indication: IUGR with reassuring testing, gestational hypertenstion, mild pre-eclampsia, oligohydramnios

Gyamfi-Bannerman C Semin Perinatol 2011; Zhang J et al Br J Obstet Gynaecol 2004;

Holland MG et al Am J Ostet Gynecol 2009


Indicated late preterm delivery
Indicated Late Preterm Delivery 2/2011

  • Placenta previa, accreta, increta, percreta

  • Prior classical cesarean

  • IUGR with abnormal studies

  • Twins: mono-mono, mono-di, fetal death, IUGR

  • Oligohydramnios

  • Chronic hypertension with difficult control

  • Severe preeclampsia

  • Diabetes- poorly controlled

  • Rupture of membranes

  • Progressive labor

Spong CY et al Obstetr & Gynecol 2011


Indicated early term delivery
Indicated Early Term Delivery 2/2011

  • Prior myomectomy necessitating cesarean

  • Singleton IUGR

  • Twins: di-di

  • Chronic hypertension-controlled

  • Mild preeclampsia

  • Diabetes- pregestational with vascular disease

Spong CY et al Obstetr & Gynecol 2011


If delivering late preterm
If Delivering Late Preterm 2/2011

  • Lung Maturity Testing

    • Lung profile does not represent other organs

    • If delivery is necessary, then deliver despite maturity

  • Antenatal Steroids

    • Recommended for preterm birth before 34 weeks

    • 1 RCT studied with elective C/section <39 weeks

      • Less neonatal respiratory distress admissions

      • However, delaying delivery to 39 weeks was associated with even less neonatal respiratory distress admissions

Spong CY et al Obstetr & Gynecol 2011; Stutchfield P et al BMJ 2005



Results of early delivery
Results of Early Delivery 2/2011

  • Birth hospitalization

    • Median length of stay similar for “near-term” (35-36 weeks) and full-term

    • However, wide variations in hospital stay for near-term infants after both vaginal and cesarean deliveries

Wang ML & Dorer DJ Pediatr 2004


Hospitalization following elective deliveries
Hospitalization Following Elective Deliveries 2/2011

  • Elective delivery with no medical indication

    • Admission to special care nursery

      • 17.8% at 37-38 weeks

      • 8% at 38-39 weeks

      • 4.6% ≥ 39 weeks

    • Mean length of stay 4.5 days

Clark SL et al Am J Obstet Gynecol 2008


Rehospitalization
Rehospitalization 2/2011

  • Rates

    • 6.3% for 35-37 weeks; 3.4% for 38-40 weeks; 2.4% for >40 weeks (Oddie SJ et al Arch Dis Child 2005)

    • 4.3% late preterm; 2.7% term

      (Tomashek KM et al Semin Perinatol 2006)

  • Late rehospitalization (15-182 days post-discharge)

    • 9.1% for 34 wks; 6.8% for 35 wks; 7.3% of 36 wks; 5.6% for 37 wks, 4.4% for 38-40 wks, 3.6% for ≥40 wks (Escobar GJ et al Semin Perinatol 2006)


Why are infants rehospitalized
Why Are Infants Rehospitalized? 2/2011

  • Most common reasons

    • Jaundice, feeding difficulties, and/or dehydration

  • Predictors of rehospitalization

CI- confidence interval

Escobar GJ et al Semin Perinatol 2006; Oddie SJ et al Arch Dis Child 2005


Risk factors for rehospitalization
Risk Factors for Rehospitalization 2/2011

  • Late preterm infants

    • 1.5 times more likely to require hospital-related care

    • 1.8 times more likely to be admitted

      Significant difference between breastfed late preterm and term infants

      No significant difference between not breastfed late preterm and term infants

Tomashek KM et al Semin Perinatol 2006


Mortality risk
Mortality Risk 2/2011

  • 2002 U.S. Mortality rate by gestational age

  • For 34-36 weeks, mortality rate of 7.9% which is 3 times higher than the term infant rate

Escobar GJ et al Semin Perinatol 2006

Tomashek KM et al Semin Perinatol 2006; Tomashek KM et al J Pediatr 2007; Mathews TJ et al Natl Vital Stat Rep 2007


Mortality risk for early term
Mortality Risk for Early Term? 2/2011

  • Relative Risk of Mortality

    • At 37 weeks, 2.6-2.9 times the risk at 39 weeks

    • Also increased at 38 weeks compared to 39 weeks

Reddy UM et al Obsetrics Gynecol 2011


Neurodevelopment of the late preterm infant
Neurodevelopment of the 2/2011Late Preterm Infant

  • Brain growth compare to 40 weeks gestation

    • Cerebral volume is only 53%

    • Weight is 66%

    • Cerebral cortex has less gyri/sulci and is smooth

    • Myelination and interneuronal connectivity is incomplete

Kinney HC Semin Perinatol 2006; Ramachandrappa A & Jain L Pediatr Clin North Am 2009;

Adams-Chapman I Clin Perinatol 2006; Verklan MT Crit Care Nurs Clin North Am 2009


Neurodevelopment studies
Neurodevelopment Studies 2/2011

  • 20-year follow-up of late preterm infants with no congenital anomalies

    • Higher incidence of

      • Cerebral palsy: Relative risk (RR) 2.7

      • Mental retardation: RR 1.6

      • Significantly increased psychological development problems, behavioral and emotional disturbances, and other major disabilities

    • More likely to receive disability allowance

    • Less likely to attain post-secondary degree

Lindstorm; Moster D et al NEJM 2008


In the united states
In the United States 2/2011

  • Late preterm compared to term births through kindergarten

    • 36% higher risk for developmental delay or disability

    • 19% higher risk for suspension in kindergarten

  • Repeat study controlling for neonatal complications

    • 35-36 week infants with admission to NICU had lower neurocognitive scores

    • Late preterm without complications were similar to term counterparts

Morse SB et al Pediatr 2009; Baron IS Early Hum Dev 2011


Early years
Early Years 2/2011

  • Within first 3 years, compared to term infants

    • Increased diagnosis of developmental delay

    • Increased referrals for special needs preschool resources

    • Increased difficulties with school readiness

Inder TE et al Ann Neurol 1999; Verklan MT Crit Care Nurs Clin North Am 2009


So experts are worried
So, experts are worried… 2/2011

  • NICHD and Association of Women’s Health, Obstetric, and Neonatal Nurses

    • Research agenda to better understand short- and long-term medical complications that are associated with late preterm births

    • Anticipation and management of potential morbidities

    • Assistance with non-emergent obstetric intervention decisions


We need further evidence for late preterm infant management and further medical support to extend pregnancies

Why do we do in the meantime?


Short term late preterm problems
Short-term Late Preterm Problems and further medical support to extend pregnancies

  • Feeding Difficulties

  • Dehydration

  • Breastfeeding difficulties

  • Hypoglycemia

  • Hyperbilirubinemia

  • Temperature Instability

  • Increased sepsis work-ups

  • Respiratory Failure

  • RDS

  • TTN


What is the morbidity risk
What is the Morbidity Risk? and further medical support to extend pregnancies

  • Newborn morbidity risk

    • Late preterm infant- 22%

    • Term infant-3%

      Late preterm infants were 7 times more likely

  • Risk increases with decreasing gestational age

  • 38-41 wks: 3% 37 wks: 6% 34 wks: 52%

  • Compared to 40 weeks

    • 35 week infants had 10X’s the risk

    • 36 week infants had 5X’s the risk

Shapiro-Mendoza CK et al Pediatr 2008


How many early term infants born by elective repeat c section1
How Many Early Term Infants Born By Elective Repeat C/section?

  • 24,077 at 19 centers 1999-2002

  • 13,258 elective

  • 35.8% before 39 completed weeks

    • 6.3% at 37 weeks

    • 29.5% at 38 weeks

    • 49.1% at 39 weeks

  • Increased respiratory disease, mechanical ventilation, newborn sepsis, hypoglycemia, admission to NICU, and hospital stay >5 days

    • 37 weeks, adjusted odds 1.8-4.2

    • 38 weeks, adjusted odds 1.3-2.1

Tita AT NEJM 2009


Outcomes after lung maturity testing
Outcomes After Lung Maturity Testing C/section?

  • 36-38 6/7 weeks vs. 39-40 6/7 weeks

    • 6.1 vs. 2.5% for composite adverse neo outcome

    • Adjusted odds ratio

      • RDS 7.6 (Confidence interval 2.2-26.6)

      • Treated hyperbilirubinemia 11.2 (CI 3.6-34)

      • Hypoglycemia 5.8 (2.4-14.3)

Bates E et al Obstet Gynecol 2010


What are the newborn morbidities
What are the Newborn Morbidities? C/section?

  • In the Shapiro-Mendoza et al study

    • Temperature instability

    • Hypoglycemia

    • Respiratory distress

    • Hyperbilirubinemia

    • Prolonged hospitalization

  • In the Wang et al study

    • Temperature instability

    • Hypoglycemia

    • Respiratory distress

    • Jaundice

Shapiro-Mendoza CK et al Pediatr 2008; Wang ML & Dorer DJ Pediatr 2004


Neonatal resuscitation
Neonatal Resuscitation C/section?

  • Depends on gestational age AND mode of delivery

  • Near-term and term infants

    • Comparable 1 and 5 minute Apgar scores

  • Late preterm and term infants

    • 14% require more resuscitation interventions when delivered by elective c/section

Wang ML & Dorer DJ Pediatr 2004; De Almelda MF et al J Perinatol 2007


Respiratory distress
Respiratory Distress C/section?

  • For late preterm infants

    • Lungs are at the end of the terminal sac period of lung development

    • Synchrony and control of breathing is improving

    • Changes in epithelial sodium channels with length of gestation AND labor

  • Likely late preterm infant lung disease is a combination of delayed fluid absorption and surfactant insufficiency

Jain L & Eaton DC Semin Perinatol 2006; Verklan MT Crit Care Nurs Clin North Am 2009


Respiratory distress1
Respiratory Distress C/section?

  • At delivery

    • 8% of 35-36 week infants required supplemental oxygen for at least 1 hour (3X’s the term rate)

  • Any respiratory distress incidence

  • 2004 study, late preterm have 9 times the odds of respiratory distress (28.9% vs. 4.2%)

Escobar GJ et al Semin Perinatol 2006; Italian study; Wang ML & Dorer DJ Pediatr 2004


Ventilation
Ventilation C/section?

  • Compared to 38-40 weeks gestation, likelihood of ventilation

    • 37 weeks: 2X

    • 36 weeks: 5X

    • 35 weeks: 9X

  • When delivered by c/section without labor,

    • 37 week infant had 5X the odds of severe respiratory morbidity compared to a 39 week infant delivered vaginally

Escobar GJ et al Semin Perinatol 2006; Hansen AK et al BMJ 2008


Temperature instability
Temperature Instability C/section?

  • Late preterm infants have

    • Decreased

      • Brown fat

      • Hormonal regulation of brown fat breakdown

      • Subcutaneous fat

    • Increased

      • Body-surface area to body-weight ratio

Fanaroff and Martin 2006; Polin and Fox 2003


Hypothermia
Hypothermia C/section?

  • Primary reason for NICU admission for 5.2% of late preterm infants

  • Hypothermia is associated with

    • Hypoglycemia

    • Respiratory distress/failure

    • Poor feeding

    • Sepsis evaluations

Vachharajani AJ & Dawson JG Clin Pediatr 2009


Hypoglycemia
Hypoglycemia C/section?

  • Newborn glucose control

    • Hepatic glycogenolysis and gluconeogenesis

  • Late preterm infants

    • Immature hormonal control

    • Immature hepatic enzymes

    • Decreased hepatic glycogen stores

    • Immature ketogenic response increased risk for neurologic sequelae

    • Increased risk for cold stress and feeding difficulties

Ramachandrappa A & Jain L Pediatr Clin North Am 2009; Verklan MT Crit Care Nurs Clin North Am 2009


Hypoglycemia in late preterm infants
Hypoglycemia in Late Preterm Infants C/section?

  • Defined as <40 mg/dl in these studies

  • 8% of all neonates in the 1st 4 hours

  • Late preterm infants

    • 3X’s more likely

  • IV fluid support

    • 5% of term infants

    • 27% of 35-36 week infants

Wang ML & Dorer DJ Pediatr 2004; Garg M & Devaskar SU Clin Perinatol 2006


Sepsis evaluations
Sepsis Evaluations C/section?

  • Likelihood of sepsis screen with gestational age

  • Rates of sepsis evaluations

    • Late preterm infants 36.7% vs. 12.6% in term

    • 34 weeks 33% vs. 12% at 39 weeks

  • Only 0.4% of screened infants had culture-proven sepsis

  • Screened late preterm infants were

    • More likely to be treated with antibiotics

    • More likely to be treated longer

Wang ML & Dorer DJ Pediatr 2004; McIntire DD et al Obstet Gynecol 2008


Hyperbilirubinemia
Hyperbilirubinemia C/section?

  • Prematurity is associated with

    • Reduced hepatic uptake

    • Decreased conjugation

    • Decreased GI function and motility

  • Compounded by feeding difficulties

Ramachandrappa A & Jain L Pediatr Clin North Am 2009; Verklan MT Crit Care Nurs Clin North Am 2009


What s the risk
What’s the Risk? C/section?

  • Odds for developing serum bilirubin >20 mg/dl

    • 4 times greater for infant born at 36 weeks compared to infant born at 39-40 weeks

  • Likelihood of hospital readmission for phototherapy compared to infants ≥ 40 weeks gestation

    • 35-36 weeks: 13.2%

    • 36-37 weeks: 7.7%

    • 37-38 weeks: 7.2%

Newman TB et al Pediatr 1999; Maisels MJ & Kring E Pediatr 1998


Also, C/section?

  • Only one prospective study,

    • 35-37 week compared to 38-42 week infants were 2.4X more likely to develop “significant hyperbilirubinemia”

    • Nearly 25% of 35-37 week infants required phototherapy

    • Of concern, serum bilirubin was significantly higher for 35-37 week infants on Day 5 and Day 7

    • For late preterm infants

      • Delayed bilirubin peak

      • Prolonged duration

Sarici SU et al Pediatr 2004


Feeding issues
Feeding Issues C/section?

  • Related to all other morbidities

  • Late preterm infants

    • Poor suck and swallow coordination

      • Neuronal immaturity

      • Decreased oromotor tone

      • Decreased feeding cues (do not wake up when hungry)

  • Have mentioned the need for IV fluids

    • 27% of 35-36 week infants

    • Also, 76% of 35-36 week infants with poor feeding required prolonged hospital stay

Wang ML & Dorer DJ Pediatr 2004; Meier PP et al J Midwifery Womens Health 2007


Hospitalization for feeding difficulties
Hospitalization for Feeding Difficulties C/section?

  • For late preterm infants, feeding issues are the most common cause for increased length of stay

  • At 35 weeks gestation

    • Nearly 7.3% admitted to NICU for feeding difficulties

  • Rehospitalization

    • Late preterm infants are 2X as likely as term infants to be rehospitalized with feeding difficulties

Vachharajani AJ & Dawson JG Clin Pediatr 2009; Adamkin DH Clin Perinatol 2006; Escobar GJ et al Arch Dis Child 2005


The role of breastfeeding
The Role of Breastfeeding C/section?

  • Factors associated with prematurity

    • Preterm delivery

    • Diabetes, hypertension of pregnancy

    • C/section delivery

      are also associated with delayed lactogenesis

  • Add the decreased oral ability of preterm infants

    • Unable to completely empty breast

    • Decreased stimulation for mother’s milk production

  • Add the likelihood of separation due to sepsis evaluations, IV infusions, and phototherapy

Henderson JJ et al. 2007; Hartmann P & Cregan M 2001; Rasmussen KM et al. 2004


Options to promote breastfeeding success for the late preterm infant
Options to Promote Breastfeeding Success for the Late Preterm Infant

  • Encourage skin-to-skin

  • PO ad lib but with minimum of 8 feeds in 24 hours

  • Monitor weight loss closely, if >3% in 1 day or >7% in 2-3 days, intervene

  • Thorough lactation evaluation

    • If intake is worrisome,

      • Have mother pump and give by bottle or other mechanism

      • Consider nipple shield with expert support

  • Monitor for special circumstances such as hypoglycemia, dehydration, hyperbilirubinemia, or maternal/infant separation

Academy of Breastfeeding Medicine Protocol


At discharge
At Discharge Preterm Infant

  • Discharge should not occur prior to 48 hours

  • Temperature of 97.7°-99.3° F

  • Weight loss <7% of birth weight

  • Normal vital signs for 12 hours prior to discharge

  • Risk assess for hyperbilirubinemia with follow-up arranged

  • Car seat safety test passed

Adamkin DH J Perinatol 2009; Ramachandrappa A & Jain L Pediatr Clin North Am 2009


Early and frequent outpatient evaluations
Early and Frequent Outpatient Evaluations Preterm Infant

  • Feeding difficulties may present after birth hospitalization

  • Hyperbilirubinemia is often delayed and prolonged

    • Reassess for jaundice within 72 hours of birth

  • Weight loss is often evident week 2

  • Late preterm infant at risk for rehospitalization and mortality


Realistic risk with opportunity for great improvement
Realistic Risk with Opportunity for Great Improvement Preterm Infant

  • An improvement in care of late preterm infants effects the greatest population of preterm infants

  • Large number of opportunities for prospective studies

  • Opportunity to show cost effectiveness

    • Average cost for treating 25 week infant: $202,000

    • Average cost for treating 35 week infant:$4,200

      However, population costs

    • $38.9 million dollars for 25 week infant

    • $41.1 million dollars for 35 week infant

Gilbert WM et al Obstet Gynecol 2003


Pediatrician neonatologist role
Pediatrician/Neonatologist Role Preterm Infant

  • Promote obstetrical intervention to optimize pregnancy until term gestation

  • Respect the morbidity and mortality risk of the late preterm infant population

  • Intensive clinic follow-up for the first postnatal weeks



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