Perinatal history . Most of the pregnancies have a physiological evolution and it is a normal event. For parents it is always an extraordinarily sensitive event against which they feel with doubts and insecurities. We have defined that what characterizes the neonatal period is adaptation to extrauterine life. That is why the anamnesis of the newborn is oriented to look for all those factors that can alter it.
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- 1 Concept
- 2 Main factors that alter neonatal adaptation
- 1 Prematurity and low birth weight
- 2 Perinatal hypoxia
- 3 Mother’s medical and pregnancy-related illnesses
- 4 Intrauterine infections
- 5 History of ingestion of medications and drugs
- 6 Congenital malformations, hereditary diseases and genetopathies
- 3 History of previous pregnancies
- 4 Practical guideline for Perinatal history
- 5 Source
The facts that allow evaluating a newborn begin with the prenatal period that goes from the moment of fertilization to birth. This stage is conditioned by the genetic background of the parents and the pathologies that the mother has during pregnancy . Then, it is required to know and evaluate labor and the way to resolve it. When the newborn is seen in hours or days after birth, it is essential to know his condition at birth and its evolution in the first hours of life (transition period). In this period, a large part of the adaptation problems that this may present such as thermoregulation disorders, respiratory distress and others can be detected.
Main factors that alter neonatal adaptation
Prematurity and low birth weight
These are two essential factors to define the risk that a newborn will have an altered adaptation. The lower the birth weight and gestational age, the greater the adaptation problems, and the higher the risk of morbidity and mortality. When starting the presentation of the clinical history of a newborn, the first thing to specify is its gestational age, weight, and its adequacy at that gestational age.
Hypoxia alters neonatal adaptation in various systems. There are various pathologies of pregnancy that favor chronic or acute hypoxia. These can be medical illnesses of the mother or own of the pregnancy, congenital malformations, infections and genetopatías. The evolution of labor and delivery will give us a history to investigate acute hypoxia and the risk of being born depressed.
Acute hypoxia at birth usually manifests in cardiorespiratory depression, altering the onset of respiration and circulatory readjustment. The severity of hypoxia and respiratory depression is assessed with various cynical and laboratory parameters. One of these is the Apgar Test. This has proven over the years to be very useful for evaluating the condition of the newborn at birth. It is evaluated at one minute and at 5 minutes of life. The Apgar to the minute mainly expresses the prenatal evolution. The Apgar at 5 minutes has a greater prognostic value in terms of normality or potential neurological abnormality and risk of mortality. Low minute Apgar (0-3) is significantly more frequent at lower weight and increases the risk of mortality. The Apgar test is therefore
Mother’s medical and pregnancy-related illnesses
Fetal development and maturation can be altered by various maternal and pregnancy pathologies. It is necessary to know which are the prevalent pathologies in the reality in which one works, the mechanism by which they alter fetal development and growth, and what are the limitations that this newborn will suffer in his neonatal adaptation. The most frequent ones in our setting are gravitational hypertension, maternal diabetes, intrahepatic cholestasis, Rh group incompatibility, and heart disease. Less frequently are thyroid problems, mesenchymal diseases, thrombocytopenic purpura, and others. In most cases these pathologies produce placental insufficiency with chronic hypoxia and less fetal development. In others, like diabetes, fetal erythroblastosis, and thyroid disorders, neonatal adaptation is altered in more specific endocrine and immunological aspects. It should be added that many times the evaluation of the fetus shows placental insufficiency, with intrauterine growth retardation without being able to find a precise cause.
Finally we must add that multiple pregnancy, acute third trimester bleeding and dystocic presentations also cause adaptation problems.
Several of the mentioned pathologies are frequently associated with prematurity and perinatal hypoxia. The history should make a systematic and complete count of these data. In this way, the problems that a given newborn may present can be identified, prevented and evaluated in an orderly manner.
Infections in the fetus and the newborn have a very different evolution and consequences from those in the infant, older child or adult. This is because the microorganisms attack an organism that is in the period of the organization and maturation of its systems and with an immature immune system. Therefore, depending on the stage of development in which the infection occurs, it can produce various types of sequelae and congenital malformations. This is the case of some viral and parasitic diseases such as rubella, herpes simplex, cytomegalovirus, parvovirus, syphilis and Chagas disease. Bacterial infections follow a course that quickly tends to generalize in the form of sepsis.
Especially important is the mother vaginal colonization with streptococcus B . In these cases, care must be taken to intervene in a timely manner depending on whether the mother has been adequately treated. Premature rupture of the membranes and signs of chorioamnionitis are essential factors to determine in order to suspect an infection, investigate it and treat it promptly. Integration with the obstetric team is necessary to have complete and complementary information. In certain cases, questioning directed at epidemiological factors is required. Examples of this are the case of rubella, Chagas disease and Herpes .
History of ingestion of medications and drugs
Drugs and medications can alter adaptation in four fundamental ways:
- Producing malformation, when its administration is in the first trimester of pregnancy: eg. thalidoamide, immunosuppressants.
- Producing intrauterine growth retardation: ex. cigarette, cocaine.
- Altering physiological mechanisms of the newborn when they are generally administered in the third trimester: eg. anticoagulants, propanolol, demerol and anesthetics.
- Producing deprivation syndromes in the newborn, when the mother has ingested drugs that produce addiction: heroin, cocaine , LSD , alcohol and others.
Congenital malformations, hereditary diseases and genetopathies
The progress of fetal ultrasound currently allows screening for a high percentage of congenital malformations such as: esophageal or duodenal atresia , diaphragmatic hernia , hydrocephalus , myelomeningocele , kidney malformations and congenital heart defects . The advance knowledge of these facts allows an elective preparation to provide the opportune treatment. The mother should be transferred to a center with an appropriate level of medical-surgical care.
A history of family hereditary diseases helps a targeted screening. Likewise in the case of chromosomal alterations. Some of these can be determined prenatally by chromosomal studies in amniotic fluid or by cord blood. Decision that must be justified considering that these are procedures that are life-threatening for the fetus.
History of previous pregnancies
This is a very important aspect since there are pathologies that tend to repeat themselves such as: prematurity, some genetic diseases and certain malformations. If a mother has had a previous child with congenital heart disease, the risk of it recurring increases. Other pathologies, such as Rh isimmunization, tend to be more serious in subsequent pregnancies. The antecedent of a poor obstetric history with history of stillbirths or previous neonatal deaths should also be investigated. This information, in addition to being important for evaluation and behavior with pregnancy and the newborn, is a great emotional burden for parents and a factor of uncertainty and anguish.
Perinatal history requires very good obstetric-neonatal integration. In the most complex cases, a joint evaluation prior to delivery is required.
Practical guideline for Perinatal history
Before the birth of the child, the following information must be known and recorded:
- Gestational age by last rule and obstetric estimation of fetal weight.
- Background and characteristics of previous pregnancies.
- Biological data of the mother: age, weight and weight gain in pregnancy, height.
- Maternal and pregnancy diseases.
- History of ingestion of medications and drugs.
- Fetal ultrasoundresults .
- Evolution of labor.
- Delivery resolution form.
After birth: Weight, gestational age, Apgar and condition at birth, the presence of congenital malformations and evolution in the first hours of life, are essential facts to record. At birth, they are part of the physical examination, but later constitute an essential part of the clinical history of every newborn.
Clinical record: In our Neonatology Unit we have been using a coded clinical record for 20 years, which is arranged in order to record the data mentioned above. She has proven to be very useful in healthcare and teaching. It is made as an ordered guideline for recording perinatal history data. It also allows having a reliable database to obtain statistical and research data.