What is the best approach to presenting a 20-day-old preterm baby's case to an audit, including their medical history and current health status?

Presenting a 20-Day-Old Preterm Baby Case to an Audit

Structure your preterm infant case presentation around standardized perinatal outcome definitions, maternal/pregnancy risk factors, neonatal complications, and current clinical status at 20 days of age, ensuring all data points are objectively documented and comparable across institutions. 1

Essential Maternal and Pregnancy History

Maternal Demographics and Pre-existing Conditions:

• Document maternal age, pre-pregnancy weight, height, and BMI 1
• Record all pre-existing medical conditions including diabetes, hypertension, cardiovascular disease, thyroid disorders, and autoimmune conditions 2
• List all medications used during pregnancy, including over-the-counter drugs and supplements 2
• Document substance exposure: tobacco (active and passive), alcohol consumption frequency/quantity, and illicit drug use 2

Complete Obstetric History:

• Gravidity and parity using standardized scoring (term births, preterm births, spontaneous abortions, therapeutic abortions, living children) 2
• Gestational age at delivery for each previous birth, as history of preterm birth increases recurrence risk 2
• Mode of delivery for each pregnancy, specifically number of prior cesarean sections 2
• Previous pregnancy complications: pre-eclampsia, gestational hypertension, gestational diabetes, placental complications (previa, abruption, retained placenta) 2

Current Pregnancy Details:

• Planned versus unplanned pregnancy 1
• Assisted reproduction technology use 1
• Estimated date of conception (day/month/year) 1
• Singleton versus multiple pregnancy 1
• Best obstetric estimate of gestational age determined by early ultrasound, last menstrual period, and/or perinatal details 1

Pregnancy Complications Leading to Preterm Birth

Classification of Preterm Birth Type:

• Spontaneous labor with intact membranes 3
• Preterm premature rupture of membranes (PPROM) 3
• Medically indicated preterm birth for maternal or fetal indications 4, 3

Specific Indications for Medically Indicated Preterm Birth:

• Pre-eclampsia or eclampsia (accounts for over 50% of indicated preterm births) 4
• Intrauterine growth restriction (IUGR) 4
• Placental abruption 4
• Other ischemic placental disease 4

Adverse Events During Pregnancy:

• Gestational hypertension, pre-eclampsia, eclampsia, HELLP syndrome (document date of onset and whether hospitalization occurred) 1
• Gestational diabetes 1
• Thromboembolic events 1
• Other serious adverse events requiring hospitalization 1

Birth and Immediate Neonatal Period

Delivery Details:

• Gestational age at birth in weeks and days 1
• Mode of delivery: spontaneous vaginal, operative vaginal, cesarean section (if CS, specify elective versus emergency and indication) 1
• Preterm premature rupture of membranes (yes/no) 1

Birth Measurements:

• Birth weight in grams (collected within 24 hours using calibrated electronic scale with 10-g resolution) 1
• Classification as small for gestational age (SGA, <10th centile on Fenton chart) versus appropriate for gestational age (AGA), as SGA more reliably identifies neonates at risk of adverse outcomes than antenatal suspicion of FGR 5
• Gender 1

Immediate Resuscitation and Stabilization:

• Whether CPR by trained medical providers was required 1
• Use of plastic bag/wrap for temperature maintenance in infants <34 weeks 1
• Use of heated and humidified respiratory gases 1
• Ambient delivery room temperature 1
• Initial body temperature (axillary) and whether hypothermia (<36.5°C), normothermia, or hyperthermia occurred 1

Neonatal Complications and Morbidities

Major Neonatal Morbidities (Document Presence/Absence):

• Intraventricular hemorrhage (IVH) with grade 5, 6
• Periventricular leukomalacia (PVL) 6
• White matter abnormalities (WMA) 6
• Bronchopulmonary dysplasia (BPD) 5
• Retinopathy of prematurity (ROP) with stage 5
• Necrotizing enterocolitis (NEC) with stage 5
• Neonatal sepsis (early-onset versus late-onset) 3

Neuroimaging Findings:

• Cranial ultrasound (CUS) results with dates performed 6
• Brain MRI results if performed 6
• Specific findings of IVH, PVL, or other white matter abnormalities 6

Major Congenital Anomalies:

• Structural, functional, or genetic anomalies requiring surgical repair, visually evident, life-threatening, or causing death 1
• Classify using standardized taxonomy 1

Current Clinical Status at 20 Days of Age

Growth Parameters:

• Current weight in grams 1
• Weight gain trajectory since birth
• Current feeding method: breast milk (maternal versus donor), formula, parenteral nutrition 1
• Feeding tolerance and volumes

Respiratory Status:

• Current respiratory support: none, supplemental oxygen, CPAP, mechanical ventilation
• Oxygen saturation levels
• Fraction of inspired oxygen (FiO2) required

Cardiovascular Status:

• Hemodynamic stability
• Need for inotropic support
• Patent ductus arteriosus (PDA) status

Neurological Status:

• Tone and activity level
• Seizure activity (if any)
• Most recent neuroimaging findings

Infectious Disease Status:

• Active infections or recent infections treated
• Antibiotic courses completed or ongoing

Laboratory Values:

• Recent complete blood count
• Electrolytes and renal function
• Liver function tests if indicated
• C-reactive protein if infection suspected 1

Monitoring and Interventions at 20 Days

Current Monitoring:

• Continuous pulse oximetry 1
• Cardiorespiratory monitoring
• Serial observations frequency 1

Ongoing Treatments:

• Medications (list all with doses)
• Nutritional support details
• Phototherapy if indicated
• Other supportive care measures

Prognosis and Discharge Planning

Risk Stratification:

• Postconceptional age (gestational age at birth plus chronological age) 1
• Presence of multiple risk factors: extreme prematurity (<28 weeks), very low birth weight (<1500g), SGA status, major morbidities 5, 6

Expected Outcomes:

• Mortality risk based on gestational age and complications 5
• Long-term morbidity risk: learning disabilities, visual and hearing problems, cerebral palsy 6
• Functional deficits related to white matter abnormalities (present in 50-80% of extremely and very preterm neonates) 6

Discharge Criteria Progress:

• Ability to maintain temperature in open crib
• Adequate oral feeding without cardiorespiratory compromise
• Stable respiratory status without significant apnea/bradycardia
• Appropriate weight gain

Documentation Standards for Audit

Ensure Standardized Reporting:

• Use consistent definitions for gestational age, birth weight, and neonatal outcomes 1
• Report gestational age as median and interquartile range (mean and standard deviation support meta-analysis) 1
• Document whether infant is singleton or part of multiple birth set 1
• Classify neonatal mortality as early (first 7 days) versus late (8-28 days) if applicable 1

Common Pitfalls to Avoid:

• Do not adjust birthweight for gestational age 1
• Ensure gestational age calculation uses best obstetric estimate (early ultrasound preferred over last menstrual period alone) 1
• For assisted reproductive technology pregnancies, calculate gestational age by adding 14 days to completed weeks since fertilization 1
• Distinguish between antenatal suspicion of FGR versus actual SGA classification at birth, as SGA by Fenton chart more reliably identifies adverse outcomes 5