الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Intraventricular hemorrhage is a major central nervous system injury affecting preterm infants. Itaffects 15‑20% of neonates born before 32 weeks ofpregnancy. About 90% of cases of IVH occur within the first three postnatal days.
According tocranial ultrasonography, IVH was classified into four grades of IVH. Grade I including the sub-ependymal parenchyma and/or expending in less than 10% of the ventricle, grade II with intraventricular bleeding not extending in more than 50% of the ventricle, grade III associated with consistent >50% intraventricular bleeding with ventricular dilatation. A concomitant intra parenchymal lesion (IPL), result to a venous infarction (grade IV), can be accompanied by any grade of IVH, worsening the prognosis.Grades I and II are defined as mild IVH, and grades III and IV as severeIVH.
In the majority of cases involving mild IVH, no clinical effects were observed. Severe IVH may manifest itself as a sudden deterioration in the clinical condition, seizures, consciousness disorders, and neurological symptom.About 40-80% of newborns with severe IVH develop symptoms of cerebral palsy.
Unfortunately, no treatment improves clinical outcome in neonatal IVH. However, increasing IVH awareness andimplementation of bundle of measures for IVH prevention among preterm infants significantly carry high success in limiting the occurrence of IVH. The bundle of IVH prevention include measures that are concerned with the steps taken immediately after delivery, special transportation measures of preterm infants from Resuscitation Department to NICU, and care of them after admission to NICU within the first first three postnatal days.
This work aimed to study theimplementation of a bundle approach for IVH prevention among preterm infants less than 32 weeks of gestation and birth weight less than 1500 gm.The specific objectives wereto estimate the incidence rate of IVH among preterm infants,to assess the knowledge of HCPs (obstetricians, neonatologists and nursing team) regarding the IVH preventive bundle among preterm infants, to implement a health education program about IVH preventive bundle for all HCPs, to evaluate the impact of the health education program on HCPs knowledge and also their compliance with the bundle elements after the program. In addition, to assessthe effect of bundle implementation on the incidence rate of IVH among preterm infants.
The study was designed as an intervention study. It included 132 preterm infants at pre-intervention phase and 135 preterminfants at post-intervention phase. In addition, all HCPs (obstetricians, neonatologists and nursing team) who dealt with preterm infants during the first three post-natal days comprised the study subjects.
The intervention educational program was conducted over a period of 2 months. Thirty-five IVH prevention bundle of measures sessions were carried out at El-Shatby University Hospital. These sessions were distributed as following: obstetricians received 5 sessions, neonatologists in Resuscitation Departmentsreceived 4 sessions, neonatologists in NICU received 3 sessions, nursing team in Obstetrics Department received 10 sessions, nursing team in Resuscitation Departmentsreceived 4 sessions and nursing team in NICU received 9 sessions. Different educational methods were used to make the sessions more interesting such as lectures, group discussions, role play, videos and power point presentation.
Data collection were done using a pre-designed structured questionnaire, which included the characteristics of the of preterm infants and the incidence rate of IVH among them (Appendix I).Another a pre-designed structured self-administered questionnaire for HCPs included:sociodemographic data and assessment of knowledge of all HCPs regarding definition of the IVH among preterm infants, neurodevelopmental outcome of the IVH, risk factors of the IVH among preterm infants, and IVH preventive bundle of measures among preterm infants(Appendix II). An observational checklist was used to assess the compliance of HCPs regarding the IVH prevention bundleamong preterm infants (Appendix III).
Data entry and statistical analysis were done using SPSS® Statistics 25. statistical analysis was performed in both descriptive and analytical forms.
The study revealed the following main results:
1. Pre-intervention phase
A. Description of preterm infants:
• About one-third (32%) of mothers reported that they were pregnant by ART approach.
• More than one-fourth (28%) of mothers suffered from antepartum hemorrhage.
• More than one-half (55%) of mothers received antenatal corticosteroid, only 10% of the mothers received magnesium sulphate treatment.
• About one-half (47%) of the mothers of the preterm infants delivered by C/S.
• The gestational age of the preterm infants ranged from 26 to 31 weeks with mean±SD 29.6 ± 1.3 weeks,and their BW ranged from 500 to 1499 gm with a mean ±SD 960 ±200 gm among preterm infants.
• More than two-fifths (44%) of the preterm infants were males.
• The preterm infants who needed PPV were41%. About two- thirds (65%) of the preterm infants received PPV using ETT.
• The medianAPGAR score at 1 min was 5.5, while the medianAPGAR score at 5 min was8.
• About one-fifth (17%) of the preterm infants were transported to NICU within < 15min at pre- intervention phase.
• The mean ±SD admission temperature of preterm infants was 36.1±1oc.
• The preterm infants who needed invasive ventilation technique constituted 15.9%, with a mean ±SD time distributes of 47.0 ±20.3 hours.
• More than one-third (38%) of the preterm infants received surfactant and less than one-half (45%) of the preterm infants needed inotropes.
• The transfusion of blood and its products, RBCstransfusion was needed for 45% of the preterm infants. Platelets transfusion was needed for 18% of the preterm infants. Plasma transfusion was needed for 39 % of the preterm infants.
• Pneumothorax was reported among 17% of the preterm infants and the occurrence of convulsions was reported in about one- fourth (23%) of the preterm infants.
B. The incidence rate of the IVH among preterm infants:
More than half (52.3%)of preterm infants suffered from IVH. On the day 1; (18.2% had mild IVH and 2.3% had severe IVH). On the day 3; (29% had mild IVH, and 14% had severe IVH).
II. Intervention phase
A. Sociodemographic characteristics of the HCPs:
• There was no significant difference in the age between the physicians’team (p= 0.63).
• All the enrolled physicians in the study had less than 5 years of experience.
• All the included physicians’ team (obstetricians and neonatologists) reported that they didn’t receive any education regarding the IVH prevention among preterm infants.
• There was a significant difference in the age between the nursing team (p = 0.04).
• The majority (94.4%) of the nursing team didn’t receive any education regarding the IVH prevention among preterm infants. There was a significant difference among the nursing teamas regards the previous IVH prevention measures education (p = 0.001).
B. Assessment of knowledge of HCPs before and after the IVH prevention intervention program:
• For neonatologists in NICU, there were statistically significant differences in their knowledge regarding therisk factors of IVH(p=0.003), immediate care after delivery (p<0.001) and care of preterm infants in NICU (p<0.001) before and after the intervention.
• For neonatologists in the Resuscitation Departments,there was a statistically significant difference in their knowledge regarding risk factors of IVH (p = 0.042) before and after the intervention.
• For obstetricians,there were statistically significant differencesin their knowledge regarding the IVH definition, risk factors of IVH and immediate care after delivery (p<0.001) before and after the intervention.
• For nursing team in NICU, there were statistically significant differences in their knowledge regarding IVHdefinition, risk factors of IVH, immediate care after delivery, transportation to NICU and care of preterm infants in NICU (p<0.001) before and after the intervention.
• For nursing team in Resuscitation Departments, there were statistically significant differences in their knowledge regarding IVH definition, risk factors of IVH and immediate care after delivery (p < 0.001) before and after the intervention.
• For nursing team in Obstetrics Department, there were statistically significant differences in their knowledge regarding IVHdefinition, risk factors, neurodevelopmental outcome of IVH and immediate care after delivery (p < 0.001) before and after the intervention.
C. Assessment of HCPs compliance with IVH prevention bundle after the IVH prevention intervention program.
The overall compliance of HCPs regarding the application of IVH prevention bundle elements was 93%.
III. Post- intervention phase
A. Description of the preterm infants:
• About one-fourth (24%) of mothers reported that they were pregnant by ART approach.
• Two-fifths (40%) of mothers suffered from antepartum hemorrhage.
• More than two-thirds (67%) of mothers received antenatal corticosteroids. One-fifth (20%) of mothers received magnesium sulphate treatment.
• As regardsmode of delivery, 71% of the mothers of preterm infants delivered by C/S.
• The gestational age of the preterm infants ranged from 26 to 31 weeks with mean ±SD 29.6 ±1.3 weeks, and the BW ranged from 500 to 1499 gm with a mean ±SD 980 ± 190 gm.
• More than half (56%) of the preterm infants were males.
• More than half (55%) of the preterm infants needed PPV. About half (49%) of the preterm infants received PPV using ETT.
• The median APGAR score at 1 min was 5, while the medianAPGAR score at 5 min was 8.
• About one-third (30%)of the preterm infants transported to NICU within < 15 min.
• The mean ±SD admission temperature of preterm infants was 35.7 ± 1.1oC.
• The preterm infants who needed invasive ventilation technique, constituted 12.6%, with a mean ±SD time distributes of 39.7 ± 20.2 hours.
• About one-third (31%) of the preterm infants received surfactant. More than one-third (36%) of the preterm infants needed inotropes.
• Regarding the transfusion of blood and its products, RBCs transfusion was needed for 17% of the preterm infants, platelets transfusion was needed for only 4% of the preterm infants, and plasma transfusion was needed in about one- fourth of the preterm infants (24%).
• Pneumothorax was reported in only 7% of the preterm infants, and occurrence of convulsions was reported in 8% of the preterm at post-intervention phase.
B. Comparison amongpreterm infantsat pre and post- intervention phases:
• There was a significant difference in the gender between the pre and post intervention group (p = 0.04).
• There was a significant difference among pre and post intervention group as regards,the resuscitation using PPV (p = 0.02).
• The medianAPGAR score at 1 min was significantly higher among preterm infants at pre-intervention phase compared to post intervention phase (p=0.02).
• At pre-intervention phase, 17% of the preterm infants were transported to NICU within< 15 min compared to about one-third (30%) of the preterm infants at the post intervention phase. This difference was statistically significant (p= 0.008).
• As regards the mean±SD admission temperature of preterm infants at pre-intervention phase, it was 36.1±1oC, compared to 35.7±1.1oCamong preterm infants at post- intervention phase. This difference was statistically significant (p=0.001).
• The mean ±SD initial hemoglobin of preterm infants at pre-intervention phase was 14.8±2.3 gm/dl compared to 16±2.4gm/dl among preterm infants at post- intervention phase. This difference was statistically significant (p=0.001).
• There was a significant difference in the duration of invasive ventilation in hours at pre and post -intervention phase (p= 0.04).
• The percentage of preterm infants received RBCs, platelets and plasma transfusion was significantly different between pre and post intervention group (p<0.001).
• The occurrence of pneumothorax was significantly differentbetween pre and post intervention group (p<0.01).
• The occurrence of convulsionswas significantly differentbetween pre and post intervention group (p=0.001).
• The overall incidence rate of the IVH was significantly lower at post-intervention phase compared to pre-intervention phase (25.4 % versus 52.3%, p< 0.001).
• On day 1;the incidence rate of the IVH among preterm infants was10.4% mild IVH and 1.5% severe IVH at post-intervention phase compared to 18.2% who had mild IVH and 2.3% who had severe IVHof preterm infants at pre-intervention phase.
• On day 3;the incidence rate of the IVH among preterm infants was 16% mild IVH and 6% severe IVH at post-intervention phase compared to 29% who had mild IVH and 14% who had severe IVH of preterm infants at pre-intervention phase.
• There was a statistically significant inverse correlation between the incidence rate of the IVH and GA (rs= -0.31, p < 0.001).
• There was a statistically significant inverse correlation between the incidence rate of the IVH and BW (rs = -0.17, p=0.004).
• The mortality rate among preterm infants diagnosed with IVH was more than two-fifths (44%) at pre-intervention. It decreased to about one-third (31%) at post-intervention phase.
• The overall mortality rate among preterm infants within hospital stay was 89% at pre-intervention phase. It decreased to 71% at post-intervention phase. This difference was a highly statistically significant (p<0.001).
• The logistic regression analysis was done to identify the different predictors of IVH among preterm infants.The incidence rate of IVH decreased by 36% for each week increase inGA and the interventioneducational programreduced the incidence rate of IVH among preterm infants by 71%.
• The cox regression analysis was done to identify the different predictors of mortality among preterm infants. The intervention educational programwas responsible for reducing the mortality rate by 29%, and per I week increase in GA, the risk of mortality decreased by 17%, and per I gm increase in BW, the risk of mortality decreased by 3%.
Conclusion
• More than half (52.3%) of the studied preterm infants suffered from IVH in the NICU.
• All physicians’team reported that they didn’t receive any education program regarding the IVH prevention among preterm infants.
• The majority of the nursing team didn’t receive any education program regarding the IVH prevention among preterm infants.
• The intervention educational program had an effect on upgrading the knowledge of the HCPs as regards IVH definition, neurodevelopmental outcome, risk factors and tools of prevention.
• The majority of HCPs were compliant with IVH prevention bundle of measures.
• The intervention educational program had a positive effect on preterm infant’s outcomes.
• Use of IVH prevention bundle of measures had been proven to decrease the incidence rate of IVH by more than one-half percent and consequently the mortality rate among preterm infants.
• There was an inverse correlation between GA or BW and severity of IVH.
• Both the intervention educationalprogram and increasing GA were the only protective predictors factors for the development of IVH among preterm infants.
• The mortality rate among preterm infants decreased by increasing GA, BW, and by application of the intervention educational program.
Recommendations
I. For the university hospitals, administration:
1. Try to organize the number of preterm deliveries at El-Shatby UniversityHospital with other governmental hospitals to reduce the work load in the NICU at El-Shatby UniversityHospital.
2. Reconstruct and renovate the NICU at El-Shatby UniversityHospital to accommodate with one-hundred neonates to cope for the increasing number of preterm deliveries.
3. Arrange regular training for all HCPs to follow the current guidelines and our recommendations in the prevention of IVH among preterm infants.
II. For the obstetricians:
1. Prevent or postpone preterm delivery as much as possible.
2. Give antenatal steroids therapy for all imminent preterm birth.
3. Give magnesium sulphate to mothers shortly before delivery to reduce the risk of cerebral palsy in those infants born preterm.
4. Administer appropriate maternal antibiotic therapy in case of antenatal infections.
5. Promote care during preterm infant’s delivery; maintain delivery room temperature control and avoid passage of uninvolved persons.
6. Insure that preterm infant be handled after delivery in the supine position at the level of placenta or below, while maintaining the head in the midline position at birth.
7. Handle preterm infants very gently.
8. Perform placental transfusion; either as DCC for 30-60 sec for all vigorous neonates or intact umbilical cord milking three times for flaccid neonates.
III. For the neonatologists:
1. Attend the delivery room within proper time before birth, which is crucial.
2. Handle preterm infants very gently, while maintaining supine position and heads in midline position.
3. Place wet preterm infant in transparent side opening plastic wrap or bag and cover the head with a cap immediately after birth to prevent hypothermia.
4. Strictly optimize neonatal resuscitation guidelines and reduce fluctuation in cerebral blood flow.
5. Record all steps of neonatal resuscitation accurately in a separate sheet in the patient’s file.
6. Use pre-warmed portable incubator for preterm infant’s transportation from the resuscitation unit to NICU.
7. Implement minimal handling protocol during the first week of the preterm infant’s life.
8. Give pre-medication prior to intubation of preterm newborn to decrease the pain.
9. The judicious use of inotropesin the first few hours of preterm infant’s life.
10. Establish contact between the mother and her preterm newborn as early as possible.
11. Continue to monitor the use of the IVH prevention bundle for all preterm infants.
12. Do regular cranial ultrasound screen for early IVH detection as a part of the IVH prevention program.
13. Develop an accurate recording system in NICU for all cases of the IVH.
IV. For the nursing team:
1. Handle preterm infants very gently; maintain babies nursed in a flexed position surrounded by soft, well-defined boundaries (Nest) to improve their continued physical maturation and neurodevelopment outside the womb.
2. Ensure that preterm infants be maintained in the supine position and their heads in midline position, covered with a cap.
3. Maintain the normal sleep cycles (at least 60 min) for preterm infants as much as possible, which is necessary for early neurosensory, learning and memory development.
4. Maintain thermal stability for all preterm infants.
5. Protect preterm infants skin through using of incubator humidity, emollients and suitable protective adhesive tapes.
6. Implement minimal handling protocol during the first week of the preterm infant’s life.
7. Reduce routine nursing activities such as diaper changing, and decreasing endotracheal tube suctioning as much as possible.
8. Record all steps of neonatal resuscitation accurately in a separate sheet in the patient’s file.
9. Engage mothers in the process of care by encouraging breast milk expression. The expressed milk is used in oral care, feeding, as an analgesic and for its neuroprotective properties.
10. Provide support to the preterm infants and their families by the nursing team. This is a cornerstone in the success of the whole process.
V. For the researchers:
1. Further epidemiological studies should be implemented to identify the risk factors of preterm birth on a population basis and by identifying high risk groups that can be targeted by clinical services.
2. Explore the benefits of providing breast milk through other researches particularly in terms of its role in neuroprotection of preterm infants.
3. Implement further studies that focus on identifying multiple potential mechanisms for reducing brain damage and enhancing brain repair.