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Indian Pediatr 2014;51: 804-806 |
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Risk of Retinopathy of Prematurity in Small
for Gestational Age Premature Infants
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Sumru Kavurt, Beyza Özcan, Ozge Aydemir, Ahmet Yagmur
Bas and Nihal Demirel
From Etlik Zübeyde Haním Women’s Health Teaching and
Research Hospital, Department of Neonatology, Ankara, Turkey.
Correspondence to: Dr Sumru Kavurt, Neonatal Intensive
Care Unit, Etlik Zübeyde Haním Women’s Health Teaching and Research
Hospital, Yeni Etlik Caddesi 55, Etlik, 06010, Ankara, Turkey.
Email: [email protected]
Received: November 17, 2013;
Initial review: December 03, 2013;
Accepted: August 05, 2014.
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Objectives: To evaluate the
incidence, risk factors and severity of retinopathy of prematurity
in neonatal intensive care unit and to evaluate its relationship
with gestational age.
Methods: Cohort study of
neonates with gestational age £32
weeks or birthweight £1500g.
Results: Of the 495 neonates
screened, 43 (8.7%) infants were small for gestational age; the
frequency of severe retinopathy of prematurity was 5.8%. Sepsis and
being small for gestational age were independent risk factors for
severe retinopathy of prematurity.
Conclusions: Clinicians
should be aware of the presence of presence of retinopathy of
prematurity when caring for protein small for gestational age
infants.
Keywords: Intrauterine growth retardation,
Prematurity, Retina.
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Retinopathy of prematurity (ROP) is a major cause
of preventable blindness in children all over the world [1]. Although
the etiology of ROP is multifactorial, low birth weight (BW) and low
gestational age (GA) are recognised as the most important risk factors
[2]. Small for gestational age (SGA) infants have a greater risk for
mortality and morbidity than appropriate for gestational age (AGA)
infants [3,4]. The influence of being SGA on the retinopathy of
prematurity is controversial with some studies reporting higher risk
[4-6]. We aimed to evaluate the incidence, risk factors and severity of
ROP and the relationship between SGA and retinopathy.
Methods
In this prospective study, preterm infants born with
birth weight £1500
g or gestational age £32
weeks at Etlik Zubeyde Haním Women’s Health Teaching and Research
Hospital, Ankara, Turkey, between January 2011 and January 2013 were
recruited. Infants with lethal congenital anomalies, those who died or
were lost to follow-up before development of threshold ROP/full
vascularization of the retina were also excluded.
The first eye examination was performed at 4 weeks of
chronologic age for infants born at
³27 weeks or at 31 weeks of postmenstrual age for
infants born at 22 to 26 weeks. Severe ROP was defined as that needing
treatment. The criteria for treatment were: zone I any stage of ROP with
plus disease or zone I stage 3 without plus and zone 2 stage 2 or 3 with
plus disease (Type 1 ROP) as defined by Early Treatment for Retinopathy
of Prematurity Cooperative Group [7]. Staging of ROP was recorded
according to the International classification of ROP [8].
SGA was defined as birth weight below 10th percentile
according to intrauterine growth charts of Usher and McClean [9]. The
data recorded for each neonate included maternal, perinatal and
postnatal characteristics.
Statistical analyses were conducted using the SPSS
version 17.0 (SPSS Inc., Chicago, IL).
Results
During the study period, complete clinical and eye
examination data were available for 495 patients. Mean (SD) BW and GA
for the cohort was 1266.8 (278.3) g (range 600-1690g) and 29.3 (2.1)
weeks (range 23-33 weeks), respectively. Any stage of ROP was detected
in 140 babies (28.2%), and severe ROP occurred in 29 (5.8%) babies.
During the study period, 43 (8.7%) infants admitted to our NICU were
SGA.
Risk factors for severe ROP were analyzed in patients
≤32 weeks GA
or ≤1500 g BW
(n=495) (Table I). Amongst morbidity variables
examined, all were found significantly more frequent in the neonates
with severe ROP.
TABLE I Characteristics and Risk Factors for Severe ROP in the Study Subjects
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No ROP+mild ROP (n=466) |
Severe ROP (n=29) |
PValue |
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Gestational age (wks) |
29.47 (1.98) |
27.10 (2.14) |
<0.001 |
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Birth weight (g) |
1289.9 (276.3) |
965.3 (244.7) |
<0.001 |
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Sex (F/M) |
232/234 |
14/15 |
0.875 |
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Delivery(C/S/VD) |
369/97 |
22/9 |
0.670 |
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Small for gestational age |
38 (8.2%) |
5 (17.2%) |
0.096 |
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Multiple gestation |
142 (30.5%) |
8 (27.6%) |
0.743 |
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In vitro fertilization |
46 (9.9%) |
5 (17.2%) |
0.206 |
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Resuscitation at birth |
124 (26.6%) |
18 (62.1%) |
<0.001 |
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5 minute APGAR score |
8 6 |
<0.001 |
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Maternal age (y) |
28.1 (5.7) |
29.1 (7.0) |
0.665 |
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Antenatal steroids |
255 (54.7%) |
18 (62.1%) |
0.440 |
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Preeclampsia |
102 (21.9%) |
6 (20.7%) |
0.875 |
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PPROM |
78 (16.7%) |
2 (6.9%) |
0.201 |
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Chorioamnionitis |
27 (5.8%) |
4 (13.8%) |
0.101 |
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Gestational diabetes mellitus |
20 (4.3%) |
0 |
0.622 |
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Days on mechanical ventilation |
1.1 (3.0) |
8.1 (12.7) |
<0.001 |
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Days on nasal CPAP |
2.5 (3.8) |
9.6 (7.5) |
<0.001 |
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Days on supplemantal O2 |
10.6 (15.8) |
31.1 (31.4) |
<0.001 |
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Respiratory distress syndrome |
201 (43.1%) |
23 (79.3%) |
<0.001 |
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Patent ductus arteriosus |
71 (15.2%) |
11(37.9%) |
0.004 |
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Sepsis |
63 (13.5%) |
14 (48.3%) |
<0.001 |
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Intra-ventricular hemorrhage |
25 (5.4%) |
5 (17.2%) |
<0.001 |
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Necrotizing enterocolitis |
4 |
3 (10.3%) |
0.005 |
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≥2 transfusions |
58 (12.4%) |
14 (48.3%) |
<0.001 |
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Duration of TPN infusion (d) |
16.1 (9.7) |
23.8 (15.9) |
<0.001 |
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Time to regain birth weight (d) |
11.03 (5.04) |
13.97 (9.39) |
<0.001 |
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PPROM: preterm premature rupture of
membranes; Values in Mean (SD) or No. (%). |
In the logistic regression model, presence of sepsis
(Adjusted OR 3.8, 95% (I 1.6-9.1; P =0.002) and being SGA were
(Adjusted OR 3.0, 95% (I 1.0-9.3; P =0.049) independent risk
factors for severe ROP
Discussion
In the present study, the incidence of any stage of
ROP was 28.2% and severe ROP was 5.8% in babies
£1500 g birth weight
or £32 weeks
gestational age. Sepsis and being SGA were independently related with
the presence of severe ROP.
The observed association of low GA or BW with ROP is
in agreement with the most of the other studies [2,10]. Recent studies
showed ROP incidence is higher in SGA infants than AGA infants [4,5,11].
Factors that may be responsible for the increased risk of severe ROP and
the rapidity of its development in SGA babies include chronic uterine
hypoxia, abnormal growth factor levels, antioxidant deficiency, and free
oxygen radicals in utero [3,12,13].
Allegaert, et al. [5] from a tertiary
neonatal intensive care unit in Belgium reported SGA infants were 3.7
times more likely to develop threshold ROP than their AGA peers. On the
other hand, a cohort from Brazil reported that being SGA was not a
significant risk factor for any stage of ROP or severe ROP [14].
The incidence of fetal growth restriction varies
among populations and increases with decreasing gestational age. The
limitations of our study include a small sample size and absence of AGA
controls. In conclusion, preterm SGA infants are at higher risk of
developing severe ROP. Clinicians should be aware of the presence of
this morbidity when caring for preterm SGA infants.
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What This Study Adds?
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Preterm SGA infants are more
likely to develop severe ROP.
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