Premature birth

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Premature birth

ICD-10	O601
ICD-9	659.0
OMIM	[1]
DiseasesDB	[2]
MedlinePlus	[3]
eMedicine	/
MeSH	{{{MeshNumber}}}

This is a general article. See Psychological aspects of premature birth for in depth consideration of psychological factors surrounding this event.

Premature birth (also known as preterm birth) is defined medically as childbirth occurring earlier than 37 completed weeks of gestation. Most pregnancies last about 40 weeks. About 12 percent of babies in the United States — or 1 in 8 — are born prematurely each year. In 2003, more than 490,000 babies in the U.S. were born prematurely. The shorter the term of pregnancy is, the greater the risks of complications. Infants born prematurely have an increased risk of death in the first year of life; prematurity itself is the leading cause of newborn death within one month of birth at 25%. They are also at a greater risk for developing serious health problems such as: cerebral palsy, chronic lung disease, gastrointestinal problems, mental retardation, vision and hearing loss.

Although there are several known risk factors for prematurity (see below), nearly half of all premature births have no known cause. When conditions permit, doctors may attempt to stop premature labor, so that the pregnancy can have a chance to continue to full term, thereby increasing the baby's chances of health and survival. However, there is currently no reliable means to stop or prevent preterm labor in all cases. In fact, the rate of preterm births in the United States has actually increased 30% in the past two decades.

After being born, a premature baby is cared for in a special section of the hospital known as the NICU (Neonatal Intensive Care Unit). The physicians who specialize in the care of very sick or premature babies are known as neonatologists. In the NICU, babies are kept in incubators (or isolettes), a bassinet enclosed in plastic with climate control equipment designed to keep babies warm and limit their exposure to germs. In some cases, an oxygen-enriched atmosphere may be used, although this is avoided where possible, as it can cause damaging side effects. Premature babies may be released from the hospital when they no longer need the constant hospital care the NICU provides.

Factors

There are many known factors related to premature births. However, the nature of the relationship between these factors and premature births are unclear.

• A woman's previous history of preterm birth, or pregnancies that ended in miscarriage.
• Multiple pregnancies (twins, triplets, etc.) are at a higher risk for premature birth.
• Uterine or cervical abnormalities.
• Certain chronic disease such as high blood pressure, kidney disease and diabetes.
• Infections of the cervix, uterus or urinary tract. Certain STDs, Beta Strep.
• Substance abuse of tobacco, alcohol and other drugs.
• Women who have tried to conceive for more than a year before getting pregnant are at a higher risk for premature birth. A recent study done by Dr. Olga Basso of the University of Aarhus in Denmark and Dr. Donna Baird of the U.S. National Institute of Environmental Health Sciences suggests that women who had difficulty conceiving were about 40 percent higher risk of preterm birth than those who had conceived easily.
• Women under 18 or over 35 are at a higher risk for premature birth.
• Inadequate nutrition during pregnancy.
• Antepartum hemorrhage
• Pre-eclampsia
• Stress
• Periodontal disease increases the risk of preterm birth more than 4 times. As a matter of fact this is one of the most serious risk factors, that is completely preventable.

Prevention of preterm birth

Some newer research has identified possible methods to prevent preterm birth, pre-eclampsia/eclampsia, premature rupture of membranes, and preterm labor.

This research includes self-care methods to reduce infections, nutritional and psychological interventions, and the control of preterm birth risk factors (eg. working long hours standing on feet, carbon monoxide exposure, domestic abuse, and other factors).

This research is quite new; however, doctors using these newer strategies have obtained preterm birth rates as low as 1 to 2%, compared to the 11 to 16% currently in the US.

Symptoms and indications

The symptoms of an imminent premature birth include:

• Four or more uterine contractions in one hour, before 37 weeks' gestation.
• A watery discharge from the vagina which may indicate premature rupture of the membranes surrounding the baby.
• Pressure in the pelvis or the sensation that the baby has "dropped".
• Menstrual cramps or abdominal pain.
• Pain or rhythmic tightening in lower abdomen or back.
• Vaginal spotting or bleeding.

Treatments for premature birth

There are two tactics that can be used to deal with a potential premature birth: delay the arrival of birth as much as possible, or prepare the prospectively premature fetus for arrival. Both of these tactics may be used simultaneously.

Delaying the premature birth from occurring is typically the most favored option. This gives the fetus or fetuses as much time as possible to mature in the womb. There are a number of techniques that can be used to try to accomplish this. The first resort is usually complete bed rest. Maintaining a horizontal position reduces pressure on the cervix, which may allow it to stay lengthened longer, and avoiding unnecessary movement may reduce uterine irritation, which can lead to contractions. Likewise, proper nutrition and especially hydration are important: dehydration can lead to premature uterine contractions. In a hospital setting, a drug-free IV drip may be used to try to stop premature labor simply by improving the mother's hydration. Lastly, there are anti-contraction medications (tocolytics), such as ritodrine, fenoterol]], nifedipine and atosiban.

Premature birth can not always be prevented. Severely premature infants may have underdeveloped lungs, because they are not yet producing their own surfactant. This can lead directly to Respiratory Distress Syndrome, also called hyaline membrane disease, in the neonate. To try to reduce the risk of this outcome, pregnant mothers are routinely administered at least one course of glucocorticoids, a steroid that easily passes the placental barrier and stimulates growth in the lungs of the fetus. Typical glucocorticoids that would be administered in this context are betamethasone or dexamethasone, often when the fetus has reached viability at 23 weeks. In cases where premature birth is imminent, a second "rescue" dose of steroids may be administered 12 to 24 hours before the anticipated birth. There is no research consensus on the efficacy and side-effects of a second dose of steroids, but the consequences of RDS are so severe that a second dose is often viewed as worth the risk.

Aspects of prematurity

Infants born more than 3 weeks prior to 40 weeks show physical signs of their prematurity and may develop other problems as well. Common problems in infants with severe to moderate prematurity (26 to 34 weeks) include jaundice, hypoglycemia, hypocalcemia, infant respiratory distress syndrome (IRDS), bronchopulmonary dysplasia (BPD) which is also called Chronic Lung Disease, intracranial hemorrhage, retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), urinary tract infection ^[4], inguinal hernia, anemia, and rickets.

The earliest gestational age at which the infant has at least a 50% chance of survival is referred to as the limit of viability^[5]. As NICU care has improved over the last 40 years, the limit of viability has declined to about 23 weeks. As risk of brain damage and developmental delay is significant at that threshold even if the infant survives, there are ethical controversies over the aggressiveness of the care rendered to such infants. The limit of viability has also become a factor in the abortion debate.

Some of the complications related to prematurity are not apparent until years after the birth. For example, children who were premature babies (especially if born less than 1500 grams) have a higher likelihood of having behavioral problems, delays in motor development, and difficulties in school than their peers who were healthy full term babies. More than their peers who were full term, former preemies need services provided by physical therapists, occupational therapists or speech therapists.

Treatment measures for a premature infant

The required care for premature infants differs greatly depending on the child's gestational age, birth weight, and overall maturity. Measures common among extremely premature infants include:

• Placing the infant in a warmer or isolette. Premature infants are easily susceptible to infection, and preventing this is a key priority.
• Infants under 32 weeks typically do not produce enough surfactant in their lungs to enable them to breathe on their own. In these cases, surfactant will be administered to assist them.
• In extremely premature infants, a breathing tube may be inserted in the infant's trachea, and a respirator and supplemental oxygen may be used.
• Adequate nutrition, via a feeding tube or, in extremely premature infants, intravenously. If a feeding tube is used, expressed breast milk from the mother or a breastmilk bank can be used, which lowers the risk of necrotizing enterocolitis.

Prematurity and the parent

Adjustment after preterm birth for parents can be very difficult. The NICU setting is foreign and often intimidating and scary. Additionally, parents often have difficulty becoming involved in their child's care because of the NICU setting. This affects the parents transition into parenthood because they are unable to fulfill their expected roles. Furthermore, often premature birth is accompanied by a difficult NICU course and therefore parents are forced to confront difficult decisions about their child's care. Studies have shown that the transition to parenthood for parents of preterm infants follows a different and longer course than that of parents with term infants.

In a study by Jackson et al (2003)^[6] researchers found that both mothers and fathers travel a course from alienation to responsibility to confidence to familiarity in approximately the first 18 months of the child's life.

In a separate study by McHaffie^[7], researchers found that parents of very low birth weight infants (<1500g/3.3lbs) follow a similar but slightly different course, likely because their infants tend to be more in peril. Mothers travel from anticipatory grief to anxious waiting to positive anticipation while the infant is in the NICU. After discharge the mother travels from anxious adjustment to exhausted accommodation to confident caring, usually within the first three months following discharge.

In Popular Culture

• On the show Freak Show, one member of the Freak Squad is Primi the Premature Baby.
• On medical drama, House in episode Forever, in a dialogue between protagonist Dr. Gregory House and Dr. Robert Chase who kissed an underaged girl because she had terminal cancer, House mocks his subordinate for working in the NICU, supposing that he's only trying to expand his "work-out pool" to include preemies as well.

References

5. Khader YS, Ta’ani Q. Periodontal diseases and the risk of preterm birth and low birth weight: a meta-analysis. J Periodontol 2005;76:161-5.

Links for Parents of Preemies

• Overview of Premature Infant Issues and the NICU
• [http://www.allceus.com Continuing Education Credits for clinicians working with preemies based on the Infant Toddler Development modules at http://www.cms-kids.com/ESproviders/itds/index.html
• Primer on Preemies
• Kangaroo Care
• Doula

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