prematurity


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Prematurity

 

Definition

The length of a normal pregnancy or gestation is considered to be 40 weeks (280 days) from the date of conception. Infants born before 37 weeks gestation are considered premature and may be at risk for complications.

Description

More than one out of every ten infants born in the United States is born prematurely. Advances in medical technology have made it possible for infants born as young as 23 weeks gestational age (17 weeks premature) to survive. These premature infants, however, are at higher risk for death or serious complications, which include heart defects, respiratory problems, blindness, and brain damage.

Causes and symptoms

The birth of a premature baby can be brought on by several different factors, including premature labor; placental abruption, in which the placenta detaches from the uterus; placenta previa, in which the placenta grows too low in the uterus; premature rupture of membranes, in which the amniotic sac is torn, causing the amniotic fluid to leak out; incompetentcervix, in which the opening to the uterus opens too soon; and maternal toxemia, or blood poisoning. While one of these conditions are often the immediate reason for a premature birth, its underlying cause is usually unknown. Prematurity is much more common in multiple pregnancy and for mothers who have a history of miscarriages or who have given birth to a premature infant in the past. One of the few, and most important, identifiable causes of prematurity is drug abuse, particularly cocaine, by the mother.
Infants born prematurely may experience major complications due to their low birth weight and the immaturity of their body systems. Some of the common problems among premature infants are jaundice (yellow discoloration of the skin and whites of the eyes), apnea (a long pause in breathing), and inability to breast or bottle feed. Body temperature, blood pressure, and heart rate may be difficult to regulate in premature infants. The lungs, digestive system, and nervous system (including the brain) are under-developed in premature babies, and are particularly vulnerable to complications. Some of the more common risks and complications of prematurity are described below.
Respiratory distress syndrome (RDS) is the most common problem seen in premature infants. Babies born too soon have immature lungs that have not developed surfactant, a protective film that helps air sacs in the lungs to stay open. With RDS, breathing is rapid and the center of the chest and rib cage pull inward with each breath. Extra oxygen can be supplied to the infant through tubes that fit into the nostrils of the nose, or by placing the baby under an oxygen hood. In more serious cases, the baby may have to have a breathing tube inserted and receive air from a respirator or ventilator. A surfactant drug can be given in some cases to coat the lung tissue. Extra oxygen may be need for a few days or weeks, depending on how small and premature the baby was at birth. Bronchopulmonary dysplasia is the development of scar tissue in the lungs, and can occur in severe cases of RDS.
Necrotizing enterocolitis (NEC) is a further complication of prematurity. In this condition, part of the baby's intestines are destroyed as a result of bacterial infection. In cases where only the innermost lining of the bowel dies, the infant's body can regenerate it over time; however, if the full thickness of a portion dies, it must be removed surgically and an opening (ostemy) must be made for the passage of wastes until the infant is healthy enough for the remaining ends to be sewn together. Because NEC is potentially fatal, doctors are quick to respond to its symptoms, which include lethargy, vomiting, a swollen and/or red abdomen, fever, and blood in the stool. Measures include taking the infant off mouth feedings and feeding him or her intravenously; administering antibiotics; and removing air and fluids from the digestive tract via a nasal tube. Approximately 70% of NEC cases can be successfully treated without surgery.
Intraventricular hemorrhage (IVH) is another serious complication of prematurity. It is a condition in which immature and fragile blood vessels within the brain burst and bleed into the hollow chambers (ventricles) normally reserved for cerebrospinal fluid and into the tissue surrounding them. Physicians grade the severity of IVH according to a scale of I-IV, with I being bleeding confined to a small area around the burst vessels and IV being an extensive collection of blood not only in the ventricles, but in the brain tissue itself. Grades I and II are not uncommon, and the baby's body usually reabsorbs the blood with no ill effects. However, more severe IVH can result in hydrocephalus, a potentially fatal condition in which too much fluid collects in the ventricles, exerting increased pressure on the brain and causing the baby's head to expand abnormally. To drain fluid and relieve pressure on the brain, doctors will either perform lumbar punctures, a procedure in which a needle is inserted into the spinal canal to drain fluids; install a reservoir, a tube that drains fluid from a ventricle and into an artificial chamber under or on top of the scalp; or install a ventricular shunt, a tube that drains fluid from the ventricles and into the abdomen, where it is reabsorbed by the body. Infants who are at high risk for IVH usually have an ultrasound taken of their brain in the first week after birth, followed by others if bleeding is detected. IVH cannot be prevented; however, close monitoring can ensure that procedures to reduce fluid in the brain are implemented quickly to minimize possible damage.
Apnea of prematurity is a condition in which the infant stops breathing for periods lasting up to 20 seconds. It is often associated with a slowing of the heart rate. The baby may become pale, or the skin color may change to a blue or purplish hue. Apnea occurs most commonly when the infant is asleep. Infants with serious apnea may need medications to stimulate breathing or oxygen through a tube inserted in the nose. Some infants may be placed on a ventilator or respirator with a breathing tube inserted into the airway. As the baby gets older, and the lungs and brain tissues mature, the breathing usually becomes more regular. A group of researchers in Cleveland reported in 2003, however, that children who were born prematurely are 3-5 times more likely to develop sleep-disordered breathing by age 10 than children who were full-term babies.
As the fetus develops, it receives the oxygen it needs from the mother's blood system. Most of the blood in the infant's system bypasses the lungs. Once the baby is born, its own blood must start pumping through the lungs to get oxygen. Normally, this bypass duct closes within the first few hours or days after birth. If it does not close, the baby may have trouble getting enough oxygen on its own. Patent ductus arteriosus is a condition in which the duct that channels blood between two main arteries does not close after the baby is born. In some cases, a drug, indomethacin, can be given to close the duct. Surgery may be required if the duct does not close on its own as the baby develops.
Retinopathy of prematurity is a condition in which the blood vessels in the baby's eyes do not develop normally, and can, in some cases, result in blindness. Premature infants are also more susceptible to infections. They are born with fewer antibodies, which are necessary to fight off infections.

Diagnosis

Many of the problems associated with prematurity depend on how early the baby is born and how much it weighs at birth. The most accurate way of determining the gestational age of an infant in utero is calculating from a known date of conception or using ultrasound imaging to observe development. When a baby is born, doctors can use the Dubowitz exam to estimate gestational age. This standardized test scores responses to 33 specific neurological stimuli to estimate the infant's neural development. Once the baby's gestational age and weight are determined, further tests and electronic fetal monitoring may need to be used to diagnose problems or to track the baby's condition. A blood pressure monitor may be wrapped around the arm or leg. Several types of monitors can be taped to the skin. A heart monitor or cardiorespiratory monitor may be attached to the baby's chest, abdomen, arms, or legs with adhesive patches to monitor breathing and heart rate. A thermometer probe may be taped on the skin to monitor body temperature. Blood samples may be taken from a vein or artery. X rays or ultrasound imaging may be used to examine the heart, lungs, and other internal organs.

Treatment

Treatment depends on the types of complications that are present. It is not unusual for a premature infant to be placed in a heat-controlled unit (an incubator) to maintain its body temperature. Infants that are having trouble breathing on their own may need oxygen either pumped into the incubator, administered through small tubes placed in their nostrils, or through a respirator or ventilator, which pumps air into a breathing tube inserted into the airway. The infant may require fluids and nutrients to be administered through an intravenous line in which a small needle is inserted into a vein in the hand, foot, arm, leg, or scalp. If the baby needs drugs or medications, they may also be administered through the intravenous line. Another type of line may be inserted into the baby's umbilical cord. This can be used to draw blood samples or to administer medications or nutrients. If heart rate is irregular, the baby may have heart monitor leads taped to the chest. Many premature infants require time and support with breathing and feeding until they mature enough to breathe and eat unassisted. Depending on the complications, the baby may require drugs or surgery.
A form of treatment that is being recommended by many mainstream practitioners as of 2003 is massage therapy. Research has shown that the risks of massaging preterm infants are minimal, and that the infants benefit from improved developmental scores, more rapid weight gain, and earlier discharge from the hospital. An additional benefit of massage therapy is closer bonding between the parents and their newborn child.

Prognosis

Advances in medical care have made it possible for many premature infants to survive and develop normally. However, whether or not a premature infant will survive is still intimately tied to his or her gestational age:
  • 21 weeks or less: 0% survival rate
  • 22 weeks: 0-10% survival rate
  • 23 weeks: 10-35% survival rate
  • 24 weeks: 40-70% survival rate
  • 25 weeks: 50-80% survival rate
  • 26 weeks: 80-90% survival rate
  • 27 weeks: greater than 90% survival rate
Physicians cannot predict long-term complications of prematurity; some consequences may not become evident until the child is school-aged. Minor disabilities like learning problems, poor coordination, or short attention span may be the result of premature birth, but can be overcome with early intervention. The risks of serious long-term complications depend on many factors, including how premature the infant was at birth, weight at birth, and the presence or absence of breathing problems. Gender is a definite factor: a Swedish study published in 2003 found that boys are at greater risk of death or serious long-term consequences of prematurity than girls; for example, 60% of boys born at 24 weeeks' gestation die, compared to 38% mortality for girls. The development of infection or the presence of a birth defect can also affect long-term prognosis. Infections in premature and very low birth weight infants are a risk factor for later disorders of the nervous system; a study done at Johns Hopkins reported that 77 out of a group of 213 premature infants developed neurologic disorders. Severe disabilities like brain damage, blindness, and chronic lung problems are possible and may require ongoing care.

Prevention

Some of the risks and complications of premature delivery can be reduced if the mother receives good prenatal care, follows a healthy diet, avoids alcohol or drug consumption, and refrains from cigarette smoking. In some cases of premature labor, the mother may be placed on bed rest or given drugs that can stop labor contractions for days or weeks, giving the developing infant more time to develop before delivery. The physician may prescribe a steroid medication to be given to the mother before the delivery to help speed up the baby's lung development. The availability of neonatal intensive care unit, a special hospital unit equipped and trained to deal with premature infants, can also increase the chances of survival.
A new medication may help to prevent spontaneous premature births. Researchers at Wake Forest University reported in June 2003 that a drug known as 17 alpha-hydroxyprogesterone caproate not only reduced the number of premature births in a group of women who received weekly injections of the drug compared to a placebo group, but also lowered the rates of necrotizing enterocolitis, intraventricular hemorrhage, and need for supplemental oxygen in their infants.

Key terms

Apnea — A long pause in breathing.
Dubowitz exam — A standardized test that scores responses to 33 specific neurological stimuli to estimate an infant's neural development and, hence, gestational age.
Intraventricular hemorrhage (IVH) — A condition in which blood vessels within the brain burst and bleed into the hollow chambers (ventricles) normally reserved for cerebrospinal fluid and into the tissue surrounding them.
Jaundice — Yellow discoloration of skin and whites of the eyes that results from excess bilirubin in the body's system.
Necrotizing enterocolitis (NEC) — A condition in which part of the intestines are destroyed as a result of bacterial infection.
Respiratory distress syndrome (RDS) — Condition in which a premature infant with immature lungs does not develop surfactant, a protective film that helps air sacs in the lungs to stay open. RDS is the most common problem seen in premature infants.
Retinopathy of prematurity — A condition in which the blood vessels in a premature infant's eyes do not develop normally, and can, in some cases, result in blindness.
Surfactant — A protective film that helps air sacs in the lungs to stay open. Premature infants may not have developed this protective layer before birth and are more susceptible to respiratory problems without it. Some surfactant drugs are available. These can be given through a respirator and will coat the lungs when the baby breathes the drug in.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Premature Infant." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Periodicals

Beachy, J. M. "Premature Infant Massage in the NICU." Neonatal Network 22 (May-June 2003): 39-45.
Holcroft, C. J., K. J. Blakemore, M. Allen, and E. M. Graham. "Association of Prematurity and Neonatal Infection with Neurologic Morbidity in Very Low Birth Weight Infants." Obstetrics and Gynecology 101 (June 2003): 1249-1253.
Ingemarsson, I. "Gender Aspects of Preterm Birth." British Journal of Obstetrics and Gynecology 110, Supplement 20 (April 2003): 34-38.
Meis, P. J., M. Klebanoff, E. Thom, et al. "Prevention of Recurrent Preterm Delivery by 17 Alpha-Hydroxyprogesterone Caproate." New England Journal of Medicine 348 (June 12, 2003): 2379-2385.
Rosen, C. L., E. K. Larkin, H. L. Kirchner, et al. "Prevalence and Risk Factors for Sleep-Disordered Breathing in 8- to 11-Year-Old Children: Association with Race and Prematurity." Journal of Pediatrics 142 (April 2003): 383-389.
Ward, R. M., and J. C. Beachy. "Neonatal Complications Following Preterm Birth." British Journal of Obstetrics and Gynecology 110, Supplement 20 (April 2003): 8-16.

Organizations

American Academy of Pediatrics (AAP). 141 Northwest Point Boulevard, Elk Grove Village, IL 60007. (847) 434-4000. http://www.aap.org.
National Institute of Child Health and Human Development (NICHD) Information Resource Center (IRC). P. O. Box 3006, Rockville, MD 20847. (800) 370-2943. http://www.nichd.nih.gov.

Other

Brazy, J. E. For Parents of Preemies. 〈http://www2.medsch.wisc.edu/childrenshosp/parents_of_preemies/index.html〉.
Levison, Donna. "When Is It Too Early? A Guide to Help Prevent Premature Birth." Health Net. 〈http://www.health-net.com/preme.htm〉.
"Survival of Extremely Premature Babies." Dr. Plain Talk Health Care Information. 〈http://www.drplaintalk.org〉.

prematurity

 [pre″mah-chur´ĭ-te]
underdevelopment; the condition of a premature infant.

pre·ma·tu·ri·ty

(prē'mă-tū'ri-tē),
1. The state of being premature.
2. In dentistry, deflective occlusal contact.

prematurity

/pre·ma·tur·i·ty/ (-mah-chldbomacr´ĭ-te) underdevelopment; the condition of a premature infant.premature´

prematurity

[-məcho̅o̅′ritē]
Etymology: L, praematurus, too soon
pertaining to an event that occurs before the usual or expected time, such as a premature birth.

prematurity

Obstetrics The state of being premature, which encompasses a constellation of clinical findings in an infant delivered before 37 wks–from the 1st day of the last menstrual period of gestation, who is also immature Clinical Anemia due to ↓ iron and vitamin E, bronchopulmonary dysplasia, intraventricular hemorrhage, especially in very LBW infants, permanent neurologic sequelae and retinopathy. See Low birth weight, Premature infant. Cf Post-term pregnancy.

pre·ma·tu·ri·ty

(prē'mă-chŭr'i-tē)
1. The state of being premature.
2. dentistry Deflective occlusal contact.

prematurity

Birth of a baby before the 37th week of pregnancy gestation or of a baby weighing less than 2500 g, regardless of the gestation period.

prematurity

underdevelopment; the condition of being born prematurely.
References in periodicals archive ?
Grimes says that while the Finnish study finds a 40% risk of subsequent prematurity among women having three or more abortions, it finds (unlike other studies the Finnish study itself cites) "No significant relationship" between one or two abortions and later prematurity.
Initiatives such as the elimination of elective delivery before 39 weeks and administration of progesterone to women with a prior history of pre-term delivery are two improvement projects that have been shown to reduce prematurity rates in selected studies.
Incidence and severity of retinopathy of prematurity in Vietnam, a developing middle-income country.
The conundrum that we find ourselves in at this point is that there does not appear to be an effective means of altering the status of infection or inflammation in order to have a direct impact on prematurity rates.
Extreme prematurity and fibroblastic overgrowth of persistent vascular sheath behind each crystalline lens.
These extremely premature infants, who previously did not survive, are probably especially vulnerable and prone to develop complications such as retinopathy of prematurity," the study's authors said.
Infants were screened for retinopathy of prematurity beginning at five weeks after birth and were treated for the condition.
Extreme prematurity is a risk factor for permanent hearing loss (PHL) that is often delayed in onset and progressive, according to a study.
For example, it calls on the federal government to support research on prematurity and the care of preterm infants, on hospital leaders to ensure that all cesarean deliveries and labor inductions are performed in accordance with professional guidelines, and on policymakers to expand women's access to health care coverage.
Neil Marlow, professor of neonatal medicine at the University of Nottingham, emphasized that it would not be appropriate to interpret the results as indicating that extreme prematurity is associated with a formal diagnosis of autism.
Seattle Children's Hospital Research Institute announced today that it has received a US$1 million grant from the Bill & Melinda Gates Foundation to study ways to prevent global prematurity and stillbirth.
Apart from the fact that the council under Padilla's leadership accomplished no more for the public benefit than it did under the lackluster leadership of his predecessors, the oddest aspect of the affair was its prematurity.