Преждевременные роды

Преждевременные роды
Другие имена	Преждевременные роды, недоношенные, недоношенные
Интубированный недоношенный ребенок в инкубаторе
Специальность	Неонатология , Педиатрия , Акушерство
Symptoms	Birth of a baby at younger than 37 weeks' gestational age
Complications	Cerebral palsy, delays in development, hearing problems, sight problems
Causes	Often unknown
Risk factors	Diabetes, high blood pressure, Multiple gestation, obesity or underweight, a number of vaginal infections, celiac disease, tobacco smoking, psychological stress
Prevention	Progesterone
Treatment	Corticosteroids, keeping the baby warm through skin-to-skin contact, supporting breastfeeding, treating infections, supporting breathing
Frequency	~15 million a year (12% of deliveries)
Deaths	805,800

Преждевременные роды , также известные как преждевременные роды , — это рождение ребенка . менее 37 недель на сроке гестации , в отличие от доношенных родов примерно на 40 неделе Крайняя недоношенность составляет менее 28 недель, очень ранние преждевременные роды - между 28 и 32 неделями, ранние преждевременные роды - между 32 и 34 неделями, поздние преждевременные роды - между 34 и 36 неделями беременности. Эти дети также известны как недоношенные дети или в просторечии недоношенные (американский английский). или недоношенные (австралийский английский). Симптомы преждевременных родов включают сокращения матки , которые происходят чаще, чем каждые десять минут, и/или выделение жидкости из влагалища до 37 недель. Недоношенные дети подвергаются большему риску развития церебрального паралича , задержки развития , проблем со слухом и зрением . Чем раньше родится ребенок, тем выше будут эти риски.

Причина спонтанных преждевременных родов часто неизвестна. Факторы риска включают диабет , высокое кровяное давление , многоплодную беременность (беременность более чем одним ребенком), ожирение или недостаточный вес , вагинальные инфекции , загрязнения воздуха воздействие , курение табака и психологический стресс . For a healthy pregnancy, medical induction of labor or cesarean section are not recommended before 39 weeks unless required for other medical reasons. There may be certain medical reasons for early delivery such as preeclampsia.

Preterm birth may be prevented in those at risk if the hormone progesterone is taken during pregnancy. Evidence does not support the usefulness of bed rest. It is estimated that at least 75% of preterm infants would survive with appropriate treatment, and the survival rate is highest among the infants born the latest in gestation. In women who might deliver between 24 and 37 weeks, corticosteroid treatment may improve outcomes. A number of medications, including nifedipine, may delay delivery so that a mother can be moved to where more medical care is available and the corticosteroids have a greater chance to work. Once the baby is born, care includes keeping the baby warm through skin-to-skin contact or incubation, supporting breastfeeding and/or formula feeding, treating infections, and supporting breathing. Preterm babies sometimes require intubation.

Preterm birth is the most common cause of death among infants worldwide. About 15 million babies are preterm each year (5% to 18% of all deliveries). Late preterm birth accounts for 75% of all preterm births. This rate is inconsistent across countries. In the United Kingdom 7.9% of babies are born pre-term and in the United States 12.3% of all births are before 37 weeks gestation. Approximately 0.5% of births are extremely early periviable births (20–25 weeks of gestation), and these account for most of the deaths. In many countries, rates of premature births have increased between the 1990s and 2010s. Complications from preterm births resulted in 0.81 million deaths in 2015, down from 1.57 million in 1990. The chance of survival at 22 weeks is about 6%, while at 23 weeks it is 26%, 24 weeks 55% and 25 weeks about 72%. The chances of survival without any long-term difficulties are lower.

Signs and symptoms

A new mother holds her premature baby at Kapiolani Medical Center NICU in Honolulu, Hawaii.

Signs and symptoms of preterm labor include four or more uterine contractions in one hour. In contrast to false labour, true labor is accompanied by cervical dilation and effacement. Also, vaginal bleeding in the third trimester, heavy pressure in the pelvis, or abdominal or back pain could be indicators that a preterm birth is about to occur. A watery discharge from the vagina may indicate premature rupture of the membranes that surround the baby. While the rupture of the membranes may not be followed by labor, usually delivery is indicated as infection (chorioamnionitis) is a serious threat to both fetus and mother. In some cases, the cervix dilates prematurely without pain or perceived contractions, so that the mother may not have warning signs until very late in the birthing process.

Causes

The main categories of causes of preterm birth are preterm labor induction and spontaneous preterm labor.

Risk factors

The exact cause of spontaneous preterm birth is difficult to determine and it may be caused by many different factors at the same time as labor is a complex process. The research available is limited with regard to the cervix and therefore is limited in discerning what is or is not normal. Four different pathways have been identified that can result in preterm birth and have considerable evidence: precocious fetal endocrine activation, uterine overdistension (placental abruption), decidual bleeding, and intrauterine inflammation or infection.

Identifying women at high risk of giving birth early would enable the health services to provide specialized care for these women and their babies, for example a hospital with a special care baby unit such as a neonatal intensive care unit (NICU). In some instances, it may be possible to delay the birth. Risk scoring systems have been suggested as an approach to identify those at higher risk, however, there is no strong research in this area so it is unclear whether the use of risk scoring systems for identifying mothers would prolong pregnancy and reduce the numbers of preterm births or not.

Maternal factors

Risk factor	Relative risk	95% confidence interval
Fetal fibronectin	4.0	2.9–5.5
Short cervical length	2.9	2.1–3.9
Prenatal Care Absent	2.9	2.8–3.0
Chlamydia	2.2	1.0–4.8
Low socio-economic status	1.9	1.7–2.2
Large or small pregnancy weight gain	1.8	1.5–2.3
Short maternal height	1.8	1.3–2.5
Periodontitis	1.6	1.1–2.3
Celiac disease	1.4	1.2–1.6
Asymptomatic bacteriuria	1.1	0.8–1.5
High or low BMI	0.96	0.66–1.4
	odds ratio
History of spontaneous preterm birth	3.6	3.2–4.0
Bacterial vaginosis	2.2	1.5–3.1
Black ethnicity/race	2.0	1.8–2.2
Filipino ancestry	1.7	1.5–2.1
Unwanted pregnancy	1.5	1.41–1.61
Unintended pregnancy	1.31	1.09–1.58
Being single/unmarried	1.2	1.03–1.28

Percentage premature births in England and Wales 2011, by age of mother and whether single or multiple birth

Risk factors in the mother have been identified that are linked to a higher risk of a preterm birth. These include age (either very young or older), high or low body mass index (BMI), length of time between pregnancies, endometriosis, previous spontaneous (i.e., miscarriage) or surgical abortions, unintended pregnancies, untreated or undiagnosed celiac disease, fertility difficulties, heat exposure, and genetic variables.

Studies on type of work and physical activity have given conflicting results, but it is opined that stressful conditions, hard labor, and long hours are probably linked to preterm birth. Obesity does not directly lead to preterm birth; however, it is associated with diabetes and hypertension which are risk factors by themselves. To some degree those individuals may have underlying conditions (i.e., uterine malformation, hypertension, diabetes) that persist. Couples who have tried more than one year versus those who have tried less than one year before achieving a spontaneous conception have an adjusted odds ratio of 1.35 (95% confidence interval 1.22–1.50) of preterm birth. Pregnancies after IVF confers a greater risk of preterm birth than spontaneous conceptions after more than one year of trying, with an adjusted odds ratio of 1.55 (95% CI 1.30–1.85).

Certain ethnicities may have a higher risk as well. For example, in the U.S. and the UK, Black women have preterm birth rates of 15–18%, more than double than that of the white population. Many Black women have higher preterm birth rates due to multiple factors but the most common is high amounts of chronic stress, which can eventually lead to premature birth. Adult chronic disease is not always the case with premature birth in Black women, which makes the main factor of premature birth challenging to identify. Filipinos are also at high risk of premature birth, and it is believed that nearly 11–15% of Filipinos born in the U.S. (compared to other Asians at 7.6% and whites at 7.8%) are premature. Filipinos being a big risk factor is evidenced with the Philippines being the eighth-highest ranking in the world for preterm births, the only non-African country in the top 10. This discrepancy is not seen in comparison to other Asian groups or Hispanic immigrants and remains unexplained. Genetic make-up is a factor in the causality of preterm birth. Genetics has been a big factor into why Filipinos have a high risk of premature birth as the Filipinos have a large prevalence of mutations that help them be predisposed to premature births. An intra- and transgenerational increase in the risk of preterm delivery has been demonstrated. No single gene has been identified.

Marital status has long been associated with risks for preterm birth. A 2005 study of 25,373 pregnancies in Finland revealed that unmarried mothers had more preterm deliveries than married mothers (P=0.001). Pregnancy outside of marriage was associated overall with a 20% increase in total adverse outcomes, even at a time when Finland provided free maternity care. A study in Quebec of 720,586 births from 1990 to 1997 revealed less risk of preterm birth for infants with legally married mothers compared with those with common-law wed or unwed parents. A study conducted in Malaysia in 2015 showed a similar trend, with marital status being significantly associated with preterm birth. However, the result of a study conducted in the US showed that between 1989 to 2006, marriage became less protective of preterm births which was attributed to the changing social norms and behaviors surrounding marriage.

Factors during pregnancy

Medications during pregnancy, living conditions, air pollution, smoking, illicit drugs or alcohol, infection, or physical trauma may also cause a preterm birth.

Air pollution: Living in an area with a high concentration of air pollution is a major risk factor for preterm labor, including living near major roadways or highways where vehicle emissions are high from traffic congestion or are a route for diesel trucks that tend to emit more pollution.

The use of fertility medication that stimulates the ovary to release multiple eggs and of IVF with embryo transfer of multiple embryos has been implicated as a risk factor for preterm birth. Often labor has to be induced for medical reasons; such conditions include high blood pressure, pre-eclampsia, maternal diabetes, asthma, thyroid disease, and heart disease.

Certain medical conditions in the pregnant mother may also increase the risk of preterm birth. Some women have anatomical problems that prevent the baby from being carried to term. These include a weak or short cervix (the strongest predictor of premature birth). Women with vaginal bleeding during pregnancy are at higher risk for preterm birth. While bleeding in the third trimester may be a sign of placenta previa or placental abruption—conditions that occur frequently preterm—even earlier bleeding that is not caused by these conditions is linked to a higher preterm birth rate. Women with abnormal amounts of amniotic fluid, whether too much (polyhydramnios) or too little (oligohydramnios), are also at risk. Anxiety and depression have been linked as risk factors for preterm birth.

The use of tobacco, cocaine, and excessive alcohol during pregnancy increases the chance of preterm delivery. Tobacco is the most commonly used drug during pregnancy and contributes significantly to low birth weight delivery. Babies with birth defects are at higher risk of being born preterm.

Passive smoking and/or smoking before the pregnancy influences the probability of a preterm birth. The World Health Organization published an international study in March 2014.

Presence of anti-thyroid antibodies is associated with an increased risk preterm birth with an odds ratio of 1.9 and 95% confidence interval of 1.1–3.5.

Intimate violence against the mother is another risk factor for preterm birth.

Physical trauma may case a preterm birth. The Nigerian cultural method of abdominal massage has been shown to result in 19% preterm birth among women in Nigeria, plus many other adverse outcomes for the mother and baby. This ought not be confused with massage therapy conducted by a fully trained and certified/licensed massage therapist or by significant others trained to provide massage during pregnancy, which—in a study involving pregnant females with prenatal depression—has been shown to have numerous positive results during pregnancy, including the reduction of preterm birth, less depression, lower cortisol, and reduced anxiety. In healthy women, however, no effects have been demonstrated in a controlled study.

Infection

The frequency of infection in preterm birth is inversely related to the gestational age. Mycoplasma genitalium infection is associated with increased risk of preterm birth, and spontaneous abortion.

Infectious microorganisms can be ascending, hematogenous, iatrogenic by a procedure, or retrograde through the fallopian tubes. From the deciduae they may reach the space between the amnion and chorion, the amniotic fluid, and the fetus. A chorioamnionitis also may lead to sepsis of the mother. Fetal infection is linked to preterm birth and to significant long-term disability including cerebral palsy.

It has been reported that asymptomatic colonization of the decidua occurs in up to 70% of women at term using a DNA probe suggesting that the presence of micro-organism alone may be insufficient to initiate the infectious response.

As the condition is more prevalent in black women in the U.S. and the UK, it has been suggested to be an explanation for the higher rate of preterm birth in these populations. It is opined that bacterial vaginosis before or during pregnancy may affect the decidual inflammatory response that leads to preterm birth. The condition known as aerobic vaginitis can be a serious risk factor for preterm labor; several previous studies failed to acknowledge the difference between aerobic vaginitis and bacterial vaginosis, which may explain some of the contradiction in the results.

Untreated yeast infections are associated with preterm birth.

A review into prophylactic antibiotics (given to prevent infection) in the second and third trimester of pregnancy (13–42 weeks of pregnancy) found a reduction in the number of preterm births in women with bacterial vaginosis. These antibiotics also reduced the number of waters breaking before labor in full-term pregnancies, reduced the risk of infection of the lining of the womb after delivery (endometritis), and rates of gonococcal infection. However, the women without bacterial vaginosis did not have any reduction in preterm births or pre-labor preterm waters breaking. Much of the research included in this review lost participants during follow-up so did not report the long-term effects of the antibiotics on mothers or babies. More research in this area is needed to find the full effects of giving antibiotics throughout the second and third trimesters of pregnancy.

A number of maternal bacterial infections are associated with preterm birth including pyelonephritis, asymptomatic bacteriuria, pneumonia, and appendicitis. A review into giving antibiotics in pregnancy for asymptomatic bacteriuria (urine infection with no symptoms) found the research was of very low quality but that it did suggest that taking antibiotics reduced the numbers of preterm births and babies with low birth weight. Another review found that one dose of antibiotics did not seem as effective as a course of antibiotics but fewer women reported side effects from one dose. This review recommended that more research is needed to discover the best way of treating asymptomatic bacteriuria.

A different review found that preterm births happened less for pregnant women who had routine testing for low genital tract infections than for women who only had testing when they showed symptoms of low genital tract infections. The women being routinely tested also gave birth to fewer babies with a low birth weight. Even though these results look promising, the review was only based on one study so more research is needed into routine screening for low genital tract infections.

Also periodontal disease has been shown repeatedly to be linked to preterm birth. In contrast, viral infections, unless accompanied by a significant febrile response, are considered not to be a major factor in relation to preterm birth.

Genetics

There is believed to be a maternal genetic component in preterm birth. Estimated heritability of timing-of-birth in women was 34%. However, the occurrence of preterm birth in families does not follow a clear inheritance pattern, thus supporting the idea that preterm birth is a non-Mendelian trait with a polygenic nature.

Prenatal care

The absence of prenatal care has been associated with higher rates of preterm births. Analysis of 15,627,407 live births in the United States in 1995–1998 concluded that the absence of prenatal care carried a 2.9 (95%CI 2.8, 3.0) times higher risk of preterm births. This same study found statistically significant relative risks of maternal anemia, intrapartum fever, unknown bleeding, renal disease, placental previa, hydramnios, placenta abruption, and pregnancy-induced hypertension with the absence of prenatal care. All these prenatal risks were controlled for other high-risk conditions, maternal age, gravidity, marital status, and maternal education. The absence of prenatal care prior to and during the pregnancy is primarily a function of socioeconomic factors (low family income and education), access to medical consultations (large distance from the place of residence to the healthcare unit and transportation costs), quality of healthcare, and social support. Efforts to decrease rates of preterm birth should aim to increase the deficits posed by the aforementioned barriers and to increase access to prenatal care.

Diagnosis

Placental alpha microglobulin-1

Placental alpha microglobulin-1 (PAMG-1) has been the subject of several investigations evaluating its ability to predict imminent spontaneous preterm birth in women with signs, symptoms, or complaints suggestive of preterm labor. In one investigation comparing this test to fetal fibronectin testing and cervical length measurement via transvaginal ultrasound, the test for PAMG-1 (commercially known as the PartoSure test) has been reported to be the single best predictor of imminent spontaneous delivery within 7 days of a patient presenting with signs, symptoms, or complaints of preterm labor. Specifically, the PPV, or positive predictive value, of the tests were 76%, 29%, and 30% for PAMG-1, fFN and CL, respectively (P < 0.01).

Fetal fibronectin

Fetal fibronectin (fFN) has become an important biomarker—the presence of this glycoprotein in the cervical or vaginal secretions indicates that the border between the chorion and decidua has been disrupted. A positive test indicates an increased risk of preterm birth, and a negative test has a high predictive value. It has been shown that only 1% of women in questionable cases of preterm labor delivered within the next week when the test was negative.

Ultrasound

Further information: Cervical incompetence

Obstetric ultrasound has become useful in the assessment of the cervix in women at risk for premature delivery. A short cervix preterm is undesirable: A cervical length of less than 25 mm (0.98 in) at or before 24 weeks of gestational age is the most common definition of cervical incompetence.

Emerging Technologies

Technologies under research and development to facilitate earlier diagnosis of preterm births include sanitary pads that identify biomarkers such as fFN and PAMG-1 and others, when placed into the vagina. These devices then calculate a risk of preterm birth and send the findings to a smartphone. The notion that risk scoring systems are accurate in predicting preterm birth has been debated in multiple literature reviews.

Classification

Stages in prenatal development, with weeks and months numbered from last menstruation

In humans, the usual definition of preterm birth is birth before a gestational age of 37 complete weeks. In the normal human fetus, several organ systems mature between 34 and 37 weeks, and the fetus reaches adequate maturity by the end of this period. One of the main organs greatly affected by premature birth is the lungs. The lungs are one of the last organs to mature in the womb; because of this, many premature babies spend the first days and weeks of their lives on ventilators. Therefore, a significant overlap exists between preterm birth and prematurity. Generally, preterm babies are premature and term babies are mature. Preterm babies born near 37 weeks often have no problems relating to prematurity if their lungs have developed adequate surfactant, which allows the lungs to remain expanded between breaths. Sequelae of prematurity can be reduced to a small extent by using drugs to accelerate maturation of the fetus, and to a greater extent by preventing preterm birth.

Prevention

Historically efforts have been primarily aimed to improve survival and health of preterm infants (tertiary intervention). Such efforts, however, have not reduced the incidence of preterm birth. Increasingly primary interventions that are directed at all women, and secondary intervention that reduce existing risks are looked upon as measures that need to be developed and implemented to prevent the health problems of premature infants and children. Smoking bans are effective in decreasing preterm births. Different strategies are used in the administration of prenatal care, and future studies need to determine if the focus can be on screening for high-risk women, or widened support for low-risk women, or to what degree these approaches can be merged.

Before pregnancy

Adoption of specific professional policies can immediately reduce risk of preterm birth as the experience in assisted reproduction has shown when the number of embryos during embryo transfer was limited.Many countries have established specific programs to protect pregnant women from hazardous or night-shift work and to provide them with time for prenatal visits and paid pregnancy-leave. The EUROPOP study showed that preterm birth is not related to type of employment, but to prolonged work (over 42 hours per week) or prolonged standing (over 6 hours per day). Also, night work has been linked to preterm birth. Health policies that take these findings into account can be expected to reduce the rate of preterm birth. Preconceptional intake of folic acid is recommended to reduce birth defects. There is also some evidence that folic acid supplement preconceptionally (before becoming pregnant) may reduce premature birth. Reducing smoking is expected to benefit pregnant women and their offspring.

During pregnancy

Self-care methods to reduce the risk of preterm birth include proper nutrition, avoiding stress, seeking appropriate medical care, avoiding infections, and the control of preterm birth risk factors (e.g. working long hours while standing on feet, carbon monoxide exposure, domestic abuse, and other factors). Reducing physical activity during pregnancy has not been shown to reduce the risk of a preterm birth. Healthy eating can be instituted at any stage of the pregnancy including nutritional adjustments and consuming suggested vitamin supplements. Calcium supplementation in women who have low dietary calcium may reduce the number of negative outcomes including preterm birth, pre-eclampsia, and maternal death. The World Health Organization (WHO) suggests 1.5–2 g of calcium supplements daily, for pregnant women who have low levels of calcium in their diet. Supplemental intake of C and E vitamins have not been found to reduce preterm birth rates.

While periodontal infection has been linked with preterm birth, randomized trials have not shown that periodontal care during pregnancy reduces preterm birth rates. Smoking cessation has also been shown to reduce the risk. The use of personal at home uterine monitoring devices to detect contractions and possible preterm births in women at higher risk of having a preterm baby have been suggested. These home monitors may not reduce the number of preterm births, however, using these devices may increase the number of unplanned antenatal visits and may reduce the number of babies admitted to special care when compared with women receiving normal antenatal care. Support from medical professionals, friends, and family during pregnancy may be beneficial at reducing caesarean birth and may reduce prenatal hospital admissions, however, these social supports alone may not prevent preterm birth.

Screening during pregnancy

Screening for asymptomatic bacteriuria followed by appropriate treatment reduces pyelonephritis and reduces the risk of preterm birth. Extensive studies have been carried out to determine if other forms of screening in low-risk women followed by appropriate intervention are beneficial, including screening for and treatment of Ureaplasma urealyticum, group B streptococcus, Trichomonas vaginalis, and bacterial vaginosis did not reduce the rate of preterm birth. Routine ultrasound examination of the length of the cervix may identify women at risk of preterm labour and tentative evidence suggests ultrasound measurement of the length of the cervix in those with preterm labor can help adjust management and results in the extension of pregnancy by about four days. Screening for the presence of fibronectin in vaginal secretions is not recommended at this time in women at low risk of preterm birth.

Reducing existing risks

Women are identified to be at increased risk for preterm birth on the basis of their past obstetrical history or the presence of known risk factors. Preconception intervention can be helpful in selected patients in a number of ways. Patients with certain uterine anomalies may have a surgical correction (i.e. removal of a uterine septum), and those with certain medical problems can be helped by optimizing medical therapies prior to conception, be it for asthma, diabetes, hypertension, and others.

Multiple pregnancies

In multiple pregnancies, which often result from use of assisted reproductive technology, there is a high risk of preterm birth. Selective reduction is used to reduce the number of fetuses to two or three.

Reducing indicated preterm birth

A number of agents have been studied for the secondary prevention of indicated preterm birth. Trials using low-dose aspirin, fish oil, vitamin C and E, and calcium to reduce preeclampsia demonstrated some reduction in preterm birth only when low-dose aspirin was used. Even if agents such as calcium or antioxidants were able to reduce preeclampsia, a resulting decrease in preterm birth was not observed.

Reducing spontaneous preterm birth

Reduction in activity by the mother—pelvic rest, limited work, bed rest—may be recommended although there is no evidence it is useful with some concerns it is harmful. Increasing medical care by more frequent visits and more education has not been shown to reduce preterm birth rates. Use of nutritional supplements such as omega-3 polyunsaturated fatty acids is based on the observation that populations who have a high intake of such agents are at low risk for preterm birth, presumably as these agents inhibit production of proinflammatory cytokines. A randomized trial showed a significant decline in preterm birth rates, and further studies are in the making.

Antibiotics

While antibiotics can get rid of bacterial vaginosis in pregnancy, this does not appear to change the risk of preterm birth. It has been suggested that chronic chorioamnionitis is not sufficiently treated by antibiotics alone (and therefore they cannot ameliorate the need for preterm delivery in this condition).

Progestogens

Progestogens—often given in the form of vaginal progesterone or hydroxyprogesterone caproate—relax the uterine musculature, maintain cervical length, and possess anti-inflammatory properties; all of which invoke physiological and anatomical changes considered to be beneficial in reducing preterm birth. Two meta-analyses demonstrated a reduction in the risk of preterm birth in women with recurrent preterm birth by 40–55%.

Progestogen supplementation also reduces the frequency of preterm birth in pregnancies where there is a short cervix. A short cervix is one that is less than 25mm, as detected during a transvaginal cervical length assessment in the midtrimester. However, progestogens are not effective in all populations, as a study involving twin gestations failed to see any benefit. Despite extensive research related to progestogen effectiveness, uncertainties remain concerning types of progesterone and routes of administration.

Cervical cerclage

In preparation for childbirth, the woman's cervix shortens. Preterm cervical shortening is linked to preterm birth and can be detected by ultrasonography. Cervical cerclage is a surgical intervention that places a suture around the cervix to prevent its shortening and widening. Numerous studies have been performed to assess the value of cervical cerclage and the procedure appears helpful primarily for women with a short cervix and a history of preterm birth. Instead of a prophylactic cerclage, women at risk can be monitored during pregnancy by sonography, and when shortening of the cervix is observed, the cerclage can be performed.

Treatment

Preterm birth at 32 weeks 4 days, with a weight of 2,000 g attached to medical equipment

Tertiary interventions are aimed at women who are about to go into preterm labor, or rupture the membranes or bleed preterm. The use of the fibronectin test and ultrasonography improves the diagnostic accuracy and reduces false-positive diagnosis. While treatments to arrest early labor where there is progressive cervical dilatation and effacement will not be effective to gain sufficient time to allow the fetus to grow and mature further, it may defer delivery sufficiently to allow the mother to be brought to a specialized center that is equipped and staffed to handle preterm deliveries. In a hospital setting women are hydrated via intravenous infusion (as dehydration can lead to premature uterine contractions).

If a baby has cardiac arrest at birth and is less than 22 to 24 weeks gestational age, attempts at resuscitation are not generally indicated.

Steroids

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 with threatened premature delivery prior to 34 weeks are often administered at least one course of glucocorticoids, an antenatal steroid that crosses the placental barrier and stimulates the production of surfactant in the lungs of the baby. Steroid use up to 37 weeks is also recommended by the American Congress of Obstetricians and Gynecologists. Typical glucocorticoids that would be administered in this context are betamethasone or dexamethasone, often when the pregnancy has reached viability at 23 weeks.

In cases where premature birth is imminent, a second "rescue" course of steroids may be administered 12 to 24 hours before the anticipated birth. There are still some concerns about the efficacy and side effects of a second course of steroids, but the consequences of RDS are so severe that a second course is often viewed as worth the risk. A 2015 Cochrane review (updated in 2022) supports the use of repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven days or more after an initial course.

A Cochrane review from 2020 recommends the use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. Treatment with antenatal corticosteroids reduces the risk of perinatal death, neonatal death and respiratory distress syndrome and probably reduces the risk of IVH.

Concerns about adverse effects of prenatal corticosteroids include increased risk for maternal infection, difficulty with diabetic control, and possible long-term effects on neurodevelopmental outcomes for the infants. There is ongoing discussion about when steroids should be given (i.e. only antenatally or postnatally too) and for how long (i.e. single course or repeated administration). Despite these unknowns, there is a consensus that the benefits of a single course of prenatal glucocorticosteroids vastly outweigh the potential risks.

Antibiotics

The routine administration of antibiotics to all women with threatened preterm labor reduces the risk of the baby being infected with group B streptococcus and has been shown to reduce related mortality rates.

When membranes rupture prematurely, obstetrical management looks for development of labor and signs of infection. Prophylactic antibiotic administration has been shown to prolong pregnancy and reduced neonatal morbidity with rupture of membranes at less than 34 weeks. Because of concern about necrotizing enterocolitis, amoxicillin or erythromycin has been recommended but not amoxicillin + clavulanic acid (co-amoxiclav).

Tocolysis

A number of medications may be useful to delay delivery including: nonsteroidal anti-inflammatory drugs, calcium channel blockers, beta mimetics, and atosiban. Tocolysis rarely delays delivery beyond 24–48 hours. This delay, however, may be sufficient to allow the pregnant woman to be transferred to a center specialized for management of preterm deliveries and give administered corticosteroids to reduce neonatal organ immaturity. Meta-analyses indicate that calcium-channel blockers and an oxytocin antagonist can delay delivery by 2–7 days, and β2-agonist drugs delay by 48 hours but carry more side effects. Magnesium sulfate does not appear to be useful to prevent preterm birth. Its use before delivery, however, does appear to decrease the risk of cerebral palsy.

Mode of delivery

The routine use of caesarean section for early delivery of infants expected to have very low birth weight is controversial, and a decision concerning the route and time of delivery probably needs to be made on a case-by-case basis.

Neonatal care

Incubator for preterm baby

In developed countries premature infants are usually cared for in a neonatal intensive care unit (NICU). The physicians who specialize in the care of very sick or premature babies are known as neonatologists. In the NICU, premature babies are kept under radiant warmers or in incubators (also called isolettes), which are bassinets enclosed in plastic with climate control equipment designed to keep them warm and limit their exposure to germs. Modern neonatal intensive care involves sophisticated measurement of temperature, respiration, cardiac function, oxygenation, and brain activity. After delivery, plastic wraps or warm mattresses are useful to keep the infant warm on their way to the NICU. Treatments may include fluids and nutrition through intravenous catheters, oxygen supplementation, mechanical ventilation support, and medications. In developing countries where advanced equipment and even electricity may not be available or reliable, simple measures such as kangaroo care (skin to skin warming), encouraging breastfeeding, and basic infection control measures can significantly reduce preterm morbidity and mortality. Kangaroo mother care (KMC) can decrease the risk of neonatal sepsis, hypothermia, hypoglycemia and increase exclusive breastfeeding. Bili lights may also be used to treat newborn jaundice (hyperbilirubinemia).

Water can be carefully provided to prevent dehydration but not so much to increase risks of side effects.

Breathing support

In terms of respiratory support, there may be little or no difference in the risk of death or chronic lung disease between high flow nasal cannulae (HFNC) and continuous positive airway pressure (CPAP) or nasal intermittent positive pressure ventilation (NPPV). For extremely preterm babies (born before 28 weeks' gestation), targeting a higher versus a lower oxygen saturation range makes little or no difference overall to the risk of death or major disability. Babies born before 32 weeks have been shown to have a lower risk of death from bronchopulmonary dysplasia if they have CPAP immediately after being born, compared to receiving either supportive care or assisted ventilation.

There is insufficient evidence for or against placing preterm stable twins in the same cot or incubator (co-bedding).

Nutrition

Meeting the appropriate nutritional needs of preterm infants is important for long-term health. Optimal care may require a balance of meeting nutritional needs and preventing complications related to feeding. The ideal growth rate is not known, however, preterm infants usually require a higher energy intake compared to babies who are born at term. The recommended amount of milk is often prescribed based on approximated nutritional requirements of a similar aged fetus who is not compromised. An immature gastrointestinal tract (GI tract), medical conditions (or co-morbidities), risk of aspirating milk, and necrotizing enterocolitis may lead to difficulties in meeting this high nutritional demand and many preterm infants have nutritional deficits that may result in growth restrictions. In addition, very small preterm infants cannot coordinate sucking, swallowing, and breathing. Tolerating a full enteral feeding (the prescribed volume of milk or formula) is a priority in neonatal care as this reduces the risks associated with venous catheters including infection, and may reduce the length of time the infant requires specialized care in the hospital. Different strategies can be used to optimize feeding for preterm infants. The type of milk/formula and fortifiers, route of administration (by mouth, tube feeding, venous catheter), timing of feeding, quantity of milk, continuous or intermittent feeding, and managing gastric residuals are all considered by the neonatal care team when optimizing care. The evidence in the form of high quality randomized trials is generally fairly weak in this area, and for this reason different neonatal intensive care units may have different practices and this results in a fairly large variation in practice. The care of preterm infants also varies in different countries and depends on resources that are available.

Human breast milk and formula

The American Academy of Pediatrics recommended feeding preterm infants human milk, finding "significant short- and long-term beneficial effects," including lower rates of necrotizing enterocolitis (NEC). In the absence of evidence from randomised controlled trials about the effects of feeding preterm infants with formula compared with mother's own breast milk, data collected from other types of studies suggest that mother's own breast milk is likely to have advantages over formula in terms of the baby's growth and development. A recent (2019) large review of evidence suggests that feeding preterm infants with formula rather than donor breast milk is associated with faster rates of growth, but with a near‐doubling of the risk of developing NEC.

Fortified human breast milk and preterm/term formula

Breast milk or formula alone may not be sufficient to meet the nutritional needs of some preterm infants. Fortification of breast milk or formula by adding extra nutrients is an approach often taken for feeding preterm infants, with the goal of meeting the high nutritional demand. High quality randomized controlled trials are needed in this field to determine the effectiveness of fortification. It is unclear if fortification of breast milk improves outcomes in preterm babies, though it may speed growth. Supplementing human milk with extra protein may increase short-term growth but the longer-term effects on body composition, growth and brain development are uncertain. Higher protein formula (between 3 and 4 grams of protein per kilo of body weight) may be more effective than low protein formula (less than 3 grams per kilo per day) for weight gain in formula-fed low-birth-weight infants. There is insufficient evidence about the effect on preterm babies' growth of supplementing human milk with carbohydrate, fat, and branched-chain amino acids. Conversely, there is some indication that preterm babies who cannot breastfeed may do better if they are fed only with diluted formula compared to full strength formula but the clinical trial evidence remains uncertain.

Individualizing the nutrients and quantities used to fortify enteral milk feeds in infants born with very low birth weight may lead to better short-term weight gain and growth but the evidence is uncertain for longer term outcomes and for the risk of serious illness and death. This includes targeted fortification (adjusting the level of nutrients in response to the results of a test on the breast milk) and adjustable fortification (adding nutrients based on testing the infant).

Multi-nutrient fortifier used to fortify human milk and formula has traditionally been derived from bovine milk. Fortifier derived from humans is available, however, the evidence from clinical trials is uncertain and it is not clear if there are any differences between human-derived fortifier and bovine-derived fortifier in terms of neonatal weight gain, feeding intolerance, infections, or the risk of death.

Timing of feeds

For very preterm infants, most neonatal care centres start milk feeds gradually, rather than starting with a full enteral feeding right away, however, is not clear if starting full enteral feeding early effects the risk of necrotising enterocolitis. In these cases, the preterm infant would be receiving the majority of their nutrition and fluids intravenously. The milk volume is usually gradually increased over the following weeks. Research into the ideal timing of enteral feeding and whether delaying enteral feeding or gradually introducing enteral feeds is beneficial at improving growth for preterm infants or low birth weight infants is needed. In addition, the ideal timing of enteral feeds to prevent side effects such as necrotising enterocolitis or mortality in preterm infants who require a packed red blood cell transfusion is not clear. Potential disadvantages of a more gradual approach to feeding preterm infants associated with less milk in the gut and include slower GI tract secretion of hormones and gut motility and slower microbial colonization of the gut.

Regarding the timing of starting fortified milk, preterm infants are often started on fortified milk/formula once they are fed 100 mL/kg of their body weight. Other some neonatal specialists feel that starting to feed a preterm infant fortified milk earlier is beneficial to improve intake of nutrients. The risks of feeding intolerance and necrotising enterocolitis related to early versus later fortification of human milk are not clear. Once the infant is able to go home from the hospital there is limited evidence to support prescribing a preterm (fortified) formula.

Intermittent feeding versus continuous feeding

For infants who weigh less than 1500 grams, tube feeding is usually necessary. Most often, neonatal specialists feed preterm babies intermittently with a prescribed amount of milk over a short period of time. For example, a feed could last 10–20 minutes and be given every 3 hours. This intermittent approach is meant to mimic conditions of normal bodily functions involved with feeding and allow for a cyclic pattern in the release of gastrointestinal tract hormones to promote development of the gastrointestinal system. In certain cases, continuous nasogastric feeding is sometimes preferred. There is low to very low certainty evidence to suggest that low birth weight babies who receive continuous nasogastic feeding may reach the benchmark of tolerating full enteral feeding later than babies fed intermittently and it is not clear if continuous feeding has any effect on weight gain or the number of interruptions in feedings. Continuous feeding may have little to no effect on length of body growth or head circumference and the effects of continuous feeding on the risk of developing necrotising enterocolitis is not clear.

Since preterm infants with gastro-oesophageal reflux disease do not have a fully developed antireflux mechanism, deciding on the most effective approach for nutrition is important. It is not clear if continuous bolus intragastric tube feeding is more effective compared to intermittent bolus intragastric tube feeding for feeding preterm infants with gastroesophageal reflux disease.

For infants who would benefit from intermittent bolus feeding, some infants may be fed using the "push feed" method using a syringe to gently push the milk or formula into the stomach of the infant. Others may be fed using a gravity feeding system where the syringe is attached directly to a tube and the milk or formula drips into the infant's stomach. It is not clear from medical studies which approach to intermittent bolus feeding is more effective or reduces adverse effects such as apnea, bradycardia, or oxygen desaturation episodes.

High volume feeds

High-volume (more than 180 mL per kilogram per day) enteral feeds of fortified or non-fortified human breast milk or formula may improve weight gain while the pre-term infant is hospitalized, however, there is insufficient evidence to determine if this approach improves growth of the neonate and other clinical outcomes including length of hospital stay. The risks or adverse effects associated with high-volume enteral feeding of preterm infants including aspiration pneumonia, reflux, apnea, and sudden oxygen desaturation episodes have not been reported in the trials considered in a 2021 systematic review.

Parenteral (intraveneous) nutrition

For preterm infants who are born after 34 weeks of gestation ("late preterm infants") who are critically ill and cannot tolerate milk, there is some weak evidence that the infant may benefit from including amino acids and fats in the intravenous nutrition at a later time point (72 hours or longer from hospital admission) versus early (less than 72 hours from admission to hospital), however further research is required to understand the ideal timing of starting intravenous nutrition.

Gastric residuals

For preterm infants in neonatal intensive care on gavage feeds, monitoring the volume and colour of gastric residuals, the milk and gastrointestinal secretions that remain in the stomach after a set amount of time, is common standard of care practice. Gastric residual often contains gastric acid, hormones, enzymes, and other substances that may help improve digestion and mobility of the gastrointestinal tract. Analysis of gastric residuals may help guide timing of feeds. Increased gastric residual may indicate feeding intolerance or it may be an early sign of necrotizing enterocolitis. Increased gastric residual may be caused by an underdeveloped gastrointestinal system that leads to slower gastric emptying or movement of the milk in the intestinal tract, reduced hormone or enzyme secretions from the gastrointestinal tract, duodenogastric reflux, formula, medications, and/or illness. The clinical decision to discard the gastric residuals (versus re-feeding) is often individualized based on the quantity and quality of the residual. Some experts also suggest replacing the fresh milk or curded milk and bile-stained aspirates, but not replacing haemorrhagic residual. Evidence to support or refute the practice of re-feeding preterm infants with gastric residuals is lacking.

Hyponatraemia and hypernatraemia

Imbalances of sodium (hyponatraemia and hypernatraemia) are common in babies born preterm. Hypernatraemia (sodium levels in the serum of more than 145-150 mmol/L) is common early on in preterm babies and the risk of hyponatraemia (sodium levels of less than 135 nmol/L) increases after about a week of birth if left untreated and prevention approaches are not used. Preventing complications associated with sodium imbalances is part of standard of care for preterm infants and includes careful monitoring of water and sodium given to the infant. Оптимальная доза натрия, вводимая сразу после рождения (в первый день), не ясна, и необходимы дальнейшие исследования, чтобы понять подход к управлению идеями.

Оценка слуха

Объединенный комитет по слуху младенцев (JCIH) утверждает, что недоношенным новорожденным, находящимся в отделении интенсивной терапии новорожденных (ОИТН) в течение длительного времени, необходимо пройти диагностическое аудиологическое обследование перед выпиской из больницы. Что ж, младенцы следуют контрольному графику в 1-2-3 месяца, когда их обследуют, диагностируют и получают лечение по поводу потери слуха. Однако для глубоко недоношенных детей пройти проверку слуха в возрасте одного месяца может быть невозможно из-за нескольких факторов. Как только ребенок стабилизируется, необходимо провести аудиологическое обследование. Недоношенным детям, находящимся в отделении интенсивной терапии, рекомендуется проводить тестирование слуховой реакции ствола мозга (ABR). Если ребенок не проходит проверку, его следует направить на аудиологическое обследование к аудиологу. Если ребенок принимает аминогликозиды, такие как гентамицин, менее пяти дней, за ним следует наблюдать и наблюдать в течение 6–7 месяцев после выписки из больницы, чтобы убедиться в отсутствии поздней потери слуха из-за приема лекарства.

Результаты и прогноз

Выживаемость недоношенных детей

Основная статья: Результаты для здоровья недоношенных взрослых

Преждевременные роды могут привести к ряду проблем, включая смертность, а также физические и умственные задержки.

Смертность и заболеваемость

В США, где число неонатальных инфекций и других причин неонатальной смертности заметно сократилось, недоношенность является ведущей причиной неонатальной смертности (25%). Недоношенные дети также подвергаются большему риску возникновения последующих серьезных хронических проблем со здоровьем, как описано ниже.

Самый ранний срок беременности , при котором вероятность выживания ребенка составляет не менее 50%, называется пределом жизнеспособности . Поскольку за последние 40 лет уход в отделениях интенсивной терапии улучшился, предел жизнеспособности снизился примерно до 24 недель. Большинство умирающих новорожденных и 40% умирающих детей старшего возраста родились на сроке от 20 до 25,9 недель (гестационный возраст) во втором триместре .

Поскольку риск повреждения головного мозга и задержки развития на этом пороге значителен, даже если ребенок выживет, существуют этические разногласия по поводу агрессивности ухода, оказываемого таким детям. Предел жизнеспособности также стал фактором в дебатах об абортах .

Специфические риски для недоношенных новорожденных

У недоношенных детей физические признаки недоношенности обычно обратно пропорциональны гестационному возрасту. В результате они подвергаются риску возникновения многочисленных медицинских проблем, затрагивающих различные системы органов.

• Неврологические проблемы могут включать апноэ недоношенных , гипоксически-ишемическую энцефалопатию (ГИЭ), ретинопатию недоношенных (РН), отставание в развитии , преходящая гипераммониемия , церебральный паралич и внутрижелудочковое кровоизлияние , причем последнее поражает 25% детей, рожденных недоношенными, обычно до 32 недель беременности. Легкие кровоизлияния в мозг обычно не оставляют или не оставляют серьезных осложнений, но тяжелые кровотечения часто приводят к повреждению головного мозга или даже смерти. Проблемы развития нервной системы связаны с недостатком гормонов щитовидной железы у матери , в то время как ее собственная щитовидная железа не способна удовлетворить послеродовые потребности.
• Сердечно-сосудистые осложнения могут возникнуть из-за невозможности закрытия артериального протока после рождения: открытый артериальный проток (ОАП).
• Распространены респираторные проблемы, в частности респираторный дистресс-синдром (РДС или ИРДС) (ранее называвшийся болезнью гиалиновых мембран). Другой проблемой может быть хроническое заболевание легких (ранее называемое бронхолегочной дисплазией или ПРЛ).
• Желудочно-кишечные и метаболические проблемы могут возникнуть в результате неонатальной гипогликемии , трудностей с кормлением, рахита недоношенных, гипокальциемии , паховой грыжи и некротизирующего энтероколита (НЭК).
• Гематологические осложнения включают анемию недоношенных , тромбоцитопению и гипербилирубинемию (желтуху), которые могут привести к ядерной желтухе .
• Инфекции, включая сепсис , пневмонию и инфекции мочевыводящих путей. ^[1]

Выживание

Шанс на выживание на 22 неделе составляет около 6%, на 23 неделе — 26%, на 24 неделе — 55% и на 25 неделе — около 72% по состоянию на 2016 год. По состоянию на 2019 год при интенсивном лечении до 30% тех, кто выживает при рождении на сроке 22 недели, живут дольше. Шансов выжить без долгосрочных трудностей меньше. Из тех, кто выживает после рождения на сроке 22 недели, 33% имеют тяжелую инвалидность. В развитых странах общая выживаемость составляет около 90%, тогда как в странах с низкими доходами выживаемость составляет около 10%.

Некоторые дети хорошо адаптируются в детстве и подростковом возрасте. хотя инвалидность, скорее всего, ближе к пределам жизнеспособности. В крупном исследовании наблюдали за детьми, родившимися в период от 22 до 25 недель до возраста 6 лет. Из этих детей 46% имели нарушения от умеренной до тяжелой степени, такие как церебральный паралич, потеря зрения или слуха и неспособность к обучению, 34% имели легкие нарушения, а 20% не имели инвалидности; У 12% был инвалидизирующий церебральный паралич. До 15% недоношенных детей имеют значительную потерю слуха.

По мере улучшения выживаемости фокус вмешательств, направленных на новорожденного, сместился в сторону уменьшения долговременной инвалидности, особенно связанной с травмой головного мозга. Некоторые осложнения, связанные с недоношенностью, могут проявиться лишь спустя годы после рождения. Долгосрочное исследование показало, что риски медицинских и социальных нарушений распространяются и на взрослый возраст и увеличиваются с уменьшением гестационного возраста при рождении и включают церебральный паралич , умственную отсталость , расстройства психологического развития, поведения и эмоций, нарушения зрения и слуха, и эпилепсия . Стандартные тесты интеллекта показали, что 41% детей, родившихся в сроке от 22 до 25 недель, имели умеренные или тяжелые нарушения обучаемости по сравнению с результатами тестов группы аналогичных одноклассников, родившихся в срок. Также показано, что более высокий уровень образования с меньшей вероятностью можно было получить при уменьшении гестационного возраста при рождении. Люди, родившиеся преждевременно, могут быть более подвержены развитию депрессии в подростковом возрасте. Некоторые из этих проблем можно отнести к исполнительной сфере и предполагают, что они возникают из-за снижения миелинизации лобных долей . Исследования людей, рожденных недоношенными и позднее обследованных с помощью МРТ головного мозга , демонстрируют качественные аномалии структуры мозга и дефицит серого вещества в структурах височных долей и мозжечка, которые сохраняются и в подростковом возрасте. На протяжении всей жизни им чаще требуются услуги физиотерапевтов, эрготерапевтов или логопедов. У них больше шансов заболеть диабетом 1 типа (примерно в 1,2 раза) и диабетом 2 типа (в 1,5 раза).

Несмотря на нейросенсорные, психические и образовательные проблемы, изучаемые в школьном возрасте и у детей-подростков, рожденных крайне недоношенными, обнаружено, что большинство выживших недоношенных детей, рожденных в первые годы интенсивной терапии новорожденных, чувствуют себя хорошо и ведут вполне нормальную жизнь в молодом возрасте. Молодые люди, родившиеся недоношенными, похоже, признают, что у них больше проблем со здоровьем, чем у их сверстников, но при этом чувствуют такую ​​же степень удовлетворенности качеством своей жизни.

Помимо последствий недоношенности для развития нервной системы, недоношенные дети имеют больший риск возникновения многих других проблем со здоровьем. Например, недоношенные дети имеют повышенный риск развития хронической болезни почек .

Эпидемиология

Год жизни с поправкой на инвалидность из-за недоношенности и низкой массы тела при рождении на 100 000 жителей в 2004 г.

  нет данных

  менее 120

  120–240

  240–360

  360–480

  480–600

  600–720

  720–840

  840–960

  960–1080

  1080–1200

  1200–1500

  более 1500

Преждевременные роды осложняют 5–18% родов во всем мире. В Европе и многих развитых странах уровень преждевременных родов обычно составляет 5–9%. тогда как в США с 2007 по 2022 год ставка колебалась от 9,6 до 10,5 процента.

Поскольку вес определить легче, чем гестационный возраст, Всемирная организация здравоохранения отслеживает показатели низкой массы тела при рождении (<2500 граммов), которая наблюдалась у 16,5% рождений в менее развитых регионах в 2000 году. По оценкам, одна треть этих родов с низким весом при рождении происходит из-за преждевременных родов. Вес обычно коррелирует с гестационным возрастом; однако дети могут иметь недостаточный вес и по другим причинам, помимо преждевременных родов. Новорожденные с низкой массой тела при рождении (LBW) имеют массу тела при рождении менее 2500 г (5 фунтов 8 унций) и в основном, но не исключительно, являются недоношенными детьми, поскольку к ним также относятся дети , малые для гестационного возраста (SGA). Классификация на основе веса дополнительно признает очень низкую массу тела при рождении (ОНМТ), которая составляет менее 1500 г, и чрезвычайно низкую массу тела при рождении (ЭНМТ), которая составляет менее 1000 г. Почти все новорожденные в этих двух последних группах рождаются недоношенными.

Около 75% из почти миллиона смертей в результате преждевременных родов выжили бы, если бы им было обеспечено тепло, грудное вскармливание, лечение инфекций и поддержка дыхания. Осложнения, вызванные преждевременными родами, привели к 740 000 смертей в 2013 году по сравнению с 1,57 миллионами в 1990 году.

Общество и культура

Экономика

Преждевременные роды являются значительным фактором затрат в здравоохранении, даже если не учитывать расходы на долгосрочный уход за людьми с ограниченными возможностями из-за преждевременных родов. Исследование, проведенное в США в 2003 году, определило, что неонатальные затраты составляют 224 400 долларов США для новорожденного с массой тела 500–700 г против 1000 долларов США при массе тела более 3000 г. Затраты растут в геометрической прогрессии с уменьшением гестационного возраста и веса. за 2007 год Института медицины Отчет «Преждевременные роды» обнаружили, что 550 000 недоношенных детей, рожденных каждый год в США, ежегодно обходятся примерно в 26 миллиардов долларов, в основном связанных с уходом в отделениях интенсивной терапии новорожденных, но реальная сумма может превысить 50 миллиардов долларов.

Известные случаи

Джеймс Элджин Гилл (родился 20 мая 1987 года в Оттаве , Онтарио, Канада) был самым ранним недоношенным ребенком в мире, пока этот рекорд не был побит в 2004 году. Он родился на 128 дней раньше срока, на 21 неделе 5 дней беременности, и весил 624 г ( 1 фунт 6 унций). Он выжил.

В 2014 году Лайла Стенсруд, родившаяся в Сан-Антонио , штат Техас, США, стала самым молодым недоношенным ребенком в мире. Она родилась на сроке 21 неделя 4 дня и весила 410 граммов (меньше фунта). Каашиф Ахмад реанимировал ребенка после его рождения. По состоянию на ноябрь 2018 года Лайла посещала детский сад. У нее была небольшая задержка речи, но других известных проблем со здоровьем или инвалидности не было.

Амилию Тейлор также часто называют самым недоношенным ребенком. Она родилась 24 октября 2006 года в Майами , Флорида, США, на сроке беременности 21 неделя и 6 дней. Этот отчет вызвал некоторую путаницу, поскольку ее беременность измерялась по дате зачатия (путем экстракорпорального оплодотворения), а не по дате последней менструации ее матери, в результате чего она выглядела на 2 недели моложе, чем если бы срок беременности рассчитывался более распространенным методом. При рождении ее рост составлял 23 см (9 дюймов) и вес 280 г (10 унций). У нее были проблемы с пищеварением и дыханием , а также в мозг кровоизлияние . 20 февраля 2007 года ее выписали из Баптистской детской больницы.

Рекорд по выживанию самого маленького недоношенного ребенка в течение значительного времени принадлежал Мэдлин Манн, которая родилась в 1989 году на сроке 26 недель, весом 280,0 г (9,875 унции) и длиной 24 см (9,5 дюйма). Этот рекорд был побит в сентябре 2004 года Румайсой Рахман, родившейся в той же больнице Медицинского центра Университета Лойолы в Мейвуде, штат Иллинойс. на сроке беременности 25 недель. При рождении ее рост составлял 20 см (8 дюймов), а вес - 261 г (9,2 унции). Ее сестра-близнец тоже была маленьким ребенком и весила при рождении 563 г (1 фунт 3,9 унции). Во время беременности у их матери была преэклампсия , потребовавшая родов путем кесарева сечения . Более крупный близнец покинул больницу в конце декабря, а меньший оставался там до 10 февраля 2005 г., когда ее вес увеличился до 1,18 кг (2 фунта 10 унций). В целом здоровые близнецы были вынуждены пройти лазерную операцию на глазах, чтобы исправить проблемы со зрением, что является обычным явлением среди недоношенных детей.

В мае 2019 года больница для женщин и новорожденных Шарп Мэри Берч в Сан-Диего объявила, что ребенок по прозвищу «Сэйби» был выписан почти через пять месяцев после рождения на сроке 23 недели беременности и весом 244 г (8,6 унции). подтвердил, что Сэйби является новым самым маленьким выжившим недоношенным ребенком в этом реестре. Доктор Эдвард Белл из Университета Айовы , который ведет Реестр самых маленьких детей,

Джонатон Уайтхилл родился в феврале 2009 года в детской больнице и клинике Миннесоты , на сроке беременности всего 25 недель и весе 310 г (11 унций). Его госпитализировали в отделение интенсивной терапии новорожденных на пять месяцев, а затем выписали.

Ричард Хатчинсон родился в Детских больницах и клиниках Миннесоты в Миннеаполисе, штат Миннесота, 5 июня 2020 года на сроке беременности 21 неделя 2 дня. При рождении он весил 340 г (12 унций). Он оставался в больнице до ноября 2020 года, после чего его выписали.

5 июля 2020 года Кертис Минс родился в больнице Университета Алабамы в Бирмингеме на сроке 21 неделя 1 день и весил 420 г (15 унций). Выписан в апреле 2021 года. По состоянию на март 2023 года. , он является действующим рекордсменом мира.

Исторические личности, родившиеся преждевременно, включают Иоганна Кеплера (родившегося в 1571 году на семимесячном сроке беременности), Исаака Ньютона (родившегося в 1642 году, достаточно маленького чтобы поместиться в литровую , по словам его матери, кружку), Уинстона Черчилля (родившегося в 1874 году на семимесячном сроке беременности). месяцев беременности) и Анна Павлова (родилась в 1885 году на семи месяцах беременности).

Последствия пандемии коронавируса

Во время пандемии COVID-19 во многих странах было зарегистрировано резкое снижение уровня преждевременных родов: от 20% до 90% в наиболее тяжелых случаях. Исследования в Ирландии и Дании впервые заметили это явление, и оно было подтверждено в других местах. Не существует общепризнанного объяснения такого падения по состоянию на август 2020 года. Гипотезы включают дополнительный отдых и поддержку для будущих матерей, остающихся дома, меньшее загрязнение воздуха из-за отключений и уменьшения автомобильного дыма, а также снижение вероятности заражения другими болезнями и вирусами в целом из-за к локдаунам.

Исследовать

У недоношенных детей часто встречается повреждение головного мозга, варьирующееся от повреждения белого вещества до внутрижелудочковых и мозжечковых кровоизлияний . Характерная невропатология недоношенных была описана как « энцефалопатия недоношенных». Число недоношенных детей, получающих специальное образование, удваивается по сравнению с населением в целом. Школьные оценки ниже, как и баллы за вербальное обучение, исполнительные функции, языковые навыки и память. а также показатели IQ. В поведении подростки, родившиеся сильно недоношенными и/или с очень низкой массой тела при рождении, имеют аналогичные самоотчеты о качестве жизни, состоянии здоровья и самооценке, что и подростки из контрольной группы.

Различные исследования структурного магнитного резонанса выявили последовательное уменьшение объема всего мозга. Обширный список отдельных областей с меньшими объемами по сравнению с контролем включает множество областей коры (височные, лобные, теменные, затылочные и поясные), области гиппокампа , таламус , базальные ганглии , миндалевидное тело , ствол мозга , внутреннюю капсулу , мозолистое тело и мозжечок. . Уменьшение объема мозга, по-видимому, наблюдается по всему мозгу. Напротив, большие объемы были обнаружены в некоторых из тех же областей, включая медиальную/переднюю лобную, теменную и височную кору, мозжечок, среднюю височную извилину , парагиппокампальную извилину и веретенообразную извилину , а также более крупные боковые желудочки . в среднем Причина этих несоответствий неизвестна. Кроме того, уменьшение площади поверхности/толщины коры было обнаружено в височных долях с обеих сторон, а также в левой лобной и теменной областях. Более толстая кора была обнаружена с двух сторон в медиальных нижних и передних частях лобных долей и в затылочных долях.Гестационный возраст положительно коррелировал с объемами височной и веретенообразной извилин , сенсомоторной коры двусторонней , левой нижней теменной доли , ствола головного мозга и различных трактов белого вещества, а также специфическими положительными связями с мозжечком и таламусом. Некоторые структурные изменения мозга были связаны с показателями когнитивных и поведенческих результатов. Например, общий объем мозговой ткани объясняет от 20 до 40% различий в IQ и результатах обучения между крайне недоношенными подростками и подростками из контрольной группы. В другом исследовании квартильное снижение значений белого вещества средней височной извилины на 25% было связано с увеличением риска когнитивных нарушений на 60%. Носарти и его коллеги ранее предположили, что закономерности созревания мозга недоношенных детей соответствуют возрастным стадиям, обычно наблюдаемым у более молодых людей. Однако их последнее исследование предполагает, что их траектория может быть не только отсроченной, но и принципиально отличающейся. Поскольку как меньшие, так и большие региональные объемы были обнаружены у сильно недоношенных лиц по сравнению с контрольной группой.

Доказательства в поддержку использования остеопатических манипуляций для оказания помощи новорожденным слабы.

См. также

• Канадская перинатальная сеть
• Всемирный день недоношенности