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PubMed2001

Management of the extremely preterm infant: is the replacement of estradiol and progesterone beneficial?

This review presents data to suggest that postnatal estradiol and progesterone replacement therapy may be beneficial in preterm infants. During pregnancy, maternal plasma levels of estradiol and progesterone increase up to 100-fold compared to the nonpregnant status. The fetus is also exposed to these increasing hormone levels. After delivery, estradiol and progesterone levels drop by a factor of 100 within 1 day. Whereas this is a physiological condition for an infant born at term, preterm delivery means withdrawal from the placental supply of these hormones at an earlier developmental stage. Seventy years ago, the idea was raised that preterm infants may benefit from the replacement of estrogens. Studies in which estrogen was injected subcutaneously showed only a slightly better bodyweight gain compared to placebo-treated controls and therefore routine use was not established. The effective treatment of postmenopausal osteoporosis with hormone replacement therapy led to a pilot study of estradiol and progesterone therapy to prevent osteopenia of prematurity. The highest median bone mineral accretion rate was found in the replacement group when the supplementation with calcium and phosphorus was also sufficient. None of the previous studies dealing with estrogen replacement controlled for achieved plasma levels of estradiol in the infants. In our controlled randomised pilot study with 30 preterm infants (15 in each group), we aimed to maintain intra-uterine plasma levels of estradiol and progesterone. Preterm infants with replacement of estradiol and progesterone for 6 weeks postnatally showed trends to higher bone mineral accumulation. In addition, a trend towards a lower incidence of chronic lung disease was found. Neurodevelopmental follow-up showed normal psychomotor development in infants given estradiol and progesterone, whereas the untreated infants (controls) showed a trend towards delayed development. Recent research emphasises that estradiol and progesterone may be important for brain development. Thus, while there is data indicating that postnatal estradiol and progesterone replacement therapy may be beneficial in preterm infants, experience with this new therapy is limited and extensive research is needed to address the potential benefits and to rule out adverse effects.

Estrogen Replacement Therapy↗

PubMed2007

The postnatal maturation of the immunoglobulin heavy chain IgG repertoire in human preterm neonates is slower than in term neonates.

During the perinatal period the development of the IgH chain CDR3 (CDR-H3) repertoire of IgM transcripts is maturity-dependent and not influenced by premature exposure to Ag. To study whether maturity-dependent restrictions also predominate in the perinatal IgG repertoire we compared 1000 IgG transcripts from cord blood and venous blood of extremely preterm neonates (24-28 wk of gestation) and of term neonates from birth until early infancy with those of adults. We found the following. First, premature contact with the extrauterine environment induced the premature development of an IgG repertoire. However after preterm birth the diversification of the IgG repertoire was slower than that after term birth. Second, the IgG repertoire of preterm neonates retained immature characteristics such as short CDR-H3 regions and overrepresentation of D(H)7-27. Third, despite premature exposure to the extrauterine environment, somatic mutation frequency in IgG transcripts of preterm infants remained low until they reached a postconceptional age corresponding to the end of term gestation. Thereafter, somatic mutations accumulated with age at similar rates in preterm and term neonates and reached 30% of the adult level after 6 mo. In conclusion, class switch was inducible already at the beginning of the third trimester of gestation, but the developing IgG repertoire was characterized by similar restrictions as those of the developing IgM repertoire. Those B cells expressing more "mature" H chain sequences were not preferentially selected into the IgG repertoire. Therefore, the postnatal IgG repertoire of preterm infants until the expected date of delivery differs from the postnatal repertoire of term neonates.

Antibody Diversity↗

PubMedDate not supplied

The role of the nursing staff in promoting the development of preterm infants through their contribution to mother-infant interaction.

Preterm birth constitutes a potential risk factor for infant development. There is evidence that parental sensitivity and responsivity can compensate for biological risk. Since the birth of a preterm infant often constitutes a crisis for parents, they may be impaired in their ability to relate appropriately to their infants. The nursing staff can play a vital role in enhancing the interaction between parents (in particular mothers) and their preterm infants, thereby indirectly promoting optimal infant development. This paper describes the psychological tasks faced by mothers of preterm infants, parents' experiences of preterm birth and suggestions as to what the nursing staff can do to facilitate healthy relationships between parents and their preterm infants, thereby preventing possible pathological development.

Adaptation, Psychological↗

PubMed1999

Changing paternity and the risk of preterm delivery in the subsequent pregnancy.

I studied whether changing a partner, and thus changing the likelihood of human leukocyte antigen (HLA) sharing between mating partners, affects the risk of preterm delivery in the subsequent pregnancy. I identified a total of 128,239 women who had two consecutive births during 1989-1991 through data linkage of the California birth certificates. Paternal date of birth and names on the records of the two consecutive births were compared to determine whether the same father was reported on both records. Three cohorts of women were formed on the basis of the gestational age of their first delivery: <34, 34-36, and >36 weeks. If parental HLA sharing is associated with preterm delivery, the likelihood of HLA sharing was expected to be in a decreasing order from most likely among a <34-week cohort to least likely among a >36-week cohort. Among women in the <34-week cohort, changing partners resulted in a 33% reduction in the risk of early preterm delivery in the subsequent pregnancy compared with those who did not change partners [95% confidence interval (CI), 0.52-0.88]. In contrast, among women in the >36-week cohort, changing partners led to a 16% increase in the risk of early preterm delivery in the subsequent pregnancy (95% CI = 1.04-1.30). Among women in the 34-36-week cohort, changing partners did not affect the risk of preterm delivery (95% CI = 0.78-1.25). These estimates were adjusted for maternal race/ethnicity, age, educational level, prenatal smoking, prenatal care, parity, and interval from birth to conception of the subsequent pregnancy. The findings from this study suggest that the effect of changing paternity depends on the pregnancy outcome with the previous partner and support the hypothesis that parental HLA sharing may be related to preterm delivery.

Adult↗

PubMed1998

Identification and case management in an HMO of patients at risk of preterm labor.

We carried out a study of pregnant patients in a health maintenance organization to identify and provide case management of women at risk of preterm labor and to determine important risk factors for preterm labor in a managed care population. Data were collected on 794 women who completed an initial prenatal care visit at HealthAmerica of Pittsburgh between July 15, 1994, and March 31, 1995, and delivered at a local Pittsburgh hospital. The patients were assessed during an initial call to schedule their first prenatal visit and also at the 8- to 15-week and 24- to 28-week prenatal visits. Patients scoring 10 or higher on the risk assessment form were referred to a nurse case manager who provided education and support. Results of a logistic regression analysis suggest that the risk assessment tool was effective in identifying women at risk for preterm labor. "Physical/stressful work", as assessed by the patient, history of a prior preterm birth, and multiple gestation were all statistically significant predictors of preterm birth. Further research is needed to confirm the finding that physical or stressful work is a significant predictor of preterm births and to determine which aspects of the work may increase the patient's risk. This study was based on 8 months of data; however, additional program implementation is needed to evaluate fully the potential long-term benefits of the program.

Case Management↗

PubMed1999

Progesterone and prostaglandin H synthase-2 involvement in alcohol-induced preterm birth in mice.

BACKGROUND: Recently, an association between alcohol consumption during pregnancy and shortened gestational length has been reported, but the underlying mechanisms remain unknown. Progesterone (P4) and prostaglandins have been shown to play important roles in parturition in both human and animal models. Recently, it has been suggested that prostaglandin H synthase-2 (PGHS-2) is responsible for prostaglandin changes associated with term and preterm labor. It is possible that alcohol induces preterm birth by altering P4 or PGHS-2 levels. These studies were designed to determine the role of P4 and PGHS-2 in alcohol-induced preterm labor in mice. METHODS: Experiment 1: Pregnant dams treated with either vehicle or alcohol (6 g/kg, intragastrically) on gestational day (GD) 16 were killed at various times in gestation up to the time of delivery. Plasma P4 levels were measured by radioimmunoassay and uterine PGHS-2 mRNA expression was measured by Ribonuclease Protection Assay. Results indicated that alcohol treatment was associated with an earlier decline in plasma P4 levels and an earlier rise in uterine PGHS-2 mRNA levels during gestation. Experiment 2: Pregnant C57BL/6J females were treated with either P4 (2.0 mg, subcutaneously) or vehicle (sesame oil) 2 hr before receiving either 6 g/kg alcohol (intragastrically) or vehicle (isocaloric sucrose) on gestational day (GD) 16. Results indicate that P4 pretreatment effectively antagonized alcohol-induced preterm delivery. Experiment 3: On GD16, pregnant dams received either 100 mg/kg nimesulide (a specific PGHS-2 inhibitor) or vehicle (saline) subcutaneously, 2 hr before treatment with either 6 g/kg alcohol (given intragastrically) or isocaloric sucrose. Nimesulide was effective in antagonizing alcohol-induced preterm labor. CONCLUSIONS: Together, these data suggest that both P4 and PGHS-2 may play roles in alcohol-induced preterm birth.

Animals↗

PubMed2000

Smoking during pregnancy increases the risk of preterm births among parous women.

BACKGROUND: We wanted to study a possible association between smoking during pregnancy and preterm birth. METHODS: A population based prospective study was performed among 7,236 consecutive pregnancies over seven years delivered at one birth clinic. Smoking habits were obtained at a routine ultrasound examination around 18 gestational weeks, and preterm birth was defined as delivery of a child between 24 and 37 gestational weeks. We estimated relative risk (odds ratio) between smoking, possible confounding variables and preterm birth using multiple logistic regression analysis. RESULTS: Overall, 1,769 (25%) women said that they smoked every day during their pregnancy. The smoking women had an increased risk of preterm delivery compared with non-smokers (odds ratio 1.53, 95% confidence interval 1.24, 1.89). However, this association was only demonstrated among the multiparous women (odds ratio 1.88, 95% confidence interval 1.39, 2.54). The association was statistically significant after adjusting for maternal age, diabetes, cervical conization, preeclampsia, placental abruption and placenta previa in a multivariate analysis, and we observed a dose-response effect of maternal smoking on preterm birth among multiparous women. CONCLUSION: For multiparous women smoking during pregnancy increases the risk of preterm delivery, and there seems to be a dose-response effect of smoking.

Adolescent↗

PubMed2000

[The amniotic fluid of term and preterm delivery and its influence on contractions of human myometrium in vitro].

Initiation of labour is a complex process that involves fetal-maternal communication. Although the mechanism of the initiation of preterm labour has not been elucidated fully, it may differ from that in normal labour. The aim of this research was to study the effect of amniotic fluid from term and preterm deliveries on human myometrial contractions. The amniotic fluid was obtained from 45 women, who underwent caesarean section preterm (18) and at term (27) for routine obstetric indications. The influence of preterm and term amniotic fluid on spontaneous and oxytocin stimulated by in vitro isometric myometrial contractions was evaluated. Repeated measured ANOVA was performed for statistical analysis. Amniotic fluid from preterm delivery successfully inhibits myometrial contractions stimulated by oxytocin, so it may play role in maintaining normal pregnancy and preventing preterm delivery.

Adult↗

PubMed1979

Normalized thyroxine as a screening test for hypothyroidism in full-term and preterm newborn babies.

Thyroid function was assessed in full-term and preterm newborn babies by serum thyroxine (T4), normalized thyroxine (T4N) and thyroid-stimulating hormone (TSH) assays. At age 24 h, there was a significant difference in T4 and TSH values between the full-term and preterm groups; no such difference was found in the T4N values. By 21 days of age, the TSH values were still significantly higher in full-term babies compared with preterm ones, but the T4 values were similar. The T4, T4N and TSH values at 24 h in preterm newborns with respiratory distress syndrome were similar to those in normal preterm babies, and the changes in these values with age had no consistent pattern. In preterm babies with low 24-h T4 and T4N values, these two parameters increased with age, reaching normal adult values by 21 days. We concluded that T4N could serve as a useful thyroid function test in the newborn.

Female↗

PubMed2001

Obstetrical outcomes amongst preterm singleton births.

OBJECTIVE: The purpose of this study was to review the outcome of preterm singleton neonatal morality based on birthweight and gestational age at delivery. METHODS: A retrospective review of hospital case notes of maternity data and neonatal mortality data was carried out on all singleton preterm deliveries from 26 to < 37 completed weeks between 1996 and 1999 to investigate neonatal death. RESULTS: There were 20,758 live-born singleton deliveries over the study period, of which 638 were preterm (3%). The overall neonatal mortality in the preterm group was 42/1000. The neonatal mortality rate fell with advancing gestational age from 174/1000 live births at 28 weeks to 37/1000 live births at < 37 completed weeks of gestation. The neonatal mortality rate also fell with increasing birth-weight from 285/1000 live births of 1000g to 14/1000 live births at 2500g. There was a significant increase in the proportion of babies delivered spontaneously. CONCLUSION: This study has demonstrated neonatal mortality using gestational age and birth weight. The results will be of use in obstetric management when elective preterm delivery is considered, and for providing prognostic guidance following preterm delivery.

Adult↗

PubMed1999

Detection of secretory immunoglobulin A (SIgA) in saliva of ventilated and non-ventilated preterm neonates.

The very young preterm neonate has multiple immune deficiencies which may increase his or her vulnerability to infection. Secretory Immunoglobulin A (SIgA) plays an important role in the protection of epithelial surfaces exposed to the external environment; nevertheless controversy exists with regards to the ontogeny of SIgA in newborns and especially the preterm neonate. The objective was to investigate if SIgA could be detected in the saliva of very/extremely low birthweight neonates (V/ELBW). A total of 707 samples which were collected twice daily (morning and afternoon) for three consecutive days were obtained from sixty-eight preterm neonates (mean gestational age 28 weeks; conceptional age ranged from 25-35 weeks). A repeated measures design was used. Total concentration of SIgA was determined from unstimulated saliva by an Enzyme Linked Immunosorbant Assay technique. Results indicated that SIgA was detectable in the early postnatal period in the saliva of both ventilated preterms who were receiving intravenous total parenteral nutrition (TPN) and non-ventilated preterms. A 3-way repeated measures Analysis of Variance (ANOVA) showed no significant effect from 'before' and 'after' samples during a period of spontaneous activity, time and day of sampling. A significant effect of mode of nutrition was found; neonates who were receiving expressed breast milk had significantly higher concentrations of SIgA than those infants receiving TPN (df=3, F=14.27, p<0.0001). These results have implications for the care of the preterm neonate in intensive care.

Journal Article↗

PubMed2000

Survival pattern among extreme preterm infants.

OBJECTIVE: To look at the survival pattern of extreme preterm Omani infants (23-26 weeks gestation) and compare it with the western countries. METHODS: All extreme preterm Omani infants (gestational age of 23 to 26 weeks) admitted from November 1991 to February 1998 at the Neonatal Intensive Care Unit of Sultan Qaboos University Hospital were reviewed. The detailed records of the infants, including name of mother, age, gravidity, parity, route of delivery, Apgar score, time of birth, inborn or outborn, birth weight, gestational age, sex, need for resuscitation, course in the Neonatal Intensive Care Unit, admission and discharge diagnosis, and outcome were collected from the register. The infants were stratified according to the gestational age and then analyzed for the survival rate among the different gestational ages. RESULTS: A total of 32 extreme preterm infants were admitted to the Neonatal Intensive Care Unit of Sultan Qaboos University Hospital from November 1991 to February 1998. The mean birth weight of the cohort was noted to be 798+123 gram (Range 480-1015 grams). The mean gestational age was noted to be 25.5+0.95 weeks (Range 23-26 weeks). An equal number of males and females were noted in the cohort, with male to female ratio of 1:1. A total of 13 infants survived out of 32 infants. The overall survival rate for the cohort was noted to be 41%. For the present study, the western statistics are averaged and than compared with the Omani statistics. The survival rate for western 26 week preterm infants was (on average) 61% as compared to 44% among Omani preterm infants. The same trend of low survival was noted for 23 and 24 week Omani infants, except for only one 25 week infant. CONCLUSION: The significant lower survival rate suggests the need for more attention and improvement in the management and care provided to the extreme preterm Omani infants.

Birth Weight↗

PubMed2002

[Medically indicated preterm birth. Maternal and fetal consequences].

One of the principal challenges of obstetrics is to reduce the percentage of perinatal mortality. Preterm birth is considered the main cause of neonatal morbidity and mortality. Preterm birth by medical indication, is a condition rarely documented in medical literature, but it requires analysis to determine the effect in perinatal health. In a third care hospital setting, a prospective study was performed on 154 pregnant women that delivered preterm babies between 25 and 36 weeks of gestation. The Relative Risk (RR) was obtained to compare the association between the medical indication of the preterm birth, the use of fetal pulmonary maturants, type of delivery, the health status of the newborn at birth and hospital discharge. The main causes of preterm birth by medical indication were: premature rupture of membranes, preeclampsia, intrauterine growth retardation and fetal distress. Neonatal mortality was 13%. The rate of cesarean section was higher than expected. Despite the various types of delivery, there were no significant differences between mortality, length of hospital stay or hospital complications. The probability of death to preterm born was explained to gestational age and was not modified for medical decision to interrupt pregnancy.

Adolescent↗

PubMed2002

[Home care for preterm labor].

OBJECTIVE: To analyze the different modalities of home care management for women hospitalized for preterm labor. METHODS: We reviewed all reports in French and English on Medline using the following key-words: home uterine activity monitoring, home care management, midwives follow-up. Reports were categorized by level of proof (LP 1 to 5). For each study, method, results and authors'conclusions were recorded. We gave our comments for each report. RESULTS: We could not find any report concerning indications of leaving hospital after treatment for preterm labor. We only could find expert recommendations. Concerning home uterine activity monitoring, the results demonstrated that there were no arguments to recommend this method for early detection of preterm labor or to avoid preterm delivery. Most of these studies had weak power and multiple methodological biases. Very few studies reported about home care midwives follow-up. Some rare randomized studies demonstrated the non efficient effect of this management on the reduction of prematurity rates. The rates of hospitalization did not decrease. Conversely, patients satisfaction was increased. CONCLUSION: Home uterine activity monitoring seems to be unnecessary, having no incidence on early diagnosis of preterm labor or rates of prematurity (LP2 or 3). Home care follow-up by midwives for patients treated for preterm labor did not reduce rates of prematurity (LP1). It slightly increased the women's satisfaction.

Female↗

PubMed2002

[Management of threatening preterm labor with intact membranes: indications for antibiotics].

OBJECTIVE: To analyse the benefits and disadvantages of systematic antibiotic therapy in patient presenting a preterm labor with intact membranes. METHODS: We reviewed French and English reports on Medline using to the following key words: "antibiotic therapy and preterm labor, preterm labor, streptococcus B, vaginose, mycoplasma, antenatal infection". RESULTS: The systematic prescription of antibiotics is not recommended for patients presenting preterm labor who have intact membranes and no symptoms of infection. The benefit of antibiotics is small and shows a tendency to prolong the pregnancy and the reduction of maternal infection. No benefit has been shown for neonatal results. When early-onset neonatal sepsis develops in a case in which antepartum chemoprophylaxis was used, the isolated bacteria will present an increasing risk of bacterial drug resistance. Local treatment (cream or pessary) do not belong in the treatment of threatening preterm labor and are not recommended for the prevention of prematurity or materno fetal infection. Risk groups of patients who present a positive vaginal colonization are subject to discussion. Studies do not allow us to ascertain that antibiotics have a beneficial effect on prematurity in these groups. Antibiotics are recommended for the treatment of asymptomatic bacteriuria. This treatment reduces prematurity and maternal infections. Despite poor consensus criteria, if threatening preterm labor is associated with a bacteriuria, experts usually recommend treatment.

Anti-Bacterial Agents↗

PubMed2002

Oral erythromycin for treatment of feeding intolerance in preterm infants: a preliminary report.

UNLABELLED: Feeding intolerance is a common problem in preterm infants resulting in a prolonged hyperalimentation which is associated with an increased risk of serious and sometimes even life threatening complications, including cholestasis jaundice, liver impairment, nutritional deficiency, biochemical rickets and catheter-related septicaemia. Erythromycin, a commonly used macrolide antibiotic, has been reported as having potent prokinetic properties and enhancing gastrointestinal motor activity. The authors, therefore, conducted a preliminary study of oral erythromycin for the treatment of feeding intolerance in preterm infants to evaluate the safety and efficacy of this drug. AIM: To evaluate the safety and efficacy of oral erythromycin as a prokinetic agent in promoting enteral feeding in preterm infants with feeding intolerance. METHOD: Preterm infants, gestational age (GA) < or = 36 wk, who met the feeding intolerance criteria, were enrolled in the study. Inclusion criteria included infants who received enteral feeding less than half of full feeding or less than 75 ml/kg/day by day 14 post-natal age or gastric residual > or = 50 per cent of a given amount of feeding, more than 2 consecutive feeds by day 7 post-natal age. All patients received oral erythromycin ethylsuccinate 12 mg/kg every six hours for 2 days, then 3 mg/kg every six hours for 5 days. The times taken to establish full enteral feeding after the drug treatment and time to stop hyperalimentation were recorded. Potential adverse effects of erythromycin were assessed. Response to treatment was defined as decreased gastric residual < 30 per cent of a similar amount of the previous feed and was able to continue to full feeding. RESULTS: Ten preterm infants were enrolled in this study with a mean GA of 30.8 weeks (26-35), mean birth weight of 1,489 g (range 900-2,560 g) and mean age at entry of 9.2 days (range 7-12 days). Nine of 10 infants responded to treatment within 24 hours. The average time to establish full enteral feeding after the drug treatment was 6.6 days (range 4-10 days). None of the infants developed adverse effects such as vomiting, diarrhea, or pyloric stenosis. CONCLUSION: The preliminary data indicates that oral erythromycin is effective and safe in facilitating enteral feeding in preterm infants with feeding intolerance. Infants can achieve full feeding within a week after treatment, and this may shorten the course of hyperalimentaiton. Further randomized controlled trials are warranted.

Administration, Oral↗

PubMed2003

Socio-economic and psychosocial factors in the management and prevention of preterm labour.

Socio-economic factors associated with preterm labour include social class, (usually assessed by earnings and education), working conditions (professional status, ergonomic environment, working hours), physical and travelling activities, daily life activities, lifestyle, family status and psychosocial state as related to past and current pregnancy history together with current stress factors. A review of the association of these factors with preterm birth will be reported with an emphasis of the biological plausibility linking mostly emotional, and at a lesser degree, physical and psychological stress to the occurrence of preterm labour. A case control study, carried out in Quebec City among 101 women in preterm labour and 202 matched pregnancies for parity and gestational age, identified 7 risk factors in an explanatory multivariate model among 117 variables: Body mass index (BMI) <20 (OR; 95% CI: 3.96; 2.61-7.09), previous preterm labour (OR; 95% CI: 3.61; 1.12-11.65) previous low birth weight (OR; 95% CI: 2.24; 1.05-7.71), standing at work >2 hours (OR; 95% CI: 3.90; 1.53-9.91), Abruptio placentae (OR; 95% CI: 5.88; 1.20-28.76), urinary tract infection (UTI) (OR; 95% CI: 4.4.3; 1.47-13.34), and stress score >5 (OR; 95% CI: 2.56; 1.20-5.54). The most stressful events were related to family illness, mortality, disruption, violence or financial distress. Some risk factors cannot be modified (previous preterm labour, low birth weight and UTI), while preventive efforts should be directed towards attaining BMI >20 before conception, modifying working conditions during current pregnancy and appropriate management of acute emotional stress.

Body Mass Index↗

PubMed2003

Problems and challenges in the management of preterm labour.

The main problem with preterm labour is our lack of progress in the successful management of this condition. We need to reassess our approach to this problem because preterm labour is not a disease, but an event, which may result from multiple independent pathways. This problem has also been affected significantly by medical advances such as infertility treatments and changes in neonatal survival at the limit of viability. The specific challenges that we face in managing preterm labour include: problems with definition; aetiology, including genetic and infection components; diagnostic problems, such as true versus false labour and role of cervical length and fetal fibronectin; and specific interventions according to the antepartum, intrapartum and postpartum challenges. In order to address the main issue, and make future progress in the management of preterm labour, we should consider the implementation of a 'Postpartum Preterm Labour Diagnostic Workup Protocol'. These data/workup results could be entered on web-based databases for each preterm labour 'event'. An international research team could analyse data relating to specific aetiological patterns and subgroup analyses, leading to the collaborative development of 'aetiology specific' management modalities. This approach requires a close collaboration between clinicians and researchers, in order to make significant progress in this difficult area, and ultimately improve perinatal outcomes.

Ambulatory Care↗