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PubMed2000

[Fetal fibronectin as a predictor of preterm delivery in patients with preterm contractions and cervical changes].

OBJECTIVE: The purpose of the study was to assess the clinical value of fetal fibronectin assay in the group of women presenting with preterm contractions and cervical changes. STUDY DESIGN: We prospectively evaluated 82 patients between 23-34 weeks of gestation presenting with signs and symptoms of preterm labor, intact membranes and cervical dilatation < 3 cm. In all cases cervico-vaginal samples were collected and assayed for the presence of fetal fibronectin. The primary outcome was delivery < or = 28 days from examination. RESULTS: The rate of preterm delivery (< 37 weeks) was 25.6% (21/82) and 17.1% (14/82) of the patients delivered < or = 28 days from the examination. The mean Bishop score was significantly higher in patients delivered < 28 days (5.9 +/- 1.2 vs 4.7 +/- 1.4; p = 0.004). Positive result of fFN (> 0.05 mg/ml) was found in 71.4% of patients that were delivered < or = 28 days and in 7.4% delivered > 28 days (p < 0.001). For predicting delivery < or = 28 days the positive fFN testing had sensitivity of 71.4%, specificity of 92.7%, PPV of 66.7% and NPV of 94%. The cutoff value for Bishop's score > or = 5 had sensitivity of 85.7% and specificity of 48.5%. Performing fFN testing only in patients with Bishop score > or = 5 resulted in the sensitivity of 71.4%, specificity of 95.6%, PPV of 76.9% and NPV of 94.2%. CONCLUSIONS: Fetal fibronectin is a very good predictor of imminent preterm delivery. It needs further research whether performing of the fFN assay can be limited only to the patients with the estimated Bishop's score > or = 5.

Abortion, Spontaneous↗

PubMedDate not supplied

The impact of preterm birth on the family and society. Part 1: Psychologic sequelae of preterm birth.

Preterm birth has been identified as the number one perinatal and neonatal problem in the United States today. During the past decade, clinical and technologic advances in the treatment of preterm and other medically complex infants have resulted in more "survivors." But what are the costs of these advances? Many survivors face serious lasting medical complications. The focus of this series is an overview of the common pathophysiologic, psychologic and long-term care needs of the preterm infant. This article provides a discussion on the relationship between the birth of a preterm infant and the stress it evokes on the family and society.

Family↗

PubMed1994

Active management of preterm labour and preterm prelabour rupture of membranes.

Hundred cases of preterm labour (before 36 weeks) with cervix 4 cm or less dilated and preterm prelabour rupture of membranes (excluding cases of uterine overdistension, maternal medical disorders and fetal congenital abnormalities) were treated with bed rest and sedation. Labour set in within 2-6 days with high fetal morbidity and mortality. Another fifty similar patients were given in addition to rest in hospital for 48 hours, 1000 ml of 5% dextrose in six hours, intravenous antibiotics (after sending off cultures from the vagina per speculum), corticosteroids and a single dose of analgesia/sedation injection. In 85% painful contractions ceased and membranes stopped leaking until near term. In 10% painful contractions ceased, but leakage continued for 2-7 weeks, and the gain in intrauterine life led to 100% neonatal survival with short hospital stay in the neonates born after 31 weeks. Only 5% failed to respond to treatment and after delivery these premature neonates developed pneumonia and septicaemia from the same organisms that were colonizing their maternal genital tract and had entered the fetus via the infected amniotic fluid. It is recommended that all patients in preterm labour or preterm prelabour rupture of membranes (excluding overdistension) be given besides bed rest and sedation, corticosteroids and antibiotics intravenously for 48 hours and then orally for eight more days. Tocolytics are not recommended. This regime saves babies.

Analgesics↗

PubMed2004

Fetal fibronectin and bacterial vaginosis are associated with preterm birth in women who are symptomatic for preterm labor.

OBJECTIVE: The purpose of this study was to codify the relationship between bacterial vaginosis/fetal fibronectin and preterm labor/birth. STUDY DESIGN: In this prospective study, 185 women who were symptomatic for preterm labor were assessed for bacterial vaginosis and fetal fibronectin. RESULTS: These women comprised 4 groups: group A (n=23 women; +bacterial vaginosis/+fetal fibronectin); group B (n=31 women; -bacterial vaginosis/+fetal fibronectin); group C (n=47 women; +bacterial vaginosis/-fetal fibronectin); and group D (n=84 women; -bacterial vaginosis/-fetal fibronectin). The time interval from gestational age at testing until delivery was significantly shorter for groups A and B versus groups C and D (P < or =.05 and P <.001, respectively). Similarly, delivery at <32 weeks of gestation was increased in group B (26%) compared with groups A (9%), C (2%), and D (5%; P <.009; odds ratio, 165.90; 95% CI, 30.02, 916.08). CONCLUSION: Women who are symptomatic for preterm labor should be considered for fetal fibronectin and bacterial vaginosis testing.

Adult↗

PubMed2005

Detection of interleukin 6 mRNA by RT-PCR in vaginal secretions: association with preterm delivery and neonatal infection in women with preterm labour and intact membranes.

OBJECTIVE: To find a biological marker associated with preterm delivery or neonatal infection in pregnant women with preterm labour and intact membranes. STUDY DESIGN: Cervical secretions were collected from 286 women hospitalized for preterm labour with intact membranes at 24-34 weeks' gestation. The outcomes studied were delivery before 33 and 35 weeks' gestation, chorioamnionitis, and neonatal infection, and their association with the presence of IL-6 mRNA in cervical secretions as detected by RT-PCR. The other infectious markers tested were: bacterial vaginosis and fetal fibronectin in cervical secretions; serum CRP and white blood cell count. RESULTS: The vaginal secretions of 13 of 286 women (4.7%) contained IL-6 mRNA. The only other marker tested significantly associated with IL-6 mRNA+ was the presence of streptococcus in vaginal secretions (30.8% versus 9.4% in the IL-6+ and-groups, p = 0.03). Although the difference did not reach statistical significance (p<0.06 and 0.08, respectively), in women with IL-6 mRNA in cervical secretions we observed a tendency to give birth before 33 and 35 weeks more often than the population as a whole. This group was at higher risk of neonatal infection (38.5% versus 15.1%; p = 0.04). After adjustment for infectious risk factors, IL-6 remained significantly associated with neonatal infection (OR = 4.6, 95% CI [1.1-18.9]). The sensitivity of IL-6 mRNA for neonatal infection was 11.1%. The specificity was 96.7%. CONCLUSION: The detection of IL-6 mRNA by RT-PCR in vaginal secretions allows identification of a small group of women at high risk of neonatal infection, independently of other markers of infection.

Adult↗

PubMed1998

Periventricular leukomalacia causes visual impairment in preterm children. A study on the aetiologies of visual impairment in a population-based group of preterm children born 1989-95 in the county of Värmland, Sweden.

PURPOSE: To determine the causes of visual impairment in a population-based group of visually impaired preterm children. METHODS: Ophthalmological examination and magnetic resonance imaging or computed tomography of the brain were performed in all visually impaired preterm children born 1989-95 in Värmland. RESULTS: Ten of 18 children had periventricular leukomalacia affecting the optic radiation, six had other lesions or malformations in the posterior visual pathways/cortex, but no child had visually impairing retinopathy of prematurity. CONCLUSION: We conclude that cerebral lesions or malformations are common causes of the visual functional deficit in visually impaired children born preterm. Brain damage should be suspected in a prematurely born child who presents with either of the signs: fixation difficulties, strabismus or nystagmus.

Adult↗

PubMed1998

The value of transvaginal ultrasonographic examination of the uterine cervix in predicting preterm delivery in patients with preterm premature rupture of membranes.

The objective of this study was to compare the value of ultrasonographic assessment of the uterine cervix and amniotic fluid tests in the prediction of the interval from admission to delivery in patients with preterm premature rupture of membranes. Ninety-two patients admitted to the hospital for preterm premature rupture of membranes between 24 and 32 weeks of gestation underwent both transabdominal amniocentesis and transvaginal ultrasonographic evaluation of the uterine cervix. Amniotic fluid analyses included cultures for aerobic and anaerobic bacteria, mycoplasmas and ureaplasmas, white blood cell count and glucose and interleukin-6 determinations. The ultrasonographic variables evaluated were cervical length, presence of funneling and cervical index ((funnel length + 1)/cervical length). The outcome measure was the interval from admission to delivery. The median interval from admission to delivery was 4.5 days (range 0-36). An abnormal uterine cervix was associated with a short time interval (cervical length < or = 20 mm, median 2 days, range 0-14 vs. median 6 days, range 0-36; p < or = 0.0001; presence of funneling, median 3 days, range 1-31 vs. median 8 days, range 0-36; p < or = 0.001; cervical index > 0.50, median 2 days, range 0-7 vs. median 8 days, range 1-36; p < or = 0.0001). However, interleukin-6 concentration in the amniotic fluid was the best predictor of the interval from admission to delivery when compared to the ultrasonographic indices and to all the amniotic variables considered. Moreover, when a multiple model was applied, the cervical index significantly and independently improved the performance of interleukin-6 in the prediction of the interval from admission to delivery. These data suggest that the combined use of the amniotic fluid interleukin-6 assay and the cervical index in patients with preterm premature rupture of membranes provides a good prediction of the interval from admission to delivery, thus identifying a subgroup of patients at high risk of imminent delivery.

Adult↗

PubMed2006

Spontaneous preterm labor and premature rupture of membranes at late preterm gestations: to deliver or not to deliver.

Nationwide the American College of Obstetricians and Gynecologists noted in 1995 that the survival rate for newborns at 34 weeks is within 1% of those born at or beyond 37 weeks. Newborn major morbidity is slightly but significantly increased from 34(0) to 36(6) compared with 37 or greater weeks. These data form the basis for and reflect the perinatal outcomes associated with the standardized obstetric practices of effecting delivery for women with amnion rupture and also of not attempting tocolysis for preterm labor at or beyond 34(0) weeks gestation. Pragmatically, a prospective randomized management trial of women at late preterm gestation (34(0) to 36(6)) and with spontaneous preterm labor or amnion rupture would require multi-institutional support to achieve a required study population.

Female↗

PubMed2006

Continuing challenges in treating preterm labour: preterm prelabour rupture of the membranes.

Preterm prelabour rupture of the membranes (PPROM) is defined as prelabour rupture of the membranes prior to 37 weeks of gestation. It occurs in approximately 3% of pregnancies and is responsible for one-third of all preterm births. Effective treatment relies on accurate diagnosis, and it is gestational age dependent because the potential complications change with gestational age. Diagnosis itself is made by clinical suspicion, patient history and simple testing. Studies have shown that if a combination of patient history, nitrazine testing and ferning was used, the accuracy of at least two positive tests was 93.1%. PPROM is associated with significant maternal and neonatal morbidity and mortality from infection, umbilical cord compression, placental abruption and preterm birth. Subclinical uterine infection has been implicated as a major aetiological factor in the pathogenesis and subsequent morbidity associated with PPROM and antenatal antibiotics, together with corticosteroid therapies, have clear benefits and should be offered to all women without contraindications. Women with PPROM after 32 weeks should be considered for delivery, and after 34 weeks of gestation the benefits of elective delivery appear to outweigh the risks. Here, two cases are discussed that were experienced in our unit.

Adult↗

PubMed2003

Influence of slight to moderate risk for birth hypoxia on acquisition of cognitive and language function in the preterm infant: a cross-sectional comparison with preterm-birth controls.

The cognitive and language performance of a group of 26 preterm-birth preschool and early school-age children with slight to moderate risk for perinatal hypoxia was compared with the performance of a preterm-birth comparison group of 26 children. Despite the relatively small discrepancy in degree of risk, the cognitive performance of the 2 groups diverged significantly. When data for children with known perinatal arterial pH were combined, a curvilinear (quadratic) regression model provided the best fit. Increasing acidosis was linearly related to decreases in cognitive skills, with the bend in the curve occurring well within the normal range of pH values. Hence, in the preterm infant, even minor risk for birth hypoxia may result in discernible deviation from the expected developmental trajectory.

Acidosis, Respiratory↗

PubMed2000

Extubation from low-rate intermittent positive airways pressure versus extubation after a trial of endotracheal continuous positive airways pressure in intubated preterm infants.

BACKGROUND: Failure of extubation and subsequent reintubation may result in additional stress and trauma to the premature infant. Testing infants about to be extubated with a period of endotracheal CPAP has been suggested as a method of demonstrating readiness for extubation. However, this process has been criticized as increasing the neonate's work of breathing and perhaps increasing the likelihood of extubation failure. OBJECTIVES: In premature infants having their endotracheal tube removed, is direct extubation from low rate intermittent positive pressure ventilation (IPPV) more successful than that following a period of endotracheal continuous positive airway pressure (CPAP)? SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register, MEDLINE, previous reviews including cross references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching mainly in the English language. SELECTION CRITERIA: All trials using random or quasi-random allocation of premature infants to endotracheal CPAP or direct extubation following a period of IPPV were included. DATA COLLECTION AND ANALYSIS: Data were extracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk. MAIN RESULTS: Direct extubation from low rate ventilation is associated with a trend to increased chance of successful extubation when compared to extubation after a period of endotracheal CPAP, RR 0.45 (0.19,1.07), RD -0.103 (-0.200,-0.006), NNT 10 (5,167). When only truly randomized trials are considered, this result becomes both statistically significant and clinically important, RR 0.10 (0.01,0.78), RD -0.201 (-0.319,-0.083), NNT 5 (3, 12). Similar differences are seen for the secondary outcome, apnea. REVIEWER'S CONCLUSIONS: Preterm infants no longer requiring endotracheal intubation and IPPV should be directly extubated without a trial of ETT CPAP.

Humans↗

PubMed2005

The Assessment of Preterm Infants' Behavior (APIB): furthering the understanding and measurement of neurodevelopmental competence in preterm and full-term infants.

The Assessment of Preterm Infants' Behavior (APIB) is a newborn neurobehavioral assessment appropriate for preterm, at risk, and full-term newborns, from birth to 1 month after expected due date. The APIB is based in ethological-evolutionary thought and focuses on the assessment of mutually interacting behavioral subsystems in simultaneous interaction with the environment. The subsystems of functioning assessed include the autonomic (respiration, digestion, color), motor (tone, movement, postures), state organization (range, robustness, transition patterns), attention (robustness, transitions), and self-regulation (effort, success) systems as well as the degree of facilitation required to support reorganization and subsystem balance. The environment is represented by a sequence of distal, proximal, tactile, and vestibular challenges, derived from the BNBAS. The APIB conceptualizes infant competence as the degree of differentiation of subsystem function and degree of modulation of subsystem balance at any stage in infant development. Infants are understood as actively seeking their next differentiation, while counting on good enough environments to assure progressing developmental competence. In the case of interference such as premature birth, the mismatch of expectation and actual experience causes misalignment, which may become developmentally costly. The assessment is a finely tuned dialogue between examiner and infant, which requires training, skill and self-knowledge. The APIB has well established inter-rater-reliability, concurrent and construct validity, and is clinically relevant for behavioral intervention and individually appropriate and supportive care.

Brain↗

PubMed1991

Impairments, disabilities, and handicaps of very preterm and very-low-birthweight infants at five years of age. The Collaborative Project on Preterm and Small for Gestational Age Infants (POPS) in The Netherlands.

The Project On Preterm and Small for gestational age infants (POPS) was started in the Netherlands in 1983 to investigate the relation between prenatal/perinatal factors and mortality/morbidity in very preterm and very-low-birthweight infants. Of the 1338 liveborn infants (less than 32 weeks and/or less than 1500 g) 966 were enrolled in the five-year (chronological age) follow-up programme; 96% of these children were assessed during a home visit. The overall outcome was expressed as impairments, disabilities, and handicaps according to World Health Organisation criteria. Of the assessed children, 13% had a disability and 14% were handicapped, which are much higher frequencies than those found in the general population. Handicaps were due mainly to abnormalities of neuromotor function, mental development, or language and speech development. Compared with the handicap frequency in the same cohort at two years of age, a more favourable outcome at five years of age was seen in 10%, and a less favourable outcome in 7% of the children. The findings show that most of those high-risk children survived without handicap or serious disability at preschool age.

Child, Preschool↗

PubMed2006

The Alabama Preterm Birth study: polymorphonuclear and mononuclear cell placental infiltrations, other markers of inflammation, and outcomes in 23- to 32-week preterm newborn infants.

OBJECTIVE: The purpose of this study was to better understand the relationship between placental polymorphonuclear and mononuclear cell infiltrations with bacterial cultures, markers of inflammation, and preterm outcomes. STUDY DESIGN: This was a prospective study in 446 women who were delivered of a singleton infant at <32 weeks of gestational age. Five placental sites were categorized as having polymorphonuclear or mononuclear infiltrations. Results were compared with placental and cord cultures, umbilical cord interleukin-6 levels, and neonatal outcomes. RESULTS: Polymorphonuclear, but not mononuclear, cell infiltrations were more common at the earliest gestational ages and in black women (56.0% vs 39.3%; P < .01). Polymorphonuclear infiltration was associated with spontaneous preterm birth (73.9% vs 8.0%; P < .0001), but not with preeclampsia (9.9% vs 34%; P < .0001). Women with positive cultures, high interleukin-6 levels, and clinical chorioamnionitis all had significantly more polymorphonuclear infiltrations than did women without those conditions (all probability values, <.0001). In all sites, polymorphonuclear infiltration was associated with neonatal systemic inflammatory response syndrome (P < .0001) and in the cord with necrotizing enterocolitis (22.4% vs 13.5%; P = .02). Intraventricular hemorrhage and neonatal death were not associated with polymorphonuclear infiltration. Polymorphonuclear infiltration at all sites was associated with less respiratory distress syndrome (P < .01). Mononuclear cell infiltration, when present in the decidua basalis, was associated with an increase in neonatal intraventricular hemorrhage (23.8% vs 7.4%; P < .0004). Plasmacytic infiltrates were associated with increased intraventricular hemorrhage (29.4% vs 8.3%; P = .01) and neonatal death (27.8% vs 9.2%; P = .02). CONCLUSION: Polymorphonuclear infiltrations of the free membranes, chorionic plate, and umbilical cord were associated with positive intrauterine cultures and elevated cord blood interleukin-6. There was also an association with systemic inflammatory response syndrome and necrotizing enterocolitis, but not with intraventricular hemorrhage or death, and with decreased respiratory distress syndrome. Decidual mononuclear cell infiltration was associated with an increased risk of intraventricular hemorrhage and decidual plasma cell infiltration with increased intraventricular hemorrhage and neonatal death.

Black or African American↗

PubMed2006

Association of a maternal CD14 -159 gene polymorphism with preterm premature rupture of membranes and spontaneous preterm birth in multi-fetal pregnancies.

CD14, the major receptor for bacterial lipopolysaccharide (LPS) as well as other microbial antigens, is a component of the innate immune system. We hypothesized that a single nucleotide C>T polymorphism at position -159 in the CD14 gene that results in elevated CD14 production would influence susceptibility to preterm premature rupture of membranes (PPROM) and spontaneous preterm birth (SPTB) in multi-fetal pregnancies. DNA from 107 mother-twin and three mother-triplet pairs was analyzed. Pregnancy outcomes were obtained after completion of testing. CD14*T homozygosity was present in 39.3% of 28 women whose pregnancies ended with PPROM, as opposed to 18.1% of 72 pregnancies without a SPTB (P=0.03). There was no relation between the fetal CD14 genotype and PPROM. The likelihood ratio (LR) for PPROM was 2.2 for women homozygous for CD14*T. The LR increased to 3.3 and 3.6 if the CD14 polymorphism was present in combination with previously determined maternal polymorphisms in the genes coding for the inducible 70kDa heat shock protein (hsp70-2) and the interleukin-1 receptor antagonist (IL1RN), respectively. Thus, an enhanced maternal pro-inflammatory immune response to LPS may increase susceptibility to PPROM in multi-fetal pregnancies.

Female↗

PubMed2003

Outcome in preterm small for gestational age infants compared to appropriate for gestational age preterms at the age of 2 years: a prospective study.

OBJECTIVES: To investigate the effects of small for gestational age (SGA) in preterm infants on growth and development until the age of 22 months. STUDY DESIGN: Seventy-four preterm infants being born SGA (birth weight <10th percentile) were compared with 74 appropriate for gestational age (AGA) infants matched prospectively according to gestational age with respect to growth parameters and neurodevelopment (using Griffiths developmental scores) at the age of 22 months corrected age. RESULTS: Birth weight was significantly lower in SGA-infants compared to AGA-infants (1503 g (430-2205 g) versus 1995 g (680-3300 g); P<0.0001 (median and range)). There were no significant differences regarding the median gestational age (34 weeks), gender distribution, mode of delivery, umbilical artery pH, and APGAR-scores. Mean Griffiths-scores did not differ significantly between both groups (96.7% versus 97.6%). Developmental retardation was diagnosed in 9 SGA-infants versus 10 AGA-infants. Within the total group a positive correlation was observed between gestational age and developmental scoring. Body weight, head circumference, and height were significantly lower in SGA-infants at 22 months corrected age. CONCLUSION: No significant differences regarding neurodevelopmental outcome at 22 months were observed between SGA- and AGA-infants. SGA-infants did not show catch-up growth.

Apgar Score↗

PubMed2001

Tocolytic therapy for preterm labour: assessing its potential for reducing preterm delivery.

Preterm labour (PTL) is a major contributor to preterm delivery (PTD) but delivery is often not preventable by current therapies. We conducted this study to determine the proportion of women with PTL who were and who were not candidates for tocolytic therapy. The cohort comprised residents of Olmsted County, Minnesota who delivered at >20 weeks' gestation in 1985--94 and who experienced PTL. Medical records were abstracted to identify episodes of PTL, its treatment and outcome. We developed an algorithm that accounted for gestation at delivery and pregnancy complications to determine the proportion of pregnancies complicated by PTL that were candidates for tocolytic therapy. Of 651 pregnancies complicated by PTL, a 50% probability sample, stratified by delivery year, were selected and abstracted. The cumulative incidence of PTL ranged from 3.6 to 6.4 per 100 deliveries of live or stillborn infants. Tocolysis was not contraindicated for 49.4% of all women with PTL and for a third of women with only one PTL episode. Delivery was delayed to >35 weeks in 53.8% of candidates for tocolysis. Only an additional 11.7% of women with one or more PTL episodes could have had their PTD delayed beyond 35 weeks if a perfect tocolytic therapy had been available. Many pregnancies complicated by PTL occurred at > or =35 weeks or involved maternal or obstetric factors that contraindicated tocolytic medications. The maximum incremental benefit that could be expected of a new safe and efficacious tocolytic therapy would be to reduce current PTD rates resulting from PTL by about 12%.

Adolescent↗

PubMed2004

Are reported preterm birth rates reliable? An analysis of interhospital differences in the calculation of the weeks of gestation at delivery and preterm birth rate.

We investigated the possibility of preterm birth misclassification as a determinant of variation in its reported rates. Using a database of 497,105 deliveries from 17 hospitals, the best estimate of gestational age made at delivery and entered into the database at that time was recalculated from the menstrual dates and mid-trimester ultrasound scan. The recalculated completed weeks of gestation at delivery was compared with that made at birth. Calculation of estimated gestational age varied between hospitals due to inconsistencies in 'rounding' and 'truncating' the weeks of gestation at delivery. This resulted in preterm birth misclassification rates of up to 10.1%.

Birth Rate↗