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This is a general article. See Psychological aspects of premature birth for in depth consideration of psychological factors surrounding this event.
In humans, preterm birth refers to the birth of a baby of less than 37 weeks gestational age. Premature birth, commonly used as a synonym for preterm birth, refers to the birth of a premature infant. The child may commonly be referred to throughout their life as being born a "preemie" or "preemie baby". Because it is by far the most common cause of prematurity, preterm birth is the major cause of neonatal mortality in developed countries. Premature infants are at greater risk for short and long term complications, including intellectual and physical disabilities and impediments in physical and psychological development. Significant progress has been made in the care of premature infants, but not in reducing the prevalence of preterm birth. The cause for preterm birth is in many situations elusive and unknown; many factors appear to be associated with the development of preterm birth, making the reduction of preterm birth a challenging proposition.
In that they continue developing after birth, most animals are not born mature. At birth, a normal human infant is less mature than infants of some other primate species, possibly to allow the disproportionately large head to fit through a pelvis adapted for walking on two legs.
In humans, whereas the usual definition of preterm birth is birth before 37 weeks gestation, a "premature" infant is one that has not yet reached the level of fetal development that generally allows life outside the womb. 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 develop in the womb; because of this, premature babies typically spend the first days/weeks of their life on a ventilator. Therefore, a significant overlap exists between preterm birth and prematurity: generally, preterm babies are premature and term babies are mature. 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.
Signs and symptoms
Symptoms of imminent spontaneous preterm birth are signs of premature labor; such signs consists of four or more uterine contractions in one hour before 37 weeks' gestation. In contrast to false labor, true labor is accompanied by cervical shortening 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 real 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.
Mortality and morbidity
The shorter the term of pregnancy, the greater the risks of mortality and morbidity for the baby primarily due to the related prematurity. Preterm-premature babies ("preemies" or "premies") have an increased risk of death in the first year of life (infant mortality), with most of that occurring in the first month of life (neonatal mortality). Worldwide, prematurity accounts for 10% of neonatal mortality, or around 500,000 deaths per year. In the U.S. where many infections and other causes of neonatal death have been markedly reduced, prematurity is the leading cause of neonatal mortality at 25%. Prematurely born infants are also at greater risk for having subsequent serious chronic health problems as discussed below.
The earliest gestational age at which the infant has at least a 50% chance of survival is referred to as the limit of viability. As NICU care has improved over the last 40 years, viability has reduced to approximately 24 weeks, although rare survivors have been documented as early as 21 weeks. This date is controversial as gestation in this case was measured from the date of conception rather than the date of her mother's last menstrual period. Gestation appears 2 weeks less than if calculated by the more common method. As risk of brain damage and developmental delay is significant at that threshold even if the infant survives, there are ethical controversies over the aggressiveness of the care rendered to such infants. The limit of viability has also become a factor in the abortion debate.
Specific risks for the preterm neonate
Preterm infants usually show physical signs of prematurity in reverse proportion to the gestational age. As a result they are at risk for numerous medical problems affecting different organ systems.
- Neurological problems include apnea of prematurity, hypoxic-ischemic encephalopathy (HIE), retinopathy of prematurity (ROP), developmental disability, cerebral palsy and intraventricular hemorrhage, the latter affecting 25 percent of babies born preterm, usually before 32 weeks of pregnancy. Mild brain bleeds usually leave no or few lasting complications, but severe bleeds often result in brain damage or even death.
- Cardiovascular complications may arise from the failure of the ductus arteriosus to close after birth: patent ductus arteriosus (PDA).
- Respiratory problems are common, specifically the respiratory distress syndrome (RDS or IRDS) (previously called hyaline membrane disease). Another problem can be chronic lung disease (previously called bronchopulmonary dysplasia or BPD).
- Gastrointestinal and metabolic issues can arise from hypoglycemia, feeding difficulties, rickets of prematurity, hypocalcemia, inguinal hernia, and necrotizing enterocolitis (NEC).
- Hematologic complications include anemia of prematurity, thrombocytopenia, and hyperbilirubinemia (jaundice) that can lead to kernicterus.
- Infectious include sepsis, pneumonia, and urinary tract infection 
As the cause of labor still remains elusive, the exact cause of preterm birth is also unsolved. Labor is a complex process involving many factors. Four different pathways have been identified that can result in preterm birth and have considerable evidence: precocious fetal endocrine activation, uterine overdistension, decidual bleeding, and intrauterine inflammation/infection. Activation of one or more of these the these pathways may have been gradually over weeks, even months. From a practical point a number of factors have been identified that are associated with preterm birth, however, an association does not establish causality.
A number of factors have been identified that are linked to a higher risk of a preterm birth: low socio-economic or educational standing and single motherhood, as well as age at the upper and lower end of the reproductive years be it more than 35 or less than 18 years of age. Further, in the US and the UK Afro-American and Afro-Caribbean women have preterm birth rates of 15–18% more than double than that of the white population. This discrepancy is not seen in comparison to Asian or Hispanic immigrants and remains unexplained.
Pregnancy interval makes a difference as women with a 6 months span or less between pregnancies have a two-fold increase in preterm birth. 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. Patients who had undergone previous induced abortions have been shown to have a higher risk of preterm birth only if the termination was performed surgically but not medically. Adequate maternal nutrition is important. Women with a low BMI are at increased risk for preterm birth. Further, women with poor nutritional status may also be deficient in vitamins and minerals. Adequate nutrition is critical for fetal development and a diet low in saturated fat and cholesterol may help reduce the risk of a preterm delivery. Obesity does not directly lead to preterm birth; however, it is associated with diabetes and hypertension which are risk factors by themselves. Women with a previous preterm birth are at higher risk for a recurrence at a rate of 15–50% depending on number of previous events and their timing. To some degree those individuals may have underlying conditions (i.e. uterine malformation, hypertension, diabetes) that persist. Genetic make-up is a factor in the causality of preterm birth. An intra- and transgenerational increase in the risk of preterm delivery has been demonstrated. No single gene has been identified, and it appears with the complexity of the labor initiation, that numerous polymorphic genetic interactions are possible.
Factors during pregnancy
Multiple pregnancies (twins, triplets, etc.) are a significant factor in preterm birth. The March of Dimes Multicenter Prematurity and Prevention Study found that 54% of twins were delivered preterm vs. 9.6% of singleton births. Triplets and more are even more endangered. 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 an important factor in preterm birth. Maternal medical conditions increase the risk of preterm birth, and 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. In a number of women anatomical issues prevent that the baby is carried to term. Some women have a weak or short cervix (the strongest predictor of premature birth) The cervix may also have been compromised by previous cervical conization or loop excision. In women with uterine malformations the capacity of the uterus to hold the growing pregnancy may be limited and preterm labor ensues. 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 two conditions is linked to a higher preterm birth rate. Women with abnormal amounts of amniotic fluid, too much (polyhydramnios) or too little (oligohydramnios) are also at risk. The mental status of the women is of significance. Anxiety and depression have been linked to preterm birth. Finally, the use of tobacco, cocaine, and excessive alcohol during pregnancy also increases the chance of preterm delivery. Tobacco is the most commonly abused drug during pregnancy and also contributes significantly to low birth weight delivery. Babies with birth defects are at higher risk of being born preterm.
Infections play a major role in the genesis of preterm birth and may account for 25–40% of events. The frequency of infection in preterm birth is inversely related to the gestational age. Endotoxins released by microorganisms and cytokines stimulate deciduasl responses including the release of prostaglandins which may stimulate uterine contractions. Further the decidual response may include release of matrix-degrading enzymes that weaken fetal membranes leading to premature rupture. Intrauterine infection appears to be a chronic process. Typical organisms identified in the uterus before rupture of the membranes are genital Mycoplasma spp and specifically Ureaplasma urealyticum. Micro-organisms may reach the decidua in a number of ways, ascending, hematogeneous, iatrogenic by a procedure, or retrograde through the fallopian tubes. From the deciduas they may reach the space between the amnion and chorion, the amniotic fluid, and finally the fetus. A chorioamnionitis also may lead to sepsis of the mother. Fetal infection not only is linked to preterm birth but to significant long-term handicap 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. Bacterial vaginosis has been linked to preterm birth raising the risk by a factor of 1.5 – 3. As the condition is more prevalent in black women in the US and the UK, it has been suggested to be an explanation for the higher rate of preterm birth in this population. It is opined that bacterial vaginosis before or during pregnancy may affect the decidual inflammatory response that leads to preterm birth. A number of maternal bacterial infections are associated with preterm birth including pyelonephritis, asymptomatic bacteriuria, pneumonia, and appendicitis. 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.
Helpful clinical test should predict a high risk for preterm birth during the early and middle part of the third trimester, when their impact is significant. Many women experience false labor (not leading to cervical shortening and effacement) and are falsely labelled to be in preterm labor. The study of preterm birth has been hampered by the difficulty in distinguishing between "true" preterm labor and false labor. These new test are used to identify women at risk for preterm birth.
Fetal fibronectin has become the most important biomarker—the presence of this glycoprotein in the cervical or vaginal secretions indicates that the border between the chorion and deciduas 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.
Ultrasonography of the cervix
Obstetric ultrasound has become useful in the assessment of the cervix in women at risk for premature delivery. A short cervix preterm is undesirable: At 24 weeks gestation a cervix length of less than 25 mm defines a risk group for preterm birth. Further, the shorter the cervix the greater the risk. It also has been helpful to use ultrasonography in women with preterm contractions, as those whose cervix length exceeds 30 mm are unlikely to deliver within the next week.
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.
Primary (aimed at all women)
The prevention of premature births is what needs to be focused on today. That is what the professionals in the health care community are struggling with. “Reasons for this include a lack of universal access to health care for women of childbearing age or pregnant women of any age”. Depression is a leading cause for premature births. Women suffering with this disorder need to make sure they are in continuous treatment in order for their symptoms to be controlled and monitored. Becoming overly stressed and upset can trigger premature labor in an otherwise healthy woman. 
There needs to be more focus on the decisions pregnant women make and the potential effects on their unborn child, including smoking, drugs, and alcohol. Partaking in any of these activities first and foremost denies the fetus from proper nourishment. Smoking increases the risk of premature births and possibly stillbirths. Abusing alcohol while pregnant has been linked to children with behavioral problems later in life, as well as fetal alcohol syndrome. Illegal drugs attribute to birth defects and premature births. All of the above should be enough for a woman to make better lifestyle changes while she is caring a child, but unfortunately it is not made public enough.
Other than the lifestyle choices an expecting mother can make, there are some cases that a premature birth is not in the mother’s hands. Of all premature births, 40 percent do not have a known cause. There are though four main routes that can lead to a premature birth or spontaneous premature labor. Infections is the first of these four. Usually urinary tract infections or infections involving the genitals can trigger a woman to go into preterm labor. Fetal and maternal stress is the second of the four. CRH, corticotrophin-releasing hormone, which is produced when the mother and or fetus are under unusual stress can cause other hormones to be released which can trigger uterine contractions, resulting in a premature birth. Placental abruption is the third and can cause bleeding. Multiple births or an abundance of amniotic fluid may cause the uterus to stretch which is the fourth route that is identified in the causes of premature births. This can also lead to chemicals being released that cause uterine contractions. Scientists are and have been working on interventions to prevent premature births, but there is not one final answer to prevent all children from being born prematurely.
Raising public and professional awareness about the scope of the problem and its significance as the major contributor to infant mortality is a beginning to reduce avoidable risk factor. Among them is the need to reduce repeated uterine instrumentation (ie repeated surgical abortions) and to avoid risky choices in infertility treatments. 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 were limited. Society has established in many countries programs specifically to protect pregnant women from hazardous work and night shift and provided 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 (>42 h per week) or prolonged standing (>6 h 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. Avoidance of weight extremes and good nutritional support are important. Although a study failed to show that multivitamin preparation taken prior to conception reduces the risk of preterm birth, preconceptional intake of folic acid is recommended to reduce birth defects. There is some evidence that long term (> one year) use of folic acid may reduce premature birth. Reducing smoking is expected to benefit pregnant women and their offspring.
Interventions that should have been initiated prior to pregnancy, can still be instituted during pregnancy including nutritional adjustments, use of vitamin supplements, and smoking cessation. Calcium supplementation as well as supplemental intake of C and E vitamins could not be shown to reduce preterm birth rates. Different strategies are used in the administration of prenatal care, and future studies need to determine if the focus should be on screening for high risk women, or widened support for low-risk women, or to what degree these approaches should be merged. While periodontal infection has been linked with preterm birth, randomized trials have not shown that periodontal care during pregnancy reduces preterm birth rates.
Screening of low risk women
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 identifies patients at risk, but cerclage is not proven useful, and the application of a progesterone is under study. Screening for the presence of fibronectin in vaginal secretions is not recommended at this time in women at low risk.
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). Self-monitoring vaginal pH followed by yogurt treatment or clindamycin treatment if the pH was too high all seem to be effective at reducing the risk of preterm birth.
Secondary (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 prior to conception, be it for asthma, diabetes, hypertension and others.
Reducing indicated preterm birth
A number of agents have been studied for 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-aspirin was used. Interestingly, 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 maternal activity – pelvic rest, limited work, bed rest – is frequently recommended although there is no clear proof of its efficacy. Also, increasing medical care by more frequent visits and more education has not shown a reduction in 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.
Studies examining the use of antibiotics have provided mixed results; a Cochrane review of 15 trials shows no major benefit, in contrast a review by Lamont suggested that treatment of bacterial vaginosis if initiated prior to 20 w gestation is beneficial. It has been suggested that the presence of a chronic chorioamnionitis may not be amenable to antibiotics, thus the difficulty to demonstrate their effectiveness.
Progesterone, often given in the form of 17-hydroxyprogesterone caproate, relaxes the uterine musculature, maintains cervical length, and has anti-inflammatory properties, and thus exerts activities expected to be beneficial in reducing preterm birth. Two meta-analyses demonstrated a deduction in the risk of preterm birth in women with recurrent preterm birth by 40–55%. However, progesterone is not effective in all populations, as a study involving twin gestations failed to see any benefit.
- 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. Women with a short cervix but no history of preterm birth, and women with twin gestation, do not benefit from a cerclage.
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. Centers for the care of women with preterm delivery are usually staffed by maternal-fetal specialists and highly trained staff and linked to neonatal intensive care units (vi). In a hospital setting women are hydrated via intravenous infusion as dehydration can lead to premature uterine contractions.
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, a steroid that crosses the placental barrier and stimulates the production of surfactant in the lungs of the fetus. Typical glucocorticoids that would be administered in this context are betamethasone or dexamethasone, often when the fetus has reached viability at 23 weeks. In cases where premature birth is imminent, a second "rescue" course of steroids may be administered 12 to 24 hours before the anticipated birth. There is no research consensus on the efficacy and side-effects of a second course of steroids, but the consequences of RDS are so severe that a second course is often viewed as worth the risk. Beside reducing respiratory distress, other neonatal complication are reduced by the use of glucocorticosteroids, namely intraventricular haemorrhage, necrotising enterocolitis, and patent ductus arteriosus.
Despite being used for over 50 years to treat respiratory distress syndrome, glucocorticosteroid therapy is still controversial. Much of this concern is based on when these steroids should be administered (i.e. prenatally or postnatally) or for how long (i.e. acutely or chronically). For instance, recent clinical research has shown that the postnatal administration of dexamethasone can lead to permanent neuromotor and cognitive deficits. This has led to a drastic reduction in the postnatal use of glucocorticosteroids in prematurely born infants. In addition, a recent large scale study has found that a second “rescue” dose of betamethasone prenatally does not improve preterm birth outcomes and leads to decreased weight, length, and head circumference. Finally, while glucocorticosteroid exposure in the adult is considered safe, recent animal research has shown that a single exposure to these same drugs during brain development causes rapid brain degeneration. Despite these concerns, there is a consensus that the benefits of a single regimen of prenatal glucocorticosteroids vastly outweigh the potential risks.
The routine administration of antibiotics to all women with threatened preterm labor reduces the risk of the baby to get infected with group B streptococcus and has been shown to reduce related mortality rates.
Research reported at the 2008 conference of the Society for Maternal-Fetal Medicine suggests that administration of magnesium sulfate (Epsom salt) to women just before premature birth can cut the rate of cerebral palsy in half. While the compound is cheap and safe, it may make mothers and infants groggy, and details are pending scientific publication.
Anti-contraction medications (tocolytics), such as Beta2-agonist drugs (ritodrine, terbutaline, fenoterol), calcium-channel blockers nifedipine and oxytocin antagonists (atosiban) appear only to have a temporary effect in delaying delivery. Tocolysis has not fulfilled its promise as it is rarely successful beyond 24–48 hours because current medication do not alter the fundamentals of labor activation. However, just gaining 48 hours is sufficient to allow the pregnant women to be transferred to a center specialized for management of preterm deliveries and give administered corticosteroids the possibility 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. Meta-analyses of magnesium sulfate failed to support it as a tocolytic agent.
When membranes rupture prematurely, obstetrical management looks for development of labor and signs of infection. Administration of corticosteroids is indicated prior to 34 weeks gestation. Prophylactic antibiotic administration has been shown to prolong pregnancy and reduced neonatal morbidity. Because of concern about necrotizing enterocolitis, amoxicillin or erythromycin has been recommended, but not amoxicillin + clavulanic acid (co-amoxiclav).
The routine use of cesarean 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.
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. 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. Bili lights may also be used to treat newborn jaundice (hyperbilirubinemia).
Most children even if born very preterm adjust very well during childhood and adolescence. As survival has improved, the focus of interventions directed at the newborn has shifted to reduce long-term disabilities, particularly those related to brain injury. Some of the complications related to prematurity may not be apparent until years after the birth. A long-term study demonstrated that the risks of medical and social disabilities extend into adulthood and are higher with decreasing gestational age at birth and include cerebral palsy, mental retardation, disorders of psychological development, behavior, and emotion, disabilities of vision and hearing, and epilepsy. Also it was shown that higher levels of education were less likely to be obtained with decreasing gestational age at birth. People born prematurely may be more susceptible to developing depression as teenagers. Some of these problems can be described as being within the executive domain and have been speculated to arise due to decreased myelinization of the frontal lobes. Throughout life they are more likely to require services provided by physical therapists, occupational therapists, or speech therapists. Further long-term studies are needed to get a better picture about the sequalae of preterm birth.
In Europe and many developed countries the preterm birth rate is generally 5–9%, and in the USA it has even risen to 12–13% in the last decades. Three obstetric events precede preterm birth: spontaneous preterm births are the 40–45% preterm births that follow preterm labor and the 25–30% preterm births after premature rupture of membranes. The remainder (30–35%) are preterm births that are induced for obstetrical reasons; obstetricians may have to deliver the baby preterm because of a deteriorating intrauterine environment (i.e. infection, intrauterine growth retardation) or significant endangerment of the maternal health (i.e. preeclampsia, cancer). By gestational age, 5% of preterm births occur at less than 28 weeks (extreme prematurity), 15% at 28–31 weeks (severe prematurity), 20% at 32–33 weeks (moderate prematurity), and 60–70% at 34–36 weeks (near term).
As weight is easier to determine than gestational age, the World Health Organization tracks rates of low birth weight (< 2,500 grams), which occurred in 16.5 percent of births in less developed regions in 2000. It is estimated that one-third of these low birth weight deliveries are due to preterm delivery. Weight generally correlates to gestational age, however, infants may be underweight for other reasons than a preterm delivery. Neonates of low birth weight (LBW) have a birth weight of less than 2500 g (5 lb 8 oz) and are mostly but not exclusively preterm babies as they also include small for gestational age (SGA) babies. Weight-based classification further recognizes Very Low Birth Weight (VLBW) which is less than 1500 g, and Extremely Low Birth Weight (ELBW) which is less than 1000 g. Almost all neonates in these latter two groups are born preterm.
Preterm birth is a significant cost factor in healthcare, not even considering the expenses of long-term care for individuals with disabilities due to preterm birth. A 2003 study in the US determined neonatal costs to be $224,400 for a newborn at 500–700 g versus $1,000 at over 3,000 g. The costs increase exponentially with decreasing gestational age and weight.
Society and culture
Notable preterm births
James Elgin Gill (born on 20 May 1987 in Ottawa, Canada) was the earliest premature baby in the world. He was 128 days premature (21 weeks and 5 days gestation) and weighed 1 pound 6 ounces (624 g). He survived and is quite healthy.
Amillia Taylor is also often cited as the most-premature baby. She was born on 24 October 2006 in Miami, Florida, at 21 weeks and 6 days gestation. This report has created some confusion as her gestation was measured from the date of conception (through in-vitro fertilization) rather than the date of her mother's last menstrual period making her appear 2 weeks younger than if gestation was calculated by the more common method. At birth, she was Template:Convert/LoffAnoneDbSoffTemplate:Convert/test/Aoff long and weighed 10 ounces (283 grams). She suffered digestive and respiratory problems, together with a brain hemorrhage. She was discharged from the Baptist Children's Hospital on 20 February 2007.
The record for the smallest premature baby to survive was held for some time by Madeline Mann, who was born at 26 weeks weighing Template:Convert/ozTemplate:Convert/test/Aon and Template:Convert/LoffAnoneDbSoffTemplate:Convert/test/Aoff long. This record was broken in September 2004 by Rumaisa Rahman, who was born in the same hospital at 25 weeks gestation. At birth, she was eight inches (20 cm) long and weighed 244 grams (8.6 ounces). Her twin sister was also a small baby, weighing 563 grams (1 pound 4 ounces) at birth. During pregnancy their mother had suffered from pre-eclampsia, which causes dangerously high blood pressure putting the baby into distress and requiring birth by caesarean section. The larger twin left the hospital at the end of December, while the smaller remained there until 10 February 2005 by which time her weight had increased to Template:Convert/LoffAonDbSoffTemplate:Convert/test/Aon. Generally healthy, the twins had to undergo laser eye surgery to correct vision problems, a common occurrence among premature babies.
The autistic savant Derek Paravicini was born at 25 weeks. The oxygen therapy given during his time in a neonatal intensive care unit rendered him blind and affected his developing brain, resulting in his severe learning disability. Furthermore Paravicini developed autism. However, he also has absolute pitch and his musical abilities developed to genius levels.
The world's smallest premature boy to survive was born in June 2004 at Saint Barnabas Medical Center in Livingston, New Jersey. Tyler Martin was born at 23 weeks with a weight of 320 grams (11 ounces). He was hospitalized in the Neonatal Intensive Care Unit for five months. His twin brother was hospitalized for four months. There was also another boy who was born at the same weight in Ulm, Germany in 1998. However, the status after birth could not be verified.
Historical figures who were born prematurely include Johannes Kepler (born in 1571 at 7 months gestation), Isaac Newton (born in 1643, small enough to fit into a quart mug, according to his mother), Winston Churchill (born in 1874 at 7 months gestation), and Anna Pavlova (born in 1885 at 7 months gestation).
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 Goldenberg RL, Culhane JF, Iams JD, Romero R (2008). Epidemiology and causes of preterm birth. The Lancet 371: 75–84.
- ↑ Steer P (2005). The epidemiology of preterm labour. British Journal of Obstetrics & Gynaecology 112 (Suppl 1): 1–3.
- ↑ (1999). Reducing Perinatal and Neonatal Mortality. 'Child Health Research Project Special Report'.
- ↑ Mathew TJ, MacDorman MF (2006). Infant Mortality Statistics from the 2003 Period Linked Birth/Infant Death Data Set. National Vital Statistics Reports 54 (16).
- ↑ Kaempf JW, Tomlinson M, Arduza C, et al. (2006). Medical staff guidelines for periviability pregnancy counseling and medical treatment of extremely premature infants. Pediatrics 117 (1): 22–29. — in particular see TABLE 1 Survival and Neurologic Disability Rates Among Extremely Premature Infants
- ↑ Morgan MA, Goldenberg RL, Schulkin J (2008). Obstetrician-gynecologists' practices regarding preterm birth at the limit of viability. Journal of Maternal-Fetal and Neonatal Medicine 21 (2): 115–121.
- ↑ James SD (2007). Life at 21 weeks:Immature Lungs and a Handful of Fragile Skin and Pain. ABC News. URL accessed on 2008-12-16.
- ↑ 8.0 8.1 March of Dimes --> Neonatal Death Retrieved on September 2, 2009
- ↑ 9.0 9.1 9.2 9.3 9.4 Simhan HN, Caritis SN (2007). Prevention of Preterm Delivery. New England Journal of Medicine 357: 477–487.
- ↑ Martius JA, Steck T, Oehler MK, Wulf KH (1998). Risk factors associated with preterm (<37+0 weeks) and early preterm birth (<32+0 weeks): univariate and multivariate analysis of 106 345 singleton births from the 1994 statewide perinatal survey of Bavaria. European Journal of Obstetrics & Gynecology and Reproductive Biology 80 (2): 183–189.
- ↑ Smith GC, Pell JP, Dobbie R (2003). Interpregnancy interval and risk of preterm birth and neonatal death: retrospective cohort study. British Medical Journal 327: 313.
- ↑ Virk J, Zhang J, Olsen J (2007). Medical Abortion and the Risk of Subsequent Adverse Pregnancy Outcomes. New England Journal of Medicine 357: 648–653.
- ↑ Hendler I, Goldenberg RL, Mercer BM, et al. (2005). The preterm prediction study: association between maternal body mass index (BMI) and spontaneous preterm birth. American Journal of Obstetrics & Gynecology 192: 882–886.
- ↑ (2005) Cholesterol Lowering Diet for Pregnant Women May Help Prevent Preterm Birth. British Medical Journal 331: 1093.
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Pathology of pregnancy, childbirth and the puerperium (O, 630-676)
|Complications of pregnancy||
|Obstetric labor complications||
Preterm birth · Postmature birth · Cephalopelvic disproportion · Dystocia (Shoulder dystocia) · Fetal distress · Vasa praevia · Uterine rupture · Hemorrhage (Postpartum) · placenta (Placenta accreta) · Umbilical cord prolapse · Amniotic fluid embolism