Preterm birth and its complications

Preterm birth (premature birth) is a significant public health problem across the world because of
associated neonatal period mortality and short- and long-term morbidity and disability in later life. As
per World Health Organization (WHO) any neonate born alive before 37 completed weeks of gestation
or fewer than 259 days of gestation since the first day of a woman’s last menstrual period (LMP) is
called a preterm neonate.
Preterm birth is classified as per gestational age:
1. Extremely preterm – neonates born before 28 weeks
2. Early preterm – neonates born before 34 weeks
3. Late preterm – neonates born between 34 to 37 weeks
According to WHO, every year about 15 million babies are born prematurely around the world and that
is more than 1 in 10 of all babies born globally. Almost 1 million children die each year due to
complications of preterm birth (2013). Across 184 countries, the rate of preterm birth ranges from 5%
to 18% of babies born. According to Born Too Soon: The Global Action Report on Preterm Birth,
released by Save the Children, The March of Dimes Foundation, the Partnership for Maternal,
Newborn & Child Health and The World Health Organization - India tops the list of 10 nations
contributing 60% of the world’s premature deliveries – with the maximum number of preterm births
with 3,519,100 of them, almost 24% of the total number.
Newborn deaths (those in the first month of life) account for 40 percent of all deaths among children
under five years of age. Preterm birth is the world’s number one cause of newborn deaths, and the
second leading cause of all child deaths under five, after pneumonia. The chance of survival at 22
weeks is about 6%, while at 23 weeks it is 26%, 24 weeks 55% and 25 weeks about 72%. The
chances of survival without long-term difficulties is less. In the developed world overall survival is
about 90% while in low-income countries survival rates are about 10%.
Many of the preterm babies who survive suffer from various disabilities like cerebral palsy, sensory
deficits, learning disabilities and respiratory illnesses. The morbidity associated with preterm birth often
extends to later life, resulting in physical, psychological and economic stress to the individual and the
family.
Though occurrence of preterm birth is a global problem, but more than 60% of preterm births occur in
Africa and South Asia. In the lower-income countries, on average, 12% of babies are born too early
compared with 9% in higher-income countries. Within countries, poorer families are at higher risk.
Survival of premature babies also depends on where they are born; almost 9 out of every 10 preterm
babies survive in high-income countries because of enhanced basic care and awareness, in sharp
contrast to about 1 out of 10 in low-income countries.

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More than three-quarters of preterm /premature babies can be saved with often inexpensive care such
as essential care during child birth, antenatal steroid injections (given to pregnant women at risk of
preterm labour under set criteria to strengthen the babies’ lungs) and postnatal care like kangaroo
mother care (the baby is carried by the mother with skin-to-skin contact and frequent breastfeeding),
and basic care for infections and breathing difficulties.
Identification of risk factors in women with improved care before, between and during pregnancies;
better access to contraceptives and increased empowerment/ education can further decrease the
preterm birth rate (the number of preterm births divided by the number of live births).

Preterm birth is a syndrome with a variety of causes which can be classified into two broad subtypes:
1. Spontaneous preterm birth: may occur after spontaneous onset of labour or following
prelabour premature rupture of membranes (PPROM).The cause of spontaneous preterm
labour cannot be unidentified in up to half of all cases.
2. Provider-initiated preterm birth is defined as induction of labour or elective caesarian birth
before 37 completed weeks of gestation for maternal or fetal indications (both “urgent” and
“discretionary”), or other non-medical reasons.
Approximately 45–50% of preterm births are idiopathic (unknown cause), 30% are related to preterm
rupture of membranes (PROM) and another 15–20% are attributed to medically indicated or elective
preterm deliveries.

Risk factors for preterm birth

 Age at pregnancy: adolescent pregnancy and advanced maternal age
 Previous preterm birth
 Multiple pregnancies (such as twins, triplets)
 Infections and chronic maternal illnesses such as diabetes and high blood pressure
 Obstetrics factors: uterine malformations, antepartum haemorrhage, uterine trauma,
premature rupture of membranes, preterm cervical shortening, previous cervical surgery.
 Genetic influences
 Nutritional: under nutrition, obesity, micronutrient deficiencies
 Life style: Women who smoke cigarettes, drink alcohol or take other recreational drugs are at
a higher risk of having preterm babies.

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  Stress from any cause, excessive physical work or long times spent standing are also known
to increase a woman’s risk of having preterm birth.

Complications of preterm birth- related to difficulty in extrauterine function due to immaturity

of organ system.
1. Respiratory
 Respiratory distress syndrome due to surfactant deficiency and lung immaturity seen in 80%
of babies born before 27 weeks of gestation.
 Apnea due to immaturity in mechanisms controlling breathing. Seen in almost all infants < 28
weeks gestational age. 25% infants who weigh < 1800 gms have at least one apneic episode.
2. Neurologic
 Perinatal depression
 Intracranial haemorrhage - The incidence and severity of IVH(intraventricular
hemorrhage)increase with decreasing gestational age and birth weight. Factors that contribute
to IVH include hypotension, hypertension, fluctuating blood pressures, poor autoregulation of
cerebral blood flow, disturbances in coagulation, hyperosmolarity, and injury to the vascular
endothelium by oxygen free radicals. In 10 to 15 percent of infants a germinal matrix
hemorrhage will obstruct venous return and lead to venous infarction of brain tissue. As many
as 11 percent of infants with birth weights of less than 1,500 grams have IVH with ventricular
dilation or IPH. The prevalence of neurodevelopmental disabilities in preterm infants with
severe IVH and ventricular dilation or posthemorrhagic hydrocephalus ranges from 20 to 75
percent.
 Periventricular leukomalacia (PVL) - Injury to the periventricular white matter is a sign of CNS
injury and is a complication of preterm birth. A meta-analysis found significant relationships
between clinical chorioamnionitis, PVL, and cerebral palsy in preterm infants
3. Cardiovascular
 Hypotension due to hypovolemia, cardiac dysfunction and sepsis induced vasodilatation
 Patent ductus arteriosus (PDA)- Approximately 5 percent of infants with birth weights of less
than 1,500 grams are treated for patent ductus arteriosus.
4. Hematologic
 Anaemia - Anemia of prematurity is an exaggeration of the physiological anemia of infancy
because of suppressed hematopoiesis for 6 to 12 weeks after birth and is earlier in onset and
symptomatic.
 Hyperbilirubinemia
5. Nutritional
 Preterm babies have specific requirement for feeds in relation to the content, caloric density,
volume and route of feeding.
6. Gastrointestinal
 Necrotising enterocolitis (NEC) occurs in 3% of infants born < 33 weeks and 7% of VLBW
infants. Gastro-esophageal reflux is very common in preterm babies and adversely affects the
growth and health. It may also manifest as aspiration pneumonia, wheezing or worsening BPD
(bronchopulmonary dysplasia)/CLD 9chronic lung disease).
7. Metabolic
 Hypoglycaemia or persistent hyperglycemia is frequently seen in VLBW and ELBW babies.
 Hypercalcaemia – preterm infants have poor target organ responsiveness to parathyroid
hormone.
8. Renal

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  Immature kidneys have low GFR and have poor ability to process water, solute and acid loads.
They are at risk of electrolyte imbalance, renal tubular acidosis and late onset hyponatremia of
prematurity.
9. Thermoregulation
 Poor control of thermoregulation and at risk of hypothermia. Preterm infants have increased
heat loss and poor heat generating capabilities. They are more prone to cold stress and have
high caloric loss.
10. Immunologic
 At risk of infection due to immature humoral and cellular response. The most serious
manifestations commonly seen in preterm infants include pneumonia, sepsis, meningitis, and
urinary tract infections. As many as 65 percent of infants with birth weights of less than 1,000
grams have at least one infection during their initial hospitalization. Neonates with birth
weights of less than 1,000 gram and infections have been found to have poorer head growth,
more cognitive impairment, and higher rates of cerebral palsy than those who did not have
infections as neonates. Invasive fungal infections occur in 6 to 7 percent of infants in an NICU,
and the rates of such infections increase with decreasing gestational age and birth weight.
Disseminated fungal infection, in which the infection is spread throughout the body, has a
mortality rate of 30 percent.

Long term complications of preterm babies

1. Neurologic disabilities
 Cerebral palsy - the incidence of cerebral palsy is 7% to 12% in VLBW and 11% to 15%in
ELBW infants. Most common type of cerebral palsy is Spastic diplegia.

 developmental delay – specially poor motor coordination

 Cognitive dysfunction like language disorders, learning disabilities, hyperactivity, attention

deficits, behavioural disorders. They have lower IQ and DQ. Between 5% to 20% of VLBW
and 14% to 40% of ELBW children have cognitive delay. More than 50% of ELBW infants
require special education assistance.

 Sensory impairments like hearing loss occurs in 2% to 11% of VLBW infants.

2. Ophthalmological issues - Retinopathy of prematurity (ROP) can lead to significant vision loss or
blindness in the setting of retinal detachment. ROP occurs in 16 to 84 percent of infants born with
gestational ages of less than 28 weeks, 90 percent of infants with birth weights of less than 500 or 750
grams, and 42 to 47 percent of infants with birth weights of less than 1,000 or 1,500 grams. About 2%
to 9% ELBW infants can be blind if they have severe ROP. Other eye problems seen in preterm babies
is refractive errors, amblyopia, strabismus, anisometropia.
3. Chronic lung disease (CLD) or Bronchopulmonary dysplasia (BPD) is seen in 23% of VLBW
infants and 35% to 45% of ELBW infants. They frequently suffer from other co-morbidities like acute
respiratory exacerbations, upper and lower respiratory infections, reactive airway disease, pulmonary
hypertension, growth failure and developmental delay.
4. Poor growth, anemia and osteopenia of prematurity is seen commonly.
5. Increased rates of childhood illnesses and frequent hospitalisations – VLBW infants are four times
more likely to be rehospitalised during first year of life than term infants. At least 60% are
rehospitalised at least once by the time they reach school age.
6. Social – financial, psychological and emotional impact can be unbearable for parents in developing
countries in a resource limited scenario. 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.
The 2007 Institute of Medicine report Preterm Birth found that the 550,000 preemies born each year in

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the U.S. run up about $26 billion in annual costs, mostly related to care in NICUs, but the real tab may
top $50 billion.

Conclusion – With fast ongoing medical advancements, even in developing nations like ours, there is
increasing trend in the survival of preterm infants. It is pertinent to know the complications associated
with prematurity. As many of these preterm infants might live upto adulthood with many complications
related to prematurity. With more advanced training, many of these premature babies can be saved
and have a comfortable life. Besides the economic burden, developing nations like India have to
develop community support systems to cater to the needs of the preterm babies.