Premature Birth and Its Prevention
Babies who are born prematurely (before 39 weeks, according to ACOG) are at a higher risk of birth injuries because of their underdeveloped organs and low birth weight. Premature births occur more often with twins or triplets, as well as in cases where there is an untreated incompetent cervix, history of prior preterm birth, pre-existing health issues, or untreated infection (among many other risk factors). Premature birth is often preventable – doctors can prolong a pregnancy to the proper time using progesterone or cerclage if they properly diagnose issues that are risk factors for premature birth. Once these factors are diagnosed, physicians must tailor a customized health plan for the mother to help her support a baby. This custom plan varies greatly from case to case, given the wide variety of factors that can cause premature birth.
Why Is Preterm Birth a Health Risk?
When a baby is born preterm, they are not yet fully developed, which can predispose them to injuries. One of the biggest concerns with babies born preterm is lung development. The lungs are some of the last organs to fully develop, so preterm birth can have effects on a baby’s ability to breathe and circulate oxygenated blood throughout the body.
Babies born preterm often cannot produce enough surfactant on their own yet, and surfactant is one of the key chemical compounds that help the lungs function and stay flexible and pliant. Without surfactant, the lungs stay stiff, which means they cannot expand and contract well enough to get the air they need. Because of this, preterm babies often need extra help breathing. Medical practitioners can provide surfactant to keep the lungs flexible. They can also help the baby’s breathing with methods like positive-pressure ventilation, or in some cases where both the baby’s heart and lungs need support, with extracorporeal membrane oxygenation (ECMO).
Breathing Support: Risk of Overventilation and Hypocarbia
One of the problems we sometimes see in our office with babies born preterm is brain injury stemming from overventilation and hypocarbia. The human body’s regulatory mechanisms operate under specific ratios of CO2 and oxygen in the blood. If a baby is being ventilated at too high a setting, the amount of CO2 in their blood can drop below a safe level in a condition called hypocarbia. If hypocarbia continues for too long, this can cause brain injuries like periventricular leukomalacia (PVL), among others. If a baby is being over-ventilated, the pressure from the machine can also cause lung damage like bronchopulmonary dysplasia (BPD) and pneumothorax (when the baby’s lung collapses). This can cause long-term scarring in the lungs and can compromise how well oxygen is delivered to the baby’s brain and other organs.
Babies born prematurely are also more likely to have brain bleeds and are less likely to be able to tolerate labor. The brain structure of preterm babies is very delicate, and the forces of labor can put pressure on the baby’s skull. In some cases, this can cause the networks of capillaries feeding critical parts of the brain to collapse, resulting in fetal strokes or intracranial hemorrhages (brain bleeds).
Because there are risks associated with improper ventilation of a baby and with preterm babies undergoing trials of labor, it is very important to prevent preterm births as often as possible in order to avoid the development of conditions that could compromise the baby’s health.
Why is Preventing Preterm Birth So Important?
Babies delivered by 28 weeks or later usually do very well, and develop without long-term problems. Each additional week of gestation and 100-gram increase in birth weight (in the lower-to-mid ranges of gestational age and birth weight) greatly reduces mortality risk. The longer a baby gestates, the less likely it is they will have a prematurity-related injury.
What Kinds of Conditions Are Associated with Preterm Birth?
Health conditions preemies may have if improperly managed include:
- Cerebral palsy (CP)
- Hypoxic-ischemic encephalopathy (HIE/birth asphyxia)
- Intraventricular hemorrhage (brain bleeds)
- Developmental disabilities
There are other health conditions that can stem from issues related to preterm birth, such as cognitive or learning disabilities, certain sensory issues, and atypical behavioral patterns, but these can vary. Because each mother’s and baby’s health histories are different, and because the severity of injury can differ, some babies with birth injuries related to preterm birth may have milder disabilities, while others may have multiple disabilities affecting several areas of function.
There are, however, ways that medical practitioners can decrease the risk of preterm birth, especially when analyzing a mother’s prior health history closely.
How Can Preterm Birth Be Prevented?
First and foremost, it’s very important for medical practitioners to take a full and accurate health history of the mother to identify any potential risk factors for preterm birth. If a mother has these risk factors, doctors and nurses should monitor her pregnancy more closely than that of a mother without these risk factors. This will often mean more appointments with different kinds of assessments – the exact details vary from mother to mother.
What kinds of factors could contribute to preterm birth?
- Prior history of preterm birth (increases the risk of premature birth by 10-35%)
- Prior history of short cervix (25mm or less) (increases the risk of premature birth by 30-60%)
- Evidence of debris or sludge on ultrasound
- Maternal age (under 16 or over 25)
- Low socioeconomic status
- Presence of:
- Infection (chorioamnionitis or bacterial vaginosis)
- Cardiovascular disorders
- Polyhydramnios (excessive amniotic fluid levels)
- Multiple gestations (twins, triplets, and other multiples)
- Placenta previa
- Placental abruption
Depending on a mother’s health history, the kinds of interventions that may be recommended can differ:
A cervical cerclage is a stitch placed in the cervical tissue to help keep the cervix closed. Medical professionals use transvaginal ultrasounds to determine the cervical length and recommend cervical cerclage based on their findings. Cerclage can help relieve some of the pressure on weakened cervical tissue and help the pregnancy last longer. Cerclages can also reduce the risk that there will be an ‘ascending infection’ – an infection that ascends from the vagina into the upper genital tract. The cervix acts as a physical barrier between the vagina and the upper genital tract, and a cerclage can help maintain the barrier’s integrity. Cerclages are removed typically around the 37th week of pregnancy, or earlier if the mother goes into preterm labor.
Progesterone is a hormone that has many purposes in the body and is very important during pregnancy. It can help avert preterm birth by modulating inflammatory responses – one of the factors that can lead to early labor. It also inhibits cervical ripening and myometrial activity. Progesterone is given either as a vaginal suppository or injection.
Vaginal suppository progesterone is given to women with a short cervix, whether or not they’ve had a prior preterm birth. This treatment decreases the risk of:
- Respiratory distress syndrome (RDS) in the baby
- Low birth weight under 1500 grams
- NICU admission
- Need for mechanical intervention
This treatment is typically provided starting around 19-23 weeks and ends around 36 weeks.
Injected progesterone (17P) is given to women who have had a prior preterm delivery and is provided weekly. It is started around 14-16 weeks and administered once a week until around 26-36 weeks. This treatment reduces the risk of:
- Preterm birth
- Low birth weight
- Complications like IVH and NEC
- NICU admission
- Need for supplemental oxygen therapy
Some women benefit from the use of both cerclage and progesterone, particularly those with a prior preterm birth at less than 34 weeks, and with a current cervical length of less than 25 mm at less than 24 weeks’ gestation.
While cervical cerclage and progesterone are the only two approved treatments for prolonging pregnancy and preventing preterm birth, there are other methods that can be used to reduce the risk of injury in babies who are about to be born preterm.
Reducing the Risk of Injury in Preterm Babies
If a preterm birth is imminent and interventions do not stop it, there are two treatments that are given to the mother while the baby is still in-utero that help protect the baby’s brain and help mature the baby’s lungs. These treatments are called antenatal steroids (one example is betamethasone) and magnesium sulfate.
Antenatal Steroids (Betamethasone)
Antenatal steroids are given to women who are at risk of having a preterm birth within 7 days. These are typically given around 24 to 34 weeks gestational age, though recent recommendations suggest offering them up to 36 weeks. They are given in two doses over 24 hours and are effective when given up to 4 months before birth. They are most effective, however, 1-7 days before birth. This treatment can benefit the baby in several ways:
- Accelerates lung maturity to decrease respiratory distress syndrome (RDS) rates
- Stabilizes the baby’s intracranial vasculature
- Decreases IVH incidence
- Decreases PVL incidence
- Decreases NEC incidence
- Shortens preemie hospital stays
- Increases preemie survival rates
- Decreases inflammation rates
If a mother comes to the hospital with spontaneous preterm labor, she should be given magnesium sulfate to inhibit uterine contractions. This therapy also helps protect the fetal brain and improves long-term outcomes. This treatment decreases the rate of all severities of cerebral palsy, according to the BEAM Trial. This treatment is provided at a gestational age of fewer than 32 weeks if the mother has either:
- Active preterm labor with 4-8 cm cervical dilation (or PPROM after 22 weeks)
- Indicated preterm birth within 24 hours
Magnesium sulfate both protects babies’ brains and helps prolong pregnancy in the short-term.
There are ways to properly manage risk factors for preterm birth. If these risk factors are properly managed, preterm birth and prematurity-related injuries can be avoided. Progesterone and cerclage can help avert preterm birth, while betamethasone and magnesium sulfate can improve outcomes in preemies. If medical professionals don’t take the proper actions to avert preterm birth and a baby is injured, parents can seek justice for their child.
More Information on Premature Birth:
- Premature Birth: Increased Risk with Twins, Multiples
- Incompetent Cervix
- Progesterone: Prevention of Pre-Term Birth
- Premature Birth: Periventricular Leukomalacia (PVL), Neonatal Brain Damage and Cerebral Palsy
- Calculating Your Premature Baby’s Age: Adjusted (Corrected) Age
Video: Premature Birth
How Do You Pronounce Preterm Birth?
Legal Help for Birth Injuries | Detroit, Michigan Cerebral Palsy and Premature Birth Lawyers
Physicians, nurses, midwives, and other medical professionals are obligated to do everything in their power to prevent premature birth. This includes diagnosing and treating its risk factors, preventing its causes, planning for delivery, calling necessary emergency C-sections, and providing all other means of care in accordance with a strict set of rules. The failure to properly handle or prevent premature birth is medical negligence, and when it causes injury, it is medical malpractice.
We encourage you to reach out to our Detroit, Michigan birth injury, cerebral palsy, and premature birth lawyers today with your legal questions or case inquiries. Reiter & Walsh ABC Law Centers is a niche law firm that specifically takes cases involving birth injury, so our attorneys have the specific skills, experience, and knowledge necessary to win these complex, multi-million dollar cases. While our team is based in Michigan, we handle cases all over the United States. Many of our clients have hailed from Michigan, Ohio, Washington D.C., Arkansas, Mississippi, Pennsylvania, Tennessee, Texas, Wisconsin and other states. The Reiter & Walsh, P.C. birth trauma team has also handled FTCA cases involving military medical malpractice and federally-funded clinics.
Contact our Michigan birth injury and premature birth lawyers today for a free legal consultation. We will review your case free of charge, determine the cause of your loved one’s injuries, and inform you of your legal options. Contact us in whichever way best suits your needs:
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