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http://www.nytimes.com/2003/04/08/health/children/08BROD.html?ei=5070&en=9e82762ce925ad04&ex=1051070400&pagewanted=print&position=top

April 8, 2003

Vaccination News

PERSONAL HEALTH

Preventing Premature Birth and Its Toll of Anguish

By JANE E. BRODY

e hear about the miracles: the babies born weighing two pounds or less who grow up to play sports and graduate from high school, even college.

But rarely do people hear the very sad stories of the thousands of tiny babies born months before their time who do not do nearly as well, who spend three months in the hospital, sometimes suffering crisis after crisis and finally emerging with lifelong sensory, mental or physical disabilities.

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With nearly one in eight births now occurring prematurely and the rate of preterm births rising, the nation's leaders in maternal-fetal medicine are struggling to improve understanding of the many causes of premature labor and delivery and find more effective ways to thwart it.

Meanwhile, they are urging doctors and mothers-to-be to know the factors that raise the risk of early birth and to be aware of the signs of premature labor. The goal is twofold: to prevent the problem that is the leading cause of newborn deaths and, when prevention fails, to ensure that these births occur in settings most favorable to the babies' survival and well-being.

Who Is at Risk?

Much is known about the circumstances that can impair a woman's ability to carry a pregnancy for 37 weeks. Demographics play a role. Women younger than 17 and older than 35 are more likely to deliver prematurely, and births to women 35 and older have risen by 53 percent in the last decade.

Poverty, lack of prenatal care and chronic stress raise the risk as well. Women who smoke raise their risk by 20 percent to 30 percent. As many as 15 percent of all preterm births are attributable to smoking during pregnancy. Body weight also matters: the risk rises if a woman is too thin before pregnancy or gains too little or too much during the pregnancy.

Women who had a previous premature birth are more likely to have another; their risk can be 2.5 times as great as that of women without this history. Treating them with progesterone was recently shown to decrease the risk of a recurrent premature delivery significantly.

One of the highest risks involves women pregnant with twins or more. Half of twin pregnancies and nearly all pregnancies of triplets or more end prematurely. The rate of multiple births has increased by more than 35 percent in the last decade.

Women with certain health problems are more likely to deliver prematurely. These include diabetes, whether it developed in pregnancy or beforehand; high blood pressure, either before or during pregnancy; and serious infections like bacterial pneumonia, kidney infection, acute appendicitis or a sexually transmitted disease.

Women without symptoms who have bacteria in their urine are also at increased risk, as are those with yeast infections and a common disorder called bacterial vaginosis, an overgrowth of organisms that are normally present in a healthy vagina.

Having infections detected and treated, if necessary, can help diminish the risk of premature rupture of the membranes, premature contractions and a preterm birth, although no treatment has yet stemmed the effect of bacterial vaginosis.

Other problems that develop during pregnancy can result in preterm birth, including vaginal bleeding during the second or third trimester caused by a misplaced placenta (placenta previa) or a small separation of the placenta from the wall of the uterus (abruption), as well as a level of amniotic fluid that is too low or too high.

It is very important for women to drink plenty of water throughout pregnancy, and especially in the latter half of pregnancy and in hot weather.

Another potentially important sign of possible preterm birth is the presence of uterine contractions that begin long before the completion of pregnancy. But even when women are equipped with home monitors and taught how to recognize these contractions, this has not been useful in preventing premature births. Furthermore, half to three-fourths of women with these contractions go on to deliver at term, even if cervical changes begin in preparation for birth

When a woman is known to face a significantly increased risk of delivering prematurely, she may be best cared for by a specialist in high-risk pregnancies. Besides being able to recognize early signs of trouble, nearly all such physicians are affiliated with hospitals that have neonatal intensive care units, which provide optimal care.

Is It Premature Labor?

The March of Dimes, which is running a campaign to reduce the rate of prematurity, wants every pregnant woman to know the signs of preterm labor. When any of these symptoms occurs three or more weeks before a woman's due date, she should call her doctor or midwife immediately:

Uterine contractions that occur four or more times an hour. These may resemble menstrual cramps or intermittent dull backaches that may radiate around toward the abdomen. Or the contractions may feel like gas pains, with or without diarrhea. Or the contractions may not cause any pain, only discomfort and a feeling that the stomach is tight.

¶Pelvic pressure, a feeling that the baby is pushing down or is going to fall out.

¶An increase or change in vaginal discharge, which may be clear, pink or brownish and either watery or thick like mucus. A sudden gush of clear, watery fluid from the vagina is a sign that the fetal membranes have ruptured. Birth may sometimes be delayed for a time with in-hospital treatment, which may include antibiotics to prevent infection.

Many women experience what are called Braxton Hicks contractions, which are usually irregular and painless and may begin in the first three months of pregnancy. These contractions, commonly called "false labor," tend to increase in frequency and intensity toward the end of pregnancy.

Because they do not cause the cervix to dilate, they do not herald a preterm delivery. But only a physician's examination can reveal whether the cervix has begun to dilate and preterm labor may be imminent.

A pregnant woman experiencing contractions that occur less than 15 minutes apart should be prepared to tell her physician or midwife when the discomfort started, the type and frequency of the contractions, what she was doing when the symptoms began and whether there were any other signs or symptoms like an increased vaginal discharge, pelvic pressure or dull backache.

Dr. Robert K. Creasy, chairman of obstetrics and gynecology at the University of Texas Health Science Center in Houston, suggests that women lie down with their feet elevated and drink two or three glasses of water or juice while waiting for returned calls from the doctors or midwives.

If the symptoms do not subside in an hour and the woman is unable to reach the doctor or midwife, she should go to the nearest hospital, Dr. Creasy said.

It is especially important for a woman who lives far from a major hospital to know the symptoms of preterm labor and delivery. It is far better for a preterm birth to occur in a hospital with a neonatal intensive care unit than it is to take a dangerously premature baby by ambulance to a center.

Copyright 2003 The New York Times Company

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