The epidemiology of preterm birth

Preterm birth is a major clinical problem, accounting for 47% of all neonatal deaths. The preterm delivery rate in UK is approximately 7%, and rates of preterm birth are steadily increasing. The diagnosis of preterm labour is difficult and most interventions to halt labour are unsuccessful. Despite this, the lack of good data hinders high quality research. The West Midlands has the highest perinatal mortality in the UK and a Perinatal Institute was set up in 2000 to address this, and aid improvements in care. Survival rates amongst preterm infants have changed dramatically over the last decade, with 88% survival for 2728 weeks, and 21% for > or =24 weeks (depending on birth weight). Risk factors include lower social class, less education, single marital status, low income, younger maternal age, low body weight, ethnicity, smoking, poor housing along with medical factors such as induction, premature rupture of membranes, infection, multiple pregnancy intrauterine death, fetal and uterine abnormalities and chorioamnionitis. Data from further detailed, robust studies are required to facilitate a comprehensive understanding of risk factors and their relationship with each other. Only then will it be possible to influence the adverse outcomes described.     

Aerosolized surfactant treatment of preterm lambs

To evaluate the potential for aerosolized surfactant treatments of surfactant deficiency, twin lamb fetuses were delivered at 130-132 days gestational age and received nebulized natural surfactant (Neb NS), nebulized Survanta (Neb Surv), tracheally instilled natural surfactant (Inst NS), or nebulized saline (Neb Saline). Neb NS and Neb Surv groups had significant increases in ventilatory efficiency index and dynamic compliance values (P less than 0.05). Both groups also had pressure-volume curves that were comparable to the Inst NS group. The Neb Saline control group had deterioration of the ventilation efficiency index and dynamic compliance values over time as well as pressure-volume curves that demonstrated smaller lung volumes compared with all three surfactant-treated groups (P less than 0.01). Delivery of aerosolized surfactant to the lung was only approximately 2 mg lipid/kg for the nebulized groups, a dose one-twentieth of that previously noted to be effective in instillation protocols. Distribution histograms of the aerosolized surfactant-treated groups differed from the instilled animals as there was more deposition in the right upper lobes and tracheae in the nebulized groups compared with the instilled group (P less than 0.05). Pulmonary blood flow was not altered by aerosolized surfactant treatment. Administration of aerosolized surfactant to preterm lambs improved lung function at a very low surfactant dose.     

Pathway-based genetic analysis of preterm birth

Preterm birth in the United States is now 12%. Multiple genes, gene networks, and variants have been associated with this disease. Using a custom database for preterm birth (dbPTB) with a refined set of genes extensively curated from literature and biological databases, we analyzed GWAS of preterm birth for complete genotype data on nearly 2000 preterm and term mothers. We used both the curated genes and a genome-wide approach to carry out a pathway-based analysis. There were 19 significant pathways, which withstood FDR correction for multiple testing that were identified using both the curated genes and the genome-wide approach. The analysis based on the curated genes was more significant than genome-wide in 15 out of 19 pathways. This approach demonstrates the use of a validated set of genes, in the analysis of otherwise unsuccessful GWAS data, to identify gene–gene interactions in a way that enhances statistical power and discovery.     

Immunology of term and preterm labor

During pregnancy there is an alteration in maternal immunity within the uterus where innate, proinflammatory immune responses are tightly regulated to prevent immunological rejection of the fetal allograft. Disruption of the delicate balance of cytokines by bacteria or other factors increases the production of proinflammatory cytokines at the maternal-fetal interface and activates the parturition mechanism prematurely. Despite years of searching, there is still no broadly effective strategy for preventing preterm labor and most therapies are directed at inhibiting myometrial contractions and improving neonatal outcome. Recent studies with progestins and interleukin-10 (IL-10), however, are showing promise in randomized clinical trials and animal studies. Furthermore, the identification of the Toll-like receptors as upstream mediators of inflammation may offer alternative therapeutic targets for preventing this common pregnancy complication.     

Sensing senescence in preterm birth

Comment on: Hirota Y, et al. Proc Natl Acad Sci USA 2011; 108:18073-8     

Maternal fatness and viability of preterm infants

To investigate the effect of maternal fatness on the mortality of infants born preterm up to the corrected age of 18 months 795 mother-infant pairs were studied. Maternal fatness was defined by Quetelet''s index (weight/(height²)) and all infants weighed less than 1850 g at birth. In 771 mother-infant pairs maternal age, complications of pregnancy, mode of delivery, parity, social class, and the baby''s sex and gestation were analysed by a logistic regression model for associations with infant mortality (but deaths from severe congenital abnormalities and those occurring during the first 48 hours after birth were excluded). In a subgroup of 284 mother-infant pairs all infant deaths except those from severe congenital abnormalities were analysed in association with the infant''s birth weight and gestation and the mother''s height and weight; this second analysis included another 24 infants who had died within 48 hours after birth. In the first analysis mortality overall was 7% (55/771), rising from 4% (71/173) in thin mothers (Quetelet''s index <20) to 15% (6/40) in mothers with grades II and III obesity (Quetelet''s index >30). After adjusting for major demographic and antenatal factors, including serious complications of pregnancy, maternal fatness was second in importance only to length of gestation in predicting death of infants born preterm. In the second analysis mortality overall was 15% (44/284), rising from 9% (5/53) in thin mothers to 47% (8/17) in mothers with grades II and III obesity. In both analyses the relative risk of death by 18 months post-term was nearly four times greater in infants born to obese mothers than in those born to thin mothers. In addition, maternal fatness was associated with reduced birth weight, whereas it is associated with macrosomia in term infants.These data differ fundamentally from those reported in full term babies of obese mothers. It is speculated that the altered metabolic milieu in obesity may reduce the ability of the fetus to adapt to extrauterine life if it is born preterm.     

Dynamics of chest wall in preterm infants

The chest wall of the preterm infant has visible paradoxical movement during breathing, because of its greater flexibility than those of older children and adults. We studied the dynamics of the chest wall in 10 preterm infants to describe the interaction of the chest wall volume, as partitioned by the inductance plethysmograph, and the transthoracic and abdominal pressures. There was considerable hysteresis between the chest wall volume and the transthoracic pressure, and it had linear pressure-volume behavior during airway occlusion, late inspiration, and early expiration. The slope of this pressure-volume relationship, or the instantaneous chest wall compliance, averaged 0.89 +/- 0.16 and 0.94 +/- 0.18 ml/cmH2O for the respiratory effort during airway occlusion and early expiration, respectively. The dynamic compliance was considerably greater, averaging 7.8 +/- 2.3 ml/cmH2O. This resistive pressure-volume behavior was not related to the absolute value of or the rate of development of the esophageal or abdominal pressures. This additional degree of freedom of motion of the chest wall suggests that its linkage to the diaphragm is flexible, which provides a braking force for expiration and allows free movement of the diaphragm for breathing movements before birth.     

Chromium status of full-term and preterm newborns

In order to obtain reference values from normal babies, Cr status of full-term newborns has been studied. Plasma and urine values were (mean±SEM) 0.7±0.1 μg/L and 0.9±0.3 μg/L, respectively, for the first month of life (n=19), and 0.6±0.1 μg/L and 0.8±0.2 μg/L for the second-to-third-month period (n=31). Premature newborns (gestational age 28–36 wk) were compared to these control values; concentrations were 0.9±0.1 μg/L and 1.1±0.2 μg/L for the first month (n=47), and 1.0±0.2 μg/L and 1.5±0.3 μg/L for the second to third months (n=27). For the whole group, there was a positive correlation between plasma and urine concentrations (p=0.0001); multiple regression analysis was performed between plasma levels and gestational age at birth (p=?0.002) and postnatal age (NS). Plasma levels of prematures and full terms were statistically different (p=0.03) only for the second- to third-month period. It is suggested that these high Cr levels result from high dietary intakes and/or high absorption rates.