PREMATURE BABIES

A premature baby, or preemie, is born before the 37th week of pregnancy. Premature birth occurs in between 8 percent to 10 percent of all pregnancies in the United States. Because they are born too early, preemies weigh much less than full-term babies. They may have health problems because their organs did not have enough time to develop. Preemies need special medical care in a neonatal intensive care unit, or NICU. They stay there until their organ systems can work on their own.

As Australia's mothers get older, their chances of a premature birth are rising too. Neo-natal specialists say parents should be better prepared for an early arrival.

Around one in 12 Australian babies are now born more than three weeks before the full pregnancy term of 40 weeks, and the number is growing. Premature births increased by 20 per cent over the decade between 1995 and 2005, while births overall rose by only 5 per cent.

Dr Kei Lui, Director of the Newborn Care Unit at Sydney's Royal Hospital for Women, says that while much of the cause of increased prematurity is uncertain, the increased age of first-time mothers is thought to be a contributing factor.

"We have many more older mums…leading people to have problems with fertility and then they are moving towards IVF, we are getting more multiple births – these are all compounding factors."

But despite the rising trend in early arrivals, few pregnant women are prepared for an early birth, says Fiona Dixon, whose second child, Airlie, was born at 27 weeks gestation, despite a normal first pregnancy.

"People don't think about it until it happens to them, and it can have implications for all sorts of things – like parental leave and health insurance cover," she says.

And while there is widespread public education for other risks in pregnancy –such as listeriosis and rubella – Dixon says there is far less information given to pregnant women about prematurity.

"We need to raise the education level about the risks of prematurity and also about the issues that lead to prematurity," she says.

Dixon suffered from pre-eclampsia, a serious pregnancy-induced condition that causes raised blood pressure in the mother and affects around 10 per cent of pregnancies. It is one of the most common causes of premature birth.

"I was OK at 24 weeks, but then I had symptoms like swelling in my hands and feet and bad headaches for a couple of weeks," she says.
Dixon believes that, if she had known more about the early signs of pre-eclampsia, she may have been able to access treatment in time to prevent her baby arriving quite so early.

How early?

The majority of premature babies (US estimates suggest about 84 per cent) are born between 32 and 36 weeks gestation. A further 10 per cent of premature babies are born between 28 and 31 weeks, and the remaining six per cent are born before 28 weeks.
Most babies born before 37 weeks will spend some time in neo-natal intensive care or in the special care nursery. They are more vulnerable to infection than babies born at full term, and many will need help with feeding.
Most babies born before 30 weeks need help with breathing until their lungs develop.

The grey zone

Around one per cent of births in Australia are classed as 'extremely premature' – that is, between 23 and 25 weeks. Babies born in this early period, referred to as 'the grey zone' at the limits of viability, need high-level intensive care for a number of months if they are to survive.

It is these babies that cause the most heartache. Many weigh close to one kilogram at birth and their parents face an agonising decision: whether to agree to lengthy intensive care treatment to save their child, with the possibility of long-term serious disability, or to stop treatment and allow their baby to die.

In some countries, regulations determine treatment decisions; in Holland, for example, doctors do not routinely administer intensive care to babies born before 25 weeks of pregnancy. In Australia, decisions about the level of intervention and treatment are left to doctors and parents and made on a case-by-case basis.

But survival rates have lifted significantly, especially at the 25-week mark. Australian statistics released in 2006 show that more than three-quarters of babies born at 25 weeks will survive and more than 80 per cent will not have a major disability – and prospects improve for each day that a baby is born closer to their due date.

Good news on outcomes

Dr Lui points out that advances in technology and medical care are good news for premature babies.
"Despite the increase in survival rate for premature babies, we are not trading survival for injured children; we are actually also seeing a drop in the rate of disability," he says.
"If you compare the morbidity and mortality rates of neo-natal intensive care with adult intensive care, it is far more cost-efficient. Younger patients tend to do much better; those who survive are doing very well."

Survive Cancer, Have Baby

The emerging field of oncofertility offers hope to patients who worried that they couldn't conceive.

When Annie Dauer's oncologist told her she'd need a stem-cell transplant to cure her non-Hodgkin's lymphoma, Dauer's first thought wasn't about death but about life. "I asked what would happen to my fertility," she says. Her oncologist dismissed the question: " 'Honey, you're fighting for your life; forget the fertility at this point,' she told me." But Dauer, then 30 and newly married, pressed the subject until the oncologist referred her to a fertility specialist. Since Dauer's chemotherapy regimen would most likely destroy her body's egg supply, the specialist, in an experimental procedure, removed one of her ovaries, froze it and reimplanted it when Dauer recovered. Three years later, Dauer, now cancer-free, and her husband, Greg, have a 2-year-old daughter, Sienna, and a second baby on the way.

Welcome to the burgeoning world of oncofertility. As cancer survival rates climb and patients focus on quality-of-life issues, especially fertility, Dauer and others like her are forcing two very different medical specialties—oncology and assisted reproduction—to come together. "The narrative of cancer is no longer that it's a death sentence; it's a bump in your medical history that you overcome and go back to what we hope is a healthy lifestyle," says Teresa Woodruff of Northwestern University's Feinberg School of Medicine, who last fall received a first-of-its-kind $21 million NIH grant to develop ways of protecting cancer patients' reproductive health.

Of the 125,000 people under the age of 45 who are diagnosed with cancer each year, roughly half will receive treatments that will affect their fertility. The cancers that most commonly strike the young—leukemias, lymphomas and breast cancers—require some of the most toxic forms of chemotherapy, which target rapidly growing and fragile cells like hair follicles, sperm and eggs. The good news: patients who would like to become parents have a growing array of options. Men are benefiting from a procedure that allows urologists to find a single live sperm to bank, which can then be used in an in vitro fertilization method that requires just one sperm. Women can freeze eggs or ovarian tissue, though success rates are still low. Those with partners (or donor sperm) can freeze embryos, the procedure with the best track record, though, like egg freezing, it's available only to patients who have two to six weeks before starting treatment. On the horizon are less toxic chemotherapy agents as well as methods of shielding eggs and sperm from harm.

Up to now, few oncologists passed this vital information to patients, either because they were not aware of fertility advances, or because they were understandably preoccupied with saving lives. As the field grows (at least 50 centers now provide oncofertility services), more cancer docs are tackling the issue, and even altering treatments to aid fertility. Advocacy groups like Fertile Hope, which educate cancer patients about assisted reproduction, deserve credit for spreading the word. "It's being talked about more," says Nancy Lin, an oncologist at Boston's Dana-Farber Cancer Institute. "There's a growing awareness among doctors, and patients are more proactive."

Two years after Dauer completed her cancer treatment, her doctor, Kutluk Oktay, founder of New York City's Institute for Fertility Preservation, sutured a one-inch strip of ovary, containing tens of thousands of microscopic eggs, under the skin just below Dauer's belly button. "Every month, I would feel little eggs, sometimes pea-sized, sometimes as big as a quarter," says Dauer. Normally, Oktay, who pioneered this procedure, would have harvested mature eggs, fertilized them with Greg's sperm and implanted them into Dauer's uterus. But in an unexpected development, Dauer became pregnant naturally; somehow, the implanted ovary jump-started her remaining, inactive ovary and she began to ovulate. Oktay is at a loss for an explanation. "The healthy ovary may contain signals or hormones that may enable the [dormant] ovary to regenerate eggs," says Oktay. "That's the theory, other than a miracle."

When cancer's involved, even joy can be shadowed by uncertainty. Ronny Villarreal, 32, survived breast cancer, then, with her oncologist's OK, stopped a common hormone-suppressing treatment early in order to conceive. Unfortunately, the cancer recurred during her second trimester of pregnancy. Villarreal's daughter, Maddy Hunt, now 4 months old, is healthy, but Villarreal is facing more chemotherapy and a cloudy prognosis. "We are trying our hardest to stay positive," she says. "We have so much to live for." More, certainly, than if she never had the chance to get pregnant at all.

© 2008

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