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Prematurity, we still have everything to learn
Every year in France, nearly 55 babies are born before their time. Most will not suffer from it. But the others? Despite a number of advances, the causes of prematurity still remain a mystery. Inventory and testimonials.
Giving birth early
“For my first baby, I gave birth urgently. At 6 and a half months of pregnancy. I could not believe it. I hadn’t even read the chapter on childbirth in my guide yet! And I had just made an appointment for my first prep session, ”says Christine. In France, each year, nearly 55 children are born too early. That is to say about 000% of births. A figure that has increased by 7% over the past ten years. There are several reasons for this: thanks to advances in medicine and a better organization of the healthcare network, teams are treating more and more premature babies, who previously had no chance. But to explain this increase, we must also add a change in our behavior and our living conditions: the decline in the age of childbearing, the more frequent use of medically assisted procreation (AMP) with, as a result, more multiple pregnancies, increased insecurity, stress at work … These situations can indeed lead to complications during pregnancy, such as hypertension and pre-eclampsia, growth retardation in utero , placental problems … Fortunately, these risk factors are generally detected from the first trimester of pregnancy and specific monitoring is in place to prevent a birth too early: close monitoring, hospitalization at home or in a type 15 maternity hospital, associated with serial examinations, ultrasounds and appropriate treatments. But sometimes this arsenal is not enough. In nearly 3% of premature deliveries, it is the doctor and the patient who together decide to voluntarily extract the child from a worrying situation. This is the case, for example, when the placenta which nourishes it no longer fulfills its role correctly and there is a fear of significant growth retardation with sequelae. We can also make the decision to terminate the pregnancy to preserve the mother. In severe forms of preeclampsia, the only effective treatment is to deliver the baby.
Prematurity: unexplained in almost 60% of cases
But for the rest, about 60% of cases, how to explain these early births? Uterine malformations, such as open cervix, which no longer plays its role as a lock, are only responsible for 5% of preterm deliveries. Professor François Goffinet, obstetrician gynecologist at the Cochin-Port-Royal maternity hospital, in Paris, recognizes that “the causes of spontaneous prematurity are still quite mysterious today. Hence the need for further research ”. Among the avenues studied, infection as a trigger for preterm delivery is by far the most serious hypothesis. Biomarkers for rapidly detecting these expectant mothers are currently under study. With the hope of early antibiotic treatment to significantly reduce these births. According to recent studies, but only in certain indications, progesterone, in gel or in an egg in the vagina, may also be of benefit.
Treatment to delay birth
In the meantime, the only thing that we can do today for these spontaneous deliveries is to try to delay the birth by 48 hours, or even at most a week, thanks to a so-called tocolytic treatment, which aims to reduce the contractions. A delay taken advantage of by the medical team to prescribe the mother a course of corticosteroids to better prepare the baby’s lungs for life in the open air and accelerate his cerebral maturation. This treatment has revolutionized the management of premature babies. The risks of respiratory distress were almost halved and brain hemorrhages reduced by 30%. The transfer of future mothers, who threaten to give birth prematurely to type 3 maternities equipped with neonatal resuscitation services (in utero transfer), has also considerably increased the survival rate of these children. The challenge now is to better prevent complications.
Beyond sophisticated diagnostic tools, more and more neonatal departments are emphasizing what is called “developmental care”. “It is a more humanistic approach, where we privilege the environment of the child and the bond with his parents”, explains Prof. Umberto Simeoni, head of the neonatology service Public Assistance-Hospitals of Marseille. Gone are the rooms of twenty incubators lined up in rows of onions under the neon lights, with alarms that howl constantly. We try to favor boxes with two or three incubators, equipped with indicator lights and with alarms which sound in the on-call room of the medical team. Subdued lighting in the room, respect for the baby’s biological rhythm to carry out care, pain prevention thanks to analgesics and devices designed to avoid physical attacks as much as possible… These incubators are also equipped with mattresses filled with hot water and covered with a kind of little nest to create a feeling of security in the infant. An armchair, or even a bed, is often provided to accommodate mom or dad. This program, called Kangourou or NIDCAP, indeed considers parents as co-actors in care. Skin to skin, hygiene care, bath … With these daily actions, they learn to discover their child, and vice versa. With results. The infants who have benefited from this care are hospitalized for a shorter period of time because they are in better shape and, in the medium term, around 18 months, their development seems better.
Still insufficient resources
As for the parents, the creation of the first links is much better, breastfeeding is prolonged and the conditions for returning home are facilitated by this learning. Unfortunately, this more humane approach, without compromising the safety and quality of care, requires additional resources, which slows down its generalization.
Too bad, these tailor-made treatments constitute real progress. On the other hand, we still know very little how to prevent the consequences of prematurity. It is estimated that 40% of very premature babies present at the age of 5 years a motor, sensory or neuro-cognitive sequela, that is to say four times more than a child born at term. Admittedly, the most serious forms concern only 5% of these children. But research has yet to advance. Several avenues are being studied. French researchers are working, for example, on the neuroprotective role of melatonin, a hormone deficient in very premature babies. While waiting for the promise of effective treatments, specific follow-up has been set up until the child is 6 years old. It is not all over when you leave the neonatal department. These specialized consultations, particularly the Centers for Early Medico-Social Action (CAMSP), offer regular check-ups with a pediatrician and a neuro-pediatrician. A multidisciplinary team (speech therapist, psychomotor therapist, psychologist, physiotherapist) can also support the child: assessments of language and behavior disorders, sensory screening, etc. However, due to lack of resources again, these centers are still insufficient in number. The same goes for home return assistance systems. Parents of premature children too often have the impression of being released into the wild with their still fragile baby.
Small lexicon
Full term pregnancy 41 weeks of amenorrhea, or 9 months of pregnancy.
Average prematurity Between 33 and 36 weeks (from 7 to 8 months of pregnancy).
Very prematurity between 28 and 32 weeks (6 to 7 months).
Extreme prematurity before 28 weeks (before 6 months).