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correspondence

Indian Pediatr 2012;49: 929-930

Early term – Continuing Conundrum of Immaturity


Suman Rao PN and Swarnarekha Bhat

Department of Neonatology, St. John’s Medical College Hospital, Bangalore 560 034, India.
Email: [email protected]
 


In the past decade, the focus in newborn care has been on the concept of "late preterm". The short term and long term complications of preterm birth between 340/7 and 366/7 weekly have become well recognized. Most doctors and patients assume that once "term" gestation is reached; the outcome is uniformly optimal [1]. However recent reports have highlighted the differential outcomes even in term infants born before 39 weeks and after. Respiratory distress, need for ventilation, hypoglycemia, sepsis, and NICU admissions, are higher in the infants born between 370/7 and 386/7 as compared to after 39 weeks [2-3]. Tita, et al. [4] determined the risk of adverse outcomes such as mechanical ventilation, newborn sepsis, hypoglycemia, admission to the neonatal ICU, and hospitalization for 5 days or more to be increased by a factor of 1.8 to 4.2 for births at 37 weeks and 1.3 to 2.1 for births at 38 weeks compared to 39 weeks. Long term neurodevelopmental outcomes and need for special education has also been found to be higher [5]. We reviewed our 2011 annual data (Table I) and compared the outcomes in 3 groups: late preterm (340/7 to 366/7 weeks), 37 weeks and 39 weeks. A delay of 2 weeks after 37 weeks added 300 g to the weight and significantly reduced NICU admissions, hypoglycemia and jaundice requiring phototherapy.

TABLE I Neonatal Outcomes by Gestational Age
34-36wk 37wk 39wk
(n=287) (n=329) (n=633)
Mean birthweight (g)$ 2279 2769 3024
LSCS (%) 48.8 33.4 26.7
NICU admission (n)%* 46.3 (133) 18.2 (60) 12.9 (82)
Hypoglycemia (n)%#  11.5 (33) 4.5 (15)   1.7 (11) 
Need for phototherapy (n)%* 44.6 (128) 25.8 (85) 19.7 (125) 
Respiratory distress (n)%* 13.4(38) 3.6 (12) 3.6 (23)
* Comparison between morbidities at gestational age 37 weeks and 39 weeks; *P<0.05; #P<0.05; $P<0.005.

This heterogeneity in outcomes in the group of "term" births has generated 2 categories: "early term" births (370/7 and 386/7 weeks) and "full term" births ( 390/7 to 41 6/7 weeks). This new definition of "early term" emphasizes the continuing immaturity and potential for adverse outcomes. Though spontaneous onset of labor before "full term" or indicated delivery due to maternalfetal complications are inevitable, the growing menace of delivering high risk mothers early – as soon as term gestation is reached – needs to be limited. As recommended, induction or scheduled cesarean section without any obstetric reason should be after 39 weeks. This has even become accepted as a quality indicator of obstetric care.

References

1. Reddy UM, Bettegowda VR, Dias T, Yamada-Kushnir T, Ko C, Willinger M. Term pregnancy: A period of heterogeneous risk. Obstet Gynecol. 2011;117: 1279-87.

2. Balit JL, Greory KD, Reddy UM, Gonzalez-Quintero VH, Hibbard JU, Ramirez MM, et al. Maternal and neonatal outcomes by labor onset type and gestational age. Am J Obstet Gynecol. 2010;202:245.e1-12.

3. Wilmink FA, Hukkelhoven CW, Lunshof S, Mol BW, van der Post JA, Papatsonis DN. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. Am J Obstet Gynecol. 2010;202:250,e1–8.

4. Tita A, Landon MB, Spong CY, Lai Y, Leveno KJ, Varner MW, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med. 2009;360:111-20.

5. Mackay DF, Smith GC, Dobbie R, Pell JP. Gestational age at delivery and special educational need: retrospective cohort study of 407,503 school children. PLoS Med. 2010; 7: e1000289.

 

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