Little Mar Perea Muñoz is two and half months old, but she should only have been coming into the world about now. Her mother, África Muñoz, was due to give birth on 10 December but she began to have contractions when she was only 20 weeks pregnant. At 26 weeks doctors admitted her to the Materno Infantil to try to delay the birth as long as possible, but Mar was in a hurry to get here. She was born on 19 September, in the 28th week of pregnancy, and weighed barely 1.26 kilos.
These days, technological and medical advances have made it possible for such premature babies to survive and, what is most important, to do so without suffering major problems in the future. However, they are at risk and it is essential that they are carefully monitored to minimise the consequences of them being born so far ahead of time.
A normal pregnancy lasts for 40 weeks, but the Spanish Society of Gynaecology and Obstetrics considers that a foetus is ready to be born from 37 weeks onwards. All babies who are born before that time are considered premature, but it is not the same to give birth at 33 weeks - which is described as moderately premature - as at 27 weeks. One week more in the womb increases the chances of survival by about ten per cent, and determines the quality of life in the future. Babies who are born before 31 weeks are known as very premature, and before 27 weeks as extremely premature.
Of the 5,000 babies who are born at the Materno Infantil hospital in Malaga every year, around 14 per cent (about 700) are premature. Of these, approximately 140, or 20 per cent, are considered very premature, born before 30 weeks of pregnancy and weighing less than 1.5 kilos.
Enrique Salguero, director of the Neonatal Unit, says that in Spain there is no legal limit of viability as there is in other countries, but from a medical point of view the Spanish Cardiopulmonary Reanimation Group is to do everything possible for babies who are born at 23 weeks of gestation. However, this is only possible in specialist hospitals such as the Materno Infantil in Malaga, which have sufficient material and human resources and staff trained in caring for these babies.The limits are delicate, bearing in mind that the legal limit for abortion in this country is 22 weeks.
The reasons for an early birth also determine a premature baby’s state of health. Enrique Salguero says that 40 per cent of premature births occur because of a spontaneous rupture of integral membranes, 30 per cent by a premature rupture of membranes and about 30 per cent because of hypertension or eclampsia in the mother, which mean that the baby does not grow well.
“In the latter case, we can find 28-week foetuses who ought to weigh 1.2 kilos but are only 800 grammes, and that means that the birth has to be scheduled because the alternative would be to let the babies die; a child who is born in these circumstances has other complications, in addition to being premature,” he says.
A difficult decision
The most difficult thing, says Dr, Salguero, is helping parents of a very premature baby decide what should be done, because they have the final say.
“We specialists give them all the information about possible consequences which they may face; when the foetuses are born after 24 weeks we tell them that we are going to do everything we can for them and that there many not be any consequences, although we can never know that for sure,” he explains.
In the first days the babies are kept in intensive care in the Neonatal unit because they need specialised treatment. Out of all the babies in intensive care at the Materno hospital, around 60 per cent are premature. Their care does not only involve constant monitoring: one of the first things doctors have to do is support their breathing. “The alveoli of these babies are not developed,” says Enrique Salguero.
They are also given vasoactive drugs to improve the state of their heart and send blood to the tissues, and they have to be fed intravenously. As their immune system is not very developed they are given antiobotics from the start and their temperature is regulated in the incubators.
“Even a full-term newborn baby regulates its temperature badly, so it is much worse for premature ones because their skin is much thinner,” says Dr Salguero.
But what problems might these babies face in the future? In the final weeks of pregnancy the lungs and brain are still being developed, so a premature baby’s organs will be very immature. For this reason, some of the most common problems are bronchopulmonary dysplasias - many of these babies have to go home with a programme of hospital visits and respiratory support for the first few weeks - or sensory problems such as deafness (in only a few cases)or retinopathies - often from the use of oxygen therapy or antibiotics - which are generally overcome as they grow older.
Other possible consequences are related with neurological development, and these are more difficult to determine in the early weeks.
The Materno Infantil hospital in Malaga is part of the Spanish NeoNatal Society’s SEN-1.00 network, which registers the data and evolution of babies who are born weighing less than 1.5 kilos.
They are monitored closely for the first two years of their lives to determine whether there are motor neurological problems, or problems with coordination, and to see whether they fulfil the first landmarks in a baby’s development (whether and when they laugh, sit up, crawl, walk etc).
“After two years we do a neurological evaluation and so does an early stimulation centre, but we are convinced that they should be monitored until they are school age because there are many problems such as language, socialisation or behaviour, which can’t be detected at the age of two,” says Dr Salguero.
After spending ten days in intensive care and several weeks in the Neonatal Unit, Mar is now at home with her parents. The anguish of the first few days, when they didn’t know whether or not their daughter would survive, is behind them now. Other families have not been so lucky. The survival rate in verypremature babies who are born at 25 or 26 weeks is 60 per cent. However, this family is grateful for the affection and support they received during those weeks at the Materno, from other parents and from the staff.
“They spend a lot of time here and it is the hardest time of their lives,” says Josefa Cuevas Jaime, the supervisor of the Neonatal Unit. “Mothers come and see us with their children years later, so we can see how they’re doing,” she says, pointing to ‘before and after’ photos on the wall. They are pictures full of hope, like the words of Enrique Salguero: “They may be premature, but with luck that need not affect them for the rest of their lives,” he says.