الفهرس 
INTRODUCTION AND AIM OF THE WORKOnly 14 pages are availabe for public view
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Abstract
Preterm Birth is a public health issue due to its worldwide prevalence, increasing survival rate, short and long-term morbidity, high economic burden, and its contribution to infant and under-5 mortality rate (U5MR). Preterm birth is defined as birth occurring before complete 37 weeks of gestation. Prematurity was the main cause of one million neonatal deaths globally every year. Prematurity is the outcome of several risk factors and considered as one of the most important causes of referral to the Nutrition clinic. In the present study, the estimated proportion of preterm birth was 20.3% out of the deliveries occurred in Alexandria University Maternity Hospital, while the proportion of preterm infants attended the Nutrition outpatient clinic in Smouha Alexandria University Children’s Hospital was 23.9%. The highest percentage of preterm deliveries was recorded during May-July (21.5%), while the lowest percentage was during September-November (19%). Most of maternal age for cases was recorded among age groups 20- (60.7%) and 30- (30%). Illiterate/read& write mothers constituted 17.1%, while 40.7% of them had secondary education. Most of the mothers were housewives (95%) in both groups. On the other hand, illiterate fathers or those with lower level of education were at risk to have a preterm offspring relative to university educated fathers (34.3% vs. 16.4%). More than two thirds of the fathers (79.3%) were working unskilled/semiskilled occupations.
Consanguineous parents constituted 15% of cases; nearly half of the consanguineous parents (7.1%) were first cousins compared to 10.4% among general population. The percentage of cases that had two or more abortions was 8.6% compared to 7.2% among controls with no significant risk. The inter-pregnancy spacing period <2 years was recorded in 10.3% of cases compared to 5.9% among controls with no significant risk. Assisted fertilization recorded in 15% of cases compared to 2.1% among controls with significant difference. Among cases with assisted conception, the risk of preterm deliveries was 8 times relatively to cases with spontaneous conception.
Cesarean Section deliveries were high among both cases and controls, but were higher among cases (92.1%) than among controls (74.3%). Mothers of preterm were 4 times likely to deliver by Cesarean section relatively to controls.
Multiple births constituted 20% among cases vs. 2.1% among controls with significant risk. The risk of preterm birth among multiple pregnancies was eleven times more relative to single pregnancy. For gravidity and parity, both cases and controls were almost similar with no significant risk. Previous history of preterm delivery recorded in 21.7% among cases vs. 2.3% among controls. The likelihood history of preterm among cases was 10 times relatively to controls with significant risk. Irregular antenatal care visits were recorded to be almost similar among both groups (11.4% among cases vs.10.7% among controls).
Concerning pregnancy complications, 74.3% of the cases had associated pregnancy complications vs. 23.6% among controls. The most common complications among cases were PROM (26.4%) with non among controls. This was followed by pre-eclampsia/eclampsia (18.6% among cases vs. 2.1% among controls group). Ante-partum hemorrhage was recorded in 5% among cases vs. 0.7% among controls. Vaginal infection/UTI was recorded in 3.6% among cases vs. 2.1% among controls.
Positive relevant medical history was recorded in 7.6% of cases vs. 3.6% among controls with no significant risk. Cases were about 2.5 times more likely to have a history of previous abdominal surgery (OR=1.78, 95% CI=1.11-2.86). Premature rupture of membrane was the most common indication of preterm birth (55%) followed by preterm labor pain (22.8%), fetal distress (10%), pre-eclampsia/eclampsia (4.3%), and antepartum hemorrhage (4.3%). Most of the mothers of the preterm cases had received antenatal steroid (90.8%).
Concerning months of delivery among preterm births, winter months (December, January, and February) had the highest percentage (28.6%) vs. 10% among controls and the difference was statistically significant. Preterm cases were 8.9 times more likely to be associated with congenital anomalies relative to controls, and this was statistically significant.
Almost two thirds of the preterm cases (64.3%) were born between 34-<37weeks, 20.7% were born between 32-<34 weeks and 15 % were born between 28-<32 weeks. Almost half (49.3%) of the preterm cases were LBW compared to 10.7% among controls. About one third (29.3%) of the cases were VLBW compared to 0% among controls. Referring to birth weight for GA, most of the cases and controls were appropriate for gestational age (82.9% of cases vs. 86.4% of the controls). Birth length among the cases (94.7%) were between 3rd -<97th percentile compared to 97.6% among controls, and head circumference of 93.2% of cases were between 3rd -< 97th percentile compared to 97.6% among the controls.
Three fourth of cases (75.7%) were formula fed compared to 20.7% among controls. Breast fed preterm infants constituted 9.2% vs. 55% of controls with significant difference. Special formula (premature formula and post discharge formula) was followed by 72.8% of cases compared to. 2.1% among controls. The age of one third of the cases at the initial visit was between 22-30 days (31.4%). While 18.6% were among age group between 46-60 days and 15.7% were in the age group between 31-45 days, and 11.4% of cases their age at initial visit was >60 days.
Multiple regression analysis full models of variables predicting preterm births revealed that six variables contributed significantly in the prediction of the dependent variable (preterm birth) which were in order of their importance: pregnancy complications, inter-pregnancy spacing (<2 years), congenital anomalies, multiple pregnancy, previous history of preterm delivery, and previous abdominal surgery.
Out of the total number of preterm cases, 40% at initial visit their weight was recorded below 3rd percentile. This percentage decreased to 27%, 27.4%, and 25.7% in the followed three visits respectively.
Regarding length, 24.3% were below 3rd percentile in the initial visit, while in the followed visits their percentage was 23%, 26.5% and 24.8% respectively. On the other hand, those with head circumference below 3rd percentile constituted 20.7% in the initial visit and 22.1%, 20.4% and 19% in the followed three visits. The progress in weight, length, and head circumference among the studied preterm cases were significantly affected by their birth weight, gestational age, type of feeding, and the presence of congenital anomalies.
During the initial visit, 12.9% of preterm infants were developmentally delayed and increased to 19.7%, 22.1% and 22.9% in the followed three visits respectively. Delayed development was significantly more among those with associated congenital anomalies and birth weight <1.5Kg during the four visits.
Logistic regression analysis for growth and development revealed that the significant predictor for delayed linear growth (weight, length and head circumference) and delayed developmental mile stones was low birth weight. Those of irregular maternal antenatal care where more liable for delayed growth in weight. Preterm infants who needed assisted mechanical ventilation were more liable to have delay in growth of length. On the other hand, preterm infants who needed more intensive resuscitation were more liable to have delay in head circumference growth and in developmental mile stones.
Among those carried out ophthalmological examination, 20% had ROP. Among those who carried out automated Auditory Brain stems Response (aABR), 0.9% had abnormal results. Among those who carried out Cranial Ultrasound/CT brain/MRI brain, 35.1% had abnormal findings; Hypoxic Ischemic Encephalopathy (12.9%), Intra-ventricular hemorrhage (11.7%).
Conclusions:
In the present study, the estimated proportion of preterm birth was 20.3% out of the deliveries occurred in Alexandria University Maternity Hospital, while the proportion of preterm infants attended the Nutrition outpatient’s clinic in Smouha Alexandria University Children’s Hospital was 23.9%. The highest percentage of preterm deliveries was recorded during May-July(21.5%),while the lowest percentage was during September-November (19%).Most of maternal age for cases was recorded among age groups 20-(60.7%) and 30- (30%).It is difficult to determine the precise cause of preterm birth which assumed to be multi-factorial. Preterm birth rate is higher among women with lower levels of education Consanguineous parents constituted 15% of cases.. Assisted fertilization was recorded in15%of cases compared to 2.1% among controls with significant difference. The effect of consanguinity was not observed in the present study (85% of cases vs. 71.4% of controls were non consanguineous The present study showed that cases with assisted fertilization were (15%) more than those among controls (2.1%). Multiple births constituted 20% among cases vs. 2.1% among controls with significant risk. The risk of preterm birth among multiple pregnancies was eleven times more relative to single pregnancy.The likelihood history of preterm among cases was 10 times relatively to controls with significant risk. Multiple regression analysis full models of variables predicting preterm births revealed that six variables contributed significantly in the prediction of preterm birth which were in order of their importance: pregnancy complications, inter-pregnancy spacing (<2 years), congenital anomalies, multiple pregnancy, previous history of preterm delivery, and previous abdominal surgery. Logistic regression analysis for growth and development revealed that the significant predictor for delayed linear growth and developmental mile stones was low birth weight. Those of irregular maternal antenatal care where more liable for delayed growth in weight. Preterm infants who needed assisted mechanical ventilation were more liable to have delay in growth of length. On the other hand, preterm infants who needed more intensive resuscitation were more liable to have delay in head circumference growth and in developmental mile stones.
Recommendations:
1- More efforts should be exerted to evaluate the magnitude of the problem of prematurity in Egypt through better statistical systems in both primary care facilities and hospitals, improving the data base and the reporting about preterm birth rate in Egypt and frequently update these data.
2- Continuous medical education and practical training of the medical staff for better assessment, and management of premature cases to reduce the complications in premature infants.
3- Providing neonatal care units with modern technical instruments and medications (e.g. surfactant, antibiotics and IV alimentation) to improve the outcome of prematurity. Also, improving the communication between delivery centers and NICUs as well as the availability of means of transportation for transfer of seriously ill cases.
4- Post-discharge follow up for high risk preterm at high-risk neonatal follow-up clinics, which are multidisciplinary clinics for the early detection and management of any complications.
5- Setting up an evidence based national guidelines for how to approach and screen preterm cases for early detection of prematurity associated problems.
6- Policies to support the early initiation and continuation of breast-milk feeding to increase the rates of breast feeding at discharge. Training of healthcare workers about how to maintain breast feeding during the period of separation and how to manage relactation.