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Table 1 Summary of the main observations on prematurity and the influence of fetal sex from unidisciplinary fields

From: A transdisciplinary approach to the decision-making process in extreme prematurity

Field Main observations
Epidemiology -The major causes of prematurity are: planned premature delivery for maternal or foetal reasons, spontaneous preterm labor, and preterm premature rupture of membranes.
-A birth at 22–24 weeks is considered at the limit of viability, with 11-30% survival at 23 weeks, 54-76% at 25 weeks, and 90-95% at 28–31 weeks.
-Risk factors of prematurity related to the mother: maternal age, infections, in vitro fertilization, background of premature delivery, smoking, psychosocial background.
-Risk factors related to the foetus: intra-uterine growth restriction, multiple births, males are at higher risk of premature birth.
-The use of antenatal corticosteroids reduces the mortality rate and the risk and severity of respiratory distress syndrome, cerebral hemorrhage, and necrotizing enterocolitis.
Biomedical -Main organs at risk in prematurity: skin (homeostasis), eyes (retinopathy), cardiovascular system (arteriovenous shunt), intestine (necrotizing enterocolitis), brain (cerebral palsy, hemorrhage), lung (respiratory distress syndrome, bronchopulmonary dysplasia).
-Respiratory distress syndrome is a main concern, with males being more susceptible than females due to a delay in lung maturation that is related to androgens.
-Some lung maturation biomarkers can be tested in the amniotic fluid, but this is not always feasible and/or useful in the clinic.
-Commonly used treatments: antenatal corticosteroids have well documented positive effects on the maturation of the surfactant system; the use of surfactant mixtures and assisted ventilation protocols greatly improves outcomes.
Psychosocial -Cognitive sequelae of prematurity: some retardation at preschool (2–3 years) and school age (6–8 years), with a male disadvantage. Not much difference is observed in school performance at 10 years old. In adolescents and young adults, some high-level cognitive functions (suppression of automatic responses, mental flexibility) may be affected and translate into learning problems in school.
-Behavioral and affective sequelae of prematurity: deficits are more prevalent at preschool age, and psychiatric disorders (especially attention deficit hyperactivity disorder) are more prevalent at school age, with sex differences in type and severity. In young adults, some confidence and behavior problems are reported, with a male disadvantage..
-At cognitive, behavioral, and affective levels, most “problems” tend to decrease with age.
-In parents, prematurity can lead to high stress, anxiety, and depression, especially when the child has severe health problems. The stress experienced by parents can negatively impact on the development of the child.
Ethics -Technical advances lead in some cases to extended time to death; use of invasive treatments that may or may not be beneficial.
-Importantly, an initial reanimation/life-support, that can be temporary, will allow time to evaluate the situation.
-Main types of prioritization of risks: above all, avoid wrongfully stopping treatment; avoid wrongfully continuing treatment; above all, avoid damage.
-The risk of heroic measures is always present and has to be considered.
-Main ethic principles involved: beneficience, autonomy, best interest of the child (to be considered by parents and physicians), free and enlightened consent, respect of human life and quality of life, justice and equity, precautionary principle.
-The communication between parents and physicians and the involvement of parents in the decision process are of high importance.
-Palliative/confort care should be provided if needed.
-Unfortunately, decisions made in the so-called “grey zone” can be mistakes.
Law -Legal status of the premature infant: the legal status begins and ends with life, and associated civil rights are the right to life, to inviolability, and to bodily integrity. According to Canadian Law, the foetus does not have a legal status. The child becomes a person when out of the mother’s body, alive, and viable; breathing or not, with independent circulation or not, umbilical cord severed or not. A medical evaluation is required to assess the viability of the child. The legal status is a prerequisite to be eligible to receive treatments.
-Rights and duties of the parents: parental authority, free and enlightened consent to treatments or arrest of treatments, in the best interest of the child.
-Duties and obligations of the physicians: duty to inform, obligation to treat when consent is obtained.
-It is possible to contest a decision (parents against physicians, or vice versa) in a court of law if needed, where the judge will render a judgement in the best interest of the child.
-Some shifts exist between law and scientific knowledge.