Nașterea prematură – o provocare în cadrul unui spital multidisciplinar de urgență din România

Introduction

Preterm birth, defined as delivery before 37 comple­ted weeks of gestation, is a major public health concern all around the world. Its incidence is 5-18%, with important variations across different countries and regions, depending on socioeconomic and demographic factors⁽¹⁾. The incidence of preterm birth in Europe is 5.3-11.3%, Romania being one of the countries in the EU with the highest incidence (10%)⁽²⁾. Annually, more than 14 million children are born too early, and 1 million children die each year because of prematurity-related complications. Preterm birth is the leading cause of neonatal mortality and ranks second in mortality rates among children under 5 years old. In the past decades, neonatal care advances in some developed countries allowed the survival of extreme preterm newborns, and the viability limit was lowered to 20 weeks and below 500 g. In 2024, the world’s most premature baby was born in Iowa, at only 21 weeks and weighing 283 g. Despite advancements in medical technology, pregnancy and perinatal care, the prevention of preterm birth remains a global constant challenge. The stagnating rates suggest the need of new tools for preterm prediction and prevention⁽³⁾. In Romania, there are only 23 tertiary unit hospitals, of which seven are in Bucharest, prepared to manage complex obstetrical and neonatal cases. The smallest preterm baby in Romania was born in 2023, at 24 weeks and weighing 390 g⁽⁴⁾. We present our experience with preterm birth at the Emergency University Hospital Bucharest, Romania, between 2020 and 2025.

Materials and method

We performed a retrospective analysis of data collected from the patients’ files between 2020 and 2025, regarding preterm births, the major obstetric causes related to preterm delivery, and neonatal outcomes.

Results

Between 2020 and 2025, in the Emergency University Hospital Bucharest, there were 11,114 registered live newborns, of which 1620 were preterm. Therefore, the incidence of preterm birth was 14%.

Maternal outcomes

The main causes of preterm birth were: preterm rupture of membranes, either idiopathic or due to infections, placental abnormalities, preeclampsia and gestational diabetes. Maternal age also played a significant role in the incidence of preterm birth. The data are summarized in Table 1.

Placental abnormalities and placenta accreta spectrum, preeclampsia and gestational diabetes have an increased incidence in our hospital, because University Emergency Hospital Bucharest is a tertiary unit hospital, therefore we manage mainly such cases. In the selected period (2020-2025), 43 peripartum hysterectomies were performed for placenta accreta spectrum (PAS). The mean gestational age was 34 weeks. Other complex cases, which require direct admission of the pregnant patient to the intensive care unit department, are also transferred to us from other settings from Bucharest and the country. The maternal chronic pathologies vary widely, from hematologic disease to different types of neoplasia during pregnancy. Extreme maternal age at birth was also found in many of the cases we investigated, with an increased prevalence of adolescent mothers. The youngest patient was 12 years old, and the oldest one was 48.

Neonatal outcomes

The rate of admission to the Neonatal Intensive Care Unit (NICU) was 9%, with a neonatal mortality rate of 5%. Most preterm newborns were moderate to late preterm (32-37 weeks).  An increased incidence of preterm babies below 1000 g was observed in the selected period (Table 2). The smallest preterm baby born in our hospital in the selected period was a female born at 24 weeks and 5 days, who weighed only 430 g. The little girl, born in 2022, survived and developed well until present, with few prematurity-related sequelae.

Discussion

Definition and classification of preterm birth

Preterm birth is defined as birth before 37 comple­ted weeks of gestation. The World Health Organization (WHO) classifies preterm birth according to gestational weight as follows:

• extremely preterm (
• very preterm (28-32 weeks)
• moderate or late preterm (32-37 weeks).

The ability to accurately assess the completed weeks of gestation vary widely between pregnant patients, with the most precise methods not uniformly used across different clinics. A limitation of the WHO definition is that there is no uniformly accepted definition between spontaneous abortion and a viable birth. The fetal viability limit defines the gestational age at which the survival of the newborn outside the maternal body is possible. WHO also recommended fetal weight to be above 500 g, if gestational age could not be correctly assessed. In Romania, the lower limit of gestational age that separates late abortion from preterm birth is set at 24 completed weeks of amenorrhea⁽⁵⁾. In some countries (Canada, Australia) this limit is currently considered to be around 20 weeks of amenorrhea. The American Academy of Pediatrics and the ACOG defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. This limit has been lowered in the past decades because of the advances in neonatal care.

Decisions about medical intervention for periviable infants involve considering the likelihood of survival, the potential for long-term disability, and the required medical interventions⁽⁶⁾.

The Romanian Society of Obstetrics and Gynecology guidelines recommends that, “in special situations and at the request of the parents, the evacuation of the product of conception between 20 and 24 weeks of amenorrhea may be considered preterm birth and not late abortion, which requires adequate measures to resuscitate and support the vital functions of the newborn”⁽⁷⁾.

Fetal weight is another criterion used in the classification of preterm babies, but gestational age is preferred due to its better correlations with fetal outcomes and survival. Depending on the weight of the newborn correlated with their gestational age, they can be small for gestational age, normal weight, or large for gestational age. The classification in a certain category is made in relation to the standard mean according to the Gaussian distribution. Thus, the classification in a certain birth weight category has a relative value, and it is related to the population average. Small-for-gestational-age newborns are those whose gestational weight is below 10% of the representative sample for gestational age. Large-for-gestational-age newborns have a weight above 90% of the representative sample for gestational age. Thus, newborns with a weight between 10% and 90% fall into the category with normal birth weight. According to absolute birth weight, preterm newborns are classified as:

low birth weight (LBW):

very low birth weight (VLBW):

extremely low birth weight (ELBW):

Microprematurity is a term used to describe preterm babies born below 26 weeks and weighing below 750 g. These newborns are extremely fragile and require special care in intensive neonatal care units^(1,2,6). A study conducted in the University Emergency Hospital Bucharest between 2007 and 2012 found an increase in neonatal survival rates, but a 100% mortality in babies born with less than 750 g⁽⁶⁾. By comparison, our current study found an increase in the incidence of birth rate and survival of ELBW babies between 2020 and 2025.

Causes of preterm birth

Several risk factors are relevant for the preterm birth issue in the European context: pregnancy history (parity, shorter interval between pregnancies, prior preterm birth), maternal age (35 years old), infections, inflammation, cervical length, cervical surgery/trauma, assisted reproductive techniques, smoking, recreational drug use, maternal stress, environmental exposure, diabetes, hypertension, placental and umbilical cord abnormalities, Body Mass Index (BMI), multiple pregnancy, fetal sex (male), ethnicity^(2,8).

In the context of an increasing rate of caesarean births worldwide, placental abnormalities and placenta accreta spectrum incidence are also increased. Therefore, our study found PAS to be among the first causes of preterm birth in our unit. Other placental abnormalities involved in the pathophysiology of preterm birth are abruptio placentae, placental insufficiency, chorioamnionitis, vascular lesions and vasa praevia⁽⁹⁾.

Adolescent motherhood in Europe is characterized by significant regional differences, with Eastern Europe having higher rates than Northern, Western or Southern Europe (41.7/1000). Romania stands out with the highest rates, particularly for mothers under 15 years old, where it accounts for nearly half of all such births in the EU, and one in ten newborns has a teenage mother (according to a study by “Save the Children”, 2024). The causes are complex, including a cycle of poverty, and factors like access to comprehensive sex education and contraception are key to prevention and support^(2,4).

Preterm birth prevention

Current strategies for preterm birth prevention in Romania are similar to those from international guidelines, and they focus on early risk factor identification, prenatal care and targeted medical interventions. Key challenges include significant socioeconomic and geographical disparities, limited healthcare access in rural areas and underreporting of risk factors^(1,2,7,10).

Current prevention strategies include:

• early and consistent prenatal care
• lifestyle modifications
• infection management
• targeted medical interventions (progesterone, low-dose aspirin, tocolytics)
• dietary supplementation.

The challenges in Romania are:

• socioeconomic and geographical disparities
• inadequate antenatal care coverage 
• resource and infrastructure issues
• underestimation and underreporting
• behavioral risk factors
• diagnostic limitations.

There are only 23 tertiary-unit maternity hospitals in Romania, of which seven are in Bucharest. Also, 16 of the 41 counties have less than five neonatologists, which makes it impossible to have a tertiary-unit maternity with neonatal intensive care unit beds. The Romanian National Institute of Statistics reveals that there are 368 public hospitals in the country, of which 200 should have a maternity or an obstetrics and gynecology department, but they lack medical staff^(4,7).

Recently, the Romanian Ministry of Health has announced a new national prevention and screening program which brings hope for better future maternal and fetal outcomes. Strategies and protocols are yet to be developed and uniformly applied.

Conclusions

Preterm birth is a global health concern, despite recent medical progress. The increased rate of preterm births in a tertiary-unit hospital is due to the severe obstetrical cases admitted and/or transferred from lower grade units. The main challenges such hospital faces are represented by the complexity of cases, the variety of pathologies which need to be managed and the limited number of NICU beds. Placenta accreta spectrum, preeclampsia and sepsis are among the most serious obstetrical complications leading to preterm labor and possible maternal and neonatal morbidity. The peculiarities of the Romanian population and the gaps in the medical system regarding pregnancy monitoring put a constant burden on the medical staff and make preterm birth management a constant challenge.

Autor corespondent: Oana-Maria Cosma E-mail: email: oanamb8@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.