Major Causes Attributing to Long Term Morbidity

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• 早產兒定義
• 國內死亡率及罹病率
• 國外死亡率及罹病率
• 醫療費用
• 目前處理的guideline
• 倫理問題
• 處理倫理問題的原則
• 傑出早產兒
Definition
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Prematurity ≤ 37 complete weeks
Low birth wt < 2.5 kg
Very low birth wt (VLBW) < 1.5 kg
Extremely low birth wt (ELBW) < 1.0 kg
Micronates < 750 gm
Live birth (WHO > 500 gm)
(U.S.A. > 300 gm or 20 wks)
Survival Rate of VLBW in Taiwan
(1996 台灣)
Overall
70.1%
• 1001-1500 gm
88.3%
• ≤ 1000 gm
49.7%
Survival Rate (VLBW)
• Overall
• 1001-1500 gm
• <1000 gm
77%
92%
62%
Percent mortality before discharge by 100 gm birth weight subgroups with 95%
confidence intervals. Inborn infants 501 to 1500 gm. Born May 1, 1991, to Dec. 31,
1992. Numbers of infants in each 100 gm birth weight category are indicated
above each bar. (Fanaroff et al.)
Percent mortality before discharge by gestational age according to obstetric
measures and 95% confidence intervals. Inborn infants 501 to 1500 gm. Born
May 1, 1991, to Dec. 31, 1992. Numbers of infants at each week of gestational age
are indicated above each bar. (Fanaroff et al.)
Disability Status Outcomes of VLBW and ELBW Children
Major Causes Attributing to
Long Term Morbidity
• Intraventricular hemorrhage (> Gr II)
• Periventricular leukomalacia
• Hypoxic-ischemic encephalopathy
• Chronic lung disease
• Retinopathy of prematurity
• Failure to thrive
Direct Hospital Cost
(California 1998)
500-749 gm
• hospital day
• cost per day
• total hosp. cost.
≒139 days
U.S. $ 2,930
U.S. $ 407,270
750-999 gm
• hospital day
• cost per day
• total hosp. cost.
≒116 days
U.S. $ 2,500
U.S. $ 290,000
Future Direction
(未來的方向)
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Prevention of Preterm Birth (預防早產)
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Research on Teratology (畸形學的研究)
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Prevention of Infection (感染的預防)
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Develop and Evaluate New Technologies
(發展並評估新的科技技術)
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Develop Guidelines for Medical Ethics
(醫學倫理準則)
Develop The Guidelines For
Medical Ethics In Perinatology
(週產期醫學的倫理準則)
• Limit of viability (活存的最低週數)
• Long term outcome (愈後)
• Cost and benefit (成本與收益的平衡)
How Small Is Too Small?
• < 23-24 weeks
• < 500-600 gm
Discontinuance of ICU Care
• Infants < 22 weeks
• Infants < 750 gm with severe RDS, IVH ( > Gr II)
• Lethal chromosome anomalies
• Infants with severe lethal congenital malformation
• Infants with severe birth asphyxia (Apgar score < 3
at 25 min) and without detetable cerebral blood flow
Frame work for Medical Ethics
• Ethical Principles
• Professional virtues
Ethical Principles
Beneficence (行善行為)
• Doing good, preserving life, alleviating suffering
Nonmaleficence (避免傷害)
• Doing no harm
Autonomy (自主權利)
• Respecting the wishes of patient or surrogate
Justice (正義公平)
• Protecting patient’s right and fairy allocating
medical resource
Professional Virtues
1. Scientifically and clinically competent
2. Primarily to benefit the patient in practice
and research, reasonably sacrifice selfinterest.
3. Consistently practice according to
standards of intellectual and moral
excellence.
• Parental counseling
• The role of the parents
• The role of the doctors
• The role of the community
Ethic Issues in Neonatal and
Perinatal Medicine
1. How small is too small ?
2. Selective reduction
3. Fetal anomalies
– ethical and legal consideration in screening,
detection and management
4. Refusal of treatment during pregnancy
5. Maternal
– fetal research and protection policy
6. Fetal surgery
7. The effect of insurance policy on the ethics in
perinatal medicine
Some Famous
“High Risk”
Newborn Babies
Johannes Kepler
German astronomer and mathematician.
Born 1571. Lived 59 years. Estimated I.Q. 160.
He had a bad start in life as he was a seven
month baby and seven month babies were
proverbially thought to be weak in body and
mind. As he grew, however, his body became
strong and his superior intellect evolved. He
became the Principal Mathematician to the
Emperor and a founder of modern astronomy
and physics. He elucidated the Copernican
concept of the Universe.
Sir Isaac Newton
British mathematician, astronomer, and
physicist. Born 1642. Lived 85 years. Estimated I.Q.
170. On Christmas Day in the house of Woolthrope,
a three pound baby, newly born, rested on a pillow
near his mother. He was alive but fighting for
breath. Frightened old midwives went for the doctor
remarking. “The baby’s as good as dead. It’s a
miracle if he lives until we get back. Such a tiny mite,
he is.” Later Isaac would remember fondly his
mother’s remark. “ You were so tiny that you might
have been put into a quart mug!” This tiny mite
came to be known as one of the greatest scientific
geniuses of all time.
Francois Marie Arouet De Voltaire
French philoscopher, writer. Born 1694.
Lived 84 years. Estimated I.Q. 180. On the
day of his birth, because of poor chance of
living, he was hurriedly baptized. The nurses
had slapped him to life. Every morning they
would come down from the attic (where the
young one was kept) saying that he would not
live an hour. The puny little boy, however,
defied then morbid expectations. Voltaire is
considered as a rare genius.
Samuel Johnson
British poet, critic, lexicographer. Born 1709.
Lived 75 years. Estimated I.Q. 155. Sarah Johnson
was 40 when she gave birth to her first son on the
afternoon of a cold September day. The labor was
long and difficult. His father, a 52 year old
bookseller, greeted him: “Here is a brave boy.”
The infant was , however, strangely inert and bad
no cry but finally, with persuasion, he made a few
whimpers, breaking a long silence. Fearing
impending death he was christened that evening.
This inert boy lived to become one of the world’s
most important English lexicographers and literary
critics. His conversational word and the style of his
essays are legendary.
Johann Wolfgang Goethe
German poet. Born 1749. Lived 83 years.
Estimated I.Q. 200. When he was 75, Goethe
remarked, “….. there has been nothing but toil and
tumble (for me), …..throughout my 75 years. I have
not had 9 months of real freedom from care.” His
18 year old mother suffered three days of modal
agony before the baby was delivered. He looked so
lifeless and miserable that he was thought to be
stillborn. For hours they rubbed his body with wine
until, finally, he opened his eyes and lived.
Thomus Hardy
English writer. Born 1840. Lived 88
years. At birth he was thrown aside as
dead, but the midwife exclaimed to the
surgeon, “Dead, Sir! Stop a minute. He is
alive enough, sure.” A good slapping from
her revived the baby who later became a
prestigious English novelist and poet.
Sir Winston Churchill
British statesman. Born 1874. Lived 91
years. He was not expected to be born until
sometime in January of the following year. He
upset a ball by his early birth on November 30.
He had good lungs, the Duchess of
Marlborough shook her head and observed,…
I have myself given life of quite a number of
infants----such an earth shaking noise as this
newborn baby made, I have never heard.”
Poblo Picasso
Spanish artist. Born 1881. Lived 92
years. The sun-drenched seaport of Malaga
on Spain’s Mediterranean coast was the scene
of his dramatic birth on October 25. The
midwife judged the child just born to be dead
and left him on the table while attending to
his mother. Uncle Don Salvador, an
experienced physician, resuscitated the little
one and saved this future great artist.
Franklin Delano Roosevelt
United States President. Born 1882. Lived 63
years. Sara Delano Roosevelt was in great agony from
a long and difficult delivery and an overdose of
chloroform nearly ended her life and that of her baby
boy. The infant had a “death-like respiratory standstill,
the skin blue and body limp.” Mouth-to-mouth
breathing revived the baby. Years later, his mother
would recall, “……too much of chloroform was nearly
fatal to us….the nurse said later she never expected
the baby to live.” Elected to four terms as president of
the United States, Roosevelt occupies an important
place in modern American history.
Anna Pavlova
Russian ballerina, Born 1882. Lived 49
years. As a premature infant she “…was so
weak and puny that her parents had her
baptized three days after birth . She spent
most of her time in the next few
months…wrapped in cotton wool.” She
ultimately became and was proclaimed the
worlds’s most famous ballerina.
D (David) H (erbert) Lawrence
English writer. Born 1885. Lived 45 years.
He was a frail child at birth and at two weeks of
age he developed a severe attack of bronchitis. He
remained, in his own words, “a delicate brat with a
stuffy nose, whom most people treated quite gently
as just an ordinary little lad.” D.H. Lawrence
ranks among the most influential literary figures
of the 20th century. At 45, he died of tuberculosis.
Three ‘pans” need to balanced on the Scale of Justice in
neonatal rescue; moveover, the symbolic figure needs to lift her
blindfold and look at future consequences, if she is to make a
just decision about present action. Drawn by Chan Lane of the
Bowman Gray School of Medicine, Winston-Salem, NC.