研究發現22周早產兒有機會存活

A small number of very premature babies are surviving earlier outside the womb than doctors once thought possible, a new study has documented, raising questions about how aggressively they should be treated and posing implications for the debate about abortion.

一項新研究提出證據表明，少數極度早產兒能在子宮外存活，而醫生過去認爲這是不可能的。這一發現提出了究竟應該怎樣努力護理這些早產兒的問題，也可能會影響有關墮胎的爭論。

The study, of thousands of premature births, found that a tiny minority of babies born at 22 weeks who were medically treated survived with few health problems, although the vast majority died or suffered serious health issues. Leading medical groups had already been discussing whether to lower the consensus on the age of viability, now cited by most medical experts as 24 weeks.

這項對數千早產兒的研究發現，極少數在妊娠22周時出生的嬰兒，經過醫療護理後存活了下來，而且幾乎沒有影響他們健康的後遺症。雖然絕大多數如此早產的嬰兒死亡，或有嚴重的健康問題。一些知名的醫學團體已經在討論是否要降低公認的可獨立存活胎齡，目前絕大多數醫學專家引用的是24周。

The Supreme Court has said that states must allow abortion if a fetus is not viable outside the womb, and changing that standard could therefore raise questions about when abortion is legal.

美國最高法院曾表示，如果胎兒不能在子宮外存活，各州必須允許墮胎。因此改變可獨立存活胎齡的標準可能會催生何時墮胎合法的問題。

For most parents and doctors, the new study will intensify the agonizing choices faced about how intensively to treat such infants.

對於大多數家長和醫生來說，新研究將使他們面臨的究竟要在多大程度上特別護理這些嬰兒的選擇變得更加艱難。

The study, one of the largest and most systematic examinations of care for very premature infants, found that hospitals with sophisticated neonatal units varied widely in their approach to 22-week-olds, ranging from a few that offer no active medical treatment to a handful that assertively treat most cases with measures like ventilation, intubation and surfactant to improve the functioning of babies’ lungs.

這項研究是對極度早產兒護理的最大範圍也是最系統的考察之一。研究發現，有先進新生兒病房的醫院在對22周出生嬰兒的護理方法上差異很大。有爲數不多的醫院不提供任何積極的醫療護理，也有極少數的醫院果斷地治療大多數早產兒，對他們使用呼吸機、氣管插管，以及表面活性劑來提高嬰兒的肺部功能等措施。

“It confirms that if you don’t do anything, these babies will not make it, and if you do something, some of them will make it,” said Dr. David Burchfield, the chief of neonatology at the University of Florida, who was not involved in the research. “Many who have survived have survived with severe handicaps.”

“研究證實，如果你什麼都不做，這些早產兒不可能活，而如果你做點什麼，其中一些能活下來，”佛羅里達大學新生兒科主任醫生大衛·伯奇菲爾德博士(Dr. David Burchfield)說，“但許多活下來的早產兒有嚴重的身體障礙。”伯奇菲爾德博士沒有參與這項研究。

Results of the study, published Wednesday in The New England Journal of Medicine, are likely to influence a discussion taking place among professional medical associations about how to counsel parents and when to offer treatment to such tiny babies.

該研究的結果週三發表在《新英格蘭醫學雜誌》(The New England Journal of Medicine)上，很可能會影響專業醫學協會就如何爲家長提供諮詢、以及在什麼情況下該對這些特別早產的嬰兒提供醫療護理的問題所進行的討論。

The study, involving nearly 5,000 babies born between 22 and 27 weeks gestation, found that 22-week-old babies did not survive without medical intervention. In the 78 cases where active treatment was given, 18 survived, and by the time they were young toddlers, seven of those did not have moderate or severe impairments. Six had serious problems such as blindness, deafness or severe cerebral palsy.

這項研究涉及近5000名在妊娠22周到27周出生的嬰兒，研究發現，22周出生的嬰兒在沒有醫療干預的情況下不能生存。在進行了積極治療的78個病例中，有18個活了下來。他們長到兩、三歲時，有七人沒有中度或重度身體障礙，有六人有嚴重的問題，如失明、失聰或嚴重腦癱。

Of the 755 born at 23 weeks, treatment was given to 542. About a third of those survived, and about half of the survivors had no significant problems.

在23周出生的755個早產兒中，有542個得到了醫療護理。其中大約有三分之一存活，約一半存活者沒有明顯的健康問題。

As techniques for keeping babies alive improve, parents face wrenching choices that are sometimes based on whether the estimated age is 22 weeks and one day or six days. The study found that hospitals tend to “round up,” with babies closer to 23 weeks more likely to receive treatment.

隨着讓嬰兒能存活技術的改善，父母面臨着痛苦的選擇。有時這種選擇是基於對可獨立存活胎齡的估計是22周零一天還是零六天。這項研究發現，醫院往往會“四捨五入”，接近23周出生的早產兒更有可能得到醫療護理。

But the authors and other experts also noted that gestational age is an educated guess, based on women’s recollection of their last menstrual period and estimated fetal size. Other factors, including prenatal care and the fact that girls are often a week more mature than boys, should also influence decisions, experts say.

但是，論文作者和其他專家也指出，胎齡只是一個有根據的推測，根據的是孕婦對自己最近一次月經來潮日期的回憶，以及所估計的胎兒大小。專家說，其他因素，包括產前檢查，以及女胎兒往往比男胎兒早成熟一週的事實，也應該影響決定。

“It’s very difficult to say to a mother, ‘If you deliver today, I’m going to do nothing, but if you deliver tomorrow, I’m going to do everything,’ ” said Dr. Neil Marlow, a neonatologist at University College London.

倫敦大學學院(University College London)的新生兒專家尼爾·馬洛博士(Dr. Neil Marlow)說，“很難對一位母親說，‘如果你今天生，我會什麼都不做，但如果你明天生，我會盡一切努力。’”

The study, which evaluated cases from 2006 to 2011 at 24 hospitals in a neonatal network supported by the National Institute of Child Health and Human Development, found that four of the hospitals intervened for no 22-week-olds, five intervened for all 22-week-olds and the rest varied. In all, about a fifth of the 357 babies that age were treated. The reasons could include family preferences and hospital policy, the authors wrote.

這項研究評估了由美國兒童健康和人類發展研究所支持的24家醫院參與的新生兒網絡中，從2006年至2011年期間的病例，發現四家醫院對22周出生的早產兒沒有進行醫學干預，五家醫院對22周出生的嬰兒進行了干預，其他的醫院視情況而定。總的來說，所有接受醫療護理的357名22周出生的嬰兒中大約有五分之一接受了護理。是否治療的原因可能包括家庭的選擇和醫院的政策，作者寫道。

“We can’t really say whether the differences revolve around differences in values, that for some physicians or parents the risk of impairment might outweigh the decision for treatment,” said Matthew Rysavy, a medical student at the University of Iowa, who led the study with Dr. Edward Bell, a pediatrics professor there. At Iowa, Dr. Bell said, treatment is offered to most 22-week-olds, and he considers 22 weeks a new marker of viability.

“我們確實不能說，治療選擇上的差異是否是價值觀上的差異。對一些醫生或家長來說，（孩子存在）身體障礙的風險可能在做治療決定時起較大作用，”艾奧瓦大學醫學院學生馬修·萊薩維(Matthew Rysavy)說，他和醫學院的小兒科教授愛德華·貝爾博士(Dr. Edward Bell)一起領導了這項研究。貝爾說，在艾奧瓦州，大多數22周的早產兒都得到醫療護理，他認爲22周是獨立存活的新標準。

“That’s what we think, but this is a pretty controversial area,” Dr. Bell said. “I guess we would say that these babies deserve a chance.”

“我們這樣認爲，但這是一個非常有爭議的領域，”貝爾說。 “我想我們會說，這些嬰兒應該得到一個機會。”

Dr. Jeffrey M. Perlman, medical director of neonatal intensive care at NewYork-Presbyterian Hospital Weill Cornell Medical Center, takes a different view. He said it was important to consider that long months in neonatal units can be “like riding an obstacle course or flying in a plane with bad turbulence, and each of these down spirals can have an impact on the brain.”

紐約長老會醫院威爾康奈爾醫學中心(NewYork-Presbyterian Hospital Weill Cornell Medical Center)負責新生兒特別護理的醫務主任傑弗裏·M·佩爾曼(Jeffrey M. Perlman)則有不同看法。他表示，很重要的一點是，要考慮到新生兒待在特護室的長達數月的時間裏，可能會“像參加障礙賽，或是坐飛機時遇到了嚴重的氣流，每一次下降都可能會影響大腦”。

At his hospital, “we go after the 24-weekers,” he said. “If it’s 23, we will talk to the family and explain to them that for us it’s an unknown pathway. At 22 weeks, in my opinion, the outcomes are so dismal that I don’t recommend any interventions.”

在他所在的醫院，“我們會救治24周出生的早產兒，”他說。“如果是23周，我們會和家人溝通，向他們解釋，我們不知道未來會發生什麼。如果是22周，我個人認爲，結果非常悲觀，我不建議進行任何干預。”

Dr. Bell pointed to success stories, including Chrissy Hutchinson, 32, of Manchester, Iowa. Her water broke in 2010 when she was 21 weeks and six days pregnant. The first hospital she went to “said there really was no chance of survival, and if the baby was born not breathing that they weren’t going to resuscitate or anything,” she said.

貝爾醫生列舉了一些成功的例子，比如艾奧瓦州曼徹斯特的克麗茜·哈欽森(Chrissy Hutchinson)。哈欽森現年32歲，2010年，她在懷孕21周零六天之後羊水破了。她去就診的第一家醫院“說不可能存活，如果胎兒出來之後沒有呼吸，他們也不會採取復甦措施，”她說。

The Hutchinsons called the University of Iowa, and there, at 22 weeks and one day, Alexis was delivered, weighing 1.1 pounds. Alexis was treated and stayed in neonatal intensive care for almost five months. Now, Ms. Hutchinson, a pharmacy technician, said, aside from being more vulnerable to respiratory viruses, Alexis is a healthy 5-year-old.

哈欽森一家給艾奧瓦大學打了電話，在那裏，亞力克西絲(Alexis)在孕育22周零一天後誕生了，當時體重之有1.1磅（約0.5公斤）。她在新生兒重症監護室待了近五個月，並接受了治療。如今，從事藥劑師工作的哈欽森女士說，亞力克西絲五歲了，除了呼吸系統比較容易受到細菌侵襲之外，她很健康。

Some of the study’s results suggest that among 22-week-olds who are treated, experiences like the Hutchinsons’ would be exceedingly rare because Ms. Hutchinson delivered so close to 22 weeks and did not have time for corticosteroids beforehand.

這項研究的一些結果顯示，在接受治療的22周的胎兒中，哈欽森家這樣的例子極其罕見，因爲哈欽森女士分娩時孕期纔剛過22周，產前也沒來得及給她服用皮質類固醇激素。