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Peterson J, Smith DM, Johnstone ED, Mahaveer A. Perinatal optimisation for periviable birth and outcomes: a 4-year network analysis (2018-2021) across a change in national guidance. Front Pediatr 2024; 12:1365720. [PMID: 38694726 PMCID: PMC11061457 DOI: 10.3389/fped.2024.1365720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/11/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction The British Association of Perinatal Medicine (BAPM) released their revised framework for extremely preterm infant management in 2019. This revised framework promotes consideration of perinatal optimisation and survival-focused care from 22 weeks gestation onwards. This was a departure from the previous BAPM framework which recommended comfort care as the only recommended management for infants <23 + 0 weeks. Methods Our study evaluates the clinical impact that this updated framework has had across the Northwest of England. We utilised anonymised network data from periviable infants delivered across the region to examine changes in perinatal optimisation practices and survival outcomes following the release of the latest BAPM framework. Results Our data show that after the introduction of the updated framework there has been an increase in perinatal optimisation practices for periviable infants and an 80% increase in the number of infants born at 22 weeks receiving survival-focused care and admission to a neonatal unit. Discussion There remain significant discrepancies in optimisation practices by gestational age, which may be contributing to the static survival rates that were observed in the lowest gestational ages.
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Affiliation(s)
- J. Peterson
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- St Mary’s Maternity Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - D. M. Smith
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - E. D. Johnstone
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- St Mary’s Maternity Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - A. Mahaveer
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- St Mary’s Maternity Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Rallis D, Ben-David D, Woo K, Robinson J, Beadles D, Bernardini L, Abdulhayoglu E, Flanigan E, Christou H. Single center experience with first-intention high-frequency jet vs. volume-targeted ventilation in extremely preterm neonates. Front Pediatr 2024; 11:1326668. [PMID: 38239592 PMCID: PMC10794594 DOI: 10.3389/fped.2023.1326668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024] Open
Abstract
Objectives To examine whether first-intention high-frequency jet ventilation (HFVJ), compared to volume-targeted ventilation (VTV), in extremely preterm infants is associated with lower incidence of bronchopulmonary dysplasia (BPD) and other adverse clinical outcomes. Study design We conducted a retrospective cohort study evaluating neonates with gestational age (GA) ≤28 weeks, who received first-intention HFJV (main exposure) or VTV (comparator), between 11/2020 and 3/2023, with a subgroup analysis including neonates with GA ≤26 weeks and oxygenation index (OI) >5. Results We identified 117 extremely preterm neonates, 24 (GA 25.2 ± 1.6 weeks) on HFJV, and 93 (GA 26.4 ± 1.5 weeks, p = 0.001) on VTV. The neonates in the HFJV group had higher oxygenation indices on admission, higher inotrope use, and remained intubated for a longer period. Despite these differences, there were no statistically significant differences in rates of BPD, survival, or other adverse outcomes between the two groups. In subgroup analysis of 18 neonates on HFJV and 39 neonates on VTV, no differences were recorded in the GA, and duration of mechanical ventilation, while neonates in the HFJV group had significantly lower rates of BPD (50% compared to 83%, p = 0.034), and no significant differences in other adverse outcomes compared to neonates in the VTV group. In neonates ≤26 weeks of GA with OI >5, HFJV was significantly associated with lower rates of BPD (OR 0.21, 95% CI 0.05-0.92), and combined BPD or death (OR 0.18, 95% CI 0.03-0.85), after adjusting for birth weight, and Arterial-alveolar gradient on admission. Conclusions In extremely preterm neonates ≤26 weeks of GA with OI >5, first-intention HFJV, in comparison to VTV, is associated with lower rates of BPD.
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Affiliation(s)
- Dimitrios Rallis
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Neonatal Intensive Care Unit, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Danielle Ben-David
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Kendra Woo
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jill Robinson
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - David Beadles
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Laura Bernardini
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Elisa Abdulhayoglu
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Elizabeth Flanigan
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Helen Christou
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
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Bitas C, Onishi K, Saade G, Kawakita T. Neonatal and Maternal Outcomes at 22-28 Weeks of Gestation by Mode of Delivery. Obstet Gynecol 2024; 143:113-121. [PMID: 37769304 DOI: 10.1097/aog.0000000000005379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/13/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE To compare neonatal and maternal outcomes after 22- to 28-week delivery between cesarean and vaginal delivery after stratification by gestational age and fetal presentation. METHODS This study was a repeated cross-sectional analysis using U.S. birth certificate data linked to infant death data from 2017 to 2020. We limited analyses to women with singleton pregnancies who gave birth at 22-28 weeks of gestation and whose neonates were admitted to the intensive care unit. Our primary outcome was neonatal death within 28 days. We also examined infant mortality within 1 year and severe maternal morbidity (SMM; any transfusion, unplanned hysterectomy, and intensive care unit admission). Outcomes were compared between cesarean and vaginal delivery after stratification by gestational age and fetal presentation. Multivariable logistic regression was performed to calculate adjusted odds ratios (vaginal delivery as a referent), controlling for potential confounders. RESULTS Of 69,672 individuals with eligible deliveries, 1,740 (2.5%) delivered at 22 weeks of gestation, 6,155 (8.8%) delivered at 23 weeks, 9,341 (13.4%) delivered at 24 weeks, 10,516 (15.1%) delivered at 25 weeks, 11,994 (17.2%) delivered at 26 weeks, 13,662 (19.6%) delivered at 27 weeks, and 16,264 (23.3%) delivered at 28 weeks. In cephalic fetuses, cesarean delivery compared with vaginal delivery was associated with neonatal death and infant mortality at 24 weeks of gestation and greater (not significant at 22-23 weeks) and SMM in all gestational age groups. In contrast, in noncephalic fetuses, cesarean delivery compared with vaginal delivery was associated with decreased odds of neonatal death and infant mortality in all gestational age groups. Sample size for SMM in noncephalic fetuses precluded multivariable modeling. CONCLUSION Cesarean delivery in cephalic fetuses was associated with increased odds of adverse neonatal outcomes (24 weeks of gestation or greater) and SMM (all gestational age groups). Cesarean delivery was associated with decreased odds of neonatal death compared with vaginal delivery for noncephalic fetuses in all gestational age groups.
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Affiliation(s)
- Christiana Bitas
- Department of Obstetrics and Gynecology-Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, Virginia
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Battarbee AN. Antenatal Corticosteroids at 21-23 Weeks of Gestation. Obstet Gynecol 2024; 143:35-43. [PMID: 37708497 PMCID: PMC10840910 DOI: 10.1097/aog.0000000000005352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/13/2023] [Indexed: 09/16/2023]
Abstract
Neonates born at the cusp of viability are at particularly high risk of severe morbidity and mortality. With advances in medicine and technology, the ability to resuscitate smaller, more premature neonates has become possible, and survival as early as 21 weeks of gestation has been reported. Although administration of antenatal corticosteroids has been shown to reduce the risk of morbidity and mortality at later gestational ages, neonates born before 24 weeks of gestation have not been included in randomized clinical trials. Changing clinical practices surrounding neonatal resuscitation with intervention offered after birth at earlier gestational ages has prompted re-evaluation of the use of antenatal corticosteroids at these very early gestational ages. Recent observational data demonstrate that antenatal corticosteroids administered before deliveries at or after 22 weeks of gestation are associated with lower risks of neonatal mortality, although survival with severe morbidity remains high. Future research is needed to determine the efficacy of antenatal corticosteroids for deliveries before 22 weeks of gestation and should evaluate the timing of corticosteroid administration. Furthermore, efforts should be made to include diverse populations and clinically meaningful long-term outcomes. At this time, the decision surrounding antenatal corticosteroids for threatened periviable deliveries should incorporate multidisciplinary counseling with the goal of achieving concordant prenatal and postnatal management aligned with the patient's desires.
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Affiliation(s)
- Ashley N Battarbee
- Center for Women's Reproductive Health and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
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Piette V, Deliens L, Debulpaep S, Cohen J, Beernaert K. Appropriateness of end-of-life care for children with genetic and congenital conditions: a cohort study using routinely collected linked data. Eur J Pediatr 2023; 182:3857-3869. [PMID: 37328636 DOI: 10.1007/s00431-023-05030-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/10/2023] [Accepted: 05/17/2023] [Indexed: 06/18/2023]
Abstract
This study aims to evaluate the appropriateness of end-of-life care for children with genetic and congenital conditions. This is a decedent cohort study. We used 6 linked, Belgian, routinely collected, population-level databases containing children (1-17) who died with genetic and congenital conditions in Belgium between 2010 and 2017. We measured 22 quality indicators, face-validated using a previously published RAND/UCLA methodology. Appropriateness of care was defined as the overall "expected health benefit" of given healthcare interventions within a healthcare system exceeding expected negative outcomes. In the 8-year study period, 200 children were identified to have died with genetic and congenital conditions. Concerning appropriateness of care, in the last month before death, 79% of children had contact with specialist physicians, 17% had contact with a family physician, and 5% received multidisciplinary care. Palliative care was used by 17% of the children. Concerning inappropriateness of care, 51% of the children received blood drawings in the last week before death, and 29% received diagnostics and monitoring (2 or more magnetic resonance imaging scans, computed tomography scans, or X-rays) in the last month. Conclusion: Findings suggest end-of-life care could be improved in terms of palliative care, contact with a family physician and paramedics, and diagnostics and monitoring in the form of imaging. What is Known: • Previous studies suggest that end-of life care for children with genetic and congenital conditions may be subject to issues with bereavement, psychological concerns for child and family, financial cost at the end of life, decision-making when using technological interventions, availability and coordination of services, and palliative care provision. Bereaved parents of children with genetic and congenital conditions have previously evaluated end-of-life care as poor or fair, and some have reported that their children suffered a lot to a great deal at the end of life. • However, no peer-reviewed population-level quality evaluation of end-of-life care for this population is currently present. What is New: • This study provides an evaluation of the appropriateness of end-of-life care for children who died in Belgium with genetic and congenital conditions between 2010 and 2017, using administrative healthcare data and validated quality indicators. The concept of appropriateness is denoted as relative and indicative within the study, not as a definitive judgement. • Our study suggests improvements in end-of-life care may be possible, for instance, in terms of the provision of palliative care, contact with care providers next to the specialist physician, and diagnostics and monitoring in terms of imaging (e.g., magnetic resonance imaging, computed tomography scans). Further empirical research is necessary, for instance, into unforeseen and foreseen end-of-life trajectories, to make definitive conclusions about appropriateness of care.
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Affiliation(s)
- Veerle Piette
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Sara Debulpaep
- Department of Pediatrics, University Hospital Ghent, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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Chiang MC. Therapeutic trajectory for improving survival and outcomes of very low birth weight (VLBW) preterm infants. Pediatr Neonatol 2023; 64:493-494. [PMID: 37612206 DOI: 10.1016/j.pedneo.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023] Open
Affiliation(s)
- Ming-Chou Chiang
- Division of Neonatology and Division of Respiratory Therapy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Boddy MG, Davis AS, Perlman N. The pregnancy at risk for delivery at the threshold of viability. Curr Opin Obstet Gynecol 2023; 35:101-105. [PMID: 36912247 DOI: 10.1097/gco.0000000000000850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
PURPOSE OF REVIEW To examine updated recommendations for obstetrical interventions that may improve neonatal outcomes in extremely preterm births. RECENT FINDINGS Several recent studies of antenatal steroids at the threshold of viability have demonstrated benefits in both survival and survival without major morbidity. This has led to revised recommendations from the American College of Obstetricians and Gynecologist regarding the timing of antenatal steroids in these extremely preterm fetuses. SUMMARY These recent developments have important implications for clinical care in patients at risk for extremely preterm birth based on a model of best practices and shared decision-making.
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Affiliation(s)
- Mark G Boddy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology
| | - Alexis S Davis
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, California, USA
| | - Nicola Perlman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology
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