Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists

Enhanced Survival of 22-25 Week Preterm Infants After Proactive Care Implementation: A Comparative Analysis of Two Time Periods

OBJECTIVES

To investigate the impact of proactive perinatal care on periviable preterm infants before and after its implementation.

METHODS

This retrospective cohort study was conducted over a period of 10 y, from 2013 to 2019, referred to as Phase I, and from 2020 to 2022, referred to as Phase II. A total of 162 eligible infants born between 220/7 and 256/7 wk of gestation were included in this analysis.

RESULTS

A total of 125 infants were born in phase I, and 37 infants in phase II received proactive care with minimal handling. The mortality decreased from 54.4% to 24.3% (P = 0.001). The composite outcomes of severe brain injury or death, sepsis or death and necrotizing enterocolitis or death were also improved with proactive care. Gestational age [adjusted odds ratio (aOR) 0.900; 95% confidence interval (CI), 0.836-0.970], air leak syndrome (aOR 4.958; 95% CI, 1.681-14.624), massive pulmonary hemorrhage (aOR 4.944; 95% CI, 2.055-11.893), and birth in phase II (aOR 0.324; 95% CI, 0.115-0.912) were independently associated with mortality.

CONCLUSIONS

The implementation of proactive care with minimal handling resulted in an increased survival rate and a reduction in the combined morbidities between the two time periods. The provision of proactive perinatal care with minimal handling is crucial for improving both the survival rates and clinical outcomes of these vulnerable infants.

Prognosis of 22- and 23-Gestational-Week-Old Infants at Our Facility: A Retrospective Cohort Study

OBJECTIVE

 This study aimed to compare inborn infants aged 22 and 23 gestational weeks at our hospital to assess for differences in survival and long-term prognosis.

STUDY DESIGN

 We retrospectively analyzed 22- and 23-gestational-weeks-old infants born in our hospital between January 2011 and December 2018. The prognosis of inborn infants in Japan was also calculated using the Neonatal Research Network of Japan (NRNJ) data during the same period.

RESULTS

 The survival rates at our institution's neonatal intensive care unit discharge, including stillbirth, were 72 and 89% at 22 and 23 gestational weeks, respectively. The mortality rate and neurodevelopmental impairment (NDI) rate at 3 years of age, including stillbirth, were 58 and 32% at 22 and 23 weeks, respectively. Cerebral palsy, mental developmental retardation, visual impairment, and hearing impairment defined NDI. The prognosis at our hospital was better than the average calculated using NRNJ data. Survival rates varied among facilities, and some facilities had survival rates similar to that of our hospital.

CONCLUSION

 The prognosis of 22-gestational-week-old inborn infants was inferior to that of 23 gestational weeks in our institution but was better than previously reported. If aggressive treatment is provided, survival without sequelae can be fully expected even for 22-gestational-week-old infants.

KEY POINTS

· We examined babies of gestation ages 22 and 23 weeks.. · We examined the survival and neurological prognoses.. · We compared our facility with that in entire Japan..

Resuscitation, survival and morbidity of extremely preterm infants in California 2011-2019

OBJECTIVE

To describe changes over time in resuscitation, survival, and morbidity of extremely preterm infants in California.

STUDY DESIGN

This population-based, retrospective cohort study includes infants born ≤28 weeks. Linked birth certificates and hospital discharge records were used to evaluate active resuscitation, survival, and morbidity across two epochs (2011-2014, 2015-2019).

RESULTS

Of liveborn infants, 0.6% were born ≤28 weeks. Active resuscitation increased from 16.9% of 22-week infants to 98.1% of 25-week infants and increased over time in 22-, 23-, and 25-week infants (p-value ≤ 0.01). Among resuscitated infants, survival to discharge increased from 33.2% at 22 weeks to 96.1% at 28 weeks. Survival without major morbidity improved over time for 28-week infants (p-value < 0.01).

CONCLUSION

Among infants ≤28 weeks, resuscitation and survival increased with gestational age and morbidity decreased. Over time, active resuscitation of periviable infants and morbidity-free survival of 28-week infants increased. These trends may inform counseling around extremely preterm birth.

Fetal aortic isthmus Doppler assessment to predict the adverse perinatal outcomes associated with fetal growth restriction: systematic review and meta-analysis

PURPOSE

Fetal growth restriction (FGR) management and delivery planning is based on a multimodal approach. This meta-analysis aimed to evaluate the prognostic accuracies of the aortic isthmus Doppler to predict adverse perinatal outcomes in singleton pregnancies with FGR.

METHODS

PubMed, EMBASE, the Cochrane Library, ClinicalTrials.gov and Google scholar were searched from inception to May 2021, for studies on the prognostic accuracy of anterograde aortic isthmus flow compared with retrograde aortic isthmus flow in singleton pregnancy with FGR. The meta-analysis was registered on PROSPERO and was assessed according to PRISMA and Newcastle-Ottawa Scale. DerSimonian and Laird's random-effect model was used for relative risks, Freeman-Tukey Double Arcsine for pooled estimates and exact method to stabilize variances and CIs. Heterogeneity was quantified using I2 statistics.

RESULTS

A total of 2933 articles were identified through the electronic search, of which 6 studies (involving 240 women) were included. The quality evaluation of studies revealed an overall acceptable score for study group selection and comparability and substantial heterogeneity. The risk of perinatal death was significantly greater in fetuses with retrograde Aortic Isthmus blood flow, with a RR of 5.17 (p value 0.00001). Similarly, the stillbirth rate was found to have a RR of 5.39 (p value 0.00001). Respiratory distress syndrome had a RR of 2.64 (p value = 0.03) in the group of fetuses with retrograde Aortic Isthmus blood flow.

CONCLUSION

Aortic Isthmus Doppler study may add information for FGR management. However, additional clinical trial are required to assess its applicability in clinical practice.

Antenatal Corticosteroids at 21-23 Weeks of Gestation

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.

The use of projected autonomy in antenatal shared decision-making for periviable neonates: a qualitative study

BACKGROUND

In this study, we assessed the communication strategies used by neonatologists in antenatal consultations which may influence decision-making when determining whether to provide resuscitation or comfort measures only in the care of periviable neonates.

METHODS

This study employed a qualitative study design using inductive thematic discourse analysis of 'naturally occurring data' in the form of antenatal conversations around resuscitation decisions at the grey zone of viability. The study occurred between February 2017 and June 2018 on a labor and delivery unit within a large Midwestern tertiary care hospital. Participants included 25 mothers who were admitted to the study hospital with anticipated delivery in the grey zone of viability and practicing neonatologists or neonatology fellows who partnered in antenatal consultation. We used a two-stage inductive analytic process to focus on how neonatologists' discourses constructed SDM in antenatal consultations. First, we used a thematic discourse analysis to interpret the recurring patterns of meaning within the transcribed antenatal consultations, and second, we theorized the subsequent effects of these discourses on shaping the context of SDM in antenatal encounters.

RESULTS

In this qualitative study, that included discourse analysis of real-time audio conversations in 25 antenatal consults, neonatologists used language that creates projected autonomy through (i) descriptions of fetal physiology (ii) development of the fetus's presence, and (iii) fetal role in decision-making.

CONCLUSION

Discourse analysis of real-time audio conversations in antenatal consultations was revelatory of how various discursive patterns brought the fetus into decision-making, thus changing who is considered the key actor in SDM.

Association of Antenatal Corticosteroid Exposure and Infant Survival at 22 and 23 Weeks

OBJECTIVE

In 2014, the leading obstetric societies published an executive summary of a joint workshop to establish obstetric interventions to be considered for periviable births. Antenatal corticosteroid administration between 220/7 and 226/7 weeks was not recommended given existing evidence. We sought to evaluate whether antenatal steroid exposure was associated with improved survival among resuscitated newborns delivered between 22 and 23 weeks of gestation.

STUDY DESIGN

We conducted a population-based cohort study of all resuscitated livebirths delivered between 220/7 and 236/7 weeks of gestation in the United States during 2009 to 2014 utilizing National Center for Health Statistics data. The primary outcome was rate of survival to 1 year of life (YOL) between infant cohorts based on antenatal steroid exposure. Multivariable logistic regression estimated the association of antenatal steroid exposure on survival outcomes.

RESULTS

In the United States between 2009 and 2014, there were 2,635 and 7,992 infants who received postnatal resuscitation after delivery between 220/7 to 226/7 and 230/7 to 236/7 weeks of gestation, respectively. Few infants born at 22 (15.9%) and 23 (26.0%) weeks of gestation received antenatal corticosteroids (ANCS). Among resuscitated neonates, survival to 1 YOL was 45.2 versus 27.8% (adjusted relative risk [aRR]: 1.6, 95% confidence interval [CI]: 1.2-2.1) and 57.9 versus 47.7% (aRR: 1.3, 95% CI: 1.1-1.5) for infants exposed to ANCS compared with those not exposed at 22 and 23 weeks of gestation, respectively. When stratified by 100 g birth weight category, ANCS were associated with survival among neonates weighing 500 to 599 g (aRR: 1.9, 95% CI: 1.3-2.9) and 600 to 699 g (aRR: 1.7, 95% CI: 1.1-2.6) at 22 weeks.

CONCLUSION

Exposure to ANCS was associated with higher survival rates to 1 YOL among resuscitated infants born at 22 and 23 weeks. National guidelines recommending against ANCS utilization at 22 weeks should be re-evaluated given emerging evidence of benefit.

KEY POINTS

· Exposure to antenatal steroids was associated with higher survival rates at 22 and 23 weeks of gestation.. · Women exposed to antenatal steroids were more likely to have an adverse outcome.. · The association between steroids and survival was observed among infants with birth weights > 500 g..

Video Education in Early Pregnancy and Parent Knowledge of Neonatal Resuscitation Options: A Secondary Analysis of a Randomized Clinical Trial

This secondary analysis of a randomized clinical trial investigates the proportion of correct answers on neonatal resuscitation options among parents after seeing a video on these options.

Effect of Presenting Survival Information as Text or Pictograph During Periviable Birth Counseling: A Randomized, Controlled Trial

OBJECTIVES

To examine whether presenting a 30% or a 60% chance of survival in different survival information formats would influence hypothetical periviable birth treatment choice and whether treatment choice would be associated with participants' recall or their intuitive beliefs about the chances of survival.

STUDY DESIGN

An internet sample of women (n = 1052) were randomized to view a vignette with either a 30% or 60% chance of survival with intensive care during the periviable period. Participants were randomized to survival information presented as text-only, in a static pictograph, or in an iterative pictograph. Participants chose intensive care or palliative care and reported their recall of the chance of survival and their intuitive beliefs about their infant's chance of survival.

RESULTS

There was no difference in treatment choice by presentation with a 30% vs 60% chance of survival (P = .48), by survival information format (P = .80), or their interaction (P = .18). However, participants' intuitive beliefs about chance of survival significantly predicted treatment choice (P < .001) and had the most explanatory power of any participant characteristic. Intuitive beliefs were optimistic and did not differ by presentation of a 30% or 60% chance of survival (P = .65), even among those with accurate recall of the chance of survival (P = .09).

CONCLUSIONS

Physicians should recognize that parents may use more than outcome data to make treatment choices and in forming their own, often-optimistic, intuitive beliefs about their infant's chance of survival.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04859114.

How to survive a periviable birth baby with birth weight of 450g: A case report

RATIONALE

An increasing number of periviable birth newborns (PVBs) have emerged with concurrent growing high-risk pregnancy. To date, postnatal management of PVBs remains one of the most challenging issues and limited studies have been reported.

PATIENT CONCERNS

A female baby born at 230/7 weeks of gestation with birth weight of 450g.

DIAGNOSIS

PVB baby, respiratory distress syndrome (RDS), ventilator associated pneumonia (VAP), intraventricular hemorrhage (IVH), metabolic bone disease of prematurity (MBDP), transient hypothyroxinemia of prematurity (THOP), bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP).

INTERVENTIONS

Individualized treatment and intensive care, including neonatal resuscitation, effective respiratory and circulatory support, venous access and nutrition, prevention and treatment of infection, management of endocrine and metabolic problems, individualized nursing such as developmental supportive care, integrated oral motor interventions, skin care, family-integrated-care, etc were performed according to existing literature.

OUTCOMES

The baby was discharged home after 138 days of hospitalization with body weight of 2700 g, a full oral feed achieved, and without any requirement of respiratory support or oxygen supply. Now she is 38-month-old, with no significant long-term adverse sequelae.

LESSONS

Our case expands the experience and knowledges of individualized and intensive management of PVB babies in their early life days, which increase PVBs' survival and improves their prognosis.

Prenatal counseling for extreme prematurity at the limit of viability: A scoping review

OBJECTIVES

To explore, based on the existing body of literature, main characteristics of prenatal counseling for parents at risk for extreme preterm birth.

METHODS

A scoping review was conducted searching Embase, Medline, Web of Science, Cochrane, CINAHL, and Google Scholar.

RESULTS

46 articles were included. 27 of them were published between 2017 and 2021. More than half of them were conducted in the United States of America. Many different study designs were represented. The following characteristics were identified: personalization, parent-physician relationships, shared decision-making, physician bias, emotions, anxiety, psychosocial factors, parental values, religion, spirituality, hope, quality of life, and uncertainty.

CONCLUSIONS

Parental values are mentioned in 37 of the included articles. Besides this, uncertainty, shared decision-making, and emotions are most frequently mentioned in the literature. However, reflecting on the interrelation between all characteristics leads us to conclude that personalization is the most notable trend in prenatal counseling practices. More and more, it is valued to adjust the counseling to the parent(s).

PRACTICE IMPLICATIONS

This scoping review emphasizes again the complexity of prenatal counseling at the limit of viability. It offers an exploration of how it is currently approached, and reflects on how future research can contribute to optimizing it.

Perspectives on Resuscitation Decisions at the Margin of Viability among Specialist Newborn Care Providers in Ghana and Ethiopia: A Qualitative Analysis

Background

In high income countries, guidelines exist recommending gestational age thresholds for offering and obligating neonatal resuscitation for extremely preterm infants. In low- and middle- income countries, this approach may be impractical due to limited/inconsistent resource availability and challenges in gestational dating. Scant literature exists on how clinicians in these settings conceptualize viability or make resuscitation decisions for premature infants.

Methods

Qualitative interviews of interprofessional neonatal clinicians were conducted in Kumasi, Ghana, at Komfo Anokye Teaching Hospital and Suntreso Government Hospital, and in Addis Ababa, Ethiopia, at St. Paul’s Hospital Millennium Medical College. Transcribed interviews were coded through the constant comparative method.

Results

Three discrete major themes were identified. The principal theme was a respect for all life, regardless of the likelihood for survival. This sense of duty arose from a duty to God, a duty to the patient, and a duty intrinsic to one’s role as a medical provider. The duty to resuscitate was balanced by the second major theme, an acceptance of futility for many premature infants. Lack of resources, inappropriate staffing, and historically high local neonatal mortality rates were often described. The third theme was a desire to meet global standards of newborn care, including having resources to adopt the 22–25-week thresholds used in high income countries and being able to consistently provide life-saving measures to premature infants.

Conclusions

Neonatal clinicians in Ghana and Ethiopia described respect for all life and desire to meet global standards of newborn care, balanced with an awareness of futility based on local resource limitations. In both countries, clinicians highlighted how wide variations in regional survival outcomes limited their ability to rely on structured resuscitation guidelines based on gestational age and/or birthweight.

Controversies in treatment practices of the mother-infant dyad at the limit of viability

In the setting of threatened extreme preterm birth, balancing maternal and fetal risks and benefits in order to choose the best available treatment options is of utmost importance. Inconsistency in treatment practices for infants born between 22 and 24 weeks of gestatotional age may account for inter-hospital variation in survival rates with and without impairment. Most importantly, non-biased and accurate information must be presented to the family as soon as extremely preterm birth is suspected, including counseling on morbidities and mortality associated with delivery at the limits of viability. This review will focus on different therapeutic medical and surgical practices available for threatened extremely preterm birth to improve fetal and maternal outcomes while highlighting the importance of patient-centered approaches.

Creating a small baby program: a single center's experience

Creation of a small baby program requires special resources and multidisciplinary engagement. Such a program has the potential to improve patient care, parent and staff satisfaction, collaboration and communication. We have described benefits, challenges, and practical approaches to creating and maintaining a small baby program that could be a model for the development of special programs for other sub-populations within in the NICU.

Information Order for Periviable Counseling: Does It Make a Difference?

OBJECTIVES

To examine whether the order of presenting survival vs disability information, with or without the description of infant neonatal intensive care unit (NICU) experiences would influence treatment choice during hypothetical periviable birth counseling.

STUDY DESIGN

An internet sample of childbearing-aged women (n = 839) viewed a pictograph displaying the chances of survival and a pictograph on the chances of disability for a baby resuscitated during the periviable period. The sample was randomized to the order of pictographs and level of description of infant NICU experiences. Participants selected between intensive care or comfort care and reported their personal values.

RESULTS

The order of the information influenced treatment choices (P = .02); participants were more likely to choose intensive care if they saw the survival pictograph first (70%) than the disability pictograph first (62%). Level of description of premature infant NICU experiences did not influence treatment choice (P = .92). Participants who valued sanctity of life, autonomy in making decisions, who were more religious, and had adequate health literacy were more likely to choose intensive care. Such participant characteristics had greater explanatory power than the experimental manipulations.

CONCLUSIONS

Subtle differences in how information is presented may influence critical decisions. However, even among women with the same values, diversity in treatment choice remains.

The ethics of neurologically complicated pregnancies

Bioethical conflicts in pregnancy are distinguished from those in other areas of medicine due to competing interests between mother and fetus because of their shared biology. Historically, prior to the advent of fetal therapy and advances in medical technology, the maternal-fetal complex was considered to be a single entity. With advances in medicine, treatment options can now be directed at both the mother and the fetus, and a duality has evolved in the maternal-fetal unit. Thus at some point during pregnancy, two individuals rather than just one are the responsibility of the physician. In determining how to properly care for the pregnant woman with a neurologic condition, therapeutic choices must take into consideration the impact a treatment will have on both the mother and the fetus. Since what benefits one may harm the other, tension results from the need to choose. This chapter will highlight ethical conflicts arising at the interface of obstetrics and neurology. We will delve into situations where difficult reproductive and therapeutic decisions must be made in pregnant women with intellectual disabilities, stroke, brain tumors, and epilepsy. The complexity of brain death in pregnancy will be analyzed, acknowledging the influence of politics, law, and religion that bears on ethical decision-making. In approaching ethical dilemmas encountered in pregnancies complicated by neurologic conditions, frameworks based on principles, virtues, care, and feminist ethics, and case precedents will be applied to facilitate ethically appropriate shared decision-making. We hope that this chapter will provide valuable guidance for providers caring for this complex obstetric population.

FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction

Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.

Comfort care plan to periviable infants: associated decision reversals and missed opportunity of antenatal steroids

OBJECTIVE

This study aims to identify how often families of periviable infants had a care plan stating whether to provide active or comfort care and how often the care plan was reversed, close to or after the delivery.

STUDY DESIGN

In this retrospective study, we reviewed the medical records of all mother-infant dyads (single or twin infants with no known congenital anomalies) who were delivered between 23 0/7 and 24 6/7 weeks gestational age from January 2012 to December 2016.

RESULT

Ninety-nine women met the inclusion criteria - 6 (6%) did not have a care plan available, 85 women (86%) chose for active care and received antenatal steroids (ANS). Six women (6%) who chose comfort care and two women (2%) who chose limited resuscitation during antenatal counseling opted out of the ANS. Two thirds of the women (4/6) who initially opted for comfort care later desired active care, while none of the women who chose active care reversed their decisions.

CONCLUSION

The majorities of the families (94%) had a prenatal care plan in place. Two-thirds (4/6) of the families who opted for comfort care changed their decisions resulting in a missed opportunity for ANS.

A hierarchical procedure to select intrauterine and extrauterine factors for methodological validation of preterm birth risk estimation

Background

Etiopathogenesis of preterm birth (PTB) is multifactorial, with a universe of risk factors interplaying between the mother and the environment. It is of utmost importance to identify the most informative factors in order to estimate the degree of PTB risk and trace an individualized profile. The aims of the present study were: 1) to identify all acknowledged risk factors for PTB and to select the most informative ones for defining an accurate model of risk prediction; 2) to verify predictive accuracy of the model and 3) to identify group profiles according to the degree of PTB risk based on the most informative factors.

Methods

The Maternal Frailty Inventory (MaFra) was created based on a systematic review of the literature including 174 identified intrauterine (IU) and extrauterine (EU) factors. A sample of 111 pregnant women previously categorized in low or high risk for PTB below 37 weeks, according to ACOG guidelines, underwent the MaFra Inventory. First, univariate logistic regression enabled p-value ordering and the Akaike Information Criterion (AIC) selected the model including the most informative MaFra factors. Second, random forest classifier verified the overall predictive accuracy of the model. Third, fuzzy c-means clustering assigned group membership based on the most informative MaFra factors.

Results

The most informative and parsimonious model selected through AIC included Placenta Previa, Pregnancy Induced Hypertension, Antibiotics, Cervix Length, Physical Exercise, Fetal Growth, Maternal Anxiety, Preeclampsia, Antihypertensives. The random forest classifier including only the most informative IU and EU factors achieved an overall accuracy of 81.08% and an AUC of 0.8122. The cluster analysis identified three groups of typical pregnant women, profiled on the basis of the most informative IU and EU risk factors from a lower to a higher degree of PTB risk, which paralleled time of birth delivery.

Conclusions

This study establishes a generalized methodology for building-up an evidence-based holistic risk assessment for PTB to be used in clinical practice. Relevant and essential factors were selected and were able to provide an accurate estimation of degree of PTB risk based on the most informative constellation of IU and EU factors.

Supplementary Information

The online version contains supplementary material available at (10.1186/s12884-021-03654-3).

Antenatal counseling in the gray zone of viability

OBJECTIVE

The objective of this study is to determine the resuscitation choices at 22-24 weeks gestation, related to whether mothers received antenatal counseling and the timing relative to delivery.

STUDY DESIGN

A retrospective chart review was performed of infants inborn at 22-24 weeks, over a 5-year period. Infants were excluded if they had major birth defects, were still hospitalized, or the consult occurred before 22 weeks.

RESULT

Of 121 infants born at 22⁰-24⁶ weeks, 91 were born to mothers who received a neonatology consult. For 80 infants resuscitated after consult, the median time between consult and delivery was 51.7 h (range: 0.1-366.3 h). For 11 infants who received comfort care after consult, the median time between consult and delivery was 20.0 h (range: 0.8-64.4 h).

CONCLUSIONS

After receiving counseling on the morbidity and mortality of delivery at 22-24 weeks, most parents chose resuscitation. Overall, 12-24 h between consult and delivery, parents were more likely to choose comfort care.

Joint periviability counseling between neonatology and obstetrics is a rare occurrence

OBJECTIVE

To investigate the frequency with which neonatal and maternal-fetal medicine (MFM) providers perform joint periviability counseling (JPC), compare content of counseling, and identify perceived barriers to JPC.

STUDY DESIGN

An anonymous REDCap survey was e-mailed to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine and to members of the Society for MFM.

RESULTS

There were 424 neonatal and 115 MFM participants. Fifty-two percent of neonatal and 35% of MFM respondents reported rarely/never performing JPC (p < 0.001), while 80% and 82%, respectively felt it would improve counseling. Content of counseling was similar, except for length of stay with 93% of neonatal vs. 85% of MFM respondents addressing this (p = 0.03). The majority (>60%) of respondents in both groups reported that clinical duties posed a significant/great barrier to JPC.

CONCLUSION

JPC is recommended but infrequently performed, with both specialties interested in further collaboration to strengthen the counseling provided.

Conceptualizing Pain and Personhood in the Periviable Period: Perspectives from Reproductive Health and Neonatal Intensive Care Unit Clinicians

In 2020, the Pain Capable Unborn Child Protection Act was brought to an unsuccessful Senate vote for the third time in five years. The Act seeks to prohibit abortions after 20 weeks post-conception based on the scientifically contested claim that fetuses are at that point capable of feeling pain. It thus seeks to undermine Roe v. Wade's viability standard by asserting that the capacity for pain perception is sufficient for "compelling governmental interest" in fetal life. The ability of many NICUs to offer life-sustaining interventions for periviable neonates means that, in many states, neonatologists and physicians who provide second-trimester abortion care may manage cases of the same gestational age. Given this overlap, this qualitative study examines how clinicians think about the capacity of periviable entities to feel pain and how these ideas shape clinical practice and understandings of compassionate care. Drawing on twenty semi-structured interviews conducted between June 2019 and April 2020 with clinicians providing second-trimester abortion care and NICU care in the Northeast United States, it examines how pain is "known" in the periviable period and how clinicians think about pain in relationship to personhood. A key finding is that the meaning of pain and implications for clinical care is shaped by the anticipated futures and personhood status of periviable entities as determined by pregnant people and families of neonates. Clinicians also stated that concerns around the alleviation of suffering, defined as long-term or chronic distress for pregnant people and/or neonates and their families, were more pressing than the potential experience of short-term physical pain. Legislative attempts to make contested ideas of "fetal pain" the basis for "governmental interest" ignores other forms of suffering that might result from denial of options, and potentially places clinicians at odds with their own conceptions of competent and compassionate care.

Analysis of the impact of antimicrobial management and rational use of antibiotics

OBJECTIVE

The scientific antimicrobial management strategy (AMS) was used to standardise the clinical use of antibiotics and optimise the anti-infection treatment protocol.

METHODS

By formulating antibiotic use indicators and policy interventions, carrying out prescription audits and drug analysis by pharmacists, and establishing an early warning mechanism for bacterial drug resistance, we formed a long-term and scientific antimicrobial management strategy.

RESULTS

From 2012 to 2017, the clinical antibiotics use indicators appeared to trend downward. The rate of antibiotic use in outpatients, the rate of antibiotic use in hospitalised patients, and the antimicrobial use density decreased by 40.36%, 20.93%, and 10.71%, respectively, and the per capita drug cost of antibiotics in outpatients and inpatients decreased. The microbiological susceptibility test rate of antibiotics in hospitalised patients increased each year, and the resistance rate of the main detected bacteria did not significantly increase in the last 6 years. In the evaluation of rational drug use, the use of antibiotics has become more reasonable and standardised, and irrational drug use has been significantly reduced, but we still need to strengthen the optimisation of treatment prescription.

CONCLUSIONS

Scientific management can promote the rational use of antibiotics, reduce the expense of drug use and slow the development of drug resistance, but we need to further optimise the prescription of antibiotics to improve the level of drug treatment.

Premature rupture of the membranes at 16 weeks: report of a successful outcome of pregnancy and review of the literature

Prelabor rupture of the fetal membranes (premature rupture of membranes, PROM) before or at the limit of fetal viability is condition associated with significant and serious pediatric morbidity and mortality. It is a rare problem, with an estimated incidence between 0.1 and 0.7%. Management of this condition is one of the most challenging clinical situations in obstetrics. We report the case of a pregnant woman presenting at 16 weeks gestation with ruptured membranes. The course of pregnancy was further complicated by complete placenta previa. Expectant management was undertaken, with term delivery and successful outcome of pregnancy. Expectant management is a reasonable approach in properly selected patients. Better understanding of the mechanisms of spontaneous membrane resealing is needed in order to improve poor outcomes. More published data and evidence are necessary to standardize treatment options for this rare condition.

Maternal morbidity after early preterm delivery (23-28 weeks)

BACKGROUND

Previous research has focused mainly on neonatal outcomes associated with preterm and periviable delivery, but maternal outcomes with preterm delivery are less well described.

OBJECTIVE

This study aimed to determine if early preterm delivery results in an increase in maternal morbidity.

STUDY DESIGN

This is a retrospective cohort study conducted at a tertiary care center over a 5-year time period. Subjects were women identified by review of neonatal intensive care unit admission logs. Women were included if they delivered between 23 0/7 and 28 6/7 weeks' gestation and their neonate was admitted to the neonatal intensive care unit. The prevalence of maternal morbidities was assessed, including blood transfusion, maternal infection, placental abruption, postpartum depression or positive depression screen, hemorrhage, and prolonged maternal postpartum hospitalization. A composite outcome comprising blood transfusion, maternal infectious morbidity, placental abruption, and postpartum depression was developed. Outcomes for women who delivered between 23 0/7 and 25 6/7 weeks' gestation (early group) and 26 0/7 and 28 6/7 weeks' gestation (late group) were compared. Multivariate logistic regression analysis was performed to evaluate contributors to the composite morbidity, controlling for confounding.

RESULTS

A total of 82 women met the inclusion criteria: 38 in the early group and 44 in the late group. Maternal demographics were similar between the groups. The early group was significantly more likely to experience composite maternal morbidity (60.5% vs 27.3%; P=.004) and infection (42.1% vs 13.6%; P=.006). Regression analysis determined that delivery at a later gestational age was associated with lower rates of composite morbidity (odds ratio, 0.6; 95% confidence interval, 0.41-0.83).

CONCLUSION

In this study, data suggest that maternal morbidity is higher with delivery at periviable gestational ages. Composite morbidity and maternal infection were more frequent in women who delivered at less than 26 weeks' gestation. The management of women at risk for delivery at early gestational ages should include a discussion of increased maternal complications.

Regional and Racial-Ethnic Differences in Perinatal Interventions Among Periviable Births

OBJECTIVE

To examine whether there are: 1) regional differences in three perinatal interventions that reflect active treatment among periviable gestations and 2) racial-ethnic differences in the receipt of these perinatal interventions after accounting for hospital region.

METHODS

We conducted a retrospective study on neonates born at 776 U.S. centers that participated in the Vermont Oxford Network (2006-2017) with a gestational age of 22-25 weeks. The primary outcome was postnatal life support. Secondary outcomes included maternal administration of antenatal corticosteroids and cesarean delivery. We examined rates and 99% CI of the three outcomes by region. We also calculated the adjusted relative risks (aRRs) and 99% CIs for the three outcomes by race and ethnicity within each region using modified Poisson regression models with robust variance estimation.

RESULTS

Major regional variation exists in the use of the three interventions at 22 and 23 weeks of gestation but not at 24 and 25 weeks. For example, at 22 weeks of gestation, rates of life support in the South (38.3%; 99% CI 36.3-40.2) and the Midwest (32.7%; 99% CI 30.4-35.0) were higher than in the Northeast (20.2%; 99% CI 17.6-22.8) and the West (22.2%; 99% CI 20.0-24.4). Particularly in the Northeast, black and Hispanic neonates born at 22 or 23 weeks of gestation had a higher provision of postnatal life support than white neonates (at 22 weeks: black: aRR 1.84 [99% CI 1.33-2.56], Hispanic: aRR 1.80 [1.23-2.64]; at 23 weeks: black: aRR 1.14 [99% CI 1.08-1.20], Hispanic: aRR 1.12 [1.05-1.19]). In the West, black and Hispanic neonates born at 23 weeks of gestation also had a higher provision of life support (black: aRR 1.11 [99% CI 1.03-1.19]; Hispanic: aRR 1.10 [1.04-1.16]).

CONCLUSION

Major regional variation exists in perinatal interventions when managing 22- and 23-week neonates. In the Northeast and the West regions, minority neonates born at 22 and 23 weeks of gestation had higher provision of postnatal life support.

Contemporary Trends in Cesarean Delivery Utilization for Live Births Between 22 0/7 and 23 6/7 Weeks of Gestation

OBJECTIVE

In 2014, the Society for Maternal-Fetal Medicine, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists published an executive summary of a joint workshop to establish obstetric interventions to be considered for periviable births. We sought to evaluate changes in practice patterns since the publication of these guidelines.

METHODS

We conducted a population-based cohort study of all singleton live births delivered between 22 0/7 and 23 6/7 weeks of gestation in the United States within two time epochs: pre-executive summary (Epoch 1: 2012-2013) and post-executive summary (Epoch 2: 2015-2016) guideline release. The primary outcome was the difference in the rate of cesarean delivery between pre-executive summary and post-executive summary guideline publication. Secondary outcomes included differences in rates of individual and composite neonatal interventions (neonatal intensive care unit admission, ventilation, surfactant and antibiotic administration), maternal adverse outcomes (intensive care unit admission, transfusion, hysterectomy, uterine rupture), and neonatal mortality. Multivariable logistic regression estimated the association of delivery epoch with outcomes.

RESULTS

There were 15,846,405 live births in the United States between 2012-2013 and 2015-2016, of which 14,799 (0.1%) were singletons delivered between 22 and 24 weeks of gestation. Among these live births, 7,374 (52.3%) were delivered in Epoch 1 and 7,425 (47.7%) in Epoch 2. Cesarean delivery rates increased from Epoch 1 to Epoch 2 (24.3% vs 28.4%, P<.001), which was attributable to increased cesarean utilization during the 23rd week (36.3% vs 40.8%, difference 4.5%, 95% CI 2.3-6.6). Likewise, the rate of composite neonatal interventions increased (50.6% vs 56.9%, difference 6.3%, 95% CI 4.6-8.0) between Epochs 1 and 2, in association with a slight reduction in neonatal mortality (67.2% vs 64.6%, P=.009). There was no statistically significant difference in composite (8.9% vs 9.5%, P=.261) adverse maternal outcomes between delivery epochs.

CONCLUSION

The frequency of delivery by cesarean in the 23rd week increased by 4.5% after publication of the periviable birth executive summary. The observed increase in cesarean delivery and composite neonatal interventions between delivery cohorts was associated with a small reduction in neonatal mortality.

Ethics and Medico-legal implications in delivery room emergencies

There is very little law-either case law or statutory law - that regulates delivery room decisions about resuscitation of critically ill newborns. Most of the case law that exists is decades old. Thus, physicians cannot look to the law for much guidance about what is permissible or prohibited. Local hospital policies and professional society statements provide some guidance, but they cannot be all-inclusive and encompass all potentially encountered scenarios. Ultimately, the physician, the medical team, and the parents must try to reach a shared decision about the best course of action for each individual infant and each unique family. In this paper, we review some of the case law that may be applicable to such decisions and make recommendations about how decisions should be made.

The cultural construction of preterm birth in the United States

This commentary explores four features of the cultural construction of pregnancy and childbirth in the United States: risk categorization as an aspect of reproductive governance, medicalization, intensive mothering with its implications for gender stratification, and the definition of personhood as beginning at conception. The cultural construction of preterm births (those that end before gestation is complete at about 37 weeks) is interwoven with beliefs about risk in pregnancy. Health risk categories overlap with socially stigmatized characteristics and behaviors, opening sub-groups of women up to intensive surveillance and control. The belief that preterm births are preventable and treatable reinforces medical authority and rationalizes the large allocation of resources to specialty (as opposed to primary) maternal and infant care. Expectations for maternal behavior when preterm birth is threatened and when it occurs reinforce norms of intensive mothering, while the ability to keep preterm infants alive reinforces beliefs about fetal personhood. In these ways, the cultural construction of preterm birth in the U.S. holds the broader construction of pregnancy and childbirth in place by raising the stakes of deviation from norms of reproduction to matters of criminality, death, or serious disability.

Perinatal care provided for babies born at 23 and 24 weeks of gestation

In recent years, significant improvements in survival and survival-free of major morbidity in babies born at 23⁺⁰ to 24⁺⁶  weeks of gestation have led to a more pro-active approach to resuscitation at these peri-viable gestations. Antenatal counselling and interventions, intrapartum care and postnatal advice should be part of the package of care provided to optimise outcomes for these babies and their families. This observational study assesses the perinatal care provided to mothers and their babies who were born at 23 and 24 weeks of gestations over a two-year period at a tertiary maternity hospital in New Zealand.

Outcomes of infants born at 23 and 24 weeks' gestation with gut perforation

PURPOSE

The provision of neonatal intensive care to infants born at 23 or 24 weeks' gestation poses medical, surgical and ethical challenges. Gastrointestinal perforation is a well-recognized complication of preterm birth, occurring most often as a result of necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). Given the risk of morbidity and mortality in these 'periviable' infants, this complication may prompt transition from active management to palliative care. In our institution, the surgical care of periviable infants with gut perforation has not been dictated by gestational age. This study reports our outcomes.

METHODS

A retrospective cohort analysis of integrated neonatal medical and surgical care of all infants born between 23⁺⁰ and 24⁺⁶ weeks' gestation admitted to a tertiary level neonatal intensive care unit (NICU) during a 16 year period (2002-2017).

RESULTS

A total of 198 periviable neonates (73 born at 23 weeks' gestation and 125 born at 24 weeks) were admitted during the 16-year period; most were inborn with only 26 retrieved from regional centers. Twenty-six of these infants developed gut perforation: 14 SIP, 8 NEC, 3 esophageal perforation and one after reduction of an incarcerated inguinal hernia. Twelve (46%) periviable infants with gut perforation survived to discharge home, seven of whom had no/mild disability at 2-3 years corrected gestational age. Of the 198 periviable infants admitted to NICU, 116 (58%) were alive at a corrected gestational age of 2-3 years and 29 of the 56 (51%) assessed had mild or no disability.

CONCLUSIONS

In the setting of combined medical and surgical care in a tertiary level NICU almost half of all periviable infants with a gut perforation survived, many with no/mild disability at 2-3 years corrected gestational age. Rigid protocols that rely on gestational age alone to guide treatment are not appropriate. These results support the contention that, when possible, extremely preterm infants should be born and cared for in units with combined medical and surgical expertise.

LEVEL OF EVIDENCE

Level III cohort study.

Coping strategies of mothers with preterm babies admitted in a public hospital in Cape Town

BACKGROUND

Most pregnancies run a normal course, ending in a healthy mother-infant relationship, but sometimes, it can also be a life-threatening and stressful condition. The stress levels of mothers are more aggravated when they deliver preterm babies.

OBJECTIVES

To explore the coping strategies of mothers of preterm babies with the stress of preterm delivery and subsequent admission of the preterm neonate to a neonatal care unit.

METHOD

A qualitative research approach applying an exploratory and descriptive design was applied to explore the coping strategies of mothers with preterm babies admitted in a neonatal care unit. The study applied a purposive sampling technique to select mothers with preterm babies. The population for this study included women who delivered preterm babies and whose babies were admitted in the neonatal care unit at a public hospital in Cape Town. Semi-structured interviews were conducted until data saturation was reached, and 11 mothers with preterm babies in the selected public hospital participated in the study. Data were analysed manually using thematic content analysis with an inductive approach.

RESULTS

Results were deductively interpreted and supported by the Brief COPE model. The main themes that emerged from data analysis included praying, attachment with baby and acceptance of the situation. Under praying the following subthemes emerged, namely praying for God's strength, God's grace, babies' survival and thanksgiving to God for babies' health and preferred gender. The theme of attachment with the baby emerged with the following subthemes: bonding with the baby and seeing the baby. The last theme that was acceptance of the situation emerged with the following subtheme: perseverance in the situation and mother's awareness of her responsibility.

CONCLUSION

Even though the mothers of preterm babies cope differently after delivery, their coping abilities, which included praying, attachment to baby and acceptance of the situation, were greatly determined by the condition of their babies as well as the support they receive from significant others.

Maternal Complications Associated With Periviable Birth

OBJECTIVE

To quantify the rate of maternal complications associated with a periviable birth in a contemporary population of live births in the state of Ohio.

METHODS

We conducted a population-based retrospective cohort study of all live births in Ohio (2006-2015). Maternal, obstetric, and neonatal characteristics were compared between women who delivered in the periviable period (20-25 weeks of gestation) with those who delivered preterm (26-36 weeks of gestation) and at term (greater than 36 weeks of gestation). Women were also stratified by 3-week gestational age epochs (ie, 20-22, 23-25 weeks of gestation). The primary study outcome was a composite of individual adverse maternal outcomes (chorioamnionitis, blood product transfusion, hysterectomy, unplanned operation, and intensive care unit [ICU] admission). Multivariate logistic regression estimated the relative association of periviable birth with maternal complications.

RESULTS

Of 1,457,706 live births in Ohio during the 10-year study period, 6,085 live births (0.4%) occurred during the periviable period (20-25 weeks of gestation). The overall rate of the composite adverse outcome was 17.2%. In multivariate analysis, periviable birth was associated with an increased risk of the composite adverse maternal outcome (adjusted relative risk [RR] 5.8, CI 5.4-6.2) and individual complications including transfusion (adjusted RR 4.4, CI 3.4-5.7), unplanned operative procedure (adjusted RR 2.0, CI 1.7-2.4), unplanned hysterectomy (adjusted RR 7.8, CI 4.6-13.0), uterine rupture (adjusted RR 7.1, CI 3.8-13.4), and ICU admission (adjusted RR 9.6, CI 7.2-12.7) compared with the term cohort. Delivery between 20-22 weeks and 23-25 weeks of gestation was associated with the highest risk of composite adverse outcome. The risk of composite adverse outcome decreased with advancing gestational age stratum.

CONCLUSION

Periviable birth is associated with significant maternal morbidity. Nearly one in five women in this cohort had a serious morbidity associated with their periviable delivery.

Perinatal palliative care: a dedicated care pathway

OBJECTIVE

Ensure access to perinatal palliative care (PnPC) to all eligible fetuses/infants/parents.

DESIGN

During 12 meetings in 2016, a multidisciplinary work-group (WG) performed literature review (Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method was applied), including the ethical and legal references, in order to propose shared care pathway.

SETTING

Maternal-Infant Department of Padua's University Hospital.

PATIENTS

PnPC eligible population has been divided into three main groups: extremely preterm newborns (first group), newborns with prenatal/postnatal diagnosis of life-limiting and/or life-threatening disease and poor prognosis (second group) and newborns for whom a shift to PnPC is appropriate after the initial intensive care (third group).

INTERVENTIONS

The multidisciplinary WG has shared care pathway for these three groups and defined roles and responsibilities.

MAIN OUTCOME MEASURES

Prenatal and postnatal management, symptom's treatment, end-of-life care.

RESULTS

The best care setting and the best practice for PnPC have been defined, as well as the indications for family support, corpse management and postmortem counselling, as well suggestion for conflicts' mediation.

CONCLUSIONS

PnPC represents an emerging field within the paediatric palliative care and calls for the development of dedicated shared pathways, in order to ensure accessibility and quality of care to this specific population of newborns.

A meta-analysis of neurodevelopmental outcomes at 4-10 years in children born at 22-25 weeks gestation

AIM

To update our meta-analysis on neurodevelopmental disability rates in children born at 22-25 weeks gestation. The main outcome measure was rates of neurodevelopmental disability in survivors at age 4-10 years.

METHODS

We used a peer-reviewed electronic and grey search to identify articles. Two authors independently reviewed cohorts published after May 2012 with: born ≥1995 in a developed nation; assessed at 4-10 years; prospective; >65% follow-up; definitions for neurodevelopmental disability as per the EPICure cohort; results reported by gestation. We contacted authors for clarification. Random effects meta-analysis was used to estimate pooled proportions of neurodevelopmental disability. Within each study, the absolute change in proportions with each week was estimated and then pooled.

RESULTS

We reviewed 3980 records; 21 articles were assessed and six were included. With the previous 9 cohorts, the meta-analysis now contains 15. Rates of moderate-to-severe neurodevelopmental disability were as follows: 42% (95% CI 23,64%; I² 0%) at 22; 41% (95% CI 31,52%; I² 20%) at 23; 32% (95% CI 25,39%; I² 45%) at 24; 23% (95% CI 18,29%; I² 60%) at 25 weeks. The analysis shows a significant decrease in risk of moderate-to-severe neurodevelopmental disability between each week (8.1% (95% CI -11.8, -4.5%); I² 0%; p < 0.001).

CONCLUSION

Physicians can use this high-quality data to support parents during decision-making.

Gestational Age, Health, and Educational Outcomes in Adolescents

BACKGROUND AND OBJECTIVES

As outcomes for extremely premature infants improve, up-to-date, large-scale studies are needed to provide accurate, contemporary information for clinicians, families, and policy makers. We used nationwide New Zealand data to explore the impact of gestational age on health and educational outcomes through to adolescence.

METHODS

We performed a retrospective cohort study of all births in New Zealand appearing in 2 independent national data sets at 23 weeks' gestation or more. We report on 2 separate cohorts: cohort 1, born January 1, 2005 to December 31, 2015 (613 521 individuals), used to study survival and midterm health and educational outcomes; and cohort 2, born January 1, 1998 to December 31, 2000, and surviving to age 15 years (146 169 individuals), used to study high school educational outcomes. Outcomes described by gestational age include survival, hospitalization rates, national well-being assessment outcomes at age 4 years, rates of special education support needs in primary school, and national high school examination results.

RESULTS

Ten-year survival increased with gestational age from 66% at 23 to 24 weeks to >99% at term. All outcomes measured were strongly related to gestational age. However, most extremely preterm children did not require special educational support and were able to sit for their national high school examinations.

CONCLUSIONS

Within a publicly funded health system, high-quality survival is achievable for most infants born at periviable gestations. Outcomes show improvement with gestational ages to term. Outcomes at early-term gestation are poorer than for children born at full term.

[Multiple birth trends in the region of Castilla y León (Spain) in a 13 year period]

INTRODUCTION

Multiple pregnancy has increased in prevalence in the last few years, which could lead to more foetal and maternal morbidity issues. The aim of this study is to describe the trend of multiple pregnancy deliveries in Castilla y León during the last 13years and the subsequent impact on foetal and maternal health.

MATERIAL AND METHODS

Data was collected from the hospital discharge reports registered in the Regional Health-care database (SACYL: Health care in Castilla y León) between 2001 and 2013. A cross sectional descriptive study was conducted, including trend analysis with log-linear joint point model, a rhythm metric study, as well as a risk assessment with multivariate analysis.

RESULTS

A pronounced upward trend was observed in the proportion of multiple deliveries in this time period, compared to single ones, with an annual percentage change of 3.4% (95% CI: 2.5-4.4). Multiple pregnancy was significantly correlated with advanced maternal age, abnormal glucose tolerance, dystocia and caesarean section delivery, premature birth, foetal malposition, foetal macrosomia, stillbirth, in vitro fertilisation, and hypertensive episodes of pregnancy. In vitro fertilization showed a 9.3 fold increased risk in multiple pregnancy (95% CI: 7.4-11.5), with maternal age increasing the risk up to 5% per year of age (OR: 1.05: 95%CI: 1.04-1.05). No seasonal rhythm was observed in multiple deliveries compared with single ones.

CONCLUSION

Multiple pregnancy has experienced a continuous increase, with no seasonal trend, and is associated with the increase in assisted reproductive technology and advanced maternal age. This involves more problems regarding foetal and maternal morbidity and mortality.

[Maternal outcomes in case of cesarean before 32weeks of gestation: A retrospective observational study]

OBJECTIVES

In recent years, active neonatal care in case of prematurity leads to an increase of cesarean delivery rate. Data remains sparse on maternal morbidity induced by preterm cesareans and especially before 32 weeks of gestation. The main aim of this study was to evaluate per-partum maternal morbidity in case of cesarean performed before 32 week of gestation. As secondary objectives, we assessed post-partum maternal morbidity and factors associated with maternal morbidity.

METHODS

This is a retrospective single-center study conducted in a tertiary care unit between 2014 and 2016 including cesareans performed before 32 week of gestation in the study period. The primary outcome was a composite criterion of per partum maternal morbidity including post-partum hemorrhage, blood transfusion, general anesthesia, surgical wounds and maternal death. The secondary outcome was the post-partum maternal morbidity, defined by a composite criterion including hospitalization more than 7 days, infectious disease, wall and digestive complication and venous thromboembolic disease.

RESULTS

Two hundred and eleven women were included. Maternal morbidity occurred in 21.3% in per partum and in 20.4% in post-partum. The factors associated with per partum morbidity were low-lying placenta (OR=4.40 [1.01-19.09]) and non-fetal indication of cesarean (OR=2.10[1.01-4.42]). The factors associated with post-partum morbidity were twin-pregnancy (OR=2.90 [1.12-7.54]), general anesthesia (OR=4.19 [1.68-10.49]) and non-cephalic fetal presentation (OR= 2.70 [1.23-5.93]).

CONCLUSION

The maternal morbidity of cesareans before 32 week of gestation is more than 20%. This study confirms the high maternal morbidity associated with caesareans performed before 32 weeks of gestation.

Reproductive suppression, birth defects, and periviable birth

We argue that reproductive suppression has clinical implications beyond its contribution to the burden of spontaneous abortion. We theorize that the incidence of births before the 28th week of gestation, which contribute disproportionately to infant morbidity and mortality, varies over time in part due to reproductive suppression in the form of selection in utero. We further theorize that the prevalence of structural birth defects among survivors to birth from conception cohorts gauges selection in utero. We based these theories on literature positing that natural selection conserved mechanisms that spontaneously abort "risky" pregnancies including those otherwise likely to yield infants with structural birth defects or small-for-gestational age males. We test our theory using high-quality birth defect surveillance data. We identify 479,885 male infants exposed to strong selection defined as membership in conception cohorts ranked in the lowest quartile of odds of a birth defect among live-born females. We estimate the risk of periviable birth among these infants as a function of selective pressure as well as of mother's race/ethnicity and age. We find that male infants from exposed conception cohorts exhibited 10% lower odds of periviable birth than males from other conception cohorts. Our findings support the argument that selection in utero has implications beyond its contribution to the burden of spontaneous abortion.

Mortality and pulmonary outcomes of extremely preterm infants exposed to antenatal corticosteroids

BACKGROUND

Antenatal corticosteroids are given primarily to induce fetal lung maturation but results from meta-analyses of randomized controlled trials have not shown mortality or pulmonary benefits for extremely preterm infants although these are the infants most at risk of mortality and pulmonary disease.

OBJECTIVE

We sought to determine if exposure to antenatal corticosteroids is associated with a lower rate of death and pulmonary morbidities by 36 weeks' postmenstrual age.

STUDY DESIGN

Prospectively collected data on 11,022 infants 22 0/7 to 28 6/7 weeks' gestational age with a birthweight of ≥401 g born from Jan. 1, 2006, through Dec. 31, 2014, were analyzed. The rate of death and the rate of physiologic bronchopulmonary dysplasia by 36 weeks' postmenstrual age were analyzed by level of exposure to antenatal corticosteroids using models adjusted for maternal variables, infant variables, center, and epoch.

RESULTS

Infants exposed to any antenatal corticosteroids had a lower rate of death (2193/9670 [22.7%]) compared to infants without exposure (540/1302 [41.5%]) (adjusted relative risk, 0.71; 95% confidence interval, 0.65-0.76; P < .0001). Infants exposed to a partial course of antenatal corticosteroids also had a lower rate of death (654/2520 [26.0%]) compared to infants without exposure (540/1302 [41.5%]); (adjusted relative risk, 0.77; 95% confidence interval, 0.70-0.85; P < .0001). In an analysis by each week of gestation, infants exposed to a complete course of antenatal corticosteroids had lower mortality before discharge compared to infants without exposure at each week from 23-27 weeks' gestation and infants exposed to a partial course of antenatal corticosteroids had lower mortality at 23, 24, and 26 weeks' gestation. Rates of bronchopulmonary dysplasia in survivors did not differ by antenatal corticosteroid exposure. The rate of death due to respiratory distress syndrome, the rate of surfactant use, and the rate of mechanical ventilation were lower in infants exposed to any antenatal corticosteroids compared to infants without exposure.

CONCLUSION

Among infants 22-28 weeks' gestational age, any or partial antenatal exposure to corticosteroids compared to no exposure is associated with a lower rate of death while the rate of bronchopulmonary dysplasia in survivors did not differ.

Outcomes of 23- and 24-weeks gestation infants in Wellington, New Zealand: A single centre experience

Optimal perinatal care of infants born less than 24 weeks gestation remains contentious due to uncertainty about the long-term neurodevelopment of resuscitated infants. Our aim was to determine the short-term mortality and major morbidity outcomes from a cohort of inborn infants born at 23 and 24 weeks gestation and to assess if these parameters differed significantly between infants born at 23 vs. 24 weeks gestation. We report survival rates at 2-year follow-up of 22/38 (58%) at 23 weeks gestation and 36/60 (60%) at 24 weeks gestation. Neuroanatomical injury at the time of discharge (IVH ≥ Grade 3 and/or PVL) occurred in in 3/23 (13%) and 1/40 (3%) of surviving 23 and 24 weeks gestation infants respectively. Rates of disability at 2 years corrected postnatal age were not different between infants born at 23 and 24 weeks gestation. We show evidence that with maximal perinatal care in a tertiary setting it is possible to achieve comparable rates of survival free of significant neuroanatomical injury or severe disability at age 2 in infants born at 23-week and 24-weeks gestation.

Counseling parents at risk of delivery of an extremely premature infant: Differing strategies

BACKGROUND

It is not known how neonatologists address the affective and cognitive loads on parents deciding whether to resuscitate infants born extremely preterm. This study explores expert neonatologists' views on these decision-making processes and their own roles in counseling parents.

METHODS

Semistructured interviews asked internationally recognized experts to share their perspectives on perinatal consultations. Their responses were subjected to thematic analysis.

RESULTS

Eighteen of 22 invited experts participated. Approximately equal numbers reported employing a physician-driven approach, a parent-driven approach, and a combined approach during these consultations. Those who followed a physician-driven approach typically focused on conveying standard information about adverse outcomes. Those who followed a parent-driven approach typically focused on addressing parents' information requests, guiding their decision making, and providing affective support. Nearly all experts, in each group, endorsed addressing the child's quality of life, in terms of functionality, when discussing long-term outcomes. Although many believed that families adjusted to life with a disabled child, few discussed the topic during prenatal consultations. Most, in each group, reported trying to alleviate future "decisional regret" for parents whose premature infants subsequently became disabled. None spoke to parents about possible decisional regret after deciding to forgo resuscitation.

CONCLUSIONS

Expert neonatologists are deeply concerned that parents understand the decision facing them. However, they differ on what information they offer and how they balance parents' need for cognitive and affective support. They expressed more concern about parents' decisional regret should their child survive resuscitation, but have severe disability, than about decisional regret after foregoing resuscitation.

Medical and Surgical Interventions Available Before a Periviable Birth

Periviable birth contributes disproportionately to perinatal morbidity and mortality. By analyzing the most relevant outcomes after a preterm birth some information can be provided on the potential benefit of interventions. This article discusses surgical and medical interventions that may offer neonatal benefit including cerclage, amniocentesis, progesterone, antenatal corticosteroids, magnesium sulfate for neuroprotection, and tocolysis. Cervical cerclage has the greatest promise at reducing morbidity and mortality related to periviable birth even though it may not reduce the overall preterm birth rate. The use of antenatal corticosteroids, magnesium sulfate, progesterone, and tocolytics may also improve outcome. Studies specifically evaluating these interventions are needed.

Exposure to any antenatal corticosteroids and outcomes in preterm infants by gestational age: prospective cohort study

Objective To determine whether exposure to any antenatal corticosteroids is associated with a lower rate of death at each gestational age at which administration is currently recommended.Design Prospective cohort study.Settings 300 participating neonatal intensive care units of the Pediatrix Medical Group in the United States.Participants 117 941 infants 23 0/7 to 34 6/7 weeks' gestational age born between 1 January 2009 and 31 December 2013.Exposure Any antenatal corticosteroids.Main outcomes measures Death or major hospital morbidities analyzed by gestational age and exposure to antenatal corticosteroids with models adjusted for birth weight, sex, mode of delivery, and multiple births.Results Infants exposed to antenatal corticosteroids (n=81 832) had a significantly lower rate of death before discharge at each gestation 29 weeks or less, 31 weeks, and 33-34 weeks compared with infants without exposure (range of adjusted odds ratios 0.32 to 0.55). The number needed to treat with antenatal corticosteroids to prevent one death before discharge increased from six at 23 and 24 weeks' gestation to 798 at 34 weeks' gestation. The rate of survival without major hospital morbidity was higher among infants exposed to antenatal corticosteroids at the lowest gestations. Infants exposed to antenatal corticosteroids had lower rates of severe intracranial hemorrhage or death, necrotizing enterocolitis stage 2 or above or death, and severe retinopathy of prematurity or death compared with infants without exposure at all gestations less than 30 weeks and most gestations for infants born at 30 weeks' gestation or later.Conclusion Among infants born from 23 to 34 weeks' gestation, antenatal exposure to corticosteroids compared with no exposure was associated with lower mortality and morbidity at most gestations. The effect size of exposure to antenatal corticosteroids on mortality seems to be larger in infants born at the lowest gestations.

Gestational dating by metabolic profile at birth: a California cohort study

BACKGROUND

Accurate gestational dating is a critical component of obstetric and newborn care. In the absence of early ultrasound, many clinicians rely on less accurate measures, such as last menstrual period or symphysis-fundal height during pregnancy, or Dubowitz scoring or the Ballard (or New Ballard) method at birth. These measures often underestimate or overestimate gestational age and can lead to misclassification of babies as born preterm, which has both short- and long-term clinical care and public health implications.

OBJECTIVE

We sought to evaluate whether metabolic markers in newborns measured as part of routine screening for treatable inborn errors of metabolism can be used to develop a population-level metabolic gestational dating algorithm that is robust despite intrauterine growth restriction and can be used when fetal ultrasound dating is not available. We focused specifically on the ability of these markers to differentiate preterm births (PTBs) (<37 weeks) from term births and to assign a specific gestational age in the PTB group.

STUDY DESIGN

We evaluated a cohort of 729,503 singleton newborns with a California birth in 2005 through 2011 who had routine newborn metabolic screening and fetal ultrasound dating at 11-20 weeks' gestation. Using training and testing subsets (divided in a ratio of 3:1) we evaluated the association among PTB, target newborn characteristics, acylcarnitines, amino acids, thyroid-stimulating hormone, 17-hydroxyprogesterone, and galactose-1-phosphate-uridyl-transferase. We used multivariate backward stepwise regression to test for associations and linear discriminate analyses to create a linear function for PTB and to assign a specific week of gestation. We used sensitivity, specificity, and positive predictive value to evaluate the performance of linear functions.

RESULTS

Along with birthweight and infant age at test, we included 35 of the 51 metabolic markers measured in the final multivariate model comparing PTBs and term births. Using a linear discriminate analyses-derived linear function, we were able to sort PTBs and term births accurately with sensitivities and specificities of ≥95% in both the training and testing subsets. Assignment of a specific week of gestation in those identified as PTBs resulted in the correct assignment of week ±2 weeks in 89.8% of all newborns in the training and 91.7% of those in the testing subset. When PTB rates were modeled using the metabolic dating algorithm compared to fetal ultrasound, PTB rates were 7.15% vs 6.11% in the training subset and 7.31% vs 6.25% in the testing subset.

CONCLUSION

When considered in combination with birthweight and hours of age at test, metabolic profile evaluated within 8 days of birth appears to be a useful measure of PTB and, among those born preterm, of specific week of gestation ±2 weeks. Dating by metabolic profile may be useful in instances where there is no fetal ultrasound due to lack of availability or late entry into care.