Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care

Ethical considerations regarding the treatment of extremely preterm infants at the limit of viability: a comprehensive review

Advancements in perinatal care have improved survival rates of extremely preterm infants born at 22 to 23 weeks of gestation, thus introducing new ethical challenges associated with their treatment. Therefore, we reviewed the epidemiological prognosis, treatment evolution, and ethical considerations associated with the care of preterm infants at the limit of viability. We comprehensively searched PubMed to find relevant English-language articles published between January 2014 and July 2024. Survival rates of infants born at 22 to 23 weeks of gestation have improved but remain low. Proactive treatment can result in survival rates exceeding 50% for infants born at 22 weeks; however, these infants are at high risk for complications and neurodevelopmental impairment. Advancements in obstetric and neonatal care have contributed to improved outcomes. Ethical challenges include balancing survival with the disability risk, managing patients with uncertain prognoses, and considering parental wishes.Conclusion: The care of preterm infants at the limit of viability presents complex ethical dilemmas. Shared decision-making between healthcare providers and families as well as engaging in societal discourse are crucial to addressing these challenges.

Bridging the Gap: Subspecialty Telemedicine Consultations at a Level III Neonatal Intensive Care Unit

Background: Many neonatal intensive care units (NICUs) lack access to subspecialist consultants and may transfer patients requiring subspecialty care to referral facilities or seek informal consultation. The objective of this work was to evaluate the feasibility, acceptability, and impact of extending pediatric subspecialty services from a children's hospital to a level III NICU via teleconsultation and describe processes, facilitators, and challenges. Methods: Monitored consultations for 1 year and surveyed clinicians regarding feasibility, perceived benefits, and challenges. Results: Fifty-nine teleconsultations were conducted. NICU providers indicated improved care quality with subspecialty input. Subspecialists reported advantages of documenting, billing, and providing more complete care, but noted logistical strains. Both parties perceived better interdisciplinary communication. Conclusions: This teleconsultation service was feasible, generally acceptable, improved access to subspecialty services, and improved NICU clinicians' perceived care quality. Challenges included infrastructure development costs, workflow training time, logistics, and subspecialist patient volumes. This is among the first descriptions of a pediatric subspecialty teleconsultation service supporting a NICU.

Time trends in antithrombotic therapy during pregnancy and maternal and perinatal outcomes in the Netherlands (2013-19): a nationwide cohort study

BACKGROUND

Considering the paucity of data, we aimed to describe nationwide time trends in antithrombotic therapy during pregnancy and risks of maternal and perinatal outcomes in the Netherlands.

METHODS

In this nationwide cohort study, all female individuals aged 16-45 years with delivery records in the Dutch perinatal registry between Jan 1, 2013, and Dec 31, 2019, and their infants, were included. Individually linked data from Statistics Netherlands on outpatient medication prescriptions, in-hospital diagnoses, and mortality were used to evaluate time trends in antithrombotic therapy during pregnancy, and risks of maternal and perinatal outcomes (including thromboembolism, bleeding, preeclampsia and eclampsia, and low birthweight).

FINDINGS

A total of 1 122 711 pregnancies and 1 139 116 infants were included (median maternal age 30·5 years [IQR 27·3-33·7]; 886 085 [78·9%] White; median gravidity 2 (IQR 1-3); and median gestational age at delivery 39 weeks [IQR 38-40]). Low-molecular-weight heparin (LMWH) was the most commonly (more than 99%) prescribed anticoagulants during pregnancy, which slightly increased from 0·7% (1063 of 163 479) in 2013 to 0·9% (1352 of 158 654) in 2019. LMWH was generally started at 5-8 weeks' gestation when oral anticoagulant prescriptions dropped. Antiplatelet drug prescriptions increased from 0·7% (1129 of 163 479) to 4·8% (7671 of 158 654), which primarily initiated around week 12. Maternal risks of venous and arterial thromboembolism and bleeding remained constant from 2013 to 2019; the risk of preeclampsia and eclampsia gradually increased from 1·70% (95% CI 1·63-1·76) in 2013 to 2·05% (1·98-2·13) in 2017, after which it decreased to 1·83% (1·77-1·90) in 2019. There was a significant decrease (2019 vs 2013) in low birthweight (adjusted odds ratio 0·92 [0·90-0·94]; p<0·0001), whereas 28-day neonatal bleeding risk remained unchanged.

INTERPRETATION

Exposure to anticoagulants during pregnancy is not uncommon, and health-care providers and female individuals of reproductive age should be mindful of this to avoid unintended oral anticoagulant exposure. Adhering to guidelines for aspirin use to prevent preeclampsia might lead to a population-level reduction in disease burden and potential improvement in neonatal prognosis.

FUNDING

None.

TRANSLATION

For the Dutch translation of the abstract see Supplementary Materials section.

XIII Consenso SIBEN sobre Traslado Neonatal: Establecer protocolos estructurados para el proceso del traslado neonatal podría mejorar los desenlaces

La centralización de los partos de alto riesgo en los hospitales con el más alto nivel de atención es fundamental para ampliar el margen de seguridad materno-neonatal y mejorar los desenlaces. Por lo tanto, es altamente recomendable trasladar oportunamente a las pacientes gestantes portadoras de embarazos de alto riesgo y/o con amenazas de parto pretérmino a centros de atención terciaria, sin embargo, no siempre es posible anticipar los riesgos antenatalmente, lo cual resulta en la necesidad de trasladar a neonatos en estado crítico. Lamentablemente, la movilización de los recién nacidos compromete aún más su estado de salud, especialmente en los países latinoamericanos. El presente trabajo resume los resultados del XIII Consenso Clínico de SIBEN de Traslado Neonatal, en el cual colaboraron 65 miembros de SIBEN, neonatólogos y licensiados en enfermería de 14 países de Iberoamérica, que participaron activamente durante el 2022, antes, durante y después de la reunión presencial que se llevó a cabo en Mérida, Yucatán, México el 12 de noviembre del 2022. En esta reunión se consensuaron las recomendaciones aquí vertidas.

Maternal Transport, What Do We Know: A Narrative Review

Objective

This review examines the initial development of a transport system for neonates, followed by a subsequent evolution of a transportation system for the maternal/fetal unit, and then a maternal transport system (antepartum, intrapartum, and postpartum) to specifically address maternal morbidity/mortality.

Methods

A literature search was undertaken using the electronic databases PubMed, Embase, and CINAHL. The search terms used were "maternal transport" AND "perinatal care" OR "labor" "obstetrics" OR "delivery". The years searched were 1960-2023.

Results

There were 260 abstracts identified and 52 of those are the basis of this review. The utilization of a transportation system with the regionalization of levels of care has resulted in a significant reduction in neonatal, perinatal, and maternal morbidity and mortality. Although preterm delivery remains a concern in women transported, the number of deliveries that have occurred during transport is relatively small. Reimbursement for transportation continues to be a problem in several states.

Conclusion

A state-of-the-art transportation system has evolved that transfers neonates, maternal/fetal dyad, and pregnant women (antepartum, intrapartum, postpartum) to the appropriate level of care facility to ensure the best maternal/fetal/neonatal outcomes.

Special Issue: Intensive Care for Critically Ill Neonates: Clinical Diagnosis and Treatment

Many physicians and researchers in the recent past have recognized the need to provide care and to study term and preterm infants when sufficient knowledge had not yet been attained, and to research how to approach and care for the most vulnerable children, i [...].

The Need for Reliable Robust Maternal Transport Program to Improve Maternal Outcomes in Rural America

There is great evidence to support improved maternal and neonatal outcomes when a patient delivers in a center that is suited to the needs of both the birthing person and the fetus. As rural centers have closed, access remains challenging. This manuscript examines The Emergency Medical Treatment and Labor Act, Emergency Medical Services (EMS) challenges, needs of rural hospitals including education, and elaborates further upon the need to expand maternal transport in rural areas to improve outcomes in the future.