Recomendaciones en reanimación neonatal

[Influence of gestational age, type of delivery, and resuscitation, on the incidence of pneumothorax in term neonates]

BACKGROUND

Elective caesarean section before 39 weeks gestational age (GA) has been associated with a higher incidence of iatrogenic respiratory distress and pneumothorax in term newborn babies, probably because of a higher respiratory morbidity and the need for resuscitation. These factors have not been systematically evaluated in our patients.

OBJECTIVE

To determine whether the gestational age, type of delivery, and intensity of resuscitation, are associated with an increase in the incidence of pneumothorax in term neonates.

PATIENTS AND METHODS

Full term neonates (≥ 37 weeks GA) born in our maternity unit from January 2006 to December 2010 were studied, along with the type of delivery (vaginal, forceps or caesarean section). Advanced cardiopulmonary resuscitation (CPR) was defined as the need of bag and mask intermittent ventilation, intubation, chest compression, and/or administration of medication. The diagnosis of pneumothorax was clinical and radiological in all cases.

RESULTS

A total of 32,238 full term newborns were included. Type of delivery: vaginal 76.1%, C-section 12.4%, and forceps 11.5%. The incidence of pneumothorax was 0.316%. It was significantly higher in C-section (0.85%), than in forceps (0.59%), or non-instrumental vaginal deliveries (0.19%) (P<.001), and in infants ≥ 40 weeks GA (0.37%) compared to ≤ 39 weeks GA (0.24%) (P=.033), and in advanced CPR (4.29%) compared to basic CPR (0.18%) (P<.001).

CONCLUSIONS

A GA ≥ 40 weeks, C-section, or forceps delivery, and advanced CPR immediately after birth were significantly associated with a higher incidence of pneumothorax in full term newborn babies. In our population, we did not observe an increase in pneumothorax among neonates born by elective C-section before 39 weeks of gestation.

Periviable babies: Italian suggestions for the ethical debate

With the advancement of medical technology, the outcomes for high-risk infants have greatly improved. However, hand and hand with the more positive result of saving neonates, modern neonatal intensive care has also brought to light several issues regarding the ethical grounds in infant care. One of the greatest problems concerns newborns at the threshold of viability. Treatment guidelines have been formulated for these babies in different countries all around the world and there is the general consensus to withhold resuscitation in neonates when gestational age in less than, or equal to 23 weeks, with intensive care ensured for infants at 25 weeks' gestational age. In order to provide helpful suggestions during the initial management of the threatened birth of an infant with a gestational age of 25 completed weeks or less, we conducted a study for reviewing international studies on survival and morbidity rates, international guidelines and practice recommendations. This gave rise to the creation of a consensus document subsequently submitted to the Italian Scientific Societies for approval. The 'Carta di Firenze' does not attempt to deal with the problems related to pediatric euthanasia or eugenetics: its aim is to protect the infant and the mother from undue suffering although addressing recommendations for the work of clinicians.