Antenatal counseling in the gray zone of viability

Assessing risks at 22-24 weeks gestation

The recent British Association of Perinatal Medicine (BAPM) guidance published in 2019 suggested for the first time that we can consider resuscitation of extremely premature infants (EPI) at 22-24 weeks gestational age (GA) on a case-by-case basis in the UK. This has sent waves throughout UK neonatal units, and we believe this arises because we're now confronted with challenging decisions about whether a foetus under 24 weeks will be viable or not, and whether it's in their best interests to provide 'survival-focused' care (SFC) or 'comfort-focused' care (CFC). Despite a robust framework introduced by BAPM, we believe uncertainty still remains.

Prognostic value of clinicians' predictions of neonatal outcomes in counseling at the margin of gestational viability

Within antenatal counseling sessions at the margin of gestational viability, clinicians frequently to use population-based outcome data and statistical models to guide the decision-making process. These tools often utilize non-modifiable prenatal factors to estimate outcomes based on population averages. However, most parents prefer individualized predictions, which cannot be supported by these models. Additionally, prognostic accuracy is limited by institutional practices surrounding active management of infants at the margin of viability. Throughout the literature, parental perspectives emphasize the importance of communicating subjective information, such as providing hope and supporting personal values, over the importance of accurate prognostic information from the clinician. In this review we aim to describe the value of clinician prognoses in the decision-making process at the margin of gestational viability and emphasize the importance of addressing parental values during the counseling process, regardless of the expected outcome.