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Lamau MC, Ruiz E, Merrer J, Sibiude J, Huon C, Lepercq J, Goffinet F, Jarreau PH. A new individualized prognostic approach to the management of women at risk of extreme preterm birth in France: Effect on neonatal outcome. Arch Pediatr 2021; 28:366-373. [PMID: 34059380 DOI: 10.1016/j.arcped.2021.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/19/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION After discussion with the parents, periviable infants can receive either active treatment or palliative care. The rate of active treatment in France is lower than in other developed countries, as is the survival rate of infants in this gestational age range. This study's main objective was to assess the effect of a standardized perinatal management protocol (EXPRIM) on the neonatal outcome of children born before 27 weeks of gestation. METHODS A before-and-after study was conducted in the two level-3 hospitals of the Risks and Pregnancy DHU to compare two 16-month periods. The EXPRIM protocol was based on routine administration of prenatal corticosteroid therapy and a scheduled combined obstetric-pediatric group prenatal prognostic evaluation, not based solely on gestational age. The study included all births between 22 weeks and 26 weeks+6 days of gestation, except in utero deaths diagnosed at admission and medical terminations of pregnancy for fetal malformation, both excluded. The principal endpoint was survival without severe neonatal morbidity. RESULTS The study included 267 women: 116 (128 newborns) in period 1 and 151 (172 newborns) in period 2. The median gestational age at admission to the maternity unit was 2.5 days younger in period 2, and the number of women admitted at 22-23 weeks doubled in period 2 (59 vs 29, respectively). Overall, the rates of live births, NICU transfer, and survival without severe morbidity were similar during the two periods. More infants were liveborn between 22 and 24 weeks in period 2 (66 vs 43). Of all newborns transferred to the NICU, 26 (29%) survived without severe morbidity in period 1 and 46 (39%) in period 2. After multivariate analysis, survival without severe morbidity did not differ significantly. CONCLUSION Implementation of the EXPRIM protocol led to active treatment of more mothers and their children at the border of viability, and increased the number of children who survived without severe morbidity even if, overall, there was no statistically significant difference in percentage.
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Affiliation(s)
- M C Lamau
- Maternité Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France
| | - E Ruiz
- Service de médecine et réanimation néonatales de Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France
| | - J Merrer
- Clinical Research Unit of Paris Descartes Necker Cochin, AP-HP, 123, Bd de Port-Royal, 75014 Paris, France; Université de Paris, INSERM U1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Épidémiologie et Biostatistique Sorbonne Paris Cité (CRESS), 123, Bd de Port-Royal, 75014 Paris, France
| | - J Sibiude
- Service de Gynécologie-Obstétrique, AP-HP, Nord-Université de Paris, Hôpital Louis Mourier, DMU Gynécologie-Périnatalité, FHU PREMA, Colombes, France, IAME-INSERM, Paris, France
| | - C Huon
- Service de Néonatologie, AP-HP, APHP. Nord-Université de Paris, Hôpital Louis Mourier, DMU Gynécologie-Périnatalité, FHU PREMA, 178, rue des Renouillers, 92700 Colombes, France
| | - J Lepercq
- Maternité Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France
| | - F Goffinet
- Maternité Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France; Université de Paris, INSERM U1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Épidémiologie et Biostatistique Sorbonne Paris Cité (CRESS), 123, Bd de Port-Royal, 75014 Paris, France
| | - Pierre Henri Jarreau
- Service de médecine et réanimation néonatales de Port-Royal, AP-HP, APHP, Centre-Université de Paris, FHU PREMA, 123, Bd de Port-Royal, 75014 Paris, France; Université de Paris, INSERM U1153, Équipe de recherche en Epidémiologie Obstétricale, Périnatale et Pédiatrique (EPOPé), Centre de Recherche Épidémiologie et Biostatistique Sorbonne Paris Cité (CRESS), 123, Bd de Port-Royal, 75014 Paris, France.
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Catalano R, Karasek D, Bruckner T, Casey JA, Saxton K, Ncube CN, Shaw GM, Elser H, Gemmill A. African American Unemployment and the Disparity in Periviable Births. J Racial Ethn Health Disparities 2021. [PMID: 33783756 DOI: 10.1007/s40615-021-01022-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 11/16/2022]
Abstract
Periviable infants (i.e., born before 26 complete weeks of gestation) represent fewer than .5% of births in the US but account for 40% of infant mortality and 20% of billed hospital obstetric costs. African American women contribute about 14% of live births in the US, but these include nearly a third of the country’s periviable births. Consistent with theory and with periviable births among other race/ethnicity groups, males predominate among African American periviable births in stressed populations. We test the hypothesis that the disparity in periviable male births among African American and non-Hispanic white populations responds to the African American unemployment rate because that indicator not only traces, but also contributes to, the prevalence of stress in the population. We use time-series methods that control for autocorrelation including secular trends, seasonality, and the tendency to remain elevated or depressed after high or low values. The racial disparity in male periviable birth increases by 4.45% for each percentage point increase in the unemployment rate of African Americans above its expected value. We infer that unemployment—a population stressor over which our institutions exercise considerable control—affects the disparity between African American and non-Hispanic white periviable births in the US.
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Gemmill A, Catalano R, Alcalá H, Karasek D, Casey JA, Bruckner TA. The 2016 presidential election and periviable births among Latina women. Early Hum Dev 2020; 151:105203. [PMID: 33091853 PMCID: PMC8128056 DOI: 10.1016/j.earlhumdev.2020.105203] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/23/2020] [Accepted: 09/29/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Research suggests that sociopolitical stressors connected with the 2016 presidential election were associated with increases in preterm birth among Latina women. This study determined whether periviable births (<26 weeks gestation), which exhibit extremely high rates of infant morbidity and mortality, among US Latina women increased above expected levels after the 2016 US presidential election. METHODS We assigned singleton live births among Latina and non-Latina white women in the US to 96 monthly conception cohorts conceived from January 2009 through December 2016. We constructed risk ratios by dividing the rate of periviable birth among Latina women by the rate among non-Latina white women. We used time-series methods to determine if the risk ratio of periviable births in cohorts conceived by Latina women and exposed to the election of 2016 exceeded those expected from autocorrelation and calendar effects. RESULTS We found an outlying sequence of risk ratios among Latina women starting with the cohort conceived in April and ending with that conceived in November 2016. Increases in the ratios ranged from 0.07 above an expected of 1.61 for the cohort conceived in June, to 0.39 above an expected of 1.27 for the cohort conceived in April. CONCLUSION We find that pregnancies in gestation at the time of the 2016 election among Latina women yielded more than expected periviable births. These findings support the argument that the prospect of anti-immigrant policies promised by the Trump campaign sufficiently stressed Latina women to affect the timing of birth.
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Affiliation(s)
- Alison Gemmill
- Department of Family, Population, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Ralph Catalano
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Héctor Alcalá
- Program in Public Health, Department of Family, Population and Prevention Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Deborah Karasek
- Department of OB/GYN and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Joan A Casey
- Department of Environmental Health Sciences, Columbia Mailman School of Public Health, New York, NY, USA
| | - Tim A Bruckner
- Program in Public Health, University of California, Irvine, Irvine, CA, USA
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Abstract
Periviable deliveries (less than 26 weeks) are a small percentage of deliveries but account for a disproportionately high number of long-term morbidities. Few studies describe interventions and outcomes for periviable preterm premature rupture of membranes (PPROM). The available reports may include only those neonates who received resuscitation, making interpretation and application difficult. Counseling should consider the impact of oligohydramnios on fetal lung development. This article discusses standard and experimental interventions that may offer neonatal benefit. Antenatal corticosteroids, antibiotics, and magnesium sulfate may improve outcomes but data to support an improvement in outcome are limited. Studies specifically evaluating these interventions are needed.
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Affiliation(s)
- Kelly S Gibson
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Case Western Reserve University, The MetroHealth System, Suite G240, 2500 MetroHealth Drive, Cleveland, Ohio 44109, USA.
| | - Kerri Brackney
- Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Case Western Reserve University, The MetroHealth System, Suite G240, 2500 MetroHealth Drive, Cleveland, Ohio 44109, USA
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Catalano R, Bruckner T, Avalos LA, Stewart H, Karasek D, Kariv S, Gemmill A, Saxton K, Casey J. Understanding periviable birth: A microeconomic alternative to the dysregulation narrative. Soc Sci Med 2019; 233:281-4. [PMID: 29274689 DOI: 10.1016/j.socscimed.2017.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/28/2017] [Accepted: 12/11/2017] [Indexed: 01/12/2023]
Abstract
Periviable infants (i.e., those born in the 20th through 26th weeks of gestation) suffer much morbidity and approximately half die in the first year of life. Attempts to explain and predict these births disproportionately invoke a "dysregulation" narrative. Research inspired by this narrative has not led to efficacious interventions. The clinical community has, therefore, urged novel approaches to the problem. We aim to provoke debate by offering the theory, inferred from microeconomics, that risk tolerant women carry, without cognitive involvement, high risk fetuses farther into pregnancy than do other women. These extended high-risk pregnancies historically ended in stillbirth but modern obstetric practices now convert a fraction to periviable births. We argue that this theory deserves testing because it suggests inexpensive and noninvasive screening for pregnancies that might benefit from the costly and invasive interventions clinical research will likely devise.
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Abstract
Periviable birth carries a high risk of fetal and newborn death, and the potential for life-long complications in survivors. The family at risk for periviable birth should receive objective, accurate, and up to date information regarding fetal, newborn, and maternal risks and outcomes with delivery or with continued pregnancy. This article describes the various descriptive terms for delivery near the limit of viability, considers the evolving limit of viability over time, and highlights the importance of adjusted counseling with brief pregnancy prolongation and/or changing clinical circumstances within the periviable period.
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Affiliation(s)
- Brian M Mercer
- Department of Obstetrics & Gynecology, The MetroHealth System, Suite G267, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
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Abstract
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.
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Abstract
The periviable period is associated with a rapid improvement in both mortality and morbidity with increasing gestational age. Therapies that can prolong gestation have the potential for markedly improving outcome compared to later in pregnancy. The therapies commonly prescribed in order to prolong gestation include bed rest, tocolysis, progesterone, and cerclage. Although these therapies are used to prevent preterm birth throughout gestation, their impact on perinatal outcome during the periviable period remains largely unknown. These therapies are discussed relative to the periviable period exploring available data and possible impact on perinatal outcome. Studies specifically evaluating therapeutic interventions during the periviable period are lacking.
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Affiliation(s)
- Edward K Chien
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109.
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Abstract
Antenatal corticosteroids have been proven to accelerate fetal lung development and reduce neonatal morbidity and mortality when given between 28 and 34 weeks of gestation. However, there is only limited research to guide their use in the periviable period (22-26 weeks). Laboratory studies suggest that it is biologically plausible for antenatal steroids to be effective in this gestational period. In addition, cohort studies have demonstrated the efficacy of antenatal corticosteroids in reducing neonatal mortality and IVH. Follow-up studies performed between 18 and 22 months of age also suggest a long-term benefit to antenatal use in this period. Based on this information, antenatal corticosteroids should be used in appropriate patients at high risk for preterm birth at 23-26 weeks of gestation. An advantageous outcome to treatment at 22 weeks is less certain.
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Affiliation(s)
- Ronald J Wapner
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, 622 W. 168th St, New York, NY 10032.
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