Search Results (6)

Background: Presentations of preterm labour at <25 weeks of gestational age (GA) require timely evidence-based counselling and management to optimise outcomes and facilitate informed decisions. In non-tertiary centres, this counselling is often especially challenging. Objectives: (1) To develop a tool to support counselling for preterm births at <25 weeks of GA, and (2) to refine and facilitate the utilisation of this tool and develop targeted supports through an understanding of challenges to providing counselling in non-tertiary centres. Methods: Perinatal risk factors and local outcome data were incorporated into a counselling tool. Semi-structured virtual interviews were conducted with participants with experience in counselling or receiving care at <25 weeks of GA in non-tertiary centres. Interviewees included transport team members, paediatricians, obstetricians, one family physician, and one parent. Analysis using interpretive description methodology was performed to identify themes in participant practice and experience. Results: A risk-based counselling tool was developed, including guidance for counselling discussions. Twenty-one interviews were completed. Practice challenges that were identified included a lack of updated knowledge on practices in tertiary centres, discomfort in providing counselling, variability in counselling content, and a variation in health care provider teams involved in counselling. All providers expressed a desire for further education in this area. Conclusions: Support for providers in non-tertiary centres in the counselling of periviable preterm families is much needed. The development of our practice tool targeted for non-tertiary centres provides an important step in this process. The next steps include responding to the expressed need from providers for education and training in the counselling and management of periviable preterm pregnancies. Full article

Background: Reports on the survival of infants born at periviable gestation (GA of ≤24 weeks and birth weight of <500 gm) vary significantly. We aimed to determine hospital factors associated with their survival and to assess the trend for the timing of postnatal mortality in these periviable infants. Methods: We utilized the de-identified National Inpatient Sample (NIS) dataset of the Healthcare Cost and Utilization Project (HCUP) from the Agency for Healthcare Research and Quality (AHRQ). National data were analyzed for the years 2010–2018. Hospitals were categorized according to delivery volume, USA regions, and teaching status. Results: We identified 33,998,014 infants born during the study period; 76,231 infants were ≤24 weeks. Survival at birth and first 2 days of life was greatest in urban teaching hospitals in infants <24 weeks and those who completed 24 weeks, respectively. The Northeast region has the lowest survival rate. There was a significant delay in the postnatal day of mortality in periviable infants. Conclusions: Hospital factors are associated with increased survival rates. Improved survival in large teaching hospitals supports the need for the regionalization of care in infants born at the limits of viability. There was a significant delay in the postnatal mortality day. Full article

Advances in neonatal care have pushed the limit of viability to incrementally lower gestations over the last decades. However, surviving extremely premature neonates are prone to long-term neurodevelopmental handicaps. This makes ethics a crucial dimension of periviable birth management. At 22 weeks, survival ranges from 1 to 15%, and profound disabilities in survivors are common. Consequently, there is no beneficence-based obligation to offer any aggressive perinatal management. At 23 weeks, survival ranges from 8 to 54%, and survival without severe handicap ranges from 7 to 23%. If fetal indication for cesarean delivery appears, the procedure may be offered when neonatal resuscitation is planned. At a gestational age ≥24 weeks, up to 51% neonates are expected to survive the neonatal period. Survival without profound neurologic disability ranges from 12 to 38%. Beneficence-based obligation to intervene is reasonable at these gestations. Nevertheless, autonomy of parents should also be respected, and parental consent should be sought prior to any intervention. Optimal counselling of parents involves harmonized cooperation of obstetric and neonatal care providers. Every fetus/neonate and every pregnant woman are different and have the right to be considered individually when treatment decisions are being made. Full article

Preterm prelabour rupture of membranes (PPROMs) before viability carries significant perinatal mortality and morbidity. Clinical management and prenatal counselling are a challenge, especially in twin pregnancies, due to scarce evidence on how previable PPROM affects this population. The aim of this study was to describe pregnancy outcomes of twin pregnancies complicated with previable PPROM and evaluate potential prognostic factors that may predict perinatal mortality. A retrospective cohort including dichorionic and monochorionic diamniotic twin pregnancies complicated with PPROM before 24 + 0 weeks of pregnancy was evaluated. Perinatal outcomes of pregnancies managed expectantly were described. Factors predicting perinatal mortality or reaching periviability (defined from 23 + 0 weeks onwards) were evaluated. Of the 45 patients included, 7 (15.6%) spontaneously delivered within the first 24 h after diagnosis. Two patients (5.3%) requested selective termination of the affected twin. In the 36 ongoing pregnancies that opted for expectant management, the overall survival rate was 35/72 (48.6%). There were 25/36 (69.4%) patients who delivered after 23 + 0 weeks of pregnancy. When periviability was achieved, neonatal survival increased up to 35/44 (79.5%). Gestational age at delivery was the only independent risk factor of perinatal mortality. The overall survival rate of twin pregnancies complicated with previable PPROM is poor but similar to singletons. No prognostic factors, apart from achieving periviability, were identified as individual predictors of perinatal mortality. Full article

We aimed to determine the differences in the growth trajectories of the youngest gestational survivors (<25 weeks’ gestation) up to 6 years of age compared to those of older gestational ages. Preterm infants were divided into two groups: 22–24 weeks’ gestation (male (M) 16, female (F) 28) and 25–29 weeks’ gestation (M 84, F 59). Z-scores of body weight (BW), body length (BL), and body mass index (BMI) were derived from Japanese standards at 1, 1.5, 3, and 6 years of corrected age. Comparisons between the two groups by sex were made using the Wilcoxon test and linear regression analysis to examine the longitudinal and time-point associations of anthropometric z-scores, the presence of small for gestational age (SGA), and the two gestational groups. BW, BL, BMI, and z-scores were significantly lower in the 22–24 weeks group at almost all assessment points. However, there were no significant differences in BW, BL, BMI, and z-scores between the two female groups after 3 years. BMI z-scores were significantly associated with the youngest gestational age and the presence of SGA at all ages in males, but not in females. The youngest gestational age had a greater influence in males on the z-score of anthropometric parameters up to 6 years of age. Full article

Periviable infants (PIs) born at 22–25 weeks gestational age (wGA) have a variable survival rate (49.7–86.2%) among hospitals. One factor involved in this difference may be the definition of the threshold of viability. The American Academy of Pediatrics revised the neonatal resuscitation program in late 2015 (NRP 2015) and altered the threshold of viability from 23 to 22 wGA. The impact on the survival of PIs after the guideline alteration has seldom been discussed. Since 2016, the unit of this study has implemented the renewed guideline for PIs. We retrospectively reviewed and analyzed the survival and clinical variables of PIs before and after implementation of the guideline, which included a 10-year cohort in a single center in Taiwan. There were 168 PIs enrolled between 2010 and 2019 (Epoch-I, 2010–2015; Epoch-II, 2016–2019), after excluding those with congenital anomalies and parent-decided comfort care. Compared to those in Epoch-I, the PIs in Epoch-II had significantly higher odds ratios (2.602) (95% confidence interval: 1.170–5.789; p = 0.019) for survival. Younger gestational age, small size for gestational age, cesarean delivery, low blood pH at birth, and surfactant therapeutic treatment were found to be significant risk factors associated with the survival of PIs (p < 0.05 for each). The altered threshold of viability by NRP 2015 may impact the survival of PIs. However, long-term follow-up for surviving PI is required in the future. Full article