Survival and major neonatal complications in infants born between 22 0/7 and 24 6/7 weeks of gestation (1999-2003)

Analysis of risk factors related to extremely and very preterm birth: a retrospective study

Background:

Preterm birth is one of the main causes of perinatal morbidity and mortality and imposes a heavy burden on families and society. The aim of this study was to identify risk factors and analyze birth conditions and complications of newborns born at < 32 gestational weeks for extremely preterm (EP) and very preterm (VP) birth in the clinic to further extend the gestational period.

Methods:

We performed a retrospective cohort study and collected data from 1598 pregnant women and 1660 premature newborns (excluding 229 premature babies who died due to severe illness and abandonment) admitted to the Obstetrics and Gynecology Hospital Affiliated with Nanjing Medical University in China from 2016 to 2020. We compared women’s and newborns’ characteristics by t-tests and Chi-square tests for continuous and categorical variables, respectively. Multivariable logistic regression was performed to estimate the effects of risk factors on EP and VP birth.

Results:

We identified 3 independent risk factors for EP birth: cervical incompetency (P < 0.001); multiple pregnancy (P < 0.01), primipara (P < 0.001). Additionally, we identified 4 independent risk factors for VP birth: gestational diabetes mellitus (GDM) (P < 0.05), preterm premature rupture of membrane (PPROM) (P < 0.01), fetal intrauterine distress (P < 0.001), and hypertensive disorder complicating pregnancy (HDCP) (P < 0.001). In addition, pairwise comparisons revealed statistically significant differences in the incidence rates of neonatal pneumonia, bronchopulmonary dysplasia (BPD) and sepsis between the 28–28 + 6 and 29–29 + 6 weeks of gestation groups (P < 0.05). Compared with 28–28 + 6 weeks of gestation, neonatal complications were significantly more common at < 26 weeks of gestation (P < 0.05). The incidence rates of neonatal intracranial hemorrhage(NICH), patent ductus arteriosus(PDA), patent foramen ovale(PFO), pneumonia, BPD and sepsis were significantly higher in the 26–26 + 6 and 27–27 + 6 gestational weeks than in the 28–28 + 6 gestational weeks (P < 0.05).

Conclusion:

PPROM, is the most common risk factor for EP and VP birth, and cervical insufficiency, multiple pregnancy, and primipara are independent risk factors for EP birth. Therefore, during pregnancy, attention should be devoted to the risk factors for PPROM, and reproductive tract infection should be actively prevented to reduce the occurrence of PPROM. Identifying the risk factors for cervical insufficiency, actively intervening before pregnancy, and cervical cervix ligation may be considered to reduce the occurrence of EP labor. For iatrogenic preterm birth, the advantages and disadvantages should be carefully weighed, and the gestational period should be extended beyond 28 weeks to enhance the safety of the mother and child and to improve the outcomes of preterm birth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05119-7.

Global incidence of intraventricular hemorrhage among extremely preterm infants: a systematic literature review

OBJECTIVES

To conduct a systematic literature review to evaluate the global incidence of intraventricular hemorrhage grade 2-4 among extremely preterm infants.

METHODS

We performed searches in MEDLINE and Embase for intraventricular hemorrhage and prematurity cited in English language observational studies published from May 2006 to October 2017. Included studies analyzed data from infants born at ≤28 weeks' gestational age and reported on intraventricular hemorrhage epidemiology.

RESULTS

Ninety-eight eligible studies encompassed 39 articles from Europe, 31 from North America, 25 from Asia, five from Oceania, and none from Africa or South America; both Europe and North America were included in two publications. The reported global incidence range of intraventricular hemorrhage grade 3-4 was 5-52% (Europe: 5-52%; North America: 8-22%; Asia: 5-36%; Oceania: 8-13%). When only population-based studies were included, the incidence range of intraventricular hemorrhage grade 3-4 was 6-22%. The incidence range of intraventricular hemorrhage grade 2 was infrequently documented and ranged from 5-19% (including population-based studies). The incidence of intraventricular hemorrhage was generally inversely related to gestational age.

CONCLUSIONS

Intraventricular hemorrhage is a frequent complication of extremely preterm birth. Intraventricular hemorrhage incidence range varies by region, and the global incidence of intraventricular hemorrhage grade 2 is not well documented.

Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to provide a systematic review and meta-analysis to quantify prognosis and identify factors associated with variations in reported mortality estimates among infants who were born at 22 weeks of gestation and provided proactive treatment (resuscitation and intensive care).

DATA SOURCES

PubMed, Scopus, and Web of Science databases, with no language restrictions, were searched for articles published from January 2000 to February 2020.

STUDY ELIGIBILITY CRITERIA

Reports on live-born infants who were delivered at 22 weeks of gestation and provided proactive care were included. The primary outcome was survival to hospital discharge; secondary outcomes included survival without major morbidity and survival without neurodevelopmental impairment. Because we expected differences across studies in the definitions for various morbidities, multiple definitions for composite outcomes of major morbidities were prespecified. Neurodevelopmental impairment was based on Bayley Scales of Infant Development II or III. Data extractions were performed independently, and outcomes agreed on a priori.

STUDY APPRAISAL AND SYNTHESIS METHODS

Methodological quality was assessed using the Quality in Prognostic Studies tool. An adapted version of the Grading of Recommendations Assessment, Development and Evaluation approach for prognostic studies was used to evaluate confidence in overall estimates. Outcomes were assessed as prevalence and 95% confidence intervals. Variabilities across studies attributable to heterogeneity were estimated with the I² statistic; publication bias was assessed with the Luis Furuya-Kanamori index. Data were pooled using the inverse variance heterogeneity model.

RESULTS

Literature searches returned 21,952 articles, with 2034 considered in full; 31 studies of 2226 infants who were delivered at 22 weeks of gestation and provided proactive neonatal treatment were included. No articles were excluded for study design or risk of bias. The pooled prevalence of survival was 29.0% (95% confidence interval, 17.2-41.6; 31 studies, 2226 infants; I²=79.4%; Luis Furuya-Kanamori index=0.04). Survival among infants born to mothers receiving antenatal corticosteroids was twice the survival of infants born to mothers not receiving antenatal corticosteroids (39.0% vs 19.5%; P<.01). The overall prevalence of survival without major morbidity, using a definition that includes any bronchopulmonary dysplasia, was 11.0% (95% confidence interval, 8.0-14.3; 10 studies, 374 infants; I²=0%; Luis Furuya-Kanamori index=3.02). The overall rate of survival without moderate or severe impairment was 37.0% (95% confidence interval, 14.6-61.5; 5 studies, 39 infants; I²=45%; Luis Furuya-Kanamori index=-0.15). Based on the year of publication, survival rates increased between 2000 and 2020 (slope of the regression line=0.09; standard error=0.03; P<.01). Studies were highly diverse with regard to interventions and outcomes reported.

CONCLUSION

The reported survival rates varied greatly among studies and were likely influenced by combining observational data from disparate sources, lack of individual patient-level data, and bias in the component studies from which the data were drawn. Therefore, pooled results should be interpreted with caution. To answer fundamental questions beyond the breadth of available data, multicenter, multidisciplinary collaborations, including alignment of important outcomes by stakeholders, are needed.

Global incidence of bronchopulmonary dysplasia among extremely preterm infants: a systematic literature review

BACKGROUND

Infants born extremely preterm (<28 weeks gestational age (GA)) face a high risk of neonatal mortality. Bronchopulmonary dysplasia (BPD) is the most common morbidity of prematurity.

OBJECTIVE

To evaluate the global incidence of BPD among infants born extremely preterm.

DESIGN

A systematic review of the literature was conducted in Embase and MEDLINE (via PubMed) using a prespecified search strategy for BPD and prematurity. Observational studies published in English between 16 May 2006 and 16 October 2017 reporting on the occurrence of BPD in infants born <28 weeks GA were included.

RESULTS

Literature searches yielded 103 eligible studies encompassing 37 publications from Europe, 38 publications from North America, two publications from Europe and North America, 19 publications from Asia, one publication from Asia and North America, six publications from Oceania, and zero publications from Africa or South America. The reported global incidence range of BPD was 10-89% (10-73% in Europe, 18-89% in North America, 18-82% in Asia, and 30-62% in Oceania). When only population-based observational studies that defined BPD as requiring supplemental oxygen at 36 weeks postmenstrual age were included, the global incidence range of BPD was 17-75%. The wide range of incidences reflected interstudy differences in GA (which was inversely related to BPD incidence), birthweight, and survival rates across populations and institutions.

CONCLUSIONS

BPD is a common health morbidity occurring with extremely preterm birth. Further study of factors that impact incidence, aside from low GA, may help to elucidate modifiable risks.

The Joint Effects of Antenatal Steroids and Gestational Age on Improved Outcomes in Neonates

OBJECTIVES

Antenatal corticosteroids are standard of care for women at risk of a preterm birth and demonstrated to be protective against poor outcomes in neonates including respiratory disorders, mortality and intraventricular hemorrhage (IVH). Its benefits may vary by gestational age, and accurate estimation is needed in a single-center population to account for practice variation.

METHODS

A retrospective cohort of infants admitted to the hospital's neonatal intensive care unit, 1997-2015. Using Poisson regression, we separately modeled the incidence rate ratio of death, grade III or IV intraventricular hemorrhage (IVH), and moderate to severe bronchopulmonary dysplasia (BPD) testing the moderating effects of gestation on antenatal steroids, controlling for potential confounding.

RESULTS

Among 5314 infants admitted, death occurred in 298 (6%), severe IVH in 244 (5%), and BPD in 527 (10%). Antenatal steroids were protective of death and BPD in the adjusted analysis, and there was multiplicative interaction where each week increase in gestational age combined with steroid therapy resulted in 13% reduced incidence for each outcome.

CONCLUSIONS FOR PRACTICE

Antenatal steroids are protective against severe IVH and moderate to severe BPD, and when combined with gestational age, steroids are associated with greater protective benefits in older neonates. There is likely an ideal window to maximize the benefits of antenatal steroids, and future etiologic research should consider the joint effects with gestational age.

Survival and Impairment of Extremely Premature Infants: A Meta-analysis

CONTEXT

Survival of infants born at the limit of viability varies between high-income countries.

OBJECTIVE

To summarize the prognosis of survival and risk of impairment for infants born at 22 + 0/7 weeks' to 27 + 6/7 weeks' gestational age (GA) in high-income countries.

DATA SOURCES

We searched 9 databases for cohort studies published between 2000 and 2017 in which researchers reported on survival or neurodevelopmental outcomes.

STUDY SELECTION

GA was based on ultrasound results, the last menstrual period, or a combination of both, and neurodevelopmental outcomes were measured by using the Bayley Scales of Infant Development II or III at 18 to 36 months of age.

DATA EXTRACTION

Two reviewers independently extracted data and assessed the risk of bias and quality of evidence.

RESULTS

Sixty-five studies were included. Mean survival rates increased from near 0% of all births, 7.3% of live births, and 24.1% of infants admitted to intensive care at 22 weeks' GA to 82.1%, 90.1%, and 90.2% at 27 weeks' GA, respectively. For the survivors, the rates of severe impairment decreased from 36.3% to 19.1% for 22 to 24 weeks' GA and from 14.0% to 4.2% for 25 to 27 weeks' GA. The mean chance of survival without impairment for infants born alive increased from 1.2% to 9.3% for 22 to 24 weeks' GA and from 40.6% to 64.2% for 25 to 27 weeks' GA.

LIMITATIONS

The confidence in these estimates ranged from high to very low.

CONCLUSIONS

Survival without impairment was substantially lower for children born at <25 weeks' GA than for those born later.

Survival and Major Morbidity of Extremely Preterm Infants: A Population-Based Study

OBJECTIVES

To assess the rates of mortality and major morbidity among extremely preterm infants born in California and to examine the rates of neonatal interventions and timing of death at each gestational age.

METHODS

A retrospective cohort study of all California live births from 2007 through 2011 linked to vital statistics and hospital discharge records, whose best-estimated gestational age at birth was 22 through 28 weeks. Major morbidities were based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Survival beyond the first calendar day of life and procedure codes were used to assess attempted resuscitation after birth.

RESULTS

A total of 6009 infants born at 22 through 28 weeks' gestation were included. Survival to 1 year for all live births ranged from 6% at 22 weeks to 94% at 28 weeks. Seventy-three percent of deaths occurred within the first week of life. Major morbidity was present in 80% of all infants, and multiple major morbidities were present in 66% of 22- and 23-week infants. Rates of resuscitation at 22, 23, and 24 weeks were 21%, 64%, and 93%, respectively. Survival after resuscitation was 31%, 42%, and 64% among 22-, 23-, and 24-week infants, respectively. Improved survival was associated with increased birth weight, female sex, and cesarean delivery (P < .01) for resuscitated 22-, 23-, and 24-week infants.

CONCLUSIONS

In a population-based study of extreme prematurity, infants ≤24 weeks' gestation are at highest risk of death or major morbidity. These data can help inform recommendations and decision-making for extremely preterm births.

Trends in Survival and Incidence of Bronchopulmonary Dysplasia in Extremely Preterm Infants at 23-26 Weeks Gestation

The aim of this study was to investigate the relationship between survival and incidence of bronchopulmonary dysplasia (BPD) in extremely premature infants, and identify clinical factors responsible for this association. Medical records of 350 infants at 23-26 weeks gestation from 2000 to 2005 (period I, n = 137) and 2006 to 2010 (period II, n = 213) were retrospectively reviewed. The infants were stratified into 23-24 and 25-26 weeks gestation, and the survival, BPD incidence, and clinical characteristics were analyzed. BPD was defined as oxygen dependency at 36 weeks postmenstrual age. The overall survival rate was significantly improved in period II compared to period I (80.3% vs. 70.0%, respectively; P = 0.028), especially in infants at 23-24 weeks gestation (73.9% vs. 47.4%, respectively; P = 0.001). The BPD incidence in survivors during period II (55.0%) was significantly decreased compared to period I (67.7%; P = 0.042), especially at 25-26 weeks gestation (41.7% vs. 62.3%, respectively; P = 0.008). Significantly improved survival at 23-24 weeks gestation was associated with a higher antenatal steroid use and an improved 5-minute Apgar score. A significant decrease in BPD incidence at 25-26 weeks gestation was associated with early extubation, prolonged use of less invasive continuous positive airway pressure, and reduced supplemental oxygen. Improved perinatal and neonatal care can simultaneously lead to improved survival and decreased BPD incidence in extremely premature infants.

Maternal and perinatal outcomes of pregnancies delivered at 23 weeks' gestation

OBJECTIVE

To evaluate the maternal and perinatal outcomes of pregnancies delivered at 23+0 to 23+6 weeks' gestation.

METHODS

This prospective cohort study included women in the Canadian Perinatal Network who were admitted to one of 16 Canadian tertiary perinatal units between August 1, 2005, and March 31, 2011, and who delivered at 23+0 to 23+6 weeks' gestation. Women were included in the network if they were admitted with spontaneous preterm labour with contractions, a short cervix without contractions, prolapsing membranes with membranes at or beyond the external os or a dilated cervix, preterm premature rupture of membranes, intrauterine growth restriction, gestational hypertension, or antepartum hemorrhage. Maternal outcomes included Caesarean section, placental abruption, and serious complication. Perinatal outcomes were mortality and serious morbidity.

RESULTS

A total of 248 women and 287 infants were included in the study. The rate of Caesarean section was 10.5% (26/248) and 40.3% of women (100/248) had a serious complication, the most common being chorioamnionitis (38.6%), followed by blood transfusion (4.5%). Of infants with known outcomes, perinatal mortality was 89.9% (223/248) (stillbirth 23.3% [67/287] and neonatal death 62.9% [156/248]). Of live born neonates with known outcomes (n = 181), 38.1% (69/181) were admitted to NICU. Of those admitted to NICU, neonatal death occurred in 63.8% (44/69). Among survivors at discharge, the rate of severe brain injury was 44.0% (11/25), of retinopathy of prematurity 58.3% (14/24), and of any serious neonatal morbidity 100% (25/25). Two subgroup analyses were performed: in one, antepartum stillbirths were excluded, and in the other only centres that indicated they offered fetal monitoring at 23 weeks' gestation were included and antepartum stillbirths were excluded. In each of these, perinatal outcomes similar to the overall group were found.

CONCLUSION

Pregnant women delivering at 23 weeks' gestation are at risk of morbidity. Their infants have high rates of serious morbidity and mortality. Further research is needed to identify strategies and forms of management that not only increase perinatal survival but also reduce morbidities in these extremely low gestational age infants and reduce maternal morbidity.

Schul- und Verhaltensauffälligkeiten nach extremer Frühgeburtlichkeit im Alter von 7 bis 10 Jahren

Aufgrund verbesserter medizinischer Versorgung überleben heute immer mehr extrem Frühgeborene und haben Chancen auf ein Leben ohne Behinderung. Allerdings darf das Risiko langfristiger Entwicklungsstörungen nicht unterschätzt werden. In dieser Studie wurden 79 von 105 Kinder (75 %), die zwischen 1999 und 2003 vor vollendeter 25. Schwangerschaftswoche in zwei Perinatalzentren geboren wurden, im Alter von 7 bis 10 Jahren standardisiert nachuntersucht hinsichtlich neurologischer, körperlicher, kognitiver Fähigkeiten, schulischer Leistungen, Verhalten und Förderbedarf. Im Mittel lag der Gesamt-IQ bei 87, bei 38 % unter 85. Knapp die Hälfte der Kinder besuchte keine Regelschule. Neben Entwicklungsverzögerungen (64 %) traten gehäuft Entwicklungsstörungen schulischer Fertigkeiten (30 %), Aufmerksamkeitsdefizit-/Hyperaktivitätsstörungen (17 %) und Autismus-Spektrum-Erkrankungen (6 %) auf. Es bestand erhöhter medizinischer Therapie- sowie schulischer Förderbedarf. Bei extrem Frühgeborenen sind kognitive Einschränkungen, Verhaltensauffälligkeiten und Probleme der schulischen Adaptation häufig und erfordern langfristig Therapien und Fördermaßnahmen.

Long-term outcome at age 7-10 years after extreme prematurity - a prospective, two centre cohort study of children born before 25 completed weeks of gestation (1999-2003)

OBJECTIVE

We aimed to determine the long-term neurodevelopmental outcome in extremely preterm infants of 22-23 completed weeks' gestation as compared to infants of 24 weeks with immediate postnatal life support born in two German tertiary perinatal centres between 1999 and 2003.

METHODS

Children were assessed for cognitive and neurological outcomes at the age of 7-10 years. The test battery included a neurological examination, the Wechsler Intelligence Scale for children (WISC-IV) and the Frostigs Developmental Test of Visual Perception (DTVP-2). Gross motor function was classified according to the GMFCS and functional activity was assessed with the Lincoln Oseretzky Motor Development Scale (LOS KF 18).

RESULTS

Outcome data were available for 79/105 children. 75.9% of the entire study cohort showed no or mild impairment. There was no difference seen between the two gestational age groups. Risk factors for moderate or severe impairment were an intracerebral haemorrhage >II° and/or periventricular leukomalacia or a retinopathy of prematurity >II°. Neither the gestational age (GA) nor the birth weight was associated with long-term outcome.

CONCLUSIONS

Gestational age was not a predictor for long-term impairment of preterm infants born <25 completed weeks' GA. Other prognostic factors should be taken into account for counselling in the grey zone of viability.

Counselling and management for anticipated extremely preterm birth

Extremely preterm birth (birth between 22(0/7) and 25(6/7) weeks' gestational age [GA]) often requires parents to make complex choices about the care of their infant. Health professionals have a significant role in providing information, guidance and support. Parents facing the birth of an extremely preterm infant should have the chance to meet with both obstetrical and paediatric/neonatal care providers to receive accurate information about their infant's prognosis, provided with clarity and compassion. Decision making between parents and health professionals should be an informed and shared process, with documentation of all management decisions. Consultation with and transfer to tertiary perinatal centres are important for the care of both mother and fetus. As the survival of infants born before or at 22 completed weeks' GA remains uncommon, a noninterventional approach is recommended, whereas at 23, 24 and 25 weeks' GA, counselling about outcomes and decision making should be individualized for each infant and family, using factors which influence prognosis. All extremely preterm infants who are not resuscitated, or for whom resuscitation is not successful, must receive compassionate palliative care.

Medical practice and legal background of decisions for severely ill newborn infants: viewpoints from seven European countries

AIM

To comparing attitudes towards end-of-life (EOL) decisions in newborn infants between seven European countries.

METHODS

One paediatrician and one lawyer from seven European countries were invited to attend a conference to discuss the practice of EOL decisions in newborn infants and the legal aspects involved.

RESULTS

All paediatricians/neonatologists indicated that the best interest of the child should be the leading principle in all decisions. However, especially when discussing cases, important differences in attitude became apparent, although there are no significant differences between the involved countries with regard to national legal frameworks.

CONCLUSION

Important differences in attitude towards neonatal EOL decisions between European countries exist, but they cannot be explained solely by medical or legal reasons.

Outcome of extremely low gestational age newborns after introduction of a revised protocol to assist preterm infants in their transition to extrauterine life

AIM

To evaluate the outcome of a cohort of extremely low gestational age newborn infants (ELGAN) below 26-week gestation who were treated following a revised, gentle delivery room protocol to assist them in the transition and adaptation to extrauterine life.

METHODS

A cohort of infants with a gestational age (GA) below 26 weeks (study group; n = 164) was treated according to a revised delivery room protocol. The protocol included an optimized prenatal management, strict use of continuous positive airway pressure (CPAP), avoiding mechanical ventilation and early administration of surfactant without intubation. The parameters management of respiratory distress syndrome, survival, neonatal morbidity and neurodevelopmental outcome were compared with a historical control group (n = 44).

RESULTS

Seventy-four per cent of the study group infants were initially treated with CPAP and surfactant administration without intubation. In comparison with the control group, significantly less children were intubated in the delivery room (24% vs. 41%) and needed mechanical ventilation (51% vs. 72%; both p < 0.05). Furthermore, compared with the historical control overall mortality (20% vs. 39%), rate of bronchopulmonary dysplasia (18% vs. 37%) and IVH > II° (10% vs. 33%) in survivors were significantly lower during the observational period (all p < 0.05). Neurodevelopmental outcome was normal in 70% of examined study group infants.

CONCLUSIONS

A revised delivery room management protocol was applied safely to infants with a GA below 26 completed weeks with improved rates of survival and morbidity.

Antenatal corticosteroids promote survival of extremely preterm infants born at 22 to 23 weeks of gestation

OBJECTIVE

To evaluate the effectiveness of antenatal corticosteroid (ACS) to improve neonatal outcomes for infants born at <24 weeks of gestation.

STUDY DESIGN

We performed a retrospective analysis of 11,607 infants born at 22 to 33 weeks of gestation between 2003 and 2007 from the Neonatal Research Network of Japan. We evaluated the gestational age effects of ACS administered to mothers with threatened preterm birth on several factors related to neonatal morbidity and mortality.

RESULTS

By logistic regression analysis, ACS exposure decreased respiratory distress syndrome and severe intraventricular hemorrhage in infants born between 24 and 29 weeks of gestation. Cox regression analysis revealed that ACS exposure was associated with a significant decrease in mortality of preterm infants born at 22 or 23 weeks of gestation (adjusted hazard ratio, 0.72; 95% CI, 0.53 to 0.97; P=.03). This effect was also observed at 24 to 25 and 26 to 27 weeks of gestation and in the overall study population.

CONCLUSIONS

ACS exposure improved survival of extremely preterm infants. ACS treatment should be considered for threatened preterm birth at 22 to 23 weeks of gestation.

[Very premature births: Dilemmas and management. Part 1. Outcome of infants born before 28 weeks of postmenstrual age, and definition of a gray zone]

With very preterm deliveries, the decision to institute intensive care, or, alternatively, to start palliative care and let the baby die, is extremely difficult, and involves complex ethical issues. The introduction of intensive care may result in long-term survival of many infants without severe disabilities, but it may also result in the survival of severely disabled infants. Conversely, the decision to withhold resuscitation and/or intensive care at birth, which is an option at the margin of viability, implies allowing babies to die, although some of them would have developed normally if they had received resuscitation and/or intensive care. Withholding intensive care at birth does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. The likelihood of survival without significant disabilities decreases as gestational age at birth decreases. In addition to gestational age, other factors greatly influence the prognosis. Indeed, for a given gestational age, higher birth weight, singleton birth, female sex, exposure to prenatal corticosteroids, and birth in a tertiary center are favorable factors. Considering gestational age, there is a gray zone that corresponds to major prognostic uncertainty and therefore to a major problem in making a "good" decision. In France today, the gray zone corresponds to deliveries at 24 and 25 weeks of postmenstrual age. In general, babies born above the gray zone (26 weeks of postmenstrual age and later) should receive resuscitation and/or full intensive care. Below 24 weeks, palliative care is the only option offered in France at the present time. Decisions within the gray zone will be addressed in the 2nd part of this work.

Survival and major disability rate in infant born at 22-25 weeks of gestation

Our aim was to evaluate the literature on survival and major disability rate in preterm infants born at 22- 25 weeks of gestational age (GA). Thirty-three studies were identified and reviewed. Survival was lower in population-based studies (2% at 22, 13% at 23, 35% at 24, and 56% at 25 weeks) than in center-based study (15% at 22, 41% at 23, 58% at 24, and 74% at 25 weeks). The severe disability rate was slightly higher in population-based studies than in center-based studies at 23 (29 vs. 32%) and at 24 (30 vs. 27%) week of GA, whereas it was similar in population and center-based studies at 25 (21 vs. 22%) weeks of GA. Survival rate seems to improve with time, whereas the change of severe disability rate cannot be adequately evaluated due to the paucity of available data. We conclude that the survival of infants born at 22 weeks is still an uncommon event, whereas the survival of infants born at 23, and mostly at 24 and 25 weeks of GA is significant in the majority of studies.

Implementation of a multidisciplinary guideline-driven approach to the care of the extremely premature infant improved hospital outcomes

AIM

To test the hypothesis that implementing guidelines for the standardized care of the extremely premature infant (<27 weeks) in the first week of life would improve patient outcomes in an all referral NICU.

METHODS

Data were collected on all infants <27 weeks gestational age and <7 days of age on admission cared for using these small baby guidelines (SBG), as well as on all age-matched infants admitted the year prior (comparison).

RESULTS

Thirty-seven patients were cared for utilizing the SBG and 40 patients were in the comparison group. There were no differences between the groups in gestational age, birthweight or age on admission. There was no difference in survival to discharge (73% SBG, 70% comparison). The mean length of stay for survivors was 112 +/- 38 days SBG and 145 +/- 76 days (p < 0.05) comparison group. Survival without BPD was greater in the SBG group (24%) than in the comparison group (9%; p < 0.05), and survival without severe IVH was greater in the SBG group (65%) than in the comparison group (38%; p < 0.01).

CONCLUSIONS

These data demonstrate that applying a unified approach to the care of the extremely premature infant in the first week of life resulted in a decrease in the length of hospitalization and improved patient outcomes.

Single-centre vs. population-based outcome data of extremely preterm infants at the limits of viability

AIM

In response to the disappointing outcome data of the population-based EPICure study published in 2000, we compared the outcome of infants 22 0/7 to 25 6/7 weeks of gestational age (GA) in a single tertiary care centre 2000-2004 with that of EPICure.

METHODS

EPICure tools and definitions, including 30 months' Bayley Scales.

RESULTS

Of 83 infants <26 weeks born alive, more were admitted to intensive care--82% vs. 68% (p < 0.0001)--and more infants survived to discharge (57% vs. 26%, p < 0.0001; 69% vs. 39%, p < 0.01, of those admitted to intensive care). More infants, as a percentage of live births, survived without severe (41%, 34/83 vs. 20%, 233/1185, p < 0.0001) or overall disability (22%, 18/83 vs. 13%, 155/1185, p = 0.03). However, at the border of viability--GA 23 and 24 weeks--the rate of infants surviving without overall disability was not significantly higher (13%, 6/45 vs. 9%, 56/623).

CONCLUSION

In infants <26 weeks of GA, increased rates of survival and survival without disability were observed in a single-centre inborn cohort born 5-8 years later than the EPICure cohort. This did not translate into increased survival without overall disability in infants of 23-24 weeks of GA.

Clinical report--Antenatal counseling regarding resuscitation at an extremely low gestational age

The anticipated delivery of an extremely low gestational age infant raises difficult questions for all involved, including whether to initiate resuscitation after delivery. Each institution caring for women at risk of delivering extremely preterm infants should provide comprehensive and consistent guidelines for antenatal counseling. Parents should be provided the most accurate prognosis possible on the basis of all the factors known to affect outcome for a particular case. Although it is not feasible to have specific criteria for when the initiation of resuscitation should or should not be offered, the following general guidelines are suggested. If the physicians involved believe there is no chance for survival, resuscitation is not indicated and should not be initiated. When a good outcome is considered very unlikely, the parents should be given the choice of whether resuscitation should be initiated, and clinicians should respect their preference. Finally, if a good outcome is considered reasonably likely, clinicians should initiate resuscitation and, together with the parents, continually reevaluate whether intensive care should be continued. Whenever resuscitation is considered an option, a qualified individual, preferably a neonatologist, should be involved and should be present in the delivery room to manage this complex situation. Comfort care should be provided for all infants for whom resuscitation is not initiated or is not successful.

The ethics of delivery-room resuscitation

Perinatal care continues to improve and the number of extremely preterm babies delivered increases. What is the outcome for those babies? Under what circumstances should we not initiate resuscitation or under what circumstances should we discontinue support? How accurate and predictive are the data we have and how can these be improved? Who should make the decisions and how should they be made? Should we follow different guidelines in different settings? The following narrative will examine some of these questions but cannot answer them all.

Mortality and morbidity of neonates born at <26 weeks of gestation (1998-2003). A population-based study

OBJECTIVE

To describe mortality and morbidity of neonates born at <26 weeks' gestation in a contemporary population-based cohort.

METHODS

We analyzed data of neonates born at <26 weeks between 1998 and 2003 in the Federal State of Hesse, Germany. Survival was calculated at 28 days and at discharge from hospital.

RESULTS

Out of a total of 800 births, 572 infants were liveborn. Among those admitted for neonatal intensive care, 62.3% survived until day 28. Among the neonates followed until death or discharge, 59.6% were discharged home. Logistic regression analyses showed the following variables to be associated with an increased risk of death: Twins (Odds Ratio (OR) 3.7; 95% Confidence Interval (CI) 1.34-10.26), multiple birth >or=3 (OR 8.14; CI 1.23-53.86), intraventricular hemorrhage (IVH) >or=grade III (OR 4.79; CI 1.89-12.14), clinical risk index for babies score >15 (OR 2.9; CI 1.09-7.76), and a gestational age <or=23 weeks (OR 5.34; CI 1.24-22.98). Among infants discharged home, bronchopulmonary dysplasia was diagnosed in 52.2%, IVH >or=grade III and/or periventricular leukomalacia in 15%, and severe retinopathy of prematurity in 29.8%.

CONCLUSIONS

This study provides outcome data derived from a contemporary population-based cohort. Mortality and complication rates remain high.

Neurodevelopmental follow-up of very preterm infants after proactive treatment at a gestational age of > or = 23 weeks

OBJECTIVE

To determine the long-term neurodevelopmental outcome in extremely preterm infants after offering life support to all infants > or = 23 weeks gestation ("pro-active management").

STUDY DESIGN

With parental consent, all infants born at 23 to 25 completed weeks gestation were treated proactively. Surviving infants born from July 1996 to June 1999 were assessed for standardized cognitive and neurological outcomes at 5 years corrected age.

RESULTS

70 of 91 infants admitted to the neonatal intensive care unit survived until follow-up. 67 of the 70 surviving infants were examined at a median corrected age of 5.6 years; 12% had cerebral palsy and a Gross Motor Function Classification Scale score > 2; 4% were blind; 1% required a hearing aid; and 12% had a Kaufmann Assessment Battery for Children mental processing composite < 51, resulting in 18% sustaining a severe disability. 43% had normal results on a neurological examination, Gross Motor Function Classification Scale score = 0, mental processing composite > 85, and had neither severe visual nor hearing impairment. 57% qualified for regular schooling.

CONCLUSION

Improved survival was not associated with an increased risk of severe disability when compared with results of earlier publications. These findings may result from proactive management and are important for counseling patients at risk of imminent extremely preterm delivery.

Caregivers attitudes for very premature infants: what if they knew?

BACKGROUND

Decisions about resuscitation of extremely premature babies are controversial. Such decisions may reflect poor understanding of outcomes.

OBJECTIVE

To compare caregivers' attitudes towards the resuscitation of a premature infant if they are only told the infant's gestational age or if they are only given prognostic information for infants at that gestational age.

DESIGN/METHODS

Residents and nurses involved in perinatal care were asked whether they would resuscitate a depressed AGA 24-week gestation infant at birth. In another question they were asked whether they would resuscitate a depressed preterm infant with a 50% chance of survival, knowing that of those who survived, 50% would have a development 'within normal limits', 20-25% a serious handicap and 40% with behavioural and/or learning disability.

RESULTS

Two hundred and seventy-nine caregivers responded (91% response rate). In the scenario that only presented gestational age, 21% of respondents would resuscitate. In the scenario that only presented prognostic statistics, 51% of respondents would resuscitate (p<0.05).

CONCLUSIONS

Providers of perinatal health care respond to vignettes differently depending upon the format in which information is provided. The relative unwillingness to resuscitate a baby of 24-week gestation is surprising since outcomes for such babies are the same or better than those we described in the scenario that provided only outcome data without specifying gestational age. Two explanations are possible: (1) respondents have irrational negative associations with low gestational ages or (2) respondents are unaware of actual outcomes.

Treatment of preterm infants at the lower margin of viability--a comparison of guidelines in German speaking countries

INTRODUCTION

The treatment of preterm infants at the lower margin of viability is carried out amid growing tension between increasing survival rates, uncertain clinical outcomes, and financial and ethical considerations. The three German speaking countries have released guidelines on this issue, based on a previous common guideline. That is why the differences in national guidelines between the three countries is of peculiar interest in respect of medical ethics.

METHODS

Current guidelines from Germany, Switzerland, and Austria were compared and similarities and differences discussed.

RESULTS

The three countries' guidelines follow broadly similar principles, with almost identical intellectual underpinnings and formulations. Some national differences are apparent, nevertheless.

DISCUSSION

All three guidelines call for a pragmatic approach. National guidelines can only predetermine the framework, with long-term collection of sound local data on morbidity and mortality forming a prerequisite for decision-making, and also in discussions with parents.

PAPP-A levels as an early marker of idiopathic preterm birth: a pilot study

OBJECTIVE

To evaluate late PAPP-A levels as predictive of preterm birth in symptomatic women.

STUDY DESIGN

Prospective cohort study of singleton gestations, 23 to 34 weeks, and symptoms of preterm labor. PAPP-A, IGF-I and IGF-III analysis were performed. Primary end point was delivery < or =7 days. Accuracy and optimally predictive PAPP-A values were based on receiver operator characteristic (ROC) curves.

RESULT

In all, 26 women (51%) delivered < or =7 days post-admission (Group 1); 25 women (49%) >7 days (Group 2). Group 1 mean PAPP-A=38 000 vs 55 333 for Group 2 (P<0.04). Group 1 mean gestational age at delivery=29 weeks vs 37 weeks for Group 2 (P<0.00014). PAPP-A level < or =30,000 mU l(-1) had highest specificity (88%), sensitivity (50%), and positive predictive (81%) and negative predictive (62%) values for delivery < or =7 days. ROC area under curve=0.703.

CONCLUSION

PAPP-A levels < or =30,000 mU l(-1) at admission was associated with increased risk for preterm birth < or =7 days, supporting active management and therapeutic approach in these women.

FGF-10 is decreased in bronchopulmonary dysplasia and suppressed by Toll-like receptor activation

Many extremely preterm infants continue to suffer from bronchopulmonary dysplasia, which results from abnormal saccular-stage lung development. Here, we show that fibroblast growth factor-10 (FGF-10) is required for saccular lung development and reduced in the lung tissue of infants with bronchopulmonary dysplasia. Although exposure to bacteria increases the risk of bronchopulmonary dysplasia, no molecular target has been identified connecting inflammatory stimuli and abnormal lung development. In an experimental mouse model of saccular lung development, activation of Toll-like receptor 2 (TLR2) or Toll-like receptor 4 (TLR4) inhibited FGF-10 expression, leading to abnormal saccular airway morphogenesis. In addition, Toll-mediated FGF-10 inhibition disrupted the normal positioning of myofibroblasts around saccular airways, similar to the mislocalization of myofibroblasts seen in patients with bronchopulmonary dysplasia. Reduced FGF-10 expression may therefore link the innate immune system and impaired lung development in bronchopulmonary dysplasia.