Limits of viability: definition of the gray zone

Limits of Viability: Perspectives of Portuguese Neonatologists and Obstetricians

INTRODUCTION

Advances in neonatal care have improved the prognosis in extremely preterm infants. The gestational age considered for active treatment has decreased globally. Despite implemented guidelines, several studies show variability in practice. The aim of this study was to understand theperspectives of Portuguese neonatologists and obstetricians regarding the management of extremely preterm infants.

METHODS

An online survey was sent through the Portuguese Neonatology Society and the Portuguese Society of Obstetrics and Maternal-Fetal Medicine from August to September 2023.

RESULTS

We obtained 117 responses: 53% neonatologists, 18% pediatricians, and 29% obstetricians, with 62% having more than 10 years of experience. The majority (80%) were familiar with the Portuguese Neonatology Society consensus on the limits of viability and 46% used it in practice; 62% were unaware of Portuguese morbidity-mortality statistics associated with extremely preterm infants. Most (91%) informed parents about morbiditymortality concerning the gestational age more frequently upon admission (64%) and considered their opinion in the limit of viability situations (95%). At 22 weeks gestational age, 71% proposed only comfort care, while at 25 and 26 weeks, the majority suggested active care (80% and 96%, respectively). Less consensus was observed at 23 and 24 weeks. At 24 weeks, most obstetricians offered active care with the option of comfort care by parental choice (59%), while the neonatology group provided active care (65%), p < 0.001. Regarding the lower limit of gestational age for in utero transfer, corticosteroid administration, cesarean section for fetal indication, neonatologist presence during delivery, and endotracheal intubation; neonatologists considered a lower gestational age than obstetricians (23 vs 24 weeks; p = 0.036; p < 0.001; p < 0.001; p = 0.021; p < 0.001, respectively).

CONCLUSION

Differences in perspectives between obstetricians and neonatologists in limits of viability situations were identified. Neonatologists considered a lower gestational age in various scenarios and proposed active care earlier. Standardized counseling for extremely preterm infants is crucial to avoid ambiguity, parental confusion, and conflicts in perinatal care.

Estimation of the causal effect of sex on neonatal intensive care unit outcomes among very low birth weight infants

OBJECTIVE

Estimate the causal effect of sex on outcomes in the neonatal intensive care unit (NICU) among very low birth weight (VLBW) infants.

STUDY DESIGN

Retrospective cohort study using Vermont Oxford Network data to compare NICU outcomes for VLBW males versus females. Odds ratios (OR) for outcomes that differed significantly by sex were computed using standard unweighted analysis and inverse probability weighted (IPW) analysis to correct for selection bias.

RESULTS

Using standard analysis, males were significantly more likely to die before discharge and experience six other adverse outcomes. From IPW analysis, male sex caused a 56% increase in the odds of death before discharge (OR = 1.56, 95% confidence interval: 1.18-1.94). Standard unweighted results were significantly biased towards increased risk of adverse outcomes for males (p = 0.005) compared to IPW results for which three outcomes were no longer significantly associated with male sex.

CONCLUSION

Standard statistical methods generally overestimate the casual effect of sex among VLBW infants.

FIVE-YEAR VISUAL OUTCOME OF TREATMENT FOR RETINOPATHY OF PREMATURITY IN INFANTS WEIGHING <500 G AT BIRTH: A Multicenter Cohort Study From J-CREST

PURPOSE

To investigate the 5-year treatment outcomes of retinopathy of prematurity in infants <500 g birth weight and compare laser and anti-vascular endothelial growth factor therapies.

METHODS

A multicenter retrospective study comprised 24 eyes of 13 patients treated for Type 1 retinopathy of prematurity, followed for 5 years. Initial treatment was laser and anti-vascular endothelial growth factor in 13 and 11 eyes, respectively. Data collected included sex, birth characteristics, retinopathy of prematurity characteristics at the time of treatment, best-corrected visual acuity (BCVA), spherical equivalent, and astigmatism at 5 years posttreatment.

RESULTS

Median BCVA was 0.15 logarithm of the minimum angle of resolution (interquartile range, 0.0-0.5). Snellen BCVA was ≥20/40 in 73% and ≥20/20 in 27% of eyes. Median spherical equivalent was -2.37 (interquartile range, -6.1 to -0.1); 75% had myopia (≤-0.5 D), and 25% had high myopia (≤-6.0 D). Median astigmatism was 1.25 (interquartile range, 0.9-3.0); 46% had ≥1.5 D. Anti-vascular endothelial growth factor-treated eyes showed less myopia ( P < 0.009), with no BCVA or astigmatism difference ( P = 0.997, P = 0.271) compared with laser-treated eyes.

CONCLUSION

One-quarter of the eyes exhibited good visual acuity (Snellen BCVA of ≥20/20) 5 years after retinopathy of prematurity treatment. Refractive errors were common. Anti-vascular endothelial growth factor therapy may be superior to laser therapy in myopic refractive error.

A scoping review and narrative synthesis of neonatal skin injury severity scales

BACKGROUND

Mechanical force skin injuries are common for critical care patients, especially neonates. Currently, identification and severity assessments of injuries are dependent on clinical experience and/or utilization of severity tools. Compared with adults, neonates sustain skin injuries in different anatomical locations and have decreased layers of healthy tissue (from 0.9 to 1.2 mm) creating questions around direct application of adult injury severity scales reliant on visual assessment.

AIMS

The aim of this scoping review (ScR) was to investigate severity scales used to report hospital acquired skin injuries for neonates.

METHODS

This study utilized the 2015 Joanna Briggs Institute methodology for scoping reviews and is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews extension. PubMed, CINAHL, COCHRANE Central, Scopus, and the reference lists of included studies were searched for studies published between 2001 and 2023, that included severity scales use within neonatal population. Two authors independently identified studies for full review, data extraction, and quality assessment.

RESULTS

A systematic database search returned 1163 records. After full test review of 109 studies, 35 studies were included. A majority of studies included were cohort or action research and conducted in the United States of America. Most studies (57%, n = 20) reported skin injuries acquired throughout the body, 14 (40%) of the studies reported the nasal area alone and one study reported no anatomical location. A total of nine severity scales or combination of scales were utilized within studies (n = 31) and four studies did not report a scale. Various versions of scales from the National Pressure Ulcer Advisory Panel (n = 16), European Pressure Ulcer Advisory Panel (n = 8) or Neonatal Skin Condition Score (n = 4) were reported, compared with locally developed classifications/scales (n = 4). Scales were predominantly of ordinal grouping (74%, n = 26) or categorical assessment (14%, n = 5). Only one scale from 2004 was validated for neonates.

CONCLUSION

Neonatal skin injuries will continue to be reported subjectively until severity scales are consistently applied or other measurements are identified to support assessment. Additionally, without skin injury assessment uniformity, critical examination of effectiveness of skin care treatment practices will have subjective comparison. This review suggests there is a need for consistent skin assessment and severity scales that are valid for the neonatal population and their unique skin considerations.

Differences in the attitudes towards resuscitation of extremely premature infants between neonatologists and obstetricians: a survey study in China

Objectives

Neonatologists and obstetricians are crucial decision-makers regarding the resuscitation of extremely preterm infants (EPIs). However, there is a scarcity of research regarding the differing perspectives on EPI resuscitation between these medical professionals. We aim to determine the differences and influential factors of their attitudes towards EPIs resuscitation in China.

Methods

This cross-sectional study was conducted in public hospitals of 31 provinces in Chinese mainland from June to July 2021. Influential factors of binary variables and those of ordinal variables were analyzed by modified Poisson regression models and multinomial logistic regression models due to the invalid parallel line assumption of ordinal logistic regression models.

Results

A total of 832 neonatologists and 1,478 obstetricians who were deputy chief physicians or chief physicians participated. Compared with obstetricians, neonatologists delivered a larger proportion of infants of <28-week gestational age (87.74% vs. 84.91%) and were inclined to think it inappropriate to use 28 weeks as the cutoff of gestational age for providing full care to premature infants [63.34% vs. 31.60%, adjusted prevalence ratio = 1.61 (95% CI: 1.46-1.77)], and to suggest smaller cutoffs of gestational age and birth weight for providing EPIs resuscitation. Notably, 46.49% of the neonatologists and 19.01% of the obstetricians believed infants ≤24 weeks' gestation should receive resuscitation.

Conclusions

In China, notable disparities exist in attitudes of neonatologists and obstetricians towards resuscitating EPIs. Strengthening collaboration between these two groups and revising the pertinent guidelines as soon as possible would be instrumental in elevating the resuscitation rate of EPIs.

The analysis of pregnancies terminated before and after the limit of viability: A medicolegal view

PURPOSE

In the present study, the purpose was to determine the indications of pregnancy termination procedures that are performed before and after the limit of viability (between 10 and 22 weeks) in a tertiary center and to investigate the characteristics of the cases in which fetocide procedure was offered after the limit of viability (22 weeks and later). It also aimed to discuss the legal deadline for the fetocide procedure and legal aspect of pregnancy termination.

MATERIAL AND METHOD

The present study was conducted as a result of the retrospective examination of 198 cases who underwent pregnancy termination after the 10th week of pregnancy (the legal limit for voluntary termination of pregnancy in our country) in our clinic and met the study criteria. The cases were divided into two main groups as Early Termination (10-22 weeks) and Late Termination (22 weeks and later). The characteristics of these groups (i.e. reason for termination, termination week) and the characteristics of the cases in which fetocide procedure was performed and the cases that were not (i.e. termination week, reasons for termination) were compared.

RESULTS

A total of 171 (86%) cases were under 22 weeks and 27 (14%) were 22 weeks or more. In the cases terminated early, the gestational week was found to be highest [20 + 1 (12+3-21 + 1)] in those with preterm premature rupture of membranes, and lowest in those with fetal gastrointestinal abnormalities. No statistically significant differences were detected between the termination reason and the gestational week in the late-terminated group, and also, although the termination week of 5 patients for whom the fetocide procedure was offered [median = 23 + 1 (22+4-26 + 0] was higher than the week of 22 patients for whom the fetocide procedure was not offered [median = 22 + 4 (22+1-25 + 4], the difference was not found to be statistically significant.

CONCLUSION

Since the majority of pregnancy terminations are performed before the viable period, the need for the fetocide procedure in pregnancy terminations is relatively low, and we think that this rate will decrease even more because the rate of early diagnosis of fetal anomalies increases as a result of developments in ultrasonographic imaging. Families who choose the termination of pregnancy search for other countries with appropriate legislation and the loss of time and the indecision of the family might cause the application of pregnancy termination after the viable period because of the limitations in the legal regulations of countries.

Design and In Vitro Evaluation of an Artificial Placenta Made From Hollow Fiber Membranes

For infants born at the border of viability, care practices and morbimortality rates vary widely between centers. Trends show significant improvement, however, with increasing gestational age and weight. For periviable infants, the goal of critical care is to bridge patients to improved outcomes. Current practice involves ventilator therapy, resulting in chronic lung injuries. Research has turned to artificial uterine environments, where infants are submerged in an artificial amniotic fluid bath and provided respiratory assistance via an artificial placenta. We have developed the Preemie-Ox, a hollow fiber membrane bundle that provides pumpless respiratory support via umbilical cord cannulation. Computational fluid dynamics was used to design an oxygenator that could achieve a carbon dioxide removal rate of 12.2 ml/min, an outlet hemoglobin saturation of 100%, and a resistance of less than 71 mmHg/L/min at a blood flow rate of 165 ml/min. A prototype was utilized to evaluate in-vitro gas exchange, resistance, and plasma-free hemoglobin generation. In-vitro gas exchange was 4% higher than predicted results and no quantifiable plasma-free hemoglobin was produced.

Dutch guidelines on care for extremely premature infants: Navigating between personalisation and standardization

OBJECTIVE

There is no international consensus on what type of guideline is preferred for care at the limit of viability. We aimed to conceptualize what type of guideline is preferred by Dutch healthcare professionals: 1) none; 2) gestational-age-based; 3) gestational-age-based-plus; or 4) prognosis-based via a survey instrument. Additional questions were asked to explore the grey zone and attitudes towards treatment variation.

FINDING

769 surveys were received. Most of the respondents (72.8%) preferred a gestational-age-based-plus guideline. Around 50% preferred 24^+0/7 weeks gestational age as the lower limit of the grey zone, whereas 26^+0/7 weeks was the most preferred upper limit. Professionals considered treatment variation acceptable when it is based upon parental values, but unacceptable when it is based upon the hospital's policy or the physician's opinion.

CONCLUSION

In contrast to the current Dutch guideline, our results suggest that there is a preference to take into account individual factors besides gestational age.

Viability and thresholds for treatment of extremely preterm infants: survey of UK neonatal professionals

BACKGROUND

Decisions about treatments for extremely preterm infants (EPIs) born in the 'grey zone' of viability can be ethically complex. This 2020 survey aimed to determine views of UK neonatal staff about thresholds for treatment of EPIs given a recently revised national Framework for Practice from the British Association of Perinatal Medicine.

METHODS

The online survey requested participants indicate the lowest gestation at which they would be willing to offer active treatment and the highest gestation at which they would withhold active treatment of an EPI at parental request (their lower and upper thresholds). Relative risks were used to compare respondents' views based on profession and neonatal unit designation. Further questions explored respondents' conceptual understanding of viability.

RESULTS

336 respondents included 167 consultants, 127 registrars/fellows and 42 advanced neonatal nurse practitioners (ANNPs). Respondents reported a median grey zone for neonatal resuscitation between 22⁺¹ and 24⁺⁰ weeks' gestation. Registrars/fellows were more likely to select a lower threshold at 22⁺⁰ weeks compared with consultants (Relative Risk (RR)=1.37 (95% CI 1.07 to 1.74)) and ANNPs (RR=2.68 (95% CI 1.42 to 5.06)). Those working in neonatal intensive care units compared with other units were also more likely to offer active treatment at 22⁺⁰ weeks (RR=1.86 (95% CI 1.18 to 2.94)). Most participants understood a fetus/newborn to be 'viable' if it was possible to survive, regardless of disability, with medical interventions accessible to the treating team.

CONCLUSION

Compared with previous studies, we found a shift in the reported lower threshold for resuscitation in the UK, with greater acceptance of active treatment for infants <23 weeks' gestation.

Survival and Morbidities in Infants with Birth Weight Less than 500 g: a Nationwide Cohort Study

BACKGROUND

This study aimed to investigate the survival and morbidities of infants in the Korean Neonatal Network (KNN) with birth weight (BW) < 500 g.

METHODS

The demographic and clinical data of 208 live-born infants with a BW < 500 g at a gestational age of ≥ 22 weeks who were treated in the neonatal intensive care units of the KNN between 2013 and 2017 were reviewed.

RESULTS

The survival rate of the infants was 28%, with a median gestational age and BW of 243/7 weeks (range, 220/7-336/7) and 440 g (range, 220-499), respectively. Multivariable Cox proportional hazards analysis demonstrated that survival to discharge was associated with longer gestation, higher BW, female sex, singleton gestation, use of any antenatal corticosteroids, and higher Apgar scores at 5 minutes. The overall survival rates were significantly different between the BW categories of < 400 g and 400-499 g. However, there was no significant difference in the incidence of any morbidity between the BW groups. Half of the deaths of infants with BW < 500 g occurred within a week of life, mainly due to cardiopulmonary and neurologic causes. The major causes of death in infants after 1 week of age were infection and gastrointestinal disease. Among the surviving infants, 79% had moderate to severe bronchopulmonary dysplasia, 21% underwent surgical ligation of patent ductus arteriosus, 12% had severe intraventricular hemorrhage (grade III-IV), 38% had sepsis, 9% had necrotizing enterocolitis (stage ≥ 2), and 47% underwent laser treatment for retinopathy of prematurity. The median length of hospital stay was 132 days (range, 69-291), and 53% required assistive devices at discharge.

CONCLUSION

Despite recent advances in neonatal intensive care, the survival and morbidity rates of infants with BW < 500 g need further improvement.

Adverse Pregnancy Outcomes Following the Assassination of John F. Kennedy in 1963

INTRODUCTION

Women exposed to stressful events during pregnancy are thought to be at increased risk of adverse birth outcomes. However, studies investigating stressful events are often unable to control for important confounders, such as behavioral and genetic characteristics, or to isolate the impact of the stressor from other secondary effects. We used a discordant-sibling design, which provides stronger inferences about causality, to examine whether a widespread stressor with limited impact on day-to-day life (John F. Kennedy assassination) resulted in an increased risk of adverse birth outcomes.

METHODS

Data were obtained from the Collaborative Perinatal Project, a prospective, multi-site cohort study conducted in the US from 1959 to 1965. Our analysis was restricted to singleton live births ≥24 weeks born before the assassination (n = 24,406) or in utero at the time (n = 5833). We also evaluated associations within siblings discordant for exposure (n = 1144). We used survival analysis to evaluate associations between exposure and preterm birth and marginal models to evaluate associations with birthweight and placental pathology.

RESULTS

First trimester exposure was associated with preterm birth (hazard ratio (HR): 1.17; 95% CI: 1.05, 1.31). In the discordant-sibling model, the point estimate was similar (HR: 1.22; 95% CI: 0.36, 4.06). Third trimester exposure was associated with increased odds of fetal acute inflammation in the placenta (odds ratio (OR): 1.34, 95% CI: 1.05, 1.71).

CONCLUSIONS FOR PRACTICE

First trimester exposure to an acute stressor was associated with preterm birth. We did not observe increased odds of placental pathology with first trimester exposure; however, stress may increase preterm birth risk through chronic placental inflammation, which was not evaluated in this sample.

When should intensive care be provided for the extremely preterm infants born at the margin of viability? A survey of Australasian parents and clinicians

AIM

This study aimed to explore clinician and parent opinions of risk limits on resuscitation and intensive care (IC) for extremely premature infants born at the margin of viability.

METHODS

Two anonymous on-line surveys were conducted from August 2016 to January 2017. Survey participants were: (i) clinicians affiliated with neonatal intensive care units in Australia; and (ii) parents or individuals who expressed interest in premature babies through the Facebook page of Miracle Babies Foundation.

RESULTS

A total of 961 responses were received. Among 204 clinicians, 52% were neonatologists, 22% obstetricians, 20% neonatal intensive care unit nurses and 4% were midwives. Among 757 parents, 98% had a premature baby. Only 75% of clinicians responded to the risk limits questions. Median mortality risk above which they would not recommend resuscitation/IC was 70% (interquartile range (IQR) 50-80%); major disability risk in survivors 60% (IQR 50-75%); and composite risk of mortality and major disability 70% (IQR 50-80%). All parents answered the risk limit questions. The median mortality risk for not planning resuscitation was 90% (IQR 60-90%); major disability risk in survivors 50% (IQR 30-90%); and composite risk 90% (IQR 50-90%). Most clinicians (82%) stated that decisions should be guided by parent opinions if there are uncertainties. Parents had varying perception of previous counselling, and 57% stated that both their viewpoint and doctor's predicted risk influenced their decision-making.

CONCLUSIONS

Clinicians and parents had different views on mortality and major disability risks when deciding on resuscitation/neonatal IC treatment. When there was uncertainty, both agreed on working together.

Case Report: Treatment of Extremely Preterm Infants With Birthweight Below 300 g: Case Series

Reports on the birth of infants weighing <300 g are quite rare and little is known about the best practices in treating such micropreemies. Therefore, we report here on three cases of low birthweight infants weighing <300 g, of whom two infants survived. The birthweights and gestational ages were ranging 279-293 g and 22 + 6/7 - 23 + 6/7 weeks, respectively. All the infants had severe fetal growth restriction and prematurity. The infant in case 1 died of hepatic rupture, perhaps due to birth trauma, which emphasized the need for less invasive obstetric procedures including en caul delivery. The infant in case 2 managed to survive through severe prematurity secondary to hydrops fetalis. However, complications followed soon as tracheal granulation tissue was formed with neurodevelopmental impairment. The infant in case 3 was born recently and her clinical course was less remarkable without severe complications, despite having the least gestational age and birthweight among the three patients. The improved care protocols for extremely low birthweight infants over these years through experiential learning including that with cases 1 and 2 may have ensured the better outcome of case 3. Accumulating evidence and recording the experience of such cases with continuous constructive discussion can contribute to better outcomes and appropriate parental counseling for extremely small babies in the future.

Prediction of In-Hospital Mortality After 24 Hours in Very Low Birth Weight Infants

BACKGROUND AND OBJECTIVES

The existing prediction formulas for in-hospital mortality of very low birth weight (VLBW) infants were mostly developed in the 1990s or 2000s and thus may not reflect the recently improved levels of neonatal care. We conducted this study to build a model for predicting the in-hospital mortality using perinatal factors available soon after birth.

METHODS

We gathered data on VLBW infants from the Korean Neonatal Network, a nationwide, prospective, Web-based registry that enrolled patients from 2013 to 2017. Perinatal variables that were significantly associated with mortality in univariate logistic regression or those with apparent clinical importance were included in the multivariable logistic regression model. The final formula was constructed by considering the collinearity, parsimony, goodness of fit, and clinical interpretation.

RESULTS

A total of 9248 VLBW infants were analyzed, including 1105 (11.9%) who died during hospitalization. The mean gestational age was 29.0 ± 2.9 weeks and the mean birth weight was 1096 ± 280 g. Significant variables used in the final equation included polyhydramnios, oligohydramnios, gestational age, Apgar score at 1 minute, intubation at birth, birth weight, and base excess. In internal validation, the area under the curve (AUC) for the prediction of in-hospital mortality was 0.870 and the optimism-corrected AUC was 0.867. The prediction equation revealed good discrimination and calibration in the external validation as well (AUC: 0.876).

CONCLUSIONS

The newly developed Korean Neonatal Network prediction formula for in-hospital mortality could be a useful tool in counseling by providing a reliable prediction for the in-hospital mortality of VLBW infants.

A Model of Germinal Matrix Hemorrhage in Preterm Rat Pups

Germinal matrix hemorrhage (GMH) is a serious complication in extremely preterm infants associated with neurological deficits and mortality. The purpose of the present study was to develop and characterize a grade III and IV GMH model in postnatal day 5 (P5) rats, the equivalent of preterm human brain maturation. P5 Wistar rats were exposed to unilateral GMH through intracranial injection into the striatum close to the germinal matrix with 0.1, 0.2, or 0.3 U of collagenase VII. During 10 days following GMH induction, motor functions and body weight were assessed and brain tissue collected at P16. Animals were tested for anxiety, motor coordination and motor asymmetry on P22–26 and P36–40. Using immunohistochemical staining and neuropathological scoring we found that a collagenase dose of 0.3 U induced GMH. Neuropathological assessment revealed that the brain injury in the collagenase group was characterized by dilation of the ipsilateral ventricle combined with mild to severe cellular necrosis as well as mild to moderate atrophy at the levels of striatum and subcortical white matter, and to a lesser extent, hippocampus and cortex. Within 0.5 h post-collagenase injection there was clear bleeding at the site of injury, with progressive increase in iron and infiltration of neutrophils in the first 24 h, together with focal microglia activation. By P16, blood was no longer observed, although significant gray and white matter brain infarction persisted. Astrogliosis was also detected at this time-point. Animals exposed to GMH performed worse than controls in the negative geotaxis test and also opened their eyes with latency compared to control animals. At P40, GMH rats spent more time in the center of open field box and moved at higher speed compared to the controls, and continued to show ipsilateral injury in striatum and subcortical white matter. We have established a P5 rat model of collagenase-induced GMH for the study of preterm brain injury. Our results show that P5 rat pups exposed to GMH develop moderate brain injury affecting both gray and white matter associated with delayed eye opening and abnormal motor functions. These animals develop hyperactivity and show reduced anxiety in the juvenile stage.

Joint periviability counseling between neonatology and obstetrics is a rare occurrence

OBJECTIVE

To investigate the frequency with which neonatal and maternal-fetal medicine (MFM) providers perform joint periviability counseling (JPC), compare content of counseling, and identify perceived barriers to JPC.

STUDY DESIGN

An anonymous REDCap survey was e-mailed to members of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine and to members of the Society for MFM.

RESULTS

There were 424 neonatal and 115 MFM participants. Fifty-two percent of neonatal and 35% of MFM respondents reported rarely/never performing JPC (p < 0.001), while 80% and 82%, respectively felt it would improve counseling. Content of counseling was similar, except for length of stay with 93% of neonatal vs. 85% of MFM respondents addressing this (p = 0.03). The majority (>60%) of respondents in both groups reported that clinical duties posed a significant/great barrier to JPC.

CONCLUSION

JPC is recommended but infrequently performed, with both specialties interested in further collaboration to strengthen the counseling provided.

Outcomes of preterm infants born with marginal viability in a University Hospital in Thailand

AIM

Reports of the outcomes of infants born with marginal viability in developing countries are limited. This study aimed to determine the mortality rate and major disabilities of extremely preterm infants.

METHODS

A retrospective cohort with a prospective part of neurodevelopmental assessment was performed in infants born at 23-25⁺⁶ weeks' gestational age (GA) who received active resuscitation and were admitted to neonatal intensive care unit during 2005-2015. Surviving infants were recruited for neurodevelopmental assessment including cognition, gross motor and neurosensory disorders. Major disability was defined as one of the following: severe cognitive impairment, severe cerebral palsy, blindness or deafness.

RESULTS

A total of 67 infants were enrolled (8, 22 and 37 in the 23, 24 and 25 weeks' GA groups, respectively). The overall mortality rate before discharge was 26%. Infants in the 23 and 24 weeks' GA groups had a significantly higher mortality rate than did those in the 25 weeks' GA group (42 vs. 10%). Of 50 survivors (aged 2-12 years), 3 and 2 had blindness and deafness, respectively. Cognitive function assessment in 37 survivors showed that 4 (11%) and 15 (40%) had severe and borderline cognitive impairment, respectively. Death or major disability was found in 100, 63 and 38% in the 23, 24 and 25 weeks' GA groups, respectively.

CONCLUSION

In our centre, infants born at 23-24 weeks had a much higher chance of death or major disability than those born at 25 weeks' GA. Given such information, active management should be offered together with the family's involvement.

[Epidemiological difference could explain the higher infant mortality in Chile compared with Cuba]

INTRODUCTION

Cuba has the lowest infant mortality rate in Latin America, while Chile has an infant mortality rate above the average of Organization for Economic Cooperation and Development (OECD) countries.

OBJECTIVE

To compare the epidemiology of infant mortality between Chile and Cuba in order to find characteristics that may explain the differences found.

METHOD

Comparative analysis between Chile and Cuba of infant mortality rate, causes of mortality, live birth weight, and maternal age, in 2015.

RESULTS

Cuba had a lower infant, neonatal, early and late mortality than Chile, with no differences in post-neonatal mortality. Chile had a higher infant mortality due to, alterations of the nervous system, urinary system, chromosomal alterations, respiratory distress syndrome, and disorders related to the short duration of gestation. Chile had a higher frequency of mothers ≥ 35 years old and live births weighing <2,500 g. The possible effects of health inequities could not be analyzed due to lack of data.

CONCLUSIONS

It is possible to attribute the lower infant mortality rate in Cuba to: selective abortion due to congenital malformations and chromosomal anomalies, lower epidemiological risk of the Cuban pregnant population, and lower frequency of live births with low birth weight.

Decision-making at the limit of viability

Babies born at the limit of viability have a high risk of morbidity and mortality. Despite great advances in science, the approach to these newborns remains challenging. Thus, this study reviewed the literature regarding the treatment of newborns at the limit of viability. There are several interventions that can be applied before and after birth to increase the baby's survival with the least sequelae possible, but different countries make different recommendations on the gestational age that each treatment should be given. There is more consensus on the extremities of viability, being that, at the lower extremity, comfort care is preferred and active care in newborns with higher gestational age. The higher the gestational age at birth, the higher the survival and survival without morbidity rates. At all gestational ages, it is important to take into account the suffering of these babies and to provide them the best quality of life possible. Sometimes palliative care is the best therapeutic approach. The parents of these babies should be included in the decision-making process, if they wish, always respecting their needs and wishes. Nevertheless, the process of having such an immature child can be very painful for parents, so it is also important to take into account their suffering and provide them with all the necessary support. This support should be maintained even after the death of the newborn.

Volume of Neonatal Care and Survival without Disability at 2 Years in Very Preterm Infants: Results of a French National Cohort Study

OBJECTIVES

To investigate the relation between neonatal intensive care unit (NICU) volume and survival, and neuromotor and sensory disabilities at 2 years in very preterm infants.

STUDY DESIGN

The EPIPAGE-2 (Etude Epidémiologique sur les Petits Âges Gestationnels-2) national prospective population-based cohort study was used to include 2447 babies born alive in 66 level III hospitals between 24 and 30 completed weeks of gestation in 2011. The outcome was survival without disabilities (levels 2-5 of the Gross Motor Function Classification System for cerebral palsy with or without unilateral or bilateral blindness or deafness). Units were grouped in quartiles according to volume, defined as the annual admissions of very preterm babies. Multivariate logistic regression analyses with population average models were used.

RESULTS

Survival at discharge was lower in hospitals with lower volumes of neonatal activity (aOR 0.55, 95% CI 0.33-0.91). Survival without neuromotor and sensory disabilities at 2 years increased with hospital volume, from 75% to 80.7% in the highest volume units. After adjustment for gestational age, small for gestational age, sex, maternal age, infertility treatment, multiple pregnancy, principal cause of prematurity, parental socioeconomic status, and mother's country of birth, survival without neuromotor or sensory disabilities was significantly lower in hospitals with a lower volume of neonatal activity (aOR 0.60, 95% CI 0.38-0.95) than in the highest quartile hospitals.

CONCLUSIONS

These results suggest that lower neonatal intensive care unit volume is associated with lower survival without an increase in disabilities at 2 years. These results could be useful to generate improvements of perinatal regionalization.

Active care of infants born between 22 and 26 weeks of gestation does not follow consensus expert recommendations

AIM

To determine the relationship between clinical practice and publication of an Australian consensus statement for management of extremely preterm infants in 2006.

METHODS

A population-based study using linked data from New South Wales, Australia for births between 22 + 0 and 26 + 6 weeks of gestation between 2000 and 2011.

RESULTS

There were 4746 births of whom 2870 were liveborn and 1876 were stillborn. Of the live births, 2041 (71%) were resuscitated, 1914 (67%) were admitted into a neonatal intensive care unit (NICU) and 1310 (46%) survived to hospital discharge. Thirty-nine (2%) stillbirths were resuscitated but none survived. No 22-week infant survived to hospital discharge. Fewer 23-week gestation infants were resuscitated between 2004 (52%) and 2005 (20%) but resuscitation rates increased by 2008 (44%). There was no difference at other gestations. Adjusted odds ratio (OR) for resuscitation was increased by birthweight (OR: 1.01), tertiary hospital birth (OR: 3.4) and Caesarean delivery (OR: 11.3) and decreased by rural residence (OR: 0.4) and male gender (OR: 0.7).

CONCLUSION

Expert recommendations may be shaped by clinical practice rather than the converse, especially for 23-week gestation infants. Recommendations should be revised regularly to include clinical practice changes.

Opinions of Argentinean neonatologists on the initiation of life-sustaining treatment in preterm infants

BACKGROUND

In June 2014, the Argentinean Ministry of Health published guidelines for the management of neonates born at the limit of viability (≤25 weeks of gestation). We explored the opinion of neonatologists in Buenos Aires, Argentina, regarding the initiation of life-sustaining treatment (LST) in critically ill neonates, focusing on the effect of sociocultural factors on their opinion.

METHODS

An anonymous survey was designed to explore the opinions of Argentinean neonatologists on whether or not to initiate LST in newborns born prematurely. Five hundred eighty neonatologists from 36 neonatal units were invited to participate, and 315 specialists from 34 neonatal units completed the survey (response rate 54%). The survey was conducted between June 2014 and February 2015.

RESULTS

9.5% (30/315) of the neonatologists answered they would begin LST on neonates born at 22 weeks, 42.5% (134/315) at 23 weeks, 37% (117/315) at 24 weeks, 7% (22/315) at 25 weeks, and 4% (12/315) at ≥26 weeks. Cumulatively then, 96% of participants stated they would start LST at 25 weeks of gestation or less. On multivariate analysis, a "transcendent" value of life and lack of consideration of the local legal framework for making medical decisions in the delivery room were statistically associated with an opinion in favor of initiation of LST in neonates born at the limit of viability. More than 50% of the Argentinean neonatologists surveyed answered they would initiate treatment at a gestational age of less than 23 weeks, despite the fact that the recommendations of the Argentinean Ministry of Health are to only give comfort care for these neonates. The opinion of most Argentinean neonatologists surveyed thus differs from that recommended by the guidelines of Argentina.

CONCLUSION

The most frequent opinion of Argentinean neonatologists was to initiate LST in neonates at the limit of viability. Certain factors, in particular the sense of a transcendent meaning to life and lack of consideration of the local legal framework for making medical decisions in the delivery room, seem to influence the decision to start LST.

Placental abruption and hemorrhage-review of imaging appearance

Placental and periplacental bleeding are common etiologies for antepartum bleeding. Placental abruption complicates approximately 1% of pregnancies and is associated with increased maternal, fetal, and neonatal morbidity and mortality. This article reviews the normal placental appearance on ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) and then discusses the different morphological appearance of placental and periplacental hematomas along with their mimics. Hematomas are classified based on the location as retroplacental, marginal subchorionic, preplacental (subamniotic), or intraplacental. Placenta-related bleeding is a common finding during first trimester ultrasound and its detection can help triage the pregnant females into low- and high-risk groups. This article reviews placenta related bleeding in the setting of trauma. Trauma can complicate pregnancy with potential severe maternal and fetal outcomes. CT is usually performed as part of the trauma workup and it can be challenging for placental evaluation. MRI can characterize the age of the hematomas and can differentiate hematomas from tumors.

Prospective study of early and late outcomes of extremely low birthweight in Central Saudi Arabia

BACKGROUND

Survival of preterm neonates has steadily improved over the past five decades, due to changes in the neonatal intensive care. However, in Saudi Arabia, there are no written guidelines on the definition of the lower limit of viability, and there has been a call for such a limit. The aims of this study were: (1) to determine lower limits of viability and survival in extremely low birthweight (ELBW) infants, and (2) to determine incidence of neurodevelopmental and cognitive abnormalities within 3-6 years after birth.

METHODS

Prospective study of all live inborn ELBW infants admitted to the neonatal unit of King Abdulaziz Medical City, Riyadh, Saudi Arabia, within 3 years [between January 1st, 2005 and December 31st, 2007] was conducted (n = 117). Data were collected on demographic and birth data, neonatal complications & interventions and death on discharge. Prospective follow up of all survivors was done, within 6 years after birth, to assess the outcome in terms of neurodevelopmental and cognitive abnormalities. Predictors of survival were determined using logistic regression model. Significance was considered at p-value ≤0.05.

RESULTS

Of all ELBW infants, 41% died before discharge. Survival rate was directly correlated with gestational age (GA) and birthweight (p < 0.05). The 50% limits of viability were those at 25 weeks' gestation or with > 600 g. After adjusting for possible confounders, significant predictors of survival were birthweight (p = 0.001) and Apgar score (p < 0.001). The following impairments were reported during follow up of survivors: developmental delay (39.2%), cerebral palsy (36.2%), speech problems (33.3%), wasting (12.5%), intellectual disability (10%), visual problems (6.6%) and hyperactivity (5.6%).

CONCLUSION

More than one-third of ELBW died before discharge from NICU, and two-thirds of survivors had one or more neurodevelopmental and/or cognitive abnormalities during their first 6 years of life. The 50% limits of viability of ELBW infants were those at week 25 of gestation or with a birthweight of more than 600 g. Birthweight could be considered as more valid than gestational age in the prediction of viability of ELBW infants. The process of care of ELBW infants in Saudi Arabia may need to be revisited taking these findings into consideration.

Initial Metabolic Profiles Are Associated with 7-Day Survival among Infants Born at 22-25 Weeks of Gestation

OBJECTIVE

To evaluate the association between early metabolic profiles combined with infant characteristics and survival past 7 days of age in infants born at 22-25 weeks of gestation.

STUDY DESIGN

This nested case-control consisted of 465 singleton live births in California from 2005 to 2011 at 22-25 weeks of gestation. All infants had newborn metabolic screening data available. Data included linked birth certificate and mother and infant hospital discharge records. Mortality was derived from linked death certificates and death discharge information. Each death within 7 days was matched to 4 surviving controls by gestational age and birth weight z score category, leaving 93 cases and 372 controls. The association between explanatory variables and 7-day survival was modeled via stepwise logistic regression. Infant characteristics, 42 metabolites, and 12 metabolite ratios were considered for model inclusion. Model performance was assessed via area under the curve.

RESULTS

The final model included 1 characteristic and 11 metabolites. The model demonstrated a strong association between metabolic patterns and infant survival (area under the curve [AUC] 0.885, 95% CI 0.851-0.920). Furthermore, a model with just the selected metabolites performed better (AUC 0.879, 95% CI 0.841-0.916) than a model with multiple clinical characteristics (AUC 0.685, 95% CI 0.627-0.742).

CONCLUSIONS

Use of metabolomics significantly strengthens the association with 7-day survival in infants born extremely premature. Physicians may be able to use metabolic profiles at birth to refine mortality risks and inform postnatal counseling for infants born at <26 weeks of gestation.

Trends in Mortality and Morbidity in Infants Under 500 Grams Birthweight: Observations from Our Neonatal Intensive Care Unit (NICU)

BACKGROUND In our previous study, some changes were presented in obstetric care and we studied the morbidity and mortality trends of infants with <500 grams birth weight. Several neonatal protocol changes occurred during the study period. The aim of this study was to analyze the changes in mortality and morbidity of premature infants in light of changing neonatal protocols. MATERIAL AND METHODS We performed a retrospective study of premature infants with <500 grams birth weight, born at our department between 2006 and 2015. We divided the study period into two 5-year epochs and compared mortality and morbidity rates. We calculated the duration of mechanical ventilation and non-invasive respiratory support, and also investigated the potential impact of the differences in clinical practice. RESULTS The survival rate was 30.8% during first epoch, which was significantly lower than the 70.4% survival rate during second epoch. There was no difference in the rate of complications between the 2 epochs. The total number of ventilator and non-invasive ventilation days was significantly lower in the second epoch. CONCLUSIONS We found significant differences in survival rates but no change in the incidence of morbidities between the 2 epochs. Therefore, although the number of neonates surviving with morbidities has increased, so did the number of those with intact survival. The increased survival of infants born with <500 grams birth weight is not associated with increased rate of morbidities. Protocol changes may have contributed to these findings; however, in a retrospective study it is not possible to separate the impact of individual changes.

Very preterm born children at early school age: Healthcare therapies and educational provisions

AIM

To explore changes in motor and cognitive outcomes in very preterm (VP; gestational age<30weeks) born children between ages five and six years, and to determine whether changes in these outcomes were associated with the use of healthcare therapies and educational provisions.

STUDY DESIGN

Single-center observational cohort study. Five-year-old VP born children of a one-year-cohort of our neonatal follow-up program (N=90) were invited for re-assessments at age six. Use of healthcare therapies and educational provisions was registered at ages five and six years. Motor function (Movement Assessment Battery for Children-2 [M-ABC-2]; higher scores indicate better functioning) and IQ (Wechsler Preschool and Primary Scale for Intelligence [WPPSI-III-NL]) were assessed at both ages.

RESULTS

Sixty-four VP born children were seen at ages five and at six years. In this year, 61% received healthcare therapies and/or educational provisions. M-ABC-2 scores of VP born children who received healthcare therapy and/or educational provisions were significantly higher (M=8.9 [SD=3.2]) at age six years than at age five years (M=7.5 [SD=3.3]); p<0.00). M-ABC-2 scores remained stable in the average range in VP born children without any support. IQ scores remained stable irrespective of received support.

CONCLUSIONS

Improvements in motor outcomes are associated with the use of healthcare therapies and/or educational support between ages five and six years in VP born children. Future studies need to determine the efficacy of existing interventions, and to develop tailored interventions to support VP born children in the transfer period from preschool to primary education.

Proactive approach at the limits of viability improves the short-term outcome of neonates born after 23 weeks' gestation

OBJECTIVE

The aim of this single-center study was to identify factors that affect the short-term outcome of newborns delivered around the limits of viability.

METHODS

A group of 137 pregnant women who gave birth between 22+0/7 and 25+6/7 weeks of gestation was retrospectively studied. The center supports a proactive approach to infants around the limits of viability. Perinatal and neonatal characteristics were obtained and statistically evaluated.

RESULTS

A total of 166 live-born infants were enrolled during a 6-year period; 162 (97.6%) of them were admitted to the neonatal intensive care unit (ICU) and 119 (73.5%) survived until discharge. The decrease in neonatal mortality was associated with an advanced gestational age (P<0.001) and a completed course of corticosteroids (P=0.002). Neonatal morbidities were common among infants of all gestational ages. The incidence of severe intraventricular hemorrhage significantly depended on gestational age (P<0.001) and a completed course of corticosteroids (P=0.002). Survival without severe neonatal morbidities was 39.5% and occurred mostly after 24+0/7 weeks of gestation.

CONCLUSION

The short-term outcome of newborns delivered around the limits of viability is mostly affected by gestational age and antenatal corticosteroid treatment. A consistently proactive approach improves the survival of infants at the limits of viability. This is most pronounced in cases where the delivery is delayed beyond 24 completed gestational weeks.

Antenatal consultations for preterm labour: how are future mothers reassured?

OBJECTIVE

To evaluate whether the antenatal consultation for preterm labour worries or reassures women, and to identify factors contributing to these feelings.

DESIGN

This is a prospective survey study from April 2012 to September 2013. This mixed-methodology tool was co-constructed with patients and first tested in a single-centre pilot study.

SETTING

Three university-affiliated, tertiary care, high-risk obstetrics inpatient units in Quebec, Canada.

PARTICIPANTS

Women hospitalised with threatened preterm labour between 26 and 32 weeks' gestational age completed the survey within 72 hours of an antenatal consultation by neonatology. 341 women were invited to participate and 226 mothers completed the survey (72% response rate), at a median gestational age of 30 weeks.

MAIN OUTCOME MEASURES

Participant worry, reassurance and change in perception after the antenatal consultation were the main outcome measures. Multivariable logistic regression was used to identify factors associated with these outcomes.

RESULTS

23% of participants were worried by the consultation, and 87% were reassured by it. Lower gestational age and higher maternal education were associated with feeling worried (adjusted OR=0.83, 95% CI 0.70 to 0.99; and adjusted OR=2.15, 95% CI 1.04 to 4.44, respectively). Longer consultations were associated with reassurance (adjusted OR=8.21, 95% CI 2.67 to 25.26). Women were reassured by (1) feeling well informed about prematurity with optimistic outlooks, and (2) a trusting and reassuring expert neonatology team. High-quality interactions with neonatologists were associated with reassurance, while poorer communications were associated with feelings of worry.

CONCLUSIONS

To be reassuring, neonatologists should strive to establish a trusting relationship with mothers, in which realistic and clear, but optimistic, information is offered.

Evaluation of the Completeness, Data Quality, and Timeliness of Fetal Mortality Surveillance in Wyoming, 2006-2013

Purpose The number of fetal deaths in the United States each year exceeds that of infant deaths. High quality fetal death certificate data are necessary for states to effectively address preventable fetal deaths. We evaluated completeness of detection of fetal deaths among Wyoming residents that occur out-of-state, quality of cause-of-death data, and timeliness of Wyoming fetal death certificate registration during 2006-2013. Description The numbers of out-of-state fetal deaths among Wyoming residents recorded by Wyoming surveillance and reported by the National Vital Statistics System were compared. Quality of cause-of-death data was assessed by calculating percentage of fetal death certificates completed in Wyoming with ill-defined, unknown, or missing cause-of-death entries. Timeliness was determined using the time between the fetal death and filing of the fetal death certificate with the Wyoming Department of Health Vital Statistics Service. Assessment Wyoming surveillance detected none of the 76 out-of-state fetal deaths among Wyoming residents reported by the National Vital Statistics System. Among 263 fetal death certificates completed in Wyoming and collected by Wyoming surveillance, 108 (41%) contained ill-defined, unknown, or missing cause-of-death entries. Median duration between the fetal death and filing with the Wyoming Vital Statistics Service was 33 days. Conclusion Wyoming fetal mortality surveillance is limited by failure to register out-of-state fetal deaths among residents, poor quality of cause-of-death data, and lack of timeliness. Strategies to improve surveillance include automating interjurisdictional sharing of fetal death data, certifier education, and electronic fetal death registration.

Retrospective cohort study of all deaths among infants born between 22 and 27 completed weeks of gestation in Switzerland over a 3-year period

OBJECTIVES

The aim of this research is to assess causes and circumstances of deaths in extremely low gestational age neonates (ELGANs) born in Switzerland over a 3-year period.

DESIGN

Population-based, retrospective cohort study.

SETTING

All nine level III perinatal centres (neonatal intensive care units (NICUs) and affiliated obstetrical services) in Switzerland.

PATIENTS

ELGANs with a gestational age (GA) <28 weeks who died between 1 July 2012 and 30 June 2015.

RESULTS

A total of 594 deaths were recorded with 280 (47%) stillbirths and 314 (53%) deaths after live birth. Of the latter, 185 (59%) occurred in the delivery room and 129 (41%) following admission to an NICU. Most liveborn infants dying in the delivery room had a GA ≤24 weeks and died following primary non-intervention. In contrast, NICU deaths occurred following unrestricted life support regardless of GA. End-of-life decision-making and redirection of care were based on medical futility and anticipated poor quality of life in 69% and 28% of patients, respectively. Most infants were extubated before death (87%).

CONCLUSIONS

In Switzerland, most deaths among infants born at less than 24 weeks of gestation occurred in the delivery room. In contrast, most deaths of ELGANs with a GA ≥24 weeks were observed following unrestricted provisional intensive care, end-of-life decision-making and redirection of care in the NICU regardless of the degree of immaturity.

Personalized Decision Making: Practical Recommendations for Antenatal Counseling for Fragile Neonates

Emphasis has been placed on engaging parents in processes of shared decision making for delivery room management decisions of critically ill neonates whose outcomes are uncertain and unpredictable. The goal of antenatal consultation should rather be to adapt to parental needs and empower them through a personalized decision-making process. This can be done by acknowledging individuality and diversity while respecting the best interests of neonates. The goal is for parents to feel like they have agency and ability and are good parents, before birth, at birth, and after, either in the NICU or until the death of their child.

Trauma in pregnant women: assessing detection of post-traumatic placental abruption on contrast-enhanced CT versus ultrasound

OBJECTIVES

To evaluate detection of post-traumatic placental abruption with contrast-enhanced CT (CECT) and comparison with Ultrasound (US).

METHODS

Picture Archive and Date System database at a level-1 trauma center was retrospectively reviewed using keywords pregnancy, trauma, and/or placental abruption over 10 years. CT was compared to US, if performed within 24 h. Two subspecialty-trained radiologists blindly reviewed the studies. Placental features on delivery and pregnancy outcomes were used as reference standard. Lack of adverse pregnancy/fetal outcome was treated as the absence of abruption.

RESULTS

CECT was performed in 36 patients, with 27 US within 24 h. There were three complete and eight partial abruptions. Reader sensitivity for CT was 100% for both reviewers; however, specificity was 54.5% and 56.7%. No sonographic abnormality was noted in both partial and complete abruption. Using kappa statistics, inter-observer agreement was low for both CT (0.169) and US (0.078). False-positive reads were from misinterpretation of normal placental structures like cotyledons, age-related infarcts, and marginal sinus of the placenta.

CONCLUSIONS

CECT identifies post-traumatic placental abruption with high sensitivity but low specificity for clinically significant abruptions, and performs better than US. Pitfalls from normal placental structures mimicking abruption should be avoided. US markedly underdiagnoses abruption.

Decision-making at the borderline of viability: Who should decide and on what basis?

Parents and medical staff usually agree on the management of preterm labour at borderline viability, when there is a relatively high risk of long-term neurodevelopmental problems in survivors. If delivery is imminent and parents and staff cannot agree on the best management, however, who should decide what will happen when the baby is delivered? Should the baby be resuscitated? Should intensive care be initiated? Three ethicists, one of whom is also a neonatologist, discuss this complex issue.

End-of-Life Care and Survival without Major Brain Damage in Newborns at the Limit of Viability

BACKGROUND

The probabilities of survival and survival without major brain damage (MBD) are low in newborns at the limit of viability. Survival without MBD constitutes a major concern for parents and professionals.

OBJECTIVES

To know the probabilities of survival without MBD in newborns ≤26 weeks' gestational age (GA) relative to the total number of survivors, whether these probabilities vary with GA, and how end-of-life (EoL) decisions influence these results.

METHODS

We included all live-inborn patients of 22-26 weeks' GA, without major congenital anomalies, born in collaborating centers of the Spanish SEN1500 Network (2004-2010). MBD was defined as the presence of severe intraventricular hemorrhage and/or periventricular leukomalacia.

RESULTS

A total of 3,371 patients were born alive, 3,236 of whom were admitted to the neonatal intensive care unit (NICU). Survival without MBD was 44.4% among patients admitted to the NICU, increasing from 12.5% at 22 weeks to 57.9% at 26 weeks' GA. The proportion of survivors without MBD relative to the total number of survivors was 81.1%, and it was independent of GA. EoL decisions preceded one-third of all deaths and were more frequent among the most immature patients.

CONCLUSIONS

The proportion of survivors without MBD, when referred to the total number of survivors, is relatively high and is independent of GA. EoL decisions after the occurrence of MBD seem to play an important role in this respect. These results support the attitude of "giving an opportunity" even to the most immature patients, if this is in accordance with the parents' wishes.

Ethical decision-making regarding infant viability: A discussion

BACKGROUND:

There are no universally agreed rules of healthcare ethics. Ethical decisions and standards tend to be linked to professional codes of practice when dealing with complex issues.

OBJECTIVES:

This paper aims to explore the ethical complexities on who should decide to give infants born on the borderline of viability lifesaving treatment, parents or the healthcare professionals.

METHOD:

The paper is a discussion using the principles of ethics, professional codes of practice from the UK, Nursing Midwifery Council and UK legal case law and statute. Healthcare professionals' experiences that influence parental decision are also considered.

FINDINGS & DISCUSSION:

There are considerable barriers to an effective discussion taking place in an environment where clinical decisions have to be made quickly once the baby is born. This is compounded by the need and respect for parental autonomy and the difficulties they face when making a best interest's decision knowing that this could cause more harm than good for their infant child and balancing any decision they make with quality of life.

CONCLUSION:

On deciding whether to give lifesaving treatment born at the borderline of viability, it should be a joint decision between the parents and the neonatal team.

Artificial placenta: Analysis of recent progress

The artificial placenta (AP) has for many decades captured the imagination of scientists and authors with popular fiction including The Matrix and Aldous Huxley's "Brave New World", depicting a human surviving ex-utero in an artificial uterine environment (AUE). For scientists this has fascinated as a way forward for extremely preterm infants (EPIs) born less than 28 weeks of gestation. Early successes with mechanical ventilation (MV) for infants born above 28 weeks of gestation meant that AP research lost momentum. More recently, the gestational age limit for survival now borders on 23 weeks and corresponds to the biological milestone of lung development marked by the early canalicular stage of lung morphogenesis. The so called greyzone of 23-25 weeks represents a steep increase in mortality with decreasing gestational age and current options in neonatal care are on the fringes of efficacy for this population. A shift in thinking recognizes the vitality of EPIs as a fetus rather than a 37-40 week neonate and this has reinvigorated the concept of the AP. This review will discuss the scale of extreme preterm birth with special reference to previable infants born in the greyzone. Recent AP studies using sheep models are compared, technical obstacles discussed and future research themes identified.

Opinions of paediatricians who teach neonatal resuscitation about resuscitation practices on extremely preterm infants in the delivery room

OBJECTIVE

To describe the opinions of paediatricians who teach resuscitation in Brazil regarding resuscitation practices in the delivery room (DR) of preterm infants with gestational ages of 23-26 weeks.

METHODS

Cross-sectional study with an internationally validated electronic questionnaire (December 2011-September 2013) sent to the instructors of the Neonatal Resuscitation Program of the Brazilian Society of Paediatrics on parental counselling practices, medical limits for resuscitation of extremely preterm infants and medical considerations for decision-making in this group of infants. The analysis was descriptive.

RESULTS

Among 685 instructors, 560 (82%) agreed to participate. Only 5%-13% reported having opportunity for antenatal counselling parents: if called, 22% reported discussing with the family about the possibility not to resuscitate in the DR; 63% about the possibility of death in the DR and 89% about the possibility of death in the neonatal unit. If the parents did not agree with the advice of the paediatrician, 30%-50% of the respondents would follow the procedures they advised regardless of the opinion of the parents. The higher the gestational age, the lower is the percentage of paediatricians who believed that parents should participate in decision-making. Only 9% participants reported the existence of written guidelines at their hospital on initiation of resuscitation in the DR at limits of viability, but 80% paediatricians reported using some criteria for limiting resuscitation in the DR.

CONCLUSION

The picture obtained in this study of Brazilian paediatricians indicates that resuscitation of extremely preterm infants is permeated by ambivalence and contradictions.

Opinions of Brazilian resuscitation instructors regarding resuscitation in the delivery room of extremely preterm newborns

OBJECTIVE

To describe the opinions of pediatricians who teach resuscitation in Brazil on initiating and limiting the delivery room resuscitation of extremely preterm infants.

METHOD

Cross-sectional study with electronic questionnaire (Dec/2011-Sep/2013) sent to pediatricians who are instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics, containing three hypothetical clinical cases: (1) decision to start the delivery room resuscitation; (2) limitation of neonatal intensive care after delivery room resuscitation; (3) limitation of advanced resuscitation in the delivery room. For each case, it was requested that the instructor indicate the best management for each gestational age between 23 and 26 weeks. A descriptive analysis was performed.

RESULTS

560 (82%) instructors agreed to participate. Only 9% of the instructors reported the existence of written guidelines at their hospital regarding limitations of delivery room resuscitation. At 23 weeks, 50% of the instructors would initiate delivery room resuscitation procedures. At 26 weeks, 2% would decide based on birth weight and/or presence of fused eyelids. Among the participants, 38% would re-evaluate their delivery room decision and limit the care for 23-week neonates in the neonatal intensive care unit. As for advanced resuscitation, 45% and 4% of the respondents, at 23 and 26 weeks, respectively, would not apply chest compressions and/or medications.

CONCLUSION

Difficulty can be observed regarding the decision to not resuscitate a preterm infant with 23 weeks of gestational age. At the same time, a small percentage of pediatricians would not resuscitate neonates of unquestionable viability at 26 weeks of gestational age in the delivery room.

A new biological and clinical resource for research into pregnancy complications: The Baby Bio Bank

About 20% of pregnancies are affected by some form of complication. Research has shown that anomalies in implantation, development, and growth of the fetus; ineffective nutrient exchange between mother and fetus due to placental dysfunction; and maternal problems such as hypertension or infection during pregnancy can all lead to adverse pregnancy outcomes. However, the molecular aetiology of such events remains poorly understood. Fetal growth restriction (FGR), recurrent miscarriage (RM), preterm birth (PTB), and pre-eclampsia (PE) are the most common pregnancy complications encountered in the UK and these outcomes can result in an array of morbidities in both mother and baby, and in the most severe cases in mortality. We need to know more about normal pregnancy and where the important triggers are for failure. This prompted us to collect a large set of biological samples with matching clinical data from over 2500 normal and abnormal pregnancies, for use in research into these conditions. This paper outlines the nature of these sample sets and their availability to academia and industry, with the intention that their widespread use in research will make significant contributions to the improvement of maternal and fetal health worldwide (http://www.ucl.ac.uk/tapb/sample-and-data-collections-at-ucl/biobanks-ucl/baby-biobank).