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Kornhauser Cerar L, Lucovnik M. Ethical Dilemmas in Neonatal Care at the Limit of Viability. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10050784. [PMID: 37238331 DOI: 10.3390/children10050784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/03/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023]
Abstract
Advances in neonatal care have pushed the limit of viability to incrementally lower gestations over the last decades. However, surviving extremely premature neonates are prone to long-term neurodevelopmental handicaps. This makes ethics a crucial dimension of periviable birth management. At 22 weeks, survival ranges from 1 to 15%, and profound disabilities in survivors are common. Consequently, there is no beneficence-based obligation to offer any aggressive perinatal management. At 23 weeks, survival ranges from 8 to 54%, and survival without severe handicap ranges from 7 to 23%. If fetal indication for cesarean delivery appears, the procedure may be offered when neonatal resuscitation is planned. At a gestational age ≥24 weeks, up to 51% neonates are expected to survive the neonatal period. Survival without profound neurologic disability ranges from 12 to 38%. Beneficence-based obligation to intervene is reasonable at these gestations. Nevertheless, autonomy of parents should also be respected, and parental consent should be sought prior to any intervention. Optimal counselling of parents involves harmonized cooperation of obstetric and neonatal care providers. Every fetus/neonate and every pregnant woman are different and have the right to be considered individually when treatment decisions are being made.
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Affiliation(s)
- Lilijana Kornhauser Cerar
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Center Ljubljana, Zaloska 11, 1525 Ljubljana, Slovenia
| | - Miha Lucovnik
- Department of Perinatology, Division of Obstetrics and Gynecology, University Medical Center Ljubljana, Zaloska 11, 1525 Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia
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Does active treatment in infants born at 22-23 weeks correlate with outcomes of more mature infants at the same hospital? An analysis of California NICU data, 2015-2019. J Perinatol 2022; 42:1301-1305. [PMID: 35361887 PMCID: PMC9522931 DOI: 10.1038/s41372-022-01381-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/10/2022] [Accepted: 03/22/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To investigate whether hospital rates of active treatment for infants born at 22-23 weeks is associated with survival of infants born at 24-27 weeks. STUDY DESIGN We included all liveborn infants 22-27 weeks of gestation delivered at California Perinatal Quality Care Collaborative hospitals from 2015 to 2019. We assessed (1) the correlation of active treatment (e.g., endotracheal intubation, epinephrine) in 22-23 week infants and survival until discharge for 24-27 week infants and (2) the association of active treatment with survival using multilevel models. RESULT The 22-23 week active treatment rate was associated with infant outcomes at 22-23 weeks but not 24-27 weeks. A 10% increase in active treatment did not relate to 24-25 week (adjusted OR: 1.00 [95% CI: 0.95-1.05]), or 26-27 week survival (aOR: 1.02 [0.95-1.09]). CONCLUSION The hospital rate of active treatment for infants born at 22-23 weeks was not associated with improved survival for 24-27 week infants.
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Nourkami-Tutdibi N, Tutdibi E, Faas T, Wagenpfeil G, Draper ES, Johnson S, Cuttini M, Rafei RE, Seppänen AV, Mazela J, Maier RF, Nuytten A, Barros H, Rodrigues C, Zeitlin J, Zemlin M. Neonatal Morbidity and Mortality in Advanced Aged Mothers-Maternal Age Is Not an Independent Risk Factor for Infants Born Very Preterm. Front Pediatr 2021; 9:747203. [PMID: 34869105 PMCID: PMC8634642 DOI: 10.3389/fped.2021.747203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 10/20/2021] [Indexed: 12/02/2022] Open
Abstract
Background: As childbearing is postponed in developed countries, maternal age (MA) has increased over decades with an increasing number of pregnancies between age 35-39 and beyond. The aim of the study was to determine the influence of advanced (AMA) and very advanced maternal age (vAMA) on morbidity and mortality of very preterm (VPT) infants. Methods: This was a population-based cohort study including infants from the "Effective Perinatal Intensive Care in Europe" (EPICE) cohort. The EPICE database contains data of 10329 VPT infants of 8,928 mothers, including stillbirths and terminations of pregnancy. Births occurred in 19 regions in 11 European countries. The study included 7,607 live born infants without severe congenital anomalies. The principal exposure variable was MA at delivery. Infants were divided into three groups [reference 18-34 years, AMA 35-39 years and very(v) AMA ≥40 years]. Infant mortality was defined as in-hospital death before discharge home or into long-term pediatric care. The secondary outcome included a composite of mortality and/or any one of the following major neonatal morbidities: (1) moderate-to-severe bronchopulmonary dysplasia; (2) severe brain injury defined as intraventricular hemorrhage and/or cystic periventricular leukomalacia; (3) severe retinopathy of prematurity; and (4) severe necrotizing enterocolitis. Results: There was no significant difference between MA groups regarding the use of surfactant therapy, postnatal corticosteroids, rate of neonatal sepsis or PDA that needed pharmacological or surgical intervention. Infants of AMA/vAMA mothers required significantly less mechanical ventilation during NICU stay than infants born to non-AMA mothers, but there was no significant difference in length of mechanical ventilation and after stratification by gestational age group. Adverse neonatal outcomes in VPT infants born to AMA/vAMA mothers did not differ from infants born to mothers below the age of 35. Maternal age showed no influence on mortality in live-born VPT infants. Conclusion: Although AMA/vAMA mothers encountered greater pregnancy risk, the mortality and morbidity of VPT infants was independent of maternal age.
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Affiliation(s)
- Nasenien Nourkami-Tutdibi
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Erol Tutdibi
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Theresa Faas
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
| | - Gudrun Wagenpfeil
- Saarland University Medical Center, Institute of Medical Biometry, Epidemiology and Medical Informatics, Homburg, Germany
| | - Elizabeth S Draper
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Samantha Johnson
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Marina Cuttini
- Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rym El Rafei
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Anna-Veera Seppänen
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Jan Mazela
- Department of Neonatology and Neonatal Infectious Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Rolf Felix Maier
- Children's Hospital, University Hospital, Philipps University Marburg, Marburg, Germany
| | | | - Henrique Barros
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Carina Rodrigues
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Jennifer Zeitlin
- Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Michael Zemlin
- Saarland University Medical Center, Hospital for General Pediatrics and Neonatology, Homburg, Germany
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