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Table of contents
- Nrp obstetric dating and assessment
- ➤ Obstetric dating nrp
- Periviable Birth
- Women's Health Care Physicians
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Nrp obstetric dating and assessment
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Short term outcomes after extreme preterm birth in England: Neonatal Research Network, Japan. Survival and neurodevelopmental outcomes among periviable infants. N Engl J Med ; Percentage of surviving neonates with severe or moderate disability by gestational age. Between-hospital variation in treatment and outcomes in extremely preterm infants.
Neurologic and developmental disability after extremely preterm birth. Neurologic and developmental disability at six years of age after extremely preterm birth.
Because of the wide range of outcomes associated with periviable birth, counseling should attempt to include accurate information that is as individualized as possible regarding anticipated short-term and long-term outcomes. Nevertheless, it is important to realize that outcomes that have been reported in the medical literature may have some biases because of a variety of factors, including study inclusion criteria eg, whether studies include all births or are limited to liveborn infants, nonanomalous newborns, liveborn resuscitated newborns, or neonatal intensive care unit [NICU] admissions only , variation in management between centers, and changes in NICU practices over time eg, administration of antepartum steroids, resuscitative efforts, NICU admission criteria; see Table 1 5, 9—11, 15— Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth Table 1.
These include, but are not limited to, nonmodifiable factors eg, fetal sex, weight, plurality , potentially modifiable antepartum and intrapartum factors eg, location of delivery [ 21 ], intent to intervene by cesarean delivery [ 22 ] or induction of labor, administration of antenatal corticosteroids and magnesium sulfate , and life-sustaining interventions and postnatal management eg, starting or withholding and continuing or withdrawing intensive care after birth.
Birth weight and gestational age, alone or in combination, often have been used as predictors of outcome and as criteria for offering resuscitation. However, in recognition of the effect of other clinical factors and in an attempt to create a better prediction tool, the NICHD Neonatal Research Network developed a tool to estimate outcomes among liveborn infants that was based on prospectively collected information for live births at 22—25 weeks of gestation in 19 academic NICU centers available at https: Using these data, the combination of five variables— 1 gestational age, 2 birth weight, 3 exposure to antenatal corticosteroids, 4 sex, and 5 plurality—was found to be more predictive of outcomes than gestational age and birth weight alone.
The NICHD estimator estimates frequencies of outcomes for all live births and for resuscitated newborns receiving mechanical ventilation. In addition to NICHD data and estimates, other organizations may have access to data from their own networks that can be useful for counseling, and they should be encouraged to use available contemporary data to develop and evaluate alternative prediction tools. After delivery, a number of initial illness severity scoring systems have been used in newborn care to predict death or adverse neurologic outcomes American College of Obstetricians and Gynecologists.
Prediction models for estimating neonatal outcomes after periviable birth were developed based on populations of neonates born during a given period, but as medical care advances, these models if not updated based on more recent information may not provide estimates with an accuracy equivalent to that initially reported.
Prediction of outcome frequencies based on gestational age, birth weight, or both in combination with other predictors provides only a point estimate reflecting a population average and cannot predict with certainty the outcome for an individual newborn. Further, gestational age is a key component of any predictive model and may not be known accurately in all cases. Furthermore, before delivery, newborn birth weight can only be estimated. The inherent inaccuracy of ultrasound-estimated fetal weight introduces a degree of uncertainty to the prediction of newborn outcomes.
In addition, how parents weigh and value these potential outcomes ie, death, degree of neurodevelopmental impairment can vary widely, and individual values need to be incorporated into decision making. Finally, the response of an individual neonate to resuscitation can never be known with certainty before delivery.
Thus, when a specific estimated probability for an outcome is offered, it should be stated clearly that this is an estimate for a population and not a prediction of a certain outcome for a particular patient in a given institution. These limitations highlight the need for further research and development of improved prediction models and counseling tools.
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The effect of periviable delivery on maternal health is an important consideration that should be incorporated into counseling. In the setting of possible periviable birth, interventions intended to delay delivery or to improve newborn outcomes often are undertaken but may affect maternal outcomes. Although some interventions eg, antenatal corticosteroid administration or magnesium sulfate for neuroprotection pose relatively low risk to the pregnant woman and offer the prospect of a fetal benefit, others eg, emergent cerclage placement or classical cesarean delivery may result in significant short-term and long-term maternal morbidity.
Because preterm birth frequently is associated with fetal malpresentation, whether to undertake a cesarean delivery for malpresentation is a relatively common question related to periviable gestation. Earlier cesarean delivery is associated with a higher likelihood that the needed hysterotomy will be a vertical uterine incision classical hysterotomy extending into the upper muscular portion of the uterus.
Hysterotomy that involves the muscular portion of the uterus has been associated with more frequent perioperative morbidities than low transverse cesarean delivery and also leads to the recommendation for repeat cesarean delivery in future pregnancies because of the increased risk of uterine rupture with labor. In addition, recent data indicate that regardless of incision type, periviable cesarean delivery results in an increased risk of uterine rupture in a subsequent pregnancy Finally, cesarean delivery is associated with future reproductive risks, which increase further with each additional repeat cesarean delivery.
Maternal morbidity and mortality may arise not just with interventions surrounding periviable pregnancy management but also with decisions not to intervene. Periviable infants do not survive without life-sustaining interventions immediately after delivery. Delivery of a pregnancy in the periviable period at a center with a level III—IV NICU, level III—IV maternal care designation, or both, allows for immediate resuscitation with additional needed ancillary supports eg, respiratory technology, newborn imaging 24 hours daily and advanced maternal care to optimize outcomes for the neonate and woman Accordingly, whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services 28 — Efforts should be made to transfer women before delivery, if feasible, because antenatal transfer has been associated with improved neonatal outcome when compared with transport of a neonate after delivery 31 , It similarly stands to reason that transfer of a parturient for advanced care before her condition worsens may improve her outcome as well.
To facilitate needed transfers, hospitals without the optimal resources for maternal, fetal, and neonatal care needed for periviable birth should have policies and procedures in place to facilitate timely transport to a receiving hospital. Protocols with guidelines for the initial management and safe transport of the periviable gestation should include recommendations for such treatments as antenatal corticosteroids, magnesium sulfate for neuroprotection, tocolytic therapy, antibiotics for latency after preterm PROM, and group B streptococci prophylaxis.
In some cases, circumstances may preclude antenatal maternal transport because of a rapidly evolving clinical situation or because of maternal instability due to severe illness. In such cases, neonatal transport after delivery may be needed, and protocols also should be in place to facilitate postpartum consultation and transfer. Final decisions regarding interventions to be initiated before transfer, as well as the optimal timing and method of transport, should be individualized and made in consultation with the accepting physician.
As in any pregnancy, obstetric interventions should be undertaken only after a discussion with the family regarding individual risks and benefits of management options in addition to alternate approaches. In order to facilitate informed decision making, this discussion should include an unbiased presentation of data related to the chance of both survival and long-term neurodevelopmental impairment.
This discussion also should present the option of nonintervention. In light of the high likelihood of death and the significant degree of neurodevelopmental impairment that may result from periviable birth, the American Academy of Pediatrics has stated that parents should be given the choice for palliative care alongside the option to attempt resuscitation. Clinicians should recognize that parental goals of care may be oriented toward optimizing survival or minimizing pain and suffering and should formulate an antenatal plan of care in accordance with these parental goals.
Rather than treat patients based upon algorithms organized solely by gestational age, a plan of care should be informed primarily by whether the goal is to optimize the chance of survival or minimize the likelihood of suffering. Given the potential for maternal and perinatal morbidity and mortality, the option of pregnancy termination should be reviewed with the patient. Individual obstetrician—gynecologists and other obstetric providers or institutions may have objections to discussing or providing this option, but in the case of such objections, there should be a system in place to allow families to receive counseling about their options and access to such care The management plan for ongoing pregnancies should be reassessed and follow-up counseling should be provided as the clinical situation develops and gestational age increases.
Initiation of interventions to help improve outcome eg, administration of antenatal antibiotics or corticosteroids does not mandate that all other interventions eg, cesarean delivery or newborn resuscitation subsequently be undertaken. Further interventions should be considered in the context of clinical circumstances at that time.
Accurate pregnancy dating is of particular importance in the periviable period, and the best estimate of gestational age should be used for counseling and decision making Obstetric interventions often considered in pregnancies at risk of periviable delivery include treatments to delay delivery as well as efforts to improve newborn outcomes should delivery occur despite such efforts.
Treatment options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow additional time for administration of antenatal steroids, emergent cerclage, antibiotics to prolong latency after preterm PROM or for intrapartum group B streptococci prophylaxis, and delivery including cesarean delivery for concern regarding fetal well-being or fetal malpresentation.
Data regarding the use of obstetric interventions during the periviable period, especially for gestational ages less than 24 weeks, however, are limited, as these gestational ages were not included in many studies, especially those performed in the s and s. Even the studies that included subjects in the periviable gestational age range typically had small numbers in these groups, with corresponding limited power to evaluate the effect of interventions. As a result, most recommendations for management in the periviable gestational age range are extrapolated from data available for women who gave birth between 26 weeks and 34 weeks of gestation.
Guidance offered in this document for the management of the pregnancy at risk of periviable birth is based, therefore, on a mix of direct evidence, data extrapolated from more advanced gestational ages, and expert opinion. This guidance, summarized in Table 2 and Table 3, is considered in more detail below.
There are a few perspectives that serve to frame these recommendations:. Corticosteroid administration before anticipated preterm birth is one of the most important antenatal therapies available to improve newborn outcomes 35— Specific data on the use of steroids in the periviable period are supported by a combination of laboratory data on the response of lung tissue and clinical observational studies 35, 39 , Data from a Eunice Kennedy Shriver NICHD Neonatal Research Network observational cohort revealed a significant reduction in death and neurodevelopmental impairment at 18—22 months for infants who had been exposed to antenatal corticosteroids and born at 23 weeks of gestation At 22 weeks of gestation, no significant difference in these outcomes was noted In this study, antenatal corticosteroid exposure also decreased incidence of death, intraventricular hemorrhage, periventricular leukomalacia, and necrotizing enterocolitis in infants born between 23 weeks and 25 weeks of gestation.
Maternal treatment with magnesium sulfate has been shown to improve neurologic outcomes when administered before anticipated early preterm birth. The use of magnesium sulfate for this indication has been studied in five randomized controlled trials, with enrollment started as early as 24 weeks of gestation 19, Although data specific to the periviable period are not available, antenatal magnesium sulfate treatment has been shown to reduce the incidence of any cerebral palsy relative risk, 0.
Given these findings, magnesium sulfate prophylaxis is recommended if periviable delivery of a potentially viable infant is anticipated. Administration of broad-spectrum antibiotics during expectant management of preterm PROM has been shown to prolong pregnancy and reduce newborn infections Alternatively, antibiotic treatment of women with preterm labor and intact membranes has been shown to have no effect on pregnancy prolongation or on the improvement of newborn outcomes; indeed, the combination of amoxicillin—clavulanic acid in the setting of preterm labor may worsen long-term outcomes for the offspring Thus, although data specific to the periviable period are not available, broad-spectrum antibiotic treatment to prolong pregnancy during expectant management of periviable preterm PROM generally is recommended at 24 weeks of gestation and beyond.
Conversely, there are inadequate data to help obstetrician—gynecologists and other obstetric providers balance any potential efficacy at earlier gestational ages against potential risks. In the setting of preterm labor with intact membranes, because of the lack of evidence of benefit and the potential risks, such treatment is not recommended. Studies suggest that nifedipine and indomethacin tocolysis of women in preterm labor with intact membranes may delay delivery between 48 hours and 72 hours after 26 weeks of gestation, but specific data for pregnancies treated before 26 weeks of gestation are lacking 44 , Theoretically, a brief delay of delivery with tocolytic therapy for preterm labor could reduce neonatal morbidity and mortality in the periviable period, particularly if antenatal steroids can be administered.
However, although some studies have found that tocolytics delay delivery for a short time, improvements in actual neonatal outcomes have not been consistently demonstrated Because there is some evidence of brief pregnancy prolongation but no consistent data suggesting improved newborn outcomes at any gestational age, a specific and strong recommendation in favor of or against tocolytic therapy for preterm labor cannot be made.
Observational and randomized controlled studies of emergency cerclage placement based on physical examination findings of dilation have revealed an association between cerclage placement and pregnancy prolongation, as well as increased live births and neonatal survival, when compared with those treated without cerclage 48— Routine cesarean delivery is not recommended for the indication of periviable delivery alone because it has not been shown to decrease mortality or intraventricular hemorrhage after early preterm birth Randomized controlled trials comparing cesarean delivery with vaginal delivery have not been done in the periviable period.
Although limited retrospective data provide some support for cesarean delivery in the presence of malpresentation, delivery for women in the periviable period should be individualized, recognizing increased maternal morbidity associated with cesarean delivery, particularly if the need for classical cesarean delivery is anticipated 7, 53— Cesarean delivery before 22 weeks of gestation is appropriate only for maternal indications eg, placenta previa or uterine rupture.
The medical team plays a key role in helping the family navigate the complex decisions needed regarding periviable delivery and in giving the patient and her family the opportunity to express their values and preferences 56 , However, except in the rare case when the patient is not competent to do so, only the pregnant woman can provide consent for maternal interventions. The counseling process should concurrently address clinical considerations regarding the pregnant woman, her fetus, and the newborn if delivered. This information is optimally addressed by a multidisciplinary team that includes obstetricians, neonatologists and, when available, maternal—fetal medicine subspecialists, who can speak to their individual and combined considerations and perspectives Because of the complexity and ramifications of management decisions in the periviable period, other health care team members eg, bioethicists, social workers, palliative care experts, spiritual care providers, and nurses may provide important contributions to the counseling process as well as psychological and emotional support.
Ideally, counseling by the obstetric and neonatology teams will occur simultaneously or will occur in such a way that each team keeps the other informed of the content of their discussions. These efforts will help to optimize coordination so as to avoid the provision of conflicting information to the patient and her family. These efforts should include the acknowledgement of when data are uncertain and consensus cannot be obtained. It is important that the health care team provide accurate, balanced, and unbiased information and guidance. Because obstetrician—gynecologists and other obstetric providers may have divergent opinions and practices based on personal beliefs or professional experiences, it is preferable that institutions develop consensus guidelines regarding counseling about outcomes and a general approach to resuscitation of the periviable newborn.
Women's Health Care Physicians
Effective communication within the health care team will identify conflicts of conscience that may arise. The family should be counseled regarding short-term and long-term consequences that are anticipated in the context of evolving clinical findings for their newborn. Family counseling should recognize the fact that additional information may become available subsequent to initial conversations that may change recommendations and decision making. It is recognized that those attending a delivery or providing neonatal care may not be the same as those who have counseled patients and made plans for their care.
Optimally, the family should be counseled before delivery regarding possible pregnancy and newborn outcomes, with adequate time available for the woman and her family to process the information needed to make an informed decision. However, delivery may occur quickly in some cases, precluding adequate time for full discussion of all options and expectations before birth.
In line with recommendations already emphasized, maternal transport should be recommended when appropriate and feasible. When a decision has been made to withhold or withdraw life-sustaining treatment after birth, the newborn should receive individualized compassionate care that is directed toward providing warmth, minimizing discomfort, and allowing the family to spend as much time with their newborn as desired.
It should be emphasized that decisions to redirect care do not mean forgoing all care but instead mean focusing on the palliative care that is appropriate based on the clinical circumstances. Bereavement care for the family is of great importance in this situation. Creating memories eg, by making footprints or taking photographs often is appreciated by the family.
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Thus, the recommendations can be 1 of the following 6 possibilities: Society for Maternal—Fetal Medicine [editorial]. Am J Obstet Gynecol ;