Ethical and clinical issues
Providing clinical care to infants born at the edge of viability is challenging and raises many ethical and clinical concerns.12,13 For an infant born at the edge of viability, clinicians and parents do not want to initiate a care process that improves survival but results in an extremely poor quality of life. At the same time, clinicians and parents do not want to withhold care that could help an extremely premature newborn survive and thrive. Consequently, the counseling process is complex and requires coordination between the obstetrical and neonatology disciplines, involving physicians and nurses from both. A primary consideration in deciding to institute active treatment at birth is the preference of the pregnant patient and the patient’s trusted family members. A thorough discussion of these issues is beyond the scope of this editorial. ACOG provides detailed advice about the approach to counseling patients who face the possibility of a periviable birth.14
To help standardize the counseling process, institutions may find it helpful to recommend that clinicians consistently use a calculator to provide newborn outcome data to patients. The National Institute of Child Health and Human Development’s Extremely Preterm Birth Outcomes calculator uses the following inputs:
- gestational age
- estimated birth weight
- sex
- singleton/multiple gestation
- antenatal steroid treatment.
It also provides the following outputs as percentages:
- survival with active treatment at birth
- survival without active treatment at birth
- profound neurodevelopmental impairment
- moderate to severe neurodevelopmental impairment
- blindness
- deafness
- moderate to severe cerebral palsy
- cognitive developmental delay.15
A full assessment of all known clinical factors should influence the interpretation of the output from the clinical calculator. An alternativeis to use data from the Vermont Oxford Network. NICUs with sufficient clinical volume may prefer to use their own outcome data in the counseling process.
Institutions and clinical teams may improve the consistency of the counseling process by identifying criteria for 3 main treatment options:
- clinical situations where active treatment at birth is not generally offered (eg, <22 weeks’ gestation)
- clinical situations where active treatment at birth is almost always routinely provided (eg, >25 weeks’ gestation)
- clinical situations where patient preferences are especially important in guiding the use of active treatment.
Most institutions do not routinely offer active treatment of the newborn at a gestational age of less than 22 weeks and 0 days. Instead, comfort care often is provided for these newborns. Most institutions routinely provide active treatment at birth beginning at 24 or 25 weeks’ gestation unless unique risk factors or comorbidities warrant not providing active treatment (TABLE 3A). Some professional societies recommend setting a threshold for recommending active treatment at birth. For example, the British Association of Perinatal Medicine recommends that if there is 50% or higher probability of survival without severe disability, active treatment at birth should be considered because it is in the best interest of the newborn.16 In the hours and days following birth, the clinical course of the newborn greatly influences the treatment plan and care goals. After the initial resuscitation, if the clinical condition of an extremely preterm infant worsens and the prognosis is grim, a pivot to palliative care may be considered.
Final thoughts
Periviability is the earliest stage of fetal development where there is a reasonable chance, but not a high likelihood, of survival outside the womb. For decades, the threshold for periviability was approximately 24 weeks of gestation. With current obstetrical and neonatal practice, the new threshold for periviability is 22 to 23 weeks of gestation, but death prior to hospital discharge occurs in approximately half of these newborns. For the survivors, lifelong neurodevelopmental complications and pulmonary disease are common. Obstetricians play a key role in counseling patients who are at risk of giving birth before 24 weeks of gestation. Given the challenges faced by an infant born at 22 and 23 weeks’ gestation, pregnant patients and trusted family members should approach the decision to actively resuscitate the newborn with caution. However, if the clinical team, patient, and trusted family members agree to pursue active treatment, completion of a course of antenatal steroids and appropriate respiratory and cardiovascular support at birth are key to improving long-term outcomes. ●