Ethical dimensions of periviability

Skupski, Daniel D.W.; Chervenak, Frank A.; MCCULLOUGH, Laurence; Bancalari, Eduardo; Haumont, Denis; Simeoni, Umberto; Saugstad, Ola Didrik; Donn, Steven S.; Arabin, Birgit; Greenough, Anne; Donzelli, Gabriele; Levene, Malcolm; Şen, Cihat; Carbonell, Xavier X.; Dudenhausen, Joachim; Vlădăreanu, Radu; Antsaklis, Aris A.; Papp, Zoltán; Aksit, Mehmet M.; Carrapato, Manuel M.

doi:10.1515/jpm.2010.098

Cited by 29 publications

(26 citation statements)

References 19 publications

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“…18,22 A study using US vital statistics data for the years 2000 to 2003 showed that Cesarean section seems to provide survival advantages for infants born from 22 to 25 weeks of gestation, independent of maternal risk factors. 5 According to the World Association of Perinatal Medicine, in 2010, Cesarean delivery for fetal indication should be offered 23 for births at 24 weeks and after if there are no severe fetal anomalies or growth restrictions. Proactive management of extreme prematurity R Guinsburg et al…”

Section: Discussionmentioning

confidence: 99%

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

et al. 2012

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Objective: To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death.Study Design: Prospective cohort of 484 infants with 23 0/7 to 26 6/7 weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of X1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life.Result: Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/ neonatal clinical conditions. Conclusion:In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day. Keywords: fetal viability; steroids; cesarean section; cardiopulmonary resuscitation; infant newborn; neonatal mortality Introduction According to the International Liaison Group on Resuscitation, in 2010, 1 for neonates at the margins of viability or those with conditions that predict a high risk of mortality or morbidity, attitudes and practice vary according to region and availability of resources. 2 A systematic review 3 shows that at p22 weeks, no scientific society recommends active treatment for the mother to protect the fetus beyond offering compassionate care. A general agreement is also evident for week 25 0/7 to 25 6/7 : antenatal steroid administration are recommended, prenatal transport and Cesarean section are indicated to protect the fetus and resuscitation is offered to all infants without fatal anomalies. However, there exists a gray area for infants between 23 and 24 weeks, which, in some countries, extends through 25 weeks. 3 The active management of gestations at the limit of viability involves three important clinical decisions: the use of antenatal steroids, delivery method and resuscitation at birth. One prospective cohort study between 1993 and 2007 followed 5476 infants with 23 to 29 weeks gestation admitted for neonatal care. The overall mortality among infants exposed to maternal steroids was lower than in infants not exposed: 19% vs 35% at 24 to 29 weeks and 79% vs 89% at 23 weeks. 4 23, 24, 25 and 26 weeks, respectively. 5 In the same study, 8% of the 125 542 live births with 22 to 31 weeks of gestation had Apgar scores <4 at 5 min, which indicates that resuscitation procedures were frequently needed among preterm infants. However, extensive cardiopulmonary resuscitation at birth

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Section: Discussionmentioning

confidence: 99%

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

et al. 2012

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“…Wherever possible, the SIMP creates "spaces and actors" for shared bioethics as an alternative to the prejudicial attitude, often assumed by various parties in dealing with the sensitive issues of perinatal medicine [5,6].…”

Section: The Difficult Choicesmentioning

confidence: 99%

The Progress of Perinatal Medicine in Italy

Gp¹,

Renzo²

2013

J Health Med Inform

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“…The viable fetus also becomes a patient when the pregnant woman is presented for obstetrical care [11] . The obstetrician has benefi cencebased obligations to the viable fetal patient [3,14] . The previable fetus becomes a patient when the pregnant woman is presented for obstetrical care and the pregnant woman confers the moral status of being a patient on her fetus [11] .…”

Section: The Professional Responsibility Model Of Perinatal Ethicsmentioning

confidence: 99%

“…If the woman elects selective feticide, the perinatologist should perform it or make an appropriate referral [14] . An important dimension of this decision is the role of directive counseling regarding the fetus to be targeted: the less healthy fetus as identifi ed by ultrasound evaluation.…”

Section: Twin-to-twin Transfusion Syndromementioning

confidence: 99%

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Ethical challenges in the management of multiple pregnancies: the professional responsibility model of perinatal ethics

Chervenak

McCullough

2012

Journal of Perinatal Medicine

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Ethics is an essential component for the responsible clinical management of multiple gestation and decision-making about such pregnancies with pregnant women. The ethical concept of the fetus as a patient is presented as the basis for identifying a professionally responsible approach to selective termination, twin-to-twin transfusion syndrome, and to discordant benefi cence-based obligations that exist when one or more fetuses are adversely affected by a fetal anomaly or complication of pregnancy. The roles for directive counseling, i.e., making evidence-based recommendations, and for non-directive counseling, i.e., offering evidence-based alternatives but making no recommendations, are described. The professional responsibility model of perinatal ethics creates a practical framework to guide the clinical judgment of perinatologists and the informed process about the clinical management of multiple pregnancies.

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Ethical dimensions of periviability

Cited by 29 publications

References 19 publications

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

The Progress of Perinatal Medicine in Italy

Ethical challenges in the management of multiple pregnancies: the professional responsibility model of perinatal ethics

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