Perinatal care at the limit of viability between 22 and 26 completed weeks of gestation in Switzerland

Abstract

Perinatal care of pregnant women at high risk for preterm delivery and of preterm infants born at the limit of viability (22-26 completed weeks of gestation) requires a multidisciplinary approach by an experienced perinatal team. Limited precision in the determination of both gestational age and foetal weight, as well as biological variability may significantly affect the course of action chosen in individual cases. The decisions that must be taken with the pregnant women and on behalf of the preterm infant in this context are complex and have far-reaching consequences. When counselling pregnant women and their partners, neonatologists and obstetricians should provide them with comprehensive information in a sensitive and supportive way to build a basis of trust. The decisions are developed in a continuing dialogue between all parties involved (physicians, midwives, nursing staff and parents) with the principal aim to find solutions that are in the infant's and pregnant woman's best interest. Knowledge of current gestational age-specific mortality and morbidity rates and how they are modified by prenatally known prognostic factors (estimated foetal weight, sex, exposure or nonexposure to antenatal corticosteroids, single or multiple births) as well as the application of accepted ethical principles form the basis for responsible decision-making. Communication between all parties involved plays a central role. The members of the interdisciplinary working group suggest that the care of preterm infants with a gestational age between 22 0/7 and 23 6/7 weeks should generally be limited to palliative care. Obstetric interventions for foetal indications such as Caesarean section delivery are usually not indicated. In selected cases, for example, after 23 weeks of pregnancy have been completed and several of the above mentioned prenatally known prognostic factors are favourable or well informed parents insist on the initiation of life-sustaining therapies, active obstetric interventions for foetal indications and provisional intensive care of the neonate may be reasonable. In preterm infants with a gestational age between 24 0/7 and 24 6/7 weeks, it can be difficult to determine whether the burden of obstetric interventions and neonatal intensive care is justified given the limited chances of success of such a therapy. In such cases, the individual constellation of prenatally known factors which impact on prognosis can be helpful in the decision making process with the parents. In preterm infants with a gestational age between 25 0/7 and 25 6/7 weeks, foetal surveillance, obstetric interventions for foetal indications and neonatal intensive care measures are generally indicated. However, if several prenatally known prognostic factors are unfavourable and the parents agree, primary non-intervention and neonatal palliative care can be considered. All pregnant women with threatening preterm delivery or premature rupture of membranes at the limit of viability must be transferred to a perinatal centre with a level III neonatal...

Short-term Survival and Morbidity of Extremely premature Infants Born between 20 Weeks and 24 Weeks+6 Days Gestation

“…This variation may be because we included very early births up to 20 WG. The causes of death in these EPIs were mainly neurological and respiratory, which were similar to the results of most previous studies [6,9,13].…”

“…There is debate concerning neonatal resuscitation of EPIs with gestational ages between 22 and 24 WG. Some obstetrical and paediatric teams limit neonatal resuscitation to palliative care before 24 weeks [9,10]. However, in practice, the results of neonatal resuscitation of EPIs are sometimes unpredictable but are often solicited at the parent's request even when the prognosis seems poor.…”

Guidelines for the Management of Extremely Premature Deliveries: A Systematic Review

“…1,2 By 25 weeks' gestation, the range of survival rates is narrower but still wide: 61% to 67% in Switzerland and Australia, respectively, to 85% in Japan. [1][2][3] These differences have been attributed to either a more active interventionist approach or to underreporting of perinatal deaths. [4][5][6] Many professional organizations and scientific societies in industrialized countries promulgate management guidelines for the extremely preterm infant.…”

Prise en charge périnatale des nouveau-nés prématurés à la limite de la viabilité (âge gestationnel de 22 à 26 semaines complétées)

“…Comme déjà en 2002, la commission centrale d'éthique (CCE) de l'académie des sciences médicales (ASSM) soutient ces nouvelles recommandations. Les recommandations détaillées ont été publiées en anglais dans le Swiss Medical Weekly [25] et peuvent être lues en ligne sur www.smw.ch ou par l'intermédiaire de PubMed, ou téléchargées sous format PDF (open accès). Seules les modifications essentielles seront soulignées et présentées ici ainsi que la traduction française du résumé.…”