Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

Abstract

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

First- and fifth-minute Apgar scores of 0–3 and infant mortality: a population-based study in São Paulo State of Brazil

“…Another study conducted in the United States found that among 271 premature infants with a gestational age of 23-30 weeks, birth weight of between 400 and 1000 g, and 5-min Apgar score of 0 or 1, 34% were alive at 18-22 months old [38]. This difference in preterm survival following birth asphyxia between Brazilian and American data is probably more related to the difficulties in the quality of hospital care than to the decision of obstetricians and pediatricians to invest in such care [9].…”

Survival of Infants Born at Periviable Gestational Ages

“…During the past 5 years, large cohort studies from developed nations in North America, 11–13,20,21 South America, 22 Europe, 14,15,23–25 Asia, 18,19,26 and Australia 27 have reported estimates of gestational age-specific survival following periviable birth. Direct comparisons of estimated survival rates among these studies are limited, however, by potential biases introduced from differences in the data sources, ascertainment of death, selection of denominators, and definitions of live birth.…”

Providing active antenatal care depends on the place of birth for extremely preterm births: the EPIPAGE 2 cohort study

“…Guinsburg et al considered that antenatal care was active when corticosteroids were administered or a caesarean delivery was performed 17. Serenius et al added to the definition of active care delivery in a level 3 maternity unit and tocolytic treatment 18.…”