In the grey zone—survival and morbidities of periviable births

Shukla, Ankita; Beshers, Caroline; Worley, Sarah; Chowdhary, Vikas; Collin, Marc

doi:10.1038/s41372-022-01355-z

Cited by 8 publications

(5 citation statements)

References 43 publications

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“…At 23 weeks gestation (23 0/7-23 6/7 weeks; often called the "gray zone"), survival of neonates ranges from 8% to 56% [70,71]. Disease-free survival ranges from 7% to 23% worldwide.…”

Section: Clinical Guidelinesmentioning

confidence: 99%

Ethical Dilemmas in Neonatal Care at the Limit of Viability

Cerar

Lučovnik

2023

Children

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Advances in neonatal care have pushed the limit of viability to incrementally lower gestations over the last decades. However, surviving extremely premature neonates are prone to long-term neurodevelopmental handicaps. This makes ethics a crucial dimension of periviable birth management. At 22 weeks, survival ranges from 1 to 15%, and profound disabilities in survivors are common. Consequently, there is no beneficence-based obligation to offer any aggressive perinatal management. At 23 weeks, survival ranges from 8 to 54%, and survival without severe handicap ranges from 7 to 23%. If fetal indication for cesarean delivery appears, the procedure may be offered when neonatal resuscitation is planned. At a gestational age ≥24 weeks, up to 51% neonates are expected to survive the neonatal period. Survival without profound neurologic disability ranges from 12 to 38%. Beneficence-based obligation to intervene is reasonable at these gestations. Nevertheless, autonomy of parents should also be respected, and parental consent should be sought prior to any intervention. Optimal counselling of parents involves harmonized cooperation of obstetric and neonatal care providers. Every fetus/neonate and every pregnant woman are different and have the right to be considered individually when treatment decisions are being made.

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“…At 23 weeks gestation (23 0/7-23 6/7 weeks; often called the "gray zone"), survival of neonates ranges from 8% to 56% [70,71]. Disease-free survival ranges from 7% to 23% worldwide.…”

Section: Clinical Guidelinesmentioning

confidence: 99%

Ethical Dilemmas in Neonatal Care at the Limit of Viability

Cerar

Lučovnik

2023

Children

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“…This review focuses on periviable infants, a high-risk subset of extremely premature infants. Periviable birth is defined as those births occurring from gestational ages 20+0 to 25+6 weeks ( 7 - 9 ). However, over the last decade with improving technology and management of periviable infants there has been a shift to increased resuscitation in younger gestations, creating the “grey zone” at 22 to 24 weeks’ gestational age ( 9 - 11 ).…”

Section: Introductionmentioning

confidence: 99%

“…Periviable birth is defined as those births occurring from gestational ages 20+0 to 25+6 weeks ( 7 - 9 ). However, over the last decade with improving technology and management of periviable infants there has been a shift to increased resuscitation in younger gestations, creating the “grey zone” at 22 to 24 weeks’ gestational age ( 9 - 11 ). There has been increased focus on periviable infants in recent years with improving capability to resuscitate infants and keep them alive at lower gestational ages.…”

Section: Introductionmentioning

confidence: 99%

Withdrawal and withholding of life sustaining treatment (WWLST): an under recognised factor in the morbidity or mortality of periviable infants?—a narrative review

Galloway,

Roehr,

Tan

2024

Transl Pediatr

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Background and Objective The morbidity and mortality of infants born extremely preterm varies substantially across networks, within countries and throughout the globe. Most of the literature tends to focus on the management at birth and choices around active resuscitation of extremely preterm infants. Withdrawal and withholding of life sustaining treatment (WWLST) is an important and central process in the neonatal intensive care unit (NICU) and practices vary substantially. As such, our objective in this review was to explore whether end of life decisions also contribute to variations in the morbidity and mortality of periviable infants. Methods This narrative literature review is based on studies from the last 15 years found using several searches of medical databases (OVID Medline, Scopus and Cochrane Systematic Reviews) performed between March 2021 and December 2023. Key Content and Findings Just as outcomes in periviable infants vary, the rates of and processes behind WWLST differ in the periviable population. Variation increases as gestational age decreases. Parental involvement is crucial to share decision making but the circumstances and rates of parental involvement differ. Strict guidelines in end-of-life care may not be appropriate, however there is a need for more targeted guidance for periviable infants as a specific population. The current literature available relating to periviable infants or WWLST is minimal, with many datasets rapidly becoming outdated. Conclusions Further research is needed to establish the role of WWLST in variation of periviable infants’ outcomes. The unification of data, acquisition of more recent datasets and inclusion of variables relating to end-of-life decisions in data collection will aid in this process.

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“…Over the past decades, significant progress has been made in the treatment of extremely premature infants (EPIs) due to advancements in medical technologies and improved collaboration between obstetricians and neonatologists ( 1 ). EPIs are at high risk of mortality and morbidity due to their extremely immature organ and tissue development ( 2 , 3 ). The mortality and risk of sequelae increase with decreasing gestational age ( 4 ).…”

Section: Introductionmentioning

confidence: 99%

Differences in the attitudes towards resuscitation of extremely premature infants between neonatologists and obstetricians: a survey study in China

Wang,

Li,

Ming

et al. 2023

Front. Pediatr.

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ObjectivesNeonatologists and obstetricians are crucial decision-makers regarding the resuscitation of extremely preterm infants (EPIs). However, there is a scarcity of research regarding the differing perspectives on EPI resuscitation between these medical professionals. We aim to determine the differences and influential factors of their attitudes towards EPIs resuscitation in China.MethodsThis cross-sectional study was conducted in public hospitals of 31 provinces in Chinese mainland from June to July 2021. Influential factors of binary variables and those of ordinal variables were analyzed by modified Poisson regression models and multinomial logistic regression models due to the invalid parallel line assumption of ordinal logistic regression models.ResultsA total of 832 neonatologists and 1,478 obstetricians who were deputy chief physicians or chief physicians participated. Compared with obstetricians, neonatologists delivered a larger proportion of infants of <28-week gestational age (87.74% vs. 84.91%) and were inclined to think it inappropriate to use 28 weeks as the cutoff of gestational age for providing full care to premature infants [63.34% vs. 31.60%, adjusted prevalence ratio = 1.61 (95% CI: 1.46–1.77)], and to suggest smaller cutoffs of gestational age and birth weight for providing EPIs resuscitation. Notably, 46.49% of the neonatologists and 19.01% of the obstetricians believed infants ≤24 weeks' gestation should receive resuscitation.ConclusionsIn China, notable disparities exist in attitudes of neonatologists and obstetricians towards resuscitating EPIs. Strengthening collaboration between these two groups and revising the pertinent guidelines as soon as possible would be instrumental in elevating the resuscitation rate of EPIs.

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In the grey zone—survival and morbidities of periviable births

Cited by 8 publications

References 43 publications

Ethical Dilemmas in Neonatal Care at the Limit of Viability

Ethical Dilemmas in Neonatal Care at the Limit of Viability

Withdrawal and withholding of life sustaining treatment (WWLST): an under recognised factor in the morbidity or mortality of periviable infants?—a narrative review

Differences in the attitudes towards resuscitation of extremely premature infants between neonatologists and obstetricians: a survey study in China

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