Intensity of perinatal care for extremely preterm babies and outcomes at a higher gestational age: evidence from the EPIPAGE-2 cohort study

Abstract

Background: Perinatal decision-making affects outcomes for extremely preterm babies (22-26 weeks' gestational age (GA)): more active units have improved survival without increased morbidity. We hypothesised such units may gain skills and expertise meaning babies at higher gestational ages have better outcomes than if they were born elsewhere. We examined mortality and morbidity outcomes at age two for babies born at 27-28 weeks' GA in relation to the intensity of perinatal care provided to extremely preterm babies. Methods: Fetuses from the 2011 French national prospective EPIPAGE-2 cohort, alive at maternal admission to a level 3 hospital and delivered at 27-28 weeks' GA, were included. Morbidity-free survival (survival without sensorimotor (blindness, deafness or cerebral palsy) disability) and overall survival at age two were examined. Sensorimotor disability and Ages and Stages Questionnaire (ASQ) result below threshold among survivors were secondary outcomes. Perinatal care intensity level was based on birth hospital, grouped using the ratio of 24-25 weeks' GA babies admitted to neonatal intensive care to fetuses of the same gestation alive at maternal admission. Sensitivity analyses used ratios based upon antenatal steroids, Caesarean section, and newborn resuscitation. Multiple imputation was used for missing data; hierarchical logistic regression accounted for births nested within centres. Results: 633 of 747 fetuses (84.7%) born at 27-28 weeks' GA survived to age two. There were no differences in survival or morbidity-free survival: respectively, fully adjusted odds ratios were 0.96 (95% CI: 0.54 to 1.71) and 1.09 (95% CI: 0.59 to 2.01) in medium and 1.12 (95% CI: 0.63 to 2.00) and 1.16 (95% CI: 0.62 to 2.16) in high compared to low-intensity hospitals. Among survivors, there were no differences in sensorimotor disability or ASQ below threshold. Sensitivity analyses were consistent with the main results.

Does active treatment in infants born at 22–23 weeks correlate with outcomes of more mature infants at the same hospital? An analysis of California NICU data, 2015–2019

“…All models were adjusted for the following maternal and infant covariates that have been shown to be related to birth outcomes: maternal age (<25 years, 25–35 years, >35 years), maternal diabetes (of any type or severity), maternal hypertension (includes diagnosis of hypertension, chronic or pregnancy-induced, eclampsia, and preeclampsia), infant sex, birth weight, small for gestational age status (defined as an infant with birth weight <10 th percentile for gestational age 16 ), gestational plurality (singleton or multiple), antenatal steroid exposure (at any time prior to birth), mode of delivery (cesarean section as compared to spontaneous or operative vaginal birth). 7 – 9 …”

“…It has been hypothesized that the approach to caring for infants born at 22–23 weeks could impact mortality and morbidity rates for older infants at that same hospital. Some have speculated that the provision of intensive care to infants born at 22–23 weeks may confer experience, protocol development, and improved skill for caring for older high-risk infants; however, current evidence for this is mixed 8 , 9 . The aim of this study was to investigate whether hospital rates of active treatment, defined as any potentially lifesaving intervention following birth, for infants born at 22–23 weeks’ gestation, was associated with outcomes of infants born at 24–27 weeks in a contemporary population-based U.S. cohort.…”

Pratiques anténatales en cas de prématurité extrême en France : faut-il reconsidérer notre prise en charge ?

“…La comparaison des études EPIPAGE 1 et 2 a montré qu'il y avait eu en 2011 plus d'interventions anténatales et plus de réanimation pour les extrêmes prématurés qu'en 1997. Ces changements de pratiques ont été associés une augmentation des taux de survie de 50 à 60% pour les enfants nés à 25 SA et de 55 à 75% pour les enfants nés à 26 SA sans augmentation de la morbidité néonatale sévère et sans augmentation de la morbidité à 2 ans (Figure 1) (8). Une des inquiétudes majeures en cas d'extrême prématurité étant le risque de séquelles et donc de handicap à plus long terme, l'impact de ces augmentations de la survie sur le devenir de ces enfants à plus long terme reste à évaluer à partir des données françaises.…”

Neonatal Morbidity and Mortality in Advanced Aged Mothers—Maternal Age Is Not an Independent Risk Factor for Infants Born Very Preterm

“…Large multicenter epidemiological research studies have investigated differences between patient cohorts throughout different countries to identify targets for obstetric and/or neonatal interventions (4)(5)(6)(7)(8). Randomized controlled trials and technological advances have contributed to this success story, identifying key evidence-based obstetric and neonatal interventions that can be monitored to assess quality of care for very preterm infants (9,10). Evidence-based practices and the achievement of standardized treatment strategies are main pillars for an improved outcome in preterm infants, especially for those born at the limits of viability (11).…”