To describe a single center’s experience with the management of neonates born at 22 weeks of gestation.
Study Design
Retrospective review of 18 neonates born alive at 22 weeks GA to 16 mothers (cohort included 2 sets of twins) from January 2017 to December 2020, and admitted to a level IV Neonatal Intensive Care Unit. Data on antenatal management was collected from maternal charts.
Results
Nine mothers delivered due to preterm labor, 5 due to preterm pre-labor rupture of membranes with intra-amniotic infection, and 2 after antepartum hemorrhage. Fourteen mothers received antenatal counseling, 75% received antenatal steroids (25% received a full course), and 31% delivered via caesarean section in honor of parental wishes. All the neonates were actively resuscitated, with 5 surviving to discharge (28%). All survivors had at least 1 morbidity at discharge. None of the infants who underwent extensive resuscitation including chest compressions, epinephrine administration, or volume expansion survived to discharge.
Conclusions
Adequate antenatal counseling with personalized decision-making consistent with parental desires is the preferred approach at the limits of viability. Although not evident in this study, antenatal interventions such as corticosteroids may improve outcomes and should be considered for families who desire neonatal resuscitation at 22 weeks.
RysavyMA, LiL, & BellEF, . Between-hospital variation in treatment and outcomes in extremely preterm infants [published correction appears in N Engl J Med. 372(25):2469]. N Engl J Med. 2015;372(19):1801-1811.
2.
GuillénÚ, WeissEM, & MunsonD, . Guidelines for the management of extremely premature deliveries: a systematic review. Pediatrics. 2015;136(2):343-350.
3.
HumbergA, HärtelC, & RauschTK, . Active perinatal care of preterm infants in the German Neonatal Network. Arch Dis Child Fetal Neonatal Ed. 2020;105(2):190-195.
4.
WilkinsonD, VerhagenE, & JohanssonS. Thresholds for resuscitation of extremely preterm infants in the UK, Sweden, and Netherlands. Pediatrics. 2018Sep;142(Suppl 1):S574-S584.
5.
JanvierA, PrenticeT, WallaceJ, RobsonK, MannP, & LantosJD. Does it matter if this baby is 22 or 23 weeks?Pediatrics. 2019;144(3):e20190113.
6.
TonismaeTR, Tucker EdmondsB, & BhamidipalliSS, . Intention to treat: obstetrical management at the threshold of viability. Am J Obstet Gynecol MFM. 2020;2(2):100096
7.
RiederTN. Saving or creating: which are we doing when we resuscitate extremely preterm infants?Am J Bioeth. 2017;17(8):4-12.
8.
American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric care consensus No. 6: periviable birth. Obstet Gynecol. 2017;130(4):e187-e199.
9.
MactierH, BatesSE, & JohnstonT, . Perinatal management of extreme preterm birth before 27 weeks of gestation: a framework for practice. Arch Dis Child Fetal Neonatal Ed. 2020;105(3):232-239.
10.
LemyreB, & MooreG. Counselling and management for anticipated extremely preterm birth. Paediatr Child Health. 2017Sep;22(6):334-341.
11.
FanaroffJM, HascoëtJM, & HansenTW, . The ethics and practice of neonatal resuscitation at the limits of viability: an international perspective. Acta Paediatr. 2014;103(7):701-708.
12.
Tucker EdmondsB, McKenzieF, PanochJE, BarnatoAE, & FrankelRM. Comparing obstetricians’ and neonatologists’ approaches to periviable counseling. J Perinatol. 2015;35(5):344-348.
13.
ChanKL, KeanLH, & MarlowN. Staff views on the management of the extremely preterm infant. Eur J Obstet Gynecol Reprod Biol. 2006;128(1-2):142-147.
14.
RajuTN, MercerBM, BurchfieldDJ, JosephGFJr.Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Am J Obstet Gynecol. 2014;210(5):406-417.
15.
EhretDEY, EdwardsEM, & GreenbergLT, . Association of antenatal steroid exposure with survival among infants receiving postnatal life support at 22 to 25 weeks’ gestation. JAMA Netw Open. 2018;1(6):e183235.
16.
ParkCK, IsayamaT, & McDonaldSD. Antenatal corticosteroid therapy before 24 weeks of gestation: a systematic review and meta-analysis. Obstet Gynecol. 2016;127(4):715-725.
17.
BackesCH, RiveraBK, & PavlekL, . Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol. 2021;224(2):158-174.
18.
McKenzieF, RobinsonBK, & Tucker EdmondsB. Do maternal characteristics influence maternal-fetal medicine physicians’ willingness to intervene when managing periviable deliveries?J Perinatol. 2016;36(7):522-528.
19.
RysavyMA, BellEF, & IamsJD, . Discordance in antenatal corticosteroid use and resuscitation following extremely preterm birth. J Pediatr. 2019;208:156-162.
20.
BackesCH, SöderströmF, & ÅgrenJ, . Outcomes following a comprehensive versus a selective approach for infants born at 22 weeks of gestation. J Perinatol. 2019;39(1):39-47.
21.
KonoY, YonemotoN, NakanishiH, KusudaS, & FujimuraM. Changes in survival and neurodevelopmental outcomes of infants born at <25 weeks’ gestation: a retrospective observational study in tertiary centres in Japan. BMJ Paediatr Open. 2018;2(1):e000211. Published 2018 Jan 20.
22.
WatkinsPL, DagleJM, BellEF, & ColaizyTT. Outcomes at 18 to 22 months of corrected age for infants born at 22 to 25 weeks of gestation in a Center Practicing Active Management. J Pediatr. 2020;217:52-58.e1.
23.
SöderströmF, NormannE, JonssonM, & ÅgrenJ. Outcomes of a uniformly active approach to infants born at 22-24 weeks of gestation [published online ahead of print, 2021 Jan 15]. Arch Dis Child Fetal Neonatal Ed. 2021;fetalneonatal-2020-320486.
24.
CummingsJ; Committee on Fetus and Newborn. Antenatal counseling regarding resuscitation and intensive care before 25 weeks of gestation. Pediatrics. 2015;136(3):588-595.
25.
KaempfJW, & DirksenK. Extremely premature birth, informed written consent, and the Greek ideal of sophrosyne. J Perinatol. 2018;38(4):306-310.
26.
HawardMF, GaucherN, PayotA, RobsonK, & JanvierA. Personalized decision making: practical recommendations for antenatal counseling for fragile neonates. Clin Perinatol. 2017;44(2):429-445.
27.
Tucker EdmondsB, HoffmanSM, LaitanoT, JeffriesE, JagerS, & KavanaughK. Diverse perspectives on death, disability, and quality of life: an exploratory study of racial differences in periviable decision-making. J Perinatol. 2021;41(3):396-403.
28.
KällénK. Mid-trimester ultrasound prediction of gestational age: advantages and systematic errors. Ultrasound Obstet Gynecol. 2002;20(6):558-563.
29.
MorinI, MorinL, & ZhangX, . Determinants and consequences of discrepancies in menstrual and ultrasonographic gestational age estimates. BJOG. 2005;112(2):145-152.
30.
TysonJE, ParikhNA, LangerJ, GreenC, & HigginsRD; National Institute of Child Health and Human Development Neonatal Research Network. Intensive care for extreme prematurity–moving beyond gestational age. N Engl J Med. 2008;358(16):1672-1681.
31.
PatelRM, RysavyMA, BellEF, & TysonJE. Survival of infants born at periviable gestational ages. Clin Perinatol. 2017;44(2):287-303.
MercurioMR, & CummingsCL. Critical decision-making in neonatology and pediatrics: the I-P-O framework. J Perinatol. 2021;41(1):173-178.
34.
MitraS, ReidM, McDougallB, & JohnstonBC. Are neonatal clinical practice guidelines truly evidence-based? A case for incorporating family values and preferences. Acta Paediatr. 2019;108(9):1564-1566.
35.
SinghJ, FanaroffJ, & AndrewsB, . Resuscitation in the “gray zone” of viability: determining physician preferences and predicting infant outcomes. Pediatrics. 2007;120(3):519-526.
36.
American Academy of Pediatrics Committee on Fetus and Newborn; BellEF. Noninitiation or withdrawal of intensive care for high-risk newborns. Pediatrics. 2007;119(2):401-403.
37.
PetrouS, YiuHH, & KwonJ. Economic consequences of preterm birth: a systematic review of the recent literature (2009-2017). Arch Dis Child. 2019;104(5):456-465.
38.
KilpatrickSJ, SchlueterMA, PiecuchR, LeonardCH, RogidoM, & SolaA. Outcome of infants born at 24-26 weeks’ gestation: I. Survival and cost. Obstet Gynecol. 1997;90(5):803-808.
39.
SaigalS. In their own words: Life at adulthood after very premature birth. Semin Perinatol. 2016;40(8):578-583.
40.
SaigalS, StoskopfBL, & FeenyD, . Differences in preferences for neonatal outcomes among health-care professionals, parents, and adolescents. JAMA. 1999;281(21):1991-1997.
