Assessing risks at 22–24 weeks gestation

Abbreviations

BAPM

British Association of Perinatal Medicine

1 Commentary

The recent British Association of Perinatal Medicine (BAPM) guidance published in 2019 suggested for the first time that we can consider resuscitation of extremely premature infants (EPI) at 22–24 weeks gestational age (GA) on a case-by-case basis in the UK [1]. Needless to say, this sent waves throughout UK neonatal units, perhaps because we are now confronted with challenging decisions about whether a fetus at 22–24 weeks GA will be viable or not, and whether it’s in their best interests to provide ‘survival-focused’ care (SFC) or ‘comfort-focused’ care (CFC).

This BAPM framework has been put in place to allow for discrepancy in estimated gestational dates and due to increasing international evidence of improved survival rates and long-term outcomes for EPIs from the following trials: EPICure-2 (England, 2006), EPIPAGE-2 (France, 2011), and EXPRESS (Sweden, 2004-7) [2]. Even so, the framework still emphasizes careful decision-making based on a risk assessment for survival or severe disability. A risk assessment should be made antenatally based on steroid maturity and magnesium sulphate administration, estimated fetal weight, scan abnormalities, gender, and singleton or multiple pregnancy [3–5]. A risk assessment should also be made perinatally based on the place of delivery (e.g. Level 3 neonatal unit), cardiotocography trace, risk factors for early-onset neonatal sepsis, time to cord clamping, and the response to bag-valve mask ventilation after delivery [3–5]. Although in practice, it seems the new framework has led to an unprecedented steep increase in ‘SFC’ of EPI, primarily due to parental request for resuscitation, in spite of a poor predicted outcome based on these aforementioned risk factors and thorough antenatal counselling.

In fact, a few years following the publication of the recent BAPM framework, a survey of UK neonatal healthcare professionals conducted in 2021 showed that now 58% registrars, 42% consultants, and 22% ANNPs would consider stabilizing an infant between 22 + 0–22 + 6 weeks GA [6]. But is this a reflection of a general shift in attitudes towards pro-SFC management of EPI at 22–24 weeks GA or is this actually because we are not comfortable making these difficult decisions on a case by case basis and are ultimately swayed by parental requests for resuscitation?

This was tested in an online survey to UK neonatal healthcare professionals (of which the majority were consultants) [7]. They were given 5 scenarios involving EPI deliveries with different protective and risk factors, and they were asked to use the BAPM framework to assign a risk category, management option, and estimate chance of survival and severe disability if they survived [7]. For the 5 scenarios, 68–85% indicated they would base their decisions on parental views, and in one of the scenarios, 92% would advise CFC, but would provide SFC if the parents requested it [7]. This study also noted wide variations in outcome estimates and risk assessments, and suggested that UK clinicians needed support to incorporate risk factors into individualised decision making [7].

Additionally, despite advancements in resuscitation practices, antenatal steroid and magnesium sulphate administration, early intubation and surfactant administration, and regular routine postnatal echocardiogram and cranial ultrasound surveillance, the outcomes for this cohort are still poor, which is why a careful risk assessment is necessary. A study conducted in Australia illustrates the necessity of this; it was found that over 9 years, 796 live births occurred at 22-24 weeks GA, of which 438 (55%) received SFC (of which 5% were born at 22 weeks GA, 45% at 23 weeks GA, and 90% at 24 weeks GA) [8]. The survival rate for an EPI between 22–24 weeks GA receiving SFC rose over time, albeit very minimally (adjusted odds ratio 1.09 per year, 95% CI 1.01–1.18, p = 0.03) [8]. Those that do survive are known to suffer with multiple co-morbidities; one study in the UK showed that 45% babies born under 24 + 0 weeks had neurodevelopmental impairment (NDI) by discharge [9]. Another study found that 65–70% infants born at 22–24 weeks GA had bronchopulmonary dysplasia at 36 weeks corrected GA with 20–30% requiring an FiO2 > 30% [10].

Despite these poor outcomes, clinicians’ interpretation of the new BAPM framework has potentially caused uncertainty and discomfort in deciding between SFC or CFC in EPI between 22–24 weeks GA, leading us to base the decision-making mostly, if not solely, on parental wishes. Predicted outcomes of survival, and the risk of moderate to severe disability needs to be clearly documented, and communicated to the parents when providing antenatal counselling, in order to facilitate shared decision-making, whilst keeping the best interests of the EPIs in mind [5]. A retrospective study of infants born at 22–24 weeks found that 75% received neonatal counselling prior to delivery, and a majority had requested for SFC, however they were more likely to choose CFC around 12–24 hours prior to delivery [12]. Therefore, antenatal neonatal counselling in good time prior to delivery is also crucial. If parents are still adamant to pursue SFC in this gestation bracket, then it may be beneficial to have parents in the delivery room to witness the resuscitation process so that they understand the extreme measures these infants require for survival. It is also encouraged to have senior neonatal clinicians present to provide a second opinion on whether CFC or SFC is appropriate based on the baby’s clinical condition at birth, and to assist with stabilisation if the latter is decided upon [5].

Overall, although the BAPM framework is a collaborative effort led by senior neonatal clinicians introducing the idea of considering SFC in EPIs between 22–24 weeks, this may have unintentionally created more uncertainty than clarity, leading to an unintended steep increase in SFC in this patient group. We understand that as with any guidance, a degree of clinical equipoise is required when deciding whether to resuscitate an EPI between 22–24 weeks GA, and how we communicate this decision effectively to the parents, whilst involving them in the decision-making process to a certain degree. However, SFC in an EPI at 22–24 weeks GA is not always in the best interests of the infant nor the parents and there should be more clear guidance on how to make such challenging decisions between SFC and CFC. As we gain more collective experience and data across different units, we can work collaboratively to formulate more clear-cut guidelines on how to stratify risk in this tentative gestation bracket.

Disclosure statements

The authors report no conflicts of interest.