403 Improving Perinatal Regionalisation by Predicting the Need for Neonatal Intensive Care: A Study Based on the Epipage Cohort

Abstract

Perinatal regionalisation is organised in three ascending levels of care, fitting increasing degrees of pathology. Recommendations request that very premature infants be prenatally referred to level III facilities. Yet, not all very preterm neonates require level III intensive care. Some of them could thus be handled in maternity wards closer to their parents' home, avoiding useless intrauterine transfers.Aim. To determine the antenatal factors predicting the need for neonatal intensive care in preterms, to fit the site of birth to the level of care required.Methods. Our study sample is a cohort of preterm infants born in 1997, in nine French regions. We defined the need for neonatal intensive care as the requirement for mechanical ventilation for more than 48 hours, high frequency oscillation, inhaled nitric oxide, or transfer for more intensive care to a level III facility within the first two days of life, and early neonatal death. Triple pregnancies, pregnancies marked by foetal malformations or by intensive care requirement for mothers' purpose before delivery, were excluded.Results. The need for neonatal intensive care decreased from 100% at 24 weeks' gestation (GA), to 54% at 29 weeks' GA and 13% at 33 weeks' GA. We hence focused our study on the 1267 neonates aged 30, 31 and 32 weeks' gestation, where the need for intensive care was 43, 34 and 23% respectively. Risk factors adjusted on gestational age for intensive care requirement were maternal arterial hypertension (aRR=1.12;95%Cl=[1.04–1.20]), twin pregnancies (1.10;[1.04–1.17]), haemorrhagic pathology (1.06;[1.01–1.10]), foetal asphyxia (1.12;[1.01–1.23]) and infection (1.04;[1.01–1.08]). Antenatal corticotherapy (0.67;[0.55–0.80]) and premature rupture of membranes (0.81;[0.75–0.88]) were protective factors.Conclusion. Infants <30 weeks' GA should be referred to level III facilities, since >50% require intensive care. Above 29 weeks' GA, decision of appropriate level of care could rely upon prenatal risk factors.