Is there a ‘borderline of viability’?

Abstract

The article by Lui et al. that leads the obstetrics section of this issue is a significant contribution to the debate about resuscitation at the extreme of prematurity, when both survival and intact survival are in doubt. They report the results of a consensus conference, which I was fortunate to attend, at which those involved in perinatal care in New South Wales and the Australian Capital Territory debated the concept of the ‘borderline of viability’. The outcome from this was the clear view that there should be a ‘grey zone’ at which the wishes of parents should be paramount. The second important concept is that not only gestational age, but also the obstetric risk factors present around the time of birth should determine the strength of the advice given concerning prognosis. What may surprise some readers is that a sizable group of participants felt that even up to the end of the twenty-fifth week, it was reasonable to withhold active resuscitation if the parents held that view. Not everyone will agree with this conclusion, and in particular it is important to acknowledge that outcomes may be dependent on where you are born, as well as the population from which you are derived. It is therefore vital that the information given to parents is based on local data that truly reflect the outcomes that can be expected. It is also essential that this information be given to parents in a way that ensures that they are as well informed as they can be in such a crisis as the imminent birth of an extremely preterm infant. There is perhaps a role for developing an information package that could be given to all pregnant women so that they are at least forewarned of the possibility of facing this extremely difficult ethical dilemma. Notwithstanding the degree of certainty about gestational age and prognosis, it is absolutely essential that every preterm infant be given the best possible chance, if resuscitation is to be initiated. This means being born in the right place (ie a tertiary perinatal centre) and in the best possible condition, as well as having received a course of antenatal corticosteroids. It is concerning that there are still significant numbers of extremely preterm infants who are born without these three major advantages, and this remains a major challenge for modern perinatal care. Recently, the National Health and Medical Research Council rescinded the Clinical Practice Guidelines, ‘Care Around Pre-term Birth’, that were published in early 1997, as they are now in need of updating. It should be a responsibility of all those health professionals involved in perinatal care to ensure that these guidelines are both updated and implemented. Also in this issue is an interesting review article on the conventional and non-conventional management of recurrent vulvovaginal candidiasis. This should be a valuable article that discusses in some detail the evidence for and against the various management strategies of this very common problem. Finally, the report on the use of rosiglitazone for reducing the size of endometriosis implants in a rat model may be the first step towards a novel approach to treatment of this debilitating disease.