Periviable Gestational Ages Research Articles

Expectant management of preeclampsia with severe features diagnosed at less than 24 weeks

BackgroundThe recent ACOG practice bulletin offers no guidance on management of preeclampsia with severe features (PreE with SF) less than 24 weeks. Historically, immediate delivery was recommended due to poor perinatal outcomes and high maternal morbidity. Recently, advances in neonatal resuscitation have led to increased survival at peri-viable gestational ages. Study designWe aimed to report perinatal and maternal outcomes after expectant management of PreE with SF at < 24 weeks. MethodsThis was a retrospective case series of PreE with SF at < 24 weeks at a Level IV center between 2017-2023. Individuals requiring delivery within 24 hours of diagnosis were excluded. Perinatal and maternal outcomes were analyzed. Categorical variables from our database were compared to previously published data using chi squared tests. ResultsThere were 41 individuals diagnosed with PreE with SF < 24 weeks. After excluding for delivery within 24 hours, 30 individuals (73%) were evaluated. Median gestational age at diagnosis was 22 weeks (IQR 22-23 weeks). 16% had assisted reproductive technology, 27% had chronic hypertension, 13% had pregestational diabetes, 30% had prior preeclampsia, and 73% had BMI >30 kg/m2. Median latency at 22 and 23 weeks was 7 (IQR 4-23) and 8 days (IQR 4-13 days). Neonatal survival was 44% (95% CI 3-85%) for PreE with SF onset at 22 weeks and 29% (95% CI 1-56%) at 23 weeks. There were two cases of acute kidney injury (7%) and two cases of pericardial/pleural effusions (7%). Overall perinatal survival < 24 weeks was 30% in our current study versus 7% in previous reports (p=0.02). ConclusionFor cases of expectant management of PreE with SF at < 24 weeks, our findings show an increased rate of perinatal survival with decreased maternal morbidity compared to previously published data. This information may be used when counseling on expectant management of PreE with SF < 24 weeks.

Survival of infants born at periviable gestation: The US national database

Substantial differences exist in the approach to resuscitating infants born at periviable gestation. Evaluation of current survival may help guide prenatal counselling and provide accurate expectations of clinical outcomes. We aimed to assess the US national survival trends in periviable infants born at gestational age (GA) ≤24 weeks. We used de-identified patient data obtained from the US Healthcare Cost and Utilization Project (HCUP) from 2007 to 2018. All infants with documented GA ≤24 weeks were included. The Cochran-Armitage test was used for trend analyses. Regression analyses were conducted for variables associated with survival. A total of 44,628,827 infant records were identified with 124,345 (0.28%) infants born ≤24 weeks; of those, 77,050 infants <24 weeks and 47,295 infants had completed 24 weeks. Survival rates for infants <24 weeks and with completed 24 weeks were 15.4% and 71.6%, respectively, with higher survival over the years (Z = 9.438, P<0.001 & Z = 3.30, P<0.001, respectively). Survival was lower in males compared to females (aOR = 0.96, CI: 0.93-0.99 & aOR = 0.94, CI: 0.92-0.96, respectively) and with private insurance compared to public insurance (aOR = 0.74, CI: 0.71-0.77 & aOR = 0.67, CI: 0.65-0.69, respectively). Survival was higher when birth weight was >500g compared to ≤500g (aOR = 4.62, CI:3.23-5.02 & aOR = 5.44, CI: 4.59-5.84, respectively). Black (aOR = 1.33, CI: 1.31-1.36 & aOR = 1.24, CI: 1.20-1.32, respectively) and Hispanic (aOR = 1.29, CI: 1.27-1.32 & aOR = 1.27, CI: 1.22-1.30, respectively) had higher survival than White. There is a national increase in survival over the years in infants born at periviable GA. BW >500 is associated with >4 folds higher survival compared to ≤500g. The results of this study should be cautiously interpreted as long-term outcomes are unknown. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Neonatal outcomes in women with preterm premature rupture of membranes at periviable gestational age

To examine the outcomes of preterm infants born to women with preterm premature rupture of membranes (PPROM) at periviable gestational age. This is an observational retrospective cohort study analyzing data collected on singleton deliveries complicated by prolonged premature rupture of membranes occurring between 17 and 33 weeks of gestation. Neonatal outcomes including birth weight, Apgar score, retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, hearing impairment and mortality were evaluated. Ninety-four preterm infants who were born after a prolonged premature rupture of membranes of at least 7 days were included in the study. Median gestational week at onset of membrane rupture was 27.1 ± 4.2 weeks (range 17–33) and median latency period in days was 16 ± 21.8 (range 7–105). The cohort was stratified by gestational week (GW) at onset of PPROM (group 1: 17–23, group 2: 24–27, and group 3: 28–33). We found that the survival rate to discharge within neonates born after prolonged rupture of membrane at gestational week less than 24 weeks is 79.2% and 88.9% in group 2. These neonates did not show an increased rate of major morbidities compared to neonates born following membrane rupture at gestational week 24 to 27. We described a high survival rate to discharge without major morbidities following prolonged preterm membrane rupture of at least 7 days of latency before viability.

Care practices and outcomes of extremely preterm neonates born at 22-24 weeks - A single centre experience.

Wide variation in the care practices and survival rates of neonates born at peri-viable gestational ages of 22+0 - 24+6 weeks. This study elucidates the postnatal risk factors for morbidity/mortality, contrasts the care practices and short-term outcomes of this vulnerable group of preterm neonates from a single center with others. Retrospective study of neonates born at 22+0 -24+6 weeks in a level 3 neonatal intensive care unit in UK, over a period of 4 years (2016-2019). 94 neonates given active care were studied. Survival until discharge was 51.1%(22-23 wks -44%, 24 wks -59.1%) and survival with no major brain injury (MBI) [grade III/IV IVH, cystic periventricular leukomalacia] was 38.3%(22-23 wks -32%, 24 wks -45.4%). Of those who survived until discharge, 75%had no MBI (22-23 wks -72.7%, 24 wks -76.9%). Neonates requiring significant respiratory support within first 72 hours as well as needing rescue high frequency ventilation had significantly high risk of mortality or MBI [aOR -7.17 (2.24-25.79), p = 0.00; 4.76 (1.43-20.00), p = 0.01]. Survival rate differed from other centres. MBI was low amongst survivors. Severe respiratory disease in the initial days was associated with a higher risk of death or MBI.

Long-Term Amnioinfusion through an Intrauterine Catheter in Preterm Premature Rupture of Membranes before 26 Weeks of Gestation: A Retrospective Multicenter Study

Introduction: The objective of this study was to elucidate the efficacy of long-term amnioinfusion on perinatal outcomes in patients with preterm premature rupture of membranes (PPROM) before 26 weeks’ gestation. Material: A total of 31 patients with PPROM at a periviable gestational age (21 + 0–25 + 0 weeks) were enrolled. Long-term amnioinfusion was performed in 22 patients, and 9 patients did not receive amnioinfusion. Data were collected retrospectively from 2 clinical sites between January 2017 and March 2019. Results: In the medical management group, there was a significantly higher rate of chorioamnionitis compared to the long-term amnioinfusion group (89 vs. 15%, p = 0.001). The latency period between PPROM and delivery was higher in the amnioinfusion group (median, 5.5 vs. 3 weeks, p = 0.04). The frequency of bronchopulmonary dysplasia was higher in the control group compared to the amnioinfusion group (89 vs. 40%, p = 0.03). The rates of other neonatal complications were similar in both groups. Conclusions: Long-term amnioinfusion through an intrauterine catheter in PPROM before 26 weeks’ gestation may improve pregnancy and newborn outcomes.

Maternal morbidity after early preterm delivery (23–28 weeks)

Previous research has focused mainly on neonatal outcomes associated with preterm and periviable delivery, but maternal outcomes with preterm delivery are less well described. This study aimed to determine if early preterm delivery results in an increase in maternal morbidity. This is a retrospective cohort study conducted at a tertiary care center over a 5-year time period. Subjects were women identified by review of neonatal intensive care unit admission logs. Women were included if they delivered between 23 0/7 and 28 6/7 weeks' gestation and their neonate was admitted to the neonatal intensive care unit. The prevalence of maternal morbidities was assessed, including blood transfusion, maternal infection, placental abruption, postpartum depression or positive depression screen, hemorrhage, and prolonged maternal postpartum hospitalization. A composite outcome comprising blood transfusion, maternal infectious morbidity, placental abruption, and postpartum depression was developed. Outcomes for women who delivered between 23 0/7 and 25 6/7 weeks' gestation (early group) and 26 0/7 and 28 6/7 weeks' gestation (late group) were compared. Multivariate logistic regression analysis was performed to evaluate contributors to the composite morbidity, controlling for confounding. A total of 82 women met the inclusion criteria: 38 in the early group and 44 in the late group. Maternal demographics were similar between the groups. The early group was significantly more likely to experience composite maternal morbidity (60.5% vs 27.3%; P=.004) and infection (42.1% vs 13.6%; P=.006). Regression analysis determined that delivery at a later gestational age was associated with lower rates of composite morbidity (odds ratio, 0.6; 95% confidence interval, 0.41-0.83). In this study, data suggest that maternal morbidity is higher with delivery at periviable gestational ages. Composite morbidity and maternal infection were more frequent in women who delivered at less than 26 weeks' gestation. The management of women at risk for delivery at early gestational ages should include a discussion of increased maternal complications.

Bronchopulmonary dysplasia: how can we improve its outcomes?

Bronchopulmonary dysplasia (BPD) is a chronic lung disease of preterm infants with multiple factors affected from prenatal to postnatal periods. Despite significant advances in neonatal care over almost 50 years, BPD rates have not decreased; in fact, they may have even increased. Since more preterm infants, even at periviable gestational age, survive today, different stages of lung development affect the pathogenesis of BPD. Hence, the definition of BPD has changed from “old” to “new.” In this review, we discuss the various definitions of BPD, risk factors from the prenatal to postnatal periods, management strategies by phase, and future directions for research.

Impact of Regional Variation and Practitioner Bias on Infant Mortality Rate: A Survey Study [12L

INTRODUCTION: Periviable birth is a primary driver of IMR in the US and varies significantly among regions. We measured practice variation in how periviable pregnancy outcomes are categorized and how this impacts reported regional IMRs. METHODS: We distributed a 28-item questionnaire to practitioners associated with US birth hospitals. Five clinical scenarios were included to identify how participants classify birth outcomes from 15-22 weeks. Practice characteristics potentially affecting reporting of birth outcomes were assessed. IRB approval was obtained. RESULTS: Of 1024 questionnaires distributed, 237 were completed (23% response rate). Responses were compared among US census regions; 8.4% from the Northeast, 56.1% Midwest, 13.9% South, 5.4% West; 16% did not disclose. Despite >90% participants classifying a 14-week loss without signs of life as a miscarriage, 19% would provide a certificate of fetal death. 51% who would not initially provide a certificate would give one upon request, yielding a potential fetal death reporting rate of 32% for a 14-week pregnancy loss. Likewise, 32% would provide a certificate of live birth for a 16-week loss with signs of life, with notable regional variation in classifying this as a live birth (41% Northeast, 44% Midwest, versus 13% South, 18% West, p=0.003). CONCLUSION: Practice variation in recording birth outcomes at periviable gestational ages was noted in our study. This may contribute to significant misrepresentation of the frequency of miscarriage, stillbirth and live births and could influence regional variation in reported birth outcomes.

Neonatologists less frequently discuss long term complications: A simulation-based study of prenatal consults beyond the threshold of viability.

Guidelines exist for counseling expectant families of infants at periviable gestational ages (22-25 weeks), but it is much more common for neonatologists to counsel families at gestational ages beyond the threshold of viability when several aspects of these guidelines do not apply. We aimed to develop an understanding of what information is shared with mothers at risk of preterm delivery beyond periviability and to evaluate communication skills of our participants. We developed a checklist of elements to include in counseling based on a comprehensive literature review. The checklist was divided into an information sharing section and a connect score. The information sharing list was sub-divided into general information and specific complications. Neonatologists engaged in a simulated prenatal counseling session with a standardized patient. Videotaped encounters were then analyzed for checklist elements. Neonatologists all scored well in communication using our tool and two other validated communication tools - the SEGUE and the analytic global OSCE. There was no difference in scoring based on years of experience or level of training. Information sharing from neonatologists more often discussed general information over specific. Neonatologists also focused more on early outcomes over long-term outcomes. Only 12% of neonatologists quoted the correct survival rate for the case. Neonatologists generally communicate well but share less information specific to prematurity and the long-term sequelae of prematurity. Our tool may be used to test if other interventions improve information sharing or communication.

Induction of Labor for Maternal Indications at a Periviable Gestational Age; Survey on Management, Reporting and Auditing amongst Dutch Maternal-Fetal Medicine Specialists and Neonatologists.

Background In cases of life-threatening maternal conditions in the periviable period, professionals may consider immediate delivery with fetal demise as a consequence of the treatment. We sought the opinion of involved medical professionals on management, reporting, and auditing in these cases. Methods We performed an online survey amongst all registered maternal-fetal medicine (MFM) specialists and neonatologists in the Netherlands. The survey presented two hypothetical cases of severe early-onset pre-eclampsia at periviable gestational ages. Management consisted of immediate termination or expectant management directed towards newborn survival. Findings In the case managed by immediate termination, 62% percent answered that fetal demise resulting from induction of labor for maternal indications should be audited only within the medical profession. In the case of expectant management, 17% of the participants agreed with this management. Some answers revealed a significant difference in opinion between the medical specialists. Conclusion Perspective of MFM specialists and neonatologists differs with regard to counseling prospect parents in case of severe early onset pre-eclampsia. The majority of professionals is willing to report late termination (after 24 weeks' gestation) for severe maternal disease to medical experts for internal audits but not for legal auditing.

13. Induction of labor for maternal indications at a periviable gestational age; survey on management, reporting and auditing amongst dutch maternal-fetal medicine specialists and neonatologists

Background In exceptional cases of severe and life-theatening maternal conditions in the periviable period, professionals may consider immediate delivery the only option to prevent deterioration of the maternal illness. Fetal demise is then the inevitable consequence of the treatment of the mother. We sought the opinion of involved medical specialists on management, reporting and auditing in these difficult cases. Methods All registered fetal-maternal medicine specialists (MFM-specialists) (n = 197) and neonatologists (n = 282) were invited to participate in an online survey. The survey presented to hypothetical cases of severe early-onset preeclampsia at periviable gestational age. Two management-options were presented: immediate delivery and expectant management directed towards newborn survival. During expectant management two epsiodes with eclamptic seizures occured. Findings In the case managed by immediate termination, 62% answered that fetal demise resulting from induction of labor for severe maternal illness should be audited within the medical profession only. In the case managed expectantly, 17% agreed with this management. 75% of MFM-specialists answered that an eclamptic seizure is always a reason for immediate delivery. Some answers revealed a significant difference in opinion between the MFM-specialists and the neonatologists. The first concern of the MFM-specialists is the health of the mother, while the first concern of the neonatologists is, to achieve optimal gestational age for the newborn. Conclusion Perpective of MFM-specialists and neonatologists differs with regard to counseling prospect parents in case of severe early-onset preeclampsia. The majority of professionals is willing to report late termination of pregnancy (after 24 weeks’ gestation) for severe maternal disease to medical experts for internal audits, but not for legal auditing.

Continuous amnioinfusion in women with PPROM at periviable gestational ages

Objective: To elucidate the efficacy of continuous amnioinfusion on perinatal outcome in women with preterm premature rupture of membranes (PPROM) at periviable gestational ages.Methods: A database was reviewed to identify women with singleton pregnancies who were admitted to the Japanese Red Cross Nagoya Daiichi Hospital due to PPROM before 26 + 0-week gestation between July 2009 and July 2017.Results: A total of 81 women met the criteria for inclusion in this study including 70 and 11 women with and without amnioinfusion, respectively. The latency period between PPROM and delivery was significantly longer in women who underwent amnioinfusion compared with women without amnioinfusion (median: 13 versus 4 days, p < .001). In the survival analysis, the number of women who remained undelivered was significantly higher in the amnioinfusion group than in the non-amnioinfusion group for each gestational age after PPROM (p < .001). Cox’s proportional hazards analysis with stepwise backward selection showed that both white blood cell counts on admission and amnioinfusion finally remained as variables that affected the time interval between PPROM and delivery [hazard ratio (95% confidence interval): 1.12 (1.06–1.18) and 0.34 (0.12–0.98), respectively].Conclusions: Continuous amnioinfusion in women with PPROM at periviable gestational ages resulted in significant prolongation of pregnancy and may help improve neonatal outcomes.

Uterine Rupture Risk After Periviable Cesarean Delivery

To investigate the risk of uterine rupture in women with prior periviable cesarean delivery and prior term cesarean delivery independent of initial incision type. We conducted a retrospective longitudinal cohort study using Washington state birth certificate data and hospital discharge records, identifying primary cesarean deliveries performed at 20-26 weeks and 37-41 weeks of gestation with subsequent delivery between 1989 and 2008. We compared subsequent uterine rupture risk in the two groups considering both primary incision type and subsequent labor induction and augmentation. We identified 456 women with index periviable cesarean delivery and 10,505 women with index term cesarean delivery. Women with index periviable cesarean delivery were younger, more frequently of nonwhite race, more likely to smoke, and more likely to have hypertension. Women in the periviable group had more index classical incisions (42% compared with 1%, P<.001) and fewer subsequent inductions and augmentations (8% compared with 16%, P<.001). Uterine rupture in the subsequent pregnancy occurred more frequently among women in the index periviable group than those in the index term group (8/456 [1.8%] compared with 38/10,505 [0.4%], odds ratio [OR] 4.9, 95% confidence interval [CI] 2.3-10.6). This relationship persisted among women with a low transverse incision (4/228 [1.8%] compared with 36/9,558 [0.4%], OR 4.7, 95% CI 1.7-13.4). Cesarean delivery at periviability compared with term is associated with an increased risk for uterine rupture in a subsequent pregnancy, even after low transverse incision. These data support judicious use of cesarean delivery at periviable gestational ages and inform subsequent counseling. II.

Shades of Gray: Managing Delivery at the Edge of Viability

The management and counseling of women at risk for delivering fetuses of periviable gestational age (defined as 20 0/7 weeks through 25 6/7 weeks) is

86: Estimation of fetal weight at peri-viable gestational ages: how inaccurate are we and does that impact risk of death?

86: Estimation of fetal weight at peri-viable gestational ages: how inaccurate are we and does that impact risk of death?

197: Neonatal outcomes at periviable gestational ages: does half a week make a difference?

197: Neonatal outcomes at periviable gestational ages: does half a week make a difference?

Mode of delivery at periviable gestational ages: impact on subsequent reproductive outcomes

Mode of delivery at periviable gestational ages: impact on subsequent reproductive outcomes

Mode of delivery at periviable gestational ages: impact on subsequent reproductive outcomes

The aim of this study was to assess the risk of subsequent delivery complications after extremely preterm deliveries by initial (index) pregnancy mode of delivery (MOD): cesarean (CD) versus vaginal (VD). This is a retrospective, longitudinal cohort study using Washington State birth certificate data and International Classification of Diseases, Ninth Revision codes, 1989-2008, identifying women with deliveries 20-26 weeks' gestation and linked subsequent deliveries. Index MOD was considered as a predictor of adverse subsequent maternal and neonatal outcomes, using t-test, χ(2)-test or Fisher's exact test, and regression analysis. Of 2472 women with periviable delivery and subsequent birth, index CD (n=386) and index VD (n=2086) showed similar risks of composite morbidity (16.1% vs. 15.4%, P=0.76) and subsequent hemorrhage (9.6% vs. 11.1%, P=0.39). Women with index CD were more likely than index VD to experience uterine rupture (1.8% vs. 0.1%, P<0.001), to deliver earlier (35.9 vs. 36.9 weeks, P<0.001), and to have lower birth weight (2736 vs. 3014 g, P<0.001) subsequently. Neonatal hospital charges and lengths of stay were also higher after index CD. MOD at extreme prematurity did not impact subsequent maternal hemorrhage or overall morbidity. However, CD was associated with substantial uterine rupture risk despite evidence of practice to avoid labor (lower birth weight and earlier delivery) in the subsequent pregnancy.

536: Twin gestations at periviable gestational age: are two worse than one?

536: Twin gestations at periviable gestational age: are two worse than one?