Periviable Delivery Research Articles

Assessment of obstetric characteristics and outcomes associated with pregnancy with Turner syndrome

To assess national-level trends, characteristics, and outcomes of pregnancies with Turner syndrome in the United States. Cross-sectional study. The Healthcare Cost and Utilization Project's National Inpatient Sample. A total of 17,865,495 hospital deliveries from 2016-2020. A diagnosis of Turner syndrome, identified according to the World Health Organization's International Classification of Disease 10th revision code of Q96. Obstetrics outcomes related to Turner syndrome, assessed with inverse probability of treatment weighting cohort and multivariable binary logistic regression modeling. The prevalence of pregnant patients with Turner syndrome was 7.0 per 100,000 deliveries (one in 14,235). The number of hospital deliveries with patients who have a diagnosis of Turner syndrome increased from 5.0 to 11.7 per 100,000 deliveries during the study period (adjusted-odds ratio [aOR] for 2020 vs. 2016; 2.18, 95% confidence interval [CI] 1.83-2.60). Pregnant patients with Turner syndrome were more likely to have a diagnosis of pregestational hypertension (4.8% vs. 2.8%; aOR 1.65; 95% CI 1.26-2.15), uterine anomaly (1.6% vs. 0.4%; aOR, 3.01; 95% CI 1.93-4.69), and prior pregnancy losses (1.6% vs. 0.3%; aOR 4.70; 95% CI 3.01-7.32) compared with those without Turner syndrome. For the index obstetric characteristics, Turner syndrome was associated with an increased risk of intrauterine fetal demise (10.9% vs. 0.7%; aOR 8.40; 95% CI 5.30-13.30), intrauterine growth restriction (8.5% vs. 3.5%; aOR 2.11; 95% CI 1.48-2.99), and placenta accreta spectrum (aOR 3.63; 95% CI 1.20-10.97). For delivery outcome, pregnant patients with Turner syndrome were more likely to undergo cesarean delivery (41.6% vs. 32.3%; aOR 1.53; 95% CI 1.26-1.87). Moreover, the odds of periviable delivery (22-25 weeks: 6.1% vs. 0.4%; aOR 5.88; 95% CI 3.47-9.98) and previable delivery (<22 weeks: 3.3% vs. 0.3%; aOR 2.87; 95% CI 1.45-5.69) were increased compared with those without Turner syndrome. The results of contemporaneous, nationwide assessment in the United States suggest that although pregnancy with Turner syndrome is uncommon this may represent a high-risk group, particularly for intrauterine fetal demise and periviable delivery. Establishing a society-based approach for preconception counseling and antenatal follow-up would be clinically compelling.

Feasibility and acceptability of chaplain decision coaching on Periviable resuscitation decision quality: A pilot study

ObjectiveTo pilot test and assess the feasibility and acceptability of chaplain-led decision coaching alongside the GOALS (Getting Optimal Alignment around Life Support) decision support tool to enhance decision-making in threatened periviable delivery. MethodsPregnant people admitted for threatened periviable delivery and their ‘important other’ (IO) were enrolled. Decisional conflict, acceptability, and knowledge were measured before and after the intervention. Chaplains journaled their impressions of training and coaching encounters. Descriptive analysis and conventional content analysis were completed. ResultsEight pregnant people and two IOs participated. Decisional conflict decreased by a mean of 6.7 (SD = 9.4) and knowledge increased by a mean of 1.4 (SD = 1.8). All rated their experience as “good” or “excellent,” and the amount of information was “just right.” Participants found it “helpful to have someone to talk to” and noted chaplains helped them reach a decision. Chaplains found the intervention a valuable use of their time and skillset. ConclusionThis is the first small-scale pilot study to utilize chaplains as decision coaches. Our results suggest that chaplain coaching with a decision support tool is feasible and well-accepted by parents and chaplains. InnovationsOur findings recognize chaplains as an underutilized, yet practical resource in value-laden clinical decision-making.

Short Cervix Following Initial Cerclage-Reinforcing Cerclage Versus Expectant Management

ObjectivesTo determine whether reinforcing cerclage following ultrasound evidence of cerclage failure before 24 weeks is an effective method to delay gestational age at delivery, and to decrease the rate of preterm and peri-viable delivery. MethodsA retrospective review was conducted for all patients who underwent any cervical cerclage procedure at a single tertiary care centre in Toronto, Canada between 1 December 2007 and 31 December 2017. ResultsOf 1482 cerclage procedures completed during the study period, 40 pregnant persons who underwent reinforcing cerclage were compared with 40 pregnant persons who were found to have cerclage failure before 24 weeks but were managed expectantly. After adjusting for the shortest cervical length measured prior to 24 weeks, there was no significant difference between the reinforcing cerclage and control group for gestational age at delivery, preterm, or peri-viable birth (P = 0.52, P = 0.54, P = 0.74, respectively). In an unadjusted model, there was a statistically significant increase in placental infection identified on postpartum placenta pathology in the reinforcing cerclage group compared with the expectant management group, 92.9% compared with 66.7% (P = 0.028). ConclusionReinforcing cerclage is unlikely to successfully delay the gestational age at delivery and reduce rates of preterm and pre-viable birth, especially if irreversible and progressive cervical change has begun. Future work should examine the role of preoperative amniocentesis to explore the impact of pre-existing intra-amniotic infection and reinforcing cerclage success.

Threatened Periviable Delivery and Abortion: Clinical Considerations.

Periviable delivery, or a pregnancy at risk of delivery between 20 0/7 and 25 6/7 weeks gestational, is an uncommon event with profound physical, psychological, and financial impact. Neonatal outcomes can be hard to predict and with the changing legal landscape around abortion access, management options may be compromised. Dynamic maternal and fetal factors make a cohesive and supportive care team critical for optimal care. Management of threatened periviable delivery in a post-Roe United States may prioritize fetal outcomes regardless of threat to maternal health due to legal restrictions.

Pregnancy with retained intrauterine device: national-level assessment of characteristics and outcomes

Although intrauterine devices provide effective contraceptive protection, unintentional pregnancy can occur. Previous studies have shown that a retained intrauterine device during pregnancy is associated with adverse pregnancy outcomes but there is a paucity of nationwide data and analysis. This study aimed to describe characteristics and outcomes of pregnancies with a retained intrauterine device. This serial cross-sectional study used data from the Healthcare Cost and Utilization Project's National Inpatient Sample. The study population comprised 18,067,310 hospital deliveries for national estimates from January 2016 to December 2020. The exposure was retained intrauterine device status, identified by the World Health Organization's International Classification of Diseases, Tenth Revision, code O26.3. The co-primary outcome measures were incidence rate, clinical and pregnancy characteristics, and delivery outcome of patients with a retained intrauterine device. To assess the pregnancy characteristics and delivery outcomes, an inverse probability of treatment weighting cohort was created to mitigate the prepregnant confounders for a retain intrauterine device. A retained intrauterine device was reported in 1 in 8307 hospital deliveries (12.0 per 100,000). In a multivariable analysis, Hispanic individuals, grand multiparity, obesity, alcohol use, and a previous uterine scar were patient characteristics associated with a retained intrauterine device (all P<.05). Current pregnancy characteristics associated with a retained intrauterine device included preterm premature rupture of membrane (9.2% vs 2.7%; adjusted odds ratio, 3.15; 95% confidence interval, 2.41-4.12), fetal malpresentation (10.9% vs 7.2%; adjusted odds ratio, 1.47; 95% confidence interval, 1.15-1.88), fetal anomaly (2.2% vs 1.1%; adjusted odds ratio, 1.71; 95% confidence interval, 1.03-2.85), intrauterine fetal demise (2.6% vs 0.8%; adjusted odds ratio, 2.21; 95% confidence interval, 1.37-3.57), placenta malformation (1.8% vs 0.8%; adjusted odds ratio, 2.12; 95% confidence interval, 1.20-3.76), placenta abruption (4.7% vs 1.1%; adjusted odds ratio, 3.24; 95% confidence interval, 2.25-4.66), and placenta accreta spectrum (0.7% vs 0.1%; adjusted odds ratio, 4.82; 95% confidence interval, 1.99-11.65). Delivery characteristics associated with a retained intrauterine device included previable loss at <22 weeks' gestation (3.4% vs 0.3%; adjusted odds ratio, 5.49; 95% confidence interval, 3.30-9.15) and periviable delivery at 22 to 25 weeks' gestation (3.1% vs 0.5%; adjusted odds ratio, 2.81; 95% confidence interval, 1.63-4.86). Patients in the retained intrauterine device group were more likely to have a diagnosis of retained placenta at delivery (2.5% vs 0.4%; adjusted odds ratio, 4.45; 95% confidence interval, 2.70-7.36) and to undergo manual placental removal (3.2% vs 0.6%; adjusted odds ratio, 4.81; 95% confidence interval, 3.11-7.44). This nationwide analysis confirmed that pregnancy with a retained intrauterine device is uncommon, but these pregnancies may be associated with high-risk pregnancy characteristics and outcomes.

Association Between Periviable Delivery and New Onset of or Exacerbation of Existing Mental Health Disorders.

To evaluate whether there is an association between periviable delivery and new onset of or exacerbation of existing mental health disorders within 12 months postpartum. We conducted a retrospective cohort study of individuals with liveborn singleton neonates delivered at 22 or more weeks of gestation from 2008 to 2017 in the MarketScan Commercial Research Database. The exposure was periviable delivery , defined as delivery from 22 0/7 through 25 6/7 weeks of gestation. The primary outcome was a mental health morbidity composite of one or more of the following: emergency department encounter associated with depression, anxiety, psychosis, posttraumatic stress disorder, adjustment disorder, self-harm, or suicide; new psychotropic medication prescription; new behavioral therapy visit; and inpatient psychiatry admission in the 12 months postdelivery. Secondary outcomes included components of the primary composite. Those with and without periviable delivery were compared using multivariable logistic regression adjusted for clinically relevant covariates, with results reported as adjusted incident rate ratios (aIRRs). Effect modification by history of mental health diagnoses was assessed. Incidence of the primary outcome by 90-day intervals postdelivery was assessed. Of 2,300,244 included deliveries, 16,275 (0.7%) were periviable. Individuals with periviable delivery were more likely to have a chronic health condition, to have undergone cesarean delivery, and to have experienced severe maternal morbidity. Periviable delivery was associated with a modestly increased risk of the primary composite outcome, occurring in 13.8% of individuals with periviable delivery and 11.0% of individuals without periviable delivery (aIRR 1.18, 95% CI 1.12-1.24). The highest-risk period for the composite primary outcome was the first 90 days in those with periviable delivery compared with those without periviable delivery (51.6% vs 42.4%; incident rate ratio 1.56, 95% CI 1.47-1.66). Periviable delivery was associated with a modestly increased risk of mental health morbidity in the 12 months postpartum.

Evaluating maternal quality of life following a periviable delivery

Data on long-term maternal quality of life (QOL) following a periviable delivery are lacking. We investigated QOL measures among patients who delivered a periviable infant. Retrospective cohort study of patients who delivered between gestational ages 22 0/7 - 25 6/7 at a single institution from 2013-2019. Trained personnel contacted eligible participants by phone and administered the validated World Health Organization Quality of Life Instrument (WHOQOL-BREF). Patients who had a surviving infant discharged from the hospital were compared with those who had an intrauterine or neonatal demise. Baseline characteristics were summarized, and scores were evaluated based on the 4 prespecified domains: physical health, psychological, social relationships, and environment. A total of 58 patients participated: 32 with a surviving infant and 26 with a demise. Maternal age was lower in the surviving infant cohort (25.2 ± 3.9 vs 29.0 ± 6.0, p< 0.01). Race, insurance status, maternal medical conditions, marital status, and delivery mode did not differ. Mean duration from delivery to study start date did not differ (5.1 ± 2.0 vs 4.5 ± 2.1 years, p=0.31). Complications in surviving infants included intraventricular hemorrhage (44%), necrotizing enterocolitis (16%), retinopathy of prematurity requiring treatment (37%), pulmonary hypertension (28%), respiratory support at discharge (56%), and concern for cerebral palsy (31%). Higher scores indicate higher QOL. Patients with surviving infants scored higher in the WHOQOL-BREF psychological and social relationship domains compared to those who had a demise. Patients with a surviving infant were more likely to be satisfied with their own health (4.3 ± 0.7 vs. 3.8 ± 0.8, p=0.02), but reported a similar QOL (Table). Additionally, patients who experienced a demise were less likely to be satisfied with their health, finances, sleep, sex life, and social support. Patients with an infant who survives a periviable birth, despite possible long term health complications for the infants, appear to have an improved quality of life in some domains.

Mode of delivery in the context of periviable birth: informed deference and shared decision-making.

To qualitatively evaluate women's perspectives on shared decision-making for periviable (22-25 weeks' gestational age) mode of delivery (MOD). Interviews were conducted at two Midwestern academic hospitals with 30 women hospitalized for threatened periviable delivery between September 2016 and January 2018. Prior to delivery (T1) and at 3-months postpartum (T2), MOD-related decision-making was explored using prompts. Interviews were coded and analyzed using NVivo 12. The majority of women perceived the MOD options as cesarean section or vaginal delivery. Most ultimately preferred "whatever's best for baby." Understanding of MOD risks was limited, and physicians recommended each option equally. Sixteen participants perceived themselves as decision-makers at T1, while at T2, only nine participants identified themselves as such. Informed deference is introduced as a novel concept in the setting of periviable MOD decision-making, whereby the mother defers decisional authority to the provider, the baby, a higher power, or the circumstance itself.

Periviable Decision-Making in a New Era of Parentage: Ethical and Legal Considerations and Provider Perspectives on Shared Decision-making in Diverse Family Structures

To explore providers' perspectives about decisional authority, conflict resolution, and diverse family structures within the context of periviable delivery (eg, between 22 and 25weeks of gestation), with the ultimate goal of helping practitioners support, engage, and navigate conflict with parents facing periviable delivery. Qualitative interviews with 30 neonatologists and obstetricians sought opinions about whether and how a pregnant person's partner should be involved in making periviable treatment decisions and how health care teams should proceed when parents do not agree on a treatment plan. Physicians were asked to consider whether their opinions changed under different scenarios involving marriage, biological relationship, adoption, and surrogacy. Interviews revealed 4 main themes corresponding to providers' perspectives regarding partner involvement and decisional authority: providers care; involvement matters; mom is the priority; and uncertainty and guidance needed. Unique themes arose when discussing diverse family structures. Shared decision making is optimal in the setting of periviable delivery, where decisions are both preference sensitive and value laden. Our interviews suggest that incorporating the dynamics and impact of partners' involvement in periviable resuscitation decision-making may facilitate more shared, equitable, and high-quality decision-making tailored to the needs of both pregnant people and their partners.

Factors Associated with Receiving No Maternal or Neonatal Interventions among Periviable Deliveries.

The aim of this study was to quantify the influence of maternal sociodemographic, medical, and pregnancy characteristics on not receiving maternal and neonatal interventions with deliveries occurring at 22 to 23 weeks of gestation. This was a case-control study of U.S. live births at 220/6 to 236/7 weeks of gestation using vital statistics birth records from 2012 to 2016. We analyzed births that received no interventions for periviable delivery. Births were defined as having no interventions if they did not receive maternal (cesarean delivery, maternal hospital transfer, or antenatal corticosteroid administration) or neonatal interventions (neonatal intensive care unit admission, surfactant administration, antibiotic administration, or assisted ventilation). Logistic regression estimated the influence of maternal and pregnancy factors on the receipt of no interventions when delivery occurred at 22 to 23 weeks. Of 19,844,580 U.S. live births in 2012-2016, 24,379 (0.12%) occurred at 22 to 23 weeks; 54.3% of 22-week deliveries and 15.7% of 23-week deliveries received no interventions. Non-Hispanic Black maternal race was associated with no maternal interventions at 22 and 23 weeks. Private insurance, singleton pregnancy, and small for gestational age were associated with receiving no neonatal interventions at 22 and 23 weeks of gestation. Withholding or refusing maternal and neonatal interventions occurs frequently at the threshold of viability. Our data highlight various sociodemographic, pregnancy, and medical factors associated with decisions to not offer or receive maternal or neonatal interventions when birth occurs at the threshold of viability. The data elucidate observed practices and may assist in the development of further research. · Non-Hispanic Black race was associated with receiving no maternal interventions.. · Indicators of high socioeconomic status were associated with no neonatal inventions.. · Patient-level factors influence the receipt of no interventions for periviable birth..

Periviable Delivery Management and Outcomes in a Largely Native Hawaiian, Pacific Islander, and Asian Population [A170

INTRODUCTION: Racial disparities among Native Hawaiian, Pacific Islanders, and select Asian subgroups have been reported in obstetric outcomes. We describe periviable delivery management and outcomes by maternal race at the highest-volume labor and delivery unit in Hawai‘i. METHODS: This was a retrospective cohort study of births from 2017 to 2019 between 22 and 24 weeks of gestation at our institution. Maternal and neonatal outcomes were stratified by self-reported race and analyzed with Fisher’s exact tests. A P value &lt;.05 was considered significant. RESULTS: A total of 74 neonates were born of 63 gravidas (53 singleton, nine twins, one triplets). Of these, 13 were born at 22 weeks, 22 at 23 weeks, and 32 at 24 weeks. In all, 65 neonates received some form of resuscitation. Native Hawaiians comprised 38% of periviable births, followed by Asians (19%) and White individuals (15%). The racial composition of periviable deliveries was similar to that of the overall State of Hawai‘i live birth rate. Among maternal outcomes, the cesarean delivery rate was 54%, of which 90% were classical hysterotomies. Neonatal survival among those who received resuscitation was 14% at 22 weeks, 41% at 23 weeks, and 63% at 24 weeks. Survival at 22 and 23 weeks did not vary by race, but at 24 weeks this trended toward significance (P=.056). CONCLUSION: Survival rates between 22 and 24 weeks of gestation at our institution were comparable to other published cohorts, without obvious racial disparities. Neonatal resuscitation and cesarean delivery were common among all racial groups. These data provide background for future studies examining periviable outcomes in this uniquely diverse and understudied population.

Periviable Breech Delivery Decision Analysis

Background/Objective: The optimal mode of delivery (MOD) for malpresentation in periviable deliveries (22-24 weeks), remains a source of debate. Neonatal and maternal complications can arise from both vaginal (VD) and cesarean delivery (CD), and the threat of maternal morbidity extends to subsequent pregnancies. It has been difficult to compare these risks while counseling patients about MOD options, so we sought to create a decision tree that maps probable outcomes associated with breech deliveries at 23- and 24-weeks’ gestation, as well as complications posed for subsequent pregnancies. &#x0D; &#x0D; Methods: An extensive literature review was conducted to identify risk estimates of periviable maternal and neonatal outcomes, along with elective repeat CD (ERCD) and trial of labor after cesarean (TOLAC) for subsequent pregnancies. Probabilities were inputted into TreeAge software, starting with primary maternal health states that may result from CD and VD – “death”, “hysterectomy”, or “no hysterectomy”, followed by the probability of neonatal health states– “death”, “severe morbidity”, or “no severe morbidity”. The likelihood of placenta previa or normal placenta was considered for subsequent pregnancies. We factored in the possibility of ERCD or TOLAC and the associated maternal and neonatal risks for each. &#x0D; &#x0D; Results: Final design of the tree is complete and risk estimates have been inputted. Primary analysis and sensitivity analyses are planned for August 2021. Ultimately, we will also be able to use measured utility values to calculate quality adjusted life years (QALYs) for each health state. &#x0D; &#x0D; Conclusion and Clinical Impact: Whether CD or VD is optimal for breech presentation in periviable delivery is influenced by a complex array of factors, including future reproductive plans and maternal values related to potential neonatal and maternal morbidity and mortality. Quantifying risks associated with each MOD will aid providers in their efforts to help families make informed decisions and reduce morbidity across the reproductive lifespan.

Periviability Decision-Making: Assessing Provider Characteristics and Cognitive Traits.

Background: To investigate maternal-fetal medicine (MFM) physicians' approaches to periviable delivery management and examine whether personal characteristics, practice features, or cognitive traits are associated with these approaches.Study Design: This was a cross-sectional survey study of Society for Maternal-Fetal Medicine members. Participants were queried regarding recommendations for periviable delivery management based on eight scenarios, as well as personal/practice characteristics and cognitive traits. Responses to scenarios were summarized as “willingness to intervene” and “willingness to recommend termination” scores. We performed a planned sensitivity analysis of the 21-week scenarios, a point considered by some to have clinical equipoise. Top quartile scores were compared with those in the lower three using bivariable and multivariable analyses. Primary analysis assessed association of recommendations with cognitive traits. Secondary analyses included assessment of recommendations with provider personal and practice characteristics.Results: Of 166 respondents, mean age was 45.5 years (±11.4) and 68.7% were female. Willingness to recommend termination was associated with less willingness to consider cerclage for self or loved one (26.7% vs. 69.4%, p < 0.001) and residence in the West or Northeast (p = 0.037). Cognitive scores were not associated with recommendations. At 21 weeks, respondents in the top quartile for coping skills were more likely to recommend termination (88% vs. 50%, p = 0.017), a finding which persisted after controlling for region (adjusted odds ratio 7.3, 95% confidence interval 1.6–33.0).Conclusion: MFM physician recommendations for management of pregnancies at risk of periviable delivery were not associated with provider cognitive traits overall, but did vary by provider personal and practice characteristics. In this small, exploratory study, cognitive traits such as coping skills were associated with recommendations, specifically when counseling women at points of clinical equipoise.

User-testing of a decision-support tool for parents facing threatened periviable delivery: The Periviable GOALS decision aid

BackgroundTo report user-centered design methods and stakeholder acceptability ratings of the Periviable GOALS (Getting Optimal Alignment around Life Support) decision aid (DA). Methods‘Experienced’ and ‘expectant’ mothers engaged in content and design refining sessions. Five videos (10 families) were embedded in the DA to highlight life after delivery. User-testing sessions were conducted with mothers and providers to assess acceptability. End-user testing was conducted with hospitalized women facing potential periviable delivery to assess acceptability and feasibility in the clinical setting. Results108 participants engaged in sessions from July 2017-January 2020. Twenty-seven refining sessions resulted in a DA providing survival estimates, neonatal outcomes descriptions, and values clarification exercises. Five white and five black women participated in the videos; six having surviving children (ages 16 months-4 years). Twelve mothers, 16 providers, and six hospitalized women evaluated acceptability. 95.1 % found the content “just right,” 94.9 % rated the videos “good” or “excellent,” and 97.2 % believed GOALS would support families in periviable decision-making. ConclusionOur results highlight the importance of developing a DA that is acceptable for patient use with direct involvement of stakeholders. Practice ImplicationsThe GOALS DA may prepare families to engage in shared decision-making to facilitate more patient-centered models of periviable care.

Tolerance of uncertainty: a unifying theme in pregnancy care.

High-risk obstetricians are accustomed to uncertainty-in fact, we have limited ability to predict the outcomes of even the most common clinical scenarios we encounter. For example: when will a short cervix lead to a periviable delivery? When will delivery occur following preterm premature rupture of membranes? Which macrosomic infants will experience a shoulder dystocia during vaginal birth? When will a term patient go into spontaneous labor?

Management of Impending Periviable Delivery

To review the role of obstetric interventions, the evidence behind these interventions, and the importance of offering these interventions to women and their families as they make decisions on whether to provide active neonatal management. Outcomes for infants born at periviability are improving with advancing neonatal care and management. Obstetric interventions play a role in helping to improve these outcomes. Administration of antenatal corticosteroids and magnesium sulfate should be considered if delivery is suspected. Cesarean delivery should be offered in cases of malpresentation or for other obstetric indications, with appropriate discussion around the associated maternal risks. Delayed cord clamping is considered beneficial and should be applied whenever possible. When active management is considered, or if further discussion is required, transfer to an advanced level NICU should be facilitated if possible. Obstetric management in the setting of an impending periviable delivery can have profound effects on neonatal outcomes. More research into what kind of impact these interventions have on outcomes is necessary. Until then, individualized counseling, shared decision-making, and interdisciplinary involvement are all needed to ensure women and families make as informed a decision as possible.

Diverse perspectives on death, disability, and quality of life: an exploratory study of racial differences in periviable decision-making.

To qualitatively explore perceptions of pain/suffering, disability, and coping by race among pregnant women facing the threat of a periviable delivery (22 0/7-24 6/7 weeks). Interviews were conducted in-hospital prior to delivery. Transcripts were coded verbatim and responses were stratified by race (white vs non-white). Conventional content analysis was conducted using NVivo 12. We recruited 30 women (50% white, 50% non-white). Most women expressed love and acceptance of their babies and described pain as a "means to an end." Non-white women focused almost exclusively on immediate survival and perseverance, while white women expressed concerns about quality of life beyond the NICU. The majority of non-white women were unable to recall any discussions with their doctors about their baby's comfort, pain, or suffering. These findings may suggest that culturally tailored approaches to counseling and decision-support may be beneficial for patients from marginalized or minoritized groups.

Factors Associated With Maternal and Neonatal Interventions at the Threshold of Viability.

To quantify the influence of maternal sociodemographic, medical, and pregnancy characteristics on decisions to offer or receive antepartum and neonatal interventions with deliveries occurring at 22-23 weeks of gestation. This is a case-control study of U.S. live births at 22 0/7-23 6/7 weeks of gestation using National Center for Health Statistics vital statistics birth records from 2012 to 2016. We analyzed three outcomes in the treatment of periviable delivery: 1) maternal interventions (cesarean delivery, maternal hospital transfer or antenatal corticosteroid administration), 2) neonatal interventions (neonatal intensive care unit admission, surfactant administration, antibiotic administration, or assisted ventilation), and 3) combined interventions (at least one maternal and at least one neonatal intervention). Logistic regression estimated the influence of characteristics on interventions received. Of 19,844,580 U.S. live births from 2012 to 2016, 24,379 (0.12%) occurred at 22-23 weeks of gestation. Of these, 37.5% received maternal interventions, 51.7% received neonatal interventions, and 28.0% received combined interventions. Rates of births receiving at least one intervention were 38.9% and 78.3% for 22 and 23 weeks of gestation, respectively. Preeclampsia was the factor most positively associated with interventions. Other factors positively associated with interventions were increasing maternal age, Medicaid, low educational attainment, multiparity, twin gestation, and infertility treatment. Some factors had opposite influences on maternal compared with neonatal interventions. The presence of birth defects was positively associated with maternal interventions but negatively associated with neonatal interventions, whereas being of black race was negatively associated with maternal interventions but positively associated with neonatal interventions. Maternal and neonatal interventions occur frequently at the threshold of viability, especially at 23 weeks of gestation where the occurrence of interventions exceeds 50%. This study identifies sociodemographic and medical factors associated with using interventions with periviable deliveries. These data elucidate observed practice patterns in the management of periviable births and may assist providers in the counseling of women at risk of periviable birth.

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.

Bringing Statistics to Life: Developing “Lived-Experience” Family Videos for a Periviable Decision-Support Tool [06K

INTRODUCTION: To develop and incorporate ‘lived-experience’ videos of families describing their lives following periviable delivery into the Periviable GOALS (Getting Optimal Alignment around Life Support) decision-support tool. METHODS: Through patient-engaged research methodology, patient-partners advocated ‘bringing statistics to life’ by including videos into the tool (IRB-approved). Five videos were created; each contained two families’ stories reflecting: death following comfort care, non-survival following resuscitation, or survival with mild, moderate, or severe neurodevelopmental impairment (NDI). Diverse families represented the spectrum of NDI, using different scripts for bereavement versus survival. Professional videographers filmed and edited the segments (3-5 minutes), which were embedded into the GOALS tool. Focus groups were conducted with pregnant women (20-26 weeks) and women who have delivered periviably to assess the videos’ acceptability. RESULTS: Ten families participated in the ‘lived-experience’ videos. Half were African American and half were white; children were age 16 months to 4 years. Bereaved parents were asked about end-of-life experiences and support after loss, while survivor segments described typical days, on-going medical care, and family adjustment. The videos were rated “excellent” (41.7%) or “good” (25%) by focus group participants (n=12). Most (91.7%) thought the tool provided sufficient information and would be useful in helping families make treatment decisions. CONCLUSION: Videos provide context for families to make meaning of complex prognostic information on long-term outcomes. They must be developed with caution due to their potential to introduce anchoring, conformity, or optimistic biases. Stakeholder engagement and diverse representation across the spectrum of outcomes and decisions may help to mitigate potential biases.