Short Term Survival of Extreme Preterm Newborns at 23–26 Weeks’ Gestation in a Middle East Modern Referral Maternity Hospital

Background: Caring about ELBW newborns at the limit of viability is demanding with a high rate of mortality and long-term morbidity. Society expectations become high and persistent while health care coast inside NICU is very high. Objective: The purpose of this study is to examine the short-term survival (till discharge) of extremely low birth weight (ELBW) newborns at limits of viability 23–26 weeks gestation (WG) age in a large tertiary maternity hospital. Methods: A population-based retrospective study of babies born at 23–26 WG age over 3 years period. Results: Over the study period 2016 to mid-2018, a total of 283 ELBW newborns were delivered in our institute. Of those, 250 were admitted to NICU (88%). The number of newborns who survived till discharge from NICU was 174 (61.5%) while the rate of delivery room death was 33 newborns (11.75%). The survival rates during 2016–2018 period were 35%, 64%, 73%, and 81.4% for 23, 24, 25, and 26 WG respectively. 76 newborns (26.9%) of NICU admissions died before discharge. Most deaths occurred during the first two weeks of life (64%). The main cause of death inside the NICU during the first 2 weeks was respiratory failure, followed by infection. Conclusion: Counseling Parent using local data become more convincing and reflecting local experience. Short term survival rate of ELBW is comparable to those reported in the literature. The first two weeks are very crucial where the mortality rate is highest.

Shifting Provider Attitudes and Institutional Resources Surrounding Resuscitation at the Limit of Gestational Viability

Objective This study aimed to provide contemporary data regarding provider perceptions of appropriate care for resuscitation and stabilization of periviable infants and institutional resources available to providers. Study Design A Qualtrics survey was emailed to 672 practicing neonatologists in the United States by use of public databases. Participants were asked about appropriate delivery room care for infants born at 22 to 26 weeks gestational age, factors affecting decision-making, and resources utilized regarding resuscitation. Descriptive statistics were used to analyze the dataset. Results In total, 180 responses were received, and 173 responses analyzed. Regarding preferred course of care based on gestational age, the proportion of respondents endorsing full resuscitation decreased with decreasing gestational age (25 weeks = 99%, 24 = 64%, 23 = 16%, and 22 = 4%). Deference to parental wishes correspondingly increased with decreasing gestational age (25 weeks = 1%, 24 = 35%, 23 = 82%, and 22 = 46%). Provision of comfort care was only endorsed at 22 to 23 weeks (23 weeks = 2%, 22 = 50%). Factors most impacting decision-making at 22 weeks gestational age included: outcomes based on population data (79%), parental wishes (65%), and quality of life measures (63%). Intubation with a 2.5-mm endotracheal tube (84%), surfactant administration in the delivery room (77%), and vascular access (69%) were the most supported therapies for initial stabilization. Availability of institutional resources varied; the most limited were obstetric support for cesarean delivery at the limit of viability (37%), 2.0-mm endotracheal tube (45%), small baby protocols (46%), and a consulting palliative care teams (54%). Conclusion There appears to be discordance in provider attitudes surrounding preferred actions at 23 and 22 weeks. Provider attitudes regarding decision-making at the limit of viability and identified resource limitations are nonuniform. Between-hospital variations in outcomes for periviable infants may be partly attributable to lack of provider consensus and nonuniform resource availability across institutions. Key Points

Preterm birth

This chapter discusses the epidemiology, prediction, prevention, and management of spontaneous preterm birth. Preterm birth is usually defined as delivery at any gestation before 37 completed weeks of pregnancy (<37+0 weeks, <259 days). The lower limit of preterm birth and upper limit of late spontaneous miscarriage are blurred as the limit of viability varies with differences in healthcare settings. This condition remains one of the biggest challenges facing obstetricians globally as a result of continuing high rates of morbidity and mortality. Spontaneous preterm birth is caused by a complex collection of pathophysiology with overlapping environmental interactions and behavioural influences that contribute to individual risk. Much debate exists regarding best prevention therapies and there remains a huge need for novel therapies and interventions for both prediction and prevention