New ACOG, SMFM Consensus Document Addresses Periviable Birth

Troy Brown, RN

October 22, 2015

A new joint consensus document from the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) addresses treatment and decision making around periviable birth. The "landmark document" is the third in a series of joint consensus documents released by the two groups, according to a joint news release. It replaces ACOG's Practice Bulletin, "Perinatal Care at the Threshold of Viability." It was published online October 21 in the American Journal of Obstetrics and Gynecology.

"Care during the periviable period is incredibly complex, and requires providers to take into account a wide variety of considerations," Brian M. Mercer, MD, past president of SMFM and chair of the Department of Obstetrics and Gynecology at MetroHealth in Cleveland, Ohio, and a lead author of the document, said in the news release. "Just as important as trying to predict outcomes is the role of counseling patients in a way that is both accurate and empathetic."

Periviable birth refers to those that occur from 20 0/7 weeks to 25 6/7 weeks of gestation. About 0.5% of all births take place before the third trimester of pregnancy, the authors write. These births account for most neonatal deaths and more than 40% of infant deaths.

"Recommendations presented in this document vary in some aspects from those published and summarized previously in part because of further stratification of advice offered for anticipated deliveries between 23 0/7 weeks and 25 6/7 weeks of gestation," the authors explain.

Clinicians have often used birth weight and gestational age, alone or together, to predict outcome and determine whether or not to offer resuscitation, the authors write.

"However, in recognition of the effect of other clinical factors and in an attempt to create a better prediction tool, the [Eunice Kennedy Shriver National Institute of Child Health and Human Development] Neonatal Research Network developed a tool to estimate outcomes among liveborn infants that was based on prospectively collected information for live births at 22–25 weeks of gestation in 19 academic [neonatal intensive care unit] centers."

On the basis of those data, the tool uses a combination of gestational age, birth weight, exposure to antenatal corticosteroids, sex, and plurality, rather than gestational age and birth weight alone.

"Without question, it is challenging to accurately anticipate outcomes of deliveries during the periviable period, but we do know that the circumstances surrounding periviable birth often require advanced care and resources to optimize outcomes," Anjali Kaimal, MD, MAS, a maternal-fetal medicine specialist at Massachusetts General Hospital in Boston, and another lead author of the document, said in the news release.

"That's why it's important for periviable deliveries in which maternal or neonatal interventions are planned to occur, when possible, at health centers that have the resources, expertise and infrastructure to provide high levels of maternal and neonatal care," Dr Kaimal explained.

The ACOG and SMFM recommend:

  • On the basis of expected neonatal or maternal complications, transferring the mother before birth to a center with advanced levels of neonatal or maternal care when feasible and appropriate.

  • When counseling patients before and after birth about expected short-term and long-term outcome, considering anticipated gestational age at delivery and other variables that may change the probability of survival and adverse newborn outcomes. These include fetal sex, multiple gestation, presence of suspected major fetal malformations, antenatal corticosteroid administration, birth weight, and response to initial neonatal resuscitation.

  • A multidisciplinary team including obstetrician-gynecologists and other obstetric providers, maternal-fetal medicine specialists, if available, and neonatologists to provide family counseling. Provide follow-up counseling when there is pertinent new information about the status of the mother or fetus or the newborn's changing condition.

  • Making a predelivery plan with the parents, family, or both; modify the plan as neonatal providers assess the newborn's condition and response. A recommendation about assessment for resuscitation does not mean that resuscitation should always occur or not, or that providers should offer every possible intervention. Follow a stepwise approach "concordant with neonatal circumstances and condition and with parental wishes." Reevaluate care regularly and redirect when appropriate as the clinical situation evolves.

Clinicians should talk with the parents about "whether their goal is optimizing survival or minimizing suffering," the authors write.

"A decision not to undertake resuscitation of a liveborn infant should not be seen as a decision to provide no care, but rather a decision to redirect care to comfort measures." When the parents have decided not to have the newborn resuscitated, "individualized compassionate care" should be provided to the infant. This care should include keeping the baby warm, minimizing discomfort, and giving the family as much time with their newborn as they desire.

The document includes a table with recommendations about specific interventions, "tailored to gestational age and other clinical data, and taking into account individual family preferences and values." The table addresses neonatal assessment for resuscitation, antenatal corticosteroids, tocolysis for preterm labor to allow for antenatal corticosteroid administration, magnesium sulfate for neuroprotection, antibiotics to prolong latency during expectant management of preterm premature rupture of membranes if delivery is not considered imminent, intrapartum antibiotics for Group B streptococci prophylaxis, and caesarean delivery for fetal indication.

The authors have disclosed no relevant financial relationships.

Am J Obstet Gynecol. Published online October 21, 2015. Abstract


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