When Delivering Multiples With Discordant Anomalies, Resuscitation Decisions Are Complicated

By Will Boggs MD

April 09, 2020

NEW YORK (Reuters Health) - Delivering twins, triplets, or other multiples when the newborns have discordant anomalies that call for different resuscitation strategies calls for careful shared decision-making, doctors say.

"If multiples are the same gender and approximately the same size at birth, rapidly identifying unique medical needs in the delivery room can be very challenging," Dr. Autumn Kiefer of School of Medicine, West Virginia University, in Morgantown, told Reuters Health by email. "Ultimately, our advice for physicians is to return to the simple principle of letting the baby in front of you be the guide as to how much support is needed."

Writing in Pediatrics, Dr. Kiefer and colleagues present a hypothetical case of male quadruplets, one of which is identified early in pregnancy as having a left congenital diaphragmatic hernia (CDH). The parents are offered the option of selective fetal reduction, which they decline.

When the mother experiences premature preterm rupture of membranes at 26 4/7 weeks' gestation followed by preterm labor, Cesarean delivery is planned because of the multiple gestations and breech and transverse lie of all four fetuses.

The first practical concern is how the team can be sure that they have correctly identified the newborn with CDH, because his standard treatment would be immediate intubation to avoid gaseous distention of the stomach and bowel, which would worsen ventilation.

Because of the uncertainty involved, some team members suggest that each of the quadruplets should be immediately intubated to properly resuscitate the child with CDH, which would optimize his chance of survival but would increase the risk of lung injury from mechanical ventilation in the unaffected newborns.

Other team members advocate for routine resuscitation for all four quadruplets, where each neonate would be assessed frequently during resuscitation and care would be tailored according to each neonate's specific medical needs.

In light of the parents' continued desire to give their son with CDH a chance, even if it means their entire family faces a greater challenge, the decision is made to intubate all four neonates, regardless of clinical status, to protect the affected child.

Events progress rapidly, and the infants are delivered over a four-minute window. Each infant is initially apneic and limp with heart rate below 60 bpm.

Two quadruplets require extensive resuscitation, including chest compressions, while the third responds to intubation alone. All three of these siblings survive with bronchopulmonary dysplasia and require home oxygen at hospital discharge.

The fourth quadruplet, the smallest neonate with CDH, has poor chest rise despite increasing support and never achieves a heart rate above 70 bpm. The care team and parents agree to transition to palliative care, and he dies shortly thereafter in his parents' arms.

"Although this case is more complex than most, it illustrates a rule that should apply to all decisions involving newborns: avoid making difficult and irreversible decisions about delivery room management prenatally!" co-author Dr. John D. Lantos from Children's Mercy Hospital, Kansas City, Missouri comments. "In this case, the treatment would likely have been the same for these four infants without the agonizing prenatal discussions."

"Neonatologists are often faced with making quick decisions about medically complex newborns," Dr. Kiefer said. "We try to let the baby be the guide in these situations. We offer support and hope to see the baby respond to our help. Unfortunately, not every child responds. If our efforts to save the child's life are futile, then we encourage the family to hold the child, bond with them, and make the most of every moment."

"Coincidentally," she said, "as the mother of triplets myself, multiples seem to point out whenever possible that they are indeed very different people with different needs."

"Parents want the best for their children, and as doctors we want the best for our patients," Dr. Kiefer added. "However, parents can have very different views of what is best for their child based on their own values and experiences in comparison to the medical team. One of the most important things is to keep open and honest communication with the parent(s). Often concerns about 'futile' treatment are not able to be resolved in one conversation, but what makes the most sense for the child's medical care becomes more clear to everyone involved over time."

Dr. Ola D. Saugstad of Oslo University Hospital in Norway, who studies newborn resuscitation but was not connected to the new report, told Reuters Health by email, "I always go 'the second mile' in the rare cases I have experienced when parents want to continue what I/the team consider as futile and possibly harmful treatment. By respecting the parents, being patient, giving them ample time to come to a conclusion, I have never experienced a long-lasting conflict. During my 40 years as a neonatologist, I have never acted against the parents will; that has never been necessary."

SOURCE: https://bit.ly/348h79I Pediatrics, online April 2, 2020.