Should newborns at 22 or 23 weeks’ gestational age be aggressively resuscitated?
At 22 weeks 0 days of gestation, pediatricians and parents should be cautious about choosing to aggressively resuscitate a newborn because survival is very unlikely. Toward the end of the 23rd week, survival becomes more likely, but severe morbidity occurs frequently.
Prior to birth, team meetings that include the obstetricians, pediatricians, mother, and family will help to set expectations about the course of care and, in turn, improve perceived outcomes.5 If feasible, obstetricians and pediatricians should develop joint institutional guidelines about the general approach to pregnant women when birth may occur at 22 or 23 weeks’ gestation.5
A neonatal outcomes predictor
The National Institute of Child Health and Human Development provides a Web-based tool for estimating newborn outcomes based on gestational age (22 to 25 weeks), birth weight, gender, singleton or multiple gestation, and exposure to antenatal glucocorticoid treatment. The outcomes tool provides estimates for survival and survival with severe morbidity. It uses data collected by the Neonatal Research Network to predict outcomes. To access the outcomes data assessment, visit https://www.nichd.nih.gov/about/org/der/branches/ppb/programs/epbo/Pages/epbo_case.aspx.
Is aggressive management of preterm birth and neonatal resuscitation a self-fulfilling prophecy?The beliefs and training of clinicians may influence the outcome of extremely preterm newborns. For example, if obstetricians and pediatricians focus on the fact that birth at 23 weeks is not likely to result in survival without severe morbidity, they may withhold key interventions such as antenatal glucocorticoids, antibiotics for rupture of the membranes, and aggressive newborn resuscitation.7 Consequently the likelihood of survival may be reduced.
If clinicians believe in maximal interventions for all newborns at 22 and 23 weeks’ gestation, their actions may result in a small increase in newborn survival—but at the cost of painful and unnecessary interventions in many newborns who are destined to die. Finding the right balance along the broad spectrum from expectant management to aggressive and extended resuscitation is challenging. Clearly there is no “right answer” with these extremely difficult decisions.
Future trends in the limit of viabilityIn 1963, Jacqueline Bouvier Kennedy, at 34 weeks’ gestation, went into preterm labor and delivered her son Patrick at a community hospital. Patrick developed respiratory distress syndrome and was transferred to the Boston Children’s Hospital. He died shortly thereafter.8 Would Patrick have survived if he had been delivered at an institution capable of providing high-risk obstetric and newborn services? Would such modern interventions as antenatal glucocorticoids, antibiotics for ruptured membranes, liberal use of cesarean delivery, and aggressive neonatal resuscitation have improved his chances for survival?
From our current perspective, it is surprising that a 34-week newborn died shortly after birth. With modern obstetric and pediatric care that scenario is unusual. It is possible that future advances in medical care will push the limit of viability to 22 weeks’ gestation. Future generations of clinicians may be surprised that the medicine we practice today is so limited.
However, given our current resources, it is unlikely that newborns at 22 weeks’ gestation will survive, or survive without severe morbidity. Consequently, routine aggressive resuscitation of newborns at 22 weeks should be approached with caution. At 23 weeks and later, many newborns will survive and a few will survive without severe morbidity. Given the complexity of the issues, the approach to resuscitation of infants at 22 and 23 weeks must account for the perspectives of the birth mother and her family, obstetricians, and pediatricians. Managing threatened preterm birth at 22 and 23 weeks is one of our greatest challenges as obstetricians, and we need to meet this challenge with grace and skill.
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