The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine have released a new consensus document recommending best practices in the care of neonates born between 20 and 25 weeks’ gestation.
The periviable birth guidance provides recommendations on the proper level of care at the hospital, the need for counseling on short- and long-term neonatal outcomes, family counseling, and a predelivery plan. The guidance also makes specific recommendations for interventions based on the best estimate of gestational age (Obstet Gynecol. 2015;126:e82-e94).
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“Care during the periviable period is incredibly complex, and requires providers to take into account a wide variety of considerations,” Dr. Brian M. Mercer, past president of SMFM and a lead author of the document, said in a statement. “Just as important as trying to predict outcomes is the role of counseling patients in a way that is both accurate and empathetic.”
ACOG and SMFM suggest that clinicians use a prediction tool, rather than relying on gestational age and birth weight estimates alone, when estimating outcomes before a periviable birth. The National Institute of Child Health and Human Development has a tool that can aid in predicting outcomes for extremely preterm births that is based on data from more than 4,400 live births between 22 and 25 weeks’ gestation.
Since both infant and mother will need immediate advanced care after delivery, the groups also recommend that deliveries during the periviable period occur at centers with level III-IV neonatal intensive care units and a level III-IV maternal care designation. These facilities can provide immediate resuscitation, as well as other resources such as respiratory technology and 24-hour newborn imaging. When possible, transfers should be made before delivery, according to the consensus document.
Counseling is another essential element in the management of periviable birth. Family counseling with a team of physicians, including the ob.gyn., maternal-fetal medicine specialist, and neonatologist, should address the likely maternal and neonatal outcomes and the family’s values, including the option for palliative care. ACOG and SMFM recommended making a predelivery plan with the family with the recognition that it would be modified based on the clinical situation.
The document also provides general guidance for performing specific obstetric interventions based on gestational age. For instance, ACOG and SMFM suggest that clinicians “consider” antenatal corticosteriod administration when the estimated gestational age is 23 weeks. They “recommend” antenatal corticosteriods starting at 24 weeks’ gestation through 25 weeks’ gestation.