Counselling and management for anticipated extremely preterm birth

Question 1

What is the WHO definition of GA?

Answer 1

Completed days and weeks from the first day of the last menstrual period

Question 2

What is the definition of an extremely preterm birth?

Answer 2

Birth that occurs between 22+0 weeks to 25+6 weeks

Question 3

What information do parents report as useful to receive during counseling?

Answer 3

1. Likelihood of survival
2. Risk of disability
3. Medical treatments
4. Anticipated problems
5. NICU experience
6. Parenting
7. Coping with stress

Question 4

What are some strategies to enhance consistency in information provided to parents?

Answer 4

1. Joint counseling from obstetrics and neonatal team
2. Interdisciplinary consensus guidelines
3. Staff information cards
4. Case management rounds
5. Clearly documented and readily available antenatal consultations
6. Updated management plans incld. management of labour, mode of delivery, care of infant

Question 5

What mode of decision making is recommended in the perinatal setting?

Answer 5

Shared decision making between health professionals and parents
Decision aids assist parents in making decisions

Question 6

What are the recommendations for the care of the mother at risk of extremely preterm birth?

Answer 6

1. Accurate assessment of GA (early US 8-14wk, precise to +/-5d in 1st trimester, +/-10d at 16-22wk)
2. Transfer care to tertiary perinatal centres
3. Antenatal corticosteroids should be offered
4. Short-term tocolysis should be considered to facilitate in-utero transfer
5. Consider administering MgSO4 for fetal neuroprotection
6. Decision re: mode of delivery should be made jointly between mother and her obstetrician
7. Classical c-section is required before 24wks GA and includes risks of maternal blood loss, impaired fertility, and uterine rupture in future pregnancies

Question 7

What are the Canadian survival rates for extremely preterm infants?

Answer 7

< 22 wks 8%
23 wks 36%
24 wks 62%
25 wks 78%

Question 8

What are significant short-term neonatal morbidities that are associated with long term disability?

Answer 8

1. > Grade 3 IVH
2. PVL
3. ROP
4. CLD/BPD

Question 9

What is the difference in significant short term neonatal morbidities in extremely premature infants?

Answer 9

No difference among surviving infants born @ 22/23, 24, and 25 wks GA

Question 10

What are severe adverse neurodevelopmental outcomes at 18-24mo?

Answer 10

1. Cerebral palsy
2. Cognitive impairment (test score > 2SD below mean)
3. Seizures
4. Blindness
5. Deafness

Question 11

What is the survival free of severe adverse neurodevelopmental outcome in Canada?

Answer 11

At 23wks 35-50%
At 24wks 37-57%
At 25wks 37-70%

Question 12

What other problems are more common in preterms?

Answer 12

1. ADHD
2. Language delays
3. Health-related issues
4. Hospital readmissions

Question 13

What additional factors influence outcome in preterm infants?

Answer 13

1. Birth at a tertiary perinatal centre
2. ANCS therapy
3. Female sex
4. Multiplicity

Question 14

What are the recommendations regarding elective cesarean section before 24wks GA?

Answer 14

Not recommended unless for maternal indications

Question 15

What are the recommendations regarding care at 22 weeks GA?

Answer 15

Non-interventional approach w/ focus o comfort care

Question 16

What are the recommendations regarding care at 23-25 weeks GA?

Answer 16

1. Counselling about outcomes and decision making around whether to institute active treatment should be individualized
2. At 23-24wks GA active treatment is appropriate for some infants
3. Most infants of 25 wks GA have improved survival and neurodevelopmental outcomes and active treatment is appropriate for these infants except when there are significant additional risk factors

Question 17

What are the recommendations for all extremely preterm infants who are not resuscitated?

Answer 17

They must receive compassionate palliative care, incld. warmth and pain relief