Intensive Care for Extreme Prematurity — Moving beyond Gestational Age

Center for Clinical Research and Evidence-Based Medicine, University of Texas Medical School at Houston, Houston, TX 77030, USA.
New England Journal of Medicine (Impact Factor: 55.87). 05/2008; 358(16):1672-81. DOI: 10.1056/NEJMoa073059
Source: PubMed


Decisions regarding whether to administer intensive care to extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients.
We prospectively studied a cohort of 4446 infants born at 22 to 25 weeks' gestation (determined on the basis of the best obstetrical estimate) in the Neonatal Research Network of the National Institute of Child Health and Human Development to relate risk factors assessable at or before birth to the likelihood of survival, survival without profound neurodevelopmental impairment, and survival without neurodevelopmental impairment at a corrected age of 18 to 22 months.
Among study infants, 3702 (83%) received intensive care in the form of mechanical ventilation. Among the 4192 study infants (94%) for whom outcomes were determined at 18 to 22 months, 49% died, 61% died or had profound impairment, and 73% died or had impairment. In multivariable analyses of infants who received intensive care, exposure to antenatal corticosteroids, female sex, singleton birth, and higher birth weight (per each 100-g increment) were each associated with reductions in the risk of death and the risk of death or profound or any neurodevelopmental impairment; these reductions were similar to those associated with a 1-week increase in gestational age. At the same estimated likelihood of a favorable outcome, girls were less likely than boys to receive intensive care. The outcomes for infants who underwent ventilation were better predicted with the use of the above factors than with use of gestational age alone.
The likelihood of a favorable outcome with intensive care can be better estimated by consideration of four factors in addition to gestational age: sex, exposure or nonexposure to antenatal corticosteroids, whether single or multiple birth, and birth weight. ( numbers, NCT00063063 [] and NCT00009633 [].).

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    • "kánsan rontotta, ha többes terhességből született a koraszülött [11]. Az irodalmi adatok alapján túlélést befolyásoló tényezőnek tekintett gesztációs kor, nagyobb születési súly, szteroidprofi laxis, női nem, a császármetszés gyakorisága és az ikerterhességek arányában nem találtunk szignifi káns eltérést a két vizsgált csoportunk között. "
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    ABSTRACT: The mortality and morbidity of extremely low birth weight infants (birth weight below 1000 grams) are different from low birth weight and term infants. The Centers for Disease Control statistics from the year 2009 shows that the mortality of preterm infants with a birth weight less than 500 grams is 83.4% in the United States. In many cases, serious complications can be expected in survivals. The aim of this retrospective study was to find prognostic factors which may improve the survival of the group of extremely low birth weight infants (<500 grams). Data of extremely low birth weight infants with less than 500 grams born at the 1st Department of Obstetrics and Gynecology, Semmelweis University between January 1, 2006 and June 1, 2012 were analysed, and mortality and morbidity of infants between January 1, 2006 and December 31, 2008 (period I) were compared those found between January 1, 2009 and June 1, 2012 (period II). Statistical analysis was performed with probe-t, -F and -Chi-square. Survival rate of extremely low birth weight infants less than 500 grams in period 1 and II was 26.31% and 55.17%, respectively (p = 0.048), whereas the prevalence of complications were not significantly different between the period examined. The mean gestational age of survived infants (25.57 weeks) was higher than the gestational age of infants who did not survive (24.18 weeks) and the difference was statistically significant (p = 0.0045). Education of the team of the Neonatal Intensive Care Unit, professional routine and technical conditions may improve the survival chance of preterm infants. The use of treatment protocols, conditions of the Neonatal Intensive Care Unit and steroid prophylaxis may improve the survival rate of extremely low birth weight infants. Orv. Hetil., 2015, 156(10), 404-408.
    Orvosi Hetilap 03/2015; 156(10):404-8. DOI:10.1556/OH.2015.30101
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    • "또한 전반적으로 과거에 비 Table 1. Survival rates in extreme preterm birth 1 Authors Region Years of Birth 22 wk (%) 23 wk (%) 24 wk (%) 25 wk (%) Wood et al., 3 2000 United Kingdom and Ireland 1995 1 11 26 44 Bodeau-Livinec et al., 4 2008 British Isles 1995 NA 4.2 15.7 29.4 France 1997–1998 0 11.3 28.9 Doyle et al., 5 2010 Australia 1992 0 10 33 51 1997 7 45 41 59 2005 5 22 51 77 Field et al., 6 2008 United Kingdom 1994–2005 0 19 24 52 2000–2005 0 18 41 63 Mercier et al., 7 2010 Vermont Oxford 1998–2003 4.5 38.1 63.2 76.5 Tyson et al., 8 2008 United States 1998–2003 5 26 56 75 Fellman et al., 9 2009 Sweden 2004–2007 10 53 67 81 Hintz et al., 10 2005 United States 2004–2005 2 22.5 53.5 NA Ishii et al., 11 2013 Japan 2003–2005 37.3 64.5 77.7 85.7 Itabashi et al., 12 2009 Japan 2006 34 54 77 85 Costeloe et al., 13 2012 United Kingdom 2006 2 19 40 66 Manktelow et al., 14 2013 United Kingdom NA M/ F M/ F M/ F 1994–1997 20/18 45/44 56/65 2008–2010 29/35 48/56 73/67 "
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    ABSTRACT: Survival of extreme preterm birth infants had recently been increasing steadily. Proper counseling and optimal management of women with impending periviable birth is one of the most intricate situations in both obstetricians and pediatricians. This article aimed 1) to discern several international recommendations on perinatal care of periviable birth proposed recently, 2) to provide reviews of best available evidence on the use of antenatal corticosteroids and magnesium sulfate in impending periviable birth, and 3) to present the results from survey on the obstetrical management in periviable birth targeting maternal-fetal medicine faculty members of the tertiary hospitals in our country.
    01/2015; 26(1). DOI:10.14734/kjp.2015.26.1.1
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    • "Pharmacological interventions on the mother and/or the baby are also considered. Of note, an algorithm designed to predict outcomes, that considers gestational age, birth weight, gender, use of prenatal steroids, and singleton pregnancy, may be useful to the caregivers [22]. In addition, the parents and the medical team have to consider the accessibility to specialized healthcare in neonatology and the experience level of the caregiving team, that may be different from a hospital to another. "
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    ABSTRACT: Background A wide range of dilemmas encountered in the health domain can be addressed more efficiently by a transdisciplinary approach. The complex context of extreme prematurity, which is raising important challenges for caregivers and parents, warrants such an approach. Methods In the present work, experts from various disciplinary fields, namely biomedical, epidemiology, psychology, ethics, and law, were enrolled to participate in a reflection. Gathering a group of experts could be very demanding, both in terms of time and resources, so we created a web-based discussion forum to facilitate the exchanges. The participants were mandated to solve two questions: “Which parameters should be considered before delivering survival care to a premature baby born at the threshold of viability?” and “Would it be acceptable to give different information to parents according to the sex of the baby considering that outcome differences exist between sexes?” Results The discussion forum was performed over a period of nine months and went through three phases: unidisciplinary, interdisciplinary and transdisciplinary, which required extensive discussions and the preparation of several written reports. Those steps were successfully achieved and the participants finally developed a consensual point of view regarding the initial questions. This discussion board also led to a concrete knowledge product, the publication of the popularized results as an electronic book. Conclusions We propose, with our transdisciplinary analysis, a relevant and innovative complement to existing guidelines regarding the decision-making process for premature infants born at the threshold of viability, with an emphasis on the respective responsabilities of the caregivers and the parents.
    BMC Research Notes 07/2014; 7(1):450. DOI:10.1186/1756-0500-7-450
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