Neonatal/Perinatal Medicine Fellow University of Chicago Medical Center Chicago, Illinois, United States
Background: Variation inattitudes and practices of offering resuscitation to infants born at the margin of viability between 22-24 weeks’ gestational age (GA) has been extensively described. Recent ethical debate, including resource utilization arguments, is centered on whether to offer active resuscitation (AR) in the 22nd week. “Obstetric Care Consensus No. 6: Periviable Birth” (ACOG, 2017) now recommends offering AR for births occurring during or after 24 weeks’ GA and considering AR for births between 22-23 weeks’ GA.
Objective: To evaluate practice change over time for mothers and their fetuses inborn at 22, 23, and 24 weeks’ GA relative to infant outcomes and NICU resource utilization at 15 study centers over two epochs.
Design/Methods: INDEED (Investigating Neonatal Decisions for Extremely Early Deliveries) is a retrospective cohort which includes mothers and their infants delivered between 22 0/7 and 24 6/7 weeks’ GA. The cohort initially included six tertiary centers between 2011-2015, with expansion underway to include 15 tertiary centers over a 10 year period, divided into two epochs. Chi-square tests and ANOVA were used to compare perinatal interventions and LOS.
Results: Epoch 1 and 2 cohorts included 497 and 139 mothers, 569 and 153 infants, and six and two centers, respectively. Antenatal corticosteroid use increased at 22 and 23 weeks’ GA (13 vs 46% and 59 vs 86%, respectively). The rate of AR at 22 and 23 weeks’ GA increased (42 vs 67% and 79 vs 96%, respectively). Rates of cesarean delivery did not differ (Table 1 and 2).
Figures 1 and 2 report LOS to death in the NICU, NICU discharge, or transfer to a long-term care (LTC) institution in Epochs 1 and 2, respectively. LOS did not differ for those who died in the NICU or who were discharged from the NICU within or between the two epochs. In Epoch 2 more infants were transferred to LTC facilities, without statistically significant differences in the LOS between epochs for that subgroup. Due to modest changes in survival over time, the total mean LOS per patient at 22 weeks was significantly less than 23 and 24 weeks in Epoch 1, but not in Epoch 2. Conclusion(s): Consistent with new ACOG recommendations, we identified an increase in prenatal steroid administration and AR at 22 and 23 weeks, without an increase in cesarean delivery, in the last decade. Importantly, this AR increase was not accompanied by an increase in LOS to discharge or death, suggesting that increased NICU resource utilization is not a justice-based argument to withhold AR at the margin of viability.
Authors/Institutions: Allison Schuh, The University of Chicago Medicine, Chicago, Illinois, United States; Samantha Millikan, The University of Chicago Medicine, Bloomingdale, Illinois, United States; Leah Thomas, University of Chicago Pritzker School of Medicine, Chicago, Illinois, United States; Naomi T. Laventhal, University of Michigan, Ann Arbor, Michigan, United States; Christine Carlos, University of Chicago, Chicago, Illinois, United States; Dalia M. Feltman, NorthShore University HealthSystem Evanston Hospital, Evanston, Illinois, United States; Bree Andrews, The University of Chicago, Chicago, Illinois, United States
