Impact of Active Antenatal Management on Morbidity and Mortality at the Limits of Viability

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ESPR385
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Background: The limits of viability (LOV: 23 0/7 through 25 5/7 weeks gestational age (GA); the GA at which resuscitation is offered) for preterm infants continues to decrease over time as new strategies develop to improve survival. Antenatal care, and delivery room cardiopulmonary resuscitation (DR-CPR) policies for infants born at the LOV vary by institution and range from resuscitating all above a certain GA, to using clinician and parental involvement making individual decisions on a case by case basis, 

Objective: To assess the impact on morbidity and mortality for infants born at the LOV by institutional policy, comparing selective antenatal care and DR-CPR to a trial of life among all infant above a designated GA. A trial of life includes antenatal treatment: maternal steroids, magnesium, fetal monitoring, antibiotics when appropriate and cesarean delivery when indicated.  All live infants are provided complete DR-CPR. 

Design/Methods: Interim, retrospective cohort study of infants born at the LOV in a single center between two time epochs: Epoch 1 (E1): January 1, 2006 through June 30 2011: antenatal obstetrical management and DR-CPR was varied on individual basis with clinician and parental input.  Epoch 2 (E2): July 1, 2011 to December 31, 2018: all infants with impending delivery at 23 0/7 weeks and beyond were given a trial of life. Chi square test was performed for categorical variables, and t test or Mann Whitney U test was used for continuous variables to compare E1 to E2 for survival rates, timing to mortality and discharge. P <0.05 is statistically significant.

Results: 428 neonates included during the dates studied (E1: 185; E2: 243) (table 1).  Survival rates increased significantly in E2 (E1: 57% v E2: 71%) (table 2), Neonates born at 24 weeks GA received the most benefit.  Improved survival was not associated with an extended time to death. However, among survivors, the overall length of stay (LOS) was extended in E2 (table 3). 

Conclusions: A trial of life among infants born at the LOV appears to improve survival without increasing pain or suffering among those infants who went on to die. However, LOS was extended for survivors which may be a product of other unmeasured conditions.  

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The Regional Neonatal ICU Maria Fareri Children’s Hospital at Westchester Medical Center-NYMC Valhalla, NY, White Plains, NY, US

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