At the Edge of Viability Does Every Day Count?

Preterm infants born between 22 to 25 weeks gestational age has been a topic covered in this blog before.

Winnipeg hospital now resuscitating all infants at 22 weeks! A media led case of broken telephone.

Is anything other than “perfect practice” acceptable for resuscitating infants from 22 – 25 weeks?

Winnipeg Hospital About to Start Resuscitating Infants at 23 weeks!

I think it is safe to say that this topic stirs up emotions on both sides of the argument of how aggressive to be when it comes to resuscitating some of these infants, particularly those at 22 and 23 weeks.  Where I work we have drawn a line at 23 weeks for active resuscitation but there are those that would point out the challenge of creating such a hard-line when the accuracy of dating a  pregnancy can be off by anywhere from 5 – 14 days.  Having said that, this is what we have decided after much deliberation and before entertaining anything further it is critical to determine how well these infants are doing not just in terms of survival but also in the long run.  In the next 6 months our first cohort should be coming up for their 18 month follow ups so this will be an informative time for sure.

Do Days Matter?

This is the subject of a short report out of Australia by Schindler T et al.  In this communication they looked at the survival alone for preterm infants in a larger study but broke them down into 3 and four-day periods from 23  to 25 weeks as shown below.

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The asterisk over the two bars means that the improvement in survival was statistically significant between being born in the last half of the preceding week and the first half of the next week. In this study in other words days make a difference.  A word of caution is needed here though.  When you look at the variation in survival in each category one sees that while the means are statistically different the error bars show some overlap with the previous half week.  At a population level we are able to say that for the average late 23 week infant survival is expected to be about 30% in this study and about 55% at 24 +0-3 days.  What do you say to the individual parent though?  I am not suggesting that this information is useless as it serves to provide us with an average estimate of outcome.  It also is important I believe in that it suggests that dating on average is fairly accurate.  Yes the dates may be off for an individual by 5 – 14 days but overall when you group everyone together when a pregnancy is dated it is reasonably accurate for the population.

Don’t become a slave to the number

The goal of this post is to remind everyone that while these numbers are important for looking at average outcomes they do not provide strict guidance for outcome at the individual level.  For an individual, the prenatal history including maternal nutrition, receipt of antenatal steroids, timing of pregnancy dating and weight of the fetus are just some of the factors that may lead us to be more or less optimistic about the chances for a fetus.  Any decisions to either pursue or forego treatment should be based on conversations with families taking into account all factors that are pertinent to the decision for that family.  Age is just a number as people say and I worry that a graph such as the one above that is certainly interesting may be used by some to sway families one way or another based on whether the clock has turned past 12 AM.  At 23 weeks 3 days and 23 hours do we really think that the patient is that much better off than at 24 weeks 4 days and 1 hour?

 

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2 thoughts on “At the Edge of Viability Does Every Day Count?

  1. I was encouraged to let my 23wk6day baby die. Have her, love her til she’s gone. Needless to say, I transferred hospitals, and my daughter waited til then. She is 6 now with less than half of the issues they warned about. She is awesome. Dr’s just don’t always know. Statistics are vital. These babies deserve a chance. Just my opinion. I just can’t imagine if I’d listened to them!

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