2/25/06njm

**Q. What are some of the issues about viability in the range of 23-25
EGA weeks?**

A. Try a collaborative approach that involves providers and the parents
in decisions. See details

Because of the uncertainty about survival and the high risk for
development of neurodevelopmental abnormalities, decision-making about
providing treatment for infants at the threshold of viability is
complex. We recommend a collaborative approach that involves physicians
and other care providers and the parents in treatment decisions.

**Background**

In one review of ELBW outcomes in the 1990s, survival at 23, 24, and 25
weeks ranged from 2 to 35, 17 to 58, and 35 to 85 percent, respectively.

A second study examined outcomes of 1193 infants born at GA
![](media/image1.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}20 weeks and BW
![](media/image2.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}500 g in Alberta, Canada between 1983
and 1994. Of these, 68 percent were stillborn and the remainder were
liveborn. Intensive care was initiated in 30 percent of the liveborn
infants. Of those, only 11 percent survived to 36 months of age, and 69
percent of the survivors had
![](media/image1.png){width="8.333333333333333e-2in"
height="9.236111111111112e-2in"}1 major disability.

In a subsequent population based Norwegian report (1999-2000), there
were no survivors of infants born with GA \< 23 weeks. In the majority
of these cases, resuscitation was not attempted. Survival rates of 16
and 44 percent were reported for infants with GA 23 and 24 weeks,
respectively.

Here are some thoughts from the 2005 policy statement from the American
Academy of pediatrics on \"Perinatal Care at the Threshold of Viabilty\"
by the AAP Committee on the fetus and newborn. You can access the full
article at the link below.

[To summarize:]{.underline} resuscitation is not usually instituted for
infants \< 23 weeks gestation or \< 400 grams at birth. Prenatal
estimations of weight and gestational age have a range of accuracy and
the infant\'s viability needs to be reevaluated at birth and with an
extrauterine judgment of weight and gestational age.

Infants less than 23 weeks have survived but it is uncommon and they
often have severe disabilities. Conversely, even with optimal medical
care only 50-60% of 25 week infants survive and many have significant
disabilities. In general, resuscitation would be done on any infant
thought to be \> 25 weeks gestation though support might be withdrawn at
a later time. On the other hand, it would be rare to aggressively treat
an infant \< 23 weeks gestation unless they appeared to be older,
heavier or more vigorous at birth. The 23-24 week gestational age
infants are the most difficult and the degree of treatment may vary
depending on the parents wishes and the pediatrician\'s practice style.

**Obstetric Management**\
When the fetus' prognosis is uncertain, decisions regarding obstetric
management must be made by the parents and their physicians and
documented in the obstetric records. Parents should be encouraged to
participate actively in discussions regarding delivery, maternal
transport, and other management decisions. Counseling about management
options and potential infant survival and long-term outcome allows the
family to have the information they need to choose a course of action
that is medically appropriate and consistent with their own personal
values and goals. Whenever possible, a nondirective approach needs to be
used; in some circumstances, however, directive counseling may be
appropriate. Counseling may result in the family choosing not to have
active intervention for the delivery and care of the infant. Because the
relative benefits of different types of obstetric management are not
always known, families should be supported in these often difficult and
sometimes controversial decisions.

Some decisions, such as the choice of cesarean birth, can result in an
increased risk of morbidity to the woman. Few studies have been
performed to evaluate the influence of obstetric management on the
outcome of infants at the threshold of viability. Furthermore,
literature on this subject is largely retrospective and often lacks
sufficient data regarding potential confounding variables. Despite these
limitations, study results have consistently failed to document benefits
of cesarean delivery for extremely preterm infants. It has even been
difficult to document improved outcome with cesarean birth for infants
in the breech position who are extremely preterm. However, in one study,
the opinion of the obstetrician regarding the potential viability of an
extremely preterm fetus, as measured by the willingness to perform
cesarean delivery, was found to have a major impact on the likelihood of
survival of the fetus to birth.

Physicians should avoid characterizing managements of uncertain benefit
as \"doing everything possible\" or \"doing nothing\" so as not to place
a value on the judgment. Rather, they should hold discussions with the
family regarding available data and provide an explanation of the risks
incurred by management options, including route of delivery. In the case
of cesarean delivery, risks to the woman include not only those incurred
during the perioperative period but also long-term implications for
childbearing, because a vertical uterine incision is often made. A
vertical uterine incision at these gestational ages may extend into the
fundus, thus precluding the option of vaginal birth in a future
pregnancy. Counseling regarding management decisions, such as whether to
use maternal transport, should include a discussion of the potential
disadvantages of separating the mother from supportive family members
and familiar caregivers when benefit for the mother or infant is
uncertain versus potential advantages of ensuring that the infant is
delivered in a setting with maximum expertise in caring for an extremely
preterm infant should the infant be more mature and/or larger than
anticipated.

+-----------------------------------------------------------------------+
|   ------------------------------------------------------------------  |
|   ![](media/image3.png){width="5.46875in"                             |
|   height="2.6034722222222224in"}                                      |
|                                                                       |
|   ------------------------------------------------------------------  |
+-----------------------------------------------------------------------+
|   ------------------------------------------------------------------  |
|   ![](media/image4.png){width="5.46875in"                             |
|   height="2.6333333333333333in"}                                      |
|                                                                       |
|   ------------------------------------------------------------------  |
+-----------------------------------------------------------------------+

[http://www.uptodateonline.com/utd/content/image.do?imageKey=pedi_pix\\infant_m.gif\~pedi_pix\\infant_s.gif](http://www.uptodateonline.com/utd/content/image.do?imageKey=pedi_pix\infant_m.gif~pedi_pix\infant_s.gif)

![](media/image5.png){width="5.46875in" height="4.904861111111111in"}

[http://www.uptodateonline.com/utd/content/image.do?imageKey=pedi_pix\\infant_m.gif\~pedi_pix\\infant_s.gif](http://www.uptodateonline.com/utd/content/image.do?imageKey=pedi_pix\infant_m.gif~pedi_pix\infant_s.gif)

**Resources:**

**Perinatal Care at the Threshold of Viability, AAP**

[[http://aappolicy.aappublications.org/cgi/content/full/pediatrics;110/5/1024]{.underline}](http://aappolicy.aappublications.org/cgi/content/full/pediatrics;110/5/1024)

**Perinatal mortality, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=neonatol/14943&type=P&selectedTitle=8~17>

**Premature infant, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=neonatol/13045>