Neonatal and Obstetric Provider Perceptions and Management at 22 Weeks' Gestation

Abstract

Objective Active treatment for periviable infants may be influenced by neonatal and obstetric provider perceptions of prognosis. The two aims of this study are to (1) quantify prognostic discordance between provider and data-driven survival estimates and (2) evaluate if prognostic discordance is associated with the threshold probability of survival at which neonatal providers recommend active treatment or obstetric providers recommend antenatal corticosteroids.

Study Design Provider survival estimates and threshold probabilities of survival for active treatment and antenatal steroid use were obtained from a case-based survey for an infant or pregnancy at 22 weeks' gestation that was administered at two Atlanta hospitals. Data-driven survival estimates, including ranges, were acquired through the National Institute of Child Health and Human Development Extremely Preterm Birth Outcomes Tool. Prognostic discordance was calculated as the difference between a provider and data-driven estimates and classified as pessimistic (provider estimate below data-driven estimate range), accurate (within range), or optimistic (above range). The association between prognostic discordance and the threshold probability of survival was evaluated using nonparametric tests.

Results We had 137 neonatal respondents (51% response rate) and 57 obstetric responses (23% response rate). The overall median prognostic discordance was 1.5% (interquartile range: 17, 13) and 52 (27%) of all respondents were pessimistic, 100 (52%) were accurate, and 42 (22%) were optimistic. The survival threshold above which neonatal and obstetric providers recommended active treatment or antenatal corticosteroids was 30% (20–45%) and 10% (0–20%), respectively. Thresholds did not significantly differ among the three prognostic discordance groups (p = 0.45 for neonatal and p = 0.53 for obstetric providers). There was also no significant correlation between the magnitude of prognostic discordance and thresholds.

Conclusion Prognostic discordance exists among both neonatal and obstetric providers. However, this discordance is not associated with the threshold probability of survival at which providers recommend active treatment or antenatal corticosteroids at 22 weeks' gestation.

Key Points

• Prognostic discordance at 22 weeks' gestation exists for neonatal and obstetric providers.

• Prognostic discordance is not associated with survival thresholds for neonatal active treatment.

• Prognostic discordance is not associated with survival thresholds for the use of antenatal corticosteroids.

Keywords

prognosis - periviable infants - resuscitation - active treatment - antenatal corticosteroids - preterm infants

Publikationsverlauf

Eingereicht: 26. Juni 2022

Angenommen: 14. Oktober 2022

Accepted Manuscript online:
27. Oktober 2022

Artikel online veröffentlicht:
15. Dezember 2022

• References

• 1 Rysavy MA, Li L, Bell EF. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med 2015; 372 (19) 1801-1811
• 2 Backes CH, Rivera BK, Pavlek L. et al. Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis. Am J Obstet Gynecol 2021; 224 (02) 158-174
• 3 American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus no. 6: periviable birth. Obstet Gynecol 2017; 130 (04) e187-e199
• 4 Rysavy MA. Prognosis as an intervention. Clin Perinatol 2018; 45 (02) 231-240
• 5 Rysavy MA, Tyson JE. The problem and promise of prognosis research. JAMA Pediatr 2016; 170 (05) 411-412
• 6 Morse SB, Haywood JL, Goldenberg RL, Bronstein J, Nelson KG, Carlo WA. Estimation of neonatal outcome and perinatal therapy use. Pediatrics 2000; 105 (05) 1046-1050
• 7 Mulvey S, Partridge JC, Martinez AM, Yu VY, Wallace EM. The management of extremely premature infants and the perceptions of viability and parental counselling practices of Australian obstetricians. Aust N Z J Obstet Gynaecol 2001; 41 (03) 269-273
• 8 Boland RA, Cheong JLY, Stewart MJ, Kane SC, Doyle LW. Disparities between perceived and true outcomes of infants born at 23–25 weeks' gestation. Aust N Z J Obstet Gynaecol 2022; 62 (02) 255-262
• 9 Haywood JL, Morse SB, Goldenberg RL, Bronstein J, Nelson KG, Carlo WA. Estimation of outcome and restriction of interventions in neonates. Pediatrics 1998; 102 (02) e20
• 10 Boland RA, Davis PG, Dawson JA, Doyle LW. What are we telling the parents of extremely preterm babies?. Aust N Z J Obstet Gynaecol 2016; 56 (03) 274-281
• 11 Blanco F, Suresh G, Howard D, Soll RF. Ensuring accurate knowledge of prematurity outcomes for prenatal counseling. Pediatrics 2005; 115 (04) e478-e487
• 12 Cavolo A, Dierckx de Casterlé B, Naulaers G, Gastmans C. Physicians' attitudes on resuscitation of extremely premature infants: a systematic review. Pediatrics 2019; 143 (06) e20183972
• 13 Arbour K, Lindsay E, Laventhal N. et al. Shifting provider attitudes and institutional resources surrounding resuscitation at the limit of gestational viability. Am J Perinatol 2020; 39 (08) 869-877
• 14 Raju TN, Mercer BM, Burchfield DJ, Joseph GF. Periviable birth: executive summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. J Perinatol 2014; 34 (05) 333-342
• 15 Rysavy MA, Horbar JD, Bell EF. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network and Vermont Oxford Network. Assessment of an updated neonatal research network extremely preterm birth outcome model in the vermont oxford network. JAMA Pediatr 2020; 174 (05) e196294
• 16 Travers CP, Clark RH, Spitzer AR, Das A, Garite TJ, Carlo WA. Exposure to any antenatal corticosteroids and outcomes in preterm infants by gestational age: prospective cohort study. BMJ 2017; 356: j1039
• 17 Cahill AG, Kaimal AJ, Kuller JA, Turrentine MA. American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Accessed November 19 at: https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/09/use-of-antenatal-corticosteroids-at-22-weeks-of-gestation
• 18 Singh J, Fanaroff J, Andrews B. et al. Resuscitation in the “gray zone” of viability: determining physician preferences and predicting infant outcomes. Pediatrics 2007; 120 (03) 519-526
• 19 British Association of Perinatal Medicine. Perinatal Management of Extreme Preterm Birth before 27 weeks of gestation: A Framework for Practice. Accessed September 1, 2022 at: https://www.bapm.org/resources/80-perinatal-management-of-extreme-preterm-birth-before-27-weeks-of-gestation-2019
• 20 Guinsburg R, Branco de Almeida MF, Dos Santos Rodrigues Sadeck L. et al; Brazilian Network on Neonatal Research. Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists. J Perinatol 2012; 32 (12) 913-919
• 21 Janvier A, Barrington K, Deschênes M, Couture E, Nadeau S, Lantos J. Relationship between site of training and residents' attitudes about neonatal resuscitation. Arch Pediatr Adolesc Med 2008; 162 (06) 532-537
• 22 Janvier A, Lantos J, Deschênes M, Couture E, Nadeau S, Barrington KJ. Caregivers attitudes for very premature infants: what if they knew?. Acta Paediatr 2008; 97 (03) 276-279
• 23 Patel RM, Rysavy MA, Bell EF, Tyson JE. Survival of infants born at periviable gestational ages. Clin Perinatol 2017; 44 (02) 287-303
• 24 Venkatesh KK, Lynch CD, Costantine MM. et al. Trends in active treatment of live-born neonates between 22 weeks 0 days and 25 weeks 6 days by gestational age and maternal race and ethnicity in the US, 2014 to 2020. JAMA 2022; 328 (07) 652-662 10.
• 25 Sklar A, Yang A, Martinez NG, Yee LM. Periviability decision-making: assessing provider characteristics and cognitive traits. Womens Health Rep (New Rochelle) 2021; 2 (01) 201-209
• 26 Vermont Oxford Network. Accessed June 1, 2022 at: https://nightingale.vtoxford.org