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Perinatal care at an extremely low gestational age (22–25 weeks). An Italian approach: the “Carta di Firenze”
  1. Maria Serenella Pignotti1,
  2. Gianfranco Scarselli2,
  3. Ignazio Barberi3,
  4. Mauro Barni4,
  5. Giulio Bevilacqua5,
  6. Francesco Branconi6,
  7. Giovanni Bucci7,
  8. Mario Campogrande8,
  9. Pietro Curiel9,
  10. Romolo Di Iorio10,
  11. Gian Carlo Di Renzo11,
  12. Mariarosaria Di Tommaso12,
  13. Massimo Moscarini13,
  14. Gian Aristide Norelli14,
  15. Aldo Pagni15,
  16. Antonio Panti16,
  17. Ivana Pela17,
  18. Giorgio Rondini18,
  19. Giuseppe Saggese19,
  20. Giampaolo Salvioli20,
  21. Enrico Scarano21,
  22. Gianpaolo Donzelli22
  1. 1
    Neonatal Medicine, University of Florence, Florence, Italy
  2. 2
    Department of Obstetrics and Gynaecology, University of Florence, Florence, Italy
  3. 3
    Department of Paediatrics and Neonatology, University of Messina, Messina, Italy
  4. 4
    Bioethics Committee, Tuscany, Italy
  5. 5
    Department of Gynaecology, Obstetrics and Neonatology, University of Parma, Parma, Italy
  6. 6
    Department of Obstetrics and Gynaecology, University of Florence, Florence, Italy
  7. 7
    Emeritus of Paediatrics and Neonatology, Rome, Italy
  8. 8
    Department of Obstetrics and Gynaecology, Sant’Anna Hospital, Turin, Italy
  9. 9
    Past President, Associazione degli Ostetrici e Ginecologi Ospedalieri Italiani (AOGOI), Italy
  10. 10
    Department of Gynaecology, Perinatology and Child Health, La Sapienza University, Rome, Italy
  11. 11
    Department of Obstetrics and Gynaecology, University of Perugia, Italy
  12. 12
    Department of Obstetrics and Gynaecology, University of Florence, Florence, Italy
  13. 13
    Department of Gynaecology, Perinatology and Child Health, La Sapienza University, Rome, Italy
  14. 14
    Department of Legal Medicine, University of Florence, Florence, Italy
  15. 15
    President, Commissione Codice Deontologico of the FNOMCeO, Italy
  16. 16
    President, Ordine dei Medici of Florence, Florence, Italy
  17. 17
    Bioethics Committee, Tuscany, Italy
  18. 18
    Department of Paediatrics, University of Pavia, Pavia, Italy
  19. 19
    Department of Paediatrics, University of Pisa, Pisa, Italy
  20. 20
    Department of Paediatrics and Neonatology, University of Bologna, Bologna, Italy
  21. 21
    Neonatal Medicine, University of Florence, Florence, Italy
  22. 22
    Neonatal Medicine, University of Florence, Florence, Italy
  1. Dr Maria Serenella Pignotti, Neonatal Medicine, A Meyer Children Hospital, University of Florence, Italy, Via Luca Giordano 13- 50132 – Firenze; m.pignotti{at}meyer.it

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Guidelines on life or death strategies in extremely preterm infants have been formulated in various countries worldwide.115 The general agreement is not to initiate resuscitation in neonates when gestational age is less than or equal to 22 weeks, and intensive care is assured for infants of 25 weeks and over; in the middle there is a sort of “grey zone”. To provide helpful suggestions for initial management of threatened birth in infants at a gestational age of 25 completed weeks or less, a working group in Florence recently reviewed existing studies on survival and morbidity rates, international guidelines and practice recommendations. A consensus document was drawn up, and this was evaluated by several scientific societies (Italian Paediatric Society (SIP), Italian societies of obstetricians and gynaecologists (AGUI, AOGOI), Italian Society of Legal Medicine (SIMLA), Italian Society of Perinatal Medicine (SIMP), Italian Society of Anaesthesiologists (SIARTI), and the Italian Society of Paediatric Anaesthesia (SARNePI), and is currently being examined by the Italian National Bioethical Committee. The issues addressed include:

  1. suggestions arising from the need to guarantee mothers and neonates adequate assistance solely for safeguarding them against useless, painful, or inefficacious treatments resulting in futile treatment;

  2. suggestions for treatment stratified per gestational age in weeks (considered by the entire scientific world as the most efficacious measure of maturity of the fetus/neonate), while leaving room for deviations in specific cases at the discretion of the attending doctors and in compliance with the parents’ will (as per Italian Legislation regarding late pregnancy terminations [Law 194/1978] that forces clinicians to plan either palliative or intensive care for the fetus/neonate after a postnatal evaluation);

  3. parents’ desires are paramount in borderline cases and must be complied with if medically acceptable

  4. generally aggressive management is recommended at or after 25 weeks and is not suggested at or under 22 weeks. Decisions must be made on an individual level in the grey zone (23–24 weeks), although aggressive management of the mother and fetus/neonate is not recommended

  5. the attending clinician’s main duty is to provide honest, updated and adequate information for the parents.

Our document offers an overview of different positions that may be helpful for clinicians and parents. It also provides the basis for a debate—which is necessary in Italy, where any discussion about end-of-life decisions, particularly in infancy and childhood, is still controversial.

Table 1 Suggestions for treatment at an extremely preterm age

Competing interests: None.

Acknowledgements

We thank Francesca Ceroni, Judge of the Juvenile Court, Florence, Roberta Filippi, Attorney of the Court of Florence, and Patrizia Pompei, Judge of the Civil Court of Florence for their work in addressing and reviewing the document.

REFERENCES

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Footnotes

  • Competing interests: None.

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