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  • Original Article
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Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists

Abstract

Objective:

To verify, in extremely preterm infants, if disagreement between obstetricians and neonatologists regarding proactive management is associated with early death.

Study Design:

Prospective cohort of 484 infants with 230/7 to 266/7 weeks, without malformations, born from January 2006 to December 2009 in eight Brazilian hospitals. Pro-active management was defined as indication of 1 dose of antenatal steroid or cesarean section (obstetrician) and resuscitation at birth according to the international guidelines (neonatologist). Main outcome was neonatal death in the first 24 h of life.

Result:

Obstetricians and neonatologists disagreed in 115 (24%) patients: only neonatologists were proactive in 107 of them. Disagreement between professionals increased 2.39 times the chance of death in the first day (95% confidence interval 1.40 to 4.09), adjusted for center and maternal/neonatal clinical conditions.

Conclusion:

In infants with 23 to 26 weeks of gestation, disagreement between obstetricians and neonatologists, translated as lack of antenatal steroids and/or vaginal delivery, despite resuscitation procedures, increases the odds of death in the first day.

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References

  1. Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L, Goldsmith JP et al. Part 11: Neonatal resuscitation: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation 2010; 122 (16 Suppl 2): S516–S538.

    Article  Google Scholar 

  2. De Leeuw R, Cuttini M, Nadai M, Berbik I, Hansen G, Kucinskas A et al. Treatment choices for extremely preterm infants: an international perspective. J Pediatr 2000; 137: 608–616.

    Article  CAS  Google Scholar 

  3. Pignotti MS, Donzelli G . Perinatal care at the threshold of viability: an international comparison of practical guidelines for the treatment of extremely preterm births. Pediatrics 2008; 121: e193–e198.

    Article  Google Scholar 

  4. Manktelow BN, Lal MK, Field DJ, Sinha SK . Antenatal corticosteroids and neonatal outcomes according to gestational age: a cohort study. Arch Dis Child Fetal Neonatal Ed 2010; 95: F95–F98.

    Article  Google Scholar 

  5. Malloy MH . Impact of cesarean section on neonatal mortality rates among very preterm infants in the United States, 2000–2003. Pediatrics 2008; 122: 285–292.

    Article  Google Scholar 

  6. Shah PS . Extensive cardiopulmonary resuscitation for VLBW and ELBW infants: a systematic review and meta-analyses. J Perinatol 2009; 29: 655–661.

    Article  CAS  Google Scholar 

  7. Batton DG . Committee on fetus and newborn. clinical report - antenatal counseling regarding resuscitation at an extremely low gestational age. Pediatrics 2009; 124: 422–427.

    Article  Google Scholar 

  8. Chan KL, Kean LH, Marlow N . Staff views on the management of the extremely preterm infant. Eur J Obstet Gynecol Reprod Biol 2006; 128: 142–147.

    Article  Google Scholar 

  9. Wilkinson AR, Ahluwalia J, Cole A, Crawford D, Fyle J, Gordon A et al. Management of babies born extremely preterm at less than 26 weeks of gestation: a framework for clinical practice at the time of birth. Arch Dis Child Fetal Neonatal Ed 2009; 94: F2–F5.

    Article  Google Scholar 

  10. Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R . New Ballard Score, expanded to include extremely premature infants. J Pediatr 1991; 119: 417–423.

    Article  CAS  Google Scholar 

  11. American Heart Association; American Academy of Pediatrics. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: neonatal resuscitation guidelines. Pediatrics 2006; 117: e1029–e1038.

    Article  Google Scholar 

  12. Almeida MF, Guinsburg R, Martinez FE, Procianoy RS, Leone CR, Marba ST et al. Perinatal factors associated with early deaths of preterm infants born in Brazilian Network on Neonatal Research centers. J Pediatr (Rio J) 2008; 84: 300–307.

    Google Scholar 

  13. Stoll BJ, Hansen NI, Bell EF, Shankaran S, Laptook AR, Walsh MC et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010; 126: 443–456.

    Article  Google Scholar 

  14. Been JV, Degraeuwe PL, Kramer BW, Zimmermann LJ . Antenatal steroids and neonatal outcome after chorioamnionitis: a meta-analysis. BJOG 2011; 118: 113–122.

    Article  CAS  Google Scholar 

  15. Fishman SG, Gelber SE . Evidence for the clinical management of chorioamnionitis. Semin Fetal Neonatal Med 2012; 17: 46–50.

    Article  Google Scholar 

  16. Jolly MC, Sebire N, Harris J, Robinson S, Regan L . Obstetric risks of pregnancy in women less than 18 years old. Obstet Gynecol 2000; 96: 962–966.

    CAS  PubMed  Google Scholar 

  17. Devender R, Stuart DR . Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Library 2011; 06: CD004454.

    Google Scholar 

  18. Tyson JE, Parikh NA, Langer J, Green C, Higgins RD . National institute of child health and human development neonatal research network. Intensive care for extreme prematurity--moving beyond gestational age. N Engl J Med 2008; 358: 1672–1681.

    Article  CAS  Google Scholar 

  19. Mori R, Kusuda S, Fujimura M . Neonatal research network japan. antenatal corticosteroids promote survival of extremely preterm infants born at 22 to 23 weeks of gestation. J Pediatr 2011; 159: 110–114.

    Article  CAS  Google Scholar 

  20. Mwansa-Kambafwile J, Cousens S, Hansen T, Lawn JE . Antenatal steroids in preterm labour for the prevention of neonatal deaths due to complications of preterm birth. Int J Epidemiol 2010; 39 (Suppl 1): i122–i133.

    Article  Google Scholar 

  21. Lee HC, Gould JB . Survival advantage associated with cesarean delivery in very low birth weight vertex neonates. Obstet Gynecol 2006; 107: 97–105.

    Article  Google Scholar 

  22. Bader D, Kugelman A, Boyko V, Levitzki O, Lerner-Geva L, Riskin A et al. Risk factors and estimation tool for death among extremely premature infants: a national study. Pediatrics 2010; 125: 696–703.

    Article  Google Scholar 

  23. Skupski DW, Chervenak FA, McCullough LB, Bancalari E, Haumont D, Simeoni U et al. Ethical dimensions of periviability. J Perinat Med 2010; 38: 579–583.

    PubMed  Google Scholar 

  24. Khan RA, Burgoyne L, O’Connell MP, Dempsey EM . Resuscitation at the limits of viability—an Irish perspective. Acta Paediatr 2009; 98: 1456–1460.

    Article  CAS  Google Scholar 

  25. Morse SB, Haywood JL, Goldenberg RL, Bronstein J, Nelson KG, Carlo WA . Estimation of neonatal outcome and perinatal therapy use. Pediatrics 2000; 105: 1046–1050.

    Article  CAS  Google Scholar 

  26. Kollée LA, Cuttini M, Delmas D, Papiernik E, den Ouden AL, Agostino R et al. Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study. BJOG 2009; 116: 1481–1491.

    Article  Google Scholar 

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Acknowledgements

We thank all the centers and members of the Brazilian Network on Neonatal Research that helped to gather the data for this study. Funding: Ministry of Health of Brazil (MS/VIGISUS 1755/2000; MS/FNS 274; FIOCRUZ/PDTSP).

Ethics approval

The Institutional Review Boards from the Federal University of São Paulo and the Clinical Board of each participating institution approved the study protocol.

Brazilian Network on Neonatal Research

Universidade Federal de São Paulo/Escola Paulista de Medicina (São Paulo, SP): Maria Fernanda Branco de Almeida, Ruth Guinsburg, Daniela Miguel Gibertoni.

Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (São Paulo, SP): Lílian Rodrigues dos Santos Rodrigues Sadeck, Cléa Rodrigues Leone, Vera Lucia Jornada Krebs.

Universidade Estadual de Campinas (Campinas, SP): Sérgio Tadeu Martins Marba, Jamil Pedro de Siqueira Caldas, Fernanda de Castro Millen.

Faculdade de Medicina de Botucatu/Universidade Estadual Paulista Júlio de Mesquita Neto (Botucatu, SP): Lígia Maria Suppo de Souza Rugolo, Maria Regina Bentlin, Adriana Saito.

Pontifícia Universidade Católica do Rio Grande do Sul (Porto Alegre, RS): Jorge Hecker Luz, Humberto Holmer Fiori, Manuel Rutkay Pereira, Alexandre Holmer Fiori, Renato Machado Fiori.

Instituto Fernandes Figueira da Fundação Oswaldo Cruz (Rio de Janeiro, RJ): José Maria de Andrade Lopes, Olga Bomfim, Ana Beatriz Souza Machado, Paola Azara Tabicas Lima.

Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (Ribeirão Preto, SP): Francisco Eulógio Martinez, Walusa Assad Gonçalves Ferri, Maria Lucia Silveira Ferlin.

Universidade Federal do Rio Grande do Sul/Hospital de Clínicas de Porto Alegre (Porto Alegre, RS): Renato Soibelmann Procianoy, Rita de Cássia Silveira.

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Correspondence to R Guinsburg.

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Guinsburg, R., Branco de Almeida, M., dos Santos Rodrigues Sadeck, L. et al. Proactive management of extreme prematurity: disagreement between obstetricians and neonatologists. J Perinatol 32, 913–919 (2012). https://doi.org/10.1038/jp.2012.28

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