The age of Viability

To use this blog as awareness and information in the month of November I would like to share some info about the age of viability.

As a disclaimer: I am not suggesting that anyone who made the heart wrenching choice to do comfort care at any given time in the NICU journey made a bad choice NOR am I saying that making the choice to continue care is the best option I would just like to make information available to those who are seeking out more information about prematurity and the outcomes.


That said.. this is what the Docs on maternal and fetal medicine have to say about the age of viability.

The survival rate for infants born preterm has improved over the last 2 decades and is likely to continue to improve. An infant born at the threshold of viability presents a variety of complex medical, social, and ethical decisions. Although the incidence of such births is low, the number of extremely preterm births has increased, and the impact on the infants, their families, the health care system, and society is profound.

The survival rate for infants born from 22 to 25 weeks of gestation increases with each additional week of gestation. However, the incidence of moderate or severe neurodevelopmental disability in surviving children assessed at the age of 18 to 30 months is high (approximately 30%–50%) and does not appear to decrease over the 23- to 25-week gestation period.2–9 Many of these infants require prolonged intensive and long-term care. The commitment for all aspects of care may be extensive, multidisciplinary, lifelong, and costly. Because the families bear the emotional and financial consequences of the birth of an extremely preterm infant, it is essential to inform the prospective parents regarding the expectations for infant survival and outcome and the risks and benefits of various approaches to care.

* according to the Special delivery show only about 400 infants are born each year at 25 weeks gestation. * (not sure of where they got their info... but found it interesting.)

COUNSELING REGARDING POTENTIAL FETAL OUTCOMES
Most parents are unfamiliar with the complexities of care required for an extremely preterm infant in the intensive care unit and after discharge from the hospital. It is often necessary to provide the information in small segments at frequent intervals to help the parents begin to comprehend the issues. They need clear and consistent explanations of the various supportive procedures that will likely be necessary during the first days after the infant’s birth. Family members should also be provided with an overview of the potential complications of extreme prematurity and prolonged intensive care. They should be informed of the range of survival rates and of the types and rates of long-term disabilities that can be expected. In providing such information, physicians should consider data reported in the current literature as well as outcomes based on local experience. They should allow for some error in the best estimate of gestational age and fetal weight, and they must make provisions for unique qualifiers, such as the presence of intrauterine growth restriction and other factors that affect the risk assessment.

Long-term outcomes of a large collaborative network cohort (n = 1151) of extremely preterm infants born in the United States in 1993–19943 and a population-based cohort (n = 1185 [303 survivors]) of infants born in the United Kingdom and Ireland in 19952 have recently been reported. In these 2 studies, neurodevelopmental status at 18 to 30 months of age was assessed with uniform validated tools. Approximately 30% to 50% of surviving children who weighed less than 750 g at birth or whose gestational age was less than 25 weeks had moderate or severe disability, including blindness, deafness, and cerebral palsy. Many infants had more than 1 disability. The incidence of moderate to severe disability did not change significantly between 23 and 25 weeks’ gestation, although the survival rate increased over the same gestation range. Outcomes of these populations at school age and beyond are not known; however, data from earlier cohorts have shown an increased incidence of learning disabilities at school age.

Using sonographic weight estimate to assess risk is confounded by the inclusion of infants who are gestationally more mature but growth restricted.1213 Even in ideal circumstances, the 95% confidence limits for a formula-based estimate of fetal weight are plus or minus 15% to 20%.14 Thus, an infant estimated to weigh 600 g may have an actual birth weight of less than 500 g or more than 700 g. Even relatively small discrepancies of 1 or 2 weeks in gestational age or 100 to 200 g in birth weight may have major implications for survival and long-term morbidity. This underscores the importance of counseling about the range of possible outcomes. Multiple gestation increases the difficulty of accurate ultrasonic gestational age assessment, and the prognosis for one infant may differ from that of the other(s). Gender and gestational age significantly affect the likelihood of survival for infants weighing less than 750 g. In one large cohort of infants weighing less than 1500 g at birth,1 a birth weight of 600 g was associated with a survival rate ranging from approximately 15% for a male of 22 weeks’ gestational age to 65% for a female of 25 weeks’ gestational age. Similarly, at 23 weeks’ gestation, the survival rate ranged from approximately 20% for a male weighing 520 g to 60% for a female weighing 740 g.

* we heard it a lot in the NICU that girls did better than boys... Who knew*

Obstetric and neonatal physicians, primary care physicians, and other appropriate staff should confer to ensure that consistent and accurate information is provided to the parents. The range of possible outcomes and management options for the mother can then be outlined to the family. If maternal transport is to be considered, the obstetrician should be knowledgeable about the available regional resources and be prepared to provide information to the parents. More detailed counseling can then be accomplished at the receiving unit. Additional input from other important sources, such as clergy, social workers, and the institution’s bioethics committee, may be offered to the parents. Counseling should be sensitive to cultural and ethnic diversity, and a skilled translator should be available for parents whose primary language differs from the language of the care providers. It should be emphasized that there is some uncertainty with any predictive process, because every infant is unique. The prognosis for the fetus may change after birth, when a more accurate assessment of the gestational age and actual condition can be made. Ongoing risk assessment must be individualized depending on the infant’s subsequent course and response to treatment

* During our quick labor and deliver we were not given as much information. However, I do not think that would have changed the outcome of our choice.*

I think for today.. that will be it. I have a few other bits of information that I want to share. But this is a lot of information for one day.