Periviable birth
Periviable birth
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DOI：
10.1016/j.ajog.2015.08.035
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发表时间：
2015-11-01
影响因子：
9.8
通讯作者：
Sciscione, Anthony C.
中科院分区：
文献类型：
--
作者：
Ecker, Jeffrey L.;Kaimal, Anjali;Sciscione, Anthony C.
大约0.5%的分娩发生在妊娠晚期之前，这些非常早的分娩导致大多数新生儿死亡和40%以上的婴儿死亡。最近一次联合研讨会的会议纪要将围产定义为妊娠20 /7周至25 /7周的分娩。当预期分娩接近生存能力极限时，家庭和保健团队面临着复杂和具有道德挑战性的决定。除了出生时的胎龄外，还发现了与围产儿的短期和长期结局相关的多种因素。这些因素包括但不限于不可改变的因素（如胎儿性别、体重、胎数）、可能改变的产前和产时因素（如分娩地点、是否有意通过剖宫产或诱导分娩进行干预、产前皮质类固醇和硫酸镁的使用）以及产后管理（如出生后开始或停止、继续或退出重症监护）。产前和产时的处理方案因具体情况而异，但可能包括针对早产的短期溶胎治疗，以便有时间给予产前类固醇、抗生素，以延长早产胎膜早破后的潜伏期，或用于产时B群链球菌预防，以及分娩，包括剖宫产，以考虑胎儿健康或胎儿表现不良。只要有可能，计划进行孕产妇或新生儿干预的围产应在提供孕产妇和新生儿护理专业知识和必要基础设施（包括重症监护病房）的中心进行，以支持此类服务。本文件描述围生期分娩后的新生儿结局，提供当前的证据和关于这种情况下干预措施的建议，并为家庭咨询提供大纲，目标是纳入知情的患者偏好。其目的是根据个人情况和患者价值观，提供有关决定的支持和指导，包括拒绝和接受干预和治疗。
Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.