Obstet Gynecol. 2017 Oct;130(4):e187-e199. doi: 10.1097/AOG.0000000000002352.
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.
大约有 0.5%的婴儿在妊娠第三个 trimester 前出生，这些非常早期的分娩导致了大多数新生儿死亡和超过 40%的婴儿死亡。最近一份关于联合研讨会会议记录的执行摘要将围产儿期出生定义为发生在妊娠 20 0/7 周到 25 6/7 周之间的分娩。当分娩预计接近存活极限时，家庭和医疗保健团队将面临复杂且具有伦理挑战性的决策。除了出生时的 gestational age 外，还有多种因素与围产儿期出生的短期和长期结局相关。这些因素包括但不限于不可改变的因素（例如胎儿性别、体重、多胎）、可能改变的产前和产时因素（例如分娩地点、是否打算通过 cesarean delivery 或引产进行干预、产前使用皮质类固醇和硫酸镁）以及产后管理（例如出生后开始或停止、继续或停止 intensive care）。产前和产时管理选择取决于具体情况，但可能包括早产临产的短期 tocolytic 治疗，以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 组链球菌预防，以及分娩，包括 cesarean delivery，以关注胎儿健康或胎儿胎位不正。只要可能，应在提供孕产妇和新生儿护理专业知识以及必要基础设施（包括 intensive care units）的中心进行计划对母婴进行干预的围产儿期分娩。本文档描述了围产儿期出生后的新生儿结局，提供了该环境下干预的当前证据和建议，并为家庭咨询提供了大纲，目的是纳入知情患者的偏好。其目的是根据个人情况和患者价值观为基于个人情况的决策提供支持和指导，包括拒绝和接受干预和治疗。
