Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN; Johns Hopkins All Children's Hospital; Maternal, Fetal, & Neonatal Institute; St. Petersburg, FL.
Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN.
Am J Obstet Gynecol MFM. 2020 May;2(2):100096. doi: 10.1016/j.ajogmf.2020.100096. Epub 2020 Feb 27.
Despite medical advances in the care of extremely preterm neonates and growing acceptance of resuscitation at 23 and even 22 weeks gestation, controversy remains concerning the use of antepartum obstetric intervention s that are intended to improve outcomes in the setting of anticipated extremely preterm birth. In the absence of demonstrated benefit at <23 weeks gestation and with uncertain benefit at 23 weeks gestation, previous obstetric committee opinions have advised against their use at these gestational ages.
The purpose of this study was to review the use of obstetric intervention s at the threshold of viability based on neonatal resuscitation plan and to review the odds of survival to neonatal intensive care unit discharge based on use of obstetric intervention s with adjustment for neonatal factors.
This retrospective study of 6 study centers reviewed pregnant patients who were admitted between 22+0/7 and 24+6/7 weeks gestation facing delivery from 2011-2015. Patients with known anomalies or missing data were excluded. Records were reviewed for demographics, resuscitation plan, and obstetric intervention s. Mode of delivery, delivery room care, and final infant dispositions were recorded. Multiple gestations were included as 1 pregnancy in regard to the use of obstetric intervention s and were excluded from survival analysis.
Four hundred seventy-eight mothers met the inclusion criteria. When resuscitation was planned, mothers were more likely to receive all conventional obstetric intervention s (antenatal steroids, magnesium sulfate for neuroprotection, tocolytics, and Group Beta Streptococcus prophylaxis), regardless of gestational age at admission, and were more likely to be delivered by cesarean section (P<.05). Analyzed as a group, when antenatal steroids, magnesium sulfate, tocolytics and Group Beta Streptococcus prophylaxis were administered, the odds of survival to neonatal intensive care unit discharge increased for newborn infants who were born at 22 (odds ratio, 11.33; 95% confidence interval, 1.405-91.4) and 23 weeks gestation (odds ratio, 15.5; 95% confidence interval, 3.747-64.11; P<.05). In singletons, the odds of survival to neonatal intensive care unit discharge was not improved by cesarean delivery vs vaginal delivery, even after adjustment for the use of additional interventions, weight, gender, and gestational age (odds ratio, 1.0; 95% confidence interval, 0.59-1.8; P=.912).
In this study, when postnatal resuscitation was planned at 22 and 23 weeks gestation, women were more likely to receive antenatal steroids, magnesium sulfate, and antibiotics; provision of this bundle imparted survival benefit at 23 weeks gestation but could not be demonstrated at 22 weeks gestation because of the small sample size. These findings support of neonate-oriented obstetric interventions in the setting of delivery at 23 weeks gestation when resuscitation is planned and further exploration of optimal obstetric care when resuscitation of infants who were born at 22 weeks gestation is anticipated.
尽管在早产儿护理方面取得了医学进步，并且越来越多的人接受在 23 甚至 22 周妊娠时进行复苏，但对于预期早产儿出生时使用产前产科干预措施以改善结局仍存在争议。在 23 周妊娠前没有显示出益处，并且在 23 周妊娠时益处不确定的情况下，以前的产科委员会意见建议不要在这些妊娠周数使用这些干预措施。
本研究的目的是根据新生儿复苏计划回顾在生存能力阈值使用产科干预措施，并根据使用产科干预措施和新生儿因素调整后评估存活至新生儿重症监护病房出院的几率。
这项回顾性研究对 6 个研究中心的孕妇进行了研究，这些孕妇在 2011 年至 2015 年期间面临从 22+0/7 周到 24+6/7 周妊娠的分娩。排除了已知异常或数据缺失的患者。记录人口统计学、复苏计划和产科干预措施。记录分娩方式、分娩室护理和最终婴儿处置。多胎妊娠在使用产科干预措施方面被视为 1 次妊娠，并且在生存分析中被排除在外。
478 名母亲符合纳入标准。当计划复苏时，母亲更有可能接受所有常规产科干预措施（产前类固醇、神经保护用硫酸镁、宫缩抑制剂和 B 组链球菌预防），无论入院时的胎龄如何，并且更有可能通过剖宫产分娩（P<.05）。作为一个整体进行分析时，当给予产前类固醇、硫酸镁、宫缩抑制剂和 B 组链球菌预防时，在 22 周（优势比，11.33；95%置信区间，1.405-91.4）和 23 周妊娠（优势比，15.5；95%置信区间，3.747-64.11；P<.05）出生的新生儿存活至新生儿重症监护病房出院的几率增加。在单胎妊娠中，即使在调整了其他干预措施、体重、性别和胎龄的使用后，剖宫产分娩与阴道分娩相比，存活至新生儿重症监护病房出院的几率也没有提高（优势比，1.0；95%置信区间，0.59-1.8；P=.912）。
在这项研究中，当 22 周和 23 周妊娠时计划进行产后复苏时，女性更有可能接受产前类固醇、硫酸镁和抗生素；提供这种套餐在 23 周妊娠时具有生存获益，但由于样本量小，在 22 周妊娠时无法证明。这些发现支持在 23 周妊娠时进行复苏时，以新生儿为导向的产科干预措施，并进一步探讨在预计对 22 周妊娠时出生的婴儿进行复苏时的最佳产科护理。
