Clinical Updates on Management & Outcomes of Extreme Preterm Birth
Management Options:
The panel advised for shared decision making and counselling to women and their families to be partners in clinical decision making. They noted that the active participation of parents in treatment may positively influence bonding as well as longer-term outcomes for child and family.
They further recommended the following best practice for obstetrics management:
- “Transfer the mother antenatally to a tertiary centre that can provide appropriate care to optimise the outcome
- Tocolysis may be useful if it is safe for mother and baby to delay delivery short term and allow timely administration of antenatal corticosteroid treatment
- Administer antenatal corticosteroids to facilitate fetal lung maturation
- Provide peripartum magnesium sulphate infusion to reduce neurological injury (as recommended by the National Institute for Health and Care Excellence (NICE) in the UK and various professional societies)
- Caesarean section is indicated for risks to the mother’s life or when an agreement has been made to resuscitate the neonate and labour would be detrimental to the outcome
- Perform delayed cord clamping of at least 60 seconds to facilitate placental transfusion to the newborn”.
For prevention of preterm birth, the panel recommended the following:
- “Both partners should stop smoking; even smoking cessation during pregnancy protects against preterm birth. Behavioural interventions for smoking cessation during pregnancy are effective, but evidence for the efficacy of drugs or nicotine replacement therapy is limited
- Optimise care of existing maternal medical diseases such as hypertension, diabetes and thyroid disorders
- Advice on healthy diet and exercise as being underweight or overweight increases the risk of complications including congenital anomalies, pre-eclampsia and small for gestational age, all of which may contribute to extreme preterm delivery
- Advise women before conceiving to reduce alcohol and caffeine consumption, stop recreational drugs, take folic acid, and ensure adequate vitamin D intake
- Screen for sexually transmitted infections in higher-risk women as these are associated with preterm birth
- Consider mid-stream urine culture (MSU) in early pregnancy as asymptomatic urinary tract infection and pyelonephritis is associated with preterm birth
- Low dose aspirin begun before 16 weeks of gestation reduces the risk of pre-eclampsia, fetal growth restriction and associated preterm birth
- Other interventions to reduce preterm birth include vaginal progestogen and cervical cerclage”.
For further information:
Extreme preterm birth has a social impact on mothers, fathers, children born preterm, and their families; the value of investing early in life to prevent later complications is now widely recognised.
Recently, Dr Andrei S Morgan and his team provided a broad overview of extreme preterm birth epidemiology, recent changes, and best practices in obstetric and neonatal management. They explored short and long term medical, psychological, and experiential consequences for individuals born extremely preterm, their mothers and families, as well as preventive measures that may reduce the incidence of extreme preterm birth. The updates were published in the BMJ on January 10, 2022.
Based on gestational age World Health Organization (WHO) categorizes preterm into the following 4 criteria:
- Preterm is defined as birth at less than 37 weeks or 259 days' gestation
- Moderate to late preterm is defined as birth at 32-36 completed weeks of gestation
- Very Preterm is defined as birth before 32 completed weeks of gestation
- Extremely preterm is defined as birth before 28 completed weeks of gestation (up to and including 27 weeks and 6 days of gestation)
Based on birth weight WHO defines preterm by:
- Low birth weight as birth weight of less than 2500 g
- Very low birth weight as birth weight of less than 1500 g
- Extremely low birth weight as birth weight of less than 1000 g
Perinatal survival has improved in recent years. The panel noted that extreme preterm birth has been stable in high-income countries over the past 25 years. However, they observed variability between countries and noted that the variabilities are due to differences in the definition of stillbirth and recording of data.
Regarding stillbirth, the panel wrote, "No agreed international definition of stillbirth exists, and the recording of fetal deaths at extreme preterm gestations varies by country. European recommendations are that all births from 22 weeks' gestational age should be officially recorded, but some countries define stillbirth using higher thresholds or birth weight. For example, stillbirth is defined as fetal death from 24 weeks in the UK and by the World Health Organization, 180 days in Italy, and 28 weeks in Bulgaria; in Austria, Belgium, Czech Republic, Germany, and Poland, fetal deaths are recorded at 500 g and above."
With regards to long term morbidity, the panel noted that higher intensities of perinatal and neonatal care are related to improved survival. They also addressed that limitation in the evidence for improvements in longer-term neurodevelopmental outcomes. They noted variability in the provision of care for extreme preterm birth has an impact on morbidity and mortality outcomes.
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