Women's Health Experts Address Treatment and Decision-Making Around Periviable Birth
New Document, Third in ACOG/SMFM Obstetric Care Consensus Series, Reflects Evidence and Considerations Regarding Outcomes, Treatment and Counseling
October 21, 2015
Washington, DC — Organizations representing women's healthcare providers today released a landmark document addressing the complex considerations around deliveries that occur during the periviable period. Periviable Birth is the third in the joint American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM) Obstetric Care Consensus series.
Periviable birth is delivery occurring from 20 weeks and 0 days of gestation through 25 weeks and six days of gestation; approximately 0.5 percent of all births occur before the third trimester, and these very early deliveries result in the majority of neonatal deaths. However, even within that period, neonatal outcomes vary dramatically. Delivery prior to 23 weeks of gestation typically results in neonatal death regardless of resuscitation and intervention, and each additional week of gestation shows a progressive increase in the rate of survival of the neonate as well as a reduction in moderate to severe neurodevelopmental impairment.
Because of the wide range of outcomes, patient counseling during the periviable period must include accurate information that is as individualized as possible, with the goal of incorporating informed patient preferences, the consensus document states. It is essential for obstetric care providers to be familiar with the tools available to predict outcomes and with the potential implications of various interventions. These interventions should only be undertaken after a discussion with the family that includes an unbiased presentation of data related to the chance of survival and long-term neurodevelopmental impairment.
In addition, providers should evaluate and counsel about the impact of interventions on maternal health, with providers and parents together considering the risks to the woman in the context of the neonate's predicted outcome.
"Care during the periviable period is incredibly complex, and requires providers to take into account a wide variety of considerations," said Brian M. Mercer, MD, past president of SMFM and chair of the Department of Ob/Gyn at MetroHealth in Cleveland, OH, and a lead author of the document. "Just as important as trying to predict outcomes is the role of counseling patients in a way that is both accurate and empathetic."
The consensus document lays out evidence supporting common approaches and interventions during the periviable period, including antenatal corticosteroids, magnesium sulfate for neuroprotection, antibiotics for pregnancy prolongation after premature rupture of membranes, tocolytic therapy for preterm labor, cervical cerclage, and cesarean delivery.
"Without question, it is challenging to accurately anticipate outcomes of deliveries during the periviable period, but we do know that the circumstances surrounding periviable birth often require advanced care and resources to optimize outcomes ," said Anjali Kaimal, MD, MAS a maternal-fetal medicine specialist at Massachusetts General Hospital and another lead author of the document. "That's why it's important for periviable deliveries in which maternal or neonatal interventions are planned to occur, when possible, at health centers that have the resources, expertise and infrastructure to provide high levels of maternal and neonatal care."
Given the high likelihood of death and the significant degree of neurodevelopmental impairment associated with periviable birth, counseling of patients should also include palliative care as an option, the consensus document recommends. In situations in which the parental goals are to minimize suffering upon delivery, the antenatal plan of care should reflect this priority.
The new consensus document replaces ACOG's Practice Bulletin, Perinatal Care at the Threshold of Viability.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org