#PAGE_PARAMS# #ADS_HEAD_SCRIPTS# #MICRODATA#
preLekára.sk / Journals / Czech and Slovak Neonatology / 2025 - 1

Periviable births: A marginal issue in neonatology?

Czech version

Authors: A. Staníková
Authors‘ workplace: Lékařská fakulta Masarykovy Univerzity, Brno ;  Neonatologické oddělení, Fakultní nemocnice Brno, Brno
Published in: Čes-slov Neonat 2025; 31 (1): 43-49.
Category: Reviews

Overview

Periviable births: A marginal issue in neonatology?

Most newborns are born at full term and even though they are born in the safe environment of a hospital, they require little to no assistance. However, sometimes pregnancies end much earlier, and a baby is born too soon and too small. The issue of babies born at the threshold of viability, or in the so-called gray zone, concerns only a few dozen children each year, and may therefore seem marginal. Yet such a situation can occur anytime, anywhere, and besides medical questions, it also presents significant ethical challenges. That is why it is important for everyone working in any type of maternity hospital to have sufficient awareness of this issue.

Keywords:

morbidity – palliative care – mortality – viability threshold – grey zone – extremely preterm newborn – periviable newborn

Sources
  1. ACOG. Obstetric care consensus No. 3 Summary: Periviable birth. Obstet Gynecol 2015; 126(5): 1123−1125. doi: 10.1097/ AOG.0000000000001101.
  2. American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Obstetric care consensus No. 6: Periviable birth. Obstet Gynecol 2017; 130(4): e187-e199. doi: 10.1097/AOG.0000000000002352.
  3. Ecker JL, Kaimal A, Mercer BM, Blackwell SC, deRegnier RA, Farrell RM, Grobman WA, Resnik JL, Sciscione AC; American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. No. 3: Periviable birth. Am J Obstet Gynecol 2015; 213(5): 604−14. doi: 10.1016/j.ajog.2015.08.035.
  4. Anani U, Tucker Edmonds B, Andrews BL, Famuyide M, Feltman D. Default withdrawal: exacerbating mistrust for our most vulnerable families. Am J Bioeth 2022; 22(11): 46−48. doi: 10.1080/15265161.2022.2123980.
  5. Char D. The advance of rescue technologies and the border of viability. Am J Bioeth. 2017; 17(8): 40−41. doi: 10.1080/15265161.2017.1340995.
  6. Domellöf M, Jonsson B. The swedish approach to management of extreme prematurity at the borderline of viability: A historical and ethical perspective. Pediatrics 2018; 142(Suppl 1): S533−S538. doi: 10.1542/peds.2018-0478C.
  7. Fellman V, Hellström-Westas L, Norman M, Westgren M, Källén K, Lagercrantz H, Marsál K, Serenius F, Wennergren M; EXPRESS Group. One-year survival of extremely preterm infants after active perinatal care in Sweden. JAMA 2009; 301(21): 2225−2233. doi: 10.1001/jama.2009.771.
  8. Guillén Ú, Weiss EM, Munson D, Maton P, Jefferies A, Norman M, Naulaers G, Mendes J, Justo da Silva L, Zoban P, Hansen TW, Hallman M, Delivoria-Papadopoulos M, Hosono S, Albersheim SG, Williams C, Boyle E, Lui K, Darlow B, Kirpalani H. Guidelines for the management of extremely premature deliveries: A systematic review. Pediatrics 2015; 136(2): 343−350. doi: 10.1542/peds.2015-0542.
  9. Hagen EM, Therkelsen ØB, Førde R, Aasland O, Janvier A, Hansen TW. Challenges in reconciling best interest and parental exercise of autonomy in pediatric life-or-death situations. J Pediatr 2012; 161(1): 146−151. doi: 10.1016/j.jpeds.2012.01.017.
  10. Humberg A, Härtel C, Rausch TK, Stichtenoth G, Jung P, Wieg C, Kribs A, von der Wense A, Weller U, Höhn T, Olbertz DM, Felderhoff-Müser U, Rossi R, Teig N, Heitmann F, Schmidtke S, Bohnhorst B, Vochem M, Segerer H, Möller J, Eichhorn JG, Wintgens J, Böttger R, Hubert M, Dördelmann M, Hillebrand G, Roll C, Jensen R, Zemlin M, Mögel M, Werner C, Schäfer S, Schaible T, Franz A, Heldmann M, Ehlers S, Kannt O, Orlikowsky T, Gerleve H, Schneider K, Haase R, Böckenholt K, Linnemann K, Herting E, Göpel W. Active perinatal care of preterm infants in the German Neonatal Network. Arch Dis Child Fetal Neonatal Ed 2020; 105(2): 190−195. doi: 10.1136/archdischild-2018-316770.
  11. Itabashi K, Horiuchi T, Kusuda S, Kabe K, Itani Y, Nakamura T, Fujimura M, Matsuo M. Mortality rates for extremely low birth weight infants born in Japan in 2005. Pediatrics 2009; 123(2): 445−50. doi: 10.1542/peds.2008-0763. Erratum in: Pediatrics 2009; 123(6): 1611. PMID: 19171608.
  1. Janvier A, Leblanc I, Barrington KJ. Nobody likes premies: The relative value of patients‘ lives. J Perinatol 2008 Dec; 28(12): 821−826. doi: 10.1038/jp.2008.103.
  2. Jonsen AR, Phibbs RH, Tooley WH, Garland MJ. Critical issues in newborn intensive care: A conference report and policy proposal. Pediatrics 1975; 55(6): 756−768. PMID: 1169753.
  3. Koc E, Unal S. Viability of extremely premature neonates: clinical approaches and outcomes. J Perinat Med 2024. doi: 10.1515/ jpm-2024-0432.
  4. Kornhauser Cerar L, Lucovnik M. Ethical dilemmas in neonatal care at the limit of viability. Children (Basel) 2023; 10(5): 784. doi: 10.3390/children10050784.
  5. Lantos JD. Ethical Problems in Decision Making in the Neonatal ICU. N Engl J Med 2018; 379(19): 1851−1860. doi: 10.1056/ NEJMra1801063.
  6. LoRe D, Groden CM, Schuh AR, Holmes C, Ostilla L, Vogel MM, Murray PD, Yamasato K, Tonismae T, Anani UE, Henner N, Famuyide M, Leuthner SR, Laventhal N, Andrews BL, Tucker Edmonds BM, Brennan KG, Feltman DM; Investigating neonatal decisions for extremely early deliveries (indeed) study group. Variability of care practices for extremely early deliveries. Pediatrics 2024; 154(3): e2023065521. doi: 10.1542/peds.2023-065521.
  7. Mactier H, Bates SE, Johnston T, Lee-Davey C, Marlow N, Mulley K, Smith LK, To M, Wilkinson D; BAPM Working Group. Perinatal management of extreme preterm birth before 27 weeks of gestation: A framework for practice. Arch Dis Child Fetal Neonatal Ed. 2020; 105(3): 232−239. doi: 10.1136/archdischild-2019-318402.
  8. Mercurio MR, Peterec SM, Weeks B. Hypoplastic left heart syndrome, extreme prematurity, comfort care only, and the principle of justice. Pediatrics 2008; 122(1): 186−189. doi: 10.1542/ peds.2008-0143.
  9. Morsing E, Lundgren P, Hård AL, Rakow A, Hellström-Westas L, Jacobson L, Johnson M, Nilsson S, Smith LEH, Sävman K, Hellström A. Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation. Acta Paediatr 2022; 111(6): 1167−1175. doi: 10.1111/apa.16316.
  10. Navne LE, Svendsen MN, Gammeltoft TM. The attachment imperative: Parental experiences of relation-making in a danish neonatal intensive care unit. Med Anthropol Q 2018; 32(1): 120−137. doi: 10.1111/maq.12412.
  11. Norman M. Nya nationella riktlinjer för extremt för tidigt födda: Ett viktigt steg framåt för bättre vård [New Swedish guideline on periviable births]. Lakartidningen 2017; 114: EH7Z. Swedish. PMID: 28463391.
  12. Norman M, Padkaer Petersen J, Stensvold HJ, Thorkelsson T, Helenius K, Brix Andersson C, Ørum Cueto H, Domellöf M, Gissler M, Heino A, Håkansson S, Jonsson B, Klingenberg C, Lehtonen L, Metsäranta M, Rønnestad AE, Trautner S. Preterm birth in the Nordic countries: Capacity, management and outcome in neonatal care. Acta Paediatr 2023; 112(7): 1422−1433. doi: 10.1111/apa.16753.
  13. Norman M, Jonsson B, Wallström L, Sindelar R. Respiratory support of infants born at 22−24 weeks of gestational age. Semin Fetal Neonatal Med 2022; 27(2): 101328. doi: 10.1016/j. siny.2022.101328.
  14. Oehmke F, Lauer T, Baecker J, Mader S, Soydan N, Born T, Brumhard M, Dettmeyer R, Staszewski S, Heinemann T, Kilian U, Sarikaya Y, Kress H, Tinneberg HR, Bilgin Y, Zimmer KP, Ehrhardt H. Ethical, legal, and religious aspects at the border of viability. Front Pediatr 2019; 7: 175. doi: 10.3389/ fped.2019.00175.
  15. Oygür N, Önal EE, Zenciroğlu A. National guidelines for delivery room management. Turk Pediatri Ars 2018; 53(Suppl 1): S3−S17. doi: 10.5152/TurkPediatriArs.2018.01803.
  16. Pignotti MS, Moratti S. The Italian Ministry of Health recommends resuscitation for all preterm infants irrespective of gestational age and parental consent. Arch Dis Child Fetal Neonatal Ed 2010; 95(2): F150−151. doi: 10.1136/ adc.2009.164376.
  17. Prasath A, Kumar VHS. Special issue: Advances in healthcare for neonates. Children (Basel). 2023; 10(6): 1048. doi: 10.3390/ children10061048.
 
  1. Rysavy MA, Mehler K, Oberthür A, Ågren J, Kusuda S, McNamara PJ, Giesinger RE, Kribs A, Normann E, Carlson SJ, Klein JM, Backes CH, Bell EF. An immature science: Intensive care for infants born at ≤23 weeks of gestation. J Pediatr 2021; 233: 16−25.e1. doi: 10.1016/j.jpeds.2021.03.006.
  2. Serenius F, Ewald U, Farooqi A, Fellman V, Hafström M, Hellgren K, Maršál K, Ohlin A, Olhager E, Stjernqvist K, Strömberg B, Ådén U, Källén K; Extremely preterm infants in sweden study group. Neurodevelopmental outcomes among extremely preterm infants 6.5 years after active perinatal care in Sweden. JAMA Pediatr 2016; 170(10): 954−963. doi: 10.1001/jamapediatrics.2016.1210.
  3. Singh J, Fanaroff J, Andrews B, Caldarelli L, Lagatta J, Plesha-Troyke S, Lantos J, Meadow W. Resuscitation in the „gray zone“ of viability: Determining physician preferences and predicting infant outcomes. Pediatrics 2007; 120(3): 519−526. doi: 10.1542/peds.2006-2966.
  4. Staub K, Baardsnes J, Hébert N, Hébert M, Newell S, Pearce R. Our child is not just a gestational age. A first-hand account of what parents want and need to know before premature birth. Acta Paediatr 2014 Oct; 103(10): 1035−1038. doi: 10.1111/ apa.12716.
  5. Syltern J. Scandinavian perspectives on life support at the border of viability. Front Pediatr 2024; 12: 1394077. doi: 10.3389/ fped.2024.1394077.
  6. Syltern J, Ursin L, Solberg B, Støen R. Postponed withholding: Balanced decision-making at the margins of viability. Am J Bioeth 2022; 22(11): 15−26. doi: 10.1080/15265161.2021.1925777.
  7. Šimják P, Smíšek J, Koucký M, Lamberská T, Plavka R, Hájek Z. Proactive approach at the limits of viability improves the short-term outcome of neonates born after 23 weeks‘ gestation. J Perinat Med 2018; 46(1): 103−111. doi: 10.1515/ jpm-2016-0264.
  8. South Australian Perinatal Practice Guideline Perinatal Care at the Threshold of Viability. [online] [cit. 2025-02-27]. Dostupný na: https://www.sahealth.sa.gov.au/wps/wcm/ connect/8ddf798042ac004d9f11bfad100c470d/Perinatal+Care+at+the+Threshold+of+Viability_PPG_v2_0.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-8dd-f798042ac004d9f11bfad100c470d-p4cjgIK
  9. Tyson JE, Parikh NA, Langer J, Green C, Higgins RD; National Institute of Child Health and Human Development Neonatal Research Network. Intensive care for extreme prematurity: Moving beyond gestational age. N Engl J Med 2008; 358(16): 1672−1681. doi: 10.1056/NEJMoa073059.
  10. Ursin LØ. Withholding versus withdrawing treatment: Why medical guidelines should omit „theoretical equivalence“. Am J Bioeth 2019; 19(6): W5−W9. doi: 10.1080/15265161.2019.1607920.
  11. Ursin L, Syltern J. Protect us from ourselves: Balancing the parental instinct of saving. Nurs Ethics 2020 Aug; 27(5): 1282−1296. doi: 10.1177/0969733019871691.
  12. Verhagen AA, Janvier A, Leuthner SR, Andrews B, Lagatta J, Bos AF, Meadow W. Categorizing neonatal deaths: A cross-cultural study in the United States, Canada, and The Netherlands. J Pediatr 2010; 156(1): 33−37. doi: 10.1016/j.jpeds.2009.07.019.
  13. Walther F, Küster DB, Bieber A, Rüdiger M, Malzahn J, Schmitt J, Deckert S. Impact of regionalisation and case--volume on neonatal and perinatal mortality: An umbrella review. BMJ Open. 2020; 10(9): e037135. doi: 10.1136/bmjopen-2020-037135.
  14. Wilkinson D, Butcherine E, Savulescu J. Withdrawal aversion and the equivalence test. Am J Bioeth 2019; 19(3): 21−28. doi: 10.1080/15265161.2019.1574465.
  15. Wilkinson D, Verhagen E, Johansson S. thresholds for resuscitation of extremely preterm infants in the UK, Sweden, and Netherlands. Pediatrics 2018; 142(Suppl 1): S574−S584. doi: 10.1542/peds.2018-0478I.
  16. Wyatt J, Hain R. Redirecting care: compassionate management of the sick or preterm neonate at the end of life. Children (Basel) 2022; 9(3): 344. doi: 10.3390/children9030344.
  17. Wyckoff MH, Salhab WA, Heyne RJ, Kendrick DE, Stoll BJ, Laptook AR; National Institute of Child Health and Human Development Neonatal Research Network. Outcome of extremely low birth weight infants who received delivery room cardiopulmonary resuscitation. J Pediatr 2012; 160(2): 239−244.e2. doi: 10.1016/j.jpeds.2011.07.041.
  1. Younge N, Goldstein RF, Bann CM, Hintz SR, Patel RM, Smith PB, Bell EF, Rysavy MA, Duncan AF, Vohr BR, Das A, Goldberg RN, Higgins RD, Cotten CM; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Survival and neurodevelopmental outcomes among periviable infants. N Engl J Med 2017; 376(7): 617−628. doi: 10.1056/NEJMoa1605566.
  2. Zlatohlávková B. Viabilita plodu a novorozence. Actual Gyn 2011; 3: 47−51.
Labels
Neonatology Neonatal Nurse
EDITORIAL
Foetal oxygen from conception to birth, the miraculous way of oxygen from the mother to the fetus
Fetal growth restriction – current options for prenatal diagnosis and management during pregnancy
Preterm prelabor rupture of the membranes
Intrapartum fetal hypoxia, the current state of intrapartum fetal well-being assessment
Current options for fetal surgery in the Czech Republic
Ophthalmia neonatorum prophylaxis
The use of dexmedetomidine in the neonatal period
Article was published in

Czech and Slovak Neonatology

2025 Issue 1
Most read in this issue
Login
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account

#ADS_BOTTOM_SCRIPTS#