Intervention at the border of viability: Perspective over a decade

Objective: To investigate prenatal management and outcome of infants born at the border of viability during 2 periods, 2001 to 2003 (late epoch) and 1993 to 1995 (early epoch). Design: Cohort study. Setting: Single academic, high-risk perinatal referral center. Participants: All 160 women admitted to labor and delivery with a live fetus who delivered at an estimated gestational age of 22 0/7 weeks to 24 67 weeks. Main Outcome Measures: Prenatal management and time between maternal admission and delivery or death of the fetus, infant resuscitation efforts, neonatal intensive care unit interventions, time of death, and morbidities in survivors. Results: Mothers in both epochs were of similar age, race, and duration of pregnancy at hospital admission. Compared with the early epoch, women during the late epoch were more likely to be transported to a higher level of care (relative risk [RR], 2.01; 95% confidence interval [CI], 1.58-2.57) and receive sonographic surveillance (RR, 1.48; 95% CI, 1.07-2.04), antibiotics (RR, 1.60; 95% CI, 1.10-2.33), and antenatal steroids (RR, 1.61; 95% CI, 1.22-2.12). Life-sustaining interventions were provided for infants admitted to the neonatal intensive care unit more frequently during the late epoch than the early epoch, including high-frequency ventilation (RR, 3.57; 95% CI, 1.93-6.61), chest tubes (RR, 1.44; 95% CI, 1.06-1.94), dopamine administration (RR, 2.49; 95% CI, 1.24-4.97), and steroid administration for blood pressure support (RR, 2.18; 95% CI, 1.60-2.92). Gestational age-specific mortality was the same in the 2 epochs. Conclusions: More interventions were provided for infants born at 22 to 24 weeks' gestation in the late epoch than the early epoch. Despite these changes in management, there has been no reduction in mortality in more than a decade.