End-of-Life Care and Survival without Major Brain Damage in Newborns at the Limit of Viability.

BACKGROUND: The probabilities of survival and survival without major brain damage (MBD) are low in newborns at the limit of viability. Survival without MBD constitutes a major concern for parents and professionals. OBJECTIVES: To know the probabilities of survival without MBD in newborns ≤26 weeks' gestational age (GA) relative to the total number of survivors, whether these probabilities vary with GA, and how end-of-life (EoL) decisions influence these results. METHODS: We included all live-inborn patients of 22-26 weeks' GA, without major congenital anomalies, born in collaborating centers of the Spanish SEN1500 Network (2004-2010). MBD was defined as the presence of severe intraventricular hemorrhage and/or periventricular leukomalacia. RESULTS: A total of 3,371 patients were born alive, 3,236 of whom were admitted to the neonatal intensive care unit (NICU). Survival without MBD was 44.4% among patients admitted to the NICU, increasing from 12.5% at 22 weeks to 57.9% at 26 weeks' GA. The proportion of survivors without MBD relative to the total number of survivors was 81.1%, and it was independent of GA. EoL decisions preceded one-third of all deaths and were more frequent among the most immature patients. CONCLUSIONS: The proportion of survivors without MBD, when referred to the total number of survivors, is relatively high and is independent of GA. EoL decisions after the occurrence of MBD seem to play an important role in this respect. These results support the attitude of "giving an opportunity" even to the most immature patients, if this is in accordance with the parents' wishes.

Outcomes of very-low-birth-weight infants exposed to maternal clinical chorioamnionitis: a multicentre study.

BACKGROUND: Chorioamnionitis is a recognized risk factor of preterm delivery; however, controversy still persists concerning the relationship between maternal inflammation and neonatal morbidity and mortality. OBJECTIVE: To determine the incidence of clinical chorioamnionitis and its relationship to morbidity and mortality among very-low-birth-weight (VLBW) infants. METHODS: This was a retrospective analysis of prospectively collected data of VLBW neonates ≤ 32 weeks' gestational age (GA) admitted to collaborating units in the Spanish SEN1500 Network between January 2008 and December 2011. Clinical chorioamnionitis was defined by obstetricians based on clinical findings, and neonatal outcomes were compared between exposed and non-exposed infants by multivariate logistic regression analysis. RESULTS: During the study period, 11,464 VLBW newborns were admitted to our units and 10,026 were ≤ 32 weeks' GA. Among them, 8,330 (83.1%) had complete data and were included. Of these, 1,480 (17.8%) were exposed to maternal clinical chorioamnionitis. The incidence was higher at lower GA and, after adjusting for confounding factors, exposed infants had higher risks of early-onset neonatal sepsis (EONS) (10.0 vs. 2.8%; aOR 3.102; 95% CI 2.306-4.173; p < 0.001) and necrotizing enterocolitis (NEC) (11.2 vs. 7.7%; aOR 1.300; 95% CI 1.021-1.655; p < 0.033), but lower risks of patent ductus arteriosus (PDA) (43.2 vs. 34.9%; aOR 0.831; 95% CI 0.711-0.971; p < 0.02) and late-onset bacterial sepsis (LONS) (36.6 vs. 32.5%; aOR 0.849; 95% CI 0.729-0.989; p < 0.035). There were no differences in mortality between the groups. CONCLUSIONS: The incidence of maternal clinical chorioamnionitis is inversely related to GA at delivery, and in VLBW infants ≤ 32 weeks' GA it is associated with higher risks of EONS and NEC, but lower risks of PDA and LONS. We did not found differences in survival.