What is the management of periviable birth?

Management of Periviable Birth

Periviable birth (20 0/7 to 25 6/7 weeks gestation) requires immediate transfer to a Level III-IV center when intervention is planned, comprehensive family counseling that includes both resuscitative and palliative care options, and gestational age-specific pharmacologic interventions including antenatal corticosteroids at ≥23 weeks, magnesium sulfate for neuroprotection, and antibiotics for PPROM at ≥24 weeks. 1

Immediate Triage and Transfer

Transfer the patient to a tertiary care center before delivery whenever possible, as antenatal transfer significantly improves neonatal outcomes compared to postnatal transport. 1

• Periviable infants require immediate life-sustaining interventions that are only available at centers with Level III-IV NICUs and Level III-IV maternal care designations. 1
• Initiate stabilization protocols during transfer, including antenatal corticosteroids, magnesium sulfate, tocolytics if appropriate, antibiotics for PPROM, and GBS prophylaxis. 1
• When maternal instability (severe preeclampsia, hemorrhage, infection) precludes antenatal transfer, arrange for neonatal transport after delivery with advance consultation. 1

Family Counseling Framework

Conduct joint obstetric-neonatal team counseling sessions that present both resuscitative and palliative care options with unbiased data on survival and neurodevelopmental outcomes. 1

• Present gestational age-specific survival rates and long-term neurodevelopmental impairment data, emphasizing that outcomes vary significantly based on multiple factors beyond gestational age alone. 2, 3
• Explicitly offer pregnancy termination as an option, with referral systems in place for providers with conscientious objections. 1
• Clarify that parental goals may prioritize either optimizing survival or minimizing suffering, and formulate care plans accordingly rather than using rigid gestational age algorithms. 1
• Emphasize that initiating one intervention (e.g., corticosteroids) does not mandate all subsequent interventions (e.g., cesarean delivery or neonatal resuscitation). 1
• Provide serial counseling as gestational age advances and clinical circumstances evolve, since even brief pregnancy prolongation significantly changes outcomes. 1, 4

Pharmacologic Interventions by Gestational Age

Antenatal Corticosteroids

Administer antenatal corticosteroids at 23-25 weeks gestation when resuscitation is planned, as they significantly reduce death and neurodevelopmental impairment. 1, 5

• At 23 weeks: reduces death/neurodevelopmental impairment from 90.5% to 83.4%. 1
• At 24 weeks: reduces death/neurodevelopmental impairment from 80.3% to 68.4%. 1
• At 25 weeks: reduces death/neurodevelopmental impairment from 67.9% to 52.7%. 1
• At 22 weeks: no significant benefit demonstrated (90.2% vs 93.1%). 1
• Do not administer until the gestational age when neonatal resuscitation and intensive care would be considered appropriate. 5, 6

Magnesium Sulfate for Neuroprotection

Administer magnesium sulfate when delivery is anticipated before 32 weeks and resuscitation is planned, as it reduces cerebral palsy risk (RR 0.68,95% CI 0.54-0.87) without increasing mortality. 1, 5

• Only give when neonatal resuscitation would be appropriate, not before the family has decided on resuscitative care. 5, 6
• Evidence supports use from 24 weeks onward based on randomized controlled trial data. 1

Antibiotics for PPROM

Administer broad-spectrum antibiotics for PPROM at ≥24 weeks gestation to prolong pregnancy and reduce neonatal infections. 1, 5, 7

• At 20-23 6/7 weeks: antibiotics may be considered but evidence is weaker; use shared decision-making. 5, 7, 6
• At <20 weeks (previable): use shared decision-making regarding antibiotic use. 5
• Avoid amoxicillin-clavulanic acid, which increases necrotizing enterocolitis risk. 5, 7
• Use azithromycin as an alternative to erythromycin when unavailable. 5
• Do not use prolonged or repeated antibiotic courses beyond the standard 7-day regimen. 7, 6

Antibiotics for Preterm Labor with Intact Membranes

Do not administer antibiotics for preterm labor with intact membranes, as they provide no benefit and amoxicillin-clavulanic acid may worsen long-term outcomes. 1

Tocolytic Therapy

Consider short-term tocolytics (nifedipine or indomethacin) to delay delivery 48-72 hours for corticosteroid administration, though consistent neonatal outcome improvements have not been demonstrated. 1

• Evidence for tocolysis before 26 weeks is limited. 1
• Use tocolytics primarily to allow time for corticosteroid administration and maternal transfer, not as definitive therapy. 1, 3

Obstetric Interventions and Maternal Risk Considerations

Cesarean Delivery Decision-Making

Weigh the significant maternal risks of periviable cesarean delivery against uncertain neonatal benefit, particularly given the high likelihood of classical hysterotomy and increased future reproductive risks. 1

• Periviable cesarean delivery frequently requires classical (vertical) hysterotomy, which increases perioperative morbidity and mandates repeat cesarean delivery in future pregnancies due to uterine rupture risk. 1
• Periviable cesarean delivery increases uterine rupture risk in subsequent pregnancies regardless of incision type. 1
• Each additional cesarean delivery compounds future reproductive risks. 1
• Base the decision on parental goals (resuscitative vs. palliative), predicted neonatal survival benefit, and maternal risk tolerance. 1

Expectant Management Risks

Recognize that expectant management also carries maternal risks, including infection with PPROM and HELLP syndrome or eclampsia with severe preeclampsia. 1

• Balance the risks of pregnancy prolongation against potential neonatal benefit from increased gestational age. 1
• Monitor closely for maternal fever ≥38°C, tachycardia, uterine tenderness, purulent discharge, and fetal compromise requiring immediate delivery. 6

Cerclage Management

Either remove the cerclage or leave it in situ after PPROM, though removal is generally preferred to reduce infection risk, as retention does not prolong pregnancy. 7, 6

Interventions NOT Recommended

Avoid serial amnioinfusions and amniopatch, as these are investigational only and not supported for routine care. 7, 6

Do not use electronic fetal heart rate monitoring routinely unless intrauterine resuscitation would affect newborn outcome and intervention is planned. 1

Monitoring During Expectant Management

• Check maternal vital signs, fetal heart rate, and perform physical examination weekly. 6
• Instruct patients on daily self-monitoring for temperature, bleeding, discharge changes, contractions, and pain. 6
• Deliver immediately for maternal fever, tachycardia, uterine tenderness, purulent discharge, fetal tachycardia/compromise, or placental abruption. 6

Subsequent Pregnancy Management

Counsel patients that nearly 50% of immediate subsequent pregnancies result in recurrent preterm birth after periviable PPROM. 6

• Follow guidelines for previous spontaneous preterm birth, typically including progesterone supplementation and increased surveillance. 7, 6

Critical Pitfalls to Avoid

• Do not use gestational age alone to determine management; incorporate fetal sex, weight, plurality, location of delivery, and parental goals. 2, 3
• Do not administer corticosteroids or magnesium sulfate before the gestational age when resuscitation would be pursued. 5, 6
• Avoid amoxicillin-clavulanic acid in all periviable scenarios due to necrotizing enterocolitis risk. 5, 7
• Do not assume that starting one intervention mandates all others; reassess as circumstances evolve. 1
• Ensure accurate pregnancy dating, as even small gestational age errors significantly impact periviable counseling and outcomes. 1