Limit of viability
- Richard A Ehrenkranz, MD, FAAP
Richard A Ehrenkranz, MD, FAAP
- Professor of Pediatrics and Obstetrics, Gynecology & Reproductive Sciences
- Yale University School of Medicine
- Mark R Mercurio, MD, MA
Mark R Mercurio, MD, MA
- Professor of Pediatrics
- Chief, Neonatal-Perinatal Medicine
- Director, Yale Pediatric Ethics Program
- Yale University School of Medicine
The limit of viability is defined as the stage of fetal maturity that ensures a reasonable chance of extrauterine survival. Determining the limit of viability is desirable so that interventions that are costly and painful can be avoided in the infant who does not have a chance of survival. However, deciding upon a threshold of viability is challenging because it remains uncertain which extremely preterm infants have a reasonable chance of survival.
Survival and morbidity of extremely preterm infants born below 26 weeks gestation will be reviewed here. In addition, a management approach for infants born at the limit of viability based upon prognosis will be presented. The management of pregnancies at or near the limit of viability is discussed separately. (See "Delivery of the preterm low birth weight singleton fetus", section on 'Management at the limit of viability'.)
Factors that affect survival rates in extremely premature infants (gestational age [GA] <26 weeks) include GA, birth weight (BW), gender, plurality, and the use of antenatal corticosteroid therapy [1-3].
Gestational age — The major factor in determining viability is GA. Survival rates reported in several studies [1,4-17] during the initial neonatal intensive care unit (NICU) admission for infants 22 to 25 completed weeks gestation (220/7 to 256/7 weeks gestation) are displayed in the table (table 1). These reports span time periods ranging from six months to six years between 1993 and 2012, and represent several large geographic areas in Western Europe, Japan, a network of tertiary level academic centers in the United States, and a population-based study of California. These data clearly demonstrated the rise of survival rate as GA increased from 22 to 25 weeks. In addition, they also showed improved survival, as survival rates increased significantly for infants born at 23 to 25 weeks gestation.
An observational study that used the analysis of video recordings to evaluate the neonatal response to a standardized resuscitation protocol in 73 preterm infants (<29 weeks gestation ) suggested that infants born between 22 to 24 weeks GA might require different resuscitative interventions than infants born between 25 to 26 weeks GA and 27 to 28 weeks GA to achieve similar heart rate and pulse oximetry responses . Higher rates of death and severe intraventricular hemorrhage (IVH) were associated with the need for more resuscitative interventions and a delay in their implementation.
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- SURVIVAL RATES
- Gestational age
- Other factors
- Estimates of survival
- Neurodevelopmental outcome
- MANAGEMENT APPROACH
- Interpreting the data
- - Survival to discharge
- Accuracy of gestational age
- Impact of initial management
- - Long-term morbidity
- Ethical issues
- Professional standards and recommendations
- - American societies
- - United Kingdom guidelines
- Our approach
- SUMMARY AND RECOMMENDATIONS