Progress in perinatal care - Clinical decisions in extremely premature infants at the treshold of viability

摘要

Current progress in perinatal care has allowed for a significant and continuous improvement of the prognosis of extremely premature infants. Nevertheless, the prognosis of extremely low birth weight infants remains critical, in particular for those born before 25 weeks of gestation and with less that 750 g birth weight. The chance of survival decreases with increasing prematurity, in parallel the risk of complications and permanent disability rises. In this threshold period, individual decisions have to be made regarding the mode of delivery and the course of action to be taken after delivery. Recommendations and guidelines to facilitate these decisions have been provided by the national societies involved in perinatal medicine. However, these recommendations may vary significantly. In all countries, infants born prior to completed 22~(nd) weeks of gestation receive palliative treatment, i.e. comfort care. In the current Swiss guideline, palliative care is recommended for children born in the 23~(rd) or 24~(th) week of gestation, too. In contrast, the German guideline recommends an individual decision in this period of pregancy, based on close reconcilement with the parents. This recommendation is based on the experience that the individual prognosis cannot be calculated based on perinatological parameters. Moreover, the individual risk of complications and permanent disability cannot be estimated during primary care after delivery. In principle, the right of life is intangible and stands superior to an estimation of potential quality of life in the future. There is no right to distinguish between worthy and unworthy, livable or unlivable life. As a consequence, the decision between palliative care "and life support with intensive neonatological care has to be taken under consideration of the current and future interests of the child. To reach this goal, close communication between all parties involved is central. Open, comprehensive and truthful information has to be provided to the parents in a sensitive way, and the parents have to be closely involved in all decisions.