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Oct 10, 2023 228 likes •400 views

Disclosures Periviable Pregnancies: Decision No financial disclosures related to this talk Making Under Uncertainty Medical Advisor to Celmatix, Mindchild Bobs Red Mill Father Aaron B. Caughey, MD, PhD Professor and Chair

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Periviable Pregnancies: Decision Making Under Uncertainty

Aaron B. Caughey, MD, PhD

Professor and Chair Department of Obstetrics and Gynecology Associate Dean for Women’s Health Research & Policy Oregon Health & Science University caughey@ohsu.edu

Disclosures

  • No financial disclosures related to this talk
  • Medical Advisor to Celmatix, Mindchild
  • Bob’s Red Mill
  • Father

Overview

  • What is periviable?
  • What is viability? Why does it matter?
  • What are the outcomes?
  • How do we counsel in this setting?
  • Decision making under uncertainty

Case Presentation

  • 27 yo G1P0 at 23 2/7 wks GA presents with

PTL – ctxns Q3’ / cvx- 3/80/0

  • Who counsels her and about what?
  • Outcomes
  • Mgmt
  • MgSo4
  • Tocolysis
  • BMZ
  • MOD
  • Fetal monitoring
  • Resuscitation
  • Expt mgmt
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Case Presentation – 23 wks PTL

What are reasonable options?

A.

Expt Mgmt

B.

Interventions (BMZ, MgSO4, Abx, etc)

C.

No Resuscitation

D.

Induction termination

E.

A&B

F.

A, B, & C

G.

A, B, C, & D

Expt Mgmt Interventions (BMZ, MgS... No Resuscitation Induction termination A&B A, B, & C A, B, C, & D 5% 11% 7% 22% 38% 14% 3%

Case Presentation – 22 wks PTL

What are reasonable options?

A.

Expt Mgmt

B.

Interventions (BMZ, MgSO4, Abx, etc)

C.

No Resuscitation

D.

Induction termination

E.

A&B

F.

A, B, & C

G.

A, B, C, & D

Expt Mgmt Interventions (BMZ, MgS... No Resuscitation Induction termination A&B A, B, & C A, B, C, & D 21% 2% 16% 21% 28% 6% 6%

Case Presentation – 24 wks PTL

What are reasonable options?

A.

Expt Mgmt

B.

Interventions (BMZ, MgSO4, Abx, etc)

C.

No Resuscitation

D.

Induction termination

E.

A&B

F.

A, B, & C

G.

A, B, C, & D

Expt Mgmt Interventions (BMZ, MgS... No Resuscitation Induction termination A&B A, B, & C A, B, C, & D 2% 14% 2% 11% 38% 30% 4%

Case Presentation – 25 wks PTL

What are reasonable options?

A.

Expt Mgmt

B.

Interventions (BMZ, MgSO4, Abx, etc)

C.

No Resuscitation

D.

Induction termination

E.

A&B

F.

A, B, & C

G.

A, B, C, & D

Expt Mgmt Interventions (BMZ, MgS... No Resuscitation Induction termination A&B A, B, & C A, B, C, & D 1% 23% 1% 3% 25% 43% 4%

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Overview

  • What is periviable?
  • What is viability? Why does it matter?
  • What are the outcomes?
  • Decision making under uncertainty
  • How do we counsel in this setting?

Roe V. Wade

“ For the stage subsequent to viability the State, in promoting its interest in the potentiality of human life, may, if it chooses, regulate, and even proscribe, abortion except where necessary, in appropriate medical judgment, for the preservation of the life or health of the mother.”

Translation: After viability, states may restrict or ban abortions except “necessary to preserve the life or health” of the woman.

No Oregon No Colorado

From Guttmacher institute 2015

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Overview

  • What is periviable?
  • What is viability?
  • What are the outcomes?
  • Decision making under uncertainty
  • How do we counsel in this setting?

Neonatal outcomes at 22-25 weeks

Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6.

Neonatal outcomes at 22-25 weeks

Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6.

Periviable – Long-term outcomes

Moore, et al. JAMA Pediatr. 2013;167(10):967-974.

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Periviable – Long-term outcomes

Moore, et al. JAMA Pediatr. 2013;167(10):967-974.

Periviable – Long-term outcomes

Moore, et al. JAMA Pediatr. 2013;167(10):967-974.

Periviable – Long-term outcomes

Moore, et al. JAMA Pediatr. 2013;167(10):967-974.

Impact of Long-term Outcomes

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Impact of Long-term Outcomes

Severe MR/CP Down Syndrome CP MR/CP

Overview

  • What is periviable?
  • What is viability?
  • What are the outcomes?
  • What are the potential interventions?
  • Decision making under uncertainty
  • How do we counsel in this setting?

Decision Making Under Certainty

  • Many of our day to day decisions
  • What to eat?
  • What to wear?
  • Entertainment (what to watch)?

Decision Making Under Uncertainty

  • Many decisions with less certainty
  • What to eat in a foreign city? (e.g. Shanghai)
  • What to wear on a trip?
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Decision Making Under Uncertainty

  • Examples of uncertainty
  • What to eat in a foreign city?
  • Will you need to eat? Very certain
  • How enjoyable will the food be? Variable
  • How dangerous will the food be? Variable
  • What to wear on a trip?
  • Will you need underwear? Very certain
  • Will you need a raincoat? Variable
  • How comfortable will you be (warm/cold)? Variable
  • How dangerous will the clothing be (exposed skin)? V

Decision Making Under Uncertainty

  • Examples of uncertainty in medicine
  • Effect of therapy
  • Cesarean for delivery of baby – very certain
  • Abx in labor for T of 100.4 degrees – uncertain need
  • Cerclage for a short cervix – uncertain benefit
  • MgSO4 for CP prophylaxis – uncertain benefit/need
  • Chemotherapy for Ovarian CA – uncertain benefit / harm

Decision Making Under Uncertainty

  • One approach – Rational, expected value
  • Think of this as lottery
  • Two potential outcomes:
  • 50% chance Win - $10, 50% chance Lose – Price of lottery
  • A fair price - $5 – who will pay $5?
  • 60% chance Win - $10, 40% chance Lose – Price of lottery
  • A fair price - $6 – who will pay $5?

Decision Making Under Uncertainty

  • One approach – Rational, expected value
  • Think of this as lottery
  • Two potential outcomes:
  • 50% chance Win - $10, 50% chance Lose – Price of lottery
  • A fair price - $5 – who will pay $5?
  • 60% chance Win - $10, 40% chance Lose – Price of lottery
  • A fair price - $6 – who will pay $5?
  • 60% chance Win - $1M, 40% chance Lose – Price of lottery
  • A fair price - $600,000 – who will pay $500,000?
  • (Isn’t this more like periviable resuscitation?)
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Periviable – Long-term outcomes

Moore, et al. JAMA Pediatr. 2013;167(10):967-974.

Periviable – Long-term outcomes

Moore, et al. JAMA Pediatr. 2013;167(10):967-974.

Overview

  • What is periviable?
  • What is viability?
  • What are the outcomes?
  • Decision making under uncertainty
  • How do we counsel in this setting?

23 0/7 – 23 6/7: NICHD - To resuscitate or not - Is 23 weeks the new 24 weeks?

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9 23 0/7 – 23 6/7: To resuscitate or not?

New OCC Document

OCC – periviability. SMFM/ACOG, Obstet Gynecol / Am J Obstet Gynecol 11/2015

Summary

  • Periviability
  • Outcomes
  • Interventions
  • Should be driven by plans for resuscitation
  • Shared decision making with a focus on

the unknown and long-term patient prefs

  • Team counseling – MFM / Neo / RN
  • 20% severely disabled – is that acceptable?

Case Presentation – 23 wks PTL

Did your management options change?

  • A) Yes
  • B) No
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Thank You Consider Regional Approach

5 Astoria Seaside St Helens Tillamook Cape Lookout Lincoln City The Dalles Condon Madras Redmond Prineville Florence Reedsport North Bend Coos Bay Roseburg Port Orford Grants Pass Ashland Bly Brookings Klamath Falls Lakeview Hermiston Pendleton La Grande Enterprise Baker City Canyon City John Day Ontario Vale Burns Jordan Valley

Portland

Eugene Gresham Hillsboro Beaverton McMinnville Keizer Albany Corvallis Springfield Bend Medford Salem

MILES

Satellite Regional Hub

Silverton

Decision Making Under Uncertainty

  • Expected Utility Theory
  • Nonsatiation
  • Diminishing Marginal Utility
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Decision Making Under Uncertainty

  • Prospect Theory
  • Distortions in:
  • Values
  • Probabilities

Gains domain Loss domain Mug experiments

Decision Making Under Uncertainty

  • Prospect Theory
  • Distortions in:
  • Values
  • Probabilities

Lottery Airline insurance Kaiser Hayward Example

Decision Making Under Uncertainty

  • Prenatal Dx vs. Periviability Resusc.
  • Termination vs. Nonintervention
  • “losing” aneuploid vs. “losing” normal fetus
  • Uncertainty of specificity of phenotype (DS vs. range)
  • Uncertainty about phenotype (What is NDD?)
  • Uncertainty of severity of phenotype

Decision Making Under Uncertainty

  • Prenatal Dx Example
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Decision Making Under Uncertainty

OHSU Periviablity Guidelines

Weeks Obstetric Care Neonatal Care < 23

No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of neonate provided.

23 0/7 – 23 6/7

Steroids and C/S for fetal indications not recommended but offered based on neonatal care plan. NICU care not recommended but may be

  • ffered based on prognostic factors and

shared decision making with parents.

24 0/7 – 24 6/7

Steroids and C/S for fetal indications neutral: may be declined or accepted based

  • n neonatal care plan.

NICU care conditionally offered based on prognostic factors and shared decision making with parents. NICU care may be declined and comfort care provided.

25 0/7 – 25 6/7

Steroids and C/S for fetal indications recommended. Neonatal resuscitation and NICU care provided in the majority of cases. NICU care may be declined and comfort care provided; an Ethics consult is strongly recommended.

≥ 26 0/7

Steroids and C/S for fetal indications provided. Neonatal resuscitation and NICU care provided unless known fetal lethal anomalies.

OHSU Periviablity Guidelines

Weeks Obstetric Care Neonatal Care < 23

No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of infant provided.

23 0/7 – 23 6/7

Steroids and C/S for fetal indications not recommended but offered based on neonatal care plan. NICU care not recommended but may be

  • ffered based on prognostic factors and

shared decision making with parents.

24 0/7 – 24 6/7

Steroids and C/S for fetal indications neutral: may be declined or accepted based

  • n neonatal care plan.

NICU care conditionally offered based on prognostic factors and shared decision making with parents. NICU care may be declined and comfort care provided.

25 0/7 – 25 6/7

Steroids and C/S for fetal indications recommended. Neonatal resuscitation and NICU care provided in the majority of cases. NICU care may be declined and comfort care provided; an Ethics consult is strongly recommended.

≥ 26 0/7

Steroids and C/S for fetal indications provided. Neonatal resuscitation and NICU care provided unless known fetal lethal anomalies.

OHSU Periviablity Guidelines

Weeks Obstetric Care Neonatal Care < 23

No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of infant provided.

23 0/7 – 23 6/7

Steroids and C/S for fetal indications not recommended but offered based on neonatal care plan. NICU care not recommended but may be

  • ffered based on prognostic factors and

shared decision making with parents.

24 0/7 – 24 6/7

Steroids and C/S for fetal indications neutral: may be declined or accepted based

  • n neonatal care plan.

NICU care conditionally offered based on prognostic factors and shared decision making with parents. NICU care may be declined and comfort care provided.

25 0/7 – 25 6/7

Steroids and C/S for fetal indications recommended. Neonatal resuscitation and NICU care provided in the majority of cases. NICU care may be declined and comfort care provided; an Ethics consult is strongly recommended.

≥ 26 0/7

Steroids and C/S for fetal indications provided. Neonatal resuscitation and NICU care provided unless known fetal lethal anomalies.

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13 OHSU Periviablity Guidelines

Weeks Obstetric Care Neonatal Care < 23

No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of infant provided.

23 0/7 – 23 6/7

Steroids and C/S for fetal indications not recommended but offered based on neonatal care plan. NICU care not recommended but may be

  • ffered based on prognostic factors and

shared decision making with parents.

24 0/7 – 24 6/7

Steroids and C/S for fetal indications neutral: may be declined or accepted based

  • n neonatal care plan.

NICU care conditionally offered based on prognostic factors and shared decision making with parents. NICU care may be declined and comfort care provided.

25 0/7 – 25 6/7

Steroids and C/S for fetal indications recommended. Neonatal resuscitation and NICU care provided in the majority of cases. NICU care may be declined and comfort care provided; an Ethics consult is strongly recommended.

≥ 26 0/7

Steroids and C/S for fetal indications provided. Neonatal resuscitation and NICU care provided unless known fetal lethal anomalies.

OHSU Periviablity Guidelines

Weeks Obstetric Care Neonatal Care < 23

No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of infant provided.

23 0/7 – 23 6/7

Steroids and C/S for fetal indications not recommended but offered based on neonatal care plan. NICU care not recommended but may be

  • ffered based on prognostic factors and

shared decision making with parents.

24 0/7 – 24 6/7

Steroids and C/S for fetal indications neutral: may be declined or accepted based

  • n neonatal care plan.

NICU care conditionally offered based on prognostic factors and shared decision making with parents. NICU care may be declined and comfort care provided.

25 0/7 – 25 6/7

Steroids and C/S for fetal indications recommended. Neonatal resuscitation and NICU care provided in the majority of cases. NICU care may be declined and comfort care provided; an Ethics consult is strongly recommended.

≥ 26 0/7

Steroids and C/S for fetal indications provided. Neonatal resuscitation and NICU care provided unless known fetal lethal anomalies.

OHSU Periviablity Guidelines

Weeks Obstetric Care Neonatal Care < 23

No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of infant provided.

23 0/7 – 23 6/7

Steroids and C/S for fetal indications not recommended but offered based on neonatal care plan. NICU care not recommended but may be

  • ffered based on prognostic factors and

shared decision making with parents.

24 0/7 – 24 6/7

Steroids and C/S for fetal indications neutral: may be declined or accepted based

  • n neonatal care plan.

NICU care conditionally offered based on prognostic factors and shared decision making with parents. NICU care may be declined and comfort care provided.

25 0/7 – 25 6/7

Steroids and C/S for fetal indications recommended. Neonatal resuscitation and NICU care provided in the majority of cases. NICU care may be declined and comfort care provided; an Ethics consult is strongly recommended.

≥ 26 0/7

Steroids and C/S for fetal indications provided. Neonatal resuscitation and NICU care provided unless known fetal lethal anomalies.

Patient needs to decide about resuscitation in this model

  • http://www.nichd.nih.gov/about/org/der/bran

ches/ppb/programs/epbo/pages/epbo_case.as px NICHD survival calculator

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14 NICHD survival calculator

Enter the characteristics below. Gestational Age (Best Obstetric Estimate in Completed Weeks): Birth Weight (401 Grams to 1,000 Grams): grams Sex: Sex Female Male Singleton Birth: Singleton Birth Yes No Antenatal Corticosteroids (Within Seven Days Before Delivery): Antenatal Corticosteroids Yes No

Enter the characteristics below.

  • -S

e le ct--

Neonatal outcomes at 23 vs. 24 weeks NICHD

Reference: NICHD. Pediatrics.2010;126(3):443-455.

23 weeks 24 weeks Survived, % 26 55 Died, % 74 45 Survived without morbidity*, % 8 9 RDS, % 98 98 Early-onset sepsis, % 4 4 NEC – med management, % 31 39 NEC – surgical management, % 69 61 ROP ≥3, % 48 42 IVH grade 3, % 15 12 IVH grade 4, % 21 14

Neonatal outcomes at 6 years of age

Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6.

Neonatal outcomes at 6 years of age

Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6.

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15 Neonatal outcomes at 6 years of age

Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6.