Available data on survival rates and outcomes of extremely low gestational age (GA) infants (22–25 weeks’ gestation) display wide variation by country. Whether similar variation is found in statements by national professional bodies is unknown. The objectives were to perform a systematic review of management from scientific and professional organizations for delivery room care of extremely low GA infants.
We searched Embase, PubMed, and Google Scholar for management guidelines on perinatal care. Countries were included if rated by the United Nations Development Programme’s Human Development Index as “very highly developed.” The primary outcome was rating of recommendations from “comfort care” to “active care.” Secondary outcomes were specifying country-specific survival and considering potential for 3 biases: limitations of GA assessment; bias from different definitions of stillbirths and live births; and bias from the use of different denominators to calculate survival.
Of 47 highly developed countries, 34 guidelines from 23 countries and 4 international groups were identified. Of these, 3 did not state management recommendations. Of the remaining 31 guidelines, 21 (68%) supported comfort care at 22 weeks’ gestation, and 20 (65%) supported active care at 25 weeks’ gestation. Between 23 and 24 weeks’ gestation, much greater variation was seen. Seventeen guidelines cited national survival rates. Few guidelines discussed potential biases: limitations in GA (n = 17); definition bias (n = 3); and denominator bias (n = 7).
Although there is a wide variation in recommendations (especially between 23 and 24 weeks’ GA), there is general agreement for comfort care at 22 weeks’ GA and active care at 25 weeks’ GA.
We would like to complement the authors with this extensive and structured review on management of extremely premature deliveries. Authors have included two guidelines / recommendations from the Netherlands and we would like to clarify those(1, 2).
The first source was Verloove-Vanhoricks’ paper. This paper (2006) comments on the Dutch guideline from 2005, made by the Dutch Society of Pediatrics and the Dutch Society of Obstetrics and Gynecology. The authors state that source correctly in table 1, although the paper is from 2006 and the actual guideline is from 2005. The second reference was to the guideline entitled “perinatal practice in extremely premature delivery” from 2010. This guideline is published by the Dutch Society of Pediatrics and the Dutch Society of Obstetrics and Gynecology (NVK and NVOG). This guideline was a revision of the former guideline, and this was upon request by the Dutch national government (ministry of health). So, the latest is is in fact a revised / renewed guideline, replacing the 2005 guideline
Authors make in their paper an important and to our opinion incorrect assumption, namely that multiple guidelines coexist; which is not correct, it’s simply an old and a new version. Consequential, the statement “ there is disagreement on the management at 22-24 weeks’ GA” is not correct, it is revised and the Dutch view on management of neonates at 24 weeks GA has changed. Furthermore the newest guideline says literally; at a gestational age below 24 weeks and 0 days, management focusing on comfort care and family seems warrantable so the author’s statement that there were no recommendations for 22 and 23 weeks might need more nuance.
Again, we would like to thank the authors for their comprehensive review and useful overview. With this comment we hoped have clarified the Dutch situation.
Rosa Geurtzen and Marije Hogeveen
1. de Laat MW, Wiegerinck MM, Walther FJ, Boluyt N, Mol BW, van der Post JA, et al. [Practice guideline 'Perinatal management of extremely preterm delivery']. Ned Tijdschr Geneeskd. 2010;154:A2701.
2. Verloove-Vanhorick SP. Management of the neonate at the limits of viability: the Dutch viewpoint. BJOG. 2006;113 Suppl 3:13-6.