Extremely preterm infant viability and periviable counselling — formative SAQs

SAQ 1 (10)

A 29-year-old woman presents at 23+4 weeks gestation with regular uterine contractions and is found to be 6 cm dilated. First-trimester crown-rump-length dating is confirmed. The estimated fetal weight is 620 g and the fetus is female and singleton. The mother has received one dose of betamethasone and has not yet received magnesium sulfate. [8]

1. Outline the antenatal management steps you would take to optimise fetal outcomes before delivery. (3) [8]
2. Describe the counselling framework you would use with the parents, including the specific survival and impairment data you would present. (3) [1] [9]
3. Explain the role of each prognostic factor (gestational age, estimated fetal weight, sex, singleton status, antenatal steroids) in modifying the outcome estimate for this infant. (2) [2]
4. State the management decision framework for this gestational age and what role parental preference plays. (2) [8] [9]

Model answer

Antenatal optimisation. I would administer the second dose of betamethasone 12 mg intramuscularly to complete the corticosteroid course, administer magnesium sulfate 4 g intravenous loading over 20 to 30 minutes for fetal neuroprotection (indicated before 32 weeks), offer tocolysis to delay delivery and allow steroid completion, arrange in-utero transfer to a tertiary perinatal centre with neonatal intensive care capability, and conduct a formal antenatal neonatal consultation with both parents. I would also administer Group B Streptococcus prophylaxis and ensure a senior neonatal team is present at delivery. [8]

Counselling framework. I would use shared decision-making principles: present honest, balanced, probabilistic outcome data using local institutional data where available. I would explain that at 23+4 weeks with active treatment, survival is approximately 30 to 50 per cent, and that among survivors, approximately 40 to 60 per cent will have moderate-to-severe neurodevelopmental impairment including cerebral palsy, cognitive impairment, and sensory deficits. I would describe the neonatal intensive care journey, potential complications, and the option of comfort care. I would avoid both false reassurance and undue pessimism, use plain language, create space for genuine parental autonomy, and document the conversation. [1] [9]

Prognostic factors. Each week of gestational age increases survival substantially; estimated fetal weight independently predicts outcome (each additional 100 g improves survival); female sex confers approximately a 5 to 10 per cent survival advantage; singleton status confers a 10 per cent or more advantage compared to multiple gestation; and a complete antenatal corticosteroid course roughly doubles the odds of survival without major morbidity. This infant's female sex, singleton status, and partial corticosteroid course all favour her prognosis, but she remains in the high-risk grey zone. [2]

Decision framework. At 23+4 weeks, the infant is squarely within the grey zone (22+0 to 24+6 weeks). The standard framework is shared decision-making: clinicians provide outcome data and the parents participate in deciding between active resuscitation and comfort care. Parental preference is central and decisive within this zone. If parents choose active treatment, a clear birth plan is documented and the neonatal team is mobilised. If parents choose comfort care, palliative and bereavement support is provided. [8] [9]