Coping with the dilemmas of extremely preterm birth: Outcome or ethics?

Overtreatment in extreme prematurity, is an ongoing debate and often translated as 'what are the limits of viability?' The concerns stemming from this issue are the risks of long-term morbidity and mortality. Although many medical specialties are concerned with overtreatment, in neonatology and especially in extreme prematurity, the paradox of the emotional impact of happiness of a new life and fear about worrying outcome issues is absolutely unique. Many discussants have asked for defining therapeutic limits in extreme prematurity. Statistical approaches from epidemiologic outcomes have oversimplified those limits in terms of criteria as simple as gestational age or birth weight. Current scientific, epidemiologic and medical-economic knowledge have demonstrated the complexity of the issue. For example, in recent years, these infants have required intensive care less often than in previous years. Gestational age alone has been shown to be a poor prognostic factor for both mortality and severe morbidity. Recently more complex models have been proposed including more relevant prognostic risk factors like chorioamnionitis, prenatal steroids or gender. Furthermore, the absolute number of preterm infants increases significantly with increasing gestational age. The impact on public health resources of late preterms, who are not concerned by futile treatment issues, is much more important compared to extreme preterm infants. But, the emotional and symbolic aspects of periviability are dramatic and very complex. Ethical and medical dilemmas in decision making around withholding or withdrawing treatment will be strongly influenced by the underlying culture, economic situations of countries and individual spiritual believes of both caregivers and families. © 2013 Bentham Science Publishers.SCOPUS: ar.j