Neonatal and Obstetric Provider Perceptions and Management at 22 Weeks' Gestation

Author:

Nair Shah Nitya1,Krishna Iris2,Vyas-Read Shilpa1,Patel Ravi Mangal1ORCID

Affiliation:

1. Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia

2. Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia

Abstract

Objective Active treatment for periviable infants may be influenced by neonatal and obstetric provider perceptions of prognosis. The two aims of this study are to (1) quantify prognostic discordance between provider and data-driven survival estimates and (2) evaluate if prognostic discordance is associated with the threshold probability of survival at which neonatal providers recommend active treatment or obstetric providers recommend antenatal corticosteroids. Study Design Provider survival estimates and threshold probabilities of survival for active treatment and antenatal steroid use were obtained from a case-based survey for an infant or pregnancy at 22 weeks' gestation that was administered at two Atlanta hospitals. Data-driven survival estimates, including ranges, were acquired through the National Institute of Child Health and Human Development Extremely Preterm Birth Outcomes Tool. Prognostic discordance was calculated as the difference between a provider and data-driven estimates and classified as pessimistic (provider estimate below data-driven estimate range), accurate (within range), or optimistic (above range). The association between prognostic discordance and the threshold probability of survival was evaluated using nonparametric tests. Results We had 137 neonatal respondents (51% response rate) and 57 obstetric responses (23% response rate). The overall median prognostic discordance was 1.5% (interquartile range: 17, 13) and 52 (27%) of all respondents were pessimistic, 100 (52%) were accurate, and 42 (22%) were optimistic. The survival threshold above which neonatal and obstetric providers recommended active treatment or antenatal corticosteroids was 30% (20–45%) and 10% (0–20%), respectively. Thresholds did not significantly differ among the three prognostic discordance groups (p = 0.45 for neonatal and p = 0.53 for obstetric providers). There was also no significant correlation between the magnitude of prognostic discordance and thresholds. Conclusion Prognostic discordance exists among both neonatal and obstetric providers. However, this discordance is not associated with the threshold probability of survival at which providers recommend active treatment or antenatal corticosteroids at 22 weeks' gestation. Key Points

Publisher

Georg Thieme Verlag KG

Subject

Obstetrics and Gynecology,Pediatrics, Perinatology and Child Health

Reference23 articles.

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3. Obstetric care consensus no. 6: periviable birth;American College of Obstetricians and Gynecologists;Obstet Gynecol,2017

4. Prognosis as an intervention;M A Rysavy;Clin Perinatol,2018

5. The problem and promise of prognosis research;M A Rysavy;JAMA Pediatr,2016

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