Limits of Viability: Perspectives of Portuguese Neonatologists and Obstetricians

Advances in neonatal care have improved the prognosis in extremely preterm infants. The gestational age considered for active treatment has decreased globally. Despite implemented guidelines, several studies show variability in practice. The aim of this study was to understand theperspectives of Portuguese neonatologists and obstetricians regarding the management of extremely preterm infants.

An online survey was sent through the Portuguese Neonatology Society and the Portuguese Society of Obstetrics and Maternal-Fetal Medicine from August to September 2023.

We obtained 117 responses: 53% neonatologists, 18% pediatricians, and 29% obstetricians, with 62% having more than 10 years of experience. The majority (80%) were familiar with the Portuguese Neonatology Society consensus on the limits of viability and 46% used it in practice; 62% were unaware of Portuguese morbidity-mortality statistics associated with extremely preterm infants. Most (91%) informed parents about morbiditymortality concerning the gestational age more frequently upon admission (64%) and considered their opinion in the limit of viability situations (95%). At 22 weeks gestational age, 71% proposed only comfort care, while at 25 and 26 weeks, the majority suggested active care (80% and 96%, respectively). Less consensus was observed at 23 and 24 weeks. At 24 weeks, most obstetricians offered active care with the option of comfort care by parental choice (59%), while the neonatology group provided active care (65%), p < 0.001. Regarding the lower limit of gestational age for in utero transfer, corticosteroid administration, cesarean section for fetal indication, neonatologist presence during delivery, and endotracheal intubation; neonatologists considered a lower gestational age than obstetricians (23 vs 24 weeks; p = 0.036; p < 0.001; p < 0.001; p = 0.021; p < 0.001, respectively).

Differences in perspectives between obstetricians and neonatologists in limits of viability situations were identified. Neonatologists considered a lower gestational age in various scenarios and proposed active care earlier. Standardized counseling for extremely preterm infants is crucial to avoid ambiguity, parental confusion, and conflicts in perinatal care.