What determines survival and morbidity at very early gestation? Alaska's experience

The charts of all infants (N = 46) 22-25 weeks gestation admitted to the Newborn Intensive Care Unit at Providence Alaska Medical Center from 1991-1994 were reviewed to determine factors associated with mortality and severe morbidity. Survival rates at 22 & 23 weeks gestation was poor (25% and 14% respectively). Survival rates of 24 and 25 week gestation infants were similar (53% and 62% respectively). Infants with "poor" outcomes (death or survival with Grade 3 or Grade 4 intraventricular hemorrhage or periventricular leukomalacia) were more likely to have suboptimal intrapartum care which primarily involved delayed intervention on behalf of the fetus. This was manifested as perinatal asphyxia needing vigorous resuscitation at birth with cardiac compression and epinephrine use, and the development of persistent pulmonary hypertension of the newborn in the first 24 hours of life. Ten of the fifteen deaths were primarily due to intractable respiratory failure complicated by barotrauma from ventilator therapy. The fetus at 24 and 25 weeks should be considered viable. Improving the survival and morbidity of these extremely low birthweight babies will require us to optimize fetal care in complicated pregnancies at previable and very early viable gestations (20-25 weeks).