Obstetric management of threatened or imminent delivery of pregnancies at a periviable gestational age

Recommendations for periviable birth
Recommendations				Grade of recommendations
Based on anticipated neonatal or maternal complications, antepartum transport to a center with advanced levels of neonatal or maternal care is recommended when feasible and appropriate.				Best practice
Prenatal and postnatal counseling regarding anticipated short-term and long-term neonatal outcome should take into consideration anticipated gestational age at delivery, as well as other variables that may alter the likelihood of survival and adverse newborn outcomes (eg, fetal sex, multiple gestation, the presence of suspected major fetal malformations, antenatal corticosteroid administration, birth weight, and response to initial newborn resuscitation).				Best practice
Family counseling should be provided by a multidisciplinary team that includes obstetrician-gynecologists and other obstetric providers, maternal-fetal medicine specialists, if available, and neonatologists who can address their individual and shared considerations and perspectives. Maternal and neonatal outcomes should be considered. Follow-up counseling should be provided when there is relevant new information about the maternal and fetal status or the newborn's evolving condition.				Best practice
A predelivery plan, made with the parents, family, or both, should be recognized as a general plan of approach, which may be modified as the neonate's condition and response is evaluated by the neonatal providers. A recommendation regarding assessment for resuscitation is not meant to indicate that resuscitation should always either be undertaken or deferred, or that every possible intervention need be offered. A stepwise approach concordant with neonatal circumstances and condition and with parental wishes is appropriate. Care should be reevaluated regularly and potentially redirected based on the evolution of the clinical situation.				Best practice
Recommendations regarding specific interventions, tailored to gestational age and other clinical data, and taking into account individual family preferences and values, are summarized below.
General guidance regarding obstetric interventions for threatened and imminent periviable birth by best estimate of gestational age*
	20^0/7 weeks to 21^6/7 weeks	22^0/7 weeks to 22^6/7 weeks	23^0/7 weeks to 23^6/7 weeks	24^0/7 weeks to 24^6/7 weeks	25^0/7 weeks to 25^6/7 weeks
Neonatal assessment for resuscitation*	Not recommended 1A	Consider 2B	Consider 2B	Recommended 1B	Recommended 1B
Antenatal corticosteroids	Not recommended 1A	Not recommended 1A	Consider 2B	Recommended 1B	Recommended 1B
Tocolysis for preterm labor to allow for antenatal corticosteroid administration	Not recommended 1A	Not recommended 1A	Consider 2B	Recommended 1B	Recommended 1B
Magnesium sulfate for neuroprotection	Not recommended 1A	Not recommended 1A	Consider 2B	Recommended 1B	Recommended 1B
Antibiotics to prolong latency during expectant management of preterm PROM if delivery is not considered imminent	Consider 2C	Consider 2C	Consider 2B	Recommended 1B	Recommended 1B
Intrapartum antibiotics for group B streptococci prophylaxis^¶	Not recommended 1A	Not recommended 1A	Consider 2B	Recommended 1B	Recommended 1B
Cesarean delivery for fetal indication^Δ	Not recommended 1A	Not recommended 1A	Consider 2B	Consider 1B	Recommended 1B

PROM: prelabor rupture of membranes.
* Survival of infants born in the periviable period is dependent on resuscitation and support. Between 22 weeks and 25 weeks of gestation, there may be factors in addition to gestational age that will affect the potential for survival and the determination of viability. Importantly, some families, concordant with their values and preferences, may choose to forgo such resuscitation and support. Many of the other decisions on this table will be linked to decisions regarding resuscitation and support and should be considered in that context.
¶ Group B streptococci carrier, or carrier status unknown.
Δ For example, persistently abnormal fetal heart rate patterns or biophysical testing, malpresentation.

Reproduced from: American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric Care Consensus No. 4: Periviable Birth. Am J Obstet Gynecol 2016; 127:e157. Table used with the permission of Elsevier Inc. All rights reserved.
Consensus reaffirmed in: American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric Care Consensus No. 6: Periviable Birth. Obstet Gynecol 2017; 130:e187.

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Obstetric management of threatened or imminent delivery of pregnancies at a periviable gestational age