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Volume 2, ¹1.2



Art of Medicine
International Medical Scientific journal

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ART of MEDICINE

International Medical Scientific
Journal

Volume 2, ¹1.2 February 2022



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Volume 2, ¹1.2

Art of Medicine
International Medical Scientific journal

Founder and Publisher Pascual Izquierdo-Egea
Published science may 2021 year. Issued Quarterly.
Internet address: http://artofmedicineimsj.us
E-mail: info@artofmedicineimsj.us
11931 Barlow Pl  Philadelphia, PA 19116, USA

CHIEF EDITOR

Dr. Pascual Izquierdo-Egea

EDITORIAL BOARD

Prof. Dr. Francesco Albano

Dr. Catherine J. Andersen

Prof. Dr. Sandro Ardizzone

Dr. Dmitriy Atochin

Prof. Dr. Antonio Aversa

Prof. Dr. Tamam Bakchoul

Prof. Dr. Pierre-Gregoire Guinot

Prof. Dr. Rainer Haak

Prof. Henner Hanssen



Art of Medicine
International Medical Scientific journal

4

NEONATAL RESUSCITATION IN 22-WEEK PREGNANCIES

Debasis Basu
Ph.D.,

Harish Kumar
Ph.D.,

Internal, Family Medicine Physician - Staten Island

A 20-year-old woman pregnant with her second child presents to the emergency
department with premature contractions at 22 weeks’ gestation. Her first child had been
born by spontaneous vaginal delivery at 34 weeks’ gestation and is currently a healthy 2-
year-old. The woman has no chronic medical conditions and takes a prenatal vitamin
daily. She has had routine prenatal care, and prenatal ultrasonography has shown no
fetal or placental anomalies.

Her vital signs are within normal limits. Physical examination is notable only for a
gravid abdomen. Cervical examination shows dilation to 3 cm, 40% effacement, and a
fetal station of -2. She is admitted to the obstetrics ward for further management of her
pregnancy.

You are an administrator in the hospital. The physicians caring for this patient contact
you for guidance, since you have been charged with deciding whether resuscitation
should be routinely performed for all neonates born at 22 weeks’ gestation or whether
selective resuscitation should be offered.

Which one of the following approaches would you take? Base your choice on the
literature, your own experience, published guidelines, and other information sources.

Recommend resuscitation for all neonates born at 22 weeks’ gestation.
Recommend selective resuscitation for neonates born at 22 weeks’ gestation.

To aid in your decision making, we asked two experts in the field to summarize the
evidence in favor of approaches assigned by the editors. Given your knowledge of the
issue and the points made by the experts, which approach would you choose?

Option 1: Recommend Resuscitation for All Neonates Born at 22 Weeks’ Gestation
Option 2: Recommend Selective Resuscitation for Neonates Born at 22 Weeks’

Gestation

The issue of the initial management and resuscitation of infants born at 22 completed
weeks of gestation has led to substantial debate among neonatology and maternal–fetal
medicine specialists. Both the exact definition of and the approach to the limit of
viability are major sources of anxiety for families and health care providers. That limit
has changed drastically in the past 30 years, from 27 to 28 weeks of completed gestation
to the current 22 to 23 weeks.

It is important to note that delaying delivery as long as it is safe for the mother and
the fetus is the preferred approach. Now let us consider the question of resuscitation in
all infants. After all, wouldn’t it be easier to take a case-by-case approach? The answer
is an emphatic “no.” First, a standard approach to neonatal resuscitation and early post-
resuscitative care, within the so-called golden hour, is well accepted to improve
outcomes.1 Second, these decisions are often made quickly, as in this vignette. Having
a truly informed discussion is difficult given the stressors involved and the need to focus



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Volume 2, ¹1.2
on the mother’s medical care as well. Third, prenatal gestational age assessments are
suboptimal, which makes it difficult to be certain of a fetus’s exact gestational age.2
Fourth, a case-by-case approach allows for implicit biases to potentially influence
decisions and contribute to the well-documented disparities in infant mortality in the
United States.

Data have been published that support the use of a standard approach to resuscitating
the neonates in all deliveries at 22 weeks’ gestation. For example, in a study by Backes
et al., the mortality rate at a hospital that used selective resuscitation was worse than the
rate at a hospital in which active care was provided to all infants (survival, 19% vs. 53%,
P<0.05).3 A report from a hospital in Iowa in which active resuscitation was offered for
all infants born at 22 to 23 weeks’ gestation showed that 70% of the infants born at 22
weeks survived and 55% of these patients had no or only mild neurodevelopmental
impairment at follow-up.4 A cohort study of Swedish infants born at 22 to 24 weeks’
gestation showed that 52% of the infants born at 22 weeks’ gestation survived, with 50%
of the survivors having no neurodevelopmental impairment at 2.5 years of age, outcomes
that mirrored those in infants born at 23 to 24 weeks.5 In pediatric cardiology practices,
the survival rate of 30 to 70% among patients who require extracorporeal life support is
considered reasonable for initiating that form of invasive therapy, so it certainly appears
from the available data that birth at 22 weeks’ gestation with resuscitation for all
neonates also meets this mark.6

The earliest gestational age at birth after which survival is possible has decreased
incrementally over time. Such improved survival has occurred as vanguard centers
challenged conventional limits and demonstrated survival of infants born at gestational
ages previously considered nonsurvivable. In this case vignette, an expectant mother
presents with threatened preterm delivery at 22 weeks’ gestation, the current “limit of
viability.” During antenatal counseling, parents should be offered selective resuscitation
for their child.

What is selective resuscitation? Almost all extremely preterm infants require resuscitative
interventions after birth to survive. Antenatal counseling for parents facing extremely
preterm delivery of their baby is recommended and is typically possible, despite known
challenges.7 “Do not resuscitate” orders are accepted and encouraged in other medical
settings when the possibility of survival is low and the burden of treatment is high.
Selective resuscitation represents shared decision making to ensure that plans to initiate
intensive care immediately after birth respect parental autonomy and wishes. As proxy
decision makers, parents may select resuscitation as the first step of providing intensive
care for their extremely premature infant or they may reasonably prioritize comfort
care over invasive and potentially futile interventions.

Predicting outcomes with certainty after extremely preterm birth is difficult, owing
to imprecise statistical models and the influence of factors beyond gestational age.8
Morbidity and mortality are very high among infants born at 22 weeks’ gestation, and
nuanced features that influence outcomes should be acknowledged. In a 2021 meta-
analysis of 2226 infants born at 22 weeks’ gestation who received active treatment, the
pooled prevalence of survival was 29%, and survival without major in-hospital
complications was 11%.9 Furthermore, the burden of treatment is high. Extremely
preterm newborns who survive spend months in the neonatal intensive care unit, undergo
hundreds of painful procedures, and are at high risk for subsequent neurodevelopmental
impairment.10,11

Isolated centers have reported survival rates higher than 50% for infants born at 23
weeks or less of gestation. It is tempting to speculate that similar outcomes would be
uniform after universal resuscitation, but that conclusion would be premature. First,



Art of Medicine
International Medical Scientific journal

6

such accounts represent the limited experience of specific and highly resourced hospitals,
a factor that reduces generalizability. Survival estimates after active treatment are lower
when pooled from more inclusive settings.9 Second, many reports combine outcomes
among infants born at 22 weeks’ gestation with those among infants born at 23 and 24
weeks’ gestation, making it difficult to ascertain the experience for infants at 22 weeks.
Finally, infants born at the limits of viability are poorly represented in clinical trials and
receive largely experimental care extrapolated from the care given to more mature
patients. Ongoing scientific collaborations focused on this population may produce an
evidence base for future widespread implementation, but this is not yet the current state
of the field.

As perinatal medicine continues to advance, there always will be a gestational age
threshold at which survival is possible but unlikely. Resuscitation should be offered but
not universally mandated for these infants. The current limit of viability is 22 weeks’
gestation. Prospective parents such as the mother in the vignette should be counseled
regarding the range of possible outcomes and provided the opportunity to inform the
goals of their child’s medical care.

These studies call into question the notion that gestational age is itself a signal for
determining the need for neonatal resuscitation. As is true for ill neonates of any
gestational age who require intensive care, a universal approach to resuscitation improves
overall outcomes; if severe life-limiting complications develop, a palliative approach
can be offered when more prognostic information is available.

The use of a standard approach for infants born at 22 weeks’ gestation results in
outcomes that are as good as those among infants born at 23 to 24 weeks’ gestation; thus,
at this time there seems to be no persuasive argument against offering resuscitation to all
neonates born at 22 weeks.

This section asks about your  financial relationships with entities in the bio-medical
arena that could be perceived to influence, or that give the appearance of potentially
influencing, what you wrote in the submitted work. You should disclose interactions
with ANY entity that could be considered broadly relevant to the work. For example,
if your article is about testing an epidermal growth factor receptor (EGFR) antagonist
in lung cancer, you should report all associations with entities pursuing diagnostic or
therapeutic strategies in cancer in general, not just in the area of EGFR or lung cancer.

Report all sources of revenue paid (or promised to be paid) directly to you or your
institution on your behalf over the 36 months prior to submission of the work. This
should include all monies from sources with relevance to the submitted work, not just
monies from the entity that sponsored the research. Please note that your interactions
with the work's sponsor that are outside the submitted work should also be listed here.
If there is any question,  it is usually better  to disclose a relationship  than not to do so.

For grants you have received for work outside the submitted work, you should
disclose support ONLY from entities that could be perceived to be affected financially
by the published work, such as drug companies, or foundations supported by entities
that could be perceived to have a financial stake in the outcome. Public funding sources,
such as government agencies, charitable foundations or academic institutions, need not
be disclosed. For example, if a government agency sponsored a study in which you have
been involved and drugs were provided by a pharmaceutical company, you need only list
the pharmaceutical company. This section asks for information about the work that you
have submitted for publication. The time frame for this reporting is that of the work
itself, from the initial conception and planning to the present. The requested information
is about resources that you received, either directly or indirectly (via your institution),
to enable you to complete the work. Checking "No" means that you did the work without



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Volume 2, ¹1.2
receiving any financial support from any third party -- that is, the work was supported
by funds from the same institution that pays your salary and that institution did not
receive third-party funds with which to pay you. If you or your institution received
funds from a third party to support the work, such as a government granting agency,
charitable foundation or commercial sponsor, check "Yes".

It is important to note that delaying delivery as long as it is safe for the mother and
the fetus is the preferred approach. Now let us consider the question of resuscitation in
all infants. After all, wouldn’t it be easier to take a case-by-case approach? The answer
is an emphatic “no.” First, a standard approach to neonatal resuscitation and early post-
resuscitative care, within the so-called golden hour, is well accepted to improve
outcomes.1 Second, these decisions are often made quickly, as in this vignette. Having
a truly informed discussion is difficult given the stressors involved and the need to focus
on the mother’s medical care as well. Third, prenatal gestational age assessments are
suboptimal, which makes it difficult to be certain of a fetus’s exact gestational age.2
Fourth, a case-by-case approach allows for implicit biases to potentially influence
decisions and contribute to the well-documented disparities in infant mortality in the
United States.

Data have been published that support the use of a standard approach to resuscitating
the neonates in all deliveries at 22 weeks’ gestation. For example, in a study by Backes
et al., the mortality rate at a hospital that used selective resuscitation was worse than the
rate at a hospital in which active care was provided to all infants (survival, 19% vs. 53%,
P<0.05).3 A report from a hospital in Iowa in which active resuscitation was offered for
all infants born at 22 to 23 weeks’ gestation showed that 70% of the infants born at 22
weeks survived and 55% of these patients had no or only mild neurodevelopmental
impairment at follow-up.4 A cohort study of Swedish infants born at 22 to 24 weeks’
gestation showed that 52% of the infants born at 22 weeks’ gestation survived, with 50%
of the survivors having no neurodevelopmental impairment at 2.5 years of age, outcomes
that mirrored those in infants born at 23 to 24 weeks.5 In pediatric cardiology practices,
the survival rate of 30 to 70% among patients who require extracorporeal life support is
considered reasonable for initiating that form of invasive therapy, so it certainly appears
from the available data that birth at 22 weeks’ gestation with resuscitation for all
neonates also meets this mark.6.



Art of Medicine
International Medical Scientific journal

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Used literature.
1.Wyckoff MH. Initial resuscitation and stabilization of the periviable neonate: the

Golden-Hour approach. Semin Perinatol 2014;38:12-16.
2.Committee opinion no 700: methods for estimating the due date. Obstet Gynecol

2017;129:e150-e154.
3.Backes CH, Söderström F, Ågren J, et al. Outcomes following a comprehensive

versus a selective approach for infants born at 22 weeks of gestation. J Perinatol 2019;39:39-
47.

4.Watkins PL, Dagle JM, Bell EF, Colaizy TT. Outcomes at 18 to 22 months of
corrected age for infants born at 22 to 25 weeks of gestation in a center practicing active
management. J Pediatr 2020;217:52-58.e1.

5.Söderström F, Normann E, Jonsson M, Ågren J. Outcomes of a uniformly active
approach to infants born at 22–24 weeks of gestation. Arch Dis Child Fetal Neonatal
Ed 2021;106:413-417.

6.Di Nardo M, MacLaren G, Marano M, Cecchetti C, Bernaschi P, Amodeo A.
ECLS in pediatric cardiac patients. Front Pediatr 2016;4:109-109.

7.Cummings J; Committee on Fetus and Newborn. Antenatal counseling regarding
resuscitation and intensive care before 25 weeks of gestation. Pediatrics 2015;136:588-
595.

8.Rysavy MA, Horbar JD, Bell EF, et al. Assessment of an updated neonatal research
network extremely preterm birth outcome model in the Vermont Oxford Network.
JAMA Pediatr 2020;174(5):e196294-e196294.


