Presentation by Helen Mactier, Consultant Neonatologist President of BAPM : Revising and Updating National Guidance at the North West Coast Maternity and Neonatal Learning System: Framework for practice on the Perinatal management of extreme preterm birth Wednesday 29th January at Haydock Park Racecourse

1. Perinatal management of extreme preterm
birth before 27 weeks of gestation
- A new BAPM Framework for Practice
Helen Mactier
President BAPM
Academic Health Science
Network for the North
West Coast
29th January 2020

2. Arch Dis Child Fetal Neonatal Ed 2009;94:F2-5
Previous guidance

3. 11 years ago No mention of
place of birth

4. Why new guidance?
•Neonatal outcomes changing
•Gestational week cut offs somewhat
arbitrary
•More cognisance of the benefits of
optimisation of perinatal care
•Practice changing

5. EPICure ‘95 v EPICure 2
BMJ 2012;345:e7976

6. International comparisons

7. MBRRACE-UK

9. Current practice – days matter
Rysavvy et al. NEJM 2015

10. MBRRACE-UK

11. Willingness to offer intensive care

12. Pediatrics 2018
In a 2016 survey, 40% UK neonatologists would actively
resuscitate at parental request at 22 weeks’ gestation

13. Updating the Framework for Practice
• working group established 2018
• draft document for consultation June 2019
• 50 responses!
• launched at BAPM Conference September 2019
• final version on-line October 2019
freely available

14. Consultation – what mattered?
• category of risk
– no low risk!
• denominator
– liveborn babies in whom active treatment is
attempted
• use of “severe” disability
– ethical consideration
– more emphasis in the parental information
on lesser disability

15. • obstetric management
– aligned with NICE and RCOG
• more emphasis on the best interests of the
baby
• advice around advanced resuscitation
– little evidence; framework aligned with UK
Resuscitation Council
• (resources)

16. What does BAPM advise?
• Family-centred care
• Management of labour, birth and the immediate neonatal period should
reflect the wishes and values of the mother and her partner, informed
and supported by consultation and in partnership with obstetric and
neonatal professionals
• Right place
• Whenever possible, extreme preterm birth should be managed in a
maternity facility co-located with a NICU
• Obstetrics and neonatology working together
• Both with the same aim
• Some guidance on gestation
• Neonatal stabilisation may be considered for babies born from 22+0
weeks of gestation following assessment of risk, and multi-professional
discussion with parents
• Not appropriate to attempt to resuscitate babies born before 22+0
weeks of gestation

17. Risk assessment
• gestational age + factors modifying risk
• informed consultation with parents
→ agreed management plan

19. Three modified risk categories
> 90% risk* of death or severe impairment**
Extremely
high risk
High risk
Moderate risk
*if actively managed
** “severe impairment” - definition linked to best interests
50 - 90% risk of death or severe impairment
< 50% risk of death or severe impairment

20. High risk Moderate risk
Life-sustaining
treatment should
usually not be
provided*
Confirm management
with parents
Life sustaining
treatment can be
offered based upon
individual assessment
and informed by
parental wishes
Seek parental views
about treatment
Palliative
management:
Provide palliative
obstetric
management
and palliative
care for newborn
Life sustaining
treatment should
usually be provided
Confirm
management plan
with parents
Active
management:
Provide active
obstetric
management
and active
management
for newborn
*However, assess for modifiable risk factors and reassess risk if/when circumstances change
Extremely
high risk
Management

21. Extremely high risk
> 90% chance of either dying or surviving with severe impairment
if active care is instigated
babies at 22+0 - 22+6 weeks of gestation with unfavourable risk
factors
some babies at 23+0 - 23+6 weeks of gestation with unfavourable risk
factors, including severe fetal growth restriction
(rarely) babies ≥ 24+0 weeks of gestation with significant
unfavourable risk factors, including severe fetal growth restriction

22. High and moderate risk
High risk: 50-90% chance of either dying or surviving with severe
impairment if active care is instituted
babies at 22+0 - 23+6 weeks of gestation with favourable risk factors
some babies ≥ 24+0 weeks of gestation with unfavourable risk
factors and/or co-morbidities
Moderate risk: < 50% chance of either dying or surviving with
severe impairment if active care is instituted
most babies ≥ 24+0 weeks of gestation
some babies at 23+0 – 23+6 weeks of gestation with favourable risk
factors

23. Active obstetric management –
potential options
• antenatal steroids
• tocolysis
• antenatal transfer to a tertiary obstetric centre co-located with
a NICU
– death: OR 0.73 (95% CI 0.59 to 0.90)
– morbidity: OR 1.27 (0.93 to 1.74)
• magnesium sulphate for neuroprotection
– RR 0.68 (95% CI 0.54 to 0.87)
– NNT 52 (95% 31 to 154)
• intrapartum fetal heart rate monitoring
– no CEFM before 26 weeks
• caesarean section
– no evidence & lots of risk
• deferred cord clamping

24. Neonatal management
• right place
• right team
– senior involvement
• deferred cord clamping – 60 seconds
• normothermia
• CPAP +/- intubation
• palliative care just as important
– Together for Short Lives

25. Explaining

26. Place of birth
Upward transfer → ↑ risk of severe brain injury
OR 2.32, 95% CI 1.78 – 3.06
NNT = 8
Out born and not transferred → ↑ risk of death
OR 1.34, 95% CI 1.02 – 1.77
NNT = 20

27. Hot off the press….

28. What next?
•data and reflection
•local and national learning
•should we agree (and share) criteria for
reorientating care?
•do we need a national trial?

29. Thank you
• Dr Sarah Bates
• Ms Erica Everett
• Ms Heather Gilbert
• Dr Tracey Johnston
• Ms Caroline Lee-Davey
• Prof Neil Marlow
• Ms Kate Mulley
• Dr Tara Selman
• Dr Lucy Smith
• Dr Meekai To
• Prof Dominic Wilkinson
• Jessica Jefferys and Phil Johns
• Mrs Kate Dinwiddy

30. Questions?