Periviable Pregnancies: Decision Making Under Uncertainty Aaron B. Caughey, MD, PhD Disclosures No financial disclosures related to this talk Medical Advisor to Celmatix, Mindchild Bob s Red Mill Father Professor and Chair Department of Obstetrics and Gynecology Associate Dean for Women s Health Research & Policy Oregon Health & Science University caughey@ohsu.edu Overview What is periviable? What is viability? Why does it matter? What are the outcomes? How do we counsel in this setting? Decision making under uncertainty Case Presentation 27 yo G1P0 at 23 2/7 wks GA presents with PTL ctxns Q3 / cvx- 3/80/0 Who counsels her and about what? Outcomes Mgmt MgSo4 Tocolysis BMZ MOD Fetal monitoring Resuscitation Expt mgmt 1
A, B, & C A, B, C, & D Case Presentation 23 wks PTL What are reasonable options? A. Expt Mgmt B. Interventions (BMZ, MgSO4, Abx, etc) C. No Resuscitation D. Induction termination E. A&B F. A, B, & C G. A, B, C, & D 2 A, B, & C A, B, C, & D 11% 7% 5% 3% 14% 38% 22% Case Presentation 22 wks PTL What are reasonable options? A. Expt Mgmt B. Interventions (BMZ, MgSO4, Abx, etc) 21% 16% 6% C. No Resuscitation D. Induction termination 2% A & B E x p t M g m t I n t e r v e n t i o n s ( B M Z, M g S... N o R e s u s c i t a t i o n I n d u c t i o n t e r m i n a t i o n E. A&B F. A, B, & C G. A, B, C, & D 6% 28% 21% A, B, & C A, B, C, & D A, B, & C A, B, C, & D A & B E x p t M g m t I n t e r v e n t i o n s ( B M Z, M g S... N o R e s u s c i t a t i o n I n d u c t i o n t e r m i n a t i o n Case Presentation 24 wks PTL What are reasonable options? A. Expt Mgmt B. Interventions (BMZ, MgSO4, Abx, etc) C. No Resuscitation 14% D. Induction termination 2% 2% A & B E x p t M g m t I n t e r v e n t i o n s ( B M Z, M g S... N o R e s u s c i t a t i o n I n d u c t i o n t e r m i n a t i o n E. A&B F. A, B, & C G. A, B, C, & D 4% 30% 38% 11% Case Presentation 25 wks PTL What are reasonable options? A. Expt Mgmt B. Interventions (BMZ, MgSO4, Abx, etc) 23% C. No Resuscitation 4% D. Induction termination 1% 1% A & B E x p t M g m t I n t e r v e n t i o n s ( B M Z, M g S... N o R e s u s c i t a t i o n I n d u c t i o n t e r m i n a t i o n E. A&B F. A, B, & C G. A, B, C, & D 43% 25% 3%
Overview What is periviable? What is viability? Why does it matter? What are the outcomes? Decision making under uncertainty How do we counsel in this setting? Roe V. Wade For the stage subsequent to viability the State, in promoting its interest in the potentiality of human life, may, if it chooses, regulate, and even proscribe, abortion except where necessary, in appropriate medical judgment, for the preservation of the life or health of the mother. No Colorado Translation: After viability, states may restrict or ban abortions except necessary to preserve the life or health of the woman. No Oregon From Guttmacher institute 2015 3
Overview Neonatal outcomes at 22-25 weeks What is periviable? What is viability? What are the outcomes? Decision making under uncertainty How do we counsel in this setting? Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6. Neonatal outcomes at 22-25 weeks Periviable Long-term outcomes Moore, et al. JAMA Pediatr. 2013;167(10):967-974. Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6. 4
Periviable Long-term outcomes Periviable Long-term outcomes Moore, et al. JAMA Pediatr. 2013;167(10):967-974. Moore, et al. JAMA Pediatr. 2013;167(10):967-974. Periviable Long-term outcomes Impact of Long-term Outcomes Moore, et al. JAMA Pediatr. 2013;167(10):967-974. 5
Impact of Long-term Outcomes Overview Down Syndrome CP Severe MR/CP What is periviable? What is viability? What are the outcomes? What are the potential interventions? Decision making under uncertainty How do we counsel in this setting? MR/CP Decision Making Under Certainty Many of our day to day decisions What to eat? What to wear? Entertainment (what to watch)? Many decisions with less certainty What to eat in a foreign city? (e.g. Shanghai) What to wear on a trip? 6
Examples of uncertainty What to eat in a foreign city? Will you need to eat? Very certain How enjoyable will the food be? Variable How dangerous will the food be? Variable What to wear on a trip? Will you need underwear? Very certain Will you need a raincoat? Variable How comfortable will you be (warm/cold)? Variable How dangerous will the clothing be (exposed skin)? V Examples of uncertainty in medicine Effect of therapy Cesarean for delivery of baby very certain Abx in labor for T of 100.4 degrees uncertain need Cerclage for a short cervix uncertain benefit MgSO4 for CP prophylaxis uncertain benefit/need Chemotherapy for Ovarian CA uncertain benefit / harm One approach Rational, expected value Think of this as lottery Two potential outcomes: 50% chance Win - $10, 50% chance Lose Price of lottery A fair price - $5 who will pay $5? 60% chance Win - $10, 40% chance Lose Price of lottery A fair price - $6 who will pay $5? One approach Rational, expected value Think of this as lottery Two potential outcomes: 50% chance Win - $10, 50% chance Lose Price of lottery A fair price - $5 who will pay $5? 60% chance Win - $10, 40% chance Lose Price of lottery A fair price - $6 who will pay $5? 60% chance Win - $1M, 40% chance Lose Price of lottery A fair price - $600,000 who will pay $500,000? (Isn t this more like periviable resuscitation?) 7
Periviable Long-term outcomes Periviable Long-term outcomes Moore, et al. JAMA Pediatr. 2013;167(10):967-974. Moore, et al. JAMA Pediatr. 2013;167(10):967-974. Overview 23 0/7 23 6/7: NICHD - To resuscitate or not - Is 23 weeks the new 24 weeks? What is periviable? What is viability? What are the outcomes? Decision making under uncertainty How do we counsel in this setting? 8
23 0/7 23 6/7: To resuscitate or not? New OCC Document OCC periviability. SMFM/ACOG, ObstetGynecol / Am J Obstet Gynecol 11/2015 Periviability Outcomes Interventions Summary Should be driven by plans for resuscitation Shared decision making with a focus on the unknown and long-term patient prefs Team counseling MFM / Neo / RN 20% severely disabled is that acceptable? Case Presentation 23 wks PTL Did your management options change? A) Yes B) No 9
Thank You Consider Regional Approach Astoria Seaside St Helens Hermiston Cape Lookout Hillsboro Gresham Tillamook Beaverton Portland The Dalles Pendleton La Grande Enterprise Condon Regional Hub Satellite McMinnville Keizer Silverton Salem Lincoln City Albany Madras Baker City Corvallis Prineville Canyon City John Day Florence 5 Eugene Springfield Redmond Bend Vale Ontario Reedsport Burns North Bend Coos Bay Roseburg Jordan Valley Port Orford Grants Pass Bly Medford Ashland Brookings Klamath Falls Lakeview MILES Expected Utility Theory Nonsatiation Diminishing Marginal Utility 10
Prospect Theory Distortions in: Values Probabilities Gains domain Loss domain Mug experiments Prospect Theory Distortions in: Values Probabilities Lottery Airline insurance Kaiser Hayward Example Prenatal Dx vs. Periviability Resusc. Termination vs. Nonintervention losing aneuploid vs. losing normal fetus Uncertainty of specificity of phenotype (DS vs. range) Uncertainty about phenotype (What is NDD?) Uncertainty of severity of phenotype Prenatal Dx Example 11
OHSU Periviablity Guidelines Weeks Obstetric Care Neonatal Care < 23 No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of neonate provided. 23 0/7 23 6/7 not recommended but offered based on neonatal care plan. NICU care not recommended but may be offered based on prognostic factors and shared decision making with parents. 24 0/7 24 6/7 neutral: may be declined or accepted based on neonatal care plan. NICU care conditionally offered based on prognostic factors and shared decision making with parents. care provided. 25 0/7 25 6/7 26 0/7 provided. provided in the majority of cases. care provided; an Ethics consult is strongly provided unless known fetal lethal anomalies. OHSU Periviablity Guidelines Weeks Obstetric Care Neonatal Care OHSU Periviablity Guidelines Weeks Obstetric Care Neonatal Care < 23 No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of infant provided. < 23 No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of infant provided. 23 0/7 23 6/7 not recommended but offered based on neonatal care plan. NICU care not recommended but may be offered based on prognostic factors and shared decision making with parents. 23 0/7 23 6/7 not recommended but offered based on neonatal care plan. NICU care not recommended but may be offered based on prognostic factors and shared decision making with parents. 24 0/7 24 6/7 neutral: may be declined or accepted based on neonatal care plan. NICU care conditionally offered based on prognostic factors and shared decision making with parents. care provided. 24 0/7 24 6/7 neutral: may be declined or accepted based on neonatal care plan. NICU care conditionally offered based on prognostic factors and shared decision making with parents. care provided. 25 0/7 25 6/7 provided in the majority of cases. care provided; an Ethics consult is strongly 25 0/7 25 6/7 provided in the majority of cases. care provided; an Ethics consult is strongly 26 0/7 provided. provided unless known fetal lethal anomalies. 26 0/7 provided. provided unless known fetal lethal anomalies. 12
OHSU Periviablity Guidelines Weeks Obstetric Care Neonatal Care OHSU Periviablity Guidelines Weeks Obstetric Care Neonatal Care < 23 No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of infant provided. < 23 No steroids or C/S for fetal indications. No neonatal resuscitation. Comfort care of infant provided. 23 0/7 23 6/7 not recommended but offered based on neonatal care plan. NICU care not recommended but may be offered based on prognostic factors and shared decision making with parents. 23 0/7 23 6/7 not recommended but offered based on neonatal care plan. NICU care not recommended but may be offered based on prognostic factors and shared decision making with parents. 24 0/7 24 6/7 neutral: may be declined or accepted based on neonatal care plan. NICU care conditionally offered based on prognostic factors and shared decision making with parents. care provided. 24 0/7 24 6/7 neutral: may be declined or accepted based on neonatal care plan. NICU care conditionally offered based on prognostic factors and shared decision making with parents. care provided. 25 0/7 25 6/7 provided in the majority of cases. care provided; an Ethics consult is strongly 25 0/7 25 6/7 provided in the majority of cases. care provided; an Ethics consult is strongly 26 0/7 provided. provided unless known fetal lethal anomalies. 26 0/7 provided. provided unless known fetal lethal anomalies. OHSU Periviablity Guidelines Weeks Obstetric Care Neonatal Care < 23 No steroids or C/S for fetal indications. 23 0/7 23 6/7 24 0/7 24 6/7 not recommended but offered based on neonatal care plan. neutral: may be declined or accepted based on neonatal care plan. No neonatal resuscitation. Comfort care of infant provided. NICU care not recommended but may be offered based on prognostic factors and shared decision making with parents. Patient needs to decide about resuscitation in this model NICU care conditionally offered based on prognostic factors and shared decision making with parents. care provided. NICHD survival calculator http://www.nichd.nih.gov/about/org/der/bran ches/ppb/programs/epbo/pages/epbo_case.as px 25 0/7 25 6/7 26 0/7 provided. provided in the majority of cases. care provided; an Ethics consult is strongly provided unless known fetal lethal anomalies. 13
Enter the characteristics below. --Select-- NICHD survival calculator Neonatal outcomes at 23 vs. 24 weeks NICHD Enter the characteristics below. Gestational Age (Best Obstetric Estimate in Completed Weeks): Birth Weight (401 Grams to 1,000 Grams): Sex: Singleton Birth: Antenatal Corticosteroids (Within Seven Days Before Delivery): grams Sex Female Male Singleton Birth Yes No Antenatal Corticosteroids Yes No 23 weeks 24 weeks Survived, % 26 55 Died, % 74 45 Survived without morbidity*, % 8 9 RDS, % 98 98 Early-onset sepsis, % 4 4 NEC med management, % 31 39 NEC surgical management, % 69 61 ROP 3, % 48 42 IVH grade 3, % 15 12 IVH grade 4, % 21 14 Reference: NICHD. Pediatrics.2010;126(3):443-455. Neonatal outcomes at 6 years of age Neonatal outcomes at 6 years of age Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6. Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6. 14
Neonatal outcomes at 6 years of age Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6. 15