Ethical implications of aggressive obstetric management at less than 28 weeks of gestation

Background. The purpose of this study is to evaluate the outcome of infants born between 23 and 28 completed weeks of gestational age for whom aggressive obstetric management was performed. Methods. Prenatal data were collected retrospectively from medical records. Neonatal mortality, early morbidity, and the outcome at one year corrected for postconceptional age (corrected age) were determined. Results. Ninety-seven infants were included in the study. Serious early morbidity decreased with increasing gestational age. All the infants born prior to 24 weeks showed serious early morbidity: only 26% of the infants born at 24 weeks or later did. There was a significant decline in mortality with increasing gestational age, as there was also in birth weight (p<0.001, p<0.001). Sixty-seven percent of the infants prior to 24 weeks showed disability at one year corrected age whereas only 13% at 24 weeks or older did. The likelihood of having a surviving child without disability was 12.5% at 23 weeks, 39% at 24 weeks, 50% at 25 weeks, 52% at 26 weeks, and 70% at 27 weeks. Conclusion. Viability of fetuses at 23 and 24 weeks of gestation remains ethically and clinically controversial. It cannot be reliably established at that time that there is a fair balance of clinical goods over harms for the survivor at 23 weeks. On the other hand we should continue to treat fetuses at 24 weeks as viable, because 50% of them survived and 78% of those survived without disability. Neonatal mortality and survival with disability further decreases with increasing gestational age.