Short Term Survival of Extreme Preterm Newborns at 23–26 Weeks’ Gestation in a Middle East Modern Referral Maternity Hospital

Short Term Survival of Extreme at Weeks’ Gestation a Abstract Background : Caring about ELBW newborns at the limit of viability is demanding with a high rate of mortality and long-term morbidity. Society expectations study of study mid-2018, a total of 283 of till was 33 survival 35%, and and 26 WG respectively. Most two life


Introduction
Periviability is defined as the ability for a fetus to survive outside the uterus post-birth. With early intervention methods, an infant of 22-24 gestational age is considered in the lower end of fetal viability, in which virtually none below 22 weeks of gestational age will survive. Infants born at 26 weeks of gestational age and above are considered to have high extrauterine chances of survival [1][2][3]. The average daily cost of an NICU bed is around 1392 USD per day (excluding staff wages). An extremely premature baby costs an average of 62,000 USD during hospitalization in the WWRC depending on the gestational age. International figures are around the same amount [4,5].
Periviable newborn infants undergo embryological developmental changes that affect their normal functioning. The lack of normal development results in low chances of a periviable newborn meeting the extra-uterine requirements.
Gestational age (GA) is an influential factor that determines the extrauterine survival rate of premature infants. Proactive life support provided to periviable infants born of 22-24 weeks of gestational age has improved as a result of advanced intervention methods and prenatal/postnatal care. The mortality rates and levels of morbidity in many healthcare institutions pose critical questions related to the different factors that influence newborn survival rates inside a modern tertiary NICU unit. Several perinatal risk factors contribute to a death or severe morbidity in which around 68% of periviable newborns die within the first 2 weeks of life as demonstrated by Patel et al [3]. Environmental risk factors including delivery room conditions, proactive life support, and general NICU post-delivery care significantly contribute to the overall mortality rate. Earlier studies suggest that 90% of ELBW newborns' mortality occurs within the first 28 days while most occur within the first 72 hours after birth [1][2][3].
The delivery of a periviable newborn is a challenging procedure that requires pressing support from NICU special care. There are notable significant psychological, clinical, and administrative loads in the management of ELBW newborns among health care providers, neonatal physicians, and nurses [6]. The WWRC is a state-of-the-art tertiary referral maternity hospital where 40 to 50 deliveries occur daily. The WWRC accommodates 214 maternity beds and has 110 NICU cots distributed across two floors one of the floors is dedicated towards 23 to 28 weeks' gestation age. The WWRC is a referral hospital for five governmental and five private maternity services. In 2004 and 2005, 12 newborns at 23 WG were admitted to our NICU and only one baby survived to discharge (8%). Since then, the unit policy has discouraged admitting newborns of this gestational age to WWRC-NICU, as the cumulative survival rate over 10 years was less than 18%, with an average length of stay is 140 days for those who survived. In 2013 the unit introduced a health care package specifically designed to manage very premature babies in general. The package included delivery room golden hour, noninvasive ventilation, volume guarantee ventilation, early nutritional support, strict infection control guidance, early surfactants, and environmentally friendly policies. Along with this approach, the unit promoted an orientation of dealing with newborns of 23/26 WG age positively and proactively [7]. The literature lacks prompt description of this outcome in the Arab Gulf countries whom they share similar socioeconomic circumstances and similar health care facilities. The first aim of this current study is to assess and analyze the short survival rate (till discharge) of 283 ELBW newborns between 2016-2018 delivered at 23-26 WG in the WWRC. The second aim is to compare the outcomes with 9 reports from 7 regional and international countries.

Methods
This study is a population-based retrospective study; new resuscitation guidelines concerning the limits of viability for 23-26 WG age newborns were introduced in 2013 (golden hour) [7], along with a dedicated, wellequipped separate unit catering only ELBW newborns younger than 28 WG age. We evaluated the outcomes of ELBW newborns delivered at 23-26 WG in the WWRC following the implementation of these arrangements. We retrieved the patient's data from the medical records of each newborn, the Pearl-Peristat Maternal and Newborn registry, and the Vermont Oxford database related to our hospital. We included cases who were born alive, or admitted to the NICU, at 23 weeks plus 0 days to 26 weeks plus 6 days. The estimation of gestational age was verified from the maternal ultrasound, in vitro fertilization dates, firsttrimester ultrasound, and/or menstrual dating confirmed by second-trimester ultrasound. The study excluded confirmed intrauterine fetal death and newborns with significant anomalies. The rate of NICU admission, death before 2 weeks of age, and death before discharge were assessed. The patient data included gestational age, birth weight, sex, Apgar score, antenatal steroid, mode of deliveries, death in the delivery room, death inside NICU, hospital stay, chronic lung disease, and intraventricular hemorrhage. In this study, we also compared our outcome with outcomes of Nine reports from seven different developed countries and other members of Gulf Cooperation Council (GCC). Pearl newborn data registry has developed after ethical approval of the medical research center of Hamad Medical Corporation. WWRC is a member of the Vermont oxford database.
Data analysis was performed with SPSS software, V.26.0.0.2 (SPSS Inc., Chicago, IL, USA). Birth weight, gestation age and Apgar score, were presented as mean values ± standard deviation (SD). Categorical variables were presented as percentages. Sample distribution data are presented as a histogram with relative frequency in percentages. Survival rate was calculated as a function of the following variables: total deliveries and total NICU admissions and presented as percentages. The annual survival rate of limits of viability was calculated for 23-26 WG newborns from 2016 to 2018, presented as a histogram with relative frequency in percentages.

Discussion
Over the last decade, perinatal mortality has been significantly reduced in the Arabian Gulf region particularly in the State of Qatar, in which the current perinatal mortality rate is 5.7% [8]. The significant decline witnessed is attributed to factors including the rationalization of human and financial resources, modern technological advancement regarding highrisk pregnancies, and lastly, an overall adjustment of national public health policies supported with a national antenatal follow-up program. The development of sophisticated, high-tech neonatal intensive care is effective in the survival of preterm newborns without a significant increase in later morbidity. Whether consciously or otherwise, modern NICUs measure their sophistication and affluence based on their ability to maintain ELBW newborn care effectively.
The World Health Organization places 22 WG age or 500 grams birthweight as the lower limit of birth viability for perinatal statistics. The international classification of diseases describes the perinatal period as that which starts at 22 completed WG. Survival and outcome data on extreme preterm newborns, between 23 and 26 weeks has been widely reported and reviewed [9][10][11][12][13][14][15][16]. The question, with all its medical, legal, social, and financial implications, is how close are we, in Qatar as a whole, in this pursuit? As well, the urgent need to develop local data that reflect local experience when counseling the parents.

Fig-1:
Sample distribution of 283 of ELBW newborns between 2016-2018: total deliveries, DR deaths, number of NICU admission, newborns died within the first 2 weeks, newborns died after two weeks and newborns survived until discharge.

Fig-2:
Interventions and approach to Newborns Born at 23 to 26 Weeks' Gestation: 283 newborns

Fig-3:
Leading cause of death in 250 ELBW newborns admitted to NICU MOF= multiorgan failure

Fig-4:
International survival rate of limits of viability of newborns admitted to NICU 1.
In USA 1 survival report did not include 25-or 26-weeks' gestation.
The rate of preterm birth in the State of Qatar is 9.1%, 8 % of such are ELBW 23-26 weeks of gestation age [18]. In WWRC-NICU, the overall short-term survival has shown significant improvement, particularly among 23-25 WG newborns however it remained at eighties percent for 26 WG (Fig-4). In this cohort study, we attempted to describe the short-term survivability of ELBW newborns born in Qatar over 3 years. The results obtained were compared to literature studies derived from North America and Europe.
The introduction of early surfactants, enforcement of the use of antenatal steroids, gentler ventilation techniques, non-invasive ventilation, strict infection control, delivery room golden hour program, adequate nutritional support for these age groups beside dedicating well equipped tiny baby unite to manage only those vulnerable gestation ages are all added value in this regard. However, 23-24 WG survival lags those born at 25 weeks and later. The value of ethics comes in conflict with the socioeconomic factors, parents' expectations, health care policymakers, and society's developmental ranking [19,20]

Limitation of the study and Conclusion
In this study, we focused on the short-term survival until discharge recorded over 3 years in our institute which was 35%, 66%, 73%, and 81.4% for 23, 24, 25, and 26 WG, respectively. Within this study, we can use such outcome figures during counseling parents at risk of premature delivery. As well, although such figures are more consistent with reports from several developed countries, however there is rooms to improve especially 2 years long-term outcome is more important than short outcome inside the NICU. The sample size in this study is comparatively adequate for single institute while the duration covered in the study is short and need to be longer to reflect an established survival rate.