Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 150 No. 0506 (2020)

Overlapping borders: limit of viability and late terminations of pregnancy – a retrospective multicentre observational study

  • Fabienne Berger
  • Hans U. Bucher
  • Jean-Claude Fauchère
  • Sven M. Schulzke
  • Thomas M. Berger
  • for the Swiss End-of-Life Study Group
DOI
https://doi.org/10.4414/smw.2020.20186
Cite this as:
Swiss Med Wkly. 2020;150:w20186
Published
07.02.2020

Summary

AIMS OF THE STUDY

Based on an incidental observation made in the context of the Swiss National Science Foundation (SNSF) Project 67 “End-of-life decision-making in extremely low birth weight infants in Switzerland”, this retrospective multicentre observational study aimed to analyse circumstances of delivery room deaths after late termination of pregnancy (LTOP) in Switzerland over a 3-year period.

METHODS

All delivery room deaths (including live and stillbirths) following LTOP among infants with a gestational age between 22 0/7 and 27 6/7 weeks at the nine Swiss level III perinatal centres between 1 July 2012 and 30 June 2015 were analysed. Indications for LTOP were classified as either (a) maternal emergencies or (b) fetal anomalies severe enough to cause significant maternal psychological distress. Whenever possible, specific diagnoses were recorded. Spontaneous intrapartum death and fetal death caused by injection of a cardioplegic drug were distinguished for stillborn infants.

RESULTS

A total of 465 delivery room deaths among extremely low gestational age newborns (ELGANs) were identified over the 3-year study period of the SNSF project. Of these, 195 (42%) occurred in the context of LTOP. Central nervous system malformations, chromosomal anomalies, severe congenital heart disease, multiple malformations and maternal emergencies accounted for 70% of all LTOPs. LTOPs resulted in live births in 76 (39%) cases. No correlation between gestational age and rate of live births was observed. Fetal death caused by injection of a cardioplegic drug was documented in only three cases. All infants born alive after LTOP died in the delivery room without resuscitation attempts. The use of drugs for palliative care in these patients was either rare or, alternatively, incompletely documented.

CONCLUSION

LTOPs contribute significantly to mortality rates among ELGANs and should therefore be included in perinatal registries. Uniform reporting of LTOPs should be established. Infants born alive after LTOP are entitled to comprehensive palliative care like any other infant born under different circumstances. Development of national guidelines for LTOPs (including the role of fetal death caused by injection of a cardioplegic drug and palliative birth as an alternative to induced abortion) would be highly desirable to guarantee acceptable standards of care.

References

  1. Schweizer Strafgesetzbuch, Artikel 119. 2011, Mar 23.
  2. Sedgh G, Bearak J, Singh S, Bankole A, Popinchalk A, Ganatra B, et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet. 2016;388(10041):258–67. doi:.https://doi.org/10.1016/S0140-6736(16)30380-4
  3. Singh S, Remez L, Sedgh G, Kwok L, Onda T. Abortion Worldwide 2017: Uneven Progress and Unequal Access. https://www.guttmacher.org/report/abortion-worldwide-2017, accessed 01 April 2019.
  4. Bundesamt für Statistik. Schwangerschaftsabbrüche. https://www.bfs.admin.ch/bfs/de/home/statistiken/gesundheit/gesundheitszustand/reproduktive/schwangerschaftsabbrueche.html, accessed 21 April 2019.
  5. Schwarzenegger C. Schwangerschaftsabbruch in der Spätphase - Kriminologische und rechtsdogmatische Perspektiven. Nomos. 2011. http://www.zora.uzh.ch/49959, accessed 01April 2019.
  6. Garne E, Khoshnood B, Loane M, Boyd P, Dolk H ; EUROCAT Working Group. Termination of pregnancy for fetal anomaly after 23 weeks of gestation: a European register-based study. BJOG. 2010;117(6):660–6. doi:.https://doi.org/10.1111/j.1471-0528.2010.02531.x
  7. Berger TM, Steurer MA, Bucher HU, Fauchère JC, Adams M, Pfister RE, et al.; Swiss Neonatal End-of-Life Study Group. Retrospective cohort study of all deaths among infants born between 22 and 27 completed weeks of gestation in Switzerland over a 3-year period. BMJ Open. 2017;7(6):e015179. doi:.https://doi.org/10.1136/bmjopen-2016-015179
  8. Nationale Ethikkommission im Bereich der Humanmedizin. Zur Praxis des Abbruchs im späteren Verlauf der Schwangerschaft - Ethische Erwägungen und Empfehlungen. 2018. Available at: https://www.nek-cne.admin.ch/inhalte/Themen/Stellungnahmen/NEK_Stellungnahme_Abbruch_im_spaeteren_Verlauf_der_Schwangerschaft_D.pdf
  9. Rey A, Seidenberg A. Schwangerschaftsabbruch: die Praxis der Spitäler und Kliniken in der Schweiz. Schweiz Arzteztg. 2010;91:(13):551–4. doi:https://doi.org/10.4414/saez.2010.15075
  10. Berger TM, Bernet V, El Alama S, Fauchère JC, Hösli I, Irion O, et al. Perinatal care at the limit of viability between 22 and 26 completed weeks of gestation in Switzerland. 2011 revision of the Swiss recommendations. Swiss Med Wkly. 2011;141:w13280. doi:.https://doi.org/10.4414//smw.2011.13280
  11. Boland R. Second trimester abortion laws globally: actuality, trends and recommendations. Reprod Health Matters. 2010;18(36):67–89. doi:.https://doi.org/10.1016/S0968-8080(10)36521-9
  12. Schechtman KB, Gray DL, Baty JD, Rothman SM. Decision-making for termination of pregnancies with fetal anomalies: analysis of 53,000 pregnancies. Obstet Gynecol. 2002;99(2):216–22. doi:.https://doi.org/10.1097/00006250-200202000-00010
  13. Monier I, Lelong N, Ancel P-Y, Benachi A, Khoshnood B, Zeitlin J, et al. Indications leading to termination of pregnancy between 22+0 and 31+6 weeks of gestational age in France: A population-based cohort study. Eur J Obstet Gynecol Reprod Biol. 2019;233(233):12–8. doi:.https://doi.org/10.1016/j.ejogrb.2018.11.021
  14. Courtwright AM, Laughon MM, Doron MW. Length of life and treatment intensity in infants diagnosed prenatally or postnatally with congenital anomalies considered to be lethal. J Perinatol. 2011;31(6):387–91. doi:.https://doi.org/10.1038/jp.2010.124
  15. D’Antonio F, Pagani G, Familiari A, Khalil A, Sagies T-L, Malinger G, et al. Outcomes Associated With Isolated Agenesis of the Corpus Callosum: A Meta-analysis. Pediatrics. 2016;138(3):e20160445. doi:.https://doi.org/10.1542/peds.2016-0445
  16. Wilkinson DJ, Thiele P, Watkins A, De Crespigny L. Fatally flawed? A review and ethical analysis of lethal congenital malformations. BJOG. 2012;119(11):1302–8. doi:.https://doi.org/10.1111/j.1471-0528.2012.03450.x
  17. Haward MF, Murphy RO, Lorenz JM. Message framing and perinatal decisions. Pediatrics. 2008;122(1):109–18. doi:.https://doi.org/10.1542/peds.2007-0620
  18. Koper JF, Bos AF, Janvier A, Verhagen AAE. Dutch neonatologists have adopted a more interventionist approach to neonatal care. Acta Paediatr. 2015;104(9):888–93. doi:.https://doi.org/10.1111/apa.13050
  19. Garten L, Glöckner S, Siedentopf J-P, Bührer C. Primary palliative care in the delivery room: patients’ and medical personnel’s perspectives. J Perinatol. 2015;35(12):1000–5. doi:.https://doi.org/10.1038/jp.2015.127
  20. Janvier A, Meadow W, Leuthner SR, Andrews B, Lagatta J, Bos A, et al. Whom are we comforting? An analysis of comfort medications delivered to dying neonates. J Pediatr. 2011;159(2):206–10. doi:.https://doi.org/10.1016/j.jpeds.2011.01.022

Most read articles by the same author(s)