Outcomes of 28+1 to 32+0 Weeks Gestation Babies in the State of Qatar
Reported, January 4, 2012
In this retrospective study we did a comparative analysis of the outcome of 28+1 to 32+0 weeks gestation babies between the State of Qatar and some high income countries with an objective of providing an evidence base for improving the survival of preterm neonates in low income countries. Data covering a five year period (20022006) was ascertained on a pre-designed Performa. A comparative analysis with the most recent data from VON, NICHD, UK, France and Europe was undertaken. Qatars 28+1 to 32+0 weeks Prematurity Rate (9.23 per 1,000 births) was less than the UKs (p < 0.0001). Of the 597 babies born at 28+1 to 32+0 weeks of gestation, 37.5% did not require any respiratory support, while 31.1% required only CPAP therapy. 80.12% of the MV and 96.28% of CPAP therapy was required for <96 hours. 86.1% of the mothers had received antenatal steroids. The 28+1 to 32+0 weeks mortality rate was 65.3/1,000 births with 30.77% deaths attributable to a range of lethal congenital and chromosomal anomalies. The survival rate increased with increasing gestational age (p < 0.001) and was comparable to some high income countries. The incidence of in hospital pre discharge morbidities in Qatar (CLD 2.68%, IVH Grade III 0.84%, IVH Grade IV 0.5%, Cystic PVL 0.5%) was less as compared to some high income countries except ROP = Stage 3 (5.69%), which was higher in Qatar. The incidence of symptomatic PDA, NEC and severe ROP decreased with increasing gestational age (p < 0.05). We conclude that the mortality and in hospital pre discharge morbidity outcome of 28+1 to 32+0 weeks babies in Qatar are comparable with some high income countries. In two thirds of this group of preterm babies, the immediate postnatal respiratory distress can be effectively managed by using two facility based cost effective interventions; antenatal steroids and postnatal CPAP. This finding is very supportive to the efforts of international perinatal health care planners in designing facility-based cost effective options for low income countries.
Very Preterm Babies (=32 weeks of gestation) constitute 12% of all live births in high income countries, but account for at least one third of perinatal mortality, the majority of neonatal mortality, as well as both short-term (pre discharge, in hospital) and long-term (at two years corrected age) morbidity . Although neonatal mortality and morbidity are known to worsen with decreasing gestational age and weight at birth , the dramatic improvement in the intact survival of preterm babies has been one of the most remarkable features of neonatology in high income countries over the last three decades . Correspondingly, the question of how small is small has, over the last two decades, gradually decreased in terms of gestation period from 32 weeks to 28 weeks and then 24 weeks; and in terms of birth weight from 1,500 g to 1,000 g, to 800 g and then 500 g . However, the long term outcomes, the cost of care of babies born =28 weeks (particularly =26 weeks) and/or birth weight =1,000 g (and particularly =750 g), and the futility of intervention at the edge of viability remains a hot debate, even among the most resource rich countries and the care of extremely premature babies (=28 weeks and = 1,000 g at birth) is not an option for resource restricted developing countries. Instead these countries should focus on babies born =28 weeks gestation and =1,000 g at birth. Over the last decade the intact survival of this group of preterm babies has risen to a level which has put to rest any major controversy concerning cost effectiveness . In fact by the 1990s almost all NICUs in the high income countries had achieved = 90% survival of babies with a birth weight of >1,000 g .
The worlds nations are divided in providing equity in newborn care [16] and the global picture of newborn care and outcomes presents an unfortunate contrast on both sides of the divide between high income countries versus low income countries . The scenario and challenges of neonatal survival are unique in low income countries burdened by very high neonatal mortality and socioeconomic and political constraints . Worldwide some 12.9 million babies are born preterm each year; of which 1.12 million die each year (28% of 4 million global neonatal deaths; 98% of which occur in low income countries) . The very high cost and highly technology dependent care of extremely premature babies (<28 weeks and <1,000 g at birth) is neither a viable nor a sustainable option for low income countries. Therefore UNICEFs Annual Global Child Survival Reports exclude babies <1,000 g from the mortality data published for low income countries . These countries might be better off investing their limited resources in the care of full term and bigger preterm babies, the majority of which die of potentially preventable diseases . Indeed some developing countries e.g., Sri Lanka, Indonesia, Moldova, Nicaragua, Vietnam and Honduras have, within their limited resources and without resorting to very expensive high tech intensive care facilities, successfully reduced their neonatal mortality rates .
According to the March of Dimes 2009 Global Report on Preterm Births , there are huge gaps in the data with regards to preterm birth, prevalence, mortality, acute morbidity and long term impairment in low income countries. Such deficiencies in the available data makes the much needed systematic scaling up of neonatal care [20] in these countries an extremely difficult task. The present study aims to bridge this gap. We collected, analyzed and compared the gestational age specific mortality and morbidity data from the State of Qatar which has achieved excellent Neonatal mortality rates in recent years (4.37, 5.1, 4.4, and 4.0/1,000 births in 2006, 2007, 2008 and 2009 respectively) with the data from the developed countries. In addition, the current study also explored the feasibility of facility based cost effective options for saving babies at the lowest limits of viability (28+1 to 32+0 weeks) in low income countries.
A total of 64,689 live births were recorded during the study period with 597 of these babies being babies between 28+1 to 32+0 weeks gestation, thus giving a prematurity rate of 9.23 per 1,000 total births for the target gestational age category during the study period. Our 28+1 to 32+0 weeks gestation prematurity rate was less than the rates for the same gestation group in the UK (p < 0.0001). It highlights the patient characteristics of our sample in comparison to VON, which is an international database of more than 800 Neonatal ICUs; more than 95% of which are located in North America, Western Europe and Australia. 86.44% of our babies had birth weights between 1,001 and 2,000 g and only 3.9% were SGA as compared to 12% in VON database (p < 0.0001). Singleton babies comprised 81.91% of the sample. The gender distribution was equal, and almost 45% of the babies were born to native Qatari families and 55% to expatriate families living and working in Qatar. This is in line with the general distribution of population in Qatar . The rate of antenatal steroid administration in our sample (86.1%) was better (p < 0.0001) than VON (73%). The 28+1 to 32+0 weeks mortality rate in our sample was 65.3/1,000, which was higher (p < 0.0001) than VON (29.9/1,000). 35.89% of deaths in our cohort were Early Neonatal Deaths (07 days of life) and 64.11% Late Neonatal Deaths (828 days of life). Lethal Congenital and Chromosomal Anomalies accounted for 12 deaths (30.77%); Trisomy 18 (four cases), Trisomy 13 (one case), multiple congenital anomalies (one case), and complex congenital heart disease (four cases including two with Downs syndrome).
Then it shows the characteristics of the respiratory support required by the 28+1 to 32+0 weeks gestation babies of our cohort during their stay in the NICU. Slightly more than one third of our babies (37.52%, n = 224) did not require any respiratory support during their entire NICU stay. Of the remaining 373 babies (62.48%) who required respiratory support, 186 (31.3% of total and 50% of babies requiring respiratory support) needed CPAP alone. One hundred and eighty seven (31.3% of total and 50% of babies requiring respiratory support) needed MV. Among the babies requiring MV, 83 (13.9% of total babies and 44.4% of babies requiring MV) needed post extubation CPAP support. Surfactant therapy was required only by one third (32.16%) of total babies. The need for respiratory support decreased (p < 0.001) with increasing gestational age (MV decreased from 88.71% at 29 weeks to 13.26% at 32 weeks; CPAP decreased from 66.13% at 29 weeks to 31.44% at 32 weeks; and surfactant replacement decreased from 88.71% at 29 weeks to 15.53% at 32 weeks). Most of the respiratory support (80.12% MV, 96.28% CPAP) was required for short duration (<96 hours).
Further it depicts the total and gestational age specific mortality and survival rates with a comparison with recent data from UK . Qatars average Neonatal Mortality Rates for the study period 6.34/1,000 and 28+1 to 32+0 weeks gestation mortality rate was 65.33/1,000. Qatars 28+1 to 32+0 weeks gestation survival rate of 93.47% was significantly less (p < 0.0001) than the same gestational age survival rate in UK during 2006. Within our own cohort the gestational age specific survival rate increased significantly (p < 0.001) with every single week increase in gestational age (from 85.49% at 29 weeks to 96.66% at 32 weeks).
Tables 4 illustrates the total and gestational age specific in hospital pre discharge morbidity of 28+1 to 32+0 weeks gestation babies in Qatar with comparative figures for 3032 weeks gestation babies from the expanded data base in VON 2007 report .
Our incidence of CLD and symptomatic PDA was significantly less (p < 0.0001), while the incidences of NEC, IVH grade III, IVH grade IV and PVL were similar to VON. On the other hand, our incidence of ROP was significantly higher (p < 0.0001) than VON. Within our cohort the incidence of symptomatic PDA, NEC and ROP (=Stage 3) decreased with every single week increase in gestational age (p < 0.05).
We constructed Table 5 using a subanalysis of our data restricted to babies with birth weight 1,0011,500 g (n = 282). This included 205 babies from our study, as shown in earlier, plus 77 babies who were <28 weeks gestation from another yet unpublished study conducted for the same time period (20022006) by our group on extremely low birth weight babies. This subanalysis made it more rational for us to compare our pre-discharge in hospital morbidity outcome with studies based on birth weight instead of gestational age.It depicts comparative data for 1,0011,500 g babies between Qatar and recent studies from the USA (NICHD) , Italy (Trento study) and UAE . The incidence of pre-discharge respiratory and neurologic morbidity was very low among our cohort as compared to NICHD, but comparable to the Trento and UAE studies. Severe ROP (=Stage 3) was high (5.69%) in our study as compared to all the other groups.
Credits:Hussain Parappil,Sajjad Rahman,Husam Salama,Hilal Al Rifai,Najeeb Kesavath Parambil and Walid El Ansari
More information at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2905565/?tool=pubmed