773 - On the cusp of viability: Delivery and resuscitative outcomes in infants born during the 21st week of gestation

Publication Number: 2754.773

Rachel L. Benz, UAB, Birmingham, AL, United States; Rachel Holcombe, University of Alabama School of Medicine, Birmingham, AL, United States; Kathryn Foshee, UAB, Birmingham, AL, United States; Ashley Battarbee, University of Alabama School of Medicine, Birmingham, AL, United States; Colm P. Travers, University of Alabama at Birmingham, Birmingham, AL, United States

Background: With improving survival rates, the boundaries of viability in the past decade have moved to 22-23 weeks' gestation. There are recent reports of survival at 21 weeks' gestation, but data are lacking on parental desires for comfort versus survival-focused care and resulting clinical outcomes at this gestational age.

Objective: To describe the perinatal decision-making and clinical outcomes among infants born at 21 weeks' gestation.

Design/Methods: Single-center retrospective cohort study including pregnant patients with delivery at 21 weeks' 0 days to 21 weeks' and 6 days gestation at a level IV regional NICU from July 2020 through September 2025. Electronic medical records of mothers and infants were reviewed to abstract information about counseling and medical decision-making, perinatal care practices, resuscitation practices (including oxygen, continuous positive airway pressure, positive pressure ventilation, intubation, surfactant, chest compressions, and epinephrine), and neonatal outcomes.

Results: Sixty-one parent/infant dyads were included (Figure 1). All mothers were counseled by a physician regarding the risks and likely outcomes of birth at this gestation, while 24 (40%) mothers were specifically counseled by a neonatologist. While not offered to all mothers, parental requests regarding resuscitative efforts were documented, with 24 requesting active resuscitation prenatally. Twenty-nine (48%) pregnancies ended in intrauterine/intrapartum fetal demise . Five (3 live born) infants were born to mothers who received antenatal corticosteroids. Fifty-nine (97%) infants were delivered vaginally, of whom 18 were breech. Two (3%) were delivered by cesarean section. Any resuscitation was attempted in 22/32 (69%) live born infants with a mean (SD) birthweight of 434 (50) grams and gestational age of 21 weeks' 4 days (Table 1). Of the infants in whom resuscitation was attempted, 16 (73%) were intubated, 13 of whom received surfactant. Twelve infants were admitted to the NICU, 4 infants survived to discharge, while 8 died before reaching 36 weeks' postmenstrual age. Major morbidities among infants admitted to the NICU were common (Table 2).

Conclusion(s): Approximately half of all infants delivered at 21 weeks' gestation were live born and a majority received survival-focused care. Survival occurred in nearly one in five infants who received any active care, but major morbidities were common. Proactive care at the cusp of viability has become more prevalent in the recent years raising ethical and medical considerations for the neonatal and obstetric teams.

Rates of Prenatal and Resuscitative Intervention


Major Morbidities of Infants Admitted to the NICU


Survival Diagram
This diagram lays out the timing of death for infants represented in this study.