Saturday, 9 February 2013

Saving sick fetuses may have bad outcomes


Growth restriction in an unborn child is the single largest risk factor for stillbirth, yet it is currently missed in most pregnancies. The authors of a report published in the British Medical Journal last month say spotting it early could substantially reduce the risk, and this needs to become a cornerstone of safety and effectiveness in antenatal care.

You might think that with modern ultrasound scans growth restriction would be easy to spot. Yet the report shows that detection ranges from 12.5% to 50% in different maternity units. Such a wide disparity is worrying and according to the authors it depends on staff training and adherence to protocols.

But before we rush into investing resources and rescuing poorly growing fetuses, I think we should consider the implications more carefully. In recent times there has been a trend to 'demedicalise' pregnancy. After all, pregnancy is not an illness. Attention has focussed on the birthing environment and where possible keeping obstetrics at bay.

The authors of the report suggest that with better detection of growth restriction, action could be taken to rescue the fetuses. But, simply saving sick fetuses may not produce outcomes we would wish. Measures that can be taken to enhance fetal growth are extremely limited. It is more likely to drive an increase in caesarean  sections and increase the numbers of babies born premature. Many of these babies are likely to be very poorly and require intensive care.  Many would not survive, and for those that do, they may have long-term handicaps.

Recent reports from the epicure study, a long term follow up of the outcome for babies born prematurely, show that survival for babies born very premature has improved considerably since 1995. Just over half (53%) now survive. However, despite these improvements, the number of babies leaving neonatal units with abnormalities showing on their brain ultrasound scans, and with lung, bowel and eye problems has not diminished. Babies born before 27 weeks "face a battle for survival" and many go on to live with long-term health problems such as lung conditions, learning difficulties and cerebral palsy. The rates of premature birth are on the rise in many European countries and are particularly high in the UK.

Professor Neil Marlow, an MRC-funded researcher from the UCL Institute for Women’s Health and an author of the recent epicure reports, said:

“Our findings show that more babies now survive being born too soon than ever before, which is testament to the highly-skilled and dedicated staff in our neonatal services. But as the number of children that survive pre-term birth continues to rise, so will the number who experience disability throughout their lives. This is likely to have an impact on the demand for health, education and social care services.”

Increasing CS deliveries and the numbers of babies born prematurely will increase the burden on already stretched neonatal intensive care units. Deciding which fetuses to 'rescue' will depend on availability of such expertise and resources, and on the assessment of likely outcome. It cannot be based simply on the fact that a fetus stops growing. Difficult decisions will have to be made and these should be made from both the obstetric and neonatal care perspective.


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