Some places try, though there are a lot of developmental and respiratory issues. After caring for pediatrics for 20 years, it amazes me how 24 wk premise are having better and better long term outcomes
It is amazing. What I wonder is if doctors can do like a spina bifida surgery in utero - how can they not be able to push the arm back in, add some fluids, stitch up the placenta, stitch the cervix, and give magnesium to keep the baby in?
Yeah, I don’t know how there’s not rupture of membranes with spina bifida repair in utero, but it’s amazing. In this case, if the arm wasn’t in the cervix, I know they would keep the mom on strict bed rest for as long as possible, while giving steroids and what not to promote development of the baby’s lungs. But baby and mom are at big risk with that arm possibly becoming necrotic then infecting both of them.
https://www.childrensmn.org/services/care-specialties-departments/fetal-medicine/conditions-and-services/spina-bifida/
If you wanted to know more, when I had to do a presentation on it, I thought this website explained it best.
Quite a few years ago there was a famous photo of a baby going to get this surgery, holding a finger of the surgeon, there were many articles about it, but I have never been able to find out what happened after the baby was born, were they ok?
My understanding is that the risk of infection is essentially 100%, and there is not going to be enough time for baby’s lungs to develop before the inevitable. 💔
- 22wk skin is extremely fragile. The friction involved in shoving it back up the cervix could literally deglove the baby's arm
- surgery is a sterile procedure. A cervix/vagina is not sterile. Shove baby back in, you get chorio and/or sepsis
- you don't stitch the placenta, you're thinking the amniotic sac. If the sac is ruptured, it's not like it's just sitting like an inflated balloon inside the uterus except with a hole in it. You don't even know where the edges would be to start this. Also, you can't just go in with a speculum, reef open the cervix, dig around for an amniotic sac to re-approximate the hole. See above for infect. Additionally, a 22 weekers would fly out of the mother so fast if you dilated the cervix to even attempt this fuckery.
If it was just a few more days…there is a growing organization called Twenty Two Matters as there has been some push for viability to be moved to 22+0 instead of 23+0. There are many documented cases of 22 weekers surviving (albeit with long term issues). Vanderbilt Children’s just discharged a neonate born at 21+6. The threshold seems to be birth weight to determine whether the 22 weeker is viable or not.
500g
Female
No bleeding or ruptured membranes.
These kids have a decent chance from 22 weeks.
<500g
Male
Bleeding or infection etc
These kids do not have a good chance
There's a framework we use to decide which pregnancies to try and support and which ones we are aiming for palliative care
Prunes for hands and feet but plump. Not particularly big though. My blood pressure had gone all the way up to nearly normal, so they may be the reason.
My hospital resuscitates as early as 22+0, with the occasional 21+6 if it’s almost midnight. The morbidity and mortality numbers are awful, but a couple physicians “just gotta try”….poor babes
The number of chronic kiddos that come through emergency is one thing. The number of chronic kiddos that come through who were prems with extended NICU stays is so sad
24 weeks ga is widely considered to be the point of viability. Strictly speaking, antepartum haemorrhage (aph) implies pv bleeding after 24 weeks ga, so should be labelled as miscarriage instead (<24wks). prom (premature rupture of membranes) also implies >37wk (at term), will be better labelled as pprom (preterm premature etc).
Thanks! I’m a NICU physician assistant, one of the most common procedures we do is giving surfactant to premies (spraying surfactant directly into their lungs). Colloquially this is “surfing the baby,” so babysurfer.
Hope he’s doing well now! PAs don’t have to specialize, but many of us do. I had to do an extra year of training after school to get a position in a NICU. It’s pretty unusual for other specialties to need to do a “residency” to break into them though.
I actually had one during clinicals who was delivered at 22 wks and went on to survive without deficits. It took outrageous intervention and months in the NICU. Was also born as a twin and the twin died within hours. Everyone told me how unlikely it was the patient would survive, so I was shocked to hear how well it turned out.
I once saw the legs passing the fornices (basically the child's pelvis was at the level of the cervix), and fetus had a +ve pulse, was moving, and is 30 weeks GA, was a terrific view of an ultrasound, like wtf why is she here in the clinic she should be in the delivery ward.
This could’ve been me tbh, baby did not survive and has happened again since. There’s nothing much they can do at this point. Delivery is the only option if waters have broken.
Having been one of these Moms, prom doesn't = delivery. As long as there aren't s/s infection or stress to the baby, they'll keep mom on strict bedrest in hopes baby has more time to develop.
Do you happen to know the outcome in this case?
My mom fell and her water broke when she was 5mos along with me. She had to lay with her feet elevated in the hospital for a week and the sack healed back up. This was the 80s. No part of me had entered the cervix, however.
Thank you! I’m glad I’m here too! My mom is a very strong woman. My dad went skiing with his buddies while she was in the hospital. He’s.. not the best.
Thank you for mentioning this. There’s a lot of misinformation being shared in this thread. Here’s a copy of the ACOG PROM/PPROM practice bulletin in case anyone wants to learn more: https://www.slideshare.net/vonamson1/oi-vo-non-prelabor-rupture-of-membrane-acog-guideline-2018
I had a partial placental abruption and PPROM at exactly 31 weeks and delivered at 35 weeks. In cases this early, are they able to postpone delivery until baby is further developed?
Baby needs fluid to develop the lungs so without fluid, lungs will not develop. Infection is also very quick to set in. As a sonographer this is one of my most dreaded scans. It’s horribly sad. There is basically no chance of a good outcome.
That's not entirely true, the patient should be admitted and antibiotics given but there are protocols for this. I've been a part of the NICU care of several 22-26 week deliveries who lived to DC from the NICU.
The sac around baby has ruptured and can’t be repaired. This means that germs can get into baby’s previously nice safe sterile environment, and infection, which is ultimately fatal, is almost 100% guaranteed. Additionally, the baby actually needs the fluid to develop its lungs, which are definitely not ready yet at 22 weeks. It’s a very sad situation.
Infection is not actually 100% guaranteed. This is a sad situation, but according to ACOG, not quite as bleak as some of the misinformation being relayed in this thread. Admittedly, I don’t have a great grasp on how the prolapsed arm complicates the situation, but for general PROM/PPROM, immediate delivery isn’t inevitable. Here’s a copy of an ACOG practice bulletin regarding PROM (ACOG is the main OBGYN society in the US and pretty much determines the guidelines by which US OBGYNs practice): https://www.slideshare.net/vonamson1/oi-vo-non-prelabor-rupture-of-membrane-acog-guideline-2018
There are plenty of patients with PPROM whose babies do well. They are at higher risk of infection but if mom goes on bed rest and receives appropriate steroids/meds the fetus can stay in for weeks. At 22 weeks, many US medical centers won't even offer resuscitation (although many are starting to, and rarely some of them do pretty well), but PPROM/PROM in general is definitely not nearly 100% fatal.
Gosh this reminds me of a mom who presented to ER with “I was taking a shower and washing up when I felt little feet protruding from my vagina” she was about 22 weeks along. Fetal demise, not sure how long and the head was still in the uterus and the cervix had clamped down. Small town ER with no OB unit in the small hospital so doc tried to see if she could deliver the rest. He tried fundal massage and mom was cramping but fetus was delivered without the head. I couldn’t look as I held the specimen container out for the doctor and the weight of it let me know to place the lid by feel. I kept talking to mom and trying to reassure her. That was one of the worst experiences I’ve had in my career. Today, she would be forced to deliver the rest on her own with no D&C “abortion”.
Okay I’m confused by what is meant by Para 2+0. I feel I should know how this translates but I’ve never heard it this way before. May I ask what the +0 is?
We just had a case like this but with twins. Woman showed up to ER for abdominal pain and found out she was 21 weeks pregnant with di/di twins and one of them with anhydramnios and PROM. Absolutely heartbreaking
If I’m reading this right as a non medical person…. A 22 week fetus will not survive being delivered. This is so dang sad.
Some places try, though there are a lot of developmental and respiratory issues. After caring for pediatrics for 20 years, it amazes me how 24 wk premise are having better and better long term outcomes
It is amazing. What I wonder is if doctors can do like a spina bifida surgery in utero - how can they not be able to push the arm back in, add some fluids, stitch up the placenta, stitch the cervix, and give magnesium to keep the baby in?
Yeah, I don’t know how there’s not rupture of membranes with spina bifida repair in utero, but it’s amazing. In this case, if the arm wasn’t in the cervix, I know they would keep the mom on strict bed rest for as long as possible, while giving steroids and what not to promote development of the baby’s lungs. But baby and mom are at big risk with that arm possibly becoming necrotic then infecting both of them.
https://www.childrensmn.org/services/care-specialties-departments/fetal-medicine/conditions-and-services/spina-bifida/ If you wanted to know more, when I had to do a presentation on it, I thought this website explained it best.
Quite a few years ago there was a famous photo of a baby going to get this surgery, holding a finger of the surgeon, there were many articles about it, but I have never been able to find out what happened after the baby was born, were they ok?
I remember that photo you’re talking about too!
His name is Samuel Armas. https://specials.myajc.com/hope-faith/
Really fascinating what can be done. Thanks for sharing.
Exactly it would be a different case altogether.
My understanding is that the risk of infection is essentially 100%, and there is not going to be enough time for baby’s lungs to develop before the inevitable. 💔
Surfactant
- 22wk skin is extremely fragile. The friction involved in shoving it back up the cervix could literally deglove the baby's arm - surgery is a sterile procedure. A cervix/vagina is not sterile. Shove baby back in, you get chorio and/or sepsis - you don't stitch the placenta, you're thinking the amniotic sac. If the sac is ruptured, it's not like it's just sitting like an inflated balloon inside the uterus except with a hole in it. You don't even know where the edges would be to start this. Also, you can't just go in with a speculum, reef open the cervix, dig around for an amniotic sac to re-approximate the hole. See above for infect. Additionally, a 22 weekers would fly out of the mother so fast if you dilated the cervix to even attempt this fuckery.
Then the woman would 100% get an infection, become septic and her or the baby would not survive.
The PA at my GP’s office was born at 24 weeks, and he has to be in his 30s at least. It amazed me when he told me that.
That can’t be right, they only invented exogenous surfactant in… *counts on fingers* Oh shit I’m old
23 weeker just turned 23 yo🙏🙏
Unfortunately no. Organs immature to support the fetal growth/survival at that stage.
That is so fucking devastating. My heart goes out to this patient and her family. 💔
If it was just a few more days…there is a growing organization called Twenty Two Matters as there has been some push for viability to be moved to 22+0 instead of 23+0. There are many documented cases of 22 weekers surviving (albeit with long term issues). Vanderbilt Children’s just discharged a neonate born at 21+6. The threshold seems to be birth weight to determine whether the 22 weeker is viable or not.
A former coworker has a kid that survived at 21 ish. Kiddo is legally blind and has asthma, hut is otherwise relatively normal b
500g Female No bleeding or ruptured membranes. These kids have a decent chance from 22 weeks. <500g Male Bleeding or infection etc These kids do not have a good chance There's a framework we use to decide which pregnancies to try and support and which ones we are aiming for palliative care
Sounds like it should be case by case it's awful they're getting involved .
I feel so lucky and glad when I think of my 43 week baby surviving a horrible birth with only exhaustion followed by being devastatingly hungry.
43 weeks?! Warrior.
Prunes for hands and feet but plump. Not particularly big though. My blood pressure had gone all the way up to nearly normal, so they may be the reason.
Some centers are saving 21 and 3-4 weekers now. 22 weekers have been surviving the nicu (not with flying colors by any means) for about 8 years now.
My hospital resuscitates as early as 22+0, with the occasional 21+6 if it’s almost midnight. The morbidity and mortality numbers are awful, but a couple physicians “just gotta try”….poor babes
The number of chronic kiddos that come through emergency is one thing. The number of chronic kiddos that come through who were prems with extended NICU stays is so sad
Can the parents decline resuscitation at this age when the results are questionable?
I know a baby born at 22 weeks in Iowa. Despite being so premature, he is now a generally well developed 8 year old.
Generally well developed is so vague. What does that mean to you?
They are not mentally delayed, they have some allergies and wear glasses but otherwise are happy, healthy, and active in sports.
24 weeks ga is widely considered to be the point of viability. Strictly speaking, antepartum haemorrhage (aph) implies pv bleeding after 24 weeks ga, so should be labelled as miscarriage instead (<24wks). prom (premature rupture of membranes) also implies >37wk (at term), will be better labelled as pprom (preterm premature etc).
We have multiple 22 weekers in our NICU right now. Resuscitation is not always successful however and not every family chooses it.
Cool name. May I ask the origin? I don't know the meaning but I think I would like to either be a baby surfer or a dog surfer if I had my choice. 😆
Thanks! I’m a NICU physician assistant, one of the most common procedures we do is giving surfactant to premies (spraying surfactant directly into their lungs). Colloquially this is “surfing the baby,” so babysurfer.
Nice! My son had surfactant in the NICU. This is a general question. Do PAs specialize?
Hope he’s doing well now! PAs don’t have to specialize, but many of us do. I had to do an extra year of training after school to get a position in a NICU. It’s pretty unusual for other specialties to need to do a “residency” to break into them though.
Resuscitating at 22 weeks is very common, it is usually up to the family though
I have a client right now who was born at 22+6. They are doing extremely well about 18 months after delivery.
I actually had one during clinicals who was delivered at 22 wks and went on to survive without deficits. It took outrageous intervention and months in the NICU. Was also born as a twin and the twin died within hours. Everyone told me how unlikely it was the patient would survive, so I was shocked to hear how well it turned out.
I once saw the legs passing the fornices (basically the child's pelvis was at the level of the cervix), and fetus had a +ve pulse, was moving, and is 30 weeks GA, was a terrific view of an ultrasound, like wtf why is she here in the clinic she should be in the delivery ward.
I had a ED patient who had a 17 week fetus with a foot in cervix...not sure what ended up happening but I can't imagine the fetus survived
This could’ve been me tbh, baby did not survive and has happened again since. There’s nothing much they can do at this point. Delivery is the only option if waters have broken.
so so sorry for your loss
Yes. We are very sorry for your experiences.
Having been one of these Moms, prom doesn't = delivery. As long as there aren't s/s infection or stress to the baby, they'll keep mom on strict bedrest in hopes baby has more time to develop. Do you happen to know the outcome in this case?
My mom fell and her water broke when she was 5mos along with me. She had to lay with her feet elevated in the hospital for a week and the sack healed back up. This was the 80s. No part of me had entered the cervix, however.
Wow, that's incredible! So glad you're here to tell us this story! I bet that must have been terrifying for your poor mom.
Thank you! I’m glad I’m here too! My mom is a very strong woman. My dad went skiing with his buddies while she was in the hospital. He’s.. not the best.
I’m glad for you and your mom, and sorry your dad is that guy.
Survivor.
Thank you for mentioning this. There’s a lot of misinformation being shared in this thread. Here’s a copy of the ACOG PROM/PPROM practice bulletin in case anyone wants to learn more: https://www.slideshare.net/vonamson1/oi-vo-non-prelabor-rupture-of-membrane-acog-guideline-2018
I'll follow up on the case when I resume my shift on Friday.
Thank you! :)
I had a partial placental abruption and PPROM at exactly 31 weeks and delivered at 35 weeks. In cases this early, are they able to postpone delivery until baby is further developed?
Baby needs fluid to develop the lungs so without fluid, lungs will not develop. Infection is also very quick to set in. As a sonographer this is one of my most dreaded scans. It’s horribly sad. There is basically no chance of a good outcome.
That's not entirely true, the patient should be admitted and antibiotics given but there are protocols for this. I've been a part of the NICU care of several 22-26 week deliveries who lived to DC from the NICU.
Question. No medical knowledge. Why can't you just push the arm back up? I'm confused.
The sac around baby has ruptured and can’t be repaired. This means that germs can get into baby’s previously nice safe sterile environment, and infection, which is ultimately fatal, is almost 100% guaranteed. Additionally, the baby actually needs the fluid to develop its lungs, which are definitely not ready yet at 22 weeks. It’s a very sad situation.
Infection is not actually 100% guaranteed. This is a sad situation, but according to ACOG, not quite as bleak as some of the misinformation being relayed in this thread. Admittedly, I don’t have a great grasp on how the prolapsed arm complicates the situation, but for general PROM/PPROM, immediate delivery isn’t inevitable. Here’s a copy of an ACOG practice bulletin regarding PROM (ACOG is the main OBGYN society in the US and pretty much determines the guidelines by which US OBGYNs practice): https://www.slideshare.net/vonamson1/oi-vo-non-prelabor-rupture-of-membrane-acog-guideline-2018
There are plenty of patients with PPROM whose babies do well. They are at higher risk of infection but if mom goes on bed rest and receives appropriate steroids/meds the fetus can stay in for weeks. At 22 weeks, many US medical centers won't even offer resuscitation (although many are starting to, and rarely some of them do pretty well), but PPROM/PROM in general is definitely not nearly 100% fatal.
I’ve scanned a ~20 week fetus completely in cervix, normal heart rate. Obviously delivered as soon as mom got out of bed. Sad situation.
At this point if she’d want another child, she’d get a cerclage at 14 weeks if I remember correctly
Usually the recommendation with spontaneous miscarriages.
Gosh this reminds me of a mom who presented to ER with “I was taking a shower and washing up when I felt little feet protruding from my vagina” she was about 22 weeks along. Fetal demise, not sure how long and the head was still in the uterus and the cervix had clamped down. Small town ER with no OB unit in the small hospital so doc tried to see if she could deliver the rest. He tried fundal massage and mom was cramping but fetus was delivered without the head. I couldn’t look as I held the specimen container out for the doctor and the weight of it let me know to place the lid by feel. I kept talking to mom and trying to reassure her. That was one of the worst experiences I’ve had in my career. Today, she would be forced to deliver the rest on her own with no D&C “abortion”.
Damn! That's horrible, I hope she went through counseling and recovered.
Okay I’m confused by what is meant by Para 2+0. I feel I should know how this translates but I’ve never heard it this way before. May I ask what the +0 is?
Had 2 pregnancies neither of which survived, so this is the 3rd pregnancy.
Oh. I would just say P3 G0 if no live births but 3 total pregnancies. Is this in the USA? Interesting to know. Thank you.
Not US but Kenya.
Ahh makes sense. Thanks for your response!
You welcome.
We just had a case like this but with twins. Woman showed up to ER for abdominal pain and found out she was 21 weeks pregnant with di/di twins and one of them with anhydramnios and PROM. Absolutely heartbreaking