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Arch Dis Child Fetal Neonatal Ed. 2007 November; 92(6): F515–F516.
PMCID: PMC2675411

Perinatal care at an extremely low gestational age (22–25 weeks). An Italian approach: the “Carta di Firenze”

Guidelines on life or death strategies in extremely preterm infants have been formulated in various countries worldwide.1,2,3,4,5,6,7,8,9,10,11,12,13,14,15 The general agreement is not to initiate resuscitation in neonates when gestational age is less than or equal to 22 weeks, and intensive care is assured for infants of 25 weeks and over; in the middle there is a sort of “grey zone”. To provide helpful suggestions for initial management of threatened birth in infants at a gestational age of 25 completed weeks or less, a working group in Florence recently reviewed existing studies on survival and morbidity rates, international guidelines and practice recommendations. A consensus document was drawn up, and this was evaluated by several scientific societies (Italian Paediatric Society (SIP), Italian societies of obstetricians and gynaecologists (AGUI, AOGOI), Italian Society of Legal Medicine (SIMLA), Italian Society of Perinatal Medicine (SIMP), Italian Society of Anaesthesiologists (SIARTI), and the Italian Society of Paediatric Anaesthesia (SARNePI), and is currently being examined by the Italian National Bioethical Committee. The issues addressed include:

  1. suggestions arising from the need to guarantee mothers and neonates adequate assistance solely for safeguarding them against useless, painful, or inefficacious treatments resulting in futile treatment;
  2. suggestions for treatment stratified per gestational age in weeks (considered by the entire scientific world as the most efficacious measure of maturity of the fetus/neonate), while leaving room for deviations in specific cases at the discretion of the attending doctors and in compliance with the parents' will (as per Italian Legislation regarding late pregnancy terminations [Law 194/1978] that forces clinicians to plan either palliative or intensive care for the fetus/neonate after a postnatal evaluation);
  3. parents' desires are paramount in borderline cases and must be complied with if medically acceptable
  4. generally aggressive management is recommended at or after 25 weeks and is not suggested at or under 22 weeks. Decisions must be made on an individual level in the grey zone (23–24 weeks), although aggressive management of the mother and fetus/neonate is not recommended
  5. the attending clinician's main duty is to provide honest, updated and adequate information for the parents.

Our document offers an overview of different positions that may be helpful for clinicians and parents. It also provides the basis for a debate—which is necessary in Italy, where any discussion about end‐of‐life decisions, particularly in infancy and childhood, is still controversial.

Table thumbnail
Table 1 Suggestions for treatment at an extremely preterm age

Acknowledgements

We thank Francesca Ceroni, Judge of the Juvenile Court, Florence, Roberta Filippi, Attorney of the Court of Florence, and Patrizia Pompei, Judge of the Civil Court of Florence for their work in addressing and reviewing the document.

Footnotes

Competing interests: None.

References

1. Anon Frühgeburt an der Grenze der Lebensfähigkeit des Kindes. Z Geburtsh Neonatol 1998. 202261–263.263. [PubMed]
2. Dehan M, Gold F, Grassin M. et al Pour la Federation nationale des pediatres neonatologistes. Dilemmes éthiques de la période périnatale: recommandations pour le décisions de fin de vie. Arch Pediatr 2001. 8407–419.419. [PubMed]
3. Desfrere L, Tsatsaris V, Sanchez L. et al Critères de réanimation des prematurissimes en salle de naissance: quel discours en anténatal? J Gynecol Obstet Biol Reprod 2004. 331S84–1S87.1S87. [PubMed]
4. Fetus and Newborn Committee, Canadian Paediatric Society and Maternal Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada Management of the woman with threatened birth of an infant of extremely low gestational age. CMAJ. 2000. http://www.cps.ca/english/statements/FN/fn94‐01.htm (accessed 9 March 2003) [PMC free article] [PubMed]
5. Gee H, Dunn P; for the BAPM Executive Committee Fetuses and newborn infants at the threshold of viability. A framework for practice. British Association of Perinatal Medicine, 2000. http://www.bapm.org/publications/index.php#guidelines (accessed on 14 May 2003)
6. Thames Regional Perinatal Group Guidelines relating to the birth of extremely immature babies (22–26 weeks gestation). British Association of Perinatal Medicine, 2000. http://www.bapm.org/publications/index.php#guidelines (accessed on 14 May 2003)
7. Nuffield Council on Bioethics Critical care decisions in fetal and neonatal medicine: ethical issues. November 2006. Search via http://www.nuffieldbioethics.org (accessed December 14 2006)
8. ACOG Perinatal care at the threshold of viability Pract Bull. 2002;100:617–624. [PubMed]
9. AAP Clinical Report Perinatal care at the threshold of viability. Pediatrics 2002. 1101024–1027.1027. [PubMed]
10. FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health Recommendations on ethical issues in obstetrics and gynaecology. November 2003. http://www.figo.org/about‐guidelines.asp (accessed 13 August 2007)
11. Swiss Society of Neonatology Recommendations for the care of infants born at the limit of viability (gestational age 22–26 weeks). 2003 Guidelines. http://www.neonet.ch/en/04_Recommendations/rec_ssn.asp (accessed 2 September 2004)
12. Asociacion Espanola De Pediatria Recomendaciones en reanimacion neonatal. Grupo de Reanimacion Cardiopulmonar de la Sociedad Espanola de Neonatologia. An Pediatr Barc 2004. 6065–74.74. [PubMed]
13. American Heart Association Neonatal resuscitation guidelines. Circulation 2005. 112188–195.195.
14. Dutch Pediatric Association Guidelines for decisions regarding extremely premature birth in the Netherlands [Nederlands beleid bij extreme vroeggeboorte] Dutch Pediatric Association, November, 2005.
15. Verloove‐Vanhorick S P. Management of the neonate at the limits of viability: the Dutch viewpoint. BJOG 2006. 133(Suppl 3)13–16.16. [PubMed]

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