BACKGROUND: In the United States, fetal development markers, including \"viability\" and the point when a fetus can \"feel pain\", have permeated the social imaginary of abortion, affecting public support and the legality and availability of care, but the extent to which they describe and orient the experience of abortion at later gestations is unclear.
METHODS: Using interviews with 30 cisgender women in the U.S. who obtained an abortion after 24 weeks of pregnancy, we investigate whether and how notions of fetal viability and/or pain operated in their lived experiences of pregnancy and abortion.
RESULTS: By respondents\' accounts, fetal development-based laws restricting abortion based in purported points of fetal development operated as gestational limits, privileged the viability and pain status of the fetus over that of the prospective neonate, and failed to account for the viability and pain of the pregnant person.
CONCLUSIONS: The discursive practice of centering fetal development in regulating abortion access makes denial of abortion care because of the status of the fetus conceptually available-even at the point of fertilization-and naturalizes the erasure of the subjectivity of women and others who can become pregnant.

Periviable birth refers to births occurring between 20 0/7 and 25 6/7 weeks gestational age. Management of pregnant people and neonates during this fragile time depends on the clinical status, as well as the patient\'s wishes. Providers should be prepared to counsel patients at the cusp of viability, being mindful of the uncertainty of outcomes for these neonates. While it is important to incorporate the data on projected morbidity and mortality into one\'s counseling, shared-decision making is most essential to caring for these patients and optimizing outcomes for all.

An arbitrary gestational age limit of viability cannot be set, and in clinical practice the focus should be on a periviability interval-the so-called \"gray zone\" of prognostic uncertainty. For cases within this interval, the most appropriate decision-making process remains debatable and periviability has emerged as one of the greatest challenges in bioethics. Universally recognized ethical principles may be interpreted differently due to socioeconomic, cultural, and religious aspects. In the case of periviability, there is considerable uncertainty over whether interventions result in a greater balance of clinical good over harm. Furthermore, the fetus or neonate is unable to exercise autonomy and the physicians and parents will act as patient surrogates. When parents and physicians disagree about the infant\'s best interest, a dialogue without paternalistic attitudes is essential, whereby physicians should only offer, but not recommend, perinatal interventions. Parental choice, based on thorough information, should be respected within the limits of what is medically feasible and appropriate. When disagreements between parents and physicians occur, how is consensus to be achieved? Professional guidelines can be helpful as a framework and starting point for discussion. In reality, however, guidelines only rarely draw categorical lines and in many cases remain vague and ambiguously worded. Local ethics committees can provide counseling and function as moderators during discussions, but ethics committees do not have decision precedence. Counseling assumes the most significant role in periviability discussions, taking into consideration the particular fetal and maternal characteristics, as well as parental values. Several caveats should be observed relative to counseling: message fragmentation or inconsistence should be minimized, prognosis should preferably be presented in a positive framing, and overreliance on statistics should be avoided. It is recommended that decisions regarding neonatal resuscitation in the periviability interval be made before birth and not conditional on the newborn\'s appearance at birth. Regardless of decision, it is important to assure pre- and postnatal coherence. The present article describes how individual physicians, centers, and countries differ in the approach to the decision to initiate or forgo intensive care in the periviability interval. It is impossible to provide a global consensus view and there can be no unifying ethical, moral, or practical strategy. Nevertheless, ethically justified, quality care comprises early involvement of the obstetric and neonatal team to enable a coherent, comprehensible, nonpaternalistic, and balanced plan of care. Ultimately, physicians will need to adjust the expectations to the local standards, local outcome data, and local neonatal support availability.

Despite improved survival of extremely preterm infants born at <28 weeks gestational age (GA) since the 1990s, only few reports on long-term outcomes have been published. The aim of our study was to determine risk factors among mothers and outcomes for their children born at the limit of viability (GA 22 + 0 - 23 + 6 weeks) at the Karolinska university hospital in 2009-19, before and after the introduction of new national interventionist guidelines in 2016. We hypothesized that infant survival, morbidity and cognitive functions at 2 years\' corrected age had improved after the new clinical practice. Maternal risk factors were identified, which emphasize the need of standardized follow-up and counseling for women at increased risk of extreme preterm birth. The intrauterine fetal death rates were unchanged. Among births at 22 weeks, the neonatal mortality tended to decrease 96 vs. 76 percent of live births (p = 0,05), and the 2-year survival tended to increase 4 vs 24 percent (p = 0,05). At 23 weeks, the neonatal mortality decreased 56 vs 27 percent of live births (p = 0,01), and the 2-year survival increased 42 vs 64 percent (p = 0,03). In contrast, the morbidity and cognitive disability at 2 years\' corrected age were unchanged. Our results were in accordance with previous reports where no substantial improvement in cognitive functions are reported among infants born at GA <24 weeks since the 1990s. They highlight the importance of comprehensive ethical considerations before active interventions at threatening preterm birth < 24 weeks.

Given the complex ethical and emotional nature of births during the periviable period for both health care providers and families, this investigation sought to identify strategies for improved counseling of pregnant patients facing preterm birth at the cusp of viability at a tertiary care center in Hawai\'i. As part of a larger quality improvement project on periviability counseling, 10 patients were interviewed during either individual or small focus groups using a progression of hypothetical scenarios. Interviews were analyzed independently by 3 investigators to identify themes of patient experience and potential areas for improvement when counseling patients who are carrying periviable pregnancies. Several common themes emerged from the interviews. Patients expressed the desire for more information throughout the process delivered in a jargon-free manner with unified messaging from the medical teams, and emotional support. These findings add to a limited body of literature which addresses patient perceptions of interactions with health care providers in the face of uncertainty, particularly in a Pacific Islander population. The authors recommend increasing provider training and developing a more structured process to counsel pregnant women facing periviable pregnancy loss to improve the patient experience.

OBJECTIVE: This study aims to examine the perspectives of neonatologists in Israel regarding resuscitation of preterm infants born at 22-24 weeks gestation and their consideration of parental preferences. The factors that influence physicians\' decisions on the verge of viability were investigated, and the extent to which their decisions align with the national clinical guidelines were determined.
METHODS: Descriptive and correlative study using a 47-questions online questionnaire.
RESULTS: 90 (71%) of 127 active neonatologists in Israel responded. 74%, 50% and 16% of the respondents believed that resuscitation and full treatment at birth are against the best interests of infants born at 22, 23 and 24 weeks gestation, respectively. Respondents\' decisions regarding resuscitation of extremely preterm infants showed significant variation and were consistently in disagreement with either the national clinical guidelines or the perception of what is in the best interest of these newborns. Gender, experience, country of birth and the level of religiosity were all associated with respondents\' preferences regarding treatment decisions. Personal values and concerns about legal issues were also believed to affect decision-making.
CONCLUSIONS: Significant variation was observed among Israeli neonatologists regarding delivery room management of extremely premature infants born at 22-24 weeks gestation, usually with a notable emphasis on respecting parents\' wishes. The current national guidelines do not fully encompass the wide range of approaches. The country\'s guidelines should reflect the existing range of opinions, possibly through a broad survey of caregivers before setting the guidelines and recommendations.

Counseling of pregnancies complicated by pre- and periviable premature rupture of membranes to reach shared decision-making is challenging, and the current limited evidence hampers the robustness of the information provided. This study aimed to elucidate the rate of obstetrical and neonatal outcomes after expectant management for premature rupture of membranes occurring before or at the limit of viability.
Medline, Embase, CINAHL, and Web of Science databases were searched electronically up to September 2023.
Our study included both prospective and retrospective studies of singleton pregnancies with premature rupture of membranes before and at the limit of viability (ie, occurring between 14 0/7 and 24 6/7 weeks of gestation).
Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for cohort studies. Moreover, our study used meta-analyses of proportions to combine data and reported pooled proportions. Given the clinical heterogeneity, a random-effects model was used to compute the pooled data analyses. This study was registered with the International Prospective Register of Systematic Reviews database (registration number: CRD42022368029).
The pooled proportion of termination of pregnancy was 32.3%. After the exclusion of cases of termination of pregnancy, the rate of spontaneous miscarriage or fetal demise was 20.1%, whereas the rate of live birth was 65.9%. The mean gestational age at delivery among the live-born cases was 27.3 weeks, and the mean latency between premature rupture of membranes and delivery was 39.4 days. The pooled proportion of cesarean deliveries was 47.9% of the live-born cases. Oligohydramnios occurred in 47.1% of cases. Chorioamnionitis occurred in 33.4% of cases, endometritis in 7.0%, placental abruption in 9.2%, and postpartum hemorrhage in 5.3%. Hysterectomy was necessary in 1.2% of cases. Maternal sepsis occurred in 1.5% of cases, whereas no maternal death was reported in the included studies. When focusing on neonatal outcomes, the mean birthweight was 1022.8 g in live-born cases. The neonatal intensive care unit admission rate was 86.3%, respiratory distress syndrome was diagnosed in 66.5% of cases, pulmonary hypoplasia or dysplasia was diagnosed in 24.0% of cases, and persistent pulmonary hypertension was diagnosed in 40.9% of cases. Of the surviving neonates, the other neonatal complications included necrotizing enterocolitis in 11.1%, retinopathy of prematurity in 27.1%, and intraventricular hemorrhage in 17.5%. Neonatal sepsis occurred in 30.2% of cases, and the overall neonatal mortality was 23.9%. The long-term follow-up at 2 to 4 years was normal in 74.1% of the available cases.
Premature rupture of membranes before or at the limit of viability was associated with a great burden of both obstetrical and neonatal complications, with an impaired long-term follow-up at 2 to 4 years in almost 30% of cases, representing a clinical challenge for both counseling and management. Our data are useful when initially approaching such patients to offer the most comprehensive possible scenario on short- and long-term outcomes of this condition and to help parents in shared decision-making. El resumen está disponible en Español al final del artículo.

暂无摘要。

In June 2022, the Dobbs v. Jackson Women\'s Health Organization Supreme Court decision ended the constitutional right to the professional practice of abortion throughout the United States. The removal of the constitutional right to abortion has significantly altered the practice of obstetricians and gynecologists across the US. It potentially increases risks to pregnant patients, leads to profound changes in how physicians can provide care, especially in states with strict bans or gestational limits to abortion, and has introduced personal challenges, including moral distress and injury as well as legal risks for patients and clinicians alike. The professional responsibility model is based on the ethical concept of medicine as a profession and has been influential in shaping medical ethics in the field of obstetrics and gynecology. It provides the framework for the importance of ethical and professional conduct in obstetrics and gynecology. Viability marks a stage where the fetus is a patient with a claim to access to medical care. By allowing unrestricted abortions past this stage without adequate justifications, such as those concerning the life and health of the pregnant individual, or in instances of serious fetal anomalies, the states may not be upholding the equitable ethical consideration owed to the fetus as a patient. Using the professional responsibility model, we emphasize the need for nuanced, evidence-based policies that allow abortion management prior to viability without restrictions and allow abortion after viability to protect the pregnant patient\'s life and health, as well as permitting abortion for serious fetal anomalies.

Restrictive abortion laws have impacts reaching far beyond the immediate sphere of reproductive health, with cascading effects on clinical and ethical aspects of neonatal care, as well as perinatal palliative care. These laws have the potential to alter how families and clinicians navigate prenatal and postnatal medical decisions after a complex fetal diagnosis is made. We present a hypothetical case to explore the nexus of abortion care and perinatal care of fetuses and infants with life-limiting conditions. We will highlight the potential impacts of limited abortion access on families anticipating the birth of these infants. We will also examine the legally and morally fraught gray zone of gestational viability where both abortion and resuscitation of live-born infants can potentially occur, per parental discretion. These scenarios are inexorably impacted by the rapidly changing legal landscape in the U.S., and highlight difficult ethical dilemmas which clinicians may increasingly need to navigate.