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Place: England; OBJECTIVE: Many extremely preterm neonates die in the delivery room (DR) after decisions to withhold or withdraw life-sustaining treatments or after failed resuscitation. Specific palliative care is then recommended but sparse data exist about the actual management of these dying babies. The objective of this study was to describe the clinical course and management of neonates born between 22 and 26 weeks of gestation who died in the DR in France. DESIGN, SETTING, PATIENTS: Prospective study including neonates, who were liveborn between 22(+0) and 26(+6) weeks of gestation and died in the DR in 2011, among infants included in the EPIPAGE-2 study at the 18 centres participating in this substudy of extremely preterm neonates. Data were collected by a questionnaire completed by the professional caring for each baby. RESULTS: The study included 73 children, with a median (IQR) gestational age of 24 (23-24) weeks. Median (IQR) duration of life was 53 (20-82) min. All but one were both wrapped and warmed. Pain was assessed for 72%, although without using any scale. Gasping was described for 66%. Comfort medications were administered to 35 children (50%), significantly more frequently to babies with gasping (p=0.001). Mother-child contact was reported for 78%, and psychological support offered to parents of 92%. CONCLUSIONS: Non-pharmacological comfort care and parental support were routinely given. Comfort medication was given much more frequently than previously reported in other DRs. These data should encourage work on the indications for comfort medication and the interpretation of gasping.

Resume En reanimation neonatale, la prise des decisions de limitation ou d’arret de traitements, et leur mise en œuvre, se sont considerablement modifiees au cours des dernieres annees, notamment du fait de l’evolution des lois. L’amelioration la plus importante concerne la loyaute de l’information donnee aux parents et la prise en compte de leur point de vue. Rechercher le meilleur interet de l’enfant constitue une obligation permanente pour guider les decisions medicales. Le plus souvent l’obstination therapeutique caracterisant la reanimation est raisonnable, car le benefice previsible en est important (survie sans lourdes sequelles), et la charge correspondante (souffrances), moderee du fait d’un sejour en reanimation bref. Parfois elle est, ou devient deraisonnable au cours de l’evolution, car le benefice est tres incertain, et la charge tres lourde (souffrances majeures du fait d’un sejour en reanimation long et de traitements invasifs), obligeant a une re-orientation des soins vers une approche palliative. Il faut s’efforcer de prendre ces decisions difficiles en partenariat avec les parents. La loi precise les autres conditions de ces prises de decision de limitation ou d’arret des traitements. Dans la grande majorite des cas, ces conditions peuvent etre respectees, dans l’interet des patients. Mais, notamment chez le nouveau-ne a terme, il persiste de rares situations cliniques qui, a notre sens, ne peuvent trouver de solution conforme a la fois au meilleur interet de l’enfant, a l’ethique et a la loi. Il nous semble qu’il faille alors donner la primaute aux deux premiers elements auxquels s’ajoute la prise en compte du point de vue des parents. En revanche un respect particulierement strict de la loi, amenant notamment a des arrets d’hydratation–alimentation, ne nous apparait respecter ni le meilleur interet de l’enfant, ni l’ethique, puisque ces arrets ne respectent pas a notre sens les criteres de bienfaisance et de non malfaisance. Aux limites de la viabilite, il est souvent souhaitable de prendre avec les futurs parents des decisions prenatales concernant l’attitude a adopter en salle de naissance. En cas de pronostic tres defavorable, on peut prevoir d’adopter une approche palliative menant au deces dans le respect de l’ethique et de la loi.

Twin-to-twin transfusion syndrome (TTTS) is due to unbalanced inter-twin bloodflow through placental vascular anastomoses. We present a TTTS case treated with fetoscopic laser photocoagulation (FLP) that was complicated by perinatal meconium peritonitis in both twins. Ten weeks following laser treatment, the two fetuses showed intra-abdominal hyperechogenicity and ascites. After birth, the two newborns were surgically managed for peritonitis. We discuss the pathogenesis of this double insult. The present case highlights the role of end-circulation bowel thrombi as the potential cause of subsequent intestinal perforation.