American Journal of
Obstetrics and Gynecology \'olume 137
Transactions of the Forty -second Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists
Fetal survival--What price Presidential address WILLIAM H. KIRKLEY, M.D. Fort
NEONATAL INTENSIVE CARE UNITS have sprung up all over the country in the last 15 to 20 years. As these centers develop in the United States, there are many physicians who are beginning to question the presentday trend of admitting all live-born infants to an Intensive Care Nursery. What we, as obstetricians and pediatricians, are striving for is a quality product. When one goes into an Intensive Care Nursery, he will almost always find a group of dedicated people who have as their goal survival of the neonate. If they receive a 300 gm infant, they are all very enthusiastic. This is their burning question: "Will this be the smallest baby who ever survived in our unit?" Their every effort is toward that accomplishment. Whether or not the infant has a congenital anomaly is secondary. No thought is given to the fact that it will probably die and the parents will have spent thousands of dollars for naught or, worse still, will have spent thousands of dollars and countless hours in anxiety only to have a less than normal child survive. Somewhere this latter possibility must be taken into consideration. We are all finally reaching the point of realizing that this country does not have unlimited funds for medical purposes and certainly our patients do not. Presented at the Forty-second Annual Meeting
South Atlantic Association of Obstetricians and Gynecologists, Atlanta, Georgia, February 3-6, 1980. Reprint requests: William H. Kirkley, M.D., 2000 South Andrews Ave., Fort Lauderdale, Florida 33316. 0002-9378/80/160873+03$00.30/0
1980 The C. V. Mosby Co.
Thus priorities must be set, and some thought must be given to economics, even though economics is a very emotional factor when priorities are being set on human life. I am very thankful that during the 1960s I never had to sit on a board that determined who would have renal dialysis and survive, realizing that the ones not selected would die. At this time I would like to summarize two an ides very briefly. The first articles is a report of 75 infants weighing 1,000 gm or less, born between 1973 and 1975. Of these infants. 40% of the survivor$ appeared normal at I to 3 years of age, and 30% had significant physical and/or mental defects. The average cost of the infant who died was $14,236 each. The average cost for the infant who survived was $40,287 each. (The cost ac· tually ranged from $10,700.00 to $106,050.) The cost for a "normal" survivor was found to be $8H.058. An additum stated that in 1977 these costs had risen 30/f. It is reasonable to assume that they have risen 60;)( today. Thus the projected cost now would be $64.4!i9 for any survivor and $140,800 for rhe "normal" child. These were hospital costs only; they did not include the charges made by the doctors involved. The second article~ deals with the status of infants of 1,000 gm or less and their survival record. The mortal· ity rate was 70%. Of the 43 survivors, !J5fi'(, had lung problems requiring later hospitalization. [f the infant had a diagnosis of chronic lung disease, 869~ had sig873
nificant lung problems the first year and 57% did the second year. Six of 43 underwent major surgery. There were seven cases of retrolental fibroplasia, with two being totally blind. Major neurological defects were present in four children and minor neurological defects were present in 16 others. Thirteen infants or :~09( had significant handicaps at age 18 months. Four had severe neurological defects. (In this study, only infants considered capable of survival were included.) In two other studies, Rush and associates. of John Radford Hospital, Oxford, England, reported a 27% survival rate of infants weighing 1,000 gm or less, and Stewart and as~ociates reported a 32% survival rate of a similar group." Prior to 1950, most neural tube defects (especially if open and leaking) were managed by "benign neglect" and death occurred rather quickly. In the 1950s a very aggressive early surgical approach was begun, with the result that most of these infants survived. 5- 7 Lorber, of the Department of Child Health of the University of Sheffield (England), has written several articles on the results of this aggressive treatment. The following are some of his quotes: "No person with severe handicaps is likely to be able to earn his living in competitive employment unless his J.Q. is at least 100." (They had very few with IQs above 100.) "With increased technical experience we could save more and more badly handicapped children without increasing the percentage of those less severely affected. Treating all babies without selection has resulted in much suffering for a great number of people in spite of the massive effort of large, dedicated teams. The cost of medical care and of special education of each severely handicapped child exceeded 50,000 pounds by the time they had reached sixteen years of age." He went on to point out the disastrous consequences to the family of such offspring. DeLong, 1 a British neurosurgeon, stated, "Large numbers of spina bifida children kept alive by early closure of the defect and more efficient treatment of the hydrocephalus are now adolescents, most of them painfully aware of their deficiencies.'' Some of us consider their presence not as a tribute to a medical achievement but as an accusation against misuse of medical power. Dr. Lorber categorizes survivors by results: In Category I, no handicap, there were four patients. In Category 2, moderate handicap, there were 20 patients. Of these, five had an IQ of 75 to 79 and the others had a higher IQ. These children had physical handicaps, such as incontinence, paraplegia, hydrocephalus, etc. In Category 3, severe handicaps and normal intelligence, there were 65 patient-s. Only two were continent, but both of these had severe paraplegia. In Category 4.
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severe handicaps, with a moderate degree of mental retardation (I Q of 61 to 79), there were 2R patients. In Category 5, profound retardation with gross phvsir,d handicaps, there were 16 patients. Lorber summarized by saying that at most 7% of those treated had less than grossly crippling disabilities and could be considered to have a quality of life conSIStent with self-respect, earning capacity, happiness. ;md even marriage. I believe this aggressive approach to neural tube defects shows what horrors well-intended medical management may produce. If I were a neurosurgeon, looking back on the results such as those just presented. I would have a great deal of guilt and depression in realizing what unfortunate and unhappy products I had produced, not to mention the millions of dollars spent on the noble experiment. I fear the thousands of unfortunate neural tube defect survivors will represent only a small percentage of the problems we create with the aggressive treatment of low-birth weight babies. The present policy of managing all cases of hvdrocephaly with the thought of survival is, in my opinion, wrong. Many leading authorities feel that hydrocephalic infants having very large heads with only 4 mrn of cortex should be delivered by cesarean section, thus obtaining a very questionable product at a greater risk to the mother. I recently saw one of these children who was markedly retarded. This child was causing severe financial and emotional burdens to his family. At times, the present concept that everything that is alive (even in utero) has a right to live at all costs, even with greater risks to the mother, bothers most of us who practice obstetrics. We are so intimidated by the hospital administration, legal profession, and, yes, many nurses that we rush all living ''things" to the nursery: The ultimate in this stupidity was the case of an anencephalic infant who was sent to the nursery and the support team was proud of the fact that they kept it alive for over 12 hours, although at a significant cost to the parents. Recently one of my partners delivered a grossly abnormal neonate by cesarean sectimt. The pediatrician immediately began to resuscitate it, even though the Apgar score was very low. Fortunately, in a few seconds he looked around very sheepishly and asked if anyone objected to his not resuscitating this baby. Knowing that prematurity is a leading cause of mental retardation, I feel very uncomfortable with the intentional termination of pregnancy at 30 to 32 weeks for a dropping estriol level or other signs of impending fetal death. If one takes the average figure in all of the American
Fetal survival-What price
articles I reviewed, one will find that about 15% of all babies of 2,000 gm or less have physical and/or mental handicaps. If one treated only I ,500 gm babies in an intensive care unit, I believe we would have a very significant decrease in mental and physical retardation in this country. The 1,000 gm neonate admitted to an intensive care nursery, loudly crying, with a good Apgar score, etc., has a far better prognosis than a l ,000 gm neonate admitted that must be on a resuscitator to survive. Whether or not the resuscitator should be used in such a case is the question. It has been pointed out that the "normal" child cannot truly be given this label until it has been in school several years, because subtle learning disabilities and social maladjustments may not be apparent until such time. Sick neonates who are admitted to a neonatal intensive care unit in a university setting have a better prognosis than those who are not. Those of us who work
outside the university have seen neonates who are not doing well and immediately improved alter being transferred to a university hospital. Therefore, the facilities available to the neonate unfortunately will influence our management and the ultimate outcome. I have not heard anyone state that we must take action to limit the tremendous costs in producing these retarded infants or that we must make any recommendations that some selection be made as to who will receive this intensive care. However, the Supreme Court upheld the rights of Dr. Kenneth Edelin to withhold care for a very low-birth weight baby. So we, as obstetricians, face a real dilemma when we deliver a baby of 1,000 gm or less or when we deliver a child who has significant congenital anomalies. This dilemma is much worse when the child has a low Apgar score at birth. In the past, many times we elected not to resuscitate these babies. At the present time, this is almost impossible. It is my feeling that it is time we address ourselves to this problem and, as a profession, consider taking a stand.
REFERENCES I. DeLong, S.: Critical review of the treatment of my-
2. 3. 4. 5.
elomeningocele, Div. Med. Child Neurol. (Suppl. 32) 16:27, 1974. De La Vega, A.: Is intensive care of newborn really worthwhile? Schweiz. Med. Wochenschr. 109:213, 1979. Franco, S.: Reduction of cerebral palsy by neonatal intensive care, Pediatr. Clin. North Am. 24:3, 1977. Kitchen, W., et al.: A longitudinal study of very lowbirthweight infants, Dev. Med. Child Neurol. 20:605, 1978. Lorber, J.: Ethical problems in the management of my-
6. 7. 8. 9.
elomeningocele and hydrocephalus, J. R. Coli. Physicians Lond. 10:47, 1975. Lorber,].: Results of treatment of myelomeningocele, Dev. Med. Child Neurol. 13:279, 1971. Lorber, J.: Spina bifida cystica: results of treatment of 270 consecutive cases with criteria for selection fi)l· the future, Arch. Dis. Child. 47:854, 1972. Pomerance, J., et al.: Cost of living for infams weighing 1,000 grams or less at birth, Pediatrics 61:908, 1978. Thompson, T., et al.: The results of intensive rare therapv for the neonate, J. Perinat. Med. 5:59, 1977.