Disclosures Periviable Pregnancies: Decision No financial - PowerPoint PPT Presentation

Disclosures Periviable Pregnancies: Decision • No financial disclosures related to this talk Making Under Uncertainty • Medical Advisor to Celmatix, Mindchild • Bob’s Red Mill • Father Aaron B. Caughey, MD, PhD Professor and Chair Department of Obstetrics and Gynecology Associate Dean for Women’s Health Research & Policy Oregon Health & Science University caughey@ohsu.edu Case Presentation Overview • 27 yo G1P0 at 23 2/7 wks GA presents with • What is periviable? PTL – ctxns Q3’ / cvx- 3/80/0 • What is viability? Why does it matter? • Who counsels her and about what? • Outcomes • What are the outcomes? • Mgmt • How do we counsel in this setting? • MgSo4 • Tocolysis • Decision making under uncertainty • BMZ • MOD • Fetal monitoring • Resuscitation • Expt mgmt 1

Case Presentation – 23 wks PTL Case Presentation – 22 wks PTL 38% 28% What are reasonable options? What are reasonable options? 21% 21% Expt Mgmt Expt Mgmt A. A. 22% 16% Interventions (BMZ, MgSO4, Abx, etc) Interventions (BMZ, MgSO4, Abx, etc) B. B. 14% 11% No Resuscitation No Resuscitation C. C. 6% 6% 7% 5% 3% Induction termination Induction termination 2% D. D. A&B A&B E. E. Expt Mgmt A&B A, B, & C A, B, C, & D Expt Mgmt A&B A, B, & C A, B, C, & D No Resuscitation Induction termination No Resuscitation Induction termination Interventions (BMZ, MgS... Interventions (BMZ, MgS... A, B, & C A, B, & C F. F. A, B, C, & D A, B, C, & D G. G. Case Presentation – 24 wks PTL Case Presentation – 25 wks PTL 38% 43% What are reasonable options? What are reasonable options? 30% Expt Mgmt Expt Mgmt A. A. 25% 23% Interventions (BMZ, MgSO4, Abx, etc) Interventions (BMZ, MgSO4, Abx, etc) B. B. 14% 11% No Resuscitation No Resuscitation C. C. 4% 4% Induction termination Induction termination 3% 2% 2% D. D. 1% 1% A&B A&B E. E. Expt Mgmt A&B A, B, & C A, B, C, & D Expt Mgmt A&B A, B, & C A, B, C, & D No Resuscitation Induction termination No Resuscitation Induction termination Interventions (BMZ, MgS... Interventions (BMZ, MgS... A, B, & C A, B, & C F. F. A, B, C, & D A, B, C, & D G. G. 2

Overview • What is periviable? • What is viability? Why does it matter? • What are the outcomes? • Decision making under uncertainty • How do we counsel in this setting? Roe V. Wade No Colorado “ For the stage subsequent to viability the State, in promoting its interest in the potentiality of human life, may, if it chooses, regulate, and even proscribe, abortion except where necessary, in appropriate medical judgment, for the preservation of the life or health of the mother.” Translation: After viability, states may restrict or ban abortions except “necessary No Oregon to preserve the life or health” of the woman. From Guttmacher institute 2015 3

Neonatal outcomes at 22-25 weeks Overview • What is periviable? • What is viability? • What are the outcomes? • Decision making under uncertainty • How do we counsel in this setting? Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6. Neonatal outcomes at 22-25 weeks Periviable – Long-term outcomes Moore, et al. JAMA Pediatr. 2013;167(10):967-974. Reference: Tomlinson et al. AJOG. 2010;202:529.e1-6. 4

Periviable – Long-term outcomes Periviable – Long-term outcomes Moore, et al. JAMA Pediatr. 2013;167(10):967-974. Moore, et al. JAMA Pediatr. 2013;167(10):967-974. Periviable – Long-term outcomes Impact of Long-term Outcomes Moore, et al. JAMA Pediatr. 2013;167(10):967-974. 5

Impact of Long-term Outcomes Overview • What is periviable? • What is viability? Down Syndrome • What are the outcomes? • What are the potential interventions? CP • Decision making under uncertainty Severe MR/CP • How do we counsel in this setting? MR/CP Decision Making Under Certainty Decision Making Under Uncertainty • Many of our day to day decisions • Many decisions with less certainty • What to eat? • What to eat in a foreign city? (e.g. Shanghai) • What to wear? • What to wear on a trip? • Entertainment (what to watch)? 6

Decision Making Under Uncertainty Decision Making Under Uncertainty • Examples of uncertainty • Examples of uncertainty in medicine • What to eat in a foreign city? • Effect of therapy • Will you need to eat? Very certain • Cesarean for delivery of baby – very certain • How enjoyable will the food be? Variable • Abx in labor for T of 100.4 degrees – uncertain need • How dangerous will the food be? Variable • Cerclage for a short cervix – uncertain benefit • MgSO4 for CP prophylaxis – uncertain benefit/need • What to wear on a trip? • Chemotherapy for Ovarian CA – uncertain benefit / harm • Will you need underwear? Very certain • Will you need a raincoat? Variable • How comfortable will you be (warm/cold)? Variable • How dangerous will the clothing be (exposed skin)? V Decision Making Under Uncertainty Decision Making Under Uncertainty • One approach – Rational, expected value • One approach – Rational, expected value • Think of this as lottery • Think of this as lottery • Two potential outcomes: • Two potential outcomes: • 50% chance Win - $10, 50% chance Lose – Price of lottery • 50% chance Win - $10, 50% chance Lose – Price of lottery • A fair price - $5 – who will pay $5? • A fair price - $5 – who will pay $5? • 60% chance Win - $10, 40% chance Lose – Price of lottery • 60% chance Win - $10, 40% chance Lose – Price of lottery • A fair price - $6 – who will pay $5? • A fair price - $6 – who will pay $5? • 60% chance Win - $1M, 40% chance Lose – Price of lottery • A fair price - $600,000 – who will pay $500,000? • (Isn’t this more like periviable resuscitation?) 7

Periviable – Long-term outcomes Periviable – Long-term outcomes Moore, et al. JAMA Pediatr. 2013;167(10):967-974. Moore, et al. JAMA Pediatr. 2013;167(10):967-974. 23 0/7 – 23 6/7: NICHD - To resuscitate or not - Is 23 weeks the new 24 weeks? Overview • What is periviable? • What is viability? • What are the outcomes? • Decision making under uncertainty • How do we counsel in this setting? 8

New OCC Document 23 0/7 – 23 6/7: To resuscitate or not? OCC – periviability. SMFM/ACOG, Obstet Gynecol / Am J Obstet Gynecol 11/2015 Summary Case Presentation – 23 wks PTL • Periviability • Outcomes • Interventions Did your management options change? • Should be driven by plans for resuscitation • A) Yes • Shared decision making with a focus on • B) No the unknown and long-term patient prefs • Team counseling – MFM / Neo / RN • 20% severely disabled – is that acceptable? 9

Consider Regional Approach Thank You Astoria Seaside St Helens Hermiston Pendleton Hillsboro The Dalles Gresham Enterprise Beaverton Tillamook Portland Cape Lookout La Grande Condon McMinnville Regional Hub Keizer Silverton Satellite Salem Baker City Lincoln City Albany Madras Corvallis John Day Prineville Canyon City 5 Redmond Eugene Ontario Springfield Bend Florence Vale Reedsport Burns North Bend Coos Bay Roseburg Jordan Valley Port Orford Grants Pass Bly Medford Ashland Klamath Falls Brookings Lakeview MILES Decision Making Under Uncertainty • Expected Utility Theory • Nonsatiation • Diminishing Marginal Utility 10

Decision Making Under Uncertainty Decision Making Under Uncertainty • Prospect Theory • Prospect Theory • Distortions in: • Distortions in: • Values • Values • Probabilities • Probabilities Gains domain Lottery Loss domain Airline insurance Kaiser Hayward Example Mug experiments Decision Making Under Uncertainty Decision Making Under Uncertainty • Prenatal Dx vs. Periviability Resusc. • Prenatal Dx Example • Termination vs. Nonintervention • “losing” aneuploid vs. “losing” normal fetus • Uncertainty of specificity of phenotype (DS vs. range) • Uncertainty about phenotype (What is NDD?) • Uncertainty of severity of phenotype 11