ABSTRACT
In Chapter 16 it is shown that women with recurrent miscarriage have a higher incidence of preterm labor. In addition, uterine anomalies and cervical incompetence are two causes of recurrent pregnancy loss (RPL) that predispose to second-trimester fetal loss. Women with recurrent second-trimester fetal loss contribute disproportionately to the stillbirth rate, and second-trimester delivery of live births contributes disproportionately to the neonatal mortality rate, thus significantly increasing the overall perinatal mortality rate. However, a proactive policy of transfer in utero of high-risk pregnancies in danger of extremely preterm delivery to a tertiary perinatal centre for management by maternal-fetal medicine specialists, together with competent resuscitation at birth and prompt initiation of neonatal intensive care by neonatologists, has been found to improve survival and quality-adjusted survival for extremely low-birthweight (ELBW) infants born under 1000 g, including those born in the second trimester between 23 and 26 weeks’ gestation. Clinical protocols have been established for the management of those infants born alive at borderline viability, but continued advances made in the knowledge and technology in neonatal intensive care will result in ongoing revisions of current medicolegal and ethical guidelines. Principles behind decision-making on initiating and withdrawing intensive care will, however, remain interpersonal and intimate, respectful to the infants’ lives and their parents’ autonomy, and sensitive to the emotional concerns of parents and staff.
