Improving perinatal regionalization by predicting neonatal intensive care requirements of preterm infants: an EPIPAGE-based cohort study.

OBJECTIVE: Perinatal regionalization has been organized into 3 ascending levels of care, fitting increasing degrees of pathology. Current recommendations specify that very premature infants be referred prenatally to level III facilities, yet not all very preterm neonates require level III intensive care. The objective of our study was to determine the antenatal factors that, in association with gestational age, predict the need for neonatal intensive care in preterm infants, to match the size of birth with the level of care required.
METHODS: Data were analyzed from a cohort of very preterm infants born in nine French regions in 1997. We defined the need for neonatal intensive care as follows: (1) the requirement for specialized management (mechanical ventilation for >48 hours, high frequency oscillation, or inhaled nitric oxide) or (2) poor outcome (transfer to a level III facility within the first 2 days of life or early neonatal death). Triplet pregnancies and pregnancies marked by fetal malformations or intensive care requirements for the mother before delivery were excluded.
RESULTS: We focused our study on 1262 neonates aged 30, 31 and 32 weeks' gestation, where the need for intensive care was 42.8%, 33.2%, and 22.8%, respectively. Multivariate analysis showed that the risk factors for intensive care requirement with low gestational age were twin pregnancies, maternal hypertension, antepartum hemorrhage, infection, and male gender. Antenatal steroid therapy and premature rupture of membranes were protective factors against intensive care requirement.
CONCLUSION: Infants <31 weeks' gestation should be referred to level III facilities. From 31 weeks' gestation, some infants can be safely handled in level IIb facilities. However, the quality of perinatal regionalization may only be fully assessed by long-term follow-up.