Perinatal care at an extremely low gestational age (22-25 weeks). An Italian approach: the "Carta di Firenze"

Guidelines on life or death strategies in extremely preterm infants have been formulated in various countries worldwide. The general agreement is not to initiate resuscitation in neonates when gestational age is less than or equal to 22 weeks, and intensive care is assured for infants of 25 weeks and over; in the middle there is a sort of “grey zone”. To provide helpful suggestions for initial management of threatened birth in infants at a gestational age of 25 completed weeks or less, a working group in Florence recently reviewed existing studies on survival and morbidity rates, international guidelines and practice recommendations. A consensus document was drawn up, and this was evaluated by several scientific societies (Italian Paediatric Society (SIP), Italian societies of obstetricians and gynaecologists (AGUI, AOGOI), Italian Society of Legal Medicine (SIMLA), Italian Society of Perinatal Medicine (SIMP), Italian Society of Anaesthesiologists (SIARTI), and the Italian Society of Paediatric Anaesthesia (SARNePI), and is currently being examined by the Italian National Bioethical Committee. The issues addressed include: suggestions arising from the need to guarantee mothers and neonates adequate assistance solely for safeguarding them against useless, painful, or inefficacious treatments resulting in futile treatment; suggestions for treatment stratified per gestational age in weeks (considered by the entire scientific world as the most efficacious measure of maturity of the fetus/neonate), while leaving room for deviations in specific cases at the discretion of the attending doctors and in compliance with the parents' will (as per Italian Legislation regarding late pregnancy terminations [Law 194/1978] that forces clinicians to plan either palliative or intensive care for the fetus/neonate after a postnatal evaluation); parents' desires are paramount in borderline cases and must be complied with if medically acceptable generally aggressive management is recommended at or after 25 weeks and is not suggested at or under 22 weeks. Decisions must be made on an individual level in the grey zone (23–24 weeks), although aggressive management of the mother and fetus/neonate is not recommended the attending clinician's main duty is to provide honest, updated and adequate information for the parents. Our document offers an overview of different positions that may be helpful for clinicians and parents. It also provides the basis for a debate—which is necessary in Italy, where any discussion about end‐of‐life decisions, particularly in infancy and childhood, is still controversial.