Association between gestational age and severe maternal morbidity and mortality of preterm cesarean delivery: a population-based cohort study

Delivery at an inadequate level of maternal care is associated with severe maternal morbidity

BACKGROUND

Implementing levels of maternal care is one strategy proposed to reduce maternal morbidity and mortality. The levels of maternal care framework outline individual medical and obstetrical comorbidities, along with hospital resources required for individuals with these different comorbidities to deliver safely. The overall goal is to match individuals to hospitals so that all birthing people get appropriate resources and personnel during delivery to reduce maternal morbidity.

OBJECTIVE

This study examined the association between delivery in a hospital with an inappropriate level of maternal care and the risk of experiencing severe maternal morbidity.

STUDY DESIGN

The 40 birthing hospitals in Massachusetts were surveyed using the Centers for Disease Control and Prevention's Levels of Care Assessment Tool. We linked individual delivery hospitalizations from the Massachusetts Pregnancy to Early Life Longitudinal Data System to hospital-level data from the Levels of Care Assessment Tool surveys. Level of maternal care guidelines were used to outline 16 high-risk conditions warranting delivery at hospitals with resources beyond those considered basic (level I) obstetrical care. We then used the Levels of Care Assessment Tool assigned levels to determine if delivery occurred at a hospital that had the resources to meet an individual's needs (ie, if a patient received risk-appropriate care). We conducted our analyses in 2 stages. First, multivariable logistic regression models predicted if an individual delivered in a hospital that did not have the resources for their risk condition. The main explanatory variable of interest was if the hospital self-assessed their level of maternal care to be higher than the Levels of Care Assessment Tool assigned level. We then used logistic regression to examine the association between delivery at an inappropriate level hospital and the presence of severe maternal morbidity at delivery.

RESULTS

Among 64,441 deliveries in Massachusetts from January 1 to December 31, 2019, 33.2% (21,415/64,441) had 1 or more of the 16 high-risk conditions that require delivery at a center designated as a level I or higher. Of the 21,415 individuals with a high-risk condition, 13% (2793/21,415), equating to 4% (2793/64,441) of the entire sample, delivered at an inappropriate level of maternal care. Birthing individuals with high-risk conditions who delivered at a hospital with an inappropriate level had elevated odds (adjusted odds ratio, 3.34; 95% confidence interval, 2.24-4.96) of experiencing severe maternal morbidity after adjusting for patient comorbidities, demographics, average hospital severe maternal morbidity rate, hospital level of maternal care, and geographic region.

CONCLUSION

Birthing people who delivered in a hospital with risk-inappropriate resources were substantially more likely to experience severe maternal morbidity. Delivery in a hospital with a discrepancy in their self-assessment and the Levels of Care Assessment Tool assigned level substantially predicted delivery in a hospital with an inappropriate level of maternal care, suggesting inadequate knowledge of hospitals' resources and capabilities. Our data demonstrate the potential for the levels of maternal care paradigm to decrease severe maternal morbidity while highlighting the need for robust implementation and education to ensure everyone receives risk-appropriate care.

The association between gestational age and maternal adverse outcomes in patients undergoing trial of labor after cesarean

BACKGROUND

Although successful trial of labor after cesarean (TOLAC) resulting in vaginal birth after cesarean (VBAC) can lead to improved maternal and neonatal outcomes, an unsuccessful TOLAC is associated with increased risk of uterine rupture, higher blood loss, and increased risk of infection. Data remain limited in terms of whether differences in gestational age of patients who attempt TOLAC affect maternal morbidity. The aim of this study was to examine the association between gestational age and maternal adverse outcomes in women undergoing trial of labor after cesarean.

METHODS

This population-based cross-sectional study used birth data from the U.S. National Vital Statistics from 2014 to 2018. Women with liveborn singleton gestation who underwent TOLAC at 23-41 weeks' gestation were included in the analytic population. The primary outcome was a composite of maternal adverse outcomes: admission to the Intensive Care Unit, blood transfusion, uterine rupture, or unplanned hysterectomy. Secondary outcomes were individual measures within the primary composite outcome. Outcomes were compared between patients who underwent TOLAC at term (37-41 weeks gestational age) and those who underwent TOLAC at preterm (23-36 weeks gestational age). Multivariable analyses were adjusted for demographic and obstetric differences between the two groups.

RESULTS

455,284 patients met inclusion criteria for the study; 39,589 (8.7%) were at a preterm gestational age (GA) and 415,695 (91.3%) were at a term GA. The overall composite maternal adverse outcome was significantly higher for patients undergoing TOLAC at preterm GA (12.0 per 1000 live births) compared to term GA (8.0 per 1000 live births; aRR=1.42; 95% CI: 1.29-1.56). Among individual conditions within the primary composite outcome, preterm gestational age was associated with increased risk of admission to the Intensive Care Unit, blood transfusion, and unplanned hysterectomy.

CONCLUSIONS

In patients who underwent TOLAC, preterm gestational age was associated with increased risk of adverse maternal outcomes.

The Ethics and Practice of Periviability Care

Since the 1960s, the gestational age at which premature infants typically survive has decreased by approximately one week per decade [...].

Cesarean delivery was associated with low morbidity in very low birth weight infants: A retrospective cohort study

To estimate the relationship among the cesarean delivery (CD), mortality and morbidity in very low birth weight (VLBW) infants weighing less than 1500 g. This retrospective cohort study enrolled 242 VLBW infants delivered between the 24 to 31week of gestation from 2015 to 2021. We compared CD with vaginal delivery (VD). The primary outcome was a composite neonatal morbidity including bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, late-onset sepsis and retinopathy of prematurity. The secondary outcome included mortality within 28 days. A multivariate logistic regression was used and adjusted for birthweight, twin pregnancy and antenatal steroids intake. The overall CD rate was 80.6%. Compared with VD, a significantly lower composite neonatal morbidity was associated with CD (adjusted odds ratio, 0.33, 95% confidence interval, 0.12-0.90, P = .031). The relationship between CD and neonatal morbidity disappeared when the VLBW infants were stratified according to the gestational age. No significant difference was observed between the VD and CD cohorts regarding mortality. Compared with VD, CD was associated with a lower morbidity in VLBW infants. Further studies are required to clarify how this association is influenced by gestational age.

Extremely premature birth bioethical decision-making supported by dialogics and pragmatism

Moral values in healthcare range widely between interest groups and are principally subjective. Disagreements diminish dialogue and marginalize alternative viewpoints. Extremely premature births exemplify how discord becomes unproductive when conflicts of interest, cultural misunderstanding, constrained evidence review, and peculiar hierarchy compete without the balance of objective standards of reason. Accepting uncertainty, distributing risk fairly, and humbly acknowledging therapeutic limits are honorable traits, not relativism, and especially crucial in our world of constrained resources. We think dialogics engender a mutual understanding that: i) transitions beliefs beyond bias, ii) moves conflict toward pragmatism (i.e., the truth of any position is verified by subsequent experience), and iii) recognizes value pluralism (i.e., human values are irreducibly diverse, conflicting, and ultimately incommensurable). This article provides a clear and useful Point-Counterpoint of extreme prematurity controversies, an objective neurodevelopmental outcomes table, and a dialogics exemplar to cultivate shared empathetic comprehension, not to create sides from which to choose. It is our goal to bridge the understanding gap within and between physicians and bioethicists. Dialogics accept competing relational interests as human nature, recognizing that ultimate solutions satisfactory to all are illusory, because every choice has downside. Nurturing a collective consciousness via dialogics and pragmatism is congenial to integrating objective evidence review and subjective moral-cultural sentiments, and is that rarest of ethical constructs, a means and an end.

Substance-related diagnosis type predicts the likelihood and co-occurrence of preterm and cesarean delivery

This article aimed to evaluate whether a substance-related diagnosis (SRD; i.e., alcohol, opioids, cannabis, stimulants, nicotine) predicts the likelihood and co-occurrence of preterm (20-37 weeks' gestation) and cesarean delivery.

This study reviewed electronic health record data on women (aged 18-44 years) who delivered a single live or stillbirth at ≥ 20 weeks of gestation from 2012 to 2019. Women with and without an SRD were matched on key demographic characteristics at a 1:1 ratio. Adjusting for covariates, odds ratios and 95% confidence intervals were calculated.

Of the 19,346 deliveries, a matched cohort of 2,158 deliveries was identified. Of these, 1,079 (50%) had an SRD, 280 (13%) had a preterm delivery, 833 (39%) had a cesarean delivery, and 166 (8%) had a co-occurring preterm and cesarean delivery. An SRD was significantly associated with preterm and cesarean delivery (AOR = 1.84 [95% CI, 1.41-2.39], p-value= <0.0001; AOR = 1.51 [95% CI, 1.23-1.85], p-value= <0.0001). An alcohol-related diagnosis (AOR = 1.82 [95% CI, 1.01-3.28], p-value= 0.0471), opioid-related diagnosis (AOR = 1.94 [95% CI, 1.26-2.98], p-value= 0.0027), stimulant-related diagnosis (AOR = 1.65 [95% CI, 1.11-2.45], p-value= 0.0142), and nicotine-related diagnosis (AOR = 1.54 [95% CI, 1.05-2.26], p-value= 0.0278) were associated with co-occurring preterm and cesarean delivery.

Pregnant women with an SRD experienced disproportionally higher odds of preterm and cesarean delivery compared to pregnant women without an SRD. Substance-type predicts the type of delivery outcome. An SRD in pregnant women should be identified early to reduce potential harm through intervention and treatment.

Risk Factors for Adverse Maternal Outcomes following Expectantly Managed Preterm Prelabor Rupture of Membranes

OBJECTIVE

We sought to characterize the incidence and risk factors associated with developing maternal morbidity following preterm prelabor rupture of membranes.

STUDY DESIGN

Retrospective case-control study of patients with preterm prelabor rupture of membranes at a single institution from 2013 to 2019 admitted at ≥23 weeks gestational age. The primary outcome was a composite of maternal morbidity which included: death, sepsis, intensive care unit (ICU) admission, acute kidney injury, postpartum dilation and curettage, postpartum hysterectomy, venous thromboembolism, postpartum hemorrhage, postpartum wound complication, postpartum endometritis, pelvic abscess, postpartum pneumonia, readmission, and/or need for blood transfusion were compared with patients without above morbidities. Severe morbidity was defined as: death, ICU admission, venous thromboembolism, acute kidney injury, postpartum hysterectomy, sepsis, and/or transfusion >2 units. Demographics, antenatal, and delivery characteristics were compared between patients with and without maternal morbidity. Bivariate statistics and regression models were used to compare outcomes and calculate adjusted odd ratios.

RESULTS

Of 361 included patients, 64 patients (17.7%) experienced maternal morbidity and nine (2.5%) had severe morbidity. Patients who experienced maternal morbidity were significantly (p < 0.05) more likely to be older, have private insurance, have BMI ≥40, have chorioamnionitis at delivery, and undergo cesarean or operative vaginal delivery when compared with patients who did not experience morbidity. After controlling for confounders, cesarean delivery (aOR 2.38, 95% CI[1.30,4.39]), body mass index ≥40 at admission (aOR 2.54, 95% CI[1.12,5.79]), private insurance (aOR 3.08, 95% CI[1.54,6.16]), and tobacco use (aOR 3.43, 95% CI[1.58,7.48]) were associated with increased odds of maternal morbidity.

CONCLUSION

In this cohort, maternal morbidity occurred in 17.7% of patients with preterm prelabor rupture of membranes. Private insurance, body mass index ≥40, tobacco use, and cesarean delivery were associated with higher odds of morbidity. These data can be used in counseling and to advocate for smoking cessation.

KEY POINTS

· 17.7% of patients with PPROM experienced maternal morbidity.. · BMI ≥40 was associated with higher odds of maternal morbidity.. · Tobacco use and cesarean delivery were associated with higher odds of maternal morbidity..

Benefits of the «en caul» technique for extremely preterm breech vaginal delivery

INTRODUCTION

The "en caul" technique, i.e. delivery with intact membranes, may reduce the risk of obstetric trauma in vaginal breech delivery of extreme preterm infants. We aimed at comparing perinatal mortality and morbidity among extremely preterm breech vaginal deliveries between infants delivered "en caul" and those with "ruptured membranes".

MATERIAL AND METHODS

We performed a fourteen-year retrospective study in a tertiary university center. All vaginal deliveries of singleton breech live infants with an antenatal decision of active resuscitation between 24 weeks and 27⁺⁶ weeks were included. Perinatal outcomes were compared between the "en caul" group, with intact membranes at the onset of pushing efforts and the "ruptured membranes" group, with ruptured membranes at the onset of pushing efforts. The primary outcome was perinatal mortality defined by intrapartum or neonatal death. The secondary outcomes were fetal extraction difficulties, arterial pH and 5 min Apgar score.

RESULTS

We included 52 infants in the "en caul" group and 71 in the "ruptured membranes" group. The perinatal mortality rate did not differ between the two groups (19.2% in the "en caul" group versus 28.2% in the "ruptured membranes" group, p = 0.25). The mean arterial pH at birth was higher in the « en caul » group (7.32 ± 0.1 vs 7.24 ± 0.1, p = 0.001). There were no differences between the groups for fetal extraction difficulties, especially fetal head entrapment (9.6% versus 9.9%).

CONCLUSION

Even though the "en caul" technique does not seem to decrease the perinatal mortality rate, it remains a simple technique, which could improve neonatal morbidity.

Is vaginal delivery of a fetus in breech presentation at an extremely preterm gestational age associated with an increased risk of neonatal death? A comparative study

BACKGROUND

The effect on neonatal mortality of mode of delivery of a fetus in breech presentation at an extremely preterm gestational age remains controversial.

OBJECTIVE

To compare mortality associated with planned vaginal delivery (PVD) of fetuses in breech presentation with that of fetuses in breech presentation with a planned cesarean delivery (PCD).

MATERIAL AND METHODS

Retrospective study reviewing records over a 19-year period in a level 3 university referral center of singleton infants born between 25+0 and 27+6 weeks of gestation, alive on arrival in the delivery room, and weighing at least 500 grams at birth. Infants in the first group were in breech presentation with PVD and the second in breech presentation with PCD. The principal endpoint was neonatal death.

RESULTS

During the study period, we observed 113 breech presentations with PVD, and 80 breech presentations with PCD. Although not significant after adjustment, neonatal mortality in the breech PVD group was more than twice that of the breech PCD group (19.5 vs 7.8%, P = 0.031, ORa = 2.6, 95% CI 0.8-9.3, NNT = 8). This higher neonatal mortality in the breech PVD group was exclusively associated with a higher risk of death in the delivery room (12.4 vs 0.0% P = 0.001, OR not calculable, NNT = 8). In these extremely preterm breech presentations with PVD, neonatal mortality in the delivery room was associated with entrapment of the aftercoming head, cord prolapse, and a short duration of labor.

CONCLUSION

For deliveries between 25+0 and 27+6 weeks' gestation, vaginal delivery in breech presentation is associated with a higher risk of death in the delivery room.

Correlates of alcohol and other substance use and severe maternal morbidity

BACKGROUND

Pregnant women with a substance-related diagnosis, such as alcohol use disorder, are a vulnerable population who may be experiencing disproportionate rates of severe maternal morbidity, such as hemorrhage and eclampsia, compared to pregnant women without a substance-related diagnosis.

METHODS

This retrospective cross-sectional study reviewed electronic health record data on women (ages 18-44 years) who delivered a single live or stillbirth at ≥ 20 weeks of gestation from March 1^st , 2016-August 30^th , 2019. Women with and without a substance-related diagnosis were matched on key demographic characteristics such as age at a 1:1 ratio. Adjusting for these covariates, odds ratios and 95% confidence intervals were calculated.

RESULTS

There were a total of 10,125 deliveries that met the eligibility criteria for this study. In the matched cohort of 1,346 deliveries, 673 (50.0%) had a substance-related diagnosis and 94 (7.0%) had severe maternal morbidity. The most common indicators in those with a substance-related diagnosis included hysterectomy (17.7%), eclampsia (15.8%), air and thrombotic embolism (11.1%), and conversion of cardiac rhythm (11.1%). Having a substance-related diagnosis was associated with severe maternal morbidity (adjusted odds ratio = 1.81 [95% CI, 1.14-2.88], p-value = 0.0126). In the independent matched cohorts by substance type, an alcohol-related diagnosis was significantly associated with severe maternal morbidity (adjusted odds ratio = 3.07 [95% CI, 1.58-5.95], p-value = 0.0009), the patterns for stimulant- and nicotine-related diagnoses were not as well resolved with SMM, and opioid- and cannabis-related diagnoses were not associated with SMM.

CONCLUSION

Our data showed that an alcohol-related diagnosis had the lowest prevalence and the highest odds of severe maternal morbidity compared to any other substance assessed in this study. The results from this study reinforce the need to identify an alcohol related-diagnosis in pregnant women early to minimize potential harm through intervention and treatment.

Severe maternal morbidity in preterm cesarean delivery: A systematic review and meta-analysis

OBJECTIVE

More than half of extremely preterm infants are delivered by cesarean section. Few data are available about severe maternal morbidity (SMM) of these extremely preterm cesarean. The objective was to determine whether gestational age under 26 weeks of gestation (weeks) was associated with an increased risk of SMM compared with gestational age between 26 and 34 weeks in women having a cesarean delivery.

MATERIAL AND METHODS

We searched MEDLINE, ISI Web of Science, the Cochrane Database, PROSPERO, and ClinicalTrials.gov on January 31, 2020. The search strategy clustered terms describing SMM and preterm cesarean delivery. No restrictions on language, publication status, and study design were applied. Abstracts were included if there was sufficient information to assess study quality. The authors of all identified studies were contacted to request for aggregated data. Relative risks (RR) were calculated using the inverse variance method. The primary outcome was SMM as defined in each study. We analyzed data on preterm cesarean deliveries between 22 and 34 weeks. The protocol was registered in PROSPERO (registration: CRD42019128644).

RESULTS

Six studies involving 45,572 women (3,440 delivering < 26 weeks; 42,132 delivering between 26 and 34 weeks) were included. SMM occurred in 607 women (17.6 %) < 26 weeks and 4,483 women (10.6 %) between 26 and 34 weeks. Gestational age < 26 weeks was associated with an increased risk of SMM (RR, 1.65; 95 % CI [Confidence Interval], 1.52-1.78; I² = 40 %). Gestational age < 26 weeks remained associated with SMM in the subgroup analyses depending on the type of the study (prospective or retrospective), country of the study (European or non-European), and high quality of the study. A sensitivity analysis showed that gestational age < 25 weeks was also associated with SMM in preterm cesarean delivery (RR, 1.66; 95 % CI, 1.50-1.83; I² = 3%).

CONCLUSIONS

Gestational age < 26 weeks was associated with an increased risk of SMM in women having a preterm cesarean delivery. Obstetricians and neonatologists should be aware of the increased risk of SMM in cesarean.

Maternal outcomes of cesarean delivery performed at early gestational ages: a systematic review and meta-analysis

OBJECTIVE

This study aimed to report maternal outcomes of preterm (<34 weeks of gestation) cesarean delivery.

DATA SOURCES

Medline, Embase, and ClinicalTrials.gov databases were searched electronically on September 1, 2020, utilizing combinations of the relevant medical subject heading terms, key words, and word variants for "cesarean delivery" and "outcome."

STUDY ELIGIBILITY CRITERIA

We included only studies reporting maternal outcomes of cesarean delivery performed at <34 weeks of gestation.

STUDY APPRAISAL AND SYNTHESIS METHODS

The primary outcome was a composite score of maternal surgical morbidity including maternal death, severe intrasurgical or postpartum hemorrhage, hysterectomy, need for blood transfusion, and damage to adjacent organs. Secondary outcomes were individual components of the primary outcome, need for reoperation, postsurgical infection, thromboembolism, and hysterectomy. We also performed 2 subgroup analyses considering cesarean delivery performed at <28 and <26 weeks of gestation. Meta-analyses of proportions using random effects model were used to combine data.

RESULTS

A total of 15 studies involving 8378 women undergoing cesarean delivery at <34 weeks of gestation were included in the systematic review. Composite adverse maternal outcome was reported in 16.2% of women (95% confidence interval, 15.4-17.0) undergoing a cesarean delivery before 34 weeks of gestation. Hemorrhage, either intra- or postoperative, was observed in 6.9% of cases (95% confidence interval, 6.4-7.5), whereas 6.3% (95% confidence interval, 4.2-8.7) required blood transfusion. Damage to adjacent organs complicated the primary surgery in 2.0% of women (95% confidence interval, 0.1-6.4), whereas 1.2% (95% confidence interval, 0.3-3.4) required a reoperation after cesarean delivery. Maternal death occurred in 0.1% (95% confidence interval, 0.0-1.4). In women undergoing cesarean delivery at <28 weeks of gestation, composite adverse maternal outcome complicated 22.9% of cases (95% confidence interval, 16.7-33.8) and 14.0% (95% confidence interval, 5.8-24.9) experienced hemorrhage whereas 7.7% (95% confidence interval, 4.4-11.8) required blood transfusion. Finally, when considering women undergoing cesarean delivery at <26 weeks of gestation, composite adverse maternal outcome was reported in 24.8% (95% confidence interval, 10.1-43.4), whereas the corresponding figures for hemorrhage and need for blood transfusion were 9.2% (95% confidence interval, 1.7-21.6) and 6.1% (95% confidence interval, 0.3-10.0), respectively.

CONCLUSION

Early cesarean delivery is affected by a high rate of maternal intra- and postoperative complications. The findings from systematic review can help clinicians in counseling parents when cesarean delivery is required in an early gestational age.

A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance

Background

Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors.

Objective

To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM.

Search methods

Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term “severe maternal morbidity.”

Selection criteria

Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded.

Data collection and analysis

Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed.

Main results

Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty).

Conclusions

The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-020-00123-1.

Trends in cesarean delivery rates in primipara and the associated factors

Background

Few studies have focused on cesarean delivery (CD) trends among primipara under the one-child and the two-child policies. This study aimed to explore the trends in CD rates among primipara during 1995–2019 and the associated factors with CD risk.

Methods

This study obtained clinical data on primiparous mothers and newborns from 1995 to 2019 at a large tertiary hospital in Wuhan, China. Trends in CD rates were calculated using the joinpoint regression analysis. The Chi-square tests and log-binomial regression analyses were used to evaluate the associations between primary variables and CD risk.

Results

CD rates showed a significant upward trend with an average annual percentage change (APC) of 2.2% (95% CI: 0.6, 3.8%) during the study period. In 1995–2006, the CD rates continued to increase with an APC of 7.8% (95% CI: 4.8, 10.9%). After 2006, the CD rates started to decline by an APC of − 4.1% (95% CI: − 5.5, − 2.6%). The CD rates non-significantly increased from 36.2% in 2016 to 43.2% in 2019. Moreover, the highest CD rate during 2015–2019 was observed on August 30 (59.2%) and the lowest on September 1 (29.7%). Primipara of older age and those with >3pregnancies had higher risks of CD. Furthermore, primipara who gave birth to newborns with low birth weight and macrosomia had higher risks of CD.

Conclusions

Maternal and fetal as well as social and cultural factors may contribute to the rising trend of CD rates. Effective measures should be taken to control CD under the two-child policy, especially for primipara.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03398-6.

Association between extremely preterm caesarean delivery and maternal depressive and anxious symptoms: a national population-based cohort study

OBJECTIVE

To evaluate whether caesarean delivery before 26 weeks of gestation was associated with symptoms of depression and anxiety in mothers in comparison with deliveries between 26 and 34 weeks.

DESIGN

Prospective national population-based EPIPAGE-2 cohort study.

SETTING

268 neonatology departments in France, March to December 2011.

POPULATION

Mothers who delivered between 22 and 34 weeks and whose self-reported symptoms of depression (Center for Epidemiologic Studies Depression Scale: CES-D) and anxiety (State-Trait Anxiety Inventory: STAI) were assessed at the moment of neonatal discharge.

METHODS

The association of caesarean delivery before 26 weeks with severe symptoms of depression (CES-D ≥16) and anxiety (STAI ≥45) was assessed by weighted and design-based log-linear regression model.

MAIN OUTCOME MEASURES

Severe symptoms of depression and anxiety in mothers of preterm infants.

RESULTS

Among the 2270 women completing CES-D and STAI questionnaires at the time of neonatal discharge, severe symptoms of depression occurred in 25 (65.8%) women having a caesarean before 26 weeks versus in 748 (50.6%) women having a caesarean after 26 weeks. Caesarean delivery before 26 weeks was associated with severe symptoms of depression compared with caesarean delivery after 26 weeks (adjusted relative risk [aRR] 1.42, 95% CI 1.12-1.81) adjusted to neonatal birthweight and severe neonatal morbidity among other factors. There was no evidence of an association between mode of delivery and symptoms of anxiety.

CONCLUSIONS

Mothers having a caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression and may benefit from specific preventive care.

TWEETABLE ABSTRACT

Mothers having caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression.

The Real Maternal Risks in a Pregnancy: A Structured Review to Enhance Maternal Understanding and Education

This review sought to use high-level published data sources for system knowledge translation, collaborative enhanced maternal education and understanding, and prospective maternal quality and safety care planning. The goal was to answer the following question: What are the short- and long-term maternal risks ("near misses," adverse events, severe morbidity and mortality) associated with pregnancy and childbirth? A structured analysis of the literature (systematic review, meta-analysis, observational case-control cohort), focusing on publications between 2016 and April 2019, was undertaken using the following key word search strategy: maternal, morbidity, mortality, co-morbidities (BMI, fertility, hypertension, cardiac, chronic renal disease, diabetes, mental health, stroke), preconception, antepartum, intrapartum, postpartum, "near miss," and adverse events. Only large cohort database sources with control comparison studies were accepted for inclusion because maternal mortality events are rare. Systematic review and meta-analysis were not undertaken because of the wide clinical scope and the goal of creating an education algorithm tool. For this educational tool, the results were presented in a counselling format that included a control group of common maternal morbidity from a regional maternity cohort (2017) of 54 000 births and published risk estimates for pre-conception, pregnancy-associated comorbidity, pregnancy-onset conditions, long-term maternal health associations, and maternal mortality scenarios. Because issues related to maternal comorbidities are increasing in prevalence, personalized pre-conception education on maternal pregnancy risk estimates needs to be encouraged and available to promote greater understanding. This maternal morbidity and mortality evaluation tool allows for patient-provider review and recognition of the possible leading factors associated with an increased risk of maternal morbidity: pre-conception risks (maternal age >45 years; pre-existing cardiac or hypertensive conditions) and pregnancy-obstetrical risks (gestational hypertension, preeclampsia, eclampsia; caesarean delivery, whether preterm or term; operative vaginal delivery; maternal sepsis; placenta accreta spectrum; and antepartum or postpartum hemorrhage).

Planned delivery route and outcomes of cephalic singletons born spontaneously at 24-31 weeks' gestation: The EPIPAGE-2 cohort study

INTRODUCTION

The objective of this study was to investigate the association between planned mode of delivery and neonatal outcomes with spontaneous very preterm birth among singletons in cephalic presentation.

MATERIAL AND METHODS

Etude Epidémiologique sur les Petits Ages Gestationnels 2 is a French national, prospective, population-based cohort study of preterm infants. For this study, we included women with a singleton cephalic pregnancy and spontaneous preterm labor or preterm premature rupture of membranes at 24-31 weeks' gestation. The main exposure was the planned mode of delivery (ie planned vaginal delivery or planned cesarean delivery at the initiation of labor). The primary outcome was survival at discharge and secondary outcome survival at discharge without severe morbidity. Propensity scores were used to minimize indication bias in estimating the association.

RESULTS

The study population consisted of 1008 women: 206 (20.4%) had planned cesarean delivery and 802 (79.6%) planned vaginal delivery. In all, 723 (90.2%) finally had a vaginal delivery. Overall, 187 (92.0%) and 681 (87.0%) neonates in the planned cesarean delivery and planned vaginal delivery groups were discharged alive, and 156 (77.6%) and 590 (76.3%) were discharged alive without severe morbidity. After matching on propensity score, planned cesarean delivery was not associated with survival (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 0.48-2.28) or survival without severe morbidity (aOR 0.64, 95% CI 0.36-1.16).

CONCLUSIONS

Planned cesarean delivery for cephalic presentation at 24-31 weeks' gestation after preterm labor or preterm premature rupture of membranes does not improve neonatal outcomes.

Maternal morbidity after early preterm delivery (23-28 weeks)

BACKGROUND

Previous research has focused mainly on neonatal outcomes associated with preterm and periviable delivery, but maternal outcomes with preterm delivery are less well described.

OBJECTIVE

This study aimed to determine if early preterm delivery results in an increase in maternal morbidity.

STUDY DESIGN

This is a retrospective cohort study conducted at a tertiary care center over a 5-year time period. Subjects were women identified by review of neonatal intensive care unit admission logs. Women were included if they delivered between 23 0/7 and 28 6/7 weeks' gestation and their neonate was admitted to the neonatal intensive care unit. The prevalence of maternal morbidities was assessed, including blood transfusion, maternal infection, placental abruption, postpartum depression or positive depression screen, hemorrhage, and prolonged maternal postpartum hospitalization. A composite outcome comprising blood transfusion, maternal infectious morbidity, placental abruption, and postpartum depression was developed. Outcomes for women who delivered between 23 0/7 and 25 6/7 weeks' gestation (early group) and 26 0/7 and 28 6/7 weeks' gestation (late group) were compared. Multivariate logistic regression analysis was performed to evaluate contributors to the composite morbidity, controlling for confounding.

RESULTS

A total of 82 women met the inclusion criteria: 38 in the early group and 44 in the late group. Maternal demographics were similar between the groups. The early group was significantly more likely to experience composite maternal morbidity (60.5% vs 27.3%; P=.004) and infection (42.1% vs 13.6%; P=.006). Regression analysis determined that delivery at a later gestational age was associated with lower rates of composite morbidity (odds ratio, 0.6; 95% confidence interval, 0.41-0.83).

CONCLUSION

In this study, data suggest that maternal morbidity is higher with delivery at periviable gestational ages. Composite morbidity and maternal infection were more frequent in women who delivered at less than 26 weeks' gestation. The management of women at risk for delivery at early gestational ages should include a discussion of increased maternal complications.

Lower gestational age is associated with severe maternal morbidity of preterm cesarean delivery

OBJECTIVE

To evaluate whether gestational age was associated with the severe maternal morbidity (SMM) of preterm cesarean delivery between 22 and 34 weeks of gestation (weeks).

MATERIAL AND METHODS

We performed an observational retrospective cohort study in two tertiary university hospitals in 2018. We included all mothers of preterm infants born by caesarean delivery between 22 and 34 weeks, excluding mothers with multiple births greater than two, with pregnancy terminations or stillbirths, and who died unrelated to obstetrical causes. The principal endpoint, SMM, was a composite outcome (classical uterine incision, postpartum hemorrhage defined by blood loss ≥ 500 mL, blood transfusion, any injury to adjacent organs, unplanned procedure/need for reintervention, Intensive Care Unit (ICU) stay longer than 24 h, postpartum fever, and/or death).

RESULTS

Among the 252 women, SMM occurred in 89 (35.3 %) cases. After multivariate analysis, gestational age was independently associated with SMM (adjusted Odds Ratio [aOR] 0.87; 95 % Confidence Interval [CI] 0.78-0.97). The other variables statistically associated with SMM were type of pregnancy with a negative association with twin pregnancy (aOR, 0.44; 95 % CI, 0.20-0.93) and a positive association with general anesthesia (aOR, 2.52; 95 % CI, 1.25-5.13). A sensitivity analysis was performed and found an association, at the limit of significance, between gestational age < 28 weeks and SMM (aOR, 1.80; 95 % CI, 0.99-3.27, p = 0.05).

CONCLUSION

Lower gestational age was associated with the risk of SMM for preterm caesarean delivery between 22 and 34 weeks. Obstetricians should integrate this knowledge into their shared decision-making processes with parents.

Outcomes at 18 to 22 Months of Corrected Age for Infants Born at 22 to 25 Weeks of Gestation in a Center Practicing Active Management

OBJECTIVE

To assess the outcomes in actively managed extremely preterm infants after admission to a neonatal intensive care unit.

STUDY DESIGN

Retrospective cohort of 255 infants born at 22-25 weeks of gestation between 2006 and 2015 at a single study institution. Infants were excluded for congenital anomaly, death in delivery room, or parental request for palliation (n = 7). Neurodevelopmental outcomes were analyzed for 169 of 214 survivors (78.9%) at 18-22 months of corrected age. Outcomes were evaluated using the Mann-Whitney U, χ², or Fisher exact test, where appropriate. In addition, cognitive scores of the Bayley Scales of Infant-Toddler Development (3rd edition) were assessed using generalized estimating equations.

RESULTS

Seventy infants born at 22-23 weeks of gestation (22 weeks, n = 20; 23 weeks, n = 50) and 178 infants born at 24-25 weeks of gestation (24 weeks, n = 79; 25 weeks, n = 99 infants) were included. Survival to hospital discharge of those surviving to NICU admission was 78% (55/70; 95% CI, 69%-88%) at 22-23 weeks and 89% (159/178; 95% CI, 84%-93% at 24-25 weeks; P = .02). No or mild neurodevelopmental impairment in surviving infants was 64% (29/45; 95% CI, 50%-77%) at 22-23 weeks and 76% (94/124; 95% CI, 68%-83%; P = .16) at 24-25 weeks.

CONCLUSIONS

Although survival was lower in infants born at 22-23 weeks than at 24-25 weeks of gestation, the majority of survivors in both groups had positive outcomes with no or mild neurodevelopmental impairments. Further evaluation of school performance is warranted.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Case Selection for Trial of Labour]

OBJECTIVE

The objective of this chapter is to examine on the basis of the knowledge currently available the criteria available before labour for selecting women who would be eligible for trial of vaginal delivery.

METHODOLOGY

Bibliographical research in French and English using the Medline and Cochrane databases between 1980 and 2019 and the recommendations of international societies.

RESULTS

It is recommended to offer women who wish to attempt a vaginal delivery at term a pelvimetry to decide with them on their mode of delivery (Grade C). The pelvimetric standards used at the time of the PREMODA study were anteroposterior diameter of inlet≥105mm, a transverse diameter of inlet≥120mm, a transverse interspinous diameter≥100mm. However, since there is no evidence about which pelvic measures to use, nor any evidence to set decision-making thresholds other than those set in published studies, the selected decision-making thresholds can be adjusted according to gestational age at delivery or fetal biometrics (Professional consensus). There is no argument for recommending the practice of pelvimetry in the case of delivery before 37 weeks gestational age (Professional consensus) and in the case of breech presentation discovered at the time of beginning of labour, the absence of pelvimetry alone does not contraindicate the attempt of vaginal delivery (Professional consensus). There is insufficient data to recommend the systematic use of fetal weight estimation and/or biparietal diameter measurement as acceptance criteria for a vaginal delivery attempt. In the event of a known fetal weight estimation before birth greater than 3800g, a cesarean section is to be preferred (Professional consensus). The breech presentation is not in itself a contraindication to an attempt of vaginal delivery for a small fetus for gestational age (Professional consensus). The presentation of the non-frank breech is not in itself a contraindication to an attempt of vaginal delivery (Professional consensus). In the case of premature breech delivery, current data do not allow to recommend one delivery route over another (Professional consensus). It is recommended to check the absence of hyperextension of the fetal head by ultrasound before an attempt of vaginal delivery (Professional consensus) and to prefer a cesarean section if such a position is found (Professional consensus). It is not recommended to propose a caesarean section with the sole reason of nulliparity (Grade C). The history of cesarean section is not in itself a contraindication to an attempt of vaginal delivery in the case of fetal breech presentation (Professional consensus). Premature rupture of the membranes is not in itself a contraindication to an attempt of vaginal delivery (Professional consensus).

CONCLUSION

A number of the factors analyzed in this chapter are to be incorporated into the decision-making process in order to choose with the woman whose fetus is in breech presentation the delivery route.