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Unger V, Gasparics Á, Nagy Z, Hernádfői M, Nagy R, Walter A, Farkas N, Szabó M, Hegyi P, Garami M, Varga P. Cesarean delivery is associated with lower neonatal mortality among breech pregnancies: a systematic review and meta-analysis of preterm deliveries ≤32 weeks of gestation. Am J Obstet Gynecol 2024:S0002-9378(24)00683-5. [PMID: 38908650 DOI: 10.1016/j.ajog.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 06/05/2024] [Accepted: 06/14/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE To investigate the association between actual and planned modes of delivery, neonatal mortality, and short-term outcomes among preterm pregnancies ≤32 weeks of gestation. DATA SOURCES A systematic literature search was conducted in 3 main databases (PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to November 16, 2022. The protocol was registered in advance in the International Prospective Register of Systematic Reviews (CRD42022377870). STUDY ELIGIBILITY CRITERIA Eligible studies examined pregnancies ≤32nd gestational week. All infants received active care, and the outcomes were reported separately by different modes of delivery. Singleton and twin pregnancies at vertex and breech presentations were included. Studies that included pregnancies complicated with preeclampsia and abruptio placentae were excluded. Primary outcomes were neonatal mortality and intraventricular hemorrhage. STUDY APPRAISAL AND SYNTHESIS METHODS Articles were selected by title, abstract, and full text, and disagreements were resolved by consensus. Random effects model-based odds ratios with corresponding 95% confidence intervals were calculated for dichotomous outcomes. Risk Of Bias In Non-randomized Studies - of Interventions-I was used to assess the risk of bias. RESULTS A total of 19 observational studies were included involving a total of 16,042 preterm infants in this systematic review and meta-analysis. Actual cesarean delivery improves survival (odds ratio, 0.62; 95% confidence interval, 0.42-0.9) and decreases the incidence of intraventricular hemorrhage (odds ratio, 0.70; confidence interval, 0.57-0.85) compared to vaginal delivery. Planned cesarean delivery does not improve the survival of very and extremely preterm infants compared to vaginal delivery (odds ratio, 0.87; 95% confidence interval, 0.53-1.44). Subset analysis found significantly lower odds of death for singleton breech preterm deliveries born by both planned (odds ratio, 0.56; 95% confidence interval, 0.32-0.98) and actual (odds ratio, 0.34; 95% confidence interval, 0.13-0.88) cesarean delivery. CONCLUSION Cesarean delivery should be the mode of delivery for preterm ≤32 weeks of gestation breech births due to the higher mortality in preterm infants born via vaginal delivery.
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Affiliation(s)
- Vivien Unger
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Pediatric Center, Csolnoky Ferenc Hospital, Veszprém, Hungary
| | - Ákos Gasparics
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary; Division of Neonatology, Pediatric Center, Semmelweis University, Budapest, Hungary
| | - Zsuzsanna Nagy
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary; Division of Neonatology, Pediatric Center, Semmelweis University, Budapest, Hungary
| | - Márk Hernádfői
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Bethesda Children's Hospital, Budapest, Hungary
| | - Rita Nagy
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Heim Pál National Pediatric Institute, Budapest, Hungary
| | - Anna Walter
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Nelli Farkas
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Miklós Szabó
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Division of Neonatology, Pediatric Center, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute for Translational Medicine, University of Pécs, Pécs, Hungary; Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Miklós Garami
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Pediatric Center, Semmelweis University, Budapest, Hungary
| | - Péter Varga
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary; Division of Neonatology, Pediatric Center, Semmelweis University, Budapest, Hungary.
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Demertzidou E, Chatzakis C, Cavoretto P, Sarafidis K, Eleftheriades M, Gerede A, Dinas K, Sotiriadis A. Effect of mode of delivery on perinatal outcome in severe preterm birth: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:471-485. [PMID: 37128165 DOI: 10.1002/uog.26241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To review the evidence on the effect of mode of delivery on perinatal outcome of fetuses born before 32 weeks' gestation. METHODS MEDLINE, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), the ClinicalTrials.gov registry and gray literature sources were searched, starting from the year 2000 to reflect contemporary practice in perinatal care. Non-randomized or randomized studies that included singleton fetuses without chromosomal abnormality or major congenital defect delivered vaginally or via Cesarean section were eligible for inclusion in the analysis. Primary outcomes were neonatal death, defined as death in the first 28 days of age, and survival to discharge. Secondary outcomes were other adverse perinatal events. The ROBINS-I tool was used to assess the risk of bias. The overall quality of evidence for the outcomes was assessed according to GRADE. Summary odds ratios (ORs) with 95% CIs were calculated, and random-effects models were used for data synthesis. Subgroup analysis was performed for delivery before 28 weeks, delivery between 28 and 32 weeks and according to fetal presentation at delivery. RESULTS A total of 27 retrospective studies (22 887 neonates) were included in the systematic review and meta-analysis, all of which reported on singleton pregnancies. Among cases born before 28 weeks, vaginal delivery significantly increased the risk of neonatal death of fetuses with any type of presentation (n = 1496) (OR 1.87 (95% CI, 1.05-3.35); I2 = 65%, very low quality of evidence) and of fetuses with breech presentation (n = 733) (OR 3.55 (95% CI, 2.42-5.21); I2 = 21%, moderate quality of evidence). The odds of survival to discharge were significantly decreased among fetuses with breech presentation delivered before 28 weeks (n = 646) (OR 0.36 (95% CI, 0.24-0.54); I2 = 21%, low quality of evidence). Among breech fetuses born between 28 and 32 weeks, vaginal delivery increased the odds of perinatal death (intrapartum and neonatal) (n = 1581) (OR 3.06 (95% CI, 1.47-6.35); I2 = 0%, high quality of evidence). In non-cephalic fetuses born between 24 and 32 weeks, vaginal delivery decreased the odds of survival to discharge (n = 1030) (OR 0.28 (95% CI, 0.19-0.40); I2 = 0%, moderate quality of evidence). No significant effect on mortality of mode of delivery was observed in cephalic fetuses at any gestational age. CONCLUSIONS This systematic review and meta-analysis suggests that vaginal delivery in severe preterm birth is associated with an increased risk of neonatal and perinatal death in breech fetuses, while no significant association was observed for cephalic fetuses. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- E Demertzidou
- Second Department of Obstetrics and Gynecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - C Chatzakis
- Second Department of Obstetrics and Gynecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - P Cavoretto
- Department of Obstetrics and Gynecology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - K Sarafidis
- First Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - M Eleftheriades
- Second Department of Obstetrics and Gynecology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A Gerede
- Department of Obstetrics and Gynecology, University of Thrace, Alexandroupolis, Greece
| | - K Dinas
- Second Department of Obstetrics and Gynecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - A Sotiriadis
- Second Department of Obstetrics and Gynecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Kekki M, Koukkula T, Salonen A, Gissler M, Laivuori H, Huttunen TT, Tihtonen K. Birth injury in breech delivery: a nationwide population-based cohort study in Finland. Arch Gynecol Obstet 2023; 308:1139-1150. [PMID: 36074174 PMCID: PMC10435420 DOI: 10.1007/s00404-022-06772-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/25/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Previous studies have examined the optimal mode of breech delivery extensively, but there is a scarcity of publications focusing on the birth injuries of neonates born in breech presentation. This study aimed to examine birth injury in breech deliveries. METHODS In this retrospective register-based nationwide cohort study, data on birth injuries in vaginal breech deliveries with singleton live births were compared to cesarean section with breech presentation and cephalic vaginal delivery between 2004 and 2017 in Finland. The data were retrieved from the National Medical Birth Register. Primary outcome variables were severe and mild birth injury. Incidences of birth injuries in different gestational ages and birthweights were calculated in different modes of delivery. Crude odds ratios of risk factors for severe birth injury were analyzed. RESULTS In vaginal breech delivery (n = 4344), there were 0.8% of neonates with severe birth injury and 1.5% of neonates with mild birth injury compared to 0.06% and 0.2% in breech cesarean section (n = 16,979) and 0.3% and 1.9% in cephalic vaginal delivery (n = 629,182). Brachial plexus palsy was the most common type of injury in vaginal breech delivery. Increasing gestational age and birthweight had a stronger effect on the risk for injury among cephalic vaginal deliveries than among vaginal breech deliveries. CONCLUSION Birth injuries were rare in vaginal breech deliveries. The incidence of severe birth injury was two times higher in vaginal breech delivery compared to cephalic vaginal delivery. Brachial plexus palsy was the most common type of injury in vaginal breech delivery.
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Affiliation(s)
- Maiju Kekki
- Department of Obstetrics and Gynecology, Tampere University Hospital, Elämänaukio 2, 33520, Tampere, Finland.
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.
| | - Topias Koukkula
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Anne Salonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Pediatric and Adolescent Surgery, Tampere University Hospital, Tampere, Finland
| | - Mika Gissler
- Department of Knowledge Brokers, Finnish Institute for Health and Welfare, Helsinki, Finland
- Department of Molecular Medicine and Surgery, Karolinska Institute and Region Stockholm, Academic Primary Health Care Centre, Stockholm, Sweden
| | - Hannele Laivuori
- Department of Obstetrics and Gynecology, Tampere University Hospital, Elämänaukio 2, 33520, Tampere, Finland
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Institute for Molecular Medicine Finland, Helsinki Institute of Life Science, University of Helsinki, Helsinki, Finland
| | - Tuomas T Huttunen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Tampere University Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Elämänaukio 2, 33520, Tampere, Finland
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Claire G, Diane K, Olivier S. Neonatal morbidity and mortality for preterm in breech presentation regarding the onset mode of labor. Arch Gynecol Obstet 2023; 307:729-738. [PMID: 35474495 DOI: 10.1007/s00404-022-06526-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/11/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE To assess severe neonatal morbidity and mortality in induced labor in preterm breech deliveries, compared to spontaneous labor. METHODS This is a retrospective study conducted in a tertiary university center in France. Women with single live breech pregnancy between 28 + 0 and 36 + 6 weeks gestation were included. We excluded situations with medical contraindication to vaginal delivery and fetal malformations. We compared women with an unfavorable cervix, who had an indication for deliver and could receive cervical ripening to induce labor, to women in spontaneous labor. The primary outcome was a composite criterion of severe neonatal morbidity and mortality including perinatal death, traumatic event during delivery, Apgar score at 5-min < 4, moderate or severe encephalopathy, seizures within the first 24 h, Intra-Ventricular Hemorrhage grade 3 or 4, necrotizing enterocolitis grade 2 or 3. RESULTS We included 212 patients: 64 in the induced labor group and 136 in the spontaneous labor group. In the induced labor group, 45.3% of patients delivered vaginally, and 86% in spontaneous labor group. The neonatal morbidity and mortality rate were similar in both groups: 4.7% in the induced labor group, and 5.2% in the spontaneous labor group, p = 0.889, aOR = 1.5 (0.28-8.28). CONCLUSION Nearly half of the patient who received induction of labor delivered vaginally. The onset mode of labor does not appear to have an effect on severe neonatal morbidity and mortality in preterm breech fetuses. Induction of labor could be an option for patients in this setting.
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Affiliation(s)
- Guerini Claire
- Service de Gynécologie Obstétrique, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Paris, France
| | - Korb Diane
- Service de Gynécologie Obstétrique, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Paris, France. .,Centre for Epidemiology and Statistics, Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Université de Paris, Paris, France.
| | - Sibony Olivier
- Service de Gynécologie Obstétrique, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Paris, France
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Roeckner JT, Peterson E, Rizzo J, Flores-Torres J, Odibo AO, Duncan JR. The Impact of Mode of Delivery on Maternal and Neonatal Outcomes during Periviable Birth (22-25 Weeks). Am J Perinatol 2022; 39:1269-1278. [PMID: 35253122 DOI: 10.1055/a-1788-5802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The objective of our study was to compare the maternal and neonatal complications of periviable birth by the delivery route. STUDY DESIGN A retrospective cohort study of periviable deliveries (220/7-256/7weeks) from 2013 to 2020 at a tertiary teaching institution was conducted. Deliveries were grouped by the mode of delivery. Excluded deliveries included pregnancy termination, anomaly, or undesired neonatal resuscitation. The primary composite maternal outcome included death, intensive care admission, sepsis, surgical site infection, unplanned operation, or readmission. Secondary outcomes included maternal blood loss, length of stay, neonatal survival, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), and retinopathy of prematurity (ROP). Outcomes were compared using Student's t-test, Wilcoxon-Mann-Whitney and Chi-squared tests. Relative risk (RR) and 95% confidence intervals were calculated with log-binomial regression. p-Values <0.05 were considered significant. Demographic and intervention variables associated with the outcome and the exposure were included in an adjusted relative risk (aRR) model. Subgroup analyses of singleton pregnancies and 220/7 to 236/7 weeks deliveries were conducted. RESULTS After exclusion, 230 deliveries were included in the cohort. Maternal characteristics were similar between cohorts. For the primary outcome, cesarean delivery was associated with a trend toward increased maternal morbidity (22.6 vs. 10.7%, RR = 2.11 [1.03-4.43], aRR = 1.95 [0.94-4.03], p-value 0.07). Administration of magnesium sulfate, antenatal corticosteroids, and tocolytics were similar between cohorts. Neonatal survival to discharge was not different between the groups (54/83, 65.1% vs. 118/191, 61.8%, aRR = 0.93 [0.77-1.13]). Among the 172 neonates discharged alive, there was no difference in BPD, IVH, NEC, PDA, ROP, or intact survival. CONCLUSION Periviable birth has a high rate of maternal morbidity with a trend toward the highest risk among women undergoing cesarean delivery. These risks should be included in shared decision-making. KEY POINTS · Periviable birth has high maternal morbidity (19%) and is highest after cesarean delivery (23%).. · Route of delivery does not impact neonatal survival or intact neonatal survival.. · Head entrapment is rare during vaginal breech delivery..
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Affiliation(s)
- Jared T Roeckner
- Division of Maternal-Fetal Medicine, University of South Florida Morsani College of Medicine and Tampa General Hospital, Tampa, Florida
| | - Erica Peterson
- Division of Neonatology, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, Florida
| | - Jennifer Rizzo
- Division of Maternal-Fetal Medicine, University of South Florida Morsani College of Medicine and Tampa General Hospital, Tampa, Florida
| | - Jaime Flores-Torres
- Division of Neonatology, University of South Florida Morsani College of Medicine, Tampa General Hospital, Tampa, Florida
| | - Anthony O Odibo
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri
| | - Jose R Duncan
- Division of Maternal-Fetal Medicine, University of South Florida Morsani College of Medicine and Tampa General Hospital, Tampa, Florida
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Toijonen A, Heinonen S, Gissler M, Macharey G. Neonatal outcome in vaginal breech labor at 32 + 0-36 + 0 weeks of gestation: a nationwide, population-based record linkage study. BMC Pregnancy Childbirth 2022; 22:211. [PMID: 35296277 PMCID: PMC8928595 DOI: 10.1186/s12884-022-04547-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 03/07/2022] [Indexed: 11/25/2022] Open
Abstract
Background In many countries, vaginal breech labor at term is an option in selected cases. However, the safety of vaginal breech labor in preterm is still unclear. Therefore our study aimed to evaluate the safety of vaginal breech labor in late preterm deliveries. Design A retrospective register-based study. Setting Maternity hospitals in Finland, 2004–2017. Participants The study population included 762 preterm breech deliveries at 32 + 0—36 + 6 gestational weeks according to the mode of delivery, 535 (70.2%) of them were born vaginally in breech presentation, and 227 (29.8%) were delivered by non-urgent cesarean section. Methods The study compared short-term neonatal adverse outcomes of singleton vaginal breech deliveries with non-urgent cesarean deliveries at 32 + 0 to 36 + 6 weeks of gestation. An odd ratio with 95% confidence intervals was calculated to estimate the relative risk of adverse outcomes. Outcome measures Neonatal death, an arterial umbilical pH below seven, a five-minute Apgar score below four and seven, admission to neonatal intensive care unit, neonatal intubation, neonatal antibiotic therapy, neonatal birth trauma, respiratory distress syndrome, neonatal convulsions, cerebral ischemia, hypoxic-ischemic encephalopathy, congenital hypotonia, and a composite of severe adverse outcomes. Results A five-minute Apgar scores below seven were increased in vaginal breech labor at 32 + 0 to 36 + 6 weeks of gestation compared to non-urgent cesarean sections (aOR 2.48, 95% CI 1.08–5.59). Neonatal antibiotic therapy, the admission to neonatal intensive care unit, and neonatal respiratory distress syndrome were decreased after vaginal breech labor compared to the outcomes of non-urgent cesarean section (neonatal antibiotic therapy aOR 0.60, 95% CI 0.40–0.89; neonatal NICU admission aOR 0.47, 95% CI 0.33–0.68; respiratory distress syndrome aOR 0.30, 95% CI 0.19–0.48). Conclusion Vaginal breech labor at 32 + 0—36 + 6 gestational weeks does not increase severe neonatal short-term morbidity or mortality compared to cesarean section.
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Affiliation(s)
| | - Seppo Heinonen
- Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
| | - Mika Gissler
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Georg Macharey
- Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290, Helsinki, Finland
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Zahedi-Spung LD, Raghuraman N, Macones GA, Cahill AG, Rosenbloom JI. Neonatal morbidity and mortality by mode of delivery in very preterm neonates. Am J Obstet Gynecol 2022; 226:114.e1-114.e7. [PMID: 34331893 DOI: 10.1016/j.ajog.2021.07.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/13/2021] [Accepted: 07/22/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The safest mode of delivery to use for very preterm infants is an ongoing topic of debate. There are many reasons to perform a cesarean delivery in cases of extremely preterm and very preterm infants, including indication for labor, fetal distress, maternal indications, and malpresentation. OBJECTIVE This study aimed to determine whether cesarean delivery is associated with a considerable improvement in neonatal morbidity. STUDY DESIGN This study is a retrospective cohort study of all singleton pregnancies, delivered from 22 to 29 weeks' gestation between 2010 and 2015, admitted for preterm labor or preterm premature rupture of membranes and excluded neonates with a delivery weight ≤500 g, multiple gestations, cases with intrauterine fetal demise, and induced terminations. The primary outcome for the study was a neonatal morbidity composite (Apgar score of <5 at 5 minutes, prolonged ventilation (>28 days), intraventricular hemorrhage, necrotizing enterocolitis, coagulopathy, discharged on home ventilator support, or discharged with enteric feeding tube). Cesarean deliveries were performed for standard obstetrical indications. Regression models were used and adjusted for nulliparity, delivery year, and presentation at the time of delivery to determine whether cesarean delivery is associated with neonatal morbidity or neonatal death. RESULTS There were 271 eligible deliveries, which included 128 cesarean deliveries and 143 vaginal deliveries. The cesarean delivery group had fewer nulliparous patients and more fetuses presenting in breech position at the time of delivery. The overall composite neonatal morbidity occurred in 202 of the 271 (74.5%) deliveries and mortality occurred in 26 of the 271 (9.59%) deliveries. When adjusting for nulliparity, delivery year, and fetal presentation at the time of delivery, cesarean delivery was associated with a decreased risk for death in the delivery room or within 24 hours after delivery (adjusted risk ratio, 0.18; 95% confidence interval, 0.05-0.63; P=.03). Cesarean delivery was associated with an increased use of exogenous surfactant (adjusted risk ratio, 1.20; 95% confidence interval, 1.05-1.38; P=.01) and bag mask ventilation (adjusted risk ratio, 1.17; 95% confidence interval, 1.01-1.37; P=.03). In a secondary analysis that included only patients who received a complete course of steroids, there were no differences in the composite morbidity or mortality. CONCLUSION Cesarean delivery performed for standard obstetrical indications in cases of very preterm neonates is associated with a decreased risk for death in the delivery room or within 24 hours of delivery but is not associated with an improvement in the overall morbidity or mortality.
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Affiliation(s)
- Leilah D Zahedi-Spung
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO.
| | - Nandini Raghuraman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - George A Macones
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Joshua I Rosenbloom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO; Hadassah University Medical Center, Jerusalem, Israel
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Girault A, Carteau M, Kefelian F, Menard S, Goffinet F, Le Ray C. Benefits of the «en caul» technique for extremely preterm breech vaginal delivery. J Gynecol Obstet Hum Reprod 2021; 51:102284. [PMID: 34906693 DOI: 10.1016/j.jogoh.2021.102284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/19/2021] [Accepted: 12/03/2021] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- A Girault
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, 123 boulevard de Port Royal, Paris 75014, France; Hôpital Cochin Port Royal, Maternité Port Royal, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.
| | - M Carteau
- Hôpital Cochin Port Royal, Maternité Port Royal, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - F Kefelian
- Hôpital Cochin Port Royal, Maternité Port Royal, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - S Menard
- Hôpital Cochin Port Royal, Maternité Port Royal, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - F Goffinet
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, 123 boulevard de Port Royal, Paris 75014, France; Hôpital Cochin Port Royal, Maternité Port Royal, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - C Le Ray
- INSERM UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, FHU PREMA, Université de Paris, 123 boulevard de Port Royal, Paris 75014, France; Hôpital Cochin Port Royal, Maternité Port Royal, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
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Abstract
Prematurity remains a leading cause of perinatal morbidity and mortality, and also has significant implications for long-term health. Obstetricians have a key role to play in improving outcomes for infants born at extremely preterm gestations. This review explores the evidence for interventions available to obstetricians caring for women at risk of birthing at extremely preterm gestations, including antenatal corticosteroids, magnesium sulfate, tocolysis and antibiotics. It also addresses the importance of strategies to facilitate safe in-utero transfer, to maximise the chance of extremely preterm births occurring in tertiary centers, and the clinical value of strategies by which preterm birth can be predicted. The paper concludes with an appraisal of evidence for different modes of birth at extremely preterm gestations, and for delayed cord clamping.
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10
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Toijonen A, Heinonen S, Gissler M, Seikku L, Macharey G. Impact of fetal presentation on neurodevelopmental outcome in a trial of preterm vaginal delivery: a nationwide, population-based record linkage study. Arch Gynecol Obstet 2021; 306:29-35. [PMID: 34718843 PMCID: PMC9300511 DOI: 10.1007/s00404-021-06146-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/13/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the risk of adverse neurodevelopmental outcomes at the age of four after an attempted vaginal delivery according to the fetal presentation in birth. METHODS This retrospective record linkage study evaluated the risks of cerebral palsy, epilepsy, intellectual disability, autism spectrum disorder, attention-deficit/hyperactivity disorder, and speech, visual, and auditory disabilities among preterm children born after an attempted vaginal breech delivery. The control group comprised children born in a cephalic presentation at the same gestational age. This study included 23 803 singleton deliveries at gestational weeks 24 + 0-36 + 6 between 2004 and 2014. RESULTS From 1629 women that underwent a trial of vaginal breech delivery, 1122 (66.3%) were converted to emergency cesarean sections. At extremely preterm and very preterm gestations (weeks 24 + 0-31 + 6), no association between a trial of vaginal breech delivery and neurodevelopmental delay occurred. At gestational weeks 32 + 0-36 + 6, the risks of visual disability (aOR 1.67, CI 1.07-2.60) and autism spectrum disorders (aOR 2.28, CI 1.14-4.56) were increased after an attempted vaginal breech delivery as compared to vaginal cephalic delivery. CONCLUSION A trial of vaginal breech delivery at extremely preterm and very preterm gestations appears not to increase the risk of adverse neurodevelopmental outcomes at the age of four. In moderate to late preterm births, a trial of vaginal breech delivery was associated with an increased risk of visual impairment and autism spectrum disorders compared to children born in cephalic presentation. A trial of vaginal preterm breech delivery requires distinctive consideration and careful patient selection.
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Affiliation(s)
- Anna Toijonen
- Department of Obstetrics and Gynecology, University of Helsinki, Riihiuunintie 12 c, 02620 Espoo, Finland
| | - Seppo Heinonen
- Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290 Helsinki, Finland
| | - Mika Gissler
- National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Laura Seikku
- Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290 Helsinki, Finland
| | - Georg Macharey
- Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290 Helsinki, Finland
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11
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Pierre C, Leroy A, Pierache A, Storme L, Debarge V, Depret S, Rakza T, Garabedian C, Subtil D. 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. PLoS One 2021; 16:e0258303. [PMID: 34669715 PMCID: PMC8528279 DOI: 10.1371/journal.pone.0258303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 09/23/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Clémentine Pierre
- Univ. Lille, CHU Lille, Hôpital Jeanne de Flandre, Pôle Femme Mère Nouveau-né, Lille, France
- Univ. Lille, EA 2694, METRICS, Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Audrey Leroy
- Univ. Lille, CHU Lille, Hôpital Jeanne de Flandre, Pôle Femme Mère Nouveau-né, Lille, France
| | - Adeline Pierache
- Univ. Lille, CHU Lille, Département de Biostatistiques, Lille, France
| | - Laurent Storme
- Univ. Lille, CHU Lille, Hôpital Jeanne de Flandre, Pôle Femme Mère Nouveau-né, Lille, France
- Univ. Lille, EA 2694, METRICS, Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Véronique Debarge
- Univ. Lille, CHU Lille, Hôpital Jeanne de Flandre, Pôle Femme Mère Nouveau-né, Lille, France
- Univ. Lille, EA 2694, METRICS, Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Sandrine Depret
- Univ. Lille, CHU Lille, Hôpital Jeanne de Flandre, Pôle Femme Mère Nouveau-né, Lille, France
| | - Thameur Rakza
- Univ. Lille, CHU Lille, Hôpital Jeanne de Flandre, Pôle Femme Mère Nouveau-né, Lille, France
- Univ. Lille, EA 2694, METRICS, Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Charles Garabedian
- Univ. Lille, CHU Lille, Hôpital Jeanne de Flandre, Pôle Femme Mère Nouveau-né, Lille, France
- Univ. Lille, EA 2694, METRICS, Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
| | - Damien Subtil
- Univ. Lille, CHU Lille, Hôpital Jeanne de Flandre, Pôle Femme Mère Nouveau-né, Lille, France
- Univ. Lille, EA 2694, METRICS, Evaluation des Technologies de Santé et des Pratiques Médicales, Lille, France
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12
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Aviram A, Barrett JFR, Melamed N, Mei-Dan E. Mode of delivery in multiple pregnancies. Am J Obstet Gynecol MFM 2021; 4:100470. [PMID: 34454159 DOI: 10.1016/j.ajogmf.2021.100470] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/25/2021] [Accepted: 08/18/2021] [Indexed: 11/25/2022]
Abstract
The mode of delivery in multiple pregnancies has been subject to vigorous debates during the last few decades. Although observational and retrospective data were accumulated, it was not until the publication of the Twin Birth Study that evidence-based recommendations could emerge. However, although some of the most pressing questions were answered by the Twin Birth Study, other questions were left outside the scope of the study. The questions were of great interest and included the following topics: the impact of gestational age, the influence of chorionicity, and the generalizability of the results for women with a previous uterine scar. The current evidence supported a trial of labor in dichorionic-diamniotic or monochorionic-diamniotic twin pregnancies in which the first twin is in cephalic presentation at ≥32 weeks' gestation. Dichorionic-diamniotic, monochorionic-diamniotic, and monochorionic-monoamniotic twins should be delivered at 37 0/7 to 38 0/7, 36 0/7 to 37 0/7, and 32 0/7 to 34 0/7 weeks' gestation, respectively. Breech extraction done by a competent healthcare provider seemed to offer a higher chance of successful vaginal delivery of the second twin than the external cephalic version. The current data did not allow for a clear recommendation regarding the mode of delivery in very preterm birth of low birthweight twins, but most studies did not demonstrate a clear benefit of cesarean delivery vs trial of labor. Furthermore, a trial of labor seemed safe in women with a previous cesarean delivery. Cesarean delivery is likely beneficial for twin pregnancies with the first twin in breech presentation, monochorionic-monoamniotic twins, and higher-order multiple pregnancies. In all multiple pregnancies, delivery should be performed by an experienced practitioner competent in multiple pregnancy deliveries.
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Affiliation(s)
- Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan).
| | - Jon F R Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
| | - Elad Mei-Dan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada (Drs Aviram and Melamed); Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada (Drs Aviram, Melamed, and Mei-Dan); Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada (Dr Barrett); Department of Obstetrics and Gynaecology, North York General Hospital, Toronto, Ontario, Canada (Dr Mei-Dan)
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13
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Tietzmann MR, Teichmann PDV, Vilanova CS, Goldani MZ, Silva CHD. Risk Factors for Neonatal Mortality in Preterm Newborns in The Extreme South of Brazil. Sci Rep 2020; 10:7252. [PMID: 32350375 PMCID: PMC7190611 DOI: 10.1038/s41598-020-64357-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 04/07/2020] [Indexed: 11/08/2022] Open
Abstract
Neonatal mortality still remains a complex challenge to be addressed. In Brazil, 60% of neonatal deaths occur among preterm infants with a gestational age of 32 weeks or less (≤32w). The aim of this study was to evaluate the factors involved in the high mortality rates among newborns with a gestational age ≤32w in a socioeconomically developed southern city in Brazil. Data on retrospective births and deaths (2000-2014) were analyzed from two official Brazilian national databases. The risk of neonatal death for all independent variables (mother's age and schooling, prenatal visits, birth hospital, delivery method, gestational age, and the newborn's sex, age, and birth year, gemelarity, congenital anomalies and birthplace) was assessed with a univariable and a multivariable model of Cox's semiparametric proportional hazards regression (p < 0.05). Data of 288,904 newborns were included, being 4,514 with a gestational age ≤32w. The proportion of these early newborns remained stable among all births, while the neonatal mortality rate for this group tended to decrease (p < 0.001). The adjusted risk was significantly for lower birthweight infants (mean 659.13 g) born from Caesarean (HR 0.58 [95% CI 0.47-0.71]), but it was significantly higher for heavier birth weight infants (mean 2,087.79) also born via Caesarean section (HR 3.71 [95% CI 1.5-9.15]). Newborns with lower weight seemed to benefit most from Cesarean deliveries. Effort towards reducing unacceptably high surgical deliveries must take into account cases that the operations may be lifesaving for mother and/or the baby.
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Affiliation(s)
- Marcos Roberto Tietzmann
- Graduate Program in Child and Adolescent Health, Faculdade de Medicina - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - Pedro do Valle Teichmann
- Faculdade de Medicina - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil.
| | - Cassia Simeão Vilanova
- Graduate Program in Child and Adolescent Health, Faculdade de Medicina - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - Marcelo Zubaran Goldani
- Graduate Program in Child and Adolescent Health, Faculdade de Medicina - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
- Faculdade de Medicina - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
- Pediatric Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, 90035-007, Brazil
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
| | - Clécio Homrich da Silva
- Graduate Program in Child and Adolescent Health, Faculdade de Medicina - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
- Faculdade de Medicina - Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
- Pediatric Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, 90035-007, Brazil
- Department of Pediatrics, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, 90035-003, Brazil
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14
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Sirgant D, Rességuier N, d'Ercole C, Auquier P, Tosello B, Blanc J. Lower gestational age is associated with severe maternal morbidity of preterm cesarean delivery. J Gynecol Obstet Hum Reprod 2020; 49:101764. [PMID: 32335351 DOI: 10.1016/j.jogoh.2020.101764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 04/05/2020] [Accepted: 04/07/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Delphine Sirgant
- Department of Obstetrics and Gynecology, Nord Hospital, APHM, chemin des Bourrely, 13015, Marseille, France
| | - Noémie Rességuier
- EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Claude d'Ercole
- Department of Obstetrics and Gynecology, Nord Hospital, APHM, chemin des Bourrely, 13015, Marseille, France; EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Pascal Auquier
- EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France
| | - Barthélémy Tosello
- Department of Neonatology, North Hospital, Assistance Publique des Hôpitaux de Marseille, France; Aix-Marseille Univ, CNRS, EFS, ADES, Marseille, France
| | - Julie Blanc
- Department of Obstetrics and Gynecology, Nord Hospital, APHM, chemin des Bourrely, 13015, Marseille, France; EA3279, CEReSS, Health Service Research and Quality of Life Center, Aix-Marseille University, 13284, Marseille, France.
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15
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Spatulas for entrapment of the after-coming head during vaginal breech delivery. Arch Gynecol Obstet 2019; 299:1283-1288. [DOI: 10.1007/s00404-019-05115-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 03/04/2019] [Indexed: 11/24/2022]
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16
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Schmidt S, Norman M, Misselwitz B, Piedvache A, Huusom LD, Varendi H, Barros H, Cammu H, Blondel B, Dudenhausen J, Zeitlin J, Weber T. Mode of delivery and mortality and morbidity for very preterm singleton infants in a breech position: A European cohort study. Eur J Obstet Gynecol Reprod Biol 2019; 234:96-102. [PMID: 30682601 DOI: 10.1016/j.ejogrb.2019.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Revised: 12/29/2018] [Accepted: 01/03/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Caesarean section (CS) may reduce mortality and morbidity for very preterm breech infants, but evidence is inconclusive. We evaluated neonatal outcomes for singleton breech infants by mode of delivery in a European cohort. STUDY DESIGN Data come from the EPICE population-based cohort of very preterm births in 19 regions in 11 European countries (7770 live births). The study population was singleton spontaneous-onset breech births at 24-31 weeks gestational age (GA) without antenatal medical complications requiring caesarean delivery (N = 572). Mixed-effects regression models adjusting for maternal and pregnancy covariates and propensity score matching was used to examine the effect of (1) CS and (2) a unit policy of systematic CS for breech presentation by GA. The primary outcome was a composite of in-hospital mortality, intraventricular haemorrhage grades III & IV or cystic periventricular leukomalacia. Secondary outcomes were each component separately, five minute Apgar score below seven and mortality within six hours of delivery. RESULTS 64.4% of infants were delivered by CS with a range across regions from 41% to 100%; these infants had higher GA and were more likely to be small for gestational age, receive antenatal steroids, and have mothers who were hospitalised for more than one day before delivery compared to those delivered vaginally. CS was associated with lower risks of all outcomes in mixed-effects adjusted models (odds ratio (OR) for the composite outcome: 0.50, 95% confidence interval (CI): 0.30-0.81), but not in propensity score matched models (OR: 0.72, 95% CI: 0.41; 1.29). A systematic CS policy was associated with lower mortality and morbidity in unadjusted, but not adjusted models (OR for composite outcome: 0.76, 95% CI: 0.44; 1.28). 35% of births 24-25 weeks were delivered by CS and protective effects were consistently stronger, but not statistically significant. CONCLUSIONS Point estimates indicated protective effects of caesarean delivery for very preterm breech infants in conventional statistical models. However, analyses using propensity scores and based on unit policies did not confirm statistically significant associations. Prospective large-scale studies are needed to establish best practice and could be implemented in European regions where vaginal delivery remains an option.
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Affiliation(s)
- Stephan Schmidt
- Department of Obstetrics, University Hospital, Philipps University, Marburg, D-35043, Germany
| | - Mikael Norman
- Department of Clinical Science, Intervention & Technology, Karolinska Institutet, Stockholm, Sweden; Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - Lene D Huusom
- Department of Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark
| | - Heili Varendi
- University of Tartu, Tartu University Hospital, Tartu, Estonia
| | - Henrique Barros
- EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
| | - Hendrik Cammu
- H Cammu, Study centre of Perinatal Epidemiology & Vrije Universiteit Brussel, Belgium
| | - Béatrice Blondel
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
| | | | - Jennifer Zeitlin
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.
| | - Tom Weber
- Department of Obstetrics, Hvidovre University Hospital, Hvidovre, Denmark
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17
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Lorthe E, Sentilhes L, Quere M, Lebeaux C, Winer N, Torchin H, Goffinet F, Delorme P, Kayem G, Ancel P, Arnaud C, Blanc J, Boileau P, Debillon T, Delorme P, D'Ercole C, Desplanches T, Diguisto C, Foix‐L'Hélias L, Garbi A, Gascoin G, Gaudineau A, Gire C, Goffinet F, Kayem G, Langer B, Letouzey M, Lorthe E, Maisonneuve E, Marret S, Monier I, Morgan A, Rozé J, Schmitz T, Sentilhes L, Subtil D, Torchin H, Tosello B, Vayssière C, Winer N, Zeitlin J. Planned delivery route of preterm breech singletons, and neonatal and 2‐year outcomes: a population‐based cohort study. BJOG 2018; 126:73-82. [DOI: 10.1111/1471-0528.15466] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2018] [Indexed: 11/30/2022]
Affiliation(s)
- E Lorthe
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé) Center for Epidemiology and Statistics Sorbonne Paris Cité DHU Risks in pregnancy, Paris Descartes University Paris France
- EPIUnit – Institute of Public Health University of Porto Porto Portugal
| | - L Sentilhes
- Department of Obstetrics and Gynaecology Bordeaux University Hospital Bordeaux France
| | - M Quere
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé) Center for Epidemiology and Statistics Sorbonne Paris Cité DHU Risks in pregnancy, Paris Descartes University Paris France
| | - C Lebeaux
- Reference Centre on Teratogenic Agents Trousseau University Hospital Assistance Publique – Hôpitaux de Paris Paris France
| | - N Winer
- Department of Obstetrics and Gynecology CIC Mère Enfant University Hospital Nantes France
- INRA, UMR 1280 Physiologie des adaptations nutritionnelles Nantes France
| | - H Torchin
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé) Center for Epidemiology and Statistics Sorbonne Paris Cité DHU Risks in pregnancy, Paris Descartes University Paris France
- Neonatal Medicine and Resuscitation Service Port‐Royal, Hôpital Cochin Assistance Publique – Hôpitaux de Paris Paris France
| | - F Goffinet
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé) Center for Epidemiology and Statistics Sorbonne Paris Cité DHU Risks in pregnancy, Paris Descartes University Paris France
- Department of Obstetrics and Gynaecology Cochin, Broca, Hôtel‐Dieu Assistance Publique – Hôpitaux de Paris Paris France
| | - P Delorme
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé) Center for Epidemiology and Statistics Sorbonne Paris Cité DHU Risks in pregnancy, Paris Descartes University Paris France
- Department of Obstetrics and Gynaecology Cochin, Broca, Hôtel‐Dieu Assistance Publique – Hôpitaux de Paris Paris France
| | - G Kayem
- Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé) Center for Epidemiology and Statistics Sorbonne Paris Cité DHU Risks in pregnancy, Paris Descartes University Paris France
- Department of Obstetrics and Gynaecology Trousseau University Hospital Assistance Publique – Hôpitaux de Paris Sorbonne Universités, Université Pierre and Marie Curie Paris 06 Paris France
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18
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Impact of the mode of delivery on maternal and neonatal outcome in spontaneous-onset breech labor at 32 +0-36 +6 weeks of gestation: A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2018; 225:13-18. [PMID: 29626709 DOI: 10.1016/j.ejogrb.2018.03.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 03/26/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare neonatal and maternal outcomes in spontaneously onset preterm breech deliveries after trial of labor (BTOL) and intended cesarean section (BCS), and between BTOL and vertex control deliveries, in singleton fetuses at 32+0-36+6 weeks of gestation. STUDY DESIGN Retrospective single center cohort study in a Finnish University Hospital including all spontaneous-onset preterm breech deliveries with 32 completed gestational weeks in 2003-2015. The study population comprised a total of 176 preterm breech and 103 vertex control deliveries, matched by gestational age and whether the mother had given birth vaginally before or not. Infants with severe malformations and antepartum fetal distress were excluded. Subgroup analyses were made in two cohorts according to gestational age. Main outcome measures were maternal and neonatal mortality and morbidity, low cord pH and Apgar score. RESULTS No mortality was observed, and severe morbidity was rare. No difference in incidence of low cord pH or five-minute Apgar score was observed between the groups. Apgar scores at the age of one minute were comparable in the breech groups but more often low in the BTOL group compared to the vertex control group. 16.5% of neonates in the BTOL group, 23.3% in the BCS group and 7.8% in the vertex group needed intensive care. In logistic regression analysis, lower gestational age and being small for gestational age were associated with the need for neonatal intensive care. Being allowed a trial of labor was not associated with the need for neonatal intensive care. Maternal morbidity was similar across the groups, but median blood loss was more pronounced in the BCS group compared to the BTOL group. CONCLUSION In breech deliveries at 32+0-36+6 gestational weeks, trial of labor did not increase neonatal morbidity compared to intended cesarean delivery. Infants born after a trial of labor in breech presentation display low one-minute Apgar score and need intensive care more often compared to vertex controls.
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Bertholdt C, Menard S, Delorme P, Lamau MC, Goffinet F, Le Ray C. Intraoperative adverse events associated with extremely preterm cesarean deliveries. Acta Obstet Gynecol Scand 2018; 97:608-614. [PMID: 29336477 DOI: 10.1111/aogs.13290] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 01/06/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION At the same time as survival is increasing among premature babies born before 26 weeks of gestation, the rates of cesarean deliveries before 26 weeks is also rising. Our purpose was to compare the frequency of intraoperative adverse events during cesarean deliveries in two gestational age groups: 24-25 weeks and 26-27 weeks. MATERIAL AND METHODS This single-center retrospective cohort study included all women with cesarean deliveries performed before 28+0 weeks from 2007 through 2015. It compared the frequency of intraoperative adverse events between two groups: those at 24-25 weeks of gestation and at 26-27 weeks. Intraoperative adverse events were a classical incision, transplacental incision, difficulty in fetal extraction (explicitly mentioned in the surgical report), postpartum hemorrhage (≥500 mL of blood loss), and injury to internal organs. A composite outcome including at least one of these events enabled us to analyze the risk factors for intraoperative adverse events with univariate and multivariable analysis. Stratified analyses by the indication for the cesarean were performed. RESULTS We compared 74 cesarean deliveries at 24-25 weeks of gestation and 214 at 26-27 weeks. Intraoperative adverse events occurred at higher rates in the 24-25-week group (63.5 vs. 30.8%, p < 0.001). After adjustment for confounding factors, this group remained at significantly higher risk of intraoperative adverse events [adjusted odds ratio 5.04 (2.67-9.50)], even after stratification by indication for the cesarean. CONCLUSION These results should help obstetricians and women making decisions about cesarean deliveries at these extremely low gestational ages.
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Affiliation(s)
- Charline Bertholdt
- Port-Royal Maternity Unit, Cochin Hospital, Paris-Descartes University, DHU Risk and Pregnancy, Assistance Publique-Hôpitaux de Paris, Paris, France.,Obstetric and Gynecology Unit, Regional University Hospital Center of Nancy, Nancy, France
| | - Sophie Menard
- Port-Royal Maternity Unit, Cochin Hospital, Paris-Descartes University, DHU Risk and Pregnancy, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Pierre Delorme
- Port-Royal Maternity Unit, Cochin Hospital, Paris-Descartes University, DHU Risk and Pregnancy, Assistance Publique-Hôpitaux de Paris, Paris, France.,National Institute of Health and Medical Research (Inserm), UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, Paris-Descartes University, Paris, France
| | - Marie-Charlotte Lamau
- Port-Royal Maternity Unit, Cochin Hospital, Paris-Descartes University, DHU Risk and Pregnancy, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Goffinet
- Port-Royal Maternity Unit, Cochin Hospital, Paris-Descartes University, DHU Risk and Pregnancy, Assistance Publique-Hôpitaux de Paris, Paris, France.,National Institute of Health and Medical Research (Inserm), UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, Paris-Descartes University, Paris, France
| | - Camille Le Ray
- Port-Royal Maternity Unit, Cochin Hospital, Paris-Descartes University, DHU Risk and Pregnancy, Assistance Publique-Hôpitaux de Paris, Paris, France.,National Institute of Health and Medical Research (Inserm), UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics, Paris-Descartes University, Paris, France
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Dagenais C, Lewis-Mikhael AM, Grabovac M, Mukerji A, McDonald SD. What is the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs? A systematic review and meta-analyses. BMC Pregnancy Childbirth 2017; 17:397. [PMID: 29187166 PMCID: PMC5707900 DOI: 10.1186/s12884-017-1554-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/31/2017] [Indexed: 12/21/2022] Open
Abstract
Background Given the controversy around mode of delivery, our objective was to assess the evidence regarding the safest mode of delivery for actively resuscitated extremely preterm cephalic/non-cephalic twin pairs before 28 weeks of gestation. Methods We searched Cochrane CENTRAL, MEDLINE, EMBASE and http://clinicaltrials.gov from January 1994 to January 2017. Two reviewers independently screened titles, abstracts and full text articles, extracted data and assessed risk of bias. We included randomized controlled trials and observational studies. Our primary outcome was a composite of neonatal death (<28 days of life) and severe brain injury in survivors (intraventricular hemorrhage grade ≥ 3 or periventricular leukomalacia). We performed random-effects meta-analyses, generating odds ratios with 95% confidence intervals for the first and second twin separately, and for both twins together. We assessed the risk of bias using a modified Newcastle Ottawa Scale (NOS) for observational studies and used Grading of Recommendations Assessment, Development and Evaluation approach (GRADE). Results Our search generated 2695 articles, and after duplicate removal, we screened 2051 titles and abstracts, selecting 113 articles for full-text review. We contacted 36 authors, and ultimately, three observational studies met our inclusion criteria. In cephalic/non-cephalic twin pairs delivered by caesarean section compared to vaginal birth at 24+0–27+6 weeks the odds ratio for our composite outcome of neonatal death and severe brain injury for the cephalic first twin was 0.35 (95% CI 0.00–92.61, two studies, I2 = 76%), 1.69 for the non-cephalic second twin (95% CI 0.04–72.81, two studies, I2 = 55%) and 0.83 for both twins (95% CI 0.05–13.43, two studies, I2 = 56%). According to the modified Newcastle Ottawa Scale we assessed individual study quality as being at high risk of bias and according to GRADE the overall evidence for our primary outcomes was very low. Conclusion Our systematic review on the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs found very limited existing evidence, without significant differences in neonatal death and severe brain injury by mode of delivery. Electronic supplementary material The online version of this article (10.1186/s12884-017-1554-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catherine Dagenais
- Department of Obstetrics & Gynecology, McMaster University, 1280 Main St W, HSC 3N52B, Hamilton, ON, L8S 4K1, Canada
| | - Anne-Mary Lewis-Mikhael
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4K1, Canada
| | - Marinela Grabovac
- Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4K1, Canada
| | - Amit Mukerji
- Department of Pediatrics, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4K1, Canada
| | - Sarah D McDonald
- Department of Obstetrics & Gynecology, McMaster University, 1280 Main St W, HSC 3N52B, Hamilton, ON, L8S 4K1, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4K1, Canada.
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Niles KM, Barrett JFR, Ladhani NNN. Comparison of cesarean versus vaginal delivery of extremely preterm gestations in breech presentation: retrospective cohort study. J Matern Fetal Neonatal Med 2017; 32:1142-1147. [PMID: 29157039 DOI: 10.1080/14767058.2017.1401997] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Objective: As survival increases at earlier gestational ages, the optimal mode of delivery, especially in cases of breech presentation, is of increasing importance. The objective of this study was to compare outcomes of vaginal delivery (VD) and cesarean section (CS) births for infants in breech presentation at borderline viability. Study design: A retrospective chart review of live breech births between 23 + 0 and 25 + 6 weeks gestation at a tertiary university center from 2003 to 2013 was conducted. Those delivered vaginally were compared with those delivered by CS. Stillbirths and deliveries where no resuscitation was intended were removed from the analysis. Variables were compared using a Student t-test (continuous), Mann-Whitney U test (categorical), or a Chi-squared test (count). Logistic regression analysis was performed to further evaluate the results. Results with p < .05 were considered significant. Results: One hundred seventy-six births were included, 36 VD and 140 CS. Baseline characteristics were similar between groups. Gestational age at delivery was significantly higher in CS deliveries (24.9 ± 0.6 versus 24.5 ± 0.7, p = .0007). The rate of neonatal death (23.6% versus 44.4%, p = .0127) was significantly lower in those born by CS. All other neonatal outcomes including Apgar scores at one and 5 min, cord gases, birth weight, length of stay in NICU, incidence of respiratory complications, and incidence of high-grade IVH demonstrated no significant differences. Logistic regression suggested that male sex, lower birth weight, and earlier gestational age are significantly associated with neonatal mortality. Thirty percent of uterine incisions were of the classical, high transverse or inverted-T types. The estimated blood loss was significantly higher in CS births (706.6 ± 226.4 versus 327.4 ± 174.1 mL, p < .0001), but there was no difference in the rate of blood transfusion. Conclusion: CS delivery of breech infants at borderline viability had a protective effect on neonatal mortality compared to VD depending on the regression model utilized. Infant sex, birth weight, and gestational age also contribute significantly to neonatal mortality. A prospective study of planned method of delivery is recommended to further explore this finding.
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Affiliation(s)
- Kirsten M Niles
- a Department of Obstetrics and Gynecology , University of Toronto , Toronto , Canada
| | - Jon F R Barrett
- a Department of Obstetrics and Gynecology , University of Toronto , Toronto , Canada.,b Department of Obstetrics and Gynaecology , Sunnybrook Health Sciences Centre , Toronto , Canada
| | - Noor Niyar N Ladhani
- a Department of Obstetrics and Gynecology , University of Toronto , Toronto , Canada.,b Department of Obstetrics and Gynaecology , Sunnybrook Health Sciences Centre , Toronto , Canada
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Grabovac M, Karim JN, Isayama T, Liyanage SK, McDonald SD. What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses. BJOG 2017; 125:652-663. [PMID: 28921813 DOI: 10.1111/1471-0528.14938] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The safest delivery mode of extremely preterm breech singletons is unknown. OBJECTIVES To determine safest delivery mode of actively resuscitated extremely preterm breech singletons. SEARCH STRATEGY We searched Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL and ClinicalTrials.gov from January 1994 to May 2017. SELECTION CRITERIA We included studies comparing outcomes by delivery mode in actively resuscitated breech infants between 23+0 and 27+6 weeks. DATA COLLECTION AND ANALYSIS We synthesised data using random effects, generated odds ratios, 95% confidence intervals and number-needed-to-treat (NNT). Our primary outcomes were death (neonatal, before discharge, or by 6 months) and severe intraventricular haemorrhage (grades III/IV), stratified by gestational age (23+0 -24+6 , 25+0 -26+6 , 27+0 -27+6 weeks). MAIN RESULTS We included 15 studies with 12 335 infants. We found that caesarean section was associated with a 41% decrease in odds of death between 23+0 and 27+6 weeks [odds ratio (OR) 0.59, 95% CI 0.36-0.95, NNT 8], with the greatest decrease at 23+0 -24+6 weeks (OR 0.58, 95% CI 0.44-0.75, NNT 7). The OR at 25+0 -26+6 and 27+0 -27+6 weeks were 0.72 (95% CI 0.34-1.52) and 2.04 (95% CI 0.20-20.62), respectively. We found that caesarean section was associated with 49% decrease in odds of severe intraventricular haemorrhage between 23+0 and 27+6 weeks (OR 0.51, 95% CI 0.29-0.91, NNT 12), whereas the OR at 25+0 -26+6 and 27+0 -27+6 was 0.29 (95% CI 0.07-1.12) and 0.91 (95% CI 0.27-3.05), respectively. CONCLUSIONS Caesarean section was associated with reductions in the odds of death by 41% and of severe intraventricular haemorrhage by 49% in actively resuscitated breech singletons < 28 weeks of gestation. The data are mostly observational, which may be inherently biased, and scarce on other morbidities, necessitating thorough discussion between parents and clinicians. TWEETABLE ABSTRACT Caesarean section associated with lower odds of death and severe intraventricular haemorrhage in actively resuscitated breech singletons <28 weeks.
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Affiliation(s)
- M Grabovac
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - J N Karim
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - T Isayama
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Neonatal Intensive Care Unit, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - S Korale Liyanage
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada
| | - S D McDonald
- Department of Obstetrics & Gynecology, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Department of Radiology, McMaster University, Hamilton, ON, Canada
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Hejl L, Perdriolle-Galet E, Gauchotte E, Callec R, Morel O. [Vaginal delivery in case of breech presentation: Impact of a service's incentive]. ACTA ACUST UNITED AC 2017; 45:596-603. [PMID: 28964728 DOI: 10.1016/j.gofs.2017.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 08/23/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The mode of delivery in podalic presentation was controvertible since the 2000s, which led to a high rate of caesarean section. In our center, the delivery mode was physician-dependent before 2012. Since 2012, the management of podalic presentations was supervised by a protocol allowing a collegiate management to promote vaginal delivery. The objective of this study was to evaluate the impact of this policy on neonatal outcomes and obstetric practices. METHODS A retrospective study was carried out with comparison of 135 patients who gave birth in 2008 with 110 patients who gave birth in 2014, before and after the implementation of the protocol in a type III university maternity hospital. Two hundred and forty-five singleton pregnancies with podalic presentation and a gestational age more than 32 weeks of gestation were included in this study. The rate of vaginal delivery trial, the evolution of clinical practices and neonatal outcomes were respectively compared. RESULTS One hundred and twenty-six patients who gave birth in 2008 were compared to the 105 one of 2014. The rate of successful vaginal birth trial increased from 32.7% (n=16/49) to 63.8% (n=37/58) (P>0.05) between the two periods, this induced a decrease of 16.3% of planned caesarean sections rate [(77/126) versus (47/105) (P<0.02)] and of 6.2% of emergency caesarean sections rate [(33/126) versus (21/105) (P<0.001)]. No significant difference was observed regarding neonatal outcomes. CONCLUSIONS This work shows that it is possible to limit the rate of planned and emergency caesarean sections because of an incentive policy of service without impact on neonatal morbidity and mortality.
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Affiliation(s)
- L Hejl
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France.
| | - E Perdriolle-Galet
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France; Laboratoire IADI, unité Inserm U947, université de Lorraine, 54500 Vandoeuvre-lès-Nancy, France
| | - E Gauchotte
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France
| | - R Callec
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France; Laboratoire IADI, unité Inserm U947, université de Lorraine, 54500 Vandoeuvre-lès-Nancy, France
| | - O Morel
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France; Laboratoire IADI, unité Inserm U947, université de Lorraine, 54500 Vandoeuvre-lès-Nancy, France; France PremUp Foundation, Paris, France
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Lorthe E, Quere M, Sentilhes L, Delorme P, Kayem G. Incidence and risk factors of caesarean section in preterm breech births: A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 212:37-43. [DOI: 10.1016/j.ejogrb.2017.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 03/08/2017] [Indexed: 11/26/2022]
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Mottet N, Riethmuller D. [Mode of delivery in spontaneous preterm birth]. ACTA ACUST UNITED AC 2016; 45:1434-1445. [PMID: 27776847 DOI: 10.1016/j.jgyn.2016.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the benefit/risk balance of way of birth according to fetal presentation, to assess monitoring during preterm labor, to discuss method of delivery and practice of delayed cord clamping in case of spontaneous preterm birth. METHODS Bibliographic research from the Pubmed database and recommendations issued by the main scientific societies, and assignment of a level of evidence and a recommendation grade. RESULTS In case of vertex presentation, no studies suggest that cesarean section improve neonatal outcome during spontaneous preterm birth (LE4). Nevertheless, cesarean is associated with higher maternal morbidity than vaginal delivery. Thus, routine cesarean is not recommended simply because of a spontaneous preterm labor (professional consensus). The available data do not allow specific recommendations about the choice of mode of delivery for preterm breech presentation in view of the low levels of proof (Professional consensus). Fetal rate monitoring is necessary during preterm labor (Professional consensus). Current data about second lines method for fetal surveillance (fetal scalp blood for pH or lactates) are insufficient to recommend their use before 34 WG (Professional consensus). Systematic assisted vaginal delivery is not recommended during preterm birth (Professional consensus). Use of vacuum is possible after 34 WG when cranial vertex ossification is considered satisfactory (Professional consensus). Systematic use of episiotomy in case of preterm birth is not recommended (Professional consensus). A delayed cord clamping is possible if the neonatal or maternal state so permits (Professional consensus). The available data are insufficient to recommend a systematic use of this procedure (LE3). CONCLUSION In case of preterm delivery, the available data do not allow specific recommendations about the choice of mode of delivery regardless of fetal presentation.
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Affiliation(s)
- N Mottet
- Pôle Mère-Femme, CRHU Jean-Minjoz, 3, boulevard Flemming, 25030 Besançon cedex, France; Université de Franche comté, 25000 Besançon, France.
| | - D Riethmuller
- Pôle Mère-Femme, CRHU Jean-Minjoz, 3, boulevard Flemming, 25030 Besançon cedex, France; Université de Franche comté, 25000 Besançon, France
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Abstract
Stillbirths are among the most common pregnancy-related adverse outcomes but are more common in low-income and middle-income countries than in high-income countries. In high-income countries, most stillbirths occur early in the preterm period, whereas in low-income and middle-income countries, most occur in term or in late preterm births. In low-income and middle-income countries, conditions, such as prolonged or obstructed labor, placental abruption, preeclampsia/eclampsia, fetal growth restriction, fetal distress, breech and other abnormal presentations, and multiple births, are associated with stillbirth. In high-income countries, placental abnormalities are the most common associations. Globally, fetal asphyxia is likely the most common final pathway to stillbirth.
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