Uterine rupture risk after periviable cesarean delivery

Periviability for the Ob-Gyn Hospitalist

Periviable birth refers to births occurring between 20 0/7 and 25 6/7 weeks gestational age. Management of pregnant people and neonates during this fragile time depends on the clinical status, as well as the patient's wishes. Providers should be prepared to counsel patients at the cusp of viability, being mindful of the uncertainty of outcomes for these neonates. While it is important to incorporate the data on projected morbidity and mortality into one's counseling, shared-decision making is most essential to caring for these patients and optimizing outcomes for all.

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 [...].

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Threatened Periviable Delivery and Abortion: Clinical Considerations

Periviable delivery, or a pregnancy at risk of delivery between 20 0/7 and 25 6/7 weeks gestational, is an uncommon event with profound physical, psychological, and financial impact. Neonatal outcomes can be hard to predict and with the changing legal landscape around abortion access, management options may be compromised. Dynamic maternal and fetal factors make a cohesive and supportive care team critical for optimal care. Management of threatened periviable delivery in a post-Roe United States may prioritize fetal outcomes regardless of threat to maternal health due to legal restrictions.

Ethical challenges in first-in-human trials of the artificial placenta and artificial womb: not all technologies are created equally, ethically

Artificial placenta and artificial womb technologies to support extremely premature neonates are advancing toward clinical testing in humans. Currently, no recommendations exist comparing these approaches to guide study design and optimal enrollment eligibility adhering to principles of research ethics. In this paper, we will explore how scientific differences between the artificial placenta and artificial womb approaches create unique ethical challenges to designing first-in-human trials of safety and provide recommendations to guide ethical study design for initial human translation.

Association of mode of delivery with short-term and neurodevelopmental outcomes in periviable singleton infants: A nationwide database study

OBJECTIVE

To evaluate the association of mode of delivery (MOD) with short-term and neurodevelopmental outcomes at 2 years of corrected age (CA) in periviable singleton infants.

METHODS

This retrospective cohort study of the Taiwan Premature Infant Follow-up Network database between 2010 and 2016 compared non-anomalous singleton deliveries (cesarean delivery [CD] vs vaginal delivery [VD]) between 22 0/7 and 25 6/7 gestational weeks. Major morbidities, mortality, and neurodevelopmental outcomes were evaluated at 2-year CA.

RESULTS

The CD and VD groups included 354 and 472 infants, respectively. The intraventricular hemorrhage (IVH) rate was lower in the CD group (54% vs 66%, P = 0.001), but severe IVH differed non-significantly between groups (20% vs 26%, P = 0.057). In the small-for-gestational age subgroup, CD was associated with lower IVH (56% vs 84%, adjusted odds ratio [aOR] 0.17, 95% confidence interval [CI] 0.04-0.69) and better survival without neurodevelopmental impairment (29% vs 8%, aOR, 6.64, 95% CI 1.02-43.29) after controlling for potential confounders.

CONCLUSION

The optimal MOD for periviable singleton birth and its impact are unclear. CD in periviable singleton births is associated with a decreased IVH risk, without improvement in severe IVH, mortality, or neurodevelopment at 2-year CA. The small-for-gestational age subgroup may benefit from CD for better survival without neurodevelopmental impairment.

The new frontier in ECLS: Artificial placenta and artificial womb for premature infants

Outcomes for extremely low gestational age newborns (ELGANs), defined as <28 weeks estimated gestational age (EGA), remain disproportionately poor. A radical paradigm shift in the treatment of prematurity is to recreate the fetal environment with extracorporeal support and provide an environment for organ maturation using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). In this article, we will review clinical indications, current approaches in development, ongoing challenges, remaining milestones and ethical considerations prior to clinical translation.

Safety of performing classical versus low transverse caesarean sections in extremely preterm and very preterm births: Maternal and neonatal complications

AIMS

Improved survivability of extremely preterm infants has led to increased rates of caesarean sections. Short-term maternal and neonatal risks of classical caesarean sections (CCS) in the context of extreme prematurity remain unclear. The aim was to examine maternal and neonatal complications associated with CCSs versus low transverse caesarean sections (LTCS) at extremely preterm (23 0/7-27 6/7 weeks) and very preterm gestational ages (28 0/7-31 6/7 weeks).

METHODS

A retrospective cohort study was conducted at Royal Brisbane and Womens Hospital, Queensland, Australia between 2016 and 2020. Maternal and neonatal outcomes were examined using univariate and multivariate statistical analysis.

RESULTS

CCSs (extremely preterm: n = 93; very preterm: n = 83) were associated with higher estimated blood loss than LTCS (extremely preterm: n = 70; very preterm: n = 287) in very preterm births (CCS: 638 ± 410 mL; LTCS: 556 ± 397 mL; P = 0.01). There was no significant difference in composite maternal outcomes between CCS and LTCS for extremely preterm (adjusted odds ratio (aOR): 1.11; 95% confidence interval (CI): 0.58-2.12; P = 0.75) or very preterm births (aOR: 1.08; 95% CI: 0.63-1.94; P = 0.79) after accounting for multiple pregnancy, placenta accreta and non-cephalic fetal presentations. Although CCSs were associated with lower Apgar scores at 1 min post-birth than LTCSs at very preterm gestational ages (CCS: 5.58 ± 2.10; LTCS: 6.25 ± 2.14; P = 0.02), there was no statistical difference in the rates of intraoperative neonatal injuries or composite outcomes when corrected for low birth weight.

CONCLUSION

Short-term maternal and neonatal outcomes do not significantly differ between CCS and LTCS for extremely preterm or very preterm births.

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.

Milestones for clinical translation of the artificial placenta

Despite significant advances in the treatment of prematurity, premature birth results in significant mortality and morbidity. In particular, extremely low gestational age newborns (ELGANs) defined as <28 weeks estimated gestational age (EGA) suffer from disproportionate mortality and morbidity. A radical paradigm shift in the treatment of prematurity is to recreate fetal physiology using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). Over the past 15 years, tremendous advances have been made in the laboratory confirming long-term support and organ protection and ongoing development. The major milestones to clinical application are miniaturization, anticoagulation, clinical risk stratification, specialized critical care protocols, a regulatory path and a strategy and platform to translate technology to the bedside. Currently, several groups are addressing the remaining milestones for clinical translation.

Patient Decisions Regarding Fetal Monitoring in the Periviable Period and Perinatal and Maternal Outcomes

OBJECTIVE

Management of delivery at periviable gestation requires complex counseling and decision making, including difficult choices about monitoring and potential cesarean delivery (CD) for fetal benefit. Our objective was to characterize decisions that patients make regarding fetal monitoring and potential CD for fetal benefit when delivering in the periviable period, and associations with perinatal and obstetric outcomes. We hypothesize that a significant number of patients forgo monitoring and potential CD for fetal benefit in the periviable period when offered the opportunity to do so.

STUDY DESIGN

Retrospective cohort study of nonanomalous singleton pregnancies delivering between 23^0/7 and 25^6/7 weeks at a tertiary care center from 2015 to 2020 as based on our institutional clinical practice. Since 2015, these patients are offered the ability to accept or decline fetal monitoring, potential CD for fetal benefit, and active resuscitation of a liveborn neonate. The frequency of patients desiring potential CD for fetal benefit was identified, and associations with CD and intrapartum demise were analyzed.

RESULTS

Fifty subjects were included. Seventy-eight percent (n = 39) desired monitoring and potential CD for fetal benefit, and 84% (n = 42) desired resuscitation if the neonate was born alive. This varied by gestational age: 55% (6/11) of patients delivering between 23^0/7 and 23^6/7 weeks desired fetal monitoring and potential CD for fetal benefit, while 90% (19/21) of patients delivering between 25^0/7 and 25^6/7 weeks desired fetal monitoring and potential CD for fetal benefit (p = 0.02). Sixty-nine percent of pregnancies in which potential CD for fetal benefit was desired resulted in CD (27/39), of which 85% were classical (23/27). Intrapartum fetal demise occurred in 45% (5/11) of pregnancies in which monitoring was not performed.

CONCLUSION

While a majority of patients delivering between 23^0/7 and 25^6/7 weeks desired monitoring and potential CD for fetal benefit, this varied significantly by gestational age. The decision to perform monitoring and potential CD for fetal benefit was associated with a high frequency of CD, while the decision to forgo monitoring was associated with high frequency of intrapartum demise.

KEY POINTS

· Patients desires vary in the setting of periviable delivery.. · Periviable monitoring is associated with cesarean delivery.. · Forgoing monitoring is associated with intrapartum demise..

Uterine rupture after previous caesarean section with hysterotomy above the lower uterine segment

Background Spontaneous uterine rupture is a severe pregnancy complication. Several risk factors have been described, especially for women with a previous caesarean section. Method We reported two cases of uterine rupture (UR) occurring outside of labour in patients with a history of caesarean section (CS) due to placenta previa. Results: The current study evaluates how a higher hysterotomy, combined with some risk factors, can increase the prevalence of UR in the subsequent pregnancy. Conclusion This study supports that a careful evaluation of risk factors can identify patients who need a specific follow up to early diagnose and treat UR and thus improve the maternal-fetal outcome.

Controversies in treatment practices of the mother-infant dyad at the limit of viability

In the setting of threatened extreme preterm birth, balancing maternal and fetal risks and benefits in order to choose the best available treatment options is of utmost importance. Inconsistency in treatment practices for infants born between 22 and 24 weeks of gestatotional age may account for inter-hospital variation in survival rates with and without impairment. Most importantly, non-biased and accurate information must be presented to the family as soon as extremely preterm birth is suspected, including counseling on morbidities and mortality associated with delivery at the limits of viability. This review will focus on different therapeutic medical and surgical practices available for threatened extremely preterm birth to improve fetal and maternal outcomes while highlighting the importance of patient-centered approaches.

Pregnancy outcomes and associated factors for uterine rupture: an 8 years population-based retrospective study

Background

Uterine rupture is an obstetrical emergency with serious undesired complications for laboring mothers resulting in fatal maternal and neonatal outcomes. The aim of this study was to assess the incidence of uterine rupture, its association with previous uterine surgery and vaginal birth after caesarean section (VBAC), and the maternal and perinatal implications.

Methods

This is a population-based retrospective study. All pregnant women treated for ruptured uterus in one center between 2013 and 2020 were included. Their information retrieved from the medical records department were reviewed retrospectively.

Results

A total of 209,112 deliveries were included and 41 cases of uterine rupture were identified. The incidence of uterine rupture was 1.96/10000 births. Among the 41 cases, 16 (39.0%) had maternal and fetal complications. There were no maternal deaths secondary to uterine rupture, while perinatal fatality related to uterine rupture was 7.3%. Among all cases, 38 (92.7%) were scarred uterus and 3 (7.3%) were unscarred uterus. The most common cause of uterine rupture was previous cesarean section, while cases with a history of laparoscopic myomectomy were more likely to have serious adverse outcomes, such as fetal death. 24 (59.0%) of the ruptures occurred in anterior lower uterine segment. Changes in Fetal heart rate monitoring were the most reliable signs for rupture.

Conclusions

Incidence of uterine rupture in the study area, Shanghai, China was consistent with developed countries. Further improvements in obstetric care and enhanced collaboration with referring health facilities were needed to ensure maternal and perinatal safety.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04415-6.

Mode of delivery and adverse short- and long-term outcomes in vertex-presenting very preterm born infants: a European population-based prospective cohort study

OBJECTIVES

To compare mortality, morbidity and neurodevelopment by mode of delivery (MOD) for very preterm births with low prelabour risk of caesarean section (CS).

METHODS

The study was a population-based prospective cohort study in 19 regions in 11 European countries. Multivariable mixed effects models and weighted propensity score models were used to estimate adjusted odds ratios (aOR) by observed MOD and the unit's policy regarding MOD. Population: Singleton vertex-presenting live births at 24 + 0 to 31 + 6 weeks of gestation without serious congenital anomalies, preeclampsia, HELLP or eclampsia, antenatal detection of growth restriction and prelabour CS for fetal or maternal indications.

RESULTS

Main outcome measures: A composite of in-hospital mortality and intraventricular haemorrhage (grade III/IV) or periventricular leukomalacia. Secondary outcomes were components of the primary outcome, 5 min Apgar score <7 and moderate to severe neurodevelopmental impairment at two years of corrected age. The rate of CS was 29.6% but varied greatly between countries (8.0-52.6%). MOD was not associated with the primary outcome (aOR for CS 0.99; 95% confidence interval [CI] 0.65-1.50) when comparing units with a systematic policy of CS or no policy of MOD to units with a policy of vaginal delivery (aOR 0.88; 95% CI 0.59-1.32). No association was observed for two-year neurodevelopment impairment for CS (aOR 1.15; 95% CI 0.66-2.01) or unit policies (aOR 1.04; 95% CI 0.63-1.70).

CONCLUSIONS

Among singleton vertex-presenting live births without medical complications requiring a CS at 24 + 0 to 31 + 6 weeks of gestation, CS was not associated with improved neonatal or long-term outcomes.

Development of an artificial placenta for support of premature infants: narrative review of the history, recent milestones, and future innovation

Over 50 years ago, visionary researchers began work on an extracorporeal artificial placenta to support premature infants. Despite rudimentary technology and incomplete understanding of fetal physiology, these pioneering scientists laid the foundation for future work. The research was episodic, as medical advances improved outcomes of premature infants and extracorporeal life support (ECLS) was introduced for the treatment of term and near-term infants with respiratory or cardiac failure. Despite ongoing medical advances, extremely premature infants continue to suffer a disproportionate burden of mortality and morbidity due to organ immaturity and unintended iatrogenic consequences of medical treatment. With advancing technology and innovative approaches, there has been a resurgence of interest in developing an artificial placenta to further diminish the mortality and morbidity of prematurity. Two related but distinct platforms have emerged to support premature infants by recreating fetal physiology: a system based on arteriovenous (AV) ECLS and one based on veno-venous (VV) ECLS. The AV-ECLS approach utilizes only the umbilical vessels for cannulation. It requires immediate transition of the infant at the time of birth to a fluid-filled artificial womb to prevent umbilical vessel spasm and avoid gas ventilation. In contradistinction, the VV-ECLS approach utilizes the umbilical vein and the internal jugular vein. It would be applied after birth to infants failing maximal medical therapy or preemptively if risk stratified for high mortality and morbidity. Animal studies are promising, demonstrating prolonged support and ongoing organ development in both systems. The milestones for clinical translation are currently being evaluated.

[Pregnancy outcomes in women with previous preterm cesarean delivery between 22 and 28 weeks of gestation]

INTRODUCTION

The rate of caesarean delivery between 22 and 28 weeks of gestation (weeks) has increased for several years. The aim of the study was to describe subsequent pregnancies in women with a history of caesarean delivery between 22 and 28 weeks.

METHODS

We performed a retrospective, observational, bicentric cohort study in tertiary care maternity units. We included women who had a caesarean delivery between 22 and 28 weeks from December 1, 2014 to December 31, 2017. We then retrospectively collected data on subsequent pregnancies of these patients up to March 2020. We described the subsequent pregnancy rate and the outcomes of these pregnancies.

RESULTS

Among the 186 women who had a caesarean between 22 and 28 weeks, data from 103 of them could be collected, including 47 (45.6%) women who had 64 new pregnancies. Of the 47 first pregnancies after the preterm cesarean, 19 (40.4%) were completed at≥37 weeks. The mode of delivery was a cesarean in 23 cases (79.3%). A trial of labor after cesarean was only considered in 7 cases (24.1%), and 6 women (20.7%) gave birth vaginally.

CONCLUSIONS

If pregnancy is desired after a caesarean between 22 and 28 weeks, the pregnancy rate is high without recurrence of prematurity in the majority of cases. Cesarean delivery is the most common mode of delivery. In case of trial of labor after cesarean, the success rate is reasonable.

Maternal morbidity by attempted route of delivery in periviable birth

OBJECTIVE

Much of the literature on clinical decision-making regarding the optimal route of delivery for periviable birth, 23 0/7-25 6/7 weeks gestation, has focused on neonatal risks. In fact, routine cesarean delivery at these early gestational ages has not been shown to improve neonatal mortality or neurological outcomes. Neonatal risks associated with the route of delivery are well known. Conversely, there is a paucity of data on maternal morbidity associated with the route of delivery. We examined maternal morbidity according to the attempted route of delivery in women undergoing periviable birth.

STUDY DESIGN

In a secondary analysis of the Consortium on Safe Labor, a retrospective cohort study, maternal outcomes were compared between attempted vaginal delivery and planned cesarean delivery in women undergoing periviable birth. Analyses were repeated to compare maternal outcomes among actual mode of delivery (vaginal delivery versus cesarean delivery). Multivariable Poisson regression was used to estimate adjusted relative risks (aRR) with 95% confidence intervals (95% CI), controlling for predefined covariates.

RESULTS

Of 678 women who underwent periviable birth, 558 (82.3%) and 120 (17.7%) attempted vaginal delivery and planned cesarean delivery, respectively. Of 558 women who attempted a vaginal delivery, 411 (73.7%) achieved a vaginal delivery. Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery were less likely to have endometritis (3.1 versus 15.0%; aRR 0.18, 95% CI 0.09-0.35). Women who attempted a vaginal delivery compared to those who had a planned cesarean delivery had 7-day shorter total length of hospital stay (p < .001). Comparison of actual mode of delivery showed that women with vaginal had decreased risks of fever (2.9 versus 7.9%; aRR 0.42, 95% CI 0.20-0.90), endometritis (0.5 versus 12.4%; aRR 0.03, 95% CI 0.01-0.13), and maternal thrombosis (0.2 versus 3.0%; aRR 0.08, 95% CI 0.01-0.93) compared to cesarean delivery. Women with vaginal delivery had 3-day shorter total length of hospital stay (p < .001) compared to cesarean delivery.

CONCLUSION

The majority of women (73.7%) who attempted a vaginal delivery achieved a vaginal delivery. Attempting a vaginal delivery between 23 0/7 and 25 6/7 weeks gestation compared to a planned cesarean delivery was associated with decreased risks of maternal infectious morbidity. Deciding the route of delivery is challenging in women undergoing periviable delivery. Our analysis provides important information on short-term maternal risks when considering the risks and benefits during these discussions.

Previous preterm cesarean delivery and risk of uterine rupture in subsequent trial of labor-a national cohort study

BACKGROUND

Previous cesarean delivery is the major risk factor for uterine rupture in subsequent trial of labor. It has been suggested that a previous preterm cesarean delivery is associated with an increased risk of uterine rupture compared with a previous term cesarean delivery. However, the proposed association has only been investigated in a few studies and never in a study based on unselected contemporary prospectively collected data.

OBJECTIVE

This study aimed to investigate the risk of uterine rupture among women attempting trial of labor after 1 previous preterm cesarean delivery compared with women with 1 previous term cesarean delivery.

STUDY DESIGN

In this population-based cohort study, we used the Swedish Medical Birth Register between 1983 and 2016 and identified 9300 women with 1 previous preterm index cesarean delivery, 57,168 women with 1 previous term index cesarean delivery, and a second outcome delivery defined as trial of labor after 1 previous cesarean delivery. The risk of the main outcome uterine rupture and secondary outcomes placental abruption; placenta accreta spectrum; postpartum hemorrhage; blood transfusion; appearance, pulse, grimace, activity, and respiration of <7 at 5 minutes; neonatal cerebral dysfunction; and neonatal seizures were assessed using multivariate logistic regression models adjusted for potential confounders.

RESULTS

Among women with a preterm index cesarean delivery, 102 (1.1%) had uterine rupture in the outcome delivery compared with 759 of women (1.4%) with term index cesarean delivery. This corresponded to a decreased risk of uterine rupture for women with preterm index cesarean delivery (odds ratio, 0.79; 95% confidence interval, 0.64-0.97), which did not remain significant in the analysis adjusted for maternal age, interdelivery interval, maternal body mass index, maternal height, induction of labor, postoperative infection after index cesarean delivery, and birthweight (odds ratio, 0.94; 95% confidence interval, 0.74-1.18). Stratifying by gestational week at index cesarean delivery (32+0 to 36+6 and <32+0 weeks' gestation) did not alter the main result. Stratifying by interdelivery interval revealed that women with a preterm index cesarean delivery were at a decreased risk of uterine rupture (odds ratio, 0.55 [95% confidence interval, 0.39-0.78]; adjusted odds ratio, 0.74 [95% confidence interval, 0.51-1.07]) in interdelivery intervals of >36 months whereas there were no significant differences within other time intervals. Of the secondary outcomes, 89 women (1.0%) with preterm index cesarean delivery were diagnosed as having placental abruption compared with 331 women (0.6%) with term index cesarean delivery, which corresponded to an approximately 60% increased risk (odds ratio, 1.66; 95% confidence interval, 1.31-2.10), which remained significant after adjusting for confounders (odds ratio, 1.49; 95% confidence interval, 1.13-1.96). Likewise, there was a slightly increased risk of postpartum hemorrhage for women with preterm index cesarean delivery (adjusted odds ratio, 1.12; 95% confidence interval, 1.02-1.24). There were no significant differences in the remaining secondary outcomes.

CONCLUSION

The findings of this study suggest that preterm cesarean delivery is not associated with an increased risk of uterine rupture. Hence, women with 1 previous preterm cesarean delivery (with lower uterine segment incision) should receive medical management and counseling similar to women with previous term cesarean delivery before trial of labor after cesarean delivery.

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.

Advances in Management for Preterm Fetuses at Risk of Delivery

Preterm birth accounts for only 11% of live births but contributes to up to 75% of neonatal mortality and more than half of long-term morbidity. Targeted interventions to reduce the most common causes of perinatal morbidity and mortality include intrapartum group B Streptococcus prophylaxis, magnesium sulfate for fetal neuroprotection, antenatal corticosteroids for fetal lung maturity, latency antibiotics for preterm premature rupture of membranes, and tocolysis to allow corticosteroid administration and transfer to a tertiary care center. This article reviews the evidence for interventions to improve outcomes for fetuses at risk for preterm delivery at different gestational ages.

Impact of Medical Doctors Global Health and Tropical Medicine on decision-making in caesarean section: a pre- and post-implementation study in a rural hospital in Malawi

BACKGROUND

Medical doctors with postgraduate training in Global Health and Tropical Medicine (MDGHTM) from the Netherlands, a high-income country with a relatively low caesarean section rate, assist associate clinicians in low-income countries regarding decision-making during labour. Objective of this study was to assess impact of the presence of MDGHTMs in a rural Malawian hospital on caesarean section rate and indications.

METHODS

This retrospective pre- and post-implementation study was conducted in a rural hospital in Malawi, where MDGHTMs were employed from April 2015. Indications for caesarean section were audited against national protocols and defined as supported or unsupported by these protocols. Caesarean section rates and numbers of unsupported indications for the years 2015 and 2016 per quarter for different staff cadres were assessed by linear regression.

RESULTS

Six hundred forty-five women gave birth by caesarean section in the study period. The caesarean rate dropped from 20.1 to 12.8% (p < 0.05, R² = 0.53, y = - 0.0086x + 0.2295). Overall 132 of 501 (26.3%) auditable indications were not supported by documentation in medical records. The proportion of unsupported indications dropped significantly over time from 47.0 to 4.4% (p < 0.01, R² = 0.71, y = - 0.0481x + 0.4759). Stratified analysis for associate clinicians only (excluding caesarean sections performed by medical doctors) showed a similar decrease from 48.3 to 6.5% (p < 0.05, R² = 0.55, y = - 0.0442x + 0.4805).

CONCLUSIONS

Our results indicate that presence of MDGHTMs was accompanied by considerable decreases in caesarean section rate and proportion of unsupported indications for caesarean section in this facility. Their presence is likely to have influenced decision-making by associate clinicians.

Decision-making at the limit of viability

Babies born at the limit of viability have a high risk of morbidity and mortality. Despite great advances in science, the approach to these newborns remains challenging. Thus, this study reviewed the literature regarding the treatment of newborns at the limit of viability. There are several interventions that can be applied before and after birth to increase the baby's survival with the least sequelae possible, but different countries make different recommendations on the gestational age that each treatment should be given. There is more consensus on the extremities of viability, being that, at the lower extremity, comfort care is preferred and active care in newborns with higher gestational age. The higher the gestational age at birth, the higher the survival and survival without morbidity rates. At all gestational ages, it is important to take into account the suffering of these babies and to provide them the best quality of life possible. Sometimes palliative care is the best therapeutic approach. The parents of these babies should be included in the decision-making process, if they wish, always respecting their needs and wishes. Nevertheless, the process of having such an immature child can be very painful for parents, so it is also important to take into account their suffering and provide them with all the necessary support. This support should be maintained even after the death of the newborn.

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.

Periviability: A Review of Key Concepts and Management for Perinatal Nursing

One of the most complex clinical problems in obstetrics and neonatology is caring for pregnant women at the threshold of viability. Births near viability boundaries are grave events that carry a high prevalence of neonatal death or an increased potential for severe lifelong complications and disabilities among those who survive. Compared with several decades ago, premature infants receiving neonatal care by today's standards have better outcomes than those born in other eras. However, preterm labor at periviability represents a more complex counseling and management challenge. Although preterm birth incidence between 20/7 and 25/7 weeks has remained unchanged, survival rates at earlier gestational ages have increased as perinatal and neonatal specialties have become more adept at caring for this at-risk population. Women face difficult choices about obstetric and neonatal interventions in light of uncertainties around survival and outcomes. This article reviews current neonatal statistics in reference to short- and long-term outcomes, key concepts in obstetric clinical management of an anticipated periviable birth, and counseling guidance to ensure shared-decision making.

Contemporary Trends in Cesarean Delivery Utilization for Live Births Between 22 0/7 and 23 6/7 Weeks of Gestation

OBJECTIVE

In 2014, the Society for Maternal-Fetal Medicine, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists published an executive summary of a joint workshop to establish obstetric interventions to be considered for periviable births. We sought to evaluate changes in practice patterns since the publication of these guidelines.

METHODS

We conducted a population-based cohort study of all singleton live births delivered between 22 0/7 and 23 6/7 weeks of gestation in the United States within two time epochs: pre-executive summary (Epoch 1: 2012-2013) and post-executive summary (Epoch 2: 2015-2016) guideline release. The primary outcome was the difference in the rate of cesarean delivery between pre-executive summary and post-executive summary guideline publication. Secondary outcomes included differences in rates of individual and composite neonatal interventions (neonatal intensive care unit admission, ventilation, surfactant and antibiotic administration), maternal adverse outcomes (intensive care unit admission, transfusion, hysterectomy, uterine rupture), and neonatal mortality. Multivariable logistic regression estimated the association of delivery epoch with outcomes.

RESULTS

There were 15,846,405 live births in the United States between 2012-2013 and 2015-2016, of which 14,799 (0.1%) were singletons delivered between 22 and 24 weeks of gestation. Among these live births, 7,374 (52.3%) were delivered in Epoch 1 and 7,425 (47.7%) in Epoch 2. Cesarean delivery rates increased from Epoch 1 to Epoch 2 (24.3% vs 28.4%, P<.001), which was attributable to increased cesarean utilization during the 23rd week (36.3% vs 40.8%, difference 4.5%, 95% CI 2.3-6.6). Likewise, the rate of composite neonatal interventions increased (50.6% vs 56.9%, difference 6.3%, 95% CI 4.6-8.0) between Epochs 1 and 2, in association with a slight reduction in neonatal mortality (67.2% vs 64.6%, P=.009). There was no statistically significant difference in composite (8.9% vs 9.5%, P=.261) adverse maternal outcomes between delivery epochs.

CONCLUSION

The frequency of delivery by cesarean in the 23rd week increased by 4.5% after publication of the periviable birth executive summary. The observed increase in cesarean delivery and composite neonatal interventions between delivery cohorts was associated with a small reduction in neonatal mortality.

Putting the "M" back in maternal-fetal medicine: A 5-year report card on a collaborative effort to address maternal morbidity and mortality in the United States

The Centers for Disease Control and Prevention have demonstrated continuous increased risk for maternal mortality and severe morbidity with racial disparities among non-Hispanic black women an important contributing factor. More than 50,000 women experienced severe maternal morbidity in 2014, with a mortality rate of 18.0 per 100,000, higher than in many other developed countries. In 2012, the first "Putting the 'M' back in Maternal-Fetal Medicine" session was held at the Society for Maternal-Fetal Medicine's (SMFM) Annual Meeting. With the realization that rising risk for severe maternal morbidity and mortality required action, the "M in MFM" meeting identified the following urgent needs: (i) to enhance education and training in maternal care for maternal-fetal medicine (MFM) fellows; (ii) to improve the medical care and management of pregnant women across the country; and (iii) to address critical research gaps in maternal medicine. Since that first meeting, a broad collaborative effort has made a number of major steps forward, including the proliferation of maternal mortality review committees, advances in research, increasing educational focus on maternal critical care, and development of comprehensive clinical strategies to reduce maternal risk. Five years later, the 2017 M in MFM meeting served as a "report card" looking back at progress made but also looking forward to what needs to be done over the next 5 years, given that too many mothers still experience preventable harm and adverse outcomes.

Maternal Complications Associated With Periviable Birth

OBJECTIVE

To quantify the rate of maternal complications associated with a periviable birth in a contemporary population of live births in the state of Ohio.

METHODS

We conducted a population-based retrospective cohort study of all live births in Ohio (2006-2015). Maternal, obstetric, and neonatal characteristics were compared between women who delivered in the periviable period (20-25 weeks of gestation) with those who delivered preterm (26-36 weeks of gestation) and at term (greater than 36 weeks of gestation). Women were also stratified by 3-week gestational age epochs (ie, 20-22, 23-25 weeks of gestation). The primary study outcome was a composite of individual adverse maternal outcomes (chorioamnionitis, blood product transfusion, hysterectomy, unplanned operation, and intensive care unit [ICU] admission). Multivariate logistic regression estimated the relative association of periviable birth with maternal complications.

RESULTS

Of 1,457,706 live births in Ohio during the 10-year study period, 6,085 live births (0.4%) occurred during the periviable period (20-25 weeks of gestation). The overall rate of the composite adverse outcome was 17.2%. In multivariate analysis, periviable birth was associated with an increased risk of the composite adverse maternal outcome (adjusted relative risk [RR] 5.8, CI 5.4-6.2) and individual complications including transfusion (adjusted RR 4.4, CI 3.4-5.7), unplanned operative procedure (adjusted RR 2.0, CI 1.7-2.4), unplanned hysterectomy (adjusted RR 7.8, CI 4.6-13.0), uterine rupture (adjusted RR 7.1, CI 3.8-13.4), and ICU admission (adjusted RR 9.6, CI 7.2-12.7) compared with the term cohort. Delivery between 20-22 weeks and 23-25 weeks of gestation was associated with the highest risk of composite adverse outcome. The risk of composite adverse outcome decreased with advancing gestational age stratum.

CONCLUSION

Periviable birth is associated with significant maternal morbidity. Nearly one in five women in this cohort had a serious morbidity associated with their periviable delivery.

Caesarean section improves neonatal outcomes only from 24 + 0 weeks for periviable breech but not for cephalic infants

Background: Although caesarean delivery at periviable gestations may minimize birth trauma, it may not necessarily improve perinatal outcomes. The aim of this study was to assess the impact of mode of birth on outcomes for breech versus cephalic presentation at 22 + 0-25 + 6 weeks.Methods: Retrospective cohort study of single, nonanomalous infants at 22 + 0-25 + 6 weeks gestation born at a tertiary center in Australia. Neonatal outcomes were analyzed comparing both breech and cephalic presentation and mode of delivery.Results: Six hundred and eighty eight women fulfilled the inclusion criteria with 39.7% (273/688) breech and 60.3% (415/688) cephalic infants. Survival was 31.5% (86/273) and 38.1% (158/415) in the breech and cephalic cohorts respectively. Vaginal breech infants had reduced odds of survival compared to the vaginal cephalic group (aOR 0.37, 95% CI 0.17-0.75, p < .01) with no difference in survival if delivery occurred by caesarean section. Vaginal breech birth had higher odds of very low Apgar scores, stillbirth, and neonatal death. At 22 + 0-22 + 6 weeks, outcomes were universally fatal. At 24 + 0-24 + 6 and 25 + 0-25 + 6 weeks, vaginal breech birth had lower odds of survival (aOR 0.33, 95% CI 0.13-0.84, p < .05 and aOR 0.10, 95% CI 0.03-0.34, p < .001 respectively) compared to caesarean breech births.Conclusions: Caesarean section improves perinatal outcomes for periviable breech infants > 24 + 0 weeks.

Indications for increase in caesarean delivery

BACKGROUND

The increasing caesarean delivery rate worldwide is followed by increased maternal morbidity due to pathological placentation, peripartum hysterectomy and obstetric bleeding. The aim of this study was to investigate the indications for caesarean delivery.

STUDY DESIGN

A retrospective observational study. Data were retrieved from the Swedish Pregnancy Register and obstetric records at a tertiary hospital in Sweden between the early 1990s and 2015.

RESULTS

Caesarean delivery in Sweden increased from 10% in the early 1990s to 17% in 2015 concomitantly with decreased instrumental delivery and increased labour induction. Most planned caesareans at the tertiary hospital were performed on maternal request with a rate increasing from 0.6 to 4.6% of all deliveries (p < 0.001), and 60% of these women reported secondary fear of vaginal delivery. The second most common indication previous uterine scar increased from 1.2 to 2.3% (p < 0.001). Most urgent caesareans in 2015 were carried out because of prolonged labour with the rate increasing from 2.1% to 5.4% of all deliveries (p < 0.001). The second most common indication was imminent fetal asphyxia which increased from 2.4 to 2.6% (p < 0.01).

CONCLUSIONS

The Swedish caesarean delivery rate increased concomitantly with a decrease in instrumental delivery and an increase in labour induction. Most of the planned caesareans were performed on maternal request and most of the urgent caesareans were carried out because of prolonged labour. These findings emphasise the importance of standardised definitions of maternal request and follow-up after a negative birth experience, as well as adequate definitions of prolonged labour and foetal asphyxia to decrease unnecessary caesareans.

Induction of Labor for Maternal Indications at a Periviable Gestational Age; Survey on Management, Reporting and Auditing amongst Dutch Maternal-Fetal Medicine Specialists and Neonatologists

Background  In cases of life-threatening maternal conditions in the periviable period, professionals may consider immediate delivery with fetal demise as a consequence of the treatment. We sought the opinion of involved medical professionals on management, reporting, and auditing in these cases. Methods  We performed an online survey amongst all registered maternal-fetal medicine (MFM) specialists and neonatologists in the Netherlands. The survey presented two hypothetical cases of severe early-onset pre-eclampsia at periviable gestational ages. Management consisted of immediate termination or expectant management directed towards newborn survival. Findings  In the case managed by immediate termination, 62% percent answered that fetal demise resulting from induction of labor for maternal indications should be audited only within the medical profession. In the case of expectant management, 17% of the participants agreed with this management. Some answers revealed a significant difference in opinion between the medical specialists. Conclusion  Perspective of MFM specialists and neonatologists differs with regard to counseling prospect parents in case of severe early onset pre-eclampsia. The majority of professionals is willing to report late termination (after 24 weeks' gestation) for severe maternal disease to medical experts for internal audits but not for legal auditing.

[Maternal outcomes in case of cesarean before 32weeks of gestation: A retrospective observational study]

OBJECTIVES

In recent years, active neonatal care in case of prematurity leads to an increase of cesarean delivery rate. Data remains sparse on maternal morbidity induced by preterm cesareans and especially before 32 weeks of gestation. The main aim of this study was to evaluate per-partum maternal morbidity in case of cesarean performed before 32 week of gestation. As secondary objectives, we assessed post-partum maternal morbidity and factors associated with maternal morbidity.

METHODS

This is a retrospective single-center study conducted in a tertiary care unit between 2014 and 2016 including cesareans performed before 32 week of gestation in the study period. The primary outcome was a composite criterion of per partum maternal morbidity including post-partum hemorrhage, blood transfusion, general anesthesia, surgical wounds and maternal death. The secondary outcome was the post-partum maternal morbidity, defined by a composite criterion including hospitalization more than 7 days, infectious disease, wall and digestive complication and venous thromboembolic disease.

RESULTS

Two hundred and eleven women were included. Maternal morbidity occurred in 21.3% in per partum and in 20.4% in post-partum. The factors associated with per partum morbidity were low-lying placenta (OR=4.40 [1.01-19.09]) and non-fetal indication of cesarean (OR=2.10[1.01-4.42]). The factors associated with post-partum morbidity were twin-pregnancy (OR=2.90 [1.12-7.54]), general anesthesia (OR=4.19 [1.68-10.49]) and non-cephalic fetal presentation (OR= 2.70 [1.23-5.93]).

CONCLUSION

The maternal morbidity of cesareans before 32 week of gestation is more than 20%. This study confirms the high maternal morbidity associated with caesareans performed before 32 weeks of gestation.

Intraoperative adverse events associated with extremely preterm cesarean deliveries

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.

Comparison of cesarean versus vaginal delivery of extremely preterm gestations in breech presentation: retrospective cohort study

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.

Short interpregnancy interval increases the risk of preterm premature rupture of membranes and early delivery

OBJECTIVES

Preterm premature rupture of membranes (PPROM) is a major contributor to overall preterm birth (PTB) rates. A short interpregnancy interval (IPI) is a well-known risk factor for PTB. It is unknown if a short IPI specifically affects the risk of developing PPROM in a subsequent pregnancy. We sought to determine the association between IPI and the risk of PPROM in a subsequent pregnancy.

METHODS

A retrospective cohort study using the Missouri birth certificate database of singleton births from 2003 to 2013 was conducted. A short IPI (delivery of the prior pregnancy to conception of the index pregnancy) was defined as ≤6 months. IPI >6 months was categorized into two groups: IPI 7-23 months and IPI ≥24 months. PPROM was defined as premature rupture of membranes between 16⁰ and 36⁶ weeks. Multivariable logistic regression was conducted to determine the association between IPI and PPROM while controlling for maternal age, race, body mass index (BMI), education level, use of social services (Medicaid insurance, food stamps, or participation in the WIC [Women, Infants, and Children] program), tobacco use, and history of PTB. Secondary outcome included the gestational age at delivery, categorized into five subgroups (≤24⁰, 24¹-28⁰, 28¹-32⁰, 32¹-34⁰, and 34¹-36⁶ weeks).

RESULTS

474,957 subjects with singleton gestations had data available to calculate the IPI. Of these, 1.4% (n = 6797) experienced PPROM. IPI ≤6 months was significantly associated with an increased risk of developing PPROM compared with patients with IPI ≥24 months (odds ratio (OR) 1.80, 95% CI 1.70-1.90, p < .001). A higher proportion of women with IPI ≤6 months delivered between 28¹ and 32⁰ weeks compared to the other two IPI groups (27.0 versus 15.0 and 16.4%, p < .001). Individual maternal factors associated with an increased risk of PPROM included advanced maternal age, African American race, BMI <18.5 kg/m², BMI ≥30 kg/m², use of social services, tobacco use, and a prior PTB.

CONCLUSION

Our data demonstrate that an IPI of ≤6 months is significantly associated with an increased risk of developing PPROM in the subsequent pregnancy. Of greater clinical relevance is that these women were more likely to deliver between 28¹ and 32⁰ weeks as compared with women with a longer IPI. Novel to this study is the establishment of a specific link between a short IPI and PPROM with subsequent early delivery. Several maternal demographic factors known to be associated with PTB risk were also found to be associated with an increased risk of PPROM. Further studies are necessary to elucidate plausible biologic mechanisms ultimately leading to the development and implementation of preventive and therapeutic strategies for this high-risk cohort.

Incidence and outcomes of uterine rupture among women with prior caesarean section: WHO Multicountry Survey on Maternal and Newborn Health

Caesarean section (CS) is increasing globally, and women with prior CS are at higher risk of uterine rupture in subsequent pregnancies. However, little is known about the incidence, risk factors, and outcomes of uterine rupture in women with prior CS, especially in developing countries. To investigate this, we conducted a secondary analysis of the World Health Organization Multicountry Survey on Maternal and Newborn Health, which included data on delivery from 359 facilities in 29 countries. The incidence of uterine rupture among women with at least one prior CS was 0.5% (170/37,366), ranging from 0.2% in high-Human Development Index (HDI) countries to 1.0% in low-HDI countries. Factors significantly associated with uterine rupture included giving birth in medium- or low-HDI countries (adjusted odds ratio [AOR] 2.0 and 3.88, respectively), lower maternal educational level (≤6 years) (AOR 1.71), spontaneous onset of labour (AOR 1.62), and gestational age at birth <37 weeks (AOR 3.52). Women with uterine rupture had significantly higher risk of maternal death (AOR 4.45) and perinatal death (AOR 33.34). Women with prior CS, especially in resource-limited settings, are facing higher risk of uterine rupture and subsequent adverse outcomes. Further studies are needed for prevention/management strategies in these settings.

Maternal outcomes associated with early preterm cesarean delivery

BACKGROUND

Data on complications associated with classic cesarean delivery are conflicting. In extremely preterm cesarean delivery (22 0/7-27 6/7 weeks' gestation), the lower uterine segment is thicker. It is plausible that the rates of maternal complications may not differ between classic and low transverse cesarean.

OBJECTIVE

We sought to compare maternal outcomes associated with classic versus low transverse cesarean after stratifying by gestation (23 0/7-27 6/7 and 28 0/7-31 6/7 weeks' gestation).

STUDY DESIGN

We conducted a multihospital retrospective cohort study of women undergoing cesarean delivery at 23 0/7 to 31 6/7 weeks' gestation from 2005 through 2014. Composite maternal outcome (postpartum hemorrhage, transfusion, endometritis, sepsis, wound infection, deep venous thrombosis/pulmonary embolism, hysterectomy, respiratory complications, and intensive care unit admission) was compared between classic and low transverse cesarean. Outcomes were calculated using multivariable logistic regression models yielding adjusted odds ratios with 95% confidence intervals and adjusted P values controlling for maternal characteristics, emergency cesarean delivery, and comorbidities. Analyses were stratified by gestational age categories (23 0/7-27 6/7 and 28 0/7-31 6/7 weeks' gestation).

RESULTS

Of 902 women, 221 (64%) and 91 (16%) underwent classic cesarean between 23 0/7 and 27 6/7 and between 28 0/7 and 31 6/7 weeks' gestation, respectively. There was no increase in maternal complications for classic cesarean versus low transverse cesarean between 23 0/7 and 27 6/7 weeks' gestation. However, between 28 0/7 and 31 6/7 weeks' gestation, classic cesarean was associated with increased risks of the composite maternal outcome (adjusted odds ratio, 1.95; 95% confidence interval, 1.10-3.45), transfusion (adjusted odds ratio, 2.42; 95% confidence interval, 1.06-5.52), endometritis (adjusted odds ratio, 3.23; 95% confidence interval, 1.02-10.21), and intensive care unit admission (adjusted odds ratio, 5.05; 95% confidence interval, 1.37-18.52) compared to low transverse cesarean.

CONCLUSION

Classic cesarean delivery compared with low transverse was associated with higher maternal complication rates between 28 0/7 and 31 6/7 weeks, but not between 23 0/7 and 27 6/7 weeks' gestation.

Maternal complications in settings where two-thirds of extremely preterm births are delivered by cesarean section

OBJECTIVE

To investigate the maternal complications associated with cesarean section (CS) in the extremely preterm period according to the gestational week (GW) and to indication of delivery.

STUDY DESIGN

This is a retrospective case-referent study with a review of medical records of women who delivered at 22-27 weeks of gestation (n=647) at two level III units in Sweden. For abdominal delivery, gestational length was stratified into 22-24 (n=105) and 25-27 (n=301) weeks. For comparison, data on women who underwent a CS at term were identified in a register-based database.

RESULTS

The rate of CS in extremely preterm births was 62.8%. There was no difference in the complication rates, but types of incisions other than the low transverse incision were required more often at 22-24 (18.1%) weeks than at 25-27 GWs (9.6%) (P=0.02). Major maternal complications occurred in 6.6% compared with 2.1% in the extremely preterm and term CS, respectively (P<0.01). A maternal indication of extremely preterm CS increased the risk of complications.

CONCLUSIONS

Almost two-thirds of the births at 22-27 GWs had an abdominal delivery. No increase in short-term morbidity was observed at 22-24 weeks compared to 25-27 weeks. CS performed extremely preterm had more major complications recorded than cesarean at term. The complications are driven by the underlying maternal condition.

[Mode of delivery in spontaneous preterm birth]

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.

Periviable birth: Interim update

Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.

#3: Periviable birth

Approximately 0.5% of all births occur before the third trimester of pregnancy, and these very early deliveries result in the majority of neonatal deaths and more than 40% of infant deaths. A recent executive summary of proceedings from a joint workshop defined periviable birth as delivery occurring from 20 0/7 weeks to 25 6/7 weeks of gestation. When delivery is anticipated near the limit of viability, families and health care teams are faced with complex and ethically challenging decisions. Multiple factors have been found to be associated with short-term and long-term outcomes of periviable births in addition to gestational age at birth. These include, but are not limited to, nonmodifiable factors (eg, fetal sex, weight, plurality), potentially modifiable antepartum and intrapartum factors (eg, location of delivery, intent to intervene by cesarean delivery or induction for delivery, administration of antenatal corticosteroids and magnesium sulfate), and postnatal management (eg, starting or withholding and continuing or withdrawing intensive care after birth). Antepartum and intrapartum management options vary depending upon the specific circumstances but may include short-term tocolytic therapy for preterm labor to allow time for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units, to support such services. This document describes newborn outcomes after periviable birth, provides current evidence and recommendations regarding interventions in this setting, and provides an outline for family counseling with the goal of incorporating informed patient preferences. Its intent is to provide support and guidance regarding decisions, including declining and accepting interventions and therapies, based on individual circumstances and patient values.