Maternal and infant morbidity following birth before 27 weeks of gestation: a single centre study

Abstract

Delivery at extreme preterm gestational ages (GA) $$<\;27$$ < 27 weeks is challenging with limited evidence often focused only on neonatal outcomes. We reviewed management and short term maternal, fetal and neonatal outcomes of births for 132 women (22 + 0 to 26 + 6 weeks’ GA) with a live fetus at admission to hospital and in labour or at planned emergency Caesarean section: 103 singleton and 29 (53 live fetuses) twin gestations. Thirty women (23%) had pre-existing medical problems, 110 (83%) had antenatal complications; only 17 (13%) women experienced neither. Major maternal labour and delivery complications affected 35 women (27%). 151 fetuses (97%) were exposed to antenatal steroids, 24 (15%) to tocolysis and 70 (45%) to magnesium sulphate. Delivery complications affected 11 fetuses, with 12 labour or delivery room deaths; survival to discharge was 75% (117/156), increasing with GA: 25% (1/4), 75% (18/24), 69% (29/42), 73% (33/45) and 88% (36/41) at 22, 23, 24, 25 and 26 weeks GA respectively (p = 0.024). No statistically important impact was seen from twin status, maternal illness or obstetric management. Even in a specialist perinatal unit antenatal and postnatal maternal complications are common in extreme preterm births, emphasising the need to include maternal as well as neonatal outcomes.

Management and outcomes of extreme preterm birth

“…Antenatally, counselling should cover risks to the mother as well as longer term outcomes affecting the child: more than a quarter of women in a recent study from a regional referral centre for extreme preterm birth experienced labour or delivery complications such as sepsis and haemorrhage. 2 Predicting outcomes for children born extremely preterm is challenging, however. The child’s long term prognosis is likely to change during the course of the neonatal hospitalisation, particularly if the child experiences major events such as severe brain injury or the need for surgery.…”

“…In women who deliver extremely preterm, and particularly in those who give birth by caesarean, risks include haemorrhage, infection, and admission to the intensive care unit. 2 64 A midline uterine incision or “classic” caesarean section, which has a higher chance of scar dehiscence in subsequent labours than lower segment caesarean section, is more frequently performed, and women are therefore advised against having future vaginal deliveries. Pregnancy related conditions that are associated with extreme preterm birth are also associated with increased risks of disease in the mother.…”

“…Severe maternal morbidity, including sepsis and peripartum haemorrhage, affects around a quarter of mothers delivering at these gestations. 2 For the babies, survival and morbidity rates vary, particularly by gestational age at delivery but also according to other risk factors (birth weight and sex, for example) and by country. 3 4 In this update, we focus on high income countries and provide a broad overview of extreme preterm birth epidemiology, recent changes, and best practices in obstetric and neonatal management, including new treatments such as antenatal magnesium sulphate or changes in delivery management such as delayed cord clamping and placental transfusion.…”

Refining regional organization of services in the UK to improve outcomes of pregnancies delivering at extremely low gestational age

“…It also demands that attention is paid to comfort-focused or palliative care in situations where it is considered that the situation is of extremely high risk to either baby or mother. Indeed, little consideration has been given to the risks of extremely preterm birth to the mother, [26] which are certainly not trivial, [27] see below.…”

“…Eleven fetuses developed intrapartum complications (cord prolapse, unanticipated delivery and head entrapment) and there were 5 intrapartum fetal deaths. [27] Care for women presenting at extremely low gestational ages is accompanied by complex care needs and senior input is necessary. The RCOG has reviewed the evidence base to support care at 23-24 weeks of gestation and suggests a strategy.…”