Maternal outcomes associated with early preterm cesarean delivery

Abstract

Background Data on complications associated with classical 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 classical and low transverse cesarean. Objective To compare maternal outcomes associated with classical comparing with 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 multi-hospital retrospective cohort study of women undergoing cesarean delivery at 23 0/7–31 6/7 weeks’ gestation between 2005 and 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 classical 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 classical 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 classical cesarean compared to low transverse cesarean between 23 0/7 and 27 6/7 weeks’ gestation. However, between 28 0/7 and 31 6/7 weeks’ gestation, classical 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 Classical 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.

Medications and in-hospital outcomes in infants born at 22–24 weeks of gestation

“…Cesarean section (63%) was much more common than vaginal delivery (37%) in our cohort, consistent with other studies of periviable infants that have found a prevalence of cesarean sections between 59 and 64% [5,7]. With more interventions, and higher survival of periviable infants over time, cesarean delivery of periviable infants is becoming more common [30][31][32]. Some studies support the idea that delivery via cesarean section may provide benefits for the most immature infants, delivered at 22-25 weeks of gestation, independent of maternal risk factors for cesarean section [33][34][35].…”

“…Some studies support the idea that delivery via cesarean section may provide benefits for the most immature infants, delivered at 22-25 weeks of gestation, independent of maternal risk factors for cesarean section [33][34][35]. However, in one recent study of cesarean sections done at this early GA, almost one in four women experienced a serious maternal complication, regardless of incision type [32]. There have been no randomized controlled trials comparing cesarean delivery with vaginal delivery in the periviable period.…”

Intraoperative adverse events associated with extremely preterm cesarean deliveries

“…They showed that maternal Position of the first fetus for the multiple pregnancies. complications did not differ according to whether women had classical or low-transverse incisions between 23 and 28 weeks of gestation (18). Women in the two groups had significantly different obstetric diseases, with more chorioamnionitis in those at 24-25 weeks and more fetal growth restriction in those at 26-27 weeks.…”

“…Recently, Kawakita et al studied maternal complications according to type of uterine incision and stratified by gestational age. They showed that maternal complications did not differ according to whether women had classical or low‐transverse incisions between 23 and 28 weeks of gestation .…”

“…Neonatal morbidity in extremely preterm births has been studied extensively in the literature, unlike maternal morbidity, especially at gestational ages of 24-25 weeks (11)(12)(13)(14)(15). Data about maternal morbidity of these very early cesareans remain sparse and there are no data about intraoperative adverse events (16)(17)(18)(19).…”