Vaginal birth vs caesarean section for extremely preterm vertex infants: a systematic review and meta-analyses

Jarde, Alexander; Feng, Yu Yang; Viaje, Kristen; Shah, Prakeshkumar S; McDonald, Sarah D.

doi:10.1007/s00404-019-05417-0

Cited by 21 publications

(14 citation statements)

References 36 publications

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“…It is well known that the mode of delivery does not affect the mortality or morbidity rate in preterm infants. However, recent prospective cohort studies and systematic reviews have shown the protective effect of cesarean section on neonatal mortality in EPIs at the threshold of viability [43-45]. Because our study population had an extremely low gestational age (≤25 weeks), we speculated that the highest mortality rate in period 3 might be partly attributed to the lowest cesarean section rate, along with the highest histologic chorioamnionitis rate therein.…”

Section: Discussionmentioning

confidence: 95%

Increased Risk of Meconium-Related Ileus in Extremely Premature Infants Exposed to Antenatal Magnesium Sulfate

et al. 2022

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Introduction: We experienced an increased incidence of meconium-related ileus (MRI) in extremely premature infants (EPIs) while adopting the antenatal magnesium sulfate (MgSO4) protocol for fetal neuroprotection in our neonatal intensive care unit. This study aimed to test whether antenatal MgSO4 use was associated with increased risk of MRI in EPIs. Methods: The incidences of complicated MRI requiring aggressive enema or surgical intervention and other intestinal complications were compared among period 1 (January 2012–December 2013, n = 79), before adoption of the antenatal MgSO4 protocol for fetal neuroprotection; period 2 (January 2014–March 2016, n = 72), when the protocol was adopted; and period 3 (April 2016–September 2018, n = 75), when the protocol was temporarily withdrawn due to concern regarding intestinal complications in EPIs. Results: Despite similar baseline clinical characteristics among infants across the study periods, the MRI and MRI with surgical treatment incidences were higher in period 2 than those in periods 1 and 3 (13% vs. 8% and 6%, p = 0.391, and 11% vs. 0% and 1%, p = 0.001, respectively). In multivariable analysis, exposure to antenatal MgSO4 independently increased the risk of MRI (adjusted odds ratio, 3.8; 95% confidence interval, 1.4, 10.6). Conclusion: Antenatal MgSO4 may increase the risk of MRI, frequently requiring surgical intervention, in EPIs with a gestational age of 25 weeks or less.

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Section: Discussionmentioning

confidence: 95%

Increased Risk of Meconium-Related Ileus in Extremely Premature Infants Exposed to Antenatal Magnesium Sulfate

et al. 2022

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“…If the pregnant woman is not healthy, the fetus will be adversely affected. Studies regarding routine cesarean section in extreme prematurity do not provide risk–benefit clarity, complicating uncertainty about providing palliative care or intensive care for the infant [ 70 ]. Shared decision-making should be used to support the pregnant woman regarding cesarean section decisions if intensive care is going to be provided to the infant [ 11 , 12 , 30 , 71 ].…”

Section: Main Text (Dialogic Discussion)mentioning

confidence: 99%

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

Kaempf

Moore

2023

BMC Med Ethics

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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.

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“…There are two previous meta‐analyses and one Cochrane review on the topic. Jarde et al 60 . included only cephalic fetuses born before 28 weeks.…”

Section: Discussionmentioning

confidence: 99%

“…There are two previous meta-analyses and one Cochrane review on the topic. Jarde et al 60 included only cephalic fetuses born before 28 weeks. However, inclusion of cases with congenital anomaly and the use of birth certificate data, which may be subject to low reliability and validity, potential systematic errors and uncontrollable missing information 61 , constituted major limitations of the study.…”

Section: Comparison With Previous Studiesmentioning

confidence: 99%

Effect of mode of delivery on perinatal outcome in severe preterm birth: systematic review and meta‐analysis

Demertzidou

Chatzakis

Cavoretto

et al. 2023

Ultrasound in Obstet & Gyne

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ObjectiveTo review the evidence on the effect of the mode of delivery on perinatal outcomes of fetuses born before 32 gestational weeks (GW).MethodsMEDLINE, Scopus, Cochrane Central Register of Controlled Trials (Central), the US Registry of clinical trials (www.ClinicalTrials.gov) and grey literature sources were searched, starting from the year 2000, to reflect contemporary practice in perinatal care. Non‐randomized trials that included singleton fetuses, without chromosomal abnormality or major congenital defects, and were born either vaginally or via cesarean delivery, were included in the analysis. Primary outcomes were neonatal death, defined as death in the first 28 days of life, and survival at discharge. Secondary outcomes were other adverse perinatal outcomes. ROBINS‐I tool was used to assess the risk of bias. The overall quality of the evidence for the outcomes was assessed per GRADE. Summary odds ratios (ORs) with 95% confidence intervals (CI) were calculated, and random effects models were used for data synthesis. Subgroup analyses were performed for births before 28 gestational weeks, and births between 28 and 32 gestational weeks, and according to presentation at delivery.Results27 retrospective studies (22317 neonates) were included in the meta‐analysis. All studies reported on singleton pregnancies. Vaginal birth significantly increased the risk of neonatal death (N=1496 neonates) of fetuses born <28w, when all presentations were analyzed (OR 1.87, 95%CI 1.05‐3.35; I2 65%, very low quality), and in breech (N=733) (OR 3.55, 95%CI 2.42‐5.21; I2 21%, moderate quality), while the odds of survival at discharge (N=646) were significantly decreased among the latter as well (OR 0.36, 95%CI 0.24‐0.54; I2 21%, low quality). For breech fetuses born between 28 and 32 gestational weeks, vaginal birth increased the risk of perinatal death (N=1581) (intrapartum and neonatal) (OR 3.06, 95%CI 1.47‐6.35; I2 0%, high quality). In non‐cephalic fetuses born between 24 and 32 gestational weeks, vaginal birth decreases the odds of survival at discharge (N=1068) (OR 0.34, 95%CI 0.22‐0.52; I2 16%, moderate quality).ConclusionThis meta‐analysis suggests that vaginal birth in severe preterm births is associated with an increased risk of neonatal and perinatal death in breech fetuses, while an effect could not be demonstrated in cephalic fetuses.This article is protected by copyright. All rights reserved.

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Vaginal birth vs caesarean section for extremely preterm vertex infants: a systematic review and meta-analyses

Cited by 21 publications

References 36 publications

Increased Risk of Meconium-Related Ileus in Extremely Premature Infants Exposed to Antenatal Magnesium Sulfate

Increased Risk of Meconium-Related Ileus in Extremely Premature Infants Exposed to Antenatal Magnesium Sulfate

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

Effect of mode of delivery on perinatal outcome in severe preterm birth: systematic review and meta‐analysis

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