The Impact of Mode of Delivery on Maternal and Neonatal Outcomes during Periviable Birth (22–25 Weeks)

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 (22^0/7–25^6/7weeks) 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 22^0/7 to 23^6/7 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.

Keywords

periviable birth - mode of delivery - maternal morbidity - neonatal survival - cesarean delivery - fetal head entrapment

Authors' Contributions

All authors made substantial contributions to the conception and design of the work and to the acquisition, analysis, and interpretation of the data. The authors drafted and critically revised the work and approval of the final version submitted for publication.

Note

This work will be presented at the Society for Maternal-Fetal Medicine 42nd Annual Pregnancy Meeting, January 31 to February 5, 2022, in Orlando, FL.

Publikationsverlauf

Eingereicht: 16. Dezember 2021

Angenommen: 22. Februar 2022

Accepted Manuscript online:
04. März 2022

Artikel online veröffentlicht:
31. Mai 2022

• References

• 1 Edmonds BT, McKenzie F, Macheras M, Srinivas SK, Lorch SA. Morbidity and mortality associated with mode of delivery for breech periviable deliveries. Am J Obstet Gynecol 2015; 213 (01) 70.e1-70.e12
• 2 Watkins PL, Dagle JM, Bell EF, Colaizy TT. Outcomes at 18 to 22 months of corrected age for infants born at 22 to 25 weeks of gestation in a center practicing active management. J Pediatr 2020; 217: 52-58.e1
• 3 Ishii N, Kono Y, Yonemoto N, Kusuda S, Fujimura M. Neonatal Research Network, Japan. Outcomes of infants born at 22 and 23 weeks' gestation. Pediatrics 2013; 132 (01) 62-71
• 4 Younge N, Goldstein RF, Bann CM. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Survival and neurodevelopmental outcomes among periviable infants. N Engl J Med 2017; 376 (07) 617-628
• 5 Czarny HN, Forde B, DeFranco EA, Hall ES, Rossi RM. Association between mode of delivery and infant survival at 22 and 23 weeks of gestation. 2021; 3 (04) 100340
• 6 Reddy UM, Rice MM, Grobman WA. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network, Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Serious maternal complications after early preterm delivery (24-33 weeks' gestation). Am J Obstet Gynecol 2015; 213 (04) 538.e1-538.e9
• 7 Rossi RM, DeFranco EA. Maternal complications associated with periviable birth. Obstet Gynecol 2018; 132 (01) 107-114
• 8 Kawakita T, Sondheimer T, Jelin A. et al. Maternal morbidity by attempted route of delivery in periviable birth. J Matern Fetal Neona 2019; 34 (08) 1-8
• 9 Sciscione AC, Landon MB, Leveno KJ. et al; National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU). Previous preterm cesarean delivery and risk of subsequent uterine rupture. Obstet Gynecol 2008; 111 (03) 648-653
• 10 Boyd GE, Lodge J, Flatley CJ, Kumar S. Caesarean section improves neonatal outcomes only from 24 + 0 weeks for periviable breech but not for cephalic infants. J Matern Fetal Neona 2021; 34 (04) 599-605
• 11 Običan SG, Small A, Smith D, Levin H, Drassinower D, Gyamfi-Bannerman C. Mode of delivery at periviability and early childhood neurodevelopment. Am J Obstet Gynecol 2015; 213 (04) 578.e1-578.e4
• 12 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 2021; 28 (21) 00827-00829
• 13 American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus no. 6: periviable birth. Obstet Gynecol 2017; 130 (04) e187-e199
• 14 Rossi RM, Hall E, DeFranco EA. Contemporary trends in cesarean delivery utilization for live births between 22 0/7 and 23 6/7 weeks of gestation. Obstet Gynecol 2019; 133 (03) 451-458
• 15 American College of Obstetricians and Gynecologists. Practice Advisory: Use of Antenatal Corticosteroids at 22 Weeks of Gestation. Website: www.acog.org Published September 2021. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/09/use-of-antenatal-corticosteroids-at-22-weeks-of-gestation#:~:text=More%20recent%20retrospective%2C%20observational%20data,of%20survival%20without%20major%20morbidities
• 16 Carlo WA, McDonald SA, Fanaroff AA. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Association of antenatal corticosteroids with mortality and neurodevelopmental outcomes among infants born at 22 to 25 weeks' gestation. JAMA 2011; 306 (21) 2348-2358
• 17 Travers CP, Carlo WA, McDonald SA. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Mortality and pulmonary outcomes of extremely preterm infants exposed to antenatal corticosteroids. Am J Obstet Gynecol 2018; 218 (01) 130.e1-130.e13
• 18 Gentle SJ, Carlo WA, Tan S. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network. Association of Antenatal corticosteroids and magnesium sulfate therapy with neurodevelopmental outcome in extremely preterm children. Obstet Gynecol 2020; 135 (06) 1377-1386
• 19 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)statement: guidelines for reporting observational studies. PLoS Med 2007; Oct 16; 4 (10) e296
• 20 Berríos-Torres SI, Umscheid CA, Bratzler DW. et al; Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; 152 (08) 784-791
• 21 Lever A, Mackenzie I. Sepsis: definition, epidemiology, and diagnosis. BMJ 2007; 335 (7625): 879-883
• 22 Walsh MC, Kliegman RM. Necrotizing enterocolitis: treatment based on staging criteria. Pediatr Clin North Am 1986; 33 (01) 179-201
• 23 Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr 1978; 92 (04) 529-534
• 24 Jensen EA, Dysart K, Gantz MG. et al. The diagnosis of bronchopulmonary dysplasia in very preterm infants. An evidence-based approach. Am J Respir Crit Care Med 2019; 200 (06) 751-759
• 25 International Committee for the Classification of Retinopathy of Prematurity. The International Classification of Retinopathy of Prematurity revisited. Arch Ophthalmol 2005; 123 (07) 991-999
• 26 Romagano MP, Fofah O, Apuzzio JJ, Williams SF, Gittens-Williams L. Maternal morbidity after early preterm delivery (23–28 weeks). 2020; 2 (03) 100125
• 27 Tucker Edmonds B, McKenzie F, Robinson BK. Maternal-fetal medicine physicians' practice patterns for 22-week delivery management. J Matern Fetal Neonatal Med 2016; 29 (11) 1829-1833
• 28 Sentilhes L, Vayssière C, Beucher G. et al. Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF). Eur J Obstet Gynecol Reprod Biol 2013; 170 (01) 25-32
• 29 Brumbaugh JE, Hansen NI, Bell EF. et al; National Institute of Child Health and Human Development Neonatal Research Network. Outcomes of extremely preterm infants with birth weight less than 400 g. JAMA Pediatr 2019; 173 (05) 434-445
• 30 Lorthe E, Torchin H, Delorme P. et al. Preterm premature rupture of membranes at 22-25 weeks' gestation: perinatal and 2-year outcomes within a national population-based study (EPIPAGE-2). Am J Obstet Gynecol 2018; 219 (03) 298.e1-298.e14
• 31 Kayem G, Combaud V, Lorthe E. et al. Mortality and morbidity in early preterm breech singletons: impact of a policy of planned vaginal delivery. Eur J Obstet Gynecol Reprod Biol 2015; 192: 61-65
• 32 Bodmer B, Benjamin A, McLean FH, Usher RH. Has use of cesarean section reduced the risks of delivery in the preterm breech presentation?. Am J Obstet Gynecol 1986; 154 (02) 244-250
• 33 Pierre CA-O, Leroy A, Pierache A. et al. 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. 2021; 16 (10) e0258303