BACKGROUND AND PURPOSE:

• The reasoning behind performing scheduled sections for preterm infants with growth restriction is the concern that the fetus will not tolerate labor
• Baalbaki et al. (American Journal of Perinatology, 2017) compared neonatal outcomes in preterm FGR following induction of labor vs planned cesarean section

METHODS:

• Retrospective cohort study (2011-2014)
• Cohort: Indicated preterm births with prenatally diagnosed FGR (defined as EFW <10th percentile)
• Exclusion criteria: Delivery <23 weeks or >34 weeks; fetal anomalies; spontaneous labor, maternal cardiac disease or HIV, lack of intrapartum fetal monitoring or IUFD
• Patients were classified based on intended mode of delivery
  • Choice was based on physician’s judgement
  • Cesarean section for obstetric indications such as malposition and nonreassuring fetal status
  • Cesarean not usually based on abnormal umbilical artery Dopplers alone
• Primary outcome was a composite of adverse neonatal outcomes, including perinatal death, cord blood acidemia, chest compressions during neonatal resuscitation, seizures, culture-proven sepsis, necrotizing enterocolitis, and grade III–IV intraventricular hemorrhage
• Secondary analysis was performed examining the impact of umbilical artery Dopplers

RESULTS:

• The study included 101 fetuses with growth restriction between 23 and 34 weeks
• 75 underwent planned C-section
• 46.2% of inductions resulted in vaginal deliveries
• Cesarean section was associated with earlier gestational age, lower EFW and abnormal Dopplers
  • Nonreassuring fetal status was the primary indication for cesarean section
• Scheduled cesarean was not associated with a decreased risk of the composite outcome after adjusting for gestational age and antenatal steroids
  • Adjusted odds ratio [aOR] 1.61 (95% CI, 0.45–5.78)
• This remained true even when only those with abnormal umbilical artery Dopplers (absent or reversed flow) were considered
  • aOR, 2.8 (95% CI, 0.40–20.2)
  • Only 20% with abnormal/critical Dopplers delivered vaginally

CONCLUSION:

• Authors recognize limitations of study including small sample size; however, the study strengths included detailed patient-level data
• Planned cesarean section was not associated with decreased risk of neonate morbidity, even when considering critical umbilical artery Dopplers
• Results suggest that cesarean should not be considered a contraindication to induction of labor in the setting of preterm FGR, even in the setting of critical Dopplers
• Future studies should be conducted to validate the findings in this paper

Learn More – Primary Sources:

Impact of Intended Mode of Delivery on Outcomes in Preterm Growth-Restricted Fetuses

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