Cesarean or Vaginal Delivery for Preterm Fetal Growth Restriction?
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
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
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
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
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