Delivery at 37 or 39 Weeks for Higher Order Cesarean Sections?
The increasing cesarean section rate has resulted in more women who have undergone multiple cesarean sections
Significant risks include intraperitoneal adhesions, hemorrhage and organ injury
The risks of unscheduled delivery need to be balanced against the risk of early term delivery
Miller et al. (American Journal of Perinatology 2018) assessed whether women undergoing a higher order cesarean (3 cesarean deliveries or more) had a difference in perinatal outcome based on timing of delivery
Retrospective cohort study
Participants: Women with singleton gestations and a history of three or more prior cesareans
Higher order cesareans were delivered at two centers
One center delivers at 39 weeks gestation
One center delivers at 37 weeks gestation (following after fetal lung maturity analysis or antenatal steroids)
maternal and neonatal morbidities
Adjustments were made for confounders, including maternal age, race/ethnicity, gravidity, parity, body mass index (BMI) at delivery, number of previous cesareans, concomitant major medical problems, indication for delivery (i.e., scheduled versus unscheduled), and gestational age at delivery
440 women met criteria
2% of women were delivered at the 39 week institution vs 56.8% who delivered at the 37 week institution
Delivery at 37-weeks was associated with a decrease in unscheduled deliveries (15.3 vs. 41.1%; p < 0.001)
Planned delivery at 37 weeks was initially associated with decreased
Incidence of composite maternal morbidity (1.6 vs. 7.9%; p = 0.002)
5-minute Apgar scores less than 7 (0.4 vs. 6.4%; p < 0.001),
These differences were no longer significant after adjusting for confounders
There were no other differences in perinatal outcomes
There were no significant differences between delivery at 37- and 39 weeks gestation for maternal or neonatal outcome
However, delivery at 37 weeks did lead to fewer unscheduled deliveries
The current study was powered (80%) to detect a 10-fold increased incidence of bowel injury and a 5-fold increased incidence of transfusion but not more rare outcomes such as maternal death or hysterectomy
Authors recommend a well powered RCT to further determine impact on maternal and neonatal risks
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