Cesarean or Vaginal Delivery for Extremely Preterm Breech Singletons Less Than 28 Weeks?
BACKGROUND AND PURPOSE:
Breech presentation occurs in 30 to 35% of pregnancies between 22-28 weeks
Best mode of delivery for preterm and extremely preterm breech is unclear
Gravovac et al. (BJOG 2018) assessed the safest mode of delivery for preterm breech singletons
Systematic review and meta-analysis
Database search of studies comparing outcomes by delivery mode in actively resuscitated breech infants
All published RCTs and observational (cohort and case-control) studies
Extremely preterm: Defined as <28 weeks
Not actively resuscitated removed so as not to bias toward cesarean section
Primary outcomes (stratified by gestational age)
Death (neonatal, before discharge, or by 6 months)
Severe intraventricular hemorrhage (IVH grades III/IV)
15 studies were included, totaling 12,335 infants
Recommendations based on GRADE methods
‘Strong’ recommendation for those findings that were significant
Cesarean delivery associated with decreased odds of death
23w0d–27w6d: Odds Ratio (OR) 0.59; 95% CI, 0.36-0.95 (strong recommendation for cesarean)
23w0d-24w6d: OR 0.58; 95% CI, 0.44–0.75 (strong recommendation for cesarean)
25w0d-26w6d: OR 0.72; 95% CI, 0.34-1.52 (weak recommendation for cesarean)
27w0d-27w6d: OR 2.04; 95% CI, 0.20-20.62 (weak recommendation against cesarean)
Cesarean delivery associated with decreased odds of severe IVH
23w0d-27w6d: OR 0.51; 95% CI, 0.29-0.91 (strong recommendation for cesarean)
25w0d-26w6d: OR 0.29; 95% CI, 0.07–1.12 (weak recommendation for cesarean)
27w0d-27w6d: OR 0.91; 95% CI, 0.27-3.05 (weak recommendation for cesarean)
Mean proportion of head entrapment
1.1% with caesarean delivery vs 5.5% with vaginal delivery in 4 studies
Dührssen incisions were performed in one study for three cases of head entrapment
C-sections were associated with a 41% reduction in odds for death (particularly in the youngest GA bracket) and a 49% reduction in odds for intraventricular hemorrhage in actively resuscitated breech singletons <28 weeks of gestation
The authors state that “In infants born between 23+0 and 24+6 weeks, caesarean section was associated with a significant reduction in odds of death before discharge to 6 months corrected age, which according to GRADE would have a strong recommendation.”
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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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