BACKGROUND AND PURPOSE:

• Breech presentation can remain undiagnosed until a woman is in labor, with potential increased fetal morbidity and mortality
• Wastlund et al. (PLoS Medicine, 2019) investigated universal ultrasound screening for breech presentation at 36 weeks from and sought to assess outcomes and cost-effectiveness

METHODS:

• Prospective cohort study
  • Pregnancy Outcome Prediction study (POP)
• Participants
  • Nulliparous women
• Research screening ultrasound exam at 36 weeks gestation
  • Presentation | Biometry | Doppler | Placental location
  • Findings blinded unless
    • Breech | Low lying placenta | Fetal abnormality (e.g., anomaly or low fluid)
• If a breech ( management based on RCOG guidance)
  • External cephalic version (ECV) if no contraindication
  • Failed ECV: Vaginal breech or elective cesarean
• Fetal outcomes
  • Mode of delivery | Birth weight | Gestational age at delivery
• Cost-Benefit Analysis
  • Compared universal ultrasound to current practice
  • Costs obtained from English National Health Service (NHS)

RESULTS:

• 3,879 women participated in the study
• Breech presentation at 36 weeks
  • 4.6% diagnosed with breech
  • Most unsuspected: 1/40 among undiagnosed women
  • No breech presentations were missed using ultrasound
• ECV
  • Attempted: 46.9%
  • Success rate: 14.3%
• Delivery
  • Vaginal: 10.6%
  • Elective cesarean: 61.5%
  • Emergency cesarean: 27.9%

Economic analysis

Compared to current practice, late pregnancy ultrasound would

• Identify 14,826 otherwise undiagnosed breech presentations across England annually
• Reduce emergency section and vaginal breech delivery
  • Emergency cesarean: Reduction of 0.7% | Approx. 4,196 pregnancies across England annually
  • Vaginal breech delivery: Reduction of 1.0 % | Approx. 6,061 pregnancies across England annually
• Prevent 7.89 neonatal mortalities annually
• This strategy would be cost-effective if fetal presentation could be assessed for ≤£19.80 (approx. $26 USD)/ woman

CONCLUSION:

• Benefits of universal late-term ultrasound for nulliparous women include
  • Eliminating undiagnosed breech presentation
  • Reducing fetal mortality in breech presentation
• Authors conclude this strategy is cost-effective if price brought down to approx. <£20.00/ woman
• Cost-effectiveness analysis will not be generalizable to other countries because costs differ
  • However, calculations were based on a simple scan to primarily identify the presenting part

Learn More – Primary Sources:

Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis

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