Severe maternal morbidity in preterm cesarean delivery: A systematic review and meta-analysis.

More than half of extremely preterm infants are delivered by cesarean section. Few data are available about severe maternal morbidity (SMM) of these extremely preterm cesarean. The objective was to determine whether gestational age under 26 weeks of gestation (weeks) was associated with an increased risk of SMM compared with gestational age between 26 and 34 weeks in women having a cesarean delivery. We searched MEDLINE, ISI Web of Science, the Cochrane Database, PROSPERO, and ClinicalTrials.gov on January 31, 2020. The search strategy clustered terms describing SMM and preterm cesarean delivery. No restrictions on language, publication status, and study design were applied. Abstracts were included if there was sufficient information to assess study quality. The authors of all identified studies were contacted to request for aggregated data. Relative risks (RR) were calculated using the inverse variance method. The primary outcome was SMM as defined in each study. We analyzed data on preterm cesarean deliveries between 22 and 34 weeks. The protocol was registered in PROSPERO (registration: CRD42019128644). Six studies involving 45,572 women (3,440 delivering < 26 weeks; 42,132 delivering between 26 and 34 weeks) were included. SMM occurred in 607 women (17.6 %) < 26 weeks and 4,483 women (10.6 %) between 26 and 34 weeks. Gestational age < 26 weeks was associated with an increased risk of SMM (RR, 1.65; 95 % CI [Confidence Interval], 1.52-1.78; I2 = 40 %). Gestational age < 26 weeks remained associated with SMM in the subgroup analyses depending on the type of the study (prospective or retrospective), country of the study (European or non-European), and high quality of the study. A sensitivity analysis showed that gestational age < 25 weeks was also associated with SMM in preterm cesarean delivery (RR, 1.66; 95 % CI, 1.50-1.83; I2 = 3%). Gestational age < 26 weeks was associated with an increased risk of SMM in women having a preterm cesarean delivery. Obstetricians and neonatologists should be aware of the increased risk of SMM in cesarean.

Blanc J ，Rességuier N ，Loundou A ，Boyer L ，Auquier P ，Tosello B ，d'Ercole C ... -  《-》

Confirmed severe maternal morbidity is associated with high rate of preterm delivery.

Because severe maternal morbidity (SMM) is increasing in the United States, affecting up to 50,000 women per year, there was a recent call to review all mothers with SMM to better understand their morbidity and improve outcomes. Administrative screening methods for SMM have recently been shown to have low positive predictive value for true SMM after chart review. To ultimately reduce maternal morbidity and mortality we must better understand risk factors, and preventability issues about true SMM such that interventions could be designed to improve care. Our objective was to determine risk factors associated with true SMM identified from California delivery admissions, including the relationship between SMM and preterm delivery. In this retrospective cohort study, SMM cases were screened for using International Classification of Diseases, Ninth Revision codes for severe illness and procedures, prolonged postpartum length of stay, intensive care unit admission, and transfusion from all deliveries in 16 hospitals from July 2012 through June 2013. Charts of screen-positive cases were reviewed and true SMM diagnosed based on expert panel agreement. Underlying disease diagnosis was determined. Women with true-positive SMM were compared to SMM-negative women for the following variables: maternal age, ethnicity, gestational age at delivery, prior cesarean delivery, and multiple gestation. In all, 491 women had true SMM and 66,977 women did not have SMM for a 0.7% rate of true SMM. Compared to SMM-negative women, SMM cases were significantly more likely to be age >35 years (33.6 vs 23.8%; P < .0001), be African American (14.1 vs 7.9%; P < .0001), have had a multiple gestation (9.7 vs 2.1%; P < .0001), and, for the multiparous women, have had a prior cesarean delivery (58 vs 30.2%; P < .0001). Preterm delivery was significantly more common in SMM women compared to SMM-negative women (41 vs 8%; P < .0001), including delivery <32 weeks (18 vs 2%; P < .0001). The most common underlying disease was obstetric hemorrhage (42%) followed by hypertensive disorders (20%) and placental hemorrhage (14%). Only 1.6% of women with SMM had cardiovascular disease as the underlying disease category. An extremely high proportion of women with severe morbidity (42.5%) delivered preterm with 17.8% delivering <32 weeks, which underscores the importance of access to appropriate-level care for mothers with SMM and their newborns. Further, the extremely high rate of preterm delivery (75%) in women with placental hemorrhage in combination with their 63% prior cesarean delivery rate highlights another risk of prior cesarean delivery: subsequent preterm delivery. These data provide a reminder that a cesarean delivery could be a contributing factor to not only hemorrhage-related SMM, but also to increased subsequent preterm delivery, more reason to continue national efforts to safely reduce initial cesarean deliveries.

Kilpatrick SJ ，Abreo A ，Gould J ，Greene N ，Main EK ... -  《-》

Lower gestational age is associated with severe maternal morbidity of preterm cesarean delivery.

To evaluate whether gestational age was associated with the severe maternal morbidity (SMM) of preterm cesarean delivery between 22 and 34 weeks of gestation (weeks). We performed an observational retrospective cohort study in two tertiary university hospitals in 2018. We included all mothers of preterm infants born by caesarean delivery between 22 and 34 weeks, excluding mothers with multiple births greater than two, with pregnancy terminations or stillbirths, and who died unrelated to obstetrical causes. The principal endpoint, SMM, was a composite outcome (classical uterine incision, postpartum hemorrhage defined by blood loss ≥ 500 mL, blood transfusion, any injury to adjacent organs, unplanned procedure/need for reintervention, Intensive Care Unit (ICU) stay longer than 24 h, postpartum fever, and/or death). Among the 252 women, SMM occurred in 89 (35.3 %) cases. After multivariate analysis, gestational age was independently associated with SMM (adjusted Odds Ratio [aOR] 0.87; 95 % Confidence Interval [CI] 0.78-0.97). The other variables statistically associated with SMM were type of pregnancy with a negative association with twin pregnancy (aOR, 0.44; 95 % CI, 0.20-0.93) and a positive association with general anesthesia (aOR, 2.52; 95 % CI, 1.25-5.13). A sensitivity analysis was performed and found an association, at the limit of significance, between gestational age < 28 weeks and SMM (aOR, 1.80; 95 % CI, 0.99-3.27, p = 0.05). Lower gestational age was associated with the risk of SMM for preterm caesarean delivery between 22 and 34 weeks. Obstetricians should integrate this knowledge into their shared decision-making processes with parents.

Sirgant D ，Rességuier N ，d'Ercole C ，Auquier P ，Tosello B ，Blanc J ... -  《Journal of Gynecology Obstetrics and Human Reproduction》

Association between gestational age and severe maternal morbidity and mortality of preterm cesarean delivery: a population-based cohort study.

Cesarean delivery rates at extreme prematurity have regularly increased over the past years, and few previous studies have investigated severe maternal morbidity associated with extreme preterm cesarean delivery. The aim of this study was to evaluate whether gestational age <26 weeks of gestation (weeks) was associated with severe maternal morbidity and mortality (SMMM) of preterm cesarean deliveries in comparison with cesarean deliveries between 26 and 34 weeks. The Etude Epidémiologique sur les petits âges gestationnels (EPIPAGE) 2 is a national prospective population-based cohort study of preterm births in 2011. We included mothers with cesarean deliveries between 22 and 34 weeks, excluding those who had a cesarean delivery for the second twin only and those with pregnancy terminations. SMMM was analyzed as a composite endpoint defined as the occurrence of at least 1 of the following complications: severe postpartum hemorrhage defined by the use of a blood transfusion, intensive care unit admission, or death. To assess the association of gestational age <26 weeks and SMMM, we used multivariate logistic regression and a propensity score-matching approach. Among 2525 women having preterm cesarean deliveries, 116 before 26 weeks and 2409 between 26 and 34 weeks, 407 (14.4%) presented with SMMM. The SMMM occurred in 31 mothers (26.7%) who were at gestational age <26 weeks vs 376 (14.2%) between 26 and 34 weeks (P < .001). Cluster multivariate logistic regression showed significant association of gestational age <26 weeks and SMMM (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.42-4.40) and propensity score-matching analysis was consistent with these results (aOR, 2.27; 95% CI, 1.31-3.93). Obstetricians should know about the higher SMMM associated with cesarean deliveries before 26 weeks, integrate this knowledge into decisions regarding cesarean delivery, and be prepared to manage the associated complications.

Blanc J ，Resseguier N ，Goffinet F ，Lorthe E ，Kayem G ，Delorme P ，Vayssière C ，Auquier P ，D'Ercole C ... -  《-》

Term cesarean delivery in the first pregnancy is not associated with an increased risk for preterm delivery in the subsequent pregnancy.

Prior studies have reported an increased risk for preterm delivery following a term cesarean delivery. However, these studies did not adjust for high-risk conditions related to the first cesarean delivery and are known to recur. The objective of the study was to determine whether there is an association between term cesarean delivery in the first pregnancy and subsequent spontaneous or indicated preterm delivery. This was a retrospective cohort study of women with the first 2 consecutive singleton deliveries (2007-2014) identified through a linked pregnancy database at a single institution. Women with a first pregnancy that resulted in cesarean delivery at term were compared with women whose first pregnancy resulted in a vaginal delivery at term. Exclusion criteria were known to recur medical or obstetrical complications during the first pregnancy. A propensity score analysis was performed by matching women who underwent a cesarean delivery with those who underwent a vaginal delivery in the first pregnancy. The association between cesarean delivery in the first pregnancy and preterm delivery in the second pregnancy in this matched set was examined using conditional logistic regression. The primary outcome was overall preterm delivery <37 weeks in the second pregnancy. Secondary outcomes included type of preterm delivery (spontaneous vs indicated), late preterm delivery (34-36 6/7 weeks), early preterm delivery (<34 weeks), and small-for-gestational-age birth. Of a total of 6456 linked pregnancies, 2284 deliveries were matched; 1142 were preceded by cesarean delivery and 1142 were preceded by vaginal delivery. The main indications for cesarean delivery in the first pregnancy were dystocia in 703 (61.5%), nonreassuring fetal status in 222 (19.4%), breech presentation in 100 (8.8%), and other in 84 (7.4%). The mean (SD) gestational ages at delivery for the second pregnancy was 38.8 (1.8) and 38.9 (1.7) weeks, respectively, for prior cesarean delivery and vaginal delivery. The risks of preterm delivery in the second pregnancy among women with a previous cesarean and vaginal delivery were 6.0% and 5.2%, respectively (adjusted odds ratio, 1.46, 95% confidence interval, [CI] 0.77-2.76). In an analysis stratified by the type of preterm delivery in the second pregnancy, no associations were seen between cesarean delivery in the first pregnancy and spontaneous preterm delivery (4.6% vs 3.9%; adjusted odds ratio, 1.40, 95% confidence interval, 0.59-3.32) or indicated preterm delivery (1.6% vs 1.4%; adjusted odds ratio, 1.21, 95% confidence interval, 0.60-2.46). Similarly, no significant differences were found in late preterm delivery (4.6% vs 4.1%; adjusted odds ratio, 1.13, 95% confidence interval, 0.55-2.29), early preterm delivery (1.6% vs 1.2%; adjusted odds ratio, 1.25, 95% confidence interval, 0.59-2.67), or neonates with birthweight less than the fifth percentile for gestational age (3.6% vs 2.2%; adjusted odds ratio, 1.26, 95% confidence interval, 0.52-3.06). After robust adjustment for confounders through a propensity score analysis related to the indication for the first cesarean delivery at term, cesarean delivery is not associated with an increase in preterm delivery, spontaneous or indicated, in the subsequent pregnancy.

Vahanian SA ，Hoffman MK ，Ananth CV ，Croft DJ ，Duzyj C ，Fuchs KM ，Gyamfi-Bannerman C ，Kinzler WL ，Plante LA ，Ranzini AC ，Rosen TJ ，Skupski DW ，Smulian JC ，Vintzileos AM ，Perinatal Research Consortium ... -  《-》