3 years ago

What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses

Sarah D McDonald, Tetsuya Isayama, Jehan N Karim, Sugee Korale Liyanage, Marinela Grabovac
Background The safest delivery mode of extremely preterm breech singletons is unknown. Objectives To determine safest delivery mode of actively resuscitated extremely preterm breech singletons. Search Strategy We searched Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL and ClinicalTrials. gov from 1994-May 2017. Selection Criteria We included studies comparing outcomes by delivery mode in actively resuscitated breech infants between 23+0-27+6 weeks. Data Collection and Analysis We synthesized data using random effects, generated odds ratios, 95% confidence intervals and number needed to treat (NNT). Our primary outcomes were death (neonatal, before discharge, or by 6 months) and severe intraventricular hemorrhage (grades III/IV), stratified by gestational age (23+0-24+6, 25+0-26+6, 27+0-27+6 weeks). Main Results We included 15 studies with 12,335 infants. We found that caesarean was associated with a 41% decrease in odds of death between 23+0-27+6 weeks (OR 0.59, 95% CI 0.36-0.95, NNT=8), with the greatest decrease at 23+0-24+6 weeks (OR 0.58, 95% CI 0.44-0.75, NNT=7). The OR at 25+0-26+6 and, 27+0-27+6 weeks were 0.72 (0.34-1.52) and 2.04 (0.20-20.62), respectively. We found that caesarean was associated with 49% decrease in odds of severe IVH between 23+0-27+6 weeks (OR 0.51, 95% CI 0.29-0.91, NNT=12), while the OR at 25+0-26+6 and 27+0-27+6 was 0.29 (0.07-1.12) and 0.91 (0.27-3.05), respectively. Conclusions Caesarean section was associated with reductions in the odds of death by 41% and of severe IVH by 49% in actively resuscitated breech singletons <28 weeks. The data are mostly observational, which may be inherently biased, and scarce on other morbidities, necessitating thorough discussion between parents and clinicians. This article is protected by copyright. All rights reserved.

Publisher URL: http://onlinelibrary.wiley.com/resolve/doi

DOI: 10.1111/1471-0528.14938

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