126 Association of mode of delivery on infant survival at 22 and 23 weeks of gestation

Abstract

Selecting the optimal route of delivery in the setting of periviable birth is a complex decision balancing both maternal and fetal outcomes. ACOG and SMFM do not recommend cesarean delivery prior to 23 0/7 wks for fetal indications based on available, limited evidence. We sought to compare survival rates at 1 year of life (YOL) among resuscitated infants at 22 and 23 wks based on route of delivery. We conducted a population-based cohort study of all resuscitated live births between 22 0/7 and 23 6/7 wks in the United States (US) from 2007-2013. The primary outcome was rate of infant survival to 1 YOL based on delivery route (cesarean vs vaginal). Secondary outcomes included survival rates for neonates surviving beyond 1 day of life (DOL), neonatal survival (beyond 28 days), length of survival, and survival stratified by fetal presentation, steroid exposure, and ventilation. Composite adverse maternal outcome (CAMO) (blood transfusion, unplanned operation or hysterectomy, ICU admission) was also compared between mode of delivery cohorts. Multivariable logistic regression analysis estimated the association of cesarean on these outcomes. There were a total of 11,146 resuscitated neonates delivered between 22 0/7 – 23 6/7 wks in the US during 2007-2013. Resuscitated infants delivered by cesarean had higher rates of survival at 22 (44.9 vs 23.0%, p<0.001) and 23 (53.3 vs 43.4%, p<0.001) wks regardless of fetal presentation. Survival remained significantly improved after adjustment for coexisting risk factors for infants delivered by cesarean at 22 (aRR 2.3, 95% CI 1.9-2.8) and 23 (aRR 1.4, 95% CI 1.2-1.5) wks compared to those delivered vaginally. When limited to neonates surviving beyond 1 DOL, vertex neonates born by cesarean were not more likely to survive at 22 or 23 wks. Cesarean delivery increased risk for CAMO (aRR 1.7, 95% CI 1.1-2.7) with births at 22-23 wks of gestation. Cesarean delivery is associated with increased survival at 1 YOL among resuscitated infants born between 22 0/7 – 23 6/7 wks gestation and increased maternal morbidity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)