Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Pediatric Center, Csolnoky Ferenc Hospital, Veszprém, Hungary.
Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary; Division of Neonatology, Pediatric Center, Semmelweis University, Budapest, Hungary.
Am J Obstet Gynecol. 2024 Dec;231(6):589-598.e21. doi: 10.1016/j.ajog.2024.06.015. Epub 2024 Jun 20.
To investigate the association between actual and planned modes of delivery, neonatal mortality, and short-term outcomes among preterm pregnancies ≤32 weeks of gestation.
A systematic literature search was conducted in 3 main databases (PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to November 16, 2022. The protocol was registered in advance in the International Prospective Register of Systematic Reviews (CRD42022377870).
Eligible studies examined pregnancies ≤32nd gestational week. All infants received active care, and the outcomes were reported separately by different modes of delivery. Singleton and twin pregnancies at vertex and breech presentations were included. Studies that included pregnancies complicated with preeclampsia and abruptio placentae were excluded. Primary outcomes were neonatal mortality and intraventricular hemorrhage.
Articles were selected by title, abstract, and full text, and disagreements were resolved by consensus. Random effects model-based odds ratios with corresponding 95% confidence intervals were calculated for dichotomous outcomes. Risk Of Bias In Non-randomized Studies - of Interventions-I was used to assess the risk of bias.
A total of 19 observational studies were included involving a total of 16,042 preterm infants in this systematic review and meta-analysis. Actual cesarean delivery improves survival (odds ratio, 0.62; 95% confidence interval, 0.42-0.9) and decreases the incidence of intraventricular hemorrhage (odds ratio, 0.70; confidence interval, 0.57-0.85) compared to vaginal delivery. Planned cesarean delivery does not improve the survival of very and extremely preterm infants compared to vaginal delivery (odds ratio, 0.87; 95% confidence interval, 0.53-1.44). Subset analysis found significantly lower odds of death for singleton breech preterm deliveries born by both planned (odds ratio, 0.56; 95% confidence interval, 0.32-0.98) and actual (odds ratio, 0.34; 95% confidence interval, 0.13-0.88) cesarean delivery.
Cesarean delivery should be the mode of delivery for preterm ≤32 weeks of gestation breech births due to the higher mortality in preterm infants born via vaginal delivery.
探讨实际分娩方式与计划分娩方式对妊娠≤32 周早产儿新生儿死亡率和短期结局的影响。
系统检索了 3 个主要数据库（PubMed、EMBASE 和 Cochrane 对照试验中心注册库）从成立到 2022 年 11 月 16 日的文献。该方案已在国际前瞻性系统评价注册库（CRD42022377870）中预先注册。
研究对象为妊娠≤32 周的孕妇。所有婴儿均接受积极治疗，不同分娩方式的结局单独报告。包括头位和臀位的单胎和双胎妊娠。排除了伴有子痫前期和胎盘早剥的妊娠。主要结局是新生儿死亡率和脑室出血。
根据标题、摘要和全文筛选文章，意见分歧通过协商解决。二分类结局采用基于随机效应模型的比值比及其 95%置信区间进行计算。采用非随机干预研究的偏倚风险评估工具（Risk Of Bias In Non-randomized Studies - of Interventions-I）评估偏倚风险。
本系统评价和荟萃分析共纳入 19 项观察性研究，涉及 16042 例早产儿。与阴道分娩相比，实际剖宫产可提高生存率（比值比，0.62；95%置信区间，0.42-0.9），降低脑室出血发生率（比值比，0.70；置信区间，0.57-0.85）。与阴道分娩相比，计划性剖宫产并不能提高极早产儿和超早产儿的生存率（比值比，0.87；95%置信区间，0.53-1.44）。亚组分析发现，计划性剖宫产（比值比，0.56；95%置信区间，0.32-0.98）和实际剖宫产（比值比，0.34；95%置信区间，0.13-0.88）分娩的单胎臀位早产儿的死亡风险显著降低。
对于妊娠≤32 周的臀位早产儿，剖宫产应作为首选分娩方式，因为阴道分娩的早产儿死亡率更高。
