Maternal outcomes of cesarean delivery performed at early gestational ages: a systematic review and meta-analysis

OBJECTIVE: This study aimed to report maternal outcomes of preterm (<34 weeks of gestation) cesarean delivery. DATA SOURCES: Medline, Embase, and ClinicalTrials.gov databases were searched electronically on September 1, 2020, utilizing combinations of the relevant medical subject heading terms, key words, and word variants for cesarean delivery and outcome. STUDY ELIGIBILITY CRITERIA: We included only studies reporting maternal outcomes of cesarean delivery performed at <34 weeks of gestation. STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcome was a composite score of maternal surgical morbidity including maternal death, severe intrasurgical or postpartum hemorrhage, hysterectomy, need for blood transfusion, and damage to adjacent organs. Secondary outcomes were individual components of the primary outcome, need for reoperation, postsurgical infection, thromboembolism, and hysterectomy. We also performed 2 subgroup analyses considering cesarean delivery performed at <28 and <26 weeks of gestation. Meta-analyses of proportions using random effects model were used to combine data. RESULTS: A total of 15 studies involving 8378 women undergoing cesarean delivery at <34 weeks of gestation were included in the systematic review. Composite adverse maternal outcome was reported in 16.2% of women (95% confidence interval, 15.4-17.0) undergoing a cesarean delivery before 34 weeks of gestation. Hemorrhage, either intra- or postoperative, was observed in 6.9% of cases (95% confidence interval, 6.4-7.5), whereas 6.3% (95% confidence interval, 4.2-8.7) required blood transfusion. Damage to adjacent organs complicated the primary surgery in 2.0% of women (95% confidence interval, 0.1-6.4), whereas 1.2% (95% confidence interval, 0.3-3.4) required a reoperation after cesarean delivery. Maternal death occurred in 0.1% (95% confidence interval, 0.0-1.4). In women undergoing cesarean delivery at <28 weeks of gestation, composite adverse maternal outcome complicated 22.9% of cases (95% confidence interval, 16.7-33.8) and 14.0% (95% confidence interval, 5.8-24.9) experienced hemorrhage whereas 7.7% (95% confidence interval, 4.4-11.8) required blood transfusion. Finally, when considering women undergoing cesarean delivery at <26 weeks of gestation, composite adverse maternal outcome was reported in 24.8% (95% confidence interval, 10.1-43.4), whereas the corresponding figures for hemorrhage and need for blood transfusion were 9.2% (95% confidence interval, 1.7-21.6) and 6.1% (95% confidence interval, 0.3-10.0), respectively. CONCLUSION: Early cesarean delivery is affected by a high rate of maternal intra- and postoperative complications. The findings from systematic review can help clinicians in counseling parents when cesarean delivery is required in an early gestational age.

Automated summary

Early cesarean delivery in preterm mothers has a high rate of maternal intra- and postoperative complications, including hemorrhage, blood transfusion, and damage to adjacent organs. Women undergoing cesarean delivery at <28 and <26 weeks of gestation have a higher probability of experiencing adverse maternal outcomes.