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Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes

Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes. David Guernsey MD. Case Scenario. 26 yo G4P2 female at 36 weeks who has had a prior low transverse cesarian section

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Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes

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  1. Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes David Guernsey MD

  2. Case Scenario • 26 yo G4P2 female at 36 weeks who has had a prior low transverse cesarian section • She has be an L&D 3 times already in the last 2 weeks and has called or been in the office 2 times a week. • “Dr Guernsey this baby is kicking my butt, I’m having a C-section, why can’t we just take this baby out next week since I’ll be full term”

  3. Why shouldn’t I just do the C-section next week? She will be full term right…

  4. Million Dollar Question • Does it make any difference in fetal outcomes if I perform a cesarean section at 37 weeks versus 40 weeks in a healthy uncomplicated pregnancy?

  5. Study Design • COHORT STUDY • Used the cesarean registry from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network • 19 academic centers • Data from 1999-2002

  6. Patient Selection • 28,867 repeat C-section • 24,077 had term C-sections • 13,258 patients had term repeat C-sections with no indication for immediate delivery

  7. Separation by gestational weeks • 6.3% delivered at 37 weeks • 29.5% delivered at 38 weeks • 49.1% delivered at 39 weeks • 15% delivered at 40 weeks or later • Patients <39 weeks were usually older, lower BMI, white, married, insured, had a 1st trimester sono

  8. Outcome Measurements • Death • Adverse respiratory outcomes (RDS, transient tachypnea of the newborn) • Hypoglycemia • Sepsis • Seizures • Necrotizing entercolitis • Hypoxic-ischemic encephalopathy • CPR • Ventalation support within 24 hours • Umbilical pH below 7 • 5 minute APGAR below 3 • NICU admission • Prolonged hospitalization (over 5 days)

  9. Analysis • Incidence of an adverse outcome decreased from 37-39 weeks • 15.3% @37wks • 11.0% @38wks • 8.0% @39wks • 7.3% @40wks • Incidence of an adverse outcome increased after 40 weeks • 11.3% @41wks • 19.5% @42wks

  10. Odds Ratio Compares disease in exposed and nondisease in unexposed populations with disease in unexposed and nondisease in exposed populations to determine if there is a difference in the two. (A X D)/(B X C) Compared neonatal outcomes and gestational age at delivery relative to 39 weeks

  11. Odds Ratios

  12. Attributable Risk • Number of cases attributable to one risk factor • (A/(A+B))-(C/(C+D)) OR • [(relative risk-1)/relative risk] X100 • Where RR=[A/(A+B)]/[C/(C+D)]

  13. Attributable Risk • Attributable Risk at 37 weeks is 48% • Attributable Risk at 38 weeks is 27%

  14. Study Limitations • Smaller population of patients delivered at 37 weeks • Accuracy of determining estimated gestational age (1st vs 2nd trimester sonograms) • Study does not asses fetal lung maturity • Study does not asses effect of stillbirths

  15. Why do I care? • Over 1/3 of elective cesarean sections are before 39 weeks • Many of us are going to towns where we will be deciding when to do our patients cesarean sections • All of us have whiney patients

  16. Conclusions • My kids are cuter than yours!

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