External Cephalic Version for breech presenting fetus does not hike the cesarean section rates.

Women who had a successful External Cephalic Version (ECV) are not at increased risk of cesarean section as compared to women who had Spontaneous Cephalic Version (SCV) says the results of a study published ahead of print on August 2, 2017 in Journal of Obstetrics and Gynecology Canada. 

  

This is first study conducted to compare the outcome between spontaneous and external version in breech presenting fetuses.

It is estimated that term fetal malpresentation occurs in about 3% of pregnancies—and is a common indication for cesarean. External Cephalic version is an important tool to reduce the rate of cesarean births in breech presentation.

This secondary analysis of Early External Cephalic Version Trial data identified 931 women who had breech presenting fetuses between 34-36 weeks of pregnancy, but cephalic presentation at term.

Out of these study subjects, 557 women have undergone successful ECV while in 374 women the fetus reverted spontaneously.

Obstetric outcomes between the two groups were comparable: 96 women in ECV arm had Cesarean section as compared to 76 in the SCV group. (adjusted OR [aOR] 0.89; 95% CI 0.63-1.26); 393 had vaginal delivery in ECV arm vs 268 in SCV arm. (aOR 0.92; 95% CI 0.68-1.24).

Women in the ECV had 45% increased odds of undergoing instrumental intervention as compared to women in SCV group. (aOR 1.55; 95% CI 0.96-2.50).

Multiparous women with ECV were half as likely to require a cesarean section as compared to women with spontaneous version or no version at all. ( aOR 0.45; 95% CI 0.26-0.80).

The authors concluded, “Women with a cephalic-presenting fetus at birth as a result of successful ECV are not at greater risk of obstetrical interventions at birth when compared with women with fetuses who spontaneously turn to a cephalic presentation in the third trimester.”

Media Courtesy: American Association of Family Physicians 

ACOG updates guidelines on External Cephalic Version

According to the new practice bulletin published in the February issue of Obstetrics & Gynecology, all antenatal patients near term with breech presentation should be offered External Cephalic Version (ECV)  to decrease unnecessary C-sections provided they have no contraindication for it.

This replaces the earlier guidelines issued in February 2000.

The ACOG committee member says that “[ECV] is a valuable management technique and, in a properly selected population, poses little risk to either the woman or the fetus. If successful, ECV provides a clear benefit to the woman by allowing her an opportunity for a successful vertex vaginal delivery,"  

These recommendations are based on previous studies showing successful vaginal birth after ECV and a movement to decrease unnecessary Cesarean Deliveries.

The 6 points in the guidelines included 1 Level  A recommendation, 3 Level  B recommendations  and 2 recommendation based on expert opinion and consensus.

Level A recommendations:

1)      Every woman near term, with breech presentation should be offered ECV attempt near term unless contraindicated.  Women may choose not to undergo ECV because of fear of the procedure, incomplete information, and preference for scheduled cesarean delivery.

Level B recommendations:

1)      Fetal presentation should be confirmed beginning at 36 weeks to plan for ECV. The spontaneous version would have happened most likely by 36 weeks and chances of reversion to breech after ECV is also less at this time in pregnancy .

2)      Having a history of previous C-section  does not lessen the chance of success, but whether it augments the risk for uterine rupture is not known.

3)      Using parenteral beta-agonist improves the chance of successful version.

Expert opinion recommendations:

1)      A biophysical profile and nonstress test must be carried out before and after the ECV to ascertain fetal well being.

2)      The procedure should only be attempted in s setting where facilities for emergency C section are available round the clock.  

If ECV persists after the version, the mode of delivery should depend on the expertise of healthcare provider.

Absolute contraindications for ECV are those which are likely to be associated with increased mortality or morbidity:

1. where caesarean delivery is required
2. antepartum haemorrhage within the last 7 days
3. abnormal cardiotocography
4. major uterine anomaly
5. ruptured membranes
6. multiple pregnancy (except delivery of second twin).

Relative contraindications where ECV might be more complicated:

1. small-for-gestational-age fetus with abnormal Doppler parameters
2. proteinuric pre-eclampsia
3. oligohydramnios
4. major fetal anomalies
5. scarred uterus
6. unstable lie

References:

https://www.rcog.org.uk/globalassets/documents/guidelines/gt20aexternalcephalicversion.pdf

http://journals.lww.com/greenjournal/Abstract/2016/02000/Practice_Bulletin_No__161_Summary___External.44.aspx

http://libraryguides.missouri.edu/ACOG

Few decisive articles in obstetrics from 2015

Role of progesterone in preventing recurrent preterm births (PTB)

It is widely accepted that progesterone supplementation in pregnancy reduces the risk of recurrent preterm birth. But, according to a secondary analysis of data  from Maternal-Fetal Medicine Units Network Trial of hydroxyprogesterone caproate for prevention of recurrent preterm birth before 37wks concluded that the drug may not be effective in women with a BMI>30 kg/m^2. The cut off weight is 168 pounds or 75 kg. This finding may be due to subtherapeutic serum levels in women with increased BMI or weight. Further larger and planned studies in women with BMI >30 kg/m² are warranted and also the universal use of progesterone in women independent of BMI also deserves reassessment.

Heyborne KD et al - Does 17-alpha hydroxyprogesterone caproate prevent recurrent preterm birth in obese women?

Am J Obstet Gynecol. 2015 Aug;

Maternal Hypertension in Pregnancy predisposes the offspring for higher risks of Congenital Heart Disease

According to a systemic review and metaanalysis published in the journal of pediatric cardiology robust associations were observed between maternal hypertension and overall CHDs, irrespective of being treated or untreated. The authors identified 16 studies that met the study criteria. The effect was also uniform across all the subtypes of CHDs. The results were also similar for various type of antihypertensive medications used.

The authors propose to understand the mechanisms to design strategies to reduce the risks..

Ramakrishnan A et al- Maternal Hypertension During Pregnancy and the Risk of Congenital Heart Defects in Offspring: A Systematic Review and Meta-analysis.

Pediatr Cardiol. 2015 Oct;36(7):1442-51. Epub 2015 May 8.

The downside of improved control of malaria.

We are recently seeing improved malaria control in many endemic areas worldwide, leading to a decrease in immunity in the population. A large observational study carried out in Mozambique assessed the prevalence of Plasmodium falciparum infection among 1819 Mozambican women who delivered infants between 2003 and 2012.

A major decline in maternal level of antimalarial IgG antibodies were seen in pregnant women both for pregnancy specific parasitic lines as well as general parasitic lines.

It was also seen that those women who developed malaria antenatally had a larger reduction in hemoglobin levels as well as the neonatal birthweight as the immunity declined.

Mayor A et al- Changing Trends in P. falciparum Burden, Immunity, and Disease in Pregnancy. N Engl J Med. 2015 Oct 22;373(17):1607-17.

Uterine exteriorization at cesarean delivery

Uterine exteriorization vs in situ repair has always been a topic of debate among obstetricians.  In A large meta-analysis of 16 studies amounting to a total of 19,439 subjects 9,736 underwent exteriorization, 9,703 had in situ uterine repair. It was seen that the estimated blood loss was not statistically significant between the two groups as well as other perioperative outcomes. Individual preferences and individual intraoperative circumstances should guide the decision.

Zaphiratos V et al- Uterine exteriorization compared with in situ repair for Cesarean delivery: a systematic review and meta-analysis.

Can J Anaesth. 2015 Nov;62(11):1209-1220.

The best time to perform External Cephalic Version (ECV)

The optimum age to perform ECV has always been a debatable issue.

External cephalic version (ECV) of the breech fetus at term (after 37 weeks) has been shown to be effective in reducing the number of breech presentations and caesarean sections, but the rates of success are relatively low. This systemic review of Cochrane Data base examines studies initiating ECV prior to term (before 37 weeks' gestation).

Pooled results suggested that early ECV reduced the risk of non-cephalic presentation at birth, failure to achieve vaginal cephalic birth, and vaginal breech delivery. However there was no statistical significant difference in Caesarean Section rate between the two groups. There was evidence that risk of preterm labour was increased with early ECV compared with ECV after 37 weeks. Future research reporting infant morbidity outcomes in these late preterm births is warranted.

Hutton E.K et al- External cephalic version for breech presentation before term.

Cochrane Database Syst Rev. 2015 Jul 29;7:CD000084.

Limited value of fetal ST-segment analysis

STAN S31 is a one-of-a-kind fetal monitor which exclusively combines standard CTG technology with ST-Analysis of the fetal ECG (FECG) during labour. The combined analysis of the CTG and fetal ECG helps to detect a fetus that is exposed to hypoxia and which needs remedial action, and also provides reassurance when no intervention is required.

However, It is not clear whether use of STAN 31 as an adjunct to other conventional fetal heart rate monitor improves the intrapartum and neonatal outcome.

This Multicenter RCT of about 11,108 subjects included women with a single fetus undergoing vaginal delivery at more than 36 weeks of gestation with cervical dilation of 2 to 7 cm. They were randomly assigned to "open" or "masked" monitoring with fetal ST-segment analysis. The masked system functioned as a normal fetal heart-rate monitor (FHR). The open system functioned as both FHR as well as fetal ECG monitor.

The primary outcome was a composite of intrapartum fetal death, neonatal death, an Apgar score of 3 or less at 5 minutes, neonatal seizure, an umbilical-artery blood pH of 7.05 or less with a base deficit of 12 mmol per liter or more, intubation for ventilation at delivery, or neonatal encephalopathy.

It was observed that fetal ECG monitoring along with FHR  did not improve perinatal outcome or decreased the rate of caesarean delivery. The primary outcome occurred in 52 fetuses or neonates of women in the Fetal ECG group  and 40 fetuses or neonates of women in the FHR  group.

Belfort M.A- A Randomized Trial of Intrapartum Fetal ECG ST-Segment Analysis.

N Engl J Med. 2015 Aug 13;373(7):632-41.

Expectant management of mild preeclampsia near term is feasible.

There is little guidelines for the management of women with mild preeclampsia with stable maternal and fetal conditions at 34 to 36 weeks of gestation. The study by Broekhuijsen K et al in Lancet 2015, investigated the effect of immediate delivery versus expectant monitoring on maternal and neonatal outcomes in such women. This open-label, randomised controlled trial, in seven academic hospitals and 44 non-academic hospitals in the Netherlands confirmed that most patients will reach term without progressing into severe disease and the expectant management buys us valuable time for optimum neonatal maturity without any harm to the mother.

References:

• Relation of body mass index to frequency of recurrent preterm birth in women treated with 17-alpha hydroxyprogesterone caproate.Co AL, Walker HC, Hade EM, Iams JD. Am J Obstet Gynecol. 2015 Aug; 213(2):233.e1-5
• Ramakrihnan A et al- Maternal Hypertension During Pregnancy and the Risk of Congenital Heart Defects in Offspring: A Systematic Review and Meta-analysis.Pediatr Cardiol. 2015 Oct;36(7):1442-51
• Mayor A et al- Changing Trends in P. falciparum Burden, Immunity, and Disease in Pregnancy. N Engl J Med. 2015 Oct 22;373(17):1607-17.
• Zaphiratos V et al- Uterine exteriorization compared with in situ repair for Cesarean delivery: a systematic review and meta-analysis.Can J Anaesth. 2015 Nov;62(11):1209-1220.
• http://www.news-medical.net/Stan-S31-Fetal-Monitor-from-Neovent