Breech Presentation: Vaginal Versus Cesarean Delivery, Which Intervention Leads to the Best Outcomes?

INTRODUCTION: The best route of delivery for the term breech fetus is still controversial. We aim to compare maternal and neonatal outcomes between vaginal and cesarean term breech deliveries. MATERIAL AND METHODS: Multicentric retrospective cohort study of singleton term breech fetuses delivered vaginally or by elective cesarean section from January 2012 - October 2014. Primary outcomes were maternal and neonatal morbidity or mortality. RESULTS: Sixty five breech fetuses delivered vaginally were compared to 1262 delivered by elective cesarean. Nulliparous women were more common in the elective cesarean group (69.3% vs 24.6%; p < 0.0001). Gestational age at birth was significantly lower in the vaginal delivery group (38 ± 1 weeks vs 39 ± 0.8 weeks; p = 0.0029) as was birth weight (2928 ± 48.4 g vs 3168 ± 11.3 g; p < 0.0001). Apgar scores below seven on the first and fifth minutes were more likely in the vaginal delivery group (1st minute: 18.5% vs 5.9%; p = 0.0006; OR 3.6 [1.9 - 7.0]; 5th minute: 3.1% vs 0.2%; p = 0.0133; OR 20.0 [2.8 - 144.4]), as was fetal trauma (3.1% vs 0.3%: p = 0.031; OR 9.9 [1.8-55.6]). Neither group had cases of fetal acidemia. Admission to the Neonatal Intensive Care Unit, maternal postpartum hemorrhage and the incidence of other obstetric complications were similar between groups. DISCUSSION: Although vaginal breech delivery was associated with lower Apgar scores and higher incidence of fetal trauma, overall rates of such events were low. Admission to the neonatal intensive care unit and maternal outcomes were similar. CONCLUSION: Both delivery routes seem equally valid, neither posing high maternal or neonatal complications' incidence.

Introdução: A melhor via de parto do feto pélvico de termo ainda é controversa. Pretendemos comparar desfechos maternos e neonatais entre partos vaginais e cesarianas de fetos pélvicos de termo. Material e Métodos: Estudo de coorte, multicêntrico e retrospetivo, incluindo gestações de feto único de termo, em apresentação pélvica, que terminaram em parto vaginal ou cesariana eletiva entre janeiro de 2012 e outubro de 2014. Os desfechos primários foram a morbilidade e mortalidade maternas e neonatais. Resultados: Sessenta e cinco partos vaginais foram comparados com 1262 cesarianas eletivas. As nulíparas foram mais frequentes no grupo das cesarianas (69,3% vs 24,6%; p < 0,0001). A idade gestacional foi inferior nos partos vaginais (38 ± 1 semanas vs 39 ± 0,8 semanas; p = 0,0029), verificando-se o mesmo para o peso ao nascer (2928 ± 48,4 g vs 3168 ± 11,3 g; p < 0,0001). Índices de Apgar < 7 foram mais frequentes nos partos vaginais (1º minuto: 18,5% vs 5,9%; p = 0,0006; OR 3,6 [1,9 - 7,0]; 5º minuto: 3,1% vs 0,2%; p = 0,0133; OR 20,0 [2,8 - 144,4]). Verificou-se também uma maior incidência de traumatismo fetal neste grupo (3,1% vs 0,3%; p = 0,031; OR 9,9 [1,8 - 55,6]). Nenhum grupo teve casos de acidemia fetal. As taxas de internamento na unidade de cuidados intensivos neonatais, de hemorragia materna pós-parto ou de outras complicações obstétricas foram idênticas. Discussão: O parto vaginal associou-se a índices de Apgar inferiores e a uma maior incidência de traumatismo fetal, com taxas globalmente baixas. Não se verificaram diferenças nas taxas de internamento neonatal nem nos desfechos maternos. Conclusão: Ambas as vias de parto parecem adequadas, nenhuma condicionando incidências elevadas de complicações maternas ou neonatais.

Concurrence of gestational diabetes and pre-gravid obesity ("diabesity") in twin gestations.

OBJECTIVE: To assess the effect of the concurrence of gestational diabetes mellitus (GDM) and pre-gravid obesity in twin gestations ("diabesity"). METHODS: We compared perinatal outcomes of twin gestation in mothers with GDM and pre-gravid obesity (1.7%), mothers with GDM but with normal BMI (6.2%), and obese mothers without GDM (7.0%). RESULTS: Twin pregnancies with "diabesity" were associated with significantly higher incidence of stillbirth (OR = 6.4; 95%CI = 1.4, 33.4) and existing chronic hypertension (OR = 4.2; 95%CI = 1.2, 14.8) than in GDM pregnancies without obesity, and with births at 33-36 weeks as compared with the other groups. Otherwise, the comparisons showed remarkable similar results in terms of gestational age, birth weight, preeclampsia, cesarean section rate, and fetal-neonatal outcomes. CONCLUSION: It appears that diabesity has a relatively minor effect in twins. If this will be confirmed by other studies, it would be important to elucidate how twins ameliorate the adverse outcomes of diabesity.

Prediction of birth weight discordance from fetal weight estimations at 21-24 weeks' scans in monochorionic and dichorionic twins.

OBJECTIVE: To evaluate if inter-twin estimated fetal weight (EFW) differences at 21-24 weeks' scans predict birth weight discordance in monochorionic and dichorionic twins born at three gestational age periods. METHODS: We counted the number of pairs with discordant EFWs (EFWs greater than the mean + 1SD; i.e. a difference above 12% in dichorionic and 21% in monochorionic twins) derived during a 21-24 weeks' scan as compared to actual discordant birth weight (>25%) in monochorionic and dichorionic pairs born at ≤32, 33-36 and >36 weeks. RESULTS: We studied 416 dichorionic and 244 monochorionic twins. The frequency of EFWs discordance at 21-24 weeks was the same for dichorionic and monochorionic twins but the total number of birth weight discordant pairs was significantly smaller among dichorionic twins (OR 0.2, 95% CI 0.1, 0.6). Generally, the positive predictive values for birth weight discordance by using the EFWs difference were quite poor, but always better in monochorionic than in dichorionic twins. Whereas the negative predictive value and hence the sensitivity for monochorionic twins was 100% irrespective of gestational age at birth, it was much lower in the dichorionic pairs. CONCLUSION: Concordant EFWs at 21-24 weeks exclude discordant birth weight in monochorionic twins whereas discordant EFWs are poor predictors of birth weight discordance especially in dichorionic twins irrespective when the twins were born.