Association between gestational age and severe maternal morbidity and mortality of preterm cesarean delivery: a population-based cohort study

Am J Obstet Gynecol. 2019 Apr;220(4):399.e1-399.e9. doi: 10.1016/j.ajog.2019.01.005. Epub 2019 Jan 8.


Background: Cesarean delivery rates at extreme prematurity have regularly increased over the past years, and few previous studies have investigated severe maternal morbidity associated with extreme preterm cesarean delivery.

Objective: The aim of this study was to evaluate whether gestational age <26 weeks of gestation (weeks) was associated with severe maternal morbidity and mortality (SMMM) of preterm cesarean deliveries in comparison with cesarean deliveries between 26 and 34 weeks.

Materials and methods: The Etude Epidémiologique sur les petits âges gestationnels (EPIPAGE) 2 is a national prospective population-based cohort study of preterm births in 2011. We included mothers with cesarean deliveries between 22 and 34 weeks, excluding those who had a cesarean delivery for the second twin only and those with pregnancy terminations. SMMM was analyzed as a composite endpoint defined as the occurrence of at least 1 of the following complications: severe postpartum hemorrhage defined by the use of a blood transfusion, intensive care unit admission, or death. To assess the association of gestational age <26 weeks and SMMM, we used multivariate logistic regression and a propensity score-matching approach.

Results: Among 2525 women having preterm cesarean deliveries, 116 before 26 weeks and 2409 between 26 and 34 weeks, 407 (14.4%) presented with SMMM. The SMMM occurred in 31 mothers (26.7%) who were at gestational age <26 weeks vs 376 (14.2%) between 26 and 34 weeks (P < .001). Cluster multivariate logistic regression showed significant association of gestational age <26 weeks and SMMM (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.42-4.40) and propensity score-matching analysis was consistent with these results (aOR, 2.27; 95% CI, 1.31-3.93).

Conclusion: Obstetricians should know about the higher SMMM associated with cesarean deliveries before 26 weeks, integrate this knowledge into decisions regarding cesarean delivery, and be prepared to manage the associated complications.

Keywords: cesarean; extreme prematurity; prematurity; severe maternal morbidity.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Blood Transfusion
  • Cesarean Section / statistics & numerical data*
  • Cohort Studies
  • Female
  • Gestational Age*
  • Hospitalization / statistics & numerical data*
  • Humans
  • Intensive Care Units / statistics & numerical data*
  • Logistic Models
  • Maternal Mortality*
  • Multivariate Analysis
  • Postpartum Hemorrhage / epidemiology*
  • Postpartum Hemorrhage / therapy
  • Pregnancy
  • Pregnancy Trimester, Second
  • Pregnancy Trimester, Third
  • Premature Birth
  • Propensity Score
  • Prospective Studies
  • Young Adult