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

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