PMID- 27404120 OWN - NLM STAT- MEDLINE DCOM- 20160921 LR - 20211113 IS - 1469-493X (Electronic) IS - 1361-6137 (Linking) VI - 7 IP - 7 DP - 2016 Jul 12 TI - Immediate versus deferred delivery of the preterm baby with suspected fetal compromise for improving outcomes. PG - CD008968 LID - 10.1002/14651858.CD008968.pub3 [doi] LID - CD008968 AB - BACKGROUND: Immediate delivery of the preterm fetus with suspected compromise may decrease the risk of damage due to intrauterine hypoxia. However, it may also increase the risks of prematurity. OBJECTIVES: To assess the effects of immediate versus deferred delivery of preterm babies with suspected fetal compromise on neonatal, maternal and long-term outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2016) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised trials comparing a policy of immediate delivery with deferred delivery or expectant management in preterm fetuses with suspected in utero compromise. Quasi-randomised trials and trials employing a cluster-randomised design were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS: We included one trial of 548 women (588 babies) in the review. Women with pregnancies between 24 and 36 weeks' gestation took part. The study took place in 13 European countries, between 1993 and 2001. The difference in the median randomisation to delivery interval between immediate delivery and deferred delivery was four days (median: 0.9 (inter-quartile range (IQR) 0.4 to 1.3) days for immediate delivery, median: 4.9 (IQR 2.0 to 10.8) days in the delay group).There was no clear difference in the primary outcomes of extended perinatal mortality (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.67 to 2.04, one trial, 587 babies, moderate-quality evidence) or the composite outcome of death or disability at or after two years of age (RR 1.22, 95% CI 0.85 to 1.75, one trial, 573 babies, moderate-quality evidence) with immediate delivery compared to deferred delivery. The results for these outcomes are consistent with both appreciable benefit and harm. More babies in the immediate delivery group were ventilated for more than 24 hours (RR 1.54, 95% CI 1.20 to 1.97, one trial, 576 babies). There were no differences between the immediate delivery and deferred delivery groups in any other infant mortality outcome (stillbirth, neonatal mortality, postneonatal mortality > 28 days to discharge), individual neonatal morbidity or markers of neonatal morbidity (cord pH less than 7.00, Apgar less than seven at five minutes, convulsions, interventricular haemorrhage or germinal matrix haemorrhage, necrotising enterocolitis and periventricular leucomalacia or ventriculomegaly).Some important outcomes were not reported, in particular infant admission to neonatal intensive care or special care facility, and respiratory distress syndrome. We were not able to calculate composite rates of serious neonatal morbidity, even though individual morbidities were reported, due to the risk of double counting infants with more than one morbidity.More children in the immediate delivery group had cerebral palsy at or after two years of age (RR 5.88, 95% CI 1.33 to 26.02, one trial, 507 children). There were, however, no differences in neurodevelopment impairment at or after two years (RR 1.72, 95% CI 0.86 to 3.41, one trial, 507 children), death at or after two years of age (RR 1.04, 95% CI 0.66 to 1.63, one trial, 573 children), or death or disability in childhood (six to 13 years of age) (RR 0.82, 95% CI 0.48 to 1.40, one trial, 302 children). More women in the immediate delivery group had caesarean delivery than in the deferred delivery group (RR 1.15, 95% CI 1.07 to 1.24, one trial, 547 women, high-quality evidence). Data were not available on any other maternal outcomes.There were several methodological weaknesses in the included study, and the level of evidence for the primary outcomes was graded high for caesarean section and moderate for extended perinatal mortality and death or disability at or after two years. The evidence was downgraded because the CIs for these outcomes were wide, and were consistent with both appreciable benefit and harm. Bias may have been introduced by several factors: blinding was not possible due to the nature of the intervention, data for childhood follow-up were incomplete due to attrition, and no adjustment was made in the analysis for the non-independence of babies from multiple pregnancies (39 out of 548 pregnancies). This study only included cases of suspected fetal compromise where there was uncertainty whether immediate delivery was indicated, thus results must be interpreted with caution. AUTHORS' CONCLUSIONS: Currently there is insufficient evidence on the benefits and harms of immediate delivery compared with deferred delivery in cases of suspected fetal compromise at preterm gestations to make firm recommendations. There is a lack of trials addressing this question, and limitations of the one included trial means that caution must be used in interpreting and generalising the findings. More research is needed to guide clinical practice.Although the included trial is relatively large, it has insufficient power to detect differences in neonatal mortality. It did not report any maternal outcomes other than mode of delivery, or evaluate maternal satisfaction or economic outcomes. The applicability of the findings is limited by several factors: Women with a wide range of obstetric complications and gestational ages were included, and subgroup analysis is currently limited. Advances in Doppler assessment techniques may diagnose severe compromise more accurately and help make decisions about the timing of delivery. The potential benefits of deferring delivery for longer or shorter periods cannot be presumed.Where there is uncertainty whether or not to deliver a preterm fetus with suspected fetal compromise, there seems to be no benefit to immediate delivery. Deferring delivery until test results worsen or increasing gestation favours delivery may improve the outcomes for mother and baby.There is a need for high-quality randomised controlled trials comparing immediate and deferred delivery where there is suspected fetal compromise at preterm gestations to guide clinical practice. Future trials should report all important outcomes, and should be adequately powered to detect differences in maternal and neonatal morbidity and mortality. FAU - Stock, Sarah J AU - Stock SJ AD - MRC Centre for Reproductive Health, University of Edinburgh Queen's Medical Research Centre, Edinburgh, UK, EH16 4TJ. FAU - Bricker, Leanne AU - Bricker L FAU - Norman, Jane E AU - Norman JE FAU - West, Helen M AU - West HM LA - eng GR - 13/89/05/DH_/Department of Health/United Kingdom PT - Journal Article PT - Research Support, Non-U.S. Gov't PT - Review PT - Systematic Review DEP - 20160712 PL - England TA - Cochrane Database Syst Rev JT - The Cochrane database of systematic reviews JID - 100909747 SB - IM UOF - Cochrane Database Syst Rev. 2012;(7):CD008968. PMID: 22786520 MH - Cerebral Palsy/etiology MH - Cesarean Section/statistics & numerical data MH - Delivery, Obstetric/adverse effects/*methods MH - Female MH - Fetal Distress/*complications MH - Humans MH - Infant MH - Infant Mortality MH - Infant, Newborn MH - *Infant, Premature MH - Pregnancy MH - Randomized Controlled Trials as Topic MH - Respiration, Artificial/statistics & numerical data MH - Watchful Waiting PMC - PMC6457969 COIS- Sarah Stock has received grants (paid to her institution) from NIHR HTA, SPARKS, the British Maternal and Fetal Medicine Society, and Tommy's in order to research into preterm labour and stillbirth. She has received payment (to her institution) in respect of travel expenses, accommodation and meeting costs as invited speaker about research at conferences and meetings. Leanne Bricker - none known. Jane Norman has received a grant of pound11,000 (paid to her institution) from the Chief Scientist's Office, Scottish Executive, for an epidemiological study entitled: "Ferguson EF, Norman JE, Chalmers J, Shanks E, Finlayson A. Investigation of the beneficial and adverse effects of induction of labour." Jane Norman's has received a number of research grants (paid to her institution) to support research into improving perinatal outcome - none specifically related to immediate vs deferred delivery. Jane has also received small amounts of money for speaking at meetings about prematurity but not immediate vs deferred delivery. Helen West is paid to work on Cochrane reviews by a grant to Cochrane Pregnancy and Childbirth. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health. EDAT- 2016/07/13 06:00 MHDA- 2016/09/23 06:00 PMCR- 2017/07/12 CRDT- 2016/07/13 06:00 PHST- 2016/07/13 06:00 [entrez] PHST- 2016/07/13 06:00 [pubmed] PHST- 2016/09/23 06:00 [medline] PHST- 2017/07/12 00:00 [pmc-release] AID - CD008968.pub3 [pii] AID - 10.1002/14651858.CD008968.pub3 [doi] PST - epublish SO - Cochrane Database Syst Rev. 2016 Jul 12;7(7):CD008968. doi: 10.1002/14651858.CD008968.pub3.