(265) Cesarean delivery in life-limiting fetal anomalies: all risk and no benefit?

Life-limiting anomalies (LLA) are a heterogeneous group of congenital malformations at high risk of poor outcomes. Pregnancy management options in LLA cases are limited in states with restrictive abortion laws, likely contributing to increased rates of infant and neonatal death. In these cases, conventional medical ethics call for maximization of maternal benefit. When pregnancy continues, avoidance of cesarean delivery (CD) is a harm-reduction strategy. Our objectives were to determine the CD rate, adverse pregnancy outcomes, and clinical drivers of CD in a cohort with LLA.

Study Design:

Retrospective cohort study of pregnancies complicated by LLA from 2011-2023 (n=131) (Table 1). Eligibility was determined by ultrasound findings or genetic testing. Spontaneous abortion, non-lethal anomaly, molar and ectopic pregnancy were excluded. Descriptive statistics were calculated, and Chi-square used for analysis.

Results: 37 cases underwent CD. CD rate did not differ from the institutional rate (28% vs. 29%, p=0.86). Among CD cases, the average gestational age at delivery was 37.5 weeks (SD±2.6), with mean interval from diagnosis to delivery of 15.1 weeks (SD±5.2). Common indications for CD were fetal (46%) followed by elective repeat (30%) (Figure 1). 73% of patients received mode of delivery (MOD) counseling. 57% were offered palliative care, of which 62% accepted. Severe hypertension and postpartum hemorrhage rates did not differ from the institutional rate (16% vs. 21%, p=0.52; 19% vs. 17%, p=0.79). Fetal or neonatal death rate was 73%. All surviving children have significant medical comorbidities or developmental delays.

Conclusion: Cesarean delivery in pregnancy affected by LLA did not demonstrate increased morbidity related to hypertension or hemorrhage. Although CD rate was not higher, any maternal morbidity unbalanced by fetal benefit poses an ethical challenge. Fetal pathology, particularly cranial, played a significant role in MOD. This should be factored into candidacy for vaginal delivery and weighed against the surgical risks of CD. Further study of obstetric management of LLA is warranted.