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Breech Presentation at Delivery: a Marker for Congenital Anomaly?

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Breech Presentation at Delivery: a Marker for Congenital Anomaly? Journal of Perinatology (2014) 34, 11–15 & 2014 Nature America, Inc. All rights reserved 0743-8346/14 www.nature.com/jp ORIGINAL ARTICLE Breech presentation at delivery: a marker for congenital anomaly? D Mostello1, JJ Chang2, F Bai2, J Wang3, C Guild4, K Stamps2 and TL Leet2,{ OBJECTIVE: To determine whether congenital anomalies are associated with breech presentation at the time of birth. STUDY DESIGN: A population-based, retrospective cohort study was conducted among 460 147 women with singleton live births using the Missouri Birth Defects Registry, which includes all defects diagnosed during the first year of life. Maternal and obstetric characteristics and outcomes between breech and cephalic presentation groups were compared using w2-square statistic and Student’s t-test. Multivariable binary logistic regression analysis was used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULT: At least one congenital anomaly was more likely present among infants breech at birth (11.7%) than in those with cephalic presentation (5.1%), whether full-term (9.4 vs 4.6%) or preterm (20.1 vs 11.6%). The relationship between breech presentation and congenital anomaly was stronger among full-term births (aOR 2.09, CI 1.96, 2.23, term vs 1.40, CI 1.26, 1.55, preterm), but not in all categories of anomalies. CONCLUSION: Breech presentation at delivery is a marker for the presence of congenital anomaly. Infants delivered breech deserve special scrutiny for the presence of malformation. Journal of Perinatology (2014) 34, 11–15; doi:10.1038/jp.2013.132; published online 24 October 2013 Keywords: congenital abnormalities; labor presentation; pregnancy outcome; registries INTRODUCTION been an obstetric maxim that congenital anomalies are associated 5 In about 4% of pregnancies, the fetus is in breech presentation at with breech presentation, the data supporting this assertion are 2,5,6,9–11 the time of delivery.1 Although the immediate impact of this from studies limited by their small sample sizes (especially finding for the obstetrician is typically on mode of delivery, the problematic when reporting rates of uncommon anomalies), lack 5,11 reason why the fetus failed to assume the cephalic presentation of stated method of ascertainment of anomalies, incomplete 2,10 warrants consideration. Unfortunately, the mechanism controlling statistical analysis, findings limited to those reported on birth 7 5 fetal alignment for delivery is not clear. Hypotheses to explain why certificates, and experience reported from a single institution. the fetus fails to assume the cephalic presentation include primary If breech presentation is indeed a marker for underlying fetal disorders, such as fetal neuromuscular dysfunction or abnormality, the presence of breech presentation near the time neurologic deficits2,3 or spatial considerations, such as uterine of delivery becomes an important trigger for the obstetrician and anomalies,1 site of placental implantation4 or amount of amniotic pediatrician to think beyond scheduling the Cesarean section and fluid,5,6 which may interfere with the process of achieving cephalic checking for hip clicks to an enhanced scrutiny of the fetal/ presentation. These theories revolve around primarily mechanical newborn anatomy and function. factors due to the lack of proper fetal movement or tone,7 a bulky We sought to address the question of whether congenital hydrocephalic head or lack of proper uterine architecture due to anomaly in the newborn is associated with breech presentation at over-distention or a lax maternal abdominal wall. the time of live birth, using population-based data with a reliable Although these explanations seem logical, existing data do not source of anomaly ascertainment, and multivariable analysis to support these hypotheses. For example, although breech presenta- identify and control for relevant confounding factors. tion occurs in almost one-third of infants with dysautonomia, no greater hypotonia is noted in those who present breech vs cephalic.8 In addition, when controlled for gestational age at birth, breech METHODS presentation was not associated with polyhydramnios or placenta The Missouri Birth Defects Registry is a passive data collection system that previa in a large population-based study.7 Indeed, recognition of a identifies live-born infants diagnosed with birth defects during the first potential mechanical factor to explain presentation is found in only year of life. This registry receives information from multiple sources, 15% of breech deliveries systematically assessed for them.6 including birth and death certificates, abstracts of medical records of 2 newborn and pediatric patients from both inpatient and outpatient Braun et al. proposed the concept that breech presentation encounters, and a special healthcare needs database. may constitute an important indicator of a ‘deeper underlying Using this resource, a population-based, retrospective cohort study was problem in fetal morphogenesis and/or function’ of which the conducted among women who gave birth at 24 weeks gestation or greater breech presentation is only one manifestation. Although it has in Missouri between January 1, 1993 and December 31, 1999, and the 1Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, St Louis, MO, USA; 2Department of Epidemiology, School of Public Health, Saint Louis University, St Louis, MO, USA; 3Department of Biostatistics, School of Public Health, Saint Louis University, St Louis, MO, USA and 4Department of Pediatrics and the Center for Outcomes Research, School of Medicine, Saint Louis University, St Louis, MO, USA. Correspondence: Dr D Mostello, Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women’s Health, School of Medicine, Saint Louis University, 6420 Clayton Road, St Louis, MO 63117, USA. E-mail: [email protected] Presented at the 32nd Annual Meeting of the Society for Maternal-Fetal Medicine, February 6–11, 2012, Dallas, TX, USA. {Dr Leet is deceased. Received 1 May 2013; revised 1 September 2013; accepted 13 September 2013; published online 24 October 2013 Breech presentation and congenital anomaly D Mostello et al 12 Table 1. Demographic, obstetric and medical characteristics by fetal presentation at delivery stratified by term status Characteristics X37 weeks P-value o37 weeks P-value Cephalic Breech Cephalic Breech n ¼ 415 273 (%) n ¼ 11 939 (%) n ¼ 30 063 (%) n ¼ 2872 (%) Maternal age (years), Mean (s.d.) 26.3 (5.9) 27.3 (6.0) o0.0001 25.8 (6.3) 26.7 (6.5) o0.0001 12–18 9 7.5 o0.0001 12.7 9.5 o0.0001 19–27 49.2 43.8 49.3 46.9 28–35 34.7 38.9 30.5 33 435 7.1 9.8 7.6 10.7 Maternal race o0.0001 o0.0001 Non-Hispanic whites 82 89 71.3 81 Non-Hispanic blacks 14.7 7.7 25.6 16.3 Others 3.4 3.3 3.1 2.7 Maternal education o0.0001 o0.0001 High school diploma or lower 53.7 48.9 62.3 58.2 Some college or higher 46.3 51.1 37.7 41.8 Maternal low SES 47.6 40.8 o0.0001 57.3 51.5 o0.0001 Parity o0.0001 o0.0001 0 40.8 54.5 45.7 49.4 1 33.6 27.3 27.9 28.4 X2 25.6 18.1 26.4 22.2 Smoking usage 19.5 21.2 o0.0001 25.7 27.5 0.04 Alcohol usage 1.3 1.5 0.12 2.4 2.1 0.3 Hydramnios/oligohydramnios 1.5 3.2 o0.0001 4.4 10.7 o0.0001 Diabetes 2.4 3.2 o0.0001 4.3 4.8 0.23 Renal disease 0.24 0.22 0.70 0.77 0.9 0.43 Hypertension, preeclampsia 4.5 4.6 0.72 14.8 15.1 0.64 Cardiac disease 0.63 0.75 0.12 0.83 0.87 0.80 Late or no prenatal care 14.5 12 o0.0001 20.9 16.7 o0.0001 Female child 54.7 48.8 o0.0001 50.0 46.9 0.002 Child’s birth weight (g), Mean (s.d.) 3442 (476) 3334 (505) o0.0001 2446 (652) 2083 (749) o0.0001 Gestational age (weeks), Mean (s.d.) 39.4 (1.1) 39.0 (1.1) o0.0001 34.4 (2.3) 32.7 (3.3) o0.0001 SGA 9.5 13.8 o0.0001 15.9 20.2 o0.0001 Abbreviations: SES, socioeconomic status; SGA, small for gestational age. Data are percent of n unless specified as mean þ / À standard deviation (s.d.). resulting offspring from these births. The study population consisted of all a categorical variable to account for a potential nonlinear relationship and Missouri residents who delivered singleton pregnancies. Eligible women categorized as less than 18 years, 19 to 27 years, 28 to 35 years, and 36 were identified by using birth certificate and birth defects registry data. years or older. Race was categorized as non-Hispanic white, non-Hispanic Only singleton live births were included to avoid the confounding effects black and other. Low socioeconomic status was defined as enrollment in of multiple gestation on breech presentation and other adverse outcomes, any of the programs including Medicaid, Women, Infants and Children, or such as shorter pregnancy duration and low birth weight. We excluded the Food Stamp Program. Education was divided into two groups: lower pregnancies complicated by placenta previa as a possible confounder for than or equal to a high school degree and some college or more. Cigarette breech presentation.1,4 The study cohort included women with a fetus in smoking and alcohol consumption were treated as dichotomous variables. either breech or cephalic presentation at the time of delivery. Other Parity was defined as prior live births and categorized into three groups, 0, presentations were excluded.
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