Vasa Praevia: Risk-Adapted Modification of the Conventional Management – a Retrospective Study

Abstract

Purpose: Undiagnosed vasa praevia carries an imminent risk of fetal death and increases with IVF. When diagnosed, the question arises as to whether the conventional prenatal management of routine steroid administration for fetal lung maturation and elective caesarean section in week 35 is generally justified in face of the risks involved. We present a retrospective study of a risk-adapted modification of the conventional management of vasa praevia.

Material and Methods: We analysed 11 years of records involving 18 cases of antenatally diagnosed vasa praevia at our perinatal centre. Each case was managed by a risk-adapted modification of the conventional treatment where both, the steroid administration and the timing of delivery, were dependent on the patient history and clinical signs for preterm birth.

Results: There were no lethal fetal, neonatal, or maternal complications. The earliest caesarean section took place at 34 weeks 1 day, the latest at 37 weeks 1 day, and in more than half of the cases at ≥ 36 weeks.

Conclusion: Steroid application is generally recommended for pregnancies before 34 weeks carrying a risk for preterm birth. Thus, retrospectively, none of our cases required steroid administration. This supports our protocol of not obligatorily administering steroids. Delaying the caesarean section up to two weeks beyond the conventionally recommended date of 35 weeks in 78 % of our cases resulted in no complications. This justifies the suitability of determining the timing of delivery based on our individual patient assessment. In conclusion, the following recommendations for a risk-adapted management of vasa praevia can be made: 1. weekly evaluation of risk factors for preterm delivery; 2. steroid administration only at risk for preterm birth; 3. admission to hospital with full obstetric and neonatal care facilities between 32 and 34 weeks; 4. elective caesarean section between 35 and 37 weeks, risk-adapted.

Zusammenfassung

Ziel: Undiagnostizierte Vasa praevia haben eine hohe fetale Letalität und werden mit steigenden IVF-Maßnahmen zunehmen. Selbst wenn sie diagnostiziert werden, stellt sich die Frage, ob das pränatale Standardmanagement – die obligate Steroidapplikation zur fetalen Lungenreifeinduktion und eine geplante Sektio mit 35 SSW – die Risiken rechtfertigen. Wir präsentieren eine retrospektive Studie einer risikoadaptierten Modifikation des konventionellen Managements von Vasa praevia.

Material und Methoden: Wir analysierten an unserem Perinatalzentrum 18 pränatal diagnostizierte Fälle von Vasa praevia. Jeder Fall wurde risikoadaptiert behandelt, wobei die Steroidapplikation und der Entbindungszeitpunkt von der Anamnese der Schwangeren und ihren Frühgeburtsbestrebungen abhingen.

Ergebnisse: Es gab keine letalen Komplikationen der Kinder und Mütter. Die früheste Entbindung lag bei 34 + 1 SSW, die späteste bei 37 + 1 SSW. In mehr als der Hälfte der Fälle wurde in ≥ 36 SSW entbunden.

Schlussfolgerung: Retrospektiv gesehen wäre in keinem Fall eine Steroidapplikation nötig gewesen, was unsere Methode der nicht obligaten Administration rechtfertigt. In 78 % unserer Fälle verschoben wir den Entbindungszeitpunkt um bis zu 2 Wochen hinter die üblicherweise empfohlenen 35 SSW, was zu keinen Komplikationen führte. Zusammenfassend empfehlen wir folgendes risikoadaptiertes Vorgehen bei Vasa praevia: 1. wöchentliche Evaluation der Frühgeburtsbestrebungen; 2. Steroidapplikation nur im Falle erhöhten Frühgeburtsrisikos; 3. Hospitalisierung in einer geeigneten Klinik ab 32 – 34 SSW; 4. primäre Sektio risikoadaptiert zwischen 35 und 37 SSW.

Key words

vasa praevia - obstetric management - prenatal ultrasound - diagnosis

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