Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study.

OBJECTIVE: To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section. DESIGN: Prospective population-based study. SETTING: All 176 maternity hospitals of eight French regions. POPULATION: Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries. METHODS: Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared. MAIN OUTCOME MEASURES: Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes. RESULTS: The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally. CONCLUSION: More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean. TWEETABLE ABSTRACT: Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

[Perinatal health and medical administrative data: What uses, which stakeholders, what the issues for birth data? - Special REDSIAM]. / Périnatalité et bases de données médico-administratives : quels usages, quels acteurs, quels enjeux pour les données sur les naissances ? ­ Spécial REDSIAM.

BACKGROUND: The uses of medical administrative data (MAD/BDMA) emerged in perinatal health following the work on regionalization of very pre-term birth. They have become more numerous since the late 2000s. The objective of this article is to take stock of the existing work carried out within the REDSIAM-perinatality group, on MAD/BDMA and their uses for the period of "birth". METHODS: The studied MADs are the Hospital Discharge Data (PMSI) and the French national health database (SNIIRAM). The material includes knowledge shared by the members of the REDSIAM-perinatality group, scientific references and gray literature. RESULTS: Our exploratory study shows that the uses of MAD in perinatal health are diversified at the local, regional and national levels. The works and publications, increasing, take the form of public access of processed data. Collective thinking makes it possible to move from a localized use to an institution, a network or several, to a national use and an inscription in public authorities' responses. In 2015/2016, two institutional sites provide access to data on maternal and child health: Data.Drees and ATIH ScanSanté. MAD/BDMA uses are multiple: epidemiological use (count of births by gestational age, weight in particular; perinatal indicators), quality of care, planning (maternity activities, regionalization of care). There is an increasing interest among stakeholders, producers and/or operators of MAD/BDMA (decision-makers, professionals or researchers). CONCLUSION: The BDMA, including the PMSI and the SNIIRAM, are used and relevant in Perinatal health with the rise of health networks, the territorialisation of health, in an increased demand for quality of care. Their use will increase the reliability of the data collected and an inscription in the validation studies, more and more numerous in the field of BDMA. The algorithms need to be more finely compiled, validated and enhanced.

[Record linkage of hospital discharge data and first health certificates: a test in the Val d'Oise]. / Chaînage d'enregistrements de séjours PMSI aux premiers certificats de santé: un test dans le Val d'Oise.

BACKGROUND: Our objective was to test the feasibility of an indirect linkage of data on births from health certificates (HC) with hospital discharge (HD) data. METHODS: The linkage was carried out for live births between April 1st and June 30th, 2011 in six of the nine maternity units in the district of Val d'Oise. The HC and HD had 3284 and 3550 births registered during this period, respectively. Linkage was conducted using variables available in both sources: number of fetuses, baby's birth date, gender, maternity unit of birth, maternal age, municipality of residence, gestational age and birth-weight. Two linkage methods were tested: a deterministic and a semi-deterministic method and a probabilistic approach. The latter method calculates a probability estimate for the strength of the relationship between two linked observations related to the discriminatory power and the error rate of the matched variables. For cases that were linked despite discordance on some of the matching variables, random samples of observations were checked against both HC and HD records to compute rates of false matches. RESULTS: The deterministic and semi-deterministic method linked 92.5% and 85.6% of observations in the HC and HD, respectively. The probabilistic method achieved a linkage rate of 99.6% for HC and 92.7% for HD. Cases only linked by the probabilistic method were more often preterm and had low birth-weight. Cases matched using the probabilistic method only had an error rate of 0.4% with 95% CI [0.2-0.6%]. CONCLUSION: Common items in the HC and HD make it possible to achieve a high rate of linkage. The probabilistic method links more births and, in particular, those at higher risk, and error rates were low.

Etravirine concentrations in the cervicovaginal compartment in HIV-1-infected women receiving etravirine-containing antiretroviral therapy: DIVA 02 study.

We studied the penetration of etravirine and HIV shedding in the genital tract among 12 HIV-1-infected women receiving an etravirine-containing regimen who had <40 copies/ml blood plasma (BP) HIV RNA. None of the cervicovaginal fluid (CVF) samples showed detectable HIV RNA. Median etravirine concentrations were 663 ng/ml in BP and 857 ng/ml in CVF, with a CVF/BP etravirine ratio of approximately 1.2. This good penetration of etravirine may contribute to the control of viral replication in the female genital tract.

Do perinatal guidelines have an impact on obstetric practices?

BACKGROUND: The publication of several sets of French guidelines was unfortunately not accompanied by planned assessment of their impact on practices. The goal of this study was to assess the impact of eight French perinatal guidelines on actual obstetric practices. METHODS: Historical cohort setting in France: the Audipog database of 299,412 pregnancies from 1994 to 2006, from which we extracted a sub-sample by randomLy selecting from each participating maternity ward all births occurring during a single month of each year (n=107,450 pregnancies). The main outcome measure was the incidence of pertinent perinatal indicators related to these guidelines. These included site of delivery for low-birth-weight infants (1998), caesarean delivery (2000), preterm delivery (2002), breastfeeding (2002), smoking and pregnancy (2004), immediate postpartum hemorrhages (2004), early discharge after delivery (2004) and episiotomies (2005). Standardised rates, before and after the year of each guideline, were compared using a Chi(2) test. RESULTS: The percentage of children weighing less than 1500 g at birth born in Level III hospitals increased through 1999 but dropped subsequently, without ever returning to the 1994 level (P<0.0001). The overall caesarean rate climbed slowly but regularly from 1994 through 2006 (P<0.0001). Use of antenatal corticosteroids for women hospitalised for threatened preterm labour and in children born before 33 weeks has fluctuated since the release of the guideline (P>0.05). Exclusive breastfeeding at discharge from the maternity ward has increased slowly (P<0.0001). The percentage of deliveries with active management of the third stage of labour rose notably from 1999 to 2006 (P<0.0001), and smoking cessation during pregnancy rose slightly in 2006 (P<0.0001). Since 1994, early discharges have become slowly, slightly, but regularly more frequent for all women (P<0.0001). The guideline on episiotomies has had a slight positive effect in the short term (P<0.0001). CONCLUSIONS: Globally, the impact on actual practices of clinical practice guidelines, except the guideline concerning the active management of the third stage of labour, was low. Most of the changes observed in practices began before the pertinent guideline was published.

[Screening and healthcare for pregnant women with psycho-social vulnerability : A French national study]. / Dépistage et parcours de soins en cas de vulnérabilités psycho-sociales maternelles : une enquête nationale française.

INTRODUCTION: Psycho-social vulnerabilities are a medical risk factor for both fetus and mother. Association between socioeconomic status and prenatal follow-up has been well established and inadequate follow-up is associated with higher morbidity and mortality in women in unfavorable situations. OBJECTIVE: The objective is to identify screening strategies and to describe existing systems for pregnant women in psycho-social vulnerability in French maternity hospitals. MATERIAL AND METHODES: This is a national survey conducted by questionnaire in all French maternities. RESULTS: Screening by means of targeted questions is carried out by 96.7% of maternity units. Early prenatal interviews are offered systematically by 64% of maternity units and access to them is still difficult for women in vulnerable situations. In order to organize care pathways, 28.7% of maternities have a structured unit within their establishment and 81% state that they have mobilizable caregivers. Multidisciplinary meetings for the coordination of the various stakeholders are held by 85.8% of maternity units. Collaboration with networks and associations is emphasized. CONCLUSION: A large proportion of maternities seek to identify women in situation of psycho-social vulnerabilities and to organize care paths. However, the resources implemented still appear insufficient for many maternity units. Each maternity hospital has resources and is developing initiatives to deal with the difficulties of care.

[Overview of induction of labor practices in France]. / État des lieux des pratiques de déclenchement en France.

OBJECTIVE: To describe induction of labor practices in France and to identify factors associated with the use of different methods. METHODS: The data came from the French prospective population-based cohort MEDIP (MEthodes de Déclenchement et Issues Périnatales), including consecutively during one month in 2015 all women with induction of labor and a live fetus in 7 perinatal networks. The characteristics of women, maternity units, gestational age, Bishop's score, decision mode, indication and methods of labor induction were described. Factors associated with the use of different methods were sought in univariate analyzes. RESULTS: The rate of induction of labor during the study was 21% and 3042 women were included (95.9% participation rate). The two main indications were prolonged pregnancy (28.7%) and premature rupture of the membranes (25.4%). More than one-third of women received intravenous oxytocin in first method, 57.3% prostaglandins, 4.5% balloon catheter and 1.4% another method. Among the prostaglandins, the vaginal device of dinoprostone was the most used (71.6%) then the gel (20.7%) and the vaginal misoprostol (6.7%). Women with a balloon were more often of higher body mass index and multiparous with scarred uterus. The balloon and misoprostol were mainly used in university public hospitals. CONCLUSIONS: The evolution of induction of labor methods, due to new data from the literature and the development of new drugs or devices, invites to regularly repeat population-based studies on induction of labor.

[Audipog perinatal network. Part 1: principal perinatal health indicators, 2004-2005]. / Réseau sentinelle Audipog 2004-2005. Partie 1 : résultats des principaux indicateurs périnatals.

OBJECTIVE: To present the principal perinatal indicators for 2004-2005, based on data from the Audipog sentinel network. PATIENTS AND METHODS: The database for 2004 and 2005 covers 71,406 pregnancies from 86 maternity units throughout the year. We constructed a random subsample each year by including only the births occurring during a single month for each maternity ward. Our study therefore analyzes 6987 pregnancies in 2004 and 7648 pregnancies in 2005. RESULTS: The number of women working during pregnancy increased between 2004 and 2005 (62.3% versus 66.3%) (p=0.0008) as did the percentage with a postsecondary education (35.1% versus 41.9%) (p<0.0001). The percentage of amniocenteses declined (10.4% versus 7.9%) (p<0.0001). Use of prenatal care improved: more women had prenatal visits before week 14 (30.5% versus 33.9%) (p=0.0002), and fewer women had no prenatal care at all (1.1% versus 0.4%) (p=0.0003). The percentage of preterm deliveries was 6.4% in 2004 and 7% in 2005 (p=0.14) and the percentage of induced preterm deliveries was 37% in 2004 and 41.2% in 2005 (p=0.18). The cesarean rate was essentially stable (19 and 19.2%) and the rate of instrumental intervention in vaginal deliveries fell from 13.1% in 2004 to 11.2% in 2005 (p=0.0015). DISCUSSION AND CONCLUSION: The rates of cesarean and of preterm deliveries remained stable between 2004 and 2005, but the rate of induced preterm deliveries rose. These indicators are consistent with trends that began earlier.

[Audipog perinatal network 2004-2005. Part 2: assessment of medical practices]. / Réseau Sentinelle Audipog 2004-2005. Partie 2 : évaluation des pratiques professionnelles.

OBJECTIVE: To describe specific clinical practices in France in 2004-2005 based on data from the Audipog sentinel network. PATIENTS AND METHODS: The database for 2004 and 2005 covers 71406 pregnancies from 86 maternity units throughout the year. We constructed a random subsample each year by including only the births occurring during a single month for each maternity ward. Our study therefore analyzes 6987 pregnancies in 2004 and 7648 pregnancies in 2005. RESULTS: Among the very preterm (<33 weeks of gestation) infants from multiple pregnancies, 77.4% were born in level 3 hospitals in 2000-2001, and only 44.9% in 2004-2005 (p<0.0001). Among the very preterm infants from singleton pregnancies, the percentage born in level 3 maternity hospitals rose between 1996-1997 and 2004-2005 (55% versus 73%; p=0.001). The rate of corticosteroid therapy before delivery among very preterm infants did not change significantly between 2000 and 2005 (p=0.58). The cesarean rate rose from 14% in 1994 to 20.0% in 2005. The percentage of actively managed third stages of labor increased from 1994-1995 to 2005 (6.2% versus 31.3%). Fewer episiotomies were performed: 56% in 1994-1995 and 41.3% in 2005. Exclusive breast-feeding rose from 51.2% in 2000-2001 to 58.5% in 2005 (p<0.0001). Early discharge increased between 1994-1995 and 2005 (p<0.0001). DISCUSSION AND CONCLUSION: Indicators monitoring implementation of some of the national clinical practice guidelines have improved slightly over time, although most often before the publication of these guidelines.

[Medical practice assessment: an introduction]. / Introduction à l'évaluation des pratiques professionnelles.

Medical practice assessment is mandatory in France. The goal of this article is to explain to perinatal care providers the concept and the process, which do not seem simple, given the multitude of possible ways to evaluate and validate its medical practices. Concrete examples help to illustrate the process. French regulations now link medical practice assessment with continuing medical education (CME) for physicians. While certification is voluntary, a practice assessment conducted during hospital certification processes and during CME is required for all French physicians.

[Pregnancy and psychoactives substances: prevalence study based on the declared consumption]. / Grossesse et substances psychoactives: étude de prévalence de la consommation déclarée.

OBJECTIVES: Evaluate substance use (tobacco, alcohol, psychotropic drugs, illicit drugs) declared before and during pregnancy. PATIENTS AND METHODS: Two hundred and forty-five pregnant women were interviewed through a self-administered and anonymous questionnaire as they were going to a prenatal consultation in a maternity hospital in the Parisian area. RESULTS: Before pregnancy, 16.3% of women reported smoking and 10.2% carried on smoking during pregnancy. Altogether, 40.8% of women reported alcohol consumption before pregnancy; 25.3% of women had contact with alcohol during pregnancy; 4.5% reported tobacco and alcohol consumption during pregnancy. During the month preceding the study, the consumption of psychotropic drugs (hypnotics, antidepressants or sedatives) was reported by 3.7% of women and that of marijuana by 2.4%. Moreover, the marijuana consumers, who tend to drink alcohol more often, combine important social and familial difficulties and represent a high-risk group. CONCLUSION: Tobacco and alcohol use in this study were lower than in any previously conducted French surveys. Methodological specificities and cultural factors might explain those results. However, this is the first study that asses substance use and marijuana use, in particular, by French pregnant women.

Can hospital discharge data be used for monitoring indicators associated with postpartum hemorrhages? The HERA multicenter observational study.

OBJECTIVES: The principal objective of this study was to assess the reliability of measuring the incidence of postpartum hemorrhages (PPH) from the national hospital discharge summary database (PMSI). The secondary objectives were to assess this reliability according to the maternity unit level and status and to assess the measurement of second-line procedures for PPH. MATERIALS AND METHODS: This study compared PPH incidence rates from February through July 2011 in 131 maternity units, as measured in the PMSI and the prospective HERA study cohort, considered as the reference standard. RESULTS: Compared with the cohort, PPH incidence was over-reported in the PMSI among vaginal deliveries (4.0% vs. 3.5; P<0.0001), but not cesareans (3.2 vs. 2.9%; P=0.1). For the second-line curative procedures, PMSI data underestimated the incidence of vessel embolization and transfusion (P<0.0001) among vaginal deliveries and of hypogastric ligation (P=0.002), other vessel ligation (P=0.005), and transfusion (P<0.0001) among cesareans. CONCLUSION: Despite some coding inaccuracy in the PMSI, routinely collected data can provide acceptable estimates for maternity units and perinatal networks to use to improve quality of care through the monitoring of quality indicators. Improvements are nonetheless needed for international comparisons and other epidemiologic purposes.

Labour induction practices in France: A population-based declarative survey in 94 maternity units.

INTRODUCTION: In 2016, 22.0% of deliveries in France were induced. The current lack of high level of evidence data about the methods and indications for induction of labour has promoted heterogeneous and non-recommended practices. The extent of these different practices is not adequately known in France today, although they may influence perinatal outcomes. The objective of this study was to report current practices of induction of labour in France. MATERIAL AND METHODS: This study surveyed 94 maternity units in seven perinatal networks. A questionnaire was sent by email to either the department head or delivery room supervisor of these units to ask about their methods for induction and their attitudes in specific obstetric situations. RESULTS: The rate of induction varied between maternity units from 7.7% to 33% of deliveries. Most units used two (39.4%) or three or more (35.1%) agents for cervical ripening. In all, 87 (92.6%) units reported using dinoprostone as a vaginal slow-released insert, 59 units dinosprostone as a vaginal gel (62.8%) and 46 units a balloon catheter (48.9%). Only three units reported using vaginal misoprostol. Inductions without medical indication were reported by 71 (75.5%) maternity units, and 22 (23.4%) units even when the cervix was unfavourable. Obstetric attitudes in cases of breech presentation, previous caesareans, fetal growth restriction or macrosomia and prelabour rupture of the membranes varied widely. DISCUSSION: The variability of practices for induction of labour and the persistence of disapproved practices call for an assessment of the effectiveness and the safety of the different strategies.

[Perinatal care for extremely preterm infants. Considerations of the "risks in pregnancy" department]. / Prise en charge de la prématurité extrême. Réflexions du département hospitalo-universitaire (DHU) « risques et grossesse ¼.

Decisions regarding whether to initiate or forgo intensive care for extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients and must be taken into account. After a short review of these factors, we present the thoughts and proposals of the Risks and Pregnancy department. The proposals are to limit emergency decisions, to better take into account other factors than gestational age and prenatal predicted fetal weight in assessing the prognosis, to introduce multidisciplinary consultation in the evaluation and proposals that will be discussed with the parents, and to separate prenatal steroid therapy from decision-making regarding whether or not to administer intensive care.

How singleton breech babies at term are born in France: a survey of data from the AUDIPOG network.

Based on data from the AUDIPOG sentinel network between 1994 and 2010, we can say that the rate of singleton breech presentation at term is 3% and remains unchanged despite an external cephalic version rate of 35%. The total cesarean section rate is currently 75%. This rate increased by nearly 20% after the Hannah publication in 2000, regardless of the type of breech and type of maternity unit. The rate of planned cesarean sections increased in particular, going from 40% to 60%, and even reaching 67% for footling breech presentations. The rate is higher in type I maternity units than in type II or III. This cesarean section rate has been stable since 2005 and has even decreased for the Frank breech. The average rate of external cephalic version remains stable at around 23%. The episiotomy rate is 28%. The rate of babies transferred to neonatology units is higher for breech babies at term than for babies presenting cephalically (3.9% compared to 2.9%), but the newborns most often transferred are those born by cesarean section (4.1% compared to 3.4%).

Comparative prevalence, incidence and short-term prognosis of cervical squamous intraepithelial lesions amongst HIV-positive and HIV-negative women.

OBJECTIVE: To investigate the impact of HIV infection on the prevalence, incidence and short-term prognosis of squamous intraepithelial lesions (SIL), in a prospective study with 1-year follow-up. METHODS: Between 1993 and 1995, 271 HIV-positive and 171 HIV-negative women at high risk of HIV infection were recruited, 365 (82.6%) of whom completed the 1-year follow-up. The women underwent a Papanicolaou smear test at inclusion and at 6 and 12 months. Human papillomavirus (HPV) was detected at inclusion by Southern blot and PCR. RESULTS: The SIL prevalence ranged from 7.5% for HIV-negative to 31.3% for HIV-positive women with CD4 cell counts < 500 x 10(6)/l (P < 0.001). Other factors associated independently and significantly with SIL prevalence were HPV-16, 18, 33 and related types, HPV-31, -35, -39 and related types, lifetime number of partners, younger age, past history of SIL and lack of past cervical screening. The SIL incidence ranged from 4.9% in HIV-negative women to 27% in HIV-positive women with CD4 cells < 500 x 10(6)/l (P < 0.001). Progression from low- to high-grade SIL during follow-up was detected in 38.1% of HIV-positive women with CD4 cells < or = 500 x 10(6)/l but in no HIV-negative nor HIV-positive women with CD4 cells > 500 x 10(6)/l. HPV-16, 18, 33 and related types were also associated with higher incidence of SIL and progression from low- to high-grade SIL. CONCLUSION: HIV-induced immunodeficiency is associated with high prevalence, incidence and persistence/progression of SIL. A pejorative influence of HIV infection without marked immunodeficiency is less clear. HIV-positive women with SIL may thus benefit from early treatment when a useful immune response is still present.

[Prenatal health in 2002-2003. Survey of medical practice. Results from the Audipog sentinel network]. / La santé périnatale en 2002-2003. L'observatoire des pratiques médicales. Résultats du réseau sentinelle Audipog.

Perinatal health survey has been ensured for 10 years by the AUDIPOG Sentinel Network (AUDIPOG, Association of Users of Computerized Files in Perinatology, Obstetrics and Gynecology). It was created, in 1994, by a group of birth specialists having the same concern for a common system of perinatal health survey and assessment of medical practices. Every year, the network includes about 100 voluntary maternity units pooling data about pregnant women and their newborns. To date, the AUDIPOG database comprises 180,000 births gathered between 1994 and 2003, including 78,287 births for the 2002 and 2003 period. The use of a standardization method of the rates makes it possible to provide valid estimations at the national level. This report presents the perinatal health indicators in 2002-2003 and confirms a very alarming situation: the rate of preterm births has not decreased since 1999 (7.1% of births) and high prematurity (< 33 weeks of gestation) affects 1.6% of newborns. Only 65% of high premature infants are born in care level III maternity units, while the figure of 80% has been reached as soon as 1999 and has not stopped to decrease since. The rate of cesarean section keeps on increasing, reaching 18.7% including 9.6% before the beginning of labour. The AUDIPOG network constitutes a continuous, and in real time, perinatal health survey and also a tool to assess medical practices. Members of the Audipog network can log in to the common data base, using the AUDIPOG website (http://audipog.inserm.fr), in order to find answers to their own questionnings and to compare their practices with the external reference formed by the network: such an access represents an innovating method of self-assessment of medical practices and quality control.

[Management of drug addict pregnant women and their children]. / Prise en charge des femmes enceintes toxicomanes et de leurs enfants.

Children of substance abuse mothers have an increased risk of severe pathological disorders such as perinatal diseases (prematurity, intrauterine growth retardation, infections) with their neurological and respiratory complications and sequelae, and transmission of drug addiction related infections, ie human immunodeficiency virus, hepatitis B and C virus, syphilis. Many of these children present a drug withdrawal syndrome characterized by restlessness and jetteriness during the neonatal period. This is frequently followed by a post withdrawal period of several weeks duration with crying, excitement, sleep and feeding difficulties. Although these drug withdrawal manifestations have no incidence on the vital prognosis, it severely impairs the mother-infant interaction. Despite these disorders it appears that the outcome of these children is mainly related to their familial environment which is exposed to many risk factors: mother-child separation, violence, delinquency, precariousness, unhealthy housing, prostitution, drug dependency, parental death or imprisonment... Early medico-psycho-social intervention starting during pregnancy and a prolonged support for several years are the only way to improve their spontaneously poor outcome.

[Evaluation of uterine activity by ambulatory tocography]. / Evaluation de l'activité utérine par tocographie ambulatoire.

The mother's sensations of uterine contractions were compared to the graphs made by the ambulatory tocograph linked to a telephone system (system Tokos), 95 women were assessed. They felt only 20% of their contractions. When the pregnancies were single pregnancies the sensation was found in more women (26%). In a group of women who had a threat of premature labor only 12% of contractions were felt.