Promptness of oxytocin administration for first-line treatment of postpartum hemorrhage: a national vignette-based study among midwives.

BACKGROUND: Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. Midwives play a key role in the initial management of PPH. Uterotonic agents are widely used in its prevention and treatment, with oxytocin the first-line agent. Nonetheless, a standardized guideline for optimal dose and rate of administration has not been clearly defined. The aim of this study was to investigate French midwives' practices regarding first-line oxytocin treatment and the factors influencing its delayed administration. METHODS: This multicenter study was based on clinical vignettes of PPH management collected using an anonymous online questionnaire. A random sample of midwives from 145 maternity units in France from 15 randomly selected perinatal networks were invited to participate by email. The Previously validated case vignettes described two different scenarios of severe PPH. Vignette 1 described a typical immediate, severe PPH, and vignette 2 a less typical case of severe but gradual PPH They were constructed in three successive steps and included multiple-choice questions proposing several types of clinical practice options at each stage. For each vignette separately, we analyzed the lack of prompt oxytocin administration and the factors contributing to them, that is, characteristics of the midwives and organizational features of maternity units. Bivariate analysis and multivariable logistic regression analysis were applied. RESULTS: In all, 450 midwives from 87 maternity units provided complete responses. Lack of promptness was observed in 21.6% of responses (N = 97) in Vignette 1 and in 13.8% (N = 62) in Vignette 2 (p < .05). After multivariate analysis, the risk of delay was lower among with midwives working in university maternity hospitals (ORa 0.47, 95% 0.21, 0.97) and in units with 1500 to 2500 births per year (ORa 0.49, 95% CI 0.26, 0.90) for Vignette 1. We also noticed that delay increased with the midwives' years of experience (per 10-year period) (ORa 1.30, 95% CI 1.01, 1.69). CONCLUSIONS: This study using clinical vignettes showed delays in oxytocin administration for first-line treatment of PPH. Because delay in treatment is a major cause of preventable maternal morbidity in PPH, these findings suggest that continuing training of midwives should be considered, especially in small maternity units.

Comparative satisfaction and effectiveness of virtual simulation and usual supervised work for postpartum hemorrhage management: a crossover randomized controlled trial.

BACKGROUND: Because virtual simulation promotes learning and cognitive skill development, it may be useful for teaching students to manage postpartum hemorrhage (PPH) and its complex decision algorithm. OBJECTIVE: This study aimed to compare the satisfaction and effectiveness of virtual simulation with usual supervised work in producing knowledge and satisfaction. METHODS: This two-center two-stage crossover randomized controlled trial included student midwives. One group underwent the virtual simulation intervention in the first period (January 2018) and the usual supervised classroom work in the second (May 2018); the other group followed the reverse chronology. Satisfaction was the primary outcome. The secondary outcome was knowledge of the PPH management algorithm, assessed by responses to a case vignette after each intervention session. RESULTS: The virtual simulation -supervised work (VS-SW) chronology was allocated to 48 students, and its inverse (SW-VS) to 47; Satisfaction was significantly higher for the virtual simulation for its overall grade (6.8 vs. 6.1, P = 0.009), engagingness (very good 82.1% vs. 24.3%, P < 0.001), and ease of use (very good 77.9% vs. 46.1%, P < 0.001). Knowledge did not differ between the two groups (respectively, 89.5% versus 83.5%, P = 0.3). CONCLUSION: Satisfaction is higher with virtual simulation without lowering knowledge scores, which argues for the use of such innovative teaching strategies. This could lead to an increase in students' motivation to learn.

Early exposure of pregnant women to non-steroidal anti-inflammatory drugs delivered outside hospitals and preterm birth risk: nationwide cohort study.

OBJECTIVE: To assess the risk of preterm birth associated with nonsteroidal anti-inflammatory drugs (NSAIDs), focusing on early exposure in the period from conception to 22 weeks of gestation (WG). DESIGN: National population-based retrospective cohort study. SETTING: The French National Health Insurance Database that includes hospital discharge data and health claims data. POPULATION: Singleton pregnancies (2012-2014) with a live birth occurring after 22WG from women between 15 and 45 years old and insured the year before the first day of gestation and during pregnancy were included. We excluded pregnancies for which anti-inflammatory medications were dispensed after 22WG. METHODS: The association between exposure and risk of preterm birth was evaluated with GEE models, adjusting on a large number of covariables, socio-demographic variables, maternal comorbidities, prescription drugs and pregnancy complications. MAIN OUTCOME MEASURES: Prematurity, defined as a birth that occurred before 37WG. RESULTS: Among our 1 598 330 singleton pregnancies, early exposure to non-selective NSAIDs was associated with a significantly increased risk of preterm birth, regardless of the severity of prematurity: adjusted odds ratio (aOR) = 1.76 (95% CI 1.54-2.00) for extreme prematurity (95% CI 22-27WG), 1.28 (95% CI 1.17-1.40) for moderate prematurity (28-31WG) and 1.08 (95% CI 1.05-1.11) for late prematurity (32-36WG), with non-overlapping confidence intervals. We identified five NSAIDs for which the risk of premature birth was significantly increased: ketoprofen, flurbiprofen, nabumetone, etodolac and indomethacin: for the latter, aOR = 1.92 (95% CI 1.37-2.70) with aOR = 9.33 (95% CI 3.75-23.22) for extreme prematurity. CONCLUSION: Overall, non-selective NSAID use (delivered outside hospitals) during the first 22WG was found to be associated with an increased risk of prematurity. However, the association differs among NSAIDs. TWEETABLE ABSTRACT: French study for which early exposure to non-selective NSAIDs was associated with increased risk of prematurity.

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 outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy.

OBJECTIVE: To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned. METHODS: JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation). RESULTS: Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery. CONCLUSION: When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

[Validation of the questionnaire for assessing the childbirth experience (QACE) in a French population]. / Validation de l'échelle d'évaluation du vécu de l'accouchement (QEVA) auprès d'une population française.

BACKGROUND: A woman's negative perception of her subjective childbirth experience can have consequences on the mother's psychological state and on early mother-baby relationships. To date, there is no validated tool in France allowing to evaluate childbirth experience in a multidimensional way. The aim of this study is to validate the Questionnaire Assessing the Childbirth Experience (QEVA) in a French sample of mothers. This tool was developed in a previous study where the authors combined 25 items into 6 dimensions: representations and expectations, sensory perceptions, feeling of control, perceived social support (medical staff and partner), emotions (positive and negative) and first moments with the baby. METHODS: The sample included 256 women recruited in a maternity ward. Sociodemographic and obstetric characteristics of our sample were compared to those of the French national perinatal survey. The structure of the QEVA with 17 items was explored by an exploratory structural equation modeling (ESEM). An analysis of the internal consistency was conducted on the sub-scores of the identified factors, and the concurrent validity was assessed with the Peri-traumatic Distress Inventory (PDI) through a correlation and its associated t-test. RESULTS: The characteristics of our sample and those of the national perinatal survey do not differ on age, marital status, parity, cannabis use, infertility treatment, epidural and baby weight, in favour of the good representativeness of our sample. The study of the QEVA structure revealed a 4-dimensional structure. Analysis of the psychometric qualities showed a good internal consistency, with an observed alpha value ranging from 0.69 to 0.86. The QEVA also shows a good concurrent validity with the peri-traumatic distress scores (r=0.51). CONCLUSION: To date, the QEVA is the first standardized tool allowing a multidimensional evaluation of the subjective experience of childbirth. It has been validated on a French population using an exploratory structural equation modeling. This tool, which is simple to use and well accepted by mothers, enables health professionals not only to screen mothers experiencing difficult childbirth and in need of support, but also to adapt health care according to the dimensions of the birth experience and its associated difficulties (emotions during the birth, interactions with health professionals, first moments with the baby, or post-partum emotions).

Risk of preterm birth in a twin pregnancy after an early-term birth in the preceding singleton pregnancy: a retrospective cohort study.

OBJECTIVE: To evaluate whether a history of spontaneous early-term birth (37+0 -38+6  weeks of gestation) in the previous singleton pregnancy is a risk factor for preterm birth (PTB) in a subsequent twin pregnancy. DESIGN: Retrospective cohort study. SETTINGS: Two French university hospitals (2006-2016). POPULATION: All women who delivered twins from 24+0  weeks after a preceding singleton pregnancy birth at 37+0 to 41+6  weeks. METHODS: Multivariate logistic regression analysis of association between twin PTB and a previous spontaneous singleton early-term birth. MAIN OUTCOME MEASURES: Twin PTB rate before 37, 34 and 32 weeks of gestation. RESULTS: Among 618 twin pregnancies, 270 were born preterm, 92 of them with a preceding spontaneous singleton early-term birth. The univariate analysis showed a significantly higher risk of twin PTB before 37, 34 and 32 weeks among those 92 women compared with those with a full- or late-term birth in their previous singleton pregnancy. This association remained significant after logistic regression (odds ratio [OR] between 2.42 and 3.88). The secondary analysis, restricted to the twin pregnancies with spontaneous PTB found similar results, with a risk of PTB before 37, 34 and 32 weeks significantly higher among women with a previous spontaneous singleton early-term birth, including after logistic regression analysis (OR between 3.51 and 3.56). CONCLUSION: A preceding spontaneous singleton early-term birth is a strong and easily identified risk factor for PTB in twin pregnancies. TWEETABLE ABSTRACT: Spontaneous 'early-term' birth of a singleton is a significant risk factor for future preterm births in twin pregnancies.

ISUOG Practice Guidelines: intrapartum ultrasound.

PURPOSE AND SCOPE: The purpose of these Guidelines is to review the published techniques of ultrasound in labor and their practical applications, to summarize the level of evidence regarding the use of ultrasound in labor and to provide guidance to practitioners on when ultrasound in labor is clinically indicated and how the sonographic findings may affect labor management. We do not imply or suggest that ultrasound in labor is a necessary standard of care.

Universal cervical length screening for singleton pregnancies with no history of preterm delivery, or the inverse of the Pareto principle.

Ultrasound measurement of cervical length in the general population enables the identification of women at risk for spontaneous preterm delivery. Vaginal progesterone is effective in reducing the risk of preterm delivery in this population. This screening associated with treatment by vaginal progesterone is cost-effective. Universal screening of cervical length can therefore be considered justified. Nonetheless, this screening will not appreciably reduce the preterm birth prevalence: in France or UK, where the preterm delivery rate is around 7.4%, this strategy would make it possible to reduce it only to 7.0%. This small benefit must be set against the considerable effort required in terms of screening ultrasound scans. TWEETABLE ABSTRACT: Universal ultrasound screening of cervical length is the inverse of Pareto's principle: a small benefit against a considerable effort.

Intrauterine balloon tamponade for management of severe postpartum haemorrhage in a perinatal network: a prospective cohort study.

OBJECTIVE: To evaluate the effectiveness of intrauterine balloon tamponade (IUBT) for management of severe postpartum haemorrhage (PPH). To identify the factors predicting IUBT failure. DESIGN: Prospective cohort study. SETTING: Ten maternity units in a perinatal network. POPULATION: Women treated by IUBT from July 2010 to March 2013. METHODS: The global IUBT success rate was expressed as the number of women with severe PPH who were successfully treated by IUBT divided by the total number treated by IUBT. IUBT failure was defined as the need for arterial embolisation or surgery. Logistic regression analysis was used to estimate factors predicting IUBT failure. MAIN OUTCOME MEASURES: Global IUBT success rate. Factors associated with IUBT failure. RESULTS: Intrauterine balloon tamponade was attempted in 226 women: 171 after vaginal delivery (VD) (75.7%) and 55 during or after caesarean delivery (CD) (24.3%). The global success rate was 83.2% (188/226) and was significantly higher after VD (152/171, 88.9%) than CD (36/55, 65.5%, P < 0.01). The percentage of CD was significantly higher in the failure group (50.0 versus 19.1%, P < 0.01), as was mean (SD) estimated blood loss before IUBT: 1508 ± 675 ml versus 1064 ± 476, P < 0.01. Coagulopathy was significantly more frequent in the failure group (50.0% versus 17.2%, P < 0.01). CD [Odds ratio (OR) 3.5; 95% CI 1.6-7.6], estimated blood loss before IUBT (OR 3.2; 95% CI 1.5-6.8) and coagulopathy (OR 5.6; 95% CI 2.5-13.0) were predictive of IUBT failure. CONCLUSION: Intrauterine balloon tamponade is an effective method for treating severe PPH. Early balloon deployment before the development of coagulopathy increases its success rate. TWEETABLE ABSTRACT: Intrauterine balloon tamponade is effective for achieving haemostasis in intractable postpartum haemorrhages.

Angle of fetal head progression measured using transperineal ultrasound as a predictive factor of vacuum extraction failure.

OBJECTIVE: To evaluate the predictive value of angle of progression (AoP) of the fetal head for a failed vacuum delivery. METHODS: This was a prospective observational study that included women with a singleton pregnancy of ≥ 37 weeks' gestation, in cephalic presentation requiring vacuum extraction. Transperineal ultrasound was performed immediately before vacuum extraction, although AoP was measured on stored images after delivery. Vacuum extraction was defined as failed when the duration of extraction exceeded 20 min or the vacuum cup detached more than three times. We compared the demographic and ultrasound data of failed vacuum deliveries with those that were successful. The predictive value of AoP for failure of vacuum delivery was calculated. RESULTS: AoP was measured in 235 women. Vacuum extractions failed in 30 (12.8%) women (29/184 nulliparous and 1/51 parous) and resulted in 28 vaginal deliveries by forceps and two Cesarean deliveries. Median AoP was significantly lower in the vacuum failure group compared with those with successful vacuum delivery (136.6° (interquartile range (IQR), 129.8-144.1°) vs 145.9° (IQR, 135.0-158.4°); P < 0.01). As all but one failed vacuum extraction occurred among nulliparous women, the predictive value of AoP was calculated in this subgroup of women. The area under the receiver-operating characteristics curve for prediction of vacuum extraction failure was 0.67 (95% CI, 0.57-0.77) and the optimal AoP cut-off was 145.5°. Above this value, the rate of vacuum extraction failure fell below 5%. CONCLUSION: AoP is a predictive factor of failed vacuum extraction, especially among nulliparous women whose risk of failure is high. AoP measurement may help in choosing between forceps and vacuum extraction. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Influence of ultrasound determination of fetal head position on mode of delivery: a pragmatic randomized trial.

OBJECTIVE: To evaluate the influence of ultrasound determination of fetal head position on mode of delivery. METHODS: This was a pragmatic open-label randomized controlled trial that included women with a singleton pregnancy in the vertex presentation at ≥ 37 weeks' gestation, cervical dilation ≥ 8 cm and who received epidural anesthesia. Women were assigned randomly to undergo either digital vaginal examination (VE group) or both digital vaginal and ultrasound examinations (VE+US group) to determine fetal head position. When the ultrasound and digital vaginal findings were inconsistent in the VE+US group, the ultrasound result was used for clinical management. The primary outcome assessed was operative delivery (Cesarean or instrumental vaginal delivery), and maternal and fetal morbidity were also assessed. RESULTS: The VE and VE+US groups included 959 and 944 women, respectively. The overall rate of operative delivery was significantly higher in the VE+US group than in the VE group: 33.7% vs 27.1%, respectively (relative risk (RR), 1.24 (95% CI, 1.08-1.43)), as was the rate of Cesarean delivery: 7.8% vs 4.9%, respectively (RR, 1.60 (95% CI, 1.12-2.28)). The rate of instrumental vaginal delivery was also higher, albeit not significantly: 25.8% in the VE+US group vs 22.2% in the VE group (RR, 1.16 (95% CI, 0.99-1.37)). Neonatal outcomes did not differ between the two groups. When analysis was restricted to instrumental vaginal deliveries only, maternal and neonatal morbidity outcomes were similar in both groups. CONCLUSION: Correction of fetal occiput position, determined initially by digital vaginal examination, using systematic ultrasound examination did not improve management of labor and increased the rate of operative delivery without decreasing maternal and neonatal morbidity.

Non-invasive prenatal testing for trisomy 21 based on analysis of cell-free fetal DNA circulating in the maternal plasma.

OBJECTIVE: By-the-book implementation of non-invasive prenatal test and clinical validation for trisomy 21. STUDY DESIGN: Publicly funded prospective study of 225 cases. Women at risk for trisomy 21 > 1/250 based on combined ultrasound and serum markers during first or second trimester were eligible following an informed consent. The technique was established from the available literature and performed on 10 mL of venous blood collected prior to chorionic villus sampling or amniocentesis. Investigators were blinded to the fetal karyotype. Results were expressed in Z-scores of the percentage of each chromosome. RESULTS: Among 976 eligible cases, 225 were processed: 8 were used for pretesting phase and 23 to build a reference set. One hundred thirty six euploid cases and 47 with trisomy 21 were then run randomly. Eleven cases yielded no result (4.8%). Z-scores were above 3 (7.58+/-2.41) for chromosome 21 in all 47 trisomies and in none of the euploid cases (0.11+/-1.0). Z-scores were within normal range for the other chromosomes in both groups. Using a cut-off of 3, sensitivity and specificity were of 100% 95% CI [94.1, 100] and 100% 95% CI [98, 100], respectively. CONCLUSION: Non-invasive prenatal test for trisomy 21 is a robust strategy that can be translated from seminal publications. Publicly funded studies should refine its indications and cost-effectiveness in prenatal screening and diagnosis. © 2015 John Wiley & Sons, Ltd.

[Severe post-obstetric perineal tears: Medium-term consequences on women's quality of life]. / Déchirures périnéales post-obstétricales sévères : conséquences à moyen terme sur la qualité de vie des femmes.

AIMS: To assess the prevalence of anal (AI) and urinary (UI) incontinence at medium term after 3rd and 4th degree anal sphincter tears and their impact on sexuality and women's quality of life. MATERIAL: It is a case-control, single center study. Sixty-eight primiparous women delivered with severe anal sphincter tear (exposed group) were compared to 136 women without (control group). Questionnaires on anal and urinary incontinence, sexual function and quality of life, using validated scores, were sent between two and five years after the first delivery. Maternal and obstetric data were collected retrospectively on the medical files. RESULTS: The answer rate was 22.5% (46/204) of which 30.9% (21/68) in the exposed group and 18.4% (25/136) in the unexposed group. In case of severe anal sphincter tear, 57.1% of women reported an AI vs 48% in the control group (P=0.76). The rate of AI for liquid stool was significantly higher in the exposed group (P=0.05). Patients with severe perineal tears reported a greater impact of symptoms on their quality of life but the difference with the control group was not significant. CONCLUSIONS: The severity of symptoms related to anal sphincter tears is common and underestimated. Preventive measures must be improved in order to maintain women's quality of life. LEVEL OF EVIDENCE: 4.

EG-VEGF controls placental growth and survival in normal and pathological pregnancies: case of fetal growth restriction (FGR).

Identifiable causes of fetal growth restriction (FGR) account for 30 % of cases, but the remainders are idiopathic and are frequently associated with placental dysfunction. We have shown that the angiogenic factor endocrine gland-derived VEGF (EG-VEGF) and its receptors, prokineticin receptor 1 (PROKR1) and 2, (1) are abundantly expressed in human placenta, (2) are up-regulated by hypoxia, (3) control trophoblast invasion, and that EG-VEGF circulating levels are the highest during the first trimester of pregnancy, the period of important placental growth. These findings suggest that EG-VEGF/PROKR1 and 2 might be involved in normal and FGR placental development. To test this hypothesis, we used placental explants, primary trophoblast cultures, and placental and serum samples collected from FGR and age-matched control women. Our results show that (1) EG-VEGF increases trophoblast proliferation ([(3)H]-thymidine incorporation and Ki67-staining) via the homeobox-gene, HLX (2) the proliferative effect involves PROKR1 but not PROKR2, (3) EG-VEGF does not affect syncytium formation (measurement of syncytin 1 and 2 and ß hCG production) (4) EG-VEGF increases the vascularization of the placental villi and insures their survival, (5) EG-VEGF, PROKR1, and PROKR2 mRNA and protein levels are significantly elevated in FGR placentas, and (6) EG-VEGF circulating levels are significantly higher in FGR patients. Altogether, our results identify EG-VEGF as a new placental growth factor acting during the first trimester of pregnancy, established its mechanism of action, and provide evidence for its deregulation in FGR. We propose that EG-VEGF/PROKR1 and 2 increases occur in FGR as a compensatory mechanism to insure proper pregnancy progress.

[Induction of labour with oral misoprostol versus vaginal misoprostol: A before-after study]. / Induction du travail par misoprostol oral versus misoprostol vaginal : étude avant-après.

OBJECTIVE: The rate of induction of labor represented 22 % of deliveries in 2016 in France. Oral misoprostol (Angusta®) was marketed in France in the last quarter of 2018. The objective of our study was to compare the efficacy and safety of induction of labor with oral misoprostol compared to vaginal misoprostol in women with an unripe cervix. MATERIAL AND METHODS: We carried out a retrospective study before and after the implementation of oral misoprostol including all women with an unripe cervix who benefited from an induction of labor with a viable infant in vertex presentation, without uterine scar. During the first two-year period, women received 50µg of misoprostol in the posterior fornix, repeated 6hours later if needed. If labor had not started after 24hours, women received another dose of 50µg, which was repeated every 4hours until labor was established, up to a total dose of 150µg. During the second two-year period, women received two tablets of oral misoprostol 25µg every four hours if necessary, up to a total dose of 200µg. The primary endpoints were mode of delivery and neonatal safety. RESULTS: During the two study periods, 1199 women received vaginal misoprostol and 1199 women received oral misoprostol including. The cesarean delivery rate was 21.8% during the first period and 21,3% during the second period (P=0.83). A 5-minutes Apgar score<7 was observed in 23 (1.9%) and 14 (1.2%) newborns in the vaginal misoprostol and oral misoprostol groups (P=0.14), respectively. An arterial cord pH<7.00 was observed in 6 (0.5%) and 7 (0.6%) newborns (P=0.99), respectively. CONCLUSION: Oral misoprostol administered at the dose of 50µg every 4hours (up to a total dose of 200µg) is as effective and safe as the vaginal misoprostol to induce labor in women with an unripe cervix.

Is first-trimester crown-rump length associated with birthweight?

OBJECTIVE: To evaluate the relationship between first-trimester crown-rump length (CRL) and birthweight (BW) Z scores. DESIGN: Retrospective cohort study. SETTING: Two tertiary centres in France. POPULATION: Three hundred and seventeen pregnancies conceived through assisted reproductive techniques between April 2001 and December 2008. METHODS: We used CRL and worked forward to BW. Only pregnancies examined during the first trimester by an Fetal Medicine Foundation-certified operator were included. CRL was expressed as Z scores, and BW was transformed into Z scores by taking gestational age and gender into account. The influence of abnormal first-trimester CRL Z scores on BW was examined. MAIN OUTCOME MEASURES: Weight and gestational age at birth. RESULTS: Birth weight was significantly greater in babies with larger CRL: BW Z scores (± SD) were -0.36 (± 1.05), -0.27 (± 0.97), -0.10 (± 1.04) and 0.13 (± 0.96) in the first, second, third and fourth quartiles of CRL Z scores, respectively (P = 0.01). In contrast, there was no difference in gestational length according to the quartiles of the CRL Z scores. The CRL Z score was a significant predictor of the BW Z score (ß = 0.17, P = 0.001). After adjustment for maternal body mass index, a one-point increase in the first-trimester CRL Z score (i.e. 3.6 mm) was associated with a 39% decrease, 64% increase, 114% increase and 62% increase in the risk of having a BW below the 10th centile [odds ratio (OR), 0.61; 95% confidence intervals (95% CI), 0.39; 0.95; P=0.03], above the 90th centile (OR, 1.64; 95% CI, 1.03; 2.60; P = 0.02), above the 95th centile (OR, 2.14; 95% CI, 1.25; 3.68; P = 0.006) and above 4000 g (OR, 1.62; 95% CI, 1.04; 2.51; P = 0.04), respectively. CONCLUSIONS: Variations in BW may be partly explained by differences in growth trajectories that may express as early as the first trimester.