[Propositions for perinatal care at extremely low gestational ages - Working group on "Extremely low gestational ages" for SFMP, CNGOF, and SFN]. / Propositions sur la prise en charge en cas d'extrême prématurité ­ Le groupe de travail « Extrême Prématurité ¼ pour la SFMP, le CNGOF et la SFN.

OBJECTIVES: International literature suggests that active perinatal management at extremely low gestational ages improves survival without increasing the risk of impairment in survivors, compared to less active management. Although these results are limited to a small number of countries, they question current practices in France. New propositions on perinatal management of extremely preterm infants have carried out by the French Society of Perinatal Medicine, the French Society of Neonatology and the National College of French Obstetricians and Gynecologists. METHODS: This group was set up in 2015 on the initiative of the professional societies and in collaboration with parents' and users' associations. The work was based on a review of the literature on the prognosis of extremely preterm children, as well as on recommendations by European societies. Based on this information, a text was produced, submitted to all members of the working group and definitively validated in April 2019. RESULTS: This text offers a decision-making guideline for the management at extremely low gestational ages. Its principles are: the administration of steroids independently of management (resuscitation or comfort care); a prognostic evaluation and a collegial decision, outside the context of the emergency; a consensus on the information to be given to parents before going to inform them and gather their opinion. CONCLUSIONS: These new propositions will contribute to modifying perinatal care at extremely low gestational ages in France.

Public health impact of Infanrix hexa™ (DTPa-HBV-IPV/Hib) reimbursement: A study programme in France. Part 2: Evolution of the acceptability of infants' vaccination against hepatitis B in general and pediatric practices - the PRALINE study.

BACKGROUND: The reimbursement of the hexavalent vaccine (Infanrix hexa™), comprising the DTPa-IPV-Hib components and the hepatitis B recombinant in a single vaccine, was approved in France in March of 2008. The impact of its reimbursement on physicians' decisions to vaccinate infants against hepatitis B was assessed in a study conducted with general practitioners and pediatricians. METHODS: The PRALINE study (NCT01777074) was a national, cross-sectional, repeated study with two measurement periods (T1 and T2) that measured the changes in physicians' acceptance of hepatitis B vaccination of infants before and for the 3 years after the approval of the hexavalent vaccine reimbursement. Two patient registers were created for each measurement period to enroll the first 15 12- to 15-month-old infants and the first 15 24- to 27-month-old children seen by the practitioners. The proportion of eligible children receiving a hepatitis B vaccine for each physician's practice was calculated. Practitioners also answered a vaccination practice questionnaire via telephone interviews. RESULTS: Across the two study periods, 418 general practitioners and 463 pediatricians were recruited and responded to the telephone interview on their vaccination practices. The overall number of children included in the study in both study periods reached almost 20,000. In the general practitioners group, there was a significant increase in the proportion of physicians "practicing hepatitis B vaccination" (i.e., at least 50% of eligible children receiving the initial hepatitis B vaccination) in children 24-27 months old (79% T2 versus 47% T1, P-value [P]<0.001). Similarly, the proportion of pediatricians initiating hepatitis B vaccination increased from 51% (T1) to 94% (T2) (P<0.0001). General practitioners offered hepatitis B vaccination to infants more systematically in the second study period (87% T2 versus 73% T1, P<0.001) and also suggested the use of the hexavalent vaccine to more patients after reimbursement (92% T2 versus 78% T1, P<0.0001). The proportion of pediatricians offering vaccination to every infant was high at T1 (94%) and remained steady (97%) with a high use of the hexavalent vaccine (94% T1 and 96% T2). CONCLUSION: The PRALINE study shows a significant and immediate change in the hepatitis B vaccination practices of general practitioners and pediatricians following hexavalent vaccine reimbursement with a significant increase in hepatitis B vaccine coverage in infants.

Public health impact of Infanrix hexa (DTPa-HBV-IPV/Hib) reimbursement: A study programme in France. Part 1: Evolution of hepatitis B vaccine coverage rates in infants aged less than 27 months, in the general population - the PopCorn study.

BACKGROUND: Reimbursement of the hexavalent vaccine (Infanrix hexa) comprising the DTPa-IPV-Hib components and the hepatitis B valence in a single vaccine was decided in March 2008 in France. The impact of its reimbursement on the hepatitis B vaccine coverage rate was assessed in a study conducted in the general population prior to and after implementation of the reimbursement policy. METHODS: The PopCorn study (NCT01782794) was a national, cross-sectional and repeated study, with four assessment periods over 3 years, from 2009 to 2012, to assess the hepatitis B vaccine coverage in 12- to 15- and 24- to 27-month-old children, vaccinated between 2007 and 2011 and selected by the quota sampling method. Face-to-face interviews were conducted at their homes and vaccination status was collected using their child's health record. Parents were also interviewed on their perceptions and acceptance of hepatitis B vaccination. Three indicators were calculated to assess hepatitis B vaccination coverage: proportions of infants with at least one dose before 6 months of age, with at least two doses before 6 months of age and with a complete schedule at 24 months of age. RESULTS: A total of 4903 children were enrolled in the study. An overall significant increase (P-value [P<0.05]) of the three indicators of interest over the four periods of time was observed for both age groups. The proportion of children receiving hepatitis B vaccination before 6 months increased from 21% at baseline (before vaccine reimbursement) to almost 75% at the last assessment period in 2012. More than 60% of 24- to 27-month-old children received a complete schedule in 2012 compared to 33% at baseline. No significant increases in the proportions of parents "favourable" and "moderately in favour" of hepatitis B vaccination were observed across the four evaluation periods (respectively, 17-22% and 48-50%, P=0.09). CONCLUSION: The rapid increase of hepatitis B vaccination coverage suggests a significant change in hepatitis B vaccination practice related to the hexavalent vaccine's reimbursement. This change was observed in a context of stability regarding parents' perceptions and acceptance of hepatitis B vaccination and of coverage rates for other infant vaccinations.

[Post-partum: Guidelines for clinical practice--Short text]. / Post-partum: recommandations pour la pratique Clinique--Texte court.

OBJECTIVE: To determine the post-partum management of women and their newborn whatever the mode of delivery. MATERIAL AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: Because breastfeeding is associated with a decrease in neonatal morbidity (lower frequency of cardiovascular diseases, infectious, atopic or infantile obesity) (EL2) and an improvement in the cognitive development of children (EL2), exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (Professional consensus). In order to increase the rate of breastfeeding initiation and its duration, it is recommended that health professionals work closely with mothers in their project (grade A) and to promote breastfeeding on demand (grade B). There is no scientific evidence to recommend non-pharmacological measures of inhibition of lactation (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). For women aware of the risks of pharmacological treatment of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Whatever the mode of delivery, numeration blood count is not systematically recommended in a general population (Professional consensus). Anemia must be sought only in women with bleeding or symptoms of anemia (Professional consensus). The only treatment of post-dural puncture headache is the blood patch (EL2), it must not be carried out before 48 h (Professional consensus). Women vaccination status and their family is to be assessed in the early post-partum (Professional consensus). Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (Professional consensus). An analgesic multimodal protocol developed by the medical team should be available and oral way should be favored (Professional consensus) (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (Professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). Early postoperative rehabilitation is encouraged (Professional consensus). Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, after normal pregnancy and delivery (Professional consensus). Starting effective contraception later 21 days after delivery in women who do not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended (grade B). Rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long-term is not recommended (Expert consensus). Pelvic-floor rehabilitation using pelvic-floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C). Postpartum pelvic-floor rehabilitation is not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). The optimal time for maternity discharge for low risk newborn depends more on the organisation of the post-discharge follow up (Professional consensus). The months following the birth are a transitional period, and psychological alterations concern all parents (EL2). It is more difficult in case of psychosocial risk factors (EL2). In situations of proven psychological difficulties, the impact on the psycho-emotional development of children can be important (EL3). Among these difficulties, postpartum depression is the most common situation. However, the risk is generally higher in the perinatal period for all mental disorders (EL3). CONCLUSION: Postpartum is, for clinicians, a unique and privileged opportunity to address the physical, psychological, social and somatic health of their patients.

[Perceived morbidity and community burden of chikungunya in La Reunion]. / Morbidité perçue et impact communautaire du chikungunya a l'île de La Réunion: enquête de cohorte en population TELECHIK.

BACKGROUND: Persistence of clinical manifestations, especially polyarthralgia and fatigue, is a characteristic feature of chikungunya virus (CHIK-v) infection. The purpose of this study was to measure the impact of prolonged or late-onset manifestations of CHIK-v infection on the self-perceived health of people on Reunion Island. METHODS: This retrospective cohort survey, dubbed TELECHIK survey, was conducted eighteen months after the end of the chikungunya outbreak on a representative random sample from the SEROCHIK population-based survey conducted on Reunion Island. A total of 1094 subjects whose CHIK-v specific IgG antibody status had been documented were interviewed about current symptoms. RESULTS: Analysis of data showed 45% of CHIK+ vs 14% of CHIK- subjects reporting musculoskeletal pain (P < 0.001), 56% vs. 44% reporting fatigue (P = 0.003), 77% vs. 53% reporting cerebral manifestations (P < 0.001), 51% vs. 34% reporting sensorineural impairments (P < 0.001), 18% vs. 13% reporting digestive complaints (P = 0.06), and 38% vs. 32% reporting skin involvement (P = 0.13). The mean delay between infection and interview was two years (range, 15-34 months). Analysis of data after correction for age, gender, body mass index and comorbidity indicated that rheumatic pain, fatigue, cerebral manifestations and sensorineural impairments were more likely in CHIK+ than CHIK- subjects but the likelihood of digestive and skin manifestations was the same. CONCLUSION: With a mean delay of two years after infection, 45% to 77% of CHIK+ subjects reported prolonged or late-onset symptoms attributable to CHIK-v. These results indicate that persistent manifestations of chikungunya infection have a heavy impact on rheumatologic, neurological and sensorineural health.

[The eastern Paris perinatal network (2008-2010). Defining the target population and assessing health needs]. / Le réseau périnatal de l'Est parisien (2008-2010). Définition de la population concernée pour évaluer les besoins à couvrir par le réseau.

BACKGROUND: Since the 1990s, governmental plans in France have imposed the regionalization of perinatal care to improve both safety and quality of care. The Eastern Paris Perinatal Network is under construction in health area 75-2, which includes the 11th, 12th, 13th and 20th arrondissements of Paris. A major issue is ensuring that the network can meet the needs of its target population. The objective is to define the network's target population of mothers and newborns. METHODS: We designed a matrix to help assess these needs and identify the data required to define the network's population. Four principal data sources were analyzed: the National Statistics and Economic Studies Institute (Insee) data, annual health facility activity data, national medical informatics program data, and 8th-day health certificates. RESULTS: The network's target population varies according to the precise perinatal period and the planning stage. For the conception period, it includes the general population and specifically all women of childbearing age (15-49 years). The health area included 672,000 inhabitants in 2006, 29% of them are women of childbearing age. The proportion of people born outside France and who are of foreign nationality ranges, according to arrondissement, from 13.2 to 20.0%; the mean for the Paris metropolitan area is 14.7%. Approximately 16,500 women gave birth in 2007, at nine obstetric facility sites in the health area (five level I, three level II, and one type III); only 41.46% of them resided in the health area. Approximately 2500 women living in the health area gave birth at a facility outside the area. The population likely to be covered by the network is thus estimated at approximately 19,000 women. CONCLUSION: A network must simultaneously take into account the local resident population and the population using its health care system. In an urban area such as Paris, where the health care supply is dense, it is essential for policy planning process to define the contours of the target population of a health network.

Osteoporosis and venous thromboembolism: a retrospective cohort study in the UK General Practice Research Database.

UNLABELLED: In a retrospective cohort study using the General Practice Research Database (GPRD), there was a greater association of venous thromboembolism (VTE) in osteoporotic than in non-osteoporotic female patients. No greater association was shown in treated patients with strontium ranelate or alendronate compared to untreated osteoporotic female patients. INTRODUCTION: We explored the risk of VTE in usual practice in osteoporotic and non-osteoporotic women with and without anti-osteoporotic treatment. METHODS: A retrospective study was conducted using the GPRD in the UK. The cohorts consisted of untreated osteoporotic women (N = 11,546), osteoporotic women treated with alendronate (N = 20,084), or strontium ranelate (N = 2,408), and a sample of non-osteoporotic women (N = 115,009). Cohorts were compared using a Cox proportional hazards regression model. RESULTS: There was a significantly increased relative risk for VTE in untreated osteoporotic women versus non-osteoporotic women (annual incidence 5.6 and 3.2 per 1,000 patient-years, respectively; relative risk 1.75 [95% confidence interval (CI), 1.09-1.84]). Results were confirmed using adjusted models. The annual incidences of VTE in osteoporotic patients treated with strontium ranelate and alendronate were 7.0 and 7.2 per 1,000 patient-years, respectively, with no significant difference between untreated and treated patients whatever the treatment. Adjusted hazard ratios for treated versus untreated osteoporotic women were 1.09 (95% CI, 0.60-2.01) for strontium ranelate and 0.92 (95% CI, 0.63-1.33) for alendronate. CONCLUSION: This study shows a greater association of VTE in osteoporotic compared to non-osteoporotic patients, but does not show any greater association in treated patients with strontium ranelate or alendronate compared to untreated osteoporotic patients.

[Special outpatient services at 5 and 8 years in very-preterm children in the EPIPAGE study]. / Prises en charge éducatives spécifiques de l'enfant grand prématuré à 5 et 8 ans: résultats de l'étude EPIPAGE.

UNLABELLED: The immature brain is highly susceptible to the consequences of very preterm birth with a high rate of long-term neurodisabilities in survivors and high use of specific outpatient services to limit the functional effects of the disabilities. To assess the economic burden for the social and health care system, it is necessary to inventory the community supports and need for special education or rehabilitation used by preterm children. Such studies are few and were done only in extremely low-birthweight or extremely preterm newborns in the United States. OBJECTIVE: To study the rates of specific outpatient services and special education at 5 years of age and between 5 and 8 years of age in a geographically-defined population of children born very preterm. DESIGN, SETTING AND PATIENTS: 2901 liveborn children before 33 weeks'gestation (WG) and one control group of 666 liveborn children at 39-40WG were included in nine regions of France in 1997 corresponding to more than one third of all births. At five years, these children had a medical examination and were evaluated by a psychologist at local centres organised for the study in every region. Cognitive function was assessed by the mental processing composite scale (PMC) of the Kauffmann Assessement Battery for Children test, which is considered to be equivalent to intelligence quotient and behavioral difficulties using the Strength and Difficulties questionnaire completed by the parents. Data for dependence or compensatory aids, i.e. occupational therapy or physical therapy, speech therapy, psychologist or psychiatrist visits, orthoptic therapy, wearing glasses, wearing hearing aid, specific equipment to walk (walker, wheelchair...), orthopaedic treatment or anti-epileptic treatment were collected from parents. At eight years, a postal questionnaire was sent to the parents to collect data on specific outpatient services and special treatments at home and school. Stata software was used (version 9.0). Main outcome measures. Parent Questionnaire for identifying children with chronic conditions and specific health care needs at 5 and 8 years and categorization of developmental neurodisabilities based on examination of children and psychometric evaluation at 5 years. RESULTS: At 5 years data were obtained for respectively 1817 and 396 children born before 33WG or at 39-40WG, which represent 80% of the very preterm children and 71% of the at term children. At 8 years we obtained data for 63% of the very preterm children and 59% of the at term children. At 5 years, care in a rehabilitation center and/or specific outpatient services were required for 41% of children born between 24 and 28WG, 32% of children born between 24 and 32WG and 15% of those born at 39-40WG. Between 5 and 8 years, these figures were respectively 61%, 50% and 36%. In the very preterm group, rates of specific outpatient services were higher than 80% if the child had a motor and/or a neurosensory deficit. In case of cognitive deficiencies (PMC < 85), rates of specific outpatient services were low at 37% at 5 years and increases at 63% between 5 and 8 years. CONCLUSION: Compared to the children born at term, the very preterm children have considerable educational needs, which are inversely related to gestational age at birth and to age of the children at the time of reporting. Despite economic burden, efforts to improve access to services are necessary, in particular in case of cognitive impairment.

Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study.

OBJECTIVE: To describe obstetric intervention for extremely preterm births in ten European regions and assess its impact on mortality and short term morbidity. DESIGN: Prospective observational cohort study. SETTING: Ten regions from nine countries participating in the 'Models of Organising Access to Intensive Care for Very Preterm Babies in Europe' (MOSAIC) project. POPULATION: All births from 22 to 29 weeks of gestation (n = 4146) in 2003, excluding terminations of pregnancy. METHODS: Comparison of three obstetric interventions (antenatal corticosteroids, antenatal transfer and caesarean section for fetal indication) rates at 22-23, 24-25 and 26-27 weeks to that at 28-29 weeks and the association of the level of intervention with pregnancy outcome. MAIN OUTCOME MEASURES: Use of antenatal corticosteroids, antenatal transfer and caesarean section by two-week gestational age groups as well as a composite score of these three interventions. Outcomes included stillbirth, in-hospital mortality and intraventricular haemorrhage (IVH) grades III and IV and/or periventricular leucomalacia (PVL) and bronchopulmonary dysplasia (BPD). RESULTS: There were large differences between regions in interventions for births at 22-23 and 24-25 weeks. Differences were most pronounced at 24-25 weeks; in some regions these babies received the same care as babies of 28-29 weeks, whereas elsewhere levels of intervention were distinctly lower. Before 26 weeks and especially at 24-25 weeks, there was an association between the composite intervention score and mortality. No association was observed at 26-27 weeks. For survivors at 24-25 weeks, the intervention score was associated with higher rates of BPD, but not with IVH or PVL. CONCLUSIONS: There are large differences between European regions in obstetric practices at the lower limit of viability and these are related to outcome, especially at 24-25 weeks.

Comparison of fundal height measurement and sonographically measured fetal abdominal circumference in the prediction of high and low birth weight at term.

OBJECTIVES: To compare the diagnostic value of fundal height and sonographically measured fetal abdominal circumference in the prediction of high and low birth weight in routine practice between 37 and 41 weeks' gestation. METHODS: Data were obtained from a multicenter study of 19 415 women in France and Belgium. In this study we included 7138 low-risk women from that population who underwent fundal height measurements no more than 8 days before delivery (Population A). We also included another 1689 women with both fundal height measurements and fetal ultrasound measurements obtained no more than 8 days before delivery (Population B). Population A was used to calculate the parameters of equations for estimating fetal weight according to fundal height alone (EFW(FH)) or fundal height in combination with other clinical indicators (EFW(FH+)). The ultrasound fetal weight estimation was based on fetal abdominal circumference (EFW(AC)) using Campbell and Wilkins' equation. The correlation between the estimated fetal weight calculated using each of the formulae and the birth weight was then evaluated in Population B, and the diagnostic value of each of the methods for predicting birth weight or=4000 g was also compared. RESULTS: EFW(AC) was better correlated with birth weight than was either EFW(FH) or EFW(FH+). With specificity set at 95%, the sensitivity of EFW(AC) in screening for neonates weighing or=4000 g was significantly higher than that of EFW(FH) (54.0% vs. 37.1%, P < 0.05) or EFW(FH+) (54.0% vs. 45.1%, P < 0.05). CONCLUSIONS: Sonographic measurement of fetal abdominal circumference predicts high and low birth weight better than does clinical examination based on fundal height in routine practice between 37 and 41 weeks' gestation.

The influence of level of care on admission to neonatal care for babies of low-risk nullipara.

OBJECTIVE: To analyze the risk of admission to neonatal care for newborns of low-risk nullipara and its variation with level of care of the maternity unit. STUDY DESIGN: The sample included infants born to low-risk nulliparas from the PREMODA study of 138 French maternity units (n=3652). Medical records of children admitted to neonatal care were reviewed to determine the reasons for admission and the severity of morbidity. The risk factors associated with admission to neonatal care, including maternal, infant and delivery unit characteristics, were studied by univariable analysis, followed by a multivariable analysis using a multilevel logistic model. RESULTS: The newborns of 3.5% (n=129) of the nulliparous mothers at low risk were admitted to neonatal care at birth. The two principal reasons were infections (57%) and respiratory diseases (19%). Babies born in level 2 maternity units were twice as likely to be admitted to neonatal care as those born in level 1 units (ORa=2.0 [1.1-3.7]) and those born in level 3 units, 1.5 times more often, although this was not statistically significant (ORa=1.5 [0.8-2.8]). Babies admitted to neonatal care after delivery in level 1 had more severe morbidity (n=4, 26.7%) than those admitted from level 2 (n=4, 5.7%) or level 3 (n=3, 6.8%) facilities (p=0.046). CONCLUSION: In low-risk populations, the level of care could have an influence on the decision to admit babies to neonatal care at birth. These findings add to the on-going debate about the optimal organization of care for women at low obstetrical risk.

Anaesthesia mode for caesarean section and mortality in very preterm infants: an epidemiologic study in the EPIPAGE cohort.

BACKGROUND: Little is known about the influence of anaesthesia for caesarean section on outcome in very preterm infants. METHODS: A prospective, population-based, cohort study (the EPIPAGE cohort) included all births before 33 weeks in nine French regions in 1997. Of 2360 infants live-born between 27 and 32 weeks, 1338 were delivered by caesarean section with general anaesthesia (n=711, 53.1%), spinal anaesthesia (n=419, 31.3%), or epidural anaesthesia (n=208, 15.6%). Neonatal mortality was compared among these three groups using bi- (according to gestational age and to anaesthetic technique) and multivariate analyses. RESULTS: Neonatal mortality was 10.1% with general anaesthesia, 12.2% with spinal anaesthesia and 7.7% with epidural anaesthesia. After adjustment for gestational age and characteristics of pregnancy, delivery and neonate, spinal anaesthesia was associated with a higher risk of neonatal death than general anaesthesia (adjusted odds ratio, 1.7; 95% confidence interval 1.1 to 2.6). CONCLUSION: In this population-based study, spinal anaesthesia was associated with an increased risk of neonatal mortality in very preterm infants compared to general anaesthesia (and epidural anaesthesia), independently from gestational age and characteristics of the pregnancies, deliveries and neonates. Although this multivariate analysis does not prove a causal relationship, the results suggest it could exist, particularly if maternal haemodynamics are poorly controlled. With recent significant change in the conduct of spinal anaesthesia, further studies are needed to investigate potential harmful effects of anaesthesia on very preterm infants delivered by caesarean section.

Investigating the variations in survival rates for very preterm infants in 10 European regions: the MOSAIC birth cohort.

OBJECTIVE: To investigate the variation in the survival rate and the mortality rates for very preterm infants across Europe. DESIGN: A prospective birth cohort of very preterm infants for 10 geographically defined European regions during 2003, followed to discharge home from hospital. PARTICIPANTS: All deliveries from 22 + 0 to 31 + 6 weeks' gestation. MAIN OUTCOME MEASURE: All outcomes of pregnancy by gestational age group, including termination of pregnancy for congenital anomalies and other reasons, antepartum stillbirth, intrapartum stillbirth, labour ward death, death after admission to a neonatal intensive care unit (NICU) and survival to discharge. RESULTS: Overall the proportion of this very preterm cohort who survived to discharge from neonatal care was 89.5%, varying from 93.2% to 74.8% across the regions. Less than 2% of infants <24 weeks' gestation and approximately half of the infants from 24 to 27 weeks' gestation survived to discharge home from the NICU. However large variations were seen in the timing of the deaths by region. Among all fetuses alive at onset of labour of 24-27 weeks' gestation, between 84.0% and 98.9% were born alive and between 64.6% and 97.8% were admitted to the NICU. For babies <24 weeks' gestation, between 0% and 79.6% of babies alive at onset of labour were admitted to neonatal intensive care. CONCLUSIONS: There are wide variations in the survival rates to discharge from neonatal intensive care for very preterm deliveries and in the timing of death across the MOSAIC regions. In order to directly compare international statistics for mortality in very preterm infants, data collection needs to be standardised. We believe that the standard point of comparison should be using all those infants alive at the onset of labour as the denominator for comparisons of mortality rates for very preterm infants analysing the cohort by gestational age band.

[Prevention and early management of immediate postpartum haemorrhage: policies in six perinatal networks in France]. / Politiques de prévention et de prise en charge précoce de l'hémorragie du post-partum immédiat dans six réseaux de maternités françaises.

OBJECTIVES: Postpartum haemorrhage (PPH) constitutes the leading cause of maternal deaths in France, and the majority of these deaths are preventable. The objective of this study was to ascertain policies for prevention and early management of PPH in maternity units, and to compare the results with scientific evidence. The survey was part of the Euphrates European project, and was conducted in France in 2003 before national recommendations for clinical practice related to PPH were launched. MATERIALS AND METHODS: A cross-sectional declarative survey was conducted in six perinatal networks representing 132 maternity units. A postal questionnaire was sent to all units. Main outcomes measured were stated policies for prevention, diagnosis and management of PPH. RESULTS: There was no definition of PPH in one out of four units, and no written protocol for PPH management in one out of six. Policies of using preventive uterotonics were widespread, but variation was observed concerning the timing of administration, and association with the other components of active management of the third stage of labour. Policies about drugs used for management of PPH also varied. CONCLUSION: Variations in policies show firstly that evidence-based improvement in practice is possible, and secondly that further research is needed on poorly documented aspects of PPH management.

Termination of pregnancy among very preterm births and its impact on very preterm mortality: results from ten European population-based cohorts in the MOSAIC study.

OBJECTIVE: To study the impact of terminations of pregnancy (TOP) on very preterm mortality in Europe. DESIGN: European prospective population-based cohort study. SETTING: Ten regions from nine European countries participating in the MOSAIC (Models of OrganiSing Access to Intensive Care for very preterm babies) study. These regions had different policies on screening for congenital anomalies (CAs) and on pregnancy termination. POPULATION OR SAMPLE: Births 22-31 weeks gestational age. METHODS: The analysis compares the proportion of TOP among very preterm births and assesses differences in mortality between the regions. MAIN OUTCOME MEASURES: Pregnancy outcomes (termination, antepartum death, intrapartum death and live birth) and reasons for termination, presence of CAs and causes of death for stillbirths and live births in 2003. RESULTS: Pregnancy terminations constituted between 1 and 21.5% of all very preterm births and between 4 and 53% of stillbirths. Most terminations were for CAs, although some were for obstetric indications (severe pre-eclampsia, growth restriction, premature rupture of membranes). TOP contributed substantially to overall fetal mortality rates in the two regions with late second-trimester screening. There was no clear association between policies governing screening and pregnancy termination and the proportion of CAs among stillbirths and live births, except in Poland, where neonatal deaths associated with CAs were more frequent, reflecting restrictive pregnancy termination policies. CONCLUSION: Proportions of TOP among very preterm births varied widely between European regions. Information on terminations should be reported when very preterm live births and stillbirths are compared internationally since national policies related to screening for CAs and the legality and timing of medical terminations differ.