Extreme prematurity: Factors associated with perinatal management and morbi-mortality in western Normandy, France.

BACKGROUND: Extreme prematurity (birth before 26 weeks of gestation), presents complex challenges and can lead to various complications. Survival rates of extremely preterm infants are lower in France than in other countries. The choice between active and palliative care is decisive in managing these births. OBJECTIVE: To conduct an observational study focused on factors associated with perinatal management, mortality, and morbidity outcomes among extremely preterm births in a regional perinatal network. METHODS: We undertook a retrospective, multicenter study within the western Normandy perinatal network, encompassing live births between 230/6 and 256/6 weeks from 2015 to 2019. Data were extracted from the perinatal network database and medical records. RESULTS: One hundred and seven infants born from 94 women were included. In the antenatal period, 79 were exposed to corticosteroids, 66 to magnesium sulfate, and 67 to antibiotics. Active care at birth was provided to 84 neonates of whom 42 survived. In total, 65 infants died. Among the 42 surviving neonates, 9 experienced no severe morbidity, 29 displayed one and 4 exhibited two criteria of severe morbidity. Active care was associated with gestational age. Neonatal survival was correlated with antenatal exposure to antibiotics and magnesium sulfate as well as with postnatal corticosteroids. We found no significant association between mortality and gestational age at birth. CONCLUSION: Prognostic factors must be weighed to discuss active antenatal care which is crucial for survival of extremely preterm neonates. Cooperation between obstetricians and neonatal caregivers is a cornerstone on a regional perinatal network scale.

Impact of maternal underweight on obstetric and neonatal prognosis: A retrospective study.

INTRODUCTION: Maternal underweight (BMI < 18.5) is an uncommon situation with potentially serious obstetric consequences, though data in the literature are scarce. OBJECTIVE: To compare the obstetrical prognosis of patients with normal BMI and BMI < 18.5. STUDY DESIGN: We performed a retrospective study in France (Normandy). RESULTS: We included 14,246 patients between January 2011 and November 2017, among whom 12,648 (88.8 %) had normal BMI, 1269 were considered mild underweight (17 ≤ BMI < 18.5 kg/m²) and 329 (2.3 %) were considered severe to moderate underweight (BMI < 17 kg/m²). The risk of preterm birth was all the greater as the thinness was severe (ORa: 1.34 [1.12-1.60] and ORa 1.77 [1.31-2.34]) and the risk of intrauterine growth retardation also increased with severe thinness (ORa: 1.63 [1.35-1.96] and ORa 2.28 [1.69-3.07]). The risk of a caesarean section or scheduled labour was no different. Neonatal parameters were comparable between the groups. CONCLUSION: Our study confirms an increased risk of preterm delivery and intrauterine growth retardation with increased thinness after adjusting for confounding factors. This link had only been shown previously in 2 studies Neither the type of prematurity (induced or spontaneous) nor the severity of prematurity is influenced by the severity of thinness; however, the low prevalence of thinness limits the power of these data. It would be interesting to study the medico-economic relevance of a policy of close maternal-foetal surveillance in this target population.

Maternal obesity in prolonged pregnancy: Labor, mode of delivery, maternal and fetal outcomes.

INTRODUCTION: Obesity is currently not a medical indication for elective induction of labor although obese patients may not be eligible for expectant management after 41 W G. Few data on labor and complications in this population undergoing prolonged pregnancy are known. The objective of our study was to evaluate labor, mode of delivery, maternal and fetal outcomes in prolonged pregnancy in obese patients compared to normal body mass index (BMI). MATERIALS AND METHODS: It was a retrospective cohort study in patients who, after prolonged pregnancy gave birth to a single fetus, in cephalic presentation, between the first of January 2002 and December 31, 2018 in the Caen University Hospital Center. Patient's characteristics were compared within each BMI class using uni- and multivariate analysis with regression logistics models. RESULTS: Overall, 9159 patients were included. Term of birth and spontaneous labor calculated rates were significantly increased in case of obesity (p < 0.001). The adjusted Odds Ratio (ORa) for induced labor in class III obesity was 1.73 [1.13-2.66]. After induction of labor, 83.0 % patients with normal BMI delivered vaginally versus 61.8 % in case of class III obesity (p < 0.001). The ORa for an emergency cesarean was 3.39 [2.04-5.63] and 1.78 [1.06-2.99] for neonatal morbidity in class III obesity. CONCLUSION: Morbid obese patients do not belong to a low risk patient's group when pregnancy is prolonged. Elective induction in case of morbid obesity may entail less risk than allowing the pregnancy to progress after 41 W G or even 39 W G. Further randomized prospective studies are nevertheless required.

Neonatal and maternal outcomes of pregnancy with maternal cardiac disease (the NORMANDY study) : Years 2000-2014.

Pregnancies complicated by congenital or acquired heart diseases are at high risk of maternal, obstetrical and neonatal poor outcomes. During the period 2000-2014, 197 pregnancies occurring in 147 women with heart disease were managed in our institution. A maternal cardiac event complicated 13 pregnancies. Obstetrical and neonatal complications occurred respectively in 35.0% (95% CI [28.3-41.7]) and 37.0% (95% CI [30.3-43.7]) of pregnancies. All complications were more frequent amongst cardiomyopathies or obstructive and conotruncal lesions, whereas left-to-right shunts were less prone to present with complications. Complications occurred between the end of the second trimester and the middle of the third trimester or during the post-partum period. Caesarean section was the mode of delivery in 37% (95% CI [30.3-43.7]) of cases, and general anaesthesia was performed in 8.6% of cases (95% CI [4.7-12.5]). Although reporting relatively mild heart diseases, this retrospective study shows an evolution in the management of pregnancies complicated by cardiopathies. Vaginal delivery under locoregional anaesthesia can be achieved in many pregnancies, whereas others require strict multi-disciplinary follow-up in a specialized centre. The creation of a large, multi-centric registry might help improve and personalize the management of these high-risk pregnancies.

Pseudoamniotic Band Syndrome After Fetoscopic Laser Ablation of Placental Anastomoses for Twin-Twin Transfusion Syndrome: Two Case Reports and Systematic Review.

Pseudoamniotic band syndrome is a rare complication that occurs after invasive procedures for complicated monochorionic twins. We report 2 cases of intrauterine recipient fetal death after laser therapy for twin-twin transfusion syndrome due to umbilical cord constriction by the amniotic band.

Postpartum hemorrhage: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF): in collaboration with the French Society of Anesthesiology and Intensive Care (SFAR).

Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patient's hemodynamic condition so allows (professional consensus).

Prenatal diagnosis of clubfoot: Chromosomal abnormalities associated with fetal defects and outcome in a tertiary center.

PURPOSE: Our aim was to evaluate the rate of occurrence of chromosomal abnormalities, associated findings, and outcome in a series of cases of prenatally diagnosed clubfoot. METHODS: We conducted a retrospective study of all cases of clubfoot diagnosed prenatally in the ultrasound unit of a French tertiary center from January 2004 through December 2011. Clubfoot was scored as complex or isolated depending on the presence or absence of another structural abnormality observed on sonographic examination. RESULTS: Data from 90 fetuses prenatally diagnosed with clubfoot were included in this study. Thirty-four cases were considered complex (38%) and 56 were considered isolated (62%). A chromosomal abnormality was identified in 10 of 33 of the fetuses with complex clubfoot and in 1 of 45 of those with isolated clubfoot (p < 0.001). Clubfoot was associated with a poor outcome in 5 of 52 cases of isolated clubfoot and in 31 of 34 cases associated with other structural defects (p < 0.001). The deformity was bilateral in 62 cases (69%) and unilateral in 28 (31%). No statistically significantly higher rate of poor outcome was identified when the deformity occurred bilaterally nor was a significantly higher rate of chromosomal abnormality noted in this condition. CONCLUSIONS: Aneuploidy and adverse pregnancy outcomes occur more commonly in prenatally diagnosed cases of complex clubfoot than in those of isolated clubfoot. Fetal karyotyping is required in cases of complex clubfoot, but the need for that procedure in isolated clubfoot remains controversial.