Severe postpartum hemorrhage and the risk of adverse maternal outcome: A comparative analysis of two population-based studies in France and the Netherlands.

Objectives: Among women with severe PPH (sPPH) in France and the Netherlands, we compared incidence of adverse maternal outcome (major obstetric hemorrhage (≥2.5L blood loss) and/or hysterectomy and/or mortality) by mode of delivery. Second, we compared use and timing of resuscitation and transfusion management, second-line uterotonics and uterine-sparing interventions (intra-uterine tamponade, compression sutures, vascular ligation, arterial embolization) by mode of delivery. Methods:  Secondary analysis of two population-based studies of women with sPPH in France and the Netherlands. Women were selected by a harmonized definition for sPPH: (total blood loss ≥ 1500 ml) AND (blood transfusion of ≥ 4 units packed red blood cells and/or multicomponent blood transfusion). Findings: Incidence of adverse maternal outcome after vaginal birth was 793/1002, 9.1 % in the Netherlands versus 88/214, 41.1 % in France and 259/342, 76.2% versus 160/270, 59.3% after cesarean. Hemostatic agents such as fibrinogen were administered less frequently (p < 0.001) in the Netherlands (vaginal birth: 83/1002, 8.3% versus 105/2014, 49.5% in France; cesarean: 47/342, 13.7% and 152/270, 55.6%). Second-line uterotonics were started significantly later after PPH-onset in the Netherlands than France (vaginal birth: 46 versus 25 min; cesarean: 45 versus 18 min). Uterine-sparing interventions were less frequently (p < 0.001) applied in the Netherlands after vaginal birth (394/1002,39.3 %, 134/214, 62.6%) and cesarean (133/342, 38.9 % and 155/270, 57.4%), all initiated later after onset of refractory PPH in the Netherlands. Interpretation: Incidence of adverse maternal outcome was higher among women with sPPH in the Netherlands than France regardless mode of birth. Possible explanatory mechanisms are earlier and more frequent use of second-line uterotonics and uterine-sparing interventions in France compared to the Netherlands.

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]. / La technique de la césarienne : recommandations pour la pratique clinique du Collège national des gynécologues obstétriciens français.

OBJECTIVE: To identify procedures to reduce maternal morbidity during cesarean. MATERIAL AND METHODS: The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS: Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds. CONCLUSION: In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

Benefits of the «en caul¼ technique for extremely preterm breech vaginal delivery.

INTRODUCTION: The "en caul" technique, i.e. delivery with intact membranes, may reduce the risk of obstetric trauma in vaginal breech delivery of extreme preterm infants. We aimed at comparing perinatal mortality and morbidity among extremely preterm breech vaginal deliveries between infants delivered "en caul" and those with "ruptured membranes". MATERIAL AND METHODS: We performed a fourteen-year retrospective study in a tertiary university center. All vaginal deliveries of singleton breech live infants with an antenatal decision of active resuscitation between 24 weeks and 27+6 weeks were included. Perinatal outcomes were compared between the "en caul" group, with intact membranes at the onset of pushing efforts and the "ruptured membranes" group, with ruptured membranes at the onset of pushing efforts. The primary outcome was perinatal mortality defined by intrapartum or neonatal death. The secondary outcomes were fetal extraction difficulties, arterial pH and 5 min Apgar score. RESULTS: We included 52 infants in the "en caul" group and 71 in the "ruptured membranes" group. The perinatal mortality rate did not differ between the two groups (19.2% in the "en caul" group versus 28.2% in the "ruptured membranes" group, p = 0.25). The mean arterial pH at birth was higher in the « en caul ¼ group (7.32 ± 0.1 vs 7.24 ± 0.1, p = 0.001). There were no differences between the groups for fetal extraction difficulties, especially fetal head entrapment (9.6% versus 9.9%). CONCLUSION: Even though the "en caul" technique does not seem to decrease the perinatal mortality rate, it remains a simple technique, which could improve neonatal morbidity.

Comparison of the performance of estimated fetal weight charts for the detection of small- and large-for-gestational age newborns with adverse outcomes: a French population-based study.

OBJECTIVE: To compare the performance of estimated fetal weight (EFW) charts at the third trimester ultrasound for detecting small- and large-for-gestational age (SGA/LGA) newborns with adverse outcomes. DESIGN: Nationally representative observational study. SETTING: French maternity units in 2016. POPULATION: 9940 singleton live births with an ultrasound between 30 and 35 weeks of gestation. METHODS: We compared three prescriptive charts (INTERGROWTH-21st, World Health Organization (WHO), Eunice Kennedy Shriver National Institute of Child Health and Human Development [NICHD]), four descriptive charts (Hadlock, Fetal Medicine Foundation, two French charts) and a French customised growth model (Epopé). MAIN OUTCOME MEASURES: SGA and LGA (birthweights <10th and >90th percentiles) associated with adverse outcomes (low Apgar score, delivery-room resuscitation, neonatal unit admission). RESULTS: 2.1% and 1.1% of infants had SGA and LGA and adverse outcomes, respectively. The sensitivity and specificity for detecting these infants with an EFW <10th and >90th percentile varied from 29-65% and 84-96% for descriptive charts versus 27-60% and 83-96% for prescriptive charts. WHO and French charts were closest to the EFW distribution, yielding a balance between sensitivity and specificity for SGA and LGA births. INTERGROWTH-21st and Epopé had low sensitivity for SGA with high sensitivity for LGA. Areas under the receiving operator characteristics curve ranged from 0.62 to 0.74, showing low to moderate predictive ability, and diagnostic odds ratios varied from 7 to 16. CONCLUSION: Marked differences in the performance of descriptive as well as prescriptive EFW charts highlight the importance of evaluating them for their ability to detect high-risk fetuses. TWEETABLE ABSTRACT: Choice of growth chart strongly affected identification of high-risk fetuses at the third trimester ultrasound.

Respiratory morbidity in children with congenital heart disease.

OBJECTIVE: To evaluate the respiratory outcome in children with congenital heart disease (CHD), considering recent management procedures and the CHD pathophysiology. DESIGN AND SETTING: Clinical and functional respiratory outcome were evaluated in 8-year-old children with isolated CHD followed up from birth in the prospective population-based EPICARD cohort. PATIENTS: Children were assigned to two groups, based on the pathophysiology of the CHD: CHDs with left-to-right shunt (n = 212) and CHDs with right outflow tract obstruction (n = 113). RESULTS: Current wheezing episodes were observed in 15% of the children with isolated CHD and left-to-right shunt, and 11% of the children with isolated CHD and right outflow tract obstruction (not significant). Total lung capacity (TLC) was the only respiratory function parameter that significantly differed between the two groups. It was lower in children with left-to-right shunt (88.72 ± 0.65% predicted) than in those with right outflow tract obstruction (91.84 ± 0.96, p = 0.006). In multivariate analysis, CHD with left-to-right shunt (coeff. [95% CI]: -3.17 [-5.45; -0.89]) and surgery before the age of 2 months (-6.52 [-10.90; -2.15]) were identified as independent factors associated with significantly lower TLC values. CONCLUSION: Lower TLC remains a long-term complication in CHD, particularly in cases with left-to-right shunt and in patients requiring early repair. These findings suggest that an increase in pulmonary blood flow may directly impair lung development.

A new individualized prognostic approach to the management of women at risk of extreme preterm birth in France: Effect on neonatal outcome.

INTRODUCTION: After discussion with the parents, periviable infants can receive either active treatment or palliative care. The rate of active treatment in France is lower than in other developed countries, as is the survival rate of infants in this gestational age range. This study's main objective was to assess the effect of a standardized perinatal management protocol (EXPRIM) on the neonatal outcome of children born before 27 weeks of gestation. METHODS: A before-and-after study was conducted in the two level-3 hospitals of the Risks and Pregnancy DHU to compare two 16-month periods. The EXPRIM protocol was based on routine administration of prenatal corticosteroid therapy and a scheduled combined obstetric-pediatric group prenatal prognostic evaluation, not based solely on gestational age. The study included all births between 22 weeks and 26 weeks+6 days of gestation, except in utero deaths diagnosed at admission and medical terminations of pregnancy for fetal malformation, both excluded. The principal endpoint was survival without severe neonatal morbidity. RESULTS: The study included 267 women: 116 (128 newborns) in period 1 and 151 (172 newborns) in period 2. The median gestational age at admission to the maternity unit was 2.5 days younger in period 2, and the number of women admitted at 22-23 weeks doubled in period 2 (59 vs 29, respectively). Overall, the rates of live births, NICU transfer, and survival without severe morbidity were similar during the two periods. More infants were liveborn between 22 and 24 weeks in period 2 (66 vs 43). Of all newborns transferred to the NICU, 26 (29%) survived without severe morbidity in period 1 and 46 (39%) in period 2. After multivariate analysis, survival without severe morbidity did not differ significantly. CONCLUSION: Implementation of the EXPRIM protocol led to active treatment of more mothers and their children at the border of viability, and increased the number of children who survived without severe morbidity even if, overall, there was no statistically significant difference in percentage.

[Factors associated with inadequate folic acid supplementation for the prevention of neural tube defects in eight Parisian maternity units]. / Facteurs associés à un défaut de supplémentation en acide folique pour la prévention des anomalies de fermeture du tube neural dans huit maternités parisiennes.

OBJECTIVES: Despite the guidelines in effect, too few women in France receive folic acid supplementation. The principal objective of this study was to identify the factors associated with the inadequacy of this supplementation in the periconceptional period. The secondary objective was to assess women's knowledge about the prevention of neural tube defects (NTDs). METHODS: This study included 400 women and took place in 8 Parisian maternity. Folic acid supplementation was inadequate when started after the beginning of the pregnancy. RESULTS: Among the women questioned, 68% had inadequate folic acid supplementation. They were significantly younger (ORa= 1,8; 95% IC [1,1-2,8]), didn't had health insurance (ORa=3,9; 95% IC [1,5-10,1]), had not studied after high school (ORa=2,9; 95% IC [1,2-6,9]) and had regular gynecological care less often than the women with adequate supplementation (ORa=3,0; 95% IC [1,6-5,6]). More than half (55.5%) had insufficient knowledge of the benefits of folic acid; the factors related to this lack of knowledge were the absence of regular gynecological care and of health insurance. CONCLUSION: Individual factors associated with a lack of supplementation have been identified. These results provide health professionals and supervisors with useful information for developing strategies adapted to certain subgroups of women for better prevention of AFTN in these populations.

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.

Association between extremely preterm caesarean delivery and maternal depressive and anxious symptoms: a national population-based cohort study.

OBJECTIVE: To evaluate whether caesarean delivery before 26 weeks of gestation was associated with symptoms of depression and anxiety in mothers in comparison with deliveries between 26 and 34 weeks. DESIGN: Prospective national population-based EPIPAGE-2 cohort study. SETTING: 268 neonatology departments in France, March to December 2011. POPULATION: Mothers who delivered between 22 and 34 weeks and whose self-reported symptoms of depression (Center for Epidemiologic Studies Depression Scale: CES-D) and anxiety (State-Trait Anxiety Inventory: STAI) were assessed at the moment of neonatal discharge. METHODS: The association of caesarean delivery before 26 weeks with severe symptoms of depression (CES-D ≥16) and anxiety (STAI ≥45) was assessed by weighted and design-based log-linear regression model. MAIN OUTCOME MEASURES: Severe symptoms of depression and anxiety in mothers of preterm infants. RESULTS: Among the 2270 women completing CES-D and STAI questionnaires at the time of neonatal discharge, severe symptoms of depression occurred in 25 (65.8%) women having a caesarean before 26 weeks versus in 748 (50.6%) women having a caesarean after 26 weeks. Caesarean delivery before 26 weeks was associated with severe symptoms of depression compared with caesarean delivery after 26 weeks (adjusted relative risk [aRR] 1.42, 95% CI 1.12-1.81) adjusted to neonatal birthweight and severe neonatal morbidity among other factors. There was no evidence of an association between mode of delivery and symptoms of anxiety. CONCLUSIONS: Mothers having a caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression and may benefit from specific preventive care. TWEETABLE ABSTRACT: Mothers having caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression.

The impact of chorionicity on pregnancy outcome and neurodevelopment at 2 years old among twins born preterm: the EPIPAGE-2 cohort study.

OBJECTIVE: To compare the short- and mid-term outcomes of preterm twins by chorionicity of pregnancy. DESIGN: Prospective nationwide population-based EPIPAGE-2 cohort study. SETTING: 546 maternity units in France, between March and December 2011. POPULATION: A total of 1700 twin neonates born between 24 and 34 weeks of gestation. METHODS: The association of chorionicity with outcomes was analysed using multivariate regression models. MAIN OUTCOME MEASURES: First, survival at 2-year corrected age with or without neurosensory impairment, and second, perinatal, short-, and mid-term outcomes (survival at discharge, survival at discharge without severe morbidity) were described and compared by chorionicity. RESULTS: In the EPIPAGE 2 cohort, 1700 preterm births were included (850 twin pregnancies). In all, 1220 (71.8%) were from dichorionic (DC) pregnancies and 480 from monochorionic (MC) pregnancies. MC pregnancies had three times more medical terminations than DC pregnancies (1.67 versus 0.51%, P < 0.001), whereas there were three times more stillbirths in MC than in DC pregnancies (10.09 versus 3.78%, P < 0.001). Both twins were alive at birth in 86.6% of DC pregnancies compared with 80.0% among MC pregnancies (P = 0.008). No significant difference according to chorionicity was found regarding neonatal deaths and morbidities. Likewise, for children born earlier than 32 weeks, the 2-year follow-up neurodevelopmental results were not significantly different between DC and MC twins. CONCLUSIONS: This study confirms that MC pregnancies have a higher risk of adverse outcomes. However, the outcomes among preterm twins admitted to neonatal intensive care units are similar irrespective of chorionicity. TWEETABLE ABSTRACT: Monochorionicity is associated with adverse perinatal outcomes, but outcomes for preterm twins are comparable irrespective of their chorionicity.

[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.

Evaluation of the 4 diagnosis criteria proposed by the SMFM and the AFE foundation for amniotic fluid embolism in a monocentric population.

OBJECTIVE: The Society of Maternal Fetal Medicine (SMFM) and the Amniotic Fluid Embolism Foundation have recently proposed four diagnostic criteria for amniotic fluid embolism (AFE): presence of (1) sudden cardiac arrest or both respiratory and hemodynamic collapse, and (2) biological disseminated intravascular coagulopathy (DIC), and (3) absence of fever, and (4) clinical onset during labor or within 30 min of delivery. The objectives of our study were to describe the clinical presentation of women with a strong suspicion of AFE and to assess the validity of the four criteria proposed for AFE definition. MATERIAL AND METHODS: We performed a retrospective study including all patients with a strong suspicion of AFE who delivered between 2006 and 2018 at the Port Royal maternity unit, Paris. Strong suspicion of AFE was defined by a clinical presentation in favor of AFE associated with a biological pattern and/or autopsy result supporting AFE. The mention of AFE in files was essential to include the patients in our study. We estimated the incidence and mortality rate of AFE. Then, the presence of each of the four diagnosis criteria of the SMFM score was described, as well as the clinical and biological patterns. RESULTS: Among the 54 140 women who delivered during the study period, 14 had a strong suspicion of AFE (0.03 %), accounting for 25.9/100 000 deliveries (95 %CI (12.3-39.5/100,000)). All women had biological tests or autopsy supporting the diagnosis of AFE. Six of 14 patients (43 %) presented with all the four diagnostic criteria of the SMFM definition. All 14 women presented a hemodynamic collapse, but respiratory symptoms were lacking in 8 patients (57 %); 71 % fulfilled the criterion of biological DIC, and all patients had a clinical coagulopathy and a massive postpartum hemorrhage. Absence of fever was lacking in three women. In addition, all patients presented premonitory symptoms such as neurological disorders or irreversible and inaugural fetal bradycardia. CONCLUSION: The four SMFM diagnostic criteria were present in less than half of the women with a strong suspicion of AFE. We propose an alternative clinical and pragmatic definition to diagnose AFE, which has to be validated in the future. Early diagnosis of AFE based solely on clinical criteria can help clinicians anticipate the severity of the situation and optimize care.

Reform of the 3rd cycle in surgery training.

The main objectives of the reform of the 3rd cycle of medical studies in France that was instituted in 2017 after eight years of preparation, are to train future specialists in a consistent and equitable fashion and to replace the previous time-based qualification by training based on the progressive acquisition of skills. This reform was an opportunity for the 13 different French surgical specialty Colleges involved to share reflections on what a surgeon actually was and to define training in surgical sub-specialties. The current reform is well adapted to these specifications and has fostered training models that are consistent with each other. This article discusses the historical construction of this reform, what will change in the training of future surgeons, as well as some points that warrant caution. The third cycle reform has also triggered a reform of the second cycle, which is expected to come into force for the 2020 academic year. Its objective will be to eliminate the guillotine effect created by the National Classifying Examinations and to allow students to better understand and test their desire and skills for a given specialty. It will be up to these same surgical Colleges to determine how to do this for the sub-specialties of the "surgery" discipline.

Neurodevelopment at 2 years and umbilical artery Doppler in cases of very preterm birth after prenatal hypertensive disorder or suspected fetal growth restriction: EPIPAGE-2 prospective population-based cohort study.

OBJECTIVE: To investigate the association between absent or reversed end-diastolic flow (ARED) on umbilical artery Doppler ultrasound and poor neurological outcome at 2 years of age after very preterm birth associated with suspected fetal growth restriction (FGR) or maternal hypertensive disorders. METHODS: The study population comprised all very preterm (22-31 completed weeks) singleton pregnancies delivered because of suspected FGR and/or maternal hypertensive disorders that had umbilical artery Doppler and 2-year follow-up available included in EPIPAGE-2, a prospective, nationwide, population-based cohort of preterm births in France in 2011. Univariate and two-level multivariable logistic regression analyses were used to assess the association of ARED in the umbilical artery, as compared with normal or reduced end-diastolic flow, with severe or moderate neuromotor and/or sensory disability and with an Ages and Stages Questionnaire (ASQ) score below a threshold. This was defined as a score more than 2 SD below the mean in any of the five domains, at age 2, adjusting for gestational age at delivery. ASQ is used to identify children at risk of developmental delay requiring reinforced follow-up and further evaluation. Descriptive statistics and bivariate tests were weighted according to the duration of the inclusion periods. RESULTS: The analysis included 484 children followed up at 2 years of age, for whom prenatal umbilical artery Doppler ultrasound was available. Among them, 8/484 (1.6%) had severe or moderate neuromotor and/or sensory disability, and 156/342 (45.4%) had an ASQ score below the threshold. Compared with normal or reduced end-diastolic flow in the umbilical artery (n = 305), ARED (n = 179) was associated with severe or moderate neuromotor and/or sensory disability (adjusted odds ratio (OR), 11.3; 95% CI, 1.4-93.2) but not with an ASQ score below the threshold (adjusted OR, 1.2; 95% CI, 0.8-1.9). CONCLUSION: Among children delivered before 32 weeks of gestation due to suspected FGR and/or maternal hypertensive disorder who survived until 2 years of age, prenatal ARED in the umbilical artery was associated with a higher incidence of severe or moderate neuromotor and/or sensory disability. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Prognostic value of diffusion-weighted magnetic resonance imaging of brain in fetal growth restriction: results of prospective multicenter study.

OBJECTIVE: To measure prospectively apparent diffusion coefficient (ADC) values between 28 and 32 weeks of gestation in different cerebral territories of fetuses with estimated fetal weight (EFW) ≤ 5th centile, and analyze their association with adverse perinatal outcome. METHODS: This was a prospective study involving six tertiary-level perinatal centers. In the period 22 November 2016 to 11 September 2017, we included singleton, small-for-gestational-age (SGA) fetuses with EFW ≤ 5th percentile, between 28 and 32 weeks of gestation, regardless of the umbilical artery Doppler and maternal uterine artery Doppler findings. A fetal magnetic resonance imaging (MRI) examination with diffusion-weighted sequences (DWI) was performed within 14 days following inclusion and before 32 weeks. ADC values were calculated in the frontal and occipital white matter, basal ganglia and cerebellar hemispheres. An ultrasound examination was performed within 1 week prior to the MRI examination. The primary outcome was a composite measure of adverse perinatal outcome, defined as any of the following: perinatal death; admission to neonatal intensive care unit with mechanical ventilation > 48 h; necrotizing enterocolitis; Grade III-IV intraventricular hemorrhage; periventricular leukomalacia. A univariate comparison of median ADC values in all cerebral territories between fetuses with and those without adverse perinatal outcome was performed. The association between ADC values and adverse perinatal outcome was then analyzed using multilevel logistic regression models to adjust for other common prognostic factors for growth-restricted fetuses. RESULTS: MRI was performed in 64 patients, of whom five were excluded owing to fetal movement artifacts on DWI and two were excluded for termination of pregnancy with no link to fetal growth restriction (FGR). One intrauterine death occurred secondary to severe FGR. Among the 56 liveborn neonates, delivered at a mean ± SD gestational age of 33.6 ± 3.0 weeks, with a mean birth weight of 1441 ± 566 g, four neonatal deaths occurred. In addition, two neonates required prolonged mechanical ventilation, one of whom also developed necrotizing enterocolitis. Overall, therefore, seven out of 57 (12.3%) cases had an adverse perinatal outcome (95% CI, 3.8-20.8%). The ADC values in the frontal region were significantly lower in the group with adverse perinatal outcome vs those in the group with favorable outcome (mean values of both hemispheres, 1.68 vs 1.78 × 10-3 mm2 /s; P = 0.04). No significant difference in ADC values was observed between the two groups in any other cerebral territory. A cut-off value of 1.70 × 10-3 mm2 /s was associated with a sensitivity of 57% (95% CI, 18-90%), a specificity of 78% (95% CI, 63-88%), a positive predictive value of 27% (95% CI, 8-55%) and a negative predictive value of 93% (95% CI, 80-98%) for the prediction of adverse perinatal outcome. A mean frontal ADC value < 1.70 × 10-3 mm2 /s was not associated significantly with an increased risk of adverse perinatal outcome, either in the univariate analysis (P = 0.07), or when adjusting for gestational age at MRI and fetal sex (odds ratio (OR), 6.06 (95% CI, 0.9-37.1), P = 0.051) or for umbilical artery Doppler (OR, 6.08 (95% CI, 0.89-41.44)). CONCLUSION: This first prospective, multicenter, cohort study using DWI in the setting of SGA found lower ADC values in the frontal white-matter territory in fetuses with, compared with those without, adverse perinatal outcome. To determine the prognostic value of these changes, further standardized evaluation of the neurodevelopment of children born with growth restriction is required. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

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.

[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.

Risk of cesarean after induction of labor in twin compared to singleton pregnancies.

OBJECTIVE: To assess the risk of cesarean delivery after induction of labor in twin compared with singleton pregnancies. STUDY DESIGN: This retrospective multicenter study compared data from two nationwide prospective cohorts: one of twin pregnancies established from February 2014 through March 2015 (JUMODA cohort), and the other of singleton pregnancies in November and December 2015 (MEDIP cohort). This study includes all women in both cohorts who had labor induced at ≥ 35 weeks of gestation, with a live fetus in cephalic presentation (Twin 1 for the twin pregnancies). Multivariate analyses with multilevel logistic regression models were used to study twin pregnancy as an independent risk factor for cesarean delivery, overall and stratified for parity and Bishop score. RESULTS: The outcomes of 1995 twin births after induction of labor were compared to those of 2771 induced singleton births. The cesarean rate differed significantly between the two populations and was higher in twins (23% in twins vs 19.4% in singletons, P = 0.002). After adjustment for factors associated with cesareans, twin pregnancy was independently associated with it (aOR = 1.8, 95% CI 1.4-2.2). CONCLUSION: Twin pregnancy appears to be an independent risk factor for cesarean births after induction of labor, but more than three-quarters of inductions culminated in vaginal delivery.