Risk of severe maternal morbidity associated with in vitro fertilisation: a population-based study.

OBJECTIVE: To investigate the association between in vitro fertilisation IVF and severe maternal morbidity (SMM) and to explore the role of multiple pregnancy as an intermediate factor. DESIGN: Population-based cohort-nested case-control study. SETTING: Six French regions in 2012/13. POPULATION: Cases were 2540 women with SMM according to the EPIMOMS definition; controls were 3651 randomly selected women who gave birth without SMM. METHODS: Analysis of the associations between IVF and SMM with multivariable logistic regression models, differentiating IVF with autologous oocytes (IVF-AO) from IVF with oocyte donation (IVF-OD). The contribution of multiple pregnancy as an intermediate factor was assessed by path analysis. MAIN OUTCOME MEASURES: Severe maternal morbidity overall and SMM according to its main underlying causal condition and by severity (near misses). RESULTS: The risk of SMM was significantly higher in women with IVF (adjusted OR = 2.5, 95% CI 1.8-3.3). The risk of SMM was significantly higher with IVF-AO, for all-cause SMM (aOR = 2.0, 95% CI 1.5-2.7), for near misses (aOR = 1.9, 95% CI 1.3-2.8), and for intra/postpartum haemorrhages (aOR = 2.3, 95% CI 1.6-3.2). The risk of SMM was significantly higher with IVF-OD, for all-cause SMM (aOR = 18.6, 95% CI 4.4-78.5), for near misses (aOR = 18.1, 95% CI 4.0-82.3), for SMM due to hypertensive disorders (aOR = 16.7, 95% CI 3.3-85.4) and due to intra/postpartum haemorrhages (aOR = 18.0, 95% CI 4.2-77.8). Path-analysis estimated that 21.6% (95% CI 10.1-33.0) of the risk associated with IVF-OD was mediated by multiple pregnancy, and 49.6% (95% CI 24.0-75.1) of the SMM risk associated with IVF-AO. CONCLUSION: The risk of SMM is higher in IVF pregnancies after adjustment for confounders. Exploratory results suggest higher risks among women with IVF-OD; however, confidence intervals were wide, so this finding needs to be confirmed. A large part of the association between IVF-AO and SMM appears to be mediated by multiple pregnancy. TWEETABLE ABSTRACT: The risk of severe maternal morbidity is higher in IVF-conceived pregnancies than in pregnancies conceived by other means.

Avenues for measuring and characterising violence in perinatal care to improve its prevention: A position paper with a proposal by the National College of French Midwives.

BACKGROUND: France is somewhat behind other countries in its consideration of the issue of violence in perinatal care. Its consequences on maternal, but also neonatal and infant health are recognised internationally. Nonetheless, research and data measuring its frequency and its determinants are inadequate, and the relevant definitions are not always consensual. In this context, we, as midwives and researchers in public health and as members of the National College of French Midwives, seek to propose a scientific and clinical contribution to this debate. AIM: We propose avenues for measuring and characterising violence in perinatal care. Our objective is to quantify and characterise the situations of violence in perinatal care in population-based studies and based on the perceptions of each woman questioned. DISCUSSION: This proposal for questions, simplified compared with those currently in used in the international scientific literature, has the advantage of focusing reflection around three categories: inappropriate medical care, inappropriate human behaviours in care, and sexual abuse. It should also allow the identification of the contexts of care during which violence may be experienced, as well as the categories of health-care workers concerned. CONCLUSION: It seems important to us to distinguish these situations, causal and context, for they require different responses if we hope to reduce the frequency and the effects of violence in perinatal care in the future. We propose questions that could also be used in clinical situations by midwives and other clinicians.

Does a three-hour delayed pushing benefit the mode of delivery?

OBJECTIVE: The objective of this study was to compare two strategies for passive second stage management: three-hour vs two-hour delayed pushing after the diagnosis of full cervical dilation on mode of delivery and perinatal outcomes. STUDY DESIGN: This retrospective observational study included low-risk nulliparous women who reatched full cervical dilation under epidural analgesia with a single term fetus in cephalic presentation and normal fetal heart rate, between September and December 2016. Mode of delivery (spontaneous vaginal delivery versus operative delivery including cesarean section and instrumental vaginal delivery) and perinatal outcomes (post-partum hemorrhage, perineal lacerations, 5-min Apgar score, umbilical cord pH and transfer to neonatal intensive care unit) were compared between two maternity units: maternity unit A, where women could have up to a three-hour delayed pushing period after full cervical dilation diagnosis, and maternity unit B, where the delayed pushing period was a maximum of 2 h. Outcomes were compared using univariate and multivariable analyses. Adjusted odds ratios (aOR) were estimated using a logistic regression multivariable model that included potential cofounders. RESULTS: During the study period, 614 women were included, 305 in maternity unit A and 309 in maternity unit B. Women's pre-existing characteristics were comparable between the two maternity units. Women delivering in the maternity unit A had significantly lower risks of having an operative delivery compared to women delivering in the maternity unit B (respectively 18.4 vs 26.9%; aOR = 0.64; 95%CI [0.43 - 0.96]). Perinatal outcomes were comparable in the two maternity units, particularly in terms of post-partum hemorrhage rates (7.4 vs 7.8%; aOR = 1,19 [0.65 - 2.19]). CONCLUSION: Increasing the possible length of the delayed pushing period from 2 to 3 h after the diagnosis of full cervical dilation in low-risk nulliparous women appears to reduce operative deliveries without adverse effects on maternal or neonatal morbidity.

[French hospital discharge database: data production, validity, and origins of errors in the field of severe maternal morbidity]. / Le programme de médicalisation du système d'information (PMSI) - processus de production des données, validité et sources d'erreurs dans le domaine de la morbidité maternelle sévère.

BACKGROUND: The organization of obstetric care in France brings all women in contact with the hospital system. Thus, hospital discharge data from the Program of Medicalization of the Information System (PMSI) constitute a potentially valuable source of information, particularly regarding rare events such as severe maternal morbidity. These data cover a large population but their quality has not been assessed in that field. Our objectives were to study the processes of production and the validity of PMSI data related to severe maternal morbidity. METHODS: The study was conducted in four French tertiary teaching hospitals (Caen, Cochin [AP-HP, Paris], Grenoble and Lille). First, the organization of each step of the medical information process -production, formatting, verification and processing- was detailed in each center with a standardized form. Second, the validation study was based on the comparison of data related to severe maternal morbid events in the PMSI from these centers for 2006 and 2007, with the content of medical records which constituted the gold standard. Indicators of sensitivities and positive predictive values of PMSI were calculated. RESULTS: The processes of PMSI data production showed major differences between the four centers. In hospital discharge data, diagnoses (eclampsia and pulmonary embolism) had a high proportion of false-positives (68%). Inversely, procedures (four procedures for management of severe haemorrhage) had less than 1% of false-positives, but a low sensitivity with 37% false-negatives which could be corrected in 95%. Regarding intensive care provision, all indicators of hospital data quality were very high. In addition, the validity of hospital data in centers 1 and 2 was higher for all events. CONCLUSION: The heterogeneity of the process of PMSI data production is associated with a variable quality of these data. Intensive care provision can be used in the PMSI, as well as procedures after correction. For diagnoses, the quality of the PMSI data is better in centers having both computerized medical records and steps for verification of medical information.

[Medical attitudes regarding the announcement of suspected foetal abnormality in ultrasound scans]. / Attitudes et vécu des échographistes lors de l'annonce d'une anomalie fœtale.

OBJECTIVES: This study's primary objective was to analyse the personal experience of different ultrasonographers during the announcement of suspected foetal abnormalities, seen either in screening or diagnostic ultrasound. The secondary objectives aimed to explore the factors influencing the announcement of the foetal abnormality, whether they complicated or facilitated the consultation. These also comprised the analysis of the knowledge, practice and attitudes of the healthcare professionals as well as the different techniques used during the consultation. Finally, this study aimed to analyse the various tools and skills used by ultrasonographers to improve the quality of their announcement of the diagnosis. METHODS: This qualitative study was based on both the observation of consultations and the results of semi-structured interviews with ultrasonographers, in a maternity hospital in France. RESULTS: The results highlighted feelings of great discomfort for the ultrasonographers on discovering an abnormality on the scan. The different perceptions and practices regarding the announcement of a diagnosis varied between screening ultrasonographers and specialist doctors. The uncertainty of foetal prognosis seemed to complicate the announcement for specialist doctors. Qualities that made the communication of the diagnosis easier included the ultrasonographer's availability and their attitude. Although professional experience was considered a very powerful skill, training for the communication of a diagnosis accelerates the development of good medical practice. CONCLUSIONS: The announcement of suspected foetal abnormalities is a difficult exercice, which impacts the ultrasonographer's personal experience and his attitude. Some professional practices are to be encouraged while others are to be put under question. A trust-based relationship between the healthcare professional and the patient is partly reinforced by the quality of the announcement and its follow-up, as well as the healthcare professional's thoroughness and humanity.

[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.

Maternal admissions to intensive care units in France: Trends in rates, causes and severity from 2010 to 2014.

INTRODUCTION: Maternal intensive care unit admission is an indicator of severe maternal morbidity. The objective of this study was to estimate rates of maternal intensive care unit admission during or following pregnancy in France, and to describe the characteristics of women concerned, the severity of their condition, associated diagnoses, regional disparities, and temporal trends between 2010 and 2014. METHODS: Women hospitalised in France in intensive care units during pregnancy or up to 42 days after pregnancy between January 2010 and December 2014 were identified using the national hospital discharge database (PMSI-MCO). Trends in incidence rates were quantified using percentages of average annual variation based on a Poisson regression model. RESULTS: In total, 16,011 women were admitted to intensive care units, representing an overall incidence of 3.97‰ deliveries. This number decreased significantly by 1.7% on average per year. For women who gave birth (60.5% by C-section), 62.5% of admissions occurred during their hospitalisation for delivery. The SAPS II score, an indicator of severity, significantly increased from 18.4 in 2010 to 21.5 in 2014. Obstetrical haemorrhage (39.8%) and hypertensive complications during pregnancy (24.8%) were the most common reasons for admission. In mainland France, the Ile-de-France (i.e., greater Paris) region had the highest rates of intensive care units admission (5.05‰) while the Pays-de-la-Loire region had the lowest (2.69‰). CONCLUSION: The rate of maternal intensive care unit admission decreased from 2010 to 2014 in France, with a concomitant increase in case severity. In-depth studies are needed to understand the territorial disparities identified.

Factors affecting rotation of occiput posterior position during the first stage of labor.

INTRODUCTION: Fetal occiput posterior (OP) positions account for 15 to 20% of cephalic presentations and are associated with poorer maternal and neonatal outcomes than occiput anterior (OA) positions. The aim of this study was to identify maternal, neonatal and obstetric factors associated with rotation from OP to OA position during the first stage of labor. MATERIAL AND METHODS: This secondary analysis of a multicenter randomized controlled trial (EVADELA) included 285 laboring women with ruptured membranes and a term fetus in OP position. After excluding women with cesarean deliveries before full dilatation, we compared two groups according to fetal head position at the end of the first stage of labor: those with and without rotation from OP to OA position. Factors associated with rotation were assessed with univariate and multivariate analyses using multilevel logistic regression models. RESULTS: The rate of anterior rotation during the first stage was 49.1%. Rotation of the fetal head was negatively associated with excessive gestational weight gain (adjusted odds ratio [aOR]: 0.37, 95% confidence interval [CI]: 0.17-0.80), macrosomia (aOR: 0.35, 95% CI: 0.14-0.90), direct OP position (aOR: 0.24, 95% CI: 0.09-0.65), and prelabor rupture of membranes (aOR: 0.40, 95% CI: 0.19-0.86). Oxytocin administration was the only factor positively associated with fetal head rotation (aOR: 2.17, 95% CI: 1.20-3.91). DISCUSSION: Oxytocin administration may affect rotation of OP positions during the first stage of labor. Further studies should be performed to assess the risks and benefits of its utilization for managing labor with a fetus in OP position.

[Association between oxytocin augmentation intervals and the risk of postpartum haemorrhage]. / Association entre les intervalles d'augmentation de l'oxytocine pendant le travail et le risque d'hémorragie du post-partum.

OBJECTIVE: To study the association between the duration of oxytocin augmentation intervals and the risk of postpartum haemorrhage (PPH) among primiparous women in spontaneous labour. MATERIALS AND METHODS: Retrospective cohort including primiparous women in spontaneous labour who received oxytocin during labour (n=454). Oxytocin augmentation intervals were dichotomized in intervals<20minutes and≥20minutes. Obstetrical and neonatal issues were analyzed according to the duration oxytocin augmentation intervals. The association between oxytocin augmentation intervals and PPH was analyzed using univariate and multivariate analysis. RESULTS: Oxytocin augmentation intervals were shorter than 20minutes for 43.8% of the study population. The rate of PPH was higher (9.1% vs 3.5%; P=0.014), and the use of sulprostone was more frequent (6.5% vs 3.5%; P=0.013) if oxytocin augmentation intervals were shorter than 20minutes in comparison with intervals≥20minutes. The association between oxytocin augmentation intervals and PPH remains significant after adjustment on other PPH risk factors (adjusted OR=3.48, 95% CI [1.45-8.34]). The rate of adverse neonatal issue, defined by arterial pH at birth≤7.10 and/or 5minutes score d'Apgar≤7, was higher if oxytocin augmentation intervals were<20minutes (12.1% vs 4.3%; P=0.002). CONCLUSION: Our study demonstrated an increased risk of PPH for primiparous women in spontaneous labour who received oxytocin with augmentation intervals shorter than 20minutes.

[Breastfeeding (part III): Breastfeeding complications--Guidelines for clinical practice]. / Allaitement maternel (partie III): complications de l'allaitement--Recommandations pour la pratique clinique.

OBJECTIVE: Provide guidelines for management of breastfeeding complications. MATERIALS AND METHODS: Systematically review of the literature between 1972 and May 2015 from the database Medline, Google Scholar, Cochrane Library, and the international recommendations about inhibition of lactation with establishment of levels of evidence (EL) and grades of recommendation. RESULTS: Nipple stimulation preparation techniques or antenatal correction an anatomical variation of the nipple are not recommended to decrease nipple complications or improve the success of breastfeeding (grade B). The use of lanolin and application of breast milk may have an interest in diseases of the nipple (EL4). The current published data are insufficient to conclude on the effectiveness of nipple shield, (professional consensus). Manual breast expression or using a breast pump may have an interest in preventing breast engorgement (professional agreement). A bacteriological sample of milk for mastitis is necessary to decide an antibiotic and interrupt breastfeeding with breast infected while continuing its drainage with a breast pump (professional consensus). Incision and drainage of breast abscess are recommended (professional consensus) and iterative puncture is an alternative to surgical drainage in the moderate forms (professional consensus). Breastfeeding is not contraindicated for women with a past history of esthetic breast surgery or breast cancer (professional consensus). There is no scientific justification to recommend the use of breast pumps to improve breastfeeding (grade B). Because of the potential side effects, the use of domperidone and metoclopramide are not recommended in the stimulation of lactation (grade C). CONCLUSION: Breastfeeding exposes women to specific complications, which may impede the continuation of breastfeeding. Prevention of mastitis is essential.

[Breast-feeding (part IV): Therapeutic uses, dietetic and addictions--guidelines for clinical practice]. / Allaitement maternel (partie IV) : usages des médicaments, diététique et addictions--recommandations pour la pratique clinique.

OBJECTIVE: To describe the practical aspects of the use of the most commonly prescribed drugs during the postpartum period, the dietetic measures and the management of breast-feeding in case of addictive behaviors. METHODS: Review of the literature between 1972 and May 2015 from the databases Medline, Google Scholar, Cochrane Library, and international recommendations of learned societies. RESULTS: The precaution to stop breast-feeding when drugs are necessary is not justified in many situations (professional consensus). Aspirin at antiaggregant dose is allowed during breast-feeding while high doses are not recommended; NSAIDs with short half-life can be used (professional consensus). Precautions are needed in cases of use of morphonics (professional consensus). There is no justification to delay the initiation of breast-feeding in case of locoregional or general analgesia or for caesarean section. Antibiotic treatment does not justify discontinuing breast-feeding (professional consensus). Anxiolytics of the class of antihistaminic sedating H1 such as hydroxyzine (Atarax®) should not be prescribed in case of breast-feeding (professional consensus). Imaging does not justify to stop breast-feeding (professional consensus). Tobacco consumption is discouraged but is not a contraindication to breast-feed (professional consensus). It is recommended to avoid the consumption of alcohol (professional consensus). In case of occasional and moderate consumption of alcohol, delaying breast-feeding for a minimum of two hours is recommended (professional consensus). Cocaine consumption is a contraindication of breast-feeding (professional agreement), and breast-feeding is not recommended in case of cannabis use (professional consensus). CONCLUSION: Few drug treatments are not compatible with breast-feeding that can be continued in most of the cases.

[Breast-feeding (part II): Lactation inhibition--Guidelines for clinical practice]. / Allaitement maternel (partie II): méthodes d'inhibition de la lactation--recommandations pour la pratique clinique.

OBJECTIVE: Provide guidelines for clinical use of non-pharmacological and pharmacological treatments of inhibition of lactation and the management of the weaning. MATERIALS AND METHODS: Systematically review of the literature between 1972 and May 2015 from the databases Medline, Google Scholar, Cochrane Library, and the international recommendations about inhibition of lactation with establishment of levels of evidence (LE) and grades of recommendation. RESULTS: The available data on the effectiveness of non-pharmacological measures are limited, with very low levels of evidence that fail to make recommendations (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breast-feed (Professional consensus). For women aware of the risks of pharmacological treatments of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). Available data on management of lactation weaning fail to provide recommendation and no treatment is recommended (Professional consensus). CONCLUSION: Bromocriptin is contraindicated in the treatment of inhibiting lactation. Women who do not wish to breast-feed have to be informed of the benefits and disadvantages of the pharmacological treatment for inhibition of lactation.

[Breastfeeding (part one): Frequency, benefits and drawbacks, optimal duration and factors influencing its initiation and prolongation. Clinical guidelines for practice]. / Allaitement maternel (partie 1) : fréquence, bénéfices et inconvénients, durée optimale et facteurs influençant son initiation et sa prolongation. Recommandations pour la pratique clinique.

OBJECTIVES: The objectives were to on assess the frequency and the duration of breastfeeding in France. On the other hand, the objectives were to identify its benefits and drawbacks, and to study the factors influencing its initiation and its extension. MATERIAL AND METHODS: Bibliographic research in Medline, Google Scholar and in the Cochrane Library. RESULTS: Breastfeeding concerns in France about 70% of children at birth (EL2). Its median duration is about 15 weeks and 3 weeks ½ for exclusive breastfeeding. At three months, only one third of children breastfed at birth are still being breastfed (EL2). Whether this is due to the composition of breast milk or the behavior of mothers with their children or their socio-cultural level, or even by all these components at once, breastfeeding is associated with better cognitive development children (EL2). This effect is even more reinforced that mothers breastfeed exclusively and prolonged (EL2). As part of the prevention of many diseases (ear infections, gastrointestinal infections, atopic diseases, obesity and cardiovascular diseases…), exclusive and prolonged breastfeeding (grade B) between 4 to 6 months is recommended (professional consensus). Breastfeeding is not a means of preventing postpartum depression (professional consensus). To reduce the incidence of breast cancer, prolonged breastfeeding is recommended (grade B). In order to increase the rate of initiation of breastfeeding as well as its duration, it is recommended that health professionals work closely with mothers in their project (grade A), the breastfeeding promotion messages include message to husbands (grade B), and to promote breastfeeding on demand without fixed interval between feedings (grade B). However, there is not enough data to recommend the use of a specific position during breastfeeding, or the use of one or two breast or to early start breastfeeding or not (professional consensus). CONCLUSION: Exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (professional consensus).

[Epidemiology of prolonged pregnancy: incidence and maternal morbidity]. / Épidémiologie de la grossesse prolongée : incidence et morbidité maternelle.

OBJECTIVE: To estimate the frequency of prolonged pregnancy and study its associated maternal morbidity. METHODS: Abstracts and articles were searched using Pubmed and Cochrane Library. RESULTS: Nearly 15% of pregnant women in France are concerned by prolonged pregnancy (≥41(+0) weeks), whereas post-term pregnancy (≥42(+0) SA) only concern 1% of them. The post-term pregnancy frequency is heterogeneous between Europe and United States. It varies between 0.5% and 10% (EL2). In Europe, Scandinavian countries present discrepancies with high proportions of post-term pregnancies between 5 and 7%. These observations identified time variations and variations between countries. They can be explained by two factors: pregnancy datation by ultrasound and the evolution of labor induction practices. Moreover, post-term pregnancy constitute a risk factor of maternal complications as: cesarean section, postpartum haemorrhages, infections and perineum lacerations (EL2). On the contrary, limited conclusions about associations between prolonged pregnancies and labor inductions are due to insufficient data and the lack of high quality studies. Nowadays, we still ignore if labor inductions in the particular context of prolonged pregnancies are associated or not to an increase of maternal morbidities. CONCLUSION: Prolonged pregnancy is associated with an excess of maternal morbidity.

[Fetal and neonatal complications related to prolonged pregnancy]. / Complications fœtales et néonatales des grossesses prolongées.

OBJECTIVE: To evaluate fetal and neonatal outcomes related to prolonged pregnancy. METHODS: This study is based on Pubmed search, Cochrane library and HAS recommendations. RESULTS: The risk of fetal complications including macrosomia (6 %), oligohydramnios (10 %-15 %), abnormal fetal heart rate pattern and meconium-stained fluid is increased in prolonged pregnancy (≥ 41(+0) weeks). The rate of stillbirth was estimated between 1.6 ‰ and 3.0 ‰ live births according to countries in post-term pregnancies (≥ 42(+0) weeks). The risk of umbilical cord pH less than 7.10, Apgar score at five minutes inferior to 7, ICU admissions and perinatal asphyxia is increased in post-term infants (≥ 42(+0) weeks) compared with term infants. The risk of neurologic complications including neonatal convulsion, hypoxic ischemic encephalopathy, cerebral palsy, developmental deviations and epilepsy in childhood is increased in post-term infants. The risk of meconium aspiration syndrome, neonatal sepsis, and birth trauma including shoulder dystocia and bone fracture is increased in post-term infants. The rate of perinatal mortality increases in post-term infants. The perinatal mortality in post-term infants could be explained by perinatal asphyxia and meconium aspiration syndrome. CONCLUSIONS: The risk of perinatal complications and mortality are increased in prolonged pregnancy.