Prediction of adverse neonatal adaptation in fetuses with severe fetal growth restriction after 34 weeks of gestation.

OBJECTIVE: To establish a predictive model for adverse immediate neonatal adaptation (INA) in fetuses with suspected severe fetal growth restriction (FGR) after 34 gestational weeks (GW). METHODS: We conducted a retrospective observational study at the University Hospitals of Strasbourg between 2000 and 2020, including 1,220 women with a singleton pregnancy and suspicion of severe FGR who delivered from 34 GW. The primary outcome (composite) was INA defined as Apgar 5-minute score <7, arterial pH <7.10, immediate transfer to pediatrics, or the need for resuscitation at birth. We developed and tested a logistic regression predictive model. RESULTS: Adverse INA occurred in 316 deliveries. The model included six features available before labor: parity, gestational age, diabetes, middle cerebral artery Doppler, cerebral-placental inversion, onset of labor. The model could predict individual risk of adverse INA with confidence interval at 95 %. Taking an optimal cutoff threshold of 32 %, performances were: sensitivity 66 %; specificity 83 %; positive and negative predictive values 60 % and 87 % respectively, and area under the curve 78 %. DISCUSSION: The predictive model showed good performances and a proof of concept that INA could be predicted with pre-labor characteristics, and needs to be investigated further.

[Women's experience following prophylactic low molecular weight heparin treatment post-cesarean section]. / Ressenti des femmes après traitement prophylactique par héparine de bas poids moléculaire après une césarienne.

OBJECTIVE: To assess women's experiences with skin-related side effects following subcutaneous low molecular weight heparin (LMWH) injections after a cesarean section, and to analyze their impact on treatment adherence. METHOD: A questionnaire was developed in collaboration with Cesarine, a patients' association, to explore various aspects of LMWH administration, including prevention methods, cutaneous side effects, treatment compliance, perceived constraints, apprehension, and understanding of treatment benefits. Additionally, women's opinions on an alternative oral administration approach were solicited, taking into consideration breastfeeding contraindication. The questionnaire was on the Facebook® page and blog of the association. RESULTS: One hundred and sixty-four women participated in the survey. Among them, 139 women (84.8%) reported bruising, while 117 (71.3%) reported pruritus, erythema, or nodules at the injection site. Treatment discontinuation was observed in 36 cases (22%), decided mostly by the women themselves (77.8%). The main reasons cited for discontinuation were discomfort during injection (71.4%), skin reactions (31.4%), and a perceived lack of effectiveness (54.3%). Furthermore, 88 women (53.7%) wanted to quit the treatment prematurely, citing similar reasons. Thirty-three women (20.1%) reported oversights. For most women, the treatment was perceived as burdensome and caused apprehension. An alternative oral administration method was of interest to 131 women (79.9%). However, only 28 (17.8%) would have accepted if the medication was incompatible with breastfeeding. CONCLUSION: Cutaneous side effects of LMWH injections, as well as injection process itself, have a negative impact on adherence in the postpartum period following a c-section. These findings highlight the need to explore alternative to improve women's compliance and comfort.

Maternal vaccination against COVID-19 and neonatal outcomes during Omicron: INTERCOVID-2022 study.

BACKGROUND: In early 2023, when Omicron was the variant of concern, we showed that vaccinating pregnant women decreased the risk for severe COVID-19-related complications and maternal morbidity and mortality. OBJECTIVE: This study aimed to analyze the impact of COVID-19 during pregnancy on newborns and the effects of maternal COVID-19 vaccination on neonatal outcomes when Omicron was the variant of concern. STUDY DESIGN: INTERCOVID-2022 was a large, prospective, observational study, conducted in 40 hospitals across 18 countries, from November 27, 2021 (the day after the World Health Organization declared Omicron the variant of concern) to June 30, 2022, to assess the effect of COVID-19 in pregnancy on maternal and neonatal outcomes and to assess vaccine effectiveness. Women diagnosed with laboratory-confirmed COVID-19 during pregnancy were compared with 2 nondiagnosed, unmatched women recruited concomitantly and consecutively during pregnancy or at delivery. Mother-newborn dyads were followed until hospital discharge. The primary outcomes were a neonatal positive test for COVID-19, severe neonatal morbidity index, severe perinatal morbidity and mortality index, preterm birth, neonatal death, referral to neonatal intensive care unit, and diseases during the neonatal period. Vaccine effectiveness was estimated with adjustment for maternal risk profile. RESULTS: We enrolled 4707 neonates born to 1577 (33.5%) mothers diagnosed with COVID-19 and 3130 (66.5%) nondiagnosed mothers. Among the diagnosed mothers, 642 (40.7%) were not vaccinated, 147 (9.3%) were partially vaccinated, 551 (34.9%) were completely vaccinated, and 237 (15.0%) also had a booster vaccine. Neonates of booster-vaccinated mothers had less than half (relative risk, 0.46; 95% confidence interval, 0.23-0.91) the risk of being diagnosed with COVID-19 when compared with those of unvaccinated mothers; they also had the lowest rates of preterm birth, medically indicated preterm birth, respiratory distress syndrome, and number of days in the neonatal intensive care unit. Newborns of unvaccinated mothers had double the risk for neonatal death (relative risk, 2.06; 95% confidence interval, 1.06-4.00) when compared with those of nondiagnosed mothers. Vaccination was not associated with any congenital malformations. Although all vaccines provided protection against neonatal test positivity, newborns of booster-vaccinated mothers had the highest vaccine effectiveness (64%; 95% confidence interval, 10%-86%). Vaccine effectiveness was not as high for messenger RNA vaccines only. Vaccine effectiveness against moderate or severe neonatal outcomes was much lower, namely 13% in the booster-vaccinated group (all vaccines) and 25% and 28% in the completely and booster-vaccinated groups, respectively (messenger RNA vaccines only). Vaccines were fairly effective in protecting neonates when given to pregnant women ≤100 days (14 weeks) before birth; thereafter, the risk increased and was much higher after 200 days (29 weeks). Finally, none of the neonatal practices studied, including skin-to-skin contact and direct breastfeeding, increased the risk for infecting newborns. CONCLUSION: When Omicron was the variant of concern, newborns of unvaccinated mothers had an increased risk for neonatal death. Neonates of vaccinated mothers had a decreased risk for preterm birth and adverse neonatal outcomes. Because the protective effect of COVID-19 vaccination decreases with time, to ensure that newborns are maximally protected against COVID-19, mothers should receive a vaccine or booster dose no more than 14 weeks before the expected date of delivery.

[Pain assessment during medical abortion up to 14 weeks: A 1-year prospective comparative study]. / Évaluation de la douleur lors des interruptions volontaires de grossesse médicamenteuses jusqu'à 14 semaines d'aménorrhées : une étude prospective comparative sur 1 an.

OBJECTIVES: Pain assessment of patients requesting a medical abortion according to the term, up to 14 weeks, by a numerical rating scale (NRS). METHODS: This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020. RESULTS: There was no significant difference in pain assessed by the NRS for medical abortion performed between 7-9 weeks and those performed between 9-14 weeks (6.5±2.5 vs. 6.6±2.2, P=0.85). Regardless of the term (before 7 weeks, between 7-9 weeks and between 9-14 weeks), patients felt relieved by taking painkillers in the case of medical abortion in 88.9%, 80.3% and 87.3% of cases respectively (P=0.18). The use of analgesics allowed a decrease of 3 points of the NRS in the 3 groups (P=0.67). Patients were more painful in case of medical protocol vs. surgical (maximum pain at 6.0±2.6 vs. 1.4±2.0, P<0.01), but declared to be relieved by analgesics in 85.1 and 94.3% of cases (P=0.24). CONCLUSIONS: As pain is similar whatever the term in the case of medical abortion, and its management by analgesics seems to be effective, this criterion should not guide the professional in the choice of method, particularly between 9 and 14 weeks. This choice must be made by the patient.

Women satisfaction on choosing the cervical ripening method: Oral misoprostol versus balloon catheter.

Objective: Induction of labor concerns about 29 % of women in Unites States and 33 % in Europe. Among the various methods for cervical ripening, the efficacy and safety profiles of oral misoprostol and balloon catheter are comparable, but data in the literature on maternal satisfaction during induction of labor are few. The objective of this study was to assess the satisfaction of women who chose the method of cervical ripening, i.e. either balloon catheter or oral misoprostol, for induction of labor. Study design: This retrospective study asked women who had undergone induction of labor between February 1, 2020 and February 28, 2021. After receiving verbal and written information, the choice of method between oral misoprostol and balloon catheter was left to the patient's free appreciation. Satisfaction was assessed by means of a questionnaire distributed to all women during their stay in the maternity unit. The principal assessment criterion was based on women' inclination to choose the same cervical ripening method if induction of labor were to prove necessary in a future pregnancy, and their willingness to recommend this method to a friend. Univariate analyses were conducted using Student's t-test, Chi-2 test or Fisher's exact test. Results: On 575 women eligible for analysis, 365 (63.5 %) of these women replied to the satisfaction questionnaire. Of this number, 236 (64.7 %) chose cervical ripening by balloon catheter, and 129 (35.3 %) by oral misoprostol. No significant difference was found between the two groups: 68.2 % of women in the balloon catheter group would opt for the same method of cervical ripening if it proved necessary in a future pregnancy and 64.7% would recommend it to a pregnant friend, versus 65.9 % and 63.6 % in the oral misoprostol group, respectively. Women were overall pleased to be able to choose their method of cervical ripening: 90.5 % of patients in the balloon catheter group and 95.3 % in the oral misoprostol group. Conclusions: When women choose the method of cervical ripening, satisfaction is overall good, irrespective of the method, whether by balloon catheter or misoprostol.

Prediction of cesarean delivery in class III obese nulliparous women: An externally validated model using machine learning.

BACKGROUND: class III obese women, are at a higher risk of cesarean section during labor, and cesarean section is responsible for increased maternal and neonatal morbidity in this population. OBJECTIVE: the objective of this project was to develop a method with which to quantify cesarean section risk before labor. METHODS: this is a multicentric retrospective cohort study conducted on 410 nulliparous class III obese pregnant women who attempted vaginal delivery in two French university hospitals. We developed two predictive algorithms (a logistic regression and a random forest models) and assessed performance levels and compared them. RESULTS: the logistic regression model found that only initial weight and labor induction were significant in the prediction of unplanned cesarean section. The probability forest was able to predict cesarean section probability using only two pre-labor characteristics: initial weight and labor induction. Its performances were higher and were calculated for a cut-point of 49.5% risk and the results were (with 95% confidence intervals): area under the curve 0.70 (0.62,0.78), accuracy 0.66 (0.58, 0.73), specificity 0.87 (0.77, 0.93), and sensitivity 0.44 (0.32, 0.55). CONCLUSIONS: this is an innovative and effective approach to predicting unplanned CS risk in this population and could play a role in the choice of a trial of labor versus planned cesarean section. Further studies are needed, especially a prospective clinical trial. FUNDING: French state funds "Plan Investissements d'Avenir" and Agence Nationale de la Recherche.

Women and health professionals' perspectives on a conditional cash transfer programme to improve pregnancy follow-up: a qualitative analysis of the NAITRE randomised controlled study.

OBJECTIVES: Women of low socioeconomic status have been described as having suboptimal prenatal care, which in turn has been associated with poor pregnancy outcomes. Many types of conditional cash transfer (CCT) programmes have been developed, including programmes to improve prenatal care or smoking cessation during pregnancy, and their effects demonstrated. However, ethical critiques have included paternalism and lack of informed choice. Our objective was to determine if women and healthcare professionals (HPs) shared these concerns. DESIGN: Prospective qualitative research. SETTING: We included economically disadvantaged women, as defined by health insurance data, who participated in the French NAITRE randomised trial assessing a CCT programme during prenatal follow-up to improve pregnancy outcomes. The HP worked in some maternities participating in this trial. PARTICIPANTS: 26 women, 14 who received CCT and 12 who did not, mostly unemployed (20/26), and - 7 HPs. INTERVENTIONS: We conducted a multicentre cross-sectional qualitative study among women and HPs who participated in the NAITRE Study to assess their views on CCT. The women were interviewed after childbirth. RESULTS: Women did not perceive CCT negatively. They did not mention feeling stigmatised. They described CCT as a significant source of aid for women with limited financial resources. HP described the CCT in less positive terms, for example, expressing concern about discussing cash transfer at their first medical consultation with women. Though they emphasised ethical concerns about the basis of the trial, they recognised the importance of evaluating CCT. CONCLUSIONS: In France, a high-income country where prenatal follow-up is free, HPs were concerned that the CCT programme would change their relationship with patients and wondered if it was the best use of funding. However, women who received a cash incentive said they did not feel stigmatised and indicated that these payments helped them prepare for their baby's birth. TRIAL REGISTRATION NUMBER: NCT02402855.

Pregnancy outcomes and vaccine effectiveness during the period of omicron as the variant of concern, INTERCOVID-2022: a multinational, observational study.

BACKGROUND: In 2021, we showed an increased risk associated with COVID-19 in pregnancy. Since then, the SARS-CoV-2 virus has undergone genetic mutations. We aimed to examine the effects on maternal and perinatal outcomes of COVID-19 during pregnancy, and evaluate vaccine effectiveness, when omicron (B.1.1.529) was the variant of concern. METHODS: INTERCOVID-2022 is a large, prospective, observational study, involving 41 hospitals across 18 countries. Each woman with real-time PCR or rapid test, laboratory-confirmed COVID-19 in pregnancy was compared with two unmatched women without a COVID-19 diagnosis who were recruited concomitantly and consecutively in pregnancy or at delivery. Mother and neonate dyads were followed until hospital discharge. Primary outcomes were maternal morbidity and mortality index (MMMI), severe neonatal morbidity index (SNMI), and severe perinatal morbidity and mortality index (SPMMI). Vaccine effectiveness was estimated, adjusted by maternal risk profile. FINDINGS: We enrolled 4618 pregnant women from Nov 27, 2021 (the day after WHO declared omicron a variant of concern), to June 30, 2022: 1545 (33%) women had a COVID-19 diagnosis (median gestation 36·7 weeks [IQR 29·0-38·9]) and 3073 (67%) women, with similar demographic characteristics, did not have a COVID-19 diagnosis. Overall, women with a diagnosis had an increased risk for MMMI (relative risk [RR] 1·16 [95% CI 1·03-1·31]) and SPMMI (RR 1·21 [95% CI 1·00-1·46]). Women with a diagnosis, compared with those without a diagnosis, also had increased risks of SNMI (RR 1·23 [95% CI 0·88-1·71]), although the lower bounds of the 95% CI crossed unity. Unvaccinated women with a COVID-19 diagnosis had a greater risk of MMMI (RR 1·36 [95% CI 1·12-1·65]). Severe COVID-19 symptoms in the total sample increased the risk of severe maternal complications (RR 2·51 [95% CI 1·84-3·43]), perinatal complications (RR 1·84 [95% CI 1·02-3·34]), and referral, intensive care unit (ICU) admission, or death (RR 11·83 [95% CI 6·67-20·97]). Severe COVID-19 symptoms in unvaccinated women increased the risk of MMMI (RR 2·88 [95% CI 2·02-4·12]) and referral, ICU admission, or death (RR 20·82 [95% CI 10·44-41·54]). 2886 (63%) of 4618 total participants had at least a single dose of any vaccine, and 2476 (54%) of 4618 had either complete or booster doses. Vaccine effectiveness (all vaccines combined) for severe complications of COVID-19 for all women with a complete regimen was 48% (95% CI 22-65) and 76% (47-89) after a booster dose. For women with a COVID-19 diagnosis, vaccine effectiveness of all vaccines combined for women with a complete regimen was 74% (95% CI 48-87) and 91% (65-98) after a booster dose. INTERPRETATION: COVID-19 in pregnancy, during the first 6 months of omicron as the variant of concern, was associated with increased risk of severe maternal morbidity and mortality, especially among symptomatic and unvaccinated women. Women with complete or boosted vaccine doses had reduced risk for severe symptoms, complications, and death. Vaccination coverage among pregnant women remains a priority. FUNDING: None.

Physical activity and gestational weight gain: a systematic review of observational studies.

BACKGROUND: Now that excessive weight gain during pregnancy is recognized as leading to complications during pregnancy that affect foetal growth, limiting weight gain during pregnancy has become a public health concern. Our aim was to perform a systematic review to assess whether observational studies reported associations between Physical Activity (PA) and Gestational Weight Gain (GWG). We were particularly interested in whether insufficient PA might be associated with high GWG. METHODS: Using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, we searched the MEDLINE ® databases for articles published up to February 2020 concerning case-control, cohort, and ecological studies assessing the association between PA during pregnancy and the risk of excessive and/or inadequate GWG. RESULTS: 21 observational studies on the PA of pregnant women were screened. 11 of these focused on excessive GWG, and of these a majority tend to show a significant association between various aspects of PA and excessive GWG. However, the results were more mitigated when it came to rate of GWG: three studies found that neither meeting PA recommendations nor high levels of total PA nor time spent in moderate vigorous physical activity (MVPA) or engaged in sedentary behaviour were associated with weekly GWG, while two others suggested that pregnant women not meeting PA guidelines in late pregnancy did have a higher rate of GWG. Of the seven studies investigating total GWG, only one found no association with PA. All studies suggested an inverse association between PA and total GWG - yet not all studies are statistically significant. CONCLUSION: Despite the small number of observational studies selected for our research, our findings support the main international findings, suggesting that active pregnant women gained less weight than inactive women; a lack of PA may therefore contribute to excessive GWG. The limitations of this body of evidence impede the formulation of firm conclusions. Further studies focusing clearly on the general PA assessment classification scheme are called for, to address limitations capable of affecting the strength of association.

Maternal obesity reduces apelin level in cord blood without altering the placental apelin/elabela-APJ system.

The APJ receptor and its two endogenous ligands, apelin and elabela, exert key roles in fetoplacental development. In adult, this system is altered by obesity but no data are available during pregnancy. We measured apelin and elabela levels in maternal plasma and cord blood and quantified placental gene expression of apelin, elabela and APJ in obese and non-obese mothers. We found that obesity reduced apelin level in cord blood without affecting maternal and cord blood elabela levels as well as placental gene expression of this system. Our data suggest that obesity alters fetal apelinemia in humans.

Effects of prenatal exposure to maternal COVID-19 and perinatal care on neonatal outcome: results from the INTERCOVID Multinational Cohort Study.

BACKGROUND: The effect of COVID-19 in pregnancy on maternal outcomes and its association with preeclampsia and gestational diabetes mellitus have been reported; however, a detailed understanding of the effects of maternal positivity, delivery mode, and perinatal practices on fetal and neonatal outcomes is urgently needed. OBJECTIVE: To evaluate the impact of COVID-19 on fetal and neonatal outcomes and the role of mode of delivery, breastfeeding, and early neonatal care practices on the risk of mother-to-child transmission. STUDY DESIGN: In this cohort study that took place from March 2020 to March 2021, involving 43 institutions in 18 countries, 2 unmatched, consecutive, unexposed women were concomitantly enrolled immediately after each infected woman was identified, at any stage of pregnancy or delivery, and at the same level of care to minimize bias. Women and neonates were followed up until hospital discharge. COVID-19 in pregnancy was determined by laboratory confirmation and/or radiological pulmonary findings or ≥2 predefined COVID-19 symptoms. The outcome measures were indices of neonatal and perinatal morbidity and mortality, neonatal positivity and its correlation with mode of delivery, breastfeeding, and hospital neonatal care practices. RESULTS: A total of 586 neonates born to women with COVID-19 diagnosis and 1535 neonates born to women without COVID-19 diagnosis were enrolled. Women with COVID-19 diagnosis had a higher rate of cesarean delivery (52.8% vs 38.5% for those without COVID-19 diagnosis, P<.01) and pregnancy-related complications, such as hypertensive disorders of pregnancy and fetal distress (all with P<.001), than women without COVID-19 diagnosis. Maternal diagnosis of COVID-19 carried an increased rate of preterm birth (P≤.001) and lower neonatal weight (P≤.001), length, and head circumference at birth. In mothers with COVID-19 diagnosis, the length of in utero exposure was significantly correlated to the risk of the neonate testing positive (odds ratio, 4.5; 95% confidence interval, 2.2-9.4 for length of in utero exposure >14 days). Among neonates born to mothers with COVID-19 diagnosis, birth via cesarean delivery was a risk factor for testing positive for COVID-19 (odds ratio, 2.4; 95% confidence interval, 1.2-4.7), even when severity of maternal conditions was considered and after multivariable logistic analysis. In the subgroup of neonates born to women with COVID-19 diagnosis, the outcomes worsened when the neonate also tested positive, with higher rates of neonatal intensive care unit admission, fever, gastrointestinal and respiratory symptoms, and death, even after adjusting for prematurity. Breastfeeding by mothers with COVID-19 diagnosis and hospital neonatal care practices, including immediate skin-to-skin contact and rooming-in, were not associated with an increased risk of newborn positivity. CONCLUSION: In this multinational cohort study, COVID-19 in pregnancy was associated with increased maternal and neonatal complications. Cesarean delivery was significantly associated with newborn COVID-19 diagnosis. Vaginal delivery should be considered the safest mode of delivery if obstetrical and health conditions allow it. Mother-to-child skin-to-skin contact, rooming-in, and direct breastfeeding were not risk factors for newborn COVID-19 diagnosis, thus well-established best practices can be continued among women with COVID-19 diagnosis.

Impact of COVID-19-Related Lockdown on Delivery and Perinatal Outcomes: A Retrospective Cohort Study.

OBJECTIVE: The magnitude and direction of effects on pregnancy outcomes of the lockdown imposed during COVID-19 have been uncertain and debated. Therefore, we aimed to quantify delivery and perinatal outcomes during the first nationwide lockdown due to the COVID-19 pandemic compared with the same durations of time for the pre- and post-lockdown periods. STUDY DESIGN: This was a retrospective cohort study of six university hospital maternity units distributed across France, each of which serves as the obstetric care referral unit within its respective perinatal network. Maternal and perinatal outcomes were compared between the lockdown period and same-duration (i.e., 55-day) periods before and after the 2020 lockdown (pre-lockdown: 22 January-16 March; lockdown: 17 March-10 May; post-lockdown: 11 May-4 July). We compared the overall rates of Caesarean delivery (CD), pre-labor CD, labor induction, operative vaginal delivery, severe postpartum hemorrhage (≥1 L), severe perineal tear, maternal transfusion, and neonatal mortality and morbidity (1- and 5-min Apgar scores < 7), hypoxia and anoxia (umbilical arterial pH < 7.20 or <7.10, respectively), and admission to a neonatal intensive care unit before discharge. Adjusted odds ratios were estimated using logistic regression, controlling for region of birth, maternal age category, multiparity, multiple pregnancies, diabetes, and hypertensive disorders. RESULTS: The study sample consisted of 11,929 women who delivered consecutively at one of the six maternity units studied (4093 pre-lockdown, 3829 during lockdown, and 4007 post-lockdown) and their 12,179 neonates (4169 pre-lockdown, 3905 during lockdown, and 4105 post-lockdown). The maternal and obstetric characteristics of the women delivering during the lockdown period were alike those delivering pre- and post-lockdown on maternal age, parity, body mass index, rate of complication by hypertensive disorders or insulin-treated diabetes, and gestational age at delivery. Overall CD rates were similar during the three periods (23.6%, 24.8%, and 24.3% pre-lockdown, lockdown, and post-lockdown, respectively) and no outcome differed significantly during lockdown compared to pre- and post-lockdown. These findings were consistent across maternity units. CONCLUSION: The maternal and perinatal outcomes are reassuring regarding the performance of the health-care system during the COVID-19 lockdown studied. Such information is crucial, because additional COVID-19-related lockdowns might still be needed. They are also instructive regarding potential future pandemics.

Pregnant women's perceptions of the COVID-19 vaccine: A French survey.

INTRODUCTION: Pregnant women are at increased risk for COVID-19, and COVID-19 vaccine is the most promising solution to overcome the current pandemic. This study was conducted to evaluate pregnant women's perceptions and acceptance of COVID-19 vaccination. MATERIALS & METHODS: A cross-sectional study was conducted from February 18 to April 5 2021. An anonymous survey was distributed in 7 French obstetrics departments to all pregnant women before a prenatal visit. All pregnant women attending a follow-up consultation were asked to participate in the study. An anonymous web survey was available through a QR code and participants were asked whether or not they would agree to be vaccinated against SARS-CoV-2, and why. The questionnaire included questions on the patients' demographics and their knowledge of COVID-19 vaccines. RESULTS: Of the 664 pregnant women who completed the questionnaire, 29.5% (95% CI 27.7; 31.3) indicated they would agree to be vaccinated against COVID-19. The main reason for not agreeing was being more afraid of potential side effects of the SARS-CoV-2 vaccine on the fetus than of COVID-19. Factors influencing acceptance of vaccination were: being slightly older, multiparity, having discussed it with a caregiver and acceptance of the influenza vaccine. DISCUSSION: Nearly one-third of pregnant women in this population would be willing to be vaccinated. In addition to studies establishing fetal safety, public health agencies and healthcare professionals should provide accurate information about the safety of COVID-19 vaccines.

Evaluation of the usefulness of ultrasound measurement of the lower uterine segment before delivery of women with a prior cesarean delivery: a randomized trial.

BACKGROUND: The main reason to avoid trial of labor after cesarean delivery is the possibility of uterine rupture. Identifying women at risk is thus an important aim, for it would enable women at low risk to proceed with a secure planned vaginal birth. OBJECTIVE: To evaluate the impact of proposing mode of delivery based on the ultrasound measurement of the lower uterine segment thickness on a composite outcome of maternal-fetal mortality and morbidity, compared with usual management, among pregnant women with a previous cesarean delivery. STUDY DESIGN: This multicenter, randomized, controlled, parallel-group, unmasked trial was conducted at 8 referral university hospitals with a neonatal intensive care unit and enrolled 2948 women at 36 weeks 0 days to 38 weeks 6 days of gestation with 1 previous low transverse cesarean delivery and no contraindication to trial of labor. Women in the study group had their lower uterine segment thickness measured by ultrasound. Those with measurements >3.5 mm, were encouraged to choose a planned vaginal delivery, and those with measurements ≤3.5 mm, were encouraged to choose a planned repeat cesarean delivery. This measurement was not taken in the control group; their mode of delivery was decided according to standard management. The primary outcome was a composite criterion comprising maternal mortality, uterine rupture, uterine dehiscence, hysterectomy, thromboembolic disease, transfusion, endometritis, perinatal death, or neonatal encephalopathy. Prespecified secondary outcomes were repeat cesarean deliveries, elective or after trial of labor. RESULTS: The study group included 1472 women, and the control group included 1476 women. These groups were similar at baseline. The primary outcome occurred in 3.4% of the study group and 4.3% of the control group (relative risk, 0.78; 95% confidence interval, 0.54-1.13: risk difference, -1.0%; 95% confidence interval, -2.4 to 0.5). The uterine rupture rate in the study group was 0.4% and in the control group 0.9% (relative risk, 0.43; 95% confidence interval, 0.15-1.19). The planned cesarean delivery rate was 16.4% in the study group and 13.7% in the control group (relative risk, 1.21; 95% confidence interval, 1.00-1.47), whereas the rates of cesarean delivery during labor were 25.1% and 25.0% (relative risk, 1.01; 95% confidence interval, 0.89-1.14) in the study and control groups, respectively. CONCLUSION: Ultrasound measurements of lower uterine segment thickness did not result in a statistically significant lower frequency of maternal and perinatal adverse outcomes than standard management. However, because this study was underpowered, further research should be encouraged.