Planned delivery route and outcomes of cephalic singletons born spontaneously at 24-31 weeks' gestation: The EPIPAGE-2 cohort study.

INTRODUCTION: The objective of this study was to investigate the association between planned mode of delivery and neonatal outcomes with spontaneous very preterm birth among singletons in cephalic presentation. MATERIAL AND METHODS: Etude Epidémiologique sur les Petits Ages Gestationnels 2 is a French national, prospective, population-based cohort study of preterm infants. For this study, we included women with a singleton cephalic pregnancy and spontaneous preterm labor or preterm premature rupture of membranes at 24-31 weeks' gestation. The main exposure was the planned mode of delivery (ie planned vaginal delivery or planned cesarean delivery at the initiation of labor). The primary outcome was survival at discharge and secondary outcome survival at discharge without severe morbidity. Propensity scores were used to minimize indication bias in estimating the association. RESULTS: The study population consisted of 1008 women: 206 (20.4%) had planned cesarean delivery and 802 (79.6%) planned vaginal delivery. In all, 723 (90.2%) finally had a vaginal delivery. Overall, 187 (92.0%) and 681 (87.0%) neonates in the planned cesarean delivery and planned vaginal delivery groups were discharged alive, and 156 (77.6%) and 590 (76.3%) were discharged alive without severe morbidity. After matching on propensity score, planned cesarean delivery was not associated with survival (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 0.48-2.28) or survival without severe morbidity (aOR 0.64, 95% CI 0.36-1.16). CONCLUSIONS: Planned cesarean delivery for cephalic presentation at 24-31 weeks' gestation after preterm labor or preterm premature rupture of membranes does not improve neonatal outcomes.

Tocolysis after preterm premature rupture of membranes and neonatal outcome: a propensity-score analysis.

BACKGROUND: There are conflicting results regarding tocolysis in cases of preterm premature rupture of membranes. Delaying delivery may reduce neonatal morbidity because of prematurity and allow for prenatal corticosteroids and, if necessary, in utero transfer. However, that may increase the risks of maternofetal infection and its adverse consequences. OBJECTIVE: The objective of the study was to investigate whether tocolytic therapy in cases of preterm premature rupture of membranes is associated with improved neonatal or obstetric outcomes. STUDY DESIGN: Etude Epidémiologique sur les Petits Ages Gestationnels 2 is a French national prospective, population-based cohort study of preterm births that occurred in 546 maternity units in 2011. Inclusion criteria in this analysis were women with preterm premature rupture of membranes at 24-32 weeks' gestation and singleton gestations. Outcomes were survival to discharge without severe morbidity, latency prolonged by ≥48 hours and histological chorioamnionitis. Uterine contractions at admission, individual and obstetric characteristics, and neonatal outcomes were compared by tocolytic treatment or not. Propensity scores and inverse probability of treatment weighting for each woman were used to minimize indication bias in estimating the association of tocolytic therapy with outcomes. RESULTS: The study population consisted of 803 women; 596 (73.4%) received tocolysis. Women with and without tocolysis did not differ in neonatal survival without severe morbidity (86.7% vs 83.9%, P = .39), latency prolonged by ≥48 hours (75.1% vs 77.4%, P = .59), or histological chorioamnionitis (50.0% vs 47.6%, P = .73). After applying propensity scores and assigning inverse probability of treatment weighting, tocolysis was not associated with improved survival without severe morbidity as compared with no tocolysis (odds ratio, 1.01 [95% confidence interval, 0.94-1.09], latency prolonged by ≥48 hours (1.03 [95% confidence interval, 0.95-1.11]), or histological chorioamnionitis (1.03 [95% confidence interval, 0.92-1.17]). There was no association between the initial tocolytic drug used (oxytocin receptor antagonists or calcium-channel blockers vs no tocolysis) and the 3 outcomes. Sensitivity analyses of women with preterm premature rupture of membranes at 26-31 weeks' gestation, women who delivered at least 12 hours after rupture of membranes, women with direct admission after the rupture of membranes and the presence or absence of contractions gave similar results. CONCLUSION: Tocolysis in cases of preterm premature rupture of membranes is not associated with improved obstetric or neonatal outcomes; its clinical benefit remains unproven.

Planned Mode of Delivery of Preterm Twins and Neonatal and 2-Year Outcomes.

OBJECTIVE: To assess neonatal and 2-year outcomes for preterm twins born after planned vaginal delivery compared with planned cesarean delivery. METHODS: Women with preterm cephalic first twins delivered after preterm labor or preterm prelabor rupture of membranes from 24 0/7 to 34 6/7 weeks of gestation, with both fetuses alive at the beginning of labor, were identified from the national prospective population-based Etude Epidémiologique sur les Petits Ages Gestationnels 2 cohort study. Planned vaginal delivery was defined as vaginal delivery or cesarean delivery performed during labor. Planned cesarean delivery was considered if performed during labor for the indication of preterm twins or before labor whatever the indication. A propensity score analysis was used to compare planned vaginal delivery and planned cesarean delivery. Outcomes analyzed separately for the first and second twins were survival at discharge, survival at discharge without severe morbidity, and survival at 2 years of corrected age without neurosensory impairment. RESULTS: Among the 932 women with a twin pregnancy, 549 were excluded mainly as a result of the first twin in noncephalic presentation, cause of delivery other than preterm labor or preterm prelabor rupture of membranes, at least one twin died before labor, and gestational age at delivery less than 24 weeks of gestation. The planned vaginal delivery group included 276 women and the planned cesarean delivery group 107. For first and second twins, survival at discharge (97.7% vs 98.3% and 95.6% vs 97.1%, respectively), survival at discharge without severe morbidity (91.6% vs 88.8% and 90.3% vs 84.5%, respectively), and survival at 2 years of corrected age without neurosensory impairment (96.0% vs 95.4% and 92.9% vs 90.8%, respectively) did not differ significantly between the planned vaginal delivery and planned cesarean delivery groups. Propensity score analysis showed that planned cesarean delivery was not associated with improved outcomes with the caveat that the infrequency of death and disability limited the statistical power of the study to detect potentially clinically meaningful differences between planned modes of delivery. CONCLUSION: Planned cesarean delivery for women in preterm labor or with preterm prelabor rupture of membranes was not associated with improved neonatal outcomes or 2-year outcomes.

Incidence and risk factors of caesarean section in preterm breech births: A population-based cohort study.

OBJECTIVES: To describe the incidence of breech presentation at 22-34 weeks' gestation, estimate the incidence of cesarean section delivery by cause of prematurity, and assess the factors associated with caesarean delivery in preterm breech births with preterm labor or preterm premature rupture of membranes. STUDY DESIGN: EPIPAGE 2 is a French national prospective population-based cohort study of preterm births that occurred in 546 maternity units in 2011. We estimated the overall incidence of breech presentation and the incidence of cesarean delivery by cause of prematurity. Among the 579 singletons with breech presentation born at 22-34 weeks in a context of spontaneous preterm labor or membrane rupture, multivariable logistic regression was used to assess the association between individual and institutional characteristics and caesarean delivery. RESULTS: Among the 3660 singletons born at 22-34 weeks' gestation in the EPIPAGE 2 study, 20.1% (n=911) were breech presentation. Among these births, the rate of cesarean section was 99.6% with vascular pathologies, intrauterine growth retardation or placental abruption as compared with 60.1% with spontaneous preterm labor or membrane rupture. The main indication for caesarean delivery was gestational age associated with breech presentation (61.0%). Delivery mode varied by region of birth. Other characteristics associated with caesarean delivery were hospital status (public teaching, public non-teaching or private), clinical chorioamniotitis, hospital admission after labor onset, and gestational age. CONCLUSION: Breech presentation is common in preterm infants and is associated with widespread use of cesarean delivery with significant regional disparities that could reflect the lack of consensus and recommendations on the preferential mode of delivery. Other factors associated with caesarean delivery are the status of the maternity unit, clinical chorioamniotitis, admission after labor onset and gestational age.

Alcohol use, smoking and their co-occurrence during pregnancy among Canadian women, 2003 to 2011/12.

INTRODUCTION: The co-occurrence of alcohol use and smoking during pregnancy has been shown to have a negative synergistic effect on fetal and perinatal risks. The objectives were to: 1) obtain an estimate of the prevalence of smoking during pregnancy in Canada by province and territory from 2003 to 2011/12; 2) determine if the prevalence of smoking during pregnancy has increased or decreased over time; 3) investigate whether smoking status is differentially associated with alcohol use during pregnancy; and 4) examine the risk factors predictive of alcohol use only, smoking only, and the co-occurrence of alcohol use and smoking during pregnancy. METHODS: Secondary data analysis was conducted using five cycles of the Canadian Community Health Survey (CCHS; 2003, 2005, 2007/08, 2009/10 and 2011/12). The prevalence of smoking during pregnancy, and 95% confidence interval (CI) was calculated by province and territory and by year. The likelihood ratio test was used to determine if the prevalence of smoking during pregnancy has increased or decreased over time. The relationship between smoking status and alcohol use during pregnancy was explored using a quasi-Poisson regression model. A multinomial logistic regression model was utilized to determine which factors were predictive of alcohol use only, smoking only, and the co-occurrence of alcohol use and smoking during pregnancy. RESULTS: In Canada, between 2003 and 2011/12, the weighted pooled prevalence of smoking during pregnancy was 14.3% (95% CI: 13.6%-15.0%). Women who smoked daily during pregnancy, occasionally during pregnancy, or had a lifetime history of smoking (but did not smoke while pregnant) were 2.54 (95% CI: 2.11-3.06, P < 0.0001), 2.71 (95% CI: 2.25-3.27, P < 0.0001), and 2.09 (95% CI: 1.85-2.37, P < 0.0001), respectively, times more likely to have consumed alcohol during pregnancy, compared to pregnant women who were lifetime non-smokers when controlling for age, household income, ethnicity and CCHS cycle. Risk factors that predicted alcohol use only, smoking only, and the co-occurrence of alcohol use and smoking during pregnancy differed. CONCLUSION: It is apparent that smoking in any capacity, whether during pregnancy or not, increases the likelihood that a woman consumed alcohol while pregnant. Ascertaining smoking status among pregnant women and women of childbearing age could be a useful screening method for identifying those at-risk of consuming alcohol during pregnancy, and vice versa.