[Maternal mortality by stroke in France 2016-2018]

Between 2016 and 2018, twenty maternal deaths were associated with a stroke. The 20 deaths whose main cause was stroke represent 7.4% of all maternal deaths, i.e. a maternal mortality ratio (MMR) of 0.9 per 100,000 live births (95%CI 0.6-1.3). Among the 20 stroke deaths, it was hemorrhagic in 17 cases (85%), ischemic in 2 cases, and due to thrombophlebitis in 1 case. Stroke occurred during pregnancy in 8 women (40%) - one case before 12 weeks, 3 cases between 28 and 32 weeks, and 4 cases between 34 and 40 weeks; in 3 cases the stroke occurred intrapartum, and for the other 9 cases (45%) the stroke occurred postpartum between Day 1 and Day 15. Care was assessed as non-optimal in 10/19 (56%) of cases but mortality as possibly avoidable in 24% of cases (4/17 cases with conclusion established by the CNEMM) and not established in two cases. The potentially improvable elements identified were a delay in carrying out initial brain imaging in three cases (one case antepartum, two cases postpartum) and insufficient hemodynamic monitoring in intensive care in one case.

[Indirect causes of maternal deaths (except stroke, cardiovascular diseases and infections) in France 2016-2018]

Maternal deaths from indirect obstetric cause result from a preexisting condition or a condition that occurred during pregnancy without obstetric causes but was aggravated by the physiological effects of pregnancy. Twenty-nine deaths with an indirect cause related to a preexisting condition, excluding circulatory diseases or infections, were analysed by the expert committee. Pre-pregnancy pathology was documented in 16 women (epilepsy, n=7; amyloid angiopathy, n=1; Dandy-Walker syndrome, n=1; autoimmune diseases, n=3; diffuse infiltrative pneumonitis, n=1; thrombotic thrombocytopenic purpura, n=1; ovarian cancer in fragile X, n=1; major sickle cell disease, n=1). In 13 women, the pathology was unknown before pregnancy (breast cancer, n=9, epilepsy diagnosed during pregnancy, n=1, brain tumours, n=2 meningioma type, macrophagic activation syndrome, n=1). Death was associated with neoplastic or tumour pathology in 13 women (45%). At the same time, epilepsy was responsible for the death of 8 women (27%), making it the most common cause of death. For both neoplasia and epilepsy, about 50% of deaths were preventable, mainly due to undiagnosed and/or delayed treatment in the case of cancer and failure to monitor or adjust treatment in the case of epilepsy. Pre-conception counselling is therefore strongly recommended if a woman has a known chronic medical condition prior to pregnancy. Finally, if there is a family history of breast cancer, a breast examination is strongly recommended from the first visit during pregnancy, and any breast lumps should be investigated as soon as possible to avoid delaying appropriate treatment.

[Maternal mortality due to genital tract infection in France, 2016-2018]

Over the 2016-2018 period, maternal mortality due to direct infectious causes accounted for 13% of maternal deaths by direct causes. The increasing trend in genital-tract infections related-deaths noted in the 2013-2015 report continues for the 2016-2018 period, but this 2010-2018 increase remains at the limit of statistical significance given the low number of cases (p 0.08). The 13 deaths from direct infectious causes for the 2016-2018 period were due to 4 cases of puerperal toxic shock syndrome (Streptococcus A beta hemolyticus or Clostridium group bacilli), 6 sepsis caused by intrauterine infection due to E. Coli and 3 cases of septic shock from intrauterine origin and no documented bacteria. In this 2016-2018 triennium, the quality of care concerning women who died of direct infections was considered non-optimal in 85% (11/13). Death was considered possibly or probably avoidable in 9/13 cases (69%), which made it one of the most avoidable causes of maternal mortality. Preventable factors related to the medical management were the most frequent (9/13), with in particular a diagnostic failure or delayed diagnosis leading to a delay in the introduction of medical treatment. The others contributory factors to these deaths were related to the organization of healthcare (delayed transfer, lack of communication between practitioners) as well as factors related to patient social and/or mental vulnerability.

[How to respond to a stubborn refusal of care during delivery]

Our team was confronted with a situation of stubborn refusal of care, including the indication of a cesarean section for an adult patient able to express her wishes. This refusal was formulated during pregnancy follow-up, during the discussion of the birth plan and during delivery, the patient having accepted the indication of a possible emergency cesarean section under general anesthesia only in the occurrence of severe fetal heart rate abnormalities. The impasse forced caregivers to violate the rules of good clinical practice, which indicated the performance of a cesarean section, and to wait for a complication to arise in order to be able to act, taking the risk of intervening too late. This situation has led to direct risks to the health of the mother and the unborn child, without putting the life of either of them in imminent danger. Finally, the time devoted to this patient in a tense organization was to the detriment of the care of other patients.

Risk of disseminated intravascular coagulation in postpartum hemorrhage associated with intrauterine infection

OBJECTIVE

To evaluate the risk of disseminated intravascular coagulation (DIC) in postpartum hemorrhage (PPH) associated with intrauterine infection.

MATERIAL AND METHODS

A retrospective cohort study of pregnancies complicated by PPH performed at a tertiary academic center in France from 2017 through 2021. Patients giving birth after 22 weeks of gestation with PPH were eligible. Patients with a PPH associated with an intrauterine infection were compared to patients with a PPH without intrauterine infection. Intrauterine infection was defined by a composite criterion available at delivery. DIC was defined by a specific pregnancy DIC score. The association between DIC and intrauterine infection was assessed by logistic regression. The causal effect of intrauterine infection on DIC was estimated by mediation analysis.

RESULTS

Of 2,093 patients with PPH, 49 exposed to a clinical intrauterine infection were compared to 49 unexposed patients. The rate of DIC was higher in patients with than without infection (22 (45.8%) vs. 7 (14.6%), P = .001), and coagulation anomalies occurred sooner in patients with than without infection (7, 2-11 h vs. 14, 9-19 h, P < .001). In the multivariate analysis, intrauterine infection was the only factor independently associated with DIC (adjusted odds ratio 5.01, 95% CI 1.83-13.73). Mediation analysis showed that 14% (95% CI, 0-50%) of this association between intrauterine infection and DIC was mediated by severe PPH, and 86% resulted from the direct effect of intrauterine infection on DIC.

CONCLUSION

In PPH, intrauterine infection had a major direct effect on the occurrence, timing, and severity of DIC.

Meconium-stained amniotic fluid and neonatal morbidity in nulliparous patients with prolonged pregnancy

INTRODUCTION

Our objective was to study the strength of the association between meconium-stained amniotic fluid and severe morbidity among neonates of nulliparas with prolonged pregnancies.

MATERIAL AND METHODS

This was a secondary analysis of the NOCETER randomized trial that took place between 2009 and 2012 in which 11 French maternity units included 1373 nulliparas at 41⁺⁰  weeks of gestation onwards with a single live fetus in cephalic presentation. This analysis excluded patients with a cesarean delivery before labor and those with bloody amniotic fluid or of unreported consistency. The principal end point was a composite criterion of severe neonatal morbidity (neonatal death, 5-minute Apgar <7, convulsions in the first 24 h, meconium aspiration syndrome, mechanical ventilation ≥24 h, or neonatal intensive care unit admission for 5 days or more). The neonatal outcomes of pregnancies with thin or thick meconium-stained amniotic fluid were compared with those with normal amniotic fluid. The association between the consistency of the amniotic fluid and neonatal morbidity was tested by univariate and then multivariate analysis adjusted for gestational age at birth, duration of labor, and country of birth.

RESULTS

This study included 1274 patients: 803 (63%) in the group with normal amniotic fluid, 196 (15.4%) in the thin amniotic fluid group, and 275 (21.6%) in the thick amniotic fluid group. The neonates of patients with thick amniotic fluid had higher rates of neonatal morbidity than those of patients with normal amniotic fluid (7.3% vs. 2.2%; p < 0.001; adjusted relative risk [aRR] 3.3, 95% confidence interval [CI] 1.7-6.3), but those of patients with thin amniotic fluid did not (3.1% vs. 2.2%; p = 0.50; aRR 1.0, 95% CI, 0.4-2.7).

CONCLUSIONS

Among nulliparas at 41⁺⁰  weeks onwards, only thick meconium-stained amniotic fluid is associated with a higher rate of severe neonatal morbidity.

Risk factors for hypoxic-ischemic encephalopathy or neonatal death in placental abruption

OBJECTIVE

To identify risk factors for moderate or severe hypoxic-ischemic encephalopathy (HIE), or neonatal death in clinical placental abruption.

MATERIAL AND METHODS

A nested case-control study within a cohort of singleton pregnancies complicated by placental abruption with a live born infant at two academic reference centers in France, from 2006 to 2019. Cases were patients who gave birth to an infant with moderate or severe HIE or death within 28 days (HIE/death group), and controls were patients whose infant did not have any of these outcomes (no-HIE group). Independent risk factors were identified by logistic regression. Binary decision tree discriminant (CART) analysis was performed to define high-risk subgroups of HIE or death.

RESULTS

Among 152 patients, the infants of 44 (29%) had HIE or death. Out-of-hospital placental abruption and fetal bradycardia at admission were more frequent in cases than in controls: 39 (89%) vs 61 (56%), p < .01 and 24 (59%) vs 19 (18%), p < .01, respectively. In multivariate analysis, out-of-hospital placental abruption (aOR, 7.05; 95% CI, 1.94-25.66) and bradycardia at admission (aOR, 8.60; 95% CI, 2.51-29.42) were independently associated with an increased risk of HIE or death. The combination of out-of-hospital placental abruption and bradycardia was the highest risk situation associated with HIE or death (67%). The decision-to-delivery interval was 15 [12-20] minutes among cases.

CONCLUSION

Out-of-hospital placental abruption combined with bradycardia at admission was associated with a major risk of moderate or severe HIE or death. An optimal decision-to-delivery interval does not guarantee the absence of an adverse neonatal outcome.

Risk of preeclampsia in patients with symptomatic COVID-19 infection

Objectives

Recent studies suggest an association between COVID-19 infection during pregnancy and preeclampsia. Nonetheless, these studies are subject to numerous biases. We compared the onset of preeclampsia in a group with symptomatic COVID-19 during pregnancy to that in a group whose non-exposure to the virus was certain, in a center where pregnancy management was identical in both groups.

Study Design

This was a single-center study comparing exposed and unexposed patients. The exposed group included pregnant women with symptomatic COVID-19 infection (diagnosed by RT-PCR or CT scan), who gave birth between March and December, 2020. The unexposed group included pregnant women who gave birth between March and December, 2019. Only cases of preeclampsia that occurred after COVID-19 infection were considered. A multivariate analysis was performed to study the existence of an association between COVID-19 and preeclampsia. A sensitivity analysis was performed among nulliparous patients.

Results

The frequency of preeclampsia was 3.2% (3/93) in the exposed group, versus 2.2% (4/186) in the unexposed group (P = 0.58). Among the nulliparous patients, the frequency of preeclampsia was 4.9% (2/41) in the exposed group versus 0.9% (1/106) in the unexposed group (P = 0.13). The association between COVID-19 and preeclampsia was not significant after multivariate analysis (OR 3.12, 95% CI 0.39-24.6).

Conclusion

Symptomatic COVID-19 infection during pregnancy does not appear to increase the risk of preeclampsia strongly, although the size of our sample prevents us from reaching a conclusion about a low or moderate risk. It therefore does not appear necessary to reinforce preeclampsia screening in patients with symptomatic COVID-19 infection during pregnancy.

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.

Early- and late-onset postpartum depression exhibit distinct associated factors: the IGEDEPP prospective cohort study

OBJECTIVE

To identify risk factors for early- and late-onset postpartum depression (PPD) among a wide range of variables, including sociodemographic characteristics, childhood trauma, stressful life events during pregnancy and history of personal and family psychiatric disorders, and to assess the contribution of each risk factor.

DESIGN

Nested case-control study in a prospective longitudinal cohort study.

SETTING

Eight maternity departments in the Paris metropolitan area, France.

SAMPLE

A cohort of 3310 women with deliveries between November 2011 and June 2016.

METHODS

Cases were women with early- or late-onset PPD. Controls were women without depression during pregnancy or the postpartum period. Logistic regression adjusted on sociodemographic variables was performed for each outcome and a multivariable model was proposed based on a stepwise selection procedure.

MAIN OUTCOME MEASURES

Early- and late-onset PPD assessed at 2 months and 1 year postpartum, respectively.

RESULTS

Stressful life events during pregnancy have a dose-response relationship with both early- and late-onset PPD.

CONCLUSIONS

Early- and late-onset PPD presented distinct patterns of determinants. These results have important consequences in terms of prevention and specific care.

TWEETABLE ABSTRACT

Early- and late-onset postpartum depression are associated with stressful life events and psychiatric history.

Risk factors of relaparotomy for intra-abdominal hemorrhage after cesarean delivery

OBJECTIVE

the main objective was to identify risk factors of relaparotomy for intra-abdominal hemorrhage (IAH) after cesarean delivery. The secondary objectives were to identify clinical warning signs associated with IAH: heart rate>120/min, systolic blood pressure<90 mmHg, scar bleeding, unconsciousness or abdominal pain with visual analog pain scale > 7 or use of category 3 analgesic medications, in the post-anesthesia care unit and in the post-partum unit.

STUDY DESIGN

a case-control study (1:2 ratio), in two academic tertiary perinatal centers during 2008-2017. Postpartum laparotomies performed for another indication were excluded. The cases were women who underwent relaparotomy for IAH. A control group comprised women who had an uncomplicated cesarean delivery before and after each case.

RESULTS

19,007 women had a cesarean delivery during the study period and among them 52 relaparotomies (0.27 %) for IAH were performed. 48 cases were compared to 96 controls. In multivariate analysis, the existence of a preeclampsia (aOR = 2.8, 95 % IC 1.1-7.4), urgent cesarean (aOR = 3.2, 95 % IC 1.1-9.6), surgical difficulties during initial cesarean (aOR = 9.0, 95 % IC 2.8-23.8), and estimated blood loss > 500 mL during initial cesarean (aOR = 7.4, 95 % IC 2.4-22.5) were independently associated with IAH. Tachycardia > 120/min was the most discriminating factor associated with the occurrence of relaparotomy for IAH (84 %). In the absence of tachycardia, hypotension < 90 mmHg was the second most discriminant factor for IAH (73 %).

CONCLUSION

preeclampsia, urgent cesarean, surgical difficulties and blood loss > 500 mL during initial cesarean were independently associated with an increased risk of relaparotomy for IAH. Tachycardia and/or hypotension were discriminant-warning signs for severe IAH.

Fetal heart rate nadir during bradycardia and umbilical artery acidemia at birth

INTRODUCTION

Fetal bradycardia due to sentinel events such as placental abruption, cord prolapse or uterine rupture is associated with an increased risk of acidemia at birth. In the absence of a sentinel event, data regarding neonatal prognosis are scarce, and it seems plausible that the depth of bradycardia might be associated with an increased risk of acidosis at birth. The objective was to determine whether the depth of bradycardia is associated with a higher risk of umbilical artery acidemia at birth in term singleton pregnancies requiring cesarean delivery during labor.

MATERIAL AND METHODS

A retrospective comparative study of all cesarean deliveries for bradycardia in an academic tertiary center in the 6-year period of 2013-2018, among term singleton pregnancies. Bradycardia associated with a sentinel event such as placental abruption, cord prolapse or uterine rupture, were excluded. The nadir of the bradycardia was defined as the lowest fetal heart rate baseline lasting at least 3 minutes during bradycardia. Women who delivered an infant with an umbilical pH at birth <7.00 (acidosis group) were compared with women who delivered an infant with an umbilical pH at birth ≥7.00 (non-acidosis group).

RESULTS

Among 111 eligible cases, 32 women in the acidosis group were compared with 79 in the non-acidosis group. The median nadir of the bradycardia was lower in the acidosis than in the non-acidosis group (60 bpm, interquartile range [56-65] vs 70 [60-76], P < .01). A bradycardia nadir <60 bpm emerged as the optimal threshold for predicting acidemia and was more frequently observed in the acidosis than in the non-acidosis group (10 [31%] vs 10 [13%], P = .02). In the multivariable analysis, a nadir <60 bpm was independently associated with an umbilical artery pH <7.00 (adjusted OR 3.16, 95% CI 1.10-9.04).

CONCLUSIONS

A bradycardia nadir <60 bpm was associated with a tripled risk of umbilical artery acidemia at birth.

Fetal scalp blood sampling: Do pH and lactates provide the same information?

OBJECTIVE

Assess the discordance between scalp pH and lactates performed from the same sample during labor.

METHOD

This single-center retrospective study included all women with a singleton fetus who had at least one fetal blood sample taken during labor. Some of them had up to seven samples. Scalp pH was the reference parameter for obstetric decision-making. The correlation between the pH and lactates was studied using Pearson coefficient. By categorizing the values as normal, pre-acidosis and acidosis, we were able to estimate agreement with Cohen's kappa coefficient. The frequency of discordance in the categorization and the factors related to it were studied with univariate and multivariable analyses. Cases of severe acidosis at birth (cord pH < 7.00) and cases with acidosis scalp lactates but normal scalp pH were analyzed.

RESULTS

We analyzed 480 samples from 268 fetuses among the 2644 deliveries during the study periode. Fetal blood sampling represented 10 % of deliveries. The scalp pH and lactates results were strongly correlated (r=-0.83), but their agreement was only fair (K = 0.36). In 29.4 % of cases, pH and lactates were discordant. Factors related to discordance were meconium-stained fluid, sampling at full dilation and multiple sampling. Six infants (2.2 %) had severe acidosis at birth. Cases' analyses did not allow to conclude severe acidosis could have been avoided using scalp lactates for obstetric decision-making.

CONCLUSION

For more than a quarter of the samples, results were discordant between scalp pH and lactates, especially when cervix was full dilated and when the amniotic fluid was meconium-stained. A randomized controlled trial comparing the relevance of each parameter according to the obstetrical situation would be necessary.

Intrahepatic cholestasis of pregnancy: Is a screening for differential diagnoses necessary?

OBJECTIVE

To evaluate the benefit of performing a screening for differential diagnoses by hepatobiliary ultrasound and viral serologies, in case of suspected intrahepatic cholestasis of pregnancy (ICP).

METHODS

Retrospective single-center study in a tertiary maternity unit, including all women with a suspected ICP between January 2012 and September 2018. The primary outcome was the differential diagnosis rate obtained through initial screening. We described women characteristics, symptoms, and blood results that led to ICP suspicion. We evaluated the rate of differential diagnosis established by the initial screening. We described the population of women presenting with an ICP differential diagnosis.

RESULTS

The study included 254 women. Prevalence of differential diagnosis was 2 %. ICP was suspected in more than 50 % of cases in third trimester of pregnancy (79.5 %). Women presented with pruritus in 90.9 % of cases. Bile acid levels were between 20 and 40 μmol/L in 56.3 % of cases and above 40 μmol/L in 12.2 % of cases. The screening to rule out differential diagnosis of ICP was performed in half of the cases. When performed, the screening did not lead to the diagnosis of any differential disease.

CONCLUSION

In this cohort, among the 254 women, one (0.4 %) would have been wrongly diagnosed with ICP if the initial screening for differential diagnosis had not been performed. Screening for differential diagnosis does not seem to provide any benefit regarding the management of suspected ICP and could therefore only be performed in case of atypical clinical presentation of ICP, resistance to treatment or persisting abnormal liver function tests in the postpartum period.

Are there specific factors associated with prenatally undiagnosed foetal macrosomia?

OBJECTIVE

Fetal macrosomia is known to increase maternal and neonatal complications, but 20%-50% of the macrosomic fetuses are prenatally undiagnosed. Our objective was to identify specific factors associated with undiagnosed fetal macrosomia in women without diabetes.

METHODS

Retrospective case-control study in a tertiary maternity unit between January 1st and December 31st, 2016. Inclusion of all women delivering after 37 weeks of a single live-born macrosomic infant, i.e., with a birth weight ≥ 90th percentile for gestational age (GA). Women with pre-existing or gestational diabetes were excluded. To identify specific factors associated with undiagnosed foetal macrosomia, we compared risk factors for macrosomia, maternal characteristics, father's body mass index (BMI) and prenatal follow up between two groups depending on whether macrosomia was prenatally diagnosed or not.

RESULTS

Among 428 macrosomic newborns, 224 (52.3 %) were prenatally undiagnosed. Known risk factors for macrosomia, maternal characteristics (such as low socio-economic level, low education level) and father's BMI were similar between the two groups. The prenatal follow up was comparable between the two groups. Ultrasound estimated foetal weight during the 3rd trimester was lower in the undiagnosed macrosomic foetuses compared to diagnosed macrosomic foetuses (2130±279 vs 2445±333, p<0.001).

CONCLUSIONS

No specific factor of undiagnosed macrosomia was identified, and women with prenatally undiagnosed fetal macrosomia had the same risk factors than women with diagnosed macrosomia. Our study suggests that our groups have different growth curves. This hypothesis has yet to be studied.

Determinants of the persistency of macrosomia and shoulder dystocia despite treatment of gestational diabetes mellitus

Aims

to identify potentially modifiable risk factors associated with the persistency of macrosomia and/or shoulder dystocia in infants born to women treated for gestational diabetes mellitus (GDM).

Methods

this case-control retrospective study included 113 cases complicated by macrosomia (ponderal index ≥97^th percentile) and/or shoulder dystocia, and 226 controls without these complications. Factors associated with macrosomia and/or shoulder dystocia and with failure of diabetes management were assessed by multivariable analyses.

Results

Macrosomia and/or shoulder dystocia were associated with previous delivery of a large for gestational age (LGA) infant (adjusted odds ratio, 2.34, 95% confidence interval [1.01–5.45]), three abnormal glucose values during oral glucose tolerance test (2.83 [1.19–6.72]), a higher gestational weight gain before treatment (1.08 [1.01–1.15]), and failure of diabetes management (2.68 [1.32–5.45]). A non-Euro Caucasian origin (3.08 [1.37–6.93]), previous delivery of a LGA infant (3.21 [1.31–7.87]), institution of treatment after 32 weeks of gestation (3.92 [1.86–8.25]), and insulin therapy (2.91 [1.20–7.03]) were associated with failure of diabetes management.

Conclusions

supportive care in at risk women, limitation of weight gain in early pregnancy, shortened delay between diagnosis and treatment of GDM, and intensive insulin dosage adjustments might be means to improve the neonatal prognosis of GDM.

Determinants of a good perinatal outcome in 588 pregnancies in women with type 1 diabetes

AIM

This study assessed pregnancy outcomes in women with type 1 diabetes (T1D) over the last 15 years and identified modifiable factors associated with good perinatal outcomes.

METHODS

Pregnancy outcomes were prospectively assessed in this cohort study of 588 singleton pregnancies (441 women) managed by standardized care from 2000 to 2014. A good perinatal outcome was defined as the uncomplicated delivery of a normally formed, non-macrosomic, full-term infant with no neonatal morbidity. Factors associated with good perinatal outcomes were identified by logistic regression.

RESULTS

The rate of severe congenital malformations was 1.5%, and 0.7% for perinatal mortality. The most frequent perinatal complications were macrosomia (41%), preterm delivery (16%) and neonatal hypoglycaemia (11%). Shoulder dystocia occurred in 2.6% of cases, but without sequelae. Perinatal outcomes were good in 254 (44%) pregnancies, and were associated with lower maternal HbA_1c values at delivery [adjusted odds ratio (aOR): 2.78, 95% CI: 2.04-3.70, for each 1% (11mmol/mol) absolute decrease], lower gestational weight gains (aOR: 1.06, 95% CI: 1.02-1.10) and absence of preeclampsia (aOR: 2.63, 95% CI: 1.09-6.25). The relationship between HbA_1c at delivery and a good perinatal outcome was continuous, with no discrimination threshold.

CONCLUSION

In our study, rates of severe congenital malformations and perinatal mortality were similar to those of the general population. Less severe complications, mainly macrosomia and late preterm delivery, persisted. Also, our study identified modifiable risk factors that could be targeted to further improve the prognosis of pregnancy in T1D.

[Venous thromboembolism and pregnancy]

Venous thromboembolism (VTE) is a major cause of maternal morbidity and mortality during or early after pregnancy. Prior VTE or family history of VTE, clinical or biological risk factors increased the risk of pregnancy-related VTE. Defining the risk of VTE before or at the beginning of pregnancy is necessary to propose the best prevention. However, the management is not standardized between physicians, centres and countries. Current guidelines for prophylaxis and treatment of VTE are discussed in this review.

[Maternal refusal to consent to a cesarean delivery, stillbirth]

The doctor-lawyer perspective that we discuss is a maternal refusal to consent to a cesarean delivery for a fetal indication in June 2011. Despite repeated information of the risks during a three-week hospitalization for pre-eclampsia, after being assured of the proper understanding of the seriousness of the situation by the patient and spouse, and after consideration to transfer to another hospital, the reiterated refusal led to a late fetal extraction resulting in term stillbirth.

Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR)

OBJECTIVE

To assess the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting.

DESIGN

Randomised controlled trial.

SETTING

Five university hospital maternity units in France.

PARTICIPANTS

Women aged 18 or more with a singleton fetus at 35 or more weeks' gestation and planned vaginal delivery.

INTERVENTIONS

Women were randomly assigned to management of the third stage of labour by controlled cord traction or standard placenta expulsion (awaiting spontaneous placental separation before facilitating expulsion). Women in both arms received prophylactic oxytocin just after birth.

MAIN OUTCOME MEASURE

Incidence of postpartum haemorrhage ≥ 500 mL as measured in a collector bag.

RESULTS

The incidence of postpartum haemorrhage did not differ between the controlled cord traction arm (9.8%, 196/2005) and standard placenta expulsion arm (10.3%, 206/2008): relative risk 0.95 (95% confidence interval 0.79 to 1.15). The need for manual removal of the placenta was significantly less frequent in the controlled cord traction arm (4.2%, 85/2033) compared with the standard placenta expulsion arm (6.1%, 123/2024): relative risk 0.69, 0.53 to 0.90); as was third stage of labour of more than 15 minutes (4.5%, 91/2030 and 14.3%, 289/2020, respectively): relative risk 0.31, 0.25 to 0.39. Women in the controlled cord traction arm reported a significantly lower intensity of pain and discomfort during the third stage than those in the standard placenta expulsion arm. No uterine inversion occurred in either arm.

CONCLUSIONS

In a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum haemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum haemorrhage is therefore lacking.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01044082.

Low rate of pandemic A/H1N1 2009 influenza infection and lack of severe complication of vaccination in pregnant women: a prospective cohort study

BACKGROUND

In 2009, pregnant women were specifically targeted by a national vaccination campaign against pandemic A/H1N1 influenza virus. The objectives of the COFLUPREG study, initially set up to assess the incidence of serious forms of A/H1N1 influenza, were to assess the consequences of maternal vaccination on pregnancy outcomes and maternal seroprotection at delivery.

METHODS

Pregnant women, between 12 and 35 weeks of gestation, non vaccinated against A/H1N1 2009 influenza were randomly selected to be included in a prospective cohort study conducted in three maternity centers in Paris (France) during pandemic period. Blood samples were planned to assess hemagglutination inhibition (HI) antibody against A/H1N1 2009 influenza at inclusion and at delivery.

RESULTS

Among the 877 pregnant women included in the study, 678 (77.3%) had serum samples both at inclusion and delivery, and 320 (36.5%) received pandemic A/H1N1 2009 influenza vaccine with a median interval between vaccination and delivery of 92 days (95% CI 48-134). At delivery, the proportion of women with seroprotection (HI antibodies titers against A/H1N1 2009 influenza of 1∶40 or greater) was 69.9% in vaccinated women. Of the 422 non-vaccinated women with serological data, 11 (2.6%; 95%CI: 1.3-4.6) had laboratory documented A/H1N1 2009 influenza (1 with positive PCR and 10 with serological seroconversion). None of the 877 study's women was hospitalized for flu. No difference on pregnancy outcomes was evidenced between vaccinated women, non-vaccinated women without seroconversion and non-vaccinated women with flu.

CONCLUSION

Despite low vaccine coverage, incidence of pandemic flu was low in this cohort of pregnant women.No effect on pregnancy and delivery outcomes was evidenced after vaccination.

[Pre-existing diabetes and pregnancy]

The prevalence of pre-existing diabetes associated with pregnancy is 0.5 to 1%. A third are type 1 diabetes, two-thirds are type 2 diabetes, whose prevalence is increasing due to rising obesity. The improved prognosis of pregnancies in women with pre-existing diabetes relies on preconception programming (therefore an effective contraception), multidisciplinary collaboration and appropriate management of these pregnancies.

Onset of autoimmune type 1 diabetes during pregnancy: Prevalence and outcomes

Although this has been recently challenged, gestational diabetes mellitus (gestational diabetes) is still defined as an "impairment of glucose tolerance with onset or first recognition during pregnancy". According to this definition, all pathophysiological conditions leading to beta cell deficiency may reveal as gestational diabetes, due to the physiological insulin resistance associated with pregnancy. In rare patients, gestational diabetes is associated with the presence of islet autoantibodies and with a high risk of progression to overt type 1 diabetes after delivery. This condition has often been compared to the Latent Autoimmune Diabetes in Adults. The frequency of islet autoantibodies in gestational diabetes has been assessed in many studies, but data about the clinical presentation of this subtype and about its prognosis are few. We review these studies and discuss the links of autoimmune gestational diabetes with type 1 diabetes mellitus.

[Gestational diabetes mellitus]

Gestational diabetes mellitus is characterised by glucose intolerance of variable severity that begins or is first diagnosed during pregnancy and usually resolves not long after delivery. Unknown type 2 diabetes mellitus must be diagnosed in women with risk factors, ideally before pregnancy, otherwise at first prenatal visit. Universal screening of gestational diabetes mellitus is performed between 24 and 28 weeks of gestation with a 75 g 2-hour oral glucose tolerance test. Thresholds are 0.95 g/ and/or 1.55 g/l, respectively and could be mildly modified soon. The evidence clearly supports the treatment of gestational diabetes mellitus and the modifications of obstetrical management in these women. According to the increased risk of the subsequent development of type 2 diabetes, fasting glycemia should be performed at 6-12 weeks postpartum and every three years. Obese and overweight women have increased risks of perinatal complications.

Differential regulation of genes for fetoplacental lipid pathways in pregnancy with gestational and type 1 diabetes mellitus

OBJECTIVE

Changes in metabolic homeostasis in pregnant diabetic women are potential determinants of increased adiposity of the fetus. The aim of this study was to characterize diabetes mellitus-induced changes in genes for fetoplacental energy metabolism in relation to fetal adiposity.

STUDY DESIGN

Placentas of women with type 1 diabetes mellitus, gestational diabetes mellitus (GDM), or no complications were analyzed by microarray profiling. The pattern of gene expression was assessed in primary placental cell cultures.

RESULTS

Diabetes mellitus was associated with 49 alterations in gene expression at key steps in placental energy metabolism, with 67% of the alterations related to lipid pathways and 9% of the alterations related to glucose pathways. Preferential activation of lipid genes was observed in pregnancy with GDM. Type 1 diabetes mellitus induced fewer lipid modifications but an enhancement of glycosylation and acylation pathways. Oleate enhanced expression of genes for fatty acid esterification and the formation of lipid droplets 3 times as much as glucose in cultured placental cells.

CONCLUSION

These results point to fatty acids as preferential lipogenic substrates for placental cells and suggest that genes for fetoplacental lipid metabolism are enhanced selectively in GDM. The recruited genes may be instrumental in increasing transplacental lipid fluxes and the delivery of lipid substrates for fetal use.

A standardized protocol to achieve normoglycaemia during labour and delivery in women with type 1 diabetes

AIM

To evaluate a standardized protocol for maintaining near-normoglycaemia during labour and delivery in women with type 1 diabetes.

METHODS

Over a nine-year period (1997-2005), 229 pregnancies in 174 women with type 1 diabetes were delivered at one centre. The same regimen was used for the induction of labour (group 1) and in women admitted in spontaneous labour (group 2): 10% dextrose (80ml/h) intravenous was given along with short-acting insulin, starting at 1IU/h intravenous via an infusion pump. Capillary blood glucose (CBG) was determined hourly, and the insulin infusion rate was modified accordingly.

RESULTS

Labour was induced in 85 cases (37%) and spontaneous in 23 cases (10%), and an elective C-section was performed in 121 cases (53%). Maternal glycaemia during labour was 6.1+/-1.6 (range: 3.9-9.2)mmol/l in group 1, and 6.9+/-2.0 (range: 4.7-12.0)mmol/l in group 2. Maternal glycaemia at delivery was 5.8+/-1.5 (range: 3.4-9.4) and 6.3+/-1.9 (range: 4.1-11.4)mmol/l in groups 1 and 2, respectively. Women who underwent an elective C-section were not included in the standardized protocol and had higher glycaemia at delivery 7.1+/-2.0 (range: 2.7-13.5)mmol/l. Neonatal hypoglycaemia occurred in 30 infants (13%), and was only associated with preterm delivery.

CONCLUSION

Using a standardized simple protocol during labour, maternal glycaemia was maintained within a near-normal range in 80-85% of cases.

Leptine et grossesse: dogmes, questions et perspectives

Leptin has been primarily considered as a protein secreted by the adipocyte and a regulator of satiety and energy homeostasis. A role for leptin in pregnancy was later suggested as circulating levels of leptin are high in the pregnant woman and leptin is synthetized within the placenta. Placental leptin production is increased in various obstetrical conditions associated with alterations of fetal growth (diabetes, preeclampsia). Furthermore, umbilical leptin can be viewed as a biomarker of fetal adiposity. Our aim is to review the putative roles of leptin in pregnancy.

Échec d'un traitement conservateur d'un placenta accreta

We report a case of placenta accreta left fully in situ during a cesarean section. Postoperative courses were complicated with a thrombosis of the right external iliac artery after embolization and with a pyometra needing n hysterectomy. We discuss the risks of such conservative treatment of a placenta accreta, compared with classical ablation.

Identification of distinct quantitative trait Loci affecting length or weight variability at birth in humans

CONTEXT

The variability of human fetal growth is multifactorial. Twin and family studies demonstrate that genetic determinants influence normal fetal growth, but the responsible genetic polymorphisms are unknown.

OBJECTIVE

The objective of the study was the mapping of quantitative trait loci (QTLs) for birth length and weight.

DESIGN AND METHODS

To approach the genetic factors implicated in the normal variation of birth length and weight, we conducted a genome-wide approach of these two quantitative traits in 220 French Caucasian pedigrees (412 sibling pairs) using a variance components method.

RESULTS

We observed evidence for several QTLs influencing birth length or birth weight independently. Whereas birth length and weight showed a close correlation (r = 0.76, P < 0.0001), their genetic variability appeared largely determined by distinct genomic loci. Birth length was influenced by two major QTLs located in 2p21 and 2q11 (LOD scores 2.69 and 3.57). The variability of birth weight was linked to another QTL on 7q35 (LOD score 3.1). Several other regions showed more modest evidence for linkage with LOD score values of 1-2 on chromosomes 7, 8, 10, 13, and 17 for birth length and chromosomes 1, 2, 6, 8, 10, 13, 14, 15, 17, and 20 for birth weight.

CONCLUSION

These preliminary QTLs provide a first step toward the identification of the genomic variants involved in the variability of human fetal growth. Our results should, however, be considered preliminary until they are replicated in other studies.

The known and unknown of leptin in pregnancy

Leptin, which was identified originally as an adipocyte-derived protein, was regarded for years as an exclusive regulator of satiety and energy homeostasis. A role for leptin in pregnancy was later suggested by the findings that plasma levels during gestation are greater than in nongravid individuals and that leptin is synthesized within the fetoplacental unit. Observational studies have established that leptin production is dysregulated in several pathologic stages of pregnancy in association with alterations of fetal growth. For example, an overproduction of leptin by the placenta in pregnancy with diabetes mellitus or hypertension is associated with maternal hyperleptinemia. Evidence is also accumulating that umbilical leptin levels can be viewed as a biomarker of fetal adiposity. Ten years after its discovery as a hormone, we review the known and unknowns of leptin in pregnancy with particular emphasis on its functions in health and disease. We aim to demonstrate that studies of leptin in pregnancy largely have contributed to insight into the mechanisms of leptin action, both as a hormone and as a cytokine.

Abcès primaire de l'ovaire. Diagnostic et approche thérapeutique

Primary ovarian abscess is a rare infection. A new case has led us to carry out a literature review in order to optimize the treatment. Exceptionally isolated, primary ovarian abscess usually belongs to the postoperative complications. Nevertheless, its etiopathogenies are numerous. The symptoms are often poor; therefore the diagnosis is difficult to establish. The curative treatment must associate surgery and antibiotherapy. Even if laparoscopic surgery is the first line treatment in many cases, laparotomy remains the choice procedure. Ultrasonographically-guided evacuation has to be further evaluated. Preventive treatment is of major importance.

'Non-Mendelian' genetics of fetal growth

Mendelian genetics showed that a few mutated genes, or errors in parental imprinting, can lead to major phenotypic changes (diseases) in pre-natal growth. Mendelian genetics, however, do not explain the individual subtle variability of size at birth within the normal range. Fetal growth is a complex multifactorial, multigenic trait made of various sub-traits, such as body mass, fat and muscle, brain mass, head circumference, skeletal growth of the spine and limbs. It is likely that multiple genetic factors and genomic variants are responsible for the variations of these sub-traits. A study has been launched to investigate the genetics of the variation of human birth weight, with the ultimate aim of identifying genomic variations that are within or near certain genes and are associated with variations of human height and weight at birth.

Factors associated with preterm delivery in women with type 1 diabetes: a cohort study

OBJECTIVE

The reported rate of preterm delivery in women with type 1 diabetes ranges from 22 to 45%, but the reasons are unclear. The purpose of this study was to identify factors associated with preterm delivery in these women.

RESEARCH DESIGN AND METHODS

We studied the influence of maternal and diabetes-related factors on the occurrence of preterm delivery in 168 single pregnancies occurring in 127 women with type 1 diabetes. Women with spontaneous or indicated preterm delivery were compared with those who delivered after 37 weeks of gestation using polytomous logistic regression.

RESULTS

The overall rate of preterm delivery was 24%, fivefold higher than the French prematurity rate in single pregnancy. Preterm delivery was spontaneous in 9% and indicated in 15%. HbA1c > or =7% at delivery was associated with spontaneous preterm delivery (odds ratio [OR] 5.3 [95% CI 1.1-26.8]). Nulliparity (12.0 [2.3-64.1]), progression of nephropathy (7.7 [1.3-46.9]), preeclampsia (12.0 [3.1-47.1]), and HbA1c > or =7% (7.5 [1.5-37.9]) at delivery were all associated with indicated preterm delivery. Preterm delivery was associated with significant neonatal morbidity as the risks for neonatal hypoglycemia and respiratory distress syndrome were increased by three- to sixfold compared with the reference group.

CONCLUSIONS

The rate of preterm delivery remains high in women with type 1 diabetes. Different factors were associated with spontaneous and indicated preterm delivery, respectively. Because poor glycemic control was a risk factor for both outcomes, part of preterm delivery might be preventable.