Survival and morbidity of preterm children born at 22 through 34 weeks' gestation in France in 2011: results of the EPIPAGE-2 cohort study

IMPORTANCE

Up-to-date estimates of the health outcomes of preterm children are needed for assessing perinatal care, informing parents, making decisions about care, and providing evidence for clinical guidelines.

OBJECTIVES

To determine survival and neonatal morbidity of infants born from 22 through 34 completed weeks' gestation in France in 2011 and compare these outcomes with a comparable cohort in 1997.

DESIGN, SETTING, AND PARTICIPANTS

The EPIPAGE-2 study is a national, prospective, population-based cohort study conducted in all maternity and neonatal units in France in 2011. A total of 2205 births (stillbirths and live births) and terminations of pregnancy at 22 through 26 weeks' gestation, 3257 at 27 through 31 weeks, and 1234 at 32 through 34 weeks were studied. Cohort data were collected from January 1 through December 31, 1997, and from March 28 through December 31, 2011. Analyses for 1997 were run for the entire year and then separately for April to December; the rates for survival and morbidities did not differ. Data are therefore presented for the whole year in 1997 and the 8-month and 6-month periods in 2011.

MAIN OUTCOMES AND MEASURES

Survival to discharge and survival without any of the following adverse outcomes: grade III or IV intraventricular hemorrhage, cystic periventricular leukomalacia, severe bronchopulmonary dysplasia, retinopathy of prematurity (stage 3 or higher), or necrotizing enterocolitis (stages 2-3).

RESULTS

A total of 0.7% of infants born before 24 weeks' gestation survived to discharge: 31.2% of those born at 24 weeks, 59.1% at 25 weeks, and 75.3% at 26 weeks. Survival rates were 93.6% at 27 through 31 weeks and 98.9% at 32 through 34 weeks. Infants discharged home without severe neonatal morbidity represented 0% at 23 weeks, 11.6% at 24 weeks, 30.0% at 25 weeks, 47.5% at 26 weeks, 81.3% at 27 through 31 weeks, and 96.8% at 32 through 34 weeks. Compared with 1997, the proportion of infants surviving without severe morbidity in 2011 increased by 14.4% (P < .001) at 25 through 29 weeks and 6% (P < .001) at 30 through 31 weeks but did not change appreciably for those born at less than 25 weeks. The rates of antenatal corticosteroid use, induced preterm deliveries, cesarean deliveries, and surfactant use increased significantly in all gestational-age groups, except at 22 through 23 weeks.

CONCLUSIONS AND RELEVANCE

The substantial improvement in survival in France for newborns born at 25 through 31 weeks' gestation was accompanied by an important reduction in severe morbidity, but survival remained rare before 25 weeks. Although improvement in survival at extremely low gestational age may be possible, its effect on long-term outcomes requires further studies. The long-term results of the EPIPAGE-2 study will be informative in this regard.

Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium

OBJECTIVE

A large trial published in 2000 concluded that planned vaginal delivery of term breech births is associated with high neonatal risks. Because the obstetric practices in that study differed from those in countries where planned vaginal delivery is still common, we conducted an observational prospective study to describe neonatal outcome according to the planned mode of delivery for term breech births in 2 such countries.

STUDY DESIGN

Observational prospective study with an intent-to-treat analysis to compare the groups for which cesarean and vaginal deliveries were planned. Associations between the outcome and planned mode of delivery were controlled for confounding by multivariate analysis. The main outcome measure was a variable that combined fetal and neonatal mortality and severe neonatal morbidity. The study population consisted of 8105 pregnant women delivering singleton fetuses in breech presentation at term in 138 French and 36 Belgian maternity units.

RESULTS

Cesarean delivery was planned for 5579 women (68.8%) and vaginal delivery for 2526 (31.2%). Of the women with planned vaginal deliveries, 1796 delivered vaginally (71.0%). The rate of the combined neonatal outcome measure was low in the overall population (1.59%; 95% CI [1.33-1.89]) and in the planned vaginal delivery group (1.60%; 95% CI [1.14-2.17]). It did not differ significantly between the planned vaginal and cesarean delivery groups (unadjusted odds ratio = 1.10, 95% CI [0.75-1.61]), even after controlling for confounding variables (adjusted odds ratio = 1.40, 95% CI [0.89-2.23]).

CONCLUSION

In places where planned vaginal delivery is a common practice and when strict criteria are met before and during labor, planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women.

Induction of labour versus expectant management for large-for-date fetuses: a randomised controlled trial

BACKGROUND

Macrosomic fetuses are at increased risk of shoulder dystocia. We aimed to compare induction of labour with expectant management for large-for-date fetuses for prevention of shoulder dystocia and other neonatal and maternal morbidity associated with macrosomia.

METHODS

We did this pragmatic, randomised controlled trial between Oct 1, 2002, and Jan 1, 2009, in 19 tertiary-care centres in France, Switzerland, and Belgium. Women with singleton fetuses whose estimated weight exceeded the 95th percentile, were randomly assigned (1:1), via computer-generated permuted-block randomisation (block size of four to eight) to receive induction of labour within 3 days between 37(+0) weeks and 38(+6) weeks of gestation, or expectant management. Randomisation was stratified by centre. Participants and caregivers were not masked to group assignment. Our primary outcome was a composite of clinically significant shoulder dystocia, fracture of the clavicle, brachial plexus injury, intracranial haemorrhage, or death. We did analyses by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00190320.

FINDINGS

We randomly assigned 409 women to the induction group and 413 women to the expectant management group, of whom 407 women and 411 women, respectively, were included in the final analysis. Mean birthweight was 3831 g (SD 324) in the induction group and 4118 g (392) in the expectant group. Induction of labour significantly reduced the risk of shoulder dystocia or associated morbidity (n=8) compared with expectant management (n=25; relative risk [RR] 0·32, 95% CI 0·15-0·71; p=0·004). We recorded no brachial plexus injuries, intracranial haemorrhages, or perinatal deaths. The likelihood of spontaneous vaginal delivery was higher in women in the induction group than in those in the expectant management group (RR 1·14, 95% CI 1·01-1·29). Caesarean delivery and neonatal morbidity did not differ significantly between the groups.

INTERPRETATION

Induction of labour for suspected large-for-date fetuses is associated with a reduced risk of shoulder dystocia and associated morbidity compared with expectant management. Induction of labour does not increase the risk of caesarean delivery and improves the likelihood of spontaneous vaginal delivery. These benefits should be balanced with the effects of early-term induction of labour.

FUNDING

Assistance Publique-Hôpitaux de Paris and the University of Geneva.

Customized versus population-based birth weight standards for identifying growth restricted infants: a French multicenter study

OBJECTIVE

This study was undertaken to describe the characteristics of pregnancies according to a customized definition of fetal growth restriction and to determine the association between customized standards and adverse pregnancy outcomes.

STUDY DESIGN

Two definitions of growth restriction, a population and a customized standard, were applied to 56,606 births in 5 tertiary maternity hospitals in France from 1997 to 2002. The customized definition was adjusted for maternal height and weight, parity, fetal gender, and gestational age. Odds ratios and 95% CIs for neonatal morbidity and mortality were calculated to compare small for gestational age and non-small for gestational age births.

RESULTS

By using customized standards, 2.7% of births were reclassified as small for gestational age. These births were to taller, heavier, multiparous women. Compared with non-small for gestational age births, these newly detected small-for-gestational-age newborn infants showed an increased risk of stillbirth (odds ratio = 4.52, 95% CI 2.47-8.14) and perinatal death (odds ratio = 2.60, 95% CI 1.62-4.15). These infants were also more likely to be born to women with hypertensive disease in pregnancy (7.0%) versus those reclassified as non-small for gestational age (2.3%) and those non-small for gestational age by both standards (5.5%).

CONCLUSION

These findings highlight the interest of using customized birth weight standard adjusted for maternal and neonatal characteristics to identify fetuses at risk, particularly among apparently normal fetuses. Individual growth norms should be used to define small for gestational age.

Prevalence, causes, and outcome at 2 years of age of newborn encephalopathy: population based study

OBJECTIVES

To ascertain the prevalence of newborn encephalopathy in term live births, and also the underlying diagnoses, timing, and outcome at 2 years of surviving infants.

DESIGN

Population based observational study.

SETTING

North Pas-de-Calais area of France, January to December 2000.

PATIENTS

All 90 neonates with moderate or severe newborn encephalopathy.

RESULTS

The prevalence of moderate or severe newborn encephalopathy was 1.64 per 1000 term live births (95% confidence interval (CI) 1.30 to 1.98). The prevalence of birth asphyxia was 0.86 per 1000 term live births (95% CI 0.61 to 1.10). The main cause of newborn encephalopathy was birth asphyxia, diagnosed in 47 (52%) infants. It was associated with another diagnosis in 11/47 cases (23%). The timing was intrapartum in 56% of cases, antepartum in 13%, ante-intrapartum in 10%, and postpartum in 2%. In 19% of cases, no underlying cause was identified during the neonatal course. Twenty four infants died in the neonatal period, giving a fatality rate of 27% (95% CI 17% to 36%). Three infants died after the neonatal period. At 2 years of age, 38 infants had a poor outcome, defined by death or severe disability, a prevalence of 0.69 per 1000 term live births (95% CI 0.47 to 0.91). In infants with isolated birth asphyxia, this prevalence was 0.36 per 1000 term live births (95% CI 0.20 to 0.52).

CONCLUSIONS

The causes of newborn encephalopathy were heterogeneous but the main one was birth asphyxia. The prevalence was low, but the outcome was poor, emphasising the need for prevention programmes and new therapeutic approaches.

Fetal macrosomia: risk factors and outcome. A study of the outcome concerning 100 cases >4500 g

OBJECTIVE

Because difficult vaginal delivery is more frequent with macrosomic fetuses, some authors recommend routine caesarean section for the delivery of fetuses >4500 g. The purpose of this study was to evaluate the appropriateness of this recommendation, in particular, to analyze maternal and fetal complications according to the mode of delivery.

METHOD

Maternal and neonatal records of 100 infants with weights of at least 4500 g were identified retrospectively from January 1991 to December 1996. Outcome variables included the mode of delivery and the incidence of maternal and perinatal complications.

RESULTS

The study sample consisted of 100 infant and mother pairs. Macrosomic fetuses represented 0.95% of all deliveries during this period and only ten were >5000 g. Mean birth weight was 4730 g (maximum, 5780 g). Gestational diabetes was present in nineteen patients. Diabetes was present in three patients. A trial of labour was allowed in 87 women, and elective caesarean delivery was performed in thirteen patients. The overall cesarean rate, including elective caesarean delivery and failed trial of labour, was 36%. Of those undergoing a trial of labour, 73% (64/87) delivered vaginally. Shoulder dystocia occurred fourteen times (22% of vaginal deliveries) and it was the most frequent complication in our series. There were five cases of Erb's palsy, one of which was associated with humeral fracture, and four cases of clavicular fracture. By three months of age, all affected infants were without sequelae. There was no related perinatal mortality and only two cases of birth asphyxia. Maternal complications with vaginal delivery of macrosomic infants included a high incidence of lacerations requiring repair (eleven cases). No complications were noticed in the patients who had a caesarean section.

CONCLUSION

Vaginal delivery is a reasonable alternative to elective cesarean section for infants with estimated birth weights of less than 5000 g and a trial of labour can be offered. For the fetuses with estimated birth weight >5000 g, an elective caesarean section should be recommended, especially in primiparous women.

Previous induced abortions and the risk of very preterm delivery: results of the EPIPAGE study

OBJECTIVES

To evaluate the risk of very preterm birth (22-32 weeks of gestation) associated with previous induced abortion according to the complications leading to very preterm delivery in singletons.

DESIGN

Multicentre, case-control study (the French EPIPAGE study).

SETTING

Regionally defined population of births in France.

SAMPLE

The sample consisted of 1943 very preterm live-born singletons (< 33 weeks of gestation), 276 moderate preterm live-born singletons (33-34 weeks) and 618 unmatched full-term controls (39-40 weeks).

METHODS

Data from the EPIPAGE study were analysed using polytomous logistic regression models to control for social and demographic characteristics, lifestyle habits during pregnancy and obstetric history. The main mechanisms of preterm delivery were classified as gestational hypertension, antepartum haemorrhage, fetal growth restriction, premature rupture of membranes, idiopathic preterm labor and other causes.

MAIN OUTCOME MEASURES

Odds ratios for very preterm birth by gestational age and by pregnancy complications leading to preterm delivery associated with a history of induced abortion.

RESULTS

Women with a history of induced abortion were at higher risk of very preterm delivery than those with no such history (OR + 1.5, 95% CI 1.1-2.0); the risk was even higher for extremely preterm deliveries (< 28 weeks). The association between previous induced abortion and very preterm delivery varied according to the main complications leading to very preterm delivery. A history of induced abortion was associated with an increased risk of premature rupture of the membranes, antepartum haemorrhage (not in association with hypertension) and idiopathic spontaneous preterm labour that occur at very small gestational ages (< 28 weeks). Conversely, no association was found between induced abortion and very preterm delivery due to hypertension.

CONCLUSION

Previous induced abortion was associated with an increased risk of very preterm delivery. The strength of the association increased with decreasing gestational age.

Early clindamycin for bacterial vaginosis in pregnancy (PREMEVA): a multicentre, double-blind, randomised controlled trial

BACKGROUND

Preterm delivery during pregnancy (<37 weeks' gestation) is a leading cause of perinatal mortality and morbidity. Treating bacterial vaginosis during pregnancy can reduce poor outcomes, such as preterm birth. We aimed to investigate whether treatment of bacterial vaginosis decreases late miscarriages or spontaneous very preterm birth.

METHODS

PREMEVA was a double-blind randomised controlled trial done in 40 French centres. Women aged 18 years or older with bacterial vaginosis and low-risk pregnancy were eligible for inclusion and were randomly assigned (2:1) to three parallel groups: single-course or triple-course 300 mg clindamycin twice-daily for 4 days, or placebo. Women with high-risk pregnancy outcomes were eligible for inclusion in a high-risk subtrial and were randomly assigned (1:1) to either single-course or triple-course clindamycin. The primary outcome was a composite of late miscarriage (16-21 weeks) or spontaneous very preterm birth (22-32 weeks), which we assessed in all patients with delivery data (modified intention to treat). Adverse events were systematically reported. This study is registered with ClinicalTrials.gov, number NCT00642980.

FINDINGS

Between April 1, 2006, and June 30, 2011, we screened 84 530 pregnant women before 14 weeks' gestation. 5630 had bacterial vaginosis, of whom 3105 were randomly assigned to groups in the low-risk trial (n=943 to receive single-course clindamycin, n=968 to receive triple-course clindamycin, and n=958 to receive placebo) or high-risk subtrial (n=122 to receive single-course clindamycin and n=114 to receive triple-course clindamycin). In 2869 low-risk pregnancies, the primary outcome occurred in 22 (1·2%) of 1904 participants receiving clindamycin and 10 (1·0%) of 956 participants receiving placebo (relative risk [RR] 1·10, 95% CI 0·53-2·32; p=0·82). In 236 high-risk pregnancies, the primary outcome occurred in 5 (4·4%) participants in the triple-course clindamycin group and 8 (6·0%) participants in the single-course clindamycin group (RR 0·67, 95% CI 0·23-2·00; p=0·47). In the low-risk trial, adverse events were more common in the clindamycin groups than in the placebo group (58 [3·0%] of 1904 vs 12 [1·3%] of 956; p=0·0035). The most commonly reported adverse event was diarrhoea (30 [1·6%] in the clindamycin groups vs 4 [0·4%] in the placebo group; p=0·0071); abdominal pain was also observed in the clindamycin groups (9 [0·6%] participants) versus none in the placebo group (p=0·034). No severe adverse event was reported in any group. Adverse fetal and neonatal outcomes did not differ significantly between groups in the high-risk subtrial.

INTERPRETATION

Systematic screening and subsequent treatment for bacterial vaginosis in women with low-risk pregnancies shows no evidence of risk reduction of late miscarriage or spontaneous very preterm birth. Use of antibiotics to prevent preterm delivery in this patient population should be reconsidered.

FUNDING

French Ministry of Health.

Prolonged and post-term pregnancies: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF)

The duration of pregnancy varies between 40(+0) and 41(+3) weeks. Conventionally, and essentially arbitrarily, a pregnancy is considered to be "prolonged" after 41(+0) weeks, but the infant is not considered "post-term" until 42(+0) weeks (Professional consensus). A term birth thus occurs during the period from 37(+0) to 41(+6) weeks. In France, prolonged pregnancies (≥41(+0)weeks) involve 15-20% of pregnant women, and post-term pregnancies (≥42(+0) weeks) approximately 1%. The frequency of post-term pregnancies is very heterogeneous: in Europe and the United States, it ranges from 0.5% to 10% according to country. In prolonged pregnancies, the cesarean section rate-especially the emergency cesarean rate-is multiplied by approximately 1.5 (grade B). From 37(0-6) to 43(0-6) weeks, the risk of perinatal mortality increases regularly, from 0.7‰ to 5.8‰. Meconium aspiration syndrome is responsible for substantial morbidity and mortality, and its incidence increases regularly between 38(+0) and 42(+6) weeks, from 0.24‰ to 1.42‰ (grade B). Similarly, the risks of neonatal acidosis (grade B), 5-min Apgar scores less than 7 (grade B) and admissions to neonatal intensive care (grade B) increase progressively between 38(+0) and 42(+6) weeks. These risks appear to double for post-term growth-restricted newborns (grade C). Ultrasound dating of the pregnancy makes it possible to reduce the risk that it will be incorrectly considered prolonged and that labor will therefore be induced unnecessarily. To harmonize practices, if the crown-rump length (CRL) is correctly measured (this measurement should be taken between 11(+0) and 13(+6) weeks, when CRL should measure from 45 to 84mm), ultrasound dating based on it should be used to determine the official date pregnancy began, regardless of its difference from the date assumed by the patient or estimated based on the date of the last menstrual period. This rule does not apply to pregnancies by IVF, for which the date pregnancy began is defined by the date of oocyte retrieval (Professional consensus). From 37(0-6) to 43(0-6) weeks, the risk of perinatal mortality increases regularly and there is no threshold at which a clear increase in perinatal mortality becomes visible. Fetal monitoring by cardiotocography (CTG) that begins at 41(+0) weeks would cover approximately 20% of women and reduce perinatal morbidity compared with monitoring that begins at 42(+0) weeks (grade C). The frequency recommended for this monitoring ranges between two and three times a week (Professional consensus). For ultrasonography assessment, measurement of the largest fluid pocket is recommended, because measurement of the amniotic fluid index (that is, the sum of the four quadrants) is accompanied by more diagnoses of oligohydramnios, inductions of labor, and cesareans for fetal distress without any improvement in neonatal prognosis (grade A). The practice of assessing the Manning biophysical score increases the number of diagnoses of oligohydramnios and fetal heart rage (FHR) abnormalities and generates an increase in the rates of inductions and cesareans without improving neonatal prognosis. The use of this biophysical score in monitoring prolonged pregnancies is therefore not recommended (grade B). In the absence of a specific disorder, induction of labor can be proposed in patients between 41(+0) and 42(+6) weeks (grade B). Nonetheless, the choice of prolongation beyond above 42(+0) weeks appears to involve an increase in fetal risk, which must be explained to the patient and balanced against the potential disadvantages of induction (Professional consensus). Stripping the membranes can reduce the duration of pregnancy by increasing the number of patients going into labor spontaneously during the week afterward (grade B). Compared to an expectant approach, it does not increase the cesarean section rate (grade A). It reduces recourse to induction by 41% at 41(+0) weeks and by 72% at 42(+0) weeks (grade B), without increasing the risk of either membrane rupture or maternal or neonatal infection (grade B). Used as a tampon or vaginal gel, prostaglandins E2 (PGE2) are an effective method of inducing labor (grade A). They can be used to induce labor successfully, regardless of cervical ripeness (grade A). If misoprostol is chosen, the lowest dose is to be preferred, starting with a vaginal dose of 25μg every 3-6h (grade A). For misoprostol, more powerful studies remain necessary for better defining the doses, routes of administration, tolerance and indications. Misoprostol at any dose is contraindicated in women with uterine scars (grade B). Placement of an intracervical Foley catheter is an effective mechanical means of inducing labor, with less uterine hyperstimulation than prostaglandins and no increase in the cesarean section rate (grade A). Nonetheless, as the risk of infection might be increased, this technique requires more robust evaluation before entering general practice (grade B). In cases of meconium-stained amniotic fluid, pharyngeal aspiration before delivery of the shoulders is not recommended (grade A). The team managing a post-term newborn with meconium-stained amniotic fluid at birth must know how to perform intubation and, if the intubation is not helpful, endotracheal aspiration (grade C) and ventilation with a mask. Routine endotracheal intubation of a vigorous newborn is not recommended (grade A).

Apoptosis: a programmed cell death involved in ovarian and uterine physiology

Apoptosis is a form of programmed cell death which occurs through the activation of a cell-intrinsic suicide machinery. The biochemical machinery responsible for apoptosis is expressed in most, if not all, cells. Contrary to necrosis, an accidental form of cell death, apoptosis does not induce inflammatory reaction noxious for the vicinity. Apoptosis is primarily a physiologic process necessary to remove individual cells that are no longer needed or that function abnormally. Apoptosis plays a major role during development, homeostasis. Many stimuli can trigger apoptotic cell death, but expression of genes can modulate the sensibility of the cell. The aim of this review is to summarise current knowledge of the molecular mechanisms of apoptosis and its roles in human endometrium and ovary physiology.

Effects of birth weight of alcohol and caffeine consumption during pregnancy

The aim of this study was to investigate the effect of alcohol and caffeine consumption on birth weight and the possible interaction of these substances with smoking. The sample included 628 women who were interviewed at their first visit to the maternity hospital of Roubaix, France, in 1985-1986. A significant reduction in birth weight was found to be associated with an average daily alcohol consumption of three drinks or more after gestational age, infant sex, maternal age, parity, weight, and height, and cigarette smoking had been controlled for. There was no interaction between smoking and alcohol consumption on birth weight, but a significant relation between alcohol consumption and birth weight was observed among nonsmokers as well as heavy smokers. The relation observed between caffeine and birth weight disappeared after adjustment for smoking. Our results indicate that alcohol reduces birth weight, but do not support the hypothesis of an interaction between smoking and alcohol consumption.

Preterm premature rupture of membranes at 22-25 weeks' gestation: perinatal and 2-year outcomes within a national population-based study (EPIPAGE-2)

BACKGROUND

Most clinical guidelines state that with early preterm premature rupture of membranes, obstetric and pediatric teams must share a realistic and individualized appraisal of neonatal outcomes with parents and consider their wishes for all decisions. However, we currently lack reliable and relevant data, according to gestational age at rupture of membranes, to adequately counsel parents during pregnancy and to reflect on our policies of care at these extreme gestational ages.

OBJECTIVE

We sought to describe both perinatal and 2-year outcomes of preterm infants born after preterm premature rupture of membranes at 22-25 weeks' gestation.

STUDY DESIGN

EPIPAGE-2 is a French national prospective population-based cohort of preterm infants born in 546 maternity units in 2011. Inclusion criteria in this analysis were women diagnosed with preterm premature rupture of membranes at 22-25 weeks' gestation and singleton or twin gestations with fetus(es) alive at rupture of membranes. Latency duration, antenatal management, and outcomes (survival at discharge, survival at discharge without severe morbidity, and survival at 2 years' corrected age without cerebral palsy) were described and compared by gestational age at preterm premature rupture of membranes.

RESULTS

Among the 1435 women with a diagnosis of preterm premature rupture of membranes, 379 were at 22-25 weeks' gestation, with 427 fetuses (331 singletons and 96 twins). Median gestational age at preterm premature rupture of membranes and at birth were 24 (interquartile range 23-25) and 25 (24-27) weeks, respectively. For each gestational age at preterm premature rupture of membranes, nearly half of the fetuses were born within the week after the rupture of membranes. Among the 427 fetuses, 51.7% were survivors at discharge (14.1%, 39.5%, 66.8%, and 75.8% with preterm premature rupture of membranes at 22, 23, 24, and 25 weeks, respectively), 38.8% were survivors at discharge without severe morbidity, and 46.4% were survivors at 2 years without cerebral palsy, with wide variations by gestational age at preterm premature rupture of membranes. Survival at 2 years without cerebral palsy was low with preterm premature rupture of membranes at 22 and 23 weeks but reached approximately 60% and 70% with preterm premature rupture of membranes at 24 and 25 weeks.

CONCLUSION

Preterm premature rupture of membranes at 22-25 weeks is associated with high incidence of mortality and morbidity, with wide variations by gestational age at preterm premature rupture of membranes. However, a nonnegligible proportion of children survive without severe morbidity both at discharge and at 2 years' corrected age.

Immediate and delayed effects of antenatal corticosteroids on fetal heart rate: a randomized trial that compares betamethasone acetate and phosphate, betamethasone phosphate, and dexamethasone

OBJECTIVE

The purpose of this study was to evaluate the role of different formulations and different administration kinetics of antenatal corticosteroid therapy on fetal heart rate.

STUDY DESIGN

One hundred five patients who were at high risk for preterm delivery were assigned randomly to receive two injections of betamethasone acetate + phosphate, four injections of betamethasone phosphate, or four injections of dexamethasone phosphate. Computerized fetal heart rate was recorded daily through day 4.

RESULTS

The three formulations did not differ in their effect on fetal heart rate, which varied significantly as a function of the time of injection. During treatment (day 0-day 1), fetal heart rate variability increased (+9%, P <.05), as did the number of fetal movements felt by the mother (+60% at day 0, P <.001). After treatment (day 2-day 3), variability fell significantly (-14%, P <.01), as did accelerations (-35% at day 2, P <.01). No modifications were still detectable on day 4.

CONCLUSION

Antenatal corticotherapy is responsible for two different phases of fetal heart rate modifications that do not vary according to the corticosteroid or the dosage regimen.

Acute pulmonary oedema during nicardipine therapy for premature labour; Report of five cases

We report five maternal cases of acute pulmonary oedema which occurred during treatment with nicardipine for tocolysis.

Chronic histiocytic intervillositis: outcome, associated diseases and treatment in a multicenter prospective study

Introduction: In this prospective multicenter study, we aimed to describe (1) the outcome of pregnancy in the case of previous chronic histiocytic intervillositis (CHI), (2) the immunological findings and associated diseases, (3) the treatments, and (4) the factors associated with pregnancy loss.

METHODS

We prospectively included all patients with a prior CHI with ongoing pregnancy between 2011 and 2013.

RESULTS

Twenty-four women (age 34±5 years) were included in this study. An autoimmune disease was present in seven (29%) cases. Twenty-one prospective pregnancies were treated. The number of live births was more frequent comparatively to the previous obstetrical issues (16/24 versus 24/76; p=0.003). Most of the pregnancies were treated (88%), whereas only 13% of previous pregnancies were treated (p<0.05). No difference was found with respect to the pregnancy outcome in the different treatment regimens. In univariate analyses, a prior history of intrauterine death and intrauterine growth restriction and the presence of CHI in prospective placentas were associated with failure to have a live birth.

DISCUSSION

In this multicenter study, we show the frequency of the associated autoimmune diseases in CHI, as well as the presence of autoantibodies without characterized autoimmune disease. The number of live births increased from 32% to 67% in the treated pregnancies. Despite the treatment intervention, the risk of preterm delivery remained at 30%. Last, we show that the recurrence rate of an adverse pregnancy outcome persisted at 30% despite treatment intervention.

CONCLUSION

CHI is associated with high recurrence rate and the combined regimen seems to be necessary, in particular, in the presence of previous intrauterine death.

Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery

OBJECTIVES

Uterine rupture is a rare but potentially catastrophic complication of pregnancy that requires rapid diagnosis. Classically, its signs and symptoms combine pain, fetal heart rate (FHR) abnormalities, and vaginal bleeding. The purpose of this study is to identify these signs and symptoms as well as the immediate complications of complete and incomplete (partial) ruptures of the uterine wall, whether or not they follow a previous cesarean delivery.

STUDY DESIGN

Retrospective study of case records from two university hospital maternity units, from 1987 to 2008.

RESULTS

In a total of 97,028 births during the study period, we identified 52 uterine ruptures (0.05%): 25 complete and 27 partial. Most (89%) occurred in women with a previous cesarean delivery. In complete ruptures, FHR abnormalities were the most frequent sign (82%), while the complete triad of FHR abnormalities-pain-vaginal bleeding was present in only 9%. The signs and symptoms of partial ruptures were very different; these were asymptomatic in half the cases (48%). Neonatal mortality reached 13.6% among the complete ruptures; 27 and 40% of these newborns had pH<6.80 and pH<7.0, respectively. Among the incomplete ruptures, only 7.7% of the newborns had a pH<7.0 and there were no deaths.

CONCLUSION

Although complete rupture of the uterus has a severe neonatal prognosis, the complete set of standard symptoms is present in less than 10% of cases. FHR abnormalities are by far the most frequent sign.

Impact of Latency Duration on the Prognosis of Preterm Infants after Preterm Premature Rupture of Membranes at 24 to 32 Weeks' Gestation: A National Population-Based Cohort Study

OBJECTIVE

To assess the impact of latency duration on survival, survival without severe morbidity, and early-onset sepsis in infants born after preterm premature rupture of membranes (PPROM) at 24-32 weeks' gestation.

STUDY DESIGN

This study was based on the prospective national population-based Etude Épidémiologique sur les Petits Ȃges Gestationnels 2 cohort of preterm births and included 702 singletons delivered in France after PPROM at 24-32 weeks' gestation. Latency duration was defined as the time from spontaneous rupture of membranes to delivery, divided into 4 periods (12 hours to 2 days [reference], 3-7 days, 8-14 days, and >14 days). Multivariable logistic regression was used to assess the relationship between latency duration and survival, survival without severe morbidity at discharge, or early-onset sepsis.

RESULTS

Latency duration ranged from 12 hours to 2 days (18%), 3-7 days (38%), 8-14 days (24%), and >14 days (20%). Rates of survival, survival without severe morbidity, and early-onset sepsis were 93.5% (95% CI 91.8-94.8), 85.4% (82.4-87.9), and 3.4% (2.0-5.7), respectively. A crude association found between prolonged latency duration and improved survival disappeared on adjusting for gestational age at birth (aOR 1.0 [reference], 1.6 [95% CI 0.8-3.2], 1.2 [0.5-2.9], and 1.0 [0.3-3.2] for latency durations from 12 hours to 2 days, 3-7 days, 8-14 days, and >14 days, respectively). Prolonged latency duration was not associated with survival without severe morbidity or early-onset sepsis.

CONCLUSION

For a given gestational age at birth, prolonged latency duration after PPROM does not worsen neonatal prognosis.

Long-term prognosis for infants after massive fetomaternal hemorrhage

OBJECTIVE

To evaluate the fetal, neonatal, and long-term prognosis of massive fetomaternal hemorrhage (20 mL or more).

METHODS

This series includes all patients with Kleihauer test values of 40 per 10,000 or higher over an 8-year period at two university hospitals. We examined obstetric, neonatal, and subsequent outcome data for the children.

RESULTS

During the study period, 48 patients had massive fetomaternal hemorrhage (crude incidence 1.1 per 1,000; corrected incidence for Rh-negative women 4.6 per 1,000). Six fetal deaths were observed, representing 1.6% of all fetal deaths during the period. Nine newborns (18.7%) were transferred to neonatal intensive care unit (NICU) and five (10.4%) had transfusions. Fetomaternal hemorrhages of 20 mL/kg or more significantly increased the risk of fetal death, induced preterm delivery, transfer to NICU, and neonatal anemia requiring transfusion. Long-term follow-up was not associated with neurological sequelae (0%, 95% confidence interval 0.0-11.6%).

CONCLUSION

When the transfused volume equals or exceeds 20 mL/kg, massive fetomaternal hemorrhage may lead to severe prenatal or neonatal complications.

LEVEL OF EVIDENCE

III.

Thrombotic thrombocytopenic purpura: medical and biological monitoring of six pregnancies

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) is a rare cause of severe thrombocytopenia in pregnancy.

METHODS

Six pregnancies in five patients with TTP were followed prospectively over 5 years. Ultralarge von Willebrand factor (ULvWF) multimers and cleaving protease (cp) levels were measured.

RESULTS

TTP relapsed, complicating four of the six pregnancies. Of three patients who relapsed, two had complete or partial vWF-cleaving protease (vWF-cp) deficiency, and one had a normal vWF-cleaving protease level. In all three we found abnormal UL multimers. The two women who did not relapse had normal vWF-cleaving protease level and an absence or loss of UL multimers.

CONCLUSIONS

Pregnant patients with a history of TTP must be followed in a tertiary obstetric unit with plasmapheresis available. Influence of vWF-cleaving protease and vWF multimeric abnormalities on TTP relapsing during pregnancy has to be evaluated in a further multicentre study.

Management of threatened preterm delivery in France: a national practice survey (the EVAPRIMA study)

OBJECTIVES

To describe the management of threatened preterm delivery (TPD) in France 3 years after publication of the French guidelines and to analyse the factors of variation of the practices observed.

DESIGN

Population-based study.

SETTING

Representative sample of French maternity units. The study included 107 hospitals, accounting for 20% of all French maternity units.

POPULATION

Women hospitalised for TPD during May 2005.

METHODS

Cross-sectional national practice survey.

RESULTS

Of the 734 admissions for TPD, 12.1% involved premature rupture of membranes and 12.9% were in utero transfers. Women admitted for TPD accounted for roughly 6% of all annual deliveries, regardless of the unit's level of care, and 42.4% of these women delivered preterm: none delivered before 32 weeks in level 1 maternity units, 11.6% in level 2 and 88.4% in level 3. Transvaginal cervical ultrasound was performed for 54.5% of the women with intact membranes. Tocolysis was administered in 87.1% of women with intact membranes, with 45.6% of such women receiving this intervention for longer than 48 hours. First-line tocolytics used were calcium channel blockers (53.7%), beta-agonists (34.7%) or atosiban (8.8%), but their distribution differed substantially according to level of care. Maintenance tocolysis was administered to 385 women (59.8%) with intact membranes. Of the women admitted before 34 weeks, 21.1% did not receive corticosteroids.

CONCLUSIONS

Practices for the management of TPD vary widely and appear to depend on the level of care. Some practices appear less than optimal, especially those related to duration of tocolysis, maintenance tocolysis, antenatal corticosteroid and use of cervical ultrasound.

Survival analysis of fertility after ectopic pregnancy

OBJECTIVE

To evaluate the reproductive outcome after ectopic pregnancy and to assess the contribution of risk factors to future fertility.

DESIGN

Prospective follow-up in a population-based sample.

SETTING

Register of ectopic pregnancies established in an urban area around Lille, France.

PATIENT(S)

Three hundred and twenty-eight women treated between April 1994 and March 1997 who had not been using an IUCD at the time of the ectopic pregnancy and were trying to become pregnant.

INTERVENTION(S)

Interviews by telephone every 6 months for 2 years and once yearly thereafter.

MAIN OUTCOME MEASURE(S)

Cumulative pregnancy rate.

RESULT(S)

Two hundred fifteen (65.5%) women became pregnant after a mean of 5 months. One hundred eighty-two (84.7%) pregnancies were intrauterine; 22 (10.2%) were recurrent ectopic pregnancies; and in 11 women (5.1%), it was too early to define implantation. The cumulative intrauterine pregnancy rate was 56% at 1 year and 67% at 2 years. After applying Cox regression, three factors associated with fertility seemed to decrease reproductive performance: age > 35 years, history of infertility, and anterior tubal damage .

CONCLUSION(S)

More than half of the women treated for ectopic pregnancy spontaneously conceived and had a normally progressive pregnancy at 1 year. Fertility depends more on established patient characteristics than characteristics of ectopic pregnancy itself or treatment thereof.