C. Le Ray

Association between oocyte donation and maternal and perinatal outcomes in women aged 43 years or older

BACKGROUND Although older maternal age is a risk factor for pregnancy complications, an increasing number of women delay conception until the age of 40, and some must resort to IVF with oocyte donation. Our objective was to study the association between IVF, both with and without oocyte donation, and maternal and perinatal outcomes in a population of older women. METHODS This retrospective study covered all women, aged 43 or more, who gave birth between 2008 and 2010. Univariate and multivariate analyses with logistic regression models were used to compare maternal and perinatal outcomes as a function of mode of conception: without IVF, with IVF using own oocytes or with IVF and oocyte donation. RESULTS The study included 380 women, including 40 who had IVF without oocyte donation (10.5%) and 104 who had both (27.4%). There were 326 singleton and 54 multiple pregnancies. Overall, the complication rate was high: 8.7% pre-eclampsia, 6.1% gestational diabetes, 20.2% preterm delivery and 8.2% very preterm delivery (before 33 weeks), 44.8% Cesarean sections and 7.4% severe post-partum hemorrhage (PPH). The pre-eclampsia rate differed significantly between the groups (3.8% after no IVF, 10.0% after IVF only and 19.2% after IVF with oocyte donation, P< 0.001). After adjustment, the risk of pre-eclampsia was significantly higher in women with donated oocytes compared with pregnant women without IVF [adjusted OR = 3.3 (1.2-8.9)]. The rate of twin pregnancy was significantly higher in women with IVF and oocyte donation (39.4 versus 15.0% with IVF only and 2.5% without IVF, P< 0.001). Twin pregnancy was significantly associated with the risk of preterm delivery [adjusted OR = 8.9 (4.0-19.9)] and PPH [adjusted OR = 3.5 (1.3-9.5)]. CONCLUSION In women aged 43 years or older, pregnancies obtained by IVF with oocyte donation are associated with higher rates of pre-eclampsia and twin pregnancies than those obtained without IVF or with IVF using their own oocytes.

Trends in perinatal health in metropolitan France from 1995 to 2016: Results from the French National Perinatal Surveys

OBJECTIVE To study trends in the main indicators of perinatal health, medical practices and risk factors in France since 1995. POPULATION AND METHOD All live births during one week in 1995 (n=13,318), 2003 (n=14,737), 2010 (n=14,903) and 2016 (n=13,384). Data were from interviews of women in postpartum wards and from medical records and were compared between years. RESULTS Between 1995 and 2016, maternal age and body mass index increased steadily. Pregnancies that occurred with use of contraception increased from 7.4% in 2010 to 9.3% in 2016. Smoking during pregnancy (16.6%) did not decrease since 2010. The frequency of more than three ultrasounds during pregnancy was 48.5% in 1995 and 74.7% in 2016. Deliveries in large public hospitals increased steadily. The caesarean section rate has been relatively stable since 2003 (20.4% in 2003, 21.1% in 2010 and 20.4% in 2016). The rate of induction of labour was 22% in 2010 and 2016. Overall, 83.8% of women had epidural analgesia/anaesthesia in 2016. Rates of pre-term birth in 2016 ranged from 7.5% among all live births to 6.0% among live born singletons; for singletons, this rate increased steadily from 1995 to 2016, whereas there was no clear trend for low birth weight. Exclusive breastfeeding decreased from 60.3% in 2010 to 52.2% in 2016. CONCLUSION Routine national perinatal surveys highlight successful policies and recommendations but also point out some health indicators, practices, preventive behaviours and risk factors that need special attention.

Oxytocin administration during spontaneous labor: Guidelines for clinical practice. Guidelines short text

C. Dupont *, M. Carayol , C. Le Ray , C. Deneux-Tharaux , D. Riethmuller , the Clinical practice guidelines group a AURORE Perinatal Network, Lyon university hospital, pôle IMER, 69003 Lyon, France b University Lyon, Claude-Bernard Lyon 1 university, health services and performance research (HESPER), EA 7425, 69008 Lyon, France c Mother and child protection services, Paris Direction of Family and Early Childhood, Paris City Hall, 75014 Paris, France d Port-Royal maternity unit, Cochin hospital, AP–HP, DHU risks in pregnancy, Paris Descartes university, 75014 Paris, France e Inserm UMR 1153, obstetrical, perinatal and pediatric epidemiology research team (Epopé), center for epidemiology and statistics Sorbonne Paris Cité (CRESS), DHU risks in pregnancy, Paris Descartes university, 75014 Paris, France f Besançon university hospital, 3, boulevard Fleming, 25000 Besançon, France

Classification de Robson : un outil d’évaluation des pratiques de césarienne en France

OBJECTIVE To give a description of caesarean rates in France in 2010 using Robson classification, to assess practices according to the level of care of the maternity units. MATERIALS AND METHODS The study population was the sample of the French National Perinatal Survey in 2010 (n=14,165). Data were stratified by the level of care of the maternity unit (1, 2 or 3). Women were classified in 12 groups according to Robson classification, using maternal characteristics and obstetrical history. In each level of care, we calculated for each group, its relative size, its crude caesarean rate and its contribution to the overall caesarean rate. RESULTS The overall rate of caesarean in 2010 in France was 20.8% in level 1, 21.1% in level 2 and 20.0% in level 3 maternity units. In the three levels, the main contributors to the overall caesarean rate were primiparous women in spontaneous labour (group 1; contribution: 3.5% in level 1 units, 2.2% in level 2 units, 2.7% in level 3 units) or with induced labour (group 2a; contribution: 2.9, 2.5 and 3.0%, respectively) and multiparous women with previous caesarean (group 5; contribution: 5.8, 5.3 and 6.0%, respectively). Premature singletons (group 10) contributed to 0.8% to the overall caesarean rate in level 1 units, 1.4% in level 2 units and 3.5% in level 3 units. CONCLUSION The Robson classification is easy to use. Each maternity unit can compare its rates with those of units with similar level, to find whether some groups of women have very high rates of caesarean sections.

Elective induction of labour and maternal request: a national population‐based study

To estimate the rate of elective inductions in France and the proportion of them that were maternally requested, and to study the factors associated with elective inductions that were or were not requested by women.

Conduite à tenir en cas de dystocie des épaules

OBJECTIVE The objective of this review is to propose recommendations on the management of shoulder dystocia. MATERIALS AND METHODS The PubMed database, the Cochrane Library and the recommendations from the foreign obstetrical societies or colleges have been consulted. RESULTS In case of shoulder dystocia, if the obstetrician is not present at delivery, he should be systematically informed as quickly as possible (professional consensus). A third person should also be called for help in order to realize McRoberts maneuver (professional consensus). The patient has to be properly installed in gynecological position (professional consensus). It is recommended not to pull excessively on the fetal head (grade C), do not perform uterine expression (grade C) and do not realize inverse rotation of the fetal head (professional consensus). McRoberts maneuver, with or without a suprapubic pressure, is simple to perform, effective and associated with low morbidity, thus, it is recommended in the first line (grade C). Regarding the maneuvers of the second line, the available data do not suggest the superiority of one maneuver in relation to another (grade C). We proposed an algorithm; however, management should be adapted to the experience of the operator. If the posterior shoulder is engaged, Woods maneuver should be performed preferentially; if the posterior shoulder is not engaged, delivery of the posterior arm should be performed preferentially (professional consensus). Routine episiotomy is not recommended in shoulder dystocia (professional consensus). Other second intention maneuvers are described. It seems necessary to know at least two maneuvers to perform in case of shoulder dystocia unresolved by the maneuver McRoberts (professional consensus). CONCLUSION All physicians and midwives should know and perform obstetric maneuvers if needed quickly but without precipitation.

Anomalies du RCF précocement au cours du travail : intérêt du pH au scalp

OBJECTIVE When fetal heart rate (FHR) abnormalities occur early during the first stage of labour, the risk of caesarean increases. In this study, we assessed the value of fetal scalp pH sampling on delivery mode, among women with FHR abnormalities before or at 5 cm cervical dilatation. METHODS It is a retrospective observational study setting in a tertiary maternity center. All women with a live singleton cephalic fetus at term, who had a fetal scalp pH sampling, between January and July 2009, were included. We compared vaginal delivery and neonatal morbidity rates according to cervical dilatation at the time of the first fetal scalp pH sampling (≤ 5 or >5 cm). Neonatal morbidity was defined by pH at birth less or equal to 7.10 and/or 5 minutes Apgar score less or equal to 7 and/or neonatal transfer. RESULTS During the study period, 108 women had at least one fetal scalp pH sampling, 8.5% of eligible women. Forty-six (42.6%) had a first pH at or before 5 cm cervical dilatation. The vaginal delivery rate was 62% and increased with increasing cervical dilatation at the time of the first fetal scalp pH (P<0.001). Among women who had fetal scalp pH early during the first stage of labour (≤ 5 cm), 50% delivered vaginally versus 71% when the fetal scalp pH was performed after 5 cm (P=0.026). The frequency of pH at birth less or equal to 7.10 was lower when the fetal scalp pH was performed before or at 5 cm (4.4% versus 16.9%, P=0.04). Neonatal morbidity rates were similar in both groups. CONCLUSION In this study, when FHR abnormalities occur early during the first stage of labour, use of fetal scalp pH sampling allows a vaginal delivery in half of cases without an increase in neonatal morbidity.

Les risques périnataux sont-ils plus importants après don d’ovocytes à l’étranger ?

OBJECTIVES In France, egg donation is covered by Social insurance among women<43 years old. Because of shortage of egg donor, women aged 43 years or more cannot resort to egg donation in French infertility centers, leading them to turn to the foreign centers having practices different and less regulated than in France. We are thus brought to take care of the pregnancy and of the delivery of these women. Our objective was to estimate if the perinatal risks are more important after egg donation abroad than in case of egg donation in a French center. MATERIAL AND METHODS Retrospective study between January, 2010 and April, 2013, comparing women having had an egg donation to Cochin then having delivered in the maternity hospital of their choice (n=88) and the women having had an egg donation abroad then having delivered in the Port-Royal maternity (n=121). First, the modalities of egg donation were compared between the Cochin hospital and the foreign centers. Second, the obstetric and perinatal outcomes were compared between both groups, then by stratifying according to the type of pregnancy (singleton or multiple). RESULTS Among women having had an egg donation abroad, the age of the donor was lower (25.7 vs. 31.7, P=0.001), the average number of embryos transferred higher (2.1±0.6 vs. 1.7±0.5, P=0.001) and the rate of multiple pregnancies higher (47.9% vs. 9.1%, P=0.001) than among women having had an egg donation at Cochin. We observed after egg donation abroad compared to egg donation at Cochin, a birth weight significantly lower (2678±745g vs. 3045±682g, P=0.001) and a prevalence of intrauterine growth retardation higher (11.1% vs. 4.2%, P=0.04). Among singletons, abnormal placentation was more frequent in case of egg donation abroad (17.5% vs. 5.1%, P=0.02). In case of twin pregnancy, we highlighted very high rates of complications, without significant difference according to the place where egg donation was practiced. CONCLUSION We observed an increased risk of intrauterine growth retardation after egg donation abroad, which could essentially be explained by the association between advanced maternal age and multiple gestation. For other obstetric and perinatal complications, the differences between both groups were less important than expected, but very high in both groups, whether the egg donation was realized in France or abroad. The complications seem mainly due to the multiple gestations, justifying the transfer of a single embryo whenever possible.

pH au scalp pendant le travail : quel seuil décisionnel pour intervenir ?

OBJECTIVE In case of abnormal fetal heart rate, there is no consensus on the decision threshold pH scalp leading to a rapid birth. The objective of this study was to compare neonatal issues and cesarean rate in two maternity using different decision thresholds of scalp pH. MATERIAL AND METHODS A comparative retrospective study conducted in two level III maternity units between January 2013 and May 2014, one maternity unit used a decision threshold of 7.20 (maternity unit 7,20), and the other one a threshold of 7.25 (maternity unit 7,25). An adverse neonatal outcome was defined by a composite endpoint of neonatal morbidity. The risk of cesarean was assessed using a multivariate analysis. RESULTS One hundred and four patients were included in the maternity unit 7,20 and 163 patients in the maternity 7,25. Adverse neonatal outcome was similar in both maternities (25% vs. 30,1%; P=0.4). The average pH at birth was similar in both maternities, as well as the Apgar score at 5minutes and neonatal transfer rates. However, BE<-12 was more frequent in maternity using 7,20 scalp pH threshold (7% vs. 0%; P<0.01). The cesarean rate was higher in maternity 7,25 (adjusted OR=2.23 95% CI [1.17-4.25]). CONCLUSION It seems that a decisional threshold fixed to 7,20 could be used reasonably. It could allow to reduce cesarean rate. Other studies are, however, needed to confirm that such threshold of 7,20 does not increase the risk of severe acidosis.

Labour induction practices in France: A population-based declarative survey in 94 maternity units

INTRODUCTION In 2016, 22.0% of deliveries in France were induced. The current lack of high level of evidence data about the methods and indications for induction of labour has promoted heterogeneous and non-recommended practices. The extent of these different practices is not adequately known in France today, although they may influence perinatal outcomes. The objective of this study was to report current practices of induction of labour in France. MATERIAL AND METHODS This study surveyed 94 maternity units in seven perinatal networks. A questionnaire was sent by email to either the department head or delivery room supervisor of these units to ask about their methods for induction and their attitudes in specific obstetric situations. RESULTS The rate of induction varied between maternity units from 7.7% to 33% of deliveries. Most units used two (39.4%) or three or more (35.1%) agents for cervical ripening. In all, 87 (92.6%) units reported using dinoprostone as a vaginal slow-released insert, 59 units dinosprostone as a vaginal gel (62.8%) and 46 units a balloon catheter (48.9%). Only three units reported using vaginal misoprostol. Inductions without medical indication were reported by 71 (75.5%) maternity units, and 22 (23.4%) units even when the cervix was unfavourable. Obstetric attitudes in cases of breech presentation, previous caesareans, fetal growth restriction or macrosomia and prelabour rupture of the membranes varied widely. DISCUSSION The variability of practices for induction of labour and the persistence of disapproved practices call for an assessment of the effectiveness and the safety of the different strategies.