Elsa Lorthe

Mortality and morbidity in early preterm breech singletons: impact of a policy of planned vaginal delivery

OBJECTIVE To compare neonatal morbidity and mortality rates in preterm singleton breech deliveries from 26(0/7) to 29(6/7) weeks of gestation in centers with a policy of either planned vaginal delivery (PVD) or planned cesarean delivery (PCD). STUDY DESIGN Women with preterm singleton breech deliveries occurring after preterm labor or preterm premature rupture of membranes (pPROM) were identified from the databases of five perinatal centers and classified as PVD or PCD according to the centers management policy. The independent association between planned mode of delivery and the risk of neonatal hospital death or morbidity was tested and quantified with ORs through two-level multivariable logistic regression modeling. RESULTS Of 142 782 deliveries during the study period, 626 (0.4%) were singletons in breech presentation from 26(0/7) to 29(6/7) weeks of gestation: after exclusions, 130 were in the PVD group and 173 in the PCD group. Severe newborn morbidity was similar in the two groups. Newborn mortality was 12% in the PCD group and 16% in the PVD group. Three neonates (1.7%, 95% CI: 0.34-5.0) died from head entrapment after vaginal delivery in the PVD group. Nonetheless, the policy of PVD was not associated with increased risks of neonatal death (aOR: 1.01, 95% CI: 0.33-2.92) or severe morbidity. CONCLUSION Risks of mortality and severe morbidity in preterm breech were not increased by a policy of vaginal delivery. Head entrapment leading to death is however possible in cases of vaginal delivery but its rarity should be balanced with the maternal consequences of early preterm cesarean delivery.

Preterm Breech Presentation: A Comparison of Intended Vaginal and Intended Cesarean Delivery.

OBJECTIVE: To study the association of the intended mode of delivery and perinatal morbidity and mortality among breech fetuses who are delivered preterm. METHODS: We conducted a nationwide cohort study of women with a singleton pregnancy in breech presentation who delivered preterm (26 0/7–36 6/7 weeks of gestation) in the years 2000–2011. We compared perinatal outcomes according to the intended and actual mode of delivery using multivariate logistic regression analysis. We performed subgroup analyses of gestational age and parity. RESULTS: We studied 8,356 women with a preterm singleton breech delivery. Intended cesarean delivery (n=1,935) was not associated with a significant reduction in perinatal mortality compared with intended vaginal delivery (n=6,421) (1.3% compared with 1.5%; adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.60–1.57). However, the composite of perinatal mortality and morbidity was significantly reduced in the intended cesarean delivery group (8.7% compared with 10.4%; adjusted OR 0.77, 95% CI 0.63–0.93). In the subgroup of women delivering at 28–32 weeks of gestation, intended cesarean delivery was associated with a 1.7% risk of perinatal mortality compared with 4.1% with intended vaginal delivery (adjusted OR 0.27, 95% CI 0.10–0.77) and significantly reduced composite mortality and severe morbidity, 5.9% compared with 10.1% (adjusted OR 0.37, 95% CI 0.20–0.68). CONCLUSION: In women delivering a preterm breech fetus, cesarean delivery is associated with reduced perinatal mortality and morbidity. LEVEL OF EVIDENCE: II

Providing active antenatal care depends on the place of birth for extremely preterm births: the EPIPAGE 2 cohort study

Survival rates of infants born before 25 weeks of gestation are low in France and have not improved over the past decade. Active perinatal care increases these infants’ likelihood of survival. Objective Our aim was to identify factors associated with active antenatal care, which is the first step of proactive perinatal care in extremely preterm births. Methods The population included 1020 singleton births between 220/6 and 260/6 weeks of gestation enrolled in the Etude Epidémiologique sur les Petits Ages Gestationnels 2 study, a French national population-based cohort of very preterm infants born in 2011. The main outcome was ‘active antenatal care’ defined as the administration of either corticosteroids or magnesium sulfate or delivery by caesarean section for fetal rescue. A multivariable analysis was performed using a two-level multilevel model taking into account the maternity unit of delivery to estimate the adjusted ORs (aORs) of receiving active antenatal care associated with maternal, obstetric and place of birth characteristics. Results Among the population of extremely preterm births, 42% received active antenatal care. After standardisation for gestational age, regional rates of active antenatal care varied between 22% (95% CI 5% to 38%) and 61% (95% CI 44% to 78%). Despite adjustment for individual and organisational characteristics, active antenatal care varied significantly between maternity units (p=0.03). Rates of active antenatal care increased with gestational age with an aOR of 6.46 (95% CI 3.40 to 12.27) and 10.09 (95% CI 5.26 to 19.36) for infants born at 25 and 26 weeks’ gestation compared with those born at 24 weeks. No other individual characteristic was associated with active antenatal care. Conclusion Even after standardisation for gestational age, active antenatal care in France for extremely preterm births varies widely with place of birth. The dependence of life and death decisions on place of birth raises serious ethical questions.

Histologic Chorioamnionitis and Bronchopulmonary Dysplasia in Preterm Infants: The Epidemiologic Study on Low Gestational Ages 2 Cohort

OBJECTIVE To investigate the association between histologic chorioamnionitis (HCA) and bronchopulmonary dysplasia (BPD) in very preterm infants, both in a general population and for those born after spontaneous preterm labor and after preterm premature rupture of membranes (pPROM). STUDY DESIGN This study included 2513 live born singletons delivered at 24-31 weeks of gestation from a national prospective population-based cohort of preterm births; 1731 placenta reports were available. HCA was defined as neutrophil infiltrates in the amnion, chorion of the membranes, or chorionic plate, associated or not with funisitis. The main outcome measure was moderate or severe BPD. Analyses involved logistic regressions and multiple imputation for missing data. RESULTS The incidence of HCA was 28.4% overall: 38% in cases of preterm labor, 64% in cases of pPROM, and less than 5% in cases of vascular disorders. Overall, the risk of BPD after adjustment for gestational age, sex, and antenatal steroids was reduced for infants with HCA (HCA alone: aOR 0.6 [95% CI 0.4-0.9]; associated with funisitis: aOR 0.5 [95% CI 0.3-0.8]). This finding was explained by the high rate of BPD and low rate of chorioamnionitis among children with fetal growth restriction. HCA was not associated with BPD in the preterm labor (13.4% vs 8.5%; aOR 0.9; 95% CI 0.5-1.8) or in the pPROM group (12.9% vs 12.1%; aOR 0.6; 95% CI 0.3-1.3). CONCLUSION In homogeneous groups of infants born after preterm labor or pPROM, HCA is not associated with BPD.

Association of Intraventricular Hemorrhage and Death With Tocolytic Exposure in Preterm Infants

Key Points Question Is tocolysis associated with lower rates of death and intraventricular hemorrhage in preterm infants owing to an effect on the fetal blood-brain barrier? Findings In this cohort study of 1127 mothers who experienced preterm labor and delivered at gestational weeks 24 through 31, the estimated prevalence of death and/or grades III to IV intraventricular hemorrhage was significantly lower in preterm infants with vs without tocolytic exposure (25.3% vs 32.5%). Differences between atosiban and nifedipine exposure for death and/or intraventricular hemorrhage (44.9% vs 51.2%) and for intraventricular hemorrhage (39.1% vs 45.3%) were not significant. Meaning Results for tocolytics are reassuring regarding death and/or intraventricular hemorrhage in preterm infants, but other studies appear to be necessary to compare the effects of atosiban vs nifedipine.

Planned delivery route of preterm breech singletons, and neonatal and 2‐year outcomes: a population‐based cohort study

To assess whether planned route of delivery is associated with perinatal and 2‐year outcomes for preterm breech singletons.

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.

Maintaining and repeating tocolysis: A reflection on evidence

It is inherent to human logic that both doctors and patients want to suppress uterine contractions when a woman presents in threatened preterm labor. Tocolysis is widely applied in women with threatened preterm labor with a variety of drugs. According to literature, tocolysis is indicated to enable transfer to a tertiary center as well as to ensure the administration of corticosteroids for fetal maturation. There is international discrepancy in the content and the implementation of guidelines on preterm labor. Tocolysis is often maintained or repeated. Nevertheless, the benefit of prolonging pregnancy has not yet been proven, and it is not impossible that prolongation of the pregnancy in a potential hostile environment could harm the fetus. Here we reflect on the use of tocolysis, focusing on maintenance and repeated tocolysis, and compare international guidelines and practices to available evidence. Finally, we propose strategies to improve the evaluation and use of tocolytics, with potential implications for future research.