F. Vendittelli

Twin pregnancies: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF)

The rate of twin deliveries in 2008 was 15.6 per 1000 in France, an increase of approximately 80% since the beginning of the 1970s. It is recommended that chorionicity be diagnosed as early as possible in twin pregnancies (Professional Consensus). The most relevant signs (close to 100%) are the number of gestational sacs between 7 and 10 weeks and the presence of a lambda sign between 11 and 14 weeks (Professional Consensus). In twin pregnancies, nuchal translucency is the best parameter for evaluating the risk of aneuploidy (Level B). The routine use of serum markers during the first or the second trimester is not recommended (Professional Consensus). In the case of a choice about sampling methods, chorionic villus sampling is recommended over amniocentesis (Professional Consensus). Monthly follow-up by a gynaecologist-obstetrician in an appropriate facility is recommended for dichorionic pregnancies (Professional Consensus). A monthly ultrasound examination including an estimation of fetal weight and umbilical artery Doppler is recommended (Professional Consensus). It is recommended to plan delivery of uncomplicated dichorionic diamniotic twin pregnancies from 38 weeks and before 40 weeks (Level C). Monthly prenatal consultations and twice-monthly ultrasound are recommended for monochorionic twins (Professional Consensus). It is reasonable to consider delivery from 36 weeks but before 38 weeks+6 days, with intensified monitoring during that time (Professional Consensus). Prenatal care of monochorionic pregnancies must be provided by a physician working in close collaboration with a facility experienced in the management of this type of pregnancy and its complications (Professional Consensus). The increased risk of maternal complications and the high rate of medical interventions justify the immediate and permanent availability of a gynaecologist-obstetrician with experience in the vaginal delivery of twins (Professional Consensus). It is recommended that the maternity ward where delivery takes place have rapid access to blood products (Professional Consensus). Only obstetric history (history of preterm delivery) (Level C) and transvaginal ultrasound measurement of cervical length (Level B) are predictive factors for preterm delivery. No study has shown that the identification by transvaginal sonography (TVS) of a group at risk of preterm delivery makes it possible to reduce the frequency of such deliveries in asymptomatic patients carrying twins (Professional Consensus). It is important to recognize signs of TTTS early to improve the management of these pregnancies (Professional Consensus). Treatment and counseling must be performed in a center that can offer fetoscopic laser coagulation of placental anastomoses (Professional Consensus). This laser treatment is the first-line treatment (Level B). In the absence of complications after laser treatment, planned delivery is recommended from 34 weeks and no later than 37 weeks (Professional Consensus). For delivery, it is desirable for women with a twin pregnancy to have epidural analgesia (Professional Consensus). The studies about the question of mode of delivery have methodological limitations and lack of power. Active management of the delivery of the second twin is recommended to reduce the interval between the births of the two twins (Level C). In the case of non-cephalic presentation, total breech extraction, preceded by internal version manoeuvres if the twins position is transverse, is associated with the lowest cesarean rates for second twins (Level C). In the case of high and not yet engaged cephalic presentation and if the team is appropriately trained, version by internal manoeuvres followed by total breech extraction is to be preferred to a combination of resumption of pushing, oxytocin perfusion, and artificial rupture of the membranes, because the former strategy appears to be associated with fewer cesareans for the second twin (Level C).

Is pregnancy the time to change alcohol consumption habits in France

BACKGROUND Although it is well known that France has a cultural history of alcohol use, no recent French data on alcohol consumption during pregnancy in a large sample are available. METHODS To determine the alcohol consumption patterns among pregnant women in France, we analyzed data from a 1-year multicenter self-survey. Sociodemographic profile, obstetrical history, neonatal data, and a self-report for assessing drinking patterns during pregnancy including AUDIT were recorded from women who delivered recently. Cases of fetal alcohol syndrome (FAS) were also reported. RESULTS A total of 837 pregnant women have described all parameters. The mean age at delivery of our sample was 29.7 years (SD = 4.8 years). A total of 52.2% of women indicated that they had consumed alcohol at least once during their pregnancy, and among abstainers 54.5% had a positive AUDIT score. Of the pregnant women who consumed alcohol, 13.7% reported at least one binge drinking episode (5 or more drinks on 1 occasion) during pregnancy. Binge drinking is significantly more frequent than regular alcohol consumption (at least 1 drink more than 1 time per week) during pregnancy. A prevalence rate of FAS of 1.8 per 1,000 live births was observed. CONCLUSIONS There is a large population of women who still drink alcohol during pregnancy, particularly in binge drinking episodes. This underlines the need to clearly inform women of childbearing age about the dangers of alcohol during pregnancy as related to all types of consumption. Moreover, acting to prevent alcohol consumption prior to pregnancy may also greatly influence prenatal drinking.

Obstetrical outcomes and biomarkers to assess exposure to phthalates: A review.

Studies of the effects on pregnancy outcomes of in utero exposure to phthalates, contaminants that are widely present in the environment, have yielded conflicting results. In addition, the mode of assessment of exposure varies between studies. The aim of this review was therefore to establish a current state of knowledge of the phthalates and metabolites involved in unfavorable pregnancy outcomes. Extant data were analyzed to determine which biomarker is the best suited to assess the relation between in utero exposure to phthalates and pregnancy outcomes. This review of the literature was conducted using the database of PubMed. A search was made of studies investigating exposure to phthalates and the following birth outcomes: preterm birth (gestational age <37 weeks), change in gestational age, change in body size at birth (birth weight, length, head circumference), anti-androgenic function, decreased anogenital distance, cryptorchidism, hypospadias and congenital malformation. The methodological approach adopted in each study was examined, in particular the methods used for exposure assessment (biomarkers and/or questionnaire). Thirty-five studies were included. Premature birth and decreased anogenital distance were the most commonly reported outcomes resulting from a moderate level of exposure to phthalates. The principal metabolites detected and involved were primary metabolites of di-2(ethylhexyl)-phthalate (DEHP) and di-n-butyl-phthalate (DnBP). No clear conclusion could be drawn with regard to gestational age at birth, body size at birth and congenital malformations. In epidemiological studies, maternal urine is the most suitable matrix to assess the association between in utero exposure to phthalates and pregnancy outcomes: in contrast to other matrices (cord blood, amniotic fluid, meconium and milk), sampling is easy, non-invasive and, can be repeated to assess exposure throughout pregnancy. Oxidative metabolites are the most relevant biomarkers since they are not prone to external contamination. Further epidemiological studies are required during pregnancy to i) determine the role of phthalates other than DEHP [currently replaced by various substitution products, in particular diisononyl-phthalate (DiNP)]; ii) establish the effect of phthalates on other outcomes (body size adjusted for gestational age, and congenital malformations); iii) determine the pathophysiological pathways; and iv) identify the most suitable time for biomarker determination of in utero exposure to phthalates.

Is a breech presentation at term more frequent in women with a history of cesarean delivery

OBJECTIVE The purpose of this study was to determine whether breech presentation at term is more common among women with at least 1 previous cesarean delivery. STUDY DESIGN This historic cohort study (n = 84,688) included women with a singleton term pregnancy and at least 1 previous delivery. Results were expressed as crude relative risks and adjusted odds ratios. RESULTS While 2.46% of women had a fetus in breech presentation at term, 14.91% of women had had 1 or more previous cesareans. The relative risk of a breech presentation at term for women with a history of cesarean was 2.18 (95%CI: 1.98-2.39). It did not differ according to the number of previous cesareans. The logistic regression analysis took into account confounding factors including gestational age, maternal age, parity, birthweight, and oligohydramnios. The adjusted odds ratio was 2.12 (95%CI: 1.91-2.36). CONCLUSION Women with previous cesarean deliveries have a risk of breech presentation at term twice that of women with previous vaginal deliveries.

Occult maternal exposure to environmental tobacco smoke exposure

Background: Environmental tobacco smoke (ETS) is a recognised air pollutant. Its harmful effects have been found to be implicated in health disorders, including unfavourable pregnancy outcomes. The discrepancy between self-reported emvironmental tobacco smoke exposure and cotinine levels in pregnant non-smokers in France was examined. Method: Plasma cotinine was determined by a CPG-SM method on women who had answered a self-questionnaire describing their habits and environment during pregnancy. Results: Of 698 pregnant women reported as non-smokers, 305 (43.7%) claimed not to be exposed to ETS, yet 196 of these (64.3%) had plasma cotinine levels above the limit of detection. Conclusion: Self-reported data on ETS exposure in pregnant women therefore underestimate actual exposure. However, cotinine assay cab rectify this misclassification. An accurate identification of this risk factore will help to change attitudes towards ETS and avert its adverse effects on mother and fetus.

Oxytocin administration during spontaneous labor: Guidelines for clinical practice. Chapter 3: Interventions associated with oxytocin administration during spontaneous labor

Objectives: The objective of our work was to determine the effects of co-interventions used during labor with oxytocin or for labor dystocia. Methods: We searched for reports of the interventions we sought to study published between 1987 and 2015, looking especially for meta-analyses and randomized trials via the Medline database and the Cochrane Library. We limited our research to studies of spontaneous labor in singleton pregnancies at term. Results: In the absence of labor dystocia, active management of labor is not recommended (Grade B). It is recommended that amniotomy should not be performed routinely during the first stage of labor (Grade B). In cases of labor dystocia during the active phase, an amniotomy is recommended before the administration of oxytocin (professional consensus). The encouragement of continuous support during labor is recommended (Grade B). No scientific evidence justifies the recommendation of any of the following methods for the sole purpose of limiting oxytocin use during labor: maternal position during the first or second stages of labor (grade C), immersion in a water during the first stage (grade B), intravenous infusion, oral hydration, or solid food (grade B), antenatal preparation with hypnosis sessions (grade C), use of relaxation techniques (grade C), acupuncture or acupressure (Grade B), or the use of muscle-relaxant agents (professional consensus). Conclusions: Few of the co-interventions studied appear to modulate recourse to oxytocin.

Introduction à l’évaluation des pratiques professionnelles

Medical practice assessment is mandatory in France. The goal of this article is to explain to perinatal care providers the concept and the process, which do not seem simple, given the multitude of possible ways to evaluate and validate its medical practices. Concrete examples help to illustrate the process. French regulations now link medical practice assessment with continuing medical education (CME) for physicians. While certification is voluntary, a practice assessment conducted during hospital certification processes and during CME is required for all French physicians.

Is a planned cesarean necessary in twin pregnancies

Objective. Evaluation of elective cesarean section for twin delivery as a standard of care. Design. Historical cohort in a national database (2 597 twin pregnancies). Setting. France. Sample. Twins with first child in cephalic presentation. Methods. Decision analysis. Main Outcome Measures. All neonatal complications, i.e. death, whether intrapartum or in the delivery room or the immediate postpartum period, or neonatal transfer to intensive (or special) care, or trauma, of one or both twins. Results. When we focused on neonatal complications for either or both twins, the strategy of planned vaginal delivery was preferable; the weight of its decision tree branch was lower than that for planned cesarean (26.5 vs. 31.7). If only twin 2 was considered, vaginal delivery was also preferred (weight of vaginal delivery=27.6 vs. 32.7 for planned cesarean). As long as the morbidity and mortality of twin 1 or twin 2 or both during a cesarean for twin 2 in the case of planned vaginal delivery does not exceed 31.5%, all else being equal, vaginal delivery should be preferred to a planned cesarean for twin 1 and twin 2. The two‐variable sensitivity analysis confirmed the robustness of the results. Conclusions. The results of our study do not support a policy of planned cesarean delivery for twin pregnancies at and after 34 weeks of gestation. Level of evidence: II.

Do perinatal guidelines have an impact on obstetric practices

BACKGROUND The publication of several sets of French guidelines was unfortunately not accompanied by planned assessment of their impact on practices. The goal of this study was to assess the impact of eight French perinatal guidelines on actual obstetric practices. METHODS Historical cohort setting in France: the Audipog database of 299,412 pregnancies from 1994 to 2006, from which we extracted a sub-sample by randomLy selecting from each participating maternity ward all births occurring during a single month of each year (n=107,450 pregnancies). The main outcome measure was the incidence of pertinent perinatal indicators related to these guidelines. These included site of delivery for low-birth-weight infants (1998), caesarean delivery (2000), preterm delivery (2002), breastfeeding (2002), smoking and pregnancy (2004), immediate postpartum hemorrhages (2004), early discharge after delivery (2004) and episiotomies (2005). Standardised rates, before and after the year of each guideline, were compared using a Chi(2) test. RESULTS The percentage of children weighing less than 1500 g at birth born in Level III hospitals increased through 1999 but dropped subsequently, without ever returning to the 1994 level (P<0.0001). The overall caesarean rate climbed slowly but regularly from 1994 through 2006 (P<0.0001). Use of antenatal corticosteroids for women hospitalised for threatened preterm labour and in children born before 33 weeks has fluctuated since the release of the guideline (P>0.05). Exclusive breastfeeding at discharge from the maternity ward has increased slowly (P<0.0001). The percentage of deliveries with active management of the third stage of labour rose notably from 1999 to 2006 (P<0.0001), and smoking cessation during pregnancy rose slightly in 2006 (P<0.0001). Since 1994, early discharges have become slowly, slightly, but regularly more frequent for all women (P<0.0001). The guideline on episiotomies has had a slight positive effect in the short term (P<0.0001). CONCLUSIONS Globally, the impact on actual practices of clinical practice guidelines, except the guideline concerning the active management of the third stage of labour, was low. Most of the changes observed in practices began before the pertinent guideline was published.

How singleton breech babies at term are born in France: a survey of data from the AUDIPOG network

Based on data from the AUDIPOG sentinel network between 1994 and 2010, we can say that the rate of singleton breech presentation at term is 3% and remains unchanged despite an external cephalic version rate of 35%. The total cesarean section rate is currently 75%. This rate increased by nearly 20% after the Hannah publication in 2000, regardless of the type of breech and type of maternity unit. The rate of planned cesarean sections increased in particular, going from 40% to 60%, and even reaching 67% for footling breech presentations. The rate is higher in type I maternity units than in type II or III. This cesarean section rate has been stable since 2005 and has even decreased for the Frank breech. The average rate of external cephalic version remains stable at around 23%. The episiotomy rate is 28%. The rate of babies transferred to neonatology units is higher for breech babies at term than for babies presenting cephalically (3.9% compared to 2.9%), but the newborns most often transferred are those born by cesarean section (4.1% compared to 3.4%).