Gilles Faron

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.

Prediction of preterm delivery by fetal fibronectin: A meta-analysis

Abstract Objective: To assess the cervicovaginal fetal fibronectin test to predict preterm delivery. Data Sources: We searched MEDLINE, Current Contents, Index Medicus , and proceedings of meetings for studies published between 1991 and June 1997. Methods of Study Selection: Inclusion criteria were prospective cohort study; test performed between 20 and 36 weeks’ gestation; fetal fibronectin measured by a previously described assay, with a cutoff level set at 50 ng/mL; test results not disclosed to women or physicians; and fewer than 20% of study participants excluded from the analysis. Tabulation, Integration, and Results: Twenty-nine relevant studies were stratified according to the prevalence of preterm delivery, the number of tests performed, and delivery before 34, 35, or 37 weeks. Sensitivities, specificities, and likelihood ratios were calculated in each study. The summary estimates of the likelihood ratio for tests yielding positive results or tests yielding negative results along with their 95% confidence intervals (CIs) were computed in each stratum according to a random-effects model. All summary likelihood ratios for a test yielding positive results indicated a significant association with preterm delivery. The strongest association was found between a single test with positive results and delivery before 37 weeks in a low-risk population (likelihood ratio 7.5; 95% CI 4.6, 12.3). This association also was found in high-risk women (likelihood ratio 3.5; 95% CI 2.6, 4.6). In high-risk women, a test yielding negative results was associated with a reduction in risk of preterm delivery (likelihood ratio 0.4; 95% CI 0.3, 0.5). Conclusion: Fetal fibronectin in cervicovaginal secretions is associated with preterm delivery in both high-risk and low-risk women.

Trial of labour after caesarean section in sub‐Saharan Africa: ameta‐analysis

Objective To evaluate the safety and effectiveness of apolicy of trial of labour for women with a previous caes are an section, delivering in hospitals in sub‐Saharan Africa.

A single cervical fetal fibronectin screening test in; population at low risk for preterm delivery: an improvement on clinical indicators?

Objective To assess the accuracy of a single cervical fetal fibronectin test to predict spontaneous preterm delivery in an unselected antenatal population.

Spontaneous delivery or manual removal of the placenta during caesarean section: a randomised controlled trial

Objective  To compare blood loss with spontaneous delivery and manual removal of the placenta during caesarean section.

Intrapartum Fetal ECG ST-Segment Analysis.

To the Editor: Belfort et al. (Aug. 13 issue)1 report that fetal electrocardiographic (ECG) STsegment analysis (STAN) combined with conventional intrapartum electronic fetal heart-rate monitoring did not improve perinatal outcomes or decrease operative-delivery rates, as compared with conventional monitoring. However, other randomized trials2,3 with adequate power have shown that strict use of the International Federation of Gynecology and Obstetrics classification for cardiotocography (FIGO-CTG) and STAN guidelines resulted in a relative decrease of 46% in the rate of operative vaginal deliveries (P<0.001) and of 53% in the rate of postnatal metabolic acidosis (P = 0.02). The study by Belfort et al. used deviant STAN guidelines and was associated with numerous protocol violations that we think led to unnecessary operative deliveries and avoidable primary-outcome events in the STAN group. (Details regarding the STAN guidelines used by Belfort et al. and investigators in other studies are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org.) Such methodologic issues must be considered in the interpretation of these findings. The latest meta-analysis of trials of STAN4 excluded cases with guideline violations and concluded that a combination of conventional intrapartum electronic fetal heart-rate monitoring plus STAN significantly reduced rates of operative deliveries and neonatal metabolic acidosis. Efforts should be made to develop closer intercontinental collaborations for future studies with the use of homogeneous methods and consensual guidelines.

Perception and knowledge of early pregnancy assessment units among perinatal practitioners in Europe

To investigate perceptions of early pregnancy assessment units (EPAUs) among perinatal practitioners working in Belgium, France, and Switzerland.

Effect of Genital Sampling Site on the Detection and Quantification of Ureaplasma Species with Quantitative Polymerase Chain Reaction during Pregnancy

Objective. This study aimed to compare the qualitative and quantitative reproducibility of quantitative PCR (qPCR) for Ureaplasma species (Ureaplasma spp.) throughout pregnancy and according to the genital sampling site. Study Design. Between 5 and 14 weeks of gestation (T1), vaginal, fornix, and two cervical samples were taken. Sampling was repeated during the 2nd (T2) and 3rd (T3) trimester in randomly selected T1 positive and negative women. Qualitative and quantitative reproducibility were evaluated using, respectively, Cohens kappa (κ) and interclass correlation coefficients (ICC) and repeated measures ANOVA on the log-transformed mean number of DNA copies for each sampling site. Results. During T1, 51/127 women were positive for U. parvum and 8 for U. urealyticum (4 patients for both). Sampling was repeated for 44/55 women at T2 and/or T3; 43 (97.7%) remained positive at the three timepoints. κ ranged between 0.83 and 0.95 and the ICC for cervical samples was 0.86. Conclusions. Colonization by Ureaplasma spp. seems to be very constant during pregnancy and vaginal samples have the highest detection rate.

Spontaneous Uterine Rupture in a Primigravida at 35 Weeks of Gestation. A Case Report and Review of the Literature

Abstract Spontaneous uterine rupture is a rare but life-threatening event. Usually, this complication is associated with such risk factors as previous injury of the uterine wall. We report a case of spontaneous rupture of an unscarred uterus in the absence of classical risk factors, and review the literature with respect to the possible aetiologies of this condition. We conclude that the differential diagnosis of atypical abdominal pain in pregnancy should include spontaneous uterine rupture, even in the absence of classical risk factors.