Julie Blanc

Is maternal posturing during labor efficient in preventing persistent occiput posterior position? A randomized controlled trial

OBJECTIVEnWe sought to evaluate the efficacy of maternal posturing during labor on the prevention of persistent occiput posterior (OP) position.nnnSTUDY DESIGNnWe conducted a randomized trial including 220 patients in labor with a single fetus in documented OP position. Main outcome was the proportion of anterior rotation from OP position.nnnRESULTSnThe rates of anterior rotation were, respectively, 78.2% and 76.4% in the intervention group and the control group without significant difference (P = .748). Rates of instrumental and cesarean section deliveries were not significantly different between intervention and control groups (18.2% vs. 19.1%, P = .89, and 19.1% vs. 17.3%, P = .73, respectively). In intervention and control groups, persistent OP position rates were significantly higher among women who had cesarean section (71.4% and 89.5%, respectively) and an instrumental delivery (25% and 33.3%, respectively) than among women who achieved spontaneous vaginal birth (5.8% and 2.8%, respectively). In multivariable analysis, body mass index and parity were found to have significant and independent impact on the probability of fetal head rotation.nnnCONCLUSIONnOur study failed to demonstrate any maternal or neonatal benefit to a policy of maternal posturing for the management of OP position during labor.

Prevention of spontaneous preterm birth: Guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF)

In France, 60,000 neonates are born preterm every year (7.4%), half of them after the spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated with decreased prematurity (level of evidence [LE]1). It is therefore recommended (Grade A). Routine screening and treatment of vaginal bacteriosis is not recommended in the general population (Grade A). The only population for which vaginal progesterone is recommended is that comprising asymptomatic women with singleton pregnancies, no history of preterm delivery, and a short cervix at 16-24 weeks of gestation (Grade B). A history-indicated cerclage is not recommended for women with only a history of conization (Gradeu2009C), uterine malformation (professional consensus), isolated history of preterm delivery (Grade B), or twin pregnancies for primary (Grade B) or secondary (Gradeu2009C) prevention of preterm birth. A history-indicated cerclage is recommended for a singleton pregnancy with a history of at least 3 late miscarriages or preterm deliveries (Grade A). Ultrasound cervical length screening is recommended between 16 and 22 weeks for women with a singleton previously delivered before 34 weeks gestation, so that cerclage can be offered if cervical lengthu2009<25mm before 24 weeks (Gradeu2009C). A cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with twin pregnancies (Grade A) or in populations of asymptomatic women with a short cervix (professional consensus). Although the implementation of universal screening by transvaginal ultrasound for cervical length at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In cases of preterm labor, (i) it is not possible to recommend any one of the several methods (ultrasound of the cervical length, vaginal examination, or fetal fibronectin assay) over any other to predict preterm birth (Grade B); (ii) routine antibiotic therapy is not recommended (Grade A); (iii) prolonged hospitalization (Grade B) and bed rest (Gradeu2009C) are not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (Grade B), unlike beta-agonists (Gradeu2009C), can be used for tocolysis in spontaneous preterm labor without preterm premature rupture of membranes. Maintenance tocolysis is not recommended (Grade B). Antenatal corticosteroid administration is recommended for all women at risk of preterm delivery before 34 weeks of gestation (Grade A). After 34 weeks, the evidence is insufficiently consistent to justify recommending systematic antenatal corticosteroid treatment (Grade B), but a course of this treatment might be indicated in clinical situations associated with high risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (Grade C). Repeated courses of antenatal corticosteroids are not recommended (Grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended for women at high risk of imminent preterm birth before 32 weeks (Grade A). Cesareans are not recommended for fetuses in vertex presentation (professional consensus). Both planned vaginal and elective cesarean delivery are possible for breech presentations (professional consensus). Delayed cord clamping may be considered if the neonatal or maternal state allows (professional consensus).

Is uterine-sparing surgical management of persistent postpartum hemorrhage truly a fertility-sparing technique?

Among 23 women who underwent diagnostic hysteroscopy after triple uterine artery ligation with or without hemostatic multiple square suturing for the management of postpartum hemorrhage (PPH), five had abnormal findings. Endometritis was statistically significantly associated with abnormal diagnostic hysteroscopy findings. Twelve patients developed subsequent pregnancies, and four had abnormal obstetric outcomes: one placenta percreta, one placenta accreta, one recurrent postpartum hemorrhage, and one intrauterine growth retardation.

Uterine-sparing surgical management of postpartum hemorrhage: is it always effective?

PurposeTo further study the efficacy of uterine-sparing procedures based on triple uterine artery ligation (TUAL) possibly complemented with hemostatic multiple square suturing (HMSS) for the management of post-partum hemorrhage (PPH).MethodsCases of PPH occurring during cesarean section and treated, according to our institution guidelines, by TUAL possibly complemented with HMSS between 2000 and 2009 were retrospectively analyzed.ResultsFifty-six patients were included; 13 (23.2%) had TUAL only, while 43 (76.8%) had additional HMSS performed. Surgical conservative management of PPH was effective in 51 (91.1%) cases. PPH due to placenta accreta, either unanticipated or after failure of conservative management, showed an independent and significant impact on the risk of failure of the procedure (AOR 15.07, 95% CI 1.12–201.9, pxa0=xa00.041).ConclusionObstetricians should be aware that a higher risk of failure of the procedure is to be expected in cases of PPH due to placenta accreta. In such situation, to avoid any useless delay in management, our findings suggest that peripartum hysterectomy should be immediately considered.

Short and medium-term outcomes of live-born twins after fetoscopic laser therapy for twin-twin transfusion syndromea

Abstract Objective: To evaluate short and medium term outcomes of children born of monochorionic pregnancies complicated by twin-twin transfusion syndrome treated by fetoscopic laser surgery. Methods: This was a retrospective observational study performed between May 2007 and 2012. Neonatal data was from 45 patients under 5 years of age. The prospective observational study was of the neurologic outcome of these children using the Ages and Stages Questionnaire (ASQ), 2nd edition, French version, at up to 5 years of age. Results: Neurologic assessment at discharge from maternity unit was normal for 41 infants (93.2%). Logistic regression suggested that the risk of neurosensory sequelae was significantly related to the status of donor [odds ratio=4.62 (1.18; 18.0)] and significantly preterm birth <32 weeks of gestation [odds ratio=5.50 (1.38; 21.9)]. Eleven questionnaires were considered abnormal (31.1%). Two children presented a severe neurologic abnormality (5.7%). There was no significant correlation between any area of the questionnaire and status at birth (donor or recipient). Conclusions: The data from our cohort, particularly as regards neurologic outcome, were satisfactory and concordant with previously published results. The use of the ASQ as a screening tool for neurologic outcome in children is original, which allowed in our cohort to highlight early neurological disorders.

Is gestational diabetes an independent risk factor of neonatal severe respiratory distress syndrome after 34 weeks of gestation? A prospective study

PurposeTo evaluate if neonates delivered after 340/7 weeks from mothers diagnosed with gestational diabetes (GD) are exposed to an increased risk of neonatal severe respiratory distress syndrome (SRDS).MethodsWomen with singleton pregnancy in labour after 340/7 weeks of gestation or admitted for planned caesarean section and who had been systematically screened for GD were eligible to participate to this prospective cohort study. Diagnosis of SRDS was defined by the association of clinical signs of early neonatal respiratory distress, with consistent radiologic features and requiring mechanical ventilation with a fraction of inspired oxygen (FiO2) >0.25 for a minimum of 24xa0h and admission to neonatal intensive care unit.ResultsA total of 444 women were included. GD was diagnosed in 60 patients (13.5%). A neonatal SRDS was diagnosed in 32 cases (7.2%). Compared to others, neonatal SRDS was significantly more often observed in neonates from women diagnosed with GD: 12 (20%) vs. 20 (5.2%), respectively (pxa0<xa00.001). Women whose neonates presented neonatal SRDS were significantly more likely to be obese (pxa0=xa00.002), to have undergone a caesarean section (pxa0<xa00.001) and to have received corticosteroids therapy before 340/7 weeks (pxa0=xa00.013). In multivariate analysis, GD was identified as an independent risk factor of neonatal SRDS (aOR 3.6; 95% CI 1.5–8.6; pxa0=xa00.005). Other risk factors were maternal obesity (aOR 2.8; 95% CI 1.1–7.1; pxa0=xa00.029) and assisted vaginal delivery (aOR 5.5; 95% CI 1.9–15.9; pxa0=xa00.002).ConclusionsGD is an independent risk factor of neonatal SRDS after 340/7 weeks.

Teaching and performing audits on caesarean delivery reduce the caesarean delivery rate

Aim To assess the factors associated with lower rate of caesarean deliveries in the South of France, based on the characteristics and organisation of the region’s 40 maternity facilities and the characteristics of the practitioners in these facilities. Method A retrospective study from 1 January 2012 to 31 December 2015. Data were collected by the Mediterranean network and a declarative survey was completed by each maternity facility in the region to study factor which could be associated with lower caesarean rate by univariate and multivariate analysis. Results 250 564 women gave birth during this period, of which 55 097 by caesarean section. The mean caesarean delivery rate over the four years was 22.0%. The rate was significantly higher in private maternity facilities [23.9% (21.9%– 25.8%), p<0.05] and type III (maximum care level) maternity facilities [24.2% (21.3%– 27.1%), p<0.05]. After a stepwise regression, the factors associated with a decrease in the caesarean delivery rate were audits concerning caesarean delivery (19.83%, β = - 2.48, p = 0.03 over the four years) and the provision of training to trainee doctors at the maternity facility (20.28%, β = - 1.08, p = 0.04 over the four years). Conclusion Performing audits in relation to caesarean deliveries could affect the caesarean. Teaching trainee doctors could be an indicator of quality of caesarean practices. They should be encouraged in maternity facilities to reduce the rate of caesareans.

Development of a nomogram for individual preterm birth risk evaluation

OBJECTIVEnThis study aimed to develop a new tool for personalised preterm birth risk evaluation in high-risk population.nnnSTUDY DESIGNn813 high-risk asymptomatic pregnant women included in a French multicentric prospective study were analysed. Clinical and paraclinical variables, including screening for bacterial vaginosis with molecular biology, cervical length, have been used to create the nomogram, based on the logistic regression model. The validity was checked by bootstrap. A downloadable calculator was build.nnnRESULTSnNine risk factors were included in this model: history of late miscarriage and/or preterm delivery, active smoking, ultrasound cervical length, term of pregnancy at screening, bacterial vaginosis, premature rupture of membranes, daily travel more than 30min. Discrimination and calibration of the nomogram revealed good predictive abilities. The area under the receiver operating characteristic curve was 0.77 (95% CI; 0.72-0.81). The mean absolute error was 0.018, which showed proper calibration. The optimal risk threshold was 23.2% with a sensitivity of 74%, a specificity of 72.7% and a predictive negative value of 90.6%.nnnCONCLUSIONnThe nomogram can help to better define individual preterm birth risk in high-risk pregnancies.

Primary cesarean delivery rate: Potential impact of a checklist

BACKGROUNDnCesarean section is the most common surgical procedure performed in developed countries. Its incidence is increasing to a worrisome extent. The 2003 French National Perinatal Survey showed that the inflation in the overall cesarean rate was mainly due to an increase in the first cesarean delivery rate.nnnOBJECTIVEnTo evaluate a new tool: a checklist that intent to decrease the first cesarean delivery rate.nnnSTUDY DESIGNnRetrospective, observational, multi-center study. A new tool, a First cesarean delivery checklist was built according American and French guidelines. Women with full-term of pregnancy, nulliparous or multiparous with a first caesarean delivery including arrest of labor, breech presentation or suspected fetal macrosomia were included. The checklist was applied. Potentially preventable cesareans were analyzed.nnnRESULTSnAmong 571 first cesarean section, 178 were eligible to check list application. 147 charts were analyzed in the study. 11.9% of first cesarean deliveries performed were potentially avoidable after applying the checklist. This represented 6.6% of all cesareans.nnnCONCLUSIONnThe checklist based on the recall of good practices could be an interesting tool to decrease the first cesarean rate.

Devenir neurodéveloppemental des nouveau-nés issus de grossesses monochoriales compliquées avec interruption sélective par ablation par radiofréquence

OBJECTIVEnTo describe perinatal data and to evaluate the neonatal neurological outcome of monochorionic twin pregnancies with selective termination by radiofrequency ablation.nnnMETHODSnRetrospective data of perinatal data for nine consecutive monochorionic pregnancies eligible for radiofrequency ablation from Januaryxa02013 to Augustxa02015 were collected. A prospective observational study of the neurological outcome of nine children was conducted using the Ages & Stages Questionnaire (ASQ), 2nd edition, French version, adapted to the age.nnnRESULTSnThe radiofrequency procedures were performed at a mean gestational age (GA) of 21.4xa0weeks (±7xa0weeks). The indications for a selective interruption of a pregnancy were: acardiac twin (n=4), brain malformation (n=1), severe intrauterine growth restriction (IUGR) with massive cerebral ischemia in the context of twin-twin transfusion syndrome gradexa0III (n=1), severe selective IUGR associated with a polymalformative syndrome (n=1) and severe selective IUGR (n=2). The mean GA at birth was 36.7xa0weeks GA (±3.8xa0weeks). No infant showed neurological neonatal morbidity. Any ASQ area explored was pathological (<-2SD) for the nine children (mean age at follow-up [±SD], 14.8xa0months [±8.8xa0months]).nnnCONCLUSIONnThis work constitutes a preliminary study for developing long-term follow-up and early care programs for those children born subsequent to a radiofrequency ablation for selective reduction.