Publications

J Gynecol Obstet Hum Reprod. 2020 Feb;49(2):101662. doi: 10.1016/j.jogoh.2019.101662.Epub 2019 Dec 4.

Abstract

Background: Neonatal morbidity among fetuses in breech presentation is not associated with planned mode of delivery in France. Data about consequences to these mothers are sparse.

Methods: The prospective PREMODA study took place in France and Belgium (2001-2002) in 138 maternity units and included all women with a singleton fetus in breech presentation ≥ 37 weeks of gestation (n=8105). We excluded women with more than one previous cesarean delivery, an in utero fetal death, or for whom cesarean delivery or induction of labor was planned due to maternal disease. The composite variable “severe acute maternal morbidity” (SAMM) grouped severe events. Associations between planned modes of delivery and SAMM were estimated from multivariable Poisson regression models adjusted for potential confounders. A control group with fetuses in cephalic presentation enabled us to compare maternal complications by fetal presentation.

Results: Among the 7564 women included in the analysis, 5098 (67.4%) had a planned cesarean and 2466 (32.6%) a planned vaginal delivery; their SAMM rates did not differ: 48/8098 (0.9%) versus 17/2466 (0.7%), respectively, with an adjusted risk ratio (aRR) of 1.60, 95% confidence interval (95% CI) 0.81-3.15. The SAMM rate was significantly higher in the planned vaginal breech group than in the planned vaginal cephalic group: 17/2466 (0.7%) versus 39/10156 (0.4%) (aRR 2.10, 95% CI 1.18-3.74).

Conclusion: In women with a fetus in breech presentation at term, the short-term risk of severe maternal morbidity did not differ significantly according to planned mode of delivery.

Abstract

Background: Facilitating factors and barriers to breast milk feeding (BMF) very preterm (VP) infants have been widely studied at the individual level. We aimed to describe and analyse factors associated with BMF at discharge for VP infants, with a special focus on unit policies aiming to support BMF.

Methods: We described BMF at discharge in 3108 VP infants enrolled in EPIPAGE-2, a French national cohort. Variables of interest were kangaroo care during the 1st week of life (KC); unit’s policies supporting BMF initiation (BMF information systematically given to mothers hospitalised for threatened preterm delivery and breast milk expression proposed within 6 hours after birth) and BMF maintenance (availability of protocols for BMF and a special room for mothers to pump milk); the presence in units of a professional trained in human lactation and regional BMF initiation rates in the general population. Associations were investigated by multilevel logistic regression analysis, with adjustment on individual factors.

Results: In total, 47.2% of VP infants received BMF at discharge (range among units 21.1%-84.0%). Unit policies partly explained this variation, regardless of individual factors. BMF at discharge was associated with KC (adjusted odds ratio (aOR) 2.26 (95% confidence interval (CI) 1.40, 3.65)), with policies supporting BMF initiation (aOR 2.19 (95% CI 1.27, 3.77)) and maintenance (aOR 2.03 (95% CI 1.17, 3.55)), but not with BMF initiation rates in the general population.

Conclusion: Adopting policies of higher performing units could be an effective strategy for increasing BMF rates at discharge among VP infants.

Abstract

Objective: To assess whether planned route of delivery is associated with perinatal and 2-year outcomes for preterm breech singletons.
Design: Prospective nationwide population-based EPIPAGE-2 cohort study.
Setting: France, 2011.
Sample: Three hundred and ninety women with breech singletons born at 26-34 weeks of gestation after preterm labour or preterm prelabour rupture of membranes.
Methods: Propensity-score analysis.
Main outcome measures: Survival at discharge, survival at discharge without severe morbidity, and survival at 2 years of corrected age without neurosensory impairment.
Results: Vaginal and caesarean deliveries were planned in 143 and 247 women, respectively. Neonates with planned vaginal delivery and planned caesarean delivery did not differ in survival (93.0 versus 95.7%, P = 0.14), survival at discharge without severe morbidity (90.4 versus 89.9%, P = 0.85), or survival at 2 years without neurosensory impairment (86.6 versus 91.6%, P = 0.11). After applying propensity scores and assigning inverse probability of treatment weighting, as compared with planned vaginal delivery, planned caesarean delivery was not associated with improved survival (odds ratio, OR 1.31; 95% confidence interval, 95% CI 0.67-2.59), survival without severe morbidity (OR 0.75, 95% CI 0.45-1.27), or survival at 2 years without neurosensory impairment (OR 1.04, 95% CI 0.60-1.80). Results were similar after matching on propensity score.
Conclusions: No association between planned caesarean delivery and improved outcomes for preterm breech singletons born at 26-34 weeks of gestation after preterm labour or preterm prelabour rupture of membranes was found. The route of delivery should be discussed with women, balancing neonatal outcomes with the higher risks of maternal morbidity associated with caesarean section performed at low gestational age.

Presse Med.2019 Jan;48(1 Pt 1):34-45. doi: 10.1016/j.lpm.2018.11.022. Epub2019 Jan 18

Indications for aspirin during pregnancy are a matter of debate and there is a recent trend to an extended prescription and an overuse of aspirin in pregnancy. Aspirin is efficient in secondary prevention of preeclampsia essentially in patients with a personal history of preeclampsia. The effect of aspirin on platelet aggregation and on the TXA2/PGI2 balance is dose-dependent. The optimum dosage, from 75mg/day to 150mg/day, needs to be determined. Fetal safety data at 150mg/day are still limited. The efficacy of aspirin seems to be subject to a chronobiological effect. It is recommended to prescribe an evening or bedtime intake. Aspirin, in primary prevention of preeclampsia, given to high-risk patients identified in the first trimester by screening tests, seems to reduce the occurrence of early-on set preeclampsia. Nevertheless, there are insufficient data for the implementation of such screening procedures in practice.

Abstract

Objective: Caesarean section (CS) may reduce mortality and morbidity for very preterm breech infants, but evidence is inconclusive. We evaluated neonatal outcomes for singleton breech infants by mode of delivery in a European cohort.

Study design: Data come from the EPICE population-based cohort of very preterm births in 19 regions in 11 European countries (7770 live births). The study population was singleton spontaneous-onset breech births at 24-31 weeks gestational age (GA) without antenatal medical complications requiring caesarean delivery (N = 572). Mixed-effects regression models adjusting for maternal and pregnancy covariates and propensity score matching was used to examine the effect of (1) CS and (2) a unit policy of systematic CS for breech presentation by GA. The primary outcome was a composite of in-hospital mortality, intraventricular haemorrhage grades III & IV or cystic periventricular leukomalacia. Secondary outcomes were each component separately, five minute Apgar score below seven and mortality within six hours of delivery.

Results: 64.4% of infants were delivered by CS with a range across regions from 41% to 100%; these infants had higher GA and were more likely to be small for gestational age, receive antenatal steroids, and have mothers who were hospitalised for more than one day before delivery compared to those delivered vaginally. CS was associated with lower risks of all outcomes in mixed-effects adjusted models (odds ratio (OR) for the composite outcome: 0.50, 95% confidence interval (CI): 0.30-0.81), but not in propensity score matched models (OR: 0.72, 95% CI: 0.41; 1.29). A systematic CS policy was associated with lower mortality and morbidity in unadjusted, but not adjusted models (OR for composite outcome: 0.76, 95% CI: 0.44; 1.28). 35% of births 24-25 weeks were delivered by CS and protective effects were consistently stronger, but not statistically significant.

Conclusions: Point estimates indicated protective effects of caesarean delivery for very preterm breech infants in conventional statistical models. However, analyses using propensity scores and based on unit policies did not confirm statistically significant associations. Prospective large-scale studies are needed to establish best practice and could be implemented in European regions where vaginal delivery remains an option.

BMC Med. 2018 Dec 5;16(1):227. doi: 10.1186/s12916-018-1206-4.

BACKGROUND:

Emerging evidence suggests intensity of perinatal care influences survival for extremely preterm babies. We evaluated the effect of differences in perinatal care intensity between centres on sensorimotor morbidity at 2 years of age. We hypothesised that hospitals with a higher intensity of perinatal care would have improved survival without increased disability.

METHODS:

Foetuses alive at maternal admission to a level 3 hospital in France in 2011, subsequently delivered between 22 and 26 weeks gestational age (GA) and included in the EPIPAGE-2 national prospective observational cohort study formed the baseline population. Level of intensity of perinatal care was assigned according to hospital of birth, categorised into three groups using ‘perinatal intensity’ ratios (ratio of 24-25 weeks GA babies admitted to neonatal intensive care to foetuses of the same GA alive at maternal admission to hospital). Multiple imputation was used to account for missing data; hierarchical logistic regression accounting for births nested within centres was then performed.

RESULTS:

One thousand one hundred twelve foetuses were included; 473 survived to 2 years of age (126 of 358 in low-intensity, 140 of 380 in medium-intensity and 207 of 374 in high-intensity hospitals). There were no differences in disability (adjusted odds ratios 0.93 (95% CI 0.28 to 3.04) and 1.04 (95% CI 0.34 to 3.14) in medium- and high- compared to low-intensity hospitals, respectively). Compared to low-intensity hospitals, survival without sensorimotor disability was increased in the population of foetuses alive at maternal admission to hospital and in live-born babies, but there were no differences when considering only babies admitted to NICU or survivors.

CONCLUSIONS:

No difference in sensorimotor outcome for survivors of extremely preterm birth at 2 years of age was found according to the intensity of perinatal care provision. Active management of periviable births was associated with increased survival without sensorimotor disability.

Abstract

Aim: Children born very preterm require additional specialist care because of the health and developmental risks associated with preterm birth, but information on their health service use is sparse. We sought to describe the use of specialist services by children born very preterm in Europe.

Method: We analysed data from the multi-regional, population-based Effective Perinatal Intensive Care in Europe (EPICE) cohort of births before 32 weeks’ gestation in 11 European countries. Perinatal data were abstracted from medical records and parents completed a questionnaire at 2 years corrected age (4322 children; 2026 females, 2296 males; median gestational age 29wks, interquartile range [IQR] 27-31wks; median birthweight 1230g, IQR 970-1511g). We compared parent-reported use of specialist services by country, perinatal risk (based on gestational age, small for gestational age, and neonatal morbidities), maternal education, and birthplace.

Results: Seventy-six per cent of the children had consulted at least one specialist, ranging across countries from 53.7% to 100%. Ophthalmologists (53.4%) and physiotherapists (48.0%) were most frequently consulted, but individual specialists varied greatly by country. Perinatal risk was associated with specialist use, but the gradient differed across countries. Children with more educated mothers had higher proportions of specialist use in three countries.

Interpretation: Large variations in the use of specialist services across Europe were not explained by perinatal risk and raise questions about the strengths and limits of existing models of care.

What this paper adds: Use of specialist services by children born very preterm varied across Europe. This variation was observed for types and number of specialists consulted. Perinatal risk was associated with specialist care, but did not explain country-level differences. In some countries, mothers’ educational level affected use of specialist services.

J Pediatr. 2018 Dec;203:150-155. doi: 10.1016/j.jpeds.2018.07.072. Epub 2018 Sep 27.

OBJECTIVE:

To evaluate the association between active antenatal management and neonatal outcomes in extremely preterm newborns admitted to a neonatal intensive care unit (NICU).

STUDY DESIGN:

This population-based cohort study was conducted in 25 regions of France. Infants born in 2011 between 22^0/7 and 26^6/7 weeks of gestation and admitted to a NICU were included. Infants with lethal congenital malformations or death in the delivery room were excluded. A multilevel multivariable analysis was performed, accounting for clustering by mother (multiple pregnancies) and hospital plus individual characteristics, to estimate the association between the main exposure of no active antenatal management (not receiving antenatal corticosteroids, magnesium sulfate, or cesarean delivery for fetal indications) and a composite outcome of death or severe neonatal morbidity (including severe forms of brain or lung injury, retinopathy of prematurity, and necrotizing enterocolitis).

RESULTS:

Among 3046 extremely preterm births, 783 infants were admitted to a NICU. Of these, 138 (18%) did not receive active antenatal management. The risk of death or severe morbidity was significantly higher for infants without active antenatal management (crude OR, 2.60; 95% CI, 1.44-4.66). This finding persisted after adjustment for gestational age (OR, 2.08; 95% CI, 1.19-3.62) and all confounding factors (OR, 1.86; 95% CI, 1.09-3.20).

CONCLUSIONS:

The increased risk of severe neonatal outcomes for extremely preterm babies admitted to a NICU without optimal antenatal management should be considered in individual-level decision making and in the development of professional guidelines for the management of extremely preterm births.

PLoS One.2018 Sep 24;13(9):e0204498. doi:10.1371/journal.pone.0204498. eCollection 2018

BACKGROUND AND OBJECTIVES:

Small for gestational age and preeclampsia have both been described as risk factors for bronchopulmonary dysplasia in preterm neonates, but their respective role in the occurrence of bronchopulmonary dysplasia is debated. We evaluated the relation between small for gestational age and bronchopulmonary dysplasia in neonates born to mothers with preeclampsia. We hypothesized that low birth weight is still associated with bronchopulmonary dysplasia in this homogeneous population.

METHODS:

Retrospective single-center cohort study including 141 neonates born between 24 and 30 weeks’ gestation to mothers with preeclampsia. The main outcome measure was moderate to severe bronchopulmonary dysplasia at 36 weeks’ postmenstrual age. Neonates born small for gestational age (birthweight < 10th percentile on the AUDIPOG curves) were compared to those with appropriate birthweight for gestational age by bivariable analyses and logistic regression models, estimating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS:

Bronchopulmonary dysplasia rates were 61.5% (32/52) and 27.4% (20/73) for small for gestational age and appropriate birthweight for gestational age neonates (p < .001). On adjustment for gestational age and other confounding factors, the risk of moderate to severe bronchopulmonary dysplasia was greater for small for gestational age than appropriate birthweight for gestational age neonates (adjusted OR = 5.9, 95% CI [2.2-15.4]), as was the composite outcome death or moderate to severe bronchopulmonary dysplasia (adjusted OR = 4.7, 95% CI [1.9-11.3]).

CONCLUSIONS:

Small for gestational age was associated with bronchopulmonary dysplasia in very preterm neonates born to mothers with preeclampsia.

Erratum in

• Risk of Severe Acute Maternal Morbidity According to Planned Mode of Delivery in Twin Pregnancies: Correction.[No authors listed]Obstet Gynecol. 2018 Dec;132(6):1507. doi: 10.1097/AOG.0000000000002998.PMID: 30461682 No abstract available.

Abstract

Objective: To evaluate the association between the planned mode of delivery and severe acute maternal morbidity in women with twin pregnancies.

Methods: In this planned secondary analysis of the JUmeaux MODe d’Accouchement cohort, a national prospective population-based study of twin deliveries conducted from February 2014 to March 2015 in 176 hospitals performing more than 1,500 annual deliveries in France, we included women with twin pregnancies at 24 weeks of gestation or greater with two live fetuses. Women delivering before 24 weeks of gestation, those with recognized indications for cesarean delivery, and those with severe acute maternal morbidity symptomatic before labor were excluded to limit confounding by indication. The primary outcome was a composite measure of intra- or postpartum severe acute maternal morbidity. Multivariate Poisson regression models and propensity score matching were used to control for potential confounding by indication. Analyses were conducted for the overall study cohort as well as stratified by maternal age in years (younger than 30, 30-34, 35 years or older). No adjustments were made for multiple comparisons.

Results: Among the 8,124 women included in this analysis, 3,062 (37.7%) had planned cesarean deliveries and 5,062 (62.3%) had planned vaginal deliveries, of whom 4,015 (79.3%) delivered both twins vaginally. No significant overall association was found between the planned mode of delivery and severe acute maternal morbidity (6.1% in the planned cesarean delivery group and 5.4% in the planned vaginal group; adjusted relative risk 1.00, 95% CI 0.81-1.24). In women 35 years or older, the risk of severe acute maternal morbidity was significantly higher for those with planned cesarean delivery than planned vaginal delivery (7.8% vs 4.6%, adjusted relative risk 1.44, 95% CI 1.02-2.06). Propensity score and secondary analyses yielded similar results.

Conclusion: In twin pregnancies, there is no overall association between planned mode of delivery and severe acute maternal morbidity. Women older than 35 years may be at higher risk of severe acute maternal morbidity after planned cesarean delivery.