Delivery In France Research Articles

Maternal and neonatal outcomes according to the timing of diagnosis of hyperglycaemia in pregnancy: a nationwide cross-sectional study of 695,912 deliveries in France in 2018.

We aimed to assess maternal-fetal outcomes according to various subtypes of hyperglycaemia in pregnancy. We used data from the French National Health Data System (Système National des Données de Santé), which links individual data from the hospital discharge database and the French National Health Insurance information system. We included all deliveries after 22 gestational weeks (GW) in women without pre-existing diabetes recorded in 2018. Women with hyperglycaemia were classified as having overt diabetes in pregnancy or gestational diabetes mellitus (GDM), then categorised into three subgroups according to their gestational age at the time of GDM diagnosis: before 22 GW (GDM<22); between 22 and 30 GW (GDM22-30); and after 30 GW (GDM>30). Adjusted prevalence ratios (95% CI) for the outcomes were estimated after adjusting for maternal age, gestational age and socioeconomic status. Due to the multiple tests, we considered an association to be statistically significant according to the Holm-Bonferroni procedure. To take into account the potential immortal time bias, we performed analyses on deliveries at ≥31 GW and deliveries at ≥37 GW. The study population of 695,912 women who gave birth in 2018 included 84,705 women (12.2%) with hyperglycaemia in pregnancy: overt diabetes in pregnancy, 0.4%; GDM<22, 36.8%; GDM22-30, 52.4%; and GDM>30, 10.4%. The following outcomes were statistically significant after Holm-Bonferroni adjustment for deliveries at ≥31 GW using GDM22-30 as the reference. Caesarean sections (1.54 [1.39, 1.72]), large-for-gestational-age (LGA) infants (2.00 [1.72, 2.32]), Erb's palsy or clavicle fracture (6.38 [2.42, 16.8]), preterm birth (1.84 [1.41, 2.40]) and neonatal hypoglycaemia (1.98 [1.39, 2.83]) were more frequent in women with overt diabetes. Similarly, LGA infants (1.10 [1.06, 1.14]) and Erb's palsy or clavicle fracture (1.55 [1.22, 1.99]) were more frequent in GDM<22. LGA infants (1.44 [1.37, 1.52]) were more frequent in GDM>30. Finally, women without hyperglycaemia in pregnancy were less likely to have preeclampsia or eclampsia (0.74 [0.69, 0.79]), Caesarean section (0.80 [0.79, 0.82]), pregnancy and postpartum haemorrhage (0.93 [0.89, 0.96]), LGA neonate (0.67 [0.65, 0.69]), premature neonate (0.80 [0.77, 0.83]) and neonate with neonatal hypoglycaemia (0.73 [0.66, 0.82]). Overall, the results were similar for deliveries at ≥37 GW. Although the estimation of the adjusted prevalence ratio of perinatal death was five times higher (5.06 [1.87, 13.7]) for women with overt diabetes, this result was non-significant after Holm-Bonferroni adjustment. Compared with GDM22-30, overt diabetes, GDM<22 and, to a lesser extent, GDM>30 were associated with poorer maternal-fetal outcomes.

Anesthesia practices for management of labor pain and cesarean delivery in France (EPIDOL): A cross-sectional survey

BackgroundThis study aimed to collect obstetric anesthesia practice and patient-reported outcomes as an update to the last French Obstetric Anesthesia survey from 1996. MethodsMaternity units were randomly selected across France and surveyed for 7 consecutive days from February, 2016, to January, 2017. Data was gathered prospectively by questionnaires filled out by patients and anesthesia providers. ResultsThere were 1885 questionnaires received from 56 units, with 379 cesarean delivery (CD) and 1506 vaginal delivery (VD) cases analyzed. The overall neuraxial labor analgesia (NLA) rate was 82.5% (95% CI [82.4–82.6]), with 70.3% (95% CI [71.4–71.6]) receiving automated administration (PCEA/PIEB). NLA was effective throughout labor in 68.2% of cases, however, severe pain was reported by 29.4% of patients. The overall rate of alternative approaches for labor analgesia was 19.5% (95%CI [19.2–19.7]). Obesity (OR 2.8; 95% CI [1.0−7.5], p < 0.04) and delivery in level I units (OR 0.6; 95% CI [0.5−0.9], p < 0.01) were associated with severe pain during VD. Satisfaction was found to be similar in patients delivering with or without NLA. The incidence of pain during CD was similar in scheduled versus non-scheduled CD. Failure of NLA during CD was associated with severe pain (OR 10.0; 95% CI [3.1−31.9], p < 0.01) and dissatisfaction (OR 26.2; 95% CI [3.0–225.1], p < 0.01). ConclusionDespite the high NLA rate in France, a significant proportion of women experience severe pain during labor and delivery. This study emphasizes the need for further practice guidelines in obstetric anesthesia to ensure optimal pain management and improve patients' experience during childbirth.clinicaltrials.govNCT02853890.

In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study.

To investigate maternal and neonatal outcomes after a delivery in France in 2019, according to hospital characteristics and the impact of distance and time of travel on mother and newborn. All parturients above 18 years of age who delivered in 2019 and were identified in the French health insurance database were included, with their newborns, in this retrospective cohort study. Main outcome measures were Severe Maternal Morbidity score and the Neonatal Adverse Outcome Indicator (NAOI). Among the 733 052 pregnancies included, 10 829 presented a severe maternal morbidity (1.48%) and 77 237 had a neonatal adverse outcome (10.4%). Factors associated with an unfavorable maternal or neonatal outcome were Obstetric Comorbidity Index, primiparity, and cesarean or instrumental delivery. Prematurity was associated with less severe maternal morbidity but more neonatal adverse outcomes. Time of travel above 30 min was associated with a higher NAOI rate. Results suggest the efficiency of regionalization of perinatal care in France, although a difference in both outcomes persists according to unit volume, suggesting the need for a further step in concentrating perinatal care. Perinatal care organization should focus on mapping the territory with high-level, high-volume maternity throughout the territory; this suggests closing down high-volume units and improving low-volume ones to maintain coherent mapping.

Acute coronary syndrome during pregnancy and postpartum in France: the nationwide CONCEPTION study

Cardiovascular diseases, including acute coronary syndromes, are the leading cause of maternal death in many developed countries. We assessed acute coronary syndrome incidences during pregnancy, peripartum, and postpartum periods. We also compared overall pregnancy (ie, covering all 3 periods) incidence with that found in nonpregnant women of childbearing age. All women aged between 15 and 49 years without ischemic heart disease who delivered between 2010 and 2018 in France were included in the CONCEPTION cohort. Data were extracted from the French National Health Insurance Information System database. Acute coronary syndromes were defined according to the International Classification of Diseases, Tenth Revision codes recorded in the principal hospital diagnosis. We used Poisson regression to estimate crude acute coronary syndrome incidences, and tested age-adjusted Poisson models to compare the incidence risk ratio of acute coronary syndrome between pregnant and nonpregnant women, with 95% confidence intervals. Among 6,298,967 deliveries in France, we observed 225 first-time acute coronary syndrome diagnoses during overall pregnancy (overall pregnancy-related acute coronary syndrome incidence, 4.34/100,000 person-years; 1 case/23,000 pregnancies). In multivariate analysis, independent factors associated with acute coronary syndrome were age, social deprivation, obesity, tobacco use, chronic hypertension, and hypertensive disorders of pregnancy (all P<.05). Among the nonpregnant women aged 15 to 49 years in the general French population, 18,247 cases of acute coronary syndrome (incidence, 16.5/100,000 person-years) occurred throughout the whole study period (>100 million person-years). Compared with the acute coronary syndrome incidence in nonpregnant women, age-adjusted overall pregnancy-related acute coronary syndrome incidence was lower (incidence rate ratio, 0.76; 95% confidence interval, 0.57-0.98; P<.05). Although compared with nonpregnant women, age-adjusted incidence rates were lower during pregnancy, risk was increased during peripartum and postpartum periods. With an incidence of 4.34 per 100,000 person-years, acute coronary syndrome still accounts for a significant proportion of maternal mortality. The peripartum and postpartum periods remain high-risk periods, and greater efforts should be made in terms of acute coronary syndrome prevention, especially because several cardiovascular risk factors are treatable, such as tobacco use and hypertensive disorders of pregnancy.

Is there still an indication for episiotomy? Results from a French national database analysis.

To assess the link between mediolateral episiotomy and the occurrence of obstetrical anal sphincter injury (OASIS). Data were collected from the national database (PMSI; Programme de Médicalisation des Systèmes d'Information). Women between 18 and 50 years old, undergoing a vaginal delivery in France in 2018 were included. The main outcome was factors associated with a higher adjusted OASIS rate after a vaginal delivery. Of 623 003 women with a vaginal delivery, 239 949 were primiparous (38.5%), 62 310 experienced mediolateral episiotomy (10.0%) and 7077 had a third- or fourth-degree perineal tear (1.14%). Risk factors for OASIS were primiparity (adjusted odds ratio [OR] 2.97), shoulder dystocia (aOR 2.57), instrumental delivery (aOR 2.81), gestational diabetes (aOR 1.20), and post-term delivery (aOR 1.53). Mediolateral episiotomy increased the occurrence of OASIS for women without an instrumental delivery, either for parous (OR 1.32, 95% confidence interval [CI] 1.07-1.62) or primiparous (OR 1.26, 95% CI 1.13-1.39) women. In contrast, episiotomy among primiparous women with episiotomy and a vacuum or forceps delivery significantly decreased the risk for OASIS (OR 0.62, 95% CI 0.56-0.67). The practice of routine episiotomy should be discouraged. Selective mediolateral episiotomy should be considered with extreme caution and mainly for primiparous women during instrumental vaginal delivery. Further randomized trial may confirm such results.

412 Preliminary efficacy and satisfaction study of a new single-use obstetrical vacuum: Icup2®

Objective: The 2016 National Perinatal Survey showed that 12.2% of women had an operative delivery in France. Vacuum delivery is the most frequent obstetrical instrument used in 49.8% of cases in our country. The 2006 initial concept of the Icup® vacuum was based on the development of a single-use device with a partially deformable cup to avoid any fetal scalp injury. However, owing to a significant rate of premature cup release, this first device required technical improvements which resulted in a new version: the Icup2® which obtained the CE label in February 2017.

Pregnancy, delivery and neonatal complications in women with schizophrenia: a national population-based cohort study.

BackgroundExisting studies evaluating the association between schizophrenia and complications associated with pregnancy, delivery and neonatal outcomes are based on data prior to 2014 and have reported heterogeneous results. The objective of our study was to determine whether pregnant women with schizophrenia were at increased risk of pregnancy, delivery and neonatal complications compared with women without severe mental disorders.MethodsWe performed a population-based cohort study of all singleton deliveries in France between Jan. 1, 2015, and Dec. 31, 2019. We divided this population into cases (i.e., women with schizophrenia) and controls (i.e., women without a diagnosis of severe mental disorder). Cases and controls were matched (1:4) inside the same hospital and the same year by age, social deprivation, parity, smoking, alcohol and substance addictions, malnutrition, obesity, and comorbidities. Univariate and multivariate models with odds ratios and 95% confidence intervals (ORs [95% CIs]) were used to estimate the association between schizophrenia and 24 pregnancy, delivery and neonatal outcomes.FindingsOver 5 years, 3,667,461 singleton deliveries were identified, of which 3,108 occurred in women with schizophrenia. Compared to controls, women with schizophrenia were found to be older; have more frequent smoking, alcohol and substance addictions; suffer from obesity, diabetes and chronic obstructive pulmonary disease; and often be hospitalized in tertiary maternity hospitals. Compared to matched controls, women with schizophrenia had more pregnancy complications (adjusted OR=1.41[95%CI 1.31-1.51]) (i.e., gestational diabetes, gestational hypertension, genito-urinary infection, intrauterine growth retardation and threatened preterm labour). They had more delivery complications (aOR=1.18[95%CI 1.09 1.29]) with more still births/medical abortions (aOR=2.17[95%CI 1.62-2.90]) and caesarean sections (aOR=1.15[95%CI 1.05-1.25]). Newborns of women with schizophrenia had more neonatal complications (aOR=1.38[95%CI 1.27-1.50]) with more born preterm (aOR=1.64[95%CI1.42 -1.90]), small for gestational age (aOR=1.34[95%CI 1.19-1.50]) and low birth weight (aOR=1.75[95%CI 1.53-2.00]).InterpretationOur results highlight the importance of health disparities between pregnant women with and without schizophrenia, as well as in their newborns. Our study calls for health policy interventions during and before pregnancy, including proportionate intensified care to the level of needs, effective case management and preventive and social determinant approaches.FundingNo funding.

Increased Risk of Hospitalization for Pancreatic Cancer in the First 8 Years after a Gestational Diabetes Mellitus regardless of Subsequent Type 2 Diabetes: A Nationwide Population-Based Study.

Simple SummaryPancreatic cancer is one of the cancers with the highest mortality rate which is most often attributed to late diagnosis. The identification of risk factors is therefore important. While gestational diabetes also shares mechanisms of action with diabetes mellitus, several studies have provided hypotheses that could explain the pathophysiology of the link between diabetes mellitus and risk of pancreatic cancer. Accordingly, the aim of our study was to determine the risk of developing pancreatic cancer in women with a history of gestational diabetes from a quasi-exhaustive national medico-administrative database for deliveries in France. We included 1,368,755 women in our study. We showed that gestational diabetes was significantly associated with a greater risk of pancreatic cancer, regardless of subsequent type 2 diabetes. Our results suggest a better follow-up of patients after a gestational diabetes in order to identify high-risk profiles of developing more serious conditions, such as pancreatic cancer.The aim of this large retrospective cohort study was to use a quasi-exhaustive national medico-administrative database of deliveries in France to determine the risk of developing pancreatic cancer (PC) in women with a history of gestational diabetes mellitus (GDM). This nationwide population-based study included women aged 14–55 who gave birth between 1st January 2008 and 31 December 2009. The women were followed-up epidemiologically for eight years. Survival analyses using Cox regression models, adjusted for age, subsequent type 2 diabetes, and tobacco consumption, were performed on the time to occurrence of hospitalization for PC. The onset of GDM, tobacco consumption and subsequent type 2 diabetes were considered as time-dependent variables. Among 1,352,560 women included, 95,314 had a history of GDM (7.05%) and 126 women were hospitalized for PC (0.01%). Over the eight years of follow-up, GDM was significantly associated with a higher risk of hospitalization with PC in the first Cox regression model adjusted for age and subsequent type 2 diabetes (HR = 1.81 95% CI [1.06–3.10]). The second Cox regression model adjusted for the same covariates, plus tobacco consumption, showed that GDM was still significantly associated with a higher risk of hospitalization for PC with nearly the same estimated risk (HR = 1.77 95% CI [1.03–3.03]). Gestational diabetes was significantly associated with a greater risk of hospital admission for pancreatic cancer within eight years, regardless of subsequent type 2 diabetes.

Does Programmed Intermittent Epidural Bolus Improve Childbirth Conditions of Nulliparous Women Compared With Patient-controlled Epidural Analgesia? A Multicentre, Randomized, Controlled, Triple-blind Study

(Eur J Anaesthesiol. 2019;36:755–762) Currently about 80% of deliveries in France involve an epidural for labor analgesia. Epidural rates and programs have changed over time, but various authors have found that a programmed intermittent epidural bolus (PIEB) plus patient-controlled epidural analgesia (PCEA) demand dosing strategy for maintenance of labor analgesia decreased the rate of instrumental vaginal delivery, lessened anesthetic drug consumption and increased maternal satisfaction scores compared with a continuous background infusion+PCEA. This study aimed to investigate whether the use of a modern PIEB pump improved the mechanics of the second stage of labor compared with a conventional epidural analgesia technique.

Out-of-maternity deliveries in France: A nationwide population-based study.

IntroductionIn France, many maternity hospitals have been closed as a result of hospital restructuring in an effort to reduce costs through economies of scale. These closures have naturally increased the distance between home and the closest maternity ward for women throughout the country. However, studies have shown a positive correlation between this increase in distance and the incidence of unplanned out-of-maternity deliveries (OMD). This study was conducted to estimate the frequency of OMD in France, to identify the main risk factors and to assess their impact on maternal mortality and neonatal morbidity and mortality.Materials and methodsWe conducted a population-based observational retrospective study using data from 2012 to 2014 obtained from the French hospital discharge database. We included 2,256,797 deliveries and 1,999,453 singleton newborns in mainland France, among which, 6,733 (3.0‰) were OMD. The adverse outcomes were maternal mortality in hospital or during transport, stillbirth, neonatal mortality, neonatal hospitalizations, and newborn hypothermia and polycythemia. The socio-residential environment was also included in the regression analysis. Maternal and newborn adverse outcomes associated with OMD were analyzed with Generalized Estimating Equations regressions.ResultsThe distance to the nearest maternity unit was the main factor for OMD. OMD were associated with maternal death (aRR 6.5 [1.6–26.3]) and all of the neonatal adverse outcomes: stillbirth (3.3 [2.8–3.8]), neonatal death (1.9 [1.2–3.1]), neonatal hospitalization (1.2 [1.1–1.3]), newborn hypothermia (5.9 [5.2–6.6]) and newborn polycythemia (4.8 [3.5–6.4]).DiscussionIn France, OMD increased over the study period. OMD were associated with all the adverse outcomes studied for mothers and newborns. Caregivers, including emergency teams, need to be better prepared for the management these at-risk cases. Furthermore, the increase in adverse outcomes, and the additional generated costs, should be considered carefully by the relevant authorities before any decisions are made to close or merge existing maternity units.

Association of Oxytocin Use and Artificial Rupture of Membranes With Cesarean Delivery in France.

To evaluate whether the decrease in the frequency of oxytocin administration and artificial rupture of membranes observed between the 2010 and 2016 French Perinatal Surveys was associated with a change in the frequency of cesarean delivery or cesarean delivery indications among women who entered labor spontaneously. This cross-sectional study included women who participated in the 2010 and 2016 French National surveys who had singleton pregnancies and who gave birth at at least 37 weeks of gestation after spontaneous labor to a liveborn neonate in cephalic presentation. To test whether the observed decrease of oxytocin administration and artificial rupture of membranes between the two study years was explained by the women's individual characteristics and maternity units' organizational characteristics change, multivariable analyses were performed. The same strategy was applied for the change in intrapartum cesarean delivery rates between the 2 years. These analyses were repeated in nulliparous, low obstetric risk women, multiparous low obstetric risk women, and women with a previous cesarean delivery. The cesarean delivery indications were compared in 2010 and 2016. Oxytocin administration decreased significantly from 58.3% in 2010 to 45.2% in 2016 (adjusted odds ratio [aOR] 0.51; 95% CI 0.47-0.55), as did artificial rupture of membranes, from 52.4% to 42.6% (aOR 0.66; 95% CI 0.62-0.71). The intrapartum cesarean delivery rate remained stable-6.9% compared with 6.6% (aOR 0.93; 95% CI 0.82-1.06). The same patterns were observed in low risk groups and women with a previous cesarean delivery. The cesarean delivery indications were similar in both years. The significant decrease in oxytocin administration and artificial rupture of membranes in 2016 compared with 2010 was not accompanied by an increase in the intrapartum cesarean delivery rate for women in France who entered labor spontaneously. These results support the recent international guidelines.

Caesarean delivery in a migration context: the role of prior delivery in the host country

Migrant women in industrialised countries experience high caesarean section (CS) rates but little is known about the effect of a previous delivery in the host country. This study set out to investigate this effect among migrant women in France, using data from the DSAFHIR study on healthcare access of migrant women living in emergency housing hotels, collected in the Paris Metropolitan area in 2017. Respondents reported life-long history of deliveries. We focused on deliveries occurring in France in 2000–2017: 370 deliveries reported by 242 respondents. We conducted chi-square tests and multivariate logistic regressions, adjusting for the clustering of deliveries among respondents by computing standard errors allowing for intragroup correlation. Mode of delivery was associated with duration of residence among multiparous women with no prior CS, with a higher CS rate with shorter duration of residence (16% vs. 7%, p = 0.04). In this group, a previous delivery in France was associated with a lower CS rate (5% vs. 16%, p = 0.008). In multivariate analysis, compared with women with previous birth in France, women giving birth in France for the first time had a higher risk of CS, regardless of duration of residence (aOR = 4.0, 95% CI = 1.3–12.1 for respondents with short duration of residence, aOR = 4.7, 95% CI = 1.2–18.0 for respondents with longer duration of residence). Efforts directed at decreasing the CS rate among migrant women should target women giving birth in the host country for the first time.

Association between planned mode of delivery and severe maternal morbidity in women with breech presentations: A secondary analysis of the PREMODA prospective general population study

BackgroundNeonatal morbidity among fetuses in breech presentation is not associated with planned mode of delivery in France. Data about consequences to these mothers are sparse. MethodsThe 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. ResultsAmong 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). ConclusionIn 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.

Recent Developments at DG Competition: 2018/2019

The Directorate General for Competition at the European Commission enforces competition law in the areas of antitrust, merger control, and state aids. This year’s article provides first a general presentation of the role of the Chief Competition Economist’s team and surveys some of the main achievements of the Directorate General for Competition over 2018/2019. The article then reviews the Siemens/Alstom merger, the Google Android case, as well as two state aid cases that related to a public service compensation for obligations that involved press delivery in France and Italy.

A population-based analysis of French transfusion practices for women experiencing severe postpartum hemorrhage

BackgroundTransfusion is a major therapy for severe postpartum hemorrhage but there are few population-based descriptions of practice. The objective of this retrospective French population-based study was to describe transfusion practices in women with severe postpartum hemorrhage and the compliance with guidelines. MethodsStudy data were sourced from a prior prospective population-based study of 182 309 deliveries in France between 2012 and 2013. Transfusion practices and compliance with French national guidelines were described for all women with severe postpartum hemorrhage who had been transfused with red blood cells. ResultsIn 1495 women with severe postpartum hemorrhage (0.8% of all deliveries), 35.1% were not transfused, 50.0% were transfused during active bleeding and 14.9% exclusively after control of bleeding. Among 697 women with a hemoglobin level <7 g/dL, 21.4% were not transfused. In 747 women transfused during active bleeding, 68.8% also received fresh frozen plasma (fresh frozen plasma to red blood cell ratio between 0.5 and 1 in 80.4%). Forty-four percent received fibrinogen concentrate (including 37.4% with a plasma fibrinogen level >2 g/L) and 8.6% had a massive transfusion. Among 223 women transfused after bleeding was controlled, 5.4% received fresh frozen plasma and 13% had a hemoglobin level >7 g/dL. ConclusionsOne in five women with severe postpartum hemorrhage and a low hemoglobin concentration did not receive blood transfusion, which does not comply with French national recommendations. Over-transfusion occurred in women in whom bleeding had been controlled. The use of tools to help clinicians with transfusion decision-making should be developed.

147: Risk factors of severe maternal morbidity in twin pregnancy: national population-based cohort study in France

Compared to women with singletons, women with twin pregnancy are at higher risk of maternal complications. However, among women with twin pregnancy, risk factors for maternal morbidity and subgroups at higher risk of severe maternal outcomes have been poorly characterized. Our objective was to estimate the incidence, causes and risk factors of severe acute maternal morbidity (SAMM) in women with twin pregnancy In a national prospective population-based study of twin deliveries, the JUMODA cohort, all women with twin pregnancies at or after 22 weeks of gestation were recruited in 176 hospitals performing more than 1,500 annual deliveries in France from 02/2014 to 03/2015. SAMM was a composite criterion which combines diagnoses, organ dysfunctions and interventions. The incidence of SAMM was estimated, its timing of occurrence and its causes described. Multilevel multivariate Poisson regression modeling was used to determine risk factors of SAMM and regression tree (CART) analysis to identify high-risk clinical subgroups. Among the 8,823 women with twin pregnancy of the JUMODA cohort, 542 developed SAMM, ie a global incidence of 6.14% (95% CI 5.64-6.64). Most SAMM events occurred during the postpartum period (79.6%). The leading cause was severe obstetric hemorrhage (77.5%; 4.8 for 100 twin maternities). Admission to an Intensive Care Unit occurred in 121 women (1.4 for 100 twin maternities). Women at higher risk of developing severe acute maternal morbidity were those born in Sub-Saharan Africa (aRR 1.44, 95% CI 1.01-2.07), nulliparous (aRR 1.48, 95% CI 1.18-1.85), with pregnancy obtained by vitro fertilization with autologous oocyte (aRR 1.25, 95% CI 1.01-1.55) or with oocyte donation (aRR 1.65, 95% CI 1.17-2.31), with preeclampsia (aRR 2.48, 95% CI 1.94-3.17), placenta praevia (aRR 3.48, 95% CI 2.27-5.32) or macrosomia for either twins (aRR 1.67, 95% CI 1.34-2.07). CART identified women with preeclampsia and oocyte donation as those with the highest risk (28.9%), and multiparous without preeclampsia, placenta praevia and macrosomia as those with the lowest risk (3.8%). About one woman with twin pregnancy out of 17 will develop severe acute maternal morbidity. Identification of subgroups of women at increased risk will allow accurate information of women carrying twins early in and along pregnancy as well as anticipation and potentially prevention of these events in antenatal care and at delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

387: Neonatal morbidity of cephalic second twins according to the obstetrical strategy adopted at delivery

To assess neonatal mortality and morbidity of cephalic second twins according to the obstetrical strategy adopted after vaginal birth of the first twin, either internal version followed by total breech extraction, as recommended by the French College of Gynecologists and Obstetricians, or pushing efforts. In this planned secondary analysis of the JUMODA cohort, a national prospective population-based study of twin deliveries conducted from 02/2014 to 03/2015 in 176 hospitals performing more than 1,500 annual deliveries in France, we included cephalic second twins after vaginal birth of the first twin at 32 weeks and more. Intrauterine fetal deaths, fetal malformations, twin-to-twin transfusion syndromes, monoamniotic pregnancies, and unknown presentations and managements of second twins were excluded. The primary outcome was a composite of neonatal mortality and morbidity. To control for potential confounders, we used multivariate Poisson regression models. Of 2261 cephalic second twins included in the study, 494 (21.8%) were born in breech presentation after internal version and total breech extraction and 1767 (78.2%) in cephalic presentation after pushing efforts. The mean inter-twin delivery interval was shorter in the internal version group compared to the pushing efforts group (6.6 ± 5.9 versus 10.0 ± 13.0, p<0.01). Neither rates of cesarean for the second twin (10/494 (2.0%) versus 61/1767 (3.2%), p=0.1) nor rates of composite neonatal mortality and morbidity (17/494 (3.4%) versus 36/1767 (2.2%); aRR 1.4, 95% CI 0.8-2.4) differed significantly between the two groups. Compared with pushing efforts after vaginal birth of the first twin, internal version followed by total breech extraction of cephalic second twins is associated with shorter inter-twin delivery intervals but not with improved neonatal outcomes.

Risk of Severe Acute Maternal Morbidity According to Planned Mode of Delivery in Twin Pregnancies.

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

How did episiotomy rates change from 2007 to 2014? Population-based study in France

BackgroundSince the 2000s, selective episiotomy has been systematically recommended worldwide. In France, the recommended episiotomy rate in vaginal deliveries is less than 30%. The aims of this study were to describe the evolution of episiotomy rates between 2007 and 2014, especially for vaginal deliveries without instrumental assistance and to assess individual characteristics and birth environment factors associated with episiotomy.MethodsThis population-based study included all hospital discharge abstracts for all deliveries in France from 2007 to 2014. The use of episiotomy in vaginal deliveries was identified by one code in the French Common Classification of Medical Procedures. The episiotomy rate per department and its evolution is described from 2007 to 2014. A mixed model was used to assess associations with episiotomy for non-operative vaginal deliveries and the risk factors related to the women’s characteristics and the birth environment.ResultsThere were approximately 540,000 non-operative vaginal deliveries per year, in the study period. The national episiotomy rate for vaginal deliveries overall significantly decreased from 26.7% in 2007 to 19.9% in 2014. For non-operative deliveries, this rate fell from 21.1% to 14.1%. For the latter, the use of episiotomy was significantly associated with breech vaginal delivery (aOR = 1.27 [1.23–1.30]), epidural analgesia (aOR = 1.45 [1.43–1.47]), non-reassuring fetal heart rate (aOR = 1.47 [1.47–1.49]), and giving birth for the first time (aOR = 3.85 [3.84–4.00]).ConclusionsThe episiotomy rate decreased throughout France, for vaginal deliveries overall and for non-operative vaginal deliveries. This decrease is probably due to proactive changes in practices to restrict the number of episiotomies, which should be performed only if beneficial to the mother and the infant.

Genomics in service delivery in France

Genomics in service delivery in France