docFactors associated with adverse perinatal outcomes for term breech
download 
Plainte Transcription
Factors associated with adverse perinatal outcomes for term breech
Research www. AJOG.org OBSTETRICS Factors associated with adverse perinatal outcomes for term breech fetuses with planned vaginal delivery Elie Azria, MD, PhD; Jean-Patrick Le Meaux, MD; Babak Khoshnood, MD, PhD; Sophie Alexander, MD, PhD; Damien Subtil, MD, PhD; François Goffinet, MD, PhD; for the PREMODA Study Group OBJECTIVE: We sought to identify factors associated with adverse perinatal outcomes (APO) among term breech neonates with planned vaginal deliveries. STUDY DESIGN: We conducted univariable and multilevel multivariable analysis of the data collected in the multicenter prospective observational study PREsentation et MODe d’Accouchement (PREMODA) in women with planned vaginal delivery giving birth to singleton term breech babies. The end point was a composite set of APO. RESULTS: Of 2502 women with planned vaginal delivery recruited in the 174 participating centers, 1772 (71%) delivered vaginally. Adverse outcomes were observed in 165 cases (6.59%). After adjustment, the factors associated with them were geographic origin, gestational age ⬍39 weeks at birth, birthweight ⬍10th percentile, and annual number of maternity unit births ⬍1500. CONCLUSION: When strict conditions governed the selection of delivery route and management of labor was rigorous, APO were not associated with any prenatal or peripartum obstetric factors. Key words: adverse perinatal outcome, breech, labor management, vaginal delivery Cite this article as: Azria E, Le Meaux J-P, Khoshnood B, et al. Factors associated with adverse perinatal outcomes for term breech fetuses with planned vaginal delivery. Am J Obstet Gynecol 2012;207:285.e1-9. T he publication of the Term Breech Trial (TBT) in 20001 abruptly changed clinical practices around the world, dramatically increasing the cesarean rate for breech births in those countries that had not already adopted routine cesareans for breech presentations.2-4 The trial’s conclusions, that neonatal mortality and severe morbidity were higher in the births with trial of labor than in those with planned cesarean deliveries, must nonetheless be interpreted in the light of its limitations.5-8 Its protocol for selecting women for vaginal delivery and for managing labor re- sulted in a lack of external validity in the eyes of many. Furthermore, at 2 years of age, the risk of death or neurodevelopmental delay did not differ between the children of the 2 groups,9 and several retrospective single-center series comparing planned vaginal delivery with planned cesarean delivery have demonstrated the safety of vaginal delivery in settings where the staff is experienced and the selection criteria for planned vaginal delivery strict.10-13 In 2006, the PREsentation et MODe d’Accouchement (PREMODA) study, a descriptive prospective multi- From Institut national de la santé et de la recherche médicale U953, Epidemiological Research Unit on Perinatal Health and Women’s Health (Drs Azria, Le Meaux, Koshnood, and Goffinet); the Department of Obstetrics and Gynaecology, Bichat Claude Bernard Hospital, University Paris VII (Dr Azria); and the Department of Obstetrics and Gynaecology, Port Royal Maternity, Cochin-Saint Vincent-de-Paul Hospital, University Paris V (Dr Goffinet), Paris, and the Department of Obstetrics and Gynaecology, Hôpital Jeanne de Flandre, Lille (Dr Subtil), France, and the Perinatal Epidemiology and Reproductive Health Unit, Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium (Dr Alexander). Received Feb. 26, 2012; revised May 31, 2012; accepted Aug. 14, 2012. This study was supported mainly by 2 grants from the French Ministry of Health: numbers AOM01123 (PH-RC 2001) and AOM03040 (PH-RC 2003). The research was also partly funded by the French College of Gynecologists and Obstetricians, the French Society of Perinatal Medicine, and the Belgian National Funds for Scientific Research. The funding sources had no role in the study design, data collection, data interpretation, or writing of the report. The authors report no conflict of interest. Reprints: Elie Azria, MD, PhD, Service de Gynécologie Obstétrique, Groupe Hospitalier Bichat Claude Bernard, 46, rue Henri Huchard, 75877 Paris Cedex 18 France. [email protected]. 0002-9378/$36.00 • © 2012 Mosby, Inc. All rights reserved. • http://dx.doi.org/10.1016/j.ajog.2012.08.027 center study conducted in 174 centers in France and Belgium (Appendix) and including ⬎8000 breech deliveries, reported that risks of perinatal mortality or serious neonatal morbidity were not higher in planned vaginal, compared with planned cesarean, deliveries (1.6% vs 1.45%, odds ratio [OR], 1.1; 95% confidence interval [CI], 0.75–1.61).14 This combination of reports has led some to reconsider what might have been hasty reactions. The American Congress of Obstetricians and Gynecologists, which stated in 2001 that planned vaginal delivery might no longer be appropriate,15 revised their guidelines to state that such delivery might be reasonable under hospital-specific protocol guidelines for both eligibility and management.16 The Society of Obstetricians and Gynaecologists of Canada has reached similar conclusions.17 Residual complications for term breech fetuses undergoing trial of labor nonetheless remain possible. A better understanding of the factors associated with adverse perinatal outcomes (APO) in planned vaginal deliveries could improve screening of patients eligible for trial of labor, but few studies have sought to identify these. The purpose of this secondary analysis of the PREMODA data was to estimate the effect of individual, practice, and in- OCTOBER 2012 American Journal of Obstetrics & Gynecology 285.e1 Research Obstetrics www.AJOG.org TABLE 1 TABLE 2 Criteria for planned vaginal delivery recommended by Collège National des Gynécologues Obstétriciens Français Perinatal outcome (excluding congenital abnormalities) Criteria recommended by CNGOF in 2001 Birth traumaa,b Perinatal outcome 8 (0.32) ..................................................................................................................................................................................................................................... Brachial plexus injury 5 (0.2) Parietal skull fracture 1 (0.04) Significant genital injury 2 (0.08) ..................................................................................................................................................................................................................................... Normal pelvimetry (x-ray or computed tomography) ..................................................................................................................................................................................................................................... .................................................................................................. Anteroposterior diameter of inlet ⱖ105 mma .............................................................................................................................................................................................................................................. a,b Transverse diameter of inlet ⱖ120 mma Intraventricular hemorrhage .................................................................................................. .................................................................................................. Transverse interspinous diameter of midpelvis ⱖ100 mma ........................................................................................................... No hyperextension of fetal head (ultrasonography) ........................................................................................................... Fetal weight estimated between 25003800 g ........................................................................................................... Frank breech ........................................................................................................... Continuous electronic fetal heart rate monitoring during labor ........................................................................................................... Patient’s informed consent ........................................................................................................... CNGOF, Collège National des Gynécologues Obstétriciens Français (French national college of obstetricians and gynecologists). a Planned vaginal delivery N ⴝ 2502 n (%) Measurements commonly accepted as defining normal pelvimetry. Azria. Planned vaginal delivery of term breech fetuses. Am J Obstet Gynecol 2012. Subdural hematoma M ATERIALS AND M ETHODS Patients The PREMODA study was designed to compare perinatal outcomes according to planned mode of delivery for term breech births in France and Belgium; its methods and results are reported elsewhere.14 The secondary analysis presented here focuses on the planned vaginal delivery group. Using specific data collected for this purpose about the process for deciding mode of delivery and the management of labor and delivery, we sought to identify the individual, practice, and institutional factors associated with an increased risk of APO. The data were prospectively collected in volunteer maternity units from June 1, 2001, through May 31, 2002, in 138 centers in France, for 232,999 births, and 285.e2 1 (0.04) .............................................................................................................................................................................................................................................. b 5-min Apgar ⬍7 37 (1.48) 5-min Apgar ⬍4 4 (0.16) .............................................................................................................................................................................................................................................. a .............................................................................................................................................................................................................................................. b Tracheal intubation 26 (1.04) Tracheal intubation and ventilation ⬎24 h 10 (0.4) NICU hospitalization ⬎24 h 42 (1.68) NICU hospitalization ⬎4 d 23 (0.92) Intermediate care unit hospitalization ⬎4 d 78 (3.12) .............................................................................................................................................................................................................................................. a .............................................................................................................................................................................................................................................. b .............................................................................................................................................................................................................................................. a .............................................................................................................................................................................................................................................. b .............................................................................................................................................................................................................................................. a,b Seizure 4 (0.16) .............................................................................................................................................................................................................................................. b Parenteral or tubal feeding ⬎4 d 15 (0.60) .............................................................................................................................................................................................................................................. a,b Fetal death 2 (0.08) Neonatal death 0 .............................................................................................................................................................................................................................................. a,b .............................................................................................................................................................................................................................................. Fetal and neonatal mortality or serious neonatal morbidity 40 (1.60) .............................................................................................................................................................................................................................................. Adverse perinatal outcome 165 (6.59) .............................................................................................................................................................................................................................................. Perinatal outcome in planned cesarean delivery group is presented elsewhere.14 NICU, neonatal intensive care unit. a stitutional factors on the risk of APO in term breech births for which vaginal delivery was planned. 0 .............................................................................................................................................................................................................................................. a,b Criteria included in combined outcome “Fetal and neonatal mortality or serious neonatal morbidity”; b Criteria included in combined outcome “Adverse perinatal outcome.” Azria. Planned vaginal delivery of term breech fetuses. Am J Obstet Gynecol 2012. from Jan. 1, 2002, through Dec. 31, 2002, in 36 centers in Belgium, for 31,106 births. The study was approved by the French Data Protection Authority. The study included all women giving birth in a participating maternity unit to a singleton fetus in breech presentation ⬎37 weeks’ gestation, alive or not. Detailed reports were obtained for all deaths before discharge and transfers to neonatal intensive or intermediate care units. All existing autopsy reports were sought and obtained. All congenital anomalies and reasons for hospitalization were coded according to the International Statistical Classification of Diseases, 10th Revision. All deaths before discharge–fetal, neonatal, and postneonatal–were reviewed by an independent expert committee to determine the cause of each death and whether a planned ce- American Journal of Obstetrics & Gynecology OCTOBER 2012 sarean delivery at 39 weeks might have prevented it. In 2001, vaginal delivery of fetuses in breech presentation remained an acceptable option in France and Belgium. During the study period, the recommendations by the Collège National des Gynécologues Obstétriciens Français (French national college of obstetricians and gynecologists) served as the reference for determining mode of delivery (Table 1).18 Outcomes An APO was defined as ⱖ1 of the following: fetal mortality after the delivery route decision, neonatal mortality before discharge, 5-minute Apgar score ⬍7, tracheal intubation, seizures ⬍24 hours of age, tube feeding for at least 4 days, admission to the neonatal intensive care unit for ⬎24 hours, admission to an intermediate care unit for Obstetrics www.AJOG.org ⬎4 days, birth trauma including subdural hematoma, intracerebral or intraventricular hemorrhage, spinal cord injury, basal skull fracture, peripheral-nerve injury present at discharge, or clinically significant genital injury. Research TABLE 3 Factors associated with adverse perinatal outcomes, univariate analysis of all women in planned vaginal delivery group (n ⴝ 2502) APO, n ⴝ 165 n (%) Factors OR (95% CI) Maternal characteristics Factors studied We studied 3 types of factors: individual, practice, and institutional. Individual factors included maternal characteristics such as age at delivery, geographic origin (native country), educational level, parity, previous vaginal delivery, and previous cesarean delivery. It also included neonatal characteristics such as gestational age at birth, birthweight, and sex. At birth, small for gestational age was defined as birthweight ⱕ10th percentile according to the French birthweight standards.19 Practice factors included prenatal care, ie, factors related to management of labor and delivery: type of breech (frank or not), premature rupture of membranes (yes/no), induction of labor (yes/ no), labor augmentation with intravenous oxytocin (yes/no), lack of progress of cervical dilatation for at least 1 hour between 5-10 cm (yes/no), duration of first stage of labor between 5-10 cm, duration of passive phase of the second stage of labor, duration of active pushing (ⱕ20 minutes, ⬎20 minutes), and status of medical staff present at delivery (midwife alone, junior physician without senior, senior obstetrician). The presence or absence of a formal prenatal decision about mode of delivery, recorded in the medical file, was also collected, as were each of the criteria for breech vaginal delivery listed in the French national guidelines (listed in Table 1). Institutional factors were those related to the institution in which delivery occurred, specifically, the number of annual births and level of care. In France, maternity units are ranked in 4 levels according to the neonatal care they provide: 1 (maternity unit with a pediatrician but no neonatology unit), 2a (maternity unit with a special neonatal care nursery), 2b (maternity unit with an intermediate neonatal care unit able to provide mechanical ventilation), and level 3 (maternity unit with neonatal intensive care unit). ..................................................................................................................................................................................................................................... Maternal age ⬎35 y (n ⫽ 380) 34 (9) 1.49 (1.02–2.22) ..................................................................................................................................................................................................................................... Geographic origin ............................................................................................................................................................................................................................ Europe (n ⫽ 2047) 123 (6) 1 ............................................................................................................................................................................................................................ Sub-Saharan Africa (n ⫽ 59) 6 (10.2) 1.77 (0.75–4.20) ............................................................................................................................................................................................................................ North Africa (n ⫽ 182) 14 (7.7) 1.30 (0.73–2.32) Other (n ⫽ 87) 13 (14.9) 2.75 (1.48–5.09) 43 (7.8) 1.52 (1.02–2.28) ............................................................................................................................................................................................................................ ..................................................................................................................................................................................................................................... Educational level ⱕsecondary school (n ⫽ 553) ..................................................................................................................................................................................................................................... Nulliparous (n ⫽ 1181) 84 (7.1) 1.18 (0.86–1.61) No previous vaginal delivery (n ⫽ 1201) 87 (7.2) 1.23 (0.90–1.69) 4 (8.7) 1.36 (0.48–3.84) ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... Uterine scar (n ⫽ 46) .............................................................................................................................................................................................................................................. Pregnancy care ..................................................................................................................................................................................................................................... Cephalic version trial (n ⫽ 790) 47 (29) 0.85 (0.60–1.21) No x-ray pelvimetry (n ⫽ 426) 36 (22) 1.39 (0.94–2.04) ..................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................. Pelvic measurements ..................................................................................................................................................................................................................................... Anteroposterior diameter of inlet ⬍105 mm (n ⫽ 25) 2 (1.6) 1.30 (0.30–5.55) ..................................................................................................................................................................................................................................... Transverse diameter of inlet ⬍120 mm (n ⫽ 228) 18 (14.6) 1.33 (0.79–2.24) Transverse interspinous diameter ⬍100 mm (n ⫽ 236) 13 (11.3) 0.87 (0.48–1.58) No US assessment of fetal head flexion (n ⫽ 874) 66 (42) 1.30 (0.93–1.80) No formal decision of delivery route before labor (n ⫽ 354) 31 (19) 1.42 (0.94–2.14) ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................. Labor ..................................................................................................................................................................................................................................... Complete breech (n ⫽ 744) 59 (36.9) 1.32 (0.95–1.85) PROM (n ⫽ 491) 37 (24.3) 1.22 (0.83–1.80) Induction of labor (n ⫽ 222) 13 (7.9) 0.87 (0.49–1.56) ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... No labor augmentation with oxytocin (n ⫽ 519) 39 (36.1) 1.43 (0.95–2.15) Lack of progress in dilatation (n ⫽ 470) 33 (22.5) 1.12 (0.75–1.67) ..................................................................................................................................................................................................................................... a .............................................................................................................................................................................................................................................. Neonate characteristics ..................................................................................................................................................................................................................................... Gestational age at delivery, wk ............................................................................................................................................................................................................................ 37 (n ⫽ 282) 33 (20.1) 2.51 (1.62–2.87) 38 (n ⫽ 491) 40 (24.4) 1.68 (1.12–2.51) 39-40 (n ⫽ 1394) 70 (42.7) 1 ⱖ41 (n ⫽ 334) 21 (12.8) 1.27 (0.77–2.10) ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ..................................................................................................................................................................................................................................... Birthweight percentile ............................................................................................................................................................................................................................ ⬍10th (n ⫽ 142) 37 (22.7) 6.15 (4.05–9.36) ............................................................................................................................................................................................................................ 10-90th (n ⫽ 2142) 116 (71.2) 1 ............................................................................................................................................................................................................................ ⬎90th (n ⫽ 202) 10 (6.1) 0.91 (0.47–1.76) 82 (50) 1.25 (0.91–1.72) ..................................................................................................................................................................................................................................... Male .............................................................................................................................................................................................................................................. Azria. Planned vaginal delivery of term breech fetuses. Am J Obstet Gynecol 2012. (continued ) OCTOBER 2012 American Journal of Obstetrics & Gynecology 285.e3 Research Obstetrics www.AJOG.org TABLE 3 Factors associated with adverse perinatal outcomes, univariate analysis of all women in planned vaginal delivery group (n ⴝ 2502) (continued) APO, n ⴝ 165 n (%) Factors OR (95% CI) Institutional characteristics ..................................................................................................................................................................................................................................... Maternity unit activity, birth/y ............................................................................................................................................................................................................................ ⱕ1500 (n ⫽ 663) 54 (32.8) 1.85 (1.18–2.91) 1500-2000 (n ⫽ 700) 32 (19.4) 1 2000-2500 (n ⫽ 566) 36 (21.8) 1.42 (0.87–2.31) ⬎2500 (n ⫽ 573) 43 (26.1) 1.69 (1.06–2.71) ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ..................................................................................................................................................................................................................................... Level of maternity unit ............................................................................................................................................................................................................................ 1 (n ⫽ 422) 16 (11.4) 0.49 (0.28–0.88) 2a (n ⫽ 346) 16 (11.4) 0.61 (0.35–1.08) 2b (n ⫽ 667) 48 (34) 0.98 (0.66–1.46) 3 (n ⫽ 834) 61 (43.3) 1 ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ .............................................................................................................................................................................................................................................. APO, adverse perinatal outcome; CI, confidence interval; OR, odds ratio; PROM, premature rupture of membranes; US, ultrasound. a Defined as failure to progress ⱖ1 h. Azria. Planned vaginal delivery of term breech fetuses. Am J Obstet Gynecol 2012. Analysis All characteristics were studied in patients included in the planned vaginal group except characteristics of the late stages of labor, which were studied only in patients who actually delivered vaginally. Categorical variables were compared with a 2 test or Fisher exact test if re- quired. Continuous variables were compared by Student t test. A P value ⬍ .05 was considered significant. Crude OR and 95% CI were calculated for all factors studied in the univariable analysis. The numerous candidate variables for multivariable analysis were grouped in 5 categories (maternal, pregnancy, labor, TABLE 4 Factors associated with adverse perinatal outcomes, univariate analysis on women who delivered vaginally (n ⴝ 1772) No APO n ⴝ 1668 APO n ⴝ 104 151 (96) 155 (99) Duration of second stage, min (SD) 30 (36) 33 (35) Duration of active phase of second stage, min (SD) 12 (9) 14 (10) Factors 5-10 cm labor duration, min (SD) OR (95% CI) .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..................................................................................................................................................................................................................................... ⬎20 min (n ⫽ 193) 176 (10.8) 17 (17.5) 1.76 (1.02–3.03) .............................................................................................................................................................................................................................................. Person present at delivery ..................................................................................................................................................................................................................................... Senior obstetrician (n ⫽ 1617) 1521 (92.5) 109 (95.1) 1 ..................................................................................................................................................................................................................................... Resident without senior obstetrician (n ⫽ 41) 39 (2.4) 2 (2) 0.81 (0.19–3.42) Midwife alone (n ⫽ 87) 84 (5.1) 3 (3) 0.57 (0.18–1.82) ..................................................................................................................................................................................................................................... .............................................................................................................................................................................................................................................. All values are expressed as n (%) except as specified. APO, adverse perinatal outcome; CI, confidence interval; OR, odds ratio. Azria. Planned vaginal delivery of term breech fetuses. Am J Obstet Gynecol 2012. 285.e4 American Journal of Obstetrics & Gynecology OCTOBER 2012 neonatal, and institutional characteristics) and analyzed in 5 separate multivariable models. Factors included in these models were those with P ⬍ .25 in the univariable analysis. Because gestational age and birthweight are standard confounders, they were forced in the models. Factors considered significant (P ⬍ .20) were selected for the final multivariable analysis model. We used multilevel logistic regression models21 to take into account the hierarchical nature of data, ie, patients (level 1) nested within maternity units (level 2). These models consider correlations that may exist for outcomes at a given center. By taking such “cluster” effects into account, these models can better estimate the effects associated with predictor variables and their variance, particularly those associated with level-2 (here maternity-level) characteristics. The analysis of factors related to labor was performed on the entire population, while analyses of the factors related to end of labor and delivery were limited to women with vaginal deliveries. Only the final model is presented in this report. Statistical analysis was performed with Stata software, Version 9 (StataCorp, College Station, TX) and HLM (SSI, Lincolnwood, IL). R ESULTS During the 12-month study period, PREMODA included 8105 women: 1133 in Belgium and 6972 in France. During this period, 264,105 births occurred in the 174 participating centers, for a rate of singleton term fetuses in breech presentation of 3.1%. The planned vaginal delivery group comprised 2526 women; 24 were excluded because of lethal congenital abnormalities. Among the 2502 women finally analyzed, 1772 (71%) delivered vaginally. Mean maternal age was 29.9 years (SD 5) and 15.4% were age ⬎35 years. The principal outcome measure, APO, was observed in 165 newborns (6.59%) (Table 2), including 2 fetal deaths. The first death involved a woman with planned vaginal delivery after a previous cesarean section; she delivered a stillborn baby during an emergency cesarean during la- Obstetrics www.AJOG.org bor for uterine rupture. The second mother had had 5 previous vaginal deliveries and missed several prenatal visits. Fetal death was diagnosed at 39 weeks and 6 days of gestation, but remained unexplained. There were no neonatal deaths. Research TABLE 5 Factors associated with adverse perinatal outcomes, multivariate analysis Factors aOR (95% CI) Maternal characteristics ..................................................................................................................................................................................................................................... Univariable analysis Maternal age ⬎35 years, geographic origin, and educational level below secondary school were the only individual maternal factors associated with an increased risk of APO (Table 3). No pregnancy or labor factors were associated with increased risk. Among the neonatal factors, gestational age at birth of 37 and 38 weeks, compared with 39-40 weeks, and birthweight ⬍10th percentile were associated with this risk (Table 3). Birthweight ⬎90th percentile was not associated with APO. An annual number of births ⬍1500 was an institutional characteristic associated with an increased risk of APO, and birth at a level-1 compared with a level-3 facility was associated with reduced risk (Table 3). In the univariable analysis limited to the subgroup of women who delivered vaginally, the only factor related to the end of labor and delivery associated with an increased risk of APO was pushing efforts ⬎20 minutes (Table 4). Maternal age ............................................................................................................................................................................................................................ ⬎35 y 1.55 (0.98–2.44) ..................................................................................................................................................................................................................................... Geographic origin ............................................................................................................................................................................................................................ Europe 1 Sub-Saharan Africa 1.69 (0.68–4.21) North Africa 1.30 (0.71–2.39) Other 2.48 (1.25–4.92) ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ..................................................................................................................................................................................................................................... No previous vaginal delivery 1.30 (0.90–1.85) .............................................................................................................................................................................................................................................. a Late labor and delivery ..................................................................................................................................................................................................................................... Duration of active phase of second stage ............................................................................................................................................................................................................................ ⬎20 min 1.63 (0.87–3.02) .............................................................................................................................................................................................................................................. Neonate ..................................................................................................................................................................................................................................... Gestational age at delivery, wk ............................................................................................................................................................................................................................ 37 2.22 (1.38–3.59) 38 1.72 (1.12–2.65) 39-40 1 ⱖ41 1.57 (0.93–2.66) ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ..................................................................................................................................................................................................................................... Birthweight, g (SD) ............................................................................................................................................................................................................................ ⬍10th centile 5.75 (3.62–9.12) 10-90th centile 1 ⬎90th centile 1.03 (0.52–2.04) ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ .............................................................................................................................................................................................................................................. Multivariable analysis In the multivariable analysis of all women for whom vaginal delivery had been planned, the only maternal characteristic that remained significantly associated with APO was maternal geographic origin (Table 5). No factors related to pregnancy, labor, or delivery were associated with the risk of APO. Specifically, in the subgroup of women who delivered vaginally, pushing efforts ⬎20 minutes were not independently associated with APO. Among the neonatal factors, gestational age at birth of 37 weeks (adjusted OR [aOR], 2.22; 95% CI, 1.38 –3.59) or 38 weeks (aOR, 1.72; 95% CI, 1.12– 2.65), compared with 39-40 weeks, and birthweight ⬍10th percentile (aOR, 5.75; 95% CI, 3.62–9.12) remained associated with an increased risk of APO. An annual number of births ⬍1500 (aOR, 1.99; 95% CI, 1.17–3.40) re- Institutional characteristics ..................................................................................................................................................................................................................................... Maternity unit activity, birth/y ............................................................................................................................................................................................................................ ⱕ1500 1.99 (1.17–3.40) 1500-2000 1 2000-2500 1.28 (0.75–2.18) ⬎2500 1.36 (0.76–2.45) ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ..................................................................................................................................................................................................................................... Level of maternity unit ............................................................................................................................................................................................................................ 1 0.39 (0.18–0.83) 2a 0.67 (0.34–1.31) 2b 0.98 (0.58–1.69) 3 1 ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ ............................................................................................................................................................................................................................ .............................................................................................................................................................................................................................................. aOR, adjusted odds ratio; CI, confidence interval. a Analysis performed only among women who delivered vaginally (N ⫽ 1772). Azria. Planned vaginal delivery of term breech fetuses. Am J Obstet Gynecol 2012. mained associated with increased risk after adjustment, and delivery in a level-1 compared with level-3 facility, with a reduced risk (aOR, 0.39; 95% CI, 0.18 –0.83). C OMMENT This study shows that when vaginal delivery is planned for term breech fetuses under standard practice conditions, a geographic origin other than European, OCTOBER 2012 American Journal of Obstetrics & Gynecology 285.e5 Research Obstetrics sub-Saharan, or North African; a birthweight ⬍10th percentile; and delivery ⬍39 weeks were the only individual factors independently associated with APO. Practice factors were not independently associated with an increased risk. Delivery at a level-1 (compared with level-3) maternity unit was associated with reduced risk, whereas an annual number of births ⬍1500 was associated with increased risk. A strength of this analysis is the use of a mixed model with random effects to prevent the bias inherent in standard logistic models involving mutual dependence among subjects in the study population.20 This analysis strategy can take into account the differences between hospitals in both treatment policies and expertise. As the principal outcome variable in the primary PREMODA analysis–fetal and neonatal mortality and severe neonatal morbidity–was present in only 40 of the 2502 cases, a multivariable analysis of that outcome lacked the power to assess all factors of interest. We thus defined an outcome criterion including moderate morbidity. We did, nonetheless, perform the analysis with the initial outcome and identified no relevant factors other than those identified with the new outcome. The most relevant criterion is nonetheless the risk of death or neurodevelopmental delay at the age of 2 years, used by Whyte et al9 in the TBT. Unfortunately, the PREMODA study did not have the substantial logistic resources required to assess this outcome. Choosing APO, as defined above, as our main outcome had the advantage of providing a global view of the risk for ⱖ1 adverse outcomes. The association found between geographic origin and neonatal risk is difficult to interpret. Genetic, economic, and social factors are likely linked simultaneously with geographic origin and perinatal risk and are thus confounding factors. The category “other geographic origin” is very heterogeneous (including the Americas, Australia, and Asia) and perhaps includes the minority communities that are less well integrated in France. As only 87 women (3.5%) fell into this category, this result must be interpreted 285.e6 www.AJOG.org with caution. The finding of elevated perinatal risk among ethnic minorities is consistent with previous studies.21 A large part of this risk, however, has been linked to preterm deliveries22 excluded from our study. The high prevalence of low socioeconomic status among the non-Western women might be an explanation, at least partial, of their elevated risks,23 but as we lack additional socioeconomic data about them, we cannot adjust for it or further investigate this point. Communication issues, such as mother caregiver collaboration during the second stage, may also be at stake here. Birthweight ⬍10th percentile was the main risk factor for APO in this study. As PREMODA did not include preterm pregnancies, these low birthweights were due principally to growth restriction. This finding is consistent with a secondary analysis of the TBT data reporting that birthweight ⬍2800 g was associated with an increased risk of APO (OR, 2.13; 95% CI, 1.20 –3.80).24 Others have also observed this association between low birthweight and adverse outcome.25,26 Applying our logistic model to the planned cesarean group (data not shown) showed that birthweight ⬍10th percentile was again the factor most closely associated with APO (OR, 12.01; 95% CI, 8.35– 12.28). This finding suggests that the perinatal risk of low birthweight is related not to the delivery route but to the growth restriction itself. Other support for this hypothesis comes from a report that the most important risk factor for breech births is low birthweight, and that cesarean delivery does not improve perinatal outcome.26 A similar comment can be made about delivery ⬍39 weeks. This factor was also associated with an increased risk of APO in the planned cesarean group, a finding that suggests that the perinatal risk of birth ⬍39 weeks is not related to mode of delivery. APO was not associated with failure to comply with guidelines for vaginal delivery of term breech fetuses. These failures include the absence of pelvic measurements, planning vaginal delivery despite abnormal measurements, and failure to explore fetal head flexion. The absence of association might be due to lack of power American Journal of Obstetrics & Gynecology OCTOBER 2012 related to the high guideline compliance rate (82.8% had x-ray pelvimetry, 63.7% had fetal head flexion assessed, and a formal decision about delivery route was made before labor for 85.5%). It might also reflect the minor nature of the noncompliance, as in planning vaginal delivery when transverse diameter of the inlet measured 118 mm instead of 120 mm or not taking pelvic measurements in women with previous vaginal deliveries. Evidence supporting this interpretation can be found in the percentages of women with a transverse diameter ⬍115 mm: only 2.9% in the planned vaginal group, vs 18.3% in the planned cesarean group. The failure to comply with these criteria might therefore be interpreted as decisions related to individual contexts and thus less likely to generate adverse outcomes. We must nonetheless remember that no scientific evidence justifies the usefulness of these examinations or the relevance of the thresholds chosen. No practice-related factors (pregnancy or management of labor) were independently associated with APO. Perinatal outcome was not influenced by type of breech, premature rupture of membranes, labor induction, or poor progress of labor. This finding is explained by the results of another analysis of the PREMODA data, which showed that these factors were associated with cesarean delivery during labor27 and suggests that such delivery is indeed protective in those conditions. This point is important in guiding our practices, as it shows that the current management of labor in the participating centers is generally appropriate and further validate our guidelines. Looking at the institutional factors, we note that the decreased risk in maternity units with limited neonatal facilities might well be due to a selection bias linked to the higher prevalence of lowrisk pregnancies in these units compared with level-3 maternity units. Another relevant factor is that the variables listed in our composite criteria included care more easily–and more likely to have been–provided for mild neonatal disorders in level-3 units than elsewhere. This phenomenon, which leads to misclassification bias, was previously described in Obstetrics www.AJOG.org a low-risk population with cephalic presentation.28 Senior obstetricians were nearly always present at these deliveries (between 93.6-96.8%), and the proportion did not differ according to type of maternity unit. The increased risk associated with the smallest maternity units (⬍1500 annual deliveries), compared with others, suggests that their lack of practice with vaginal breech deliveries might account for some portion of the APO. The Canadian guidelines address this important issue of training for infrequently used skills,29 which calls attention to the need to develop new methods to train physicians.17 This study showed that planned vaginal delivery for term breech fetuses was associated with rare APO. Moreover, most of the factors associated with the risk of an adverse outcome were not related to the medical care provided nor to the planned route of delivery. These findings provide additional evidence in favor of the guidelines used in our population to decide on mode of delivery and further suggest that planned vaginal delivery under strict conditions for selection of patients and their clinical management remains a safe option for term breech fetuses. The role of the annual volume of delivery calls attention to the need to develop new methods to train physicians in rarely used skills. f REFERENCES 1. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomized multicenter trial; term breech trial collaborative group. Lancet 2000;356:1375-83. 2. Hogle KL, Kilburn L, Hewson S, Gafni A, Wall R, Hannah ME. Impact of the international term breech trial on clinical practice and concerns: a survey of center collaborators. J Obstet Gynaecol Can 2003;25:14-6. 3. Alexandersson O, Bixo M, Hogberg U. Evidence-based changes in term breech delivery practice in Sweden. Acta Obstet Gynecol Scand 2005;84:584-7. 4. Molkenboer JF, Bouckaert PX, Roumen FJ. Recent trends in breech delivery in the Netherlands. BJOG 2003;110:948-51. 5. Goffinet F, Blondel B, Breart G. Breech presentation: questions raised by the controlled trial by Hannah et al on systematic use of cesarean section for breech presentations [in French]. J Gynecol Obstet Biol Reprod (Paris) 2001;30:187-90. 6. van Roosmalen J, Rosendaal F. There is still room for disagreement about vaginal delivery of breech infants at term. BJOG 2002;109:967-9. 7. Kotaska A. Inappropriate use of randomized trials to evaluate complex phenomena: case study of vaginal breech delivery. BMJ 2004; 329:1039-42. 8. Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol 2006;194:20-5. 9. Whyte H, Hannah ME, Saigal S, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the international randomized term breech trial. Am J Obstet Gynecol 2004;191:864-71. 10. Giuliani A, Scholl WM, Basver A, Tamussino KF. Mode of delivery and outcome of 699 term singleton breech deliveries at a single center. Am J Obstet Gynecol 2002;187:1694-8. 11. Kayem G, Goffinet F, Clement D, Hessabi M, Cabrol D. Breech presentation at term: morbidity and mortality according to the type of delivery at Port Royal Maternity Hospital from 1993 through 1999. Eur J Obstet Gynecol Reprod Biol 2002;102:137-42. 12. Alarab M, Regan C, O’Connell MP, Keane DP, O’Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol 2004;103:407-12. 13. Albrechtsen S, Rasmussen S, Reigstad H, Markestad T, Irgens LM, Dalaker K. Evaluation of a protocol for selecting fetuses in breech presentation for vaginal delivery or cesarean section. Am J Obstet Gynecol 1997;177:586-92. 14. Goffinet F, Carayol M, Foidart JM, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194: 1002-11. 15. American College of Obstetricians and Gynecologists. Committee on Obstetric Practice. ACOG committee opinion no. 265, December 2001; mode of term single breech delivery. Obstet Gynecol 2001;98:1189-90. 16. American College of Obstetricians and Gynecologists Committee on Obstetric Practice. ACOG committee opinion no. 340: mode of term singleton breech delivery. Obstet Gynecol 2006;108:235-7. 17. Kotaska A, Menticoglou S, Gagnon R, et al. Vaginal delivery of breech presentation. J Obstet Gynaecol Can 2009;31:557-78. 18. Carbonne B, Goffinet F, Breart G, Frydman R, Maria B, Uzan S. The debate on breech presentation: delivery of breech presentations; the position of the National College of French Gynecologists [in French]. J Gynecol Obstet Biol Reprod (Paris) 2001;30:191-2. 19. Leroy B, Lefort F. The weight and size of newborn infants at birth [in French]. Rev Fr Gynecol Obstet 1971;66:391-6. 20. Raudenbush S, Bryk A. Hierarchical linear models: applications and data analysis meth- Research ods. Thousand Oaks, CA: Sage Publications; 2002. 21. Gagnon AJ, Zimbeck M, Zeitlin J, et al. Migration to western industrialized countries and perinatal health: a systematic review. Soc Sci Med 2009;69:934-46. 22. Blondel B, Supernant K, Du Mazaubrun C, Breart G. Trends in perinatal health in metropolitan France between 1995 and 2003: results from the national perinatal surveys [in French]. J Gynecol Obstet Biol Reprod (Paris) 2006;35: 373-87. 23. Kramer MS, Seguin L, Lydon J, Goulet L. Socio-economic disparities in pregnancy outcome: why do the poor fare so poorly? Paediatr Perinat Epidemiol 2000;14:194-210. 24. Su M, McLeod L, Ross S, et al. Factors associated with adverse perinatal outcome in the term breech trial. Am J Obstet Gynecol 2003;189:740-5. 25. Gimovsky ML, Petrie RH, Todd WD. Neonatal performance of the selected term vaginal breech delivery. Obstet Gynecol 1980;56: 687-91. 26. Oian P, Skramm I, Hannisdal E, Bjoro K. Breech delivery: an obstetrical analysis. Acta Obstet Gynecol Scand 1988;67:75-9. 27. Roman H, Carayol M, Watier L, Le Ray C, Breart G, Goffinet F. Planned vaginal delivery of fetuses in breech presentation at term: prenatal determinants predictive of elevated risk of cesarean delivery during labor. Eur J Obstet Gynecol Reprod Biol 2008;138:14-22. 28. Le Ray C, Zeitlin J, Jarreau PH, Breart G, Goffinet F. The influence of level of care on admission to neonatal care for babies of low-risk nullipara. Eur J Obstet Gynecol Reprod Biol 2009;144:21-6. 29. Queenan JT. Teaching infrequently used skills: vaginal breech delivery. Obstet Gynecol 2004;103:405-6. A PPENDIX PREMODA Study Group Scientific Committee: F. Goffinet, S. Alexander, J. M. Foidart, S. Uzan, D. Subtil, G. Bréart. Data Monitoring and Analysis Committee: M. Carayol, F. Goffinet, D. Subtil, S. Alexander, J. M. Foidart, G. Bréart. Institut national de la santé et de la recherche médicale U953, Epidemiological Research Unit on Perinatal Health and Women’s Health (Goffinet, Bréart, Carayol); Department of Obstetrics and Gynaecology, Port Royal Maternity, Cochin-Saint Vincent-de-Paul Hospital, University Paris V (Goffinet); and Department of Obstetrics and Gynaecology, Tenon Hospital, University Paris VI (Uzan, Bréart), Paris, and Department of Obstetrics and Gynaecology, Hôpital OCTOBER 2012 American Journal of Obstetrics & Gynecology 285.e7 Research Obstetrics Jeanne de Flandre, Lille (Subtil), France, and Ecole de Santé Publique, Université Libre de Bruxelles, Brussels (Dr Alexander) and Department of Obstetrics and Gynaecology, La Citadelle Hospital, Liège (Foidart), Belgium. Independent Expert Committee: Pediatricians: Professor (Pr) U. Simeoni (Timone Hospital, Marseille, France); Pr J. C. Rozé (Mother and Children’s Hospital, Nantes, France); Pr J. B. Gouyon (Dijon University Hospital, France); Pr P. Lequien (Hôpital Jeanne de Flandre, Lille, France); P. H. Jarreau (Port-Royal Maternity, Cochin Hospital, Paris, France); Pr D. Haumont (Saint-Pierre University Hospital, Brussels, Belgium). Obstetricians: Pr F. Puech (Hôpital Jeanne de Flandre, Lille, France); Pr P. Gaucherand (Croix-Rousse Hospital, Lyon, France). List of collaborators and participating centers: France Région Alsace: Coordonnateur: Pr Langer: Centre hospitalo-universitaire (CHU) de Strasbourg (Pr Langer), Centre médicochirurgical obstétrique de Schiltigheim (Dr Vayssiere), Centre hospitalier régional (CHR) de Haguenau (Dr Lehmann), Centre médico-chirurgical de Colmar (Dr Kutnahorsky), CHR de Mulhouse (Dr Wiedemann), Clinique Sainte Anne, Strasbourg (Dr Jeanmougin), Clinique Diaconat, Mulhouse (Dr Blum)–Basse-Normandie: Coordonnateur: Pr Dreyfus: CHU de Caen (Pr Dreyfus/Dr DenoualZiad), Centre hospitalier (CH) de Cherbourg (Dr Ulmann), CH de Lisieux (Dr Zerger), CH de Saint Lo (Dr Refahi), CH de Flers (Dr André), CH de la Ferté Macé (Dr Nelle)–Région Bretagne: Coordonnateur: Pr Grall: CHU de Brest (Pr Collet), CHU Hôtel Dieu, Rennes (Pr Poulain), CHU Hôpital Sud, Rennes (Mme Pérrigot), CH de Lorient (Dr Getin), Clinique mutualiste de la Sagesse, Rennes (Dr Aussel), CH de Saint Brieuc (Dr Giono-Renaud), CH de Saint Malo (Dr Weyl), CH de Vannes (Mme Pierson), CH de Cornouaille (Dr Germain)–Région Centre: Coordonnateur: Pr Perrotin: CHU Bretonneau, Tours (Dr Alonso), CHU Beffroi, Tours (Dr Rapp), CH de Blois (Dr Montmasson), CHR d’Orléans (Dr Ceccaldi), 285.e8 www.AJOG.org CHG de Chartres (Dr Guilbaud)–Région Franche-Comté: Coordonnateur: Pr Schaal: CHU de Besançon (Dr Riethmuller), CHG de Montbéliard (Dr Zurlinden), CHG de Belfort (Dr Terzibachian)–Région Haute-Normandie: Coordonnateur: Pr Verspyck: CHU de Rouen (Pr Verspyck), CH de Mont Saint Aignan (Dr Fournet), CH du Havre (Dr Degré), CH d’Elbeuf (Dr Paquet), CH de Dieppe (Dr Gandour), Clinique Saint-Romain, Rouen (Dr Thobois)–Région Ile de France: Réseau Sud Ouest Francilien: Coordonnateur: Dr Audibert: CHU de Clamat (Dr Audibert), Clinique des Vallées, Châtenay-Malabry (Dr Proust), Clinique de Meudon la Forêt (Dr Chene), CH de Dourdan (Dr Lambert), CH Sud Francilien site d’Evry (Mme Lose), CH de Fontainebleau (Dr Fillippini), CH d’Orsay (Dr Devianne); Réseau Ile de France Port-Royal: Coordonnateur: Dr Harvey: CHU Cochin, Paris (Dr Kayem), CHU Saint Vincent de Paul, Paris (Pr Lepercq), CHU Saint Antoine, Paris (Pr Carbonne), CH Notre Dame de Bonsecours, Paris (Dr Grovangrandi), CHU Beaujon, Paris (Mme Grapin), CHU de Colombes (Dr Crenn-Hebert), CH de Neuilly sur Seine (Dr Galimard), CH de Saint Cloud (Mme Pecourt), Hôpital Militaire Begin, Saint Mandé (Dr Ponties), Clinique Armand Brillard, Nogent sur Marne (Dr Helvin), CH Les Diaconesses, Paris (Dr Harvey); Réseau de Poissy: Coordonnateur: Dr Rozenberg: Centre hospitalier intercommunal (CHI) de PoissySaint Germain (Mme Bertaud); Réseau inter-maternités de Saint-Denis: Coordonnateur: Pr Uzan: CH de Bondy (Dr Seince), CHI de Montreuil (Dr Chitrit), CHI de Villepinte (Dr Debièvre), Clinique Vauban, Livry-Gardan (Dr Kamoun), Clinique du bois d’amour, Drancy (Dr Masson), CH de Montfermeil (Dr Ropert), CHG de Saint-Denis (Dr Ekoukou), Clinique de l’Estrée, Stains (Dr Franche); Réseau Tenon: Coordonnateurs: Pr Uzan et Dr Berkane: CHU Tenon, Paris (Dr Berkane), CHU Bichat, Paris (Pr Mandelbrot); CHI de Créteil (Pr Haddad et Dr Touboul); CH de Saint Maurice (Dr Bardou)–Région Limousin: Coordonnateur: Pr Philippe: CH de Brive (Mme Peron), CH de Tulle (Mme Barbé), CHU de Limoges (Dr Eyraud), CH d’Ussel (Mme Leclerc) American Journal of Obstetrics & Gynecology OCTOBER 2012 –Région Lorraine: Coordonnateurs: Pr Boutroy, Dr Thiebaugeorges: CHU de Nancy (Dr Thiebaugeorges), CH d’Epinal (Dr Scotton), CHR Bonsecours, Metz (Dr Lemarié), CH de Thionville (Dr Szwarcberg), CH Sainte Croix, Metz (Dr Ragage), Polyclinique Majorelle, Nancy (Dr Cledat), Clinique Arc en Ciel, Epinal (Dr Gaillet-Schiochet), Clinique Claude Bernard, Metz (Dr Adami)–Nord Pas de Calais: Coordonnateur: Pr Subtil: CH d’Arras (Mme Finet), CH de Béthune (Dr Hay), CH de Boulogne (Dr Churlet), Clinique Côte d’Opale, Saint Martin les Boulognes (Dr Renault), CH de Douai (Dr Dognin), Clinique Saint Amé, Lambre-lez-Douai (Dr Doutrelant), Clinique Villette, Dunkerque (Mme Gosselin, Mme Deroose), CH de Maubeuge (Dr Hubert), CH de Roubaix (Dr Le Goueff), CH de Seclin (Dr Biausque), CH de Valenciennes (Dr Massoni), CHU de Lille (Pr Subtil), Clinique Cotteel, Villeneuve d’Ascq (Mme Dumon)–Région Pays de Loire: Coordonnateur: Dr Winer: Centre hospitalierdépartementaleLaRochesurYon (Dr Barreteau), CH de Saint Nazaire (Dr Gerard), Clinique du jardin des plantes, Saint Nazaire (Dr Rousseau), CH de Cholet (Dr Aireau), CHU de Nantes (Dr Winer), Maison de naissance, St Sébastien/Loire (Dr Berlivet), CHU d’Angers (Dr Gilard)–Picardie: Coordonnateur:PrGondry:CHUd’Amiens (Pr Gondry), Clinique Sainte Claire, Amiens (Dr Degroote), CHG de Beauvais (Dr Manela), CHG de Creil (Dr Cesbron), CHG de Laon (Dr Boury), CHG de Saint Quentin (Dr Closset), CHG de Soissons (Dr Abboud)–Région Poitou-Charentes: Coordonnateur: Pr Pierre: CHU de Poitiers (Pr Pierre), Clinique du Fief de Grimoire, Poitiers (Dr Bascou), CHG de Niort (Dr Breheret), CHG d’Angoulême (Dr Tariel), CHG de la Rochelle (Dr Quentin), Clinique Sainte Anne, Châtellerault (Dr Boisselier), CHGdeChâtellerault(DrGodard),CHGde Bressuire(DrVillemonteix),CHGdeSaintes (Dr Trousselle)–Région Provence Alpes Côtes d’Azur: Coordonnateur: Pr D’Ercole: CHU la Conception, Marseille (Dr Agostini), CHR de Draguignan (Dr Diquelou), CHR de Hyères (Dr Eymery), CHR de la Ciotat (Dr Pechikof), CHU Hôpital Nord, Marseille (Pr D’Ercole), CHR de Salon de Provence (Dr Maldiney), CHR de la Seyne sur Mer (Dr Joly)–Région Rhône-Alpes Lyon: Coordonnateur: Dr Vaudoyer: CHU Obstetrics www.AJOG.org l’Hôtel Dieu, Lyon (Dr Vaudoyer), CHU la Croix Rousse, Lyon (Pr Gaucherand), CHU Lyon Sud, Lyon (Dr Coste)–Région RhôneAlpesGrenoble:Coordonnateur:DrVendittelli: CHU Nord et Sud, Grenoble (Dr Venditelli), Clinique Belledone, Saint Martin d’Hères (Dr Benbassa), Clinique des Cédres, Grenoble (Dr Boschetto), Clinique Mutualiste, Grenoble (Dr Leger), CHU de Saint Etienne (Dr Collet), CH de Bourg en Bresse (Dr Frobert), CH d’Alberville (Dr Dardenne), CH de Chambéry (Dr Houman), CH d’Annecy (Dr Bernardi), CH de Valence (Dr Broussard), CH de Roanne (Dr Gaja), CH d’Evian les Bains et de Thonon les Bains (Dr Thery), CH de Saint Julien en Genevois (Dr Tognelli), CH de Firminy (Dr Albersammer). Belgium Belgique Coordonnateur: Pr Foidart: CH Luxembourg (Dr Arendt), Hôpital St Nikolaus Eupen (Dr Chantraine), Hôpital Ste Anne-St-Remi Bruxelles (Dr Befahy), CH Etterbeek-Ixelles (Dr Houben), Hôpital Braine l’Alleud Waterloo Lillois (Dr Busine), Hôpital St Elisabeth Bruxelles (Dr Depierreux), CHR Warquignies Boussu (Dr Mathieu), Intercommunale Famenne Ardenne Condroz Ste Thérèse Bastogne (Dr Colin), Réseau Hospitalier de Médecine Sociale La Madeleine Ath (Dr Coulon), CHU Saint-Pierre Bruxelles (Dr Barlow), Réseau Hospitalier de Médecine Sociale Tournai (Dr Delvoye), CH Françoise Rabelais Cesar de Paepe Bruxelles (Dr Verougstraete), CH Peltzer La Tourelle Verviers (Dr Deville), Centre de Santé des Fagnes Chimay (Dr Dewille), CHR Namur (Dr D’Huslt), Hôpital St Joseph Mons (Dr du Bois d’Enghien), CHU Liège (Pr Foidart), CHU Tivoli La Louvière (Dr Francotte), CHR Haute Senne Soignies (Dr Gielen), Intercommunale Fa- Research menne Ardenne Condroz Princesse Paola Marche (Dr Gilles), CHR Val de Sambre Auvelais (Dr Verheyen), Cliniques Universitaires St Luc Bruxelles (Pr Bernard, Pr Hubinont), CH Mouscron (Dr Jacob), Hôpital Reine Astrid Malmedy (Dr Lavalleye), CHU Brugmann Bruxelles (Pr Vokaer), Hôpital St Pierre Ottignies (Dr Longueville), CH Jolimont (Dr Guilmot), CHU Erasme Bruxelles (Dr Kirkpatrick), CH Notre Dame Charleroi (Dr Sartenaer), CH Hornu-Frameries (Dr Semoulin), CHBA Seraing (Pr Van Cauwenberge), Hôpital St Jean Bruxelles (Dr Venderick), CH François Rabelais Français Reine Elisabeth Bruxelles (Dr Vermeulen), Hôpital Notre Dame des Bruyères Chenée (Dr Vigis), Hôpital Notre Dame Tournai (Dr Wauters), Hôpital Notre Dame Hermalle (Dr Romedenne). OCTOBER 2012 American Journal of Obstetrics & Gynecology 285.e9
