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Objectives: To investigate the efficacy of antenatal corticosteroid (ACS) therapy on short-term neonatal outcomes in preterm twins, and further document the influence of the ACS-to-delivery interval., Design: EPIPAGE-2 is a nationwide observational multicentre prospective cohort study of neonates born between 22 and 34 completed weeks of gestation., Setting: All French maternity units, except in a single administrative region, between March and December 2011., Population: A total of 750 twin neonates born between 24 and 31 weeks of gestation., Methods: Exposure to ACSs was examined in four groups: single complete course, with an ACS administration-to-delivery interval of ≤7 days; single complete course, with an ACS-to-delivery interval of >7 days; repeated courses; or no ACS treatment., Main Outcome Measures: Neonatal outcomes analysed were severe bronchopulmonary dysplasia, periventricular leukomalacia or intraventricular haemorrhage grade III/IV, in-hospital mortality, and a composite indicator of severe outcomes., Results: Compared with no ACSs, in multivariable analysis, a single course of ACSs with an administration-to-delivery interval of ≤7 days was significantly associated with a reduced rate of periventricular leukomalacia or intraventricular haemorrhage grade III/IV (aOR 0.2; CI 95% 0.1-0.5), in-hospital mortality (0.3; 0.1-0.6), and the composite indicator (0.1; 0.1-0.3), whereas a single course of ACDs with an administration-to-delivery interval of >7 days did not significantly reduce the frequency of in-hospital mortality (0.7; 0.3-1.8). No significant differences in terms of benefit or risk were found when comparing repeated courses with a single complete course., Conclusion: In preterm twins, a single complete course of antenatal corticosteroids was associated with an improvement of severe neurological outcome, whereas reduced in-hospital mortality was seen only when the ACS-to-delivery interval was ≤7 days., Tweetable Abstract: A single complete course of antenatal steroids reduced severe neurological morbidity in preterm twins (24-31 weeks)., (© 2017 Royal College of Obstetricians and Gynaecologists.)

Objective: To investigate the impact of gestational age (GA) at diagnosis of fetal growth restriction (FGR) on obstetric management and rates of live birth and survival for very preterm infants with early-onset FGR., Design: Population-based cohort study., Setting: All maternity units in 25 French regions in 2011., Population: Fetuses diagnosed with FGR before 28 weeks of gestation among singleton births between 22 and 31 weeks of gestation without severe congenital anomalies., Methods: We studied the effects of GA at diagnosis on perinatal management and outcomes. We used multivariable regression to identify antenatal factors (maternal characteristics, ultrasound measurements and sex) associated with the probability of live birth., Main Outcomes Measures: Live birth and survival to discharge from neonatal care., Results: A total of 436 of 3698 fetuses were diagnosed with FGR before 28 weeks (11.8%); 66.9% were live born and 54.4% survived to discharge. 50% were live born when diagnosis occurred before 25 weeks, 66% at 25 weeks and >90% at 26 and 27 weeks of gestation. In all, 94.1% of live births were by prelabour caesarean, principally for maternal indications before 26 weeks. Low GA at diagnosis, an estimated fetal weight or abdominal circumference below the third centile and male sex were adversely associated with live birth in adjusted models., Conclusion: Gestational age at FGR diagnosis had an impact on the probability of live birth and survival, after consideration of other perinatal characteristics. Investigations of the outcomes of births with early-onset FGR need to include stillbirths and information on the GA at which FGR is diagnosed., Tweetable Abstract: Evaluations of active management of pregnancies with early onset growth restriction should include stillbirths., (© 2017 Royal College of Obstetricians and Gynaecologists.)

Objectives: To determine the measures to prevent spontaneous preterm birth (excluding preterm premature rupture of membranes)and its consequences., Materials and Methods: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted., Results: In France, premature birth concerns 60,000 neonates every year (7.4 %), half of them are delivered after spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated to a decrease of prematurity (level of evidence [LE] 1). This is therefore recommended (grade A). Routine screening and treatment of vaginal bacteriosis in general population is not recommended (grade A). Asymptomatic women with single pregnancy without history of preterm delivery and a short cervix between 16 and 24 weeks is the only population in which vaginal progesterone is recommended (grade B). A history-indicated cerclage is not recommended in case of only past history of conisation (grade C), uterine malformation (Professional consensus), isolated history of pretem delivery (grade B) or twin pregnancies in primary (grade B) or secondary (grade C) prevention of preterm birth. A history-indicated cerclage is recommended for single pregnancy with a history of at least 3 late miscarriages or preterm deliveries (grade A).). In case of past history of a single pregnancy delivery before 34 weeks gestation (WG), ultrasound cervical length screening is recommended between 16 and 22 WG in order to propose a cerclage in case of length<25mm before 24 WG (grade C). Cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with a twin pregnancy (grade A) and in populations of asymptomatic women with a short cervix (Professional consensus). Although the implementation of a universal transvaginal cervical length screening at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In case of preterm labor, (i) it is not possible to recommend one of the methods over another (ultrasound of the cervical length, vaginal examination, fetal fibronectin) to predict preterm birth (grade B); (ii) routine antibiotic therapy is not recommended (grade A); (iii) prolonged hospitalization (grade B) and bed rest (grade C) is not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (grade B), contrary to betamimetics (grade C), can be used for tocolysis in spontaneous preterm labour without preterm premature rupture of membranes. Maintenance tocolysis is not recomended (grade B). Antenatal corticosteroid administration is recommended to every woman at risk of preterm delivery before 34 weeks of gestation (grade A). After 34 weeks, evidences are not consistent enough to recommend systematic antenatal corticosteroid treatment (grade B), however, a course might be indicated in the clinical situations associated with the higher risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (grade C). Repeated courses of antenatal corticosteroids are not recommended (grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended to women at high risk of imminent preterm birth before 32WG (grade A). Cesarean is not recommended in case of vertex presentation (Professional consensus). Both planned vaginal or elective cesarean delivery is possible in case of breech presentation (Professional consensus). A delayed cord clamping may be considered if the neonatal or maternal state so permits (Professional consensus)., Conclusion: Except for antenatal corticosteroid and magnesium sulfate administration, diagnostic tools or prenatal pharmacological treatments implemented since 30 years to prevent preterm birth and its consequences have not matched expectations of caregivers and families., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Objective: To synthesize the available evidence regarding the incidence and several risk factors of preterm birth. To describe neonatal outcomes according to gestational age and to the context of delivery., Materials and Methods: Consultation of the Medline database., Results: In 2010, 11% of live births (15 million babies) occurred before 37 completed weeks of gestation worldwide. About 85% of these births were moderate to late preterm babies (32-36 weeks), 10% were very preterm babies (28-31 weeks) and 5% were extremely preterm babies (<28 weeks). In France, premature birth concerns 60,000 neonates every year, 12,000 of whom are born before 32 completed weeks of gestation. Half of them are delivered after spontaneous onset of labor or preterm premature rupture of the membranes, and the other half are provider-initiated preterm births. Several maternal factors are associated with preterm birth, including sociodemographic, obstetrical, psychological, and genetic factors; paternal and environmental factors are also involved. Gestational age is highly associated with neonatal mortality and with short- and long-term morbidities. Pregnancy complications and the context of delivery also have an impact on neonatal outcomes., Conclusion: Preterm birth is one of the leading cause of the under-five mortality and of neurodevelopmental impairment worldwide; it remains a major public health issue., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

Objective: To evaluate in preterm born children the neuroprotective benefits and the risks, at short- and long-term outcome, of the antenatal administration of magnesium sulphate (MgSO 4 ) in women at imminent risk of preterm delivery., Material and Methods: Computer databases Medline, the Cochrane Library and the recommendations of various international scientific societies., Results: Given the demonstrated benefit of antenatal MgSO 4 intravenous administration on the reduction of cerebral palsy rates and the improvement of motor development in children born preterm, it is recommended for all women whose imminent delivery is expected or programmed before 32 weeks of gestation (WG) (grade A). The analysis of the literature finds no argument for greater benefit of antenatal MgSO 4 administration in sub-groups of gestational age, or depending on the type of pregnancy (single or multiple pregnancy) or with the cause of preterm birth (NP2). Its administration is recommended before 32 WG, if single or multiple pregnancy, whatever the cause of prematurity (grade B). It is recommended 4g loading dose (professional consensus). With a loading dose of 4g intravenous (IV) in 20min, the serum magnesium is lower than with intramuscular suggesting a preference for the IV route (professional consensus). It is proposed to use a maintenance dose of 1g/h until delivery with a maximum recommended duration of 12hours without exceeding a cumulative dose of 50g (professional consensus). These doses are without severe adverse maternal side effects or adverse effects in newborns at short- and medium-term outcome (NP1)., Conclusion: It is recommended to administer magnesium sulfate to the women at high risk of imminent preterm birth before 32 WG, whether expected or planned (grade A), with a 4g IV loading dose followed by a maintenance dose of 1g/h for 12hours (professional consensus), the pregnancy is single or multiple, whatever the cause of prematurity (professional consensus)., (Copyright © 2016. Published by Elsevier Masson SAS.)

Every year, approximately 15 million babies are born preterm worldwide (before 37 completed weeks of gestation), putting the global preterm birth rate at 11%; they are about 60,000 in France. About 85% of these births are moderate (32-33 weeks) to late preterm babies (34-36 weeks), 10% are very preterm babies (28-31 weeks) and 5% are extremely preterm babies (< 28 weeks). Though neonatal mortality rates are dropping, they remain high and are largely determined by gestational age at birth (over 10% mortality for infants born before 28 weeks, 5-10% at 28-31 weeks and 1-2% at 32-34 weeks). Severe neonatal morbidity and disabilities during childhood are also frequent and vary with gestational age. For example, the risk of motor or cognitive impairment is 2 to 3 times higher among children born between 34 and 36 weeks than among children born full-term. Therefore, every preterm baby must be carefully monitored. Recent cohort studies have focused on extremely preterm births; however, awareness of potential outcome and prognosis of all preterm babies is a crucial step for health professionals caring for these children. Huge disparities exist between high- and low-income countries, but also among high-income countries themselves., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)