Intentional early delivery versus expectant management for preterm premature rupture of membranes at 28-32 weeks' gestation: A multicentre randomized controlled trial (MICADO STUDY).

OBJECTIVES: Preterm premature rupture of fetal membranes (PPROM) exposes the fetus to preterm birth, and optimal timing for delivery is controversial. The aim of this study was to compare intentional early delivery ("active management") with expectant management in very preterm birth (28-32 weeks). STUDY DESIGN: We conducted a prospective randomized controlled trial with intent-to-treat analysis, at 19 tertiary-care hospitals in France and 1 in Geneva, Switzerland. Inclusion criteria were women age ≥18 years, PPROM at 280/7 to 316/7 weeks' gestation, singleton pregnancy. Exclusion criteria were maternal/fetal indications for immediate delivery. All participants received prophylactic antibiotics (amoxicillin + gentamicin) and two doses of corticosteroids. Women in expectant management delivered at 34 weeks, sooner if medically indicated. Women in active management delivered 24 h after the second steroid dose. The primary outcome measure was a composite of neonatal death/severe adverse events: periventricular leukomalacia, intraventricular hemorrhage, sepsis, oxygen requirement at 36 weeks, and necrotizing enterocolitis. The secondary outcome was clinical chorioamnionitis. RESULTS: The trial was stopped prematurely, due to recruitment difficulties. Of 360 women assessed, 139 (40% of calculated sample size) were randomized: 70 to expectant management, 69 to active management. Mean gestational age at PPROM was similar in both groups (30 ± 1.3 vs. 30.2 ± 1.2 weeks, respectively). There were 35 cases of medical/suspected complications requiring delivery in expectant management vs. 4 in active management. Mean latency between PPROM and delivery was 11.7 ± 9.8 vs. 2.8 ± 0.6 days, respectively; P < 0.0001 (median 8.4 (1.8-44.2) vs. 2.7 (1.9-4.3)). There were more caesarean deliveries in active than expectant management (80% vs. 60%, respectively; P < 0.01). There were 2 chorioamnionitis cases, both in expectant management. One baby died in expectant management; 2 in active management (one with heart defect). There was no significant difference in sepsis rates. The combined neonatal death/severe adverse events measure was 12.9% for expectant management and 13.0% for active management (OR 0.98; 95% CI: 0.33-2.93, P = 0.97). CONCLUSION: For PPROM at 28-32 weeks, and with antenatal antibiotic and steroid therapy, there were no observed differences in neonatal health when comparing expectant management to early delivery. As expected, expectant management resulted in higher gestational age and birth weight. However, our study was underpowered to draw firm and reliable conclusions.

Current beliefs and attitudes regarding epilepsy in Mali.

PURPOSE: In Mali, epilepsy affects 15 individuals per thousand. Perceptions and attitudes have not seemingly evolved with advancing medical knowledge. The objective of this study was to assess parental beliefs and attitudes in families with and without affected children. METHODS: We enrolled 720 pediatric patients, half of whom had epilepsy, at Mali's largest hospital. We conducted semistructured interviews with the accompanying parent. Control families with unaffected patients and also had affected children were excluded. RESULTS: In total, 67% and 24% of families with and without epilepsy, respectively, lived in rural environments. Interviewees were mostly mothers in their 30s; 80% had not completed high school. About 22% of parents without an affected child had witnessed a seizure. During a seizure, 94% of parents with an affected child and 49% of parents without an affected child, respectively, would intervene; 7.5% and 21%, respectively, would wet the patient's face with cool water. Although parents with an affected child had more intimate knowledge of seizures, misconceptions prevailed, perhaps more so than in families without epilepsy: 79% and 66% of parents, respectively, considered epilepsy contagious; 43% vs. 69% thought that it inevitably led to psychosis; and 53% vs. 29% attributed epilepsy to supernatural causes. Finally, 63% of parents with an affected child reported consulting a traditional healer as first-line management for epilepsy. CONCLUSIONS: Our study demonstrates widespread misconceptions in Mali regarding epilepsy. Our findings argue for more education initiatives focused on the entire population, including traditional healers, to provide knowledge, reduce stigma, and improve quality of life for individuals living with epilepsy.

Predicting preterm birth in twin pregnancy: was the previous birth preterm? A Canadian experience.

OBJECTIVE: Most studies determining risk of preterm birth in a twin pregnancy subsequent to a previous preterm birth are based on linkage studies or small sample size. We wished to identify recurrent risk factors in a cohort of mothers with a twin pregnancy, eliminating all known confounders. METHODS: We conducted a retrospective cohort study of twin births at a tertiary care centre in Montreal, Quebec, between 1994 and 2008, extracting information, including chorionicity, from patient charts. To avoid the effect of confounding factors, we included only women with a preceding singleton pregnancy and excluded twin-to-twin transfusion syndrome, fetal chromosomal/structural anomalies, fetal demise, and preterm iatrogenic delivery for reasons not encountered in both pregnancies. We used multiple regression and sensitivity analyses to determine recurrent risk factors. RESULTS: Of 1474 twin pregnancies, 576 met the inclusion criteria. Of these, 309 (53.6%) delivered before 37 weeks. Preterm birth in twins was strongly associated with preterm birth of the preceding singleton (adjusted OR 3.23; 95% CI 1.75 to 5.98). The only other risk factors were monochorionic twins (adjusted OR 1.82; 95% CI 1.21 to 2.73) and oldest or youngest maternal ages. Chronic or gestational hypertension, preeclampsia, and insulin-dependent diabetes during the singleton pregnancy did not significantly affect risk. CONCLUSION: Preterm birth in a previous singleton pregnancy was confirmed as an independent risk factor for preterm birth in a subsequent twin pregnancy. This three-fold increase in risk remained stable regardless of year of birth, inclusion/exclusion of pregnancies following assisted reproduction, or defining preterm birth as < 34 or < 37 weeks' gestational age. Until the advent of optimal preventive strategies, close obstetric surveillance of twin pregnancies is warranted.

Objectif : La plupart des études qui cherchent à déterminer le risque d'accouchement préterme dans le cadre d'une grossesse gémellaire se déroulant à la suite d'un accouchement préterme sont fondées sur des études de liaison ou des échantillons de faible envergure. Nous souhaitions identifier les facteurs de risque récurrents au sein d'une cohorte de mères connaissant une grossesse gémellaire, en éliminant toutes les variables de confusion connues. Méthodes : Nous avons mené une étude de cohorte rétrospective qui portait sur les grossesses gémellaires ayant donné lieu à un accouchement au sein d'un centre de soins tertiaires de Montréal, au Québec, entre 1994 et 2008; nous avons extrait les données requises (dont la chorionicité) des dossiers des patientes. Pour éviter l'effet des facteurs de confusion, nous n'avons inclus que des femmes ayant déjà connu une grossesse monofœtale et avons exclu les cas de syndrome transfuseur-transfusé, d'anomalies chromosomiques / structurelles fœtales, de décès fœtal et d'accouchement préterme iatrogène pour des motifs n'ayant pas été constatés au cours des deux grossesses. Nous avons fait appel à des analyses de régression multiple et de sensibilité pour déterminer les facteurs de risque récurrents. Résultats : Parmi les 1 474 grossesses gémellaires recensées, 576 ont satisfait aux critères d'inclusion. Parmi celles-ci, 309 (53,6 %) accouchements ont eu lieu avant 37 semaines. L'accouchement préterme dans le cadre d'une grossesse gémellaire à été fortement associé au fait d'avoir connu un accouchement préterme dans le cadre de la grossesse monofœtale précédente (RC corrigé, 3,23; IC à 95 %, 1,75 - 5,98). Les seuls autres facteurs de risque ont été les jumeaux monozygotes (RC corrigé, 1,82; IC à 95 %, 1,21 - 2,73) et les âges maternels les plus vieux ou les plus jeunes. La présence d'une hypertension chronique ou gestationnelle, d'une prééclampsie et d'un diabète insulino-dépendant au cours de la grossesse monofœtale n'a pas exercé un effet significatif sur le risque. Conclusion : Le fait d'avoir connu un accouchement préterme dans le cadre d'une grossesse monofœtale précédente a été confirmé comme étant un facteur de risque indépendant d'accouchement préterme dans le cadre d'une grossesse gémellaire subséquente. Ce triplement du risque est demeuré stable, peu importe l'année de naissance, l'inclusion / exclusion des grossesses attribuables à la procréation assistée ou la définition de l'accouchement préterme comme étant < 34 ou < 37 semaines de gestation. Jusqu'à ce que des stratégies de prévention optimales soient mises au point, la mise en œuvre d'une étroite surveillance obstétricale s'avère justifiée dans les cas de grossesse gémellaire.