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Uterine artery pseudoaneurysm is a rare complication of cesarean section. It can lead to severe postpartum hemorrhage. We report three cases of pseudoaneurysm diagnosed late after cesarean delivery, one followed by hemorrhagic shock. Ultrasound may point to the diagnosis, but arteriography of uterine arteries is decisive for the diagnosis. Selective artery embolization is recommended for treatment. Main advantages are complete occlusion of the pseudoaneurysm and fertility preservation., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objective: While a number of glossaries have been produced by various authorities in different countries, at present there is no internationally accepted common set of definitions for many terms used to describe pregnancy losses. The objective of the current study was to provide a standardized French/English terminology/glossary relating to pregnancy losses., Methods: Literature review, construction of a glossary and rating of proposals using a formal consensus method. The glossary was subject of a critical comprehensive review by a meeting of professionals (multidisciplinary panel)., Results: A miscarriage is a spontaneous evacuation of an intra-uterine pregnancy<22WG. A missed early miscarriage is when ultrasound (<14WG) shows no growth of intra-uterine sac/embryo and/or loss of fetal heart activity. An early miscarriage is when spontaneous evacuation of intra-uterine pregnancy occurs <14WG. A complete early miscarriage is when there is no retained products of conception (empty uterus on ultrasound) and no bleeding nor pain. Incomplete early miscarriage is when ultrasonography shows retained products of conception in the uterine cavity (including cervical canal). Repeat miscarriage or recurrent pregnancy loss is when the woman experiences 3 or more consecutive miscarriages <14WG. A late miscarriage is when there is spontaneous evacuation of pregnancy ≥14WG and <22WG. A threatened late miscarriage is when shortening/opening of the cervix±uterine contraction occur ≥14WG and <22WG. An intra-uterine fetal demise is when there is a spontaneous loss of fetal heart activity ≥14 WG., Conclusion: The final current terminology should be used by all healthcare professionals., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: Study of epidemiology of pregnancy loss., Materials and Method: A systematic review of the literature was performed using Pubmed and the Cochrane library databases and the guidelines from main international societies., Results: The occurrence of first trimester miscarriage is 12% of pregnancies and 25% of women. Miscarriage risk factors are ages of woman and man, body mass index greater than or equal to 25kg/m(2), excessive coffee drinking, smoking and alcohol consumption, exposure to magnetic fields and ionizing radiation, history of abortion, some fertility disorders and impaired ovarian reserve. Late miscarriage (LM) complicates less than 1% of pregnancies. Identified risk factors are maternal age, low level of education, living alone, history of previous miscarriage, of premature delivery and of previous termination of pregnancy, any uterine malformation, trachelectomy, existing bacterial vaginosis, amniocentesis, a shortened cervix and a dilated cervical os with prolapsed membranes. Fetal death in utero has a prevalence of 2% in the world and 5/1000 in France. Its main risk factors are detailed in the chapter., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objective: To assess early and late benefits and harms of different management options for first trimester miscarriage and for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14weeks of gestation., Methods: French and English publications were searched using PubMed and Cochrane Library., Results: Concerning missed miscarriage, expectant management is not recommended (LE1) because it increases the risk of failure, need of unplanned surgical procedure and blood transfusion (LE1). Surgical uterine evacuation remains more effective than medical treatment using misoprostol (LE1), but both techniques involve rare and comparable risks (EL1). When chosen, medical treatment should be a vaginal dose of 800μg of misoprostol, possibly repeated 24 to 48hours later (EL2). Administration of mifepristone prior to misoprostol is not recommended (EL2). In case of incomplete miscarriage, expectant management can be offered because it does not increase the risk of complications, neither haemorrhagic nor infectious (EL1). Medical treatment using misoprostol is not recommended (EL2) because it does not improve the evacuation rate when compared to our first option, and does not reduce the risk of complications (EL2). Surgical uterine evacuation leads to high evacuation rate (97-98%) and low risk of complications, haemorrhagic and infectious (<5%) (EL1). However, this option should not be the only one because of the good efficiency of the expectant management (more than 75% of evacuation) and comparably low risk of complications (EL1). Surgical aspiration should be favoured to curettage because it is quicker, less painful and leads to less bleeding (EL2). After a first trimester miscarriage future fertility is identical with each treatment (EL2). When a trophoblastic retention is suspected, a diagnostic hysteroscopy is recommended (EL2). In case of late intrauterine foetal death beyond 14weeks of gestation and without a past caesarean section, the most efficient protocol seems to be vaginal administration of misoprostol 200 to 400μg every 4 to 6hours (EL2). Twenty-four hours prior to misoprostol the administration of 200mg of mifepristone is recommended (EL3) because it improves the induction-expulsion time and diminishes the quantity of needed misoprostol (and so the complications linked to it) (EL3)., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: To define initial steps of obstetrical treatment of post-partum hemorrhage (PPH) after vaginal delivery., Materials and Method: We searched the Medline and the Cochrane Library and checked the international guidelines: HAS, RCOG, SOGC, ACOG and WHO., Results: In case of PPH, the use of a collecting bag is recommended (professional consensus). All the concerned professional (midwife, obstetrician, anesthesiology team) must be warned immediately (professional consensus). If placenta is retained, manual removal needs to be performed and after placental delivery, manual uterine exploration is recommended (professional consensus). At the same time, a dose of 5 or 10 IU of oxytocin must be administrated IV over at least 1minute or directly by an intramuscular injection followed by an infusion of 5 to 10 UI/h during 2hours (professional consensus). In some situations at risk of cervical and high vaginal laceration, the low genital tract needs to be carefully examined (professional consensus). Appropriate management of PPH has to be known by the concerned professional (professional consensus). Retrospective study of each case of PPH should be done (professional consensus)., Conclusion: The PPH initial treatment involves a team work that, most of times, leads to stop the bleeding in least than 30minutes (professional consensus)., (Copyright © 2014. Published by Elsevier Masson SAS.)

Objectives: To define guidelines for the management of women diagnosed with threatened late miscarriage (TLM)., Materials and Methods: A systematic review of the literature was performed using Pubmed and the Cochrane library databases and the guidelines from main international societies., Results: Management of women diagnosed with threatened LM requires a complete history-taking searching for a previous history of LM and/or of premature delivery (Grade B). Speculum examination is required to diagnose membrane prolapse (Grade B) and vaginal ultrasound scan is recommended to measure the cervical length (Grade B). Finally, initial management should allow to rule out chorioamniotitis (Grade B). Vaginal progesterone therapy (90-200mg daily) is recommended for women diagnosed with a sole shortened cervix (<25mm) in mid-pregnancy (Grade A). Cerclage is only recommended in women with both history of previous premature delivery and/or previous LM and shortened cervical length diagnosed before 24 weeks of gestation (Grade A). Finally, cervical cerclage (Mc Donald technique) associated with systematic tocolytic therapy (indometacine) and antibiotics are to be recommended in women diagnosed with TLM with dilated cervical os eventually associated with membrane prolapse (GradeC)., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objective: State of knowledge about misoprostol's use out of its marketing authorization during the first trimester of pregnancy, in early miscarriage or to induce abortion or medical termination of pregnancy., Methods: French and English publications were searched using PubMed, Cochrane Library and international learned societies recommendations., Results: Cervical ripening prior to surgical uterine evacuation during the first trimester of pregnancy facilitates cervical dilatation and reduces operative time and uterine retention risk. Misoprostol, mifepristone and osmotic cervical dilators are equally efficient. Concerning first trimester miscarriage, surgical uterine evacuation remains the most effective and the quickest method of treatment (EL 1). Depending on the clinical situation, medical treatment using misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) does not increase the risk of complications, neither haemorrhagic nor infectious (EL 1). However, these alternatives generally require longer outpatient follow-up, which leads to more consultations, prolonged bleeding and not planned surgical procedures (EL 1). Concerning missed miscarriage, a vaginal dose of 800 μg of misoprostol, possibly repeated 24 to 48 hours later, seems to offer the best efficiency/tolerance ratio (EL 2). Concerning early abortion, medical method is a safe and efficient alternative to surgery (EL 2). Success rates are inversely proportional to gestational age (EL 2). According to the modalities of its marketing authorization, 400 μg of misoprostol can only be given by oral route, for less than 7 weeks of amenorrhea (WA) pregnancies and after 36 to 48 hours following 600 mg of mifepristone (EL 1). However, 200mg of mifepristone is as efficient as 600 mg (EL 1). Beyond 7WA, misoprostol buccal dissolution (sublingual or prejugal) or vaginal administration are more efficient and better tolerated than oral ingestion (EL 1). Between 7 and 9WA, the best protocol in terms of efficiency and tolerance is the association of 200mg of mifepristone followed 24 to 48 hours later by 800 μg of vaginal, sublingual or buccal misoprostol (EL 1). An additional dose of 400 μg can be given 3 hours later if necessary (EL 3). In case of buccal administration, the dose of 400 μg seems to offer the same efficiency with a better tolerance but further evaluation is needed (EL 2). Between 9 and 12WA, medical treatment is less efficient than surgery and its tolerance is lower (EL 2). However, a protocol of 200mg of mifepristone followed 36 to 48 hours later by 800 μg of vaginal or sublingual misoprostol, plus an additional 400 μg dose every 3-4 hours (until 4-5 doses maximum) seems safe and efficient (EL 5)., Conclusion: Misoprostol use during the first trimester of pregnancy is a safe and efficient alternative to surgery as long as detailed protocols adjusted to each clinical situation are respected., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objectives: Determine cases which are at risk of vacuum extraction failure as well as maternal and foetal issues depending on the delivery outcome., Material and Methods: It was a retrospective study comparing 147 vacuum failures, from January 2002 to December 2010, with a control group randomly composed of 526 successful vacuum extractions. The outcomes were high risk situations of vacuum failure, maternal and neonatal morbidity depending on the delivery method (caesarean section or other instrumental extraction)., Results: The global vacuum failure rate was 3.3 %. During labour, we identified several situations at risk of vacuum extraction failure: cephalhematomas prior to extraction (P<0.001), deflexion attitude (P<0.001), posterior variety (P<0.001), entering above the inlet strait (P<0.001), occiput posterior delivery (P<0.001), fœtal weight greater than 3500g (P=0.023). Neonatals consequency were more Apgar score below 7 at five minutes life (P=0.007), fœtal acidosis (pH<7,20) (P=0.032), neonatal resuscitation (P<0.001), and craniofacial damages (P<0.001)., Conclusion: Many dystocic situations occurring during labour require intense care when practicing vacuum extraction since they more frequently result in failure. In case of vacuum extraction failure, immediate adaptation to extra-uterine life seems to be more difficult for new-born babies., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objectives: To evaluate the prevention of fetomaternal rhesus-D allo-immunization between 2008 and 2010. This evaluation was a part of the continuous medical evaluation (CME) that is compulsory in French hospitals. It was carried out using the tools recommended by the Haute Autorité de santé. We followed the national guidelines for the prevention of fetomaternal rhesus-D allo-immunization as outlined in 2005 by the national French college of Obstetrics and Gynecology., Materials and Methods: We audited 3926 consultations in the first four months of 2008. Based on the results of the audit, actions were implemented to improve care. In 2009, we audited 4021 consultations to look for improvement, and another 3932 consultations in 2010., Results: In 2008, 14% of the patients had an overall optimal prevention. After actions were taken, 44% of patients in 2009 and 58% of patients in 2010 demonstrated optimal prevention (P<0,05). Especially, the prevention of fetomaternal allo-immunization has been explained for 43% of the patients in 2008 and to 90% of them in 2010. And immunoprophylaxia has been prescribed to 70% of the patients in 2008 and to 93% of them in 2010., Conclusion: This CME has resulted in a statistically significant improvement of the prevention of allo-immunization., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objectives: Women who had severe preeclampsia are at high risk of gestational vascular complications (preeclampsia, gestational hypertension, fetal death, small for gestational age, placenta abruptio) in subsequent pregnancies. The aim of this study was to describe outcomes of subsequent pregnancy after severe preeclampsia with delivery before 34 weeks of gestation during the first pregnancy., Patients and Methods: One hundred and thirty-four primiparous women delivered before 34 weeks of gestation resulting in severe preeclampsia between January 2002 and December 2009. The data of the index pregnancy were identified from the medical record of our maternity, those of the subsequent pregnancy from paper or computerized medical records of the hospitals where deliveries took place. Our study ended on December 31 2011 for a decrease of at least 2 years after the index pregnancy., Results: Of the 75 subsequent pregnancies, 59 have been studied. Twenty patients (34%) had gestational vascular complications, in type of gestational hypertension alone (10%), preeclampsia (65%), isolated small for gestational age (20%) or fetal death (5%). Thirty-nine patients (66%) showed no recurrence of gestational vascular complications but only 33 patients (56%) had a pregnancy of course totally physiological. The only risk factor for recurrent gestational vascular complications in subsequent pregnancy was a long time interval between two pregnancies, with an increased risk in case of delay beyond 26 months., Conclusion: Women with a history of severe preeclampsia with delivery before 34 weeks of gestation during first pregnancy are at increased risk for gestational vascular complications during the next pregnancy. A close obstetrical monitoring is recommended during a subsequent pregnancy., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objective: To assess maternal outcomes during trial of labor (TOL) and elective repeat caesarean delivery (ERCD) in women with a previous caesarean delivery., Methods: French and English publications were searched using PubMed and Cochrane Library., Results: Maternal mortality remains a very rare event regardless of the planned mode of delivery (EL2). It is potentially reduced after a TOL but the presence of biases in many studies does not allow any conclusion (EL3). Maternal morbidity is mainly due to the failure of the TOL and to the risk of unplanned caesarean delivery during labor (EL2). The risk of complete uterine rupture significantly increases with TOL versus ERCD but it remains low at about 0.2 to 0.8% for women with one scar on the uterus (EL2). The occurrence of a post-surgical wound, mostly from the bladder, is rare (less than 0.5%) regardless of the planned mode of delivery (EL2). Facing the risk of hemorrhage requiring hysterectomy or blood transfusion, data are heterogeneous because of the nature of the populations studied. These risks do not seem to vary with the mode of delivery (EL3). The risk of post-partum venous thrombo-embolic complications and infections (endometritis and maternal fever) appears to be similar in both TOL and ERCD (EL3). The risk of infection is primarily related to the additional presence of obesity (EL2). While maternal morbidity progressively increases with the number of iterative caesarean sections, maternal morbidity in TOL after a previous caesarean delivery decreases with the number of successful TOL (EL2)., Conclusion: In patients with a previous caesarean delivery, the risks of maternal complications are rare and similar between TOL and ERCD. There is an increased risk of complete uterine rupture in case of TOL. Nevertheless TOL has a favorable benefit/risk balance in most cases and its success reduces the risk of short and long-term maternal complications (EL3)., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objective: To describe the incidence and the etiologies of acute pulmonary edema (APE) and the diagnostic procedure used during pregnancy and immediate post-partum., Materials and Methods: We analyzed records from a search of codes of heart failure and APE as well as from the term "pulmonary edema" in computerized obstetric records from 2002 to 2010 in a university center of level 3. We identified maternal characteristics, the term of appearance and route of delivery, the time between symptoms and diagnosis, additional tests performed, and data from echocardiography., Results: Fifteen patients had an APE during pregnancy or in the immediate post-partum period during the study period (0.05%). The mean age was 28.6 years and the mean term of appearance was 31.2±3.1 weeks of amenorrhea. The diagnosis was made in 11 cases (73.3%) before delivery and in four during post-partum. The main etiology was preeclampsia (46.6%) followed by heart disease (26.7%), then tocolysis and overfilling (13.3%). In 55% of cases, we found a diagnostic wander characterized by carrying out further unnecessary tests. The echocardiography has led to a change in management in 27.3% of cases., Conclusion: The APE is a rare event during pregnancy and the post-partum period and its main etiology is preeclampsia. Some other etiologies are avoidable like the use of beta-agonists by intravenous route. The diagnosis is sometimes difficult, but the realization of a chest X-ray, a simple and inexpensive test, is enough to confirm it., (Copyright © 2012. Published by Elsevier Masson SAS.)

Objective: To assess the effectiveness and the safety of prevention and treatment of iron deficiency anemia during pregnancy., Methods: French and English publications were searched using PubMed and Cochrane library., Results: Early screening of iron deficiency by systematic examination and blood analysis seemed essential. Maternal and perinatal complications were correlated to the severity and to the mode of appearance of anemia. Systematic intakes of iron supplements seemed not to be recommended. In case of anemia during pregnancy, iron supplementation was not associated with a significant reduction in substantive maternal and neonatal outcomes. Oral iron supplementation increased blood parameters but exposed to digestive side effects. Women who received parenteral supplementation were more likely to have better hematological response but also severe potential side effects during pregnancy and in post-partum. The maternal tolerance of anemia motivated the choice between parenteral supplementation and blood transfusion., Conclusion: Large and methodologically strong trials are necessary to evaluate the effects of iron supplementation on maternal health and pregnancy outcomes., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objective: To estimate maternal outcome of treated or untreated gestational diabetes mellitus (GDM)., Methods: French and English publications were searched using PubMed and Cochrane library., Results: The diagnosis of GDM gathers a high risk population of preeclampsia and cesarean section (EL3). These risks are positively correlated with the level of hyperglycemia in a linear way (EL2). Intensive treatment of mild GDM compared with routine care reduces the risk of pregnancy-induced hypertension (preeclampsia, gestational hypertension). Moreover, it does not increase the risk of operative vaginal delivery, cesarean section and postpartum haemorrhage (EL1). Overweight, obesity and maternal hyperglycemia are independent risk factors for preeclampsia (EL2). Their association with GDM increases the risk of preeclampsia and cesarean section compared to diabetic women with normal body mass index (EL3). The association of several risk factors (such as advanced maternal age, pre-existing chronic hypertension, pre-existing nephropathy, obesity, suboptimal glycemic control) increases the risk of preeclampsia. In that case, the classical follow-up (blood pressure measurement, proteinuria) should be more frequent than monthly (professional consensus). The risk of cesarean section is increased by macrosomia, whether it was prenatally suspected or not. But this increased risk remains whatever the birth weight is (EL3). Diagnosis and treatment of GDM do not reduce the risk of severe perineal lesions, operative vaginal delivery and postpartum haemorrhage (EL2). Some psychological symptoms, such as anxiety and alteration of self-perception, can occur at the diagnosis of GDM (EL3). The treatment of GDM seems to reduce the risk of postpartum depression symptoms (EL2)., Conclusion: Most of the informations published on GDM cover the risks of preeclampsia and cesarean section. Intensive care of GDM reduces theses risks. The pregnancy follow-up should be adjusted to the risk factors., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Operative vaginal delivery significantly increases the risk of anal sphincter injury compared with spontaneous vaginal delivery, particularly when an instrumental application at high station, persistent occipital posterior presentation and/or macrosomia are associated. Risks of vaginal tears, postpartum haemorrhage and urinary retention appear to be increased compared with spontaneous vaginal delivery. There is no evidence that one type of forceps is less safe than another. Different vacuum extractors (soft, rigid and single-use instruments) have similar maternal outcomes. A risk of anal incontinence in the first year postpartum is associated with operative vaginal delivery, particularly forceps. Operative vaginal delivery also appears to increase the risk of occult anal sphincter injury regardless of the instrument used, but does not appear to be associated with the risk of postpartum urinary incontinence and genital prolapse compared with spontaneous vaginal delivery. It does, however, increase the risks of perineal pain, postpartum dyspareunia and sexual disorders compared with spontaneous vaginal delivery, particularly in cases of perineal tears.

The classic pregnancy term is between 37 and 42 weeks of gestation and the perinatal mortality and morbidity rates increasing progressively during this period, it is difficult to decide of an "ideal" term above which a medical intervention (induction of labour) brings more benefits than risks linked to the natural evolution of pregnancy. There is a good scientific evidence for the induction of labour from 41 weeks of gestation, defined like "postdating" term, when the cervical conditions are favourable (Bishop score>5) and systematically from 42 weeks (significative reduction of perinatal mortality rate and not increased rate of cesarean delivery compared with expectant management). An intensive antenatal surveillance involving a nonstress test and an evaluation of amniotic fluid volume is an efficient alternative when the conditions of delivery are unfavourable between 41 and 42 weeks of gestation or when the woman does not wish induction.

Vein of Galen aneurysm is a rare vascular congenital malformation. We report an antenatal diagnosis with duplex Doppler at 26 weeks gestation. Magnetic resonance imaging was used before and after delivery in order to determine neurological prognosis. The neonatal prognosis is poor if fetal cardiac insufficiency or cerebral lesions are present antenatally. Premature delivery does not improve the neonatal outcome. When the aneurysm is not life threatening, embolization of the malformation is at best delayed five months after birth.

Objective: To evaluate indications, mode of administration and safety of magnesium sulphate in severe preeclampsia., Material and Methods: We conducted a retrospective descriptive study from January 2000 to December 2002, including patients with severe preeclampsia which was defined as elevated blood pressure >or=140 and/or 90 mmHg with proteinuria >or=0.3g per day, associated with one or more of the following: elevated blood pressure >or=170 and/or 110 mmHg, proteinuria>3g per day, functional symptoms such as headache, hyperreflexia, oliguria<500 ml per day, thrombocytopenia, creatinine level>100 micromol/l, HELLP syndrome. We studied a group of 57 women treated by magnesium sulphate (intravenous bolus of 4.5g during 20 minutes followed by a perfusion of 1.5g/h) associated or not with an antihypertensive treatment., Results: Treatment by magnesium sulphate was started antenatally in 53 women or during immediate postpartum in 4, associated (n=25) or not (n=32) with an antihypertensive treatment. Hyperreflexia was the main indication to start magnesium sulphate treatment (75%). About half (47%) of the cases occurred before 33 weeks of gestation No eclampsia occurred in this group. There was one overdosage which regressed when perfusion was stopped. One patient presented minor side effects attributed to magnesium sulphate., Conclusion: Providing a rigorous protocol, indications of magnesium sulfate therapy in severe preeclampsia are well defined. It seems that this treatment could be easily used without severe complications and major side effects.

Accurate management of primary postpartum hemorrhage requires perfect knowledge of a recent protocol accessible at all times. Staff members and equipment need to be adjusted to the emergency situation. The first step is to establish a rapid diagnosis. This could be done with collecting bags, placed immediately after the birth. Once the diagnosis has been established, it has to be communicated to the whole team including obstetricians, midwives and anesthetists. A search for the cause of the hemorrhage is premordial. Abdominal uterine palpation confirms the diagnosis of uterine atony, the most frequent cause of postpartum hemorrhage. Two management schemes are possible depending on whether or not there is retention of the placenta. When the placenta is retained, manual removal has to be performed to empty the uterine cavity and to rule out uterine rupture. After placental delivery, manual control of the uterine cavity is always required. Uterine massage has to be performed after the intrauterine manoeuvres and must not be stopped too quickly. Rapidly other origins can be excluded: episiotomy or low genital tract lacerations requiring rapid repair, coagulation disorders requiring specialised care, or hematomas. During the same time, uterotonic drugs have to be used. Oxytocin (intravenous injection of 5 to 10 IU) is generally employed. Prostaglandins cannot be proposed as publications reporting their efficiency are not validated. Meanwhile, the anesthetists will have begun the first measures of resuscitation.