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Resume La grossesse represente une periode de vulnerabilite psychique importante pour les femmes. Vingt pour cent d’entre elles presenteraient pendant la periode perinatale des troubles mentaux variant de l’anxiete a la depression. Chez celles presentant une maladie mentale preexistante, le risque de decompensation aigue est important. Dans ce sens, l’Organisation mondiale de la sante recommande de classer les suicides survenant pendant la grossesse et jusqu’a un an du post-partum comme mort maternelle. Ainsi, entre 2013 et 2015, 35 suicides maternels sont survenus en France, soit un ratio de mortalite maternelle de 1,4 pour 100 000 naissances vivantes (IC95 %: 1,0–2,0). Constituant 13,4 % de l’ensemble des morts maternelles pour la periode, ce groupe est l’un des 2 premieres causes de mortalite maternelle. Un total de 23 % des suicides sont survenus dans les 42 premiers jours du post-partum, et 77 % entre 43 jours et un an apres la naissance. 33,3 % des meres suicidees presentaient des antecedents psychiatriques connus et 30,3 % des antecedents de soins psychiatriques, meconnus des maternites. Les soins non optimaux sont presents dans 72 % des cas avec 91 % de deces potentiellement evitables, lies a un defaut de prise en charge multidisciplinaire, et une interaction inadequate entre la patiente et le systeme de soins. De l’analyse des cas, ont ete tires des messages forts permettant d’optimiser la prise en charge : ameliorer la connaissance des antecedents psychiatriques des l’inscription en maternite, ameliorer le reperage des symptomes d’alerte et le recours au psychologue et/ou au psychiatre, mettre en place un parcours de soins specifique et une collaboration multidisciplinaire en cas de pathologie psychiatrique connue.

Resume Objectif Determiner la prise en charge des patientes avec une rupture prematuree des membranes avant 37 semaines d’amenorrhee (SA). Methodes Synthese de la litterature a partir des bases de donnees PubMed et Cochrane et des recommandations des societes et colleges francais et etrangers. Resultats En France, la frequence de la rupture prematuree des membranes (RPM) est de 2 a 3 % avant 37 SA (Niveau de preuve [NP] 2) et de moins de 1 % avant 34 SA (NP2). La prematurite et l’infection intra-uterine sont les complications majeures de la RPM avant terme (NP2). La prolongation de la duree de latence est benefique (NP2). Par rapport aux autres causes de prematurite, la RPM avant terme n’est pas associee a un sur-risque evident de morbi-mortalite neonatale, sauf en cas d’infection intra-uterine, qui est associee a une augmentation des morts fœtales in utero (NP3), des infections neonatales precoces (NP2) et des enterocolites ulceronecrosantes (NP2). Le diagnostic de la RPM avant terme est principalement clinique (accord professionnel). En cas de doute diagnostique, il est recommande d’utiliser les tests de detection d’IGFBP-1 ou de PAMG-1 (accord professionnel). Il est recommande d’hospitaliser les patientes lors du diagnostic de RPM avant terme (accord professionnel). Il n’existe pas d’argument suffisant pour recommander ou ne pas recommander une tocolyse initiale (grade C). Si une tocolyse etait prescrite, il est recommande de ne pas la prolonger plus de 48 heures (grade C). Il est recommande d’administrer une cure antenatale de corticoides si l’âge gestationnel est inferieur a 34 SA (grade A) et du sulfate de magnesium en cas d’accouchement imminent avant 32 SA (grade A). Il est recommande de prescrire une antibioprophylaxie a l’admission (grade A) pour reduire la morbidite neonatale et maternelle (NP1). L’amoxicilline, les cephalosporines de 3eme generation et l’erythromycine (accord professionnel) peuvent etre utilisees en monotherapie, ou l’association erythromycine–amoxicilline (accord professionnel), pour une duree de 7 jours (grade C). Toutefois, un arret precoce de l’antibioprophylaxie semble acceptable en cas de prelevement vaginal initial negatif (accord professionnel). Il n’est pas recommande de prescrire comme antibioprophylaxie l’association amoxicilline-acide clavulanique (accord professionnel), des aminosides, des glycopeptides, des cephalosporines de premiere ou deuxieme generation, de la clindamycine ou du metronidazole (accord professionnel). La prise en charge a domicile des patientes cliniquement stables apres au moins 48 heures de surveillance hospitaliere est possible (accord professionnel). Au cours de la surveillance, il est recommande d’identifier les elements cliniques et biologiques evocateurs d’une infection intra-uterine (accord professionnel). Il n’est pas possible d’emettre de recommandations sur la frequence de cette surveillance (accord professionnel). En cas d’examen de surveillance isolement positif chez une patiente asymptomatique (CRP augmentee, hyperleucocytose, prelevement vaginal positif), il n’est pas recommande d’initier systematiquement une antibiotherapie (accord professionnel). En cas d’infection intra-uterine, il est recommande d’administrer immediatement une antibiotherapie associant une betalactamine a un aminoside (grade B), par voie intraveineuse (grade B) et de faire naitre l’enfant (grade A). La cesarienne en cas d’infection intra-uterine est reservee aux indications obstetricales habituelles (accord professionnel). Il est recommande d’avoir une attitude expectative en cas de RPM non compliquee avant 37 SA (grade A), meme en cas de prelevement positif pour le streptocoque B, sous couvert d’une antibioprophylaxie a l’admission (accord professionnel). L’ocytocine et les prostaglandines sont deux options envisageables pour le declenchement du travail en cas de RPM avant terme (accord professionnel). Conclusion La prise en charge de la rupture prematuree des membranes avant terme non compliquee repose sur l’expectative jusqu’a 37 SA (grade A).

Resume La mortalite maternelle de cause infectieuse a represente au cours de la periode 2010–2012, 5 % des causes directes de deces et 16 % des morts maternelles indirectes. Parmi les 22 deces releves de causes infectieuses, 6 morts maternelles ont ete attribuees a une infection a porte d’entree genitale confirmant la diminution depuis 10 ans des morts maternelles directes par infection. A l’inverse, les morts maternelles indirectes par infection, a porte d’entree extragenitale, ont double au cours de la meme periode avec 16 deces au cours du dernier triennium, domines par les infections respiratoires hivernales en particulier grippales : la pandemie grippale A (H1N1) de 2009–2010 est, au cours de la periode etudiee, la premiere cause de mortalite maternelle indirecte par infection. Les principaux agents infectieux a l’origine des deces de cause infectieuse directe sont les Streptococcus pyogenes , Escherichia Coli et Clostridium perfringens , responsables de chocs toxi-infectieux, de sepsis graves, secondaires pour plusieurs cas a une cellulite ou une fasciite necrosante. Sur les 6 deces par infection directe, 4 ont ete juges peut-etre evitables en raison de soins inadaptes : retard ou defaut diagnostique, traitement medical et/ou chirurgical initie avec retard ou inadapte. Parmi les 16 morts maternelles indirectes par infection, le virus grippal A(H1N1) et le Streptococcus pneumoniae complique de purpura fulminans ont ete le plus souvent en cause : l’absence de vaccination antigrippale au cours de la grossesse, le retard diagnostique et a l’initiation en urgence d’un traitement specifique sont les principaux facteurs d’evitabilite retrouves dans 70 % des dossiers expertises.

Decisions regarding whether to initiate or forgo intensive care for extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients and must be taken into account. After a short review of these factors, we present the thoughts and proposals of the Risks and Pregnancy department. The proposals are to limit emergency decisions, to better take into account other factors than gestational age and prenatal predicted fetal weight in assessing the prognosis, to introduce multidisciplinary consultation in the evaluation and proposals that will be discussed with the parents, and to separate prenatal steroid therapy from decision-making regarding whether or not to administer intensive care.

International audience; In France, the frequency of premature rupture of the membranes (PROM) is 2%-3% before 37 weeks' gestation (level of evidence [LE] 2) and less than 1% before 34 weeks (LE2). Preterm delivery and intrauterine infection are the major complications of preterm PROM (PPROM) (LE2). Prolongation of the latency period is beneficial (LE2). Compared with other causes of preterm delivery, PPROM is associated with a clear excess risk of neonatal morbidity and mortality only in cases of intrauterine infection, which is linked to higher rates of in utero fetal death (LE3), early neonatal infection (LE2), and necrotizing enterocolitis (LE2). The diagnosis of PPROM is principally clinical (professional consensus). Tests to detect IGFBP-1 or PAMG-1 are recommended in cases of uncertainty (professional consensus). Hospitalization is recommended for women diagnosed with PPROM (professional consensus). Adequate evidence does not exist to support recommendations for or against initial tocolysis (Grade C). If tocolysis is prescribed, it should not continue longer than 48 h (Grade C). The administration of antenatal corticosteroids is recommended for fetuses with a gestational age less than 34 weeks (Grade A) and magnesium sulfate if delivery is imminent before 32 weeks (Grade A). The prescription of antibiotic prophylaxis at admission is recommended (Grade A) to reduce neonatal and maternal morbidity (LE1). Amoxicillin, third-generation cephalosporins, and erythromycin (professional consensus) can each be used individually or eythromycin and amoxicillin can be combined (professional consensus) for a period of 7 days (Grade C). Nonetheless, it is acceptable to stop antibiotic prophylaxis when the initial vaginal sample is negative (professional consensus). The following are not recommended for antibiotic prophylaxis: amoxicillin-clavulanic acid (professional consensus), aminoglycosides, glycopeptides, first- or second-generation cephalosporins, clindamycin, or metronidazole (professional consensus). Women who are clinically stable after at least 48 h of hospital monitoring can be managed at home (professional consensus). Monitoring should include checking for clinical and laboratory factors suggestive of intrauterine infection (professional consensus). No guidelines can be issued about the frequency of this monitoring (professional consensus). Adequate evidence does not exist to support a recommendation for or against the routine initiation of antibiotic therapy when the monitoring of an asymptomatic woman produces a single isolated positive result (e.g., elevated CRP, or hyperleukocytosis, or a positive vaginal sample) (professional consensus). In cases of intrauterine infection, the immediate intravenous administration (Grade B) of antibiotic therapy combining a beta-lactam with an aminoglycoside (Grade B) and early delivery of the child are both recommended (Grade A). Cesarean delivery of women with intrauterine infections is reserved for the standard obstetric indications (professional consensus). Expectant management is recommended for uncomplicated PROM before 37 weeks (Grade A), even when a sample is positive for Streptococcus B, as long as antibiotic prophylaxis begins at admission (professional consensus). Oxytocin and prostaglandins are two possible options for the induction of labor in women with PPROM (professional consensus).

Resume Objectifs Definir les stades du travail spontane, preciser les indications, les modalites et l’efficacite de l’administration d’oxytocine ainsi que decrire les effets indesirables maternels, fœtaux et neonataux lies a cette administration. Methode Revue systematique de la litterature a partir de la base de donnees Medline interrogee jusqu’en mars 2016 et completee par une recherche sur les sites des societes savantes. Resultats Le 1er stade debute par une phase de latence, definie par des contractions uterines entrainant une modification du col jusqu’a 5 cm de dilatation, et se termine par une phase active, de 5 cm a dilatation complete. Le 2e stade debute par la phase de descente et se termine par la phase d’expulsion. En phase de latence, il est recommande de ne pas intervenir a titre systematique. Une pose precoce d’analgesie peridurale est possible sans attendre la phase active du travail et, dans ce cas, il est recommande de ne pas associee de facon systematique une administration d’oxytocine. En phase active du premier stade, une dystocie dynamique est definie par une vitesse de dilation inferieure a 1 cm/4 h de 5 cm a 7 cm ou inferieure a 1 cm/2 h de 7 cm a dilation complete. En cas de dystocie dynamique en phase active, il est recommande de pratiquer une amniotomie en premiere intention. En l’absence d’amelioration une heure apres l’amniotomie, une administration d’oxytocine peut etre realisee. En cas de prolongation du 2e stade au-dela de 2 h, il est recommande d’administrer de l’oxytocine pour corriger une absence de progression de la presentation. En cas de dystocie dynamique, l’oxytocine doit etre administree a un debit initial de 2 mUI/min, augmentee par palier de 2 mUI/min en respectant un delai de 30 min, et sans depasser un debit de 20 mUI/min. Les effets indesirables maternels rapportes concernent l’hyperactivite uterine, la rupture uterine et l’hemorragie du post-partum (HPP). Les effets indesirables fœtaux discutes concernent les anomalies du rythme cardiaque fœtal liees a une hyperactivite uterine, l’hyponatremie, l’ictere neonatal, les difficultes de succion et l’autisme. Conclusion L’administration d’oxytocine durant le travail spontane ne doit pas etre consideree comme une prescription anodine. L’etat actuel des connaissances doivent inciter les acteurs de la perinatalite a la plus grande vigilance. L’administration d’oxytocine durant le travail spontane expose la mere et le fœtus a des effets nefastes pouvant avoir des consequences a court terme et possiblement a long terme. Ses modalites d’administration doivent faire l’objet d’un protocole. Sa prescription et le consentement de la mere doivent etre precises dans son dossier medical.

Resume Objectif Decrire les pratiques medicales face a certaines recommandations. Patientes et methodes Entre 1994 et 2005, la base de donnees Audipog comprend 247 405 grossesses. Nous avons constitue un sous-echantillon, par tirage au sort, ne comprenant que les naissances survenues pendant un mois par maternite (n = 100 315 grossesses). L’evolution de certains indicateurs a ete analysee en regard de huit recommandations nationales et des decrets de perinatalite de 1998. Les taux standardises ont ete compares par un test de tendance. Resultats Les enfants de moins de 33 semaines d’amenorrhee (SA) issus de grossesses multiples sont nes dans 77,4 % des cas dans un niveau III en 2000–2001 contre 44,9 % en 2004–2005 (p Discussion et conclusion L’impact des recommandations pour la pratique clinique (RPC) sur les pratiques est globalement faible. Il est observe une amelioration des pratiques avant la publication des RPC.

High-frequency oscillation (HFO) is a technique frequently used in neonatal resuscitation, but which has yet to be evaluated. The use of intrathoracic pressures may have an effect on the cerebral circulation of immature neonates. The aim of this study was to examine the variations in cerebral blood velocity and oxygenation during brief pulmonary inflations (sighs), by focusing on alveolar recruitment. In this prospective study performed in 13 intubated and ventilated neonates (α = 5%; 1 - β = 80%), mean blood velocity and Doppler Resistance Index were measured, and variations in chromophores concentrations were evaluated by near infrared spectroscopy. Brief inflations at 4 cmH 2 O above the mean regulated intra-thoracic pressure did not cause any variation in the parameters measured. An explanation for this discordance with animal studies may be the level of pressure chosen, which could be more appropriate for the pulmonary compliance of neonates. □ Cerebral blood flow, high frequency oscillation, newborn, NIRS.

International audience; Small for gestational age (SGA) is defined by weight (in utero estimated fetal weight or birth weight) below the 10th percentile (professional consensus). Severe SGA is SGA below the third percentile (professional consensus). Fetal growth restriction (FGR) or intra-uterine growth restriction (IUGR) usually correspond with SGA associated with evidence indicating abnormal growth (with or without abnormal uterine and/or umbilical Doppler): arrest of growth or a shift in its rate measured longitudinally (at least two measurements, 3 weeks apart) (professional consensus). More rarely, they may correspond with inadequate growth, with weight near the 10th percentile without being SGA (LE2). Birthweight curves are not appropriate for the identification of SGA at early gestational ages because of the disorders associated with preterm delivery. In utero curves represent physiological growth more reliably (LE2). In diagnostic (or reference) ultrasound, the use of growth curves adjusted for maternal height and weight, parity and fetal sex is recommended (professional consensus). In screening, the use of adjusted curves must be assessed in pilot regions to determine the schedule for their subsequent introduction at national level. This choice is based on evidence of feasibility and the absence of any proven benefits for individualized curves for perinatal health in the general population (professional consensus). Children born with FGR or SGA have a higher risk of minor cognitive deficits, school problems and metabolic syndrome in adulthood. The role of preterm delivery in these complications is linked. The measurement of fundal height remains relevant to screening after 22 weeks of gestation (Grade C). The biometric ultrasound indicators recommended are: head circumference (HC), abdominal circumference (AC) and femur length (FL) (professional consensus). They allow calculation of estimated fetal weight (EFW), which, with AC, is the most relevant indicator for screening. Hadlock's EFW formula with three indicators (HC, AC and FL) should ideally be used (Grade B). The ultrasound report must specify the percentile of the EFW (Grade C). Verification of the date of conception is essential. It is based on the crown-rump length between 11 and 14 weeks of gestation (Grade A). The HC, AC and FL measurements must be related to the appropriate reference curves (professional consensus); those modelled from College Francais d'Echographie Fetale data are recommended because they are multicentere French curves (professional consensus). Whether or not a work-up should be performed and its content depend on the context (gestational age, severity of biometric abnormalities, other ultrasound data, parents' wishes, etc.) (professional consensus). Such a work-up only makes sense if it might modify pregnancy management and, in particular, if it has the potential to reduce perinatal and long-term morbidity and mortality (professional consensus). The use of umbilical artery Doppler velocimetry is associated with better newborn health status in populations at risk, especially in those with FGR (Grade A). This Doppler examination must be the first-line tool for surveillance of fetuses with SGA and FGR (professional consensus). A course of corticosteroids is recommended for women with an FGR fetus, and for whom delivery before 34 weeks of gestation is envisaged (Grade C). Magnesium sulphate should be prescribed for preterm deliveries before 32-33 weeks of gestation (Grade A). The same management should apply for preterm FGR deliveries (Grade C). In cases of FGR, fetal growth must be monitored at intervals of no less than 2 weeks, and ideally 3 weeks (professional consensus). Referral to a Level IIb or III maternity ward must be proposed in cases of EFW

Presents a synthesis of works undertaken by the Hyperthermia Group of Lille (France) concerning the utilization of microwave radiometry for temperature control in hyperthermia therapy. This technique of noninvasive temperature control within biological tissues has been integrated on many hyperthermia systems now commercialized. The authors describe the principle of a new radiometer as well as the calculation of the radiometric signals. This allows a noninvasive determination of thermal maps inside tissues during the hyperthermia treatments. Many comparisons between theory and experiment have validated the authors' models of thermal dosimetry and provide a quantitative guidance for the planning of hyperthermia treatments.

Congenital diaphragmatic hernia (CDH) is a severe disorder in neonates. The prognosis has been improved in the past 10 years by a combination of HFO ventilation, sedation and analgesia, nitric oxide and delayed surgery. Extracorporeal oxygenation (ECMO) has been proposed by certain teams. A decrease in mortality from 70% to approximately 40% has recently been reported [1,2]. However, little is known about the outcome of such patients. We report the outcome of a group of patients after 10 years' follow-up.

Ventilation by HFO or CMV in premature neonates of less than 30 weeks' gestational age with hyaline membrane disease: functional outcome at one year

International audience; OBJECTIVE: To estimate the accuracy and reliability of the reporting of diagnoses and procedures related to severe acute maternal morbidity in French hospital discharge data. STUDY DESIGN AND SETTING: The study, conducted in four French tertiary teaching hospitals, covered the years 2006 and 2007 and 30,607 deliveries. We identified severe maternal morbid events-eclampsia, pulmonary embolism, procedures related to postpartum hemorrhages, and intensive care-in administrative hospital discharge data and medical records and compared their recording. Information from medical records was the gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value of the hospital discharge data for these events were calculated. False positives and false negatives were examined to identify the reasons for misrecorded information. RESULTS: The PPV of the hospital discharge data was 20% for eclampsia. For procedures related to postpartum hemorrhages, the PPVs were high, but sensitivities were lower; however, 95% of recording errors could be corrected. All indicators for intensive care exceeded 98%. CONCLUSION: Intensive care and procedures seem reliably reported in the hospital administrative database, which, therefore, can be used to monitor them. Using these data for monitoring diagnoses will require a greater investment by clinicians in the accuracy of their reporting.