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Introduction: Relevance of fetal brain magnetic resonance imaging (MRI) in cases of cleft lip and/or palate (CL/P) is still discussed to date. The aim of our study was to review the contribution of fetal brain MRI for detecting cerebral anomalies in cases of CL/P comparing antenatal data with neonatal outcomes. Methods: A retrospective multicenter study was conducted from January 2010 to October 2020 in two multidisciplinary prenatal diagnosis centers among women with a fetal ultrasound (US) diagnosis of CL/P. Prenatal imaging and genetic analysis data were collected, as well as postnatal data, including outcomes of children who had an abnormal prenatal MRI. Results: Among the 202 fetuses with a US diagnosis of CL/P, 96 underwent US and fetal brain MRI. 19 brain MRIs were found to be abnormal: 14 (73.7%) involved CL/P associated with other US abnormalities and five (26.3%) involved isolated clefts, of which four were cleft lip and alveolus and secondary palate (CLP). MRI identified severe abnormalities that changed the prognoses of 3 cases of clefts associated with other US abnormalities. In contrast, MRI found only minor abnormalities for the five isolated clefts, with no postnatal disorders found in these children. Conclusion: Fetal brain MRI should be proposed in cases of clefts associated with other anomalies or if US examination is limited by local conditions. MRI could also be discussed in cases of isolated CLP but should not be performed in cases of isolated cleft lip.

Resume Introduction Le taux de cesarienne entre 22+0 et 28+0 semaines d’amenorrhee (SA) a progresse depuis plusieurs annees. L’objectif de l’etude etait de decrire les grossesses ulterieures chez les femmes ayant un antecedent de cesarienne entre 22+0 et 28+0 SA. Methodes Nous avons effectue une etude de cohorte, retrospective, observationnelle, bi-centrique au sein de maternites de type III. Nous avons inclus les femmes ayant eu une cesarienne entre 22+0 et 28+0 SA du 1er decembre 2014 au 31 decembre 2017. Nous avons par la suite recueilli de facon retrospective les donnees concernant les grossesses ulterieures de ces femmes jusqu’en mars 2020. Nous avons decrit le taux de grossesses ulterieures et les issues de la premiere grossesse apres la cesarienne prematuree index. Resultats Parmi les 186 femmes ayant eu une cesarienne entre 22+0 et 28+0 SA, les donnees de 103 d’entre elles ont pu etre recueillies dont 47 (45,6 %) femmes ayant presente 64 nouvelles grossesses. Parmi les 47 premieres grossesses apres la cesarienne prematuree index, 19 (40,4 %) ont ete menees a un terme ≥ 37+0 SA. Le mode d’accouchement etait dans 23 cas (79,3 %) une cesarienne. Une tentative de voie basse n’etait envisagee que pour 7 femmes (24,1 %), et seulement 6 femmes (20,7 %) ont accouche par voie basse. Conclusions En cas de desir de grossesse apres une cesarienne entre 22+0 et 28+0 SA, le taux de grossesse est eleve sans recidive de la prematurite dans la majorite des cas. La cesarienne est le mode d’accouchement majoritaire. Si une tentative de voie basse est envisagee, le taux de succes est raisonnable.

Resume Objectifs Des etudes internationales ont montre que la prise en charge perinatale active aux âges gestationnels les plus faibles s’accompagnait d’une amelioration de la survie sans augmentation des handicaps graves par rapport a une prise en charge moins active. Un travail mene par les societes savantes (SFMP, SFN et CNGOF) a permis d’elaborer de nouvelles propositions pour une prise en charge plus optimaledes enfants extremement prematures en France. Methode Ce groupe a ete constitue en 2015 a l’initiative des societes savantes et en lien avec les associations de parents et d’usagers. Le travail s’est appuye sur la revue de la litterature sur le pronostic des enfants extremement prematures, ainsi que sur les recommandations emises par des societes savantes europeennes. Sur la base de ces informations, un texte a ete produit, soumis a l’ensemble des membres du groupe de travail et definitivement accepte par les societes savantes en avril 2019. Resultats Ce texte propose une aide a la decision dans la prise en charge de ces naissances. Il pose comme principes : l’administration de la corticotherapie independamment de la prise en charge (reanimation ou soins de confort) ; une evaluation pronostique et une decision collegiale, hors contexte de l’urgence ; un consensus sur l’information a delivrer aux parents avant de les informer et de recueillir leur avis. Cette demarche suppose une coherence de la prise en charge avant, pendant et apres la naissance et elle s’appuie sur une etroite collaboration obstetrico-pediatrique. Conclusion Ces propositions doivent permettre de faire evoluer la prise en charge perinatale de l’extreme prematurite en France.

Midtrimester sonographic short cervix is a good predictor of preterm birth in singleton pregnancies.This study aimed to assess the impact of implementing a universal transvaginal cervical length screening program on preterm birth rate.This study consisted of 2 parts: a before-and-after multicenter study and a study on the ECHOCOL ("echo"="ultrasound" and "col"="cervix" in French) prospective cohort. We compared the rate of preterm birth before and after the introduction of universal cervical length screening at the time of midtrimester anatomy ultrasound. The multicenter before-and-after regional study included all women with a singleton pregnancy who gave birth after 24 weeks' gestation in the South East of France from January 1, 2012 to April 30, 2018. In parallel, the ECHOCOL cohort study was prospectively conducted from May 2015 to July 2018, including 17 maternity hospitals in the South East region of France. In case of asymptomatic short cervix25 mm, treatments offered included 200 mg of vaginal progesterone, or cerclage, or a pessary until 34 weeks' gestation.We observed a significant decrease rate of preterm birth between periods A and B after multivariate analysis. (respectively, 5.8% vs 5.6%; adjusted odds ratio, 0.92; 95% confidence interval, 0.89-0.95; P.0001). In parallel, the percentage of cervical length screening significantly increased from 28.9% in period A to 52.9% in period B (odds ratio, 2.76; 95% confidence interval, 2.71-2.80; P.0001). Among the 3468 patients of the ECHOCOL prospective cohort, 38 (1.1%) asymptomatic short cervices were detected, and 192 patients gave birth prematurely (11 with an asymptomatic short cervix and 181 without). In the ECHOCOL cohort, a marked but statistically insignificant tendency toward a reduced rate of preterm birth before 37 weeks of gestation was observed (from 5.8% to 5.5%; adjusted odds ratio, 0.72; 95% confidence interval, 0.51-1.03; P=.068).This study showed a significantly lower rate of preterm birth after the implementation of a universal cervical length screening and treating policy during the second trimester of pregnancy. The clinical trial was registered under NCT02598323.

Uncertain fetal head engagement represents 4% of obstetrical situations associated with an increased risk of postpartum hemorrhage, notably in cases of cesarean delivery and increased neonatal impairment owing to failed vaginal instrumental delivery. In this obstetrical condition, cesarean delivery is recommended, but vaginal delivery is possible in two-thirds of the cases. During the second stage of labor, the descent of the fetal head can be assessed by sonography, particularly by measuring the angle of progression.To evaluate, after a prolonged second stage of labor, the impact of measuring the angle of progression in addition to a digital examination on cesarean delivery rates when fetal head engagement remains uncertain.This open multicenter randomized pragmatic trial included women at term with a singleton cephalic fetus in a clinical occiput anterior position after a prolonged 2-hour second stage of labor with uncertain fetal head engagement. After inclusion in the study, an independent investigator performed ultrasound systematically to confirm the occiput anterior position and measured the angle of progression at the climax of Valsalva pushing. This operator did not participate in labor management. In the study group but not in the control group, the angle of progression was communicated to the obstetrician in charge of labor management. Obstetricians were encouraged to attempt vaginal birth if the angle of progression was120°. The primary outcome was the cesarean delivery rate. Secondary outcomes were operative delivery rate (cesarean delivery and operative vaginal delivery), maternal complications (third and fourth-degree perineal tears, failed vaginal instrumental delivery, postpartum hemorrhage, hysterectomy), and neonatal outcomes (Apgar score5 at 10 minutes, umbilical arterial pH7.10, neonatal wounds, neonatal intensive care unit admission).A total of 45 women were included in the study. Occiput anterior position was confirmed in 33 women: 16 in the study group and 17 in the control group. Women's characteristics at baseline were similar between the groups. The median (range) angles of progression were similar: 138.4° (15) and 140.3° (16.9) in the study and control group, respectively. Cesarean delivery rates were 12.5% in the study group and 41.1% in the control group (P=.06). Secondary outcomes were similar between the 2 groups. No failed vaginal instrumental delivery was reported.Measurement of the angle of progression in addition to digital examination when fetal head engagement remained uncertain showed promising results in decreasing cesarean delivery rates. A larger multicenter randomized controlled trial is needed to confirm these results.

Place: France; International audience; OBJECTIVE: This study compares the neonatal morbidity and mortality of the smallest twins of monochorionic diamniotic (MCDA) pregnancies complicated with selective intrauterine growth restriction (sIUGR) with newborns from singleton pregnancies with intrauterine growth restriction (IUGR). METHODS: We conducted a retrospective cohort study of patients managed at the prenatal diagnosis center in a single tertiary care hospital between 2012 and 2019. MCDA twin pregnancies complicated with sIUGR (sIUGR group) were compared with singleton pregnancies with IUGR (IUGR group). The primary outcome was the comparison in neonatal morbidity and mortality between the two groups. RESULTS: The analysis included 251 patients: 67 in the sIUGR group and 184 in the IUGR group. The two groups were comparable in gestational age and birth weight (p \textgreater 0.05). Multivariate analysis controlling for factors that may influence neonatal status showed no significant difference between the two groups in any of the neonatal morbidity criteria or the composite morbidity-mortality endpoint (adjusted OR = 0.946 [95% CI = 0.317-2.827]; p = 0.921). CONCLUSION: Despite supposedly different pathophysiological mechanisms, neonates from MCDA pregnancies complicated with sIUGR and those from singleton pregnancies with IUGR appear to have identical neonatal morbidity and mortality .

Objective The objective of this study was to evaluate the accuracy of fetal diffusion-weighted magnetic resonance imaging with apparent diffusion coefficient (ADC) determination to predict postnatal renal function (nadir creatinine at 1 year and eGFR) of men with posterior urethral valves (PUV). Methods Between 2003 and 2014, 11 MRI were performed on fetuses (between 28 and 32 weeks) in whom second trimester sonography suggested severe bilateral urinary tract anomalies, suspected of PUV. Results The ADC of the 11 fetuses ranged from 1.3 to 2.86 mm2 s-1 (median = 1.79 mm2 s-1 , normal range for fetal kidney: 1.1-1.8). Two pregnancies with ADC > 2.6 mm2 s-1 were interrupted; the autopsy confirmed PUV and Potter syndrome. For the remaining nine babies, the follow-up was 5.4 years (0.8-10). Four children with abnormal ADC (1.8-2.3) had chronic kidney disease. The remaining five cases with normal nadir creatinine and eGFR had normal ADC. One case with unilateral elevated ADC had a poor ipsilateral renal function on dimercaptosuccinic acid scan. Conclusion Here, it seems that diffusion-weighted magnetic resonance imaging with ADC determination could be useful in accurately evaluating fetal kidneys in PUV and predicting renal function. It may be an additional, non-invasive method when biologic and sonographic findings are inconclusive, especially in the case of oligohydramnios. Further studies are needed to confirm our data. © 2017 John Wiley & Sons, Ltd.

Objective: To compare the short- and mid-term outcomes of preterm twins by chorionicity of pregnancy. Design: Prospective nationwide population-based EPIPAGE-2 cohort study. Setting: 546 maternity units in France, between March and December 2011. Population: A total of 1700 twin neonates born between 24 and 34 weeks of gestation. Methods: The association of chorionicity with outcomes was analysed using multivariate regression models. Main outcome measures: First, survival at 2-year corrected age with or without neurosensory impairment, and second, perinatal, short-, and mid-term outcomes (survival at discharge, survival at discharge without severe morbidity) were described and compared by chorionicity. Results: In the EPIPAGE 2 cohort, 1700 preterm births were included (850 twin pregnancies). In all, 1220 (71.8%) were from dichorionic (DC) pregnancies and 480 from monochorionic (MC) pregnancies. MC pregnancies had three times more medical terminations than DC pregnancies (1.67 versus 0.51%, P < 0.001), whereas there were three times more stillbirths in MC than in DC pregnancies (10.09 versus 3.78%, P < 0.001). Both twins were alive at birth in 86.6% of DC pregnancies compared with 80.0% among MC pregnancies (P = 0.008). No significant difference according to chorionicity was found regarding neonatal deaths and morbidities. Likewise, for children born earlier than 32 weeks, the 2-year follow-up neurodevelopmental results were not significantly different between DC and MC twins. Conclusions: This study confirms that MC pregnancies have a higher risk of adverse outcomes. However, the outcomes among preterm twins admitted to neonatal intensive care units are similar irrespective of chorionicity. EPIPAGE-2 was funded by the French Institute of Public Health Research/Institute of Public Health and its partners: the French Health Ministry, the National Institute of Health and Medical Research (INSERM), the National Institute of Cancer, and the National Solidarity Fund for Autonomy (CNSA); the National Research Agency through the French EQUIPEX programme of investments for the future (reference ANR-11-EQPX-0038); and the PREMUP Foundation. The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

Objective To study whether history of cesarean delivery for arrest of descent (failure of fetal head engagement or unsuccessful instrumental delivery), is a factor of unsuccessful vaginal birth after cesarean delivery. Methods Multicenter prospective study of patients undergoing TOL after previous caesarean delivery between May 2012 and May 2013 in 6 maternities. Univariate statistical analysis was performed depending of previous cesarean delivery indication. Multivariate analysis was used to determine independent association between these factors and TOLAC success. Results Four hundred and eighty women with previous cesarean delivery were included and separated into two groups: the study group was composed of patients with history of CD for arrest of descent (failure of fetal head engagement or unsuccessful instrumental delivery) (n = 31); control group included all other indications for CD (n = 449). Overall, of the 480 women included in the study, 71.2 % underwent a TOL for a subsequent delivery (n = 342): 68 % in the study group (n = 21) vs 71.5 % in the control group (n = 321). Vaginal birth after cesarean (VBAC) was obtained in 66.6 % vs 61% in the study and control group respectively (p = 0.656). Univariate analysis of factors that may influence the success rate of (VBAC) did not show any difference between the two groups. Multivariate analysis showed that VBAC was only significantly associated with history of vaginal delivery subsequent to prior CD for arrest of descent. Conclusion This study reassures us in our clinical practice allowing TOL in cases of history of CD for fetal head engagement failure or instrumental delivery failure in the second stage of labor.

Cesarean delivery rates at extreme prematurity have regularly increased over the past years, and few previous studies have investigated severe maternal morbidity associated with extreme preterm cesarean delivery.The aim of this study was to evaluate whether gestational age26 weeks of gestation (weeks) was associated with severe maternal morbidity and mortality (SMMM) of preterm cesarean deliveries in comparison with cesarean deliveries between 26 and 34 weeks.The Etude Epidémiologique sur les petits âges gestationnels (EPIPAGE) 2 is a national prospective population-based cohort study of preterm births in 2011. We included mothers with cesarean deliveries between 22 and 34 weeks, excluding those who had a cesarean delivery for the second twin only and those with pregnancy terminations. SMMM was analyzed as a composite endpoint defined as the occurrence of at least 1 of the following complications: severe postpartum hemorrhage defined by the use of a blood transfusion, intensive care unit admission, or death. To assess the association of gestational age26 weeks and SMMM, we used multivariate logistic regression and a propensity score-matching approach.Among 2525 women having preterm cesarean deliveries, 116 before 26 weeks and 2409 between 26 and 34 weeks, 407 (14.4%) presented with SMMM. The SMMM occurred in 31 mothers (26.7%) who were at gestational age26 weeks vs 376 (14.2%) between 26 and 34 weeks (P .001). Cluster multivariate logistic regression showed significant association of gestational age26 weeks and SMMM (adjusted odds ratio [aOR], 2.50; 95% confidence interval [CI], 1.42-4.40) and propensity score-matching analysis was consistent with these results (aOR, 2.27; 95% CI, 1.31-3.93).Obstetricians should know about the higher SMMM associated with cesarean deliveries before 26 weeks, integrate this knowledge into decisions regarding cesarean delivery, and be prepared to manage the associated complications.

International audience; Objectives. - To evaluate the risk of severe perineal tear following instrumental vaginal delivery (IVD) performed with spatulas and vacuum extraction. Secondary objectives were to estimate the impact of episiotomy on this risk. Methods. - From December 2008 to October 2012, women who underwent spatulas or vacuum were prospectively included. Each spontaneous vaginal delivery (SVD) following each included IVD were included as control cases (1-1 ratio). Careful perineal examination was systematically performed. Severe perineal tear was defined by the occurrence of anal sphincter rupture with or without anal mucosa tear. Results. - A total of 761 patients were included in the current study: 248 (64%) spatulas, 137 (36%) vacuums and 381 (49%) SVDs. Severe perineal tear was diagnosed in 19 (2.5%) cases. Episiotomy had been performed in 276 (36.9%) patients. Only spatulas extraction was found to significantly increase the risk of severe perineal tear (AOR = 7.66; 95% CI: 2.06-28; P=0.02). Although vacuum extraction seemed to increase this risk, it was not found to be significant (AOR = 3.25; 95% CI: 0.65-16.24; P=0.15). No significant difference was observed between the risk of severe perineal tear following spatulas and vacuum (AOR = 2.36; 95% CI: 0.63-8.82; P=0.202). Finally, neither foetal macrosomia, nor episiotomy, nor foetal extraction with the head in the deep pelvis, nor delivery at night had a significant impact on the probability of severe perineal tear. Conclusions. - Spatulas extraction is an independent risk factor for severe perineal tear. The practice of episiotomy was not shown to have any significant impact on this risk. (C) 2015 Elsevier Masson SAS. All rights reserved.

Resume But Les recommandations pour la pratique clinique (RPC) concernant l’information des patientes presentant un uterus uni- ou bi-cicatriciel sur leur mode d’accouchement ont ete actualisees en France en 2012. L’objectif de notre etude a ete d’evaluer le suivi des RPC par les medecins obstetriciens de notre maternite. Patientes et methodes Etude observationnelle retrospective realisee de juin a aout 2014 a partir du dossier medical des patientes porteuses d’un uterus uni- ou bi-cicatriciel ayant accouches apres 37 SA a la maternite de la Conception a Marseille. L’information des patientes devait porter sur les risques d’un antecedent de cesarienne, les benefices et risques des differentes voies d’accouchement. Resultats Sur 758 accouchements, 77 dossiers ont ete etudies : 48 patientes avaient ete suivies des le debut de la grossesse, 23 a partir du 2e trimestre et 6 n’ont pas ete suivies. Parmi celles suivies des le debut, aucune donnee ecrite n’a ete trouvee sur les dossiers concernant l’information a donner en post-partum immediat, en pre-conceptionnel et en debut de grossesse sur les risques des uterus cicatriciels et le mode d’accouchement. Au 8e mois, 45 % avaient recu une information sur les benefices et risques du mode d’accouchement prevu. Conclusion L’information a theoriquement donner aux patientes en cas d’uterus cicatriciel apparaissait peu ou insuffisamment sur les dossiers medicaux ; cette observation pouvant etre due soit a un defaut d’information, soit a un defaut de transcription de l’information pourtant donnee. La mise en place d’une « check-list » dans le dossier obstetrical permettrait la systematisation de l’information a donner aux patientes.

ObjectiveTo study the related knowledge of French residents in obstetrics concerning maneuvers for shoulder dystocia (SD).Materials and methodsMulticenter descriptive transversal study conducted from June to September 2014. Data collection was performed through questionnaires sent by email to French resident in obstetrics.ResultsAmong the 1080 questionnaires sent, 366 responses were obtained with a response rate of 33.9%. One hundred and forty-three residents (39.1%) were in the first part of their training (≤ 5th semester) and 60.9% (n = 223) were in the second part of their training. Theoretical training on the SD was provided to 88.2% of resident (n = 323). In total, 38.8% (n = 142) obtained their French degree in mechanical and technical obstetric and among them 77.5% (n = 110) had the opportunity to train on simulators and dummies. Concerning their practical experiences, 31.5% (n = 45) residents ≤ 5th semester reported having experienced SD during their residency vs 58.3% (n = 130) amongst oldest residents (P < 0.001). In the second part of residency, 40% of residents (n = 89) expressed to feel able to manage shoulder dystocia. Only 19.1% (n = 70) were satisfied with their residency training program vs 39.1% (n = 143) who were unsatisfied.ConclusionOur study showed that less than one resident out of two (40%) felt able to perform maneuvers for SD in the second part of residency. We think that simulation activities should be mandatory for residency training programs in Obstetrics and Gynecology, which have to develop dependable measures to assess resident competencies to execute practical maneuvers for clinical emergencies in obstetrics., ObjectifÉtat des lieux de la formation initiale des internes de gynécologie-obstétrique en France aux manœuvres de réduction d’une dystocie des épaules (DDE).Matériels et méthodesEnquête transversale descriptive multicentrique réalisée par auto-questionnaires entre juin et septembre 2014, envoyés par e-mail aux internes de gynécologie-obstétrique adhérents à l’AGOF.RésultatsSur 1080 questionnaires envoyés, 366 réponses ont été obtenues donnant un taux de réponse de 33,9 % : 143 internes (39,1 %) étaient dans leur première moitié de formation (≤ 5e semestre) et 60,9 % (n = 223) étaient dans leur deuxième moitié d’internat. Une formation théorique sur la DDE a été dispensée à 88,2 % des internes (n = 323). Au total, 38,8 % (n = 142) ont passé le Diplôme inter-universitaire (DIU) de mécanique et techniques obstétricales (MTO) et, parmi eux, 77,5 % (n = 110) se sont entraînés sur mannequin dans le cadre de ce DIU. Concernant la pratique, 31,5 % (n = 45) des internes (≤ 5e semestre) ont déclaré avoir été confrontés à une DDE lors de leur stage d’apprentissage vs 58,3 % (n = 130) chez les internes plus anciens (p < 0,001). En deuxième partie d’internat, 40 % des internes (n = 89) se déclaraient capables de réduire une DDE. Seuls 19,1 % (n = 70) étaient satisfaits de leur formation vs 39,1 % (n = 143) d’insatisfaits.ConclusionNotre étude a montré que moins d’un interne sur deux (40 %) se sentait capable de réduire une DDE en deuxième partie d’internat. Il semble nécessaire que les internes puissent bénéficier d’un enseignement sur simulateur avec validation de leur capacité effective à réaliser ce type de manœuvre en urgence.

Resume Objectifs Proposer un protocole de declenchement des interruptions medicales de grossesse (IMG) apres 22 semaines d’amenorrhee permettant de diminuer la duree du travail et d’hospitalisation mais aussi, permettant de reduire le nombre de fœticides en urgence, d’ameliorer le vecu des patientes et de limiter le cout des IMG. Methodes Nous avons realise une etude retrospective monocentrique incluant 269 patientes et comparant trois protocoles de declenchement, avec et sans laminaire et avec differents intervalles mifepristone-misoprostol (14 et 38 heures). Les criteres de jugement etaient le delai misoprostol-accouchement, l’heure d’accouchement et le nombre de fœticides realises en urgence. Resultats Nous avons montre que le delai misoprostol-accouchement et l’heure d’accouchement etaient comparables dans les trois periodes de notre etude, c’est-a-dire apres diminution de 24 heures de l’intervalle mifepristone-misoprostol et en l’absence de pose de laminaire. Le delai misoprostol-accouchement etait compris entre 7 h 30 et 8 h 35 entre les protocoles ( p = 0,055). L’heure d’accouchement etait comprise entre 17 h 18 et 18 h 48 entre les protocoles ( p = 0,252). Par contre, la prise precoce du misoprostol le jour du declenchement permettait aux patientes d’accoucher plus tot ( p = 0,001). Enfin, nous avons montre que l’augmentation de la taille et du nombre de laminaires etaient des facteurs de risque de fœticide en urgence (respectivement p = 0,013 et p = 0,002). Conclusion L’absence de laminaire et le raccourcissement de l’intervalle mifepristone-misoprostol de 24 heures ne modifient pas la duree du travail et permettent de reduire la duree d’hospitalisation, le nombre de fœticides en urgence et le cout des IMG.

Congenital heart diseases (CHDs) are the most common congenital malformations. The objective of our study was to evaluate the prenatal screening accuracy of congenital heart disease (CHD) in Southern France and to evaluate the impact of a prenatal diagnosis on pregnancies outcomes and neonatal outcomes. We performed a bicentric, retrospective observational study in the southern region over 4 years was conducted between 1 January 2014 and 31 December 2017. All foetuses and children under one year of age with CHD monitored in the UTHs (University Teaching Hospitals) in Marseille and Nice were included. CHD cases were divided into 3 groups: group 1, those with no possible options for anatomical repair; group 2, those with anatomical repair possibilities but that may require neonatal cardiologic management; and group 3, those with anatomical repair possibilities that do not require an emergency neonatal procedure. Among the 249070 deliveries during the study period, 677 CHD cases were included in the study. The overall prenatal screening rate was 71.5%. The screening rates were 97.8%, 63.6%, and 65.9% for groups 1, 2 and 3, respectively. Among group 2 CHD cases, 80% of the transpositions of the great arteries, 56% of the aortic coarctations, and 20% of the total anomalous pulmonary venous returns were detected during the prenatal period. A genetic anomaly was found in 16% of CHD cases. The overall mortality rate was 11.3% with a higher death rate in cases of prenatal screening (17.2% versus 2.1%; p < 0.001). However, when focusing only on children who died of CHD, prenatal screening did not create an impact (56.6% versus 100%, p = 0,140). Our data showed that the prenatal screening rate of CHD appears satisfactory in Southern France. Nevertheless, it could be improved for some CHD. This study did not find any benefit in terms of mortality from prenatal screening for CHD.

Objective To evaluate whether gestational age was associated with the severe maternal morbidity (SMM) of preterm cesarean delivery between 22 and 34 weeks of gestation (weeks). Material and methods We performed an observational retrospective cohort study in two tertiary university hospitals in 2018. We included all mothers of preterm infants born by caesarean delivery between 22 and 34 weeks, excluding mothers with multiple births greater than two, with pregnancy terminations or stillbirths, and who died unrelated to obstetrical causes. The principal endpoint, SMM, was a composite outcome (classical uterine incision, postpartum hemorrhage defined by blood loss ≥ 500 mL, blood transfusion, any injury to adjacent organs, unplanned procedure/need for reintervention, Intensive Care Unit (ICU) stay longer than 24 h, postpartum fever, and/or death). Results Among the 252 women, SMM occurred in 89 (35.3 %) cases. After multivariate analysis, gestational age was independently associated with SMM (adjusted Odds Ratio [aOR] 0.87; 95 % Confidence Interval [CI] 0.78−0.97). The other variables statistically associated with SMM were type of pregnancy with a negative association with twin pregnancy (aOR, 0.44; 95 % CI, 0.20−0.93) and a positive association with general anesthesia (aOR, 2.52; 95 % CI, 1.25−5.13). A sensitivity analysis was performed and found an association, at the limit of significance, between gestational age Conclusion Lower gestational age was associated with the risk of SMM for preterm caesarean delivery between 22 and 34 weeks. Obstetricians should integrate this knowledge into their shared decision-making processes with parents.

International audience; Persistant occiput posterior (OP) positions are the commonest malpresentations of the fetal head during labor and their diagnosis remains challenging. They are associated to prolonged second stage of labor, prolonged expulsive efforts, labor augmentation, cesarean sections and instrumental deliveries. On the maternal side, severe perineal tears, post-partum hemorrhage or chorioamnionitis are more frequent. Currently, prevention of persistent OP positions is based on the maintain of precise maternal positions. Several positions have been evaluated but only lateral position on the same side of the fetal spine has proved its effectiveness. Fetal head rotation can also be achieved with extraction instruments though none has ever been evaluated by a randomized controlled trial. Obstetrical forceps seem more efficient than vacuum but are associated with severe perineal tears. Evaluation of rotation with Thierry's spatulas is scarce. Last, manual rotation is of routine use in many wards. This management is associated with a twofold reduction of operative delivery rate and rare adverse outcomes but has never been evaluated through randomized control trial.; Les variétés postérieures sont les malpositions fœtales les plus fréquentes rencontrées au cours du travail. De diagnostic clinique difficile, elles sont associées à de nombreuses situations dystociques (allongement de la durée du deuxième stade, des efforts expulsifs) qui nécessitent un recours plus fréquent à l’oxytocine, aux accouchements instrumentaux ou par césarienne. Sur le versant maternel, les déchirures périnéales graves et la survenue d’une hémorragie du post partum ou d’une chorioamniotite sont plus fréquentes. Les stratégies de prise en charge proposées reposent actuellement sur le maintien de postures maternelles particulières au cours du travail. Plusieurs postures ont fait l’objet d’essais cliniques randomisés : seule celle consistant à positionner la parturiente en décubitus latéral asymétrique du côté homolatéral au dos fœtal semble prometteuse. La rotation de la tête fœtale peut également être obtenue au moyen d’un instrument d’extraction. Bien qu’aucun n’ait été évalué par un essai clinique randomisé, la rotation par forceps semble plus efficace qu’avec l’utilisation d’une ventouse obstétricale mais associée à des traumatismes périnéaux graves plus fréquents. L’utilisation des spatules, peu évaluée, peut sembler intéressante mais les risques maternels et fœtaux en sont mal appréciés. Enfin, la rotation manuelle consiste à appliquer manuellement un mouvement de rotation afin d’amener la tête en variété antérieure. Bien que très utilisée et pouvant permettre de diviser par deux le recours à un accouchement opératoire, son efficacité n’a pas été confirmée et des essais cliniques randomisés sont en cours

Objective This study aimed to develop a new tool for personalised preterm birth risk evaluation in high-risk population. Study design 813 high-risk asymptomatic pregnant women included in a French multicentric prospective study were analysed. Clinical and paraclinical variables, including screening for bacterial vaginosis with molecular biology, cervical length, have been used to create the nomogram, based on the logistic regression model. The validity was checked by bootstrap. A downloadable calculator was build. Results Nine risk factors were included in this model: history of late miscarriage and/or preterm delivery, active smoking, ultrasound cervical length, term of pregnancy at screening, bacterial vaginosis, premature rupture of membranes, daily travel more than 30 min. Discrimination and calibration of the nomogram revealed good predictive abilities. The area under the receiver operating characteristic curve was 0.77 (95% CI; 0.72–0.81). The mean absolute error was 0.018, which showed proper calibration. The optimal risk threshold was 23.2% with a sensitivity of 74%, a specificity of 72.7% and a predictive negative value of 90.6%. Conclusion The nomogram can help to better define individual preterm birth risk in high-risk pregnancies.

International audience; Background - The efficacy of prophylaxis to prevent prenatal toxoplasmosis transmission is controversial, without any previous randomized clinical trial. In France, spiramycin is usually prescribed for maternal seroconversions. A more potent pyrimethamine + sulfadiazine regimen is used to treat congenital toxoplasmosis and is offered in some countries as prophylaxis. Objective - We sought to compare the efficacy and tolerance of pyrimethamine + sulfadiazine vs spiramycin to reduce placental transmission. Study design - This was a randomized, open-label trial in 36 French centers, comparing pyrimethamine (50 mg qd) + sulfadiazine (1 g tid) with folinic acid vs spiramycin (1 g tid) following toxoplasmosis seroconversion. Results - In all, 143 women were randomized from November 2010 through January 2014. An amniocentesis was later performed in 131 cases, with a positive Toxoplasma gondii polymerase chain reaction in 7/67 (10.4%) in the pyrimethamine + sulfadiazine group vs 13/64 (20.3%) in the spiramycin group. Cerebral ultrasound anomalies appeared in 0/73 fetuses in the pyrimethamine + sulfadiazine group, vs 6/70 in the spiramycin group (P = .01). Two of these pregnancies were terminated. Transmission rates, excluding 18 children with undefined status, were 12/65 in the pyrimethamine + sulfadiazine group (18.5%), vs 18/60 in the spiramycin group (30%, P = .147), equivalent to an odds ratio of 0.53 (95% confidence interval, 0.23-1.22) and which after adjustment tended to be stronger (P = .03 for interaction) when treatment started within 3 weeks of seroconversion (95% confidence interval, 0.00-1.63). Two women had severe rashes, both with pyrimethamine + sulfadiazine. Conclusion - There was a trend toward lower transmission with pyrimethamine + sulfadiazine, but it did not reach statistical significance, possibly for lack of statistical power because enrollment was discontinued. There were also no fetal cerebral toxoplasmosis lesions in the pyrimethamine + sulfadiazine group. These promising results encourage further research on chemoprophylaxis to prevent congenital toxoplasmosis.

Background Cesarean section is the most common surgical procedure performed in developed countries. Its incidence is increasing to a worrisome extent. The 2003 French National Perinatal Survey showed that the inflation in the overall cesarean rate was mainly due to an increase in the first cesarean delivery rate. Objective To evaluate a new tool: a checklist that intent to decrease the first cesarean delivery rate. Study design Retrospective, observational, multi-center study. A new tool, a “First cesarean delivery” checklist was built according American and French guidelines. Women with full-term of pregnancy, nulliparous or multiparous with a first caesarean delivery including arrest of labor, breech presentation or suspected fetal macrosomia were included. The checklist was applied. Potentially preventable cesareans were analyzed. Results Among 571 first cesarean section, 178 were eligible to check list application. 147 charts were analyzed in the study. 11.9% of first cesarean deliveries performed were potentially avoidable after applying the checklist. This represented 6.6% of all cesareans. Conclusion The checklist based on the recall of good practices could be an interesting tool to decrease the first cesarean rate.

International audience; BACKGROUND: Most clinical guidelines state that with early preterm premature rupture of membranes, obstetric and pediatric teams must share a realistic and individualized appraisal of neonatal outcomes with parents and consider their wishes for all decisions. However, we currently lack reliable and relevant data, according to gestational age at rupture of membranes, to adequately counsel parents during pregnancy and to reflect on our policies of care at these extreme gestational ages.OBJECTIVE: We sought to describe both perinatal and 2-year outcomes of preterm infants born after preterm premature rupture of membranes at 22-25 weeks' gestation.STUDY DESIGN: EPIPAGE-2 is a French national prospective population-based cohort of preterm infants born in 546 maternity units in 2011. Inclusion criteria in this analysis were women diagnosed with preterm premature rupture of membranes at 22-25 weeks' gestation and singleton or twin gestations with fetus(es) alive at rupture of membranes. Latency duration, antenatal management, and outcomes (survival at discharge, survival at discharge without severe morbidity, and survival at 2 years' corrected age without cerebral palsy) were described and compared by gestational age at preterm premature rupture of membranes.RESULTS: Among the 1435 women with a diagnosis of preterm premature rupture of membranes, 379 were at 22-25 weeks' gestation, with 427 fetuses (331 singletons and 96 twins). Median gestational age at preterm premature rupture of membranes and at birth were 24 (interquartile range 23-25) and 25 (24-27) weeks, respectively. For each gestational age at preterm premature rupture of membranes, nearly half of the fetuses were born within the week after the rupture of membranes. Among the 427 fetuses, 51.7% were survivors at discharge (14.1%, 39.5%, 66.8%, and 75.8% with preterm premature rupture of membranes at 22, 23, 24, and 25 weeks, respectively), 38.8% were survivors at discharge without severe morbidity, and 46.4% were survivors at 2 years without cerebral palsy, with wide variations by gestational age at preterm premature rupture of membranes. Survival at 2 years without cerebral palsy was low with preterm premature rupture of membranes at 22 and 23 weeks but reached approximately 60% and 70% with preterm premature rupture of membranes at 24 and 25 weeks.CONCLUSION: Preterm premature rupture of membranes at 22-25 weeks is associated with high incidence of mortality and morbidity, with wide variations by gestational age at preterm premature rupture of membranes. However, a nonnegligible proportion of children survive without severe morbidity both at discharge and at 2 years' corrected age.

To validate Grobman nomogram for predicting vaginal birth after cesarean delivery (VBAC) in a French population and adapt it.Multicenter retrospective study of maternal and obstetric factors associated with VBAC between May 2012 and May 2013 in 6 maternity units. External validation and adaptation of the prenatal and intrapartum Grobman nomograms for vaginal birth prediction after cesarean delivery in a French cohort.The study included 523 women with previous cesarean deliveries; 70% underwent a trial of labor for a subsequent delivery (n=367) with a success rate of 65% (n=240). In the univariate analysis, 5 factors were associated with successful VBAC: previous vaginal delivery before the cesarean (P0.001), the number of previous vaginal deliveries (P0.001), and a favorable cervix at delivery room admission, cervical effacement (P=0.035), or cervical dilatation at least 3cm (P0.001), or a Bishop score6 (P=0.03). A potentially recurrent indication (defined as arrest of dilation or descent as the indication for the previous cesarean) (P=0.039), a hypertensive disorder during pregnancy (P=0.05), and labor induction (P=0.017) were each associated with failed VBAC. External validation of the prenatal and intrapartum Grobman nomograms showed an area under the ROC curve of 69% (95% CI: 0.638, 0.736) and 65% (95% CI: 0.599, 0.700) respectively. Adaptation of the nomogram to the French cohort resulted in the inclusion of the following factors: maternal age, body mass index at last prenatal visit, hypertensive disorder, gestational age at delivery, recurring indication, cervical dilatation, and induction of labor. Its area under the curve to predict successful VBAC was 78% (95% CI: 0.738, 0.825).The nomogram to predict VBAC developed by Grobman et al. is validated in the French population. Adaptation to the French population, by excluding ethnicity, appeared to improve its performance. Impact of the nomogram use on the caesarean section rate has to be validated in a randomized control trial.

International audience; Objective: The aim of this study was to identify antenatal prognostic factors of neonatal outcomes in cases of fetal echogenic bowel (FEB). Study design: A retrospective study in three tertiary referral centers including fetal echogenic bowel over a 10-year period (from January 2003 to December 2013). The echogenicity of the fetal bowel was graded from 1 to 3, according to Slotnick's definition. Associated echographic findings such as bowel dilations, gallbladder abnormalities, calcifications, extra-abdominal abnormalities, intrauterine growth restriction (IUGR) and a decrease in amniotic fluid volume, if present were also recorded. This was followed by the FEB's sonographic evolution. The sonographic evolution was considered favorable if it was stable or decreasing and unfavorable if the echogenicity of the bowel increased or if additional sonographic findings appeared. Neonates had a pediatric examination in the delivery room and upon discharge from the maternity hospital. An outcome was considered good in the case of on-term delivery of a newborn with normal clinical examination and meconium elimination. Results: Complete pregnancy outcome data were available for 409 pregnancies. 338 newborns had uneventful outcomes (82.6%). Antenatal exploration diagnosed 4 cases of aneuploidy (1 case of trisomy 13, 1 case of trisomy 18 and 2 cases of triploidies), 16 cases of congenital infections, 9 cases of cystic fibrosis and 11 cases of bowel abnormalities. After a multivariate analysis, we discovered the sonographic grade of the echogenic bowel was not a prognostic factor of neonatal outcome. The isolated fetal echogenic bowel had a 6.6-fold increase chance of uneventful outcomes (adjusted odd ratio (aOR) 6.6, 95% CI 3-14.4). Notably, favorable sonographic evolution (aOR 8.1, 95% CI 4.1-16) and late gestational age at the time of the diagnosis (aOR 1.17, 95% CI 1.07-1.27) are independent, good prognostic factors of good neonatal outcomes. None of the 180 fetuses with isolated fetal echogenic bowel and favorable sonographic evolution had adverse outcomes. Among these, 4 cases (0.98%) of aneuploidy, 17 cases (4.2%) of congenital infections and 9 cases (2.2%) of cystic fibroses were also diagnosed. No cases of Down syndrome (DS) were reported. Conclusion: Our study shows that the grade should not be considered a prognostic factor of neonatal outcomes. Our data suggests the need to reevaluate the concept of systematic amniocentesis. Sonographic evolution of fetal bowel is an independent, strong prognostic factor for good neonatal outcomes. It also better defines the FEB prognostic. (C) 2017 Elsevier B.V. All rights reserved.

Resume Objectifs Definir la prise en charge des patientes presentant une menace de fausse couche tardive (MFCT). Methode Recherche bibliographique en langue francaise et anglaise effectuee par consultation des banques de donnees PubMed, Cochrane Library et des recommandations des societes savantes internationales. Resultats Une MFCT impose un interrogatoire recherchant un antecedent de FCT ou d’accouchement premature (grade A), un examen au speculum recherchant une eventuelle protrusion des membranes dans le vagin (grade B), une mesure echographique par voie vaginale de la longueur cervicale (grade B) et un bilan infectieux maternel (grade B). Une MFCT caracterisee par un col court (

Resume Objectif Revue de la litterature sur les differentes techniques chirurgicales de l’hemorragie du post-partum (HPP). Elaborer une strategie chirurgicale a adopter en cas d’HPP resistant au traitement medical. Methodes Recherche bibliographique en langue francaise et anglaise effectuee par consultation des banques de donnees PubMed et Cochrane. Resultats Chaque maternite doit disposer d’un protocole de prise en charge chirurgicale de l’HPP rapidement disponible en salle de naissance (accord professionnel). Traitement chirurgical conservateur : en absence d’etudes comparatives portant sur l’efficacite des differentes techniques chirurgicales, aucune des techniques de chirurgie conservatrice n’est a privilegier plutot qu’une autre (accord professionnel). L’efficacite sur l’arret des saignements des techniques de ligatures vasculaires (ligature bilaterale des arteres uterines (LBAU) ou ligature bilaterale des arteres hypogastriques (LBAH)) en premiere ligne de traitement chirurgical conservateur de l’HPP est de l’ordre de 60 a 70 % (NP4). La LBAU est une technique chirurgicale simple et a faible risque de complications immediates severes (accord professionnel). La LBAU comme la LBAH ne semblent pas affecter la fertilite et le devenir obstetrical ulterieur (NP4). L’efficacite des techniques de compression ou de plicature uterine sur l’arret des saignements en cas d’HPP resistant au traitement medical est de l’ordre de 75 % (NP3). Les grossesses obtenues apres plicature uterine ne semblent pas plus pourvoyeuses de complications de grossesse (NP4). Traitement chirurgical radical : l’hysterectomie totale ne semble pas augmenter significativement la survenue de plaie de l’appareil urinaire par rapport a la technique d’hysterectomie subtotale (NP3). Le type d’hysterectomie (totale ou subtotale) est laisse libre a l’appreciation de l’operateur (accord professionnel). Strategie chirurgicale : les traitements conservateurs de l’uterus sont peu morbides et efficaces, ils doivent etre realises en priorite en cas de desir de conservation de fertilite. Certaines situations (HPP massive, etat hemodynamique precaire) doivent faire envisager la realisation d’une hysterectomie d’hemostase de premiere intention. HPP en cours de cesarienne : en cas d’HPP per-cesarienne (a ventre ouvert), la realisation d’une embolisation n’est pas recommandee, un traitement conservateur par ligature vasculaire ou compression uterine doit etre envisage (accord professionnel). Le choix de la technique chirurgicale conservatrice (LBAU, LBAH ou compression uterine) dependra des habitudes de chacun (accord professionnel). Le diagnostic d’une HPP apres cesarienne devrait faire envisager une reprise chirurgicale. Cependant, en presence d’une unite de radiologie interventionnelle au sein de l’etablissement, si l’etat hemodynamique est conserve et en absence d’hemoperitoine faisant craindre une complication chirurgicale, une embolisation arterielle peut etre envisagee (accord professionnel). HPP apres accouchement par voie basse : un etat hemodynamique instable contre-indique formellement le transfert inter-hospitalier et doit conduire a realiser une chirurgie d’hemostase sur place (accord professionnel). En presence d’une unite d’embolisation au sein de la maternite d’accouchement, il est preferable de s’orienter vers l’embolisation, si l’etat hemodynamique maternel et l’organisation des soins le permettent (accord professionnel). Si l’etat hemodynamique est stable et en absence de saignement abondant, un transfert vers une structure hospitaliere disposant d’une unite d’embolisation peut etre envisage (accord professionnel). Conclusion En cas d’echec du traitement medical de l’HPP, la realisation d’un traitement chirurgical conservateur de l’uterus a une efficacite de l’ordre de 70 % sur l’arret des saignements quelle que soit la technique utilisee (ligature vasculaire ou compression uterine). En absence de reponse rapide a une premiere ligne de traitement conservateur, une hysterectomie d’hemostase doit etre realisee sans delai (accord professionnel).

Resume But Evaluer les particularites des patientes avec un placenta accreta (PA) en fonction de l’antecedent ou non de cesarienne. Patientes et methodes Il s’agissait d’une etude retrospective du 1/12/1993 au 1/4/2010 menee sur les deux maternites du CHU de Marseille. Nous avons compare les patientes presentant un PA avec un antecedent d’une cesarienne au moins (n : 63) aux patientes avec PA sans antecedent de cesarienne (n : 35) au niveau des caracteristiques cliniques et therapeutiques. Resultats Dans le groupe sans antecedent de cesarienne, le taux de placenta praevia etait diminue ainsi que le taux de diagnostic antenatal (16/35 [46 %] vs 44/63 [70 %], [p : 0,02] et 4/35 [11 %] vs 28/63 [44 %], [p Conclusions Les patients avec un PA sans antecedent de cesarienne semblent presenter des caracteristiques cliniques et therapeutiques specifiques.

Resume Introduction La rupture prematuree des membranes (RPM) est une complication frequente des grossesses entrainant un risque de prematurite et d’infection neonatale. Leur prise en charge en France n’etant pas consensuelle, les attitudes sont variables entre les maternites. Nous avons soumis les maternites de type 2B et 3 a un questionnaire portant sur leur pratique concernant les RPM. Resultats L’etude inclut 59 maternites de type 2B et 59 de type 3. La corticotherapie est proposee dans toutes les maternites de type 3 et dans 96,5 % des maternites de type 2B. L’antibiotherapie est instauree a l’admission de la patiente dans 96,6 % des maternites de type 3 et 86 % des maternites de type 2B. La tocolyse est prescrite systematiquement dans 31 % des maternites et uniquement en cas de contractions dans 62 % des maternites. Aucune maternite ne propose de naissance anticipee systematique avant 32 SA. Entre 32 et 34 SA, un accouchement anticipe est propose par 9,5 % des maternites. Entre 34 et 37 SA, 58 % des maternites indiquent une naissance. Conclusion La corticotherapie et l’antibiotherapie sont majoritairement instaurees lors du diagnostic de RPM, comme le preconisent l’HAS et le CNGOF. Malgre l’absence de recommandation, une attitude expectative jusqu’a 34 SA en l’absence de signe de chorioamniotite semble adoptee par la majorite des maternites.

International audience; Objective: To compare intrapartum cardiotocography (CTG) analysis in case of first caesarean section (CS) for non-reassuring CTG according to international guidelines.Methods: Four ObGyns retrospectively analysed first CS for non-reassuring CTG during labour blind to neonatal outcome. CTG were analysed according to French National College of Obstetricians and Gynaecologists (CNGOF) and to the FIGO guidelines. First, CTG analysis was done without obstetrical context, then secondly, it was given. ObGyns stated if CS was justified or not. Inter-operator ObGyn agreement was analysed.Results: Among 587 CS, 100 women met the inclusion criteria with a first CS for non-reassuring CTG. The overall inter observer agreement was low but fair. ObGyns were significantly more concordant using the FIGO than the CNGOF guidelines (kappa coefficient=0.331 [0.27-0.39] versus 0.209 [0.16-0.26] p

Place: England; International audience; OBJECTIVE: To identify the gestational age (GA) at which risk of mortality and severe outcome was minimized comparing preterm delivery and expectant management. METHODS: Retrospective study performed between 2009 and 2014 of newborns with gastroschisis in three large French level III neonatal intensive care units. Each department followed two distinct strategies: elective delivery at 35 weeks' GA and a delayed approach. RESULTS: We included 69 gastroschisis cases. The lengths of stay lasting more than 60 days were significantly greater in the planned delivery group than in the expectant approach group (18/30 (60%) vs. 8/39 (20.5%), p = 0.001). Gastroschisis cases receiving antenatal corticoids during the last two weeks of gestation required significantly less surgeries during their initial stay (p = 0.003) as well as shorter parenteral feedings (p = 0.002). A multivariate logistic regression showed that a GA of less than 36 weeks' GA was is a pejorative factor for a stay above 60 days, regardless of whether it was a simple or complex gastroschisis, (OR= 3.8; p = 0.021). A complex gastroschisis was a risk factor for significantly longer parenteral feedings, regardless of the center where patient is treated (Beta = -0.3, p = 0.035). CONCLUSIONS: Future research should focus on decisions about delivery timing by incorporating risk of neonatal morbidity.

International audience; OBJECTIVE: To evaluate the association between the planned mode of delivery and neonatal mortality and morbidity in an unselected population of women with twin pregnancies. METHODS: The JUmeaux MODe d'Accouchement (JUMODA) study was a national prospective population-based cohort study. All women with twin pregnancies and their neonates born at or after 32 weeks of gestation with a cephalic first twin were recruited in 176 maternity units in France from February 2014 to March 2015. The primary outcome was a composite of intrapartum mortality and neonatal mortality and morbidity. Comparisons were performed according to the planned mode of delivery, planned cesarean or planned vaginal delivery. The primary analysis to control for potential indication bias used propensity score matching. Subgroup analyses were conducted, one according to gestational age at delivery and one after exclusion of high-risk pregnancies. RESULTS: Among 5,915 women enrolled in the study, 1,454 (24.6%) had planned cesarean and 4,461 (75.4%) planned vaginal deliveries, of whom 3,583 (80.3%) delivered both twins vaginally. In the overall population, composite neonatal mortality and morbidity was increased in the planned cesarean compared with the planned vaginal delivery group (5.2% compared with 2.2%; odds ratio [OR] 2.38, 95% confidence interval [CI] 1.86–3.05). After matching, neonates born after planned cesarean compared with planned vaginal delivery had higher composite neonatal mortality and morbidity rates (5.3% compared with 3.0%; OR 1.85, 95% confidence interval 1.29–2.67). Differences in composite mortality and morbidity rates applied to neonates born before but not after 37 weeks of gestation. Multivariate and subgroup analyses after exclusion of high-risk pregnancies found similar trends.CONCLUSION: Planned vaginal delivery for twin pregnancies with a cephalic first twin at or after 32 weeks of gestation was associated with low composite neonatal mortality and morbidity. Moreover, planned cesarean compared with planned vaginal delivery before 37 weeks of gestation might be associated with increased composite neonatal mortality and morbidity.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 1 - p. 71-75

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 8 - p. 735-752

To further study the efficacy of uterine-sparing procedures based on triple uterine artery ligation (TUAL) possibly complemented with hemostatic multiple square suturing (HMSS) for the management of post-partum hemorrhage (PPH). Cases of PPH occurring during cesarean section and treated, according to our institution guidelines, by TUAL possibly complemented with HMSS between 2000 and 2009 were retrospectively analyzed. Fifty-six patients were included; 13 (23.2%) had TUAL only, while 43 (76.8%) had additional HMSS performed. Surgical conservative management of PPH was effective in 51 (91.1%) cases. PPH due to placenta accreta, either unanticipated or after failure of conservative management, showed an independent and significant impact on the risk of failure of the procedure (AOR 15.07, 95% CI 1.12–201.9, p = 0.041). Obstetricians should be aware that a higher risk of failure of the procedure is to be expected in cases of PPH due to placenta accreta. In such situation, to avoid any useless delay in management, our findings suggest that peripartum hysterectomy should be immediately considered.

Among 23 women who underwent diagnostic hysteroscopy after triple uterine artery ligation with or without hemostatic multiple square suturing for the management of postpartum hemorrhage (PPH), five had abnormal findings. Endometritis was statistically significantly associated with abnormal diagnostic hysteroscopy findings. Twelve patients developed subsequent pregnancies, and four had abnormal obstetric outcomes: one placenta percreta, one placenta accreta, one recurrent postpartum hemorrhage, and one intrauterine growth retardation.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 40 - N° 4 - p. 334-339

Objective The aim of the study was to evaluate our results in the management of placenta accreta. Study design In a retrospective study we reviewed cases of placenta accreta diagnosed in two university teaching hospitals between 1993 and 2003. For a subgroup of patients a conservative approach was attempted. In this procedure placenta was left in place until spontaneous resorption. Results Fifty cases (0.12%) of placenta accreta were observed in 41, 119 deliveries during the study period. Of the 50 cases, 24 patients (48%) were managed by the standard approach and 26 patients (52%) underwent conservative treatment. Additional surgical or medical treatment was performed in 35 of the 50 patients (70%). There was no maternal death. Overall hysterectomy rate was 40%, 10 patients were transferred to intensive care unit (20%), 7 had fever (14%), 5 had endometritis (10%) and 19 patients had blood transfusion (38%). Conservative treatment did not lead to hysterectomy in 21 cases (80.7%) and failed in 5 (19.3%). During the follow-up period, 3 women had successful pregnancy. Conclusion Analysis of management of placenta accreta shows that for a subgroup of selected patients a conservative approach could preserve subsequent fertility without evident increase in morbidity.

International audience; OBJECTIVE: The objective of the study was to evaluate the intra-and interobserver agreement among obstetric experts in court regarding the retrospective review of abnormal fetal heart rate tracings and obstetrical management of patients with abnormal fetal heart rate during labor. STUDY DESIGN: A total of 22 French obstetric experts in court reviewed 30 cases of term deliveries of singleton pregnancies diagnosed with at least 1 hour of abnormal fetal heart rate, including 10 cases with adverse neonatal outcome. The experts reviewed all cases twice within a 3-month interval, with the first review being blinded to neonatal outcome. For each case reviewed, the experts were provided with the obstetric data and copies of the complete fetal heart rate recording and the partogram. The experts were asked to classify the abnormal fetal heart rate tracing and to express whether they agreed with the obstetrical management performed. When they disagreed, the experts were asked whether they concluded that an error had been made and whether they considered the obstetrical management as the cause of cerebral palsy in children if any. RESULTS: Compared with blinded review, the experts were significantly more likely to agree with the obstetric management performed (P \textless .001) and with the mode of delivery (P \textless .001) when informed about the neonatal outcome and were less likely to conclude that an error had been made (P \textless .001) or to establish a link with potential cerebral palsy (P = .003). The experts' intraobserver agreement for the review of abnormal fetal heart rate tracing and obstetrical management were both mediocre (kappa = 0.46-0.51 and kappa = 0.48-0.53, respectively). The interobserver agreement for the review of abnormal fetal heart rate tracing was low and was not improved by knowledge of the neonatal outcome (kappa = 0.11-0.18). The interobserver agreement for the interpretation of obstetrical management was also low (kappa = 0.08-0.19) but appeared to be improved by knowledge of the neonatal outcome (kappa = 0.15-0.32). CONCLUSION: The intra-and interobserver agreement among obstetric experts in court for the review of abnormal fetal heart rate tracing and the appropriateness of obstetrical care is poor, suggesting a lack of objectivity of obstetrical expertise as currently performed in court.

Objective To identify antenatal events associated with emergency caesarean sections in women presenting with antepartum bleeding and placenta praevia and to establish a score to predict the risk of emergency caesarean after a first bleeding episode has resolved. Study design This retrospective multicentre study included 250 women presenting with antepartum bleeding and placenta praevia from 20 weeks of gestation until term in three maternity units. The score was constructed from data from 163 women after identification of antenatal risk factors associated with emergency caesareans for profuse bleeding due to placenta praevia. It was validated on a second independent cohort of 87 women. Results Three variables were significantly associated with emergency caesareans: major or complete praevia, defined as complete or partial praevia (OR = 33.15 (95% CI 4.3–257); p = 0.001), occurrence of 3 or more episodes of antepartum of uterine bleeding (OR = 2.53 (95% CI 1.1–5.86); p = 0.03), and a first (sentinel) bleeding episode before 29 weeks of gestation (OR = 2.64 (95% CI 1.17–5.98); p = 0.02). A fourth variable, moderate or severe antepartum uterine bleeding, was significantly associated with emergency caesareans in the univariate but not the multivariate analysis (p = 0.006). These four variables were incorporated into a weighted scoring system that included major praevia (4 points), three or more episodes of antepartum bleeding (3), first bleeding episode before 29 weeks of gestation (3), and bleeding episode estimated as moderate or severe (1). A score ≥6/11 had a sensitivity of 83% and a specificity of 65% for predicting an emergency caesarean in the score development group and 95% and 62% in the validation group. Conclusion A scoring system for placenta praevia with previous bleeding events, based on intensity, gestational age at sentinel bleed (before 29 weeks), number of bleeding episodes (≥3) and type of praevia (major) might be helpful to guide obstetric management and especially to determine the need for admission.

Establishing a prognosis in prenatal medicine is often a complex and uncertain task. Predictive tools such as imagery techniques and biological markers may lack accuracy since they are used while the fetus is still pursuing its development. In France, antenatal euthanasia and fetal abandon are legal issues and socially accepted. Several non-medical factors may interfere with the final outcome such as the manner a condition is announced by the staff, the way it is experienced by the parents and the acceptance of the handicap within the society. We analysed the different medical and non medical factors intervening in the prognosis work up for Down's syndrome. Currently, the outcome of fetus with Down's syndrome is influenced by the orientation of our society that promotes screening tests and pregnancy interruptions instead of emphasizing on therapeutic research and improving their social integration.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 3 - p. 302-304

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 33 - N° SUP8 - p. 103-119