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Prelabour rupture of membranes (PROM) exposes both foetuses and mothers to the risk of infection. Induction of labour has been proposed to reduce this risk, but its neonatal and maternal risks and benefits must be balanced against those of expectant management (EM). Recent randomized studies of preterm PROM show that EM until 37 weeks of gestation is associated with lower overall neonatal morbidity. In term PROM, active management is associated with a shorter birth interval but not with lower rates of neonatal infection. Similar maternal and neonatal outcomes are reported regardless of whether induction uses oxytocin, PGE2, or oral misoprostol.

We investigated whether nonsurgical termination of pregnancy after 14 weeks of gestation increases the risk of preterm delivery in a subsequent pregnancy. We conducted a two-centre retrospective case-control study. Patients who underwent non-surgical termination of pregnancy after 14 weeks of gestation between 2012 and 2015 and who gave birth after 14 weeks of gestation to a live-born singleton infant were included. Control patients were those who gave birth after 37 weeks of gestation (the same month as a case patient) and had a second delivery of a singleton foetus after 14 weeks of gestation. The primary outcome was preterm delivery during the second pregnancy period. We included 151 cases and 302 controls and observed 13 (8.6%) preterm births during the second pregnancy in the case group versus 8 (2.6%) (odds ratio: 3.62; 95% confidence interval: 1.40-8.65

Background Preterm prelabor rupture of membranes (PPROM) before 34 weeks of gestation complicates 1% of pregnancies and accounts for one-third of preterm births. International guidelines recommend expectant management, along with antenatal steroids before 34 weeks and antibiotics. Up-to-date evidence about the risks and benefits of administering tocolysis after PPROM, however, is lacking. In theory, reducing uterine contractility could delay delivery and reduce the risks of prematurity and its adverse short- and long-term consequences, but it might also prolong fetal exposure to inflammation, infection, and acute obstetric complications, potentially associated with neonatal death or long-term sequelae. The primary objective of this study is to assess whether short-term (48 h) tocolysis reduces perinatal mortality/morbidity in PPROM at 22 to 33 completed weeks of gestation. Methods A randomized, double-blind, placebo-controlled, superiority trial will be performed in 29 French maternity units. Women with PPROM between 220/7 and 336/7 weeks of gestation, a singleton pregnancy, and no condition contraindicating expectant management will be randomized to receive a 48-hour oral treatment by either nifedipine or placebo (1:1 ratio). The primary outcome will be the occurrence of perinatal mortality/morbidity, a composite outcome including fetal death, neonatal death, or severe neonatal morbidity before discharge. If we assume an alpha-risk of 0.05 and beta-risk of 0.20 (i.e., a statistical power of 80%), 702 women (351 per arm) are required to show a reduction of the primary endpoint from 35% (placebo group) to 25% (nifedipine group). We plan to increase the required number of subjects by 20%, to replace any patients who leave the study early. The total number of subjects required is thus 850. Data will be analyzed by the intention-to-treat principle. Discussion This trial will inform practices and policies worldwide. Optimized prenatal management to improve the prognosis of infants born preterm could benefit about 50,000 women in the European Union and 40,000 in the United States each year. Trial registration ClinicalTrials.gov identifier: NCT03976063 (registration date June 5, 2019).

Although prophylactic tranexamic acid administration after cesarean delivery resulted in a lower incidence of calculated estimated blood loss of1000 mL or red cell transfusion by day 2, its failure to reduce the incidence of hemorrhage-related secondary clinical outcomes (TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial) makes its use questionable. The magnitude of its effect may differ in women at higher risk of blood loss, including those with multiple pregnancies.This study aimed to compare the effect of tranexamic acid vs placebo to prevent blood loss after cesarean delivery among women with multiple pregnancies.This was a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial data, a double-blind, randomized controlled trial from March 2018 to January 2020 in 27 French maternity hospitals, that included 319 women with multiple pregnancies. Women with a cesarean delivery before or during labor at ≥34 weeks of gestation were randomized to receive intravenously 1 g of tranexamic acid (n=160) or placebo (n=159), both with prophylactic uterotonics. The primary outcome was a calculated estimated blood loss of1000 mL or a red blood cell transfusion by 2 days after delivery. The secondary outcomes included clinical and laboratory blood loss measurements.Of the 4551 women randomized in this trial, 319 had a multiple pregnancy and cesarean delivery, and 298 (93.4%) had primary outcome data available. This outcome occurred in 62 of 147 women (42.2%) in the tranexamic acid group and 67 of 152 (44.1%) receiving placebo (adjusted risk ratio, 0.97; 95% confidence interval, 0.68-1.38; P=.86). No significant between-group differences occurred for any hemorrhage-related clinical outcomes: gravimetrically estimated blood loss, provider-assessed clinically significant hemorrhage, additional uterotonics, postpartum blood transfusion, arterial embolization, and emergency surgery (P.05 for all comparisons).Among women with a multiple pregnancy and cesarean delivery, prophylactic tranexamic acid did not reduce the incidence of any blood loss-related outcomes.

There is no consensus on an optimal strategy for managing the active phase of the second stage of labor. Intensive pushing could not only reduce pushing duration, but also increase abnormal fetal heart rate because of cord compression and reduced placental perfusion and oxygenation resulting from the combination of uterine contractions and maternal expulsive forces. Therefore, it may increase the risk of neonatal acidosis and the need for operative vaginal delivery.This study aimed to assess the effect of the management encouraging "moderate" pushing vs "intensive" pushing on neonatal morbidity.This study was a multicenter randomized controlled trial, including nulliparas in the second stage of labor with an epidural and a singleton cephalic fetus at term and with a normal fetal heart rate. Of note, 2 groups were defined: (1) the moderate pushing group, in which women had no time limit on pushing, pushed only twice during each contraction, and observed regular periods without pushing, and (2) the intensive pushing group, in which women pushed 3 times during each contraction and the midwife called an obstetrician after 30 minutes of pushing to discuss operative delivery (standard care). The primary outcome was a composite neonatal morbidity criterion, including umbilical arterial pH of7.15, base excess of10 mmol/L, lactate levels of6 mmol/L, 5-minute Apgar score of7, and severe neonatal trauma. The secondary outcomes were mode of delivery, episiotomy, obstetrical anal sphincter injuries, postpartum hemorrhage, and maternal satisfaction.The study included 1710 nulliparous women. The neonatal morbidity rate was 18.9% in the moderate pushing group and 20.6% in the intensive pushing group (P=.38). Pushing duration was longer in the moderate group than in the intensive group (38.8±26.4 vs 28.6±17.0 minutes; P.001), and its rate of operative delivery was 21.1% in the moderate group compared with 24.8% in the intensive group (P=.08). The episiotomy rate was significantly lower in the moderate pushing group than in the intensive pushing group (13.5% vs 17.8%; P=.02). We found no significant difference for obstetrical anal sphincter injuries, postpartum hemorrhage, or maternal satisfaction.Moderate pushing has no effect on neonatal morbidity, but it may nonetheless have benefits, as it was associated with a lower episiotomy rate.

The aim of the study was to identify the obstetric risk factors for hypoxic-ischemic encephalopathy (HIE) in infants with asphyxia at birth.This multicenter case-control study covered the 5-year period from 2014 through 2018 and included newborns ≥36 weeks of gestation with an umbilical pH at birth ≤7.0. Cases were newborns who developed moderate or severe HIE; they were matched with controls with pH ≤7.0 at birth over the same period without moderate or severe HIE. The factors studied were maternal, gestational, intrapartum, delivery-related, and neonatal characteristics. A multivariable analysis was performed to study the maternal, obstetric, and neonatal factors independently associated with moderate or severe HIE.Our review of the records identified 41 cases and 98 controls. Compared with controls, children with moderate or severe HIE had a lower 5-min Apgar score, lower umbilical artery pH, and higher cord lactate levels at birth and at 1 h of life. Obstetric factors associated with moderate or severe HIE were the occurrence of an acute event (adjusted odds ratio [aOR] 6.4; 95% confidence interval [CI] 1.8-22.5), maternal fever (aOR 3.5; 95% CI 1.0-11.9), and thick meconium during labor (aOR 2.9; 95% CI 1.0-8.6).HIE is associated with a lower 5-min Apgar score and with the severity of acidosis at birth and at 1 h of life. In newborns with a pH7.0 at birth, the occurrence of an acute obstetric event, maternal fever, and thick meconium are independent factors associated with moderate or severe HIE.

International audience; Background: The main reason to avoid trial of labor after cesarean delivery is the possibility of uterine rupture. Identifying women at risk is thus an important aim, for it would enable women at low risk to proceed with a secure planned vaginal birth. bjective: To evaluate the impact of proposing mode of delivery based on the ultrasound measurement of the lower uterine segment thickness on a composite outcome of maternal-fetal mortality and morbidity, compared with usual management, among pregnant women with a previous cesarean delivery.Study Design: This multicenter, randomized, controlled, parallel-group, unmasked trial was conducted at 8 referral university hospitals with a neonatal intensive care unit and enrolled 2948 women at 36 weeks 0 days to 38 weeks 6 days of gestation with 1 previous low transverse cesarean delivery and no contraindication to trial of labor. Women in the study group had their lower uterine segment thickness measured by ultrasound. Those with measurements >3.5 mm, were encouraged to choose a planned vaginal delivery, and those with measurements ≤3.5 mm, were encouraged to choose a planned repeat cesarean delivery. This measurement was not taken in the control group; their mode of delivery was decided according to standard management. The primary outcome was a composite criterion comprising maternal mortality, uterine rupture, uterine dehiscence, hysterectomy, thromboembolic disease, transfusion, endometritis, perinatal death, or neonatal encephalopathy. Prespecified secondary outcomes were repeat cesarean deliveries, elective or after trial of labor.Results: The study group included 1472 women, and the control group included 1476 women. These groups were similar at baseline. The primary outcome occurred in 3.4% of the study group and 4.3% of the control group (relative risk, 0.78; 95% confidence interval, 0.54–1.13: risk difference, −1.0%; 95% confidence interval, −2.4 to 0.5). The uterine rupture rate in the study group was 0.4% and in the control group 0.9% (relative risk, 0.43; 95% confidence interval, 0.15–1.19). The planned cesarean delivery rate was 16.4% in the study group and 13.7% in the control group (relative risk, 1.21; 95% confidence interval, 1.00–1.47), whereas the rates of cesarean delivery during labor were 25.1% and 25.0% (relative risk, 1.01; 95% confidence interval, 0.89–1.14) in the study and control groups, respectively.Conclusion: Ultrasound measurements of lower uterine segment thickness did not result in a statistically significant lower frequency of maternal and perinatal adverse outcomes than standard management. However, because this study was underpowered, further research should be encouraged.

International audience; Objective To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section.Design Prospective population-based study.Setting All 176 maternity hospitals of eight French regions.Population Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries.Methods Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared.Main outcome measures Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes.Results The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally.Conclusion More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean.Tweetable abstract Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

Resume Objectifs Les calcifications intra-abdominales (iA) retrouvees lors d’une echographie obstetricale peuvent etre isolees ou associees a d’autres anomalies. Notre objectif etait d’etudier tous les cas de calcifications iA isolees echographiquement pris en charge dans notre centre, en decrivant leur localisation precise, leur bilan etiologique et l’issue neonatale associee. Methodes Nous avons realise une etude monocentrique retrospective descriptive sur les nouveau-nes ayant eu un diagnostic de calcification iA isolee en echographie de reference antenatale ainsi qu’un avis au centre pluridisciplinaire de diagnostic prenatal a l’hopital Trousseau et nes entre le 1er janvier 2008 et le 30 juin 2018. Les criteres d’exclusion etaient : les calcifications retro-peritoneales, les calcifications iA associees a des anomalies digestives ou autres malformations congenitales. Resultats Les 32 cas de calcifications iA isolees representaient 46 % de toutes les calcifications iA. Apres exclusion de 9 dossiers pour donnees neonatales manquantes, parmi les 23 cas de calcifications isolees, 15 concernaient des calcifications hepatiques, 5 des peri-hepatiques et 2 des peritoneales. Un fœtus etait porteur a la fois de calcifications intra- et peri-hepatiques. La majorite des calcifications sont restees stables tout au long de la grossesse. Aucun cas d’aneuploidie, de fœtopathie infectieuse, ni de mucoviscidose n’a ete retrouve. L’issue neonatale de tous ces enfants a ete favorable. Conclusions En cas de calcification iA paraissant isolee apres echographie de reference et stable sur plusieurs echographies, apres avoir elimine une fœtopathie infectieuse et recherche les mutations les plus frequentes de la mucoviscidose chez les parents, le pronostic est favorable.

International audience; Background: The number of twin pregnancies continues to increase worldwide as both the number of pregnancies obtained by medically assisted reproduction and age at first pregnancy keep rising. Preterm delivery is the major complication associated with twin pregnancies. The effectiveness of preventive treatments such as progesterone or cervical cerclage for women with a short cervix is doubtful in twin pregnancies. The effectivity of cervical pessaries in preventing preterm birth and its associated morbidity and mortality is also controversial.Objective: We sought to investigate if the Arabin pessary reduces adverse neonatal outcomes in twin pregnancies with a short cervix.Study design: This open-label, multicenter, randomized controlled trial on twin pregnancies with a cervical length of

Villitis of unknown etiology (VUE) is characterized by lympho-histiocytic infiltrates, which are predominant within the villous stroma. VUE can be of low grade i.e. affecting less than 10 contiguous villi or high grade with either patchy or diffuse subgroups (the later concerning more than 30 % of distal villi). Several other placental lesions could be associated with VUE, in particular in diffuse subgroups, such as diffuse perivillous fibrin deposition and chronic intervillositis. One of the most characteristic features of VUE is the late onset of fetal growth restriction after 32 weeks of gestation, and earlier detection of villitis should first raise an infectious origin. High grade VUE has been associated with fetal growth restriction, prematurity, fetal deaths, recurrent pregnancy loss, central nervous system injury and is characterized by relatively high risk of recurrence (25-50 %). Prospective and well-designed studies are necessary to determine the real prevalence of these adverse pregnancy events associated with VUE. Data about the management of VUE are extremely scarce and thus no recommendation based on the literature review could be actually done.

Introduction Recurrent miscarriages are defined as three or more early miscarriages before 12 weeks of gestation. The aim of this study was to describe a cohort of women with unexplained recurrent miscarriages, evaluate several potential biomarkers of immune origin and describe the outcome of pregnancies under immunomodulatory therapies METHODS: Women having a history of at least 3 early miscarriages without any etiology were recruited from 3 university hospitals. Results Among 101 women with recurrent miscarriages, overall, 652 pregnancies have been included in the analysis. Women which experienced miscarriages were older (33.3 ± 5.4 versus 31.9 ± 6.7; p = 0.03), with history of more pregnancies (4 (2-6) versus 3.5 (1-5.75); p 0.0008), and less frequently the same partner (406 (74%) versus 79 (86%); p=0.01). There was no difference in the level and frequencies of biomarkers of immune origin (NK, lymphocyte, gammaglobulins and blood cytokine levels and endometrial uNK activation status), except the higher rates of positive antinuclear antibodies in women with live birth (12 (13%) versus 36 (7%); p=0.03). Among the 652 pregnancies, 215 (33%) have been treated and received either aspirin/low weighted molecular heparin (LMWH) and/or combined to different lines of immunomodulatory treatment. Patients with pregnancy under treatment had a significantly higher rate of cumulative live birth rate that those with untreated ones (43.0% vs 34.8%; p = 0.04). When compared to patients with untreated pregnancies, patients with steroids during the pregnancy had twice more chances to obtain live birth (OR 2.0, CI95% 1.1 - 3.7, p = 0.02). Conclusions Unexplained recurrent miscarriages could have improved obstetrical outcome under immunomodulatory therapies and in particular steroids.

International audience

International audience; BACKGROUND: Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management.OBJECTIVE: This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ).STUDY DESIGN: From a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias.RESULTS: Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19-0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P 4 units of packed red blood cells within 6 months than cesarean hysterectomy.

Recurrent implantation failure is defined as the absence of pregnancy after at least three transfers of good-quality embryos after in vitro fecundation/intracytoplasic sperm injection.The aim of this study was to describe a multicentre cohort of women with unexplained RIF, to analyse the factors associated with clinical pregnancy and to evaluate the immunomodulatory therapies efficacy.Women were consecutively recruited from university departments with unexplained RIF.Sixty-four women were enrolled with mean age 36 ± 3 years. The rates of clinical pregnancy in 64 women were compared in untreated and treated cycles and according to therapies used during the last prospectively followed embryo transfer. A clinical pregnancy after the transfer was noted in 56 % pregnancies on intralipids and in 50 % on prednisone, versus 5 % in untreated ones (p0.001). The 340 embryo transfers of these 64 women resulted in 68 clinical pregnancies and 18 live births. Clinical pregnancies were significantly more frequent in treated versus untreated embryo transfers (44 % vs 9 %; p0.001) with odds ratio at 8.13 (95 % CI 4.49-14.72, p0.0001). Cumulative pregnancy rates were higher for steroid-treated transfers than for untreated transfers when considering overall transfers before and after using steroids and also only those under steroids. Cumulative pregnancy rates were not different from steroid- and intralipid-treated embryo transfers CONCLUSIONS: In this multicentre study of women with unexplained RIF, use of immunomodulatory treatments before embryo transfer resulted in higher clinical pregnancy. Randomised, well-designed studies in well-defined population of RIF women are necessary to confirm our preliminary data.

Background Intrahepatic cholestasis of pregnancy (ICP) is characterised by otherwise unexplained maternal pruritus, increased serum bile acid concentration over 10 μmol/L and spontaneous relief of symptoms and liver abnormalities after delivery. It occurs most frequently during the third trimester and is usually not induced by medication. Besides, azathioprine is recommended as first-line immunosuppressant in patients with steroid-dependent inflammatory bowel disease and is allowed during pregnancy, in order to stabilize maternal disease. Methods We reviewed all cases of ICP between 2010 and 2018 in two French perinatal centers. Results We encountered eight pregnancies complicated by atypical ICP among patients treated with azathioprine. ICP associated with azathioprine appears to be biologically more severe and to occur earlier than "standard" ICP. Furthermore, clinical and biochemical abnormalities related to ICP disappear when azathioprine is discontinued. Azathioprine safety should be reconsidered and practitioners advised to discuss discontinuing this drug as soon as ICP diagnosis is established.

Introduction In retrospective cohort study of women with unexplained recurrent implantation failure (RIF) and miscarriage (RM), we analyzed the efficacy and safety of intralipid therapy to obtain a live birth. Patients and methods Women with unexplained RM and/or RIF were included from 2015 to 2018 from three French university hospitals. Results Among 187 women treated for unexplained recurrent miscarriages and implantation failures, 26 women with median age of 36 years (29−43) received intralipid therapy. Among these 26 women, 10 women with a median age of 33 years (31−40) had a history of spontaneous recurrent miscarriages, with a median of 5 (4–8) previous miscarriages. Live births occurred in 7 (70 %) pregnancies under intralipids and were significantly more frequent than in women with recurrent miscarriages who did not receive intralipid therapy (n = 20, p = 0.02). Age, number of previous miscarriages, and additional therapies did not significantly differ between the two groups. Among the 26 included women, 16 had a history of recurrent implantation failures, with median age of 37 years (29−43) and median 9.5 (3–19) embryo transfers. Clinical pregnancy occurred in 9 (56 %) women receiving intralipids after embryo transfers under intralipids among which 5 (55 %) resulted in a live birth. Comparing successful pregnancies under intralipids with those with fetal loss, no significant differences have been noted. Conclusion Intralipids could be an effective and safe therapy in women with unexplained recurrent miscarriages and infertility.

International audience; Background: Endometriosis is a multifactorial pathology dependent on intrinsic and extrinsic factors, but the immune deregulation seems to play a pivotal role. In endometriosis-associated infertility this could raise the benefit of immunomodulatory strategies to improve the results of ART. In this review, we will describe (1) sera and peritoneal fluid cytokines and immune markers; (2) autoantibodies; (3) immunomodulatory treatments in endometriosis with infertility.Methods: The literature research was conducted in Medline, Embase and Cochrane Library with keywords: "endometriosis", "unexplained miscarriage", "implantation failure", "recurrent implantation failure » and « IVF-ICSI », « biomarkers of autoimmunity", "TNF-α", "TNF-α antagonists", "infliximab", "adalimumab", "etanercept", "immunomodulatory treatment", "steroids", "intralipids", "intravenous immunoglobulins", "G-CSF", "pentoxyfylline".Results: Several studies analyzed the levels of pro-inflammatory cytokines in sera and peritoneal fluid of endometriosis-associated infertility, in particular TNF-α. Various autoantibodies have been found in peritoneal fluid and sera of infertile endometriosis women even in the absence of clinically defined autoimmune disease, as antinuclear, anti-SSA and antiphospholipid autoantibodies. In few uncontrolled studies, steroids and TNF-α antagonists could increase the pregnancy rates in endometriosis-associated infertility, but well-designed trials are lacking.Conclusion: Endometriosis is characterized by increased levels of cytokines and autoantibodies. This suggests the role of inflammation and immune cell deregulation in infertility associated to endometriosis. The strategies of immunomodulation to regulate these immune deregulations are poorly studied and well-designed studies are necessary.

Intentional retention of the placenta (IRP), or 'conservative' treatment or management, entails opening the uterus, delivering the baby, tying and cutting the umbilical cord at its placental insertion site, leaving the placenta in the uterus and waiting for its complete spontaneous resorption in women with placenta accreta spectrum (PAS). The uterine preservation rate with this approach is about 78%, and severe maternal morbidity about 6%; these rates are respectively lower and higher in subgroups of women with placenta percreta. IRP has become a recommended option for women with PAS reluctant to undergo caesarean-hysterectomy and wanting to preserve their fertility, after appropriate information about the uterine preservation rate, but also the risk of a subsequent emergency hysterectomy due to unpredictable haemorrhage and/or infection, and the need for follow-up with regular visits for several months. Some authorities also recommend IRP when hysterectomy is at very high risk of surgical complications.

Objective To describe the course over time of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in French women from the beginning of the pandemic until mid-April, the risk profile of women with respiratory complications, and short-term pregnancy outcomes. Methods We collected a case series of pregnant women with COVID-19 in a research network of 33 French maternity units between March 1 and April 14, 2020. All cases of SARS-CoV-2 infection confirmed by a positive result on real-time reverse transcriptase polymerase chain reaction tests of a nasal sample and/or diagnosed by a computed tomography chest scan were included and analyzed. The primary outcome measures were COVID-19 requiring oxygen (oxygen therapy or noninvasive ventilation) and critical COVID-19 (requiring invasive mechanical ventilation or extracorporeal membrane oxygenation, ECMO). Demographic data, baseline comorbidities, and pregnancy outcomes were also collected. Results Active cases of COVID-19 increased exponentially during March 1–31, 2020; the numbers fell during April 1–14, after lockdown was imposed on March 17. The shape of the curve of active critical COVID-19 mirrored that of all active cases. By April 14, among the 617 pregnant women with COVID-19, 93 women (15.1 %; 95 %CI 12.3–18.1) had required oxygen therapy and 35 others (5.7 %; 95 %CI 4.0–7.8) had had a critical form of COVID-19. The severity of the disease was associated with age older than 35 years and obesity, as well as preexisting diabetes, previous preeclampsia, and gestational hypertension or preeclampsia. One woman with critical COVID-19 died (0.2 %; 95 %CI 0−0.9). Among the women who gave birth, rates of preterm birth in women with non-severe, oxygen-requiring, and critical COVID-19 were 13/123 (10.6 %), 14/29 (48.3 %), and 23/29 (79.3 %) before 37 weeks and 3/123 (2.4 %), 4/29 (13.8 %), and 14/29 (48.3 %) before 32 weeks, respectively. One neonate (0.5 %; 95 %CI 0.01–2.9) in the critical group died from prematurity. Conclusion COVID-19 can be responsible for significant rates of severe acute, potentially deadly, respiratory distress syndromes. The most vulnerable pregnant women, those with comorbidities, may benefit particularly from prevention measures such as a lockdown.

International audience; OBJECTIVE: To assess neonatal morbidity and mortality according to whether cephalic second twins were born after internal version followed by total breech extraction or after instructions to push. We hypothesized that interval version would result in shorter intertwin delivery intervals and lower cesarean delivery rates for the second twin and therefore better neonatal outcomes. METHODS: These planned analyses of the JUMODA (JUmeaux MODe d'Accouchement) cohort, a national prospective population-based study of twin deliveries, examined births of cephalic second twins after vaginal birth of the first twin at or after 32 weeks of gestation. The internal version group of second twins born in breech presentation after obstetric maneuvers was compared with the pushing group, comprising those born in cephalic presentation. The primary outcome was a composite of neonatal morbidity and mortality. Multivariate modified Poisson regression models were used to control for potential confounders. RESULTS: Of 2,256 cephalic second twins, 487 (21.6%) were born in breech presentation after internal version and total breech extraction and 1,769 (78.4%) in cephalic presentation after pushing. Composite neonatal morbidity and mortality was not lower in the internal version (17/487 [3.5%]) compared with the pushing group (38/1,769 [2.1%]; adjusted relative risk [aRR] 1.73 [95% CI 0.98-3.05]), although median [quartile 1-quartile 3] intertwin delivery intervals were shorter (5 [4-8] vs 8 [5-12] minutes, P

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.

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 Contexte et problematique Le syndrome des antiphospholipides (SAPL) est defini par une thrombose ou une complication obstetricale (≥ 3 fausses couches spontanees ou une mort fœtale ou une prematurite

Resume Contexte En cas d’antecedent de cesarienne, la pauvrete des donnees de haut niveau scientifique empeche la quantification precise des risques et des benefices qui pourraient aider cliniciens et patientes a prendre une decision eclairee sur la tentative de voie basse ou la cesarienne elective iterative. Une voie de recherche interessante consiste a evaluer les benefices potentiels d’une regle de decision integrant les donnees de l’echographie du segment inferieur cicatriciel. En effet, l’echographie peut etre utile pour determiner le risque specifique d’une patiente en mesurant l’epaisseur du segment inferieur de l’uterus, c’est-a-dire, l’epaisseur de la zone sur laquelle siege la cicatrice de cesarienne. Bien que les etudes publiees soient le plus souvent de petite taille, elles sont encourageantes car leurs resultats sont tous concordants : les mesures echographiques de l’epaisseur du segment inferieur sont fortement correlees aux constatations peroperatoires lors de la realisation de la cesarienne. En outre, plus le segment inferieur est mince en echographie, plus la probabilite d’un defect du segment inferieur est elevee. Finalement, l’evaluation echographique du segment inferieur a une excellente valeur predictive negative sur le risque de defect de la cicatrice uterine. C’est pourquoi, cet examen associe a une regle de decision pourrait aider a diminuer le taux de cesariennes electives iteratives et surtout diminuer la mortalite et la morbidite fœtale et maternelle liee a tentative de voie basse parmi les patientes ayant un antecedent de cesarienne. Methodes/conception de l’etude Il s’agit d’un essai pragmatique randomise, controle, multicentrique, ouvert, en deux bras paralleles. La randomisation sera centralisee et informatisee. L’aveugle etant impossible, un comite d’adjudication evaluera les elements constitutifs du critere de jugement principal afin d’eviter les biais d’evaluation. Une analyse intermediaire sera planifiee a mi-effectifs de l’essai. Les echographies seront realisees par des echographistes experts apres certification par l’investigateur principal. Seront incluses dans le protocole les patientes âgees de 18 ans et plus presentant une grossesse unique, une presentation cephalique, un âge gestationnel compris entre 36+0 et 38+6 SA, un antecedent de cesarienne segmentaire, et ayant signe le consentement eclaire. Entre 36+0 et 38+6 SA, les patientes seront invitees a participer a l’etude et seront randomises dans deux groupes : dans le bras experimental, la mesure echographique de l’epaisseur du segment inferieur sera realisee et la patiente sera informee qu’en cas de mesure superieure au seuil de 3,5 mm, elle sera consideree « a bas risque » de complications et sera encouragee a tenter une epreuve du travail alors qu’en cas de mesure inferieure ou egale au seuil de 3,5 mm, elle sera consideree « a risque » de complications et sera encouragee a accoucher par cesarienne elective iterative ; dans le bras controle, la mesure echographique du segment inferieur ne sera pas realisee. Le mode d’accouchement sera decide selon la pratique habituelle. Le critere de jugement principal sera composite incluant rupture uterine, dehiscence uterine, hysterectomie, complications thromboemboliques, transfusion, endometrite, mortalite maternelle, mortalite fœtale antepartum et intrapartum, encephalopathie hypoxique ischemique, et mortalite neonatale. Discussion Cet essai evalue l’utilite clinique de l’echographie du segment inferieur parmi les patientes ayant un antecedent de cesarienne pour reduire la morbidite et la mortalite fœtale et maternelle et fournira des preuves afin d’etablir des recommandations cliniques. Enregistrement de l’essai Identifiant ClinicalTrials.gov : NCT01916044 (date d’inscription : 5 aout 2013).

Resume Objectif L’objectif de la detection des fœtus petits pour l’âge gestationnel (PAG) est de reduire la morbi-mortalite perinatale. A contrario, elle peut se reveler iatrogene en induisant une prise en charge excessive. L’objectif etait d’evaluer l’impact de l’identification antenatale des fœtus PAG sur le pronostic neonatal et obstetrical. Methode Il s’agit d’une etude de cohorte retrospective. Tous les fœtus nes de poids inferieur au 3e percentile entre le premier janvier 2011 et le 31 decembre 2012 ont ete inclus. Les PAG etaient consideres comme suspectes lorsque le poids fœtal estime en antenatal etait Resultats Cent quarante-sept nouveau-nes ont ete inclus. Le petit poids avait ete suspecte dans 54 % des cas avant la naissance. L’âge gestationnel de naissance etait plus precoce (38,5 SA vs 39,6 SA ; p Conclusion Le depistage des fœtus PAG est associe a une augmentation de la prematurite par interventionnisme medical sans benefice neonatal franc. Neanmoins la puissance de l’etude et sa methodologie ne sont pas adaptees pour depister les risques de mort fœtale in utero ou d’asphyxie severe potentiellement associes a la non-identification d’un fœtus PAG pendant la grossesse.

Resume Objectif Determiner les mesures permettant de prevenir la prematurite spontanee et ses consequences (hors rupture des membranes). Materiel et methodes Consultation de la base de donnees MedLine, de la Cochrane Library et des recommandations des societes savantes francaises et etrangeres. Resultats En France, 60 000 enfants (7,4 %) par an naissent avant 37 SA, dont la moitie survient apres un travail spontane. Parmi les facteurs de risque modifiables de prematurite spontanee, seul le sevrage tabagique est associe a une diminution de la prematurite (NP1). Ce sevrage est recommande (grade A). Le depistage systematique et le traitement de la vaginose bacterienne en population generale n’est pas recommande (grade A). Le traitement par progestatif est recommande uniquement pour les grossesses monofœtales asymptomatiques et sans antecedent d’accouchement premature presentant un col mesure a moins de 20 mm entre 16 et 24 SA (grade B). Un cerclage sur antecedent n’est pas recommande du fait du seul antecedent de conisation (grade C), de malformation uterine (accord professionnel), d’antecedent isole d’accouchement premature (grade B). Le cerclage n’est pas non plus recommande pour les grossesses gemellaires, en prevention primaire (grade B) ou secondaire (grade C). Il est recommande pour les femmes presentant une grossesse unique avec un antecedent d’au moins 3 FCT ou d’accouchement premature (grade A). En cas d’antecedent de FCT ou d’accouchement premature spontane avant 34 SA d’une grossesse monofœtale, il est recommande de realiser une surveillance echographique de la longueur cervicale entre 16 et 22 SA afin de proposer un cerclage en cas de col inferieur a 25 mm avant 24 SA (grade C). Il n’est pas recommande d’utiliser un pessaire pour la prevention de l’accouchement premature dans une population generale asymptomatique de grossesse gemellaire (grade A) et dans les populations asymptomatiques a col court (accord professionnel). Bien que la mise en œuvre d’un depistage echographique universel de la longueur du col parmi les grossesses monofœtales sans antecedent d’accouchement premature entre 18 et 24 SA puisse etre consideree par les praticiens individuellement, ce depistage ne peut pas etre recommande universellement (accord professionnel). En cas de menace d’accouchement premature, (i) il n’est pas recommande d’utiliser un outil plus qu’un autre (echographie du col, toucher vaginal ou fibronectine fœtale) pour predire l’accouchement premature (grade B) ; (ii) il est recommande de ne pas administrer systematiquement d’antibiotiques (grade A) ; (iii) l’hospitalisation prolongee (grade B) et le repos au lit strict (grade C) ne sont pas recommandes. Aucun tocolytique n’est associe a une diminution de la mortalite et de la morbidite neonatale par rapport au placebo (NP2) et tous les tocolytiques peuvent engendrer des effets indesirables graves (NP4). L’atosiban et la nifedipine (grade B) peuvent etre utilises a visee tocolytique mais plus les betamimetiques (grade C). Il est recommande de ne pas prescrire un traitement d’entretien a l’issue des 48 heures de la tocolyse initiale (grade A). L’administration antenatale d’une cure de corticoides est recommandee a toutes les patientes a risque d’accouchement premature avant 34 SA (grade A). Apres 34 SA, il n’existe pas d’arguments suffisants pour recommander l’administration systematique de corticoides antenatals (grade B), mais une cure pourra toutefois etre discutee dans les situations a haut risque de detresse respiratoire severe, en particulier en cas de cesarienne programmee (grade C). La strategie de repetition des cures de corticoides n’est pas recommandee (grade A). La cure de sauvetage ne peut pas etre recommandee (accord professionnel). L’administration antenatale de sulfate de magnesium intraveineux est recommandee en cas d’accouchement imminent avant 32 SA (grade A). La cesarienne systematique n’est pas recommandee en cas de presentation cephalique (accord professionnel). Il n’est pas recommande une voie d’accouchement plutot qu’une autre en cas de presentation du siege (accord professionnel). Si l’etat neonatal ou maternel le permet, un clampage du cordon retarde peut etre envisage (accord professionnel). Conclusion En dehors de l’administration antenatale des corticoides et du sulfate de magnesium, les outils diagnostiques ou traitements prenatals mis en œuvre depuis 30 ans afin de prevenir la prematurite et ses consequences n’ont pas ete a la hauteur des attentes des professionnels et des familles.

Preterm prelabor rupture of membranes is a frequent obstetric condition associated with increased risks of maternal and neonatal morbidity and mortality. Conventional management is in hospital. Outpatient management is an alternative in selected cases; however, the safety of home management has not been established.To study the obstetric and neonatal outcomes of women with preterm premature rupture of membranes between 24 and 34 weeks who were managed as outpatient (outpatient care group), compared with those managed in hospital (hospital care group).A retrospective cohort study between 1 January 2009 and 31 December 2013 in three French tertiary care centers.Ninety women were included in the outpatient care group and 324 in the hospital care group. In the outpatient care group, the gestational age at membrane rupture was lower, compared to the hospital care group (28.8 (26.6-30.5) vs. 30.3 (27.6-32.1) weeks; p .01) and the cervical length at admission was higher (31.7 ± 10.4 vs. 24.3 ± 11.8 mm; p .01). In the outpatient care group, no delivery or major obstetric complication occurred at home.We observed no major complication related to home care after a period of observation. A randomized study would be necessary to confirm its safety.

International audience; Survival rates of infants born before 25 weeks of gestation are low in France and have not improved over the past decade. Active perinatal care increases these infants’ likelihood of survival.ObjectiveOur aim was to identify factors associated with active antenatal care, which is the first step of proactive perinatal care in extremely preterm births.MethodsThe population included 1020 singleton births between 220/6and 260/6weeks of gestation enrolled in the Etude Epidémiologique sur les Petits Ages Gestationnels 2 study, a French national population-based cohort of very preterm infants born in 2011. The main outcome was ’active antenatal care’ defined as the administration of either corticosteroids or magnesium sulfate or delivery by caesarean section for fetal rescue. A multivariable analysis was performed using a two-level multilevel model taking into account the maternity unit of delivery to estimate the adjusted ORs (aORs) of receiving active antenatal care associated with maternal, obstetric and place of birth characteristics.resultsAmong the population of extremely preterm births, 42% received active antenatal care. After standardisation for gestational age, regional rates of active antenatal care varied between 22% (95% CI 5% to 38%) and 61% (95% CI 44% to 78%). Despite adjustment for individual and organisational characteristics, active antenatal care varied significantly between maternity units (p=0.03). Rates of active antenatal care increased with gestational age with an aOR of 6.46 (95% CI 3.40 to 12.27) and 10.09 (95% CI 5.26 to 19.36) for infants born at 25 and 26 weeks’ gestation compared with those born at 24 weeks. No other individual characteristic was associated with active antenatal care.conclusionEven after standardisation for gestational age, active antenatal care in France for extremely preterm births varies widely with place of birth. The dependence of life and death decisions on place of birth raises serious ethical questions.Survival rates of infants born before 25 weeks of gestation are low in France and have not improved over the past decade. Active perinatal care increases these infants’ likelihood of survival.ObjectiveOur aim was to identify factors associated with active antenatal care, which is the first step of proactive perinatal care in extremely preterm births.MethodsThe population included 1020 singleton births between 220/6and 260/6weeks of gestation enrolled in the Etude Epidémiologique sur les Petits Ages Gestationnels 2 study, a French national population-based cohort of very preterm infants born in 2011. The main outcome was ’active antenatal care’ defined as the administration of either corticosteroids or magnesium sulfate or delivery by caesarean section for fetal rescue. A multivariable analysis was performed using a two-level multilevel model taking into account the maternity unit of delivery to estimate the adjusted ORs (aORs) of receiving active antenatal care associated with maternal, obstetric and place of birth characteristics.resultsAmong the population of extremely preterm births, 42% received active antenatal care. After standardisation for gestational age, regional rates of active antenatal care varied between 22% (95% CI 5% to 38%) and 61% (95% CI 44% to 78%). Despite adjustment for individual and organisational characteristics, active antenatal care varied significantly between maternity units (p=0.03). Rates of active antenatal care increased with gestational age with an aOR of 6.46 (95% CI 3.40 to 12.27) and 10.09 (95% CI 5.26 to 19.36) for infants born at 25 and 26 weeks’ gestation compared with those born at 24 weeks. No other individual characteristic was associated with active antenatal care.conclusionEven after standardisation for gestational age, active antenatal care in France for extremely preterm births varies widely with place of birth. The dependence of life and death decisions on place of birth raises serious ethical questions.

Objective Examine the predictive value for maternal-fetal infection of routine bedside tests detecting the proinflammatory cytokines, TNFα and IL-6, in the vaginal secretions of women with premature rupture of the membranes (PROM). Study design This prospective two-center cohort study included all women hospitalized for PROM over a 2-year period. A bedside test assessed IL-6 and TNFα in vaginal secretions. Both centers routinely tested CRP and leukocytes, assaying both in maternal serum, and analyzed vaginal bacterial flora; all samples were repeated twice weekly until delivery. Results The study included 689 women. In cases of preterm PROM (PPROM) before 37 weeks (n = 184), a vaginal sample positive for one or more bacteria was the only marker associated with early neonatal infection (OR 5.6, 95%CI; 2.0–15.7). Its sensitivity was 82% (95%CI; 62–94) and its specificity 56% (95%CI; 47–65). All positive markers of infection were associated with the occurrence of chorioamnionitis. In cases of PROM from 37 weeks onward (n = 505), only CRP >5 mg/dL was associated with early neonatal infection (OR = 8.3, 95%CI; 1.1–65.4) or clinical chorioamnionitis (OR = 6.8, 95%CI; 1.5–30.0). The sensitivity of CRP >5 mg/dL was 91% (95%CI; 59–100) and its specificity 45% (95%CI; 40–51) for predicting early neonatal infection, and 89% (95%CI; 65–99) and 46% (95%CI; 41–51), respectively, for predicting clinical chorioamnionitis. Conclusion The association of vaginal cytokines with maternal-fetal infection is weak and thus prevents their use as a good predictor of maternal-fetal infection. CRP and vaginal samples may be useful for identifying a group of women at low risk of infection.

Objective To determine the impact of clinical and/or histological chorioamnionitis on neurodevelopmental outcomes in premature infants. Methods A review of the literature appeared in PubMed between 1997 and 2016 was conducted to examine the association between clinical and/or histological chorioamnionitis and neurologic impairment in the neonates (intraventricular hemorrhage, periventricular leukomalacia and white matter damage) and in infants (cerebral palsy and neurodevelopmental delay). Results The first meta-analysis published in 2000 observed that clinical chorioamnionitis was associated with cystic periventricular leukomalacia and cerebral palsy and that histologic chorioamnionitis was associated with periventricular leukomalacia only. A second meta-analysis in 2010 found that cerebral palsy was associated with both clinical and histological chorioamnionitis. But most recent studies over the last decade based on large cohorts found no effect of chorioamnionitis on neurological outcomes, even if they had several methodological limitations. Conclusion According to the findings of the most recent studies, clinical or histological chorioamnionitis does not seem to be associated with neonatal white matter injuries, or with cerebral palsy. Further studies are needed to assess the impact of chorioamnionitis on long-term neurological development.

Resume Le syndrome des antiphospholipides (SAPL) est defini par l’association des manifestations thrombotiques et/ou d’une morbidite obstetricale associees a la presence d’anticorps antiphospholipides persistants (APL). L’association de l’aspirine a dose antiagregante avec une heparine de bas poids moleculaire (HBPM) a dose prophylactique a permis d’ameliorer considerablement le pronostic obstetrical au cours du SAPL primaire obstetrical. Plusieurs facteurs pourraient etre associes a la survenue de complications obstetricales chez les patientes presentant un SAPL. L’existence d’une thrombose arterielle ou veineuse anterieure, d’un lupus associe, d’un SAPL avec un anticoagulant circulant (ACC) ou une triple positivite des antiphospholipides (ACC lupique avec un anticorps anticardiolipide et un anticorps anti-β2GP1) est associee a un mauvais pronostic obstetrical. En revanche, le SAPL obstetrical comportant des fausses couches precoces isolees est le plus souvent associe aux anticardiolipides isoles et son pronostic obstetrical est meilleur. Il faut noter qu’il n’y a pas de definition reellement etablie de SAPL obstetrical refractaire, qui pourrait etre defini par une perte fœtale malgre un traitement par aspirine et HBPM bien conduit, en l’absence d’autres etiologies retrouvees et la frequence de SAPL refractaire ainsi defini serait de 20–39 %. Plusieurs traitements associes a la combinaison aspirine–HBPM ont ete utilises dans le SAPL obstetrical tel que les corticoides, l’hydroxychloroquine, les immunoglobulines intraveineuses et les echanges plasmatiques, d’autres traitements tel que l’eculizumab ou les statines pouvant avoir egalement un interet clinique, bien que des etudes soient necessaires pour demontrer l’efficacite et la place de ces differentes strategies.