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Aspirin initiated between 11 and 14 weeks of gestation reduces the risk of preterm preeclampsia and other placenta-mediated complications in screen-positive women. Most of these adverse outcomes are associated with maternal vascular malperfusion of the placenta, a disease that begins during the early first trimester. Assuming that aspirin has direct beneficial actions on the developing placenta, tempts clinicians to believe in the maxim that "the earlier the better", however neither the safety nor the effectiveness of aspirin started before 11th week of gestation has been demonstrated. Therefore, outside of research protocols, aspirin should not be started before the 11th week of pregnancy for the prevention of preeclampsia.

Purpose To evaluate women’s choice in the method of labour induction between oral misoprostol, PGE2 pessary and the Foley catheter. To compare women’s satisfaction according to their choice and to identify factors associated with patient satisfaction. Methods We conducted a comparative, prospective cohort study of 520 women who chose their preferred method for labour induction, in a French tertiary hospital, from July 2019 to October 2020. Before and after the delivery, they were asked to argument their choice and to evaluate their satisfaction through the use of questionnaires. The primary outcome was global level of satisfaction. Results Of the 520 women included, 67,5% of women chose oral Misoprostol compared to 21% PGE2 pessary and 11.5% the Foley catheter. Regarding global satisfaction, we found no significant difference between the three groups: 78,4%, 68,8% and 71,2% (p = 0,091) for respectively oral misoprostol, PGE2 pessary and the Foley catheter. Factors that seem to improve women’s satisfaction were nulliparity (OR = 2.03, 95%CI [1.19–3.53]), delivery within 24 hours after the start of induction (OR = 3.46, 95%CI. [2.02–6.14]) and adequate information (OR = 4.21,95%CI [1.86–9.64]). Factors associated with lower satisfaction rates were postpartum hemorrhage (OR = 0.51, 95%CI [0.30–0.88]) and caesarean section (OR = 0.31, 95%CI [0.17–0.54]). Conclusion Women satisfaction rates were not different between the three methods, when chosen by the patients themselves. These finding should encourage caregivers to promote shared decision making when possible.

The aim of this study was to assess perinatal morbidity associated with spatulas or forceps assisted delivery in preterm birth.This is a retrospective cohort study including all women with assisted deliveries on singleton pregnancy in cephalic presentation, before 37 weeks of gestation, in two tertiary care centers. We compared forceps-assisted deliveries with spatula-assisted deliveries. The main outcome was the rate of neonatal birth trauma. Secondary outcomes included other neonatal parameters, maternal outcomes and obstetric anal sphincter injuries.Out of 37 002 deliveries, 59 (0.2 %) preterm assisted deliveries with forceps and 111 (0.3%) preterm spatulas deliveries were included. The rate of neonatal birth trauma was low for both devices, without significant difference (3.4% in Forceps group vs 0.9% in Spatulas group, p = 0.28). The rate of episiotomy was 79.7% after forceps-assisted delivery and 48.6% for spatulas (p 0.001). The rate of obstetric anal sphincter injuries was 1.7% and 2.7% respectively (p = 0,9).The rate of birth trauma was low in both forceps-assisted deliveries and spatula-assisted deliveries and was not significantly different between the two groups.

To assess the association between marked variability in fetal heart rate and neonatal acidosis.Bicentric prospective cohort study.From 01/2019 to 12/2019, in two French tertiary care maternity units.Women in labor at or after 37 weeks, with continuous FHR monitoring until delivery and availability of umbilical arterial pH. Women with intrauterine fetal death or medical termination, multiple pregnancies, non-cephalic presentation, or planned cesarean delivery were excluded.The exposure was marked variability in fetal heart rate in the 60 minutes before delivery, defined as a variability greater than 25 beats per minute, with a minimum duration of 1 minute. To assess the association between marked variability and neonatal acidosis, we used multivariable modified Poisson regression modeling. We then conducted subgroup analyses according to the NICHD category of the associated fetal heart rate.Neonatal acidosis, defined as an umbilical artery pH ≤ 7.10.Among the 4,394 women included, 177 (4%) had marked variability in fetal heart rate in the 60 minutes before delivery. Acidosis occurred in 6.0% (265/4394) of the neonates. In the multivariable analysis, marked variability was significantly associated with neonatal acidosis (adjusted relative risk 2.30, 95% confidence interval 1.53- 3.44). In subgroup analyses, the association between marked variability and neonatal acidosis remained significant in NICHD category I and category II groups.Marked variability was associated with a two-fold increased risk of neonatal acidosis.

OBJECTIVE To evaluate the delivery rate in the occiput posterior position according to the result of manual rotation performed in the case of persistent occiput posterior position. Secondary objectives were perinatal outcomes. METHODS This was a prospective cohort study conducted in two French tertiary care units. All women with a singleton pregnancy after 37 weeks of gestation with a fetus in persistent occiput posterior position and an attempt of manual rotation were included. The main outcome was the occiput position at delivery. The secondary outcomes were duration of labor, mode of delivery, and perineal tears. Two groups were compared according to the result of manual rotation. RESULTS In total, 460 women were included, with a manual rotation success of 62.4%. The success was significantly associated with a decrease in occiput posterior position at vaginal delivery (1.4% vs 57.2%, P

To evaluate the obstetrical prognosis of term breech delivery in case of asymmetric pelvis. An observational, comparative, retrospective, bi-centric study of 559 patients who had a computer tomography pelvimetry prior to delivery of a term breech presentation was conducted between August 2013 and August 2019. Patients with an attempted vaginal delivery were divided into two groups: a group of asymmetric pelvis (AP) when the difference between the lengths of both oblique diameters was ≥ 1 cm and a group of symmetric pelvis (SP) when the two oblique diameters differed by

Objectives To estimate the ability of a combination of first-trimester markers to predict preterm preeclampsia in nulliparous women. Methods We conducted a prospective cohort study of nulliparous women with singleton gestations, recruited between 110 and 136 weeks gestation. Data on the following were collected: maternal age; ethnicity; chronic diseases; use of fertility treatment; body mass index; mean arterial blood pressure (MAP); serum levels of pregnancy-associated plasma protein A (PAPP-A), placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), alpha fetoprotein (AFP), free beta human chorionic gonadotropin (s-hCG); and mean uterine artery pulsatility index (UtA-PI). We constructed a proportional hazard model for the prediction of preterm preeclampsia selected based on the Akaike information criterion. A receiver operating characteristic curve was created with the predicted risk from the final model. Our primary outcome was preterm preeclampsia and our secondary outcome was a composite of preeclampsia, small for gestational age, intrauterine death, and preterm birth. Results Among 4659 nulliparous women with singleton gestations, our final model included 4 variables: MAP MoM, log10PlGF MoM, log10AFP MoM and log10UtA-PI MoM. We obtained an area under the curve of 0.84 (95% CI 0.75–0.93) with a detection rate of preterm preeclampsia of 55% (95% CI 37%–73%) and a false-positive rate of 10%. Using a risk cut-off with a false-positive rate of 10%, the positive predictive value for our composite outcome was 33% (95% CI 29%–37%). Conclusions The combination of MAP, maternal serum PlGF and AFP, and UtA-PI are useful to identify nulliparous women at high risk of preterm preeclampsia but also at high risk of other great obstetrical syndromes.

Objective Preeclampsia is associated with a higher maternal blood levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and lower levels of placental growth factor (PlGF) that appear before clinical onset. We aimed to estimate the normal progression of these biomarkers in normal pregnancies and in those affected by preeclampsia. Methods We conducted a case-cohort study including low-risk nulliparous women recruited at 11–13 weeks gestation (cohort) and women with preeclampsia (cases). Maternal blood was collected at different points during pregnancy including at the time of diagnosis of preeclampsia for cases. Maternal serum PlGF and sFlt-1 concentrations and the sFlt-1/PlGF ratio were measured using B•R•A•H•M•S plus KRYPTOR automated assays and were compared between patients in both groups matched for gestational age. Cases were stratified as early- (≤34 weeks), intermediate- (35–37 weeks) and late-onset (>37 weeks) preeclampsia. Results The cohort consisted of 45 women whose results were compared with those of 31 women who developed preeclampsia, diagnosed at a median gestational age of 32 weeks (range 25–38 weeks). We observed that sFlt-1, PlGF and their ratio fluctuated during pregnancy in both groups, with a significant correlation with gestational age after 28 weeks (P Conclusion PlGF, sFlt-1, and their ratio may be useful in the prediction and diagnosis of early- and intermediate-onset preeclampsia but are not useful for late-onset preeclampsia.

Traditional obstetric units are inadequate for the level of monitoring required in pre-eclamptic patients. It remains to be determined which facility and tools should be implemented. The aim of this work was to identify predictive factors of admission to Intensive Care Unit (ICU) admissions for pregnancy-related hypertensive complications.We conducted an observational, retrospective multicenter study (Toulouse, Nantes). Both have a level III maternity unit and an ICU. The selected patients had one or more of the following diagnoses on admission in the ICU or during hospitalization: pre-eclampsia, eclampsia, HELLP syndrome, Acute Fatty Liver of Pregnancy (AFLP), Hemolytic Uremic Syndrome (HUS). SAPS II, SOFA and APACHE II on admission, and a validated nursing workload assessment score: TISS 28, were collected.211 parturient women were included. According to the multivariate analysis: APACHE II and SAPS 2 severity scores15 were significantly higher in the TISS 28 ≥ 20 group. There were also higher rates of uricemia360 mmol/l.To date, there are no reliable and validated predictive factors of severity to guide the transfer of pre-eclamptic patients to an ICU. The combination of an increased APACHE II score and uricemia, as well as a high care workload score that could help with the transfer of high-risk pre-eclamptic patients to a specific care facility. This hypothesis should be tested prospectively. This work could incite reflection on the value of creating obstetric intensive care units, according to the size of the maternity unit.

Other methods of cigarette consumption include a variety of electronic products, as well as heated tobacco, snus and shisha. The questions in this chapter are: what other methods of consumption are used during pregnancy (either electronic or containing tobacco) and what is their prevalence? What is their benefit/risk balance? Can their use during pregnancy be proposed? Although the fetus is not exposed to the combustible toxins of tobacco, e-cigarette products may contain nicotine, which maintains the exposure of the fetus. Further research is needed on the other components of the electronic cigarette, such as flavorings and propylene glycol and/or glycerol, in order to assess the benefit/risk balance. In addition, some solvents contain ethanol. In the current state of knowledge, the precautionary principle should be respected and not recommend the initiation or continuation of the electronic cigarette during pregnancy (professional agreement). For smoking cessation or electronic cigarette cessation, it is recommended to provide the same advice and to use methods that have already been evaluated (professional agreement). For the JUUL, there are currently no data on obstetrical outcome when used. The use of shisha during pregnancy is associated with decreased fetal growth. It is recommended not to use shisha during pregnancy (GradeC). There are currently no data on the use of heated tobacco and obstetrical outcome.

Objective This study was aimed to estimate the value of transabdominal (TA) ultrasound measurement of cervical length (CL), as an alternative of transvaginal (TV) ultrasound, for universal screening of short cervix in the midtrimester. Study Design We conducted a prospective cohort study of nulliparous women with singleton pregnancy at 20 to 24 weeks of gestation. All participants underwent TA ultrasound followed by TV ultrasound with acquisitions of images and videos of the uterine cervix. A second sonographer, blinded to the participants' data and pregnancy outcomes, measured the CL using TA and TV images and videos. Pearson's correlation test and receiver operating characteristic (ROC) curve analyses were performed. Results A total of 805 participants were recruited, including 780 (97%) where TA CL measurement was feasible. We observed a strong correlation of CL between TA and TV (correlation coefficient: 0.57; p Conclusion Universal short cervix screening in nulliparous women could be performed using TA ultrasound, which could allow the avoidance of TV ultrasound in more than three quarter of women. In low-risk population, TV ultrasound could be reserved to women with TA CL Key Points

HELLP syndrome is a rare and severe pregnancy complication which exposes to severe maternal and fetal morbidity. Management of HELLP syndrome occurring before 34 weeks of gestation (WG) is still controversial but conservative management may be beneficial in patients with stable HELLP syndrome. The aim of the study was thus to identify which maternal and fetal prognostic factors could be predictive of HELLP syndrome evolution.From 2003 to 2016, all patients with HELLP syndrome occurring between 26 and 34 WG were retrospectively enrolled. Study population was stratified according to obstetrical management. Patients in whom delivery was initiated within 48 h following diagnosis constituted the active management group. In the expectant management group, pregnancy was prolonged until maternal or fetal follow up indicated delivery.Ninety-nine patients were included in our study. Among them, 61 were managed expectantly. At baseline, the active management group was more likely to suffer from persistent hyperreflexia (While expectant management in HELLP syndrome might be beneficial through its reduction of prematurity, it cannot be conducted in all patients. Identification of baseline parameters predictive of disease evolution is thus of tremendous importance to define which obstetrical approach should be prioritized.

To evaluate the risk of spontaneous preterm birth on subsequent pregnancies after second stage cesarean section.This is a retrospective cohort study. Women were included if they had their two consecutive births in Toulouse University Hospital in the study period. The first birth was a singleton livebirth at term (≥37 weeks of gestation), divided in three categories according to the mode of delivery: vaginal delivery (group A), cesarean section before the second stage of labor (group B), cesarean section during the second stage of labor (group C). The subsequent pregnancy was the first subsequent pregnancy, conducted after 16 weeks of gestation. The primary outcome was spontaneous preterm birth in the subsequent pregnancy, defined as delivery before 37 weeks of gestation. Secondary endpoints included preterm rupture of membranes in the subsequent pregnancy.Between 2003 and 2018, 7776 women (84.7%) in group A, 1263 (13.8%) in group B and 143 (1.5%) in group C were included. The adjusted odds ratio of spontaneous preterm birth before 37 weeks of gestation after second stage cesarean section was 2.4 (group C vs group A + B, 95% confidence interval: 1.2-4.8), P = 0.01). The rate of preterm rupture of membranes was also significantly higher in group C (6% vs 2% in group A, P = 0.009, 6% vs 3% in group B, P= 0.05) with OR = 3.0 (group C vs group A + B, 95% CI: 1.55-6.16, P 0.001).History of term second stage of labor cesarean section is an independent risk factor for spontaneous preterm birth and for preterm rupture of membrane in the subsequent pregnancy.

This study aimed to estimate the impact of third-trimester ultrasound with measurement of the lower uterine segment thickness (LUST) and estimation of fetal weight (EFW) on maternal and perinatal morbidity among women with a prior cesarean delivery.We performed a secondary analysis of the QUARISMA trial, including women who delivered at term after one prior cesarean delivery in tertiary care centres. Major and minor maternal and perinatal morbidities were compared between centres that had introduced LUST and EFW measurements into routine practice and those that had not, using generalised estimating equations and adjusted odds ratios (aOR). In a secondary analysis, we compared women who underwent a trial of labour with and without LUST and EFW measurements.We observed a significant reduction in major perinatal morbidity (aOR 0.52; 95% CI 0.28-0.96, P = 0.04), minor perinatal morbidity (aOR 0.49; 95% CI 0.25-0.96, P = 0.04), and minor maternal morbidity (aOR 0.56; 95% CI 0.34- 0.94, P = 0.03) but no significant difference in major maternal morbidity (aOR 0.40; 95% CI 0.04-3.69, P = 0.42) in the 2 centres that had introduced third-trimester ultrasound with EFW and LUST measurements (1458 women), compared with the 4 centres (1247 women) that had not. Among women who underwent a trial of labour, we observed a reduction in major perinatal morbidity (aOR 0.25; 95% CI 0.11-0.54, P0.001) and a lower rate of uterine rupture (0% vs. 0.3%, P = 0.045) with LUST and EFW measurements.Third-trimester ultrasound with EFW and LUST measurement is associated with a significant reduction in major perinatal morbidity in women with a prior cesarean delivery.

To estimate the role of first-trimester uterine artery pulsatility index (UtA-PI) for the prediction of small-for-gestational age (SGA).We conducted a prospective cohort study of nulliparous women with singleton pregnancy (Great Obstetrical Syndromes study). UtA-PI was performed at 11 + 0 to 13 + 6 weeks and was reported in multiple of median (MoM). SGA was defined as birth weight below the 10th percentile and stratified as term or preterm SGA. Receiver operating characteristic curves analyses with their area under the curve (AUC) were used to estimate the predictive values of UtA-PI, alone and UtA-PI combined with maternal characteristics. We computed the detection rate and false-positive rate (FPR) of the SOGC SGA screening guidelines in our population.Of 4610 participants, SGA was identified in 486 pregnancies (10.3%), including 15 (0.3%) associated with preterm delivery. Compared with unaffected pregnancies, the mean log UtA-PI was significantly higher in term SGA and preterm SGA. The difference between preterm SGA and unaffected pregnancies remains significant after exclusion of SGA without preeclampsia. First-trimester UtA-PI was more predictive of preterm (AUC: 0.89) than term (AUC: 0.60) SGA (P 0.01). Combined with maternal characteristics, UtA-PI could have predicted 64% of preterm and 20% of term SGA (10% FPR). The SOGC guidelines criteria for early screening of SGA had a detection rate of 21% for a FPR of 21%.First-trimester UtA-PI can be used to predict SGA, but mainly preterm SGA. The current SOGC guidelines criteria for SGA screening are not efficient in nulliparous women.

Resume Objectif L’objectif de ce travail est de fournir des recommandations pour la pratique clinique concernant la contraception intra-uterine. Methodes Une revue exhaustive de la litterature a ete effectuee a l’aide des moteurs de recherche Pubmed et Cochrane database. Les recommandations recentes sur le sujet, en langue francaise et anglaise, ont egalement ete considerees. Resultats La contraception intra-uterine peut etre proposee dans de nombreuses situations, y compris chez les nullipares, les adolescentes, les patientes vivant avec le VIH avant le stade SIDA (Grade B) et les femmes presentant un antecedent de grossesse extra-uterine (GEU) (Grade C). Il est recommande de ne pas modifier le schema de depistage du cancer du col chez les utilisatrices de dispositif intra-uterin (DIU) (Grade B). Seuls le toucher vaginal avec examen bimanuel et l’inspection cervicale sont formellement recommandes avant la pose d’un DIU (Grade B). Un depistage systematique des infections sexuellement transmises n’est pas recommande (Grade B). Ce depistage est effectue idealement le jour de la prescription du DIU mais peut etre realise le jour de la pose si la patiente est asymptomatique (Grade B). Le DIU peut etre pose a n’importe quel moment du cycle (Grade B). Il n’est pas recommande de realiser une antibioprophylaxie ou une premedication systematique lors de l’insertion (Grade A). Une visite de suivi peut etre proposee dans les semaines suivant la pose (AP). Il n’est pas recommande de realiser une echographie de controle systematique si la patiente est asymptomatique, que l’insertion du dispositif s’est deroulee sans difficulte et qu’a l’examen les fils sont vus et de longueur attendue (Grade B). Quel que soit le type de DIU, les metrorragies persistantes ou associees a des douleurs pelviennes doivent motiver des explorations complementaires a la recherche d’une complication (AP). Devant une suspicion de perforation uterine, des examens complementaires doivent etre realises pour localiser le DIU (AP). L’abord laparoscopique est la voie a privilegier pour le retrait des DIU en situation abdominale (AP). En cas de grossesse sur DIU, il convient en premier lieu d’eliminer une GEU (Grade B). En presence d’une grossesse intra-uterine evolutive et desiree, il est recommande de retirer le DIU si les fils sont accessibles (Grade C). La presence d’organismes Actinomyces-like au frottis cervico-vaginal chez une patiente asymptomatique ne doit pas motiver d’exploration complementaire, de retrait anticipe ou de traitement anibiotique (Grade B). Il n’est pas recommande de retirer d’emblee le DIU en cas de survenue d’une infection sexuellement transmise ou d’une infection genitale haute (Grade B). En l’absence d’evolution favorable a 48–72 h de l’institution du traitement, le retrait du dispositif doit etre discute (Grade B). Conclusion La contraception intra-uterine constitue un moyen contraceptif de longue duree d’action efficace avec un taux de continuation elevee qui s’accompagne d’un risque faible de complications. Elle peut donc etre proposee a un tres grand nombre de patientes, independamment de la parite.

Objective The study aimed to estimate the predictive value of midtrimester cervical length (CL) and the optimal cut-off of CL that should be applied with asymptomatic nulliparous women for the prediction of spontaneous preterm birth (sPTB). Study Design This is a prospective cohort study of asymptomatic nulliparous women with a singleton gestation. Participants underwent CL measurement by transvaginal ultrasound between 20 and 24 weeks of gestation. The participants and their health care providers remained blinded to the results of CL measurement. The primary outcomes were sPTB before 35 weeks and sPTB before 37 weeks. Receiver operating characteristics (ROC) curve analyses were performed. Analyses were repeated by using multiples of median (MoM) of CL adjusted for gestational age. Results Of 796 participants, the mean midtrimester CL was 40 ± 6 mm with a 1st, 5th, and 10th percentile of 25, 29, and 32 mm, respectively. ROC curve analyses suggest that a cut-off of 30 mm was the optimal CL to predict sPTB before 35 weeks (area under the ROC curve [AUC]: 0.70, 95% confidence interval [CI]: 0.56–0.85) and before 37 weeks (AUC: 0.70, 95% CI: 0.59–0.80). Midtrimester CL Conclusion A midtrimester CL cut-off of 30 mm (instead of 25 mm), or CL less than 0.75 MoM, should be used to identify nulliparous women at high risk of sPTB. Key Points

Objective Daily aspirin, started in the first trimester of pregnancy, is commonly used for the prevention of preeclampsia and fetal growth restriction in multiple gestation. However, the optimal dose remains controversial and the evidence for the use of aspirin in multiple pregnancies is scarce. We aimed to estimate the impact of 80 mg of aspirin in twin pregnancies. Study Design We performed a pilot double-blind randomized trial of women with twin pregnancies recruited between 8 and 14 weeks of gestation. Fifty participants (25 in each group) were randomized to 80 mg of aspirin daily at bedtime or a placebo from randomization until 36 weeks of gestation. Primary and secondary outcomes included the birth weight of live infants, preeclampsia, and aspirin responsiveness evaluated by a platelet aggregation test (platelet function assay [PFA]-100). Results All participants were followed until birth, including 48 and 47 live newborns in the aspirin and the placebo groups, respectively. The mean birth weight difference between the aspirin (2,385 ± 529 g) and placebo (2,224 ± 706 g) groups was of 179 g (95% confidence interval [CI]: −172–531 g, p = 0.32). We observed two (8%) cases of preeclampsia in the aspirin group and no case with placebo (p = 0.49). Most importantly,16 of 24 participants who received aspirin (67%; 95% CI: 45–84%) had a normal PFA-100 test at 22 to 23 weeks, including the two cases of preeclampsia, suggesting that the majority of the participants were nonresponsive to 80 mg of aspirin. Conclusion Our results suggest that the majority of women with twin pregnancies showed a lack of response to a daily dose of 80 mg of aspirin according to the PFA-100 test, compared with the expected 29% of nonresponsiveness in singleton pregnancies. A daily dose of 80 mg of aspirin is likely to be insufficient for the prevention of preeclampsia and other placenta-mediated complications in twin pregnancies. Key Points

INTRODUCTION: Preeclampsia (PE), but mainly preterm PE, is associated with deep placentation disorders. We aimed to compare placental pathologies in pregnancies affected by term and preterm PE comp...

International audience; Objectives: To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy and the post-partum period.Study design: A systematic review of the international literature was undertaken between January 2003 and April 2019. MEDLINE, EMBASE databases and the Cochrane library were searched for a range of predefined key words. All relevant reports in English and French were classified according to their level of evidence ranging from 1(highest) to 4(lowest). The strength of each recommendation was classified according to the Haute Autorité de Santé (French National Authority for Health) ranging from A (highest) to C (lowest).Results: \"Counselling\", including all types of non-pharmacological interventions, has a moderate benefit on smoking cessation, birth weight and prematurity. The systematic use of measuring expired air CO concentration does not influence smoking abstinence, however, it may be useful in assessing smoked tobacco exposure prior to and after quitting. The use of self-help therapies and health education are recommended in helping pregnant smokers quit and should be advised by healthcare professionals. Nicotine replacement therapies (NRT) may be prescribed to pregnant women who have failed to stop smoking after trying non-pharmacological interventions. Different modes of delivery and dosages can be used in optimizing their efficacy. Smoking in the postpartum period is essential to consider. The same treatment options as during pregnancy can be used.Conclusion: Smoking during pregnancy concerns more than a hundred thousand women each year in France resulting in a major public health burden. Healthcare professionals should be mobilised to employ a range of methods to reduce or even eradicate it.

Objectives To determine whether the surgical learning curve impact the spontaneous pregnancy rate in infertile patients undergoing removal of deep infiltrating endometriosis Material and Methods Single center retrospective study including the first 50 consecutive infertile women suffering from deep infiltrating endometriosis and referred to a single surgeon. All patients underwent laparoscopic removal of deep endometriosis lesions. The study population was stratified in two subgroups, namely the early group (including the first 25 cases) and the late group (comprising the 25 subsequent cases). Pregnancy and live birth rates, surgical morbidity and clinical recurrence rate were compared between study groups. Results Overall, spontaneous pregnancy rate (40 % in the early group versus 56 % in the late group, p = 0.25), live birth rate (40 % versus 44 %, p = 0.77) and clinical recurrence rate (16 % versus 4%, p = 0.16) did not significantly differ between the study groups. Logistic regression analysis revealed that ASRM stage, EFI score, and body mass index were the only significant prognostic factors of postoperative spontaneous fertility. Conclusion Surgical resection of deep infiltrating endometriosis in infertile women is associated with high spontaneous pregnancy and live birth rates. The surgeon’s learning curve does not impact postoperative fertility outcomes.

Objective Increased expression of soluble fms-like tyrosine kinase 1 (sFlt-1), associated with a decrease in placental growth factor (PlGF), plays a key role in the pathogenesis of preeclampsia (PE). We evaluated the prognostic value of the sFlt-1/PlGF ratio for the onset of adverse maternofetal outcomes (AMFO) in case of early-onset PE with attempted expectant management. Study Design From October 2016 through November 2018, all singleton pregnancies complicated by early-onset PE (before 34 weeks of gestation) were included in a cohort study. The plasma levels of sFlt-1 and PlGF were blindly measured on admission. For the statistical analysis, we performed a bivariate analysis, a comparison of the receiving operating characteristic curves and a survival analysis estimated by the Kaplan–Meier method. Results Among 109 early PE, AMFO occurred in 87 pregnancies (79.8%), mainly hemolysis, elevated liver enzymes, and low platelet count syndrome and severe fetal heart rate abnormalities requiring urgent delivery. The area under the curve (AUC) of sFlt-1/PlGF ratio was 0.82 (95% confidence interval [CI]: 0.73–0.88) for the risk of AMFO and the difference between the AUCs was significant for each separate standard parameter (p = 0.018 for initial diastolic blood pressure, p = 0.013 for alanine aminotransferase, p Conclusion The sFlt-1/PlGF ratio is an additional tool in the prediction of AMFO in proven early-onset PE, which is likely to improve care by anticipating severe complications. Key Points

Objective To compare the effects of 80 mg and 160 mg of aspirin, initiated in the first trimester of pregnancy, on mid-trimester uterine artery pulsatility index (UtA-PI) in women with a history of preeclampsia. Methods We performed a pilot double-blind randomized controlled trial. Pregnant women with a history of preeclampsia were recruited between 100/7 and 136/7 weeks gestation and randomly assigned to take either 80 or 160 mg of aspirin daily at bedtime from randomization to 356/7 weeks gestation. The primary outcome was mean UtA-PI at 22–24 weeks. Secondary outcomes included the rate of fetal growth restriction and preeclampsia, stratified as term (≥37 weeks), preterm ( Results A total of 107 participants were randomized, including 41 (38%) with a history of preterm preeclampsia and 16 (15%) with a history of early-onset preeclampsia. We observed no significant difference in mean UtA-PI at 22–24 weeks between the 2 groups (0.97; 95% CI 0.88–1.05 vs. 0.97; 95% CI 0.88–1.07, P = 0.9). The rates of fetal growth restriction (8% vs. 2%; P = 0.20); preeclampsia (12% vs. 15%; P = 0.78), preterm preeclampsia (4% vs. 2%; P = 0.56), and early-onset preeclampsia (0% vs. 2%; P = 0.52) were similar in both groups. No serious adverse events associated with the study treatment were reported. Conclusion We observed no significant difference in UtA-PI between the two doses of aspirin, but we observed low rates of fetal growth restriction and preterm and early-onset preeclampsia (all less than 5%). The benefits of aspirin for the prevention of preterm preeclampsia is probably not related to the improvement of deep placentation alone.

Resume Objectifs Evaluer les connaissances sur le tabagisme en cours de grossesse et elaborer les recommandations de prise en charge, en utilisant la litterature fondee sur les niveaux de preuve. Methodes Revue systematique de la litterature internationale. Nous avons identifie des articles publies entre janvier 2003 et avril 2019 dans les bases de donnees Cochrane, PubMed et Embase a partir des mots cles predefinis. Toutes les etudes publiees en langue francaise ou anglaise ont ete considerees et classees par leur niveau de preuve (de 1, le plus eleve a 4 le plus bas) et la force des recommandations selon la cotation proposee par la Haute Autorite de sante (HAS) (grades A a C). Resultats Le « conseil global », signifiant tout conseil ou aide comportementale confondu, apporte un benefice modeste comme aide au sevrage et un benefice modere sur le poids de naissance et la prematurite. L’activite physique moderee n’a pas montre d’effet significatif. Le retrocontrole par l’evaluation dans l’air expire de la concentration de monoxyde de carbone n’influence pas l’abstinence tabagique mais il y a l’accord professionnel pour utiliser cette mesure en vue d’etablir une alliance therapeutique. L’utilisation d’interventions d’entraide et d’education a la sante est recommandee pour favoriser l’arret du tabac pendant la grossesse. La prescription des traitements de substitution nicotinique (TSN) peut etre proposee a toute femme enceinte qui n’a pas reussi a arreter de fumer sans aide medicamenteuse. Cette prescription peut etre initiee par le professionnel de sante prenant en charge la femme enceinte en debut de grossesse. Il n’y a pas de preuve scientifique pour proposer la cigarette electronique comme aide a l’arret du tabac ; il est recommande d’utiliser des conseils et des methodes de sevrage tabagique deja evaluees. L’utilisation de chicha pendant la grossesse est associee a une diminution de la croissance fœtale, il est recommande de ne pas l’utiliser pendant la grossesse. L’allaitement maternel est possible chez les fumeuses, bien que moins souvent initie par elles. Si ses bienfaits pour le developpement de l’enfant ne sont pas demontres a ce jour, l’allaitement toutefois permet a la mere de limiter son tabagisme. Le risque de rechute du post-partum est eleve (jusqu’a 82 % a 1 an). Les principaux facteurs associes a l’abstinence du post-partum sont l’allaitement maternel, le fait de ne pas avoir de fumeur a la maison, et l’absence de symptomes de depression. Conclusion Le tabagisme pendant la grossesse concerne des centaines de milliers de femmes et leurs enfants par an en France. Il est un probleme de sante publique majeur. Les professionnels de sante doivent se mobiliser pour le reduire voire l’eradiquer.

To evaluate the rate of mid-trimester microbial invasion of the amniotic cavity (MIAC) in asymptomatic women and its association with preterm birth. This is a prospective cohort study of asymptomatic women undergoing mid-trimester amniocentesis for genetic testing between 14 and 24 weeks of gestation. For each participant, a sample of amniotic fluid was incubated in an aerobic and anaerobic facultative culture media and another sample was tested for the presence of specific Mycoplasma species (Ureaplasma urealyticum, Ureaplasma parvum, and Mycoplasma hominis) using quantitative-PCR. Results were not revealed to the participants or their health care providers. All participants were followed until delivery. MIAC was defined by a positive culture or a positive PCR for Mycoplasma species. The primary outcome was a spontaneous preterm birth or preterm premature rupture of membranes before 35 weeks of gestation. We included 812 women at a median gestational age of 16 5/7 (interquartile: 15 6/7–17 4/7) weeks. Twenty-six (3.2%) had a spontaneous delivery before 35 weeks. We observed no case of positive PCR for Mycoplasma species and 4 (0.5%) cases of positive culture that were all considered to be skin contaminants. None of those four cases was associated with preterm birth. Nulliparity, low family income and history of preterm birth were associated with spontaneous delivery before 35 weeks. We found no case of mid-trimester MIAC using a combination of culture and Mycoplasma-specific PCR techniques in a large cohort of low-risk asymptomatic pregnant women. We estimate that mid-trimester MIAC is rare in low-risk population but more sensitive and broad-range microbiologic techniques, such as 16S DNA detection by PCR, could be further evaluated.

International audience

To estimate the optimal midtrimester cervical length (CL) threshold for the prediction of spontaneous preterm birth (sPTB) in asymptomatic pregnant women.This is a prospective observational cohort study including asymptomatic women with singleton pregnancies who underwent CL measurement by transabdominal and/or transvaginal ultrasound between 19°Out of 3,449 participants, 28 (0.8%) had a sPTB before 35 weeks and 99 (2.9%) had a sPTB before 37 weeks. Receiver operating characteristics (ROC) curves suggest that a cut-off of 30 mm was the optimal CL to predict sPTB before 35 weeks (sensitivity: 43%; specificity: 97%) and sPTB before 37 weeks (sensitivity: 21%; specificity: 97%). While a CL25 mm was an important risk factor for sPTB before 35 weeks (relative risk: 31; 95% confidence interval: 13-73), women with a CL between 25 and 30 mm were also at greater risk (relative risk: 12; 95% confidence interval: 4 - 35) compared to women with CL ≥30 mm.A midtrimester CL30 mm should be considered to identify women at high-risk of sPTB.

Resume Objectif Evaluer l’evolution des pratiques dans la prise en charge chirurgicale des prolapsus des organes pelviens au sein d’une equipe traditionnellement « vaginaliste » au cours de la periode 2010–2015, marquee par les recommandations francaises et americaines et l’abandon de la commercialisation des protheses vaginales pionnieres. Methodes Etude retrospective incluant toute patiente operee pour un prolapsus symptomatique concernant au moins les etages anterieurs et/ou moyens au cours des annees civiles 2010 et 2015, independamment du stade de l’affection et du type de reparation employe. Ont ete consideres aussi bien les primo-traitements que les recidives. Resultats Au total 338 patientes ont ete incluses : 187 en 2010 et 151 en 2015. La prise en charge des prolapsus non recidives s’est accompagnee d’une evolution significative des pratiques marquee par l’essor de la promontofixation laparoscopique (11,1 % en 2010 versus 34,4 % en 2015, p = 0,001), au detriment de la chirurgie vaginale autologue (67,6 % en 2010 versus 39 % en 2015, p = 0,001). Le nombre de protheses positionnees par voie vaginale est reste stable (28,7 % en 2010 versus 31,8 % en 2015, p = 0,155) avec toutefois une modification des indications au profit des stades 3 et 4. Aucune difference n’a ete objectivee concernant le traitement du prolapsus recidive. La voie vaginale demeurait l’abord privilegie dans cette indication. Conclusion La periode 2010–2015 a ete marquee par une diversification de l’offre de soins, au travers de l’integration de la promontofixation dans les algorithmes de prise en charge. Cette pluri-potence nous semble primordiale. En effet, la preference de la patiente doit conserver une place preponderante dans le choix de la technique, par dela les ecoles et les phenomenes de mode.

International audience; Background: While phloroglucinol is widely prescribed in European countries for its antispasmodic properties, recent high quality data failed to demonstrate its superiority to placebo in alleviating abdominal pain. Rumors suggest that injectable presentation of phloroglucinol may erase povidone-iodine stains. We thus aimed to evaluate its efficacy in this new indication.Methods: In this double-blind, controlled trial, we randomly assigned 9 squares of fabric obtained from common white coat to receive injectable phloroglucinol (experimental arm), stain remover (active control arm) or water (placebo arm). The primary efficacy endpoint was the change in stain intensity 10 min after the intervention.Results: In placebo and active control arms, povidone-iodine stains remained unchanged 10 min after treatment application. In contrast, the stain disappeared completely in the experimental arm.Conclusion: Injectable phloroglucinol was more effective than usual stain remover and water to remove povidone-iodine stains from white coats.

Resume Objectifs Evaluer la faisabilite et l’impact sur les symptomes et la qualite de vie de la double promontofixation cœlioscopique chez des patientes presentant un prolapsus exteriorise (stade > 3). Methodes Toute patiente incluse dans cette etude prospective presentait un prolapsus de stade POP-Q > 3 traite par double promontofixation cœlioscopique. Les symptomes pelviens et la qualite de vie etaient evalues grâce aux questionnaires valides PFDI-20 et PFIQ-7 en preoperatoire, puis a 1, 4 et 18 mois de la chirurgie. Resultats Entre septembre 2012 et janvier 2014, 63 femmes ont ete incluses. Une hysterectomie sub-totale a ete pratiquee chez 36 % des patientes; 34 % ont beneficie de la pose concomitante d’une bandelette sous-uretrale. Une seule complication peroperatoire a ete relevee (plaie vesicale). Les taux postoperatoires d’incontinence urinaire d’effort de novo et de dyspareunies de novo persistantes a 18 mois etaient respectivement de 10 % et 3 %. Un seul cas de recidive a ete retrouve a 18 mois. Les scores PFDI-20 et PFIQ-7 diminuaient significativement et durablement des le premier mois suivant l’intervention, passant respectivement de 98,8 en preoperatoire a 33,9 a 18 mois ( p p Conclusion Nos resultats confirment la faisabilite et la bonne efficacite anatomique de la promontofixation cœlioscopique dans le traitement du prolapsus exteriorise. Nous rapportons egalement une amelioration franche, rapide et durable de la symptomatologie et de la qualite de vie dans cette categorie de patientes.

Placental Growth Factor (PlGF) is used for the prediction of preeclampsia (PE), a syndrome associated with maternal vascular malperfusion (MVM). Our goal is to determine the correlation between PlGF and MVM.We performed a secondary analysis of the PEARL study that included nulliparous women with PE (cases), and low-risk nulliparous women recruited in early pregnancy (controls). All participants provided blood samples at diagnosis of PE (cases), or between 26 and 34 weeks (controls) for measurement of PlGF (B·R·A·H·M·S plus KRYPTOR automated assays), that was transformed into multiple of median (MoM). Placental examination was performed for the diagnosis of MVM based on the Amsterdam Placental Workshop Group Consensus Statement. Nonparametric tests and receiver operating characteristic (ROC) curves were used to compare PlGF in pregnancies with, and without PE, stratified by the presence of MVM.Third trimester PlGF was lower in PE cases with MVM (N = 20; median: 0.04 MoM; interquartile: 0.03-0.09; p0.0001), and in controls with MVM (N = 4; 0.30MoM; 0.07-0.52; p = 0.002) compared to controls without MVM (N = 29; 0.99 MoM; 0.67-1.52). PlGF in PE cases without MVM (N = 5; 0.18 MoM; 0.17-1.64) was not significantly different than in controls without MVM but the sample size was small. ROC curve demonstrated a greater predictability of PlGF for PE with MVM than PE without MVM (AUC: 0.99 vs. 0.38; p0.0001).Third trimester PlGF is a better predictor of PE associated with MVM than a predictor of PE without MVM. We hypothesize that PlGF is a stronger marker of MVM than PE.

Identify a group with a high risk of postoperative complications after deep bowel endometriosis surgery. We conducted a retrospective study on patients treated from 2012 to 2018 in two departments of gynecological surgery at the Toulouse University Hospital, France. The postoperative complications were evaluated in relation to the surgical management, associated with or without non-digestive surgical procedures, initial disease and patient's characteristics. 164 patients were included. A postoperative complication occurred in 37.8% (n = 62) of the cases and required a secondary surgery in 18.3% (n = 30) of the cases. In the univariate analysis, the risk of postoperative complications increased significantly in the presence of segmental resection, disease progression, and associated urinary tract procedure or vaginal incision. In the multivariate analysis, the risk of overall postoperative complications was associated with the surgical management (p = 0.013 and 0.017) and particularly in the presence of segmental resection [Odds Ratio (OR): 20.87; CI 95% (1.96–221.79)]. The risk of rectovaginal fistula increased in the presence of segmental resection [OR: 22.71; CI 95% (2.74–188.01)] as well as in vaginal incision [OR: 19.67; CI 95% (2.43–159.18); p = 0.005]. The risk of overall postoperative complications and rectovaginal fistula in particular increases significantly in the presence of vaginal incision, segmental resection and urinary tract procedures after deep bowel endometriosis surgery.

International audience; OBJECTIVE:HELLP syndrome exposes to severe maternal and fetal complications. Prompt delivery is thus recommended after 34 weeks of gestation, or earlier in case of nonreassuring maternofetal conditions. However, no consensus has been raised in the treatment of HELLP syndrome occurring before 34 weeks of gestation, when both maternal and fetal conditions are stable: it remains still unclear whether an active attitude should be prioritized over expectant management. Herein, we aimed to compare mother and child outcomes according to the type of obstetrical management, either active or conservative.STUDY DESIGN:Retrospective and multicenter study involving two tertiary care units. In Center A, obstetrical attitude consisted in expectant management: all women received full antenatal betamethasone therapy and pregnancy was prolonged until maternal or fetal follow up indicated delivery. In Center B, management was active: all deliveries were initiated within 48 hours following diagnosis.RESULTS:From 2003 to 2011, 118 patients were included (87 in Center A, 31 in Center B). Both groups of patients were similar regarding maternal and fetal features at baseline. Active management led to increased risks of post-partum hemorrhage (relative risks (RR) = 5.38, 95%CI: 1.2-24.06) and neonatal morbidity including respiratory distress syndrome (RR = 3.1, 95%CI: 1.4-7.1), sepsis (RR = 2.5, 95%CI: 1.1-6.0), necrotizing enterocolitis (RR = 4.8, 95%CI: 1.1-21.2), intracerebral hemorrhage (RR = 5.4, 95%CI: 2.1-13.6), and blood transfusion (RR = 6.1, 95%CI: 1.7-21.7).CONCLUSIONS:Conservative management may be beneficial for both mother and newborn in patients with stable HELLP syndrome. Identification of maternal and fetal specific prognostic factors would allow a better stratification of women with HELLP syndrome according to illness progressive potential, resulting in a more personalized management.