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Premature placental senescence is a hallmark of pregnancy-related disorders such as intrauterine growth restriction (IUGR) and preeclampsia (PE), two major cause of maternal and neonatal morbidity and mortality. Oxidative stress and lipid peroxidation are involved in the pathogenesis of PE and IUGR, and may play a role in placental aging. In this study, we investigated whether 4-hydroxy-2-nonenal (HNE), a lipid peroxidation-derived aldehyde present in preeclamptic placentas, may contribute to premature senescence in placenta-related complications. Placentas from PE-affected women, exhibited several senescence patterns, such as an increased expression of phosphorylated (serine-139) histone γH2AX, a sensitive marker of double-stranded DNA breaks, the presence of lipofuscin granules, and an accumulation of high molecular weight cross-linked and ubiquitinated proteins. PE placentas showed an accumulation of acetylated proteins consistent with the presence of HNE-adducts on sirtuin 1 (SIRT1). Likewise, oxidative stress and senescence markers together with SIRT1 modification by HNE, were observed in murine placentas from mice treated with lipopolysaccharide during gestation and used as models of IUGR. The addition of HNE and ONE (4-oxo-2-nonenal), to cultured HTR-8/SVneo human trophoblasts activated the senescence-associated- β-galactosidase, and generated an accumulation of acetylated proteins, consistent with a modification of SIRT1 by HNE. Altogether, these data emphasize the role of HNE and lipid peroxidation-derived aldehydes in premature placental senescence in PE and IUGR, and more generally in pathological pregnancies., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Prolonged pregnancies are a frequent indication for induction of labour. When the cervix is unfavourable, cervical ripening before oxytocin administration is recommended to increase the likelihood of vaginal delivery, but no particular method is currently recommended for cervical ripening of prolonged pregnancies. This trial evaluates whether the use of mechanical cervical ripening with a silicone double balloon catheter for induction of labour in prolonged pregnancies reduces the cesarean section rate for nonreassuring fetal status compared with pharmacological cervical ripening by a vaginal pessary for the slow release of dinoprostone (prostaglandin E2)., Methods and Findings: This is a multicentre, superiority, open-label, parallel-group, randomised controlled trial conducted in 15 French maternity units. Women with singleton pregnancies, a vertex presentation, ≥41+0 and ≤42+0 weeks' gestation, a Bishop score <6, intact membranes, and no history of cesarean delivery for whom induction of labour was decided were randomised to either mechanical cervical ripening with a Cook Cervical Ripening Balloon or pharmacological cervical ripening by a Propess vaginal pessary serving as a prostaglandin E2 slow-release system. The primary outcome was the rate of cesarean for nonreassuring fetal status, with an independent endpoint adjudication committee determining whether the fetal heart rate was nonreassuring. Secondary outcomes included delivery (time from cervical ripening to delivery, number of patients requiring analgesics), maternal and neonatal outcomes. Between January 2017 and December 2018, 1,220 women were randomised in a 1:1 ratio, 610 allocated to a silicone double balloon catheter, and 610 to the Propess vaginal pessary for the slow release of dinoprostone. The mean age of women was 31 years old, and 80% of them were of white ethnicity. The cesarean rates for nonreassuring fetal status were 5.8% (35/607) in the mechanical ripening group and 5.3% (32/609) in the pharmacological ripening group (proportion difference: 0.5%; 95% confidence interval (CI) -2.1% to 3.1%, p = 0.70). Time from cervical ripening to delivery was shorter in the pharmacological ripening group (23 hours versus 32 hours, median difference 6.5 95% CI 5.0 to 7.9, p < 0.001), and fewer women required analgesics in the mechanical ripening group (27.5% versus 35.4%, difference in proportion -7.9%, 95% CI -13.2% to -2.7%, p = 0.003). There were no statistically significant differences between the 2 groups for other delivery, maternal, and neonatal outcomes. A limitation was a low observed rate of cesarean section., Conclusions: In this study, we observed no difference in the rates of cesarean deliveries for nonreassuring fetal status between mechanical ripening with a silicone double balloon catheter and pharmacological cervical ripening with a pessary for the slow release of dinoprostone., Trial Registration: ClinicalTrials.gov NCT02907060., Competing Interests: The authors have declared that no competing interests exist.

Objective: To determine the optimal management of singleton fetuses in breech presentation., Materials and Methods: Consultation of the PubMed database, the Cochrane Library and guidelines issued by the French and foreign obstetrical societies or colleges., Results: In France, 5% of women have breech deliveries (level of evidence [LE] 3). One third of them have a planned vaginal delivery (LE3), and 70% of these give birth vaginally (LE3). External cephalic version (ECV) is associated with lower rates of both breech presentation at birth (LE2) and of cesarean deliveries (LE3) without any increase in severe maternal (LE3) or perinatal morbidity (LE3). Women with a fetus in breech presentation at term should be informed that ECV can be attempted starting at 36 weeks of gestation (professional consensus). Planned vaginal delivery of breech presentation may be associated with a higher risk of composite perinatal mortality or serious neonatal morbidity than planned cesarean birth (LE2). These two modes do not differ for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), or adult intellectual performance (LE4). Short- and long-term maternal complications appear similar in the two groups, unless subsequent pregnancies are under consideration. Pregnancies after a cesarean delivery are at higher risk of uterine rupture, placenta accreta spectrum disorders, and hysterectomy (LE2). Women who want a planned vaginal delivery should be offered a pelvimetry at term (Grade C) and should have ultrasonography to verify that the fetal head is not hyperextended (professional consensus) to plan their mode of delivery. Complete breech presentation, a previous cesarean, nulliparity, and term prelabor rupture of membranes are not, each one by itself, per se contraindications to planned vaginal delivery (professional consensus). Term breech presentation is not a contraindication to labor induction when the criteria for planned vaginal delivery are met (Grade C)., Conclusion: In cases of breech presentation at term, the child and the mother are at low risk of severe morbidity after either planned vaginal or planned cesarean delivery. The French College of Obstetricians and Gynecologists (CNGOF) considers that planned vaginal delivery is a reasonable option in most cases (professional consensus). The decision about the planned route of delivery should be shared by the woman and her healthcare provider, who must respect her right to autonomy., Competing Interests: Declaration of Competing Interest LS was a board member and carried out consultancy work and lectured for Ferring. The other authors report no conflict of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Fetal bladder rupture causing urinary ascites is uncommon. It is generally related to invasive fetal medicine procedures or obstructive disorders such as in posterior urethral valves in male fetuses. An exceptional case of spontaneous bladder rupture in a female fetus occurred in a pregnant woman treated with high doses of opiates in an intensive care unit. This unusual obstetric situation leads to discussion of the possible causes of fetal bladder rupture, its management, and the pediatric prognosis., Case Presentation: We report the case of a 30-year-old nulliparous black woman with a history of mesenteric cystic lymphangioma and multiple bowel resections leading to chronic malabsorption. During her pregnancy, our patient presented with an occlusive syndrome and major bilateral renal dilation. Urinary derivation resulted in iatrogenic bilateral ureteral perforation. Our patient thus presented with major uroperitoneum, bilateral pleural effusion and acute renal failure, treated by thoracic drainage and bilateral nephrostomy. Postoperative pain required treatment with level III analgesics. In this context, 5 days after morphine treatment introduction an enlarged fetal bladder was observed, followed 3 days later by voluminous fetal ascites. The diagnosis of spontaneous bladder rupture was suspected. After multidisciplinary discussion, expectant management was decided. At 31 weeks and 4 days gestation, our patient went into spontaneous labor with a subsequent vaginal delivery. The infant required resuscitation and paracentesis of ascites at birth. Her neonatal course was favorable with a simple urethral bladder drainage. Cystography at day 9 was normal. At 2 years of follow-up, the mother and the child have a normal course., Conclusions: An iatrogenic origin of megacystis in a female fetus must be evoked in the event of maternal administration of high doses of opiates in the second part of her pregnancy. In our case, the megacystis was followed by spontaneous bladder rupture at 30 weeks of gestation, with a favorable maternal fetal issue.

Objective: To compare neonatal mortality and morbidity of first twins according to the planned mode of delivery when the first twin is in breech presentation, in a country where planned vaginal delivery is an option., Methods: This is a planned secondary analysis of the JUMODA (JUmeaux MODe d'Accouchement) cohort, a national prospective population-based study of twin deliveries conducted in 176 French hospitals. We analyzed pregnancies with first twins in breech presentation and applied the inclusion criteria of the Twin Birth Study (except the criterion for first-twin presentation): both fetuses alive, with a birth weight between 1,500 g and 4,000 g, at or after 32 0/7 weeks of gestation. The primary outcome was a composite of neonatal mortality and morbidity. We used multivariate Poisson regression models to control for potential confounders and propensity score analyses, that is, matching and inverse probability of treatment weighting to control for indication bias., Results: Among the 1,467 women with a breech-presenting first twin included in this analysis, 1,169 (79.7%) had planned cesarean and 298 (20.3%) planned vaginal births, of whom 185 (62.1%) delivered both twins vaginally. The neonatal mortality and severe morbidity rate for first twins was 1.7% (5/298) in the planned vaginal and 1.9% (22/1,169) in the planned cesarean delivery groups (crude relative risk [RR] 0.90, 95% CI 0.34-2.34). Planned vaginal delivery was not associated with higher neonatal mortality and morbidity than planned cesarean delivery, regardless of the statistical method used: adjusted RR 0.71, 95% CI 0.27-1.86; RR 0.61, 95% CI 0.20-1.83 after matching for propensity score; RR 0.63, 95% CI 0.23-1.74 with inverse probability of treatment weighting. Analyses of neonatal mortality and morbidity of second twins yielded similar results., Conclusion: Although our sample size precluded a robust assessment for small differences in outcomes between planned cesarean and planned vaginal delivery in twin pregnancies in which the first twin was in breech presentation, in our cohort planned vaginal delivery was not associated with higher neonatal mortality and morbidity for either twin.

For the past decades, growing attention has been given to aspirin use during pregnancy. It favors placentation by its proangiogenic, antithrombotic, and anti-inflammatory effects. Therefore, low doses of aspirin are prescribed in the prevention of placenta-mediated complications, mainly preeclampsia and fetal growth restriction. However, questions regarding its clinical application are still debated. Aspirin is effective in preventing preeclampsia in a high-risk population. Most guidelines recommend that risk stratification should rely on medical history. Nevertheless, screening performances dramatically improve if biochemical and biophysical markers are included. Concerning the appropriate timing and dose, latest studies suggest aspirin should be started before 16 weeks of pregnancy and at a daily dose of 100 mg or more. Further studies are needed to improve the identification of patients likely to benefit from prophylactic aspirin. Besides, the role of aspirin in the prevention of fetal growth restriction is still questioned., (© 2020 John Wiley & Sons, Ltd.)

Objectives: To issue guidelines on management of labour induction and breech vaginal delivery., Materials and Methods: Bibliographic search restricted to French and English languages using Medline database®, Cochrane Library and international guidelines of medical societies., Results: Breech delivery must take place in a maternity ward, in the presence of an obstetrician and gynaecologist and with the immediate availability of an anesthesiologist and a pediatrician during active second stage (Professional consensus). Term breech is not a contraindication to labour induction when the criteria for acceptance of vaginal delivery are met (Grade C). In this case, oxytocin or prostaglandins can be used (Grade C). Epidural analgesia with low concentrations of local anesthetics should be encouraged in case of vaginal delivery attempt (Professional consensus). It is recommended to use continuous monitoring of the CTG (Professional consensus). The use of second-line fetal monitoring is not recommended (Professional consensus). The administration of oxytocin is possible for labour augmentation (Professional consensus). It is better to start the expulsive efforts when the presentation is engaged as low as possible in the pelvic excavation (Professional consensus). Breech presentation is not an indication of episiotomy (Professional consensus). Due to insufficient data, it was not possible to make recommendations on specificities of preterm breech delivery., Conclusion: In case of planned vaginal delivery, labour induction is possible for term breech fetuses, even with unfarable cervix. Guidelines for labour and vaginal delivery management have a low level of evidence., (Copyright © 2019. Published by Elsevier Masson SAS.)

Objective: To evaluate the use of new bipolar vessel sealing system like LigaSure™ compared to the standard surgical technique (suture) during emergency peripartum hysterectomy (EPH)., Methods: A retrospective observational bicentric study was conducted from February 2005 to August 2018 in the maternity wards of the University Hospital of Toulouse and Angers. All EPHs performed up to 24 h after delivery were included. The main outcome was the total blood loss. Secondary outcomes were operating time, number of blood transfusions, per and postoperative complications. A subgroup analysis was performed between hysterectomies performed in emergency and scheduled hysterectomies., Results: Among 111,266 deliveries, 86 women (0.07%) underwent EPH, 29 were operated upon with LigaSure™, 57 with the traditional technique. In the LigaSure™ arm, there were statistically lower blood loss (3198 mL vs 4223 mL, p = 0.02), fewer blood transfusions (62.1% vs 94.7%, p = 0.0003, confirmed in subgroup analysis), and fewer perioperative complications (8.3% vs 45.5%, p = 0.04) for scheduled hysterectomies., Conclusion: Bipolar vessel sealing systems such as LigaSure™ are a surgical instrument, easy to use for the surgeon, with an interest in the management of EPH, particularly for total blood loss, transfusions, and intraoperative complications.

Objectives: To determine the optimal management of singleton breech presentation., Materials and Methods: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted., Results: In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long term maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies. A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy (LE2). It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term (Grade C) and to check the absence of hyperextension of the fetal head by ultrasonography (Professional consensus) to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery (Professionnal consensus). Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met (Grade C)., Conclusion: In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Preeclampsia (PE) is a leading cause of pregnancy complications, affecting 3-7% of pregnant women worldwide. The pathophysiology of preeclampsia involves a redox imbalance, oxidative stress and a reduced nitric oxide (NO) bioavailability. The molecular and cellular mechanisms leading to the dysfunction of the placental endothelial NO synthase (eNOS) are not clarified. This study was designed to investigate whether aldehydes generated by lipid peroxidation products (LPP), may contribute to placental eNOS dysfunction in PE. The analysis of placentas from PE-affected patients and normal pregnancies, showed a significant increase in protein carbonyl content, indicative of oxidative stress-induced protein modification, as shown by the accumulation of acrolein, 4-hydroxynonenal (HNE), and 4-oxo-2(E)-nonenal (ONE) adducts in PE placentas. In contrast, the levels of these LPP-adducts were low in placentas from normal pregnancies. Immunofluorescence and confocal experiments pointed out a colocalization of eNOS with ONE-Lys adducts, whereas eNOS was not modified in normal placentas. LC-MS/MS analysis of recombinant eNOS preincubated with ONE, allowed to identify several ONE-modified Lys-containing peptides, confirming that eNOS may undergo post-translational modification by LPP. The preincubation of HTR-8/SVneo human trophoblasts (HTR8) with ONE, resulted in ONE-Lys modification of eNOS and a reduced generation of NO. ONE inhibited the migration of HTR8 trophoblasts in the wound closure model, and this was partly restored by the NO donor, NOC-18, which confirmed the important role of NO in the invasive potential of trophoblasts. In conclusion, placental eNOS is modified by ONE in PE placentas, which emphasizes the sensitivity of this protein to oxidative stress in the disturbed redox environment of preeclamptic pregnancies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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.

Purpose: To evaluate spatulas for entrapment of the after-coming head (EAH) during vaginal breech delivery, in the setting of failed usual manoeuvres (Bracht or Mauriceau)., Methods: We led a retrospective cohort study in two tertiary referral hospital in France. From 2003 to 2018, we included all deliveries of live children requiring the use of spatulas (Thierry's and Teissier's) for EAH during vaginal breech delivery., Results: Over the period, 59 breech deliveries with spatulas for EAH were enrolled (prevalence 2.3%). No vaginal delivery failures were found. The average term was 36 weeks of gestation. Mean maternal age was 29.4 years and median parity was 1. 50.8% of the foetuses presented as complete breech, 40.7% as frank breech, and 8.5% as footling breech. Maternal morbidity was low: no obstetrical lesions of the anal sphincter, 28% episiotomy (performed before application of instruments in most cases). There was no evidence of foetal over-morbidity. The average weight of the foetuses was 2635g. There was no serious trauma associated with the use of spatulas: only one case of skin lesion and a case of non-severe cephalhematoma could be attributed to the instrument. Mean arterial pH was 7.19, the median 5-min Apgar score was 10., Conclusion: In compliance with obstetrical mechanics, spatulas should be considered as an effective instrument during EAH with maternal and foetal safety. This is the first cohort describing the use of an instrument to manage EAH during vaginal breech delivery, while knowledge and mastery of this technique are essential to manage this situation.

Background: The denial of pregnancy is the non-recognition of the state of the current pregnancy by a pregnant woman. It lasts for a few months or for the whole pregnancy, with generally few physical transformations. In this study, we will consider the denial of pregnancy as a late declaration of pregnancy (beyond 20 weeks of gestation) as well as a lack of objective perceptions of this pregnancy. The main objective of this study is to explore the relationship between pregnancy denial and the development of the infant (attachment pattern of the infant, early interactions of mother-infant dyads, and early development of the infant)., Methods: The design is a case-control prospective study, which will compare two groups of mother-infant dyads: a "case" group with maternal denials of pregnancy and a "control" group without denials of pregnancy. A total of 140 dyads (mother + infant) will be included in this study (70 cases and 70 controls) and followed for 18 months. The setting is a national recruitment setting with 10 centers distributed all over France. The follow-up of the "cases" and the "controls" will be identical and will occur over 5 visits. It will include measures of the infant attachment pattern, the quality of early mother-infant interaction and infant development., Discussion: This study aims to examine the pathogenesis of pregnancy denial as well as its consequences on early infant development and early mother-infant interaction., Trial Registration: Clinical Trial Number: NCT02867579 on the date of 16 August 2016 (retrospectively registered).

Decreased nitric oxide (NO) bioavailability plays a critical role in the pathophysiology of preeclampsia (PE). Recent evidence indicates that S-glutathionylation may occur on the endothelial nitric oxide synthase (eNOS), leading to eNOS uncoupling, characterized by a decreased NO production and an increased generation of superoxide anion (O 2 •- (O 2 (O 2 changes (O 2 changes (O 2 1-20%), in order to generate oxidative stress. Trophoblasts exposed to low pO 2 , did not undergo oxidative stress nor eNOS S-glutathionylation, and were able to generate NO and migrate in a wound closure model. In contrast, trophoblasts submitted to low/high pO 2 changes, exhibited oxidative stress and a (DTT reversible) S-glutathionylation of eNOS, associated with reduced NO production and migration. The autonomous production of NO seemed necessary for the migratory potential of HTR8, as suggested by the inhibitory effect of eNOS silencing by small interfering RNAs, and the eNOS inhibitor L-NAME, in low pO 2 conditions. Finally, the addition of the NO donor, NOC-18 (5 µM), restored in part the migration of HTR8, thereby emphasizing the role of NO in trophoblast homeostasis. In conclusion, the high level of eNOS S-glutathionylation in PE placentas provides new insights in the mechanism of eNOS dysfunction in this disease., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: We aimed to assess the prognostic significance of early βhCG change and baseline progesterone level on treatment outcome among women receiving single dose Methotrexate protocol for tubal ectopic pregnancy (EP)., Material and Methods: Retrospective study involving all consecutive patients diagnosed with EP and receiving Methotrexate therapy form January 2015 to December 2016. Patients were stratified into 2 groups according to treatment outcome: success group (n = 66) involved women who displayed complete resolution of serum βhCG levels following a single course of Methotrexate; failure group (n = 55) included patients who required repeated Methotrexate administration and/or surgical management. Predictive performances of baseline progesterone and ratio"βhCG level on day 4/ βhCG level on day 1″ (d 4 /d 1 ) on treatment outcome were assessed using Receiving Operating Characteristics curves., Results: The ratio d 4 /d 1 displayed good performances in predicting treatment outcome (AUC = 0.826). A ratio ≤ 0.7 was associated with a success rate of 94% after 1 course of Methotrexate and 100% after 2 courses. In contrast, a ratio >1.7 was associated with a failure rate of 100%. Conversely, baseline progesterone showed poor performances (AUC = 0.611)., Conclusions: Patients with extreme βhCG changes (n = 33) on day 4 might benefit from a more personalized approach: simplified monitoring in those with a decline ≥30%, anticipated second course of treatment in those with an increase > 70%.

Objective: This study aimed to assess the application of the French guidelines for pregnancies in Turner syndrome (TS) and their impact on perinatal prognosis., Study Design: We performed a French multi-center retrospective study (14 centers), including TS pregnant patients (spontaneously or by Assisted Reproductive Technology (ART)) between January 2006 and July 2017. Only clinical pregnancies were analyzed. The adjustment of medical follow-up modalities to French guidelines was evaluated for all pregnancies after 2009. Pregnancies from oocyte donation (OD) after 2009 were compared to those of a cohort of TS pregnancies obtained by OD before 2009, which were reported by the French Study Group for Oocyte Donation., Results: One hundred seventy pregnancies in 103 patients were included: 35 spontaneous, 5 by means of intra-conjugal ART, and 130 with OD. No serious maternal complications were observed. We reported two stillbirths and one intra uterine fetal death. The French guidelines were partially respected. The preconceptional assessment was carried out in 74% of cases. Cardiology follow-up during pregnancy was performed in accordance with guidelines in 74% of patients. Postpartum cardiac ultrasonography was performed in 45% of pregnancies but only in 11% within 8 days post-partum. When compared to the 2009 historical cohort, the rates of high blood pressure (19% vs. 38%; p < 0.005) pre-eclampsia (8% vs. 21%; p < 0.005) and prematurity <35 weeks (15% vs 38%; p < 0.0001) were lower., Conclusions: The implementation of guidelines has allowed the standardization of TS pregnancy care and improved perinatal indicators for both mothers and children. However, an effort must be done, in a postpartum survey., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: To determine whether the 2011 FDA alert and French Guidelines have impacted the routine surgical practice in the management of pelvic organ prolapse in a "vaginalist" team over the period 2010-2015., Methods: Retrospective study involving all patients undergoing surgical management of anterior and/or apical symptomatic pelvic organ prolapse during the civil years 2010 and 2015. Both naive and relapsed prolapses were eligible., Results: Overall, 338 patients were included: 187 in 2010 and 151 in 2015. Among patients with naive prolapse, we observed a significant increase in the number of laparoscopic sacrocolpopexies (11.1% in 2010 versus 34.4% in 2015, P=0.001) and a significant decline in the use of native tissue repair (67.6% in 2010 versus 39% in 2015, P=0.001). While the number of transvaginal meshes did not decline over the study period, their indications displayed a significant evolution towards a restricted use to advanced stages. We did not observe any difference regarding the treatment of recurred pelvic organ prolapse. Vaginal route remained the preferred approach in this indication., Conclusion: In our "vaginalist" team, routine practice has significantly evolved over the period 2010-2015, resulting in a diversification of the healthcare offer. This paradigm shift towards pluripotency is mandatory, since patients' preference should also drive the choice of both surgical route and technique., (Copyright © 2018. Published by Elsevier Masson SAS.)

Purpose: To compare the short- and long-term perineal consequences (at 6 months postpartum) and short-term neonatal consequences of instrumental rotation (IR) to those induced by assisted delivery (AD) in the occiput posterior (OP) position, in case of manual rotation failure., Methods: A prospective observational cohort study; tertiary referral hospital including all women presenting with persistent OP position who delivered vaginally after manual rotation failure with attempted IR or AD in OP position from September 2015 to October 2016. Maternal and neonatal outcomes of all attempted IR deliveries were compared with OP operative vaginal deliveries. Main outcomes measured were pelvic floor function at 6 months postpartum including Wexner score for anal incontinence and ICIQ-FLUTS for urinary symptoms. Perineal morbidity comprised severe perineal tears, corresponding to third and fourth degree lacerations. Fetal morbidity parameters comprised low neonatal Apgar scores, acidaemia, major and minor fetal injuries and neonatal intensive care unit admissions., Results: Among 5265 women, 495 presented with persistent OP positions (9.4%) and 111 delivered after manual rotation failure followed by AD delivery: 58 in the IR group and 53 in the AD in OP group. The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.7% vs. 24.5%; p < 0.001) without increasing neonatal morbidity. At 6 months postpartum, AD in OP position was associated with higher rate of anal incontinence (30% vs. 5.5%, p = 0.001) and with more urinary symptoms, dyspareunia and perineal pain., Conclusions: OP operative deliveries are associated with significant perineal morbidity and pelvic floor dysfunction at 6 months postpartum.

Introduction: To compare the maternal and neonatal outcomes associated with Instrumental Rotation (IR) to operative vaginal delivery in occiput posterior (OP) position with Thierry's spatulas (TS), in the setting of failed manual rotation (MR)., Study Design: We led a prospective observational cohort study in a tertiary referral hospital in Toulouse, France. All women presenting in labor with persistent OP position at full cervical dilatation and who delivered vaginally after failed MR and with IR or OP assisted delivery were included from January 2014 to December 2015. The main outcomes measured were maternal morbidity parameters including episiotomy rate, incidence and severity of perineal lacerations, perineal hematomas and postpartum hemorrhage. Severe perineal tears corresponded to third and fourth degree lacerations. Fetal morbidity outcomes comprised neonatal Apgar scores, acidemia, fetal injuries, birth trauma and neonatal intensive care unit admissions., Results: Among 9762 women, 910 (9.3%) presented with persistent OP position at full cervical dilatation and 222 deliveries were enrolled. Of 111 attempted IR, 97 were successful (87.4%). The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.8% vs. 12.6%; p < 0.002). Both groups were similar regarding most fetal outcomes and no birth trauma occurred in our study population. In a multivariable logistic regression analysis, OP operative delivery was a significant risk factor of severe perineal lacerations (OR = 9.5; 95% CI: 2.05-44.05)., Conclusion: Our results support the use of IR in order to reduce perineal morbidity associated with OP assisted delivery, in the setting of a failed manual rotation.

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

Background: The diagnosis of gestational diabetes mellitus (GDM) usually requires an oral glucose tolerance test, but this procedure seems inappropriate after gastric bypass surgery (Roux-en-Y gastric bypass (RYGB)) due to specific altered glycemic responses. We aimed here at describing continuous glucose monitoring (CGM) profile of pregnant women after RYGB., Methods: CGM was performed in 35 consecutive pregnant women after RYGB at 26.2 ± 5 weeks of gestation., Results: After RYGB, pregnant women display high postprandial interstitial glucose (IG) peaks and low IG before and 2 h after meals. The postprandial IG peak is reached early, within 54 ± 9 min. The maximum IG values reach 205 mg/dl, and the percentage of time above 140 mg/dl (6.6 ± 7 %) is similar to what is described in GDM women., Conclusions: This study is the first to describe CGM profile in pregnant women after RYGB. CGM features are similar to those of non-pregnant post-RYGB patients, characterized by wide and rapid changes in postprandial IG, and high exposure to hyperglycemia. The exposure to hyperglycemia is similar to what is reported in GDM although the time to postprandial peak is shorter. CGM could be an additional useful approach to screen for glucose intolerance during pregnancy after RYGB.

Objectives: To describe the characteristics of the management of pregnancy and child birth in women with spinal cord injury., Materials and Methods: Retrospective cohort study including paraplegics patients with motor deficit (whatever the etiology) who gave birth at the University Hospital of Toulouse between March 2003 and March 2014 (11 years). Monitoring and outcome of pregnancy were studied., Results: Seventeen deliveries (15 patients) were performed on a total of 46,888 in the studied period (prevalence=0.4‰). All patients had urinary tract infections: lower urinary tract (100%), recurrent cystitis (75%), pyelonephritis (31.3%). One patient (6.3%) presented dysautonomia during pregnancy. The cesarean rate was 47% (the indication was in any case an obstetrical reason). Among vaginal deliveries, four (44%) required an instrumental extraction. Epidural analgesia was the method of choice in the absence of contraindication., Conclusion: Pregnancy associated with spinal cord injury requires a multidisciplinary approach. Autonomic hyperreflexia syndrome must be known and can be avoided by epidural analgesia in early labor. Vaginal delivery should be the rule., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patient's hemodynamic condition so allows (professional consensus)., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Problem: Platelet reactivity has not been evaluated in integrated functional testing during normal pregnancy. Here, we analysed platelet functions under arterial shear rate in comparison with static conditions., Method of Study: Thirty pregnant women with uncomplicated pregnancies and 30 healthy non-pregnant women were enrolled in this study. Platelet adhesion to collagen and fibrinogen and subsequent thrombus formation were measured at arterial shear rate in whole blood using a microfluidic and imaging system. Standard light transmission aggregometry, flow cytometry of activation markers in washed platelets and impedance aggregometry in whole blood were also used to assess platelet responsiveness in static conditions., Results: Compared to non-pregnant controls, thrombus formation on collagen fibres and firm platelet adhesion on fibrinogen under arterial shear rate were significantly reduced in pregnant women. Platelet aggregometry assays in suspension showed a slight increase in platelet reactivity in pregnant women., Conclusion: While platelet aggregometry and platelet activation markers in static conditions show little changes in platelet reactivity, monitoring of platelet adhesion and thrombus growth on collagen or fibrinogen under flow condition in whole blood indicates a significant decrease in pregnant women compared to controls. This decrease might contribute to counteract a hypercoagulable state and to reduce the risk of arterial thrombosis., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Preeclampsia is a leading cause of pregnancy complications and affects 3-7% of pregnant women. Pathophysiology of preeclampsia is still unclear. According to the two-stage model of preeclampsia, the abnormal and hypoperfused placenta (stage 1) releases factors to the bloodstream, which are responsible for the maternal symptoms (stage 2), characterised by a systemic inflammation and endothelial dysfunction. Oxidative stress plays an important role in the pathophysiology of the preeclampsia and could be the common denominator between the two. This review summarizes the current knowledge of a new potential etiology of the disease, with a special focus on oxidative stress. We also review the different factors that have been proposed to cause endothelial cell dysfunction in preeclampsia, and trials investigating the role of antioxidant supplementation in preeclampsia., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

The authors report an uncommon case of a pregnant woman with Turner syndrome (TS) whose pregnancy (with favorable outcome) was complicated by a pemphigoid gestationis in third trimester. This case points out that monitoring of these pregnancies is not limited to cardiac monitoring. Prevalence of auto-immune diseases is increased in the TS. Auto-immune dermatoses, such as pemphigoid gestationis, are one of the potential complications during pregnancy and should be known to practitioners., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: Calcium channel blockers (CCB) are routinely off-label used for tocolysis. The purpose of this study is to establish an inventory of the use of CCB for tocolysis in France and abroad., Materials and Methods: Four complementary approaches were performed: (i) a literature review of clinical practice and guidelines of scientific societies; (ii) a national declarative practice survey among French tertiary care centers; (iii) a regional declarative practice survey among all maternities of the Midi-Pyrénées Perinatal Network (MATERMIP); (iv) an evaluation of outpatient tocolysis prescription, analyzing the departmental database EFEMERIS in order to examine drug prescribing during pregnancy., Results: CCB appear to be currently used as first-line, initial tocolysis, in the majority of French maternity hospitals (82.5% of tertiary care centers). Oral Nifedipine is the predominant regimen (86%). CCB utilization rates appear higher than those reported in 2005 in the EVAPRIMA study. Beta-agonists appear rarely prescribed in 1st line (poor maternal tolerance) and even abandoned by many institutions (75% of tertiary care centers). Using a maintenance tocolysis (usually by long-acting CCB) seems to vary depending on the hospitals. It would be prescribed in more than 50% of cases (and probably more in type 1 or 2 hospitals), despite the lack of demonstrated benefit. Furthermore, we can estimate that about 1.5 to 2% of outpatient pregnant women receive a prescription of Nifedipine LP in France., Conclusion: CCB (especially Nifedipine) are widely used in the treatment of threatened preterm labor in France, regardless of the type of hospital. The terms of off-label prescribing are not met., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Introduction: Pregnancy and the postpartum periods are particular for the mother's use of drugs. Therapeutic prescription must take into account the potential risk of fetal malformation, newborn's withdrawal syndrome, feeding type and potential risk of untreated maternal mental illness. Recommendations for good practice are constantly remodeling and their conclusions are sometimes contradictory., Method: The aim of this work is to develop an updated review, easy to use for any professional involved in the monitoring or prescription of a psychotropic medication (antidepressants, anxiolytics-hypnotics, neuroleptics, mood stabilizers and substitution treatment of opioid dependance) for pregnant or nursing women., Results: These updates in tabular form are also based on our clinical experience as a team specializing in perinatal medicine., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: The aim of this study was to evaluate the modalities of induction of labour in twin pregnancies compared with singleton pregnancies and to identify risk factors for failure., Materials Et Methods: A retrospective population-based study was conducted at the Toulouse University Hospital to compare a cohort of diamniotic twin gestations (Twin A in vertex presentation), with induction of labour ≥36 weeks of gestation, between January 2007 and December 2012, to a singleton's cohort that were induced ≥36 weeks of gestation during the 2007 year. One singleton pregnancy was matched for each twin pregnancy with parity and gestational age., Results: One hundred and fifty-six twins pregnancies met the inclusion criteria for an induction of labor and were compared to 156 single pregnancies. The same and standard protocol of induction of labor was used for the two cohorts (intrauterine balloon catheter±dinoprostone/ocytocine). The cesarean section rate for failed labor induction (cesarean in latent phase) was similar in the 2 populations (14.7% for twin vs 13.5% for single; P=0.66). The factors associated to failed induction of labor in the total population were nulliparity (OR=1.49) and Bishop score<6 at the beginning of the induction (OR=2.83)., Conclusion: Twin did not appear as risk of failed induction. The protocol for induction of labor in singletons may be safely proposed to twin gestations., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: To describe the characteristics of post-partum hemorrhage (PPH) associated with cesarean section (CS), the modalities diagnosis and specific obstetric and anesthetic management., Materials and Methods: Bibliographic search restricted to French and English languages using Medline database(®) and international guidelines of medical societies., Results: Primary PPH associated with CS (incidence 3-15%) is defined as vaginal bleeding ≥500mL within 24hours after surgery. Severe PPH is defined by bleeding ≥1000mL (professional consensus). The intervention threshold to initiate an active management depends on the flow rate of bleeding, the etiology and the clinical context. It can be higher than 500mL after cesarean (professional consensus). The main risk factor for bleeding is the realization of an emergency CS during labor (EL 3). In the case of persistent or severe intraoperative PPH due to uterine atony, conservative surgical procedures should be initiated in association with maternal resuscitation and second-line uterotonic therapy (sulprostone) (professional consensus). If general anesthesia is required, it is recommended to opt for a maintenance treatment limiting sevoflurane or desflurane in case of uterine atony (professional consensus). Severe bleeding during or after cesarean is a thrombotic risk factor and requires antithrombotic prophylaxis with heparin (the duration of treatment may vary depending on the associated risk factors) after normalization of coagulation (professional consensus). Postoperative hemoperitoneum (ultrasound) or suspected vascular wound require urgent laparotomy under general anesthesia (professional consensus). Otherwise, an uterotonic therapy (oxytocin or sulprostone depending on the severity) should be initiated. Balloon intrauterine tamponade or embolization may be discussed in the absence of hemodynamic instability (professional consensus)., Conclusion: The occurrence of PPH associated with cesarean delivery requires close collaboration between obstetrician and anesthesiologist to ensure a rapid and coordinated management (professional consensus)., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

We report the case of a massive posterior leiomyoma leading to a bowel acute obstruction and an obstructive renal failure in a 33 years old primigest woman during pregnancy. The patient underwent a urinal and an intestinal derivation during de second trimester of pregnancy as a conservative management. End of pregnancy was uneventful and she gave birth to an healthy boy (2345g) at term, by cesarean section for praevia leiomyoma. The myoma was removed 6 weeks after delivery with restoration of digestive continuity in the same time. This case report shows the morbidity of 10cm and larger leiomyoma during pregnancy., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Background: Kidney transplantation increases the chances for pregnancy and live birth for women with end-stage kidney disease. The aims of this study were to describe the outcomes of pregnancies in women with a kidney transplant and to evaluate the impact on anti-human leucocyte antigen (HLA) alloimmunization., Methods: We analysed 61 pregnancies that occurred in 46 patients after having excluded 10 miscarriages during the first trimester and 10 other pregnancies from which important data were missing. Anti-HLA antibodies were screened using the Luminex assay., Results: Overall, the live birth rate was 83% (94% after exclusion of miscarriages during the first trimester). Pre-eclampsia and gestational diabetes occurred in 26 and 21% of cases, respectively. The use of tacrolimus was an independent predictive factor for gestational diabetes. Twenty-four newborns (42%) were premature (<37 weeks). The median birth weight was 2720 (1040-3730) g. Nine newborns (15%) had low birth weights (<2.5 kg). At least one severe complication occurred in 56% of pregnancies. A high glomerular-filtration rate (GFR) before pregnancy was the sole independent protective factor that avoided a severe complication. Death-censored kidney-allograft survival was 80.4% at 6 years. De novo donor-specific anti-HLA antibodies were detected after only 5.9% of pregnancies: for two women, the father had the same HLA antigens as those from the deceased organ donor. The determination of the HLA of the father before pregnancy can better inform the woman about the possible impact of pregnancy on her kidney-allograft function., Conclusions: Despite many complications, the outcomes for pregnancy and kidney allografts are good. The risk of anti-HLA alloimmunization was low., (© The Author 2014. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Objective: To evaluate immediate perineal and neonatal morbidity associated with instrumental rotations performed with Thierry's spatulas for the management of persistent posterior occiput (OP) positions., Methods: Retrospective study including all persistent occiput posterior positions with vaginal OP delivery, from August 2006 to September 2007. Occiput anterior deliveries following successful instrumental rotation were included as well. We compared maternal and neonatal immediate outcomes between spontaneous deliveries, rotational and non rotational assisted deliveries, using χ(2) and Anova tests., Results: 157 patients were enrolled, comprising 46 OP spontaneous deliveries, 58 assisted OP deliveries and 53 deliveries after rotational procedure. Instrumental rotation failed in 9 cases. Mean age and parity were significantly higher in the spontaneous delivery group, while labor duration was shorter. There were no significant differences in the rate of severe perineal tears and neonatal adverse outcomes between the 3 groups., Conclusion: Instrumental rotation using Thierry's spatulas was not associated with a reduced risk of maternal and neonatal morbidity for persistent OP deliveries. Further studies are required to define the true interest of such procedure in modern obstetrics.

Objective: To assess the quality of intrapartum care in birth asphyxia cases., Methods: Prospective analysis of all cases of birth asphyxia in nine maternity units during one year (2010). Birth asphyxia was defined as the combination of at least one clinical factor (Apgar≤7 at 5 minutes, signs of encephalopathy at birth) and at least one biological factor in cord (pH≤7, BD≥12 mmol/L, lactates>10 mmol/L). These cases were analyzed with a peer review from French guidelines 2007., Results: Fifty cases of birth asphyxia were identified. After peer-review, they were defined as 46% non preventable, 27% possibly preventable, 24% definitely preventable and 3% not established. The main causes have been described as (i) misinterpretation of CTG during the first and second stages of labour, (ii) delayed response time to CTG anomalies and (iii) prolonged second stage., Conclusion: In half of the cases of birth asphyxia, this dreaded event was considered as preventable by a group of peers., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3). Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans. The risks of fetal, perinatal, and neonatal mortality during TOLAC are low. Nonetheless, these risks are significantly higher than those associated with ERCD (LE2). The risks of mask ventilation, intubation for meconium-stained amniotic fluid, and neonatal sepsis all increase in TOLAC (LE2). The risk of transient respiratory distress increases in ERCD (LE2). To reduce this risk, and except in particular situations, ERCD must not be performed before 39 weeks (grade B). TOLAC is possible for women with a previous cesarean before 37 weeks, with 2 previous cesareans, with a uterine malformation, a low vertical incision or an unknown incision, with a myomectomy, postpartum fever, an interval of less than 6 months between the last cesarean delivery and the conception of the following pregnancy, if the obstetric conditions are favorable (professional consensus). ERCD is recommended in women with a scar in the uterine body (grade B) and a history of 3 or more cesareans (professional consensus). Ultrasound assessment of the risk of uterine rupture in women with uterine scars has not been shown to have any clinical utility and is therefore not recommended during pregnancy to help decide the mode of delivery (professional consensus). Use of X-ray pelvimetry to decide about TOLAC is associated with an increase in the repeat cesarean rate without any reduction in the rate of uterine rupture (LE2). It is unnecessary for deciding mode of delivery and for managing labor during TOLAC (grade C). TOLAC should be encouraged for women with a previous vaginal delivery either before or after the cesarean, a favorable Bishop score or spontaneous labor, and for preterm births (grade C). For women with a fetus with an estimated weight of more than 4500 g, especially in the absence of a previous vaginal delivery and those with supermorbid obesity (BMI>50), ERCD must be planned from the outset (grade C). For all of the other clinical situations envisioned (maternal age>35 years, diabetes, morbid obesity, prolonged pregnancy, breech presentation and twin pregnancy), TOLAC is possible but the available data do not allow specific guidelines about the choice of mode of delivery, in view of the low levels of proof (grade C). The decision about planned mode of delivery must be shared by the patient and her physician and made by the 8th month, taking into account the individual risk factors for TOLAC failure and uterine rupture (professional consensus). TOLAC is the preferred choice for women who do not have several risk factors (professional consensus). The availability onsite of an obstetrician and anesthetist must be pointed out to the patient. If the woman continues to prefer a repeat cesarean after adequate information and time to think about it, her preference should be honored (professional consensus). Labor should be induced in woman with a previous cesarean only for medical indications (professional consensus). Induction of labor increases the risk of uterine rupture, which can be estimated at 1% if oxytocin is used and 2% with vaginal prostaglandins (LE2). Mechanical methods of induction have not been studied sufficiently. Misoprostol appears to increase the risk of uterine rupture strongly (LE4). Based on the information now available, its use is not recommended (professional consensus). Routine use of internal tocodynamometry does not prevent uterine rupture (professional consensus). The increased risk of uterine rupture associated with oxytocin use is dose-dependent (LE3). In the active phase, it is recommended that the total duration of failure to progress should not exceed 3h; at that point, a cesarean should be performed (professional consensus). Epidural analgesia must be encouraged. The simple existence of a uterine scar is not an indication for a routine manual uterine examination after VBAC (grade C)., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Introduction: Chronic histiocytic intervillositis of unknown etiology (CIUE) is a rare placental lesion characterized by an intervillous mononuclear inflammatory infiltrate of maternal origin. Although the mechanism and origin of these lesions are currently not understood, they appear to be related to an immune conflict between mother and fetus cells., Aim: To clarify the inflammatory cell profile and evaluate the T regulatory lymphocyte (Treg) status in CIUE., Materials and Methods: All cases of CIUE that occurred over an 8-year period were analyzed using immunohistochemistry., Results: The inflammatory profile of CIUE was characterized by a clearly predominant component of histiocytic cells (80% ± 6.9) associated with some T cells (24% ± 5.7). The ratio of CD4+ versus CD8+ T cells was close to 1. This profile differs from infectious disease and chronic histiocytic villitis, the main differential diagnoses of CIUE. As for normal pregnancies most regulatory T cells were localized in the decidua basalis. Nevertheless, their appearance was also noted in the intervillous space. In both the intervillous space and the deciduas the number of Tregs gradually increased from grade 1 to 3., Conclusion: We found that CIUE is associated with an increase in Treg lymphocytes in the decidua basalis and the intervillous space. Contrary to previously published data on human miscarriage, this result appears to be specific to CIUE and would support the hypothesis of an immunopathological disorder for CIUE., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objectives: To evaluate predictors of uterine rupture (UR) after previous cesarean birth. To define the diagnosic criteria of UR, management and prognosis of subsequent pregnancies., Materials and Methods: Analysis of Medline database(®), Cochrane Library Database(®) and international guidelines., Results: Uterine rupture is a serious complication both for mother (mortality<1 %, severe morbidity 15 %) and child (mortality at term 3-6%, perinatal asphyxia 6-15%), occurring in 0,2 to 0,8 % of trial of labour after cesarean (TOLAC). The individual risk for UR after TOLAC is multifactorial and predictive scores showed no clinical utility in routine (grade B). The risk of UR is decreased in case of previous vaginal delivery and increased in case of classical C-section, previous UR, induction of labour (especially using prostaglandins), more than one previous caesarean section, fetal macrosomia and interval less than 6 months before the next pregnancy. Monitoring of labor, including intrauterine pressure catheters, do not allow to anticipate the diagnosis. This one relies on a combination of severe pathologic patterns of FHM with unusual pelvic pain. Suspected UR requires expedited laparotomy (consensus opinion). A subsequent pregnancy is not contraindicated, but the risk of recurrent UR is high and a repeat cesarean section is then recommended (grade B)., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objectives: To investigate the incidence of pelvi-abdominal hematoma, to identify associated factors and to describe modalities of diagnosis and management., Patients and Methods: A retrospective observational study including all patients presenting with a pelvi-abdominal hematoma among women who delivered between January 2005 and December 2010 in Toulouse university hospital., Results: Twenty five thousand, one hundred and eighty-four women delivered during the study period and nine women were included (estimated incidence: 1/4200 deliveries). The main associated obstetrical factors were perineal injuries (episiotomy or lacerations) in 100% of cases and instrumental extraction (spatula) in 50% of cases. Arterial embolisation was performed in one third of cases. No death was observed., Conclusion: Pelvi-abdominal hematoma is a severe and infrequent postpartum complication. A better knowledge of clinical and radiological presentations together with obstetrical associated factors will allow an early diagnosis and a multidisciplinary management., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Routine use of a partograph is associated with a reduction in the use of forceps, but is not associated with a reduction in the use of vacuum extraction (Level A). Early artificial rupture of the membranes, associated with oxytocin perfusion, does not reduce the number of operative vaginal deliveries (Level A), but does increase the rate of fetal heart rate abnormalities (Level B). Early correction of lack of progress in dilatation by oxytocin perfusion can reduce the number of operative vaginal deliveries (Level B). The use of low-concentration epidural infusions of bupivacaine potentiated by morphinomimetics reduces the number of operative interventions compared with larger doses (Level A). Placement of an epidural before 3-cm dilatation does not increase the number of operative vaginal deliveries (Level A). Posterior positions of the fetus result in more operative vaginal deliveries (Level B). Manual rotation of the fetus from a posterior position to an anterior position may reduce the number of operative deliveries (Level C). Walking during labour is not associated with a reduction in the number of operative vaginal deliveries (Level A). Continuous support of the parturient by a midwife or partner/family member during labour reduces the number of operative vaginal deliveries (Level A). Under epidural analgesia, delayed pushing (2h after full dilatation) reduces the number of difficult operative vaginal deliveries (Level A). Ultrasound is recommended if there is any clinical doubt about the presentation of the fetus (Level B). The available scientific data are insufficient to contra-indicate attempted midoperative delivery (professional consensus). The duration of the operative intervention is slightly shorter with forceps than with a vacuum extractor (Level C). Nonetheless, the urgency of operative delivery is not a reason to choose one instrument over another (professional consensus). The cup-shaped vacuum extractor seems to be the instrument of choice for operative deliveries of fetuses in a cephalic transverse position, and may also be preferred for fetuses in a posterior position (professional consensus). Vacuum extraction deliveries fail more often than forceps deliveries (Level B). Overall, immediate maternal complications are more common for forceps deliveries than vacuum extraction deliveries (Level B). Compared with forceps, operative vaginal delivery using a vacuum extractor appears to reduce the number of episiotomies (Level B), first- and second-degree perineal lesions, and damage to the anal sphincter (Level B). Among the long-term complications, the rate of urinary incontinence is similar following forceps, vacuum extraction and spontaneous vaginal deliveries (Level B). Anal incontinence is more common following forceps delivery (Level B). Persistent anal incontinence has a similar prevalence regardless of the mode of delivery (caesarean or vaginal, instrumental or non-instrumental), suggesting the involvement of other factors (Level B). Rates of immediate neonatal mortality and morbidity are similar for forceps and vacuum extraction deliveries (Level B). It appears that difficult instrumental delivery may lead to psychological sequelae that may result in a decision not to have more children (Level C). The rates of neonatal convulsions, intracranial haemorrhage and jaundice do not differ between forceps and vacuum extraction deliveries (Levels B and C). Rapid sequence induction with a Sellick manoeuvre (pressure to the cricoid cartilage) and tracheal intubation with a balloon catheter is recommended for any general anaesthesia (Level B). Training must ensure that obstetricians can identify indications and contra-indications, choose the appropriate instrument, use the instruments correctly, and know the principles of quality control applied to operative vaginal delivery. Nowadays, traditional training can be accompanied by simulations. Training should be individualized and extended for some students., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)