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The objective of this study was to determine the prevalence and identify risk factors for obstetric anal sphincter injuries (OASIS), and to determine the prevalence of episiotomy and whether it is protective for the posterior perineum.This is a retrospective case-control study carried out in a level 2 maternity unit and a level 3 maternity unit between 1 January 2006 and 31 December 2015. The sample population included all vaginal deliveries at term of a living singleton foetus in cephalic presentation. The case group comprised patients with an OASIS. The control group comprised patients without OASIS. Statistical analysis was subdivided into descriptive and inferential parts.42,626 patients were included in the study of whom 496 were cases of OASIS, i.e. a rate of 1.2%. The overall episiotomy rate was 10.0%, which reflects a restrictive practice. Episiotomy doesn't appear to be a statistically significant protective factor for OASIS (OR=0.89-95%CI [0.68-1.16]). The principal independent risk factors for OASIS were nulliparity (ORa=4.19-95%CI [3.03-5.84] - p0.001), previous caesarean (ORa=5.59-95%CI [3.68-8.44] - p0.001), uterine fundal height greater than 32cm (ORa=1.35-95%CI [1.03-1.77] - p=0.03), gestational or pre-pregnancy diabetes (ORa=1.76-95%CI [1.22-2.46] - p=0.002), birthweight of more than 3500g (ORa=1.48-95%CI [1.17-1.87] - p=0.001), assisted delivery (ORa=1.81-95%CI [1.18-2.86] - p=0.007), and use of a second instrument or obstetrical manoeuvre (ORa=1.93-95%CI [1.05-3.30] - p=0.02).Episiotomy doesn't appear to be a statistically significant protective factor on the perineal prognosis. A deeper understanding of the factors which promote OASIS and greater awareness of them would improve the perineal prognosis of parturient women.

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

International audience; Introduction The objective of this study was to investigate the association between planned mode of delivery and neonatal outcomes with spontaneous very preterm birth among singletons in cephalic presentation. Material and methods Etude Epidemiologique sur les Petits Ages Gestationnels 2is a French national, prospective, population-based cohort study of preterm infants. For this study, we included women with a singleton cephalic pregnancy and spontaneous preterm labor or preterm premature rupture of membranes at 24-31 weeks' gestation. The main exposure was the planned mode of delivery (ie planned vaginal delivery or planned cesarean delivery at the initiation of labor). The primary outcome was survival at discharge and secondary outcome survival at discharge without severe morbidity. Propensity scores were used to minimize indication bias in estimating the association. Results The study population consisted of 1008 women: 206 (20.4%) had planned cesarean delivery and 802 (79.6%) planned vaginal delivery. In all, 723 (90.2%) finally had a vaginal delivery. Overall, 187 (92.0%) and 681 (87.0%) neonates in the planned cesarean delivery and planned vaginal delivery groups were discharged alive, and 156 (77.6%) and 590 (76.3%) were discharged alive without severe morbidity. After matching on propensity score, planned cesarean delivery was not associated with survival (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 0.48-2.28) or survival without severe morbidity (aOR 0.64, 95% CI 0.36-1.16). Conclusions Planned cesarean delivery for cephalic presentation at 24-31 weeks' gestation after preterm labor or preterm premature rupture of membranes does not improve neonatal outcomes.

Objective To assess whether chorioamnionitis is associated with cerebral palsy (CP) or death at 2 years' corrected age in infants born before 32 weeks of gestation after spontaneous birth. Study design EPIPAGE-2 is a national, prospective, population-based cohort study of children born preterm in France in 2011; recruitment periods varied by gestational age. This analysis includes infants born alive after preterm labor or preterm premature rupture of membranes from 240/7 to 316/7 weeks of gestation. We compared the outcomes of CP, death at 2 years' corrected age, and “CP or death at age 2” according to the presence of either clinical chorioamnionitis or histologic chorioamnionitis. All percentages were weighted by the duration of the recruitment period. Results Among 2252 infants born alive spontaneously before 32 weeks of gestation, 116 (5.2%) were exposed to clinical chorioamnionitis. Among 1470 with placental examination data available, 639 (43.5%) had histologic chorioamnionitis. In total, 346 infants died before 2 years and 1586 (83.2% of the survivors) were evaluated for CP at age 2 years. CP rates were 11.1% with and 5.0% without clinical chorioamnionitis (P = .03) and 6.1% with and 5.3% without histologic chorioamnionitis (P = .49). After adjustment for confounding factors, CP risk rose with clinical chorioamnionitis (aOR 2.13, 95% CI 1.12-4.05) but not histologic chorioamnionitis (aOR 1.21, 95% 0.75-1.93). Neither form was associated with the composite outcome “CP or death at age 2.” Conclusions Among infants very preterm born spontaneously, the risk of CP at a corrected age of 2 years was associated with exposure to clinical chorioamnionitis but not histologic chorioamnionitis.

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

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

Resume Objectif Decrire la signification clinique des anticorps anti-SG2NA egalement appeles anti-pseudo-PCNA de type 1 ( proliferating cell nuclear antigen auto-antibodies ) qui sont des anticorps antinucleaires (ANA) rares detectes par immunofluorescence indirecte (IFI) sur cellules proliferatives HEp-2 en phase S/G2. Par analogie avec les anticorps anti-PCNA, ils sont associes au lupus erythemateux systemique (LES), aux cancers ou aux pathologies virales. Methodes Entre mai 2006 et fevrier 2013, 16 827 patients ont eu une recherche d’ANA positive au laboratoire d’immunologie de Strasbourg (France). Nous avons analyse de facon retrospective les donnees cliniques et biologiques des 126 patients ayant un aspect de fluorescence de type anti-pseudo-PCNA de type 1. Resultats La prevalence des anticorps anti-pseudo-PCNA de type 1 etait de 0,75 % parmi les patients ayant une recherche d’ANA positive. L’âge median etait de 56,9 ans (deviation standard [DS] 13,4 ans), avec un sex-ratio de 1,9 en faveur des femmes. En comparaison avec les patients porteurs d’anticorps antinucleaires, significativement plus de patients etaient hospitalises dans le service d’oncologie et hematologie de l’hopital (23 % vs 6,3 %, p + ( p −6 ). Finalement, la presence de l’anticorps anti-pseudo-PCNA de type 1 etait associee dans 30 cas sur 126 avec d’autres auto-anticorps (en particulier diriges contre les proteines du cycle cellulaire), suggerant un mecanisme plus general de rupture de tolerance lymphocytaire B envers les auto-antigenes. Conclusion A la lumiere de nos resultats, l’exploration des tumeurs devrait etre recommandee pour les patients ayant des Ac anti-pseudo-PCNA de type 1. Aucune association de ces auto-anticorps avec le lupus n’a pu etre montree.

Objective The primary objective of our study was to evaluate the long-term neurodevelopment outcome after laser surgery for twin-twin transfusion syndrome (TTTS). The secondary objective was to identify perinatal prognostic factors associated with neurodevelopmental impairment. Method This was a single-center cohort prospective study carried out in pregnancies complicated by TTTS and treated by laser. Neurodevleopmental assesment included the administration of Ages and Stages Questionnaires® (ASQ), for the infants between two and five years of age. Results A total of 187 patients underwent a laser for TTTS between 2004 and 2013. Significant brain lesions were detected in 8 (2.9%) cases by ultrasound and/or MRI including intraventricular hemorrhage, periventricular leukomalacia and porencephaly. Questionnaires were administered to 126 children (50.4%) at 24 months or older at the moment of testing. There were 13.5% of those infants who had an abnormal ASQ (established as 1 area or more scoring

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

Resume Le cerclage a pour but de renforcer non seulement les proprietes mecaniques du col uterin, mais egalement ses proprietes immunologiques et anti-infectieuses. La mise en evidence d’une forte intrication entre insuffisance cervicale, longueur du col diminuee a l’echographie endovaginale et infection a modifie les indications de cerclage. On peut ainsi aujourd’hui distinguer 3 types de cerclages : le cerclage prophylactique pour antecedents, le cerclage therapeutique pour longueur de col diminuee a l’echographie chez des patientes a risque et le cerclage en urgence pour col menacant a l’examen physique. La technique de cerclage la plus recommandee est celle de McDonald. En cas d’echec, on propose de realiser des cerclages plus haut places par voie vaginale ou par voie abdominale.

Resume L’appendice caudal est une malformation exceptionnelle qui a toujours suscite de l’interet. Nous presentons le cas d’une decouverte antenatale d’une anomalie du rachis fœtal compatible avec un appendice caudal. Le bilan d’imagerie objectivait une extension de cette malformation superficielle a la moelle epiniere. La prise en charge obstetricale etait sans particularite. L’enfant a ete operee a 2 mois de vie. Les diagnostics differentiels sont le spina bifida, le teratome sacro-coccygien et le kyste du sinus pilonidal. L’appendice caudal est un des marqueurs de dysraphisme spinal, au meme titre qu’une touffe de poils ou qu’un hemangiome. Le risque est le syndrome de moelle attachee avec les complications neurologiques qu’il peut entrainer.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 43 - N° 10 - p. 1161-1169

Transnasal humidified rapid-insufflation ventilatory exchange has been shown to improve oxygenation and increase apnea time in difficult airway cases. It may also be beneficial in patients vulnerable to rapid desaturation due to limited pulmonary reserve. We report the use of transnasal humidified rapid-insufflation ventilatory exchange for preoxygenation before a cesarean delivery under general anesthesia in a patient with respiratory distress because of pneumonia and heart failure from severe mitral stenosis. To our knowledge, the use of this technique has not been previously reported in pregnant patients.

International audience; In France, 60,000 neonates are born preterm every year (7.4%), half of them after the spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated with decreased prematurity (level of evidence [LE]1). It is therefore recommended (Grade A). Routine screening and treatment of vaginal bacteriosis is not recommended in the general population (Grade A). The only population for which vaginal progesterone is recommended is that comprising asymptomatic women with singleton pregnancies, no history of preterm delivery, and a short cervix at 16-24 weeks of gestation (Grade B). A history-indicated cerclage is not recommended for women with only a history of conization (Grade C), uterine malformation (professional consensus), isolated history of preterm delivery (Grade B), or twin pregnancies for primary (Grade B) or secondary (Grade C) prevention of preterm birth. A history-indicated cerclage is recommended for a singleton pregnancy with a history of at least 3 late miscarriages or preterm deliveries (Grade A). Ultrasound cervical length screening is recommended between 16 and 22 weeks for women with a singleton previously delivered before 34 weeks gestation, so that cerclage can be offered if cervical length < 25 mm before 24 weeks (Grade C). A cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with twin pregnancies (Grade A) or in populations of asymptomatic women with a short cervix (professional consensus). Although the implementation of universal screening by transvaginal ultrasound for cervical length at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In cases of preterm labor, (i) it is not possible to recommend any one of the several methods (ultrasound of the cervical length, vaginal examination, or fetal fibronectin assay) over any other to predict preterm birth (Grade B); (ii) routine antibiotic therapy is not recommended (Grade A); (iii) prolonged hospitalization (Grade B) and bed rest (Grade C) are not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (Grade B), unlike beta-agonists (Grade C), can be used for tocolysis in spontaneous preterm labor without preterm premature rupture of membranes. Maintenance tocolysis is not recommended (Grade B). Antenatal corticosteroid administration is recommended for all women at risk of preterm delivery before 34 weeks of gestation (Grade A). After 34 weeks, the evidence is insufficiently consistent to justify recommending systematic antenatal corticosteroid treatment (Grade B), but a course of this treatment might be indicated in clinical situations associated with high risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (Grade C). Repeated courses of antenatal corticosteroids are not recommended (Grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended for women at high risk of imminent preterm birth before 32 weeks (Grade A). Cesareans are not recommended for fetuses in vertex presentation (professional consensus). Both planned vaginal and elective cesarean delivery are possible for breech presentations (professional consensus). Delayed cord clamping may be considered if the neonatal or maternal state allows (professional consensus). (C) 2017 Elsevier Ireland Ltd. All rights reserved.

Disseminated peritoneal leiomyomatosis (DPL) is a rare disease entity belonging to the category of smooth muscle tumours of uncertain growth. It is characterized by proliferation of multiple smooth muscle nodules in the peritoneal cavity mimicking a malignant process such as peritoneal carcinomatosis but which when studied histologically proves to be of benign nature. Its origin is still unknown. Genomic analysis of DPL cases is of interest in order to understand its pathogenesis and subsequent course, but there are few extant studies. In this article we set out the genomic profiles, analysed by array-based comparative genomic hybridization (array-CGH), of peritoneal and uterine lesions in two cases of DPL detected after previous uterine morcellation for fibroids, as well as a "sporadic" case of DPL. Array-CGH findings revealed in all three cases a flat genomic profile. It is not possible to establish a genetic lineage between two lesions on the basis of the genomic profiles alone, owing to the absence of an unbalanced rearrangement. CGH is not conclusive enough in this type of disorder. Analysis of the exome could provide us with fresh information, not least about driving events in the cancerogenesis of these tumours.

Introduction: The aim of this study is to evaluate the utility of digital examination in addition to ultrasonic measurement of cervical length for predicting spontaneous preterm delivery in women with threatened preterm labor. Material and methods: This was a prospective cohort study in Strasbourg University Hospital, France, between January 2013 and January 2015 All the women with a singleton pregnancy hospitalized with threatened preterm labor between 23 to 34 weeks of gestation were included. Cases of iatrogenic preterm delivery were excluded. A multivariable logistic regression model to estimate the significant predictive parameters of spontaneous preterm delivery was performed. The primary endpoint of our study was a preterm birth before 34 weeks of gestation. Results: A total of 395 women were included in our study. The rate of preterm delivery before 34 weeks was 13%. In univariate analysis every single cervical parameter assessed by the digital examination and all the ultrasound parameters were significantly associated with preterm delivery. The final model included five variables predicting preterm birth: visualization of the membranes at the speculum examination (OR, 15.8; 95%CI, 2.43-146), ultrasound cervical length (OR, 0.82; 95%CI, 0.75-0.89), signs of inflammation (OR, 6.23; 95%CI, 2.07-22.9), gestational age on admission (OR, 0.84; 95%CI, 0.71-1.0), and presence of vaginal infection (OR, 4.28; 95%CI, 1.52-12.7). None of the cervical parameters assessed by the digital examination provided additional predictive value of preterm delivery. Conclusion: Our study suggests that digital examination does not add to the information given by vaginal ultrasound evaluation in predicting preterm labor. This article is protected by copyright. All rights reserved.

Objective To assess the impact of latency duration on survival, survival without severe morbidity, and early-onset sepsis in infants born after preterm premature rupture of membranes (PPROM) at 24-32 weeks' gestation. Study design This study was based on the prospective national population-based Etude Epidemiologique sur les Petits Ages Gestationnels 2 cohort of preterm births and included 702 singletons delivered in France after PPROM at 24-32 weeks' gestation. Latency duration was defined as the time from spontaneous rupture of membranes to delivery, divided into 4 periods (12 hours to 2 days [reference], 3-7 days, 8-14 days, and >14 days). Multivariable logistic regression was used to assess the relationship between latency duration and survival, survival without severe morbidity at discharge, or early-onset sepsis. Results Latency duration ranged from 12 hours to 2 days (18%), 3-7 days (38%), 8-14 days (24%), and >14 days (20%). Rates of survival, survival without severe morbidity, and early-onset sepsis were 93.5% (95% CI 91.894.8), 85.4% (82.4-87.9), and 3.4% (2.0-5.7), respectively. A crude association found between prolonged latency duration and improved survival disappeared on adjusting for gestational age at birth (aOR 1.0 [reference], 1.6 [95% CI 0.8-3.2], 1.2 [0.5-2.9], and 1.0 [0.3-3.2] for latency durations from 12 hours to 2 days, 3-7 days, 8-14 days, and >14 days, respectively). Prolonged latency duration was not associated with survival without severe morbidity or early-onset sepsis. Conclusion For a given gestational age at birth, prolonged latency duration after PPROM does not worsen neonatal prognosis.

Introduction: Active management of extreme prematurity, defined as birth occurring before 26WG, has medical and familial repercussions on account of the uncertain future of these infants. The aim of this paper is to describe our experience in the obstetrical and paediatric management of extreme preterm births based on choices made by the families. Methods: We retrospectively included all infants born between 22WG and 25WG+6days in our level III maternity unit in the period from January 2010 to December 2014. These births were documented along with family choices, methods of obstetrical management and birth outcomes. Results: 166 infants were included. After 24WG, active management was requested by the parents in 90% of cases versus 13% at 23WG and none at 22WG. Corticosteroid therapy was administered in 0% of cases at 22WG, 19% at 23WG, 92% at 24WG and 94% at 25WG. Caesarean section was performed in 0% of cases before 24WG, 10% at 24WG and 48% at 25WG. Six per cent of infants at 22WG, 32% at 23WG, 89% at 24WG and 92% at 25WG were live births. The survival rate for infants admitted to neonatal intensive care was 17% at 23WG, 47% at 24WG and 71% at 25WG. Conclusion: Optimal management of extreme preterm births requires a solidly cooperative obstetrical-paediatric team guided by respect for parental choice.

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

Objective To compare laser data, complications and neonatal outcome in pregnancies that undergo ‘early’ (≤ 17 weeks' gestation) fetoscopic laser ablation of placental vascular anastomoses for twin–twin transfusion syndrome (TTTS) with those from ‘conventional’ cases treated after 17 weeks. Methods This was a cohort study of data collected prospectively between January 2004 and December 2012. We included monochorionic diamniotic twin pregnancies complicated by TTTS and treated by fetoscopic laser coagulation. Pregnancies were grouped according to laser treatment ≤ 17 gestational weeks or > 17 weeks and obstetric and neonatal outcomes were compared between groups. Results A total of 178 pregnancies with TTTS underwent laser therapy: 40 at or before 17 weeks and 138 after 17 weeks. There was no statistically significant difference between these two groups with respect to the rate of preterm prelabor rupture of membranes (PPROM), gestational age at PPROM and rate of PPROM occurring in the 7 days following fetoscopic laser coagulation. In the early group, the interval between performing fetoscopic laser coagulation and the time of delivery was significantly longer (104 days vs 74 days, P = 0.0002) and the delivery rate within 7 days of laser treatment was significantly lower (2.5% vs 15.9%, P = 0.026). There was no significant difference between the two groups with regard to the rates of pregnancy without live birth (15.4% vs 15.4%, P = 0.993), with one live birth (84.6% vs 84.6%, P = 0.993) and with two live births (64.1% vs 58.1%, P = 0.500). Conclusion In the event of early TTTS, fetoscopic laser coagulation is technically feasible before 17 gestational weeks and obstetric and neonatal outcomes are comparable with those in cases of laser treatment performed after 17 weeks. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd

To evaluate the efficacy and safety of induction in women with a single prior Caesarean section.This was a cohort study in which we included all singleton pregnancies in patients with a single prior Caesarean who delivered between 2007 and 2012. Methods of induction were ocytocic infusion plus amniotomy (if Bishop score ≥6) or insertion of a Foley catheter (Bishop6).Of the 2,075 patients included, 806 (38.8 %) had an elective repeat Caesarean, 1,045 (50.4 %) went into spontaneous labour, 89 (4.3 %) were induced by artificial rupture of the membranes and infusion of ocytocics and 135 (6.5 %) were induced using a Foley catheter. Rates of vaginal delivery were 79.2, 79.8 and 43.7 %, respectively. Six cases of uterine rupture were reported in the group of patients who went into spontaneous labour. There was no difference between groups with regard to neonatal morbidity. On multivariate analysis, risk factors for Caesarean delivery were macrosomia (OR 2.04, 95 % CI 1.31-3.18) and induction by Foley catheter (OR 3.73, 95 % CI 2.47-5.62); protective factors were previous vaginal delivery (OR 0.41, 95 % CI 0.29-0.57) and cervical dilatation (OR 0.84, 95 % CI 0.78-0.91).Uterine induction after a single Caesarean section with ocytocic infusion and amniotomy where the cervix is favourable does not appear to entail any significant added risk in terms of maternal or foetal morbidity. Foley catheter induction is a reasonable option if the cervix is not ripe.

Objective The Quintero staging of twin-to-twin transfusion syndrome (TTTS) does not include a comprehensive cardiovascular assessment. The aim of this study is to assess the predictive value of the myocardial performance index (MPI) and the Children's Hospital of Philadelphia (CHOP) score on recipient survival in Quintero stages 1 and 2 TTTS. Methods The cohort study was based on prospectively collected data between May 2008 and February 2013 in a population of stages 1 and 2 TTTS. Comparisons between groups were carried out using Student's t-test and χ2-test. A stepwise ascending multivariate logistic regression model was then built. Results A total of 73 pregnancies in stages 1 and 2 of Quintero's classification were treated with laser. Rates of recipient fetal losses were higher when MPI was above 0.43 ms (71.4% vs 28.6%, p = 0.022). Rate of CHOP score above 5 was higher in the fetal loss group (28.6% vs 5.1%, p = 0.022). After adjustment for Quintero stages 1 or 2, the risk of recipient loss rate is higher according to CHOP score [OR 7.6; 95% confidence interval (CI) 1.3–43.5] or MPI value (OR 3.7; 95% CI 1.0–13.9). Conclusion The CHOP score and MPI are correlated with the recipient survival in stages 1 and 2 TTTS. © 2014 John Wiley & Sons, Ltd.

Resume Objectif Le declenchement artificiel du travail est l’une des procedures les plus frequentes en France chez la femme enceinte. Le plus souvent, l’indication est posee sur un col immature. On releve dans la litterature une importante heterogeneite concernant les recommandations pour la maturation cervicale. L’objectif de cette etude est d’analyser la maniere dont ces recommandations sont appliquees dans les centres hospitalo-universitaires francais. Methodes Il s’agit d’une enquete telephonique realisee aupres des 46 departements de gynecologie-obstetrique francais. Pour chaque centre, nous avons contacte le medecin referent en salle d’accouchement ou responsable des protocoles. Resultats L’integralite des 46 centres interroges a repondu au questionnaire. Tous evaluaient le statut cervical par examen clinique avec un score de Bishop juge favorable lorsque superieur ou egal a 7 pour 37 maternites (90,2 %). Pour 56,5 % d’entre elles, ce score etait ajuste selon la parite. Trente-huit maternites (82,6 %) realisaient la maturation cervicale a proximite d’une salle de cesarienne. La methode la plus diffusee etait la dinoprostone a liberation prolongee (89,1 %), suivie par la dinoprostone en gel vaginal (65,2 %), les ballonnets (50 %) et le misoprostol (17,4 %). Le nombre de methodes utilisees par centre ainsi que les protocoles d’administration et de surveillance etaient tres variables d’une maternite a une autre. Discussion et conclusion La dinoprostone reste la molecule la plus largement utilisee, que ce soit sous forme de gel ou de dispositif a liberation prolongee. Les differences de protocoles mises en evidence devraient etre comparees en termes d’efficacite pour permettre d’etablir une pratique consensuelle entre les differentes equipes.

Resume Objectif Actualiser les connaissances concernant l’hematome retroplacentaire car il existe peu de series recentes publiees alors que la prise en charge perinatale a connu des progres. Patientes et methodes Nous avons realise une etude observationnelle retrospective portant sur 100 cas successifs d’hematome retroplacentaire, survenus de janvier 2008 a juin 2011, dans les deux maternites du CHU de Strasbourg. Resultats Il y a eu 105 naissances dont cinq grossesses gemellaires. Le contexte clinique etait manifeste dans 91 % des cas mais la triade clinique classique presente dans seulement 4 % des cas. Des caillots etaient retrouves a l’examen immediat du placenta dans 77 % des cas. L’examen anatomopathologique etait en accord direct avec le diagnostic clinique dans la moitie des cas. L’issue moyenne de la grossesse etait de 33 semaines d’amenorrhee (SA) et six jours. Soixante-sept patientes ont accouche prematurement dont 50 patientes avant 34 SA. Soixante cesariennes ont ete realisees en urgence avant travail avec 47 anesthesies generales. Douze patientes ont presente une hemorragie de la delivrance et dix des troubles de l’hemostase. Il n’y a eu aucun deces maternel. La mortalite perinatale etait de 19 % avec 13 morts fœtales in utero (12,4 %), quatre enfants nes en etat de mort apparente avec echec de reanimation (3,8 %) et trois deces neonataux (2,8 %). Discussion et conclusion L’hematome retroplacentaire est une situation grave et imprevisible. Une prise en charge conjointe des obstetriciens et des reanimateurs est souvent necessaire. Aujourd’hui, la mortalite perinatale est essentiellement in utero.

To illustrate a laparoscopic technique for the resection of cesarean scar ectopic pregnancy, associated with isthmocele repair.Case report (Canadian Task Force classification III).A tertiary referral center in Strasbourg, France.Cesarean scar pregnancy is a rare form of ectopic pregnancy. The major risk of this type of pregnancy is the early uterine rupture with massive, sometimes life-threatening, bleeding. Thus, active management of these pregnancies starting immediately after diagnosis is crucial. Therapeutic options can be medical, surgical, or a combination. Numerous case reports or case series can be found in the literature, but there are few clinical studies, which are difficult to conduct because of case rarity and inconclusiveness. A 2016 meta-analysis that included 194 articles published between 1978 and 2014 (126 case reports, 45 cases series, and 23 clinical studies) concluded that hysteroscopy or laparoscopic hysterotomy seems to be the best first-line approach to treating cesarean scar ectopic pregnancy, with uterine artery embolization reserved for significant bleeding and/or a high suspicion index for arteriovenous malformation [1]. There is no consensus on the treatment of reference, however.The case involves a 38-year-old primiparous women who underwent a cesarean section delivery in 2010 and who was diagnosed by ultrasound scan at 7 weeks gestation with cesarean scar ectopic pregnancy, which was confirmed by pelvic magnetic resonance imaging. The patient initially received medical treatment with 2 intramuscular injections of methotrexate and one local intragestational injection of KCl. Her initial human chorionic gonadotropin (hCG) level was 82 000 IU/L. Rigorous weekly biological and ultrasound monitoring revealed an involution of the ectopic pregnancy associated with decreasing hCG. No bleeding or infectious complications occurred during this period. After 10 weeks of monitoring, her hCG had stabilized at 300 IU/L, and a residual image persisted next to the cesarean scar, and thus surgical treatment was considered.This video illustrates the laparoscopic resection of a cesarean scar ectopic pregnancy associated with isthmocele repair. The originality of this video lies in the fact that it is the first demonstration of the laparoscopic treatment of total caesarean scar dehiscence.The total operative time was 180 minutes. First, hysteroscopic evaluation revealed the cesarean scar dehiscence and the posterior pole of the ectopic pregnancy. Then the diagnosis of cesarean scar ectopic pregnancy was confirmed laparoscopically. The utero-ombilical truncs were clamped bilaterally. Complete enucleation of pregnancy was achieved after dissection of the vesicouterine peritoneum. Isthmocele repair was performed with closure in 2 planes. A blue dye test confirmed the tightness of the stitches. The utero-ombilical truncs were unclamped, and antiadhesion gel was applied to the new uterine scar [1]. The operation was performed successfully without complications. Intraoperative blood loss was100 mL. The patient was discharged on postoperative day 3. No immediate complications were noticed. At 1 month after the intervention, ultrasound was normal.Surgical management of caesarean scar ectopic pregnancy with total dehiscence of hysterotomy can be performed safely and efficiently under laparoscopy.

Contexte : Depuis 2004, l’examen de la fin du 2eme cycle des etudes medicales en France, appele epreuves classantes nationales (ECN), a ete modifie dans son organisation, sa forme et son fond. Objectif : L’objectif de ce travail est d’analyser ce qu’evalue l’epreuve de dossiers des ECN. Materiel et methodes : Nous avons analyse, selon une grille preetablie, chaque dossier des annales des ECN de 2004 a 2011, soient 72 dossiers avec 525 questions sur 8 ans. L’etude a porte sur les connaissances et aptitudes requises par l’etudiant ainsi que sur la concordance entre les conseils donnes par le Centre National des Concours de l’Internat (CNCI) aux auteurs des dossiers et sur les sujets eux-memes, a savoir la forme et le contenu. Resultats : Les enonces contiennent en moyenne 214 mots (extremes : 59-514) avec en moyenne 3 a 4 types de donnees a analyser, ce qui necessite un reel travail de synthese. Les questions portent majoritairement sur le diagnostic (20 % des questions), sur tout ce qui est du domaine du paraclinique (26 %), sur la prise en charge (32 %), et pour seulement 5 % de questions sur l’examen clinique. Un veritable raisonnement est demande a l’etudiant dans 80 % des dossiers et une prise en charge du patient dans sa globalite est requise dans 75 % des dossiers. Enfin, l’information que le medecin doit savoir donner a son patient est evaluee dans 18 % des dossiers. Conclusion : Au regard des objectifs pedagogiques terminaux pour la deuxieme partie du deuxieme cycle des etudes medicales, qui constituent le programme officiel des ECN, les dossiers utilises lors des epreuves administrees de 2004 a 2008 se revelent satisfaire une validite de contenu satisfaisante. D’une facon globale, ils sont egalement elabores de facon formelle en conformite avec les recommandations formulees aux auteurs de dossiers par le CNCI.

Objective This study aims to evaluate the utility of first trimester cervical ultrasonography in predicting preterm delivery by separate analysis of measurements of cervical and isthmus length. Methods This is a cohort study based on data collected prospectively on singletons between 1 July 2011 and 1 February 2013. Mean cervical, isthmus and cervico-isthmic complex length were measured for deliveries before and after 37 weeks. Results A total of 1494 pregnancies were analysed, including 51 cases of spontaneous preterm delivery (3.4%). The cervico-isthmic complex in the first trimester was significantly shorter in patients who delivered before term (43.8 mm vs 47.5 mm, p = 0.04). This difference is related to differences in length at the isthmus (10.7 mm vs 14.1 mm, p = 0.005) rather than at the cervix proper (34.5 mm vs 35.0 mm, p = 0.56). Conclusions Measurement of the cervico-isthmic complex enables detection of a number of patients who will go on to deliver before term. Further studies are necessary to confirm that isthmic length and not cervical length is predictive of preterm delivery. © 2013 John Wiley & Sons, Ltd.

Resume Les patientes presentent un avortement tardif ou un accouchement tres premature dans 2–3 % des grossesses. Leur prise en charge lors d’une grossesse ulterieure doit rechercher une infection, une cause fœtale (aneuploidie, syndrome polymalformatif, mort in utero) ou une pathologie de type vasculaire (pre-eclampsie, RCIU, mort in utero). Chez les femmes ayant dans leurs antecedents un avortement tardif ou un accouchement tres premature, plusieurs therapeutiques preventives de la prematurite sont aujourd’hui proposees. La principale cause de prematurite est l’infection ascendante a partir de la cavite vaginale. Le cerclage ou le pessaire a pour but de mieux isoler la cavite uterine. Leur efficacite a ete validee chez les patientes ou la mesure repetee de la longueur du col uterin par echographie endovaginale montre un col

Objective Noonan syndrome is a frequent genetic disorder with autosomal dominant transmission. Classically, it combines postnatal growth restriction with dysmorphic and malformation syndromes that vary widely in expressivity. Lymphatic dysplasia induced during the embryonic stage might interfere with tissue migration. Our hypothesis is that the earlier the edema, the more severe postnatal phenotype. Method This retrospective study analyzed data from all 32 cases of Noonan syndrome diagnosed in the Medical Genetics Department of Hautepierre Hospital in Strasbourg, France, between 1995 and 2011. The postnatal evolution of Noonan syndrome was compared according to the presence of at least one prenatal ultrasound feature of lymphatic dysplasia. Results The most frequent prenatal ultrasound features found were increased nuchal translucency, cystic hygroma and polyhydramnios; their global prevalence was 46.4%. The presence of these features was not significantly associated with the postnatal phenotype of Noonan syndrome. Conclusion The results of our study indicate that prenatal ultrasound features of lymphatic dysplasia do not predict an unfavorable postnatal prognosis for Noonan syndrome. © 2013 John Wiley & Sons, Ltd.

Introduction The objective of this study was to compare neonatal respiratory morbidity and rate of emergency caesarean section between elective caesarean sections at 38 gestational weeks following a course of corticosteroids and planned caesarean sections at 39 gestational weeks. Material and methods This was a multicentre randomised controlled trial. The study was conducted between 2007 and 2013 in level 2 and 3 maternity units in France. A total of 208 women with an indication for elective caesarean section were enrolled and 200 analysed in per-protocol analysis. Women were randomised to either elective caesarean section at 38 gestational weeks after a course of corticosteroids (trial group) or elective caesarean section at 39 weeks (control group). The primary outcome was the rate of admission to the neonatal intensive care unit for respiratory distress. Results Two (2.1%) newborn in the tested group were admitted because of respiratory distress versus four (3.8%) in the control group. The relative risk was 0.54 in favour of the corticosteroid group (95% CI: 0.10; 2.86). There were fewer emergency caesareans in the trial group than in the control group: 12 (12.69%) versus 28 (26.67%), p = 0.01. Conclusions Our study suggests that planning caesarean sections at 38 gestational weeks after a course of corticosteroids would enable a significant reduction in the number of emergency caesareans without increasing the risk of neonatal respiratory distress. Limitations of this study include difficulties in patient recruitment and the small number of subjects.

Background: Several studies have investigated the efficacy of moxibustion with or without acupuncture for fetal version, but the results are discordant. Meta-analyses pointed out the need for robust, methodologically sound, randomized controlled trials. Objective: The objective of this study was to assess the effectiveness of acupuncture with fire needling on acupoint BL67 for version of breech presentation. Study design: This was a randomized, sham-controlled, single-blinded trial, which took place in Strasbourg teaching maternity hospital, France. A total of 259 patients between 32 and 34 weeks of gestation have been randomized and analyzed. Patients were randomized to either acupuncture with fire needling or sham group, and were analyzed in their initial allocation group. Statistical analysis was conducted using Bayesian methods, in univariate analysis and in multivariate analysis after adjustment on parity. Results: The primary outcome was the rate of cephalic presentations at ultrasound examination performed between 35 and 36 weeks of gestation. A total of 49 (37.7%) fetuses were in cephalic presentation in the acupuncture group, versus 37 (28.7%) in the sham group: RR 1.34 [0.93-1.89], Pr RR>1=94.3%. After adjustment on parity, the acupuncture did not increase the rate of fetal cephalic version: OR 1.47 [0.84-2.42], Pr OR>1=90.3%. Conclusions: Our study suggests that acupuncture with fire needling on acupoint BL67 does not promote fetal cephalic version. Further studies might investigate effectiveness of other protocols of acupuncture. Randomization should be stratified for nulliparous and parous patients. Keywords: Acupuncture; Breech presentation; Fire needling; Version.

The primary objective of our study was to evaluate the long-term neurodevelopment outcome after laser surgery for twin-twin transfusion syndrome (TTTS). The secondary objective was to identify perinatal prognostic factors associated with neurodevelopmental impairment.This was a single-center cohort prospective study carried out in pregnancies complicated by TTTS and treated by laser. Neurodevleopmental assesment included the administration of Ages and Stages Questionnaires® (ASQ), for the infants between 2 and 5 years of age.A total of 187 patients underwent a laser for TTTS between 2004 and 2013. Significant brain lesions were detected in eight (2.9%) cases by ultrasound and/or magnetic resonance imaging including intraventricular hemorrhage, periventricular leukomalacia, and porencephaly. Questionnaires were administered to 126 children (50.4%) at 24 months or older at the moment of testing. There were 13.5% of those infants who had an abnormal ASQ (established as one area or more scoring 2 SD) at 3.6 years ±1.3 follow-up. There was a higher rate of abnormal ASQ among the infants with a birth weight below the fifth percentile (p = 0.036).Twin-twin transfusion syndrome is associated with a risk of abnormal neurological development, even in case of laser surgery. Further studies are necessary to identify the risk factors for neurological impairment. © 2016 John WileySons, Ltd.

International audience; 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).

International audience; ObjectiveTo determine whether breech presentation is an independent risk factor for neonatal morbidity, mortality, or long-term neurologic morbidity in very preterm infants.DesignProspective population-based cohort.PopulationSingletons infants without congenital malformations born from 27 to 32 completed weeks of gestation enrolled in France in 1997 in the EPIPAGE cohort.MethodsThe neonatal and long-term follow-up outcomes of preterm infants were compared between those in breech presentation and those in vertex presentation. The relation of fetal presentation with neonatal mortality and neurodevelopmental outcomes was assessed using multiple logistic regression models.ResultsAmong the 1518 infants alive at onset of labor included in this analysis (351 in breech presentation), 1392 were alive at discharge. Among those eligible to follow up and alive at 8 years, follow-up data were available for 1188 children. Neonatal mortality was significantly higher among breech than vertex infants (10.8% vs. 7.5%, P = 0.05). However the differences were not significant after controlling for potential confounders. Neonatal morbidity did not differ significantly according to fetal presentation. Severe cerebral palsy was less frequent in the group born in breech compared to vertex presentation but there was no difference after adjustment. There was no difference according to fetal presentation in cognitive deficiencies/learning disabilities or overall deficiencies.ConclusionOur data suggest that breech presentation is not an independent risk factor for neonatal mortality or long-term neurologic deficiencies among very preterm infants.

Purpose: The aim of our study was to determine the risk factors and to describe the clinical presentation of women with uterine rupture without previous caesarean delivery. Methods: Case-control study involving all cases of uterine rupture in the unscarred uterus detected during labour or in the post-partum between January 1, 2004 and April 1, 2016. For the control we included four controls for one case among all the patients with no record of previous caesarean delivery and planned vaginal delivery in the same period. For each woman we collected the maternal and labour characteristics. We evaluate the risk factors of uterine rupture, using Bayesian’s method. Each result is presented as a differential with a 95% credibility interval and the probability that the difference is greater or less than 0 (or 1 for the odds ratio). Results: We identified seven cases of spontaneous rupture. Deep and variable decelerations were the most frequent abnormal fetal rhythm. There was not maternal death but one neonatal death. Multiparity (estimated difference of 1.59 (95% CI=0.55, 2.95) Pr (diff>0)=1); use of oxytocin (OR=26.4 (95% CI=1.79-103) Pr (diff>0)=0.99), induced labour (OR=14 (95% CI=2.5, 122) Pr (diff>0)=1) ultrasound macrosomia (OR 30.0 (95% CI=4.3-327) Pr (diff>0)=0.99), were associated with uterine rupture. Conclusion: Even in developed countries, uterine rupture remains a serious complication with high maternal and fetal morbidity. We identified some risk factors like multiparity, induction of labour and macrosomia. These factors can help us to detect earlier this complication.

To compare intervention rates associated with labor in low-risk women who began their labor in the "home-like birth centre" and the traditional delivery room.This retrospective study used data that were collected from January 2005 through June 2008, from women admitted to the "home-like birth centre" (n=316) and compared to a group of randomly selected low-risk women admitted to the traditional labor ward (n=890) using the Baysian Information Criterion to select the best predictive model.Women in the "home-like birth centre" had spontaneous vaginal deliveries more often (88.6% versus 82.8%, P value 0.034) and perineal lesions less often (60.1% versus 62.5%, P value 0.013). The frequency of adverse neonatal outcomes did not differ statistically between the two groups, although mean clamped at birth umbilical arterial pH level was higher in the "home-like birth centre" group. The transfer rate from "home-like birth centre" to traditional labor ward was 31.3%.It appears that women could benefit from "home-like birth centre" care in settings such as the one studied. Larger observational studies are warranted to validate these results.

Resume Objectif Comparer le taux d’interventions medicales chez des patientes a bas risque en debut de travail en « maison de la naissance » versus salle de naissance traditionnelle. Patientes et methodes Cette etude retrospective utilise les donnees collectees entre janvier 2005 et juin 2008, des patientes admises en « maison de la naissance » ( n = 316) et d’un groupe de patientes a bas risque admises en salle de naissance traditionnelle selectionnees aleatoirement ( n = 890). L’analyse statistique univariee et multivariee a ete completee par une procedure de selection de modeles pour retenir le meilleur modele predictif. Resultats Les patientes admises en « maison de la naissance » avaient plus frequemment un accouchement par voie basse spontanee (88,6 % versus 82,8 % ; p 0,034) et moins de lesions perineales (60,1 % versus 62,5 % ; p 0,013). Pour autant, la frequence d’issues neonatales defavorables n’etait pas significativement differente entre les deux groupes bien que le pH arteriel neonatal etait significativement plus eleve dans le groupe « maison de la naissance ». Le taux de transfert de « maison de la naissance » en salle de naissance traditionnelle etait de 31,3 %. Discussion et conclusions Dans une « maison de la naissance » situee a proximite de la salle de naissance traditionnelle, les patientes desirant accoucher sans peridurale accouchent plus souvent spontanement sans que la morbidite perinatale ne soit alteree.

Summary Introduction Since 2004, the national exam for the validation of the second medicine cycle in France has been changed in its organization, its form and contents. The objective of this study is to analyze the records and the contents of this exam. Material and method We analyzed according to a predetermined grid, each record in the annals of the national exam for the validation of the second medicine cycle in France since 2004. This represents 72 records with 525 questions in 8 years. The study focused on the knowledge and skills required by the student as well as the correlation between the advice given by the National College that organizes this exam and the authors of the files on the subjects themselves, to namely the form and content. Results The record files contain on average 214 words (range 59–514) with an average of three to four types of data for analysis, which requires a real work of synthesis. Eighty percent of cases require a diagnostic approach for students, underpinned by a genuine reason and paraclinical strategy. Three quarters of the questions are questions of paraclinical, diagnostic and treatment. More than a record of three requires the interpretation of laboratory results and a record of two requires the interpretation of imaging or other diagnostic tests varied. They meet in large part to the objectives followed by the National College that organizes the national exam for the validation of the second medicine cycle in France. Conclusion The national exam for the validation of the second medicine cycle in France assesses students in their diagnostic approach and their ability to develop a coherent approach to manage the patient.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 2 - p. 115-121

Background Assisted vaginal delivery by vacuum extraction is frequent. Metallic resterilizible metallic vacuum cups have been routinely used in France. In the last few years a new disposable semi-soft vacuum extraction cup, the iCup, has been introduced. Our objective was to compare maternal and new-born outcomes between this disposable cup and the commonly used Drapier-Faure metallic cup. Methods This was a multicenter prospective randomized controlled open clinical trial performed in the maternity units of five university hospitals and one community hospital in France from October 2009 to February 2013. We included consecutive eligible women with a singleton gestation of at least 37 weeks who required vacuum assisted delivery. Women were randomized to vacuum extraction using the iCup or usual Drapier-Faure metallic cup. The primary outcome was a composite criterion including both the risk of cup dysfunction and the most frequent maternal and neonatal harms: the use of other instruments after attempted vacuum extraction, caesarean section after attempted vacuum extraction, three detachments of the cup, caput succedaneum, cephalohaematoma, episiotomy and perineal tears. Results 335 women were randomized to the disposable cup and 333 to extraction using the metallic cup. There was no significant difference between the two groups for the primary outcome. However, failed instrumental delivery was more frequent in the disposable cup group, mainly due to detachment: 35.6 % vs 7.1 %, p

Widespread use of intrapartum antimicrobial prophylaxis has significantly reduced the incidence of early-onset neonatal infection (EONI); however, little is known about the effects of increased maternal exposure to antibiotics on late-onset neonatal infection (LONI). This study aims to evaluate LONI epidemiology in our region after the application of French recommendations and to determine whether LONI-causing organisms and their antibiotic susceptibility are influenced by peripartum antibiotic exposure. We performed a prospective epidemiologic study of 139 confirmed and possible cases of bacterial LONI in patients treated with antibiotics for at least 5 days of the 22,458 infants born in our region in the year 2007. The overall incidence of LONI caused by all pathogens, Group B streptococcus (GBS) and Escherichia coli (E. coli) were 6.19, 0.36 and 2.72, respectively, per 1,000 live births. Our findings revealed three major types of LONI: E. coli-induced urinary tract infection (UTI) among term infants, coagulase negative Staphylococcus septicemia affecting preterm infants, and GBS infections with severe clinical presentation. Univariable analysis revealed that maternal antibiotic exposure was significantly associated with the risk of amoxicillin-resistant E. coli infection (p = 0.01). Postnatal antibiotic exposure was associated with an increased risk of E. coli LONI (p = 0.048). This link persisted upon multivariable analysis; however, no additional risk factors were identified for LONI caused by antibiotic-resistant E. coli. Conclusion Our findings confirm that despite the benefits of antenatal antibiotics, this treatment can increase the risk of antibiotic-resistant cases of LONI. National and international surveillance of LONI epidemiology is essential to assess benefits and potential negative consequences of perinatal antibiotic exposure.