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Background: induction of labor affects more than one in five deliveries in France. Some of them end in caesarean sections for failed induction, with varying rates between French Maternities. Different practices concerning the management of the latent phase of induction of labor could be one of the explanatory elements, as there is no professional recommendation on the maximum duration of stagnation before concluding that the induction has failed.Objective: to evaluate the effect of a more wait-and-see protocol on the duration of stagnation in the latent phase after an induction of labor on caesarean rates and perinatal outcomes.Study population and method: we conducted a retrospective bicentric observational “hereelsewhere” study. We collected data from medical chart from June 1st, 2019 to December 31st, 2019, in two level III maternities from “Assistance Publique – Hôpitaux de Paris”: Port-Royal (group A, “6 hours latent period” after amniotomy and with oxytocin) and Louis Mourier (group B, “12 hours latent period” after amniotomy and with oxytocin). We included all women with induction of labor receiving oxytocin, with a term, cephalic, singleton fetus, and without history of caesarean section. Primary outcome was the rate of caesarean.Results: we included 427 patients in Port-Royal and 147 patients in Louis Mourier. There were significantly fewer caesarean sections for failed induction in the more wait-and-see protocol group (20,6% in group A and 12,2% in group B (p=0,003)); but the global caesarean rate was not different (25,1% in group A and 27,9% in group B, with no significant difference). The more waitand-see protocol was associated with lower rate of postpartum haemorrhage (16,9% in group A and 7,5% in group B (p=0,01)). No difference was observed for neonatal morbidity (artery blood pH ≤ 7,20, Apgar score < 7 at 5 minutes of life, neonatal resuscitations rates, neonatal transfers rates for suspected or proven materno-foetal infection).Conclusion: a protocol with longer duration of stagnation in the latent phase seems to reduce caesarean rates for failure of induction and allow more women to enter the active phase of labor, without reducing the global caesarean rates. However, those results merit further examination with a larger randomised study.; Contexte : le déclenchement du travail concerne plus d’une femme sur cinq accouchant en France. Une partie d’entre eux aboutissent à des césariennes pour échec de déclenchement, dont les taux sont variables selon les maternités. Des pratiques différentes concernant la durée maximale de stagnation en phase de latence lors d’un déclenchement avant d’objectiver un échec de ce déclenchement pourraient en être un des éléments explicatifs, car aucune recommandation professionnelle française n’existe.Objectif : évaluer l’effet d’un protocole plus attentiste vis-à-vis de la durée d’une stagnation en phase de latence après un déclenchement du travail sur le taux de césariennes, ainsi que sur les issues périnatales.Population d’étude et méthode : nous avons mené une étude observationnelle ici-ailleurs, bicentrique, rétrospective sur dossiers entre le 1er Juin 2019 et le 31 Décembre 2019, dans deux maternités de l’AP-HP de type 3, avec deux protocoles différents de gestion de la phase de latence : Port-Royal (groupe A « latence 6 heures » après amniotomie et sous oxytocine) et Louis Mourier (groupe B « latence 12 heures » après amniotomie et sous oxytocine). Ont été inclues toutes les femmes avec une grossesse unique, à terme, sans utérus cicatriciel, ayant un fœtus vivant en présentation céphalique, ayant eu un déclenchement du travail et reçu de l’oxytocine. Le critère de jugement principal était le taux de césariennes.Résultats : nous avons inclus 427 patientes à Port-Royal et 147 patientes à Louis Mourier. Il y avait significativement moins de césariennes pour échec de déclenchement dans le groupe avec un protocole plus attentiste (20,6% dans le groupe A et 12,2% dans le groupe B (p=0,03)) ; mais le taux global de césariennes n’était pas moins important (25,1% dans le groupe A et 27,9% dans le groupe B, sans différence significative). Le protocole plus attentiste était associé à moins d’hémorragie du post-partum (16,9% dans le groupe A, 7,5% dans le groupe B (p=0,009)). Aucune différence n’était observée pour la morbidité néonatale (pH artériel au cordon ≤ 7,20, score d’Apgar < 7 à 5 minutes de vie, réanimation néonatale, transferts néonataux pour infection materno-foetale suspectée ou avérée).Conclusion : un protocole plus attentiste vis-à-vis de la durée de stagnation en phase de latence semble diminuer le nombre de césariennes pour échec de déclenchement en permettant à plus de femmes d’entrer en phase active du travail, sans pour autant diminuer le taux global de césariennes. Ces résultats seraient à confirmer par une étude randomisée de plus grande envergure.

Kleine-Levin syndrome (KLS) is a rare disorder characterized by severe episodic hypersomnia, with cognitive impairment accompanied by apathy or disinhibition. Pathophysiology is unknown, although imaging studies indicate decreased activity in hypothalamic/thalamic areas during episodes. Familial occurrence is increased, and risk is associated with reports of a difficult birth. We conducted a worldwide case.control genome-wide association study in 673 KLS cases collected over 14 y, and ethnically matched 15,341 control individuals. We found a strong genome-wide significant association (rs71947865, Odds Ratio [OR] = 1.48, P = 8.6 × 10-9) within the 3'region of TRANK1 gene locus, previously associated with bipolar disorder and schizophrenia. Strikingly, KLS cases with rs71947865 variant had significantly increased reports of a difficult birth. As perinatal outcomes have dramatically improved over the last 40 y, we further stratified our sample by birth years and found that recent cases had a significantly reduced rs71947865 association. While the rs71947865 association did not replicate in the entire follow-up sample of 171 KLS cases, rs71947865 was significantly associated with KLS in the subset follow-up sample of 59 KLS cases who reported birth difficulties (OR = 1.54, P = 0.01). Genetic liability of KLS as explained by polygenic risk scores was increased (pseudo R2= 0.15; P < 2.0 ∼ 10-22at P = 0.5 threshold) in the follow-up sample. Pathway analysis of genetic associations identified enrichment of circadian regulation pathway genes in KLS cases. Our results suggest links between KLS, circadian regulation, and bipolar disorder, and indicate that the TRANK1 polymorphisms in conjunction with reported birth difficulties may predispose to KLS.

Background: premature rupture of the membranes at term (PROM) is a frequent event. Its occurrence can lead to several complications, both maternal, fetal and neonatal. Approximately 25 percent of these patients have a favorable cervix at the time of admission to maternity. As there is no consensus on management, the identification of an optimal interval for the onset of labor that minimises obstetric and infectious risks appears to be a real challenge in this context. Materials and methods: we conducted a retrospective, multi-centered, observational study in three centers with different treatment policies: immediate induction (Robert Debré maternity), 24-hours expectation (Port-Royal maternity) or 48-hours expectation (Trousseau maternity). Our main judgment criterion was caesarean section by failure to induce. Our secondary endpoints were infectious maternal outcomes, infectious neonatal outcomes, and obstetrical outcomes related to oxytocin use. Our analyses were performed with intent to treat and then per-protocol. Main results: the rate of caesarean section by failure to rinduce was similar in all three groups. In case of expectation, the extension of this one beyond 24 hours did not increase the rate of spontaneous labour. Despite higher use of oxytocin at Robert Debré, related obstetrical consequences (uterine rupture, postpartum hemorrhage) were not more frequent compared with other centers. Moreover, the waiting period did not influence the infectious outcomes of the mother-child couple. Conclusion: this study did not allow us to identify an optimal management protocol to reduce maternal-fetal risks. On the other hand, though, the data in the literature does not recommend an expectation of more than 48 hours. The decision concerning the mode of management in the case of premature rupture of the membranes at term with favorable local conditions should therefore take into account the patient's wishes and the service constraints. Further researches are needed to conclude.; Introduction : la rupture des membranes à terme avant travail est un évènement fréquent. Sa survenue peut entrainer un certain nombre de complications tant sur le plan maternel que sur le plan fœtal et néonatal. Environ 25% de ces patientes présentent un col favorable au moment de leur admission en maternité. La prise en charge n’étant pas consensuelle, l’identification d’un intervalle optimal d’entrée en travail minorant les risques obstétricaux et infectieux apparait être dans ce contexte un réel enjeu. Matériel et méthode : nous avons mené une étude observationnelle, rétrospective et multicentrique au sein de trois centres préconisant des politiques de prise en charge différentes : déclenchement d’emblée (maternité Robert Debré), expectative 24h (maternité Port-Royal) ou expectative 48h (maternité Trousseau). Notre critère de jugement principal était la césarienne par échec de déclenchement. Nos critères de jugement secondaires étaient les suivants : les issues maternelles infectieuses, les issues néonatales infectieuses ainsi que les issues obstétricales liées à l’utilisation d’oxytocine. Nos analyses ont été réalisées en intention de traiter puis en per-protocole. Résultats principaux : le taux de césarienne par échec de déclenchement retrouvé était similaire dans les trois groupes. En cas d’expectative, la prolongation de celle-ci au-delà de 24h n’augmentait pas significativement le taux d’entrée en travail spontané. Malgré une utilisation plus importante d’oxytocine à Robert Debré, les conséquences obstétricales liées à celle-ci (rupture utérine, hémorragie du post-partum) n’étaient pas plus fréquentes comparativement aux autres centres. Par ailleurs, le délai d’expectative retenu n’influençait pas les issues infectieuses du couple mère-enfant. Conclusion : cette étude ne nous a pas permis d’identifier un protocole de prise en charge optimal réduisant les risques materno-fœtaux. En revanche, les données de la littérature ne préconisent pas une expectative supérieure à 48h. La prise de décision concernant le mode de prise en charge en cas de rupture des membranes à terme avant travail avec des conditions locales favorables devrait donc intégrer les souhaits de la patiente et les contraintes de service. Une étude de plus grande envergure serait nécessaire pour conclure.

The optimum time between two pregnancies which would allow to avoid maternal, fetal or neonatal complications is unknown. A too short period between two pregnancies could be deleterious. We find in the literature risk factors of these closely-spaced pregnancies. Objective: Identify eventual maternal, fetal and neonatal complications in a patient population presenting or not a scar womb and define the risk factors for the onset of these closely-spaced pregnancies. Materials and methods: It is a retrospective monocentric comparative case-control study, realized in a level 3 Parisian maternity (Robert-Debré) between January 2000 and July 2016 and including patients who gave birth at a time interval which is equal to or less than 21 months between two pregnancies (period between the beginning of the first and the second pregnancy).Results: The main determinant, independent from closely-spaced pregnancies are: age equal to or less than 21 years old, the lack of profession, the histories of " fetal loss ", prematurity, newborn children with a small born weight, the geographical origin. The tobacco as well as the artificial feeding and the lack of contraception in post-partum are determinants found during the first pregnancy. A short period between pregnancies is associated with a significant higher risk of maternal transfusion in the immediate post-partum, prematurity, child with small born weight, hypotrophy, neonatal resuscitation and medical termination. Conclusion: A period of 24 months issued by the WHO and of 12 months for the CNGOF in case of scar womb are partially justified because of the increase of fetal and neonatal morbidity. However, it seems possible to prevent this morbidity by giving the couples information, correcting the risk factors and introducing an adapted monitoring.; Le délai optimal entre deux grossesses qui permettrait d'éviter des complications maternelles, fœtales ou néonatales n'est pas connu. Un délai trop court entre deux grossesses pourrait être délétère. On retrouve dans la littérature des facteurs de risques de ces grossesses rapprochées. Objectif : Identifier les éventuelles complications maternelles, fœtales et néonatales dans une population de patientes présentant ou non un utérus cicatriciel et définir les facteurs de risques de survenue de ces grossesses rapprochées. Matériels et méthodes : Il s'agit d'étude rétrospective comparative monocentrique, de type exposé-non exposé, réalisée au sein d'une maternité parisienne de niveau III (Robert-Debré) entre janvier 2000 et juillet 2016 chez les patientes qui ont accouché avec un intervalle ≤ 21 mois entre deux grossesses (délai entre le début de la première grossesse et le début la seconde). Résultats : Les principaux déterminants indépendants de grossesses rapprochées sont : l'âge ≤ 21 ans, l'absence de profession, les antécédents de « pertes fœtales », de prématurité, de nouveau-nés avec un petit poids de naissance, l'origine géographique. Le tabac ainsi que l'allaitement artificiel et l'absence de contraception dans le post-partum sont des déterminants retrouvés lors de la première grossesse. Un intervalle court entre les grossesses est associé à un risque significativement plus élevé de transfusion maternelle dans le post-partum immédiat, de prématurité, d'enfant de petit poids de naissance, d'hypotrophie, de réanimation néonatale et d'IMG. Conclusion : Les délais de 24 mois émis par l'OMS et de 12 mois en cas d'utérus cicatriciel par le CNGOF sont partiellement justifiés du fait de la morbidité fœtale et néonatale accrus. Toutefois, il semble possible de prévenir cette morbidité par l’information des couples, la correction des facteurs de risques et par la mise en place d'une surveillance adaptée.

Obstetric fistula has been eliminated in developed countries, but remains highly prevalent in sub-Saharan Africa. The End fistula campaign is the first concerted effort to eradicate the disease. The objective of this review is to retrieve and link available evidence to obstetric fistula prevention strategies in sub-Saharan Africa, since the campaign began. We searched databases for original research on obstetric fistula prevention. Fifteen articles meeting inclusion criteria were assessed for quality, and data extraction was performed. Grey literature provided context. Evidences from the articles were linked to prevention strategies retrieved from grey literature. The strategies were classified using an innovative target-focused method. Gaps in the literature show the need for fistula prevention research to aim at systematically measuring incidence and prevalence of the disease, identify the most effective and cost-effective strategies for fistula prevention and utilise innovative tools to measure impact of strategies in order to ensure eradication of fistula. (Afr J Reprod Health 2014; 18[3]: 118-127)Keywords: Obstetric fistula; Fistula prevention; Prevention strategies; Sub-Saharan Africa

International audience; OBJECTIVES: To determine whether prenatal identification of macrosomia (≥4000g) reduces neonatal complications and maternal perineal lesions during delivery. STUDY DESIGN: This historical cohort study (n=14,684 from the National perinatal database of the Audipog Association, France) included women with cephalic singleton term pregnancies. Among the babies born with macrosomia, we compared those who had been identified as such in utero (n=1211) with those who were not (n=13,473). The principal outcome was a composite variable defined as resuscitation in the delivery room, death in the delivery room or the immediate postpartum period, or transfer to a neonatal intensive care unit (NICU). The secondary outcome measures were neonatal trauma, 5-min Apgar score (≤4 and

International audience; AIM: To evaluate our practice following Clinical Practice Guidelines (CPG) of the French College of Obstetricians and Gynecologists (CNGOF) in 2005 advocating a policy of restrictive episiotomy and to show that a significative decrease in the rate of episiotomy does not increase the number of third and fourth degree perineal tears. MATERIAL AND METHODS: A retrospective study of episiotomies and third/fourth degree perineal tears of the year 2003 (before the CPG) was compared with the year 2007 (after the CPG). We analyzed the indications of episiotomies and compared the rate of episiotomies and severe perineal tears between the two periods. RESULTS: In 2003, the rate of episiotomies was 18.8% (upon 1755 vaginal deliveries). We observed 16 (9 per thousand) third-degree perineal tears, five of which was associated with episiotomies; and two (1 per thousand) fourth-degree perineal tears. In 2007, the rate of episiotomies was 3.4% (upon 1940 vaginal deliveries). There were eight (4 per thousand) third-degree and four (2 per thousand) fourth-degree perineal tears. The two periods of study were similar in terms of age, parity, gestational age, birthweight, rate of spontaneous deliveries, breech and instrumental deliveries. There were a difference regarding deliveries in the occipitoposterior position (5.8% vs 13.8% ; p=0.02). No significant difference was found between the rates of third degree (9 per thousand vs 4 per thousand ; p=0.059) and fourth degree perineal tears (1 per thousand vs 2 per thousand ; p=0.487). However, there was a significant decrease in the rate of episiotomies between the two periods (18.8% vs 3.4% ; p

International audience; We report a case of spontaneous uterine rupture in a 19 year-old patient Gravida 1 para 2 with no past history of uterine surgery. The diagnosis of uterine rupture, evoked in the early post-partum in the presence of acute abdominal pain, collapsus and haemoperitoneum on ultrasonography, was confirmed by laparotomy. Treatment consisted in hysterorrhaphy. The etiopathogenesis, clinical and therapeutical aspects of spontaneous unscarred uterine ruptures are discussed throughout a literature review.

Objective To compare two policies for episiotomy: restrictive and systematic. Design Quasi-randomised comparative study. Setting Two French university hospitals with contrasting policies for episiotomy: one using episiotomy restrictively and the second routinely. Population Seven hundred and seventy-four nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37–41 weeks. Methods A questionnaire was mailed 4 years after delivery. Sample size was calculated to allow us to show a 10% difference in the prevalence of urinary incontinence with 80% power. Main outcome measures Urinary incontinence, anal incontinence, perineal pain, and pain during intercourse. Results We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, there was no difference in the prevalence of urinary incontinence (26 versus 32%), perineal pain (6 versus 8%), or pain during intercourse (18 versus 21%) between the two groups. Anal incontinence was less prevalent in the restrictive group (11 versus 16%). The difference was significant for flatus (8 versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR = 1.84, 95% CI: 1.05–3.22). Conclusions A policy of routine episiotomy does not protect against urinary or anal incontinence 4 years after first delivery.

International audience; PURPOSE: To analyze the literature comparing two different policies for episotomy practice: liberal versus restrictive use. To search and discuss specific indications for episiotomy. METHODS: The Medline base was analyzed from 1970 to 2005. The articles where selected by using the key word episiotomy and selective or restrictive and routine or liberal. Every potential indications was crossed with episotomy. RESULTS: A policy implying a liberal practice of episiotomy is not better compared to a restrictive policy. The evidence-based medical literature favors avoiding routine episiotomy in low risk deliveries. Data are quite scarce concerning the different specific indications for episiotomy, and finally we can retain only one specific indication which is the short perineum when the distance between the fourchette and the center of the anus is less than 3 cm. Nevertheless, in order to improve delivery conditions obstetricians can advisably use episiotomy in accordance with their clinical assessment. CONCLUSION: There is no evidence in the literature favoring a liberal policy over a restrictive policy for the use of episiotomy, both in terms of fetal (Grade C) and maternal (Grade A) indications. A number of obstetrical situations considered as at risk do not systematically indicate an episiotomy. There are however circumstances in which a pertinent and prudent clinical assessment will lead the obstetrician to use an episiotomy.