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Objective. – To identify procedures to reduce maternal morbidity during cesarean. Material and methods. – The quality of evidence of the literature was assessed following the GRADE1 method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. Results. – Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the caesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood lossgt; 1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned caesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommenda- tion). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds. Conclusion. – In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

IntroductionOne of the drawbacks of fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia is the need for a second invasive intervention to reestablish airway patency. The “Smart-TO” (Strasbourg University-BSMTI, France) is a new balloon for FETO, which spontaneously deflates when positioned near a strong magnetic field, e.g., generated by a magnetic resonance image (MRI) scanner. Translational experiments have demonstrated its efficacy and safety. We will now use the Smart-TO balloon for the first time in humans. Our main objective is the efficacy of prenatal deflation of the balloon by the magnetic field generated by an MRI scanner.Material and methodsThis is a phase-I study conducted in the fetal medicine units of Antoine–Béclère Hospital, France, and UZ Leuven, Belgium. Conceived in parallel, protocols were amended by the local Ethics Committees, resulting in some minor differences. This trial is a single-arm interventional feasibility study. Twenty (France) and 25 (Belgium) participants will have FETO with the Smart-TO balloon. Balloon deflation will be scheduled at 34 weeks or earlier if clinically required. The primary endpoint is the successful deflation of the Smart-TO balloon after exposure to the magnetic field of an MRI, assessed through ultrasound immediately after MRI-exposure. The secondary objective is to report on the safety of the balloon. The percentage of fetuses in whom the balloon is deflated after exposure will be calculated with its 95% confidence interval. Safety will be evaluated by reporting the nature, number, and percentage of serious unexpected or adverse reactions.ConclusionThis phase-I study may provide the first evidence of the potential to reverse the occlusion by Smart-TO and free the airways non-invasively, as well a safety data.

Objective: The objective of our study was to assess the utility of sequential fetal urine analysis in severe lower urinary tract obstruction (LUTO) when selecting cases suitable for vesicoamniotic shunting. Material and Methods: This was a retrospective cohort study of cases of severe LUTO treated in our fetal medicine center from 1994 to 2013. Two fetal bladder samples were taken 24–48 h apart to assess renal function. A vesicoamniotic shunt was inserted in case of improvement in urinary biochemistry between the 2 samples. We assessed perinatal morbidity and mortality and renal function at 5 years. Results: Among a total of 26 LUTO cases with sequential urine analysis, 5 showed normal urinary biochemistry, 13 were abnormal, and 8 improved between the 2 samples. These 8 cases underwent vesicoamniotic shunt placement, leading to the birth of 6/8 (75%) live infants, 5/6 (83%) of whom had normal renal function at 5 years. The 5 cases with normal biochemistry occasioned 2 neonatal deaths and 3 children with normal renal function at 5 years. Elective termination of pregnancy was requested by parents for the fetuses exhibiting abnormal biochemistry. Conclusion: An improvement in urinary biochemistry between 2 sequential fetal bladder punctures in severe LUTO could be an effective criterion in the selection of candidates for vesicoamniotic shunting. However, the benefit of a shunt in fetuses with normal amniotic fluid remains to be evaluated in clinical trials.

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

Amniotic band syndrome is a rare condition. There have been few cases reported of fetoscopic band dissection. The aim of this case series is to report 3 cases of fetoscopic treatment for amniotic band syndrome, including indication for surgery, technical aspects, complications and outcomes. Fetoscopic treatment was performed respectively at 23 5/7 , 26 5/7 and 18 3/7 weeks' gestation. Two procedures were performed with a laser fiber through a single trocar whereas one surgery was performed with scissors. In conclusion, fetoscopic release of the amniotic bands in case of amniotic band syndrome is feasible with encouraging results in order to prevent amputation and dysfunction of the extremities.

OBJECTIVE Monochorionic twins with twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) are at increased risk of neurodevelopmental impairment (NDI). This meta-analysis aimed to identify the prevalence of and perinatal risk factors for NDI in TTTS survivors treated with FLP. METHODS We performed a search in PubMed, EMBASE, Scopus and Web of Science, from inception to 13 February 2021, for studies evaluating perinatal risk factors for NDI in children diagnosed prenatally with TTTS managed by FLP. Data on severity of TTTS at the time of diagnosis, defined according to the Quintero staging system, FLP-related complications and perinatal outcomes were compared between children with a history of TTTS treated with FLP with and those without NDI, which was defined as performance on a cognitive or developmental assessment tool ≥ 2 SD below the mean or a defined motor or sensory disability. A random-effects model was used to pool the mean differences or odds ratios (OR) with the corresponding 95% CIs. Heterogeneity was assessed using the I2 statistic. RESULTS Nine studies with a total of 1499 TTTS survivors were included. The overall incidence of NDI was 14.0% (95% CI, 9.0-18.0%). The occurrence of NDI in TTTS survivors was associated with later gestational age (GA) at FLP (mean difference, 0.94 weeks (95% CI, 0.50-1.38 weeks); P

International audience; Objective: Women with planned cesareans can require delivery before the scheduled date. However, data describing the morbidity associated with planned cesarean deliveries performed before the originally scheduled date is lacking. The objective of this study was to compare the morbidity associated with planned cesarean delivery performed before compared with on the scheduled date. Study design: This retrospective single-center cohort study included all 3595 women with singleton pregnancies and cesarean deliveries after 36+6 weeks. All cases were reviewed individually to identify the initial intended mode of delivery, determined before 37 weeks. We excluded the 2145 (59.7%) unplanned cesareans initially planned as vaginal deliveries. Finally, the analysis included 1450 women with planned cesareans: 1232 (85.0%) performed as scheduled, and 218 (15.0%) before that date. The composite outcomes of maternal morbidity was one or more of the morbidity measures, including surgical complications, postpartum hemorrhage, infection and thrombo-embolism. Neonatal morbidity measures included 5 min Apgar score < 7, arterial cord blood pH < 7.00, and admission to the neonatal intensive care unit (NICU). Results: Reasons for performing planned cesarean delivery before the scheduled date were as follows: onset of labor (n = 109; 50.0%), rupture of membranes (n = 85; 39.0%), preeclampsia (n = 9; 4.1%), scar pain in women with a previous cesarean (n = 6; 2.8%), unexplained vaginal bleeding (n = 5; 2.3%), and nonreassuring fetal heart rate (n = 4; 1.8%). Mean gestational age for planned cesarean deliveries before the scheduled date was 38.7 weeks ± 0.8 versus 39.2 weeks ± 0.7 for those performed when scheduled (P < 0.0001). The maternal morbidity composite outcome rate was significantly higher among planned cesareans performed early compared with those on the scheduled date: 18.3% vs 9.7%, respectively, P = 0.0002. It was still higher in the multivariable analysis: aOR 2.17, 95% CI 1.46–3.21, P = 0.0001. The neonatal composite outcome did not differ significantly between the two groups. Conclusion: In planned cesarean deliveries, maternal morbidity is higher for cesareans performed before rather than on the scheduled date. Studies without accurate intent-to-treat analyses underestimate the morbidity associated with planned cesareans. Accordingly, medical records must make it possible to distinguish planned cesarean deliveries performed before the scheduled date from those performed as planned.

Introduction: Testing for COVID-19 is a cornerstone of pandemic control. If conducted inappropriately, nasopharyngeal swab collection can be painful and preanalytical sample collection errors may lead to false negative results. Our objective was to develop a realistic and easily available synthetic simulator for nasopharyngeal swab collection.Materials and methods: The nasopharyngeal swab collection simulator was designed through different development steps: segmentation, computer-aided design (CAD), and 3D printing. The model was 3D printed using PolyJet technology, which allows multi-material printing using hard and soft materials.Results: The simulator splits in the parasagittal plane close to the septum to allow better visualization and understanding of nasal cavity landmarks. The model is able to simulate the softness and texture of different structural elements. The simulator allows the user to conduct realistic nasopharyngeal swab collection. A colored pad on the posterior wall of the nasopharynx provides real-time feedback to the user. The simulator also permits incorrect swab insertion, which is of obvious benefit from a training perspective. Comprehensive 3D files for printing and full instructions for manufacturing the simulator is freely available online via an open access link.Conclusion: In the context of the COVID-19 pandemic, we developed a nasopharyngeal swab collection simulator which can be produced by 3D printing via an open access link, which offers complete operating instructions.

BackgroundPre-pregnancy obesity and excessive gestational weight gain (GWG) are established risk factors for adverse pregnancy, delivery and birth outcomes. Pregnancy is an ideal moment for nutritional interventions in order to establish healthier lifestyle behaviors in women at high risk of obstetric and neonatal complications.MethodsElectronic-Personalized Program for Obesity during Pregnancy to Improve Delivery (ePPOP-ID) is an open multicenter randomized controlled trial which will assess the efficacy of an e-health web-based platform offering a personalized lifestyle program to obese pregnant women in order to reduce the rate of labor procedures and delivery interventions in comparison to standard care. A total of 860 eligible pregnant women will be recruited in 18 centers in France between 12 and 22 weeks of gestation, randomized into the intervention or the control arm and followed until 10 weeks of postpartum.The intervention is based on nutrition, eating behavior, physical activity, motivation and well-being advices in which personalization is central, as well as the use of a mobile/tablet application. Inputs includes data from the medical record of participants (medical history, anthropometric data), from the web platform (questionnaires on dietary habits, eating behavior, physical activity and motivation in both groups), and adherence to the program (time of connection for the intervention group only). Data are collected at inclusion, 32 weeks, delivery and 10 weeks postpartum. As primary outcome, we will use a composite endpoint score of obstetrical interventions during labor and delivery, defined as caesarean section and instrumental delivery (forceps and vacuum extractor). Secondary outcomes will consist of data routinely collected as part of usual antenatal and perinatal care, such as GWG, hypertension, preeclampsia, as well as fetal and neonatal outcomes including premature birth, gestational age at birth, birth weight, macrosomia, Apgar score, arterial umbilical cord pH, neonatal traumatism, hyperbilirubinemia, respiratory distress syndrome, transfer in neonatal intensive care unit, and neonatal adiposity. Post-natal outcomes will be duration of breastfeeding, maternal weight retention and child weight at postnatal visit.DiscussionThe findings of the ePPOP-ID trial will help design e-health intervention program for obese women in pregnancy.Trial registrationClinicalTrials.govIdentifier:NCT02924636/ October 5th 2016.

Objectives: Most of the ultrasound machines include a tool allowing real-time display of the standard value of the biometric measurement being taken. Our hypothesis was that this tool influences the sonographer as measurements are taken, by inducing a normalization, thus a tendency towards the 50th percentile. The objective of this study was to evaluate the impact of a real-time display of the standard value in prenatal ultrasound screening. Methods: We conducted an observational, prospective, controlled and open study including all patients who underwent a prenatal ultrasound scan in the 2nd or 3rd trimester at the University Hospitals in Strasbourg between December 2017 and June 2018. Exclusion criteria were the presence of a fetal morphological abnormality or a karyotypic abnormality. The tool being tested was the real-time display on screen of the gestational age, of which the measurement corresponds to the 50th percentile. The measurements were retrospectively transformed into Z-scores. The main end-point was to compare the distribution of Z-scores between the groups. Results: We included 3551 ultrasound examinations: 696 performed with the tool and 2796 performed without. Fifty-nine scans were excluded due to morphological abnormalities. There was no statistically significant difference between the Z-scores distributions of measurements performed with or without the tool, regardless of the parameter studied. There was also no difference in the detection of pathological measurements: below the 10th percentile or above the 90th percentile. Conclusion: The use of such a tool does not seem to be detrimental to biometric screening, but on the other hand does not seem useful either. Keywords: Contrôle qualité; Dépistage prénatal; Fetal biometry; Prenatal ultrasonography; Quality Control; Z-scores; Échographie.

Objective To investigate the efficacy and safety of the 'smart' tracheal occlusion (Smart-TO) device in fetal lambs with diaphragmatic hernia (DH). Methods DH was created in fetal lambs on gestational day 70 (term, 145 days). Fetuses were allocated to either pregnancy continuation until term (DH group) or fetoscopic endoluminal tracheal occlusion (TO), performed using the Smart-TO balloon on gestational day 97 (DH + TO group). On gestational day 116, the presence of the balloon was confirmed on ultrasound, then the ewe was walked around a 3.0-Tesla magnetic resonance scanner for balloon deflation, which was confirmed by ultrasound immediately afterwards. At term, euthanasia was performed and the fetus retrieved. Efficacy of occlusion was assessed by the lung-to-body-weight ratio (LBWR) and lung morphometry. Safety parameters included tracheal side effects assessed by morphometry and balloon location after deflation. The unoccluded DH lambs served as a comparator. Results Six fetuses were included in the DH group and seven in the DH + TO group. All balloons deflated successfully and were expelled spontaneously from the airways. In the DH + TO group, in comparison to controls, the LBWR at birth was significantly higher (1.90 (interquartile range (IQR), 1.43-2.55) vs 1.07 (IQR, 0.93-1.46); P = 0.005), while on lung morphometry, the alveolar size was significantly increased (mean linear intercept, 47.5 (IQR, 45.6-48.1) vs 41.9 (IQR, 38.8-46.1) μm; P = 0.03); whereas airway complexity was lower (mean terminal bronchiolar density, 1.56 (IQR, 1.0-1.81) vs 2.23 (IQR, 2.14-2.40) br/mm2 ; P = 0.005). Tracheal changes on histology were minimal in both groups, but more noticeable in fetal lambs that underwent TO than in unoccluded lambs (tracheal score, 2 (IQR, 1-3) vs 0 (0-1); P = 0.03). Conclusions In fetal lambs with DH, TO using the Smart-TO balloon is effective and safe. Occlusion can be reversed non-invasively and the deflated intact balloon expelled spontaneously from the fetal upper airways. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

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

OBJECTIVE The long-term morbidity associated with isolated left-sided congenital diaphragmatic hernia (CDH) has been described previously. However, antenatal criteria impacting gastrointestinal morbidity (GIM) are not yet defined. The objective of this study was to evaluate the effect of fetal stomach position on the risk of GIM at 2 years of age in children with left-sided CDH. METHODS This was a retrospective, observational multicenter cohort study of data obtained from January 2010 to January 2014, that included patients whose fetus had isolated left-sided CDH, with or without fetal endoscopic tracheal occlusion (FETO). Prenatal maternal, fetal and pediatric data were collected. Fetal stomach position was evaluated a posteriori by two observers, using ultrasound images at the level of the four-chamber view of the heart that had been obtained to calculate the observed-to-expected lung-area-to-head-circumference ratio (O/E-LHR). Fetal stomach position was graded as follows: Grade 1, stomach not visualized; Grade 2, stomach visualized anteriorly, next to the apex of the heart, with no structure in between the stomach and the sternum; Grade 3, stomach visualized alongside the left ventricle of the heart, and abdominal structures anteriorly; or Grade 4, as Grade 3 but with stomach posterior to the level of the atrioventricular heart valves. The primary outcome was GIM at 2 years of age, assessed in a composite manner, including the occurrence of gastroesophageal reflux disease, need for gastrostomy, duration of parenteral and enteral nutrition and persistence of oral aversion. Regression analysis was performed in order to investigate the effect of O/E-LHR, stomach position and FETO on various GIM outcome variables. RESULTS Forty-seven patients with fetal left-sided CDH were included in the analysis. Thirteen (27.7%) infants did not meet the criterion of exclusive oral feeding at 2 years of age. Fetal stomach position grade was associated significantly and independently with the duration of parenteral nutrition (odds ratio (OR), 19.86; P = 0.031) and persistence of oral aversion at 2 years (OR, 3.40; P = 0.006). On multivariate analysis, O/E-LHR was predictive of the need for prosthetic patch repair, but not for GIM. FETO did not seem to affect the risk of GIM at 2 years. CONCLUSION In isolated left-sided CDH, fetal stomach position is the only factor that is predictive of GIM at 2 years of age. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Vanishing gastroschisis (VG) is a severe complication of gastroschisis with a high mortality rate. We report here a case of VG with a favorable outcome after a 3-year follow-up. A 26-year-old primigravida woman was referred to Strasbourg University Hospital because her fetus was diagnosed with an isolated gastroschisis at 13-week gestation. The ultrasound evolution was marked by a progressive closure of the abdominal wall defect from 19-week gestation and the appearance of dilated intra-abdominal loops. The child was born with a closed abdominal wall except a small remnant at the level of the former gastroschisis orifice. Explorative laparotomy revealed extensive midgut atresia with only 50 cm of remaining midgut. A jejunocolic anastomosis was performed. The child is now 3 years old and has a favorable outcome with only 2 nights a week of parenteral nutrition. A total of 39 cases of VG type D from Perrone et al. classification are described in the literature from 1991 to 2019, among which 19 (48.7%) are alive at the time of publication but only 4 cases are described with a long-term follow-up of 3 years or more. This is the fifth case described with a favorable evolution after 3-year follow-up.

International audience; Objective: To determine the optimal management of singleton fetuses in breech presentation. Materials and methods: Consultation of the PubMed database, the Cochrane Library and guidelines issued by the French and foreign obstetrical societies or colleges. Results: In France, 5% of women have breech deliveries (level of evidence [LE] 3). One third of them have a planned vaginal delivery (LE3), and 70% of these give birth vaginally (LE3). External cephalic version (ECV) is associated with lower rates of both breech presentation at birth (LE2) and of cesarean deliveries (LE3) without any increase in severe maternal (LE3) or perinatal morbidity (LE3). Women with a fetus in breech presentation at term should be informed that ECV can be attempted starting at 36 weeks of gestation (professional consensus). Planned vaginal delivery of breech presentation may be associated with a higher risk of composite perinatal mortality or serious neonatal morbidity than planned cesarean birth (LE2). These two modes do not differ for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), or adult intellectual performance (LE4). Short- and long-term maternal complications appear similar in the two groups, unless subsequent pregnancies are under consideration. Pregnancies after a cesarean delivery are at higher risk of uterine rupture, placenta accreta spectrum disorders, and hysterectomy (LE2). Women who want a planned vaginal delivery should be offered a pelvimetry at term (Grade C) and should have ultrasonography to verify that the fetal head is not hyperextended (professional consensus) to plan their mode of delivery. Complete breech presentation, a previous cesarean, nulliparity, and term prelabor rupture of membranes are not, each one by itself, per se contraindications to planned vaginal delivery (professional consensus). Term breech presentation is not a contraindication to labor induction when the criteria for planned vaginal delivery are met (Grade C). Conclusion: In cases of breech presentation at term, the child and the mother are at low risk of severe morbidity after either planned vaginal or planned cesarean delivery. The French College of Obstetricians and Gynecologists (CNGOF) considers that planned vaginal delivery is a reasonable option in most cases (professional consensus). The decision about the planned route of delivery should be shared by the woman and her healthcare provider, who must respect her right to autonomy.

International audience; Objectives. – To determine the optimal management of singleton breech presentation. Materials and methods. – The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. Results. – In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long terms maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies. A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy (LE2). It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term (Grade C) and to check the absence of hyperextension of the fetal head by ultrasonography (Professional consensus) to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery (Professionnal consensus). Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met (Grade C). Conclusion. – In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy.; ObjectifDéterminer les modalités de prise en charge en cas de présentation du siège.Matériel et méthodesConsultation de la base de données MedLine, de la Cochrane Library et des recommandations des sociétés savantes françaises et étrangères.RésultatsEn France, 5 % des femmes accouchent d’un enfant en présentation du siège (NP3). Un tiers d’entre elles ont une tentative de voie basse (TVB) (NP3), et 70 % de ces dernières accouchent par voie basse (NP3). La tentative de version par manoeuvre externe (VME) est associée à une diminution du taux des présentations du siège à l’accouchement (NP2) et à une diminution du taux de césarienne (NP3) sans augmentation de la morbidité maternelle (NP3) et périnatale sévère (NP3). Il est recommandé d’informer les femmes ayant une présentation du siège de la possibilité de réaliser une tentative de VME à partir de 36 SA (Accord professionnel). En cas de présentation du siège à terme, la TVB pourrait être associée à une augmentation du risque composite de mortalité périnatale ou de survenue d’une morbidité néonatale sévère comparativement à la césarienne programmée (CP) (NP2). Il n’a pas été retrouvé de différence entre la TVB et la CP concernant le développement neurologique de l’enfant à 2 ans (NP2), le développement psychomoteur et cognitif entre 5 et 8 ans (NP3), et le niveau intellectuel à l’âge adulte (NP4). Les risques de complications maternelles sévères à court et à long terme semblent comparables après une TVB et une CP en l’absence de grossesse ultérieure. En cas de grossesse ultérieure, l’antécédent de césarienne expose la femme à des complications sévères (placenta accreta, rupture utérine notamment). Il est recommandé de proposer aux femmes qui souhaitent une TVB à terme une pelvimétrie (Grade C) et de vérifier l’absence d’hyperextension de la tête fœtale (Accord professionnel) pour décider avec elles de leur voie d’accouchement. La présentation du siège complet, l’antécédent de césarienne, la nulliparité, la rupture des membranes à terme avant travail ne contre-indiquent pas la TVB (Accord professionnel). La présentation du siège à terme n’est pas une contre-indication à un déclenchement du travail lorsque les critères d’acceptation de la voie basse sont réunis (Grade C).ConclusionEn cas de présentation du siège à terme, les risques de complications sévères pour l’enfant et la mère sont faibles en cas de TVB ou de CP. Pour le Collège national des gynécologues et obstétriciens français, la TVB est une option raisonnable dans la majorité des cas (Accord professionnel). Le choix de la voie d’accouchement doit être partagé par la patiente et le médecin, en respectant le droit à l’autonomie de la patiente (Accord professionnel).

Resume Objectif Determiner les mesures permettant de diagnostiquer, prevenir et traiter l’infection herpetique genitale au cours de la grossesse et de l’accouchement ainsi que l’infection neonatale. Materiel et methodes Consultation de la base de donnees Medline, de la Cochrane Library et des recommandations des societes savantes francaises et etrangeres. Resultats L’eruption herpetique genitale est le plus souvent due a l’Herpes simplex virus 2 (HSV2) (NP2). Le risque de seroconversion HSV pendant la grossesse est de 1 a 5 % (NP2). Devant une lesion genitale typique d’un herpes chez une femme ayant un antecedent d’herpes genital connu, il s’agit d’une recurrence herpetique et une confirmation virologique n’est pas necessaire (grade B). Chez une femme n’ayant pas d’antecedent d’herpes genital connu il est recommande d’effectuer un prelevement par ecouvillonnage de la lesion et de privilegier l’amplification genique (PCR) (Accord professionnel) et des serologies specifiques de type (Accord professionnel). En cas d’episode initial d’herpes genital pendant la grossesse, il est recommande d’initier un traitement antiviral par aciclovir (200 mg × 5 par jour) ou valaciclovir (1000 mg × 2 par jour) pendant 5 a 10 jours (grade C). En cas de recurrence herpetique en cours de grossesse, un traitement par aciclovir (200 mg × 5 par jour) ou valaciclovir (500 mg × 2 par jour) pendant 5 jours peut etre propose (grade C). Le risque d’herpes neonatal est estime entre 25 % et 44 % en cas d’episode initial (NP2) et a 1 % en cas de recurrence (NP3) lors de l’accouchement. Une prophylaxie antivirale doit etre proposee aux femmes ayant un episode initial ou une recurrence herpetique en cours de grossesse, a partir de 36 SA et jusqu’a l’accouchement (grade B). En cas d’antecedent d’herpes genital sans episode de recurrence au cours de la grossesse, il n’est pas recommande de proposer systematiquement un traitement prophylactique (Accord professionnel). Il est recommande de realiser une cesarienne en cas de suspicion d’episode initial d’herpes genital au moment du travail (grade B), ou de rupture de la poche des eaux a terme (Accord professionnel), ou en cas d’episode initial d’herpes genital survenu moins de 6 semaines avant l’accouchement (Accord professionnel). En cas de recurrence herpetique en debut de travail, une cesarienne sera d’autant plus a considerer que les membranes sont intactes. En revanche un accouchement par voie vaginale sera d’autant plus a considerer qu’il existe une rupture prolongee des membranes (Accord professionnel). L’herpes neonatal est rare et principalement du a HSV-1 (NP3). Dans la majorite des cas d’herpes neonatal, l’interrogatoire ne retrouve aucun antecedent maternel d’herpes (NP3). En cas de suspicion d’herpes neonatal, des prelevements (sang et liquide cephalorachidien) avec recherche d’ADN viral par PCR doivent etre realises pour confirmer le diagnostic (Accord professionnel) et un traitement par aciclovir intraveineux (grade A) a la posologie de 60 mg/kg/j reparti en 3 injections (grade C) doit etre debute sans attendre les resultats des prelevements (Accord professionnel). La duree du traitement depend de la forme clinique (Accord professionnel). Conclusion Il n’existe pas de preuve formelle qu’il soit possible de diminuer le risque d’herpes neonatal en cas d’herpes genital pendant la grossesse. Cependant, une prise en charge adaptee permet de diminuer la symptomatologie liee a l’herpes, le risque de recurrence a terme, ainsi que le taux de cesariennes realisees pour lesions herpetiques.

Entre las distintas exploraciones para la vigilancia del feto durante la gestacion, el analisis informatizado del ritmo cardiaco fetal (RCF) permite, al contrario que el RCF convencional, una lectura objetiva y reproducible del RCF. De los diferentes sistemas de analisis informatizado disponibles en la actualidad, el sistema Oxford, desarrollado por Dawes y Redman hace mas de 30 anos, es el mas avanzado y el mejor evaluado, y es el que se presenta en este articulo. El analisis informatizado, que segmenta el registro del RCF en periodos de 3,75 segundos, calcula el valor promedio del RCF para cada periodo y proporciona parametros numericos, unos de ellos clasicos (ritmo basal, numero de aceleraciones, etc.), pero tambien otros parametros no visibles a simple vista, como la variabilidad a corto plazo (VCP) o los episodios de alta y baja variacion. El sistema Sonicaid Oxford trata de validar una serie de criterios, que, una vez reunidos, le permiten juzgar si el trazado es satisfactorio. Este modo de analisis suprime cualquier subjetividad y permite tambien reducir de forma significativa la duracion del registro, sobre todo en fases alejadas de la fecha probable de parto. En los embarazos de alto riesgo y, en particular, en los casos de crecimiento intrauterino retardado antes de la fecha probable de parto, la VCP es el parametro mas util (entre las distintas informaciones extraidas del RCF) para decidir una extraccion antes de dicha fecha. Correlaciona con el estado acidobasico del feto, pero varia con la edad gestacional. La VCP, que es facil de obtener, es uno de los ultimos parametros que se alteran antes de que se produzca una muerte intrauterina o una interrupcion de la gestacion. Por ello, forma parte del arsenal de vigilancia de los fetos de riesgo, sobre todo antes de las 32 semanas de amenorrea.

Resume But Rapporter les donnees preoperatoires, caracteristiques chirurgicales, complications et le devenir perinatal des grossesses gemellaires compliquees de syndrome transfuseur-transfuse (STT) traitees par coagulation laser fœtoscopique. Analyser les facteurs predictifs de survie neonatale et comparer les 100 cas les plus recents avec les 100 les plus anciens. Materiels et methodes Etude de cohorte observationnelle monocentrique de 200 grossesses gemellaires monochoriales biamniotiques compliquees de STT prises en charge entre janvier 2004 et decembre 2014 et traitees par coagulation laser fœtoscopique. Resultats Parmi les 200 patientes traitees, on note 49 stades I, 88 stades II, 55 stades III et 8 stades IV. L’âge gestationnel moyen au laser etait de 20,1 ± 3,0 semaines d’amenorrhee (SA) tandis que l’âge gestationnel a l’issue de grossesse etait en moyenne de 31,6 SA ± 5,4. Le taux de survie neonatal global etait de 68,0 % avec la survie d’au moins un enfant dans 84,0 % des cas. Une rupture prematuree des membranes est survenue dans 39 cas en moyenne a 28,8 SA ± 4,6. Les parametres predictifs d’avoir au moins un enfant vivant etaient le stade de Quintero et l’âge gestationnel a l’accouchement. Dans la periode la plus recente, il y avait significativement plus de STT stade I de Quintero traites par laser, plus de coagulations selon Solomon et un nombre de vaisseaux coagules plus important. Conclusion La survie neonatale en cas de STT est amelioree par la photocoagulation laser fœtoscopique, idealement selon une technique de Solomon. L’interet d’une prise en charge active des stades I est a l’etude.

Ante el descubrimiento de una masa anexial, conviene ante todo descartar una urgencia quirurgica que pueda comprometer la funcion ovarica. Estas urgencias estan dominadas por las torsiones anexiales. En ausencia de urgencia terapeutica, un estudio completo (clinico, pruebas de imagen y biologico) debe permitir estimar el riesgo de malignidad y discutir la indicacion operatoria, asi como la via de abordaje quirurgica. Otros elementos pueden entrar en juego en la indicacion terapeutica: la existencia de infertilidad, en particular en caso de endometriosis, y el riesgo de torsion, sobre todo en caso de quistes de gran tamano. Este articulo revisa de manera practica los principales problemas que se plantean ante el descubrimiento de un tumor ovarico supuestamente benigno.

International audience; Objectives: The objective of this study was to assess whether the laterality of congenital diaphragmatic hernia (CDH) was a prognostic factor for neonatal survival.Methods : This was a cohort study using the French national database of the Reference Center for Diaphragmatic Hernias. The principal endpoint was survival after hospitalization in intensive care.We made a comparative study between right CDH and left CDH by univariate and multivariate analysis. Terminations and stillbirths were excluded from analyses of neonatal outcomes.Results: A total of 506 CDH were included with 67 (13%) right CDH and 439 left CDH (87%). Rate of survival was 49% for right CDH and 74% for left CDH (P < .01). Multivariate analysis showed two factors significantly associated with mortality: thoracic herniation of liver (OR 2.27; IC 95% [1.07-4.76]; P = .03) and lung-to-head-ratio over under expected (OR 2.99; IC 95% [1.41-6.36]; P < .01). Side of CDH was not significantly associated with mortality (OR 1.87; IC 95% [0.61-5.51], P = .26).Conclusion : Rate of right CDH mortality is more important than left CDH. Nevertheless after adjusting for lung-to-head-ratio and thoracic herniation of liver, right CDH does not have a higher risk of mortality than left CDH.

Objective We developed a new balloon called "Smart-TO," which allows noninvasive and easy unplugging, thanks to a magnetic valve actuated by the magnetic fringe field of a magnetic resonance imaging (MRI) scanner. The objective of this feasibility study was to evaluate the operation of this new balloon in a nonhuman primate model. Methods Four pregnant rhesus monkeys underwent fetal endoscopic tracheal occlusion using the "Smart-TO" balloon. The pregnant monkeys were simply carried around the perimeter of an MRI scanner a few days later. Study outcomes were feasibility of fetal tracheal occlusion using the "Smart-TO" balloon, persistence of the balloon in the fetal trachea, and deflation of the balloon when subjected to the magnetic fringe field of an MRI. Results At the time of the unplug procedure, in all cases, the balloon was still in a correct position, and its shape did not change based on their ultrasound appearance. After bringing the pregnant monkeys into the fringe field of the MRI scanner, the balloon deflated in all cases. Conclusion The balloon we developed allows noninvasive, easily triggered, and externally controlled reversal occlusion, based on the nonhuman primate model. Further tests evaluating occlusiveness and potential adverse effects are necessary.

No abstract available

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

Resume Introduction Les placentas anormalement adherents ne cessent d’augmenter au cours des dernieres annees et leur prise en charge est controversee. La cesarienne-hysterectomie, traitement habituellement recommande, est associee a une morbimortalite maternelle elevee. Le traitement conservateur, qui consiste au maintien in utero du placenta apres extraction fœtale, a ete propose par certaines equipes. Il semble associe a une morbidite maternelle moindre et permet la preservation de la fertilite. L’objectif de cette etude est d’evaluer les avantages/desavantages de ce traitement sur une serie continue de placenta accreta/increta ou percreta. Patientes et methodes Cette etude retrospective a inclus toutes les patientes presentant un placenta accreta, increta ou percreta diagnostiquees en antenatal entre le 1 er janvier 2007 et le 31 decembre 2014. Un traitement conservateur etait systematiquement tente. Le critere de jugement principal etait la conservation uterine et le critere de jugement secondaire, la morbimortalite maternelle definie par la survenue d’une complication dans les suites de l’accouchement. Resultats Quinze patientes (0,07 % des accouchements) ont ete incluses. Le traitement conservateur s’est deroule avec succes dans 80 % des cas. Aucun cas de deces maternel n’est survenu. Un episode hemorragique severe a ete rapporte chez 4 patientes (33,3 %) controle par la realisation dans un cas d’une embolisation des arteres uterines en urgence et dans 3 cas d’une hysterectomie d’hemostase en urgence. Une transfusion massive de 13,5 ± 4,5 culots globulaires en moyenne a ete necessaire pour ces 4 patientes. Aucune patiente n’a presente d’episode infectieux severe. Quatre patientes ont presente une endometrite 2,6 ± 0,5 mois en moyenne apres l’accouchement ; l’evolution a ete favorable apres antibiotherapie parenterale en hospitalisation conventionnelle. En moyenne, la vacuite uterine a ete obtenue apres 23,0 ± 7,2 semaines. A ce jour, 3 grossesses spontanees sans recidive sont survenues chez 2 patientes apres un delai moyen de conception de 19 ± 16,9 mois apres l’accouchement. Conclusion Le traitement conservateur semble prometteur, mais est associe a un risque non negligeable de complications secondaires necessitant une surveillance au long cours chez des patientes compliantes.

Se distinguen cuatro tipos de hipertension arterial (HTA) durante el embarazo: la HTA gravidica o gestacional (4,9%), la preeclampsia (2,1%), la HTA cronica (1%) y la preeclampsia sobreanadida a la HTA cronica. Los conocimientos sobre la fisiopatologia de la preeclampsia han avanzado mucho estos ultimos anos. La disfuncion placentaria que origina la preeclampsia tiene relacion con una anomalia de la invasion trofoblastica de las arterias espirales uterinas. Se asocia una disfuncion endotelial que da lugar a un aumento de la produccion de sustancias vasoconstrictoras (endotelina, tromboxano A2 y angiotensina II) y a una inhibicion de la produccion de sustancias vasodilatadoras (oxido nitrico [NO] y prostaciclina). La expresion anormal de ciertos factores angiogenicos (factor de crecimiento endotelial vascular, factor de crecimiento placentario, endoglina) desempena un papel a la vez en el defecto de invasion trofoblastica y en la disfuncion endotelial. Actualmente, se intentan precisar lo antes posible los factores de riesgo de preeclampsia para definir una deteccion precoz. Los que se estan estudiando en la actualidad combinan diferentes caracteristicas maternas, datos de los Doppler uterinos y determinaciones hoy disponibles de factores angiogenicos. La preeclampsia es un sindrome polifacetico que puede presentar numerosas complicaciones maternas y perinatales. Su estudio de evaluacion realizado con la paciente hospitalizada busca signos de gravedad de la preeclampsia, porque se tienen en cuenta segun la semana de embarazo para decidir el tratamiento. La corticoterapia es sistematica, mientras que los tratamientos antihipertensores solo tienen por objeto evitar las complicaciones vasculares cerebrales. La prevencion del episodio de eclampsia, asi como de su recidiva, se basa en el sulfato de magnesio. En las pacientes de riesgo, se propone, en un nuevo embarazo, una prevencion precoz con acido acetilsalicilico, pues el interes de las heparinas de bajo peso molecular esta en estudio. La HTA cronica es cada vez mas frecuente durante el embarazo. Su pronostico depende de la aparicion de preeclampsia sobreanadida. Esta ultima es mas frecuente en las pacientes que tienen antecedentes obstetricos o una enfermedad subyacente. Cuando la HTA cronica se considera de alto riesgo, el control y el tratamiento son muy diferentes.

Research question: Is luteal phase stimulation capable of improving fertility preservation? Materials and methods: We performed a retrospective cohort study of consecutive ovarian stimulations, during July 2012 and September 2018 at Strasbourg University Teaching Hospital in France. Enrollment criteria were patients aged below 40 who had been referred to our center following a diagnosis of cancer or requiring gonadotoxic treatment. All patients enrolled had regular menstrual cycles and normal ovulation. Non-enrollment criteria were an expected low ovarian response (defined by an anti-Müllerian hormone (AMH) level

Objective: Identify measures to diagnose, prevent, and treat genital herpes infection during pregnancy and childbirth as well as neonatal herpes infection. Materials and methods: Bibliographic search from the Medline and Cochrane Library databases and review of international clinical practice guidelines. Results: Genital herpes lesions are most often due to HSV-2 (LE2). The risk of HSV seroconversion during pregnancy is 1-5% (LE2). Genital herpes lesions during pregnancy in a woman with a history of genital herpes is a recurrence. In this situation, there is no need for virologic confirmation (Grade B). In pregnant women with genital lesions who report they have not previously had genital herpes, virological confirmation by PCR and identifying the specific IgG type is necessary (professional consensus). A first episode of genital herpes during pregnancy should be treated with aciclovir (200 mg 5 times daily) or valaciclovir (1000 mg twice daily) for 5-10 days (Grade C), and recurrent herpes during pregnancy with aciclovir (200 mg 5 times daily) or valaciclovir (500 mg twice daily) (Grade C). The risk of neonatal herpes is estimated at between 25% and 44% if a non primary and primary first genital herpes episode is ongoing at delivery (LE2) and 1% for a recurrence (LE3). Antiviral prophylaxis should be offered to women with either a first or recurrent episode of genital herpes during pregnancy from 36 weeks of gestation until delivery (Grade B). Routine prophylaxis is not recommended for women with a history of genital herpes but no recurrence during pregnancy (professional consensus). A cesarean delivery is recommended if a first episode of genital herpes is suspected (or confirmed) at the onset of labor (Grade B) or if it occured less than 6 weeks before delivery (professional consensus) or in the event of premature rupture of the membranes at term. When a recurrence of genital herpes is underway at the onset of labor, cesarean delivery is most likely to be considered when the membranes are intact and vaginal delivery in cases of prolonged rupture of membranes (professional consensus). Neonatal herpes is rare and mainly due to HSV-1 (LE3). In most cases of neonatal herpes, mothers have no history of genital herpes (LE3). When neonatal herpes is suspected, various samples (blood and cerebrospinal fluid) for HSV PCR must be taken to confirm the diagnosis (professional consensus). Any newborn with suspected neonatal herpes should be treated with intravenous acyclovir (20 mg/kg 3 times daily) (grade A) before the PCR results are available (professional consensus). The duration of the treatment depends on the clinical form (professional consensus) CONCLUSION: There is no formal evidence that it is possible to reduce the risk of neonatal herpes in genital herpes during pregnancy. However, appropriate care can reduce the symptoms associated with herpes and the risk of recurrence at term, as well as cesarean rate because of herpes lesions. Keywords: First episode of genital herpes; Mode of delivery; Prophylactic treatment; Recurrence.

Resume Objectif L’allo-immunisation est une pathologie dont l’incidence a fortement diminue mais dont le pronostic reste sombre en l’absence de traitement. L’objectif de notre etude etait d’evaluer le pronostic fœtal, le taux ainsi que les facteurs de risque de complications des transfusions in utero (TIU). Methodes Il s’agit d’une etude observationnelle retrospective portant sur 86 TIU chez 37 fœtus entre 2001 et 2017. Notre critere de jugement principal etait la survenue d’une complication secondaire a la procedure. Le critere composite de complications etait defini comme suit : rupture prematuree des membranes ou accouchement premature dans les 7 jours suivant le geste, chorioamniotite, anomalies du rythme cardiaque fœtal indiquant la realisation d’une cesarienne en urgence dans les 24 heures suivant une TIU, et deces in utero ou neonatal secondaire a une TIU. Resultats Le taux de survie etait de 88,9 % avec un taux de complications severes de 5,8 % par TIU et de 13,5 % par grossesse. Une TIU avant 20 semaines d’amenorrhee etait un facteur de risque de complications : 50 % de complications en cas de premiere TIU avant 20SA versus 1,3 % en cas de premiere TIU apres 20SA, p = 0,8 × 10−3. Au contraire, l’anasarque ne semblait pas etre un facteur de risque de complication (16,7 % en cas d’anasarque versus 3,9 % en l’absence d’anasarque, p = 0,27) mais ce resultat est a nuancer du fait du faible effectif d’anasarque. La voie d’abord, qu’elle soit intra-abdominale ou au niveau de l’insertion placentaire, n’avait pas d’influence sur le pronostic. Conclusion La TIU est une therapeutique permettant un pronostic obstetrical favorable et peu pourvoyeuse de complications graves. Neanmoins, la necessite de realiser une TIU precoce est souvent associee a des complications.

International audience; Among women with vaginal delivery who received prophylactic oxytocin, the use of tranexamic acid did not result in a rate of postpartum hemorrhage of at least 500 ml that was significantly lower than the rate with placebo. (Funded by the French Ministry of Health; TRAAP ClinicalTrials.gov number, NCT02302456 .).

Introduction: The objective was to report on a consecutive series of monochorionic diamniotic pregnancies complicated by selective Intra-Uterine Growth Restriction (sIUGR) and to describe perinatal outcomes based on whether or not there were umbilical Doppler findings, and specifically to study those pregnancies treated by laser. Material and methods: This was a retrospective cohort study enrolling monochorionic diamniotic pregnancies presenting isolated sIUGR after 16 weeks' gestation (WG). Results: Of the 25 cases of sIUGR, 16 were type I and 9 type II or III. Types II and III occurred earlier than type I (22.3 versus 24.3 WG), were more severe (discordance of 37% versus 23%), and delivered earlier (31.3 versus 33.9 WG). Survival was 12/18 (66.7%) for types II or III versus 32/32 (100%) for type I. Five laser photocoagulation procedures were attempted and allowed the survival of both twins in 2 cases. Overall survival after laser was 6/10 (60%). Discussion: Isolated sIUGR is associated with high perinatal morbidity and mortality. Laser photocoagulation treatment is feasible and may enable survival of both twins in some cases, but may be technically difficult. Keywords: Bichorionization; Laser photocoagulation; Monochorionic diamniotic pregnancies; Selective intra-uterine growth restriction; Umbilical Doppler.

Resume Objectif Determiner les mesures permettant de diagnostiquer, prevenir et traiter l’infection herpetique genitale au cours de la grossesse et de l’accouchement ainsi que l’infection neonatale. Methodes Consultation de la base de donnees MedLine, de la Cochrane Library et des recommandations des societes savantes francaises et etrangeres. Resultats L’eruption herpetique genitale est le plus souvent due a l’herpes simplex virus 2 (HSV2) (NP2). Le risque de seroconversion HSV pendant la grossesse est de 1 a 5 % (NP2). Devant une lesion genitale typique d’un herpes chez une femme ayant un antecedent d’herpes genital connu, il s’agit d’une recurrence herpetique et une confirmation virologique n’est pas necessaire (Grade B). Chez une femme n’ayant pas d’antecedent d’herpes genital connu, il est recommande d’effectuer un prelevement par ecouvillonnage de la lesion et de privilegier la polymerase chain reaction (PCR) (accord professionnel) et des serologies specifiques de type (accord professionnel). En cas d’episode initial d’herpes genital pendant la grossesse, il est recommande d’initier un traitement antiviral par aciclovir (200 mg × 5 par jour) ou valaciclovir (1000 mg × 2 par jour) pendant 5 a 10 jours (grade C). En cas de recurrence herpetique en cours de grossesse, un traitement par aciclovir (200 mg × 5 par jour) ou valaciclovir (500 mg × 2 par jour) peut etre propose (grade C). Le risque d’herpes neonatal est estime entre 25 % et 44 % en cas d’episode initial (NP2) et de 1 % en cas de recurrence (NP3) lors de l’accouchement. Une prophylaxie antivirale doit etre proposee aux femmes ayant un episode initial ou une recurrence herpetique en cours de grossesse, a partir de 36 SA et jusqu’a l’accouchement (grade B). En cas d’antecedent d’herpes genital sans episode de recurrence au cours de la grossesse, il n’est pas recommande de proposer systematiquement un traitement prophylactique (accord professionnel). Il est recommande de realiser une cesarienne en cas de suspicion d’episode initial d’herpes genital au moment du travail (grade B), ou de rupture de la poche des eaux a terme (accord professionnel), ou en cas d’episode initial d’herpes genital survenu moins de 6 semaines avant l’accouchement (accord professionnel). En cas de recurrence herpetique en debut de travail, une cesarienne sera d’autant plus a considerer que les membranes sont intactes. En revanche, un accouchement par voie vaginale sera d’autant plus a considerer qu’il existe une rupture prolongee des membranes (accord professionnel). L’herpes neonatal est rare et principalement du a HSV-1 (NP 3). Dans la majorite des cas d’herpes neonatal, l’interrogatoire ne retrouve aucun antecedent maternel d’herpes (NP 3). En cas de suspicion d’herpes neonatal, des prelevements (sang et liquide cephalorachidien) avec recherche d’ADN viral par PCR doivent etre realises pour confirmer le diagnostic (accord professionnel) et un traitement par aciclovir intraveineux (grade A) a la posologie de 60 mg/kg/j reparti en 3 injections (grade C) doit etre debute sans attendre les resultats des prelevements (accord professionnel). La duree du traitement depend de la forme clinique (accord professionnel). Conclusion Il n’existe pas de preuve formelle qu’il soit possible de diminuer le risque d’herpes neonatal en cas d’herpes genital pendant la grossesse. Cependant, une prise en charge adaptee permet de diminuer la symptomatologie liee a l’herpes, le risque de recurrence a terme, ainsi que le taux de cesariennes realisees pour lesions herpetiques.

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 But Les fausses couches repetees precoces sont un motif frequent de consultation. Un bilan etiologique est classiquement propose aux couples et une prise en charge preventive doit etre discutee. Nous avons voulu etudier les issues de grossesses suite a 3 fausses couches consecutives ainsi que les prises en charge proposees dans notre service de gynecologie-obstetrique en hopital universitaire. Materiels et methodes Une etude retrospective sur 10 ans a ete realisee dans notre centre permettant de retrouver 296 patientes ayant eu 3 fausses couches repetees. Les renseignements concernant les bilans de fausses couches realises et les modalites de prise en charge preventive ainsi que l’issue de la grossesse suivante ont ete recherches. Resultats Au total, 62,5 % des patientes ont eu un accouchement et 64,9 % avaient une anomalie au bilan quand celui-ci etait realise ( n = 148). Les pourcentages d’accouchements sont plus importants en cas de caryotype ou de bilan de thrombophilie normal ( p respectivement a 0,30 et 0,45). On note un meilleur pronostic de naissance vivante dans le groupe de patientes avec bilan normal ayant beneficie d’un traitement preventif ( n = 20 : 85 % d’accouchements, p = 0,19). Conclusion Lorsqu’ils sont realises les bilans de fausses couches permettent de retrouver des anomalies dans deux tiers des cas. Mais etonnamment les issues de la grossesse suivante sont tres encourageantes car pres de deux tiers des patientes ont eu une naissance vivante a la quatrieme grossesse. L’indication, l’interpretation et la prise en charge d’un bilan de fausse-couche doivent etre reflechies mais un traitement preventif semblerait avoir un effet positif dans le groupe de patientes avec bilan normal.

Objective To evaluate the efficacy of fetal intervention using fetal cystoscopy or vesicoamniotic shunting in the treatment of severe lower urinary obstruction (LUTO). Methods A cohort of 111 fetuses with severe LUTO attending two centers between January 1990 and August 2013 were included retrospectively. Fetuses were categorized into three groups based on the method of intervention: (1) fetal cystoscopy, (2) vesicoamniotic shunting or (3) no intervention. Multivariate analyses were performed to determine the probability of survival and normal renal function until 6 months of age by comparing fetal cystoscopy and vesicoamniotic shunting to no fetal intervention. Results Of the 111 fetuses with severe LUTO that were included in the analysis, fetal cystoscopy was performed in 34, vesicoamniotic shunting was performed in 16 and there was no fetal intervention in 61. Gestational age at diagnosis, method of fetal intervention and cause of bladder obstruction were associated with prognosis. In multivariate analysis and after adjustment for potential confounders (considering all causes of LUTO) the overall probability of survival was significantly higher with fetal cystoscopy and vesicoamniotic shunting when compared to no intervention (adjusted relative risk (ARR), 1.86 (95% CI, 1.01–3.42; P = 0.048) and ARR, 1.73 (95% CI, 1.01–3.08; P = 0.04) respectively). A clear trend for normal renal function was present in the fetal cystoscopy group (ARR, 1.73 (95% CI, 0.97–3.08; P = 0.06)) but was not observed in the vesicoamniotic shunt group (ARR, 1.16 (95% CI, 0.86–1.55; P = 0.33)). In cases in which there was a postnatal diagnosis of posterior urethral valves, fetal cystoscopy was effective in improving both the 6-month survival rate and renal function (ARR, 4.10 (95% CI, 1.75–9.62; P

La enfermedad tromboembolica (ETE) es, durante el embarazo, una de las causas principales de mortalidad y morbilidad materna en los paises desarrollados. Las modificaciones fisiologicas vinculadas al embarazo y otros factores como la edad materna, la paridad, la obesidad, un parto instrumental o por cesarea y la anestesia general aumentan el riesgo de ETE en los tres trimestres del embarazo y en el posparto. Casi el 15% de la poblacion europea caucasica tiene trombofilia, un trastorno congenito o adquirido de la hemostasia responsable de mas del 50% de los accidentes tromboembolicos. La trombosis venosa de los miembros inferiores puede adoptar numerosos aspectos clinicos mas o menos orientadores. Su diagnostico depende en primer lugar de la ecografia Doppler. Debido al embarazo, si se sospecha una embolia pulmonar no debe vacilarse en recurrir a la gammagrafia de perfusion-ventilacion o a la angiografia pulmonar. El tratamiento de la ETE se basa en el reposo en cama, la contencion elastica y los tratamientos heparinicos. En los ultimos anos se han intentado definir tratamientos profilacticos adecuados a la gravedad de los factores de riesgo y, en particular, al tipo de trombofilia.

We report below a case of in utero tracheoscopy with laser collapse of a bronchogenic cyst obstructing the fetal trachea. The patient was referred for ultrasonography at 24 weeks of gestation because of fetal hydrops. Tracheoscopy was performed via fetoscopic approach using a single trocar under local anesthesia with lidocaine and ultrasound guidance. This revealed an image suggestive of a cyst obstructing the middle third at the anterior base of the trachea. Coagulation using a diode laser enabled us to collapse this fluid-filled cyst with three 10-watt bursts (3 times 3 s) and to visualize a completely unobstructed tracheobronchial tree with significant pulmonary fluid reflux on removal of the obstacle. The fetal condition improved markedly within 48 h after the procedure. To the best of our knowledge, this is the first described case of in utero treatment of a tracheal obstruction by tracheoscopy and laser. In severe cases of obstruction of the fetal airways, whether the obstacle is situated in a high or low position, fetal endoscopy is of diagnostic and potentially therapeutic utility.

Objective To describe the surgical technical aspects associated with the development of urological fistulas after fetal antegrade cystoscopic laser fulguration of the posterior urethral valves (PUV). Methods The perioperative data for all fetal cystoscopies performed between January 2004 and August 2013 at three institutions in the USA, France and Brazil were reviewed, with particular emphasis on surgical technical aspects of the procedure and the complications encountered. Results A total of 40 fetal cystoscopies were performed at the three institutions. Laser fulguration of the PUV was performed in 23 of these cases, with a survival rate of 60.9% (14/23) and normal renal function in 85.7% (12/14) of these infants. Urological fistulas were diagnosed postnatally in four (10%) newborns. The presence of fistulas was associated with a higher gestational age at diagnosis of PUV (P

Objective The aim of this study is to analyze the relevance of the prenatal and postnatal diagnostic parameters of twin anemia-polycythemia sequence (TAPS). Methods Diagnostic data of all cases of TAPS followed in our institution between 2006 and 2013 were reviewed. Statistical analyses were conducted using Bayesian methods. Results Twenty cases of TAPS were included. We found a relationship between the hemoglobin level and the middle cerebral artery peak systolic velocity (coefficient −0.25 [−0.34, −0.15], Pr(coef 1) = 14.8%)], the mean diameter (OR = 0.98 [0.32, 3.06], Pr(OR > 1) = 48.9%), or the total diameter (OR = 0.79 [0.36, 1.53], Pr(OR > 1) = 26.3%) of arteriovenous anastomoses and the severity of TAPS. Conclusion Middle cerebral artery peak systolic velocity is a reliable tool for estimating the hemoglobin level in cases of TAPS. The correspondence between prenatal and postnatal diagnosis is imperfect. Further studies are required to evaluate opportunity of widening postnatal diagnostic criteria. © 2014 John Wiley & Sons, Ltd.

Objective: The aim of this study is to evaluate the interest in the in utero treatment of twin anemia-polycythemia sequence (TAPS). Methods: The obstetrical and neonatal data on all cases of TAPS followed up in our institution between 2006 and 2013 were reviewed. Statistical analyses were conducted using Bayesian methods. Results: Twenty cases of TAPS were included. Laser therapy or intrauterine transfusion (IUT) was performed on the donor twin in 9 cases. Eleven cases were included in the ‘nontreated' group (managed expectantly or diagnosed at birth). The gestational age at diagnosis was lower in the group with treated TAPS [difference (diff) = -22.20 days (-57.13, 14.28), probability (Pr) (diff >0) = 10.6%]. The rate of preterm premature rupture of membranes was higher in the group with treated TAPS [diff = 22.5% (-14, 57), Pr (diff >0) = 89%], but overall mortality was similar. The interval between diagnosis and delivery was longer [diff = 44.37 days (9.41, 77.90), Pr (diff >0) = 99.2%], the TAPS resolution rate was higher [diff = 49.9% (12, 81), Pr (diff >0) = 99.4%], and the neonatal transfusion rate was lower [diff = -30.5% (-60, 0), Pr (diff >0) = 2.6%] in the treated group. Conclusion: In utero treatment for TAPS is associated with a higher resolution rate of TAPS and a longer time between diagnosis and birth, but overall mortality is the same as with expectant management.