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To evaluate women's choice in the method of labour induction between oral misoprostol, PGE2 pessary and the Foley catheter. To compare women's satisfaction according to their choice and to identify factors associated with patient satisfaction.We conducted a comparative, prospective cohort study of 520 women who chose their preferred method for labour induction, in a French tertiary hospital, from July 2019 to October 2020. Before and after the delivery, they were asked to argue their choice and to evaluate their satisfaction through the use of questionnaires. The primary outcome was global level of satisfaction.Of the 520 women included, 67.5% of women chose oral misoprostol compared to 21% PGE2 pessary and 11.5% Foley catheter. Regarding global satisfaction, we found no significant difference between the three groups: 78.4%, 68.8% and 71.2% (p = 0.107) for, respectively, oral misoprostol, PGE2 pessary and Foley catheter. Factors that seem to improve women's satisfaction were nulliparity (aOR = 2.03, 95% CI [1.19-3.53]), delivery within 24 h after the start of induction (aOR = 3.46, 95% CI [2.02-6.14]) and adequate information (aOR = 4.21, 95% CI [1.869.64]). Factors associated with lower satisfaction rates were postpartum haemorrhage (aOR = 0.51, 95% CI [0.30-0.88]) and caesarean section (aOR = 0.31, 95% CI [0.17-0.54]).Women satisfaction rates were not different between the three methods, when chosen by the patients themselves. These finding should encourage caregivers to promote shared decision making when possible.The protocol was approved by the French ethics committee for research in obstetrics and gynaecology (CEROG, reference number 2019-OBS-0602) on 1st June 2019.

To identify risk factors for cesarean section of the second twin after vaginal delivery of the first twin.Case-control study conducted between 2004 and 2018 in a tertiary center, CHU Toulouse. Cases were women with twin pregnancy who had vaginal delivery of the first twin and emergency cesarean of the second twin. Controls were women with twin pregnancy who delivered both twins vaginally. Deliveries before 24 weeks of gestation, birth weight of less than 500 grams, fetal death in utero, terminations of pregnancy and delayed delivery were excluded. The association between potential risk factors and cesarean delivery of the second twin was analyzed using multivariable logistic regression.Twenty-four patients who had vaginal delivery of the first twin and emergency cesarean of the second twin and 48 patients who delivered both twins vaginally were included. Neonatal morbidity was increased in the group of women who had an emergency cesarean of the second twin. In multivariable analysis, overweight (OR=10.5 [95% CI: 1.78-62.03] for women with body mass index above 25 compared to women with body mass index below 25), weight gain during pregnancy (OR=1.27 [95% CI: 1.01-1.48] for each kilogram) and preterm labor (OR=4,43 [IC 95%:1,10-17,80]) were associated with significantly increased risk of cesarean section of the second twin.Overweight and weight gain during pregnancy are associated with increased risk for cesarean section of the second twin.

Pregnancy after gastric bypass (RYGB) surgery remains at high risk for gestational diabetes mellitus, prematurity, and small for gestational age infants (SGA). Our objective was to describe the interstitial glucose (IG) profiles and weight changes during such pregnancies, and the association of these factors with adverse pregnancy outcomes.One hundred twenty two pregnancies were analyzed in a monocentric retrospective study. IG profiles were evaluated by continuous glucose monitoring for 4 days. Maternal (hypertension, hospitalizations, and caesarean section) and neonatal outcomes (prematurity, weight for gestational age, hospitalizations, and malformations) were recorded. A logistic stepwise regression model assessed the influence of weight gain and impaired IG on pregnancy outcomes.Pregnancies occurred 33 (SD 21 months) after surgery. 73% of the women had IG abnormalities (55% with an increased % of time140 mg/dl and 69% with an increased % of time60 mg/dl). Five (4%) children were large for gestational age (LGA), 24 (20%) were SGA and 16 (13%) were born prematurely. There were 3 malformations but no stillbirth. LGA was associated with a high % of time140 mg/dl and an excessive maternal weight gain. Prematurity was associated with a high % of time60 mg/dl and an insufficient maternal weight gain. In the multivariate analysis, inappropriate weight gain explained LGA and prematurity independently. SGA was associated with a shorter % of time60 mg/dl.The relationship between IG abnormalities and/or maternal weight gain and neonatal outcomes in pregnancies after RYGB, suggests a careful monitoring of these parameters.

To assess the effectiveness of a multidisciplinary consultation meeting created in collaboration between a perinatal psychiatry team and professionals from a level 3 maternity hospital, whose purpose is to prepare the delivery and postpartum of pregnant women at high medico-psycho-social risk. I) Study the functioning of these multidisciplinary meetings. II) Assess the concordance between the decisions made in antenatal care and the actual management of the delivery and postpartum care.This is a retrospective study of 140 files for which the opinion of the multidisciplinary meeting was requested in the years 2012, 2014, 2016 and 2018. We looked at the psychiatric files of the patients, as well as the summary sheets written after staff meetings.The selection of files is compliant in 98% of cases and the traceability of information in the summary sheet is over 80% for half of the process indicators. The overall compliance rate between the decisions taken at meetings and their implementation in the post-partum period is 68%. Acute psychiatric episode and reporting could be anticipated.This multidisciplinary consultation meeting is efficient in the early detection of risk situations. The decisions taken during the multidisciplinary meetings in antenatal care are mostly applied postpartum in the Maternity Ward. In cases where they are not applied, the system offers great reactivity to postpartum professionals.

En la mayoria de los casos, la mejora del tratamiento de la diabetes permite a las mujeres gozar de una vida sexual y familiar normal. Sin embargo, el embarazo en una mujer diabetica siempre es un embarazo de riesgo, a pesar de los progresos de los ultimos 20 anos en el tratamiento de la diabetes, el control obstetrico y la medicina neonatal. Los riesgos dependen del contexto, tanto en la diabetes de tipo 1 (DT1), a veces antigua, complicada o mal controlada, como en caso de la diabetes de tipo 2 (DT2), situacion cada vez mas frecuente en la que se asocian otros factores de riesgo: obesidad, sindrome de la apnea del sueno, hipertension arterial, precariedad. Dependen tambien de la preparacion de los embarazos, que todavia es insuficiente, y de los tratamientos, que no permiten un control perfecto. La programacion de los embarazos, que implica una eleccion anticonceptiva adecuada, y el control ginecologico de las mujeres diabeticas desde la pubertad hasta la menopausia requieren pues una coordinacion de la atencion, en la que la educacion terapeutica y la investigacion clinica ocupan un lugar importante.

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

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

Introduction : Les traumatismes de la femme enceinte sont frequemment la cause de deces maternel et fœtal non obstetrical ainsi que de complications maternofœtales durant la grossesse. L'objectif de notre etude etait de decrire la population des femmes enceintes consultant pour un traumatisme dans un service d'urgences gyneco-obstetricales et de rechercher les criteres predictifs d'hospitalisation et de complications obstetricales.Methodes : Etude retrospective, basee sur l'analyse des dossiers medicaux des femmes enceintes admises aux urgences pour un traumatisme, entre le 1er janvier 2007 et le 31 decembre 2010. Les circonstances et les localisations des traumatismes, leurs complications obstetricales et leur prise en charge ont ete etudiees.Resultats : Parmi les 144 femmes etudiees, les traumatismes etaient dus a des chutes (45 %), des accidents de la voie publique (32 %) ou des violences conjugales (16 %). L'âge gestationnel moyen etait de 29 semaines d'amenorrhee (SA). Leur localisation etait abdominale dans 72 % des cas. Soixante-deux patientes (43 %) etaient hospitalisees dans les suites immediates du traumatisme pendant une duree mediane de 2,5 jours. L'hospitalisation etait plus frequente lorsque le traumatisme etait abdominal, l'âge gestationnel avance (3e trimestre), qu'il existait des facteurs de risque anterieurs de grossesse compliquee ou que les examens realises en urgence etaient anormaux. L'âge gestationnel median a l'accouchement etait de 39 SA. Les complications obstetricales survenaient chez 25 patientes et comprenaient 18 ruptures prematurees des membranes, 3 hematomes retroplacentaires, 2 ruptures uterines, 2 morts fœtales et 17 accouchements prematures.Conclusion : Les traumatismes durant la grossesse, meme mineurs, sont un facteur de morbidite et de mortalite fœtale. Il est important de faire un bilan obstetrical complet devant tout traumatisme. Les patientes sont souvent hospitalisees par la suite, d'autant plus que le traumatisme est abdominal, que la grossesse est avancee ou qu'il existe des facteurs de risque de grossesse compliquee.

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

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 8 - p. 803-816

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 41 - N° 3 - p. 290-297

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 37 - N° 8S1 - p. 222-230

Objectives To describe the management of threatened preterm delivery (TPD) in France 3 years after publication of the French guidelines and to analyse the factors of variation of the practices observed. Design Population-based study. Setting Representative sample of French maternity units. The study included 107 hospitals, accounting for 20% of all French maternity units. Population Women hospitalised for TPD during May 2005. Methods Cross-sectional national practice survey. Results Of the 734 admissions for TPD, 12.1% involved premature rupture of membranes and 12.9% were in utero transfers. Women admitted for TPD accounted for roughly 6% of all annual deliveries, regardless of the unit’s level of care, and 42.4% of these women delivered preterm: none delivered before 32 weeks in level 1 maternity units, 11.6% in level 2 and 88.4% in level 3. Transvaginal cervical ultrasound was performed for 54.5% of the women with intact membranes. Tocolysis was administered in 87.1% of women with intact membranes, with 45.6% of such women receiving this intervention for longer than 48 hours. First-line tocolytics used were calcium channel blockers (53.7%), beta-agonists (34.7%) or atosiban (8.8%), but their distribution differed substantially according to level of care. Maintenance tocolysis was administered to 385 women (59.8%) with intact membranes. Of the women admitted before 34 weeks, 21.1% did not receive corticosteroids. Conclusions Practices for the management of TPD vary widely and appear to depend on the level of care. Some practices appear less than optimal, especially those related to duration of tocolysis, maintenance tocolysis, antenatal corticosteroid and use of cervical ultrasound.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 36 - N° 6 - p. 607-610

The rupture of gravid uterus is a rare complication concerning less than one percent of the pregnant women involved in a motor vehicle accident. The authors report the case of a 39-year woman, gravida 4, referred for an uterine rupture with intrauterine fetal death at 24 weeks gestation, following a car crash. The surgical laparotomic exploration in emergency showed a wide fundal uterine tear with placental abruption. The placenta and the fetus were found in the abdominal cavity. A conservative surgical treatment could be realized. Principles of management, which must be quick and co-ordinated, are reminded.

Resume Objectifs La technique de cerclage du col uterin par voie abdominale a ete decrite en alternative a l'abord vaginal pour la prise en charge des incompetences cervicales severes. L'objectif de cette etude est de rapporter notre experience de cette technique chez des patientes a haut risque. Materiel et methode Nous rapportons une serie retrospective de 12 cerclages cervico-isthmiques par voie abdominale effectues entre 1988 et 2005. Les patientes avaient des antecedents de fausses couches spontanees tardives a repetition ou d'accouchements prematures. Quatre-vingt-deux pour cent ont presente un echec de cerclage par voie vaginale lors d'une grossesse precedente. Quatorze grossesses ont ete observees. Resultats Le cerclage a ete mis en place a un âge moyen de 14 SA (12–17 SA). Toutes les patientes ont accouche par cesarienne a un âge gestationnel moyen de 35 SA. Le taux de survie fœtale globale etait de 93 % en comparaison a 17 % avant la pose du cerclage. Il n'a pas ete rapporte de complications majeures. Conclusion Le cerclage par voie abdominale demeure une technique fiable pour la prise en charge des incompetences cervicales apres echec d'un cerclage vaginal et lorsque l'abord vaginal est difficile. L'approche laparoscopique est en cours de developpement.

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

Human decidual NK cells are massively recruited at the site of embryonic implantation ( decidua basalis ). They differ in many ways from their peripheral blood NK cell counterparts in terms of gene expression, phenotype and functionality. The major subpopulation of decidual NK cells is CD56 bright whereas the minor subset is CD56 dim , contrasting with the peripheral blood NK cells whose major subpopulation is CD56 dim . Decidual NK cell cytolytic function is much reduced despite the presence of several activating receptors and the essential machinery required for lysis. Decidual NK cells produce a number of cytokines that are not normally secreted by peripheral blood NK cells. Human decidual NK cell potential functions at the maternal–fetal interface are not yet clearly established but several hypotheses are being evaluated, including control of extravillous invasion, control of uterine vascular remodeling, and local anti-viral activity.

Resume Contexte La prophylaxie anti-RH1 actuellement pratiquee en France est basee sur une prevention postnatale systematique dont l’efficacite est validee (risque relatif = 0,04 versus placebo) associee a une prevention antenatale ciblee sur les situations a risque d’hemorragie fœto-maternelle. La plupart des autres pays industrialises ont adopte une politique de prevention systematique consistant a injecter en plus des situations precedentes, des immunoglobulines au 3e trimestre afin de couvrir le risque lie aux hemorragies fœto-maternelles spontanees occultes de fin de grossesse. Objectif Comparer l’efficacite des 2 politiques de prevention antenatale. Materiel et methodes Revue bibliographique des differentes etudes comparatives publiees. Onze etudes ont ete retenues (2 essais randomises, 7 etudes comparatives, 1 etude avant-apres, 1 etude en population), incluant plus de 30 000 patientes traitees. Resultats Globalement, le taux d’immunisation est de l’ordre de 1,5 % (1,2 a 1,9 %) en cas de prevention ciblee limitee aux situations a risque et de l’ordre de 0,2 % (0 a 0,9 %) toute parite confondue en cas de prevention antenatale systematique. Les analyses comparatives retrouvent, vis-a-vis de l’effet preventif de la prevention antenatale systematique, des Odds Ratios significatifs compris entre 0,20 et 0,37 dans tous les sous-groupes. Conclusion Malgre l’heterogeneite et le peu d’etudes publiees, les donnees disponibles sont en faveur d’une proposition de prevention systematique : soit a la posologie de 300 μg a 28 SA, soit a la posologie de 100 μg a 28 SA et a 34 SA, en complement de la prevention post-natale. Peu de donnees sont cependant disponibles sur benefice perinatal reel de la prevention systematique.

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

Resume L’accouchement gemellaire est un accouchement a haut risque, surtout pour le 2 e jumeau dont la mortalite perinatale est majoree. Le taux de cesarienne est globalement eleve (30 a 45 %). Lorsque les 2 jumeaux sont en presentation cephalique (Vertex/Vertex), la voie basse est consensuelle, quel que soit le terme de la grossesse. En cas de presentation Vertex/NonVertex (30 a 40 % des cas), le mode d’accouchement optimal est toujours controverse, surtout en cas de prematurite. Les donnees disponibles sont plutot en faveur de la voie basse, surtout lorsque les poids de naissance sont superieurs a 1 500 g. La prudence s’impose a terme lorsque le poids fœtal estime de J2 est superieur a celui de J1 et avant 32 SA en raison du risque majore de difficultes d’extraction fœtale. Lorsque J1 est en presentation podalique (20 a 30 % des cas), le mode d’accouchement est controverse. Il s’agit pour beaucoup d’une contre-indication a la voie basse et la cesarienne est le plus souvent recommandee par manque de donnees epidemiologiques fiables. Lorsque la voie basse a ete acceptee, 2 options sont possibles pour l’accouchement de J2 : soit une attitude interventionniste visant a reduire au maximum le delai entre les 2 naissances, soit une attitude « d’expectative » respectant le mecanisme physiologique (intervalle libre) dont l’objectif est d’eviter les manœuvres obstetricales. Les etudes comparatives semblent plutot etre en faveur d’une approche active autorisant les manœuvres intra-uterines. La VME n’est pas recommandee, et la cesarienne sur J2 doit rester une solution de dernier recours reservee a la retraction cervicale avec souffrance fœtale, la procidence du cordon, ou l’echec des manœuvres d’extraction. Les protocoles obstetricaux actuels doivent privilegier la voie basse en l’absence de donnees contradictoires irrefutables. L’experience de l’operateur joue ici un role essentiel, ce qui souligne l’importance de l’enseignement pratique.

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

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

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

The aim of this study was to evaluate the modalities of induction of labour in twin pregnancies compared with singleton pregnancies and to identify risk factors for failure.A retrospective population-based study was conducted at the Toulouse University Hospital to compare a cohort of diamniotic twin gestations (Twin A in vertex presentation), with induction of labour ≥36 weeks of gestation, between January 2007 and December 2012, to a singleton's cohort that were induced ≥36 weeks of gestation during the 2007 year. One singleton pregnancy was matched for each twin pregnancy with parity and gestational age.One hundred and fifty-six twins pregnancies met the inclusion criteria for an induction of labor and were compared to 156 single pregnancies. The same and standard protocol of induction of labor was used for the two cohorts (intrauterine balloon catheter±dinoprostone/ocytocine). The cesarean section rate for failed labor induction (cesarean in latent phase) was similar in the 2 populations (14.7% for twin vs 13.5% for single; P=0.66). The factors associated to failed induction of labor in the total population were nulliparity (OR=1.49) and Bishop score6 at the beginning of the induction (OR=2.83).Twin did not appear as risk of failed induction. The protocol for induction of labor in singletons may be safely proposed to twin gestations.

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

Post-partum eclampsia is an unfrequent entity (11 to 44 % of eclampsia), which can sometimes occur late, beyond the 48th hour. We report a case of late post-partum eclampsia which occurred 12 days after an uncomplicated pregnancy and delivery. Post-partum eclampsia differs from antepartum by a pauci symptomatic or unexpected context. The mortality rate is comparable with that of the ante-partum eclampsia. Brain MRI appears to be the investigation of choice in case of uncertain diagnosis. Magnesium sulfate treatment should be considered under the same conditions as during pregnancy. Identifying and informing high-risk women would allow early diagnosis, which may improve the prognosis of this atypical type of eclampsia.

Resumen El sufrimiento fetal agudo (SFA), la hipoxia y la asfixia perinatales siguen existiendo y causando trastornos graves. Los medios modernos de vigilancia del parto, que se analizan en este trabajo, han disminuido su frecuencia. Algunas causas aun son dificiles de evitar (hematoma retroplacentario, prolapsos del cordon, etc.), pero una vigilancia atenta de los partos con riesgo deberia permitir una reaccion rapida, y el estudio del pH es irreemplazable. Las patologias del embarazo, en particular la hipotrofia, no siempre se reconocen o evaluan correctamente, por lo que se justifica el control de todos los partos. Por ultimo, se puede deplorar que la determinacion del pH del cordon no se considere como un criterio de calidad de la actividad obstetrica.

Chickenpox is rare during pregnancy (1 to 7 per 10,000). The infection can be severe for the mother and indirectly may affect the fetus. Before 20 weeks of amenorrhea, the varicella-zoster virus may be responsible for a rare embryofetopathy (incidence rate: 0.4 to 2%). After the 20th week of amenorrhea, fetal infection is not symptomatic, but it may lead to neonatal or infantile herpes zoster infection. During the perinatal period, a primary maternal infection may be responsible for severe neonatal varicella if delivery occurs prior to maternal antibody production. Practical guidelines are proposed according to the date of infection during pregnancy and prenatal diagnosis using amniocentesis and/or cordocentesis is discussed.

Resume Nous rapportons la prise en charge chirurgicale d'un kyste paratubaire geant chez une jeune fille de 19 ans. La lesion est decouverte devant une importante augmentation de taille de l'abdomen. L'exploration radiologique montre une lesion evaluee a 36 × 25 cm. Le caractere habituellement benin de ces lesions nous a fait choisir une chirurgie mini-invasive par cœlioscopie premiere suivie d'une tres courte laparotomie sus-pubienne. Les suites operatoires ont ete simples, l'examen anatomopathologique confirmant la benignite du kyste paratubaire. Malgre la taille inhabituelle de la lesion, l'abord cœlioscopique premier a permis d'eviter une laparotomie mediane.

Objectif en 2005, le College national des gynecologues obstetriciens francais (CNGOF) publiait des recommandations sur l’episiotomie plaidant pour une politique restrictive dans le but d’obtenir un taux moyen global en France inferieur a 30 %. Notre objectif etait de faire un etat des lieux des pratiques francaises sept ans apres.

To evaluate predictors of uterine rupture (UR) after previous cesarean birth. To define the diagnosic criteria of UR, management and prognosis of subsequent pregnancies.Analysis of Medline database(®), Cochrane Library Database(®) and international guidelines.Uterine rupture is a serious complication both for mother (mortality1 %, severe morbidity 15 %) and child (mortality at term 3-6%, perinatal asphyxia 6-15%), occurring in 0,2 to 0,8 % of trial of labour after cesarean (TOLAC). The individual risk for UR after TOLAC is multifactorial and predictive scores showed no clinical utility in routine (grade B). The risk of UR is decreased in case of previous vaginal delivery and increased in case of classical C-section, previous UR, induction of labour (especially using prostaglandins), more than one previous caesarean section, fetal macrosomia and interval less than 6 months before the next pregnancy. Monitoring of labor, including intrauterine pressure catheters, do not allow to anticipate the diagnosis. This one relies on a combination of severe pathologic patterns of FHM with unusual pelvic pain. Suspected UR requires expedited laparotomy (consensus opinion). A subsequent pregnancy is not contraindicated, but the risk of recurrent UR is high and a repeat cesarean section is then recommended (grade B).

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

To assess the quality of intrapartum care in birth asphyxia cases.Prospective analysis of all cases of birth asphyxia in nine maternity units during one year (2010). Birth asphyxia was defined as the combination of at least one clinical factor (Apgar≤7 at 5 minutes, signs of encephalopathy at birth) and at least one biological factor in cord (pH≤7, BD≥12 mmol/L, lactates10 mmol/L). These cases were analyzed with a peer review from French guidelines 2007.Fifty cases of birth asphyxia were identified. After peer-review, they were defined as 46% non preventable, 27% possibly preventable, 24% definitely preventable and 3% not established. The main causes have been described as (i) misinterpretation of CTG during the first and second stages of labour, (ii) delayed response time to CTG anomalies and (iii) prolonged second stage.In half of the cases of birth asphyxia, this dreaded event was considered as preventable by a group of peers.

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