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Resume La grossesse represente une periode de vulnerabilite psychique importante pour les femmes. Vingt pour cent d’entre elles presenteraient pendant la periode perinatale des troubles mentaux variant de l’anxiete a la depression. Chez celles presentant une maladie mentale preexistante, le risque de decompensation aigue est important. Dans ce sens, l’Organisation mondiale de la sante recommande de classer les suicides survenant pendant la grossesse et jusqu’a un an du post-partum comme mort maternelle. Ainsi, entre 2013 et 2015, 35 suicides maternels sont survenus en France, soit un ratio de mortalite maternelle de 1,4 pour 100 000 naissances vivantes (IC95 %: 1,0–2,0). Constituant 13,4 % de l’ensemble des morts maternelles pour la periode, ce groupe est l’un des 2 premieres causes de mortalite maternelle. Un total de 23 % des suicides sont survenus dans les 42 premiers jours du post-partum, et 77 % entre 43 jours et un an apres la naissance. 33,3 % des meres suicidees presentaient des antecedents psychiatriques connus et 30,3 % des antecedents de soins psychiatriques, meconnus des maternites. Les soins non optimaux sont presents dans 72 % des cas avec 91 % de deces potentiellement evitables, lies a un defaut de prise en charge multidisciplinaire, et une interaction inadequate entre la patiente et le systeme de soins. De l’analyse des cas, ont ete tires des messages forts permettant d’optimiser la prise en charge : ameliorer la connaissance des antecedents psychiatriques des l’inscription en maternite, ameliorer le reperage des symptomes d’alerte et le recours au psychologue et/ou au psychiatre, mettre en place un parcours de soins specifique et une collaboration multidisciplinaire en cas de pathologie psychiatrique connue.

The sixth report of the National Confidential Survey on Maternal Deaths provides insights into the frequency, risk factors, causes, adequacy of care, and preventability of maternal deaths occurring in 2013-2015 in France. The method developed ensures an exhaustive identification and a confidential analysis of maternal deaths. It was organized in three steps. 1) All deaths occurring during pregnancy or up to 1 year after its end, whatever the cause or mode of termination, being considered 2) A pair of volunteer assessors (midwives, gyneco-obstetricians, anesthesiologists, psychiatrists) was in charge of collecting the information (history of the woman, course of her pregnancy, circumstances of the event that led to the death and management); 3) Review and classification of deaths by the National Committee of Experts on Maternal Mortality which made a collective judgment on the cause of death, on the adequacy of the care provided, and on what could been done to avoid the death depending on the existence of circumstances that could have prevented the fatal outcome. The operation of the committee has been enriched by new resources to further explore these cases. Specifically, a module of the survey questionnaire, the recruitment of psychiatrists whose contribution allows relevant documentation of the suicides, and the participation of a psychiatrist as an associate expert for the analysis of the appropriateness of the management and the variable determining factors of these cases. Suicide becomes one of the two main causes of maternal mortality, (the other cause being cardiovascular pathologies), with 35 suicides on the triennium among the 262 maternal deaths, that is to say 13.4 % of maternal deaths, about 1 per month. In this population, the average age of women who died by suicide was 31.4years. The majority of the women were born in France, 68 % were prima parous, and in 9 % of cases suicide followed a twin pregnancy. Psychiatric history was known in 33.3 % of the suicidal mothers, and 30.3 % had a history of psychiatric care that was unknown to the maternity team.43 % of the women had psychosocial vulnerability factors, a history of violence, and eviction from the home and/or financial difficulties. In 23 % of the cases, the time of occurrence of these suicides was within the first 42days postpartum, and in 77 % between 43 days and one year after birth with a median delay of 126days. Only one suicide occurred during pregnancy. Maternal suicides were mostly violent deaths. Suboptimal care was present in 72 % of cases, where 91 % of potentially preventable deaths related to a lack of multidisciplinary management and/or inadequate interaction between the patient and the health care system. Among these potentially avoidable deaths, we were able to distinguish: women whose psychiatric pathology was known and for whom multidisciplinary management was not optimal, and women whose psychiatric pathology was not known or was not present - for whom it was rather a matter of a failure to detect and identify the signs, particularly by obstetric care providers or general emergency services. Based on the analysis of the cases, strong messages were identified, with the aim of optimizing management: - The screening by structured questioning of psychiatric history from the moment of registration in the maternity ward, repeated at each consultation throughout the pregnancy. - The reassessment of the psychological and somatic state through an early postnatal interview at one month; - The identification of warning symptoms, with screening tools for depression. If necessary, a further recourse to the psychologist and/or psychiatrist of the maternity hospital, organisation of a home hospitalization, and a private midwife to provide a link in the pre- and postpartum period. This, in addition to the earliest possible care in the PMI (Maternal and Infantile Protection, of the French social care system), appointments with mental health professionals,and the link with the attending physician; - The implementation of a coordinated care pathway in case of a known psychiatric pathology with pre conception counselling. This includes a multidisciplinary collaboration, an adaptation of psychotropic treatment, management of comorbidities referral to specialized perinatal psychopathology teams, prenatal meeting with the pediatrician of the maternity hospital, anticipation of the birth, postpartum and discharge options, liaison sheet established for the organization of the delivery and postpartum, and a regular written transmissions between the intervening parties throughout the care; - The generalization of medico-psycho-social staffs, in maternity wards, for all situations identified as at risk. In addition to the need for training and increased awareness on psychological issues during the perinatal period and on the different pathologies encountered by adult mental health professionals and front-line workers, it is necessary to encourage the development of resources in the country. Particularly, joint child psychiatrist-adult psychiatrist consultations at the territorial level, responsible for being resource contacts for maternity wards and local care professionals, as well as the promotion of case pathway referrals.

Resume Objectif Determiner la prise en charge des patientes avec une rupture prematuree des membranes avant 37 semaines d’amenorrhee (SA). Methodes Synthese de la litterature a partir des bases de donnees PubMed et Cochrane et des recommandations des societes et colleges francais et etrangers. Resultats En France, la frequence de la rupture prematuree des membranes (RPM) est de 2 a 3 % avant 37 SA (Niveau de preuve [NP] 2) et de moins de 1 % avant 34 SA (NP2). La prematurite et l’infection intra-uterine sont les complications majeures de la RPM avant terme (NP2). La prolongation de la duree de latence est benefique (NP2). Par rapport aux autres causes de prematurite, la RPM avant terme n’est pas associee a un sur-risque evident de morbi-mortalite neonatale, sauf en cas d’infection intra-uterine, qui est associee a une augmentation des morts fœtales in utero (NP3), des infections neonatales precoces (NP2) et des enterocolites ulceronecrosantes (NP2). Le diagnostic de la RPM avant terme est principalement clinique (accord professionnel). En cas de doute diagnostique, il est recommande d’utiliser les tests de detection d’IGFBP-1 ou de PAMG-1 (accord professionnel). Il est recommande d’hospitaliser les patientes lors du diagnostic de RPM avant terme (accord professionnel). Il n’existe pas d’argument suffisant pour recommander ou ne pas recommander une tocolyse initiale (grade C). Si une tocolyse etait prescrite, il est recommande de ne pas la prolonger plus de 48 heures (grade C). Il est recommande d’administrer une cure antenatale de corticoides si l’âge gestationnel est inferieur a 34 SA (grade A) et du sulfate de magnesium en cas d’accouchement imminent avant 32 SA (grade A). Il est recommande de prescrire une antibioprophylaxie a l’admission (grade A) pour reduire la morbidite neonatale et maternelle (NP1). L’amoxicilline, les cephalosporines de 3eme generation et l’erythromycine (accord professionnel) peuvent etre utilisees en monotherapie, ou l’association erythromycine–amoxicilline (accord professionnel), pour une duree de 7 jours (grade C). Toutefois, un arret precoce de l’antibioprophylaxie semble acceptable en cas de prelevement vaginal initial negatif (accord professionnel). Il n’est pas recommande de prescrire comme antibioprophylaxie l’association amoxicilline-acide clavulanique (accord professionnel), des aminosides, des glycopeptides, des cephalosporines de premiere ou deuxieme generation, de la clindamycine ou du metronidazole (accord professionnel). La prise en charge a domicile des patientes cliniquement stables apres au moins 48 heures de surveillance hospitaliere est possible (accord professionnel). Au cours de la surveillance, il est recommande d’identifier les elements cliniques et biologiques evocateurs d’une infection intra-uterine (accord professionnel). Il n’est pas possible d’emettre de recommandations sur la frequence de cette surveillance (accord professionnel). En cas d’examen de surveillance isolement positif chez une patiente asymptomatique (CRP augmentee, hyperleucocytose, prelevement vaginal positif), il n’est pas recommande d’initier systematiquement une antibiotherapie (accord professionnel). En cas d’infection intra-uterine, il est recommande d’administrer immediatement une antibiotherapie associant une betalactamine a un aminoside (grade B), par voie intraveineuse (grade B) et de faire naitre l’enfant (grade A). La cesarienne en cas d’infection intra-uterine est reservee aux indications obstetricales habituelles (accord professionnel). Il est recommande d’avoir une attitude expectative en cas de RPM non compliquee avant 37 SA (grade A), meme en cas de prelevement positif pour le streptocoque B, sous couvert d’une antibioprophylaxie a l’admission (accord professionnel). L’ocytocine et les prostaglandines sont deux options envisageables pour le declenchement du travail en cas de RPM avant terme (accord professionnel). Conclusion La prise en charge de la rupture prematuree des membranes avant terme non compliquee repose sur l’expectative jusqu’a 37 SA (grade A).

Resume Objectif Determiner la prise en charge des patientes avec une rupture prematuree des membranes avant 37 semaines d’amenorrhee (SA). Methodes Synthese de la litterature a partir des bases de donnees PubMed et Cochrane et des recommandations des societes et colleges francais et etrangers. Resultats En France, la frequence de la rupture prematuree des membranes (RPM) est de 2 a 3 % avant 37 SA (Niveau de preuve [NP] 2) et de moins de 1 % avant 34 SA (NP2). La prematurite et l’infection intra-uterine sont les complications majeures de la RPM avant terme (NP2). La prolongation de la duree de latence est benefique (NP2). Par rapport aux autres causes de prematurite, la RPM avant terme n’est pas associee a un sur-risque evident de morbi-mortalite neonatale, sauf en cas d’infection intra-uterine, qui est associee a une augmentation des morts fœtales in utero (NP3), des infections neonatales precoces (NP2) et des enterocolites ulceronecrosantes (NP2). Le diagnostic de la RPM avant terme est principalement clinique (accord professionnel). En cas de doute diagnostique, il est recommande d’utiliser les tests de detection d’IGFBP-1 ou de PAMG-1 (accord professionnel). Il est recommande d’hospitaliser les patientes lors du diagnostic de RPM avant terme (accord professionnel). Il n’existe pas d’argument suffisant pour recommander ou ne pas recommander une tocolyse initiale (grade C). Si une tocolyse etait prescrite, il est recommande de ne pas la prolonger plus de 48 heures (grade C). Il est recommande d’administrer une cure antenatale de corticoides si l’âge gestationnel est inferieur a 34 SA (grade A) et du sulfate de magnesium en cas d’accouchement imminent avant 32 SA (grade A). Il est recommande de prescrire une antibioprophylaxie a l’admission (grade A) pour reduire la morbidite neonatale et maternelle (NP1). L’amoxicilline, les cephalosporines de 3eme generation et l’erythromycine (accord professionnel) peuvent etre utilisees en monotherapie, ou l’association erythromycine–amoxicilline (accord professionnel), pour une duree de 7 jours (grade C). Toutefois, un arret precoce de l’antibioprophylaxie semble acceptable en cas de prelevement vaginal initial negatif (accord professionnel). Il n’est pas recommande de prescrire comme antibioprophylaxie l’association amoxicilline-acide clavulanique (accord professionnel), des aminosides, des glycopeptides, des cephalosporines de premiere ou deuxieme generation, de la clindamycine ou du metronidazole (accord professionnel). La prise en charge a domicile des patientes cliniquement stables apres au moins 48 heures de surveillance hospitaliere est possible (accord professionnel). Au cours de la surveillance, il est recommande d’identifier les elements cliniques et biologiques evocateurs d’une infection intra-uterine (accord professionnel). Il n’est pas possible d’emettre de recommandations sur la frequence de cette surveillance (accord professionnel). En cas d’examen de surveillance isolement positif chez une patiente asymptomatique (CRP augmentee, hyperleucocytose, prelevement vaginal positif), il n’est pas recommande d’initier systematiquement une antibiotherapie (accord professionnel). En cas d’infection intra-uterine, il est recommande d’administrer immediatement une antibiotherapie associant une betalactamine a un aminoside (grade B), par voie intraveineuse (grade B) et de faire naitre l’enfant (grade A). La cesarienne en cas d’infection intra-uterine est reservee aux indications obstetricales habituelles (accord professionnel). Il est recommande d’avoir une attitude expectative en cas de RPM non compliquee avant 37 SA (grade A), meme en cas de prelevement positif pour le streptocoque B, sous couvert d’une antibioprophylaxie a l’admission (accord professionnel). L’ocytocine et les prostaglandines sont deux options envisageables pour le declenchement du travail en cas de RPM avant terme (accord professionnel). Conclusion La prise en charge de la rupture prematuree des membranes avant terme non compliquee repose sur l’expectative jusqu’a 37 SA (grade A).

Over the 2013-2015 period, maternal mortality due to infections accounted for 10 % of direct maternal deaths and 13 % of indirect maternal deaths. Among the 21 deaths from infection, and compared to the last triennium, maternal deaths from genital infection doubled with 11 deaths during the 2013-2015 period. This included 6 cases of puerperal toxic shock syndrome, 4 of which due to Streptococcus A, and 5 cases of sepsis caused by intrauterine infection due to Gram-Negative Bacillus. Indirect maternal deaths due to infections from extragenital sources represented 10 deaths in this triennium, including four influenza infections and three infectious complications of an immunosuppressive state (uncontrolled HIV infection for two patients and CMV encephalitis during an immunosuppressive treatment for one patient). Of these 21 deaths by infectious causes, 6 direct maternal deaths and 9 indirect maternal deaths were considered preventable. The most common preventable factors were those related to medical management (13 times): diagnostic failure or delayed diagnosis leading to a delayed medical treatment, absence of influenza vaccination. The other contributory factors were related to the organization of healthcare (delayed transfer, lack of communication between clincians) as well as factors related to patient social vulnerability.

Pregnancy represents a period of significant psychological vulnerability for women. During the perinatal period, twenty percent of them would present with mental disorders ranging from anxiety to depression. In those with pre-existing mental illness, the risk of acute decompensation is significant. For this reason, the World Health Organization recommends classifying suicides occurring during pregnancy and up to one-year post-partum as maternal deaths. Thus, between 2013 and 2015, 35 maternal suicides occurred in France, representing a maternal mortality ratio of 1:4 per 100,000 live births (95% CI: 1.0-2.0). By constituting 13.4% of all maternal deaths for the period, this group is the one of the 2 leading causes of maternal mortality. A total of 23% occurred in the first 42 days post-partum, and 77% between 43 days and one year after birth. 33.3% of the suicidal mothers had a known psychiatric history and 30.3% had a history of psychiatric care, unknown to obstetrical teams. Non-optimal care was present in 72% of cases with 91 % of suicides were potentially preventable, preventability factors beinga lack of multidisciplinary care and inadequate interaction between the patient and the care system. Strong messages were drawn from the analysis of these cases to optimize care: improve knowledge of the psychiatric history from the time of enrolment in maternity units, improve the identification of warning symptoms and the use of the psychologist and/or psychiatrist, set up a specific care pathway and multidisciplinary collaboration in case of known psychiatric disease.

Resume La mortalite maternelle de cause infectieuse a represente au cours de la periode 2010–2012, 5 % des causes directes de deces et 16 % des morts maternelles indirectes. Parmi les 22 deces releves de causes infectieuses, 6 morts maternelles ont ete attribuees a une infection a porte d’entree genitale confirmant la diminution depuis 10 ans des morts maternelles directes par infection. A l’inverse, les morts maternelles indirectes par infection, a porte d’entree extragenitale, ont double au cours de la meme periode avec 16 deces au cours du dernier triennium, domines par les infections respiratoires hivernales en particulier grippales : la pandemie grippale A (H1N1) de 2009–2010 est, au cours de la periode etudiee, la premiere cause de mortalite maternelle indirecte par infection. Les principaux agents infectieux a l’origine des deces de cause infectieuse directe sont les Streptococcus pyogenes , Escherichia Coli et Clostridium perfringens , responsables de chocs toxi-infectieux, de sepsis graves, secondaires pour plusieurs cas a une cellulite ou une fasciite necrosante. Sur les 6 deces par infection directe, 4 ont ete juges peut-etre evitables en raison de soins inadaptes : retard ou defaut diagnostique, traitement medical et/ou chirurgical initie avec retard ou inadapte. Parmi les 16 morts maternelles indirectes par infection, le virus grippal A(H1N1) et le Streptococcus pneumoniae complique de purpura fulminans ont ete le plus souvent en cause : l’absence de vaccination antigrippale au cours de la grossesse, le retard diagnostique et a l’initiation en urgence d’un traitement specifique sont les principaux facteurs d’evitabilite retrouves dans 70 % des dossiers expertises.

Decisions regarding whether to initiate or forgo intensive care for extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients and must be taken into account. After a short review of these factors, we present the thoughts and proposals of the Risks and Pregnancy department. The proposals are to limit emergency decisions, to better take into account other factors than gestational age and prenatal predicted fetal weight in assessing the prognosis, to introduce multidisciplinary consultation in the evaluation and proposals that will be discussed with the parents, and to separate prenatal steroid therapy from decision-making regarding whether or not to administer intensive care.

Resume Objectifs Evaluer l’impact du dispositif d’accompagnement Projet regional experimental d’accompagnement a la nutrition et allaitement chez les femmes en situation de precarite (PRENAP) 75 sur la duree d’hospitalisation dans le post-partum et sur le mode d’alimentation pour les femmes enceintes en situation de precarite. Methodes Une etude observationnelle retrospective s’est deroulee entre novembre 2013 et mai 2015 dans une maternite parisienne de type III. Une comparaison des caracteristiques sociodemographiques, des issues perinatales et du post-partum des femmes en situation de precarite sociale (pas de logement stable et absence de prise en charge sociale ou couverture medicale universelle ou aide medicale d’Etat) a ete realisee selon leur inclusion ou non dans le dispositif PRENAP. Resultats Sur la periode d’etude, 344 (4,6 %) femmes en situation de precarite ont accouche dans cette maternite. Parmi les femmes en situation de precarite, les femmes incluses dans le dispositif PRENAP etaient plus frequemment dans une situation sociale tres defavorable que celles qui n’ont pas ete incluses. L’inclusion dans le dispositif PRENAP n’a pas permis de reduire la duree de sejour en suites de couches. L’allaitement maternel etait choisi plus frequemment par les femmes incluses dans le dispositif PRENAP. Conclusion Le dispositif PRENAP semble favoriser le recours a l’allaitement, mais n’est pas associe a une diminution de la duree moyenne de sejour en suite de couches. Ce dispositif qui semble benefique en termes d’accompagnement medical et social des femmes en situation de precarite meriterait d’etre evalue de maniere prospective.

Resume But Decrire les modalites optimales d’administration de l’oxytocine dans l’indication de l’insuffisance de contractilite uterine au cours du travail spontane et les specificites de la surveillance maternelle et fœtale au cours du travail spontane. Methodes Revue systematique de la litterature par consultation des banques de donnees Medline, Micromedex, Cochrane et des recommandations internationales. Resultats L’oxytocine ne doit etre administree qu’en milieu hospitalier et necessite un monitorage encadre par un protocole de service. L’indication et les modalites d’administration doivent etre tracees et le debit employe indique en mU/min. Une surveillance de l’activite uterine et du rythme cardiaque fœtal doivent etre realisees des que l’oxytocine est administree. L’efficacite de l’oxytocine est variable en fonction des doses administrees. La dose initiale optimale recommandee en termes d’efficacite et limitant les effets deleteres est de 2 mU/min. L’augmentation des doses doit respecter un intervalle minimal de 30 min pour juger de l’effet de chaque palier et doit etre inferieure a 4 mU/min. Les augmentations des doses sont a poursuivre jusqu’a obtention d’une activite uterine satisfaisante, sans depasser 20 mU/min. Conclusion Il est recommande d’utiliser les doses efficaces d’oxytocine les plus faibles possibles. Au sein des services, l’administration d’oxytocine doit etre encadree et une tracabilite de l’administration du produit effectuee.

International audience; In France, the frequency of premature rupture of the membranes (PROM) is 2%-3% before 37 weeks' gestation (level of evidence [LE] 2) and less than 1% before 34 weeks (LE2). Preterm delivery and intrauterine infection are the major complications of preterm PROM (PPROM) (LE2). Prolongation of the latency period is beneficial (LE2). Compared with other causes of preterm delivery, PPROM is associated with a clear excess risk of neonatal morbidity and mortality only in cases of intrauterine infection, which is linked to higher rates of in utero fetal death (LE3), early neonatal infection (LE2), and necrotizing enterocolitis (LE2). The diagnosis of PPROM is principally clinical (professional consensus). Tests to detect IGFBP-1 or PAMG-1 are recommended in cases of uncertainty (professional consensus). Hospitalization is recommended for women diagnosed with PPROM (professional consensus). Adequate evidence does not exist to support recommendations for or against initial tocolysis (Grade C). If tocolysis is prescribed, it should not continue longer than 48 h (Grade C). The administration of antenatal corticosteroids is recommended for fetuses with a gestational age less than 34 weeks (Grade A) and magnesium sulfate if delivery is imminent before 32 weeks (Grade A). The prescription of antibiotic prophylaxis at admission is recommended (Grade A) to reduce neonatal and maternal morbidity (LE1). Amoxicillin, third-generation cephalosporins, and erythromycin (professional consensus) can each be used individually or eythromycin and amoxicillin can be combined (professional consensus) for a period of 7 days (Grade C). Nonetheless, it is acceptable to stop antibiotic prophylaxis when the initial vaginal sample is negative (professional consensus). The following are not recommended for antibiotic prophylaxis: amoxicillin-clavulanic acid (professional consensus), aminoglycosides, glycopeptides, first- or second-generation cephalosporins, clindamycin, or metronidazole (professional consensus). Women who are clinically stable after at least 48 h of hospital monitoring can be managed at home (professional consensus). Monitoring should include checking for clinical and laboratory factors suggestive of intrauterine infection (professional consensus). No guidelines can be issued about the frequency of this monitoring (professional consensus). Adequate evidence does not exist to support a recommendation for or against the routine initiation of antibiotic therapy when the monitoring of an asymptomatic woman produces a single isolated positive result (e.g., elevated CRP, or hyperleukocytosis, or a positive vaginal sample) (professional consensus). In cases of intrauterine infection, the immediate intravenous administration (Grade B) of antibiotic therapy combining a beta-lactam with an aminoglycoside (Grade B) and early delivery of the child are both recommended (Grade A). Cesarean delivery of women with intrauterine infections is reserved for the standard obstetric indications (professional consensus). Expectant management is recommended for uncomplicated PROM before 37 weeks (Grade A), even when a sample is positive for Streptococcus B, as long as antibiotic prophylaxis begins at admission (professional consensus). Oxytocin and prostaglandins are two possible options for the induction of labor in women with PPROM (professional consensus).

To determine management of women with preterm premature rupture of membranes (PPROM).Bibliographic search from the Medline and Cochrane Library databases and review of international clinical practice guidelines.In France, PPROM rate is 2 to 3% before 37 weeks of gestation (level of evidence [LE] 2) and less than 1% before 34 weeks of gestation (LE2). Prematurity and intra-uterine infection are the two major complications of PPROM (LE2). Compared to other causes of prematurity, PPROM is not associated with an increased risk of neonatal mortality and morbidity, except in case of intra-uterine infection, which is associated with an augmentation of early-onset neonatal sepsis (LE2) and of necrotizing enterocolitis (LE2). PPROM diagnosis is mainly clinical (professional consensus). In doubtful cases, detection of IGFBP-1 or PAMG-1 is recommended (professional consensus). Hospitalization of women with PPROM is recommended (professional consensus). There is no sufficient evidence to recommend or not recommend tocolysis (grade C). If a tocolysis should be prescribed, it should not last more than 48hours (grade C). Antenatal corticosteroids before 34 weeks of gestation (grade A) and magnesium sulfate before 32 weeks of gestation (grade A) are recommended. Antibiotic prophylaxis is recommended (grade A) because it is associated with a reduction of neonatal mortality and morbidity (LE1). Amoxicillin, 3rd generation cephalosporins, and erythromycin in monotherapy or the association erythromycin-amoxicillin can be used (professional consensus), for 7 days (grade C). However, in case of negative vaginal culture, early cessation of antibiotic prophylaxis might be acceptable (professional consensus). Co-amoxiclav, aminosides, glycopetides, first and second generation cephalosporins, clindamycin, and metronidazole are not recommended for antibiotic prophylaxis (professional consensus). Outpatient management of women with clinically stable PPROM after 48hours of hospitalization is a possible (professional consensus). During monitoring, it is recommended to identify the clinical and biological elements suggesting intra-uterine infection (professional consensus). However, it not possible to make recommendation regarding the frequency of this monitoring. In case of isolated elevated C-reactive protein, leukocytosis, or positive vaginal culture in an asymptomatic patient, it is not recommended to systematically prescribe antibiotics (professional consensus). In case of intra-uterine infection, it is recommended to immediately administer an antibiotic therapy associating beta-lactamine and aminoside (grade B), intravenously (grade B), and to deliver the baby (grade A). Cesarean delivery should be performed according to the usual obstetrical indications (professional consensus). Expectative management is recommended before 37 weeks of gestation in case of uncomplicated PPROM (grade A), even in case of positive vaginal culture for B Streptococcus, provided that an antibiotic prophylaxis has been prescribed (professional consensus). Oxytocin and prostaglandins are two possible options to induce labor in case of PPROM (professional consensus).Expectative management is recommended before 37 weeks of gestation in case of uncomplicated PPROM (grade A).

The theme of deprivation is new for the ENCMM. In view of the perceived increase in the number of maternal deaths that may be related to a deprivation situation, we sought to understand the main dimensions that could contribute to maternal death in this context, in order to propose a definition. The selection of cases made a posteriori is mainly based on a qualitative judgment. Between 2010 and 2012, among the deaths evaluated by the CNEMM, one or more elements related to social vulnerability were identified in 8.6% of the cases (18 deaths). The direct criteria used were the concepts of "deprivation" or "social difficulties", difficulties of housing, language barriers and isolation. The absence of prenatal care was retained as an indirect marker. We excluded cases where psychiatric pathology and/or addiction were predominant. Of the 18 cases identified with deprivation factors, death was considered "unavoidable" in 2 cases (11%), "certainly avoidable" or "possibly avoidable" in 13 cases (72%). In 3 cases (17%), avoidability could not be determined. Avoidability was related to the content and adequacy of care in 11 cases out of 13 (85%) and the patient's interaction with the health care system in 10 of 18 cases (56%). The analysis of maternal deaths among women in precarious situations points out that the link between socio-economic deprivation and poor maternal health outcomes potentially includes a specific risk of maternal death.

Over the period 2010-2012, maternal mortality from infectious causes accounted for 5% of maternal deaths by direct causes and 16% of maternal deaths by indirect causes. Among the 22 deaths caused by infection occurred during this period, 6 deaths were attributed to direct causes from genital tract origin, confirming thus the decrease in direct maternal deaths by infection during the last ten years. On the contrary, indirect maternal deaths by infection, from extragenital origin, doubled during the same period, with 16 deaths in the last triennium, dominated by winter respiratory infections, particularly influenza: the 2009-2010 influenza A (H1N1) virus pandemic was the leading cause of indirect maternal mortality by infection during the studied period. The main infectious agents involved in maternal deaths from direct causes were Streptococcus A, Escherichia Coli and Clostridium perfringens: these bacterias were responsible for toxic shock syndrome, severe sepsis, secondary in some cases to cellulitis or necrotizing fasciitis. Of the 6 deaths due to direct infection, 4 were considered avoidable because of inadequate management: delayed or missed diagnosis, delayed or inadequate initiation of a specific medical and/or surgical treatment. Of the 16 indirect maternal deaths due to infection causes, the most often involved infectious agents were influenza A (H1N1) virus and Streptococcus pneumonia with induced purpura fulminans: the absence of influenza vaccination during pregnancy, delayed diagnosis and emergency initiation of a specific treatment, were the main contributory factors to these deaths and their avoidability in 70% of the cases analyzed.

Les recommandations pour la pratique clinique (RPC) restent d’actualite pour les hemorragies du postpartum (HPP), causes evitables de mortalite maternelle. La base de l’Association des utilisateurs de dossiers informatises en pediatrie, obstetrique et gynecologie (AUDIPOG) permet de suivre l’evolution de certains indicateurs en obstetrique lies aux HPP severes entre 1994 et 2009. L’analyse de la base AUDIPOG permet d’observer que les HPP augmentent de 0,9 a 3,1 %, alors que dans la meme periode les pratiques recommandees evoluent dans un sens favorable. La pratique de la delivrance dirigee augmente de 6,2 a 66,2 %, celle des episiotomies baisse en continu de 56 a 31,8 %, et si les cesariennes ont augmente de 14,2 a 19 %, on observe une stabilisation depuis 2004. La fiabilite de l’indicateur HPP severes est discutee.

To assess the impact of the Regional experimental accompanying nutrition and breast-feeding for pregnant women (PRENAP) 75 social device on the duration of postpartum hospitalization and breast-feeding for pregnant women in precarious situation.A retrospective observational study took place between November 2013 and May 2015 in a type III Parisian maternity. Comparison of sociodemographic, perinatal and postpartum characteristics of women in precarious situations (no stable housing and no social care or universal medical coverage or state medical aid) was done according to whether they were included in the system PRENAP or not.Over the study period, 344 (4.6%) women in precarious situations gave birth in this maternity. Among these women, the women included in the PRENAP system were more frequently in a very unfavorable social situation than those who were not included. The inclusion in the PRENAP device did not reduce the hospitalization in post-partum. Breast-feeding was chosen more frequently by the women included in the PRENAP device.The PRENAP device seems to favor the use of breast-feeding, but is not associated with a diminution of the hospitalization time in post-partum. This social device, which seems to be beneficial in terms of social and medical support for women in precarious situations, deserves to be evaluated prospectively.

Resume Objectifs Definir les stades du travail spontane, preciser les indications, les modalites et l’efficacite de l’administration d’oxytocine ainsi que decrire les effets indesirables maternels, fœtaux et neonataux lies a cette administration. Methode Revue systematique de la litterature a partir de la base de donnees Medline interrogee jusqu’en mars 2016 et completee par une recherche sur les sites des societes savantes. Resultats Le 1er stade debute par une phase de latence, definie par des contractions uterines entrainant une modification du col jusqu’a 5 cm de dilatation, et se termine par une phase active, de 5 cm a dilatation complete. Le 2e stade debute par la phase de descente et se termine par la phase d’expulsion. En phase de latence, il est recommande de ne pas intervenir a titre systematique. Une pose precoce d’analgesie peridurale est possible sans attendre la phase active du travail et, dans ce cas, il est recommande de ne pas associee de facon systematique une administration d’oxytocine. En phase active du premier stade, une dystocie dynamique est definie par une vitesse de dilation inferieure a 1 cm/4 h de 5 cm a 7 cm ou inferieure a 1 cm/2 h de 7 cm a dilation complete. En cas de dystocie dynamique en phase active, il est recommande de pratiquer une amniotomie en premiere intention. En l’absence d’amelioration une heure apres l’amniotomie, une administration d’oxytocine peut etre realisee. En cas de prolongation du 2e stade au-dela de 2 h, il est recommande d’administrer de l’oxytocine pour corriger une absence de progression de la presentation. En cas de dystocie dynamique, l’oxytocine doit etre administree a un debit initial de 2 mUI/min, augmentee par palier de 2 mUI/min en respectant un delai de 30 min, et sans depasser un debit de 20 mUI/min. Les effets indesirables maternels rapportes concernent l’hyperactivite uterine, la rupture uterine et l’hemorragie du post-partum (HPP). Les effets indesirables fœtaux discutes concernent les anomalies du rythme cardiaque fœtal liees a une hyperactivite uterine, l’hyponatremie, l’ictere neonatal, les difficultes de succion et l’autisme. Conclusion L’administration d’oxytocine durant le travail spontane ne doit pas etre consideree comme une prescription anodine. L’etat actuel des connaissances doivent inciter les acteurs de la perinatalite a la plus grande vigilance. L’administration d’oxytocine durant le travail spontane expose la mere et le fœtus a des effets nefastes pouvant avoir des consequences a court terme et possiblement a long terme. Ses modalites d’administration doivent faire l’objet d’un protocole. Sa prescription et le consentement de la mere doivent etre precises dans son dossier medical.

To define the different stages of spontaneous labour. To determine the indications, modalities of use and the effects of administering synthetic oxytocin. And to describe undesirable maternal and perinatal outcomes associated with the use of synthetic oxytocin.A systematic review was carried out by searching Medline database and websites of obstetrics learned societies until March 2016.The 1st stage of labor is divided in a latence phase and an active phase, which switch at 5cm of cervical dilatation. Rate of cervical dilatation is considered as abnormal below 1cm per 4hour during the first part of the active phase, and below 1cm per 2hours above 7cm of dilatation. During the latent phase of the first stage of labor, i.e. before 5cm of cervical dilatation, it is recommended that an amniotomy not be performed routinely and not to use oxytocin systematically. It is not recommended to expect the active phase of labor to start the epidural analgesia if patient requires it. If early epidural analgesia was performed, the administration of oxytocin must not be systematic. If dystocia during the active phase, an amniotomy is recommended in first-line treatment. In the absence of an improvement within an hour, oxytocin should be administrated. However, in the case of an extension of the second stage beyond 2hours, it is recommended to administer oxytocin to correct a lack of progress of the presentation. If dynamic dystocia, it is recommended to start initial doses of oxytocin at 2mUI/min, to respect at least 30min intervals between increases in oxytocin doses delivered, and to increase oxytocin doses by 2mUI/min intervals without surpassing a maximum IV flow rate of 20mUI/min. The reported maternal adverse effects concern uterine hyperstimulation, uterine rupture and post-partum haemorrhage, and those of neonatal adverse effects concern foetal heart rate anomalies associated with uterine hyperstimulation, neonatal morbidity and mortality, neonatal jaundice, weak suck/poor breastfeeding latch and autism.The widespread use of oxytocin during spontaneous labour must not be considered as simply another inoffensive prescription without any possible deleterious consequences for mother or foetus. Conditions for administering the oxytocin must therefore respect medical protocols. Indications and patient consent have to be report in the medical file.

Decisions regarding whether to initiate or forgo intensive care for extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients and must be taken into account. After a short review of these factors, we present the thoughts and proposals of the Risks and Pregnancy department. The proposals are to limit emergency decisions, to better take into account other factors than gestational age and prenatal predicted fetal weight in assessing the prognosis, to introduce multidisciplinary consultation in the evaluation and proposals that will be discussed with the parents, and to separate prenatal steroid therapy from decision-making regarding whether or not to administer intensive care.

Resume Objectif Decrire les pratiques medicales face a certaines recommandations. Patientes et methodes Entre 1994 et 2005, la base de donnees Audipog comprend 247 405 grossesses. Nous avons constitue un sous-echantillon, par tirage au sort, ne comprenant que les naissances survenues pendant un mois par maternite (n = 100 315 grossesses). L’evolution de certains indicateurs a ete analysee en regard de huit recommandations nationales et des decrets de perinatalite de 1998. Les taux standardises ont ete compares par un test de tendance. Resultats Les enfants de moins de 33 semaines d’amenorrhee (SA) issus de grossesses multiples sont nes dans 77,4 % des cas dans un niveau III en 2000–2001 contre 44,9 % en 2004–2005 (p Discussion et conclusion L’impact des recommandations pour la pratique clinique (RPC) sur les pratiques est globalement faible. Il est observe une amelioration des pratiques avant la publication des RPC.

Resume Objectif Presenter, a partir du reseau sentinelle Audipog, les principaux indicateurs perinatals en 2004–2005. Patientes et methodes Nous avons recu, tout au long des deux annees 2004–2005, des donnees de maternites qui ont conduit a un fichier de 71 406 grossesses en provenance de 86 maternites. Nous avons constitue pour 2004–2005, un sous-echantillon, par tirage au sort, ne comprenant que les naissances survenues pendant un mois par maternite. Notre etude porte sur 6987 grossesses en 2004 et 7648 grossesses en 2005. Resultats Les principaux resultats concernant les indicateurs 2004–2005 ont montre une augmentation du nombre de femmes exercant une profession en cours de grossesse (62,3 % versus 66,3 %) ( p = 0,0008) et ayant eu un enseignement superieur (35,1 % versus 41,9 %) ( p p p = 0,0002) et moins souvent aucune consultation (1,1 % versus 0,4 %) ( p = 0,0003). Il y a eu plus de femmes avec un diabete (4 % versus 5 %) ( p = 0,007). Le pourcentage d’accouchements prematures etait de 6,4 % en 2004 et 7 % en 2005 ( p = 0,14). Le pourcentage de prematurite induite est passe de 37 % en 2004 a 41,2 % en 2005 ( p = 0,18). Le taux de cesarienne est passe de 19 a 19,2 % sur les deux annees et le taux d’intervention voie basse de 13,1 a 11,2 % entre 2004 et 2005 ( p = 0,0015). Discussion et conclusion Ces resultats sont globalement dans la continuite de ce qui avait ete amorce les annees precedentes. L’âge gestationnel a l’accouchement et le taux de cesarienne sont restes assez stables.

Resume L’evaluation des pratiques professionnelles est une obligation pour les medecins en France. Cet article a pour objectif d’expliquer aux professionnels de la perinatalite le concept et la demarche qui ne semblent pas simples au premier abord, vu le nombre de modalites possibles pour faire realiser et valider son evaluation des pratiques professionnelles. Nos propos seront illustres d’exemples concrets afin de faciliter la comprehension du lecteur. L’evaluation des pratiques professionnelles est desormais liee reglementairement a la formation medicale continue (FMC) pour les medecins. Seule l’accreditation des medecins est basee sur le volontariat ; l’evaluation des pratiques professionnelles individuelle, l’evaluation des pratiques professionnelles dans le cadre de la certification des etablissements de sante et la FMC sont obligatoires pour tout medecin.

High-frequency oscillation (HFO) is a technique frequently used in neonatal resuscitation, but which has yet to be evaluated. The use of intrathoracic pressures may have an effect on the cerebral circulation of immature neonates. The aim of this study was to examine the variations in cerebral blood velocity and oxygenation during brief pulmonary inflations (sighs), by focusing on alveolar recruitment. In this prospective study performed in 13 intubated and ventilated neonates (α = 5%; 1 - β = 80%), mean blood velocity and Doppler Resistance Index were measured, and variations in chromophores concentrations were evaluated by near infrared spectroscopy. Brief inflations at 4 cmH 2 O above the mean regulated intra-thoracic pressure did not cause any variation in the parameters measured. An explanation for this discordance with animal studies may be the level of pressure chosen, which could be more appropriate for the pulmonary compliance of neonates. □ Cerebral blood flow, high frequency oscillation, newborn, NIRS.

International audience; Small for gestational age (SGA) is defined by weight (in utero estimated fetal weight or birth weight) below the 10th percentile (professional consensus). Severe SGA is SGA below the third percentile (professional consensus). Fetal growth restriction (FGR) or intra-uterine growth restriction (IUGR) usually correspond with SGA associated with evidence indicating abnormal growth (with or without abnormal uterine and/or umbilical Doppler): arrest of growth or a shift in its rate measured longitudinally (at least two measurements, 3 weeks apart) (professional consensus). More rarely, they may correspond with inadequate growth, with weight near the 10th percentile without being SGA (LE2). Birthweight curves are not appropriate for the identification of SGA at early gestational ages because of the disorders associated with preterm delivery. In utero curves represent physiological growth more reliably (LE2). In diagnostic (or reference) ultrasound, the use of growth curves adjusted for maternal height and weight, parity and fetal sex is recommended (professional consensus). In screening, the use of adjusted curves must be assessed in pilot regions to determine the schedule for their subsequent introduction at national level. This choice is based on evidence of feasibility and the absence of any proven benefits for individualized curves for perinatal health in the general population (professional consensus). Children born with FGR or SGA have a higher risk of minor cognitive deficits, school problems and metabolic syndrome in adulthood. The role of preterm delivery in these complications is linked. The measurement of fundal height remains relevant to screening after 22 weeks of gestation (Grade C). The biometric ultrasound indicators recommended are: head circumference (HC), abdominal circumference (AC) and femur length (FL) (professional consensus). They allow calculation of estimated fetal weight (EFW), which, with AC, is the most relevant indicator for screening. Hadlock's EFW formula with three indicators (HC, AC and FL) should ideally be used (Grade B). The ultrasound report must specify the percentile of the EFW (Grade C). Verification of the date of conception is essential. It is based on the crown-rump length between 11 and 14 weeks of gestation (Grade A). The HC, AC and FL measurements must be related to the appropriate reference curves (professional consensus); those modelled from College Francais d'Echographie Fetale data are recommended because they are multicentere French curves (professional consensus). Whether or not a work-up should be performed and its content depend on the context (gestational age, severity of biometric abnormalities, other ultrasound data, parents' wishes, etc.) (professional consensus). Such a work-up only makes sense if it might modify pregnancy management and, in particular, if it has the potential to reduce perinatal and long-term morbidity and mortality (professional consensus). The use of umbilical artery Doppler velocimetry is associated with better newborn health status in populations at risk, especially in those with FGR (Grade A). This Doppler examination must be the first-line tool for surveillance of fetuses with SGA and FGR (professional consensus). A course of corticosteroids is recommended for women with an FGR fetus, and for whom delivery before 34 weeks of gestation is envisaged (Grade C). Magnesium sulphate should be prescribed for preterm deliveries before 32-33 weeks of gestation (Grade A). The same management should apply for preterm FGR deliveries (Grade C). In cases of FGR, fetal growth must be monitored at intervals of no less than 2 weeks, and ideally 3 weeks (professional consensus). Referral to a Level IIb or III maternity ward must be proposed in cases of EFW

Resume La prophylaxie de l’hemorragie du post-partum (HPP) est un objectif majeur etant donne sa prevalence et ses consequences sur la morbidite et la mortalite maternelles. Parmi l’ensemble des facteurs de risque d’HPP que l’on peut retrouver au cours du travail, il faut differencier les facteurs de risque etablis pour lesquels persiste une difference significative apres analyse multivariee : allongement de la duree du travail, stimulation du travail par les ocytociques, cesarienne, extraction instrumentale, dechirures genitales et episiotomie, prolongation de la 3e phase du travail, retention placentaire ; d’autres facteurs de risque restant plus discutes comme le declenchement du travail, l’hyperthermie ou la chorioamniotite, les modalites d’anesthesie ou d’analgesie, le poids du nouveau-ne, la technique de cesarienne, entre autres. L’association de facteurs de risques qui, isoles, n’augmentent pas beaucoup le risque d’HPP, doit faire craindre une augmentation de ce risque dans des proportions qui sont encore mal evaluees. Parmi les methodes prophylactiques d’HPP au cours de la 3e phase du travail, la plus efficace reste l’injection d’un bolus d’oxytocine au degagement de l’epaule anterieure associee a la traction douce du cordon. Si elle s’impose chez les femmes a haut risque hemorragique, et semble benefique quel que soit le niveau de risque, sa parfaite realisation necessite la disponibilite ponctuelle d’un personnel habilite a la realiser et la vigilance continue de la sage-femme ou de l’obstetricien, la duree de la 3e phase du travail etant nettement ecourtee. L’alternative de l’utilisation du misoprostol est moins efficace que les ocytociques en prophylaxie de l’HPP, et est associee a des effets secondaires maternels frequents et mal toleres (tremblements severes, fievre, diarrhee). Aucune des autres methodes prophylactiques proposees n’a fait la preuve de son efficacite : mise au sein precoce, drainage du cordon, injection intra-funiculaire d’ocytociques, entre autres. La promotion d’une surveillance attentive et du recueil de donnees de la delivrance et du post-partum immediat, de meme que la diffusion des techniques preventives de l’HPP et le choix de politiques adaptees aux conditions d’exercice, doivent permettre de constater une diminution de l’incidence des HPP.

Presents a synthesis of works undertaken by the Hyperthermia Group of Lille (France) concerning the utilization of microwave radiometry for temperature control in hyperthermia therapy. This technique of noninvasive temperature control within biological tissues has been integrated on many hyperthermia systems now commercialized. The authors describe the principle of a new radiometer as well as the calculation of the radiometric signals. This allows a noninvasive determination of thermal maps inside tissues during the hyperthermia treatments. Many comparisons between theory and experiment have validated the authors' models of thermal dosimetry and provide a quantitative guidance for the planning of hyperthermia treatments.

Describe management of severe postpartum haemorrhages (PPH) and its compliance with national guidelines and identify determinants of non-optimal care.Population-based cohort study of 1379 women with severe PPH due to uterine atony after vaginal delivery, conducted in 106 French maternity units between December 2004 and November 2006. Severe PPH was defined by a peripartum haemoglobin drop of 4g/dL or more, blood loss of 1000 mL or more, hysterectomy, or transfer to intensive care for PPH. The frequency of each recommended procedure for the management of PPH was described. Associations between quality of care and both individual and institutional characteristics were assessed by univariate analysis and multivariate logistic regression.Management of severe PPH was not optimal in 65.9% of cases. The recommended components that were applied least often were administration of second line uterotonics, and transfusion of patients with a low haemoglobin. After adjustment for individual characteristics, the risk of either non- or suboptimal care was significantly higher in non-university public maternity units (aOR 2.62 [95% CI: 1.49-4.54]) compared with university hospital units, in units with fewer than 2000 annual deliveries (aOR 2.32 [95% CI: 1.49-3.57]), and in units without an obstetrician always present (aOR 1.96 [95% CI: 1.26-3.03]).Management practices for severe PPH can be improved, to an extent that varies by component of care and type of hospital. A qualitative approach should help to identify the individual and organizational factors explaining why guidelines are not fully applied.

To describe specific clinical practices in France in 2004-2005 based on data from the Audipog sentinel network.The database for 2004 and 2005 covers 71406 pregnancies from 86 maternity units throughout the year. We constructed a random subsample each year by including only the births occurring during a single month for each maternity ward. Our study therefore analyzes 6987 pregnancies in 2004 and 7648 pregnancies in 2005.Among the very preterm (33 weeks of gestation) infants from multiple pregnancies, 77.4% were born in level 3 hospitals in 2000-2001, and only 44.9% in 2004-2005 (p0.0001). Among the very preterm infants from singleton pregnancies, the percentage born in level 3 maternity hospitals rose between 1996-1997 and 2004-2005 (55% versus 73%; p=0.001). The rate of corticosteroid therapy before delivery among very preterm infants did not change significantly between 2000 and 2005 (p=0.58). The cesarean rate rose from 14% in 1994 to 20.0% in 2005. The percentage of actively managed third stages of labor increased from 1994-1995 to 2005 (6.2% versus 31.3%). Fewer episiotomies were performed: 56% in 1994-1995 and 41.3% in 2005. Exclusive breast-feeding rose from 51.2% in 2000-2001 to 58.5% in 2005 (p0.0001). Early discharge increased between 1994-1995 and 2005 (p0.0001).Indicators monitoring implementation of some of the national clinical practice guidelines have improved slightly over time, although most often before the publication of these guidelines.

To present the principal perinatal indicators for 2004-2005, based on data from the Audipog sentinel network.The database for 2004 and 2005 covers 71,406 pregnancies from 86 maternity units throughout the year. We constructed a random subsample each year by including only the births occurring during a single month for each maternity ward. Our study therefore analyzes 6987 pregnancies in 2004 and 7648 pregnancies in 2005.The number of women working during pregnancy increased between 2004 and 2005 (62.3% versus 66.3%) (p=0.0008) as did the percentage with a postsecondary education (35.1% versus 41.9%) (p0.0001). The percentage of amniocenteses declined (10.4% versus 7.9%) (p0.0001). Use of prenatal care improved: more women had prenatal visits before week 14 (30.5% versus 33.9%) (p=0.0002), and fewer women had no prenatal care at all (1.1% versus 0.4%) (p=0.0003). The percentage of preterm deliveries was 6.4% in 2004 and 7% in 2005 (p=0.14) and the percentage of induced preterm deliveries was 37% in 2004 and 41.2% in 2005 (p=0.18). The cesarean rate was essentially stable (19 and 19.2%) and the rate of instrumental intervention in vaginal deliveries fell from 13.1% in 2004 to 11.2% in 2005 (p=0.0015).The rates of cesarean and of preterm deliveries remained stable between 2004 and 2005, but the rate of induced preterm deliveries rose. These indicators are consistent with trends that began earlier.

Medical practice assessment is mandatory in France. The goal of this article is to explain to perinatal care providers the concept and the process, which do not seem simple, given the multitude of possible ways to evaluate and validate its medical practices. Concrete examples help to illustrate the process. French regulations now link medical practice assessment with continuing medical education (CME) for physicians. While certification is voluntary, a practice assessment conducted during hospital certification processes and during CME is required for all French physicians.

Prevention of postpartum hemorrhage (PPH) is a major concern in regards to its impact on maternal morbidity and mortality. While established risk factors can be identified among risk factors of PPH during labor after multivariate analysis: prolonged labor, oxytocin stimulation of labor, cesarean section, instrumental delivery, genital lacerations and episiotomy, prolonged third stage of labor, retained placenta; other risk factors are still uncertain: induction of labor, hyperthermia or chorioamniotitis, analgesia or anesthesia, macrosomia, various cesarean section techniques. Isolated identified risk factors have a moderate incidence on PPH, but their cumulation in one patient is a potential high risk. Among active management schemes of third stage of labor for PPH prevention, the most efficient technique seems to be direct injection of oxytocin when the baby's shoulders are delivered, associated with controlled cord traction. If this technique is a must for high-risk patients for PPH, and seems efficient for every patient, a correctly performed procedure requires the presence of a competent professional in addition to the midwife or obstetrician in charge of delivery, and a permanent attention so the length of third stage of labor is shortened. The alternative use of prophylactic misoprostol in the third stage of labor is less effective than injectable uterotonics in reducing PPH, and is associated with more side effects (severe shivering, pyrexia, diarrhea). None of other described prophylactic methods have proved efficiency: early suckling, umbilical blood drainage, oxytocin umbilical vein injection, among others. A decrease in PPH prevalence should be obtained by particular attention on data from the early postpartum period, active diffusion of effective prophylactic techniques, and an appropriate choice in regards to each delivery unit organization.

The discussion, which was rather more of a question-answer period, focused on the user’s perspective of the future of space transportation; members of the panel gave their points of view on the topic.

High-frequency oscillation (HFO) is a technique frequently used in neonatal resuscitation, but which has yet to be evaluated. The use of intrathoracic pressures may have an effect on the cerebral circulation of immature neonates. The aim of this study was to examine the variations in cerebral blood velocity and oxygenation during brief pulmonary inflations (sighs), by focusing on alveolar recruitment. In this prospective study performed in 13 intubated and ventilated neonates (alpha = 5%; 1-beta = 80%), mean blood velocity and Doppler Resistance Index were measured, and variations in chromophores concentrations were evaluated by near infrared spectroscopy. Brief inflations at 4 cm H2O above the mean regulated intra-thoracic pressure did not cause any variation in the parameters measured. An explanation for this discordance with animal studies may be the level of pressure chosen, which could be more appropriate for the pulmonary compliance of neonates.

The development of BAL in children for both research and clinical purposes has been limited so far by the difficulty in establishing reference values. The aim of the study was (1) to define composition of BAL cellular components in control children and to evaluate the ability of these cells to express various cytokines, and (2) to study modifications of differential cytology and BAL cell cytokine responses in children with interstitial lung disorders.Two groups were investigated: a control group of 16 children who were concluded to be free of parenchymal lung disease after complete pulmonary investigation, and a group of 11 children with pulmonary sarcoidosis. Differential cytology was evaluated by standard techniques. BAL cell cytokine expression was studied at the level of messenger RNA (mRNA) by reverse transcription-polymerase chain reaction (RT-PCR) methods.In the control group, differential cell counts appeared to be similar to values reported in adult populations with normal distribution of the data and no influence of age. In this group, no transcripts for interleukin-1beta (IL-1beta), tumor necrosis factor-alpha (TNF-alpha), IL-6, and transforming (correction of tranforming) growth factor-beta (TGF-beta) could be detected. In children with sarcoidosis, different profiles of IL-1beta, TNF-alpha, IL-6, and TGF-beta expression were individualized which seemed to be related to the activity and/or severity of the disease, IL-6 and TGF-beta mRNA being observed only in the more severe forms.These data provide information on BAL cell number and function in children. Characterization of BAL cytokine expression patterns during the course of interstitial lung diseases in children may be of great interest for evaluation of disease activity and/or severity and therefore for planning of therapy.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 33 - N° 4 - p. 361

Congenital diaphragmatic hernia (CDH) is a severe disorder in neonates. The prognosis has been improved in the past 10 years by a combination of HFO ventilation, sedation and analgesia, nitric oxide and delayed surgery. Extracorporeal oxygenation (ECMO) has been proposed by certain teams. A decrease in mortality from 70% to approximately 40% has recently been reported [1,2]. However, little is known about the outcome of such patients. We report the outcome of a group of patients after 10 years' follow-up.

Ventilation by HFO or CMV in premature neonates of less than 30 weeks' gestational age with hyaline membrane disease: functional outcome at one year