Comparative satisfaction and effectiveness of virtual simulation and usual supervised work for postpartum hemorrhage management: a crossover randomized controlled trial.

BACKGROUND: Because virtual simulation promotes learning and cognitive skill development, it may be useful for teaching students to manage postpartum hemorrhage (PPH) and its complex decision algorithm. OBJECTIVE: This study aimed to compare the satisfaction and effectiveness of virtual simulation with usual supervised work in producing knowledge and satisfaction. METHODS: This two-center two-stage crossover randomized controlled trial included student midwives. One group underwent the virtual simulation intervention in the first period (January 2018) and the usual supervised classroom work in the second (May 2018); the other group followed the reverse chronology. Satisfaction was the primary outcome. The secondary outcome was knowledge of the PPH management algorithm, assessed by responses to a case vignette after each intervention session. RESULTS: The virtual simulation -supervised work (VS-SW) chronology was allocated to 48 students, and its inverse (SW-VS) to 47; Satisfaction was significantly higher for the virtual simulation for its overall grade (6.8 vs. 6.1, P = 0.009), engagingness (very good 82.1% vs. 24.3%, P < 0.001), and ease of use (very good 77.9% vs. 46.1%, P < 0.001). Knowledge did not differ between the two groups (respectively, 89.5% versus 83.5%, P = 0.3). CONCLUSION: Satisfaction is higher with virtual simulation without lowering knowledge scores, which argues for the use of such innovative teaching strategies. This could lead to an increase in students' motivation to learn.

Promptness of oxytocin administration for first-line treatment of postpartum hemorrhage: a national vignette-based study among midwives.

BACKGROUND: Postpartum hemorrhage (PPH) remains a leading cause of maternal morbidity and mortality worldwide. Midwives play a key role in the initial management of PPH. Uterotonic agents are widely used in its prevention and treatment, with oxytocin the first-line agent. Nonetheless, a standardized guideline for optimal dose and rate of administration has not been clearly defined. The aim of this study was to investigate French midwives' practices regarding first-line oxytocin treatment and the factors influencing its delayed administration. METHODS: This multicenter study was based on clinical vignettes of PPH management collected using an anonymous online questionnaire. A random sample of midwives from 145 maternity units in France from 15 randomly selected perinatal networks were invited to participate by email. The Previously validated case vignettes described two different scenarios of severe PPH. Vignette 1 described a typical immediate, severe PPH, and vignette 2 a less typical case of severe but gradual PPH They were constructed in three successive steps and included multiple-choice questions proposing several types of clinical practice options at each stage. For each vignette separately, we analyzed the lack of prompt oxytocin administration and the factors contributing to them, that is, characteristics of the midwives and organizational features of maternity units. Bivariate analysis and multivariable logistic regression analysis were applied. RESULTS: In all, 450 midwives from 87 maternity units provided complete responses. Lack of promptness was observed in 21.6% of responses (N = 97) in Vignette 1 and in 13.8% (N = 62) in Vignette 2 (p < .05). After multivariate analysis, the risk of delay was lower among with midwives working in university maternity hospitals (ORa 0.47, 95% 0.21, 0.97) and in units with 1500 to 2500 births per year (ORa 0.49, 95% CI 0.26, 0.90) for Vignette 1. We also noticed that delay increased with the midwives' years of experience (per 10-year period) (ORa 1.30, 95% CI 1.01, 1.69). CONCLUSIONS: This study using clinical vignettes showed delays in oxytocin administration for first-line treatment of PPH. Because delay in treatment is a major cause of preventable maternal morbidity in PPH, these findings suggest that continuing training of midwives should be considered, especially in small maternity units.

[Induction of labour with oral misoprostol versus vaginal misoprostol: A before-after study]. / Induction du travail par misoprostol oral versus misoprostol vaginal : étude avant-après.

OBJECTIVE: The rate of induction of labor represented 22 % of deliveries in 2016 in France. Oral misoprostol (Angusta®) was marketed in France in the last quarter of 2018. The objective of our study was to compare the efficacy and safety of induction of labor with oral misoprostol compared to vaginal misoprostol in women with an unripe cervix. MATERIAL AND METHODS: We carried out a retrospective study before and after the implementation of oral misoprostol including all women with an unripe cervix who benefited from an induction of labor with a viable infant in vertex presentation, without uterine scar. During the first two-year period, women received 50µg of misoprostol in the posterior fornix, repeated 6hours later if needed. If labor had not started after 24hours, women received another dose of 50µg, which was repeated every 4hours until labor was established, up to a total dose of 150µg. During the second two-year period, women received two tablets of oral misoprostol 25µg every four hours if necessary, up to a total dose of 200µg. The primary endpoints were mode of delivery and neonatal safety. RESULTS: During the two study periods, 1199 women received vaginal misoprostol and 1199 women received oral misoprostol including. The cesarean delivery rate was 21.8% during the first period and 21,3% during the second period (P=0.83). A 5-minutes Apgar score<7 was observed in 23 (1.9%) and 14 (1.2%) newborns in the vaginal misoprostol and oral misoprostol groups (P=0.14), respectively. An arterial cord pH<7.00 was observed in 6 (0.5%) and 7 (0.6%) newborns (P=0.99), respectively. CONCLUSION: Oral misoprostol administered at the dose of 50µg every 4hours (up to a total dose of 200µg) is as effective and safe as the vaginal misoprostol to induce labor in women with an unripe cervix.

Early exposure of pregnant women to non-steroidal anti-inflammatory drugs delivered outside hospitals and preterm birth risk: nationwide cohort study.

OBJECTIVE: To assess the risk of preterm birth associated with nonsteroidal anti-inflammatory drugs (NSAIDs), focusing on early exposure in the period from conception to 22 weeks of gestation (WG). DESIGN: National population-based retrospective cohort study. SETTING: The French National Health Insurance Database that includes hospital discharge data and health claims data. POPULATION: Singleton pregnancies (2012-2014) with a live birth occurring after 22WG from women between 15 and 45 years old and insured the year before the first day of gestation and during pregnancy were included. We excluded pregnancies for which anti-inflammatory medications were dispensed after 22WG. METHODS: The association between exposure and risk of preterm birth was evaluated with GEE models, adjusting on a large number of covariables, socio-demographic variables, maternal comorbidities, prescription drugs and pregnancy complications. MAIN OUTCOME MEASURES: Prematurity, defined as a birth that occurred before 37WG. RESULTS: Among our 1 598 330 singleton pregnancies, early exposure to non-selective NSAIDs was associated with a significantly increased risk of preterm birth, regardless of the severity of prematurity: adjusted odds ratio (aOR) = 1.76 (95% CI 1.54-2.00) for extreme prematurity (95% CI 22-27WG), 1.28 (95% CI 1.17-1.40) for moderate prematurity (28-31WG) and 1.08 (95% CI 1.05-1.11) for late prematurity (32-36WG), with non-overlapping confidence intervals. We identified five NSAIDs for which the risk of premature birth was significantly increased: ketoprofen, flurbiprofen, nabumetone, etodolac and indomethacin: for the latter, aOR = 1.92 (95% CI 1.37-2.70) with aOR = 9.33 (95% CI 3.75-23.22) for extreme prematurity. CONCLUSION: Overall, non-selective NSAID use (delivered outside hospitals) during the first 22WG was found to be associated with an increased risk of prematurity. However, the association differs among NSAIDs. TWEETABLE ABSTRACT: French study for which early exposure to non-selective NSAIDs was associated with increased risk of prematurity.

Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study.

OBJECTIVE: To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section. DESIGN: Prospective population-based study. SETTING: All 176 maternity hospitals of eight French regions. POPULATION: Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries. METHODS: Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared. MAIN OUTCOME MEASURES: Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes. RESULTS: The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally. CONCLUSION: More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean. TWEETABLE ABSTRACT: Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

[Validation of the questionnaire for assessing the childbirth experience (QACE) in a French population]. / Validation de l'échelle d'évaluation du vécu de l'accouchement (QEVA) auprès d'une population française.

BACKGROUND: A woman's negative perception of her subjective childbirth experience can have consequences on the mother's psychological state and on early mother-baby relationships. To date, there is no validated tool in France allowing to evaluate childbirth experience in a multidimensional way. The aim of this study is to validate the Questionnaire Assessing the Childbirth Experience (QEVA) in a French sample of mothers. This tool was developed in a previous study where the authors combined 25 items into 6 dimensions: representations and expectations, sensory perceptions, feeling of control, perceived social support (medical staff and partner), emotions (positive and negative) and first moments with the baby. METHODS: The sample included 256 women recruited in a maternity ward. Sociodemographic and obstetric characteristics of our sample were compared to those of the French national perinatal survey. The structure of the QEVA with 17 items was explored by an exploratory structural equation modeling (ESEM). An analysis of the internal consistency was conducted on the sub-scores of the identified factors, and the concurrent validity was assessed with the Peri-traumatic Distress Inventory (PDI) through a correlation and its associated t-test. RESULTS: The characteristics of our sample and those of the national perinatal survey do not differ on age, marital status, parity, cannabis use, infertility treatment, epidural and baby weight, in favour of the good representativeness of our sample. The study of the QEVA structure revealed a 4-dimensional structure. Analysis of the psychometric qualities showed a good internal consistency, with an observed alpha value ranging from 0.69 to 0.86. The QEVA also shows a good concurrent validity with the peri-traumatic distress scores (r=0.51). CONCLUSION: To date, the QEVA is the first standardized tool allowing a multidimensional evaluation of the subjective experience of childbirth. It has been validated on a French population using an exploratory structural equation modeling. This tool, which is simple to use and well accepted by mothers, enables health professionals not only to screen mothers experiencing difficult childbirth and in need of support, but also to adapt health care according to the dimensions of the birth experience and its associated difficulties (emotions during the birth, interactions with health professionals, first moments with the baby, or post-partum emotions).

Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy.

OBJECTIVE: To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned. METHODS: JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation). RESULTS: Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery. CONCLUSION: When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

[Which management of pregnancy after bariatric surgery?] / Quelle prise en charge de la grossesse après une chirurgie bariatrique ?

Obesity represents a major public health issue and a potential threat for people health. Moreover, the incidence of obesity has been increasing and therefore, the incidence of women with an history of bariatric surgery with a pregnancy desire has been also increased. Although the weight loss after bariatric surgery has positive effects on pregnancy outcomes, these surgical procedures may be associated with adverse outcomes as well, for example micronutrient deficiencies, dumping syndrome, surgical complications such as internal hernias, and obstetrical complications such as small for gestational age as instance. Nevertheless, physician knowledge about pregnancy management after bariatric surgery is currently insufficient and a multidisciplinary approach is therefore mandatory. The aim of this article is to provide to readers general and recent data regarding the management of pregnancy after bariatric surgery.

[Evolution of the cesarean delivery rate from 37 weeks of gestation among nulliparas or how to evaluate the external validity of a randomized North American trial about induction of labor]. / Évolution du taux de césariennes à partir de 37 semaines d'aménorrhée parmi les nullipares ou comment évaluer la validité externe d'un essai randomisé nord-américain sur le déclenchement artificiel du travail.

OBJECTIVE: To determine the risk of caesarean delivery (CD) when an expectant management is considered for a nulliparous reaching≥37 weeks of gestation (wog). METHODS: This is a prospective study, including all nulliparous women who delivered at≥37 wog a singleton fetus in a cephalic presentation between the first January 2017 and the 31st December 2017 in a French perinatal network (Mypa). For each week of gestation from 37 wog to 41 wog, the rate of CD was determined according the onset of labor (spontaneous or induced). The risk of CD when expectant management was considered at a specific gestational age was calculated by taking all the population who reached this gestational age, minus all women who had an induction of labor or underwent a caesarean delivery before labor. RESULTS: In total, 16,085 women delivered at≥24 wog, and 5498 (34.1%) were nulliparous with a singleton fetus in a cephalic presentation reaching 37SA. The risk of CD increased from 40 wog, whatever the labor was spontaneous or induced (when labor was spontaneous, the risk of CD was stable till 39 wog around 11%, and increased from 14% at 40 wog to 20% at 41 wog; similarly, when labor was induced, the risk of CD was stable till 39 wog around 28%, and increased from 40% at 40 wog to 38% at 41 wog. The risk of CD for a nulliparous reaching>37 Wog when expectant management is considered was stable around 22.3%. CONCLUSION: The risk of CD for a nulliparous reaching≥37SA when expectant management is considered is similar than the one in the United States of America.

Risk of preterm birth in a twin pregnancy after an early-term birth in the preceding singleton pregnancy: a retrospective cohort study.

OBJECTIVE: To evaluate whether a history of spontaneous early-term birth (37+0 -38+6  weeks of gestation) in the previous singleton pregnancy is a risk factor for preterm birth (PTB) in a subsequent twin pregnancy. DESIGN: Retrospective cohort study. SETTINGS: Two French university hospitals (2006-2016). POPULATION: All women who delivered twins from 24+0  weeks after a preceding singleton pregnancy birth at 37+0 to 41+6  weeks. METHODS: Multivariate logistic regression analysis of association between twin PTB and a previous spontaneous singleton early-term birth. MAIN OUTCOME MEASURES: Twin PTB rate before 37, 34 and 32 weeks of gestation. RESULTS: Among 618 twin pregnancies, 270 were born preterm, 92 of them with a preceding spontaneous singleton early-term birth. The univariate analysis showed a significantly higher risk of twin PTB before 37, 34 and 32 weeks among those 92 women compared with those with a full- or late-term birth in their previous singleton pregnancy. This association remained significant after logistic regression (odds ratio [OR] between 2.42 and 3.88). The secondary analysis, restricted to the twin pregnancies with spontaneous PTB found similar results, with a risk of PTB before 37, 34 and 32 weeks significantly higher among women with a previous spontaneous singleton early-term birth, including after logistic regression analysis (OR between 3.51 and 3.56). CONCLUSION: A preceding spontaneous singleton early-term birth is a strong and easily identified risk factor for PTB in twin pregnancies. TWEETABLE ABSTRACT: Spontaneous 'early-term' birth of a singleton is a significant risk factor for future preterm births in twin pregnancies.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Short Text]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Texte court.

OBJECTIVES: To determine the optimal management of singleton breech presentation. MATERIALS AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long 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). CONCLUSION: In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy.

[Impact of organizational factors on the cesarean delivery occurrence in a low-risk population]. / Facteurs organisationnels associés à la réalisation d'une césarienne dans une population à bas risque.

OBJECTIVE: Huge differences in cesarean delivery rate exist between maternities in a same region. In recent years, the cesarean delivery rate has increased in the low-risk population. The objective of this study was to assess the impact of organizational factors on the cesarean delivery occurence in a low-risk population. METHODS: We performed a population-based cohort study in the MYPA perinatal network from 2009 to 2015. A low-risk population was selected, keeping only groups 1 and 3 of the Robson classification. The studied organizational factors included the structural characteristics of maternity (academic or not, public or private, number of annual births, maternal intensive care unit, neonatal intensive care unit, number of delivery rooms) and the organization of the health care team (number of midwives and obstetricians, on call duty, workload and implementation of a morbi-mortality review). We used a logistic multilevel model, based on random center effect, for both univariable and multivariable analysis. RESULTS: Our study population included 64,100 women. The cesarean delivery rate ranged from 5.5 to 11.3 % among the 10 maternities. In univariate analysis, the organizational variables significantly associated with the cesarean delivery rate were maternity status (university hospital, non-university public hospital and private hospital) and the implementation of a morbi-mortality review. However, after adjustment, none of these organizational factors were significantly associated with the cesarean delivery occurence. When multivariate analysis was restricted to the nulliparous subgroup, the private status of maternity was significantly associated with a higher rate of cesarean deliveries (OR=1.39 [1.09-1.76]). Also, the probability of cesarean delivery was higher when the number of births by delivery room increased (OR=1.15 [1.01-1.31]). For the multiparous subgroup, no variable was significantly associated with cesarean delivery occurence. CONCLUSION: In our global low-risk population, no organizational factors appeared to be associated with an increase in cesarean delivery rate. On the other hand, in the low-risk nulliparous population, the private status of the maternity and a high number of births by delivery room were associated with more cesarean deliveries. Increasing the number of delivery rooms could be a way to reduce the number of cesarean deliveries. Future researches should also try to identify specific factors that can reduce differences in cesarean delivery rates between private and public maternities.

ISUOG Practice Guidelines: intrapartum ultrasound.

PURPOSE AND SCOPE: The purpose of these Guidelines is to review the published techniques of ultrasound in labor and their practical applications, to summarize the level of evidence regarding the use of ultrasound in labor and to provide guidance to practitioners on when ultrasound in labor is clinically indicated and how the sonographic findings may affect labor management. We do not imply or suggest that ultrasound in labor is a necessary standard of care.

[Lower Uterine Segment Trial: A pragmatic open multicenter randomized trial]. / Prédiction échographique du risque de rupture utérine après césarienne : LUSTrial, un essai randomisé pragmatique.

BACKGROUND: The data from literature show that trial of labor and elective repeat cesarean delivery after a prior cesarean delivery both present significant risks and benefits, and these risks and benefits differ for the woman and her fetus. The benefits to the woman can be at the expense of her fetus and vice-versa. This uncertainty is compounded by the scarcity of high-level evidence that preclude accurate quantification of the risks and benefits that could help provide a fair counseling about a trial of labor and elective repeat cesarean delivery. An interesting way of research is to evaluate the potential benefits of a decision rule associated to the ultrasound measurement of the lower uterine segment (LUS). Indeed, ultrasonography may be helpful in determining a specific risk for a given patient by measuring the thickness of the LUS, i,e, the thickness of the cesarean delivery scar area. Although only small and often methodologically biased data have been published, they look promising as their results are concordant: ultrasonographic measurements of the LUS thickness is highly correlated with the intraoperative findings at cesarean delivery. Furthermore, the thinner the LUS becomes on ultrasound, the higher the likelihood of a defect in the LUS. Finally, ultrasound assessment of LUS has an excellent negative predictive value for the risk of uterine defect. Therefore, this exam associated with a rule of decision could help to reduce the rate of elective repeat cesarean delivery and especially to reduce the fetal and maternal mortality and morbidity related to trial of labor after a prior cesarean delivery. METHODS/DESIGN: This is a pragmatic open multicenter randomized trial with two parallel arms. Randomization will be centralized and computerized. Since blindness is impossible, an adjudication committee will evaluate the components of the primary composite outcome in order to avoid evaluation bias. An interim analysis will be planned mid-strength of the trial. Ultrasound will be performed by expert sonographers after certification by the main investigator. Women aged 18 years or older are eligible for this trial if they have a singleton pregnancy in cephalic presentation at a gestational age from 36 to 38 weeks, a previous low transverse cesarean delivery and sign the informed consent sheet. Women will be asked to participate in this study when they reach a term of 36 to 38 weeks of gestation. After agreement, women will be randomized into two groups: in the study group, they will have the LUS measured by ultrasound and the patient will be informed that, based on a threshold value of 3.5mm for the ultrasound measurement of the LUS thickness, the patient with a higher measurement will be considered at low risk and will be encouraged to choose a trial of labor whereas the patient with a measurement is equal to or less than this threshold will be considered at risk and encouraged to choose an elective repeat cesarean; in the control group, ultrasound LUS measurement will not be performed. The mode of delivery will be decided according to standard practice at the center. The primary composite outcome will include: uterine rupture, uterine dehiscence, hysterectomy, thromboembolic complications, transfusion, endometritis, maternal mortality, fetal prenatal and intrapartum mortality, hypoxic-ischemic encephalopathy and neonatal mortality. DISCUSSION: This trial assesses the efficacy of ultrasound measurement of the lower uterine segment in women with a prior cesarean delivery in reducing fetal and maternal morbidity and mortality and it will provide evidence in order to establish clinical recommendations. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01916044 (date of registration: 5 August 2013).

[To the question of elective induction of labor at 39 weeks of gestation, the answer lies in the question]. / À la question du déclenchement de principe du travail à 39 semaines d'aménorrhée, la réponse est dans la question.

The goal of induction of labor is to achieve vaginal delivery when the benefits of expeditious delivery outweigh the risks of continuing the pregnancy. In order to correctly understand the problematic of the elective induction of labor at 39 weeks of gestation (WG), two questions must be raised. (i) What is the perinatal mortality evolution according the gestational age at delivery? All the most recent and methodologically well-conducted studies are convergent: they show that the fetal mortality risk exceeds the perinatal/infant (during the first year of life) mortality risk from 39 WG. The benefit/risk balance related to the expectant management is therefore reversed from 39 WG in favor of the elective induction of labor when the considered issue is the perinatal mortality. (ii) What are the associated risks with elective induction of labor? While some observational studies suggested that the elective induction of labor after 37 WG was associated with an increased risk of cesarean sections, these studies presented a major methodological bias: an error in the control group selection. Indeed, the control group consisted of women in spontaneous labor, whereas the appropriate comparison group must be an expectant management group. Several large cohort studies using a rigorous methodology have shown that elective induction of labor at 39 WG reduces the cesarean section risk compared to an expectant management. Three systematic reviews with meta-analysis of randomized controlled trials comparing induction of labor with expectant management were published: two showed that the cesarean section risk was lowered with the induction of labor compared to an expectant management and the third that the cesarean section rates were similar. Finally, the most recent randomized controlled trial, published in 2016, showed no significant difference between the 2 arms in the cesarean section rate. In all, the most recent literature data, free from comparative bias, show that elective induction of labor at term is associated with a significant reduction in the cesarean section risk and perinatal morbidity and mortality compared to an expectant management.

[What are the real purpose and scope of screening for aneuploidy?] / Quels sont l'objectif réel et la portée du dépistage des aneuploïdies ?

In France, the recommended method for Down syndrome screening is the first trimester combined test, the risk assessment, based on maternal age, ultrasound measurement of fetal nuchal translucency and maternal serum markers (free ß-hCG and PAPP-A). The Down syndrome detection rate is 78.7% at a screen positive rate of 5%. However, the best screening test is the integrated test using a combination of first trimester combined test and second trimester quadruple test (serum α-fetoprotein, human chorionic gonadotropin, unconjugated E3, and dimeric inhibin-A) and being able to achieve a detection rate for Down syndrome of approximately 96% at a screen-positive rate of 5%. In recent years, the isolation of small fragments of "fetal" cell-free DNA in the maternal blood dramatically changed the screening strategy paradigm allowing a Down syndrome detection rate and false positive rate of 99.2 and 0.09%, respectively. However, aneuploidy screening based on cell-free DNA presents two major limitations which must be taken into account because they considerably limit its benefit: (i) not every woman will receive an interpretable result and that those who fail to receive a result are at increased risk for fetal aneuploidy: whether an inconclusive result is treated as screen positive or screen negative affects the overall detection rate (sensitivity) and false-positive rate (specificity) of the test; (ii) the limited number of targeted aneuploidies (trisomies 21, 18, 13 and common sex chromosome aneuploidies) in contrast to conventional noninvasive screening which is also able to detect rare aneuploidies, duplications, deletions, and other structural rearrangements. Of course, genetic counseling has to include a discussion about benefits and limitations of aneuploidy screening based on cell-free DNA. However, it should not be considered as a new screening test to substitute for conventional noninvasive screening. Moreover, if the ultimate goal is to deliver the most information about potential risk of various chromosomal abnormalities associated with adverse perinatal outcomes, then current cell-free DNA screening strategies may not be the best approach. These data highlight the limitations of cell-free DNA screening and the importance of a clear and fair information during pretest genetic counseling about benefits and limitations of any prenatal noninvasive screening (whether conventional or by cell-free DNA), but also about risks and benefits of invasive diagnostic procedures (in first- or second-line), especially since the cytogenetic analysis with chromosomal microarray analysis has improved the detection of genome microdeletions and microduplications (variants of the copy number) that can not be detected by standard cytogenetic analysis.