[Pregnancies at advanced maternal age]. / Grossesses à un âge maternel avancé.

The definition of advanced maternal age (AMA) is debated, with an increasing risk of complications from the age of 35, but a threshold of 40 years old is adopted internationally to adjust surveillance and set the term of delivery between 39 and 40 weeks. Patients with AMA have more comorbidities, such as type 2 diabetes and chronic arterial hypertension. They are at greater risk of miscarriage, -gestational diabetes, hypertensive, thrombotic and psychiatric complications, as well as caesarean sections, placenta previa and placental abruption. Additionally, fetal and neonatal complications can occur, including genetic anomalies, fetal growth issues, stillbirths, and prematurity. AMA is a non--modifiable risk factor that must be taken into account to ensure a safe peri-natal period.

La définition de l'âge maternel avancé (AMA) est débattue, avec un risque croissant de complications à partir de 35 ans, mais un seuil de 40 ans adopté au niveau international pour ajuster la ­surveillance et fixer le terme d'accouchement entre 39 et 40 s­emaines. Les patientes avec AMA présentent ­davantage de comorbidités, comme le diabète de type 2 et l'hyper­tension artérielle chronique. Elles sont exposées à des risques accrus de fausses couches, diabète gestationnel, complications hypertensives, thrombotiques et psychiatriques, mais également de césariennes, placenta prævia et décollement placentaire. De plus, elles présentent davantage de troubles de la croissance fœtale, de décès in utero et de prématurité. L'AMA est un facteur de risque non modifiable qui doit être pris en compte pour sécuriser la période périnatale.

Physiological correction of hereditary mild hypofibrinogenemia during pregnancy.

INTRODUCTION: Hereditary hypofibrinogenemia is a rare fibrinogen disorder characterised by decreased levels of fibrinogen. Pregnant women with hypofibrinogenemia are at risk of adverse obstetrical outcomes, depending on the fibrinogen level. AIM: We investigated how the physiological changes of hemostasis throughout the pregnancy impact the hemostatic balance in a woman with hereditary mild hypofibrinogenemia. METHODS: Fibrin clot properties were analyzed by turbidimetry and scanning electron microscopy, clot weight and red blood cells retention were measured by whole clot contraction, and in vitro thrombin generation was assessed by calibrated automated thrombogram and ex vivo by TAT. RESULTS: Throughout the pregnancy, the fibrinogen levels increased reaching normal values in the third trimester (activity 3.1 g/L, antigen 3.2 g/L). In parallel, the fibrin polymerisation increased, the fibrinolysis decreased, the fibrin clot network became denser with thicker fibrin fibers, and the fibrin clot weight and red blood cells retention increased, reaching control's value at the third trimester. Similarly, in vitro and ex vitro thrombin generation increased, reaching maximum values at the delivery. CONCLUSION: In this case of hereditary mild hypofibrinogenemia we observed a physiological increase of fibrinogen and thrombin generation. Future studies should focus on moderate and severe hypofibrinogenemia, to assess fibrinogen variation and the overall impact of increased TG on the hemostasis balance.

The Apelinergic System in Pregnancy.

The apelinergic system is a highly conserved pleiotropic system. It comprises the apelin receptor apelin peptide jejunum (APJ) and its two peptide ligands, Elabela/Toddler (ELA) and apelin, which have different spatiotemporal localizations. This system has been implicated in the regulation of the adipoinsular axis, in cardiovascular and central nervous systems, in carcinogenesis, and in pregnancy in humans. During pregnancy, the apelinergic system is essential for embryo cardiogenesis and vasculogenesis and for placental development and function. It may also play a role in the initiation of labor. The apelinergic system seems to be involved in the development of placenta-related pregnancy complications, such as preeclampsia (PE) and intrauterine growth restriction, but an improvement in PE-like symptoms and birth weight has been described in murine models after the exogenous administration of apelin or ELA. Although the expression of ELA, apelin, and APJ is altered in human PE placenta, data related to their circulating levels are inconsistent. This article reviews current knowledge about the roles of the apelinergic system in pregnancy and its pathophysiological roles in placenta-related complications in pregnancy. We also discuss the challenges in translating the actors of the apelinergic system into a marker or target for therapeutic interventions in obstetrics.

[Cytomegalovirus screening during pregnancy : an ongoing debate still in 2022]. / Dépistage du cytomégalovirus pendant la grossesse : toujours débattu en 2022.

Cytomegalovirus infection remains the main congenital infectious cause of abnormal development, notably neurological or auditory. In case of early maternal infection, vertical transmission is lower than later in pregnancy, but fetal/neonatal sequelae are more frequent and severe. Until recently, there was no available treatment to prevent transmission and complications and only preventive measures were recommended. Based on a recent literature review, we will discuss the possible indication for CMV screening before conception and/or in the first trimester of pregnancy, in order to improve patient's information, prevention and treatment.

Le cytomégalovirus constitue la première cause infectieuse congénitale d'anomalie du développement, notamment aux niveaux neurologique et auditif. En cas d'infection maternelle précoce, le risque de transmission verticale est moindre que plus tard durant la grossesse, mais les séquelles fœtales/néonatales sont plus sévères. Jusqu'à présent, il n'existait pas de traitement efficace et seules les mesures de prévention primaire permettaient de combattre cette infection. Après une revue critique de la littérature récente, nous proposons de discuter l'intérêt d'un dépistage précoce en préconceptionnel et/ou au premier trimestre de la grossesse afin de permettre la mise en place des mesures de prévention et également l'introduction d'un traitement préventif/thérapeutique si nécessaire.

Maternal obesity reduces apelin level in cord blood without altering the placental apelin/elabela-APJ system.

The APJ receptor and its two endogenous ligands, apelin and elabela, exert key roles in fetoplacental development. In adult, this system is altered by obesity but no data are available during pregnancy. We measured apelin and elabela levels in maternal plasma and cord blood and quantified placental gene expression of apelin, elabela and APJ in obese and non-obese mothers. We found that obesity reduced apelin level in cord blood without affecting maternal and cord blood elabela levels as well as placental gene expression of this system. Our data suggest that obesity alters fetal apelinemia in humans.

National survey on the certification of competence in gynecologic surgical oncology: An AGOF (association of gynecologists in training) study.

INTRODUCTION: Female malignancies can require complex surgeries with expert techniques. A French certification of competence in gynecological cancer surgery has been elaborated in 2021 to certify specialized surgeons. For trainees, this would require a practical curriculum (number of rotations in certain departments), a surgical logbook and the theoretical European exam. The objective of our work was to interrogate trainees in gynecology and obstetrics on their oncological training and their opinion on the certification. MATERIAL AND METHODS: We conducted a national French prospective, observational study, using a web-based questionnaire from 06/2021-02/2022. All trainees were interrogated on their overall training in gynecological oncology. The opinion on the certification was assessed for the sub-group willing to specialize in oncological surgical gynecology. RESULTS: One hundred and twenty-five responded, and 66.1% wanted to specialize in surgical oncology. Many had completed one rotation in a specialized gynecological oncology center (45.3%) and in digestive surgery (48.8%). Concerning the theoretical training, 92% of the respondents believed it to be insufficient. Eighty participants (64%) wished to specialize in oncological surgical gynecology and were interrogated on the certification. The majority (65%) thought the three criteria were difficult to achieve but adequate. The most difficult criterium was the practical curriculum (70.5%) followed by the surgical logbook (55.1%) due to inequalities of training amongst French regions. CONCLUSION: Trainees in gynecology and obstetrics seem ready to take a specialized certification in surgical gynecological oncology to improve patient care. However, they expressed concerns due the disparities amongst regions in accessing certain specialized departments.

Predictive value of 4th post-operative-day CRP in the early detection of complications after laparoscopic bowel resection for endometriosis.

OBJECTIVE: Post-operative CRP on postoperative day 4 (POD) is used for the early detection of complications after colorectal surgery for cancer, but there is no evidence yet that justifies the use of this marker for bowel resection in case of endometriosis. STUDY DESIGN: We retrospectively included 66 consecutive patients who underwent bowel resection for endometriosis (stage 4) in Lille university hospital, France, from August 1, 2015 until January 31, 2017. The composite endpoint of our study included anastomotic leakages, infectious or thrombo-embolic complications, hematomas, bowel stenosis, rectorrhagia, voiding dysfunction, and rehospitalization for related symptoms. RESULTS: CRP on POD 4 presents a satisfying area under the curve of 0.85, for the composite endpoint. A CRP cut off value of 56 mg/L yielded a sensitivity of 0.61 (IC95%: 0.36 to 0.83) and a specificity of 0.98 (IC95%: 0.89 to 1). The negative and positive predictive values were 0.87 and 0.92. CONCLUSION: The negative predictive value of the CRP on POD 4 after bowel resection for endometriosis is a useful early indicator for detecting a complication. Therefore, this biomarker might be safely used as an additional criterion for a safe discharge from hospital after colorectal resection in endometriosis.

Maternal and neonatal outcomes according to gestational weight gain in twin pregnancies: Are the Institute of Medicine guidelines associated with better outcomes?

OBJECTIVE: The Institute of Medicine (IOM) recommended a gestational weight gain for full-term twin pregnancies of 17-25 kg for normal Body mass Index patients', and characterize its guidelines on during twin pregnancies as "provisional". Indeed, they are exclusively based on observational epidemiological data. The objective of this study was to investigate whether the IOM's gestational weight gain guidelines are optimal for maternal and neonatal. OUTCOMES STUDY DESIGN: We included all consecutive twin pregnancies delivering two live births retrospectively. Monoamniotic pregnancies, major congenital abnormalities, twin-to-twin transfusion syndrome, patients with missing gestational weight gain data in the last month before delivery, and patients with a body mass index (BMI) ≤18.5 were excluded. To control for gestational length, we divided the total weight gain by the gestational age in weeks at the last weight measurement to obtain the weight gain per week. Patients were classified as having low gestational weight gain, adequate gestational weight gain, or excessive gestational weight gain, with the results adjusted for BMI and tobacco use. RESULTS: There were 878 patients in our level-III university hospital maternity ward who met the inclusion criteria in 1997-2013. Excessive gestational weight gain women had greater rates of preeclampsia than adequate gestational weight gain women did. Low gestational weight gain women showed a lower rate of gestational hypertension than AGWG women did. Delivery before 37 weeks of gestation (26.9% vs. 17.3%, p = 0.009), birth weight <2500 g, respiratory distress syndrome, and transfer to the neonatal intensive care unit were more frequent in the LGWG group compared with the AGWG group. Apgar score <7 at 5 min were more frequent in the EGWG group. CONCLUSION: Adequate gestational weight gain was associated with better outcomes. Our results suggest that the IOM guidelines for twin pregnancy are appropriate and therefore should be routinely used.

Long-term (8.5 years) analysis of the type and rate of reoperation after transvaginal mesh repair (Prolift®) in 349 patients.

OBJECTIVE: Polypropylene meshes have specific complications, and in 2016 the Food and Drug Administration required a Premarket Approval for their use in pelvic prolapse repair, as there was a lack of long-term data. Our objectives were to determine the long-term reoperation rates and type in our patients after transvaginal mesh repair and to study their risk factors. STUDY DESIGN: We were able to follow up with 349 patients from a single University Hospital, with phone calls, after a median time of 8,5 years. The 8.5-year reoperation rates were derived from Kaplan-Meier survival curves. RESULTS: Our global, long-term reoperation rate, including mesh complications, prolapse recurrence and urinary incontinence after a median follow-up of 8.5 years, was 14.5%. The mesh-related complication rate (including mesh exposures, infections, and retractions requiring surgery) was 4.3%, the urinary incontinence rate was 5.7%. The prolapse recurrence rate was 7.2%; mainly found with posterior mesh only (18.5% of reoperations). For total Prolift, the reoperation rate for prolapse recurrence was only 4%. Moreover, 867% of the patients who had an anterior Prolift only or a posterior Prolift only and who were re-operated for prolapse recurrence showed recurrence exclusively in another compartment. In bivariate analysis, only the posterior mesh type was significantly associated with prolapse recurrence versus total meshes. CONCLUSION: Despite their market withdrawal, the transvaginal meshes are a safe and efficient option for pelvic organ prolapse surgical management. Low rates of mesh complications can be achieved with cautious dissection and adequate training of surgeons.