Pregnancy outcomes and vaccine effectiveness during the period of omicron as the variant of concern, INTERCOVID-2022: a multinational, observational study.

BACKGROUND: In 2021, we showed an increased risk associated with COVID-19 in pregnancy. Since then, the SARS-CoV-2 virus has undergone genetic mutations. We aimed to examine the effects on maternal and perinatal outcomes of COVID-19 during pregnancy, and evaluate vaccine effectiveness, when omicron (B.1.1.529) was the variant of concern. METHODS: INTERCOVID-2022 is a large, prospective, observational study, involving 41 hospitals across 18 countries. Each woman with real-time PCR or rapid test, laboratory-confirmed COVID-19 in pregnancy was compared with two unmatched women without a COVID-19 diagnosis who were recruited concomitantly and consecutively in pregnancy or at delivery. Mother and neonate dyads were followed until hospital discharge. Primary outcomes were maternal morbidity and mortality index (MMMI), severe neonatal morbidity index (SNMI), and severe perinatal morbidity and mortality index (SPMMI). Vaccine effectiveness was estimated, adjusted by maternal risk profile. FINDINGS: We enrolled 4618 pregnant women from Nov 27, 2021 (the day after WHO declared omicron a variant of concern), to June 30, 2022: 1545 (33%) women had a COVID-19 diagnosis (median gestation 36·7 weeks [IQR 29·0-38·9]) and 3073 (67%) women, with similar demographic characteristics, did not have a COVID-19 diagnosis. Overall, women with a diagnosis had an increased risk for MMMI (relative risk [RR] 1·16 [95% CI 1·03-1·31]) and SPMMI (RR 1·21 [95% CI 1·00-1·46]). Women with a diagnosis, compared with those without a diagnosis, also had increased risks of SNMI (RR 1·23 [95% CI 0·88-1·71]), although the lower bounds of the 95% CI crossed unity. Unvaccinated women with a COVID-19 diagnosis had a greater risk of MMMI (RR 1·36 [95% CI 1·12-1·65]). Severe COVID-19 symptoms in the total sample increased the risk of severe maternal complications (RR 2·51 [95% CI 1·84-3·43]), perinatal complications (RR 1·84 [95% CI 1·02-3·34]), and referral, intensive care unit (ICU) admission, or death (RR 11·83 [95% CI 6·67-20·97]). Severe COVID-19 symptoms in unvaccinated women increased the risk of MMMI (RR 2·88 [95% CI 2·02-4·12]) and referral, ICU admission, or death (RR 20·82 [95% CI 10·44-41·54]). 2886 (63%) of 4618 total participants had at least a single dose of any vaccine, and 2476 (54%) of 4618 had either complete or booster doses. Vaccine effectiveness (all vaccines combined) for severe complications of COVID-19 for all women with a complete regimen was 48% (95% CI 22-65) and 76% (47-89) after a booster dose. For women with a COVID-19 diagnosis, vaccine effectiveness of all vaccines combined for women with a complete regimen was 74% (95% CI 48-87) and 91% (65-98) after a booster dose. INTERPRETATION: COVID-19 in pregnancy, during the first 6 months of omicron as the variant of concern, was associated with increased risk of severe maternal morbidity and mortality, especially among symptomatic and unvaccinated women. Women with complete or boosted vaccine doses had reduced risk for severe symptoms, complications, and death. Vaccination coverage among pregnant women remains a priority. FUNDING: None.

Trends in preterm birth in women living with HIV in Switzerland over the last three decades: A multicentric, prospective, cohort study.

BACKGROUND: HIV infection and its management during pregnancy to reduce perinatal transmission has been associated with preterm birth (PTB). This management has drastically changed. We aimed to evaluate changes in rates of PTB over 34 years in women living with HIV (WLWH) in Switzerland, and to identify factors and interventions associated with these changes. METHODS: We analysed data from 1238 singleton pregnancies, prospectively collected by the Swiss Mother and Child HIV Cohort Study (MoCHiV) and the Swiss HIV Cohort Study (SHCS) between 1986 and 2020. Rates of PTB in this cohort were compared with that of the general Swiss population for three time periods according to changing treatment strategies recommended at the time. We evaluated the association of PTB with sociodemographic, HIV infection and obstetric variables in uni- and multivariate logistic regression. RESULTS: Rate of PTB in WLWH was highest prior to 2010 (mean 20.4%), and progressively decreased since then (mean 11.3%), but always remained higher than in the general population (5%). Older maternal age, lower CD4 count and detectable viraemia at third trimester (T3), drug consumption and mode of delivery were all significantly associated with both PTB and period of study in univariate analysis. There was no association between PTB and type of antiretroviral regimen. No difference was found in the rate of spontaneous labor between PTB and term delivery groups. Only higher CD4 count at T3 and vaginal delivery were significantly associated with a decrease in PTB over time in multivariate analysis. CONCLUSIONS: Preterm birth in WLWH in Switzerland has drastically decreased over the last three decades, but remains twice the rate of that in the general population. Improved viral control and changes in mode of delivery (vaginal birth recommended if viral loads are low near birth) have led to this progress.

Influence of Timing of Maternal Pertussis Immunization on the Avidity of Transferred Antibodies in Term and Preterm Neonates.

The timing of maternal pertussis vaccination influences the titers of cord-blood anti-pertussis antibodies. Whether it affects their avidity is unknown. We demonstrate in 298 term and 72 preterm neonates that antibody avidity is independent of the timing of maternal vaccination, whether comparing second with third trimester or intervals before birth.

[Multidisciplinary management of postpartum headaches]. / Prise en charge multidisciplinaire des céphalées du postpartum.

Headache is a common complaint in the postpartum period and is benign in most cases. Physiological adaptations during pregnancy and childbirth put women at risk of secondary headaches and the clinician must be able to identify them at an early stage. The management algorithm described in this article provides a systematic assessment based on 4 key points: the clinical presentation, which refers to specific clinical pictures or severity criteria, the clinical context and the evolution of symptoms focusing on potential complications and known associations between different diseases. Indications for imaging (CT or MRI) and possible treatments during breastfeeding are also detailed.

Les céphalées (primaires et secondaires) sont une plainte courante durant la période du postpartum et sont, dans la majorité des cas, bénignes. Les modifications physiologiques liées à la grossesse et à l'accouchement entraînent un risque de céphalées secondaires et le praticien doit savoir les identifier précocement. L'algorithme de prise en charge décrit dans cet article permet une évaluation systématisée et repose sur quatre points essentiels : la présentation clinique, qui oriente vers des tableaux cliniques spécifiques ou des critères de gravité, le contexte clinique et l'évolution de la symptomatologie, en insistant sur les complications potentielles, ainsi que les associations connues entre différentes pathologies. Les indications pour une imagerie (scanner ou IRM) sont détaillées ainsi que les traitements possibles durant l'allaitement.

Dual effect of nifedipine on pregnant human myometrium contractility: Implication of TRPC1.

Nifedipine, an L-type voltage-gated Ca2+ channel (L-VGCC) blocker, is one of the most used tocolytics to treat preterm labor. In clinical practice, nifedipine efficiently decreases uterine contractions, but its efficacy is limited over time, and repeated or maintained nifedipine-based tocolysis appears to be ineffective in preventing preterm birth. We aimed to understand why nifedipine has short-lasting efficiency for the inhibition of uterine contractions. We used ex vivo term pregnant human myometrial strips treated with cumulative doses of nifedipine. We observed that nifedipine inhibited spontaneous myometrial contractions in tissues with high and regular spontaneous contractions. By contrast, nifedipine appeared to increase contractions in tissues with low and/or irregular spontaneous contractions. To investigate the molecular mechanisms activated by nifedipine in myometrial cells, we used the pregnant human myometrial cell line PHM1-41 that does not express L-VGCC. The in vitro measurement of intracellular Ca2+ showed that high doses of nifedipine induced an important intracellular Ca2+ entry in myometrial cells. The inhibition or downregulation of the genes encoding for store-operated Ca2+ entry channels from the Orai and transient receptor potential-canonical (TRPC) families in PHM1-41 cells highlighted the implication of TRPC1 in nifedipine-induced Ca2+ entry. In addition, the use of 2-APB in combination with nifedipine on human myometrial strips tends to confirm that the pro-contractile effect induced by nifedipine on myometrial tissues may involve the activation of TRPC channels.

Transfer of antiretroviral drugs into breastmilk: a prospective study from the Swiss Mother and Child HIV Cohort Study.

INTRODUCTION: In 2018, Switzerland changed its guidelines to support women living with HIV wishing to breastfeed. The exposure of antiretroviral drugs (ARVs) in breastmilk and the ingested daily dose by the breastfed infant are understudied, notably for newer ARVs. This study aimed to quantify ARV concentrations in maternal plasma and breastmilk to determine the milk/plasma ratio, to estimate daily infant ARV dose from breastfeeding and to measure ARV concentrations in infants. METHODS: All women wishing to breastfeed were included, regardless of their ARV treatment. Breastmilk and maternal plasma samples were mostly collected at mid-dosing interval. RESULTS: Twenty-one mother/child pairs were enrolled; of those several were on newer ARVs including 10 raltegravir, 1 bictegravir, 2 rilpivirine, 2 darunavir/ritonavir and 3 tenofovir alafenamide. No vertical HIV transmission was detected (one infant still breastfed). The median milk/plasma ratios were 0.96/0.39 for raltegravir once/twice daily, 0.01 for bictegravir, 1.08 for rilpivirine, 0.12 for darunavir/ritonavir and 4.09 for tenofovir alafenamide. The median estimated infant daily dose (mg/kg) from breastfeeding was 0.02/0.25 for raltegravir once/twice daily, 0.01 for bictegravir, 0.02 for rilpivirine, 0.05 for darunavir/ritonavir and 0.007 for tenofovir alafenamide, resulting in relative infant dose <10% exposure index for all ARVs. CONCLUSIONS: ARVs were transferred to a variable extent in breastmilk. Nevertheless, the estimated daily ARV dose from breastfeeding remained low. Differential ARV exposure was observed in breastfed infants with some ARVs being below/above their effective concentrations raising the concern of resistance development if HIV infection occurs. More data on this potential risk are warranted to better support breastfeeding.

Autologous Platelet-Rich Plasma for Clitoral Reconstruction: A Case Study.

Clitoral reconstruction after female genital mutilation/cutting (FGM/C) is associated with significant post-operative pain and months-long recovery. Autologous platelet-rich plasma (A-PRP) reduces the time of healing and pain in orthopedic and burn patients and could also do so in clitoral reconstruction. In the present case, a 35-year-old Guinean woman who had undergone FGM/C Type IIb presented to our clinic for clitoral reconstruction. Her request was motivated by low sexual satisfaction and body image. We surgically reconstructed the clitoris using the Foldès method and applied plasma and glue of A-PRP. The patient was highly satisfied with the procedure. Two months post-operatively, her pain had ceased entirely and re-epithelialization was complete. We conclude that A-PRP may improve pain and healing after clitoral reconstruction. Extensive studies investigating long-term outcomes are needed.

[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.

[Management of maternal urologic issues during pregnancy]. / Prise en charge des pathologies urologiques maternelles durant la grossesse.

The management of urologic issues in pregnancy can be complex as the risk assessment of diagnostic and therapeutic options is often a challenge. This article aims to assist obstetrician-gynecologists and general practitioners in their follow-up of common urologic issues in pregnancy, of patients with previous urologic surgery (urinary derivation, urogenital reconstruction, etc.) or with a history of obstetrical complications (placenta percreta, urinary retention, trauma). This article will not cover urologic issues in the fetus.

La prise en charge de pathologies urologiques, même courantes, peut se révéler difficile dans le contexte de la grossesse. Le défi réside notamment dans les risques liés aux procédures d'investigation et aux options thérapeutiques pour cette population unique. Cet article a pour but d'aider les gynécologues-obstétriciens et les médecins de premiers recours dans leur prise en charge des pathologies urologiques courantes dans le contexte de la grossesse, du suivi de patientes avec des antécédents chirurgicaux urologiques (dérivation urinaire, reconstruction urogénitale, etc.) ou des complications obstétricales sur les structures urologiques (placenta percreta, rétention urinaire aiguë, trauma). Il ne traite pas des pathologies urologiques fœtales.

[Pregnancy and COVID-19: drugs and vaccine guidelines in 2021]. / Gynécologie-obstétrique - Grossesse et Covid-19 : recommandations médicamenteuses et vaccinales en 2021.

During this global health crisis, COVID-19 unfortunately did not spare pregnant women, who are at greater risk of becoming infected, developing severe forms and having obstetric complications. In this article we will talk about the risks associated with COVID-19 during pregnancy and in particular the existing data on the drugs to be administered in the event of illness and how to avoid infection and its complications through vaccination.

Durant cette crise sanitaire mondiale, le Covid-19 n'a malheureusement pas épargné les femmes enceintes. Celles-ci sont plus à risque d'être infectées, de développer des formes sévères et d'avoir des complications obstétricales. Dans cet article, nous allons parler des risques liés au Covid-19 durant la grossesse et notamment des données existantes sur les médicaments à administrer en cas de maladie et comment éviter l'infection et ses complications grâce à la vaccination.

Bio-Engineering of Pre-Vascularized Islet Organoids for the Treatment of Type 1 Diabetes.

Lack of rapid revascularization and inflammatory attacks at the site of transplantation contribute to impaired islet engraftment and suboptimal metabolic control after clinical islet transplantation. In order to overcome these limitations and enhance engraftment and revascularization, we have generated and transplanted pre-vascularized insulin-secreting organoids composed of rat islet cells, human amniotic epithelial cells (hAECs), and human umbilical vein endothelial cells (HUVECs). Our study demonstrates that pre-vascularized islet organoids exhibit enhanced in vitro function compared to native islets, and, most importantly, better engraftment and improved vascularization in vivo in a murine model. This is mainly due to cross-talk between hAECs, HUVECs and islet cells, mediated by the upregulation of genes promoting angiogenesis (vegf-a) and ß cell function (glp-1r, pdx1). The possibility of adding a selected source of endothelial cells for the neo-vascularization of insulin-scereting grafts may also allow implementation of ß cell replacement therapies in more favourable transplantation sites than the liver.

Congenital toxoplasmosis after adalimumab treatment before pregnancy.

We present a case of congenital toxoplasmosis (TXP) in a woman with Toxoplasma gondii infection more than 6 months before conception. The woman has been treated with adalimumab for ankylosing spondylitis for 4 years until 5 months before conception. TXP serology at the first trimester was compatible with infection prior pregnancy. An ultrasound performed at 26 weeks gestation (WG) showed cerebral echogenic lesions compatible with intrauterine infection. Amniocentesis was performed which confirmed TXP fetal infection. Termination of the pregnancy was performed upon parent's requests and the fetal autopsy confirmed the diagnosis. Here, we discuss the potential role of immunosuppressive treatments, such as adalimumab, in the risk of congenital toxoplasmosis and the importance of counseling before pregnancy.

[Telemedicine in maternal health in times of COVID-19: Five national and international projects]. / Télémédecine en santé maternelle en temps de Covid-19 : cinq projets internationaux et nationaux.

Telemedicine in maternal health consists on the use of remote communication to reach, diagnose, treat and follow up patients in the context of pre and post-natal care. Covid-19 has accelerated the use of telemedicine. In the Obstetrics Division of HUG we have developed five projects in Geneva and in low-resource zones of the world with the objective of improving access and quality of care. Based on our experience, the application of telemedicine to maternal health problems has shown three major advantages: improved access to care, standardized procedures and accelerated speed of intervention. However, to be effective, telemedicine requires a health staff with a good level of medical and computer skills as well as fluid communication among all participants and constant follow-up of the information flow.

La télémédecine en santé maternelle consiste à l'utilisation des moyens de communication à distance pour rejoindre, diagnostiquer, traiter et suivre les patientes dans le contexte des soins pré-, per- et postnatals. Le Covid-19 a accéléré l'utilisation de la télémédecine. Dans le Service d'obstétrique des HUG, nous avons développé cinq projets à Genève et dans des régions défavorisées du monde, avec l'objectif d'améliorer l'accès et la qualité des soins. Basée sur notre expérience, l'application de la télémédecine aux problèmes de santé maternelle présente trois avantages essentiels: la facilitation de l'accès aux soins, la standardisation des procédures et la vitesse d'intervention. Mais pour être efficace, elle présuppose un bon niveau de compétence médicale et informatique du staff sanitaire, une communication fluide entre les différents intervenants et un contrôle constant du flux d'informations.

[Gynécology-obstretric - Perinatal smoking cessation support : why and how ?] / Gynécologie-obstétrique - Aide à l'arrêt du tabac en période périnatale : pourquoi et comment ?

In Switzerland, tobacco smoking is a major public health problem, especially among pregnant women. Health problems encountered by pregnant women and their fetuses require specific care to assist smoking cessation. A specific consultation to support smoking cessation during pregnancy was created in May 2019 at the maternity ward of the University Hospitals of Geneva, with the support of the Fondation Privée des Hôpitaux Universitaires de Genève and Carrefour addictionS/CIPRET-Genève. The creation of a network of health professionnals trained in smoking cessation is an important step to support women during their cessation process.

Le tabagisme en Suisse, et particulièrement chez la femme enceinte, est un problème majeur de santé publique. Les problèmes de santé que rencontrent les femmes enceintes et leurs fœtus nécessitent une prise en soins spécifique pour le soutien à l'abstinence tabagique. Une consultation spécifique d'aide au sevrage tabagique durant la grossesse a été créée en mai 2019 à la maternité des HUG, avec le soutien de la Fondation privée des HUG et de Carrefour addictionS/Centre d'information pour la prévention du tabagisme de Genève. La création d'un réseau d'aide par les professionnels formés en tabacologie de base constitue une étape importante pour soutenir les femmes durant le sevrage tabagique.

Shielding islets with human amniotic epithelial cells enhances islet engraftment and revascularization in a murine diabetes model.

Hypoxia is a major cause of considerable islet loss during the early posttransplant period. Here, we investigate whether shielding islets with human amniotic epithelial cells (hAECs), which possess anti-inflammatory and regenerative properties, improves islet engraftment and survival. Shielded islets were generated on agarose microwells by mixing rat islets (RIs) or human islets (HI) and hAECs (100 hAECs/IEQ). Islet secretory function and viability were assessed after culture in hypoxia (1% O2 ) or normoxia (21% O2 ) in vitro. In vivo function was evaluated after transplant under the kidney capsule of diabetic immunodeficient mice. Graft morphology and vascularization were evaluated by immunohistochemistry. Both shielded RIs and HIs show higher viability and increased glucose-stimulated insulin secretion after exposure to hypoxia in vitro compared with control islets. Transplant of shielded islets results in considerably earlier normoglycemia and vascularization, an enhanced glucose tolerance, and a higher ß cell mass. Our results show that hAECs have a clear cytoprotective effect against hypoxic damages in vitro. This strategy improves ß cell mass engraftment and islet revascularization, leading to an improved capacity of islets to reverse hyperglycemia, and could be rapidly applicable in the clinical situation seeing that the modification to HIs are minor.

Maternal serum glycosylated fibronectin as a short-term predictor of preeclampsia: a prospective cohort study.

BACKGROUND: Preeclampsia is a major pregnancy complication that results in significant maternal and infant mortality, most of which occurs in low and middle-income countries. The accurate and timely diagnosis of preeclampsia is critical in management of affected pregnancies to reduce maternal and fetal/neonatal morbidity and mortality, yet difficulties remain in establishing the rigorous diagnosis of preeclampsia based on clinical parameters alone. Biomarkers that detect biochemical disease have been proposed as complements or alternatives to clinical criteria to improve diagnostic accuracy. This cohort study assessed the performance of several biomarkers, including glycosylated fibronectin (GlyFn), to rule-in or rule-out preeclampsia within 4 weeks in a cohort of women at increased risk for preeclampsia. METHODS: 151 women with risk factors for or clinical signs and symptoms of preeclampsia were selected from a prospective cohort. Maternal serum samples were collected between 20 and 37 weeks of gestation. Clinical suspicion of preeclampsia was defined as presence of new-onset proteinuria, or clinical symptoms of preeclampsia. Subjects with a clinical diagnosis of preeclampsia at the time of enrollment were excluded. GlyFn, pregnancy-associated plasma protein-A2 (PAPPA2), placental growth factor (PlGF), and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured by immunoassay. GlyFn was also determined using a rapid point-of care (POC) test format. Receiver-operating characteristic (ROC) curves derived from logistic regression analysis were used to determine the classification performance for each analyte. RESULTS: 32 of 151 (21%) women developed a clinical diagnosis of preeclampsia within 4 weeks. All biomarkers exhibited good classification performance [GlyFn (area under the curve (AUROC) = 0.94, 91% sensitivity, 86% specificity); PAPPA2 AUC = 0.92, 87% sensitivity, 77% specificity; PlGF AUC = 0.90, 81% sensitivity, 83% specificity; sFlt-1 AUC = 0.92, 84% sensitivity, 91% specificity. The GlyFn immunoassay and the rapid POC test showed a correlation of r = 0.966. CONCLUSIONS: In this prospective cohort, serum biomarkers of biochemical disease were effective in short-term prediction of preeclampsia, and the performance of GlyFn in particular as a POC test may meet the needs of rapid and accurate triage and intervention.

[MAVRIC study: when abdominal cerclage is preferable to vaginal cerclage]. / Étude MAVRIC: quand le cerclage par voie abdominale est préférable à la voie vaginale.

Vaginal cerclage can be used to treat cervical incompetence, thus reducing the risk of an unfavourable outcome. However, in some cases, it can be ineffective. One of the challenges for the gynaecologist-obstetrician is how to deal with a subsequent pregnancy after a failure of vaginal cerclage. The recently published MAVRIC study shows that performing abdominal cerclage prior or at the beginning of pregnancy reduces the rate of late miscarriage and premature delivery compared to vaginal cerclage. This implies a birth by caesarean section, and therefore a second surgery for the woman. However, it remains to determine the best surgical technique for abdominal cerclage. In the MAVIRC study, cerclage was done by laparotomy. It shall be elucidated whether this technique is superior to laparoscopy.

Le cerclage par voie vaginale permet de pallier une incompétence cervicale, diminuant ainsi le risque d'issues défavorables. Néanmoins, il peut s'avérer inefficace. Un des enjeux pour le gynécologue-obstétricien est de savoir quelle attitude adopter lors d'une grossesse suivante après échec de cerclage vaginal. L'étude MAVRIC, publiée récemment, apporte la preuve que la réalisation d'un cerclage par voie abdominale avant ou en début de grossesse permet une diminution du taux de fausse couche tardive et d'accouchement prématuré par rapport à la voie vaginale. Ceci implique une naissance par césarienne, et donc une deuxième intervention pour la femme. Il reste encore à déterminer le choix de la technique chirurgicale du cerclage abdominal. L'abord par laparotomie ayant été utilisé pour l'étude MAVRIC, il reste à montrer si cette approche est supérieure à la laparoscopie.

[Breastfeeding for HIV-positive mothers in Switzerland : are we ready to discuss ?] / Allaitement des femmes vivant avec le VIH : sommes-nous prêts à ouvrir la discussion ?

Mother-to-child transmission (MTCT) is almost inexistent in Switzerland nowadays. This success has been achieved with systematic screening of HIV in pregnant women, provision of antiretroviral treatment (ART), elective cesarean-section (CS), neonatal antiretroviral prophylaxis (ARP) and avoidance of breastfeeding. Elective CS and neonatal ARP are no longer recommended when the viral load (VL) is suppressed. Recent studies have shown that the risk of HIV MTCT through breastfeeding is extremely rare if not zero when the mother is treated, has a suppressed VL and is correctly followed-up. It is time to be open to discuss the risks and benefits of breastfeeding with HIV-infected pregnant women and to enter in a shared decision-making process, as recommended by the new Swiss guidelines. Close monitoring is mandatory in case of breastfeeding.

La transmission verticale du VIH est presque inexistante en Suisse aujourd'hui. Ce succès a été obtenu grâce au dépistage systématique du VIH de la femme enceinte et aux traitements antirétroviraux, à la césarienne élective (CS), à la prophylaxie postexpositionnelle néonatale (PPEn) et à l'évitement de l'allaitement. La CS et la PPEn ne sont plus recommandées en cas de charge virale indétectable. Des études récentes ont montré que le risque de transmission du VIH par l'allaitement est extrêmement faible, voire nul, lorsque la mère est correctement traitée et suivie. Il est temps de peser les risques et les bénéfices de l'allaitement maternel avec les femmes enceintes infectées par le VIH dans un processus de décision partagée, comme le suggèrent les nouvelles recommandations suisses. En cas d'allaitement, un suivi étroit est incontournable.

[Uterine transplant: Clinical and ethical challenges in Switzerland]. / La greffe utérine en Suisse: les défis à venir.

Uterine transplant is a novel treatment option for women with absolute uterine infertility. Sixty uterine transplants have been performed worldwide to date. The first live birth happened in 2014 and since then 20 children have been born after this procedure. The procedure has several challenges: The donor is usually a woman alive. Surgery is long and complex for both the donor and the recipient, with a high risk of complications. Embryos have to be obtained through IVF. Pregnancies are at high risk for complications and require cesarean delivery, and transplant is temporary (the transplanted uterus is removed after pregnancy in order to allow discontinuation of immunosuppressive therapy). Uterine transplant is a new hope for women with absolute uterine infertility but a high-risk experimental procedure for the donor, the recipient and the newborns and raises major ethical questions.

La transplantation utérine est une possibilité nouvelle offerte aux femmes présentant une infertilité utérine absolue. Environ 60 greffes utérines ont été réalisées dans le monde. La première naissance a été obtenue en 2014 et depuis 20 enfants ont vu le jour. La «donneuse¼ est le plus souvent une donneuse vivante. Les étapes chirurgicales sont longues et le risque de complications élevé. L'entrée dans un tel programme nécessite l'obtention préalable d'embryons par fécondation in vitro. Les grossesses obtenues sont à haut risque et la naissance se fait par césarienne. La greffe est transitoire car le greffon sera retiré afin d'interrompre le traitement immunosuppresseur. Eût égard aux risques qu'elle fait courir aux «donneuses¼, aux «receveuses¼ et aux enfants obtenus, cette procédure expérimentale soulève de nombreuses questions éthiques.

[Antenatal care : anticipating for future mother and child]. / Consultation prénatale†: anticiper pour les futures mères et enfants.

Prenatal care allows early detection of risks and complications in the pregnant women in an attempt to minimize problems at birth and delivery. In Geneva, prenatal care is organized as a collaboration between private and liberal in-hospital network with a ranking in the pregnancy risk levels to adapt follow-up. The perinatal care structure should be built in a way to identify risks prompting professionals to adapt from the normal physiological care to a therapeutic escalation one appropriated to the detected risk level. Effective inter-professional collaboration around the mother-child dyad (and even the family) depends on a privileged multidisciplinary interaction platform in which, wide inter-professional communication, particularly between midwife-obstetrician-neonatalogist, is essential.

La prise en charge prénatale permet d'anticiper les complications afin de minimiser les risques au moment de l'accouchement et de la naissance. En Suisse, elle s'organise autour d'une collaboration du réseau libéral et hospitalier avec une hiérarchisation du niveau de risque de la grossesse pour le suivi. La structure de la prise en charge périnatale doit être construite de façon à identifier les risques obligeant les professionnels à sortir de la voie physiologique classique pour une escalade thérapeutique anticipative, appropriée selon les niveaux de risque. Une collaboration efficace autour du couple mère-enfant (ou même de la famille) dépend donc d'une plateforme d'interaction multidisciplinaire privilégiée dans laquelle la communication interprofessionnelle, et particulièrement sage-femme-obstétricien-néonatologue, est essentielle.