Cephalad-caudad vs transverse blunt expansion of low transverse hysterotomy during caesarean section and risk of severe postpartum haemorrhage: A prospective comparative study.

BACKGROUND: The global prevalence of caesarean section as a delivery method is increasing worldwide. However, there is notable divergence among countries in their national guidelines regarding the optimal technique for blunt expansion hysterotomy of the low transverse uterine incision during caesarean section (cephalad-caudad or transverse). AIM: To compare the risk of severe postpartum haemorrhage (PPH) between cephalad-caudad and transverse blunt expansion hysterotomy during caesarean section. METHODS: This prospective comparative observational study was conducted in a university maternity hospital. All women who gave birth to one infant by caesarean section after 30 weeks of gestation between November 2020 and November 2021 were included in this study. The exclusion criteria were a coagulation disorder, the presence of placenta previa, multiple pregnancies, or enlargement of the hysterotomy with scissors. The choice between cephalad-caudad or transverse blunt expansion of the low transverse hysterotomy was left to the surgeon's discretion. The primary outcome measure was severe PPH, defined as estimated blood loss ≥ 1000 ml. Univariate and multivariate analyses were employed to assess the risk of severe PPH associated with the two methods of enlarging the low transverse hysterotomy. RESULTS: The study included 850 women, of whom 404 underwent transverse blunt expansion and 446 underwent cephalad-caudad blunt expansion. The overall incidence of severe PPH was 13.3 %. Univariate analysis revealed no significant difference in the frequency of severe PPH between the cephalad-caudad and transverse blunt expansion groups (13.9 % vs 12.6 %; p = 0.61). However, the use of additional surgical sutures (mainly additional haemostatic stitches) was less common with cephalad-caudad blunt expansion (26.7 % vs 36.9 %; p < 0.05). Multivariate analysis showed no significant difference in risk between the two techniques (odds ratio 1.17, 95 % confidence interval 0.77-1.78). CONCLUSION: No significant difference in the risk of severe PPH was found between cephalad-caudad and transverse blunt expansion of the low transverse hysterotomy during caesarean section.

[Prenatal diagnosis and postnatal outcome of isolated intra-abdominal calcifications: A 10-year experience from a referral fetal medicine center]. / Diagnostic prénatal et issue néonatale des calcifications intra-abdominales isolées : étude rétrospective sur 10 ans.

INTRODUCTION: Intra-abdominal calcifications (iAC) detected during fetal ultrasound examinations are characterized by their isolated or associated nature, as well as their location. Our objective was to describe all cases of isolated iAC along with their etiological investigations and neonatal outcome, during a 10-year practice in a referral center. METHODS: We conducted a retrospective descriptive monocentric study on neonates diagnosed with isolated iAC after antenatal expert ultrasound scan and referred to the Multidisciplinary Center for Prenatal Diagnosis at Trousseau Hospital and born between January 1st, 2008 and June 30th, 2018. The exclusion criteria were: retroperitoneal calcifications, iAC associated with other digestive abnormalities or with congenital malformations. RESULTS: The 32 isolated iAC cases accounted for 46% of all iAC. Nine cases were excluded for missing neonatal data. Among the 23 remaining isolated iAC cases, we observed 15 intra-hepatic calcifications, 5 peri-hepatic and two peritoneal calcifications. One fetus had both intra- and peri-hepatic calcifications. The majority of iAC remained stable throughout pregnancy. No cases of aneuploidy, fetal infection, or cystic fibrosis were detected. The neonatal outcome was favorable in all cases. CONCLUSIONS: In case of isolated and stable iAC after expert ultrasound scan, after having ruled out infectious diseases of the fetus and looked for the most frequent mutations of cystic fibrosis in the parents, the prognosis is favorable. Fetal karyotyping is recommended when additional structural anomalies are present.

Efficacy of antenatal corticosteroids in preterm twins: the EPIPAGE-2 cohort study.

OBJECTIVES: To investigate the efficacy of antenatal corticosteroid (ACS) therapy on short-term neonatal outcomes in preterm twins, and further document the influence of the ACS-to-delivery interval. DESIGN: EPIPAGE-2 is a nationwide observational multicentre prospective cohort study of neonates born between 22 and 34 completed weeks of gestation. SETTING: All French maternity units, except in a single administrative region, between March and December 2011. POPULATION: A total of 750 twin neonates born between 24 and 31 weeks of gestation. METHODS: Exposure to ACSs was examined in four groups: single complete course, with an ACS administration-to-delivery interval of ≤7 days; single complete course, with an ACS-to-delivery interval of >7 days; repeated courses; or no ACS treatment. MAIN OUTCOME MEASURES: Neonatal outcomes analysed were severe bronchopulmonary dysplasia, periventricular leukomalacia or intraventricular haemorrhage grade III/IV, in-hospital mortality, and a composite indicator of severe outcomes. RESULTS: Compared with no ACSs, in multivariable analysis, a single course of ACSs with an administration-to-delivery interval of ≤7 days was significantly associated with a reduced rate of periventricular leukomalacia or intraventricular haemorrhage grade III/IV (aOR 0.2; CI 95% 0.1-0.5), in-hospital mortality (0.3; 0.1-0.6), and the composite indicator (0.1; 0.1-0.3), whereas a single course of ACDs with an administration-to-delivery interval of >7 days did not significantly reduce the frequency of in-hospital mortality (0.7; 0.3-1.8). No significant differences in terms of benefit or risk were found when comparing repeated courses with a single complete course. CONCLUSION: In preterm twins, a single complete course of antenatal corticosteroids was associated with an improvement of severe neurological outcome, whereas reduced in-hospital mortality was seen only when the ACS-to-delivery interval was ≤7 days. TWEETABLE ABSTRACT: A single complete course of antenatal steroids reduced severe neurological morbidity in preterm twins (24-31 weeks).

Impact of clinical and/or histological chorioamnionitis on neurodevelopmental outcomes in preterm infants: A literature review.

OBJECTIVE: To determine the impact of clinical and/or histological chorioamnionitis on neurodevelopmental outcomes in premature infants. METHODS: A review of the literature appeared in PubMed between 1997 and 2016 was conducted to examine the association between clinical and/or histological chorioamnionitis and neurologic impairment in the neonates (intraventricular hemorrhage, periventricular leukomalacia and white matter damage) and in infants (cerebral palsy and neurodevelopmental delay). RESULTS: The first meta-analysis published in 2000 observed that clinical chorioamnionitis was associated with cystic periventricular leukomalacia and cerebral palsy and that histologic chorioamnionitis was associated with periventricular leukomalacia only. A second meta-analysis in 2010 found that cerebral palsy was associated with both clinical and histological chorioamnionitis. But most recent studies over the last decade based on large cohorts found no effect of chorioamnionitis on neurological outcomes, even if they had several methodological limitations. CONCLUSION: According to the findings of the most recent studies, clinical or histological chorioamnionitis does not seem to be associated with neonatal white matter injuries, or with cerebral palsy. Further studies are needed to assess the impact of chorioamnionitis on long-term neurological development.

[Prevention of spontaneous preterm birth (excluding preterm premature rupture of membranes): Guidelines for clinical practice - Text of the Guidelines (short text)]. / Recommandations pour la pratique clinique : prévention de la prématurité spontanée et de ses conséquences (hors rupture des membranes) ­ Texte des recommandations (texte court).

OBJECTIVES: To determine the measures to prevent spontaneous preterm birth (excluding preterm premature rupture of membranes)and its consequences. 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, premature birth concerns 60,000 neonates every year (7.4 %), half of them are delivered after spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated to a decrease of prematurity (level of evidence [LE] 1). This is therefore recommended (grade A). Routine screening and treatment of vaginal bacteriosis in general population is not recommended (grade A). Asymptomatic women with single pregnancy without history of preterm delivery and a short cervix between 16 and 24 weeks is the only population in which vaginal progesterone is recommended (grade B). A history-indicated cerclage is not recommended in case of only past history of conisation (grade C), uterine malformation (Professional consensus), isolated history of pretem delivery (grade B) or twin pregnancies in primary (grade B) or secondary (grade C) prevention of preterm birth. A history-indicated cerclage is recommended for single pregnancy with a history of at least 3 late miscarriages or preterm deliveries (grade A).). In case of past history of a single pregnancy delivery before 34 weeks gestation (WG), ultrasound cervical length screening is recommended between 16 and 22 WG in order to propose a cerclage in case of length<25mm before 24 WG (grade C). Cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with a twin pregnancy (grade A) and in populations of asymptomatic women with a short cervix (Professional consensus). Although the implementation of a universal transvaginal cervical length screening at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In case of preterm labor, (i) it is not possible to recommend one of the methods over another (ultrasound of the cervical length, vaginal examination, fetal fibronectin) to predict preterm birth (grade B); (ii) routine antibiotic therapy is not recommended (grade A); (iii) prolonged hospitalization (grade B) and bed rest (grade C) is not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (grade B), contrary to betamimetics (grade C), can be used for tocolysis in spontaneous preterm labour without preterm premature rupture of membranes. Maintenance tocolysis is not recomended (grade B). Antenatal corticosteroid administration is recommended to every woman at risk of preterm delivery before 34 weeks of gestation (grade A). After 34 weeks, evidences are not consistent enough to recommend systematic antenatal corticosteroid treatment (grade B), however, a course might be indicated in the clinical situations associated with the higher risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (grade C). Repeated courses of antenatal corticosteroids are not recommended (grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended to women at high risk of imminent preterm birth before 32WG (grade A). Cesarean is not recommended in case of vertex presentation (Professional consensus). Both planned vaginal or elective cesarean delivery is possible in case of breech presentation (Professional consensus). A delayed cord clamping may be considered if the neonatal or maternal state so permits (Professional consensus). CONCLUSION: Except for antenatal corticosteroid and magnesium sulfate administration, diagnostic tools or prenatal pharmacological treatments implemented since 30 years to prevent preterm birth and its consequences have not matched expectations of caregivers and families.

Invasive therapies for primary postpartum haemorrhage: a population-based study in France.

OBJECTIVE: To describe the characteristics, management, and outcomes of women undergoing invasive therapies for primary postpartum haemorrhage (PPH). DESIGN: A population-based observational study. SETTING: All 106 maternity units of six French regions. POPULATION: A total of 146 781 women delivering between 2004 and 2006. METHODS: Prospective identification of women with PPH managed with invasive therapies, including uterine suture, pelvic vessel ligation, arterial embolisation, and hysterectomy. MAIN OUTCOME MEASURES: Rate of use and failure rate of invasive therapies, with 95% confidence intervals (95% CIs). RESULTS: An invasive therapy was used in 296 of 6660 women with PPH (4.4%, 95% CI 4.0-5.0), and in 0.2% of deliveries (95% CI 0.18-0.23). A hysterectomy was performed in 72/6660 women with PPH (1.1%, 95% CI 0.8-1.4%), and in 0.05% of deliveries (95% CI 0.04-0.06). A conservative invasive therapy was used in 262 women, including 183 (70%) who underwent arterial embolisation and 79 (30%) who had conservative surgery as the first-line therapy. Embolisation was more frequently used after vaginal than caesarean delivery, and when arterial embolisation was available on site. The failure rate of conservative invasive therapies was 41/262 (15.6%, 95% CI 11.5-20.6) overall, and was higher after surgical than after embolisation procedures, in particular for vaginal deliveries. CONCLUSIONS: Both maternal mortality as a result of obstetric haemorrhage and the rate of invasive therapies used for PPH are high in France. These findings suggest flaws in the initial management of PPH and/or the inadequate use of invasive procedures. TWEETABLE ABSTRACT: Maternal mortality as a result of haemorrhage and the rate of invasive therapies used for PPH are high in France.

Maternal mortality among women with sickle-cell disease in France, 1996-2009.

OBJECTIVE: To describe maternal mortality among women with sickle-cell disease in France. STUDY DESIGN: Data from the national confidential enquiry into maternal deaths and from reference centres for sickle-cell disease were examined to identify women with this disease who died in France during 1996-2009. The maternal mortality ratio among women with sickle-cell disease was estimated and compared with the ratio in the general population. Characteristics of these women and their pregnancies and circumstances of their deaths were examined in detail. RESULTS: Fifteen maternal deaths occurred among an estimated 3300 live births to women with sickle-cell disease, for a maternal mortality ratio of 454 per 100000 live births (95% CI [254; 750]), versus 9.4/100000 in the general population. Ten women were homozygous (SS) for sickle-cell disease, and five were composite heterozygotes. The episode leading to death appeared in the antepartum period for seven women (47%). Two women died of septic shock during pregnancy, one at 6 weeks, the other at 24 weeks. The other 13 women (87%) died postpartum. Thirteen deaths were directly attributable to sickle-cell disease. The other two maternal deaths, both considered direct obstetric causes, were due to amniotic fluid embolism and septic shock after post-amniocentesis chorioamnionitis. The expert committee on maternal mortality judged seven of these 15 deaths (47%) to be avoidable. CONCLUSION: Sickle-cell disease is responsible for a major excess risk of maternal death in France, due mainly to direct complications of the disease.

[Management of placenta previa and accreta]. / Prise en charge des placenta praevia et accreta.

OBJECTIVE: Produce recommendations for the management of placenta previa and placenta accrete. METHODS: A literature search was conducted using Medline and the Cochrane Library over a period from 1950 to 31/12/2013. Recommendations of the latest scientific societies have also been consulted. RESULTS: In cases of placenta previa, if bleeding episode before 34weeks gestation occurs, a short hospitalization and tocolysis may help stop bleeding (grade C). Vaginal delivery is preferable when the distance between the internal cervical os and the placental edge is greater than 20mm. When this distance is less than 20mm, vaginal delivery is possible (professional consensus). Caesarean section is recommended in cases of placenta overlapping the internal os (professional consensus). Antenatal screening placenta accreta could improve care (EL3). Upon discovery of a placenta accreta during childbirth, it is better to avoid a forced removal of the placenta (grade C). Conservative treatment or cesarean hysterectomy are possible (grade C). The management of placental abnormalities should be planned and managed with a multidisciplinary team (professional consensus). The use of blood-saving techniques such as "cell saver" is possible in situations where early intraoperative bleeding would be>1500mL (grade C). There are no studies that have sufficient methodological value to recommend an anesthetic technique [general anaesthesia (GA) or neuraxial anaesthesia] over another in the context of placental abnormalities (grade B). When a major bleeding risk is identified, GA can be chosen in order to avoid emergency conversions in difficult conditions (professional consensus). CONCLUSION: Placental insertion abnormalities require anesthetic and obstetric coordination. Delivery must be planned in a suitable structure.

[What use of progesterone to prevent preterm birth?]. / Quelle utilisation de la progestérone pour prévenir la prématurité ?

Widely prescribed in the years 1970-1980 to prolong gestation, progesterone has regained interest after the publication of randomized trials since 10 years. In women at increased risk of preterm birth with a history of preterm delivery or late miscarriage, the use of progesterone, especially intramuscularly may reduce the incidence of spontaneous preterm birth. In contrast, in cases of preterm labor or twin pregnancies, progesterone efficacy to reduce preterm birth has not been demonstrated. In women with asymptomatic midtrimester sonographic short cervix, randomized studies show conflicting results and new studies are necessary before its widespread utilisation.

[Specific particularities of uterine scars and their impact on the risk of uterine rupture in case of trial of labor]. / Critères d'acceptation de la voie vaginale selon les caractéristiques de la cicatrice utérine.

OBJECTIVE: To assess the risk of uterine rupture in case of uterine scar in specific situations. To investigate whether ultrasonographic measurement of the lower uterine segment is predictive of the risk of uterine rupture. METHODS: French and English publications were identified through PubMed and Cochrane databases. RESULTS: Trial of labor after cesarean (TOLAC) is possible in cases of uterine mullerian anomalies, segmental vertical or unknown uterine incision, postpartum fever, cesarean delivery before 37 weeks during the previous cesarean (professional agreement). TOLAC can be considered if obstetrical conditions are favorable even if the delay is less than 6 months between the previous cesarean delivery and the date of conception of the following pregnancy (professional agreement). TOLAC can be considered after a previous myomectomy, depending on technical conditions under which the intervention was conducted (gradeC). TOLAC is possible even after previous hysteroscopic metroplasty for uterine septa or in cases of uterine perforation with monopolar coagulation (professional agreement). The type of uterine suture during the previous cesarean should not influence the choice of the route of delivery (professional agreement). TOLAC can be considered in cases of two previous cesarean sections if obstetrical conditions are favorable (professional agreement). Planned cesarean section is recommended from history of three previous cesarean sections (professional agreement). A planned cesarean section is recommended in cases of previous corporeal incision during cesarean (gradeC). There is not enough data to recommend ultrasonographic measurement of the lower uterine segment during pregnancy to help to determine the route of delivery (professional agreement). CONCLUSIONS: TOLAC can be considered, depending on obstetric conditions, in all situations studied, except in cases of previous obstetric corporeal incision or previous history of at least three cesareans.

[Prediction of maternofetal infection in preterm premature rupture of membranes: serum maternal markers]. / Prédiction de l'infection maternofœtale en cas de rupture prématurée des membranes par les marqueurs sériques maternels.

Premature rupture of membranes is a common situation in obstetrics that links the amniotic cavity and the bacterial cervicovaginal flora. The main risk in case of preterm premature rupture of membranes is the occurrence of an amniochorial infection, which increases neonatal morbidity and mortality. One main purpose in cases of preterm premature rupture of membranes is to identify infection early to adapt the clinical care. Among the marker used in practice, CRP has a sensitivity between 56% and 86% and specificity between 55% and 82% for predicting clinical chorioamnionitis. These values are respectively 21% to 56% and 76% to 95% for the prediction of early neonatal infection. The white blood cell count, also used in routine, has a poor predictive value of clinical chorioamnionitis although a high specificity when the threshold is of 16 giga/l. Among the pro-inflammatory cytokines, interleukin-6 has been the most studied. Its predictive value for chorioamnionitis or neonatal infection is higher but its clinical usefulness is limited by the various threshold used in the studies and the lack of routine measure. Procalcitonin appears to have low predictive values for detecting amniochorial infection but has finally been little studied. Ways to improve prediction of infection in cases of premature rupture of membranes are either looking for new markers or the analysis of local markers (vaginal secretions and amniotic fluid).

[Uterine cervical length measurement by endovaginal ultrasonography: Technique and main utilizations]. / Mesure de la longueur du col de l'utérus par voie endovaginale : technique et principales applications.

Cervical length measurement by transvaginal ultrasound is commonly used to assess the risk of preterm birth (PTB) and refine the clinical management in cases of preterm labor (PTL). The transvaginal route is considered to be the reference for the measurement of the uterine cervix. Cervical length measurement has a good diagnostic value irrespective of the clinical context or past history associated with an increased risk of PTB. In case of PTL, the measurement of the cervical length by ultrasonography allows to reduce the number of hospitalizations, and to focus on the women who really need a treatment. In case of twin pregnancy, systematic systematic measurement of cervical length at 20-25 weeks gestation is not recommended because of the lack of therapeutic applications. In cases of high risk of PTB (PTB history, conization, uterine exposure to DES, etc.), selecting a group at high risk for PTB by a systematic cervical length measurement at 20-25 weeks gestation could be useful to select women for whom treatment with progesterone would be most beneficial. In this group, a follow-up of the cervical length since 16 weeks gestation may also be useful to indicate a cerclage if the cervical length is less than 15mm. In the general population, cervical length measurement may be useful during the second trimester of pregnancy in so far as a treatment by progesterone in cases of short cervix (

[Obstetrical perinatal care in case of maternal prenatal smoking]. / Conduite obstétricale périnatale en cas d'exposition maternelle anténatale au tabagisme.

Measurement of CO during the intrapartum period is a good way to help patients become aware of the importance of smoking cessation. The objective information can be continued in the post partum period. The effect is beneficial for the neonate and helps women stop smoking during subsequent pregnancies. To date, no study has been conducted during the intrapartum period useful for adapting our clinical practice in patients who smoke during pregnancy. Prospective studies, specifically designed to measure the impact of smoking on maternal and fetal complications during labor are essential.

[Current clinical implications of transvaginal ultrasound measurement of the cervix during pregnancy]. / Implications cliniques actuelles de l'échographie du col utérin pendant la grossesse.

Transvaginal ultrasound measurement of the cervix is increasingly used for the prediction of preterm labor. In comparison to clinical vaginal examination, it has the advantages of being highly reproducible, with a low inter-observer variability, and of offering an evaluation of the entire cervical canal, including the internal os. The sensitivity and specificity of transvaginal ultrasound have been validated by several studies in women with symptoms of preterm labor, however its clinical applications and its limits have yet to be fully determined. It is likely to be of benefit in the management of multiple gestations, but it appears unlikely to be of use in low-risk pregnancies. Finally, whether it can be applied to estimate the risk of cervical incompetence, or to determine the need for cervical cerclage placement has not yet been determined by methodologically satisfactory clinical studies.

Strip test for bedside detection of interleukin-6 in cervical secretions is predictive for impending preterm delivery.

Inflammatory cytokines in amniotic fluid are markers of prematurity which could characterize preterm labour of infectious origin. To avoid amniocentesis, we analyzed IL-6, IL-8, IL-10, and IL-13 by RT-PCR in cervical secretions (CS) of 307 women with preterm labour. IL-6 was detected in 26.3% patients who delivered at less than 34 weeks (specificity: 95.8%). In addition, IL-6 was associated with delivery within 7 days (specificity: 91.6%). To render the detection more rapid and cheaper, a strip test was designed and evaluated comparatively with RT-PCR in 76 women. This bedside strip test was twice more sensitive than RT-PCR, with little decrease in specificity.

[The value of intravaginal ultrasonography of the cervix uteri for evaluation of the risk of premature labor]. / Intérêt de l'échographie endovaginale du col utérin pour l'évaluation du risque d'accouchement prématuré.

OBJECTIVE: To determinate the predictive value of cervical length, measured by transvaginal ultrasound, for preterm delivery among patients with signs of preterm labor. PLACE: Department of Gynecology & Obstetrics, Poissy Hospital Center. MATERIAL AND METHODS: A prospective study that measured cervical length by transvaginal ultrasound was performed among 108 patients with a singleton pregnancy hospitalized with signs of premature labor between 24 and 34 weeks' gestation or within 21 days of inclusion. RESULTS: The rate of preterm birth was 22.2% (24/108). When cervical length was < or = 26 mm, the gestational age at delivery was significantly lower that when it exceeded 26 mm (36.3 +/- 3.0 weeks compared with 38.5 +/- 2.1 weeks; p < 0.0001). 40.4% (19/47) of patients whose cervical length was < or = 26 mm gave birth prematurely, compared with only 8.2% (5/61) of those with a cervix > 26 mm The sensitivity, specificity, positive predictive value, and negative predictive value of transvaginal ultrasonography were, respectively, 79.2, 66.6, 40.4, and 91.8% for delivery before 37 weeks' gestation, and 75.0, 62.0, 25.5, and 93.4% for delivery within 21 days of the ultra-sound measurement. CONCLUSION: Transvaginal ultrasound of the cervix provides an objective method for evaluating the risk of preterm delivery. Its predictive values are impressive and allow better discrimination between women at high risk of preterm delivery and those in false preterm labor.