[Screening and healthcare for pregnant women with psycho-social vulnerability : A French national study]. / Dépistage et parcours de soins en cas de vulnérabilités psycho-sociales maternelles : une enquête nationale française.

INTRODUCTION: Psycho-social vulnerabilities are a medical risk factor for both fetus and mother. Association between socioeconomic status and prenatal follow-up has been well established and inadequate follow-up is associated with higher morbidity and mortality in women in unfavorable situations. OBJECTIVE: The objective is to identify screening strategies and to describe existing systems for pregnant women in psycho-social vulnerability in French maternity hospitals. MATERIAL AND METHODES: This is a national survey conducted by questionnaire in all French maternities. RESULTS: Screening by means of targeted questions is carried out by 96.7% of maternity units. Early prenatal interviews are offered systematically by 64% of maternity units and access to them is still difficult for women in vulnerable situations. In order to organize care pathways, 28.7% of maternities have a structured unit within their establishment and 81% state that they have mobilizable caregivers. Multidisciplinary meetings for the coordination of the various stakeholders are held by 85.8% of maternity units. Collaboration with networks and associations is emphasized. CONCLUSION: A large proportion of maternities seek to identify women in situation of psycho-social vulnerabilities and to organize care paths. However, the resources implemented still appear insufficient for many maternity units. Each maternity hospital has resources and is developing initiatives to deal with the difficulties of care.

Cost-effectiveness of vaccination against cytomegalovirus (CMV) in adolescent girls to prevent infections in pregnant women living in France.

BACKGROUND: CMV infections are the most frequent congenital infections worldwide. AIM: Assess the cost-effectiveness of vaccination strategies of adolescent girls vs. current practice (hygiene counseling) to prevent CMV seroconversions during pregnancy in France. METHOD: A Markov decision-tree model simulated overtime the trajectory of a single fictive cohort of 390,000 adolescent women aged 14 years old, living in France. Impact of vaccination was explored until the end of their reproductive live 40 years later. STRATEGIES COMPARED: "S1: No vaccination" (current practice); "S2: Routine vaccination"; "S3: Screening and vaccination of the seronegative". MODEL PARAMETERS: Seroconversion rate without vaccination (0.035%/pregnant woman-week); fetal transmission risk (41%). Vaccine vs. no vaccination: a 50% decrease in maternal seroconversions. OUTCOMES: Quality-Adjusted Life-Years (QALYs) of the cohort-born babies; discounted costs; Incremental Cost-Effectiveness Ratio (ICER). RESULTS: S2 was the most effective strategy (with 35,000 QALYs gained) and the most expensive (€211,533,000); S1 was the least effective and least costly (€75,423,000). ICERs of strategy S3 vs. S1, and S2 vs. S3 were 6,000€/QALY gained (95% uncertainty range [2700-13,300]) and 16,000€/QALY [negative ICER (S3 dominated by S2) - 94,000] gained, respectively; highly cost-effective because ICER < 1∗France's GPD/capita = €30,000. SENSITIVITY ANALYSIS: If the seroprevalence was >62% (vs. 20% in the base case), S3 would become the most efficient strategy. CONCLUSION: In France, systematic vaccination of adolescent girls was the most efficient strategy to prevent maternal seroconversions. If the population was less than 62% immune, systematic screening and vaccination of susceptibles would become the most cost-effective approach.

[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.

[Social inequalities in perinatal health]. / Inégalités sociales en santé périnatale.

Social insecurity is a known perinatal risk factor but beyond that, a social gradient in perinatal health is observable. This social gradient is particularly visible for the risk of neonatal mortality from congenital anomalies, premature delivery, and low birth weight. Analysis of mechanisms that would explain how the different dimensions of the social status of women interact with perinatal health indicators are not to this day fully understood. However, numbers of intermediate factors related to both the social status and perinatal risk have been identified. Among them, smoking, drug use, exposure to psychological and physical stress, genital infections, access to care, or drudgery. Finally, it was observed that the interaction of social conditions with the level of maternal education, geographic or ethnic origin, and the environment in which women live are complex and make the generalization of data obtained in a particular context sensitive.

[Termination of pregnancy and palliative care in case of vascular intra-uterine growth retardation]. / Place de l'interruption médicale de grossesse et des soins palliatifs en cas de retard de croissance intra-utérin vasculaire.

OBJECTIVE: Discuss the place of medical termination of pregnancy and palliative care in case of vascular intra uterine growth retardation. METHODS: Bibliographic review using the Medline and PubMed databases and the guidelines of the international professional societies. RESULTS: The prognostic evaluation in case of IUGR is essential. It is based on several criteria, including gestational age and ultrasound (estimated fetal weight and Doppler). In some situations, postnatal prognosis may seem so pejorative that absence of active care can be decided with the parents. The choice can then be focused on a decision not to proceed with fetal extraction while Doppler or fetal heart rate abnormalities could justify it and "wait" for spontaneous fetal death or have a more active attitude of medical termination of pregnancy (TOP) with or without feticide or palliative care after birth. In some cases, IUGR is accompanied by maternal complications such as preeclampsia. The severity of the maternal disease may sometimes justify a termination of pregnancy for maternal rescue. That either maternal or fetal indication, these situations are often difficult to manage because of the difficulty in establishing fetal prognosis, particularly when the maternal condition requires urgent decision. CONCLUSION: In these difficult situations, ultrasound assessment must be conducted by a senior and the discussion should always be multidisciplinary. If TOP is requested by the parents, it must be discussed in a multidisciplinary center for prenatal diagnosis in accordance with French law. Maternal emergency is the only derogatory status.

[Ectopic decidua: variability of presentation in pregnancy and differential diagnoses]. / La déciduose ectopique: variabilités de présentation pendant la grossesse et diagnostics différentiels.

The ectopic decidua is a common occurrence during pregnancy, corresponding to the presence of decidual tissue outside the endometrium. The pathophysiology of these lesions is not yet fully elucidated. The phenomenon is most often benign, with a favourable outcome in the post-partum and without follow-up. Because of the wide range of clinical presentations, from localized peritoneal granulation to large pelvic mass, the clinical diagnosis of ectopic decidua is difficult. Furthermore, imaging is not specific. The discovery of such lesions should lead to the realization of systematic biopsies for histological examination and rule out other causes such as lesions of tuberculosis or carcinomatosis. Immunohistochemical studies are helpful in differentiating deciduosis from malignant deciduoid mesothelioma, its main differential diagnosis with a catastrophic prognosis.

[Preterm labour after adenosine treatment for paroxysmal supraventricular tachycardia during pregnancy, a case report]. / Menace d'accouchement prématuré après administration d'adénosine pour la réduction d'une tachycardie supraventriculaire paroxystique à 30 semaines d'aménorrhée : à propos d'un cas.

Paroxysmal supraventricular tachycardia is the most frequent arrhythmia among young pregnant women. In case of failure of vagal manoeuvres, their management is preferentially intravenous infusion of adenosine. The in vitro contracturant effect of adenosine on myometrial fibres is known, but very few data are available about the in vivo effect during pregnancy. We report here the case of a 30-week gestational age pregnant woman treated successfully by adenosine for a junctional tachycardia. Adenosine administration was immediately followed by a preterm labour managed by calcium channels blockers tocolysis. Even if causal relationship remains uncertain, this observation is consistent with physiopathological data and should catch physician's attention when initiating this treatment.

[Very premature births: Dilemmas and management. Part 1. Outcome of infants born before 28 weeks of postmenstrual age, and definition of a gray zone]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Première partie : pronostic des naissances avant 28 semaines, identification d'une zone grise.

With very preterm deliveries, the decision to institute intensive care, or, alternatively, to start palliative care and let the baby die, is extremely difficult, and involves complex ethical issues. The introduction of intensive care may result in long-term survival of many infants without severe disabilities, but it may also result in the survival of severely disabled infants. Conversely, the decision to withhold resuscitation and/or intensive care at birth, which is an option at the margin of viability, implies allowing babies to die, although some of them would have developed normally if they had received resuscitation and/or intensive care. Withholding intensive care at birth does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. The likelihood of survival without significant disabilities decreases as gestational age at birth decreases. In addition to gestational age, other factors greatly influence the prognosis. Indeed, for a given gestational age, higher birth weight, singleton birth, female sex, exposure to prenatal corticosteroids, and birth in a tertiary center are favorable factors. Considering gestational age, there is a gray zone that corresponds to major prognostic uncertainty and therefore to a major problem in making a "good" decision. In France today, the gray zone corresponds to deliveries at 24 and 25 weeks of postmenstrual age. In general, babies born above the gray zone (26 weeks of postmenstrual age and later) should receive resuscitation and/or full intensive care. Below 24 weeks, palliative care is the only option offered in France at the present time. Decisions within the gray zone will be addressed in the 2nd part of this work.

[Very premature births: Dilemmas and management. Second part: Ethical aspects and recommendations]. / Naissances très prématurées : dilemmes et propositions de prise en charge. Seconde partie : enjeux éthiques, principes de prise en charge et recommandations.

In the first part of this work, the outcome following very premature birth was assessed. This enabled a gray zone to be defined, with inherent major prognostic uncertainty. In France today, the gray zone corresponds to deliveries occurring at 24 and 25 weeks of postmenstrual age. The management of births occurring below and above the gray zone was described. Withholding intensive care at birth for babies born below or within the gray zone does not mean withholding care but rather providing palliative care to prevent pain and suffering during the time period preceding death. Given the high level of uncertainty, making good decisions within the gray zone is problematic. Decisions should be based on the infant's best interests. Decisions should be reached with the parents, who are entitled to receive clear and comprehensive information. Possible decisions to withhold intensive care should be made following the procedures described in the French law of April 2005. Guidelines, based on gestational age and the other prognostic elements, are proposed to the parents before birth. They are applied in an individualized fashion, in order to take into account the individual features of each case. At 25 weeks, resuscitation and/or full intensive care are usually proposed, unless unfavorable factors, such as severe growth restriction, are associated. A senior neonatologist will attend the delivery and will make decisions based on both the baby's condition at birth and the parents' wishes. At 24 weeks, in the absence of unfavorable associated factors, the parents' wishes should be followed in deciding between initiating full intensive care or palliative care. Below 24 weeks, palliative care is the only option to be offered in France at the present time.

[Demons-Meigs syndrome: apropos of 1 case]. / Le syndrome de Demons-Meigs: à propos d'un cas.

A 33-year-old patient presented with ascites and a right abdominal mass. Ultrasound and scannography showed it was probably a solid ovarian tumor measuring 175 mm x 115 mm. Serum Ca 125 was 752 UI/mL and ACE was normal. Surgical exploration revealed 3.2 liters ascites without any suspect peritoneal implant and a bulky ovarian fibrothecoma. The patient recovered quickly and serum Ca 125 was 43 UI/mL one month post-operatively. In this case report of Meigs' syndrome serum CA 125 level was particularly high. Preoperative diagnostic difficulties are discussed.

[The rheopneumography (author's transl)]. / La rhéopneumographie.

The rheograph electrodes, placed in three symetrical leads on the axilla lines, permit recordings to be made of respiratory curves and, during respiratory apnea, of arterial pulmonary curves. The curves were recorded on 296 subjects who were either normal or attacked by lung or pleura diseases. In pathological cases, the respiratory enlargement can be validly reduced; an arterial pulmonary curve can be flattened and show abnormalities that attest to arterial compression (more particularly in cases of lung cancer or pleurisy), to the superposition of a cardiac or systemic arterial curve. An arterial curve can be replaced by a cardiac curve in cases of back-flow or attraction by the heart, an absence of parenchyma between the heart and the paries of the thorax. Information given by this method can be compared but not super imposed with those given by isotopic scanning.