[Induced abortions for maternal indications: Retrospective study in Western Normandy between 2010 and 2019]. / Interruptions médicales de grossesse pour indications maternelles : analyse rétrospective en Normandie Occidentale (2010­2019).

INTRODUCTION: Termination of pregnancy for maternal reasons (MTOP) are authorized in France without limit of term when "the continuation of the pregnancy puts in serious danger the health of the woman". The literature on the subject is rare and we wanted to make an inventory in our region. METHODS: Retrospective observational study between 2010 and 2019 at the multidisciplinary center for prenatal diagnosis in Western Normandy. RESULTS: Thirty-one cases of MTOP were included (2.5% of all TOP). At the CHU de Caen, they represented one in 1200 births. Twenty-three percent of MTOP had a psychosocial or psychiatric indication (average term=22 SA) and 29% an obstetric indication due to severe preeclampsia (23 SA). Finally, 48% were linked to a non-obstetric somatic disorder including 46% pre-existing pathologies (average term=11 SA), most often cardiological or nephrological and 54% diagnosed during pregnancy (17 SA) dominated by neoplasias. They were more often (68%) performed in the second trimester. Vaginal births were more frequent (74% against 26% of endouterine aspirations). CONCLUSION: Strict medical contraindications to pregnancy are exceptional. Recourse to the medical termination of pregnancy within the framework of a preexisting pathology must remain rare, by systematizing of the preconception consultation.

[Maternal deaths due to gestational trophoblastic diseases, results from the French confidential enquiry into maternal deaths, 2010-2012]. / Morts maternelles par maladies trophoblastiques gestationnelles. Résultats de l'enquête confidentielle française sur la mortalité maternelle, 2010­2012.

Gestational trophoblastic diseases (GTD) correspond to several entities which all have a common pattern: hypersecretion of human chorionic gondotrophin by trophoblastic hyperplasia. Between 2010 and 2012, there were 4 maternal deaths due to GTD (choriocarcinoma). The ratio of maternal death caused by GTD was 0,16/100,000 living births which was similar to the rate from the 2007-2009 period. These deaths represented 1.6% from the whole maternal mortality and 3.3% of the direct maternal mortality. These four deaths occurred after delivery and the diagnosis of GTD was made between 60 and 180 days in the postpartum period. Two cases seemed to be potentially avoidable. The main causes of suboptimal management were linked to delay either in diagnosis of GTD or in initiating the appropriate treatment. The analysis of these maternal deaths gave the opportunity to stress some major lessons to optimize medical management of GTD. Therefore, a patient presenting with persistent bleedings more than six weeks after delivery needs some specific exams such as plasma human chorionic gondotrophin measurement and histopathologic examination to affirm GTD and start early specific treatments generally leading to complete recovery.

[Case-control study of obstetrical outcomes of conisation]. / Étude cas-témoin des conséquences obstétricales de la conisation.

OBJECTIVES: Evaluate the obstetrical outcomes in the case of women with a history of conization. Determine the role of the cone length in the obstetrical issue. MATERIALS AND METHODS: Retrospective case-control study including the patients (n=39) who had undergone a conization in a university hospital between January 2002 and January 2012. The obstetrical outcomes have been compared to those from a control group (n=78). Into the exposed group the obstetrical outcomes has been compared based on the cone length. RESULTS: Thirty-one patients delivered after a conization (39 deliveries). The obstetrical outcomes have been significantly increased in the exposed group: preterm delivery before 37 weeks gestation (25.6% vs 7.7%, P=0.01), before 32 weeks gestation (15.4% vs 1.3%, P=0.005) and between 28 weeks gestation (10.2% vs 0%, P=0.01), premature onset of labor before 32 weeks gestation (12.8% vs 1.3%, P=0.01) and before 28 weeks gestation (12.8% vs 0%, P=0.01) and preterm premature rupture of membranes before 37 weeks gestation (20.5% vs 1.3%, P<0.001). There was no significant difference for a length cone more than 1.5cm. CONCLUSION: Our study showed that a history of conization is an obstetrical risk factor to consider in the management of a subsequent pregnancy.

[Maternal and neonatal outcomes of unplanned deliveries]. / Conséquences maternelles et néonatales des accouchements inopinés extrahospitaliers.

OBJECTIVES: Know the impact of the unplanned deliveries in a town of medium size, the characteristics of these women and maternal and neonatal risks. MATERIALS AND METHODS: This was a retrospective study conducted between January 2002 and December 2009. Unexpected delivery was defined as any delivery taking place outside of a non-elective way maternity. Each unexpected delivery was matched at nearest delivery of equivalent term, at the CHU maternity, with an onset of spontaneous labour. RESULTS: Ninety-four women gave birth unexpectedly for a total of 48,721 births (incidence of 0.19%). There was a significant difference between cases and controls for parity (1.8 versus 0.9), the lack of follow-up of pregnancy (21.3% versus 1.1%), tobacco (57.4% versus 25.5%), the socio-economic level, the type of feeding (artificial: 61.7% versus 30.6%), the home-hospital distance and obstetric follow-up. We found a significant increase in perinatal mortality (6.4% versus 1%) and stay in Neonatal ICU (19.1% versus 9.2%). The main neonatal morbidity was hypothermia. CONCLUSION: It is difficult to target a population at risk because the type of these women is non-specific. Prevention of unplanned deliveries and their morbidities through information of patients on the grounds of urgent consultation and support of the newborn to limit hypothermia.

[Fertility and risk of recurrence after surgical treatment of an ectopic pregnancy (EP): Salpingostomy versus salpingectomy]. / Fertilité et risque de récidive après traitement chirurgical d'une grossesse extra-utérine : salpingotomie versus salpingectomie.

UNLABELLED: Two surgical techniques can be performed for the treatment of an ectopic pregnancy (EP): a conservative one called salpingostomy and a radical one called salpingectomy. We compared both techniques to find differences about fertility or risk of recurrence. MATERIAL AND METHODS: We retrospectively reviewed all the women who underwent a surgical treatment for an ectopic pregnancy in the university's hospital of Caen between 2008 and 2011. We compared the results of both techniques. The primary end-point was the rate of intra-uterine pregnancy and the second end-point was the rate of recurrence of the EP. We also try to identify other risk factor of infertility. RESULTS: One hundred and fifty-two patients have been listed initially. Ninety-eight patients still attempt to become pregnant after the EP. In the conservative group, the rate of intra-uterine pregnancy was 88% (n=22) and the rate of recurrence was 8% (n=2). In the radical group, the rate of intra-uterine pregnancy was 68% (n=50) and the rate of recurrence was 5% (n=3). We could not identify any significant difference in the subsequent fertility or in the recurrence's risk between conservative and radical surgery. The age of the patient has been identified as a significative risk factor of infertility. CONCLUSION: To choose the surgical technique of an EP, the wish of pregnancy, the risk factor of infertility of the patient and the laparoscopic observations have to be taken into account. It seems that there is no difference between the two surgical techniques.

[Is vaginal delivery possible for patients with myomectomy? Results of a monocentric study]. / Après myomectomie, les patientes ont-elles le droit d'accoucher par voie basse ? Résultats d'une étude monocentrique.

OBJECTIVE: To compare delivery outcomes according to the scar: myomectomy versus low-segment transverse cesarean. METHODS: A retrospective cohort study was performed in a university type 3 service between 1st January 2006 and 1st January 2012. We compared 18 women who gave birth after myomectomy (exposed group) to 72 women who gave birth after cesarean section (non-exposed group). Women younger than 43 years who underwent laparotomy or laparoscopic myomectomy were included. The primary endpoint was the rate of vaginal delivery. The route of delivery, the rate of uterine rupture, complications of delivery and neonatal outcome were studied. RESULTS: The acceptance rate of vaginal delivery was 55.6% after myomectomies versus 84.7% after cesarean section (P=0.005). The success of vaginal birth was 88.9% after myomectomy versus 73.9% after cesarean (NS). No uterine rupture has occurred after myomectomy against three sub-peritoneal rupture after cesarean. The occurrence of post-partum hemorrhage was not significantly different between the 2 groups (11.1% among exposed group versus 6.9% in the non-exposed group). The cesarean section rate was even higher than the number of hysterotomy was great (P=0.0047). CONCLUSION: This study seems to show that vaginal birth after myomectomy is possible with a success rate similar to vaginal birth after cesarean section.

[Consequences of increasing and ageing population of Basse-Normandie on gynecology and obstetrics activity]. / Effet de l'augmentation et du vieillissement de la population de Basse-Normandie sur l'activité de gynécologie-obstétrique.

INTRODUCTION: In Basse-Normandie, the population over 65 years old will expend more rapidly between 2007 and 2042 (+11.6%) than the rest of the French population (+9.2%). The same population of Basse-Normandie will get old in the 15 years to come. The impact of these demographic changes over the activity in the gynecology-obstetrics field is not clearly identified. Although we cannot predict the technical and scientific developments in the next 15 years, we are presenting a model allowing to hypothesize about changes of gynecology and obstetrics according to population's aging. MATERIALS AND METHODS: We have established a projection model for the realizable surgical acts in obstetrics and gynecology in accordance with the aging of the population in Basse-Normandie. The study was realized based on the acts concerning the cesarean sections (C-section), tubal sterilization, hysteroscopy and hysterectomy as well as ovarectomy and breast surgery. For each activity branch, the codes of the Classification commune des actes médicaux (CCAM) were selected and then removed from the Programme médicalisé des systèmes d'information (PMSI) database. We have used and adapted the Omphale model of the National Statistics and Economical Studies Institute and we have applied it for the period of 2009-2025. RESULTS: Our projection model has permeated to show a 5.5% regression of the C-section acts, a 2% incretion of the hysterectomies and hysteroscopies, 7.7% of ovarectomies as well as a 9.8% augmentation of the breast surgeries. However, we predict a 11.8% diminution of the sterilizations by tubal implants. Globally, the activity in obstetrics and gynecology will remain constant with an insignificant augmentation of 46 acts (0.01%). CONCLUSION: In Basse-Normandie, the surgical activity in gynecology-obstetrics will moderately increase in the next 15 years. This constant activity signifies that there is no need to form more residents than the number of practitioner to retire. The interest of this model is that it is applicable at a national level and it permits to confront the demographic data and the projections of different activities.

Overview and expert assessment of off-label use of misoprostol in obstetrics and gynaecology: review and report by the Collège national des gynécologues obstétriciens français.

The literature suggests that misoprostol can be offered to patients for off-label use as it has reasonable efficacy, risk/benefit ratio, tolerance and patient satisfaction, according to the criteria for evidence-based medicine. Both the vaginal and sublingual routes are more effective than the oral route for first-trimester cervical dilatation. Vaginal misoprostol 800µg, repeated if necessary after 24 or 48h, is a possible alternative for management after early pregnancy failure. However, misoprostol has not been demonstrated to be useful for the evacuation of an incomplete miscarriage, except for cervical dilatation before vacuum aspiration. Oral mifepristone 200mg, followed 24-48h later by vaginal, sublingual or buccal misoprostol 800µg (followed 3-4h later, if necessary, by misoprostol 400µg) is a less efficacious but less aggressive alternative to vacuum aspiration for elective or medically-indicated first-trimester terminations; this alternative becomes increasingly less effective as gestational age increases. In the second trimester, vaginal misoprostol 800-2400µg in 24h, 24-48h after at least 200mg of mifepristone, is an alternative to surgery, sulprostone and gemeprost. Data for the third trimester are sparse. For women with an unripe cervix and an unscarred uterus, vaginal misoprostol 25µg every 3-6h is an alternative to prostaglandin E2 for cervical ripening at term for a live fetus. When oxytocin is unavailable, misoprostol can be used after delivery for prevention (sublingual misoprostol 600µg) and treatment (sublingual misoprostol 800µg) of postpartum haemorrhage. The use of misoprostol to promote cervical dilatation before diagnostic hysteroscopy or surgical procedures is beneficial for premenopausal women but not for postmenopausal women. Nonetheless, in view of the side effects of misoprostol, its use as a first-line treatment is not indicated, and it should be reserved for difficult cases. Misoprostol is not useful for placing or removing the types of intra-uterine devices used in Europe, regardless of parity.

Tranexamic acid for the prevention and treatment of postpartum haemorrhage.

Postpartum haemorrhage (PPH) is a major cause of maternal mortality, accounting for one-quarter of all maternal deaths worldwide. Uterotonics after birth are the only intervention that has been shown to be effective for PPH prevention. Tranexamic acid (TXA), an antifibrinolytic agent, has therefore been investigated as a potentially useful complement to this for both prevention and treatment because its hypothesized mechanism of action in PPH supplements that of uterotonics and because it has been proved to reduce blood loss in elective surgery, bleeding in trauma patients, and menstrual blood loss. This review covers evidence from randomized controlled trials (RCTs) for PPH prevention after caesarean (n=10) and vaginal (n=2) deliveries and for PPH treatment after vaginal delivery (n=1). It discusses its efficacy and side effects overall and in relation to the various doses studied for both indications. TXA appears to be a promising drug for the prevention and treatment of PPH after both vaginal and caesarean delivery. Nevertheless, the current level of evidence supporting its efficacy is insufficient, as are the data about its benefit:harm ratio. Large, adequately powered multicentre RCTs are required before its widespread use for preventing and treating PPH can be recommended.

[First trimester miscarriages: benefits and harms of different management options]. / Fausses couches du premier trimestre : bénéfices et risques des alternatives thérapeutiques.

The objective of this review was to assess early and late benefits and harms of different management options for first-trimester miscarriage. Surgical uterine evacuation remains the most effective and the quickest method of treatment. Depending on the clinical situation, medical treatment using misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) does not increase the risk of complications, neither haemorrhagic nor infectious. However, these alternatives generally require longer outpatient follow-up, which leads to more prolonged bleeding and not planned surgical procedures.

[Risk of uterine synechiae following uterine compression sutures during postpartum haemorrhage]. / Risque de synéchie utérine après capitonnage utérin pour hémorragie du post-partum.

OBJECTIVES: Uterine compression sutures are highly successful conservative surgical techniques used to treat severe postpartum haemorrhage. These methods can induce subsequent uterine synechiae. To determine this risk of synechiae after conservative uterine compression sutures, which may induce further fertility problems. PATIENTS AND METHODS: We retrospectively reviewed the medical and pathological records of the patients who underwent uterine compression sutures for severe postpartum haemorrhage between January 2003 and March 2013 in a French University Hospital. The Cho's, the B-Lynch's and the Hayman's techniques have been used. The results of the hysteroscopies were detailed. RESULTS: Among the 25 patients included, the B-Lynch or the Hayman's techniques have been used in 13 cases (52%). The Cho's technique has been performed alone for 5 patients (20%) and both techniques have been practiced in 7 situations (28%). In 17 cases (68%), some vascular sutures have been associated and, for 7 patients (28%), a vascular embolisation had been performed before the uterine compressive sutures. Only 19 patients underwent a diagnostic hysteroscopy and among them 13 had a normal uterine cavity (68%), 3 of them had uterine synechiae (16%) and 3 had placental retention (16%). Synechiae and retention have all been successfully removed by operative hysteroscopy. DISCUSSION AND CONCLUSION: The compressive techniques can induce uterine synechiae, which may impair subsequent fertility.

[Misoprostol: off-label use in the first trimester of pregnancy (spontaneous abortion, and voluntary medical termination of pregnancy)]. / Misoprostol: utilisation hors AMM au premier trimestre de la grossesse (fausses couches spontanées, interruptions médicales et volontaires de grossesse).

OBJECTIVE: State of knowledge about misoprostol's use out of its marketing authorization during the first trimester of pregnancy, in early miscarriage or to induce abortion or medical termination of pregnancy. METHODS: French and English publications were searched using PubMed, Cochrane Library and international learned societies recommendations. RESULTS: Cervical ripening prior to surgical uterine evacuation during the first trimester of pregnancy facilitates cervical dilatation and reduces operative time and uterine retention risk. Misoprostol, mifepristone and osmotic cervical dilators are equally efficient. Concerning first trimester miscarriage, surgical uterine evacuation remains the most effective and the quickest method of treatment (EL 1). Depending on the clinical situation, medical treatment using misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) does not increase the risk of complications, neither haemorrhagic nor infectious (EL 1). However, these alternatives generally require longer outpatient follow-up, which leads to more consultations, prolonged bleeding and not planned surgical procedures (EL 1). Concerning missed miscarriage, a vaginal dose of 800 µg of misoprostol, possibly repeated 24 to 48 hours later, seems to offer the best efficiency/tolerance ratio (EL 2). Concerning early abortion, medical method is a safe and efficient alternative to surgery (EL 2). Success rates are inversely proportional to gestational age (EL 2). According to the modalities of its marketing authorization, 400 µg of misoprostol can only be given by oral route, for less than 7 weeks of amenorrhea (WA) pregnancies and after 36 to 48 hours following 600 mg of mifepristone (EL 1). However, 200mg of mifepristone is as efficient as 600 mg (EL 1). Beyond 7WA, misoprostol buccal dissolution (sublingual or prejugal) or vaginal administration are more efficient and better tolerated than oral ingestion (EL 1). Between 7 and 9WA, the best protocol in terms of efficiency and tolerance is the association of 200mg of mifepristone followed 24 to 48 hours later by 800 µg of vaginal, sublingual or buccal misoprostol (EL 1). An additional dose of 400 µg can be given 3 hours later if necessary (EL 3). In case of buccal administration, the dose of 400 µg seems to offer the same efficiency with a better tolerance but further evaluation is needed (EL 2). Between 9 and 12WA, medical treatment is less efficient than surgery and its tolerance is lower (EL 2). However, a protocol of 200mg of mifepristone followed 36 to 48 hours later by 800 µg of vaginal or sublingual misoprostol, plus an additional 400 µg dose every 3-4 hours (until 4-5 doses maximum) seems safe and efficient (EL 5). CONCLUSION: Misoprostol use during the first trimester of pregnancy is a safe and efficient alternative to surgery as long as detailed protocols adjusted to each clinical situation are respected.

[Continuous medical evaluation of the prevention of fetomaternal rhesus-D allo-immunization]. / Évaluation des pratiques professionnelles sur la prévention de l'allo-immunisation Rhésus D.

OBJECTIVES: To evaluate the prevention of fetomaternal rhesus-D allo-immunization between 2008 and 2010. This evaluation was a part of the continuous medical evaluation (CME) that is compulsory in French hospitals. It was carried out using the tools recommended by the Haute Autorité de santé. We followed the national guidelines for the prevention of fetomaternal rhesus-D allo-immunization as outlined in 2005 by the national French college of Obstetrics and Gynecology. MATERIALS AND METHODS: We audited 3926 consultations in the first four months of 2008. Based on the results of the audit, actions were implemented to improve care. In 2009, we audited 4021 consultations to look for improvement, and another 3932 consultations in 2010. RESULTS: In 2008, 14% of the patients had an overall optimal prevention. After actions were taken, 44% of patients in 2009 and 58% of patients in 2010 demonstrated optimal prevention (P<0,05). Especially, the prevention of fetomaternal allo-immunization has been explained for 43% of the patients in 2008 and to 90% of them in 2010. And immunoprophylaxia has been prescribed to 70% of the patients in 2008 and to 93% of them in 2010. CONCLUSION: This CME has resulted in a statistically significant improvement of the prevention of allo-immunization.

[Iron deficiency anemia and pregnancy. Prevention and treatment]. / Anémie par carence martiale et grossesse. Prévention et traitement.

OBJECTIVE: To assess the effectiveness and the safety of prevention and treatment of iron deficiency anemia during pregnancy. METHODS: French and English publications were searched using PubMed and Cochrane library. RESULTS: Early screening of iron deficiency by systematic examination and blood analysis seemed essential. Maternal and perinatal complications were correlated to the severity and to the mode of appearance of anemia. Systematic intakes of iron supplements seemed not to be recommended. In case of anemia during pregnancy, iron supplementation was not associated with a significant reduction in substantive maternal and neonatal outcomes. Oral iron supplementation increased blood parameters but exposed to digestive side effects. Women who received parenteral supplementation were more likely to have better hematological response but also severe potential side effects during pregnancy and in post-partum. The maternal tolerance of anemia motivated the choice between parenteral supplementation and blood transfusion. CONCLUSION: Large and methodologically strong trials are necessary to evaluate the effects of iron supplementation on maternal health and pregnancy outcomes.

[Ogilvie's syndrome following cesarean section: Just think! Report of two cases and review of the literature]. / Syndrome d'Ogilvie après césarienne : savoir y penser ! À propos de deux cas post-césarienne et revue de la littérature.

OBJECTIVES: To identify clinical and radiological signs of the post-cesarean Ogilvie's syndrome in order to establish the appropriate treatment. PATIENTS AND METHODS: Based on the Medline research, we listed 41 cases of Ogilvie's syndrome after cesarean section. We analyzed the patient's age, the clinical and radiological signs, the time to diagnosis, and the treatments and their efficiency. RESULTS: The clinical signs generally appear in the first 72 h after cesarean. Diagnosis of Ogilvie's syndrome is based on a clinical picture of acute obstruction of the large bowel and by X-ray showing a large caecum without pathological lesion. If the caecal diameter is under 12 cm, conservative treatment is done with colonoscopic decompression when necessary, however if there are signs of peritonitis surgery is recommended. CONCLUSION: Ogilvie's syndrome after cesarean section is uncommon. Diagnosis must be fast in order to avoid the caecum to burst causing faecal peritonitis, which carries slight mortality rate.

Practices for prevention, diagnosis and management of postpartum haemorrhage: impact of a regional multifaceted intervention.

OBJECTIVE: To evaluate the effectiveness of a multifaceted intervention on practices for prevention, diagnosis and management of postpartum haemorrhage (PPH) and on the prevalence of major PPH in a French perinatal network. DESIGN: Quasi-experimental before-and-after survey. SETTING: All maternity units (n = 19) of a French administrative region, operating as a perinatal network. SAMPLE: One representative sample of all women delivering in the network, one representative sample of women with PPH deliveries and an exhaustive sample of women with major PPH. METHODS: The multifaceted intervention took place between February 2003 and March 2004. Information was retrospectively collected for two periods, 2002 (before the intervention) and 2005 (after). MAIN OUTCOME MEASURES: Practices for prevention, diagnosis and management of PPH and prevalence of major PPH. RESULTS: After the intervention, the pharmacological prevention of PPH increased from 58.8% to 75.9% of vaginal deliveries (P < 10(-4)), and the use of blood collecting bags from 3.9% to 76.3% (P < 10(-4)), but initial PPH management did not change significantly. However, the median delay for second-line pharmacological treatment was significantly shortened [from 80 min (35-130) in 2002 to 32.5 min (20-75) in 2005]. An increase was observed in the use of surgery for PPH (0.06% versus 0.12% of deliveries; P = 0.03) and in blood transfusions (0.18% versus 0.33%; P = 0.01). The prevalence of major PPH did not change (0.80% versus 0.86% of deliveries; P = 0.62). CONCLUSIONS: The intervention was effective at improving PPH-related preventive and diagnostic practices in a perinatal network. Improving management practices and reducing the prevalence of major PPH might require a different intervention design.

[Impact of a new regional management for postpartum hemorrhages by an audit of severe cases: a before and after study (2002-2005)]. / Evaluation de la mise en place d'une prise en charge régionale des hémorragies du postpartum par un audit des cas graves : étude avant-après (2002-2005).

BACKGROUND: Postpartum haemorrhage (PPH) is still the first cause of maternal mortality in France. Most of these cases include inappropriate management. In 2004, regional guidelines were diffused to all the birthplaces in Basse-Normandie. To assess the impact of this regional management, an epidemiological study "before-after" (2002-2005) has been performed. Part of this study was the evaluation of the management of severe PPH. OBJECTIVE: This study assessed the quality of care for major PPH and the correct follow-up of the guidelines before and after 2004. MATERIAL AND METHODS: A clinical audit has been conducted in all the birthplaces from the region to assess the management of all severe PPH identified during 2002 and 2005. PPH were considered as severe when they presented one or more of the following: blood transfusion, uterine embolisation, hemostatic surgery, difference in hemoglobin rates greater than 4 g / dl, or maternal death. All of these cases have been analysed except those defined by hemoglobin difference. Assessment has been carried out by pairs of practitioners (obstetrician and anesthetist) blinded to the origin of the case. Criteria assessed were the quality of care for major PPH, the correct follow-up of the guidelines and the degree of severity of the PPH which was estimated as moderate or severe on clinical arguments. RESULTS: The number of severe PPH was 34 in 2002 and 63 in 2005. The quality of care was increased with rates of inadequate management falling from 32 to 13% (p < 0,02), respectively. The follow-up of the guidelines was correct in the whole area, most of the criteria having been respected in about 90% of cases in 2005. However, active management of the third stage of delivery was only conducted in 71% of cases. The rates of severe PPH were not significantly different between 2002 (44%) and 2005 (38%). CONCLUSION: The originality from this study is that the modifications of the practices were conducted at a regional level in order to enhance the management of PPH. The assessment which was performed showed that quality of care was improved all over the area but that there is still place to progress.

[Management of the first trimester miscarriages]. / Prise en charge des fausses couches spontanées du premier trimestre.

A first trimester miscarriage is most often painfully experienced by the patients. The practitioner should be able to offer appropriate, timely, efficient and safe medical management, allowing a shorter convalescence without effect on subsequent fertility. Each step of the process of the miscarriage results in clinical and ultrasonographic characteristics, and requires a specific therapeutic strategy. Vaginal ultrasound allows confirmation of early pregnancy failure (missed miscarriage) diagnosis and to estimate the complete or incomplete removal of trophoblastic material. However, the endometrial thickness does not appear to be predictive for the risk of persistent bleeding or secondary surgery. Surgical evacuation of the product of conception remains the most effective and the quickest method of treatment. Depending on the clinical situation, medical treatment with misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) do not increase the risk of complications, particularly the infectious one. However, these alternatives generally require more prolonged outpatient follow-up leading to more frequent consultations and surgical emergencies.