[Maternal morbidity and mortality associated with conservative management for placenta morbidly adherent (accreta) diagnosed during pregnancy. Report of 15 cases]. / Morbimortalité maternelle associée au traitement conservateur d'un placenta anormalement adhérent (accreta) diagnostiqué en anténatal. À propos d'une série continue de 15 cas.

BACKGROUND: High risk of morbidly adherent placenta increased during past years. Their management is controversial. Cesarean hysterectomy, considered the gold standard treatment by American Society, is associated with high risk of maternal morbimortality. Conservative management has been sought to reduce maternal morbidity associated with caesarean hysterectomy while maintaining fertility. It consists of leaving the placenta in place but long-term monitoring. Our main objective was to determine advantage/disadvantage of conservative management on patient with an antenatal diagnosis of placenta accreta, increta or percreta. MATERIAL AND METHODS: This retrospective study included all patients with an antenatal diagnosis of placenta accreta, increta or percreta between 2007 and 2014. Conservative treatment was systematically attempted according to our protocol. The primary outcome was defined as uterine conservation and the secondary outcome as maternal morbimortality defined as any medical or surgical condition occurring after childbirth. RESULTS: Fifteen patients (0.07 % of all living childbirths) were included. Conservative management was successful in 80 % of patients. There was no case of maternal death. Severe post-partum hemorrhage occurred in 4 patients (33.3 %) requiring uterine arteries embolization in one patient and hysterectomy in the 3 others. They underwent immediate blood transfusion of 13.5±4.5 average of red blood cell units. No severe septic condition occurred but 4 patients suffered from endometritis, 2.6±0.5 months after birth requiring intravenous antibiotics treatment in conventional hospitalization. Mean duration for spontaneous abortion of the placenta was 23.0±7.2 weeks. Three spontaneous pregnancies occurred in 2 patients after 19±16.9 months. CONCLUSION: Conservative management seems encouraging but is associated with a non-insignificant risk of secondary complication requiring long-term monitoring in conciliant patients.

Cervical assessment at 22 and 27 weeks for the prediction of spontaneous birth before 34 weeks in twin pregnancies: is transvaginal sonography more accurate than digital examination?

OBJECTIVES: This study compared the accuracy of ultrasound cervical assessment (cervical length and cervical index) and digital examination (Bishop score and cervical score) in the prediction of spontaneous birth before 34 weeks in twin pregnancies. METHODS: In a prospective multicenter study, digital examination and transvaginal sonography were performed consecutively in twin pregnancies attending for routine sonography at either 22 weeks (175 women) or 27 weeks (153 women). The digital examination took place first, and the Bishop score and cervical score (cervical length minus cervical dilatation) were calculated. Ultrasound measurements were then made of cervical length and funnel length to yield the cervical index (1 + funnel length/cervical length). The association between each variable and delivery before 34 weeks was tested by the Mann-Whitney U-test. The receiver-operating characteristics (ROC) curves of the ultrasound and digital indicators were determined for both gestational age periods, and the areas under the ROC curves compared. The best cut-off values for each indicator were used to determine predictive values for delivery before 34 weeks. RESULTS: The median gestational age at delivery among the women included in the 22-week examination period was 36.0 (range, 21-40) weeks; 10.9% (19) gave birth spontaneously before 34 weeks. The median cervical length was 40 (range, 6-65) mm. All four parameters were predictors of delivery before 34 weeks. The areas under the ROC curves for cervical index, cervical length, Bishop score and cervical score did not differ significantly. The median gestational age at delivery among the women in the 27-week examination period was 36.0 (range, 27-40) weeks; 9.2% (14) gave birth spontaneously before 34 weeks. The median cervical length was 35 (range, 1-57) mm. All parameters except the Bishop score were predictors of delivery before 34 weeks. The likelihood ratio of the positive and negative tests for cervical length < or = 25 mm was 5.4 (range, 3.2-9.0) and 0.3 (range, 0.1-0.7), respectively, compared with 2.3 (range, 1.3-4.2) and 0.6 (range, 0.3-1.1), respectively, for cervical score < or = 1. The area under the curve for the cervical index was significantly larger than that for the Bishop score (P = 0.008) or cervical score (P = 0.02). CONCLUSION: Transvaginal sonography predicted spontaneous delivery before 34 weeks better than digital examination at the 27-week but not the 22-week examination.

External cephalic version with epidural anaesthesia after failure of a first trial with beta-mimetics.

OBJECTIVE: To assess the efficacy, tolerance, and cost of external version under epidural anaesthesia and beta-mimetic tocolysis after the failure of an initial attempt with tocolysis alone. DESIGN: Prospective open study. PARTICIPANTS: Sixty-eight women with breech presentation at around 36 weeks of gestation and an attempted external cephalic version under salbutamol that failed, who consented to try a second attempt under epidural anaesthesia. RESULTS: The overall success rate under epidural anaesthesia was 39.7% (27/68), and complications occurred in two cases. The total cost of attempting external version was higher than the cost of expectant management. CONCLUSIONS: The efficacy of external cephalic version under epidural reduces the rate of caesarean sections associated with breech presentation, but its relative safety remains in question. Moreover, our economic analysis discourages the hope of lowered costs suggested by earlier reports that this technique is more expensive than expectant management, except in institutions with a policy of systematic caesarean sections when version fails.

[Rational use of fetal fibronectin in the evaluation of premature labor risk]. / Utilisation rationnelle de la fibronectine foetale dans l'évaluation du risque d'accouchement prématuré.

OBJECTIVE: To better determined the usefulness of fetal fibronectin assay to identify patients at risk of premature delivery. SUBJECTS: 155 primiparous or multiparous patients presenting with single or twin pregnancies between 24 and 34 weeks and divided into 3 groups: high risk (70 patients), medium risk (35 patients), and low risk (50 patients) of premature delivery. MAIN OUTCOME MEASURES: The occurrence of delivery in the 21 days following sampling and/or a premature delivery. RESULTS: Among the 50 patients in the low risk group, there was one false positive and no premature delivery. Among the 35 patients in the medium risk group, there was no single positive fetal fibronectin test and no premature delivery. Among the 70 patients in the high risk group, 14 had a premature rupture of the membranes with very strongly positive fetal fibronectin test and all were delivery prematurely, 11 within a period of less than 21 days. The remaining 56 patients presented a threat of premature delivery without rupture of membranes; 20 gave birth prematurely (prevalence: 35.7%). In patients with a negative fetal fibronectin test, those with positive fetal fibronectin test were significantly more likely to experience preterm birth (odds ration: 12; 95% confidence interval: 3.4 to 42.1; p = 0.001) or to deliver within 21 days (odds ratio: 29.9; 95% confidence interval: 13.3 to 243; p < 0.001). CONCLUSION: Measurement of fetal fibronectin in cervico-vaginal secretions enabled us to define an authentic sub-group at high risk of premature delivery among patients presenting uterine contractions and changes in the cervix. In contrast, measurement of fetal fibronectin in cervico-vaginal secretions of patients with low and medium risk is not suitable, due to the low rate of premature delivery in these groups and the significant increase in the cost of pregnancy monitoring.