[Impact of pelvic floor muscle training on prevention of perineal pain and dyspareunia in postpartum]. / Impact de la rééducation périnéale sur la prévention des douleurs et des dyspareunies en post-partum.

OBJECTIVE: Assessing the impact of perineal rehabilitation and massage on perineal pain and dyspareunia in the postpartum period, between 15days and 12months after delivery. METHODS: We conducted an exhaustive review of the literature concerning pelvic floor rehabilitation in the postpartum between 1987 and May 2015, grading data by levels of evidence (LOE) according to the methodology recommendations for clinical guidelines. RESULTS: Pelvic floor rehabilitation in the postpartum is not associated with a decreased prevalence of perineal pain and dyspareunia at 1year (LOE3). The practice of digital perineal massage during the third trimester of pregnancy is not associated with decreased prevalence at 3-month postpartum of perineal pain or dyspareunia (RR=0.64; 95% CI [0.39-1.08] and RR=0.96; 95% CI [0.84-1.08], respectively), except for women who have delivered vaginally (RR=0.45; 95% CI [0,24-0.87]) (LOE2). The practice of digital perineal massage or application of warm packs in the second stage of labor does not reduce perineal pain (RR=0.93; 95% CI [0.66-1.32]) or dyspareunia (RR=0.99; 95% CI [0.74-1.34]) at 3-month postpartum (LOE2). CONCLUSION: There is no evidence of long-term benefit of perineal rehabilitation and perineal massage on perineal pain and dyspareunia in the year following childbirth. Further studies are needed to accurately assess the impact of therapeutic strategies proposed in France.

[Treatment of below the knee lesions: Broadening the limits of vascular surgery]. / Traitement de l'artérite jambière : les frontières de la chirurgie vasculaire sont repoussées.

One third of patients with critical limb ischemia (CLI) has below the knee lesions and requires a restoration of direct blood flow into the foot. However, many of these patients are ineligible for open surgery. The primary goals thus become pain relief and limb salvage over patency. The angiosome concept helps determine the target artery to treat in priority. The endovascular approach has decreased morbidity and mortality rates compared to distal bypass surgery; while subintimal retrograde, trans-collateral and loop techniques push the limits of open surgery by reopening the plantar arch, thereby improving run-off. Early restenosis phenomena after angioplasty have been improved by the use of - limus drug eluting balloons and balloon expandable stents in case of flow limiting dissection or recoil with increased limb salvage rates. Moreover, drug-eluting stents have been proposed, and allow a reduction in reintervention and in-stent restenosis rates in short lesions; however, results on amputation rates or survival are limited. Vessel preparation is a key to overcoming some current limitations, including atherectomy, which increases technical success rates and reduces restenosis rates, especially in calcified lesions, chronic total occlusions and restenosis. These advanced techniques in distal endovascular revascularization have revolutionized limb salvage and support the interest of an endovascular first approach in CLI treatment.

[Postpartum pelvic floor muscle training and abdominal rehabilitation: Guidelines]. / Rééducation périnéale et abdominale dans le post-partum: recommandations.

OBJECTIVE: Provide guidelines for clinical practice concerning postpartum rehabilitation. METHODS: Systematically review of the literature concerning postpartum pelvic floor muscle training and abdominal rehabilitation. RESULTS: Pelvic-floor rehabilitation using pelvic floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. At least 3 guided sessions with a therapist is recommended, associated with pelvic floor muscle exercises at home. This postpartum rehabilitation improves short-term urinary incontinence (1 year) but not long-term (6-12 years). Early pelvic-floor rehabilitation (within 2 months following childbirth) is not recommended (grade C). Postpartum pelvic-floor rehabilitation in women presenting with anal incontinence, is associated with a lower prevalence of anal incontinence symptoms in short-term (1 year) (EL3) but not long-term (6 and 12) (EL3). Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C) but results are not maintained in medium or long term. No randomized trials have evaluated the pelvic-floor rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long term. It is therefore not recommended (expert consensus). Rehabilitation supervised by a therapist (physiotherapist or midwife) is not associated with better results than simple advice for voluntary contraction of the pelvic floor muscles to prevent/correct, in short term (6 months), a persistent prolapse 6 weeks postpartum (EL2), whether or not with a levator ani avulsion (EL3). Postpartum pelvic-floor rehabilitation is not associated with a decrease in the prevalence of dyspareunia at 1-year follow-up (EL3). Postpartum pelvic-floor rehabilitation guided by a therapist is therefore not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). No randomized trials have evaluated the effect of pelvic floor muscle training after an episode of postpartum urinary retention or bladder outlet obstruction symptoms, or for the primary prevention of anal incontinence following third-degree anal sphincter tear or in patients presenting with anal incontinence after third-degree anal sphincter tear. The electrostimulation devices used alone were not assessed in this postpartum context (regardless of symptoms); therefore, isolated pelvic floor electrostimulation is not recommended (expert consensus). CONCLUSION: Pelvic floor muscle therapy is recommended for persistent postpartum urinary (grade A) or anal (grade C) incontinence (3 months after delivery).

[Post-partum: Guidelines for clinical practice--Short text]. / Post-partum: recommandations pour la pratique Clinique--Texte court.

OBJECTIVE: To determine the post-partum management of women and their newborn whatever the mode of delivery. MATERIAL AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: Because breastfeeding is associated with a decrease in neonatal morbidity (lower frequency of cardiovascular diseases, infectious, atopic or infantile obesity) (EL2) and an improvement in the cognitive development of children (EL2), exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (Professional consensus). In order to increase the rate of breastfeeding initiation and its duration, it is recommended that health professionals work closely with mothers in their project (grade A) and to promote breastfeeding on demand (grade B). There is no scientific evidence to recommend non-pharmacological measures of inhibition of lactation (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). For women aware of the risks of pharmacological treatment of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Whatever the mode of delivery, numeration blood count is not systematically recommended in a general population (Professional consensus). Anemia must be sought only in women with bleeding or symptoms of anemia (Professional consensus). The only treatment of post-dural puncture headache is the blood patch (EL2), it must not be carried out before 48 h (Professional consensus). Women vaccination status and their family is to be assessed in the early post-partum (Professional consensus). Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (Professional consensus). An analgesic multimodal protocol developed by the medical team should be available and oral way should be favored (Professional consensus) (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (Professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). Early postoperative rehabilitation is encouraged (Professional consensus). Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, after normal pregnancy and delivery (Professional consensus). Starting effective contraception later 21 days after delivery in women who do not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended (grade B). Rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long-term is not recommended (Expert consensus). Pelvic-floor rehabilitation using pelvic-floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C). Postpartum pelvic-floor rehabilitation is not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). The optimal time for maternity discharge for low risk newborn depends more on the organisation of the post-discharge follow up (Professional consensus). The months following the birth are a transitional period, and psychological alterations concern all parents (EL2). It is more difficult in case of psychosocial risk factors (EL2). In situations of proven psychological difficulties, the impact on the psycho-emotional development of children can be important (EL3). Among these difficulties, postpartum depression is the most common situation. However, the risk is generally higher in the perinatal period for all mental disorders (EL3). CONCLUSION: Postpartum is, for clinicians, a unique and privileged opportunity to address the physical, psychological, social and somatic health of their patients.