Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery.

BACKGROUND: Prophylactic administration of tranexamic acid has been associated with reduced postpartum blood loss after cesarean delivery in several small trials, but evidence of its benefit in this clinical context remains inconclusive. METHODS: In a multicenter, double-blind, randomized, controlled trial, we assigned women undergoing cesarean delivery before or during labor at 34 or more gestational weeks to receive an intravenously administered prophylactic uterotonic agent and either tranexamic acid (1 g) or placebo. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1000 ml or receipt of a red-cell transfusion within 2 days after delivery. Secondary outcomes included gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion. RESULTS: Of the 4551 women who underwent randomization, 4431 underwent cesarean delivery, 4153 (93.7%) of whom had primary outcome data available. The primary outcome occurred in 556 of 2086 women (26.7%) in the tranexamic acid group and in 653 of 2067 (31.6%) in the placebo group (adjusted risk ratio, 0.84; 95% confidence interval [CI], 0.75 to 0.94; P = 0.003). There were no significant between-group differences in mean gravimetrically estimated blood loss or in the percentage of women with provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, or postpartum blood transfusion. Thromboembolic events in the 3 months after delivery occurred in 0.4% of women (8 of 2049) who received tranexamic acid and in 0.1% of women (2 of 2056) who received placebo (adjusted risk ratio, 4.01; 95% CI, 0.85 to 18.92; P = 0.08). CONCLUSIONS: Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not result in a lower incidence of hemorrhage-related secondary clinical outcomes. (Funded by the French Ministry of Health; TRAAP2 ClinicalTrials.gov number, NCT03431805.).

Maternal occupational exposure to organic solvents and intrauterine growth in the ELFE cohort.

BACKGROUND: In developed countries, about 15% of women are occupationally exposed to solvents. Associations between this maternal occupational exposure and intrauterine fetal growth are inconsistent, but almost no existing study has investigated this relation by solvent family (oxygenated, petroleum, and chlorinated), although they may affect fetal growth differently. OBJECTIVES: To investigate the relations between maternal occupational solvent exposure, by solvent family, and the risk of neonates born small for gestational age (SGA), or with low birthweight, or with small head circumference (HC). METHODS: Among the 18,040 women enrolled in the Elfe rather than included in the Elfe birth cohort, we included 13,026 women who worked during pregnancy (72% of the cohort). Information about maternal occupations and industrial activities during pregnancy was collected by questionnaire at the maternity ward, and completed at 2-month when necessary. Using Matgéné job-exposure matrices, we assessed maternal occupational exposure to solvents. Logistic and multiple linear regressions were used to assess the association between maternal occupational solvent exposure and SGA status, birth weight, and HC. Analyses were conducted for exposure during pregnancy and also stratified by the trimester that pregnancy leave began. RESULTS: We observed a higher risk of SGA newborns among mothers occupationally exposed during pregnancy to petroleum solvents (ORadjusted = 1.26; 95%CI: 1.01 to 1.57). Among women working until the third trimester of pregnancy, we observed a higher risk of SGA newborns to those occupationally exposed to oxygenated solvents (ORadjusted = 1.75; 95%CI: 1.11 to 2.75), a significantly lower birthweight for infants of mothers exposed to petroleum solvents (ßadjusted = -47.37 g; -89.33 to -5.42), and a lower HC among newborns of those occupationally exposed to oxygenated solvents (ßadjusted = -0.28; -0.49 to -0.07) and to chlorinated solvents (ßadjusted = -0.29; -0.53 to -0.05). DISCUSSION: Our results suggest that maternal occupational solvent exposure may influence fetal growth, especially exposure into the third trimester of pregnancy.

Tranexamic acid for the prevention of blood loss after cesarean among women with twins: a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery randomized clinical trial.

BACKGROUND: Although prophylactic tranexamic acid administration after cesarean delivery resulted in a lower incidence of calculated estimated blood loss of >1000 mL or red cell transfusion by day 2, its failure to reduce the incidence of hemorrhage-related secondary clinical outcomes (TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial) makes its use questionable. The magnitude of its effect may differ in women at higher risk of blood loss, including those with multiple pregnancies. OBJECTIVE: This study aimed to compare the effect of tranexamic acid vs placebo to prevent blood loss after cesarean delivery among women with multiple pregnancies. STUDY DESIGN: This was a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial data, a double-blind, randomized controlled trial from March 2018 to January 2020 in 27 French maternity hospitals, that included 319 women with multiple pregnancies. Women with a cesarean delivery before or during labor at ≥34 weeks of gestation were randomized to receive intravenously 1 g of tranexamic acid (n=160) or placebo (n=159), both with prophylactic uterotonics. The primary outcome was a calculated estimated blood loss of >1000 mL or a red blood cell transfusion by 2 days after delivery. The secondary outcomes included clinical and laboratory blood loss measurements. RESULTS: Of the 4551 women randomized in this trial, 319 had a multiple pregnancy and cesarean delivery, and 298 (93.4%) had primary outcome data available. This outcome occurred in 62 of 147 women (42.2%) in the tranexamic acid group and 67 of 152 (44.1%) receiving placebo (adjusted risk ratio, 0.97; 95% confidence interval, 0.68-1.38; P=.86). No significant between-group differences occurred for any hemorrhage-related clinical outcomes: gravimetrically estimated blood loss, provider-assessed clinically significant hemorrhage, additional uterotonics, postpartum blood transfusion, arterial embolization, and emergency surgery (P>.05 for all comparisons). CONCLUSION: Among women with a multiple pregnancy and cesarean delivery, prophylactic tranexamic acid did not reduce the incidence of any blood loss-related outcomes.

Prenatal exposure to pesticides and risk of preeclampsia among pregnant women: Results from the ELFE cohort.

BACKGROUND: Preeclampsia is a pregnancy-specific syndrome caused by abnormal placentation. Although environmental chemicals, including some pesticides, are suspected of impairing placentation and promoting preeclampsia, its relationship with preeclampsia has been insufficiently explored. OBJECTIVES: We aimed to investigate the relation between non-occupational exposure to pesticides during pregnancy and the risk of preeclampsia. METHODS: The study cohort comprised 195 women with and 17,181 without preeclampsia from the ELFE birth cohort. We used toxicogenomic approaches to select 41 pesticides of interest for their possible influence on preeclampsia. We assessed household pesticide use (self-reported data), environmental exposure to agricultural pesticides (geographic information systems), and dietary exposure (food-frequency questionnaire with data from monitoring pesticide residues in food and water). Dietary exposures to pesticides were grouped into clusters of similar exposures to resolve collinearity issues. For each exposure source, pesticides were mutually adjusted, and odds ratios estimated with logistic regression models. RESULTS: The quantity of prochloraz applied within a kilometer of the women's homes was higher in women with than without preeclampsia (fourth quartile vs. others; adjusted odds ratio [aOR] = 1.54; 95%CI: 1.02, 2.35), especially when preeclampsia was diagnosed before 34 weeks of gestation (aOR = 2.25; 95%CI: 1.01, 5.06). The reverse was observed with nearby cypermethrin application (aOR = 0.59, 95%CI: 0.36, 0.96). In sensitivity analyses, women with preeclampsia receiving antihypertensive treatment had a significantly higher probability of using herbicides at home during pregnancy than women without preeclampsia (aOR = 2.20; 95%CI: 1.23, 3.93). No statistically significant association was found between dietary exposure to pesticide residues and preeclampsia. DISCUSSION: While the most of the associations examined remained statistically non-significant, our results suggest the possible influence on preeclampsia of residential exposures to prochloraz and some herbicides. These estimations are supported by toxicological and mechanistic data.

Performance of diagnostic ultrasound to identify causes of hydramnios.

INTRODUCTION: We aimed to assess the diagnostic yield of ultrasonography in the identification of the etiology of hydramnios, and the added value of MRI or amniocentesis. METHODS: We conducted a single-center retrospective study including pregnancies with confirmed hydramnios (defined as deepest pocket ≥8 cm) between January 2013 and May 2017. Twin pregnancies, secondary hydramnios discovered after the diagnosis of a causal pathology, and pregnancies of unknown outcome were excluded. All pregnancies underwent a targeted scan, and selected cases underwent MRI or amniocentesis. RESULTS: A total of 158 patients with confirmed hydramnios were included. Hydramnios was associated with a fetal pathology in 37 cases (23.4%), with diabetes in 39 (24.6%), isolated macrosomia in 16 (10.1%), and considered idiopathic in 66 (41.7%). Ultrasonography established a diagnosis of the underlying pathology in 73% of cases. Amniocentesis was done in 31 cases (20%) and it allowed diagnosis of chromosome anomalies, esophageal atresia, myotonic dystrophy congenital type, Prader-Willi syndrome, and Bartter syndrome. MRI was done in 15 cases (10%) and it allowed one additional diagnosis of esophageal atresia. The diagnostic yields of MRI and amniocentesis were 91.7% and 95.2%, respectively. There were five false positive diagnoses at ultrasonography, and one false positive diagnosis at MRI. CONCLUSION: Hydramnios can be associated with a wide variety of underlying pathologies. Diagnostic ultrasound can attain a diagnosis in the majority of cases. Amniocentesis offers a valuable complementary assessment.

Fertility, Pregnancy, and Clinical Outcomes after Uterine Arteriovenous Malformation Management.

STUDY OBJECTIVE: To evaluate fertility, pregnancy, and clinical outcomes after uterine arteriovenous malformation (UAVM) management. DESIGN: Single-center retrospective study (Canadian Task Force classification III). SETTING: One referral center. PATIENTS: Twenty-two patients with a UAVM diagnosed by magnetic resonance angiography or computed tomography angiography and managed by expectant management (EM) or uterine arterial embolization (UAE) during the study period were included. INTERVENTIONS: Nine of 22 patients underwent first-intention EM and 13 first-line UAE. Three of 9 EM patients (33.3%) required emergency second-intention UAE for nonresolution of the UAVM and severe genital bleeding. MEASUREMENTS AND MAIN RESULTS: To analyze fertility according to management approach, we defined 2 groups: EM only group (n = 6) and UAE group (n = 16; women who underwent first- or second-intention UAE). Overall, the median age was 29 years (range, 17-43). The mean follow-up after UAVM management was 39 months (range, 1-116). The success rate of the UAE procedure was 87.5% (14/16). Eight of 12 women (66.7%) who wished to conceive became pregnant: 2 of 5 (33.3%) in the EM group and 6 of 7 (85.7%) in the UAE group (p = 1). Overall, 11 patients (50%) conceived: 3 in the EM group (50%) and 8 in the UAE group (50%) (p = .9). The live birth rate was 36.4% (8/22) for the whole population. There were no miscarriages or ectopic pregnancies. The 8 women (72.7%) wishing to conceive who became pregnant all delivered: 1 by cesarean section and 7 by vaginal delivery. Median duration of pregnancy was 39 weeks and 5 days. The remaining 3 women (i.e., women who conceived but did not wish to become pregnant) had therapeutic abortions. One complication was experienced in the EM group (small for gestational age newborn) and none in the UAE group (p = .3). Limitations include retrospective design and small sample size. CONCLUSION: UAE for UAVM is an effective and safe technique. It does not impair fertility, and obstetric prognosis is good.

Impact of laser therapy for twin-to-twin transfusion syndrome on subsequent pregnancy.

OBJECTIVES: The objective of our study was to determine the impact of laser therapy for twin-to-twin transfusion syndrome (TTTs) on subsequent pregnancies. METHODS: This was a monocentric retrospective observational study. Women treated by laser fetoscopy for TTTs were asked to answer a postal questionnaire about subsequent pregnancies. The primary outcome was fecundity (number of pregnancies and time to pregnancy). We also assessed pregnancy complications, birth weight, and gestational age at delivery. Pregnancy complications included the following: threatened preterm labor, preeclampsia, placenta accreta, postpartum hemorrhage, and psychological disorders. Our study population was compared with an external control group made up of mothers of monochorionic twins without TTTs. RESULTS: We included 122 cases managed at the Necker Hospital between 2008 and 2012 and 39 controls. The median conception time was longer in the TTTs group (6.4 ± 11.1 versus 2 ± 1.6 months, P = .03). The numbers of live childbirths at the end of those pregnancies were equivalent (77.6% versus 66.7%, P = .56). Birth weight (3317 ± 726 versus 3240 ± 382 g, P = .81) and gestational age at delivery (38.2 ± 6.8 WG versus 39.5 ± 1.2 WG, P = .64) were similar, with no increase of obstetrical complications compared with the control group. DISCUSSION: Twin-to-twin transfusion syndrome and its treatment do not seem to impact subsequent pregnancies.

Serum hCG threshold to assess medical abortion success.

OBJECTIVES: The main aim of the study was to establish a threshold for serum human chorionic gonadotropin (hCG) level that ruled out ongoing pregnancy after induced medical abortion (MA). The secondary aim was to discover risk factors for the need for uterine aspiration. METHODS: This prospective study included women who underwent MA with mifepristone-misoprostol at ≤9 weeks of gestation between 2012 and 2014. Serum hCG levels were measured 14-21 days after MA. The main outcome measure, ongoing pregnancy, was defined as the presence of an embryo with cardiac activity on transvaginal ultrasonography after MA. The receiver operating characteristic curve was plotted to determine the optimal serum hCG threshold. Risk factors for the need for uterine aspiration were calculated using multivariate logistic regression and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: The study included 814 women. Mean gestational age was 46.5 ± 7.4 days for ongoing pregnancies and 44.2 ± 4.8 days for MA success (p = .43). The ongoing pregnancy rate after MA was 0.9%. A serum hCG threshold ≥900 IU/l to diagnose ongoing pregnancy gave 100% sensitivity and 81.5% specificity, compared with 85.7% sensitivity and 83.5% specificity using a threshold ≥1000 IU/l. Independent risk factors for uterine aspiration requirement were: gravidity (OR 3.8; 95% CI 1.1, 13.2; p = .001), gestational age >6 weeks (OR 6.0; 95% CI 1.8, 6.0; p = .006) and previous surgical abortion (OR 2.4; 95% CI 1.1, 5.2; p < .001). CONCLUSION: Serum hCG measurement <900 IU/l, 14-21 days after MA, is an efficient strategy for excluding ongoing pregnancy after first trimester MA.

The performance of an intermediate 16th-week ultrasound scan for the follow-up of euploid fetuses with increased nuchal translucency.

OBJECTIVE: The objective of the study is to assess the utility of an intermediate ultrasound scan at 16(+0) to 18(+6) weeks of gestation in euploid fetuses with increased nuchal translucency ≥ 3.5 mm. METHODS: Three hundred eighty-nine fetuses with nuchal translucency (NT) ≥ 3.5 mm were identified in two prenatal centers between January 2008 and December 2012. Pregnancy work-up included karyotyping, monthly detailed ultrasound scan starting with a 16th-week scan, a cardioechography, and a genetic counseling. Abnormal findings and pregnancy outcomes were analyzed retrospectively. RESULTS: Of the 389 fetuses included, 52% had normal karyotype. Among euploid fetuses, 51 (30.7%) structural defects were identified overall. First-trimester scan was useful to identify 16 of the major defects (31.3%), and the 16th-week scan was useful to identify an additional 21 of them (41.2%), whereas the 22nd-week pregnancy scan discovered an additional 14 (27.4%). Structural defects discovered with the 16th-week scan were cardiac defects (n = 7), polymalformative syndromes (n = 3), left diaphragmatic hernias (n = 3), limbs abnormalities (n = 2), genitourinary (n = 2), microretrognathism (n = 2), hydrops (n = 1), and exomphalos (n = 1). If the intermediate scan was normal, the chances of a favorable outcome were as high as 85% and were close to 100% after 20 weeks, irrespective of initial NT. CONCLUSION: The intermediate ultrasound was useful in fetuses with increased NT pregnancy work-up.

Probe motion during mid-trimester fetal anomaly scan in the clinical setting: A prospective observational study.

INTRODUCTION: This study aims to investigate probe motion during full mid-trimester anomaly scans. METHODS: We undertook a prospective, observational study of obstetric sonographers at a UK University Teaching Hospital. We collected prospectively full-length video recordings of routine second-trimester anomaly scans synchronized with probe trajectory tracking data during the scan. Videos were reviewed and trajectories analyzed using duration, path metrics (path length, velocity, acceleration, jerk, and volume) and angular metrics (spectral arc, angular area, angular velocity, angular acceleration, and angular jerk). These trajectories were then compared according to the participant level of expertise, fetal presentation, and patient BMI. RESULTS: A total of 17 anomaly scans were recorded. The average velocity of the probe was 12.9 ± 3.4 mm/s for the consultants versus 24.6 ± 5.7 mm/s for the fellows (p = 0.02), the average acceleration 170.4 ± 26.3 mm/s2 versus 328.9 ± 62.7 mm/s2 (p = 0.02), and the average jerk 7491.7 ± 1056.1 mm/s3 versus 14944.1 ± 3146.3 mm/s3 (p = 0.02), the working volume 9.106 ± 4.106 mm3 versus 29.106 ± 11.106 mm3 (p = 0.03), respectively. The angular metrics were not significantly different according to the participant level of expertise, the fetal presentation, or to patients BMI. CONCLUSION: Some differences in the probe path metrics (velocity, acceleration, jerk and working volume) were noticed according to operator's level.

Advanced Insights into Human Uterine Innervation: Implications for Endometriosis and Pelvic Pain.

(1) Background: Understanding uterine innervation, an essential aspect of female reproductive biology, has often been overlooked. Nevertheless, the complex architecture of uterine innervation plays a significant role in conditions such as endometriosis. Recently, advances in histological techniques have provided unprecedented details about uterine innervation, highlighting its intricate structure, distribution, and density. The intricate nature of uterine innervation and its influence on pathologies such as endometriosis has garnered increasing attention. (2) Objectives: This review aims to compile, analyze, and summarize the existing research on uterine innervation, and investigate its implications for the pathogenesis of endometriosis and associated pain. (3) Methods: A systematic review was conducted in line with PRISMA guidelines. Using the PubMed database, we searched relevant keywords such as "uterine innervation", "endometriosis", and "pain association". (4) Results: The initial literature search yielded a total of 3300 potential studies. Of these, 45 studies met our inclusion criteria and were included in the final review. The analyzed studies consistently demonstrated that the majority of studies focused on macroscopic dissection of uterine innervation for surgical purposes. Fewer studies focused on micro-innervation for uterine innervation. For endometriosis, few studies focused on neural pain pathways whereas many studies underlined an increase in nerve fiber density within ectopic endometrial tissue. This heightened innervation is suggested as a key contributor to the chronic pain experienced by endometriosis patients. (5) Conclusions: The understanding of uterine innervation, and its alterations in endometriosis, offer promising avenues for research and potential treatment.

Simulation training for pelvic examination: A systematic review.

OBJECTIVE: Pelvic examination including vaginal digital examination and speculum inspection are crucial medical skills that are challenging to teach for both professors and students, because of its intimate nature. Consequently, education has shifted from a traditional approach to a simulation-enhanced education. This literature review summarizes the level of evidence for these not-so-new training modalities. METHODS: For this systematic review, the Pudmed database have been consulted using the following keywords: (Pelvic examination OR Vaginal examination) AND simulation. Eligible studies had to be published in French or English within the past 20 years and investigate simulation training for pelvic examination in the field of gynecology and obstetrics. For each paper, the following outcomes were analyzed: Competence, confidence and communication, and were classified according to the Kirkpatrick hierarchy. RESULTS: About competence, in initial training, one meta-analysis (9 studies of which 4 randomized studies) about pelvic examination teaching on procedural simulators have shown a significant benefit of simulation. One meta-analysis and one systematic review also demonstrated that Gynecological Teaching Associates (GTAs) teaching, who exist in Northern America and Scandinavian countries, was better that pelvic task trainers in terms of technical competence, and comfort. For the vaginal examination of women in labor, two randomized trials also showed a positive impact of pelvic task trainer on students' accuracy. CONCLUSION: Simulation-enhanced education of pelvic examination brings a significant benefit in comparison to a classic education without simulation in terms of competence, confidence and communication. GTAs have the best impact on competence and communication, but they do not exist currently in France. Hybrid simulation (a patient actor combined with a pelvic task trainer) could be a solution to teach both technical skills and communication.

Trial of labor versus elective cesarean delivery for patients with two prior cesarean-sections: A retrospective propensity score analysis.

INTRODUCTION: Despite awareness of obstetricians to the constant increase in the number of cesarean sections in recent years, the fear of a uterine scar rupture is still present and influences the choice of the mode of delivery in patients with two previous cesarean sections. However, several clinical studies have suggested that, under certain conditions, vaginal birth after two cesarean sections is usually successful and safe. OBJECTIVE: The objective of this study was to compare maternal and neonatal issues according to the planned mode of delivery in patients with two previous cesarean sections. METHODS: It was a retrospective observational comparative study at Rennes University Hospital between January 1, 2013, and December 31, 2020. We performed a propensity score for the comparison of neonatal outcomes: cord pH, cord lactates, Apgar scores, transfer to neonatal unit and deaths, according to the planned delivery mode. Secondary outcomes were maternal issues: uterine rupture, post-partum hemorrhage, deaths. RESULTS: A total of 410 patients with two previous cesarean section were eligible for our study. Prophylactic cesarean was performed in 358 cases (87.3%). Trial of labor was attempted in the 52 remaining patients (12.7%), 67.3 % of whom were successful. Neonatal weight, APGAR score at 1-5-10 min, and pH on cord blood were comparable in both groups. One case of uterine rupture occurred in the trial of labor group. CONCLUSION: Trial of labor seems to be a reasonable option for women with two previous cesarean sections in a selected population.

Retrospective evaluation of labor induction with scar uterus at the university hospital of Rennes.

OBJECTIVE: The aim of the study was a retrospective evaluation of labor induction in women with one previous cesarean section. The primary outcome was the mode of delivery. We also studied the severe maternal and neonatal morbidity and identify some prediction factors of vaginal delivery after labor induction after one previous cesarean section. STUDY DESIGN: This was a retrospective observational monocentric study performed over the period from January 1st, 2016 to April 30th, 2020 at the university hospital of Rennes. Were included women with scar uterus because of one previous cesarean section with a viable singleton fetus in cephalic presentation and an induction of labor for medical reason, at term. Multivariate logistic regression analysis was used to analyze prediction of vaginal delivery after labor induction after one previous cesarean section. We also studied maternal (included uterine rupture, loss of blood, obstetrical injury of anus sphincter) and neonatal (APGAR score, arterial umbilical pH after 1 minute of life and eventual admission to neonatal unit) morbidity. We used a stepwise multivariate logistic regression model to select variables for multivariate analysis. The model with the lowest Akaike Index Criteria was chosen. RESULTS: The study enrolled 353 women with scar uterus: 121 women were induced by balloon catheter, 57 by osmotic cervical dilatators, 91 by oxytocin alone, 84 by amniotomy. Vaginal delivery rate was 47,9%. There was 45% of vaginal delivery in the group with Bishop < 6 before induction of labor versus 62% in the group with Bishop ≥ 6. There was no statistically significative difference in neonatal and maternal severe morbidities between vaginal delivery and cesarean section: 4,5% of severe maternal morbidities (n = 16). Among their, we highlighted 7 uterine ruptures (3,8%). We observed also 3% of postpartum severe hemorrhage in vaginal delivery group (n = 5) against 1,6% in cesarian section group (n = 3) with no statistical significant difference (p = 0,632). Regarding to the obstetric perineal tears and lacerations we noticed 1,2% of OASIS 3 (n = 2) and 0,6% of OASIS 4 (n = 1). Severe neonatal morbidities were comparable by mode of delivery without significant difference: APGAR score at 5 min was similar (p = 1), as well as arterial umbilical pH after 1 min. (p = 0.719) and admissions to a neonatal unit (p = 1). Two variables were statistically associated with vaginal delivery after labor induction in women with scar uterus: Bishop score ≥ 6 (OR = 0,44; 95%CI: 0,25-0,81) and/or previous vaginal delivery after cesarean section (OR = 0,17; 95%CI: 0,08-0,35). CONCLUSION: With 47,9% of vaginal delivery after labor induction in women with scar uterus, only 3.8% (n = 7/353) of uterine ruptures, less than 1% APGAR < 7 at 5 min (n = 3/353), induction on scar uterus should be consider in obstetrical practice. Bishop score ≥ 6 and/or previous vaginal delivery after cesarean section are associated to vaginal delivery after labor induction.

Assessment of the self-confidence of obstetrics & gynecology fellows to perform a postpartum hemostasis hysterectomy.

INTRODUCTION: Hemostasis Hysterectomy (HH) is a last resort surgical procedure performed in situations of uncontrolled post-partum hemorrhage in maternity wards. The chances of being confronted with this situation are scarce during residency, and the situation is not well suited for teaching. Nevertheless, every obstetrician-gynecologist can be confronted with this stressful situation, and should therefore possess the surgical competence required, regardless of his routine practice. The aim of the present study is to evaluate clinical exposure and self-awareness concerning HH amongst obstetrics and gynecology residents and fellows. MATERIEL AND METHODS: We performed a survey amongst French obstetrics and gynecology fellows. An anonymous survey was sent by email between December 1, 2020 to July 1, 2021. RESULTS: Half of the interrogated fellows had practiced (as operator) an HH during residency with a senior and only 22,6% in post-residency. During the last year of residency 70% of them had performed less than 10 scheduled hysterectomies as primary operator. The laparoscopic approach was the most frequently practiced. Very few hysterectomies were performed as primary operator. Fellows with a surgical or mixed activity (both gynecological surgery and obstetrical activity in current practice) felt significantly more capable of performing HH compared to those with exclusive obstetrical or reproductive medicine activity; respectively 60% vs 36%, p = 0.008; Odds Ratio: 2.629 (95% CI 1.2214; 5.8094). CONCLUSION: The number of scheduled hysterectomies or HH performed as primary operator is very low during residency or fellowship. It remains largely inferior to the number deemed necessary in previous publications about the learning curve for scheduled hysterectomy, which varies from 18 to 80 interventions. Nowadays, the increasing number of residents, added to the decrease of hemostasis hysterectomies through better management of post-partum hemorrhage, pushes towards the development of specific training, such as "damage control simulation".

Assessment of compliance with a color code protocol for non-elective cesarean section and its impact on time to delivery interval and neonatal outcomes.

INTRODUCTION: We set out to assess the compliance with a cesarean section color code protocol and its impact on maternal and neonatal outcomes since its implementation in our maternity ward. METHODS: This was a retrospective study including a sample of 200 patients per year who underwent a non-elective cesarean section delivery in Rennes University Hospital from January 1, 2015 to December 31, 2018. Patients were grouped by year and by color code (red, orange or green). The main outcome was compliance with the protocol (color code in accordance with indication for cesarean section) and compliance with the corresponding decision-delivery interval. Secondary outcomes were maternal and neonatal outcomes. RESULTS: Eight hundred patients were included during the study period. There was no significant difference in patient characteristics over the years. There was a significant improvement in protocol compliance: full compliance increased from 22.4% in 2015 to 76.5% in 2018 (p < 0.0001). The respect of the 15 min decision-delivery interval in red code protocol increased between 2015 and 2018 (p = 0.0020). CONCLUSION: We observed a significant improvement in compliance with the color code protocol between 2015 and 2018 and in the 15 min decision-delivery deadline for the red code.

Predictive value of head-perineum distance measured at the initiation of the active second stage of labor on the mode of delivery: A prospective cohort study.

OBJECTIVE: The objective was to assess the predictive value of head-perineum distance measured at the initiation of the active second stage of labor on the mode of delivery. MATERIAL AND METHODS: It was a prospective cohort study in an academic Hospital of Rennes, France, from July 1, 2020 to April 4, 2021 including 286 full-term parturients who gave birth to a newborn in cephalic presentation. A double-blind ultrasound measurement of the head-perineum distance was performed during the second phase of labor within five minutes after the onset of pushing efforts. The primary outcome was the mode of delivery (spontaneous vaginal delivery versus instrumental vaginal delivery or cesarean section). We performed a multivariate analysis to determine the predictive value of the head-perineum distance by adjusting on potential confounders. RESULTS: Overall, 199 patients delivered by spontaneous vaginal delivery, 80 by instrumental vaginal delivery, and seven by cesarean section. The head-perineum distance measured at the beginning of pushing efforts was predictive of the mode of delivery with a threshold at 44 mm (crude: sensitivity = 56.8 % and specificity = 79.3 %; adjusted: sensitivity = 79.4 % and specificity = 87.4 %). The risk of medical intervention was higher when the head-perineum distance is>44 mm with an adjusted OR of 2.78 [1.38; 5.76]. CONCLUSION: The head-perineum distance measured at the initiation of the active second stage of labor is predictive of the mode of delivery. Head-perineum distance below 44 mm predicts a vaginal delivery with the best diagnostic performance, and optimizes the time to start pushing efforts.

Physical environment of the operating room during cesarean section: A systematic review.

INTRODUCTION: Environmental factors in the operating room during cesarean sections are likely important for both women/birthing people and their babies but there is currently a lack of rigorous literature about their evaluation. The principal aim of this study was to systematically examine studies published on the physical environment in the obstetrical operating room during c-sections and its impact on mother and neonate outcomes. The secondary objective was to identify the sensors used to investigate the operating room environment during cesarean sections. METHODS: In this literature review, we searched MEDLINE a database using the following keywords: Cesarean section AND (operating room environment OR Noise OR Music OR Video recording OR Light level OR Gentle OR Temperature OR Motion Data). Eligible studies had to be published in English or French within the past 10 years and had to investigate the operating room environment during cesarean sections in women. For each study we reported which aspects of the physical environment were investigated in the OR (i.e., noise, music, movement, light or temperature) and the involved sensors. RESULTS: Of a total of 105 studies screened, we selected 8 articles from title and abstract in PubMed. This small number shows that the field is poorly investigated. The most evaluated environment factors to date are operating room noise and temperature, and the presence of music. Few studies used advanced sensors in the operating room to evaluate environmental factors in a more nuanced and complete way. Two studies concern the sound level, four concern music, one concerns temperature and one analyzed the number of entrances/exits into the OR. No study analyzed light level or more fine-grained movement data. CONCLUSIONS: Main findings include increase of noise and motion at specific time-points, for example during delivery or anaesthesia; the positive impact of music on parents and staff alike; and that a warmer theatre is better for babies but more uncomfortable for surgeons.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]. / Examen pelvien en gynécologie et obstétrique : recommandations pour la pratique clinique.

OBJECTIVE: To provide guidelines for the pelvic clinical exam in gynecology and obstetrics. MATERIAL AND METHODS: A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology. RESULTS: The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature. CONCLUSIONS: The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Trial of Labor Compared With Elective Cesarean Delivery for Low-Lying Placenta.

OBJECTIVE: To compare outcomes of women with low-lying placenta by planned mode of delivery and distance from the internal os distance. METHODS: Six tertiary maternity hospitals in France participated in this retrospective multicenter study of births from 2007-2012. Women with low-lying placenta , defined as an internal os distance of 20 mm or less, who gave birth after 35 weeks of gestation were included and classified in the planned trial-of-labor or elective cesarean delivery groups. The primary endpoint was severe postpartum hemorrhage (PPH) defined as blood loss exceeding 1,000 mL. Secondary outcomes were composite variables of severe maternal and neonatal morbidity. We used multivariable logistic regression and propensity scores to compare outcomes by planned mode of delivery. RESULTS: Among 128,233 births during the study period, 171 (0.13%) women had low-lying placenta: 70 (40.9%) in the trial-of-labor group and 101 (59.1%) who underwent elective cesarean delivery. The rate of severe PPH was 22.9% (16/70, 95% CI 13.7-34.4) for the trial-of-labor group and 23.0% (23/101, 95% CI 15.2-32.5) for the cesarean delivery group ( P =.9); severe maternal and neonatal morbidity rates were likewise similar (2.9% vs 2.0% [ P =.7] and 12.9% vs 9.9% [ P =.5], respectively). Trial-of-labor was not significantly associated with a higher rate of severe PPH after multivariable logistic regression and propensity score-weighted analysis (adjusted odds ratio [aOR] 1.42, 95% CI 0.62-3.24 [ P =.4]; and aOR 1.34, 95% CI 0.53-3.38 [ P =.5], respectively). The vaginal delivery rate in the trial-of-labor group was 50.0% (19/38) in those with an internal os distance of 11-20 mm and 18.5% (5/27) in those with a distance of 1-10 mm. CONCLUSION: Our results support a policy of offering a trial of labor to women with low-lying placenta after 35 weeks of gestation and an internal os distance of 11-20 mm. An internal os distance of 1-10 mm reduces the likelihood of vaginal birth considerably, compared with 11-20 mm, but without increasing the incidence of severe PPH or severe maternal morbidity.