Is homecare management associated with longer latency in preterm premature rupture of membranes?

PURPOSE: According to national guidelines, conventional management of preterm premature rupture of membranes (PPROM) is hospitalization until induction. Outpatient management could be another option. Our objective was to compare latency period between patients managed in hospital versus outpatients. METHODS: A retrospective before/after monocentric study that occured from 2002 to 2015. Were included all patients with PPROM prior to 35 weeks with homecare inclusion criteria. The primary outcome measure was to study length of latency period (delay between PPROM and delivery). Second outcome measures were maternal and perinatal morbidities and mortalities. RESULTS: Among the 395 women included after PPROM, 191 were managed as outpatients and 204 in hospital. In the outpatient group, the length of latency period was longer than in the inpatient group [39 (IQR 20 to 66) versus 21 (IQR 13 to 42) days; p < 0.001]. Clinical chorioamnionitis was observed in 30 (15.7%) in outpatient group versus 49 (24.0%) in inpatient group (p = 0.039). Concerning neonatal outcome, there were less neonatal transfer (49.2% versus 77.2%, p < 0.001), less respiratory distress syndrome (29.4% versus 47.5%; p < 0.001), less neonatal sepsis (13.9% versus 22.1%; p = 0.037), less bronchodysplasia (2.7% versus 9.8%; p = 0.004), and less pulmonary arterial hypertension (4.8% versus 10.3%; p = 0.040) in the outpatient group than in the inpatient group. CONCLUSION: Home management seems to be a safe option to hospitalization in selected patients with PPROM. However, a randomized study would be required to approve those results.

Does an intrauterine exchange transfusion improve the fetal prognosis in parvovirus infection cases?

BACKGROUND: Almost 20% of parvovirus B19 foetal infections require intrauterine transfusions. In addition, myocardial dysfunction has been observed in severe parvovirus B19 infections. One objective of an intrauterine exchange transfusion (IUET) is to avoid an overload during the transfusion. Our aim was to study the obstetrical and neonatal outcomes in cases of IUETs performed for foetal parvovirus infections and to compare our survival rate to those studies in which simple in utero transfusions were chosen. STUDY DESIGN AND METHODS: This was a retrospective monocentre study of all patients followed up for parvovirus B19 infections in which IUETs were performed. An IUET was indicated when foetal hydrops was observed and/or when severe foetal anaemia was diagnosed though an elevation in the middle cerebral artery peak systolic velocity. The characteristics of each pregnancy and the neonatal outcomes were studied until hospital discharge. RESULTS: Thirty-five IUETs were performed in 26 foetuses. The median gestational age of the first IUET was 22.6 weeks. Only one foetal bradycardia incidence was recorded during the procedure. Three medical pregnancy terminations were observed in our series, secondary to severe cerebral anomalies confirmed in the magnetic resonance imaging. Five in utero deaths occurred, in which 2 of the foetuses underwent multiple IUETs. All the neonates had normal haemoglobin levels at birth, and none were transferred to the neonatal intensive care unit. The overall survival rate was 70%. CONCLUSION: IUETs exhibit a survival rate similar to that of simple intrauterine transfusions in foetal parvovirus infection cases.

Prognosis for deliveries in face presentation: a case-control study.

PURPOSE: To estimate the maternal and fetal prognosis for attempted vaginal deliveries of fetuses in face compared with vertex presentations. To evaluate the factors associated with a cesarean during labor for fetuses in face presentation. METHODS: This case-control study collected all the cases of face presentation in a university hospital level-3 maternity ward between 22 and 42 weeks of gestation over a 16-year period. For each case, we selected three control cases with vertex presentations delivered the same day. Cesareans before labor were excluded. RESULTS: We compared 60 attempted vaginal deliveries of fetuses in face presentation with 174 of fetuses in vertex presentation. The cesarean rate during labor was more than three times higher for the face presentations (31.7 vs 9.2%, P < 0.0001). Arterial pH values and Apgar scores were similar in both sets of newborns. After logistic regression, the factors associated with a cesarean during labor were nulliparity and early diagnosis of the presentation (i.e., before 5 cm dilatation). The initial position (mentum-anterior vs. transverse or posterior) was not significantly associated with the mode of delivery. CONCLUSIONS: In face presentations, attempted vaginal delivery triples the cesarean risk. Nonetheless, more than two-thirds of these women give birth vaginally without any impairment of neonatal condition.

[Reprint of: Severe pre-eclampsia: guidelines for clinical practice from the French Society of anesthesiology and intensive care (SFAR) and the French College of gynaecologists and obstetricians (CNGOF)]. / Republication de : recommandations formalisées d'experts. Prise en charge de la patiente avec une pré-éclampsie sévère­RFE communes Société française d'anesthésie-réanimation (SFAR)­Collège national des gynécologues et obstétriciens français (CGNOF).

OBJECTIVE: To provide national guidelines for the management of women with severe preeclampsia. DESIGN: A consensus committee of 26 experts was formed. A formal conflict of interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles 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 last SFAR and CNGOF guidelines on the management of women with severe preeclampsia was published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analyzed according to the GRADE® methodology. RESULTS: The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1±), 9 have a moderate level of evidence (GRADE 2±), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. CONCLUSIONS: There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe preeclampsia.

[Use of the SBAR tool: Assessment of the value of a short training course on the quality of communication between caregivers in the short and long term]. / Utilisation de l'outil SAED : évaluation de l'intérêt d'une formation courte sur la qualité de la communication entre soignants à court et à long terme.

OBJECTIVES: Communication breakdown is one of the main causes of adverse events in clinical routine. The main objective of this study was to assess whether a short training course on medical communication based on the situation-background-assessment-recommendation (SBAR) tool improved the quality of communication in clinical practice. METHODS: Interventional study, conducted at the Jeanne de Flandre maternity unit (Lille University Hospital, France) between January 2017 and December 2019. The training sessions lasted 1 hour and consisted of a theoretical part, based on the SBAR tool, and of a practical part (video-stimulated recall and role-play case scenarios). The main outcome measure was the evaluation of the quality of the telephone calls made by a caregiver to the on-call doctor, using a questionnaire completed before (Q1) and remotely from training (Q2). RESULTS: One hundred and twenty health professionals were trained (n=120). Following the trainings, there was an improvement in communication in the short term, whether in terms of relevance (64.9 vs. 52.6, P<0.001) or conciseness of the message (36.9 vs. 32.2, P<0.001), but also in terms of long-term in a real clinical situation (Q2: 3.9 vs. Q1: 3.0, P<0.001). Finally, 81% of participants were satisfied with the training. CONCLUSIONS: Short training sessions on communication based on the SBAR tool appeared to improve participants' knowledge and skills in the short-term, but also in the longer term in a real clinical situation.

[Perinatal issues of biamniotic twin pregnancies depending on gestational ages of selective termination]. / Issues périnatales des grossesses gémellaires bichoriales biamniotiques selon le terme de réalisation des interruptions sélectives de grossesses.

OBJECTIVES: A severe fetal abnormality is found in 1-2% of biamniotic twin gestations leading to the dilemma of expectative management or selective termination of the defective fetus. The primary objective of our study was to determinate the relationship between perinatal outcomes and gestational ages of selective termination. METHODS: We conducted a single-center retrospective and observational study which reviewed 58 biamniotic twin pregnancies that underwent selective termination for discordant fetal anomalies between January 2006 and September 2017. Fetal anomalies, ages of diagnostic and selective termination, perinatal outcomes were noted. RESULTS: Selective terminations realised before 20 weeks (group A) were complicated by 8,7% of fetal loss and 28,6% of prematurity, of which 14,3% before 32 GA. In group B (selective termination planned between 20 and 32 weeks), there was no fetal loss but 40% of prematurity of which 13,3% before 32 GA. In group C (selective termination planned after 32 weeks), there was no fetal loss, but 42,1% of prematurity, and one birth before 32 GA (5%). CONCLUSIONS: Gestational age of a selective termination should be determined together with the parents, after informing them about the risks and technical difficulties at each gestational age.

[Overview of induction of labor practices in France]. / État des lieux des pratiques de déclenchement en France.

OBJECTIVE: To describe induction of labor practices in France and to identify factors associated with the use of different methods. METHODS: The data came from the French prospective population-based cohort MEDIP (MEthodes de Déclenchement et Issues Périnatales), including consecutively during one month in 2015 all women with induction of labor and a live fetus in 7 perinatal networks. The characteristics of women, maternity units, gestational age, Bishop's score, decision mode, indication and methods of labor induction were described. Factors associated with the use of different methods were sought in univariate analyzes. RESULTS: The rate of induction of labor during the study was 21% and 3042 women were included (95.9% participation rate). The two main indications were prolonged pregnancy (28.7%) and premature rupture of the membranes (25.4%). More than one-third of women received intravenous oxytocin in first method, 57.3% prostaglandins, 4.5% balloon catheter and 1.4% another method. Among the prostaglandins, the vaginal device of dinoprostone was the most used (71.6%) then the gel (20.7%) and the vaginal misoprostol (6.7%). Women with a balloon were more often of higher body mass index and multiparous with scarred uterus. The balloon and misoprostol were mainly used in university public hospitals. CONCLUSIONS: The evolution of induction of labor methods, due to new data from the literature and the development of new drugs or devices, invites to regularly repeat population-based studies on induction of labor.

[Placenta accreta: diagnosis and management in a French type-3 maternity hospital]. / Placenta accreta: diagnostic et prise en charge Etat des lieux dans une maternité de type 3.

OBJECTIVE: Placenta accreta is a rare obstetrical pathology but leads to a high morbidity. It is likely to become increasingly frequent as the rate of cesarean section increases in developed countries. The aim of our study was to describe the diagnostic and management of patients with placenta accreta, during the last ten years, in a French high-level maternity. MATERIAL AND METHOD: This is a retrospective study of the prenatal diagnosis and management of placenta accreta with histological confirmation in our department between 1996 and 2006. RESULTS: The rate of placenta accreta in our study was 0.52 per thousand. Ninety-six percent of the patients had risk factors for placenta accreta. Placenta accreta was diagnosed in 24% of the patients by sonographic examination. Magnetic resonance imaging did not increase sensitivity. Eighty-eight percent of the patients required a hysterectomy. No digestive or urinary complications occurred. There were no maternal deaths. CONCLUSION: Despite established ultrasound and MRI-based diagnostic criteria for placenta accreta, this condition remains difficult to diagnose in the general population. Morbidity associated with this pathology is serious, especially in cases of hemostatic hysterectomy. When placenta accreta is diagnosed prior to delivery, care in a high-level maternity hospital must be considered to improve management.

[Cervical ripening and labor induction: Evaluation of single balloon catheter compared to double balloon catheter and dinoprostone insert]. / Méthodes de maturation cervicale et déclenchement du travail : évaluation de la sonde simple ballonnet comparée à la sonde double ballonnet et aux prostaglandines.

OBJECTIVE: To compare the effectiveness of single balloon catheter with double balloon catheter and dinoprostone insert for cervical ripening and labor induction on unfavourable cervix. METHODS: this is a comparative, retrospective, one-center trial. Were included singleton pregnancy in cephalic presentation. Were excluded cicatricial uterus. The outcomes were vaginal delivery rate, caesarean section rate, modification in Bishop score, time from induction to delivery, second time prostaglandin E2 resort, oxytocin administration resort, maternal or neonatal adverse events. RESULTS: Were included 108 patients: 45 in single balloon catheter group, 32 in double balloon catheter group, 31 in dinoprostone insert group. Vaginal delivery rate was similar in single balloon catheter group (78 %) compared with others groups (75 % in double balloon catheter and 71 % in dinoprostone insert group respectively). Oxytocin administration resort was superior in single balloon catheter group. There was no significant difference on others outcomes. Labor induction costs were 9euros in single balloon catheter group, versus 55 and 81 euros in double balloon catheter group and dinoprostone insert group respectively. CONCLUSIONS: Single balloon catheter seems just as effective as double balloon catheter and dinoprostone insert with its major asset the low cost for labor induction.

Labour induction practices in France: A population-based declarative survey in 94 maternity units.

INTRODUCTION: In 2016, 22.0% of deliveries in France were induced. The current lack of high level of evidence data about the methods and indications for induction of labour has promoted heterogeneous and non-recommended practices. The extent of these different practices is not adequately known in France today, although they may influence perinatal outcomes. The objective of this study was to report current practices of induction of labour in France. MATERIAL AND METHODS: This study surveyed 94 maternity units in seven perinatal networks. A questionnaire was sent by email to either the department head or delivery room supervisor of these units to ask about their methods for induction and their attitudes in specific obstetric situations. RESULTS: The rate of induction varied between maternity units from 7.7% to 33% of deliveries. Most units used two (39.4%) or three or more (35.1%) agents for cervical ripening. In all, 87 (92.6%) units reported using dinoprostone as a vaginal slow-released insert, 59 units dinosprostone as a vaginal gel (62.8%) and 46 units a balloon catheter (48.9%). Only three units reported using vaginal misoprostol. Inductions without medical indication were reported by 71 (75.5%) maternity units, and 22 (23.4%) units even when the cervix was unfavourable. Obstetric attitudes in cases of breech presentation, previous caesareans, fetal growth restriction or macrosomia and prelabour rupture of the membranes varied widely. DISCUSSION: The variability of practices for induction of labour and the persistence of disapproved practices call for an assessment of the effectiveness and the safety of the different strategies.

[Acute per-partum feto-fetal transfusion. A case study on two sets of twins]. / La transfusion foeto-foetale per-partum: à propos de deux observations.

Description of acute per-partum feto-fetal transfusion. The risk of twin-twin transfusion syndrome in monochorionic twin pregnancies is well known. This pathology starts in the second trimester and has a chronic course. Acute per-partum feto-fetal transfusion seems to be less frequent and has not been studied. In the study, we described two cases of acute per-partum feto-fetal transfusion. The outcomes of the pregnancies were as follows: following a successful delivery, the first set of twins presented hypovolemic shock at birth due to an acute anemia. The second set of twins was polyglobulic, but otherwise healthy at birth. The risk of hypovolemic shock seems to be unpredictable, even if the pregnancy is monitored. Obstetricians and pediatricians must keep this pathology in mind when dealing with this kind of pregnancy. Moreover, it would be interesting to obtain systematically a full blood count of each set of twins of monochorionic pregnancies, in order to detect every case of feto-oetal transfusion.

Simulation training to teach postpartum hemorrhage surgery to residents.

OBJECTIVE: Description of the aims, the framework and the results of a postpartum hemorrhage surgery workshop for residents. STUDY DESIGN: This article is the first publication to describe a simulation workshop for the surgical management of maternal hemorrhage. Training was divided into both theoretical and practical workshops. Four obstetrician-gynecologists supervised residents who performed all the surgical procedures on a cadaver. This training course included the oldest residents at the Faculty of Medicine of Lille and was evaluated by participants using pre-test and post-test questionnaires. Medical knowledge was also evaluated. RESULTS: The pre-test questionnaire showed that medical knowledge for the treatment of postpartum hemorrhage was acceptable but that real practice was lacking. Eighty-six percent of the residents responded that they were not able deal with the situation correctly and most considered it stressful. The post-test questionnaire showed that training greatly improved the participants' theoretical knowledge and technical skills as well as significantly improving self-confidence. CONCLUSIONS: Based on these positive results this workshop will be included in the resident training program and also be extended to professionals as a part of the continuing medical education program.

[Iconographic imaging (ultrasound/MRI) in prenatal evaluation of cervical cystic lymphatic malformations]. / Bilan iconographique (échographie/IRM) dans l'évaluation anténatale des malformations lymphatiques kystiques cervicales.

OBJECTIVES: Assess imaging (ultrasound±MRI) in the diagnosis of cervical cystic lymphangioma. METHODS: Retrospective, descriptive study of the patients who underwent reference ultrasound screening for fetal anterior cervival masses in multidisciplinary prenatal diagnosis center of the Lille Regional University Hospital from 1997 to 2014. RESULTS: Seventeen lymphangiomas were identified. Seventy-three percent of lymphangiomas (n=12) were diagnosed in the baseline ultrasound and 85% (n=11) in MRI. An extra-cervical extension was identified in 10 (62%) with ultrasound and 11 (85%) with MRI. Main sites of mass extension objectived by ultrasound and MRI were respectively the face (4,23%/6,46%), the base of tongue (3, 18%/2, 15%) and buccal floor (3, 18%/3, 15%). Pharyngeal disease (5,38%) and mandible (4,31%) were detected by MRI and not found on ultrasound. Associated malformations detected with ultrasound were 2 (12%) urogenital malformation, 1 (6%) heart defect and 1 (6%) facial anomalies. Lymphangiomas remained stable in volume in 12 (71%) cases and disappeared before birth in 2 (12%) cases. CONCLUSION: MRI and ultrasound seem inseparable to assess and optimally manage fetal cervical masses. Detection of associated lesions seems to help in the final lymphangioma diagnosis. Most of the time, lymphangiomas seem to be stable lesion during pregnancy and a good prognosis in cases of uncomplicated cervical lymphatic mass and without pejorative extension.

[Preterm rupture of membranes: Is home care a safe management?]. / Rupture prématurée des membranes : peut-on proposer une prise en charge à domicile ?

OBJECTIVE: Compare the maternal and neonatal outcomes in pregnancies complicated by preterm prelabour rupture of membranes (PPROM), which were managed either at home (HAD) or hospital (HC). MATERIALS AND METHODS: Retrospective study in two level III maternities during 2 years. Inclusion criteria in HAD were: singleton pregnancy, PPROM between 24 and 35 weeks of gestation, absence of chorioamnionitis, clinical stability at D7 of the rupture, cervical dilatation <3 cm, patient residing in the geographic area. RESULTS: Thirty-two patients were included in the HAD group and 24 in the HC group. Our populations were similar in the 2 groups. The duration of latency was longer in the HAD group than in the HC group (27.5 d [20-37] versus 16.5 d [12.5 to 29.5]; P=0.026). Patients in the HAD group received fewer antibiotics with a similar rate of chorioamnionitis. No difference in terms of obstetrical and neonatal outcomes was observed. Number of days in neonatal resuscitation was lower in the HAD group than in the HC group (12.5 d [10-22] versus 43 d [20-52]; P=0.003). CONCLUSION: HAD seems to be an alternative to continuous hospitalization for patients followed for PPROM between 24 and 35 weeks. A randomized study with a larger number of patients, including other data such as maternal satisfaction and cost analysis, would be interesting to confirm those preliminary results.

[Twin pregnancy with complete mole and coexisting fetus: Reach fetal viability is possible]. / Grossesse gémellaire avec môle complète et fœtus sain coexistant : atteindre la viabilité fœtale est possible.

Twin pregnancies combining complete hydatidiform mole and coexistent fetus are a rare situation (incidence in 1/20,000 in 1/100,000 pregnancies) and a challenge for diagnosis. Their complications can be important - bleeding, preeclampsia, miscarriage - and their management remains complex and controversial. In case of continuing the pregnancy, nearly 40% of women have lives babies. Three quarters of fetal loss occur before 24weeks gestation. We report here three new cases; only one of these cases had a favorable outcome.

[Adverse effects of calcium channels blockers used as tocolytic treatment]. / Effets indésirables des inhibiteurs calciques utilisés dans le cadre de la tocolyse.

OBJECTIVE: Tocolysis with calcium channel blockers is widespread in France. However, these molecules are off label use for this indication. The objective of this work is to give an update on all the side effects of calcium channel blockers published or reported to the National Bank of Pharmacovigilance. MATERIALS AND METHODS: We conducted a literature review incorporating the animal experimental data on calcium channel blockers, retrospective and prospective studies (randomized or not) comparing different tocolytics, and the published clinical case reports. Finally we inquired the National Bank of Pharmacovigilance for reported cases of adverse effects after use of calcium channel blockers as tocolytics. RESULTS: Adverse effects are found in 2% to 6% of patients after use of nifedipine, of which 0.9% to 1.9% are severe. These are mainly headache, flushes and arterial hypotension. Data on Nicardipine are more limited. For the latter, adverse effects specifically related to the route of administration (induced phlebitis) are described but it seems that other adverse effects reported are not more frequent. Several meta-analyses have demonstrated a decrease in maternal side effects when using calcium channel blockers compared to ß-agonists. Comparison of calcium channel blockers to Atosiban is less documented. More rare serious side effects are reported as clinical cases, consisting almost exclusively of cardiovascular complications (dyspnea, pulmonary edema, myocardial infarction, arterial hypotension). They are more common with Nicardipine than Nifedipine. Similar observations are found by querying the National Bank of Pharmacovigilance. CONCLUSION: The prescription of calcium channel blockers as tocolysis exposes patients to maternal side effects, which are not serious most of the time, and less frequent than with the ß-agonist. Severe maternal complications were nonetheless reported more frequently with Nicardipine than Nifedipine, which justifies avoiding Nicardipine in tocolysis. Nifedipine is the most studied molecule. It is not possible to define a maximum posology from literature data. It seems unreasonable to associate different tocolytics and necessary to closely monitor maternal blood pressure, the occurrence of a skin reaction or hypersensitivity, dyspnea or chest pain during treatment.

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.

[Cervical ripening: is there an advantage for a double-balloon device in labor induction?]. / Maturation cervicale: y a-t-il un avantage à utiliser un double ballonnet pour le déclenchement du travail?

OBJECTIVES: To compare efficiency of a double-balloon to vaginal prostaglandins for cervical ripening in patients with unfavourable cervix. PATIENTS AND METHODS: Fifty patients induced with a double-balloon were compared to 50 patients receiving vaginal prostaglandins. Matching criteria were age, parity, history of uterine scar, gestational age and Bishop score. The primary outcome was failure induction. Secondary outcomes included improvement in Bishop score, ripening-to-delivery interval, caesarean section rate, maternal and neonatal morbidity. RESULTS: Risk of failed induction (16% in the double-balloon group vs. 14% in the prostaglandins group) and caesarean section rate (28% vs. 36%) were similar in the two groups. The proportion of favourable cervix and the time to obtain a better Bishop score were similar with the two methods. Maximal pain score during cervical ripening was significantly lower in the double-balloon group (P<0.001). Ripening-to-delivery interval (30.4 h ± 15.6h vs. 28.9 h ± 20.5h) was not different between the two groups. There was no difference about maternal and neonatal outcomes. DISCUSSION AND CONCLUSION: The double-balloon was as efficient as vaginal prostaglandins. The ripening-to-delivery interval was not different between the two groups. The main advantage of this device could be a better tolerance favourishing patient satisfaction.

[Interpretation of atypical values of maternal serum markers]. / Interprétation des valeurs atypiques des marqueurs sériques.

OBJECTIVES: Prenatal screening was set up to identify patients at high-risk of chromosome 21 trisomy based on maternal serum markers measurement. However, the risk of trisomy 21 should not be the only result considered by obstetricians. In fact, abnormal marker values can be associated with other fetal diseases and used to improve maternal and fetal follow-up. Our objective was therefore to study other predictive values of maternal serum markers. MEANS AND METHODS: A search through publications was conducted using the PubMed® or Cochrane® databases. RESULT: In case of high PAPP-A there is no link with any complications. Second trimester high hCG or first trimester low hCG are associated with an increased vascular risk. High α-fetoprotein level is a marker of neural tube defects or abdominal wall defect. Persistence of high α-fetoprotein with normal echography can suggest other rare fetal diseases. Low maternal serum markers suggests 18 trisomy. Oestriol reflects the fetal hypothalamo-hypophyseal axis and can be used as a diagnosis tool. CONCLUSION: Serum markers could be interesting tools for the identification of high-risk pregnancy and the prevention of neonatal complications. They also appear as a potential help to diagnose certain congenital malformations.

[Links between preeclampsia and intrauterine growth restriction]. / Liens entre prééclampsie et retard de croissance intra-utérin.

OBJECTIVES: Preeclampsia is one of the most frequent and most serious complications of pregnancy. Its occurrence is around 5% of the pregnancies. Its pathophysiology is complex and includes several hypotheses. Preeclampsia is inconsistently associated with intrauterine growth retardation (IUGR). The determinants that explain the variability of this association are unknown. The objective of our study was to identify in a population of French patients who had preeclampsia and/or HELLP syndrome, incidence and risk factors of IUGR to isolate specific characteristics of these women. PATIENTS AND METHODS: We studied 578 pregnant women treated for preeclampsia or HELLP syndrome according to the presence or absence of IUGR (database compiled since 1996). Comparisons between the groups were done with Wilcoxon test (quantitative data) or Fisher's exact test (qualitative data). RESULTS: We found that pre-eclampsia appeared earlier and was more severe in the group with IUGR. In addition foetal issues were more defavorable when IUGR was associated with preeclampsia. CONCLUSION: Combination of IUGR and pre-eclampsia or HELLP syndrome is a criterion of severity for both the mother and the fetus. Our data do not allow distinguishing physiopathological mechanism to explain these differences.