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.).

Anal incontinence after obstetrical anal sphincter injury significantly impacts quality of life for women: a cohort study.

PURPOSE: To assess the prevalence of anal incontinence (AI) after obstetrical anal sphincter injuries (OASIS) and its severity, as well as the risk factors for AI and AI episodes ≥ 6 months. METHODS: This prospective and observational monocentric cohort study included all the women who had an OASIS between 1 January 2005 and 31 December 2019. Information was collected by using a letter informing for the fecal incontinence quality of life (FIQL) questionnaire and by a phone interview. The main outcome measure was "1 passed or ongoing episode of AI". RESULTS: Among the 227 patients included, 19.8% had ongoing AI, and 35.2% had AI passed or ongoing episodes. A total of 46.7% of women with AI reported a change in their quality of life in all fields of the FIQL. Excluding a history of inflammatory bowel disease, no factor was associated with the incidence of an AI episode. Post-obstetrical AI ≥ 6 months (POAI ≥ 6) represented 63.7% of AI cases. This incontinence began with significant incidence in the immediate postpartum period but increased over time, unlike AI < 6 months, which appeared primarily in the immediate postpartum period. Instrumental birth was a protective factor for POAI ≥ 6 (OR = 0.24; CI 95% [0.08-0.78]; p = 0.016), while an increase in parity and BMI were risk factors for POAI ≥ 6 (OR = 4.21; CI 95% [1.01-17.71]; p = 0.05 and OR = 1.15; CI 95% [1.03-1.30]; p = 0.016, respectively). CONCLUSION: The prevalence of AI after OASIS is not underestimated. Despite the fact that women do not seek care, the impact of AI on the quality of life is significant. A case of AI that lasts for 6 months after giving birth risks becoming chronic. Therefore, specialist advice should be recommended in this case. CLINICAL TRIAL REGISTRY: NCT04940494.

Operative Hysteroscopy vs Vacuum Aspiration for Incomplete Spontaneous Abortion: A Randomized Clinical Trial.

Importance: Vacuum aspiration is commonly used to remove retained products of conception in patients with incomplete spontaneous abortion. Scarring of the uterine cavity may occur, potentially impairing future fertility. A procedural alternative, operative hysteroscopy, has gained popularity with a presumption of better future fertility. Objective: To assess the superiority of hysteroscopy to vacuum aspiration for subsequent pregnancy in patients with incomplete spontaneous abortion who intend to have future pregnancy. Design, Setting, and Participants: The HY-PER randomized, controlled, single-blind trial included 574 patients between November 6, 2014, and May 3, 2017, with a 2-year duration of follow-up. This multicenter trial recruited patients in 15 French hospitals. Individuals aged 18 to 44 years and planned for surgery for an incomplete spontaneous abortion with plans to subsequently conceive were randomized in a 1:1 ratio. Interventions: Surgical treatment by hysteroscopy (n = 288) or vacuum aspiration (n = 286). Main Outcomes and Measures: The primary outcome was a pregnancy of at least 22 weeks' duration during 2-year follow-up. Results: The intention-to-treat analyses included 563 women (mean [SD] age, 32.6 [5.4] years). All aspiration procedures were completed. The hysteroscopic procedure could not be completed for 19 patients (7%), 18 of which were converted to vacuum aspiration (8 with inability to completely resect, 7 with insufficient visualization, 2 with anesthetic complications that required a shortened procedure, 1 with equipment failure). One hysteroscopy failed due to a false passage during cervical dilatation. During the 2-year follow-up, 177 patients (62.8%) in the hysteroscopy group and 190 (67.6%) in the vacuum aspiration (control) group achieved the primary outcome (difference, -4.8% [95% CI, -13% to 3.0%]; P = .23). The time-to-event analyses showed no statistically significant difference between groups for the primary outcome (hazard ratio, 0.87 [95% CI, 0.71 to 1.07]). Duration of surgery and hospitalization were significantly longer for hysteroscopy. Rates of new miscarriages, ectopic pregnancies, Clavien-Dindo surgical complications of grade 3 or above (requiring surgical, endoscopic, or radiological intervention or life-threatening event or death), and reinterventions to remove remaining products of conception did not differ between groups. Conclusions and Relevance: Surgical management by hysteroscopy of incomplete spontaneous abortions in patients intending to conceive again was not associated with more subsequent births or a better safety profile than vacuum aspiration. Moreover, operative hysteroscopy was not feasible in all cases. Trial Registration: ClinicalTrials.gov Identifier: NCT02201732.

Does hyaluronic acid gel reduce intrauterine adhesions after dilation and curettage in women with miscarriage? A Multicentric randomized controlled trial (HYFACO Study).

BACKGROUND: Miscarriage is a frequent problem that requires dilation and curettage in 30% of cases. This routine surgery may lead to intrauterine adhesions and severe infertility. Hyaluronic acid gel is known to reduce intrauterine adhesions after hysteroscopic surgery. OBJECTIVE: This study aimed to evaluate the rate of intrauterine adhesions after dilation and curettage for miscarriage with and without hyaluronic acid gel. STUDY DESIGN: This was a multicentric (9 hospitals in France), prospective, open-label randomized trial. Patients who had a miscarriage between weeks 7 and 14 of gestation, required dilation and curettage, and wanted another pregnancy were eligible for the study. Women were randomly assigned in a 1:1 ratio to surgery alone (control group) or surgery with intrauterine instillation of hyaluronic acid gel (gel group). An office hysteroscopy was planned at 6 to 8 weeks after surgery. The primary endpoint was the rate of intrauterine adhesions during this office follow-up hysteroscopy. Two different follow-up fertility surveys were sent at 6 months and 1 year after the end of the intervention, respectively. RESULTS: Among the 343 patients who had curettage, 278 had hysteroscopy. After multiple imputation, the rate of intrauterine adhesions was lower in the gel group than in the control group (9.1% vs 18.4%, respectively; P=.0171). Among the 110 responders to the surveys, the overall pregnancy rate at 12 months after surgery was 64.5% (71/110), and similar in both groups (57.4% [27/47] in the control group vs 69.8% [44/63] in the gel group; P=.1789). CONCLUSION: Intrauterine instillation of hyaluronic acid gel reduces the rate of intrauterine adhesions in women treated with dilation and curettage for miscarriage.

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.

The experience of giving birth: a prospective cohort in a French perinatal network.

BACKGROUND: To assess women's positive and negative perceptions after giving birth. The secondary objectives were to identify the women who had a negative perception of their delivery, define the risk factors, and propose actions that maternity units can take to improve their management. METHODS/DESIGN: This study was a multicenter, prospective cohort, conducted in 23 French maternity units constituting one perinatal network, in 2019. All adult women who understood French and gave birth between February 1 and September 27, 2019, were eligible. The exclusion criterion was the woman's objection to participation. Validated self-administered questionnaire (QACE) was sent by email 6 weeks after the child's birth. The main outcome was the experience of childbirth, assessed on a scale of 0 to 10. A good experience was defined by a score ≥ 8/10, and a poor experience by a score < 5. A multinomial logistic regression model, expressed by cumulative proportional odds ratios, were used to determine the factors that might have affected women's experiences during childbirth. RESULTS: Two thousand one hundred and thirty-fifth women completed the questionnaire, for a participation rate of 49.6%. Overall, 70.7% (n = 1501/2121) of the women reported a good experience, including 38% (n = 807/2121) who graded their experience with the maximum score of 10. On the other hand, 7.3% (n = 156) of the women reported a poor experience. Vaginal delivery (aOR 3.93, 95%CI, 3.04-5.08) and satisfactory management (aOR 11.35 (7.69-16.75)) were the principal determining factors of a positive experience. Epidural analgesia increased the feeling of failure (aOR 5.64, 95%CI, 2.75-13.66). Receiving information and being asked for and agreeing to consent improved the global experience (P = 0.03). CONCLUSION: The Identikit picture of the woman associated with a poor experience of childbirth shows a nullipara who had a complication during her pregnancy, gave birth after induction of labor, or by cesarean or operative vaginal delivery, with the newborn transferred for pediatric care, and medical management considered unsatisfactory.

Efficacy of In Situ Methotrexate Injection in the Treatment of Nontubal Ectopic Pregnancies: A Retrospective Multicenter Study.

STUDY OBJECTIVE: Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies. DESIGN: Retrospective multicenter study. SETTING: Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic. PATIENTS: A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic. INTERVENTIONS: Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS + IM group). MEASUREMENTS AND MAIN RESULTS: The main end point of this study was measured via the primary success rate (defined as a negative ß-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS + IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio = 2.7; 95% confidence interval, 1.03-7.14). CONCLUSION: Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.

Prevalence and phenotype of eating disorders in assisted reproduction: a systematic review.

BACKGROUND: Eating disorders (EDs) are common conditions that mainly affect women of reproductive age and have a major impact on fertility. Our systematic review focuses on the prevalence of EDs in patients in the process of assisted reproductive technique (ART) and describes the phenotypes of EDs identified. METHODS: Our systematic review is based on the PRISMA criteria. Articles were collected using the Medline/Pubmed, Web Of Science and Cochrane databases. The articles chosen had to mention the prevalence of ED in infertile patients undergoing ART and be cohort or case-control studies assessing the prevalence of ED during fertility treatment. MAIN FINDINGS: Fifteen articles were included in this review. The prevalence of active ED varied between 0.13 and 44% depending on the types considered in each study. The main phenotypes described were EDNOS (eating disorder not otherwise specified) and binge eating disorders (BED) occurring in women with a normal body mass index (BMI) and a history of ED. Mainly subthreshold forms with cognitive distortions were described. CONCLUSION: This review highlights a 6 times higher prevalence of EDs in infertile patients undergoing fertility treatment compared to regular pregnant women. However, diagnosing these conditions is complex. As a result, it is essential that professionals in contact with this population are alert to symptoms consistent with these conditions in order to refer them to specialized psychiatric care.

Eating disorders are frequent pathologies that primarily affect women of childbearing age. Numerous articles reveal an increased risk for the mother and the child in case of an active disorder during pregnancy.We conducted a systematic review to determine the prevalence and phenotypes of eating disorders in infertile subjects undergoing fertility treatment.The results of the fifteen articles included show a prevalence six times higher than in pregnant women in the general population. Subjects with eating disorders have normal body mass indexes. The active forms are mainly characterized by episodes of binge eating disorders or other unspecified forms. Studies also describe incomplete forms characterized by the presence of dysfunctional thoughts around shape and weight without associated compensatory behavior.Professionals working in the field of reproductive medicine and providing fertility treatment have a major role to play in identifying and referring these subjects at risk to specialized care.

Evolution of anisotropic diffusion in two-dimensional heterogeneous environments.

We consider a system of two competing populations in two-dimensional heterogeneous environments. The populations are assumed to move horizontally and vertically with different probabilities, but are otherwise identical. We regard these probabilities as dispersal strategies. We show that the evolutionarily stable strategies are to move in one direction only. Our results predict that it is more beneficial for the species to choose the direction with smaller variation in the resource distribution. This finding seems to be in agreement with the classical results of Hastings (1983) and Dockery et al. (1998) for the evolution of slow dispersal, i.e. random diffusion is selected against in spatially heterogeneous environments. These conclusions also suggest that broader dispersal strategies should be considered regarding the movement in heterogeneous habitats.

Benefits of an oocyte pickup simulation training program using a high-fidelity simulator (PickUpSimTM) for obstetrics and gynaecology residents: an observational survey study.

The aim of this study was to evaluate an oocyte pick-up (OPU) simulation training program for residents using the high fidelity PickUpSimTM (Accurate, Cesena, Italy) simulator. The authors carried out an observational study during an OPU simulation workshop. A successful scenario was defined as an oocyte retrieval rate ≥70% without any complications. Forty-six residents affiliated to 23 different French university hospitals were included, and 37/46 (80.4%) of them successfully completed the scenario with a mean time of 3.4 ± 1.1 minutes. The oocyte retrieval rate was 442/561 (78.8%). All residents found training beneficial and 41/46 (87%) were in favour of having simulation-based training programs for OPU in their reproductive medicine departments. All residents who had previous experience with OPU (11/11) recommended the use of a simulator before performing OPU. This study confirms that high-fidelity OPU simulation is a simple and efficient method for training residents.Impact statementWhat is already known on this subject? Simulator-based training has been shown to be effective and useful for oocyte pick-up (OPU) training.What the results of this study add? All residents found the simulation program beneficial and formative, with 80% successfully completing their scenarios in a mean time of 3.4 ± 1.1 minutes. All residents who had previous experience with OPU recommended the use of a simulator before performing OPU.What the implications are of these findings for clinical practice and/or further research? Prospective studies are needed to confirm the short- and long-term positive clinical impact of OPU simulation training programs.

Incidence and remission of stress, urge, and mixed urinary incontinence in midlife and older women: A longitudinal cohort study.

AIMS: To analyze factors related to the incidence and remission of stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI) among women at midlife. METHODS: A total of 2115 women participants in a prospective longitudinal survey (GAZEL cohort) were included. In 2000 and 2008, a specific questionnaire about urinary incontinence (UI) symptoms was sent to all participants. Incidence, remission, and risk factors associated with each type of UI were considered. RESULTS: Within our population followed up for 8 years, we observed an overall incidence rate of UI of 21.9% (95% CI, 19.6-24.2%) and a remission rate of 33.3% (30.1-36.5%). For the different UI types, the incidence and remission rates were respectively 14.9% (12.9-24.2%) and 37.9% (37.8-42.0%) for SUI, 3.2% (2.2-4.2%) and 25.5% (3.5-37.5%) for UUI, 3.1% (2.1-4.1%) and 24.6% (19.3-29.9%) for MUI. Educational level, increase in body mass index (BMI), BMI and depression at inclusion were associated with SUI incidence. The history of surgery for UI was associated with the incidence of UUI and MUI. Surgery for SUI was significantly associated with remission, while pelvic floor rehabilitation and vaginal delivery were significantly associated with a lower SUI remission. Vaginal delivery was also negatively associated with MUI remission. CONCLUSIONS: The influence of the standard risk factors seems to differ in each type of UI.

Perioperative outcomes using LigaSure compared with conventional technique in peripartum hysterectomy.

OBJECTIVE: To evaluate the use of new bipolar vessel sealing system like LigaSure™ compared to the standard surgical technique (suture) during emergency peripartum hysterectomy (EPH). METHODS: A retrospective observational bicentric study was conducted from February 2005 to August 2018 in the maternity wards of the University Hospital of Toulouse and Angers. All EPHs performed up to 24 h after delivery were included. The main outcome was the total blood loss. Secondary outcomes were operating time, number of blood transfusions, per and postoperative complications. A subgroup analysis was performed between hysterectomies performed in emergency and scheduled hysterectomies. RESULTS: Among 111,266 deliveries, 86 women (0.07%) underwent EPH, 29 were operated upon with LigaSure™, 57 with the traditional technique. In the LigaSure™ arm, there were statistically lower blood loss (3198 mL vs 4223 mL, p = 0.02), fewer blood transfusions (62.1% vs 94.7%, p = 0.0003, confirmed in subgroup analysis), and fewer perioperative complications (8.3% vs 45.5%, p = 0.04) for scheduled hysterectomies. CONCLUSION: Bipolar vessel sealing systems such as LigaSure™ are a surgical instrument, easy to use for the surgeon, with an interest in the management of EPH, particularly for total blood loss, transfusions, and intraoperative complications.

Metabolomics shows no impairment of the microenvironment of the cumulus-oocyte complex in women with isolated endometriosis.

RESEARCH QUESTION: Is there any metabolomic evidence of impairment of the cumulus-oocyte complex (COC) microenvironment in the follicular fluid of women with endometriosis? DESIGN: A prospective observational study from January to July 2018 at the Angers University Hospital, France. Seventy-nine women undergoing IVF with or without intracytoplasmic sperm injection (ICSI) were included: 39 for endometriosis-related infertility and 40 controls with other causes of infertility. A targeted quantitative metabolomic and lipidomic analysis was performed. RESULTS: Patient characteristics (age, body mass index, smoking status, hormonal profile and ovarian reserve markers) were comparable between the endometriosis and the control groups. There was no significant difference in the cumulative FSH dose used for stimulation between the endometriosis and the control groups (2732 versus 2257 IU, respectively). There were no differences in the oocyte maturity rates (72.2% versus 77.7%), or in the fertilization rates in IVF and ICSI (49.4% versus 50.2% and 76.4% versus 68.8%, respectively) between the endometriosis and control groups. Among the 188 metabolites analysed, 150 were accurately measured. Univariate analysis did not reveal any significant modification of metabolite concentrations, and none of the multivariate models discriminated between the two groups of patients, even when the study was restricted to the most severe form of endometriosis. CONCLUSIONS: No specific metabolomic signature of endometriosis was found in the follicular fluid of women undergoing IVF. These results suggest that there is no microenvironmental impairment of the COC in cases of isolated endometriosis among women with infertility.

Timing therapeutic donor inseminations in natural cycles: human chorionic gonadotrophin administration versus urinary LH monitoring.

This cohort study assessed whether timing therapeutic donor sperm inseminations (TDI) in natural cycles (NC) using ultrasound monitoring and ovulation trigger with human chorionic gonadotrophin (US/HCG) improves cumulative live birth rates (LBR) compared with detection of LH surge with urinary kits (u-LH). It included 232 normo-ovulatory women aged ≤40 years, undergoing 538 TDI in NC between 2011 and 2014. In the u-LH group (113 women, 267 cycles), TDI was performed the day following a positive test. In the US/HCG group (119 women, 271 cycles), ovulation was triggered with HCG when a follicle ≥17 mm was noted, and TDI performed 36 h later. The first three cycles were analysed per patient. Groups were comparable for baseline characteristics. Cumulative LBR were comparable between u-LH and US/HCG groups (31.47% versus 23.11%, respectively) (log-rank test). A generalized estimating equation analysis was performed to compare outcomes per cycle. The LBR per started cycle was comparable between the u-LH and US/HCG groups (12.4% versus 9.2%, respectively). Cancellation rate was significantly higher with u-LH (19.1% versus 11.4%, P = 0.011), but did not impact overall outcomes. In conclusion, urinary LH monitoring is as effective as ultrasound monitoring and ovulation trigger with HCG in TDI performed in NC.

Assessment of Abdominal Ultrasound Guidance in Hysteroscopic Metroplasty.

STUDY OBJECTIVES: To compare the rates of re-intervention, and immediate and later complications associated with abdominal ultrasound-guided versus unguided hysteroscopic metroplasty in the surgical repair of European Society of Human Reproduction and Embryology/European Society for Gynecological Endoscopy class II intrauterine septa. DESIGN: We performed a large observational retrospective study (Canadian Task Force Classification II-2) in a selection of patients who underwent metroplasty in a tertiary university center between 2009 and 2013. PATIENTS: A total of 108 patients were included in the study. INTERVENTIONS: Patients were categorized as having abdominal ultrasound-guided metroplasty (n = 46) or unguided metroplasty (n = 62). MEASUREMENTS AND MAIN RESULTS: Data were collected with regard to medical and reproductive histories, diagnosis of septate uterus, surgical procedures, and complications. Using these data, the need for re-intervention and complication rates were compared between groups. Statistical analysis was performed using Fisher's exact test and Student's t-test. The characteristics of the 2 groups were comparable. A persistent septum of >10 mm, defined by 3-dimensional ultrasound hysterosonography, with a need for re-intervention, was found in 16 patients (39.0 %) in the unguided group versus 7 patients (18.4 %) in the ultrasound guidance group (p = .04). Risk of a persistent septum after resection (>10 mm) was reduced with ultrasound guidance (odds ratio = 0.35; 95% confidence interval 0.13-0.99). Two uterine perforations occurred in our series; both were in the unguided group. CONCLUSIONS: A systematic abdominal ultrasound-guided metroplasty by hysteroscopy seems to reduce the rates of re-intervention.

Maternal outcomes after uterine balloon tamponade for postpartum hemorrhage.

OBJECTIVE: To evaluate maternal outcomes following uterine balloon tamponade in the management of postpartum hemorrhage. DESIGN: Retrospective case-series. SETTING: Two French hospitals, a level 3 university referral center and a level 2 private hospital. POPULATION: All women who underwent balloon tamponade treatment for primary postpartum hemorrhage. METHODS: Uterine tamponade was used after standard treatment of postpartum hemorrhage had failed. The study population was divided into two groups, successful cases where the bleeding stopped after the balloon tamponade, and failures requiring subsequent surgery or embolization. MAIN OUTCOME MEASURES: Success rates. RESULTS: Uterine tamponade was used in 49 women: 30 (61%) after vaginal delivery and 19 (39%) after cesarean section. Uterine atony was the main cause of hemorrhage (86%). The overall success rate was 65%. Of 17 failures, surgery was required in 16 cases, including hysterectomy in 11, and uterine artery embolization in one case. Demographic and obstetric characteristics did not differ significantly between the success and failure groups. No complications were directly attributed to the balloon tamponade in the postpartum period. Two women had a subsequent full-term pregnancy without recurrence of postpartum hemorrhage. CONCLUSIONS: Balloon tamponade is an effective, safe and readily available method for treating primary postpartum hemorrhage and could reduce the need for invasive procedures.

Conservative management of placenta accreta: hysteroscopic resection of retained tissues.

STUDY OBJECTIVE: To evaluate the feasibility and the results of hysteroscopic removal of tissue after conservative management of retained placenta accreta. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: Tertiary care university hospital. PATIENTS: Twelve consecutive patients with hysteroscopic resection of retained tissues after conservative management of placenta accreta. INTERVENTION: Hysteroscopic removal of retained placenta tissue using a 24F bipolar resectoscope. MEASUREMENTS AND MAIN RESULTS: Twelve patients with retained placenta tissue, complete in 2 and partial in 10, were included. Mean retained placenta size on magnetic resonance imaging was 54 mm (range, 13-110 mm). Complete removal was achieved in all but 1 patient who underwent a secondary hysterectomy after the first incomplete hysteroscopic resection. Complete evacuation of the uterus was completed after 1 procedure in 5 patients, after 2 procedures in 2 patients, and after 3 procedures in 4 patients. All but 2 patients had normal menstrual bleeding after hysteroscopy. Four pregnancies occurred in our series, resulting in 1 ectopic pregnancy, 1 miscarriage, and 2 deliveries. CONCLUSION: Hysteroscopic resection of retained placenta seems to be a safe and effective procedure to prevent major complications and to preserve fertility in cases of conservative management of placenta accreta.

Pregnancy and tobacco: Practice and knowledge of French midwives.

OBJECTIVES: Evaluate the midwives' practices and knowledges with regard to the management of the smoking cessation in pregnant women and analyse the profile of midwives prescribing nicotine replacement therapy (NRT). METHODS: A national practice survey amongst 23,541 French midwives was conducted from 1 September 2020 to 15 September 2021 using an online self-administered questionnaire. RESULTS: The analysis of the 1,216 usable questionnaires (97, 7% women, mostly aged 30 to 49 years and non-smokers) showed that 93.4% of midwives frequently questioned pregnant women about their smoking consumption during pregnancy. The minimal counselling was known and practiced by 91% of midwives, the Fagerström test by 26.9% and the measurement of exhaled CO by 27.1%. Concerning NRT, 60% of the midwives prescribed them in a usual way and 36.8% were aware of the possibility of prescribing them to the pregnant woman's entourage. The profile of midwives prescribing NRT was significantly more concerned with smoking cessation in pregnant women; worked more frequently in a hospital; carried out 25% or more of antenatal monitoring consultations; and had significantly better knowledge of the evaluation tools, without influence of sex or smoking status. CONCLUSIONS: Improving the training of midwives in the screening and management of smoking cessation during pregnancy seems necessary.

In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study.

OBJECTIVE: To investigate maternal and neonatal outcomes after a delivery in France in 2019, according to hospital characteristics and the impact of distance and time of travel on mother and newborn. METHODS: All parturients above 18 years of age who delivered in 2019 and were identified in the French health insurance database were included, with their newborns, in this retrospective cohort study. Main outcome measures were Severe Maternal Morbidity score and the Neonatal Adverse Outcome Indicator (NAOI). RESULTS: Among the 733 052 pregnancies included, 10 829 presented a severe maternal morbidity (1.48%) and 77 237 had a neonatal adverse outcome (10.4%). Factors associated with an unfavorable maternal or neonatal outcome were Obstetric Comorbidity Index, primiparity, and cesarean or instrumental delivery. Prematurity was associated with less severe maternal morbidity but more neonatal adverse outcomes. Time of travel above 30 min was associated with a higher NAOI rate. CONCLUSIONS: Results suggest the efficiency of regionalization of perinatal care in France, although a difference in both outcomes persists according to unit volume, suggesting the need for a further step in concentrating perinatal care. Perinatal care organization should focus on mapping the territory with high-level, high-volume maternity throughout the territory; this suggests closing down high-volume units and improving low-volume ones to maintain coherent mapping.

Interstitial pregnancy management: A multicentric analysis of 98 patients from the FRANCOGENT group comparing surgery and medical treatment.

OBJECTIVE: To evaluate the outcomes associated with each therapeutic option for patients diagnosed with interstitial pregnancy (IP). METHODS: We conducted a multicentric retrospective cohort study within the departments of Gynecology and Obstetrics involved in the Francogent research group. Women treated for an interstitial pregnancy between January 2008 to December 2019 were included. Three therapeutic options were evaluated: surgical treatment (ST); in situ methotrexate combined with systemic methotrexate (IS-MTX); and systemic methotrexate (IM-MTX). Success of first-line treatment was defined by hCG negativation (<5I U/L). Secondary outcomes included the need for secondary surgical procedure, secondary medical treatment, emergency surgery, postoperative complications, duration of hospitalization, and delay before hCG negativation. RESULTS: A total of 98 patients were managed for IP: 42 (42.9%) patients had IM-MTX; 34 (34.7%) had IS-MTX; and 22 (22.4%) had ST. First-line treatment was successful in all patients of the ST group (22/22, 100%), in 31% of patients within the IM-MTX group (13/42) and 70.6% (24/34) in the IS-MTX group. The sole parameter associated with the risk of treatment failure was the mode of methotrexate administration. The size of the gestational sac or the presence of fetal heartbeat was not associated with decreased medical treatment (IS or IM-MTX) efficiency. CONCLUSION: Either ST or IS-MTX are good options for IP treatment associated with high success rates. A single-dose regimen of IM-MTX is less efficient than IS-MTX or ST. Symptomatic patients with severity criteria should always undergo emergency surgery. IP remains a high-risk condition that should be managed, whenever possible, in referral centers to potentialize the chances of favorable outcomes.