Comparative analysis of quality scores images between second- and third-trimester ultrasound scan.

OBJECTIVES: To evaluate whether the quality scores validated for second-trimester ultrasound scan can be used for third-trimester ultrasound scan. METHODS: Prospective multicenter ancillary study using data from the RECRET study. Nulliparous women, with no reported history, with second- and third-trimester ultrasound examinations performed by the same ultrasonographer and using the same ultrasound machine were recruited. The global score and the individual score of each ultrasound image were compared between second- and third-trimester ultrasound scan. The sample size was calculated for a non-inferiority (one-sided) paired Student t test. RESULTS: 103 women with 1606 anonymized ultrasound images were included. The median term at second- and third-trimester ultrasound scan was 22.2 weeks gestation (22.0-22.7) and 31.6 weeks gestation (30.7-34.7), respectively. The mean global score of ultrasound images was comparable between the second- and the third-trimester ultrasound examination (32.37 ± 2.62 versus 31.80 ± 3.27, p = 0.13). Means scores for each biometric parameters i.e. head circumference, abdominal circumference, and femur diaphysis length were comparable. The scores for the four-chamber view (5.11 ± 0.91 versus 5.36 ± 0.75, p = 0.02) and the spine (4.18 ± 1.17 versus 5.22 ± 1.02, p < 0.001) were significantly lower in the third trimester compared to the second trimester. The score for the kidney image was significantly higher for third trimester images compared to second trimester images (4.73 ± 0.51 versus 4.32 ± 0.67, p < 0.001. CONCLUSIONS: Biometrics parameters quality scores images previously validated for the second trimester ultrasound scan can be also used for the third trimester scan. However, anatomical quality scores images performances may vary between the second and the third trimester scan.

Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study.

OBJECTIVE: To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section. DESIGN: Prospective population-based study. SETTING: All 176 maternity hospitals of eight French regions. POPULATION: Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries. METHODS: Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared. MAIN OUTCOME MEASURES: Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes. RESULTS: The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally. CONCLUSION: More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean. TWEETABLE ABSTRACT: Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

[Maternal deaths due to haemorrhage in France 2013-2015]. / Mortalité maternelle par hémorragie en France 2013­2015.

Maternal death from haemorrhage is decreasing: in the last 15 years the number of deaths has been halved. This improvement demonstrates the progress made in hemorrhage management as a result of collective efforts. The number of deaths in this triennium is 22, representing 8.4% of maternal deaths and a maternal mortality ratio by haemorrhage of 1.0/100,000 live births. Nevertheless, there is a worrying proportion of deaths from occult haemorrhage. These occult haemorrhages most often occurred after caesarean sections. A lack of surveillance in the immediate follow-up was generally associated. One or more factors of sub-optimal care were present in 84% of the cases, and 88.9% of deaths were considered possibly or probably preventable. Delay in the diagnosis of haemorrhage, delay in surgical treatment, an insufficient transfusion strategy and inappropriate locations of care were the most frequently reported factors. The experts suggest that risk factors for haemorrhage should be identified in order to propose the most appropriate facility for childbirth. They encourage the strategies for early diagnosis of haemorrhage (attentive and regular monitoring, rapid haemoglobin measurement, abdominal ultrasound) and surgical intervention in case of hemoperitoneum.

[Maternal deaths due to hypertensive disorders in France 2013-2015]. / Morts maternelles par complications hypertensives en France 2013­2015.

Between 2013 and 2015, six maternal deaths were due to hypertensive disorders. During this period, the maternal mortality ratio was 0.2/100,000 live births. Hypertensive disorders were responsible for 2% of maternal deaths in France and for 5% of direct maternal mortality. All these deaths happened after the delivery. Mode of delivery was a cesarean section when the hypertensive complication started before the delivery (4/6; 67%). Three had DIC during the immediate post-partum. Five women were under 35 years old. Only one had a BMI over 30. Four out of six patients were primiparous. One woman was Afro-Caribbean. Medical care was estimated non-optimal in 100% of the cases. In three cases, it was prenatal care and in three cases it was obstetrical care during delivery; anesthesia and intensive care were suboptimal in five cases. Eighty percent of these deaths seemed to be preventable. The main causes of suboptimal management were inappropriate or insufficient obstetrical and/or anesthetic treatments, and delayed optimal treatment. The analysis of these maternal deaths offers the opportunity to stress major points to optimize medical management in case of hypertensive disorders during pregnancy such as management of eclampsia (use of magnesium sulfate) or recognition of DIC when HELLP syndrome is diagnosed.

[Induced abortions for maternal indications: Retrospective study in Western Normandy between 2010 and 2019]. / Interruptions médicales de grossesse pour indications maternelles : analyse rétrospective en Normandie Occidentale (2010­2019).

INTRODUCTION: Termination of pregnancy for maternal reasons (MTOP) are authorized in France without limit of term when "the continuation of the pregnancy puts in serious danger the health of the woman". The literature on the subject is rare and we wanted to make an inventory in our region. METHODS: Retrospective observational study between 2010 and 2019 at the multidisciplinary center for prenatal diagnosis in Western Normandy. RESULTS: Thirty-one cases of MTOP were included (2.5% of all TOP). At the CHU de Caen, they represented one in 1200 births. Twenty-three percent of MTOP had a psychosocial or psychiatric indication (average term=22 SA) and 29% an obstetric indication due to severe preeclampsia (23 SA). Finally, 48% were linked to a non-obstetric somatic disorder including 46% pre-existing pathologies (average term=11 SA), most often cardiological or nephrological and 54% diagnosed during pregnancy (17 SA) dominated by neoplasias. They were more often (68%) performed in the second trimester. Vaginal births were more frequent (74% against 26% of endouterine aspirations). CONCLUSION: Strict medical contraindications to pregnancy are exceptional. Recourse to the medical termination of pregnancy within the framework of a preexisting pathology must remain rare, by systematizing of the preconception consultation.

[Propositions for perinatal care at extremely low gestational ages - Working group on "Extremely low gestational ages" for SFMP, CNGOF, and SFN]. / Propositions sur la prise en charge en cas d'extrême prématurité ­ Le groupe de travail « Extrême Prématurité ¼ pour la SFMP, le CNGOF et la SFN.

OBJECTIVES: International literature suggests that active perinatal management at extremely low gestational ages improves survival without increasing the risk of impairment in survivors, compared to less active management. Although these results are limited to a small number of countries, they question current practices in France. New propositions on perinatal management of extremely preterm infants have carried out by the French Society of Perinatal Medicine, the French Society of Neonatology and the National College of French Obstetricians and Gynecologists. METHODS: This group was set up in 2015 on the initiative of the professional societies and in collaboration with parents' and users' associations. The work was based on a review of the literature on the prognosis of extremely preterm children, as well as on recommendations by European societies. Based on this information, a text was produced, submitted to all members of the working group and definitively validated in April 2019. RESULTS: This text offers a decision-making guideline for the management at extremely low gestational ages. Its principles are: the administration of steroids independently of management (resuscitation or comfort care); a prognostic evaluation and a collegial decision, outside the context of the emergency; a consensus on the information to be given to parents before going to inform them and gather their opinion. CONCLUSIONS: These new propositions will contribute to modifying perinatal care at extremely low gestational ages in France.

[Prospective evaluation of the knowledge of couples concerning the prenatal screening ultrasound]. / Évaluation prospective des connaissances des couples concernant l'échographie de dépistage prénatal.

OBJECTIVES: Evaluation of the knowledge of couples concerning the prenatal screening ultrasound in order to improve information. METHODS: This prospective, observational and comparative study was carried out in three maternal centers: a level III maternity, a level II private maternity, and a private gynecologist's office where prenatal screening ultrasounds were performed between the first of March 2018 and the 31th of April 2018. A questionnaire was given to all pregnant women coming to consult for a prenatal screening ultrasound. It included items on maternal characteristics, pregnancy characteristics, and screening ultrasound. RESULTS: One hundred and sixty-nine women answered the questionnaire. On the 138 participants who had consulted in the level III maternity, 42 % expected them to study fetal well-being, 38 % growth, and 13 % malformation. Forty-six percent attested to have received a request for consent, as well as information about these ultrasounds. The same is true for the 120 spouses in thelevel III maternity where only 7 % expected a malformation search to be carried out. The number of participants in the type II private maternity and the private gynecologist's office was insufficient. CONCLUSION: The information given and received, and the knowledge of couples in this level III maternity about the prenatal screening ultrasound seem to be insufficient. It is therefore important to inform the pregnant women and their spouse by giving consent before the first ultrasound and by a verbal message, simple and clear about what the professional is looking for in order to reduce this discrepancy, and thus prepare the couple in case of announcement of an anomaly.

[Uterine rupture of the unscarred uterus: A report of 10 cases]. / Rupture utérine sur utérus non cicatriciel : à propos de 10 cas.

INTRODUCTION: Uterine rupture in the healthy uterus is a rare obstetrical complication, not much suspected and with badly identified risk factors. Thus, there exists frequent delay for treatment and therefore fetal-maternal important morbidity and mortality. This article describes clinical signs and symptoms, management, and maternal and neonatal prognosis of uterine rupture. METHODS: Descriptive retrospective study within 13 maternity hospitals, reporting 10 series of cases of uterine rupture on gravid healthy uterus during the third trimester of pregnancy. RESULT: The incidence was 2.8/100,000 births. Surgical treatment was conservative in 9 out of 10 cases, the maternal prognosis was good with no maternal deaths and 6 out of 7 patients had at least one subsequent pregnancy. The fetal prognosis was more reserved, with 2 fetal or neonatal deaths and 1 with motor disability. 6/6 patients (100%) had at least one iterative Caesarean section during the following pregnancies with healthy fetuses. CONCLUSION: In this series of 10 cases over 25years, maternal-fetal morbidity and mortality were significant, in agreement with the literature. Maternal prognosis remained favorable. When surgical treatment is conservative a subsequent pregnancy is possible and an iterative cesarean section must be performed.

[Early and later intrahepatic cholestasis of pregnancy (ICP): Study of adverse pregnancy outcomes]. / Cholestases intrahepatiques gravidiques (CIG) précoces et tardives : étude des complications materno-fœtales.

OBJECTIVE: To compare the risk for adverse pregnancy and fetal outcomes in early or late-onset intrahepatic cholestasis of pregnancy (ICP). METHODS: In a retrospective and unicentric analysis, data were collected for all women with ICP (serum bile acid level over 8mol/L) between June 1, 2008 and January 1, 2015. Patients were divided in early-onset ICP (pregnancy duration at diagnosis<33 weeks) and late-onset ICP (pregnancy duration at diagnosis≥33 weeks). The frequency of adverse pregnancy and fetal outcomes was assessed. RESULTS: Among 138 eligible women, 40 were in the early-onset group and 98 in the late-onset group. Adverse pregnancy or fetal outcomes affected significantly more patients in early-onset ICP group (45% versus 17.3%, P<0.05). Threatened preterm birth (30% versus 10.0%, P<0.05) was significantly increased in early-onset ICP group. Prematurity was higher in early-onset group (40.0% versus 28.0%, P=0.23). Early-onset and severe ICP were not significantly linked (P=0.16). CONCLUSION: Early-onset ICP diagnosed before 33 Weeks is associated with adverse pregnancy outcomes, particularly threatened preterm birth.

Factors affecting rotation of occiput posterior position during the first stage of labor.

INTRODUCTION: Fetal occiput posterior (OP) positions account for 15 to 20% of cephalic presentations and are associated with poorer maternal and neonatal outcomes than occiput anterior (OA) positions. The aim of this study was to identify maternal, neonatal and obstetric factors associated with rotation from OP to OA position during the first stage of labor. MATERIAL AND METHODS: This secondary analysis of a multicenter randomized controlled trial (EVADELA) included 285 laboring women with ruptured membranes and a term fetus in OP position. After excluding women with cesarean deliveries before full dilatation, we compared two groups according to fetal head position at the end of the first stage of labor: those with and without rotation from OP to OA position. Factors associated with rotation were assessed with univariate and multivariate analyses using multilevel logistic regression models. RESULTS: The rate of anterior rotation during the first stage was 49.1%. Rotation of the fetal head was negatively associated with excessive gestational weight gain (adjusted odds ratio [aOR]: 0.37, 95% confidence interval [CI]: 0.17-0.80), macrosomia (aOR: 0.35, 95% CI: 0.14-0.90), direct OP position (aOR: 0.24, 95% CI: 0.09-0.65), and prelabor rupture of membranes (aOR: 0.40, 95% CI: 0.19-0.86). Oxytocin administration was the only factor positively associated with fetal head rotation (aOR: 2.17, 95% CI: 1.20-3.91). DISCUSSION: Oxytocin administration may affect rotation of OP positions during the first stage of labor. Further studies should be performed to assess the risks and benefits of its utilization for managing labor with a fetus in OP position.

Rate of caesarean sections according to the Robson classification: Analysis in a French perinatal network - Interest and limitations of the French medico-administrative data (PMSI).

INTRODUCTION: The objective of our study was to determine, in accordance with WHO recommendations, the rates of Caesarean sections in a French perinatal network according to the Robson classification and determine the benefit of the medico-administrative data (PMSI) to collect this indicator. This study aimed to identify the main groups contributing to local variations in the rates of Caesarean sections. MATERIAL AND METHODS: A descriptive multicentric study was conducted in 13 maternity units of a French perinatal network. The rates of Caesarean sections and the contribution of each group of the Robson classification were calculated for all Caesarean sections performed in 2014. The agreement of the classification of Caesarean sections according to Robson using medico-administrative data and data collected in the patient records was measured by the Kappa index. We also analysed a 6 groups simplified Robson classification only using data from PMSI, which do not inform about parity and onset of labour. RESULTS: The rate of Caesarean sections was 19% (14.5-33.2) in 2014 (2924 out of 15413 deliveries). The most important contributors to the total rates were groups 1, 2 and 5, representing respectively 14.3%, 16.7% and 32.1% of the Caesarean sections. The rates were significantly different in level 1, 2b and 3 maternity units in groups 1 to 4, level 2a maternity units in group 5, and level 3 maternity units in groups 6 and 7. The agreement between the simplified Robson classification produced using the medical records and the medico-administrative data was excellent, with a Kappa index of 0.985 (0.980-0.990). CONCLUSION: To reduce the rates of Caesarean sections, audits should be conducted on groups 1, 2 and 5 and local protocols developed. Simply by collecting the parity data, the excellent metrological quality of the medico-administrative data would allow systematisation of the Robson classification for each hospital.

[Maternal death by venous thromboembolic disease]. / Morts maternelles par thromboembolies veineuses.

Pregnancy and postpartum are very high-risk periods for venous thromboembolism events (TEE), which seems to extend far beyond the classical 6-8 weeks after childbirth. Pulmonary embolism (PE) is one of the 3 main causes of direct maternal death in western countries. Between 2010 an 2012 in France, 24 deaths were related to PE giving a maternal mortality ratio of 1/100,000, which is not different from the former report (2007-2009). PE is responsible of 9% of maternal deaths, in equal position with postpartum hemorrhage and amniotic fluid embolism. Four deaths (16%) occurred after pregnancy interruption (1 abortion, 3 medical interruptions), 7 (30%) during ongoing pregnancy (before 22 weeks of pregnancy) and 13 (54%) in the postpartum period (9 to 60 days after childbirth). Among these deaths, 9 occurred in extra hospital setting (at home or in the street). Fifty percent of these deaths seem to be avoidable, as it was in the former report. Main avoidability criteria were: diagnostic delay; mobilization before effective anticoagulation of proximal deep venous thrombosis; insufficient preventive treatment with low molecular weight heparin [duration and/or dose (obesity)]; unjustified induction of labor. Analyzing those deaths allow to remind that in case of high suspicion of TEE, effective anticoagulation should be started without delay, and that angio-TDM is not contraindicated in pregnant women. Low molecular weight heparin regiment should be adapted to real weight. Monitoring of anti-Xa activity, if not routinely recommended, is probably useful in case of obesity or renal insufficiency. Anticipating birth by induction of labor, in the absence of abnormal fetal heart rhythm, should not delay effective anticoagulation of near-term TEE.

[Maternal deaths due to hypertensive disorders. Results from the French confidential enquiry into maternal deaths, 2010-2012]. / Morts maternelles par complications hypertensives. Résultats de l'enquête confidentielle française sur la mortalité maternelle, 2010­2012.

Between 2010 and 2012, the rate of maternal death caused by hypertensive disorders (0,5/100,000 living birth) was reduced by 50% compared to the 2007-2009 period. Hypertensive disorders were responsible from 5% of maternal deaths and from 10% of direct maternal mortality. Eleven deaths happened during the postpartum period but 9 hypertensive complications began before delivery. Seventy percent of these deaths seem to be avoidable. The main causes of suboptimal management were: unappropriated or insufficient obstetrical and anesthetic treatments, undiagnosed HELLP syndrome and subcapsular liver hematoma, delayed treatment. The analysis of these maternal deaths gave the opportunity to stress some major lessons to optimize medical management in case of hypertensive diseases during pregnancy: abdominal symptoms during third trimester of pregnancy lead to search hypertensive disorders; HELLP syndrome with severe anemia indicate to carry out abdominal ultrasound.

[Maternal deaths due to gestational trophoblastic diseases, results from the French confidential enquiry into maternal deaths, 2010-2012]. / Morts maternelles par maladies trophoblastiques gestationnelles. Résultats de l'enquête confidentielle française sur la mortalité maternelle, 2010­2012.

Gestational trophoblastic diseases (GTD) correspond to several entities which all have a common pattern: hypersecretion of human chorionic gondotrophin by trophoblastic hyperplasia. Between 2010 and 2012, there were 4 maternal deaths due to GTD (choriocarcinoma). The ratio of maternal death caused by GTD was 0,16/100,000 living births which was similar to the rate from the 2007-2009 period. These deaths represented 1.6% from the whole maternal mortality and 3.3% of the direct maternal mortality. These four deaths occurred after delivery and the diagnosis of GTD was made between 60 and 180 days in the postpartum period. Two cases seemed to be potentially avoidable. The main causes of suboptimal management were linked to delay either in diagnosis of GTD or in initiating the appropriate treatment. The analysis of these maternal deaths gave the opportunity to stress some major lessons to optimize medical management of GTD. Therefore, a patient presenting with persistent bleedings more than six weeks after delivery needs some specific exams such as plasma human chorionic gondotrophin measurement and histopathologic examination to affirm GTD and start early specific treatments generally leading to complete recovery.

[Can we reduce the decision-to-delivery interval in case of emergency cesarean sections by optimizing the premises' architecture?] / Peut-on diminuer le délai décision-extraction des césariennes en urgence en optimisant l'architecture des locaux ?

OBJECTIVE: To study the influence of architectural premises' improvements on decision-to-delivery interval (DDI) in case of emergency cesarean sections. METHODS: A retrospective observational Before-After study conducted in a type III maternity, first from 2004 to 2009 (Period 1, P1) then after moving our unit to new premises from 2009 to 2013 (P2). DDI, maternal and neonatal outcomes of every emergency cesarean section were studied. RESULTS: The mean DDI of extremely urgent cesarean significantly decreased from 21.3±10.3minutes during P1 (n=294) to 14.9±7.14minutes during P2 (n=165). During P2 there was an increase in the proportion of extreme emergency cesarean sections done in less than 30minutes (85.1% versus 93.5%, P=0.003) as according to the ACOG recommendations, and also an increase of DDI of less than 15minutes (25.8% versus 61.1%, P<0.001). Also during P2 if there was a reduction of umbilical cord pHs, which were correlated to DDI, we observed a reduction of neonatal hospitalizations (42.2% versus 35.7%, P<0.001). Apgar score was correlated to umbilical cord pH and birth weight, but not to DDI. CONCLUSION: The space optimization has allowed our level III maternity to improve the rate of extreme emergency cesarean sections performed with DDI of less than 30 and even 15minutes, according to international recommendations. These results were obtained by reducing the transfer time to the operating room. Despite a positive correlation between DDI and umbilical cord pH, there was an improvement in neonatal outcomes associated with a decrease of neonatal hospitalizations.

[Maternal deaths due to haemorrhage: Results from the French confidential enquiry into maternal deaths, 2010-2012]. / Mortalité maternelle par hémorragie, résultats de l'ENCMM, France 2010­2012.

Haemorrhage is the first cause of maternal mortality and morbidity in France and a quality of care marker. Haemorrhage rate in France is around 5 to 10% of deliveries. PPH is defined as a post-partum blood loss≥500mL whatever the delivery route and sometime blood can be concealed inside the pelvis. Between 2010 and 2012 in France, 29 deaths were related to haemorrhage giving a maternal mortality ratio of 1.2/100,000 live births (CI 95% 0.8-1.7). Haemorrhage cases decreased from last triennium (2007-2009) especially for uterine atony cases (12/29) but remains the first leading cause of direct maternal death. Patients with previous cesarean birth were more represented than in general obstetrical population (11/23). Substandard care were mainly due to delays in diagnosis of hemoperitoneum, delays in adequate resuscitation because of reassuring vital signs (normal blood pressure or normal hematocrite at the initial stage of bleeding) or organisational mistakes.

High-risk behaviours for the fœtus in pregnant women: The medicolegal and judicial aspects.

Pregnancy is a period of psychological change which may lead to difficulties of adaptation and psychological suffering and give rise to high-risk behaviours for the fœtus in pregnant women. These risk behaviours, which are defined by certain authors as a form of "maltreatment" of the fœtus, usually spring from the psychological distress of the pregnant woman but are not recognised as a specific medical disorder. We illustrate the difficulties encountered in the identification of, and the specific intervention in, these situations through the clinical case of a pregnant drugs-dependent patient subjected to several stress factors who, in addition to consuming substances, developed high-risk behaviours for herself and her pregnancy: self-endangerment under the influence of substances, falls or refusals of treatment. In our first part, we discuss the medicolegal possibilities afforded by French law to protect the fœtus in the event of the future mother's high-risk behaviours. In our second part, we discuss the successive evolutions of the legal status of the fœtus and pregnancy, and their consequences for medical practice and the clinical situations concerned. The lack of an answer concerning the designation of these behaviours, as either medical, legal or social acts, will prompt perinatal practitioners to a certain medicolegal prudence.

[Caesarean section at full dilatation: What are the risks to fear for the mother and child?] / Césarienne à dilatation complète : quels sont les risques à craindre pour la mère et l'enfant ?

OBJECTIVES: Caesarean section is associated with increased maternal morbidity compared to a vaginal delivery, especially if it occurs during labour. Little data on caesarean section performed at full dilatation is available. METHODS: This was a retrospective study done in University Hospital of type 3 over a period of ten years, including future primiparous patients who had a caesarean section performed at full dilatation, compared to a control group of patients whose caesarean section was conducted in first part of the labour. We collected different maternal data per- and postoperative and neonatal. RESULTS: In total, 824 patients were enrolled including 412 in each group. For caesarean section at full dilatation, foetal extraction required more manoeuvres (RR=3.05; 95% CI: 2.1; 4.39; P<0.001); we noted more extension of hysterotomy (RR=1.79; 95% CI: 1.30; 2.46; P<0.001). Postoperative and neonatal maternal morbidity was not different, except more frequent neonatal trauma for caesarean section at full dilatation. CONCLUSION: A caesarean section at full dilatation has an excess intraoperative risk and requires great caution. Nevertheless, no significant increase of postoperative and neonatal complications can be proved.