[Mechanical methods for cervical ripening in France: An evaluation of professional practices]. / Maturation cervicale par méthodes mécaniques en France : évaluation de pratiques professionnelles.

OBJECTIVE: Mechanical methods for cervical ripening are as effective as prostaglandins for the rate of vaginal delivery. Our aim was to study professional practices of mechanical cervical ripening in France. METHODS: A declarative survey was conducted among two groups of maternity units: a sample representative of French maternity units (group 1) and on the whole of type 3 maternity units (group 2). A questionnaire was emailed to physicians of these obstetric units between May and July 2014. RESULTS: Forty-three of the 104 units (41.3%) in the first group and 43 of the 64 units in the second group (67.2%) answered the questionnaire. Among these maternity units, mechanical methods were used respectively in 44.2 and 69.8% of the establishments. The two main devices used were the trans-cervical balloon catheter and the Foley catheter. The main indication for mechanical methods was induction of labor with prior caesarean. In case of induction of labor, a prior caesarean and a Bishop score < 7, in the first group, 46.6% of the maternity units did a caesarean, 32.3% performed an induction of labor with mechanical methods, 13.9% with oxytocin and 6.9% with prostaglandins. In the second group, 25.6% of maternity units performed a caesarean, 53.6% used mechanical methods, 9.3% used oxytocin and 11.6% used prostaglandins. CONCLUSION: In France nearly half of the maternity units and nearly three-quarters of type 3 maternity units say they use mechanical cervical ripening, mainly used in case of prior caesarean.

Implementation study of patient-ready syringes containing 25 mg/mL methotrexate solution for use in treating ectopic pregnancy.

BACKGROUND: Ectopic pregnancy (EP) is a significant cause of morbidity and mortality during the first trimester of pregnancy. Small unruptured tubal pregnancies can be treated medically with a single dose of methotrexate (MTX). OBJECTIVE: The aim of this study was to evaluate the stability of a 25 mg/mL solution of MTX to devise a secure delivery circuit for the preparation and use of this medication in the management of EP. METHOD: MTX solutions were packaged in polypropylene syringes, stored over an 84-day period, and protected from light either at +2 to +8°C or at 23°C. We assessed the physical and chemical stability of the solutions at various time points over the storage period. A pharmaceutical delivery circuit was implemented that involved the batch preparation of MTX syringes. RESULTS: We show that 25 mg/mL MTX solutions remain stable over an 84-day period under the storage conditions tested. Standard doses were prepared, ranging from 50 mg to 100 mg. The results of this study suggest that MTX syringes can be prepared in advance by the pharmacy, ready to be dispensed at any time that a diagnosis of EP is made. CONCLUSION: The high stability of a 25 mg/mL MTX solution in polypropylene syringes makes it possible to implement a flexible and cost-effective delivery circuit for ready-to-use preparations of this drug, providing 24-hour access and preventing treatment delays.

[Selective termination of pregnancy for monochorionic twins: a national survey of professional practice]. / Interruption sélective sur grossesse gémellaire monochoriale: étude nationale des pratiques des Centres Pluridisciplinaires de Diagnostic Prénatal.

OBJECTIVES: Selective Termination of Pregnancy (STOP) for discordant fetal condition in monochorionic twin pregnancy is a rarely performed procedure raising technical and ethical considerations. There are no epidemiological data available in France concerning STOP and no guideline or scientific consensus on how or when to perform has been published. MATERIALS AND METHODS: We conducted a study of national practice using a declarative questionnaire sent by e-mail to each medical coordinator of every 48 Multidisciplinary Center for Prenatal Diagnosis in France. The questions focused on the issues of 2010 and 2011. Two reminders were sent in case of no answer. RESULTS: The response rate to the questionnaire was 56 %; 81 % of centers have experienced at least once during the two years 2010-2011 a discordant fetal anomaly in monochorionic twin pregnancy. Only 59 % of centers perform all the techniques of STOP. When interruption of the umbilical blood flow is considered, bipolar forceps coagulation is the most used (75 %). Achieving STOP during a cesarean section is a common practice (75 % of centers). Locoregional anesthesia is the preferred mode of anesthesia for STOP. DISCUSSION AND CONCLUSION: STOP on monochorionic twin pregnancy is not practiced in all Multidisciplinary Center for Prenatal Diagnosis in France. The most widely practiced and most studied technique is bipolar forceps coagulation. The option of an expectant management should always be considered and its risks should be balanced with those of STOP. The practice of STOP during cesarean section is not unusual.

[Cervical ripening with balloon catheter for scared uterus: a three-year retrospective study]. / Maturation cervicale par sonde à ballonnet sur utérus cicatriciel : étude rétrospective sur trois ans.

OBJECTIVES: To evaluate, for women with scared uterus, the mechanical cervical ripening with balloon catheter. METHODS: We conducted a retrospective study of our practice of ripening for scared uterus from january 2010 to august 2012. Feasibility, Bishop's score, birth modalities and complications for mothers and babies during this ripening were studied. RESULTS: Thirty-nine medical files were analysed. All patients could have mechanical ripening independently of the internal os status (open or not). The cervical ripening with balloon catheter improved Bishop's score before induction of labour, from 3.54 ± 1.23 to 5.38 ± 1.47 (p=0.02). 64.1% of women had a vaginal delivery. Concerning the predictive factors for vaginal delivery, we only found significant influence of a body mass index less than 30kg/m² (p=0.03). We didn't find any maternal or neonatal complications in our population. CONCLUSION: Mechanical ripening for scared uterus seems to be a useful option to improve vaginal delivery without increasing maternal and foetal morbidity. Anyway, these results have to be confirmed by a randomized controlled trial on a specific scared uterus population.

[Predictive factors for fetal tolerance to cordocentesis: a monocentric retrospective study]. / Facteurs prédictifs de tolérance fœtale à la cordocentèse : étude rétrospective monocentrique.

OBJECTIVES: Indications for fetal blood sampling (FBS) are getting more limited. In this context, we aimed to evaluate fetal loss and morbidity associated with FBS and to precise the predictive parameters for fetal complications. More than a retrospective evaluation of our practices, the final end point of our study was to better inform the patients coming to our centre. PATIENTS AND METHODS: Retrospective monocentric cohort (Canadian Task Force classification II-2) of the 99 FBS performed between April 2004 and June 2010 on 80 fetuses, after excluding the procedures done for termination of pregnancy. The main clinical outcome was a composite outcome criteria for fetal tolerance including cesarean section for abnormal non stress test within the 24 hours, or any event responsible of a modified obstetrical management during the 14 day following FBS. RESULTS: Mean maternal age at FBS was 30 years ± 5.13 SD and parity was 2.49 ± 1.38 SD. FBS was performed by an experienced operator in 86.5% of cases (CI 95%, 78-92.6); with a single insertion in 83.3% of circumstances (CI 95%, 74.4-90.2). The mean duration was 11 min ± 6.37 SD. The total rate of intrauterine death, in our series, was 7.1% (CI 95%, 2.9-14), including all reported fetal demise within the 14 days after FBS, whatever the relation with the procedure. Our study demonstrated a 9.1% occurrence of post-FBS altered CTG fetal testing (CI 95%, 4.2-16.6), half of it with spontaneous resolution. The rate of severe complications (main clinical outcome) was 11.1% (CI 95%, 5.7-19) including one fetal death liable to FBS and 10 emergency caesarean sections: 5.1% for fetal bradycardia (CI 95%, 1.7-11.4), 2% for placental abruption (CI 95%, 0.2-7.1), 2% for premature preterm rupture of membranes (CI 95%, 0.2-7.1) and 1% for significative umbilical cord bleeding (CI 95%, 0-5.5). Univariate factor analysis highlights 4 parameters for impaired fetal tolerance; a prolonged procedure, presence of low fetal platelets (<30.10(9)/L); and FBS performed for fetal anaemia during Parvovirus B19 infection or allo-immune thrombocytopenia. DISCUSSION AND CONCLUSION: FBS remains a tricky procedure with a substantial risk of fetal loss or complications especially when performed on high-risk fœtuses. The length of the procedure should be shortened as much as possible (trained operator, postponed procedure when all favourable condition are not available). Fetal thrombocytopenia is a meaningful risk factor encouraging carefulness when exploring allo-immune fetal thrombocytopenia.

[Management of obstetric cholestasis in France: A national survey of obstetrical practice]. / Prise en charge de la cholestase intrahépatique gravidique en France : enquête nationale des pratiques auprès des gynécologues-obstétriciens.

OBJECTIVE: Intrahepatic cholestasis of pregnancy (ICP) is the most commonly encountered pregnancy-specific liver disease. This condition, with no proven maternal morbidity, has been associated with an increased risk of prematurity and intrauterine fetal death. There is, to date, no scientific obstetrical guideline for clinical practice in France. The objective of our study was to precise, in this situation, how French obstetricians manage patients suffering from ICP. METHODS: We carried out, during 2010, a national descriptive practice survey of ICP management in France in association with the "Collège national des gynécologues-obstétriciens français". An inquiry form with 27 multiple-choice questions was sent to all obstetricians and gynecologist officiating in a maternity hospital recorded by the French Ministry of Health. The participants answered questions regarding diagnosis, perinatal management and treatment of ICP. Only the first answer received from each maternity hospital was analyzed. RESULTS: Of the 575 maternity hospitals, 275 (41.6%) responded after one mail recovery. Among them, almost half used a standardized management protocol for ICP. In most of the cases, perinatal management was performed by obstetricians alone (73%), and in only 20% of the cases in collaboration with the specialist in hepatology. Induction of labor at 37-38 weeks was the most common policy for the majority of respondents (92.4%). CONCLUSION: This is the first French national survey for ICP management. This study demonstrated that ICP is, in most of the cases, managed by the obstetrician alone, and that fetal risks warrants an active management with induction of labor in late pregnancy.