[Should French pregnant women be vaccinated against pertussis during pregnancy?] / Faut-il vacciner les femmes enceintes françaises contre la coqueluche ?

Many countries with a high perinatal level have started a policy of vaccination of pregnant women against pertussis. To date, France has not chosen this policy. The objective was to review knowledge on pertussis mortality in infants. Compare the strategies available to protect the infant before his first vaccination, scheduled for two months of age. We proceeded to a litterature analysis, from January 1998 to 2021. Search by the following keywords used ; "Whooping cough, vaccination, pregnancy, strategy, cocooning", on the scientific basis of "Pubmed", as well as French and foreign vaccination recommendations. Currently 90% of whooping cough deaths are concerning infants under six months of age and this mortality represents 2% of mortality in the first year of life. Vaccination at birth is not effective. The cocooning strategy, which consists of vaccinating those around the child, is expensive and difficult to implement. A systematic vaccination policy for pregnant women is effective and reasonably expensive when compared to the cocooning strategy. In England, it was recently accompanied by a 78% reduction in confirmed cases of pertussis in infants under six months of age. In conclusion, compared to cocooning strategy, pertussis vaccination of pregnant women appears more effective and cost-effective, and this with each pregnancy.

[Factors related to severe neonatal acidosis in planned cesarean section. A case-control study]. / Facteurs liés à la survenue d'une acidose néonatale sévère en cas de césarienne programmée. Une étude cas-témoins.

OBJECTIVES: To identify factors related to the occurrence of severe neonatal acidosis in case of planned caesarean section. METHODS: Case-control study conducted between 1997 and 2016 among women with planned caesarean delivery at term. Cases were women whose neonates had neonatal arterial pH<7,0. For each case, two planned caesarean sections with neonatal pH≥7,0 were selected as controls. Women whose fetus had a congenital malformation and those whose anesthesia was not spinal anesthesia were excluded. RESULTS: Among the 5014 planned cesarean sections of the study period, 38 severe neonatal acidosis were observed (incidence of 0,76% CI95 [0,54-1,04]). Compared to 72 controls, the 36 caesareans with severe neonatal acidosis were associated with more frequent maternal obesity (BMI≥30kg/m2), higher ephedrine doses, longer time from skin incision to infant delivery, and more extraction difficulties. After logistic regression, only maternal obesity remained associated with a significant increase in the risk of severe neonatal acidosis, ORa=3,73, 95%CI (1,11-12,56). CONCLUSIONS: In case of planned cesarean section, the main risk factor for severe neonatal acidosis is the existence of maternal obesity.

Feasibility of vaginal mesh for anterior vaginal wall prolapse in an ambulatory setting: A retrospective case series.

INTRODUCTION: Vaginal mesh has been proven to be an effective aid in the treatment of cystocele. Could an ambulatory approach be feasible for the Uphold Lite®-mesh? HYPOTHESIS: We investigate the feasibility of an ambulatory approach of Uphold Lite® insertion in a well-selected population. Risk factors for a non-successful ambulatory approach are identified. METHODOLOGY: We conducted a retrospective case series of 236 women who underwent Uphold Lite® vaginal mesh insertion for the treatment of pelvic organ prolapse at our center. Indications for surgery were symptomatic anterior and/or apical prolapse, stages POPQ≥2. We compared women having an ambulatory approach, to those having a one day hospitalization planned but needed to stay. Comparisons between percentages were calculated using the chi-square or Fisher's exact test, depending on the number of women in each group. The mean comparisons were performed using the Student t-test, and the median test comparisons by the Kruskal-Wallis test. A difference was considered significant if p<0.05. RESULTS: The most common reason for staying (85.7% of all ambulatory failures) after Uphold® surgery is the presence of an elevated post void residual. This complication was more found in the following: surgery in the afternoon, use of high-dose morphinics in general anesthesia, and in women with a higher parity. CONCLUSIONS: Our study shows that Uphold® surgery in a one-day setting is feasible and safe. Women desiring this approach should be counselled on the 42.6% risk of one-day failure though, mostly due to non-validation of a post void residual. General anesthesia with high-dose morphinics, a higher parity, and surgery in the afternoon are risk factors for failure of an ambulatory protocol.

Lower-limb neurologic deficit after vaginal delivery: a prospective observational study.

BACKGROUND: Lower limb neurologic deficit after vaginal delivery remains poorly understood. The objective of this study was to describe the incidence, characteristics and prognosis associated with nerve injury occurring to women during vaginal delivery. METHODS: A single-center observational study of women who complained about a lower limb neurologic deficit that appeared immediately after vaginal delivery. The follow-up period was up to four years. RESULTS: Among the 10 569 women with a singleton vaginal delivery during the 30-month study period, 31 (0.3%) reported a neurologic deficit. Most women were nulliparous (71%) and the mean duration of the second stage of labor was 94 min [range 13-224 min]. In two-thirds of cases, delivery required instrumental assistance. Most neurologic deficits were sensory (67.7%) and primarily involved femoral nerve territory (83.9%). Most women recovered within six weeks (69.2%). In one case (a sensory deficit of the entire right leg), recovery only occurred after 3.5 years. CONCLUSION: Neurologic deficit was identified in 0.3% of our vaginal delivery population. Recovery from neurologic deficit may take many weeks and may occasionally be disabling.

Factors associated with pregnancy after in vitro fertilization in infertile patients with posterior deep pelvic endometriosis: A retrospective study.

INTRODUCTION: The management of posterior deep endometriosis is not consensual. This is due to a great heterogeneity of data from the literature. Many series were small and overall, predictors of pregnancy were not all included and analyzed by multivariate analysis. We conducted this study to evaluate the factors associated with pregnancy during the first two in vitro fertilization (IVF) attempts in infertile women with posterior deep endometriosis. MATERIAL AND METHODS: 230 women were included in this retrospective observational study, between January 1st, 2007 and September 30th, 2013, at the University Hospital of Lille. A large set of variables were recorded and their association with the chance of pregnancy was analyzed by multivariate analysis (MVA), including patients' features, endometriosis items, surgery procedures and IVF data. RESULTS: After 2 IVF attempts, 48.7% of the 230 women achieved a pregnancy, including 39.1% of ongoing pregnancies. Logistic regression analysis retained five variables significantly associated to the chance of pregnancy: oocyte retrieval number (OR=0.468 (0.296-0.739) p=0.001), age (OR=0.888 (0.811-0.974) p=0.011), single embryo transfer number (OR=1.494 (1.036-2.153) p=0.031), presence of a recto-uterine nodule (OR=0.454 (0.235-0.877) p=0.019) and IVF technique (OR=0.509 (0.272-0.951) p=0.034). CONCLUSION: The presence of a recto uterine nodule is associated with a lower chance of pregnancy after IVF. It has to be checked by prospective studies whether the finding of a recto-uterine nodule whose pejorative effect has not been reported so far should encourage to perform surgery before IVF in patients with deep endometriosis.

Evaluation of a new technique of prophylactic cervical cerclage simplified from the Shirodkar cerclage: A pilot study.

INTRODUCTION: In terms of prophylactic cerclage, the simplest and most commonly used technique is the McDonald cervical cerclage. Cervico-isthmic cerclage techniques may have better results, but are more difficult to achieve. A simplified Shirodkar technique would have the advantage of being "cervical high" while remaining easy to achieve. OBJECTIVE: To compare the results of high cervical cerclage, according to a simplified Shirodkar technique, with those of a classic McDonald cerclage, in the case of women at high risk of prematurity in an exploratory study. METHODS: A comparative, retrospective study of prophylactic cerclage was conducted according to one or the other technique performed in a university hospital from 2006 to 2013. Women were included only if they had a history of at least two late miscarriages and/or premature delivery before 33 weeks. The primary outcome was the rate of delivery before 35 weeks. RESULTS: Our study involved 38 women: 24 in the McDonald cerclage group and 14 in the simplified Shirodkar cerclage group. The two groups were comparable for their obstetric and general characteristics. The percentage of preterm deliveries before 35 weeks was similar in both groups (7.1% and 25.0% in the Shirodkar and McDonald groups respectively; P=0.17). No significant difference was observed in the rate of surgical complications or hospitalizations during the pregnancies. CONCLUSION: In this study, we were unable to demonstrate an advantage to using the simplified Shirodkar technique - high cervical cerclage - compared with use of the McDonald technique - classical cerclage.

Inter-observer reliability of 4 fetal heart rate classifications.

OBJECTIVE: Different classification of fetal heart rate (FHR) pattern have been proposed: FHR classified as either "reassuring" or "non-reassuring", the National Institute of Child Health and Human Development (NICHD) published in 2008 a 3-tier system, the French College of Gynecology and Obstetrics (CNGOF) recommended in 2013 a 5-tier system and recently in 2015, the Federation International of Gynecology and Obstetrics (FIGO) proposed a new classification based on a 3-tier system. Our objective was to assess the inter-observer reliability of these 4 existing classifications. STUDY DESIGN: Four observers reviewed 100 FHR without clinical information. FHR were obtained from term singleton pregnancies. Fetal heart rate patterns were classified by one 2-tier ("reassuring vs. non-reassuring"), two 3-tier (NICHD 2008 and FIGO 2015), and one 5-tier (CNGOF 2013) fetal heart classifications. RESULTS: The global agreement between observers was moderate for each classification: 0.58 (0.40-0.74) for the 2-tier, 0.48 (0.37-0.58) for the NICHD 2008, 0.58 (0.53-0.63) for the CNGOF 2013 and 0.59 (0.49-0.67) for the FIGO 2015 classification. When FHR was classified as reassuring, it was classified as normal in 85.5% for the NICHD 2008 and in 94.5% for the FIGO 2015. For the CNGOF 2013, 65.0% were classified as normal and 32.5% as quasi normal. There was strong concordance between FIGO category I and "reassuring" FHR (kappa=0.95). CONCLUSION: Inter-observer agreement of FHR interpretation is moderate whatever the classification used. To evaluate the superior interest of one classification, it will be interesting to compare their impact on need of second line techniques and on neonatal outcome.

Why women with previous caesarean and eligible for a trial of labour have an elective repeat caesarean delivery? A national study in France.

OBJECTIVE: To identify the characteristics of women and maternity units associated with elective repeat caesarean delivery (ERCD) in women eligible for trial of labour after caesarean (TOLAC). DESIGN: Cross-sectional study. SETTING: France. POPULATION AND SAMPLE: Using data from the 2010 French National Perinatal Survey, a representative sample of births in France (n = 14 681 women), we studied two groups of women with prior caesarean section: (i) women eligible for TOLAC according to guidelines (n = 1179) and (ii) a subgroup of these women without any medical characteristics that might indicate ERCD (n = 575). METHODS: Associations were analysed by multilevel logistic regression. MAIN OUTCOME MEASURES: Adjusted odds ratios. RESULTS: Among the 1584 women with a previous caesarean, 1179 (74.4%) were eligible for TOLAC according to guidelines (group 1); 490 (41.6%) had ERCD. Risk of ERCD increased with increasing maternal age and body mass index, pre-existing condition and suspected macrosomia and decreased with previous vaginal deliveries. Among the unit characteristics, private status (aOR = 2.3, 95% CI 1.3-4.1) and low level of care (aOR = 2.5, 95% CI 1.4-4.5]) were independently associated with a higher risk of ERCD after adjustment on patient/pregnancy characteristics. The variability of ERCD rate between hospitals was mainly (78%) explained by the status and level of care, and not (0%) by patient/pregnancy characteristics. Associations with unit characteristics were similar for group 2. CONCLUSION: For women eligible for TOLAC, the rate of ERCD is high and not in agreement with guidelines. Some characteristics of women are associated with ERCD, but the main determinants are at the unit level, which suggests that non-medical reasons are involved in the decision process. TWEETABLE ABSTRACT: Elective repeat caesarean in women eligible for trial of labour mainly depends on maternity unit characteristics.

[Screening for gestational diabetes: Still many unsolved issues]. / Le dépistage du diabète gestationnel : encore de nombreuses questions non résolues.

For many years, there is a debate on gestational diabetes screening, including what screening test and thresholds to use. The purpose of this literature review is to determine whether gestational diabetes screening in France meets the 10 definition criteria of the WHO. The DG is a public health problem, with a natural history partially known and detectable at an early stage. Currently, there is no data showing that there is a benefit to treat patient screens by the new criteria. The one-step approach-screening test can only detect fetal complications and not maternal complications. It seems to be acceptable for the population of pregnant women. The diagnostic test and treatment also seem to be acceptable to us. To this day, its reproducibility is uncertain. Screening leads to an increase in obstetric interventions. Several studies found that screening for gestational diabetes is cost-effective but in a different context of care than in France.