Not only disease activity but also chronic hypertension and overweight are determinants of pregnancy outcomes in patients with systemic lupus erythematosus.

INTRODUCTION: Pregnancies in women with lupus nephritis are at high-risk of complications, while scarcity of scientific knowledge on prognostic factors impedes a fair medical counseling. We aimed to identify determinants associated with maternal and fetal complications. MATERIALS: We retrospectively reviewed medical charts of pregnancies that lasted more than 22 weeks in 66 patients with pre-existing lupus nephritis between 2004 and 2013 in France. Univariate and multivariate analyses were conducted to identify determinants for maternal complications, lupus renal flare and fetal prematurity or death. RESULTS: Eighty-four pregnancies were identified. A maternal complication occurred in 31 pregnancies (36.9%): mostly preeclampsia (17 pregnancies, 20.2%) and renal flares (12 pregnancies, 14.3%). Overall fetal survival was 94.0% (79/84). Maternal pregnancy complications were independently associated with prepregnancy body mass index >25 kg/m2 (OR 3.81, 95% CI 1.03-14.09) and immunological activity (positive anti-dsDNA antibodies or Farr assay lupus) (OR 4.95, 95% CI 1.33-18.43). Renal lupus flares were independently associated with maternal age (OR 1.50, 95% CI 1.12-2.01) and prepregnancy immunological activity (OR 15.99, 95% CI 1.57-162.68) while a remission time >12 months had a protective effect (OR 0.17, 95% CI 0.04-0.68). Three parameters were associated with a higher risk of fetal prematurity or death: a prepregnancy body mass index >25 kg/m2 (HR 3.58, 95% CI 1.45-8.83), hypertension (HR 8.97, 95% CI 3.32-24.25), and immunological activity (HR 3.34, 95% CI 1.30-8.63). CONCLUSION: Maternal age, prepregnancy hypertension, body mass index >25 kg/m2 and lupus immunological activity may be considered as the main determinants for fetal and maternal complications. A remission time above 12 months for patients with lupus nephritis could be associated with a reduced risk of renal flare during pregnancy.

[Tocolysis for preterm labor without premature preterm rupture of membranes]. / La tocolyse en cas de menace d'accouchement prématuré à membranes intactes.

OBJECTIVES: To propose guidelines for clinical practice for tocolysis in preterm labor without premature preterm rupture of the membranes (PPROM). MATERIALS AND METHODS: Bibliographic searches were performed in the Medline and Cochrane databases and gynecologist and obstetricians' international society guidelines. It is important to note that most studies included women in preterm labour with and without PPROM. RESULTS: Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2). Compared with betamimetics, nifedipine is associated with a reduction in necrotizing enterocolitis, intraventricular hemorrhage and respiratory distress syndrome (LE2). There is no difference between nifedipine and atosiban regarding neonatal prognosis, except a modest reduction in NICU transfer with nifedipine (LE2). Betamimetics, atosiban and nifedipine are equivalent to prolong pregnancy for more than 48hours (LE2). Compared with betamimetics, nifedipine reduces delivery before 34 WG and is associated with a longer pregnancy (LE2). Atosiban and nifedipine are equivalent to prolong the pregnancy over 7 days (LE2), but in women with spontaneous preterm labour without PPROM, nifedipine reduces deliveries before 37 WG and pregnancy prolongation is longer, without improving neonatal prognosis (LE2). Maternal severe adverse effects may occur with all tocolytics (LE4). Betamimetics cardiovascular adverse effects are frequents (LE2) and may be serious (maternal death) (LE4). Nifedipine and atosiban reduce maternal adverse effect compared with placebo (LE2). Cardiovascular adverse effects are moderately increased with nifedipine compared with atosiban (LE2), without increasing treatment discontinuation (LE2). Regarding their benefits on pregnancy prolongation and good maternal tolerance, atosiban and nifedipine can be used for tocolysis in spontaneous preterm labour without PPROM (Grade B), for singleton and multiple pregnancies (Professional Consensus). Advantageously, nifedipine is orally taken and is inexpensive (Professional Consensus). Nicardipine should not be used for tocolysis (Professional Consensus) and betamimetics should not be prescribed anymore for tocolysis (Grade C). All tocolytic treatment should be prescribed for up to 48hours (Grade B). In case of initial tocolysis failure, another treatment may be proposed with the other class of tocolytic (Professional Consensus). Different class of tocolytics should not be combined (Grade C). Scientific data are lacking to propose guidelines regarding a rescue tocolysis, after a first previous successful tocolysis with complete antenatal corticosteroid therapy (Professional Consensus). There is no scientific evidence to propose a tocolysis in women with advanced dilatation (GradeC), nor prescribe a tocolysis after 34 WG (Professional Consensus). There is no evidence to define a gestational age lower limit for tocolysis (Professional Consensus). CONCLUSION: Nifedpine and atosiban can be used for tocolysis (Grade B), including for multiple pregnancies (Professional Consensus). Maintenance tocolysis is useless (Grade C) and potentially harmful (Grade C). Betamimetics should not be used for tocolysis (Professional Consensus).

[Prevention of spontaneous preterm birth (excluding preterm premature rupture of membranes): Guidelines for clinical practice - Text of the Guidelines (short text)]. / Recommandations pour la pratique clinique : prévention de la prématurité spontanée et de ses conséquences (hors rupture des membranes) ­ Texte des recommandations (texte court).

OBJECTIVES: To determine the measures to prevent spontaneous preterm birth (excluding preterm premature rupture of membranes)and its consequences. MATERIALS AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: In France, premature birth concerns 60,000 neonates every year (7.4 %), half of them are delivered after spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated to a decrease of prematurity (level of evidence [LE] 1). This is therefore recommended (grade A). Routine screening and treatment of vaginal bacteriosis in general population is not recommended (grade A). Asymptomatic women with single pregnancy without history of preterm delivery and a short cervix between 16 and 24 weeks is the only population in which vaginal progesterone is recommended (grade B). A history-indicated cerclage is not recommended in case of only past history of conisation (grade C), uterine malformation (Professional consensus), isolated history of pretem delivery (grade B) or twin pregnancies in primary (grade B) or secondary (grade C) prevention of preterm birth. A history-indicated cerclage is recommended for single pregnancy with a history of at least 3 late miscarriages or preterm deliveries (grade A).). In case of past history of a single pregnancy delivery before 34 weeks gestation (WG), ultrasound cervical length screening is recommended between 16 and 22 WG in order to propose a cerclage in case of length<25mm before 24 WG (grade C). Cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with a twin pregnancy (grade A) and in populations of asymptomatic women with a short cervix (Professional consensus). Although the implementation of a universal transvaginal cervical length screening at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In case of preterm labor, (i) it is not possible to recommend one of the methods over another (ultrasound of the cervical length, vaginal examination, fetal fibronectin) to predict preterm birth (grade B); (ii) routine antibiotic therapy is not recommended (grade A); (iii) prolonged hospitalization (grade B) and bed rest (grade C) is not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (grade B), contrary to betamimetics (grade C), can be used for tocolysis in spontaneous preterm labour without preterm premature rupture of membranes. Maintenance tocolysis is not recomended (grade B). Antenatal corticosteroid administration is recommended to every woman at risk of preterm delivery before 34 weeks of gestation (grade A). After 34 weeks, evidences are not consistent enough to recommend systematic antenatal corticosteroid treatment (grade B), however, a course might be indicated in the clinical situations associated with the higher risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (grade C). Repeated courses of antenatal corticosteroids are not recommended (grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended to women at high risk of imminent preterm birth before 32WG (grade A). Cesarean is not recommended in case of vertex presentation (Professional consensus). Both planned vaginal or elective cesarean delivery is possible in case of breech presentation (Professional consensus). A delayed cord clamping may be considered if the neonatal or maternal state so permits (Professional consensus). CONCLUSION: Except for antenatal corticosteroid and magnesium sulfate administration, diagnostic tools or prenatal pharmacological treatments implemented since 30 years to prevent preterm birth and its consequences have not matched expectations of caregivers and families.

[Management of preterm labor]. / Prise en charge d'une menace d'accouchement prématuré.

OBJECTIVE: To define the management of preterm labor (MAP). METHOD: The literature search was conducted using computer databases Medline and the Cochrane Library for a period from 1969 to March 2016. RESULTS: Leukocytosis screening may be useful in case of hospitalization for Preterm labor (PTL). Its use is not routine (professional consensus). Screening for urinary tract infection by urine culture should be systematic and antibiotic treatment should be performed in cases of bacterial colonization or urinary tract infection for a period of 7 days (grade A). The vaginal swab is useful to detect a strep B and was prescribed antibiotics during labor if positive (grade A). Routine antibiotic therapy is not recommended in case of PTL (grade A). Prolonged hospitalization does not reduce the risk of preterm delivery (NP3) and is not recommended (grade B). Bed rest does not reduce the risk of PTL (NP3), increases the risk of thromboembolism (NP3), and is not recommended (grade C). After hospitalization for PTL, a regular visit by a caregiver at home may be helpful when patients belong to a precarious environment or are psychologically vulnerable (Professional consensus). The benefit of monitoring home uterine activity repeated in the aftermath of hospitalization for PTL is not shown (NP3). It is not recommended to follow-up uterine activity systematically after hospitalization for PTL (grade C). CONCLUSION: The management of PTL should be individualized, include searching and treatment of infection and avoid prolonged hospitalization or bed rest.

[Post-partum: Guidelines for clinical practice--Short text]. / Post-partum: recommandations pour la pratique Clinique--Texte court.

OBJECTIVE: To determine the post-partum management of women and their newborn whatever the mode of delivery. MATERIAL AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: Because breastfeeding is associated with a decrease in neonatal morbidity (lower frequency of cardiovascular diseases, infectious, atopic or infantile obesity) (EL2) and an improvement in the cognitive development of children (EL2), exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (Professional consensus). In order to increase the rate of breastfeeding initiation and its duration, it is recommended that health professionals work closely with mothers in their project (grade A) and to promote breastfeeding on demand (grade B). There is no scientific evidence to recommend non-pharmacological measures of inhibition of lactation (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). For women aware of the risks of pharmacological treatment of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Whatever the mode of delivery, numeration blood count is not systematically recommended in a general population (Professional consensus). Anemia must be sought only in women with bleeding or symptoms of anemia (Professional consensus). The only treatment of post-dural puncture headache is the blood patch (EL2), it must not be carried out before 48 h (Professional consensus). Women vaccination status and their family is to be assessed in the early post-partum (Professional consensus). Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (Professional consensus). An analgesic multimodal protocol developed by the medical team should be available and oral way should be favored (Professional consensus) (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (Professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). Early postoperative rehabilitation is encouraged (Professional consensus). Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, after normal pregnancy and delivery (Professional consensus). Starting effective contraception later 21 days after delivery in women who do not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended (grade B). Rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long-term is not recommended (Expert consensus). Pelvic-floor rehabilitation using pelvic-floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C). Postpartum pelvic-floor rehabilitation is not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). The optimal time for maternity discharge for low risk newborn depends more on the organisation of the post-discharge follow up (Professional consensus). The months following the birth are a transitional period, and psychological alterations concern all parents (EL2). It is more difficult in case of psychosocial risk factors (EL2). In situations of proven psychological difficulties, the impact on the psycho-emotional development of children can be important (EL3). Among these difficulties, postpartum depression is the most common situation. However, the risk is generally higher in the perinatal period for all mental disorders (EL3). CONCLUSION: Postpartum is, for clinicians, a unique and privileged opportunity to address the physical, psychological, social and somatic health of their patients.

[Postnatal visit: Routine and particularity after complicated pregnancy--Guidelines for clinical practice]. / Modalités de la consultation postnatale et spécificités en cas de pathologie de la grossesse: recommandations pour la pratique clinique.

OBJECTIVES: To propose guidelines for clinical practice for routine postnatal visit and after pathological pregnancies. MATERIALS AND METHODS: Bibliographic searches were performed with PubMed and Cochrane databases, and within international guidelines references. RESULTS: Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, when after normal pregnancy and delivery (Professional consensus). If any complication occurred, this visit should be handled by an obstetrician (Professional consensus). Physical examination should focus on patient symptoms and pregnancy complications (Professional consensus). Gynecological examination is not systematic (Professional consensus). Pap smear should be performed if previous exam was done more than 2years ago or when the previous exam was abnormal (Professional consensus). Weight should be measured to encourage weight loss (Professional consensus), with the aim to catch up preconceptional weight within 6 months after delivery (gradeC). Professional intervention may reduce weight retention (professional consensus). Tobacco, alcohol and illicit drugs cessation should be promoted (grade B) and supported by a professional (grade A). Obstetrical risks consecutive to short interval between pregnancies should be explained (evidence level [EL]: 3) and contraception discussed regarding family project (Professional consensus). Mother mood, mother to child relationship and breastfeeding troubles should be systematically evaluated (professional consensus). Pelvic-floor rehabilitation should be performed only when urinary of fecal incontinence persist 3 months after delivery (Professional consensus). Serological screening for toxoplamosis (grade B) and blood hemoglobin concentration should not be systematically performed (gradeC). After spontaneous preterm birth, women should be screened for uterine anomalies and treatment should be discussed (Professional consensus). Evidence is lacking to recommend any exploration to diagnose cervical incompetence (Professional consensus). When investigations are performed, there is no argument to recommend a specific exam (Professional consensus). Women should be screened for antiphospholipid antibodies after severe or early pre-eclampsia, IUGR or intra-uterine fetal death (Professional consensus) but screening for inherited thrombophilia is not recommended (grade B). Women with persistent proteinuria and/or hypertension 3 months after pre-eclampsia should be referred to a nephrologist (Professional consensus). Normalization of liver enzymes should be checked 8 to 12 weeks after intrahepatic cholestasis of pregnancy (Professional consensus). A synthetic document should be send to the women corresponding physicians (Professional consensus). Preconceptional counseling is recommended (Professional consensus). CONCLUSION: A postpartum visit is recommended 6 to 8 weeks after delivery, including mother physical and psychological evaluation and information about contraception, short interval between pregnancy, weight loss, smoking cessation (Professional consensus). To ensure continuity in the management of women health, relevant medical elements will be pass on to the corresponding physicians (Professional consensus).

[Vaccination in the early post-partum: Guidelines]. / Les vaccinations dans le post-partum immédiat: recommandations.

OBJECTIVES: To propose guidelines for clinical practice regarding pertussis, influenza, varicella and rubella vaccination in the early post-partum. MATERIALS AND METHODS: Bibliographic searches were performed with PubMed and Cochrane databases, and within national guidelines and their references. RESULTS: Women that have not got vaccinated in the past 10 years should receive a dose of diphtheria-tetanus-acellular pertussis-poliomyelitis vaccine in the early post-partum, and the family and friends should be included in the cocooning strategy (professional consensus). During seasonal influenza epidemic, influenza vaccine should be offered to women, who were not vaccinated during pregnancy, and delivered a vulnerable neonate (professional consensus). For all other women, the vaccination can be discussed on a case-by-case basis (professional consensus). In order to prevent congenital or neonatal varicella in a subsequent pregnancy, scientific data are weak to suggest a systematic screening and vaccination against varicella in women with no history or uncertain status about varicella, excepted in women coming from sub-Saharan Africa, East and Central Europe, more likely to have a negative serology for varicella (professional consensus). In order to prevent severe varicella in adulthood, the vaccination should be discussed with potentially seronegative women as recommended by the French High Council for Public Health (professional consensus). Rubella vaccine is recommended in the early post-partum with women with negative serology during pregnancy with a dose of measles-mumps-rubella vaccine (professional consensus). A new pregnancy should be avoided in the month following rubella and varicella vaccination, but contraception is not obligatory (professional consensus). Breastfeeding, recent rhesus immunoglobulin injection and blood transfusion do not prevent to perform vaccination in the early post-partum (professional consensus).

P-leader multifractal analysis and sparse SVM for intrapartum fetal acidosis detection.

Interpretation and analysis of intrapartum fetal heart rate, enabling early detection of fetal acidosis, remains a challenging signal processing task. Among the many strategies that were used to tackle this problem, scale-invariance and multifractal analysis stand out. Recently, a new and promising variant of multifractal analysis, based on p-leaders, has been proposed. In this contribution, we use sparse support vector machines applied to p-leader multifractal features with a double aim: Assessment of the features actually contributing to classification; Assessment of the contribution of non linear features (as opposed to linear ones) to classification performance. We observe and interpret that the classification rate improves when small values of the tunable parameter p are used.

Intrapartum fetal heart rate classification from trajectory in Sparse SVM feature space.

Intrapartum fetal heart rate (FHR) constitutes a prominent source of information for the assessment of fetal reactions to stress events during delivery. Yet, early detection of fetal acidosis remains a challenging signal processing task. The originality of the present contribution are three-fold: multiscale representations and wavelet leader based multifractal analysis are used to quantify FHR variability ; Supervised classification is achieved by means of Sparse-SVM that aim jointly to achieve optimal detection performance and to select relevant features in a multivariate setting ; Trajectories in the feature space accounting for the evolution along time of features while labor progresses are involved in the construction of indices quantifying fetal health. The classification performance permitted by this combination of tools are quantified on a intrapartum FHR large database (≃ 1250 subjects) collected at a French academic public hospital.

Nearest-neighbor based wavelet entropy rate measures for intrapartum fetal heart rate variability.

The interpretation and analysis of intrapartum fetal heart rate (FHR), enabling early detection of fetal acidosis, remains a challenging signal processing task. The ability of entropy rate measures, amongst other tools, to characterize temporal dynamics of FHR variability and to discriminate non-healthy fetuses has already been massively investigated. The present contribution aims first at illustrating that a k-nearest neighbor procedure yields estimates for entropy rates that are robust and well-suited to FHR variability (compared to the more commonly used correlation-integral algorithm). Second, it investigates how entropy rates measured on multiresolution wavelet and approximation coefficients permit to improve classification performance. To that end, a supervised learning procedure is used, that selects the time scales at which entropy rates contribute to discrimination. Significant conclusions are obtained from a high quality scalp electrode database of nearly two thousands subjects collected in a French public university hospital.

Low dimensional manifold embedding for scattering coefficients of intrapartum fetale heart rate variability.

Intrapartum fetal surveillance for early detection of fetal acidosis in clinical practice focuses on reducing neonatal morbidity via early detection. It is the subject of on going research studies attempting notably to improve detection performance by reducing false positive rate. In that context, the present contribution tailors to fetal heart rate variability analysis a graph-based dimensionality reduction procedure performed on scattering coefficients. Applied to a high quality and well-documented database constituted by obstetricians from a French academic hospital, the low dimensional embedding enables to distinguish between the temporal dynamics of healthy and acidotic fetuses, as well as to achieve satisfactory detection performance detection compared to those obtained by the clinical-benchmark FIGO criteria.

Risk of gestational trophoblastic neoplasia after hCG normalisation according to hydatidiform mole type.

OBJECTIVE: The risk of gestational trophoblastic neoplasia (GTN) after a hydatidiform mole (HM) is well known. However, the risk of GTN after normalisation of hCG in HM is poorly reported. The aim of this study was to evaluate the risk of GTN after normalisation of hCG according to HM types. METHODS: This prospective cohort study carried out between 2000 and 2010 used the database of the French Trophoblastic Disease Centre (FTDC). A total of 2008 registered patients with ascertained types of HM were analysed. Cases of GTN occurring after normalisation of hCG were analysed. RESULTS: A GTN developed in 239 out of 1980 HMs (12.1%) and 6 out of these 239 post-molar GTN (2.5%) were diagnosed after normalisation of hCG. The risk of GTN after normalisation of hCG was 0.34% (6/1747) following a HM, 0% (0/593) after a partial HM (PHM), 0.36% (4/1122) after a complete HM (CHM), and 9.5% (2/21) after a multiple pregnancy with HM. CONCLUSIONS: The risk of post-molar GTN justifies hCG monitoring in all women with HM. However, after normalisation of hCG, monitoring of PHM can be stopped safely while it should be maintained for CHM and more importantly for multiple pregnancies with HM.

[Prolonged hospitalization versus home management for women with arrested preterm labour: a before-after study]. / Hospitalisation prolongée ou retour à domicile des menaces d'accouchement prématuré : une étude avant-après.

OBJECTIVES: To compare gestational age at birth and incidence of preterm birth inferior to 37 weeks of gestation (WG) in single pregnancies with either prolonged hospitalization, or early home discharge after arrested preterm labour. PATIENTS AND METHODS: Management of preterm labour was changed in our public academic hospital because no evidence of benefits for prolonged hospitalization was found and because adverse effects related to long-term hospitalization were described. In this retrospective before-after study, we compare the attitude A (December 2006 to April 2008), a prolonged hospitalization until 32 or 34WG, with new attitude B (May 2008 to February 2010), an early discharge home if the cervical exam was unchanged since admission. RESULTS: A total of 140 patients were included: 70 in each group. Initial hospitalization stay was significantly shorter in Group B (respectively, 5.4±5.4 days and 11.4±12.1 days; P<0.05). Preterm spontaneous delivery is 14 (20%) in group A and 21 (28.6%) in Group B (P>0.05). Gestational ages at birth were 33(5/7) and 33(0/7) WG in groups A and B, respectively (P>0.05). If we focus on patients who were discharged home in the two groups (women who did not deliver no matter the hospitalization length), the gestational age at birth (38(4/7) and 38WG; ns) and the prematurity rate inferior to 37WG (17.2% and 22.4%; ns) were statistically similar. DISCUSSION AND CONCLUSION: This study suggests that shorter hospitalization does not decrease the delivery term, nor does it increase the premature delivery incidence.

[Adding parity to the Bishop score for term labor induction: a retrospective study]. / Score de Bishop modifié par la parité pour le déclenchement du travail à terme: une étude rétrospective.

OBJECTIVE: To evaluate the interest to add parity to the Bishop score before induction of labor by intravenous oxytocin. PATIENTS AND METHODS: This retrospective cohort study compared cesarean section rate for induction failure by intravenous oxytocin in nulliparous and multiparous with modified Bishop score from 7 to 9. The modified Bishop score is calculated by adding 2 points to the Bishop score if the patient had a previous vaginal delivery and 0 point in nulliparous. RESULTS: Over 2 years, 468 patients were included (201 nulliparous and 267 multiparous). Cesarean section rate for induction failure was higher for nulliparous with a modified Bishop score equal to 7 or varying between 7 and 9. These results confirm that parity is an important predicting factor of successful labor induction. In multiparous, cesarean section rates for induction failure were not significantly different with Bishop score or modified Bishop score equal to 7. CONCLUSION: Adding 2 points for multiparity at the Bishop score did not increase cesarean for failure of labor induction with intravenous oxytocin with a modified Bishop score from 7 to 9.

[Which biological test to confirm rupture of membranes?]. / Quel test biologique utiliser en cas de suspicion de rupture des membranes ?

Rupture of membranes (ROM) occurs frequently and requires specific management depending on gestational age in order to avoid maternal and fetal complications. In 80% of cases, ROM is associated with large amniotic fluid (AF) leakage making diagnosis easy. The aim of the current review is to precise which biological test is useful for the physician facing ambiguous clinical picture. Vaginal pH assessment demonstrates alkalinisation (6.5-7.5) when AF is present (sensitivity 73-91%, specificity 72-83%). Drying test, fern test or fetal cells staining have been supplanted by detection of AF proteins. Diamine oxidase activity required specific radioanalytical assay leading to restrictive use and progressive abandon. Immunoassay tests detecting Insulin-like Growth Factor-Binding Protein-1 (IGFBP-1) or Placental Alpha 1-Microglobulin (PAMG-1) are currently considered as the most useful tools for ROM diagnosis. Literature fails to provide sufficient evidence that one of these two approaches should be favoured. Distinction between IGFBP-1 and PAMG-1 remains controversial as they seem to correspond to the same molecule.

[Is it possible to prevent preterm births outside of level-3 maternity wards? Experience of Greater Lyon perinatal network]. / Les naissances des grands prématurés en dehors des maternités de type III sont-elles évitables? Expérience du réseau Grand Lyon.

OBJECTIVE: The main objective of this study was to calculate the percentage of preterm births before 28 weeks gestational age (weeks GA) outside level-3 maternity wards and determine how many could have been prevented. METHODS: This was an observational, multicenter, retrospective cohort study, which included all the deliveries that occurred between 24 and 27 weeks GA + 6 days in the Greater Lyon perinatal network (France) occurring between first of March 2008 and first of March 2009. In utero transfers (IUTs) and newborn transfers (NBTs) which were carried out outside the network, medical abortions, and foetal deaths in utero were excluded. The duration between patient's arrival in the level 1 and 2 maternity and birth was compared at the 97(th) percentile of the mother's transfer time in level-3 maternity. Births that occurred outside of level-3 maternity wards were considered avoidable each time the first duration was more than the second. RESULTS: During the study period, 113 infants were born alive between 24 and 27 weeks GA+6 days in the network. They were all included in the study. Ninety were born in a level-3 maternity ward and 23 were born in level-1 and 2 maternity wards (20%). There were 35 requests for IUT and 28 were carried out (80%). In 65% of non-level 3 births, no IUT was requested. In 17% of cases, an IUT request could have prevented births in level 1/2 maternity wards. If twin pregnancies had been transferred to a level-3 maternity ward, 26% of non-level 3 births would have been avoided. If all high-risk pregnancies had been transferred to a level-3 maternity ward, 40% of non-level 3 births would have been avoided. DISCUSSION AND CONCLUSION: Any time a pregnant woman is hospitalized in a type 1/2 maternity ward before 28 weeks GA, doctors should consider an in utero transfer to a level-3 maternity ward. It may be possible to lower the birth-rate of non-level 3 births by a targeted increase in in utero transfers and by transferring high-risk pregnancies to a level-3 maternity ward.

Adaptive multiscale complexity analysis of fetal heart rate.

Per partum fetal asphyxia is a major cause of neonatal morbidity and mortality. Fetal heart rate monitoring plays an important role in early detection of acidosis, an indicator for asphyxia. This problem is addressed in this paper by introducing a novel complexity analysis of fetal heart rate data, based on producing a collection of piecewise linear approximations of varying dimensions from which a measure of complexity is extracted. This procedure specifically accounts for the highly non-stationary context of labor by being adaptive and multiscale. Using a reference dataset, made of real per partum fetal heart rate data, collected in situ and carefully constituted by obstetricians, the behavior of the proposed approach is analyzed and illustrated. Its performance is evaluated in terms of the rate of correct acidosis detection versus the rate of false detection, as well as how early the detection is made. Computational cost is also discussed. The results are shown to be extremely promising and further potential uses of the tool are discussed. MATLAB routines implementing the procedure will be made available at the time of publication.

Methodology for multifractal analysis of heart rate variability: from LF/HF ratio to wavelet leaders.

The present contribution aims at proposing a comprehensive and tutorial introduction to the practical use of wavelet Leader based multifractal analysis to study heart rate variability. First, the theoretical background is recalled. Second, practical issues and pitfalls related to the selection of the scaling range or statistical orders, minimal regularity, parabolic approximation of spectrum and parameter estimation, are discussed. Third, multifractal analysis is connected explicitly to other standard characterizations of heart rate variability: (mono)fractal analysis, Hurst exponent, spectral analysis and the HF/LF ratio. This review is illustrated on real per partum fetal ECG data, collected at an academic French public hospital, for both healthy fetuses and fetuses suffering from acidosis.

[Physiologic basis for fetal heart rate analysis during labour]. / Bases physiologiques de l'analyse du rythme cardiaque foetal au cours du travail.

Fetal monitoring during labour aims to identify fetal acidosis responsible for brain lesions or perpartum death. In France, continuous recording of fetal heart rate (FHR) is largely used during labour. However, FHR interpretation remains difficult, as no specific sign for fetal hypoxia or acidosis have been described. Fetal heart rate is regulated by the autonomous nervous system including the chemoreflex, the baroreflex and the central nervous system. Appropriate regulation is conditioned by tissue oxygenation. Therefore, basal FHR physiologic instability is reduced when fetal hypoxia or acidosis occur, leading to reduce variability. FHR decelerations are frequent during labour due to either fetal response to physiologic modification of oxygenation during labour or fetal hypoxia, which should be differentiated in order to avoid inappropriate intervention. Knowledge of physiologic mechanisms involved in FHR regulation and fetal haemodynamic adaptation to hypoxia could help in learning FHR interpretation. This review is exposing the factors regulating FHR and the mechanisms involved in fetal circulatory responses to hypoxia and acidosis.