Primary cesarean delivery rate: Potential impact of a checklist.

BACKGROUND: Cesarean section is the most common surgical procedure performed in developed countries. Its incidence is increasing to a worrisome extent. The 2003 French National Perinatal Survey showed that the inflation in the overall cesarean rate was mainly due to an increase in the first cesarean delivery rate. OBJECTIVE: To evaluate a new tool: a checklist that intent to decrease the first cesarean delivery rate. STUDY DESIGN: Retrospective, observational, multi-center study. A new tool, a "First cesarean delivery" checklist was built according American and French guidelines. Women with full-term of pregnancy, nulliparous or multiparous with a first caesarean delivery including arrest of labor, breech presentation or suspected fetal macrosomia were included. The checklist was applied. Potentially preventable cesareans were analyzed. RESULTS: Among 571 first cesarean section, 178 were eligible to check list application. 147 charts were analyzed in the study. 11.9% of first cesarean deliveries performed were potentially avoidable after applying the checklist. This represented 6.6% of all cesareans. CONCLUSION: The checklist based on the recall of good practices could be an interesting tool to decrease the first cesarean rate.

French validation and adaptation of the Grobman nomogram for prediction of vaginal birth after cesarean delivery.

OBJECTIVE: To validate Grobman nomogram for predicting vaginal birth after cesarean delivery (VBAC) in a French population and adapt it. STUDY DESIGN: Multicenter retrospective study of maternal and obstetric factors associated with VBAC between May 2012 and May 2013 in 6 maternity units. External validation and adaptation of the prenatal and intrapartum Grobman nomograms for vaginal birth prediction after cesarean delivery in a French cohort. RESULTS: The study included 523 women with previous cesarean deliveries; 70% underwent a trial of labor for a subsequent delivery (n=367) with a success rate of 65% (n=240). In the univariate analysis, 5 factors were associated with successful VBAC: previous vaginal delivery before the cesarean (P<0.001), the number of previous vaginal deliveries (P<0.001), and a favorable cervix at delivery room admission, cervical effacement (P=0.035), or cervical dilatation at least 3cm (P<0.001), or a Bishop score >6 (P=0.03). A potentially recurrent indication (defined as arrest of dilation or descent as the indication for the previous cesarean) (P=0.039), a hypertensive disorder during pregnancy (P=0.05), and labor induction (P=0.017) were each associated with failed VBAC. External validation of the prenatal and intrapartum Grobman nomograms showed an area under the ROC curve of 69% (95% CI: 0.638, 0.736) and 65% (95% CI: 0.599, 0.700) respectively. Adaptation of the nomogram to the French cohort resulted in the inclusion of the following factors: maternal age, body mass index at last prenatal visit, hypertensive disorder, gestational age at delivery, recurring indication, cervical dilatation, and induction of labor. Its area under the curve to predict successful VBAC was 78% (95% CI: 0.738, 0.825). CONCLUSION: The nomogram to predict VBAC developed by Grobman et al. is validated in the French population. Adaptation to the French population, by excluding ethnicity, appeared to improve its performance. Impact of the nomogram use on the caesarean section rate has to be validated in a randomized control trial.

[Newborn outcomes after radiofrequency ablation for selective reduction in the complicated monochorionic pregnancies]. / Devenir neurodéveloppemental des nouveau-nés issus de grossesses monochoriales compliquées avec interruption sélective par ablation par radiofréquence.

OBJECTIVE: To describe perinatal data and to evaluate the neonatal neurological outcome of monochorionic twin pregnancies with selective termination by radiofrequency ablation. METHODS: Retrospective data of perinatal data for nine consecutive monochorionic pregnancies eligible for radiofrequency ablation from January 2013 to August 2015 were collected. A prospective observational study of the neurological outcome of nine children was conducted using the Ages & Stages Questionnaire (ASQ), 2nd edition, French version, adapted to the age. RESULTS: The radiofrequency procedures were performed at a mean gestational age (GA) of 21.4 weeks (±7 weeks). The indications for a selective interruption of a pregnancy were: acardiac twin (n=4), brain malformation (n=1), severe intrauterine growth restriction (IUGR) with massive cerebral ischemia in the context of twin-twin transfusion syndrome grade III (n=1), severe selective IUGR associated with a polymalformative syndrome (n=1) and severe selective IUGR (n=2). The mean GA at birth was 36.7 weeks GA (±3.8 weeks). No infant showed neurological neonatal morbidity. Any ASQ area explored was pathological (<-2SD) for the nine children (mean age at follow-up [±SD], 14.8 months [±8.8 months]). CONCLUSION: This work constitutes a preliminary study for developing long-term follow-up and early care programs for those children born subsequent to a radiofrequency ablation for selective reduction.

[Surgical treatment of postpartum hemorrhage]. / Prise en charge chirurgicale d'une hémorragie du post-partum.

OBJECTIVE: Systematic revue of different conservative and non-conservative surgical treatment of postpartum hemorrhage (PPH). Elaboration of surgical strategy after failed medical treatment of PPH. METHODS: French and English publications were identified through PubMed and Cochrane databases. RESULTS: Each obstetrical unit has to rewrite a full protocol of management of PPH depending on local environment quickly available in theatre (professional consensus). Conservative surgical treatment of PPH: efficacy of vascular ligature (bilateral uterine artery ligation (BUAL) or bilateral hypogastric artery ligation (BHAL)) as a first line of surgical treatment of PPH is about 60 % to 70 % (EL4). Bilateral uterine artery ligation (BUAL) is easy to perform with low rate of immediate severe complication (professional consensus). BUAL as BHAL seems not to affected fertility and obstetrical outcomes of next pregnancies (EL4). Efficacy of haemostatics brace suturing in case of failed medical treatment of PPH is about 75 % (EL3), without risk of major obstetrical complications at the next pregnancy (EL4). Radical surgical treatment of PPH: total hysterectomy is not significantly associated with more urinary tract injury in comparison with subtotal hysterectomy (EL3). Choice of surgical procedure of hysterectomy (total or subtotal) will depend on local consideration and clinicians habits (professional consensus). Surgical strategy: conservative surgical treatment are efficient and associated with low morbidity, they have to be primarily performed in women with further fertility desire. Specific medical consideration as massive PPH or cardiovascular instability has to consider performing haemostatic hysterectomy as the first line surgical treatment of PPH. PPH during caesarean delivery: in case of PPH during caesarean section, embolisation is not recommended, surgical treatment using vascular devascularisation or compression brace suturing should be performed (professional consensus). Surgical conservative technique will depend on local considerations and clinicians habits (professional consensus). PPH diagnosed after caesarean section should indicate relaparotomy. Arterial embolisation, if quickly vacant in the same hospital, may be performed in case of cardiovascular stability without surgical complication diagnoses on intraperitoneal hemorrhage (professional consensus). PPH during vaginal delivery: cardiovascular instability centre indicate the interhospital transfer and must lead to achieve haemostatic surgery on site (professional consensus). In the presence of a unit of embolisation in the maternity delivery, it is preferable to move towards embolisation, if maternal hemodynamic status permits (professional consensus). In case of cardiovascular stability associated with absence of heavy bleeding, the interhospital transfer may be considered for arterial embolisation (professional consensus). CONCLUSION: When medical treatment of PPH failed, conservative surgical treatment has a 70 % efficacy to stop hemorrhage whatever treatment used (vascular ligature or haemostatics brace suturing). In absence of rapid response to conservative medical and surgical treatment, hysterectomy should be performed without delay (professional consensus).

[Management of preterm and prelabour rupture of membranes in France]. / Pratiques en France de prise en charge des ruptures prématurées des membranes.

INTRODUCTION: Preterm premature rupture of the membranes (PPROM) is a frequent complication of pregnancy leading to prematurity and neonatal infection. The management of PPROM is not consensual in France and practices between maternities are variable. We subjected type 2B and 3 maternity units to a questionnaire regarding their practices concerning the PPROM. RESULTS: Our study includes 59 type 2B maternity units and 59 type 3 maternity units. Corticotherapy is proposed in all of type 3 maternity units and in 96.5% of type 2B maternity units. Antibiotics are administered at the patient admission in 96.6% of type 3 maternity units and 86% of type 2B maternity units. Tocolytics are used systematically in 31% of maternity units and only in case of contractions in 62% of maternity units. No maternity unit indicates birth systematically after corticotherapy before 32 weeks of gestation (WG). An early delivery is proposed in 9.5% of maternity units between 32 and 34 WG and in 58% of maternity units between 34 and 37 WG. CONCLUSION: Corticotherapy and antibiotics are predominantly administered at the time of the diagnosis, as recommended by the HAS and CNGOF. Despite the lack of recommendation, an expectative management until 34 WG, in absence of any sign of chorioamnionitis, seems to be the choice of most maternity units.

[Predictive factors for vaginal birth after cesarean section]. / Quels facteurs influencent la voie d'accouchement en cas de tentative de voie basse sur utérus cicatriciel ?

OBJECTIVES: Determination of predictive factors of vaginal delivery in women with a history of caesarean section undergoing a trial of labor. MATERIALS AND METHODS: Relevant studies were identified through Medline, and the Cochrane databases 1980-2012. Recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: In France in 2010, a trial of labor was attempted in 49 % with 75 % successful rate (EL2). The site of delivery does not appear to influence the rate of successful trial of labor (EL3). Two factors are strongly associated with vaginal birth after caesarean (VBAC): prior history of vaginal delivery and spontaneous labor (EL2). Many factors appear to decrease the rate of VBAC: maternal age above 40 years (EL3), body mass index greater than 30 kg/m(2) (EL3), birth weights greater than 4000 g (EL3), unfortunately, prediction of macrosomia seems to be inaccurate. Induction of labor with pharmacological (prostaglandins and oxytocin) and mechanical methods (Foley catheter) decreased rate of successful VBAC (EL2). The use of pelvimetry to accept or avoid trial of labor, increase the risk of elective caesarean section (EL2) and should therefore not be recommended (grade C). Nomograms are not accurate to predict fail trial of labor as its clinical relevance is limited and has not yet evaluated in French population (expert opinion). CONCLUSION: After caesarean, trial of labor is associated with 75 % successful rate. Two factors are strongly associated with VBAC: a prior history of vaginal delivery and spontaneous labor.

[Prolonged pregnancy: when should surveillance be started and what should be the frequency?]. / Grossesses prolongées (termes dépassés) : à partir de quand doit-on surveiller et à quelle fréquence ?

OBJECTIVE: To determine when surveillance should be started in prolonged pregnancy and what would be the more appropriate frequency for it. STUDY DESIGN: Systematic searches of Medline and the Cochrane Library were performed. RESULTS: Fetal mortality diminishes from 37 weeks of gestation to a nadir of one death for 1000 births at 40(+0) weeks. It increases thereafter up to three deaths for 1000 births at 43(+0) weeks. Perinatal mortality rates show same pattern and is estimated to be of two and four to six deaths for 1000 births at 41(+0) and 43(+0) weeks, respectively. However, current available data does not allow for the determination of a gestational age cut-off associated with major increase of perinatal mortality and on which surveillance of prolonged pregnancy should be genuinely started. French epidemiological data from 2003 indicate that although 52.5% of pregnant women have reached 40(+0) weeks only 20,7% and 1% have reaches 41(+0) and 42(+0) weeks, respectively. Intrauterine fetal growth associated with prolonged pregnancy increases perinatal mortality. In most randomized trials having compared labour induction with expectant management, fetal surveillance was started at 41(+0) weeks. CONCLUSION: Due to the increased risk of perinatal mortality, it seems appropriate that fetal surveillance is started at 41(+0) weeks (expert opinion). This implies a rational organization of care to support surveillance of 20% of pregnant women. The frequency of this monitoring consisting of at least twice-weekly cadiotocography and ultrasound estimation of amniotic fluid (expert opinion).

[Obstetrical outcome and risk of uterine rupture following a caesarean section before 32 weeks]. / Modalités d'accouchement et risque de rupture utérine après césarienne réalisée avant 32 semaines d'aménorrhée.

OBJECTIVE: Our aim was to evaluate the subsequent obstetrical outcome and rate of uterine rupture following a caesarean section before 32 weeks of gestation. PATIENTS AND METHODS: A retrospective cohort study of 200 consecutive women with a prior caesarean section performed between 25 and 32 weeks were contacted by questionnaire or followed through medical charts to determine the subsequent mode of delivery. RESULTS: Two hundred caesarean section were performed between 25 and 32 weeks from January 1997 to March 2000. Thirty-nine patients (19.2%) were lost to follow-up. Seventy-one patients had a subsequent delivery. Thirty-two attempted vaginal birth and the success rate was 87.5%. Thirty-nine patients had a subsequent caesarean. One case of uterine rupture occurred before labour at 31 weeks (1.4%, % IC 95% [0.25; 7.56]). CONCLUSION: After a previous caesarean delivery before 32 weeks, a trial of labour may be proposed when obstetrical conditions are optimal. However, uterine rupture may occur prior to labor.

[Can we foretell preeclampsia?]. / Comment prédire la prééclampsie ?

Predicting PE would enable a better understanding of the physiological mechanisms responsible for this disease. It would also permit the identification of an at-risk population and consequently ease the set up of clinical trials. Over 12,000 articles have been published on this subject. Critical review of the literature reveals that none of the investigations, performed individually, bears sufficient predictive value. However, it appears that the current tendency is to apply a combined approach associating clinical, ultrasonographic and biological factors.

[Oxygen embolism after hydrogen peroxide irrigation of a breast abscess]. / Embolie gazeuse après utilisation d'eau oxygénée pour le traitement d'un abcès mammaire.

We report the case of oxygen embolism after inappropriate hydrogen peroxide irrigation of a breast abscess in a young patient. The issue proved to be both rapid and favourable.