Cost-effectiveness of screening and valacyclovir-based treatment strategies for first-trimester cytomegalovirus primary infection in pregnant women in France.

OBJECTIVE: To assess the effectiveness, cost and cost-effectiveness of four screening strategies for first-trimester (T1) cytomegalovirus (CMV) primary infection (PI) in pregnant women in France. METHODS: In a simulated pregnant population of 800 000 (approximate number of pregnancies each year in France), using costs based on the year 2022, we compared four CMV maternal screening strategies: Strategy S1, no systematic screening (current public health recommendations in France); Strategy S2, screening of 25-50% of the pregnant population (current screening practice in France); Strategy S3, universal screening (current medical recommendations in France); Strategy S4, universal screening (as in Strategy S3) in conjunction with valacyclovir in case of T1 PI. Outcomes were total cost, effectiveness (number of congenital infections, number of diagnosed infections) and incremental cost-effectiveness ratio (ICER). Two ICERs were calculated, comparing Strategies S1, S2 and S3 in terms of euros (€) per additional diagnosis, and comparing Strategies S1 and S4 in € per avoided congenital infection. RESULTS: Compared with Strategy S1, Strategy S3 enabled diagnosis of 536 more infected fetuses and Strategy S4 prevented 375 congenital infections. Strategy S1 was the least expensive strategy (€98.3m total lifetime cost), followed by Strategy S4 (€98.6m), Strategy S2 (€106.0m) and Strategy S3 (€118.9m). In the first analysis, Strategy S2 was dominated and Strategy S3 led to an additional €38 552 per additional in-utero diagnosis, compared with Strategy S1. In the second analysis, Strategy S4 led to an additional €893 per avoided congenital infection compared with Strategy S1, and was cost-saving compared with Strategy S2. CONCLUSIONS: In France, current screening practice for CMV PI during pregnancy is no longer acceptable in terms of cost-effectiveness because this strategy was dominated by universal screening. Moreover, universal screening in conjunction with valacyclovir treatment would be cost-effective compared with current recommendations and is cost-saving compared with current practice. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Impact of variants of SARS-CoV-2 on obstetrical and neonatal outcomes.

BACKGROUND: SARS-CoV-2 can lead to several types of complications during pregnancy. Variant surges are associated with different severities of disease. Few studies have compared the clinical consequences of specific variants on obstetrical and neonatal outcomes. Our goal was to evaluate and compare disease severity in pregnant women and obstetrical or neonatal complications between variants of SARS-CoV-2 that have circulated in France over a two-year period (2020-2022). METHOD: This retrospective cohort study included all pregnant women with a confirmed SARS-CoV-2 infection (positive naso-pharyngeal RT-PCR test) from March 12, 2020 to January 31, 2022, in three tertiary maternal referral obstetric units in the Paris metropolitan area, France. We collected clinical and laboratory data for mothers and newborns from patients' medical records. Variant identification was either available following sequencing or extrapolated from epidemiological data. RESULTS: There were 234/501 (47%) Wild Type (WT), 127/501 (25%) Alpha, 98/501 (20%) Delta, and 42/501 (8%) Omicron. No significative difference was found regarding two composite adverse outcomes. There were significantly more hospitalizations for severe pneumopathy in Delta variant than WT, Alpha and Omicron respectively (63% vs 26%, 35% and 6%, p<0.001), more frequent oxygen administration (23% vs 12%, 10% and 5%, p = 0,001) and more symptomatic patients at the time of testing with Delta and WT (75% and 71%) versus Alpha and Omicron variants (55% and 66% respectively, p<0.01). Stillbirth tended to be associated with variants (p = 0.06): WT 1/231 (<1%) vs 4/126 (3%), 3/94 (3%), and 1/35 (3%) in Alpha, Delta and Omicron cases respectively. No other difference was found. CONCLUSION: Although the Delta variant was associated with more severe disease in pregnant women, we found no difference regarding neonatal and obstetrical outcomes. Neonatal and obstetrical specific severity may be due to mechanisms other than maternal ventilatory and general infection.

[Sepsis during pregnancy: Key points in 2022]. / Sepsis et grossesse.

Sepsis is a severe affection, that requires an urgent and specific treatment sequence. Physiological changes occurring during pregnancy make the diagnosis of sepsis more challenging in this setting, with possible delay in treatment initiation, that in turn is responsible for poorer maternal and fetal outcome. This review aims to summarize current knowledge on the diagnosis and treatment of maternal sepsis, as well as persistent knowledge gaps in the field.

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]. / La technique de la césarienne : recommandations pour la pratique clinique du Collège national des gynécologues obstétriciens français.

OBJECTIVE: To identify procedures to reduce maternal morbidity during cesarean. MATERIAL AND METHODS: The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS: Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds. CONCLUSION: In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

New data on efficacy of valacyclovir in secondary prevention of maternal-fetal transmission of cytomegalovirus.

OBJECTIVE: Congenital cytomegalovirus (CMV) infection is the leading cause of non-genetic hearing and neurological deficits. The aim of our study was to evaluate the efficacy and safety of valacyclovir (VCV) treatment in preventing CMV transmission to the fetus after maternal primary infection. METHODS: This was a retrospective, multicenter study evaluating the rate of maternal-fetal CMV transmission in pregnancies with maternal primary CMV infection treated with VCV at a dosage of 8 g per day (VCV group) compared with a control group of untreated women. Each case underwent virological testing to confirm maternal primary infection and to provide accurate dating of onset of infection. The primary outcome was the presence of congenital CMV infection at birth diagnosed based on polymerase chain reaction analysis of saliva, urine and/or blood samples. The efficacy of VCV treatment was assessed using logistic regression analysis adjusted for a propensity score. RESULTS: In total, 143 patients were included in the final analysis, of whom 59 were in the VCV group and 84 were in the untreated control group. On propensity-score-adjusted analysis, VCV treatment was significantly associated with an overall reduction in the rate of maternal-fetal CMV transmission (odds ratio, 0.40 (95% CI, 0.18-0.90); P = 0.029). The rate of maternal-fetal CMV transmission, determined at birth, in the VCV vs control group was 7% (1/14) vs 10% (1/10) after periconceptional maternal primary infection (P = 1.00), 22% (8/36) vs 41% (19/46) after first-trimester maternal primary infection (P = 0.068) and 25% (2/8) vs 52% (14/27) after second-trimester maternal primary infection (P = 0.244). When analyzing the efficacy of VCV treatment according to maternal viremia at treatment initiation, there was a trend towards greater efficacy when patients were viremia-positive (21% vs 43%; P = 0.072) compared with when they were viremia-negative (22% vs 17%; P = 0.659). Maternal side effects associated with VCV were mild and non-specific in most cases. CONCLUSION: Our findings indicate that VCV treatment of pregnant women with primary CMV infection reduces the risk of maternal-fetal transmission of CMV and may be effective in cases with primary infection in the first and second trimesters. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Guidelines for the management of urgent obstetric situations in emergency medicine, 2022

To provide recommendations on the management of urgent obstetrical emergencies outside the maternity ward. A group of 24 experts from the French Society of Emergency Medicine (SFMU), the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French College of Gynaecologists and Obstetricians (CNGOF) was convened. Potential conflicts of interest were formally declared at the outset of the guideline development process, which was conducted independently of industry funding. The authors followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method to assess the level of evidence in the literature. The potential drawbacks of strong recommendations in the presence of low-level evidence were highlighted. Some recommendations with an insufficient level of evidence were not graded. Eight areas were defined: imminent delivery, postpartum haemorrhage (prevention and management), threat of premature delivery, hypertensive disorders in pregnancy, trauma, imaging, cardiopulmonary arrest, and emergency obstetric training. For each field, the expert panel formulated questions according to the PICO model (population, intervention, comparison, outcomes) and an extensive literature search was conducted. Analysis of the literature and formulation of recommendations were conducted according to the GRADE method. Fifteen recommendations on the management of obstetrical emergencies were issued by the SFMU/SFAR/CNGOF panel of experts, and 4 recommendations from formalised expert recommendations (RFE) established by the same societies were taken up to answer 4 PICO questions dealing with the pre-hospital context. After two rounds of voting and several amendments, strong agreement was reached for all the recommendations. For two questions (cardiopulmonary arrest and inter-hospital transfer), no recommendation could be made. There was significant agreement among the experts on strong recommendations to improve practice in the management of urgent obstetric complications in emergency medicine.

[SARS-Cov-2 vaccine's acceptance among pregnant women-A cross-sectional survey]. / Acceptabilité du vaccin-Sars CoV-2 chez les femmes enceintes, une enquête transversale par questionnaire.

OBJECTIVE: SARS-CoV-2 is more likely to cause severe cases in pregnant women. They were part of the priority groups since April 2021 to benefit from SARS-CoV-2 vaccination before its extent to general population. This contribution aims to evaluate, in the postpartum period, the achievement of COVID-19 vaccination and factors associated in women during their pregnancy. MATERIAL AND METHOD: Multicenter cross-sectional survey study conducted from September to December 2021 with online self-questionnaire. All postpartum patients hospitalized in one of the 6 participating maternity hospitals were invited to answer. The questionnaire asked patients about their demographic characteristics, vaccination modalities, vaccine tolerance, and their general perception of vaccination. RESULTS: Of the 371 women who responded, the vaccination rate was 65.7% (IC95% [60.8-70.4]), whom 98.8% entirely during pregnancy. Associated factors with vaccination during pregnancy were older age, higher socio-professional category, and prior information provided by health professionals. Factors that appear to motivate vaccination were personal protection and protection of the newborn. Finally, main factors negatively influencing the vaccination process were the fear of vaccine side effects and the negative perception of vaccines in general. DISCUSSION: Acceptability and information about the vaccine by health professionals is in constant improvement. Information campaigns should be continued to improve the acceptability of vaccination, in light of the accumulating data.

[CNGOF clinical practice guidelines: Evaluation one year after revision of the methodology]. / Recommandations pour la pratique clinique du CNGOF : évaluation un an après révision de la méthodologie.

OBJECTIVES: To evaluate the revision of methodology of the clinical practice guidelines (CPG) of the French National College of Gynecologists and Obstetricians (CNGOF). METHOD: Three CPGs were organized in 2020 on the topics of severe preeclampsia, menorrhagia, and prophylactic surgery according to AGREE II (Apraisal of Guidelines for Research & Evaluation). Questions were presented in PICO (Population, Intervention, Comparison, Outcome) format and the grading of scientific evidence was based on the GRADE (Grading of Recommendation Assessment, Development and Evaluation) method. RESULTS: All three CPGs groups adhered to this new methodology. However, the presentation of the arguments, the formulation of the recommendations and the development of the GRADE tables were heterogeneous from one group to another. A homogenization of the presentation is proposed, as well as a guide to the critical analysis of the literature to help the experts to rate the evidence. CONCLUSION: Adherence to these quality criteria should make it easier to apply the recommendations at the national level and improve international recognition of the work done by the CNGOF.

A new individualized prognostic approach to the management of women at risk of extreme preterm birth in France: Effect on neonatal outcome.

INTRODUCTION: After discussion with the parents, periviable infants can receive either active treatment or palliative care. The rate of active treatment in France is lower than in other developed countries, as is the survival rate of infants in this gestational age range. This study's main objective was to assess the effect of a standardized perinatal management protocol (EXPRIM) on the neonatal outcome of children born before 27 weeks of gestation. METHODS: A before-and-after study was conducted in the two level-3 hospitals of the Risks and Pregnancy DHU to compare two 16-month periods. The EXPRIM protocol was based on routine administration of prenatal corticosteroid therapy and a scheduled combined obstetric-pediatric group prenatal prognostic evaluation, not based solely on gestational age. The study included all births between 22 weeks and 26 weeks+6 days of gestation, except in utero deaths diagnosed at admission and medical terminations of pregnancy for fetal malformation, both excluded. The principal endpoint was survival without severe neonatal morbidity. RESULTS: The study included 267 women: 116 (128 newborns) in period 1 and 151 (172 newborns) in period 2. The median gestational age at admission to the maternity unit was 2.5 days younger in period 2, and the number of women admitted at 22-23 weeks doubled in period 2 (59 vs 29, respectively). Overall, the rates of live births, NICU transfer, and survival without severe morbidity were similar during the two periods. More infants were liveborn between 22 and 24 weeks in period 2 (66 vs 43). Of all newborns transferred to the NICU, 26 (29%) survived without severe morbidity in period 1 and 46 (39%) in period 2. After multivariate analysis, survival without severe morbidity did not differ significantly. CONCLUSION: Implementation of the EXPRIM protocol led to active treatment of more mothers and their children at the border of viability, and increased the number of children who survived without severe morbidity even if, overall, there was no statistically significant difference in percentage.

[Efficiency of Bakri intra uterine tamponade balloon use in postpartum hemorrhage: Before and after study]. / Efficacité de l'utilisation du ballonnet de tamponnement intra-utérin dans l'hémorragie du post-partum. Étude rétrospective monocentrique avant/après.

OBJECTIVE: To assess the impact of the introduction of intrauterine balloon tamponade on second-line management practices for post-partum hemorrhage (PPH). METHOD: This retrospective study was conducted in a tertiary care centre where arterial embolisation was not available. Two periods were compared, before (2008-2010) and after (2015-2017) the introduction of an intrauterine tamponade balloon protocol using the Bakri balloon. All consecutive patients with PPH refractory to sulprostone in the two periods were included. Outcomes studied were the incidence of invasive procedures (conservative surgery, embolisation, hysterectomy) as well as transfer to centres with arterial embolisation facilities. RESULTS: A total of 109 patients had refractory PPH, 44 in the first period and 65 in the second period. The proportion of all PPH cases which required sulprostone did not differ between the periods (24.2 and 29.3%, respectively, P=0.25). There were significant decreases between the first and the second period in the proportion requiring a transfer to an embolisation centre (79.6% during period 1, vs. 6.2% respectively, P<0.001), embolisation (20.6% vs. 0%, P<0.001), uterine compression sutures (13.6% vs. 3.1% P=0.04) and surgical management (22.7% vs. 7.7%, P=0.025). The decrease in the incidence of hysterectomy did not reach statistical significance (11,4 vs. 1,5%, P=0.095). Among 29 cases of PPH following cesarean sections (14 in the first period and 15 in the second period), we observed a significant decrease in transfer rates (66.7% vs. 0%, P<0.01), as well as decreases in embolisation (26.7% vs. 0%, P=0.10) and invasive procedures (60% vs. 28.7%, P=0.089), which did not reach statistical significance. CONCLUSION: The introduction of intrauterine tamponade was associated with a decrease in the need for invasive procedures. In a centre without access to on-site arterial embolisation, transfer rates were reduced improving patient comfort and reducing costs.

[Infection with SARS-CoV-2 in pregnancy. Update of Information and proposed care. CNGOF]. / Infection par le SARS-CoV-2 chez les femmes enceintes. Actualisation de l'état des connaissances et de la proposition de prise en charge. CNGOF.

OBJECTIVES: The coronavirus SARS-CoV-2 identified late 2019 in China had spread across all continents. In the majority of cases, patients have mild symptoms (fever, cough, myalgia, headache, some digestive disorders) or are asymptomatic, however it can cause serious lung diseases and lead to death. On September 2020, over 28 million people have been infected with over 920,000 deaths. METHODS: In view of the evolution of the epidemic the French National College of Obstetricians and Gynecologists has decided to update the recommendations previously issued. To do this, the same group of experts was called upon to carry out a review of the literature and take into account the opinions of the General Directorate of Health (DGS), the "Haute Autorité de Santé" (HAS) and the "Haut Conseil de santé Publique" (HCSP). RESULTS: The data on consequences during pregnancy have accumulated. The symptoms in pregnant women appear to be similar to those of the general population, but an increased risk of respiratory distress exists in pregnant women especially in the third trimester. A case of intrauterine maternal-fetal transmission has been clearly identified. Induced prematurity and cases of respiratory distress in newborns of infected mothers have been described. CONCLUSION: In light of the new data, we propose updated recommendations. These proposals may continue to evolve in view of the pandemic and of advances in studies in pregnant women.

Causes and consequences of fever during pregnancy: A retrospective study in a gynaecological emergency department.

OBJECTIVE: Fever is a very common reason for emergency consultation during pregnancy, and may be associated with maternal, obstetrical and/or fetal adverse outcomes. The aim of this study was to determine the etiologies and to analyze the maternal or fetal complications of fever in pregnancy. STUDY DESIGN: A retrospective single center study including all patients who consulted for fever above 38 °C during pregnancy in the gynecological emergency ward from August 2016 to July 2017. RESULTS: A total of 100 pregnant women who consulted for fever were included. The etiologies were common viral infections (37 %), influenza (21 %), pyelonephritis (11 %), viral gastroenteritis (6%), chorioamnionitis (5%), other (5%). The etiology was unknown for 15 %. Fever was confirmed during consultation in 45/100 patients (45 %). Among patients with confirmed fever, 21/45 (47 %) were hospitalized with a median stay of 3 days [IQR 2-4] and 10/45(22 %) developed fetal or maternal complications. Probabilistic antibiotics were delivered for 34/45, 76 % patients. Only 14/45, 31 % had confirmed bacterial infections. Of the 32 patients with confirmed fever who had no etiologic diagnosis at the initial work-up in the emergency room, 19/32, 59 % received presumptive treatment with amoxicillin against Listeria monocytogenes. None had confirmed listeriosis, and all were probably common viral infections. Among all patients, the complications rate was 13 % and 22 % in the subgroup with fever confirmed at presentation. CONCLUSIONS: This study quantifies the main etiologies and complications of fever during pregnancy. A challenge is to reduce excessive antibiotic use by improving rapid diagnosis of bacterial and viral infections. Prospective studies are needed to target patients at risk of complications in an optimal way and to study new management strategies.

Prenatal description of retinal coloboma.

Retinal coloboma is a rare condition which is difficult to diagnose in foetuses. It can cause blindness. It can be isolated or associated with other malformations in various syndromes. Our objective is to describe the different prenatal ultrasound findings and management of coloboma. We describe a case of prenatal ultrasound diagnosis of retinal coloboma at 27.5 weeks of gestation. Our case adds to the 8 previously reported in the prenatal ultrasound literature, which together illustrate that microphthalmia is the main associated sign, present in 66.6% (6/9) of cases followed by retro-orbital cysts (44.4%) (4/9). These two ultrasound findings should alert us to a close examination of the eye to look for a posterior retinal cleft, the main direct sign of a chorioretinal coloboma.

[SARS-CoV-2 infection during pregnancy. Information and proposal of management care. CNGOF]. / Infection par le SARS-CoV-2 chez les femmes enceintes : état des connaissances et proposition de prise en charge par CNGOF.

A new coronavirus (SARS-CoV-2) highlighted at the end of 2019 in China is spreading across all continents. Most often at the origin of a mild infectious syndrome, associating mild symptoms (fever, cough, myalgia, headache and possible digestive disorders) to different degrees, SARS-Covid-2 can cause serious pulmonary pathologies and sometimes death. Data on the consequences during pregnancy are limited. The first Chinese data published seem to show that the symptoms in pregnant women are the same as those of the general population. There are no cases of intrauterine maternal-fetal transmission, but cases of newborns infected early suggest that there could be vertical perpartum or neonatal transmission. Induced prematurity and cases of respiratory distress in newborns of infected mothers have been described. Pregnancy is known as a period at higher risk for the consequences of respiratory infections, as for influenza, so it seems important to screen for Covid-19 in the presence of symptoms and to monitor closely pregnant women. In this context of the SARS-Covid-2 epidemic, the societies of gynecology-obstetrics, infectious diseases and neonatalogy have proposed a French protocol for the management of possible and proven cases of SARS-Covid-2 in pregnant women. These proposals may evolve on a daily basis with the advancement of the epidemic and knowledge in pregnant women. Subsequently, an in-depth analysis of cases in pregnant women will be necessary in order to improve knowledge on the subject.

[Term Prelabor Rupture of Membranes: CNGOF Guidelines for Clinical Practice - Timing of Labor Induction]. / Rupture des membranes à terme avant travail. Recommandations pour la pratique clinique du CNGOF ­ Faut-il déclencher ?

OBJECTIVE: To assess the effect of immediate induction versus expectant management on maternal and neonatal outcomes in case of term prelabor rupture of membranes. METHODS: We searched Medline Database, Cochrane Library and consulted international guidelines. RESULTS: In case of term prelabor rupture of membranes, induction of labor is associated with shorter rupture of membranes to delivery intervals when compared to expectant management, if induction is conducted with oxytocin (LE2), prostaglandin E2 (LE2) or misoprostol (LE2), but not when induction is conducted with Foley® catheter (LE2), osmotic dilatator (LE2) or acupuncture (LE2). The strongest evidence to date comes from a large international randomized study, the TERMPROM study, which included over 5000 women between 1992 and 1995. This study compared immediate induction with oxytocin or prostaglandin E2 to expectant management up to 96hours, followed by induction by oxytocin or prostaglandin E2. Immediate induction was not associated with a decreased neonatal infection rate (LE1), even among women with a positive streptococcus B vaginal swab (LE2). Thus, expectant management can be offered without increasing the neonatal infection risk (Grade B). Induction with oxytocin was associated with a decreased risk of intra-uterine infection and postpartum fever in the TERMPROM study (LE2), however, this study had significant limitations concerning this outcome (unknown streptococcus B status and low rate of prophylactic antibiotics), and this association was not found in other smaller studies. This decrease was not observed with induction by prostaglandin E2. In the TERMPROM study, induction was not associated with an increase or decrease in the rate of cesarean section (LE2), whatever the parity (LE2) or Bishop score at admission (LE3). Induction can thus be proposed without increasing the cesarean section risk (Grade B). There is no study evaluating expectant management over 4 days. CONCLUSION: In case of term prelabor rupture of membranes, induction can be offered without increasing the cesarean section risk (Grade B). Expectant management can be offered without increasing the neonatal infection risk (Grade B), even among women with a positive streptococcus B vaginal swab (Professional consensus). The optimal moment of induction will therefore be guided by the maternity wards organization and women's preference after having informed them of the risks and benefits associated with induction and expectant management (Professional consensus). In case of meconial fluid or term prelabor rupture of membranes>4 days, induction must be offered (Professional consensus).

[Term Prelabor Rupture of Membranes: CNGOF Guidelines for Clinical Practice - Short Text]. / Rupture des membranes à terme avant travail. Recommandations pour la pratique clinique du CNGOF ­ Texte court.

OBJECTIVE: To determine the management of patients with term prelabor rupture of membranes. METHODS: Synthesis of the literature from the PubMed and Cochrane databases and the recommendations of French and foreign societies and colleges. RESULTS: Term prelabor rupture of membranes is considered a physiological process up to 12hours of rupture (Professional consensus). In case of expectant management and with a low rate of antibiotic prophylaxis, home care compared to hospitalization could be associated with an increase in neonatal infections (LE3), especially in case of group B streptococcus colonization (LE3). Home care is therefore not recommended (Grade C). In the absence of spontaneous labor within 12hours of rupture, antibiotic prophylaxis could reduce the risk of maternal intrauterine infection but not of neonatal infection (LE3). Its use after 12hours of rupture in term prelabor rupture of the membranes is therefore recommended (Grade C). When antibiotic prophylaxis is indicated, intravenous beta-lactams are recommended (Grade C). Induction of labor with oxytocin (LE1), prostaglandin E2 (LE1) or misoprostol (LE1), is associated with shorter rupture of membranes to delivery intervals when compared to expectant management. Compared with expectant management, immediate induction of labor is not associated with lower rates of neonatal infection (LE1), even among women with a positive streptococcus B vaginal swab (LE2). Thus, expectant management can be offered without increasing the risk of neonatal infection (Grade B). Induction of labor is not associated with an increase or decrease in the cesarean delivery rate (LE2), whatever parity (LE2) or Bishop score at admission (LE3). Induction can thus be proposed without increasing the risk of cesarean delivery (Grade B). No induction method (oxytocin, dinoprostone, misoprostol or Foley® catheter) has demonstrated superiority over another, whether to reduce rate of intrauterine or neonatal infection, rate of cesarean delivery or to shorten rupture of membranes to delivery intervals regardless of Bishop's score and parity. CONCLUSION: Term prelabor rupture of membranes is a frequent event. A 12-hour delay without onset of spontaneous labor was chosen to differentiate a physiological condition from a potentially unsafe situation justifying an antibiotic prophylaxis. Expectant management or induction of labor can both be proposed, even in case of positive screening for streptococcus B, depending on the patient's wishes and maternity units' organization (Professional consensus).

[In the case of premature live birth, is very early rupture of the membranes an additional risk factor for morbidity and mortality?] / En cas de naissance vivante prématurée, la rupture très précoce des membranes est-elle un facteur de risque supplémentaire de morbi-mortalité ?

OBJECTIVE: To describe survival rate after preterm premature rupture of membranes (PPROM) before 25 weeks of gestation and compare neonatal morbidity and mortality among those born alive with a control group of infants born at a similar gestational age without premature rupture of membranes. METHODS: We conducted a retrospective single-centre study at Port-Royal maternity, from 2007 to 2015, comparing neonatal outcomes between liveborninfants exposed to PPROM prior to 25 weeks of gestation (WG) and a control group not exposed to premature rupture of the membranes. For each live-born child, the next child born after spontaneous labor without PPROM was matched for gestational age at birth, sex, and whether or not they received antenatal corticosteroid therapy. The primary endpoint was severe neonatal complications assessed by a composite endpoint including neonatal deaths, grade 3-4 HIV, bronchopulmonary dysplasia, leukomalacia and stade 3-4 retinopathies. RESULTS: Among 77 cases of very premature rupture of the membranes, 55 children were born alive. Among these, the average gestational age at birth was 28 WG and 1 day. The rate of severe neonatal complications did not differ between the two groups (43.6% in the PPROM group vs. 36.4%, P=0.44) and the survival rate at discharge was also similar in the two groups (85.5% vs. 83.6%, P=0.98). CONCLUSIONS: In our cohort and among livebirths after 24 WG, PPROM before 25 WG was not associated with an increased risk of morbidity and mortality compared to children born at the same gestational age after a spontaneous labor with intact membranes.

[Impact of the detection of small for gestational age fetuses on the neonatal prognosis]. / Impact de la détection anténatale d'un fœtus petit pour l'âge gestationnel sur le pronostic néonatal.

OBJECTIVE: We sought to evaluate whether the antenatal identification of small for gestational age (SGA) fetuses could influence the neonatal and obstetric prognosis. METHODS: This was a retrospective cohort study. All liveborn singleton neonates with a birthweight<3rd centile, born>32 weeks of gestation between January 1, 2011 and December 31, 2012 were included. Fetuses were considered "suspected SGA" when the estimated fetal weight was<10th centile or when a diagnosis of clinical or ultrasound SGA was explicitly noted in the record. Obstetrical and neonatal follow-up and outcomes of suspected SGA (SGAS group) and non-suspected (SGANS group) were compared, with Chi2 and the Fisher exact test when appropriate. RESULTS: Hundred and forty-seven neonates were included. Among these, 54% were suspected SGA before birth. Gestational age was lower (38.5 weeks gestation [WG] vs. 39.6 WG, P<0.001) and there was a higher preterm birth rate in the SGAS group (10% vs. 0%, P=0.005). The rate of elective cesarean sections (17% vs. 3%, P=0.005) was higher in the SGAS group, whereas the rate of nonelective cesarean sections was lower (20% vs. 33%, P=0.002). Neonatal morbidity was similar in both groups, as well as birth weight. CONCLUSION: SGA fetal screening in our cohort was associated with a higher rate of medical intervention and preterm birth without neonatal benefit. Nevertheless, the study's power and methodology are not adequate to reduce the risk of fetal death in utero or severe asphyxia associated with non-identification of a SGA fetus.

[Detection of small for gestational age fetuses during third trimester ultrasound. A monocentric observational study]. / Détection des fœtus petits pour l'âge gestationnel lors de l'échographie du troisième trimestre. Étude observationnelle monocentrique.

OBJECTIVES: Fetus small for gestational age (SGA) screening rate is evaluated around 21,7 % in France. Recommendations were developed to improve the efficiency of ultrasound conducted in the third trimester (T3), because neonatal consequences can be significant. This study aims to evaluate screening of SGA during T3 ultrasound and to describe causes for failure and differences with the recommendations of CNGOF. METHODS: All children born between 2011 and 2012 with a birth weight below the 3rd percentile were included in this observational, retrospective, monocentric study. We noted that the diagnosis of SGA was placed on file. Then, as recommended by the CNGOF, we calculated estimated fetal weight (EFW) with Hadlock 3 and Hadlock 4, and the corresponding percentiles, using the biometrics from the ultrasound report. We thus could evaluate a new screening rate with SGA fetus identified through this technique. RESULTS: A total of 142 patients were included. By calculating correctly all EFW and checking abdominal circumference percentiles, the screening rate of SGA fetuses with T3 ultrasound increased from 40 % to 50 % and the overall screening rate (clinical and ultrasound) from 54 % to 66 %. CONCLUSION: By following the recommendations we found a real improvement in fetal SGA screening rates to T3 ultrasound with a potential benefit for their care.