Evaluation of obstetric management of women with macrosomic foetuses in two Level 3 maternity hospitals in France and identification of predictive factors for obstetric and neonatal complications.

OBJECTIVE: Foetal macrosomia is associated with high maternal and neonatal morbidity; however, obstetric management of suspected macrosomia has not been well defined. This study aimed to analyse obstetric management in a population of women who delivered macrosomic new-borns and assess maternal and neonatal outcomes and risk factors for complications in such cases. STUDY DESIGN: This two-centre retrospective study conducted in France over a 10-year period comprised 1724 women who had delivered macrosomic new-borns (defined as those whose weight was > 90th percentile according to the Association of Users of Computerised Records in Perinatology, Obstetrics, and Gynaecology curve) from 37SA. RESULTS: In this study, the caesarean section and instrumental extraction rates were 24.1% and 15.7%, respectively, and the postpartum haemorrhage rate was 7%. The rate of shoulder dystocia was 23.1% (including brachial plexus injuries, 0.4%; and clavicular fractures, 2.0%). Significant risk factors for caesarean section were maternal height < 160 cm, nulliparity, history of caesarean section, excessive uterine height, induction of labour and duration of labour > 10 h. The risk factors for shoulder dystocia were maternal height < 160 cm and instrumental extraction. CONCLUSION: The study findings may help determine predictive factors for an unfavourable outcome at the time of delivery of a macrosomic foetus, thus allowing clinical teams to better anticipate and manage potential complications.

[Effectiveness of preventive cervical cerclage to prevent preterm birth in women with twin gestation with obstetrical history of late pregnancy loss or preterm birth]. / Efficacité du cerclage préventif indiqué sur des antécédents obstétricaux en cas de grossesse gémellaire.

OBJECTIVES: Evaluate the effectiveness of preventive cervical cerclage for twin pregnancy with obstetrical history. METHODS: Through this retrospective cohort study, subjects exposed between 2002 and 2017 were compared with unexposed ones. All patients who had twin pregnancy with at least one previous late pregnancy loss or prematurity before 34SA were included. Two groups were compared: "preventive cerclage" versus "no preventive cerclage". The outcome was the prematurity before 34 gestation weeks (GW) rate. RESULTS: Among 1972 twin pregnancies registered between 2002 and 2017, 69 (3.5%) patients with at least one previous late pregnancy loss or prematurity before 34 GW, were part of the study. There were 20 (29.0%) women in the group "preventive cerclage" and 49 (71.0%) women in the group "no preventive cerclage". Women in the "preventive cerclage" group had poorer obstetrical history. The rate of prematurity before 34GW was not significantly different between these both groups (45.0% versus 44.9%; P=0.99, crude OR: 1.00 (0.35-2.83), adjusted OR: 1.06 (0.33-3.44)). CONCLUSIONS: The prematurity rate before 34GW, in twin pregnancies with a previous late pregnancy loss or preterm birth, is not different with or without preventive cervical cerclage.

A case of non-treated Trichomonas vaginalis infection and severe preterm labor with positive obstetrical outcome.

Trichomonas vaginalis is a very common, sexually transmitted, infection that may sometimes be asymptomatic or cause vaginitis and urethritis. Recently, it has been associated with adverse obstetric outcomes such as preterm delivery, low birth weight and premature rupture of membranes. Trichomonas vaginalis can be vertically transmitted at birth. It has been found in pharynx and low respiratory tract of neonates with respiratory disease. It has also been involved in some cases of intellectual disability. The recommended treatment is a 2g metronidazole oral single dose, even for asymptomatic patients. This treatment is effective against Trichomonas and its use is safe during pregnancy. We report here a case of Trichomonas vaginalis infection diagnosed during pregnancy in a patient with severe preterm labor. The patient being allergic to nitroimidazole antibiotics, she did not receive any treatment. She finally gave birth at 34 weeks of gestation (WG) and 5 days, with no other adverse outcome than small prematurity.

Effectiveness of elective cervical cerclage according to obstetric history.

OBJECTIVE: To assess the effectiveness of elective history-indicated cervical cerclage according to obstetrical history. STUDY DESIGN: We analyzed pregnancy outcome of a retrospective cohort of women who have had history-indicated McDonald's cerclage. Principal outcome was gestational age (GA) at delivery. RESULT: Between January 2003 and December 2013, 205 women were included. We analyzed population in two risk groups: 1- Low-risk (≤2 prior preterm birth (PTB)/second trimester loss (STL), or prior success of cerclage), 2- High risk (≥3 prior PTB/STL, or prior failure of cerclage). In the high-risk group, there was a higher frequency of deliveries before 37 weeks (47.5% vs. 24.5%, P=0.001, OR=2.79, 95% CI [1.49-5.23]). Fifty percent of women (n=6/12) delivered before 37 weeks in case of three or more prior PTB/STL, and 51% (n=24/47) in case of prior failure of cervical cerclage. CONCLUSION: Elective cervical cerclage may be indicated for women with≤2 prior PTB/STL, or prior successful cerclage. For women with≥3 prior PTB/STL, trachelorraphy or cervico-isthmic cerclage could be possible alternatives to cervical cerclage.

[Insulin treatment of gestational diabetes and respiratory outcome in late-preterm and term babies]. / Diabète gestationnel traité par insuline et risque de détresse respiratoire sévère chez le nouveau-né de plus de 34 semaines d'aménorrhée.

While the incidence of diabetes mellitus (DM) during pregnancy has been steadily increasing in recent years, the link between gestational DM and respiratory outcome in neonates has not been firmly established. To address this gap in understanding, we asked whether DM status and its treatment during pregnancy influence risk of neonatal respiratory distress. We conducted retrospective analysis of a large cohort to determine the relationship between maternal DM status (non-DM, insulin-treated DM [DTI], and non-insulin-treated DM [DTR]) and respiratory distress in term and near-term singletons, born at Robert-Debré Hospital over a 7-year period. Of 18,095 singletons delivered at 34 weeks of gestation or later, 412 (2.3%) were admitted to the NICU for respiratory distress within the first hours of life. The incidence of NICU admissions due to respiratory distress was 2.2% in the non-DM group, 2.1% in the DTR group, and 5.7% in the DTI group. Insulin treatment of DM, together with several other perinatal factors, was associated with an increased risk for severe respiratory distress. In a multivariate model, we found that DTI, but not DTR, was a risk factor independent of gestational age and cesarean section, with an IRR of 1.44 (95% CI, 1.00-2.08). The data indicate that newborns of mothers with DM treated with diet are not at risk for severe respiratory distress. Conversely, newborns of mothers with DM treated with insulin are associated with elevated risk for severe respiratory disease and should therefore be closely monitored.

Trachelorraphy in cases of recurrent second trimester loss and prior failed vaginal cerclage.

OBJECTIVE: To evaluate the obstetric results of trachelorraphy in the prevention of recurrent second trimester loss in cases of prior failed vaginal cerclage. STUDY DESIGN: Data were collected retrospectively and prospectively from medical records. The analysis examined data for 18 women who underwent trachelorraphy between 2004 and 2013 at a tertiary referral unit in France. All patients in this high-risk population had a history of two or more second trimester losses, or one second trimester loss and one preterm labour, and at least one prior failed transvaginal cerclage. The main outcome measures were: livebirth rate; rate of second trimester loss; and surgical complications. RESULTS: Twenty pregnancies were conceived in 16 patients following trachelorraphy. Three patients experienced two pregnancies. Among the 20 pregnancies, there was one case of fetal loss in the first trimester; this pregnancy was excluded from the analysis. Of the remaining 19 pregnancies, there were nine (47%) term deliveries (after 37 weeks of gestation), seven (32%) preterm deliveries and three (16%) second trimester losses. The overall fetal survival rate was 84%. Surgical outcomes were excellent, with no complications. CONCLUSION: Trachelorraphy is a safe, reproducible, easy-to-learn procedure for the prevention of recurrent second trimester loss in cases of prior failed vaginal cerclage. The procedure has encouraging and favourable perinatal outcomes in patients with a poor obstetric history.

[Epignathus teratoma: diagnostic and neonatal management; a case report]. / Tératome épignathe: diagnostic et prise en charge néonatale; à propos d'un cas.

Epignathus teratoma is a rare tumor whose prognosis essentially depends on its resectability and on neonatal care. When it is undiagnosed prenatally, mortality is close to 100 % at birth, because of obstruction of the upper airways. We present a case of epignathus teratoma detected during obstetrical ultrasound screening. Diagnosis enabled planning for a safe delivery in a suitable multidisciplinary unit and use of the EXIT procedure.

[Analysis of fetal heart rate abnormalities occurring within one hour after laying of epidural analgesia]. / Analyse des anomalies du rythme cardiaque fœtal survenant dans l'heure suivant la pose d'une analgésie péridurale.

OBJECTIVES: The objective of this study is to classify abnormalities of fetal heart rate (FHR) occurring in the first hour after performing the epidural analgesia, and to assess the impact of these abnormalities on delivery and on after-birth neonatal state. PATIENTS AND METHODS: Retrospective study of 6676 patients continuously from 1 January 2007 to 31 December 2010 who benefited, during the labor, of epidural analgesia. Seven hundred and sixty (14,1%) presented anomalies of FHR in the hour following the laying of epidural (group 1), and 5916 showed no abnormalities of the RCF (group 2). RESULTS: Among the 760 anomalies of the FHR in the hour following the laying of epidural, 319 (42%) showed prolonged decelerations, 169 (22.2%) variable decelerations, 122 (16.1%) early decelerations, 110 (14.5%) late decelerations and 40 bradycardia (5.3%). In the group 1, incidence of caesarean delivery was 21.4% (163 patients); in group 2, it was 9.63% (P<0.002). In group 1, the umbilical artery pH was less than 7.20 in 13,6% of patients, whereas in group 2, the prevalence was only 6,5% (P<0.002). There is no statistically significant differences on Apgar score between the two groups. CONCLUSION: This study helped to characterize anomalies in the FHR following epidural. There is an increase of obstetric interventions. There is no impact on neonatal clinical state. The administration of systematic ephedrine shall be investigated to reduce these interventions.

[Induction of labour and breech presentation: experience of a French maternity ward]. / Induction du travail et présentation du siège : expérience de la maternité de l'hôpital Robert-Debré, Paris.

INTRODUCTION: For a few years, we can notice a progressive increase in the practice of systematic caesarean delivery as far as breech delivery is concerned. This is true notably since the publication of Hannah's "Term Breech Trial" in 2000 which recommends systematic caesarean delivery in the case of breech presentation. But the conclusions of this North-American study are questionable, knowing that French practice is often quite different from Hannah's study. OBJECTIVE: In the maternity ward of the French hospital Robert-Debré, Paris, vaginal delivery may be authorized as far as breech presentation is concerned if defined obstetrical criteria are met. Labour can be induced when a maternal or fetal indication exists. In the following study, we tried to assess our practice. STUDY DESIGN: Our retrospective study included 624 patients with a breech presentation, of which 501 within the group of spontaneous labour (group 1) and 123 within the group of cervical preparation and induced labour (group 2), for the period going from 1 January 2000 to 31 December 2008. RESULTS: The results do comfort our attitude since they show equivalent results in terms of delivery mode and neonatal issues between breech presentations with spontaneous labour on one hand, and with labour induced by cervical maturation on the other hand. CONCLUSION: The primary objective of this study was to evaluate an unusual operating practice in a well-trained level 3 obstetrical team. The results do comfort our attitude since they show equivalent results in terms of delivery mode and neonatal issues between breech presentations with spontaneous labour on one hand, and with labour induced by cervical maturation on the other hand. It seems however difficult to extrapolate our results and apply them to usual practice due to the lack of power of a retrospective and non-randomized study. Setting up a randomized and prospective study seems however difficult because of the medical and ethical problems it would raise.

Monitoring healthcare quality in an obstetrics and gynaecology department using a CUSUM chart.

OBJECTIVE: To use cumulative sum (CUSUM) charts for the early detection of variations in quality of care in a maternity department. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Maternity department of a teaching hospital in Paris (France). POPULATION: Data from 20 519 women and 21 448 infants were collected between January 2000 and December 2007. METHODS: CUSUM charts were used to monitor the rate of 19 pre-selected quality indicators over 3 years (2005-2007), against standards developed by department obstetrician gynaecologists. Periods with adverse event rates that did not meet the standards were identified. MAIN OUTCOME MEASURES: Quality indicator rates. RESULTS: Indicators fell into three groups based on the number of periods with unacceptable rates: less than one per year [e.g. the rate of intensive care unit (ICU) admission of mothers and rate of third- or fourth-degree perineal tears]; one every 2-12 months on average (e.g. blood transfusion and sulprostone use in the overall population of women); and at least one per month (insufficient availability of epidural analgesia). CONCLUSION: CUSUM charts for a broad range of quality indicators can be used to monitor the quality of care in an obstetrics department. A prospective study investigating the ability of CUSUM-based monitoring to improve maternal and neonatal outcomes would be of interest.

[Unusual complication of uterine leiomyoma: spontaneous avulsion with massive hemoperitoneum]. / Complication rare d'un léiomyome utérin: énucléation spontanée avec hémopéritoine.

A 25-year-old woman gravida 0 was seen for haemoperitoneum secondary to spontaneous avulsion of a uterine leiomyoma. It is a life-threatening complication. A myomectomy was performed. Through a case, we report a revue of the literature of haemoperitoneum complicating uterine leiomyoma.

Impact of fetal growth restriction on body composition and hormonal status at birth in infants of small and appropriate weight for gestational age.

BACKGROUND: Fetal growth restriction (FGR) has been related to several health risks, which have been generally identified in small-for-gestational age (SGA) individuals. OBJECTIVE: To evaluate the impact of FGR on body composition and hormonal status in infants born either small- or appropriate-for-gestational age (AGA). METHODS: Fetal growth was assessed by ultrasound every 4 weeks from mid-gestation to birth in 248 high-risk pregnancies for SGA. Fetal growth velocity was calculated as change in the estimated fetal weight percentiles and FGR defined as its reduction by more than 20 percentiles from 22 gestational weeks to birth. Impact of FGR on body composition, cord insulin, IGF-I, IGF binding protein-3 (IGFBP-3), and cortisol concentrations was assessed in SGA and AGA newborns. RESULTS: Growth-retarded AGA infants showed significantly reduced birth weight, ponderal index, percentage of fat mass, and bone mineral density when compared with AGA newborns with stable intrauterine growth. Cord IGF-I and IGFBP-3 concentrations were significantly decreased in growth-retarded infants in both SGA and AGA groups. Cord insulin concentration was significantly lower and cord cortisol significantly higher in AGA infants with FGR versus AGA newborns with stable intrauterine growth. After adjustment for gestational age and gender, birth weight was directly related to fetal growth velocity and cord IGF-I concentration. The variation in infant's adiposity was best explained by fetal growth velocity and cord insulin concentration. CONCLUSIONS: FGR affects body composition and hormonal parameters in newborns with birth weight within the normal range, suggesting these individuals could be at similar metabolic risks as SGA. .

[Primary ovarian leiomyosarcoma in perimenarche]. / Léiomyosarcome primitif de l'ovaire en périménarche.

Primary ovarian leiomyosarcoma is an extremely rare tumor, which is thought to arise predominantly in postmenopausal women. We report the second case in a perimenarchal adolescent. Diagnosis was grounded on light microscopic and histochemical findings. In our case, the treatment was exclusively surgical. As there was no tumoral residue, and according to the low-grade tumor, no adjuvant treatment was performed.

Uterine compression sutures for postpartum bleeding with uterine atony.

OBJECTIVE: To assess the efficacy of a new uterine compression suturing technique in reducing postpartum haemorrhage secondary to severe uterine atony. DESIGN: Retrospective study. SETTING: University hospital between December 2000 and March 2006. POPULATION: Twenty women with uterine atony and postpartum bleeding that did not react to usual medical management. METHODS: All these women underwent compression suturing of the uterus, in which the anterior and posterior walls of the uterus were attached so as to compress the uterus. MAIN OUTCOME MEASURES: Arrest of the bleeding, complications and fertility. RESULTS: Uterine compression suturing was sufficient to stop the bleeding immediately in 95% of the women. None of the women developed complications related to the procedure. All the women recovered normal menstrual cycles. Since uterine compression suturing, eight women have tried to conceive and six (75%) have had a term delivery. CONCLUSION: Uterine compression suturing is a simple conservative procedure to stop postpartum haemorrhage in the case of failure of the usual management. This surgical technique can be performed quickly and does not seem to decrease fertility.

The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage.

BACKGROUND: Postpartum hemorrhage (PPH) is a major source of maternal morbidity. OBJECTIVES: This study's objective was to determine whether changes in hemostasis markers during the course of PPH are predictive of its severity. PATIENTS AND METHODS: We enrolled 128 women with PPH requiring uterotonic prostaglandin E2 (sulprostone) infusion. Two groups were defined (severe and non-severe PPH) according to the outcome during the first 24 hours. According to our criteria, 50 of the 128 women had severe PPH. Serial coagulation tests were performed at enrollment (H0), and 1, 2, 4 and 24 hours thereafter. RESULTS: At H0, and through H4, women with severe PPH had significantly lower fibrinogen, factor V, antithrombin activity, protein C antigen, prolonged prothrombin time, and higher D-dimer and TAT complexes than women with non-severe PPH. In multivariate analysis, from H0 to H4, fibrinogen was the only marker associated with the occurrence of severe PPH. At H0, the risk for severe PPH was 2.63-fold higher for each 1 gL(-1) decrease of fibrinogen. The negative predictive value of a fibrinogen concentration >4 gL(-1) was 79% and the positive predictive value of a concentration

A comparison of the neonatal morbidity of second twins to that of a low-risk population.

OBJECTIVE: To assess the neonatal morbidity of second twins. STUDY DESIGN: Cohort study in a department of perinatalogy. The neonatal morbidity of second twins was compared to that of a low-risk population: singletons in the cephalic presentation delivered vaginally. RESULTS: Five hundred fifty-nine second twins and 18,061 vaginally delivered singletons in the cephalic presentation were studied. Of 452 (81%) second twins delivered vaginally, 310 (69%) were extracted using obstetrical maneuvers: internal version and breech extraction, breech extraction alone, or assisted breech delivery if the breech was already engaged. Before 33 weeks of gestation, there was no significant difference between the neonatal morbidity of the vaginally delivered second twins and the vaginally delivered singletons in the cephalic presentation. After 33 weeks of gestation, only the 1-min Apgar score <7 and the rate of intubation at birth were significantly higher in the second twins. Whatever the gestational age, there was no significant difference between the neonatal morbidity of the vaginally delivered second twins and that of the second twins born by cesarean section before labor. At comparable gestational ages, there was no significant difference between the death rate of the vaginally delivered second twins and that in the reference population. CONCLUSION: The neonatal morbidity of second twins was comparable to that of a low-risk population. Immediate management of the vaginally delivered second twins was, however, more intensive than that of vaginally delivered singletons in the cephalic presentation. It, therefore, requires appropriate equipment in a suitable obstetric-pediatric setting.

Esophageal ligature in experimental gastroschisis.

BACKGROUND/PURPOSE: Recently, the authors have shown that in human fetuses suffering from gastroschisis, there is an amniotic fluid inflammatory response and that amniotic fluid exchange designed to disrupt the inflammatory loop seems to have a favorable impact on outcome. The authors, therefore, designed in the fetal sheep a model of gastroschisis in which amnioinfusion significantly improved the deleterious process. They hypothesized that regurgitation and presence of digestive enzyme in the amniotic fluid triggers and maintains the process of inflammation. METHODS: To test this hypothesis, the authors used their model of gastroschisis in the fetal lamb combined with esophageal ligation and compared it with gastroschisis with or without amnioinfusion. RESULTS: Of 34 fetuses operated on at midgestation (days 70 through 80), 11 died in utero or were stillborn, 8 had gastroschisis and amnioinfusion, 8 had gastroschisis and no amnioinfusion, and 7 had gastroschisis and esophageal ligation. There were 9 control fetuses. Fetuses were killed at day 145 by cesarean section. Extraabdominal bowels with fibrous peel were processed for histologic examination. Thickness of bowel muscularis (micrometers) was 82.7 +/- 19 for controls, 159 +/- 56 for the nonamnioinfused fetuses, 126 +/- 21 for the amnioinfused fetuses (P =.001), and 240 +/- 225.8 for fetuses with esophageal ligature combined with gastroschisis. The same results were obtained for thickness of serous fibrosis and plasma cell infiltration. Assay of amniotic fluid ferritin, lipase, and protein showed that only amnioinfusion lowered ferritin and protein to levels similar to those of controls, thus, illustrating its preventive effect on inflammation and that esophageal ligature did not prevent digestive enzyme presence in the amniotic fluid. CONCLUSION: In this model of gastroschisis in the fetal sheep, ligature of the esophagus, which was supposed to protect the extruded bowel by preventing oral regurgitation of digestive enzymes and by creating a relative hydramnios, did not improve the inflammatory and deleterious process, which is best prevented by amnioinfusion.

[Interventional radiology in managing post-partum hemorrhage]. / Place de la radiologie interventionnelle dans la prise en charge des hémorragies du post-partum.

UNLABELLED: EMBOLISATION OF THE UTERINE ARTERIES: Is the technique of choice for the management of post-partum hemorrhage, since it is efficient and virtually non-invasive. However, initial obstetrical measures and appropriate reanimation should never be neglected. The decision for embolisation must be made by all of the competent staff (obstetrician, reanimator, interventional radiologist). The clinical state of the patient must be assessed and the biological controls analyzed and eventually the decision can be made to transfer the patient to a specialized unit equipped not only with a team of interventional radiologists but also a multi-disciplinary team, experienced in the management of this type of pathology. PRACTICAL METHODS: An arterial inducer is placed in the femoral artery under local anesthesia. The angiographic exploration includes, when necessary, a global series showing the aorta and the pelvic vessels followed by the successive exploration of the two internal iliac arteries. Embolisation, conducted under scopic control, must be bilateral. Gelatin fragments or powder is the most appropriate embolus. LIMITS: Very few maternal delivery structures are able to perform an arterial embolisation at any time of the day or night. This raises the problem of transporting patients with uncontrolled hemorrhages; only those who exhibit no hemorrhagic disorders can be transported fairly easily. EFFICACY AND COMPLICATIONS: Concerning the three principle causes at the origin of post-partum hemorrhages, efficacy is constant in the case of uterine atonia; conversely, failures have been reported in the case of cervical-vaginal tearing and abnormal placental insertion (placenta accreta). In young women with healthy arteries, the complications of uterine embolisation during post-partum hemorrhage are exceptional.

[Antiviral and non-antiviral local and general treatments for herpes in the pregnant woman (including prevention of mother-infant transmission): alternative propositions]. / Quelles sont les modalités des traitements locaux et généraux, médicamenteux ou non, dans la prise en charge de l'herpès de la femme enceinte (y compris la prévention de la transmission mère-enfant).

Herpes may be manifest during pregnancy as a primary infection, as a recurrent infection, or as asymptomatic excretion. Genital herpes can cause neonatal contamination with rare but very serious consequences for the child if specific treatment is not given rapidly. The gravity of neonatal herpes warrants prophylactic measures including cesarean section if the risk is high. Cesarean section must be considered as a prophylactic measure and by consequence may be performed in some cases when not absolutely necessary.