[Prospective evaluation of the knowledge of couples concerning the prenatal screening ultrasound]. / Évaluation prospective des connaissances des couples concernant l'échographie de dépistage prénatal.

OBJECTIVES: Evaluation of the knowledge of couples concerning the prenatal screening ultrasound in order to improve information. METHODS: This prospective, observational and comparative study was carried out in three maternal centers: a level III maternity, a level II private maternity, and a private gynecologist's office where prenatal screening ultrasounds were performed between the first of March 2018 and the 31th of April 2018. A questionnaire was given to all pregnant women coming to consult for a prenatal screening ultrasound. It included items on maternal characteristics, pregnancy characteristics, and screening ultrasound. RESULTS: One hundred and sixty-nine women answered the questionnaire. On the 138 participants who had consulted in the level III maternity, 42 % expected them to study fetal well-being, 38 % growth, and 13 % malformation. Forty-six percent attested to have received a request for consent, as well as information about these ultrasounds. The same is true for the 120 spouses in thelevel III maternity where only 7 % expected a malformation search to be carried out. The number of participants in the type II private maternity and the private gynecologist's office was insufficient. CONCLUSION: The information given and received, and the knowledge of couples in this level III maternity about the prenatal screening ultrasound seem to be insufficient. It is therefore important to inform the pregnant women and their spouse by giving consent before the first ultrasound and by a verbal message, simple and clear about what the professional is looking for in order to reduce this discrepancy, and thus prepare the couple in case of announcement of an anomaly.

Rate of caesarean sections according to the Robson classification: Analysis in a French perinatal network - Interest and limitations of the French medico-administrative data (PMSI).

INTRODUCTION: The objective of our study was to determine, in accordance with WHO recommendations, the rates of Caesarean sections in a French perinatal network according to the Robson classification and determine the benefit of the medico-administrative data (PMSI) to collect this indicator. This study aimed to identify the main groups contributing to local variations in the rates of Caesarean sections. MATERIAL AND METHODS: A descriptive multicentric study was conducted in 13 maternity units of a French perinatal network. The rates of Caesarean sections and the contribution of each group of the Robson classification were calculated for all Caesarean sections performed in 2014. The agreement of the classification of Caesarean sections according to Robson using medico-administrative data and data collected in the patient records was measured by the Kappa index. We also analysed a 6 groups simplified Robson classification only using data from PMSI, which do not inform about parity and onset of labour. RESULTS: The rate of Caesarean sections was 19% (14.5-33.2) in 2014 (2924 out of 15413 deliveries). The most important contributors to the total rates were groups 1, 2 and 5, representing respectively 14.3%, 16.7% and 32.1% of the Caesarean sections. The rates were significantly different in level 1, 2b and 3 maternity units in groups 1 to 4, level 2a maternity units in group 5, and level 3 maternity units in groups 6 and 7. The agreement between the simplified Robson classification produced using the medical records and the medico-administrative data was excellent, with a Kappa index of 0.985 (0.980-0.990). CONCLUSION: To reduce the rates of Caesarean sections, audits should be conducted on groups 1, 2 and 5 and local protocols developed. Simply by collecting the parity data, the excellent metrological quality of the medico-administrative data would allow systematisation of the Robson classification for each hospital.

[Fetal death beyond 14 weeks of gestation: induction of labor and obtaining of uterine vacuity]. / Mort fœtale in utero au-delà de 14SA : induction du travail et obtention de la vacuité utérine.

The objective of this review was to assess benefits and harms of different management options for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14 weeks of gestation. In second-trimester, the data are numerous but low methodological quality. In terms of efficiency (induction-expulsion time and uterine evacuation within 24 hours rate) and tolerance in the absence of antecedent of caesarean section, the best protocol for induction of labor in the second-trimester of pregnancy appears to be mifepristone 200mg orally followed 24-48 hours later by vaginal administration of misoprostol 200 to 400 µg every 4 to 6 hours. In third-trimester, there is very little data. The circumstances are similar to induction of labor with living fetus. A term or near term, oxytocin and dinoprostone have a marketing authorization in this indication but misoprostol may be an alternative as the Bishop score and dose of induction of labor with living fetus. In case of previous caesarean section, the risk of uterine rupture is increased in case of a medical induction of labor with prostaglandins. The lowest effective doses should be used (100 to 200 µg every 4 to 6 hours). Prior cervical preparation by the administration of mifepristone and possibly the use of laminar seems essential in this situation.

[Uterine artery pseudoaneurysm: an unusual cause of postpartum hemorrhage]. / Le pseudo-anévrysme de l'artère utérine: une cause parfois ignorée d'hémorragie secondaire du post-partum.

Uterine artery pseudoaneurysm is a rare complication of cesarean section. It can lead to severe postpartum hemorrhage. We report three cases of pseudoaneurysm diagnosed late after cesarean delivery, one followed by hemorrhagic shock. Ultrasound may point to the diagnosis, but arteriography of uterine arteries is decisive for the diagnosis. Selective artery embolization is recommended for treatment. Main advantages are complete occlusion of the pseudoaneurysm and fertility preservation.

[Obtaining of uterine vacuity in pregnancy loss]. / Obtention de la vacuité utérine dans le cadre d'une perte de grossesse.

OBJECTIVE: To assess early and late benefits and harms of different management options for first trimester miscarriage and for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14weeks of gestation. METHODS: French and English publications were searched using PubMed and Cochrane Library. RESULTS: Concerning missed miscarriage, expectant management is not recommended (LE1) because it increases the risk of failure, need of unplanned surgical procedure and blood transfusion (LE1). Surgical uterine evacuation remains more effective than medical treatment using misoprostol (LE1), but both techniques involve rare and comparable risks (EL1). When chosen, medical treatment should be a vaginal dose of 800µg of misoprostol, possibly repeated 24 to 48hours later (EL2). Administration of mifepristone prior to misoprostol is not recommended (EL2). In case of incomplete miscarriage, expectant management can be offered because it does not increase the risk of complications, neither haemorrhagic nor infectious (EL1). Medical treatment using misoprostol is not recommended (EL2) because it does not improve the evacuation rate when compared to our first option, and does not reduce the risk of complications (EL2). Surgical uterine evacuation leads to high evacuation rate (97-98%) and low risk of complications, haemorrhagic and infectious (<5%) (EL1). However, this option should not be the only one because of the good efficiency of the expectant management (more than 75% of evacuation) and comparably low risk of complications (EL1). Surgical aspiration should be favoured to curettage because it is quicker, less painful and leads to less bleeding (EL2). After a first trimester miscarriage future fertility is identical with each treatment (EL2). When a trophoblastic retention is suspected, a diagnostic hysteroscopy is recommended (EL2). In case of late intrauterine foetal death beyond 14weeks of gestation and without a past caesarean section, the most efficient protocol seems to be vaginal administration of misoprostol 200 to 400µg every 4 to 6hours (EL2). Twenty-four hours prior to misoprostol the administration of 200mg of mifepristone is recommended (EL3) because it improves the induction-expulsion time and diminishes the quantity of needed misoprostol (and so the complications linked to it) (EL3).

[Initial obstetrical management of post-partum hemorrhage following vaginal delivery]. / Prise en charge obstétricale initiale en cas d'hémorragie du post-partum après un accouchement par voie basse.

OBJECTIVES: To define initial steps of obstetrical treatment of post-partum hemorrhage (PPH) after vaginal delivery. MATERIALS AND METHOD: We searched the Medline and the Cochrane Library and checked the international guidelines: HAS, RCOG, SOGC, ACOG and WHO. RESULTS: In case of PPH, the use of a collecting bag is recommended (professional consensus). All the concerned professional (midwife, obstetrician, anesthesiology team) must be warned immediately (professional consensus). If placenta is retained, manual removal needs to be performed and after placental delivery, manual uterine exploration is recommended (professional consensus). At the same time, a dose of 5 or 10 IU of oxytocin must be administrated IV over at least 1minute or directly by an intramuscular injection followed by an infusion of 5 to 10 UI/h during 2hours (professional consensus). In some situations at risk of cervical and high vaginal laceration, the low genital tract needs to be carefully examined (professional consensus). Appropriate management of PPH has to be known by the concerned professional (professional consensus). Retrospective study of each case of PPH should be done (professional consensus). CONCLUSION: The PPH initial treatment involves a team work that, most of times, leads to stop the bleeding in least than 30minutes (professional consensus).

[First trimester miscarriages: benefits and harms of different management options]. / Fausses couches du premier trimestre : bénéfices et risques des alternatives thérapeutiques.

The objective of this review was to assess early and late benefits and harms of different management options for first-trimester miscarriage. Surgical uterine evacuation remains the most effective and the quickest method of treatment. Depending on the clinical situation, medical treatment using misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) does not increase the risk of complications, neither haemorrhagic nor infectious. However, these alternatives generally require longer outpatient follow-up, which leads to more prolonged bleeding and not planned surgical procedures.

[Misoprostol: off-label use in the first trimester of pregnancy (spontaneous abortion, and voluntary medical termination of pregnancy)]. / Misoprostol: utilisation hors AMM au premier trimestre de la grossesse (fausses couches spontanées, interruptions médicales et volontaires de grossesse).

OBJECTIVE: State of knowledge about misoprostol's use out of its marketing authorization during the first trimester of pregnancy, in early miscarriage or to induce abortion or medical termination of pregnancy. METHODS: French and English publications were searched using PubMed, Cochrane Library and international learned societies recommendations. RESULTS: Cervical ripening prior to surgical uterine evacuation during the first trimester of pregnancy facilitates cervical dilatation and reduces operative time and uterine retention risk. Misoprostol, mifepristone and osmotic cervical dilators are equally efficient. Concerning first trimester miscarriage, surgical uterine evacuation remains the most effective and the quickest method of treatment (EL 1). Depending on the clinical situation, medical treatment using misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) does not increase the risk of complications, neither haemorrhagic nor infectious (EL 1). However, these alternatives generally require longer outpatient follow-up, which leads to more consultations, prolonged bleeding and not planned surgical procedures (EL 1). Concerning missed miscarriage, a vaginal dose of 800 µg of misoprostol, possibly repeated 24 to 48 hours later, seems to offer the best efficiency/tolerance ratio (EL 2). Concerning early abortion, medical method is a safe and efficient alternative to surgery (EL 2). Success rates are inversely proportional to gestational age (EL 2). According to the modalities of its marketing authorization, 400 µg of misoprostol can only be given by oral route, for less than 7 weeks of amenorrhea (WA) pregnancies and after 36 to 48 hours following 600 mg of mifepristone (EL 1). However, 200mg of mifepristone is as efficient as 600 mg (EL 1). Beyond 7WA, misoprostol buccal dissolution (sublingual or prejugal) or vaginal administration are more efficient and better tolerated than oral ingestion (EL 1). Between 7 and 9WA, the best protocol in terms of efficiency and tolerance is the association of 200mg of mifepristone followed 24 to 48 hours later by 800 µg of vaginal, sublingual or buccal misoprostol (EL 1). An additional dose of 400 µg can be given 3 hours later if necessary (EL 3). In case of buccal administration, the dose of 400 µg seems to offer the same efficiency with a better tolerance but further evaluation is needed (EL 2). Between 9 and 12WA, medical treatment is less efficient than surgery and its tolerance is lower (EL 2). However, a protocol of 200mg of mifepristone followed 36 to 48 hours later by 800 µg of vaginal or sublingual misoprostol, plus an additional 400 µg dose every 3-4 hours (until 4-5 doses maximum) seems safe and efficient (EL 5). CONCLUSION: Misoprostol use during the first trimester of pregnancy is a safe and efficient alternative to surgery as long as detailed protocols adjusted to each clinical situation are respected.

[Maternal benefits and risks of trial of labor versus elective repeat caesarean delivery in women with a previous caesarean delivery]. / Bénéfices et risques maternels de la tentative de voie basse comparée à la césarienne programmée en cas d'antécédent de césarienne.

OBJECTIVE: To assess maternal outcomes during trial of labor (TOL) and elective repeat caesarean delivery (ERCD) in women with a previous caesarean delivery. METHODS: French and English publications were searched using PubMed and Cochrane Library. RESULTS: Maternal mortality remains a very rare event regardless of the planned mode of delivery (EL2). It is potentially reduced after a TOL but the presence of biases in many studies does not allow any conclusion (EL3). Maternal morbidity is mainly due to the failure of the TOL and to the risk of unplanned caesarean delivery during labor (EL2). The risk of complete uterine rupture significantly increases with TOL versus ERCD but it remains low at about 0.2 to 0.8% for women with one scar on the uterus (EL2). The occurrence of a post-surgical wound, mostly from the bladder, is rare (less than 0.5%) regardless of the planned mode of delivery (EL2). Facing the risk of hemorrhage requiring hysterectomy or blood transfusion, data are heterogeneous because of the nature of the populations studied. These risks do not seem to vary with the mode of delivery (EL3). The risk of post-partum venous thrombo-embolic complications and infections (endometritis and maternal fever) appears to be similar in both TOL and ERCD (EL3). The risk of infection is primarily related to the additional presence of obesity (EL2). While maternal morbidity progressively increases with the number of iterative caesarean sections, maternal morbidity in TOL after a previous caesarean delivery decreases with the number of successful TOL (EL2). CONCLUSION: In patients with a previous caesarean delivery, the risks of maternal complications are rare and similar between TOL and ERCD. There is an increased risk of complete uterine rupture in case of TOL. Nevertheless TOL has a favorable benefit/risk balance in most cases and its success reduces the risk of short and long-term maternal complications (EL3).

[Acute pulmonary edema and pregnancy: a descriptive study of 15 cases and review of the literature]. / Œdème aigu du poumon et grossesse : étude descriptive de 15 cas et revue de la littérature.

OBJECTIVE: To describe the incidence and the etiologies of acute pulmonary edema (APE) and the diagnostic procedure used during pregnancy and immediate post-partum. MATERIALS AND METHODS: We analyzed records from a search of codes of heart failure and APE as well as from the term "pulmonary edema" in computerized obstetric records from 2002 to 2010 in a university center of level 3. We identified maternal characteristics, the term of appearance and route of delivery, the time between symptoms and diagnosis, additional tests performed, and data from echocardiography. RESULTS: Fifteen patients had an APE during pregnancy or in the immediate post-partum period during the study period (0.05%). The mean age was 28.6 years and the mean term of appearance was 31.2±3.1 weeks of amenorrhea. The diagnosis was made in 11 cases (73.3%) before delivery and in four during post-partum. The main etiology was preeclampsia (46.6%) followed by heart disease (26.7%), then tocolysis and overfilling (13.3%). In 55% of cases, we found a diagnostic wander characterized by carrying out further unnecessary tests. The echocardiography has led to a change in management in 27.3% of cases. CONCLUSION: The APE is a rare event during pregnancy and the post-partum period and its main etiology is preeclampsia. Some other etiologies are avoidable like the use of beta-agonists by intravenous route. The diagnosis is sometimes difficult, but the realization of a chest X-ray, a simple and inexpensive test, is enough to confirm it.

[Acute-placental dysfunction by villous-maturation defect and late-fetal mortality]. / Dysfonction placentaire aiguë par retard de maturation villositaire et décès foetal tardif.

INTRODUCTION: The placental histological examination is essential in the assessment of stillbirths, especially those of third trimester, which are often of placental origin by chronic placental dysfunction and sometimes by acute dysfunction. The physiopathogenesis of the latter remains obscure. MATERIAL AND METHOD: Three stillbirths, one per partum and two after 38 and 39 weeks gestation, caused by acute-placental dysfunction by villous maturation defect were studied. The maternal aetiological investigations and the fetal autopsies were normal. Placentas were pale. Villi were numerous, normal size but fibrous, showing a severely reduced vascularization and a lack of syncytium-capillary membranes. RESULTS: Only one author studied the villous maturation defect. He defines this entity by the same characteristics as that noted in our observations. Its incidence would be of 5.7% and would be associated with fetal death only after the eighth month in 2.3 % of cases, with a risk of recurrence estimated at 10%. CONCLUSION: This entity, probably underestimated, must be indexed systematically in any late fetal death and any unexplained per partum asphyxia, in order to help the couple overcome a fetal death and to give doctors a medicolegal support.