[Intrauterine tamponade: Practices and training assessment]. / Tamponnement intra-utérin : description des pratiques et de la formation des internes.

OBJECTIVES: The main objective was to describe the practices of a French center regarding the use of intrauterine tamponade. The secondary objective was to describe the training of residents in the use of intrauterine tamponade (IUT). METHODS: This was a practice survey conducted through an anonymous quiz sent to residents in France between May 1, 2018 and July 1, 2019. Responses from first year residents were excluded. The data concerned the practices of the centers (mode of delivery, mode of insertion, ultrasound control, use of vaginal gauze or antibiotic prophylaxis) as well as the feeling of the residents concerning their training in using of the intrauterine tamponade (frequency, training sessions, learning difficulties). RESULTS: We obtained 145 responses to represent all regions of France. Responses from 27/28 centres were obtained. All the centres use it during cesarean section and after vaginal delivery. Vaginal gauze is used in 74% of cases and 65% use antibiotic prophylaxis. A specific training during the residentship is described in only 26% of cases and 21% of residents say they have never used an IUT. CONCLUSION: Intrauterine tamponade is a technique widely used in France, regardless of the mode of delivery. The training of residents is essential, especially since the simulation is perfectly adapted to the learning for using intrauterine tamponade.

[Obstetrical follow-up and perinatal prognosis in drug addict pregnant women]. / Suivi obstétrical et pronostic périnatal chez les femmes enceintes toxicomanes.

OBJECTIVE: To identify the factors associated with a good obstetric follow-up and a good perinatal prognosis, in order to adapt the management of pregnant women with addiction to opiates. METHODS: A retrospective study was carried out in our maternity between January 2012 and December 2014, including 104 women who were addicted to opiates, whether or not they were substituted, with or without associated consumptions, regardless of the term of delivery beyond 22 weeks of amenorrhea. RESULTS: A good obstetrical follow-up was observed by 32.7% of women. The father's presence (OR=3.9; P=0.0113) and investment in pregnancy (OR=4.4; P=0.0029), as well as the desired character of the pregnancy (OR=4.5; P=0.0008) appeared to be associated with the quality of the observed follow-up. Preterm deliveries (11.8 versus 35.8%; P=0.0103), and social measures taken at the discharge of the newborn from the maternity (2.9 versus 24.3%, P=0.0057) were less frequent. A good perinatal prognosis was found for 29.8% of the cases. Associated consumptions <3 (OR=2.6 [1.1-6.2]; P=0.0281) confirmed by negative urine drug screening (OR=2.9 [1.1-7.8]; P=0.0307) were more numerous. CONCLUSION: Although the follow-up and the perinatal prognosis of these pregnancies have improved considerably in recent years, it seems necessary to further optimize their management.

[Vaginal delivery in case of breech presentation: Impact of a service's incentive]. / Accouchement par voie basse des fœtus en présentation du siège : impact d'une politique incitative de service.

OBJECTIVES: The mode of delivery in podalic presentation was controvertible since the 2000s, which led to a high rate of caesarean section. In our center, the delivery mode was physician-dependent before 2012. Since 2012, the management of podalic presentations was supervised by a protocol allowing a collegiate management to promote vaginal delivery. The objective of this study was to evaluate the impact of this policy on neonatal outcomes and obstetric practices. METHODS: A retrospective study was carried out with comparison of 135 patients who gave birth in 2008 with 110 patients who gave birth in 2014, before and after the implementation of the protocol in a type III university maternity hospital. Two hundred and forty-five singleton pregnancies with podalic presentation and a gestational age more than 32 weeks of gestation were included in this study. The rate of vaginal delivery trial, the evolution of clinical practices and neonatal outcomes were respectively compared. RESULTS: One hundred and twenty-six patients who gave birth in 2008 were compared to the 105 one of 2014. The rate of successful vaginal birth trial increased from 32.7% (n=16/49) to 63.8% (n=37/58) (P>0.05) between the two periods, this induced a decrease of 16.3% of planned caesarean sections rate [(77/126) versus (47/105) (P<0.02)] and of 6.2% of emergency caesarean sections rate [(33/126) versus (21/105) (P<0.001)]. No significant difference was observed regarding neonatal outcomes. CONCLUSIONS: This work shows that it is possible to limit the rate of planned and emergency caesarean sections because of an incentive policy of service without impact on neonatal morbidity and mortality.

[Training of residents in amniocentesis: Effectiveness of a craft simulator]. / Formation des internes à l'amniocentèse : intérêt d'un simulateur artisanal.

OBJECTIVE: This prospective study aims to assess a low fidelity simulation device for learning amniocentesis to gynecology-obstetrics residents. METHODS: From 2013 to 2016, gynecology-obstetrics residents of all levels, from the maternity of Nancy hospital, which have already performed amniocentesis or not, participated in amniocentesis training on an artisanal simulator. Residents were evaluated on the amniocentesis simulator according to seven quality criteria. Three scores were assigned: the first (S1) at the beginning of the first training session, the second (S2) at the end of the first session after individualized personal training and the third (S3) two months after the first simulation. RESULTS: A total of 40 residents were included. The scores obtained by the residents were 3.2±1.8 points for S1 versus 6.2±0.9 points for S2 (P<0.001). Two months after, the residents' performances remained significantly improved compared to the initial assessment with a score (S3) of 5.8±1.3 points at S3 (P<0.001). CONCLUSION: Amniocentesis craft simulator is effective for performance improvement and allows a persistence of acquired skills two months after the training. At the time of "never the first time on the patient", it should be part of the curriculum of gynecology-obstetrics residents in order to guarantee patients quality care and optimum safety.

[X-ray pelvimetry practice survey in Northeast French maternities]. / Enquête sur la pratique de la radiopelvimétrie dans les maternités de l'inter-région Nord-Est.

OBJECTIVE: To describe and compare the indications and modalities of X-ray pelvimetry in obstetrical practice in the Northeast French maternities. MATERIALS AND METHODS: An anonymous questionnaire was sent to the heads of obstetric departments in the Northeast French maternities. The questionnaire was built around four issues: description of the hospital characteristics, assessment of the obstetrical prognosis (modalities of delivery), indications and modalities of X-ray pelvimetry. RESULTS: The response rate was 47%. The evaluation of the obstetrical prognosis was performed in 77% of maternities. Indications were: breech presentation (86%), suspicion of fetal-pelvic disproportion (78%), mother size lesser than 150cm (64%) and previous caesarean section (42%). Pelvic computed tomography was performed in the majority of the maternities (94%), between 35 and 37 weeks of amenorrhea (47%). Level III maternities and maternities with more than 2000 deliveries per year seemed to observe fewer indications than other maternities, but these indications were still globally excessive, comparing with the Collège national des gynécologues et obstétriciens français' recommendations. CONCLUSION: These results should lead professionals to develop an assessment of their practices about the indications of X-ray pelvimetry.

[Management of severe or persistent postpartum hemorrhage after vaginal delivery]. / Prise en charge obstétricale en cas d'hémorragie du post-partum qui persiste malgré les mesures initiales ou qui est sévère d'emblée, après accouchement par voie basse.

INTRODUCTION: This chapter is an update of the 2004 recommendations for the management of persistent or severe postpartum hemorrhage (PPH) after natural childbirth. Severe PPH is defined by estimated blood loss greater than 1000mL (gradeC). Persistent bleeding within 15 to 30minutes after diagnosis and initial treatment (gradeC) or abundant immediately (professional consensus) should lead to a further management. MATERIALS AND METHODS: A systematic review of the literature concerning the management of persistent or severe PPH was conducted on Medline and Cochrane Database, with no specified time period. RESULTS AND DISCUSSION: The initial clinical evaluation is the same whatever initial severity. Each possible cause of bleeding must be evaluated: uterine vacuity must be checked and birth canal lesions must be researched and repaired (gradeC). Sulprostone is effective for the treatment of severe or persistent PPH (EL4) and its use is recommended for the management of PPH resistant to oxytocin administration (grade B). In the current state of the literature, there is no argument for replacing sulprostone in France by dinoprostone or prostaglandins F2α (professional consensus). If oxytocin has been administered, it is not recommended to use misoprostol (EL1) as adjuvant treatment because there is no evidence of benefit in this indication (grade A). Balloon intra-uterine tamponade appears to be an efficient mechanical treatment of uterine atony in case of failure of the initial management by sulprostone. Tamponade allows avoiding the need for further interventional radiology or surgery in most cases (EL4). Intra-uterine tamponade may be offered in case of failure of sulprostone and prior to surgical management or interventional radiology (professional consensus). Its use is left to the discretion of the practitioner. Tamponade should not delay the implementation of further invasive procedures.

[Correlation between fetal scalp samples and umbilical cord samples]. / Corrélation entre prélèvements au scalp fœtal et prélèvements artériels au cordon.

OBJECTIVE: The objective was to evaluate the correlation between fetal scalp base excess (BE) and umbilical cord BE. Respective value of fetal scalp pH, BE and lactate for the prediction of neonatal metabolic acidosis were also evaluated. METHODS: A retrospective monocentric study was conducted in a French tertiary care academic maternity. All the patients who had a fetal scalp sampling during labor in 2010, less than 90 minutes before delivery were included. Fetal heart rate abnormalities (FHRA) were classified by degree of severity, according to the French guidelines. The differences between fetal scalp samples and umbilical cord samples over time and in relation with the type of FHRA were analyzed for pH and BE. The differences between fetal scalp pH and cord pH over time and in relation with scalp BE were analyzed. The correlation between fetal scalp samples and cord samples for pH, BE and lactate was estimated. Receiver operating characteristics (ROC) curves for fetal scalp pH, lactate and BE to predict umbilical cord pH under 7.20 were calculated. RESULTS: Seventy-one cases were included. The difference between fetal scalp sample and cord sample was lower when the sample was made closest to delivery both for pH and BE. The gravity of FHRA was not predictive of a faster decrease of pH or BE over time. The correlation was significant for pH (r=0.23, p=0.03) between scalp samples and cord samples, as for BE (r=0.49, p=0.001) and lactate (r=0.52, p=0.001). The ROC curves for pH, BE and lactate displayed a similar pattern. CONCLUSION: Fetal scalp and umbilical cord samples, for pH, BE and lactate were significantly correlated but their respective predictive value for cord pH less or equal to 7.20 was poor.

[Management of post-abortum infections]. / Prise en charge des infections du post-abortum.

In countries where induced abortions are legal and medically supervised, the frequency of post-abortion infections is low and maternal death is infrequent. Nevertheless, short and long term consequences of post-abortion infections must be addressed. Sexually transmitted pathogens are frequently in cause here. Risk factors include in particular young age (less than 24 years), low socioeconomic level, late pregnancy, nulliparity, and history of previous untreated pelvic inflammatory disease. Diagnosis is based on clinical criteria and an inflammatory syndrome occurring within 2 to 3 weeks after spontaneous or induced abortion. A pelvic ultrasound is recommended in order to ensure the uterus vacuity and to look for a possible pelvic abscess, and bacteriological samples must be performed. Management consists in a regimen combining two antibiotics intravenously, with the possible addition of intravenous heparin in case of pelvic thrombophlebitis. Antibiotics can be discontinued 48 h of a clinical improvement and further treatment by oral route brings no benefit. Intrauterine retention associated with post-abortion endometritis must be addressed either by medical or surgical method.

[Management of post-partum infections]. / Prise en charge des infections du post-partum.

Post-partum endometritis are frequent and account for the fifth cause of maternal death. This disease is preventable and effective treatments are available. Streptococcus agalactiae is the primary pathogen implicated. The clinical diagnosis is usually easy and involves pelvic pain, fever and abnormal lochia. Whenever antibiotic treatment provides no clinical improvement, or in case of doubt on the vacuity of the uterus, an ultrasound exam must be performed. Likewise, a CT scan or a MRI will be performed in case of persistent fever in search of a pelvic abscess requiring a drainage, or of a pelvic thrombophlebitis. Thromboplebitis requires heparin for the duration of antibiotic therapy, or oral anticoagulants for at least 3 months in case of pulmonary embolism or extension to the vena cava. The recommended antibiotic regimen combines clindamycin with gentamicin (once daily) intravenously. In case of contraindication or breastfeeding, other regimens may be prescribed. Adequate duration of treatment has not been evaluated and a switch to oral antibiotics after clinical improvement brings no benefit. Antibioprophylaxy (mostly cephalosporins) is recommended in cases of cesarean section (at skin incision), while it is debated in case of assisted delivery or of 3rd and 4th degree perineal tears.

[Hysteroscopic tubal sterilization with Essure® devices: a retrospective descriptive study and evaluation of hypnosis]. / Stérilisation tubaire par voie hystéroscopique avec le système Essure®: étude descriptive et évaluation de l'efficacité de l'hypnose.

OBJECTIVES: The Essure(®) system is a hysteroscopic sterilization method. The aim of our study is to retrospectively evaluate the sterilization procedure with Essure(®) devices, with and without anesthesia, and in particular with hypnosis. PATIENT AND METHODS: The descriptive study includes all tubal sterilization with Essure(®) performed during the year 2009 at the Maternité régionale de Nancy. Hypnosis efficiency is retrospectively evaluated with Verbal Numeric Rating Scale (VNRS) for peroperative pain, and analgesic medication use for postoperative pain. RESULTS: Ninety-four sterilizations are performed, 85% (85/94) of them without anesthesia. The mean VNRS is 3.0. The mean operative time is 8.7 minutes, positively correlated with the VNRS (P=0.0005). The rate of successful insertion is 94%. At 3 months, 91% of the implants have a correct location. Inadequate locations are more frequent when anesthesia have been performed (37% vs 4%, P=0.016). There is no significant difference between groups with and without hypnosis for the VNRS, the failure rate and the use of analgesic medication. CONCLUSION: Tubal sterilization with the Essure(®) system is a quick and efficient method. Our study does not demonstrate efficiency of hypnosis in pain control. This remains to be explored with a prospective study, including others parameters, such as anxiety.

[An isolated vasculitis of uterine cervix and isthmus]. / Une vascularite isolée du col et de l'isthme utérins.

Isolated lesions of vasculitis are described in different organs, notably female genital tract. Exhaustive clinic and paraclinic exams are necessary to exclude an occult systemic vasculitis. We report a case of vasculitis that was restricted to uterine cervix and isthmus, fortuitously discovered by a 45-years-old woman after hysterectomy. At histological examination, necrotizing vasculitis of small and medium-sized arteries was found, suggesting diagnosis of polyarteritis nodosa. There was no argument for systemic vasculitis.