[Comparison of diagnostic performance of two tests of premature rupture of membranes (IGFBP-1/PAMG-1) in clinical practice]. / Comparaison des performances diagnostiques de deux tests de rupture prématurée des membranes (IGFBP-1/PAMG-1) en pratique clinique.

OBJECTIVES: Evaluate the two main immunochromatographic tests of premature rupture of membranes (PROM): Actimprom(®) based on the discovery of insulin-like growth factor binding protein-1 (IGFBP-1) and Amnisure(®) based on the discovery of placental alpha 1-microglobulin (PAMG -1). The comparison was made voluntarily in clinical practice and is interested in a population whose failure is not clean break. MATERIALS AND METHODS: Prospective and comparative study performed on 2012, at the university hospital of Caen, in 85 patients with PROM suspected between 24 SA and 36 SA. The presence of blood, semen or vaginal infection has been notified. Frank rupture of membranes was an exclusion criterion. RESULTS: Actimprom(®) and Amnisure(®) were detected PROM with a specificity, sensitivity, PPV and NPV respectively 89.4% (CI 79.4-95.6%), 68.4% (CI 43.5-87.4%), 65% (CI 40.8-84.6%) and 90.8% (CI 81-96.5%). The results of both tests were not influenced by the presence of blood or inflammatory disease. CONCLUSION: Performance of these tests is probably related to the quality of the sample and the extraction step in bed of the patient. This work showed no significant difference between the two tests in terms of performance in the diagnosis of PROM. At present, there is no formally favor the use of one or the other.

[Failure of vacuum extractions: risk factors, maternal and fetal issues]. / Échecs d'extraction par ventouse obstétricale: facteurs de risque, conséquences maternelles et fœtales.

OBJECTIVES: Determine cases which are at risk of vacuum extraction failure as well as maternal and foetal issues depending on the delivery outcome. MATERIAL AND METHODS: It was a retrospective study comparing 147 vacuum failures, from January 2002 to December 2010, with a control group randomly composed of 526 successful vacuum extractions. The outcomes were high risk situations of vacuum failure, maternal and neonatal morbidity depending on the delivery method (caesarean section or other instrumental extraction). RESULTS: The global vacuum failure rate was 3.3 %. During labour, we identified several situations at risk of vacuum extraction failure: cephalhematomas prior to extraction (P<0.001), deflexion attitude (P<0.001), posterior variety (P<0.001), entering above the inlet strait (P<0.001), occiput posterior delivery (P<0.001), fœtal weight greater than 3500g (P=0.023). Neonatals consequency were more Apgar score below 7 at five minutes life (P=0.007), fœtal acidosis (pH<7,20) (P=0.032), neonatal resuscitation (P<0.001), and craniofacial damages (P<0.001). CONCLUSION: Many dystocic situations occurring during labour require intense care when practicing vacuum extraction since they more frequently result in failure. In case of vacuum extraction failure, immediate adaptation to extra-uterine life seems to be more difficult for new-born babies.

[Can we do a cesarean section in less than 30min in unsuitable premises in order to follow the recommendations of the ACOG?]. / Peut-on faire une césarienne en moins de 30min dans des locaux inadaptés afin de suivre les recommandations de l'ACOG ?

OBJECTIVES: This study aims to assess in clinical practice the "decision-to-delivery" interval for an emergency cesarean section depending on the type of care. MATERIALS AND METHODS: This is a retrospective study conducted at the maternity of the CHU of Caen Level III between 2004 and 2009. The comprehensive collection of data totals 294 emergency cesarean sections. The main indications were found to be: bradycardia, cord prolapse, uterine rupture, eclampsia, failure of vacuum extraction on fetal heart rate abnormality during expulsion, the suspicion of placental abruption and hemorrhage in placenta previa. Recorded activities day and night were individualized and the maternal and fetal complications related to the emergency. RESULTS: The mean "decision-to-delivery" interval is of 21.3±10.3minutes with 80.2% of cesarean sections within 30minutes (CE30) and 25.8% in less than 15minutes. Concerning the activity period, the average time at night is 22.5±10.3minutes with 20.7% <15minutes and 77.2% <30minutes and in the daytime, the average time is 20.1±10.1minutes with 31.2% <15minutes and 83.3% <30minutes. The laying of spinal anesthesia in the operating room significantly delays the time of extraction (54.9% vs. 91, 8% CE30, P<0.001), but the epidural before the cesarean section and general anesthesia is faster with 91.9% vs. 78.9% (P=0.002) and 91.8% vs. 81.6% (P=0.022) respectively CE30. We deplored 9 deaths of newborns. These nine deaths represent 3.2% of emergency caesarean sections with an average time of 20.7±14.7minutes. CONCLUSION: The time is influenced by the transition to the operating room, the type of anesthesia and lack of information clearly stated to the team. The fetal prognosis is not limited to the "decision-to-delivery" interval but it remains essential in situations of emergency. The 15 or 30minutes interval is discussed in the literature. Obviously, the delay must be appreciated based on certain parameters (medical personnel, architecture) and each Alpha must adapt their practice to the physical working environment to meet the recommended objectives. However, the introduction of a protocol for extreme emergencies would allow for optimal responsiveness of all the teams involved and should result in a compliance period of 30minutes. Teamwork and adherence to procedures can improve these results.

[Continuous medical evaluation of the prevention of fetomaternal rhesus-D allo-immunization]. / Évaluation des pratiques professionnelles sur la prévention de l'allo-immunisation Rhésus D.

OBJECTIVES: To evaluate the prevention of fetomaternal rhesus-D allo-immunization between 2008 and 2010. This evaluation was a part of the continuous medical evaluation (CME) that is compulsory in French hospitals. It was carried out using the tools recommended by the Haute Autorité de santé. We followed the national guidelines for the prevention of fetomaternal rhesus-D allo-immunization as outlined in 2005 by the national French college of Obstetrics and Gynecology. MATERIALS AND METHODS: We audited 3926 consultations in the first four months of 2008. Based on the results of the audit, actions were implemented to improve care. In 2009, we audited 4021 consultations to look for improvement, and another 3932 consultations in 2010. RESULTS: In 2008, 14% of the patients had an overall optimal prevention. After actions were taken, 44% of patients in 2009 and 58% of patients in 2010 demonstrated optimal prevention (P<0,05). Especially, the prevention of fetomaternal allo-immunization has been explained for 43% of the patients in 2008 and to 90% of them in 2010. And immunoprophylaxia has been prescribed to 70% of the patients in 2008 and to 93% of them in 2010. CONCLUSION: This CME has resulted in a statistically significant improvement of the prevention of allo-immunization.

[From the impact of French guidelines to reduce episiotomy's rate]. / De l'impact des RPC pour réduire le taux d'épisiotomie.

OBJECTIVES: Following the publication of the French Guidelines on episiotomy in 2005 by the French National College of Gynaecologists and Obstetricians (CNGOF), our unit decided to adopt a restrictive politics to replace the former liberal one. The goal of this study was to evaluate the impact of this modification of trend in the Unit of Gynaecology and Obstetrics of the teaching hospital from Caen. This was the start point of an internal audit with the objective of an enhancement of the care during delivery. PATIENTS AND METHODS: It was a retrospective study concerning the period going from January, 2004 till December, 2009, measuring the impact of the guidelines on the episiotomy rates and perineal tears. The totality of the population of the women naturally delivered at a term superior or equal to 37 weeks of gestation and a cephalic presentation was included. To modify the practices, after diffusion of the guidelines by some obstetrical leaders, we imposed to notify the indication of the episiotomy in the computerized obstetrical files. Moreover, we published monthly screenboards with all the detailed results to all the practioners acting in the delivery room (obstetricians, midwives). RESULTS: Between 2004 and 2009, we observed a dramatic decline of the episiotomy rates from 55.7 to 13.3%. This trend was the same for primiparae and multiparae, as wall as for spontaneous or assisted delivery (mostly vacuum extraction in our unit). We noticed a slight increased in minor perineal tears without functional consequences. There was no statistically significant difference between severe perineal tear (1.3% vs. 1.1%). By contrary, the rate of intact perineum significantly raised (17.6% vs. 21.7%, p<0.001), especially in vacuum extractions. DISCUSSION: Our results are in accordance with those of the national guidelines. However, our rate does not decrease in 2007 and 2008 (20%), contrary to some results obtained in the literature. Some reports mentioned the weak impact of the publication of national guidelines to modify the usual practice. However, we believe that retro-information to practitioners has a real impact on their daily current practice. Hence we insisted again on the importance of these national guidelines at the end of 2008 and we could demonstrate a real decline of the rate of episiotomy. Our efforts have to be continued, especially for instrumental delivery.

[Regionalisation of perinatal care in Basse-Normandie, France: evolution over 5 years]. / Régionalisation des soins périnatals en Basse-Normandie: évolution sur cinq ans.

OBJECTIVES: To compare evolution and characteristics of in utero transfers (IUT) in Basse-Normandie area, France, between 2004 and 2008, and to describe characteristics of IUT in 2008. MATERIALS AND METHODS: Analysis of data from the IUT registry, collected prospectively since 2004. RESULTS: An average of five IUT per week was observed. The rate of IUT regularly increased (P=0.003) and reached 16.2 per 1000 pregnancies in 2008. Extra network IUT decreased steadily (P=0.04). For level 3 units, the proportion of IUT from level 2 units increased (P<10(-3)). Before 32 weeks of gestational age, all IUT were done towards a level 3 unit. Median time between IUT and delivery and caesarean section rates were variable according to IUT indication (for threats of premature delivery, respectively 5 days and 23.3%). The rate of retransfer towards initial unit of towards a birth site of relevant level was 5.3%. CONCLUSION: The IUT registry gives useful information on evolution and characteristics of IUT in our area. An increased regionalisation and more frequent adequate IUT were observed. The registry must now serve as a basis for practices assessment.

[Obstetrical complications of morbid obesity]. / Complications obstétricales de l'obésité morbide.

OBJECTIVE: To determine whether morbidly obese women have an increased risk of pregnancy complications and adverse perinatal outcome. METHODS: In a retrospective study, 2472 women with morbid obesity, defined as a body mass index (BMI) more than 40 were compared with normal weight women (BMI 20-25). Fisher and Student tests were used for statistical analysis. RESULTS: In the group of morbidly obese mothers (BMI greater than 40) as compared with the normal weight mothers, there was an increased risk of the following outcomes: gravidic hypertension (7.7 vs 0.5%; p<0.05). preeclampsia (11.5 vs 2%; p<0.05), gestational diabetes (15.4 vs 1.8%; p<0.05), cesarean delivery (50 vs 15.4%; p<0.05), and macrosomia (42.3 vs 10.3%; p<0.05). However, we noted a lower rate of prematurity in the obese group (0 vs 11%). Even when morbidly obese women with preexisting diabetes and chronic hypertension were excluded from the analysis, significant differences in the perinatal outcomes still persisted. CONCLUSION: Morbid obesity appears to be an independent risk factor for perinatal and gestational complications.