[Perinatal care for extremely preterm infants. Considerations of the "risks in pregnancy" department]. / Prise en charge de la prématurité extrême. Réflexions du département hospitalo-universitaire (DHU) « risques et grossesse ¼.

Decisions regarding whether to initiate or forgo intensive care for extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients and must be taken into account. After a short review of these factors, we present the thoughts and proposals of the Risks and Pregnancy department. The proposals are to limit emergency decisions, to better take into account other factors than gestational age and prenatal predicted fetal weight in assessing the prognosis, to introduce multidisciplinary consultation in the evaluation and proposals that will be discussed with the parents, and to separate prenatal steroid therapy from decision-making regarding whether or not to administer intensive care.

Factors predictive of macrosomia in pregnancies with a positive oral glucose challenge test: importance of fasting plasma glucose.

AIM: The study aimed to determine the factors associated with fetal macrosomia following a positive oral glucose challenge test (OGCT). METHODS: In this retrospective single-centre study of 1268 pregnancies with positive 50-g OGCTs (plasma glucose≥130mg/dL, or 7.2mmol/L), gestational diabetes mellitus (GDM) was defined as fasting plasma glucose (FPG)≥95mg/dL (5.3mmol/L) and/or postprandial glucose (PPG)≥120mg/dL (6.7mmol/L). RESULTS: In GDM pregnancies, the odds ratios adjusted for confounders (age, BMI, ethnicity, parity and weight gain) were 2.02 for macrosomia (Z score≥1.28) and 2.62 for severe macrosomia (Z score≥1.88). For each 10-mg/dL increase in FPG, the mean birth-weight increase was 60g. Macrosomia risk did not differ between GDM patients with normal FPG (<95mg/dL, or 5.3mmol/L) and non-diabetics, but increased significantly in cases of FPG≥95mg/dL and regardless of the level of PPG. CONCLUSION: In our study population, birth-weight and macrosomia risk were strongly correlated with FPG, suggesting that it is a simple and efficient marker for the risk of macrosomia.

[What use of progesterone to prevent preterm birth?]. / Quelle utilisation de la progestérone pour prévenir la prématurité ?

Widely prescribed in the years 1970-1980 to prolong gestation, progesterone has regained interest after the publication of randomized trials since 10 years. In women at increased risk of preterm birth with a history of preterm delivery or late miscarriage, the use of progesterone, especially intramuscularly may reduce the incidence of spontaneous preterm birth. In contrast, in cases of preterm labor or twin pregnancies, progesterone efficacy to reduce preterm birth has not been demonstrated. In women with asymptomatic midtrimester sonographic short cervix, randomized studies show conflicting results and new studies are necessary before its widespread utilisation.

[Specific particularities of uterine scars and their impact on the risk of uterine rupture in case of trial of labor]. / Critères d'acceptation de la voie vaginale selon les caractéristiques de la cicatrice utérine.

OBJECTIVE: To assess the risk of uterine rupture in case of uterine scar in specific situations. To investigate whether ultrasonographic measurement of the lower uterine segment is predictive of the risk of uterine rupture. METHODS: French and English publications were identified through PubMed and Cochrane databases. RESULTS: Trial of labor after cesarean (TOLAC) is possible in cases of uterine mullerian anomalies, segmental vertical or unknown uterine incision, postpartum fever, cesarean delivery before 37 weeks during the previous cesarean (professional agreement). TOLAC can be considered if obstetrical conditions are favorable even if the delay is less than 6 months between the previous cesarean delivery and the date of conception of the following pregnancy (professional agreement). TOLAC can be considered after a previous myomectomy, depending on technical conditions under which the intervention was conducted (gradeC). TOLAC is possible even after previous hysteroscopic metroplasty for uterine septa or in cases of uterine perforation with monopolar coagulation (professional agreement). The type of uterine suture during the previous cesarean should not influence the choice of the route of delivery (professional agreement). TOLAC can be considered in cases of two previous cesarean sections if obstetrical conditions are favorable (professional agreement). Planned cesarean section is recommended from history of three previous cesarean sections (professional agreement). A planned cesarean section is recommended in cases of previous corporeal incision during cesarean (gradeC). There is not enough data to recommend ultrasonographic measurement of the lower uterine segment during pregnancy to help to determine the route of delivery (professional agreement). CONCLUSIONS: TOLAC can be considered, depending on obstetric conditions, in all situations studied, except in cases of previous obstetric corporeal incision or previous history of at least three cesareans.

[Postpartum diabetes screening following gestational diabetes mellitus: practices in a university hospital and focus on the role of the general practitioner]. / Dépistage du diabète de type 2 après un diabète gestationnel : rôle du médecin traitant.

OBJECTIVES: Following pregnancies with gestational diabetes mellitus (GDM), to assess: the perception by women of the risk of subsequent type 2 diabetes, the rate of screening for diabetes in the postpartum, and identify the factors leading women to undergo screening, in particular with respect to the information given to the general practitioner (GP) by the obstetrical team. METHODS: A cohort study of all women with GDM who delivered in a single academic hospital between 1st June 2008 and 31st May 2009, based on data extracted from files and from phone interviews made 6 to 12 months after the delivery. RESULTS: Out of 152 GDM cases, 147 medical files were consulted and 124 phone interviews were performed. Fifty-one percent of the interviewed women were aware of the risk of type 2 diabetes. Eighty patients (65%) underwent postpartum glucose testing, out of which 69 were prescribed by the maternity and 27 women (22%) did not get any prescription. The compliance rate was 78% (53/69) for the hospital prescriptions and 100% (18/18) for the GP's prescriptions, a significant difference in uptake (P<0.05). Although it appears that the information given to the GP is the only factor improving patient awareness about type 2 diabetes (P=0.01), as well as their compliance to postpartum glucose testing (P=0.02), only 41 reports (28%) were sent to the GP out of the 63 reports (43%) mentioning the GDM. CONCLUSION: Postpartum testing for type 2 diabetes following a GDM was not optimal in this study. In view of the key role played by the GP in the postpartum period, it appears that cooperation between maternity and GPs needs to be reinforced in order to maximise both proper screening and diabetes primary prevention following GDM.

[Screening of gestational diabetes mellitus: a new consensus?]. / Dépistage du diabète gestationnel: vers un nouveau consensus?

The choice of thresholds to diagnose gestational diabetes mellitus (GDM) is a topic of ongoing controversy. In 2008, the Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study showed continuous graded relationships between increasing maternal plasma glucose and increasing frequency of adverse perinatal outcomes. Macrosomia (birth weight>90th percentile for gestational age), primary cesarean delivery, clinical neonatal hypoglycemia and hyperinsulinemia (cord serum C peptide>90th percentile) were all related to each of the 3 glucose values (fasting plasma glucose and at 1 and 2 hours after the 75 g oral glucose test). The associations were continuous with no obvious thresholds at which risks increased. The International Association of Diabetes and Pregnancy Study Group (IADPSG) recently issued recommendations that the diagnosis of GDM be made when any of the following thresholds are met or exceeded: fasting plasma glucose: 0,92 g/L; 1 hour: 1,80 g/L; or 2 hours: 1,53 g/L after the 75 g oral glucose test. These criteria were chosen to identify pregnancy with increased risk of adverse perinatal outcomes. By the new criteria, the total incidence of gestational diabetes in the HAPO population was 17, 8%. Fasting plasma glucose (FPG) in early pregnancy appears as an important predictive factor. Higher first trimester FPG (lower than those diagnostic of diabetes) are associated with increased risks of later diagnosis of gestational diabetes and adverse pregnancy outcomes. Whether this new consensus will be adopted by public health bodies and professionals remains to be seen.

[Screening for gestational diabetes mellitus: Is it time to revise the recommendations?]. / Dépistage du diabète gestationnel : le temps est-il venu de revoir les recommandations ?

Universal screening for gestational diabetes mellitus (GDM) has been a topic of ongoing controversy for many years. In 2005, the French Health Authority concluded that no recommendation could be issued because of insufficient evidence. Recently, several studies have clarified the issues. It is now clearly established that women with GDM, including mild forms, are at increased risk of perinatal complications. Randomized controlled trials demonstrate that treatment to reduce maternal glucose levels improves perinatal outcomes. Today, the rationale for screening appears unquestionable. There are simple screening tests. However, it remains difficult to define threshold values because there is a strong, continuous association of maternal glucose levels with increased risks of adverse pregnancy outcomes.