Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study.

OBJECTIVE: To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section. DESIGN: Prospective population-based study. SETTING: All 176 maternity hospitals of eight French regions. POPULATION: Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries. METHODS: Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared. MAIN OUTCOME MEASURES: Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes. RESULTS: The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally. CONCLUSION: More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean. TWEETABLE ABSTRACT: Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy.

OBJECTIVE: To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned. METHODS: JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation). RESULTS: Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery. CONCLUSION: When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Do obstetricians apply the national guidelines? A vignette-based study assessing practices for the prevention of preterm birth.

OBJECTIVE: To describe spontaneous preterm birth prevention practices self-reported before and after the dissemination of relevant guidelines, and to identify personal and organisational factors associated with adherence. DESIGN: A repeated cross-sectional vignette-based survey study. SETTING: French obstetricians. POPULATION: French obstetricians practicing in public or private maternity units. METHODS: Before and after the dissemination of the 2017 French guidelines on the prevention of spontaneous preterm birth, participants were asked to complete a web-based self-administered questionnaire based on two clinical vignettes. Vignette 1 focused on respondents' attitudes towards strict bed rest, cerclage, and progesterone treatment for women with a short cervix in mid-trimester; vignette 2 focused on attitudes towards strict bed rest and maintenance tocolysis after successful tocolysis for preterm labour. A mixed quantitative and qualitative analysis was conducted. MAIN OUTCOME MEASURES: Non-adherence to guidelines for the prevention of spontaneous preterm birth in responses to each vignette. RESULTS: We obtained complete responses from 286 obstetricians before and 282 obstetricians after guideline dissemination, including 145 obstetricians participating in both. After dissemination, 51.4% of obstetricians self-reported non-adherent practices for vignette 1 and 22.3% of obstetricians self-reported non-adherent practices for vignette 2. No improvement was observed after dissemination. The quantitative analysis identified factors associated with non-adherence, including older age and practice in non-university or small hospitals, whereas the qualitative analysis highlighted barriers to implementation, including fear of change, habits, work overload, and lack of time. CONCLUSIONS: Adherence to guidelines was generally low, with practices unmodified by their dissemination. Improvement is required, especially regarding applicability. TWEETABLE ABSTRACT: Adherence to guidelines to prevent spontaneous preterm birth was generally low and remained unmodified after guideline dissemination.

Women and academic careers in obstetrics and gynaecology: aspirations and obstacles among postgraduate trainees - a mixed-methods study.

OBJECTIVE: To examine the relationship between gender and a career in academic medicine. DESIGN: Mixed-methods study. SETTING: Obstetrics-gynaecology postgraduate training programme in Paris, France. SAMPLE: Postgraduate trainees in obstetrics-gynaecology (n = 204). METHODS: Statistical analysis of quantitative survey data, thematic analysis of qualitative interview data and integrative analysis. MAIN OUTCOME MEASURES: Women's aspirations and obstacles related to their decision about a career in academic medicine. RESULTS: A career in academic medicine was envisaged by 13% of the women residents and 27% of the men (P = 0.01). Women reported receiving advice from a mentor less often than men (38.8% versus 52.9%, P = 0.002). Overall, 40.6% of women and 2.9% of men reported experiencing gender discrimination (P < 0.001). In response to the question 'Do you have doubts about your ability to pursue or succeed at an academic career?', 62.4% of the women and only 17.7% of the men answered yes (P < 0.001). The global analysis identified the following obstacles: persistent gender stereotypes that produce everyday sexism, lack of identification with male role models, lack of mentors, perceived discrimination, an ideal of professional excellence that is difficult to attain, constraining professional organisational norms, inequality between men and women in the domestic and family spheres, and finally self-censorship and important doubts about their ability to combine a demanding career and a fulfilling personal life. CONCLUSIONS: Women reported the desire to follow a career in academic medicine half as often as men. Improving the presence and visibility of role models for residents and combating workplace discrimination will address some of the barriers to women choosing a career in academic medicine. TWEETABLE ABSTRACT: Women obstetric trainees in France are only half as likely as men to envisage following an academic path.

Association between inadequate antenatal care utilisation and severe perinatal and maternal morbidity: an analysis in the PreCARE cohort.

OBJECTIVE: Because the effectiveness of antenatal care in reducing pregnancy complications is still discussed despite widespread recommendations of its use, we sought to assess the association between utilisation of recommended antenatal care and severe maternal (SMM) and perinatal morbidity (SPM). DESIGN: Prospective cohort study. SETTING: Four maternity units around Paris in 2010-2012. SAMPLE: 9117 women with singleton pregnancies. METHODS: Logistic regression models adjusted for maternal social, demographic and medical characteristics. MAIN OUTCOME MEASURES: Antenatal care utilisation was assessed by: (1) initiation of care after 14 weeks, (2) < 50% of recommended visits made, according to gestational age, (3) absence of the first, second or third trimester ultrasounds, (4) two modified Adequacy of Prenatal Care Utilisation indexes, combining these components. The two main outcomes were composite variables of SMM and SPM. RESULTS: According to the modified Adequacy of Prenatal Care Utilisation index, 34.6% of women had inadequate antenatal care utilisation; the incidence of severe maternal morbidity (SMM) was 2.9% and severe perinatal morbidity (SPM) 5.5%. A percentage of recommended visits below 50% (2.6% of women) was associated with SMM [adjusted odds ratio (OR) 2.40 (1.38-4.17)] and SPM [aOR 2.27 (1.43-3.59)]. Late initiation of care (17.0% of women) was not associated with SMM or SPM. Failure to undergo the recommended ultrasounds (16, 17 and 22% of women) was associated with SPM. Inadequate antenatal care utilisation according to the index was associated with SPM [aOR 1.37 (1.05-1.80)]. CONCLUSION: Inadequate antenatal care utilisation is associated with SMM and SPM, to degrees that vary with the component of care and the outcome considered. TWEETABLE ABSTRACT: Inadequate antenatal care utilisation is associated with severe maternal and perinatal morbidity.

Exploring the hypothesis of differential care for African immigrant and native women in France with hypertensive disorders during pregnancy: a qualitative study.

OBJECTIVE: To analyse whether prenatal care trajectories among women with hypertensive disorders during pregnancy in France differ between immigrants from sub-Saharan Africa (SSA) and native French women. DESIGN: Qualitative interview study. SETTING: Three public maternity units in the Paris region. POPULATION: Women born in SSA or in France of French parents and treated for hypertension or pre-eclampsia during their pregnancy. METHODS: A sociologist conducted semi-structured in-depth interviews of 33 women during their postpartum hospitalisation and collected data from their medical files. n'vivo 10 (QSR International) was used for line-by-line coding of the transcriptions, to identify emerging themes. Strauss's concept of illness trajectories was then applied to these data. MAIN OUTCOME MEASURES: Themes derived from interviews. RESULTS: Women reported during the interviews that the blood pressure measurement procedures used by hospital staff varied between the two groups, and their medical records supported this finding. Repeated urinary dipstick testing of proteinuria before laboratory testing was more frequent for African women, as was the failure to further test proteinuria levels requiring additional action. The two groups received similar standardised care after severe complications. Other findings showed that African women were less likely to rely on healthcare services. CONCLUSIONS: These results suggest non-medically justified differential prenatal care between African and native women that may have helped delay the diagnosis of hypertension or pre-eclampsia. This study suggests hypotheses for further quantitative studies to explore the potential involvement of this differential care in the higher frequency of severe complications in this subgroup, concordantly reported in European countries hosting SSA migrants. TWEETABLE ABSTRACT: Differential prenatal care may delay diagnosis of pre-eclampsia among African compared with native French women.

Reference values for biochemical tests during pregnancy: analysis of the PRECAREbio Cohort and correlation with precarious status.

OBJECTIVE: To establish normal current values of various biochemical parameters during pregnancy in the northern area of Paris (France) in a subgroup from the PreCARE cohort and to study their changes according to the term of pregnancy, and to determine the influence of maternal precarity. DESIGN: The PreCAREbio cohort of pregnant women was defined in the PreCARE study, a multicenter cohort study. SETTING: Participants completed detailed questionnaires at enrolment and immediately postpartum. Data were collected prospectively. 26 biochemical parameters were longitudinally assessed. POPULATION: All women registered to deliver or who delivered at one of the four participating university hospitals in Paris between October 2010 and November 2011 were eligible for study inclusion (n=10,419). METHODS: We studied 26 biochemical markers during pregnancy and the influence of maternal social deprivation. MAIN OUTCOME MEASURES: Baseline values for 26 biochemical markers and their changes according to the term of pregnancy, and the influence of maternal social deprivation on these biochemical markers. RESULTS: 386 patients with 1733 blood samples recruited in one of the four centers in the PreCARE cohort were included. Baseline concentrations (median, 2.5th and 97.5th percentile) for each marker and did not differ at the different time points. Mean concentrations of each biochemical marker did not differ between socially deprived women and non-socially deprived women. CONCLUSIONS: We have established normal values for 26 biochemical parameters during pregnancy. We have also shown no difference in these values between socially deprived and non- socially deprived women.

Does a three-hour delayed pushing benefit the mode of delivery?

OBJECTIVE: The objective of this study was to compare two strategies for passive second stage management: three-hour vs two-hour delayed pushing after the diagnosis of full cervical dilation on mode of delivery and perinatal outcomes. STUDY DESIGN: This retrospective observational study included low-risk nulliparous women who reatched full cervical dilation under epidural analgesia with a single term fetus in cephalic presentation and normal fetal heart rate, between September and December 2016. Mode of delivery (spontaneous vaginal delivery versus operative delivery including cesarean section and instrumental vaginal delivery) and perinatal outcomes (post-partum hemorrhage, perineal lacerations, 5-min Apgar score, umbilical cord pH and transfer to neonatal intensive care unit) were compared between two maternity units: maternity unit A, where women could have up to a three-hour delayed pushing period after full cervical dilation diagnosis, and maternity unit B, where the delayed pushing period was a maximum of 2 h. Outcomes were compared using univariate and multivariable analyses. Adjusted odds ratios (aOR) were estimated using a logistic regression multivariable model that included potential cofounders. RESULTS: During the study period, 614 women were included, 305 in maternity unit A and 309 in maternity unit B. Women's pre-existing characteristics were comparable between the two maternity units. Women delivering in the maternity unit A had significantly lower risks of having an operative delivery compared to women delivering in the maternity unit B (respectively 18.4 vs 26.9%; aOR = 0.64; 95%CI [0.43 - 0.96]). Perinatal outcomes were comparable in the two maternity units, particularly in terms of post-partum hemorrhage rates (7.4 vs 7.8%; aOR = 1,19 [0.65 - 2.19]). CONCLUSION: Increasing the possible length of the delayed pushing period from 2 to 3 h after the diagnosis of full cervical dilation in low-risk nulliparous women appears to reduce operative deliveries without adverse effects on maternal or neonatal morbidity.

Comparison of perinatal outcome after pre-viable preterm prelabour rupture of membranes in two centres with different rates of termination of pregnancy.

OBJECTIVE: To assess perinatal outcomes after expectant management in the case of preterm prelabour rupture of membranes (PPROM) before 25 weeks of gestation, according to the rate of termination of pregnancy (TOP). DESIGN: Retrospective comparative cohort study. POPULATION: Singleton pregnancies complicated by PPROM between 15(0/7) and 24(6/7) weeks of gestation, from January 2003 to January 2007. METHODS: Comparison of perinatal outcomes in two French tertiary care referral centres presumed to have different rates of TOP. MAIN OUTCOME MEASURE: Rates of TOP, survival and survival without major morbidity. RESULTS: A total of 113 women experienced PPROM (49 in centre A and 64 in centre B). A lower proportion of patients opted for TOP in centre A (40.8%) than in centre B (56.3%). The baseline characteristics of patients and pregnancies, and gestational age at PPROM, were not different between the two centres. Mean gestational age at delivery (28.1 versus 25.4 weeks of gestation; P < 0.01), mean latency period (45.5 versus 16.1 days; P < 0.01), mean birthweight (1295 versus 929 g; P = 0.04) and survival (46.9 versus 20.3%; P < 0.01) were significantly higher in centre A than in centre B. The percentage of neonates alive without major morbidity was also higher in centre A than in centre B (42.9 versus 20.3%; P = 0.01). CONCLUSIONS: Perinatal outcomes of pregnancies managed expectantly were not better in the centre where the TOP rate was higher. The perinatal risk of pregnancies complicated by pre-viable PPROM remains high.

[Screening and healthcare for pregnant women with psycho-social vulnerability : A French national study]. / Dépistage et parcours de soins en cas de vulnérabilités psycho-sociales maternelles : une enquête nationale française.

INTRODUCTION: Psycho-social vulnerabilities are a medical risk factor for both fetus and mother. Association between socioeconomic status and prenatal follow-up has been well established and inadequate follow-up is associated with higher morbidity and mortality in women in unfavorable situations. OBJECTIVE: The objective is to identify screening strategies and to describe existing systems for pregnant women in psycho-social vulnerability in French maternity hospitals. MATERIAL AND METHODES: This is a national survey conducted by questionnaire in all French maternities. RESULTS: Screening by means of targeted questions is carried out by 96.7% of maternity units. Early prenatal interviews are offered systematically by 64% of maternity units and access to them is still difficult for women in vulnerable situations. In order to organize care pathways, 28.7% of maternities have a structured unit within their establishment and 81% state that they have mobilizable caregivers. Multidisciplinary meetings for the coordination of the various stakeholders are held by 85.8% of maternity units. Collaboration with networks and associations is emphasized. CONCLUSION: A large proportion of maternities seek to identify women in situation of psycho-social vulnerabilities and to organize care paths. However, the resources implemented still appear insufficient for many maternity units. Each maternity hospital has resources and is developing initiatives to deal with the difficulties of care.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Case Selection for Trial of Labour]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Critères de sélection des femmes éligibles à une tentative d'accouchement par voie basse.

OBJECTIVE: The objective of this chapter is to examine on the basis of the knowledge currently available the criteria available before labour for selecting women who would be eligible for trial of vaginal delivery. METHODOLOGY: Bibliographical research in French and English using the Medline and Cochrane databases between 1980 and 2019 and the recommendations of international societies. RESULTS: It is recommended to offer women who wish to attempt a vaginal delivery at term a pelvimetry to decide with them on their mode of delivery (Grade C). The pelvimetric standards used at the time of the PREMODA study were anteroposterior diameter of inlet≥105mm, a transverse diameter of inlet≥120mm, a transverse interspinous diameter≥100mm. However, since there is no evidence about which pelvic measures to use, nor any evidence to set decision-making thresholds other than those set in published studies, the selected decision-making thresholds can be adjusted according to gestational age at delivery or fetal biometrics (Professional consensus). There is no argument for recommending the practice of pelvimetry in the case of delivery before 37 weeks gestational age (Professional consensus) and in the case of breech presentation discovered at the time of beginning of labour, the absence of pelvimetry alone does not contraindicate the attempt of vaginal delivery (Professional consensus). There is insufficient data to recommend the systematic use of fetal weight estimation and/or biparietal diameter measurement as acceptance criteria for a vaginal delivery attempt. In the event of a known fetal weight estimation before birth greater than 3800g, a cesarean section is to be preferred (Professional consensus). The breech presentation is not in itself a contraindication to an attempt of vaginal delivery for a small fetus for gestational age (Professional consensus). The presentation of the non-frank breech is not in itself a contraindication to an attempt of vaginal delivery (Professional consensus). In the case of premature breech delivery, current data do not allow to recommend one delivery route over another (Professional consensus). It is recommended to check the absence of hyperextension of the fetal head by ultrasound before an attempt of vaginal delivery (Professional consensus) and to prefer a cesarean section if such a position is found (Professional consensus). It is not recommended to propose a caesarean section with the sole reason of nulliparity (Grade C). The history of cesarean section is not in itself a contraindication to an attempt of vaginal delivery in the case of fetal breech presentation (Professional consensus). Premature rupture of the membranes is not in itself a contraindication to an attempt of vaginal delivery (Professional consensus). CONCLUSION: A number of the factors analyzed in this chapter are to be incorporated into the decision-making process in order to choose with the woman whose fetus is in breech presentation the delivery route.

[CNGOF Guidelines for Clinical Practice: Revision of the Methodology]. / Recommandations pour la pratique clinique du CNGOF : révision méthodologique du processus d'élaboration.

OBJECTIVES: To revise the organization and the methodology of the Practice Clinical Guidelines (PCG) of the French College of Gynecologists and Obstetricians (CNGOF). METHODS: The different available methods of PCG organization and of scientific evidence grading have been consulted after searching in the Medline database. RESULTS: The PCG group of the CNGOF has decided to adopt the AGREE II (for Appraisal of Guidelines for REsearch and Evaluation) methology for PCG organization and the GRADE (for Grading of Recommendation Assessment, Development, and Evaluation) system for grading scientific evidence. CONCLUSION: By adopting the AGREE II consortium criteria and grading scientific evidence according to the GRADE system, the CNGOF will increase the quality of the overall process, will deliver more targeted and easy to assimilate recommendations, to facilitate professional decision making.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Short Text]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Texte court.

OBJECTIVES: To determine the optimal management of singleton breech presentation. MATERIALS AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long term maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies. A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy (LE2). It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term (Grade C) and to check the absence of hyperextension of the fetal head by ultrasonography (Professional consensus) to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery (Professionnal consensus). Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met (Grade C). CONCLUSION: In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy.

[Decision making on breech delivery: information as a way to reconcile maternal autonomy and medical responsibility]. / Peut-on concilier autonomie maternelle et responsabilité médicale dans les décisions de voies d'accouchement des foetus en siège? Rôle de l'information.

As far as breech vaginal delivery remains an acceptable option, each case has to be evaluated in order to determine whether in that particular situation it is medically relevant. When vaginal delivery is to be envisaged, maternal consent is needed. This implies seeking medical information that allows women to express their autonomy and to be part of the decision regarding their delivery. This article concerns a physicians reflection on medical information and on connections between the obstetrician's responsibility, that of the future mother, and autonomy. Understanding information as necessarily arising from an exchange between the care giver and the future mother is the condition that allows the coexistence of maternal autonomy and medical responsibility.

[Is vaginal delivery in twin pregnancy still an option? An analysis of the literature data]. / L'accouchement par voie basse des grossesses gémellaires est-il encore une option raisonnable ? Analyse des données de la littérature.

The aim of this review was to analyze the nature of the data and practices reported in the literature in order to determine if vaginal delivery of twin gestations with a first twin in cephalic presentation after 34 weeks still remains an option. Compared to cesarean, large retrospective population-based studies demonstrated increased neonatal morbidity and mortality of the second twin associated with vaginal delivery. Some then suggested systematic planned cesarean could protect second twins from increased neonatal mortality and morbidity. These results have not been confirmed in hospital retrospective studies in which candidates for vaginal delivery were carefully selected, and second twin delivery actively managed, with internal version when the fetal head is above a 0 station in case of cephalic presentation and with systematic immediate total breech extraction in case of non cephalic presentation. Taking into account the poor external validity of the population-based studies, and the reassuring results of the hospital retrospective studies, attempted vaginal delivery after 34 weeks, when the first twin is in cephalic presentation, still appears as a safe option in low risk populations. Progress in the assessment of the risks associated with the mode of delivery could result from a large nationwide observational prospective study, a randomized trial being, even more than in the breech delivery issue, an inappropriate method for evaluating these risks.

[Antenatal management in case of preterm premature rupture of membranes before fetal viability: CNGOF Preterm Premature Rupture of Membranes Guidelines]. / Prise en charge anténatale en cas de rupture prématurée des membranes avant la viabilité fœtale. RPC Rupture prématurée des membranes avant terme CNGOF.

OBJECTIVES: To evaluate the maternal, perinatal and long-term prognosis in the event of previable premature rupture of the membranes (PROM) and to specify the interventions likely to reduce the risks and improve the prognosis. METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: Previable PROM is a rare event whose frequency varies from 0.3 to 1% according to estimates (NP4). When occurring as a complication of amniocentesis, the prognosis is generally better than when spontaneous (NP3). Between 23 and 39% of women will deliver in the week following PROM and nearly 40% of women will not have given birth 2 weeks after (NP3). The frequency of medical termination of pregnancy varies greatly according to the studies (NP4), as does that of fetal death (NP4). Hospital survival and survival rates without major morbidity as a proportion of conservatively treated patients range from 17-55% and 26-63%, respectively (NP4). Neonatal prognosis is largely dominated by prematurity and its complications (NP3). The frequency of maternal sepsis varies from 0.8 to 4.8% in the most recent studies (NP4). Only one case of maternal death is reported, although 3 cases were identified in France between 2007 and 2012 (NP3). Information is a major component of the care to be provided to women and their partners (Professional consensus). An initial period of hospitalization may be proposed after previable PROM (Professional consensus). Thereafter, there is no argument to recommend hospital management rather than extra-hospital management when there is no argument in favour of intrauterine infection (Professional consensus). An evaluation of the amount of amniotic fluid by ultrasound may be proposed at the initial consultation and after a period of 7 to 14 days if pregnancy continues (Professional consensus). Prophylactic antibiotic treatment is recommended as soon as PROM is diagnosed (Professional consensus). The gestational age at which corticosteroid therapy may be proposed will depend on the thresholds selected for neonatal resuscitation care. In particular, it will take into account parental positioning (Professional consensus). From the time of the decision to perform neonatal resuscitation until the gestational age of 32 weeks, it is recommended to administer MgSO4 to the woman whose delivery is imminent (Grade A). Tocolysis is not recommended in this context (Professional consensus). In certain situations, meeting strictly the conditions mentioned by the CSP article L. 2213-1, a maternal request for medical interruption of pregnancy may be discussed. CONCLUSION: The levels of evidence of scientific work on the management of previable PROM are low, therefore, most of the recommendations proposed here are based on professional agreement by "reasonable" extension of recommendations valid for later gestational ages.

Cost-effectiveness of vaccination against cytomegalovirus (CMV) in adolescent girls to prevent infections in pregnant women living in France.

BACKGROUND: CMV infections are the most frequent congenital infections worldwide. AIM: Assess the cost-effectiveness of vaccination strategies of adolescent girls vs. current practice (hygiene counseling) to prevent CMV seroconversions during pregnancy in France. METHOD: A Markov decision-tree model simulated overtime the trajectory of a single fictive cohort of 390,000 adolescent women aged 14 years old, living in France. Impact of vaccination was explored until the end of their reproductive live 40 years later. STRATEGIES COMPARED: "S1: No vaccination" (current practice); "S2: Routine vaccination"; "S3: Screening and vaccination of the seronegative". MODEL PARAMETERS: Seroconversion rate without vaccination (0.035%/pregnant woman-week); fetal transmission risk (41%). Vaccine vs. no vaccination: a 50% decrease in maternal seroconversions. OUTCOMES: Quality-Adjusted Life-Years (QALYs) of the cohort-born babies; discounted costs; Incremental Cost-Effectiveness Ratio (ICER). RESULTS: S2 was the most effective strategy (with 35,000 QALYs gained) and the most expensive (€211,533,000); S1 was the least effective and least costly (€75,423,000). ICERs of strategy S3 vs. S1, and S2 vs. S3 were 6,000€/QALY gained (95% uncertainty range [2700-13,300]) and 16,000€/QALY [negative ICER (S3 dominated by S2) - 94,000] gained, respectively; highly cost-effective because ICER < 1∗France's GPD/capita = €30,000. SENSITIVITY ANALYSIS: If the seroprevalence was >62% (vs. 20% in the base case), S3 would become the most efficient strategy. CONCLUSION: In France, systematic vaccination of adolescent girls was the most efficient strategy to prevent maternal seroconversions. If the population was less than 62% immune, systematic screening and vaccination of susceptibles would become the most cost-effective approach.

[Preterm premature rupture of membranes: CNGOF Guidelines for clinical practice - Short version]. / Rupture prématurée des membranes avant terme : recommandations pour la pratique clinique du CNGOF ­ Texte court.

OBJECTIVE: To determine management of women with preterm premature rupture of membranes (PPROM). METHODS: Bibliographic search from the Medline and Cochrane Library databases and review of international clinical practice guidelines. RESULTS: In France, PPROM rate is 2 to 3% before 37 weeks of gestation (level of evidence [LE] 2) and less than 1% before 34 weeks of gestation (LE2). Prematurity and intra-uterine infection are the two major complications of PPROM (LE2). Compared to other causes of prematurity, PPROM is not associated with an increased risk of neonatal mortality and morbidity, except in case of intra-uterine infection, which is associated with an augmentation of early-onset neonatal sepsis (LE2) and of necrotizing enterocolitis (LE2). PPROM diagnosis is mainly clinical (professional consensus). In doubtful cases, detection of IGFBP-1 or PAMG-1 is recommended (professional consensus). Hospitalization of women with PPROM is recommended (professional consensus). There is no sufficient evidence to recommend or not recommend tocolysis (grade C). If a tocolysis should be prescribed, it should not last more than 48hours (grade C). Antenatal corticosteroids before 34 weeks of gestation (grade A) and magnesium sulfate before 32 weeks of gestation (grade A) are recommended. Antibiotic prophylaxis is recommended (grade A) because it is associated with a reduction of neonatal mortality and morbidity (LE1). Amoxicillin, 3rd generation cephalosporins, and erythromycin in monotherapy or the association erythromycin-amoxicillin can be used (professional consensus), for 7 days (grade C). However, in case of negative vaginal culture, early cessation of antibiotic prophylaxis might be acceptable (professional consensus). Co-amoxiclav, aminosides, glycopetides, first and second generation cephalosporins, clindamycin, and metronidazole are not recommended for antibiotic prophylaxis (professional consensus). Outpatient management of women with clinically stable PPROM after 48hours of hospitalization is a possible (professional consensus). During monitoring, it is recommended to identify the clinical and biological elements suggesting intra-uterine infection (professional consensus). However, it not possible to make recommendation regarding the frequency of this monitoring. In case of isolated elevated C-reactive protein, leukocytosis, or positive vaginal culture in an asymptomatic patient, it is not recommended to systematically prescribe antibiotics (professional consensus). In case of intra-uterine infection, it is recommended to immediately administer an antibiotic therapy associating beta-lactamine and aminoside (grade B), intravenously (grade B), and to deliver the baby (grade A). Cesarean delivery should be performed according to the usual obstetrical indications (professional consensus). Expectative management is recommended before 37 weeks of gestation in case of uncomplicated PPROM (grade A), even in case of positive vaginal culture for B Streptococcus, provided that an antibiotic prophylaxis has been prescribed (professional consensus). Oxytocin and prostaglandins are two possible options to induce labor in case of PPROM (professional consensus). CONCLUSION: Expectative management is recommended before 37 weeks of gestation in case of uncomplicated PPROM (grade A).

[Information in perinatal medicine: ethical aspects]. / L'information dans le contexte du soin périnatal: aspects éthiques.

Besides the undeniable need to respect parental autonomy, providing information is a legal and moral obligation, to be informed a basic right. The act of informing should be considered as an exchange and necessarily begins by listening to the other. According to the jurisprudence of the Court of Cassation that draws on Article 35 of the Deontological Code, information has to be clear (implying an educational effort, availability and to check that the information has been well understood), appropriate (adapted to each situation and person) and honest (which supposes a moral contract between parents and physicians). Loyalty implies a consideration of the uncertainty underlying medical practice, and of the limitations in arriving at a prognosis. Indeed, caution needs to be exercised in conveying information, taking into account the risk of its becoming self-fulfilling, which could modify the way in which parents take care of their child. The information given has to be coherent, both within the spatial dimension (coherence of information between the different maternity services in the perinatal network) and the temporal dimension (coherence of information between pre- and postnatal stages). It must be acknowledged that information is essentially subjective. There is a fundamental difference between coherence and uniformity, and as regards information, uniformity is neither possible nor desirable. In each situation, priority must be given to oral information delivered in an appropriate material context. The principle of establishing, in the medical file, a written trace of the information given at various stages is one way to guarantee its coherence.

[Anonymous gamete donation: what to protect and does it violate the human rights?]. / Anonymat du don de gamètes: protection d'un modèle social ou atteinte aux droits de l'homme?

The French legislation about gamete donation imposes anonymity between the donor and the demanders, in reference to the principles of protection of the human dignity that are applied in other fields of biomedicine. We are here wondering about this choice: does this obligation really protect the human rights that are one of the ethical bases of law? At the time the French law was written, anonymity in gamete donation was inherited from the practice of the French CECOS but it has now become controversial. Many European countries have opened the access to the genetic origins. There is no evidence for this practice to be an efficient protection of the respect of human body and the disinterested nature of donation. Concerning gametes, it seems that it protects a social object, the parental project, but that it has no influence on the protection of parenthood, filiation, and the concept that humankind is not only biological. At last, we analyse the most important human rights documents to assume the hypothesis that anonymous gamete donation, although not violating the human rights, is an implement for Foucault's biopower, far from protecting the ethical foundations of human dignity.