Validation of the 'EPICES' social deprivation score in a population of women who have just given birth: a French cross-sectional study.

OBJECTIVES: To assess the diagnostic performance of the EPICES score for identifying social deprivation during pregnancy in a population of women in the immediate postpartum period. STUDY DESIGN: This cross-sectional survey took place between 5th June and 5th August 2017, among women who had just given birth in either of the maternity units in Clermont-Ferrand, France. METHODS: A self-administered questionnaire was completed by women. The questionnaire came in two parts: the EPICES index and the criteria for social deprivation defined by French law. These criteria were chosen to define the reference standard. The women were classified into two groups, living in precarious circumstances or not, according to the criteria defined by the French law (reference standard). To determine the most relevant threshold of the EPICES score, the precision associated with the threshold (the fraction of those predicted positive who are true positives: positive predictive value) was balanced with its sensitivity. EPICES scores above the threshold were classified as deprived, those below as non-deprived. RESULTS: Of the 947 women who gave birth during the study period, 700 (73.9%) completed the self-administered questionnaire. The best trade-off between precision and sensitivity was obtained with a threshold of 22. For this threshold value, the positive predictive value was 42.3% and the sensitivity 70.3%. CONCLUSIONS: The EPICES score with a threshold validated in the population of pregnant women is a useful, rapid, and easy-to-use tool that makes it possible to identify maternal deprivation at an individual level.

A randomised controlled trial of amnioexchange for fetal gastroschisis.

OBJECTIVE: Morbidity in fetuses affected by gastroschisis is mainly the result of bowel ischaemic and inflammatory processes. Experimental studies on animal models show that clearing amniotic fluid from the digestive secretions by amnioexchange procedures reduces the inflammatory process. We evaluated the benefit of the amnioexchange procedure for fetal gastroschisis in humans. DESIGN: Prospective, interventional, randomised study. SETTING: Eight referral centres for fetal medicine. POPULATION: Pregnant women carrying a fetus with gastroschisis. METHODS: We compared, in utero, amnioexchange with a sham procedure. The protocol included, in both arms, steroid injections at 30 weeks of gestation and the use of postnatal minimal enteral feeding. MAIN OUTCOME MEASURES: The primary outcome was a composite variable based on the duration of ventilation and parenteral nutrition. Secondary outcomes were the effectiveness and safety of the amnioexchange procedure, including the rate of perinatal death, time to full enteral feeding, primary closure, and late feeding disorders. RESULTS: Sixty-four patients were randomised. There was no difference in the composite criteria between the amnioexchange and control groups. Based on an intention-to-treat analysis, there were no significant between-group differences in pregnancy outcome or complications. When studying the relationship between digestive compounds and amniotic fluid inflammatory markers, a clear correlation was found between bile acid and both ferritin and interleukin 1ß (IL1ß). CONCLUSIONS: In humans, amnioexchange, as described in our protocol, is not an option for fetal care; however, we provide supplementary proof of the involvement of inflammation in the pathogenicity of gastroschisis and suggest that future research should aim at reducing inflammation. ClinicalTrials.gov: NCT00127946. TWEETABLE ABSTRACT: A prospective, interventional, randomised study shows no benefit of amnioexchange for fetal gastroschisis in humans.

Pregnancy and primary Sjögren's syndrome: management and outcomes in a multicentre retrospective study of 54 pregnancies.

OBJECTIVES: Primary Sjögren's syndrome (pSS) is one of the most common autoimmune diseases, mainly affecting women during the fourth decade of life. During pregnancy, the presence of anti-Ro/SSa and anti-La/SSb antibodies increases the risk of congenital heart block (CHB). Foetal and pregnancy outcomes in pregnant women with pSS compared with the general population are difficult to evaluate because of confounding factors including age and body mass index (BMI). METHOD: The aim of this case-control study was to analyse the impact of pSS in pregnant women on foetal and pregnancy outcomes. RESULTS: We enrolled 19 women with pSS (54 pregnancies) matched by age and BMI to 216 controls. Patients with pSS delivered significantly earlier (38 weeks + 3 days vs. 39 weeks + 2 days) and experienced more spontaneous abortions [< 22 weeks of gestation (WG)] than the controls [n = 16/54 (30.0%) vs. n = 1/216 (0.4%); p < 0.00001]. Preterm delivery (≤ 37+6 WG) was significantly higher in the pSS group than in the control group (29% vs. 12%, p = 0.04). pSS activity significantly affected the birthweight percentile, which was lower in pregnancies occurring after the diagnosis of pSS than in those occurring before (32.43 ± 21.57 vs. 60.46 ± 27.37; p = 0.008). No case of CHB was observed. CONCLUSIONS: pSS is responsible for an increased risk of spontaneous abortion. The duration of pregnancy is lower in patients with than without pSS, with more premature deliveries. Pregnancies that occur after the onset of the disease result in lower birthweight percentile children than when pSS is not clinically overt.

Liver X Receptors and female reproduction: when cholesterol meets fertility!

The role of cholesterol in female reproductive physiology has been suspected for a long time, while the molecular bases were unknown. Cholesterol is the precursor of ovarian steroid biosynthesis and is also essential for fertility. In the uterus, cholesterol is essential to achieve correct contractions at term, but an excessive uterine cholesterol concentration has been associated with contractility defects. Liver X Receptor (LXR) α and LXR ß are nuclear receptors activated by oxysterols, oxidized derivatives of cholesterol. Since their discovery, the role of LXR in the control of cholesterol homeostasis has been widely described. Beyond their cholesterol-lowering role, more recent data have linked these nuclear receptors to various physiological processes. In particular, they control ovarian endocrine and exocrine functions, as well as uterine contractility. Their contribution to female reproductive cancers will also be discussed. This review will try to enlighten on the LXR as a molecular link between dietary cholesterol and reproductive diseases in women. In the future, a better comprehension of the various physiological processes regulated by the LXR will help to develop new ligands to prevent or to cure these pathologies in women.

Diagnosis of medulloblastoma in pregnant women: To continue with the pregnancy or not? A case report and literature review.

BACKGROUND: Medulloblastoma (MB) is an uncommon and challenging diagnosis in pregnant women, and especially in pregnancy after in-vitro fertilization (IVF). Clinical features are easily misinterpreted and mistaken for other more common gestation-related pathologies. We report the case of a 34-year-old patient with clinical symptoms of intracranial hypertension. MB was diagnosed and operated on during the pregnancy. OBJECTIVE: To conduct a systematic literature review of other cases of MB operated on during pregnancy, and discuss the clinical and surgical management of MB in pregnancy. METHOD: We conducted a systematic literature review according to PRISMA guidelines. RESULTS: In addition to the present case, 9 cases of MB were reported as operated on during viable pregnancy. In one case, medical abortion was decided on before surgical debulking. Pregnancy term was between 8 and 30 weeks. The most common symptoms were headache, nausea and vomiting followed by dizziness. Tumor prognosis after treatment was favorable in 6 cases out of 10 and unfavorable in 4, with 3 cases of recurrence and 3 of death. CONCLUSION: We report the first case of long-term survival after MB in a woman pregnant via IVF. In standard-risk MB, it is possible to carry the pregnancy to term. Vaginal delivery is not contraindicated a priori. Early diagnosis, close clinical and radiological surveillance and surgery are the key factors for better prognosis. Multidisciplinary collaboration is crucial to determine the best timing and treatment.

[Intrahepatic cholestasis of pregnancy: French College of Obstetricians and Gynecologists guidelines for clinical practice]. / La cholestase gravidique : recommandations pour la pratique clinique du Collège national des gynécologues obstétriciens français.

OBJECTIVE: To identify strategies for reducing neonatal and maternal morbidity associated with intrahepatic cholestasis pregnancy (ICP). MATERIAL AND METHODS: The quality of evidence of the literature was assessed following the GRADE methodology with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS: Of the 14 questions (from 12 PICO questions and one definition question outside the PICO format), there was agreement between the working group and the external reviewers on 14 (100%). The level of evidence of the literature was insufficient to provide a recommendation on two questions. ICP is defined by the occurrence of suggestive pruritus (palmoplantar, nocturnal) associated with a total bile acid level>10µmol/L or an alanine transaminase level above 2N after ruling out differential diagnoses. In the absence of suggestive symptoms of a differential diagnosis, it is recommended not to carry out additional biological or ultrasound tests. In women with CIP, ursodeoxycholic acid is recommended to reduce the intensity of maternal pruritus (Strong recommendation. Quality of the evidence moderate) and to decrease the level of total bile acids and alanine transaminases. (Strong recommendation. Quality of the evidence moderate). S-adenosyl-methionine, dexamethasone, guar gum or activated charcoal should not be used to reduce the intensity of maternal pruritus (Strong recommendation. Quality of evidence low), and there is insufficient data to recommend the use of antihistamines (No recommendation. Quality of evidence low). Rifampicin (Weak recommendation. Very low quality of evidence) or plasma exchange (Strong recommendation. Very low quality of evidence) should not be used to reduce maternal pruritus and perinatal morbidity. Serum monitoring of bile acids is recommended to reduce perinatal morbidity and mortality (stillbirth, prematurity) (Low recommendation. Quality of the evidence low). The level of evidence is insufficient to determine whether fetal heart rate or fetal ultrasound monitoring are useful to reduce perinatal morbidity (No recommendation). Birth is recommended when bile acid level is above 99µmol/L from 36 weeks gestation to reduce perinatal morbidity, in particular stillbirth. When bile acid level is above 99µmol/L is below 100µmol/L, women should be informed that induction of labor could be considered 37 and 39 weeks gestation to reduce perinatal morbidity. (Strong recommendation. Quality of evidence low). In postpartum, total bile acids and alanine transaminases level should be checked and normalized before prescribing estrogen-progestin contraception, ideally with a low estrogen dose (risk of recurrence of pruritus and cytolysis) (Low recommendation. Quality of evidence very low). CONCLUSION: Although the quality of evidence regarding ICP gestational cholestasis remains low, there is a strong consensus in France, as shown by our Delphi study, on how to manage women with ICP. The reference first-line treatment is ursodeoxycholic acid.

Prenatal diagnosis of lobar bronchial atresia.

We report three cases of fetal lobar bronchial atresia referred to our Fetal Medicine Center during the mid-trimester of pregnancy over the last 15 years. Lobar bronchial atresia can mimic a main stem bronchial atresia on mid-trimester ultrasound examination as it induces extensive lobar enlargement, major mediastinal shift and eversion of the diaphragm. It was associated with severe pulmonary hypoplasia in all three cases, even though polyhydramnios and ascites were absent in two. Termination of pregnancy was performed at parental request after extensive counseling in each of the cases and necropsy confirmed one or two enlarged lung lobes leading to major compression of the remaining lobe(s) of the ipsilateral lung, the contralateral lung and the heart. No other anomalies were observed and the karyotype was normal in all cases.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Information and Management]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Information et organisation.

OBJECTIVE: To provide guidelines regarding parents' information in case of breech presentation and labour ward organisation for trial of labour in breech presentation. METHODS: Medline and Cochrane Library databases search and review of the main foreign guidelines. RESULTS: Information should be in favour of external cephalic version and describe benefits and risks for planned vaginal delivery vs planned caesarean delivery (Professional consensus). Patient should be aware of choice change according to obstetrical context (Professional consensus). Presence of an obstetrician is required at birth as well as immediate assistance of an anaesthesiologist and paediatrician if needed (Professional consensus). CONCLUSION: Information should lead to concerted choice concerning mode of delivery. Labour ward organisation requires presence of an obstetrician at birth and immediate availability of anaesthesiologist and paediatrician.

[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.

Menses recovery and fertility after artery embolization for PPH: a single-center retrospective observational study.

To evaluate long-term effects of arterial embolization (AE) for postpartum hemorrhage (PPH) on menses recovery and subsequent pregnancies. One hundred thirteen consecutive patients, recruited from 1999 to 2006, who had undergone AE for severe PPH were evaluated in a retrospective monocentric study. As embolization agents, pledgets of absorbable gelatine sponge (Curaspon) were used in 106 cases, Curaspon powder in 3 cases, and inert microparticles in 4 cases. In 111/113 cases (98.1%), AE was successful in controlling PPH. In two cases (1.7%), the AE was unsuccessful and required a total abdominal postembolization hysterectomy. Concerning fertility, 6 patients were lost to follow-up and 107 were available. The average time to follow-up was 46.4+/-21.8 months. Of the 107 patients, 99 had recovery of menses (92.5%). Of the 107 (61%) patients, 66 reported regular menstruation with normal delay after the delivery. Thirty-three patients (31%) reported subjective changes in the frequency and amount of menses. Six patients (5.6%) had documented amenorrhea after AE and developed diffuse uterine synechiae at the hysteroscopic investigation. Out of 29 patients who desired and attempted conception, 18 patients (62%) reported a total of 19 pregnancies at the end of the follow-up. One miscarriage at 12 weeks of gestation was reported. The 18 pregnancies at term were uneventful until delivery, but 3 cases of further PPH (15%) occurred due to abnormal placentation requiring a further AE. All full-term newborns were healthy. AE is a feasible, safe, and reproducible technique to control PPH, allowing a very high resumption of menses and subsequent pregnancies; in these cases, considering the elevated incidence of further PPH due to abnormal placentation, an accurate ultrasonographic monitoring during pregnancy seems appropriate.

[Laparoscopy during pregnancy: experience of the French university hospital of Clermont-Ferrand]. / Coelioscopie en cours de grossesse: expérience du centre hospitalier universitaire (CHU) de Clermont-Ferrand.

OBJECTIVE: To describe perioperative management and perinatal outcome for patients undergoing laparoscopy during pregnancy. PATIENTS AND METHODS: We conducted a retrospective study of all cases of laparoscopy during pregnancy performed in our university hospital over a period of six years (from February 2000 to February 2006). RESULTS: We observed 34 cases managed from five to 30 weeks of gestation (11 cases of adnexal torsion, ten adnexal masses, eight appendicitis, one cholecystitis, one sigmoid volvulus, one pelvic peritonitis, two heterotopic pregnancies). Open laparoscopy was used in 12 cases. Conversion was required in two cases mainly due to adherences (one borderline lesion at 16 weeks and one tubal cyst torsion at 24 weeks). No maternal complication was observed. One miscarriage occurred at Day 1 (peritonitis, five weeks of gestation) and one patient opted for abortion. No threatened preterm labour occurred after the perioperative course and no neonate required admission in neonatology unit. DISCUSSION AND CONCLUSION: This study illustrates safety and efficacy of laparoscopy in management of surgical diseases in the gravid patient. Emergent indications are the most common, highlighting the need for all physicians to know specific recommendations related to laparoscopy during pregnancy.

[Learning curve of vacuum extraction in residency: a preliminary study]. / Courbe d'apprentissage de la ventouse obstétricale par les internes : étude préliminaire.

OBJECTIVES: The aim of this study was to assess the lurning curve of young residents for vacuum extraction. MATERIALS AND METHODS: All vacuum extractions performed in our department by five residents (< or =5th semester) during a study period of nine months were systematically supervised by a senior who fulfilled an assessment questionnaire from which was calculated a score reflecting the quality of the extraction. RESULTS: Fifty-four vacuum extractions were assessed with a mean of 10.8+/-2.9 (range, 10-13) procedures by resident. We compared the group including the six first procedures performed by each resident (group 1, n = 30) with the group including the following procedures (group 2, n = 24). We observed in the group 2 compared to the group 1, a significant improvement of the scores mean (12.3+/-5.4 vs 8.4+/-6.2, p = 0.016) and a significant reduction of the need for manual assistance by the senior (12.5% vs 40%, p = 0.034). CONCLUSION: We report a method for the learning and assessment of vacuum extraction feasible at "the bed" of the patient. This approach allows to observe a significant progression of the resident for the technique of vacuum extraction on a dozen of procedures.

[Correlation between automated optical reading and double human reading for two tests of fetal membranes rupture]. / Concordance entre la lecture optique automatisée et la lecture visuelle double pour deux tests de rupture des membranes.

OBJECTIVES: To assess concordance between double human and automated optical reading (AOR) concerning two biological tests for rupture of membranes (ROM) METHODS: We conducted a monocentric, prospective, observational study comparing Actim Prom® (Alere SAS, Jouy-en Josas, France) and Hiprom Duo® (Fumouze, Levallois-Perret, France). Each test was performed simultaneously in patients with suspected ROM and read independently by 2 biologists and AOR device. ROM was clinically confirmed in case of recurrent leakage or spontaneous labour with no perceived membranes within 48hours. RESULTS: Concerning Actim Prom®, concordance was 100 %, 92.5 % and 91.6 % between biologists, biologists-AOR device and biologists or AOR vs. clinical presentation respectively. Concerning Hiprom Duo®, concordance was 97.2 % between biologists, 97.2 % between biologist 1 and AOR, 95.3 % between biologist 2 and AOR, 63.5 % between clinical presentation and human reading, 62.3 % between clinical presentation and AOR. False positive cases were significantly associated with modified cervix (21 % vs. 46 %, P=0.006). CONCLUSION: We demonstrated excellent correlation between biologists and good or excellent correlation between AOR and human reading supporting the use of AOR in clinical practice.

Prenatal diagnosis of thrombosis of the dural sinuses: report of six cases, review of the literature and suggested management.

OBJECTIVES: To describe and assess the sonographic findings, evolution and clinical implications of thrombosis of the fetal dural sinuses. METHODS: We compiled a multicenter report of the outcomes of five cases with a prenatal diagnosis of thrombosis of the dural sinuses, and one case in which thrombosis of the dural sinus was diagnosed at necroscopy after termination of pregnancy. Prognostic factors are discussed, and suggestions made for prenatal and postnatal management. RESULTS: The mean (range) gestational age at diagnosis of thrombosis of the dural sinuses in the five cases in which it was made prenatally was 25.2 (22-31) weeks. In these five cases, diagnosis was made by sonography and confirmed by magnetic resonance imaging (MRI), which showed a blood clot in the region of the torcular herophili. Three of the six cases delivered vaginally with favorable sonographic findings, and normal clinical neurological development. Two pregnancies were terminated at the request of the parents. In one of these cases the prognosis was poor, with signs of fetal decompensation or cardiac failure; the pregnancy was terminated and necropsy revealed thrombosis of the occipital dural sinuses associated with a hemangioma. One infant, in whom the thrombosis developed in conjunction with a dural sinus malformation, died at 4 months of age. CONCLUSIONS: Thrombosis of the cerebral venous circulation can occur antenatally and is detectable by fetal real-time and color Doppler ultrasound examination. A review of the literature supports targeted evaluation of the fetus by serial ultrasound imaging and MRI to help guide the diagnosis, and to improve the counseling and management of such cases. Partial or total regression, isolated abnormality, absence of fetal decompensation or signs of cardiac failure and favorable clinical evolution are suggestive of favorable prognosis. In such cases, non-interventional neonatal management is recommended.

Pathology underrates colon cancer extranodal and nodal metastases; ex vivo radioimmunodetection helps staging.

PURPOSE: Colorectal carcinoma is frequently accompanied by small lymph nodes metastases that often escape pathologic examination. We evaluated whether ex vivo radioimmunodetection with the Affinity Enhancement System (AES) could improve detection of mesocolonic metastases. EXPERIMENTAL DESIGN: A bivalent 111In-labeled hapten was injected (16 patients) 4 days after a bispecific antibody (anticarcinoembryonic antigen, antihapten). Surgery was done 1 to 3 days later, and radioactive uptake in the mesocolon was recorded. Extensive pathologic examination of the mesocolon (reference method) was done after fat dissolution. This method visualizes all lymph nodes but is not in routine use. RESULTS: The reference method disclosed 705 nodes. There was no significant difference between the number of node metastases detected by AES or by the reference method (16 versus 17). Better detection would have been obtained by AES than by routine pathology (P<0.01). In addition 12 extranodal metastases were found in this study of which eight were detected by AES. The prognostic importance of such extranodal metastases has been underlined in the literature. Routine pathology combined with AES would have disclosed all node metastases and 86% of total metastases versus 35% by routine pathology alone. CONCLUSIONS: Ex vivo radioimmunodetection could improve nodal and extranodal metastases detection in patients with colorectal cancer. Its value for improving pathologic analysis, together with the effect of these small metastases on prognosis, should be further evaluated. The benefit of adjuvant chemotherapy for patients upstaged with radioimmunodection should also be assessed because adjuvant chemotherapy improves the 5-year survival of stage III patients.

[The use of ultrasonographic 3D power Doppler to describe an ovarian Sertoli-Leydig cell tumor]. / Description échographique d'une tumeur ovarienne de Sertoli-Leydig à l'aide du doppler énergie tridimensionnel.

We report one case of unilateral ovarian Sertoli-Leydig tumor with intermediate grade and heterologous element, in a young woman with clinical and biological typical presentation. We discuss 2D and 3D ultrasonographic and doppler features.

[Congenital lobar emphysema: a rare etiology of hyperechoic lung]. / Une étiologie rare de poumon hyperéchogène: l'emphysème lobaire géant congénital.

Lobar congenital emphysema is a rare pulmonary malformation corresponding to progressive overinflation of a pulmonary lobe secondary to partial bronchial obstruction. Prenatal diagnosis is mainly based on lung hyperechoic area. Sonographic features are not specific highlighting the interest of fetal MRI or postnatal tomodensitometry. This case report describes prenatal detection including pitfalls and postnatal management.

[Diagnosis of rupture of fetal membranes: CNGOF Preterm Premature Rupture of Membranes Guidelines]. / Diagnostic de la rupture des membranes. RPC Rupture prématurée des membranes avant terme CNGOF.

OBJECTIVE: To describe clinical and paraclinical tests diagnosing rupture of fetal membranes (ROM). METHODS: Bibliographic search over the period 1980-2017 considering articles in French and English as well as guidelines from national obstetrical societies. RESULTS: Typical amniotic fluid leakage occurs in ¾ of cases. In this situation, no additional test is required (Professional consensus). For ambiguous cases, a speculum examination can demonstrate pooling of amniotic fluid but suspicion can persist in 50% of cases (evidence level IV). In this context, we recommend to consider performing an IGFBP-1 or PAMG-1 test of vaginal fluid (evidence level III). Ability of these tests to reduce maternal or neonatal morbidity has never been demonstrated (Professional consensus). An isolated positive test should be considered cautiously as false positive does exist (Professional consensus). CONCLUSION: Symptoms suggestive of ROM and speculum examination demonstrating pooling of amniotic fluid are sufficient to diagnose ROM. If pooling is not observed, we recommend to consider performing an IGFBP-1 or PAMG-1 test of vaginal fluid.

Are there risk factors for false-positive malformation diagnoses on obstetric ultrasound? A nested case-control study.

INTRODUCTION: In a population-based study, we found an overall false-positive rate of 8.8% for the second and third trimester ultrasounds. Although numerous studies have been performed to examine factors which lead to false negatives, the same is not true for the factors associated with false positives. The principal objective of this study was to look for risk factors for false-positive diagnoses of fetal malformations on obstetric ultrasound scans. MATERIAL AND METHODS: In this nested case-control study, the case infants were those whose mother had a false-positive antenatal ultrasound diagnosis of a malformation during the second or third trimester (ultrasound false-positives) and who were live - or stillborn in Auvergne in 2006-2010. The control group comprised all children who were ultrasound true-negatives in 2005 and 2007. The study included 46 cases and 184 controls, matched according to the level of the maternity unit in which they were born. RESULTS: Most false-positive diagnoses were minor malformations. The mean term at this false-positive diagnosis was 27.7±5.4 weeks; in 46.8% of cases, the diagnosis was made during the second-trimester ultrasound. A single malformation was suspected in 95.7% of the cases. In 97.9% of cases, only one anatomical system was affected. In all, 49 malformations were identified among the 46 cases and their distribution differed according to anatomical system. The only risk factor identified was a body mass index (BMI)<25 (ORa=1.7; 95%CI: 1.2-2.4). DISCUSSION: A maternal BMI<25 was the only risk factor identified for a false-positive ultrasound diagnosis of a fetal malformation.

[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).