[Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Épidémiologie, facteurs de risque et complications.

OBJECTIVES: To study the frequency, the risk factors and the mode of delivery of breech presentation. To analyze the perinatal morbidity and mortality associated with breech presentation in comparison to cephalic presentation from all mode of delivery. METHODS: MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019. RESULTS: Three modes of breech presentation exist according to fetal lower limbs position: frank in 2/3 of cases, complete in 1/3 of cases or, more rarely, incomplete (LE3). About 5% of women gave birth in breech presentation in France (LE3). As the frequency of breech presentation decreases with increasing gestational age, this incidence is lower after 37 WG and represents only 3% of term deliveries (LE3). Congenital uterine malformation (LE3) and fibroma (LE3), prematurity (LE3), oligoamnios (LE3), some fetal congenital malformations (LE3) and low birthweight for gestational age (LE3) are the main risk factors with breech presentation. In France, one-third of women with a term fetus in breech presentation attempt a vaginal delivery (LE3), which is successful in 70% of cases (LE3). Neonatal outcome is not associated with type of breech presentation (frank or complete) in case of vaginal delivery attempt after 37 WG (LE3). Overall, perinatal morbidity and mortality after 37 WG of breech presentation appear to be greater than in cephalic presentation from all mode of delivery (LE3). The risk of traumatic injury in breech delivery is estimated under 1% (LE3). The most common injuries are collarbone fractures, hematomas or contusions, and brachial plexus injury (LE3). Breech presentation is associated with an increased risk of hip dysplasia (LE3) and cesarean delivery does not seem to be a protective factor (LE3). Breech presentation does not appear to be associated with an increased risk of cerebral palsy compared to cephalic presentation after exclusion of fetuses with congenital malformations (LE3). CONCLUSION: Worldwide, mode of delivery of breech presentation has undergone profound changes since the publication of the TBT (Term Breech Trial). There are intrinsic factors associated with breech presentation, which should not be overlooked when interpreting the increased perinatal morbidity and mortality observed in case of breech presentation.

[Abortions and stillbirths caused by Coxiella burnetii in goats]. / Aborte und Totgeburten bei Ziegen unter besonderer Berücksichtigung von Coxiella burnetii.

INTRODUCTION: Coxiellosis, caused by the bacterium Coxiella burnetii, is a reportable disease in animals and humans in Switzerland. The number of cases in farm animals and humans has risen continuously in recent years. The aim of this work was to investigate abortions and stillbirths in goats with a focus on C. burnetii, to identify excretory routes which pose a zoonotic risk and the excretion time after an acute infection. Besides the submitted fetuses, does were screened with a serological antibody test. In addition, excretion via milk, faeces and vaginal mucus were investigated in dams with fetuses tested positive for C. burnetii at 14-day intervals.C. burnetii were isolated in 8 cases (3× in the placenta, 2× in the abomasum, 3× in the placenta and abomasum) of 13 examined stillbirths/abortions. Ten abomasums of goat kids and 8 placentas were examined using modified Ziehl-Neelsen staining (ZN) according to Stamp simultaneously with a real-time PCR. Four of 18 samples were false negative using modified ZN staining according to Stamp in contrast to real-time PCR. Seven does had serum antibodies against Coxiella. The excretion of C. burnetii persisted for 63 days in the milk, for 96 days in the vaginal mucus and for 96 respectively 114 days in two does monitored extensively. Intermittent excretion could also be observed in the milk during these 63 days. The present study showed that confirmation of disease, respectively transmission cannot be based on a single test. Only combined serological antibody test and real-time PCR examinations of birth material, milk, feces and vaginal mucus can result in a conclusive diagnosis. In addition, the examination using modified ZN staining according to Stamp is less sensitive and specific than the real-time PCR examination.

INTRODUCTION: La coxiellose, causée par la bactérie Coxiella burnetii, est une maladie à déclaration obligatoire en Suisse qui touche les animaux et les humains. Le nombre de cas chez les animaux de rente et les humains n'a cessé d'augmenter ces dernières années. Le but de ce travail était d'étudier les avortements et la mortalité périnatale chez les chèvres avec un focus sur C. burnetii, d'en identifier les voies d'excrétion qui présentent un risque zoonotique et de déterminer le temps d'excrétion après une infection aiguë. Pour ce faire, des examens sérologiques d'anticorps ont été effectués sur les mères en parallèle des examens sur les fœtus envoyés. L'excrétion par le lait, les selles et les sécrétions vaginales ont été examinées à intervalles de 14 jours sur les mères dont les fœtus ont été testés positifs à C. burnetii. Sur les 13 mort-nés et avortements examinés, C. burnetii a été isolés dans 8 échantillons (3× dans le placenta, 2× dans la caillette, 3× dans le placenta et la caillette). Dix caillettes de chevr­eaux et 8 placentas ont été simultanément examinés en utilisant une coloration Ziehl-Neelsen (ZN), modifiée selon Stamp, et un real-time PCR. Sur les 18 échantillons examinés, 4 échantillons ont donné des faux négatifs en utilisant la coloration Ziehl-Neelsen modifiée par rapport à la real-time PCR. La sérologie a dévoilé que 7 femelles présentaient des anticorps contre Coxiella. Pour 2 femelles, suivies durant une période plus longue, l'excrétion de C. burnetii dans le lait a persisté durant 63 jours, dans les sécrétions vaginales durant 96 jours pour les 2 femelles et dans les selles durant 96 et 114 jours respectivement. Une excrétion intermittente par le lait a également pu être observée durant les 63 jours. Cette étude a démontré que la mise en évidence de la maladie respectivement de l'excrétion ne peut pas être assurée sur la base d'un seul test. Seul la combinaison de la sérologie et des examens au moyen de la real-time PCR sur les arrière-faix, le lait, les selles et les sécrétions vaginales peuvent aboutir à un diagnostic concluant. De plus, l'examen au moyen de la coloration ZN modifiée selon Stamp est moins sensible et moins spécifique que la real-time PCR.

[Why is perinatal and infant mortality high in the Seine-Saint-Denis district? A consultation with healthcare providers using a Delphi process]. / Quelles sont les causes de la mortalité périnatale et infantile élevée en Seine-Saint-Denis ? Consultation des professionnels du département par un processus Delphi.

OBJECTIVE: In Seine-Saint-Denis, stillbirth and infant mortality rates are markedly higher than in other French departments. Before implementing an audit on stillbirths and neonatal deaths in 2014, we carried out a Delphi consensus process with healthcare providers to generate research hypotheses. MATERIALS AND METHODS: A Delphi process in 3 questionnaires was conducted in 2013 with 32 healthcare providers (pediatricians, obstetricians, general practitioners, midwives, social workers, psychologists, pediatric nurses) and user representatives. The first questionnaire asked open questions about why mortality rates were higher and possible solutions to remedy the situation. In subsequent questionnaires, the panel ranked factors identified in the first questionnaires by importance. RESULTS: One hundred and thirty factors were identified from 42 pages of text responses in the first round. From these, the 75 most highly ranked were grouped into 14 main topics organized around three themes: 1) more underlying health problems in the population, 2) access and organization of care, 3) the health consequences of poor socioeconomic conditions. Coordination of care, provider and patient communication, and access to care were highlighted. CONCLUSION: The Delphi consensus process identified a wide range of hypotheses for the higher mortality in Seine-Saint-Denis which are adapted to the local context and based on the concerns of health practitioners.

[Placental abruption: Background and revisited pronostic factors about a series of 171 cases]. / Hématome rétroplacentaire : terrain et facteurs pronostiques revisités à propos d'une série de 171 cas en Guyane francaise.

OBJECTIVE: To describe the epidemiological, clinical and prognostic factors of placental abruption and fetal death in utero and to investigate possible risk factors for their occurrence. PATIENTS AND METHODS: Observational retrospective study including the women having presented a placental abruption between January 2001 and January 2012, in a IIB maternity. Women's sociodemographic characteristics, clinical symptoms and the method used to detect placental abruption were collected. Patient data of those whose pregnancy resulted in fetal death were compared to those with more favorable outcomes. RESULTS: There were 171 cases of placental abruption among 21,913 patients having delivered, which represents a 0.78% incidence. Diagnosis was rarely based on clinical data (30%). The rate of fetal death in utero represented 25% of the pregnancy's outcomes. A history of fetal death in utero increased the risk of placental abruption (P<0.001). This complication was more frequent for patients who did not have pregnancy monitoring (P=0.054) and before 37 weeks of amenorrhoea (P=0.005). CONCLUSION: Placental abruption is an important cause of perinatal mortality and maternal morbidity. Among the observed risk factors, only regular pregnancy monitoring can be an easy way to prevent these complications.

[Perinatal mortality and quality of clinical management in the Aurore network from 2005 to 2011. Implementation of morbidity and mortality conferences]. / Mortalité périnatale et qualité des prises en charge au sein du réseau Aurore de 2005 à 2011. Mise en place des réunions de morbi-mortalité au sein du réseau.

OBJECTIVES: Evaluate the incidence of perinatal mortality and evaluate the percentage of non optimal care management of fatal pregnancies between 2005 and 2011 in the Rhone-Alpes region in France, by the use of the Aurore network. Evaluate the development of morbi-mortality revues (MMR) in this region. METHODS: Retrospective study of perinatal mortality in the Aurore network, from 2005 to 2011. Systematic analysis of care management (adapted, non adapted, non evaluable), of each perinatal death that occurred in the Aurore network, by a multidisciplinary committee during regional MMR. RESULTS: The incidence of perinatal mortality has diminished from 2005 to 2011 (8,4‰ vs. 6,4‰, P<0.07) as well as the percentage of non adapted care management (13% vs. 5,6%, P<0.001). An underestimation of irregularities in the fetal heart rate was described in 34% of per partum deaths. The percentage of optimal care management was significantly higher when the obstetrician was in the maternity rather than on call at home (P<0.03) and in type 3 maternities compared to type 1 and 2 maternities (P<0.04). The attendance of the MMR organized in the AURORE network progressed between 2006 and 2011. CONCLUSION: Since 2005, a decrease in perinatal mortality and in non-adapted care management was observed. More studies are necessary to evaluate the link between the development of MMR in this network and the amelioration of these two indicators.

To what extent do English language RCT meta-analysis justify induction of low-risk pregnancy for postdates?

Induction for postdates in low-risk pregnancy was adopted with the intent to prevent post-term antepartum stillbirth, the most common cause of perinatal death, based on evidence derived in English language RCT meta-analysis. Systematic English language meta-analysis of RCT studies of induction for postdates in low-risk pregnancy report perinatal mortality rates (PMRs) for low-risk pregnancy ranging from 2.6 to 7.6/1000, based on 2-5 stillbirths among 13-16 perinatal deaths, including diabetic pregnancies as well as other high-risk pregnancies irrelevant to the study question. Baseline PMR≥41 weeks in large international databases for high and low risk pregnancies before routine induction 1998-2003 range from 0.9 to 2.4/1000 or about 300% lower than the reported PMR rates for postdate pregnancies in the expectant management arm in English language RCT meta-analysis. Deaths in the first week far exceed stillbirths in the RCT meta-analysis, the opposite of what is expected. These 2 implausible results bring into question the evidence used to justify induction for postdates≥41 weeks.

[Abruptio placentae. Diagnosis, management and maternal-fetal prognosis: a retrospective study of 100 cases]. / Hématome rétroplacentaire. Diagnostic, prise en charge et pronostic maternofœtal: étude rétrospective de 100 cas.

OBJECTIVES: To update knowledge on placental abruption because there are few recent series published although the perinatal care has progressed. PATIENTS AND METHODS: A retrospective observational study has been conducted on 100 consecutive cases of abruptio placentae, occurring from January 2008 to June 2011, in the two maternity units of the University Hospital of Strasbourg (France). RESULTS: One hundred and five births among which five twin pregnancies were included. Clinical context was evident in 91% of cases, but the classic clinical triad was present in only 4% of cases. Clots were found at immediate placenta examination in 77% of cases. Pathological diagnosis was directly in accordance with clinical diagnosis in half the cases. Mean date of childbirth was 33 weeks of amenorrhea and 6 days. Sixty-seven patients gave birth prematurely. Among them, 50 patients delivered before 34 weeks. Sixty caesareans were performed in emergency before labor, including 47 with general anesthesia. Twelve patients had post-partum haemorrhage and ten coagulation disorders. There was no maternal death. Perinatal mortality was 19% with 13 fetal deaths in utero (12.4%), four children born in an apparent death state with resuscitation failure (3.8%) and three neonatal deaths (2.8%). DISCUSSION AND CONCLUSION: Placental abruption is a serious and unpredictable situation. Joint medical care of obstetricians and intensivists is often required. Perinatal mortality mainly occurs in utero.

[Definitions: small for gestational age and intrauterine growth retardation]. / Définitions: petit poids pour l'âge gestationnel et retard de croissance intra-utérin.

OBJECTIVES: Screening for intrauterine growth restriction (IUGR) is a major component of antenatal care, but the debate about the choice of birthweight standards is longstanding. The objective of this first chapter is to provide guidelines about optimal definition of IUGR. MATERIALS AND METHODS: Literature review about available birthweight curves to define IUGR, including the analysis of their diagnosis accuracy and their relevance to identify babies at risk of poor perinatal outcomes. RESULTS: Intrauterine growth curves are more suitable for "normal" growth modeling than birth weight curves, and fetal growth is influenced by individual characteristics, fetal gender being the most important among them (EL2). Infants with a low birth weight are either constitutionally small babies or babies with pathological fetal growth failure. Use of "SGA" for all Small for Gestational Age infants is now recommended, "IUGR" being appropriate only for infants with pathological growth restriction (Professional consensus). Depending on reference curves, identified SGA babies and pregnancy outcomes may be different. Customized birth weight standards are based on an intrauterine growth modeling adjusted for fetal gender, maternal height, weight and parity, and appear to be the most accurate to identify SGA births at risk (EL3). However, their benefit on perinatal morbidity and mortality has not been demonstrated by prospective studies. CONCLUSION: Benefits and drawbacks of customized birth weight curves seem in favor of their use. Their application in ante and postnatal investigations is a real opportunity to standardize clinical practice and make information provided to parents more consistent.