Epidural analgesia information sessions provided by anesthetic nurses: impact on satisfaction and anxiety of parturient women a prospective sequential study.

BACKGROUND: Information on epidural analgesia delivered to parturient women is frequently incomplete, making it difficult for expectant mothers to make an appropriate choice for their delivery. We assessed the impact of a multimodal information session on epidural analgesia delegated to anesthetic nurses on new-mothers' satisfaction. METHODS: We performed a prospective sequential study including parturient women who gave birth with epidural analgesia. During the first period, information on epidural analgesia was delivered by anesthetists during the scheduled anesthesia consultation, according to French standard-of-care. Then, a dedicated information session about epidural analgesia provided by anesthetic nurses was implemented. The primary endpoint was the satisfaction of women with the quality of information received. Main secondary endpoints were knowledge of women about epidural analgesia, anxiety before epidural catheter placement, and satisfaction with delivery. RESULTS: 259 and 298 women were included during the first and second periods respectively, among whom 178 and 188 were analyzed. Information on epidural analgesia delivered by anesthetic nurses was associated with improvement of new-mothers' satisfaction with information received (9 (8-10) vs. 10 (9-10) - p < 0.001). Moreover, information delivered by anesthetic nurses was associated with decreased anxiety before epidural catheter placement (4 (1-8) vs. 3 (1-6) - p = 0.006) and increased satisfaction with delivery (8 (7-10) vs. 9 (8-10) - p = 0.01). Women's knowledge on epidural analgesia was durably increased when information was delivered by anesthetic nurses compared to conventional information by anesthetists. After adjustment, the only variable associated with both new mothers' satisfaction with information and delivery was the information session taught by anesthetic nurses. CONCLUSIONS: Information sessions on epidural analgesia delivered by anesthetic nurses was associated with improved satisfaction of women with their delivery. Such information sessions may be used in maternity wards to improve new-mothers' childbirth experience.

[Pregnancy planning and follow-up of a pregnant woman with sickle cell disease]. / Projet de grossesse et suivi d'une femme enceinte porteuse de la drépanocytose.

Pregnancy is a high-risk situation in sickle cell patients, both for the mother and the foetus. It considerably increases the risk of an acute complication (vaso-occlusive crisis, acute chest syndrome, infection, thrombosis) of sickle cell disease. In addition, this condition increases the risk of placental vascular complications (in utero growth retardation, pre-eclampsia, retroplacental haematoma and in utero foetal death).

Impact of pre-eclampsia on renal outcome in sickle cell disease patients.

The long-term consequences of pre-eclampsia (PrE) for renal function have never been determined in patients with sickle cell disease (SCD). Between 2008 and 2015, we screened 306 pregnancies in women with SCD and identified 40 with PrE (13%). The control group consisted of 65 pregnant SCD patients without PrE. In multivariable analysis, PrE events were associated with an increase of 1 log of lactate dehydrogenase level (adjusted odds ratio, aOR = 3·83, P = 0·05), a decrease of 10 g/l of haemoglobin levels (aOR = 2·48, P = 0·006) and one or more vaso-occlusive crisis during pregnancy (aOR = 16·68, P = 0·002). Estimated glomerular filtration rate (eGFR) was similar in the two groups at steady state but was significantly lower in the PrE group after one year of follow-up and at last follow-up (130 vs 148 ml/min/1·73 m2 , P < 0·001 and 120 vs 130 ml/min/1·73 m2 , P < 0·001, respectively). In multivariable analysis, eGFR had returned to steady-state levels one year after pregnancy in patients without PrE but continued to decrease in patients with PrE (ß = -18·15 ml/min/1·73 m2 , P < 0·001). This decline was more marked at the end of follow-up (ß = -31·15 ml/min, P < 0·001). In conclusion, PrE episodes are associated with a significant risk of subsequent renal function decline in SCD patients.

Treatment of Intramyometrial Pregnancy by In Situ Injection of Methotrexate.

Intramyometrial ectopic pregnancies are rare, and various management modalities have been described. We report a patient with intramyometrial pregnancy who was successfully treated by in situ injection of methotrexate (MTX) after the failure of 2 intramuscular injections of MTX. We emphasize the difficult management of intramyometrial pregnancy and show that in situ MTX injection may be indicated for this particular type of ectopic pregnancy.

Diagnostic Value of MR Imaging in the Diagnosis of Adnexal Torsion.

PURPOSE: To retrospectively evaluate the diagnostic performance of magnetic resonance (MR) imaging for the diagnosis of adnexal torsion in a series of patients with an equivocal adnexal mass at ultrasonography (US) in the context of acute or subacute pelvic pain. MATERIALS AND METHODS: The institutional ethics committee approved the study and waived informed consent. All patients with acute or subacute pelvic pain who were undergoing MR examination for the exploration of an equivocal adnexal mass (January 2007 to December 2012) with surgical exploration or clinical and radiologic follow-up of at least 3 months were retrospectively included (n = 58). The prospective interpretations were recorded. Additionally, three radiologists who were blinded to the clinical, US, and surgical data retrospectively and independently reviewed MR images. Features associated with adnexal torsion were identified by using univariate and recursive partitioning multivariate analysis. RESULTS: Twenty-two patients (38%) had a diagnosis of adnexal torsion. The accuracy of MR imaging at the time of prospective interpretation was 80.6% (25 of 31 patients) and 85.1% (23 of 27 patients) in acute and subacute torsion, respectively. The accuracy of image interpretation by each retrospective reader was 83.9% (26 of 31 patients), 90.3% (28 of 31 patients), and 83.9% (26 of 31 patients) in the context of acute pelvic pain and 92.6% (25 of 27 patients), 88.9% (24 of 27 patients), and 81.5% (22 of 27 patients) in the context of subacute pelvic pain for readers 1, 2, and 3, respectively. At multivariate analysis, the whirlpool sign (odds ratio = 6.5 [95% confidence interval: 1.36, 31.0], P = .01) and a thickened tube (>10 mm) (odds ratio = 8.2 [95% confidence interval: 1.2, 56.8], P = .03) were associated with adnexal torsion, with substantial interreader agreement (κ = 0.71-0.84 and 0.82-0.86, respectively). The presence of adnexal hemorrhagic content was associated with nonviable ovaries in seven of 10 patients (70%) and with viable ovaries in 12 of 45 patients (27%) (P = .009). CONCLUSION: MR imaging is an accurate technique for the diagnosis of adnexal torsion in patients who have an adnexal mass with acute or subacute pelvic pain.

B-type natriuretic peptide measurement for early diagnosis of acute pulmonary edema during pregnancy.

Calcium-channel blockers administered to pregnant women as tocolytic agents can cause acute pulmonary edema. The first signs of this severe complication can be atypical and so delay introduction of appropriate therapy. We describe three cases in whom B-type natriuretic peptide measurements proved to be relevant in early diagnosis and monitoring of pregnant women with acute pulmonary edema. B-type natriuretic peptide measurement in this setting could contribute to timely diagnosis and improve follow-up.

Outcome and etiologies of fetal megacystis according to the gestational age at diagnosis.

OBJECTIVE: To investigate the gestational age-specific outcomes and the different etiologies of megacystis diagnosed at screening ultrasound. METHODS: A retrospective single-center study was conducted between 1989 and 2009. We identified all consecutive cases of megacystis prenatally diagnosed during routine ultrasound screening. Outcome, final diagnosis, and renal function were recorded. RESULTS: Eighty-four patients were included. An isolated lower urinary tract obstruction was observed in 38/84 (45.2%), ureterovesical reflux in 9/84 (10.7%), an associated congenital abnormality in 32/84 (38.1%) and a normal bladder in 5/84 (6%). Increased gestational age at diagnosis was correlated with an increased rate of live born children (P < 0.01). No cases of megacystis diagnosed in the first trimester were born alive. When diagnosis of posterior urethral valves (PUV) was made in the third trimester, the ultimate survival rate was 11/13 (84.6%) compared with 3/12 (25%) for a diagnosis made in the second trimester (P = 0.02). CONCLUSION: Lower urinary tract obstruction is the main etiology of megacystis. Megacystis can also be part of more complex malformations. Outcome of megacystis detected in the first trimester is poor. PUV detected in the third trimester had a better overall survival rate than PUV detected in the second trimester.

Sickle cell disease and COVID-19 in pregnant women.

INTRODUCTION: The effect of coronavirus disease (COVID-19) on pregnancy outcome in women with sickle cell disease (SCD) is unknown. OBJECTIVES: To analyze the severity of the SARS-CoV-2 infection in pregnant women with SCD and its impact on pregnancy. METHODS: This retrospective cohort study included SCD pregnant women tested positive for COVID-19 between March 2020 - February 2021. The primary endpoint was the severity of the COVID-19 infection. Secondary endpoints were pregnancy complications and fetal outcomes. RESULTS: During the study period among 82 pregnant women with SCD, 8 have presented symptoms suggestive of COVID-19 and were tested positive. A common mild clinical presentation was observed in 6 women (75%), one woman was asymptomatic and one required oxygen. The latter was admitted to the Intensive Care Unit and a cesarean section was performed in the context of an ongoing vaso-occlusive crisis and acute chest syndrome together with incidental preeclampsia. Labor was induced in another patient who developed a vaso-occlusive crisis after COVID-19 remission. Fetal outcomes were good with an average Apgar score of 10 and normal umbilical blood pH at birth. Two newborns were small-for-gestational-age as expected on the ultrasound follow-up before occurrence of COVID-19. CONCLUSION: COVID-19 infection in our population of pregnant women with SCD had typical presentation and rarely triggered a sickle cell crisis or other complications. Fetal outcomes were good and did not seem to be directly influenced by the SARS-CoV-2 virus. Further studies are required to confirm these observations as compared to the population of women with SCD without COVID-19 infection.

Clinical and prognostic significance of antinuclear antibodies in primary antiphospholipid syndrome: A multicenter retrospective study.

INTRODUCTION: The antiphospholipid syndrome (APS) (1) is defined by the development of vascular thrombosis, or pregnancy morbidity in the presence of persistent antiphospholipid antibodies (aPL). Antinuclear antibodies (ANA) can be detected in primary APS patients without any clinical systemic autoimmune disease. The presence of ANA antibodies could confer a specific phenotype in primary APS. OBJECTIVE: To evaluate the characteristics of APS patients with antinuclear antibodies without other autoimmune disease (ANA positive APS patients) in comparison with primary APS without ANA or secondary APS patients with associated systemic lupus erythematosus (SLE). METHODS: Clinical and biologic data from 195 APS were retrospectively collected and patients were classified as primary APS with positive ANA (ANA-positive APS), primary APS without any ANA (ANA-negative APS), and SLE-associated APS (SLE-APS). RESULTS: Fourty patients (21%) were classified into ANA-positive APS group, 77 (39%) in ANA-negative APS and 78 (40%) in SLE-APS. In ANA-positive APS patients, 20 patients (51%) had arterial thrombosis, 14 (41%) had veinous thrombosis and 19% had obstetrical complications. There was no difference between the three groups for the frequency of thrombotic manifestations and obstetrical complications. ANA-positive APS patients had more non-criteria manifestations than ANA-negative APS (48% versus 25%; P≤0.01). ANA-positive APS had more triple aPL positivity (59% versus 18%; P<0.001) and more thrombosis and obstetrical recurrences (63% versus 36%; P<0.01) in comparison with ANA-negative APS patients. ANA-positive APS had more triple aPL positivity than SLE-APS patients (54% versus 33%; P<0.05). ANA-positive APS and SLE-APS patients had similar clinical manifestations, and recurrences. Despite a limited follow-up (28 months (11-50)) none of the ANA-positive APS develop SLE. Antiplatelet and anticoagulant therapies were similar for the three groups. SLE-APS patients received more immunomodulatory therapies. CONCLUSION: ANA positivity in patients with APS enables to individualize a subset of patients with a more severe phenotype. Whereas the ANA positivity does not seem to be associated with the risk to develop SLE, prospective studies with a longer follow-up are necessary, in particular to evaluate the effect of additional therapies in this subset of APS.

Chronic Villitis of unknown etiology (VUE): Obstetrical features, outcome and treatment.

Villitis of unknown etiology (VUE) is characterized by lympho-histiocytic infiltrates, which are predominant within the villous stroma. VUE can be of low grade i.e. affecting less than 10 contiguous villi or high grade with either patchy or diffuse subgroups (the later concerning more than 30 % of distal villi). Several other placental lesions could be associated with VUE, in particular in diffuse subgroups, such as diffuse perivillous fibrin deposition and chronic intervillositis. One of the most characteristic features of VUE is the late onset of fetal growth restriction after 32 weeks of gestation, and earlier detection of villitis should first raise an infectious origin. High grade VUE has been associated with fetal growth restriction, prematurity, fetal deaths, recurrent pregnancy loss, central nervous system injury and is characterized by relatively high risk of recurrence (25-50 %). Prospective and well-designed studies are necessary to determine the real prevalence of these adverse pregnancy events associated with VUE. Data about the management of VUE are extremely scarce and thus no recommendation based on the literature review could be actually done.

Language barrier as a risk factor for obstetric anal sphincter injury - A case-control study.

INTRODUCTION: The incidence of grade 3-4 perineal tears, also known as obstetric anal sphincter injury (OASI), is reported to be between 0.5 and 2.5%. Beyond the medico-economic burden, the consequences of OASI on a woman's emotional, psychological, sexual, and physical wellbeing are considerable. Among the various risk factors of OASI, few data are available about the impact of a language barrier on its incidence. MATERIAL AND METHODS: We conducted a case-control study to evaluate the effect of language barriers on the risk of OASI comparing 171 women with OASI and 163 matched controls. The matched criteria included ethnicity, age, previous vaginal delivery, delivery mode, prophylactic episiotomy and birthweight. Patients' characteristics were compared and crude ORs and 95% CIs estimated using unadjusted logistic models. Multivariate analysis was performed with recognized potential confounders. RESULTS: All of the cases had grade 3 tears. Language barrier was a determinant factor of OASI with an OR of 3.32 [1.36-8.90], p = 0.01. Other risk factors were occipito-posterior delivery, African origin and prolonged labor duration (OR 6.33, 95% CI: 2.04-27.78, p = 0.004, OR 1.85, 95% CI: 1.08-3.19, p = 0.03 and OR 1.03, 95% CI: 1.01-1.05, p = 0.004, respectively). CONCLUSION: Our data suggest that language barrier is an independent risk factor of OASI. Physicians and midwives should attempt to identify patients with a language barrier during prenatal visits. Education about simple terms used during delivery could decrease the incidence of this complication.

Endometriosis with infertility: A comprehensive review on the role of immune deregulation and immunomodulation therapy.

BACKGROUND: Endometriosis is a multifactorial pathology dependent on intrinsic and extrinsic factors, but the immune deregulation seems to play a pivotal role. In endometriosis-associated infertility, this could raise the benefit of immunomodulatory strategies to improve the results of ART. In this review, we will describe (1) sera and peritoneal fluid cytokines and immune markers; (2) autoantibodies; and (3) immunomodulatory treatments in endometriosis with infertility. METHODS: The literature research was conducted in MEDLINE, Embase, and Cochrane Library with the following keywords: "endometriosis", "unexplained miscarriage", "implantation failure", "recurrent implantation failure ¼ and « IVF-ICSI ¼, « biomarkers of autoimmunity", "TNF-α", "TNF-α antagonists", "infliximab", "adalimumab", "etanercept", "immunomodulatory treatment", "steroids", "intralipids", "intravenous immunoglobulins", "G-CSF", "pentoxyfylline". RESULTS: Several studies analyzed the levels of pro-inflammatory cytokines in sera and peritoneal fluid of endometriosis-associated infertility, in particular TNF-α. Various autoantibodies have been found in peritoneal fluid and sera of infertile endometriosis women even in the absence of clinically defined autoimmune disease, as antinuclear, anti-SSA, and antiphospholipid autoantibodies. In few uncontrolled studies, steroids and TNF-α antagonists could increase the pregnancy rates in endometriosis-associated infertility, but well-designed trials are lacking. CONCLUSION: Endometriosis is characterized by increased levels of cytokines and autoantibodies. This suggests the role of inflammation and immune cell deregulation in infertility associated with endometriosis. The strategies of immunomodulation to regulate these immune deregulations are poorly studied, and well-designed studies are necessary.

Unexplained recurrent miscarriages: predictive value of immune biomarkers and immunomodulatory therapies for live birth.

INTRODUCTION: Recurrent miscarriages are defined as three or more early miscarriages before 12 weeks of gestation. The aim of this study was to describe a cohort of women with unexplained recurrent miscarriages, evaluate several potential biomarkers of immune origin, and describe the outcome of pregnancies under immunomodulatory therapies. METHODS: Women having a history of at least 3 early miscarriages without any etiology were recruited from 3 university hospitals. RESULTS: Among 101 women with recurrent miscarriages, overall, 652 pregnancies have been included in the analysis. Women which experienced miscarriages were older (33.3 ± 5.4 versus 31.9 ± 6.7; p = 0.03), with history of more pregnancies (4 (2-6) versus 3.5 (1-5.75); p 0.0008), and less frequently the same partner (406 (74%) versus 79 (86%); p=0.01). There was no difference in the level and frequencies of biomarkers of immune origin (NK, lymphocyte, gamma globulins and blood cytokine levels and endometrial uNK activation status), except the higher rates of positive antinuclear antibodies in women with live birth (12 (13%) versus 36 (7%); p=0.03). Among the 652 pregnancies, 215 (33%) have been treated and received either aspirin/low weighted molecular heparin (LMWH) and/or combined to different lines of immunomodulatory treatment. Patients with pregnancy under treatment had a significantly higher rate of cumulative live birth rate than those with untreated ones (43.0% vs 34.8%; p = 0.04). When compared to patients with untreated pregnancies, patients with steroids during the pregnancy had twice more chances to obtain live birth (OR 2.0, CI95% 1.1 - 3.7, p = 0.02). CONCLUSIONS: Unexplained recurrent miscarriages could have improved obstetrical outcome under immunomodulatory therapies and in particular steroids.

Gigantomastia and vulvar lactating adenoma in a patient with myasthenia during pregnancy.

We report the association of gigantomastia during pregnancy and a lactating adenoma in ectopic breast tissue of the vulva in a context of myasthenia in a 27-year-old primigravid woman. We discuss the pathophysiologic condition and management of gigantomastia that involves ectopic breast tissue during pregnancy.

Annexin-A5 resistance and non-criteria antibodies for the diagnosis of seronegative antiphospholipid syndrome.

In this study, we aimed to analyze the value of annexin-A5 anticoagulant ratio (A5R) and non-criteria antibodies for the diagnosis of APS in patients with clinical seronegative APS. Three groups were defined, including 21 seronegative APS patients with unexplained obstetrical adverse events or thrombosis history, 15 confirmed APS patients with triple aPL positivity, and a control group of 20 healthy patients without any history of thrombosis or pregnancy complications. Seronegative APS patients have similar levels of A5R in comparison to healthy controls (202% [171%-238%] versus 191% [178%-221%]; p = 0.65), whereas triple-positive APS patients have significantly more reduced A5R in comparison to both seronegative and healthy patients (149% [138%-158%] versus 202% [171%-238%] and 191% [178%-221%], respectively, p < 0.001). The non-criteria aPL were found in 24% of seronegative APS: anti-PE IgM in 3 cases (14%) and anti-PS/PT IgG and anti-PS/PT IgM in 1 (5%) case each. The frequency of non-criteria APL was significantly more frequent in comparison to healthy controls (p = 0.048). All triple-positive APS patients have at least one non-criteria aPL, and the non-criteria aPL were significantly more frequent in these patients compared to seronegative APS and healthy controls (p < 0.001). Whereas A5R levels do not allow to discriminate seronegative APS from healthy controls, our results demonstrate that non-criteria aPL can help to APS diagnosis in clinical seronegative APS.Key points• Annexin-A5 resistance testing does not help for the diagnosis of seronegative APS.• The non-criteria antiphospholipid antibodies can contribute to APS diagnosis in patients without conventional antibodies.

Intralipid therapy for unexplained recurrent miscarriage and implantation failure: Case-series and literature review.

INTRODUCTION: In retrospective cohort study of women with unexplained recurrent implantation failure (RIF) and miscarriage (RM), we analyzed the efficacy and safety of intralipid therapy to obtain a live birth. PATIENTS AND METHODS: Women with unexplained RM and/or RIF were included from 2015 to 2018 from three French university hospitals. RESULTS: Among 187 women treated for unexplained recurrent miscarriages and implantation failures, 26 women with median age of 36 years (29-43) received intralipid therapy. Among these 26 women, 10 women with a median age of 33 years (31-40) had a history of spontaneous recurrent miscarriages, with a median of 5 (4-8) previous miscarriages. Live births occurred in 7 (70 %) pregnancies under intralipids and were significantly more frequent than in women with recurrent miscarriages who did not receive intralipid therapy (n = 20, p = 0.02). Age, number of previous miscarriages, and additional therapies did not significantly differ between the two groups. Among the 26 included women, 16 had a history of recurrent implantation failures, with median age of 37 years (29-43) and median 9.5 (3-19) embryo transfers. Clinical pregnancy occurred in 9 (56 %) women receiving intralipids after embryo transfers under intralipids among which 5 (55 %) resulted in a live birth. Comparing successful pregnancies under intralipids with those with fetal loss, no significant differences have been noted. CONCLUSION: Intralipids could be an effective and safe therapy in women with unexplained recurrent miscarriages and infertility.

Obstetrical outcome and treatments in seronegative primary APS: data from European retrospective study.

OBJECTIVE: To compare characteristics, pregnancies and treatments during pregnancies of seronegative and seropositive antiphospholipid syndrome (APS), to analyse factors associated with obstetrical outcome. PATIENTS AND METHODS: Inclusion criteria were: (1) thrombotic and/or obstetrical APS (Sydney criteria); (2) absence of conventional antiphospholipid antibodies (APL); (3) at least one persistent non-conventional APL among IgA anticardiolipin antibodies, IgA anti-B2GPI, anti-vimentin G/M, anti-annexin V G/M, anti-phosphatidylethanolamine G/M and anti-phosphatidylserine/prothrombin G/M antibodies. The exclusion criteria were: (1) systemic lupus erythematosus ( SLE) or SLE-like disease; and (2) other connective tissue disease. RESULTS: A total of 187 women (mean 33±5 years) with seronegative APS were included from 14 centres in Austria, Spain, Italy, Slovenia and France and compared with 285 patients with seropositive APS. Seronegative APS has more obstetrical rather than thrombotic phenotypes, with only 6% of venous thrombosis in comparison to seropositive APS. Cumulative incidence of adverse obstetrical events was similar in seronegative and seropositive APS patients, although higher rates of intrauterine deaths (15% vs 5%; p=0.03), of preeclampsia (7% vs 16%, p=0.048) and lower live birth term (36±3 vs 38±3 weeks of gestation; p=0.04) were noted in seropositive APS. The cumulative incidence of adverse obstetrical events was significantly improved in treated versus untreated seronegative APS (log rank<0.05), whereas there was no difference between patients who received aspirin or aspirin-low-molecular weighted heparin combination. CONCLUSION: Several non-criteria APL can be detected in patients with clinical APS features without any conventional APL, with various rates. The detection of non-criteria APL and thus the diagnosis of seronegative APS could discuss the therapeutic management similar to seropositive APS, but well-designed controlled studies are necessary.

A snapshot of the Covid-19 pandemic among pregnant women in France.

OBJECTIVE: To describe the course over time of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in French women from the beginning of the pandemic until mid-April, the risk profile of women with respiratory complications, and short-term pregnancy outcomes. METHODS: We collected a case series of pregnant women with COVID-19 in a research network of 33 French maternity units between March 1 and April 14, 2020. All cases of SARS-CoV-2 infection confirmed by a positive result on real-time reverse transcriptase polymerase chain reaction tests of a nasal sample and/or diagnosed by a computed tomography chest scan were included and analyzed. The primary outcome measures were COVID-19 requiring oxygen (oxygen therapy or noninvasive ventilation) and critical COVID-19 (requiring invasive mechanical ventilation or extracorporeal membrane oxygenation, ECMO). Demographic data, baseline comorbidities, and pregnancy outcomes were also collected. RESULTS: Active cases of COVID-19 increased exponentially during March 1-31, 2020; the numbers fell during April 1-14, after lockdown was imposed on March 17. The shape of the curve of active critical COVID-19 mirrored that of all active cases. By April 14, among the 617 pregnant women with COVID-19, 93 women (15.1 %; 95 %CI 12.3-18.1) had required oxygen therapy and 35 others (5.7 %; 95 %CI 4.0-7.8) had had a critical form of COVID-19. The severity of the disease was associated with age older than 35 years and obesity, as well as preexisting diabetes, previous preeclampsia, and gestational hypertension or preeclampsia. One woman with critical COVID-19 died (0.2 %; 95 %CI 0-0.9). Among the women who gave birth, rates of preterm birth in women with non-severe, oxygen-requiring, and critical COVID-19 were 13/123 (10.6 %), 14/29 (48.3 %), and 23/29 (79.3 %) before 37 weeks and 3/123 (2.4 %), 4/29 (13.8 %), and 14/29 (48.3 %) before 32 weeks, respectively. One neonate (0.5 %; 95 %CI 0.01-2.9) in the critical group died from prematurity. CONCLUSION: COVID-19 can be responsible for significant rates of severe acute, potentially deadly, respiratory distress syndromes. The most vulnerable pregnant women, those with comorbidities, may benefit particularly from prevention measures such as a lockdown.

Threatened preterm birth: Validation of a nomogram to predict the individual risk of very preterm delivery in a secondary care center.

INTRODUCTION: Very preterm delivery (22-32 weeks of gestation) remains a major cause of neonatal morbidity and mortality. The objective of this study was to validate a statistical model allowing to predict the risk of preterm delivery to use as a clinical decision-making tool for in utero transfer from a secondary to a tertiary care center. METHODS: Retrospective observational study in a secondary care center (approximately 2500 births) in Paris, France. 137 women were admitted for threatened preterm delivery between 22 and 32 weeks. Women were retrospectively allocated to the following groups based on medical decision: "transfer group" (in utero transfer to a tertiary care unit) and "no transfer group" (no in utero transfer). The risk of preterm delivery within 48 h and before 32 weeks gestation was assessed for each group using a nomogram previously validated in a tertiary care center. The primary objective of the study was to determine the accuracy of the prediction model. RESULTS: The discrimination and calibration of the nomogram were excellent (preterm delivery risk within 48 h, ROC AUC: 0.98, 95% CI: 0.95-1.00; probability of preterm delivery before 32 weeks gestation, ROC AUC: 0.94, 95% CI: 0.89-0.99). A threshold set at 0.16 helped minimize the risk of unnecessary in utero transfers with an excellent negative predictive value of 0.99. CONCLUSIONS: We validated nomograms to predict the individual probability of preterm birth after admission in a secondary care center. Those nomograms could be helpful when making decisions regarding an in utero transfer to a tertiary care unit.

Antagonists of TNFα for recurrent miscarriages: 2 Illustrative cases.

Approximately 1 to 3% of women have recurrent early miscarriages, defined as ≥3 pregnancy losses before 14 weeks of gestation. The immune deregulation and tolerance rupture could be the origin of these miscarriages in at least 30% of these women. Chronic intervillositis of unknown etiology (CIUE) is a rare placental lesion characterized by intrauterine deaths, growth restriction and high recurrence rate. In cases with recurrent obstetrical adverse events and intrauterine deaths, we previously reported the benefit of hydroxychloroquine combination to prednisone. Even few data raised the potential value of TNF antagonists in early recurrent miscarriages, these cases show its potential value in the setting of recurrent refractory chronic intervillositis and unexplained miscarriages.