Efficacy and safety of labour induction in patients with a single previous caesarean section: a proposal for a clinical protocol.

PURPOSE: To evaluate the efficacy and safety of induction in women with a single prior Caesarean section. METHODS: This was a cohort study in which we included all singleton pregnancies in patients with a single prior Caesarean who delivered between 2007 and 2012. Methods of induction were ocytocic infusion plus amniotomy (if Bishop score ≥6) or insertion of a Foley catheter (Bishop <6). RESULTS: Of the 2,075 patients included, 806 (38.8 %) had an elective repeat Caesarean, 1,045 (50.4 %) went into spontaneous labour, 89 (4.3 %) were induced by artificial rupture of the membranes and infusion of ocytocics and 135 (6.5 %) were induced using a Foley catheter. Rates of vaginal delivery were 79.2, 79.8 and 43.7 %, respectively. Six cases of uterine rupture were reported in the group of patients who went into spontaneous labour. There was no difference between groups with regard to neonatal morbidity. On multivariate analysis, risk factors for Caesarean delivery were macrosomia (OR 2.04, 95 % CI 1.31-3.18) and induction by Foley catheter (OR 3.73, 95 % CI 2.47-5.62); protective factors were previous vaginal delivery (OR 0.41, 95 % CI 0.29-0.57) and cervical dilatation (OR 0.84, 95 % CI 0.78-0.91). CONCLUSIONS: Uterine induction after a single Caesarean section with ocytocic infusion and amniotomy where the cervix is favourable does not appear to entail any significant added risk in terms of maternal or foetal morbidity. Foley catheter induction is a reasonable option if the cervix is not ripe.

Placental abruption: risk factors, management and maternal-fetal prognosis. Cohort study over 10 years.

OBJECTIVE: To describe maternal and fetal risk factors, diagnosis, management and prognosis of placental abruption (PA). STUDY DESIGN: A retrospective cohort study between January 2003 and December 2012 within the three maternity units of a French university hospital. We included 55,926 deliveries after 24 weeks' gestation including 247 cases of PA (0.4%). We conducted univariate analyses to compare PA and control groups. Multivariate models were constructed in order to study PA risk factors and perinatal morbidity and mortality. RESULTS: Independent risk factors for PA were preterm premature rupture of membranes (OR 9.5; 95% CI [6.9-13.1]), gestational hypertension (OR 7.4; 95% CI [5.1-10.8]), preeclampsia (OR 2.9; 95% CI [1.9-4.6]) and major multiparity (OR 1.6; 95% CI [1.1-2.4]). The classic clinical triad associating metrorrhagia, uterine hypertonia and abdominopelvic pains was present in only 9.7% of cases. Caesarean section rate was 90.3% with 51.8% being performed under general anesthesia. There was no case of maternal death, but maternal morbidity was considerable, with 7.7% of coagulation disorders and 16.6% of transfusion. After adjustment for the gestational age, we found an increased risk for pH≤7.0 (OR 14.9; 95% CI [9.2-23.9]) and neonatal resuscitation (OR 4.6; 95% CI [3.1-6.8]). Perinatal mortality was 15.8%, including 78% of fetal deaths. CONCLUSIONS: Appropriate multidisciplinary management can limit maternal morbidity and mortality but perinatal mortality, which occurs essentially in utero, remains high.

Amniotic band syndrome (ABS): can something be done during pregnancy in African poor countries? Three cases and review of the literature.

Amniotic band syndrome (ABS) is a fetal congenital malformation, affecting mainly the limbs, but also the craniofacial area and internal organs. Two mains pathogenic mechanisms are proposed in its genesis. Firstly the early amnion rupture (exogenous theory) leading to fibrous bands, which wrap up the fetal body; secondly, the endogenous theory privileges vascular origin, mesoblastic strings not being a causal agent. The authors believe that the second theory explain the occurrence of ABS. The outcome of the disease during pregnancy depends on the gravity of the malformations. Interruption of the pregnancy is usually proposed when diagnosis of severe craniofacial and visceral abnormalities is confirmed. Whereas minor limb defects can be repaired with postnatal surgery. In case of an isolated amniotic band with a constricted limb, in utero lysis of the band can be considered to avoid a natural amputation. In an African country, such treatment is not possible as far as the antenatal diagnosis.

Prediction of spontaneous preterm delivery in singleton pregnancies: where are we and where are we going? A review of literature.

Prematurity is the chief cause of neonatal morbidity and mortality. The objective of this study is to review the different methods for predicting preterm delivery in asymptomatic pregnant women and in situations of threatened preterm delivery. A search of the PubMed/Medline database was carried out for the years 1980-2012. We included studies for predicting preterm birth in asymptomatic and symptomatic patients. Models for predicting preterm delivery based on maternal factors, cervical length and obstetric history in first trimester of pregnancy is a valuable avenue of research. Nevertheless, prediction accuracy still needs to be improved. In the second and third trimesters, routine digital vaginal examination is of no value in asymptomatic women. Echography of the cervix is not useful except in patients with a history of late miscarriage or preterm delivery in order to offer them a preventive treatment. In symptomatic women, the combination of digital vaginal examination, cervical echography and fibronectin gives the best predictive results. Electromyography of the uterus and elastography of the cervix are interesting avenues for future research. Identifying patients at risk of preterm delivery should be considered differently at each stage of pregnancy.

[Klippel-Trenaunay syndrome and pregnancy: difficult choice of delivery from a case and a review of the literature]. / Syndrome de Klippel-Trenaunay et grossesse: difficile choix du mode d'accouchement à partir d'un cas et revue de la littérature.

Klippel-Trenaunay syndrome (SKT) is a rare disease characterized by cutaneous haemangiomas, capillary malformations venous (venous varicosities), bone and soft tissue hypertrophy affecting one or more limbs. It is often associated with hemorrhagic and thrombotic complications, especially during pregnancy. Vulvovaginal anomalies at risk of bleeding may occur in late trimester of pregnancy, affecting delivery. The terms of delivery depends on the severity of vascular malformations and the experience of the obstetrician. We report the case of a woman in labor at 38 weeks gestation with a SKT with involvement of the left leg up to the corresponding large lip. She presented after vaginal delivery a severe post-partum hemorrhage (2000mL) secondary to vaginal lacerations requiring sutures and supplemented by arterial embolization. A multidisciplinary approach is required at delivery.

[Exceptional hemoperitoneal third trimester of pregnancy]. / Hémopéritoine exceptionnel du troisième trimestre de la grossesse.

We report a case of spontaneous break of the wide ligament revealed by an abdominal pelvic painful syndrome of rough appearance in 36 weeks+2 days with an acute foetal suffering and an important hemoperitoneal to a primigeste of 32 years. The laparotomy explorer allowed to make the diagnosis but the foetal forecast was dramatic. The foetal extraction has to be made as a matter of urgency and at the same time that the vascular haemostasis.

[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.

Spontaneous rupture of uterine varices in third trimester pregnancy: an unexpected cause of hemoperitoneum. A case report and literature review.

The authors report a case of spontaneous rupture of uterine varices occurring in the third trimester of pregnancy. It was responsible for a collapse in breast hemoperitoneum. The patient, whose pregnancy was a simple, suddenly felt symptoms of preterm labor. There was a rapid onset of maternal collapse with acute fetal distress. Only emergency exploratory laparotomy allowed for etiological diagnosis and treatment.

[Vasa previa: Of the diagnosis to neonatal prognosis]. / Vasa prævia: du diagnostic au pronostic néonatal.

Vasa previa is a rare complication of pregnancy (1/2000 to 1/6000) with a high fetal mortality rate (75 to 100%). We will discuss two case reports of vasa previa: the first was diagnosed before labor, while the second was during delivery. In the first case, the diagnosis of vasa previa was confirmed by a transvaginal ultrasound and color doppler, while the second case involved late diagnosis during delivery and after gross examination of the placenta. Risk factors for vasa previa are: low-lying placenta, bilobed or succenturiate lobed placenta, velamentous and in vitro fertilization (IVF). Antenatal diagnosis of vasa previa is crucial because it allows for prophylactic caesarean section and prevents severe Benckiser's hemorrhage responsible for a very high neonatal mortality.

[Advantages of laparoscopic assisted vaginal hysterectomy in surgery of endometrial carcinoma]. / Avantages de la voie vaginale coelio-assistée dans la chirurgie des cancers de l'endomètre.

INTRODUCTION: In to respect the principles of oncological surgery and to reduce the operative morbidity, the authors of this study propose to find the proper place of the laparoscopic-assisted vaginal hysterectomy in the surgery of endometrial carcinomas. PATIENTS AND METHODS: Between the 1st of June 2002 and 31 of May 2005, we realize a retrospective and comparative study for 36 laparoscopic-assisted vaginal hysterectomy and 20 laparotomies concerning 56 patients. RESULTS: In primary stages (stages I and II of FIGO), laparoscopic assisted vaginal hysterectomy is as powerful as the laparotomy whereas in more advanced stages, laparotomy was more complete and effective (p=0,07). One conversion case was observed (2.8%) in a context of peritoneal carcinosis (stage IIIc). There was not statistically significant difference about the operatives complications (p = 0.51). On the other hand, the postoperative comfort was so far better in the laparoscopic-assisted vaginal hysterectomy group (p=0.0002). The average delay of followed without relapses was 22,3 months in the laparoscopic-assisted vaginal hysterectomy group versus 23 months in the laparotomy group (p=0.51). CONCLUSION: Considering these results, the authors retain that, in primary stages (I-II, FIGO), laparoscopic-assisted vaginal hysterectomy represents a real option in the surgery of endometrial carcinoma. On the other hand, the advanced stages should be reserved for laparotomy.

Avantages de la voie vaginale coelio-assistee

Introduction : Apres l'enjeu carcinologique et de survie de la chirurgie des cancers de l'endometre; les auteurs de cette etude se proposent d'evaluer l'impact reel de la voie coelio-vaginale dans la chirurgie des cancers de l'endometre. Patientes et methodes : Entre le 1er Juin 2002 et le 31 Mai 2005; nous avons effectue une etude retrospective; comparative portant sur 36 interventions par voie colio-vaginale et 20 laparotomies realisees chez 56 patientes. Resultats : Dans les stades precoces (I et II de la FIGO); la voie coelio-vaginale est aussi performante que la laparotomie (p =0;07) alors que dans les stades plus avances la laparotomie etait plus complete et efficace. Le cas de conversion observe (soit 2;8) etait du a une des adherences complexes dans un contexte de carcinose peritoneale chez une patiente au stade IIIc. Il n'y avait pas de difference significative dans les complications (p=0;51). Le confort post operatoire etait; par contre; de loin meilleur dans le groupe de coelio-vaginale (p=0;0002). Le delai moyen de suivi sans recidive etait de 22;3 mois dans le groupe de coelio-vaginale versus 23 mois dans le groupe de laparotomie (p = 0;51). Conclusion : Devant ces resultats; les auteurs retiennent que dans les stades precoces (I- II de la FIGO); la voie coelio-vaginale constitue une reelle option dans la chirurgie des cancers de l'endometre par contre les stades avances devraient etre reserves a la laparotomie

Le decollement premature du placenta normalement insere pronostic foeto-maternel: a propos de 1062 cas colleges a la clinique obstetricale du CHU de Treichville

Cette etude est retrospective et porte sur 1062 cas de decollement premature du placenta normalement insere recenses en 18 ans. Elle a permis de faire les constatations suivantes: frequence = 0;93 per cent; cet accident survient chez les femmes agees; grandes multipares de conditions socio-economiques mauvaises ayant neglige les consultations prenatales et connues hypertendues; la symptomatologie est en general grave dans 72;68 per cent des cas; le pronostic maternel est domine par: - le choc hypovolemique: 59;69 per cent - la coagulopathie: 24;10 per cent - l'oligo anurie: 13;93 per cent - l'hysterectomie en urgence: 0;75 per cent - la frequence des cesariennes: 80; 68 per cent - le deces maternel: 03;29 per cent; le pronostic foetal est domine par les deces foetaux dans 82; 81 per cent

Influence du niveau d'instruction des gestantes sur le prognostic foeto-maternel dans l'association diabete et grossesse

Cette etude porte sur l'association diabete et grossesse au sein d'une population de 30 gestantes diabetiques. Elle met en evidence les faits suivants: le retard dans la prise en charge medico-obstetricale des gestantes d'une maniere generale; le role important du niveau d'instruction dans la observance du traitement dans 60 pour cent des cas et donc sur le pronostic foeto-maternel; le taux de mortalite perinatale tres eleve a 178 pour cent; la necessite de l'elaboration d'un protocole de prise en charge des gestantes diabetiques