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

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

Gestational anaemia and severe acute maternal morbidity: a population-based study.

Anaemia is frequently diagnosed during pregnancy. However, there are few data regarding its incidence, and the association with severe maternal morbidity remains uncertain and potentially biased in high-resource countries. The purpose of this study was to explore the association between gestational anaemia and severe acute maternal morbidity during and after delivery. We performed a cohort-nested case-control analysis from the epidemiology of severe maternal mortality (EPIMOMS) prospective study conducted in six French regions (2012-2013, n = 182,309 deliveries). There were 1669 women with severe acute maternal morbidity during or after delivery, according to a standardised definition obtained by expert consensus. The control group were randomly selected among women without severe morbidity who delivered in the same health centres (n = 3234). We studied the association between gestational anaemia and severe acute maternal morbidity during or after delivery overall, by cause, and by mode of delivery, using multivariable logistic regression and multiple imputation. Gestational anaemia was significantly more frequent in women with severe acute maternal morbidity (25.3%) than in controls (16.3%), p < 0.001, and mostly mild in both groups. After adjustment for confounders, women with gestational anaemia were at increased risk of overall severe acute maternal morbidity during and after delivery (adjusted OR (95%CI) 1.8 (1.5-2.1)). This association was also found for severe postpartum haemorrhage (adjusted OR (95%CI) 1.7 (1.5-2.0)), even after omitting the transfusion criterion (adjusted OR (95%CI) 1.9 (1.6-2.3)), and for severe acute maternal morbidity secondary to causes other than haemorrhage or pregnancy-related hypertensive disorders (adjusted OR (95%CI) 2.7 (1.9-4.0)). These results highlight the importance of optimising the diagnosis and management of anaemia during pregnancy.

[Overview of induction of labor practices in France]. / État des lieux des pratiques de déclenchement en France.

OBJECTIVE: To describe induction of labor practices in France and to identify factors associated with the use of different methods. METHODS: The data came from the French prospective population-based cohort MEDIP (MEthodes de Déclenchement et Issues Périnatales), including consecutively during one month in 2015 all women with induction of labor and a live fetus in 7 perinatal networks. The characteristics of women, maternity units, gestational age, Bishop's score, decision mode, indication and methods of labor induction were described. Factors associated with the use of different methods were sought in univariate analyzes. RESULTS: The rate of induction of labor during the study was 21% and 3042 women were included (95.9% participation rate). The two main indications were prolonged pregnancy (28.7%) and premature rupture of the membranes (25.4%). More than one-third of women received intravenous oxytocin in first method, 57.3% prostaglandins, 4.5% balloon catheter and 1.4% another method. Among the prostaglandins, the vaginal device of dinoprostone was the most used (71.6%) then the gel (20.7%) and the vaginal misoprostol (6.7%). Women with a balloon were more often of higher body mass index and multiparous with scarred uterus. The balloon and misoprostol were mainly used in university public hospitals. CONCLUSIONS: The evolution of induction of labor methods, due to new data from the literature and the development of new drugs or devices, invites to regularly repeat population-based studies on induction of labor.

[Diagnosis and management of intra-uterine infection: CNGOF Preterm Premature Rupture of Membranes Guidelines]. / Infection intra-utérine : diagnostic et traitement. RPC rupture prématurée des membranes avant terme CNGOF.

OBJECTIVE: To determine the diagnosis criteria and management of intra-uterine inflammation or infection (Triple I, III). METHODS: PubMed and Cochrane Central databases search. RESULTS: III is defined as an infection of the fetal membranes, and/or other components like the decidua, fetus, amniotic fluid or placenta. This word should be preferred to the word chorioamnionitis that is less precise (Professional consensus). III clinical signs exhibit poor limited sensibility and specificity (EL3). The diagnosis of III is retained in case of maternal fever (defined by a body temperature≥38°C) with no alternative cause identified and at least 2 signs among the following: fetal tachycardia>160 bpm for 10min or longer, uterine pain of labor, purulent fluid from the cervical canal (Professional consensus). Maternal hyperleukocytosis>20 giga/L in the absence of corticosteroids treatment or increased plasmatic C-reactive protein also argue for III, despite their limited sensibility and specificity (EL3). III requires prompt delivery (Grade A). III is not by itself an indication for cesarean delivery (Professional consensus). Antibiotic treatment should cover Streptococcus agalactiae and Escherichia coli. Antibiotics should be started immediately and maintained all over delivery, to reduce neonatal and maternal morbidity (Grade B). Treatment should rely on a combination of betalactamin and aminoglycoside (Grade B). After vaginal delivery, one single dose of antibiotic is required. Antibiotic duration should be longer in case of bacteremia. Longer duration could be considered in case of persistent fever or of cesarean delivery (Professional consensus).

[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).

Labour induction practices in France: A population-based declarative survey in 94 maternity units.

INTRODUCTION: In 2016, 22.0% of deliveries in France were induced. The current lack of high level of evidence data about the methods and indications for induction of labour has promoted heterogeneous and non-recommended practices. The extent of these different practices is not adequately known in France today, although they may influence perinatal outcomes. The objective of this study was to report current practices of induction of labour in France. MATERIAL AND METHODS: This study surveyed 94 maternity units in seven perinatal networks. A questionnaire was sent by email to either the department head or delivery room supervisor of these units to ask about their methods for induction and their attitudes in specific obstetric situations. RESULTS: The rate of induction varied between maternity units from 7.7% to 33% of deliveries. Most units used two (39.4%) or three or more (35.1%) agents for cervical ripening. In all, 87 (92.6%) units reported using dinoprostone as a vaginal slow-released insert, 59 units dinosprostone as a vaginal gel (62.8%) and 46 units a balloon catheter (48.9%). Only three units reported using vaginal misoprostol. Inductions without medical indication were reported by 71 (75.5%) maternity units, and 22 (23.4%) units even when the cervix was unfavourable. Obstetric attitudes in cases of breech presentation, previous caesareans, fetal growth restriction or macrosomia and prelabour rupture of the membranes varied widely. DISCUSSION: The variability of practices for induction of labour and the persistence of disapproved practices call for an assessment of the effectiveness and the safety of the different strategies.

[Caesarean section at full dilatation: What are the risks to fear for the mother and child?] / Césarienne à dilatation complète : quels sont les risques à craindre pour la mère et l'enfant ?

OBJECTIVES: Caesarean section is associated with increased maternal morbidity compared to a vaginal delivery, especially if it occurs during labour. Little data on caesarean section performed at full dilatation is available. METHODS: This was a retrospective study done in University Hospital of type 3 over a period of ten years, including future primiparous patients who had a caesarean section performed at full dilatation, compared to a control group of patients whose caesarean section was conducted in first part of the labour. We collected different maternal data per- and postoperative and neonatal. RESULTS: In total, 824 patients were enrolled including 412 in each group. For caesarean section at full dilatation, foetal extraction required more manoeuvres (RR=3.05; 95% CI: 2.1; 4.39; P<0.001); we noted more extension of hysterotomy (RR=1.79; 95% CI: 1.30; 2.46; P<0.001). Postoperative and neonatal maternal morbidity was not different, except more frequent neonatal trauma for caesarean section at full dilatation. CONCLUSION: A caesarean section at full dilatation has an excess intraoperative risk and requires great caution. Nevertheless, no significant increase of postoperative and neonatal complications can be proved.

Intervention of the obstetrician during childbirth in a supposedly low-risk population and influence of parity.

OBJECTIVE: Compare obstetrician intervention and calling rates during labour and delivery between low-risk and high-risk women and study the influence of parity on these rates. MATERIAL AND METHODS: Descriptive retrospective study conducted on 227 patients in a university maternity unit (level 3 university hospital maternity unit) between 1st and 30th January 2014. The low- and high-risk populations were characterised according to the French National Authority for Health (HAS) and NICE guidelines. The obstetrician intervention criteria were: Caesarean section, instrumental vaginal delivery, artificial delivery/uterus examination and postpartum haemorrhage. The obstetrical team also had to call the obstetrician in case of foetal heart rate abnormalities, scalp blood pH measurement, third and/or fourth degree perineal tears, labour dystocia, or any other severe event occurring during labour or delivery. RESULTS: In univariate analysis, the obstetrician intervention rates were respectively 44.5% and 34.4% in the high- and low-risk groups (P=0.13). The obstetrician calling rates were similar between the two groups. Using logistic regression model including parity, the obstetrician intervention rate became significantly higher in the "high-risk" group (OR 2.044, 95% CI 1.129-3.703, P=0.018). In the low-risk population, the intervention rate was significantly increased for nulliparous women compared with multiparas (47.5% versus 9.7%, P<0.001, OR=8.2, CI 95% 2.2 to 46.9). CONCLUSION: One third of the women defined as low-risk patients appear to need an obstetrician intervention during labour and delivery, with a major influence of parity.

Pregnancy loss: French clinical practice guidelines.

In intrauterine pregnancies of uncertain viability with a gestational sac without a yolk sac (with a mean of three orthogonal transvaginal ultrasound measurements <25mm), the suspected pregnancy loss should only be confirmed after a follow-up scan at least 14 days later shows no embryo with cardiac activity (Grade C). In intrauterine pregnancies of uncertain viability with an embryo <7mm on transvaginal ultrasound, the suspected pregnancy loss should only be confirmed after a follow-up scan at least 7 days later (Grade C). In pregnancies of unknown location after transvaginal ultrasound (i.e. not visible in the uterus), a threshold of at least 3510IU/l for the serum human chorionic gonadotrophin assay is recommended; above that level, a viable intrauterine pregnancy can be ruled out (Grade C). Postponing conception after an early miscarriage in women who want a new pregnancy is not recommended (Grade A). A work-up for women with recurrent pregnancy loss should include the following: diabetes (Grade A), antiphospholipid syndrome (Grade A), hypothyroidism with anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies (Grade A), vitamin deficiencies (B9, B12) (Grade C), hyperhomocysteinaemia (Grade C), hyperprolactinaemia (Grade B), diminished ovarian reserve (Grade C), and a uterine malformation or an acquired uterine abnormality amenable to surgical treatment (Grade C). The treatment options recommended for women with a missed early miscarriage are vacuum aspiration (Grade A) or misoprostol (Grade B); and the treatment options recommended for women with an incomplete early miscarriage are vacuum aspiration (Grade A) or expectant management (Grade A). In the absence of both chorioamnionitis and rupture of the membranes, women with a threatened late miscarriage and an open cervix, with or without protrusion of the amniotic sac into the vagina, should receive McDonald cerclage, tocolysis with indomethacin, and antibiotics (Grade C). Among women with a threatened late miscarriage and an isolated undilated shortened cervix (<25mm on ultrasound), cerclage is only indicated for those with a history of either late miscarriage or preterm delivery (Grade A). Among women with a threatened late miscarriage, an isolated undilated shortened cervix (<25mm on ultrasound) and no uterine contractions, daily treatment with vaginal progesterone up to 34 weeks of gestation is recommended (Grade A). Hysteroscopic section of the septum is recommended for women with a uterine septum and a history of late miscarriage (Grade C). Correction of acquired abnormalities of the uterine cavity (e.g. polyps, myomas, synechiae) is recommended after three early or late miscarriages (Grade C). Prophylactic cerclage is recommended for women with a history of three late miscarriages or preterm deliveries (Grade B). Low-dose aspirin and low-molecular-weight heparin at a preventive dose are recommended for women with obstetric antiphospholipid syndrome (Grade A). Glycaemic levels should be controlled before conception in women with diabetes (Grade A).

Overview and expert assessment of off-label use of misoprostol in obstetrics and gynaecology: review and report by the Collège national des gynécologues obstétriciens français.

The literature suggests that misoprostol can be offered to patients for off-label use as it has reasonable efficacy, risk/benefit ratio, tolerance and patient satisfaction, according to the criteria for evidence-based medicine. Both the vaginal and sublingual routes are more effective than the oral route for first-trimester cervical dilatation. Vaginal misoprostol 800µg, repeated if necessary after 24 or 48h, is a possible alternative for management after early pregnancy failure. However, misoprostol has not been demonstrated to be useful for the evacuation of an incomplete miscarriage, except for cervical dilatation before vacuum aspiration. Oral mifepristone 200mg, followed 24-48h later by vaginal, sublingual or buccal misoprostol 800µg (followed 3-4h later, if necessary, by misoprostol 400µg) is a less efficacious but less aggressive alternative to vacuum aspiration for elective or medically-indicated first-trimester terminations; this alternative becomes increasingly less effective as gestational age increases. In the second trimester, vaginal misoprostol 800-2400µg in 24h, 24-48h after at least 200mg of mifepristone, is an alternative to surgery, sulprostone and gemeprost. Data for the third trimester are sparse. For women with an unripe cervix and an unscarred uterus, vaginal misoprostol 25µg every 3-6h is an alternative to prostaglandin E2 for cervical ripening at term for a live fetus. When oxytocin is unavailable, misoprostol can be used after delivery for prevention (sublingual misoprostol 600µg) and treatment (sublingual misoprostol 800µg) of postpartum haemorrhage. The use of misoprostol to promote cervical dilatation before diagnostic hysteroscopy or surgical procedures is beneficial for premenopausal women but not for postmenopausal women. Nonetheless, in view of the side effects of misoprostol, its use as a first-line treatment is not indicated, and it should be reserved for difficult cases. Misoprostol is not useful for placing or removing the types of intra-uterine devices used in Europe, regardless of parity.

[Fetal death beyond 14 weeks of gestation: induction of labor and obtaining of uterine vacuity]. / Mort fœtale in utero au-delà de 14SA : induction du travail et obtention de la vacuité utérine.

The objective of this review was to assess benefits and harms of different management options for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14 weeks of gestation. In second-trimester, the data are numerous but low methodological quality. In terms of efficiency (induction-expulsion time and uterine evacuation within 24 hours rate) and tolerance in the absence of antecedent of caesarean section, the best protocol for induction of labor in the second-trimester of pregnancy appears to be mifepristone 200mg orally followed 24-48 hours later by vaginal administration of misoprostol 200 to 400 µg every 4 to 6 hours. In third-trimester, there is very little data. The circumstances are similar to induction of labor with living fetus. A term or near term, oxytocin and dinoprostone have a marketing authorization in this indication but misoprostol may be an alternative as the Bishop score and dose of induction of labor with living fetus. In case of previous caesarean section, the risk of uterine rupture is increased in case of a medical induction of labor with prostaglandins. The lowest effective doses should be used (100 to 200 µg every 4 to 6 hours). Prior cervical preparation by the administration of mifepristone and possibly the use of laminar seems essential in this situation.

[Uterine artery pseudoaneurysm: an unusual cause of postpartum hemorrhage]. / Le pseudo-anévrysme de l'artère utérine: une cause parfois ignorée d'hémorragie secondaire du post-partum.

Uterine artery pseudoaneurysm is a rare complication of cesarean section. It can lead to severe postpartum hemorrhage. We report three cases of pseudoaneurysm diagnosed late after cesarean delivery, one followed by hemorrhagic shock. Ultrasound may point to the diagnosis, but arteriography of uterine arteries is decisive for the diagnosis. Selective artery embolization is recommended for treatment. Main advantages are complete occlusion of the pseudoaneurysm and fertility preservation.

[Definition of pregnancy losses: Standardization of terminology from the French National College of Obstetricians and Gynecologists (CNGOF)]. / Standardisation de la terminologie des pertes de grossesse : consensus d'experts du Collège national des gynécologues et obstétriciens français (CNGOF).

OBJECTIVE: While a number of glossaries have been produced by various authorities in different countries, at present there is no internationally accepted common set of definitions for many terms used to describe pregnancy losses. The objective of the current study was to provide a standardized French/English terminology/glossary relating to pregnancy losses. METHODS: Literature review, construction of a glossary and rating of proposals using a formal consensus method. The glossary was subject of a critical comprehensive review by a meeting of professionals (multidisciplinary panel). RESULTS: A miscarriage is a spontaneous evacuation of an intra-uterine pregnancy<22WG. A missed early miscarriage is when ultrasound (<14WG) shows no growth of intra-uterine sac/embryo and/or loss of fetal heart activity. An early miscarriage is when spontaneous evacuation of intra-uterine pregnancy occurs <14WG. A complete early miscarriage is when there is no retained products of conception (empty uterus on ultrasound) and no bleeding nor pain. Incomplete early miscarriage is when ultrasonography shows retained products of conception in the uterine cavity (including cervical canal). Repeat miscarriage or recurrent pregnancy loss is when the woman experiences 3 or more consecutive miscarriages <14WG. A late miscarriage is when there is spontaneous evacuation of pregnancy ≥14WG and <22WG. A threatened late miscarriage is when shortening/opening of the cervix±uterine contraction occur ≥14WG and <22WG. An intra-uterine fetal demise is when there is a spontaneous loss of fetal heart activity ≥14 WG. CONCLUSION: The final current terminology should be used by all healthcare professionals.

[Epidemiology of loss pregnancy]. / Épidémiologie des pertes de grossesse.

OBJECTIVES: Study of epidemiology of pregnancy loss. MATERIALS AND METHOD: A systematic review of the literature was performed using Pubmed and the Cochrane library databases and the guidelines from main international societies. RESULTS: The occurrence of first trimester miscarriage is 12% of pregnancies and 25% of women. Miscarriage risk factors are ages of woman and man, body mass index greater than or equal to 25kg/m(2), excessive coffee drinking, smoking and alcohol consumption, exposure to magnetic fields and ionizing radiation, history of abortion, some fertility disorders and impaired ovarian reserve. Late miscarriage (LM) complicates less than 1% of pregnancies. Identified risk factors are maternal age, low level of education, living alone, history of previous miscarriage, of premature delivery and of previous termination of pregnancy, any uterine malformation, trachelectomy, existing bacterial vaginosis, amniocentesis, a shortened cervix and a dilated cervical os with prolapsed membranes. Fetal death in utero has a prevalence of 2% in the world and 5/1000 in France. Its main risk factors are detailed in the chapter.

[Obtaining of uterine vacuity in pregnancy loss]. / Obtention de la vacuité utérine dans le cadre d'une perte de grossesse.

OBJECTIVE: To assess early and late benefits and harms of different management options for first trimester miscarriage and for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14weeks of gestation. METHODS: French and English publications were searched using PubMed and Cochrane Library. RESULTS: Concerning missed miscarriage, expectant management is not recommended (LE1) because it increases the risk of failure, need of unplanned surgical procedure and blood transfusion (LE1). Surgical uterine evacuation remains more effective than medical treatment using misoprostol (LE1), but both techniques involve rare and comparable risks (EL1). When chosen, medical treatment should be a vaginal dose of 800µg of misoprostol, possibly repeated 24 to 48hours later (EL2). Administration of mifepristone prior to misoprostol is not recommended (EL2). In case of incomplete miscarriage, expectant management can be offered because it does not increase the risk of complications, neither haemorrhagic nor infectious (EL1). Medical treatment using misoprostol is not recommended (EL2) because it does not improve the evacuation rate when compared to our first option, and does not reduce the risk of complications (EL2). Surgical uterine evacuation leads to high evacuation rate (97-98%) and low risk of complications, haemorrhagic and infectious (<5%) (EL1). However, this option should not be the only one because of the good efficiency of the expectant management (more than 75% of evacuation) and comparably low risk of complications (EL1). Surgical aspiration should be favoured to curettage because it is quicker, less painful and leads to less bleeding (EL2). After a first trimester miscarriage future fertility is identical with each treatment (EL2). When a trophoblastic retention is suspected, a diagnostic hysteroscopy is recommended (EL2). In case of late intrauterine foetal death beyond 14weeks of gestation and without a past caesarean section, the most efficient protocol seems to be vaginal administration of misoprostol 200 to 400µg every 4 to 6hours (EL2). Twenty-four hours prior to misoprostol the administration of 200mg of mifepristone is recommended (EL3) because it improves the induction-expulsion time and diminishes the quantity of needed misoprostol (and so the complications linked to it) (EL3).

[Threatened late miscarriage. French guidelines]. / Menace de fausse couche tardive. Recommandations françaises.

OBJECTIVES: To define guidelines for the management of women diagnosed with threatened late miscarriage (TLM). MATERIALS AND METHODS: A systematic review of the literature was performed using Pubmed and the Cochrane library databases and the guidelines from main international societies. RESULTS: Management of women diagnosed with threatened LM requires a complete history-taking searching for a previous history of LM and/or of premature delivery (Grade B). Speculum examination is required to diagnose membrane prolapse (Grade B) and vaginal ultrasound scan is recommended to measure the cervical length (Grade B). Finally, initial management should allow to rule out chorioamniotitis (Grade B). Vaginal progesterone therapy (90-200mg daily) is recommended for women diagnosed with a sole shortened cervix (<25mm) in mid-pregnancy (Grade A). Cerclage is only recommended in women with both history of previous premature delivery and/or previous LM and shortened cervical length diagnosed before 24 weeks of gestation (Grade A). Finally, cervical cerclage (Mc Donald technique) associated with systematic tocolytic therapy (indometacine) and antibiotics are to be recommended in women diagnosed with TLM with dilated cervical os eventually associated with membrane prolapse (GradeC).

[Initial obstetrical management of post-partum hemorrhage following vaginal delivery]. / Prise en charge obstétricale initiale en cas d'hémorragie du post-partum après un accouchement par voie basse.

OBJECTIVES: To define initial steps of obstetrical treatment of post-partum hemorrhage (PPH) after vaginal delivery. MATERIALS AND METHOD: We searched the Medline and the Cochrane Library and checked the international guidelines: HAS, RCOG, SOGC, ACOG and WHO. RESULTS: In case of PPH, the use of a collecting bag is recommended (professional consensus). All the concerned professional (midwife, obstetrician, anesthesiology team) must be warned immediately (professional consensus). If placenta is retained, manual removal needs to be performed and after placental delivery, manual uterine exploration is recommended (professional consensus). At the same time, a dose of 5 or 10 IU of oxytocin must be administrated IV over at least 1minute or directly by an intramuscular injection followed by an infusion of 5 to 10 UI/h during 2hours (professional consensus). In some situations at risk of cervical and high vaginal laceration, the low genital tract needs to be carefully examined (professional consensus). Appropriate management of PPH has to be known by the concerned professional (professional consensus). Retrospective study of each case of PPH should be done (professional consensus). CONCLUSION: The PPH initial treatment involves a team work that, most of times, leads to stop the bleeding in least than 30minutes (professional consensus).

[First trimester miscarriages: benefits and harms of different management options]. / Fausses couches du premier trimestre : bénéfices et risques des alternatives thérapeutiques.

The objective of this review was to assess early and late benefits and harms of different management options for first-trimester miscarriage. Surgical uterine evacuation remains the most effective and the quickest method of treatment. Depending on the clinical situation, medical treatment using misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) does not increase the risk of complications, neither haemorrhagic nor infectious. However, these alternatives generally require longer outpatient follow-up, which leads to more prolonged bleeding and not planned surgical procedures.