[Potential teratogenicity of modafinil - Conflicting evidence, need for research]. / Tératogénicité potentielle du modafinil ­ des données contradictoires, un besoin de recherche.

Central disorders of hypersomnolence include narcolepsy type 1, narcolepsy type 2, idiopathic hypersomnia and hypersomnia associated with medical or mental disorders. Treatment is both non-pharmacological and pharmacological, including wake enhancing drugs and stimulants. One of the first-line treatment (modafinil, MODIODAL®) was the subject of a health authority alert in 2019 concerning a risk of major congenital malformations when taken during organogenesis. Since this date, three epidemiological studies have presented contradictory results. Given their methodological weaknesses, it is not possible at this stage to confirm or deny such a risk for the embryo and its nature if there is one. In clinical practice, because of these uncertainties, it is preferable if possible to suspend the treatment of a pregnant woman during the first 10 weeks from last menstrual period (organogenesis). There is an unmet clinical need for research to clarify the potential teratogenic impact of modafinil.

[Pegabalin and congenital abnormalities]. / Prégabaline et malformations congénitales : une fausse alerte.

Pregabalin is frequently prescribed for neuropathic pain, generalized anxiety disorder and, to a lesser extent, epilepsy. On the basis of the analysis of a study conducted in 4 European countries, the European Medicines Agency and the French National Agency for the Safety of Medicines and Health Products considered that this drug should be avoided in pregnant women. An alarmist interpretation of these study results retains an increased risk of major congenital malformations in case of in utero exposure to pregabalin during the first trimester of pregnancy. Our analysis of this study and the overall evaluation of the data available on this drug in pregnant women do not lead us to the same conclusion.

[Nausea and vomiting in pregnancy: A place for ondansetron?] / Nausées et vomissements gravidiques : quelle place pour l'ondansétron ?

Although there is no recommendation in France relating to the treatment of nausea and vomiting of pregnancy, there are some in other countries, where ondansetron, widely used, appears to be an effective second-line treatment option behind doxylamine/vitamin B6 association and metoclopramide. However, based on some recent publication suggesting an increased risk of orofacial clefts and congenital heart defects in fetuses exposed in utero to ondansetron in the 1st trimester of pregnancy, the European Medicines Agency now states that this drug should not longer be used during this period. This 2019 decision is controversial and whether ondansetron can be used in pregnant women with severe vomiting during pregnancy is still in question.

Trends in perinatal health in metropolitan France from 1995 to 2016: Results from the French National Perinatal Surveys.

OBJECTIVE: To study trends in the main indicators of perinatal health, medical practices and risk factors in France since 1995. POPULATION AND METHOD: All live births during one week in 1995 (n=13,318), 2003 (n=14,737), 2010 (n=14,903) and 2016 (n=13,384). Data were from interviews of women in postpartum wards and from medical records and were compared between years. RESULTS: Between 1995 and 2016, maternal age and body mass index increased steadily. Pregnancies that occurred with use of contraception increased from 7.4% in 2010 to 9.3% in 2016. Smoking during pregnancy (16.6%) did not decrease since 2010. The frequency of more than three ultrasounds during pregnancy was 48.5% in 1995 and 74.7% in 2016. Deliveries in large public hospitals increased steadily. The caesarean section rate has been relatively stable since 2003 (20.4% in 2003, 21.1% in 2010 and 20.4% in 2016). The rate of induction of labour was 22% in 2010 and 2016. Overall, 83.8% of women had epidural analgesia/anaesthesia in 2016. Rates of pre-term birth in 2016 ranged from 7.5% among all live births to 6.0% among live born singletons; for singletons, this rate increased steadily from 1995 to 2016, whereas there was no clear trend for low birth weight. Exclusive breastfeeding decreased from 60.3% in 2010 to 52.2% in 2016. CONCLUSION: Routine national perinatal surveys highlight successful policies and recommendations but also point out some health indicators, practices, preventive behaviours and risk factors that need special attention.

[Oxytocin administration during spontaneous labour: Guidelines for clinical practice. Guidelines short text]. / Recommandations pour l'administration d'oxytocine au cours du travail spontané. Texte court des recommandations.

OBJECTIVES: To define the different stages of spontaneous labour. To determine the indications, modalities of use and the effects of administering synthetic oxytocin. And to describe undesirable maternal and perinatal outcomes associated with the use of synthetic oxytocin. METHOD: A systematic review was carried out by searching Medline database and websites of obstetrics learned societies until March 2016. RESULTS: The 1st stage of labor is divided in a latence phase and an active phase, which switch at 5cm of cervical dilatation. Rate of cervical dilatation is considered as abnormal below 1cm per 4hour during the first part of the active phase, and below 1cm per 2hours above 7cm of dilatation. During the latent phase of the first stage of labor, i.e. before 5cm of cervical dilatation, it is recommended that an amniotomy not be performed routinely and not to use oxytocin systematically. It is not recommended to expect the active phase of labor to start the epidural analgesia if patient requires it. If early epidural analgesia was performed, the administration of oxytocin must not be systematic. If dystocia during the active phase, an amniotomy is recommended in first-line treatment. In the absence of an improvement within an hour, oxytocin should be administrated. However, in the case of an extension of the second stage beyond 2hours, it is recommended to administer oxytocin to correct a lack of progress of the presentation. If dynamic dystocia, it is recommended to start initial doses of oxytocin at 2mUI/min, to respect at least 30min intervals between increases in oxytocin doses delivered, and to increase oxytocin doses by 2mUI/min intervals without surpassing a maximum IV flow rate of 20mUI/min. The reported maternal adverse effects concern uterine hyperstimulation, uterine rupture and post-partum haemorrhage, and those of neonatal adverse effects concern foetal heart rate anomalies associated with uterine hyperstimulation, neonatal morbidity and mortality, neonatal jaundice, weak suck/poor breastfeeding latch and autism. CONCLUSION: The widespread use of oxytocin during spontaneous labour must not be considered as simply another inoffensive prescription without any possible deleterious consequences for mother or foetus. Conditions for administering the oxytocin must therefore respect medical protocols. Indications and patient consent have to be report in the medical file.

Elective induction of labour and maternal request: a national population-based study.

OBJECTIVE: To estimate the rate of elective inductions in France and the proportion of them that were maternally requested, and to study the factors associated with elective inductions that were or were not requested by women. DESIGN: Cross-sectional population-based study. SETTING: All maternity units in France. POPULATION: About 14 681 women from the 2010 French National Perinatal Survey of a representative sample of births. METHODS: Inductions were classified as elective based on their indications and maternal and fetal characteristics, collected from medical records. Elective inductions requested by women were identified from the mother's postpartum interviews. Polytomous logistic regression analysis was used to study the determinants of inductions that were or were not maternally requested. Women with spontaneous labour served as the comparison group. MAIN OUTCOME MEASURE: Rate of elective inductions. RESULTS: The induction rate was 22.6, 13.9% elective. Among elective inductions, 47.3% were requested by women. The characteristics of mothers, pregnancies, and maternity units were similar in both groups of elective inductions. The main associated factors were parity 2 or more [adjusted odds ratio (OR) 4.7, 95% confidence interval (CI) 3.1-7.2 for maternally requested inductions and aOR of 1.8 (95% CI1.2-2.7) for unrequested inductions, compared with parity 0] and private hospital status [aOR 4.5 95% (CI 3.3-6.0) for maternally requested inductions and aOR 3.7 (95% CI 2.8-4.9) for inductions not requested by the mother]. We found no association between maternal social characteristics and type of elective induction. CONCLUSION: Parity and organisational factors appear to influence the decision about elective inductions. It would be interesting to determine how obstetricians and women make this decision and for what reasons. TWEETABLE ABSTRACT: About 13.9% of inductions of labour were elective in France, 47.3% of these requested by women.

[Postpartum pelvic floor muscle training and abdominal rehabilitation: Guidelines]. / Rééducation périnéale et abdominale dans le post-partum: recommandations.

OBJECTIVE: Provide guidelines for clinical practice concerning postpartum rehabilitation. METHODS: Systematically review of the literature concerning postpartum pelvic floor muscle training and abdominal rehabilitation. RESULTS: Pelvic-floor rehabilitation using pelvic floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. At least 3 guided sessions with a therapist is recommended, associated with pelvic floor muscle exercises at home. This postpartum rehabilitation improves short-term urinary incontinence (1 year) but not long-term (6-12 years). Early pelvic-floor rehabilitation (within 2 months following childbirth) is not recommended (grade C). Postpartum pelvic-floor rehabilitation in women presenting with anal incontinence, is associated with a lower prevalence of anal incontinence symptoms in short-term (1 year) (EL3) but not long-term (6 and 12) (EL3). Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C) but results are not maintained in medium or long term. No randomized trials have evaluated the pelvic-floor rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long term. It is therefore not recommended (expert consensus). Rehabilitation supervised by a therapist (physiotherapist or midwife) is not associated with better results than simple advice for voluntary contraction of the pelvic floor muscles to prevent/correct, in short term (6 months), a persistent prolapse 6 weeks postpartum (EL2), whether or not with a levator ani avulsion (EL3). Postpartum pelvic-floor rehabilitation is not associated with a decrease in the prevalence of dyspareunia at 1-year follow-up (EL3). Postpartum pelvic-floor rehabilitation guided by a therapist is therefore not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). No randomized trials have evaluated the effect of pelvic floor muscle training after an episode of postpartum urinary retention or bladder outlet obstruction symptoms, or for the primary prevention of anal incontinence following third-degree anal sphincter tear or in patients presenting with anal incontinence after third-degree anal sphincter tear. The electrostimulation devices used alone were not assessed in this postpartum context (regardless of symptoms); therefore, isolated pelvic floor electrostimulation is not recommended (expert consensus). CONCLUSION: Pelvic floor muscle therapy is recommended for persistent postpartum urinary (grade A) or anal (grade C) incontinence (3 months after delivery).

[Oxytocin administration during labor. Results from the 2010 French National Perinatal Survey]. / Administration d'ocytocine au cours du travail en France. Résultats de l'enquête nationale périnatale 2010.

OBJECTIVES: To estimate the frequency of oxytocin administration during labor, in all women in labor, in low-risk women, and in women with a previous cesarean delivery. Our objectives were also to identify characteristics of women and of maternity units associated with this practice in France. POPULATION AND METHOD: Analysis of the 2010 French Perinatal Survey data (n=14,681 women who delivered in continental France). The frequency of oxytocin administration during labor was estimated in all women in labor (n=12,845) and in low-risk women (n=9798). The independent associations between oxytocin administration during labor and characteristics of women and units were quantified with multivariate logistic regression modeling. RESULTS: Sixty-four percent of laboring women received oxytocin during labor, and 58% of women with a spontaneous onset of labor. In the population of low-risk women with spontaneous labor and epidural, nulliparity and over-weight, as well as the private status and small size of the maternity unit, were independently associated with a more frequent administration of oxytocin during labor. CONCLUSION: Oxytocin administration during labor is very frequent in France, probably beyond classical indications.

[Hospital length-of-stay after childbirth in France]. / Durée de séjour en maternité après un accouchement par voie basse en France.

OBJECTIVE: To study hospital length-of-stay (LOS) after childbirth and its determinants and to describe home care offered after discharge. POPULATION AND METHOD: We studied 10,302 women with vaginal delivery from the 2010 French National Perinatal Survey. Maternal, newborn, maternity unit characteristics and the region of birth were considered. Simple and polytomial regression analyses were used to study determinants of postpartum LOS. Maternity units that offered routinely home visits by midwives after discharge were described. RESULTS: Around 29,0% of women had a LOS ≤ 3 days, with significant variations between regions. LOS ≤ 3 days was more common among multiparas and women who bottle-fed their newborn. In the Greater Parisian Region, LOS ≤ 3 days ranged from 16,6% in private units <1000 del/year to 72,9% in teaching units ≥ 3000 del/y. Among women who had a LOS ≤ 3 days, only 19,7% were in a unit, which offered home visits routinely. CONCLUSION: LOS varies mainly according to the place of delivery. The trends towards short LOS are likely to continue due to economic pressures and home care services should be developed to ensure continuity of care for all mothers after discharge.