[Pregnancy outcomes in women with previous preterm cesarean delivery between 22 and 28 weeks of gestation]. / Issues de grossesses chez les femmes ayant un antécédent de césarienne réalisée entre 22 et 28 semaines d'aménorrhée.

INTRODUCTION: The rate of caesarean delivery between 22 and 28 weeks of gestation (weeks) has increased for several years. The aim of the study was to describe subsequent pregnancies in women with a history of caesarean delivery between 22 and 28 weeks. METHODS: We performed a retrospective, observational, bicentric cohort study in tertiary care maternity units. We included women who had a caesarean delivery between 22 and 28 weeks from December 1, 2014 to December 31, 2017. We then retrospectively collected data on subsequent pregnancies of these patients up to March 2020. We described the subsequent pregnancy rate and the outcomes of these pregnancies. RESULTS: Among the 186 women who had a caesarean between 22 and 28 weeks, data from 103 of them could be collected, including 47 (45.6%) women who had 64 new pregnancies. Of the 47 first pregnancies after the preterm cesarean, 19 (40.4%) were completed at≥37 weeks. The mode of delivery was a cesarean in 23 cases (79.3%). A trial of labor after cesarean was only considered in 7 cases (24.1%), and 6 women (20.7%) gave birth vaginally. CONCLUSIONS: If pregnancy is desired after a caesarean between 22 and 28 weeks, the pregnancy rate is high without recurrence of prematurity in the majority of cases. Cesarean delivery is the most common mode of delivery. In case of trial of labor after cesarean, the success rate is reasonable.

Association between extremely preterm caesarean delivery and maternal depressive and anxious symptoms: a national population-based cohort study.

OBJECTIVE: To evaluate whether caesarean delivery before 26 weeks of gestation was associated with symptoms of depression and anxiety in mothers in comparison with deliveries between 26 and 34 weeks. DESIGN: Prospective national population-based EPIPAGE-2 cohort study. SETTING: 268 neonatology departments in France, March to December 2011. POPULATION: Mothers who delivered between 22 and 34 weeks and whose self-reported symptoms of depression (Center for Epidemiologic Studies Depression Scale: CES-D) and anxiety (State-Trait Anxiety Inventory: STAI) were assessed at the moment of neonatal discharge. METHODS: The association of caesarean delivery before 26 weeks with severe symptoms of depression (CES-D ≥16) and anxiety (STAI ≥45) was assessed by weighted and design-based log-linear regression model. MAIN OUTCOME MEASURES: Severe symptoms of depression and anxiety in mothers of preterm infants. RESULTS: Among the 2270 women completing CES-D and STAI questionnaires at the time of neonatal discharge, severe symptoms of depression occurred in 25 (65.8%) women having a caesarean before 26 weeks versus in 748 (50.6%) women having a caesarean after 26 weeks. Caesarean delivery before 26 weeks was associated with severe symptoms of depression compared with caesarean delivery after 26 weeks (adjusted relative risk [aRR] 1.42, 95% CI 1.12-1.81) adjusted to neonatal birthweight and severe neonatal morbidity among other factors. There was no evidence of an association between mode of delivery and symptoms of anxiety. CONCLUSIONS: Mothers having a caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression and may benefit from specific preventive care. TWEETABLE ABSTRACT: Mothers having caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression.

The impact of chorionicity on pregnancy outcome and neurodevelopment at 2 years old among twins born preterm: the EPIPAGE-2 cohort study.

OBJECTIVE: To compare the short- and mid-term outcomes of preterm twins by chorionicity of pregnancy. DESIGN: Prospective nationwide population-based EPIPAGE-2 cohort study. SETTING: 546 maternity units in France, between March and December 2011. POPULATION: A total of 1700 twin neonates born between 24 and 34 weeks of gestation. METHODS: The association of chorionicity with outcomes was analysed using multivariate regression models. MAIN OUTCOME MEASURES: First, survival at 2-year corrected age with or without neurosensory impairment, and second, perinatal, short-, and mid-term outcomes (survival at discharge, survival at discharge without severe morbidity) were described and compared by chorionicity. RESULTS: In the EPIPAGE 2 cohort, 1700 preterm births were included (850 twin pregnancies). In all, 1220 (71.8%) were from dichorionic (DC) pregnancies and 480 from monochorionic (MC) pregnancies. MC pregnancies had three times more medical terminations than DC pregnancies (1.67 versus 0.51%, P < 0.001), whereas there were three times more stillbirths in MC than in DC pregnancies (10.09 versus 3.78%, P < 0.001). Both twins were alive at birth in 86.6% of DC pregnancies compared with 80.0% among MC pregnancies (P = 0.008). No significant difference according to chorionicity was found regarding neonatal deaths and morbidities. Likewise, for children born earlier than 32 weeks, the 2-year follow-up neurodevelopmental results were not significantly different between DC and MC twins. CONCLUSIONS: This study confirms that MC pregnancies have a higher risk of adverse outcomes. However, the outcomes among preterm twins admitted to neonatal intensive care units are similar irrespective of chorionicity. TWEETABLE ABSTRACT: Monochorionicity is associated with adverse perinatal outcomes, but outcomes for preterm twins are comparable irrespective of their chorionicity.

[Propositions for perinatal care at extremely low gestational ages - Working group on "Extremely low gestational ages" for SFMP, CNGOF, and SFN]. / Propositions sur la prise en charge en cas d'extrême prématurité ­ Le groupe de travail « Extrême Prématurité ¼ pour la SFMP, le CNGOF et la SFN.

OBJECTIVES: International literature suggests that active perinatal management at extremely low gestational ages improves survival without increasing the risk of impairment in survivors, compared to less active management. Although these results are limited to a small number of countries, they question current practices in France. New propositions on perinatal management of extremely preterm infants have carried out by the French Society of Perinatal Medicine, the French Society of Neonatology and the National College of French Obstetricians and Gynecologists. METHODS: This group was set up in 2015 on the initiative of the professional societies and in collaboration with parents' and users' associations. The work was based on a review of the literature on the prognosis of extremely preterm children, as well as on recommendations by European societies. Based on this information, a text was produced, submitted to all members of the working group and definitively validated in April 2019. RESULTS: This text offers a decision-making guideline for the management at extremely low gestational ages. Its principles are: the administration of steroids independently of management (resuscitation or comfort care); a prognostic evaluation and a collegial decision, outside the context of the emergency; a consensus on the information to be given to parents before going to inform them and gather their opinion. CONCLUSIONS: These new propositions will contribute to modifying perinatal care at extremely low gestational ages in France.

[Pathophysiology, diagnosis and management of occiput posterior presentation during labor]. / Variétés postérieures au cours du travail : mécanique obstétricale, diagnostic et prise en charge.

Persistant occiput posterior (OP) positions are the commonest malpresentations of the fetal head during labor and their diagnosis remains challenging. They are associated to prolonged second stage of labor, prolonged expulsive efforts, labor augmentation, cesarean sections and instrumental deliveries. On the maternal side, severe perineal tears, post-partum hemorrhage or chorioamnionitis are more frequent. Currently, prevention of persistent OP positions is based on the maintain of precise maternal positions. Several positions have been evaluated but only lateral position on the same side of the fetal spine has proved its effectiveness. Fetal head rotation can also be achieved with extraction instruments though none has ever been evaluated by a randomized controlled trial. Obstetrical forceps seem more efficient than vacuum but are associated with severe perineal tears. Evaluation of rotation with Thierry's spatulas is scarce. Last, manual rotation is of routine use in many wards. This management is associated with a twofold reduction of operative delivery rate and rare adverse outcomes but has never been evaluated through randomized control trial.

Primary cesarean delivery rate: Potential impact of a checklist.

BACKGROUND: Cesarean section is the most common surgical procedure performed in developed countries. Its incidence is increasing to a worrisome extent. The 2003 French National Perinatal Survey showed that the inflation in the overall cesarean rate was mainly due to an increase in the first cesarean delivery rate. OBJECTIVE: To evaluate a new tool: a checklist that intent to decrease the first cesarean delivery rate. STUDY DESIGN: Retrospective, observational, multi-center study. A new tool, a "First cesarean delivery" checklist was built according American and French guidelines. Women with full-term of pregnancy, nulliparous or multiparous with a first caesarean delivery including arrest of labor, breech presentation or suspected fetal macrosomia were included. The checklist was applied. Potentially preventable cesareans were analyzed. RESULTS: Among 571 first cesarean section, 178 were eligible to check list application. 147 charts were analyzed in the study. 11.9% of first cesarean deliveries performed were potentially avoidable after applying the checklist. This represented 6.6% of all cesareans. CONCLUSION: The checklist based on the recall of good practices could be an interesting tool to decrease the first cesarean rate.

[Medical simulation as a tool in the training of perinatal professionals]. / La simulation médicale comme outil dans la formation des professionnels de la périnatalité.

Though technology plays an increasingly important role in modern health systems, human performance remains a major determinant of safety, effectiveness and efficiency of patient care. This is especially true in the delivery room. Thus, the training of professionals must aim not only for the acquisition of theory and practical skills on an individual basis, but also for the learning of teamwork systematically. Training health professionals with simulation enhances their theoretical knowledge and meets formal requirements in literacy, technical skills and communication. Therefore, we intend to explore how, in perinatal care, training with simulation is actually a key teaching tool in initial education and in perpetuation of knowledge. We will approach three main aspects: individual, collective (team) and the impact of simulation in medical practice. The choice of this educational strategy improves the clinical skills that are required for optimal performance in complex, unpredictable and high-stake environments such as the delivery room. Nonetheless, the long term clinical impact of simulation and whether it's modalities, technical or not, are beneficial to the mother and the newborn are areas still to be explored.

French validation and adaptation of the Grobman nomogram for prediction of vaginal birth after cesarean delivery.

OBJECTIVE: To validate Grobman nomogram for predicting vaginal birth after cesarean delivery (VBAC) in a French population and adapt it. STUDY DESIGN: Multicenter retrospective study of maternal and obstetric factors associated with VBAC between May 2012 and May 2013 in 6 maternity units. External validation and adaptation of the prenatal and intrapartum Grobman nomograms for vaginal birth prediction after cesarean delivery in a French cohort. RESULTS: The study included 523 women with previous cesarean deliveries; 70% underwent a trial of labor for a subsequent delivery (n=367) with a success rate of 65% (n=240). In the univariate analysis, 5 factors were associated with successful VBAC: previous vaginal delivery before the cesarean (P<0.001), the number of previous vaginal deliveries (P<0.001), and a favorable cervix at delivery room admission, cervical effacement (P=0.035), or cervical dilatation at least 3cm (P<0.001), or a Bishop score >6 (P=0.03). A potentially recurrent indication (defined as arrest of dilation or descent as the indication for the previous cesarean) (P=0.039), a hypertensive disorder during pregnancy (P=0.05), and labor induction (P=0.017) were each associated with failed VBAC. External validation of the prenatal and intrapartum Grobman nomograms showed an area under the ROC curve of 69% (95% CI: 0.638, 0.736) and 65% (95% CI: 0.599, 0.700) respectively. Adaptation of the nomogram to the French cohort resulted in the inclusion of the following factors: maternal age, body mass index at last prenatal visit, hypertensive disorder, gestational age at delivery, recurring indication, cervical dilatation, and induction of labor. Its area under the curve to predict successful VBAC was 78% (95% CI: 0.738, 0.825). CONCLUSION: The nomogram to predict VBAC developed by Grobman et al. is validated in the French population. Adaptation to the French population, by excluding ethnicity, appeared to improve its performance. Impact of the nomogram use on the caesarean section rate has to be validated in a randomized control trial.

Severe perineal morbidity of instrumental deliveries using Thierry's spatulas and vacuum extraction: A prospective observational cohort study.

OBJECTIVES: To evaluate the risk of severe perineal tear following instrumental vaginal delivery (IVD) performed with spatulas and vacuum extraction. Secondary objectives were to estimate the impact of episiotomy on this risk. METHODS: From December 2008 to October 2012, women who underwent spatulas or vacuum were prospectively included. Each spontaneous vaginal delivery (SVD) following each included IVD were included as control cases (1-1 ratio). Careful perineal examination was systematically performed. Severe perineal tear was defined by the occurrence of anal sphincter rupture with or without anal mucosa tear. RESULTS: A total of 761 patients were included in the current study: 248 (64%) spatulas, 137 (36%) vacuums and 381 (49%) SVDs. Severe perineal tear was diagnosed in 19 (2.5%) cases. Episiotomy had been performed in 276 (36.9%) patients. Only spatulas extraction was found to significantly increase the risk of severe perineal tear (AOR=7.66; 95% CI: 2.06-28; P=0.02). Although vacuum extraction seemed to increase this risk, it was not found to be significant (AOR=3.25; 95% CI: 0.65-16.24; P=0.15). No significant difference was observed between the risk of severe perineal tear following spatulas and vacuum (AOR=2.36; 95% CI: 0.63-8.82; P=0.202). Finally, neither foetal macrosomia, nor episiotomy, nor foetal extraction with the head in the deep pelvis, nor delivery at night had a significant impact on the probability of severe perineal tear. CONCLUSIONS: Spatulas extraction is an independent risk factor for severe perineal tear. The practice of episiotomy was not shown to have any significant impact on this risk.

[Newborn outcomes after radiofrequency ablation for selective reduction in the complicated monochorionic pregnancies]. / Devenir neurodéveloppemental des nouveau-nés issus de grossesses monochoriales compliquées avec interruption sélective par ablation par radiofréquence.

OBJECTIVE: To describe perinatal data and to evaluate the neonatal neurological outcome of monochorionic twin pregnancies with selective termination by radiofrequency ablation. METHODS: Retrospective data of perinatal data for nine consecutive monochorionic pregnancies eligible for radiofrequency ablation from January 2013 to August 2015 were collected. A prospective observational study of the neurological outcome of nine children was conducted using the Ages & Stages Questionnaire (ASQ), 2nd edition, French version, adapted to the age. RESULTS: The radiofrequency procedures were performed at a mean gestational age (GA) of 21.4 weeks (±7 weeks). The indications for a selective interruption of a pregnancy were: acardiac twin (n=4), brain malformation (n=1), severe intrauterine growth restriction (IUGR) with massive cerebral ischemia in the context of twin-twin transfusion syndrome grade III (n=1), severe selective IUGR associated with a polymalformative syndrome (n=1) and severe selective IUGR (n=2). The mean GA at birth was 36.7 weeks GA (±3.8 weeks). No infant showed neurological neonatal morbidity. Any ASQ area explored was pathological (<-2SD) for the nine children (mean age at follow-up [±SD], 14.8 months [±8.8 months]). CONCLUSION: This work constitutes a preliminary study for developing long-term follow-up and early care programs for those children born subsequent to a radiofrequency ablation for selective reduction.

[Methods of induction of labor in termination of pregnancy after 22weeks: About 3procedures]. / Modalités d'induction du travail des interruptions médicales de grossesse après 22SA : à propos de 3protocoles.

OBJECTIVES: To propose a protocol for induction of labor to terminate pregnancy after 22weeks of amenorrhea allowing to decrease the duration of labor and of hospitalization but also, allowing to reduce the number of emergency pretreatment-induced fetal death, to improve the experience of the patients and to limit the cost. METHODS: We realized a retrospective single-center study including 269patients and comparing three protocols, with and without laminaria and with various intervals mifepristone-misoprostol (14 and 38hours). The outcome measures were the misoprostol-delivery interval, the delivery time and the number of emergency pretreatment-induced fetal death. RESULTS: We showed that the misoprostol-delivery interval and the delivery time were comparable for the three periods of our study, even after decrease of 24hours of the mifepristone-misoprostol interval and in the absence of laminaria. The misoprostol-delivery interval was between 7h30 and 8h35 between protocols (P=0.055). The delivery time was between 5:18pm and 6:48pm between protocols (P=0.252). The early administration of misoprostol allowed the patients to give birth earlier (P=0.001). Finally, we showed that the increase of the size and the number of laminarias were risk factors of emergency pretreatment-induced fetal death (respectively P=0.013 and P=0.002). CONCLUSION: The absence of laminaria and the reduction of the interval mifepristone-misoprostol of 24hours do not change the time to delivery and allow to reduce the duration of hospitalization, the number of emergency pretreatment-induced fetal death and the cost of the TOP.

[Assessment of shoulder dystocia related knowledge among French obstetrics and gynecology residents]. / Dystocie des épaules : état des lieux de la formation initiale des internes en France.

OBJECTIVE: To study the related knowledge of French residents in obstetrics concerning maneuvers for shoulder dystocia (SD). MATERIALS AND METHODS: Multicenter descriptive transversal study conducted from June to September 2014. Data collection was performed through questionnaires sent by email to French resident in obstetrics. RESULTS: Among the 1080 questionnaires sent, 366 responses were obtained with a response rate of 33.9%. One hundred and forty-three residents (39.1%) were in the first part of their training (≤5th semester) and 60.9% (n=223) were in the second part of their training. Theoretical training on the SD was provided to 88.2% of resident (n=323). In total, 38.8% (n=142) obtained their French degree in mechanical and technical obstetric and among them 77.5% (n=110) had the opportunity to train on simulators and dummies. Concerning their practical experiences, 31.5% (n=45) residents ≤5th semester reported having experienced SD during their residency vs 58.3% (n=130) amongst oldest residents (P<0.001). In the second part of residency, 40% of residents (n=89) expressed to feel able to manage shoulder dystocia. Only 19.1% (n=70) were satisfied with their residency training program vs 39.1% (n=143) who were unsatisfied. CONCLUSION: Our study showed that less than one resident out of two (40%) felt able to perform maneuvers for SD in the second part of residency. We think that simulation activities should be mandatory for residency training programs in Obstetrics and Gynecology, which have to develop dependable measures to assess resident competencies to execute practical maneuvers for clinical emergencies in obstetrics.

[Evaluation of adherence to French guidelines concerning the information of the women having a scarred uterus on their mode of delivery]. / Évaluation du suivi des recommandations concernant l'information des patientes ayant un utérus cicatriciel sur leur mode d'accouchement.

OBJECTIVE: To evaluate adherence of obstetricians from our maternity to French practice guidelines concerning information to give to pregnant patients with a history of scarred uterus. MATERIALS AND METHODS: Observational retrospective study performed on medical files from June to August 2014 and concerning women with a scarred uterus that gave live-birth after 37weeks of gestation. Information of patients had to concern the risks of a history of caesarean, the benefits and risks of the various delivery modes. RESULTS: On 758 deliveries, 77 cases were studied: 48 patients were followed up from the beginning of pregnancy, 23 from the 2nd trimester and 6 were not followed. Among patients followed from the beginning, no data was written on medical file concerning information that should to be given in immediate post-partum, in preconception counseling, and at the beginning of pregnancy about the risks of scarred uterus and the mode of delivery. In the 8th month, information about benefits and risks of the planned delivery mode was noticed in 45% of files. CONCLUSION: The information that need in theory to be given to the patients with scarred uterus appeared little or insufficiently noticed on medical files; which can be due either to an inaccurate information, or to a lack of transcription of the information nevertheless given. A check-list in obstetrical file would help to systematize the information to provide in scarred uterus patients.

[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).

[Surgical treatment of postpartum hemorrhage]. / Prise en charge chirurgicale d'une hémorragie du post-partum.

OBJECTIVE: Systematic revue of different conservative and non-conservative surgical treatment of postpartum hemorrhage (PPH). Elaboration of surgical strategy after failed medical treatment of PPH. METHODS: French and English publications were identified through PubMed and Cochrane databases. RESULTS: Each obstetrical unit has to rewrite a full protocol of management of PPH depending on local environment quickly available in theatre (professional consensus). Conservative surgical treatment of PPH: efficacy of vascular ligature (bilateral uterine artery ligation (BUAL) or bilateral hypogastric artery ligation (BHAL)) as a first line of surgical treatment of PPH is about 60 % to 70 % (EL4). Bilateral uterine artery ligation (BUAL) is easy to perform with low rate of immediate severe complication (professional consensus). BUAL as BHAL seems not to affected fertility and obstetrical outcomes of next pregnancies (EL4). Efficacy of haemostatics brace suturing in case of failed medical treatment of PPH is about 75 % (EL3), without risk of major obstetrical complications at the next pregnancy (EL4). Radical surgical treatment of PPH: total hysterectomy is not significantly associated with more urinary tract injury in comparison with subtotal hysterectomy (EL3). Choice of surgical procedure of hysterectomy (total or subtotal) will depend on local consideration and clinicians habits (professional consensus). Surgical strategy: conservative surgical treatment are efficient and associated with low morbidity, they have to be primarily performed in women with further fertility desire. Specific medical consideration as massive PPH or cardiovascular instability has to consider performing haemostatic hysterectomy as the first line surgical treatment of PPH. PPH during caesarean delivery: in case of PPH during caesarean section, embolisation is not recommended, surgical treatment using vascular devascularisation or compression brace suturing should be performed (professional consensus). Surgical conservative technique will depend on local considerations and clinicians habits (professional consensus). PPH diagnosed after caesarean section should indicate relaparotomy. Arterial embolisation, if quickly vacant in the same hospital, may be performed in case of cardiovascular stability without surgical complication diagnoses on intraperitoneal hemorrhage (professional consensus). PPH during vaginal delivery: cardiovascular instability centre indicate the interhospital transfer and must lead to achieve haemostatic surgery on site (professional consensus). In the presence of a unit of embolisation in the maternity delivery, it is preferable to move towards embolisation, if maternal hemodynamic status permits (professional consensus). In case of cardiovascular stability associated with absence of heavy bleeding, the interhospital transfer may be considered for arterial embolisation (professional consensus). CONCLUSION: When medical treatment of PPH failed, conservative surgical treatment has a 70 % efficacy to stop hemorrhage whatever treatment used (vascular ligature or haemostatics brace suturing). In absence of rapid response to conservative medical and surgical treatment, hysterectomy should be performed without delay (professional consensus).

Fetal skeletal computed tomography: when? How? Why?

PURPOSE: To study the additional role of fetal skeletal computed tomography in suspected prenatal bone abnormalities. MATERIALS AND METHODS: Two centers included in a retrospective study all fetuses who benefited from skeletal computed tomography for a suspected constitutional bone disease or focal dysostosis. RESULTS: A total of 198 patients were included. CT was performed in 112 patients (56%) for an isolated short femur below the third percentile (group A), in 15 patients (8%) for bowed or fractured femur (group B), in 23 patients (12%) for biometric discrepancy between a short femur and increased head circumference (group C) and in 48 patients (24%) for suspected focal dysostosis (group D). CT was interpreted as normal in 126 cases (64%), i.e. 87% in group A, 0% in group B, 65% in group C and 25% in group D. When including only cases with postnatal or postmortem clinical and/or radiological confirmation was available, CT provided additional and/or more accurate information than ultrasound in 20% of cases in group A, 66% in group B, 30% in group C and 72% in group D. Sixty-seven percent of patients in whom CT was interpreted as normal were lost to follow-up. CONCLUSION: In isolated short femur, fetal skeletal CT is normal in the great majority of cases although protocolized follow-up of these babies is absolutely compulsory, as a large proportion is lost to follow-up. Fetal skeletal CT can confirm or improve imaging for the suspected diagnosis in suspected focal dysostosis or constitutional bone disease.

[Comparative study of patients with placenta accreta with or without a history of cesarean section]. / Étude comparative des patientes présentant un placenta accreta avec ou sans antécédent de césarienne.

OBJECTIVE: To evaluate characteristics of placenta accreta (PA) in patients without previous cesarean section. MATERIAL AND METHODS: Retrospective cohort study from December 1993 to April 2010 in two departments of obstetrics in university hospitals, Marseille, France. Comparison of clinical characteristics, circumstances of diagnosis, maternal morbidity and treatment was performed between PA diagnosed in patients with (n=63) and without prior cesarean section (n=35). RESULTS: In group of patients without previous caesarean section, rate of placenta praevia, and antenatal diagnosis were lower (16/35 [46 %] vs. 44/63 [70 %], [P: 0.02]) and (4/35 [11 %] vs. 28/63 [44 %], [P<0.001]) and rate of pregnancies obtained by IVF was higher (5/35 [15 %] vs. 2/63 [3 %], [P=0.05]). In this group, no hysterectomy was performed but risk of uterus necrosis following embolization was increased (3/35 [8.6 %] patients vs. 0/63 patients [P: 0.02]). CONCLUSIONS: Patients without previous caesarean section have specific characteristics in terms of risk factor and of management.