Low-dose aspirin to prevent preeclampsia and growth restriction in nulliparous women identified by uterine artery Doppler as at high risk of preeclampsia: A double blinded randomized placebo-controlled trial.

INTRODUCTION: This trial evaluates whether daily low-dose aspirin initiated before 16 weeks of gestation can reduce preeclampsia and fetal growth restriction in nulliparous women identified by first-trimester uterine artery Dopplers as at high risk of preeclampsia. METHODS: This randomized, blinded, placebo-controlled, parallel-group trial took place in 17 French obstetric departments providing antenatal care. Pregnant nulliparous women aged ≥ 18 years with a singleton pregnancy at a gestational age < 16 weeks of gestation with a lowest pulsatility index ≥ 1.7 or a bilateral protodiastolic notching for both uterine arteries on an ultrasound performed between 11+0 and 13+6 weeks by a certified sonographer were randomized at a 1:1 ratio to 160 mg of low-dose aspirin or to placebo to be taken daily from inclusion to their 34th week of gestation. The main outcome was preeclampsia or a birthweight ≤ 5th percentile. Other outcomes included preeclampsia, severe preeclampsia, preterm preeclampsia, preterm delivery before 34 weeks, mode of delivery, type of anesthesia, birthweight ≤ 5th percentile and perinatal death. RESULTS: The trial was interrupted due to recruiting difficulties. Between June 2012 and June 2016, 1104 women were randomized, two withdrew consent, and two had terminations of pregnancies. Preeclampsia or a birthweight ≤ 5th percentile occurred in 88 (16.0%) women in the low-dose aspirin group and in 79 (14.4%) in the placebo group (proportion difference 1.6 [-2.6; 5.9] p = 0.45). The two groups did not differ significantly for the secondary outcomes. CONCLUSION: Low-dose aspirin was not associated with a lower rate of either preeclampsia or birthweight ≤ 5th percentile in women identified by their first-trimester uterine artery Doppler as at high risk of preeclampsia. TRIAL REGISTRATION: (NCT0172946).

Diagnosis and management of placenta previa and low placental implantation.

Objective: To evaluate the migration of low-placental implantation (LPI) during the third trimester of pregnancy and its effect on delivery and post-partum hemorrhage.Methods: We conducted a retrospective study at a level 3 maternity center including all cases of placenta previa (PP) and LPI between 1998 and 2014. The distance (d) between cervical internal os (CIO) and placental edge (PE) were measured by vaginal ultrasonography in the third trimester of pregnancy at 32 and 3 weeks after. We analyzed CIO-PE distance, volume of post-partum hemorrhage, delivery decision, and mode of delivery using Kruskall-Wallis test.Results: In total, 319 patients presented with PP or LPI. All complete PP (121) and 90.6% (58 of 64) of the placentas less than 1 cm from the CIO did not migrate. Among the 138 placentas with an initial CIO-PE d greater than 1 cm, only 17 (12.3%) did not migrate above 2 cm. The patients for whom the decision to perform a cesarean section (C-section) was retained and realized had a CIO-PE d significantly lower than those who delivered vaginally (p < .001). The patients who delivered by C-section had a lower CIO-PE d when an emergency C-section was performed, specifically for hemorrhage (p < .001). The mean volume of hemorrhage was significantly higher for patients with a CIO-PE d less than 2 cm.Conclusion: Complete PP and the majority of the placentas less than 1 cm from the CIO did not migrate. Above 1 cm, the majority of the placentas migrated three to four weeks later. For the placentas less than 1 cm from the CIO, a significant risk of hemorrhage at delivery was observed. Thus, prophylactic cesarean section is required for CIO-PE distances <1 cm. For distances between 1 and 2 cm, the volume of blood loss tends to be more important than for distances >3 cm without statistical significance. A vaginal delivery could be tried after information of patients.

Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment.

OBJECTIVE: The purpose of this study was to evaluate the efficiency and morbidity of multiple square sutures in severe postpartum hemorrhage. STUDY DESIGN: A retrospective study encompassed 30 multiple square sutures that were performed for severe postpartum hemorrhage in 26,605 deliveries in a tertiary maternity center. The main outcome measures were the ability to stop hemorrhage and the assessment of the uterine cavity by hysteroscopy at 3 months. RESULTS: Multiple square sutures stopped postpartum hemorrhage in 28 of 30 cases (93%). Twenty women underwent hysteroscopy after multiple square sutures. Eight women (40%) did not have intrauterine adhesions. Nine women (45%) had thin and localized intrauterine adhesions that were removed easily by the tip of the hysteroscope; 2 women had moderate intrauterine adhesions that were resected. One patient had endometritis followed by severe intrauterine adhesions. CONCLUSION: Multiple square sutures are effective and safe for the control of severe postpartum hemorrhage and for uterine conservation in most cases. Although some patients had moderate or severe adhesions, a normal uterine cavity or minimal intrauterine adhesions that were removed easily were the most frequent findings at hysteroscopy. A prospective study may be helpful to compare the safety and efficiency of square and brace sutures.