[Induction of labor in women with previous caesarean delivery with balloon catheter: Is it worth it?] / Déclenchement par ballonnet en cas d'utérus cicatriciel et col défavorable : la tentative en vaut-elle la chandelle ?

OBJECTIF: Balloon catheters for labor induction at term after previous cesarean section is an alternative option to iterative cesarean section. The aim of this study was to analyze the maternal and neonatal outcomes of the trial of labor after cesarean (TOLAC) in women with unfavorable cervix and balloon catheter induction, 2 years after introduction of this process. METHODS: Unicentric observational study of women with term cephalic singleton, unfavorable cervix (simplified Bishop score<5) after TOLAC using double-balloon catheter. Were analyzed the mode of delivery and severe maternal (uterine rupture, post-partum hemorrhage, severe perineal tears) and neonatal (neonatal unit admission, APGAR<7 at 5minutes, pH<7.1) outcomes. Predictive factors for failed TOLAC were analyzed by using multivariate logistic regression. RESULTS: Between 2016-2017, 455 (75.4%) women had TOLAC, whose 59 (13%) women with balloon catheter. The overall vaginal delivery (VD) was 73.9%. After Balloon catheter, the VD rate was 50.8%, versus 79.1% after spontaneous labor, and 68.2% after alone oxytocin/artificial membrane rupture induction (P<0.05). Previous VD (aOR 0.176 CI-95% [0.048-0.651]) and prior sweeping membrane (aOR 0.161 CI-95% [0.034-0.761]) was protective for cesarean section after TOLAC. Severe maternal and neonatal morbidities were observed in 10 (17%) and 8 (13.6%) cases, respectively. CONCLUSION: Double-Balloon catheter is an option for unfavorable cervix and term induction after previous cesarean section. However, the TOLAC in women whose unfavorable cervix is not without maternal and neonatal risk, especially due to its failure.

Is episiotomy worthwile to prevent obstetric anal sphincter injury during operative vaginal delivery in nulliparous women?

OBJECTIVES: Episiotomy is a marker of Obstetric Anal Sphincter Injury (OASIS) condition, therefore, unmeasured factors could have biased the strength of the association between episiotomy and reduced OASIS during Operative Vaginal Delivery (OVD). The aim of this study was to compare the OASIS rate during OVD according to episiotomy practice. STUDY DESIGN: Retrospective cohort study of all nulliparous pregnant women attempting an OVD between 2014-2017. To avoid unmeasured bias, all maternal and delivery data were prospectively captured after the birth. The strong relationship between parity and episiotomy practice (indication bias) lead to analyze only nulliparous women. Association between mediolateral episiotomy and OASIS following OVD was performing by using multivariate logistic regression analysis including significant variable in univariate analysis and relevant factors known to be associated both with OASIS and/or OVD. RESULTS: Over the study period, 1709 (17.1%) women had an OVD, among them 40 (2.3%) had OASIS. In the 1342 (78.5%) nulliparous women, OASIS rate were 2% and 5.1% with and without episiotomy (p < 0.01). In multivariate analysis a lower incidence of OASIS with the use of episiotomy (OR 0.267 IC 0.132-0.541) were observed. The persistent occiput posterior position was associated with an increase risk of OASIS (OR 6.742 IC 2.376-19.124). Spatula/forceps, as compared to vacuum operative vaginal delivery increased the risk OASIS (OR 2.847 IC 1.311-7.168). Area under the curve of the model was 0.745. CONCLUSION: Episiotomy is a modifiable risk factors which can contribute to reduce the risk of OASIS in nulliparous women with operative vaginal delivery. This intervention should be included in a global management of the second stage of labor.

Delivery outcomes of term pregnancy complicated by idiopathic polyhydramnios.

OBJECTIVE: Polyhydramnios is associated with an increased risk of cesarean section. The aetiology of polyhydramnios and the characteristics of the labour may be confounding factors. The objective was to study the characteristics and mode of delivery in case of pregnancy complicated with idiopathic polyhydramnios. METHODS: This retrospective matched and controlled study included all pregnant women with idiopathic polyhydramnios (amniotic index>25cm or single deepest pocket>8cm) diagnosed at the 2nd or 3rd trimester and persistent at term delivery (>37weeks of pregnancy) in our institution. We excluded pregnancies in which the polyhydramnios could be explained by infection, gestational diabetes, congenital malformation, abnormal karyotype, placental anomalies, alloimmunization as well as pregnancies in which an amniocentesis for the purpose of diagnosis had not been performed. Data were gathered from a tertiary care university hospital register from 1998-2015. Cases of polyhydramnios were matched with the following two women who presented for labour management with spontaneous cephalic presentation, matching for delivery date, maternal age, parity, body mass index. The main outcome measure was the risk of cesarean section. Univariate and multivariate adjusted analysis were performed. RESULTS: We identified 108 women with idiopathic polyhydramnios and compared them with 216 matched women. Among them, 94 and 188 attempted a trial of labour. Maternal age, mean term delivery and birthweight were 31 years, 39+5weeks gestation and 3550 g. We did not observe differences in maternal characteristics, epidural analgesia and rate of abnormal fetal heart tracing. Induced labour and non-vertex presentations (forehead, bregma, face) were more frequent in the polyhydramnios group (respectively 57.9% versus 27.8%, P<0.05 and 7.8% versus 1%, P<0.05). Cesarean section rate was higher in the case of polyhydramnios in the overall population (45.4% versus 8%, P<0.05) and remained higher after exclusion of cases of induced labour and non-vertex presentation (38.4% versus 3.8%, P<0.05). Amniotomy was more frequent in pregnancies with polyhydramnios (55.8% versus 39.1%, P<0.05). After adjustment for matching and confounding variables, polyhydramnios was found to be a risk factor for cesarean section (OR 21.02; CI 95% 8.004-55.215, P<0.01). CONCLUSION: Idiopathic polyhydramnios increased the risk of prolonged first stage of labour, non-vertex presentation and cesarean section.

Bartholin gland abscess during pregnancy: Report on 40 patients.

OBJECTIVE(S): To study the clinical and bacterial characteristic of Bartholin gland abscesses during pregnancy and the obstetric and neonatal outcomes. STUDY DESIGN: Retrospective cohort study of all patients with surgical treatment of Bartholin gland abscesses between 2004 and 2015 in our university center. Clinical and bacterial characteristics between pregnant and non-pregnant women were compared. RESULTS: During the period study, 156 patients were included (40 pregnant and 116 non pregnant). The incidence of Bartholin gland abscesses during pregnancy was 0.13%. Eight (20%) abscesses occurred in the first, 18 (45%) in the second, 11 (47.5%) in the third trimester and 3 (7.5%) in the post-partum course. No severe perineal and neonatal infections occurred during pregnancy. One late miscarriage and one preterm delivery were observed. We found more multiparity in the pregnant woman group than in non-pregnant women (62.5% versus 45%, p<0.05). A history of Bartholin gland abscesses were also more frequent in pregnant women (55% versus 30.1%, p<0.05). First line antibiotic therapy was more frequent in non-pregnant women (20% versus 45%, p<0.05). The rate of positive culture did not differ between the two groups (70% versus 55.2%). Among negative pus cultures, no patient in the pregnant woman group had received a first line antibiotic therapy, in contrast with non-pregnant women (0% versus 25%, p<0.05). E. coli was the most common pathogen in the two groups (48.9% of positive cultures and 28.2% of the overall population). The distribution of bacterial taxa was not different between the two groups. CONCLUSION: Bacterial characteristics did not differ from non-pregnant women. Pregnancy could increase the occurrence of Bartholin gland abscesses in patients with previous surgical treatment of abscesses. When appropriate management is applied, maternal and neonatal outcomes are favorable, and severe infections are not to be expected.

Obesity in laparoscopic surgery.

Since the 1980s, minimally invasive techniques have been applied to an increasing number and variety of surgical procedures with a gradual increase in the complexity of procedures being successfully performed laparoscopically. In the past, obesity was considered a contraindication to laparoscopy due to the higher risk of co-morbid conditions such as diabetes, hypertension, coronary artery disease and venous thromboembolism. Performing laparoscopic gynaecological procedures in morbidly obese patients is no longer a rare phenomenon; however, it does necessitate changes in clinical practice patterns. Understanding of the physiological changes induced by laparoscopy, particularly in obese patients, is important so that these may be counteracted and adverse outcomes avoided. Laparoscopy in obese patients confers certain advantages such as shorter hospital stay, less post-operative pain and fewer wound infections. In addition to these benefits, minimal-access surgery has been demonstrated as safe and effective in obese patients; however, specific surgical strategies and operative techniques may need to be adopted.

[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.