[Predictive factors of 2-month postpartum anal incontinence among patients with an obstetrical anal sphincter injury]. / Facteurs pronostiques d'incontinence anale à 2 mois du post-partum après survenue d'un périnée complet.

OBJECTIVES: To determine prevalence of short-term postpartum anal incontinence after obstetrical anal sphincter injury and prognostic factors. MATERIALS AND METHODS: Retrospective study including every patient with an obstetrical anal sphincter injury between January 2006 and December 2012 in one tertiary maternity unit. Patients were interviewed and examined at 2-month postpartum. Anal incontinence was defined by the presence of at least one of the following symptoms: flatus incontinence, faecal incontinence and faecal urgency. RESULTS: Among 17,110 patients who delivered vaginally during period study, 134 (0.8%) presented an anal sphincter injury. Postpartum obstetrical data were available for 110 of them. Among those patients, 50 women (45.5%) had at least one symptom of anal incontinence at 2-month postpartum and 8 (7.3%) had faecal incontinence. Only maternal age and second stage duration were significantly associated with anal incontinence after obstetrical anal sphincter injury. The degree of sphincter damage at delivery (IIIa, b, c, IV) was not associated with the risk of anal incontinence at 2-month postpartum. CONCLUSION: Maternal age and second stage duration were the only risk factor for anal incontinence after obstetrical anal sphincter injury in this study. High prevalence of anal incontinence at 2-month postpartum of obstetrical anal sphincter injury is observed no matter what is the degree of anal sphincter damage. Our results highlight the importance to diagnose all obstetrical anal sphincter injuries whatever the degree of damage.

[Maternal effects of prolonged expulsive efforts]. / Conséquences maternelles de la prolongation des efforts expulsifs.

OBJECTIVE: Some studies found an association between duration of expulsive efforts (DEE) and risk of postpartum haemorrhage (PPH). But none demonstrated an association between DEE and severe perineal lacerations. Our aim was to evaluate the impact of prolonged expulsive efforts (EE) beyond 45min on the risk of maternal complication, especially risk of severe perineal laceration. MATERIALS AND METHODS: We performed a retrospective study comparing 2 groups, 1: women with an instrumental vaginal delivery performed before 45min for non-fetal progression without FHR abnormalities (VBI for NP<45min) and 2: women with a DEE longer than 45min (DEE≥45min). We compared maternal issues (3rd and 4th degrees perineal lacerations and PPH), using uni- and multivariate analysis. RESULTS: We compared 85 women in group VBI for NP<45min with 124 women in group EE≥45min. In the group EE≥45min, 39% of women had an instrumental vaginal delivery versus 100% in the group VBI for NP<45min (P<0.001). The rate of severe perineal lacerations was significantly higher in the group VBI for NP<45min (8.2% versus 1.7%, P=0.027) and its risk remained significant after adjustment (adjusted OR=6.5 [1.1-40.1]). The rate of PPH was higher in the group EE≥45min (12.9% versus 3.5%, P=0.016), however this association was not significant after adjustment (adjusted OR=3.4 [0.9-12.4]). There was no difference about neonatal issues between the two studied groups. CONCLUSION: In comparison with a limitation of EE, to prolong EE beyond 45min allows a spontaneous vaginal delivery for more than half of women, if FHR is normal. Such strategy should also decrease the risk of severe perineal laceration.

[Recurrent pregnancy losses: Etiological considerations and investigations, the point of view of the obstetrician-gynecologist]. / Pertes de grossesse à répétition : étiologies et bilan, le point de vue du gynécologue-obstétricien.

Pregnancy loss is a general term including distinct well-defined entities: early miscarriage, late miscarriage, and stillbirth. It is important to clarify fetal loss circumstances to guide the diagnostic assessment of this issue. Etiological considerations in the presence of a fetal loss are very important to find the causes where a treatment exists and is efficient. The aim is also to explain to the couple, very affected by the event, the reason of the fetal loss and the potential risk of recurrence in a future pregnancy. In recent years, international guidelines changed and assessment of familial thrombophilia seems to be useless in this context. Feedback of the investigations will be better in a preconception consultation and multidisciplinary management of these couples is important for both therapeutic and psychological cares.

[What is new about obstetrical interventions during labor and normal delivery?]. / Quoi de neuf concernant les interventions obstétricales lors du travail et de l'accouchement normal ?

This systematic review of the literature reports studies published over the last five years (2008-2013) about interventions during labor and normal delivery. The points made concerning active management of labor, interventions aimed at improving maternal comfort, management of occiput posterior fetal presentations, management of second stage of labor and prevention techniques for perineal lesions. Although obstetrics remains an "art" to which training is mainly based on experience and clinical expertise, this "art" at present cannot live without the evidence-based medicine. Numerous randomized trials published and in process, demonstrate awareness of this reality in our specialty.