[Management of side effects under hormonal replacement therapy in menopausal women: Abnormal uterine bleeding. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. / La gestion des effets secondaires sous traitement hormonal de la ménopause : saignements utérins anormaux. RPC Les femmes ménopausées du CNGOF et du GEMVi.

OBJECTIVES: To publish, under the aegis of the French National College of Gynecologists and Obstetricians (CNGOF) and the Study Group on Menopause and Hormonal Aging (GEMVi), recommendations based on the evidence available in the literature for the management of abnormal uterine bleeding (AUB) in women taking hormonal replacement therapy (HRT). A review of the literature was performed by consulting Medline, Cochrane Library data as well as international recommendations in French and English up to September 1, 2020. RESULTS: AUB occurring in a woman taking HRT (FIGO 2011) is one of the main factors of poor adherence to the HRT. AUB must seek an organic cause including endometrial cancer. The main functional causes of AUB in a woman taking HRT are resumption of ovarian activity, poor compliance, and trophic disorders of the endometrium. AUB are dependent on the type of HRT. In the event of AUB under HRT, it is suggested to perform a pelvic ultrasound at the end of the progestational sequence in the event of sequential HRT. In a single episode of AUB and when the ultrasound estimates the endometrial thickness less than or equal to 4mm, it is possible to postpone further uterine exploration. In case of recurrent AUB or when the endometrium thickness is greater than 4mm in a postmenopausal woman, additional uterine investigations (hysteroscopy and histology) are recommended. CONCLUSION: AUB under HRT must seek an organic cause. The measurement of endometrial thickness by pelvic ultrasound is relevant for screening for endometrial cancer.

Two miscarriages, consecutive or non-consecutive, does it change something?

OBJECTIVES: To assess the rate of anomalies in the etiological evaluation of patients presenting recurrent early miscarriages (RM) according to miscarriage chronology (number of miscarriages, history of live birth and succession of RM). METHODS: Retrospective single centre study including RM, defined as at least 2 miscarriages at less than 14 weeks of gestation (WG) between the 1st January 2012 and the 31st December 2015. Clinical data and etiological evaluation include blood glucose levels, screening for antiphospholipid syndrome (APS), endocrine assessment, vitamin levels, pelvic imaging, karyotyping of both partners, chronic endometritis and thrombophilia screening. RESULTS: Two hundred and eighty-eight patients were included over this period, 118 (41%) patients had no history of live birth. Two hundred and twenty-three (77%) patients had consecutive RM and 65 (22%) patients had non-consecutive RM. For consecutive RM, 62,8% had thrombophilic disorders versus 69,8% for non-consecutive RM (P>0,05); 44,7% had endocrine disorders or vitamin deficiencies versus 39,7%; 34,6% of patients with consecutive RM had uterine anomalies versus 45,5% respectively. No difference was found depending on the recurrence of RM or the history of live birth (P>0.05) apart from the age of the patient. Fifty-nine (17.4%) patients had uterine anomalies. There are 24 chronic endometritis on 31 biospsies performed. Seventy-eight (27%) patients were offered treatment. Ninety-four (90%) patients showed good therapy compliance. Eighty-one (78%) patients became pregnant. CONCLUSION: An etiological evaluation provides, for over half of the cases, an etiology or the identification of risk factors responsible for RM, as well as in some cases offering an adapted, efficient, therapeutic approach. This evaluation should be offered regardless of the obstetric history of the patient.

[Feasibility of outpatient laparoscopic sacrocolpopexy surgery: A pilot study]. / Étude pilote de faisabilité de la promontofixation cœlioscopique en ambulatoire.

OBJECTIVE: To evaluate the feasibility of outpatient laparoscopic sacrocolpopexy surgery. METHODS: A prospective analysis was carried out in one center from May 2014 to July 2015. The main outcome was the success of day care, meaning no hospitalization, consultation to a doctor or emergency during the first 48h following the surgery. Patients requiring laparoscopic sacrocolpopexy with eligibility for day care were included. The patients were not included if they didn't match to the administrative or medical criteria of ambulatory, or if they refused ambulatory surgery. The postoperative consultation was 1 month after surgery, the satisfaction was assessed by phone call two months after surgery. RESULTS: We included 14 patients during the study. One patient stayed the night (7.1%). The median operative time of the surgery was 95minutes (70-168minutes), no complication occurred. Ten patients of 13 (76.9%) were very satisfied or satisfied of day care. CONCLUSION: With 71% of satisfaction and only one patient who stayed the night, outpatient laparoscopic sacrocolpopexy surgery seems to be feasible. LEVEL OF EVIDENCE: 4.

[Parental project of general medicine residents from Aix-Marseille university: Theoretical knowledge in reproduction and behavior towards parenting]. / Projet parental des internes de médecine générale d'Aix-Marseille université : connaissances théoriques en reproduction et attitude vis-à-vis de la parentalité.

OBJECTIVES: Analyze residents' intentions about parenting and knowledge about fertility, as well as their alleged behavior towards a diagnosis of diminished ovarian reserve. MATERIALS AND METHODS: Prospective study with distribution of self-administered questionnaire to residents of Aix-Marseille university from June to September 2015. The questionnaire was composed of a first descriptive part including generic and personal informations about the residents and their intentions towards parenting. The second part was a 9 questions survey aimed at testing their knowledge about fertility and ovarian reserve and a final question placing them in a situation of a diminished ovarian reserve diagnosis in order to analyze their reactions. RESULTS: The overall participation rate was 53.2%, including 220 women with an average age of 27 years (SD: 1.8 years) and 116 men with an average age of 27.3 years (SD: 2.2 years). The 11.8% of female residents (n=26) already had one or more children vs.6.9% of male residents (n=8). Among the residents without children, 99% of females (n=192) and 91.7% of males (n=99) said they wanted to have children in the future, planning an average age to have their first child of 29.6 years (SD: 1.9 years) for females and 30.4 years (SD: 2.2 years) for men. Moreover, 58.3% of female residents (n=112) and 53.5% of male residents (n=53) reported that they were postponing their plan to have children after the completion of their medical studies. In a simulation of couples facing a diagnosis of diminished ovarian reserve, 73.6% of females and 61.2% of males would be ready to change their life choices and conceive a baby sooner than originally planned. CONCLUSION: Almost all the general medicine residents have plannedto have children in the future and more than half of them postpone their parental plan after the end of their residency, although the decline of female fertility in relation to aging is widely known among them.

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.

[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.

[Impact of the loop electrosurgical excision procedure for cervical dysplasia on sexual function]. / Impact de la conisation cervicale à l'anse diathermique sur la qualité de vie sexuelle.

OBJECTIVE: To assess the consequences of loop electrosurgical excision procedure (LEEP) on the quality of sexual life. MATERIAL AND METHODS: A prospective observational study in two university hospital departments in Marseille, France, including women requiring a LEEP. Sexual quality of life was assessed before LEEP and three months after the procedure with a self-administered validated questionnaire: the Brief Index of Sexual Functioning for Women (BISF-W). RESULTS: Among the 100 women included, 69 filled both questionnaires. Among the 69 women whose outcomes were available, composite BISF-W score was significantly lower before LEEP than three months after LEEP (28.3±13 vs 30.1±13.2; P=0.01). The items scores concerning desire (D1) and orgasm (D5) were significantly improved after LEEP (4.3±2.3 vs 5±2.2 [P<0.001] and 4.3±2.5 vs 4.7±2.6 [P<0.001]). CONCLUSIONS: This study found an improved quality of sexual life after LEEP. These findings suggest that the psychological impact of HPV infection on sexual function is greater than the anatomical and functional impact of LEEP.

[Evaluation of practices of excisional therapies for CIN: An audit of surgery rooms from Marseilles' area]. / Évaluation des modalités de réalisation des conisations pour le traitement des CIN : enquête auprès des blocs opératoires de la région PACA.

OBJECTIVE: To evaluate what is the proportion of surgery rooms from Marseilles' area that do perform excisional therapies for CIN without any use of colposcopic guidance. MATERIALS AND METHODS: From November 2012 to January 2013, a survey was conducted among all surgery rooms from Marseilles' area practicing excisional therapies for CIN. In addition, answers from gynecologists from Marseilles' area who participated to a national survey that evaluated practices of excisional therapies in France were specifically analyzed. RESULTS: Among the 55 surgery rooms from Marseilles' area practicing excisional therapies, 52 (94.1%) participated to the current survey. A colposcope was available in only 19 (36.5%) surgery rooms and was systematically used for the guidance of excisional therapies in only 4 (21%) of these surgery rooms. Finally, 36 (69.2%) surgery rooms answered performing excisional therapies without any use of colposcopic guidance. Colposcopy was occasionally and systematically used in 12 (23.1%) and 4 (7.7%) surgery rooms, respectively. Among the 116 gynecologists from Marseilles' area who answered to the national survey, 88 (75.9%) answered not using colposcopy when performing excision for CIN. Only 6% answered performing excision systematically under direct colposcopic vision and 18.1% occasionally. CONCLUSION: No colposcopic guidance is used when performing excision for CIN in the majority of surgery rooms from Marseilles' area.

[How are excisional therapies for CIN performed in France? A national audit]. / Comment les traitements d'exérèse des CIN sont-ils réalisés en France ? Une enquête nationale.

OBJECTIVES: Evaluate how excisional therapies are performed in France and if colposcopy is used for the guidance of excision. MATERIALS AND METHODS: A national survey was performed among French gynecologists using an anonymous online questionnaire. RESULTS: A total of 555 (14.9%) gynecologists participated to the survey, only answers from the 396 (71.3%) who answered practicing excisional therapies for CIN were considered. LLETZ was the most common excisional technique employed (84.9%). Among respondents, 275 (69.3%) answered not using colposcopy at the time of excision, 67 (16.9%) answered performing excisions under naked eye vision immediately after they had performed a colposcopic examination and 52 (13.8%) under direct colposcopic vision. Although initial colposcopic training did not influence the probability to use colposcopy at the time of excision, the probability of performing excisions immediately after a colposcopic examination or under direct colposcopic vision was significantly increased by the monthly practice of 30 or more colposcopic examinations (AOR: 3.34; 95%CI: 1.54-7.26 and AOR: 2.16; 95%CI: 1.08-4.34, respectively) and by the monthly practice of 5 or more excisional therapies (AOR: 3.06; 95%CI: 1.42-6.56 and AOR: 3.03; 95%: 1.54-5.96, respectively). CONCLUSION: Only a minority of French gynecologists uses colposcopy for the guidance of excisional therapies for CIN. Such practice seems to be influenced by the number of colposcopic examinations and of excisions they perform in a month.

[HPV prophylactic vaccine coverage and factors impacting its practice among students and high school students in Marseilles' area]. / Vaccination anti-HPV : évaluation de la couverture vaccinale et des facteurs qui l'influencent chez les lycéennes et étudiantes de la région PACA.

OBJECTIVES: To assess the coverage of HPV vaccine among young women from Marseilles' area and factors influencing the probability of this vaccination. MATERIALS AND METHODS: An anonymous survey was conducted among 2124 high school and university students from Marseilles' area, France from December 2011 to May 2012. RESULTS: Mean age of participants was 20.4years (±SD: 3.3). Only 41.6% participants reported being vaccinated against HPV, of whom 768 (93.3) had completed the 3 injections scheme. Among non-vaccinated respondents, 33.6% acknowledged they would accept a catch-up vaccination. Factors influencing the probability of being vaccinated were young age (AOR: 0.728; 95% CI: 0.681-0.779; P<0.001), socioeconomic and/or education level of parents (AOR: 1.324; 95% CI: 1.006-1.742; P=0.045), information about vaccination (AOR: 24.279; 95% CI: 5.417-108.82; P<0.001) and having a general practitioner (GP) favourable to vaccination (AOR: 68.776; 95% CI: 34.511-137.061; P<0.001). Factors influencing the probability to accept a catch-up vaccination were age (AOR: 1.059; 95% CI: 1.001-1.120; P=0.046), socioeconomic and/or education level of parents (AOR: 1.637; 95% CI: 1.198-2.237; P=0.002) and having a GP favourable to vaccination (AOR: 4.381; 95% CI: 2.978-6.445; P<0.001). Only 35.5% of respondents were aware that screening remains necessary following HPV vaccination. CONCLUSION: The coverage of HPV vaccine among young women from Marseilles' area is insufficient. Factors influencing the probability of being vaccinated against HPV are age, socioeconomic and/or education level of parents and information regarding vaccination. GP plays a major role in the acceptance of HPV vaccine.

[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).

Triple negative breast carcinoma EGFR amplification is not associated with EGFR, Kras or ALK mutations.

BACKGROUND: The amplification of epidermal growth factor receptor (EGFR) in triple negative breast carcinomas (TNBC) suggests its potential therapeutic application, as for HER-2, using standardised methods of measurement. In this regard, we aimed to compare several methods for evaluating EGFR amplification along with potential mutations for suitability in clinical practice. METHODS: Tissue sections of 138 TNBCs were used (1) to compare EGFR amplification and expression by silver in situ hybridisation (SISH) to qPCR and immunohistochemistry (IHC) and (2) to search for EGFR mutations, along with Kras, PI3K, Braf and HER-2 mutations and echinoderm microtubule associated protein like 4-anaplastic lymphoma kinase (EML4-ALK) translocation. RESULTS: (1) Amplification of EGFR was observed in well-characterised TNBCs (up to 92%); (2) qPCR correlated with SISH with 94% specificity and 75.6% sensitivity; (3) IHC correlated with SISH with 97% sensitivity and 78% specificity; (4) no EGFR, Kras mutations or EML4-ALK translocations were found, but PI3K and Braf mutations were observed in 26% of cases; and (5) small, acentric circular extrachromosomal DNA similar to 'double minutes' in glioblastomas was observed in 18% of SISH sections. CONCLUSIONS: SISH and IHC are methods that are suitable in clinical practice to screen for EGFR amplification and overexpression, which are frequently observed in TNBC. Patients with TNBC are potential candidates for EGFR-targeted therapy combined with PI3K and Braf inhibitors.

[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.

[Current and future use of surgical skills simulation in gynecologic resident education: a French national survey]. / Utilisation des simulateurs pour former les internes de chirurgie gynécologique en France : un état des lieux en 2013.

OBJECTIVES: Simulation is a promising method to enhance surgical education in gynecology. The purpose of this study was to provide baseline information on the current use of simulators across French academic schools. MATERIALS AND METHODS: Two questionnaires were created, one specifically for residents and one for professors. Main issues included the type of simulators used and the kind of use made for training purposes. Opinions and agreement about the use of simulators were also asked. RESULTS: Twenty-six percent of residents (258/998) and 24% of professors (29/122) answered the questionnaire. Sixty-five percent of residents (167/258) had experienced simulators. Laparoscopic pelvic-trainers (84%) and sessions on alive pigs (63%) were most commonly used. Residents reported access to simulators most commonly during introductory sessions (51%) and days of academic workshops (38%). Residents believed simulators very useful for training. Professors agreed that simulators should become a required part of residency training, but were less enthusiastic regarding simulation becoming a part of certification for practice. CONCLUSION: Surgical skills simulators are already experienced by a majority of French gynecologic residents. However, the use of these educational tools varies among surgical schools and remains occasional for the majority of residents. There was a strong agreement that simulation technology should be a component of training.

[Litigation in obstetrics and gynaecology: experience of a university hospital in France]. / Analyse de la sinistralité en gynécologie-obstétrique: expérience d'un CHU en France.

OBJECTIVES: To analyse the nature of medico-legal claims in a high-risk speciality. MATERIALS AND METHODS: Retrospective review of the causes of medico-legal disputes at the department of Obstetrics and Gynaecology of the North University Hospital of Marseilles between November 1997 and December 2010. Disputes were defined by complaints, judicial or conciliatory claims and intentional declaration of potential medico-legal case by physicians. RESULTS: Fifty-nine controversial medico-legal cases were identified within this 13-year period. Ninety percent (n=53) of cases concerned obstetrics and 10% (n=6) gynaecology. The rate of litigations tripled in a decade. Half of the litigations led to judicial or conciliatory expertise. The average rate of malpractice litigations was 2.4 per physician. Uterine rupture was the most common cause of complaints. CONCLUSION: Increased awareness of the nature of litigations may help elaborate risk reduction management programs in order to reduce professional liability on the long run.

[Predictive factors for vaginal birth after cesarean section]. / Quels facteurs influencent la voie d'accouchement en cas de tentative de voie basse sur utérus cicatriciel ?

OBJECTIVES: Determination of predictive factors of vaginal delivery in women with a history of caesarean section undergoing a trial of labor. MATERIALS AND METHODS: Relevant studies were identified through Medline, and the Cochrane databases 1980-2012. Recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: In France in 2010, a trial of labor was attempted in 49 % with 75 % successful rate (EL2). The site of delivery does not appear to influence the rate of successful trial of labor (EL3). Two factors are strongly associated with vaginal birth after caesarean (VBAC): prior history of vaginal delivery and spontaneous labor (EL2). Many factors appear to decrease the rate of VBAC: maternal age above 40 years (EL3), body mass index greater than 30 kg/m(2) (EL3), birth weights greater than 4000 g (EL3), unfortunately, prediction of macrosomia seems to be inaccurate. Induction of labor with pharmacological (prostaglandins and oxytocin) and mechanical methods (Foley catheter) decreased rate of successful VBAC (EL2). The use of pelvimetry to accept or avoid trial of labor, increase the risk of elective caesarean section (EL2) and should therefore not be recommended (grade C). Nomograms are not accurate to predict fail trial of labor as its clinical relevance is limited and has not yet evaluated in French population (expert opinion). CONCLUSION: After caesarean, trial of labor is associated with 75 % successful rate. Two factors are strongly associated with VBAC: a prior history of vaginal delivery and spontaneous labor.

Fetal heart disease and interruption of pregnancy: factors influencing the parental decision-making process.

OBJECTIVE: To identify factors influencing parental decision when a fetal cardiac disease is diagnosed. METHOD: All pregnancies with fetal cardiac abnormalities diagnosed at three academic hospitals of Marseille, France, between 2004 and 2008, were retrospectively studied. The association between maternal and fetal variables (maternal age, parity, ethnicity, gestational age at diagnosis, nuchal translucency, fetal gender, chromosomal and extra cardiac abnormalities, and severity of the cardiopathy) and parental decision was tested using univariate and multivariate statistical methods RESULTS: One hundred eighty-eight cases of fetal cardiac disease were analysed, of which 63 were interrupted pregnancies (IP) and 125 continued pregnancies (CP). Four factors were important in the parental decision-making process: the severity of cardiac malformation, the ethnic origin of the parents, the gestational age at diagnosis and the chromosomal abnormalities. CONCLUSION: Counselling of parents following the diagnosis of a congenital heart disease should take into account that, in addition of the severity of the congenital heart disease (CHD), ethnicity, gestational age at diagnosis and chromosomal abnormalities influence parental decision regarding pregnancy continuation or interruption.