[MAVRIC study: when abdominal cerclage is preferable to vaginal cerclage]. / Étude MAVRIC: quand le cerclage par voie abdominale est préférable à la voie vaginale.

Vaginal cerclage can be used to treat cervical incompetence, thus reducing the risk of an unfavourable outcome. However, in some cases, it can be ineffective. One of the challenges for the gynaecologist-obstetrician is how to deal with a subsequent pregnancy after a failure of vaginal cerclage. The recently published MAVRIC study shows that performing abdominal cerclage prior or at the beginning of pregnancy reduces the rate of late miscarriage and premature delivery compared to vaginal cerclage. This implies a birth by caesarean section, and therefore a second surgery for the woman. However, it remains to determine the best surgical technique for abdominal cerclage. In the MAVIRC study, cerclage was done by laparotomy. It shall be elucidated whether this technique is superior to laparoscopy.

Le cerclage par voie vaginale permet de pallier une incompétence cervicale, diminuant ainsi le risque d'issues défavorables. Néanmoins, il peut s'avérer inefficace. Un des enjeux pour le gynécologue-obstétricien est de savoir quelle attitude adopter lors d'une grossesse suivante après échec de cerclage vaginal. L'étude MAVRIC, publiée récemment, apporte la preuve que la réalisation d'un cerclage par voie abdominale avant ou en début de grossesse permet une diminution du taux de fausse couche tardive et d'accouchement prématuré par rapport à la voie vaginale. Ceci implique une naissance par césarienne, et donc une deuxième intervention pour la femme. Il reste encore à déterminer le choix de la technique chirurgicale du cerclage abdominal. L'abord par laparotomie ayant été utilisé pour l'étude MAVRIC, il reste à montrer si cette approche est supérieure à la laparoscopie.

Impact of the new guidelines on the management of premature rupture of membranes for the prevention of late preterm birth: an 11-year retrospective study.

Objectives To evaluate the number of late preterm (LPT) births (between 34 0/7 and 36 6/7 weeks) that could have been prevented if expectant management of preterm premature rupture of membranes (PPROM) had been applied according to new recommendations. Methods A retrospective cohort study included all births at one Swiss center between January 1, 2002 and December 31, 2012. Births were categorized using an adapted evidence-based classification. Two scenarios were considered: best scenario (maximum averted cases) and a conservative scenario (minimum averted cases). Results Among 2017 LPT births (5.0% of all deliveries; n=40,609), 1122 (60.6%) women had PPROM. Spontaneous labor occurred in 473 (42.2%) cases and 649 (57.8%) had induction of labor or an elective cesarean section. In the latter group, 44 (6.8%) had evidence-based indications for LPT delivery and 605 (83.2%) had non-evidence-based indications. Depending on the scenario, the rate of avoided LPT cases would have varied between 4.2% (95% confidence interval [CI]: 3.4-5.2) if the conservative scenario was applied, and 30% (95% CI: 28.0-32.0) for the best scenario. Conclusion Adoption of new guidelines for the management of PPROM will prevent a considerable number of LPT births and help decrease the adverse effects and potential disability associated with late preterm infants.

[Obstetrics]. / Obstétrique.

During the past year, we have renewed interest in old well-known problems. New studies and guidelines have been issued about lung maturation in cases of preterm delivery after 37 weeks of gestation. Short term benefits have been proven but the number of cases needed to treat to prevent one case of respiratory complications is high and with possible neurological long-term effects. Also, several studies have shown the benefits of including the ultrasound measurement of the inferior segment of the uterus in order to attempt vaginal delivery after caesarean section with the lowest risk for uterine rupture, while others studies have shown the best procedure to close the uterus during cesarean section. And finally, we will discuss about an old friend: aspirin to reduce the risk of pre-eclampsia.

Au cours de l'année écoulée, l'intérêt pour de vieux problèmes bien connus de notre spécialité médicale a été renouvelé. De nouvelles études et lignes directrices ont été publiées concernant la maturation pulmonaire en cas d'accouchement prématuré après 37 semaines de gestation. Bien qu'un bénéfice à court terme ait été prouvé, le nombre de cas à traiter pour prévenir une complication respiratoire néonatale est élevé, avec des effets neurologiques potentiels à long terme. Afin de promouvoir la tentative d'accouchement vaginal après césarienne sans augmenter le risque de rupture utérine, différents travaux indiquent qu'il faut intégrer la mesure du segment inférieur de l'utérus dans la discussion de la voie d'accouchement. D'autres ont montré la meilleure procédure pour fermer l'utérus pendant la césarienne. Enfin, nous allons parler d'une vieille amie : l'aspirine pour réduire le risque de prééclampsie.

Avoiding late preterm deliveries to reduce neonatal complications: an 11-year cohort study.

BACKGROUND: Late preterm (LPT) newborns, defined as those born between 34 0/7 and 36 6/7 gestational weeks, have higher short- and long-term morbidity and mortality than term infants (≥37 weeks). A categorization to justify a non-spontaneous LPT delivery has been proposed to distinguish evidence-based from non-evidence-based criteria. This study aims to describe rates and temporal trends of non-spontaneous LPT neonates delivered according to evidence-based or non-evidence-based criteria and to evaluate the number of avoidable LPT deliveries, including severe neonatal morbidity rates and associated risk factors. METHODS: Retrospective cohort study including all LPT neonates born at a Swiss university maternity unit between January 1, 2002 and December 31, 2012. Trends of LPT neonates and neonatal complications were assessed across time using Poisson regression and risk factors for neonatal complications by logistic regression. RESULTS: Among 40,609 singleton live births, 4223 (10.5%) were preterm and 2017 (4.9%) LPT. In the latter group, 26.2% were non-spontaneous (evidence-based: 12.0%; non-evidence-based: 14.2%). The most frequent indications for evidence-based non-spontaneous LPT delivery were severe preeclampsia (51.8%) and abnormal fetal tracing (24.7%). Indications for non-evidence-based non-spontaneous LPT deliveries were hemorrhage (36.2%) and mild preeclampsia (15.7%). LPT birth rates remained stable over time. The rate of neonatal complications after non-evidence-based LPT birth remained high over time (43.8% vs. 43.5% in 2002 and 2012, respectively; P = 0.645), whereas the annual proportion of neonatal complications overall showed a decreasing trend (from 38.0% in 2002 to 33.5% in 2012; P = 0.051). CONCLUSIONS: LPT birth rates were stable over time, but neonatal complications remained high, particularly after non-evidence-indicated LPT birth. A total of 287 LPT births could have been potentially avoided if an evidence-based protocol for delivery indications had been used. Efforts should be made to avoid non-spontaneous LPT births in order to reduce neonatal complications.