[Caesarean risk factors during labor for a class III obese nulliparous]. / Facteurs de risque de césarienne en cours de travail pour la nullipare avec une obésité morbide.

OBJECTIVES: Obesity is a well-known caesarean and obstetrical risk factor. However, the number of obese nulliparous women is increasing worldwide, creating an urgent need for research into the impact of obesity on the mode of delivery. Our objective was to identify caesarean risk factors in obese nulliparous women with a BMI (body mass index) greater than 40kg/m2. METHODS: A literature review was conducted on PubMed; including articles published between 2009 and 2019 in French and English, on caesarean risk during labor among class III obese nulliparous women. RESULTS: One prospective study, and 6 retrospective analyses were included. Their results suggest that the rate of caesarean delivery increases with the BMI. Maternal age, particularly after 35 years, as well as induced labor and the use of oxytocin during labor, were positively associated with cesarean delivery. Moreover, maternal BMI was linked to an increased risk of non-elective caesarean section due to non-reassuring fetal heart tracing. CONCLUSION: Extreme BMI, age, induced labor and oxytocin use are associated with caesarean delivery in nulliparous women with BMI≥40kg/m2. Further research are needed to estimate the best candidates for elective cesarean delivery.

[Maternal morbidity and mortality associated with conservative management for placenta morbidly adherent (accreta) diagnosed during pregnancy. Report of 15 cases]. / Morbimortalité maternelle associée au traitement conservateur d'un placenta anormalement adhérent (accreta) diagnostiqué en anténatal. À propos d'une série continue de 15 cas.

BACKGROUND: High risk of morbidly adherent placenta increased during past years. Their management is controversial. Cesarean hysterectomy, considered the gold standard treatment by American Society, is associated with high risk of maternal morbimortality. Conservative management has been sought to reduce maternal morbidity associated with caesarean hysterectomy while maintaining fertility. It consists of leaving the placenta in place but long-term monitoring. Our main objective was to determine advantage/disadvantage of conservative management on patient with an antenatal diagnosis of placenta accreta, increta or percreta. MATERIAL AND METHODS: This retrospective study included all patients with an antenatal diagnosis of placenta accreta, increta or percreta between 2007 and 2014. Conservative treatment was systematically attempted according to our protocol. The primary outcome was defined as uterine conservation and the secondary outcome as maternal morbimortality defined as any medical or surgical condition occurring after childbirth. RESULTS: Fifteen patients (0.07 % of all living childbirths) were included. Conservative management was successful in 80 % of patients. There was no case of maternal death. Severe post-partum hemorrhage occurred in 4 patients (33.3 %) requiring uterine arteries embolization in one patient and hysterectomy in the 3 others. They underwent immediate blood transfusion of 13.5±4.5 average of red blood cell units. No severe septic condition occurred but 4 patients suffered from endometritis, 2.6±0.5 months after birth requiring intravenous antibiotics treatment in conventional hospitalization. Mean duration for spontaneous abortion of the placenta was 23.0±7.2 weeks. Three spontaneous pregnancies occurred in 2 patients after 19±16.9 months. CONCLUSION: Conservative management seems encouraging but is associated with a non-insignificant risk of secondary complication requiring long-term monitoring in conciliant patients.

[Cervical cerclage]. / Le cerclage cervical.

Cervical cerclage aims to strengthen not only the mechanical properties of the cervix, but also its immunological and anti-infectious functions. The demonstration of a strong interrelation between cervical insufficiency as well as decreased cervical length at endo-vaginal ultrasonography and infection has changed the indications cerclage. Actually we can distinguish three indications for cerclage: prophylactic, for obstetrical history; therapeutic, for shortened cervical length at ultrasonography in patients at risk and; emergency cerclage in case of threatening cervix at physical examination. The McDonald's technique is the most recommended. In case of failure, it is proposed to realize cerclage at a higher level on the cervix either by vaginal or abdominal route.

[Secondary postpartum hemorrhage]. / Hémorragie secondaire du post-partum.

OBJECTIVES: To define secondary postpartum hemorrhage (HSPP), to discuss its main etiologies and suggest a proposal for its management. MATERIALS AND METHODS: Bibliographic research by crossing keywords: secondary postpartum hemorrhage, delayed postpartum hemorrhage, postpartum bleeding, placental remnant, placental and hysteroscopy. RESULTS: The HSPP (0.5 and 2%) is defined as bleeding occurring between 24hours and 6weeks after birth and requiring therapeutic action whatsoever (professional consensus). The most common etiology is retained placental fragments and/or endometritis, associated or not with incomplete uterine involution (Professional consensus). Among other etiologies: the pseudoaneurysms of the uterine artery, arteriovenous fistulae's, choriocarcinoma and coagulopathies. Management of HSPP depends on its etiology and the severity of bleeding. It includes antibiotics (grade A) and uterotonics (professional consensus). Antibiotherapy depends of the protocols of each department. Usually the patient will be hospitalized (Professional consensus). In case of persistent bleeding, suction curettage with or without hysteroscopy is recommended (Professional consensus). CONCLUSION: Although HSPP is an important source of maternal morbidity, it is concerned by a relatively few number of studies in the literature. Its management is based on a comprehensive etiological work-up in order to provide appropriate treatment.

Extensive pulmonary embolism after severe postpartum haemorrhage: management with an inferior vena cava filter.

We report the case of a 36-year-old woman with an inferior vena cava thrombosis and extensive pulmonary embolism six days after a severe postpartum haemorrhage. She had undergone caesarean section with bleeding managed by massive transfusion, hysterectomy, and two attempts at uterine artery embolization. Systemic thrombolysis and catheter-directed thrombolysis in intensive care were abandoned due to recent and incomplete uterine artery embolization. A temporary inferior vena cava filter was chosen because of significant risk of massive pulmonary embolism. This was a controversial decision because guidelines from different professional groups offer conflicting recommendations. The therapeutic options for the management of massive postpartum pulmonary embolism when thrombolysis is contraindicated are discussed.

Efficacy and safety of labour induction in patients with a single previous caesarean section: a proposal for a clinical protocol.

PURPOSE: To evaluate the efficacy and safety of induction in women with a single prior Caesarean section. METHODS: This was a cohort study in which we included all singleton pregnancies in patients with a single prior Caesarean who delivered between 2007 and 2012. Methods of induction were ocytocic infusion plus amniotomy (if Bishop score ≥6) or insertion of a Foley catheter (Bishop <6). RESULTS: Of the 2,075 patients included, 806 (38.8 %) had an elective repeat Caesarean, 1,045 (50.4 %) went into spontaneous labour, 89 (4.3 %) were induced by artificial rupture of the membranes and infusion of ocytocics and 135 (6.5 %) were induced using a Foley catheter. Rates of vaginal delivery were 79.2, 79.8 and 43.7 %, respectively. Six cases of uterine rupture were reported in the group of patients who went into spontaneous labour. There was no difference between groups with regard to neonatal morbidity. On multivariate analysis, risk factors for Caesarean delivery were macrosomia (OR 2.04, 95 % CI 1.31-3.18) and induction by Foley catheter (OR 3.73, 95 % CI 2.47-5.62); protective factors were previous vaginal delivery (OR 0.41, 95 % CI 0.29-0.57) and cervical dilatation (OR 0.84, 95 % CI 0.78-0.91). CONCLUSIONS: Uterine induction after a single Caesarean section with ocytocic infusion and amniotomy where the cervix is favourable does not appear to entail any significant added risk in terms of maternal or foetal morbidity. Foley catheter induction is a reasonable option if the cervix is not ripe.

Placental abruption: risk factors, management and maternal-fetal prognosis. Cohort study over 10 years.

OBJECTIVE: To describe maternal and fetal risk factors, diagnosis, management and prognosis of placental abruption (PA). STUDY DESIGN: A retrospective cohort study between January 2003 and December 2012 within the three maternity units of a French university hospital. We included 55,926 deliveries after 24 weeks' gestation including 247 cases of PA (0.4%). We conducted univariate analyses to compare PA and control groups. Multivariate models were constructed in order to study PA risk factors and perinatal morbidity and mortality. RESULTS: Independent risk factors for PA were preterm premature rupture of membranes (OR 9.5; 95% CI [6.9-13.1]), gestational hypertension (OR 7.4; 95% CI [5.1-10.8]), preeclampsia (OR 2.9; 95% CI [1.9-4.6]) and major multiparity (OR 1.6; 95% CI [1.1-2.4]). The classic clinical triad associating metrorrhagia, uterine hypertonia and abdominopelvic pains was present in only 9.7% of cases. Caesarean section rate was 90.3% with 51.8% being performed under general anesthesia. There was no case of maternal death, but maternal morbidity was considerable, with 7.7% of coagulation disorders and 16.6% of transfusion. After adjustment for the gestational age, we found an increased risk for pH≤7.0 (OR 14.9; 95% CI [9.2-23.9]) and neonatal resuscitation (OR 4.6; 95% CI [3.1-6.8]). Perinatal mortality was 15.8%, including 78% of fetal deaths. CONCLUSIONS: Appropriate multidisciplinary management can limit maternal morbidity and mortality but perinatal mortality, which occurs essentially in utero, remains high.

Prediction of spontaneous preterm delivery in singleton pregnancies: where are we and where are we going? A review of literature.

Prematurity is the chief cause of neonatal morbidity and mortality. The objective of this study is to review the different methods for predicting preterm delivery in asymptomatic pregnant women and in situations of threatened preterm delivery. A search of the PubMed/Medline database was carried out for the years 1980-2012. We included studies for predicting preterm birth in asymptomatic and symptomatic patients. Models for predicting preterm delivery based on maternal factors, cervical length and obstetric history in first trimester of pregnancy is a valuable avenue of research. Nevertheless, prediction accuracy still needs to be improved. In the second and third trimesters, routine digital vaginal examination is of no value in asymptomatic women. Echography of the cervix is not useful except in patients with a history of late miscarriage or preterm delivery in order to offer them a preventive treatment. In symptomatic women, the combination of digital vaginal examination, cervical echography and fibronectin gives the best predictive results. Electromyography of the uterus and elastography of the cervix are interesting avenues for future research. Identifying patients at risk of preterm delivery should be considered differently at each stage of pregnancy.

[Abruptio placentae. Diagnosis, management and maternal-fetal prognosis: a retrospective study of 100 cases]. / Hématome rétroplacentaire. Diagnostic, prise en charge et pronostic maternofœtal: étude rétrospective de 100 cas.

OBJECTIVES: To update knowledge on placental abruption because there are few recent series published although the perinatal care has progressed. PATIENTS AND METHODS: A retrospective observational study has been conducted on 100 consecutive cases of abruptio placentae, occurring from January 2008 to June 2011, in the two maternity units of the University Hospital of Strasbourg (France). RESULTS: One hundred and five births among which five twin pregnancies were included. Clinical context was evident in 91% of cases, but the classic clinical triad was present in only 4% of cases. Clots were found at immediate placenta examination in 77% of cases. Pathological diagnosis was directly in accordance with clinical diagnosis in half the cases. Mean date of childbirth was 33 weeks of amenorrhea and 6 days. Sixty-seven patients gave birth prematurely. Among them, 50 patients delivered before 34 weeks. Sixty caesareans were performed in emergency before labor, including 47 with general anesthesia. Twelve patients had post-partum haemorrhage and ten coagulation disorders. There was no maternal death. Perinatal mortality was 19% with 13 fetal deaths in utero (12.4%), four children born in an apparent death state with resuscitation failure (3.8%) and three neonatal deaths (2.8%). DISCUSSION AND CONCLUSION: Placental abruption is a serious and unpredictable situation. Joint medical care of obstetricians and intensivists is often required. Perinatal mortality mainly occurs in utero.

[Obstetrical management in the event of persistent or worsening postpartum hemorrhage despite initial measures]. / Prise en charge obstétricale en cas d'hémorragie du post-partum qui persiste malgré les mesures initiales ou qui est grave d'emblée.

Sulprostone infusion must be started without further delay if the first treatment (oxytocin, manual removal of the placenta, uterine revision, vaginal and cervical examinations) has been unsuccessful in the first 30 minutes after delivery. In France, the use of this treatment has been officially authorized in this indication (marketing approval, AMM). Intramuscular and intramyometrial injections being contraindicated, sulprostone is administered through continuous intravenous infusion. Dosage is 500 microg (one vial) per hour. Starting dose is 1.7 microg/min (10 ml/h), and can be increased if necessary in steps of 1.7 microg/min (but not exceeding 8.3 microg./min). The success rate of this treatment is linked to the rapidity of its commencement (within 30 min of the diagnosis of postpartum hemorrhage). In case of contraindications, since postpartum hemorrhage is life-threatening, the benefit-risk ratio needs to be estimated. A strict monitoring of cardiovascular parameters is compulsory before and after its administration. There is no time limit after which this treatment can be considered as ineffective: it depends on the amount of blood lost, the patient's clinical state, and on means that have already been used to stop the bleeding. However, if after 30 min of sulprostone infusion, there is no improvement or if the situation is worse, other therapeutic strategies must be considered (e.g., embolization, surgery). The use of intra-rectal misoprostol is still under assessment. To date, we have been unable to find studies that justify this treatment. Intra-uterine balloon, tube, or mesh packing has been studied in a few small series, where it was successful. Use of these strategies must not delay the treatment by sulprostone.

[Massive feto-maternal transfusion. Report of 3 cases with review of the literature]. / La macrotransfusion foeto-maternelle. A propos de 3 cas avec revue de la littérature.

Massive feto maternal hemorrhage is rare. Early diagnosis is important because massive feto-maternal hemorrhage has a poor prognosis. The clinical manifestations of transplacental hemorrhage are related not only to the size of the hemorrhage but also to the time at which the hemorrhage occurs. In women who are candidates for Rh immune prophylaxis, massive feto maternal hemorrhage may be detected by Kleihauer test and we suggest that 10 micrograms dose of immune globin should be administered for each estimated ml of Rh positive blood given, to prevent an immunization Disappearance of fetal cells by Kleihauer test or appearance residual antibody suggests the adequacy of therapy. Three cases of massive fetomaternal hemorrhage (more than 225 ml) are presented here. Two mothers was Rh negative and they are delivered of rhésus positive children, which necessitated the administration of large volume of anti D. One of the cases shows the possibility of association between choriocarcinoma and positive kleihauer test.

Etiology and prevention of pulmonary complications following beta-mimetic mediated tocolysis.

OBJECTIVES: This study documents biological (haematocrit variations) and therapeutic parameters (salbutamol doses, volumes perfused) in two groups tocolysed with salbutamol, one with and the other without APO in order to define the risk factors linked to APO and to establish a standard protocol of management. STUDY DESIGN: This retrospective study includes data from 68 intravenous salbutamol tocolysis with four resulting APOs, carried out between January 1st, 1993 and December 31st, 1995. RESULTS: There was an excessive level of salbutamol administered over 48 h in the complicated APO-group (122.5+/-52 mg) opposed to the non-APO group (44.9 21 mg) as well as an overload of perfused solute (3.1+/-1.11) versus (1.9+/-1.11). Blood hemodilution was demonstrated in the APO group with a decrease of haematocrit by over 10% between the admission and the control value. No other risk factor was found. CONCLUSION: Tocolysis should be administered at the lowest possible perfusion rate with incremental doses as long as the heart rate stays under 120 beats/min and stopped after 48 h. Administration of maximal 11 of solute perfused/day is recommended. For the patient's follow-up we estimate daily input and output fluid to avoid hydric overload, and a daily control of haematocrit whose variation must be less than 10%.

Breech presentation after 34 weeks-a meta-analysis of corrected perinatal mortality/morbidity according to the method of delivery.

We conducted a meta-analysis of the mortality and morbidity of the breech presentation according to the method of delivery. Using the term 'breech', we used the Medline data base to search the English and French-language literature from 1978 to July 1995. Twenty-two studies (7239 deliveries) were found and analysed. The meta-analysis concerning perinatal mortality did not reveal a significant increased risk, when vaginal deliveries were compared with those delivered by a caesarean section (odds ratio: 1.90; confidence interval: 0.59-8.22) or when vaginal deliveries were compared with those done by planned caesarean section (odds ratio: 4.95; confidence interval: 0.44-80.06). The neonatal morbidity showed an increased risk with vaginal delivery. It is concluded that the practice of resorting to caesarean section for every breech presentation at term does not seem defensible.

Cervico-vaginal fetal fibronectin: predictive value during false labor.

OBJECTIVE: The purpose was to determine to what extent fetal fibronectin was a discriminative test of preterm delivery in patients hospitalized for uterine contractions without modification of the cervix. STUDY DESIGN: The prospective double-blind study included patients hospitalized between 24 and 34 week for false labor. Cervicovaginal swabs were obtained and assayed for the presence of fetal fibronectin by means of a monoclonal antibody assay. RESULTS: Out of the 61 patients included, 18 showed a positive swab. The correlation of a positive result with preterm delivery revealed a sensitivity of 56%, a specificity of 81%, and positive and negative predictive values of 56% and 81% respectively. Meta-analysis of studies published shows that the presence of fibronectin represents a significant relative risk of 3.3 (IC: 2.5-42) of preterm delivery. CONCLUSION: The presence of fetal fibronectin in cervicovaginal secretions of patients presenting with false labor indicates a major risk of preterm delivery.

Antenatal diagnosis of brain damage in the survivor after the second trimester death of a monochorionic monoamniotic co-twin: case report and literature review.

At 28 weeks of amenorrhea, 1 fetus of a monoamniotic twin pregnancy died. Ultrasound and Doppler investigations of the surviving twin were normal. Three weeks later, endovaginal ultrasound and magnetic resonance imaging revealed massive bilateral cerebral ischemic necrosis in the surviving twin. In utero fetal blood sampling carried out before the termination did not reveal either anemia or thrombopenia. Current data suggest that cerebral or renal ischemic complications could set in immediately after the death of the first twin as a result of a period of acute hypotension. At least 2 weeks are necessary for them to be identifiable by ultrasound. It seems that they cannot be prevented by prompt delivery of the second twin.

Fetal pulse oximetry during labor of 62 patients.

The objectives of the study were to assess the ability of a fetal pulse oximeter to measure the fetal oxygen saturation (SPO2) continuously during labor and to assess the correlation between readings of fetal pulse oximetry and cord blood gases at birth. The Nellcor N-400 Fetal Oximeter was used in 62 women prospectively. The mean SPO2 was unchanged at the different stages of normal labor. 53.3 +/- 9.1 to 50.1 +/- 11.8% (n = 50). The SPO2 recorded during the pushing phase of stage II (n = 40) was correlated significantly with umbilical cord arterial pH (r = 0.55; p = 0.0002), venous pH (r = 0.63; p = 0.0001), venous PCO2 (r = 0.47; p = 0.002) and venous PO2 (r = 0.39; p = 0.01). SPO2 was also correlated with scalp pH (r = 0.52; p < 0.05; n = 21). No side effects were noted. Fetal pulse oximetry could be useful to assess fetal oxygenation during labor and at birth.

[The reduction of prematurity by telephone follow-up]. / La réduction de la prématurité par surveillance téléphonique.

Twice-daily check-up of the uterine contractions by the pregnant women is a recognized and accepted necessity. Using the "green" free-phone number to report the number of contractions, to answer the questions asked and to receive the instructions given has made it possible to reduce the prematurity rate and the duration of the consequent specific hospitalization. This new method of follow-up, applied to two identically recruited groups of pregnancies offers an undeniable low-cost improvement over the systems used previously.

[Update on delayed births]. / Mise au point sur la naissance différée.

Sixteen (16) cases of delayed births have been reported in the literature. All of these patients obtained at least one live child. This method can, therefore, be suggested in cases of premature birth after less than 28 weeks of amenorrhea for patients who present with a multiple, pluriamniotic pregnancy.