[Distribution of blood loss during vaginal delivery and cesarean section]. / Analyse descriptive du volume des pertes sanguines au cours de l'accouchement par voie basse et par césarienne.

OBJECTIVES: To describe the distribution of the volume of blood loss during vaginal and cesarean deliveries among women who delivered after 24 weeks of gestation. MATERIALS AND METHODS: A descriptive study of the distribution of blood loss by delivery route and for all patients after 24 weeks of gestation over a period of two years in a type III maternity. Patient and delivery characteristics were collected and blood loss was measured prospectively based on weighing pads and the use of a collector bag for vaginal deliveries, a suction cannula for cesareans sections. The following parameters were calculated: the mean (±SD), the median, interquartile range (IQR), the 5th and 95th percentile. RESULTS: Seven thousand nine hundreds and eight patients were included. After vaginal delivery (n=6134), the mean volume of bleeding was equal to 180.1 mL (± 224.7 mL), the median to 100mL (IQR [100-200]), the 95th percentile to 500 mL [CI 95% 500-550]. For cesarean sections (n=1774), the mean volume of bleeding was equal to 557.9mL (± 496.2 mL), the median volume of blood loss to 400 mL (IQR [300-700]), the 95th percentile to 1300 mL [CI 95% 1200-1500]. CONCLUSION: The distribution of blood loss after cesarean was significantly higher than the distribution of blood loss after vaginal delivery.

[Indications for methotrexate in gynecology outside the first-line treatment of ectopic tubal pregnancies]. / Indications du méthotrexate en gynécologie en dehors du traitement de première intention des grossesses extra-utérines tubaires.

The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration<2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.

[Evidence-based evaluation and expertise of methotrexate off label use in gynaecology and obstetrics: work of the CNGOF]. / États des lieux et expertise de l'usage hors AMM du méthotrexate en gynécologie-obstétrique: travail du CNGOF.

In the absence of contraindication, methotrexate by intramuscular unique injection of 1mg/kg or 50mg/m(2) is the medical treatment recommended for tubal ectopic pregnancy (EP; LE1). It can be renewed once, at the same dose, according to hCG rates decrease. The pretherapeutic biological assessment contains blood cells numeration, renal and hepatic function. Methotrexate therapy constitutes an alternative conservative treatment to laparoscopic salpingotomy for non-complicated tubal EP (LE1) with hCG level <5000 UI/L (LE2). When the rates of hCG are <1000 UI and or presented a spontaneous decreasing kinetics, the simple prospect (LE2) is preferred. It is recommended to use intramuscular methotrexate in case of surgical conservative treatment failure or more prematurely if the follow-up is not possible (LE3). Except in particular cases there is no indication to use methotrexate in local injection under sonographic control in usual tubal EP (LE2). The use of in situ injection methotrexate is an option to handle the cervical, interstitial or on caesareans scar pregnancies (LE2). In front of a persistent undetermined location pregnancy, after more than 10 days of survey, in an asymptomatic woman and/or at rate of hCG >2000 UI/L, the systematic treatment by methotrexate is an option. The methotrexate is not indicated for first trimester termination of pregnancy or miscarriage neither in placentas accreta nor in association with other treatments such myfegine or potassium.