[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) -- Text of the Guidelines (short text)]. / Accouchement normal : accompagnement de la physiologie et interventions médicales. Recommandations de la Haute Autorité de Santé (HAS) avec la collaboration du Collège National des Gynécologues Obstétriciens Français (CNGOF) et du Collège National des Sages-Femmes de France (CNSF) ­ Texte des recommandations (texte court).

OBJECTIVE: The objective of these guidelines is to define for women at low obstetric risk modalities that respect the physiology of delivery and guarantee the quality and safety of maternal and newborn care. METHODS: These guidelines were made by a consensus of experts based on an analysis of the scientific literature and the French and international recommendations available on the subject. RESULTS: It is recommended to conduct a complete initial examination of the woman in labor at admission (consensus agreement). The labor will be monitored using a partogram that is a useful traceability tool (consensus agreement). A transvaginal examination may be offered every two to four hours during the first stage of labor and every hour during the second stage of labor or before if the patient requests it, or in case of a warning sign. It is recommended that if anesthesia is required, epidural or spinal anesthesia should be used to prevent bronchial inhalation (grade A). The consumption of clear fluids is permitted throughout labor in patients with a low risk of general anesthesia (grade B). It is recommended to carry out a "low dose" epidural analgesia that respects the experience of delivery (grade A). It is recommended to maintain the epidural analgesia through a woman's self-administration pump (grade A). It is recommended to give the woman the choice of continuous (by cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring if the conditions of maternity organization and the permanent availability of staff allow it and, after having informed the woman of the benefits and risks of each technique (consensus agreement). In the active phase of the first stage of labor, the dilation rate is considered abnormal if it is less than 1cm/4h between 5 and 7cm or less than 1cm/2h above 7cm (level of Evidence 2). It is then recommended to propose an amniotomy if the membranes are intact or an oxytocin administration if the membranes are already ruptured, and the uterine contractions considered insufficient (consensus agreement). It is recommended not to start expulsive efforts as soon as complete dilation is identified, but to let the presentation of the fetus drop (grade A). It is recommended to inform the gynecologist-obstetrician in case of nonprogression of the fetus after two hours of complete dilation with sufficient uterine dynamics (consensus agreement). It is recommended not to use abdominal expression (grade B). It is recommended to carry out preventive administration of oxytocin at 5 or 10 IU to prevent PPH after vaginal delivery (grade A). In the case of placental retention, it is recommended to perform a manual removal of the placenta (grade A). In the absence of bleeding, it should be performed 30minutes but not more than 60minutes after delivery (consensus agreement). It is recommended to assess at birth the breathing or screaming, and tone of the newborn to quickly determine if resuscitation is required (consensus agreement). If the parameters are satisfactory (breathing present, screaming frankly, and normal tonicity), it is recommended to propose to the mother that she immediately place the newborn skin-to-skin with her mother if she wishes, with a monitoring protocol (grade B). Delayed cord clamping is recommended beyond the first 30seconds in neonates, not requiring resuscitation (grade C). It is recommended that the first oral dose (2mg) of vitamin K (consensus agreement) be given systematically within two hours of birth. CONCLUSION: These guidelines allow women at low obstetric risk to benefit from a better quality of care and optimal safety conditions while respecting the physiology of delivery.

A pilot study of gestational diabetes mellitus not controlled by diet alone: First-line medical treatment with myoinositol may limit the need for insulin.

AIM: This study assessed whether myoinositol might be a first-line medical treatment for gestational diabetes mellitus (GDM). METHODS: For 12 months, women with GDM not controlled by diet (n=32) were prospectively treated with myoinositol 1200mg and folic acid 400µg/day, while consecutive women (n=28) with insulin-requiring GDM treated during the previous year at our centre constituted the control group. Baseline characteristics and care were similar in both groups. RESULTS: Insulin was required in eight women (25%) in the myoinositol group who, compared with the 24 who did not need insulin, were older (37±5 vs. 32±5 years, respectively; P=0.018) and had a larger percentage of high self-monitored glucose values (45±8% vs. 32±14%; P<0.0001) during the week prior to the introduction of myoinositol treatment. All of the women had similar pregnancy outcomes regardless of their GDM management, although less labour induction was required in the myoinositol group (OR: 0.22 [0.07-0.65]), which had no side effects. CONCLUSION: This pilot study suggests that myoinositol may be a safe first-line medical treatment for uncontrolled GDM.

[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.

[Prophylactic antibiotics and intrauterine procedures]. / Antibioprophylaxie et interventions endo-utérines.

Prophylactic antibiotics (PA) are effective to prevent post hysterosalpingography pelvic inflammatory disease (PID) and should be performed in these patients. No advantages are reported concerning PA in patients undergoing intra uterine device placement, hysteroscopy (diagnosis or operative hysteroscopy), medical abortion or uterine revision. Systematic PA with tetracyclins or imadazols is effective to prevent post abortion PID in patients undergoing surgical abortion and should be performed in these patients.

[Obstetrical outcome and risk of uterine rupture following a caesarean section before 32 weeks]. / Modalités d'accouchement et risque de rupture utérine après césarienne réalisée avant 32 semaines d'aménorrhée.

OBJECTIVE: Our aim was to evaluate the subsequent obstetrical outcome and rate of uterine rupture following a caesarean section before 32 weeks of gestation. PATIENTS AND METHODS: A retrospective cohort study of 200 consecutive women with a prior caesarean section performed between 25 and 32 weeks were contacted by questionnaire or followed through medical charts to determine the subsequent mode of delivery. RESULTS: Two hundred caesarean section were performed between 25 and 32 weeks from January 1997 to March 2000. Thirty-nine patients (19.2%) were lost to follow-up. Seventy-one patients had a subsequent delivery. Thirty-two attempted vaginal birth and the success rate was 87.5%. Thirty-nine patients had a subsequent caesarean. One case of uterine rupture occurred before labour at 31 weeks (1.4%, % IC 95% [0.25; 7.56]). CONCLUSION: After a previous caesarean delivery before 32 weeks, a trial of labour may be proposed when obstetrical conditions are optimal. However, uterine rupture may occur prior to labor.

[Can we foretell preeclampsia?]. / Comment prédire la prééclampsie ?

Predicting PE would enable a better understanding of the physiological mechanisms responsible for this disease. It would also permit the identification of an at-risk population and consequently ease the set up of clinical trials. Over 12,000 articles have been published on this subject. Critical review of the literature reveals that none of the investigations, performed individually, bears sufficient predictive value. However, it appears that the current tendency is to apply a combined approach associating clinical, ultrasonographic and biological factors.

[Comparative evaluation of the Joel-Cohen cesarean section versus the transrectal incision]. / Etude prospective comparative entre les techniques de césarienne de Joël-Cohen et de Mouchel.

OBJECTIVE: The aim of this study was to compare the Joel-Cohen method for cesarean section to the traditional transrectal incision. METHOD: Fifty-two patients requiring a caesarean section were enrolled in this prospective study. Overall morbidity and post-operative pain was assessed. Four surgeons participated to this study, each included 13 patients. The main judgement criterion was post-operative pain on the first day. RESULTS: Post-operative pain on the first day was less important (50 vs 23% p=0.04) in Joel-Cohen's. This method was shorter compared to the transrectal incision (33.6+6.4 min vs 51.2+8 min p<0.0001). There was no difference in overall morbidity between the two groups. CONCLUSION: Joel-Cohen's method decrease post-operative pain and is a shorter procedure compared to the transrectal incision.

Diffusion-weighted magnetic resonance imaging with apparent diffusion coefficient (ADC) determination in normal and pathological fetal kidneys.

OBJECTIVES: To assess the use of diffusion-weighted magnetic resonance imaging (DW-MRI) in the evaluation of the fetal kidney and to estimate age-dependent changes in the apparent diffusion coefficient (ADC) of normal and pathological fetal kidneys. METHODS: DW-MRI was performed on a 1.5-T machine at 23-38 gestational weeks in 51 pregnant women in whom the fetal kidneys were normal and in 10 whose fetuses had renal pathology (three with suspected nephropathy, three with renal tract dilatation, one with unilateral renal venous thrombosis, and three with twin-twin transfusion syndrome (TTTS)). The ADC was measured in an approximately 1-cm2 region of interest within the renal parenchyma. RESULTS: ADC values in normal renal parenchyma ranged from 1.1 to 1.8 10(-3) mm2 s-1. There was no significant age-dependent change in the ADC of normal kidneys. In cases of nephropathy, the ADC value was not always pathological but an ADC map could show abnormal findings. In cases of dilatation, the ADC value was difficult to determine when the dilatation was huge. In cases of TTTS, the ADC of the donor twin was higher than that of the recipient twin and the difference seemed to be related to the severity of the syndrome. CONCLUSION: Evaluation of the ADC for fetal kidneys is feasible. Fetal measurement of the ADC value and ADC maps may be useful tools with which to explore the fetal kidney when used in conjunction with current methods. DW-MR images, ADC value and ADC map seem to be useful in cases of suspected nephropathy (hyperechoic kidneys), dilated kidney and vascular pathology (renal venous thrombosis, TTTS).

Advanced combined abdominal and intrauterine pregnancy: a case report.

We present a case of simultaneous abdominal and intrauterine pregnancy following in vitro fertilization and embryo transfer diagnosed during the second trimester. The patient had a recent history of hysteroscopic metroplasty due to in utero exposition to diethylstilboestrol. The pregnancy was managed conservatively with a favorable outcome for the mother and both fetuses.

Fetal magnetic resonance hydrography: evaluation of a single-shot thick-slab RARE (rapid acquisition with relaxation enhancement) sequence in fetal thoracoabdominal pathology.

OBJECTIVES: To evaluate the potential of a single-shot thick-slab RARE (rapid acquisition with relaxation enhancement) sequence in fetal thoracoabdominal magnetic resonance (MR) examinations compared with multislice T2-weighted sequence and postnatal imaging. METHODS: RARE sequence is rapid and provides very heavily T2-weighted images. Twenty-seven fetal thoracoabdominal MR imaging examinations were performed at 23-38 weeks using our conventional protocol. This included thin multislice T2-weighted half-Fourier acquired single-shot turbo spin-echo (HASTE) sequence and thin-slice GE (gradient echo) T1-weighted images with a 1.5-T MR unit. A single-shot thick-slab (60 mm) RARE sequence was added to all MR examinations. The acquisitions were obtained with the mother breath-holding. The thick-slab heavily T2-weighted images were compared with HASTE sequence images and with postnatal imaging in all cases. RESULTS: The thick-slab RARE sequence did not show additional abnormalities compared with the conventional protocol but displayed an overall view of the urinary tract, tracheobronchial tract and small bowel. It gave information that was highly correlated with postnatal imaging, such as abdominal plain films, chest film or cystography. The quality of the thick-slab RARE images was considered as good in 13 cases (48%), moderate in 12 cases (45%) and poor in two cases (7%). CONCLUSION: Although thick-slab RARE sequence does not show additional abnormalities compared with the conventional protocol, it illustrates very nicely static fluids such as those in urinary dilatation, the esophagus and small bowel (normal or dilated) and thoracic cystic masses. It is very rapid (5 s) to perform, allows fetal hydrography, and correlates well with postnatal imaging.

[Prognosis work-up in prenatal medicine: the example of Down's syndrome]. / Les fondements du pronostic en médecine prénatale: exemple de la trisomie 21.

Establishing a prognosis in prenatal medicine is often a complex and uncertain task. Predictive tools such as imagery techniques and biological markers may lack accuracy since they are used while the fetus is still pursuing its development. In France, antenatal euthanasia and fetal abandon are legal issues and socially accepted. Several non-medical factors may interfere with the final outcome such as the manner a condition is announced by the staff, the way it is experienced by the parents and the acceptance of the handicap within the society. We analysed the different medical and non medical factors intervening in the prognosis work up for Down's syndrome. Currently, the outcome of fetus with Down's syndrome is influenced by the orientation of our society that promotes screening tests and pregnancy interruptions instead of emphasizing on therapeutic research and improving their social integration.

Value of endorectal ultrasonography for diagnosing rectovaginal septal endometriosis infiltrating the rectum.

BACKGROUND AND STUDY AIMS: Rectovaginal septal endometriosis (RVSE) can pose serious therapeutic problems when there is infiltration of the rectal septum (which occurs in approximately half of the cases). The aim of this study was to assess the value of endoscopic ultrasonography in diagnosing rectal wall involvement by pelvic endometriosis. PATIENTS AND METHODS: A prospective study was carried out from May 1998 to March 2003 at a single hospital center. The 30 patients included in the study presented with suspected RVSE and underwent systematic anorectal endoscopic ultrasonographic exploration prior to the surgical intervention. The endoscopic ultrasonography was carried out under general anesthesia with a 7.5-MHz miniprobe equipped with a distal balloon. RESULTS: The anorectal endoscopic ultrasonographic examination (EUS) showed the presence of endometriosis in the rectovaginal septum in 26 patients (88 %), in the uterosacral ligaments in 10 patients (33 %), and in the ovaries in two patients (6 %). At EUS, the nodules were infiltrating the rectal wall in 17 patients (56 %). The surgical exploration demonstrated endometriosis in the rectovaginal septum in 26 cases, the uterosacral ligaments in 22 cases, and the ovaries in 16 cases. The rectal wall was completely infiltrated in 12 cases and only partly in four cases, and intestinal tract resection was required in 10 cases. The sensitivity, specificity, and positive and negative predictive value of anorectal endoscopic ultrasonography as a means of diagnosing endometriosis of the rectovaginal septum and infiltration of the rectal wall were found to be 96 %, 100 %, 100 % and 83 %, and 92 %, 66 %, 64 % and 92 %, respectively; and the diagnostic accuracy was at 96 % and 80 %, respectively. The sensitivity for detecting nodules in the uterosacral ligaments or in the ovaries was 42 % and 14 %, respectively, leading to diagnostic accuracy rates of 56 % and 53 %. CONCLUSIONS: In terms of its sensitivity and its negative predictive value, anorectal endoscopic ultrasonography is a very effective means of detecting endometriosis of the rectovaginal septum and assessing possible infiltration of the rectal wall. However, this method is not as accurate for nodules located far from the EUS probe, as is the case with the uterosacral ligaments and ovaries.

[Surgical management of primary postpartum hemorrhage]. / Hémorragies du post-partum immédiat: techniques et indications de la chirurgie.

Despite the development of medical, obstetrical and arterial embolization techniques to control acute postpartum hemorrhage, familiarity with surgical procedures is essential. They may be the ultimate available option in order to obtain hemostasis. Conservative techniques consist of arterial ligations and uterine compression sutures that preserve the reproductive future and may be combined together. Radical options include hysterectomy which may be total or sub-total. To date, there are no comparative trials assessing the superiority of a given surgical option. In this review, the main surgical interventions are described and a practical stepwise approach is discussed according to the etiology, based on a professional consensus work-shop. Surgical management must be timely triggered after failure of first line treatments and integrated in a global strategy aimed to cease hemorrhage. It should be adapted to the available local health resources and in compliance with the various members of the medical staff.

[Female genital mutilation: generalities, complications and management during obstetrical period]. / Les mutilations génitales féminines: généralités, complications et prise en charge obstétricale.

OBJECTIVES: Evaluation of female genital mutilation complications and their clinical management. MATERIAL AND METHODS: Review of the literature. RESULTS: Female genital mutilation is still performed in some regions of Africa. Although female genital mutilation are often considered as a religious act, tradition and social habits seems to be the best explanation. Infibulation is the most severe form, in which the clitoris, the labia minora and part of labia majora are removed. Stitching of the raw surfaces created covers the urethra and the vaginal entrance. There only remains a small opening at the base of the vulva. Health consequences directly depend on the severity of the initial mutilation. They are more severe in infibulated women. Pregnancy, childbirth and the obstetrical period are particuliary dangerous for the mother and the child. Female genital mutilation contributes to childhood and maternal mortality and morbidity. Decreasing the impact depends on the obstetrical team's competence. Defibulation is absolutely necessary for the delivery of infibulated women. This simple surgical act can be performed under local anesthesia. CONCLUSION: With increasing immigration, obstetrical teams in developed countries can be confronted with such situations. They should be aware of proper clinical management practices for these women.

[Rectal misoprostol for postpartum hemorrhage]. / Le misoprostol par voie rectale dans l'hémorragie de la délivrance.

OBJECTIVE: To evaluate a post-partum hemorrhage treatment guideline, using rectally administered misoprostol. PATIENTS AND METHODS: A descriptive study was carried out in a tertiary referral center from January 2002 to March 2003. During this period, 2670 patients delivered and 41 (1.5%) with severe post-partum hemorrhage unresponsive to oxytocin received 1000 microg of misoprostol (five tablets) rectally while awaiting sulprostone. Twenty-eight had delivered by the vaginal route and 13 by cesarean section. RESULTS: Hemorrhage was controlled among 63% (26/41) of the patients within 10 min of the administration of rectal misoprostol. Fifteen (37%) patients received both misoprostol and sulprostone and no major adverse effects were noted when combining these two prostaglandins. Overall, hemorrhage was controlled among 87% (36/41) of the patients when oxytocics were combined with misoprostol and sulprostone. Five patients (12%) did not respond to the combination of uterotonics and required a conservative surgical treatment. DISCUSSION AND CONCLUSION: Rectal misoprostol may be an effective second line treatment for the management of post-partum hemorrhage unresponsive to oxytocin. We did not observe major side effects when combining misoprostol with sulprostone. Our findings encourage further research on rectal misoprostol in the treatment of postpartum hemorrhage.

[New insight in physiopathology of preeclampsia and intra-uterine growth retardation: role of inflammation]. / Avancées dans la physiopathologie de la pré-éclampsie: place de la réponse inflammatoire.

Inflammatory response is a major component in physiopathology of preeclampsia and intra-uterine growth retardation. Endothelium is a main connection between placental ischemia and clinical manifestations during vascular pregnancy complications. In this review recent findings concerning inflammatory response and its links with endothelium are reported. Studies concerning isolated intra-uterine growth retardation confirm the hypothesis of a similar pathophysiology with an activation confined to utero-placental bed or at a lower level. Current information on oxidative stress, atherosclerosis, and apoptosis in vascular pregnancy complications are available in this review. These concepts offer innovative possibilities of treatment.