Since a 2004 randomized trial established fetoscopy as the gold standard for the treatment for twin-to-twin transfusion syndrome (TTTS), advancements in surgical technique and expert training have considerably improved survival rates to 89% for at least one fetus and 65% for both fetuses. However, many challenges remain. This review provides an update on the current principles, issues, and debates. The Solomon technique has helped improve neonatal outcomes by reducing the risks of postoperative twin anemia-polycythemia sequence and TTTS recurrence. Nevertheless, fetoscopic laser photocoagulation is associated with significant obstetrical risks, including preterm premature rupture of membranes, preterm delivery, and even placental abruption. Additionally, fetal growth restriction, observed in 30% to 50% of cases, may adversely affect double survival rates following fetoscopy, particularly when abnormal Doppler indices are present. Gestational age (GA) at the time of fetoscopy is a critical prognostic factor, as earlier GA is associated with lower survival rates. This consideration raises questions about the optimal timing of the procedure after TTTS diagnosis. Emerging evidence supports expectant management with close ultrasound monitoring for asymptomatic patients with stage I TTTS. In stage III and IV TTTS, laser photocoagulation should not be delayed, whereas stage II TTTS diagnosed at very early GAs might benefit from expectant management until 16 to 17 weeks of gestation. Further advancements, such as flexible video fetoscopy and computer-assisted fetal laser surgery, represent the next frontier in addressing these challenges.

Déterminer les stratégies permettant de réduire la morbidité maternelle et périnatale secondaire à la pré-éclampsie. Méthodologie GRADE® avec questions formulées sous le format PICO (Patients, Intervention, Comparison, Outcome) et critères de jugement définis a priori et classifiés selon leur importance. Recherche bibliographique extensive: Medline, Cochrane, Embase et Google Scholar. Analyse de la qualité de la preuve (élevée, modérée, basse, très basse) et formulation d'une recommandation (i) forte ou (ii) faible ou (iii) absence de recommandation. Deux tours de relectures de type Delphi avec des relecteurs extérieurs ont été utilisés pour retenir les recommandations faisant consensus. Une pré-éclampsie est définie par une hypertension artérielle (HTA) systolique ≥ 140 mmHg et/ou diastolique ≥ 90 mmHg associée à une protéinurie ≥ 0,3 g/24 h ou un ratio Protéinurie/Créatininurie ≥ 30 mg/mmol survenant après 20 semaines d'aménorrhée. Les données de la littérature ne montrent pas de bénéfice en termes de santé maternelle ou périnatale à implémenter une définition plus élargie de la pré-éclampsie. La totalité des 31 questions soumises au panel de relecteurs a fait l'objet d'un accord. En population générale, il est recommandé de ne pas réaliser en routine de dépistage précoce de la pré-éclampsie à l'aide d'algorithmes (Recommandation faible, Qualité de la preuve basse), ni de prescrire d'aspirine à faible dose (Recommandation forte, Qualité de preuve très basse) dans le but de réduire la morbidité maternelle ou périnatale, mais d'encourager la pratique d'une activité physique au cours de la grossesse pour réduire le risque de survenue d'une pré-éclampsie (Recommandation forte, Qualité de la preuve basse). En cas de diabète préexistant, de grossesse multiple, d'hypertension artérielle chronique, de pathologie rénale chronique, les données de la littérature sont insuffisantes en nombre et en qualité pour émettre une recommandation quant à l'intérêt de l'aspirine pendant la grossesse pour prévenir la morbidité maternelle ou périnatale (Absence de recommandation, Qualité de la preuve basse). Chez les femmes enceintes ayant un antécédent de pathologie vasculaire placentaire, il est recommandé de prescrire de l'aspirine pour prévenir la morbidité maternelle ou périnatale (Recommandation forte, Qualité de la preuve modérée), à une dose de 100 à 160 mg (Recommandation faible, Qualité de preuve basse), idéalement avant 16 semaines d'aménorrhée, et au plus tard avant 20 semaines d'aménorrhée (Recommandation forte, Qualité de la preuve basse), et de l'arrêter à partir de 36 semaines d'aménorrhée (Recommandation faible, Qualité de la preuve très basse.). Dans une population à risque, il est recommandé de ne pas administrer des HBPM en plus de l'aspirine (Recommandation faible, Qualité de la preuve modérée). En cas de suspicion de pré-éclampsie (Recommandation faible, Qualité de la preuve modérée) et de pré-éclampsie avérée (Recommandation faible, Qualité de la preuve basse), il est recommandé de ne pas utiliser en routine le dosage du PlGF ou du ratio sFLT-1/PlGF dans le seul but de réduire la morbidité maternelle ou périnatale. Dans une population de femmes ayant une pré-éclampsie non sévère, il est recommandé de prescrire un traitement antihypertenseur par voie orale en cas de pression artérielle systolique mesurée entre 140 et 159 mmHg et/ou de pression artérielle diastolique mesurée entre 90 et 109 mmHg à plusieurs reprises et au repos, pour réduire la morbidité maternelle ou périnatale (Recommandation faible, Qualité de la preuve basse). Chez les femmes présentant une pré-éclampsie non sévère, l'induction de naissance entre 34 et 36+6 semaines d'aménorrhée permet de réduire uniquement l'HTA maternelle sévère mais augmente l'incidence de la prématurité modérée. En tenant compte de la balance bénéfices/risques pour la mère et pour l'enfant, il est recommandé de ne pas induire systématiquement la naissance chez les femmes présentant une pré-éclampsie non sévère entre 34 et 36+6 semaines d'aménorrhée (Recommandation forte, Qualité de la preuve élevée). Chez les femmes avec une pré-éclampsie non sévère diagnostiquée entre 37+0 et 41 semaines d'aménorrhée, il est recommandé d'induire la naissance pour réduire la morbidité maternelle (Recommandation forte, Qualité de la preuve basse), et de réaliser une tentative de voie basse en l'absence de contre-indication obstétricale (Recommandation forte, Qualité de la preuve très basse). Chez les femmes ayant un antécédent de pré-éclampsie isolée, il est recommandé de ne pas réaliser de bilan à la recherche d'une thrombophilie héréditaire (Recommandation forte, Qualité de la preuve modérée). En raison du risque élevé de développer une hypertension artérielle chronique à moyen terme et du risque accru de complications cardiovasculaires à long terme, il est recommandé d'informer les femmes ayant présenté une pré-éclampsie de la nécessité d'un suivi médical pour surveiller la pression artérielle et prendre en charge de possibles autres facteurs de risque cardiovasculaires (Recommandation forte, Qualité de la preuve modérée). Le but de ces recommandations a été de réévaluer la définition de la pré-éclampsie, et de déterminer les stratégies permettant de réduire la morbidité maternelle et périnatale en lien avec la pré-éclampsie, pendant la grossesse mais aussi à distance de l'accouchement. Elles visent à aider dans leur pratique clinique quotidienne les professionnels de santé amenés à informer ou prendre en charge les patientes ayant eu ou ayant une pré-éclampsie. Des documents d'information synthétiques sont également proposés à destination des professionnels et du grand public. To identify strategies to reduce maternal and neonatal morbidity related to preeclampsia. The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and recommendations were formulated as a (i) strong, (ii) weak or (iii) no recommendation. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. Preeclampsia is defined by the association of gestational hypertension (systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg) and proteinuria ≥ 0.3 g/24 h or a Proteinuria/Creatininuria ratio ≥ 30 mg/mmol occurring after 20 weeks of gestation. Data from the literature do not show any benefit in terms of maternal or perinatal health from implementing a broader definition of preeclampsia. Of the 31 questions, there was agreement between the working group and the external reviewers on 31 (100%). In general population, physical activity during pregnancy should be encouraged to reduce the risk of preeclampsia (Strong recommendation, Quality of the evidence low) but an early screening based on algorithms (Weak recommendation, Quality of the evidence low) or aspirin administration (Weak recommendation, Quality of the evidence very low) is not recommended to reduce maternal and neonatal morbidity related to preeclampsia. In women with preexisting diabetes or hypertension or renal disease, or multiple pregnancy, the level of evidence is insufficient to determine whether aspirin administration during pregnancy is useful to reduce maternal and perinatal morbidity (No recommendation, Quality of the evidence low). In women with a history of vasculo-placental disease, low dose of aspirin (Strong recommendation, Quality of the evidence moderate) at a dosage of 100–160 mg per day (Weak recommendation, Quality of the evidence low), ideally before 16 weeks of gestation and not after 20 weeks of gestation (Strong recommendation, Quality of the evidence low) until 36 weeks of gestation (Weak recommendation, Quality of the evidence very low) is recommended. In a high-risk population, additional administration of low molecular weight heparin is not recommended (Weak recommendation, Quality of the evidence moderate). In case of preeclampsia (Weak recommendation, Quality of the evidence low) or suspicion of preeclampsia (Weak recommendation, Quality of the evidence moderate, the assessment of PlGF concentration or sFLT-1/PlGF ratio is not routinely recommended) in the only goal to reduce maternal or perinatal morbidity. In women with non-severe preeclampsia antihypertensive agent should be administered orally when the systolic blood pressure is measured between 140 and 159 mmHg or diastolic blood pressure is measured between 90 and 109 mmHg (Weak recommendation, Quality of the evidence low). In women with non-severe preeclampsia, delivery between 34 and 36+6 weeks of gestation reduces severe maternal hypertension but increases the incidence of moderate prematurity. Taking into account the benefit/risk balance for the mother and the child, it is recommended not to systematically induce birth in women with non-severe preeclampsia between 34 and 36+6 weeks of gestation (Strong recommendation, Quality of evidence high). In women with non-severe preeclampsia diagnosed between 37+0 and 41 weeks of gestation, it is recommended to induce birth to reduce maternal morbidity (Strong recommendation, Low quality of evidence), and to perform a trial of labor in the absence of contraindication (Strong recommendation, Very low quality of evidence). In women with a history of preeclampsia, screening maternal thrombophilia is not recommended (Strong recommendation, Quality of the evidence moderate). Because women with a history of a preeclampsia have an increased lifelong risk of chronic hypertension and cardiovascular complications, they should be informed of the need for medical follow-up to monitor blood pressure and to manage other possible cardiovascular risk factors (Strong recommendation, Quality of the evidence moderate). The purpose of these recommendations was to reassess the definition of preeclampsia, and to determine the strategies to reduce maternal and perinatal morbidity related to preeclampsia, during pregnancy but also after childbirth. They aim to help health professionals in their daily clinical practice to inform or care for patients who have had or have preeclampsia. Synthetic information documents are also offered for professionals and patients.

Chronic histiocytic intervillositis of unknown origin (CHI) is a rare placental disorder associated with adverse pregnancy outcomes, frequent recurrence, and a lack of effective preventive strategies. Recent insights indicate a potential link between CHI-associated inflammatory lesions and the inflammasome pathway, suggesting innovative therapeutic avenues. This study aims to elucidate the role of the inflammasome pathway in CHI through comprehensive transcriptomic analysis of grade 2 or 3 histopathologic CHI samples, paired with placental controls. Additionally, we present case studies of three individuals with recurrent CHI who received treatment with anakinra and colchicine throughout pregnancy, resulting in improved perinatal outcomes. Notably, all cases led to the birth of healthy, full-term infants, with reduced or absent intervillositis recurrence. Placental assessment unveiled heightened activation of the NLRP3-PYCARD inflammasome pathway and IL-1β processing in CHI samples, with downregulation observed in treated pregnancy samples devoid of intervillositis. Collectively, these findings suggest a potential therapeutic role for targeting the inflammasome pathway in preventing recurrent CHI in pregnant individuals. The molecular insights provided herein open doors for innovative interventions in managing this rare placental disorder, warranting further investigation and consideration.

BackgroundAlthough prophylactic tranexamic acid administration after cesarean delivery resulted in a lower incidence of calculated estimated blood loss of >1000 mL or red cell transfusion by day 2, its failure to reduce the incidence of hemorrhage-related secondary clinical outcomes (TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial) makes its use questionable. The magnitude of its effect may differ in women at higher risk of blood loss, including those with multiple pregnancies.ObjectiveThis study aimed to compare the effect of tranexamic acid vs placebo to prevent blood loss after cesarean delivery among women with multiple pregnancies.Study DesignThis was a secondary analysis of the TRAnexamic Acid for Preventing Postpartum Hemorrhage Following a Cesarean Delivery trial data, a double-blind, randomized controlled trial from March 2018 to January 2020 in 27 French maternity hospitals, that included 319 women with multiple pregnancies. Women with a cesarean delivery before or during labor at ≥34 weeks of gestation were randomized to receive intravenously 1 g of tranexamic acid (n=160) or placebo (n=159), both with prophylactic uterotonics. The primary outcome was a calculated estimated blood loss of >1000 mL or a red blood cell transfusion by 2 days after delivery. The secondary outcomes included clinical and laboratory blood loss measurements.ResultsOf the 4551 women randomized in this trial, 319 had a multiple pregnancy and cesarean delivery, and 298 (93.4%) had primary outcome data available. This outcome occurred in 62 of 147 women (42.2%) in the tranexamic acid group and 67 of 152 (44.1%) receiving placebo (adjusted risk ratio, 0.97; 95% confidence interval, 0.68–1.38; P=.86). No significant between-group differences occurred for any hemorrhage-related clinical outcomes: gravimetrically estimated blood loss, provider-assessed clinically significant hemorrhage, additional uterotonics, postpartum blood transfusion, arterial embolization, and emergency surgery (P>.05 for all comparisons).ConclusionAmong women with a multiple pregnancy and cesarean delivery, prophylactic tranexamic acid did not reduce the incidence of any blood loss–related outcomes.

OBJECTIVE:To identify strategies to reduce maternal and neonatal morbidity related to preeclampsia. MATERIAL AND METHODS:The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and recommendations were formulated as a (i) strong, (ii) weak or (iii) no recommendation. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS:Preeclampsia is defined by the association of gestational hypertension (systolic blood pressure≥140mmHg and/or diastolic blood pressure≥90mmHg) and proteinuria≥0.3g/24h or a Proteinuria/Creatininuria ratio≥30mg/mmol occurring after 20 weeks of gestation. Data from the literature do not show any benefit in terms of maternal or perinatal health from implementing a broader definition of preeclampsia. Of the 31 questions, there was agreement between the working group and the external reviewers on 31 (100%). In general population, physical activity during pregnancy should be encouraged to reduce the risk of preeclampsia (Strong recommendation, Quality of the evidence low) but an early screening based on algorithms (Weak recommendation, Quality of the evidence low) or aspirin administration (Weak recommendation, Quality of the evidence very low) is not recommended to reduce maternal and neonatal morbidity related to preeclampsia. In women with preexisting diabetes or hypertension or renal disease, or multiple pregnancy, the level of evidence is insufficient to determine whether aspirin administration during pregnancy is useful to reduce maternal and perinatal morbidity (No recommendation, Quality of the evidence low). In women with a history of vasculo-placental disease, low dose of aspirin (Strong recommendation, Quality of the evidence moderate) at a dosage of 100-160mg per day (Weak recommendation, Quality of the evidence low), ideally before 16 weeks of gestation and not after 20 weeks of gestation (Strong recommendation, Quality of the evidence low) until 36 weeks of gestation (Weak recommendation, Quality of the evidence very low) is recommended. In a high-risk population, additional administration of low molecular weight heparin is not recommended (Weak recommendation, Quality of the evidence moderate). In case of preeclampsia (Weak recommendation, Quality of the evidence low) or suspicion of preeclampsia (Weak recommendation, Quality of the evidence moderate, the assessment of PlGF concentration or sFLT-1/PlGF ratio is not routinely recommended) in the only goal to reduce maternal or perinatal morbidity. In women with non-severe preeclampsia antihypertensive agent should be administered orally when the systolic blood pressure is measured between 140 and 159mmHg or diastolic blood pressure is measured between 90 and 109mmHg (Weak recommendation, Quality of the evidence low). In women with non-severe preeclampsia, delivery between 34 and 36+6 weeks of gestation reduces severe maternal hypertension but increases the incidence of moderate prematurity. Taking into account the benefit/risk balance for the mother and the child, it is recommended not to systematically induce birth in women with non-severe preeclampsia between 34 and 36+6 weeks of gestation (Strong recommendation, Quality of evidence high). In women with non-severe preeclampsia diagnosed between 37+0 and 41 weeks of gestation, it is recommended to induce birth to reduce maternal morbidity (Strong recommendation, Low quality of evidence), and to perform a trial of labor in the absence of contraindication (Strong recommendation, Very low quality of evidence). In women with a history of preeclampsia, screening maternal thrombophilia is not recommended (Strong recommendation, Quality of the evidence moderate). Because women with a history of a preeclampsia have an increased lifelong risk of chronic hypertension and cardiovascular complications, they should be informed of the need for medical follow-up to monitor blood pressure and to manage other possible cardiovascular risk factors (Strong recommendation, Quality of the evidence moderate). CONCLUSION:The purpose of these recommendations was to reassess the definition of preeclampsia, and to determine the strategies to reduce maternal and perinatal morbidity related to preeclampsia, during pregnancy but also after childbirth. They aim to help health professionals in their daily clinical practice to inform or care for patients who have had or have preeclampsia. Synthetic information documents are also offered for professionals and patients.

Postpartum hemorrhage remains one of the principal causes of maternal mortality in the United States and throughout the world. Its management, which must be multidisciplinary (obstetrics, midwifery, anesthesiology, interventional radiology, and nursing), depends on the speed of both diagnosis and implementation of medical and surgical treatment to control the hemorrhage. The aim of this work is to describe the various techniques of vessel ligation and of uterine compression for controlling and treating severe hemorrhage, and to present the advantages and disadvantages of each. It is not difficult to perform vessel ligation of the uterine arteries: O'Leary's bilateral ligation of the uterine artery, Tsirulnikov's triple ligation, and AbdRabbo's stepwise uterine devascularization (that is, stepwise triple ligation). These procedures are associated with a high success rate (approximately 90%) and a low complication rate. Bilateral ligation of the internal iliac (hypogastric) arteries is more difficult to perform and potentially less effective (approximately 70% effectiveness) than the previously mentioned procedures. Its complication rate is low, but the complications are most often serious. There is no evidence that future fertility or subsequent obstetrical outcomes are impaired by ligation of either the uterine or internal iliac arteries. There are many techniques used for uterine compression sutures, and none has shown clear superiority to another. Uterine compression suture has an effectiveness rate of approximately 75% after failure of medical treatment and approximately 80% as a second-line procedure after unsuccessful vessel ligation. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but is probably around 5%. The risk of synechiae after uterine compression suture has not yet been adequately evaluated, but probably ranges between 5% and 10%. The methodologic quality of the studies assessing uterine-sparing surgical procedures remains limited, with no comparative studies. Accordingly, no evidence suggests that any one of these methods is better than any other. Accordingly, the choice of surgical technique to control hemorrhage must be guided firstly by the operator's experience. If the hemorrhage continues after a first-line uterine-sparing surgical procedure and the patient remains hemodynamically stable, a second-line procedure can be chosen. Nonetheless, the application of these procedures must not delay the performance of a peripartum hysterectomy in cases of hemodynamic instability.

OBJECTIVE:To assess severe short-term maternal and neonatal morbidity and pelvic floor disorders at 6 months postpartum after attempted operative vaginal delivery according to the instrument used.METHODS:We conducted a prospective study of women with live, singleton, term fetuses in vertex presentation. Patients attempted operative vaginal delivery in a French tertiary care university hospital from December 2008 through October 2013. We used multivariable logistic regression and propensity score methods to control for indication bias and compare outcomes associated with vacuum-assisted or forceps- or spatula-assisted delivery. Severe maternal and neonatal morbidity were composite primary endpoints. Symptoms of urinary incontinence (UI) and anal incontinence (AI) were assessed 6 months after delivery by validated self-administered questionnaires.RESULTS:Among 2,128 attempted operative vaginal deliveries, 30.7% (n=654) used vacuum and 69.3% (n=1,474) used forceps or spatulas. Severe maternal morbidity occurred in 5.4% (n=35; 95% CI 3.8-7.4) of vacuum attempts and 10.5% (n=154; 95% CI 8.3-12.1) of forceps or spatula attempts (P<.001); severe neonatal morbidity occurred in 8.4% (n=55; 95% CI 6.4-10.8) and 10.2% (n=155; 95% CI 8.7-11.8), respectively (P=.2). Although attempted operative vaginal deliveries with forceps or spatula were significantly associated with more frequent severe maternal morbidity (adjusted odds ratio [aOR] 1.99 95% CI 1.27-3.10) in the multivariable logistic regression analysis, this association was no longer significant after propensity score matching (aOR 1.46 95% CI 0.72-2.95). Attempted operative vaginal deliveries with forceps or spatula were not significantly associated with more frequent severe neonatal morbidity after multivariable logistic regression or propensity score matching. Among the 934 women (43.9%) who responded to questionnaires at 6 months, the prevalence of symptoms of UI and AI were 22.7% and 22.0%, respectively, with no significant differences between the groups.CONCLUSION:In singleton term pregnancies, neither severe short-term maternal or neonatal morbidity nor UI or AI were more frequent after attempted operative vaginal delivery by forceps or spatulas than by vacuum after controlling for indication bias with a propensity score analysis.

Our main objective was to assess maternal and neonatal morbidity according to the planned mode of delivery -trial of labor (TOL) or elective cesarean delivery (ECD)- for women with low-lying placenta. Women with low-lying placenta defined as a cervix-to-placenta distance ≤ 20 mm, confirmed by the last prenatal transvaginal ultrasound scan, who gave birth after 35 weeks of gestation from 2007 to 2012 were identified from the databases of 6 tertiary perinatal centers and classified as TOL or ECD. The main endpoint was severe postpartum hemorrhage (PPH), defined as blood loss above 1,000mL. Secondary outcomes were composites: PPH-related outcomes and severe maternal and neonatal morbidity. We used multivariate logistic regression and propensity score methods to control indication bias to compare outcomes according to the planned mode of delivery. Among 171 women with low-lying placenta (0.13%), 59.1% were in TOL group (n=70) and 40.9% in ECD group (n=101). Maternal and obstetric characteristics did not differ between the two groups except for the rates of previous cesarean delivery and recurrent episodes of antepartum hemorrhage and for the interval between delivery and last ultrasound scan that were higher in the ECD group, and for the cervix-to-placenta distance that was higher in the TOL group. The vaginal delivery rate in TOL group was 38.6% (n=27). Severe PPH occurred in 22.9% in TOL group and in 23.9% in ECD group (p=0.9). No significant association between trial of labor and severe PPH was found in multivariable logistic regression (aOR 1.64 95%CI 0.53-3.28) or propensity score weighted model (aOR 1.34 95%CI 0.53-3.38). Compared with women with elective cesarean delivery, women with trial of labor had similar rates of PPH-related outcomes, severe maternal and neonatal morbidity. Among women with low-lying placenta, trial of labor at or near term does not increase severe PPH or maternal and neonatal morbidity compared with elective cesarean delivery and produces an acceptable rate of vaginal delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

L’objectif de cette revue de la littérature est d’émettre des recommandations concernant les premiers gestes et soins apportés au nouveau-né bien portant. Consultation de la base de données Medline, de la Cochrane Library et des recommandations des sociétés savantes françaises et étrangères. L’évaluation initiale du nouveau-né permet de déterminer rapidement si des manœuvres de réanimation sont nécessaires (Avis d’Expert [AE]). Toute anomalie nécessite un recours au pédiatre (AE). Chez un nouveau-né sans difficultés d’adaptation cardiorespiratoire, le clampage retardé du cordon peut être considéré comme une modalité plus physiologique de l’accouchement, pouvant aider à prévenir une carence en fer au cours des premiers mois de vie, sans effet délétère pour l’enfant ou sa mère, en dehors du risque d’ictère néonatal légèrement augmenté (grade C). Afin d’éviter la séparation de la femme et de son enfant, il est recommandé de différer les soins de routine laissant la place au contact peau-à-peau entre la mère, si elle le souhaite, et son nouveau-né selon un protocole de surveillance défini (grade B). L’allaitement maternel doit être encouragé et accompagné surtout lors de la première mise au sein (AE). En l’absence de signes cliniques évocateurs, l’aspiration des voies aériennes supérieures et la vérification systématique de la perméabilité des choanes et de l’œsophage ne sont pas recommandées (AE). La prévention de la maladie hémorragique du nouveau-né par l’administration orale de vitamine K1 à tous les enfants nés à terme débute en salle de naissance, de préférence en présence des parents et après avoir recueilli leur consentement (AE). À la naissance d’un nouveau-né sain, il est fortement conseillé d’éviter les gestes techniques inutiles et de privilégier la relation mère–enfant dans un climat de sécurité. The purpose of this literature review is to make recommendations regarding the first steps and care provided to the healthy newborn. Consultation of the Medline database, and of national and international guidelines. The initial assessment of the newborn should quickly determine whether resuscitation is necessary or not. Any anomaly requires the help of the pediatrician (Consensus agreement). For a newborn with no cardiorespiratory adaptation, delayed cord clamping may be considered more as a physiological modality of delivery, which may help prevent iron deficiency in the first months of life, without deleterious effects for the child or his/her mother, apart from a slightly increased risk of neonatal jaundice (grade C). In order to avoid separating a woman and her child, it is recommended to postpone routine postnatal procedures, to allow for skin-to-skin contact between the mother and the newborn, if she wishes, according to a defined/specified surveillance protocol (grade B). Breastfeeding should be encouraged, and supported, especially the first time (Consensus agreement). In the absence of suggestive clinical signs, aspiration of the upper airways and systematic verification of the permeability of posterior nasal apertures and of the esophagus are not recommended (Consensus agreement). The prevention of hemorrhagic disease of the newborn by the oral administration of vitamin K1 to all healthy term babies begins in the delivery room, preferably in the presence of the parents and after having obtained their consent (Consensus agreement). Regarding the birth of a healthy newborn, it is strongly advised to avoid unnecessary technical actions and to favor the mother–child relationship in a safe environment.

There is a paucity of data on sex with bleeding in the first trimester of pregnancy. The sexuality of couples is highly diverse, and sexual intercourse frequently declines from the start of pregnancy. An increased risk of miscarriage in the first trimester has been reported when intercourse is associated with bleeding. However, it is impossible to assign a deleterious role for sex in this statistically significant association between bleeding and first-trimester miscarriage. Overall, there seems to be no danger associated with sexual activity of whatever type during pregnancy.

OBJECTIVE:To compare outcomes of women with low-lying placenta by planned mode of delivery and distance from the internal os distance. METHODS:Six tertiary maternity hospitals in France participated in this retrospective multicenter study of births from 2007-2012. Women with low-lying placenta , defined as an internal os distance of 20 mm or less, who gave birth after 35 weeks of gestation were included and classified in the planned trial-of-labor or elective cesarean delivery groups. The primary endpoint was severe postpartum hemorrhage (PPH) defined as blood loss exceeding 1,000 mL. Secondary outcomes were composite variables of severe maternal and neonatal morbidity. We used multivariable logistic regression and propensity scores to compare outcomes by planned mode of delivery. RESULTS:Among 128,233 births during the study period, 171 (0.13%) women had low-lying placenta: 70 (40.9%) in the trial-of-labor group and 101 (59.1%) who underwent elective cesarean delivery. The rate of severe PPH was 22.9% (16/70, 95% CI 13.7-34.4) for the trial-of-labor group and 23.0% (23/101, 95% CI 15.2-32.5) for the cesarean delivery group ( P =.9); severe maternal and neonatal morbidity rates were likewise similar (2.9% vs 2.0% [ P =.7] and 12.9% vs 9.9% [ P =.5], respectively). Trial-of-labor was not significantly associated with a higher rate of severe PPH after multivariable logistic regression and propensity score-weighted analysis (adjusted odds ratio [aOR] 1.42, 95% CI 0.62-3.24 [ P =.4]; and aOR 1.34, 95% CI 0.53-3.38 [ P =.5], respectively). The vaginal delivery rate in the trial-of-labor group was 50.0% (19/38) in those with an internal os distance of 11-20 mm and 18.5% (5/27) in those with a distance of 1-10 mm. CONCLUSION:Our results support a policy of offering a trial of labor to women with low-lying placenta after 35 weeks of gestation and an internal os distance of 11-20 mm. An internal os distance of 1-10 mm reduces the likelihood of vaginal birth considerably, compared with 11-20 mm, but without increasing the incidence of severe PPH or severe maternal morbidity.

(N Engl J Med. 2021;384:1623–1634. doi: 10.1056/NEJMoa2028788. PMID: 33913639) As postpartum hemorrhage (PPH) is a common and potentially deadly complication worldwide, mitigating and reducing the risk of PPH is critical. Tranexamic acid (TXA) has recently been given to reduce postpartum blood loss as it reduces the breakdown of blood clots in the body and slows bleeding, decreasing the risk of adverse outcomes and mortality of hemorrhaging postpartum women. Smaller studies have suggested that prophylactic administration of TXA reduces postpartum blood loss following a cesarean delivery, and this study aims to provide evidence-based conclusions to corroborate those findings.

Chronic intervillositis of unknown etiology (CIUE) is a rare placental disease characterized by intervillous infiltration of maternal macrophages and associated with poor pregnancy outcomes and a high risk of recurrence in subsequent pregnancies. Its pathophysiology remains unclear and prognostic factors have not yet been established. In addition, clear relationships between the histologic extent of lesions and the severity of perinatal outcomes have not been demonstrated. Our objectives were to validate a CIUE classification system based on the gradation of macrophagic infiltration of the intervillous space, and to attempt to correlate these results with perinatal outcomes. For this multicenter retrospective study, 3 pathologists reviewed all cases diagnosed with "intervillositis" between 1997 and 2018. Confirmed CIUE cases were semiquantitatively graded based on the percentage of macrophagic infiltrate in the intervillous space: grade 1 (5% to 10%), grade 2 (10% to 50%), and grade 3 (>50%). Multiple pregnancies and pregnancies with medical follow-up completed outside of the study centers were excluded. In total, 122 cases of CIUE in 102 patients were included in the study. Microscopic classification based on one criterion was easy to perform, and interobserver correlation was good. Grade 3 infiltration was strongly associated with poor perinatal outcomes and fetal growth restriction (P<0.0001). After delivery, only 16.1% of newborns from the grade 3 CIUE group were alive, compared with 59% from the grade 2 and 86.5% from the grade 1 group (P=0.0002). Recurrence risk was associated with CIUE gradation of the index case (P=0.004), with 95% of recurrent CIUE cases being from patients with grades 2 and 3 CIUE. In this study, conducted with the largest CIUE cohort to date, a classification based only on the degree of macrophagic infiltration of the intervillous space was validated, and this classification was shown to be strongly associated with poor perinatal outcomes and risk of recurrence.

OBJECTIVE: To evaluate the effectiveness and safety of an intrauterine vacuum-induced hemorrhage-control device for postpartum hemorrhage treatment. METHODS: A multicenter, prospective, single-arm treatment study of a novel intrauterine device that uses low-level vacuum to induce uterine myometrial contraction to achieve control of abnormal postpartum uterine bleeding and postpartum hemorrhage was undertaken at 12 centers in the United States. The primary effectiveness endpoint was the proportion of participants in whom use of the intrauterine vacuum-induced hemorrhage-control device controlled abnormal bleeding without requiring escalating interventions. The primary safety endpoint was the incidence, severity, and seriousness of device-related adverse events. Secondary outcomes included time to bleeding control, rate of transfusion, and device usability scored by each investigator using the device. RESULTS: Of 107 participants enrolled with primary postpartum hemorrhage or abnormal postpartum uterine bleeding, 106 received any study treatment with the device connected to vacuum, and successful treatment was observed in 94% (100/106, 95% CI 88–98%) of these participants. In those 100 participants, definitive control of abnormal bleeding was reported in a median of 3 minutes (interquartile range 2.0–5.0) after connection to vacuum. Eight adverse events deemed possibly related to the device or procedure were reported, all of which were outlined as risks in the study and all of which resolved with treatment without serious clinical sequelae. Transfusion of 1–3 units of red blood cells was required in 35 participants, and five participants required 4 or more units of red blood cells. The majority of investigators reported the intrauterine vacuum-induced hemorrhage-control device as easy to use (98%) and would recommend it (97%). CONCLUSION: Intrauterine vacuum-induced hemorrhage control may provide a new rapid and effective treatment option for abnormal postpartum uterine bleeding or postpartum hemorrhage, with the potential to prevent severe maternal morbidity and mortality. FUNDING SOURCE: Alydia Health, Inc. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02883673.

Objective The objective of these guidelines is to define for women at 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 risk of general anesthesia (grade B). It is recommended to carry out a low 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 7 cm 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 30 minutes but not more than 60 minutes 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 30 seconds in neonates, not requiring resuscitation (grade C). It is recommended that the first oral dose (2 mg) of vitamin K (Consensus agreement) be given systematically within two hours of birth. Conclusion These guidelines allow women at obstetric risk to benefit from a better quality of care and optimal safety conditions while respecting the physiology of delivery.

Intentional retention of the placenta (IRP), or 'conservative' treatment or management, entails opening the uterus, delivering the baby, tying and cutting the umbilical cord at its placental insertion site, leaving the placenta in the uterus and waiting for its complete spontaneous resorption in women with placenta accreta spectrum (PAS). The uterine preservation rate with this approach is about 78%, and severe maternal morbidity about 6%; these rates are respectively lower and higher in subgroups of women with placenta percreta. IRP has become a recommended option for women with PAS reluctant to undergo caesarean-hysterectomy and wanting to preserve their fertility, after appropriate information about the uterine preservation rate, but also the risk of a subsequent emergency hysterectomy due to unpredictable haemorrhage and/or infection, and the need for follow-up with regular visits for several months. Some authorities also recommend IRP when hysterectomy is at very high risk of surgical complications.

Objective: To determine the optimal management of singleton fetuses in breech presentation. Materials and methods: Consultation of the PubMed database, the Cochrane Library and guidelines issued by the French and foreign obstetrical societies or colleges.Results: In France, 5% of women have breech deliveries (level of evidence [LE] 3). One third of them have a planned vaginal delivery (LE3), and 70% of these give birth vaginally (LE3). External cephalic version (ECV) is associated with lower rates of both breech presentation at birth (LE2) and of cesarean deliveries (LE3) without any increase in severe maternal (LE3) or perinatal morbidity (LE3). Women with a fetus in breech presentation at term should be informed that ECV can be attempted starting at 36 weeks of gestation (professional consensus).Planned vaginal delivery of breech presentation may be associated with a higher risk of composite perinatal mortality or serious neonatal morbidity than planned cesarean birth (LE2). These two modes do not differ for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), or adult intellectual performance (LE4). Shortand long-term maternal complications appear similar in the two groups, unless subsequent pregnancies are under consideration. Pregnancies after a cesarean delivery are at higher risk of uterine rupture, placenta accreta spectrum disorders, and hysterectomy (LE2). Women who want a planned vaginal delivery should be offered a pelvimetry at term (Grade C) and should have ultrasonography to verify that the fetal head is not hyperextended (professional consensus) to plan their mode of delivery. Complete breech presentation, a previous cesarean, nulliparity, and term prelabor rupture of membranes are not, each one by itself, per se contraindications to planned vaginal delivery (professional consensus). Term breech presentation is not a contraindication to labor induction when the criteria for planned vaginal delivery are met (Grade C).Conclusion: In cases of breech presentation at term, the child and the mother are at low risk of severe morbidity after either planned vaginal or planned cesarean delivery. The French College of Obstetricians and Gynecologists (CNGOF) considers that planned vaginal delivery is a reasonable option in most cases (professional consensus). The decision about the planned route of delivery should be shared by the woman and her healthcare provider, who must respect her right to autonomy. (c) 2020 Elsevier B.V. All rights reserved.