The obstetrical follow-up of patients with a severe hypofibrinogenemia requires a multidisciplinary collaboration because of potential maternal-fetal complications (recurrent miscarriages, intrauterine fetal demise, post-partum hemorrhage, thrombosis). We report the obstetrical management of a multiparous patient with a severe congenital hypofibrinogenemia associated with a platelet disorder (abnormal phospholipid externalization). A therapeutic strategy based on a biweekly administration of fibrinogen concentrates associated with enoxaparin and aspirin allowed the maintenance of pregnancy. But this last one got complicated by a placenta percreta requiring a salvage hysterectomy with an appropriate hemorrhage prophylaxis.

INTRODUCTION:Spontaneous rupture of membranes before 37 weeks of amenorrhea (preterm premature rupture of membranes [pPROM]) is associated with two main complications: prematurity and fetal infection. Biological parameters, particularly C-reactive protein (CRP) levels, were monitored during a continued pregnancy. Group A represented our previous practice, that is, regular CRP monitoring with induced birth or cesarean section after two consecutive levels above 20 mg/L. Group B represented our practice after the publication of the national recommendations and the absence of induced delivery based on an isolated CRP level with no sign of intrauterine infection. This study aimed to assess the effect of these recommendations on neonatal morbidity and mortality rates. MATERIAL AND METHODS:This retrospective bicentric cohort study included 169 singleton pregnancies with pPROM <32 weeks, managed in 2017-2018 (Group A, n = 96) and 2020-2021 (Group B, n = 73). Maternal characteristics, inflammatory markers, delivery modalities, and neonatal outcomes were compared. Multivariate logistic regression using Firth's penalized likelihood method was employed to identify independent predictors of fetal mortality and severe neonatal morbidity. RESULTS:Group B showed higher rates of early-onset neonatal infection (19.2 % vs. 7.3 %, p = 0.03), elevated CRP levels at birth, and more frequent positive neonatal blood cultures (5.5 % vs. 0 %, p = 0.04). Histological chorioamnionitis was also more prevalent (71.2 % vs. 50 %, p < 0.005). In multivariate analysis, fetal mortality was independently associated with shorter latency between rupture and delivery and male fetal sex. Belonging to Group B was associated with lower odds of fetal death (OR 0.15, 95 % CI [0.02-1.01], p = 0.05). Severe neonatal morbidity was significantly associated with lower birth weight (OR 3.76, 95 % CI [1.56-9.02], p = 0.003), while CRP evolution, latency, sex, and gestational age at birth were not independent predictors. CONCLUSION:Severe neonatal morbidity remained frequent and was primarily influenced by fetal maturity factors, notably birth weight. These results suggest that while a less interventionist approach may be safe for maternal outcomes, careful monitoring is essential to prevent infectious complications. CRP remains a useful biomarker, but its interpretation must consider context and timing of intervention.

( Lancet . 2023;402(10417)2091–2100. doi: 10.1016/S0140-6736(23)01803-2) Oxytocin is a widely used drug worldwide, employed in either labor induction or labor augmentation. However, ambiguities persist regarding the ideal length of oxytocin delivery and its potential impact on neonatal and maternal outcomes. A previous clinical trial conducted in 2021 found a trivial rise in cesarean deliveries when oxytocin was discontinued, although this difference lacked both clinical and statistical significance. The current study sought to assess the effects of discontinuing oxytocin during the active phase of labor on neonatal morbidity and maternal complications.

Oxytocin is effective in reducing labor duration but can be associated with fetal and maternal complications. Previous studies evaluating discontinuous oxytocin were underpowered to show a reduction in neonatal morbidity. We aimed at evaluating the impact of discontinuing oxytocin during the active phase on neonatal morbidity. STOPOXY was a multicenter, randomized, open-label trial including women with a live term cephalic singleton, receiving oxytocin before 4cm. Women < 18 years with a scarred uterus, multiple pregnancy, fetal malformation, IUGR or abnormal FHR were excluded. Women were randomized < 6cm when oxytocin was continued or discontinued. The primary outcome, neonatal morbidity was assessed using a composite variable defined by an umbilical arterial pH < 7.10 and/or base excess > 10 mmol/L and/or umbilical arterial lactates > 7 mmol/L and/or 5min Apgar score < 7 and/or admission in NICU. Secondary outcomes included neonatal complications, duration of active first stage, delivery mode and maternal complications. The two groups were compared using an intention to treat analysis. We randomized 2367 women, 1175 in the intervention group (discontinuous oxytocin) and 1192 in the control group (continuous oxytocin). The population was composed of 55.8% primiparous with a median age of 32 years, and BMI of 24.1 kg/m2. The neonatal morbidity rate was 12.4% in the intervention group and 12.4% in the control group (p=0.96). Cesarean delivery rates and PPH rates were comparable between the two groups (18.8% vs 16.5%, p=0.22 and 12.9% vs 12.6%, p=0.84). Apart from active first stage duration which was significantly higher in the intervention group (100min, IQR[50;208] vs 90min, [45;150], p=0.001), there were no significant differences between the groups. Discontinuing oxytocin during the active phase of labor did not improve neonatal morbidity or increase other neonatal or maternal outcomes.

(Abstracted from Lancet 2023;402:2091–100) Oxytocin is commonly used as part of the induction or augmentation of labor. It is administered to increase the frequency and intensity of uterine contractions, which can reduce labor duration.

We read the article by Spencer and Saad1 entitled "Perforation with Bakri balloon into broad ligament during management of postpartum hemorrhage" with great interest, and we thank the authors for this interesting case report.

Disseminated peritoneal leiomyomatosis (DPL) is a rare disease entity belonging to the category of smooth muscle tumours of uncertain growth. It is characterized by proliferation of multiple smooth muscle nodules in the peritoneal cavity mimicking a malignant process such as peritoneal carcinomatosis but which when studied histologically proves to be of benign nature. Its origin is still unknown. Genomic analysis of DPL cases is of interest in order to understand its pathogenesis and subsequent course, but there are few extant studies. In this article we set out the genomic profiles, analysed by array-based comparative genomic hybridization (array-CGH), of peritoneal and uterine lesions in two cases of DPL detected after previous uterine morcellation for fibroids, as well as a "sporadic" case of DPL. Array-CGH findings revealed in all three cases a flat genomic profile. It is not possible to establish a genetic lineage between two lesions on the basis of the genomic profiles alone, owing to the absence of an unbalanced rearrangement. CGH is not conclusive enough in this type of disorder. Analysis of the exome could provide us with fresh information, not least about driving events in the cancerogenesis of these tumours.

Purpose: The aim of our study was to determine the risk factors and to describe the clinical presentation of women with uterine rupture without previous caesarean delivery. Methods: Case-control study involving all cases of uterine rupture in the unscarred uterus detected during labour or in the post-partum between January 1, 2004 and April 1, 2016. For the control we included four controls for one case among all the patients with no record of previous caesarean delivery and planned vaginal delivery in the same period. For each woman we collected the maternal and labour characteristics. We evaluate the risk factors of uterine rupture, using Bayesian’s method. Each result is presented as a differential with a 95% credibility interval and the probability that the difference is greater or less than 0 (or 1 for the odds ratio). Results: We identified seven cases of spontaneous rupture. Deep and variable decelerations were the most frequent abnormal fetal rhythm. There was not maternal death but one neonatal death. Multiparity (estimated difference of 1.59 (95% CI=0.55, 2.95) Pr (diff>0)=1); use of oxytocin (OR=26.4 (95% CI=1.79-103) Pr (diff>0)=0.99), induced labour (OR=14 (95% CI=2.5, 122) Pr (diff>0)=1) ultrasound macrosomia (OR 30.0 (95% CI=4.3-327) Pr (diff>0)=0.99), were associated with uterine rupture. Conclusion: Even in developed countries, uterine rupture remains a serious complication with high maternal and fetal morbidity. We identified some risk factors like multiparity, induction of labour and macrosomia. These factors can help us to detect earlier this complication.

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 rnorbimortality. 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 morbirnortality 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. (C) 2016 Elsevier Masson SAS. All rights reserved.

Introduction: The aim of our study was to determine the risk factors and to describe the clinical presentation of women with uterine rupture without previous caesarean delivery. Material and methods: Case–control study involving all cases of uterine rupture in the unscarred uterus detected during labor or in the post-partum between January 1, 2004 and January 1, 2015. For the control we included all the patients with no record of previous caesarean delivery and planned vaginal delivery in the same period. For each women we collected the maternal and labor characteristics. We evaluate the risk factors of uterine rupture, using Bayesian's method. Each result is presented as a differential with a 95% credibility interval and the probability that the difference is greater or less than 0 (or 1 for the odds ratio). Results: We identified six cases of spontaneous rupture. Deep and variable decelerations were the most frequent abnormal fetal rhythm. There was not maternal death but one neonatal death. Maternal age (estimated difference of 5.11 (95%CI 0.75, 9.43) Pr(diff > 0) = 0.99); parity (estimated difference of 1.8 (95%CI 0.68, 3.29) Pr(diff > 0) = 1); use of oxytocin (OR 9.59 (95%CI 1.5–79.2) Pr(diff > 0) = 0.99), ultrasound macrosomia (OR 17.5 (95%CI 4.1–776) Pr(diff > 0) = 0.99), were associated with uterine rupture. Conclusion: Even in developed countries uterine rupture remains a serious complication with high maternal and fetal morbidity. We identified some risk factors like multiparity, induction of labor and macrosomia. This factors can help us to detect earlier this complication.

Pituitary apoplexy is related to a bleeding, or less frequently an infarct, occurring in most cases on a preexisting adenoma. Its incidence during pregnancy is rare, and its management is controversial. We report a case of a 33-year-old patient, with no medical history, presenting to our consultation at the gestational age of 33 weeks and six days of her third pregnancy with acute headache. Cerebral magnetic resonance imaging (MRI) with venous sequences, showed a fluid level on an unknown median pituitary adenoma, lateralized on the right side with moderate suprasellar extension, without optic chiasm compression. Its size was 13 mm × 13 mm and it was related to a hemorrhagic necrosis of the pituitary gland. The patient was admitted in the obstetrics department. Her ophthalmologic surveillance (visual field and ocular fundus) was uneventful. Considering the absence of any visual trouble, we did not introduce any medical treatment and no surgery was performed. After multidisciplinary consultation, including obstetricians, endocrinologists and neurosurgeons, a vaginal delivery was accepted. The patient delivered normally at the gestational age of 39 weeks and one day, a 3360 g girl with favorable neonatal evolution. To our knowledge, this is the first case of hemorrhagic necrosis of the pituitary gland, occurring on an unknown adenoma, on a third trimester pregnant woman. Only eight cases were described in the literature and were all related to adenomas diagnosed before the pregnancy. Therapeutic abstention chosen by our team remains exceptional. Indeed, regarding all the cases already described, four patients were treated medically (two by bromocriptine and two by hydrocortisone) and four underwent surgical treatment by a transsphenoidal approach. Hemorrhagic necrosis of the pituitary gland during pregnancy is rare. There is no consensus on its treatment and the mode of delivery, which remain controversial. A multidisciplinary evaluation appears mandatory.

Objective: The aim of this study was to assess the benefit of umbilical cord drainage through cord blood collection (CBC) for the prevention of post-partum hemorrhage (PPH).Methods: This is a retrospective cohort study based on data collected prospectively including all vaginal delivery of singletons pregnancies after 37 weeks of gestation between July 2011 and May 2013 at the Strasbourg Teaching Hospital. We performed a univariate comparison of PPH risk factors with chi(2) tests and then we built multivariate logistic regressions to predict PPH, severe PPH (41000 cc), retained placenta over 30 min and manual removal of the placenta.Results: A total of 7810 vaginal deliveries were analyzed, among which 1957 benefited from CBC (25%). In the CBC group, 71 PPH (3.6%) were observed versus 260 (4.4%) in the control group (p = 0.12). In multivariate analysis, after adjustment on PPH risk factors, CBC revealed to be a protective factor of PPH: OR = 0.69 (95% CI 0.50-0.97; p = 0.03). CBC is neither a significant predictive factor of severe PPH, time to placental delivery nor rate of manual removal of the placenta.Conclusions: In our study, CBC and thus umbilical cord drainage was a protective factor against PPH but it did reduce neither retained placenta nor the need for artificial placental delivery.

Le cerclage a pour but de renforcer non seulement les propriétés mécaniques du col utérin, mais également ses propriétés immunologiques et anti-infectieuses. La mise en évidence d’une forte intrication entre insuffisance cervicale, longueur du col diminuée à l’échographie endovaginale et infection a modifié les indications de cerclage. On peut ainsi aujourd’hui distinguer 3 types de cerclages : le cerclage prophylactique pour antécédents, le cerclage thérapeutique pour longueur de col diminuée à l’échographie chez des patientes à risque et le cerclage en urgence pour col menaçant à l’examen physique. La technique de cerclage la plus recommandée est celle de McDonald. En cas d’échec, on propose de réaliser des cerclages plus haut placés par voie vaginale ou par voie abdominale.

Notre objectif est de faire le point sur les résultats de la rééducation périnéale dans le traitement de l’incontinence urinaire et des symptômes du prolapsus génital. Le renforcement des muscles du plancher pelvien permet de réduire les symptômes de l’incontinence urinaire. La rééducation encadrée par un rééducateur permet une guérison dans plus de la moitié des cas de l’incontinence urinaire d’effort. La visualisation de la contraction grâce au biofeedback améliore les résultats, mais cet effet pourrait être expliqué par une prise en charge plus intense et prolongée avec le rééducateur. La place de l’électrostimulation reste à préciser. Les résultats obtenus grâce à l’utilisation des cônes vaginaux sont équivalents au renforcement musculaire avec ou sans biofeedback ou à l’électrostimulation. On ne sait pas si l’effet de la rééducation périnéale avec renforcement musculaire a encore un effet après un an. Dans l’incontinence urinaire d’effort, la rééducation périnéale encadrée par un rééducateur en première intention évite l’intervention chirurgicale dans la moitié des cas à un an. La rééducation périnéale est le traitement de première intention de l’incontinence urinaire du post-partum. Son effet préventif est incertain. Le renforcement des muscles du plancher pelvien semble réduire les symptômes associés au prolapsus génital. En conclusion, la rééducation périnéale encadrée par un rééducateur est un traitement efficace, à court terme, pour réduire les symptômes d’incontinence urinaire ou de prolapsus génital.Our goal is to provide an update on the results of pelvic floor rehabilitation in the treatment of urinary incontinence and genital prolapse symptoms. Pelvic floor muscle training allows a reduction of urinary incontinence symptoms. Pelvic floor muscle contractions supervised by a healthcare professional allow cure in half cases of stress urinary incontinence. Viewing this contraction through biofeedback improves outcomes, but this effect could also be due by a more intensive and prolonged program with the physiotherapist. The place of electrostimulation remains unclear. The results obtained with vaginal cones are similar to pelvic floor muscle training with or without biofeedback or electrostimulation. It is not known whether pelvic floor muscle training has an effect after one year. In case of stress urinary incontinence, supervised pelvic floor muscle training avoids surgery in half of the cases at 1-year follow-up. Pelvic floor muscle training is the first-line treatment of post-partum urinary incontinence. Its preventive effect is uncertain. Pelvic floor muscle training may reduce the symptoms associated with genital prolapse. In conclusion, pelvic floor rehabilitation supervised by a physiotherapist is an effective short-term treatment to reduce the symptoms of urinary incontinence or pelvic organ prolapse.

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 24 hours and 6 weeks 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. (C) 2014 Published by Elsevier Masson SAS.

To evaluate the efficacy and safety of induction in women with a single prior Caesarean section.

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 16.9-13.1]), gestational hypertension (OR 7.4; 95% CI [5.1-10.8]), preeclampsia (OR 2.9; 95% CI 11.9-4.6]) and major multiparity (OR 1.6; 95% CI [1.1-2.41). 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. (C) 2014 Elsevier Ireland Ltd. All rights reserved.