Our primary objective was to evaluate the prediction of difficult vaginal operative delivery based on ultrasound measurement of the perineum-fetal head distance. The secondary objective was to assess the inter-observer variability of this technique. This was a prospective observational study that included women with a singleton pregnancy of ≥ 34 weeks of gestation, in cephalic presentation, requiring operative delivery. Ultrasound measurement of the perineum-fetal head distance was performed before attempting fetal extraction, according to a technique previously described (Figure 1). All the data relative to the operative delivery itself, so as the potential confounding factors were collected according to pre-specified items. A total of 659 patients were included: 593 (90%) vacuum extraction and 66 forceps extraction (10%). The ultrasound measurement of perineum-fetal head distance was significantly higher in case of detachment of the vacuum cup (≥1), the need for another instrument, duration of extraction longer than 10 minutes, a difficult extraction according to the operator thoughts, a shoulder dystocia requiring an obstetrical manoeuver (Table 1). The best cut-off value of perineum-fetal head distance to predict a difficult operative delivery (composite outcome) was 4 cm, based on ROC curve analysis (AUC 0.63, 95%CI 0.58-0.69). In multivariate analysis, a perineum-fetal head distance above 4 cm was predictive of a difficult operative delivery (composite outcome) with an OR of 2.38 (95%CI 1.51-3.74, p=0.002), after adjustment on parity, fetal occiput position (anterior or posterior), and fetal weight. The inter-observer correlation was 96.1% (95%CI 95.1-96.9, p<0.0001). Ultrasound measurement of the perineum-fetal head distance is a relevant and reproducible tool to predict difficult vaginal operative delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

INTRODUCTION:The objective of this study was to compare neonatal respiratory morbidity and rate of emergency caesarean section between elective caesarean sections at 38 gestational weeks following a course of corticosteroids and planned caesarean sections at 39 gestational weeks.MATERIAL AND METHODS:This was a multicentre randomised controlled trial. The study was conducted between 2007 and 2013 in level 2 and 3 maternity units in France. A total of 208 women with an indication for elective caesarean section were enrolled and 200 analysed in per-protocol analysis. Women were randomised to either elective caesarean section at 38 gestational weeks after a course of corticosteroids (trial group) or elective caesarean section at 39 weeks (control group). The primary outcome was the rate of admission to the neonatal intensive care unit for respiratory distress.RESULTS:Two (2.1%) newborn in the tested group were admitted because of respiratory distress versus four (3.8%) in the control group. The relative risk was 0.54 in favour of the corticosteroid group (95% CI: 0.10; 2.86). There were fewer emergency caesareans in the trial group than in the control group: 12 (12.69%) versus 28 (26.67%), p=0.01.CONCLUSIONS:Our study suggests that planning caesarean sections at 38 gestational weeks after a course of corticosteroids would enable a significant reduction in the number of emergency caesareans without increasing the risk of neonatal respiratory distress. Limitations of this study include difficulties in patient recruitment and the small number of subjects.

BACKGROUND: Clinical assessment of fetal head station is difficult and subjective; it is mandatory before attempting operative vaginal delivery.OBJECTIVE: The principal objective of our study was to assess whether measurement of the perineum-to-skull ultrasound distance was predictive of a difficult operative vaginal delivery. Secondary objectives included evaluation of the interobserver reproducibility of perineum-to-skull ultrasound distance and comparison of this measurement and digital examination in predicting a difficult operative delivery.STUDY DESIGN: This was a prospective cohort study including all cases of operative vaginal deliveries in singleton pregnancies in cephalic presentation >34 weeks' gestation, from 2012 through 2015. All data were entered prospectively in a medical record system specially devised to meet the requirements of this study.RESULTS: Of the 659 patients in whom perineum-to-skull ultrasound distance was measured prior to operative vaginal delivery, 120 (18%) met the composite criterion for a difficult extraction. Perineum-to-skull ultrasound distance measurement of >= 40 mm was significantly associated with the occurrence of a difficult extraction based on the composite criterion, after adjustment for parity, presentation type, and fetal macrosomia (odds ratio, 2.38; 95% confidence interval, 1.51-3.74; P = .0002). The intraclass correlation coefficient between the perineum-to-skull ultrasound distance measured by the first operator and that measured by the second operator was 0.96 (95% confidence interval, 0.95e0.97; P < .0001). Based on the receiver operating characteristic curve analyses, perineum-to-skull ultrasound distance was a more accurate predictor of difficult operative delivery than digital vaginal examination (P = .036).CONCLUSION: Measurement of the perineum-fetal skull ultrasound distance is a reproducible and predictive index of the difficulty of instrumental extraction. Ultrasound is a useful supplementary tool to the usual clinical findings.

Background: Several studies have investigated the efficacy of moxibustion with or without acupuncture for fetal version, but the results are discordant. Meta-analyses pointed out the need for robust, methodologically sound, randomized controlled trials.Objective: The objective of this study was to assess the effectiveness of acupuncture with fire needling on acupoint BL67 for version of breech presentation.Study design: This was a randomized, sham-controlled, single-blinded trial, which took place in Strasbourg teaching maternity hospital, France. A total of 259 patients between 32 and 34 weeks of gestation have been randomized and analyzed. Patients were randomized to either acupuncture with fire needling or sham group, and were analyzed in their initial allocation group. Statistical analysis was conducted using Bayesian methods, in univariate analysis and in multivariate analysis after adjustment on parity.Results: The primary outcome was the rate of cephalic presentations at ultrasound examination performed between 35 and 36 weeks of gestation. A total of 49 (37.7%) fetuses were in cephalic presentation in the acupuncture group, versus 37 (28.7%) in the sham group: RR 1.34 [0.93-1.89], Pr RR> 1= 94.3%. After adjustment on parity, the acupuncture did not increase the rate of fetal cephalic version: OR 1.47 [0.84-2.42], Pr OR> 1=90.3%.Conclusions: Our study suggests that acupuncture with fire needling on acupoint BL67 does not promote fetal cephalic version. Further studies might investigate effectiveness of other protocols of acupuncture. Randomization should be stratified for nulliparous and parous patients. (C) 2016 Elsevier Ireland Ltd. All rights reserved.

Objective: The current recommendation is to plan elective caesarean section at 39 weeks of gestation. Approximately 14% of the patients with planned caesarean section will end with an emergency caesarean section between 38 and 39 weeks, because of spontaneous labor. Antenatal corticosteroids could reduce the rate of respiratory distress syndrome after elective caesarean section. The objectives were to compare neonatal respiratory morbidity and rates of emergency caesarean section between elective caesarean sections at 38 weeks after antenatal corticosteroids and elective caesarean sections at 39 weeks. Study design: Multicenter open randomized controlled trial conducted between 2007 and 2013. Patients with an indication of elective caesarean section were randomized into 2 groups: elective caesarean section at 38 weeks after corticosteroids (tested group) and elective caesarean section at 39 weeks (control group). The primary outcome was admission to neonatal intensive care unit for respiratory distress defined by tachypnea, a positive Silverman score and the need for ventilatory support. The study was approved by the local ethics committee and recorded on clinicaltrial.gov (# NCT00446953). Results: 101 patients were included in the tested group and 107 in the control group. Two (2.1%) babies in the tested group were admitted for respiratory distress syndrome versus 4 (3.8%) in the control group (p = 0.69). Depression at birth, the need for neonatal medical intervention in the delivery room and the occurrence of SpO2 less than 90% in the first two hours of life, were comparable between both groups. There were fewer emergency caesarean sections in the tested group than in the control group: 12 (12.69%) versus 28 (26.67%), p = 0.013. Conclusion: Our study suggests that antenatal corticosteroids might allow to plan elective caesarean section at 38 weeks, avoiding emergency caesarean sections without increasing the risk of neonatal respiratory distress.

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.

BACKGROUND:Bacterial vaginosis is a risk factor for preterm birth. The various conventional methods for its diagnosis are laborious and not easily reproducible. Molecular quantification methods have been reported recently, but the specific risk factors they might identify remain unclear.METHODS:A prospective multicenter national study included pregnant women at risk of preterm birth. A quantitative molecular tool using a specific real-time polymerase chain reaction assay and serial dilutions of a plasmid suspension quantified Atopobium vaginae, Gardnerella vaginalis, lactobacilli, Mycoplasma hominis, and the human albumin gene (for quality control).RESULTS:In 813 pregnancies, high vaginal loads of either or both of A. vaginae and G. vaginalis were associated with preterm birth (hazard ratio [HR], 3.9; 95% confidence interval {CI}, 1.1-14.1; P = .031). A high vaginal load of A. vaginae was significantly associated with shortened time to delivery and therefore pregnancy length. These times were, respectively, 152.2 and 188.2 days (HR, 5.6; 95% CI, 1.5-21.3; P < .001) before 22 weeks, 149.0 and 183.2 days (HR, 2.8; 95% CI, 1.1-8.2; P = .048) before 28 weeks, and 132.6 and 170.4 days (HR, 2.2; 95% CI, 1.1-4.6; P = .033) before 32 weeks. After multivariate analysis, A. vaginae levels ≥10(8) copies/mL remained significantly associated with delivery before 22 weeks of gestation (adjusted HR, 4.7; 95% CI, .2-17.6; P = .014).CONCLUSIONS:High vaginal loads of A. vaginae and G. vaginalis are associated with late miscarriage and prematurity in high-risk pregnancies. A high vaginal load of A. vaginae (DNA level ≥10(8) copies/mL) identifies a population at high risk of preterm birth. Further studies that both screen for and then treat A. vaginae are needed.CLINICAL TRIALS REGISTRATION:NCT00484653.

We report a case of spontaneous break of the wide ligament revealed by an abdominal pelvic painful syndrome of rough appearance in 36 weeks+2 days with an acute foetal suffering and an important hemoperitoneal to a primigeste of 32 years. The laparotomy explorer allowed to make the diagnosis but the foetal forecast was dramatic. The foetal extraction has to be made as a matter of urgency and at the same time that the vascular haemostasis.

Amniotic band syndrome (ABS) is a fetal congenital malformation, affecting mainly the limbs, but also the craniofacial area and internal organs. Two mains pathogenic mechanisms are proposed in its genesis. Firstly the early amnion rupture (exogenous theory) leading to fibrous bands, which wrap up the fetal body; secondly, the endogenous theory privileges vascular origin, mesoblastic strings not being a causal agent. The authors believe that the second theory explain the occurrence of ABS. The outcome of the disease during pregnancy depends on the gravity of the malformations. Interruption of the pregnancy is usually proposed when diagnosis of severe craniofacial and visceral abnormalities is confirmed. Whereas minor limb defects can be repaired with postnatal surgery. In case of an isolated amniotic band with a constricted limb, in utero lysis of the band can be considered to avoid a natural amputation. In an African country, such treatment is not possible as far as the antenatal diagnosis.

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.

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

Klippel-Trenaunay syndrome (SKT) is a rare disease characterized by cutaneous haemangiomas, capillary malformations venous (venous varicosities), bone and soft tissue hypertrophy affecting one or more limbs. It is often associated with hemorrhagic and thrombotic complications, especially during pregnancy. Vulvovaginal anomalies at risk of bleeding may occur in late trimester of pregnancy, affecting delivery. The terms of delivery depends on the severity of vascular malformations and the experience of the obstetrician. We report the case of a woman in labor at 38 weeks gestation with a SKT with involvement of the left leg up to the corresponding large lip. She presented after vaginal delivery a severe post-partum hemorrhage (2000mL) secondary to vaginal lacerations requiring sutures and supplemented by arterial embolization. A multidisciplinary approach is required at delivery.

Objective: To develop a model for predicting premature delivery before 37 weeks' gestation based on maternal factors, obstetric history and biomarkers in the first trimester of pregnancy.Study design: Cohort study based on data collected prospectively between 1 January 2000 and 30 November 2011. Multivariate logistic regression was used to construct a model of the risk of premature delivery.Results: 31,834 pregnancies were included, of which 1188 cases were spontaneous premature deliveries before 37 weeks (3.7%). We built a predictive model based on maternal age, body mass index, smoking status and previous obstetric history. This could identify 23.3% of premature deliveries in our study population, with a false positive rate of 10%. In the group of patients who had already had at least one pregnancy at or beyond 16 weeks, the detection level increased to 29.7%. The positive predictive value was 7.4 and 7.3% respectively, while negative predictive value was 97.2 and 97.9%.Conclusions: Predicting preterm delivery on the basis of maternal characteristics and obstetric history needs to be further improved. PAPP-A levels and ultrasonographic measurement of cervical length could not be integrated in the model but require further investigations. (C) 2013 Elsevier Ireland Ltd. All rights reserved.

Journal de Gynecologie Obstetrique et Biologie de la Reproduction - Vol. 42 - N° 6 - p. 591-595

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

Vasa previa is a rare complication of pregnancy (1/2000 to 1/6000) with a high fetal mortality rate (75 to 100%). We will discuss two case reports of vasa previa: the first was diagnosed before labor, while the second was during delivery. In the first case, the diagnosis of vasa previa was confirmed by a transvaginal ultrasound and color doppler, while the second case involved late diagnosis during delivery and after gross examination of the placenta. Risk factors for vasa previa are: low-lying placenta, bilobed or succenturiate lobed placenta, velamentous and in vitro fertilization (IVF). Antenatal diagnosis of vasa previa is crucial because it allows for prophylactic caesarean section and prevents severe Benckiser's hemorrhage responsible for a very high neonatal mortality.

OBJECTIVE:Version to correct breech presentation at term remains important, because feet-first vaginal delivery of a baby is associated with a higher risk of fetal morbidity and mortality.METHOD:The technique consists of puncture at point B67. This technique is thought to work by increasing the probability of the fetus turning by increasing active fetal movements.RESULTS:Five randomised studies evaluating the value of acupuncture in cases of siege presentation indicate that this method tended to be effective. However, no placebo-controlled study has been carried out.CONCLUSION:Acupuncture should be attempted in cases of breech presentation.

La thrombomoduline membranaire (TM), récepteur endothélial de la thrombine, possède des propriétés anticoagulantes puissantes. La TM plasmatique (TMp) circulante est un marqueur de la lésion endothéliale. Les taux de TMp sont élevés dans de nombreuses pathologies (diabète, maladie athéromateuse, CIVD…). Dans la plupart des maladies systémiques avec lésions probables de l'endothélium vasculaire, il existe une élévation des taux de TMp. Les deux affections les plus étudiées sont le lupus érythémateux aigu disséminé (LEAD) et la sclérodermie systémique (SSc). Il est intéressant de noter que les taux circulants de TM sont corrélés à l'activité de la maladie. La TMp apparaît comme un marqueur non spécifique d'activité des maladies de système pouvant être utile à la surveillance de ces affections. Les études à venir devront étudier, sur des séries plus importantes, les variations des taux de TMp au cours de l'évolution spontanée et/ou sous traitement afin de déterminer si la TMp peut servir de facteur prédictif et pronostique.Membrane thrombomodulin (TM) is a very efficient natural anti-thrombin glycoprotein with anticoagulant properties expressed on endothelial cell surface. Circulating plasmatic thrombomodulin (TMp) detected by enzyme immunoassay in plasma is considered as a cell marker of endothélial injury. The TMp levels are increased in many conditions (diabetes mellitus, atheromatous disease…). In cases of collagen vascular diseases, where vascular endothelium damage is suspected, TMp is increased particularly in systemic lupus erythematosus (SLE) and systemic sclerosis (SSc). It is noteworthy that the TMp level is correlated with disease activity. Since TMp is a non specific marker of endothelial damage, it may be of interest as a useful marker for the supervision of these diseases. Furtuer studies are needed on larger series. TMp level change during spontaneous evolution or under treatment will help determine wether TMp is a predictor and pronostic marker of these systemic diseases.