Search

Objective: To identify procedures to reduce maternal morbidity during cesarean., 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 and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations., Results: Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds., Conclusion: In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Competing Interests: Intérêts concurrents: Iris Gorfinkel déclare avoir reçu des subventions de GSK, Merck, Urovant Sciences et Johnson & Johnson. Entre 1991 et 1995, la Dre Gorfinkel a reçu des honoraires en tant que médecin experte appelée à témoigner pour un centre de services aux victimes d’agressions sexuelles qui relevait de l’Hôpital Shaughnessy et ensuite de l’Hôpital pour femmes de la Colombie-Britannique. La Dre Gorfinkel a aussi reçu des honoraires en tant que conférencière pour GSK, CME Outfitters et Doctors Nova Scotia; elle détient des actions de Johnson & Johnson et de Merck et a été coprésidente d’un comité consultatif sur Shingrix (GSK). La Dre Gorfinkel a participé, parfois contre rémunération, à des projets de rédaction et de présentations médicales pour la radio et la télévision de la CBC, Zoomer Radio and Television, Global News, CTV News, Bored Panda, The Globe and Mail, le JAMC et Le Médecin de famille canadien. Aucun autre intérêt concurrent n’a été déclaré.

A new coronavirus (SARS-CoV-2) highlighted at the end of 2019 in China is spreading across all continents. Most often at the origin of a mild infectious syndrome, associating mild symptoms (fever, cough, myalgia, headache and possible digestive disorders) to different degrees, SARS-Covid-2 can cause serious pulmonary pathologies and sometimes death. Data on the consequences during pregnancy are limited. The first Chinese data published seem to show that the symptoms in pregnant women are the same as those of the general population. There are no cases of intrauterine maternal-fetal transmission, but cases of newborns infected early suggest that there could be vertical perpartum or neonatal transmission. Induced prematurity and cases of respiratory distress in newborns of infected mothers have been described. Pregnancy is known as a period at higher risk for the consequences of respiratory infections, as for influenza, so it seems important to screen for Covid-19 in the presence of symptoms and to monitor closely pregnant women. In this context of the SARS-Covid-2 epidemic, the societies of gynecology-obstetrics, infectious diseases and neonatalogy have proposed a French protocol for the management of possible and proven cases of SARS-Covid-2 in pregnant women. These proposals may evolve on a daily basis with the advancement of the epidemic and knowledge in pregnant women. Subsequently, an in-depth analysis of cases in pregnant women will be necessary in order to improve knowledge on the subject., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Both cesarean surgery and induction of labor have become common procedures performed in all labor wards in an attempt to reduce adverse obstetrical and neonatal outcomes. Thus, recent evidence, led by the ARRIVE Trial, demonstrated that elective induction at 39 weeks reduced the rates of cesarean deliveries and of hypertensive disorders of pregnancy. However, some concerns must be addressed, as the benefits of universal policies have to be outweighed with the current circumstances of implementation, the economic impact, the number of procedures needed to effectively reduce complications, and, above all, women's perception towards this approach. Therefore, it would be interesting to explore individualization strategies, instead of general recommendations, to offer personalized care., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Background: Since 2008, in France, hospital funding is determined by the nature of activities provided (activity-based funding). Quality control of hospital activity coding is essential to optimize hospital remuneration. There is a need for reliable tools to allocate human resources wisely in order to improve these controls., Methods: The main objective of this study was to identify the determinants of time needed by medical information technicians to control hospital activity coding in a Regional Hospital Center. From March 2016 to the beginning of January 2017, medical information technicians reported the time they spent on each quality control, and the time they needed when they had to code the entire stay. Multiple linear regressions were performed to identify the determinants of quality control or coding duration. A split sample validation was used: model was created on one half of the sample and validated on the remaining half., Results: Among the controls, 5431 were included in the analysis of determinants of control duration (2715 kept aside for model validation). Seven determinants have been identified (stay duration, level of complexity, month of control, type of control, medical information technician, rank of classing information, and major diagnostic category). The correlation coefficient between predicted and real control duration was 0.71 (P<10 -4 ); 808 stays were included in the analysis of determinants of coding duration (404 kept aside for model validation). Two determinants have been identified. The correlation coefficient, between predicted and real coding duration, was 0.47 (P<10 -3 ). We performed the same multiple regression, on 2017 activity data, to estimate the weight of each hospital activity pole, regarding quality control of hospital activity coding., Conclusion: We succeeded in modeling time needed for quality control of hospital stays. These results helped to estimate human resources required for quality control of each hospital pole. Nevertheless, the second analysis did not give satisfactory results: we failed in modeling time needed to code hospital stays., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

Menometrorrhagia is a frequent bleeding symptom in young women, and may be related to an inherited bleeding disorder. If there is no gynecological etiology, hemostasis tests are required. The early medical management of these teenage girls is important, especially when a bleeding disorder is known. The bleeding risk of the first periods may then be anticipated. Afterwards, the objective of the treatment is to keep the bleeding symptoms under control: anti-fibrinolytic treatment, specific replacement therapy for bleeding disorder and hormonal treatment. This management requires a multidisciplinary medical team, mainly hematologist and gynecologist, all along the genital lifespan, from the first periods to the desire for pregnancy., Competing Interests: A. Harroche déclare des liens ponctuels -interventions et prises en charge lors de congrès- avec Novo Nordisk, Bayer, Pfizer, Shire, Octopharma, LFB, CSL Behring, Sobi et Roche. S. Meunier déclare des liens ponctuels interventions et/ou prise en charge lors de congrès- avec Novo Nordisk, Bayer, Shire, Baxalta/Shire, Octapharma, Pfizer, LFB, CSL-Behring, Sobi et Roche. S. Da Costa déclare n’avoir aucun lien d’intérêts. C. Falaise déclare des liens ponctuels -interventions et/ou prise en charge lors de congrès avec Bayer, Octopharma, Pfizer, Roche, SOBI, Takeda, LFB et Novo Nordisk. C. Oudot déclare des liens -prise en charge lors de congrès avec Shire, Bayer, SOBI, CSL Behring, Octopharma et Novo Nordisk.

Objective: Assessing inter- and intra- observer agreement in the reading of fetal heart rate (FHR) between two different paper speeds (1 and 2cm/min) using FIGO classification., Material and Methods: Single-centre experimental study consisting in reading 60minutes FHR tracings by six readers (3 midwives and 3 obstetricians) during 1cm and 2cm/min sessions within a period of three weeks. The reading guideline was based on FIGO classification. Inter- and intra-observer agreement was assessed thanks to Kappa coefficient (K) and percentage of agreement (PA) using the classification of FHR tracings drawn up by readers., Results: Intra-observer agreement reached 60% between the two paper speeds, and PA ranged from 48 to 67%. Inter-observer agreement was poor to moderate (K=0.42 for 1cm/min sessions and K=0.38 for 2cm/min sessions). Inter-observer agreement was significantly higher for normal tracings (PA ranged from 55.2% for 2cm/min sessions to 57.4% for 1cm/min sessions). The preterminal category had the lowest concordance rates (PA=19% for 1cm/min sessions and 20, 7% for 2cm/min sessions)., Conclusion: This study did not highlight significant differences in intra- and inter-observer variability between the two FHR paper speeds. The 1cm/min paper speed, which is commonly used in France, is more economical and gives a better bedside overview of FHR. Therefore, it should be recommended., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

In the absence of contraindication, methotrexate by intramuscular unique injection of 1mg/kg or 50mg/m(2) is the medical treatment recommended for tubal ectopic pregnancy (EP; LE1). It can be renewed once, at the same dose, according to hCG rates decrease. The pretherapeutic biological assessment contains blood cells numeration, renal and hepatic function. Methotrexate therapy constitutes an alternative conservative treatment to laparoscopic salpingotomy for non-complicated tubal EP (LE1) with hCG level <5000 UI/L (LE2). When the rates of hCG are <1000 UI and or presented a spontaneous decreasing kinetics, the simple prospect (LE2) is preferred. It is recommended to use intramuscular methotrexate in case of surgical conservative treatment failure or more prematurely if the follow-up is not possible (LE3). Except in particular cases there is no indication to use methotrexate in local injection under sonographic control in usual tubal EP (LE2). The use of in situ injection methotrexate is an option to handle the cervical, interstitial or on caesareans scar pregnancies (LE2). In front of a persistent undetermined location pregnancy, after more than 10 days of survey, in an asymptomatic woman and/or at rate of hCG >2000 UI/L, the systematic treatment by methotrexate is an option. The methotrexate is not indicated for first trimester termination of pregnancy or miscarriage neither in placentas accreta nor in association with other treatments such myfegine or potassium., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: While a number of glossaries have been produced by various authorities in different countries, at present there is no internationally accepted common set of definitions for many terms used to describe pregnancy losses. The objective of the current study was to provide a standardized French/English terminology/glossary relating to pregnancy losses., Methods: Literature review, construction of a glossary and rating of proposals using a formal consensus method. The glossary was subject of a critical comprehensive review by a meeting of professionals (multidisciplinary panel)., Results: A miscarriage is a spontaneous evacuation of an intra-uterine pregnancy<22WG. A missed early miscarriage is when ultrasound (<14WG) shows no growth of intra-uterine sac/embryo and/or loss of fetal heart activity. An early miscarriage is when spontaneous evacuation of intra-uterine pregnancy occurs <14WG. A complete early miscarriage is when there is no retained products of conception (empty uterus on ultrasound) and no bleeding nor pain. Incomplete early miscarriage is when ultrasonography shows retained products of conception in the uterine cavity (including cervical canal). Repeat miscarriage or recurrent pregnancy loss is when the woman experiences 3 or more consecutive miscarriages <14WG. A late miscarriage is when there is spontaneous evacuation of pregnancy ≥14WG and <22WG. A threatened late miscarriage is when shortening/opening of the cervix±uterine contraction occur ≥14WG and <22WG. An intra-uterine fetal demise is when there is a spontaneous loss of fetal heart activity ≥14 WG., Conclusion: The final current terminology should be used by all healthcare professionals., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Electronic fetal monitoring during labor is the most commonly used method to evaluate the fetal status, but it remains exposed to some criticism. By comparison with intermittent auscultation and in the light of the results of the great studies in the last 30 years, it may be accused its failure to improve the neonatal outcome and its responsibility in the increase on operative deliveries. Actually, the electronic fetal monitoring is a tool whose effectiveness is linked to the accuracy of the analysis developed by the clinician. Studies on assessment of the tracing interpretation indicate that there is always a lack of quality, which may be improved through training programs. It also reveals the benefit of the fetal blood sampling to reduce operative deliveries and the generalization of this method, in addition to electronic fetal monitoring, is recommended by referral agencies. More generally, the continuous monitoring is only a part of the patient safety strategy in the labour ward and we are currently observing, in some European countries and in the United States, the development of training programs concerning the management of the adverse outcomes in obstetrics. The good performances related to the quality of care are demonstrated by the findings of the studies performed in the centers that have implemented an active training policy. In France, the professionals directly involved in the field of the perinatology should benefit from such educational programs that could be organized within the care networks under the authority of referral agencies., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

The internist has a relevant role in the medical assessment which is mandatory after every case of pre-eclampsia. This postnatal visit has to be performed to assert there is no underlying disorder such as chronic arterial hypertension or nephropathy, autoimmune disease or thrombophilia. This visit is also needed to provide information to the woman about what occurred during the pregnancy as well as to consider which would have to be done in case of a subsequent pregnancy. Long-term outcome had also to be taken into account considering risks for cardiac, arterial, renal and metabolic diseases. This visit is of outmost importance after very early-onset pre-eclampsia, and especially if it has already occurred. The postnatal visit after pre-eclampsia represents a very demonstrative example of the role that the internist can afford to the obstetrician in the management of medical disorders occurring during pregnancy and needing a specific expertise as well as a long-term follow-up., (Copyright © 2010 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

The main aim of tocolysis is to improve the health of newborns. Given the modest impact in terms of perinatal health of tocolysis we must emphasize the use of tocolytics which, equally effective, have fewer maternal side effects than beta-agonists and are devoid of potential complications for mother and the newborn. Inhibitors of prostaglandin synthesis and calcium antagonists of oxytocin seem to meet these criteria. The recent papers for the use of NSAIDs provide no fundamentally new scientific data. This therapy is potentially associated with severe neonatal complications and superiority to calcium channel blockers or antagonists of oxytocin in terms of prolongation of pregnancy is not established. It seems reasonable to reserve them for special situations by their severity, precocity of the age of gestation or by the ineffectiveness of other treatments. In practice, it is recommended not to use NSAIDs first line, beyond 32 weeks and treatment should be of short duration (less than 48 to 72 hours). Ideally, delivery should not occur within 48 hours after stopping treatment., ((c) 2010 Elsevier Masson SAS. All rights reserved.)

Objective: Clinical indicators are increasingly used to assess safety of patient care. In obstetrics, only a few indicators have been validated to date and none is used across specialties. The purpose of this study was to identify and assess for face and content validity a group of safety indicators that could be used by anaesthetists, obstetricians and neonatologists involved in labour and delivery units., Materials and Methods: We first conducted a systematic review of the literature to identify potential measures. Indicators were then validated by a panel of 30 experts representing all specialties working in labour and delivery units. We used the Delphi method, an iterative questionnaire-based consensus seeking technique. Experts determined on a 7-point Likert scale (1=most representative/7=less representative) the soundness of each indicator as a measure of safety and their possible association with errors and complications caused by medical management., Results: We identified 44 potential clinical indicators from the literature. Following the Delphi process, 13 indicators were considered as highly representative of safety during obstetrical care (mean score

Objectives: The aim of this study was to assess the lurning curve of young residents for vacuum extraction., Materials and Methods: All vacuum extractions performed in our department by five residents (< or =5th semester) during a study period of nine months were systematically supervised by a senior who fulfilled an assessment questionnaire from which was calculated a score reflecting the quality of the extraction., Results: Fifty-four vacuum extractions were assessed with a mean of 10.8+/-2.9 (range, 10-13) procedures by resident. We compared the group including the six first procedures performed by each resident (group 1, n = 30) with the group including the following procedures (group 2, n = 24). We observed in the group 2 compared to the group 1, a significant improvement of the scores mean (12.3+/-5.4 vs 8.4+/-6.2, p = 0.016) and a significant reduction of the need for manual assistance by the senior (12.5% vs 40%, p = 0.034)., Conclusion: We report a method for the learning and assessment of vacuum extraction feasible at "the bed" of the patient. This approach allows to observe a significant progression of the resident for the technique of vacuum extraction on a dozen of procedures.

Constant advances in perinatal medicine in industrialized countries have raised challenging ethical dilemmas. This review addresses the evolution over the years 2000 of the recommendations on ethical issues in the perinatal period by health professionals in France. The Committee on Ethics of the French National Federation of Neonatologists issued one first set of recommendations in 2001. Additional information provided by nation-wide epidemiological studies on the long term development of premature infants, and the recent evolution of French law prompted the french societies of Neonatology, of Perinatal Medicine, and the National board of Obstetricians and Gynaecologists to set new guidelines concerning the end of life in the neonatal period and euthanasia, neonatal palliative care, parental information, and issues related to the limits of viability, which are currently being published. These recent guidelines are characterized with attitudes favouring palliative care and discouraging active ending of life on neonates in situations with extremely poor neuro-cognitive prognosis. Around the limits of viability, a grey zone is defined over the 24-25 weeks gestational age period, during which various options are discussed, in compliance with the basic principle of the preservation of the individual rights of each infant.

Hygiene of ultrasound probes is a hot topic in obstetric and gynecologic ultrasound. The issue concerns mainly the risk of contamination and the need for specific procedures to ensure a high degree of protection against infectious diseases, even if a disposable barrier cover is used. As there are no referenced quality criteria for these disposable probe covers, it is crucial to verify that they are CE marked. The use of condoms as probe covers is not recommended even though they present a lower rate of disruption compared to commercial probe covers. The global rate of probe cover perforation is of 1 to 9%. To date, there are no case reports of contamination by ultrasound examination, be it vaginal or abdominal. Nevertheless, every patient must be regarded as a potential source of infection. The French recommendations consider endovaginal ultrasound probes as semi-critical instruments and thus require intermediate-level disinfection. Because of the risk of disruption, American as well as Canadian and Australian recommendations insist on high-level disinfection of the probe. Every operator should follow reasonable hygiene rules and appropriate precautions should be taken in order to reassure the patients about the risks of contamination during any ultrasound examination.

Objective: To provide recommendations for the management of genital herpes infection in women who want to get pregnant or are pregnant and for the management of genital herpes in pregnancy and strategies to prevent transmission to the infant., Outcomes: More effective management of complications of genital herpes in pregnancy and prevention of transmission of genital herpes from mother to infant., Evidence: Medline was searched for articles published in French or English related to genital herpes and pregnancy. Additional articles were identified through the references of these articles. All study types and recommendation reports were reviewed., Values: Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

Medical practice assessment is mandatory in France. The goal of this article is to explain to perinatal care providers the concept and the process, which do not seem simple, given the multitude of possible ways to evaluate and validate its medical practices. Concrete examples help to illustrate the process. French regulations now link medical practice assessment with continuing medical education (CME) for physicians. While certification is voluntary, a practice assessment conducted during hospital certification processes and during CME is required for all French physicians.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Objectives: This work is a study of the prophylaxis of maternal venous thromboembolism (VTE) after the publication of the French guidelines and a comparison between the practice and the guidelines., Population and Methods: Inquiry into the practice of 193 anaesthetists from maternities of the Rhône-Alps area has been made., Results: Of the 48.2% anaesthetists who answered, 92.5% of them estimate that the caesarean is a risk factor of VTE; 87% prescribe an antithrombotic treatment and 6.5% treat differently the prophylactic caesareans and the urgent ones. The classification of the risk factors is identical to the guidelines for the age, the hypertension and the prophylactic caesarean (p<0.0001). For all the other factors, the risk is overestimated, leading to an over-treatment. Eighty percent of the anaesthetists read the guidelines and 84% give them a positive value. There is a better adequacy between the guidelines and the professionals from university hospitals as compared to the non university hospitals ones (p=0.0027)., Discussion and Conclusions: Patients are managed approximately and very differently from one consultant to another. A facility of use of the guidelines will undoubtedly make it possible to obtain a more coherent attitude.

Objectives: The evaluation of an educational system is part of the essential process to get high-quality teaching. We wanted to assess the teaching and the teachers in a gynaecological unit with a view to improve the education of the trainees within a dynamic educational system., Materials and Methods: It is a prospective study which took place in the gynecology-obstetric unit of the University of Nantes. Thanks to a questionnaire called "Evaluation of the teaching during a gynecologic-obstetric training course", we evaluated the feelings of 21 medical students about their two-month training course. This questionnaire of 27 items is divided in several parts. The first one is about the quality of the teaching, the second about planification, the third about the quality of the learning resources, and the fourth is about the educational quality of each teacher (interaction teacher-student). The fifth one evaluates the perception of this work experience by the student, notably his clinical activity and his personal implication in the unity. There are also some open questions which point out the positive aspects of the teaching but also its failings and the parts that must be improved. We give here the details of the different stages of this assessment from the questionnaire up to the results, mentioning their limits considering the conceptual orientations and the methodological orientations chosen., Results: Analysis of the data was done determining the percentage of agreement and disagreement to a statement of the questionnaire. All the students find the teachings interesting and stimulating, objectives were gone through thoroughly. Courses were well organised. Their integration in the medical team was good. They feel responsible especially when they are on call (88.3%). On the other hand, for a quarter of them, educational supports are not adapted, teaching documents are not clear and adapted to the National Test. Half of them (45%) are not satisfied by the numerical campus which does not facilitate understanding. Staffs are not an opportunity to learn for 37% of them. Management by senior doctors is insufficient., Conclusion: Students are completely integrated into the process of evaluation but concrete actions to improve the teaching have to be realised in the hospital departments. Questionnaire is an informative and adapted tool. It permits to highlight the flaws in the learning process and to remedy them.

Objective: The purpose of this guideline is to provide recommendations to obstetric health care providers and to minimize practice variations for HIV screening, while taking provincial and territorial recommendations into account., Outcomes: The risk of transmission of HIV from mother to fetus is significant if the mother is not treated. The primary outcome of screening for and treating HIV in pregnancy is a marked decrease in the rate of vertical transmission of HIV from mother to fetus. Secondary outcomes include confirmation of HIV infection in the woman, which allows optimization of her health and long-term management., Evidence: The Cochrane Library and Medline were searched for English-language articles published related to HIV screening and pregnancy. Additional articles were identified through the references of these articles. All study types were reviewed.

Objective: To review the effect of the number of embryos transferred on the outcome of in vitro fertilization (IVF), to provide guidelines on the number of embryos to transfer in IVF-embryo transfer (ET) in order to optimize healthy live births and minimize multiple pregnancies., Options: Rates of live birth, clinical pregnancy, and multiple pregnancy or birth by number of embryos transferred are compared., Outcomes: Clinical pregnancy, multiple pregnancy, and live birth rates., Evidence: The Cochrane Library and MEDLINE were searched for English language articles from 1990 to April 2006. Search terms included embryo transfer (ET), assisted reproduction, in vitro fertilization (IVF), ntracytoplasmic sperm injection (ICSI), multiple pregnancy, and multiple gestation. Additional references were identified through hand searches of bibliographies of identified articles., Values: Available evidence was reviewed by the Reproductive Endocrinology and Infertility Committee and the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada and the Board of the Canadian Fertility and Andrology Society, and was qualified using the Evaluation of Evidence Guidelines developed by the Canadian Task Force on the Periodic Health Exam., Benefits, Harms, and Costs: This guideline is intended to minimize the occurrence of multifetal gestation, particularly high-order multiples (HOM), while maintaining acceptable overall pregnancy and live birth rates following IVF-ET.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Objectives: To describe obstetrical policy variations concerning the delivery management in the case of twins, at term., Patients and Methods: A mail survey was undertaken among the medical supervisors of the maternity wards belonging to the AUDIPOG Network (N=170)., Results: The participating rate was 73.35%. 124 answers were analysed. Elective caesarean was realized by 0.8% of participants for diamniotic twins and by 57% of cases for monamniotic twins An elective caesarean is planned for respectively 74% of answers if first (J1) and second twin (J2) are in a breech presentation, 81% if J1 is in breech and J2 in cephalic presentation, and 68% if J1 is in breech and J2 in transverse presentation. Delivery with J1 in breech and J2 in cephalic presentation had a higher risk than a delivery of a single breech at term. When J1 and J2 had a breech presentation 73% of participants thought that this delivery is more difficult than a delivery of a single breech at term. However, they were only 17.5% to consider that a delivery of twin with J1 in cephalic and J2 in breech presentation had a higher risk than a single breech delivery., Discussion and Conclusion: Medical policy variations are not extensive except for X-ray pelvimetry and the presence for the delivery of one paediatrician and one anaesthesiologist. An elective caesarean policy for twins is infrequent in France.

This document has been archived because it contains outdated information. It should not be consulted for clinical use, but for historical research only. Please visit the journal website for the most recent guidelines.

Objective: The prevalence of bleeding disorders, notably von Willebrand disease (vWD), among adult women with objectively documented menorrhagia is consistently reported to be 10% to 20% and is even higher in adolescents presenting with menorrhagia. This consensus document has been developed by a multidisciplinary committee consisting of an anesthesiologist, 2 hematologists, and an obstetrician/gynaecologist and has been endorsed by their relevant specialty bodies. It has been prepared with the express purpose of providing guidelines for both women with inherited bleeding disorders and for their caregivers regarding the gynaecological and obstetric management of these women, including appropriate anesthesia support where indicated., Options: Diagnostic tools and specific medical and, where appropriate, surgical alternatives to management are reviewed and evidence-based recommendations presented., Evidence: A MEDLINE search of the English literature between January 1975 and November 2003 was performed using the following key words: menorrhagia, uterine bleeding, pregnancy, von Willebrand, congenital bleeding disorder, desmopressin/DDAVP, tranexamic acid, oral contraceptives, medroxyprogesterone, therapy, hysterectomy, anesthesia, epidural, spinal. Recommendations from other society guidelines were reviewed., Recommendations: 1. Inherited bleeding disorders should be considered in the differential diagnosis of all patients presenting with menorrhagia (II-2B). The graphical scoring system presented is a validated tool which offers a simple yet practical method that can be used by patients to quantify their blood loss (II-2B). 2. Because underlying bleeding disorders are frequent in women with menorrhagia, physicians should consider performing a hemoglobin/hematocrit, platelet count, ferritin, PT (INR) and APTT in women with menorrhagia. In women who have a personal history of other bleeding or a family history of bleeding, further investigation should be considered, including a vWD workup (factor VIII, vWF antigen, and vWF functional assay) (II-2B). 3. Treatment of menorrhagia in women with inherited bleeding disorders should be individualized (III-B). 4. An inherited bleeding disorder is not a contraindication to hormonal therapy (oral contraceptives [II-1B], depot medroxyprogesterone acetate (DMPA) [II-3B], danazol [II-2B], GnRH analogs [II-3B]) or local treatments (levonorgestrel-releasing IUS [II-1B]) and non-hormonal therapy (antifibrinolytic drug tranexamic acid [II-1B]) as well as desmopressin (II-1B). These therapies represent first line treatment. Blood products should not be used for women with mild bleeding disorders (III-A). 5. In women who no longer want to preserve their fertility, conservative surgical therapy (ablation) and hysterectomy may be options (III-B). Clinicians may consult the "SOGC Clinical Practice Guideline: Guidelines for the Management of Abnormal Uterine Bleeding" for an in-depth discussion of the available therapeutic modalities, both medical and surgical. To minimize the risk of intraoperative and post-operative hemorrhage, coagulation factors should be corrected preoperatively with post-operative monitoring (II-1B). 6. Girls growing up in families with a history of vWD or other inherited bleeding disorders should be tested pre-menarchally to determine whether or not they have inherited the disease to allow both the patient and her family to prepare for her first and subsequent menstrual periods (III-C). 7. In adolescents presenting with menorrhagia, an inherited bleeding disorder should be excluded (III-B). When possible, investigation should be undertaken before oral contraceptive therapy is instituted, as the hormonally induced increase in factor VIII and vWF may mask the diagnosis (II-B). 8. Pregnancy in women with inherited bleeding disorders may require a multidisciplinary approach. A copy of their recommendations should be given to the patient and she should be instructed to present it to the health care provider admitting her to the birthing centre. Women with severe bleeding disorders or with a fetus at risk for a severe bleeding disorder should deliver in a hospital (level three) or where there is access to consultants in obstetrics, anesthesiology, hematology, and pediatrics (III-C). 9. Vacuum extraction, forceps, fetal scalp electrodes, and fetal scalp blood sampling should be avoided if the fetus is known or thought to be at risk for a congenital bleeding disorder. A Caesarean section should be performed for obstetrical indications only (II-2C). 10. Epidural and spinal anesthesia are contraindicated if there is a coagulation defect. There is no contraindication to regional anesthesia if coagulation is normalized. The decision to use regional anesthesia should be made on an individual basis (III-C). 11. The risk of early and late postpartum hemorrhage is increased in women with bleeding disorders. Women with inherited bleeding disorders should be advised about the possibility of excessive postpartum bleeding and instructed to report this immediately (III-B). 12. Intramuscular injections, surgery, and circumcision should be avoided in neonates at risk for a severe hereditary bleeding disorder until adequate workup/preparation are possible (III-B). The quality of evidence reported in this document has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam (Table 1).