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International audience; Purpose of the studyThe purpose of our study was to investigate the effects of ovine umbilical cord-derived mesenchymal stromal cells (UC-MSCs) seeded in a fibrin patch as an adjuvant therapy for fetal myelomeningocele repair in the ovine model.Materials and methodsMMC defects were surgically created at 75 days of gestation and repaired 15 days later with UC-MSCs patch or an acellular patch. At birth, motor function, tail movements, and voiding abilities were recorded. Histological and immunohistochemical analysis included study of MMC defect's healing, spinal cord, UC-MSCs survival, and screening for tumors.ResultsSix lambs were born alive in each group. There was no difference between the two groups on the median sheep locomotor rating score but all lambs in the control group had a score between lower than 3 compared to 50% in UC-MSCs group. There were more lambs with tail movements and voiding ability in UC-MSCs group (83% vs 0% and 50% vs 0%, respectively). gray matter area and large neurons density were higher in UC-MSCs group (2.5 vs 0.8 mm2 and 19.3 vs 1.6 neurons/mm2 of gray matter, respectively). Fibrosis thickness at the myelomeningocele scar level was reduced in UC-MSCs group (1269 µm vs 2624 µm). No tumors were observed.ConclusionFetal repair of myelomeningocele using allogenic UC-MSCs patch provides a moderate improvement in neurological functions, gray matter and neuronal preservation and prevented from fibrosis development at the myelomeningocele scar level.

Driven by international programs specifically targeting neonatal survival, a set of recommended care practices is being promoted in West Africa. Using data from a multi-centered anthropological study, we enquire as to how local practices integrate the recommendations disseminated by these programs.The surveys were conducted in rural localities in five countries: Benin, Burkina Faso, Mali, Mauritania, and Togo. In every site, the investigations combined ethnography of newborn care and in-depth interviews in maternity homes and homes.The care of newborns is based on a set of local social representations and logics, where medical recommendations are integrated heterogeneously. In maternity wards, health professionals face difficulties in implementing recommended practices, and make various conciliations when faced with local material and social constraints. In private homes, the "messages" promoting life-saving care for newborns punctuate conversations, but lead to various interpretations and variations in care.The irregular integration of medical recommendations in neonatal care is analyzed around three areas: the divergence of intentions around the birth, the dissonances between the recommended care and the local conceptions of the newborn, the influence of intra-family power relations. Considering the complexity of the changes in neonatal care, we argue for the implementation of programs that respect local cultures, and for health professionals to skillfully accommodate conflicting constraints.

Introduction : Clamping (and cutting) of the umbilical cord at birth is the oldest and the most common intervention in humans.However, ideal moment of cord clamping remains acontroversial subject for many years, especially for the premature babies.The aim of this study is to evaluate the impact of a delayed cord clamping protocol on the neonatal jaundice in newborns between 36 and 37weeks of amenorrhea .Study design : Monocentric study, observational and prospective including 139 newborns between 36 and 37 weeks, having been transferred to the maternity diaper suite service.Results : The analyses show no difference in the appearance of jaundice (p=0.06).Conclusion : According to our study, delayed cord clamping seems to be a safe alternative forall births.; Introduction : Le clampage (ainsi que la section) du cordon ombilical à la naissance est l’intervention la plus ancienne et la plus courante chezles humains. Cependant le moment idéal du clampage du cordon reste un sujet qui fait polémique depuis de nombreuses annéesnotamment pour les prématurés, population plus à risque.L’objectif de cette étude est d’évaluer l’impact d’une politique de clampage retardé du cordon ombilical sur l’apparition d’un ictère néonatalchez les nouveau-nés entre 36 et 37 SA.Matériel et méthode : Etude monocentrique, de type avant-après mise en place d’un protocole de clampage retardé, rétrospective observationnelle incluant 139 nouveau-nés entre 36 et 37 SA,ayant été transféré dans le service de suite de couches de la maternité d’intérêt.Résultats : Les analyses statistiques ne montrent pas de différence sur l’apparition d’un ictère(p=0.06).Conclusion : D’après notre étude, le clampage retardé semble donc être une alternative sûre qu’il faudrait réaliser pour toutes les naissances.

The monitoring of fetal well being during labor is essentially based on fetal heart rate (FHR) analysis. The recording of FHR, even continuously during labor, does not fully assess fetal oxygenation or neonatal risk of asphyxia. Indeed, this tool is imperfect and subjective with an important inter and intra-operator variability. Second-line examinations to characterize the fetal state are currently used in routine practice, i.e. scalp fetal blood sampling to study the fetal acid-base balance (pH or lactates) or scalp electrode placement to study the fetal ECG (ST segment analysis). These techniques are nevertheless invasive and subject to technical constraints. There is therefore an interest in developing both objective and non-invasive means of evaluating fetal wellbeing to reduce neonatal encephalopathy. Indeed, its prevalence is about 3 to 8 per 1000 births. Post natal mortality is about 25 to 50% and survivors will hav severe diseases (epilepsy, neurologic impairment, cerebral palsy…).One of the possibilities studied to better identify fetuses at risk for acidosis is the analysis of changes in the autonomic nervous system (ANS) in response to hypoxia.Indeed, the regulation of heart rate is dependent on the ANS and thus, its variability is a reflection of the sympathetic / parasympathetic balance. Analysis of heart rate variability (HRV) is a recognized non-invasive tool that is used to assess ANS regulation. The CHU Lille has developed a new continuous tool for the analysis of HRV, which demonstrated its efficacity in adults and neonates to evaluate the ANS. The objective of this thesis was to develop its index, called Fetal Stress Index (FSI), in the fetus and to evaluate it in conditions of acidosis.The study was experimental in a sheep model chronically instrumented and was in 2 steps. First, we evaluate the performance of our method compared to commonly used HRV analysis, regarding the ability to detect the variation of variations of the ANS. After injection of atropine, to inhibit parasympathetic tone, or propranolol to block sympathetic activity, we shown that our method appeared to be effective in detecting parasympathetic inhibition and, moreover, was superior to classical analysis of HRV in terms of sensibility and specificity.In a second time, we evaluated this new index as a predictive factor of the fetal acid-base state in 2 experimental models of fetal hypoxia by occlusion of the cord. In the first one, acidosis was obtained through a partial occlusion of the umbilical cord and in the second one, though repetitive complete occlusion as uterine contractions during labor. In those two studies, we observed a raise of our index in case of acidosis with a correlation beetween FSI and pH and also FSI and lactates in the second model.In conclusion, the FSI reflects fetal parasympathetic activity, has a better detection than others usual methods, and seems well correlated to fetal acid-base status. It is a promising index and it will be interesting to incorporate it in a multi parametric analysis of fetal heart rate to predict acidosis.; La surveillance du bien-être fœtal pendant le travail repose essentiellement sur l’enregistrement du rythme cardiaque fœtal (RCF). Celui-ci, même continu pendant le travail, ne permet pas d’évaluer parfaitement l’oxygénation du fœtus ni le risque d’asphyxie néonatale. En effet, cet outil est imparfait et son évaluation subjective avec une importante variabilité d’interprétation inter et intra opérateur. Des examens dits de seconde ligne sont utilisés en pratique courante pour caractériser l’état fœtal : le prélèvement de sang fœtal au scalp pour l’étude de l’équilibre acido-basique du fœtus (pH ou lactates) ou la pose d’électrode au scalp pour étudier l’ECG fœtal (analyse du segment ST). Ces techniques sont néanmoins invasives et sont soumises à des contraintes techniques. Il y a donc un intérêt à développer des moyens d’évaluation du bien être fœtal à la fois objectifs et non invasifs afin de diminuer la survenue d’une asphyxie périnatale. En effet, celle-ci touche 3 à 8 nouveaux nés pour 1000 naissances. La mortalité en période post-natale est de 25 à 50% des cas et ceux qui survivent développeront des troubles sévères (épilepsie, retard neuro-cognitif et comportemental, paralysie cérébrale…). Au cours de l’accouchement, l’asphyxie périnatale se caractérise par une diminution du pH artériel ombilical. Cette mesure du pH sanguin est donc la mesure de référence pour déterminer la sévérité de l’asphyxie.Une des voies étudiées pour améliorer le dépistage des fœtus à risque d’acidose est l’analyse des modifications du système nerveux autonome (SNA) par analyse de la variabilité du rythme cardiaque fœtal. En effet, la fréquence cardiaque fœtale est en permanence sous l’influence du système nerveux autonome et sa variabilité (VFC) est un reflet de la balance sympathique / parasympathique. Le CHU de Lille a développé une nouvelle méthode d’analyse continue de la VFC ayant montré son efficacité chez l’adulte et chez le nouveau né pour l’évaluation du SNA. L’objectif de ce travail de Thèse est d’adapter cette technologie à l’analyse du SNA fœtal pour obtenir un nouvel indice appelé Fetal Stress Index (FSI) et d’évaluer sa pertinence en situation d’acidose.Cette preuve de concept a été effectuée de manière expérimentale chez le fœtus de brebis. Elle s’est réalisée en 2 temps. Nous avons tout d’abord évalué la performance du FSI par rapport aux méthodes classiques d’analyse de la VFC en termes d’aptitude à détecter les variations du SNA. Après injection d’Atropine, parasympatholytique, ou de Propranolol, sympatholytique, nous avons montré que le FSI était une méthode efficace et spécifique d’évaluation des variations du tonus parasympathique du SNA. Cette étude a également montrée la supériorité du FSI par rapport aux méthodes classiques d’analyse de la VFC en termes de sensibilité et de spécificité. Dans un second temps, nous avons évalué ce nouvel indice comme facteur prédictif de l’état acido basique du fœtus dans 2 modèles expérimentaux d’occlusion cordonale. Dans le premier modèle, l’acidose était obtenue par une occlusion continue du cordon avec une réduction de partielle du débit ombilical. Dans le second, nous réalisions des occlusions totales répétées à intervalles réguliers afin de mimer les contractions utérines lors du travail. Dans les 2 études, nous avons observé une hausse du FSI en cas d’acidose avec une corrélation significative entre le FSI et le pH, mais aussi entre le FSI et les lactates dans le second modèle.En conclusion, le FSI constitue un bon reflet de l’activité parasympathique fœtale. Cet indice permet d’étudier les variations du SNA fœtal avec une meilleure sensibilité et une meilleure spécificité que les méthodes usuelles d’analyse de la VFC et semble bien corrélé à l’état acido basique fœtal. Il s’agit donc d’un indice prometteur qu’il sera intéressant d’incorporer dans une analyse multi paramétrique du rythme cardiaque fœtal.

The aim of the study is to compare placental monochorionic angioarchitecture complicated with twin-oligohydramnios-polyhydramnios sequence (TOPS), twin anemia polycythemia sequence (TAPS), twin reversed arterial perfusion (TRAP) and selective intra uterine growth restriction (sIUGR) to normal uneventful monochorionic placenta.Between December 2012 and December 2015, monochorionic placenta has been studied at the multiple pregnancy care center of the Femme-Mère-Enfant Hospital in Lyon. Umbilical chords were catheterized and dye injected for macroscopic analysis of angioarchitecture at the anatomopathology department. Placentas treated with laser foetoscopic surgery were excluded.A total of 126 placentas were injected in the post-partum period. In total, 95% (119/126) of the placentas presented arteriovenous anastomoses (AVA). Median number of AVA was 7. The prevalence of at least one velamentous cord insertion was higher in TOPS and selective intrauterine growth restrictions P0.01 and P0.01 respectively, compared to uneventful pregnancies. Arterio-arterial anastomoses (AAA) were present in 82.7% (77/93) of uneventful placentas versus 33.3% of TOPS (P0.01) and 28.5% of TAPS (P0.01). The prevalence of veno-venous anastomoses was significantly higher in TOPS (P0.01). All TAPS placentas showed marginal arteriovenous anastomoses. In TRAP placenta, the acardiac twin had no specific vascular territory.The study confirms literature findings on prevalence of vascular anastomoses in monochorial placentas, suggesting the protective role of AAA in TOPS and TAPS. The role of VVA is yet hard to determinate. Macroscopic observations of monochorionic placentas are valuable and essential keys for understanding, managing and treating anastomotic syndromes.

To study the occurrence of cords accident (nuchal cords, prolapse, and braces) after external cephalic version according to its failure or success.Retrospective study between 1998-2015 comparing in the cord accident diagnosed at delivery (by midwife or doctors according to mode of delivery): Patients with attempt ECV: Group 1 cephalic presentation after successful ECV with trial of labor, and Group 2 failed ECV followed by elective cesarean or trial of labor. Patients with no attempt ECV Group 3 spontaneous cephalic presentation matching for delivery date, maternal age, parity, body mass index, and delivery history with group 1, Group 4 Breech presentation without attempt ECV with trial of labor.A total of 776 women with breech presentation were included (198 in group 1, 446 in group 2, 396 in group 3 and 118 in group 4). The prevalence of cord accident did not differ according to ECV attempt (17.08 % versus 18.9 %), to cephalic presentation (group 1: 24.7 % versus group 3: 25 %) and to breech presentation (group 2: 16.9 % versus group 4: 17.2 %). The trial of labor after failed ECV did not increase the risk of cord accident when compared with elective cesarean (17.4 % versus 16 %). A prolapse cord was only observed after trial of labor, i.e. in groups 1, 2 and 4 without difference (respectively 1, 0.8 and 1.7 %). In each group, the rate of cesarean was not different according to the presence of nuchal cord.Success or failed External cephalic version is not associated with an increased risk of cord accident.

Many international studies have demonstrated that delayed umbilical cord clamping reduces neonatal morbidity. However, in France, delayed umbilical cord clamping is still not performed in many neonatal units. The aims of this study were to evaluate the feasibility of developing a protocol of delayed umbilical cord clamping in the maternity ward of the Toulouse university hospital and to evaluate the impact of this new protocol on neonatal mortality.We conducted a prospective observational study including 123 preterm infants born before 37 weeks of gestation between June 2012 and June 2013 and hospitalized at birth. Delayed cord clamping was performed for at least 30s after birth; otherwise, it was evaluated as early cord clamping. We excluded twin-to-twin transfusion syndrome, congenital abnormalities, alloimmunization, and perinatal asphyxia. We analyzed the reasons why delayed umbilical cord clamping was not performed and then neonatal morbidity in our population.Delayed umbilical cord clamping was performed on 79 infants and 44 infants had early umbilical cord clamping. The two groups had similar baseline characteristics. Preterm infants in the delayed cord-clamping group had a higher level of hemoglobin during the first 24h of life (17.9g/dL versus 16.6g/dL, P=0.005), fewer of them required transfusion (14% versus 35%, P=0.03), and fewer presented late-onset sepsis (8% versus 26%, P=0.02) or bronchopulmonary dysplasia (9% versus 26%, P=0.03). There was no statistically significant increase of hyperbilirubinemia requiring phototherapy.Implanting a new protocol of delayed umbilical cord clamping in our maternity ward proved to be possible without difficulty. The advantages of delayed umbilical cord clamping were observed in this prospective study. Today, delayed cord clamping has become a common practice in our maternity unit.

Simulation in obstetrical emergency is in expansion. The important economic and human cost in simulation needs a real evaluation about enhancement in technical and non-technical skills, maternal and neonatal morbidity and mortality. We present a literature review of the results published on the subject in shoulder dystocia, post-partum haemorrhage, eclampsia and cord prolaps with a selection of publications with high evidence level or positive impact of training on obstetrical emergencies. There are few publications with a positive impact of training on obstetrical emergencies. Some publications from 10years by the same obstetrical team for training and shoulder dystocia reveal a 75% reduction in brachial plexus injury after 4years of training, and 100% reduction in permanent injury after a decade of training. Only one publication is in accordance with a reduction of severe post-partum haemorrhage with training. For all obstetrical emergencies, crew resource management (communication, self-confidence…) and team training are improved.

Place: France; Anemia of prematurity remains a common complication despite recent advances in perinatal and neonatal medicine. The delayed cord clamping (at least 30seconds as recommended) has several benefits: increased hemoglobin and hematocrit levels at birth, improved initial hemodynamic, decreased incidence of transfusions and intraventricular hemorrhages. When the birth transition is difficult, wait 30seconds before clamping can be impossible. So as not to interfere with the neonatal resuscitation, the "milking" has been proposed as an alternative method to the delayed cord clamping. This is a safe and easy method, which can be done either by an obstetrician or pediatrician with comparable results for the child on his hemodynamic, hematological and neurological status. It still lacks technical information on this method and neurodevelopmental outcomes of these preterm infants.

Interest of routine umbilical cord blood gas analysis in physiological situations? Background: Perpartum asphyxia can lead to serious troubles for the child, making it necessary to identify by FHT and cord blood pH. Objective: We have studied the relevance of cord blood analysis in the diagnosis of asphyxia in physiological situations where a normal pH value is expected. Methods: A descriptive study was conducted on 1275 physiological births from June to December 2012 at the maternity Port-Royal. Cases were divided into 4 categories according to normal/abnormal FHT and normal/pathological pH. FHT was reinterpreted for the conflicting cases and the cost of cord blood sample was estimated. Results: FHT had a good negative predictive value for the identification of asphyxia (0,9% to 2,9%). When FHT was normal, there was no significant association between bad neonatal condition and pathological pH (p=1). Limiting umbilical pH sample to risk situations did not generate decisive savings (1500 to 5600 € for 7 months). Conclusion: Cord blood pH, which is non-invasive and cheap, presents mainly a medicolegal interest because it is an objective measurement. Thus, its routine use seems to be justified in a maternity with a blood gas analyser.; Contexte : L'asphyxie perpartum peut entraîner des conséquences graves chez l'enfant, d'où la nécessité de l'identifier à partir du RCF et du pH au cordon. Objectif : Nous avons étudié la pertinence de réaliser un pH au cordon en vue du diagnostic d'asphyxie dans des situations physiologiques où une valeur de pH normale est attendue. Matériel et méthodes : Une étude descriptive a été menée sur 1275 naissances physiologiques de la maternité Port-Royal de juin à décembre 2012. Les cas ont été classés en 4 catégories selon le RCF normal/anormal et le pH normal/pathologique. Le RCF a été réinterprété pour les cas discordants et le coût de la réalisation du pH a été estimé. Résultats : Le RCF avait une bonne valeur prédictive négative vis-à-vis des situations d'asphyxies (0,9 à 2,9%). En cas de RCF normal, le pH pathologique n'était pas associé à un mauvais état néonatal (p=1). Limiter la réalisation du pH aux situations à risque générerait peu d'économies (1500 à 5600€ sur 7 mois). Conclusion : Le pH au cordon, non invasif et peu coûteux, présente avant tout un intérêt médico-légal par sa mesure objective. Sa réalisation en systématique dans une maternité disposant d'un analyseur de gaz du sang semble donc justifiée.

To evaluate the placental pathological patterns in intrauterine growth restriction (IUGR) in order to determinate which placental lesions are linked to clinically significant anomalies and to predict the child outcome and the mother risk of recurrence.Bibliographic review using the Medline and PubMed databases.Placental studies designed in order to provide macroscopic and microscopic information about the mechanism of IUGR are not numerous and retrospective; files are most of the time very small. Meta-analyses are an exception. Maternal vascular underperfusion is admitted to be the most frequent etiology of IUGR. None of the associated placental lesions is pathognomonic but the combination of a number of placental changes is. Low placental weight and microscopic lesions are more frequent than gross anomalies. Other pathophysiological groups of placental pathologies are reported to be linked to fetal growth restriction: umbilical cord anomalies, fetal thrombotic vasculopathy, chronic villitis of unknown etiology and chronic histiocytic intervillositis. Some placental lesions have been reported associated with infants with neurologic impairment and can be as different as vascular lesions, villitis of unknown origin with stem villi vasculopathy, fetal thrombotic vasculopathy or umbilical cord anomalies. However, there is no direct link between a type of placental pathology and the infant's adverse outcome or his neurological risk. The maternal risk of recurrence is not easily predictable except for the chronic histiocytic intervillositis in which the estimated recurrence rate is very high.Placental morphological findings can play a critical role in explaining the IUGR. They always need to be correlated with clinical findings.

Introduction L'échographie doppler couleur permet d'étudier l'insertion du cordon ombilical sur le placenta. Les études américaines et asiatiques montrent que les insertions anormales telles les insertions vélamenteuses et marginales sont associées à une élévation de la morbidité et de la mortalité périnatales. En Afrique et plus particulièrement au Cameroun, aucune étude n'a été publiée sur le sujet. D'où notre motivation à mener ce travail. Méthodes Il s'agissait d'une étude descriptive et analytique qui s'est déroulée sur une période deux ans (2011-2012) à la maternité principale de l'Hôpital Central de Yaoundé. Cette étude a inclus 66 patientes qui ont subi chacune une échographie doppler couleur entre la 18ième et 30ième semaine de gestation, précisant le type d'insertion du cordon ombilical sur le placenta. A l'accouchement, un examen macroscopique du placenta a été réalisé afin de comparer le type d'insertion et réaliser les tests statistiques. Résultats Des 66 grossesses étudiées, nous avons eu un pourcentage de visualisation du type d'insertion de 100%. Toutes les insertions étaient normales à l'échographie soit 20 centrales et 46 latérales. A l'examen macroscopique du placenta, nous avons obtenu 19 (28,8%) insertions centrales, 47(71,2%) insertions latérales ; aucune insertion anormale n'ayant été objectivée. Les tests statistiques nous permettent d'avoir une sensibilité de 95%, une spécificité de 97,8%, une exactitude de 98%, une valeur prédictive positive de 95% et une valeur prédictive négative de 97,8%. Pour ces insertions, nous n'avons pas retrouvé d'association entre le mode d'accouchement, le poids de naissance, et le Score d'apgar avec le type d'insertion du cordon ombilical. Conclusion Nous avons conclu que l'échographie doppler couleur a une haute sensibilité et spécificité dans la détermination de l'insertion du cordon ombilical sur le placenta. Il n'y a pas d'association entre le type d'insertion et le devenir maternofoetal.

Pregnancy and delivery are at the heart of all cultures and ethnic groups, as they assure the continuity of any community. Over the millennia, each society has elaborated a combination of prescriptions, proscriptions and protective rites for future mothers and babies, based on their observations of nature in combination with their religious and mythic convictions. Common to the majority are the vulnerability of the mother-to-be to spirits, and the crucial and symbolic importance of the placenta and the umbilical cord. Delivery in hospital, in spite of its reassurance of greater security, may be an unpleasant experience (to both mother and family) because of the impossibility of respecting traditions. Medical personnel in charge of such culturally uprooted patients should, with the help of cultural mediators, become familiar with a minimum of customs and taboos (of the patient's community) and win the patient's confidence through a respectful approach and an empathetic listening in order to adapt their necessary practices of hygiene and security.

The purpose of prenatal monitoring of a fetus with intra-uterine growth restriction (IUGR) is identifying very-high-risk cases, monitoring these fetuses closely, and making an appropriate decision for fetal extraction if their condition worsens. It should be emphasized that term and birth weight are important criteria in making a decision for extraction or non-extraction. Prognostic tests used for monitoring IUGR are the same as those used in all extraction decisions. This includes fetus growth and vitality estimation using ultrasound, fetal Doppler measurement, and fetal heart rate recording. There is no randomized trial giving priority to one criterion to decide whether or not it is necessary to extract a fetus with IUGR. Therefore, monitoring strategies and the extraction decision described herein are based in part on pathophysiology and uncontrolled series, and on the authors' experience. The question of timing the extraction using a single criterion is complex: what threshold should be used and how should it be integrated with other exams? How should one take into account the wide individual variability of the degradation sequence that can be observed with various tests at our disposal? Deliberately, there is no decision tree based on the result of different criteria in this chapter. We believe that fetal extraction decisions must be discussed case by case, collaboratively if time allows, and always after information and discussion involving the couple, the obstetrician, and the neonatologist.

The timing of umbilical cord clamping remains controversial. Although most maternity wards use the early clamping (5-15s), randomized studies and meta-analyses have demonstrated the benefit of delayed clamping for term and preterm newborn infants over the past 10 years. Indeed, placentofetal transfusion of 20-30 ml/kg in 2-3 min improves the iron status of term infants and prevents infant hypochromic anemia. Infant anemia is a public health problem in many developing countries. For preterm newborns, placental transfusion for 45 s or milking the cord for 15 s improves cardiovascular adaptation, with better hemodynamic stability, as well as decreased intraventricular hemorrhages, need for transfusion, and late-onset sepsis. A new look at this symbolic act is needed and professionals need to be persuaded of the importance of the "wait a minute" policy for a better physiological delivery.

Selective Termination of Pregnancy (STOP) for discordant fetal condition in monochorionic twin pregnancy is a rarely performed procedure raising technical and ethical considerations. There are no epidemiological data available in France concerning STOP and no guideline or scientific consensus on how or when to perform has been published.We conducted a study of national practice using a declarative questionnaire sent by e-mail to each medical coordinator of every 48 Multidisciplinary Center for Prenatal Diagnosis in France. The questions focused on the issues of 2010 and 2011. Two reminders were sent in case of no answer.The response rate to the questionnaire was 56 %; 81 % of centers have experienced at least once during the two years 2010-2011 a discordant fetal anomaly in monochorionic twin pregnancy. Only 59 % of centers perform all the techniques of STOP. When interruption of the umbilical blood flow is considered, bipolar forceps coagulation is the most used (75 %). Achieving STOP during a cesarean section is a common practice (75 % of centers). Locoregional anesthesia is the preferred mode of anesthesia for STOP.STOP on monochorionic twin pregnancy is not practiced in all Multidisciplinary Center for Prenatal Diagnosis in France. The most widely practiced and most studied technique is bipolar forceps coagulation. The option of an expectant management should always be considered and its risks should be balanced with those of STOP. The practice of STOP during cesarean section is not unusual.

The objective was to evaluate the correlation between fetal scalp base excess (BE) and umbilical cord BE. Respective value of fetal scalp pH, BE and lactate for the prediction of neonatal metabolic acidosis were also evaluated.A retrospective monocentric study was conducted in a French tertiary care academic maternity. All the patients who had a fetal scalp sampling during labor in 2010, less than 90 minutes before delivery were included. Fetal heart rate abnormalities (FHRA) were classified by degree of severity, according to the French guidelines. The differences between fetal scalp samples and umbilical cord samples over time and in relation with the type of FHRA were analyzed for pH and BE. The differences between fetal scalp pH and cord pH over time and in relation with scalp BE were analyzed. The correlation between fetal scalp samples and cord samples for pH, BE and lactate was estimated. Receiver operating characteristics (ROC) curves for fetal scalp pH, lactate and BE to predict umbilical cord pH under 7.20 were calculated.Seventy-one cases were included. The difference between fetal scalp sample and cord sample was lower when the sample was made closest to delivery both for pH and BE. The gravity of FHRA was not predictive of a faster decrease of pH or BE over time. The correlation was significant for pH (r=0.23, p=0.03) between scalp samples and cord samples, as for BE (r=0.49, p=0.001) and lactate (r=0.52, p=0.001). The ROC curves for pH, BE and lactate displayed a similar pattern.Fetal scalp and umbilical cord samples, for pH, BE and lactate were significantly correlated but their respective predictive value for cord pH less or equal to 7.20 was poor.

Indications for fetal blood sampling (FBS) are getting more limited. In this context, we aimed to evaluate fetal loss and morbidity associated with FBS and to precise the predictive parameters for fetal complications. More than a retrospective evaluation of our practices, the final end point of our study was to better inform the patients coming to our centre.Retrospective monocentric cohort (Canadian Task Force classification II-2) of the 99 FBS performed between April 2004 and June 2010 on 80 fetuses, after excluding the procedures done for termination of pregnancy. The main clinical outcome was a composite outcome criteria for fetal tolerance including cesarean section for abnormal non stress test within the 24 hours, or any event responsible of a modified obstetrical management during the 14 day following FBS.Mean maternal age at FBS was 30 years ± 5.13 SD and parity was 2.49 ± 1.38 SD. FBS was performed by an experienced operator in 86.5% of cases (CI 95%, 78-92.6); with a single insertion in 83.3% of circumstances (CI 95%, 74.4-90.2). The mean duration was 11 min ± 6.37 SD. The total rate of intrauterine death, in our series, was 7.1% (CI 95%, 2.9-14), including all reported fetal demise within the 14 days after FBS, whatever the relation with the procedure. Our study demonstrated a 9.1% occurrence of post-FBS altered CTG fetal testing (CI 95%, 4.2-16.6), half of it with spontaneous resolution. The rate of severe complications (main clinical outcome) was 11.1% (CI 95%, 5.7-19) including one fetal death liable to FBS and 10 emergency caesarean sections: 5.1% for fetal bradycardia (CI 95%, 1.7-11.4), 2% for placental abruption (CI 95%, 0.2-7.1), 2% for premature preterm rupture of membranes (CI 95%, 0.2-7.1) and 1% for significative umbilical cord bleeding (CI 95%, 0-5.5). Univariate factor analysis highlights 4 parameters for impaired fetal tolerance; a prolonged procedure, presence of low fetal platelets (30.10(9)/L); and FBS performed for fetal anaemia during Parvovirus B19 infection or allo-immune thrombocytopenia.FBS remains a tricky procedure with a substantial risk of fetal loss or complications especially when performed on high-risk fœtuses. The length of the procedure should be shortened as much as possible (trained operator, postponed procedure when all favourable condition are not available). Fetal thrombocytopenia is a meaningful risk factor encouraging carefulness when exploring allo-immune fetal thrombocytopenia.

To determine the incidence of umbilical cord prolapse, the characteristics of the population, and to evaluate its management and the neonatal prognosis.Ninety-three cases of cord prolapse that occurred between January 1986 and December 2009 at our level III labour ward were studied retrospectively.The incidence of cord prolapse was 0.18%. It occurred in 66.7% of cases in multiparous patients, in 19.4% of cases in twin pregnancies, and in 41.9% of cases in breech presentations. In 34.4% of cases, the gestational age was less than 37 weeks. Birth occurred vaginally in 33.3% of cases with a delivery time interval significantly less than for caesarean sections (P0.001). At complete cervical dilation, more than three quarter of patients delivered vaginally. Vaginal birth was significantly more frequent in case of breech (P=0.009) and second twin (P=0.03). Parity did not influence birth route. Neonates with a birth weight less than 2500 g (30.1%) had significantly more frequently an Apgar score less than 7 at 5 min (P=0.02), a higher rate of transfer to intensive care (P0.001) and a longer hospital stay (P=0.002). We report six neonatal deaths (6.5%). Neonatal status was not influenced by the time interval for delivery.Umbilical cord prolapse is still nowadays a serious complication of pregnancy, responsible for a significant rate of neonatal mortality. The aim in case of cord prolapse is to obtain fetal delivery the quickest way possible so as to improve the neonatal outcome. In some particular obstetrical situations such as breech presentations and second twin deliveries, birth occurs faster if performed vaginally as shown by our case study.