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Resume L’administration precoce et multimodale d’antalgiques par voie orale fait partie du programme de rehabilitation postoperatoire apres chirurgie. Aussi efficiente que la voie parenterale, l’auto-administration d’antalgiques par voie orale (PCOA) facilite la deambulation precoce des parturientes dont le premier souhait est d’etre suffisamment autonome pour s’occuper de leur enfant et permet une analgesie de qualite notamment apres cesarienne. Les antalgiques administres dans ce contexte doivent etre evalues en termes d’efficacite mais aussi de securite par rapport a l’allaitement.

International audience; Objectives: To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy and the post-partum period.Study design: A systematic review of the international literature was undertaken between January 2003 and April 2019. MEDLINE, EMBASE databases and the Cochrane library were searched for a range of predefined key words. All relevant reports in English and French were classified according to their level of evidence ranging from 1(highest) to 4(lowest). The strength of each recommendation was classified according to the Haute Autorité de Santé (French National Authority for Health) ranging from A (highest) to C (lowest).Results: \"Counselling\", including all types of non-pharmacological interventions, has a moderate benefit on smoking cessation, birth weight and prematurity. The systematic use of measuring expired air CO concentration does not influence smoking abstinence, however, it may be useful in assessing smoked tobacco exposure prior to and after quitting. The use of self-help therapies and health education are recommended in helping pregnant smokers quit and should be advised by healthcare professionals. Nicotine replacement therapies (NRT) may be prescribed to pregnant women who have failed to stop smoking after trying non-pharmacological interventions. Different modes of delivery and dosages can be used in optimizing their efficacy. Smoking in the postpartum period is essential to consider. The same treatment options as during pregnancy can be used.Conclusion: Smoking during pregnancy concerns more than a hundred thousand women each year in France resulting in a major public health burden. Healthcare professionals should be mobilised to employ a range of methods to reduce or even eradicate it.

IntroductionPre-eclampsia (PE) and intrauterine growth restriction (IUGR) are two major pregnancy complications, related to chronic uteroplacental hypoperfusion. Nowadays, there is no screening or diagnostic test for uteroplacental vascularisation deficiency in pregnant women. Since 2004, 3 three-imensional power Doppler (3DPD) angiography has been used for the evaluation of uteroplacental vascularisation and three vascular indices are usually calculated: Vascularisation Index (VI), Flow Index (FI) and vascularisation-FI (VFI). A high intraobserver and interobserver reproducibility and a potential interest for placental function study were reported by our team and others.The main objective of our study is to determine differences in 3DPD indices at first trimester between pregnancies defined at their outcome as uncomplicated pregnancy, PE (mild and severe) and IUGR in nulliparous women.Methods and analysisThis is a national multicentre prospective cohort study conducted in four French maternity units. We expect to include 2200 women in a period of 36 months. The nulliparous pregnant women will be recruited during their first trimester consultation (11–13+6 gestation week (GW)).The 3DPD and uterine artery Doppler acquisition will be included in the current routine 11–13+6 GW ultrasound. Also, additional blood samples will be taken for biomarker analysis (PAPP-A and P1GF) and biological collection. Uteroplacental VIs (FI and VFI) will be measured. For each subgroup (uncomplicated pregnancy, PE and IUGR), mean values in 3DPD indices will be computed and compared using a pairwise t test with a Bonferroni correction p value adjustment.Ethics and disseminationThe study was approved by the French Ethics Committee, the Comité de Protection des Personnes SUD MEDITERRANEE IV on 13 February 2018 with reference number 17 12 03. The results of this study will be published in a peer-reviewed journal and will be presented at relevant conferences.Trial registration numberNCT03342014; Pre-results. PHRCN-16-0567.

International audience

International audience; The sudden arrival of the SARS-CoV-2 outbreak conducted healthcare departments to rapidly adapt their organizations. The White Plan has been activated in Strasbourg and Nancy the March 13, 2020 to deal with a massive influx of patients. Due to this new kind of sanitary emergency, build on Strasbourg’s experience, the University Maternity of Nancy has been reorganized in order to propose the best care conditions for women in an environment limiting the risk of contamination. In view of the high risk of viral transmission, antenatal follow-up by teleconsultations and home visits provided by independent midwives and general practitioners was promoted for low-risk pregnancies. A pre-admission triage system and a specific circuit for patients suspected or infected with SARS-CoV-2 have been created. Specific procedures of care in anesthesiology, obstetrics and pediatrics have been drawn up and regularly revised according to national recommendations and literature. The aim of the article is to describe our health care organization, to highlight operational difficulties and points of improvement identified.; L’arrivée brutale de l’épidémie sanitaire liée au SARS-CoV-2 dans la région Grand Est a conduit les services de soins de cette région à s’adapter rapidement à la situation. Le Plan blanc a été déployé dans les hôpitaux de Strasbourg et Nancy dès le 13 mars 2020 afin de faire face à un afflux massif de patients. Face à cette urgence sanitaire d’un type nouveau, la maternité de Nancy s’est réorganisée forte de l’expérience des services strasbourgeois rapidement mis en tension afin d’assurer l’accueil et de dispenser les meilleurs soins possible aux parturientes dans un environnement limitant au maximum leur risque de contamination. Du fait du haut risque de transmission virale, un suivi anténatal par téléconsultations et visites à domicile par le réseau de ville (sages-femmes libérales, généralistes) a été organisé pour les grossesses à bas risque. Sur site, un triage des admissions a rapidement été mis en place ainsi que la création d’un circuit spécifique dédié aux patientes à risque ou confirmées porteuses du SARS-CoV-2. Des procédures de prise en charge gynéco-obstétricales, anesthésiques et pédiatriques ont été rédigées et révisées par les différentes équipes au fur et à mesure de l’évolution des connaissances et des recommandations émises par les sociétés savantes. L’objectif de cet article est de détailler l’ensemble de l’organisation mise en place, de décrire les difficultés de fonctionnement rencontrées lors du pic de l’épidémie et d’analyser les points d’amélioration mis en évidence.

International audience; Objectifs.-É valuer l'issue postnatale des hydramnios isolé s à l'é chographie anté natale et dé terminer les facteurs associé s à la survenue d'une issue dé favorable. Me´thodes.-É tude ré trospective observationnelle ré alisé e dans un centre universitaire français de type III entre 2008 et 2018, incluant toutes les femmes pré sentant une grossesse singleton compliqué e d'hydramnios. Ont é té exclues les grossesses pré sentant une anomalie é chographique foetale ou placentaire. Le critè re de jugement principal é tait la survenue d'une issue dé favorable postnatale, dé finie par un critè re composite incluant le dé cè s ou la dé couverte postnatale d'une malformation ou d'une pathologie chronique. Les caracté ristiques maternelles, obsté tricales, pé diatriques et de l'hydramnios ont é té comparé es en fonction de l'issue postnatale. Re´sultats.-Quatre-vingt-onze femmes pré sentant un hydramnios ont é té inclues. L'issue é tait dé favorable dans 24,2 % des cas (22/91). Ce taux é tait de 20,3 % en cas d'hydramnios idiopathique et de 33,3 % en cas de diabè te maternel. Le taux de mortalité postnatale é tait de 5,5 % et celui d'anomalies morphologiques non dé tecté es en anté natal de 11 %. Les facteurs associé s à une issue dé favorable é taient l'obé sité (50 % vs 18,8 % ; p = 0,004), la pré cocité du diagnostic (72,7 % avant 32 SA vs 44,9 % ; p = 0,02) et la sé vé rité de l'hydramnios (22,7 % vs 4,3 % en cas d'hydramnios sé vè re ; p = 0,01). L'incidence de la pré maturité é tait plus é levé e en cas d'issue dé favorable. Conclusion.-La pré sence d'un hydramnios doit faire ré aliser une é chographie de seconde intention, y compris en cas de diabè te maternel isolé. La ré alisation d'un bilan gé né tique systé matique reste discutable.

Resume Objectif Etablir un etat des lieux des pratiques professionnelles concernant la prise en charge des grossesses prolongees dans les maternites lorraines. Materiels et methodes Il s’agissait d’une etude des pratiques professionnelles incluant les 20 maternites du Reseau Perinatal Lorrain. Les differentes maternites etaient interrogees sur les points suivants : moyens de datation de la grossesse, date de debut du suivi et frequence de ce suivi, moyens de surveillance, terme de declenchement, moyens utilises pour le declenchement et les adaptations eventuelles en cas d’uterus cicatriciel. Une comparaison etait ensuite realisee entre les reponses donnees et les recommandations du CNGOF. Resultats Sur les 20 maternites, 19 (95 %) datent la grossesse selon les recommandations et debutent le suivi des 41 SA, 13 (65 %) effectuent un suivi 2 a 3 fois par semaine, 12 (60 %) utilisent les moyens recommandes pour la surveillance des grossesses prolongees, 18 (90 %) effectuent une maturation cervicale en cas de col defavorable, et l’ensemble des maternites suivent les recommandations concernant la date de declenchement. Conclusion La prise en charge apparait tres heterogene en Lorraine et seules 12 des 20 maternites lorraines (60 %) suivent la totalite des recommandations nationales.

IntroductionKnowledge about the mechanisms leading to the establishment of uteroplacental vascularisation is inadequate, and some of what has been thought to be known for decades has recently been challenged by showing that the intervillous space, the major area of maternal-fetal exchange, appears to be perfused by maternal blood at as early as 6 weeks of gestation. The vascular flow then seems relatively constant until 13 weeks when it appears to increase suddenly.ObjectivesThe principal objective is to quantify the perfusion of the intervillous space by contrast-enhanced ultrasonography (CEUS) during the first-trimester at three different gestational ages (8, 11 and 13 weeks). The secondary objectives are to: (1) describe the indicators of vascularisation of the placenta (intervillous space) and the myometrium at the three gestational ages, measured by CEUS and three-dimensional power Doppler (3DPD) angiography; (2) compare the diagnostic performance of CEUS and 3DPD for the demonstration and quantification of uteroplacental vascularisation and (3) establish a biological collection of placentas to increase knowledge about placental development and functions during pregnancy.Methods and analysisThis is a prospective, cross-sectional, multicentre and non-randomised open study. We will include 42 women with ongoing pregnancy and divided into three groups of gestational ages (ie, 14 women by per group): 8, 11 and 13 weeks of gestation. 3DPD and then CEUS will be performed and the data about the perfusion kinetics and the 3DPD indices will be calculated and then compared with each other and for each gestational age.Ethics and disseminationThe appropriate French Ethics Committee Est III approved this study and the related consent forms on 5 April 2016, and the competent authority (Agence Nationale de Sécurité du Médicament et des Produits de Santé) authorised the study on 21 June 2016. The results of this study will be published in a peer-reviewed journal and will be presented at relevant conferences.Trial registration numbersClinicalTrials.gov registry (NCT02884297); EudraCT registry (2015-005655-27).

Introduction: Mini-invasive surgery of deep endometriosis is challenging. Surgical difficulties related to the technical limitations of classical laparoscopic approach might be overcome with the use of robotic assistance. The aim of this study was to evaluate the safety and feasibility of robotic surgery for deep infiltrating endometriosis in the learning phase of our team. Methods: The 20 first cases of robotic-assisted laparoscopies for endometriosis were included over a 2-year period. Baseline characteristics of patients and surgical data were reviewed. Surgical outcomes and follow-up information of the patients were analyzed. Results: Twenty women were included. The mean age was 31.9 years (range: 25–44) and mean body mass index was 23 kg/m2 (range: 16–35). Ten patients had rectovaginal or uterosacral location only (50%) and nine women had deep infiltrating endometriosis with digestive or urinary tract lesions (45%). In addition to the gynecologic surgeon, urologic or visceral surgeons were required in 10 cases, and there were 3 cases where the three specialties were needed. The mean operative time was 183.9 min (range: 85–398) and no difference was observed between the first five cases and the last five cases. There was one laparoconversion, and only two urologic postoperative complications occurred. Conclusion: Thanks to the use of robotic surgical assistance and a multidisciplinary approach, and despite the start of the team for deep endometriosis care, no learning curve effect was observed regarding surgical procedures’ success, safety, or duration. The use of robotic assistance might improve the quality of care for women facing deep endometriosis.

Resume Objectifs L’objectif de notre etude etait de realiser une evaluation des pratiques declarees par les professionnels de la naissance de la region Lorraine a propos de la protection perineale obstetricale (toute dechirure perineale confondue). L’objectif secondaire etait d’evaluer les mesures de prevention realisees en pratique par les professionnels de la naissance en fonction du risque perineal subjectivement estime pour chaque situation obstetricale. Methodes Il s’agit d’une enquete de pratique realisee grâce a un questionnaire anonyme distribue aux professionnels de la naissance (gynecologues-obstetriciens, internes de specialite, sage-femme, etudiants sage-femme) en octobre 2016. Les themes abordes concernaient les facteurs de risque maternels, obstetricaux et fœtaux associes aux lesions perineales (du 1er au 4e degres) et les mesures de protection associees. Il a ete realise une analyse descriptive des donnees recueillies. Resultats Cent cinq professionnels ont repondu au questionnaire. Les facteurs de risque identifies etaient en accord avec ceux mis en evidence dans la litterature. D’autres facteurs, non connus comme associes a un risque perineal, etaient cites par les professionnels (tabagisme, phototype). En cas de perception, subjective, par le professionnel d’un risque perineal important, ils pratiquaient plus frequemment une episiotomie (15 % vs 0 %, p Conclusion Cette evaluation montre que les professionnels de la naissance connaissent les principaux facteurs de risque de lesion perineale. En revanche, ils utilisent facilement des manœuvres de protection perineale (episiotomie par exemple) sans reelle efficacite demontree.

International audience; Introduction - Turner syndrome is one of the most frequent chromosomal abnormalities in women, with a prevalence estimated to be 1 of 2500 live birth. Pregnancy in women with Turner syndrome is known to be at high risk, whether it is spontaneous or after oocyte donation, because of miscarriages and potential cardio-vascular complications which can be life-threatening. All of these patients should therefore be screened with a comprehensive cardio-vascular assessment before pregnancy, and have a close follow-up during and after pregnancy.Patients and methods - It is a retrospective study, conducted in 10 of the 27 French oocyte donation centers between 2012 and 2016, on all the patients presenting with Turner syndrome included in an oocyte donation program.Results - 151 embryo transfers were realized in 73 patients, resulting in 39 pregnancies. Among these pregnancies, 24 children were born healthy, 11 spontaneous miscarriages, 3 voluntary abortions, 1 extra-uterine pregnancy and 1 maternal death from non-cardio-vascular origin occurred. Pregnancies were complicated by gravid arterial hypertension in 28.2% of cases, preeclampsia in 10.3% of cases, and gestational diabetes in 7.7% of cases.Conclusion - This study bring out obstetrical complications of the same magnitude than the ones described in the literature. Lead over a period of 4 years, in 10 French oocyte donation centers, it doesn't reveal any cardio-vascular complications, conversely to other studies published before French and American recommendations. This study reinforces the usefulness of specific recommendations for the care of these particular patients.

International audience; Background: The diagnosis of a fetal anomaly in perinatal medicine forces expectant parents and healthcare providers to face the difficult process of breaking bad news.Objectives: This exploratory literature review was aimed at providing a medical and psychological view of the psychological experience in expectant parents and physicians in the context of prenatal diagnosis of a fetal anomaly.Method: An exploratory search of PubMed and PsycINFO/PsycARTICLES databases performed by an interdisciplinary team composed of a physician and psychologists. Search terms were: prenatal diagnosis AND bad news; prenatal diagnosis AND psychological consequences; prenatal diagnosis AND psychological sequelae; prenatal diagnosis AND fetal abnormality. The processing of selected articles followed a standardised five-step procedure.Results: A total of 860 articles were screened of which 32 were retained for analysis. Four main themes emerged from the explanatory content analysis: (1) parents' subjective experience; (2) physicians' subjective experience; (3) encounters between expectant parents and professionals; and (4) ethical challenges in breaking bad news in prenatal medicine.Conclusion: Expectant parents go through a complex and multidimensional experience when the diagnosis of a fetal anomaly is disclosed. Simultaneously, physicians consider breaking bad news as a very stressful event and are poorly prepared in this regard. A better knowledge of factors underlying psychological adjustment of the parental dyad and on the subjective experience of physicians delivering these diagnoses could enable better adaptation for both patients and professionals.Keywords: Prenatal diagnosis; bad news disclosure; healthcare professional’s subjective experience; interdisciplinary perspective; psychological consequences.

Resume Objectif L’echographie joue un role central pour la prise en charge des suspicions de grossesses arretees. En cas d’erreur diagnostique, cet examen peut amener a mettre en œuvre une prise en charge inadaptee pouvant avoir des consequences lourdes, notamment en cas de faux positif. Les criteres de realisation de cet examen sont aujourd’hui bien definis. L’objectif etait d’evaluer la faisabilite et la reproductibilite d’une note de qualite regroupant les criteres diagnostiques echographiques de grossesse arretee. Methode Trente cliches de grossesses arretees ont ete evalues en double relecture. Deux grilles de notation ont ete evaluees. La premiere permettait d’evaluer la qualite du cliche en cas de sac gestationnel sans embryon (note du sac gestationnel), la seconde permettait d’evaluer le cliche en cas d’embryon present (note de l’embryon). Resultats Les CCI (coefficient de correlation intra-classe) etaient superieurs a 0,75 pour la note du sac gestationnel et pour celle de l’embryon en intra et en inter observateur avec une faible variabilite en fonction des notes obtenues. La reproductibilite inter observateur etait plus faible en premiere lecture pour les longueurs crânio-caudales inferieures a 5 mm mais apres ajustement des modalites de notation, le CCI etait egalement > 0,75. Conclusion Le systeme de notation de la qualite des cliches d’echographies en cas de grossesse arretee propose ici presente une reproductibilite elevee en inter et intra-observateur avec une faible variabilite. Ce systeme de note pourrait donc etre utilisable en pratique courante.

Introduction A normal placenta development is crucial for a successful pregnancy. In case of major obstetric complications such as intra-uterine growth restriction, the placental vascularization morphological alteration at macroscopic level is less known than that at microscopic scale. Ex vivo MRA has the potential to visualize whole fresh human placental vasculature fast and efficiently but can be hampered by contrast agent extravasation problem. This study aimed to provide an optimized ex vivo MRA protocol to acquire understanding of global human placenta vasculature morphology. Methods Six fresh normal human placentas were imaged with two contrast agents (i.e. Gd-chelate and pump oil) using different imaging parameters on a 3T clinical MR scanner (GE). The contrast to noise ratio, signal to noise ratio and enhancement efficiency were assessed in order to decide which contrast agent and imaging protocol was better. In the end, morphology indices were measured based on the 3D vasculature models reconstructed from the placentas imaged with the optimized protocol. Results With the same imaging parameters, the CNR and the enhancement efficiency of images enhanced with pump oil were superior to those using Gd-chelate. Enhanced by pump oil, an optimized ex vivo MRA protocol was determined, leading to a clear 3D visualization and reconstruction of human placenta vascularization. Discussion The proposed ex viv o MRA method is easy to manipulate, and can be used to investigate the human placental vasculature morphology. The acquired data are of good quality and can be used for characterization of placenta vascularization morphology.

International audience; Transition to parenthood is considered a developmental crisis and adult attachment has been identified as a key concept for a better understanding of the psychological adjustment of individuals and couples during the transition to parenthood. In the context of transition to parenthood, prenatal diagnostic of a fetal anomaly is a very demanding situation. Regardless of the degree of the illness, this experience incorporates a traumatogenic dimension, due to the impact of the diagnosis of a fetal anomaly on the psychological functioning and well being of expectant parents. It is important to continue to study the factors of psychological adaptation to parenthood in order to guide the clinical interventions protocols focused on individual and dyadic adaptation to parenthood, mainly in pathological contexts.; La transition vers la parentalité représente une crise développementale et l’attachement adulte a été identifié en tant que concept-clé dans la compréhension de l’ajustement psychologique des personnes et des couples pendant cette période. Dans le cadre de la transition vers la parentalité, le diagnostic prénatal d’une pathologie fœtale représente une situation d’extrême exigence. À cause de l’impact de l’annonce du diagnostic sur le fonctionnement psychologique et bien-être des futurs parents, cette expérience peut avoir un caractère traumatogène, indépendamment de la sévérité de la maladie diagnostiquée. L’étude des variables qui déterminent l’adaptation à la parentalité doit se poursuivre de façon à orienter les interventions cliniques qui visent l’adaptation individuelle et dyadique pendant ce parcours développemental, surtout dans les situations pathologiques.

International audience; Objective: Few studies compared growth and neurodevelopment outcome between asymmetric (aSYM) and symmetric (SYM) small for gestational age (SGA) term infants. We aimed at evaluating their respective outcome at 9 months postnatal age.Study design: A cohort study including infants born in 2010 to 2011 with a birth weight