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Objective: To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section., Design: Prospective population-based study., Setting: All 176 maternity hospitals of eight French regions., Population: Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries., Methods: Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared., Main Outcome Measures: Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes., Results: The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally., Conclusion: More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean., Tweetable Abstract: Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes., (© 2021 John Wiley & Sons Ltd.)

Background: Prophylactic administration of tranexamic acid has been associated with reduced postpartum blood loss after cesarean delivery in several small trials, but evidence of its benefit in this clinical context remains inconclusive., Methods: In a multicenter, double-blind, randomized, controlled trial, we assigned women undergoing cesarean delivery before or during labor at 34 or more gestational weeks to receive an intravenously administered prophylactic uterotonic agent and either tranexamic acid (1 g) or placebo. The primary outcome was postpartum hemorrhage, defined as a calculated estimated blood loss greater than 1000 ml or receipt of a red-cell transfusion within 2 days after delivery. Secondary outcomes included gravimetrically estimated blood loss, provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, and postpartum blood transfusion., Results: Of the 4551 women who underwent randomization, 4431 underwent cesarean delivery, 4153 (93.7%) of whom had primary outcome data available. The primary outcome occurred in 556 of 2086 women (26.7%) in the tranexamic acid group and in 653 of 2067 (31.6%) in the placebo group (adjusted risk ratio, 0.84; 95% confidence interval [CI], 0.75 to 0.94; P = 0.003). There were no significant between-group differences in mean gravimetrically estimated blood loss or in the percentage of women with provider-assessed clinically significant postpartum hemorrhage, use of additional uterotonic agents, or postpartum blood transfusion. Thromboembolic events in the 3 months after delivery occurred in 0.4% of women (8 of 2049) who received tranexamic acid and in 0.1% of women (2 of 2056) who received placebo (adjusted risk ratio, 4.01; 95% CI, 0.85 to 18.92; P = 0.08)., Conclusions: Among women who underwent cesarean delivery and received prophylactic uterotonic agents, tranexamic acid treatment resulted in a significantly lower incidence of calculated estimated blood loss greater than 1000 ml or red-cell transfusion by day 2 than placebo, but it did not result in a lower incidence of hemorrhage-related secondary clinical outcomes. (Funded by the French Ministry of Health; TRAAP2 ClinicalTrials.gov number, NCT03431805.)., (Copyright © 2021 Massachusetts Medical Society.)

Objective: To evaluate the association between the planned mode of delivery and neonatal mortality and morbidity in an unselected population of women with twin pregnancies., Methods: The JUmeaux MODe d'Accouchement (JUMODA) study was a national prospective population-based cohort study. All women with twin pregnancies and their neonates born at or after 32 weeks of gestation with a cephalic first twin were recruited in 176 maternity units in France from February 2014 to March 2015. The primary outcome was a composite of intrapartum mortality and neonatal mortality and morbidity. Comparisons were performed according to the planned mode of delivery, planned cesarean or planned vaginal delivery. The primary analysis to control for potential indication bias used propensity score matching. Subgroup analyses were conducted, one according to gestational age at delivery and one after exclusion of high-risk pregnancies., Results: Among 5,915 women enrolled in the study, 1,454 (24.6%) had planned cesarean and 4,461 (75.4%) planned vaginal deliveries, of whom 3,583 (80.3%) delivered both twins vaginally. In the overall population, composite neonatal mortality and morbidity was increased in the planned cesarean compared with the planned vaginal delivery group (5.2% compared with 2.2%; odds ratio [OR] 2.38, 95% confidence interval [CI] 1.86-3.05). After matching, neonates born after planned cesarean compared with planned vaginal delivery had higher composite neonatal mortality and morbidity rates (5.3% compared with 3.0%; OR 1.85, 95% confidence interval 1.29-2.67). Differences in composite mortality and morbidity rates applied to neonates born before but not after 37 weeks of gestation. Multivariate and subgroup analyses after exclusion of high-risk pregnancies found similar trends., Conclusion: Planned vaginal delivery for twin pregnancies with a cephalic first twin at or after 32 weeks of gestation was associated with low composite neonatal mortality and morbidity. Moreover, planned cesarean compared with planned vaginal delivery before 37 weeks of gestation might be associated with increased composite neonatal mortality and morbidity.

Unlabelled: The purpose of this study was to evaluate the proportion of indicated preterm births among all preterm births in a type 3 maternity ward; to assess practices in terms of mode of delivery in such cases; and to analyse the observed outcomes for such deliveries., Materials and Methods: A retrospective study was conducted in the obstetrics department of the regional university hospital of Tours (type 3 maternity ward) over a 22-month period. Women with an indicated preterm birth between 22 and 37 weeks of gestation, for whom vaginal delivery was possible, were included in the study. For every woman, the choice of mode of delivery (caesarean before labour or induction of labour) as well as maternal, obstetrical and neonatal factors were recorded., Results: From January 2012 to October 2013, 539 deliveries were preterm among which 42.5% were indicated preterm births. Out of 114 women for whom vaginal delivery was possible, 33.3% had a caesarean before labour and 66.7% had an induction of labour. The choice of mode of delivery is influenced by various factors such as local conditions, gestational age and type of obstetrical pathologies. Moreover, birth weight and Apgar score are significantly lower and the hospitalisation rate of newborns is significantly higher in the "caesarean before labour" group., Conclusion: Indicated preterm births represent almost half of preterm births in the maternity ward. A third of these indicated preterm births were caesareans before labour. Due to the neonatal morbidity resulting from indicated preterm birth, it is essential to regularly reassess indications of indicated preterm birth., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective: To assess whether outpatient cervical ripening at 41 0/7 weeks of gestation with the nitric oxide donor isosorbide mononitrate reduces cesarean delivery rates in nulliparous women with an unfavorable cervix., Methods: We recruited nulliparous pregnant women with a Bishop score less than 6 in a randomized, multicenter, double-blind, placebo-controlled trial. Women received 40 mg vaginal isosorbide mononitrate or a placebo at 41 0/7, 41 2/7, and 41 4/7 weeks of gestation. They returned home between visits. At 41 5/7 weeks of gestation, for women who had not yet given birth, labor was induced with oxytocin or prostaglandins, depending on cervical status. We needed 685 women per group to detect a 25% reduction in the cesarean delivery rate, the primary outcome measure, from 25% in the placebo group to 18.75% in the isosorbide mononitrate group (1-β=0.8, α=0.05, two-sided)., Results: The NOCETER (NO donors for reduction of CEsareans at TERm) trial was a negative study. The cesarean delivery rate was 27.3% (185/678) in the isosorbide mononitrate group and 27.2% (186/684) in the placebo group (relative risk 1.00, 95% confidence interval [CI] 0.84-1.19). None of the maternal secondary efficacy outcomes differed between groups. Side effects were more common among women receiving isosorbide mononitrate than in the placebo group (78.8% [534/678] compared with 27.9% [191/684], relative risk 2.82, 95% CI 2.49-3.20). Composite perinatal morbidity did not differ between groups., Conclusion: Outpatient cervical ripening with vaginal isosorbide mononitrate for prolonged pregnancy in nulliparous women does not reduce cesarean delivery rate., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00930618.

There are no guidelines for the anaesthetic management of caesarean section in women with long QT syndrome; the description of myocardial ventricular repolarisation in healthy women during caesarean delivery could be a first step. The aim of this study was to describe modification of the QT interval, corrected for heart rate, and the interval between the peak and the end of the T-wave (Tpeak-Tend interval) during caesarean section under spinal anaesthesia. We studied 40 patients scheduled for caesarean section under spinal anaesthesia. Patients were randomly assigned to receive either ephedrine or phenylephrine to prevent hypotension. We injected 5 IU oxytocin after delivery. Corrected QT and Tpeak-Tend intervals were unchanged from pre-operative values after induction of spinal anaesthesia, but increased significantly after oxytocin injection. The choice of vasopressor did not affect the Tpeak-Tend interval. The risk-benefit balance of oxytocin bolus during caesarean delivery should be discussed with women with a history of long QT syndrome.

Objective of the Study: To determine the risks and benefits of routine transcervical revision of previous cesarean uterine scar in patients with successful vaginal delivery., Material and Methods: Retrospective study, over a 10-year period, of a routine palpation practice in the two units of our Obstetric department. Then, a 30-month prospective study comparing, in each unit, two different attitudes toward uterine revision (routine exploration vs symptomatic patients exploration) was conducted., Results: The retrospective part of our study led us to report 3 uterine ruptures (0.43% of all scarred uterus) and 14 dehiscences (2%) during the ten years. All uterine ruptures were sufficiently symptomatic in order to be suspected prior to scar exploration. No dehiscence needed surgical treatment. Some patients with bloodless dehiscence and no repair had subsequent vaginal deliveries with no scar separation found on uterine exploration. In the prospective part of our study, we found a significative difference in the occurrence of fever (18.9% vs 9.9%; p < 0.05) and antibiotic treatment (22.8% vs 12.7%; p < 0.05) between the two groups based on attitude toward uterine revision., Conclusion: These data suggest that transcervical revision of previous cesarean uterine scar should be performed only in symptomatic patients (persistent suprapubic pain, placental retention, excessive bleeding during labor or delivery) or when risk factors are present (prolonged labor, prolonged expulsive efforts, instrumental extraction).

Data on obstetric outcomes in patients with a history of immunoglobulin A vasculitis (IgA-V) are lacking. The aim of this study was to assess maternal, neonatal, and vasculitis outcomes during pregnancy. We conducted a French retrospective case–control study. Pregnancies of patients with a history of IgA-V (cases) were retrospectively studied and compared to pregnancies in women who developed IgA-V after their pregnancies and to pregnancies in healthy women (controls). Twenty-six pregnancies in patients with a history of IgA-V were included and compared to 15 pregnancies in women who later developed IgA-V and 52 pregnancies in healthy women. Both gestational hypertension and pre-eclampsia were more frequent in the case group than in the other groups (23% vs 0% vs 0%, p < 0.01; 12% vs 7% vs 0%, p = 0.04). Hypertensive disorder of pregnancy occurred more frequently in patients with pre-existing kidney disease (78% vs 12%, p < 0.01). Caesarean section was more often performed in the case group than in the other groups (27% vs 0% vs 10%, p = 0.04). No foetal loss or maternal deaths occurred. There were no differences in delivery term or birth weight. No vasculitis flares were observed during pregnancy. Women with a history of IgA-V appear to be at higher risk for gestational hypertension and pre-eclampsia, especially in cases with renal involvement; however, both mother and newborn outcomes appear to be favourable. [ABSTRACT FROM AUTHOR]

Crohn's disease (CD) and sphincter injury during childbirth are two risk factors for anal incontinence (AI). The long-term risk of developing AI in women with CD after childbirth has never been studied. The main objective of the study is to assess the risk of developing severe AI after childbirth in women with CD. A retrospective study was performed in women with CD who gave birth in a French "Level 3" maternity hospital between 2000 and 2015. The primary endpoint was severe AI as defined by a Wexner score ≥ 9 or a St. Mark's score ≥ 9, at least five years after childbirth. The association between delivery route and occurrence of severe AI was assessed by univariate and multivariate analyses. Forty-six women were included, 32 of whom were delivered vaginally and 14 by Caesarean section. Thirty-one percent of the women had severe AI according to the Wexner score, and 41% according to the St. Mark's score. Two factors were associated with severe AI: vaginal delivery and the occurrence of an obstetric perineal injury: (crude OR = 8.89, 95% (CI: 1.03–76.57) and crude OR = 4.16, 95% (CI: 1.06–16.27) respectively for AI defined by the Wexner score, and crude OR = 6.8, 95% (CI: 1.30–35.41) and crude OR = 4.3, 95% (CI: 1.23–15.2) for AI defined by the St. Mark's score). After adjusting for confounding factors, only vaginal delivery was associated with severe AI (adjusted OR = 22.86, 95% CI: 1.52–931.28 for a Wexner score ≥ 9 and adjusted OR = 16. 11 (95% CI: 1.43–533.26) for a St Mark score ≥ 9). Vaginal birth was associated with the development of severe long-term AI in women with CD. [ABSTRACT FROM AUTHOR]

Objective: To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section. Design: Prospective population‐based study. Setting: All 176 maternity hospitals of eight French regions. Population: Two hundred and forty‐nine women with PAS, from a source population of 520 114 deliveries. Methods: Women with PAS were classified into two risk‐profile groups, with or without the high‐risk combination of placenta praevia (or an anterior low‐lying placenta) and at least one prior caesarean. These two groups were described and compared. Main outcome measures: Population‐based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes. Results: The PAS population‐based incidence was 4.8/10 000 (95% CI 4.2–5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally. Conclusion: More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean. Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes. Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes. [ABSTRACT FROM AUTHOR]

Summary: Objectives: The aim of this study was to evaluate our practices regarding the use of supplementation for breast-fed neonates. Methods: A descriptive and prospective study conducted between 22/05/2010 and 23/03/2010 comprising breast-fed, healthy, singleton infants at the Maternity University Hospital of Tours. Indications for supplementation were collected prospectively by paramedics. Results: The study included 281 breast-fed neonates, of whom 99 (35 %) received supplementation. Supplemented neonates were more often children of primiparae (61.6 % versus 44%; P =0.005), or born to mothers without experience of breast-feeding (69.7% versus 48.9%; P =0.001), born by cesarean section (21.2% versus 10.4%; P =0.01), or were small for gestational age (10.1 % versus 6.6%; P =0.003). The main indications were: to prevent additional weight loss, hunger of the newborn, hypoglycemia, and difficulty to breast-feed. Twenty-nine percent of the neonates were given supplements without medical indication. Conclusion: One third of breast-fed infants receive supplementation, not always medically justified. A better understanding of medical indications would avoid supplementation being given to breast-fed infants. [ABSTRACT FROM AUTHOR]

Postpartum haemorrhage (PPH) is a major cause of maternal mortality, accounting for one-quarter of allmaternal deaths worldwide. Uterotonics after birth are the only intervention that has been shown to be effective for PPH prevention. Tranexamic acid (TXA), an antifibrinolytic agent, has therefore been investigated as a potentially useful complement to this for both prevention and treatment because its hypothesized mechanism of action in PPH supplements that of uterotonics and because it has been proved to reduce blood loss in elective surgery, bleeding in trauma patients, and menstrual blood loss. This review covers evidence from randomized controlled trials (RCTs) for PPH prevention after caesarean (n=10) and vaginal (n=2) deliveries and for PPH treatment after vaginal delivery (n=1). It discusses its efficacy and side effects overall and in relation to the various doses studied for both indications. TXA appears to be a promising drug for the prevention and treatment of PPH after both vaginal and caesarean delivery. Nevertheless, the current level of evidence supporting its efficacy is insufficient, as are the data about its benefit:harm ratio. Large, adequately powered multicentre RCTs are required before its widespread use for preventing and treating PPH can be recommended. [ABSTRACT FROM AUTHOR]

Résumé: Objectifs: L’interruption sélective de grossesse (ISG) sur grossesse gémellaire monochoriale pour anomalie fœtale discordante est une intervention peu pratiquée et qui soulève des questions techniques et éthiques. Il n’existe pas de registre ou de statistiques nationales, ni de recommandation ou de consensus sur les modalités de réalisation ou le terme le plus favorable. Matériel et méthodes: Nous avons mené une étude déclarative des pratiques nationales par questionnaire mail, auprès de chaque médecin coordonnateur des 48 Centres Pluridisciplinaires de Diagnostic Prénatal français. Les questions portaient sur les dossiers de 2010 et 2011. Deux relances ont été effectuées en cas de non-réponse. Résultats: Le taux de réponse au questionnaire a été de 56 %. Quatre-vingt-un pour cent des centres ont été confrontés au moins une fois lors des 2 années 2010–2011 à une anomalie fœtale discordante sur grossesse monochoriale. Seulement 59 % des centres pratiquent des ISG toutes techniques confondues. Pour les gestes d’interruption de la circulation au cordon, c’est la coagulation bipolaire qui est la plus utilisée (75 %). La réalisation d’une ISG en cours de césarienne est une pratique fréquente (75 % des centres). Pour la réalisation d’une ISG le mode d’anesthésie le plus employé est l’anesthésie locorégionale. Discussion et conclusion: L’ISG sur grossesse monochoriale n’est pas pratiquée dans tous les centres en France. La technique la plus pratiquée et la mieux étudiée est la coagulation cordonale à la pince bipolaire. L’option de ne pas intervenir devrait cependant toujours être considérée et ses risques mis en balance avec ceux de l’ISG. La pratique d’une ISG en cours de césarienne n’est pas exceptionnelle. [Copyright &y& Elsevier]

Abstract: Objectives: 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. Patients and methods: 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 24hours, or any event responsible of a modified obstetrical management during the 14day following FBS. Results: Mean maternal age at FBS was 30years±5.13 SD and parity was 2.49±1.38SD. 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 11min±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 (<30.109/L); and FBS performed for fetal anaemia during Parvovirus B19 infection or allo-immune thrombocytopenia. Discussion and conclusion: 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. [Copyright &y& Elsevier]

Abstract: In the second stage of labor, fetal head rotation and fetal head position are determinant for the management of labor to attempt a vaginal delivery or a cesarean section. However, digital examination is highly subjective. Nowadays, delivery rooms are often equipped with compact and high performance ultrasound systems. The clinical examination can be easily completed by quantified and reproducible methods. Transabdominal ultrasonography is a well-known and efficient way to determine the fetal head position. Nevertheless, ultrasound approach to assess fetal head descent is less widespread. We can use translabial or transperineal way to evaluate fetal head position. We describe precisely two different types of methods: the linear methods (3 different types) and the angles of progression (4 different types of measurement). Among all those methods, the main pelvic landmarks are the symphysis pubis and the fetal skull. The angle of progression appears promising but the assessment was restricted to occipitoanterior fetal position cases. In the coming years, ultrasound will likely play a greater role in the management of labor. [Copyright &y& Elsevier]