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National audience; Objectives Delivery mode in breech presentation (BP) is often controversial. Spontaneous labor, when vaginal birth seems safe, allows to better estimate uterus contractility, fetus’ accommodation to maternal pelvis and optimize monitoring with a partograph. Induced labor in BP was usually contra-indicated. Lack of strong scientific evidence on this matter has permitted a progressive and careful evolution in obstetrical management, with the introduction of induced labor in BP. The aim of our study is to compare vaginal birth rates when labor is induced versus when spontaneous in BP. Maternal and fetal morbidity and mortality parameters were also evaluated. Methods In this retrospective study were included 206 patients carrying fetuses in BP, between June 2012 and June 2017. 182 of them had spontaneous labor and 24 experienced induced labor. Inclusion criteria were singleton pregnancy, BP after 34 weeks of gestation and vaginal delivery authorized by a senior obstetrician. Multiple pregnancy, birth before 34 weeks of gestation, uterine scar, planned caesarian section for BP, intra-uterine fetal death and medical termination of pregnancy were excluded. Induction of labor was performed for medical reason on a favorable cervix. Results There was no significant difference in cesarean section rates between the two “induced” and “spontaneous” labor groups in BP (OR = 1.69 [CI95%: 0.71–4.04]). We observed no difference between the two groups in neither perineum trauma nor post-partum hemorrhage. No difference was found between the two groups in rates of Apgar score < 7 5 minutes after birth, neonatal transfer, fetal trauma and pH at birth. Conclusion Despite our small population, it seems acceptable to propose induced labor for medical reason if cervix is favorable in BP if a protocol is available stating acceptability criteria for vaginal birth. It can avoid unnecessary caesarian section and allow better obstetrical outcome. It would be interesting to study fetal and maternal morbidity and mortality criteria in induced labor versus planned cesarean section when patients could be eligible for induced labor in BP.; Objectifs La voie d’accouchement des fœtus en présentation podalique est souvent débattue. L’accouchement par voie basse, lorsqu’il est accepté, concerne le plus souvent un travail spontané pour mieux apprécier la qualité de la contractilité, de l’accommodation fœtopelvienne et du partogramme. Le déclenchement des fœtus en présentation du siège était classiquement contre-indiqué ou jugé avec méfiance par les experts. L’absence de niveau de preuve concernant une contre-indication permet une prudente et progressive évolution des pratiques obstétricales, avec l’arrivée des déclenchements du siège. L’objectif de cette étude est d’analyser le taux de succès d’accouchement par voie basse lors des déclenchements versus lors des mises en travail spontané dans les déclenchements du siège. Les critères de morbi-mortalité maternels et fœtaux sont également analysés. Méthodes Cette étude rétrospective a inclus 206 patientes avec des fœtus en présentation du siège : 182 en travail spontané et 24 déclenchements, entre juin 2012 et juin 2017. Les critères d’inclusions étaient toutes les patientes présentant une grossesse unique avec un fœtus en présentation du siège après 34 semaines d’aménorrhée et avec un accord d’accouchement par voie basse par un sénior d’obstétrique. Les grossesses multiples, les termes inférieurs à 34 semaines d’aménorrhées, les utérus cicatriciels, les césariennes programmées pour présentation du siège et absence d’accord voie basse, les morts fœtales in utero et les interruptions médicales de grossesse étaient exclus. Les déclenchements étaient réalisés pour raison médicale sur un col favorable. Résultats Il n’y avait pas de différence significative sur le taux de césariennes des accouchements des sièges entre le groupe « déclenchement » et le groupe « travail spontané » (OR = 1,69 [IC95 % : 0,71–4,04]). Concernant les critères de morbidité maternels, il n’y avait pas de différence significative entre les deux groupes concernant le taux de périnée lésé ni sur le taux d’hémorragie de la délivrance. Pour les paramètres de morbi-mortalité néonataux, aucune différence n’a été mise en évidence entre les deux groupes concernant le taux de score d’Apgar < 7 à 5 minutes, de transfert en néonatologie, de traumatisme fœtal et de la valeur du pH. Conclusion Dans la limite de notre effectif, il paraît acceptable de proposer des déclenchements pour raison médicale sur les présentations du siège sous réserve d’un protocole précis de service avec des critères d’acceptabilités. En effet, cela permet d’éviter un certain nombre de césariennes de précaution, et ainsi de préserver le pronostic obstétrical des patientes pour des grossesses ultérieures. Il serait intéressant d’étudier les critères de morbi-mortalité maternels et néonataux lors des déclenchements à ceux des césariennes programmées alors que le déclenchement aurait été envisageable.

International audience

National audience; OBJECTIVES:The aim of this review was to agree on a definition of the obstetric anal sphincter injuries (OASIS), to determine the prevalence and risk factors. METHODS:A comprehensive review of the literature on the obstetric anal sphincter injuries (OASIS), establishment of levels of evidence (NP), and grades of recommendation according to the methodology of the recommendations for clinical practice. RESULTS:To classify obstetric anal sphincter injuries (OASIS), we have used the WHO-RCOG classification, which lists 4 degrees of severity. To designate obstetric anal sphincter injuries, we have used the acronym OASIS, rather than the standard French terms of "complete perineum" and "complicated complete perineum". OASIS with only isolated involvement of the EAS (3a and 3b) appears to have a better functional prognosis than OASIS affecting the IAS or the anorectal mucosa (3c and 4) (LE3). The prevalence of women with ano-rectal symptoms increases with the severity of the OASIS (LE3). In the long term, 35-60% of women who had an OASIS have anal or fecal incontinence (LE3). The prevalence of an OASI in the general population is between 0.25 to 6%. The prevalence of OASIS in primiparous women is between 1.4 and 16% and thus, should be considered more important than among the multiparous women (0.4 to 2.7%). In women with a history of previous OASIS, the risk of occurrence is higher and varies between 5.1 and 10.7% following childbirth. The priority in this context remains the training of childbirth professionals (midwives and obstetricians) to detect these injuries in the delivery room, immediately after the birth. The training and awareness of these practitioners of OASIS diagnosis improves its detection in the delivery room (LE2). Professional experience is associated with better detection of OASIS (LE3) (4). Continuing professional education of obstetrics professionals in the diagnosis and repair of OASIS must be encouraged (Grade C). In the case of second-degree perineal tear, the use of ultrasound in the delivery room improves the diagnosis of OASIS (LE2). Ultrasound decreases the prevalence of symptoms of severe anal incontinence at 1 year (LE2). The diagnosis of OASIS is improved by the use of endo-anal ultrasonography in post-partum (72h-6weeks) (LE2). The principal factors associated with OASIS are nulliparity and instrumental (vaginal operative) delivery; the others are advanced maternal age, history of OASIS, macrosomia, midline episiotomy, posterior cephalic positions, and long labour (LE2). The presence of a perianal lesion (perianal fissure, or anorectal or rectovaginal fistula) is associated with an increased risk of 4th degree lacerations (LE3). Crohn's disease without perianal involvement is not associated with an excess risk of OASIS (LE3). For women with type III genital mutilation, deinfibulation before delivery is associated with a reduction in the risk of OASIS (LE3); in this situation, deinfibulation is recommended before delivery (grade C). CONCLUSION:It is necessary to use a consensus definition of the OASIS to be able to better detect and treat them.

International audience; Objective To assess the efficacy and safety of in-utero aspiration (IUA) of anechoic fetal ovarian cysts. Methods This multicenter, prospective, randomized open trial in two parallel groups included women from nine outpatient fetal medicine departmentswith singleton pregnancy >= 28 weeks of gestation and a female fetus with an ultrasound-diagnosed simple ovarian cyst, defined as a single fully anechoic cystic structure measuring >= 30 mm. They were allocated randomly to IUA under ultrasound guidance or expectant management. All procedures were performed by trained senior obstetricians. Primary outcome was need for neonatal intervention, by laparoscopy, laparotomy or transabdominal aspiration. Secondary outcomes were in-utero involution of the cyst and oophorectomy at birth. Analyses were conducted according to the intention-to-treat principle. Results Of 61 participants, 34 were allocated to IUA and 27 to expectant management. Three IUA procedures (9%) could not be performed (one due to fetal position and two due to aspirations being dry). The remaining 31 IUA procedures were uneventful. The incidence of neonatal intervention did not differ significantly between the IUA and the expectant management groups (20.6% vs 37.0%; relative risk (RR), 0.55; 95% CI, 0.24-1.27). Nonetheless, IUA was associated with increased incidence of in-utero involution of the cyst (47.1% vs 18.5%; RR, 2.54; 95% CI, 1.07-6.05) and reduced rate of oophorectomy (3.0% vs 22.0%; RR, 0.13; 95% CI, 0.02-1.03) compared with expectant management. Conclusion IUA of anechoic fetal ovarian cysts, compared with expectant management, was not associated with a reduction in overall neonatal interventions but was associated with a reduced oophorectomy rate.

International audience; Background: The data from literature show that trial of labor and elective repeat cesarean delivery after a prior cesarean delivery both present significant risks and benefits, and these risks and benefits differ for the woman and her fetus. The benefits to the woman can be at the expense of her fetus and vice-versa. This uncertainty is compounded by the scarcity of high-level evidence that preclude accurate quantification of the risks and benefits that could help provide a fair counseling about a trial of labor and elective repeat cesarean delivery. An interesting way of research is to evaluate the potential benefits of a decision rule associated to the ultrasound measurement of the lower uterine segment (LUS). Indeed, ultrasonography may be helpful in determining a specific risk for a given patient by measuring the thickness of the LUS, i,e, the thickness of the cesarean delivery scar area. Although only small and often methodologically biased data have been published, they look promising as their results are concordant: ultrasonographic measurements of the LUS thickness is highly correlated with the intraoperative findings at cesarean delivery. Furthermore, the thinner the LUS becomes on ultrasound, the higher the likelihood of a defect in the LUS. Finally, ultrasound assessment of LUS has an excellent negative predictive value for the risk of uterine defect. Therefore, this exam associated with a rule of decision could help to reduce the rate of elective repeat cesarean delivery and especially to reduce the fetal and maternal mortality and morbidity related to trial of labor after a prior cesarean delivery. Methods/design: This is a pragmatic open multicenter randomized trial with two parallel arms. Randomization will be centralized and computerized. Since blindness is impossible, an adjudication committee will evaluate the components of the primary composite outcome in order to avoid evaluation bias. An interim analysis will be planned mid-strength of the trial. Ultrasound will be performed by expert sonographers after certification by the main investigator. Women aged 18 years or older are eligible for this trial if they have a singleton pregnancy in cephalic presentation at a gestational age from 36 to 38 weeks, a previous low transverse cesarean delivery and sign the informed consent sheet. Women will be asked to participate in this study when they reach a term of 36 to 38 weeks of gestation. After agreement, women will be randomized into two groups: in the study group, they will have the LUS measured by ultrasound and the patient will be informed that, based on a threshold value of 3.5 mm for the ultrasound measurement of the LUS thickness, the patient with a higher measurement will be considered at low risk and will be encouraged to choose a trial of labor whereas the patient with a measurement is equal to or less than this threshold will be considered at risk and encouraged to choose an elective repeat cesarean; in the control group, ultrasound LUS measurement will not be performed. The mode of delivery will be decided according to standard practice at the center. The primary composite outcome will include: uterine rupture, uterine dehiscence, hysterectomy, thromboembolic complications, transfusion, endometritis, maternal mortality, fetal prenatal and intrapartum mortality, hypoxic-ischemic encephalopathy and neonatal mortality. Discussion: This trial assesses the efficacy of ultrasound measurement of the lower uterine segment in women with a prior cesarean delivery in reducing fetal and maternal morbidity and mortality and it will provide evidence in order to establish clinical recommendations. Trial registration: ClinicalTrials.gov identifier: NCT01916044 (date of registration: 5 August 2013).

International audience

International audience

Ultrasound plays a fundamental role in the management of elective abortions. Although it can improve the quality of post-abortion care, it must not be an obstacle to abortion access. We thus studied the role of ultrasound in pregnancy dating and possible alternatives and analyzed the literature to determine the role of ultrasound in post-abortion follow-up. During an ultrasound scan, the date of conception is estimated by measurement of the crown-rump length (CRL), defined by Robinson, or of the biparietal diameter (BPD), as defined by the French Center for Fetal Ultrasound (CFEF) after 11 weeks of gestation (Robinson and CFEF curves) (grade B). Updated curves have been developed in the INTERGROWTH study. In the context of abortion, the literature recommends the application of a safety margin of 5 days, especially when the CRL and/or BPD measurement indicates a term close to 14 weeks (that is equal or below 80 and 27mm, respectively) (best practice agreement). Accordingly, with the ultrasound measurement reliable to±5 days when its performance meets the relevant criteria, an abortion can take place when the CRL measurement is less than 90mm or the BPD less than 30mm (INTERGROWTH curves) (best practice agreement). While a dating ultrasound should be encouraged, its absence is not an obstacle to scheduling an abortion for women who report that they know the date of their last menstrual period and/or of the at-risk sexual relations and for whom a clinical examination by a healthcare professional is possible (best practice agreement). In cases of intrauterine pregnancy of uncertain viability or of a pregnancy of unknown location, without any particular symptoms, the patient must be able to have a transvaginal ultrasound to increase the precision of the diagnosis (grade B). Various reviews of the literature on post-abortion follow-up indicate that the routine use of ultrasound during instrumental abortions should be avoided (best practice agreement). If it becomes clear immediately after the procedure that the endometrial thickness exceeds 8mm, immediate reaspiration is necessary. Ultrasound examination of the endometrium several days after an instrumental elective abortion does not appear to be relevant (grade B). An analysis of the literature similarly shows that routine ultrasound scans after medical abortions should be avoided. If a transvaginal ultrasound is performed after a medical abortion, it should take place at least two weeks afterwards (best practice agreement). The only aim of an ultrasound examination during follow-up should be to determine whether a gestational sac is present (best practice agreement). Finally, if an ultrasound is performed at any point during pre- or post-abortion care, a report should be drafted, specifying any potential gynecologic abnormalities found, but its absence must not delay the scheduling of the abortion (best practice agreement).

National audience; Objectif Élaborer des recommandations pour la pratique des IVG. Matériel et méthodes Consultation de la base de données Medline, de la Cochrane Library et des recommandations des sociétés savantes françaises et étrangères. Résultats Le nombre d’IVG est stable depuis plusieurs décennies. Il existe plusieurs éléments expliquant le choix de l’IVG lorsqu’il existe une grossesse non prévue (GNP). L’initiation précoce de la contraception et le choix de la contraception en rapport avec la vie de la femme sont associés à une diminution des GNP. Les contraceptions réversibles de longue durée d’action apparaissent comme une contraception à positionner en première ligne pour l’adolescente du fait de son efficacité (grade C). L’échographie avant une IVG doit être encouragée mais n’est pas indispensable pour réaliser une IVG (accord professionnel). Dès l’apparition échographique de l’embryon, l’estimation de la datation de la grossesse se fait par la mesure de la longueur cranio-caudale (LCC) ou par la mesure du diamètre bipariétal (BIP) à partir de 11 SA (grade B). Les mesures étant fiables à ± 5 jours, l’IVG peut être réalisée lorsque les mesures de LCC et/ou de BIP sont respectivement inférieures à 90 mm et 30 mm (accord professionnel). L’IVG médicamenteuse réalisée avec la dose de 200 mg de mifépristone associé au misoprostol est efficace à tout âge gestationnel (NP1). Avant 7 SA, la prise de mifépristone sera suivie entre 24 et 48 heures de la prise de misoprostol par voie orale, buccale, sublinguale voire vaginale à la dose de 400 μg éventuellement renouvelé après 3 heures (NP1, grade A). Au-delà de 7 SA, les modes d’administration du misoprostol, par voie vaginale, sublinguale ou buccale, sont plus efficaces et mieux tolérés que la voie orale (NP1). Il est recommandé d’utiliser systématiquement une préparation cervicale lors d’une IVG instrumentale (accord professionnel). Le misoprostol est un agent de première intention pour la préparation cervicale à la dose de 400 μg (grade A). L’aspiration évacuatrice est préférable au curetage (grade B). Un utérus perforé lors d’une aspiration instrumentale ne doit pas être considéré en routine comme un utérus cicatriciel (accord professionnel). L’IVG instrumentale n’est pas associée à une augmentation du risque d’infertilité ultérieure ou de GEU (NP2). Les consultations médicales pré-IVG n’influent pas sur la décision d’interrompre ou non la grossesse et une majorité de femmes est assez sûre de son choix lors de ces consultations. L’acceptabilité de la méthode et la satisfaction des femmes semblent plus grandes lorsque celles-ci sont en mesure de choisir la méthode d’IVG (grade B). Il n’y a pas de relation entre une augmentation des troubles psychiatriques et le recours à l’IVG (NP2). Les femmes ayant des antécédents psychiatriques sont à risque accru de troubles psychiques après la survenue d’une grossesse non prévue (NP2). En cas d’IVG instrumentale, la contraception estro-progestative orale et le patch devraient être débutés dès le jour de l’IVG, l’anneau vaginal inséré dans les 5 jours suivant l’IVG (grade B). En cas d’IVG médicamenteuse, l’anneau vaginal devrait être inséré dans la semaine suivant la prise de mifépristone, la contraception estro-progestative orale et le patch devraient être débutés le jour même ou le lendemain de la prise des prostaglandines (grade C). En cas d’IVG instrumentale, l’implant devrait être inséré le jour de l’IVG (grade B). En cas d’IVG médicamenteuse, l’implant peut être inséré à partir du jour de la prise de mifépristone (grade C). Le DIU au cuivre et au lévonorgestrel doit être inséré préférentiellement le jour de l’IVG instrumentale (grade A). En cas d’IVG médicamenteuse, un DIU peut être inséré dans les 10 jours suivant la prise de mifépristone après s’être assuré par échographie de l’absence de grossesse intra-utérine (grade C). Conclusion L’application de ces recommandations devrait favoriser une prise en charge plus homogène et améliorée des femmes désirant une IVG. Summary Objective Develop recommendations for the practice of induced abortion. Materials and methods The Pubmed database, the Cochrane Library and the recommendations from the French and foreign Gyn-Obs societies or colleges have been consulted. Results The number of induced abortions (IA) has been stable for several decades. There are a lot of factors explaining the choice of abortion when there is an unplanned pregnancy (UPP). Early initiation and choice of contraception in connection to the woman's life are associated with lower NSP. Reversible contraceptives of long duration of action should be positioned fist in line for the teenager because of its efficiency (grade C). Ultrasound before induced abortion must be encouraged but should not be obligatory before performing IA (Professional consensus). As soon as the sonographic apparition of the embryo, the estimated date of pregnancy is done by measuring the crown-rump length (CRL) or by measuring the biparietal diameter (BIP) from 11 weeks on (grade B). Reliability of these parameters being ± 5 days, IA could be done if measurements are respectively less than 90 mm for CRL and less than 30 mm for BIP (Professional consensus). A medical IA performed with a dose of 200 mg mifepristone combined with misoprostol is effective at any gestational age (EL1). Before 7 weeks, mifepristone followed between 24 and 48 hours by taking misoprostol orally, buccally sublingually or eventually vaginally at a dose of 400 ug possibly renewed after 3 hours (EL1, grade A). Beyond 7 weeks, misoprostol given vaginally, sublingually or buccally are better tolerated with fewer side effects than oral route (EL1). It is recommended to always use a cervical preparation during an instrumental abortion (Professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 mcg (grade A). Aspiration evacuation is preferable to curettage (grade B). A perforated uterus during an instrumental suction should not be considered as a scarred uterus (Professional consensus). IA is not associated with increased subsequent risk of infertility or ectopic pregnancy (EL2). The pre-abortion medical consultations does not affect, most of the time, the decision to request an IA. Indeed, a majority of women is quite sure of her choice during these consultations. Acceptability of the method of IA and satisfaction appears to be larger when they are able to choose the abortion method (grade B). There is no relationship between an increase in psychiatric disorders and IA (EL2). Women with psychiatric histories are at increased risk of mental disorders after the occurrence of an UPP (EL2). In case of instrumental abortion, oral estrogen-progestogen contraceptives and the patch should be started from the day of the abortion, the vaginal ring inserted within 5 days of IA (grade B). In case of medical abortion, the vaginal ring should be inserted within a week of taking mifepristone, oral estrogen-progestogen contraceptives and the patch should be initiated on the same day or the day after taking prostaglandins (grade C). In case of instrumental abortion, the contraceptive implant may be inserted on the day of the abortion (grade B). In case of medical abortion, the implant can be inserted on the day of mifepristone (grade C). The copper Intrauterine Device (IUD) and levonorgestrel should be inserted preferably on the day of instrumental abortion (grade A). In case of medical abortion, an IUD can be inserted within 10 days following mifepristone after ensuring by ultrasound of the absence of intrauterine pregnancy (grade C). Conclusion The implementation of these guidelines may promote a better and more homogenous care for women requesting IA in our country.

National audience

International audience; Background: Intrauterine growth restriction (IUGR) results from either maternal undernutrition or impaired placental blood flow, exposing offspring to increased perinatal mortality and a higher risk of metabolic syndrome and cardiovascular disease during adulthood. L-Citrulline is a precursor of L-arginine and nitric oxide (NO), which regulates placental blood flow. Moreover, L-citrulline stimulates protein synthesis in other models of undernutrition. Objective: The aim of the study was to determine whether L-citrulline supplementation would enhance fetal growth in a model of IUGR induced by maternal dietary protein restriction. Methods: Pregnant rats were fed either a control (20% protein) or a low-protein (LP; 4% protein) diet. LP dams were randomly allocated to drink tap water either as such or supplemented with L-citrulline (2 g.kg(-1) . d(-1)), an isonitrogenous amount of L-arginine, or nonessential L-amino acids (NEAAs). On day 21 of gestation, dams received a 2-h infusion of L-[1-C-13]-valine until fetuses were extracted by cesarean delivery. Isotope enrichments were measured in free amino acids and fetal muscle, liver, and placenta protein by GC-mass spectrometry. Results: Fetal weight was similar to 29% lower in the LP group (3.82 +/- 0.06 g) than in the control group (5.41 +/- 0.10 g) (P < 0.001). Regardless of supplementation, fetal weight remained below that of control fetuses. Yet, compared with the LP group, L-citrulline and L-arginine equally increased fetal weight to 4.15+/-0.08 g (P

La prise en charge active de très grands prématurés d’âge gestationnel (AG) < 26 semaines d’aménorrhée (SA) n’est pas consensuelle et mérite d’être discutée au regard des données de la littérature et de l’expérience des autres pays. Si la prise en charge active initiale est plus compliquée chez des nouveau-nés d’AG 24–25 SA avec un taux de mortalité plus élevé qu’au-delà de 26 SA (liée en partie à des décisions de limitation et arrêt des thérapeutiques actives), l’évolution neurocomportementale ultérieure chez les anciens prématurés survivants 24–25 SA n’est pas si défavorable. Ceci justifie sur un plan humain, médical et éthique d’établir une concertation pluridisciplinaire associant les parents pouvant aboutir soit à une prise en charge palliative, soit à une prise en charge active. L’AG seul ne prend pas en considération des cofacteurs importants reconnus comme associés au pronostic (corticothérapie prénatale, sexe féminin, estimation de poids fœtal, doppler et liquide amniotique). La cohérence de la concertation de l’équipe obstétricopédiatrique préalablement à l’entretien avec les parents est indispensable. De même, l’implication des parents est essentielle après un avis éclairé, honnête et loyal sur la mortalité et la morbidité à un terme < 26 SA avec toutes les difficultés que cette extrême prématurité engendre. L’accueil de ces patientes doit se faire autant que possible en maternité de type III. Une des difficultés associées à la naissance à ces termes très précoces (24–25 SA) est que le déclenchement est souvent impossible conduisant, sauf en cas de travail spontané, à l’extraction par césarienne, ce qui n’est pas dénué de risque pour les grossesses ultérieures. La réflexion sur le mode d’accouchement est limitée par l’absence d’essai randomisé, avec l’impossibilité fréquente de distinguer, dans les études rétrospectives, les accouchements spontanés et la décision médicale de provoquer la naissance. Compte tenu des risques potentiels de la césarienne pour la mère et pour d’éventuelles grossesses ultérieures, elle ne peut être recommandée de façon systématique. Inversement, il ne semble pas raisonnable non plus de renoncer à la césarienne de façon dogmatique sur le seul motif de l’âge gestationnel.

National audience