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To assess the level of stress and anxiety in healthcare workers in the departments of obstetrics and gynecology in France during and after the first Covid-19 lockdown.Two web-based cross-sectional surveys using several validated questionnaires (the HAD scale, the PSS-10 questionnaire and the Short Form 12 Questionnaire [SF-12]) were proposed to all staff of obstetrics and gynecologic departments in 18 French university hospitals.A total of 1565 respondents answered the first questionnaire and 1109 completed the second survey. Respondents reported greater levels of stress and impaired mental quality of life during the lockdown, followed by a significant improvement after the end of lockdown (respectivelyUnderstanding the heavy mental repercussions of the Covid-19 pandemic on healthcare workers could lead to the identification of high-risk in medical and non-medical staff and the implementation of targeted psychological monitoring program.

Resume Objectif En cas de retard de croissance intra-uterin, des etudes anterieures ont demontre une amelioration de l’implementation des pratiques cliniques et une amelioration du pronostic neonatal precoce en cas de suivi au sein d’un parcours standardise de soins par rapport a un parcours de soins classique. L’objectif de cette etude etait d’evaluer la prevalence des interventions obstetricales chez les fœtus petits pour l’âge gestationnel (PAG) suivi au sein d’un parcours standardise de soins par rapport au parcours traditionnel de soins classiques. Methodes Nous avons mene une etude retrospective entre 2015 et 2017, dans une maternite de type III a Lyon, au sein d’une population de fœtus PAG, consideres constitutionnellement petits en cas de diagnostic antenatal de poids foetal 3e percentile sans anomalie au Doppler ombilical au cours de la surveillance antenatale et sans argument echographique faisant suspecter un retard de croissance intra uterin (RCIU). Nous avons recueilli les interventions obstetricales effectuees au cours de la grossesse, ainsi que les modalites de naissance des PAG et leur issue neonatale immediate dans le parcours classique et dans le parcours standardise. Apres le diagnostic de PAG, le choix du parcours a ete laisse au praticien en fonction de ses habitudes, de sa capacite a gerer le suivi et de ses contraintes organisationnelles. Resultats Sur la periode de l’etude, et apres exclusion des fœtus en RCIU, 96 PAG ont ete suivi dans le parcours traditionnel et 106 PAG au sein du parcours standardise. Le parcours classique proposait en analyse multivariee une plus forte prevalence de la corticotherapie prenatale (16,6 %) en cas de PAG entre 2015 et 2017 avec OR 7,3 IC 95 % [1,41–38,43] par rapport au parcours standardise (3,7 %). De meme, le parcours classique proposait une prevalence de declenchement (54,1 %) superieure au parcours standardise (33,9 %) chez les PAG entre 2015 et 2017 avec OR 3,19 IC 95 % [1,70–7,80]. La puissance post-hoc « a posteriori » de l’etude etait de 82,9 %. Conclusion Cette etude confirme l’absence d’intervention obstetricale excessive dans la population des PAG dans un parcours de soins standardise. Ce dernier permettrait de reduire les evenements obstetricaux inutiles dans le respect du pronostic neonatal intrinseque aux fœtus petits pour l’âge gestationnel.

Background Fetal Growth restriction (FGR) is the pathological failure of a fetus to reach its biologically determined growth potential. Detection of FGR fetuses is a universally agreed key objective of antenatal care. Antenatal detection of FGR has undeniable benefits, juggling between intensive fetal surveillance and optimized timing of delivery; it reduces adverse perinatal outcomes by up to four-fold. However, FGR is still widely underdiagnosed. We aimed to identify the prevalence of FGR diagnosis in our wards and study the impact of the 2013 published French guidelines on the detection rate of FGR. The secondary objective aimed to highlight the factors of suboptimal screening in the population of non-diagnosed FGR fetuses and emphasize the screening method that led to antenatal diagnosis of FGR. Materials and methods We conducted a retrospective study at a single tertiary maternity center in Lyon-France, the Femme Mere Enfant Hospital, including the exhaustive population of FGR born after 24 + 0 weeks of gestation from 1 January 2011 to 31 December 2017. FGR was defined combining the neonatal and antenatal consensus-based definitions for early and late FGR in absence of congenital anomalies, excluding small for gestational age fetuses. For all FGR fetuses, we compared the antenatal detection rate of FGR during 2011-2013 to 2015-2017, since the French guidelines were published in December 2013. When FGR fetuses underwent an antenatal diagnosis of FGR, we retrospectively collected the characteristics that led to the diagnosis. When fetuses were not diagnosed as FGR, we retrospectively reviewed the implementation of the recommended screening method, enabling to evaluate whether screening was optimal or not. Statistical analysis was performed in July 2018, and statistical significance was regarded as a p-value Results Over the seven-year period, and among 31,052 newborns, 1020 (3.3%) infants were identified as FGR and met the inclusion criteria. The detection rate of FGR was similar before and after publication of the French Guidelines related to FGR in 2013. Indeed, 50.8% (201/395) FGR were diagnosed between 2011 and 2013 versus 52.6% (245/465) between 2015 and 2017 (p = .59). In the population of non-diagnosed FGR infants, screening was suboptimal in 80%. Symphysis-fundal height (SFH) was not measured in 10.7%, with no difference before and after 2014 (7.3 versus 11.8% p = .11). Ultrasound examination for fetal biometry had not been prescribed in spite of abnormal SFH in 47.7% of undiagnosed FGR infants. Diagnosis has been missed in 11.5% of infants because of misinterpretation of the estimated fetal weight's centile. Conclusion FGR is widely underdiagnosed. However, the limited performances can partially be explained by the regular misuse of screening method in clinical practice. Despite the systematic third trimester ultrasound screening, the detection rate of FGR was similar to the one reported in the medical literature. The timing of routine third trimester ultrasound in low-risk women may be rethought.

To assess the correlation between standard laboratory indicators at admission and severe maternal complications due to placental abruption (PA) with intrauterine fetal death (IUFD) after 24 weeks.Retrospective study in three French tertiary referral hospitals. Correlation of laboratory indicators at admission (platelet count, prothrombin, activated partial thromboplastin time, fibrinogen) and severe maternal complications (massive transfusion, multiple organ failure, hysterectomy, or maternal deaths) in patients with PA and IUFD.Over 12 years, we identified 27/344 (7.8%) pregnant women presenting PA with IUFD. No patient had coagulopathy at admission. Fifteen individuals (55.5%) underwent delivery by cesarean section before or during labor. Fifteen individuals (55.5%) presented severe complications, and 17/27 (63%) lost more than 1 L of blood during delivery. Fibrinogen level was shown to be the laboratory indicator most correlated with severe complications (r = -0.52, P = 0.01). The receiver operating characteristic curve of fibrinogen less than 1.9 g/L in the prediction of severe complications (area under the curve = 0.80, 95% confidence interval [CI] 0.54-0.97) showed both a sensitivity and specificity of 83% (95% CI 54%-96%).In cases of IUFD with PA, fibrinogen levels at admission had a prognostic value for the prediction of severe maternal complications.

Evaluate the prevalence of uterine synechia after total uterine ligation (TUL) in comparison to TUL associated with compression-penetrating-sutures (CPS) in the conservative surgical management of severe postpartum hemorrhage (PPH).Prospective observational study of pregnant women that underwent conservative surgical management for PPH in a single French tertiary referral center. We compared the risk of uterine synechia with TUL, in comparison to performing TUL in addition to CPS. The synechia rate was calculated after uterine cavity assessment by 3D hysterosonography. Hysterectomies, women with placenta accreta spectrum and patients that received additional embolization treatment were excluded.Over 6 years, 36 pregnant women underwent surgical treatment for PPH in 21,944 deliveries (1.64 per 1000). The median blood loss was 2700 [1570-3000] milliliters. Twenty-eight (77.7%) women underwent TUL, 8/36 (22.2%) underwent TUL in addition to CPS. Thirty-four (94,4%) cavity assessments were performed 2-to-6 months after delivery, since one woman of each group was lost to follow-up. When TUL was performed in addition to CPS, the prevalence of synechia was 42.9% (n = 3/7), versus 3.7% (n = 1/27) in TUL (p = 0.021; RR = 16.88, 95%CI [1.1-1051]). Synechia was absent in 30/34 (88.2%) women.The prevalence of synechia was very low after TUL unlike CPS. Further studies should evaluate TUL in the conservative surgical management of PPH, to confirm the lower prevalence of synechiae in TUL and evaluate its impact on fertility.

Indications for aspirin during pregnancy are a matter of debate and there is a recent trend to an extended prescription and an overuse of aspirin in pregnancy. Aspirin is efficient in secondary prevention of preeclampsia essentially in patients with a personal history of preeclampsia. The effect of aspirin on platelet aggregation and on the TXA2/PGI2 balance is dose-dependent. The optimum dosage, from 75mg/day to 150mg/day, needs to be determined. Fetal safety data at 150mg/day are still limited. The efficacy of aspirin seems to be subject to a chronobiological effect. It is recommended to prescribe an evening or bedtime intake. Aspirin, in primary prevention of preeclampsia, given to high-risk patients identified in the first trimester by screening tests, seems to reduce the occurrence of early-onset preeclampsia. Nevertheless, there are insufficient data for the implementation of such screening procedures in practice.

Obstetrical anal sphincter injury (OASIS) may lead to significant comorbidities, including anal incontinence, rectovaginal fistula, and pain. A correct repair is required to avoid improper healing, as a persistent defect in the external anal sphincter after delivery can increase the risk of complications and worsening of symptoms following subsequent vaginal deliveries. Herein is described the surgical repair technique for a fourth degree perineal tear. Regarding resident education, there are challenges associated with the proper training in OASIS repair. The procedure is illustrated by an instructive video article that standardizes the essential steps to make the technique ergonomic and easy to perform with step-by-step explanations.

Coronavirus pandemic is widely changing our professional daily practice and preventive measures must be taken and taught. Before any planned gynaecological or obstetric surgery, specific technics to put on and safely remove personal protective equipment should be implemented in order to avoid any contamination for both patients and healthcare workers.

We propose a simplified technique to approach the promontory and to fix the mesh on the anterior longitudinal ligament during the sacrocolpopexy procedure by using an instrument initially designed for the vaginal approach of the sacrospinous ligament. Using this easy technique in case of anatomic variations on the sacral promontory may avoid complications.

Aspirin is currently the most widely prescribed treatment in the prevention of cardiovascular complications. The indications for the use of aspirin during pregnancy are, however, the subject of much controversy. Since the first evidence of the obstetric efficacy of aspirin in 1985, numerous studies have tried to determine the effect of low-dose aspirin on the incidence of preeclampsia, with very controversial results. Large meta-analyses including individual patient data have demonstrated that aspirin is effective in preventing preeclampsia in high-risk patients, mainly those with a history of preeclampsia. However, guidelines regarding the usage of aspirin to prevent preeclampsia differ considerably from one country to another. Screening modalities, target population, and aspirin dosage are still a matter of debate. In this review, we report the pharmacodynamics of aspirin, its main effects according to dosage and gestational age, and the evidence-based indications for primary and secondary prevention of preeclampsia.

Resume Objectif Comparer l’angioarchitecture des placentas issus de grossesses gemellaires monochoriales biamniotiques (GGMCBA) compliquees d’un syndrome transfuseur-transfuse STT ou twin oligoamnios polyhydramnios sequence (TOPS), d’une sequence-anemie-polycytemie ou twin anemia polycythemia sequence (TAPS), d’un retard de croissance intra-uterin (RCIU) selectif et d’une sequence twin reversed arterial perfusion (TRAP) ou masse acardiaque a celle des grossesses monochoriales non compliquees. Methode Entre decembre 2012 et decembre 2015, tous les placentas des GGMCBA ont ete recueillis au sein du Centre des grossesses multiples de l’hopital Femme-Mere-Enfant a Lyon. Les cordons placentaires ont ete catheterises et injectes d’encre coloree afin de reveler les vaisseaux de la plaque choriale. L’interpretation macroscopique a eu lieu en service d’anatomopathologie. Ont ete exclus les placentas ayant ete traites par fœtoscopie laser. Resultats Au total, 126 placentas ont ete catheterises et injectes d’encre coloree dans le post-partum. Au total, 95 % des placentas injectes (119/126) ont presente des anastomoses arterioveineuses (AAV) avec une moyenne de 7 AAV. La prevalence d’au moins une insertion cordonale velamenteuse est plus importante dans les STT et les RCIUs (p Conclusion Notre etude confirme les donnees de la litterature, souleve le role protecteur des AAA vis-a-vis des STT et des TAPS, toutefois le role des AVV reste difficile a determiner. L’observation macroscopique des placentas est un temps essentiel dans la comprehension, la gestion et le traitement des complications propres aux grossesses monochoriales.

The prenatal examination of the placenta is often an afterthought to that of the fetus in ultrasonography. Not giving the placenta its due may however result in potentially serious placental pathologies remaining undiscovered, notably in the presence of anechoic zones. These latter have earned numerous names, including "placental lakes", "placental venous lakes", "placental lacunae" or "placental caverns" among others, but they have received little attention in the literature. We thus feel that it is essential to review the various pathologies that placental lakes may signal, since any one of them may greatly affect patient management. The difficulty resides in the diversity of these pathologies, sometimes oncological, other times fetal, and in the potential need for multidisciplinary surgery. Some of these causes of placental lakes may result in maternal or fetal complications and/or necessitate increased and casespecific surveillance. The diagnosis and treatment of such cases requires close collaboration between sonographers, obstetricians, geneticists and pathologists. The work we present here focuses on the different etiologies to consider in the presence of a lacunar placenta and the necessary diagnostic measures. Our objective is to propose a diagnostic flowchart to aid clinicians in this dense differential diagnosis.

OBJECTIVE To examine the outcome of pregnancy with fetal transverse cerebellar diameter (TCD) below the fifth percentile based on routine second- or third-trimester ultrasonography. METHODS We retrospectively analyzed the outcomes of 12 344 women according to TCD Z scores based on systematic second- or third-trimester ultrasound examination between 2007 and 2015. Information on major malformations, chromosomal anomalies, intrauterine or neonatal demise, and other abnormal findings were collected. RESULTS In total, 408 fetuses with small prenatal TCD underwent clinical investigation; 160 major malformations were noted, consisting mainly of neurological or cardiac anomalies (39,2%%). Chromosomal anomalies were reported in 39 (9.5%) and intrauterine or neonatal demise in 41 cases (10%). Major malformations and chromosomal anomalies were found in 46.4% and 10% of fetuses with extremely small TCD (Z score

Objectives Between 0.5 and 5% of vaginal deliveries involve obstetrical anal sphincter injuries (OASIS). Thirty to forty percent of patients with OASIS will suffer from anal incontinence in the subacute postpartum period. The aim of the present study was to assess the effectiveness of early pelvic floor muscle training (PFMT) combined with standard rehabilitation on anal incontinence after vaginal deliveries complicated by OASIS. Study design The present work was a retrospective quantitative study performed in a tertiary-level maternity hospital. Women with 3rd or 4th degree obstetric tears were included. Women who gave birth between January 1st, 2011 and December 31st, 2012 underwent standard pelvic-perineal rehabilitation within 6–8 weeks postpartum. Women who gave birth between January 1st, 2013 and July 1st, 2014 had early rehabilitation (within 30 days after delivery) followed by the same standard rehabilitation received by the other group. Rehabilitation was performed by physiotherapists specialized in perineology. No electrostimulation was done in early rehabilitation. An in-house-validated modification of the Jorge and Wexner questionnaire was sent by mail to the patients to assess symptoms. The main judgment criterion was anal incontinence to gas, loose stools and/or solid stool. Results Two hundred and thirty patients were diagnosed with OASIS. Nineteen women (8.3%) were lost to follow-up. The intention-to-treat analysis included 211 patients, 109 of whom underwent standard rehabilitation and 102 early rehabilitation plus standard rehabilitation. The two groups were comparable in terms of parity, birth weight, assisted delivery, epidural anesthesia and rates of mediolateral episiotomy. Multivariate analyses adjusted for type of perineal lesion were performed. Early rehabilitation significantly reduced gas leakage: OR 0.51 [0.29–0.90] ( p =0.02), liquid stool leakage: OR 0.22 [0.08–0.58] ( p =0.02) and urinary stress incontinence: OR 0.43 [0.24–0.77] ( p =0.004). Conclusions We recommend early (during the first month postpartum) PFMT after vaginal deliveries associated with OASIS. Rehabilitation should be carried out by a physiotherapist specialized in perineology in order to prevent medium-term functional consequences. A longer follow-up may be necessary to confirm the stability of results.

Indications for aspirin during pregnancy are a matter of debate and there is a recent trend to an extended prescription and an overuse of aspirin in pregnancy. Aspirin is efficient in secondary prevention of preeclampsia essentially in patients with a personal history of preeclampsia. The effect of aspirin on platelet aggregation and on the TXA2/PGI2 balance is dose-dependent. The optimum dosage, from 75mg/day to 150mg/day, needs to be determined. Fetal safety data at 150mg/day are still limited. The efficacy of aspirin seems to be subject to a chronobiological effect. It is recommended to prescribe an evening or bedtime intake. Aspirin, in primary prevention of preeclampsia, given to high-risk patients identified in the first trimester by screening tests, seems to reduce the occurrence of early-onset preeclampsia. Nevertheless, there are insufficient data for the implementation of such screening procedures in practice.

The aim of the study was to determine which mathematical formula of specimen dimensions is the most accurate method of determining volume of the excised specimen at loop excision of the transformation zone.A multicenter prospective observational study was conducted. A total of 258 patients who had a loop excision of the transformation zone performed as treatment of cervical intraepithelial neoplasia 2-3 were included. The dimensions and the volume of the specimen were measured at the time of the procedure, before formaldehyde fixation. The volume was measured by immersing the specimen in a graduated cylinder using Archimedes fluid displacement technique. The measured volume was compared with the calculated volume using different volume formulas, that is, a cone, a cylinder, a parallelepiped, and a hemiellipsoid. The main outcome measure was the relationship between calculated volume (using the dimensions of thickness, length, and circumference) and the measured volume of the specimen.The mean (SD) thickness, length, and circumference of specimens were 8.8 mm (3.8), 12.7 mm (5.9), and 45.7 mm (16.8), respectively. The mean (SD) measured volume was 2.53 (1.49) mL. Using the formula for the volume of a cone, a cylinder, a parallelepiped and a hemiellipsoid, estimated volumes were 1.03 mL (1.22), 3.10 mL (3.65), 6.20 mL (7.31), and 2.07 mL (2.44), respectively. The highest intraclass correlation coefficient between measured and calculated volume was observed when using the formula for the volume of a hemiellipsoid specimen (0.47, 95% CI = 0.36-0.56).The hemiellipsoid formula is the most accurate determinant of the excised volume. Other formulas do not allow for an accurate estimation of the excised volume.

The effects of fluid shear stress (FSS) on the human syncytiotrophoblast and its biological functions have never been studied. During pregnancy, the syncytiotrophoblast is the main source of placental growth factor (PlGF), a proangiogenic factor involved in the placental angiogenesis and the vascular adaptation to pregnancy. The role of FSS in regulating PlGF expression in syncytiotrophoblasts is unknown. We investigated the impact of FSS on the production and secretion of the PlGF by the human syncytiotrophoblasts in primary cell culture. Laminar and continuous FSS (1 dyn cm −2 ) was applied to human syncytiotrophoblasts cultured in a parallel-plate flow chambers. Secreted levels of PlGF, sFlt-1 (soluble fms-like tyrosin kinase-1), and prostaglandin E2 were tested by immunologic assay. PlGF levels of mRNA and intracellular protein were examined by RT-PCR and Western blot, respectively. Intracellular cAMP levels were examined by time-resolved fluorescence resonance energy transfer cAMP accumulation assay. Production of cAMP and PlGF secretion was significantly increased in FSS conditions compared with static conditions. Western blot analysis of cell extracts exposed to FSS showed an increased phosphorylation of protein kinase A substrates and cAMP response element-binding protein on serine 133. FSS-induced phosphorylation of cAMP response element-binding protein and upregulation of PlGF were prevented by inhibition of protein kinase A with H89 (3 μmol/L). FSS also triggers intracellular calcium flux, which increases the synthesis and release of prostaglandin E2. The enhanced intracellular cAMP in FSS conditions was blocked by COX1/COX2 (cyclooxygenase) inhibitors, suggesting that the increase in prostaglandin E2 production could activate the cAMP/protein kinase A pathway in an autocrine/paracrine fashion. FSS activates the cAMP/protein kinase A pathway leading to upregulation of PlGF in human syncytiotrophoblast.

The effects of fluid shear stress (FSS) on the human syncytiotrophoblast and its biological functions have never been studied. During pregnancy, the syncytiotrophoblast is the main source of placental growth factor (PlGF), a proangiogenic factor involved in the placental angiogenesis and the vascular adaptation to pregnancy. The role of FSS in regulating PlGF expression in syncytiotrophoblasts is unknown. We investigated the impact of FSS on the production and secretion of the PlGF by the human syncytiotrophoblasts in primary cell culture. Laminar and continuous FSS (1 dyn cm−2) was applied to human syncytiotrophoblasts cultured in a parallel-plate flow chambers. Secreted levels of PlGF, sFlt-1 (soluble fms-like tyrosin kinase-1), and prostaglandin E2 were tested by immunologic assay. PlGF levels of mRNA and intracellular protein were examined by RT-PCR and Western blot, respectively. Intracellular cAMP levels were examined by time-resolved fluorescence resonance energy transfer cAMP accumulation assay. Production of cAMP and PlGF secretion was significantly increased in FSS conditions compared with static conditions. Western blot analysis of cell extracts exposed to FSS showed an increased phosphorylation of protein kinase A substrates and cAMP response element-binding protein on serine 133. FSS-induced phosphorylation of cAMP response element-binding protein and upregulation of PlGF were prevented by inhibition of protein kinase A with H89 (3 μmol/L). FSS also triggers intracellular calcium flux, which increases the synthesis and release of prostaglandin E2. The enhanced intracellular cAMP in FSS conditions was blocked by COX1/COX2 (cyclooxygenase) inhibitors, suggesting that the increase in prostaglandin E2 production could activate the cAMP/protein kinase A pathway in an autocrine/paracrine fashion. FSS activates the cAMP/protein kinase A pathway leading to upregulation of PlGF in human syncytiotrophoblast.

International audience; Objective The aim of the study was to assess whether direct colposcopic ă vision (DCV) of the cervix during large loop excision of the ă transformation zone (LLETZ) is associated with a decrease in the volume ă and dimensions of specimens or affects margin status at histology. ă Materials and Methods A prospective multicenter observational study of ă 216 women who underwent LLETZ for grades 2 and 3 cervical ă intraepithelial neoplasia was conducted. The volume and dimensions ă (circumference, length, and thickness) of the surgical specimens were ă measured before fixation. Data were compared according to the use of ă colposcopy during LLETZ. The following 3 groups were considered: LLETZ ă performed without colposcopy (n = 91), LLETZ performed immediately after ă colposcopy (n = 51), and LLETZ performed under DCV (n = 74). ă Results Patient characteristics were comparable with regard to age, ă parity, history of excision, indication of the procedure, and the size ă of the cervix. We found a significant decrease in all dimensions of the ă specimens obtained under DCV (p < .001). Margin status was not affected. ă After adjusting for confounders, the mean volumes were significantly ă lower in the DCV group (adjusted mean difference = -0.66 mL; 95% CI = ă -1.17 to -0.14). The probability that negative margins would be achieved ă together with the attainment of a volume less than 5 mL and a thickness ă less than 10 mm was the highest in the DCV group (adjusted OR = 2.80; ă 95% CI = 1.13 to 6.90). ă Conclusions Direct colposcopic vision is associated with a significant ă decrease in the volume and in all dimensions of LLETZ specimens with no ă compromise in the margin status.