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Objective To compare maternal mortality in eight countries with enhanced surveillance systems. Design Descriptive multicountry population based study. Setting Eight countries with permanent surveillance systems using enhanced methods to identify, document, and review maternal deaths. The most recent available aggregated maternal mortality data were collected for three year periods for France, Italy, and the UK and for five year periods for Denmark, Finland, the Netherlands, Norway, and Slovakia. Population 297 835 live births in Denmark (2013-17), 301 169 in Finland (2008-12), 2 435 583 in France (2013-15), 1 281 986 in Italy (2013-15), 856 572 in the Netherlands (2014-18), 292 315 in Norway (2014-18), 283 930 in Slovakia (2014-18), and 2 261 090 in the UK (2016-18). Outcome measures Maternal mortality ratios from enhanced systems were calculated and compared with those obtained from each country’s office of vital statistics. Age specific maternal mortality ratios; maternal mortality ratios according to women’s origin, citizenship, or ethnicity; and cause specific maternal mortality ratios were also calculated. Results Methods for identifying and classifying maternal deaths up to 42 days were very similar across countries (except for the Netherlands). Maternal mortality ratios up to 42 days after end of pregnancy varied by a multiplicative factor of four from 2.7 and 3.4 per 100 000 live births in Norway and Denmark to 9.6 in the UK and 10.9 in Slovakia. Vital statistics offices underestimated maternal mortality by 36% or more everywhere but Denmark. Age specific maternal mortality ratios were higher for the youngest and oldest mothers (pooled relative risk 2.17 (95% confidence interval 1.38 to 3.34) for women aged Conclusions Variations in maternal mortality ratios exist between high income European countries with enhanced surveillance systems. In-depth analyses of differences in the quality of care and health system performance at national levels are needed to reduce maternal mortality further by learning from best practices and each other. Cardiovascular diseases and mental health in women during and after pregnancy must be prioritised in all countries.

Background: Induction of labour is one of the most common obstetric interventions globally. Balloon catheters and vaginal prostaglandins are widely used to ripen the cervix in labour induction. We aimed to compare the effectiveness and safety profiles of these two induction methods. Methods: We did an individual participant data meta-analysis comparing balloon catheters and vaginal prostaglandins for cervical ripening before labour induction. We systematically identified published and unpublished randomised controlled trials that completed data collection between March 19, 2019, and May 1, 2021, by searching the Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and PubMed. Further trials done before March 19, 2019, were identified through a recent Cochrane review. Data relating to the combined use of the two methods were not included, only data from women with a viable, singleton pregnancy were analysed, and no exclusion was made based on parity or membrane status. We contacted authors of individuals trials and participant-level data were harmonised and recoded according to predefined definitions of variables. Risk of bias was assessed with the ROB2 tool. The primary outcomes were caesarean delivery, indication for caesarean delivery, a composite adverse perinatal outcome, and a composite adverse maternal outcome. We followed the intention-to-treat principle for the main analysis. The primary meta-analysis used two-stage random-effects models and the sensitivity analysis used one-stage mixed models. All models were adjusted for maternal age and parity. This meta-analysis is registered with PROSPERO (CRD42020179924). Findings: Individual participant data were available from 12 studies with a total of 5460 participants. Balloon catheters, compared with vaginal prostaglandins, did not lead to a significantly different rate of caesarean delivery (12 trials, 5414 women; crude incidence 27·0%; adjusted OR [aOR] 1·09, 95% CI 0·95–1·24; I2=0%), caesarean delivery for failure to progress (11 trials, 4601 women; aOR 1·20, 95% CI 0·91–1·58; I2=39%), or caesarean delivery for fetal distress (10 trials, 4441 women; aOR 0·86, 95% CI 0·71–1·04; I2=0%). The composite adverse perinatal outcome was lower in women who were allocated to balloon catheters than in those allocated to vaginal prostaglandins (ten trials, 4452 neonates, crude incidence 13·6%; aOR 0·80, 95% CI 0·70–0·92; I2=0%). There was no significant difference in the composite adverse maternal outcome (ten trials, 4326 women, crude incidence 22·7%; aOR 1·02, 95% CI 0·89–1·18; I2=0%). Interpretation: In induction of labour, balloon catheters and vaginal prostaglandins have comparable caesarean delivery rates and maternal safety profiles, but balloon catheters lead to fewer adverse perinatal events. Funding: Australian National Health and Medical Research Council and Monash Health Emerging Researcher Fellowship.

IntroductionIt remains uncertain whether the most appropriate management for women with an unfavourable cervix after 24 hours of cervical ripening is repeating the ripening procedure or proceeding directly to induction by oxytocin. No adequately powered trial has compared these strategies. We hypothesise that induction of labour with oxytocin among women who have just undergone an ineffective first ripening procedure is not associated with a higher risk of caesarean delivery than a repeated cervical ripening with prostaglandins.Methods and analysisWe will conduct a multicentre, non-inferiority, open-label, randomised controlled trial aimed at comparing labour induction by oxytocin with a second cervical ripening that uses prostaglandins (slow-release vaginal dinoprostone; oral misoprostol 25 µg; dinoprostone vaginal gel 2 mg). Women (n=1494) randomised in a 1:1 ratio in 10 French maternity units must be ≥18 years with a singleton fetus in vertex presentation, at a term from ≥37+0 weeks of gestation, and have just completed a 24-hour cervical ripening procedure by any method (pharmacological or mechanical) with a Bishop score ≤6. Exclusion criteria comprise being in labour, having more than 3 contractions per 10 min, or a prior caesarean delivery or a history of uterine surgery, or a fetus with antenatally suspected severe congenital abnormalities or a non-reassuring fetal heart rate. The primary endpoint will be the caesarean delivery rate, regardless of indication. Secondary outcomes concern delivery, perinatal morbidity, maternal satisfaction and health economic evaluations. The nature of the assessed procedures prevents masking the study investigators and patients to group assignment.Ethics and disseminationAll participants will provide written informed consent. The ethics committee ‘Comité de Protection des Personnes Ile de France VII’ approved this study on 2 April 2021 (No 2021-000989-15). Study findings will be submitted for publication and presented at relevant conferences.Trial registration numberNCT04949633.

Resume Objectifs Le but de ce travail etait d’evaluer l’impact clinique du ratio de la dissemination metastatique ganglionnaire inguinale (LNR) chez les patientes prises en charge pour un cancer vulvaire de type epidermoide. Materiel et methodes La cohorte de l’etude etait representee par des patientes prises en charge pour un carcinome epidermoide vulvaire, entre janvier 2005 et decembre 2015, dans 5 institutions francaises avec bases de donnees prospectives. Population Au toal, 636 femmes, parmi lesquelles 508 (79,9 %) ont eu une chirurgie ganglionnaire inguinale. Le seuil significatif du LNR a ete determine par la methode du minimal valeur de p. Critere de jugement principal Comparaison de la survie globale et sans recidive selon le LNR. Resultats Au total, 176 femmes (34,6 %) avaient au moins un ganglion atteint. Il existait une difference significative de survie globale et de survie sans recidive selon que le LNR, soit > 0,2 ou non. Conclusion L’evaluation, dans notre etude, du ratio de ganglions positifs, semble demontrer que celui-ci pourrait etre considere comme un facteur pronostique a part entiere.

Resume La consommation de tabac pendant la grossesse dans le monde serait de 1,7 % (IC 95 % : 0,0–4,5). Parmi les 50 pays europeens evalues, la France se situe au 7e rang des pays les plus touches par le tabagisme actif pendant la grossesse. Dans l’Enquete nationale perinatale de 2016, 30,0 % des femmes interrogees ont declare fumer avant de debuter leur grossesse et 16,6 % fumaient encore au 3e trimestre de la grossesse. Il est egalement retrouve des disparites de consommation entre les regions en France (24,0 % de femmes enceintes ayant un tabagisme actif au 3e trimestre de la grossesse en Bretagne contre 9,4 % en region parisienne et 5,2 % dans les departements et regions d’outre-mer). Parmi les facteurs de risque de tabagisme pendant la grossesse, il est retrouve un âge jeune, un faible niveau d’education, un niveau socioeconomique bas, la primiparite, une origine geographique de France metropolitaine, l’absence de profession, un conjoint fumeur, l’absence de conjoint ou une depression associee. La multiparite est un facteur de risque d’echec de sevrage au cours de la grossesse. Pour les professionnels de sante au contact des femmes en âge de procreer, il est recommande d’identifier et de reperer une consommation de tabac chez la femme ou son conjoint avant une grossesse ou le plus tot possible au cours de la grossesse.

Resume Objectif Faire la synthese des connaissances sur les consequences du tabagisme actif chez la femme enceinte. Methodes Consultation de la base de donnees MedLine et de la Cochrane Library. Resultats Le tabagisme actif maternel est associe a un risque augmente de complications du premier trimestre de la grossesse comme celui de fausse couche precoce (NP2) et de grossesse extra-uterine (NP2) et ces risques sont lies a la quantite de cigarettes fumees. Le tabagisme actif maternel est associe a un risque augmente de certaines anomalies congenitales (NP3). Il est aussi associe a un risque augmente d’hematome retroplacentaire (NP2), de placenta praevia (NP2), de mort fœtale in utero (NP2) et d’accouchement par cesarienne (NP3). Le tabagisme actif maternel est associe a une reduction du risque de pre-eclampsie (NP2). Concernant le nouveau-ne, il existe un risque de naissance prematuree (NP2) et de petit poids de naissance (NP2) avec une relation dose-effet chez les enfants nes de meres fumeuses. Conclusion En dehors de la pre-eclampsie, dont le risque est reduit en cas d’exposition au tabagisme maternel , un tabagisme actif pendant la grossesse est associe a une augmentation de la morbidite maternofœtale.

Resume Objectif Determiner la prise en charge des patientes avec une rupture des membranes a terme avant travail (RMTAT). Methodes Synthese de la litterature a partir des bases de donnees PubMed et Cochrane et des recommandations des societes et colleges francais et etrangers. Resultats Une RMTAT est definie par une rupture des membranes apres 37 semaines d’amenorrhee (SA) en l’absence de travail (Accord professionnel). La RMTAT est consideree comme un processus physiologique jusqu’a 12 heures de rupture (Accord professionnel). En cas d’attitude expectative, avec un faible taux d’antibioprophylaxie, la prise en charge a domicile en comparaison a l’hospitalisation pourrait etre associee a une augmentation du taux d’infections neonatales (NP3) et ce d’autant qu’il existe une colonisation au streptocoque du groupe B (NP3). La prise en charge a domicile n’est donc pas recommandee (Grade C). Lors d’une RMTAT, en l’absence de travail spontane dans les 12 heures suivant la rupture, une antibioprophylaxie pourrait diminuer le taux d’infection intra-uterine (IIU) sans diminuer le taux d’infection neonatale bacterienne precoce (INBP) (NP3). Son utilisation dans les RMTAT, apres 12 h de RMTAT est donc recommandee (Grade C). Lorsqu’une antibioprophylaxie est indiquee, une betalactamine par voie intraveineuse sera privilegiee (Grade C). Le declenchement du travail par oxytocine (NP2), prostaglandines E2 (NP2), ou misoprostol (NP2) permet de raccourcir le delai entre la rupture des membranes et l’accouchement en comparaison a l’expectative. Un declenchement immediat du travail n’est pas associe a une reduction de l’INBP en comparaison a une attitude expectative (NP1), et ce quel que soit le statut des patientes pour le streptocoque B (NP2). Le declenchement n’est pas associe a une augmentation ou une reduction du taux de cesarienne en comparaison a une attitude expectative (NP2), quels que soient la parite (NP2) et le score de Bishop (NP3). En cas de RMTAT, l’attitude expectative peut etre proposee sans augmenter le risque infectieux neonatal (Grade B), et ce meme en cas de depistage positif pour le streptocoque B (Accord professionnel) et un declenchement peut etre propose sans augmenter le risque de cesarienne (Grade B). Les differentes methodes de declenchement (oxytocine, dinoprostone, misoprostol, sonde de Foley®) n’ont pas permis de demontrer la superiorite d’une strategie par rapport a une autre, que ce soit pour diminuer le taux d’IIU ou d’INBP, le taux de cesarienne ou raccourcir le delai declenchement-accouchement ; et ce quel que soit le score de Bishop ou la parite. Conclusion La RMTAT est un evenement frequent. Un delai de 12 heures, apres la rupture, sans entree en travail spontane, a ete retenu pour differencier une situation physiologique d’une situation potentiellement a risque pouvant justifier une antibioprophylaxie. En cas de RMTAT, l’attitude expectative ou le declenchement du travail peuvent etre proposes et ce, meme en cas de depistage positif pour le streptocoque B, en fonction du desir de la patiente et de l’organisation des soins dans les maternites (Accord professionnel).

Resume Objectif Faire la synthese des connaissances sur la definition, la frequence, la morbidite et les facteurs de risque de la rupture des membranes a terme avant travail (RMTAT). Methodes Consultation de la base de donnees MedLine, de la Cochrane Library et des recommandations des societes savantes francaises et etrangeres sur une periode allant de 1980 a 2019. Resultats Une rupture des membranes a terme (RMT) est definie par une rupture des membranes apres 37 SA. Une rupture des membranes a terme avant travail (RMTAT) est definie par une rupture des membranes apres 37 SA en l’absence de travail. D’apres les donnees non publiees de l’Enquete nationale perinatale (ENP) francaise de 2016, une RMT est survenue chez 26,5 % des femmes avec grossesse monofœtale, avant leur admission en salle de naissance, sans que l’on puisse definir precisement s’il s’agissait d’une RMTAT (NP3). La frequence rapportee dans la litterature de la RMTAT serait d’environ 6 a 22 % pour les grossesses monofœtales (NP3). Dans l’ENP de 2016, la RMTAT, 12 h apres la rupture a concerne 35,6 % des femmes avec une RMT, soit 8,9 % de l’ensemble des grossesses monofoetales (NP3). La RMTAT serait associee a un risque de fievre avant (NP3), pendant (NP3) et apres le travail (NP3), ainsi qu’a celui d’infection intra-uterine et neonatale (NP3). La frequence de ces complications dans un contexte d’antibioprophylaxie systematique n’est pas connue. Le groupe d’expert a choisi un delai de 12 h sans entree en travail spontane pour differencier une situation physiologique d’une situation potentiellement a risque pouvant justifier une intervention medicale (Accord professionnel). Les facteurs de risque de RMTAT sont un antecedent de RMTAT (NP3), la nulliparite (NP3), des contractions uterines ayant necessite un traitement (NP3) et des metrorragies au premier trimestre (NP3). Conclusion La rupture des membranes a terme avant travail (RMTAT) est un evenement pour lequel les donnees concernant la frequence, les facteurs de risque et la morbidite sont limitees ou de qualite mediocre.

AIM: To estimate the incidence of diabetic ketoacidosis (DKA) among pregnant women, describe its clinical features, management and outcomes and identify the risk factors for the condition. METHODS: A national population-based case-control study was conducted in the UK using the UK Obstetric Surveillance System between April 2019 and September 2020 including all pregnant women with DKA irrespective of the level of blood glucose. The incidence rate of DKA in pregnancy was estimated. A case-control analysis limited to women with type 1 diabetes was performed comparing characteristics of women with DKA (cases) to those of women whose pregnancies were not complicated by DKA (controls). RESULTS: Eighty-two women were identified with DKA in pregnancy; 6.3 per 100,000 maternities (95% CI 5.0-7.9). No maternal deaths occurred, but perinatal mortality was 12/73 (16%) with eleven stillbirths and one neonatal death. DKA episodes mostly occurred in women with type 1 diabetes (85%) and in the 3(rd) trimester of pregnancy (71%). Episodes were mainly precipitated by infection (21%), vomiting (21%), steroid therapy (13%) and medication errors (10%). Fifteen percent of women had more than one episode of DKA during their pregnancy. Risk factors associated with DKA among women with type 1 diabetes identified through the case-control analysis were the woman and/or partner not being in a paid employment and having at least one microvascular complication of diabetes before pregnancy. CONCLUSION: DKA in pregnancy was associated with high perinatal mortality and was linked with factors related to socio-economic deprivation, mental health problems and long-term difficulties with glycaemic control.

ObjectiveTo determine whether birth outside a level-3 centre (outborn) is associated with a difference in the combined outcome of mortality or moderate-to-severe neurological impairment at 5.5 years of age compared with birth in a level-3 centre (inborn) when antenatal steroids and gestational age (GA) are accounted for.DesignIndividual matched study nested within a prospective cohort. Each outborn infant was matched using GA and antenatal steroids with a maximum of four inborns. Conditional logistic regression was used to calculate ORs before being adjusted using maternal and birth characteristics. Analyses were carried out after multiple imputation for missing data.SettingEPIPAGE-2 French national prospective cohort including births up to 34 weeks GA inclusive.PatientsOutborn and inborn control infants selected between 24 and 31 weeks GA were followed in the neonatal period and to 2 and 5.5 years. 3335 infants were eligible of whom all 498 outborns and 1235 inborn infants were included—equivalent to 2.5 inborns for each outborn.Main outcome measureSurvival without moderate-to-severe neurodevelopmental impairment at 5.5 years.ResultsChorioamnionitis, pre-eclampsia, caesarian birth and small-for-dates were more frequent among inborns, and spontaneous labour and antepartum haemorrhage among outborns. There was no difference in the main outcome measure at 5.5 years of age (adjusted OR 1.09, 95% CI 0.82 to 1.44); sensitivity analyses suggested improved outcomes at lower GAs for inborns.ConclusionIn this GA and steroid matched cohort, there was no difference in survival without moderate-to-severe neurodevelopmental impairment to 5.5 years of age between inborn and outborn very preterm children. This suggests steroids might be important in determining outcomes.

Health consequences of tobacco exposure during pregnancy and childhood.In France, about 15% of fetuses are exposed to maternal smoking during pregnancy and about 30% of children are exposed to second-hand tobacco smoke. Furthermore, 20 to 25% of young adults are active smokers. These high rates underline the persistent need for preventive actions against tobacco exposure from pregnancy through adulthood.Tobacco exposure leads to numerous deleterious consequences on physical and mental health. During pregnancy, the main adverse effects are increased risks of congenital anomalies, in utero death, preterm delivery and low birthweight for gestational age. Children exposed to tobacco before or after birth have increased risks of sudden infant death syndrome, respiratory infections and recurrent otitis media.Adolescents and adults have similar tobacco-related complications.Conséquences somatiques de l’exposition au tabac chez l’enfant et l’adolescent. En France, les prévalences d’exposition au tabagisme sont d’environ 15 % chez le foetus pendant la grossesse, 30 % chez l’enfant via une exposition environnementale, et 20-25 % chez l’adolescent par une consommation active. Ces taux très élevés soulignent l’importance des actions de prévention à tous les âges de la vie. Les conséquences du tabagisme sur la santé physique sont multiples et peuvent survenir à court, moyen et long terme. Pour le foetus, les principaux risques sont la tératogénicité, la mort foetale in utero, la prématurité et le petit poids de naissance. Pour le jeune enfant exposé pendant la grossesse et/ou après la naissance, il s’agit essentiellement du risque de mort inattendue du nourrisson, d’infections respiratoires et d’otites moyennes aiguës récidivantes. Les complications chez l’adolescent fumeur sont les mêmes que chez l’adulte.

Resume Objectif Les cancers du sein triple negatifs, definis par l’absence d’expression des recepteurs hormonaux et de la proteine HER2, sont consideres comme des tumeurs agressives et de mauvais pronostic en comparaison aux tumeurs hormonosensibles. L’objectif de l’etude etait d’evaluer les associations entre les facteurs hormonaux et les facteurs influencant le pronostic chez les patientes prises en charge pour tumeurs triple negatives. Methodes Toutes les femmes operees d’un cancer du sein triple negatif entre janvier 2009 et decembre 2013 ont ete incluses. Pour chaque patiente, les facteurs recueillis ont ete les donnees cliniques, anatomopathologiques, la prise en charge therapeutique, ainsi que les donnees de survie. Resultats Sur la periode de l’etude, 1682 femmes ont ete operees d’un cancer du sein, dont 1444 presentaient au moins une tumeur infiltrante. Cent cinquante-cinq patientes (10,7 %) avaient une tumeur triple negative. L’âge moyen au diagnostic pour les tumeurs triple negatives etait de 56,4 ans, soit significativement plus jeune que pour les autres types de tumeurs, p = 0,0001. Chez les patientes avec une tumeur triple negative, la parite etait le seul facteur hormonal identifie comme un facteur independant d’atteinte ganglionnaire axillaire (OR = 1,53 ; IC95 % [1,10–2,25] p = 0,02) et l’antecedent de THM comme facteur independant protecteur de recidive locoregionale (OR = 0,13 [0,005–0,64] p = 0,001). Nous n’avons pas trouve de facteur hormonal identifie comme predictif de metastase a distance. Nous n’avons pas retrouve de difference de survie en fonction de la parite (p = 0,72), de la categorie d’IMC (p = 0,62), de la prise ou non de THM (p = 0,49). Conclusion Les facteurs hormonaux semblent egalement avoir une implication pronostique pour les tumeurs triples negatives malgre l’absence d’expression des recepteurs hormonaux.

To evaluate the ability of preinduction ultrasonographic cervical length to predict the interval between induction and delivery in women at term with a Bishop score of 4 to 6 at induction.This multicenter prospective observational cohort recruited 334 women from April 2010 to March 2014. Inclusion criteria were women with singleton pregnancies at a gestational age ≥37 weeks, with no previous caesarean, a medical indication for induction of labor, and a Bishop score of 4, 5, or 6. All women underwent cervical assessment by both transvaginal ultrasound and digital examination (Bishop score). The induction protocol was standardized. The primary outcome measure was the induction-delivery interval. Hazard ratios (HR) and their 95% confidence intervals (95% CI) were used to assess potential predictors.Mean gestational age at induction was 40.1 weeks, 60.8% of the women were nulliparous, and the cesarean rate was 13.4%. The mean induction-delivery interval was 20.8 h (± 10.6). Delivery occurred within 24 h for 56.9% (n=190) of the women. An ultrasonographic cervical length measurement less than 25 mm (HR=1.50, 95% CI 1.18-1.91, P0.01) and parity (HR=1.41, 95% CI 1.21-1.65, P0.01) appeared to predict induction-delivery interval. The cervical length cutoff to reduce the induction-delivery interval was 25 mm.A cervical length cutoff of 25 mm was associated with shorter induction-delivery interval in women at term with a Bishop score of 4 to 6.

BACKGROUND Regionalisation programmes aim to ensure that very preterm infants are born in level III units (inborn) through antenatal referral or transfer. Despite widespread knowledge about better survival without disability for inborn babies, 10%-30% of women deliver outside these units (outborn). OBJECTIVE To investigate risk factors associated with outborn deliveries and to estimate the proportion that were probably or possibly avoidable. METHODS We used a national French population-based cohort including 2205 women who delivered between 24 and 30+6 weeks in 2011. We examined risk factors for outborn delivery related to medical complications, antenatal care, sociodemographic characteristics and living far from a level III unit using multivariable binomial regression. Avoidable outborn deliveries were defined by pregnancy risk (obstetric history, antenatal hospitalisation) and time available for transfer. RESULTS 25.0% of women were initially booked in level III, 9.1% were referred, 49.8% were transferred, and 16.1% had outborn delivery. Risk factors for outborn delivery were gestational age

Background Prolonged pregnancies are a frequent indication for induction of labour. When the cervix is unfavourable, cervical ripening before oxytocin administration is recommended to increase the likelihood of vaginal delivery, but no particular method is currently recommended for cervical ripening of prolonged pregnancies. This trial evaluates whether the use of mechanical cervical ripening with a silicone double balloon catheter for induction of labour in prolonged pregnancies reduces the cesarean section rate for nonreassuring fetal status compared with pharmacological cervical ripening by a vaginal pessary for the slow release of dinoprostone (prostaglandin E2). Methods and findings This is a multicentre, superiority, open-label, parallel-group, randomised controlled trial conducted in 15 French maternity units. Women with singleton pregnancies, a vertex presentation, ≥41+0 and ≤42+0 weeks’ gestation, a Bishop score, In this trial, Caroline Diguisto and colleagues compare two methods for addressing non-reassuring fetal status in caesarian deliveries., Author summary Why was this study done? Induction of labour may be necessary when pregnancies reach 41 weeks of gestation. Ripening methods include mechanical and pharmacological options and both are currently used in pregnancies that reach 41 weeks of gestation. Mechanical cervical ripening leads to less uterine tachysystole and less fetal heart rate anomalies than pharmacological methods. Whether mechanical methods are associated with reduced perinatal morbidity in prolonged pregnancies in comparison with pharmacological methods needed to be investigated by a sufficiently powered randomised trial. What did the researchers do and find? We conducted a trial to compare cervical ripening with a silicone double-balloon catheter (mechanical method) to cervical ripening with a vaginal dinoprostone slow-release system (pharmacological method) among women with prolonged pregnancies. We did not find that cervical ripening with a silicone double-balloon catheter was superior to cervical ripening with a vaginal dinoprostone slow-release system to reduce the rate of cesarean for nonreassuring fetal heart rate and overall maternal and neonatal morbidity. What do these findings mean? There is no evidence to justify preferring mechanical cervical ripening over pharmacological cervical ripening in pregnancies that have reached 41 weeks.

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.

Introduction Our main objective was to evaluate whether antenatal corticosteroids increase the risk of small head circumference in children born at term. Secondary objectives were to evaluate whether they increase the risk of small birthweight and birth length among those children. Material and methods A historical cohort included 275 270 live term born children between 2000 and 2013 in 175 French maternity units. The rate of head circumference below the 5th percentile among children born at term and exposed to antenatal corticosteroids was compared with that of two unexposed groups: those children born at term whose mothers had an episode of threatened preterm labor without corticosteroids and those whose mothers had neither threatened preterm labor nor corticosteroids. The association between this treatment and head circumference was evaluated by calculating adjusted risk ratios (aRRs) and their 95% confidence intervals (CIs). The main outcome measure was a head circumference below the 5th percentile at birth, adjusted for sex, and gestational age according to the Pediatric, Obstetrics, and Gynecology Electronic Records Users Association (AUDIPOG) curves. Secondary outcomes were birthweight and birth length below the 5th percentile. Results The rate of head circumference below the 5th percentile was 5.8% (n = 3388) among children exposed to antenatal corticosteroids and 4.3% (n = 7077) and 4.6% (n = 198 462), respectively, for the two unexposed groups. After adjustment, the risk of having a head circumference below the 5th percentile did not differ between the exposed group and the two control groups (aRR 1.28, 95% confidence interval [CI] 0.97-1.69] and aRR 0.91, 95% CI 0.74-1.13). We did not find an association between antenatal corticosteroids and the rate of birthweight below the 5th percentile. Children exposed to antenatal corticosteroids had a higher risk of a birth length below the 5th percentile when compared with those not exposed to threatened preterm labor or corticosteroids. Conclusions We found no association between antenatal corticosteroids and increased risk of head circumference below the 5th percentile in children born at term.

International audience; Objective To determine the management of patients with term prelabor rupture of membranes. Methods Synthesis of the literature from the PubMed and Cochrane databases and the recommendations of French and foreign societies and colleges. Results Term prelabor rupture of membranes is considered a physiological process until 12 h have passed since rupture (professional consensus). In cases of expectant management and with a low rate of antibiotic prophylaxis, home care may be associated with an increase in neonatal infections (LE3), compared with hospitalization, especially for women with group B streptococcus (GBS) colonization (LE3). Home care is therefore not recommended (grade C). In the absence of spontaneous labor within 12 h of rupture, antibiotic prophylaxis may reduce the risk of maternal intrauterine infection but not of neonatal infection (LE3). Its use after 12 h of rupture in term prelabor rupture of the membranes is therefore recommended (grade C). When antibiotic prophylaxis is indicated, intravenous beta-lactams are recommended (grade C). Induction of labor with oxytocin (LE1), prostaglandin E2 (LE1), or misoprostol (LE1) is associated with shorter rupture-to-delivery intervals than expectant management; immediate induction is not, however, associated with lower rates of neonatal infection (LE1), even among women with a positive GBS vaginal swab (LE2). Thus, expectant management can be offered without increasing the risk of neonatal infection (grade B). Induction of labor is not associated with either an increase or decrease in the cesarean rate (LE2), regardless of parity (LE2) or Bishop score at admission (LE3). Induction can thus be proposed without increasing the risk of cesarean delivery (grade B). No induction method (oxytocin, dinoprostone, misoprostol, or Foley catheter) has demonstrated superiority over any another method for reducing rates of intrauterine or neonatal infection or of cesarean delivery or for shortening the rupture-to-delivery intervals, regardless of parity or the Bishop score. Conclusion Term prelabor rupture of membranes is a frequent event. A 12-hour interval without onset of spontaneous labor was chosen to differentiate a physiological condition from a potentially unsafe situation that justifies antibiotic prophylaxis. Expectant management or induction of labor can each be proposed, even in case of positive screening for group streptococcus. The decision should depend on the woman's wishes and maternity unit organization (professional consensus).

Resume Objectifs Evaluer les connaissances sur le tabagisme en cours de grossesse et elaborer les recommandations de prise en charge, en utilisant la litterature fondee sur les niveaux de preuve. Methodes Revue systematique de la litterature internationale. Nous avons identifie des articles publies entre janvier 2003 et avril 2019 dans les bases de donnees Cochrane, PubMed et Embase a partir des mots cles predefinis. Toutes les etudes publiees en langue francaise ou anglaise ont ete considerees et classees par leur niveau de preuve (de 1, le plus eleve a 4 le plus bas) et la force des recommandations selon la cotation proposee par la Haute Autorite de sante (HAS) (grades A a C). Resultats Le « conseil global », signifiant tout conseil ou aide comportementale confondu, apporte un benefice modeste comme aide au sevrage et un benefice modere sur le poids de naissance et la prematurite. L’activite physique moderee n’a pas montre d’effet significatif. Le retrocontrole par l’evaluation dans l’air expire de la concentration de monoxyde de carbone n’influence pas l’abstinence tabagique mais il y a l’accord professionnel pour utiliser cette mesure en vue d’etablir une alliance therapeutique. L’utilisation d’interventions d’entraide et d’education a la sante est recommandee pour favoriser l’arret du tabac pendant la grossesse. La prescription des traitements de substitution nicotinique (TSN) peut etre proposee a toute femme enceinte qui n’a pas reussi a arreter de fumer sans aide medicamenteuse. Cette prescription peut etre initiee par le professionnel de sante prenant en charge la femme enceinte en debut de grossesse. Il n’y a pas de preuve scientifique pour proposer la cigarette electronique comme aide a l’arret du tabac ; il est recommande d’utiliser des conseils et des methodes de sevrage tabagique deja evaluees. L’utilisation de chicha pendant la grossesse est associee a une diminution de la croissance fœtale, il est recommande de ne pas l’utiliser pendant la grossesse. L’allaitement maternel est possible chez les fumeuses, bien que moins souvent initie par elles. Si ses bienfaits pour le developpement de l’enfant ne sont pas demontres a ce jour, l’allaitement toutefois permet a la mere de limiter son tabagisme. Le risque de rechute du post-partum est eleve (jusqu’a 82 % a 1 an). Les principaux facteurs associes a l’abstinence du post-partum sont l’allaitement maternel, le fait de ne pas avoir de fumeur a la maison, et l’absence de symptomes de depression. Conclusion Le tabagisme pendant la grossesse concerne des centaines de milliers de femmes et leurs enfants par an en France. Il est un probleme de sante publique majeur. Les professionnels de sante doivent se mobiliser pour le reduire voire l’eradiquer.

Objective To assess whether chorioamnionitis is associated with cerebral palsy (CP) or death at 2 years' corrected age in infants born before 32 weeks of gestation after spontaneous birth. Study design EPIPAGE-2 is a national, prospective, population-based cohort study of children born preterm in France in 2011; recruitment periods varied by gestational age. This analysis includes infants born alive after preterm labor or preterm premature rupture of membranes from 240/7 to 316/7 weeks of gestation. We compared the outcomes of CP, death at 2 years' corrected age, and “CP or death at age 2” according to the presence of either clinical chorioamnionitis or histologic chorioamnionitis. All percentages were weighted by the duration of the recruitment period. Results Among 2252 infants born alive spontaneously before 32 weeks of gestation, 116 (5.2%) were exposed to clinical chorioamnionitis. Among 1470 with placental examination data available, 639 (43.5%) had histologic chorioamnionitis. In total, 346 infants died before 2 years and 1586 (83.2% of the survivors) were evaluated for CP at age 2 years. CP rates were 11.1% with and 5.0% without clinical chorioamnionitis (P = .03) and 6.1% with and 5.3% without histologic chorioamnionitis (P = .49). After adjustment for confounding factors, CP risk rose with clinical chorioamnionitis (aOR 2.13, 95% CI 1.12-4.05) but not histologic chorioamnionitis (aOR 1.21, 95% 0.75-1.93). Neither form was associated with the composite outcome “CP or death at age 2.” Conclusions Among infants very preterm born spontaneously, the risk of CP at a corrected age of 2 years was associated with exposure to clinical chorioamnionitis but not histologic chorioamnionitis.

Introduction Previous studies of fetal effects have suggested that intrahepatic cholestasis of pregnancy is associated with a higher rate of adverse neonatal outcomes including preterm birth, neonatal respiratory distress syndrome, meconium-stained amniotic fluid, neonatal intensive care unit admission, and stillbirth. The objective was to compare the neonatal and maternal consequences in pregnancies affected by intrahepatic cholestasis and normal pregnancies. Material and methods This case-control study compares pregnancies affected by intrahepatic cholestasis (pruritus and bile acid ≥ 10 μmol/L) with low-risk pregnancies managed between December 2006 and December 2014 at a French university hospital center. Results There were 83 (59.3%) cases of mild cholestasis (10≤ BA ≤39 μmol/L), 46 (32.8%) of moderate cholestasis (40≤ BA ≤99 μmol/L), and 11 (7.9%) of severe cholestasis (BA ≥100 μmol/L). No in utero fetal deaths occurred in the 140 women with cholestasis or the 560 controls analyzed. The rate of respiratory distress syndrome was higher in neonates of women with intrahepatic cholestasis (17.1% vs. 4.6%, P

Background and objectives: The aim was to review the clinical impact of groin metastatic nodal disease in women with vulvar squamous cell carcinoma (VSCC) and to evaluate the impact of adjuvant rad...

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 departments with 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. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

We report the case of a 30-year-old woman with a personal history of two medical abortions and two caesarean deliveries at term. Pregnancy was normal until 17 gestational weeks, when the woman was ...

International audience; Survival rates of infants born before 25 weeks of gestation are low in France and have not improved over the past decade. Active perinatal care increases these infants’ likelihood of survival.ObjectiveOur aim was to identify factors associated with active antenatal care, which is the first step of proactive perinatal care in extremely preterm births.MethodsThe population included 1020 singleton births between 220/6and 260/6weeks of gestation enrolled in the Etude Epidémiologique sur les Petits Ages Gestationnels 2 study, a French national population-based cohort of very preterm infants born in 2011. The main outcome was ’active antenatal care’ defined as the administration of either corticosteroids or magnesium sulfate or delivery by caesarean section for fetal rescue. A multivariable analysis was performed using a two-level multilevel model taking into account the maternity unit of delivery to estimate the adjusted ORs (aORs) of receiving active antenatal care associated with maternal, obstetric and place of birth characteristics.resultsAmong the population of extremely preterm births, 42% received active antenatal care. After standardisation for gestational age, regional rates of active antenatal care varied between 22% (95% CI 5% to 38%) and 61% (95% CI 44% to 78%). Despite adjustment for individual and organisational characteristics, active antenatal care varied significantly between maternity units (p=0.03). Rates of active antenatal care increased with gestational age with an aOR of 6.46 (95% CI 3.40 to 12.27) and 10.09 (95% CI 5.26 to 19.36) for infants born at 25 and 26 weeks’ gestation compared with those born at 24 weeks. No other individual characteristic was associated with active antenatal care.conclusionEven after standardisation for gestational age, active antenatal care in France for extremely preterm births varies widely with place of birth. The dependence of life and death decisions on place of birth raises serious ethical questions.Survival rates of infants born before 25 weeks of gestation are low in France and have not improved over the past decade. Active perinatal care increases these infants’ likelihood of survival.ObjectiveOur aim was to identify factors associated with active antenatal care, which is the first step of proactive perinatal care in extremely preterm births.MethodsThe population included 1020 singleton births between 220/6and 260/6weeks of gestation enrolled in the Etude Epidémiologique sur les Petits Ages Gestationnels 2 study, a French national population-based cohort of very preterm infants born in 2011. The main outcome was ’active antenatal care’ defined as the administration of either corticosteroids or magnesium sulfate or delivery by caesarean section for fetal rescue. A multivariable analysis was performed using a two-level multilevel model taking into account the maternity unit of delivery to estimate the adjusted ORs (aORs) of receiving active antenatal care associated with maternal, obstetric and place of birth characteristics.resultsAmong the population of extremely preterm births, 42% received active antenatal care. After standardisation for gestational age, regional rates of active antenatal care varied between 22% (95% CI 5% to 38%) and 61% (95% CI 44% to 78%). Despite adjustment for individual and organisational characteristics, active antenatal care varied significantly between maternity units (p=0.03). Rates of active antenatal care increased with gestational age with an aOR of 6.46 (95% CI 3.40 to 12.27) and 10.09 (95% CI 5.26 to 19.36) for infants born at 25 and 26 weeks’ gestation compared with those born at 24 weeks. No other individual characteristic was associated with active antenatal care.conclusionEven after standardisation for gestational age, active antenatal care in France for extremely preterm births varies widely with place of birth. The dependence of life and death decisions on place of birth raises serious ethical questions.

Resume Objectif Le but de ce travail etait d’evaluer les caracteristiques operatoires, histologiques ainsi que le pronostic des patientes traitees pour cancer du sein en fonction de leur indice de masse corporelle (IMC). Methodes Nous avons repris les donnees de toutes les patientes prises en charge pour carcinome du sein dans notre centre entre janvier 2009 et septembre 2013. l’IMC des patientes a ete categorise en : maigre, normal, surpoids et obese. Resultats Un total de 1599 patientes a ete evalue. Le recul moyen etait de 36,4 mois (1–265). Le nombre de patientes par categorie d’IMC etait de 66, 779, 463 et 291 pour les patientes maigres, de poids normal, en surpoids et obeses respectivement. Comme attendu les patientes en surpoids et obese avaient plus souvent de l’hypertension (18, 21, 35 et 47 % respectivement, p p p = 0,006), une plus grande taille tumorale histologique ( p = 0,038) ; une proportion plus importante de patientes avec atteinte ganglionnaire axillaire ( p = 0,03) avec un nombre de ganglions positifs plus important ( p = 0,02) par rapport aux autres categories d’IMC. Les patientes avaient les memes protocoles de traitements (notamment adjuvant). Il n’y avait pas de difference de la survie globale a 5 ans entre les differents groupes ( p = 0,30). Conclusions Notre etude montre une presentation clinique et histologique plus agressive pour les patientes obeses.

Resume L’objectif de l’etude etait de determiner, au sein d’une maternite de type 3, la part de prematurite induite parmi les naissances prematurees, d’etudier les pratiques de choix de voie d’accouchement et l’issue des accouchements pour ces naissances. Materiel et methodes Une etude retrospective au sein du service d’obstetrique du centre hospitalier regional universitaire de Tours (maternite de type 3) a ete menee sur les donnees d’une periode de 22 mois. Les femmes avec une indication medicale de naissance entre 22 et 37 semaines d’amenorrhee, pour lesquelles un accouchement par les voies naturelles etait envisageable, ont ete incluses. Pour chacune de ces femmes, le choix de la voie d’accouchement (cesarienne prophylactique ou declenchement du travail), des facteurs maternels, obstetricaux ainsi que des facteurs neonataux ont ete etudies. Resultats De janvier 2012 a octobre 2013, 539 femmes ont accouche prematurement d’enfants singletons nes vivants et 42,5 % de ces naissances ont eu lieu apres un declenchement ou une cesarienne avant travail. Parmi 114 femmes pour lesquelles une voie basse etait envisageable, 33,3 % ont eu une cesarienne prophylactique et 66,7 % un declenchement du travail. Le choix de la voie d’accouchement est influence par de nombreux facteurs comme les conditions locales, l’âge gestationnel ou le type de pathologies obstetricales. Concernant les donnees neonatales, le poids de naissance et le score d’Apgar sont significativement plus bas dans le groupe « cesarienne prophylactique » que dans le groupe « declenchement » et le taux d’hospitalisation du nouveau-ne en neonatologie est plus eleve. Conclusion La prematurite induite represente presque la moitie des naissances prematurees dans notre centre et un tiers des femmes ont eu une cesarienne prophylactique. Vu la morbidite perinatale qui decoule de cette prematurite induite, une reevaluation reguliere des indications de naissance est indispensable.

Lesions of the choroid plexus represent approximately 5% of the neonatal brain lesions and usually correspond to two different aetiologies: Choroid Plexus Papilloma or Carcinoma. Antenatal manageme...

Objective To evaluate the association between active antenatal management and neonatal outcomes in extremely preterm newborns admitted to a neonatal intensive care unit (NICU). Study design This population-based cohort study was conducted in 25 regions of France. Infants born in 2011 between 220/7 and 266/7 weeks of gestation and admitted to a NICU were included. Infants with lethal congenital malformations or death in the delivery room were excluded. A multilevel multivariable analysis was performed, accounting for clustering by mother (multiple pregnancies) and hospital plus individual characteristics, to estimate the association between the main exposure of no active antenatal management (not receiving antenatal corticosteroids, magnesium sulfate, or cesarean delivery for fetal indications) and a composite outcome of death or severe neonatal morbidity (including severe forms of brain or lung injury, retinopathy of prematurity, and necrotizing enterocolitis). Results Among 3046 extremely preterm births, 783 infants were admitted to a NICU. Of these, 138 (18%) did not receive active antenatal management. The risk of death or severe morbidity was significantly higher for infants without active antenatal management (crude OR, 2.60; 95% CI, 1.44-4.66). This finding persisted after adjustment for gestational age (OR, 2.08; 95% CI, 1.19-3.62) and all confounding factors (OR, 1.86; 95% CI, 1.09-3.20). Conclusions The increased risk of severe neonatal outcomes for extremely preterm babies admitted to a NICU without optimal antenatal management should be considered in individual-level decision making and in the development of professional guidelines for the management of extremely preterm births.

Our trial aimed to assess the effectiveness of amnioinfusion for a second attempt at external cephalic version (ECV).This open randomized controlled trial was planned with a sequential design. Women at a term ≥36 weeks of gestation with a singleton fetus in breech presentation and a first unsuccessful ECV were recruited in two level-3 maternity units. They were randomly allocated to transabdominal amnioinfusion with a 500-mL saline solution under ultrasound surveillance or no amnioinfusion before the second ECV attempt. Trained senior obstetricians performed all procedures. The primary outcome was the cephalic presentation rate at delivery. Analyses were conducted according to intention to treat (NCT00465712).Recruitment difficulties led to stopping the trial after a 57-month period, 119 women were randomized: 59 allocated to amnioinfusion + ECV and 60 to ECV only. Data were analyzed without applying the sequential feature of the design. The rate of cephalic presentation at delivery did not differ significantly according to whether the second version attempt was or was not preceded by amnioinfusion (20 versus 12%, p = .20). Premature rupture of the membranes occurred for 15% of the women in the amnioinfusion group.Amnioinfusion before a second attempt to external version does not significantly increase the rate of cephalic presentation at delivery.

Resume Objectif Les methodes mecaniques de maturation cervicale sont aussi efficaces que les prostaglandines pour le taux d’accouchement par voie basse. Notre etude a pour objectif d’etudier les pratiques professionnelles de maturation cervicale par methodes mecaniques en France. Methodes Enquete declarative menee sur un echantillon representatif des maternites francaises (echantillon 1), d’une part, et sur l’ensemble des maternites de type 3, d’autre part (echantillon 2). Un questionnaire a ete envoye par courrier electronique aux responsables des unites obstetricales de ces maternites entre mai et juillet 2014. Resultats Quarante-trois des 104 maternites de l’echantillon 1 (41,3 %) et 43 des 64 maternites de l’echantillon 2 (67,2 %) ont repondu au questionnaire. Des maturations mecaniques sont realisees dans 44,2 et 69,8 % des maternites de ces echantillons. Les principaux moyens utilises sont la sonde a double ballonnet et la sonde de Foley. La principale indication des maturations mecaniques est l’indication de declenchement sur uterus unicicatriciel. En cas d’indication de declenchement du travail avec uterus unicicatriciel et score de Bishop Conclusion En France, pres de 50 % de l’ensemble des maternites et pres de ¾ des maternites de type 3 disent pratiquer des maturations mecaniques. Leur principale indication est le declenchement du travail avec uterus cicatriciel.

Resume Objectif Etude comparative des complications per- et postoperatoires de deux methodes chirurgicales du traitement de l’endometriose digestive en chirurgie robot-assistee : la technique du « shaving » (exerese la plus complete possible du nodule au contact du tube digestif sans effraction de la muqueuse) et la resection colorectale. Methode Vingt-huit femmes operees en laparoscopie robot-assistee pour de l’endometriose sous-peritoneale profonde avec atteinte digestive confirmee a l’histologie ont ete incluses. Six femmes ont eu une resection digestive et vingt et une ont eu une procedure de shaving . La morbidite immediate, a deux mois et a un an ont ete comparees entre les deux groupes. Resultats Les durees d’intervention etaient plus courtes ( p = 0,0002) et les saignements etaient moins importants dans le groupe shaving (200 mL vs 560 mL ; p = 0,04) que dans le groupe resection. Nous avons observe un cas de conversion en laparotomie dans le groupe resection et une plaie de vessie dans le groupe shaving . Les durees d’hospitalisation etaient plus longues dans le groupe resection ( p = 0,0001) que dans le groupe shaving . A la reevaluation a deux mois, il n’y avait pas de difference significative entre les deux groupes pour le nombre de femmes en remission complete, pour les douleurs pelviennes, les symptomes urinaires ou digestifs ou les dyspareunies. Deux femmes du groupe resection ont rapporte des signes fonctionnels digestifs qui persistaient 24 mois apres l’intervention. Conclusion La morbidite operatoire immediate et tardive est plus importante en cas de resection digestive. La chirurgie de l’endometriose profonde, meme en laparoscopie robot-assistee, reste pourvoyeuse de complications operatoires importantes.

IntroductionInduction of labour for prolonged pregnancies (PP) when the cervix is unfavourable is a challenging situation. Cervical ripening by pharmacological or mechanical techniques before oxytocin administration is used to increase the likelihood of vaginal delivery. Both techniques are equally effective in achieving vaginal delivery but excessive uterine activity, which induces fetal heart rate (FHR) anomalies, is more frequent after the pharmacological intervention. We hypothesised that mechanical cervical ripening could reduce the caesarean rate for non-reassuring FHR especially in PP where fetuses are already susceptible to this.Methods and analysisA multicentre, superiority, open-label, parallel-group, randomised controlled trial that aims to compare cervical ripening with a mechanical device (Cervical Ripening Balloon, Cook-Medical Europe, Ireland) inserted in standardised manner for 24 hours to pharmacological cervical ripening (Propess system for slow release system of 10 mg of dinoprostone, Ferring SAS, France) before oxytocin administration. Women (n=1220) will be randomised in a 1:1 ratio in 15 French units. Participants will be women with a singleton pregnancy, a vertex presentation, a term ≥41+0 and≤42+0 week’s gestation, and for whom induction of labour is planned. Women with a Bishop score ≥6, a prior caesarean delivery, premature rupture of membranes or with any contraindication for vaginal delivery will be excluded. The primary endpoint is the caesarean rate for non-reassuring FHR. Secondary outcomes are related to delivery and perinatal morbidity. As study investigators and patients cannot be masked to treatment assignment, to compensate for the absence of blinding, an independent endpoint adjudication committee, blinded to group allocation, will determine whether the caesarean for non-reassuring FHR was justified.Ethics and disseminationWritten informed consent will be obtained from all participants. The Tours Research ethics committee has approved this study (2016-R23, 29 November 2016). Study findings will be submitted for publication and presented at relevant conferences.Trial registration numberNCT02907060; pre-results.

International audience; OBJECTIVE: The study aims to evaluate the accuracy of combining uterine artery Doppler (UAD), PlGF and sFlt-1 in the first trimester for preeclampsia screening. METHODS: Prospectively enrolled women at high risk of preeclampsia were included. Transabdominal UAD measurements and serum biomarkers were collected between 11 and 13 weeks of gestation in three university hospitals and in one general hospital. The main outcome was preeclampsia. UAD parameters and biomarker levels among women with preeclampsia were compared with those of women in the unaffected group in univariate and multivariate analyses. RESULTS: Out of 226 women included from May 2007 to January 2011, 27 (11.9%) women developed preeclampsia. Among women affected by preeclampsia, the lowest pulsatility index was higher (p\,=\,0.02), bilateral notching was more frequent (p\,=\,0.01), and PlGF was lower (p\

Objective This study aimed to determine if screening for preeclampsia could be improved between 20 and 24 weeks of gestation by uterine artery Doppler (UAD), biomarkers and lipid-related markers. Method Women at high risk of preeclampsia according to obstetric and medical characteristics and history were prospectively enrolled. Transabdominal UAD, serum biomarkers (placenta growth factor (PlGF), soluble Fms-like tyrosine kinase-1 and sEndoglin) and lipid-related markers (total and high-density lipoprotein cholesterol, triglycerides and leptin) were prospectively collected between 20 and 24 weeks of gestation. The main endpoint was preeclampsia. UAD indices and biomarker levels were compared for the groups with and without preeclampsia. Multivariate analyses took into account the laboratory and ultrasound variables significantly associated with preeclampsia in the univariate analysis and age and nulliparity. Results The study at Tours University Hospital took place from March 2003 to February 2008 and included 235 women: 56 (23.8%) developed preeclampsia, 42 were severe (17.8%) and 14 occurred before 34 weeks of gestation (5.9%). The group with preeclampsia had a higher UAD pulsatility index (p = 0.0003), more frequent bilateral notches (p = .0001), lower PlGF levels (239.90 vs 302.00 pg/mL; p = 0.0015), and higher triglyceride (1.95 vs 1.70 mmol/l; p = 0.0068) and leptin levels (37.40 vs 22.55 ng/mL; p = < 0.001). No significant differences were observed for other markers. Screening for preeclampsia using these Doppler and laboratory findings produced an area under the curve of 0.795. Conclusion Second-trimester UAD findings, and PlGF, triglyceride and leptin levels could help to predict preeclampsia. © 2013 John Wiley & Sons, Ltd.

Neuroblastoma accounts for 50% of foetal adrenal masses and is the most common congenital malignant tumour commonly arising from the adrenal gland (Sauvat et al. 2002; Cozzi et al. 2013). Sonograph...