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Resume Contexte La maladie de Crohn (MC) et les lesions sphincteriennes survenant au cours des accouchements sont deux facteurs de risque d’Incontinence Anale (IA). Le risque d’IA a long terme chez les femmes atteintes de MC apres un accouchement n’a jamais ete etudie. Objectif L’objectif principal de l’etude est d’evaluer le risque d’IA severe a distance de l’accouchement chez des femmes atteintes de MC. Methode Une etude retrospective a ete realisee chez des femmes atteintes de la MC et ayant accouche au sein d’une maternite de type 3 entre 2000 et 2015. Le critere de jugement principal etait une IA severe definie par un score de Wexner ≥ 9 ou un score de St Mark ≥ 9, au moins 5 ans apres l’accouchement. L’association entre la voie d’accouchement et la survenue d’incontinence anale severe a ete evaluee par des analyses uni et multivariees. Resultats Quarante-six femmes ont ete incluses, dont 32 avaient accouche par voie vaginale et 14 par cesarienne. Trente et un pourcent des femmes presentaient une IA severe selon le score de Wexner, et 41 % selon celui de St Mark. Deux facteurs etaient associes a une IA severe : l’accouchement par voie vaginale et la survenue d’une lesion perineale obstetricale (respectivement OR brut = 8,89 IC95 % 1,03–76,57 et OR brut = 4,16 IC95 % 1,06–16,27 (score de Wexner), et OR brut = 6,8 IC95 % 1,30–35,41 et OR brut = 4,3 IC95 % 1,23–15,2 (score de St Mark)). Apres ajustement sur les facteurs de confusion, seul l’accouchement par voie vaginale etait associe a une IA severe (OR ajuste = 22,86 IC95 % 1,52–931,28 pour un score de Wexner ≥ 9 et OR ajuste = 16,11 IC95 % 1,43–533,26 pour un score de St Mark ≥ 9). Conclusion Un accouchement par voie vaginale etait associe a la survenue d’une incontinence anale severe a long terme chez les femmes atteintes de MC.

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

To assess the efficacy and safety of in-utero aspiration (IUA) of anechoic fetal ovarian cysts.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.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.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 WileySons Ltd.

Resume Objectifs Le but de ce travail etait d’evaluer nos pratiques concernant le recours aux complements chez les nouveau-nes allaites. Methode Cette etude descriptive et prospective a ete realisee entre le 23 mars et le 22 mai 2010 incluant les nouveau-nes allaites, en bonne sante, singletons nes a la maternite universitaire de Tours. Les indications des complements ont ete recueillies de facon prospective par le personnel paramedical. Resultats Deux cent quatre-vingt-un nouveau-nes allaites ont ete inclus. Quatre-vingt-dix-neuf (35 %) ont recu du lait artificiel. Ces enfants etaient plus souvent des enfants de primipare (61,6 % versus 44 % ; p = 0,005) ou de meres sans experience de l’allaitement maternel (69,7 % versus 48,9 % ; p = 0,001), nes par cesarienne (21,2 % versus 10,4 % ; p = 0,01) et hypotrophiques (10,1 % versus 6,6 % ; p = 0,003). Les principales indications des complements etaient la perte de poids, la faim du nouveau-ne, l’hypoglycemie et les difficultes a teter le sein. Vingt-neuf pour cent des complements avaient ete donnes sans justification medicale. Conclusion Un tiers des nouveau-nes allaites recoit des complements en maternite. Une meilleure connaissance de la part de l’equipe medicale et paramedicale des indications permettrait de diminuer le recours aux complements chez les nouveau-nes allaites.

Fetal MRI is a third intention examination to prenatal diagnosis. If its diagnostic value is well known in many pathologies, its place in the management of pregnancies remains unclear.We collected retrospectively demographical, radiological (fetal MRI indications, fetal anatomical region and diagnostic information provided by fetal MRI) and obstetrical data of pregnant patients in university prenatal center during a 5 years' period.Among 2439 patients of the prenatal center, 196 (8%) patients with fetal MRI were included. The main anatomical regions studied were the brain (n=132, 67%), the thorax (n=31, 16%) and the abdomen (n=25, 13%). No cardiac fetal MRI was performed. Ninety-five percent of fetal MRI was consecutively of an ultrasound sign. Fetal brain MRI was abnormal in 65% of cases, the thoracic and abdominopelvic MRI in 81.5%. The ultrasound diagnosis was unchanged in 42%, completed in 50% and redirected in 8% of cases. A termination of pregnancy was deemed admissible in 31% of patients with MRI versus 21% in patients without MRI (P=0.001).Fetal MRI requires selective indications and provides additional diagnostic information with important implications for the future of the pregnancy, particularly in case of severe and incurable pathologies. Our results could be useful as a reference basis for the comparison with others prenatal center practices.

Resume La survenue d’une grossesse chez une patiente avec une hypertension portale est une situation inhabituelle pour le clinicien. Bien que la majoration de l’hypertension portale au cours de la grossesse ne soit pas parfaitement demontree, il existe une surmorbidite indeniable, principalement en cas de cirrhose qui justifie la notion de grossesse a risque et impose une prise en charge multidisciplinaire. Les moyens de prevention ou de lutte contre l’hemorragie sont peu differents de ceux disponibles en dehors de la grossesse. La recherche et la prise en charge de l’hypertension portale, avant ou au debut de la grossesse, peuvent reduire les risques de fausses couches, de naissance prematuree, de retard de croissance intra-uterin et la mortalite maternelle. Ces complications sont etroitement liees a la survenue d’hemorragie digestive. Les risques lies a la maladie sous-jacente doivent egalement etre pris en compte, qu’il s’agisse d’une insuffisance hepatocellulaire en cas de cirrhose ou du risque thromboembolique pour les maladies vasculaires hepatiques associees a une thrombophilie. De maniere generale, l’accouchement par voie basse, sous analgesie debutee precocement et assistee d’une extraction instrumentale, doit etre prefere a la cesarienne dont les indications doivent rester d’ordre obstetrical.

To analyze the anatomical relationship between the pubic symphysis and the ischial spines to determine reliable landmarks for the assessment of fetal head descent by intrapartum translabial ultrasound (ITU).All computed tomography (CT) scans performed for breech presentation and for twin delivery between 2006 and 2014 in a tertiary university hospital were obtained for measurement and analysis by two operators. The symphysis-left ischial spine angle (SIA) and the symphysis-left ischial spine distance (SID) were measured on three-dimensional reconstructions from the CT volume dataset. We calculated intra- and interobserver agreements for SIA and SID with 95% prediction intervals, created Bland-Altman plots with 95% limits of agreement and estimated the intraclass correlation coefficient (ICC). A sagittal plane projection from the SIA enabled calculation of a sagittal angle, corresponding to the angle of progression (AoP) on ITU.SIA and SID were obtained from CT images from 458 women. Reproducibility was good for both SIA (intraobserver ICC, 0.94 (95% CI, 0.88-0.97) and interobserver ICC, 0.81 (95% CI, 0.66-0.92)) and SID (intraobserver ICC, 0.92 (95% CI, 0.82-0.97) and interobserver ICC, 0.83 (95% CI, 0.73-0.92)). The median SIA was 106° (interquartile range (IQR), 105-109°) and median SID was 26.1 (IQR, 23.4-29.5) mm. SIA and SID were not correlated with pelvic diameter or height. The 50Knowledge of the anatomical relationship between the pubic symphysis and ischial spines makes it possible to establish a sonographic method for assesssing fetal head descent by taking into account the level of the ischial spines. Copyright © 2015 ISUOG. Published by John WileySons Ltd.

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

Mechanical methods for cervical ripening are as effective as prostaglandins for the rate of vaginal delivery. Our aim was to study professional practices of mechanical cervical ripening in France.A declarative survey was conducted among two groups of maternity units: a sample representative of French maternity units (group 1) and on the whole of type 3 maternity units (group 2). A questionnaire was emailed to physicians of these obstetric units between May and July 2014.Forty-three of the 104 units (41.3%) in the first group and 43 of the 64 units in the second group (67.2%) answered the questionnaire. Among these maternity units, mechanical methods were used respectively in 44.2 and 69.8% of the establishments. The two main devices used were the trans-cervical balloon catheter and the Foley catheter. The main indication for mechanical methods was induction of labor with prior caesarean. In case of induction of labor, a prior caesarean and a Bishop score7, in the first group, 46.6% of the maternity units did a caesarean, 32.3% performed an induction of labor with mechanical methods, 13.9% with oxytocin and 6.9% with prostaglandins. In the second group, 25.6% of maternity units performed a caesarean, 53.6% used mechanical methods, 9.3% used oxytocin and 11.6% used prostaglandins.In France nearly half of the maternity units and nearly three-quarters of type 3 maternity units say they use mechanical cervical ripening, mainly used in case of prior caesarean.

Introduction Le syndrome des anti-phospholipides (SAPL) est une maladie auto-immune rare definie par la survenue de thromboses veineuses et/ou arterielles, ou par une morbidite obstetricale (fausses couches precoces, mort fœtale ou pre-eclampsie) associee a la presence d’anticorps anti-phospholipides (APL) : anticoagulant circulant (ACC), anticorps anti-cardiolipine (aCL) de classe immunoglobuline G (IgG) et/ou immunoglobuline M (IgM) a taux eleves ou anticorps anti-β-2-glycoproteine 1 (aβ2GP1) de classe IgG et/ou IgM detectes au moins 2 fois a 12 semaines d’intervalle [1] . Vingt-trois cas de dissection ont ete rapportes au cours du SAPL dans la litterature [2] . Toutefois, cette manifestation reste exceptionnelle. Ainsi, nous rapportons l’observation originale d’un SAPL revele par une pre-eclampsie severe compliquee de dissections arterielles multiples, soulevant la question de l’association de mecanismes obstetricaux et vasculaires du SAPL chez une patiente. Observation Une femme primigeste âgee de 39 ans, aux antecedents de phenomene de Raynaud et de tabagisme sevre, etait hospitalisee pour une pre-eclampsie a 29 semaines d’amenorrhee. La grossesse obtenue par stimulation ovarienne se deroulait sans probleme, jusqu’a l’apparition d’un tableau de pre-eclampsie severe avec un scotome central de l’œil gauche justifiant une cesarienne en urgence apres instauration de sulfate de magnesium et d’inhibiteur calcique. L’examen au fond d’œil retrouvait un œdeme papillaire bilateral avec un decollement sero-retinien et l’imagerie cerebrale etait normale. La patiente etait transferee en reanimation pour l’apparition d’anomalies biologiques compatible avec un Hemolysis, Elevated Liver Enzymes and Low Platelet count (HELLP) syndrome. Apres une amelioration clinique initiale, la patiente presentait a j9 des douleurs abdominales associees a des nausees et des vomissements, ainsi qu’une majoration de la pression arterielle malgre une tritherapie anti-hypertensive. Elle se plaignait d’une baisse de l’acuite visuelle. Biologiquement, le HELLP syndrome persistait. L’imagerie par resonance magnetique (IRM) cerebrale et les elements cliniques evoquaient un syndrome d’encephalopathie posterieure reversible, initialement retenu sur l’IRM. La tomodensitometrie abdominale revelait un hematome mural sur dissection de l’artere mesenterique superieure. Des paresthesies du membre superieur gauche et des cephalees apparaissaient a j1. Une nouvelle IRM cerebrale montrait un accident ischemique constitue occipital gauche secondaire a une dissection de l’artere vertebrale gauche, ainsi qu’un accident ischemique constitue cerebelleux droit. La reevaluation ophtalmologique retrouvait une neuropathie optique ischemique anterieure aigue. Un ACC, des aCL a 120 GPL et des aβ2GP1 de classe IgG a 99 U/mL etaient retrouves et controles a 12 semaines. L’ensemble de ces elements confirmait le diagnostic de SAPL. Le traitement par anti-coagulation curative, un antiagregant plaquettaire et une monotherapie anti-hypertensive permettaient un retour a domicile. L’examen clinique et la recherche genetique de pathologie hereditaire du collegene etaient negatifs. Trois mois apres sa sortie, seuls les troubles visuels persistaient. Conclusion L’originalite de notre observation tient au mode de revelation de ce SAPL, notamment la survenue de dissections multiples, une complication rare du SAPL Nous proposons un mecanisme multifactoriel avec initialement une fragilite vasculaire acquise impliquant un âge tardif de la grossesse, un tabagisme, ainsi qu’une action directe des APL sur l’endothelium vasculaire secondaire a l’activation du complement et a une alteration du remodelage de la matrice extracellulaire par activite de la metalloprotease-9. Le role de la stimulation ovarienne restant incertain. Une synthese de facteur tissulaire et de facteur pro-inflammatoire contribue habituellement a la survenue de thrombose et a la pre-eclampsie. La pre-eclampsie, complication du SAPL obstetrical, a ensuite ete le facteur favorisant des dissections. La thrombopenie du HELLP a sans doute « proteger » la patiente d’une thrombose mesenterique, ce qui n’a pas ete le cas pour l’artere cerebral. Il est habituel de considerer le SAPL obstetrical comme une entite independante du SAPL vasculaire, notamment parce que les mecanismes thrombotiques ne peuvent pas expliquer l’ensemble des manifestations obstetricales [3] . Chez notre patiente, les complications vasculaires et obstetricales du SAPL ont probablement contribue a la survenue de cette presentation atypique.

Resume L'evolution d'une toxoplasmose congenitale grave peut etre defavorable malgre le traitement. Observation. — Un diagnostic antenatal, pratique apres une infection toxoplasmique matemelle vers 16 semaines d'amenorrhee, a montre tardivement (30 semaines d'amenorrhee) une infection fœtale, et conduit a un traitement par pyrimethamine-sulfadiazine. Cependant, une importante hydrocephalie a ete diagnostiquee par echographie a 37 semaines d'amenorrhee. Malgre une derivation ventriculoperitoneale rapidement mise en place et un traitement medical correctement suivi, le developpement neurologique de l'enfant, a 5 ans, a ete complique et le pronostic reste mauvais. Conclusion. — Cette observation doit inciter a une grande prudence quant a l'information a donner aux parents si le diagnostic ante natal est positif.

The purpose of this paper is to review available data regarding the management of delivery in intra uterine growth retarded fetuses and try to get recommendations for clinical obstetrical practice.Bibliographic research performed by consulting PubMed database and recommendations from scientific societies with the following words: small for gestational age, intra-uterine growth restriction, fetal growth restriction, very low birth weight infants, as well as mode of delivery, induction of labor, cesarean section and operative delivery.The diagnosis of severe IUGR justifies the orientation of the patient to a referral centre with all necessary resources for very low birth weight or premature infants Administration of corticosteroids for fetal maturation (before 34 WG) and a possible neuroprotective treatment by with magnesium sulphate (before 32-33 WG) should be discussed. Although elective caesarean section is common, there is no current evidence supporting the use of systematic cesarean section, especially when the woman is in labor. Induction of labor, even with unfavorable cervix is possible under continuous FHR monitoring, in favorable obstetric situations and in the absence of severe fetal hemodynamic disturbances. Instrumental delivery and routine episiotomy are not recommended. For caesarean section under spinal anesthesia, an adequate anesthetic management must ensure the maintenance of basal blood pressure.Compared with appropriate for gestational age fetus, IUGR fetus is at increased risk of metabolic acidosis or perinatal asphyxia during delivery.

To monitor and quantify uteroplacental perfusion in rat pregnancies by Doppler ultrasound (DUS) and contrast-enhanced ultrasound (CEUS).Fourteen rats were randomized in two groups (the CEUS group and the control group). On days 8, 11, 14, 17, 19 and 20 of gestation, we used DUS to measure the resistance index (RI), pulsatility index and blood velocity in the uterine, arcuate and umbilical arteries in both groups. On days 14, 17 and 20, one group was also examined by CEUS. Quantitative perfusion parameters were calculated in 4 compartments (mesometrial triangle, placenta, umbilical cord and fetus) and compared.The DUS measurement showed that the RI of the uterine and arcuate arteries decreased (p 0.01) from day 14 to day 17, while velocity increased each of these arteries (p 0.01 and p 0.05, respectively). Quantification of uteroplacental perfusion by CEUS in bolus mode revealed that blood volume and local blood flow increased from day 14 to day 20 in the mesometrial triangle (p 0.01) and the placenta (p 0.05). In the CEUS destruction-replenishment mode, the perfusion parameters showed trends similar to those observed in bolus mode. No microbubbles were detected in the umbilical vein or fetal compartments. The weights of pups in the two groups did not differ significantly.CEUS estimates of placental perfusion complement the data provided by DUS.

To assess the average number of ultrasounds per low-risk pregnancy and estimate the proportion of ultrasound scans without morphological examination of the fetus (non-morphological ultrasounds).Retrospective study conducted among patients who delivered at the University Hospital of Tours (France) between January 2012 and February 2012.Women with a singleton pregnancy who delivered after 37weeks' gestation an eutrophic child.Distinction was made between morphological and non-morphological ultrasound examinations. The type of non-morphological ultrasound examination was analyzed.Among the 300 patients of the study, the average number of scans per patient was five (SD=1.9), which is higher than the three recommended ultrasounds for these low-risk pregnancies. In this study, 77% of patients were receiving more than three ultrasounds. Moreover, 28.1% of all ultrasound examinations were non-morphological examinations. Among them, 42.2% of examinations were performed in the third trimester of pregnancy. Among these non-morphological ultrasounds performed in the third trimester, there were 51.9% of fetal biometric measurements and cervical length measurements in 18.5% of cases. We believe that resorting to non-morphological ultrasounds during low-risk pregnancies is not censurable in itself and should even be promoted. Nevertheless, we should improve the relevance of all these examinations.

Our purpose was to determine the obstructed epididymal epithelium morphometric state and to elucidate the influence of morphometric parameters on the fertilizing ability of aspirated spermatozoa.During MESA with IVF, epididymal tissue samples were carefully dissected, fixed, and prepared for morphometric analysis. The epithelium of the three regions was studied: head, body, and tail (when present). The total area/luminal area ratio, epithelium thickness, and stereocilium length were measured.We have found significant differences in the total area/luminal area ratio, epithelium thickness, and stereocilium length in obstructed epithelium length4 versus 0.5-2 cm (Por = 0.01). Epithelium thickness and stereocilium length were significantly lower when no fertilization was observed in IVF.These results suggest that morphometric data of obstructed epididymis epithelium can be used as a means of explaining the failure of IVF with epididymal spermatozoa.

In cases of placenta previa, the distance from the placental edge to the internal os is determinant in deciding on the mode of delivery that will minimize the risk of hemorrhage. The reproducibility and interobserver reliability of this measure are unknown. The internal os is not a point, as two-dimensional (2D) ultrasonography might suggest, but an oval patch that has a measurable width, which may be as wide as the distance separating it from the placenta. It is therefore difficult to determine the exact location of the os using a 2D sectional plane. We report the case of a nulliparous woman admitted for vaginal bleeding at 37 weeks' gestation in whom transvaginal ultrasound examination showed placenta previa, but for which two sonographers reported different measurements for the distance between the placental edge and the internal os. We describe a technique to measure this distance using multiplanar three-dimensional (3D) ultrasound imaging, which allows the smallest distance between the middle of the os and the edge of the placenta, which appears as a line, to be determined. In this case, measurement using 3D ultrasound showed a shorter distance than was suggested by 2D examination. This led us to schedule a Cesarean section delivery, during which there was minimal bleeding. Standardization of 3D measurements should make it possible to define more relevant cut-offs for determining the management of cases of placenta previa.

To evaluate, for women with scared uterus, the mechanical cervical ripening with balloon catheter.We conducted a retrospective study of our practice of ripening for scared uterus from january 2010 to august 2012. Feasibility, Bishop's score, birth modalities and complications for mothers and babies during this ripening were studied.Thirty-nine medical files were analysed. All patients could have mechanical ripening independently of the internal os status (open or not). The cervical ripening with balloon catheter improved Bishop's score before induction of labour, from 3.54 ± 1.23 to 5.38 ± 1.47 (p=0.02). 64.1% of women had a vaginal delivery. Concerning the predictive factors for vaginal delivery, we only found significant influence of a body mass index less than 30kg/m² (p=0.03). We didn't find any maternal or neonatal complications in our population.Mechanical ripening for scared uterus seems to be a useful option to improve vaginal delivery without increasing maternal and foetal morbidity. Anyway, these results have to be confirmed by a randomized controlled trial on a specific scared uterus population.

Selective Termination of Pregnancy (STOP) for discordant fetal condition in monochorionic twin pregnancy is a rarely performed procedure raising technical and ethical considerations. There are no epidemiological data available in France concerning STOP and no guideline or scientific consensus on how or when to perform has been published.We conducted a study of national practice using a declarative questionnaire sent by e-mail to each medical coordinator of every 48 Multidisciplinary Center for Prenatal Diagnosis in France. The questions focused on the issues of 2010 and 2011. Two reminders were sent in case of no answer.The response rate to the questionnaire was 56 %; 81 % of centers have experienced at least once during the two years 2010-2011 a discordant fetal anomaly in monochorionic twin pregnancy. Only 59 % of centers perform all the techniques of STOP. When interruption of the umbilical blood flow is considered, bipolar forceps coagulation is the most used (75 %). Achieving STOP during a cesarean section is a common practice (75 % of centers). Locoregional anesthesia is the preferred mode of anesthesia for STOP.STOP on monochorionic twin pregnancy is not practiced in all Multidisciplinary Center for Prenatal Diagnosis in France. The most widely practiced and most studied technique is bipolar forceps coagulation. The option of an expectant management should always be considered and its risks should be balanced with those of STOP. The practice of STOP during cesarean section is not unusual.

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

Identify the potential predictors of postpartum post-traumatic stress disorder (PTSD) in primiparous mothers.This longitudinal prospective study evaluated the prevalence of obstetric complications and psychiatric disorders (anxiety, depression, psychic dissociation, PTSD, personality) in the immediate postpartum and after 3-6 months.Among 456 hospitalized primiparous mothers, 314 were recruited and 212 followed-up prospectively. The prevalence of PTSD symptoms was high and stable through the postpartum (12.7% versus 13.6%). Significant risk factors were associated with postpartum PTSD: social isolation, celibacy or divorce (OR=6.6; P0.02), history of abortion (OR=6.2; P0.01) or of infertility (OR=10.4; P0.007), too long subjective length of labour (OR=3.5; P0.03), mothers' perceptions of obstetric complications (OR=18.5; P0.003), high anxiety level at the maternity hospital (OR=3.9; P0.03), PTSD symptoms after childbirth (OR=6.7; P0.01) and dependent personality disorder (OR=23.2; P0.001).Subjective experience of childbirth, history of obstetric complications, social isolation and dependent personality disorder and high level of stress-anxiety after childbirth are significant predictive factors of postpartum PTSD (3-6 months). The early identification of these factors should lead to early therapeutic intervention in the mothers at risk of PTSD.

Indications for fetal blood sampling (FBS) are getting more limited. In this context, we aimed to evaluate fetal loss and morbidity associated with FBS and to precise the predictive parameters for fetal complications. More than a retrospective evaluation of our practices, the final end point of our study was to better inform the patients coming to our centre.Retrospective monocentric cohort (Canadian Task Force classification II-2) of the 99 FBS performed between April 2004 and June 2010 on 80 fetuses, after excluding the procedures done for termination of pregnancy. The main clinical outcome was a composite outcome criteria for fetal tolerance including cesarean section for abnormal non stress test within the 24 hours, or any event responsible of a modified obstetrical management during the 14 day following FBS.Mean maternal age at FBS was 30 years ± 5.13 SD and parity was 2.49 ± 1.38 SD. FBS was performed by an experienced operator in 86.5% of cases (CI 95%, 78-92.6); with a single insertion in 83.3% of circumstances (CI 95%, 74.4-90.2). The mean duration was 11 min ± 6.37 SD. The total rate of intrauterine death, in our series, was 7.1% (CI 95%, 2.9-14), including all reported fetal demise within the 14 days after FBS, whatever the relation with the procedure. Our study demonstrated a 9.1% occurrence of post-FBS altered CTG fetal testing (CI 95%, 4.2-16.6), half of it with spontaneous resolution. The rate of severe complications (main clinical outcome) was 11.1% (CI 95%, 5.7-19) including one fetal death liable to FBS and 10 emergency caesarean sections: 5.1% for fetal bradycardia (CI 95%, 1.7-11.4), 2% for placental abruption (CI 95%, 0.2-7.1), 2% for premature preterm rupture of membranes (CI 95%, 0.2-7.1) and 1% for significative umbilical cord bleeding (CI 95%, 0-5.5). Univariate factor analysis highlights 4 parameters for impaired fetal tolerance; a prolonged procedure, presence of low fetal platelets (30.10(9)/L); and FBS performed for fetal anaemia during Parvovirus B19 infection or allo-immune thrombocytopenia.FBS remains a tricky procedure with a substantial risk of fetal loss or complications especially when performed on high-risk fœtuses. The length of the procedure should be shortened as much as possible (trained operator, postponed procedure when all favourable condition are not available). Fetal thrombocytopenia is a meaningful risk factor encouraging carefulness when exploring allo-immune fetal thrombocytopenia.

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

Intrahepatic cholestasis of pregnancy (ICP) is the most commonly encountered pregnancy-specific liver disease. This condition, with no proven maternal morbidity, has been associated with an increased risk of prematurity and intrauterine fetal death. There is, to date, no scientific obstetrical guideline for clinical practice in France. The objective of our study was to precise, in this situation, how French obstetricians manage patients suffering from ICP.We carried out, during 2010, a national descriptive practice survey of ICP management in France in association with the "Collège national des gynécologues-obstétriciens français". An inquiry form with 27 multiple-choice questions was sent to all obstetricians and gynecologist officiating in a maternity hospital recorded by the French Ministry of Health. The participants answered questions regarding diagnosis, perinatal management and treatment of ICP. Only the first answer received from each maternity hospital was analyzed.Of the 575 maternity hospitals, 275 (41.6%) responded after one mail recovery. Among them, almost half used a standardized management protocol for ICP. In most of the cases, perinatal management was performed by obstetricians alone (73%), and in only 20% of the cases in collaboration with the specialist in hepatology. Induction of labor at 37-38 weeks was the most common policy for the majority of respondents (92.4%).This is the first French national survey for ICP management. This study demonstrated that ICP is, in most of the cases, managed by the obstetrician alone, and that fetal risks warrants an active management with induction of labor in late pregnancy.

Fetal intrapericardial teratomas are uncommon and usually benign. Their histology is the same as that of teratomas located elsewhere. They may cause death from non-immune hydrops fetalis and cardiac tamponade. We report a case that was successfully managed prenatally by placement of a pericardial amniotic shunt.