Adrien Gaudineau

Âge à la ménarche : résultats français de l’étude Health Behaviour in School-aged Children

OBJECTIVE To describe age at onset of menarche in a large nationally representative sample of French schoolgirls. PATIENTS AND METHODS Age at onset of menarche was assessed in the Health Behaviour in School-aged Children French cross-sectional survey. Data were collected in 2006 by anonymous self-reported standardized questionnaire. Median age at onset of menarche was estimated using Kaplan-Meiers method from a nationally representative sample of 2323 13 and 15 years old girls in school classrooms. Mean and standard deviation was also reported in the 1059 15 years old girls who had already experienced menarche. RESULTS Median age at onset of menarche was 12.8 years (interquartile range: 12.0-13.6), as was mean age at onset of menarche (standard deviation 1.2 years). DISCUSSION AND CONCLUSION Age at onset of menarche and its variability (as measured by standard deviation) have decreased in most developed countries and seems stabilised at 13.0+/-0.5 years: our results are in line with this trend. The age limit of 9 years seems more coherent to define early menarche in French girls. These results may have an important impact on medical management of early pubertal development.

Contre la notion de grossesse et d'accouchement à bas risque ?

Être « pour ou contre » la notion de grossesse et d’accouchement à bas risque ne peut se discuter sans en préciser le contexte. On peut ainsi concevoir la notion de grossesse à bas risque lorsque l’on envisage qu’un suivi de grossesse soit assuré par des sages-femmes ou des médecins généralistes. C’est dans cet esprit que la Haute Autorité de santé (HAS) a en 2007 réuni un groupe de travail chargé d’élaborer des recommandations professionnelles pour le suivi et l’orientation des femmes enceintes en fonction des situations à risque identifiées [1]. Les objectifs étaient d’aider au suivi de la grossesse normale et d’améliorer l’identification des situations à risque de complications maternelles, obstétricales et fœtales (hors accouchement) pouvant potentiellement compliquer la grossesse afin d’en adapter si besoin le suivi. De longues discussions avaient été tenues au sein du groupe de travail quant au meilleur terme à utiliser : grossesse normale, physiologique ou à bas risque. Ce dernier mettait en avant « la probabilité de survenue d’un événement défavorable et de ce fait présentait un aspect inquiétant, plus difficile à percevoir pour les femmes, et suggérait la nécessité d’une vigilance accrue ». Ce niveau de risque peut évoluer au

A comparison of vaginal ultrasound and digital examination in predicting preterm delivery in women with threatened preterm labor: a cohort study

The aim of this study is to evaluate the utility of digital examination in addition to ultrasonic measurement of cervical length for predicting spontaneous preterm delivery in women with threatened preterm labor.

Benefits of cord blood collection in the prevention of post-partum hemorrhage: a cohort study

Abstract Objective: The aim of this study was to assess the benefit of umbilical cord drainage through cord blood collection (CBC) for the prevention of post-partum hemorrhage (PPH). Methods: This is a retrospective cohort study based on data collected prospectively including all vaginal delivery of singletons pregnancies after 37 weeks of gestation between July 2011 and May 2013 at the Strasbourg Teaching Hospital. We performed a univariate comparison of PPH risk factors with χ2 tests and then we built multivariate logistic regressions to predict PPH, severe PPH (>1000 cc), retained placenta over 30 min and manual removal of the placenta. Results: A total of 7810 vaginal deliveries were analyzed, among which 1957 benefited from CBC (25%). In the CBC group, 71 PPH (3.6%) were observed versus 260 (4.4%) in the control group (p = 0.12). In multivariate analysis, after adjustment on PPH risk factors, CBC revealed to be a protective factor of PPH: OR = 0.69 (95% CI 0.50–0.97; p = 0.03). CBC is neither a significant predictive factor of severe PPH, time to placental delivery nor rate of manual removal of the placenta. Conclusions: In our study, CBC and thus umbilical cord drainage was a protective factor against PPH but it did reduce neither retained placenta nor the need for artificial placental delivery.

Pilot randomised controlled trial comparing the risk of neonatal respiratory distress in elective caesarean section at 38 weeks’ gestation following a course of corticosteroids versus caesarean at 39 weeks

INTRODUCTION The objective of this study was to compare neonatal respiratory morbidity and rate of emergency caesarean section between elective caesarean sections at 38 gestational weeks following a course of corticosteroids and planned caesarean sections at 39 gestational weeks. MATERIAL AND METHODS This was a multicentre randomised controlled trial. The study was conducted between 2007 and 2013 in level 2 and 3 maternity units in France. A total of 208 women with an indication for elective caesarean section were enrolled and 200 analysed in per-protocol analysis. Women were randomised to either elective caesarean section at 38 gestational weeks after a course of corticosteroids (trial group) or elective caesarean section at 39 weeks (control group). The primary outcome was the rate of admission to the neonatal intensive care unit for respiratory distress. RESULTS Two (2.1%) newborn in the tested group were admitted because of respiratory distress versus four (3.8%) in the control group. The relative risk was 0.54 in favour of the corticosteroid group (95% CI: 0.10; 2.86). There were fewer emergency caesareans in the trial group than in the control group: 12 (12.69%) versus 28 (26.67%), p=0.01. CONCLUSIONS Our study suggests that planning caesarean sections at 38 gestational weeks after a course of corticosteroids would enable a significant reduction in the number of emergency caesareans without increasing the risk of neonatal respiratory distress. Limitations of this study include difficulties in patient recruitment and the small number of subjects.

L’interruption volontaire de grossesse : recommandations pour la pratique clinique – Méthodologie

This work is based on a current review of the literature (Pubmed, Medline, Cochrane library, Cochrane database of systematic reviews, EMBASE, RCOG, ACOG) including meta-analysis, randomised trials, cohorts, reviews, controlled studies published up to 2016 in French or English.

Acupuncture version of breech presentation: a randomized sham-controlled single-blinded trial.

BACKGROUND Several studies have investigated the efficacy of moxibustion with or without acupuncture for fetal version, but the results are discordant. Meta-analyses pointed out the need for robust, methodologically sound, randomized controlled trials. OBJECTIVE The objective of this study was to assess the effectiveness of acupuncture with fire needling on acupoint BL67 for version of breech presentation. STUDY DESIGN This was a randomized, sham-controlled, single-blinded trial, which took place in Strasbourg teaching maternity hospital, France. A total of 259 patients between 32 and 34 weeks of gestation have been randomized and analyzed. Patients were randomized to either acupuncture with fire needling or sham group, and were analyzed in their initial allocation group. Statistical analysis was conducted using Bayesian methods, in univariate analysis and in multivariate analysis after adjustment on parity. RESULTS The primary outcome was the rate of cephalic presentations at ultrasound examination performed between 35 and 36 weeks of gestation. A total of 49 (37.7%) fetuses were in cephalic presentation in the acupuncture group, versus 37 (28.7%) in the sham group: RR 1.34 [0.93-1.89], Pr RR>1=94.3%. After adjustment on parity, the acupuncture did not increase the rate of fetal cephalic version: OR 1.47 [0.84-2.42], Pr OR>1=90.3%. CONCLUSIONS Our study suggests that acupuncture with fire needling on acupoint BL67 does not promote fetal cephalic version. Further studies might investigate effectiveness of other protocols of acupuncture. Randomization should be stratified for nulliparous and parous patients.

Intérêt des Z-scores dans le choix d’une courbe de référence de biométrie fœtale ☆

Les calculs de Z-scores sont de plus en plus utilisés en médecine. Le Z-score est l’écart entre une valeur individuelle et la médiane d’une population de référence, divisée par l’écart type de la population de référence. Dans notre cas, il s’exprime ainsi : Z-score (âge gestationnel) = (Biométrie mesuréebiométrie moyenne attendue) / Déviation standard. En pratique, la distribution des Z-scores devrait suivre une distribution normale centrée réduite (distribution normale gaussienne de moyenne 0 et de déviation standard 1) si les mesures faites dans notre population étaient en parfaite concordance avec ceux de la référence utilisée.

Elective abortion: Clinical practice guidelines from the French College of Gynecologists and Obstetricians (CNGOF)

The number of elective abortions has been stable for several decades. Many factors explain womens choice of abortion in cases of unplanned pregnancies. Early initiation of contraceptive use and a choice of contraceptive choices appropriate to the womans life are associated with lower rates of unplanned pregnancies. Reversible long-acting contraceptives should be favored as first-line methods for adolescents because of their effectiveness (grade C). Ultrasound scan before an elective abortion must be encouraged but should not be obligatory (professional consensus). As soon as the embryo appears on the ultrasound scan, the date of pregnancy is estimated by measuring the crown-rump length (CRL) or, from 11 weeks on, by measuring the biparietal diameter (BPD) (grade A). Because reliability of these parameters is ±5 days, the abortion may be done if measurements are respectively less than 90 mm for CRL and less than 30 mm for BPD (professional consensus). A medically induced abortion, performed with a dose of 200 mg mifepristone combined with misoprostol, is effective at any gestational age (Level of Evidence (LE) 1). Before 7 weeks, mifepristone should be followed 24-48 h later by misoprostol, administered orally, buccally, sublingually, or even vaginally followed if needed by a further dose of 400 μg after 3 h, to be renewed if needed after 3 h (LE 1, grade A). After 7 weeks, administration of misoprostol by the vaginal, sublingual, or buccal routes is more effective and better tolerated than by the oral route (LE 1). Cervical preparation is recommended for systematic use in surgical abortions (professional consensus). Misoprostol is a first-line agent for cervical preparation at a dose of 400 μg (grade A). Vacuum aspiration is preferable to curettage (grade B). A uterus perforated during surgical aspiration should not routinely be considered to be scarred (professional consensus). An elective abortion is not associated with a higher risk of subsequent infertility or ectopic pregnancy (LE 2). The medical consultation before an elective abortion generally does not affect the decision to end or continue the pregnancy, and most women are sufficiently certain about their choice at this time. Women appear to find the method used most acceptable and to be most satisfied when they were able to choose the method (grade B). Elective abortions are not associated with an increased rate of psychiatric disorders (LE 2). However, women with psychiatric histories are at a higher risk of psychological disorders after the occurrence of an unplanned pregnancy than women with such a history (LE 2). For surgical abortions, combined hormonal contraceptives - oral or transdermal - should be started on the day of the abortion, while the vaginal ring should be inserted 5 days afterwards (grade B). For medical abortions, the vaginal ring should be inserted in the week after mifepristone administration, while the combined contraceptives should begin the same day as the misoprostol or the day after (grade C). Contraceptive implants should be inserted on the same day as a surgical abortion, and may be inserted the day the mifepristone is administered for medical abortions (grade B and C respectively). In case of medical abortion, the implant can be inserted the same day the mifepristone is administered (grade C). Both the copper IUDs and levonorgestrel intrauterine system should be inserted on the day of the surgical abortion (grade A). After medical abortions, an IUD can be inserted in 10 days after mifepristone administration, after ultrasound scan verification of the absence of an intrauterine pregnancy (grade C).

Usefulness of diffusion-weighted imaging for diagnosis of adrenal ischemia during pregnancy: a preliminary report

This case report aims to illustrate the clinical usefulness of diffusion-weighted imaging for diagnosis of bilateral adrenal ischemia during pregnancy. We also provide a retrospective analysis of adrenal gland diffusion data in a control group of 12 pregnant women with no adrenal dysfunction, to assess the normal range of apparent diffusion coefficient of adrenal gland during pregnancy.