Loïc Sentilhes

Delivery for women with a previous cesarean: guidelines for clinical practice from the French College of Gynecologists and Obstetricians (CNGOF).

The primary cause of uterine scars is a previous cesarean. In women with a previous cesarean, the risks of maternal complications are rare and similar after a trial of labor after cesarean (TOLAC) and after an elective repeat cesarean delivery (ERCD), but the risk of uterine rupture is higher with TOLAC (level of evidence [LE]2). Maternal morbidity in women with previous cesareans is higher when TOLAC fails than when it leads to successful vaginal delivery (LE2). Although maternal morbidity increases progressively with the number of ERCD, maternal morbidity of TOLAC decreases with the number of successful previous TOLAC (LE2). The risk-benefit ratio considering the risks of short- and long-term maternal complications is favorable to TOLAC in most cases (LE3). Globally, neonatal complications are rare regardless of the mode of delivery for women with previous cesareans. The risks of fetal, perinatal, and neonatal mortality during TOLAC are low. Nonetheless, these risks are significantly higher than those associated with ERCD (LE2). The risks of mask ventilation, intubation for meconium-stained amniotic fluid, and neonatal sepsis all increase in TOLAC (LE2). The risk of transient respiratory distress increases in ERCD (LE2). To reduce this risk, and except in particular situations, ERCD must not be performed before 39 weeks (grade B). TOLAC is possible for women with a previous cesarean before 37 weeks, with 2 previous cesareans, with a uterine malformation, a low vertical incision or an unknown incision, with a myomectomy, postpartum fever, an interval of less than 6 months between the last cesarean delivery and the conception of the following pregnancy, if the obstetric conditions are favorable (professional consensus). ERCD is recommended in women with a scar in the uterine body (grade B) and a history of 3 or more cesareans (professional consensus). Ultrasound assessment of the risk of uterine rupture in women with uterine scars has not been shown to have any clinical utility and is therefore not recommended during pregnancy to help decide the mode of delivery (professional consensus). Use of X-ray pelvimetry to decide about TOLAC is associated with an increase in the repeat cesarean rate without any reduction in the rate of uterine rupture (LE2). It is unnecessary for deciding mode of delivery and for managing labor during TOLAC (grade C). TOLAC should be encouraged for women with a previous vaginal delivery either before or after the cesarean, a favorable Bishop score or spontaneous labor, and for preterm births (grade C). For women with a fetus with an estimated weight of more than 4500 g, especially in the absence of a previous vaginal delivery and those with supermorbid obesity (BMI>50), ERCD must be planned from the outset (grade C). For all of the other clinical situations envisioned (maternal age>35 years, diabetes, morbid obesity, prolonged pregnancy, breech presentation and twin pregnancy), TOLAC is possible but the available data do not allow specific guidelines about the choice of mode of delivery, in view of the low levels of proof (grade C). The decision about planned mode of delivery must be shared by the patient and her physician and made by the 8th month, taking into account the individual risk factors for TOLAC failure and uterine rupture (professional consensus). TOLAC is the preferred choice for women who do not have several risk factors (professional consensus). The availability onsite of an obstetrician and anesthetist must be pointed out to the patient. If the woman continues to prefer a repeat cesarean after adequate information and time to think about it, her preference should be honored (professional consensus). Labor should be induced in woman with a previous cesarean only for medical indications (professional consensus). Induction of labor increases the risk of uterine rupture, which can be estimated at 1% if oxytocin is used and 2% with vaginal prostaglandins (LE2). Mechanical methods of induction have not been studied sufficiently. Misoprostol appears to increase the risk of uterine rupture strongly (LE4). Based on the information now available, its use is not recommended (professional consensus). Routine use of internal tocodynamometry does not prevent uterine rupture (professional consensus). The increased risk of uterine rupture associated with oxytocin use is dose-dependent (LE3). In the active phase, it is recommended that the total duration of failure to progress should not exceed 3h; at that point, a cesarean should be performed (professional consensus). Epidural analgesia must be encouraged. The simple existence of a uterine scar is not an indication for a routine manual uterine examination after VBAC (grade C).

Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR)

Objective To assess the impact of controlled cord traction on the incidence of postpartum haemorrhage and other characteristics of the third stage of labour in a high resource setting. Design Randomised controlled trial. Setting Five university hospital maternity units in France. Participants Women aged 18 or more with a singleton fetus at 35 or more weeks’ gestation and planned vaginal delivery. Interventions Women were randomly assigned to management of the third stage of labour by controlled cord traction or standard placenta expulsion (awaiting spontaneous placental separation before facilitating expulsion). Women in both arms received prophylactic oxytocin just after birth. Main outcome measure Incidence of postpartum haemorrhage ≥500 mL as measured in a collector bag. Results The incidence of postpartum haemorrhage did not differ between the controlled cord traction arm (9.8%, 196/2005) and standard placenta expulsion arm (10.3%, 206/2008): relative risk 0.95 (95% confidence interval 0.79 to 1.15). The need for manual removal of the placenta was significantly less frequent in the controlled cord traction arm (4.2%, 85/2033) compared with the standard placenta expulsion arm (6.1%, 123/2024): relative risk 0.69, 0.53 to 0.90); as was third stage of labour of more than 15 minutes (4.5%, 91/2030 and 14.3%, 289/2020, respectively): relative risk 0.31, 0.25 to 0.39. Women in the controlled cord traction arm reported a significantly lower intensity of pain and discomfort during the third stage than those in the standard placenta expulsion arm. No uterine inversion occurred in either arm. Conclusions In a high resource setting, the use of controlled cord traction for the management of placenta expulsion had no significant effect on the incidence of postpartum haemorrhage and other markers of postpartum blood loss. Evidence to recommend routine controlled cord traction for the management of placenta expulsion to prevent postpartum haemorrhage is therefore lacking. Trial registration ClinicalTrials.gov NCT01044082.

Postpartum hemorrhage: guidelines for clinical practice from the French ă College of Gynaecologists and Obstetricians (CNGOF) in collaboration ă with the French Society of Anesthesiology and Intensive Care (SFAR)

Postpartum haemorrhage (PPH) is defined as blood loss ≥500mL after delivery and severe PPH as blood loss ≥1000mL, regardless of the route of delivery (professional consensus). The preventive administration of uterotonic agents just after delivery is effective in reducing the incidence of PPH and its systematic use is recommended, regardless of the route of delivery (Grade A). Oxytocin is the first-line prophylactic drug, regardless of the route of delivery (Grade A); a slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM (professional consensus). After vaginal delivery, routine cord drainage (Grade B), controlled cord traction (Grade A), uterine massage (Grade A), and routine bladder voiding (professional consensus) are not systematically recommended for PPH prevention. After caesarean delivery, placental delivery by controlled cord traction is recommended (grade B). The routine use of a collector bag to assess postpartum blood loss at vaginal delivery is not systematically recommended (Grade B), since the incidence of severe PPH is not affected by this intervention. In cases of overt PPH after vaginal delivery, placement of a blood collection bag is recommended (professional consensus). The initial treatment of PPH consists in a manual uterine examination, together with antibiotic prophylaxis, careful visual assessment of the lower genital tract, a uterine massage, and the administration of 5-10 IU oxytocin injected slowly IV or IM, followed by a maintenance infusion not to exceed a cumulative dose of 40IU (professional consensus). If oxytocin fails to control the bleeding, the administration of sulprostone is recommended within 30minutes of the PPH diagnosis (Grade C). Intrauterine balloon tamponade can be performed if sulprostone fails and before recourse to either surgery or interventional radiology (professional consensus). Fluid resuscitation is recommended for PPH persistent after first line uterotonics, or if clinical signs of severity (Grade B). The objective of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8g/dL. During active haemorrhaging, it is desirable to maintain a fibrinogen level ≥2g/L (professional consensus). RBC, fibrinogen and fresh frozen plasma (FFP) may be administered without awaiting laboratory results (professional consensus). Tranexamic acid may be used at a dose of 1 g, renewable once if ineffective the first time in the treatment of PPH when bleeding persists after sulprostone administration (professional consensus), even though its clinical value has not yet been demonstrated in obstetric settings. It is recommended to prevent and treat hypothermia in women with PPH by warming infusion solutions and blood products and by active skin warming (Grade C). Oxygen administration is recommended in women with severe PPH (professional consensus). If PPH is not controlled by pharmacological treatments and possibly intra-uterine balloon, invasive treatments by arterial embolization or surgery are recommended (Grade C). No technique for conservative surgery is favoured over any other (professional consensus). Hospital-to-hospital transfer of a woman with a PPH for embolization is possible once hemoperitoneum is ruled out and if the patients hemodynamic condition so allows (professional consensus).

PACCRETA: Clinical situations at high risk of Placenta ACCRETA/Percreta: impact of diagnostic methods and management on maternal morbidity

No population‐based study has assessed the prevalence of placenta accreta, the predictive value of prenatal diagnostic examinations, the maternal morbidity associated with its management, or its psychological effects. Moreover, the technical resources necessary for the safest delivery of women at risk have not been clearly identified.

Maternal and Neonatal Morbidity After Attempted Operative Vaginal Delivery According to Fetal Head Station.

OBJECTIVE: To compare severe short-term maternal and neonatal morbidity associated with midpelvic and low pelvic attempted operative vaginal delivery. METHODS: Prospective study of 2,138 women with live singleton term fetuses in vertex presentation who underwent an attempted operative vaginal delivery in a tertiary care university hospital. We used multivariate logistic regression and propensity score methods to compare outcomes associated with midpelvic and low pelvic delivery. Severe maternal morbidity was defined as third- or fourth-degree perineal laceration, perineal hematoma, cervical laceration, extended uterine incision for cesarean delivery, postpartum hemorrhage greater than 1,500 mL, surgical hemostatic procedures, uterine artery embolization, blood transfusion, infection, thromboembolic events, admission to the intensive care unit, and maternal death; severe neonatal morbidity was defined as 5-minute Apgar score less than 7, umbilical artery pH less than 7.00, need for resuscitation or intubation, neonatal trauma, intraventricular hemorrhage greater than grade 2, neonatal intensive care unit admission for more than 24 hours, convulsions, sepsis, and neonatal death. RESULTS: From December 2008 through October 2013 there were 2,138 attempted operative vaginal deliveries; 18.3% (n=391) were midpelvic, 72.5% (n=1,550) low, and 9.2% (n=197) outlet. Severe maternal morbidity occurred in 10.2% (n=40) of midpelvic, 7.8% (n=121) of low, and 6.6% (n=13) of outlet attempts (P=.21); and severe neonatal morbidity in 15.1% (n=59), 10.2% (n=158), and 10.7% (n=21) (P=.02), respectively. Multivariable logistic regression analysis found no significant difference between midpelvic and low attempted operative vaginal delivery for either composite severe maternal (adjusted odds ratio [OR] 1.01, 95% confidence interval [CI] 0.66–1.55) or neonatal morbidity (adjusted OR 1.25, 95% CI 0.84–1.86). Similarly, propensity score matching found no significant difference between midpelvic and low operative vaginal delivery for either severe maternal (adjusted OR 0.69, 95% CI 0.39–1.22) or neonatal morbidity (adjusted OR 0.88, 95% CI 0.53–1.45). CONCLUSION: In singleton term pregnancies, midpelvic attempted operative vaginal delivery compared with low pelvic attempted operative vaginal delivery was not associated with an increase in severe short-term maternal or neonatal morbidity. LEVEL OF EVIDENCE: II

Impact of postpartum information about pertussis booster to parents in a university maternity hospital.

Parent-to-infant transmission of pertussis remains an issue in France. Although adult booster vaccination was introduced in 2004 as part of a cocooning strategy targeted primarily to parents of young infants, vaccination coverage in this population has remained low. The aim of this study was to evaluate the impact on vaccination coverage, over two consecutive years, of a protocol in which information about the pertussis booster and a prescription for pertussis vaccine were given to parents upon discharge from a French university maternity hospital. A questionnaire was administered to mothers two months after delivery, during two 3-month periods in 2008 and 2009. Participation rates were 67% (first period) and 76.3% (second period). Information about pertussis was delivered mainly by paediatricians and midwives and was considered clear and pertinent in more than 95% of cases. In 2009, 69% of mothers and 63% of fathers who received a prescription for pertussis vaccine before discharge from the maternity declared being vaccinated, with no difference as compared to 2008. Vaccination was done by a general practitioner (95.9%) and mostly in the first month after birth (81%). Postpartum information about pertussis was successfully implemented and well understood by parents in the maternity hospital and should contribute towards increasing pertussis vaccination coverage in parents of young children.

Second-trimester maternal serum markers and placenta accreta

Biochimie-Hormonologie, Hôpital Robert Debré, AP-HP, Paris, France Gynécologie-Obstétrique, Hôpital Necker-Enfants Malades, AP-HP, Paris, France Biochimie, Université Paris Ile de France Ouest, Versailles, Saint-Quentin, France Gynécologie-Obstétrique, Maternité Port-Royal, Hôpital Cochin, AP-HP, Paris, France French Collaborative Conservative Treatment of Placenta Accreta Study Group Gynécologie-Obstétrique, Hôpital Robert Debré, AP-HP, Paris, France ABA Study Group Gynécologie-Obstétrique, CHU Angers, Angers, France *Correspondence to: Françoise Muller. E-mail: francoise.muller@rdb.aphp.fr

Influence of Gestational Age on Fibrinolysis from Birth to Postnatal Day 10

OBJECTIVE To compare components of the fibrinolytic cascade in newborns of gestational age ranging from extreme prematurity to full term, at birth and for the next 10 days, and in their mothers at delivery. STUDY DESIGN We studied 10 extremely preterm neonates, 10 very preterm neonates, 10 moderately preterm neonates, 10 full-term neonates, and their mothers (n = 40). We measured the antigen levels of tissue-type plasminogen activator (t-PA), plasminogen activator inhibitors 1 (PAI-1) and 2 (PAI-2), and thrombin-activatable fibrinolysis inhibitor, as well as PAI-1 activity, in neonates at birth and on postnatal days 3 and 10 and in mothers at delivery. RESULTS On day 10, both PAI-1 antigen and activity were higher in extremely preterm neonates than in full-term neonates (P = .004 and <.0006, respectively), and the t-PA/PAI-1 activity ratio was lower in the extremely preterm and very preterm neonates compared with the full-term neonates (P = .002 and .017, respectively). No significant differences in the fibrinolytic system components were seen among the 4 groups of mothers. CONCLUSIONS The development of fibrinolysis suppression in extremely preterm infants within 10 days after birth may contribute to the increased risk of periventricular hemorrhagic infarction in these infants.

Implementation of an antenatal magnesium sulfate protocol for fetal neuroprotection in preterm infants

The aim of our study was to assess the feasibility of implementing a protocol for the use of magnesium sulfate to prevent cerebral palsy. This retrospective single-center study included all women with fetuses of gestational age <33 weeks of gestation whose birth was planned or expected within 24 hours from September 2011 to December 2012. They were to receive magnesium sulfate, administered intravenously as a 4-g bolus followed by a constant infusion of 1 g per hour. If delivery had not occurred after 12 hours and was no longer considered imminent, the infusion was to be discontinued. The study included 119 women, 81 (68.1%) of whom received magnesium sulfate. Among the latter, 71 (87.5%) gave birth within 24 hours. The reasons treatment was not given were: omission by medical team (19/38, 50%), urgent delivery (18/38, 47.4%), and contraindication to treatment (1/38, 2.6%). The mean gestational age at protocol implementation was 29.6 +/− 2.1 weeks. Maternal monitoring, especially at the onset of infusion, appeared suboptimal. No major maternal side effects were observed. Our study shows that implementing a protocol for prevention of cerebral palsy by magnesium sulfate is feasible in a tertiary obstetric center.

Relationship between ovarian cysts and infertility: what surgery and when?

The relationship between ovarian cysts and infertility is a subject of debate, mainly because it is difficult to determine the real impact of the cyst and its treatment on later fertility. For a long time it was hoped that surgical treatment could prevent potential complications (such as rupture or malignancy). For presumed benign ovarian tumors, fertility sparing should be the main concern. The goal of this survey of current knowledge on the subject is to thoroughly explore the potential relationship between cysts, their treatment, and infertility. Our study is based on a review of the literature dealing with the epidemiology of ovarian cysts and the effects of their surgical management in relation to infertility. Analysis of the epidemiologic data, drawn mainly from comparative studies and cohorts, shows that the role of cysts in infertility is controversial and that the effects of surgical treatment are often more harmful than the cyst itself to the ovarian reserve. Surgery does not seem to improve pregnancy rates. When a surgical option is nonetheless chosen, a conservative laparoscopic approach is more suitable. Besides excision, sclerotherapy and plasma vaporization are promising, offering a greater preservation of the ovarian parenchyma, especially in endometriomas. These techniques must be better defined. The context of the infertility is essential, and surgeons and specialists in reproductive medicine should decide management jointly.