Pierre Delorme

Placenta percreta is associated with more frequent severe maternal morbidity than placenta accreta

BACKGROUND: Abnormally invasive placentation is the leading cause of obstetric hysterectomy and can cause poor to disastrous maternal outcomes. Most previous studies of peripartum management and maternal morbidity have included variable proportions of severe and less severe cases. OBJECTIVE: The aim of this study was to compare maternal morbidity from placenta percreta and accreta. STUDY DESIGN: This retrospective study at a referral center in Paris includes all women with abnormally invasive placentation from 2003 through 2017. Placenta percreta and accreta were diagnosed histologically or clinically. When placenta percreta was suspected before birth, a conservative approach leaving the placenta in situ was proposed because of the intraoperative risk of cesarean delivery. When placenta accreta was suspected, parents were offered a choice of a conservative approach or an attempt to remove the placenta, to be followed in case of failure by hysterectomy. Maternal outcomes were compared between women with placenta percreta and those with placenta accreta/increta. The primary outcome measure was a composite criterion of severe acute maternal morbidity including at least 1 of the following: hysterectomy during cesarean delivery, delayed hysterectomy, transfusion of ≥10 U of packed red blood cells, septic shock, acute kidney injury, cardiovascular failure, maternal transfer to intensive care, or death. RESULTS: Of the 156 women included, 51 had placenta percreta and 105 placenta accreta. Abnormally invasive placentation was suspected antenatally nearly 4 times more frequently in the percreta than the accreta group (96.1% [49/51] vs 25.7% [27/105], P < .01). Among the 76 women with antenatally suspected abnormally invasive placentation (48.7%), the rate of antenatal decisions for conservative management was higher in the percreta than the accreta group (100% [49/49] vs 40.7% [11/27], P < .01). The composite maternal morbidity rate was significantly higher in the percreta than the accreta group (86.3% [44/51] vs 28/105 [26.7%], P < .001). A secondary analysis restricted to women with an abnormally invasive placentation diameter >6 cm showed similar results (86.0% [43/50) vs 48.7% [19/38), P < .01). The rate of hysterectomy during cesareans was significantly higher in the percreta than the accreta group (52.9% [27/51] vs 20.9% [22/105], P < .01) as was the total hysterectomy rate (43/51 [84.3%] vs 23.8% [25/105], P < .01). CONCLUSION: Severe maternal morbidity is much more frequent in women with placenta percreta than with placenta accreta, despite multidisciplinary planning, management in a referral center, and better antenatal suspicion.

Intraoperative adverse events associated with extremely preterm cesarean deliveries

At the same time as survival is increasing among premature babies born before 26 weeks of gestation, the rates of cesarean deliveries before 26 weeks is also rising. Our purpose was to compare the frequency of intraoperative adverse events during cesarean deliveries in two gestational age groups: 24–25 weeks and 26–27 weeks.

Planned delivery route of preterm breech singletons, and neonatal and 2‐year outcomes: a population‐based cohort study

To assess whether planned route of delivery is associated with perinatal and 2‐year outcomes for preterm breech singletons.

Preterm premature rupture of membranes at 22–25 weeks’ gestation: perinatal and 2-year outcomes within a national population-based study (EPIPAGE-2)

BACKGROUND: Most clinical guidelines state that with early preterm premature rupture of membranes, obstetric and pediatric teams must share a realistic and individualized appraisal of neonatal outcomes with parents and consider their wishes for all decisions. However, we currently lack reliable and relevant data, according to gestational age at rupture of membranes, to adequately counsel parents during pregnancy and to reflect on our policies of care at these extreme gestational ages. OBJECTIVE: We sought to describe both perinatal and 2‐year outcomes of preterm infants born after preterm premature rupture of membranes at 22–25 weeks’ gestation. STUDY DESIGN: EPIPAGE‐2 is a French national prospective population‐based cohort of preterm infants born in 546 maternity units in 2011. Inclusion criteria in this analysis were women diagnosed with preterm premature rupture of membranes at 22–25 weeks’ gestation and singleton or twin gestations with fetus(es) alive at rupture of membranes. Latency duration, antenatal management, and outcomes (survival at discharge, survival at discharge without severe morbidity, and survival at 2 years’ corrected age without cerebral palsy) were described and compared by gestational age at preterm premature rupture of membranes. RESULTS: Among the 1435 women with a diagnosis of preterm premature rupture of membranes, 379 were at 22–25 weeks’ gestation, with 427 fetuses (331 singletons and 96 twins). Median gestational age at preterm premature rupture of membranes and at birth were 24 (interquartile range 23–25) and 25 (24–27) weeks, respectively. For each gestational age at preterm premature rupture of membranes, nearly half of the fetuses were born within the week after the rupture of membranes. Among the 427 fetuses, 51.7% were survivors at discharge (14.1%, 39.5%, 66.8%, and 75.8% with preterm premature rupture of membranes at 22, 23, 24, and 25 weeks, respectively), 38.8% were survivors at discharge without severe morbidity, and 46.4% were survivors at 2 years without cerebral palsy, with wide variations by gestational age at preterm premature rupture of membranes. Survival at 2 years without cerebral palsy was low with preterm premature rupture of membranes at 22 and 23 weeks but reached approximately 60% and 70% with preterm premature rupture of membranes at 24 and 25 weeks. CONCLUSION: Preterm premature rupture of membranes at 22–25 weeks is associated with high incidence of mortality and morbidity, with wide variations by gestational age at preterm premature rupture of membranes. However, a nonnegligible proportion of children survive without severe morbidity both at discharge and at 2 years’ corrected age.

Prescription hors AMM des inhibiteurs calciques à visée tocolytique. Groupe de travail du CNGOF (texte court)

a Service de gynécologie-obstétrique, hôpital Mère-Enfant, CHU de Nantes, 44000 Nantes, France b Pharmacologie clinique, hôpital Bretonneau, CHRU de Tours, 37000 Tours, France c Maternité Jeanne-de-Flandre, clinique d’obstétrique, CHRU de Lille, 59000 Lille, France d Maternité Port-Royal, université René-Descartes, AP—HP, Paris 5, 75014 Paris, France e Service de gynécologie-obstétrique, hôpital Paule-de-Viguier, CHU de Toulouse, 31000 Toulouse, France f Service de gynécologie-obstétrique, université Pierre-et-Marie-Curie, hôpital Trousseau, AP—HP, Paris 6, 75012 Paris, France g Service de gynécologie-obstétrique et médecine fœtale, hôpital Bretonneau, CHRU de Tours, 37000 Tours, France