X. Carcopino

Pregnancy loss: French clinical practice guidelines

In intrauterine pregnancies of uncertain viability with a gestational sac without a yolk sac (with a mean of three orthogonal transvaginal ultrasound measurements <25mm), the suspected pregnancy loss should only be confirmed after a follow-up scan at least 14 days later shows no embryo with cardiac activity (Grade C). In intrauterine pregnancies of uncertain viability with an embryo <7mm on transvaginal ultrasound, the suspected pregnancy loss should only be confirmed after a follow-up scan at least 7 days later (Grade C). In pregnancies of unknown location after transvaginal ultrasound (i.e. not visible in the uterus), a threshold of at least 3510IU/l for the serum human chorionic gonadotrophin assay is recommended; above that level, a viable intrauterine pregnancy can be ruled out (Grade C). Postponing conception after an early miscarriage in women who want a new pregnancy is not recommended (Grade A). A work-up for women with recurrent pregnancy loss should include the following: diabetes (Grade A), antiphospholipid syndrome (Grade A), hypothyroidism with anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies (Grade A), vitamin deficiencies (B9, B12) (Grade C), hyperhomocysteinaemia (Grade C), hyperprolactinaemia (Grade B), diminished ovarian reserve (Grade C), and a uterine malformation or an acquired uterine abnormality amenable to surgical treatment (Grade C). The treatment options recommended for women with a missed early miscarriage are vacuum aspiration (Grade A) or misoprostol (Grade B); and the treatment options recommended for women with an incomplete early miscarriage are vacuum aspiration (Grade A) or expectant management (Grade A). In the absence of both chorioamnionitis and rupture of the membranes, women with a threatened late miscarriage and an open cervix, with or without protrusion of the amniotic sac into the vagina, should receive McDonald cerclage, tocolysis with indomethacin, and antibiotics (Grade C). Among women with a threatened late miscarriage and an isolated undilated shortened cervix (<25mm on ultrasound), cerclage is only indicated for those with a history of either late miscarriage or preterm delivery (Grade A). Among women with a threatened late miscarriage, an isolated undilated shortened cervix (<25mm on ultrasound) and no uterine contractions, daily treatment with vaginal progesterone up to 34 weeks of gestation is recommended (Grade A). Hysteroscopic section of the septum is recommended for women with a uterine septum and a history of late miscarriage (Grade C). Correction of acquired abnormalities of the uterine cavity (e.g. polyps, myomas, synechiae) is recommended after three early or late miscarriages (Grade C). Prophylactic cerclage is recommended for women with a history of three late miscarriages or preterm deliveries (Grade B). Low-dose aspirin and low-molecular-weight heparin at a preventive dose are recommended for women with obstetric antiphospholipid syndrome (Grade A). Glycaemic levels should be controlled before conception in women with diabetes (Grade A).

Prise en charge d’un antécédent de fausse couche tardive (14 à 22 SA)

OBJECTIVEnTo provide guidelines concerning management after a late fetal pregnancy loss: etiological assessment, follow-up and therapeutic management for subsequent pregnancy.nnnMETHODSnFrench and English publications led to guidelines.nnnRESULTSnIn case of a previous late fetal loss, exploration of cavity has to be done (grade C), except hysterosalpingography, which is not recommended (grade A). If uterine anomalies are found, it is recommended to correct them (grade C). In case of stillbirth or unknown foetal vitality before expulsion, antiphospholipid syndrome has to be looked for (grade A). In pregnant women, measurement of cervical length has to be done between 15 and 24weeks of gestation (grade B); in case of singleton pregnancy and short cervix (less than 25mm), a Mc Donald cerclage has to be done (grade A). A cerclage is also recommended in case of three previous fetal loss (grade B). In case of failure of a previous Mc Donald cerclage, a cervico-isthmic cerclage is recommended (grade C).nnnCONCLUSIONnIn case of a previous fetal loss, uterine cavity has to be explored. In subsequent pregnancy, cervical length has to be evaluated between 15 and 24SA to indicate a cervical cerclage.

Travail originalÉvaluation des modalités de réalisation des conisations pour le traitement des CIN : enquête auprès des blocs opératoires de la région PACAEvaluation of practices of excisional therapies for CIN: An audit of surgery rooms from Marseilles’ area

OBJECTIVEnTo evaluate what is the proportion of surgery rooms from Marseilles area that do perform excisional therapies for CIN without any use of colposcopic guidance.nnnMATERIALS AND METHODSnFrom November 2012 to January 2013, a survey was conducted among all surgery rooms from Marseilles area practicing excisional therapies for CIN. In addition, answers from gynecologists from Marseilles area who participated to a national survey that evaluated practices of excisional therapies in France were specifically analyzed.nnnRESULTSnAmong the 55 surgery rooms from Marseilles area practicing excisional therapies, 52 (94.1%) participated to the current survey. A colposcope was available in only 19 (36.5%) surgery rooms and was systematically used for the guidance of excisional therapies in only 4 (21%) of these surgery rooms. Finally, 36 (69.2%) surgery rooms answered performing excisional therapies without any use of colposcopic guidance. Colposcopy was occasionally and systematically used in 12 (23.1%) and 4 (7.7%) surgery rooms, respectively. Among the 116 gynecologists from Marseilles area who answered to the national survey, 88 (75.9%) answered not using colposcopy when performing excision for CIN. Only 6% answered performing excision systematically under direct colposcopic vision and 18.1% occasionally.nnnCONCLUSIONnNo colposcopic guidance is used when performing excision for CIN in the majority of surgery rooms from Marseilles area.

Évaluation des modalités de réalisation des conisations pour le traitement des CIN : enquête auprès des blocs opératoires de la région PACA

OBJECTIVEnTo evaluate what is the proportion of surgery rooms from Marseilles area that do perform excisional therapies for CIN without any use of colposcopic guidance.nnnMATERIALS AND METHODSnFrom November 2012 to January 2013, a survey was conducted among all surgery rooms from Marseilles area practicing excisional therapies for CIN. In addition, answers from gynecologists from Marseilles area who participated to a national survey that evaluated practices of excisional therapies in France were specifically analyzed.nnnRESULTSnAmong the 55 surgery rooms from Marseilles area practicing excisional therapies, 52 (94.1%) participated to the current survey. A colposcope was available in only 19 (36.5%) surgery rooms and was systematically used for the guidance of excisional therapies in only 4 (21%) of these surgery rooms. Finally, 36 (69.2%) surgery rooms answered performing excisional therapies without any use of colposcopic guidance. Colposcopy was occasionally and systematically used in 12 (23.1%) and 4 (7.7%) surgery rooms, respectively. Among the 116 gynecologists from Marseilles area who answered to the national survey, 88 (75.9%) answered not using colposcopy when performing excision for CIN. Only 6% answered performing excision systematically under direct colposcopic vision and 18.1% occasionally.nnnCONCLUSIONnNo colposcopic guidance is used when performing excision for CIN in the majority of surgery rooms from Marseilles area.