[Intrahepatic cholestasis of pregnancy: French College of Obstetricians and Gynecologists guidelines for clinical practice]

OBJECTIVE

To identify strategies for reducing neonatal and maternal morbidity associated with intrahepatic cholestasis pregnancy (ICP).

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE methodology with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 14 questions (from 12 PICO questions and one definition question outside the PICO format), there was agreement between the working group and the external reviewers on 14 (100%). The level of evidence of the literature was insufficient to provide a recommendation on two questions. ICP is defined by the occurrence of suggestive pruritus (palmoplantar, nocturnal) associated with a total bile acid level>10μmol/L or an alanine transaminase level above 2N after ruling out differential diagnoses. In the absence of suggestive symptoms of a differential diagnosis, it is recommended not to carry out additional biological or ultrasound tests. In women with CIP, ursodeoxycholic acid is recommended to reduce the intensity of maternal pruritus (Strong recommendation. Quality of the evidence moderate) and to decrease the level of total bile acids and alanine transaminases. (Strong recommendation. Quality of the evidence moderate). S-adenosyl-methionine, dexamethasone, guar gum or activated charcoal should not be used to reduce the intensity of maternal pruritus (Strong recommendation. Quality of evidence low), and there is insufficient data to recommend the use of antihistamines (No recommendation. Quality of evidence low). Rifampicin (Weak recommendation. Very low quality of evidence) or plasma exchange (Strong recommendation. Very low quality of evidence) should not be used to reduce maternal pruritus and perinatal morbidity. Serum monitoring of bile acids is recommended to reduce perinatal morbidity and mortality (stillbirth, prematurity) (Low recommendation. Quality of the evidence low). The level of evidence is insufficient to determine whether fetal heart rate or fetal ultrasound monitoring are useful to reduce perinatal morbidity (No recommendation). Birth is recommended when bile acid level is above 99μmol/L from 36 weeks gestation to reduce perinatal morbidity, in particular stillbirth. When bile acid level is above 99μmol/L is below 100μmol/L, women should be informed that induction of labor could be considered 37 and 39 weeks gestation to reduce perinatal morbidity. (Strong recommendation. Quality of evidence low). In postpartum, total bile acids and alanine transaminases level should be checked and normalized before prescribing estrogen-progestin contraception, ideally with a low estrogen dose (risk of recurrence of pruritus and cytolysis) (Low recommendation. Quality of evidence very low).

CONCLUSION

Although the quality of evidence regarding ICP gestational cholestasis remains low, there is a strong consensus in France, as shown by our Delphi study, on how to manage women with ICP. The reference first-line treatment is ursodeoxycholic acid.

[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify procedures to reduce maternal morbidity during cesarean.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds.

CONCLUSION

In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

[Expert consensus from the College of French Gynecologists and Obstetricians: Management of nausea and vomiting of pregnancy and hyperemesis gravidarum]

OBJECTIVE

To determine the management of patients with 1st trimester nausea and vomiting and hyperemesis gravidarum.

METHODS

A panel of experts participated in a formal consensus process, including focus groups and two Delphi rounds.

RESULTS

Hyperemesis gravidarum is distinguished from nausea and vomiting during pregnancy by weight loss≥5 % or signs of dehydration or a PUQE score≥7. Hospitalization is proposed when there is, at least, one of the following criteria: weight loss≥10%, one or more clinical signs of dehydration, PUQE (Pregnancy Unique Quantification of Emesis and nausea) score≥13, hypokalemia<3.0mmol/L, hyponatremia<120mmol/L, elevated serum creatinine>100μmol/L or resistance to treatment. Prenatal vitamins and iron supplementation should be stopped without stopping folic acid supplementation. Diet and lifestyle should be adjusted according to symptoms. Aromatherapy is not to be used. If the PUQE score is<6, even in the absence of proof of their benefit, ginger, pyridoxine (B6 vitamin), acupuncture or electrostimulation can be used, even in the absence of proof of benefit. It is proposed that drugs or combinations of drugs associated with the least severe and least frequent side effects should always be chosen for uses in 1st, 2nd or 3rd intention, taking into account the absence of superiority of a class over another to reduce the symptoms of nausea and vomiting of pregnancy and hypermesis gravidarum. To prevent Gayet Wernicke encephalopathy, Vitamin B1 must systematically be administered for hyperemesis gravidarum needing parenteral rehydration. Patients hospitalized for hyperemesis gravidarum should not be placed in isolation (put in the dark, confiscation of the mobile phone or ban on visits, etc.). Psychological support should be offered to all patients with hyperemesis gravidarum as well as information on patient' associations involved in supporting these women and their families. When returning home after hospitalization, care will be organized around a referring doctor.

CONCLUSION

This work should contribute to improving the care of women with hyperemesis gravidarum. However, given the paucity in number and quality of the literature, researchers must invest in the field of nausea and vomiting in pregnancy, and HG to identify strategies to improve the quality of life of women with nausea and vomiting in pregnancy or hyperemesis gravidarum.

[CNGOF clinical practice guidelines: Evaluation one year after revision of the methodology]

OBJECTIVES

To evaluate the revision of methodology of the clinical practice guidelines (CPG) of the French National College of Gynecologists and Obstetricians (CNGOF).

METHOD

Three CPGs were organized in 2020 on the topics of severe preeclampsia, menorrhagia, and prophylactic surgery according to AGREE II (Apraisal of Guidelines for Research & Evaluation). Questions were presented in PICO (Population, Intervention, Comparison, Outcome) format and the grading of scientific evidence was based on the GRADE (Grading of Recommendation Assessment, Development and Evaluation) method.

RESULTS

All three CPGs groups adhered to this new methodology. However, the presentation of the arguments, the formulation of the recommendations and the development of the GRADE tables were heterogeneous from one group to another. A homogenization of the presentation is proposed, as well as a guide to the critical analysis of the literature to help the experts to rate the evidence.

CONCLUSION

Adherence to these quality criteria should make it easier to apply the recommendations at the national level and improve international recognition of the work done by the CNGOF.

[Reprint of: Severe pre-eclampsia: guidelines for clinical practice from the French Society of anesthesiology and intensive care (SFAR) and the French College of gynaecologists and obstetricians (CNGOF)]

OBJECTIVE

To provide national guidelines for the management of women with severe preeclampsia.

DESIGN

A consensus committee of 26 experts was formed. A formal conflict of interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last SFAR and CNGOF guidelines on the management of women with severe preeclampsia was published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analyzed according to the GRADE® methodology.

RESULTS

The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1±), 9 have a moderate level of evidence (GRADE 2±), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations.

CONCLUSIONS

There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe preeclampsia.

Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy

OBJECTIVE

To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned.

METHODS

JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation).

RESULTS

Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery.

CONCLUSION

When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

[Abnormalities of umbilical-portal circulation: From screening to diagnosis]

Abnormalities of umbilical-portal circulation are rare pathologies whose detection points in screening ultrasound are poorly taught. It can present as an unusual looking portal sinus, an abnormal trajectory of the umbilical vein, an anechoic intrahepatic image or more rarely as cardiomegaly. This can also be detected in the context of investigations of fetus with intrauterine growth retardation. Subsequently, the starting point of the diagnostic approach is based on the following dichotomy: does the umbilical vein penetrate or not into the liver, followed by systematic analysis of the trajectory and size of the umbilical-portosystemic vessels with color Doppler. Determining the prognosis of this abnormality, which varies according to the type, is a major challenge and by further studying this disorder in this project, it will help define what surveillance is required and subsequently help decide the most appropriate place for delivery.

[Lower Uterine Segment Trial: A pragmatic open multicenter randomized trial]

BACKGROUND

The data from literature show that trial of labor and elective repeat cesarean delivery after a prior cesarean delivery both present significant risks and benefits, and these risks and benefits differ for the woman and her fetus. The benefits to the woman can be at the expense of her fetus and vice-versa. This uncertainty is compounded by the scarcity of high-level evidence that preclude accurate quantification of the risks and benefits that could help provide a fair counseling about a trial of labor and elective repeat cesarean delivery. An interesting way of research is to evaluate the potential benefits of a decision rule associated to the ultrasound measurement of the lower uterine segment (LUS). Indeed, ultrasonography may be helpful in determining a specific risk for a given patient by measuring the thickness of the LUS, i,e, the thickness of the cesarean delivery scar area. Although only small and often methodologically biased data have been published, they look promising as their results are concordant: ultrasonographic measurements of the LUS thickness is highly correlated with the intraoperative findings at cesarean delivery. Furthermore, the thinner the LUS becomes on ultrasound, the higher the likelihood of a defect in the LUS. Finally, ultrasound assessment of LUS has an excellent negative predictive value for the risk of uterine defect. Therefore, this exam associated with a rule of decision could help to reduce the rate of elective repeat cesarean delivery and especially to reduce the fetal and maternal mortality and morbidity related to trial of labor after a prior cesarean delivery.

METHODS/DESIGN

This is a pragmatic open multicenter randomized trial with two parallel arms. Randomization will be centralized and computerized. Since blindness is impossible, an adjudication committee will evaluate the components of the primary composite outcome in order to avoid evaluation bias. An interim analysis will be planned mid-strength of the trial. Ultrasound will be performed by expert sonographers after certification by the main investigator. Women aged 18 years or older are eligible for this trial if they have a singleton pregnancy in cephalic presentation at a gestational age from 36 to 38 weeks, a previous low transverse cesarean delivery and sign the informed consent sheet. Women will be asked to participate in this study when they reach a term of 36 to 38 weeks of gestation. After agreement, women will be randomized into two groups: in the study group, they will have the LUS measured by ultrasound and the patient will be informed that, based on a threshold value of 3.5mm for the ultrasound measurement of the LUS thickness, the patient with a higher measurement will be considered at low risk and will be encouraged to choose a trial of labor whereas the patient with a measurement is equal to or less than this threshold will be considered at risk and encouraged to choose an elective repeat cesarean; in the control group, ultrasound LUS measurement will not be performed. The mode of delivery will be decided according to standard practice at the center. The primary composite outcome will include: uterine rupture, uterine dehiscence, hysterectomy, thromboembolic complications, transfusion, endometritis, maternal mortality, fetal prenatal and intrapartum mortality, hypoxic-ischemic encephalopathy and neonatal mortality.

DISCUSSION

This trial assesses the efficacy of ultrasound measurement of the lower uterine segment in women with a prior cesarean delivery in reducing fetal and maternal morbidity and mortality and it will provide evidence in order to establish clinical recommendations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01916044 (date of registration: 5 August 2013).

Prévention et prise en charge de l’infection herpétique au cours de la grossesse et de l’accouchement : recommandations pour la pratique clinique – texte des recommandations (texte court)

OBJECTIVE

Identify measures to diagnose, prevent and treat genital herpes infection during pregnancy and childbirth and neonatal infection.

METHODS

Bibliographic search from Medline, Cochrane Library databases and research of international clinical practice guidelines.

RESULTS

Genital herpes lesion is most often due to HSV2 (LE2). The risk of HSV seroconversion during pregnancy is 1 to 5% (LE2). Genital herpes ulceration during pregnancy in a woman with history of genital herpes corresponds with a recurrence. In this situation, there is no need for virologic confirmation (grade B). In case of genital lesions in a pregnant woman that do not report any genital herpes before, it is recommended to perform a virological confirmation by PCR and HSV type specific IgG (Professional consensus). In case of first episode genital herpes during pregnancy, antiviral treatment with acyclovir (200mg 5 times daily) or valacyclovir (1000mg twice daily) for 5 to 10 days is recommended (grade C). In case of recurrent herpes during pregnancy, antiviral therapy with acyclovir (200mg 5 times daily) or valacyclovir (500mg twice daily) can be administered (grade C). The risk of neonatal herpes is estimated between 25% and 44% in case of initial episode (LE2) and 1% in case of recurrence (LE3) at the time of delivery. Antiviral prophylaxis should be offered for women with first episode genital herpes or recurrent genital herpes during pregnancy from 36 weeks of gestation and until delivery (grade B). In case of a history of genital herpes without episode of recurrence during pregnancy, it is not recommended routinely offer a prophylactic treatment (professional consensus). A cesarean section should be performed if there is a suspicion of first episode genital herpes at the onset of labor (grade B), in the event of premature rupture of the membranes at term (professional consensus), or in case of first episode genital herpes less than 6 weeks before delivery (professional consensus). In case of recurrent genital herpes at the onset of labor, cesarean delivery will be all the more considered if the membranes are intact and vaginal delivery will be all the more considered in case of prolonged rupture of membranes (professional consensus). Neonatal herpes is rare and mainly due to HSV-1 (LE3). In most of the case of neonatal herpes, the mothers have no history of genital herpes (LE 3). In case of suspicion of neonatal herpes, different samples (blood and cerebrospinal fluid) for HSV PCR must be carried out to confirm the diagnosis (professional consensus). Any newborn suspected of neonatal herpes should be treated with intravenous acyclovir (60mg/kgs/day 3 times daily) (grade A) prior to the results of HSV PCR (professional consensus). The duration of the treatment depends on the clinical form (professional consensus) CONCLUSION: There is no formal evidence that it is possible to reduce the risk of neonatal herpes in genital herpes during pregnancy. However, appropriate care can reduce the symptoms associated with herpes, the risk of recurrence term and the cesarean rate performed to decrease the risk of neonatal herpes.

[Shoulder dystocia: Guidelines for clinical practice--Short text]

OBJECTIVES

To determine the available evidence to prevent and treat shoulder dystocia to attempt to decrease its related neonatal and maternal morbidity.

MATERIALS AND METHODS

The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.

RESULTS

Shoulder dystocia, defined as a vaginal delivery that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has failed, complicates 0.5-1 % of vaginal deliveries. Risks of brachial plexus birth injury (LE3), clavicle and humeral fracture (LE3), perinatal asphyxia (LE2), hypoxic-ischemic encephalopathy (LE3) and perinatal mortality (LE2) are increased after shoulder dystocia. Its main risk factors are previous shoulder dystocia and macrosomia, but they are poorly predictive; 50 % to 70 % of shoulder dystocia cases occur in their absence, and the great majority of deliveries when they are present are not associated with shoulder dystocia. No study has proven that the correction of these risk factors (except gestational diabetes) would reduce the risk of shoulder dystocia (SD). Physical activity is recommended before and during pregnancy to reduce the occurrence of some risk factors for shoulder dystocia (grade C). In obese patients, physical activity should be coupled with dietary measures to reduce fetal macrosomia and weight gain during pregnancy (grade A). In case of gestational diabetes, diabetes care is recommended (diabetic diet, glucose monitoring, insulin if needed) (grade A) as it reduces the risk of macrosomia and shoulder dystocia (LE1). In order to avoid shoulder dystocia and its complications, only two measures are proposed. Induction of labor is recommended in case of impending macrosomia if the cervix is favourable and gestational age greater than 39 weeks of gestation (professional consensus). Cesarean delivery is recommended before labor in case of EFW greater than 4500g if associated with maternal diabetes (grade C), EFW greater than 5000g in the absence of maternal diabetes (grade C), history of shoulder dystocia associated with severe neonatal or maternal complications (Professional consensus), and finally during labor, in case of fetal macrosomia and failure to progress in the second stage, when the fetal head is above a +2 station (grade C). In case of shoulder dystocia, it is recommended not to pull excessively on the fetal head (grade C), do not perform uterine expression (grade C) and do not realize inverse rotation of the fetal head (professional consensus). McRoberts' maneuver, with or without a suprapubic pressure, is recommended in the first line (grade C). In case of failure, if the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, delivery of the posterior arm should be performed preferentially (professional consensus). It seems necessary to know at least two maneuvers to perform in case of shoulder dystocia unresolved by the maneuver of McRoberts (professional consensus). Pediatrician should be immediately informed in case of shoulder dystocia. The initial clinical examination should search complications such as brachial plexus birth injury or clavicle fracture (professional consensus). In absence of neonatal complication, monitoring of the neonate is not modified (professional consensus). The implementation of a practical training using simulation and concerning all caregivers of the delivery room is associated with a significant reduction in neonatal (LE3) but not maternal (LE3) injury.

CONCLUSION

Shoulder dystocia remains a non-predictable obstetrics emergency. All physicians and midwives should know and perform obstetric maneuvers if needed quickly but without precipitation. A training program using simulation for the management of shoulder dystocia is encouraged for the initial and continuing formation of different actors in the delivery room (professional consensus).

[Post-partum: Guidelines for clinical practice--Short text]

OBJECTIVE

To determine the post-partum management of women and their newborn whatever the mode of delivery.

MATERIAL AND METHODS

The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.

RESULTS

Because breastfeeding is associated with a decrease in neonatal morbidity (lower frequency of cardiovascular diseases, infectious, atopic or infantile obesity) (EL2) and an improvement in the cognitive development of children (EL2), exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (Professional consensus). In order to increase the rate of breastfeeding initiation and its duration, it is recommended that health professionals work closely with mothers in their project (grade A) and to promote breastfeeding on demand (grade B). There is no scientific evidence to recommend non-pharmacological measures of inhibition of lactation (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). For women aware of the risks of pharmacological treatment of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Whatever the mode of delivery, numeration blood count is not systematically recommended in a general population (Professional consensus). Anemia must be sought only in women with bleeding or symptoms of anemia (Professional consensus). The only treatment of post-dural puncture headache is the blood patch (EL2), it must not be carried out before 48 h (Professional consensus). Women vaccination status and their family is to be assessed in the early post-partum (Professional consensus). Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (Professional consensus). An analgesic multimodal protocol developed by the medical team should be available and oral way should be favored (Professional consensus) (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (Professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). Early postoperative rehabilitation is encouraged (Professional consensus). Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, after normal pregnancy and delivery (Professional consensus). Starting effective contraception later 21 days after delivery in women who do not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended (grade B). Rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long-term is not recommended (Expert consensus). Pelvic-floor rehabilitation using pelvic-floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C). Postpartum pelvic-floor rehabilitation is not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). The optimal time for maternity discharge for low risk newborn depends more on the organisation of the post-discharge follow up (Professional consensus). The months following the birth are a transitional period, and psychological alterations concern all parents (EL2). It is more difficult in case of psychosocial risk factors (EL2). In situations of proven psychological difficulties, the impact on the psycho-emotional development of children can be important (EL3). Among these difficulties, postpartum depression is the most common situation. However, the risk is generally higher in the perinatal period for all mental disorders (EL3).

CONCLUSION

Postpartum is, for clinicians, a unique and privileged opportunity to address the physical, psychological, social and somatic health of their patients.

[Management of post-term pregnancies: the role for AFI, biophysical score and doppler]

OBJECTIVE

To evaluate the role of ultrasound and doppler assessment in the management of prolonged pregnancies and to state its modalities.

METHOD

Medline, PubMed, embase and the Cochrane library were searched using terms prolonged pregnancy, post date pregnancy amniotic fluid, ultrasound assessment, doppler, biophysical profile.

RESULTS

Single deepest vertical pool measurement is the method of choice of the assessment of amniotic fluid. Indeed, when this method was used, significantly fewer case of oligohydramnios were diagnosed and fewer women had inductions of labor. However, this method is not superior to the amniotic fluid index in the prevention of poor perinatal outcomes. There is a significant difference in the incidence of fetal distress, meconium stained fluid and caesarean section for fetal distress when the amniotic fluid is reduced as compared with normal amniotic fluid. However, sensibility and predictive positive value of oligohydramnios to predict poor perinatal outcomes is moderate. Similary, in most studies, diagnosis of an abnormal uterine, umbilical, aortic or cerebral blood flow doppler was associated with a weak prediction of a poor perinatal outcome. Therefore, we do not recommend its use in management of prolonged pregnancy. There were significantly more diagnosis of oligoamnios and more abnormal antenatal monitoring results in the modified biophysical profile group as compared with the group managed with only single deepest pool but no differences in cord blood gases, neonatal outcome, or in outcomes related to labour and delivery were noted between the two groups. Therefore, biophysical profile including AFI offers no advantage in detecting adverse outcomes and may cause more interventions.

CONCLUSION

Close monitoring of fetal condition including assessment of amniotic fluid by single deepest pool twice a week from 41 weeks of gestation is recommended in the management of prolonged pregnancy. Induction of labor could be considered when oligohydramnios is diagnosed by single deepest pool less than 2 cm.

Technique de cerclage cervico-isthmique par voie vaginale avec bandelette de polypropylène: technique de Fernandez

OBJECTIVE

To assess the efficacy of performing transvaginal cervico-isthmic cerclage using synthetic tape in prevention of preterm labor in high-risk women.

PATIENTS AND METHODS

A retrospective analysis of 24 transvaginal cerclages using polypropylene tape performed in women presenting with high risk of preterm delivery: prior histories of pregnancy losses in the second trimester, prior failure of Mac Donald's cerclage and/or absent portio vaginalis of the cervix. Cerclage was performed between 12 and 16 weeks of gestation. A polypropylene tape was placed at the cervicoisthmic junction by vaginal route.

RESULTS

The median age of the patients in this series was 32.1 years (range 22-39 years). No intra-operative complication occurred. The median operating time was 34.9 minutes (+/-5.1) (range 30-45 min). Cesarean delivery was systematically performed in all patients since the cerclage was considered to be definitive. Mean gestational age and birth weight at delivery were respectively 37.1 weeks (+/-1.8) and 2850 g (+/-745). Preterm birth rate was 19% (4/21). Birth at less than 32 weeks occurred in only one patient (4%). In one case, the tape has been removed later because symptomatic vaginal erosion was noted. One neonatal death occurred following amniotic fluid infection at 34 weeks. At the present time, 3 women are at 22, 26 and 26 weeks of gestation with no preterm labor.

CONCLUSION

Transvaginal cerclage using polypropylene tape may be considered as an effective and minimally invasive alternative to transabdominal cervico-isthmic cerclage in women presenting with high risk of preterm delivery.

Comparison of two methods of cervical cerclage by ultrasound cervical measurement

OBJECTIVE

To compare the effects of cerclage performed with a modified Shirodkar procedure or with McDonald's technique using transvaginal ultrasound measurement of the distance between the external os and the suture.

MATERIALS AND METHODS

We performed a retrospective study of all patients who underwent a prophylactic cerclage with either the modified Shirodkar procedure or the McDonald's technique over a 3-year period. Physicians chose the cerclage technique according to their own preferences. Transvaginal ultrasound examination of the cervix was performed 2 weeks after the cerclage to measure its functional length and the distance between the external os and the cerclage.

RESULTS

During the study period, 14 patients had a cerclage with the modified Shirodkar procedure and 19 patients with the McDonald's technique. Twelve of these 33 patients (36.4%) delivered before 37 weeks. The obstetric characteristics of the patients in both groups were similar. There were no significant differences between the Shirodkar and McDonald groups as to the functional cervical length before (31.3 +/- 8.7 vs. 35.6 +/- 9.7 mm, respectively) or after (37.0 +/- 7.3 vs. 36.1 +/- 7.9 mm) cerclage, the distance between the external os and cerclage (16.7 +/- 3.8 vs. 14.0 +/- 5.2 mm), or the number of deliveries before 32 (0 vs. 2) and 34 (1 vs. 3) weeks.

CONCLUSION

The anterior colpotomy of the Shirodkar procedure increased the distance between the external os and the cerclage by a mean of 2.7 mm. This slight gain does not justify exposing the patient to the risks related to this procedure. When cerclage is necessary, McDonald's technique seems preferable.

Predictive value of two-dimensional and three-dimensional multiplanar ultrasound evaluation of the cervix in preterm labor

OBJECTIVE

To compare the predictive value of conventional two-dimensional ultrasound measurement of cervical length and three-dimensional multiplanar volume assessment of the cervix for delivery at < 37 weeks of gestation among patients with preterm labor.

MATERIALS AND METHODS

This preliminary prospective study was conducted in 28 patients hospitalized for preterm labor between 24(+0) and 33(+6) weeks of gestation, defined by regular and painful uterine contractions (at least two per 10 min), intact membranes and a cervical length of < or = 26 mm measured by two-dimensional transvaginal ultrasonography at admission with a Voluson 530 (Kretz, France) machine using a 7.5-MHz transvaginal transducer. The cervical volume was then assessed by the three-dimensional triplan technique. It was automatically calculated after drawing of the cervix outlines in mid-sagittal and median axial plane images. As the border between the cervix and the lower uterine segment is virtual, it was defined by a perpendicular line to the line joining the external os and the internal os. The result of the latter measurement was not disclosed to the obstetric team. The primary outcome was the rate of deliveries at < 37 weeks. We constructed a receiver operator characteristic (ROC) curve to determine the optimal cut-off point of the cervical volume, to predict preterm delivery.

RESULTS

Sixteen (57%) patients delivered at < 37 weeks. Mean (+/- SD) gestational ages at admission and delivery were 28.2 (+/- 3.2) weeks and 35.9 (+/- 4.1) weeks, respectively. Mean cervical length and volume at admission were 20.1 (+/- 9.9) mm and 23.1 (+/- 14.6) mm3, respectively. The ROC curve showed that the optimal cut-off point was 20 mm3. The predictive values of cervical length and of cervical volume on delivery at < 37 weeks were: sensitivity, 87.5% (14/16) and 75% (12/16); specificity, 50% (6/12) and 75% (9/12); positive predictive value, 70% (14/20) and 80% (12/15); negative predictive value, 75% (6/8) and 69.2% (9/13), respectively.

CONCLUSIONS

The three-dimensional multiplanar volume assessment of the cervix probably increases the positive predictive value of cervical ultrasonography in predicting preterm delivery. Screening high-risk women could be achieved by conventional two-dimensional transvaginal ultrasound and the diagnosis of true preterm labor may be improved by three-dimensional multiplanar transvaginal ultrasound assessment of the cervix.