Placenta prævia (distance placenta - col au troisième trimestre de grossesse et voie d'accouchement)

CAEN-BU Médecine pharmacie (141182102) / SudocSudocFranceF

Avenir obstétrical après une première grossesse compliquée d'une prééclampsie sévère avec accouchement avant 34 SA

CAEN-BU Médecine pharmacie (141182102) / SudocSudocFranceF

Dépistage et suivi du diabète de type 2 après un diabète gestationnel (prise en charge au sein d'un service hospitalier et en médecine générale)

CAEN-BU Médecine pharmacie (141182102) / SudocSudocFranceF

Obtention de la vacuité utérine dans le cadre d'une perte de grossesse

Objective : To assess early and late benefits and harms of different management options for first trimester miscarriage and for induction of labor and obtaining of uterine vacuity in case of fetal death beyond of 14weeks of gestation.Methods : French and English publications were searched using PubMed and Cochrane Library.Results : Concerning missed miscarriage, expectant management is not recommended (LE1) because it increases the risk of failure, need of unplanned surgical procedure and blood transfusion (LE1). Surgical uterine evacuation remains more effective than medical treatment using misoprostol (LE1), but both techniques involve rare and comparable risks (EL1). When chosen, medical treatment should be a vaginal dose of 800μg of misoprostol, possibly repeated 24 to 48hours later (EL2). Administration of mifepristone prior to misoprostol is not recommended (EL2). In case of incomplete miscarriage, expectant management can be offered because it does not increase the risk of complications, neither haemorrhagic nor infectious (EL1). Medical treatment using misoprostol is not recommended (EL2) because it does not improve the evacuation rate when compared to our first option, and does not reduce the risk of complications (EL2). Surgical uterine evacuation leads to high evacuation rate (97–98%) and low risk of complications, haemorrhagic and infectious (<5%) (EL1). However, this option should not be the only one because of the good efficiency of the expectant management (more than 75% of evacuation) and comparably low risk of complications (EL1). Surgical aspiration should be favoured to curettage because it is quicker, less painful and leads to less bleeding (EL2). After a first trimester miscarriage future fertility is identical with each treatment (EL2). When a trophoblastic retention is suspected, a diagnostic hysteroscopy is recommended (EL2). In case of late intrauterine foetal death beyond 14weeks of gestation and without a past caesarean section, the most efficient protocol seems to be vaginal administration of misoprostol 200 to 400μg every 4 to 6hours (EL2). Twenty-four hours prior to misoprostol the administration of 200mg of mifepristone is recommended (EL3) because it improves the induction-expulsion time and diminishes the quantity of needed misoprostol (and so the complications linked to it) (EL3).Objectif : Évaluer les bénéfices et les risques précoces et tardifs des traitements des fausses couches (FC) précoces et des méthodes d’induction du travail et d’évacuation utérine en cas de mort fœtale in utero (MFIU) au-delà du premier trimestre de la grossesse.Méthode : Recherche bibliographique en langue française et anglaise effectuée par consultation des banques de données PubMed et Cochrane Library.Résultats : En cas de grossesse arrêtée, l’expectative n’est pas recommandée (grade A) car elle augmente les risques d’absence d’expulsion spontanée nécessitant un traitement chirurgical non programmé et de transfusion sanguine (NP1). Le traitement par aspiration d’une grossesse arrêtée est plus efficace que le traitement par misoprostol (NP1), mais les techniques médicale et chirurgicale comportent des risques de complications rares et comparables (NP1). Lorsqu’un traitement médical a été choisi, le misoprostol doit être administré par voie vaginale à la dose unique de 800μg, éventuellement renouvelée au bout de 24–48heures (grade B). L’administration préalable de mifépristone n’est pas recommandée (grade B). En cas de FC incomplète, l’expectative peut être proposée en première intention (grade A). Le traitement par misoprostol n’est pas recommandé (grade B) car il n’améliore pas le taux d’évacuation par rapport à une simple expectative et ne réduit pas les risques de complications (NP2). L’aspiration permet des taux d’évacuation complète élevés (97–98 %) pour des risques de complications hémorragiques et infectieuses faibles (<5 %) (NP1). Toutefois, il ne doit pas être imposé à la patiente en raison de la bonne efficacité (plus de 75 %) et des risques de complications rares de l’expectative (grade A). L’aspiration chirurgicale doit être préférée au curetage car elle est plus rapide, moins douloureuse et moins hémorragique (grade B). La fertilité ultérieure est identique quel que soit le traitement d’une FC précoce (NP2). En cas de suspicion de rétention trophoblastique prolongée, une hystéroscopie diagnostique est recommandée (grade B). En cas de MFIU, le protocole d’administration du misoprostol le plus efficace en l’absence d’utérus cicatriciel est la dose de 200 à 400μg par voie vaginale, renouvelée toutes les 4 à 6heures (grade B). L’administration préalable d’une dose de 200mg de mifépristone au moins 24heures avant celle de misoprostol est recommandée (grade C) car elle améliore les délais d’expulsion et diminue les besoins en misoprostol (NP3)

Menace de fausse couche tardive. Recommandations françaises

International audienceObjectives-To define guidelines for the management of women diagnosed with threatenedlate miscarriage (TLM).Materials and Methods-A systematic review of the literature was performed using Pubmedand the Cochrane library databases and the guidelines from main international societies.Results-Management of women diagnosed with threatened LM requires a complete history-taking searching for a previous history of LM and/or of premature delivery (Grade B). Speculumexamination is required to diagnose membrane prolapse (Grade B) and vaginal ultrasound scanis recommended to measure the cervical length (Grade B). Finally, initial management shouldallow to rule out chorioamniotitis (Grade B). Vaginal progesterone therapy (90-200 mg daily) isrecommended for women diagnosed with a sole shortened cervix (< 25 mm) in mid-pregnancy(Grade A). Cerclage is only recommended in women with both history of previous prematuredelivery and/or previous LM and shortened cervical length diagnosed before 24 weeks of ges-tation (Grade A). Finally, cervical cerclage (Mc Donald technique) associated with systematictocolytic therapy (indometacine) and antibiotics are to be recommended in women diagnosedwith TLM with dilated cervical os eventually associated with membrane prolapse (Grade C)

Analyse de séquences vidéo : le projet ANR KIVAOU

International audienceThe KIVAOU project aims at developing innovative tools dedicated to two main goals: 1) Mobile facial identification and biometric indexation tool (suitcase), with real-time video analysis, and 2) Platform for offline multiple video analysis of an event (one place, one period). These videos are recorded during a particular event, and then collected for investigation purposes. After synchronisation between different sources, an analysis is performed in order to extract individual signatures, and to compute person's trajectories. The goal is to enable or to facilitate an offline analysis. The KIVAOU project brings together Sagem Sécurité, EVITECH, FACING-IT, French Ministry of Interior, Institut TELECOM, and ARMINES. It proposes innovative approaches based on the combination of components already mastered by each partner: biometrics, image analysis, video analysis, tracking, synchronization, users HMI needs, etc. It includes a test phase with end-users for assessing and improving the relevance of the developed tools.Le projet ANR CSOSG2007 KIVAOU vise à développer un démonstrateur comprenant des outils innovants d'analyse vidéo dédiés à deux problématiques : 1) Un dispositif mobile (valise) d'identification et indexation biométrique faciale portable pour une analyse temps réel vidéo et 2) Une plate-forme d'analyse de vidéos multiples enregistrées lors d'un évènement, utilisant la synchronisation de vidéos, l'extraction de signatures pour les personnes, et la constitution de trajectoires. Le but est de permettre ou de faciliter une analyse a posteriori des données enregistrées en un lieu et pendant une même période à des fins d'investigations. Le projet KIVAOU réunit Sagem Sécurité, EVITECH, FACING-IT, le Ministère de l'Intérieur, l’Institut TELECOM, et ARMINES. Il propose des approches innovantes basées sur la combinaison de briques de base maitrisées par chacun des partenaires: biométrie, analyse d'image, analyse vidéo, suivi, synchronisation, besoins IHM utilisateurs, etc. Il comporte une phase de test auprès des utilisateurs finaux pour valider ou améliorer la pertinence des outils proposé

Conservative management or cesarean hysterectomy for placenta accreta spectrum ::the PACCRETA prospective study

Background : Placenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management. Objective : This study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ). Study Design : From a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias. Results : Here, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19–0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy. Conclusion : Among women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy

Risk factors for placenta accreta spectrum disorders in women with any prior cesarean and a placenta previa or low lying: a prospective population-based study

International audienceThis study aimed to identify the risk factors for placenta accreta spectrum (PAS) in women who had at least one previous cesarean delivery and a placenta previa or low-lying. The PACCRETA prospective population-based study took place in 12 regional perinatal networks from 2013 through 2015. All women with one or more prior cesareans and a placenta previa or low lying were included. Placenta accreta spectrum (PAS) was diagnosed at delivery according to standardized clinical and histological criteria. Of the 520,114 deliveries, 396 fulfilled inclusion criteria; 108 were classified with PAS at delivery. Combining the number of prior cesareans and the placental location yielded a rate ranging from 5% for one prior cesarean combined with a posterior low-lying placenta to 63% for three or more prior cesareans combined with placenta previa. The factors independently associated with PAS disorders were BMI ≥ 30, previous uterine surgery, previous postpartum hemorrhage, a higher number of prior cesareans, and a placenta previa. Finally, in this high-risk population, the rate of PAS disorders varies greatly, not only with the number of prior cesareans but also with the exact placental location and some of the women's individual characteristics. Risk stratification is thus possible in this population

Conservative management or cesarean hysterectomy for placenta accreta spectrum: the PACCRETA prospective study

BackgroundPlacenta accreta spectrum is a life-threatening condition that has increased dramatically in recent decades along with cesarean rates worldwide. Cesarean hysterectomy is widely practiced in women with placenta accreta spectrum; however, the maternal outcomes after cesarean hysterectomy have not been thoroughly compared with the maternal outcomes after alternative approaches, such as conservative management.ObjectiveThis study aimed to compare the severe maternal outcomes between women with placenta accreta spectrum treated with cesarean hysterectomy and those treated with conservative management (leaving the placenta in situ).Study DesignFrom a source population of 520,114 deliveries in 176 hospitals (PACCRETA study), we designed an observational cohort of women with placenta accreta spectrum who had either a cesarean hysterectomy or a conservative management (the placenta left in situ) during cesarean delivery. Clinicians prospectively identified women meeting the inclusion criteria and included them at delivery. Data collection started only after the women had received information and agreed to participate in the study in the immediate postpartum period. The primary outcome was the transfusion of >4 units of packed red blood cells within 6 months after delivery. Secondary outcomes were other maternal complications within 6 months. We used propensity score weighting to account for potential indication bias.ResultsHere, 86 women had conservative management and 62 women had cesarean hysterectomy for placenta accreta spectrum during cesarean delivery. The primary outcome occurred in 14 of 86 women in the conservative management group (16.3%) and 36 of 61 (59.0%) in the cesarean hysterectomy group (risk ratio in propensity score weighted model, 0.29; 95% confidence interval, 0.19–0.45). The rates of hysterectomy, total estimated blood loss exceeding 3000 mL, any blood product transfusion, adjacent organ injury, and nonpostpartum hemorrhage-related severe maternal morbidity were lower with conservative management than with cesarean hysterectomy (all adjusted, P≤.02); but, the rates of arterial embolization, endometritis, and readmission within 6 months of discharge were higher with conservative management than with cesarean hysterectomy.ConclusionAmong women with placenta accreta spectrum who underwent cesarean delivery, conservative management was associated with a lower risk of transfusion of >4 units of packed red blood cells within 6 months than cesarean hysterectomy

Neonatal outcomes for women at risk of preterm delivery given half dose versus full dose of antenatal betamethasone : a randomised, multicentre, double-blind, placebo-controlled, non-inferiority trial

Background: Antenatal betamethasone is recommended before preterm delivery to accelerate fetal lung maturation. However, reports of growth and neurodevelopmental dose-related side-effects suggest that the current dose (12 mg plus 12 mg, 24 h apart) might be too high. We therefore investigated whether a half dose would be non-inferior to the current full dose for preventing respiratory distress syndrome. Methods: We designed a randomised, multicentre, double-blind, placebo-controlled, non-inferiority trial in 37 level 3 referral perinatal centres in France. Eligible participants were pregnant women aged 18 years or older with a singleton fetus at risk of preterm delivery and already treated with the first injection of antenatal betamethasone (11·4 mg) before 32 weeks' gestation. We used a computer-generated code producing permuted blocks of varying sizes to randomly assign (1:1) women to receive either a placebo (half-dose group) or a second 11·4 mg betamethasone injection (full-dose group) 24 h later. Randomisation was stratified by gestational age (before or after 28 weeks). Participants, clinicians, and study staff were masked to the treatment allocation. The primary outcome was the need for exogenous intratracheal surfactant within 48 h after birth. Non-inferiority would be shown if the higher limit of the 95% CI for the between-group difference between the half-dose and full-dose groups in the primary endpoint was less than 4 percentage points (corresponding to a maximum relative risk of 1·20). Four interim analyses monitoring the primary and the secondary safety outcomes were done during the study period, using a sequential data analysis method that provided futility and non-inferiority stopping rules and checked for type I and II errors. Interim analyses were done in the intention-to-treat population. This trial was registered with ClinicalTrials.gov, NCT02897076. Findings: Between Jan 2, 2017, and Oct 9, 2019, 3244 women were randomly assigned to the half-dose (n=1620 [49·9%]) or the full-dose group (n=1624 [50·1%]); 48 women withdrew consent, 30 fetuses were stillborn, 16 neonates were lost to follow-up, and 9 neonates died before evaluation, so that 3141 neonates remained for analysis. In the intention-to-treat analysis, the primary outcome occurred in 313 (20·0%) of 1567 neonates in the half-dose group and 276 (17·5%) of 1574 neonates in the full-dose group (risk difference 2·4%, 95% CI -0·3 to 5·2); thus non-inferiority was not shown. The per-protocol analysis also did not show non-inferiority (risk difference 2·2%, 95% CI -0·6 to 5·1). No between-group differences appeared in the rates of neonatal death, grade 3-4 intraventricular haemorrhage, stage ≥2 necrotising enterocolitis, severe retinopathy of prematurity, or bronchopulmonary dysplasia. Interpretation: Because non-inferiority of the half-dose compared with the full-dose regimen was not shown, our results do not support practice changes towards antenatal betamethasone dose reduction. </p