Prevention of spontaneous preterm birth: Guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF)

International audienceIn France, 60,000 neonates are born preterm every year (7.4%), half of them after the spontaneous onset of labor. Among preventable risk factors of spontaneous prematurity, only cessation of smoking is associated with decreased prematurity (level of evidence [LE]1). It is therefore recommended (Grade A). Routine screening and treatment of vaginal bacteriosis is not recommended in the general population (Grade A). The only population for which vaginal progesterone is recommended is that comprising asymptomatic women with singleton pregnancies, no history of preterm delivery, and a short cervix at 16-24 weeks of gestation (Grade B). A history-indicated cerclage is not recommended for women with only a history of conization (Grade C), uterine malformation (professional consensus), isolated history of preterm delivery (Grade B), or twin pregnancies for primary (Grade B) or secondary (Grade C) prevention of preterm birth. A history-indicated cerclage is recommended for a singleton pregnancy with a history of at least 3 late miscarriages or preterm deliveries (Grade A). Ultrasound cervical length screening is recommended between 16 and 22 weeks for women with a singleton previously delivered before 34 weeks gestation, so that cerclage can be offered if cervical length < 25 mm before 24 weeks (Grade C). A cervical pessary is not recommended for the prevention of preterm birth in a general population of asymptomatic women with twin pregnancies (Grade A) or in populations of asymptomatic women with a short cervix (professional consensus). Although the implementation of universal screening by transvaginal ultrasound for cervical length at 18-24 weeks of gestation in women with a singleton gestation and no history of preterm birth can be considered by individual practitioners, this screening cannot be universally recommended. In cases of preterm labor, (i) it is not possible to recommend any one of the several methods (ultrasound of the cervical length, vaginal examination, or fetal fibronectin assay) over any other to predict preterm birth (Grade B); (ii) routine antibiotic therapy is not recommended (Grade A); (iii) prolonged hospitalization (Grade B) and bed rest (Grade C) are not recommended. Compared with placebo, tocolytics are not associated with a reduction in neonatal mortality or morbidity (LE2) and maternal severe adverse effects may occur with all tocolytics (LE4). Atosiban and nifedipine (Grade B), unlike beta-agonists (Grade C), can be used for tocolysis in spontaneous preterm labor without preterm premature rupture of membranes. Maintenance tocolysis is not recommended (Grade B). Antenatal corticosteroid administration is recommended for all women at risk of preterm delivery before 34 weeks of gestation (Grade A). After 34 weeks, the evidence is insufficiently consistent to justify recommending systematic antenatal corticosteroid treatment (Grade B), but a course of this treatment might be indicated in clinical situations associated with high risk of severe respiratory distress syndrome, mainly in case of planned cesarean delivery (Grade C). Repeated courses of antenatal corticosteroids are not recommended (Grade A). Rescue courses are not recommended (Professional consensus). Magnesium sulfate administration is recommended for women at high risk of imminent preterm birth before 32 weeks (Grade A). Cesareans are not recommended for fetuses in vertex presentation (professional consensus). Both planned vaginal and elective cesarean delivery are possible for breech presentations (professional consensus). Delayed cord clamping may be considered if the neonatal or maternal state allows (professional consensus)

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)

International audiencePostpartum haemorrhage (PPH) is defined as blood loss >= 500 mL after ă delivery and severe PPH as blood loss >= 1000 mL, regardless of the ă route of delivery (professional consensus). The preventive ă administration of uterotonic agents just after delivery is effective in ă reducing the incidence of PPH and its systematic use is recommended, ă regardless of the route of delivery (Grade A). Oxytocin is the first ă line prophylactic drug, regardless of the route of delivery (Grade A); a ă slowly dose of 5 or 10 IU can be administered (Grade A) either IV or IM ă (professional consensus).After vaginal delivery, routine cord drainage ă (Grade B), controlled cord traction (Grade A), uterine massage (Grade ă A), and routine bladder voiding (professional consensus) are not ă systematically recommended for PPH prevention. After caesarean delivery, ă placental delivery by controlled cord traction is recommended (grade B). ă The routine use of a collector bag to assess postpartum blood loss at ă vaginal delivery is not systematically recommended (Grade B), since the ă incidence of severe PPH is not affected by this intervention. In cases ă of overt PPH after vaginal delivery, placement of a blood collection bag ă is recommended (professional consensus). The initial treatment of PPH ă consists in a manual uterine examination, together with antibiotic ă prophylaxis, careful visual assessment of the lower genital tract, a ă uterine massage, and the administration of 5-10 IU oxytocin injected ă slowly IV or IM, followed by a maintenance infusion not to exceed a ă cumulative dose of 40 IU (professional consensus). If oxytocin fails to ă control the bleeding, the administration of sulprostone is recommended ă within 30 minutes of the PPH diagnosis (Grade C). Intrauterine balloon ă tamponade can be performed if sulprostone fails and before recourse to ă either surgery or interventional radiology (professional consensus). ă Fluid resuscitation is recommended for PPH persistent after first line ă uterotonics, or if clinical signs of severity (Grade B). The objective ă of RBC transfusion is to maintain a haemoglobin concentration (Hb) >8 ă g/dL. During active haemorrhaging, it is desirable to maintain a ă fibrinogen level >= 2 g/L (professional consensus). RBC, fibrinogen and ă fresh frozen plasma (FFP) may be administered without awaiting ă laboratory results (professional consensus). Tranexamic acid may be used ă at a dose of 1 g, renewable once if ineffective the first time in the ă treatment of PPH when bleeding persists after sulprostone administration ă (professional consensus), even though its clinical value has not yet ă been demonstrated in obstetric settings. It is recommended to prevent ă and treat hypothermia in women with PPH by warming infusion solutions ă and blood products and by active skin warming (Grade C). Oxygen ă administration is recommended in women with severe PPH (professional ă consensus). If PPH is not controlled by pharmacological treatments and ă possibly intra-uterine balloon, invasive treatments by arterial ă embolization or surgery are recommended (Grade C). No technique for ă conservative surgery is favoured over any other (professional ă consensus). Hospital-to-hospital transfer of a woman with a PPH for ă embolization is possible once hemoperitoneum is ruled out and if the ă patient's hemodynamic condition so allows (professional consensus). (C) ă 2015 Elsevier Ireland Ltd. All rights reserved