To identify the ideal gestational age at delivery for preterm premature rupture of membranes and modalities of birth.
To identify studies, research was conducted using Pub-Med, Embase and Cochrane ...databases.
Prolonged latency duration after pPROM does not worsen neonatal prognosis (NP3). Therefore, it is recommended not to deliver before 34 weeks of gestation for patient with uncomplicated preterm rupture of membranes (pPROM) (Grade C). After 34 weeks of gestation, expectant management for pPROM is not associated with neonatal sepsis (NP1) but is associated to intra-uterine infection (NP2). Early delivery is associated with higher risk of respiratory distress syndrome (NP2), higher risk of cesarean section (NP2) and longer duration of NICU hospitalization (NP2). Before 37 weeks of gestation, expectant management is recommended for uncomplicated pPROM (Grade A), even if vaginal group B streptococcus is positive, as long as antibiotics are used at the time of membranes rupture (Professional consensus). Elective cesarean section is reserved for usual obstetrical indications. Oxytocin and prostaglandins are reasonable options for inducing labor (Professional consensus). Data are too scarce to establish recommendation regarding intra-cervical balloons in case of pPROM (Professional consensus).
Expectant management is recommended for uncomplicated pPROM before 37 weeks of gestation.
Objective
Present challenges are to improve the diagnosis rate of oesophageal atresia (OA) and evaluate as completely as possible a fetus affected by OA, specifically the type of OA and the length of ...the gap. Our aim was to evaluate the accuracy of fetal MR imaging (fMRI) for diagnosis of OA.
Methods
We reviewed fMRI performed because of sonographic suspicion of an OA. The signs reviewed included stomach size, “pouch sign”, bowing of the trachea and visualization of the lower oesophageal lumen. The fetuses were assigned by consensus as having or not having EA, as well as having a tracheaoesophageal fistula (TOF). All findings were correlated with postnatal data. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.
Results
Se, Sp, PPV and NPV of the technique were respectively 91 %, 100 %, 100 % and 88 %. The presence of the pouch sign yielded corresponding values of 82 %, 100 %, 100 % and 78 %. Mid-tracheal bowing was correlated positively with EA. The type of atresia was correctly evaluated in 90 % of patients.
Conclusion
fMRI is useful for the diagnosis of EA through the visualization of the oesophageal pouch or through associated signs such as tracheal bowing. Visualization of the lower oesophageal lumen seems to be a good sign of TEF.
Key Points
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Challenges are to improve the prenatal diagnosis of EA and associated malformations.
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fMRI is able to diagnose EA through demonstration of the pouch sign.
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Tracheal bowing is a promising indirect sign of EA.
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Tracheoesophageal fistula can also be suspected thanks to fMRI.
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Obstetrical US, fMRI and fetal CT are complementary for assessing associated malformations.
Chronic histiocytic intervillositis (CHI) is a placental disease that has been associated with unfavorable obstetric outcomes in small, noncomparative series. The objective was to measure the excess ...risk of adverse obstetric outcomes associated with the discovery of CHI after birth.
Retrospective single-center case-control study from 2000 through 2016. The case patients had a CHI diagnosis after a pathology analysis of the placenta. Two types of controls were defined for each case: low-risk control women were those who gave birth in our hospital immediately before each case patient, and the high-risk controls were the next women after each case for whom microscopic examination of the placenta was indicated.
We observed 111 cases of CHI during the study period. Compared with the 111 low-risk controls, the cases had a significantly higher frequency of late miscarriages (5.4 vs 0.0%, p < .03), small for gestational age (SGA) babies <3rd centile (70.4 vs 0.9%, p < .001, OR 140, 95% CI, 19.9–2800), and in utero deaths (35.1 vs 0.9%, p < .001, OR 59.6, 95% CI 8.5–1192), with significantly fewer children surviving to discharge (54.9 vs 99.1%, p < .001, OR 0.01, 95% CI, 0.00–0.08). All of these factors also differed significantly compared with the high-risk women (severe SGA: OR 3.7, 95% CI 1.9–7.0; in utero death: OR 4.1, 95% CI 1.9–8.7; children surviving to discharge: OR 0.27, 95% CI, 0.14–0.52).
Even compared with high-risk pregnancies, CHI is a severe placental disease associated with a substantial excess rate of late miscarriages, severe SGA and in utero death.
•Chronic histiocytic intervillositis (CHI) was only described in non-comparative studies.•Poor perinatal outcomes quadrupled in CHI cases compared with high-risk pregnancies.•CHI is associated with late miscarriage, severe growth restriction and in utero death.
•IUBT is essential and effective in the management of PPH.•Rapid, massive haemorrhages with coagulopathy are failure factors of IUBT.•Blood loss at 10 min is good factor prognostic of early IUBT ...failure.•At 10 mn after IUBT, blood loss greater than 250 mL should consider invasive procedure.
Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality world-wide. The arrival of intrauterine balloon devices has revolutionised PPH management. However, it seems interesting to know the situations of failure to improve the management. The objective is to define the factors related to failure of intrauterine balloon tamponade (IUBT) in women with a postpartum haemorrhage (PPH) after vaginal delivery, and especially blood loss after placement to avoid delaying management.
Retrospective cohort study was conducted in 2 centers. All PPH after vaginal deliveries treated by IUBT were included. Two groups were defined (successes and failures) and compared. Failure was defined as the need of invasive procedure. Calculated area under receiver operating characteristic (ROC) curves and thresholds of bleeding at 10 min were also calculated for prediction of failure.
127 women were included. The overall success rate was 78.0 % (95 % CI 70.7–85.1 %). Blood loss at 10 min was factor prognostic of early IUBT failure. The ROC curve of blood loss at 10 min for prediction of failure of IUBT had an area under the curve of 0.876 (95 % CI 0.782–0.970). The predictive positive value of blood loss at 10 min were respectively 0.53, 0.8 and 0.94 for blood loss of 100, 200 and 250 mL.
Physicians should be alerted if blood loss are more than 200 mL at 10 min after placement of IUBT and considered invasive procedure if more than 250 mL to avoid delaying management of PPH.
Résumé: Objectif: La rupture prématurée des membranes (RPM) est associée à un risque plus élevé de complications pour la mère et pour le foetus. La surveillance habituelle a lieu en hospitalisation ...continue (HC). L’hospitalisation à domicile (HAD) permet une réduction des coûts. Toutefois, son innocuité a été peu étudiée dans la prise en charge des RPM. Notre objectif était d’étudier le devenir maternel et foetal de grossesses compliquées de RPM en comparant la prise en charge en HAD à celle habituelle en hospitalisation. Matériel et méthodes: Étude rétrospective dans deux maternités de niveau III durant une période de deux ans entre janvier 2009 et décembre 2010. Nous avons inclus toute grossesse singleton avec une survenue d’une RPM entre 24 et 35 semaines d’aménorrhées (SA). Nous avons comparé deux groupes: patientes suivies en HAD après une courte hospitalisation dans le centre 2 (n = 32) et celles restant hospitalisées dans le centre 1 (n = 42). Nous avons étudié la survenue de complications pendant la grossesse, le mode et le terme d’accouchement ainsi que le devenir néonatal. Résultats: Nos populations étaient similaires notamment pour le terme de survenue de la RPM. Le terme d’accouchement était plus tardif dans le groupe HAD que dans le groupe HC (234,8 ± 19,54 vs 224,6 jours ± 22,02; p = 0,04). Aucune différence n’existait au niveau de l’évolution de la grossesse (notamment pour la chorioamniotite), l’accouchement et le devenir néonatal. Le nombre de jours en réanimation néonatale était plus élevé dans le groupe HC que dans le groupe HAD (n = 43,51 vs n = 24,21; p = 0,0003). Conclusion: L’HAD semble être une alternative à l’HC pour les patientes suivies pour RPM non menaçante entre 24 et 35 SA. Devant ces résultats préliminaires, il serait intéressant de mener une étude randomisée avec un nombre plus important de patientes, incluant d’autres données comme la satisfaction maternelle et une analyse des coûts.
Abstract: Objective: Premature prelabour rupture of membrane (PPROM) is associated with an increased risk for both mother and fetus. Expectant management is usually advised under hospital supervision. Home care is associated with reduced cost. However, its safety in PPROM management has not been well established. Our objective was to assess neonatal and maternal outcome in pregnancies complicated by PPROM comparing home care to in-hospital management. Study design: Retrospective study in two tertiary centers over a two-year period between January 2009 and December 2010. We included all singleton pregnancies with a history of PPROM which occured between 24 and 35 weeks of gestation. We compared women with PPROM and in-hospital management in Center 1 (Group 1; N = 42) to women with PPROM and a home care after a short period of observation in Center 2 (Group 2; N = 32), and. We studied gestational age at delivery, pregnancy complications, mode of delivery and neonatal outcome. Results: Demographic characteristics were similar at onset of PPROM between the two groups.Women in group 2 delivered later than in group 1 (234.8 ± 19.54 days vs 224.6 ± 22.02 days; P = 0.04). There was no difference between the groups in pregnancy complications including chorioamnionitis, delivery issue and neonatal outcome. The length of stay in neonatal intensive care unit was higher in group 1 compared to group 2 (N = 43.51 ± 2.67 days for group 1 vs. N = 24.21 ± 2.72 days for group 2; P = 0.0003). Conclusion: Home care appears to be a safe option for women with PPROM between 24 and 35 weeks with stable condition. These preliminary findings suggest performing a randomized control trial with a higher number of women, including further data such as assessment of maternal satisfaction and cost analysis.
Increased use of labor induction has renewed interest in outpatient cervical ripening. Post-term pregnancy (i.e., ≥41 weeks) is a specific situation of increased neonatal risk, including greater risk ...of perinatal death and adverse perinatal outcomes. While a high proportion of these patients will need induction, outpatient management of this specific population has never been studied. Therefore, our objective was to compare two policies of management of post term pregnancies: the use of a transcervical Foley catheter for outpatient cervical ripening compared with expectant management.
Multicenter, randomized controlled open-label study comparing home induction with a Foley catheter versus expectant management. Inclusion criteria were nulliparous, live singleton fetus in a vertex position, post-term (at 41 + 4 days), requiring cervical ripening (Bishop score <6), intact membranes, and distance home-hospital within 40 min. The primary endpoint was change in Bishop score beetween randomization (41 + 4 days) and consultation (41 + 5 days).
Forty-five women were included: 21 in the home induction group and 24 in the control group. The study was stopped due to low recruitment. The difference in Bishop score increases one day after randomization approached significance (p = 0.055), with home induction showing a larger change compared with expectant management (Cohen's d = 0.60; 95 % confidence interval CI −0.002 to 1.21). Regarding change in Bishop score, 81 % of home induction group patients had a better score at 41 + 5 days versus 52.2 % in the control group (relative risk = 1.55; 95 %CI 0.99 to 2.15).
By specifically evaluating home induction in nulliparous women with post term pregnancies, we observed a Bishop score improvement in the home induction group. These data support further evaluation of induction methods and birth experiences in a larger cohort of this population.
The study was registered under European policy (number EudraCT 2015-A01298–41) and on www.clinitrials.gov (number NCT02932319). Date of registration: 13/10/2016, Date of initial participant enrollment: 31/03/2017
Fetal well-being during labor is usually assessed by visual analysis of a fetal heart rate (FHR) tracing. Our primary objective was to evaluate the ability of automated heart rate variability (HRV) ...analysis methods, including our new fetal stress index (FSI), to predict neonatal acidosis. 552 intrapartum recordings were analyzed. The analysis occurred in the last 90 min before birth and was conducted during two 5-min intervals: (i) a stable period of FHR and (ii) the period corresponding to the maximum FSI value. For each period, we computed the mean FHR, FSI, short-term variability (STV), and long-term variability (LTV). Visual FHR interpretation was performed using the FIGO classification. The population was separated into two groups: (i) an acidotic group with an arterial pH at birth ≤ 7.10 and a control group. Prediction of a neonatal pH ≤ 7.10 was assessed by computing the receiver-operating characteristic area under the curve (AUC). FHR, FSI, STV, and LTV did not differ significantly between groups during the stable period. During the FSI max peak period, LTV and STV correlated significantly in the acidotic group (– 5.85 ± 2.19,
p
= 0.010 and – 0.62 ± 0.29,
p
= 0.037, respectively). The AUC values were 0.569 for FIGO classification, 0.595 for STV, and 0.622 for LTV. The multivariate model (FIGO, FSI, FC, STV, LTV) had the greatest accuracy for predicting acidosis (AUC = 0.719). FSI was not predictive of neonatal acidosis probably because of the low quality of the FHR signal in cardiotocography. When used separately, HRV indexes and visual FHR analysis were poor predictors of neonatal acidosis. Including all indexes in a multivariate model increased the predictive ability.
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