[Lucy's parturition, a way towards extinction?]. / La parturition de Lucy, chemin vers l'extinction ?

OBJECTIVES: To compare pelvic cavities in australopithecines, modern humans and non-hominid primates in order to discuss the obstetrical mechanisms in australopithecines MATERIAL AND METHODS: Bony pelves from fossil material (Australopithecus afarensis AL 288-1, Australopithecus africanus Sts14, Australopithecus Stw 431 and Mh2), 133 modern humans (82 adult females and 51 adult males) and 67 anthropoid primates (36 gorilla, 26 Pan troglodytes, 5 Pongo pygmaeus) were reconstructed and compared (shape and morphometric analysis) using 16 pelvimetric mesasurements. RESULTS: Pelves of australopithecines were characterized by lower anteroposterior (AP) and transverse (TRV) diameters in inlet pelvis than in other species. Index (AP/TRV) of pelvic inlet, midpelvis and pelvic outlet in the australopithecines were the lowest (<100) and the pelvic shape was platypelloid. A logarithmic factorial analysis showed that the pelvic morphology of australopithecines was different from humans and non-hominid primates but nearer the humans. DISCUSSION AND CONCLUSION: In contrast with apes where obstetrical mechanics seem to be easier, and because of platypelloidy, mechanism of birth in australopithecines was as difficult as in modern homo sapiens. Birth without cesarean was probably possible in an asynclitic TRV orientation.

Reduction of the use of antimicrobial drugs following the rapid detection of Streptococcus agalactiae in the vagina at delivery by real-time PCR assay.

OBJECTIVE: To assess whether the determination of the presence of group B streptococci (GBS) in the vagina using a rapid polymerase chain reaction (PCR) assay at delivery was able to spare useless antimicrobial treatments, as compared with conventional culture at 34-38 weeks of gestation. DESIGN: Practical evaluation and prospective cost-effectiveness analysis. SETTING: A university hospital in France. POPULATION: A cohort of 225 women in labour at the University-Hospital of Saint-Etienne. METHODS: Each woman had a conventional culture performed at 34-38 weeks of gestation. At the beginning of labour, two vaginal swabs were sampled for rapid PCR testing and culture. The decision to prescribe a prophylactic antimicrobial treatment or not was taken according to the result of the PCR test. A comparative cost-effectiveness analysis of the two diagnostic strategies was carried out. MAIN OUTCOME MEASURES: Number of women receiving inadequate prophylactic antimicrobial drugs following each testing strategy, costs of PCR testing and culture, frequency of vaginal GBS, and diagnostic performance of the PCR test at delivery. RESULTS: The percentage of unnecessarily treated women was significantly reduced using the rapid test versus conventional culture (4.5 and 13.6%, respectively; P < 0.001). The rate of vaginal GBS at delivery was 12.5%. The incremental cost-effectiveness ratio (ICER) for each inadequate management avoided was €36 and €173 from the point of view of the healthcare system and hospital, respectively. CONCLUSIONS: The PCR assay reduced the number of inadequate antimicrobial treatments aimed to prevent the early onset of GBS disease. However, this strategy generates extra costs that must be put into balance with its clinical benefits.

[Acute urinary retention and retroverted uterus during pregnancy]. / Rétention aiguë d'urine et grossesse.

Acute urinary retention at first trimester of pregnancy are uncommon, but have to alert the physician on the possibility of an incarcerated retroverted uterus. Through the management of iterative acute urinary retention before 18weeks of gestation with an incarcerated uterus and a review of the literature, we are going to see the various aetiologies, particularly gravid incarcerated uterus. Acute urinary retention during pregnancy is an emergency. Vaginal operations to open up the uterus should be tried at premature terms, successfully in most of cases.

[Single-dose intraincisional levobupivacaine infiltration in caesarean postoperative analgesia: a placebo-controlled double-blind randomized trial]. / Infiltration peropératoire de lévobupivacaïne après césariennes: étude randomisée en double insu contre placebo.

OBJECTIVES: The efficacy of single-dose intraincisional infiltration with levobupivacaine in postoperative analgesia and chronic pain after caesarean sections is unknown. STUDY: A placebo-controlled double-blind randomized trial. PATIENTS AND METHODS: After ethical approval, and written inform consent, 140 women scheduled for a caesarean section were randomly assigned and received 30mL of levobupivacaine 0.5% (L group) or saline (placebo-P group) into their wound. The primary endpoint was morphine consumption (using intravenous morphine patient-controlled analgesia) for the first 24h after surgery. At 1h to 48h, side effects, pain at rest and pain 2months later were recorded. RESULTS: All included patients had similar demographic and surgical characteristics. The morphine consumption was significantly lower in the L group at h6, h8 and h12 (considering both total intake and each request). At h4, the mean total morphine consumption was 25 (12) mg in the L group versus 31 (14) mg in the P group (P=0.05). Time until discharge and side effects including nausea-vomiting (14 vs 20%), wound scar complications (6 vs 8%) and chronic pain after 2months (25% in both groups complained of small pain, and 75% no pain) were similar between the two groups (P>0.05). CONCLUSION: Single-dose local infiltration of levobupivacaine 0.5% reduced opioid requirement at 12h, with no difference after 24h. www.clinicaltrials.com, number: NCT00621907.

[Preliminary study of fetal head engagement diagnosis by transperineal ultrasound before operative vaginal delivery]. / Étude préliminaire du diagnostic d'engagement par une échographie transpérinéale avant une extraction instrumentale.

OBJECTIVES: Estimate the predictive value of perineum-fetal head distance obtained by transperineal ultrasound on results of an operative vaginal delivery. PATIENTS AND METHOD: A prospective preliminary monocentric study has been conducted on 28 patients between the 18th of April and the 31st of July 2011. Three successive perineum-fetal head distance have been measured before realization of an operative vaginal delivery. RESULTS: With caesarian section deliveries, average distances were higher than with successful operative vaginal deliveries but this result was not significant (49.3mm vs 39.7 mm; P=NS). Ultrasound measured distance was significantly correlated to the time of application of the instrument (r=0.45, P=0.0165). Beyond 50mm, the relative risk of caesarian was 10.5 (IC [0.76-145.36]). The measures were corresponding, with an average time of realization of 29.9 seconds. The transvaginal examination compared to ultrasound showed a discordance of 3.6% for the diagnosis of engagement and of 25% for the descent of fetal head. CONCLUSION: A larger study is necessary to confirm this result and to recommend the realization of a transperineal ultrasound before an operative vaginal delivery in cases of doubt about engagement after the transvaginal examination.

[A new low-cost webcam-based laparoscopic training model]. / Intérêt et performances d'un pelvitrainer portable pour l'entraînement à la laparoscopie.

OBJECTIVES: To validate a new laparoscopy home training model (GYN Trainer®) in order to practise and learn basic laparoscopic surgery. PATIENTS AND METHOD: Ten junior surgical residents and six experienced operators were timed and assessed during six laparoscopic exercises performed on the home training model. RESULTS: Acquisition of skill was 35%. All the novices significantly improved performance in surgical skills despite an 8% partial loss of acquisition between two training sessions. Qualitative evaluation of the system was good (3.8/5). DISCUSSION AND CONCLUSION: This low-cost personal laparoscopic model seems to be a useful tool to assist surgical novices in learning basic laparoscopic skills.

[Prospective evaluation of an intravaginal electrical stimulation in the treatment of women with pure genuine stress urinary incontinence]. / Évaluation prospective d'un dispositif de rééducation périnéale à domicile dans l'incontinence urinaire d'effort féminine.

OBJECTIVES: To study the objective and subjective effectiveness of transvaginal electrical stimulation for treatment of female pure genuine stress incontinence. PATIENTS AND METHODS: This was a multicenter prospective trial including 207 patients with genuine stress incontinence who used the stimulator for 10 weeks. Similar pre-treatment and post-treatment assessments included both validated symptom severity index and health-related quality of life. RESULTS: Objective evaluation showed a significant improvement in 65.7% of subjects with stress incontinence. All domains of quality of life improved significantly after treatment (P=0.0001) and rate of satisfactory was 84.7%. There were no statistical differences between the two stimulators. DISCUSSION AND CONCLUSION: Pelvic floor electrical stimulation seems to be effective in treating female genuine stress incontinence and could be considered first-line therapy.

[Latest developments on risk factors and prophylaxis of thromboembolic disease in obstetrics]. / Actualités sur les facteurs de risque et la prévention des complications thrombotiques de la grossesse.

Venous thromboembolic disease and placental vascular pathology are responsible for an important maternal and foetal morbi-mortality with a modification of the hemostasis parameters. As these biological factors combined with particular clinical features can increase or reduce the risk of occurrence of these diseases, knowing the risk factors would help to prevent problems during the pregnancy. Several antithrombotic therapies exist, including very recent ones. Furthermore, a lot of recommendations are available in the literature. A lot of data are thus at our disposal but their synthesis is necessary to be really useful. We review here the risk factors, therapies and recommendations to help improve the management of these women.

[Prospective randomised study of long versus short agonist protocol with poor responder patients during in vitro fertilization]. / Étude prospective randomisée protocoles agonistes long versus court chez les patientes mauvaises répondeuses en fécondation in vitro.

OBJECTIVES: Different ovarian stimulation protocols are used for in vitro fertilization (IVF) in "poor responder" patients. Our work aims at comparing two ovarian stimulation protocols (long agonist half-dose protocol versus short agonist protocol without pretreatment) in this population of women. PATIENTS AND METHODS: This prospective, randomized study was realized at the University Hospital of Saint-Étienne and concerns "poor responder" patients (age between 38 and 42 years and FSH at day 3 more than 9.5 IU/L; and/or antral follicles count less or equal to 6; and/or failure of previous stimulation). The primary endpoint is based on the number of oocytes retrieved at the end of an IVF cycle. RESULTS: Out of the 44 patients randomized, 39 cycles were taken into account (20 in the long protocol, 19 in the short one). At the end of the stimulation (FSH-r 300 to 450 UI/d), the number of follicles recruited appears higher in the long protocol but the difference is not significant (diameter between 14 and 18 mm: 3.0±2.31 vs. 1.88±1.89 and diameter greater than 18 mm: 3.9±2 85 vs. 3.06±2.77). The same tendency is observed for all the following criteria: the number of retrieved oocytes (6.74±2.73 vs. 6.38±4.26), the total number of embryos (3.16±2.03 vs. 2.25±2.11), the pregnancy rate per retrieval (21% vs. 19%) and per cycle (20% vs. 16%), and the number of children born alive. DISCUSSION AND CONCLUSION: The study did not reveal any difference between the two protocols but the long half-dose seems to be better.

[Failed forceps extraction: risk factors and maternal and neonatal morbidity]. / Facteurs de risque et morbidité maternelle et néonatale des échecs d'extraction instrumentale par forceps.

OBJECTIVES: To evaluate risk factors associated with failed forceps delivery and to compare the maternal and neonatal morbidity. PATIENTS AND METHODS: In this retrospective case-control study, all failed forceps delivery cases were analyzed from January 2005 to June 2008 and were compared to a successful forceps delivery cohort. RESULTS: The rate of failed forceps extraction was 4.4% (40/918). Specific risk factors were extraction above a fœtal station of S+2 (OR=43.03; IC 95%: 3.8-475.41), occipito-posterior position (OR=34.64; IC 95%: 4.08-293.5), and biparietal diameter higher than 95mm (OR=10.74; IC 95%: 1.4-82.41). Maternal and neonatal morbidity was few in both groups. CONCLUSIONS: Diagnosis of presentation level and variety of presentation are necessary before instrumental extraction. A "trial of forceps" should be performed with caution in a setting where a caesarean delivery could follow. Vacuum extraction could be interesting in case of occipito-posterior position.

[Is the socioeconomic deprivation EPICES score useful in obstetrics?]. / Intérêt de l'échelle d'évaluation de la précarité EPICES en obstétrique.

OBJECTIVES: To describe a validated and multifactorial deprivation score to study the relationship between socioeconomic deprivation and perinatal risks. PATIENTS AND METHODS: The index of deprivation EPICES (Evaluation of Precarity and Inequalities in Health Examination Centers) was used to characterize the deprivation status of 234 women in post-partum in comparison with perinatal morbidity. The cutoff value of 30.7 was the threshold to define deprivation. RESULTS: Two hundred and eight patients were included in this retrospective study from whom 48 (23%) had a score of deprivation higher than 30.7. Maternofetal morbidity was more severe in deprived patients. DISCUSSION AND CONCLUSION: The current results show that the EPICES score could be a useful obstetrical tool for the identification of deprived women during pregnancy.

[Anthropometric analysis of obstetrical pelvis from Neolithic area: obstetrical consequences. Preliminary study]. / Analyse anthropométrique du bassin obstétrical datant du Néolithique : conséquences obstétricales. Étude préliminaire.

OBJECTIVES: To study female pelves from Neolithic area (5000 years AD) in order to better understand the evolution of obstetrical mecanisms. MATERIALS AND METHODS: The fossil material comprised 73 Homo sapiens pelves: we reconstructed all the 20 adult female bony pelves. We realised the shape and morphometric analysis of the pelvic cavity. Changes in pelvic neolithic morphology were compared with pelvic modern morphology. RESULTS: The pelves of prehistoric female were similar in shape with modern female. However, they differ in relative dimensions (transversal diameter of the pelvis inlet: respectively 118 mm vs 125 mm, p=0.02). DISCUSSION AND CONCLUSION: Reconstructions based on Neolithic hominin fossils suggest that obstetrical mechanisms were probably common to Neolithic and modern humans: childbirth would probably require social adaptations and risks of perinatal and obstetric complications were undoubtedly high. However, the differences in morphometric analysis could suggest a change of human pelvis and raise the question of the evolution in obstetrical mechanisms in the future.

[Computerized cardiotocography and short-term variation in management of obstetric cholestasis: a useful tool?]. / Intérêt de la variabilité à court terme dans la surveillance de la cholestase gravidique.

OBJECTIVE: To evaluate active management of obstetric cholestasis by comparing correlation between bile acid concentrations and computerized cardiotocography (Short-term variation [STV]). PATIENTS AND METHODS: Retrospective analytic study about 51 obstetric cholestasis between January 2001 and August 2009. Demographic characteristics, bile acid concentrations and STV data were recorded since diagnosis to pregnancy with evaluation of fetal outcome. RESULTS: There were no statistical correlation between bile acid concentrations, STV data and fetal outcome. Patients with cholestasis diagnosed in second trimester delivered 12 days earlier than cholestasis diagnosed in third trimester (p=0.0012). Delivery before 37 weeks was found in 37.2% of cases. There were no perinatal deaths. Sixty percent had a recurrent obstetric cholestasis. CONCLUSION: Further works are necessary to study the exact pathogeny of obstetric cholestasis in order to determinate the best surveillance.

[Ovarian carcinogenesis: recent and past hypotheses]. / La cancérogenèse ovarienne : théories actuelles et passées.

Ovarian carcinogenesis and the early stages of malignant transformation are limited because of the lack of a candidate precursor. There have been several proposed hypotheses: first, ovary and the ovarian surface epithelium and more recently observations have increasingly focused attention of the Fallopian tube. Moreover, molecular genetic analysis has designed two main pathways of tumorogenesis. In this review, we discuss the different and perhaps complementary hypotheses about ovarian carcinogenesis.

[Prenatal diagnosis and management of isolated bladder exstrophy]. / Diagnostic anténatal et prise en charge des extrophies vésicales isolées.

The isolated bladder extrophy is a major congenital malformation which prenatal diagnosis is essential. It is based on the non-visualization of the bladder during the first trimester ultrasound but in most cases, it is confirmed by the morphological ultrasound of the second trimester. For the baby, the prognosis of life quality depends on the accurate identification of the malformation, the foetal sex and the associated pathologies. Thus, a detailed ultrasound evaluation is necessary and requires an operator experienced in the search of malformations. As this abnormality has important aesthetic and functional consequences, a multidisciplinary management is required for a good information of the couple. The continuation of pregnancy is currently possible but the couple should be informed that after surgery, often a major one, more than 75% of children will have a urinary continence by reconstruction or bypass. Furthermore, their ability of reproduction will need to be medically improved.

Identification of factors influencing the decision-to-delivery interval in emergency caesarean sections.

BACKGROUND: In a life-threatening context, the American College of Obstetrics and Gynecology and the Royal College of Obstetrics and Gynaecology recommend a maximum delay of 30 min between the decision to perform an emergency caesarean and the infant's birth. Our objectives were to estimate the rate of prolonged intervals and identify the factors influencing the decision-to-delivery interval. METHODS: All women who had given birth at Saint-Etienne University Hospital by a non-prophylactic caesarean section between September 1 and November 1, 2007 were included in a prospective cohort study. A linear regression analysis was performed to identify the factors influencing the decision-to-delivery interval. RESULTS: 68 women were included in the study. Regardless of the degree of emergency, the decision-to-delivery interval exceeded the recommended interval in 50% of the cases. In extremely urgent caesarean sections, the optimal interval of 15 min was exceeded in 85.7% of cases. We found that two factors contributed to delayed patient care: urgent and extremely urgent caesareans and hospitalization in a pathological pregnancy unit. This delay leads to more paediatric reanimations. CONCLUSION: This study highlights the difficulty to reach the recommended target interval. One solution is to improve the identification of the degree of urgency and the communication between the various members of the healthcare team.

[Risk factors of mesh exposure after transvaginal repair of genital prolapse]. / Facteurs de risque d'exposition de prothèse dans les cures de prolapsus génital par voie vaginale.

OBJECTIVES: We analysed the risk factors of vaginal surgery of pelvic organ prolapse with non resobable prothesis. PATIENTS AND METHODS: This is a continuous, retrospective study of the 208 patients who had surgery between 2003 and 2007. Depending on the localisation of the prolapse, they had a prothesis under the bladder and/or a posterior tape through the sacrospinous ligament. An hysterectomy and a levator myorraphy were done if necessary. RESULTS: After a 3 years follow-up, we found 16.8% mesh exposure (23% were treated by a conservative way). The highest rate of incidence was at 4 and 10 months. The independent risk factors of exposure were the kind of prothesis, age under 60 and concomitant hysterectomy. Women treated by vaginal estrogens and those operated by the most experienced surgeon had less exposure. We had 5% of complications during the surgery. DISCUSSION AND CONCLUSION: Hysterectomy, kind of prothesis and inverted T colpotomy of Crossen are well known risk factors. Age, stage of prolapse, size of prothesis and surgeon experience are discussed. Vaginal surgery of pelvic organ prolapse with non resobable prothesis must be used only when prolapse stage is higher than 3, hysterectomy has to be avoid and vaginal estrogens must be prescribed.

[Shoulder dystocia: a ten-year descriptive study in a level-III maternity unit]. / La dystocie des épaules: analyse descriptive sur dix années dans une maternité de niveau III.

OBJECTIVE: Shoulder dystocia is one of the most dreadful complications of vaginal deliveries. The aim of this observational study was to evaluate risk factors of dystocia, maternal and neonatal complications and recurrent risk factors. PATIENTS AND METHODS: Sixty-six cases of shoulder dystocia occurring between January 1998 and August 2008 in our university hospital were identified. Demographic data, labor management, management of the shoulder dystocia and neonatal outcome were recorded. RESULTS: The incidence of shoulder dystocia was 0.3%. Multiparity, weight gain greater than 12 kg, and post-term delivery were more present in our study group. McRoberts' manoeuver and symphyseal pressure were first realised. Brachial plexus injuries affected 9% of neonates with skeletal fractures in 7.5% of cases. Maternal morbidity was evaluated at about 8%. Twenty per cent had a recurrent shoulder dystocia. DISCUSSION AND CONCLUSION: Shoulder dystocia is an obstetric emergency which requires a prompt management of trained personnel. Despite the difficulty of being able to prevent shoulder dystocia, training the obstetric staff could probably improve management of shoulder dystocia.

[Early fetal megacystis at first trimester: a six-year retrospective study]. / Diagnostic anténatal de mégavessie au premier trimestre de la grossesse. Etude rétrospective sur six années.

OBJECTIVE: A fetal megacystis is defined by a longitudinal bladder diameter more than 7 mm. The purpose of this study is to describe the prenatal ultrasound findings of this early fetal pathology and to assess pronostic and aetiologycal criteria. PATIENTS AND METHODS: Between January 2003 and December 2008, 12 cases of early fetal megacystis were identified in our referral fetal medicine unit (Saint-Etienne hospital, France). RESULTS: There were two cases of spontaneous resolution and one case wasn't a fetal megacystis. Termination of pregnancy for medical indications was realised for another cases because of associated malformations and bad evolution (six cases) and three chromosomal abnormalities (two cases of trisomy 18 and one of trisomy 21). DISCUSSION AND CONCLUSION: Sonographic follow-up and fetal karyotyping are important to evaluate prognosis. However, our data suggest that fetal megacystis is a severe condition when diagnosed in early pregnancy.