[Pelvi-perineal chronic pain, urgent demands of care and decision-making]. / Douleurs pelvipérinéales chroniques, demandes urgentes de soins et prise de décision.

OBJECTIVE: Some patients suffering from pelvi-perineal chronic pain express urgent, even vital, demands of care. The objective was to compare the profile and the psychological functioning of the patients, who have shown an imperious demand of care, in that of the patients who do not have an imperious demand of care. MATERIAL AND METHOD: From the medical consultations for chronic pelviperineal pain, we realized a comparative study including 26 patients (experimental group) expressing an urgent demand of care (i.e., patients who, during the last 3months, called an emergency service concerning the pains for which they consult in the service) and 28 patients (control group) without an urgent demand of care (i.e., patient who, during the last 3months, did not call an emergency service concerning the pains for which they consult in the service). All the patients were tested through a cognitive task of decision-making (Iowa Gambling Task) and through explicit measures of pain and its main psychological associated factors (anxiety, depression, impulsivity an catastrophism). RESULTS: In the first place, the patients from the experimental group possess decision-making abilities equivalent to the patients of the control group; however, both groups of patients show, in the beginning of the test, a deficit in the decision-making (F(4.208)=3.4116; P=.009). Secondly, the measures to questionnaires reveal that the patients of the control group have less severe scores in the scales of depression (t(52)=-2.068; P<04), catastrophism (amplification : t(52)=-3.069; P<0035; powerlessness: t(52)=-2.866, P<.006) and impulsivity (positive urgency: t(52)=-2.246, P<029; lack of premeditation: t(52)=-2.175, P<035) than the patients of the experimental group. CONCLUSION: The use of explicit measures (questionnaire) and implicit measures (experimental task) allowed to objectify more precisely the differences between the chronic pain patients in urgent demand of care and the other chronic pain patients. This psychological specificity obliges us to approach differently the caring of these patients in particular by proposing adapted cognitivo-behavioral techniques. LEVEL OF EVIDENCE: 3.

[Impact of pelvic floor muscle training on prevention of perineal pain and dyspareunia in postpartum]. / Impact de la rééducation périnéale sur la prévention des douleurs et des dyspareunies en post-partum.

OBJECTIVE: Assessing the impact of perineal rehabilitation and massage on perineal pain and dyspareunia in the postpartum period, between 15days and 12months after delivery. METHODS: We conducted an exhaustive review of the literature concerning pelvic floor rehabilitation in the postpartum between 1987 and May 2015, grading data by levels of evidence (LOE) according to the methodology recommendations for clinical guidelines. RESULTS: Pelvic floor rehabilitation in the postpartum is not associated with a decreased prevalence of perineal pain and dyspareunia at 1year (LOE3). The practice of digital perineal massage during the third trimester of pregnancy is not associated with decreased prevalence at 3-month postpartum of perineal pain or dyspareunia (RR=0.64; 95% CI [0.39-1.08] and RR=0.96; 95% CI [0.84-1.08], respectively), except for women who have delivered vaginally (RR=0.45; 95% CI [0,24-0.87]) (LOE2). The practice of digital perineal massage or application of warm packs in the second stage of labor does not reduce perineal pain (RR=0.93; 95% CI [0.66-1.32]) or dyspareunia (RR=0.99; 95% CI [0.74-1.34]) at 3-month postpartum (LOE2). CONCLUSION: There is no evidence of long-term benefit of perineal rehabilitation and perineal massage on perineal pain and dyspareunia in the year following childbirth. Further studies are needed to accurately assess the impact of therapeutic strategies proposed in France.

Prospective multicenter study of ultrasound-based measurements of fetal head station and position throughout labor.

OBJECTIVES: To assess the relationship between fetal head position and head station during labor, as measured using an ultrasound-based system, and the occurrence of occiput posterior (OP) position at delivery. METHODS: This was an international prospective observational study including women who delivered between January 2009 and September 2013 in four centers: one in Brooklyn, NY, USA; one in Haifa, Israel; and two in Paris, France. We used an ultrasound-based system (LaborPro) to monitor fetal head station and position non-invasively throughout labor. We collected data on demographics, labor parameters and outcome. RESULTS: A total of 595 women were included. In 563 (94.6%) women, fetal head position at delivery was occiput anterior (OA), in 31 (5.2%) it was OP and in one (0.2%) it was occiput transverse. In 89% of pregnancies with intrapartum OP when fetal head station was above -2, the head position turned to OA at delivery; the equivalent figures were 74% and 63% OA at delivery when intrapartum OP was diagnosed at head stations of -2 to < 0, and 0 and below, respectively. Cesarean delivery was performed in 35% of pregnancies with fetal head in OP position at delivery, as opposed to 10% of those with non-OP position at delivery. On retrospective analysis, all deliveries in OP were already in OP at station -2 and below. CONCLUSIONS: In this first assessment of fetal head position at delivery according to fetal head position at various station levels, our data show that 100% of OP positions at delivery were already in OP position at station -2 and below. We did not observe rotation from a non-OP to an OP position from station -2 and below. Nearly two-thirds of fetuses in OP at station 0 and below will rotate to an OA position for delivery.

Pregnancy outcomes in women with imported malaria in mainland France: A retrospective study from 2004 to 2014.

OBJECTIVES: There is little data on pregnant women with imported malaria in high-income countries, especially regarding offspring outcomes. We wanted to determine pregnancy outcomes of imported malaria in pregnant women in mainland France. PATIENTS AND METHODS: We conducted a retrospective, descriptive study of outcomes in pregnant women hospitalized with malaria from 2004 to 2014 in two regions of mainland France. An adverse outcome was defined as a miscarriage, stillbirth, preterm birth (<35 weeks of gestation), low birth weight (LBW) defined as less than 2500 g, or congenital malaria. RESULTS: Of 60 pregnancies, 5 were excluded because of elective abortions; 55 were investigated, of which 11 were primigravidae and 44 multigravidae. Pregnancies were singleton (n = 51) or twin (n = 4). Mean age was 30.4 years (range:19-45 y). Among the 55 cases, 9 ended in a miscarriage (8 singletons and 1 twin pregnancy) and 1 had a stillbirth at 21 weeks of gestation, all immediately after the malarial episode. 45 gave birth (29 vaginal deliveries and 16 caesarean sections) to 48 (42 singletons and 6 twins) newborns. Amongst these, 30 were healthy full-term newborns, 10 had LBW, and 8 were preterm. Overall, 26 of 55 (47.3%) pregnancies, and 29 of 59 (49.2%) offsprings had adverse outcomes. Compared to singleton pregnancies, twin pregnancies were associated with adverse outcomes (p = 0.0438). CONCLUSIONS: Imported malaria has a severe impact on pregnancy outcomes. Prevention and management of imported malaria in pregnancy should be optimized.

Experiences of parents and caregivers in pediatric intensive care units: A qualitative study.

BACKGROUND: In pediatric intensive care units (PICUs), parents and healthcare professionals attend to children who verbally and non-verbally express their pain and suffering, fears, anxieties, desires, and wishes in complex intensive care situations. What can we learn from these experiences to improve the way we can take care of and support children? OBJECTIVES: The main objective of this clinical ethics study was to focus on the experience stories of parents during their child's hospitalization in a PICU, to analyze their discourse, and to propose an ethical perspective. METHOD: The current research collects the experience reports of parents during their child's hospitalization in a PICU and those of the caregivers who treated them. A total of 17 semi-directive interviews were conducted in the PICU of the Nantes University Hospital from November 2017 to June 2019. Each interview lasted around 1 h. The main results of our study are analyzed and informed by the four ethical principles of T. Beauchamp and J. Childress: autonomy, beneficence, non-maleficence, and justice. RESULTS: The interviews highlighted the difficulties encountered by parents during the hospitalization of their children, such as the distance between their home and the hospital, the technicality of PICU environment, and the difficulty in finding their place as parents. For medical and paramedical teams, their main concerns are undoubtedly to improve the coherence and continuity of their stand toward parents, to promote parental autonomy, and to remain fully aware of the profound existential changes that the child's illness brings about for parents: It is the caregivers' duty to take this into account and to respect the parents' rhythm as much as possible. CONCLUSIONS: The main disagreements between healthcare teams and parents, where they exist, are communication problems that are easily controlled, for the most part, by caregivers.

Online evaluation of fetal second-trimester four-chamber view images: a comparison of six evaluation methods.

OBJECTIVE: To compare six online evaluation methods for auditing routine second-trimester four-chamber view still images. METHODS: We evaluated three different scoring grids (subjective, five-item score and seven-item score), which were applied with or without access to online help, resulting in a total of six evaluation methods. For the subjective scoring grid, images were rated as excellent, good, fair, poor or very poor. For the five-item score, 1 point was allocated for visualization (vs non-visualization or non-evaluable) of each of: heart crux, atria, ventricles, apex and aorta, yielding a score of 0-5. For the seven-item score, 1 point was allocated for clear (vs unclear) visualization of each of: moderator band at the apex, interventricular septum, atrioventricular valves, non-linear insertion of atrioventricular valves (normal offset), septum primum, aorta and pulmonary vein. Each evaluation method was used via the Internet by three randomly selected reviewers, who evaluated the same set of 80 images. Reviewers were experienced in fetal ultrasound, but were not involved in the design of the study. Interrater agreement was the main outcome. RESULTS: The five-item scoring grid with online help achieved the best interrater agreement (interrater intraclass correlation coefficient = 0.7). CONCLUSIONS: Evaluation of the second-trimester sonographic four-chamber view is apparently best achieved with a simple five-item scoring grid.

Association between ultrasound-based assessment of fetal head station and clinically assessed cervical dilatation.

OBJECTIVES: To describe the association between ultrasound-based determination of fetal head station and clinical assessment of cervical dilatation during active labor. METHODS: From 427 women with singleton uncomplicated term pregnancies we obtained, during the active phase of labor, 907 pairs of measurements. Fetal head station and position were determined using the LaborPro system, based on position tracking and ultrasound imaging technology, and degree of cervical dilatation was determined by digital vaginal examination. The association between them was analyzed. RESULTS: The overall correlation between cervical dilatation and fetal head station was 0.64 (P < 0.001). Complete dilatation was observed in 78% of women with fetal head engagement, and in all women with a fetal head station of + 1.5 or more. CONCLUSIONS: There is good association between non-invasive ultrasound-based determination of fetal head station and clinically assessed cervical dilatation.

Comparison of patient-led, fibromyalgia-orientated physical activity and a non-specific, standardised 6-month physical activity program on quality of life in individuals with fibromyalgia: a protocol for a randomised controlled trial.

BACKGROUND: Exercise has been shown to significantly improve pain and function in individuals with fibromyalgia. Research into the effectiveness of exercise is often based on standardised exercise programmes that are chosen by the investigating clinical research team. However, such programmes may not necessarily be appealing to the participating patients. Furthermore, in addition to being taught exercises, patients with chronic conditions like fibromyalgia also need to learn to manage their condition themselves and so be actively involved in their treatment. The primary aim of this study is to compare the effects of two, 6-month physical activity programs on quality of life in patients with fibromyalgia. One group followed a patient-led, fibromyalgia-orientated programme (experimental) whilst the control group followed a standard, general exercise programme. METHODS: This protocol is an open-label, two-centre, randomised, controlled superiority trial. Two treatment arms will be compared: an experimental group (patient-led, fibromyalgia-orientated exercise) and a control group (general exercise program). The control group will participate in the exercise programme currently provided in our centre, which involves general, group exercise for patients with various pathologies. The experimental group will be taught the principles of exercise specifically for fibromyalgia during a one-to-one coaching session. They will then be guided in the choice of one or several types of exercise that they enjoy. They will be instructed to perform the exercise according to the recommendations for exercise in fibromyalgia with regard to intensity, duration and frequency. The protocol will last for 6 months; participants will then be followed-up for a further 6 months. They will also be encouraged to continue exercising after the end of the protocol. Outcomes will be evaluated at baseline, 6 and 12 months. The primary outcome will be quality of life (Fibromyalgia Impact Questionnaire) and the secondary outcomes will include measures of pain (including a visual analogue scale and the neuropathic characteristics of the pain), depression (Hospital Anxiety and Depression Scale), kinesiophobia (Tampa scale of kinesiophobia) and adherence (Polar OH1 heart rate monitor). DISCUSSION: The results of this study will show if patient-led, fibromyalgia-orientated exercise is more effective than a general exercise programme on fibromyalgia-related outcomes, including quality of life, and on adherence to continued exercise. TRIAL REGISTRATION: ClinicalTrials.gov NCT03895086 . Registration no. 2018-A02881-54. Registered on 29 March 2019.

Perineal approach to vascular anatomy during transobturator cystocele repair.

OBJECTIVE: To evaluate the risk of vascular injury during transobturator approach of cystocele repair. DESIGN: Dissection of the obturator area by perineal approach was performed after placement of mesh needles used for cystocele mesh repair. SETTING: Surgery school of Paris. POPULATION OR SAMPLE: Twenty obturator regions in ten fresh female cadavers. METHODS: Transperineal dissection of the obturator area was conducted in ten fresh female anatomic subjects after inserting anterior Prolift needles. MAIN OUTCOME MEASURES: The vascular anatomy of the obturator region was mapped. Distances between needles and vascular structures of the obturator area were measured three times and averaged for each side. RESULTS: The anterior cannula-equipped needle perforated the gracilis and the adductor brevis muscles. The mean (SD) distance to the anterior obturator vessels was 21.2 (1.6) mm on the right side and 20.4 (1.5) mm on the left. The posterior needle perforated the adductor magnus. Its distance to the posterior division of the obturator vessels was 1.8 (1.0) mm on the right side and 1.1 (0.9) mm on the left. CONCLUSIONS: During mesh cystocele repair by transobturator approach, the posterior obturator vessels division seems at risk of injury during the posterior needle insertion.

Major venous hemorrhagic complication during transvaginal cystocele repair using the transobturator approach.

BACKGROUND: New approaches to pelvic organ prolapse have been evolving rapidly with few reports on safety and efficacy. This case describes the management of a severe intraoperative venous hemorrhage when performing this minimally invasive surgery. CASE: A postmenopausal woman experienced a life-threatening hemorrhagic complication during transvaginal cystocele repair using a transobturator approach procedure. The bleeding appeared after the posterior left needle insertion. Immediate imaging revealed that bleeding came from a terminal anterior branch of the left internal hypogastric vein. Embolization of the left hypogastric artery partially reduced the hemorrhage. Local packing was the most efficient hemostatic technique. Pelvic varicose veins were the major risk factor found in this case. CONCLUSION: Although the transobturator technique is considered minimally invasive surgery, morbidity can be severe and require specific management.

Abdominal and pelvic ultrasound findings within 24 hours following uneventful Cesarean section.

OBJECTIVES: To describe prospectively the normal abdominal and pelvic ultrasound features within 24 h following uneventful Cesarean section. METHODS: Transabdominal ultrasound examination was performed between 1 and 3 h, and again at 24 h, following lower-segment Cesarean section (LSCS). The myometrium, endometrium, and amount and distribution of free peritoneal fluid were studied in 30 women with singleton pregnancies who underwent LSCS delivery. RESULTS: Examinations were performed easily in all cases except one who was morbidly obese (body mass index > 40 kg/m(2)). At 1-3 h after delivery, mean +/- SD endometrial thickness was 13 +/- 2 mm. Mean uterine length, from the fundus to the cervical external os, was 160 +/- 15 mm. Measurement of uterine length in the mid-sagittal plane of the pelvis was impossible in eight cases (27%) owing to pain. No abnormal intrauterine findings were observed. Mean uterine width was 110 +/- 10 mm. Mean distance between the sacral promontory and uterine fundus was 104 +/- 11 mm. Mean thicknesses of the anterior and posterior walls of the uterus were 40 +/- 5 mm and 39 +/- 7 mm, respectively. No fluid was seen in Morrison's or Douglas' pouches. There was a consistent and significant reduction between the measurements performed at 1-3 h and those at 24 h after LSCS, except for the distance between the fundus and external os. CONCLUSIONS: Ultrasound examination is feasible after Cesarean section. Images are obtained easily, even when scanning through the scar. In normal pregnancies, there is no fluid in the abdomen or pelvis. These results could help clinicians in the decision-making process in cases of early postpartum hemorrhage or hemodynamic instability following LSCS.

[What do French trainees in obstetrics and gynecology wish as future professional activity in 2006? A national survey]. / Quelle activité professionnelle envisagent les internes en gynécologie-obstétrique en 2006? Résultats d'une enquête nationale.

OBJECTIVE: To survey French trainees in obstetrics and gynaecology on the type of short and long-term professional activity they wish to have following specialisation. MATERIAL AND METHODS: A questionnaire was sent to the 909 trainees in obstetrics and gynaecology during the academic year 2005-2006. RESULTS: Answer rate was 34.5%. Almost all trainees (96.5%) wish to have a two-year hospital position before applying for consultant or beginning a private practice. Only 55.6% of these trainees think this option realistic. Overall, 78.7% of trainees wish to continue practicing obstetrics, 66.9% surgery, 41.4% ultrasound screening or prenatal diagnosis, 34.1% office gynaecology, 28% oncogynaecology and 23.6% assisted medical procreation. An exclusive public hospital position was desired by 51.6% of trainees, with 45.1% in academic hospitals and 54.9% in non academic hospitals. Exclusive private practice was desired by 8.9% of trainees and 47.7% wish a private practice with a part-time public hospital position. CONCLUSION: Actual trainees in obstetrics and gynaecology see their future practice as polyvalent, mostly in public hospitals and including for most at least obstetrics.

Pregnancy and newborn outcomes in arrhythmogenic right ventricular cardiomyopathy/dysplasia.

INTRODUCTION: The prognosis of pregnancy in patients with Arrhythmogenic Right Ventricular Cardiomyopathy/dysplasia (ARVC/D) is poorly documented. The aim of this study is to assess the cardiac risks during pregnancy and the impact of ARVC/D on fetuses/neonates/children. METHODS: We included all ARVC/D women with a history of pregnancy from the ARVC/D Pitié-Salpêtrière registry. Cardiac and obstetrical events having occurred during pregnancy/delivery/post-partum periods and neonatal data/follow-up were collected. RESULTS: Sixty pregnancies in twenty-three patients were identified between 1968 and 2016. Only two major non-fatal cardiac events (one sustained non-documented tachycardia and one ventricular tachycardia) were recorded during pregnancy in two different mothers (3% of pregnancies, 9% of mothers). None occurred during delivery or in the postpartum period. No mother developed heart failure. Beta-blocker therapy during pregnancy (n=15) was associated with lower birthweight (2730 vs 3400g, p=0.004). Only two preterm deliveries occurred, unrelated to cardiac condition. Caesarean section was performed in 13% of cases. Premature sudden-death occurred in 10% (n=5) of children before 25years-old including two in the first year of life. CONCLUSION: ARVC/D is associated with a low rate of major cardiac events during pregnancy and vaginal delivery appears safe. The risk of sustained ventricular arrhythmia seems poorly predictable and supports the continuation of beta-blockers during pregnancy. Major cardiac events were frequent in childhood, justifying close cardiac monitoring.

[Indication for Doppler evaluation of the ductus venosus in the management of intrauterine growth restriction of vascular origin]. / Apport du doppler du canal d'Arantius dans la prise en charge des retards de croissance intra-utérin d'origine vasculaire.

Intra uterine growth retardation is a major cause of perinatal morbidity and mortality. These are due to prolonged intra uterine hypoxia and complications from subsequent induced prematurity. Fetal arterial doppler measurements, and more recently venous Doppler measurements, help choosing the ideal moment for delivering these fragile fetuses. Nevertheless, venous doppler measurements should be combined to other monitoring tools, used longitudinally and only when very preterm birth is expected.

[Perinatal risk at term and post-term revisited]. / Période du terme: le risque périnatal revisité.

The aim of this review was to revisit the evaluation of risk of foetal and neonatal mortality at term. We analyse the meaning of term period and difficulty to determine the normal duration of the pregnancy. Specific complications associated with post term and the statistic approach of the perinatal risk are analysed, together with various mortality rates and especially the prospective risk introducing foetal term as a new concept. We study various aspect and evolution of non specific morbidity of the term period. An optimal decision for term management should involve pregnant women and the analysed parameters should be taken into consideration.

Successful use of a Bakri Tamponade Balloon in the treatment of puerperal uterine inversion during caesarean section.

Acute puerperal inversion of the uterus is a rare life-threatening obstetric emergency, especially during caesarean section. We present the case of a 30-year-old patient with acute puerperal inversion of the uterus that occurred during placental removal. After a quick reversion of the uterus, an immediate postpartum haemorrhage (PPH) due to massive uterine atony was observed. This atony impacted the whole uterus, with a very thin uterine myometrium. The use of a Bakri Tamponade Balloon use allowed treating extreme uterine atony, immediately stop haemorrhage, and prevent a possible risk of immediate recurrence.

[What should you tell a patient with a history of cervical incompetence in the first trimester?]. / Comment informer au premier trimestre de la grossesse une patiente ayant un diagnostic de béance cervico-isthmique?

Data is now more than ever available to inform couples at risk of second trimester miscarriage or preterm delivery. We are able to give customized information according to the obstetrical history and to the evolution of the cervix during the second trimester although the level of scientific evidence is limited or poor. Elective cerclage can be proposed to patients with a history of at least 3 second trimester miscarriages or preterm deliveries. There is no clear consensus on which patients could benefit from therapeutic cerclage. Indications would have to be motivated by a short cervix on ultrasound measurements and the cerclage performed before 24 weeks of gestation.

[Evaluation of the feasibility of ultrasound in a community care outpatient pregnancy assessment clinic for high-risk pregnancies]. / Étude de la faisabilité et de la valorisation de l'échographie focalisée dans un cadre d'explorations fonctionnelles extra-hospitalières pour des grossesses à risque.

OBJECTIVES: To assess the clinical, legal, and technical roles of ultrasound in an outpatient pregnancy assessment clinic, while evaluating the feasibility for these consultations to be performed at home. MATERIALS AND METHODS: We prospectively assessed all consultations from April 3 to May 31, 2013, at the outpatient pregnancy assessment clinic of La Pitié-Salpêtrière, Paris, France. We recorded all procedures and the number and type of ultrasound examination performed, according to their indication. For each consultation, we evaluated whether the routine protocols were sufficient or if the attending obstetrician was asked for advice. Finally, we asked the patients if they would prefer having this consultation in a home-care setting. RESULTS: We recorded 429 consultations (n) for 234 patients (Np). Indications were diabetes (n=106/Np=59), assessment of fetal growth (n=90/Np=43), another single indication (n=106/Np=59), multiple indications (n=46/Np=12), term pregnancies (n=39/Np=30), and a history of abnormal pregnancy (n=27/Np=10). CTG was performed for 91 % of consultations, blood samples for 10 %, and ultrasound for 88 %, which included amniotic fluid evaluation (79 %), umbilical Doppler (69 %), fetal biometries (36 %), uterine artery Doppler (0.7 %), cervical length (2 %), suspicion of breech presentation (4 %) and placenta position (0.7 %). Most of these ultrasound examinations could not be financially value if performed by a midwife. Routine protocols were sufficient for the management of 68 % of these consultations, 26 % required the attending obstetrician, and 6 % were finally low-risk. Performing these consultations in a home-care setting was medically possible and requested by the patient for 16 % of consultations (6 % of patients). CONCLUSION: These are encouraging results to experiment the outpatient pregnancy assessment clinic in a home-care setting, although the financial valorization system in France is poorly adapted.