[Intrahepatic cholestasis of pregnancy: French College of Obstetricians and Gynecologists guidelines for clinical practice]. / La cholestase gravidique : recommandations pour la pratique clinique du Collège national des gynécologues obstétriciens français.

OBJECTIVE: To identify strategies for reducing neonatal and maternal morbidity associated with intrahepatic cholestasis pregnancy (ICP). MATERIAL AND METHODS: The quality of evidence of the literature was assessed following the GRADE methodology with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS: Of the 14 questions (from 12 PICO questions and one definition question outside the PICO format), there was agreement between the working group and the external reviewers on 14 (100%). The level of evidence of the literature was insufficient to provide a recommendation on two questions. ICP is defined by the occurrence of suggestive pruritus (palmoplantar, nocturnal) associated with a total bile acid level>10µmol/L or an alanine transaminase level above 2N after ruling out differential diagnoses. In the absence of suggestive symptoms of a differential diagnosis, it is recommended not to carry out additional biological or ultrasound tests. In women with CIP, ursodeoxycholic acid is recommended to reduce the intensity of maternal pruritus (Strong recommendation. Quality of the evidence moderate) and to decrease the level of total bile acids and alanine transaminases. (Strong recommendation. Quality of the evidence moderate). S-adenosyl-methionine, dexamethasone, guar gum or activated charcoal should not be used to reduce the intensity of maternal pruritus (Strong recommendation. Quality of evidence low), and there is insufficient data to recommend the use of antihistamines (No recommendation. Quality of evidence low). Rifampicin (Weak recommendation. Very low quality of evidence) or plasma exchange (Strong recommendation. Very low quality of evidence) should not be used to reduce maternal pruritus and perinatal morbidity. Serum monitoring of bile acids is recommended to reduce perinatal morbidity and mortality (stillbirth, prematurity) (Low recommendation. Quality of the evidence low). The level of evidence is insufficient to determine whether fetal heart rate or fetal ultrasound monitoring are useful to reduce perinatal morbidity (No recommendation). Birth is recommended when bile acid level is above 99µmol/L from 36 weeks gestation to reduce perinatal morbidity, in particular stillbirth. When bile acid level is above 99µmol/L is below 100µmol/L, women should be informed that induction of labor could be considered 37 and 39 weeks gestation to reduce perinatal morbidity. (Strong recommendation. Quality of evidence low). In postpartum, total bile acids and alanine transaminases level should be checked and normalized before prescribing estrogen-progestin contraception, ideally with a low estrogen dose (risk of recurrence of pruritus and cytolysis) (Low recommendation. Quality of evidence very low). CONCLUSION: Although the quality of evidence regarding ICP gestational cholestasis remains low, there is a strong consensus in France, as shown by our Delphi study, on how to manage women with ICP. The reference first-line treatment is ursodeoxycholic acid.

Long-term evaluation of the impact of delivery modalities on anal continence in women with Crohn's disease.

CONTEXT: Crohn's disease (CD) and sphincter injury during childbirth are two risk factors for anal incontinence (AI). The long-term risk of developing AI in women with CD after childbirth has never been studied. GOAL: The main objective of the study is to assess the risk of developing severe AI after childbirth in women with CD. METHODS: A retrospective study was performed in women with CD who gave birth in a French "Level 3" maternity hospital between 2000 and 2015. The primary endpoint was severe AI as defined by a Wexner score≥9 or a St. Mark's score≥9, at least five years after childbirth. The association between delivery route and occurrence of severe AI was assessed by univariate and multivariate analyses. RESULTS: Forty-six women were included, 32 of whom were delivered vaginally and 14 by Caesarean section. Thirty-one percent of the women had severe AI according to the Wexner score, and 41% according to the St. Mark's score. Two factors were associated with severe AI: vaginal delivery and the occurrence of an obstetric perineal injury: (crude OR=8.89, 95% (CI: 1.03-76.57) and crude OR=4.16, 95% (CI: 1.06-16.27) respectively for AI defined by the Wexner score, and crude OR=6.8, 95% (CI: 1.30-35.41) and crude OR=4.3, 95% (CI: 1.23-15.2) for AI defined by the St. Mark's score). After adjusting for confounding factors, only vaginal delivery was associated with severe AI (adjusted OR=22.86, 95% CI: 1.52-931.28 for a Wexner score≥9 and adjusted OR=16. 11 (95% CI: 1.43-533.26) for a St Mark score≥9). CONCLUSION: Vaginal birth was associated with the development of severe long-term AI in women with CD.

In-utero aspiration vs expectant management of anechoic fetal ovarian cysts: open randomized controlled trial.

OBJECTIVE: To assess the efficacy and safety of in-utero aspiration (IUA) of anechoic fetal ovarian cysts. METHODS: This multicenter, prospective, randomized open trial in two parallel groups included women from nine outpatient fetal medicine departments with singleton pregnancy ≥ 28 weeks of gestation and a female fetus with an ultrasound-diagnosed simple ovarian cyst, defined as a single fully anechoic cystic structure measuring ≥ 30 mm. They were allocated randomly to IUA under ultrasound guidance or expectant management. All procedures were performed by trained senior obstetricians. Primary outcome was need for neonatal intervention, by laparoscopy, laparotomy or transabdominal aspiration. Secondary outcomes were in-utero involution of the cyst and oophorectomy at birth. Analyses were conducted according to the intention-to-treat principle. RESULTS: Of 61 participants, 34 were allocated to IUA and 27 to expectant management. Three IUA procedures (9%) could not be performed (one due to fetal position and two due to aspirations being dry). The remaining 31 IUA procedures were uneventful. The incidence of neonatal intervention did not differ significantly between the IUA and the expectant management groups (20.6% vs 37.0%; relative risk (RR), 0.55; 95% CI, 0.24-1.27). Nonetheless, IUA was associated with increased incidence of in-utero involution of the cyst (47.1% vs 18.5%; RR, 2.54; 95% CI, 1.07-6.05) and reduced rate of oophorectomy (3.0% vs 22.0%; RR, 0.13; 95% CI, 0.02-1.03) compared with expectant management. CONCLUSION: IUA of anechoic fetal ovarian cysts, compared with expectant management, was not associated with a reduction in overall neonatal interventions but was associated with a reduced oophorectomy rate. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Tranexamic acid for the prevention and treatment of postpartum haemorrhage.

Postpartum haemorrhage (PPH) is a major cause of maternal mortality, accounting for one-quarter of all maternal deaths worldwide. Uterotonics after birth are the only intervention that has been shown to be effective for PPH prevention. Tranexamic acid (TXA), an antifibrinolytic agent, has therefore been investigated as a potentially useful complement to this for both prevention and treatment because its hypothesized mechanism of action in PPH supplements that of uterotonics and because it has been proved to reduce blood loss in elective surgery, bleeding in trauma patients, and menstrual blood loss. This review covers evidence from randomized controlled trials (RCTs) for PPH prevention after caesarean (n=10) and vaginal (n=2) deliveries and for PPH treatment after vaginal delivery (n=1). It discusses its efficacy and side effects overall and in relation to the various doses studied for both indications. TXA appears to be a promising drug for the prevention and treatment of PPH after both vaginal and caesarean delivery. Nevertheless, the current level of evidence supporting its efficacy is insufficient, as are the data about its benefit:harm ratio. Large, adequately powered multicentre RCTs are required before its widespread use for preventing and treating PPH can be recommended.

Biparietal/transverse abdominal diameter ratio ≤ 1: potential marker for open spina bifida at 11-13-week scan.

OBJECTIVE: In the first trimester of pregnancy, a biparietal diameter (BPD) below the 5(th) percentile is a simple marker that enables the prenatal detection of half of all cases of open spina bifida. We hypothesized that relating the BPD measurement to the transverse abdominal diameter (TAD) might be another simple and effective screening method. In this study we assessed the performance of using the BPD/TAD ratio during the first trimester of pregnancy in screening for open spina bifida. METHODS: A total of 20,551 first-trimester ultrasound scans (11-13 weeks' gestation), performed between 2000 and 2013, were analyzed retrospectively; there were 26 cases of open spina bifida and 17,665 unaffected pregnancies with a crown-rump length of 45-84 mm and a record of both BPD and TAD measurements. RESULTS: The mean (± SD) BPD/TAD ratio was 1.00 ± 0.06 for fetuses with spina bifida and 1.13 ± 0.06 for those without (P < 0.0001). A BPD ≤ 5(th) percentile enabled the prenatal detection of 46.2% of spina bifida cases, while a BPD/TAD ratio of ≤ 1.00 detected 69.2%. If we considered cases in which either BPD was ≤ 5(th) percentile or BPD/TAD ratio was ≤ 1, we identified 76.9% of cases. In the latter case, the false-positive rate was 5.1%, while that for using a combination of both BPD ≤ 5th percentile and BPD/TAD ratio ≤ 1 was 0.6%, with a sensitivity of 38.5%. The positive predictive value of using a combination of BPD ≤ 5th percentile and BPD/TAD ratio ≤ 1 for detecting spina bifida was 8.5%. CONCLUSIONS: Between 11 and 13 weeks' gestation, relating BPD to TAD improves considerably the diagnostic performance of using BPD measurement alone in screening for open spina bifida. Screening using this marker is simple and applicable to a large population.

[Prenatal management of a fetal pericardial teratoma with pericardio-amniotic shunting: a case report]. / Prise en charge prénatale d'un tératome péricardique par drainage péricardio-amniotique : présentation d'un cas.

Fetal intrapericardial teratomas are uncommon and usually benign. Their histology is the same as that of teratomas located elsewhere. They may cause death from non-immune hydrops fetalis and cardiac tamponade. We report a case that was successfully managed prenatally by placement of a pericardial amniotic shunt.

[Antenatal screening for HIV: knowledge, attitudes, beliefs and practices of pregnant women. Analysis of current practices and the impact of setting up an informative brochure]. / Dépistage anténatal du VIH: connaissances, attitudes, croyances et comportements des femmes enceintes. Analyse des pratiques actuelles et impact de la mise en place d'un dépliant informatif.

OBJECTIVES: To assess the impact of an information leaflet on the behavior and knowledge of pregnant women about the risks of HIV infection during pregnancy. PATIENTS AND METHODS: Comparative prospective study conducted in two phases from March 1 to September 30, 2007 on patients presenting for the first time in antenatal care at the Maternity Hospital of Tours (n=539). During the first phase, only a self-questionnaire was given during the second an informative brochure has been attached to the questionnaire. RESULTS: Currently 25.1% of pregnant women have not made a test during their pregnancy. This rate decreases to 12.9% when the test is routinely offered. It falls to 8.2% with the introduction of an informative brochure. The test was imposed in 28.7% of patients. Some risks of transmission of HIV, including those specific to pregnancy, are undervalued. A negative test before the pregnancy is the main reason for refusal of antenatal screening. A high level of education was the only risk factor identified for refusal. They are better informed as shown by the higher rate of correct answers about the risks of HIV transmission and antenatal screening. We hypothesize that the women who pursued graduate studies evaluate the risk of infection before accepting or refusing the test. CONCLUSION: The study shows that the distribution of an informative brochure on advanced prenatal screening, increased the number of women performing the test and improved their knowledge about risks of transmission, especially from mother to the child.

[Leiomyoma during pregnancy: which complications?]. / Grossesse et fibrome: quelles complications?

OBJECTIVE: We have observed the association between uterine leiomyomas and complications during pregnancy, delivery and post-partum among our patients over the last 10 years. PATIENTS AND METHODS: We realized a retrospective case-control study comparing pregnancy and delivery outcomes in women with and without leiomyomas. In order to strengthen our observations, we conducted both univariate and multivariate analyses, and carefully respected 3 matching criteria between the two groups: age, parity and date of delivery. RESULTS: Over a ten-year period, 117 (0.38%) women with at least one leiomyoma would give birth - among the 30,805 births registered in our unit. By multivariate analysis, the presence of leiomyomas was significantly associated with women's age over 35 (adjusted odds ratio [AOR] 2.48, 95% confidence interval (CI) [1.31-4.67]), smoking (AOR=4.3, [1.82-10.13]), cystitis (AOR = 6.55, [2.12-20.16]), hydramnios (AOR = 5.12, [1.57-16.65]), threatened preterm labor (AOR = 3.99, [1.66-9.56]), first trimester bleeding (AOR = 3.92, [1.62-13.26]), anaemia during pregnancy (AOR = 2.97, [1.30-6.78]), labor dystocia (AOR = 11.79, [2.80-49.56]), retained placenta (AOR = 4.25, [1.49-12.11] and neonatal pediatric intensive care (AOR = 4.44, [1.19-16.60]). Regarding cesarean delivery, the multivariate analysis found that women with several leiomyomas underwent 8.48 times more cesarean sections than women with a single leiomyoma (p = 0.001). DISCUSSION AND CONCLUSION: Our study shows how specific features are to be kept in mind regarding obstetric outcomes for women with leiomyomas. These results emphasise the need for good perinatal care and raise the question of the treatment of those leiomyomas before pregnancy with the development of non-invasive procedures.

Prenatal diagnosis of thrombosis of the dural sinuses: report of six cases, review of the literature and suggested management.

OBJECTIVES: To describe and assess the sonographic findings, evolution and clinical implications of thrombosis of the fetal dural sinuses. METHODS: We compiled a multicenter report of the outcomes of five cases with a prenatal diagnosis of thrombosis of the dural sinuses, and one case in which thrombosis of the dural sinus was diagnosed at necroscopy after termination of pregnancy. Prognostic factors are discussed, and suggestions made for prenatal and postnatal management. RESULTS: The mean (range) gestational age at diagnosis of thrombosis of the dural sinuses in the five cases in which it was made prenatally was 25.2 (22-31) weeks. In these five cases, diagnosis was made by sonography and confirmed by magnetic resonance imaging (MRI), which showed a blood clot in the region of the torcular herophili. Three of the six cases delivered vaginally with favorable sonographic findings, and normal clinical neurological development. Two pregnancies were terminated at the request of the parents. In one of these cases the prognosis was poor, with signs of fetal decompensation or cardiac failure; the pregnancy was terminated and necropsy revealed thrombosis of the occipital dural sinuses associated with a hemangioma. One infant, in whom the thrombosis developed in conjunction with a dural sinus malformation, died at 4 months of age. CONCLUSIONS: Thrombosis of the cerebral venous circulation can occur antenatally and is detectable by fetal real-time and color Doppler ultrasound examination. A review of the literature supports targeted evaluation of the fetus by serial ultrasound imaging and MRI to help guide the diagnosis, and to improve the counseling and management of such cases. Partial or total regression, isolated abnormality, absence of fetal decompensation or signs of cardiac failure and favorable clinical evolution are suggestive of favorable prognosis. In such cases, non-interventional neonatal management is recommended.

[Prospective clinical and sonographic assessment of uterine artery embolization as the treatment of symptomatic uterine leiomyomata]. / Evaluation prospective clinique et échographique de l'embolisation des artères utérines comme traitement des fibromyomes utérins symptomatiques.

OBJECTIVE: To evaluate the effectiveness of the uterine artery embolization as the treatment of symptomatic uterine leiomyomata. PATIENTS AND METHODS: Eighty-five women with symptoms caused by uterine leiomyomata underwent uterine artery embolization as an alternative to surgery from january 1997 to june 2000. The effectiveness of this method was evaluated by clinical and sonographic examination. RESULTS: The recession average was of 18.9 months. There were ten failures. We had immediate failures (n = 5) with a case of technical failure, one endometrium cancer, one adenomyosis, one larger subserosal leiomyomata and one parametrial leiomyomata. We had recurrences (n = 5) with the occurrence of new leiomyomatas (1 intramural and 3 submucosal) and an evolution of previous leiomyomata. The average volume reduction was 51% for the uterus and 65% for the main fibroid at one year follow-up. Minor complications occurred in 5%. Permanent amenorrhoea was observed for 3.75% of the women. Using cox model, no predictive factors of embolisation effectiveness were found. DISCUSSION AND CONCLUSION: In the treatment of symptomatic uterine leiomyoma, uterine artery embolization is an effective alternative to surgery. After one year and half, we had 12.5% of failures.

Prenatal diagnosis of trisomy 21 by i(21q): a rare case of fetoplacental chromosomal discrepancy.

OBJECTIVE: A study was conducted to explain the mechanism of an unusual discrepancy between short- and long-term culture examination methods of chorionic villus sampling (CVS). METHOD: In a 29-year-old Caucasian woman, transabdominal CVS was carried out at 12 weeks of gestation. Non-mosaic karyotype 46,XX,i(21q) was found on long-term CVS culture but number and morphology of chromosomes were normal on short-term culture, amniocyte culture, hygroma colli fluid and fetal fibroblast. RESULTS: Chromosomal aberration probably appeared after the trophoblast cell line differentiation, four days after fertilization, by means of a 21 centromere misdivision and formation of a i(21q) with secondary positive selection of the 46,XX,i(21q) cell line and loss of the 46,XX in the fetus. CONCLUSION: The restricted number of cases with this type of discrepancy limits the possibility of drawing generalised conclusions. In case of discrepancy, we recommend confirmation by amniocentesis or by fetal blood combined with sonographic examination to provide a more definitive diagnosis.

Histologic multifocality is predictive of skin recurrences after conserving treatment of stage I and II breast cancers.

OBJECTIVE: To distinguish various types of local recurrence after conserving treatment of breast cancer and to evaluate their predictive value. MATERIALS AND METHODS: We first researched the pronostic factors after local recurrence and second evaluated the predictive factors of skin and inflammatory recurrences out of a series of 605 cases of stage I and stage II breast cancer of less than 4 cm in diameter that occurred after conserving treatment. RESULTS: Multivariate analysis revealed two major predictors of poor prognosis associated with recurrence: early appearance Hazard ratio 3.0 (1.28-7.00) (p = 0.011) and inflammatory or skin involvement Hazard ratio 3.38 (1.36-8.45) (p = 0.009). A local recurrence multiplied the relative risk for metastasis by 2.6. This result depended on the type of recurrence: when those with inflammatory and cutaneous types were excluded, local recurrence was no longer a poor prognostic factor. Patients who experienced primary invasive tumor with histologic multifocality have a 4.08 (1.44-11.59) (p < 0.004) times greater risk of developing cutaneous or inflammatory recurrences compared with patients who experienced breast cancer unique localization. CONCLUSION: As histologic multifocality is the only factor predictive of dark prognosis local breast cancer recurrences, aggressive therapy at the time of the primary treatment could be the therapeutic implications of such finding on the original tumor.

[Maternal anxiety induced by prenatal diagnostic techniques: detection and management]. / Anxiété maternelle induite par les techniques de diagnostic prénatal: reconnaissance et prise en charge.

Recent improvement in the screening for chromosomal defects, in particular the widespread use of ultrasonography and maternal biochemistry, is leading to a high number of fetal invasive tests (amniocentesis or chorion villus sampling). An increased level of anxiety in the pregnant women, which may sometimes continue until the postnatal period, is believed to be due to these prenatal diagnosis procedures. Maternal anxiety originates in the doubts related to fetal integrity and pregnancy outcome after information of a positive biochemical screening or visualisation of an ultrasound marker of chromosomal abnormality. Each specialist involved in prenatal care should take special attention to this, because of at least two reasons. First, anxiety may reduce maternal well being during pregnancy. Second, because it could have deleterious effects on parent to infant relationships. Without any intention of lowering the positive aspects of prenatal diagnosis, it appears essential to consider the negative effects anxiety may have on both parents. From our own experience and the conclusion of previous reported studies, we suggest some measures to reduce the level of maternal anxiety related to prenatal diagnosis: (i) improvement in the quality and transparency of information offered to pregnant women; (ii) training and involvement in psychological and emotional care for each member in the medical team; (iii) special and systematic psychological care for the "high risk" pregnant women regarding anxious disorders.

[Incidence, diagnosis and prognosis of ovarian metastasis in breast cancer]. / Incidence, diagnostic et pronostic des métastases ovariennes du cancer du sein.

Ovarian metastasis are frequently encountered during the course of breast cancer, concerning one woman in five among those suffering from the disease. These secondary ovarian lesions are usually small and bilateral with a non-cystic pattern and are more likely to be from primary infiltrating lobular carcinoma of the breast. Distinction between ovarian metastasis and primary ovarian cancer may sometimes be difficult and require immunohistochemical stains with various monoclonal antibodies. Primary ovarian cancer remains preponderant however, even in a woman with breast cancer. From a clinical point of view, ovarian metastasis are frequently unknown except in case of peritoneal dissemination. Trans-vaginal ultrasonography scan is the best examination when clinical signs give cause to suspect ovarian tumour. Although, systematic ultrasonography screening, as well as blood screening program using CA 125 and CA 15-3, should not be recommended because they lack sensibility and are too expensive. The development of ovarian metastasis during the course of a breast primary carcinoma is a negative prognostic factor with regards to the presence or absence of peritoneal dissemination.

Low body mass index is an independent predictive factor of local recurrence after conservative treatment for breast cancer.

BACKGROUND: Obesity or increased body mass index (BMI) has been shown to have two important adverse effects related to breast cancer. First, several studies have identified an association between increased BMI and advanced stage breast cancer. Second, increased BMI has been shown to be associated with poorer prognosis. In a previous report, we had identified low BMI as a risk factor for local reccurence at five years. The objectives of this study were to evaluate the relationship between BMI and local control and to confirm this prognostic factor in a larger population with an important follow-up. MATERIALS AND METHODS: Between 1976 and 1988, 605 women with invasive breast carcinoma less than 4 cm in diameter underwent conservative surgery with axillary dissection and radiation therapy. The median follow-up time was 82 months. The risk of local recurrence and distant metastasis was evaluated by univariate retrospective analysis using Kaplan-Meier method for the main clinical and histologic factors. Those found to be significant were entered in a Cox model for multivariate analysis. RESULTS: Since the beginning of the study, 80 patients had developed local recurrence. The 5 years and 10 years local control rates were 91% and 83%, respectively. Four parameters were independent predictive factors of local recurrence: Age lower than 40 years (HR = 2.42 95% CI = [1.35-4.34]), BMI: elevation of one unit reducing the local recurrence of 0.92 95%CI = [0.85-0.99], multifocality of the tumor on pathological examination (HR = 2.12 95% CI = [1.16-3.88]) and positive axillary nodes HR = 0.54 95% CI = [0.31-0.95]. Size of the breast was not a predictive factor for local cancer recurrence. Low BMI did not increase risk of distant. CONCLUSION: Our study offers new data concerning the possibility that thinness may be related to local recurrence of breast cancer.