[Fetoscopic laser coagulation in 200 consecutive monochorionic pregnancies with twin-twin transfusion syndrome]. / Photocoagulation laser par fœtoscopie pour syndrome transfuseur-transfusé : analyse d'une série consécutive unicentrique de 200 cas.

OBJECTIVES: To report preoperative data, surgical characteristics, complications and perinatal outcome of twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery, to analyze predictors of neonatal survival and to compare the 100 most recent cases with the older 100. MATERIALS AND METHODS: Observational cohort moncentric study of 200 cases of TTTS consecutively treated with fetoscopic laser coagulation between January 2004 and December 2014. RESULTS: There were 49 stage I, 88 stage II, 55 stage III and eight stage IV. Median gestation at time of laser was 20.1±3.0 weeks' gestation (WG) whereas median gestation at delivery was 31.6±5.4 WG. Overall perinatal survival rate was 68.0% and 84.0% have one or more surviving twins. Preterm premature rupture of membranes occurred in 39 cases with and the median gestational age for this complication was 28.8±4.6 SA. Predictive factors to have at least one living birth were Quintero stage and gestational age at delivery. In the most recent period, there were significantly more TTTS Quintero stage I treated with laser, more coagulation by the Solomon technique and a larger number of coagulated vessels. CONCLUSION: The neonatal survival of TTTS is improved by fetoscopic laser coagulation, preferely by using Solomon tecnhique. The use of active management of stage I is currently on research.

[The practice of neonatal umbilical blood gas analysis in the "Alsace" regional French perinatal network]. / La pratique de l'analyse des gaz du sang au cordon ombilical dans le réseau périnatal alsacien.

OBJECTIVE: The assessment of neonatal well-being is paramount in delivery rooms. For that purpose, it is recommended in France to carry out a systematic neonatal umbilical cord blood gas analysis. The aim of this study is to evaluate how umbilical cord blood gas sampling is realised, analysed and interpreted by midwives in a French regional perinatal network. MATERIALS AND METHODS: We conducted a survey focused on randomly selected midwives partitioning in different maternities that constitute the "Alsace" regional perinatal network. A questionnaire concerning the modalities of umbilical cord blood sampling, its analysis and the interpretation of results was used during interviews with included midwives. RESULTS: Fifty-one midwives were included in the study (15.8% of whom were working in delivery rooms). Only 13% of maternities constituting the perinatal network did not realise systematic neonatal umbilical cord blood analysis. Among interviewed midwives, 78.4% reported umbilical cord clamping after the first breath of the child. Among the midwives included, 86.3% of them realise sampling from the umbilical artery and 29.4% from both umbilical artery and vein. For 86.3% of interviewed midwives, the leitmotif of realising umbilical blood sampling was medico-legal. More than two third of included midwives interpret blood gas taking into account two parameters (either pH and base excess, or lactate). They settled at 7.0-7.2, the limit below which a newborn might present sequelae. DISCUSSION AND CONCLUSION: This study shows that the neonatal umbilical cord blood gas analysis at birth is almost systematic in this regional French perinatal network. It is realised primarily for medico-legal purpose. However, there are significant variations in sampling procedures and interpretation. This should lead to the establishment within each maternity of a neonatal umbilical cord blood gas sampling protocol along with a midwifery training program.

Technical aspects and effectiveness of percutaneous fetal therapies for large sacrococcygeal teratomas: cohort study and literature review.

OBJECTIVES: The objectives of this study were to evaluate the efficacy of minimally invasive ablation of high-risk large sacrococcygeal teratomas (SCT) and to compare the efficacy of vascular and interstitial tumor ablation. METHODS: This was a retrospective multicenter study including a cohort of fetuses with high-risk large SCTs between 2004 and 2010. In addition, we performed a systematic literature review of all cases that underwent tumor ablation in order to compare the survival rates after 'vascular' and 'interstitial' ablation. Statistical analysis was conducted using Bayesian methods. RESULTS: In our cohort, a total of 13 fetuses had high-risk large SCT and five of them underwent tumor ablation. The estimated difference in hydrops resolution rate between the fetal intervention and the no fetal intervention groups was 44.6% (95% credibility interval, 1.5 to 81.0%; Pdiff> 0 = 97.9%). The estimated difference in survival rate between the fetal intervention and the no fetal intervention groups was 31.0% (13.9 to 48.1%; Pdiff> 0 = 99.9%). We analyzed our five cases together with 28 cases from the literature and estimated the difference in survival rate between the vascular and interstitial ablation groups as 19.8% (-13.1 to 50.1%; Pdiff> 0 = 88.3%). The estimated difference in hydrops resolution rate between the vascular and the interstitial ablation groups was 36.7% (-5.7 to 72.7%; Pdiff> 0 = 95.5%). CONCLUSION: Minimally invasive surgery seems to improve perinatal outcome in cases of high-risk large fetal SCT. Our findings suggest that 'vascular' ablation may improve outcome and may be more effective than 'interstitial' tumor ablation, but this hypothesis needs further investigation in a larger multicenter prospective study. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Overview and expert assessment of off-label use of misoprostol in obstetrics and gynaecology: review and report by the Collège national des gynécologues obstétriciens français.

The literature suggests that misoprostol can be offered to patients for off-label use as it has reasonable efficacy, risk/benefit ratio, tolerance and patient satisfaction, according to the criteria for evidence-based medicine. Both the vaginal and sublingual routes are more effective than the oral route for first-trimester cervical dilatation. Vaginal misoprostol 800µg, repeated if necessary after 24 or 48h, is a possible alternative for management after early pregnancy failure. However, misoprostol has not been demonstrated to be useful for the evacuation of an incomplete miscarriage, except for cervical dilatation before vacuum aspiration. Oral mifepristone 200mg, followed 24-48h later by vaginal, sublingual or buccal misoprostol 800µg (followed 3-4h later, if necessary, by misoprostol 400µg) is a less efficacious but less aggressive alternative to vacuum aspiration for elective or medically-indicated first-trimester terminations; this alternative becomes increasingly less effective as gestational age increases. In the second trimester, vaginal misoprostol 800-2400µg in 24h, 24-48h after at least 200mg of mifepristone, is an alternative to surgery, sulprostone and gemeprost. Data for the third trimester are sparse. For women with an unripe cervix and an unscarred uterus, vaginal misoprostol 25µg every 3-6h is an alternative to prostaglandin E2 for cervical ripening at term for a live fetus. When oxytocin is unavailable, misoprostol can be used after delivery for prevention (sublingual misoprostol 600µg) and treatment (sublingual misoprostol 800µg) of postpartum haemorrhage. The use of misoprostol to promote cervical dilatation before diagnostic hysteroscopy or surgical procedures is beneficial for premenopausal women but not for postmenopausal women. Nonetheless, in view of the side effects of misoprostol, its use as a first-line treatment is not indicated, and it should be reserved for difficult cases. Misoprostol is not useful for placing or removing the types of intra-uterine devices used in Europe, regardless of parity.

[Secondary postpartum hemorrhage]. / Hémorragie secondaire du post-partum.

OBJECTIVES: To define secondary postpartum hemorrhage (HSPP), to discuss its main etiologies and suggest a proposal for its management. MATERIALS AND METHODS: Bibliographic research by crossing keywords: secondary postpartum hemorrhage, delayed postpartum hemorrhage, postpartum bleeding, placental remnant, placental and hysteroscopy. RESULTS: The HSPP (0.5 and 2%) is defined as bleeding occurring between 24hours and 6weeks after birth and requiring therapeutic action whatsoever (professional consensus). The most common etiology is retained placental fragments and/or endometritis, associated or not with incomplete uterine involution (Professional consensus). Among other etiologies: the pseudoaneurysms of the uterine artery, arteriovenous fistulae's, choriocarcinoma and coagulopathies. Management of HSPP depends on its etiology and the severity of bleeding. It includes antibiotics (grade A) and uterotonics (professional consensus). Antibiotherapy depends of the protocols of each department. Usually the patient will be hospitalized (Professional consensus). In case of persistent bleeding, suction curettage with or without hysteroscopy is recommended (Professional consensus). CONCLUSION: Although HSPP is an important source of maternal morbidity, it is concerned by a relatively few number of studies in the literature. Its management is based on a comprehensive etiological work-up in order to provide appropriate treatment.

[Klippel-Trenaunay syndrome and pregnancy: difficult choice of delivery from a case and a review of the literature]. / Syndrome de Klippel-Trenaunay et grossesse: difficile choix du mode d'accouchement à partir d'un cas et revue de la littérature.

Klippel-Trenaunay syndrome (SKT) is a rare disease characterized by cutaneous haemangiomas, capillary malformations venous (venous varicosities), bone and soft tissue hypertrophy affecting one or more limbs. It is often associated with hemorrhagic and thrombotic complications, especially during pregnancy. Vulvovaginal anomalies at risk of bleeding may occur in late trimester of pregnancy, affecting delivery. The terms of delivery depends on the severity of vascular malformations and the experience of the obstetrician. We report the case of a woman in labor at 38 weeks gestation with a SKT with involvement of the left leg up to the corresponding large lip. She presented after vaginal delivery a severe post-partum hemorrhage (2000mL) secondary to vaginal lacerations requiring sutures and supplemented by arterial embolization. A multidisciplinary approach is required at delivery.

[Cervical ripening with misoprostol with a live fetus]. / Maturation cervicale par misoprostol sur fœtus viable.

OBJECTIVES: To evaluate the effectiveness and safety of misoprostol for cervical ripening or induction of labor at term. METHODS: A critical review of studies identified from searches of PubMed and the Cochrane libraries using the following keywords: "misoprostol", "cervical ripening", "epidemiology", "pregnancy outcome", "maternal morbidity", "perinatal death". RESULTS: Vaginal misoprostol in doses of 25 µg three- to six-hourly was similar as dinoprostone in effectiveness (caesarean section rate or vaginal delivery in 24 hours) (LE1) and risks (uterine hyperstimulation, adverse neonatal outcome, uterine rupture, maternal side-effects) (LE1). Published medico-economic studies are not sufficient to evaluate a potential profit to the use of vaginal misoprostol 25 µg (Avis d'Experts). The use of misoprostol in women with prior cesarean delivery or major uterine surgery has been associated with an increase in uterine rupture and therefore should be avoided (LE4). CONCLUSIONS: Review of the current literature favors the use of vaginal misoprostol 25 µg three- to six-hourly equally to dinoprostone accordingly with previous French and international guidelines (World Health Organization and American College of Obstetricians and Gynecologist). The use of misoprostol 25 µg supposes a preparation by the pharmacist to ensure the safety of this precise posology. Medico-economic studies are warranted to attest an economic profit to the use of misoprostol 25 µg in comparison to dinoprostone.

[Prevalence, risk factors, maternal and fetal morbidity and mortality of intrauterine growth restriction and small-for-gestational age]. / Prévalence, facteurs de risque et morbi-mortalité materno-fœtale des troubles de la croissance fœtale.

OBJECTIVES: To assess the prevalence of fetal growth restriction (FGR) and small for gestational age (SGA) in France and other populations, the risk factors associated with SGA and its impact on fetal well-being and obstetrical outcome. METHODS: A critical review of studies identified from searches of PubMed and the Cochrane libraries using the following keywords "intra-uterine growth retardation", "intra-uterine growth restriction", "small for gestational age", "epidemiology", "risk factors", "pregnancy outcome", "maternal morbidity", "perinatal death". RESULTS: Studies of FGR use multiple definitions, both with respect to cutoffs for defining restricted growth as well as growth norms; however the most common definition for epidemiological research was SGA using a birthweight less than the 10 th percentile. Following this definition, SGA births accounted for 8.9% of all live births in 2010 in France. Major risk factors identified in the literature were previous SGA birth (4 fold increase in risk) (LE2), diabetes and vascular diseases (5 fold) (LE3), chronic hypertension (2 fold) (LE2), preeclampsia (5 to 12 fold according to severity) (LE2), pregnancy induced hypertension (2 fold) (LE2), smoking (2-3 fold) (LE2), drug and alcohol use (2-4 fold) (LE2), maternal age over 35 (3 fold) (LE2) and ethnic origin (2-3 fold for African-American or Asian origins) (LE2). Other risk factors with adjusted odds ratios around 1.5 were primiparity (LE2), multiple pregnancy (but only starting at 30 weeks of gestation) (LE2), socioeconomic disadvantage (LE2) and body mass index (BMI<18.5 kg/m(2)) (LE2) SGA is associated with a four-fold increased risk of stillbirth (LE2) as well as higher rates of cesarean and induced labor before 37 weeks. CONCLUSIONS: FGR is a complication of pregnancy with adverse consequences for fetal wellbeing. Sociodemographic and clinical risk factors can help to identify pregnant women at risk for this complication.

[Management of patients with a history of late abortion or very premature delivery]. / Prise en charge des patientes ayant un antécédent d'avortement tardif ou d'accouchement très prématuré

Patients have a very late abortion or premature delivery in 2-3 % of pregnancies. Management in a subsequent pregnancy should seek an infection, a fetal cause (aneuploidy, malformation syndrome, intrauterine death) or vascular pathology (preeclampsia, IUGR, intrauterine death). In women with a late abortion or very premature childbirth history, several preventive treatments of prematurity are now available. The main cause of prematurity is ascending infection from the vagina. Cerclage or pessary is designed to better isolate the uterine cavity. Their effectiveness has been validated in patients for whom the repeated measurement of cervical length by transvaginal ultrasound shows a cervical length <25mm. Early pregnancy vaginosis and treatment with Dalacin(®) seem to significantly reduce the risk of prematurity. Finally, the routine administration of intramuscular or vaginal progesterone at the beginning of the 2(nd) quarter also proved effective in several randomized studies.

Postnatal phenotype according to prenatal ultrasound features of Noonan syndrome: a retrospective study of 28 cases.

OBJECTIVE: Noonan syndrome is a frequent genetic disorder with autosomal dominant transmission. Classically, it combines postnatal growth restriction with dysmorphic and malformation syndromes that vary widely in expressivity. Lymphatic dysplasia induced during the embryonic stage might interfere with tissue migration. Our hypothesis is that the earlier the edema, the more severe postnatal phenotype. METHOD: This retrospective study analyzed data from all 32 cases of Noonan syndrome diagnosed in the Medical Genetics Department of Hautepierre Hospital in Strasbourg, France, between 1995 and 2011. The postnatal evolution of Noonan syndrome was compared according to the presence of at least one prenatal ultrasound feature of lymphatic dysplasia. RESULTS: The most frequent prenatal ultrasound features found were increased nuchal translucency, cystic hygroma and polyhydramnios; their global prevalence was 46.4%. The presence of these features was not significantly associated with the postnatal phenotype of Noonan syndrome. CONCLUSION: The results of our study indicate that prenatal ultrasound features of lymphatic dysplasia do not predict an unfavorable postnatal prognosis for Noonan syndrome.

Neoadjuvant chemoradiotherapy followed by surgery in locally advanced squamous cell carcinoma of the vulva.

Alternative therapies have been sought to alleviate mutilation and morbidity associated with surgery for vulvar neoplasms. Our prime objective was to assess tumor absence in pathological vulvar and nodal specimens following neoadjuvant chemoradiotherapy in locally advanced vulvar neoplasms. Data were retrospectively collected from January 2001 to May 2009 from 22 patients treated with neoadjuvant therapy for locally advanced squamous cell carcinoma of the vulva. Neoadjuvant treatment consisted of inguino-pelvic radiotherapy (50 Gy) in association with chemotherapy when possible. Surgery occurred at intervals of between 5 to 8 weeks. The median age of patients at diagnosis was 74.1 years. All patients were primarily treated with radiotherapy and 15 received a concomitant chemotherapy. Additionally, all patients underwent radical vulvectomy and bilateral inguino-femoral lymphadenectomy. Tumor absence in the vulvar and nodal pathological specimens was achieved for 6 (27%) patients, while absence in the vulvar pathological specimens was only achieved for 10 (45.4%) patients. Postoperative follow-up revealed breakdown of groin wounds, vulvar wounds and chronic lymphedema in 3 (14.3%), 7 (31.8%) and 14 cases (63.6%), respectively. Within a median follow-up time of 2.3 years [interquartile range (IQR), 0.6-4.6], 12 (54.6%) patients experienced complete remission and 6 cases succumbed to metastatic evolution within a median of 2.2 years (IQR, 0.6-4.6), with 1 case also experiencing perineal recurrence. Median survival time, estimated using the Kaplan-Meier method, was 5.1 years (IQR, 1.0-6.8). We suggest that neoadjuvant chemoradiotherapy may represent a reliable and promising strategy in locally advanced squamous cell carcinoma of the vulva.

Use of emergency contraceptive pill by 15-year-old girls: results from the international Health Behaviour in School-aged Children (HBSC) study.

OBJECTIVE: To describe emergency contraceptive pill (ECP) use and variation across countries/regions; and to explore personal and contextual factors associated with ECP use and differences across countries/regions. DESIGN: Data were obtained from 11 countries/regions in the 2006 Health Behaviour in School-aged Children cross-sectional study. SETTING Data were collected by self-report questionnaire in school classrooms. POPULATION: The analysis is based on 2118 sexually active 15-year-old girls. METHODS: Contraceptive behaviours were compared across countries/regions by chi-square tests. Individual factors related to ECP use were investigated with separate logistic regression models. Multilevel random-intercept models allowed the investigation of individual and contextual effects, by partitioning the variance into student, school and country/region levels. MAIN OUTCOME MEASURES: ECP use at last sexual intercourse. RESULTS: ECP use rate varied significantly across countries/regions. Poor communication with at least one adult (odds ratio [OR] 1.62 [1.12-2.36], P = 0.011) and daily smoking (OR 1.46 [1.00-2.11], P = 0.048) were independently associated with ECP use in comparison with condom and/or birth-control pill use. Sexual initiation at 14 years or later (OR 2.02 [1.04-3.93], P = 0.039), good perceived academic achievement (OR 1.69 [1.04-2.75], P = 0.035) and daily smoking (OR 1.63 [1.01-2.64], P = 0.045) were associated with higher levels of ECP use in comparison with unprotected girls. The country-level variance remained significant in both comparisons. CONCLUSIONS: These data document the large heterogeneity in rates of ECP use between countries/regions. These differences could not be explained by individual or contextual factors, and raise further questions in relation to ECP access for adolescents and their education in its appropriate use.