Surgical management of endometriosis.

Endometriosis is a complex disease of young women in reproductive age. It's responsible for dysmenorrhea, dyspareunia, chronic pelvic pain and infertility. Medical and surgical treatments have different aims. Hormonal suppression tends to stop natural evolution of the disease and surgery enables macroscopic excisions of endometriotic implants. Outcomes depend on the stage and the preoperative symptoms. This article summarizes a review of surgical management of endometriosis describing surgical indications, techniques, and outcomes in terms of pain and fertility.

[French clinical practice guidelines developed by a modified Delphi consensus process for oocyte vitrification in women with benign gynecologic disease]. / Indications de vitrification ovocytaire dans les pathologies gynécologiques bénignes : conseils de bonne pratique du CNGOF après étude de consensus par méthode Delphi.

OBJECTIVES: To provide clinical practice guidelines about fertility preservation (FP) for women with benign gynecologic disease (BGD) developed by a modified Delphi consensus process for oocyte vitrification in women with benign gynecologic disease. METHODS: A steering committee composed of 14 healthcare professionals and a patient representative with lived experience of endometriosis identified 42 potential practices related to FP for BGD. Then 114 key stakeholders including various healthcare professionals (n=108) and patient representatives (n=6) were asked to participate in a modified Delphi process via two online survey rounds from February to September 2020 and a final meeting. Due to the COVID-19 pandemic, this final meeting to reach consensus was held as a videoconference in November 2020. RESULTS: Survey response of stakeholders was 75 % (86/114) for round 1 and 87 % (75/86) for round 2. Consensus was reached for the recommendations for 28 items, that have been distributed into five general categories: (i) Information to provide to women of reproductive age with a BGD, (ii) Technical aspects of FP for BGD, (iii) Indications for FP in endometriosis, (iv) Indications for FP for non-endometriosis BGD, (v) Indications for FP after a fortuitous diagnosis of an idiopathic diminished ovarian reserve. CONCLUSION: These guidelines provide some practice advice to help health professionals better inform women about the possibilities of cryopreserving their oocytes prior to the management of a BGD that may affect their ovarian reserve and fertility. STUDY FUNDING/COMPETING INTEREST(S): The CNGOF (Collège National des Gynécologues Obstétriciens Français) funded the implementation of the Delphi process.

Successful childbirth after intracytoplasmic morphologically selected sperm injection without assisted oocyte activation in a patient with globozoospermia.

We here report a successful pregnancy and healthy childbirth obtained in a case of total globozoospermia after intracytoplasmic morphologically selected sperm injection (IMSI) without assisted oocyte activation (AOA). Two semen analyses showed 100% globozoospermia on classic spermocytogram. Motile sperm organelle morphology examination (MSOME) analysis at ×10,000 magnification confirmed the round-headed aspect for 100% of sperm cells, but 1% of the spermatozoa seemed to present a small bud of acrosome. This particular aspect was confirmed by transmission electron microscopy and anti-CD46 staining analysis. Results from sperm DNA fragmentation and fluorescence in situ hybridization analyses were normal. The karyotype was 46XY, and no mutations or deletions in SPATA16 and DPY19L2 genes were detected. Considering these results, a single IMSI cycle was performed, and spermatozoa were selected for the absence of vacuoles and the presence of a small bud of acrosome. A comparable fertilization rate with or without calcium-ionophore AOA was observed. Two fresh top-quality embryos obtained without AOA were transferred at Day 2 after IMSI, leading to pregnancy and birth of a healthy baby boy. This successful outcome suggests that MSOME may be useful in cases of globozoospermia in order to carefully evaluate sperm morphology and to maximize the benefit of ICSI/IMSI.

Sparing the larynx during gynecological laparoscopy: a randomized trial comparing the LMA Supreme and the ETT.

BACKGROUND: We designed a prospective randomized single-blind study to compare efficiency and post-operative upper airway morbidity when the laryngeal mask airway (LMA) Supreme is used as an alternative to the endotracheal tube (ETT). METHODS: One hundred and thirty-eight elective pelvic laparoscopic ASA I-II female patients were assigned to receive either the LMA Supreme or the ETT for airway management. Balanced anesthesia and ventilation techniques were standardized to control end-tidal CO(2) and BIS value in the range 4.5-5 kPa and 40-50, respectively, and to maintain adequate hemodynamic stability. A single surgeon blinded to the airway management technique performed all surgical procedures. The ventilation efficiency of each airway was evaluated. Anesthesia- and surgery-related times were calculated and anesthesia details were recorded. Post-operative pain and pharyngolaryngeal morbidity were measured in a blind fashion using a numerical rating scale (NRS) (0-100). RESULTS: Surgery duration was similar in both groups. Airway management duration was shorter with the LMA Supreme. Post-operative pharyngolaryngeal morbidity incidence and all symptoms' intensity were significantly increased after ETT as compared with LMA Supreme anesthesia. At the end of the PACU stage, the incidence and mean NRS of post-operative hoarseness were reduced when LMA Supreme was used as an alternative to the ETT (16% vs. 47%; P<0.01 and 9 vs. 19, P<0.01, respectively). CONCLUSION: We demonstrated that choosing an LMA Supreme was an efficient pharyngolaryngeal morbidity-sparing strategy. Moreover, we showed that the LMA Supreme and the ETT were equally effective airways for a routine gynecological laparoscopy procedure.

[Evolution of surgical operations for female for stress urinary incontinence in gynaecology departments of Parisian public hospitals between 2002 and 2006]. / Evolution des interventions chirurgicales pour incontinence urinaire d'effort dans les services de chirurgie gynécologique de l'Assistance publique des Hôpitaux de Paris entre 2002 et 2006.

OBJECTIVE: To appreciate the evolution of the current surgical practice for female for stress urinary incontinence (SUI) in the gynaecologic surgery departments of Parisian public hospitals in three different periods of 12 months (2002-2003, 2003-2004, and 2006). PATIENTS AND METHODS: The 16 departments were surveyed by postal questionnaire about their surgical practice for the treatment of female SUI. The number, the type of operation, the type of suburethral tapes and their surgical routes were detailed. RESULTS: The participation rate in the survey was 87.5% (14/16) for the first two studied periods and 75% (12/16) for the last one. The number of SUI procedure decreases between the three periods (586, 505, and 263 procedures, respectively; p<0.001). Suburethral slings represent the technique of choice for SUI (86.2% in 2002-2003; 92.7% in 2003-2004, and 98.1% in 2006). Other practices are exceptional. The transobturator approach has widely progressed and became the preferred one in 2006 (31.1%; 64.5%; 95.4% in 2006; p<0.001). No transobturator route was privileged. TVT procedures have decreased between the three studied periods (48.3%, 36.5%, and 4.6% in 2006; p<0.001). TVT-O is the preferred sling in 2006 (120/258, 46.5% of suburethral tapes). DISCUSSION AND CONCLUSION: Suburethral tape placement is nowadays the main surgical treatment for female SUI amongst members in gynaecology departments in Parisian public hospitals. The transobturator approach is preferred.

[Views of each member of an Assisted Reproductive Technologies centre on the embryo transfer procedure]. / Points de vue de l'équipe multidisciplinaire d'un centre d'Assistance médicale à la procréation concernant le transfert embryonnaire.

The embryo transfer (ET) is probably the key step of Assisted Reproductive Technologies (ART), end point of the collaboration of a multidisciplinary clinical team and an infertile couple. Thus, a perfect knowledge of available data regarding ET is required to optimize the results of ART. Indeed, numerous published studies demonstrate the impact of defined parameters onto the effectiveness of ET procedure. The aim of this study is to provide views of physicians dealing with ART, i.e. endocrinologist, ultrasound scan specialist, surgeon and biologist to put in perspective questions and answers about ET.

[Postpartum perineal pain: effectiveness of local ropivacaine infiltration]. / Douleur périnéale du post-partum: intérêt de l'infiltration locale de ropivacaïne.

GOAL: To assess efficiency of local ropivacaine infiltration in perineal pain after episiotomy and perineal tear during the first 24 h after vaginal delivery. MATERIALS AND METHODS: Case control survey, including 62 consecutive patients with episiotomy and/or perineal tear during two consecutive periods: the ropivacaine group from February 2, 2008 to March 27, 2008 (n=31) and the control group from December 27, 2007 to January 1, 2008 (n=31). In the ropivacaine group, patients received 10 ml of ropivacaine 7,5mg/ml as a local infiltration along the perineal damage. In the control group no injection was done. A numerical pain rating scale (0-10) at four (H4), eight (H8), 12 (H12) and 24 h (H24) was used to evaluate patients post-partum perineal pain. A numerical rating scale was used to evaluate patients satisfaction (0: no satisfied, 5: very satisfied). RESULTS: Numerical pain rating scale for perineal pain evaluation was significantly lower in the ropivacaine group than in the control group at H4 (1.9+/-0.3 versus 3.6+/-0.5, p=0.006), H8 (3.3+/-0.4 versus 5.2+/-0.4, p=0.003), H12 (2.8+/-0.4 versus 5.2+/-0.4, p=0.0001) and H24 (2.6+/-0.4 versus 4.3+/-0.4, p=0.006). Numerical rating scale for satisfaction evaluation was significantly higher in the ropivacaine group (4.2+/-0.2 versus 3.5+/-0.2, p=0.004). CONCLUSION: Local ropivacaine infiltration in episiotomy and/or perineal tear reduce post-partum perineal pain within the first 24 h.

Predicting the likelihood of a live birth for women with endometriosis-related infertility.

OBJECTIVE: Endometriosis affects 10% of women in reproductive age and alters fertility. Its management is still debated notably the timing of surgery and ART in infertility. Several tools have been created to guide the practitioner and the couple yet many limitations persist. The objective is to create a nomogram to predict the likelihood of a live birth after surgery followed by assisted reproductive technology (ART) for patients with endometriosis-related infertility. STUDY DESIGN: All women in a public university hospital who attempted to conceive by ART after surgery for endometriosis-related infertility from 2004 to 2016 were included. We created a model using multivariable linear regression based on a retrospective database. RESULT: Of the 297 women included, 171 (57.6%) obtained a live birth. Age, duration of infertility, number of ICSI-IVF cycles, ovarian reserve and the revised American Fertility Society (rAFS) score were included in the nomogram. The predictive model had an area under the curve (AUC) of 0.77 (95% CI, 0.75-0.79) and was well calibrated. The external validation of the model was achieved with an AUC of 0.71 (95% CI, 0.69-0.73) and calibration was good. The staging accuracy according to AUC criteria for the nomogram compared to the currently used Endometriosis Infertility Index to predict live births were 0.77 (95% CI, 0.75-0.79) and 0.60 (95% CI: 0.57-0.63), respectively. CONCLUSION: This simple tool appears to accurately predict the likelihood of a live birth for a patient undergoing ART after surgery for endometriosis-related infertility. It could be used to counsel patients in their choice between spontaneous versus ART conception, or oocyte donation.

[Prospective evaluation of elective single-embryo transfer versus double-embryo transfer following in vitro fertilization: a two-year French hospital experience]. / Evaluation prospective du transfert sélectif d'un embryon: deux années d'expérience.

OBJECTIVE: Multiple embryo transfer is responsible for a high rate of multiple pregnancies (ICSI), with subsequent risks of premature birth and perinatal death. This prospective non randomized study aimed to assess the ability of an elective single-embryo transfer (eSET) policy to reduce the twin pregnancy rate, compared to a double embryo transfer (DET) approach. PATIENTS AND METHODS: Between March 2005 and May 2006, 180 eligible women were proposed to benefit from an eSET transfer rather than a DET. Inclusion criteria were (i) age less than 37 years old; (ii) at least two good quality embryos available (three to five cells at day 2 or six to nine cells at day 3; less than 20% fragmentation and the absence of multinucleates blastomeres), after IVF or ICSI and (iii) no more than one previous failed treatment cycle. Outcome analysis included cycles with frozen-thawed embryo transfer (FET). RESULTS: According to patients' decision, 107 and 73 women had an eSET (59.4%) and a DET (40.6%) respectively. No differences were found between eSET and DET groups regarding demographics and biologicals parameters. The clinical pregnancy rate (PR) per transfer was 43.9% in eSET group and 57.5% in DET group (p=0.07). The twin pregnancy rates were 0 and 14.3%, in eSET and DET groups, respectively (p=0.007). The cumulative PR per patient, including the outcome of performed FET cycles, was 63.6% in eSET group and 61.6% in DET group. In this case, the cumulative twin pregnancy rates were 2.9 and 15.6% in eSET and DET groups, respectively (p=0.02). DISCUSSION AND CONCLUSION: Our data show that in a selected population of women, transferring one fresh embryo and then, if required, one or two frozen-thawed embryos significantly reduces the twin pregnancy rate without decreasing the overall pregnancy rate. This study supports the policy of eSET in this subgroup of patients.

[Endometriosis and fertility preservation: CNGOF-HAS Endometriosis Guidelines]. / Endométriose et préservation de la fertilité, RPC Endométriose, CNGOF-HAS.

Fertility preservation (FP) techniques are progressing rapidly these past few years thanks to the oocyte vitrification. Indication of FP techniques is now extended to non-oncological situation that may induce risk of premature ovarian failure. Ovarian endometriosis can lead to premature ovarian failure and further infertility due to the high risk of ovarian cysts recurrence and surgery. To date, there is no cohort study regarding FP and endometriosis as well as no recommendation. Our purpose is to review the arguments in favor of FP in this specific area and to elaborate strategies according to each clinical form.

[Deeply infiltrating endometriosis and infertility: CNGOF-HAS Endometriosis Guidelines]. / Endométriose profonde et infertilité, RPC Endométriose CNGOF-HAS.

Deeply infiltrating endometriosis is a severe form of the disease, defined by endometriotic tissue peritoneal infiltration. The disease may involve the rectovaginal septum, uterosacral ligaments, digestive tract or bladder. Deeply infiltrating endometriosis is responsible for disabling pain and infertility. The purpose of these recommendations is to answer the following question: in case of deeply infiltrating endometriosis associated infertility, what is the best therapeutic strategy? First-line surgery and then in vitro fertilization (IVF) in case of persistent infertility or first-line IVF, without surgery? After exhaustive literature analysis, we suggest the following recommendations: studies focusing on spontaneous fertility of infertile patients with deeply infiltrating endometriosis found spontaneous pregnancy rates about 10%. Treatment should be considered in infertile women with deeply infiltrating endometriosis when they wish to conceive. First-line IVF is a good option in case of no operated deeply infiltrating endometriosis associated infertility. Pregnancy rates (spontaneous and following assisted reproductive techniques) after surgery (deep lesions without colorectal involvement) varie from 40 to 85%. After colorectal endometriosis resection, pregnancy rates vary from 47 to 59%. The studies comparing the pregnancy rates after IVF, whether or not preceded by surgery, are contradictory and do not allow, to date, to conclude on the interest of any surgical management of deep lesions before IVF. In case of alteration of ovarian reserve parameters (age, AMH, antral follicle count), there is no argument to recommend first-line surgery or IVF. The study of the literature does not identify any prognostic factors, allowing to chose between surgical management or IVF. The use of IVF in the indication "deep infiltrating endometriosis" allows satisfactory pregnancy rates without significant risk, regarding disease progression or oocyte retrieval procedure morbidity.

[Management of assisted reproductive technology (ART) in case of endometriosis related infertility: CNGOF-HAS Endometriosis Guidelines]. / Stratégies de prise en charge de l'infertilité en assistance médicale à la procréation dans un contexte d'endométriose, RPC Endométriose, CNGOF-HAS.

The management of endometriosis related infertility requires a global approach. In this context, the prescription of an anti-gonadotropic hormonal treatment does not increase the rate of non-ART (assisted reproductive technologies) pregnancies and it is not recommended. In case of endometriosis related infertility, the results of IVF management in terms of pregnancy and birth rates are not negatively affected by the existence of endometriosis. Controlled ovarian stimulation during IVF does not increase the risk of endometriosis associated symptoms worsening, nor accelerate the intrinsic progression of endometriosis and does not increase the rate of recurrence. However, in the context of IVF management for women with endometriosis, pre-treatment with GnRH agonist or with oestrogen/progestin contraception improve IVF outcomes. There is currently no evidence of a positive or negative effect of endometriosis surgery on IVF outcomes. Information on the possibilities of preserving fertility should be considered, especially before surgery.

[Management of endometriosis: CNGOF-HAS practice guidelines (short version)]. / Prise en charge de l'endométriose : recommandations pour la pratique clinique CNGOF-HAS (texte court).

First-line investigations to diagnose endometriosis are clinical examination and pelvic ultrasound. Second-line investigations include pelvic examination performed by a referent clinician, transvaginal ultrasound performed by a referent echographist, and pelvic MRI. It is recommended to treat endometriosis when it is symptomatic. First-line hormonal treatments recommended for the management of painful endometriosis are combined with hormonal contraceptives or levonorgestrel 52mg IUD. There is no evidence to recommend systematic preoperative hormonal therapy for the unique purpose of preventing the risk of surgical complications or facilitating surgery. After endometriosis surgery, combined hormonal contraceptives or levonorgestrel SIU 52mg are recommended as first-line therapy in the absence of desire of pregnancy. In case of initial treatment failure, recurrence, or multiple organ involvement by endometriosis, medico-surgical and multidisciplinary discussion is recommended. The laparoscopic approach is recommended for the surgical treatment of endometriosis. HRT may be offered in postmenopausal women operated for endometriosis. In case of infertility related to endometriosis, it is not recommended to prescribe anti-gonadotropic hormone therapy to increase the rate of spontaneous pregnancy, including postoperatively. The possibilities of fertility preservation should be discussed with the patient in case of surgery for ovarian endometrioma.

Management of endometriosis: CNGOF/HAS clinical practice guidelines - Short version.

First-line diagnostic investigations for endometriosis are physical examination and pelvic ultrasound. The second-line investigations are: targeted pelvic examination performed by an expert clinician, transvaginal ultrasound performed by an expert physician sonographer (radiologist or gynaecologist), and pelvic MRI. Management of endometriosis is recommended when the disease has a functional impact. Recommended first-line hormonal therapies for the management of endometriosis-related pain are combined hormonal contraceptives (CHCs) or the 52mg levonorgestrel-releasing intrauterine system (IUS). There is no evidence base on which to recommend systematic preoperative hormonal therapy solely to prevent surgical complications or facilitate surgery. After surgery for endometriosis, a CHC or 52mg levonorgestrel-releasing IUS is recommended as first-line treatment when pregnancy is not desired. In the event of failure of the initial treatment, recurrence, or multiorgan involvement, a multidisciplinary team meeting is recommended, involving physicians, surgeons and other professionals. A laparoscopic approach is recommended for surgical treatment of endometriosis. HRT can be offered to postmenopausal women who have undergone surgical treatment for endometriosis. Antigonadotrophic hormonal therapy is not recommended for patients with endometriosis and infertility to increase the chances of spontaneous pregnancy, including postoperatively. Fertility preservation options must be discussed with patients undergoing surgery for ovarian endometriomas.

Endometriosis mimicking hernia recurrence.

Endometriosis is a common gynecologic condition and has been described in several locations, mostly in the pelvis. Extragenital endometriosis may appear as a painful nodule evoking an inguinal hernia. Scar endometriosis after inguinal hernia repair seems to be a rare occurrence. We report an unusual case of a 28-year-old woman who developed a scar endometriosis 2 years after an inguinal hernia repair. This case highlights that the presence of a painless inguinal mass similar to a recurrent hernia, with possible swelling related to the menstrual cycle, may evoke endometriosis, especially after a previous hernia repair and should lead to prompt diagnosis, wide excision, and gynecological advice.

[Uterine malformations and reproduction]. / Malformations utérines et reproduction.

The frequency of uterine malformations impacting on reproduction seems not easy to determine. Their diagnosis needs specific explorations (hysterosalpingography, hysteroscopy and laparoscopy). Spontaneous fertility may be impaired in relation with uterine abnormalities. All these abnormalities could have repercussions on the conceptus' evolution like abortion, preterm delivery, vascular pathologies and intrauterine growth restriction. Ovarian function does not seem to be altered even though implantation rate could be reduced. Surgery, especially endoscopy, allows a precise diagnosis, a prognostic evaluation and an adequate treatment improving conception rates and pregnancy outcome. Mainly hysteroscopic septum section and expansion metroplasty were regularly described.

[Surgical management of stress urinary incontinence: a questionnaire-based survey amongst members of the Société de Chirurgie Gynécologique et Pelvienne (SCGP)]. / Prise en charge chirurgicale de l'incontinence urinaire d'effort : résultat d'une enquête par questionnaire parmi les membres de la Société de chirurgie gynécologique et pelvienne (SCGP).

OBJECTIVE: To evaluate by voluntary and anonymous declaration the current surgical practice for female stress urinary incontinence (SUI) in France. POPULATION AND METHODS: A postal survey, anonymous, sealed, and validated by the Scientific Committee of the Société de chirurgie gynécologie et pelvienne (SCGP), was conducted among all members. The questionnaire was also available online, on the SCGP website. RESULTS: One hundred and three (18%) members responded. The respondents (87%; n=90) were performing less than 10 incontinence procedures in a month. Suburethral slings represent the choice technique for SUI, prior by transobturator approach (87%; n=90). Other practices are exceptional. Urodynamics study was routinely performed prior to surgery in 69% of cases. Surgical treatment was performed using prior regional anaesthesia in retropubic approach (58%; n=40 in 68 respondents); either loco-regional (47%; n=48 in 102 respondents) or general anaesthesia (50%; n=51 in 102 respondents) were used in transobturator approach. No transobturator route was privileged. The postoperative urethral catheter was being left for 24h or less in case of retropubic or transobturator approach (70%; n=37 in 53 respondents and 68%; n=52 in 76 respondents, respectively). The patient's hospital stay was one night (83%; n=54 in 65 respondents and 85%; n=87 in 102 respondents, respectively). A postoperative audit was not done by 19% of respondents. DISCUSSION AND CONCLUSION: Suburethral tape placement is nowadays the main surgical treatment for female stress urinary incontinence amongst members of SCGP. The transobturator approach is preferred.

[Efficiency of the transobturator suburethral tape in the treatment of 61 patients presenting intrinsic sphincter deficiency]. / Efficacité de la voie trans-obturatrice dans le traitement de l'incontinence urinaire d'effort par insuffisance sphinctérienne urétrale: à propos de 61 cas.

OBJECTIVES: To evaluate the effectiveness of the transobturator route in the treatment of intrinsic sphincter deficiency in the stress urinary incontinence. PATIENTS AND METHODS: This is a retrospective multicenter study. Sixty-one patients with a low-uretral closure pressure were treated for stress urinary incontinence using the transobturator route. The intrinsic sphincter deficiency was defined according to criteria of the Société internationale francophone urodynamique (Sifud). The satisfaction of the patients was appreciated in postoperative consultation in the short run (six to 12 months) and by using the questionnaire "Contilife" evaluating the quality of postoperative life in the long run. The failure was defined when the patients declared themselves dissatisfied during the postoperative consultation and/or if their "Contilife" score was lower than seven (out of 10). RESULTS: The short-term evaluation reveals a rate of satisfaction of 92%. The questionnaire "Contilife" reveals 70% of very satisfied or satisfied patients. Eighteen percent of failure is noted. The majority of the patients in failure had urinary urgencies and/or overactive bladder. DISCUSSION AND CONCLUSION: Transobturator vaginal tape can be used in the treatment of patients having a low-uretral closure pressure. The patients must be informed of a success rate slightly lower than in women having a primary genuine stress incontinence.

[Endometriosis: good practice rules for diagnostic laparoscopy]. / Prise en charge de l'endométriose: les bonnes pratiques de la coelioscopie diagnostique.

The interest for diagnostic laparoscopy for the diagnosis of endometriosis is not longer discussed. Indications could be pelvic pain, infertility, menorragia, and/or organic ovarian tumour. Several lesions, typical and non typical, have been described and should be recognized. Histological confirmation seems suitable even though the correlation with visual inspection is not perfect. New laparoscopic techniques seem interesting to increase diagnostic relevance. Visual inspection should be associated with palpation. For deep infiltrating endometriotic lesions diagnostic laparoscopy has shown its limits. Precisions concerning peri-operative methods and operative reports are described. The place of the different classifications has been discussed.

[Pregnancy in a patient with Gitelman syndrome: a case report and review of literature]. / Syndrome de Gitelman et grossesse: à propos d'un cas et revue de la littérature.

Gitelman syndrome (GS) is a tubulopathy characterized by hypokaliemia, hypomagnesiemia, metabolic alkalosis and hypocalciuria. We report a case of a 33-year-old pregnant woman with Gitelman Syndrome. Oral potassium chloride and magnesium citrate were prescribed and the course of the pregnancy was uneventful with vaginal delivery at term. The impact of GS on the physiologic adaptations to pregnancy is not well-known, with few reports to date. Monitoring of serum potassium and magnesium levels with supplementation, amniotic fluid and fetal growth is required to prevent obstetrical and fetal complications in a patient with GS.