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Purpose: Since the Consensus Statement diffused by the Amsterdam Placental Workshop Group, knowledge of the meaning of placental vascular malperfusion has become essential in the unavoidable analysis of obstetrical history in a patient followed for autoimmune disease or any other maternal comorbidity. We aimed to analyse the prevalence of various placental lesions from a 6-months prospective observational study and to correlate the various placental profiles to obstetrical outcome, maternal diseases and pregnancy treatments. The frequency of foetal vascular malperfusion lesion could be estimated at 8.7%, in our population and to understand its neonatal associations. Methods: The study groups consisted of 208 consecutive women which ended the pregnancy and have placental analysis during the period of the study. Results: From December 2015 to October 2017, from overall 4398 delivered pregnancies in university obstetrical department, 208 (4.7%) placental analysis have been done and included in the study. The placental analysis have been done for vascular obstetrical complications during the pregnancy (nâ¯=â¯106; 51%), unexplained abnormal foetal heart rate tracings (nâ¯=â¯59; 28,3%), suspicion of intra-amniotic infection (nâ¯=â¯12; 5,7%%), term new-borns Apgar score <7 or arterial cord blood pH ≤ 7 (nâ¯=â¯7; 3,5%), spontaneous preterm delivery (nâ¯=â¯19; 9,1%), intrahepatic cholestasis of pregnancy (nâ¯=â¯5; 2,4%). An adverse obstetrical event was noted in 87 cases (42%): preeclampsia or HELLP syndrome (nâ¯=â¯15; 7%), FGR (nâ¯=â¯59; 28%), gestational diabetes (nâ¯=â¯33; 16%) and gestational hypertension (nâ¯=â¯19; 9%). Placental histological analysis showed abnormal vascular features in 159 cases (76%), inflammatory features in 16 placentas (8%), vascular and inflammatory features in 10 cases (4%), chorioamnionitis in 38 cases (18%) and absence of any abnormality in 43 cases (21%). A cluster analysis of histological features allowed distinguishing three placental patterns: a normal pattern characterised by the absence of any placental lesions, an inflammatory pattern characterised by the presence of villitis and/or chronic intervillositis; a vascular pattern with the presence of thrombosis, maternal floor infarct with massive perivillous fibrin deposition, infarction and chronic villositis hypoxia. Women with inflammatory placental profile have significantly increased frequencies of tobacco use (50% vs. 9%; Pâ¯=â¯0.03), pathological vascular Doppler (50% vs. 5%; Pâ¯=â¯0.001), FGR (100% vs. 14%; Pâ¯=â¯0.0001) and oligohydramnios (67% vs. 5%; Pâ¯=â¯0.0001) than those with normal placentas. A higher rate of vascular or inflammatory lesion were observed in women with Hypertensive disorder of pregnancy, where as those with inflammatory pattern have significantly more frequent FGR (100% vs 34%; Pâ¯=â¯0.02) and oligohydramnios (67% vs 5%; Pâ¯=â¯0.0002). Conclusion: The placenta analysis is important to understand the origin of adverse obstetrical outcome and the risk for subsequent pregnancy.
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Diabetes Mellitus Tipo 2 , Hipertensión Inducida en el Embarazo , Nacimiento Prematuro , Humanos , Femenino , Embarazo , Diabetes Mellitus Tipo 2/complicaciones , Hipertensión Inducida en el Embarazo/epidemiología , Hipertensión Inducida en el Embarazo/etiología , Nacimiento Prematuro/epidemiología , Nacimiento Prematuro/etiología , Factores de Riesgo , AdultoRESUMEN
AIM: Prognosis of treated hyperglycemia in pregnancy (HIP) may differ according to whether diagnosis following an oral glucose tolerance test (OGTT) is based on high fasting and/or high post-load glucose values. METHODS: From a multiethnic prospective study, we included 8,339 women screened for HIP after 22 weeks of gestation. We evaluated the risk of large-for-gestational-age (LGA) infant (primary endpoint) and other adverse pregnancy outcomes according to HIP status in four groups defined as follows: no HIP (n = 6,832, reference); isolated fasting HIP (n = 465), isolated post-load HIP (n = 646), and fasting and post-load HIP (n = 396). RESULTS: After adjusting for age, body mass index, ethnicity, smoking during pregnancy and parity, compared with no HIP, the adjusted odds ratios [95% confidence interval] for LGA infant were higher in the isolated fasting HIP (1.47 [1.11-1.96]) and fasting and post-load HIP (1.65 [1.23-2.21]) groups, but not in the isolated post-load HIP (1.13 [0.86-1.48]) group. The adjusted odds ratios for preterm delivery and neonatal intensive care unit were higher in the post-load HIP group (1.44 [1.03-2.03] and 1.28 [1.04-1.57], respectively), the fasting and post-load HIP group (1.81 [1.23-2.68] and 1.42 [1.10-1.81], respectively) but not in the isolated fasting HIP group (1.34 [0.90-2.00] and 1.20 [0.94-1.52], respectively). CONCLUSION: Despite glucose-lowering care and adjustment for confounders, compared with no HIP, fasting HIP was associated with a higher rate of LGA infant, whereas post-load HIP was associated with higher preterm delivery and neonatal intensive care unit admission rates.
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Diabetes Gestacional , Hiperglucemia , Nacimiento Prematuro , Embarazo , Recién Nacido , Femenino , Humanos , Resultado del Embarazo/epidemiología , Diabetes Gestacional/epidemiología , Diabetes Gestacional/diagnóstico , Glucosa , Nacimiento Prematuro/epidemiología , Estudios Prospectivos , Peso al Nacer , Glucemia , Hiperglucemia/epidemiología , Hiperglucemia/diagnóstico , AyunoRESUMEN
Postpartum anal incontinence is common. After a first delivery (D1) with perineal trauma, follow-up is advised to reduce the risk of anal incontinence. Endoanal sonography (EAS) may be considered to evaluate the sphincter and in case of sphincter lesions to discuss cesarean section for the second delivery (D2). Our objective was to study the risk factors for anal continence impairment following D2. Women with a history of traumatic D1 were followed before and 6 months after D2. Continence was measured using the Vaizey score. An increase ≥2 points after D2 defined a significant deterioration. A total of 312 women were followed and 67 (21%) had worse anal continence after D2. The main risk factors for this deterioration were the presence of urinary incontinence and the combined use of instruments and episiotomy during D2 (OR 5.12, 95% CI 1.22-21.5). After D1, 192 women (61.5%) had a sphincter rupture revealed by EAS, whereas it was diagnosed clinically in only 48 (15.7%). However, neither clinically undiagnosed ruptures nor severe ruptures were associated with an increased risk of continence deterioration after D2, and cesarean section did not protect against it. One woman out of five in this population had anal continence impairment after D2. The main risk factor was instrumental delivery. Caesarean section was not protective. Although EAS enabled the diagnosis of clinically-missed sphincter ruptures, these were not associated with continence impairment. Anal incontinence should be systematically screened in patients presenting urinary incontinence after D2 as they are frequently associated.
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Retardo del Crecimiento Fetal , Placenta , Embarazo , Femenino , Humanos , Retardo del Crecimiento Fetal/diagnóstico por imagen , Placenta/irrigación sanguínea , Arterias Umbilicales/diagnóstico por imagen , Factor de Crecimiento Placentario , Útero , Ultrasonografía Doppler , Ultrasonografía Prenatal , Arteria Uterina/diagnóstico por imagen , Circulación PlacentariaRESUMEN
PURPOSE: We set out to demonstrate the benefit of using dose-intense cisplatin-based neoadjuvant chemotherapy in terms of overall survival and progression-free survival. METHODS: We searched through MEDLINE and Cochrane Library databases up to May 2021 to identify randomized clinical trials comparing the benefit of using cisplatin-based neoadjuvant chemotherapy followed by local treatment with local treatment alone for the treatment of locally advanced cervical cancer. The PRISMA statement was applied. RESULTS: Twenty-two randomized clinical trials were retrieved between 1991 and 2019, corresponding to 3632 women with FIGO stages IB2-IVA cervical cancer. More than 50% of the randomized clinical trials were assessed as having a low risk of bias. There was no benefit of neoadjuvant chemotherapy on overall survival, but there was significant heterogeneity across studies (I2 = 45%, p = 0.01). In contrast, dose-intense cisplatin at over 72.5 mg/m2/3 weeks was significantly associated with increased overall survival (RR = 0.87, p < 0.05) with no heterogeneity across the pooled studies (I2 = 36%, p = 0.11). The survival benefit was even greater when cisplatin was administered at a dose over 105 mg/m2/3 weeks (RR = 0.79, p < 0.05). CONCLUSION: Even though radiotherapy combined with weekly cisplatin-based chemotherapy remains standard of care for the treatment of locally advanced cervical cancer, our meta-analysis makes it possible to consider the use of dose-intense cisplatin-based neoadjuvant chemotherapy when local treatment is suboptimal and opens perspectives for designing new clinical trials in this setting. Neoadjuvant chemotherapy could be proposed when surgery is local treatment instead of standard chemoradiotherapy for the treatment of locally advanced cervical cancer.
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AIM: Recent studies have shown that women with hyperglycaemia in pregnancy and insulin resistance have a greater risk of adverse pregnancy outcomes than women with normoglycaemic pregnancies. This study aimed to determine adverse pregnancy outcomes of women with hyperglycaemia in pregnancy only as a function of insulin resistance. METHODS: From a prospective cohort study, we included 1,423 women with hyperglycaemia in pregnancy whose insulin resistance was evaluated using homoeostatic model assessment for insulin resistance (HOMA-IR) when care was first provided for this condition. We compared the adverse pregnancy outcomes for different tertiles of HOMA-IR (intertertile range 1.9 and 3.3). RESULTS: Increasing HOMA-IR tertiles were positively associated with the rate of insulin therapy (tertile 1, 2 and 3: 32.7, 47.0 and 58.7%, P < 0.0001), caesarean section (23.7, 26.0 and 32.2%, respectively, P < 0.01), gestational hypertension (1.3, 2.8 and 5.4% respectively, P < 0.01), preeclampsia (1.5, 2.8 and 4.5% respectively, P < 0.05), large-for-gestational-age infant (13.3, 10.4 and 17.6% respectively, P < 0.05), and neonatal hypoglycaemia (0.8, 1.5 and 3.2% respectively, P < 0.05). Women in the 3rd HOMA-IR tertile were more likely to have insulin therapy (odds ratio 2.09 (95% interval confidence 1.61-2.71)), hypertensive disorders (2.26 (1.42-3.36)), and large-for-gestational-age infant (1.42 (1.01-1.99)) than those in the 1st and 2nd tertiles combined in multivariable logistic regression analyses adjusted for gestational age at HOMA-IR measurement, glycaemic status, age, body mass index, family history of diabetes, parity and ethnicity. CONCLUSION: Despite suitable care and increased rates of insulin therapy during pregnancy, higher insulin resistance in women with hyperglycaemia in pregnancy was associated with a greater risk of adverse pregnancy outcomes.
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Diabetes Gestacional , Hiperglucemia , Resistencia a la Insulina , Glucemia/metabolismo , Cesárea , Diabetes Gestacional/tratamiento farmacológico , Diabetes Gestacional/epidemiología , Diabetes Gestacional/metabolismo , Femenino , Prueba de Tolerancia a la Glucosa , Humanos , Hiperglucemia/epidemiología , Recién Nacido , Insulina/metabolismo , Insulina/uso terapéutico , Embarazo , Resultado del Embarazo/epidemiología , Estudios ProspectivosAsunto(s)
Complicaciones del Embarazo , Telemedicina , Femenino , Estudios de Seguimiento , Humanos , Embarazo , Embarazo de Alto RiesgoAsunto(s)
COVID-19 , Trombosis , Femenino , Humanos , Obesidad/complicaciones , Obesidad/diagnóstico , Obesidad/epidemiología , Embarazo , Mujeres Embarazadas , SARS-CoV-2RESUMEN
OBJECTIVES: A recent randomized controlled trial has reconsidered the use of laparoscopy for treating patients with early-stage cervical cancer with radical hysterectomy (RH). We aimed to evaluate if surgical approach had an impact on surgical and oncological outcomes in these patients in a French setting. METHODS: Data of 1706 patients with cervical cancer treated between 1996 and 2017 were extracted from maintained databases of 9 French University hospitals. Patients, with FIGO stage IA2 to IIB tumors, treated by radical hysterectomy were selected for further analysis. A propensity score matching was used with a ratio of 2:1 in favor of laparoscopic approach was used. The Kaplan Meier method was used to estimate the survival distribution. RESULTS: 34 patients treated with laparotomy were matched with 61 patients treated by minimally invasive surgery (MIS). There was no difference regarding overall survival (91 % vs 81 %, p > 0.05) or disease-free survival (82 % vs 78 %, p > 0.05). There was no difference regarding surgical outcomes with no excess of postoperative complication in patients with MIS. Hospital stay was significantly longer in patients operated on laparotomy. CONCLUSION: In our study, there was no evidence of a difference in survival between minimally invasive surgery and laparotomy in patients treated with radical hysterectomy for early-stage cervical cancer.
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Histerectomía/métodos , Laparoscopía , Neoplasias del Cuello Uterino/mortalidad , Neoplasias del Cuello Uterino/cirugía , Supervivencia sin Enfermedad , Femenino , Francia , Humanos , Tiempo de Internación , Análisis por Apareamiento , Persona de Mediana Edad , Estudios Retrospectivos , Análisis de Supervivencia , Neoplasias del Cuello Uterino/patologíaAsunto(s)
Antivirales , COVID-19 , Antivirales/uso terapéutico , Humanos , Hidroxicloroquina , Pandemias , Embarazo , SARS-CoV-2RESUMEN
BACKGROUND: The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies. MAIN BODY: In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed. CONCLUSION: The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.
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Presentación de Nalgas/terapia , Parto Obstétrico/métodos , Cesárea , Femenino , Humanos , Recién Nacido , Recién Nacido Pequeño para la Edad Gestacional , Embarazo , Tercer Trimestre del Embarazo , Versión FetalAsunto(s)
Anticuerpos Antinucleares/inmunología , Síndrome Antifosfolípido/complicaciones , Complicaciones del Embarazo/etiología , Síndrome de Sjögren/complicaciones , Adulto , Síndrome Antifosfolípido/diagnóstico , Síndrome Antifosfolípido/tratamiento farmacológico , Aspirina/uso terapéutico , Bases de Datos Factuales , Femenino , Francia , Humanos , Hidroxicloroquina/uso terapéutico , Incidencia , Persona de Mediana Edad , Morbilidad , Embarazo , Complicaciones del Embarazo/epidemiología , Complicaciones del Embarazo/fisiopatología , Resultado del Embarazo , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Síndrome de Sjögren/diagnóstico , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND: Sentinel node and occult lesion localization (SNOLL) calls for a combination of two specific procedures: intraoperative detection of sentinel lymph node (SLN) and radio-guided occult lesion localization (ROLL). The safety and benefits of radio-guided localization in the surgical treatment of non-palpable breast cancer have been confirmed. The aim of this study was to evaluate the potential role for an intra-operative handheld tumor resection gamma camera (TReCam) in SNOLL procedures. METHODS: Fifteen patients were enrolled. The SNOLL procedure was performed in all patients with conventional lymphoscintigraphy (LS). TReCam was used to obtain nuclear imaging in the operating theater. Concordance between LS and TReCam images, duration of use and assessment of difficulties in data acquisition with TReCam were reported. RESULTS: Concordance for tumor localization between single-detector gamma probe and TReCam was excellent (15/15). The number of radioactive SLNs visualized between LS and TReCam was equivalent in 53.3% of cases (8/15). TReCam was considered to be very easy-to-use (12/15) or easy-to-use (3/15). Average duration of acquisition with TReCam was 4 minutes and 45 seconds for the SLN procedure, and 2 minutes and 10 seconds for lumpectomy. CONCLUSIONS: This study suggests that TReCam is easy-to-use and does not increase operative time. Its exact role in radio-guided surgery needs to be clearly defined in a larger study. However, its usefulness and benefits in radio-guided breast surgery seem to be promising.