Impact of different prenatal management strategies in short- and long-term outcomes in monochorionic twin pregnancies with selective intrauterine growth restriction and abnormal flow velocity waveforms in the umbilical artery Doppler: a retrospective observational study of 108 cases.

OBJECTIVES: To review perinatal and neurodevelopmental outcome (NDO) following selective fetoscopic laser coagulation (SFLC), cord coagulation (CC) or expectant management of monochorionic diamniotic twin pregnancies complicated with selective intrauterine growth restriction (sIUGR) and absent or reverse end-diastolic flow (AREDF) in the umbilical arteries (UA). DESIGN AND SETTING: Single-centre retrospective observational study. POPULATION: 108 cases of sIUGR diagnosed before 26+6  weeks' gestation with AREDF in the UA. METHODS: Survival rate and potential risk factors were analysed. NDO was assessed using parental questionnaires. MAIN OUTCOMES MEASURES: Survival, gestational age at delivery and NDO. RESULTS: SFLC, CC and EM were performed in 13, 50 and 45 cases, respectively, with an overall survival of 23.1, 40 and 77.8% and intrauterine demise of the co-twin of 30.8, 10 and 6.7% respectively. Intrauterine demise of the sIUGR twin occurred in 76.9 and 17.8% following SFLC and EM, respectively. The discordance in EFW at diagnosis was higher and absent/negative a-wave in the ductus venosus (DV) was more prevalent in the surgical groups. NDO in survivors at follow up was abnormal in 0 and 18% in the smaller twin following SFLC and EM, respectively, and in 25, 24 and 21% in the larger twin following SFLC, CC and EM, respectively. CONCLUSION: SFLC yielded a poor result. EM seems a valid option when EFW discordance is <30% and a-wave in DV is positive. Otherwise, CC should be considered to protect the AGA co-twin. The long-term outcome of both small and large twins seems unaffected by the choice in primary prenatal management strategy. TWEETABLE ABSTRACT: In type II sIUGR in MC twins, long-term neurodevelopment is normal in over 80% of the survivors.

[Prenatal path of care following the diagnosis of a malformation for which a novel prenatal therapy is available]. / Parcours prénatal devant une malformation pour laquelle un traitement in utero émergent est disponible.

OBJECTIVES: Fetal therapy is part of the available care offer for several severe malformations. The place of these emergent prenatal interventions in the prenatal path of care is poorly known. The objective of this study is to describe the decision-making process of patients facing the option of an emergent in utero intervention. METHODS: We have conducted a retrospective monocentric descriptive study in the department of maternal-fetal medicine of Necker Hospital. We collected data regarding eligibility or not for fetal surgery and the pregnancy outcomes of patients referred for myelomeningocele, diaphragmatic hernia, aortic stenosis and low obstructive uropathies. RESULTS: All indications combined, 70% of patients opted for fetal surgery. This rate was lower in the case of myelomeningocele with 21% consent, than in the other pathologies: 69% for diaphragmatic hernias, 90% for aortic stenoses and 76% for uropathy. When fetal intervention was declined, the vast majority of patients opted for termination of pregnancy: 86%. In 14% of the considering fetal surgery, the patient was referred too far. CONCLUSION: The acceptance rate for fetal surgeries depends on condition. It offers an additional option and is an alternative for couples for which termination of pregnancy (TOP) is not an option. Timely referral to an expert center allows to discuss the place of a fetal intervention and not to deprive couples of this possibility.

Preterm premature rupture of membranes is a collateral effect of improvement in perinatal outcomes following fetoscopic coagulation of chorionic vessels for twin-twin transfusion syndrome: a retrospective observational study of 1092 cases.

OBJECTIVES: Preterm premature rupture of membranes (PPROM) is a leading complication following fetoscopic laser coagulation (FLC) for twin-twin transfusion syndrome (TTTS). Our primary objective was to describe the impact of improvements in surgical technique on survival and rate of PPROM over time. The secondary objective was to assess potential risk factors for PPROM. DESIGN AND SETTING: Single-centre retrospective observational study. POPULATION: 1092 consecutive cases of TTTS operated by FLC between 2000 and 2016, with a 6.8% rate of loss to follow up. METHODS: The incidence of PPROM and potential risk factors were analysed using competing risks models. MAIN OUTCOME MEASURES: PPROM, neonatal survival and neurological damage at 28 days. RESULTS: PPROM <32 weeks increased from 15 to 40% between 2000 and 2016 along with an overall improvement of perinatal outcomes: dual survival rose from 42 to 66% whereas dual losses dropped two-fold, from 19 to 9%. Gestational age at surgery at <17 weeks was a significant risk-factor for PPROM, with an additional risk of 10% within the first week of surgery. Although early PPROM at <20 weeks carried a 56% risk of miscarriage, the occurrence of PPROM at >20 weeks did not affect survival, despite an increase in preterm birth at <32 weeks. CONCLUSIONS: With significant improvement in perinatal outcomes, possibly related to improvements in surgical technique, postoperative complications have shifted to non-lethal obstetric complications such as PPROM, with rather reassuring postnatal outcomes, despite an increase in preterm birth and, potentially, morbidity. Early surgeries (<17 weeks) are at higher risk of postoperative PPROM. TWEETABLE ABSTRACT: Following laser/TTTS, rates of PPROM increased with perinatal survival; surgeries at <17 weeks are at highest risk.

Improving the quality of transvaginal ultrasound scan by simulation training for general practice residents.

BACKGROUND: Ultrasonography (US) is an essential tool for the diagnosis of acute gynecological conditions. General practice (GP) residents are involved in the first-line management of gynecologic emergencies. They are not familiar with US equipment. Initial training on simulators was conducted.The aim of this study was to evaluate the impact of simulation-based training on the quality of the sonographic images achieved by GP residents 2 months after the simulation training versus clinical training alone. METHODS: Young GP residents assigned to emergency gynecology departments were invited to a one-day simulation-based US training session. A prospective controlled trial aiming to assess the impact of such training on TVS (transvaginal ultrasound scan) image quality was conducted. The first group included GP residents who attended the simulation training course. The second group included GP residents who did not attend the course. Written consent to participate was obtained from all participants. Images achieved 2 months after the training were scored using standardized quality criteria and compared in both groups. The stress generated by this examination was also assessed with a simple numeric scale. RESULTS: A total of 137 residents attended the simulation training, 26 consented to participate in the controlled trial. Sonographic image quality was significantly better in the simulation group for the sagittal view of the uterus (3.6 vs 2.7, p = 0.01), for the longitudinal view of the right ovary (2.8 vs 1.4, p = 0.027), and for the Morrison space (1.7 vs 0.4, p = 0.034), but the difference was not significant for the left ovary (2.9 vs 1.7, p = 0.189). The stress generated by TVS after 2 months was not different between the groups (6.0 vs 4.8, p = 0.4). CONCLUSION: Simulation-based training improved the quality of pelvic US images in GP residents assessed after 2 months of experience in gynecology compared to clinical training alone.

[Contribution of ultrasound signs for the prenatal diagnosis of posterior urethral valves: Experience of 3years at the maternity of the Bicêtre Hospital]. / Apport des signes d'appel échographiques dans le diagnostic anténatal des valves de l'urètre postérieur : expérience de 3ans à la maternité de l'hôpital Bicêtre.

OBJECTIVES: Posterior urethral valves (PUV) are the most common cause of renal impairment in boys during early childhood. The aim of this study was to evaluate the value of ultrasound (US) criteria currently used to diagnose PUV. MATERIALS AND METHODS: From 2009 to 2012, 31 patients were referred to the Bicêtre Hospital after detection of fetal bilateral hydronephrosis in male fetus. The ultrasound criteria were bladder dilation, thick-walled bladder, urethral dilation ("keyhole sign"), and amniotic fluid volume. Patients were divided in two groups: suspected or not to have PUV. RESULTS: US diagnosis of PUV was done in 18 fetuses and confirmed in 14 new borns, one of them without prenatal diagnosis. Sensitivity and specificity of US scan were 92.8 and 66.7%. The likelihood ratio (LHR) was 4.8 for a thick-walled bladder, 4.2 for oligohydramnios, 3.6 for the "keyhole sign", 2.4 for bladder dilation and 1.6 for ureteral dilation. The first four signs were combined in four fetuses, all of them with PUV. CONCLUSION: US scan is a very sensitive exam for the diagnosis of PUV but with a low specificity. A thick-walled bladder seems to have a better diagnostic performance than the "keyhole sign".

Factors affecting feasibility and quality of second-trimester ultrasound scans in obese pregnant women.

OBJECTIVES: To evaluate the feasibility of completing in one session a second-trimester ultrasound scan in obese pregnant women, to compare the quality of images obtained with those of non-obese women and to analyze factors that can improve the completion rate. METHODS: This prospective study, from 2009 to 2011, included all obese pregnant women (prepregnancy body mass index (BMI) > 30 kg/m2) who had an ultrasound examination at 20-24 weeks in our department, and a control group of pregnant women with normal BMI (20-24.9 kg/m2) who had the same examination. A single operator reviewed the standardized ultrasound images (three biometric and six to assess key anatomical features) required under French guidelines, to assess their presence, evaluate the quality of all images and score the quality of the six anatomical images. Each image was assessed according to between four and six criteria, each worth one point. We sought excellent quality, defined as the frequency of maximum points for a given image type. The factors associated with completing the scan in one session were evaluated with multivariate logistic regression. RESULTS: The obese group included 223 women and the control group 60; a complete scan in one session was achieved in 70.4% and 81.7% of these, respectively (P = 0.08). The completion rate for each image type was at least 95% in the control group and 90% in the obese group, except for diaphragm and right outflow tract images. Significant factors associated with completing the scan in the multivariate model were: having 10 additional minutes for the scan (P = 0.03), moving the fetus so that the back was in posterior or lateral position (P = 0.01), more experienced sonographer (P = 0.03) and thinner maternal abdominal wall thickness (P = 0.01). Overall, the excellence rate varied from 35% to 92% in the normal BMI group and from 18% to 58% in the obese group, and was significantly lower in the latter for all images except abdominal circumference (P = 0.26) and spine (P = 0.06). Anatomical quality scores were also significantly lower in the obese group (22.3 vs. 27.2; P = 0.001). CONCLUSION: Although ultrasound scans of obese pregnant women are feasible, image quality and global anatomical scores are significantly lower among obese than normal-weight women. However, certain simple improvements may increase fetal visualization.

[Abnormal placental caryotype in severe intrauterine growth retardations (IUGR). Case report]. / Place du caryotype placentaire dans l'enquête étiologique des retards de croissance intra-utérins sévères précoces. A propos d'un cas.

Except for cases due to maternal hypertension, severe and early intrauterine growth retardations are most usually due to fetal abnormalities. We report a case of confined placental homogenous tetraploidy associated with major fetal growth retardation leading to the premature delivery of a life born baby with a normal caryotype. We discuss the interest of chorionic villus sampling in cases of unexplained severe fetal growth retardation.

Return to fertility in nulliparous and parous women after removal of the GyneFix intrauterine contraceptive system.

OBJECTIVE: To evaluate the return to fertility following removal of the GyneFix intrauterine implant system in women wishing to conceive. STUDY DESIGN: A retrospective study was performed on a sample of healthy, sexually active nulligravid/nulliparous and parous women. The participants were 18-41 years of age, with no apparent infertility problem, living in a stable relationship and planning to become pregnant. Women who changed their mind and did not wish to become pregnant immediately after intrauterine device (IUD) removal were excluded from the study. Women were evaluated in terms of rates of conception and fertility outcome. A total of 128 women were evaluated. RESULTS: The study shows that 119 out of 128 (93%) past users of GyneFix have conceived, accounting for a net cumulative pregnancy rate of 88% at 12 months and 99% after 2 years' observation. No statistical differences in pregnancy rates were found for age and duration of use of the IUD. A strong significant difference in pregnancy rate was shown (p = 0.007) between parous and nulligravid/nulliparous women. Seventy-seven women (66.9%) gave birth to a term infant. There were no stillbirths. Twenty-five women (21.8%) are pregnant at the time of writing. Five (4.4%) spontaneous abortions occurred and in eight women (6.9%) the pregnancy was terminated. There were no ectopic pregnancies. CONCLUSION: The results obtained compare favorably with those obtained in previous studies conducted following the removal of copper IUDs. The use of the frameless IUD does not affect future fertility in nulligravid/nulliparous and parous women wishing to become pregnant following removal of the device. Nulliparous women conceive significantly earlier than parous women.

[Prenatal bowing of the long bones]. / De prenatale buiging van lange beenderen.

A case of congenital angulation and bowing of the long bones is reported. The condition belongs to a group of bone pathologies which have as a common feature an abnormal bowing of the diaphysis. The cortex at the concave side shows a thickening while the convex side shows a cortical thinning, corresponding to a structural adaptation to external compressing forces at the site of the bowing of the bone. The angulation is a consequence of bowing of long bones over other foetal parts.

Intralysosomal hydrolysis of glycyl-L-phenylalanine 2-naphthylamide.

Glycyl-L-phenylalanine 2-naphthylamide (Gly-L-Phe-2-NNap), a cathepsin C substrate, induces an increase of the free and unsedimentable activities of this enzyme when incubated with a total mitochondrial fraction of rat liver. 1 mM-ZnSO4 considerably inhibits the cathepsin C total activity, measured with Gly-L-Phe-2-NNap as the substrate, in the presence of Triton X-100. The inhibition is markedly less pronounced when the free activity is determined; a high activity remains that depends on the integrity of the lysosomes; it decreases as the free activity of N-acetylglucosaminidase increases when lysosomes are subjected to treatments able to disrupt their membrane. Cathepsin C activity is reduced when thioethylamine hydrochloride is omitted from the incubation medium. Under these conditions at 37 degrees C, the free activity equals the total activity, although the lysosomes are intact, as indicated by the low free activity of N-acetylglucosaminidase. 1 mM-ZnSO4 strikingly inhibits the total activity, whereas more than 80% of the free activity remains. These observations are presented as evidence that Gly-L-Phe-2-NNap can possibly cause a disruption of the lysosomes as a result of its hydrolysis inside these organelles. In the presence of ZnSO4, intralysosomal hydrolysis becomes apparent, owing to a preferential inhibition by Zn2+ of extralysosomal hydrolysis; in the absence of thioethylamine hydrochloride, it is measurable because the disruption of lysosomes by Gly-L-Phe-2-NNap is delayed as a result of a slow-down of the reaction. The usefulness of Gly-L-Phe-2-NNap and related dipeptidyl naphthylamides in lysosomal-membrane-permeability studies is emphasized.