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OBJECTIVE: To evaluate whether caesarean delivery before 26 weeks of gestation was associated with symptoms of depression and anxiety in mothers in comparison with deliveries between 26 and 34 weeks. DESIGN: Prospective national population-based EPIPAGE-2 cohort study. SETTING: 268 neonatology departments in France, March to December 2011. POPULATION: Mothers who delivered between 22 and 34 weeks and whose self-reported symptoms of depression (Center for Epidemiologic Studies Depression Scale: CES-D) and anxiety (State-Trait Anxiety Inventory: STAI) were assessed at the moment of neonatal discharge. METHODS: The association of caesarean delivery before 26 weeks with severe symptoms of depression (CES-D ≥16) and anxiety (STAI ≥45) was assessed by weighted and design-based log-linear regression model. MAIN OUTCOME MEASURES: Severe symptoms of depression and anxiety in mothers of preterm infants. RESULTS: Among the 2270 women completing CES-D and STAI questionnaires at the time of neonatal discharge, severe symptoms of depression occurred in 25 (65.8%) women having a caesarean before 26 weeks versus in 748 (50.6%) women having a caesarean after 26 weeks. Caesarean delivery before 26 weeks was associated with severe symptoms of depression compared with caesarean delivery after 26 weeks (adjusted relative risk [aRR] 1.42, 95% CI 1.12-1.81) adjusted to neonatal birthweight and severe neonatal morbidity among other factors. There was no evidence of an association between mode of delivery and symptoms of anxiety. CONCLUSIONS: Mothers having a caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression and may benefit from specific preventive care. TWEETABLE ABSTRACT: Mothers having caesarean delivery before 26 weeks' gestation are at high risk of symptoms of depression.
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Ansiedad/epidemiología , Cesárea/estadística & datos numéricos , Depresión/epidemiología , Complicaciones del Embarazo/epidemiología , Nacimiento Prematuro/epidemiología , Adulto , Ansiedad/cirugía , Cesárea/psicología , Depresión/cirugía , Femenino , Francia/epidemiología , Edad Gestacional , Humanos , Recién Nacido , Madres/psicología , Embarazo , Complicaciones del Embarazo/psicología , Complicaciones del Embarazo/cirugía , Nacimiento Prematuro/psicología , Nacimiento Prematuro/cirugía , Estudios ProspectivosRESUMEN
OBJECTIVE: To compare the short- and mid-term outcomes of preterm twins by chorionicity of pregnancy. DESIGN: Prospective nationwide population-based EPIPAGE-2 cohort study. SETTING: 546 maternity units in France, between March and December 2011. POPULATION: A total of 1700 twin neonates born between 24 and 34 weeks of gestation. METHODS: The association of chorionicity with outcomes was analysed using multivariate regression models. MAIN OUTCOME MEASURES: First, survival at 2-year corrected age with or without neurosensory impairment, and second, perinatal, short-, and mid-term outcomes (survival at discharge, survival at discharge without severe morbidity) were described and compared by chorionicity. RESULTS: In the EPIPAGE 2 cohort, 1700 preterm births were included (850 twin pregnancies). In all, 1220 (71.8%) were from dichorionic (DC) pregnancies and 480 from monochorionic (MC) pregnancies. MC pregnancies had three times more medical terminations than DC pregnancies (1.67 versus 0.51%, P < 0.001), whereas there were three times more stillbirths in MC than in DC pregnancies (10.09 versus 3.78%, P < 0.001). Both twins were alive at birth in 86.6% of DC pregnancies compared with 80.0% among MC pregnancies (P = 0.008). No significant difference according to chorionicity was found regarding neonatal deaths and morbidities. Likewise, for children born earlier than 32 weeks, the 2-year follow-up neurodevelopmental results were not significantly different between DC and MC twins. CONCLUSIONS: This study confirms that MC pregnancies have a higher risk of adverse outcomes. However, the outcomes among preterm twins admitted to neonatal intensive care units are similar irrespective of chorionicity. TWEETABLE ABSTRACT: Monochorionicity is associated with adverse perinatal outcomes, but outcomes for preterm twins are comparable irrespective of their chorionicity.
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Corion/patología , Enfermedades en Gemelos/epidemiología , Enfermedades del Prematuro/epidemiología , Trastornos del Neurodesarrollo/epidemiología , Factores de Edad , Preescolar , Estudios de Cohortes , Femenino , Francia , Humanos , Lactante , Recién Nacido , Recien Nacido Prematuro , Masculino , Placenta/patología , Embarazo , Resultado del Embarazo , Embarazo GemelarRESUMEN
OBJECTIVE: To identify factors influencing parental decision when a fetal cardiac disease is diagnosed. METHOD: All pregnancies with fetal cardiac abnormalities diagnosed at three academic hospitals of Marseille, France, between 2004 and 2008, were retrospectively studied. The association between maternal and fetal variables (maternal age, parity, ethnicity, gestational age at diagnosis, nuchal translucency, fetal gender, chromosomal and extra cardiac abnormalities, and severity of the cardiopathy) and parental decision was tested using univariate and multivariate statistical methods RESULTS: One hundred eighty-eight cases of fetal cardiac disease were analysed, of which 63 were interrupted pregnancies (IP) and 125 continued pregnancies (CP). Four factors were important in the parental decision-making process: the severity of cardiac malformation, the ethnic origin of the parents, the gestational age at diagnosis and the chromosomal abnormalities. CONCLUSION: Counselling of parents following the diagnosis of a congenital heart disease should take into account that, in addition of the severity of the congenital heart disease (CHD), ethnicity, gestational age at diagnosis and chromosomal abnormalities influence parental decision regarding pregnancy continuation or interruption.
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Aborto Eugénico , Toma de Decisiones , Enfermedades Fetales/genética , Cardiopatías Congénitas/genética , Padres/psicología , Diagnóstico Prenatal , Anomalías Múltiples , Aborto Eugénico/estadística & datos numéricos , Adulto , Aberraciones Cromosómicas , Femenino , Enfermedades Fetales/diagnóstico , Enfermedades Fetales/etnología , Asesoramiento Genético , Edad Gestacional , Cardiopatías Congénitas/diagnóstico , Cardiopatías Congénitas/etnología , Humanos , Medida de Translucencia Nucal , Embarazo , Pronóstico , Estudios Retrospectivos , Factores de RiesgoRESUMEN
AIM: The aim of this study, based on the interaction between two aerobic and anaerobic metabolisms with a parallel production of both aerobic and anaerobic ATP, was to develop a high intensity training programme and increase the aerobic contribution. We examined the applicability of a 16-week training programme with an ergospirometer treadmill and field tests on eight water polo players. METHODS: Tests/retests of repeated exercises to 90V (90% of maximum personal speed over 100 m freestyle) and Speed Endurance Training (SET) after eight weeks were developed. A one-way blocked ANOVA with random blocks was used and each player represented a particular block with two before-after treatments with the aim of reducing error by subtracting both the variance due to the difference between the treatments and that due to the difference between the blocks. RESULTS: A reduction (15.2%) in blood lactate was observed in response to the same absolute workload (before-after). Furthermore the anaerobic contribution to VO2max (ESCAna, Estimated Anaerobic Contribution) after eight weeks of training at 90maxV and the anaerobic contribution to VO2max (ESCAna) after speed endurance training (SET) were very significant (P<0.004) with a reduction in the anaerobic contribution of 16%. The results of the field tests show that there was a very significant reduction (P<0.001) in lactate between 90maxV and maximal aerobic power velocity (MAPv) of 24%. CONCLUSION: With 90maxV and SET, space was gained towards those velocities, which had previously required a considerable anaerobic contribution. In this way match speed was increased.
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Rendimiento Atlético/fisiología , Educación y Entrenamiento Físico/métodos , Resistencia Física/fisiología , Deportes , Umbral Anaerobio/fisiología , Análisis de Varianza , Prueba de Esfuerzo , Humanos , Masculino , Consumo de Oxígeno/fisiología , Aptitud Física/fisiología , Agua , Adulto JovenRESUMEN
INTRODUCTION: The rate of caesarean delivery between 22 and 28 weeks of gestation (weeks) has increased for several years. The aim of the study was to describe subsequent pregnancies in women with a history of caesarean delivery between 22 and 28 weeks. METHODS: We performed a retrospective, observational, bicentric cohort study in tertiary care maternity units. We included women who had a caesarean delivery between 22 and 28 weeks from December 1, 2014 to December 31, 2017. We then retrospectively collected data on subsequent pregnancies of these patients up to March 2020. We described the subsequent pregnancy rate and the outcomes of these pregnancies. RESULTS: Among the 186 women who had a caesarean between 22 and 28 weeks, data from 103 of them could be collected, including 47 (45.6%) women who had 64 new pregnancies. Of the 47 first pregnancies after the preterm cesarean, 19 (40.4%) were completed at≥37 weeks. The mode of delivery was a cesarean in 23 cases (79.3%). A trial of labor after cesarean was only considered in 7 cases (24.1%), and 6 women (20.7%) gave birth vaginally. CONCLUSIONS: If pregnancy is desired after a caesarean between 22 and 28 weeks, the pregnancy rate is high without recurrence of prematurity in the majority of cases. Cesarean delivery is the most common mode of delivery. In case of trial of labor after cesarean, the success rate is reasonable.
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Nacimiento Prematuro , Parto Vaginal Después de Cesárea , Estudios de Cohortes , Femenino , Humanos , Recién Nacido , Embarazo , Resultado del Embarazo/epidemiología , Nacimiento Prematuro/epidemiología , Estudios RetrospectivosRESUMEN
OBJECTIVES: International literature suggests that active perinatal management at extremely low gestational ages improves survival without increasing the risk of impairment in survivors, compared to less active management. Although these results are limited to a small number of countries, they question current practices in France. New propositions on perinatal management of extremely preterm infants have carried out by the French Society of Perinatal Medicine, the French Society of Neonatology and the National College of French Obstetricians and Gynecologists. METHODS: This group was set up in 2015 on the initiative of the professional societies and in collaboration with parents' and users' associations. The work was based on a review of the literature on the prognosis of extremely preterm children, as well as on recommendations by European societies. Based on this information, a text was produced, submitted to all members of the working group and definitively validated in April 2019. RESULTS: This text offers a decision-making guideline for the management at extremely low gestational ages. Its principles are: the administration of steroids independently of management (resuscitation or comfort care); a prognostic evaluation and a collegial decision, outside the context of the emergency; a consensus on the information to be given to parents before going to inform them and gather their opinion. CONCLUSIONS: These new propositions will contribute to modifying perinatal care at extremely low gestational ages in France.
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Ginecología , Atención Perinatal , Niño , Femenino , Edad Gestacional , Humanos , Lactante , Recien Nacido Extremadamente Prematuro , Recién Nacido , Embarazo , ResucitaciónRESUMEN
Persistant occiput posterior (OP) positions are the commonest malpresentations of the fetal head during labor and their diagnosis remains challenging. They are associated to prolonged second stage of labor, prolonged expulsive efforts, labor augmentation, cesarean sections and instrumental deliveries. On the maternal side, severe perineal tears, post-partum hemorrhage or chorioamnionitis are more frequent. Currently, prevention of persistent OP positions is based on the maintain of precise maternal positions. Several positions have been evaluated but only lateral position on the same side of the fetal spine has proved its effectiveness. Fetal head rotation can also be achieved with extraction instruments though none has ever been evaluated by a randomized controlled trial. Obstetrical forceps seem more efficient than vacuum but are associated with severe perineal tears. Evaluation of rotation with Thierry's spatulas is scarce. Last, manual rotation is of routine use in many wards. This management is associated with a twofold reduction of operative delivery rate and rare adverse outcomes but has never been evaluated through randomized control trial.
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Parto Obstétrico , Presentación en Trabajo de Parto , Complicaciones del Trabajo de Parto/diagnóstico , Complicaciones del Trabajo de Parto/terapia , Corioamnionitis/etiología , Extracción Obstétrica , Femenino , Humanos , Perineo/lesiones , Hemorragia Posparto/etiología , Embarazo , Versión FetalRESUMEN
Though technology plays an increasingly important role in modern health systems, human performance remains a major determinant of safety, effectiveness and efficiency of patient care. This is especially true in the delivery room. Thus, the training of professionals must aim not only for the acquisition of theory and practical skills on an individual basis, but also for the learning of teamwork systematically. Training health professionals with simulation enhances their theoretical knowledge and meets formal requirements in literacy, technical skills and communication. Therefore, we intend to explore how, in perinatal care, training with simulation is actually a key teaching tool in initial education and in perpetuation of knowledge. We will approach three main aspects: individual, collective (team) and the impact of simulation in medical practice. The choice of this educational strategy improves the clinical skills that are required for optimal performance in complex, unpredictable and high-stake environments such as the delivery room. Nonetheless, the long term clinical impact of simulation and whether it's modalities, technical or not, are beneficial to the mother and the newborn are areas still to be explored.
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Perinatología/educación , Entrenamiento Simulado/métodos , Competencia Clínica , Salas de Parto , Distocia/terapia , Eclampsia/terapia , Femenino , Personal de Salud/educación , Humanos , Recién Nacido , Muerte Perinatal/prevención & control , Hemorragia Posparto/terapia , Embarazo , Resucitación/educaciónRESUMEN
BACKGROUND: Cesarean section is the most common surgical procedure performed in developed countries. Its incidence is increasing to a worrisome extent. The 2003 French National Perinatal Survey showed that the inflation in the overall cesarean rate was mainly due to an increase in the first cesarean delivery rate. OBJECTIVE: To evaluate a new tool: a checklist that intent to decrease the first cesarean delivery rate. STUDY DESIGN: Retrospective, observational, multi-center study. A new tool, a "First cesarean delivery" checklist was built according American and French guidelines. Women with full-term of pregnancy, nulliparous or multiparous with a first caesarean delivery including arrest of labor, breech presentation or suspected fetal macrosomia were included. The checklist was applied. Potentially preventable cesareans were analyzed. RESULTS: Among 571 first cesarean section, 178 were eligible to check list application. 147 charts were analyzed in the study. 11.9% of first cesarean deliveries performed were potentially avoidable after applying the checklist. This represented 6.6% of all cesareans. CONCLUSION: The checklist based on the recall of good practices could be an interesting tool to decrease the first cesarean rate.
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Presentación de Nalgas/cirugía , Cesárea/estadística & datos numéricos , Macrosomía Fetal/cirugía , Evaluación de Procesos y Resultados en Atención de Salud/estadística & datos numéricos , Guías de Práctica Clínica como Asunto/normas , Adulto , Cesárea/normas , Lista de Verificación , Femenino , Humanos , Embarazo , Estudios Retrospectivos , Adulto JovenRESUMEN
OBJECTIVE: To validate Grobman nomogram for predicting vaginal birth after cesarean delivery (VBAC) in a French population and adapt it. STUDY DESIGN: Multicenter retrospective study of maternal and obstetric factors associated with VBAC between May 2012 and May 2013 in 6 maternity units. External validation and adaptation of the prenatal and intrapartum Grobman nomograms for vaginal birth prediction after cesarean delivery in a French cohort. RESULTS: The study included 523 women with previous cesarean deliveries; 70% underwent a trial of labor for a subsequent delivery (n=367) with a success rate of 65% (n=240). In the univariate analysis, 5 factors were associated with successful VBAC: previous vaginal delivery before the cesarean (P<0.001), the number of previous vaginal deliveries (P<0.001), and a favorable cervix at delivery room admission, cervical effacement (P=0.035), or cervical dilatation at least 3cm (P<0.001), or a Bishop score >6 (P=0.03). A potentially recurrent indication (defined as arrest of dilation or descent as the indication for the previous cesarean) (P=0.039), a hypertensive disorder during pregnancy (P=0.05), and labor induction (P=0.017) were each associated with failed VBAC. External validation of the prenatal and intrapartum Grobman nomograms showed an area under the ROC curve of 69% (95% CI: 0.638, 0.736) and 65% (95% CI: 0.599, 0.700) respectively. Adaptation of the nomogram to the French cohort resulted in the inclusion of the following factors: maternal age, body mass index at last prenatal visit, hypertensive disorder, gestational age at delivery, recurring indication, cervical dilatation, and induction of labor. Its area under the curve to predict successful VBAC was 78% (95% CI: 0.738, 0.825). CONCLUSION: The nomogram to predict VBAC developed by Grobman et al. is validated in the French population. Adaptation to the French population, by excluding ethnicity, appeared to improve its performance. Impact of the nomogram use on the caesarean section rate has to be validated in a randomized control trial.
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Trabajo de Parto , Complicaciones del Embarazo , Pronóstico , Esfuerzo de Parto , Parto Vaginal Después de Cesárea , Adulto , Femenino , Francia , Humanos , Embarazo , Reproducibilidad de los Resultados , Estudios Retrospectivos , Parto Vaginal Después de Cesárea/estadística & datos numéricosRESUMEN
OBJECTIVE: To describe perinatal data and to evaluate the neonatal neurological outcome of monochorionic twin pregnancies with selective termination by radiofrequency ablation. METHODS: Retrospective data of perinatal data for nine consecutive monochorionic pregnancies eligible for radiofrequency ablation from January 2013 to August 2015 were collected. A prospective observational study of the neurological outcome of nine children was conducted using the Ages & Stages Questionnaire (ASQ), 2nd edition, French version, adapted to the age. RESULTS: The radiofrequency procedures were performed at a mean gestational age (GA) of 21.4 weeks (±7 weeks). The indications for a selective interruption of a pregnancy were: acardiac twin (n=4), brain malformation (n=1), severe intrauterine growth restriction (IUGR) with massive cerebral ischemia in the context of twin-twin transfusion syndrome grade III (n=1), severe selective IUGR associated with a polymalformative syndrome (n=1) and severe selective IUGR (n=2). The mean GA at birth was 36.7 weeks GA (±3.8 weeks). No infant showed neurological neonatal morbidity. Any ASQ area explored was pathological (<-2SD) for the nine children (mean age at follow-up [±SD], 14.8 months [±8.8 months]). CONCLUSION: This work constitutes a preliminary study for developing long-term follow-up and early care programs for those children born subsequent to a radiofrequency ablation for selective reduction.
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Técnicas de Ablación/métodos , Complicaciones del Embarazo/terapia , Resultado del Embarazo , Reducción de Embarazo Multifetal/métodos , Embarazo Gemelar , Gemelos Monocigóticos , Técnicas de Ablación/efectos adversos , Anomalías Congénitas , Enfermedades en Gemelos , Femenino , Retardo del Crecimiento Fetal , Transfusión Feto-Fetal , Edad Gestacional , Humanos , Recién Nacido , Embarazo , Estudios RetrospectivosRESUMEN
OBJECTIVES: To evaluate the risk of severe perineal tear following instrumental vaginal delivery (IVD) performed with spatulas and vacuum extraction. Secondary objectives were to estimate the impact of episiotomy on this risk. METHODS: From December 2008 to October 2012, women who underwent spatulas or vacuum were prospectively included. Each spontaneous vaginal delivery (SVD) following each included IVD were included as control cases (1-1 ratio). Careful perineal examination was systematically performed. Severe perineal tear was defined by the occurrence of anal sphincter rupture with or without anal mucosa tear. RESULTS: A total of 761 patients were included in the current study: 248 (64%) spatulas, 137 (36%) vacuums and 381 (49%) SVDs. Severe perineal tear was diagnosed in 19 (2.5%) cases. Episiotomy had been performed in 276 (36.9%) patients. Only spatulas extraction was found to significantly increase the risk of severe perineal tear (AOR=7.66; 95% CI: 2.06-28; P=0.02). Although vacuum extraction seemed to increase this risk, it was not found to be significant (AOR=3.25; 95% CI: 0.65-16.24; P=0.15). No significant difference was observed between the risk of severe perineal tear following spatulas and vacuum (AOR=2.36; 95% CI: 0.63-8.82; P=0.202). Finally, neither foetal macrosomia, nor episiotomy, nor foetal extraction with the head in the deep pelvis, nor delivery at night had a significant impact on the probability of severe perineal tear. CONCLUSIONS: Spatulas extraction is an independent risk factor for severe perineal tear. The practice of episiotomy was not shown to have any significant impact on this risk.
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Forceps Obstétrico/efectos adversos , Perineo/lesiones , Extracción Obstétrica por Aspiración/efectos adversos , Adulto , Canal Anal/lesiones , Estudios de Casos y Controles , Estudios de Cohortes , Episiotomía/estadística & datos numéricos , Femenino , Humanos , Mucosa Intestinal/lesiones , Perineo/cirugía , Embarazo , RoturaRESUMEN
OBJECTIVES: To propose a protocol for induction of labor to terminate pregnancy after 22weeks of amenorrhea allowing to decrease the duration of labor and of hospitalization but also, allowing to reduce the number of emergency pretreatment-induced fetal death, to improve the experience of the patients and to limit the cost. METHODS: We realized a retrospective single-center study including 269patients and comparing three protocols, with and without laminaria and with various intervals mifepristone-misoprostol (14 and 38hours). The outcome measures were the misoprostol-delivery interval, the delivery time and the number of emergency pretreatment-induced fetal death. RESULTS: We showed that the misoprostol-delivery interval and the delivery time were comparable for the three periods of our study, even after decrease of 24hours of the mifepristone-misoprostol interval and in the absence of laminaria. The misoprostol-delivery interval was between 7h30 and 8h35 between protocols (P=0.055). The delivery time was between 5:18pm and 6:48pm between protocols (P=0.252). The early administration of misoprostol allowed the patients to give birth earlier (P=0.001). Finally, we showed that the increase of the size and the number of laminarias were risk factors of emergency pretreatment-induced fetal death (respectively P=0.013 and P=0.002). CONCLUSION: The absence of laminaria and the reduction of the interval mifepristone-misoprostol of 24hours do not change the time to delivery and allow to reduce the duration of hospitalization, the number of emergency pretreatment-induced fetal death and the cost of the TOP.
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Abortivos/administración & dosificación , Aborto Inducido/métodos , Trabajo de Parto Inducido/métodos , Laminaria , Mifepristona/administración & dosificación , Misoprostol/administración & dosificación , Evaluación de Procesos y Resultados en Atención de Salud , Abortivos/farmacología , Aborto Inducido/estadística & datos numéricos , Adulto , Femenino , Humanos , Trabajo de Parto Inducido/estadística & datos numéricos , Mifepristona/farmacología , Misoprostol/farmacología , Embarazo , Segundo Trimestre del Embarazo , Tercer Trimestre del Embarazo , Estudios RetrospectivosRESUMEN
OBJECTIVE: To study the related knowledge of French residents in obstetrics concerning maneuvers for shoulder dystocia (SD). MATERIALS AND METHODS: Multicenter descriptive transversal study conducted from June to September 2014. Data collection was performed through questionnaires sent by email to French resident in obstetrics. RESULTS: Among the 1080 questionnaires sent, 366 responses were obtained with a response rate of 33.9%. One hundred and forty-three residents (39.1%) were in the first part of their training (≤5th semester) and 60.9% (n=223) were in the second part of their training. Theoretical training on the SD was provided to 88.2% of resident (n=323). In total, 38.8% (n=142) obtained their French degree in mechanical and technical obstetric and among them 77.5% (n=110) had the opportunity to train on simulators and dummies. Concerning their practical experiences, 31.5% (n=45) residents ≤5th semester reported having experienced SD during their residency vs 58.3% (n=130) amongst oldest residents (P<0.001). In the second part of residency, 40% of residents (n=89) expressed to feel able to manage shoulder dystocia. Only 19.1% (n=70) were satisfied with their residency training program vs 39.1% (n=143) who were unsatisfied. CONCLUSION: Our study showed that less than one resident out of two (40%) felt able to perform maneuvers for SD in the second part of residency. We think that simulation activities should be mandatory for residency training programs in Obstetrics and Gynecology, which have to develop dependable measures to assess resident competencies to execute practical maneuvers for clinical emergencies in obstetrics.
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Competencia Clínica/estadística & datos numéricos , Distocia/terapia , Ginecología/educación , Conocimientos, Actitudes y Práctica en Salud , Internado y Residencia/estadística & datos numéricos , Obstetricia/educación , Femenino , Francia , Humanos , Embarazo , HombroRESUMEN
OBJECTIVE: To evaluate adherence of obstetricians from our maternity to French practice guidelines concerning information to give to pregnant patients with a history of scarred uterus. MATERIALS AND METHODS: Observational retrospective study performed on medical files from June to August 2014 and concerning women with a scarred uterus that gave live-birth after 37weeks of gestation. Information of patients had to concern the risks of a history of caesarean, the benefits and risks of the various delivery modes. RESULTS: On 758 deliveries, 77 cases were studied: 48 patients were followed up from the beginning of pregnancy, 23 from the 2nd trimester and 6 were not followed. Among patients followed from the beginning, no data was written on medical file concerning information that should to be given in immediate post-partum, in preconception counseling, and at the beginning of pregnancy about the risks of scarred uterus and the mode of delivery. In the 8th month, information about benefits and risks of the planned delivery mode was noticed in 45% of files. CONCLUSION: The information that need in theory to be given to the patients with scarred uterus appeared little or insufficiently noticed on medical files; which can be due either to an inaccurate information, or to a lack of transcription of the information nevertheless given. A check-list in obstetrical file would help to systematize the information to provide in scarred uterus patients.
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Cicatriz/patología , Parto Obstétrico/métodos , Obstetricia/métodos , Guías de Práctica Clínica como Asunto , Útero/patología , Adulto , Cesárea/efectos adversos , Femenino , Francia , Edad Gestacional , Humanos , Consentimiento Informado , Médicos , Pautas de la Práctica en Medicina , Embarazo , Estudios Retrospectivos , Factores de Riesgo , Rotura Uterina , Parto Vaginal Después de CesáreaRESUMEN
Establishing a prognosis in prenatal medicine is often a complex and uncertain task. Predictive tools such as imagery techniques and biological markers may lack accuracy since they are used while the fetus is still pursuing its development. In France, antenatal euthanasia and fetal abandon are legal issues and socially accepted. Several non-medical factors may interfere with the final outcome such as the manner a condition is announced by the staff, the way it is experienced by the parents and the acceptance of the handicap within the society. We analysed the different medical and non medical factors intervening in the prognosis work up for Down's syndrome. Currently, the outcome of fetus with Down's syndrome is influenced by the orientation of our society that promotes screening tests and pregnancy interruptions instead of emphasizing on therapeutic research and improving their social integration.
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Aborto Inducido , Síndrome de Down/diagnóstico , Padres/psicología , Diagnóstico Prenatal , Responsabilidad Social , Aborto Inducido/psicología , Síndrome de Down/genética , Femenino , Francia , Asesoramiento Genético , Pruebas Genéticas , Humanos , Embarazo , PronósticoRESUMEN
OBJECTIVES: To describe the frequency of maternal and neonatal complications resulting from the use of Thierry's spatulas. MATERIALS AND METHODS: This retrospective study included 166 patients treated during a 17-month period. RESULTS: For 100% of the patients, the use of the spatulas allowed the extraction of the new born, in 68 cases (41%) the new born was engaged between one and two centimeters below the spines. A medio-lateral episiotomy was performed in 159 patients (96%). A serious perineal tear (Type 3) occurred for 6 of these patients (3.6%). A simple perineal tear (Type 1) or vaginal tear occurred in 24 (18%). Episiotomy was performed in 18 patients and was significantly protective. No case of serious neonatal complication were related to the use of the spatulas. CONCLUSION: We found that perineal tear rate is similar to that observed with other instruments used for fetal extraction. No case of fetal trauma could be related to the use of the spatulas; this was the goal of Thierry who creation the instrument. The use of Thierry's spatulas as a reference instrument is warranted, particularly for cases of prematurity, as these spatulas fulfil the modern obstetrics requirements of fetal protection, without maternal risk.
Asunto(s)
Extracción Obstétrica/efectos adversos , Extracción Obstétrica/instrumentación , Episiotomía , Extracción Obstétrica/métodos , Femenino , Humanos , Recién Nacido , Perineo/lesiones , Embarazo , Estudios Retrospectivos , Factores de Riesgo , Vagina/lesionesRESUMEN
OBJECTIVE: To compare monochorionic and dichorionic pregnancies for intertwin disparities in fetal size. METHODS: Monochorionic and dichorionic pregnancies, recruited from an ultrasound screening study at 10-14 weeks' gestation, were compared for intertwin disparities in crown-rump length and birth weight. The disparities were expressed as a percentage of the values of the larger twin. RESULTS: The study population was 123 monochorionic and 416 dichorionic twin pregnancies. In the 104 monochorionic and 381 dichorionic pregnancies resulting in two live births, there were no significant differences in median (range) intertwin disparity in crown-rump length (4.3% [0-18.8%] and 3.4% [0-25.5%]) or birth weight (10.2% [0-37.0%] and 9.3% [0-49.2%]). To determine that the observed 0.9% intertwin differences in crown-rump length and birth weight between the two groups were significant at alpha = .05 with 80% power, we would have had to examine a minimum of 984 and 926 twin pregnancies, respectively, assuming that the proportion of monochorionic to dichorionic twins remained the same as in the current study. In addition, there was no significant correlation between intertwin disparities in crown-rump length and intertwin disparities in birth weight in either the monochorionic (P = .40, Rho = 0.02, 95% confidence interval [CI] -0.17, 0.22) or dichorionic group (P = .44, Rho = 0.01, 95% CI -0.11, 0.09). The median (range) intertwin disparity in crown-rump length in 15 dichorionic pregnancies with chromosomally abnormal fetuses (6.6% [0-24.0%]) and in 20 dichorionic pregnancies that ended in miscarriage or intrauterine death of one or both fetuses (7.7% [0-43.9%]) was significantly higher than in dichorionic pregnancies resulting in two live births (Z = 2.49 and 3.26, respectively, and P = .01 and .001, respectively). However, in 19 monochorionic twins with adverse pregnancy outcome there was no significant difference in median (range) intertwin disparity in crown-rump length (4.5% [0-20.0%]) from monochorionic pregnancies resulting in two live births (4.3% [0-18.8%]). To determine that the observed 0.2% difference in intertwin difference in crown-rump length between the two groups was significant at alpha = .05 with 80% power we would have had to examine a minimum of 5652 monochorionic twin pregnancies, assuming that the proportion in each group remained the same as in the current study. CONCLUSION: The findings of this study demonstrate that monochorionic and dichorionic twin pregnancies do not differ significantly in intertwin disparity in fetal size, either in early pregnancy or at birth.
Asunto(s)
Largo Cráneo-Cadera , Feto/anatomía & histología , Embarazo Múltiple , Femenino , Feto/fisiología , Humanos , Embarazo , Gemelos , Ultrasonografía PrenatalRESUMEN
This open-label, prospective, randomized, multicenter trial compared the incidence of amenorrhea in 54 postmenopausal women (mean age, 54.9 +/- 0.6 years) who underwent six 4-week cycles of continuous hormone replacement therapy combining a progestin-nomegestrol acetate 2.5 mg/d--plus one of three estrogens: percutaneous 17beta-estradiol gel (1.5 mg/d, group A), transdermal 17beta-estradiol patch (50 microg/d, group B), or oral estradiol valerate (2 mg/d, group C). Based on an intent-to-treat analysis, the rate of amenorrhea varied significantly according to which estrogen preparation was used. Calculated cycle by cycle, rates of amenorrhea were 67% to 83% for group A, 25% to 56% for group B, and 53% to 61% for group C. Overall rates of persistent amenorrhea were not statistically different between groups for cycles 1 through 3, but for cycles 4 through 6, significantly more women in groups A and C (67% and 46%, respectively) experienced amenorrhea than did those in group B (12%). Amenorrhea rates for the entire six-cycle period were 78% for group A, 48% for group B, and 60% for group C. These differences were not statistically significant. The differences in rates could not be attributed to endometrial atrophy, since when measured by transvaginal sonography, endometrial thickness did not differ significantly between groups. Of the original population, 7% withdrew prematurely because of bleeding. The data for all three groups confirmed that in two out of three women, the occurrence of amenorrhea during the first three cycles predicted continuation of amenorrhea during subsequent cycles and that for 51% of women, < or =10 days of bleeding during the first three cycles predicted amenorrhea during the last three cycles. Calculated as a function of the number of women included in the trial, the percentage of amenorrheic women (evaluated cycle by cycle or for the second three-cycle period) was highest when the progestin was combined with percutaneous 17beta-estradiol gel, although findings were similar with estradiol valerate. The percutaneous 17beta-estradiol gel was also associated with a higher percentage of amenorrheal cycles than was estradiol valerate or transdermal estrogen, although differences were significant only in comparison with the transdermal formulation. This difference may have positive clinical implications.