Transperineal versus transvaginal ultrasound cervical length measurement and preterm labor.

OBJECTIVE: The aim was to evaluate the agreement between and the reproducibility of transperineal and transvaginal ultrasound cervical length measurements performed by the duty obstetrical team in case of preterm labor. The acceptability of transperineal ultrasonography was also assessed. METHODS: Pregnant patients between 25 and 34 weeks of gestation with contractions and a clinically modified cervix were included. Order of ultrasonography examination (transperineal or transvaginal first) and rank of operator (resident or senior) were allocated randomly. Agreement was assessed using the intraclass correlation coefficient (ICC) and the Bland and Altman plot. The patient's discomfort and preference for either method were assessed with a questionnaire. RESULTS: 62 patients admitted for preterm labor between 25 and 34 weeks of gestation were included. Six seniors and nine residents took part in the study. Among the 51 patients with an interpretable transperineal ultrasound scan, median cervical length measurements with the transperineal and the transvaginal technique were, respectively, 25 mm (0-53) and 27 mm (4-51). Concordance was good with an ICC of 0.83 [IC 95 % = (0.73-0.90)]. Transperineal ultrasonography was preferred in 56.5 % of cases. CONCLUSION: In case of preterm labor, cervical length measurement with transperineal ultrasonography seems reproducible and can be performed by the obstetric team on duty.

Amniocentesis learning: Use of a home-made simulator.

BACKGROUND: Amniocentesis is the most performed invasive prenatal diagnostic procedure. Learning the procedure is difficult for the learner, the teacher and the patient because of the risks inherent to this technique and the anxiety generated by the procedure. The objective of this work was to evaluate a theoretical and practical amniocentesis training workshop using a simulator. METHODS: We were inspired by Pierre Jean's precepts for the planning of a medical training. We then carried out the pedagogical session with the gynecology residents of our Regional University Hospital, a type 3 maternity hospital in France. We evaluated the theoretical learning through a questionnaire before and after the training and then the practical session on a home-made simulator. The satisfaction of the participants was assessed by a questionnaire at the end of the session. RESULTS: Fifteen learners, from the first to the last semester of internship, participated in the training. The median score of the pre-training questionnaire ("pre-test" questionnaire) was 3.3 out of 10 (min = 1, max = 6) and that of the post-training questionnaire ("post-test" questionnaire) was 7.9 out of 10 (min = 6, max = 9). The post-training scores were significantly higher (p < 0.0007). The average score for the practical training was 30.5 out of 40 (24-36). 93 % of the learners were fully satisfied with the theoretical training and 100 % stated that they had improved their technical skills. CONCLUSION: The residents in our department expressed a need for training in this invasive procedure of antenatal diagnosis. The training proved to be beneficial following the evaluation of the learning but also following the feedback of the learners.

[Impact of a service protocol on the practice of vaginal delivery of breech presentations at term]. / Impact d'un protocole de service sur la pratique de l'accouchement voie basse des présentations du siège à terme.

OBJECTIVES: The delivery of breech presentations remains controversial. Our study analysed the impact of a service protocol on the proportion of planned vaginal delivery and its success. Immediate neonatal morbidity and factors that may influence the success of vaginal delivery were studied. METHODS: Retrospective study, between 2009 and 2020 at the CHRU of Limoges, type 3 maternity hospital, on patients with a breech foetus at term. The proportion of planned vaginal delivery and the rate of effective vaginal delivery were compared before/after 2015. Neonatal morbidity was compared for planned vaginal delivery and planned cesarean delivery groups. RESULTS: We included 923 patients. The rate of planned vaginal delivery was significantly higher after 2015 from 5.2% to 19% (P<0.001), with a success rate increasing from 60% to 82.1% (P=0.06). The rate of vaginal breech deliveries significantly increased from 3.8% to 17% (P<0.001). We found significantly more newborns with moderate acidosis when a vaginal delivery was attempted (P<0.001). The success of vaginal delivery was correlated to the Magnin index (P=0.044), to gestational age (P=0.037), and to multiparity (OR 3.78 95% CI [1.42-10.03] P=0.006). CONCLUSION: Our study demonstrates the benefits of setting up a service protocol for the practice of breech vaginal delivery.

Is there an interest in repeating the vaginal administration of dinoprostone (Propess®), to promote induction of labor of pregnant women at term? (RE-DINO): study protocol for a randomized controlled trial.

BACKGROUND: Labor is induced in over 20% of women in France. Prostaglandins, especially intravaginal dinoprostone (Propess®), are widely used to initiate cervical ripening. If labor does not start within 24 h, there is uncertainty about whether to administer a second dinoprostone pessary or to use oxytocin to induce labor in order to achieve a vaginal delivery. METHODS: RE-DINO is a prospective, open-label, multicenter, randomized superiority trial with two parallel arms running in six French hospitals. A total of 360 patients ≥ 18 years of age at > 37 weeks of gestation who exhibit unfavorable cervical conditions (Bishop score < 6) 24 h after placement of the first Propess®, with fetuses in cephalic presentation, will be included. Patients with premature membrane rupture, uterine scars, or multiple pregnancies will be excluded. Our principal objective is to determine whether placement of a second Propess® (followed by oxytocin [Syntocinon®], if necessary) in women for whom the first Propess® failed to induce cervical ripening increases the vaginal delivery rate compared to direct oxytocin injection. The vaginal delivery rate is therefore the primary outcome. The secondary outcomes are the induction failure rates and maternofetal morbidity and mortality. DISCUSSION: This study may help in determining the optimal way to induce labor after failure of a first Propess®, an unresolved problem to date. This trial explores the effectiveness and safety of placing a second Propess® and may contribute to development of an obstetric consensus. TRIAL REGISTRATION: Registered on 2 September 2016 at clinicaltrials.gov (identification number NCT02888041).

[Cervical ripening after previous cesarean section with dinoprostone vaginal insert]. / Déclenchement par dinoprostone et utérus cicatriciel.

OBJECTIVES: Because, to date in France, 20 % of pregnant women had a scared uterus and because the best mean of cervical ripening is unknown and controversial, we want to evaluate efficacy and safety of dinoprostone for cervical ripening in women with previous cesarean. MATERIALS AND METHODS: We conducted a retrospective unicentric study, from 2010 to 2014, at Limoges regional university hospitals. Two hundred and sixty nine patients, with medical indication for induction of labor and scared uterus, were included and ripened with dinoprostone (Propess® and/or Prostine®). Women had unfavorable cervix with Bishop score inferior to 6. RESULTS: Overall rate of vaginal delivery was 62 %. Patients have had more of one prostaglandin in 19 % of cases; the cesarean rate was significantly higher in this case (cesarean: 55.6 % vs. vaginal delivery: 44.4 %; P=0.0043). Overall, there were respectively 4 % and 0.7 % of post-partum hemorrhage and uterine rupture. One percent of newborns had a severe acidosis (pH<7 in umbilical artery) and 1 % was admitted to the Intensive Neonatal Care Unit. CONCLUSION: Dinoprostone is an effective procedure in patients with previous cesarean section requiring labor induction, with a morbidity comparable to other methods of induction of labor.

Impact of screening on breast cancer detection. Retrospective comparative study of two periods ten years apart.

OBJECTIVE: The aim of this study was to evaluate changes in the mode of discovery of breast cancer in the last 15 years. We compared two periods separated by a 10-year interval, during which a mass mammographic screening programme was established in our department. MATERIALS AND METHOD: We made a retrospective comparison of the records of female patients with breast cancer diagnosed in our hospital over the period 1986-1989 (first period) and 1997-1999 (second period). The mass screening programme for breast cancer began in 1995. RESULTS: We collected 372 patients in the first period and 341 in the second. We found a significant change in the mode of the discovery of breast cancer between the two periods: 80.2% versus 51.9%, respectively, of the cases of breast cancer were discovered by breast self-examination, 10.2% versus 13.7% were discovered by a physician, and 4.8% versus 29.1% were discovered by routine mammography as part of an individual or mass screening programme. The mean size of the tumours decreased significantly (2.6 cm versus 2.3 cm: p = 0.019), and the number of tumours with initial metastases or lymph node involvement decreased, almost attaining the level of significance (p = 0.06). It is difficult to compare the survival and disease-free survival curves because of the short follow-up in the second period (median follow-up = 10 months). However, a marked difference appears to be developing (p < 0.0001): patients diagnosed by mammography are showing better survival and disease-free survival compared with the others. DISCUSSION: We observed that more widespread use of mammography screening for breast cancer led to smaller tumours being discovered during the second period, with less lymph node involvement and less initial metastasis. Breast cancer screening is one of the most intensively evaluated health care practices with eight completed randomized trials yet its net benefit has remained controversial. It has been shown that, at least for patients aged 50 to 70, properly organized mass screening for breast cancer led to a reduction in mortality rate. However, individual breast self-exam, physician and mammographic screening can interfere with assessment of mass screening programmes in terms of individual benefit. In addition, introducing a mass screening programme may induce opportunistic screening in non-invited age groups and influence health behaviour in the target and non target populations. A retrospective study was performed to evaluate the mode of discovery, the diagnostic presentation, and prognostic factors in breast cancer in a French department before and after initiation of a mass-screening programme (MSP).

[Is the Mauriceau maneuver deleterious? Study of 103 cases]. / La manoeuvre de Mauriceau est-elle délétère? Etude de 103 cas.

The Mauriceau manoeuvre has a poor reputation in France where some obstetricians believe it leads to an increase in the number of neonatal traumal injuries. To evaluate this hypothesis we examined the results of a personal series of 103 cases of breech extraction where foetal head extraction was performed using the Mauriceau manoeuvre. Our study showed that the level of traumal complications was not worse than that of the general neonatal population. We therefore conclude that this active and organized method of breech delivery is safe and provides a young obstetrician with valuable experience of practical obstetrical manipulation.

[Maternal and fetal prognosis of occipito-posterior presentation]. / Pronostic maternel et foetal du dégagement en occipito-sacré.

Occipito-posterior persistent presentation is a relatively rare obstetrical condition, occurring in 2 to 4.5% of deliveries. Failure of the occiput to spontaneously rotate has been associated with increased maternal and neonatal morbidity. We performed a retrospective study of 210 vaginal occiput posterior deliveries to investigate the influence of this position on maternal and fetal morbidity. Our results demonstrate that overall prognosis of occipito-posterior persistent presentation is good but less auspicious than occipito-anterior presentation on account of importance of perineal injuries and maternal and fetal infections. Forceps extraction in posterior presentation is criticized today. In our opinion, the vacuum extractor is the better instrument because it is less aggressive to maternal tissues and also because, in most cases, the fetal head rotates anteriorly after provoked flexion.