Risk Factors for Anal Continence Impairment Following a Second Delivery after a First Traumatic Delivery: A Prospective Cohort Study.

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.

Prevention of shoulder dystocia: A randomized controlled trial to evaluate an obstetric maneuver.

OBJECTIVE: Shoulder dystocia is a major obstetric emergency defined as a failure of delivery of the fetal shoulder(s). This study evaluated whether an obstetric maneuver, the push back maneuver performed gently on the fetal head during delivery, could reduce the risk of shoulder dystocia. STUDY DESIGN: We performed a multicenter, randomized, single-blind trial to compare the push back maneuver with usual care in parturient women at term. The primary outcome, shoulder dystocia, was considered to have occurred if, after delivery of the fetal head, any additional obstetric maneuver, beginning with the McRoberts maneuver, other than gentle downward traction and episiotomy was required. RESULTS: We randomly assigned 522 women to the push back maneuver group (group P) and 523 women to the standard vaginal delivery group (group S). Finally, 473 women assigned to group P and 472 women assigned to group S delivered vaginally. The rate of shoulder dystocia was significantly lower in group P (1·5%) than in group S (3·8%) (odds ratio [OR] 0·38 [0·16-0·92]; P = 0·03). After adjustment for predefined main risk factors, dystocia remained significantly lower in group P than in group S. There were no significant between-group differences in neonatal complications, including brachial plexus injury, clavicle fracture, hematoma and generalized asphyxia. CONCLUSION: In this trial in 945 women who delivered vaginally, the push back maneuver significantly decreased the risk of shoulder dystocia, as compared with standard vaginal delivery.

Radiative ablation with two ionizing fronts when opacity displays a sharp absorption edge.

The interaction of a strong flux of photons with matter through an ionizing front (I-front) is an ubiquitous phenomenon in the context of astrophysics and inertial confinement fusion (ICF) where intense sources of radiation put matter into motion. When the opacity of the irradiated material varies continuously in the radiation spectral domain, only one single I-front is formed. In contrast, as numerical simulations tend to show, when the opacity of the irradiated material presents a sharp edge in the radiation spectral domain, a second I-front (an edge front) can form. A full description of the mechanism behind the formation of this edge front is presented in this article. It allows us to understand extra shocks (edge-shocks), displayed by ICF simulations, that might affect the robustness of the design of fusion capsules in actual experiments. Moreover, it may have consequences in various domains of astrophysics where ablative flows occur.

Foetal thyroid dysfunction: treat the mother first!

A case is presented of foetal compensated hypothyroidism due to persisting low maternal serum FT4 at the beginning of pregnancy. Diagnosis was made by means of foetal ultrasound followed by foetal blood sampling because of atypical findings. Foetal thyroid hypertrophy resolved progressively as exogenous thyroxine was administered to the mother. This case highlights once again the importance of adequate thyroid function during pregnancy.

Uterine necrosis following pelvic arterial embolization for post-partum hemorrhage: review of the literature.

Uterine necrosis is one of the rarest complications following pelvic arterial embolization for postpartum hemorrhage (PPH). With the increasing incidence of cesarean section and abnormal placental localization (placenta previa) or placental invasion (placenta accreta/increta/percreta), more and more cases of uterine necrosis after embolization are being diagnosed and reported. Pelvic computed tomography or magnetic resonance imaging provides high diagnostic accuracy, and surgical management includes hysterectomy. We performed a Medline database query following the first description of uterine necrosis after pelvic embolization (between January 1985 and January 2013). Medical subheading search words were the following: "uterine necrosis"; "embolization"; "postpartum hemorrhage". Seventeen citations reporting at least one case of uterine necrosis after pelvic embolization for PPH were included, with a total of 19 cases. This literature review discusses the etiopathogenesis, clinical and therapeutic aspects of uterine necrosis following pelvic arterial embolization, and guidelines are detailed. The mean time interval between pelvic embolization and diagnosis of uterine necrosis was 21 days (range 9-730). The main symptoms of uterine necrosis were fever, abdominal pain, menorrhagia and leukorrhea. Surgical management included total hysterectomy (n=15, 78%) or subtotal hysterectomy (n=2, 10%) and partial cystectomy with excision of the necrotic portion in three cases of associated bladder necrosis (15%). Uterine necrosis was partial in four cases (21%). Regarding the pathophysiology, four factors may be involved in uterine necrosis: the size and nature of the embolizing agent, the presence of the anastomotic vascular system and the embolization technique itself with the use of free flow embolization.

Predictive factors for failure of pelvic arterial embolization for postpartum hemorrhage.

OBJECTIVE: To assess the efficacy of pelvic embolization in women with postpartum hemorrhage (PPH) and to determine factors associated with embolization failure. METHODS: In a retrospective observational study, data were analyzed from 98 consecutive women who underwent pelvic embolization for intractable PPH between January 2007 and November 2009 at Beaujon Hospital, Clichy, France. Women with persistent PPH despite pelvic embolization were compared with women who had cessation of hemorrhage and attained hemodynamic stability. RESULTS: Among the 98 women, 66 (67.3%) had been transferred from another hospital after delivery. Pelvic arterial embolization failed to control PPH in 8 (8.2%) women. On univariate analysis, factors significantly associated with embolization failure were the presence of placenta accreta (P<0.005), hemoglobin level (P<0.05), prothrombin time (P<0.04), fibrinogen level (P<0.03), red blood transfusion (P<0.02), number of packed red blood cell units transfused (P<0.05), and fresh-frozen plasma transfusion (P<0.02). Hospital-to-hospital transfer with a notable time interval between delivery and embolization was not associated with increased risk of failure. CONCLUSION: Predictive factors significantly associated with failed pelvic arterial embolization were the presence of placenta accreta, biologic factors, and transfusional factors. Delay due to inter-hospital transfer did not affect the outcome of embolization.

[Acute non-obstetrical diseases during pregnancy and role of the obstetrician]. / Maladies aiguës non obstétricales chez la femme enceinte et place de l'obstétricien.

The management of a pregnant woman with an acute non-obstetrical disease must be made in narrow collaboration with an obstetrician. This one must be warned from the beginning of the care of the patient. In a pregnant woman, any acute medical, surgical or traumatic non-obstetrical disease can have obstetrical consequences. The diagnostic and therapeutic management of an acute non-obstetrical disease can have iatrogenic consequences during pregnancy. The most often described risks are early pregnancy loss, intra-uterine fetal death, placenta abruption, direct fetal hurts, preterm labor, prematurity and its complications. Obstetrical complications can induce maternal and neonatal life-threatening risks. Simple and easily accessible examinations in emergency allow detecting the obstetrical consequences of an acute non-obstetrical disease. During the management of an acute non-obstetrical disease in a pregnant woman, the induced obstetrical consequence of the disease can require emergency action of the obstetrician in conditions associated with maternal life-threatening risk. During the management of an acute non-obstetrical disease in a pregnant woman, once the mother condition was stabilized, the obstetrician had to estimate the fetal consequences and to adapt his or her therapeutic attitude. He or she sets up the fetal and placental surveillance adapted to the obstetrical risks and decides on the duration of this surveillance.

Surgical management of infertility due to polycystic ovarian syndrome after failure of medical management.

OBJECTIVES: To evaluate surgical management and fertility and pregnancy outcome in women with polycystic ovarian syndrome (PCOS). STUDY DESIGN: Retrospective file review and follow-up of 74 consecutive women with PCOS resistant to citrate clomiphene (CC) who underwent ovarian drilling by fertiloscopy with bipolar energy, together with hysteroscopic surgery when indicated (Canadian TASK FORCE II-2). RESULTS: Of 77 files, only 3 women were lost to follow-up. Mean age was 30.2 years (SD 5.3) [29.0-31.4 CI 95%], and mean BMI 25.6kg/m(2) (SD 6.2) [24.2-27.0 CI 95%]. Pregnancy occurred after drilling in 47 cases (63%), spontaneously in 20 (27%), after ovarian stimulation in 5 (6.7%) and after in vitro fertilization in 22 (29.7%). Laparoscopic conversion was required in 5 cases (6.7%), due to failure to visualize the adnexa (n=3), or pelvic adhesions (n=1), or uterine hemorrhage (n=1). Hysteroscopy detected and simultaneously treated a uterine anomaly in 18 of 74 patients: uterine septum (n=10, 13%), T-shaped uterine cavity (n=3, 4%), endometrial polyp (n=2, 2.7%), endometrial hypertrophy (n=2, 2.7%), and synechiae (n=1, 1.3%). The mean overall delay to pregnancy was 11.1 months (SD 8.5) [8.7-13.5 CI 95%] and to spontaneous pregnancy, 7 months (SD 7.6) [3.7-10.3 CI 95%]. The mean follow-up was 23.4 months (SD 16.5) [18.1-28.7 CI 95%]. After multivariate analysis, the likelihood of pregnancy was significantly associated with previous ovarian stimulation by FSH (OR=2.28, 95% CI=1.08-4.83) and initial FSH level (OR=0.52, 95% CI=0.29-0.93). CONCLUSION: Ovarian drilling by hydrolaparoscopy is an effective treatment for CC-resistant PCOS. The high rate of associated uterine anomalies justifies simultaneous hysteroscopic surgery.

Pathologic response rate after concomitant neo-adjuvant radiotherapy and chemotherapy for adenocarcinoma of the uterine cervix: a retrospective multicentric study.

INTRODUCTION: Exclusive chemoradiotherapy (including brachytherapy) is the current standard of care for locoregionally advanced cervical cancer. The aim of the present study was to evaluate the responsiveness and to identify factors predicting the response to concomitant chemoradiotherapy before surgery in cervical adenocarcinoma. METHODS: A multicentric retrospective study was done in 9 French centers. A total of 54 women with cervical adenocarcinoma stage IB2 to IIIB who had undergone concurrent chemoradiation therapy followed by surgical treatment were included. The patients were stratified by histopathologic response after concomitant chemoradiotherapy (lesions smaller than 1 cm or larger). RESULTS: The median (SD) age at diagnosis was 44.2 (12.4) years (range, 19.3-77 years). The median (SD) follow-up duration was 30.9 (36.5) months (range, 4.1-17 years). After clinical evaluation, the mean (SD) tumor size was 5 (1.2) cm (range, 2-7 cm).The patients achieved a clinical complete response after concurrent chemoradiation in 18 cases (33.5%). Pathologic residual tumor was noted in 36 cases (67%); tumors smaller than 1 cm were found in 18 cases (33.5%), and lesions greater than 1 cm were observed in 18 cases (33.5%). Factors being associated with a significant decreased sensitivity to neoadjuvant chemoradiotherapy were the following: menopause (P = 0.012), parametrial invasion (P < 0.001), lymphovascular space invasion (P = 0.003), and mucinous subtype (P = 0.001). CONCLUSIONS: Identification of predictive markers associated with incomplete response to neoadjuvant chemoradiotherapy in cervical adenocarcinoma may prove clinically useful and implement an individualized treatment plan.

Correlation between colored Doppler echography of fetal thyroid goiters and histologic study.

Fetal thyroid is essential for normal fetus development. Echography of fetuses from mothers with Graves' disease is extremely specific for detecting an intrauterine thyroid dysfunction. We report the first correlation of two cases between color Doppler and histologic study of fetal thyroid goiters.

Growth rate of Rayleigh-Taylor turbulent mixing layers with the foliation approach.

For years, astrophysicists, plasma fusion, and fluid physicists have puzzled over Rayleigh-Taylor turbulent mixing layers. In particular, strong discrepancies in the growth rates have been observed between experiments and numerical simulations. Although two phenomenological mechanisms (mode-coupling and mode-competition) have brought some insight on these differences, convincing theoretical arguments are missing to explain the observed values. In this paper, we provide an analytical expression of the growth rate compatible with both mechanisms and is valid for a self-similar, low Atwood Rayleigh-Taylor turbulent mixing subjected to a constant or time-varying acceleration. The key step in this work is the presentation of foliated averages and foliated turbulent spectra highlighted in our three-dimensional numerical simulations. We show that the exact value of the Rayleigh-Taylor growth rate not only depends upon the acceleration history but is also bound to the power-law exponent of the foliated spectra at large scales.

Cornual heterotopic pregnancy: a case report.

INTRODUCTION: Cornual heterotopic pregnancy is a very rare condition; its incidence remains unknown. We report a case of cornual heterotopic pregnancy managed by laparoscopy and guided methotrexate injection into the cornual sac. CASE PRESENTATION: A cornual heterotopic pregnancy was diagnosed at 9 weeks of amenorrhoea in a 31-year-old healthy woman. Ultrasound examination showed a well-formed intrauterine gestation without detectable fetal heart pulsation, together with a gestational sac situated in the right cornual region. After uterine evacuation under ultrasound guidance, the diagnosis of cornual pregnancy was confirmed on laparoscopy followed by methotrexate injection into the cornual gestational sac. CONCLUSIONS: Cornual heterotopic pregnancy is a very rare and potentially dangerous condition. Diagnosis of cornual pregnancy could be made on ultrasound examination in this patient. Laparoscopy was useful as an alternative in confirming the diagnosis and aided further treatment.

Primary psammocarcinoma of the ovary or peritoneum.

BACKGROUND: The aim of this study was to assess the outcomes of patients treated for peritoneal or ovarian psammocarcinoma (PSC). MATERIALS AND METHODS: Review of patients with PSC who underwent cytoreductive surgery in our institution with a follow-up of more than 18 months (the ovarian or peritoneal tumor was histologically reviewed by our reference pathologist). RESULTS: From 1997 to 2006, 15 patients with PSC were histologically reviewed in our institution. Five of these patients fulfilled the inclusion criteria. Four patients had ovarian PSC, and 1 had peritoneal PSC. Four patients were surgically treated during initial management and another patient at the time of recurrence. All of them underwent complete cytoreductive surgery followed by intraperitoneal chemotherapy in 2 patients and by conventional adjuvant chemotherapy in 1. After a median follow-up of 42 months, 4 of them remain disease-free. CONCLUSIONS: Peritoneal or ovarian PSC is a rare low-grade carcinoma characterized by a more favorable prognosis than classic carcinoma. The place of debulking surgery at the time of initial or recurrent management is important.

Primary torsion of the greater omentum: case report--review of literature: diagnosis cannot always be performed before surgery.

The torsion of greater omentum is a rare cause of acute abdominal pain. After relating a case of torsion of the great omentum we review the literature. Its etiology is uncertain, although several factors have been underlined. The symptoms mimic surgical illness acute appendicitis, cholecystis, or diverticulitis. Sometimes ultrasonography and computed tomography can establish the diagnosis safely and allow conservative management. In the other ways, laparoscopy is a great help for the diagnosis and the treatment.

Rayleigh-Taylor turbulence is nothing like Kolmogorov turbulence in the self-similar regime.

An increasing number of numerical simulations and experiments describing the turbulent spectrum of Rayleigh-Taylor (RT) mixing layers came to light over the past few years. Results reported in recent studies allow to rule out a Kolmogorov-like turbulence as a mechanism acting on a self-similar RT turbulent mixing layer. A different mechanism is presented, which complies with both numerical and experimental results and relates RT flow to other buoyant flows.