[Medical termination of pregnancy for isolated intrauterine growth retardation beyond 24 weeks and more than 450g]. / Interruption médicale de grossesse pour retard de croissance intra-utérin isolé au-delà de 24 SA et de 450g.

INTRODUCTION: Fetal growth restriction (FGR) is an obstetric complication responsible for increased perinatal morbidity and mortality. In some severe and early FGR situations, termination of pregnancy (TOP) may be considered. The main objective of our study was to describe the population of fetuses for whom a TOP was performed for isolated FGR beyond 24 days' gestation and for a birth weight>450g and to analyze the immediate outcome, at 2 and 5 years, of term- and weight-matched neonates born in a context of severe FGR after 24 weeks' gestation and over 450g. MATERIAL AND METHODS: We conducted an observational, descriptive, retrospective, uni-centric study between 2008 and 2018. The primary endpoint was survival at maternity discharge, 2 years and 5 years in these children. Secondary endpoints were assessment of immediate and longer-term postnatal morbidity. Twenty-five patients (36%) were selected for the study with a fetus weight>450g and term>24 weeks. Each fetus with an TOP was matched (on gestational age and weight) with two live-born children from the perinatal network cohort to assess immediate discharge outcome, and then at 2 and 5 years. RESULTS: The mortality rate was 24%. In neonatal management, for 67% (n=17) of the newborns the evolution was complicated by death or at least two sequelae (bronchopulmonary dysplasia, hyaline membrane disease stage≥2, intraventricular of grade 3 and 4, ulcerative colitis requiring surgery, retinopathy of prematurity stage 2 and more) at discharge. In 32% (n=8) of cases, there was at least one sequela at discharge. Regardless of gestational age at birth, development at 2 years was normal for 48% (n=11/23) of them and abnormal for 22% (n=5) and development at 5 years was normal for 56% (n=9/16) of them and abnormal for 19% (n=5). CONCLUSION: An ultrasound evaluation in a reference center as well as additional information by the obstetrician and neonatologist ensures the most appropriate informed involvement of the couple in the medical decisions before and after birth.

[Tocolysis during External Cephalic Version (ECV): A retrospective before/after study in a type III maternity hospital]. / Tocolyse lors des Versions par Manœuvres Externes (VME) : étude rétrospective avant/après dans une maternité de type III.

OBJECTIVE: On January 2020, the French College of Gynecologists and Obstetricians (CNGOF) issued new Clinical Practice Guidelines (CPG) "Breech Presentation". Since then, it is recommended to use a tocolytic agent to improve the success rate of External Cephalic Version (ECV). The aim of this study, one year after these CPG, is to compare ECV without (before CPG) and with (after CPG) tocolysis in a type III maternity hospital. We intend to assess its effects on immediate success rate of ECV and obstetrical and neonatal outcomes. MATERIALS AND METHODS: This is a single-center retrospective study conducted in Nantes University Hospital. We collected patient characteristics, immediate success rate, and maternal and neonatal outcomes at delivery of all ECV over two periods: the first one during 2019 (before CPG) and the second one from June 2020 to June 2021 (after CPG). RESULTS: We included 253 patients: 126 in the first period and 127 in the second period. Immediate success rate of ECV was significantly higher since the use of tocolysis: 38.6 % (period 2) vs 23.8 % (period 1) (P=0.011). However, there was not significant difference found for cephalic presentation at birth, mode of delivery or obstetrical and neonatal outcomes. CONCLUSION: The immediate success rate is significantly improved with the widespread use of tocolysis during ECV, with no change in obstetrical and neonatal outcomes.

Diffusion tensor imaging of fetal brain: principles, potential and limitations of promising technique.

Human brain development is a complex process that begins in the third week of gestation. During early development, the fetal brain undergoes dynamic morphological changes. These changes result from events such as neurogenesis, neuronal migration, synapse formation, axonal growth and myelination. Disruption of any of these processes is thought to be responsible for a wide array of different pathologies. Recent advances in magnetic resonance imaging, especially diffusion-weighted imaging and diffusion tensor imaging (DTI), have enabled characterization and evaluation of brain development in utero. In this review, aimed at practitioners involved in fetal medicine and high-risk pregnancies, we provide a comprehensive overview of fetal DTI studies focusing on characterization of early normal brain development as well as evaluation of brain pathology in utero. We also discuss the reliability and limitations of fetal brain DTI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Prenatal diagnosis and outcome of fetuses with isolated agenesis of septum pellucidum: cohort study and meta-analysis.

OBJECTIVE: To evaluate the postnatal outcome of children with a prenatal diagnosis of apparently isolated agenesis of the septum pellucidum (ASP). METHODS: A retrospective cohort study of cases of prenatally diagnosed ASP followed in two tertiary centers and a meta-analysis combining data from the cohort study with data from published studies identified in a systematic review were carried out. Only cases with apparently isolated ASP on antenatal ultrasound and/or magnetic resonance imaging and with available postnatal follow-up data were considered eligible for inclusion. The following outcomes were analyzed: incidence of chromosomal anomalies, agreement between antenatal and postnatal findings, overall incidence of septo-optic dysplasia (SOD) and incidence of major neurological disability (motor, language, coordination or behavioral disorder or epilepsy) in non-SOD children. The incidence of SOD in infants with apparently normal optic pathways on antenatal imaging was also evaluated. RESULTS: Fifteen cases of isolated ASP, with median postnatal follow-up of 36 months (range, 12-60 months), were selected from the two centers. Six previously published studies met the inclusion criteria for the systematic review and a total of 78 cases were eligible for the analysis, including the 15 cases from our series. Genetic tests were carried out antenatally in 30 fetuses, of which two had an abnormal result (pooled proportion, 9.0% (95% CI, 1.8-20.7%); I2 = 0%). Additional or discordant imaging findings were noted postnatally in 9/70 (pooled proportion, 13.7% (95% CI, 3.5-29.0%); I2 = 63.9%) cases. Of all 78 neonates with available follow-up, SOD was diagnosed postnatally in 14 (pooled proportion, 19.4% (95% CI, 8.6-33.2%); I2 = 51.2%). In 60 cases, the optic pathways were considered to be normal on antenatal imaging, and six of these (pooled proportion, 9.1% (95% CI, 1.1-24.0%); I2 = 62.0%) were diagnosed postnatally with SOD. Of the 46 infants with available neurological follow-up who were not affected by SOD, a major neurological disability was diagnosed in three (pooled proportion, 6.5% (95% CI, 0.5-18.6%); I2 = 40.1%). CONCLUSIONS: In the vast majority of cases with a prenatal diagnosis of apparently isolated ASP, the prognosis is favorable. However, an additional anomaly is detected after birth in about 14% of cases and has a negative impact on clinical outcome. Detailed antenatal assessment of the brain and optic pathways is strongly recommended in order to identify the presence of associated anomalies. Antenatal visualization of apparently normal optic pathways does not rule out SOD. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

[Reprint of: Severe pre-eclampsia: guidelines for clinical practice from the French Society of anesthesiology and intensive care (SFAR) and the French College of gynaecologists and obstetricians (CNGOF)]. / Republication de : recommandations formalisées d'experts. Prise en charge de la patiente avec une pré-éclampsie sévère­RFE communes Société française d'anesthésie-réanimation (SFAR)­Collège national des gynécologues et obstétriciens français (CGNOF).

OBJECTIVE: To provide national guidelines for the management of women with severe preeclampsia. DESIGN: A consensus committee of 26 experts was formed. A formal conflict of interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. METHODS: The last SFAR and CNGOF guidelines on the management of women with severe preeclampsia was published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analyzed according to the GRADE® methodology. RESULTS: The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1±), 9 have a moderate level of evidence (GRADE 2±), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. CONCLUSIONS: There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe preeclampsia.

[Prolonged and post-term pregnancies: a regional survey of French clinical practices]. / Évaluation des pratiques professionnelles pour le suivi des grossesses prolongées dans un réseau de périnatalité.

OBJECTIVE: To assess professional practices of prolonged and post-term pregnancies in accordance to French guidelines. The secondary outcome was to evaluate neonatal and maternal morbidity during prolonged pregnancy. METHODS: Descriptive retrospective study was conducted in the 23 maternity hospitals of perinatal network between September and December 2018. The inclusion criterion was a birth term of≥41+0 weeks of gestation. Primary outcome was conformity to the national guidelines based on 10 items (conformity score≥80%). The secondary outcome was a composite criteria of neonatal morbidity (ventilation, resuscitation and/or Apgar score<7 at 5minutes) and maternal morbidity (obstetrical anal sphincter injury and/or postpartum hemorrhage). RESULTS: A total of 596 patients were included and the conformity was obtained in 65.3% of cases. Inconsistent criteria were amniotic fluid evaluation by the deepest vertical pocket (46.8%, n=279), and information of patients on prolonged pregnancy management (14.8%, n=88). Adverse perinatal outcome occurred for 40 newborns (6.0%) with shoulder dystocia (OR=5.2; CI 95%: 1.4-19.7) as a principal risk factor. Maternal morbidity outcome occurred in 70 cases (10.6%) primarily with increase in labour duration (OR=1.1 by hour of labour; CI 95%: 1.02-1.24) and prior caesarian section (OR=4.4; CI 95%: 1.8-11.0). CONCLUSIONS: Management of prolonged and post-term pregnancies matching with the French national guidelines. Points of improvement are amniotic fluid evaluation at term by a single deepest vertical pocket, and the information about induction of labour at term.

Management of fetal goiters: 6-year retrospective observational study in three prenatal diagnosis and treatment centers of the Pays De Loire Perinatal Network.

Introduction: The incidence of fetal goiters is reported to be around 1 per 40,000 births. The risk of complications is first of all obstetric, directly related to goiter size, but it may also affect longer term fetal and child development, depending on whether the goiter is due to hypo- or hyperthyroidism. Management is multidisciplinary, but not yet consensual and not always optimal by either endocrinologists or obstetricians.Objectives: The principal objective of this retrospective study was to analyze the data that enabled the physicians to assess whether the goiter was hypo- or hyperthyroid and then to analyze the obstetric practices used in the Pays de Loire network to describe in detail the tools used to diagnose and characterize the goiters and the management chosen in these cases. The secondary objectives are to assess, in our small cohort, the effectiveness of the in utero treatments provided, based on the examination of the children at birth and their outcome at 6 months of life, and to suggest a strategy for monitoring these women at risk that takes current guidelines into consideration.Materials and methods: This multicenter retrospective study covers a 6-year period and focused on the prenatal diagnosis centers (CPDPN) of the Pays de Loire perinatal network: in Nantes, Angers, and Le Mans. The network is responsible for around 42,000 births a year, and the study included 17 women, for a prevalence of 1 per 15,000 births.Results: Ten of the 17 fetuses had a hypothyroid goiter, 4 a hyperthyroid goiter, and 3 normal thyroid findings on fetal blood sample (FBS). For four women, these goiters were secondary to fetal dyshormonogenesis, for 9 more to Graves disease with TSH receptor antibodies (TRAb), and for four women to thyrotoxicosis at the start of pregnancy, managed by synthetic antithyroid drugs. Two newborns had severe complications associated with maternal transmission of Graves disease (TRAb positive at birth): one with exophthalmos and one with neonatal tachycardia. The other 14 had normal psychomotor development at 6 months, based on a clinical examination by a pediatric endocrinologist; only one child was lost to follow-up.Conclusion: Together, ultrasound and multidisciplinary expertise (of an endocrinologist and an obstetrician experienced with this disease) remain the best means for avoiding, or otherwise for accurately characterizing fetal goiter. An ultrasound diagnostic score, of the type proposed by Luton et al. in 2009, may make it possible to homogenize practices and thus to defer or delay the - currently too common - performance of invasive FBS procedures, which must remain rare in this management to limit comorbidities. A threshold TRAb value (>5 IU/l) makes it possible to define this group of women as at risk of fetal and neonatal hyperthyroidism and thus requiring close monitoring. The value of prenatal intra-amniotic thyroxine treatment for hypothyroid goiters (including dyshormonogenesis) remains to be demonstrated.

[Validation of the cervical length education and review program in a population of French residents in obstetrics and gynecology]. / Intérêt d'une formation théorique des internes de gynécologie obstétrique à la mesure échographique du col utérin.

OBJECTIVES: Evaluate an educational program based on "CLEAR" (Cervical Length Education and Review) in the teaching of measuring sonographic cervical length to residents in gynecology and obstetrics. METHODS: This is a prospective cohort study in a tertiary care center between May and November 2017. The residents were asked to collect 5 cervical length images from patients suspected with threatened preterm labor. A theoretical session on cervix measurement image criteria based on "CLEAR" program was taught to all residents. Then, they had to collect 5 new cervical length images. All the images were reviewed by two experienced reviewers, blinded to the resident and whether the image was obtained before or after the theoretical session and based on 8 criteria. RESULTS: Ten residents participated to the study. The mean total score CLEAR was significantly higher post-intervention: 6.6±0.9 vs. 4.3±2.1, positive difference of 2.3±2.3 (P<0.001). Improvement was most significant with the junior residents: 3.6 pre vs. 6.5 post-intervention. CONCLUSION: Educational program based on CLEAR criteria allowed to improve the competence of residents in measuring sonographic cervical length, although this can also be correlated with the progression of residents during the semester. It could be implemented systematically with the aim of CLEAR certification to standardize the teaching of residents in gynecology and obstetrics.

Comparative determination of placental perfusion by magnetic resonance imaging and contrast-enhanced ultrasound in a murine model of intrauterine growth restriction.

INTRODUCTION: Exploration of placental perfusion is essential in screening for dysfunctions impairing fetal growth. The objective of this study was to assess the potential value of contrast-enhanced ultrasonography (CEUS) and magnetic resonance imaging (MRI) for examining placental perfusion in a murine model of intrauterine growth restriction (IUGR). We also studied the reproducibility of perfusion quantification by CEUS. METHODS: Pregnant Sprague Dawley rat models of IUGR were studied during the third trimester. Unilateral uterine artery ligation induced IUGR. Placental perfusion was evaluated by CEUS and perfusion MRI with gadolinium for both ligated and control fetoplacental units. The kinetic parameters of the two imaging modalities were then compared. RESULTS: The analysis included 20 rats. The study showed good reproducibility of the CEUS indicators. The CEUS perfusion index approximated the blood flow rate and was halved in the ligation group (27.9 [u.a] (±14.8)) versus 61 [u.a] (±22.3) on the control side (P = 0.0003). MRI with gadolinium injection showed a clear reduction in the blood flow rate to 51.2 mL/min/100 mL (IQR 34.9-54.9) in the ligated horn, compared with 90.9 mL/min/100 mL (IQR 85.1-95.7) for the control side (P < 0.0001). The semiquantitative indicators obtained from the kinetic curves for both CEUS and MRI showed similar trends. Nonetheless, values were more widely dispersed with CEUS than MRI. DISCUSSION: The similar results for the quantification of placental perfusion by MRI and CEUS reinforce the likelihood that CEUS can be used to identify IUGR in a murine model induced by uterine vessel ligation.

[Comparison of obstetric prognosis of attempts of breech delivery: Spontaneous labor versus induced labor]. / Comparaison du pronostic obstétrical des tentatives d'accouchement par le siège : travail spontané versus déclenchement.

OBJECTIVES: Delivery mode in breech presentation (BP) is often controversial. Spontaneous labor, when vaginal birth seems safe, allows to better estimate uterus contractility, fetus' accommodation to maternal pelvis and optimize monitoring with a partograph. Induced labor in BP was usually contra-indicated. Lack of strong scientific evidence on this matter has permitted a progressive and careful evolution in obstetrical management, with the introduction of induced labor in BP. The aim of our study is to compare vaginal birth rates when labor is induced versus when spontaneous in BP. Maternal and fetal morbidity and mortality parameters were also evaluated. METHODS: In this retrospective study were included 206 patients carrying fetuses in BP, between June 2012 and June 2017. 182 of them had spontaneous labor and 24 experienced induced labor. Inclusion criteria were singleton pregnancy, BP after 34 weeks of gestation and vaginal delivery authorized by a senior obstetrician. Multiple pregnancy, birth before 34 weeks of gestation, uterine scar, planned caesarian section for BP, intra-uterine fetal death and medical termination of pregnancy were excluded. Induction of labor was performed for medical reason on a favorable cervix. RESULTS: There was no significant difference in cesarean section rates between the two "induced" and "spontaneous" labor groups in BP (OR=1.69 [CI95%: 0.71-4.04]). We observed no difference between the two groups in neither perineum trauma nor post-partum hemorrhage. No difference was found between the two groups in rates of Apgar score<7 5minutes after birth, neonatal transfer, fetal trauma and pH at birth. CONCLUSION: Despite our small population, it seems acceptable to propose induced labor for medical reason if cervix is favorable in BP if a protocol is available stating acceptability criteria for vaginal birth. It can avoid unnecessary caesarian section and allow better obstetrical outcome. It would be interesting to study fetal and maternal morbidity and mortality criteria in induced labor versus planned cesarean section when patients could be eligible for induced labor in BP.

Computed tomographic study of anatomical relationship between pubic symphysis and ischial spines to improve interpretation of intrapartum translabial ultrasound.

OBJECTIVE: To analyze the anatomical relationship between the pubic symphysis and the ischial spines to determine reliable landmarks for the assessment of fetal head descent by intrapartum translabial ultrasound (ITU). METHODS: All computed tomography (CT) scans performed for breech presentation and for twin delivery between 2006 and 2014 in a tertiary university hospital were obtained for measurement and analysis by two operators. The symphysis-left ischial spine angle (SIA) and the symphysis-left ischial spine distance (SID) were measured on three-dimensional reconstructions from the CT volume dataset. We calculated intra- and interobserver agreements for SIA and SID with 95% prediction intervals, created Bland-Altman plots with 95% limits of agreement and estimated the intraclass correlation coefficient (ICC). A sagittal plane projection from the SIA enabled calculation of a sagittal angle, corresponding to the angle of progression (AoP) on ITU. RESULTS: SIA and SID were obtained from CT images from 458 women. Reproducibility was good for both SIA (intraobserver ICC, 0.94 (95% CI, 0.88-0.97) and interobserver ICC, 0.81 (95% CI, 0.66-0.92)) and SID (intraobserver ICC, 0.92 (95% CI, 0.82-0.97) and interobserver ICC, 0.83 (95% CI, 0.73-0.92)). The median SIA was 106° (interquartile range (IQR), 105-109°) and median SID was 26.1 (IQR, 23.4-29.5) mm. SIA and SID were not correlated with pelvic diameter or height. The 50th percentile of AoP was 110°. CONCLUSION: Knowledge of the anatomical relationship between the pubic symphysis and ischial spines makes it possible to establish a sonographic method for assesssing fetal head descent by taking into account the level of the ischial spines. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Biparietal/transverse abdominal diameter ratio ≤ 1: potential marker for open spina bifida at 11-13-week scan.

OBJECTIVE: In the first trimester of pregnancy, a biparietal diameter (BPD) below the 5(th) percentile is a simple marker that enables the prenatal detection of half of all cases of open spina bifida. We hypothesized that relating the BPD measurement to the transverse abdominal diameter (TAD) might be another simple and effective screening method. In this study we assessed the performance of using the BPD/TAD ratio during the first trimester of pregnancy in screening for open spina bifida. METHODS: A total of 20,551 first-trimester ultrasound scans (11-13 weeks' gestation), performed between 2000 and 2013, were analyzed retrospectively; there were 26 cases of open spina bifida and 17,665 unaffected pregnancies with a crown-rump length of 45-84 mm and a record of both BPD and TAD measurements. RESULTS: The mean (± SD) BPD/TAD ratio was 1.00 ± 0.06 for fetuses with spina bifida and 1.13 ± 0.06 for those without (P < 0.0001). A BPD ≤ 5(th) percentile enabled the prenatal detection of 46.2% of spina bifida cases, while a BPD/TAD ratio of ≤ 1.00 detected 69.2%. If we considered cases in which either BPD was ≤ 5(th) percentile or BPD/TAD ratio was ≤ 1, we identified 76.9% of cases. In the latter case, the false-positive rate was 5.1%, while that for using a combination of both BPD ≤ 5th percentile and BPD/TAD ratio ≤ 1 was 0.6%, with a sensitivity of 38.5%. The positive predictive value of using a combination of BPD ≤ 5th percentile and BPD/TAD ratio ≤ 1 for detecting spina bifida was 8.5%. CONCLUSIONS: Between 11 and 13 weeks' gestation, relating BPD to TAD improves considerably the diagnostic performance of using BPD measurement alone in screening for open spina bifida. Screening using this marker is simple and applicable to a large population.