Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies.

BACKGROUND: The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies. MAIN BODY: In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed. CONCLUSION: The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

Cesarean scar pregnancy with deep serosal invasion at 16 weeks: Uterus-sparing surgery with posterior hysterotomy after transcatheter arterial embolization.

We report a case of cesarean scar pregnancy at 16 weeks. Magnetic resonance imaging confirmed the isthmic ectopic location with an empty fundus and a high suspicion of placental invasion to the anterior myometrium. Because of pelvic pain, bleeding and the major risks of hysterectomy, a decision was made to terminate the pregnancy. After a preventive pelvic artery embolization, we performed an unusual posterior isthmic hysterotomy for the extraction of the fetus, followed by conservative management of the placenta. Bleeding loss was 300 mL, and no complication was reported. Successive magnetic resonance imaging was planned and 6 months later, there were no placental remnants. At 7 months, an office hysteroscopy revealed a normal uterine cavity. In case of cesarean scar pregnancy in the second trimester with an emergency need to interrupt pregnancy, posterior hysterotomy with conservative treatment of placenta may be an option to avoid massive bleeding and hysterectomy.

Non-conventional antiphospholipid antibodies in patients with clinical obstetrical APS: Prevalence and treatment efficacy in pregnancies.

OBJECTIVES: To describe the prevalence of non-conventional APL in patients with obstetrical APS without conventional APL and the impact of treatment on pregnancy outcome. METHODS: Patients with clinical obstetrical criteria were tested for anti-phosphatidylethanolamine (aPE) IgG/M, anti-prothrombin/phosphatidylserine (anti-PS/PT) IgG/M, and anti-annexin V IgG. Pregnancy losses rates were compared between APS, non-conventional APS, and non-APL and in untreated pregnancies to treated ones for each group. RESULTS: Using the cutoffs (ROC), 65/96 (68%) patients have been considered as non-conventional APS and compared to 83 APS and 31 patients without APL. The obstetrical history in non-conventional APS did not differ in comparison to confirmed APS. The frequencies of anti-annexin V IgG antibodies tended to be more frequent in non-conventional APS (88% versus 73%; p = 0.06), and those of anti-PE IgG and M were similar. The anti-PS/PT IgG and M antibodies were more frequent in confirmed APS than in non-conventional APS (63% and 37% versus 4% and 5%, respectively, p < 0.0001). Overall, 261 pregnancies in patients with non-conventional APS were compared with 81 pregnancies of confirmed APS and 132 pregnancies from non-APL group. Out of 474, 136 (29%) patients have been treated during pregnancies, and treatment significantly increased the rate of live birth (26% in untreated versus 72% in treated pregnancies, p < 0.0001). In univariate analyses, treatment effect on pregnancy losses was similar in patients with APS and non-conventional APS, with odds ratio at 3.3 (95% CI: 1.8-6.1) and 6.9 (95% CI: 3.9-12.3) (p = 0.49) and significantly more important for the 2 APS groups pooled versus non-APL group [OR at 1.9 (95% CI: 1.1-3.5) for non-APL group versus 5.3 (95% CI: 3.5-8.1) for APS groups, p = 0.0025]. CONCLUSION: In this study, 68% of patients with clinical criteria for obstetrical APS seronegative for conventional APL have non-conventional APL. These patients have a significant decrement of pregnancy losses if they receive treatment for APS during their pregnancy.

Accessory ovary in the utero-ovarian ligament: an incidental finding.

BACKGROUND: So far, only 21 descriptions of accessory ovary have been reported since 1959. However, the true incidence of this condition is probably underestimated because the pathologic forms (ovarian tumors and endometriosis) are probably more often diagnosed and reported. CASE: We report the incident discovery of one right accessory ovary during a laparoscopic tubal sterilization. This accessory ovary was asymptomatic and structurally normal. It was connected serial to the right utero-ovarian ligament and left in situ. There was no other anomaly. CONCLUSION: Gynaecologic surgeons must be aware of this possibility when removal of the whole ovarian tissue is needed.