Prenatal markers of atypical neurodevelopment in children with congenital heart defects.

BACKGROUND: A growing body of literature demonstrates that survivors of congenital heart defects (CHD) are at increased risk of neurodevelopmental delay, which frequently manifests as motor delay during the first year of life. OBJECTIVE: The aim of this study was to determine prenatal predictors of an early atypical neurodevelopment. This information could help assist decision-making during prenatal counseling. STUDY DESIGN: In this retrospective cohort study, we evaluated the records of 75 children with CHD followed at the Clinique d'Investigation Neuro-Cardiaque (CINC) of the CHU Ste-Justine born between 2013 and 2016. The neurodevelopmental outcome was determined using the Alberta Infant Motor Scale (AIMS) at 4 months. Associations between prenatal factors and atypical neurodevelopment (AIMS < 10th percentile) were assessed using bivariate and multivariate analyses. RESULTS: Forty-four infants (58.7%) had atypical neurodevelopment. When there was no extra cardiac anomaly seen on prenatal ultrasound, a head to abdominal ratio (HC/AC) below 1.1 was associated with a four-fold increased risk of atypical neurodevelopment (OR = 4.54; 95% CI = 1.24-16.64 p = .023). There was no difference in identified genetic anomaly in both groups. However, there was a trend toward more extra cardiac anomalies in infants with atypical neurodevelopment (27.3%) compared to 9.7% in those with typical neurodevelopment (p = .061). CONCLUSION: Our study shows that early atypical neurodevelopment affects the majority of children with CHD and highlights the importance of post-natal monitoring by a specialized team. A thorough prenatal ultrasound is important to screen for those at higher risk i.e. those with extra cardiac anomaly and HC/AC below 1.1. A larger cohort is needed to validate those results.

Why and how to proceed to an ultrasound-guided transvaginal drainage of tubo-ovarian abscesses (with demonstrative video)?

The treatment of the acute phase of complicated tubo-ovarian abscesses relies on antibiotics associated with surgical management in case of visible abscess, poor clinical tolerance and resistance to medical treatment. Transvaginal, ultrasound-guided, puncture drainage can be considered as an alternative to initial laparoscopy and has multiple advantages over the latter: same success rate, less invasive nature, simple and fast to perform, easy to access, better tolerated by the patient, decreased hospitalization time and less cost. This video article describes and standardizes the essential steps to perform a transvaginal adnexal abscess drainage with a step-by-step explanation of the technique in logical sequences, making the procedure ergonomic and easy to learn. Thus, as part of minimally invasive approach, this technique is henceforth suggested as an effective alternative and signifies a first-line procedure that can promote a therapeutic de-escalation strategy.

Outcome of First-Line Hysterectomy for Gestational Trophoblastic Neoplasia in Patients No Longer Wishing to Conceive and Considered With Isolated Lung Metastases: A Series of 30 Patients.

OBJECTIVE: This study aimed to assess the outcome of first-line hysterectomy in patients diagnosed as having gestational trophoblastic neoplasia (GTN) whose postoperative imaging showed lung images considered as metastases. METHODS: From 1999 to 2016, patients no longer wishing to conceive, treated by their initial physician by hysterectomy, and whose postoperative imaging workup showed lung images considered as metastasis were identified in the French Trophoblastic Disease Reference Center database. We sought to identify significant predictive factors of requiring salvage chemotherapy. RESULTS: Thirty patients were identified with a maximum number of 2 visible lung nodules and a median largest size of 14 mm on chest x-ray. Nine of these patients had an International Federation of Gynecology and Obstetrics score of higher than 6, and there were no postterm GTN. Twenty-two patients (73.33%; 95% confidence interval, 54.11-87.72; P = 0.0053) normalized their human chorionic gonadotropin (hCG) without salvage chemotherapy, whereas 7 received 1 line of salvage monochemotherapy (8-day methotrexate) and 1 required 2 lines of monochemotherapy (5-day actinomycin D after failure of methotrexate). After a 12.45-month median follow-up (range, 3-48.4 months) since the first normalized hCG, none of these patients died. The median interval between successful hysterectomy and hCG normalization was 3.15 months (range, 1.6-8.7 months). Patients who required salvage chemotherapy had a median size of the largest lung metastasis on chest computed tomography of 4 mm larger than those cured by hysterectomy (P = 0.0455). CONCLUSIONS: For GTN patients no longer wishing to conceive with lung metastases discovered postoperatively, treated by hysterectomy, and whose hCG is decreasing, it is reasonable to expect and to inform patients that approximately 27% will require salvage chemotherapy. However, in patients with lung metastases discovered preoperatively, evidence to recommend first-line hysterectomy is insufficient and these patients should receive first-line chemotherapy.

First-line hysterectomy for women with low-risk non-metastatic gestational trophoblastic neoplasia no longer wishing to conceive.

BACKGROUND: Low-risk gestational trophoblastic neoplasia (GTN) patients (FIGO score ≤6) are generally treated with single agent chemotherapy (methotrexate or dactinomycin) resulting in a 5-year mortality rate of 0.3%. However, despite these encouraging survival rates, chemotherapy is associated with significant adverse events in most patients. Although it is generally accepted that patients who no longer wish to conceive may be treated by hysterectomy for a hydatidiform mole, the evidence to support this strategy in low-risk GTN patients is lacking. OBJECTIVES: To describe the survival, efficacy, and tolerance associated with first-line hysterectomy in low-risk non-metastatic GTN patients. STUDY DESIGN: Seventy-four of 1072 low-risk GTN patients treated in the French Center underwent first-line hysterectomy. Patients data with successful first-line hysterectomy were retrospectively compared to those requiring further salvage chemotherapy. RESULTS: First-line hysterectomy was followed by hCG normalization in 61 patients (82.4%, 95% confidence interval [CI] 71.8-90.3) without any further salvage chemotherapy, whereas 13 patients required salvage chemotherapy. After multivariate analysis, a FIGO score of 5-6 (exact OR 8.961, 95%CI 1.60-64.96), and the presence of choriocarcinoma (exact OR 14.295, 95%CI 1.78-138.13) were associated with the risk of requiring salvage chemotherapy. CONCLUSION: Hysterectomy as a first-line treatment is effective without salvage chemotherapy in 82.4% of women with low-risk non-metastatic GTN and can be presented as an alternative to single-agent chemotherapy when childbearing considerations have been fulfilled. In young patients, this therapeutic option should not be considered because single-agent chemotherapies are curative in nearly 100% of patients while maintaining fertility.

Early pelvic floor muscle training after obstetrical anal sphincter injuries for the reduction of anal incontinence.

OBJECTIVES: Between 0.5 and 5% of vaginal deliveries involve obstetrical anal sphincter injuries (OASIS). Thirty to forty percent of patients with OASIS will suffer from anal incontinence in the subacute postpartum period. The aim of the present study was to assess the effectiveness of early pelvic floor muscle training (PFMT) combined with standard rehabilitation on anal incontinence after vaginal deliveries complicated by OASIS. STUDY DESIGN: The present work was a retrospective quantitative study performed in a tertiary-level maternity hospital. Women with 3rd or 4th degree obstetric tears were included. Women who gave birth between January 1st, 2011 and December 31st, 2012 underwent standard pelvic-perineal rehabilitation within 6-8 weeks postpartum. Women who gave birth between January 1st, 2013 and July 1st, 2014 had early rehabilitation (within 30 days after delivery) followed by the same standard rehabilitation received by the other group. Rehabilitation was performed by physiotherapists specialized in perineology. No electrostimulation was done in early rehabilitation. An in-house-validated modification of the Jorge and Wexner questionnaire was sent by mail to the patients to assess symptoms. The main judgment criterion was anal incontinence to gas, loose stools and/or solid stool. RESULTS: Two hundred and thirty patients were diagnosed with OASIS. Nineteen women (8.3%) were lost to follow-up. The intention-to-treat analysis included 211 patients, 109 of whom underwent standard rehabilitation and 102 early rehabilitation plus standard rehabilitation. The two groups were comparable in terms of parity, birth weight, assisted delivery, epidural anesthesia and rates of mediolateral episiotomy. Multivariate analyses adjusted for type of perineal lesion were performed. Early rehabilitation significantly reduced gas leakage: OR 0.51 [0.29-0.90] (p=0.02), liquid stool leakage: OR 0.22 [0.08-0.58] (p=0.02) and urinary stress incontinence: OR 0.43 [0.24-0.77] (p=0.004). CONCLUSIONS: We recommend early (during the first month postpartum) PFMT after vaginal deliveries associated with OASIS. Rehabilitation should be carried out by a physiotherapist specialized in perineology in order to prevent medium-term functional consequences. A longer follow-up may be necessary to confirm the stability of results.