Gallbladder cancer during pregnancy treated with surgery and adjuvant gemcitabine: A case report and review of the literature.

Background: Gallbladder cancer (GBC) represents the most common biliary tract cancer. Prognosis remains poor with 5-year overall survival rates less than 5% in advanced stages. GBCs are diagnosed more frequently in women, supposedly due to endocrine factors. Case: A 35-year-old woman, diagnosed with a non-metastatic GBC in the 22nd week of gestation, underwent a complete surgical resection 5 weeks later. Adjuvant gemcitabine was administered without complications, temporarily discontinued in the 32nd week to allow childbirth. The patient was disease-free for more than 3 years with ongoing remission at the last visit in July 2022. During the follow-up period, the child had no developmental, cognitive, or other health issues. Conclusion: Malignant tumors occur in about 0.1% of pregnant women, many are treated with chemotherapy. In oncology, the need to deliver optimal treatment in these patients represents a major concern. Both surgery and adjuvant chemotherapy of locally advanced GBC can be performed safely, with certain considerations, in the second trimester of pregnancy.

Clinical characteristics and haemodynamic state of patients undergoing interhospital transfer for postpartum haemorrhage: A study of a single-centre helicopter emergency medical service.

OBJECTIVE: Uterine artery embolization is an attractive option for the management of postpartum haemorrhage, however it is not available in every hospital. We compared the clinical characteristics and haemodynamic state of patients with postpartum haemorrhage, before and after helicopter transfer to a tertiary hospital for possible uterine artery embolization. We also analysed whether the type of treatment could modify the outcome. STUDY DESIGN: Between 1999 and 2019 in Switzerland, we retrospectively found 82 consecutive patients with postpartum haemorrhage who were transferred by a physician-staffed helicopter emergency medical service to the tertiary hospital for potential uterine artery embolization. The collected data included the type of delivery, estimated blood loss, shock index and blood lactate levels before transfer and at destination, uterine artery embolization rate and hospital mortality rate. Our primary outcome was to describe the clinical characteristics, outcomes and haemodynamic state of the patients with postpartum haemorrhage before and after helicopter transfer. Our secondary outcome was to report the treatments performed at the tertiary hospital. The collected data were analysed with Stata version 14 (Stata Corporation, College Station, TX, USA). Continuous data are compared by using the Student's t-test or the Mann-Whitney U test, as appropriate. RESULTS: We included 69 patients. Postpartum haemorrhage occurred after vaginal delivery in 38 cases (55%). Blood loss prior to transfer exceeded 2 L in 34% of cases. The median shock index was 1 (IQR 0.8-1.1) before transfer and 0.9 (IQR 0.8-1.1) after transfer (p = 0.41). The median lactate level was 2.9 mmol/L (IQR 2.1-6.8) before, and 2.1 mmol/L (IQR 1.55-3.5) after transfer (p = 0.90). Forty-four patients underwent uterine artery embolization (64%), with an overall success rate of 93%. One patient died (1.4%), from a haemorrhagic shock of abdominal origin. CONCLUSIONS: Interhospital helicopter transfer of patients with postpartum haemorrhage to a tertiary hospital seems to be safe in our setting, despite a significant proportion of patients exhibiting signs of haemodynamic instability. Decision criteria would be helpful to better guide choices regarding the transfer of patients with postpartum haemorrhage.

[Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention]. / Incontinence anale et lésions obstétricales du sphincter anal, épidémiologie et prévention.

Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.

[Cultural adaptation of the female pelvic floor questionnaire (FPFQ) into French]. / Adaptation culturelle du Female Pelvic Floor Questionnaire (FPFQ) en langue française.

AIMS: The Female Pelvic Floor Questionnaire (FPFQ) is a self-administered tool on pelvic floor function. Our aim was to carry out a cultural adaptation of the FPFQ into French and to assess its psychometric properties. METHODS: After cross-cultural adaptation into French, acceptability and reliability of the questionnaire were assessed through a sample of 56 women in a test-retest. Discriminative construct validity was evaluated by comparing the results obtained by the FPFQ to those of other validated questionnaires. Longitudinal follow-up of the 282 pregnant women included in the PreNatal Pelvic floor Prevention trial (3PN) was used to analyze responsiveness. RESULTS: The proportion of missing data did not exceed 4 % for questions about bladder function, bowel function and pelvic organ prolapse; 10 % for issues related to sexual function. Question 9 was considered difficult to understand by 14 % of women. After rewriting, this issue was retested in a new sample of 52 women and presented no further problems. The intra-class correlation coefficient was greater than or equal to 0.7 for all domains during the test-retest. The FPFQ was strongly and significantly correlated (Spearman r>0.5) with the other validated questionnaires. The French version of FPFQ recorded changes in urinary and sexual symptoms for the women involved in 3PN trial with a standardized response mean equal to 0.83 and 0.44, respectively. CONCLUSION: The French version of the FPFQ is self-administered, reliable, valid, and can detect a change in symptoms during follow-up. LEVEL OF EVIDENCE: Level 4.

New approaches for assessing childbirth positions.

BACKGROUND: An overview of labor based only on epidemiological data cannot identify or explain the mechanisms involved in childbirth. Data about the position that women should take in giving birth are discordant. None of the studies of birth positions adequately define or describe them or their biomechanical impact (pelvic orientation, position of the back). The measurement of the effect of one position relative to that of another requires precise definitions of each position and of their maternal biomechanical consequences, as well as safe measurement methods. METHODOLOGY: We have developed a system to analyze the position of labor by quantifying the posture of the woman's body parts (including thighs, trunk, and pelvis), using an optoelectronic motion capture device (Vicon™, Oxford Metrics) widely used in human movement analysis and a system for measuring the lumbar curve (Epionics spine system). A specific body model has also been created to conduct this biomechanical analysis, which is based on external markers. With this methodology and model, it should be possible to define: (1) the hip joint angles (flexion/extension, abduction/adduction, internal/external rotation); (2) the ante/retroversion of the pelvis; (3) the lumbar curve. DISCUSSION: This methodology could become a reference for assessing delivery postures, one that makes it possible to describe the relation between the postures used in the delivery room and their impact on the pelvis and the spine in an integrated and comprehensive model. TRIAL REGISTRATION: No. Eudract 2013-A01203-42.

[In which position do women give birth in 2015? Results from a prospective multicenter study]. / Dans quelle position les femmes accouchent-elles en 2015 ? Résultats d'une étude prospective régionale multicentrique.

OBJECTIVE: To assess the frequency of labor and birth positions in 2015, and identify factors associated with choosing and changing position during labor. METHODS: Multicenter prospective study during five weeks in 2015. We collected the distribution of the observed positions during the first and second stage of labor. Then we considered the main birth position as the one used for the longest duration. Factors associated to the main birth position as well as to the changes of position during labor were studied using univariate analysis and the role of each factor was analyzed using multilevel logistic regression. RESULTS: Among women who delivered, 86.1% did so in gynecological position. There was a center effect for the position during the expulsive phase, which was not related to legal status or level of perinatal care. After adjustment, a labor duration shorter than 2hours was associated to dorsal decubitus during labor (OR=2.1 95%CI [1.01-4.3]). Prematurity and labor duration less than 2hours decreased the occurrence of changes in position during labor: OR=0.05 95%CI [0.01-0.2] and OR=0.2 95%CI [0.1-0.3]. Epidural analgesia was associated to change in birth position during labor: (OR=2.1 95%CI [1.2-3.8]). During the expulsive phase, primiparity and labor duration less than 2hours were associated to dorsal decubitus position (OR=3.6 95%CI [1.2-10.8]). CONCLUSION: Women still mostly deliver in gynecological position in 2015. A systematic collection of birth positions on the partograph, with an acute definition of these positions, could allow an evaluation of the benefits/disadvantages of the different positions currently available.

Evaluation of long-term pelvic floor symptoms after an obstetric anal sphincter injury (OASI) at least one year after delivery: A retrospective cohort study of 159 cases.

OBJECTIVES: The aim of this study was to assess long-term pelvic floor symptoms after an obstetric anal sphincter injury (OASI). METHODS: This retrospective cohort study included 237 cases of OASI (0.86% of deliveries) identified at Poitiers University Hospital between 2000 and 2011. Symptoms were assessed using validated self-administered questionnaires, including Female Pelvic Floor Questionnaire, Pescatori anal incontinence score, EuroQoL five-dimension score, and pain visual analogue scale (VAS). RESULTS: One hundred and sixty women (67%) filled out the questionnaires, on average 46 months after delivery (8-152). Among them, 93 (54%) reported at least one symptom occurring "frequently" (the most common being dyspareunia), and 45 (28%) a symptom occurring "daily" (the most common being flatus incontinence). Anal incontinence was reported by 32 (20%) women, flatus incontinence "frequently" or "daily" by 28 (18%), and stool incontinence "frequently" or "daily" by 9 (6%). Urinary incontinence was reported "frequently" or "daily" by 27 women (17%) at stress, 17 (11%) at urge, and 11 (7%) at mixed circumstances. Prolapse symptoms were reported "frequently" or "daily" by 6 women (4%). Pain during intercourse was reported "frequently" or "daily" by 17 women (11%). Twenty-four women (18%) reported chronic pelvic pain (VAS score≥4/10). Ninety-five percent of women reported a normal quality of life for mobility, self-care, and usual activities; however, alterations in pain/discomfort (32%) and anxiety/depression (33%) domains were frequently reported. CONCLUSION: Pelvic floor symptoms 4 years after OASI were highly prevalent.

[Prenatal and clinicopathological study of 6 cases of Pallister-Killian syndrome and review]. / Syndrome de Pallister-Killian : confrontation des données prénatales et fœtopathologiques de six cas et revue de la littérature.

OBJECTIVE: In multidisciplinary prenatal diagnosis centers, the search for a tetrasomy 12p mosaic is requested following the discovery of a diaphragmatic hernia in the antenatal period. Thus, the series of Pallister Killian syndromes (PKS: OMIM 601803) probably overestimate the prevalence of diaphragmatic hernia in this syndrome to the detriment of other morphological abnormalities. METHODS: A multicenter retrospective study was conducted with search for assistance from members of the French society for Fetal Pathology. For each identified case, we collected all antenatal and postnatal data. Antenatal data were compared with data from the clinicopathological examination to assess the adequacy of sonographic signs of PKS. A review of the literature on antenatal morphological anomalies in case of PKS completed the study. RESULTS: Ten cases were referred to us: 7 had cytogenetic confirmation and 6 had ultrasound screening. In the prenatal as well as post mortem period, the most common sign is facial dysmorphism (5 cases/6). A malformation of limbs is reported in half of the cases (3 out of 6). Ultrasound examination detected craniofacial dysmorphism in 5 cases out of 6. We found 1 case of left diaphragmatic hernia. Our results are in agreement with the malformation spectrum described in the literature. CONCLUSION: Some malformation associations could evoke a SPK without classical diaphragmatic hernia.

[Changes in pelvic organ mobility and ligamentous laxity during pregnancy and postpartum. Review of literature and prospects]. / Modifications de la statique pelvienne et de la laxité ligamentaire pendant la grossesse et le post-partum. Revue de la littérature et perspectives.

INTRODUCTION: The role of pregnancy in pelvic floor disorders occurrence remains poorly known. It might exist a link between changes in ligamentous laxity and changes in pelvic organ mobility during this period. Our objective was to conduct a non-systematic review of literature about changes in pelvic organ mobility as well as in ligamentous laxity during pregnancy and postpartum. METHODS: From the PubMed, Medline, Cochrane Library and Web of Science database we have selected works which pertains clinical assessment of pelvic organ mobility (pelvic organ prolapse quantification), ultrasound assessment of levator hiatus and urethral mobility, ligamentous laxity assessment during pregnancy and postpartum. RESULTS: Clinical assessments performed in these works show an increase of pelvic organ mobility and perineal distension during pregnancy followed by a recovery phase during postpartum. Pelvic floor imaging shows an increase of levator hiatus area and urethral mobility during pregnancy then a recovery phase in postpartum. Different authors also report an increase of ligamentous laxity (upper and lower limbs) during pregnancy followed by a decrease phase in postpartum. CONCLUSION: Pelvic organ mobility, ligamentous laxity, levator hiatus and urethral mobility change in a similarly way during pregnancy (increase of mobility or distension) and postpartum (recovery). LEVEL OF EVIDENCE: 3.

[Assessment of patients' knowledge of first-trimester combined Down syndrome screening at the time of their first trimester ultrasonographic evaluation: Results of a prospective study about 201 women]. / Évaluation des connaissances des patientes concernant le dépistage de la trisomie 21 lors de l'échographie du premier trimestre : résultats d'un sondage prospectif sur un échantillon de 201 femmes.

OBJECTIVE: Assess pregnant women's knowledge on first-trimester combined Down syndrome screening, at the time of their first trimester ultrasound scan. MATERIALS AND METHODS: A questionnaire was submitted to the patients coming for their 12-week pregnancy ultrasonographic evaluation in a University Hospital prenatal clinic between May 2012 and May 2013. Correct and incorrect statements on Down syndrome screening were proposed to the mothers who were asked to rate them. Each patient was questioned on her prior exposition to Down syndrome screening, the category of medical of professional she previously consulted, and the information she received. Patients' knowledge was evaluated according to these criteria. RESULTS: Two hundred and one patients were included in this study. The average correct answer rating was 4.6 (out of 8 questions). The average incorrect answer rating was 2.4 (out of 6 questions). No difference was found between the different social and demographic groups, nor according to the category of professional consulted before the first ultrasound scan. Higher correct answer ratings were observed when the patient had already been submitted to a Down syndrome screening (P=0.039), when they had previously received explanations about the screening (P=0.003); and when they stated that they had been sufficiently informed (P=0.042). CONCLUSION: These results show that patients' knowledge on Down syndrome screening is inadequate and depends on their experience of previous screening and information. It is deemed necessary to improve information especially to young women who are pregnant for the first time.

[Performance of prenatal diagnosis and postnatal development of congenital lung malformations]. / Performance du diagnostic anténatal et évolution postnatale des malformations pulmonaires congénitales.

OBJECTIVES: For many diseases, the comparison of prenatal diagnosis with a histopathological reality is not always possible. Fetal lung pathology, with its high rate of surgery in postnatal, allows this assessment. This study proposes an approach to the reliability of prenatal diagnosis and analysis of the postnatal development of all children in care for congenital pulmonary malformation (CPM). METHODS: This is a retrospective study of all cases of CPM diagnosed in Poitiers University Hospital from 1995 to 2011. Cases diagnosed prenatally were identified and the diagnostic accuracy was studied by histology when cases had surgery. The postnatal development of prenatally diagnosed cases is described and compared to children who did not receive prenatal diagnosis. RESULTS: Among the 45 cases of CPM supported at the Poitiers University Hospital, 30 had received prenatal diagnosis of isolated CPM. The diagnostic concordance between antenatal ultrasound and the final diagnosis is κ=0.67 (CI95% [0.38 to 0.94]). The sensitivity of ultrasound was 90% (CI95% [55-99.7]) in our series for the diagnosis of CAMP (cystic adenomatoid malformation pulmonary). We found a sonographic disappearance of lesions in 4 children, 1 child in regression, stable lesions in 21 cases. Four children showed an increase in volume of the malformation, with signs of poor tolerance in 3 cases. After birth, children who received a prenatal diagnosis were no more symptomatic than those whose diagnosis was made postnatal: 21 (70%) versus 11 (73%; P=1) respectively. Similarly, they often received prophylactic surgery: 18 (60%) versus 2 (13%) respectively (P<0.01) and less often suffered post-surgery complication: 3 (10%) versus 10 (67%) respectively (P<0.01). The number of children monitored was not significantly different in the two groups. CONCLUSION: Prenatal diagnosis allows for the precise nature of the lesion in 90% of cases in 2013 and had no impact on symptomatology at birth. When prenatal diagnosis is possible, preventive surgery probably reduces the occurrence of emergency surgery.

Urinary incontinence in women: study of surgical practice in France.

OBJECTIVE: To assess the number and the types of surgical intervention for urinary incontinence among women in France. We are assuming that techniques by suburethral sling (SUS) have replaced Burch colposuspension. MATERIAL: Using French hospital discharge data from the 2009 medical information system program (PMSI), we analyzed with regard to three relatively homogeneous diagnosis-related groups of patients (DRG) comprising the majority of stress urinary incontinence surgical interventions (cervicocystopexy, repair of the female genital apparatus, and hysterectomy) the detailed distribution of the different operations indexed in that information system. RESULTS: More than 42,000 cervicocystopexies (42,223) were carried out in France in 2009, and a SUS was used in 92% of the procedures (n=38,929). In 58% of the cases (n=24,387) this surgery was the only one, and in the others, it was associated with static pelvic intervention in 25% of the cases (n=10,741) or with a hysterectomy in 16% (n=6671). When a cervicocystopexy was the only operation performed, the average age of the women was 56.5 years and the average stay in hospital was 12.9 days. Fifty-seven percent of the cervicocystopexies by SUS (n=24,037) were carried out in private sector. Mean durations of stay were significantly shorter in the private sector than in the public sector for the diagnosis-related groups undergoing cervicocystopexy or repair of the female genital apparatus. CONCLUSION: In 2009, 10 years after its introduction in France, the suburethral sling is used in the overwhelming majority of cervicocystopexies in France. Among an estimated 4,000,000 incontinent women in France in 2009, this surgery was undergone by approximately 1% of them each year.

Prevalence and risk factors of bacterial vaginosis during the first trimester of pregnancy in a large French population-based study.

OBJECTIVES: Bacterial vaginosis is a risk factor for preterm delivery. Its prevalence and risk factors in Europe are not well known. Our objective was to assess both in early pregnancy. STUDY DESIGN: As part of the PREMEVA randomized controlled trial, this population-based study included 14,193 women screened before 14 weeks' gestation for bacterial vaginosis in the 160 laboratories of the Nord-Pas-de-Calais region in France. Bacterial vaginosis was defined by a Nugent score ≥ 7. Data were collected about maternal tobacco use, age, education, and history of preterm birth. We estimated the prevalence of bacterial vaginosis and used a multilevel logistic regression model to identify significant risk factors for it. RESULTS: Among the 14,193 women assessed before 14 weeks' gestation, the prevalence of bacterial vaginosis was 7.1% (95% CI: 6.6-7.5%). In the multivariate analysis, smoking during pregnancy tobacco (adjusted OR: 1.38; 95% CI: 1.19-1.60), maternal age 18-19 years (adjusted OR: 1.40; 95% CI: 1.01-1.93), and educational level (completed only primary school: adjusted OR: 1.77; 95% CI: 1.35-2.31; completed only secondary school: adjusted OR: 1.27; 95% CI: 1.10-1.48) were independent risk factors for bacterial vaginosis. History of preterm delivery was not an independent risk factor of bacterial vaginosis: adjusted OR: 1.15; 95% CI: 0.90-1.47. CONCLUSION: In a large sample of women in their first trimester of pregnancy in France, the prevalence of bacterial vaginosis was lower than rates reported in other countries, but risk factors were similar: young age, low level of education, and tobacco use during pregnancy. These results should be considered in future strategies to reduce preterm delivery.

[Twin dystocia: about one case of compaction]. / Dystocie gémellaire: à propos d'un cas de compaction.

We report a case of twin dystocia during the evacuation of full-term fetus both in cephalic presentation. A low-outlet forceps for second-phase arrest was performed for the first twin but the head remained stuck to maternal perineum, mimicking a shoulder dystocia. Digital examination found a twin compaction, that is the presence of the second twin's fetal head at the level of the first twin's chest. The discrepancy between fetal weights and the use of forceps could favor this rare complication. Various maneuvers were described previously attempted to solve the problem. Forcing back the second head may help to achieve delivery of the first twin.