[Satisfaction with obstetrical care: development and validation of a scale on quality of care]. / Satisfaction des soins obstétricaux : élaboration et validation d'une échelle de mesure de la qualité des soins.

OBJECTIVES: To develop and validate a subjective and multidimensional scale to measure satisfaction in obstetrical care (SSO) during labour, delivery and two hours postpartum, which is relevant to the French-speaking context. PATIENTS ET METHODS: Forty partially directed patient interviews during the 48 hours after delivery and four care-giver interviews were conducted to build up the questionnaire. After a prior feasibility study on 40 patients, the psychometric validity of the questionnaire was evaluated by calculating the Cronbach coefficient of reliability for 432 patients. RESULTS: Hundred and eighty items were initially obtained after content analysis of the patient interviews. Expert meetings finally selected 49 items classified within 5 dimensions. The feasibility study showed that the questionnaire was easily accepted and understood with a mean time of 15 minutes to answer it. Cronbach coefficients were respectively at 0.941, 0.949, 0.808, 0.814 et 0.869 for the 5 dimensions. DISCUSSION AND CONCLUSION: SSO questionnaire is a reliable and relevant scale to measure immediate postpartum quality of care in French.

[Tetragametic chimerism: Case report]. / Chimérisme tétragamétique : à propos d'un cas.

We report the third case of spontaneous monochorionic dizygous pregnancy, discovered on foetal sex discordance. Blood group testing on the female twin revealed a hematopoietic chimera. The mechanism of monochorionic dizygous formation could be the fusion of two independent zygotes at a late morula stage. A single placental mass with vascular anastomosis then develops. Stem cells exchanged during early foetal life can thus lead to chimeras, in similar conditions to stem cell transfusion in adults. Immaturity of the foetal immune system allows cell graft in the other twin's marrow. Assisted reproductive procedures are believed to promote such pregnancies.

Brachytelephalangic chondrodysplasia punctata: prenatal diagnosis and postnatal outcome.

We report the prenatal management of a brachytelephalangic chondrodysplasia punctata (CDPX1) case and how postnatal findings confirmed the diagnosis. The mother was initially referred after ultrasound revealed an abnormal fetal mid-face and punctuation of upper femoral epiphyses. Chondrodysplasia punctata (CP) with Binder anomaly was suspected. 3D-HCT revealed brachytelephalangy suggesting CDPX1. At birth, mid-face hypoplasia was marked. Postnatal imaging and genetic analysis confirmed the initial diagnosis. Binder anomaly is probably always associated with CP. The newly revised CP classification facilitates the diagnosis. The main etiologies are metabolic and chromosomal abnormalities, and arylsulfatase E enzyme dysfunction. Thus, screening for arylsulfatase E mutation is mandatory for an accurate diagnosis and can lead to better delineation among CP etiologies associated with a Binder phenotype.

[Length of pushing efforts: pushing is not playing. Reply to the article of C. Le Ray and F. Audibert]. / Durée des efforts expulsifs : pousser n'est pas jouer. Réponse à l'article de C. Le Ray et F. Audibert.

The aim of this work is to answer constructively to C. Le Ray and F. Audibert who were surprised that the French guidelines recommended an assisted delivery after 30 min pushing, even if the fetal heart rate is reassuring. We first resumed the definition of "second stage of labor", this word including the first phase with no pushing efforts and the second phase with active pushing of the mother. With that definition, the length of the second stage is around 60 min for the primipara and 20 min for the multipara, this length being modified by the use of peridural. We then specified the physiological mechanisms influencing the acidobasic equilibrium during the pushing time. Those mechanisms are difficult to consider because foetal heart rate monitoring is often "lost" during that phase. Altogether, these factors bring incertitude about progressive foetal acidosis and incapacity to diagnose it. Finally, the literature analysis teaches us that increasing the second stage of labor (inactive plus active phases) during the normal pregnancy seems to be at low risk for the foetus within the primiparas, but display a risk for the mother and so might be limited. Comparing the delayed pushing with the immediate pushing only lead us to conclude that delayed pushing is dangerous, as is prolonged second stage. In conclusion, we think that prolonging the second stage of labor is possible but must be by increasing the inactive first phase of the second stage, especially as long as we will not get a noninvasive and reliable method allowing assessing the well-being of the foetus.

[Pelvic floor disorders four years after first delivery: a comparative study of restrictive versus systematic episiotomy]. / Troubles périnéaux quatre ans après le premier accouchement: comparaison entre épisiotomie restrictive et systématique.

OBJECTIVE: To compare two policies for episiotomy: restrictive and systematic. PATIENTS AND METHODS: It is a quasi-randomised comparative study between two French university hospitals with contrasting episiotomy policies: one using it restrictively and the second routinely. Population included 774 nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. A questionnaire was mailed four years after delivery. Sample size was calculated to allow showing a 10% difference in the prevalence of urinary incontinence with 80% power. Main outcome measures were urinary incontinence, anal incontinence, perineal pain and pain during intercourse. RESULTS: We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, the groups did not differ in the prevalence of urinary incontinence (26% versus 32%), perineal pain (6% versus 8%), or pain during intercourse (18% versus 21%). Anal incontinence was less prevalent in the restrictive group (11% versus 16%). The difference was significant for flatus (8% versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR=1.84, 95 % CI :1.05-3.22). DISCUSSION AND CONCLUSION: A policy of routine episiotomy does not protect against urinary or anal incontinence four years after first delivery.

[Importance of human papillomavirus (HPV) screening in the follow-up after CIN2-3 treatment]. / Intérêt de la recherche du papillomavirus humain (HPV) dans le suivi post-conisation des CIN2-3. A propos de 386 cas.

INTRODUCTION: Cervical intraepithelial neoplasia (CIN) 2 and CIN3 lesions clearly represent precancerous states even if some of them would heal spontaneously. Management is based on surgical excision of part of the uterine cervix because such lesions can potentially progress into carcinomas. In most cases, this treatment leads to the cure of intraepithelial lesions. However, even after such an efficient treatment, theses patients are still at a higher risk of developing an invasive cervical cancer. That is why guidelines recommend a specific follow-up in order to screen for residual disease (incomplete excision) or for recurrences (after a complete excision). The actual problem in the follow-up strategy lies in the screening tools in use - cervical smears and colposcopy - whose sensitivities are low and hence, not quite sufficient when applied to a high risk population. These intraepithelial lesions are due to high risk human papillomaviruses (HPV) and there cannot be any lesion progression without HPV. Consequently, a viral testing would help in identifying a high risk subpopulation of women after cone loop cervical excision. MATERIAL AND METHODS: We studied, retrospectively, the contribution of HPV testing (Hybrid Capture 2((R))) in the follow-up after CIN2-3 treatment in 386 cone loop cervical excisions performed at a single centre during 80 months. RESULTS: Between three to six months follow-up after surgery, HPV remained present in 22.5% cases. The sensitivity of HPV testing in the screening for residual lesions or for recurrences was 100%, that of cervical smears cytology was 72%, whereas that of the pathological analysis of margins reached only 67%. The negative predictive value of a negative HPV detection associated with a normal cytology was 100%. DISCUSSION: Owing to its clinical relevance, HPV testing optimises postoperative follow-up and leads to the rapid and efficient selection of a subgroup, representing less than one upon three patients who are really at risk of an invasive lesion and to wholly reassure the others. Indeed, a negative HPV testing, associated with a normal cervical cytology, obtained after surgery correspond to a negative predictive value of almost 100% and this allows us to increase the time-interval between two screenings and to rapidly place the patient in a routine follow-up.

[Vacuum extractors: description, mechanics, indications and contra-indications]. / Ventouses : description, mécanique, indications et contre-indications.

The vacuum extractor, as opposed to other instruments, does not increase the fetal head diameter for vaginal delivery. Introduced half a century ago, this device is today widely used in many countries probably because of a learning-curve which is acquired quicker than for the forceps. Major benefits obtained are the flexion of the fetal head provided that the cup is correctly placed, and the compulsory rotation induced that is most useful in the conversion of occiput posterior or transverse to anterior positions. The limitations reside in the need for maternal effort at expulsion and in the fact that it is unsuitable for face presentations. Moreover, like other instruments, the vacuum extractor can be harmful and even dangerous to the mother and her fetus. Therefore, its indications and contra-indications must be respected, and its operative use mastered with as much precision as for the forceps.

[Comparison vacuum extractor versus forceps]. / Comparaison ventouse forceps.

The aim of the study was to search for objective criteria witch might help us to make a choice between obstetrical forceps and vacuum extractor in front of such a clinical situation. In that purpose, we realised a medline research to compare those two obstetrical instruments in term of advantages, disadvantages and specific complications. Vacuum extractor is the most used in the industrialized countries, learning seems to be quickest, time from decision to extraction a little bit longer than with forceps (Level II-2). Vacuum extractor is recommended in case of low presentation with transversal or posterior variety (Level III) or when no analgesia is available (Level III). Forceps are more successful than vacuum (Level II-1), are recommended in case of prematurity and complete anesthesia (Level III). Immediate maternal complications (cervical tear, vaginal and perineal laceration, use of episiotomy) are less frequent with vacuum extractor (Level II-1). Long term effects on the pelvic floor and the bladder continence are comparable with natural delivery for both forceps and vacuum (Level II-1) but anal incontinence is increased, especially with forceps (Level II-1). Benign immediate neonatal morbidity is comparable for both instruments, but there are some specific complications (Level II-1). Thus, cephalhaematomas and potentially dramatic extensive subgaleal haematomas (even rare), retinal haemorrhage are more frequent with the use of vacuum extractor (Level II-1). Facial nerve paralysis, skull fracture (even rare) are more frequent with forceps (Level II-2). Neonatal convulsions frequency is comparable with both instruments (Level II-2), such are middle and long term complications (Level II-3). Finally, failure of forceps extraction needs a caesarean section but there is no clear evidence in the literature for the sequential use of forceps after failure of vacuum (Level III).

Pelvic floor disorders 4 years after first delivery: a comparative study of restrictive versus systematic episiotomy.

OBJECTIVE: To compare two policies for episiotomy: restrictive and systematic. DESIGN: Quasi-randomised comparative study. SETTING: Two French university hospitals with contrasting policies for episiotomy: one using episiotomy restrictively and the second routinely. POPULATION: Seven hundred and seventy-four nulliparous women delivered during 1996 of a singleton in cephalic presentation at a term of 37-41 weeks. METHODS: A questionnaire was mailed 4 years after delivery. Sample size was calculated to allow us to show a 10% difference in the prevalence of urinary incontinence with 80% power. MAIN OUTCOME MEASURES: Urinary incontinence, anal incontinence, perineal pain, and pain during intercourse. RESULTS: We received 627 responses (81%), 320 from women delivered under the restrictive policy, 307 from women delivered under the routine policy. In the restrictive group, 186 (49%) deliveries included mediolateral episiotomies and in the routine group, 348 (88%). Four years after the first delivery, there was no difference in the prevalence of urinary incontinence (26 versus 32%), perineal pain (6 versus 8%), or pain during intercourse (18 versus 21%) between the two groups. Anal incontinence was less prevalent in the restrictive group (11 versus 16%). The difference was significant for flatus (8 versus 13%) but not for faecal incontinence (3% for both groups). Logistic regression confirmed that a policy of routine episiotomy was associated with a risk of anal incontinence nearly twice as high as the risk associated with a restrictive policy (OR = 1.84, 95% CI: 1.05-3.22). CONCLUSIONS: A policy of routine episiotomy does not protect against urinary or anal incontinence 4 years after first delivery.

[Obstetric management after ectopic pregnancy in the caesarean section scar: a case report and review of literature]. / Prise en charge obstétricale après grossesse ectopique intracicatricielle: à propos d'un cas et revue de la littérature.

We report the case of a patient who came out pregnancy twelve months after medical and surgical treatment of an ectopic pregnancy in a previous caesarean section scar. The preconceptional management consisted in a saline infusion sonohysterography and a pelvic magnetic resonance imaging. Judging the risks of abnormal placental insertion to be higher in this case compared to a simple caesarean section, a careful ultrasonography with color doppler imaging was carried out. The myometrium fragility caused by the ectopic pregnancy in the caesarean section brought us to recommend a prophylactic caesarean section around 37. The high risks of hemorrhage required a medical center with embolization possibilities. A review of literature in order to define the medical care adapted in this case was come out.

[Are there any factors predicting failure or complications rates of trans-obturator surgery for stress urinary incontinence?]. / Existe-t-il des facteurs prédictifs d'échec ou de complications dans la chirurgie de l'incontinence urinaire d'effort par voie transobturatrice?

OBJECTIVE: Since 2001 and the publication by Delorme of the trans-obturator route in the stress urinary incontinence (SUI), this technique has known an increasing development in France. The aim of this study is to evaluate the impact of different predicting factors on results and complications of trans-obturator surgery. PATIENTS AND METHODS: It is a retrospective, multicentric study, including 4 centers, 14 surgeons and 196 patients operated between February 2003 and August 2005. We have realized a univariate (Chi2 test) and multivariate (logistic regression test) statistic analysis concerning 7 sub-groups defined according to the literature on the TVT. RESULTS: Age>55 years (P=0,044) and SUI grade>2 (P=0,028) are statistically associated with a decrease of surgical success, age>55 years is also associated with an increase of complications rate in univariate (P=0,033) and multivariate (P=0,048) analysis. DISCUSSION AND CONCLUSION: Age>55 years should be considered, according to us, as a risk factor of surgical failure and complications in the trans-obturator surgery for SUI, none of the others risk factors found in the literature on the TVT seems to have an influence, in this study, on the results of trans-obturator surgery for SUI.

[Prenatal diagnosis and management of a case of rapidly involuting congenital hemangioma. Review of literature]. / Diagnostic prénatal et prise en charge d'un cas d'hémangiome congénital du cuir chevelu.

Rapidly involuting congenital hemangioma (RICH) is a rare vascular lesion, identified in 1996, of elective localization in the dermal-hypodermic tissue. Its name comes from its particular natural course: it is fully developed at birth and then completely involutes, usually in the first year. We present a case of a RICH of the scalp discovered with a screening ultrasonography in the 31st week of gestation. We list the differential diagnoses. After birth, positive diagnosis lies preferably on pathology examination of a biopsy specimen in order to eliminate the hypothesis of a less favorable vascular lesion, teratoma or malignant tumor.