Prognosis for deliveries in face presentation: a case-control study.

PURPOSE: To estimate the maternal and fetal prognosis for attempted vaginal deliveries of fetuses in face compared with vertex presentations. To evaluate the factors associated with a cesarean during labor for fetuses in face presentation. METHODS: This case-control study collected all the cases of face presentation in a university hospital level-3 maternity ward between 22 and 42 weeks of gestation over a 16-year period. For each case, we selected three control cases with vertex presentations delivered the same day. Cesareans before labor were excluded. RESULTS: We compared 60 attempted vaginal deliveries of fetuses in face presentation with 174 of fetuses in vertex presentation. The cesarean rate during labor was more than three times higher for the face presentations (31.7 vs 9.2%, P < 0.0001). Arterial pH values and Apgar scores were similar in both sets of newborns. After logistic regression, the factors associated with a cesarean during labor were nulliparity and early diagnosis of the presentation (i.e., before 5 cm dilatation). The initial position (mentum-anterior vs. transverse or posterior) was not significantly associated with the mode of delivery. CONCLUSIONS: In face presentations, attempted vaginal delivery triples the cesarean risk. Nonetheless, more than two-thirds of these women give birth vaginally without any impairment of neonatal condition.

Prenatal factors related to face presentation: a case-control study.

PURPOSE: Face presentation is rare. Its risk factors are debated and its mechanism is practically unknown. The objectives of the study were to determine the prenatal factors associated with face presentation at delivery and discuss the mechanism by which it occurs. METHODS: Retrospective case-control study including all cases of face presentation of infants born at a gestational age between 22 and 42 weeks of gestation over a 16 year period. For each case, we selected three control women who gave birth the same day. RESULTS: During the study period, there were 64 cases of face presentation (incidence: 0.8 per 1000 births), which we compared with 191 controls. After logistic regression, the four factors most closely associated with delivery in face presentation were twin pregnancy [OR 25.8 (4.7-141.8)], birth weight <2500 g [OR 8.9 (2.1-38.0)], polyhydramnios [OR 7.1 (2.0-25.2)], and multiparity [OR 3.6 (1.5-8.6)]. CONCLUSION: These factors are all associated with a reduction in the uterine constraints on fetal attitude. This may play a role in the mechanism resulting in face presentation.

French Multicenter Study Evaluating the Risk of Lymph Node Metastases in Early-Stage Endometrial Cancer: Contribution of a Risk Scoring System.

BACKGROUND: This study was designed to develop a risk scoring system (RSS) for predicting lymph node (LN) metastases in patients with early-stage endometrial cancer (EC). METHODS: Data of 457 patients with early-stage EC who received primary surgical treatment between January 2001 and December 2012 were abstracted from a prospective, multicentre database (training set). A risk model based on factors impacting LN metastases was developed. To assess the discrimination of the RSS, both internal by the bootstrap approach and external validation (validation set) were adopted. RESULTS: Overall the LN metastasis rate was 11.8 % (54/457). LN metastases were associated with five variables: age ≥60 years, histological grade 3 and/or type 2, primary tumor diameter ≥1.5 cm, depth of myometrial invasion ≥50 %, and the positive lymphovascular space involvement status. These variables were included in the RSS and assigned scores ranging from 0 to 9. The discrimination of the RSS was 0.81 [95 % confidence interval (CI) 0.78-0.84] in the training set. The area under the curve of the receiver-operating characteristics for predicting LN metastases after internal and external validation was 0.80 (95 % CI 0.77-0.83) and 0.85 (95 % CI 0.81-0.89), respectively. A total score of 6 points corresponded to the optimal threshold of the RSS with a rate of LN metastases of 7.5 % (29/385) and 34.7 % (25/72) for low-risk (≤6 points) and high-risk patients (>6 points), respectively. At this threshold, the diagnostic accuracy was 83 %. CONCLUSIONS: This RSS could be useful in clinical practice to determine which patients with early-stage EC should benefit from secondary surgical staging including complete lymphadenectomy.

Sacral colpopexy: long-term mesh complications requiring reoperation(s).

INTRODUCTION AND HYPOTHESIS: Sacral colpopexy (SC) is a classic procedure used for the surgical treatment of pelvic organ prolapse. Although the procedure boasts excellent success rates, there are risks of complications and reoperation may be required. The purpose of this study was to evaluate the extent of complications following SC, requiring reoperation(s), and to describe the reoperations performed. METHODS: A retrospective monocentric study of patients who were operated on following a mesh complication after SC was conducted, at Lille University Hospital, between January 2007 and January 2013. Information relating to medical and surgical history, SC surgical technique, type of complication, and reoperation techniques was gathered. RESULTS: Twenty-seven patients required surgery for complications after SC. Nineteen patients were treated for vaginal mesh exposures (VME), four for intravesical mesh (including one with VME), one for ano-rectal dyschezia, one for spondylodiscitis with a VME, one for mesh infection, and one for vaginal fistula communicating with a collection in the ischio-coccygeal muscle. The median time between the initial SC and the first reoperation was 3.9 ± 5.7 years. The median operating time was 40 ± 95 min, and the length of hospital stay was 3.0 ± 3.0 days. Ten patients needed several interventions. CONCLUSION: This case series provides a description of surgical interventions for complications related to sacral colpopexy. These complications may be serious and occur years after the initial surgery.

Implications of a two-step procedure in surgical management of patients with early-stage endometrioid endometrial cancer.

OBJECTIVE: Since European Society for Medical Oncology (ESMO) recommendations and French guidelines, pelvic lymphadenectomy should not be systematically performed for women with early-stage endometrioid endometrial cancer (EEC) preoperatively assessed at presumed low- or intermediate-risk. The aim of our study was to evaluate the change of our surgical practices after ESMO recommendations, and to evaluate the rate and morbidity of second surgical procedure in case of understaging after the first surgery. METHODS: This retrospective single-center study included women with EEC preoperatively assessed at presumed low- or intermediate-risk who had surgery between 2006 and 2013. Two periods were defined the times before and after ESMO recommendations. Demographics characteristics, surgical management, operative morbidity, and rate of understaging were compared. The rate of second surgical procedure required for lymph node resection during the second period and its morbidity were also studied. RESULTS: Sixty-one and sixty-two patients were operated for EEC preoperatively assessed at presumed low-or intermediate-risk before and after ESMO recommendations, respectively. Although immediate pelvic lymphadenectomy was performed more frequently during the first period than the second period (88.5% vs. 19.4%; p<0.001), the rate of postoperative risk-elevating or upstaging were comparable between the two periods (31.1% vs. 27.4%; p=0.71). Among the patients requiring second surgical procedure during the second period (21.0%), 30.8% did not undergo the second surgery due to their comorbidity or old age. For the patients who underwent second surgical procedure, mean operative time of the second procedure was 246.1±117.8 minutes. Third operation was required in 33.3% of them because of postoperative complications. CONCLUSION: Since ESMO recommendations, second surgical procedure for lymph node resection is often required for women with EEC presumed at low- or intermediate-risk. This reoperation is not always performed due to age/comorbidity of the patients, and presents a significant morbidity.