[Accuracy of ultrasound estimated fetal weight performed by OB-Gyn residents at due date]. / Performance de l'estimation échographique du poids foetal réalisée par les internes de spécialité le jour du terme.

OBJECTIVES: The aim of this study was to evaluate the accuracy of ultrasound fetal weight prediction at due date and to find parameters that may affect this prediction. PATIENTS AND METHODS: We retrospectively studied 201 patients at due date in a university hospital in 2006, the fetal weight estimation being performed by Obstetric-gynecology (OB-Gyn). Estimated fetal weight was calculated with the Hadlock's formula, including biparietal diameter, cephalic circumference, abdominal perimeter and femoral length and was compared with birth weight. RESULTS: The mean birth weight was 3561+/-415 g. The mean absolute weight difference was 261+/-190 g (absolute range: 0 to 1183 g, actual range: -935 to 1183 g). Body mass index>30 kg/m(2) was associated with greater fetal weight inaccuracy (p=0,013). Fetal weight estimation was not influenced by fetal macrosomia, oligoanamnios or maternal weight gain during pregnancy. DISCUSSION AND CONCLUSION: The sonographic estimated fetal weight and birth weight are correlated with a mean absolute percentage error of 7%. However, clinicians should be aware of the risk of inaccuracy in obese women.

[Evaluation of decisional elements of vaginal delivery in case of breech presentation in 19 university hospitals in France]. / Evaluation des protocoles de décision de voie d'accouchement en cas de présentation du siège dans 19 CHU en France.

BACKGROUND: Recently, a Belgo-French study led by PREMODA group showed that there was no significant difference between caesarean and vaginal delivery for neonatal outcome. OBJECTIVE: To study protocols and rate of vaginal delivery of single breech in 2006 in the 30 French teaching hospitals that participated to the PREMODA study. METHOD: Postal survey. RESULTS: Nineteen university hospitals answered (63%). Eighteen used a written protocol and three of them underwent systematic prophylactic caesarean section for breech presentation. Among 15 others, the decision criteria for the way of delivery included pelvimetry, absence of primary cephalic deflexion and foetal measurements. Some centres required additional restrictions. The rates of vaginal delivery varied from 1.7 to 49.7% depending on the centre with very different policies concerning decisional elements. Protocols with restrictions less than three were associated with higher percentages of vaginal delivery (28.9% vs. 21.6%, p<0.001). CONCLUSION: Most of teaching centres use a written protocol for breech delivery. Huge variations exist between vaginal delivery rates which seems partially linked to the number of restrictions of the protocol. However, criteria used to accept vaginal delivery in breech presentation are variable between centres and do not lie on objective findings.

[Comparative study of two single-use vacuum extractor]. / Etude comparative de deux ventouses à usage unique.

OBJECTIVE: To compare the effectiveness of two single-use vacuum devices, the Kiwi Omnicup and the Mitysoft Bell. MATERIAL AND METHODS: This retrospective study was conducted during two different periods: from January 15th to March 14th to assess the Kiwi Omnicup and from March 15th to June 15th for the Mitysoft Bell. The primary outcome was the successful completion of delivery with the allocated instrument. Secondary outcomes were fetal scalp trauma and maternal perineal lesions. All deliveries were performed by similar teams. RESULTS: Thirty-nine patients were included in the Kiwi Omnicup group and 48 in the Mitysoft Bell group. Compared to the Kiwi Omnicup, the Mitysoft Bell was associated with a greater number of cup detachments (41.7% vs. 10.3%; p<0.01) and a significantly higher rate of failure (31.3% vs. 12.8%). Rates of substantial scalp trauma and maternal trauma were similar in both groups. CONCLUSION: The Mitysoft Bell is not as successful at achieving a vaginal delivery as the Kiwi Omnicup. This could be explained by the shape of the cup.

[Labor monitoring in high-risk situations]. / Surveillance du travail dans les situations à risque.

Intrapartum asphyxia is increased in several situations such as intrauterine growth retardation, preterm labor, postdate pregnancy or maternal diabetes. In all these cases, fetal heart rate monitoring should be preferred to intermittent auscultation. Fetal scalp blood pH or lactates can be used to identify fetuses at risk of intrapartum asphyxia. However, fetal scalp blood sampling should not delay delivery in case of severe abnormal fetal heart rate as fetal asphyxia could occur rapidly in theses high-risk pregnancies. Data is insufficient to recommend fetal pulse oximetry or ECG analysis. Research should be undertaken to evaluate their performance in these situations.

[Subsequent pregnancy following uterine artery embolization for interstitial pregnancy]. / Conservation de la fertilité après embolisation sélective d'une grossesse cornuale.

Subsequent pregnancy following an interstitial pregnancy is rare. The risk of uterine rupture may be increased in this situation. Uterine selective embolization has been proposed as an effective treatment. However, no further pregnancy has ever been described after this method of management. We are reporting a case of subsequent pregnancy following interstitial pregnancy managed by embolization. The pregnancy was uneventful. A healthy male infant was delivered by C-section. This case supports the hypothesis that selective embolization for interstitial pregnancy may respect fertility. However, as actual risk of uterine rupture in subsequent pregnancies remains unknown, a C-section is advised.

Systematic prophylactic oxytocin injection and the incidence of postpartum hemorrhage: A before-and-after study.

OBJECTIVE: Assess the impact of routine injection of 5 units of oxytocin as soon as the anterior shoulder is delivered on the incidence of postpartum haemorrhage (PPH) in a context of daily practice. MATERIALS AND METHODS: Single-centre before-and-after study evaluating the effect of a change in the protocol for PPH prevention as applied in our obstetrical unit. During the first period, oxytocin (5 units) was to be injected only in case of PPH risk factors. During the second period, the injection was systematic. RESULTS: In the "before" study period, there were 1953 patients vaginal deliveries and 843 (43%) oxytocin injections, with a protocol compliance of 85%. In the "after" study period, 2018 women had vaginal deliveries and 1911 (95%) had an oxytocin injection (protocol compliance: 95%). The whole study period was associated with a reduced risk of moderate haemorrhage (13.4% vs. 9.2%, P<0.001), but no significant reduced risk of severe haemorrhage was observed (2.1% vs. 2.0%, P=0.79). After logistic regression, the study period remained associated with a significant reduction in the risk of moderate PPH (OR=0.72 [0.58-0.89]). CONCLUSION: Routine injection of 5 units of oxytocin makes it possible to reduce the risk of moderate PPH, but it does not affect the risk of severe PPH.

Determination of object resonances by vibro-acoustography and their associated modes.

Vibro-acoustography technique known by its noncontact excitation was used to detect resonance frequencies of objects in water. Two intersecting ultrasound beams generated by a 40 mm-diameter annular array transducer, focused at 35 mm and driven at f1=2.2 MHz and f2=2.22 MHz respectively, were targeted inside the object under test to produce a radiation force beating at the difference frequency f2-f1. This low frequency radiation force was used to excite the resonance vibration modes of the object by sweeping the frequency f2 between 2.22 and 2.275 MHz. The amplitude of the acoustic emission produced by the vibrations of the object was detected by a low frequency hydrophone (BW=60 kHz). By this approach, it was possible to detect resonance frequencies through amplitude variations of the measured acoustic emission. Experiments were conducted in a water tank for objects of different shapes and sizes. With a chalk sphere (15 mm-diameter) two resonance frequencies were detected at 45.75 and 68.75 kHz, and with a cylinder (10.38 mm-diameter and 32.20 mm-length) four principal resonance frequencies were identified in the 60 kHz-bandwidth of the hydrophone. It was shown with finite element calculations performed with Ansys, in which both solid and fluid parts were modelled, that the measured resonance frequencies corresponded to compressional or dilatation vibration modes of the object. It was verified that shear waves generated by torsional vibration modes were not propagated in water, as it is well known. The use of this technique to characterize heterogeneities in different media seems to be relatively more advantageous to other ultrasonic methods.

[Value of fetal fibronectin research for predicting premature delivery]. / Intérêt de la recherche de fibronectine foetale pour la prédiction de l'accouchement prématuré.

OBJECTIVE: To estimate the performance of the foetal fibronectin test as a predictor of preterm delivery. PATIENTS AND METHODS: This prospective study concern 61 patients who had a singleton pregnancy between 24 and 36 weeks of gestation and were hospitalized because of a threatened preterm labor without premature rupture of the membranes. For each patient the presence of foetal fibronectin in cervicovaginal secretions was determined with a rapid swab-test. RESULTS: Prematurity rate was 38% (23 patients). In case of positive result, delivery became before 37 weeks in 75% (12/16) against 24% in case of negative result (11/45). The prolongation of pregnancy after the test was on average 21 days in the positive group and 44 days in the negative group. About the prediction of preterm delivery, the results showed a sensibility of 52%, a specificity of 89%, a positive predictive value of 75%, a negative predictive value of 76%. To predict a delivery within the two weeks after the test, the sensibility was 88%, the specificity 83%, and the negative predictive value 98%. CONCLUSION: The presence of foetal fibronectin in cervicovaginal secretions represent an increased risk of preterm delivery, whereas its excellent negative predictive value allow to be reassuring, especially within a period of 15 days.

Signs, symptoms and complications of complete and partial uterine ruptures during pregnancy and delivery.

OBJECTIVES: Uterine rupture is a rare but potentially catastrophic complication of pregnancy that requires rapid diagnosis. Classically, its signs and symptoms combine pain, fetal heart rate (FHR) abnormalities, and vaginal bleeding. The purpose of this study is to identify these signs and symptoms as well as the immediate complications of complete and incomplete (partial) ruptures of the uterine wall, whether or not they follow a previous cesarean delivery. STUDY DESIGN: Retrospective study of case records from two university hospital maternity units, from 1987 to 2008. RESULTS: In a total of 97,028 births during the study period, we identified 52 uterine ruptures (0.05%): 25 complete and 27 partial. Most (89%) occurred in women with a previous cesarean delivery. In complete ruptures, FHR abnormalities were the most frequent sign (82%), while the complete triad of FHR abnormalities-pain-vaginal bleeding was present in only 9%. The signs and symptoms of partial ruptures were very different; these were asymptomatic in half the cases (48%). Neonatal mortality reached 13.6% among the complete ruptures; 27 and 40% of these newborns had pH<6.80 and pH<7.0, respectively. Among the incomplete ruptures, only 7.7% of the newborns had a pH<7.0 and there were no deaths. CONCLUSION: Although complete rupture of the uterus has a severe neonatal prognosis, the complete set of standard symptoms is present in less than 10% of cases. FHR abnormalities are by far the most frequent sign.

[Ten practical issues concerning acute poisoning with carbon monoxide in pregnant women]. / Dix questions pratiques concernant l'intoxication aiguë au monoxyde de carbone chez la femme enceinte.

BACKGROUND: The poisoning of carbon monoxide (CO) is the leading cause of death by poisoning in France. Its consequences are potentially serious to the fetus. Literature is ancient and little known. PURPOSE AND METHOD: Make an inventory of knowledge about carbon monoxide poisoning during pregnancy. RESULT: The CO causes maternal then fetal tissue hypoxia primarily by binding to hemoglobin with which it has a high affinity. Its transplacental passage may cause fetal harm, predominantly in the brain. Severity seems correlated with maternal symptoms during exposure. In the absence of maternal symptoms, however, the available data are reassuring. Hyperbaric oxygen therapy may reduce the risk to the fetus. DISCUSSION: Oxygen therapy should be offered in all cases of CO poisoning, especially if there are maternal symptoms during exposure. In addition, a fetal echography directed on the cephalic pole - even a fetal magnetic resonance imaging three weeks after exposure - should also be proposed.

[Development and assessment of a workshop on repair of third and fourth degree obstetric tears]. / Élaboration et évaluation d'un outil d'enseignement de la réparation des déchirures périnéales du troisième et quatrième degré

OBJECTIVES: To evaluate the educational interest of a workshop on diagnosis and repair of obstetric anal sphincter injuries (OASIS). To evaluate the theoretical and anatomical knowledge of OASIS repair by French residents in obstetrics and gynecology. MATERIALS AND METHODS: The workshop was composed of slides, video of repair and training using cadaveric sow's anal sphincters. All subjects were tested with a questionnaire before and after the course. RESULTS: Thirty residents participated. Classification of OASIS was known by 13.3% of the residents before the training versus 93.3% after the workshop (P<0.001). Initially, only 6.7% correctly classified operative procedures of OASIS versus 86.7% after the workshop (P<0.001). Per pre-test, 90% of residents did not know how to identify the internal anal sphincter (IAS) versus 3% at post-test (P<0.001). Seventy percent of trainees correctly identified the external anal sphincter (EAS) at the beginning of training. Before the course, no resident knew the repair of the IAS and only one third knew the technical repair of the EAS. After the workshop, the theoretical knowledge of EAS and IAS repair were acquired by all (P<0.001). CONCLUSION: Structured hands-on training improves significantly the knowledge of OASIS diagnosis and repair.

[The diagnosis of fetal head engagement: transperineal ultrasound, a new useful tool?]. / Engagement de la tête fœtale : échographie transpérinéale, un nouvel outil diagnostique ?

OBJECTIVE: Assessment of fetal head engagement by digital examination is highly subjective even though this method remains the gold standard. Ultrasonography could be helpful to determine fetal head engagement during the second stage of labor. PATIENTS AND METHODS: Prospective unicentric study to compare the diagnostic of fetal head orientation and engagement between digital examination and ultrasonography. One hundred measurements were performed in 100 patients at complete cervical dilatation. RESULTS: In 80 % of patients, abdominal ultrasound assessments were consistent with digital examinations in depicting fetal head position. We were not able to evaluate engagement by abdominal ultrasonography. Perineum to fetal head distance was measured between 12 and 83mm by translabial ultrasonography. When the head was not engaged (-1), the mean distance was 66.4±7.53mm. The measure was 56.15±10.86mm when the head was at the upper part of the birth canal (+1), 46.47±12.49mm at the middle part (+2) and 35.81±10.42mm at the lower part (+3; +4). A threshold of 55mm was associated with a sensibility and a negative predictive value of 100 % for vaginal birth. DISCUSSION AND CONCLUSION: Abdominal intrapartum ultrasound increases the accuracy of fetal head position assessment. Translabial ultrasound is a simple and easy method to define fetal head engagement by measuring the distance between perineum and fetal head. Ultrasound during the second stage of labor may serve as an educational tool for physicians in training.

Evaluation of a decision protocol for type of delivery of infants in breech presentation at term.

OBJECTIVES: To assess the safety of a decision protocol for type of delivery of breech presentations after 37 weeks of gestation. This protocol was based on a comparison of fetal head and maternal pelvic measurements. STUDY DESIGN: Retrospective before-and-after study of 1133 breech infants born between 2000 and 2008 in a tertiary centre, analysing neonatal condition and percentage of vaginal deliveries by study period. RESULTS: Application of the protocol was accompanied by an increase in the percentage of vaginal deliveries of breech presentations from 24.0% in 2000-2004 to 38.5% in 2004-2008 (p<0.001), without impairment of neonatal condition [composite mortality/morbidity variable: 3/567 (0.5%) vs 4/566 (0.7%), respectively; p>0.99; neonatal arterial pH<7.0: 8/521 (1.5%) vs 4/529 (0.8%), respectively; p=0.23]. CONCLUSION: The use of a protocol based on objective criteria at the authors' centre made it possible to increase the percentage of vaginal deliveries of breech presentations without impairing neonatal condition.