Clinical and ultrasound characteristics of deep endometriosis affecting sacral plexus.

OBJECTIVE: To describe the sonomorphological changes and appearance of deep endometriosis (DE) affecting the nervous tissue of the sacral plexus (SP). METHODS: This was a retrospective study of symptomatic patients who underwent radical resection of histologically confirmed DE affecting the SP and who had undergone preoperative transvaginal sonography (TVS) between 2019 and 2023. Lesions were described based on the terms and definitions of the International Deep Endometriosis Analysis (IDEA), International Ovarian Tumor Analysis (IOTA) and Morphological Uterus Sonographic Assessment (MUSA) groups. A diagnosis of DE affecting the SP on TVS was made when the sonographic criteria of DE were visualized in conjunction with fibers of the SP and the presence of related symptoms corresponding to sacral radiculopathy. Clinical symptoms, ultrasound features and histological confirmation were analyzed for each patient included. RESULTS: Twenty-seven patients with DE infiltrating the SP were identified in two contributing tertiary referral centers. Median age was 37 (range, 29-45) years and all patients were symptomatic and presented one or more of the following neurological symptoms: dysesthesia in the ipsilateral lower extremity (n = 17); paresthesia in the ipsilateral lower extremity (n = 10); chronic pelvic pain radiating in the ipsilateral lower extremity (n = 9); chronic pain radiating in the pudendal region (n = 8); and motor weakness in the ipsilateral lower extremities (n = 3). All DE lesions affecting the SP were purely solid tumors in the posterior parametrium in direct contact with, or infiltrating, the S1, S2, S3 and/or S4 roots of the SP. The median of the largest diameter recorded for each of the DE nodules was 35 (range, 18-50) mm. Echogenicity was non-uniform in 23 (85%) of the DE nodules, with all but one of these nodules containing hyperechogenic areas. The shape of the lesions was irregular in 24 (89%) cases. Only one lesion exhibited a lobulated form, with all other irregular lesions showing a spiculated appearance. An acoustic shadow was produced in 20 (74%) of the nodules, all of which were internal. On color or power Doppler examination, 21 (78%) of the nodules showed no signal (color score of 1). The remaining six (22%) lesions showed a minimal color content (color score of 2). According to pattern recognition, most DE nodules were purely solid, non-uniform, hypoechogenic nodules containing hyperechogenic areas, with internal shadows and irregular spiculated contours, and were poorly vascularized on color/power Doppler examination. CONCLUSION: The ultrasound finding of a parametrial, unilateral, solid, non-uniform, hypoechogenic nodule with hyperechogenic areas and possible internal shadowing, as well as irregular spiculated contours, demonstrating poor vascularization on Doppler examination in proximity to or involving the structures of the SP, indicates DE affecting the SP. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Visualization of sacral nerve roots and sacral plexus on gynecological transvaginal ultrasound: feasibility study.

OBJECTIVE: To investigate the feasibility of identifying and measuring the normal sacral plexus (SP) on gynecological transvaginal ultrasound (TVS) examination. METHODS: This was a prospective observational study conducted at a single tertiary gynecological referral center, including consecutive women undergoing TVS for various indications between November 2021 and January 2022. A standardized assessment of the pelvic organs was performed and the presence of any congenital or acquired uterine pathology or ovarian abnormality was recorded. Visualization of the right and left SP was attempted in all cases. The success rate and the time needed to identify the SP were recorded and measurements of the SP were made. RESULTS: A total of 326 patients were included in the study. In all women, the SP was identified successfully on at least one side. SP were visualized bilaterally in 317 (97.2% (95% CI, 94.4-98.5%)) women. Only the right SP was seen in 3/326 (0.9% (95% CI, 0.2-2.7%)) and only the left in 6/326 (1.8% (95% CI, 0.6-4.0%)) (P = 0.5048). There was no significant difference in the median time required to visualize the right vs left SP (9.0 (interquartile range (IQR), 8.0-10.0) s  vs 9.0 (IQR, 8.0-10.0) s; P = 0.0770). The median transverse diameter of the right SP was 15.0 (IQR, 14.2-15.6) mm and that of the left SP was 14.9 (IQR, 14.4-15.6) mm. CONCLUSIONS: We describe a novel method which allows for the consistent and rapid identification of the SP on TVS. Integrating assessment of the SP into routine pelvic TVS may be helpful particularly for women suffering from deep endometriosis. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Review concludes that specific recommendations are needed to harmonise the provision of fresh mother's milk to their preterm infants.

AIM: There are no specific recommendations for using a mother's fresh milk for her preterm infant. We reviewed the available evidence on its collection, storage and administration. METHODS: The working group of the French Neonatal Society on fresh human milk use in preterm infants searched the MEDLINE database and Cochrane Library up to June 2017 for papers published in English or French. They specifically analysed 282 papers providing information on prospective, retrospective and clinical studies and examined guidelines from various countries. RESULTS: The review concluded that fresh mother's own milk should be favoured in accordance with the latest recommendations. However, it must be carried out under stringent conditions so that the expected benefits are not offset by risks related to different practices. The working group has summarised the best conditions for feeding preterm infants with human milk, balancing high nutritional and immunological quality with adequate virological and bacteriological safety. Professionals must provide parents with the necessary conditions to establish breastfeeding, together with specific and strong support. CONCLUSION: Based on their review, the working group has made specific recommendations for using fresh mother's own milk under careful conditions, so that the expected benefits are not offset by risks related to practices.

[CA, P, AND MG POSTNATAL METABOLISM AND REQUIREMENTS IN PARENTERAL AND ENTERAL NUTRITION OF PREMATURE INFANTS]. / CA, P ET MG : MÉTABOLISME POSTNATAL ET BESOINS NUTRITIONNELS CHEZ LE PRÉMATURE EN ALIMENTATION PARENTÉRALE OU ENTÉRALE.

During the last trimester of gestation, transplacental mineral transfer and fetal mineral accretion is particularly high: 2.3-3.2 mmol/kg/day (90-130 mg/kg/d) of calcium, 2.4-2.7 mmol/kg/d (65-75 mg/kg/day) of phosphorus and 0.12-0.20 mmol/kg/d (2.9-4.8 mg/kg/day) of magnesium. After birth, there is a dramatic change in bone mineral metabolism from a maximal bone deposition during fetal life to a postnatal bone turnover stimulation improving bone structure and resistance. This physiological change could partly reduce the mineral requirements, as minerals available from the remodeling activities could be recycled for bone mineralization. In addition, recent studies in preterm infants, suggest that the use of early more "aggressive" nutritional support, providing high aminoacid intakes from the first day of life, may induce a "refeeding like syndrome" suggesting that early phosphorus and electrolytes supplies are also necessary. The aim of the present paper is to review the mineral metabolism of Very Low Birth Weight (VLBW) infants during the first weeks of life at the light of the more recent studies and to revise the nutritional recommendations for mineral parenteral and enteral intakes in VLBW infants.

[Recent advances in nutritional support and postnatal growth in premature infants]. / Nouvelles perspectives pour l'alimentation des prématurés et leur croissance postnatale.

Nutrition has always been described as challenging in premature infants, especially in very low birth weight (VLBW, < 1500 g) infants. Therefore, postnatal malnutrition is frequently observed in these infants and most develop a severe postnatal growth restriction with a very high incidence of hypotrophy at term corrected age. Otherwise, both insufficient nutritional intakes and postnatal growth restriction during the perinatal period have been associated with adverse developmental outcomes. In this article, an optimized nutritional policy characterized by a standardization of nutritional support is discussed. This policy implies the use of one standardized parenteral nutrition solution and a rapidly enriched feeding regimen. Recent studies in VLBW infants have demonstrated that this approach is associated with significant improvement of nutritional support, postnatal growth and biological homeostasis. Only 6% of appropriate for gestational age infants at birth were described small for gestational age at discharge. This policy has recently been reproduced by the industry that developed the first manufactured triple-chamber parenteral nutrition bags specifically designed for premature infants. It represents a great opportunity for premature infants to improve their development and long-term outcomes.

Circulating ficolin-2 and ficolin-3 in normal pregnancy and pre-eclampsia.

Ficolins are soluble molecules of the innate immune system that recognize carbohydrate molecules on microbial pathogens, apoptotic and necrotic cells. They act through two distinct routes: initiating the lectin pathway of complement activation and mediating a primitive opsonophagocytosis. In this study, we measured plasma levels of ficolin-2 and ficolin-3 in 60 pre-eclamptic patients, 60 healthy pregnant women and 59 healthy non-pregnant women by enzyme-linked immunosorbent assay (ELISA). Circulating levels of complement activation products (C4d, C3a, SC5b9), angiogenic factors (soluble fms-like tyrosine kinase-1, placental growth factor) and markers of endothelial activation (von Willebrand factor antigen), endothelial injury (fibronectin) and trophoblast debris (cell-free fetal DNA) were also determined. Plasma levels of ficolin-2 were significantly lower in healthy pregnant than in healthy non-pregnant women, while ficolin-3 levels did not differ significantly between the two groups. Furthermore, pre-eclamptic patients had significantly lower ficolin-2 and ficolin-3 concentrations than healthy non-pregnant and pregnant women. In the pre-eclamptic group, plasma ficolin-2 levels showed a significant positive correlation with serum placental growth factor (PlGF) concentrations and significant inverse correlations with serum levels of soluble fms-like tyrosine kinase-1 (sFlt-1), blood urea nitrogen and creatinine, serum lactate dehydrogenase activities, as well as with plasma VWF:antigen, fibronectin and cell-free fetal DNA concentrations. In conclusion, circulating levels of ficolin-2 are decreased in the third trimester of normal pregnancy. There is a further decrease in plasma ficolin-2 concentrations in pre-eclampsia, which might contribute to the development of the maternal syndrome of the disease through impaired removal of the trophoblast-derived material released into the maternal circulation by the hypoxic and oxidatively stressed pre-eclamptic placenta.

Importance of cytoplasmic granularity of human oocytes in in vitro fertilization treatments.

The aim of this study was to examine the effect of different stimulation protocols on oocyte granularity and to determine the influence of cytoplasmic granularity on further embryo development. A total of 2448 oocytes from 393 intracytoplasmic sperm injection (ICSI) cycles were analysed retrospectively. Oocytes were classified into 5 groups according to cytoplasmic granularity. (A) no granule or 1-2 small (<5 µm) granules; (B) more than 3 small granules; (C) large granules (>5 µm); (D) refractile body; (E) dense centrally located granular area. Correlation between characteristics of hormonal stimulation, oocyte granularity and embryo development was analysed. The occurrence of cytoplasmic granularity was influenced by the patient's age and characteristics of stimulation. The type of granulation had no effect on fertilization rate and zygote morphology. However, some type of granulation resulted in a lower cleavage rate and more fragmented embryos. Our results provided additional information on how hormonal stimulation affects oocyte quality. While cytoplasmic granularity seems not to have an effect on fertilization and embryo development, the presence of refractile body in the oocyte is associated with reduced cleavage rates and impaired embryo development.

[Neuroprotection by controlled hypothermia in neonatal hypoxic-ischemic encephalopathy]. / Neuroprotection par hypothermie contrôlée dans l'encéphalopathie anoxo-ischémique du nouveau-né.

Neonatal hypoxic-ischemic encephalopathy is a major cause of death and neurodevelopmental delay. Brain cooling by mild controlled hypothermia is currently the most promising therapy.

Pattern of invasion of the embryonic mouse spinal cord by microglial cells at the time of the onset of functional neuronal networks.

Microglial cells invade the central nervous system during embryonic development, but their developmental functional roles in vivo remain largely unknown. Accordingly, their invasion pattern during early embryonic development is still poorly understood. To address this issue, we analyzed the initial developmental pattern of microglial cell invasion in the spinal cord of CX3CR1-eGFP mouse embryos using immunohistochemistry. Microglial cells began to invade the mouse embryonic spinal cord at a developmental period corresponding to the onset of spontaneous electrical activity and of synaptogenesis. Microglial cells reached the spinal cord through the peripheral vasculature and began to invade the parenchyma at 11.5 days of embryonic age (E11.5). Remarkably, at E12.5, activated microglial cells aggregated in the dorsolateral region close to terminals of dying dorsal root ganglia neurons. At E13.5, microglial cells in the ventral marginal zone interacted with radial glial cells, whereas ramified microglial cells within the parenchyma interacted with growing capillaries. At this age, activated microglial cells (Mac-2 staining) also accumulated within the lateral motor columns at the onset of the developmental cell death of motoneurons. This cell aggregation was still observed at E14.5, but microglial cells no longer expressed Mac-2. At E15.5, microglial cells were randomly distributed within the parenchyma. Our results provide the essential basis for further studies on the role of microglial cells in the early development of spinal cord neuronal networks in vivo.

Impact of highly purified versus recombinant follicle stimulating hormone on oocyte quality and embryo development in intracytoplasmic sperm injection cycles.

The quality of oocytes and developing embryos are the most relevant factors determining the success of an in vitro fertilization (IVF) treatment. However, there are very few studies analyzing the effects of different gonadotrophin preparations on oocyte and embryo quality. A retrospective secondary analysis of data collected from a prospective randomized study was performed to compare highly purified versus recombinant follicle stimulating hormone (HP-FSH vs. rFSH). The main outcome measures were quantity and quality of oocytes and embryos, dynamics of embryo development, cryopreservation, clinical pregnancy and live birth rate. The number of retrieved and of mature (MII) oocytes showed no significant differences. Fertilization rate was significantly higher in the HP-FSH group (68.9% vs. 59.9%, p = 0.01). We also found significantly higher rate of cryopreserved embryos per all retrieved oocytes (23.4% vs. 14.5%, p = 0.002) in the HP-FSH group. There were no significant differences in clinical pregnancy and in live birth rates. Oocytes obtained with HP-FSH stimulation showed higher fertilisability, whereas pregnancy and live birth rates did not differ between the groups. However, patients treated with HP-FSH may benefit from the higher rate of embryos capable for cryopreservation, suggesting that cumulative pregnancy rates might be higher in this group.

Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition.

The number of surviving children born prematurely has increased substantially during the last 2 decades. The major goal of enteral nutrient supply to these infants is to achieve growth similar to foetal growth coupled with satisfactory functional development. The accumulation of knowledge since the previous guideline on nutrition of preterm infants from the Committee on Nutrition of the European Society of Paediatric Gastroenterology and Nutrition in 1987 has made a new guideline necessary. Thus, an ad hoc expert panel was convened by the Committee on Nutrition of the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition in 2007 to make appropriate recommendations. The present guideline, of which the major recommendations are summarised here (for the full report, see http://links.lww.com/A1480), is consistent with, but not identical to, recent guidelines from the Life Sciences Research Office of the American Society for Nutritional Sciences published in 2002 and recommendations from the handbook Nutrition of the Preterm Infant. Scientific Basis and Practical Guidelines, 2nd ed, edited by Tsang et al, and published in 2005. The preferred food for premature infants is fortified human milk from the infant's own mother, or, alternatively, formula designed for premature infants. This guideline aims to provide proposed advisable ranges for nutrient intakes for stable-growing preterm infants up to a weight of approximately 1800 g, because most data are available for these infants. These recommendations are based on a considered review of available scientific reports on the subject, and on expert consensus for which the available scientific data are considered inadequate.

[Prevalence of HIV infection among pregnant women. A study in rural Africa]. / Prévalence de l'infection par le VIH chez les femmes enceintes. Etude en milieu rural africain.

BACKGROUND: The goal of the study is to assess the prevalence and risk factors of HIV in pregnant women in the North-East rural area of the Democratic Republic of Congo. METHODS: We undertook an exploratory study on women attending the antenatal care during the study period (from December 2002 to December 2004) in the referral General hospital of the health catchments' area of Oicha (DRC). Women with gestational age equal or above 36 weeks were included in the study. After a first test using rapid test Abbott Determine locally, a second crossing check was performed in the referral HIV laboratory in Liege (Belgium). RESULTS: Among 5016 participants tested, 94 were positive (prevalence of 1.9% [CI95% 1.5-2.5]). Following factors predict a risk of being positive among participants: the statute of displacement (OR: 5.77; IC95%: 3.59-9.29); widowhood and divorces (OR: 4.47; IC95%: 1.47-13.60); mobility related to the profession of the husband (OR: 4.00; IC95%: 2.36-6,75); living the countryside (OR: 1.67; IC95%: 1.06-2.62; p: 0.0258).

[Feeding during the first months of life and prevention of allergy]. / Alimentation des premiers mois de vie et prévention de l'allergie.

Allergy consists in the different manifestations resulting from immune reactions triggered by food or respiratory allergens. Both its frequency and severity are increasing. The easiest intervention process for allergy prevention is the reduction of the allergenic load which, for a major allergen such as peanuts, has to begin in utero. The primary prevention strategy relies first on the detection of at risk newborns, i.e. with allergic first degree relatives. In this targeted population, as well as for the general population, exclusive breastfeeding is recommended until the age of 6 months. The elimination from the mother's diet of major food allergens potentially transmitted via breast milk may be indicated on an individual basis, except for peanut, which is systematically retrieved. In the absence of breastfeeding, prevention consists in feeding at-risk newborns until the age of 6 months with a hypoallergenic formula, provided that its efficiency has been demonstrated by well-designed clinical trials. Soy based formulae are not recommended for allergy prevention. Complementary feeding should not be started before the age of 6 months. Introduction of egg and fish into the diet can be made after 6 months but the introduction of potent food allergens (kiwi, celery, crustaceans, seafood, nuts, especially tree nuts and peanuts) should be delayed after 1 year. This preventive policy seems partially efficacious on early manifestations of allergy but does not restrain the allergic march, especially in its respiratory manifestations. Probiotics, prebiotics as well as n-3 fatty polyunsaturated acids have not yet demonstrated any definitive protective effect.

[Folic acid and prevention of neural tube closure defects: the question is not solved yet]. / Prévention par l'acide folique des défauts de fermeture du tube neural: la question n'est toujours pas réglée.

Between 1981 and 1996, several interventional studies proved the efficacy of periconceptional folic acid supplementation in the prevention of neural tube closure defects (NTCD), first in women at risk (with a previous case of NTCD) and also in women of the general population in age to become pregnant. The poor observance of this supplementation led several countries (USA, Canada, Chile...) to decide mandatory folic acid fortification of cereals, which permitted a 30% (USA) to 46% (Canada) reduction in the incidence of NTCD. Moreover, this benefit was accompanied by a diminished incidence of several other malformations and of stroke and coronary accidents in elderly people. However, several papers drew attention to an increased risk of colorectal and breast cancer in relation with high blood folate levels and the use of folic acid supplements. A controlled interventional study showed a higher rate of recurrence of colic adenomas and a higher percentage of advanced adenomas in subjects receiving 1mg/day of folic acid. A recent study demonstrated an abrupt reversal of the downward trend in colorectal cancer 1 year after the beginning of cereal folic acid fortification in the USA and Canada. Two studies also reported impaired cognitive functions in elder persons with defective vitamin B(12) status. Taken in aggregate, these studies question the wisdom of a nationwide, mandatory, folic acid fortification of cereals. As of today, despite their limited preventive efficacy, a safe approach is to keep our current French recommendations and to increase the awareness of all caregivers, so as to improve the observance of these recommendations.

[Care and follow-up of premature infants after discharge]. / La prise en charge et le suivi des nouveau-nés prématurés après leur retour à domicile.

Prematurity remains a public health problem with a considerable psychosocial impact. Premature infants are discharged home more fragile and more precociously than infants born at term. Post-discharge nutrition and growth of the preterm infants should be carefully followed because of specific needs of these infants. Infections and cardiorespiratory abnormalities are more frequent in ex-premature infants. Some cerebral lesions may be shown by brain imaging suggesting future sequelae. However, estimation of their real consequences remains imperfect and long term prognosis contains many uncertainties. Cerebral palsy seems to be less severe nowadays, but all current gravity is due to disabilities which express later: hearing disorders, visual impairments, alterations of eye-hand coordination skills, attention deficit disorders, psychological troubles and school difficulties. Multidisciplinary consultations are designed for these children because early screening and adapted care can improve long term prognosis. All this underlines the importance of prolonged follow-up program after discharge for premature infants and others who presented worse suffer from hypoxic/ischemic encephalopathy.

[Early nutrition, postnatal growth retardation and outcome of VLBW infants]. / Apports nutritionnels précoces, hypotrophie acquise et devenir du prématuré

Early nutrition is an important determinant of growth, morbidity and psychomotor development in very low birth weight infants. Recent data suggest that "aggressive nutrition" providing early and high protein supply from the first hours of life improves nitrogen balance, reduces postnatal growth retardation, decreases morbidity and is positively related to psychomotor development. This paper will summarize the metabolic bases of this optimal nutrition for preterm infants.

[Advantages of individualized fortification of human milk for preterm infants]. / Intérêt de la supplémentation du lait maternel << à la carte>>.

Despite the benefits of human milk fortification, nutrients of human milk are not sufficient to cover the greater needs of very low birth weight and to ensure a growth similar to that of premature infants fed with preterm formula. These differences could be related to the variation in the macronutrient composition of expressed breast milk with lower protein and energy content. Unfortunately there is unusually no information on macronutrients composition prior human milk fortification. With such data, it would be possible to individualize the fortification. In order to use adjustable fortification of human milk, we have assessed a rapid and simple method using full spectrum infrared laser technology (Milkoscan) to analyze human milk composition. We describe the variation in concentration of protein, lipid and energy in the human milk received in our neonatal unit. Then we evaluate the benefit of adjustable fortification of human milk compared with standard fortification. After standard fortification the variability of protein and lipid remains with a risk of protein deficiency or excess and a risk of energy deficiency. After adjustable human milk fortification based on human milk analysis using Milkoscan, we observe a more stable protein content and a lower amount of added fortifier decreasing the risk of hyperosmolarity. Furthermore, the energy content is higher following of the fat human milk adjusted content. Up to now, our preliminary results suggest that individualized fortification of human milk improves growth rate in preterm infants (21 g/kg/d) to a level close to formula fed infants.

[Respiratory syncytial immunoprophylaxis with palivizumab]. / Prévention de l'infection respiratoire à VRS par immunoglobulines monoclonales spécifiques (palivizumab, Synagis).

Respiratory syncytial virus (RSV) is a serious pathogen causing significant morbidity, especially in premature infants and infants with chronic lung disease or significant congenital heart disease. There is no specific treatment for RSV infection and the therapy is essentially supportive. Therefore, prophylaxis is the best strategy against RSV disease. Passive immunization with monoclonal antibodies (palivizumab) provides protection against severe RSV infection and significantly reduces hospitalizations in high-risk childrens. However, palizumab is an expensive drug and its use should be reserved for children at the highest risk of severe RSV disease.

[Update in the management of persistent pulmonary hypertension of the newborn]. / Actualités thérapeutiques dans l'hypertension artérielle pulmonaire persistante du nouveau-né.

Persistent pulmonary hypertension of the newborn is a severe disease leading to persistent and refractory hypoxemia with bad outcomes. The introduction of inhaled nitric oxide therapy significantly improved short and long term prognosis of those infants. More recently, sildenafil also appeared promising, but regimen and indications still need to be delineated.

[Hypotension in the very preterm infant]. / Hypotension du grand prématuré.

One out of four very preterm infants will present with circulatory maladaptation during the first two days of life, with an increased risk of early complications and long term sequelae. Appreciation of those transitional difficulties cannot be limited to blood pressure. Assesment of blood pressure itself must be done in relation with gestational age and birth weight adapted norms. The effects of therapies for low systemic blood flow on blood pressure, organs and cerebral circulations are better understood, but none of them has assessed for mortality or neurodevelopmental outcomes.