Asymmetric pelvis and term breech presentation: is planned vaginal delivery still a safe option?

PURPOSE: To evaluate the obstetrical prognosis of term breech delivery in case of asymmetric pelvis. METHODS: An observational, comparative, retrospective, bi-centric study of 559 patients who had a computer tomography pelvimetry prior to delivery of a term breech presentation was conducted between August 2013 and August 2019. Patients with an attempted vaginal delivery were divided into two groups: a group of asymmetric pelvis (AP) when the difference between the lengths of both oblique diameters was ≥ 1 cm and a group of symmetric pelvis (SP) when the two oblique diameters differed by < 1 cm. The primary outcome was the rate of vaginal delivery. Secondary outcomes were a composite variable of neonatal and maternal morbidity and mortality. RESULTS: Of the 370 patients who attempted a vaginal breech delivery, 8% (n = 29) had an AP and 92% (n = 341) had a SP. In the AP group, the vaginal delivery rate was higher (93% versus 78%, p = 0.05). There was no statistically significant difference in neonatal (3% versus 1% in the AP and SP groups, respectively, p = 0.4) and maternal (17% versus 23% in the AP and SP groups, respectively, p = 0.5) morbidity and mortality. CONCLUSION: When a pelvimetry is performed before an attempt of vaginal breech delivery, a difference of less than two centimetres between both oblique diameters does not seem to reduce the rate of vaginal birth and is not an indication for an elective caesarean section.

Femoral fracture during breech vaginal delivery: A case report.

Femoral fracture is a rare but significant foetal injury, more frequent and likely to happen when the foetus is malpositioned or in a breech presentation. Cesarian section does not appear to be protective and all recent publications report cases occurring during cesarian section. We report a case that occurred in a vaginal delivery of a single footling breech presentation. This complication allows us to remind that femur fracture is a complication of breech delivery whatever the modality. The prognosis is good with early diagnosis.

[Introduction of the Couder manoeuvre and perineal injuries]. / Introduction de la manœuvre de Couder et évolution des lésions périnéales.

OBJECTIVE: To analyse the introduction of the Couder manoeuvre in our level 3 maternity unit shortly after its introduction in 2019. Then, to evaluate and compare the rate of perineal injuries between 2017, when the manoeuvre was not performed at all, and 2020. MATERIALS AND METHOD: A single-centre retrospective study of patients who delivered a singleton eutociously at term from 1 January to 31 December 2017 and 2020. RESULTS: In total, 2930 records were analysed. The Couder manoeuvre rate was 32.12% in 2020. A change in the distribution of perineal lesions was observed: the rate of intact perineum increased (P<0.001), while 2nd degree lesions decreased between 2017 and 2020 (P<0.05). The 1st degree perineum and obstetric anal sphincter injuries remained stable. The rate of episiotomy decreased significantly by almost a factor of 7. CONCLUSION: The practice of the Couder manoeuvre can be implemented fairly quickly after training of the actors with nearly a third of normal deliveries at term concerned one year after its introduction. This manoeuvre seems, in our practice, to have contributed to the reduction, as previously reported, of the rate of second degree perineal injuries.

[Demelin's maneuver for arm entrapment during vaginal breech delivery]. / Manœuvre de Demelin pour le relèvement des bras lors d'un accouchement voie basse d'une présentation du siège.

OBJECTIVES: To evaluate Demelin's maneuver for arm entrapment's dystocia during vaginal breech deliveries after failure of the usual Lovset maneuver. METHODS: We led a retrospective cohort study in two French maternities. Between January 2013 and June 2020, we included all vaginal breech deliveries of live newborns after 32 weeks of gestation requiring Demelin's maneuver for persistent arm entrapment despite the Lovset maneuver. The primary endpoint was the Demelin's maneuver success without the existence of a neonatal trauma related to the maneuver. RESULTS: Among 1611 vaginal breech deliveries, 29 with Demelin's maneuver for an arm entrapment were enrolled (prevalence 0,02%). No failure of this maneuver was found. There was 10 nulliparous (34.5%). Mean gestational age was 38±2.4 weeks of gestation. The success of Demelin's maneuver without trauma related to it was estimated at 82.8%. No serious neonatal trauma was noticed. Five fractures (17.2%), one humeral and four clavicular, without sequelae were diagnosed. Mean weight of newborns was 2945.5 grams and the median arterial pH was 7.17. The median 5-minutes-Apgar score was 10. Maternal morbidity was low: one case (3.4%) of obstetric anal sphincter injuries (type III). CONCLUSION: Demelin's maneuver seems to be an effective and safe method to treat an arm entrapment's dystocia during vaginal breech delivery after failure of the Lovset's maneuver.

[Giant condyloma acuminatum in pregnancy]. / La tumeur de Buschke Lowenstein chez la femme enceinte.

Buschke Lownestein's tumour is a giant acuminate condyloma characterised by its degenerative potential, its invasive nature and its recurrence after treatment. It is a rare condition, transmitted mainly by sexual transmission and induced by to the human papillomavirus (HPV). The discussion will be illustrated by a clinical case The treatment is still under discussion but surgery seems to be the best option. Management during pregnancy is more complex since it must take into account the mother and her fetus. The delivery route is still debated. The post-treatment evolution was satisfactory and without recurrence until the delivery which, due to the antecedent of 3 caesarean sections, was carried out by cesarean section. HPV vaccination, sex education and early treatment of condyloma lesions should prevent and in any case improve the prognosis of this disease.

Non-invasive fetal monitoring: Fetal Heart Rate multimodal estimation from abdominal electrocardiography and phonocardiography.

BACKGROUND: Fetal cardiac well-being is essential during labor as the delivery is at risk for fetal distress. Continuous monitoring by cardiotocography (CTG) is daily used to record the fetal heart rate (FHR) but this technique has important drawbacks in clinical use. OBJECTIVES: We propose to monitor FHR with a non-invasive technique, using multimodal recordings of the fetus cardiac activity, associating electrocardiographic (ECG) and phonocardiographic (PCG) sensors. The aim of this study is to evaluate the quality of these multimodal FHR estimations by comparison with CTG, based on clinical criteria. METHODS: A clinical protocol was established and a prospective open label study was carried out in the University Hospital of Grenoble. The objective was to record thoracic and abdominal PCG and ECG signals on pregnant women over 37 WG (weeks of gestation), simultaneously with CTG recordings. Adapted signal processing algorithms were then applied on abdominal PCG and ECG signals to extract FHR. Quantitative evaluation was carried out on FHR estimations compared with FHR extracted from CTG. RESULTS: A total of 40 recordings were performed. Due to technical mistakes the analysis was made possible for 38. 35 recordings allowed a FHR follow-up by ECG or PCG, 30 recordings allowed a FHR follow-up by PCG only, 25 recordings allowed a FHR follow-up by ECG only and 20 recordings allowed a FHR follow-up by both ECG and PCG. CONCLUSION: Reliable multimodal recording of FHR associating ECG and PCG sensors is possible during the last month of pregnancy. These positive results encourage the study of multimodal FHR recording during labor and delivery.

[Focus on the Odon Device™: Technical improvements, mechanical principles and progress of the clinical research program]. / Mise au point sur l'Odon Device™ : amélioration technique, fonctionnement et avancée du programme de recherche clinique.

The Odon Device™ has been described in the literature since 2013 and the World Health Organization supports its development through the Human Reproduction Program. This innovative device could be easier to use than usual instruments and could be an alternative to caesarean section during the second stage of labor, especially in countries where access to obstetric care is limited. The aim of the Odon Device™ is to position an air cuff over the fetal head, past its widest point (around the level of the fetal mouth anteriorly and the nape of the fetal neck posteriorly). Three mechanical principles favor the progression of the fetal head with the Odon Device™: partial propulsion, limited flexion and traction. Preliminary clinical studies on animals and simulators are reassuring and show that an appropriate use is no more at risk than the vaccum or forceps. A phase 1 study was conducted in Argentina and South Africa between 2011 and 2017. The reported failure rate was 29%, of which 77% was secondary to a mechanical failure of one of the components of the device. Improvements concerning the applicator, the handles and the inflatable air cuff have been made to the device. Phase II of the clinical research program began in 2018 and includes two studies in two different centers: The ASSIST Study in Bristol, England, and The BESANCON ASSIST Study, Besançon, France.

Feasibility of two-dimensional ultrasound shear wave elastography of human fetal lungs and liver: A pilot study.

PURPOSE: The first aim was to evaluate feasibility and reproducibility of 2-dimensional ultrasound (2D) shear wave elastography (SWE) of human fetal lungs and liver between 24 and 34weeks of gestation. The second aim was to model fetal lung-to-liver elastography ratio (LLE ratio) and to assess its variations according to gestational age and maternal administration of corticosteroids. MATERIAL AND METHODS: 2D-SWE examinations were prospectively performed in fetuses of women with an uncomplicated pregnancy (group 1) and fetuses of women with a threatened preterm labor requiring administration of corticosteroids (group 2). Two 2D-SWE examinations were performed at "day 0" and "day 2" in group 1; before and 24hours after a course of corticosteroid in group 2. Three operators performed 2 cycles of 3 measurements on the lung (regions A1, A2, A3) and the liver (regions IV, V, VI). Repeatability and reproducibility of measurements were calculated. The fetal LLE ratio was modeled from the most reproducible regions. RESULTS: Fifty-five women were enrolled in group 1 and 48 in group 2. For the lung, 8.6% of measurements were considered invalid and 6.9% for the liver. The most reproducible region for the lung was A3 [ICC between 0.70 (95% CI: 0.42-0.85) and 0.78 (95% CI: 0.48-0.90)] and region VI for the liver [ICC between 0.70 (95% CI: 0.40-0.85) and 0.84 (95% CI: 0.60-0.94)]. According to gestational age, a moderate positive linear correlation was found for stiffness values of A3 (R=0.56), V (R=0.46) and VI (R=0.44). LLE ratio values at "day 0" were not different between the two groups but decreased at "day 2" in group 2 (0.2; 95% CI: 0.07-0.34; P<0.001). CONCLUSION: Quantitative fetal lung and liver stiffness measurements are possible with 2D-SWE with acceptable reproducibility.

[Tamoxifen in the adjuvant setting for breast cancer: Reflexions about the risk of uterine carcinosarcoma]. / Traitement adjuvant du cancer du sein par le tamoxifène : réflexions sur le risque de carcinosarcome utérin.

A descriptive analysis of available data on reported cases of uterine carcinosarcomas associated with tamoxifen therapy is undertaken. The role of aromatase inhibitors as alternative to tamoxifen therapy in the adjuvant setting of breast cancer is discussed. The eventual implications of the presumed association of uterine carcinosarcoma and tamoxifen therapy on the choice of the therapeutic agent in the adjuvant setting of hormone-sensitive breast cancer are discussed.

[Ovarian remnant syndrome: diagnostic difficulties and management]. / Syndrome de l'ovaire rémanent: difficultés diagnostiques et stratégies thérapeutiques.

OBJECTIVES: The ovarian remnant syndrome is a rare condition after unilateral or bilateral oophorectomy, with or without a hysterectomy. This syndrome occurs when a fragment of ovarian tissue is left behind and becomes functional and cystic. The purpose of this study is to report the cases of patients treated surgically for an ovarian remnant syndrome during the last 10 years and to recall the diagnostic and therapeutic difficulties. PATIENTS AND METHODS: A retrospective, observational study was carried out between 1997 and 2006. Seven patients were treated surgically for an ovarian remnant syndrome. Perioperative data analysis (history, surgical techniques, and postoperative follow-up) was carried out. RESULTS: The mean age of the patients was 46 years (36-55). The number of previous abdominal surgical procedures ranged from 2 to 5. The syndrome appeared after a mean period of 4 years and 4 months (range 5 months-12 years) after oophorectomy. Among the 7 patients, 3 had had a previous hysterectomy. Pelvic pain was found in all cases. Gonadotropin-releasing hormones agonists were used in 1 patient without success. Aspiration was performed in 2 cases before surgical treatment. Two patients underwent a laparotomy in the first place. Laparoscopy was performed in 5 cases and laparoconversion was necessary in 1 case. Intraoperative difficulties and anatomic variations were found in all cases. Ureteral catheters were placed in 2 cases. Radiotherapy was performed in 1 patient who had a recurrent ovarian remnant. DISCUSSION AND CONCLUSION: The ovarian remnant syndrome is a rare complication. Surgery, either by laparoscopy or by laparotomy, is the recommended treatment. These operations are often difficult and associated with a high risk of complications. Histologically, remnant ovarian tissue associated with hemorragic corpus luteum cysts is the most common finding. The prevention of the ovarian remnant syndrome is based on rigorous surgical treatment during the oophorectomy so as not to leave behind ovarian tissue.

[Hysterectomies performed for presumed leiomyomas: should the fear of leiomyosarcoma make us apprehend non laparotomic surgical routes?]. / Hystérectomies pour léiomyomes présumés : la crainte du léiomyosarcome doit-elle faire appréhender la voie d'abord chirurgicale autre que laparotomique ?

OBJECTIVES: The presenting symptoms of leiomyosarcoma (LMS) are the same as those of leiomyoma. The diagnosis of LMS is usually achieved retrospectively after pathological analysis of hysterectomy specimens. The aim of surgery in uterine sarcomas being resection without tumor morcellation, LMS poses the problem of the choice of surgical route because it is more likely to occur in relatively young women. This study was undertaken to determine, firstly, the frequency of LMS in a series of hysterectomies performed for presumed leiomyomas, secondly, if there exist any particular context in which LMS should be considered and how this may modify the choice of surgical route, thirdly, to discuss about the therapeutical aspects of those cases of LMS diagnosed incidentally after uterine morcellation. PATIENTS AND METHODS: A retrospective review, from 1996 to 2005, of cases of LMS diagnosed retrospectively in patients having benefited from hysterectomy for presumed leiomyomas, at the department of Obstetrics-Gynaecology, Belfort Hospital. RESULTS: From 1996 to 2005, 1297 hysterectomies have been performed for presumed leiomyomas in our department. Patients' mean age was 48 years (34 to 77 years). Menometrorraghia was the most common symptom having motivated surgery (57%), followed by pelvic pain (31%) and the notion of a rapidly growing uterine mass (12%). The distribution of surgical route was as follows: laparotomic route, n=393 (30%); vaginal route, n=855 (66%) and laparoscopic assisted vaginal route, n=49 (4%). Pathological analysis had revealed LMS in three patients (0.23%). DISCUSSION AND CONCLUSION: LMS is usually diagnosed incidentally on hysterectomy specimen analysis. Indeed, the surgeon may find himself in a therapeutic dilemma in cases where vaginal extraction has required tumour morcellation with an increased risk of peritoneal and/or vaginal dissemination. However, given the extremely low incidence of LMS in series of hysterectomies performed for presumed leiomyomas and the lack of specific preoperative context to clearly evoke this diagnosis, the fear of leiomyosarcoma should not make us apprehend nonlaparotomic surgical routes.

[Spontaneous rupture of the unscarred uterus during labor. Case report]. / Rupture spontanée de l'utérus non cicatriciel pendant le travail. A propos d'un cas et revue de la littérature.

We report a case of spontaneous uterine rupture in a 19 year-old patient Gravida 1 para 2 with no past history of uterine surgery. The diagnosis of uterine rupture, evoked in the early post-partum in the presence of acute abdominal pain, collapsus and haemoperitoneum on ultrasonography, was confirmed by laparotomy. Treatment consisted in hysterorrhaphy. The etiopathogenesis, clinical and therapeutical aspects of spontaneous unscarred uterine ruptures are discussed throughout a literature review.

[Heterotopic ovarian hydatidiform mole. A case report]. / Môle hydatiforme hétérotopique ovarienne. A propos d'un cas.

We report a case of ruptured ovarian molar pregnancy, diagnosed in the context of haemorragic shock 19 days following evacuation of an intrauterine hydatiform mole. To our knowledge, this is the first reported case of heterotopic molar pregnancy.

[Ultrasound in the diagnosis of fetal head engagement. A preliminary French prospective study]. / Diagnostic échographique d'engagement de la présentation foetale. A propos d'une série prospective préliminaire française.

OBJECTIVE: The subjectivity and inter- and intra-observer variability of transvaginal (TV) digital examination in the diagnosis of fetal head engagement set a real problem in the strategic choice of the mode of delivery. We conducted a preliminary study on the feasibility of using ultrasound in the diagnosis of fetal head engagement during labour. MATERIAL AND METHOD: From 3rd January to 20th February 2007, a prospective monocentered study was set up by comparing the fetal head position in the pelvic cavity obtained by TV digital examination with the ultrasound measurement of the perineum-fetal head distance. Sixty-five measurements were obtained from 45 patients (single pregnancies, cephalic presentations), during labour and/or at complete cervical dilatation, by a single operator. RESULTS: Whenever the perineum-fetal head distance was greater than 60 mm, the fetal head was not engaged in the pelvic cavity, with a specificity of 89% and a negative predictive value of 94.1%. However, if the distance is less or equal to 60 mm, the fetal head was engaged with a sensitivity of 97.8% and a positive predictive value of 95.6%. It was even possible to define the fetal head station in the cavity as the distances are now known: high cavity : 50 mm, mid cavity : 38 mm, low cavity : 20 mm. CONCLUSION: This technique based on a single distance measurement is not difficult and the reference point is easily localized. An abdominal probe is sufficient, making the diffusion of this method quite easy. With its excellent negative predictive value, transperineal ultrasound would allow obstetricians avoid difficult vaginal extractions, localize correctly the fetal position in the cavity and obtain the exact fetal head orientation, even in case of scalp blood humps. The feasibility and relevance of this technique must be confirmed by larger studies.

[Anatomical and histological study of the uterosacral ligament: practical surgical consequences]. / Evaluation anatomique et histologique du ligament utérosacré : conséquences pratiques en chirurgie.

OBJECTIVE: To define the vascular and nervous relationships of the uterosacral ligament and to analyze histologically its content for a better description of this structure. MATERIALS AND METHODS: Three fresh fetal cadavers, three embalmed and one fresh adult cadavers were used. The anatomical relationships of the uterosacral ligament were studied by dissecting one fresh fetal pelvis and two embalmed adult pelves. By histological and immunohistological examinations, eight biopsies of the cervical origin of the complexe ligamentaire utérosacral (USLC) were analyzed: four from fresh fetuses, two from a fresh adult cadaver and two from an embalmed adult cadaver. The specimens were stained with haematoxylin eosin safran (HES) coloration, with antinervous cell specific antibodies (PS100) and with antismooth muscle actine antibodies (to visualize vessel walls) before examination under optical microscope. RESULTS: On anatomic examination, the uterosacral ligament was covered by the visceral pelvic fascia. By removing this fascia, the uterosacral ligament appeared to be a condensation of nervous fibers made up of hypogastric and pelvic nerves forming the hypogastric plexus. Histologically, the uterosacral ligament contained connective tissue, nervous fibers, sympathetic nodes, vessels and fatty tissue. No structured ligamentous organization was identified. CONCLUSION: The uterosacral "ligament" is in fact a "ligament complex" integrating connective tissue as well as nervous and vascular elements. Radical wide excisions of the USLC during cancer or endometriosis surgery and uterosacral suspension during pelvic floor reconstructive surgery should be performed with caution in order to preserve pelvic innervation.

[Pure rhabdomyosarcoma of the uterine corpus: an exceptional tumor in postmenopausal women. Report on two cases]. / Rhabdomyosarcome pur du corps utérin: une tumeur exceptionnelle chez la femme ménopausée. A propos de deux cas.

Rhabdomyosarcoma (RMS) of the uterine corpus is rare in adult females. This tumor can be encountered in two distinct histopathological contexts: usually as a component of a malignant mixed mullerian tumor and exceptionally as a pure heterologous sarcoma. We report two cases of pure RMS of the uterine corpus occurring in postmenopausal women. The two patients suffered from vaginal bleeding and preoperative diagnosis was achieved in both cases. Both patients benefited from exploratory laparotomy, total hysterectomy and bilateral salpingo-oophorectomy. Both of them were free from the disease 15 months and 1 year respectively, after initial surgery. These two observations are worthy of publication because pure RMS of the uterine corpus is exceptional in postmenopausal women.

[Uterine carcinosarcomas associated with tamoxifen therapy. Report of two cases and review of the literature]. / Carcinosarcomes utérins associés au traitement par le tamoxifène. A propos de deux cas et revue de la littérature.

Carcinosarcomas are rare uterine cancers and carry poor prognosis. Although these tumours usually arise de novo, some cases developed under tamoxifen therapy have been reported. We report two more cases of uterine carcinosarcoma occurring in two postmenopausal patients benefiting from tamoxifen therapy as adjuvant treatment of breast cancer. A review of the literature is undertaken.

[Expected impact of a quadrivalent HPV vaccine in France]. / Modélisation de l'impact de la vaccination HPV quadrivalente en France.

OBJECTIVE: To assess the expected impact in France of a quadrivalent HPV 6/11/16/18 vaccine on the occurrence of genital HPV-induced lesions in women. METHODS: A Markov model based on a quadrivalent vaccination of 14-year-old girls as recommended in France was performed to assess the number of subjects needed to vaccinate to prevent an HPV-related event during their lifetime and the expected annual number of cases which could be prevented by vaccination. This model was based on prevalence data reported in four large French studies (EDiTH I-IV) reporting an HPV 6/11/16/18 prevalence of 82% (95% CI: 78.5-85.1) in cervical cancer (CC), 64% (95% CI: 59.7-68.1) in CIN2/3, 34% (95% CI: 28.9-38.1) in low-grade squamous intraepithelial lesions (LSIL) and 83% (95% CI 77.6-87.8) in female external acuminata condylomata (EAC) cases. RESULTS: Using a theoretical vaccine efficacy of 100%, 130 young women need to be vaccinated to prevent a case of CC, 17 for a case of CIN2/3 and 13 for a case of EAC. Immunization of 80% of 14-year-old girls could prevent 2495 CC (72%), 17,985 CIN2/3 (54%), 8004 CIN1 (27%), and 22,531 EAC female cases (65%) in France annually. CONCLUSION: A good adhesion to the preferentially recommended HPV quadrivalent vaccination would thus substantially reduce the burden of female genital lesions in France.