[Treatment of fibroadenomas by high-intensity focused ultrasound: What results? Review]. / Prise en charge des fibroadénomes par échothérapie : quels résultats ? Revue de la littérature.

OBJECTIVES: To assess benefits and adverse effects of high-intensity focused ultrasound (HIFU) as a treatment for fibroadenomas (FA). METHODS: To ensure the quality of the methodology, the PRISMA criteria have been met at all stages of the development of this review. We searched MEDLINE from inception to May 2017, without any restriction. KEYWORDS: fibroadenoma, focused ultrasound, HIFU and fibroadenomata were used. Data were extracted and the results were compared. Two reviewers independently extracted study characteristics and outcome data. RESULTS: Of 20 identified abstracts, 5 primary studies met inclusion criteria. All studies reported a reduction in the size of FA treated with an increasing effect over time. Pain tolerance was most often assessed as moderate. Adverse effects of HIFU were not severe in all studies. CONCLUSIONS: HIFU appears to be a promising technique in the treatment of fibroadenomas with a volume decrease of approximately 50 % at 6 months of therapy.

[Stained amniotic fluid and meconium amniotic fluid: Should they change our obstetric management ?] / Liquide amniotique teinté ou méconial : doivent-ils modifier notre prise en charge obstétricale ?

OBJECTIVES: To assess if a stained or meconial amniotic fluid during labor is correlated with a greater risk of neonatal metabolic acidosis. METHODS: In a retrospective case-control study carried out in a level 3 maternity from 1st of January to 31st of December 2014, all patients who delivered a singleton eutrophic fetus in cephalic presentation after 37WG and with a stained or meconial amniotic fluid during labor were included. Obstetrical and neonatal outcomes were compared according to the amniotic fluid's color. RESULTS: At all, 302 patients in the group « Abnormal amniotic fluid¼ (198 patients with stained amniotic fluid, 104 with meconial amniotic fluid) vs. 302 in the group « clear amniotic fluid¼ were included. No significant difference on the rate of neonatal severe acidosis between the two groups were found. Fetal heart rhythm abnormalities were more frequent in case of meconial amniotic fluid (11,3% vs. 31,7%, P<0,0001). The composite endpoint, defined by the association of umbilical arterial pH <7,0±base excess ≥12mmol/L±Apgar score at 5min <7, was more frequent in case of meconial amniotic fluid (4,0% vs. 12,5%, P=0,0018). CONCLUSION: The occurrence of severe neonatal metabolic acidosis was not more frequent in case of stained or meconial amniotic fluid, but with an increase in the use of fetal scalp pH and cesaerian deliveries when the fluid was meconial.

[Vaginal delivery in case of breech presentation: Impact of a service's incentive]. / Accouchement par voie basse des fœtus en présentation du siège : impact d'une politique incitative de service.

OBJECTIVES: The mode of delivery in podalic presentation was controvertible since the 2000s, which led to a high rate of caesarean section. In our center, the delivery mode was physician-dependent before 2012. Since 2012, the management of podalic presentations was supervised by a protocol allowing a collegiate management to promote vaginal delivery. The objective of this study was to evaluate the impact of this policy on neonatal outcomes and obstetric practices. METHODS: A retrospective study was carried out with comparison of 135 patients who gave birth in 2008 with 110 patients who gave birth in 2014, before and after the implementation of the protocol in a type III university maternity hospital. Two hundred and forty-five singleton pregnancies with podalic presentation and a gestational age more than 32 weeks of gestation were included in this study. The rate of vaginal delivery trial, the evolution of clinical practices and neonatal outcomes were respectively compared. RESULTS: One hundred and twenty-six patients who gave birth in 2008 were compared to the 105 one of 2014. The rate of successful vaginal birth trial increased from 32.7% (n=16/49) to 63.8% (n=37/58) (P>0.05) between the two periods, this induced a decrease of 16.3% of planned caesarean sections rate [(77/126) versus (47/105) (P<0.02)] and of 6.2% of emergency caesarean sections rate [(33/126) versus (21/105) (P<0.001)]. No significant difference was observed regarding neonatal outcomes. CONCLUSIONS: This work shows that it is possible to limit the rate of planned and emergency caesarean sections because of an incentive policy of service without impact on neonatal morbidity and mortality.

Immobilization versus immediate mobilization after intrauterine insemination: A systematic review and meta-analysis.

INTRODUCTION: The objective of this systematic review and meta-analysis was to investigate a possible association between immobilization and pregnancy rate in patients undergoing intrauterine insemination. MATERIAL AND METHODS: To ensure the quality of the methodology, the PRISMA criteria were met at all stages of the development of this meta-analysis. We searched the Cochrane Library, EMBASE, PubMed MEDLINE, ScienceDirect and reference lists of eligible studies from inception to March 2017, without any restriction. We also interviewed the ClinicalTrials.gov database for unpublished articles. Finally, we sought potentially eligible studies in meeting abstracts. Two reviewers independently extracted study characteristics and outcome data. Estimates were pooled using random effects models and sensitivity analyses. We selected studies that compared bed rest to immediate mobilization after intrauterine insemination. The primary outcome was the ongoing pregnancy rate per couple. RESULTS: Of 176 identified abstracts, four primary studies, all of them randomized controlled trials, met the inclusion criteria, including 1361 couples. The overall relative risk of ongoing pregnancy rate in bed rest versus immediate immobilization was 1.67 95% CI [0.86; 3.22]. The overall relative risk of the live birth rate was 1.11 95% CI [0.56; 2.20]. CONCLUSION: This systematic review and meta-analysis was not able to demonstrate that bed rest after intrauterine insemination effectively increases in pregnancy rate. For everyday practice, no specific strategy, bed rest or immediate mobilization, can be recommended at this time.

[Endometriosis and miscarriage: Systematic review]. / Endométriose et fausse couche spontanée. Méta-analyse et revue systématique de la littérature.

OBJECTIVES: In spontaneous pregnancies, endometriosis appears to be a risk factor of miscarriage. The aim of this study is to evaluate the association between endometriosis and miscarriage in spontaneous pregnancy. METHODS: We searched the Cochrane Library, Medline of eligible studies from inception to December 2016, without any restriction. We selected studies that compared endometriosis-affected pregnant women to disease-free pregnant women. To ensure the quality of the methodology, the PRISMA criteria have been met at all stages of the development of this meta-analysis. The primary adverse pregnancy outcomes studied was miscarriage. Three reviewers independently extracted the studies' characteristics and outcome data. RESULTS: Of 225 identified abstracts, 4 primary studies met our inclusion criteria by comparing spontaneous pregnant patients with endometriosis to disease-free women. Miscarriage rate was higher in the endometriosis group (OR 1.77 [CI 95% 1.13-2.78]). CONCLUSION: In spontaneous pregnancies, endometriosis appears to be a risk factor of miscarriages (almost 80% increased risk). Further prospective studies are needed to confirm these results in order to establish the exact impact of endometriosis on spontaneous pregnancy course.

[Training of residents in amniocentesis: Effectiveness of a craft simulator]. / Formation des internes à l'amniocentèse : intérêt d'un simulateur artisanal.

OBJECTIVE: This prospective study aims to assess a low fidelity simulation device for learning amniocentesis to gynecology-obstetrics residents. METHODS: From 2013 to 2016, gynecology-obstetrics residents of all levels, from the maternity of Nancy hospital, which have already performed amniocentesis or not, participated in amniocentesis training on an artisanal simulator. Residents were evaluated on the amniocentesis simulator according to seven quality criteria. Three scores were assigned: the first (S1) at the beginning of the first training session, the second (S2) at the end of the first session after individualized personal training and the third (S3) two months after the first simulation. RESULTS: A total of 40 residents were included. The scores obtained by the residents were 3.2±1.8 points for S1 versus 6.2±0.9 points for S2 (P<0.001). Two months after, the residents' performances remained significantly improved compared to the initial assessment with a score (S3) of 5.8±1.3 points at S3 (P<0.001). CONCLUSION: Amniocentesis craft simulator is effective for performance improvement and allows a persistence of acquired skills two months after the training. At the time of "never the first time on the patient", it should be part of the curriculum of gynecology-obstetrics residents in order to guarantee patients quality care and optimum safety.

[Does customized weight curves improve prenatal diagnosis of fetuses small for gestational age in a high-risk population?] / L'utilisation des courbes de poids personnalisées en anténatal améliore-t-elle le diagnostic des fœtus petits pour l'âge gestationnel à haut risque de morbidité néonatale ?

OBJECTIVES: To assess the accuracy of customized growth charts for the ultrasound antenatal diagnostic of fetus small for gestational age in a high-risk population of preterm. METHODS: All premature infants born in a French university maternity center for a year and classified as small for gestational age at birth by using customized growth charts developed by Ego et al. were included in this retrospective study. At the ultrasound performed closest to the term, customized growth charts and population growth curves were compared for the antenatal diagnosis of a premature infants group classified small for gestational age in post-natal by customized growth charts and more at risk of perinatal complications. RESULTS: Sixty-seven newborns were included in the study. Fifty-one (76.1%) were secondarily classified as small for gestational age although they were eutrophic on the basis of population growth curves and 16 (23.9%) were small for gestational age on both curves. The average time between the last ultrasound and birth was 2.2 weeks. On the threshold of the tenth percentile, the sensitivities of customized growth charts and curves in population were not significantly different (29.85% versus 41.79% P=0.05) for antenatal detection of fetus small for gestational age. CONCLUSION: In our study, the use of customized growth charts does not improve the antenatal detection of most at-risk children.

[Emergency caesarean sections in primary care maternity: Impact of a color code]. / Césariennes en urgence en maternité de type 1 : impact de l'utilisation d'un code couleur.

OBJECTIVES: To estimate the impact of the introduction of color code on the decision to birth-delay (DDB) used to prioritize the emergency caesarean sections in a primary care maternity. MATERIALS AND METHODS: All patients who had an emergency caesarean section, for a single fetus, were included. The obstetrician, the anesthesiologist and the nurse of operating theatre were not on call in the maternity in nighttime. The study was divided into phase I corresponding to the period before the introduction of the color code and phase II, the period after introduction of the color code. The DDB was studied for each phase and for each color code in phase II, and depending on the day or night period. RESULTS: Two hundred and seventy-six patients were included. In phase I, the average DDB was 54minutes against 44minutes in phase II (P=0.0003). The average time between the decision and caesarean birth for the green code was 62minutes, 42minutes for orange code, 22minutes for red code (P<0.001). There was no action on the time of caesarean decision on the choice of color code. There was no time difference between daytime and nighttime either in phases I or II. CONCLUSION: The introduction of color code for emergency caesarean sections was a benefit in reducing the DDB. There was no observed difference between day or night periods regarding DDB or color codes.

[Placental 3D Doppler angiography: current and upcoming applications]. / Angiographie Doppler 3D placentaire : applications actuelles et à venir.

The placental dysfunction, which seems to be caused by a defect of trophoblastic invasion and impaired uterine vascular remodeling since the first trimester, is responsible in a non-exclusive way for the chronic placental hypoxia, resulting secondarily in the intra-uterine growth restriction (IUGR) and/or pre-eclampsia (PE). The quality of utero-placental vasculature is essential for a proper fetal development and a successful progress of pregnancy. However, the in vivo assessment of placental vascularization with non-invasive methods is complicated by the small size of placental terminal vessel and its complex architecture. Moreover, imaging with contrast agent is not recommended to pregnant women. Until recently, the fetal and maternal vascularization could only be evaluated through pulse Doppler of uterine arteries during pregnancy, which has little clinical value for utero-placental vascularization defects assessment. Recently, a non-invasive study, without use of contrast agent for vasculature evaluation of an organ of interest has become possible by the development of 3D Doppler angiography technique. The objective of this review was to make an inventory of its current and future applications for utero-placental vasculature quantification. The main findings of the literature on the assessment of utero-placental vascularization in physiological situation and major placental vascular dysfunction pathologies such as PE and IUGR were widely discussed.

Impact on obstetric outcome of third-trimester screening for small-for-gestational-age fetuses.

OBJECTIVES: To evaluate the performance of screening for small-for-gestational-age (SGA) fetuses by ultrasound biometry at 30-35 weeks' gestation, and to determine the impact of screening on obstetric and neonatal outcomes. METHODS: For this prospective cohort study, pregnant women were recruited from two French university maternity centers between 2003 and 2006. Performance measures of third-trimester biometry for the prediction of SGA, defined as estimated fetal weight < 10(th) centile, were analyzed. Obstetric outcomes and neonatal health status were compared, first, between SGA neonates diagnosed correctly at ultrasound examination (true positive (TP); n = 45) and SGA neonates that went undiagnosed (false negative (FN); n = 110) and, second, between non-SGA neonates identified as normal at ultrasound examination (true negative (TN); n = 1641) and non-SGA neonates diagnosed incorrectly as SGA (false positive (FP); n = 101). RESULTS: In the prediction of SGA, third-trimester ultrasound had a sensitivity of 29.0% (95% CI, 22.5-36.6%) and specificity of 94.2% (95% CI, 93.0-95.2%). Positive and negative predictive values were 30.8% (95% CI, 23.9-38.7%) and 93.7% (95% CI, 92.5-94.8%), respectively. One hundred and ten SGA neonates went undiagnosed at ultrasound. Compared to the TN neonates considered as of normal weight at ultrasound, planned preterm delivery (before 37 weeks) and elective Cesarean section for a fetal growth indication were 2.4 (P = 0.01) and 2.85 (P = 0.003) times more likely to occur, respectively, in the FP group of non-SGA neonates, diagnosed incorrectly as SGA during the antenatal period. There was no statistically significant difference in 5-min Apgar score < 7, cord blood pH at birth < 7.15 and need for neonatal resuscitation between the two subgroups (TN vs FP and TP vs FN). CONCLUSIONS: The performance of third-trimester ultrasound screening for SGA seems poor, as it misses the diagnosis of a large number of SGA neonates. The consequences of routine screening for SGA in a low-risk population may lead to unnecessary planned preterm deliveries and elective Cesarean sections in FP pregnancies, without improved neonatal outcome in the FN pregnancies.

[Type 2 diabetes and pregnancy: epidemiology and obstetrical consequences. A 97 women continuous series]. / Diabète de type 2 et grossesse: épidémiologie et conséquences obstétricales. Étude sur une série continue de 97 femmes enceintes.

OBJECTIVES: To update the epidemiologic data of pregnant women with type 2 diabetes and to assess obstetrical outcomes. PATIENTS AND METHODS: The pregnant women with type 2 diabetes who delivered between 2002 and 2010 were systematically involved in an observational study. Maternal and fetal outcomes were reviewed, as well as the potential impact of preconceptional management. The presented data were compared with those from the 2010 French perinatal study. RESULTS: A rise in the incidence of type 2 diabetes was observed during the study period (from 0.19% to 0.35% between 2002 and 2010). Women with diabetes (n=97) were older and had a higher BMI than the general population (>35years: 49% vs 19%, P<0.00001, BMI>25: 86% vs 27.2, P<0.00001). The delivery mode was, for half of these women with diabetes, a C-section. Pregnancy was scheduled in only 4% of cases. Compared to the general population, prematurity rate was multiplied by 6 (28.7% vs 4.7%, P<0.0001) and the malformation rate by 3.2 (7.22% vs 2.2%, P<0.00001). CONCLUSION: Obstetrical complications were more frequent than in the general population. Preconception care was almost inexistent, despite its potential benefits for the mother and child.

Type 2 diabetes in pregnancy: Rates of fetal malformations and level of preconception care.

An observational study was performed to assess the prevalence of fetal malformations and the level of preconception care in women with Type 2 diabetes. Pregnant women with Type 2 diabetes who delivered between 2002 and 2010 were recruited to the study. The fetal malformation rate of patients with Type 2 diabetes was compared with the rate in a control group; the general population. The malformation rate was 3.2 (7.2-2.2%; p < 0.0001) greater in the diabetes group. In addition, only 4% of women with Type 2 diabetes had preconception care. Despite evidence of benefits in women receiving preconception care, patients with Type 2 diabetes do not attend for preconception counselling and the malformation rate is high.