Twin vaginal delivery: To maintain skill - simulation is required.

BACKGROUND: Although most societies of obstetrics advocate vaginal delivery of twins, there has been a steady rise in the rate of twin cesarean sections. We risk perhaps losing in a single generation our obstetrical learning and skills because of medicolegal and emotionally charged issues. METHODS: We have therefore designed a realistic as possible simulation model of second twin delivery and tested it on residents in obstetrics. FINDINGS: Between two trials, we noted a significant improvement in the time required for internal podalic version and breech extraction. We also observed a significant improvement in the confidence score between the two trials. INTERPRETATION: We have designed a simulation device that improves obstetrical skills for second twin delivery and which we hope will participate in the comeback of vaginal delivery for this indication and contribute to the fight against the dangerous trend of rising rates of cesarean delivery for twins. Our model completely fits the paradigm of simulation in medical pedagogy.

Premature progesterone rise on day of hCG negatively correlated with live birth rate in IVF cycles: An analysis of 1022 cycles.

OBJECTIVE: To investigate the relationship between serum P levels on the day of hCG administration and pregnancy outcomes in patients undergoing IVF. DESIGN: Retrospective study. SETTING: Teaching hospital. PATIENTS: A total of 1022 IVF-ICSI cycles, frozen embryo transfer excluded. INTERVENTION(S): Patients-all types of responder - underwent IVF with agonist or antagonist protocols. Clinical outcomes of IVF were analyzed according to plasma P levels. MAIN OUTCOME MEASURE(S): Ongoing pregnancy rates. RESULTS: We proposed a serum P level of 1.57ng/ml on day of hCG as a threshold for all types of responders and all protocols combined. Ongoing implantation rates were not affected by elevated progesterone. Live birth rate was inversely associated with serum P levels on day of hCG and more miscarriages were associated with P>1.57ng/ml. We have not found the progesterone>1.57ng/ml on the day of hCG as a prognostic factor for pregnancy. CONCLUSION(S): Elevated P level on the day of hCG administration negatively influence live birth rate and is correlated to an increase of miscarriage. The detrimental effect of P elevation on pregnancy seems not to be related substantially to endometrium receptivity. Thus, despite a comparable clinical pregnancy rate and an initial implantation rate, we demonstrate more spontaneous abortion and it would seem that the effect of progesterone is later.

Pregnancy impact on uterosacral ligament and pelvic muscles using a 3D numerical and finite element model: preliminary results.

INTRODUCTION AND HYPOTHESIS: We studied the geometry of and changes in structures that play an important role in stabilizing the pelvic system during pregnancy using a numerical system at different gestational ages and postpartum. METHODS: We developed a parturient numerical model to assess pelvic structures at different gestational stages (16, 32, and 38 weeks) and postpartum (2 months and 1 year) using magnetic resonance imaging (MRI). Organs, muscles, and ligaments were segmented to generate a 3D model of the pelvis. We studied changes in the length of uterosacral ligaments (USL) and thickness of the puborectal portion of the levator ani muscle (LAM) during and after pregnancy. We used this model to perform finite element (FE) simulation and analyze deformations of these structures under stress from the increase in uterine weight. RESULTS: Analysis reveals an increase in the length of US ligaments at 16, 32, and 38 weeks. Two months after delivery, it decreases without returning to the length at 16 weeks of pregnancy. Similar changes were observed for the puborectal portion of the LAM. Variations observed in these structures are not equivalent to other anatomical structures of pelvic suspension. FE simulation with increased uterus weight does not lead to those findings. CONCLUSION: This analysis brings new elements and a new focus for discussion relating to changes in pelvic balance of parturient women that are not simply linked to the increase in uterine volume.