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.

[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.

[Obstetrical anal sphincter injuries and vacuum-assisted delivery at term in primiparas]. / Lésions obstétricales du sphincter de l'anus et ventouse obstétricale chez des primipares à terme.

OBJECTIVES: Operative Vaginal Delivery (OVD) is subject to a risk of perineal tears especially of Obstetrical Anal Sphincter Injuries (OASIS) that are associated with more complications and impaired quality of life. The main objective of this study was to compare the rate of OASIS in primipara at term with fetus in cephalic presentation depending on the type of delivery: OVD using vacuum extractor and spontaneous delivery. METHODS: This is a single-center retrospective study between 01/01/2010 and 12/31/2014 including all primipara who delivered vaginally at term, a single and living fetus in cephalic presentation. Perineal lesions were classified according to the WHO classification. The primary endpoint was the proportion of OASIS. RESULTS: 3552 patients were included: 2496 spontaneous deliveries (SD) and 1056 OVD (29.72 %). There were twenty sphincter tears (0.56 %): 7 in SD group (0.28 %) and 13 in OVD (1.23 %), P<0.0001, OR=5.10 [2.00; 12.99]. Other risk factors associated with OASIS in univariable analysis were: maternal age (≥30 years), duration of expulsive efforts (≥20min) and a birth weight≥4000g. CONCLUSION: In these patients, the risk of OASIS in case of AI increases by a factor of 5;10. The high rate of AI in these patients exposes them to a real risk of OASIS. However, the proportion of OASIS in this group remains lower than those reported in the literature and is barely higher than the national overall rate, despite a very restrictive policy of the use of episiotomy.

[Impact of the external cephalic version on the obstetrical prognosis in a team with a high success rate of vaginal delivery in breech presentation]. / Impact de la version par manœuvre externe sur le pronostic obstétrical dans une équipe à fort taux de réussite de l'accouchement vaginal du siège.

OBJECTIVES: To analyse the impact of external cephalic version (ECV) on caesarean section rate in a team with a high success rate of vaginal delivery in breech presentation. MATERIALS AND METHODS: Retrospective monocentric study including 298 patients with a breech presentations between 33 and 35weeks of amenorrhea followed at our university hospital and delivered after 35weeks, between 1st January 2011 and 31st December 2013. Patients were divided into 2 groups: planned ECV (n=216 patients) versus no planned ECV (n=57 patients). RESULTS: Our rate of successful vaginal breech delivery over the period of the study was 61.1%. We performed 165 ECV, with a 21.8% success rate. The average term of the attempt of ECV was 36.7weeks of amenorrhea. The caesarean section rate was not significantly different in the planned ECV group, even after adjustment on age, parity and previous caesarean delivery (adjusted OR=1.67 [0.77-3.61]). Attempt of ECV did not reduce the number of breech presentation at delivery (61.1% versus 61.4% [P=0.55]). CONCLUSION: Planned ECV in our center with a high level of breech vaginal delivery did not significantly impact our cesarean section rate.

[Can we decrease cesarean rate at a university hospital treating high risk pregnancies?]. / Peut-on diminuer le taux de césarienne dans un CHU de niveau III ?

OBJECTIVE: To determine which clinical practice changes were responsible for a decrease in cesarean rate from 19.2% in 2003 to 15.5% in 2012 at our university hospital treating high risk pregnancies, while verifying the absence of any increase in neonatal morbidity and death. MATERIALS AND METHODS: A descriptive retrospective study was undertaken at our labour ward including all patients delivering in 2003 and in 2012. Maternal, obstetrical and neonatal characteristics of the two populations were compared. Cesarean rates were analysed following : (1) Robson classification, (2) some maternal and obstetrical characteristics, and (3) indications for cesarean. RESULTS: Mean age, BMI and rate of scarred uterus significantly increased in 2012. The two populations remained comparable in terms of other criteria studied. The main cause responsible for decrease in cesarean rate was breech presentations (p<0.05). Furthermore, significantly less cesareans were performed after labour induction (p=0.04). We also significantly decreased our elective cesarean rate by more than 3% without increasing cesarean sections during labour, showing a rise in successful vaginal delivery trials. The impact of in utero transfers on the global rate of cesarean is highly significant since the latter has been divided by half in 10 years in this population considered to be of high risk for cesareans. DISCUSSION: These significant decreases reflect our experience in allowing vaginal deliveries in breech presentations, and also a better selection of patients for labour induction. Furthermore, it should be noted that increasing vaginal delivery trials in various obstetrical situations participated in this decrease. We clearly found that some indications for elective cesarean can be avoided, such as multiple pregnancies and scarred uterus, thus showing the importance of restricting the first indication for cesarean. Finally, the decrease in cesarean rate had no negative effect on neonatal outcome. CONCLUSION: Decreasing cesarean rate is possible in a university hospital treating high risk pregnancies. It requires daily obstetrical case by case critical analysis, allowing wide acceptance of vaginal delivery trials, and continuously evaluating clinical practices.

[Obstetrical prognosis of breech presentation admitted in advanced first stage of labour]. / Pronostic obstétrical de la présentation du siège en cas d'admission en travail avancé.

AIM: Fear of dystocia during breech delivery brings obstetrical teams to choose elective caesarean sections. However, some patients with breech presentations will be in labour before the date scheduled and caesarean delivery during labour increases maternal morbidity. Therefore, this situation raises the question about the relevance of labour trial for breech presentations admitted in labour. Our study aimed to determine the obstetrical prognosis of breech presentations on admission in the labour ward following their degree of cervical dilation. MATERIALS AND METHODS: We conducted an observational retrospective study on 213 single breech presentations at ≥37 gestational weeks that delivered at our level 3 labour ward between1st January 2007 and 30th July 2013. Maternal, obstetrical and neonatal factors were analyzed. RESULTS: The total caesarean rate during labour was 23.4% and significantly less important (P<0.05) in patients with cervical dilation ≥5cm on admission (14% vs. 27%). Apgar scores, cordonal arterial pH and lactates, rate of transfer to intensive care were not significantly different between the two groups. CONCLUSION: In our study, any patient with a breech presentation at an advanced stage of labour on admission is of very good prognosis, although statistical power is insufficient.

[Obstetrical prognosis of breech presentations with premature rupture of membranes at term]. / Pronostic obstétrical des présentations podaliques à terme en cas de rupture des membranes avant travail.

OBJECTIVES: Breech delivery is still a controversial situation in literature. Added complexity exists when breech presentations are associated with premature rupture of membranes (PROM) as such cases are conventionally excluded in studies dealing with PROM and are often indications for elective caesarean section. Thus, the objective of this study was to evaluate the obstetrical prognosis of breech presentations after PROM at term. MATERIALS AND METHODS: We conducted a retrospective observational study at the Besançon University Medical Centre, between 1(st) January 2008 and 31(th) December 2012. Two groups of patients with breech presentations at term were constituted according to the existence or not of a PROM. The primary endpoint was the delivery mode: caesarean section or vaginal. Other endpoints were maternal characteristics, type of onset of labour and neonatal criterias. RESULTS: Two hundred and nine patients were included. In the control group, 67.9 % of vaginal deliveries occurred versus 60 % in the group with PROM (P=0.25). No difference was found on neonatal criterias such as pH, lactate and the Apgar score at 5 minutes. CONCLUSION: PROM at term in breech presentation doesn't seem to change the obstetrical prognosis and should therefore not be a systematic indication for elective caesarean section.

[Second twin delivery in cephalic presentation. Apropos of a series of 127 patients]. / L'accouchement du deuxième jumeau en présentation céphalique. À propos d'une série de 127 patientes.

INTRODUCTION: In 2009, the French National College of Obstetricians and Gynaecologists (CNGOF) clinical practice guidelines encouraged the active management of the second twin (T2) in high and mobile cephalic presentation (CP) by performing systematic internal maneuvers. In our department, this type of management is less frequent as whenever T2 is not delivered spontaneously after a short time interval, an instrumental extraction is realized. MATERIALS AND METHODS: We analyzed our practice for 5 years upon 127 twin pregnancies with a trial of vaginal delivery for T2 in CP. We compared the results following different modes of delivery which are: spontaneous delivery, instrumental extraction, and total breech extraction after manual internal version. RESULTS: No significant difference was found among the 3 groups in terms of maternal, fetal and neonatal well-being. Moreover, instrumental delivery was feasible, with a mean time interval for delivery between the 2 twins<15 minutes, even when performed by an obstetrician on training. CONCLUSION: The aim of our study was to evaluate our practice on T2 in CP, because this event can be quite tricky, thus discouraging less experienced obstetricians towards this practice and resulting in an increase in caesarean sections for T2. Instrumental delivery should be considered a possible option for any T2 in CP so as to ensure the continued existence of vaginal births for twin pregnancies.

[Active management of the second twin for vaginal delivery: ruptured versus intact membranes. Apropos a series of 182 patients]. / Accouchement manœuvrier du deuxième jumeau: membranes rompues versus membranes intactes. À propos d'une série de 182 patientes.

AIM: The vaginal management of the second twin (T2) differs throughout our country. In 2009, the French National College of Gynecologists and Obstetricians released practice guidelines, with low-level evidence, encouraging active management of the second twin, using maneuvers with intact membrane. PATIENTS AND METHODS: In our level III labour ward, these maneuvers are systematically performed when the second twin is in a breech or transverse presentation and after ruptured membranes in most cases. We studied 182 twin pregnancies with active management of the T2 at more than 28 weeks of gestation, from 1st January 1996 to 31st December 2010, by comparing the membrane status during delivery of T2. RESULTS: The results did not show any significant differences between the two groups of patients concerning the neonatal or maternal results. The technique is feasible, even by residents. Our results show that total breech extraction of the second twin with ruptured membranes is feasible, which allows for reappraisal of the national recommendations. CONCLUSION: In our practice, it is possible to actively deliver the T2 with ruptured membranes without altering maternal and fetal prognosis and thus simplifying learning for young doctors.

[Fetal heart rate patterns of breech presentations during expulsion. A comparative study with cephalic presentations]. / L'analyse du rythme cardiaque fœtal au cours de l'expulsion des présentations podaliques. Analyse comparative dans une maternité de niveau III.

INTRODUCTION: Expulsion upon vaginal delivery is a period at risk for the foetus, especially in case of breech presentation. In fact, monitoring the fetal well-being is complex in this phase. The correct interpretation of fetal heart rate (FHR) during expulsion, using Melchior's classification, is important because it helps screen for fetal acidosis. The aim of this study was to determine if it was possible to tolerate an abnormal FHR during expulsion of breech presentations. MATERIAL AND METHODS: A retrospective study was conducted to compare FHR during expulsion and neonatal results between breech and cephalic presentations at Besançon's university hospital. RESULTS: We collected data from 118 breech presentations and 236 cephalic presentations. Melchior's FHR classification types were significantly different between breech and cephalic presentations with a majority of type 1. Neonatal results were significantly less favorable for breech presentations, but without any increase in mortality and in severe morbidity. DISCUSSION AND CONCLUSION: Melchior's expulsion FHR classification seems to be applicable for breech presentations with a different distribution of FHR types compared to cephalic presentations. Following the results of this study, it seems to be possible to tolerate an abnormal FHR during expulsion of breech presentation, so far as is reasonable.

[Breech delivery and scarred uterus: a special obstetrical situation?]. / Accouchement du siège et utérus cicatriciel : une situation obstétricale particulière ?

AIM: The management of breech delivery in patients with a history of caesarean section is a special situation requiring to anticipate the delivery route if the usual prerequisites for the acceptance of vaginal breech delivery are present. Does a history of caesarean section imply a systematic refusal of vaginal delivery in case of breech presentation or an alternative to an iterative caesarean still exists? MATERIALS AND METHODS: An observational study was undertaken in our level III labour ward from January 1st 1994 to June 30th 2010 on 91 patients with a history of caesarean section and who had breech deliveries of singleton pregnancies at more than 35weeks of amenorrhea. Maternal, obstetrical and neonatal parameters were collected. Patients were divided into three groups: vaginal delivery, caesarean section after an accepted vaginal birth trial, elective caesarean section. RESULTS: The rate of an accepted vaginal birth trial was 24.2% (22 cases) with a 36.4% (eight patients) success rate in this group. There were two (2.9%) unplanned vaginal births. Fourteen patients (15.4%) had caesarian sections after an accepted vaginal birth trial: ten before labour and four during labour for dynamic dystocia or non-reassuring fetal status. Most caesarean sections before labour in case of an accepted vaginal birth trial were justified by an intercurrent factor requiring induction of labour. Neonatal factors did not show any increased morbidity or mortality in the vaginal birth group. No Apgar score was found to be less than or equal to 7 at 5minutes. Umbilical arterial pH and lactate measured as from 2001 were similar between the groups. Indeed, the mean arterial pH after vaginal birth was 7.19 as compared to 7.22 in case of caesarean section after an accepted vaginal birth trial, and 7.26 after elective caesarean section. Likewise, the mean lactate measurement was at 4.71mmol/L after vaginal birth versus 4.54 and 3.07 in the other two groups. Only neonates born after elective caesarean sections were transferred to intensive care (four cases). CONCLUSION: Vaginal breech delivery in case of a scarred uterus is possible, if each obstetrical situation is correctly studied to authorize a vaginal birth trial after a careful selection of patients and a strict management of labour. Vaginal birth does not seem to increase maternal and neonatal morbidity and mortality in this situation.

[Secondary psoas actinomycosis: a complication of an intra-uterine contraceptive device]. / Actinomycose secondaire du psoas : une complication du dispositif intra-utérin.

Genital-pelvic actinomycosis is an uncommon disease which often arises on women with long term use of intrauterine device. Its diagnostic remains difficult. Even if different clinical locations has been reported, location to the psoas muscle is exceptional. We report such a case, diagnosed on a 53 years old woman. Both a tumoral and a severe infectious syndrome appeared three months after an intra-uterine device removal. The septic syndrome led to a laparotomic approach. Unusual clinical presentation, delay between device removal and septic syndrome and lack of genital infection explain the issues to reach the final diagnosis.

[Twin delivery with the first twin in breech position. A study of 137 continuous cases]. / L'accouchement gémellaire en cas de premier jumeau en présentation podalique. Étude d'une série continue de 137 cas.

AIM: The first twin (T1) in breech position is at risk of complications during vaginal delivery, making the choice of the appropriate delivery route highly important. Although British and American practice guidelines recommend the cesarean section, the French National College of Obstetricians and Gynecologists concluded that there was not enough data to choose one delivery route or the other. In this context, we set out to describe practices in our centre. MATERIAL AND METHODS: Our retrospective study was conducted at a level III labor ward between January 1st, 1995 and December 31st, 2006. One hundred and thirty-seven twin pregnancies at more than 26 gestational weeks (GW), with T1 in breech and T2 in any position, were included. RESULTS: A cesarean section was performed before labor in 60.6 % cases. Among the 54 (39.4 %) cases where a trial of labor was accepted, 29 patients (53.7 % success rate) delivered vaginally and 25 (46.3 %) had a cesarean section during labor. No statistical difference was observed between the neonatal outcomes after cesarean section as compared to vaginal birth. However, a significant relationship was found between delivery route and parity. Less than one-third of nulliparas versus two-third of patients with a history of at least one delivery, having trials of labor, ultimately gave birth vaginally. Thus, we observed a high rate of cesarean section during labor in nulliparas (68 % of the initially accepted trials of labor). CONCLUSION: Our study is the first one that clearly shows that the success rate of the trial of labor is closely related to a history of vaginal birth. Following these results and because of more than two-third of cesarean section during labor in nulliparas, we subsequently plan an elective cesarean section at the 38th GW for nulliparas with twin pregnancies and T1 in breech position. Nevertheless, if any of these patients go in labor before the cesearean section, a careful trial of labor is offered.

[Radiation-induced breast angiosarcoma following breast-conserving therapy. Report of two cases]. / Angiosarcome mammaire radio-induit après traitement conservateur du cancer du sein. A propos de deux cas.

Breast angiosarcoma is a rare but serious complication of radiotherapy. We report two cases of radiation-induced breast angiosarcoma in two patients having benefited from breast conserving surgery with radiation. We shall put emphasis on the etiopathogeny of these tumours and their clinical and therapeutic aspects.

[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.

[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.

[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.