[Fetoscopic laser coagulation in 200 consecutive monochorionic pregnancies with twin-twin transfusion syndrome]. / Photocoagulation laser par fœtoscopie pour syndrome transfuseur-transfusé : analyse d'une série consécutive unicentrique de 200 cas.

OBJECTIVES: To report preoperative data, surgical characteristics, complications and perinatal outcome of twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery, to analyze predictors of neonatal survival and to compare the 100 most recent cases with the older 100. MATERIALS AND METHODS: Observational cohort moncentric study of 200 cases of TTTS consecutively treated with fetoscopic laser coagulation between January 2004 and December 2014. RESULTS: There were 49 stage I, 88 stage II, 55 stage III and eight stage IV. Median gestation at time of laser was 20.1±3.0 weeks' gestation (WG) whereas median gestation at delivery was 31.6±5.4 WG. Overall perinatal survival rate was 68.0% and 84.0% have one or more surviving twins. Preterm premature rupture of membranes occurred in 39 cases with and the median gestational age for this complication was 28.8±4.6 SA. Predictive factors to have at least one living birth were Quintero stage and gestational age at delivery. In the most recent period, there were significantly more TTTS Quintero stage I treated with laser, more coagulation by the Solomon technique and a larger number of coagulated vessels. CONCLUSION: The neonatal survival of TTTS is improved by fetoscopic laser coagulation, preferely by using Solomon tecnhique. The use of active management of stage I is currently on research.

[Medical induced abortion]. / Interruption volontaire de grossesse par voie médicamenteuse.

OBJECTIVE: Updated clinical recommendations for medical induced abortion procedure. METHODS: A systematic review of French and English literature, reviewing the evidence relating to the provision of medical induced abortion was carried out on PubMed, Cochrane Library and international scientific societies recommendations. RESULTS: The effectiveness of medical abortion is higher than 95% when the protocols are adjusted to gestational age (EL1). Misoprostol alone is less effective than a combination of mifepristone and misoprostol (EL1). Gemeprost is less effective than misoprostol (EL2). The dose of 200mg of mifepristone should be preferred to 600mg (NP1, Rank A). Mifepristone can be taken at home (professional agreement). The optimum interval between mifepristone and misoprostol intake should be 24 to 48 hours (EL1, grade A). Before 7 weeks LMP, the dose of 400µg misoprostol should be given orally (EL1, grade A) eventually repeated after 3hours if no bleeding occurs. For optimal effectiveness between 7 and 14 LMP, the interval between mifepristone and misoprostol should not be shortened to less than 8hours (grade 1). An interval of 24 to 48hours will not affect the effectiveness of the method provided misoprostol dosage is 800µg (EL1). Vaginal, sublingual or buccal routes of administration are more effective and better tolerated than the oral route, which should be abandoned (EL1). An amount of 800µg sublingual or buccal misoprostol route has the same effectiveness than the vaginal route but more gastrointestinal side effects (EL1, grade A). Between 7 and 9 LMP, it does not seem necessary to repeat misoprostol dose whereas it should be repeated beyond 9 SA (grade B). Between 9 and 14 LMP, the dose of 400µg misoprostol given either vaginally, buccally or sublingually should be repeated every 3hours if needed (with a maximum of 5 doses) (EL2, grade B). There is no strong evidence supporting routine antibiotic prophylaxis for medical abortion (professional agreement). Rare contraindications should be respected (known hypersensitivity to misoprostol or mifepristone, inherited porphyria, severe anemia, hemorrhagic disorders or current anticoagulation therapy, suspected or confirmed ectopic pregnancy) as well as precautions of use (severe disease or on-going corticosteroid therapy). With no risk factors or symptoms, a pregnancy of unknown location (PUL) at the endovaginal ultrasound associated with a level of hCG usually chosen at less than 1500IU (or 2500IU with an abdominal probe) is not a contraindication of medical abortion as long as the woman is informed of the risk of undiagnosed ectopic pregnancy and knows how and when to seek emergency attention. An earlier than usual follow-up of the decrease of hCG levels is highly recommended. Breastfeeding, obesity, twin pregnancy and scared uterus are not contraindications for first trimester medical abortion. Side effects (gastro intestinal and thermoregulation disorders) during the procedure are generally of low intensity and short duration. A prophylactic treatment for nausea should be proposed (professional agreement). The pain increases with gestational age of the pregnancy (EL1). Ibuprofen is the first choice of painkiller (EL1). Ibuprofen will be systematically proposed or given on demand according to the practice of each facility (professional agreement). After a medical abortion, a follow-up assessment to confirm completion of the abortion is recommended (EL2, grade B). Clinical history combined with ultrasound and/or hCG blood level are both reliable methods and can be left with the choice of each facility (grade B). A fall of more than 80% of the initial blood level of hCG, fifteen days after the procedure is in favor of the success of the method (grade B). CONCLUSION: Medical abortion is a safe and efficient abortion method up to 14 weeks LMP. To be effective, the drug regimen should be adapted to gestational age. Women should be informed of advantages and disadvantages of the method according to the gestational age and side effects so she can choose the method that fits her best.