Hervé Fernandez

Maternal Outcome After Conservative Treatment of Placenta Accreta

OBJECTIVE: To estimate maternal outcome after conservative management of placenta accreta. METHODS: This retrospective multicenter study sought to include all women treated conservatively for placenta accreta in tertiary university hospital centers in France from 1993 to 2007. Conservative management was defined by the obstetricians decision to leave the placenta in situ, partially or totally, with no attempt to remove it forcibly. The primary outcome was success of conservative treatment, defined by uterine preservation. The secondary outcome was a composite measure of severe maternal morbidity including sepsis, septic shock, peritonitis, uterine necrosis, fistula, injury to adjacent organs, acute pulmonary edema, acute renal failure, deep vein thrombophlebitis or pulmonary embolism, or death. RESULTS: Of the 40 university hospitals that agreed to participate in this study, 25 institutions had used conservative treatment at least once (range 1–46) and had treated a total of 167 women. Conservative treatment was successful for 131 of the women (78.4%, 95% confidence interval [CI] 71.4–84.4%); of the remaining 36 women, 18 had primary hysterectomy and 18 had delayed hysterectomy (10.8% each, 95% CI 6.5–16.5%). Severe maternal morbidity occurred in 10 cases (6.0%, 95% CI 2.9–10.7%). One woman died of myelosuppression and nephrotoxicity related to intraumbilical methotrexate administration. Spontaneous placental resorption occurred in 87 of 116 cases (75.0%, 95% CI 66.1–82.6%), with a median delay from delivery of 13.5 weeks (range 4–60 weeks). CONCLUSION: Conservative treatment for placenta accreta can help women avoid hysterectomy and involves a low rate of severe maternal morbidity in centers with adequate equipment and resources. LEVEL OF EVIDENCE: II

Amniotic fluid concentrations of Interleukin‐1β, Interleukin‐6 and TNF‐α in chorioamnionitis before 32 weeks of gestation: histological associations and neonatal outcome

Objectives To test the association between cytokine levels in the amniotic fluid and (i) the vascular invasion phase of intrauterine infection, (ii) the occurrence of periventricular leukomalacia; to assess the correlation between C‐reactive protein levels, a recognised biological marker of inflammation in maternal serum and cytokine levels in the amniotic fluid.

Management in intractable obstetric haemorrhage: an audit study on 61 cases.

OBJECTIVE To refine the indications of bilateral hypogastric artery ligation (BHAL) and angiographic selective embolisation (ASE) in intractable obstetric haemorrhage. DESIGN an audit study. SETTING Tertiary care university hospital. POPULATION AND METHODS Retrospective analysis of 61 cases of obstetric intractable post partum haemorrhage (PPH) initially managed either by hysterectomy or a conservative approach in a tertiary referral centre between 1983 and 1998. Procedures were reviewed as a primary (P) or secondary (S) attempt to arrest the haemorrhagic process. RESULTS Ten hysterectomies (5 P, 5 S), 49 BHAL (48 P, 1 S) and 9 ASE (8 P, 1S) were successfully performed in arresting the haemorrhagic process. There were 7 maternal deaths, 5 following hysterectomy and 2 following a conservative approach. Atony of the uterus was the main cause of haemorrhage (n=21) and genital tract laceration was associated with the worst prognosis. Time-elapse between delivery and surgery appears to be the main prognostic factor. Nine patients became pregnant 1 to 4 years later following a conservative approach. CONCLUSIONS ASE seems to be indicated in haemodynamically stable patients with birth canal trauma or uterine atony and clotting anomalies. BHAL is indicated when haemorrhage occurs after a cesarean section or when the patient is haemodynamically unstable. BHAL should be taught to Junior doctors in an attempt to decrease the number of patients transferred in tertiary referral centers for intractable PPH. This might also decrease the number of hysterectomies in intractable PPH.

Combined genital prolapse repair reinforced with a polypropylene mesh and tension‐free vaginal tape in women with genital prolapse and stress urinary incontinence: a retrospective case–control study with short‐term follow‐up

Background.  To evaluate the tension‐free vaginal tape (TVT) in both stress urinary incontinence (SUI) and occult SUI as an associated procedure at the time of tension‐free polypropylene mesh repair for the treatment of genitourinary prolapse.

Long-term anatomical and functional assessment of trans-vaginal cystocele repair using a tension-free polypropylene mesh.

We report a case series of 63 women with cystocele who underwent the same trans-vaginal procedure between October 1999 and October 2002. The polypropylene mesh (GyneMesh, Gynecare, Ethicon, France) was placed from the retropubic space to the inferior part of the bladder in a tension-free fashion. Patients were followed up for 24 to 60 months, with a mean follow-up of 37 months. Fifty-five patients returned for follow-up (87.3%). At follow-up, 49 women were anatomically cured (89.1%), five women had stage 2 anterior vaginal wall prolapse (9.1%), and one had a recurrent stage 3 (1.8%). Functional results and sexual function were also investigated. Fifty-three women had significant improvement in their quality of life (96.4%). There were a total of three cases of local pain around a mesh shrinkage (5.5%) and five vaginal erosions of the mesh (9.1%). Four out of 24 patients had dyspareunia (16.7%). In conclusion, the vaginal repair of anterior vaginal wall prolapse reinforced with a polypropylene mesh was efficient at 2 to 5 years follow-up. However, the first generation of polypropylene mesh we used was responsible for high rates of local complications and dyspareunia. Therefore, the polypropylene mesh has to be improved (lower weight) and the technique has to be documented by a randomized controlled trial before we could recommend its use in clinical practice.

Effect of dexamethasone and betamethasone on fetal heart rate variability in preterm labour: a randomised study

Objective To compare the effects of betamethasone and dexamethasone on fetal heart rate in appropriately grown fetuses.

Methotrexate treatment of ectopic pregnancy : 100 cases treated by primary transvaginal injection under sonographic control

Objective To evaluate safety and efficacy of intrasaccular methotrexate (MTX) for treatment of ectopic pregnancy (EP). Design Longitudinal nonrandomized trial of MTX treatment of EP. Setting Department of Obstetrics and Gynecology (A. Beclere Public Hospital, Clamart, France Paris-Sud University). Patients One hundred patients with an EP visualized by sonography. Patients were 31.4 ± 4.8 years old, para 0 to 4, and gravida 0 to 7. Twelve patients had a past history of EP, and 18 had previously undergone tubal surgery. Inclusion score for proposed medical treatment used six criteria graded from 1 to 3: gestational age, initial hCG level, P level, existence of abdominal pain, size of hemoperitoneum, and diameter of hematosalpinx. Eleven patients had an EP with cardiac activity. Treatment consisted of MTX, 1 mg/kg, given locally under transvaginal sonographic control. Results Eighty-three of 100 patients were considered to be completely cured (return of hCG to 12. Twenty-eight of 83 patients treated successfully required more than one injection of MTX (additional doses being given intramuscularly) because of nonresolution of hCG levels. Follow-up hysterosalpingography was performed in 80 patients showing 90% tubal patency on the side of the treated EP. Of 58 patients wishing pregnancy, 34 pregnancies occurred, including 25 ongoing or delivered. We observed a low recurrence rate of EP (3 with 1 on the same side). Conclusion Treatment by initial transvaginal injection of MTX under sonographic control appears to be simple and effective, with no demonstrable untoward effects. The tubal patency and subsequent fertility obtained appear satisfactory. The highest success rate is observed when hCG level is under 5,000 mIU/mL and/or a pretherapeutic score ≤ 12 when EP is visualized by sonography.

Obstetric patients treated in intensive care units and maternal mortality

OBJECTIVE To ascertain the frequency of serious diseases in pregnant women. STUDY DESIGN A population based survey was performed in France. The cases were all the women admitted for treatment in intensive care unit (ICU). The severity of the cases was measured with the simplified acute physiology score (SAPS) the lethality and the rate of still birth. RESULTS 435 obstetric patients were included. The estimated frequency of severe diseases was 310 S.D.36 per 100,000 live births. The most frequent diagnose that motived admission in ICU was hypertensive diseases. The lethality rates differed greatly between specific disorders. The lethality rate was lower when scheduled maternity was located in a teaching hospital. CONCLUSION Regarding these results it appears that the majority of obstetric patients with severe diseases are referred to suitable care, but a small proportion of women who had to change their type of care registered a significant higher lethality.

Efficacy and safety of repeated use of ulipristal acetate in uterine fibroids.

OBJECTIVE To investigate the efficacy and safety of repeated 12-week courses of 5 or 10 mg daily of ulipristal acetate for intermittent treatment of symptomatic uterine fibroids. DESIGN Double-blind, randomized administration of two 12-week courses of ulipristal acetate. SETTING Gynecology centers. PATIENT(S) A total of 451 patients with symptomatic uterine fibroid(s) and heavy bleeding. INTERVENTION(S) Two repeated 12-week treatment courses of daily 5 or 10 mg of ulipristal acetate. MAIN OUTCOME MEASURE(S) Amenorrhea, controlled bleeding, fibroid volume, quality of life (QoL), pain. RESULT(S) In the 5- and 10-mg treatment groups (62% and 73% of patients, respectively) achieved amenorrhea during both treatment courses. Proportions of patients achieving controlled bleeding during two treatment courses were >80%. Menstruation resumed after each treatment course and was diminished compared with baseline. After the second treatment course, median reductions from baseline in fibroid volume were 54% and 58% for the patients receiving 5 and 10 mg of ulipristal acetate, respectively. Pain and QoL improved in both groups. Ulipristal acetate was well tolerated with less than 5% of patients discontinuing treatment due to adverse events. CONCLUSION(S) Repeated 12-week courses of daily oral ulipristal acetate (5 and 10 mg) effectively control bleeding and pain, reduce fibroid volume, and restore QoL in patients with symptomatic fibroids. CLINICAL TRIAL REGISTRATION NUMBER NCT01629563 (PEARL IV).

Alternative to surgery of treatment of unruptured interstitial pregnancy: 15 cases of medical treatment.

OBJECTIVE To evaluate medical treatment of interstitial pregnancy. METHODS This series was a retrospective study of medical treatment of interstitial pregnancies which was managed in two French Departments of Obstetrics and Gynecology (Bichat public Hospital. Paris and A. Béclère public Hospital, Clamart, France). Fifteen patients with clear evidence of an unruptured interstitial pregnancy were treated by injection of methotrexate (MTX) or potassium chloride (KCL) without surgery since January 1988. The diagnosis was established either by sonography and laparoscopic confirmation in eight cases or by only transvaginal ultrasound in seven cases. Three out of 15 cases in this series, had a heterotopic pregnancy who were treated by transvaginal ultrasound-guided injection of KCL. Others received systemic MTX injection in four cases, and local MTX injection in eight cases under either laparoscopy or transvaginal ultrasound guidance. Four different protocols of MTX (Ledertrexate) administration was performed in this series with time: at the beginning of our experience, MTX1 protocol, 15 mg i.m. daily for 5 days was used; and after MTX2 protocol, 1 mg/kg body weight i.m. daily for 4 days; MTX3 protocol, 1 mg/kg body weight intratubal associated with 1 mg/kg body weight i.m. daily for 3 days; and now MTX4 protocol, only intratubal 1 mg/kg body weight is especially used. The success was defined as declining serum human chorionic gonadotropin (hCG) to undetectable levels, and no further surgical management was required. Outcome of subsequent fertility was also evaluated. RESULTS Complete resolution was obtained in 13 (86.6%) out of 15 interstitial pregnancies. Two out of 15 patients, with medical treatments failure required secondary surgery. No severe side effects of medical treatment were observed. Follow-up hysterosalpingography was performed in 12 patients showing 91.7% tubal patency on the side of interstitial pregnancy. Outcome of intra-uterine pregnancy of the three patients who had heterotopic gestation, was two miscarriages and one delivery at term. Out of the other 12 patients in this series, nine became pregnant within 1 year: eight pregnancies at term, and one induced abortion. At present, among the last three patients, two have no desire to conceive. CONCLUSION Our results suggest that unruptured interstitial pregnancies now can be managed with local MTX administration of 1 mg/kg body weight under transvaginal ultrasound or under laparoscopy procedure. This approach is particularly attractive in these patients, where the only alternative to therapy is laparotomy with cornual resection.