Israel Nisand

Thickness of the lower uterine segment: its influence in the management of patients with previous cesarean sections

OBJECTIVE To determine how ultrasound measurement of the lower uterine segment affects the decision about delivery for patients with previous cesarean sections (CS) and what are the consequences on cesarean section rates and uterine rupture or dehiscence. DESIGN Prospective open study. PATIENTS 198 patients: all women with a previous CS who gave birth in our department during 1995 and 1996 to an infant with a gestational age of at least 36 weeks and who underwent ultrasound measurement of their lower uterine segment (95-96 study group), compared with a similar population from 1989 to 1994 whose measurements were not provided to the treating obstetrician. RESULTS Among the patients with one previous CS, the vaginal delivery rate did not differ significantly during the two periods (70.3% for the 89-94 study period vs. 67.9% for the 95-96 study period, P=0.53), but the 95-96 study group experienced a significant increase in the rate of elective CS, compensated by a reduction in the rate of emergency CS (6.3% and 23.4%, respectively, for the 89-94 study period vs. 11.9% and 20.1% for the 95-96 study period, P=0.01). There was a very significant increase in the rate of vaginal delivery for the 95-96 study period among patients with two previous CS (26.7% vs. 8.0% for the 89-95 study period, P=0.01). The lower uterine segment was significantly thicker among women with a trial of labor than among those with an elective CS (4.5+/-1.4 mm compared with 3.8 +/- 1.5 mm; P=0.006); and the trial of labor group contained significantly fewer women with a lower uterine segment measurement less than 3.5 mm than did the elective CS group (24.0% compared with 56.6%; P<0.001). Two patients (0.8%) were found to have a defect of the uterine scar, a rate significantly lower than that observed in the early group (3.9%, P=0.03). CONCLUSIONS Ultrasound measurement of the lower uterine segment can increase the safe use of trial of labor, because it provides an additional element for assessing the risk of uterine rupture.

The role of fetal nuchal translucency and ductus venosus Doppler at 11-14 weeks of gestation in the detection of major congenital heart defects.

To determine whether, in a selected high‐risk population, Doppler velocimetry of the ductus venosus can improve the predictive capacity of increased nuchal translucency in the detection of major congenital heart defects in chromosomally normal fetuses at 11–14 weeks of gestation.

Umbilical artery Doppler velocimetry in unselected and low risk pregnancies : a review of randomised controlled trials

Objective Meta‐analysis of data from controlled trials performed in populations at high risk have shown that umbilical artery Doppler velocimetry (umbilical Doppler) can reduce perinatal mortality. The individual published trials among unselected or low risk populations have found no beneficial effect. Our objective was to evaluate the effect of routine use of the umbilical Doppler in unselected or low risk pregnancies by reviewing all published and unpublished randomised controlled trials.

Embryo reduction in multifetal pregnancies after infertility therapy: obstetrical risks and perinatal benefits are related to operative strategy.

To assess the benefits that can be expected from embryo reduction of multiple pregnancies after infertility therapy, we report 58 consecutive cases of selective termination using either a transcervical or a transabdominal approach. The initial number of embryos was five or more in 13 patients, four in 29 patients, and three in 15 patients. The miscarriage rate after transabdominal procedures (23%) was one half of that after transcervical aspiration. Forty pregnancies resulted in the live birth of one child or more. The rate of prematurity was strongly related to the number of embryos left. Mean gestational age at birth was 35.5 weeks but reached 37.7 weeks when only one embryo was left. A reduction in premature birth after selective termination appeared clear for pregnancies with four or more embryos but was less significant for triplets.

What about Informed Consent in First-Trimester Ultrasound Screening for Down Syndrome?

Objectives: We evaluate the level of information and informed consent given for the screening of Down syndrome (DS) before the first-trimester ultrasound scan. We evaluate the nature of the medical information given and the patient’s understanding. This makes it possible to analyze the existence of the necessary elements (level of information and consent) for the patients to exercise their autonomy as to their decision making during the first-trimester ultrasound scan. Methods: A total of 350 patients were recruited prospectively in 2 hospitals. Patients were divided into 3 groups according to the results of maternal serum screening for DS. Group 1: Patients at high risk of having a child with DS with the second-trimester maternal serum screening (MSS) (risk >1/250). Group 2: Patients having a low risk (risk <1/250). Group 3: Patients who did not undergo maternal serum screening test. A questionnaire was completed before the medical consultation, to assess the quality of the medical consultation before the ultrasound, the level of prior knowledge and the maternal consent. Results: We excluded 45 of the 350 questionnaires from the analysis because they were incomplete (13.1%). We therefore analyzed a total of 305 questionnaires. The three groups analysed were: Group 1: 89 patients (29.2%) identified as at high risk after MSS. Group 2: 137 patients (44.9%) identified as at low risk accordingly to MSS. Group 3: 79 women (25.9%) who did not undergo maternal serum screening test for diverse reasons. The frequency of genuine informed consent was significantly (p < 0.001) higher in group 3 (56.9%) than in group 1 (52.8%) or group 2 (32.1%). Finally, the number of completely uninformed patients was significantly higher in group 2 (18%) than in the other two groups (7.8% for group 1 and 6.3% for group 3, p < 0.001). With multiple regression analysis, we found that maternal consent depended on 4 independent components: (1) Educational level (<baccalaureate, baccalaureate or at least 2 years of higher education after baccalaureate) (p < 0.03). (2) The location of consultations (hospital or private doctor’s practice) (p < 0.01). (3) History of medical termination (p < 0.001). (4) The score attributed to the doctor for information about early ultrasound scans (p < 0.001). The rate of consent increased with increasing educational level and was higher for women consulting at a hospital, for women with a history medical termination and for women whose doctors had a high score. Other criteria such as belonging to group 1, 2 or 3, age of the patient, first language, number of children, history of miscarriage, sex and age group of the professionals were not found significant. Conclusions: The response to the question ‘Is the level of medical information provided to patients concerning early screening by first-trimester ultrasound scans appropriate?’ is ‘no’. There is no difference in our result according to social-economic level. However, educational level (66% consent for patients with 2 years of higher education after the baccalaureate), a history of medical termination (85% consent), being followed at a hospital (77% consent) and the score of the doctor (71% consent) were all significantly associated with the level of consent to prenatal screening. It is difficult for patients to exercise their autonomy as concerns first-trimester ultrasound scans. Too many patients (82%) consider such scans to be compulsory. Overall, the level of knowledge of the patients was moderate, with 227 of the 305 patients (74%) having a satisfactory knowledge score (≧10). The negative responses to the various questions calls into question the legitimacy of consent for first-trimester ultrasound scans, particularly as concerns the measurement of nucal translucency.

External cephalic version with epidural anaesthesia after failure of a first trial with beta-mimetics

Objective To assess the efficacy, tolerance, and cost of external version under epidural anaesthesia and beta‐mimetic tocolysis after the failure of an initial attempt with tocolysis alone.

Induction of labour with a viable infant: a randomised clinical trial comparing intravaginal misoprostol and intravaginal dinoprostone

Objective To compare the efficacy and safety of vaginal misoprostol (50μg) with vaginal dinoprostone.

Treating ectopic pregnancy with the combination of mifepristone and methotrexate: A phase II nonrandomized study

OBJECTIVE Our goal was to compare the use of a combination of methotrexate and mifepristone with methotrexate alone in the medical management of ectopic pregnancy. STUDY DESIGN This was a preliminary nonrandomized phase II study. All patients with progressing ectopic pregnancy meeting criteria for medical management were included. Treatment consisted of 50 mg/m2 of methotrexate injected intramuscularly and 600 mg of mifepristone, administered orally, compared with a previous group who received only 50 mg/m2 of methotrexate injected intramuscularly. RESULTS Of the 30 patients treated with the combination, there was only 1 failure, whereas medical treatment had failed for 11 of 42 patients treated with methotrexate alone. CONCLUSIONS The combination of mifepristone and methotrexate decreased the risk of failure in medical treatment of ectopic pregnancy.

Reflex sympathetic dystrophy in pregnancy: nine cases and a review of the literature

OBJECTIVE To better understand the diagnosis of reflex sympathetic dystrophy of the lower extremities in pregnant women. SUBJECT Disease analysis using a retrospective series of nine cases and a review of the literature (57 patients and 159 sites of reflex sympathetic dystrophy). RESULTS This disorder should be considered in any painful pelvic girdle syndrome or lower extremity pain. The hip is involved in 88% of cases. Symptoms develop in the third trimester of pregnancy, between the 26th and the 34th weeks. Magnetic resonance imaging (MRI) provides an early, accurate, and very specific diagnosis, although standard radiography continues to be the first-line diagnostic tool. Fracture occurs in 19% of patients. The etiology and pathophysiology remain unclear, although pregnancy itself appears to play a significant role in this disease. Although locoregional mechanical factors partly explain reflex sympathetic dystrophy. Hypertriglyceridemia appears to be a risk factor. This disorder develops independently, but the conclusion of pregnancy appears to be necessary for cure. Reflex sympathetic dystrophy does not appear to affect the course of the pregnancy. Indications for cesarean delivery remain obstetrical and should be discussed when a fracture is involved. Simple therapeutic management using gentle physical therapy provides rapid and complete recovery in 2-3 months. CONCLUSION Reflex sympathetic dystrophy during pregnancy remains poorly understood and underestimated. Only joints of the inferior limbs are involved. MRI appears to be the best diagnostic tool. Pathogenesis remains unclear. Fractures are not rare. Treatment should be non-aggressive.

Molecular diagnosis reveals genetic heterogeneity for the overlapping MKKS and BBS phenotypes.

Hydrometrocolpos and polydactyly diagnosed in the prenatal period or early childhood may raise diagnostic dilemmas especially in distinguishing McKusick-Kaufman syndrome (MKKS) and the Bardet-Biedl syndrome (BBS). These two conditions can initially overlap. With time, the additional features of BBS appearing in childhood, such as retinitis pigmentosa, obesity, learning disabilities and progressive renal dysfunction allow clear differentiation between BBS and MKKS. Genotype overlap also exists, as mutations in the MKKS-BBS6 gene are found in both syndromes. We report 7 patients diagnosed in the neonatal period with hydrometrocolpos and polydactyly who carry mutations in various BBS genes (BBS6, BBS2, BBS10, BBS8 and BBS12), stressing the importance of wide BBS genotyping in patients with this clinical association for diagnosis, prognosis and genetic counselling.