J. Bernard

Long-term developmental follow-up of infants who participated in a randomized clinical trial of amniocentesis vs laser photocoagulation for the treatment of twin-to-twin transfusion syndrome

OBJECTIVE We sought to assess long-term neurodevelopment of children who were treated prenatally as part of the Eurofoetus randomized controlled trial. STUDY DESIGN The study population was composed of 128 cases of twin-to-twin transfusion syndrome (TTTS) included and followed up in France. Survivors were evaluated by standardized neurological examination and by Ages and Stages Questionnaires (ASQ). Primary outcome was a composite of death and major neurological impairment. RESULTS A total of 120 children (47%) were alive at the age of 6 months and were followed up to the age of 6 years. At the time of diagnosis, only treatment and Quintero stage were predictors of a poor outcome (hazard ratio, 0.61; 95% confidence interval, 0.41-0.90; P = .01 and hazard ratio, 3.23; 95% confidence interval, 2.19-4.76; P < .001, respectively). Children treated by fetoscopic selective laser coagulation (FSLC) had higher ASQ scores at the end of follow-up (P = .04). CONCLUSION FSLC was significantly associated with a reduction of the risk of death or long-term major neurological impairment at the time of diagnosis and treatment.

Reference range for cervical length throughout pregnancy: non-parametric LMS-based model applied to a large sample

Short cervical length is an important risk factor for preterm delivery. However, because cervical length changes throughout pregnancy, adequate risk estimation needs to take into account the gestational age (GA) at which the measurement is taken. We aimed to model cervical changes throughout pregnancy in order to be able to use Z‐scores, avoiding the confounding effect of GA.

MRI and ultrasound fusion imaging for prenatal diagnosis.

OBJECTIVE A combination of magnetic resonance imaging (MRI) images with real time high-resolution ultrasound known as fusion imaging may improve prenatal examination. This study was undertaken to evaluate the feasibility of using fusion of MRI and ultrasound (US) in prenatal imaging. STUDY DESIGN This study was conducted in a tertiary referral center. All patients referred for prenatal MRI were offered to undergo fusion of MRI and US examination. All cases underwent 1.5 Tesla MRI protocol including at least 3 T2-weighted planes. The Digital Imaging and Communications in Medicine volume dataset was then loaded into the US system for manual registration of the live US image and fusion imaging examination. RESULTS Over the study period, 24 patients underwent fusion imaging at a median gestational age of 31 (range, 24-35) weeks. Data registration, matching and then volume navigation was feasible in all cases. Fusion imaging allowed superimposing MRI and US images therefore providing with real time imaging capabilities and high tissue contrast. It also allowed adding a real time Doppler signal on MRI images. Significant fetal movement required repeat-registration in 15 (60%) cases. The average duration of the overall additional scan with fusion imaging was 10 ± 5 minutes. CONCLUSION The combination of fetal real time MRI and US image fusion and navigation is feasible. Multimodality fusion imaging may enable easier and more extensive prenatal diagnosis.

Varicella zoster virus infection during pregnancy : the limits of prenatal diagnosis

In a mother with clinical evidence of chicken-pox at 12.5 weeks, fetal herpes varicella zoster infection was revealed by transient fetal ascites with liver calcifications at 27 weeks routine ultrasound. At 27 and 35 weeks fetal blood sampling and amniocentesis failed to demonstrate fetal viral infection. However, the diagnosis was confirmed postnatally based on thoracic herpes zoster at 8 months in an otherwise healthy infant. Polymerase chain reaction (PCR) on stored amniotic cells performed retrospectively was positive for varicella zoster virus (HVZV). This observation suggests that (1) in contrast to PCR, conventional fetal biology lacks sensitivity for prenatal diagnosis of HVZV infection, (2) the association of fetal sonographic abnormalities and positive amniotic PCR can be associated with a favorable pediatric outcome. Therefore, prenatal diagnosis of HVZV infection should be considered with the greatest caution.

Day-specific probabilities of conception in fertile cycles resulting in spontaneous pregnancies

STUDY QUESTION When, within the female cycle, does conception occur in spontaneously fertile cycles? SUMMARY ANSWER This study provides reference values of day-specific probabilities of date of conception in ongoing pregnancies. The maximum probability of being within a 5-day fertile window was reached on Day 12 following the last menstrual period (LMP). WHAT IS KNOWN ALREADY The true date of conception is not observable and may only be estimated. Accuracy of these estimates impacts on obstetric management of ongoing pregnancies. Timing of ovulation and fertility has been extensively studied in prospective studies of non-pregnant fertile women using error-prone proxies, such as hormonal changes, body-basal temperature and ultrasound, yielding day-specific probabilities of conception and fertile windows. In pregnant women, date of conception may be retrospectively estimated from early pregnancy fetal measurement by ultrasound. STUDY DESIGN, SIZE, DURATION Retrospective analysis of consecutive pregnancies in women referred for routine first-trimester screening, over a 3-year period (2009-2011) in a single ultrasound center (n = 6323). PARTICIPANTS/MATERIALS, SETTING, METHODS Within the overall population, 5830 cases with a certain date of last menses were selected for analysis. The date of conception was estimated using a crown-rump length biometry and an equation derived from IVF/ICSI pregnancies. Day-specific probabilities of conception were estimated across several covariates, including age, cycle characteristics and ethnicity, using deconvolution methods to account for measurement error. MAIN RESULTS AND THE ROLE OF CHANCE Overall, the day-specific probability of conception sharply rises at 7 days after the LMP, reaching its maximum at 15 days and returning to zero by 25 days. Older women tend to conceive earlier within their cycle, as did women with regular cycles and white and black women compared with Asian ethnicity. The probability of being within the fertile window was 2% probability at Day 4, a maximum probability of 58% at Day 12 and a 5% probability by Day 21 of the cycle. LIMITATIONS, REASONS FOR CAUTION Although conception is believed to occur within hours following ovulation, a discrepancy is theoretically possible. However, when comparing our results to those of prospective studies, no such difference was found. The equation used for estimating the date of pregnancy was estimated in IVF/ICSI pregnancies, which could lead to potential bias in spontaneous pregnancies. However, in our population, the observed bias was negligible. Non-fertile cycles and early pregnancy losses are necessarily overlooked because of the nature of our data. WIDER IMPLICATIONS OF THE FINDINGS Because of the wider access to retrospective data and the potential bias in prospective studies of ovulation monitoring, this study should broaden the perspectives of future epidemiologic research in fertility and pregnancy monitoring. STUDY FUNDING/COMPETING INTERESTS None.

A score-based method to improve the quality of emergency gynaecological ultrasound examination

OBJECTIVES The quality of ultrasound (US) examination in the setting of a gynaecological emergency consultation is variable. Our aims were to develop and evaluate the feasibility of an image-based scoring method for the evaluation of standardised gynaecological images in this context. STUDY DESIGN Ultrasound images of the uterus (2 planes), ovaries (1 plane of each side) and Morrisons pouch were obtained by specialist registrars as part of their assessment of gynaecological emergencies during a three-month period. Twenty images of each of these 5 planes were randomly selected and anonymised. These 100 images were analysed by two reviewers. Each image was scored according to 23 criteria yielding a maximum score of 23 points for the entire ultrasound examination. Training was then offered with special emphasis on quality criteria. Following training, another set of 100 images obtained by the same specialist registrars was scored. Scores before and after training were compared. Inter- and intra-reviewer reproducibility were analysed using intra-class correlation, adjusted Kappa and Bland-Altman plot. RESULTS The mean (+/-SD) scores were 10.22(+/-2.75) and 16.1(+/-3.35) before and after theoretical training respectively (p<10(-4)). The intra-class correlation coefficient and the mean difference in score were 0.973 [0.957;0.990] and 0.02 [-1.98;1.94], and 0.952 [0.894;1] and -0.1 [-2.44;2.24] for inter- and intra-reviewer reproducibility respectively. Kappa values were above 0.8 for all but 3 criteria. CONCLUSION A quality control policy for gynaecological emergencies based on image scoring is feasible and allows for good inter- and intra-reviewer reproducibility. A policy of this nature is likely to improve the quality of emergency gynaecological ultrasound examination.

Value of three-dimensional contrast-enhanced power Doppler ultrasound for characterizing adnexal masses

Aims:  The aim of this study was to assess the diagnostic performance of 3‐D contrast‐enhanced power Doppler ultrasonography (3‐D CEPDUS) for differentiating benign and malignant adnexal masses.

Methotrexate Provides Significant Cost Savings for the Treatment of Unruptured Ectopic Pregnancy

SummaryThe aim of this study was to compare direct and indirect costs of single-dose methotrexate and laparoscopy in the treatment of unruptured ectopic pregnancy. We conducted a prospective study between 1 January 1995 and 31 May 1997 and recorded costs accrued from outpatient and inpatient treatment with methotrexate (group I) and laparoscopy (group II). We used the French National Social Security nomenclature as reference for the different costs. Indirect costs were estimated from national demographic data. 39 patients were included in group I and 38 in group II. Single-dose methotrexate was the most economic management of unruptured tubal pregnancy (

A standardized approach for the assessment of the lower uterine segment at first trimester by transvaginal ultrasound: a flash study

US1436 per case vs

OP01.01: Second trimester growth restriction and underlying fetal anomalies

US3170 per case for laparoscopy) since it reduced the total cost by approximately 50%. This was due to a dramatic reduction in charges related to hospitalisation and the operating room. Indirect costs were also reduced, mainly as a result of a shorter recovery time (