Loïc Marpeau

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

White matter damage and intraventricular hemorrhage in very preterm infants: the EPIPAGE study☆

OBJECTIVE To evaluate the prevalence of cranial ultrasound abnormalities in very preterm infants as a function of gestational age, plurality, intrauterine growth restriction, and death before discharge. STUDY DESIGN A prospective, population-based cohort of 2667 infants born between 22 and 32 weeks of gestation in 1997 in nine regions of France, transferred to a neonatal intensive care unit, for whom at least one cranial ultrasound scan was available. RESULTS The frequencies of white matter damage (WMD), major WMD, cystic periventricular leukomalacia (PVL), periventricular parenchymal hemorrhagic involvement, and intraventricular hemorrhage with ventricular dilatation were 21%, 8%, 5%, 3%, and 3%, respectively. The risk of WMD increased with decreasing gestational age. Mean age at diagnosis of cystic PVL was older for the most premature infants. Intraventricular hemorrhage with ventricular dilatation was associated with a higher risk of cystic PVL. Intrauterine growth restriction was not associated with a lower prevalence of cystic PVL. CONCLUSION The frequency of WMD is high in very preterm babies and is strongly related to gestational age. The incidence of cystic PVL did not differ between babies with intrauterine growth restriction and babies who were appropriate for gestational age.

Neonatal and 5-year outcomes after birth at 30-34 weeks of gestation

OBJECTIVE: To evaluate the rates of in-hospital death, neonatal complications, and 5-year outcomes of infants born at 30–34 weeks of gestation. METHODS: In nine regions of France, all 2,020 stillbirths and live births at 30, 31, and 32 weeks in 1997 and all 457 births at 33 and 34 weeks in April and October 1997 were recorded. Survivors were evaluated at 5 years of age. RESULTS: Increasing gestational age from 30 to 34 weeks was associated with progressive decreases in in-hospital mortality (from 8.1% to 0.4%) and neonatal complications (respiratory distress syndrome, 43.8% to 2.6%; maternofetal infections, 7.2% to 2.6%; and severe white matter injury, 5.5% to 1.3%). Although infants at 33 and 34 weeks of gestation rarely experienced necrotizing enterocolitis, bronchopulmonary dysplasia, or nosocomial infections, they still required endotracheal ventilation, antibiotics, or parenteral nutrition. At 5 years of age, older gestational age was associated with significant decreases in rates of cerebral palsy (6.3% at 30 weeks and 0.7% at 34 weeks) and mild to severe cognitive impairments (35.3% at 30 weeks and 23.9% at 34 weeks). In singletons, preterm rupture of membranes or preterm labor carried an increased risk of cerebral palsy but not of cognitive impairment. CONCLUSION: Neonates born at 30–34 weeks experienced substantial morbidity and often required admission to neonatal intensive care units. These outcomes suggest that prolonging pregnancies beyond 34 weeks may be desirable whenever possible. Infants born at 30–34 weeks should be carefully monitored to ensure prompt detection and management of neurodevelopmental impairment. LEVEL OF EVIDENCE: II

Predictors of failed pelvic arterial embolization for severe postpartum hemorrhage.

OBJECTIVES: To estimate what factors are associated with a failed pelvic arterial embolization for postpartum hemorrhage and to attempt to estimate efficacy of pelvic arterial embolization in rare conditions. METHODS: This was a retrospective cohort study including all consecutive women who underwent pelvic arterial embolization trial for postpartum hemorrhage between 1994 and 2007 at a tertiary care center. Pelvic arterial embolization failure was defined as the requirement for subsequent surgical procedure to control postpartum hemorrhage. RESULTS: Pelvic arterial embolization was attempted in 0.3% of deliveries by the same radiologist in 87% of cases. Failures occurred in 11 of 100 cases (11%) and in 4 of 17 cases (24%) of placenta accreta or percreta. The major complication rate after pelvic arterial embolization was low (3%). Fifty patients (50%) were transferred from nine other institutions. Pelvic arterial embolization was performed in 11 cases (11%) after a failed conservative surgical procedure and in eight cases (8%) for secondary postpartum hemorrhage, with success rates of 91% and 88%, respectively. Pelvic arterial embolization demonstrated a patency throughout one ligated pedicle in 9 of the 11 cases of failed conservative surgical procedure (82%). Twin pregnancy, chorioamnionitis, operative vaginal delivery, hospital-to-hospital transfer, nature of embolizing agent and arteries embolized, failed surgical procedure, secondary postpartum hemorrhage, cause of postpartum hemorrhage, and more than one pelvic arterial embolization were not found to be significantly associated with failed pelvic arterial embolization. CONCLUSION: The only factors significantly associated with failed pelvic arterial embolization were a higher rate of estimated blood loss (more than 1,500 mL) and more than 5 transfused red blood cell units. Attempted pelvic arterial embolization after a failed vessel ligation procedure and for a secondary postpartum hemorrhage is a good option with high success rates. LEVEL OF EVIDENCE: III

Previous induced abortions and the risk of very preterm delivery: results of the EPIPAGE study

Objectives  To evaluate the risk of very preterm birth (22–32 weeks of gestation) associated with previous induced abortion according to the complications leading to very preterm delivery in singletons.

The complex relationship between smoking in pregnancy and very preterm delivery. Results of the Epipage study.

Objective  To assess the relationship between cigarette smoking during pregnancy and very preterm births, according to the main mechanisms of preterm birth.

Delayed functional outcomes associated with surgical management of deep rectovaginal endometriosis with rectal involvement: giving patients an informed choice

BACKGROUND The aim of this study was to compare delayed functional digestive and urinary outcomes following two different surgical procedures used in the management of rectal endometriosis. METHODS Women who had undergone surgical management of rectal endometriosis with at least 1 year of post-operative follow-up were included in a retrospective study. Post-operative symptoms were evaluated using specific questionnaires which focused on pelvic pain and functional outcomes. RESULTS There were 41 women who underwent surgical treatment of symptomatic rectal endometriosis. Post-operative follow-up was completed over 26 +/- 13 months (range 12-53). Colorectal segmental resection was performed in 25 women (61%) and nodule excision in 16 (39%). An increase in the number of daily stools > or =3 was observed in 13 (52%) and 3 (19%) patients managed, respectively, by segmental resection and nodule excision (P = 0.02). Severe constipation (<1 stool/5 days) was recorded in three women having undergone segmental resection. The probabilities of being free of dysmenorrhea, dyspareunia and non-cyclic pain at 24 months in women managed by segmental resection and nodule excision were, respectively, 80% (95% CI: 55-92%), 65% (95% CI: 42-81%), 43% (95% CI: 23-62%) and 62% (95% CI: 34-81%), 81% (95% CI: 52-94), 69% (95% CI: 40-86%). When pain recurrences occurred, a significantly lower post-operative score for pain was observed in both groups. No significant difference in pain improvement was found between surgical procedures. CONCLUSION Colorectal segmental resection appears to be associated with several unpleasant functional symptoms when compared with nodule excision. Information about functional outcomes should be provided to patients managed for rectal endometriosis, and should be considered when deciding on the most appropriate treatment of this disease.

Fertility and pregnancy following pelvic arterial embolisation for postpartum haemorrhage

Objectives  To determine and compare the fertility and pregnancy outcomes following embolisation with or without uterine‐sparing surgery for postpartum haemorrhage, and to attempt to identify specific risk factors associated with an increased likelihood of intrauterine synechia.

Liver resection for breast cancer metastasis: Does it improve survival?

PurposeTo assess the outcome and prognostic factors of liver surgery for breast cancer metastasis.MethodsWe retrospectively examined 16 patients who underwent partial liver resection for breast cancer liver metastasis (BCLM). All patients had been treated with chemotherapy or hormonotherapy, or both, before referral for surgery. We confirmed by preoperative radiological examinations that metastasis was confined to the liver. The survival curve was estimated using the Kaplan-Meier method. Univariate and multivariate analysis were conducted to evaluate the role of the known factors of breast cancer survival.ResultsThe median age of the patients was 54 years (range 38–68) and the median disease-free interval between the diagnoses of breast cancer and liver metastasis was 54 months (range 7–120). Nine major and 7 minor hepatectomies were performed. There was no postoperative death. The overall 1-, 3-, and 5-year survival rates were 94%, 61%, and 33%, respectively. The median survival rate was 42 months. Univariate analysis revealed that hormone receptor status, number of metastases, a major hepatectomy, and a younger age were associated with a poorer prognosis. The survival rate was not influenced by the disease-free interval, grade or stage of breast cancer, or intraoperative blood transfusions. The number of liver metastases was identified as a significant independent factor of survival according to the Cox proportional hazard model (P = 0.04).ConclusionsLiver resection, when done in combination with adjuvant therapy, can improve the prognosis of selected patients with BCLM.

Special care and school difficulties in 8-year-old very preterm children: the Epipage cohort study.

Objectives To investigate school difficulties, special care and behavioral problems in 8 year-old very preterm (VPT) children. Patient and Methods Longitudinal population-based cohort in nine regions of France of VPT children and a reference group born at 39–40 weeks of gestation (WG). The main outcome measures were information about school, special care and behavioral problems using Strengths and Difficulties Questionnaire from a questionnaire to parents. Results Among the 1439 VPT children, 5% (75/1439) were in a specialised school or class, 18% (259/1439) had repeated a grade in a mainstream class and 77% (1105/1439) were in the appropriate grade-level in mainstream class; these figures were 1% (3/327) , 5% (16/327) and 94% (308/327) , respectively, for the reference group. Also, 15% (221/1435) of VPT children in a mainstream class received support at school versus 5% (16/326) of reference group. More VPT children between the ages of five and eight years received special care (55% (794/1436)) than children born at term (38% (124/325)); more VPT children (21% (292/1387)) had behavioral difficulties than the reference group (11% (35/319)). School difficulties, support at school, special care and behavioral difficulties in VPT children without neuromotor or sensory deficits varied with gestational age, socioeconomic status, and cognitive score at the age of five. Conclusions Most 8-year-old VPT children are in mainstream schools. However, they have a high risk of difficulty in school, with more than half requiring additional support at school and/or special care. Referral to special services has increased between the ages of 5 and 8 years, but remained insufficient for those with borderline cognitive scores.