O. Morel

Correlation between uteroplacental three‐dimensional power Doppler indices and true uterine blood flow: evaluation in a pregnant sheep model

Three‐dimensional (3D) Doppler quantification within the uteroplacental unit could be of great help in understanding and screening for pre‐eclampsia and intrauterine growth restriction. Yet the correlation between 3D Doppler indices and true blood flow has not been confirmed in vivo. The aim of this study was to evaluate this correlation in a pregnant sheep model.

Quantification of utero-placental vascularization in a rabbit model of IUGR with three-dimensional power Doppler angiography

OBJECTIVES Our objective was to evaluate the 3D power Doppler angiography (PDA) in terms of feasibility and ability to detect placental hypo-perfusion in an experimental rabbit model of intrauterine growth restriction (IUGR). STUDY DESIGN 14 pregnant females were treated with NG-nitro-L-arginine methylester (L-NAME), a nitric oxide synthase inhibitor, from day 24 to day 28 of gestation, to induce an IUGR. Concomitantly, 8 pregnant rabbits were used as controls. On day 28, 3D power Doppler indices were quantified in each utero-placental unit. Morphological examination of the placentas for the control group (n = 4) and the L-NAME group (500 mg/day, n = 4) were performed with immunohistochemical staining to discriminate the fetal capillaries in the labyrinthine area. RESULTS A total of 180 live fetuses were obtained, 108 from the L-NAME group and 72 from the control group. G28 fetal weight was significantly lower in the L-NAME group than in the control group (27.40 ± 0.55 g vs 33.14 ± 0.62 g, p < 0.0001). In the L-NAME group the vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were significantly lower than in the control group (2.6 [1.4; 6.0] vs 7.6 [3.5; 12.6], p < 0.05; 28.7 [26.5; 31.3] vs 32.9 [28.3; 38.1], p < 0.05; 0.8 [0.4; 1.8] vs 2.5 [1.1; 4.1], p < 0.05, for VI, FI and VFI, respectively). Morphological examinations revealed a substantial disorganization of the placental vascular architecture in the L-NAME group. CONCLUSION This experimental study demonstrates that quantitative 3D PDA indices are sensitive enough to detect placental vascular insufficiency in an experimental rabbit model of IUGR.

Delayed hysteroscopic resection of retained tissues and uterine conservation after conservative treatment for placenta accreta

Conservative management of both the uterus and the abnormal placenta, which is left inside the uterus at the time of delivery, is one option of placenta accreta management. Complete elimination of the residual placenta is the main challenge of this procedure.

Evaluation of the rabbit as an experimental model for human uterine synechia

CONTEXT: Pathogenesis of uterine synechia remains unsolved, the causal relationship between synechia and infertility is not clearly established. AIMS: To evaluate the rabbit as an experimental model for Ashermans syndrome using the endometrial curettage as trigger mechanism then to evaluate its impact on fertility. SETTINGS AND DESIGN: Experimental study MATERIALS AND METHODS: 13 female rabbits. All submitted traumatic endometrial curettage. Animals of Group 1 (n = 7) were sacrificed at various times following surgery (day 7, 15 and 30), animals of Group 2 (n = 6) were bred and sacrificed during pregnancy. Main outcome were synechia occurring, number of implanted fetus, lumen surface/ global horn perimeter ratio (LS-GHP ratio) and epithelium thickness. STATISTICAL ANALYSIS: Means were compared using Student ‘t’ test (P < 0.05 was considered significant). Number of implantation sites of two horns were compared with the Wilcoxon test. RESULTS: No synechia have been observed. Examinations at Day 7, 15 and 30 demonstrate a complete regeneration of endometrium. We observed a significant diminished LS-GHP ratio at day 7 (0.042 ± 0.004 vs 0.074 ± 0.002 mm; P = 0.013) with a higher simple columnar epithelium compared to control (16.6 ± 3.39 vs 10.98 ± 1.7; P = 0.001). We observed a diminished ovum implantation in traumatized horns, even if it was not statistically significant. CONCLUSION: Even if no intrauterine adhesion were observed, this model represents a pathogenesis condition in the rabbit similar to intrauterine adhesions observed in the human with negative impact on implantation.BACKGROUND Polycystic ovarian syndrome is a common endocrine disorder of reproductive age women. Many controlled ovarian stimulation (COS) strategies have been offered for the treatment of patients with PCOS undergoing in vitro fertilization, but the optimal protocol is still a controversy. There is no compelling evidence for the advantage of one stimulation protocol over the other. MATERIALS AND METHODS This is a single-center prospective controlled study comparing long agonist and antagonist protocol in PCOS women. RESULTS There was no significant difference in live birth rate and clinical pregnancy rate. Rate of ovarian hyperstimulation syndrome was significantly higher in the agonist group. Number of oocytes retrieved, number of follicles and peak estradiol levels were significantly more in the agonist group. CONCLUSION The GnRH antagonist protocol is an equally effective but safer protocol in PCOS patients compared with the long agonist protocol.

Evaluation of symptomatic uterine fibroids in candidates for uterine artery embolization: comparison between ultrasonographic and MR imaging findings in 68 consecutive patients.

Ultrasonographic and magnetic resonance (MR) imaging examinations of 68 women with uterine fibroids were reviewed to determine whether MR imaging may alter the therapeutic approach based on ultrasonography alone before uterine embolization. Therapeutic decisions based on ultrasonography alone were compared to those obtained after MR imaging. Discordant findings between both examinations involved 51 women (75%), and 19 (28%) had their therapeutic approaches based on ultrasonography alone altered by MR imaging. Ultrasonography and MR imaging showed concordant findings in 17 women (25%) for whom no changes in therapeutic option were made. MR imaging alters the therapeutic approach based on ultrasonography alone in 28% of candidates for uterine artery embolization.

Analysis of placental vascularization in a pharmacological rabbit model of IUGR induced by l-NAME, a nitric oxide synthase inhibitor

OBJECTIVES We have previously validated the use of L-nitro-arginine methyl ester (L-NAME), a nitric oxide synthase inhibitor, to induce placental hypoperfusion in a rabbit model. Here, the effects of L-NAME on placental vascularization were explored. Transplacental transfer of L-NAME and/or its active metabolite, NG-nitro-L-arginine (L-NOARG), was evaluated. METHODS 25 pregnant female rabbits were allocated on day 24 to one of 5 groups: L-NAME groups (31.35, 62.5, 125 and 250 mg/kg/day) or Control group (C). On Day 28, the labyrinthine area was analyzed for stereology and gene expression. L-NAME and L-NOARG were quantified in maternal and fetal blood. RESULTS The volume density of fetal vessels was significantly decreased in L-NAME (including 62.5-250 mg/kg/day which induced an IUGR) compared to C groups. L-NAME induced an increase of the volume and surface density of the maternal blood space. The trophoblast volume density remained unchanged as well as the surface density of fetal vessels. Relative expression of eNOS, VEGFA, VEGFR-1 and VEGFR-2 in placentas was not affected by 125 mg/kg/day L-NAME treatment, whereas IGF-2 expression was significantly increased in this L-NAME group compared to C. L-NAME was not detected in maternal nor fetal plasma. In contrast, fetal to maternal L-NOARG ratio was 100% in all L-NAME groups. CONCLUSION These data demonstrate that L-NAME induced placental hypovascularization. The active L-NOARG metabolite is found in maternal and fetal plasma at similar concentrations. This could impact the fetal growth and reduces the interest of this model to study fetal outcomes of placental hypoperfusion.

Ventouse Kiwi® versus forceps et spatules: évaluation de la morbidité maternelle et fœtale. À propos de 169 cas

AIM To evaluate maternal and fetal complications resulting from the use of the Kiwi vacuum extractor and to compare them with those resulting from the use of forceps or spatula. PATIENTS AND METHODS Patients who had instrumental extraction between November 2006 and April 2007 were included in a unicentric retrospective study. Complications resulting from the use of Kiwi vacuum extractor and those of other instruments were compared. RESULTS One hundred and sixty-nine patients where included, 79 had extraction with Kiwi vacuum extractor. The two populations (women having extraction with Kiwi and woman having extraction with spatula or forceps) were similar in terms of maternal characteristics, progress of labour and delivery. The rate of episiotomies was significantly lower with KIWI (73.1% versus 94.4%; P=0.0001), as well as was postpartum haemorrhage rate (8.9 % versus 18.9%; P=0.04). No perineal tear of second or third degree occurred with Kiwi. Kiwi vacuum extractor was associated with a higher rate of shoulder dystocia (12.8% versus 6.7%, NS), but related fetal complication rates were similar in the two groups. The extraction failure rate was significantly higher with Kiwi (11.4% versus 4.4%; P=0.04), but cesarean section rate was similar for the two groups (1.3 % versus 4.4%). DISCUSSION AND CONCLUSION This study is the first comparing complications occurring after extraction with KIWI vacuum extractor to those occurring with other instruments. Although the results are limited by the retrospective nature of the study and the small size of the workforce, our study suggests that Kiwi vacuum extractor is associated with a lower rate of maternal complications and a rate of fetal complication similar to other kind of instruments. This instrument should be promoted and taught to younger patricians. Our study also revealed higher failure and shoulder dystocia rates. Larger studies are needed to better evaluate risks factor concerning these two complications in order to optimise the use of Kiwi vacuum extractor.

Critères objectifs de gravité en cas d’hémorragie grave du post-partum : à propos de 310 cas

OBJECTIVES Postpartum haemorrhage (PPH) is a major contributor to maternal morbidity and mortality in France. The objective of our study was to reveal predictive factors of severity or cure, allowing an adapted management as less invasive as possible, in case of severe PPH. PATIENTS AND METHODS This retrospective study included 310 patients, who had been treated for a severe PPH in Lariboisière university hospital from April 2007 to April 2009. RESULTS The predictive factors found for an invasive management (surgery or embolization) are: at clinical examination, heart rate (88 versus 100 pulses per minute), importance of bleeding and the tonicity of the uterine globe. At biological examination, they are haemoglobin level (9 versus 8.2g/dL) and clotting factors, especially fibrinogen (3 versus 2g/L) and prothrombin time (PT) (76 versus 63%). The identified cure factors are the same ones as severity factors. With multivariate analysis, initial independent predictive factors about an invasive management were: the tonicity of the uterine globe (OR=0.14), heart frequency (OR=1.3) and PT (OR=0.76). DISCUSSION AND CONCLUSION In case of severe haemorrhage, there may be the question of transfer of the patient. The difficulty is to avoid unnecessary transport, without delay for the future care. Very few studies searched predictive factors of severity or cure. Our study found, as predictive factors of invasive treatment, elements of physical examination (heart rate and the tonicity of the uterine globe) and biological factors (hemoglobin level and clotting factors).

P05.07: Three-dimensional power Doppler of uteroplacental vascularisation in third trimester: comparison between normal and placental insufficiency pregnancies ( EVUPA study)

Methods: Serum s-Flt-1 and PlGF and their ratio pre-eclamptic index (PEI) were measured in a case-control study of patients that developed PE before or after 34 weeks and unaffected controls. Pre-eclampsia was defined by blood pressure > 140/90mmHg and proteinuria > 300mg/24h. We analysed s-Flt-1 and PlGF (Brahms Kryptor). PEI was calculated for patients before and after 34 weeks of pregnancy. We observed gestational age at delivery (GA), incidence of PE, HELLP syndrome, FGR, SGA, IUFD and perinatal outcomes. Statistical analysis was performed using IBM SPSS Statistics 24. Results: Our study included 339 patients. Average maternal age was 32.9 years, average BMI 24.9, 43% was primigravids and 56% was nulliparous. Patients with subsequent adverse outcomes (n=87) had significantly higher sFlt-1, lower PlGF and higher PEI than women without adverse outcomes (n=252), p<0.001. PEI ratio correlated with prematurity. GA was significantly lower in the PE group: 34.7 vs 39.5 weeks, p<0.001. We calculated a cut-off for PEI ratio (>300) with good sensitivity and specificity for prediction of early PE. This cut-off shows good prediction value (AUC 0.86) for measurements by Brahms Kryptor. Conclusions: Our study shows that previously published PEI cut-off levels did not improve pre-eclampsia detection when measuring sFlt-1/PlGF ratio with Brahms Kryptor in our setting. We propose cut-off (PEI > 300) that shows high diagnostic accuracy for early PE. Further analysis is needed.

OC14.02: The practice of abdominal ultrasound in cases of severe or life‐threatening post‐partum haemorrhage: evaluation in 137 patients in a French tertiary care center

O. Morel1, R. Lousquy2, C. Malartic1, E. Gayat3, Y. Fargeaudou4, P. Soyer4, E. Barranger2 1Obstetrics and Gynecology, Maternite Regionale Universitaire de Nancy, Nancy, France; 2Obstetrics and Gynaecology Department, Lariboisiere Hospital, AP-HP, Paris, France; 3Anesthesiology Department, Lariboisiere Hospital, AP-HP, Paris, France; 4Interventional Radiology Unit, Lariboisiere Hospital, AP-HP, Paris, France