Yves Ville

Preliminary experience with endoscopic laser surgery for severe twin-twin transfusion syndrome

Background In monozygotic twin pregnancies, there are placental vascular communications between the two fetuses. In 15 percent of such pregnancies there is an imbalance in net blood flow between the twins, resulting in the twin–twin transfusion syndrome. The recipient twin may have severe hydramnios during the second trimester of pregnancy, and there is a high risk of perinatal death and cerebral palsy in survivors. This condition can now be treated by endoscopic coagulation of the vascular anastomoses responsible for fetofetal transfusion with a neodymium:yttrium–aluminum–garnet (Nd:YAG) laser. Methods We performed intrauterine surgery in 45 pregnant women carrying twins at 15 to 28 weeks of gestation (median, 21); in each case there was severe hydramnios in one fetus due to the twin–twin transfusion syndrome. With the use of local anesthesia and continuous ultrasound visualization, a rigid fetoscope 2 mm in diameter, housed in a 2.7-mm cannula, was introduced transabdominally into the amniotic cavity of...

ENDOSCOPIC LASER COAGULATION IN THE MANAGEMENT OF SEVERE TWIN-TO-TWIN TRANSFUSION SYNDROME

Objective To assess the clinical effectiveness of endoscopic laser coagulation of placental vessels in the

Analgesic effect of breast feeding in term neonates: randomised controlled trial

Abstract Objectives: To investigate whether breast feeding is effective for pain relief during venepuncture in term neonates and compare any effect with that of oral glucose combined with a pacifier. Design: Randomised controlled trial. Participants: 180 term newborn infants undergoing venepuncture; 45 in each group. Interventions: During venepuncture infants were either breast fed (group 1), held in their mothers arms without breast feeding (group 2), given 1 ml of sterile water as placebo (group 3), or given 1 ml of 30% glucose followed by pacifier (group 4). Video recordings of the procedure were assessed by two observers blinded to the purpose of the study. Main outcome measures: Pain related behaviours evaluated with two acute pain rating scales: the Douleur Aiguë Nouveau-né scale (range 0 to 10) and the premature infant pain profile scale (range 0 to 18). Results: Median pain scores (interquartile range) for breast feeding, held in mothers arms, placebo, and 30% glucose plus pacifier groups were 1 (0–3), 10 (8.5-10), 10 (7.5-10), and 3 (0–5) with the Douleur Aiguë Nouveau-né scale and 4.5 (2.25-8), 13 (10.5-15), 12 (9–13), and 4 (1–6) with the premature infant pain profile scale. Analysis of variance showed significantly different median pain scores (P<0.0001) among the groups. There were significant reductions in both scores for the breast feeding and glucose plus pacifier groups compared with the other two groups (P<0.0001, two tailed Mann-Whitney U tests between groups). The difference in Douleur Aiguë Nouveau-né scores between breast feeding and glucose plus pacifier groups was not significant (P=0.16). Conclusions: Breast feeding effectively reduces response to pain during minor invasive procedure in term neonates. What is already known on this topic Current pharmacological treatments are not appropriate for pain relief during minor procedures like venepuncture or heel prick in newborn infants Oral sweet solutions, non-nutritive sucking, and skin to skin contact reduce procedural pain in newborn infants What this study adds Breast feeding during a painful procedure effectively reduces the response to pain in newborn infants The analgesic properties of breast feeding are at least as potent as the combination of sweet solutions and a pacifier

Maternal administration of valaciclovir in symptomatic intrauterine cytomegalovirus infection

Objectives  To report early experience with treatment of intrauterine cytomegalovirus (CMV) infection using maternal oral administration of valaciclovir (VACV).

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.

The value of middle cerebral artery peak systolic velocity in the diagnosis of fetal anemia after intrauterine death of one monochorionic twin

OBJECTIVE The purpose of this study was to assess the value of the fetal middle cerebral artery peak systolic velocity in the prediction of anemia within 24 hours of the death of one monochorionic twin in twin-to-twin-transfusion syndrome and to establish the correlation between middle cerebral artery peak systolic velocity and hemoglobin concentration in fetuses who are at risk for acute anemia. STUDY DESIGN Doppler examination of the middle cerebral artery peak systolic velocity was performed in 20 monochorionic survivors of pregnancies that were complicated by twin-to-twin-transfusion syndrome that occurred between 20 and 34 weeks of gestation. Doppler examination was performed before cordocentesis and after intrauterine transfusion when appropriate. Both hemoglobin concentration and middle cerebral artery peak systolic velocity were expressed in multiples of the median. Severe anemia was defined as hemoglobin concentration of <0.55 multiples of the median, and we used the cutoff point of 1.50 times the median values at any gestational age to calculate the sensitivity and specificity of middle cerebral artery peak systolic velocity in detecting moderate or severe anemia. RESULTS Fetal anemia was confirmed in 10 of 20 fetuses. We performed seven intrauterine transfusions. The sensitivity and specificity of middle cerebral artery peak systolic velocity in the prediction of severe fetal anemia were of 90%, with a false-negative rate of 10%. The correlation between peak systolic velocity and hemoglobin concentration both before and after transfusion was evaluated by regression analysis and was strongly significant. CONCLUSION In fetuses who are at risk of acute anemia, the measurement of middle cerebral artery peak systolic velocity was found to be a reliable noninvasive diagnostic tool and may be helpful in counseling and planning invasive assessment.

The relationships between antenatal management, the cause of delivery and neonatal outcome in a large cohort of very preterm singleton infants.

Objective To determine whether the cause of very preterm delivery influences neonatal outcome.

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.

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.