Pregnancy outcome in patients with a medical history of immunoglobulin A vasculitis: a case-control study

OBJECTIVE

Data on obstetric outcomes in patients with a history of immunoglobulin A vasculitis (IgA-V) are lacking. The aim of this study was to assess maternal, neonatal, and vasculitis outcomes during pregnancy.

METHOD

We conducted a French retrospective case-control study. Pregnancies of patients with a history of IgA-V (cases) were retrospectively studied and compared to pregnancies in women who developed IgA-V after their pregnancies and to pregnancies in healthy women (controls).

RESULTS

Twenty-six pregnancies in patients with a history of IgA-V were included and compared to 15 pregnancies in women who later developed IgA-V and 52 pregnancies in healthy women. Both gestational hypertension and pre-eclampsia were more frequent in the case group than in the other groups (23% vs 0% vs 0%, p < 0.01; 12% vs 7% vs 0%, p = 0.04). Hypertensive disorder of pregnancy occurred more frequently in patients with pre-existing kidney disease (78% vs 12%, p < 0.01). Caesarean section was more often performed in the case group than in the other groups (27% vs 0% vs 10%, p = 0.04). No foetal loss or maternal deaths occurred. There were no differences in delivery term or birth weight. No vasculitis flares were observed during pregnancy.

CONCLUSION

Women with a history of IgA-V appear to be at higher risk for gestational hypertension and pre-eclampsia, especially in cases with renal involvement; however, both mother and newborn outcomes appear to be favourable.

[Intrahepatic cholestasis of pregnancy: French College of Obstetricians and Gynecologists guidelines for clinical practice]

OBJECTIVE

To identify strategies for reducing neonatal and maternal morbidity associated with intrahepatic cholestasis pregnancy (ICP).

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE methodology with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 14 questions (from 12 PICO questions and one definition question outside the PICO format), there was agreement between the working group and the external reviewers on 14 (100%). The level of evidence of the literature was insufficient to provide a recommendation on two questions. ICP is defined by the occurrence of suggestive pruritus (palmoplantar, nocturnal) associated with a total bile acid level>10μmol/L or an alanine transaminase level above 2N after ruling out differential diagnoses. In the absence of suggestive symptoms of a differential diagnosis, it is recommended not to carry out additional biological or ultrasound tests. In women with CIP, ursodeoxycholic acid is recommended to reduce the intensity of maternal pruritus (Strong recommendation. Quality of the evidence moderate) and to decrease the level of total bile acids and alanine transaminases. (Strong recommendation. Quality of the evidence moderate). S-adenosyl-methionine, dexamethasone, guar gum or activated charcoal should not be used to reduce the intensity of maternal pruritus (Strong recommendation. Quality of evidence low), and there is insufficient data to recommend the use of antihistamines (No recommendation. Quality of evidence low). Rifampicin (Weak recommendation. Very low quality of evidence) or plasma exchange (Strong recommendation. Very low quality of evidence) should not be used to reduce maternal pruritus and perinatal morbidity. Serum monitoring of bile acids is recommended to reduce perinatal morbidity and mortality (stillbirth, prematurity) (Low recommendation. Quality of the evidence low). The level of evidence is insufficient to determine whether fetal heart rate or fetal ultrasound monitoring are useful to reduce perinatal morbidity (No recommendation). Birth is recommended when bile acid level is above 99μmol/L from 36 weeks gestation to reduce perinatal morbidity, in particular stillbirth. When bile acid level is above 99μmol/L is below 100μmol/L, women should be informed that induction of labor could be considered 37 and 39 weeks gestation to reduce perinatal morbidity. (Strong recommendation. Quality of evidence low). In postpartum, total bile acids and alanine transaminases level should be checked and normalized before prescribing estrogen-progestin contraception, ideally with a low estrogen dose (risk of recurrence of pruritus and cytolysis) (Low recommendation. Quality of evidence very low).

CONCLUSION

Although the quality of evidence regarding ICP gestational cholestasis remains low, there is a strong consensus in France, as shown by our Delphi study, on how to manage women with ICP. The reference first-line treatment is ursodeoxycholic acid.

Long-term evaluation of the impact of delivery modalities on anal continence in women with Crohn's disease

CONTEXT

Crohn's disease (CD) and sphincter injury during childbirth are two risk factors for anal incontinence (AI). The long-term risk of developing AI in women with CD after childbirth has never been studied.

GOAL

The main objective of the study is to assess the risk of developing severe AI after childbirth in women with CD.

METHODS

A retrospective study was performed in women with CD who gave birth in a French "Level 3" maternity hospital between 2000 and 2015. The primary endpoint was severe AI as defined by a Wexner score≥9 or a St. Mark's score≥9, at least five years after childbirth. The association between delivery route and occurrence of severe AI was assessed by univariate and multivariate analyses.

RESULTS

Forty-six women were included, 32 of whom were delivered vaginally and 14 by Caesarean section. Thirty-one percent of the women had severe AI according to the Wexner score, and 41% according to the St. Mark's score. Two factors were associated with severe AI: vaginal delivery and the occurrence of an obstetric perineal injury: (crude OR=8.89, 95% (CI: 1.03-76.57) and crude OR=4.16, 95% (CI: 1.06-16.27) respectively for AI defined by the Wexner score, and crude OR=6.8, 95% (CI: 1.30-35.41) and crude OR=4.3, 95% (CI: 1.23-15.2) for AI defined by the St. Mark's score). After adjusting for confounding factors, only vaginal delivery was associated with severe AI (adjusted OR=22.86, 95% CI: 1.52-931.28 for a Wexner score≥9 and adjusted OR=16. 11 (95% CI: 1.43-533.26) for a St Mark score≥9).

CONCLUSION

Vaginal birth was associated with the development of severe long-term AI in women with CD.

Prenatal stomach position predicts gastrointestinal morbidity at 2 years in fetuses with left-sided congenital diaphragmatic hernia

OBJECTIVE

The long-term morbidity associated with isolated left-sided congenital diaphragmatic hernia (CDH) has been described previously. However, antenatal criteria impacting gastrointestinal morbidity (GIM) are not yet defined. The objective of this study was to evaluate the effect of fetal stomach position on the risk of GIM at 2 years of age in children with left-sided CDH.

METHODS

This was a retrospective, observational multicenter cohort study of data obtained from January 2010 to January 2014, that included patients whose fetus had isolated left-sided CDH, with or without fetal endoscopic tracheal occlusion (FETO). Prenatal maternal, fetal and pediatric data were collected. Fetal stomach position was evaluated a posteriori by two observers, using ultrasound images at the level of the four-chamber view of the heart that had been obtained to calculate the observed-to-expected lung-area-to-head-circumference ratio (O/E-LHR). Fetal stomach position was graded as follows: Grade 1, stomach not visualized; Grade 2, stomach visualized anteriorly, next to the apex of the heart, with no structure in between the stomach and the sternum; Grade 3, stomach visualized alongside the left ventricle of the heart, and abdominal structures anteriorly; or Grade 4, as Grade 3 but with stomach posterior to the level of the atrioventricular heart valves. The primary outcome was GIM at 2 years of age, assessed in a composite manner, including the occurrence of gastroesophageal reflux disease, need for gastrostomy, duration of parenteral and enteral nutrition and persistence of oral aversion. Regression analysis was performed in order to investigate the effect of O/E-LHR, stomach position and FETO on various GIM outcome variables.

RESULTS

Forty-seven patients with fetal left-sided CDH were included in the analysis. Thirteen (27.7%) infants did not meet the criterion of exclusive oral feeding at 2 years of age. Fetal stomach position grade was associated significantly and independently with the duration of parenteral nutrition (odds ratio (OR), 19.86; P = 0.031) and persistence of oral aversion at 2 years (OR, 3.40; P = 0.006). On multivariate analysis, O/E-LHR was predictive of the need for prosthetic patch repair, but not for GIM. FETO did not seem to affect the risk of GIM at 2 years.

CONCLUSION

In isolated left-sided CDH, fetal stomach position is the only factor that is predictive of GIM at 2 years of age. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study

OBJECTIVE

To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section.

DESIGN

Prospective population-based study.

SETTING

All 176 maternity hospitals of eight French regions.

POPULATION

Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries.

METHODS

Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared.

MAIN OUTCOME MEASURES

Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes.

RESULTS

The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally.

CONCLUSION

More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean.

TWEETABLE ABSTRACT

Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

A randomised controlled trial of amnioexchange for fetal gastroschisis

OBJECTIVE

Morbidity in fetuses affected by gastroschisis is mainly the result of bowel ischaemic and inflammatory processes. Experimental studies on animal models show that clearing amniotic fluid from the digestive secretions by amnioexchange procedures reduces the inflammatory process. We evaluated the benefit of the amnioexchange procedure for fetal gastroschisis in humans.

DESIGN

Prospective, interventional, randomised study.

SETTING

Eight referral centres for fetal medicine.

POPULATION

Pregnant women carrying a fetus with gastroschisis.

METHODS

We compared, in utero, amnioexchange with a sham procedure. The protocol included, in both arms, steroid injections at 30 weeks of gestation and the use of postnatal minimal enteral feeding.

MAIN OUTCOME MEASURES

The primary outcome was a composite variable based on the duration of ventilation and parenteral nutrition. Secondary outcomes were the effectiveness and safety of the amnioexchange procedure, including the rate of perinatal death, time to full enteral feeding, primary closure, and late feeding disorders.

RESULTS

Sixty-four patients were randomised. There was no difference in the composite criteria between the amnioexchange and control groups. Based on an intention-to-treat analysis, there were no significant between-group differences in pregnancy outcome or complications. When studying the relationship between digestive compounds and amniotic fluid inflammatory markers, a clear correlation was found between bile acid and both ferritin and interleukin 1β (IL1β).

CONCLUSIONS

In humans, amnioexchange, as described in our protocol, is not an option for fetal care; however, we provide supplementary proof of the involvement of inflammation in the pathogenicity of gastroschisis and suggest that future research should aim at reducing inflammation. ClinicalTrials.gov: NCT00127946.

TWEETABLE ABSTRACT

A prospective, interventional, randomised study shows no benefit of amnioexchange for fetal gastroschisis in humans.

In-utero aspiration vs expectant management of anechoic fetal ovarian cysts: open randomized controlled trial

OBJECTIVE

To assess the efficacy and safety of in-utero aspiration (IUA) of anechoic fetal ovarian cysts.

METHODS

This multicenter, prospective, randomized open trial in two parallel groups included women from nine outpatient fetal medicine departments with singleton pregnancy ≥ 28 weeks of gestation and a female fetus with an ultrasound-diagnosed simple ovarian cyst, defined as a single fully anechoic cystic structure measuring ≥ 30 mm. They were allocated randomly to IUA under ultrasound guidance or expectant management. All procedures were performed by trained senior obstetricians. Primary outcome was need for neonatal intervention, by laparoscopy, laparotomy or transabdominal aspiration. Secondary outcomes were in-utero involution of the cyst and oophorectomy at birth. Analyses were conducted according to the intention-to-treat principle.

RESULTS

Of 61 participants, 34 were allocated to IUA and 27 to expectant management. Three IUA procedures (9%) could not be performed (one due to fetal position and two due to aspirations being dry). The remaining 31 IUA procedures were uneventful. The incidence of neonatal intervention did not differ significantly between the IUA and the expectant management groups (20.6% vs 37.0%; relative risk (RR), 0.55; 95% CI, 0.24-1.27). Nonetheless, IUA was associated with increased incidence of in-utero involution of the cyst (47.1% vs 18.5%; RR, 2.54; 95% CI, 1.07-6.05) and reduced rate of oophorectomy (3.0% vs 22.0%; RR, 0.13; 95% CI, 0.02-1.03) compared with expectant management.

CONCLUSION

IUA of anechoic fetal ovarian cysts, compared with expectant management, was not associated with a reduction in overall neonatal interventions but was associated with a reduced oophorectomy rate. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Comparative determination of placental perfusion by magnetic resonance imaging and contrast-enhanced ultrasound in a murine model of intrauterine growth restriction

INTRODUCTION

Exploration of placental perfusion is essential in screening for dysfunctions impairing fetal growth. The objective of this study was to assess the potential value of contrast-enhanced ultrasonography (CEUS) and magnetic resonance imaging (MRI) for examining placental perfusion in a murine model of intrauterine growth restriction (IUGR). We also studied the reproducibility of perfusion quantification by CEUS.

METHODS

Pregnant Sprague Dawley rat models of IUGR were studied during the third trimester. Unilateral uterine artery ligation induced IUGR. Placental perfusion was evaluated by CEUS and perfusion MRI with gadolinium for both ligated and control fetoplacental units. The kinetic parameters of the two imaging modalities were then compared.

RESULTS

The analysis included 20 rats. The study showed good reproducibility of the CEUS indicators. The CEUS perfusion index approximated the blood flow rate and was halved in the ligation group (27.9 [u.a] (±14.8)) versus 61 [u.a] (±22.3) on the control side (P = 0.0003). MRI with gadolinium injection showed a clear reduction in the blood flow rate to 51.2 mL/min/100 mL (IQR 34.9-54.9) in the ligated horn, compared with 90.9 mL/min/100 mL (IQR 85.1-95.7) for the control side (P < 0.0001). The semiquantitative indicators obtained from the kinetic curves for both CEUS and MRI showed similar trends. Nonetheless, values were more widely dispersed with CEUS than MRI.

DISCUSSION

The similar results for the quantification of placental perfusion by MRI and CEUS reinforce the likelihood that CEUS can be used to identify IUGR in a murine model induced by uterine vessel ligation.

[Fetal MRI practices in a university prenatal center]

OBJECTIVES

Fetal MRI is a third intention examination to prenatal diagnosis. If its diagnostic value is well known in many pathologies, its place in the management of pregnancies remains unclear.

METHODS

We collected retrospectively demographical, radiological (fetal MRI indications, fetal anatomical region and diagnostic information provided by fetal MRI) and obstetrical data of pregnant patients in university prenatal center during a 5 years' period.

RESULTS

Among 2439 patients of the prenatal center, 196 (8%) patients with fetal MRI were included. The main anatomical regions studied were the brain (n=132, 67%), the thorax (n=31, 16%) and the abdomen (n=25, 13%). No cardiac fetal MRI was performed. Ninety-five percent of fetal MRI was consecutively of an ultrasound sign. Fetal brain MRI was abnormal in 65% of cases, the thoracic and abdominopelvic MRI in 81.5%. The ultrasound diagnosis was unchanged in 42%, completed in 50% and redirected in 8% of cases. A termination of pregnancy was deemed admissible in 31% of patients with MRI versus 21% in patients without MRI (P=0.001).

CONCLUSION

Fetal MRI requires selective indications and provides additional diagnostic information with important implications for the future of the pregnancy, particularly in case of severe and incurable pathologies. Our results could be useful as a reference basis for the comparison with others prenatal center practices.

Computed tomographic study of anatomical relationship between pubic symphysis and ischial spines to improve interpretation of intrapartum translabial ultrasound

OBJECTIVE

To analyze the anatomical relationship between the pubic symphysis and the ischial spines to determine reliable landmarks for the assessment of fetal head descent by intrapartum translabial ultrasound (ITU).

METHODS

All computed tomography (CT) scans performed for breech presentation and for twin delivery between 2006 and 2014 in a tertiary university hospital were obtained for measurement and analysis by two operators. The symphysis-left ischial spine angle (SIA) and the symphysis-left ischial spine distance (SID) were measured on three-dimensional reconstructions from the CT volume dataset. We calculated intra- and interobserver agreements for SIA and SID with 95% prediction intervals, created Bland-Altman plots with 95% limits of agreement and estimated the intraclass correlation coefficient (ICC). A sagittal plane projection from the SIA enabled calculation of a sagittal angle, corresponding to the angle of progression (AoP) on ITU.

RESULTS

SIA and SID were obtained from CT images from 458 women. Reproducibility was good for both SIA (intraobserver ICC, 0.94 (95% CI, 0.88-0.97) and interobserver ICC, 0.81 (95% CI, 0.66-0.92)) and SID (intraobserver ICC, 0.92 (95% CI, 0.82-0.97) and interobserver ICC, 0.83 (95% CI, 0.73-0.92)). The median SIA was 106° (interquartile range (IQR), 105-109°) and median SID was 26.1 (IQR, 23.4-29.5) mm. SIA and SID were not correlated with pelvic diameter or height. The 50^th percentile of AoP was 110°.

CONCLUSION

Knowledge of the anatomical relationship between the pubic symphysis and ischial spines makes it possible to establish a sonographic method for assesssing fetal head descent by taking into account the level of the ischial spines. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

[Indicated preterm birth in a type 3 maternity ward: Evaluation of practices]

The purpose of this study was to evaluate the proportion of indicated preterm births among all preterm births in a type 3 maternity ward; to assess practices in terms of mode of delivery in such cases; and to analyse the observed outcomes for such deliveries.

MATERIALS AND METHODS

A retrospective study was conducted in the obstetrics department of the regional university hospital of Tours (type 3 maternity ward) over a 22-month period. Women with an indicated preterm birth between 22 and 37 weeks of gestation, for whom vaginal delivery was possible, were included in the study. For every woman, the choice of mode of delivery (caesarean before labour or induction of labour) as well as maternal, obstetrical and neonatal factors were recorded.

RESULTS

From January 2012 to October 2013, 539 deliveries were preterm among which 42.5% were indicated preterm births. Out of 114 women for whom vaginal delivery was possible, 33.3% had a caesarean before labour and 66.7% had an induction of labour. The choice of mode of delivery is influenced by various factors such as local conditions, gestational age and type of obstetrical pathologies. Moreover, birth weight and Apgar score are significantly lower and the hospitalisation rate of newborns is significantly higher in the "caesarean before labour" group.

CONCLUSION

Indicated preterm births represent almost half of preterm births in the maternity ward. A third of these indicated preterm births were caesareans before labour. Due to the neonatal morbidity resulting from indicated preterm birth, it is essential to regularly reassess indications of indicated preterm birth.

Fetal growth restriction and intra-uterine growth restriction: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians

Small for gestational age (SGA) is defined by weight (in utero estimated fetal weight or birth weight) below the 10th percentile (professional consensus). Severe SGA is SGA below the third percentile (professional consensus). Fetal growth restriction (FGR) or intra-uterine growth restriction (IUGR) usually correspond with SGA associated with evidence indicating abnormal growth (with or without abnormal uterine and/or umbilical Doppler): arrest of growth or a shift in its rate measured longitudinally (at least two measurements, 3 weeks apart) (professional consensus). More rarely, they may correspond with inadequate growth, with weight near the 10th percentile without being SGA (LE2). Birthweight curves are not appropriate for the identification of SGA at early gestational ages because of the disorders associated with preterm delivery. In utero curves represent physiological growth more reliably (LE2). In diagnostic (or reference) ultrasound, the use of growth curves adjusted for maternal height and weight, parity and fetal sex is recommended (professional consensus). In screening, the use of adjusted curves must be assessed in pilot regions to determine the schedule for their subsequent introduction at national level. This choice is based on evidence of feasibility and the absence of any proven benefits for individualized curves for perinatal health in the general population (professional consensus). Children born with FGR or SGA have a higher risk of minor cognitive deficits, school problems and metabolic syndrome in adulthood. The role of preterm delivery in these complications is linked. The measurement of fundal height remains relevant to screening after 22 weeks of gestation (Grade C). The biometric ultrasound indicators recommended are: head circumference (HC), abdominal circumference (AC) and femur length (FL) (professional consensus). They allow calculation of estimated fetal weight (EFW), which, with AC, is the most relevant indicator for screening. Hadlock's EFW formula with three indicators (HC, AC and FL) should ideally be used (Grade B). The ultrasound report must specify the percentile of the EFW (Grade C). Verification of the date of conception is essential. It is based on the crown-rump length between 11 and 14 weeks of gestation (Grade A). The HC, AC and FL measurements must be related to the appropriate reference curves (professional consensus); those modelled from College Francais d'Echographie Fetale data are recommended because they are multicentere French curves (professional consensus). Whether or not a work-up should be performed and its content depend on the context (gestational age, severity of biometric abnormalities, other ultrasound data, parents' wishes, etc.) (professional consensus). Such a work-up only makes sense if it might modify pregnancy management and, in particular, if it has the potential to reduce perinatal and long-term morbidity and mortality (professional consensus). The use of umbilical artery Doppler velocimetry is associated with better newborn health status in populations at risk, especially in those with FGR (Grade A). This Doppler examination must be the first-line tool for surveillance of fetuses with SGA and FGR (professional consensus). A course of corticosteroids is recommended for women with an FGR fetus, and for whom delivery before 34 weeks of gestation is envisaged (Grade C). Magnesium sulphate should be prescribed for preterm deliveries before 32-33 weeks of gestation (Grade A). The same management should apply for preterm FGR deliveries (Grade C). In cases of FGR, fetal growth must be monitored at intervals of no less than 2 weeks, and ideally 3 weeks (professional consensus). Referral to a Level IIb or III maternity ward must be proposed in cases of EFW <1500g, potential birth before 32-34 weeks of gestation (absent or reversed umbilical end-diastolic flow, abnormal venous Doppler) or a fetal disease associated with any of these (professional consensus). Systematic caesarean deliveries for FGR are not recommended (Grade C). In cases of vaginal delivery, fetal heart rate must be monitored continuously during labour, and any delay before intervention must be faster than in low-risk situations (professional consensus). Regional anaesthesia is preferred in trials of vaginal delivery, as in planned caesareans. Morbidity and mortality are higher in SGA newborns than in normal-weight newborns of the same gestational age (LE3). The risk of neonatal mortality is two to four times higher in SGA newborns than in non-SGA preterm and full-term infants (LE2). Initial management of an SGA newborn includes combatting hypothermia by maintaining the heat chain (survival blanket), ventilation with a pressure-controlled insufflator, if necessary, and close monitoring of capillary blood glucose (professional consensus). Testing for antiphospholipids (anticardiolipin, circulating anticoagulant, anti-beta2-GP1) is recommended in women with previous severe FGR (below third percentile) that led to birth before 34 weeks of gestation (professional consensus). It is recommended that aspirin should be prescribed to women with a history of pre-eclampsia before 34 weeks of gestation, and/or FGR below the fifth percentile with a probable vascular origin (professional consensus). Aspirin must be taken in the evening or at least 8h after awakening (Grade B), before 16 weeks of gestation, at a dose of 100-160mg/day (Grade A).

Biparietal/transverse abdominal diameter ratio ≤ 1: potential marker for open spina bifida at 11-13-week scan

OBJECTIVE

In the first trimester of pregnancy, a biparietal diameter (BPD) below the 5(th) percentile is a simple marker that enables the prenatal detection of half of all cases of open spina bifida. We hypothesized that relating the BPD measurement to the transverse abdominal diameter (TAD) might be another simple and effective screening method. In this study we assessed the performance of using the BPD/TAD ratio during the first trimester of pregnancy in screening for open spina bifida.

METHODS

A total of 20,551 first-trimester ultrasound scans (11-13 weeks' gestation), performed between 2000 and 2013, were analyzed retrospectively; there were 26 cases of open spina bifida and 17,665 unaffected pregnancies with a crown-rump length of 45-84 mm and a record of both BPD and TAD measurements.

RESULTS

The mean (± SD) BPD/TAD ratio was 1.00 ± 0.06 for fetuses with spina bifida and 1.13 ± 0.06 for those without (P < 0.0001). A BPD ≤ 5(th) percentile enabled the prenatal detection of 46.2% of spina bifida cases, while a BPD/TAD ratio of ≤ 1.00 detected 69.2%. If we considered cases in which either BPD was ≤ 5(th) percentile or BPD/TAD ratio was ≤ 1, we identified 76.9% of cases. In the latter case, the false-positive rate was 5.1%, while that for using a combination of both BPD ≤ 5th percentile and BPD/TAD ratio ≤ 1 was 0.6%, with a sensitivity of 38.5%. The positive predictive value of using a combination of BPD ≤ 5th percentile and BPD/TAD ratio ≤ 1 for detecting spina bifida was 8.5%.

CONCLUSIONS

Between 11 and 13 weeks' gestation, relating BPD to TAD improves considerably the diagnostic performance of using BPD measurement alone in screening for open spina bifida. Screening using this marker is simple and applicable to a large population.

[Selective termination of pregnancy for monochorionic twins: a national survey of professional practice]

OBJECTIVES

Selective Termination of Pregnancy (STOP) for discordant fetal condition in monochorionic twin pregnancy is a rarely performed procedure raising technical and ethical considerations. There are no epidemiological data available in France concerning STOP and no guideline or scientific consensus on how or when to perform has been published.

MATERIALS AND METHODS

We conducted a study of national practice using a declarative questionnaire sent by e-mail to each medical coordinator of every 48 Multidisciplinary Center for Prenatal Diagnosis in France. The questions focused on the issues of 2010 and 2011. Two reminders were sent in case of no answer.

RESULTS

The response rate to the questionnaire was 56 %; 81 % of centers have experienced at least once during the two years 2010-2011 a discordant fetal anomaly in monochorionic twin pregnancy. Only 59 % of centers perform all the techniques of STOP. When interruption of the umbilical blood flow is considered, bipolar forceps coagulation is the most used (75 %). Achieving STOP during a cesarean section is a common practice (75 % of centers). Locoregional anesthesia is the preferred mode of anesthesia for STOP.

DISCUSSION AND CONCLUSION

STOP on monochorionic twin pregnancy is not practiced in all Multidisciplinary Center for Prenatal Diagnosis in France. The most widely practiced and most studied technique is bipolar forceps coagulation. The option of an expectant management should always be considered and its risks should be balanced with those of STOP. The practice of STOP during cesarean section is not unusual.

[How many ultrasound examinations for low-risk pregnancies monitoring?]

OBJECTIVES

To assess the average number of ultrasounds per low-risk pregnancy and estimate the proportion of ultrasound scans without morphological examination of the fetus (non-morphological ultrasounds).

RESEARCH DESIGN AND SETTING

Retrospective study conducted among patients who delivered at the University Hospital of Tours (France) between January 2012 and February 2012.

PARTICIPANTS

Women with a singleton pregnancy who delivered after 37weeks' gestation an eutrophic child.

DATA COLLECTION

Distinction was made between morphological and non-morphological ultrasound examinations. The type of non-morphological ultrasound examination was analyzed.

RESULTS AND DISCUSSION

Among the 300 patients of the study, the average number of scans per patient was five (SD=1.9), which is higher than the three recommended ultrasounds for these low-risk pregnancies. In this study, 77% of patients were receiving more than three ultrasounds. Moreover, 28.1% of all ultrasound examinations were non-morphological examinations. Among them, 42.2% of examinations were performed in the third trimester of pregnancy. Among these non-morphological ultrasounds performed in the third trimester, there were 51.9% of fetal biometric measurements and cervical length measurements in 18.5% of cases. We believe that resorting to non-morphological ultrasounds during low-risk pregnancies is not censurable in itself and should even be promoted. Nevertheless, we should improve the relevance of all these examinations.

Decrease of uteroplacental blood flow after feticide during second-trimester pregnancy termination with complete placenta previa: quantitative analysis using contrast-enhanced ultrasound imaging

Contrast enhanced ultrasound (CEUS) was used to quantify the dynamic changes in uteroplacental blood flow before and after the interruption of fetal villus circulation resulting from feticide during a second trimester pregnancy termination in a patient with complete placenta previa. Quantitative analysis was performed on time-intensity curves acquired 24 h before and 48 h and 120 h after feticide and demonstrated the persistence of utero-placental blood flow with a progressive and two-step reduction in intervillous space and uteroplacental blood flow. Our results suggest that placental blood flow reduction after interruption of fetal circulation is a progressive and delayed mechanism.

[Cervical ripening with balloon catheter for scared uterus: a three-year retrospective study]

OBJECTIVES

To evaluate, for women with scared uterus, the mechanical cervical ripening with balloon catheter.

METHODS

We conducted a retrospective study of our practice of ripening for scared uterus from january 2010 to august 2012. Feasibility, Bishop's score, birth modalities and complications for mothers and babies during this ripening were studied.

RESULTS

Thirty-nine medical files were analysed. All patients could have mechanical ripening independently of the internal os status (open or not). The cervical ripening with balloon catheter improved Bishop's score before induction of labour, from 3.54 ± 1.23 to 5.38 ± 1.47 (p=0.02). 64.1% of women had a vaginal delivery. Concerning the predictive factors for vaginal delivery, we only found significant influence of a body mass index less than 30kg/m² (p=0.03). We didn't find any maternal or neonatal complications in our population.

CONCLUSION

Mechanical ripening for scared uterus seems to be a useful option to improve vaginal delivery without increasing maternal and foetal morbidity. Anyway, these results have to be confirmed by a randomized controlled trial on a specific scared uterus population.

Three-dimensional transvaginal sonography in third-trimester evaluation of placenta previa

In cases of placenta previa, the distance from the placental edge to the internal os is determinant in deciding on the mode of delivery that will minimize the risk of hemorrhage. The reproducibility and interobserver reliability of this measure are unknown. The internal os is not a point, as two-dimensional (2D) ultrasonography might suggest, but an oval patch that has a measurable width, which may be as wide as the distance separating it from the placenta. It is therefore difficult to determine the exact location of the os using a 2D sectional plane. We report the case of a nulliparous woman admitted for vaginal bleeding at 37 weeks' gestation in whom transvaginal ultrasound examination showed placenta previa, but for which two sonographers reported different measurements for the distance between the placental edge and the internal os. We describe a technique to measure this distance using multiplanar three-dimensional (3D) ultrasound imaging, which allows the smallest distance between the middle of the os and the edge of the placenta, which appears as a line, to be determined. In this case, measurement using 3D ultrasound showed a shorter distance than was suggested by 2D examination. This led us to schedule a Cesarean section delivery, during which there was minimal bleeding. Standardization of 3D measurements should make it possible to define more relevant cut-offs for determining the management of cases of placenta previa.

New insights into uteroplacental perfusion: quantitative analysis using Doppler and contrast-enhanced ultrasound imaging

OBJECTIVE

To monitor and quantify uteroplacental perfusion in rat pregnancies by Doppler ultrasound (DUS) and contrast-enhanced ultrasound (CEUS).

METHODS

Fourteen rats were randomized in two groups (the CEUS group and the control group). On days 8, 11, 14, 17, 19 and 20 of gestation, we used DUS to measure the resistance index (RI), pulsatility index and blood velocity in the uterine, arcuate and umbilical arteries in both groups. On days 14, 17 and 20, one group was also examined by CEUS. Quantitative perfusion parameters were calculated in 4 compartments (mesometrial triangle, placenta, umbilical cord and fetus) and compared.

RESULTS

The DUS measurement showed that the RI of the uterine and arcuate arteries decreased (p < 0.01) from day 14 to day 17, while velocity increased each of these arteries (p < 0.01 and p < 0.05, respectively). Quantification of uteroplacental perfusion by CEUS in bolus mode revealed that blood volume and local blood flow increased from day 14 to day 20 in the mesometrial triangle (p < 0.01) and the placenta (p < 0.05). In the CEUS destruction-replenishment mode, the perfusion parameters showed trends similar to those observed in bolus mode. No microbubbles were detected in the umbilical vein or fetal compartments. The weights of pups in the two groups did not differ significantly.

CONCLUSIONS

CEUS estimates of placental perfusion complement the data provided by DUS.