Cervical assessment at 22 and 27 weeks for the prediction of spontaneous birth before 34 weeks in twin pregnancies: is transvaginal sonography more accurate than digital examination?

OBJECTIVES

This study compared the accuracy of ultrasound cervical assessment (cervical length and cervical index) and digital examination (Bishop score and cervical score) in the prediction of spontaneous birth before 34 weeks in twin pregnancies.

METHODS

In a prospective multicenter study, digital examination and transvaginal sonography were performed consecutively in twin pregnancies attending for routine sonography at either 22 weeks (175 women) or 27 weeks (153 women). The digital examination took place first, and the Bishop score and cervical score (cervical length minus cervical dilatation) were calculated. Ultrasound measurements were then made of cervical length and funnel length to yield the cervical index (1 + funnel length/cervical length). The association between each variable and delivery before 34 weeks was tested by the Mann-Whitney U-test. The receiver-operating characteristics (ROC) curves of the ultrasound and digital indicators were determined for both gestational age periods, and the areas under the ROC curves compared. The best cut-off values for each indicator were used to determine predictive values for delivery before 34 weeks.

RESULTS

The median gestational age at delivery among the women included in the 22-week examination period was 36.0 (range, 21-40) weeks; 10.9% (19) gave birth spontaneously before 34 weeks. The median cervical length was 40 (range, 6-65) mm. All four parameters were predictors of delivery before 34 weeks. The areas under the ROC curves for cervical index, cervical length, Bishop score and cervical score did not differ significantly. The median gestational age at delivery among the women in the 27-week examination period was 36.0 (range, 27-40) weeks; 9.2% (14) gave birth spontaneously before 34 weeks. The median cervical length was 35 (range, 1-57) mm. All parameters except the Bishop score were predictors of delivery before 34 weeks. The likelihood ratio of the positive and negative tests for cervical length < or = 25 mm was 5.4 (range, 3.2-9.0) and 0.3 (range, 0.1-0.7), respectively, compared with 2.3 (range, 1.3-4.2) and 0.6 (range, 0.3-1.1), respectively, for cervical score < or = 1. The area under the curve for the cervical index was significantly larger than that for the Bishop score (P = 0.008) or cervical score (P = 0.02).

CONCLUSION

Transvaginal sonography predicted spontaneous delivery before 34 weeks better than digital examination at the 27-week but not the 22-week examination.

Down's syndrome screening with nuchal translucency at 12(+0)-14(+0) weeks and maternal serum markers at 14(+1)-17(+0) weeks: a prospective study

BACKGROUND

Sonographic and biochemical methods for Down's syndrome screening have developed simultaneously, but independently. As a consequence, the rate of invasive procedures for fetal karyotyping has dramatically increased and become an important public health issue which needs to be controlled. One approach is to combine sonographic and biochemical results into a single risk assessment.

METHODS

In a multicentre interventional study, nuchal translucency (NT) was measured between 12(+0) and 14(+0) weeks of gestation. Maternal serum markers (MSM) were measured between 14(+1) and 17(+0) weeks of gestation. Karyotyping was advised when: (i) NT was > or =3 mm; or (ii) the MSM-related risk was > or =1 in 250 at term. Karyotyping was delayed until after a maternal blood sample had been taken. NT and MSM were expressed as multiples of the medians (MoMs), and risks were calculated and tailored to the study population. A combined risk for NT and MSM was estimated retrospectively. Costs per case diagnosed, and the cost per case averted were calculated for the three screening strategies.

RESULTS

A total of 9444 women was screened. Twenty-one fetuses (0.22%) had Down's syndrome, whilst 326 women (3.4%) were lost to follow-up. Among 9118 women followed up, 5506 had both NT and MSM, 821 had only NT, and 2791 had only MSM. Median maternal age was 30.5 years. False-positive rates for NT, MSM and NT combined with MSM were 3.0, 5.8 and 0.23% respectively. The false-positive rate generated by a sequential two-stage screening was 8.6%. Detection rates of Down's syndrome were 62 and 55% for NT and MSM respectively. Seven cases with Down's syndrome (35%) had raised NT and MSM, and 17 (81%) had either raised NT, MSM, or both. For a 5% false-positive rate, detection rates were 55 and 80% for NT alone and for combined NT and MSM respectively. Ultrasound alone appears to be more cost-effective ( pound50 per case diagnosed) than both tests ( pound61 per case diagnosed).

CONCLUSIONS

The study results suggest a 25% increase in the detection rate of Down's syndrome using a combination of NT measurement at 12(+0)-14(+0) weeks and MSM at 14(+1)-17(+0) weeks for a 5% false-positive rate, with modest increase in cost.

Reflex sympathetic dystrophy in pregnancy: nine cases and a review of the literature

OBJECTIVE

To better understand the diagnosis of reflex sympathetic dystrophy of the lower extremities in pregnant women.

SUBJECT

Disease analysis using a retrospective series of nine cases and a review of the literature (57 patients and 159 sites of reflex sympathetic dystrophy).

RESULTS

This disorder should be considered in any painful pelvic girdle syndrome or lower extremity pain. The hip is involved in 88% of cases. Symptoms develop in the third trimester of pregnancy, between the 26th and the 34th weeks. Magnetic resonance imaging (MRI) provides an early, accurate, and very specific diagnosis, although standard radiography continues to be the first-line diagnostic tool. Fracture occurs in 19% of patients. The etiology and pathophysiology remain unclear, although pregnancy itself appears to play a significant role in this disease. Although locoregional mechanical factors partly explain reflex sympathetic dystrophy. Hypertriglyceridemia appears to be a risk factor. This disorder develops independently, but the conclusion of pregnancy appears to be necessary for cure. Reflex sympathetic dystrophy does not appear to affect the course of the pregnancy. Indications for cesarean delivery remain obstetrical and should be discussed when a fracture is involved. Simple therapeutic management using gentle physical therapy provides rapid and complete recovery in 2-3 months.

CONCLUSION

Reflex sympathetic dystrophy during pregnancy remains poorly understood and underestimated. Only joints of the inferior limbs are involved. MRI appears to be the best diagnostic tool. Pathogenesis remains unclear. Fractures are not rare. Treatment should be non-aggressive.

[Pectineal ligament of Cooper. Micromorphometric study]

The pectineal ligament is used in surgery as a support element in the treatment of groin hernias and female urinary stress incontinence. The question is to determine the anatomical characters that account for its strength. Three complementary approaches have been considered: an anatomical dissection study established the origin of the different fibers the ligament is composed of; a morphometric study determined the areas where the ligament is the thickest; and microscopic anatomy clearly showed the arrangement of the fibers. The pectineal ligament continues the near-by fibers fibrous elements, notably thanks to its ends. The latter are significantly thicker. At microscopic level, the regular layout of the pectineal ligament fibers accounts for its resistance.

Using fetal nuchal translucency to screen for major congenital cardiac defects at 10-14 weeks of gestation: population based cohort study

OBJECTIVES

To examine the utility of measuring fetal nuchal translucency thickness in screening for major defects of the heart and great arteries at 10-14 weeks of gestation.

DESIGN

Population based cohort study.

SUBJECTS

29 154 singleton pregnancies with chromosomally normal fetuses at 10-14 weeks of gestation.

SETTING

Fetal medicine centre in London.

MAIN OUTCOME MEASURE

Prevalence of major defects of the heart and great arteries.

RESULTS

Of 50 cases with major defects of the heart and great arteries (prevalence 1.7 per 1000 pregnancies) 28 (56%, 95% confidence interval 42% to 70%) were in the subgroup of 1822 pregnancies with fetal nuchal translucency thicknesses above the 95th centile of the normal range. The positive and negative predictive values for this cut off point of nuchal translucency thickness were 1.5% and 99.9% respectively.

CONCLUSIONS

Measurement of fetal nuchal translucency thickness-traditionally used to identify fetuses at high risk of aneuploidy-at 10-14 weeks of gestation can identify a large proportion of fetuses with major defects of the heart and great arteries.

Treating ectopic pregnancy with the combination of mifepristone and methotrexate: a phase II nonrandomized study

OBJECTIVE

Our goal was to compare the use of a combination of methotrexate and mifepristone with methotrexate alone in the medical management of ectopic pregnancy.

STUDY DESIGN

This was a preliminary nonrandomized phase II study. All patients with progressing ectopic pregnancy meeting criteria for medical management were included. Treatment consisted of 50 mg/m2 of methotrexate injected intramuscularly and 600 mg of mifepristone, administered orally, compared with a previous group who received only 50 mg/m2 of methotrexate injected intramuscularly.

RESULTS

Of the 30 patients treated with the combination, there was only 1 failure, whereas medical treatment had failed for 11 of 42 patients treated with methotrexate alone.

CONCLUSIONS

The combination of mifepristone and methotrexate decreased the risk of failure in medical treatment of ectopic pregnancy.

[The value of intravaginal ultrasonography of the cervix uteri for evaluation of the risk of premature labor]

OBJECTIVE

To determinate the predictive value of cervical length, measured by transvaginal ultrasound, for preterm delivery among patients with signs of preterm labor.

PLACE

Department of Gynecology & Obstetrics, Poissy Hospital Center.

MATERIAL AND METHODS

A prospective study that measured cervical length by transvaginal ultrasound was performed among 108 patients with a singleton pregnancy hospitalized with signs of premature labor between 24 and 34 weeks' gestation or within 21 days of inclusion.

RESULTS

The rate of preterm birth was 22.2% (24/108). When cervical length was < or = 26 mm, the gestational age at delivery was significantly lower that when it exceeded 26 mm (36.3 +/- 3.0 weeks compared with 38.5 +/- 2.1 weeks; p < 0.0001). 40.4% (19/47) of patients whose cervical length was < or = 26 mm gave birth prematurely, compared with only 8.2% (5/61) of those with a cervix > 26 mm The sensitivity, specificity, positive predictive value, and negative predictive value of transvaginal ultrasonography were, respectively, 79.2, 66.6, 40.4, and 91.8% for delivery before 37 weeks' gestation, and 75.0, 62.0, 25.5, and 93.4% for delivery within 21 days of the ultra-sound measurement.

CONCLUSION

Transvaginal ultrasound of the cervix provides an objective method for evaluating the risk of preterm delivery. Its predictive values are impressive and allow better discrimination between women at high risk of preterm delivery and those in false preterm labor.

[Anatomical study of Cooper's ligament. Value in the surgical cure of urinary incontinence in women]

The objective of the study was to measure Cooper's ligament thickness in the middle and at 1, 2, 3, 4 cm and to find the best place to fix the stitches of colposuspension. This study was performed on fresh cadavers. Sixteen Cooper's ligaments were studied (8 women, mean age 78 +/- 6 years). The length, the width and thickness of Cooper's ligament at 0, 1, 2, 3, 4 cm from the middle were measured. The limits of Cooper's ligament are indefinite. This ligament is significantly thicker (p < 0.01) in the middle and at 4 cm from the middle (2.2 +/- 0.4 mm) than 1 cm (1.4 +/- 0.5), 2 cm (1.4 +/- 0.5 mm) and at 3 cm (1.9 +/- 0.3 mm) from the middle. Cooper's ligament is used to fix the stitches for colposuspension derived from Burch colposuspension (non-incision percutaneous colposuspension to Cooper's ligament, laparoscopic colposuspension...) and sometime help to fix meshes in frondes procedures and the vagina in the Bologna procedure. This study showed the best point to fix the stitches (by its thickness) for colposuspension on this ligament at 4 cm from the middle (the fixation at the origin exposing to periostitis).

[Limits of ambulatory medical treatment of ectopic pregnancies by intramuscular methotrexate: prospective study on 54 patients]

OBJECTIVE

To evaluate the limits of ambulatory treatment of ectopic pregnancy with an intramuscular injection of 50 mg/m2 methotrexate.

METHOD

Non randomised prospective study from october 1993 and april 1996 at Poissy Hospital. 100 ectopic pregnancies were diagnosed: 54 were treated medically and 46 had a surgical treatment.

RESULTS

The mean hCG for the ectopic pregnancies treated medically was 7,273 Ul/ml +/- 12,548 (90-68,220), an ectopic mass was seen in 74% and to precise the diagnosis a currettage was done in 24 cases (44%) if the initial hCG was below 2,000 Ul/ml. The medical treatment was a success for 37 (68.5%) ectopic pregnancies with a mean time of resolution of hCG of 31.9 days +/- 18 (4-90) (with a positive correlation between initial hCG titer and time to resolution of 0.5, p = 0.001). For 15 (27%) patients a second dose of methotrexate was necessary with a 73% success rate and 17 (32%) patients were operated (8 salpingectomies). Sixteen of 20 (80%) demonstrated tubal patency at follow-up hysterosalpingogram and within 7.5 +/- 4 months 26 of 30 (87%) conceived and there was no recurrence of ectopic pregnancy.

CONCLUSIONS

The medical treatment of ectopic pregnancies with methotrexate has its limits. In our series, if we treat ectopic pregnancies without cardiac activity, with a mass below 35 mm and a hCG below 10,000 Ul/ml the success rate is 81%.

Increased nuchal translucency at 10-14 weeks of gestation as a marker for major cardiac defects

Screening for fetal cardiac defects is traditionally based on the ultrasonographic examination of the four-chamber view of the fetal heart at mid-gestation, which has been shown to identify 26% of major cardiac defects. Pathological studies in fetuses with increased nuchal translucency at 10-14 weeks of gestation, a sonographic marker for chromosomal abnormalities, have shown an association between increased nuchal translucency and congenital abnormalities of the heart. This study reports the prevalence of cardiac defects in 1427 chromosomally normal fetuses with increased nuchal translucency thickness, and examines the potential value of this sonographic marker in screening for major cardiac defects. The diagnosis of cardiac defects was made either by postmortem examination in terminations of pregnancy and intrauterine or neonatal deaths or by clinical examination and appropriate investigations in live births. The prevalence of major cardiac defects was 17 per 1000 (24 of 1427 fetuses) and increased with translucency thickness from 5.4 per 1000 for translucency of 2.5-3.4 mm to 233 per 1000 for translucency of > or = 5.5 mm. These findings suggest that measurement of nuchal translucency thickness at 10-14 weeks may prove to be a useful method of screening for abnormalities of the heart and great arteries in addition to its role in screening for chromosomal defects.

Percutaneous needle colposuspension to Cooper's ligament for the treatment of stress incontinence in women: a report of 82 cases

We describe a procedure for the treatment of genuine stress urinary incontinence by percutaneous needle colposuspension of the bladder neck to Cooper's ligament. The procedure was performed in 82 patients and was associated with other procedures in 75 cases (91.5%). The mean operative time was 19 min (range 15 to 30). One peroperative hemorrhagic complication (1.2%) was noted. Nine postoperative complications were observed (10.9%) including seven urinary infections, one retropubic hematoma and one fever of unknown etiology. The mean follow-up was 13 months (range 6 to 22). Eight patients had a failure of the technique. All failures were diagnosed during the two first postoperative months. They included five cases of detrusor instability and three of persistent urinary incontinence. No additional failure was noted among the 53 patients having a follow-up greater than 12 months, suggesting a good stability of this new technique of colposuspension with a success rate of 85%.

Evaluating the risk of preterm delivery: a comparison of fetal fibronectin and transvaginal ultrasonographic measurement of cervical length

OBJECTIVE

Our purpose was to compare the predictive values for preterm delivery of fetal fibronectin and cervical length measured by transvaginal ultrasonography and to determine whether performing both tests improves their separate predictive values.

STUDY DESIGN

This prospective blinded study performed both tests on 76 patients hospitalized with signs of premature labor between 24 and 34 weeks of gestation. The outcome measure was delivery before 37 weeks' gestation.

RESULTS

The rate of preterm bith was 26.3% (20/76). The predictive values of fetal fibronectin and of a cervical length of < or = 26 mm, considered separately, were approximately equal, and the negative predictive value of each was excellent (86.6% and 89.1%, respectively). This value improved slightly when positive fetal fibronectin, a cervical length < or = 26 mm, or both defined abnormality (negative predictive value 94.4%). The positive predictive values, although less helpful, were still useful (45.2% and 50.0%, respectively). Combining both indicators did not noticeably improve the positive predictive value (52.4%). The risk of preterm delivery for a patient with a positive fetal fibronectin level and a short cervix was high (odds ratio 13.9, 95% confidence interval 3.7 to 52.2).

CONCLUSION

Fetal fibronectin and cervical length are approximately equivalent in their ability to distinguish between patients at high and low risk for preterm delivery. For physicians equipped to perform transvaginal ultrasonography, however, the additional information about the fibronectin level provides only slight benefits.

Transvaginal colpo-urethropexy with fibrin sealant: 4 years-follow up in 23 cases

A method of transvaginal colpo-urethropexy, using fibrin sealant was studied clinically. After a fingertip vaginal retropubic dissection, fibrin sealant is instilled in the retropubic space with the intent of inducing fibrosis between the elevated urethro-vesical junction and the retropubic periosteum. Twenty-three patients with urinary stress incontinence underwent this procedure with 82% of satisfactory results and 18% failure. Complications were minimal. In the future, this technique could be useful for ambulatory surgery.

[Percutaneous needle colposuspension to Cooper's ligament: 63 cases]

OBJECTIVE

To evaluate the feasibility, safety and results of a new procedure of treatment of genuine urinary stress incontinence : needle percutaneous colposuspension to Cooper's ligament.

STUDY DESIGN

From June 1994 to December 1995, 63 patients had a needle percutaneous Cooper's ligament colposuspension for stress urinary incontinence (USI). The mean age of the patients was 48 years (range : 32 to 80). Fourteen patients were menopausal (22,2 %). The mean parity was 2,7 (range 0 to 10). According to Blaivas and Olsson classification of USI, 6 patients had type 0, 32 type 1, 22 type 2 and 3 type 3. Fifty-eight patients had preoperative urodynamic control.

RESULTS

The procedure was performed in 63 patients (100%). The mean operative time was 20 minutes (range 15 to 30). Peroperative complication: hemorrhagic in one case (1,5%). Postoperative complication rate was 12,7% including seven urinary infections. The mean follow-up of the patients was 8 months (range: 6 to 17). By subjective parameters, 55 patients were cured (87,3%). Only 38 patients had postoperative urodynamic control including the 8 patients with failure of the procedure. Among these 8 patients, 1 had clinical failure with normal urodynamic control, 2 had vesical instability and 5 had a persistence of USI confirmed by urodynamic control.

CONCLUSION

Needle percutaneous colposuspension to Cooper's ligament appears as feasible and safe technique to cure USI. The interest of this new procedure of colposuspension is its fixation to the Cooper's ligament using the vaginal approach. Preliminary results are good, however longer follow-up is necessary to validate this new technique.

Abnormalities of the heart and great arteries in chromosomally normal fetuses with increased nuchal translucency thickness at 11-13 weeks of gestation

Pathological examination of trisomic fetuses with increased nuchal translucency thickness at 11-13 weeks of gestation demonstrated a high prevalence of cardiac defects and abnormalities of the great arteries. This study reports the pathological findings observed from the examination of the heart and great arteries of 21 chromosomally normal fetuses with increased nuchal translucency. In 19 of the 21 cases there were abnormalities; the commonest was narrowing of the aorta at the level of the isthmus and immediately above the aortic valve. This finding is different from that in case of trisomy 21, where narrowing of the isthmus is associated with an increased diameter of the aortic valve. These findings suggest that abnormalities of the heart and great arteries may be implicated in the pathogenesis of increased nuchal translucency not only in trisomic fetuses but also in chromosomally normal fetuses. It can be implied that increased nuchal translucency thickness at 10-14 weeks of gestation may prove to be a useful marker for the identification of fetal cardiac abnormalities.

[Isolated fetal tachycardia, a diagnostic event of Basedow's disease. Apropos of a case]

Two of thousand pregnancies are complicated by a Graves' disease. The circumstances of diagnosis are usually maternal disorders (tachycardia, exophthalmia, loss of weight...), also fetal disorders (tachycardia, intra-uterine growth retardation, stillborn...). The discovery of fetal tachycardia (160 beats per minute), and maternal tachycardia (120 beats per minute) associated with high blood pressure, allowed us to suspect, in this case, a Graves' disease, responsible of fetal hyperthyroidism by autoantibodies crossing the placenta. The measuring of T3, T4, TSH and autoantibodies confirmed the diagnosis. The drug of choice is the PTU (propylthiouracil). It prevents synthesis of thyroid hormones and inhibits peripheral deiodination of T4 to T3. It treats simultaneously mother and fetus; the surveillance must allow us to adjust treatment to avoid fetal hypothyroidism, maternal thyrotoxicosis of peripartum and neonatal thyrotoxicosis.