[Cesarean sections in the Centre-Val de Loire region: Practices and indications-the Robson Classification]

BACKGROUND

To study the cesarean section (c-section) practices in the French Centre-Val de Loire region: incidence of planned c-section and rate variations between maternities, incidence of potentially avoidable cesarean sections.

METHODS

The data were extracted from the 2016 regional birth register, which permitted classification of each planned c-section according to the pre-existing risk of c-section (high or low) as defined by the Robson classification. To enhance the data, especially the indications for c-section, which are not included in the register, a survey was conducted from September 2016 to February 2017 in all of the 20 maternities in the region.

RESULTS

In 2016, nearly 26,000 women gave birth in the CVL region, of whom 19.2% by c-section (7.0% planned c-sections). The planned c-section rate was higher for breech presentation and scarred uterus, and decreased according to level of the maternity (I 41% - II 35% - III 32%). Concerning the c-section indications, 1,979 c-sections were studied during the period (18.6% of births), including 762 planned c-sections (7.1% of births). Among them, 246 (32%) were potentially avoidable, mainly isolated indications of scarred uterus with only one previous c-section or breech presentation, and 17 due to unfavorable radiologic pelvimetry in nulliparous women.

CONCLUSION

Specific actions were identified: targeted use of radiologic pelvimetry, targeted c-section on scarred uterus with only one previous cesarean section or breech presentation, as recommended by the national guidelines. The Robson classification should be widely used to evaluate and enhance practices, in particularly through painstakingly interpreted inter-maternity comparisons.

Indications and practices of Cesarean Sections in a French region – The Robson classification

Background

Cesarian-section (CS) deliveries, although sometimes vital, are associated with increasing immediate- and long-term maternal and/or neonatal risks. The objective was to describe the indications of scheduled CS, measure the potentially avoidable CS and study the rate variations between maternities in one French region, Centre Val-de-Loire (CVL).

Methods

A cross-sectional study was conducted from September 2016 to February 2017. Information about all CS performed in the maternities of the region was collected: medical history, indication, schedule. Data collection was completed with the 2016 regional birth data repository (25,864 deliveries, including 19.2% of CS, among which 7.0% were scheduled). CS were classified according to the pre-existing risk high or low of CS as defined by the Robson classification.

Results

During the study period, 1,979 CS (18.6% of deliveries) were performed, of which 762 were scheduled (7.1% of deliveries). The main indications for planning a CS were: scarred uterus (60%, of which 56% with only one previous CS) or breech presentation (25%), considered at high risk of CS according to the Robson classification. For these two contexts, the regional birth repository showed decreasing scheduled CS rates from high to low level of maternities’ expertise. Remarkly, 22 nulliparous women with a single cephalic pregnancy in spontaneous labor before term (Robson’s low risk of CS) had a CS performed for unfavorable pelvimetry (0.2% of deliveries).

Conclusions

This study allowed identifying specific potential interventions: targeted CS on scarred uterus with only one previous CS or breech presentation, as recommended by national guidelines, and targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices through cautious maternity comparisons to improve quality of care.

Key messages

Although potentially avoidable c-sections are rare, interventions were identified: targeted CS on uterus with one previous CS or breech presentation, targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices, in order to improve healthcare quality.

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.

[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.

[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.

[Delivery in lateral position. Comparative study in low risk pregnancy between lateral and dorsal position for the delivery in eutocic vaginal birth]

OBJECTIVE

For several years in French labour wards, delivery in the lateral decubitus position (LP) has raised great interest. We wanted to assess perineal outcomes and neonatal morbidity following delivery in the lateral LP compared to the dorsal decubitus position (DP).

PATIENTS AND METHODS

Two teams of midwives, in a private and in a public hospital, performed a total of 6800 deliveries in the area of Tours following a training session on the techniques of delivery in the lateral decubitus position. The design was a retrospective case-control study including patients with low obstetrical risks and normal vaginal delivery. We included 645 patients who gave birth from May 1st to September 30th, 2007.

RESULTS

We showed a significant difference in perineum outcomes, with a lower episiotomy rate (56.7% in LP/40.7% in DP, P=0.0001), a higher rate of intact perineum (56.7% in LP/40.7% in DP, P=0.0001) and no differences with respect to perineal laceration. These differences were significant in primiparous (intact perineum: 46.8% in LP/20.2% in DP, P=0.004; episiotomy: 17% en DL/44.7% en DD, P=0.006) and secondiparous patients (episiotomy: 8.6% in LP/30.7% in DP, P=0.0001). We showed significant differences in fetal heart abnormalities during labour in favour of the lateral decubitus position (no anomaly, P=0.00004; separated decrease, P=0.04; bradycardia, P=0.0009; early decrease, P=0.04).

DISCUSSION AND CONCLUSION

The neonatal mortality and morbidity did not differ between delivery positions. The lateral position seems to be protective for the perineum without affecting neonatal outcome. Incorporating lateral decubitus deliver into daily practice is possible in large groups of midwives after appropriate training.

[Antenatal screening for HIV: knowledge, attitudes, beliefs and practices of pregnant women. Analysis of current practices and the impact of setting up an informative brochure]

OBJECTIVES

To assess the impact of an information leaflet on the behavior and knowledge of pregnant women about the risks of HIV infection during pregnancy.

PATIENTS AND METHODS

Comparative prospective study conducted in two phases from March 1 to September 30, 2007 on patients presenting for the first time in antenatal care at the Maternity Hospital of Tours (n=539). During the first phase, only a self-questionnaire was given during the second an informative brochure has been attached to the questionnaire.

RESULTS

Currently 25.1% of pregnant women have not made a test during their pregnancy. This rate decreases to 12.9% when the test is routinely offered. It falls to 8.2% with the introduction of an informative brochure. The test was imposed in 28.7% of patients. Some risks of transmission of HIV, including those specific to pregnancy, are undervalued. A negative test before the pregnancy is the main reason for refusal of antenatal screening. A high level of education was the only risk factor identified for refusal. They are better informed as shown by the higher rate of correct answers about the risks of HIV transmission and antenatal screening. We hypothesize that the women who pursued graduate studies evaluate the risk of infection before accepting or refusing the test.

CONCLUSION

The study shows that the distribution of an informative brochure on advanced prenatal screening, increased the number of women performing the test and improved their knowledge about risks of transmission, especially from mother to the child.

[How long can we wait at full dilatation. A study of maternal and neonatal morbidity related to the duration of the second stage of labour in nulliparous women]

OBJECTIVES

To determine the statistical association, in nulliparous patients, between maternal and fetal morbidity and the length of the second stage of labour. To precise whether a prolongation of this period of more than 2h may results in a dramatic increase of this morbidity.

MATERIALS AND METHODS

Retrospective cohort study conducted in a level III referral centre between 1 April 2004 and 30 April 2005, including all nulliparous, term, cephalic, live singleton birth without fetal malformation in patients reaching the second stage of labour (n=1191). All deliveries were performed without restrictions in the length of the second stage of labour in the absence of fetal heart rate abnormalities. Maternal and neonatal morbidity were examined according to the duration of the second stage of labour with univariate analysis and after statistical adjustment with multivariate logistic regression for potential confounding variables.

RESULTS

Global maternal morbidity ranged from 5.7% after 1h to 20.4% after more than 3h of full cervical dilatation. After a second stage duration of 2h, each additional completed hour resulted in a significant increase in global maternal morbidity (OR 1.78; IC 95% [1.59-1.97]), postpartum haemorrhage (OR 1.72; IC 95% [1.21-2.23]) and level three or four perineal lacerations (OR 1.24; IC 95% [1.7-1.41]). In the same time, caesarean section rate (OR 2.09; IC 95% [1.84-2.34]) and operative vaginal deliveries (OR 1.82; IC 95% [1.59-2.05]) increased significantly. Conversely, our study didn't demonstrate any significant association between neonatal morbidity and the length of the second stage of labour.

CONCLUSION

Our study confirmed the association between the duration of the second stage of labour and the increase of maternal but not neonatal morbidity. Such an association, predominantly after 3h spend at full cervical dilatation, needs to be taken into account and, according to our experience, may justify caesarean section.

[Breast angiosarcoma: sonographic, mammographic and MRI features]

The purpose of this paper is to report the clinical, imaging (sonographic, mammographic and MRI) and pathological features of breast angiosarcoma, a rare but aggressive tumor, based on a review of two cases.

Fetal ovarian cysts: a report of three cases managed by intrauterine aspiration

Small follicular or functional theca-lutein cysts are a common finding in fetal and neonatal ovaries. After delivery, decrease of hormonal stimulation may lead to spontaneous resolution of the cyst. A high rate of complication has been underlined by recent studies, the most common being ovarian torsion with subsequent loss of the ovary. Because torsion may happen with any size of cyst, however large or small, we suggest in utero decompression even in small fetal ovarian cysts (< 5 cm). We report here three cases of such cysts managed by intrauterine aspiration with good outcome and no further need for neonatal surgery. In all cases cytology of the cyst aspirate demonstrated numbers of granulosa cells and fluid biochemistry showed a high amount of estradiol, progesterone, and testosterone that confirmed the etiology as ovarian. Despite the small size of the cysts, no technical difficulties were encountered and no maternal or fetal morbidity occurred. Prenatal management of fetal ovarian cysts remains controversial, however, and our limited experience needs to be assessed on a larger number of cases.

[Prenatal outcome of sex chromosome anomalies diagnosed during pregnancy: a retrospective study of 47 cases]

OBJECTIVE

To study the circumstances of discovery and the prenatal outcome of sex hormone anomalies diagnosed by invasive prenatal techniques during pregnancy and analyze which factors could be implicated in the parents' choice to terminate or carry on with pregnancy.

METHODS

We reviewed retrospectively 47 cases of sex chromosome anomalies diagnosed and managed in our prenatal diagnosis unit over a 9-year period between January 1, 1990 and December 31, 1998. Only cases karyotyped in our laboratory and with a complete follow-up were considered.

RESULTS

Cytogenic findings were mainly turner syndrome (n=25) and Klinefelter syndrome (n=12). The other karyotypes were the following: 47, XXX (n=6), 47, XYY (n=2), and 49, XXXXY (n=2). Among the 47 pregnancies, 11 (23.4%) were carried to term. The rate of pregnancy termination (68.1%) was high. The decision to terminate varied depending on the abnormal karyotype: 88% for Turner syndrome, 42% for Klinefelter syndrome, 33% for 47, XXX, 50% for 47, XYY and 100% for 49, XXXXY. The pregnancy termination rate was significantly higher when one or more abnormal ultrasound findings was present (92.3% vs 41.2%, p<0.01).

CONCLUSION

Our study confirms that termination rates remain high in case of sex hormone anomalies. Associated ultrasonographic findings play a major role in the parents' choice to terminate or carry on with the pregnancy. It would appear that the development of consensual guidelines in pluridisciplinary fetal medicine centers can help reduce the disparities currently observed among French centers in the management of fetuses with sex chromosome anomalies.

[Ultrasonographic diagnosis and prenatal management of fetal ovarian cysts]

OBJECTIVE OF THE STUDY

To evaluate the outcome of fetal ovarian cysts in relation to their ultrasonic appearance and size. To define, on that basis, the contribution of intrauterine aspiration.

MATERIAL AND METHODS

Retrospective study of all ovarian fetal cysts detected by prenatal ultrasound examination (n = 25) during a 4 year period. All these cysts were followed during pregnancy and after delivery until spontaneous or surgical resolution.

RESULTS

At the time of prenatal sonographic detection at the mean gestational age of 32 1/2 weeks, the mean cyst diameter was 43+/-17 mm and 36% of all these cysts were already complicated (fluid-debris level, septa or finding of a retracting clot). Among the 16 non-complicated cysts (echolucent and thin-walled) 44% became twisted during the perinatal period irrespective of the size or the time of discovery. At birth, all these complicated cysts underwent surgical treatment and needed oophorectomy or adnexectomy. Surgery was therefore performed in a total of 56% of neonates. The pathologic reports confirm in all cases the benign follicular or follicular lutein nature of the cysts.

CONCLUSION

Due to this high rate of mechanical complications, cyst decompression may be considered at the time of diagnosis in case of an anechoic fetal ovarian cyst. The safety and efficacy of this approach, on the cases reported in the literature seem encouraging. Although, a prospective randomized evaluation is needed.