[Cancer during pregnancy: Proposal of a clinical care pathway based on a regional cohort]

OBJECTIVES

Cancer during pregnancy affects 1 in 1000 pregnancies. This situation requires multidisciplinary team, however there is no care pathway dedicated to these patients. The main objective was to describe oncological, obstetrical, and neonatal care through a regional inventory. Our secondary objective was to define a regional "cancer and pregnancy" care pathway.

MATERIAL AND METHOD

We carried out an observational, retrospective study from 2013 to 2019 including 48 women (all cancer types) from 2013 to 2019 in Occitania. Then, we defined an "optimal care pathway" and we assessed whether it was respected in the breast cancer subgroup of our cohort.

RESULTS

Live births occurred in 79% of the women included. Maternal treatment was initiated during pregnancy for 67% of our population (44% chemotherapy). The most frequent pregnancy complication was preterm delivery (39%), mainly iatrogenic (86.6%). No patient in the group of breast cancer benefited from all of the ten criteria of the "optimal care pathway" that we proposed.

CONCLUSIONS

A coordinated regional care pathway seems necessary to optimize communication between the healthcare providers (oncologists, gynecologists and multidisciplinary prenatal diagnosis centers, pharmacologists, pediatricians, psychologists, and general practitioners). This study identifies weaknesses in the management of women with cancer during pregnancy and suggests regional improvement opportunities.

Lésions placentaires graves dues à une infection maternelle par le SARS-CoV-2 associées à une mort fœtale intra-utérine

L’infection par le SRAS-CoV-2 peut provoquer des lésions placentaires sévères conduisant rapidement à une mort fœtale intra-utérine (MFIU). Entre août 2020 et septembre 2021, nous avons reçu et analysé 50 placentas de mères non vaccinées positives au COVID-19, dans le service de pathologie de Toulouse.

Le but de notre étude est de décrire les caractéristiques clinicopathologiques de ces atteintes placentaires et d’en comprendre la physiopathologie.

Dix d’entre eux (20 %) présentaient des lésions placentaires avec une immunohistochimie positive au SARS-CoV-2 au niveau du trophoblaste villositaire. Dans cinq cas (10 %), nous avons observé des lésions placentaires massives associant nécrose trophoblastique, dépôts fibrinoides, intervillite ainsi que des modifications hémorragiques étendues dues à l’infection par le SARS-CoV-2 probablement responsable de la MFIU par insuffisance placentaire fonctionnelle. Dans cinq autres cas, nous avons trouvé des lésions placentaires similaires mais avec une distribution focale ayant conduit à une naissance vivante.

Ces lésions sont indépendantes de la sévérité clinique maternelle de l’infection à COVID-19 car elles surviennent malgré des symptômes maternels bénins les rendant difficiles à prévoir. Dans nos cas, elles sont apparues 1 à 3 semaines après un test RT-PCR maternel positif au SRAS-CoV-2 et ont été observées au cours des 2^e et 3^e trimestres de la grossesse. Lorsque ces lésions sont focales, elles n’entraînent pas de MFIU mais peuvent être associées à un retard de croissance intra-utérin.

[Does the paper speed in fetal heart monitoring during labour influence the variability in the interpretation by professionals?]

OBJECTIVE

Assessing inter- and intra- observer agreement in the reading of fetal heart rate (FHR) between two different paper speeds (1 and 2cm/min) using FIGO classification.

MATERIAL AND METHODS

Single-centre experimental study consisting in reading 60minutes FHR tracings by six readers (3 midwives and 3 obstetricians) during 1cm and 2cm/min sessions within a period of three weeks. The reading guideline was based on FIGO classification. Inter- and intra-observer agreement was assessed thanks to Kappa coefficient (K) and percentage of agreement (PA) using the classification of FHR tracings drawn up by readers.

RESULTS

Intra-observer agreement reached 60% between the two paper speeds, and PA ranged from 48 to 67%. Inter-observer agreement was poor to moderate (K=0.42 for 1cm/min sessions and K=0.38 for 2cm/min sessions). Inter-observer agreement was significantly higher for normal tracings (PA ranged from 55.2% for 2cm/min sessions to 57.4% for 1cm/min sessions). The preterminal category had the lowest concordance rates (PA=19% for 1cm/min sessions and 20, 7% for 2cm/min sessions).

CONCLUSION

This study did not highlight significant differences in intra- and inter-observer variability between the two FHR paper speeds. The 1cm/min paper speed, which is commonly used in France, is more economical and gives a better bedside overview of FHR. Therefore, it should be recommended.

[Case report: Vasa previa diagnosis and management. How to prevent Benckiser's hemorrhage?]

Benckiser's haemorrhage is a serious obstetrical complication, following a vasa previa rupture. Incidence of vasa previa is estimated between 1/1150 and 1/5000 pregnancies. This case report illustrates the consequences of a suspected vasa previa rupture. There is no French recommendation of how to treat vasa previa. Different methods of prevention are described and examined thanks to a literature review.

Prenasal thickness to nasal bone length ratio: effectiveness as a second or third trimester marker for Down syndrome

OBJECTIVE

To assess the value of the prenasal thickness to nasal bone length ratio (PT/NBL) for detecting trisomy 21 (T21) after the first trimester.

METHOD

Two examiners blinded to fetal T21 status retrospectively measured prenasal thickness (PT) and nasal bone length (NBL) of T21 and control fetuses at 15-36 weeks' gestational age on two-dimensional images from all T21-screening ultrasounds from November 2010 to April 2013. ROC curve analysis and its diagnostic values determined the best cut-off value for the ratio. Interobserver reproducibility was assessed.

RESULTS

Good quality ultrasound profile images were available for 26 fetuses with T21 compared to 91 normal fetuses. The median PT/NBL ratio was 1.28 for T21 and 0.73 for control fetuses (p<0.0001). The PT/NBL ratio performed significantly better (AUC 0.99; 95%CI 0.97-1) than either PT (0.82; 0.73-0.91) or NBL (0.91; 0.85-0.98). The optimal PT/NBL ratio cut-off was 0.98, with a sensitivity of 88.5% [76.2-100%] and a specificity of 100%. Interobserver variability was low.

CONCLUSION

The PT/NBL ratio is a strong marker for detecting T21 in the second and third trimesters, significantly more effective than either indicator alone.

Evolution of middle cerebral artery peak systolic velocity after a successful laser procedure for iatrogenic twin anemia-polycythemia sequence

We report a case of twin anemia-polycythemia sequence (TAPS) treated by laser at 24 + 5 weeks' gestation, 7 weeks after a first laser procedure for twin-to-twin transfusion syndrome at 16 + 6 weeks. This management led to the birth of two healthy neonates by Cesarean section at 36 weeks. In this case, weekly measurement of the middle cerebral artery peak systolic velocity allowed us to monitor the twins after both laser treatments and, more specifically, to detect TAPS. Following delivery, placental injection showed a minuscule coagulated arteriovenous anastomosis. Intrauterine transfusion is generally chosen to manage TAPS, but the choice of therapy must consider gestational age, technical difficulties and disease severity. The laser procedure cannot be used as a curative treatment for TAPS in all cases. We propose a decisional algorithm to help clinicians select the appropriate treatment.