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To investigate prenatal diagnosis characteristics and pregnancy outcomes associated with isolated right aortic arch (RAA).A retrospective study including fetuses with isolated RAA, managed between January 2010 and February 2018. Cases were identified from the ultrasound databases of the expert pediatric cardiologists, who made the aforementioned diagnosis. All fetuses were examined by a fetal medicine imaging expert to exclude any extracardiac abnormality. A systematic review was performed to assess the prenatal diagnosis and outcomes of fetuses with isolated RAA.Fifty-six fetuses were diagnosed with an isolated RAA. An isolated double aortic arch (DAA) was diagnosed in one fetus. Mean gestational age at diagnosis was 24 weeks. The sex ratio (boy/girl) was 0.89. No significant abnormality was detected in invasive tests (karyotype and FISH or microarray). Only one fetus was misdiagnosed with isolated RAA. He was the only symptomatic (stridor) newborn baby and was later diagnosed with DAA. Four studies were included in our systematic review representing 115 cases of isolated RAA. One significant chromosomal abnormality was detected: a 22q11 deletion in a newborn baby who had a postnatal finding of a soft palate cleft. There was one major obstetric complication: an intrauterine fetal demise at 41 gestational weeks.Diagnosis of isolated RAA can be challenging. Invasive tests are to be discussed. The diagnosis of isolated RAA should not change obstetric monitoring. Nevertheless, an echocardiography should be performed systematically in these new newborn babies within their first month of life.

Prognosis of infants with omphalocele depends on many factors, including associated anomalies. "Small" omphaloceles are believed to have more often WB syndrome, but so far no prenatal criterion has been demonstrated to predict associated anomalies. The aim of this study was to assess the outcomes of omphaloceles with prenatal diagnosis, and to seek for any correlation between the herniated viscera in the first trimester and the risk of associated anomalies.We conducted a retrospective study at the Necker Enfants Malades Hospital between 2008 and 2018. Pregnancy outcomes and post natal data were collected and compared to the omphalocele content in the first trimester.One hundred and ninety-one women with antenatal diagnosis of omphalocele were included. Twenty-eight percent were isolated at birth, 32% had a polymalformative syndrome with chromosomal anomaly, 13% had a polymalformative syndrome without genetic anomaly, 9% had a Wiedemann-Beckwith syndrome, 7% had an association with cardiopathy, 6% had a limb body wall complex, 3% had OEIS complex and one case had a Cantrell pentalogy. The presence of the liver in the omphalocele during the first trimester was a predictive factor of heart disease (85.7% vs 48.6% P=0.01). The presence of bowel in the omphalocele during the first trimester was a predictor of chromosomal abnormalities (69.6% vs 37.2% P0.001). Omphalocele content in the first trimester was not predictive of Wiedemann-Beckwith syndrome.Ultrasound analysis in the first trimester of omphalocele content is a valuable clue for prenatal counseling and diagnosis of associated abnormalities.

Splenic abscess is septic collection which occurs after haematogenous spread or local dissemination. Splenic abscess is an uncommon and rare condition, more frequently affecting male and immunocompromised patients. There are no guidelines regarding its diagnosis and management. Computed tomography (CT) scan is highly sensitive and specific (95% and 92%, respectively) in the diagnosis of splenic abscess. Diagnosis is based on blood cultures which are positive in 24 to 80% of cases. Bacterial growth culture of abscess after drainage is more efficient (50-80%) and can be performed after surgery or percutaneous drainage under imaging, including CT scan. Microorganisms involved are frequently enterobacteriaceae, gram-positive cocci and anaerobes. This particular ecology leads to an empiric broad-spectrum antibiotic therapy, with a variable duration, from 10days to more than one month. Management remains very close to the one applied in case of liver abscesses. The role of splenectomy in the prevention of recurrence remains controversial. We reviewed the literature regarding splenic abscesses, from diagnosis to therapy.

Antibiotic treatment durations are not well documented. Yet, dramatic emergence of multi-drug resistant organisms should lead to tend to decrease antibiotic selection pressure. Furthermore, it could lower health costs and reduce associated adverse events. Unfortunately, only few studies with rigorous methodology have been performed. We present the available data on frequent infections such as urinary tract infections, community acquired pneumonia, bone and joint infections and intra-abdominal infections. We underline the difficulties to perform such trials and discuss original options to a better evaluation of treatment duration.

To evaluate the results of screening for trisomy 21 by the combined risk of first trimester (as defined by the decree of June 23, 2009) in the Prima facie structure.Single center study involving all patients that were seen for first trimester screening at Prima facie with singleton living pregnancy, not obtained by embryo donation, between 1 January 2009 and 31 December 2014.Eighteen thousand two hundred and fifty-one patients were included, of which underwent screening for trisomy 21 by the combined risk. One thousand and forty-six (6.1%) had a calculated risk higher than 1/250. Seventy-five were affected by trisomy 21, of whom 65 in the high risk group. The sensitivity and specificity of screening are 86.7% and 94.4%. The median nuchal translucency was 0.98 MoM.Screening for trisomy 21 by calculating the combined risk of first trimester enabled to detect 86.7% of trisomy 21 with a false positive rate of 5.6%.

To determine the incidence of chromosomal abnormalities, syndromic association and fetal defects associated with second trimester fetal growth restriction (FGR) in a tertiary referral center.Retrospective review of all cases referred between 14 and 27 weeks with an abdominal circumference (AC)5(th) centile between 2008 and 2012. Multiple pregnancies were excluded. Medical records were retrieved to look for the presence of associated malformations, aneuploidy and outcomes.A total of 8626 fetuses had ultrasonographic examination between 14 and 27 weeks. Of these, there were 239 cases (2.8%) with evidence of FGR as based on AC measurement. Thirty-seven fetuses had an abnormal karyotype or an identified syndromic association (15%). The most common chromosomal defect was Trisomy 18 (10 cases, 4.2%), 67 had at least one associated morphological abnormality without aneuploidy or syndromic association (28%). Most common associated abnormalities were relative short femur (5%), omphalocele (5%) and gastroschisis (4%). Last 135 cases were isolated fetal growth retardation (5%). Maternal age was higher (33 yr ± 5 yr versus 31 yr ± 5.6 yr, P0.01) and the z-score for the AC lower (2.5 ± 1 versus 2.15 ± 0.6) in the group with abnormal karyotype or syndromic association than in the group without associated malformation. Amniotic fluid was more often increased in the group with an abnormal karyotype or associated malformation (14% and 17%) than in the group without malformations (0%, P0.01).This study describes abnormalities and outcomes associated with second trimester fetal growth retardation in a large population of patients. Our results suggest that the absence of associated malformation, degree of growth restriction, maternal age and the amniotic fluid index may help in the prenatal management and counseling of this high risk population.

The management and identification of the causes for a small for gestational age (SGA) and/or an intrauterine growth restriction (IUGR) fetus is a common but complex problem in Obstetrics.The Medline, Embase and the Cochrane Library databases were examined over the last 15 years, with no language restrictions, using a combination of the words PAG (SGA), IUGR (IUGR), fetal weight (Fetal weight), sonography (ultrasound), management, cause (etiology), examinations (examinations). Some references not selected by this strategy, but associated with these publications or suggested by members of the working group were also added. The relevant articles were used to establish the text of recommendation following discussion between experts of the working group.Once the diagnosis of SGA is raised (whether on clinical, echocardiographic or Doppler), a management strategy to look for potential causes must be proposed and discussed with parents (Expert reviews). The extent of additional explorations varies depending on the exact presentation of the case (term at diagnosis, severity of anomalies). Additional explorations only make sense if they are likely to change the management of the current pregnancy and particularly to reduce perinatal morbidity and mortality. Explorations have two main objectives: (i) assess fetal vitality and possibilities for continuing the pregnancy in terms of safety for the mother and the foetus; (ii) establish the origin of SGA. The latter is detailed in this chapter recommendation. The earlier and the more severe the biometric anomalies, the more comprehensive the investigations. Maternal symptoms or fetal Doppler anomalies also require urgent management.Explorations to establish the origin of SGA and/or IUGR must follow a rigorous and systematic approach. In all cases, the practitioner will provide clear information to parents and collect information including detailed clinical and ultrasound examinations. Additional tests and in particular fetal invasive testing must be performed in some cases after parental consent and according to clinical and sonographic guidance elements.

The placenta is essential for fetal development but its in vivo study, including the study of placental perfusion is still very limited to date. MRI is a safe examination that offers new perspectives for the study of placental function that is altered in many conditions (IUGR, preeclampsia…) and placental anatomy (placenta accreta…). The different MRI sequences (DCE, IVIM, BOLD, ASL…) are new tools that may soon allow us to assess precisely placental function and anatomy, in vivo and non-invasively.

Fetal takings still concern about 6 to 7% of the pregnancies. If, in the majority of the cases, the taking does not present difficulty for a trained operator, particular circumstances related to maternal context (anticoagulating treatment, vaginal bleeding, fever…) may make the taking become more difficult. From a questionnaire sent to the French multidisciplinary centers for prenatal diagnosis and a review of the literature, we establish guidelines for fetal taking in these circumstances.

Foetal lung lesions are uncommon (1/1000 deliveries). Prenatal ultrasound can distinguish echogenic and cystic lesions.The most frequently diagnosed abnormalities are congenital cystic adenomatoid malformation (echogenic and/or cystic), pulmonary sequestration (echogenic), congenital lobar emphysema (echogenic) and bronchogenic cyst (cystic). Most of them carry a good prognosis but complications, including foetal hydrops, may occur and should be looked for regularly prenatally. Congenital upper airway obstruction syndromes are very rare and carry a very poor prognosis.The follow-up of these pregnancies should be undertaken in a tertiary centre and information regarding postnatal management should be given prenatally by the doctors who will care for the infant after birth. Serial ultrasound examinations are required to evaluate the natural history and detect complications. Spontaneous regression may occur. The occurrence of foetal hydrops is usually fatal in the absence of treatment and should be managed as an emergency.Congenital malformations of the lung are rare and usually carry a good prognosis. Careful follow-up and delivery should be performed in a tertiary centre and postnatal investigation should include clinical and radiological evaluation.

Monochorionic pregnancies accounts for only 20% of twins but are responsible for most of their morbidity and mortality. There is no randomized study evaluating management of monochorionic pregnancies. Based on expert opinion, it is recommended that monochorionic pregnancies should be followed-up by practionners working with specialized centers with expertise in monochorionic pregnancies. Optimal follow-up should include a bi-monthly ultrasound evaluation.

The authors studied the reported cases of tuberculosis diseases in Brittany between 2000 and 2007 via the mandatory notification scheme. One thousand nine hundred and seventy-five cases were notified during the study period. The incidence in French Brittany (eight cases per 100,000) was the third highest in France. A statistically significant negative trend was observed later, mainly attributable to a decrease between 2000 and 2001. The mean patient age at notification was 55 in Brittany versus 46 years of age for the rest of France (p0.001). Eighty per cent of the patients were born in France versus 46% for the rest of the country. The rate of multiresistance to antibiotics was 1.3% versus 4.6% for the rest of France (p0.001). The estimated completeness of notification was 80% compared to 70% for the whole country. Despite a decrease of tuberculosis incidence in Brittany, the withdrawal of mandatory vaccination suggests strengthening tuberculosis monitoring in the future.

To study twin pregnancy and delivery as a risk factor for developing postpartum stress urinary incontinence (SUI).Retrospective single centre study comparing 117 patients who have delivered twins to 117 patients who have given birth to singletons, between January 2003 and December 2005 in a tertiary maternal-foetal medicine unit. The risk factors associated with the onset of postpartum SUI, its severity, and its impact on the quality of life were studied.Sixty patients in the twin pregnancy group and 59 in the singleton pregnancy group have answered an auto-questionnaire and were included in the study. The medium-term follow-up of the patient was 20.2 months+/-10.1. The prevalence of SUI in the total population was 30%. The rate was significantly higher in the "twin" group (40%) than in the "singleton" group (20%) (p=0.03). Twin gestation was significantly associated with postpartum SUI for more than 20 months after delivery (OR=2.6 [1.1-5.9]). The univariate analysis found six other risk factors: prenatal urinary incontinence (OR=4.2 [1.7-10.4]), BMI greater than 30 (OR=6.3 [1.2-34.1]), labour duration greater than 8h (OR=4.8 [1.6-14.5]), fundal uterine pressure (OR=4.5 [1.1-18.3]), total intrauterine foetal weight (p=0.003), and immediate postpartum urinary incontinence (OR=12.9 [5-33.5]).The vaginal delivery of two successive foetuses does not seem more purveyor of SUI than caesarean. In twin pregnancies, the high rate of postpartum SUI appears to be related to total intrauterine weight.

Multiple pregnancies represent 2% of all pregnancies but account for 20% of admissions to neonatal intensive care units. The outcome of multiple pregnancies is mainly dependent on chorionicity. Most perinatal complications are 3 to 12 times more prevalent in monochorionic pregnancies. The increased mortality and morbidity in this setting are mainly related to vascular anastomoses on the chorionic plate, joining the two fetal circulations. Intrauterine death of a monochorionic twin leads to exsanguination of the survivor, with fatal outcome in 20 to 30% of cases and a similar rate of severe ischemic complications. The most severe and acute complication is the twin-to-twin transfusion syndrome (TTTS). The main clinical manifestations of TTTS are the polyuric polyhydramnios--oliguric oligohydramnios sequence in the recipient and donor twin, respectively. TTTS is associated with a perinatal mortality rate of around 90%, and neurological sequelae are present in 20-40% of survivors born at around 25 weeks. Serial amnioreduction was long the only fetal therapy for TTTS, improving the survival rate to around 50% for at least one twin delivered at around 28 weeks, and reducing the risk of sequelae to around 20% among survivors. We have developed an intrauterine fetoscopic surgical treatment for TTTS. A 2-mm endoscope and a diode laser fiber are introduced percutaneously, under local anesthesia, through a single 3-mm trocard Coagulation of feto-fetal anastomoses on the chorionic plate leads to the survival of at least one twin in around 80% of cases at 33 weeks. Fewer than 10% of survivors have sequelae, mainly related to prematurity. We conducted a randomized controlled trial that confirmed the superiority of laser therapy over amnioreduction. The long-term outlook of these infants is good, with up to 6 years of follow-up.

To construct French reference charts and equations for nuchal translucency thickness (NT) using a large sample of fetuses. To compare this new reference with previous ones.The study data were obtained from a single large screening center over seven years. Only measurements taken by trained and certified (Fetal Medicine Foundation) operators, with crown rump length (CRL) between of 45 to 84 mm were used. Multiple pregnancies, abnormal karyotype, cystic hygroma or measurements performed by operators performing less than 500 examinations over the study period were excluded. Raw centiles were computed for each CRL. They were then fitted using a least square regression model with high order polynomials. Predicted median values for NT were compared to previously published references and the impact of deviation in median NT was evaluated.There were 19,198 measurements included for NT modelling. New charts and equations for NT centiles calculations are reported. Median values were comparable to those reported in other populations. The small discrepancy in median NT did not impact on screening efficiency.We present new French reference charts and equations for NT at first trimester. These may serve as a basis for ongoing audit and quality control. Although they were derived from a very and unselected sample, they do not show clinically relevant difference as compared to existing references. Our results do no support the use or development of customized French reference charts and algorithm for first trimester screening.

Hygiene of ultrasound probes is a hot topic in obstetric and gynecologic ultrasound. The issue concerns mainly the risk of contamination and the need for specific procedures to ensure a high degree of protection against infectious diseases, even if a disposable barrier cover is used. As there are no referenced quality criteria for these disposable probe covers, it is crucial to verify that they are CE marked. The use of condoms as probe covers is not recommended even though they present a lower rate of disruption compared to commercial probe covers. The global rate of probe cover perforation is of 1 to 9%. To date, there are no case reports of contamination by ultrasound examination, be it vaginal or abdominal. Nevertheless, every patient must be regarded as a potential source of infection. The French recommendations consider endovaginal ultrasound probes as semi-critical instruments and thus require intermediate-level disinfection. Because of the risk of disruption, American as well as Canadian and Australian recommendations insist on high-level disinfection of the probe. Every operator should follow reasonable hygiene rules and appropriate precautions should be taken in order to reassure the patients about the risks of contamination during any ultrasound examination.

Patients with chronic neurological disorders and cognitive impairment after tick bites are difficult to manage despite standard antibiotic therapy for Lyme disease. We wanted to correctly assess the disorders.Thirty patients were hospitalized for a standardized evaluation of their disorders: clinical examination, biological and serological studies, cerebral MRI, CSF study, neurophysiological exams, and neuropsychological evaluation of cognitive functions.Clinical and biological results were non informative. We observed significant CSF abnormalities (64%), MRI Flair pictures (41%), neurophysiological exams (47%), and cognitive evaluation (100%).A large and standardized evaluation should be made for each patient to improve the management and probably the treatment of these complex chronic symptoms observed after tick bites.

One of the main complications of spinal cord injury is neurogenic bladder when the bladder fails to empty spontaneously. Urinary tract infection is the leading cause of morbidity and the second cause of mortality in these subjects. Patient education and personalized medical follow-up must ensure adapted management depending on the risk factors and the voiding mode. The risk of urinary tract infection can be decreased by perfect neurological control of detrusor activity combined with a method of drainage: intermittent self-catheterization. Despite these measures, many patients experience recurrent symptomatic urinary tract infections. Repeated antibiotic therapy increases the risk of selection of multiresistant bacteria without reducing either the incidence or the severity of symptomatic urinary tract infections. Asymptomatic bacteriuria is very frequent in patients treated by intermittent catheterization and does not justify antibiotic therapy, as antiseptics and urinary alkalinizers or acidifiers have been shown to be effective. "Antibiocycle" strategies could have a beneficial role by significantly decreasing the number of infections and hospitalizations with no major ecological risks, by using molecules that are well tolerated orally with a low selection pressure. All febrile urinary tract infections require rapid investigation and an urgent urological and infectious diseases opinion (abscess, severe sepsis, resistance). The SPILF-AFU 2002 consensus conference provided answers to major questions concerning the definition, treatment and prevention of nosocomial urinary tract infection, especially in a context of neurogenic bladder.

The HIV-positive population is still increasing because the incidence of the disease remains high while the effectiveness of highly active antiretroviral therapy (HAART) has dramatically reduced mortality. HIV infected patients have an increased life expectancy and are more readily admitted to intensive care units.We conducted a nation-wide comparative study in France of how these patients are managed by ICU specialists, on one hand, and HIV specialists, on the other, to better understand the use of antiretroviral therapy in critically ill patients.The results show heterogeneous responses of ICU specialists with an important proportion of non decisive answers. The answers of HIV specialists are more homogeneous. There appears to be little or no cooperation between the two specialties. The CISIH (French centers for the information and care of human immunodeficiency) are rarely consulted.ICU specialists must be better informed on this rapidly evolving disease. Access to updated information or to an HIV specialists must be made easier. Studies should also be made on how HAART is employed in ICUs (pharmacology, pharmacodynamics...).

To construct new reference charts and equations for birth weight and birth size using a large and exhaustive sample of newborns. To compare this new references with previous ones.The study data were obtained from a single health authority (the birth registry of Yvelines, a French Territorial division of 1.4 million people) over 3 years. Multiple pregnancies were excluded. No data were excluded on the basis of abnormal biometry or birth weight. For each measurement, a least square regression model with high order polynomials was fitted to predict mean, standard deviation and therefore Z scores of birth weigh and birth size at any gestational age at birth from 25 to 42 weeks'.There were 58934 and 56956 measurements included for weight and size at birth respectively. New charts and equations for Z scores calculations, adjusted for sex, are reported based on polynomial regression methods.We present new French reference charts and equations for birth biometrics. Because they were derived from a very large and unselected sample, there might be more relevant to clinical practice than others and can be easily used to compute centiles and Z-scores.

Because of an increasing demand for limited health care resources as well as an increasing impact of legal aspects in ultrasound practice, it has become necessary to ensure that screening procedures are cost-effective and clinically effective and to develop systems that could help sonographists in certifying their practice. Based on the literature, various approaches for quality control are reviewed. Special emphasis is put on the use of fetal biometry and statistical tools to develop quality control systems based on both qualitative and quantitative approach. Besides their potentials for audit and quality control, such tools could also be useful during the process of training.

Placental insufficiency, a process due to either poor placental perfusion or permeability, may lead to progressive deterioration in placental function and materno-fetal morbidity. Advances in MR contrast media pharmacokinetic studies of transit through tissues and dynamic MRI allow to characterize organs microcirculation in vivo. Placental function assessment might be achieved using analysis of dynamic contrast enhanced MRI of tracers. A murine model of placental assessment has been constructed. Herein, principles, results and limitations of such techniques are discussed as well as their potential interest and weaknesses in humans.

A 54-year-old man presented with tuberculous spondylodiscitis associated to E. coli found in an intervertebral disc space needle biopsy. The enterobacteria came from a cholecystitis. The patient was cured by medical treatment, consisting in a non-surgical immobilization, antitubercular quadritherapy in association with a specific antibiotic treatment. No other case of spondylodiscitis caused by a mycobacterial coinfection pathogen has been reported so far.

The object of this study was to audit the policy of hysterectomy in nulliparous women in a university hospital.A retrospective medical records analysis of all hysterectomies performed during an 8-year period. Patients with no history of vaginal delivery were stratified into three groups: group 1, patients who underwent abdominal hysterectomies; group 2, patients undergoing vaginal hysterectomy (2a) or laparoscopy-assisted vaginal hysterectomy (2b). The groups were compared as to demographic data, surgical complications and outcomes.During the study period, there were 243 hysterectomies in patients with no history of vaginal delivery. Among these, vaginal hysterectomies (group 2) were undertaken in 75% (182 patients) and successfully performed in all but 13 patients (7.1%). Mean uterine weight was 943 grams in group 1 and 370 grams in group 2. Abdominal route (group 1) was associated with longer operative time (average: 105 min) than vaginal route (group 2a; 81 min) but shorter operative time that laparoscopy-assisted vaginal route (group 2b; 173 min). There was no significant difference in mean estimated blood loss and complications rates between groups 1 and 2. Hospital stay was shorter in group 2. Laparoscopic assistance was not associated with bigger uteri, neither with fewer complications.Nulliparity should no longer be considered a contraindication to vaginal hysterectomy. In such patients, many more hysterectomies should be carried out vaginally and laparoscopic assistance does not offer obvious advantages over the standard vaginal approach.

Osteomyelitis is a bacterial implant in bone matrix. Infection occurs as a result of a bacteremia, an inoculation during aseptic or orthopedic surgery, or a contiguous infectious focus. Persistent and relapsing infection may be due to three situations: underlying conditions such as diabetes mellitus or rheumatoid arthritis, presence of foreign surgical implant, and a causative bacterial strain. The pathogenesis of osteomyelitis has been explored through various experimental models, involving mostly Staphylococcus (S. aureus, S. epidermidis) and has given new insights. Bacterial adherence to implanted devices or bone matrix via surface proteins is critical for bacterial survival. Further bacterial growth depends on various mechanisms: the capacity to exhibit matrix-embedded lifestyle known as biofilm and the ability for bacterial subpopulations to switch to a dormant metabolic state known as small colony variants. In addition to bacterial factors, the presence of foreign material induces a defect in local inflammatory response partly responsible for the high susceptibility to infection.

Struma ovarii is a rare benign tumor which represents less than 3% of ovarian teratomas. We report a case of struma ovarii occurring in a 64-year-old woman. This tumor was thought to be a malignant ovarian tumor until surgical exploration. Based on this observation and the review of the literature we describe the main characteristics and propose a diagnostic and therapeutic management scheme for such tumors.