The European Trauma Course: Transforming systems through training

The European Trauma Course (ETC) exemplifies an innovative approach to multispecialty trauma education. This initiative was started as a collaborative effort among the European Society for Emergency Medicine, the European Society for Trauma and Emergency Surgery, and the European Society of Anaesthesiology under the auspices of the European Resuscitation Council. With the robust support of these societies, the project has evolved into the independent European Trauma Course Organisation. Over the past 15 years, the ETC has transcended traditional training by integrating team dynamics and non-technical skills into a scenario-based simulation course, helping to shape trauma care practice and education. A distinctive feature of the ETC is its training of doctors and allied healthcare professionals, fostering a collaborative and holistic approach to trauma care. The ETC stands out for its unique team-teaching approach, which has gained widespread recognition as the standard for in-hospital trauma care training not only in Europe but also beyond. Since its inception ETC has expanded geographically from Finland to Sudan and from Brazil to the Emirates, training nearly 20,000 healthcare professionals and shaping trauma care practice and education across 25 countries. Experiencing exponential growth, the ETC continues to evolve, reflecting its unmet demand in trauma team education. This review examines the evolution of the ETC, its innovative team-teaching methodology, national implementation strategies, current status, and future challenges. It highlights its impact on trauma care, team training, and the effect on other life support courses in various countries.

Therapeutic Vaccines for HPV-Associated Cervical Malignancies: A Systematic Review

IMPORTANCE

Despite widespread prophylactic vaccination, cervical cancer continues to be a major health problem with considerable mortality. Currently, therapeutic vaccines for HPV-associated cervical malignancies are being evaluated as a potential complement to the standard treatment.

OBJECTIVE

The present systematic review was conducted on randomized controlled trials (RCTs) to investigate the effects of therapeutic vaccines on the treatment of patients with cervical cancer and cervical intraepithelial neoplasia (CIN) of Grades 2 and 3.

EVIDENCE REVIEW

The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched. Only articles in English published up until 31 January 2024 were selected. Also, reference lists of the selected original papers and recent review articles were manually searched for additional sources. Data on study characteristics were extracted from the selected articles. Data on outcomes of interest were synthesized, and vaccine efficacy endpoints (histological lesion regression, clinical response, and overall survival) were selected as the basis for grouping the studies.

FINDINGS

After screening 831 articles, nine RCTs with 800 participants were included, of which seven studies with 677 participants involved CIN2 and CIN3 and examined lesion regression to ≤CIN1 as the efficacy endpoint. Results of two of these studies were deemed to have a high risk of bias, and another one did not contain statistical analyses. Results of the other four studies were quantitively synthesized, and the pooling of p-values revealed a significant difference between the vaccine and placebo groups in terms of lesion regression (p-values of 0.135, 0.049, and 0.034 in RCTs, yielding a combined p-value of 0.010). The certainty of the evidence was rated as moderate. Patients with advanced cervical cancers were studied in two RCTs with 123 participants. Clinical response and overall survival were taken as endpoints, and the results were reported as not significant. The certainty of the evidence of these results was rated as very low, mainly due to the very small number of events. All studies reported good tolerance for the vaccines.

CONCLUSIONS AND RELEVANCE

The results indicate the potential for therapeutic vaccines in the regression of CIN2 and CIN3 lesions. Moreover, a potential gap in evidence is identified regarding the very low number of RCTs in patients with advanced cervical cancer.

Manually Controlled, Continuous Infusion of Phenylephrine or Norepinephrine for Maintenance of Blood Pressure and Cardiac Output During Spinal Anesthesia for Cesarean Delivery: A Double-Blinded Randomized Study

BACKGROUND

To counteract the vasoplegia induced by spinal anesthesia (SA) and maintain blood pressure (BP) during cesarean delivery, phenylephrine is currently recommended, but norepinephrine might offer superior preservation of cardiac output. We aimed to compare the hemodynamic effects of phenylephrine and norepinephrine administered by manually adjusted continuous infusion during elective cesarean delivery.

METHODS

In this pragmatic, parallel-group, double-blind randomized controlled trial, 124 parturients scheduled for elective cesarean delivery under SA in a tertiary maternity in France, between February 2019 and December 2020, were randomized to receive norepinephrine at a starting rate of 0.05 μg·kg -1 ·min -1 (n = 62) or phenylephrine at a starting rate of 0.5 μg·kg -1 ·min -1 (n = 62). In both groups, the vasopressor infusion rate was then manually adjusted to maintain maternal systolic BP above 90% of the baseline value. The primary outcome, the change in cardiac index (CI) measured by thoracic bioreactance from SA to umbilical cord clamping, was analyzed through repeated measures analysis of variance and post hoc t tests. Secondary outcomes included maternal BP and neonatal outcomes.

RESULTS

In the norepinephrine group, cardiac index was maintained between 90% and 100% of baseline from SA to umbilical cord clamping, whereas it was maintained at significantly lower values (81%-88%) in the phenylephrine group ( P = .001). The percentage of elapsed time with a mean maternal BP <65 mm Hg and with systolic BP <80% of the baseline value was higher in the phenylephrine group: 2.9% (7.3) vs 0.5% (1.8) (absolute risk difference [ARD], -2.4%; 95% confidence interval, -4.4 to -0.5; P = .012) and 8.5% (16.6) vs 2.3% (5.2) (ARD, -6.2%; 95% confidence interval, -10.6 to -1.8; P = .006). Excluding parturients with gestational diabetes, severe neonatal hypoglycemia was more common in the phenylephrine group at 19.6% (9/46) vs 4.1% (2/49) ( P = .02). The other neonatal outcomes did not differ significantly between the groups.

CONCLUSIONS

When administered by manually adjusted infusion during SA for cesarean delivery, norepinephrine was associated with a higher CI; both infusions were effective for maintaining BP.

Pelvic Floor Muscle Training for Urinary Incontinence with or without Biofeedback or Electrostimulation in Women: A Systematic Review

To determine the effectiveness of pelvic floor muscle training (PFMT) with or without biofeedback or electrostimulation in reducing urinary incontinence and pelvic floor muscle con-traction in non-pregnant women with urinary incontinence. Methods: The following electronic databases were searched: PubMed, Cochrane Central, ClinicalTrials.gov, EU Clinical Trials Register, and sources from NICE, FDA, EMA, and SMC (articles only in English, 2000–2021). Search terms were: urinary incontinence, pelvic floor muscle training or exercises, biofeedback, electrostimulation. We used the PRISMA statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) for this systematic review. Relevant articles were selected, data were extracted, and quality was assessed. Data were extracted in predesigned form, followed by narrative synthesis. Results: Following the search, 15 RCTs were retrieved using the strict inclusion and exclusion criteria, assessing 2441 non-pregnant women with urinary incontinence. Of the 15 studies, 7 were low risk, 5 were medium risk, and 3 were high-risk studies. Of the 2441 patients, 970 were in PFMT, 69 were in extracorporeal magnetic innervation (ExMi) or with PFMT + BF, 30 were in electrostimulation (ES), 21 were in whole body vibration training (WBVT), 23 were in pelvic floor muscle + abdominal muscle therapy (PFM + AMT), 326 were in PFMT + biofeedback, 93 were in vaginal cones (VC), 362 were in PFMT + education, 318 were in education, and 229 were in control groups. The most often measures employed were pad tests, bladder diary, and questionnaire on the quality of life. Stress, urge and mixed urinary incontinence were studied. In all RCT, PFMT significantly reduced urinary incontinence, essentially SIU and MUI, when compared with the control group before and after treatment. Overall, out of 997 PFMT or PFMT + education patients, 504 patients (50.5%) showed improvement in urinary incontinence, and 218 became continent (21.8%) (negative pad test). In total, 62% of patients significantly reduced their urinary incontinence or cured it and improved their pelvic floor muscle contraction. All other physiotherapist techniques also significantly reduced urinary leakages, e.g., vaginal cones, biofeedback, ExMI, and WBVT when compared with the control group. There were no significant differences between these methods in reducing the severity of urinary incontinence. Conclusion: PFMT alone or with bio-feedback or electrostimulation was effective in reducing urinary incontinence and improving pelvic floor muscle contraction. PFMT when compared with other interventions such as bio-feedback, VC, and WBVT did not show significant differences but was superior to the control group. RCT studies with similar parameters used for measuring the outcomes need to be included.

Diagnosis and Management of Pregnant Women With Placental Abruption and Neonatal Outcomes

Background

Placenta abruptio (PA) remains a serious materno-fetal complication. According to progress realized in maternal-fetal medicine, we aimed to evaluate the diagnosis and management of PA and neonatal outcomes.

Methods

We conducted a retrospective study that involved all the patients that were diagnosed with PA in a tertiary maternity hospital between 2006 and 2013. Data were analyzed to determine mean and standard deviation and statistically analyzed using the Chi-square test.

Results

In total, 201 patients were diagnosed with PA out of 35184 deliveries (0.56%). The mean age of patients was 30 years and most of them were multiparous (56.2%). Thirty-six out of 201 patients (17.9%) smoked tobacco or consumed alcohol during the pregnancy. Three patients came from their homes. Twenty-eight patients had preeclampsia and 105 presented with high blood pressure. Furthermore, 117 patients presented metrorrhagia (58.2%) and 39% of patients exhibited abdominal pain. We reported fetal heart rate abnormalities in 57% of the cases. Ultrasound examination revealed PA in only 48 patients (23.9%). One hundred eighty out of 201 patients (84.6%) underwent an emergency caesarean section. One hundred sixty-seven fetuses were born prematurely. Thirteen out of 201 fetuses died, and 98 newborns needed neonatal resuscitation. In total, 31 fetuses had an umbilical artery (UA) with pH ≤ 7 (31/188). The mean time for delivery was 18.7 min. However, UA pH did not differ when the delivery time was shorter (p = 0.09). Seventy-six percent of cases came from their homes. The mean UA pH was significantly lower for PA cases who came from their homes compared to hospitalized women (p = 0.0015). Histological examination of the placenta confirmed the diagnosis in 71 out of 148 cases (47.9%). The mean duration of hospital stay of the newborns was 17 days.

Conclusion

PA remains a serious materno-fetal emergency with a bad fetal prognosis for many newborns. Many fetuses either died or exhibited severe acidosis. Clinical signs and radiological images of PA are absent in many cases. There was more fetal acidosis for mothers who came from their homes at the time of delivery. We recommend that the delivery should not be delayed and a cesarean section must be the preferred mode of delivery. Pregnant women with vascular and metabolic diseases should be carefully monitored and informed on the risk of PA.

The role of parliamentarians in promoting self-care interventions for sexual and reproductive health and rights: applying COVID-19 lens in the Eastern Mediterranean region

Innovative people-centered care modalities including self-care interventions offer an opportunity to ensure continuity of healthcare services during COVID-19 and in post-COVID-19, as well as contribute to the achievement of universal health coverage. Parliamentarians are uniquely positioned to promote self-care interventions for sexual and reproductive health and rights through their legislative, budget allocation, oversight, and advocacy roles. However, existing health systems governance challenges in the Eastern Mediterranean region such as weak institutions setups, fragmentation of health programs, and limitation of resources could impede parliamentarians’ progress. To address these challenges, the following recommended actions should be considered: (1) promote the adaptation of sexual and reproductive health and rights service packages at primary healthcare level to integrate self-care interventions (2) govern innovative people-centered care channels including self-care interventions; and (3) engage in a dialogue with civil society and communities to meet needs, raise public awareness and generate demand.

Diagnosis and management of placenta previa and low placental implantation

Objective: To evaluate the migration of low-placental implantation (LPI) during the third trimester of pregnancy and its effect on delivery and post-partum hemorrhage.Methods: We conducted a retrospective study at a level 3 maternity center including all cases of placenta previa (PP) and LPI between 1998 and 2014. The distance (d) between cervical internal os (CIO) and placental edge (PE) were measured by vaginal ultrasonography in the third trimester of pregnancy at 32 and 3 weeks after. We analyzed CIO-PE distance, volume of post-partum hemorrhage, delivery decision, and mode of delivery using Kruskall-Wallis test.Results: In total, 319 patients presented with PP or LPI. All complete PP (121) and 90.6% (58 of 64) of the placentas less than 1 cm from the CIO did not migrate. Among the 138 placentas with an initial CIO-PE d greater than 1 cm, only 17 (12.3%) did not migrate above 2 cm. The patients for whom the decision to perform a cesarean section (C-section) was retained and realized had a CIO-PE d significantly lower than those who delivered vaginally (p < .001). The patients who delivered by C-section had a lower CIO-PE d when an emergency C-section was performed, specifically for hemorrhage (p < .001). The mean volume of hemorrhage was significantly higher for patients with a CIO-PE d less than 2 cm.Conclusion: Complete PP and the majority of the placentas less than 1 cm from the CIO did not migrate. Above 1 cm, the majority of the placentas migrated three to four weeks later. For the placentas less than 1 cm from the CIO, a significant risk of hemorrhage at delivery was observed. Thus, prophylactic cesarean section is required for CIO-PE distances <1 cm. For distances between 1 and 2 cm, the volume of blood loss tends to be more important than for distances >3 cm without statistical significance. A vaginal delivery could be tried after information of patients.

Operative hysteroscopy versus vacuum aspiration for incomplete spontaneous abortion (HY-PER): study protocol for a randomized controlled trial

Background

Incomplete spontaneous abortions are defined by the intrauterine retention of the products of conception after their incomplete or partial expulsion. This condition may be managed by expectant care, medical treatment or surgery. Vacuum aspiration is currently the standard surgical treatment in most centers. However, operative hysteroscopy has the advantage over vacuum aspiration of allowing the direct visualization of the retained conception product, facilitating its elective removal while limiting surgical complications. Inadequately powered retrospective studies reported subsequent fertility to be higher in patients treated by operative hysteroscopy than in those treated by vacuum aspiration. These data require confirmation in a randomized controlled trial comparing fertility rates between women undergoing hysteroscopy and those undergoing vacuum aspiration for incomplete spontaneous abortion.

Methods

After providing written informed consent, 572 women with incomplete spontaneous abortion recruited from 15 centers across France will undergo randomization by a centralized computer system for treatment by either vacuum aspiration or operative hysteroscopy. Patients will not be informed of the type of treatment that they receive and will be cared for during their hospital stay in accordance with standard practices at each center. The patients will be monitored for pregnancy or adverse effects by a telephone conversation or questionnaire sent by e-mail or post over a period of two years. In cases of complications, failure of the intervention or diagnosis of uterine cavity disease, patient care will be left to the discretion of the medical center team.

Discussion

If our hypothesis is confirmed, this study will provide evidence that the use of operative hysteroscopy can increase the number of pregnancies continuing beyond 22 weeks of gestation in the two-year period following incomplete spontaneous abortion without increasing the incidence of morbidity and peri- and postoperative complications. The standard surgical treatment of this condition would thus be modified. This study would therefore have a large effect on the surgical management of incomplete spontaneous abortion.

Trial registration

ClinicalTrials.gov Identifier: NCT02201732; registered on 17 July 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0900-1) contains supplementary material, which is available to authorized users.

[Bakri balloon tamponade for severe post-partum haemorrhage: efficiency and fertility outcomes]

AIM

To evaluate efficiency of Bakri balloon tamponade (BB) to stop severe post-partum haemorrhage (PPH) and fertility outcomes.

METHODS

Retrospective study including all patients who underwent Bakri balloon tamponade for severe PPH between January 2009 and December 2013. The objectives were to stop PPH by BB and to evaluate the fertility after Bakri balloon tamponade.

RESULTS

Sixty-one women had a Bakri balloon inserted in utero for severe PPH. The PPH was stopped in 55 patients out of 61 (88%). The reasons of severe PPH were uterine atony in 44 cases (72%), placental retention in 10 cases, placenta praevia in 3 cases, and cervical or vaginal tears in 4 cases. In one third of cases, the pregnancy was complicated by diabetes, placenta praevia, hypertensive troubles. A cesarean section or an instrumental delivery was performed for one third of patients. The mean duration of the Bakri balloon insertion was of 7 hours [5-9] and the mean filling of the balloon was of 350 ml [205-450]. The mean blood loss was of 1600 [1200-2250]. Sixty-three percent of patients (n=38) received red blood cells transfusion. The BB was efficient after a vaginal delivery or after a caesarean section and in all cases of placenta praevia. In 6 cases, the BB was inefficient and uterine embolisation or a surgical procedure was performed to stop PPH. Nine women underwent a new pregnancy after the insertion of Bakri balloon for severe PPH and 3 delivered healthy newborns.

CONCLUSION

Bakri balloon tamponade is a minimally invasive intrauterine device efficient to stop severe post-partum haemorrhage. New pregnancies and deliveries are possible after tamponade by Bakri balloon.

[Anal sphincter tears after vaginal delivery: risks factors and means of prevention]

To identify incidence and risks factors of obstetrical anal sphincter lacerations, we reviewed all cases of 3rd and 4th degree sphincter lacerations after vaginal deliveries (VD) occured in a tertiary maternity between 2005 and 2010. 78 anal sphincter lacerations were identified (3.8/1000 deliveries). 66 women (85%) were nulliparous. The mean age of women was of 29 +/- 5 years. The mean duration of the second stage of labour was of 3.4 +/- 1,7 hour. The birth weight of 12 newborns (15%) was greater than 4000 grams. Fourty-six women (2.5%) had sphincter lacerations after instrumental delivery and 32 after spontaneous vaginal delivery (0.2%). 51 patients out of 78 (65%) had a medio-lateral episiotomy, 82% occured after instrumental extraction and 43% after spontaneous delivery. A forceps of Tarnier was used in 18 cases, a Suzor forceps in 12 cases, spatula in 12 cases and vacuum in 4 cases. 76% of foetuses were in anterior presentation and 78% at the medium part of the pelvis. 2 patients experienced anal incontinence in early post-partum. Anal sphincter lacerations are relatively frequent after VD especially after instrumental delivery. Macrosomia, nulliparous women, prolonged second stage of labor were associated with anal sphincter tears. Medio-lateral episiotomy does not protect enough anal sphincters. Anal sphincter lacerations lead to anal incontinence in some cases.A long follow-up is useful for these patients.

Multiple square sutures for postpartum hemorrhage: results and hysteroscopic assessment

OBJECTIVE

The purpose of this study was to evaluate the efficiency and morbidity of multiple square sutures in severe postpartum hemorrhage.

STUDY DESIGN

A retrospective study encompassed 30 multiple square sutures that were performed for severe postpartum hemorrhage in 26,605 deliveries in a tertiary maternity center. The main outcome measures were the ability to stop hemorrhage and the assessment of the uterine cavity by hysteroscopy at 3 months.

RESULTS

Multiple square sutures stopped postpartum hemorrhage in 28 of 30 cases (93%). Twenty women underwent hysteroscopy after multiple square sutures. Eight women (40%) did not have intrauterine adhesions. Nine women (45%) had thin and localized intrauterine adhesions that were removed easily by the tip of the hysteroscope; 2 women had moderate intrauterine adhesions that were resected. One patient had endometritis followed by severe intrauterine adhesions.

CONCLUSION

Multiple square sutures are effective and safe for the control of severe postpartum hemorrhage and for uterine conservation in most cases. Although some patients had moderate or severe adhesions, a normal uterine cavity or minimal intrauterine adhesions that were removed easily were the most frequent findings at hysteroscopy. A prospective study may be helpful to compare the safety and efficiency of square and brace sutures.

[Gynecological emergencies: etiology and degree of gravity]

OBJECTIVE

To evaluate the type and the emergency degree of the pathologies met in gynecological emergencies.

METHODS

prospective study including 205 patients presented to the Emergency department of a maternity level 3 between the 2011 January 4 and February 15.

RESULTS

One hundred and ninety-four patients (95%) came from their own initiative. One hundred and eighty-one patients (88%) consulted for abdominal/pelvic or lumbar pain and or metrorragia. The mean age of the patients was of 31 ± 11 years and the average waiting time before being examined was of 84 ± 101 minutes. For 94 patients (46%), the diagnosis was an asymptomatic intra-uterine pregnancy in 41 cases or associated with minor symptoms. 21 patients (8.9%) consulted for menstruation with or without dysmenorrhea, 17 (8,3%) had a miscarriage, 14 (7%) a genital infection, 11 (5%) an ovarian pathology and eight (4%) an ectopic pregnancy or its follow-up. Seven patients had an axillary lymphocele or a breast tumor and four symptomatic myomas. Six patients presented with non-gynecological pathologies. In 23 cases (11%) no organic cause was found. Only 24 patients (12%) were hospitalized and nine (4.5%) operated.

CONCLUSION

Most of the patients consulted for minor obstetrical or gynecological pathologies without relation with the function of Emergency department. Ectopic pregnancy remains a rare event. Better information of the users on the significance of the urgency is desirable. Consultation of a referent physician before emergency services should be privileged.

Information for patients undergoing a prenatal diagnosis

OBJECTIVES

Lack of information is a frequent complaint with regard to physicians dealing with prenatal diagnosis (PD). The aim of the study was to find out how information on PD was perceived by patients and if they considered that they had been correctly informed by their physicians.

METHODS

We conducted a prospective study in Lariboisière Hospital (Paris) with 86 patients undergoing prenatal diagnosis between 2001 and 2003. A 23-item questionnaire was given to patients after delivery or termination of pregnancy (TP).

RESULTS

Fifty patients out of 86 answered the questionnaire. Twelve patients out of 50 underwent a TP. Information on foetal anomaly was insufficient for 11 patients out of 50 (22%). Some patients found the information too technical; others would like to see photos to illustrate the anomalies and the possible surgical repairs to be performed. Information was insufficient for one in four patients concerning maternal serum screening for Down's syndrome. Information before amniocentesis was considered sufficient by 9 out of 10 patients. Information on the risks of TP was not given or not understood by 10 out of 12 patients.

CONCLUSION

Information on prenatal diagnosis could be improved by using simple and accessible language, supported by written documents and photos for certain anomalies. More information should be given in cases of abstract anomalies and should be adapted to the social, ethnic and cultural background of the patient.

[Cyanobacteria and their toxic potential in dam water content in Northern Tunisia]

In order to get data about toxic cyanobacteria and their potential sanitary risk in 12 waterbodies situated in the north of Tunisia, some taxonomic, ecological and toxicological studies were undertaken since 2001. This paper provides the first screening of the potential toxic species of cyanobacteria as well as their geographical distribution. The microscopic examination of the phytoplankton samples show 42 species of cyanobacteria; 9 are frequently quoted by the literature as being potentially toxic. Among the inventoried cyanobacteria genera there are Pseudanabaena, Planktothrix Phormidium, Lyngbya, Microcystis,... Oscillatoria constitutes the most widespread one. The content of total microcystin (MCYST) was determined by protein phosphatase inhibition assays (PP2A). The total microcystin, detected in dissolved and particulate fractions in all the examined samples is generally low and varies between 2 and 7455 ng/l microcystin-LR equivalent per liter. The highest MCYST concentration is observed in autumn and generally in particulate MCYST concentrations.

Knowledge about contraception in women undergoing repeat voluntary abortions, and means of prevention

AIMS

Despite reliable and effective means of contraception, cases of repeat abortion are on the increase in all developed countries. The aim of this work was to determine whether women undergoing repeat abortions are exposed to risk factors which might be amenable to preventative measures, and the methods employed by carers in these cases.

METHODS

We set out to evaluate practices in the Family Planning Centre of l'Hôpital Jean Verdier (Bondy, France) by sending a questionnaire to 147 women who had undergone two abortions up to 1997, and by conducting interviews with the care team. Thirty patients responded to the questionnaire.

RESULTS

Twenty-two women (73%) underwent one or more further abortions between 1999 and 2000. Twenty-seven out of 30 women were unaware of the existence of emergency contraception. The 'morning after' pill, indicated for cases of unprotected sex, was unknown to one woman in two (15), nine out of 30 did not know what 'back-up' measures they should take after missing a dose of the contraceptive pill. Psychological problems were found in nine cases. These were followed up with a psychological consultation in three cases. The information given to the patients by the carers was the same irrespective of the number of abortions. Poverty and psychological problems were noted by the carers.

CONCLUSION

Patients who have undergone two abortions might benefit, in addition to their routine visits, from a consultation with a psychologist and a consultation providing information about contraception. Providing the contraceptive pill free of charge to low-income patients is essential.

Intervillous and spiral artery flows in normal pregnancies between 5 and 10 weeks of amenorrhea using color Doppler ultrasonography

OBJECTIVE

The aim of our study was to investigate early placental circulation development and spiral and uterine artery flows in normal 1st-trimester pregnancies.

METHODS

A prospective study of intervillous and spiral artery flows in 49 normal pregnancies (5-10 weeks of amenorrhea) was performed. Transvaginal color and pulsed-wave Doppler techniques (6-MHz probe) were used as routine ultrasound scanning modalities before pregnancy termination for psychosocial reasons.

RESULTS

In all pregnancies, between 5 and 10 weeks, continuous nonpulsatile intervillous flow (mean V(max) 3.55 cm/s) and spiral artery flow (mean peak systolic velocity 16.2 cm/s, mean diastolic index D/S 0.49 +/- 0.089) were detected. In the 47 women in whom the uterine artery flow was measured, the mean peak systolic velocity was 67.5 cm/s, the mean diastolic index was 0.12, and bilateral notching was observed.

CONCLUSIONS

In all cases, between 5 and 10 weeks, slow and continuous nonpulsatile intrachorionic flow could be detected, whereas pulsatile flow was detected in spiral arteries. The true nature of this early intervillous circulation remains to be determined.

[Evaluation of the risk of abortion abuse resulting from the two-week legal delay in France]

OBJECTIVE

The legal delay for abortion in France has recently been prolonged from 10 (12 weeks of amenorrhea) to 12 weeks (14 weeks of amenorrhea). With the progress in sonography, certain foetuses may exhibit malformations during the first trimester. Diagnosis of foetal gender at 12 weeks of amenorrhea is sometimes possible. We studied the possibility that the prolonged legal delay before abortion might incite women to abort, simply on sonographic criteria.

METHODS

Our enquiry was conducted in March 2001 in the department of Obstetrics and Gynaecology of the Jean Verdier hospital in Bondy. Two questionnaires were drawn-up by the Medical Ethics Laboratory of the Necker Hospital in Paris and were distributed to 128 women and 24 nurses.

RESULTS

Recourse to abortion was high if laparoschisis or the absence of a hand was revealed, low in the case of opacity of the neck, and almost inexistent in the case of unwanted gender, in a female population with less than one child.

CONCLUSION

A national consensus on foetal abnormalities to be searched for, and not to be searched for (Number of fingers? Upper lip?...) and the eventual detection of the gender during sonography of the 1st trimester is urgent in view of the technological progress made. Clear and reassuring information is essential when confronted with foetal abnormalities and must lead to complete and precise antenatal diagnosis (caryotyping, sonographic control 2 or 3 weeks later).

Uteroplacental circulation development: Doppler assessment and clinical importance

In the first weeks of pregnancy, columns of endovascular cytotrophoblastic plugs develop in the lumen of spiral arteries. Morphologic data show that these plugs become loosened as soon as the end of the second month and the intervillous circulation of maternal blood is likely to be established progressively between the 8th and 12th weeks. The disorganization of the musculo-elastic layers of these vessels provokes a dramatic decrease in vascular tone in the uteroplacental circulation. These modifications appear to govern the establishment of a low-pressure blood flow in the placenta, and hence determine the quality of uteroplacental circulation and normal fetal growth. Placental bed biopsies in women with pre-eclampsia and in a proportion of pregnancies with intrauterine growth retardation have shown that these physiologic changes were absent in the myometrial segments of spiral arteries. Recently, colour Doppler was used to assess intervillous and spiral artery flow in early pregnancy, confirming in vivo free intervillous flow at 12 weeks and a progressive significant decrease in spiral artery resistance with advancing gestation during the first trimester. However, certain data at an earlier gestational age are still contradictory. Particularly, the exact nature of the contents of the intervillous space before 8 weeks, and whether or not this fluid can be considered maternal blood, remains controversial.