[Systemic lupus erythematosus and antiphospholipid syndrome: How to manage pregnancy?]. / Lupus systémique et syndrome des antiphospholipides : comment prendre en charge la grossesse ?

Pregnancy in systemic lupus erythematosus patients is a common situation that remains associated with higher maternal and fetal mortality/morbidity than in the general population. Complications include lupus flares, obstetrical complications (fetal loss, in utero growth retardation, prematurity) and neonatal lupus syndrome. The association with antiphospholipid antibodies or antiphospholipid syndrome increases the risk of obstetrical complications. Improving the care of these pregnancies depends upon a systematic pregnancy planning, ideally during a preconception counseling visit and a multidisciplinary approach (internist/rheumatologist, obstetrician and anesthetist). The absence of lupus activity, the use of appropriate medications during pregnancy adjusted to the patient's medical history and risk factors, and a regular monitoring are the best tools for a favorable outcome for these high-risk pregnancies. The aim of this review article is to perform an update on the medical care of pregnancy in systemic lupus erythematosus or antiphospholipid syndrome to reduce the risk of complications and to ensure the best maternal and fetal prognosis.

[In vitro fertilization and systemic lupus erythematosus or antiphospholipid syndrome: An update]. / Fécondation in vitro au cours du lupus érythémateux systémique ou du syndrome des antiphospholipides : mise au point.

Fertility is not impaired in systemic lupus erythematosus or antiphospholipid syndrome, but, similarly to the general population, these patients may undergo in vitro fertilization. This type of treatment increases the risk of lupus flare, thrombosis, and ovarian hyperstimulation syndrome. This review will focus on in vitro fertilization in systemic lupus erythematosus or antiphospholipid syndrome. Literature data are relatively scant with only 3 reported studies. The first one included 17 patients and 63 cycles of induction ovulation/in vitro fertilization leading to 25 % of lupus flare, no thrombosis, and 3 % of ovarian hyperstimulation syndrome. The second study included 10 patients and 40 cycles of in vitro fertilization showing 31 % of lupus flare, no thrombosis and no ovarian hyperstimulation syndrome. The last one included 34 patients and 83 procedures of in vitro fertilization leading to 8 % of flares, 5 % of thrombosis and no ovarian hyperstimulation syndrome. Interestingly, in this last study, half of the complications were explained by poor adherence to treatment. These data are reassuring but it is important to remember that in vitro fertilization should be scheduled and carefully supervised in the same way as the high-risk pregnancies occurring in these patients.

[Obstetrical management of patients at risk of neonatal lupus syndrome: review of the literature]. / Prise en charge obstétricale des patientes à risque de "lupus néonatal"

Fetuses and infants of women with anti-SSA/Ro and anti-SSB/La antibodies are at risk of neonatal lupus syndrome, featuring skin lesions, hematological and hepatic disorders, and congenital heart block (CHB) in the absence of severe cardiac malformation. The prevalence of CHB in newborns of anti-SSA/Ro positive women with known connective tissue disease is 1 to 2% and the risk of recurrence ranges from 10 to 17%. CHB is definitive and is associated with significant morbidity (pacemaker must be implanted in 2/3 of cases) and mortality (16 to 19%). Myocardial involvement may either be associated or appear subsequently. Other manifestations are discussed. For anti-SSA/Ro positive pregnant women, echocardiograms should be performed every 2 weeks from 16 to 24 weeks of gestation, and every week in case of past history of CHB. Electrocardiogram should be performed in the first days of life for all children to detect incomplete CHB. Therapy for CHB detected in utero is based on fluorinated steroids, especially betamethasone. Its efficiency is variable.

[Neonatal lupus syndrome: review of the literature]. / Lupus néonatal: revue de la littérature.

PURPOSE: Neonatal lupus syndrome include skin lesions, hematological and hepatic disorders, and congenital heart block (CHB) in the absence of severe cardiac malformation. This rare disorder is closely linked to transplacental transport of anti-SSA/Ro and anti-SSB/La maternal antibodies. CURRENT KNOWLEDGE AND KEY POINTS: The prevalence of CHB in newborns of anti-Ro/SSA positive women with known connective tissue disease is 2% and the risk of recurrence ranges from 10 to 17%. Skin and systemic lesions are transient, whereas CHB is definitive and is associated with significant morbidity and mortality (estimated at 16-19%). A pacemaker must be implanted in 2/3 of cases. Myocarditis may be associated or may appeared secondarily. Mothers of children with CHB are usually asymptomatic or have Gougerot-Sjögren, or undifferentiated connective tissue disease. Mothers of children with cutaneous manifestations may present with more severe disease and systemic lupus erythematosus. In anti-Ro/SSA positive pregnant women, echocardiograms should be performed at least every 2 weeks from 16 to 24 weeks gestation. Electrocardiogram should be performed for all children. FUTURE PROSPECTS AND PROJECTS: The efficiency of prophylactic treatment of CHB is not established. Therapy for CHB detected in utero is not standardized and involves fluorinated steroids (especially betamethasone).

Questions about dexamethasone use for the prevention of anti-SSA related congenital heart block.

BACKGROUND: Mothers with anti-SSA/Ro antibodies who have had a previous fetus with congenital heart block (CHB) have a risk of recurrence estimated to be up to 16%. OBJECTIVE: To improve the management of these "high risk patients" by determining (a) whether or not prophylactic treatment is efficient; (b) whether or not fluorinated steroids (betametasone and dexamethasone) that do cross the placenta in an active form are safe for the fetus; and (c) which prophylactic treatment should be used. METHODS: Retrospective study performed on seven mothers sent to a university hospital owing to a past history of one (six mothers) or two children (one mother) with CHB. RESULTS: 13 subsequent pregnancies occurred. No CHB was observed. All four pregnancies in women treated with 10 mg/day prednisone were uneventful. Three pregnancies in women receiving no steroids resulted in two early spontaneous abortions and one live birth. The six pregnancies in women treated with dexamethasone (4-5 mg/day) ended in one early and one late spontaneous abortion, two stillbirths, and two live births with intrauterine growth restriction and mild adrenal insufficiency. A histological study of one stillbirth disclosed intrauterine growth restriction and marked adrenal hypoplasia. CONCLUSION: Adverse obstetric outcomes were often seen here and major concerns have been raised by paediatricians about the safety of fluorinated steroids, owing to the results of animals studies, retrospective data, and randomised trials. Because fluorinated steroids have not been shown to improve prophylactic treatment of CHB in pregnant women at high risk, their use is questionable.

Comparison of two diagnostic tests for gestational diabetes in predicting macrosomia.

OBJECTIVES: To validate a diagnostic test for gestational diabetes which predicts the risk of macrosomia. METHODS: A prospective study was carried out among 354 women at risk for gestational diabetes to compare two glucose tests diagnosing pregnancies at risk of macrosomia. The "practical" test consisted in glucose measurement in the fasting state and two hours after an usual breakfast and the "reference" test was the test proposed in France (O'Sullivan test with or without a 100 g oral glucose tolerance test). Both tests were made between the 24(th) and 28(th) week of gestation. Women at high risk for macrosomia were treated. The first assessment criterion was macrosomia (babies large for gestational age). Because of the presence of women treated for gestational diabetes in our sample, the sensitivity and specificity of the tests in diagnosing pregnancies at risk of macrosomia were calculated using either the incidence of macrosomia observed in our population, or the incidence of macrosomia observed theoretically in the absence of treatment (22% in literature). RESULTS: Macrosomia was diagnosed in 49 neonates (14%). The "practical" test was significantly more sensitive than the reference test (respectively 46.9% versus 16.3%, p=0.0001 in the first case, and 54.3% versus 20.1%, p=0.0001 in the second case). The "reference" test was significantly more specific than the "practical" test (respectively 80% versus 68.2%, p=0.0001 in the first case, and 80.6% versus 70%, p=0.0001 in the second case). CONCLUSION: Our study shows that the simplified "practical" test is more sensitive than the "reference" test currently used in France in screening women at risk of macrosomia.

[Diabetic pregnancy. Evaluation and prospects from the study of 212 diabetic pregnancies followed-up between 1985 and 1992]. / Grossesse diabétique. Bilan et perspective à partir de l'étude de 212 grossesses diabétiques suivies entre 1985 et 1992.

A total of 212 diabetic pregnancies were studied prospectively over the period 1985 to 1986, included: 76 insulinodependent diabetics (IDD), 34 non insulinodependent diabetics (NIDD), and 102 gestational diabetes. The perinatal mortality rate for all diabetic pregnancies was 1.4% (n = 3); 3 congenital malformations were recorded (a therapeutic abortion was performed in 2 cases). These results are comparable with those of the non diabetic population. However, it is to be noticed that maternal as well as neonatal morbidity was important (hypoglycaemic comas: 18 in 9 IDD, preeclampsia: 7 IDD, 2 NIDD, 1 DG; caesarean delivery: 50% IDD, 50% NIDD, 25% DG; neonatal morbidity 20% of the new born. The main objectives must be targeted on the prevention of severe hypoglycaemia in IDD, the early diagnosis of DG and the development of pregnancy care in NIDD.

[Pregnancy and obesity. A case control study of 140 cases]. / Grossesse et obésité. A propos d'une étude cas-témoins de 140 cas.

A retrospective study of 70 fat women and 70 women of normal weight was carried out to compare their obstetric performance. The patients were assessed before pregnancy for corpulence by estimating the body mass index (IMC). Obesity was defined by having an index of 30 or above. The mean weight of the obese patients at delivery was 142 kgs and of the controls 65.4 kgs. The main risk in obese patients is a raised blood pressure (34%); and in spite of this no child showed intrauterine growth retardation. The mean weight of the newborn infants was 3.7 kgs against a mean weight of 3.2 kgs in the control group. Eighteen infants born to obese mothers were very heavy (25%). The increase in fetal weight explains why the caesarean section rate was three times as high in the obese patients as in the control due to disproportion (25%). These differences are statistically significant. Neonatal morbidity was similar in the two groups. It is debatable whether a slimming diet was worthwhile. All the same calorie intake reduced slightly to about 1.800 calories a day together with vitamin supplements is advisable. It does not have any ill effect on the fetus.

Assisted reproductive technology and superfetation: a case report.

This observation reports a case of human superfetation. Fertilizable oocytes and embryos were obtained after ovarian stimulation in a women already several weeks pregnant. Spontaneous monofetal pregnancy had normal development and the embryos obtained after in vitro fertilization were actually frozen.

[Analysis of 10 cases of pregnancy after renal transplantation]. / Analyse de 10 cas de grossesse après transplantation rénale.

Renal transplantation has changed completely the fertility of women who had been dialysed. Our study is on 10 pregnancies which we followed up in 7 women who had had renal transplants in the University Hospital of Pitié Salpêtrière (Professor Y. Darbois) between 1979 and 1985. All patients were treated by the same technique and the same methods of prevention of rejection of the transplant. The mean interval between the transplant and pregnancy was 53 months. In 3 cases there was hypertension and raised creatinine levels (more than 150 in 3 cases). In 2 cases the two conditions were associated. The prognosis is bad when a raised blood pressure or a change in renal function occurs before pregnancy starts, leading to a real deterioration in renal function during the pregnancy when such function was abnormal before the pregnancy started. As far as the infants were concerned, the most common complication was IUGR (intrauterine growth retardation) which was found in half of all cases. Blood flow studies in these fetuses are particularity interesting. There were two cases of intra-uterine fetal death. The reasons for these were not necessarily connected with the deterioration in renal function. All the deliveries were by caesarean section, for medical reasons in 7 out of 10 cases. The average duration of the pregnancy was 35 weeks of amenorrhoea. As far as the mothers were concerned, they did not have more infections than other women in spite of being immuno-suppressed (this was excluding urinary tract infections).(ABSTRACT TRUNCATED AT 250 WORDS)

The use of gonadotropin-releasing hormone analogs for in vitro fertilization: comparison between the standard form and long-acting formulation of D-Trp-6-luteinizing hormone-releasing hormone.

The introduction of luteinizing hormone-releasing hormone (LH-RH) analogs into treatment schemes for the stimulation of ovulation has enabled the authors' in vitro fertilization (IVF) team to overcome two problems; they can now suppress spontaneous LH peaks and program their activity. Two hundred and five IVF cycles were investigated. The agent used was D-Trp-6-LH-RH, either in a sustained release formulation (112 cases, group 1) or in a standard form (93 cases, group 2). The quantity of human menopausal gonadotropin (hMG) necessary for adequate ovarian stimulation was much lower when the standard form of the analog was used. The number of oocytes recovered per puncture was greater in group 1 (7.6 compared with 5.1), but the difference was not significant when considering the number of embryos (2.4 compared with 2.1). The corrected pregnancy rate (with allowance for progressive introduction of freezing from the third embryo onwards) was identical in both groups. The authors conclude that systems in which LH-RH analogs are employed have a clear advantage over the classical treatment with clomiphene citrate/hMG, and that the immediate-action formulation of D-Trp-6-LH-RH is preferable.

[Risks of fertilization in vitro]. / Aléas de la FIV.

The authors report the results of four IVF attempts, performed on the same couple, in 16 months, because of tubal problems. June 1985 (T1): spontaneous miscarriage after 8 weeks of amenorrhea; october 1985 (T2): negative tap; january 1986 (T3): extra-uterine pregnancy; october 1986 (T4): rejected because of "poor response" and spontaneous extra-uterine pregnancy during the same cycle.

[In vitro fertilization. Analysis of results after the first 2 years' activity]. / Fécondation in vitro. Analyse des résultats sur les deux premières années d'activité.

413 menstrual cycles were monitored in the first two years of the work of the In-Vitro Fertilization Unit in La Pitié-Salpêtrière. On-going pregnancies were achieved from the very first months of activity, with a level which stayed relatively constant in the first year. Technical changes were introduced and in particular a higher recovery rate of oocytes when ultrasound was used and above all when LH-RH analogues were used in the process of stimulation. It is this last point that seems to be the most interesting. In fact, when the results are examined there is a definite rise in the number of on-going pregnancies of which the level went up by 2.3 times as compared with using a classical protocol of Clomithene citrate and HMG. In the 153 cycles when D-Trp6 LH-RH was used, the percentage of on-going pregnancies was 13.7% for each cycle and 20% for embryo implants. Furthermore, it became possible to work out the dates for the patients and this appears to us essential as the numbers of couples attending increase.

[Retrospective study of 33 cases of obstetric paralysis of the brachial plexus]. / Etude rétrospective de 33 paralysies obstétricales du plexus brachial.

Thirty-three cases of obstetrical paralysis of the brachial plexus have been seen in 15 years in the gynaecological and obstetrical department of the University Hospital Pitié Salpêtrière. The authors, from studying these cases, work out the factors that tend to bring about this pathological condition. They are: multiparity, excessive weight gain in pregnancy, fetal excessive growth, prolonged second stage of labour, instrumental delivery and shoulder dystocia in cephalic presentations. In breech presentations it is mainly faulty performance of the manoeuvres that are needed to deliver the shoulders. These lesions involve, in most cases, the roots of C5 and C6. Spontaneous regression occurs very often. The authors have found 25% of sequellae. It is difficult to prevent shoulder dystocia. It consists in realising well the size of the fetus and using instruments really sensibly when the presenting part is high in a primiparous woman. In a multiparous woman one has to be on the look-out for increasing macrosomia of the fetus and it is important to teach the manoeuvres that are necessary to deal with shoulder dystocia. As far as breech delivery is concerned the major risk is the delivery itself without there being any need for fetal or maternal criteria to alter matters. Therefore prevention in this presentation has to be the presence of a competent obstetrician at each delivery always.

[Pelvimetry using x-ray computed tomography]. / Pelvimétrie par tomodensitométrie.

The accuracy and the low radiation dosage administered when tomodensitometry is carried out for pelvimetry has led us to specify the use of this technique in every day practice. We propose to make is still more reliable and to simplify it. We have correlated the measurements obtained on the ultrasound screen with those that have been obtained by measuring the dried pelvis and have sought ways of measuring directly the three fundamental diameters of the pelvis. We have achieved exact measurements within one millimeter. This very precise correlation has been reproduced when we examined skeletons using the tomodensitometer. Then, when we checked again the accuracy of these measurements, we used the method on pregnant women. We have taken two views and two slices: an AP view to study the contents of the uterus and the morphology of the upper strait; a profile view to measure the diameter between the promontory of the sacrum and posterior surface of the symphysis, and we have programmed the two following slices: a perpendicular slice at the level of the upper strait measuring directly the transverse median diameter; another slice at the level of the sciatic spines to measure directly the diameter between these spines. We present this method because it is very simple and absolutely precise and gives all the information that is necessary. The patient does not have to stay still for long and only has a small dose of irradiation. This procedure does not need the use of conversion tables, nor parallel rulers nor standardisation.