Modulation of free corticotrophin-releasing hormone, adrenal and placental steroid hormone levels induced by mifepristone during pregnancy.

UNLABELLED: Mifepristone is a progesterone receptor antagonist widely used in obstetrics. The aim of the study was to focus on free corticotrophin-releasing hormone (CRH) and also describe modulation of adrenal and placental steroid hormone concentrations induced by mifepristone. METHODS: Twenty-six women were enrolled in the study. They received mifepristone for termination of pregnancy. Maternal blood samples were retrieved before administration of mifepristone (600 mg) and 48 h after, just before induction of labor. Bound and free CRH levels were determined in maternal blood concomitantly with cortisol, estriol, progesterone and SDHEA levels. Also paired fetal cord blood samples were collected. RESULTS: Maternal plasmatic CRH level did not change after mifepristone absorption but free CRH increased significantly (0.500 ± 0.326 vs. 0.388 ± 0.303 ng/ml, p = 0.040). A significant decrease of progesterone was observed (83.6 ± 49.3 vs. 95.6 ± 54.9 ng/ml, p = 0.001) with a lower progesterone/estriol ratio (26.9 ± 15.7 vs. 40.7 ± 31.1, p = 0.004). There was a strong association between maternal and fetal free CRH (r² = 0.675, p = 0.001), cortisol (r² = 0.570, p = 0.019), and positive but modest correlation for progesterone (r² = 0.341, p = 0.046) and estriol (r² = 0.379, p = 0.025) levels. CONCLUSION: Mifepristone has an effect on free CRH level and changes the estriol-progesterone balance.

Modes of delivery of first and second twins as a function of their presentation. Study of 614 consecutive patients from 1992 to 2000.

OBJECTIVES: To study modes of delivery and neonatal morbidity of twins as a function of their presentation. STUDY DESIGN: The study related to 614 consecutive patients who gave birth to twins in the maternity ward of the Hôpital Robert Debré from 1992 to 2000. Group A (n=529) included patients who gave birth after 33 weeks of gestation and group B (n=85) before 33 weeks. The parameters studied were the mode of delivery, the need for intubation at birth, 5-min Apgar score <9, transfer to intensive care, death in the neonatal period. The chi-square test was used for statistical analysis. RESULTS: In group A, significantly more cesarean sections were performed for breech-breech (22.6%) and breech-vertex (16%) presentations than for vertex-vertex (10.3%) and vertex-breech (4.6%) presentations. In group B, there was no significant difference in the rate of vaginal delivery. Second vertex twins of group A had significantly higher frequencies of intubation (3%) at birth and transfer to intensive care (3%) than the vertex first twins born by vaginal delivery (p=0.01). These percentages were not significantly different from those observed for the second twins born by planned Cesarean section before the start of labor (2.8 and 5.6%, respectively). In group B, neonatal parameters did not differ significantly with the type of presentation at delivery. CONCLUSIONS: The type of presentation should not influence the choice of mode of delivery of twin pregnancies, whatever the gestational age.

Ultrasonographic cervical length measurement is not a better predictor of preterm delivery than digital examination in a population of patients with idiopathic preterm labor.

OBJECTIVE: To compare digital and ultrasonographic cervical examination for the prediction of preterm delivery in patients hospitalized for preterm labor. STUDY DESIGN: Fifty-nine patients were included. The Bishop score was evaluated upon admission, weeks gestational age. Ultrasonographic measurement of cervical length was done within 24h after entry. Delivery before 37 weeks gestational age was the primary endpoint. Attending obstetricians were blinded to the results of echography. RESULTS: Preterm delivery rate was 39% (23/59). The risk of preterm delivery was significantly increased when the Bishop score was greater than or equal to 6 (OR = 4.45 [1.41-14.01]) or when ultrasonographic cervical length was less than or equal to 27 mm (OR = 4.04 [1.32-12.3]), but digital examination was the only independent risk factor in multivariate analysis. Sensitivity, specificity, positive and negative predictive value for digital examination and ultrasonography were respectively 74, 61, 55 and 79%, 70, 64, 55 and 77%. Combination of digital examination and ultrasonography did not yield better results. CONCLUSION: In our series, prediction of preterm delivery was not improved by ultrasonography compared to digital examination. The size of the cervical shift observed in most patients hospitalized for preterm labor may render ultrasonography less relevant in identifying patients anticipated to deliver prematurely.

Maternal and neonatal outcome of 93 consecutive triplet pregnancies with 71% vaginal delivery.

BACKGROUND: The aim of this study was to investigate neonatal and maternal data in a large series of triplet pregnancies as a function of the decision regarding the route of delivery. METHODS: A retrospective series of 93 triplet pregnancies managed and delivered between 1989 and 2001 in a single perinatal department was analyzed. Seventy-eight women with triplet gestations who underwent a trial of labor were compared with 15 women with triplet gestations who delivered their infants by elective cesarean delivery. Neonatal outcomes assessed included respiratory distress syndrome, retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage and Apgar scores. Maternal outcomes assessed included preeclampsia, blood transfusion, endometritis and urinary tract infection. RESULTS: Sixty-six of 78 women (84%) who underwent a trial of labor had a successful vaginal delivery of all three neonates. The other 12 delivered their infants by cesarean delivery. Perinatal mortality referred to 104 triplet pregnancies was 48/1000. CONCLUSIONS: Our experience suggests that offering vaginal delivery is an acceptable management plan for triplet gestation in a center with a sufficient number of triplet deliveries.

Amniotic fluid inflammatory proteins and digestive compounds profile in fetuses with gastroschisis undergoing amnioexchange.

OBJECTIVE: In gastroschisis, an inflammatory process related to the presence of digestive compounds may be involved in intestinal damage. We measured the amniotic fluid concentrations of total protein, ferritin and amylase, lipase, gamma-glutamyl transferase and bile acids before each amnioexchange performed in women whose infants had gastroschisis. We estimated the correlation among total proteins, ferritin and digestive compounds and postnatal outcome. DESIGN: All women whose infants had gastroschisis in our fetal medicine unit are offered repeated amnioexchange during the third trimester of pregnancy to improve the quality of the exteriorised bowel at birth. Amniotic fluid was sampled at the beginning of each amnioexchange and total proteins, ferritin and digestive compounds were assayed. SETTING: This study was conducted in the Department of Perinatology of the University Hospital Robert Debré in Paris. POPULATION: Thirty pregnant women with a gastroschisis affected fetus diagnosed antenatally. METHODS: The biological results were expressed as multiples of the median with respect to a control population. MAIN OUTCOME MEASURE: Gestational age at delivery and the outcome of the infants were recorded and correlated with amniotic fluid total proteins, ferritin and digestive compounds. RESULTS: There was a positive correlation (P < 0.01) between digestive compounds (except amylase at the final amnioexchange) and ferritin on the one hand, and all digestive compounds and total proteins concentration at the final amnioexchange on the other. In addition, among total proteins amylase and lipase, lipase concentrations were related with parameters of short term outcome (P < 0.05). CONCLUSION: Amniotic total proteins and ferritin are elevated in fetuses presenting with gastroschisis as a consequence of an inflammatory process. Inflammation may be induced by the presence of digestive compounds in the amniotic fluid. The concentrations of which may constitute a marker of short term outcome of the newborn infant.

Criteria for transfusion in severe postpartum hemorrhage: analysis of practice and risk factors.

OBJECTIVE: To analyze the accuracy of postpartum hemorrhage risk factors to determine patients at risk of severe postpartum hemorrhage and transfusion. POPULATION AND METHODS: Retrospective cohort study from a database in one high-risk obstetric unit over a 7-year period. RESULTS: In a cohort of 19,204 deliveries, 44 patients were transfused of whom five were given frozen fresh plasma only. Of the 39 who received red blood cells, 35 received at least three units. Multivariate analysis of postpartum hemorrhage risk factors revealed a significant role of placenta previa/accreta, cesarean section, multiple pregnancy, prematurity and vascular disease. Nevertheless 28% of women transfused had none of these risk factors. CONCLUSION: The percentage of patients transfused has probably decreased markedly with improved prevention, surveillance and treatment. This study emphasizes that the transfusion risk in the presence of anomalous placental insertion justifies special obstetrical and anesthetic management.

Six hundred and ten breech versus 12,405 cephalic deliveries at term: is there any difference in the neonatal outcome?

OBJECTIVES: To compare neonatal morbidity of breech and cephalic deliveries at term. STUDY DESIGN: Cohort study of 610 consecutive singleton breech presentations and 12,405 consecutive singleton cephalic presentations in term between 1992-1998. Five hundred and fourteen breech and 11,989 cephalic presentations were candidates for vaginal delivery, of which 407 (79%) breeches and 11,265 (94%) cephalic delivered vaginally. RESULTS: Neonatal intensive care admissions were significantly greater for breech than cephalic vaginal deliveries (2.7% versus 0.25%, P = 0.000), but newborn intensive care admission and mortality were equally distributed between the two groups. CONCLUSIONS: A low caesarean rate is possible (21% beech and 6% cephalic). Neonatal morbidity was equal in the two populations. Admission to neonatal intensive care was significantly more frequent for caesarean section than for vaginal delivery in the cephalic group and equal in the breech group. This study justifies our obstetrical policy and the realisation of a trial in several centres similar in terms of perinatal management.

Differences in management and results in term-delivery in nine European referral hospitals: descriptive study.

OBJECTIVE: To compose obstetric interventions around Europe. STUDY DESIGN: A survey of obstetric practices, logistics and statistical outcomes in nine tertiary referral hospitals in Europe between November 1999 and October 2000. RESULTS: There was wide variation in the management of pre labour rupture of the membranes at term, methods of analgesia, induction of labour, and mode of cephalic and breech delivery. Midwives practised normal deliveries at only three sites. Rates of epidural analgesia varied from 0% in Perugia to 98% in Barcelona, instrumental delivery from 3% in Perugia to 40% in Barcelona, episiotomy from 9.7% in Uppsala to 58% in Perugia, caesarean section before and during labour from 12% in Paris to 32% in Athens, vaginal breech delivery from 15% in Barcelona to 70% in Paris. The percentage of primipara varied from 40% in Uppsala to 65% in Perugia; birth weight under 2500g from 5% in Uppsala to 23% in Amsterdam, over 4000g from 3.1% in Athens to 22% in Uppsala and gestational age less than 37 weeks from 6% in Dublin to 26% in Amsterdam. CONCLUSION: There are considerable differences in obstetric practices without any major difference in maternal and perinatal mortality.

A comparative study of manganese and lead levels in human umbilical cords and maternal blood from two urban centers exposed to different gasoline additives.

Manganese (Mn) and lead (Pb) are two neurotoxic chemicals and experimental evidence suggests that they can cross the placental barrier. Tetraethyl lead was still in use as an antiknock agent in Paris during the sampling period of the study, while it has been replaced by methylcyclopentadienyl manganese tricarbonyl (MMT) in Canada since 1977. By 1990, MMT was in 100% of gasoline in Canada. In a study of 160 pairs of mothers-neonates in Montreal and 206 pairs in Paris, we compared levels of Mn and Pb in the umbilical cord and in maternal blood. Neonates and mothers had significantly higher Pb levels in Paris where lead additives were still used in gasoline. Geometric mean maternal blood Pb levels were 5.4 microg/dl compared to 2.1 microg/dl in Montreal and cord blood Pb levels were 3.2 microg/dl in Parisian mothers compared to 1.7 microg/dl in Montreal. The prevalence of Paris Pb values superior to the 95th percentile of the Montreal distribution was highly elevated in all media studied. The prevalence of high Mn levels in umbilical cord blood was also significantly higher in Montreal. Surveillance programs are important to limit Pb overexposure and associated neurological effects in neonates where tetraethyl Pb is still in use as a gasoline additive. Since Mn is an essential element and dietary Mn intake may differ between Montreal and Paris, the difference observed with regard to high Mn values between Montreal and Paris cannot, at this time, be attributed to MMT in Montreal's gasoline. Further studies are needed to infer an association between Mn emissions from MMT and prenatal exposure to Mn.