[First-trimester cystic hygroma: prenatal diagnosis and fetal outcome]. / Hygroma kystique découvert à l'échographie obstétricale du 1er trimestre : caractéristiques échographiques, caryotypiques et devenir de la grossesse.

OBJECTIVES: To describe the ultrasonographic (US) and fetal karyotyping data of fetuses with cystic hygroma diagnosed in the first trimester. PATIENTS & METHODS: Maternal and fetal data of 69 consecutive fetal cystic hygroma were analysed between 2002 and 2009. RESULTS: The mean size of the cystic hygroma was 6.3 mm ± 2.4 mm. US abnormalities were present in 54% of cases (37/69) (essentially hydrops fetalis in 45%), with an unfavourable prognosis (P=0.006). Chromosomal abnormalities were present in 53% of cases (36/68) (including 44% of Down syndrome). The rate of unfavourable outcome of pregnancy was 71% of cases (49/69) and was associated with the oldest mothers (P=0.011). In the chromosomally normal pregnancies, there were 59% (19/32) fetus with no apparently abnormalities. Among these 19 children, 13 have been followed up until an average age of 5 years and a half, the infant development was strictly normal. DISCUSSION AND CONCLUSION: The current results suggest to look for the poor prognosis data: nuchal thickness superior to 6 to 6,5 mm, presence of a hydrops fetalis and/or US abnormalities, fetal karyotyping and/or US evolution of cystic hygroma.

Reduction of the use of antimicrobial drugs following the rapid detection of Streptococcus agalactiae in the vagina at delivery by real-time PCR assay.

OBJECTIVE: To assess whether the determination of the presence of group B streptococci (GBS) in the vagina using a rapid polymerase chain reaction (PCR) assay at delivery was able to spare useless antimicrobial treatments, as compared with conventional culture at 34-38 weeks of gestation. DESIGN: Practical evaluation and prospective cost-effectiveness analysis. SETTING: A university hospital in France. POPULATION: A cohort of 225 women in labour at the University-Hospital of Saint-Etienne. METHODS: Each woman had a conventional culture performed at 34-38 weeks of gestation. At the beginning of labour, two vaginal swabs were sampled for rapid PCR testing and culture. The decision to prescribe a prophylactic antimicrobial treatment or not was taken according to the result of the PCR test. A comparative cost-effectiveness analysis of the two diagnostic strategies was carried out. MAIN OUTCOME MEASURES: Number of women receiving inadequate prophylactic antimicrobial drugs following each testing strategy, costs of PCR testing and culture, frequency of vaginal GBS, and diagnostic performance of the PCR test at delivery. RESULTS: The percentage of unnecessarily treated women was significantly reduced using the rapid test versus conventional culture (4.5 and 13.6%, respectively; P < 0.001). The rate of vaginal GBS at delivery was 12.5%. The incremental cost-effectiveness ratio (ICER) for each inadequate management avoided was €36 and €173 from the point of view of the healthcare system and hospital, respectively. CONCLUSIONS: The PCR assay reduced the number of inadequate antimicrobial treatments aimed to prevent the early onset of GBS disease. However, this strategy generates extra costs that must be put into balance with its clinical benefits.

[Preliminary study of fetal head engagement diagnosis by transperineal ultrasound before operative vaginal delivery]. / Étude préliminaire du diagnostic d'engagement par une échographie transpérinéale avant une extraction instrumentale.

OBJECTIVES: Estimate the predictive value of perineum-fetal head distance obtained by transperineal ultrasound on results of an operative vaginal delivery. PATIENTS AND METHOD: A prospective preliminary monocentric study has been conducted on 28 patients between the 18th of April and the 31st of July 2011. Three successive perineum-fetal head distance have been measured before realization of an operative vaginal delivery. RESULTS: With caesarian section deliveries, average distances were higher than with successful operative vaginal deliveries but this result was not significant (49.3mm vs 39.7 mm; P=NS). Ultrasound measured distance was significantly correlated to the time of application of the instrument (r=0.45, P=0.0165). Beyond 50mm, the relative risk of caesarian was 10.5 (IC [0.76-145.36]). The measures were corresponding, with an average time of realization of 29.9 seconds. The transvaginal examination compared to ultrasound showed a discordance of 3.6% for the diagnosis of engagement and of 25% for the descent of fetal head. CONCLUSION: A larger study is necessary to confirm this result and to recommend the realization of a transperineal ultrasound before an operative vaginal delivery in cases of doubt about engagement after the transvaginal examination.

[Failed forceps extraction: risk factors and maternal and neonatal morbidity]. / Facteurs de risque et morbidité maternelle et néonatale des échecs d'extraction instrumentale par forceps.

OBJECTIVES: To evaluate risk factors associated with failed forceps delivery and to compare the maternal and neonatal morbidity. PATIENTS AND METHODS: In this retrospective case-control study, all failed forceps delivery cases were analyzed from January 2005 to June 2008 and were compared to a successful forceps delivery cohort. RESULTS: The rate of failed forceps extraction was 4.4% (40/918). Specific risk factors were extraction above a fœtal station of S+2 (OR=43.03; IC 95%: 3.8-475.41), occipito-posterior position (OR=34.64; IC 95%: 4.08-293.5), and biparietal diameter higher than 95mm (OR=10.74; IC 95%: 1.4-82.41). Maternal and neonatal morbidity was few in both groups. CONCLUSIONS: Diagnosis of presentation level and variety of presentation are necessary before instrumental extraction. A "trial of forceps" should be performed with caution in a setting where a caesarean delivery could follow. Vacuum extraction could be interesting in case of occipito-posterior position.

[Is the socioeconomic deprivation EPICES score useful in obstetrics?]. / Intérêt de l'échelle d'évaluation de la précarité EPICES en obstétrique.

OBJECTIVES: To describe a validated and multifactorial deprivation score to study the relationship between socioeconomic deprivation and perinatal risks. PATIENTS AND METHODS: The index of deprivation EPICES (Evaluation of Precarity and Inequalities in Health Examination Centers) was used to characterize the deprivation status of 234 women in post-partum in comparison with perinatal morbidity. The cutoff value of 30.7 was the threshold to define deprivation. RESULTS: Two hundred and eight patients were included in this retrospective study from whom 48 (23%) had a score of deprivation higher than 30.7. Maternofetal morbidity was more severe in deprived patients. DISCUSSION AND CONCLUSION: The current results show that the EPICES score could be a useful obstetrical tool for the identification of deprived women during pregnancy.

[Anthropometric analysis of obstetrical pelvis from Neolithic area: obstetrical consequences. Preliminary study]. / Analyse anthropométrique du bassin obstétrical datant du Néolithique : conséquences obstétricales. Étude préliminaire.

OBJECTIVES: To study female pelves from Neolithic area (5000 years AD) in order to better understand the evolution of obstetrical mecanisms. MATERIALS AND METHODS: The fossil material comprised 73 Homo sapiens pelves: we reconstructed all the 20 adult female bony pelves. We realised the shape and morphometric analysis of the pelvic cavity. Changes in pelvic neolithic morphology were compared with pelvic modern morphology. RESULTS: The pelves of prehistoric female were similar in shape with modern female. However, they differ in relative dimensions (transversal diameter of the pelvis inlet: respectively 118 mm vs 125 mm, p=0.02). DISCUSSION AND CONCLUSION: Reconstructions based on Neolithic hominin fossils suggest that obstetrical mechanisms were probably common to Neolithic and modern humans: childbirth would probably require social adaptations and risks of perinatal and obstetric complications were undoubtedly high. However, the differences in morphometric analysis could suggest a change of human pelvis and raise the question of the evolution in obstetrical mechanisms in the future.

[Computerized cardiotocography and short-term variation in management of obstetric cholestasis: a useful tool?]. / Intérêt de la variabilité à court terme dans la surveillance de la cholestase gravidique.

OBJECTIVE: To evaluate active management of obstetric cholestasis by comparing correlation between bile acid concentrations and computerized cardiotocography (Short-term variation [STV]). PATIENTS AND METHODS: Retrospective analytic study about 51 obstetric cholestasis between January 2001 and August 2009. Demographic characteristics, bile acid concentrations and STV data were recorded since diagnosis to pregnancy with evaluation of fetal outcome. RESULTS: There were no statistical correlation between bile acid concentrations, STV data and fetal outcome. Patients with cholestasis diagnosed in second trimester delivered 12 days earlier than cholestasis diagnosed in third trimester (p=0.0012). Delivery before 37 weeks was found in 37.2% of cases. There were no perinatal deaths. Sixty percent had a recurrent obstetric cholestasis. CONCLUSION: Further works are necessary to study the exact pathogeny of obstetric cholestasis in order to determinate the best surveillance.

[Prenatal diagnosis and management of isolated bladder exstrophy]. / Diagnostic anténatal et prise en charge des extrophies vésicales isolées.

The isolated bladder extrophy is a major congenital malformation which prenatal diagnosis is essential. It is based on the non-visualization of the bladder during the first trimester ultrasound but in most cases, it is confirmed by the morphological ultrasound of the second trimester. For the baby, the prognosis of life quality depends on the accurate identification of the malformation, the foetal sex and the associated pathologies. Thus, a detailed ultrasound evaluation is necessary and requires an operator experienced in the search of malformations. As this abnormality has important aesthetic and functional consequences, a multidisciplinary management is required for a good information of the couple. The continuation of pregnancy is currently possible but the couple should be informed that after surgery, often a major one, more than 75% of children will have a urinary continence by reconstruction or bypass. Furthermore, their ability of reproduction will need to be medically improved.

[Immunoglobulin treatment for neonatal hemochromatosis: a case report in a context of immunoglobulin delivery quotas]. / Traitement par immunoglobuline polyvalente en situation de contingentement. A propos d'un cas à risque d'hémochromatose néonatale.

Neonatal hemochromatosis is a rare disease characterized by iron deposits in several organs. The natural course leads to lethal liver failure. A preventive treatment was recently introduced: high-dose intravenous immunoglobulins during pregnancy to prevent fetomaternal allo-immunization. Nevertheless, the prescription of massive quantities of immunoglobulins can lead to a drug shortage which the hospital pharmacist must deal with. We report the case of a pregnant woman with high risk of transmitting neonatal hemochromatosis. We discuss the pharmaceutical difficulties encountered when managing patients with a high risk of neonatal hemochromatosis in the context of immunoglobulin shortage with the delivery quotas established by the French National Health Authority. In this context, a national stock would be useful to deal with rare diseases and thus to support hospitals.

[Shoulder dystocia: a ten-year descriptive study in a level-III maternity unit]. / La dystocie des épaules: analyse descriptive sur dix années dans une maternité de niveau III.

OBJECTIVE: Shoulder dystocia is one of the most dreadful complications of vaginal deliveries. The aim of this observational study was to evaluate risk factors of dystocia, maternal and neonatal complications and recurrent risk factors. PATIENTS AND METHODS: Sixty-six cases of shoulder dystocia occurring between January 1998 and August 2008 in our university hospital were identified. Demographic data, labor management, management of the shoulder dystocia and neonatal outcome were recorded. RESULTS: The incidence of shoulder dystocia was 0.3%. Multiparity, weight gain greater than 12 kg, and post-term delivery were more present in our study group. McRoberts' manoeuver and symphyseal pressure were first realised. Brachial plexus injuries affected 9% of neonates with skeletal fractures in 7.5% of cases. Maternal morbidity was evaluated at about 8%. Twenty per cent had a recurrent shoulder dystocia. DISCUSSION AND CONCLUSION: Shoulder dystocia is an obstetric emergency which requires a prompt management of trained personnel. Despite the difficulty of being able to prevent shoulder dystocia, training the obstetric staff could probably improve management of shoulder dystocia.

[Toxoplasma gondii serology in pregnant woman: characteristics and pitfalls]. / Sérologie de la toxoplasmose chez la femme enceinte : caractéristiques et pièges.

Screening program of congenital toxoplasmosis depends principally on serological testing and follow-up of pregnant women with negative serology from the onset of pregnancy. This program is particularly efficient because the majority of cases of obstetrical seroconversion are diagnosed and followed up. Serological techniques have evolved with time and are many on the market. The "IgG" tests are more and more specific at the detriment of their sensitivity. The latter is variable from one technique to the other. In 2008, despite the presence of an international standard, serological titrations are particularly variable making interpretation of the kinetics impossible between two different series, two techniques or two laboratories. In cases of interpretation discordance or borderline values, it is useful to do a confirmatory technique. The dye test or the western blot are useful in these cases and prevent up to 2 to 8% of unnecessary obstetric follow up. IgM tests are becoming more and more sensitive and precocious. These tests frequently detect "non specific IgM" as well as "residual IgM" (associated with a stable positive IgG titre). In such cases and in the absence of a preceding positive result, a complementary test done by specialized laboratories (such as ISAgA IgM or IgA, IgG avidity test, differential agglutination, etc.) is indispensable in order to prevent any error of interpretation. These complementary tests as well as the serological evolution (control done in 15 days) permit, in a large number of cases, to reassure the patient with full confidence.

[Early fetal megacystis at first trimester: a six-year retrospective study]. / Diagnostic anténatal de mégavessie au premier trimestre de la grossesse. Etude rétrospective sur six années.

OBJECTIVE: A fetal megacystis is defined by a longitudinal bladder diameter more than 7 mm. The purpose of this study is to describe the prenatal ultrasound findings of this early fetal pathology and to assess pronostic and aetiologycal criteria. PATIENTS AND METHODS: Between January 2003 and December 2008, 12 cases of early fetal megacystis were identified in our referral fetal medicine unit (Saint-Etienne hospital, France). RESULTS: There were two cases of spontaneous resolution and one case wasn't a fetal megacystis. Termination of pregnancy for medical indications was realised for another cases because of associated malformations and bad evolution (six cases) and three chromosomal abnormalities (two cases of trisomy 18 and one of trisomy 21). DISCUSSION AND CONCLUSION: Sonographic follow-up and fetal karyotyping are important to evaluate prognosis. However, our data suggest that fetal megacystis is a severe condition when diagnosed in early pregnancy.

[Water-electrolyte abnormalities during pregnancy: maternal and fetal complications (about a case)]. / Troubles hydroélectrolytiques pendant la grossesse: complications maternelles et foetales (à propos d'un cas).

Water-electrolyte abnormalities while pregnancy or for infant are very serious. We present a case of a woman at 26 weeks who had gestation pernicious vomiting that led to major extracellular dehydration, water intoxication and acute renal insufficiency. The etiology was a volvulus on common mesentery. Hyperemesis disappeared thanks to surgical treatment. The mother and her fetus would later present serious complications due to the water-electrolyte imbalance correction. The fetus suffered from cerebral hemorrhage and subdural hematoma subordinate to brain edema resorption. The mother presented centropontine myelinolysis. The treatment of electrolyte abnormalities during pregnancy could lead to serious complications for the mother and fatal for the foetus.

[Prenatal Bartter's syndrome. Report of two cases]. / Le syndrome de Bartter anténatal. A propos de deux cas.

Antenatal Bartter Syndrome (ABS) is a rare autosomic recessive tubulopathy characterized by idiopathic hydramnios, fetal polyuria and elevated levels of amniotic chloride. It is related to mutations affecting several transporters in the loop of Henle e.g. the Na-K-2Cl cotransporter, the chloride channel CLC-NKB and the potassium channel ROMK. We report two cases of ABS in siblings born to consanguineous parents (first cousins). The first pregnancy showed hydramnios of unknown etiology at week 23. Two amnio drains were performed at weeks 26 and 27. The baby was born in week 29 and developed polyuria with hyponatremia, hypokalemia and hyperaldosteronism. After eliminating diabetes insipidus and adrenal insufficiency, ABS was diagnosed. The baby was treated with 0.5 mg/kg/d indomethacine, which controlled the polyuria and the hydroelectrolytic disorder. The second pregnancy showed idiopathic hydramnios at week 24. The elevated amniotic chloride level (above 112 mmole/l) led to the antenatal diagnosis of ABS. The mother was treated with 1 mg/kg/d indomethacine until week 31 in order to stabilize the hydramnios. Two amnio drains at weeks 31 and 33 allowed the pregnancy to be prolonged until week 34. A genetic study of the family showed homozygosity of the NKCC2 gene marker suggesting its implication in the disease.

[Relevance of the new test Access Toxo IgM (II) in the serological interpretation of toxoplasmosis in pregnancy]. / Intérêt du nouveau test Access Toxo IgM (II) dans l'interprétation sérologique de la toxoplasmose au cours de la grossesse.

The detection of specific IgM is an important element in the diagnosis of seroconversion. In this study, we compared the new test Access Toxo IgM (II) versus the previous test Access Toxo IgM (I). This comparative study was done with 507 random sera and 89 selected sera (seroconversion, residual IgM, non specific IgM). The sensitivity and the specificity are higher with the new test (100% & 100% versus 97% & 98,6% respectively). Then, the high sensitivity of Access Toxo IgM (II) is more convenient for the earlier diagnosis of primary Toxoplasma infection. Moreover, the Access Toxo IgM (II) test was evaluated with our first results in routine laboratory (11,000 serology results between June 2000 and June 2001). With these results, we can confirm the specificity of the new test, and also determine the relevance of anti-toxoplasmic IgM. Moreover, an increase of sensitivity leads to an increase of residual IgM detection: 64% (37/58) of positive IgM is residual (> 4 months) as compared to 35% (27/78) with the previous test. In these case, the initiation of other tests such as the avidity test is necessary to validate or invalidate a seroconversion during pregnancy.

[Prevention of thrombosis during pregnancy: from recommendations to practice from 26 cases]. / Prévention des thromboses durant la grossesse: recommandations et pratique à partir de 26 dossiers.

Recommendations have recently been published regarding the prescription of low-molecular-weight heparin (LMWH) during pregnancy in women at risk of thromboembolism. To assess how well these recommendations are followed, we retrospectively recorded all pregnancy consultations in a thrombosis unit for two years. Of the 26 women included (mean age 30 +/- 4.8 years), 81% presented with a history of thromboembolism, 35% thrombophilia, and 15% a history of pregnancy termination for medical reasons. Clinical follow-up concerned 17% of the women; 8% were given aspirin, 63% LMWH at prophylactic dosages, 4% combination of aspirin and prophylactic LMWH, and 8% were on curative LMWH. Neither thromboembolic nor neonatal events were observed. One case of termination of pregnancy for medical reasons was observed at the 5th month. Although we also took into account the gravity of previous thromboembolism, our prescriptions were globally in compliance with the recommendations. This approach has still to be validated with a decision-making tree.

[Thrombocytopenia due to materno-fetal allo-immunization. Report of a familial case]. / Thrombocytopénie par allo-immunisation materno-foetale. A propos d'une observation familiale.

The diagnosis of fetomaternal alloimmune thrombocytopenia (FMAT) was made in a newborn with thrombocytopenia and intracranial hemorrhage. The first child of the family was severely affected with neurodevelopmental sequelae secondary to intracranial hemorrhage. According to the maternal HPA phenotype, close to 100% of subsequent pregnancies could be expected to be affected as the homozygous state was observed in both platelet systems. Another infant was born after a poorly followed pregnancy and was affected as was his elder brother. Prednisolone was given during another pregnancy. A thrombocytic newborn without intracranial hemorrhage was delivered by prudent cesarian section. The infant received platelet transfusion (maternal platelets). We present case histories of FMAT, and stress the conditions for prenatal diagnosis and management.

[Exanthematic pustulosis of pregnancy: favorable evolution using calcium and vitamin D2]. / Pustulose exanthématique de la grossesse d'évolution favorable sous calcium et vitamine D2.

A 26-year-old pregnant woman was hospitalized in an emergency setting for a skin eruption. She had developed pustules distributed on round patch-like areas of rash localized at the umbilicus and the larger skin folds. She was given calcitriol and calcium with good results. Systemic steroids are usually given for exanthematic pustulosis of pregnancy but with variable efficacy. Few cases of successful treatment with calcium and vitamin D have been reported. We suggest this alternative treatment could be useful in other cases.